For decades now, the general American population has been neurotically avoiding cholesterol-rich foods for fear of developing heart disease, thanks to the promulgation of the unfortunate Diet-Heart hypothesis. (1)

Those of us that follow a paleo diet are well aware by now that dietary cholesterol does not significantly affect cholesterol levels in the blood or risk for heart disease, and that there is no reason to avoid whole foods with naturally high levels of cholesterol.

However, beyond just ‘not avoiding’ high cholesterol foods, there is a significant reason for us to make a special effort to include many high cholesterol foods in our diet.

The reason? The much under-appreciated B-vitamin called choline, found primarily in cholesterol-rich foods.

If you haven’t heard of choline, or don’t know much about this vital nutrient, you’re not alone. Choline has only been ‘officially’ recognized as an essential nutrient since 1998, when the Food and Nutrition Board of the Institute of Medicine established an Adequate Intake (AI) level of 425 mg per day for women and 550 mg per day for men. (2) Even though it has been deemed a nutrient vital for human health, only 10% of Americans are meeting the conservative AI levels established by the IOM.

If you eat a strict paleo diet, you may be closer to meeting your choline needs than the average American, but only if you are regularly including choline rich foods in your diet. The best whole food sources of dietary choline are egg yolks and liver, which are often avoided by many Americans due to unfounded fear of dietary fat and cholesterol. However, these high cholesterol foods are at the top the choline-rich foods list, followed (albeit distantly) by beef, cod, brussels sprouts, and broccoli. (3)

Why is choline such an important nutrient to consider in one’s diet?

Choline has a variety of functions in the body, including the synthesis of the neurotransmitter acetylcholine, cell-membrane signaling, lipid transport, and methylgroup metabolism. (4) In addition, it is an essential component of the many phospholipids that make up cell membranes, regulates several metabolic pathways, and aids detoxification in the body. During pregnancy, low choline intake is significantly associated with a higher risk of neural tube defects in the newborn.

Choline deficiency over time can have serious implications for our health. Symptoms of choline deficiency include fatigue, insomnia, poor kidney function, memory problems, and nerve-muscle imbalances. Extreme dietary deficiency of choline can result in liver dysfunction, cardiovascular disease, impaired growth, abnormalities in bone formation, lack of red blood cell formation, infertility, kidney failure, anemia, and high blood pressure. Incredibly, choline deficiency is the only nutrient deficiency shown to induce the development of spontaneous carcinoma. (5)

Chris Masterjohn has written extensively about choline deficiency and its relationship to fatty liver disease which affects as many as 100 million Americans and is often attributed to excess alcohol and sugar consumption by conventional practitioners. After a review of the literature, Masterjohn concludes that choline deficiency plays a role in virtually every type of diet-induced fatty liver model, and that adequate dietary choline is essential for proper liver function. He also suggests that high consumption of dietary fat, including saturated fats, increases the amount of choline required to prevent the accumulation of fat in the liver. (6)

This means that if you’re eating a higher fat diet, it is even more crucial that you include a variety of choline rich foods in your diet.

Another important factor to consider is that while humans are able to produce some level of endogenous choline, some people have a common gene variation that further increases the amount of choline they must consume to satisfy their body’s requirements. (7) These particular people are more susceptible to choline deficiency, and must be especially vigilant about including choline rich food in their diets.

As choline is so important, you may be wondering what the best food sources are in order to improve your intake. There are many natural, whole foods that are excellent sources of bioavailable choline, with the best sources being beef liver, poultry liver, and whole eggs. (8) These foods are not only high in choline, but are also very high in many different vitamins and minerals such as as vitamin A, arachidonic acid, DHA, and the B vitamins. (9)

We already know liver is an amazing superfood. Liver from pastured animals is a great source of trace elements such as copper, zinc and chromium, plus highly bioavailable folate and iron. (10)

Liver is also the most potent source of dietary choline that we know of.

For example, a three ounce serving of pan-fried beef liver has over 400 mg of choline in it, compared to less than 80 mg in the same amount of cooked ground beef. (11) While you don’t need to consume beef liver on a daily basis to reap the benefits of this superfood, it should be clear that including pastured liver and other organ meats as part of a nutritionally complete diet is one of the best ways to improve your health and prevent the many types of chronic disease caused by nutrient deficiencies.

If you’re not used to including lots of liver and whole eggs in your regular meal plan, give a few of the following recipes a try. It’s never too late to start incorporating more choline into your diet!

Liver recipes: get your choline!

• http://cavegirleats.com/2011/09/09/baked-liver-pate-yum-seriously-seriously
• http://balancedbites.com/2011/05/easy-recipe-chicken-liver-pate.html
• http://paleodietlifestyle.com/simple-and-delicious-liver-pate-recipes/
• http://www.foodnetwork.com/recipes/ina-garten/chopped-liver-recipe/index.html
• http://www.foodrenegade.com/egg-drop-soup/
• http://nomnompaleo.com/post/1983505174/easy-paleo-frittata
• http://www.theclothesmakethegirl.com/2011/01/17/dont-be-lily-livered-aromatic-chickenlivers/
• http://www.theclothesmakethegirl.com/2010/05/17/scotch-eggs-a-k-a-protein-pellets/
• http://www.primal-palate.com/2011/01/root-vegetable-hash-with-poached-egg.html

You’ve probably noticed that I haven’t been able to write as much lately for the blog. I’ve been incredibly busy with my private practice, launching the Paleo Detox program, preparing and delivering talks locally, developing new content like ongoing class series and an eBook, and of course continuing my research on various topics.

I’ve got one more article to write for the series on diabesity. I’ll discuss what I believe to be the most effective form of exercise for restoring glucose tolerance and insulin sensitivity. I hope to get to that this weekend.

After that, I’ll be sending out a survey to get your input on the next series, as well as several other topics related to the blog and various projects I’ve got in the works.

I hope to get back to a more regular writing schedule at some point, but with everything going on it may take a while. In the meantime, I may try out some new formats, like posting a brief summary of articles from around the web that I’ve found interesting during the week.

Here are a few from this week.

Why Is My Cholesterol So High On This Diet?

In this article, Chris Masterjohn explains why some people see their cholesterol go up (often temporarily) when they switch to a nutrient-dense, whole-foods based diet. His theory, which is plausible from a physiological standpoint, is that the temporary cholesterol elevation is occurs because these folks are curing themselves of fatty liver disease.

In any event, we know that total and LDL cholesterol are weakly correlated with heart disease, so I’m never concerned when I see people’s cholesterol go up on a paleo or nutrient-dense diet. It’s expected. Especially when their HDL goes up and their triglycerides go down, which is the typical response.

Huge Metastudy: “Non Diabetic” Blood Sugars Cause “Diabetic” Retionopathy

Throughout my series on diabesity, I’ve presented evidence that blood sugar levels considered to be “normal” by mainstream standards are anything but, and that they can lead to complications like retinopathy and peripheral neuropathy.

Jenny Ruhl blogged today about a recently published meta-analysis that confirms this once again. In the study, blood sugar levels of 117 mg/dL or above, and an A1c of 6.3 or above (both below current limits) significantly increased the risk of retinopathy. But, as Jenny points out, the safe limits are lower still, because retinopathy is one of the last complications of diabetes to appear. Heart disease risk increases as post-meal blood sugars rise above 155 mg/dL, and increases in a straight line with A1c above 4.7, becoming quite significant as it rises above 6.

Grasse Based Health: Food For Thought

In this video, Peter Ballerstedt argues that animal protein and animal fat are not only superior to grains for human health, but also more sustainable from an agricultural and ecological perspective.

The presentation is quite dry, but the information is solid and it’s definitely worth watching.

Summary

Sorry, folks. Another long one. It was unavoidable, though, because I really did want this to be a “definitive guide” that covers all (or at least most) of the relevant issues involved with choosing a fish oil. Here’s a summary for the time-challenged:

• There are seven important factors to consider when choosing a fish oil: purity, freshness, potency, nutrients, bioavailability, sustainability, and cost.
• Not all fish oils are created equal. It’s essential to do your homework and make an informed choice. Many fish oils are oxidized or made with poor quality ingredients, and may actually cause health problems instead of solving them.
• The potency of various products depends not only upon the levels of EPA and DHA, but also upon the molecular structure of the fats in the oil, which in turn affects absorption.
• Natural fish oils are better absorbed than purified fish oils. Preliminary evidence suggests that krill oil (KO) may be better absorbed than fish oil, and anecdotal reports indicate that KO may be more effective for some than fish oil for reducing inflammation in some people.
• Many fish oils are made from fish that are endangered. Choose products made from fish that are certified by organizations such as the Marine Stewardship Council.

Introduction

So far in this series we’ve looked at why fish is superior to plant-based sources of omega-3. We’ve examined the importance of reducing consumption of omega-6 fats. We’ve considered how much omega-3 is needed to support health and treat disease. We’ve revealed that concerns about the safety of fish consumption have been overblown, and that eating fish regularly is not only safe, but incredibly beneficial. And in the previous article we compared the benefits of eating fish to taking fish oil.

In this final article of the series we’re going to take a closer look at fish oil. Fish oil has become wildly popular these days. Most people who are at least relatively health conscious understand that they need omega-3 in their diet, and are probably not getting enough from food (unless they eat a lot of fish).

Health care practitioners have caught on, too. I constantly hear both conventional and alternative practitioners telling their patients to take fish oil. In fact, I was listening to a podcast last week by one popular health and fitness guru in the paleo/primal world, and he advises his clients to take up to 20 grams of fish oil a day. That made me cringe.

Why? Because what most people – including health care practitioners – don’t seem to understand is that not all fish oils are created alike. There’s a tremendous difference in the ingredients, purity, freshness and therapeutic benefit of the fish oils available today. The supplement industry is rife with false claims and unsavory companies that are far more interested in profiting on the fish oil craze than they are in your health and well-being.

Recommending that people take up to 20g/d of fish oil without conveying the importance of choosing a high quality fish oil, and teaching them how to do that, is irresponsible and possibly dangerous. Taking 20g/d of a poor quality, oxidized fish oil could dramatically increase oxidative damage and inflammation – which is of course exactly the opposite of the desired effect.

In this article, I’ll focus more on dispelling common misconceptions about fish oil and helping you to choose the best product for your needs.

Factors to consider when buying fish oil

There are seven primary variables to be aware of when shopping for a fish oil:

1. Purity. The oil must meet international standards for heavy metals, PCBs, dioxins and other contaminants. Many do not – even when they claim they do.
2. Freshness. Omega-3 oils are susceptible to oxidation, which makes them rancid. Rancid oils are pro-inflammatory and contribute to the diseases you’re trying to relieve or prevent by taking fish oil in the first place!
3. Potency. In order to have the desired anti-inflammatory effect, fish oil must contain an adequate amount of the long-chain omega-3 derivatives EPA and DHA. DHA is especially important.
4. Nutrients. All fish oils contain some amount of EPA and DHA. However, fish liver oil (from cod, skate or shark) also contains naturally occurring fat-soluble vitamins that are difficult to obtain from foods.
5. Bio-availability. The ability to absorb the beneficial components of fish oil is based on the molecular shape of the fatty acids. The more natural the structure the better.
6. Sustainability: The fish should be harvested in a sustainable manner and species that are under threat should be avoided.
7. Cost: the product must be relatively affordable to be practical for most people.

Purity

Many species of fish are known to concentrate toxic chemicals like heavy metals, PCBs, and dioxins which can cause serious disease, especially in children and developing fetuses. In a previous article I explained how these chemicals are typically not a concern when eating whole fish, because fish also contain selenium. Selenium binds to mercury and makes it unavailable to tissues, thus protecting against any damage it may cause.

And while fish constitute only 9% of our dietary intake of dioxins and PCBs, high doses of fish oils taken every day (as is often recommended) may raise this percentage significantly and expose us to undesirable levels of these toxins.

To address this, fish oil manufacturers use a process called molecular distillation to remove the toxins from the oil. When done correctly, molecular distillation is capable of reducing the toxins in fish oil to levels considered to be safe by the EPA and other agencies.

Although almost any fish oil manufacturer will tell you their product is free of these toxins, independent lab analyses tell a different story. Just last month (March, 2010), a lawsuit was filed in California court against the manufacturers of ten popular fish oils because they contained undisclosed and (possibly) unsafe levels of contaminants.

Unfortunately, this kind of deception is all too common in the supplement industry. That’s why it’s essential that you ask for something called a Certificate of Analysis (COA) from the manufacturer before you buy their product. A COA is an analysis performed by an independent lab to measure the ingredients of a product and confirm whether it lives up to the claims made by the manufacturer.

If the manufacturer won’t provide a COA, I start to get suspicious. This is standard practice in the industry and there’s no reason they shouldn’t be happy to show you theirs. Make sure that the independent lab they use is in fact independent and is preferably accredited, sponsored by a government agency, or has a solid reputation in the field.

This may seem like unnecessary paranoia, but when it comes to the possibility of ingesting powerful neurotoxins, it pays to do your homework.

In general, fish that are lower on the food chain like sardines and anchovies naturally have a lower concentration of contaminants. For this reason, it may be wise to look for a product made from these fish.

So what levels of these toxins are safe? As you might imagine, there is some disagreement on this question since there is no single governing body that determines acceptable levels. However, the standards that are most often followed by fish oil manufacturers are summarized in the table below.

* ppt = parts per trillion
* ppb = parts per billion

In a previous article we discussed selenium’s protective effect against mercury toxicity. If you are taking large doses of fish oil, and not eating any whole fish, it may be wise to ensure another regular source of selenium. Brazil nuts are by far the highest dietary source, with 1917mcg of selenium per 100g. (But they are also very high in n-6, so watch out!)

Freshness

I have written extensively about the dangers of oxidized, rancid oils. They promote oxidative damage and increase inflammation, both of which are risk factors for nearly every modern disease. The more unsaturated an fat is, the more vulnerable it is to oxidation. Long-chain, omega-3 fats found in fish oil are the most unsaturated of the fats, and thus the most susceptible to being damaged.

This is why it’s absolutely crucial to ensure that the fish oil you select is fresh and not rancid. Once it has gone rancid, it will have the exact opposite effect on your body than you want it to.

The first thing to do is to check something called the “peroxide value” on the COA. This is a measure of rancidity reactions in the oil that have occurred during storage. and should be less than 5 meq/kg.

If this checks out, and you decide to order that product, break open a capsule once you receive it. There should be no “fishy” odors. They should smell like the ocean, but not like a rotten fish. They should also not have a strong lemon or lime scent, which could be an indicator that the manufacturer is trying to mask the rancidity.

A common misconception is that you can determine the quality of a fish oil by freezing it. The theory goes that if you freeze the oil and it is cloudy, it’s rancid. That is not the case. All fish contain saturated and monounsaturated fatty acids, albeit in small amounts. These fatty acids make the capsules appear cloudy when frozen in products that contain whole fish oil (i.e. Vital Choice’s Wild Salmon Oil).

Potency

This is another area surrounded by significant controversy. Some argue the levels of individual constituents in fish oil aren’t paramount. Scientists discovered the healthful effects of omega-3s by studying people with fish-heavy diets, before supplemental fish oil even existed. Clinical trials using supplemental fish oils over the past few decades have contained widely variable levels of both long-chain omega-3 derivatives (EPA and DHA), and not super-high concentrations of either or both.

However, due to poor conversion of ALA to EPA and DHA, unless you are eating fish it is very likely you are deficient in long-chain omega-3s.

Following this line of reasoning, the DHA content in particular of fish and fish oils does seem important if we wish to obtain the best possible therapeutic effect. Many recent studies demonstrating the anti-inflammatory potential of fish oil used a daily dosage of DHA in the range of 1-3 grams. What’s more, foods like salmon roe that have been prized by traditional cultures for their nourishing and healing effects contain large amounts of DHA. A single 6 oz. serving of salmon roe contains 1 g of DHA. (In fact, this would be the best way by far of supplementing with DHA if money were no object. (Unfortunately, wild salmon roe goes for about $28/serving.)

The suggested DHA dose will of course depend upon the condition being treated. If you have a chronic inflammatory condition (heart disease, arthritis, Crohn’s or ulcerative colitis, etc.) I would suggest taking between 1 and 2 grams per day. If you are taking it simply for health maintenance, 500 mg is probably sufficient.

Unfortunately, many fish oils do not have significant amounts of DHA. This means you’d have to take an impractically high number of capsules each day to obtain the therapeutic dose. This is not desirable, since all unsaturated oils (including fish oils) are subject to oxidative damage. We don’t want to take large quantities of them for this reason.

Remember to check the label and ensure that your product has approximately 200-300 mg of DHA per capsule. This will allow you to achieve the therapeutic dose by taking no more than 3 capsules twice a day.

Nutrients

All fish oils contain some amount of EPA and DHA, the long-chain omega-3 derivatives that provide the majority of the anti-inflammatory benefits seen in studies. However, fish liver oils (from cod, skate or shark) contain significant amounts of vitamins A and D in addition to EPA and DHA. Vitamins A and D are fat-soluble nutrients that are crucial to human health. Vitamin D, in particular, is difficult to obtain from commonly eaten foods – especially now that eating seafood carries a much higher risk of contamination with toxins.

Fermented cod liver oil is even more beneficial, because it contains vitamin K2. Vitamin K2 has been called “the missing nutrient” because it was only recently discovered, and many people are deficient in it.

It has been commonly believed that the benefits of vitamin K are limited to its role in blood clotting. Another popular misconception is that vitamins K1 and K2 are simply different forms of the same vitamin – with the same physiological functions.

New evidence, however, has confirmed that vitamin K2’s role in the body extends far beyond blood clotting to include protecting us from heart disease, ensuring healthy skin, forming strong bones, promoting brain function, supporting growth and development and helping to prevent cancer – to name a few.

Cod liver oil was traditionally processed by fermentation, which is likely to make it more absorbable and bio-available. Processing by fermentation also avoids the use of heat, which can damage the fragile fatty acids and cause fish oils to go rancid. Unfortunately, I am aware of only one company that sells fermented cod liver oil at this time (see below).

Bio-availability

The ability to absorb the beneficial components of fish oil is based on the molecular shape of the fatty acids. In short, the more natural the structure and the less it is chemically altered, the better.

This is true for any nutrient, of course, and it explains why I am always in favor of obtaining nutrients from food or food-based sources when possible. Each additional step in processing from the natural state of a food to extract or isolate nutrients introduces the potential of damaging the nutrient, or changing it’s chemical form so that it’s more difficult to absorb or affects the body in a different way.

When it comes to fish oils, there are three forms currently available on the market:

1. Natural triglyercide oil. This is what you get when you “squeeze” the whole fish and extract the natural oil from it. It is the closest to eating fish oil in its natural form, and is highly bioavailable. The drawback of this form is that, because it’s not concentrated, it usually has low levels of EPA and DHA. And because it isn’t purified, it can have high levels of contaminants such as heavy metals, PCBs, and dioxins.
2. Ethyl ester oil. Occurs when natural triglyceride oil is concentrated and molecularly distilled to remove impurities. The ester form is still in a semi-natural state because it is the result of a process that naturally occurs in the body. The advantage to this form is that it can double or triple the levels of EPA and DHA.
3. Synthetic triglyceride oil. This form occurs when natural triglycerides are converted to ethyl esters for concentration (as above), but then re-converted into synthetic triglycerides. The original position of the triglyceride’s carbon bonds change and the molecule’s overall structure is altered, which impacts the bioavailability of the oil.

Studies on absorption of the various types of fish oil suggest that, unsurprisingly, the natural triglyceride form is absorbed better than the ethyl ester form, which in turn is absorbed better than the synthetic triglyceride form.

One study by Lawson & Hughes in 1988 showed that 1 gram of EPA and 0.67 grams of DHA as natural triglycerides were absorbed 3.4 and 2.7 fold as well as the ethyl ester triglycerides.

In the previous article we saw that fish oils were better absorbed when taken with a high-fat meal. In another study by Lawson & Hughes later the same year, they showed that the absorption of EPA & DHA from natural triglycerides improved from 69% with a low-fat meal (8g total fat) to 90% with a high-fat meal (44g total fat). Absorption of both EPA and DHA from ethyl ester oils was increased three-fold from 20% with a low-fat meal to 60% with a high fat meal.

What about krill oil?

In addition to the three types of fish oil listed above, there is another type of oil that provides EPA & DHA: krill oil. Krill oil (KO) is extracted from Anarctic krill, Euphausia superba, a zooplankton crustacean rich in phospholipids carrying EPA and DHA. Krill oil also contains various potent antioxidants, including vitamins A & E, astaxanthin, and a novel flavonoid whose properties are not yet fully understood.

Krill oil has a unique biomolecular profile that distinguishes it from other fish oils. While EPA and DHA in fish oils comes in the form of triglycerides, the EPA and DHA is already incorporated into phospholipids, which facilitates the passage of the fatty acids through the intestinal wall. This increases the bioavailability of the EPA and DHA and improves absorption and assimilation.

Werner et al demonstrated essential fatty acids in the form of phospholipids were superior to essential fatty acids as triglycerides in significantly increasing the phospholipid concentrations of EPA and DHA in mice.

In a human study, Bunea et al compared the effect of krill oil and fish oil on blood lipids, specifically total cholesterol, triglycerides, LDL, and HDL. Krill oil was given at dosages of 1g/d, 1.5g/d, 2g/d or 3g/d, and fish oil was given at a single dose of 3g/d. The authors found the following:

• KO at a daily dose of 1g, 1.5g, 2g or 3g achieved significant reductions of LDL of 32%, 36%, 37% and 39% respectively. Patients treated with 3g fish oil daily did not achieve a significant reduction in LDL.
• HDL was significantly increased in all patients receiving KO. HDL increased 44% at 1g/d, 43% at 1.5g/d, 55% at 2g/d and 59% at 3g/d. Fish oil taken at 3g/d increased HDL by only 4%.
• KO did not decrease triglycerides significantly at 1g and 1.5g. However, KO reduced triglycerides by 28% at 2g/d and 27% at 3g/d. Fish oil at 3g/d did not achieve a significant reduction of triglycerides.
• Blood glucose levels were reduced by 6.3% in patients receiving 1g/d and 1.5g/d of KO, and 5.6% in patients receiving 2g/d and 3g/d of KO. A daily dose of 3g of fish oil reduced blood glucose by 3.3%.

Thus, in this study krill oil led to a significantly greater improvement in blood lipids compared to fish oil.

Note that the dosage of KO that obtained the best results, either 2g/d or 3g/d, is quite high. However, study participants received a maintenance dose of 0.5g/d for another 12 weeks after the therapeutic period of the study ended. These patients maintained the reductions in total cholesterol they attained in the study, and LDL, triglycerides and blood glucose were further reduced from baseline. There was a moderate decrease (of 3%) in HDL, but HDL was still significantly increased from baseline.

There is also unpublished research suggesting that 300 mg/d of KO reduces biochemical and subjective measures of inflammation and improves joint function and mobility in patients with rheumatoid arthritis (RA).

However, as this research is not published or peer-reviewed, and was sponsored by Neptune Technologies (the manufacturer of Neptune Krill Oil (NKO), I am cautious about interpreting its results.

So what does all of this information about bio-availability tell us?

1. Taking fish oil capsules with a high-fat meal is essential to improve absorption of EPA and DH.
2. Even when taken with a high-fat meal, ethyl ester oils are absorbed only 66% as well as natural triglyceride oils.
3. Krill oil appears to significantly improve blood lipids when compared to fish oils, possibly because of its unique phospholipid structure.

Sustainability

The sustainability of fish oil production is difficult to gauge. Some oils are produced as a byproduct of fish harvesting, and manufacturers claim that they are simply making use of something that would normally be discarded. While this is certainly better than harvesting fish solely for their oil, it still supports harmful fishing practices.

The safest bet is to only use fish oil that is made from fish that are certified by MSF or a similar organization, such as the Environmental Defense Fund. Vital Choice Wild Salmon Oil is one example, as is Jarrow Max DHA (which is made from anchovies and sardines, both of which are generally regarded as safe to eat from an environmental standpoint).

Cost

I cover cost in the recommendations section below.

Recommendations

Which product you might choose from this list depends in large part upon what your goals are.

I have provided product recommendations in two different categories: baseline, and supplemental. Those wishing to to maintain health and ensure adequate nutrient intake should choose a product from the “baseline” category. Those who are dealing with a chronic inflammatory condition should also choose a product from the baseline category, but should consider adding a product from the “supplemental” category.

However, keep in mind that the absorption of the natural triglyceride oils (like the Wild Salmon Oil and Fermented Cod Liver Oil below) will be 1.5 times greater than the ethyl ester oils in the supplemental section. As a rule of thumb, all purified and molecularly distilled oils are ethyl esters.

This means you have to take 1.5 times as much of the ethyl ester oils to get the same dose of DHA that you’d get from the natural triglyceride oils. For example, Vital Choice Wild Salmon Oil has 220 mg DHA per serving. To get the same amount of DHA from Jarrow Max DHA, which is an ethyl ester oil, you’d have to take a serving that provides 333 mg of DHA.

Baseline

Green Pastures Fermented Cod Liver Oil and Butter Oil Blend (GP FCLO)

Ingredients: about 270 mg omega-3 (about 139 mg EPA, 83 mg DHA), about 1,100 IU vitamin D, about 2,300 IU vitamin A. Values listed are approximate (see disadvantages).

Price: $47.00 for 120 capsules, 2 capsules per serving. $0.78/serving.

Advantages: a whole-food product in its natural form, rather than a supplement. Is relatively low in EPA & DHA compared to other products, but contains high levels of vitamin D, as well as vitamins A & K. The fat soluble vitamins A, D & K2 are important co-factors and likely improve the absorption and assimilation of EPA & DHA. Addition of grass-fed butter oil increases levels of K2. Cold-processed with fermentation, which means this is the least oxidized product available.

Disadvantages: levels of PCBs are posted on Green Pastures’ website here, but I’ve been unable to obtain information on heavy metals or dioxins. The EPA and DHA levels are what would be expected in a whole food product, but may not be high enough for a significant anti-inflammatory effect. Values for vitamins A, D, EPA and DHA are approximate and vary batch to batch due to fermentation processing method. Peroxide values are not provided, but because it is processed without heat they are likely to be very low.

Notes: because fermented cod liver oil contains vitamins A, D and K2 in addition to EPA and DHA, and because most people are deficient in some or all of these nutrients, this is currently the only product I recommend to everyone – patients, family and friends – regardless of their health status.

Vital Choice Wild Salmon Oil (VC WSO)

Ingredients: 600 mg of omega-3 (240 mg EPA, 220 mg DHA), 340 IU vitamin D, 2,060 IU vitamin A (per 3 1,000 mg softgels).

Price: $40 bottle, 180 capsules. 3 capsules/serving, $0.68/serving.

Advantages: processed without heat using micro-filtration, which retains naturally occurring vitamins A and D. Fatty acids are in their natural triglyceride form, which makes them more absorbable. Also contains astaxanthin, which protects the oil from oxidative damage and rancidity. Contains more EPA and DHA than GP FCLO. Nutrient levels are more consistent from batch to batch and certification is performed by independent, not-for-profit organization (NSF International).

Disadvantages: when compared to GP FCLO, does not have vitamin K2 and the dose of vitamin D is significantly lower. Otherwise no disadvantages.

Supplemental

Jarrow Max DHA

Ingredients: 600 mg of omega-3 (250 mg DHA, 36 mg EPA) per capsule; one capsule is one serving.

Price: $14.85 (at Vitacost) for 180 capsules. $0.08/serving.

Advantages: even after considering the differences in absorptions between Jarrow Max (an ethyl ester) and the two natural triglyceride oils listed above, Jarrow Max is significantly cheaper. It’s possible to get 1g/d of DHA for $0.32. Made with anchovies and sardines, both of which are naturally low in contaminants. Jarrow faxed me their certificate of analysis, which checked out fine. This is a good choice for those wishing a high-dose of DHA in addition to eating fish or taking one of the natural triglyceride oils above.

Disadvantages: has a 7:1 ratio of DHA to EPA. Although I believe DHA to be more beneficial than EPA, the research is mixed on this and some people report that they do better with EPA.

V-Pure Vegetarian DHA

Ingredients: 350 mg DHA, 50 mg EPA per serving, 2 capsules per serving.

Price: $21.95 for 60 capsules. $0.73 per serving.

Advantages: I received several emails from vegetarians asking me what I recommended they do to meet DHA needs. This is a DHA/EPA blend derived from marine algae, which is where oily fish get EPA & DHA in the first place. The algae in this product is organically grown and 100% free of toxins and contaminants. The capsules are quite small and can be easily swallowed.

Disadvantages: I haven’t seen much research on the marine-algae DHA/EPA blends. Although it’s plausible to assume their effects would be similar to fish oils, I’d like to see some studies backing that up. Likewise, I don’t know much about V-Pure as a company. Another potential issue is that the capsules have carrageenan in them, which has been shown to exacerbate intestinal inflammation in several studies. People with gut problems like IBS and IBD may want to avoid this product. Finally, at $0.73/serving this product is expensive. To get a therapeutic dose of 1g/d taking this alone, you’d have to take 9 capsules per day which be 4.5 bottles/month, or almost $100!

Tentatively Recommended

Neptune Krill Oil

Ingredients: 300 mg of omega-3 (90 mg DHA, 150 mg EPA) per serving, two capsules per serving.

Price: $16.86 for 60 capsules. $0.56/serving, 2 capsules per serving.

Advantages: KO has a unique phospholipid structure that appears to improve the absorption of EPA & DHA. At least one study suggests that KO is superior to fish oil in improving blood lipids. KO also contains vitamins E & A, as well as astaxanthin, an antioxidant claimed to be 10 times more potent than other carotenoids. KO capsules are much smaller than fish oil capsules, are easier to swallow, and many report they don’t cause the burping common with other fish oil capsules. Several anecdotal reports suggest that krill oil can be more effective than fish oil in reducing inflammation for some people.

Disadvantages: there are few studies demonstrating the effectiveness of KO, whereas fish oil has decades of research behind it. Most of the studies that do exist on KO were sponsored by Neptune, the largest manufacturer of KO. The dosages used in the study on KO and blood lipids were very high, and taking KO at those dosages would be expensive. (However, the therapeutic dose of 2-3g/d would only be necessary for 12 weeks, as the maintenance dose of 0.5g seemed to maintain the benefits attained during the therapeutic period.) The sustainability of krill harvesting is controversial.

The reason KO gets a tentative recommendation is that there’s still comparatively little research supporting its use, and because I am still uncertain about the environmental impact of harvesting the krill for the oil. If you have information to share on either of these questions, I’m all ears!

I want to get some Juno-inspired T-shirts printed up for researchers that say “What other kind of shenanigans can I get into?” Seriously. I cannot believe the stuff that gets published in medical journals these days. I don’t know which is the scarier possibility: that the researchers are really so poorly trained that they consistently violate the most basic principles of medical research (that you probably learned in your 8th grade science class), or that they are so dishonest that they intentionally and blatantly lie about their results.

A prime example of this is an article that came across my newsfeed a couple of days ago. The headline read “High fat diet during pregnancy leads to severe liver disease“. I’m always very, very suspicious when I see articles like this because of my previous experience evaluating such studies. All too often researchers make basic (and frankly, inexcusable) mistakes like lumping all fat types together (i.e. combining saturated fat with polyunsaturated fat, although the two fatty acids have completely different effects on human physiology).

I didn’t have time to review the study and write about it, so I emailed Chris Masterjohn, a researcher pursuing a PhD in Nutritional Sciences with a concentration in Biochemical and Molecular Nutrition at the University of Connecticut. Chris has a blog called The Daily Lipid where he writes about the benefits of saturated fat and the dangers of polyunsaturated fat. Turns out Chris had seen the article on ScienceDaily too and was planning to write a critique. Here’s what he wrote. I encourage you to check out his blog, and also his website, both of which have some great information about the health benefits of cholesterol and saturated fat.

I’ve received several questions about the safety of cod liver oil (CLO) since the Vitamin D Council warned consumers about the ingestion of CLO due to concerns about potential vitamin A toxicity in their November bulletin.

Sally Fallon, president of the Weston A. Price Foundation, recently wrote a letter to members clarifying the issues raised by the Vitamin D council and exonerating cod liver oil.

If you’re having second thoughts about the health benefits of CLO, please read this and pass it on to anyone you know who currently takes or is considering taking cod liver oil.

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Dear Members,

We are obliged to issue another official statement on cod liver oil after the November bulletin of the Vitamin D Council, which contains “an unprecedented warning about the ingestion of cod liver oil and resultant vitamin A toxicity.”

The warning accompanies a report on a review article co-authored by Dr. John Cannell, head of the Vitamin D Council, and fifteen other researchers, entitled “Cod Liver Oil, Vitamin A Toxicity, Frequent Respiratory Infections, and the Vitamin D Deficiency Epidemic” in the November issue of Annals of Otology, Rhinology and Laryngology.

NO PROOF THAT VITAMIN A IS TOXIC
Most of this paper is a review of studies showing the benefits of vitamin D in protecting against various illnesses, including respiratory infection. THIS PAPER DOES NOT PRESENT ANY INFORMATION WHATSOEVER INDICATING THAT COD LIVER OIL IS TOXIC, and, in fact, admits that vitamin A can significantly reduce the incidence of acute lower respiratory tract infections in Third World children.

A portion of the review article is an attempt to explain why a 2004 study providing 600 to 700 IU of vitamin D and 3,500 IU of vitamin A in the form of cod liver oil and a multivitamin failed to meaningfully reduce upper respiratory tract infections when studies from the 1930s found that cod liver oil could reduce the incidence of these infections by 30 to 50 percent. The authors of the recent commentary suggested that the older studies were more effective because cod liver oil in the 1930s contained much more vitamin D. They suggested that modern cod liver oil is low in vitamin D because the deodorization process removes the vitamin while manufacturers fortify the oil with only a fraction of the original amount. As an example, they cited cod liver oil made by Nordic Naturals, advertised as containing only “naturally occurring vitamins A and D,” which has only 3 to 60 IU of vitamin D per tablespoon but between 150 and 12,000 times as much vitamin A.

This conclusion is essentially the same as the conclusion reached by the Weston A. Price Foundation and the research of Chris Masterjohn; we have continually pointed out that vitamins A and D work together and that without vitamin D, vitamin A can be ineffective or even toxic. We do not recommend Nordic Naturals regular cod liver oil or any brand of cod liver oil that is low in vitamin D. But it is completely inappropriate to conclude from this 2004 study that cod liver oil is toxic because of its vitamin A content. Similar reviews could be put together showing the benefits of vitamin A and cod liver oil in numerous studies, including the studies from the 1930s. Obviously the solution is to use the type of cod liver oil that people took in the 1930s, which did not have most of the vitamin D removed by modern processing techniques.

Our recommendations for cod liver oil brands can be found here.

VITAMIN A DOES NOT ANTAGONIZE VITAMIN D
The Vitamin D Council report claims that the vitamin A in cod liver oil is excessive and antagonizes vitamin D by inhibiting the binding of its active form to DNA and thus preventing its ability to regulate the expression of vitamin D-responsive genes.

Vitamins A and D are both precursors to active hormones that regulate the expression of genes. The body possesses certain enzymes that convert each of these in a two-step process to their active forms: vitamin A is converted to retinal and then to active retinoic acid while vitamin D is converted to calcidiol and then to active calcitriol. While directly consuming either retinoic acid or calcitriol would be unnatural, consuming vitamins A and D, together, as in cod liver oil, is perfectly natural. The enzymes involved in these conversions are responsible for producing incredibly powerful hormones and are therefore highly regulated.

In order for vitamin D to activate the expression of its target genes, it must bind to the vitamin D receptor (VDR) and then combine with the retinoid X receptor (RXR), which is activated by a particular form of vitamin A called 9-cis retinoic acid. RESEARCHERS FROM SPAIN RECENTLY SHOWED THAT VITAMIN D CAN ONLY EFFECTIVELY ACTIVATE TARGET GENES WHEN ITS PARTNER RECEPTOR IS ACTIVATED BY VITAMIN A.

In the ABSENCE OF VITAMIN A, molecules called “corepressors” bind to the VDR/RXR complex and PREVENT vitamin D from functioning.

The molecular biology of 9-cis¬ retinoic acid, however, is extremely complex, and this has led to some confusion. The RXR and its activator 9-cis retinoic acid partner up not only with the vitamin D receptor, but also with the receptors for steroid hormones, thyroid hormone, and most other nuclear receptors. In fact, if enough 9-cis retinoic acid is present, RXRs will even partner up with themselves. Ordinarily, this versatile form of vitamin A is gradually derived in small amounts from the larger pool of all-trans retinoic acid as needed. When scientists add large amounts of 9-cis retinoic acid to isolated cells, then, it may cause effects that smaller amounts naturally produced in the cell would not cause.

Researchers have shown, for example, that 9-cis retinoic acid interferes with the ability of vitamin D to stimulate the production of osteocalcin, a vitamin K-dependent protein involved in organizing the mineralized matrix of bone. This may have been because the excessive amount of 9-cis retinoic acid caused RXRs to pair up with themselves and thereby made these receptors unavailable to vitamin D. When scientists incubate cells with activated vitamin D and all-trans retinoic acid, ordinarily the source of 9¬-cis retinoic acid in the cell, the two hormones stimulate the production of osteocalcin with remarkable synergy.

More information on the interactions between vitamins A and D can be found in these articles:

Vitamin K2

Does Vitamin A Cause Osteoporosis?

Vitamin D Safety

The Spanish research demonstrating the necessity of 9-cis¬ retinoic acid for the functioning of the vitamin D receptor can be found here, and here:

PLANT FOODS ARE NOT A GOOD SOURCE OF VITAMIN A
In the December Vitamin D Council newsletter, Dr. Cannell further claims that consuming preformed vitamin A is “unnatural” and that the body highly regulates the conversion of carotenoids found in vegetables to vitamin A as needed. However, the enzymes that convert carotenoids to vitamin A are less critically maintained because they are unneeded when preformed vitamin A is provided in the diet-as it usually is. They are therefore, like the enzymes that convert essential fatty acids in plant oils to their elongated and desaturated forms, subject to variations in genetics, circumstantial health, and dietary and environmental influences.

Many factors can interfere with the conversion of carotenoids into vitamin A including thyroid problems, liver problems, diabetes and genetics. Babies and children convert carotenes very poorly if at all.

The statement that preformed vitamin A is unnatural is ludicrous in the light of what we know about traditional diets. The chief source of calories in the traditional Inuit diet, for example, is seal oil, which Weston Price found to be higher in vitamin A than cod liver oil. Fish heads, extremely rich in vitamin A, are a staple in the Japanese diet. Many cultures consume liver, often in high amounts-yet the authors of the review paper imply that liver is toxic. Tell that to the Frenchman enjoying his foie gras, the Englishman consuming liver and onions, or the South Sea Islander who submits to great danger to obtain shark liver for men and women, in order to ensure healthy children. The truth is that pre-formed vitamin A is more plentiful in traditional foods than vitamin D, yet politically correct nutrition insists that we must obtain vitamin A through the laborious process of converting carotenes.

More information on the conversion of carotenoids to vitamin A can be found in this article and this one: (see the section “Vitamin A Vagary”).

COD LIVER OIL IN PREGNANCY
The Annals paper does not cite any studies showing toxic effects from cod liver oil, but Dr. Cannell cites one study in his December newsletter associating intake of cod liver oil with hypertensive disorders during pregnancy. Users of cod liver oil in this study had about twice the intake of vitamins A and D as non-users and eight times the intake of long-chain omega-3 fatty acids. The study found the most robust association with long-chain omega-3 fatty acids, which were associated with lower risk between 0.1 and 0.9 grams per day and higher risk above 0.9 grams per day. The authors suggested that the association with high blood pressure might be related to oxidative stress caused by a high intake of polyunsaturated fatty acids.

The abstract of the study can be found here:

The new Annals article offers nothing new to incriminate cod liver oil. It provides a well-written argument that vitamin D intakes need to be higher and incriminates only highly processed modern cod liver oils that have inadequate amounts of this critical nutrient. We recommend only high-vitamin cod liver oils that provide abundant vitamins A and D without an excess of polyunsaturated fatty acids.

THE COD LIVER OIL PUBLIC HEALTH INITIATIVE
As we pointed out in our last update on cod liver oil, during the first half of the century, cod liver oil was the focus of a worldwide health initiative. Parents were urged to give cod liver oil to their children by doctors, by government officials, by teachers and principals in schools, and even by their ministers in churches. A large portion of adults in America born before the Second World War received cod liver oil as children and this practice contributed to a high level of health, intelligence and physical development in those lucky enough to receive it. In many European countries, children received a daily ration of cod liver oil, especially during the war years. In the UK, for example, the government issued cod liver oil to all growing children until the early 1950s.

What has led to the demise of this obviously beneficial practice? Cod liver oil is a food; it can’t be patented, it can’t be created in a laboratory; it can’t create millions for the drug companies. So interest in this wonderful superfood has naturally waned. But if you are basing your dietary habits on the principles of healthy nutritional diets, don’t hesitate to include cod liver oil-our recommended brands of cod liver oil–as a healthy and natural food source of critical vitamins so lacking in modern diets.

Sally Fallon, President
The Weston A. Price Foundation

recommended links

• Dr. Ron’s: a great place to purchase Blue Ice High Vitamin and Fermented Cod Liver oil.  I also like Dr. Ron’s line of additive-free supplements.

Conventional dietary wisdom holds that the micronutrients (vitamins, minerals and trace elements) we need from foods are most highly concentrated in fruits and vegetables. While it’s true that fresh fruits and veggies are full of vitamins and minerals, their micronutrient content pales in comparison to what is found in meats and organ meats – especially liver.

The chart below lists the micronutrient content of apples, carrots, red meat and beef liver. Note that every nutrient in red meat except for vitamin C surpasses those in apples and carrots, and every nutrient—including vitamin C—in beef liver occurs in exceedingly higher levels in beef liver compared to apple and carrots. In general, organ meats are between 10 and 100 times higher in nutrients than corresponding muscle meats.

In fact, you might be surprised to learn that in some traditional cultures, only the organ meats were consumed. The lean muscle meats, which are what we mostly eat in the U.S. today, were discarded or perhaps given to the dogs.

A popular objection to eating liver is the belief that the liver is a storage organ for toxins in the body. While it is true that one of the liver’s role is to neutralize toxins (such as drugs, chemical agents and poisons), it does not store these toxins. Toxins the body cannot eliminate are likely to accumulate in the body’s fatty tissues and nervous systems. On the other hand, the liver is a is a storage organ for many important nutrients (vitamins A, D, E, K, B12 and folic acid, and minerals such as copper and iron). These nutrients provide the body with some of the tools it needs to get rid of toxins.

Remember that it is essential to eat meat and organ meats from animals that have been raised on fresh pasture without hormones, antibiotics or commercial feed. Pasture-raised animal products are much higher in nutrients than animal products that come from commercial feedlots. For example, meat from pasture-raised animals has 2-4 times more omega-3 fatty acids than meat from commercially-raised animals. And pasture-raised eggs have been shown to contain up to 19 times more omega-3 fatty acids than supermarket eggs! In addition to these nutritional advantages, pasture-raised animal products benefit farmers, local communities and the environment.

For more information on the incredible nutritional benefits of liver and some suggestions for how to prepare it, click here.