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Omega-3: Study published in BMJ claiming no benefit for type 2 diabetes has myopic vision

Most respondents in the omega-3 study published in the BMJ are from Europe and North America; such results can hardly be applied worldwide

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Prateek Dasguptahttps://www.sirfnews.com
Founder of Rebel Health and Fitness Solutions, combat sports enthusiast, history and culture nerd and lifelong seeker of knowledge

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A recent study published in the British Medical Journal (BMJ) claimed that consumption of omega-3 fatty acids had little to no effect on the prevention and reducing the risk of type 2 diabetes[I]Omega-3, omega-6, and total dietary polyunsaturated fat for prevention and treatment of type 2 diabetes mellitus: systematic review and meta-analysis of randomised controlled trials in BMJ 2019;366:l4697. Are these claims true and should physicians and dieticians decide their dietary recommendations based on this study? A major limitation of this study is the fact that they have investigated the effect of omega-3 on glucose metabolism, a rather myopic view of type 2 diabetes.

Most respondents of the study are from Europe and North America. Can such results be applied worldwide? The effect of omega-3 on triglyceride levels and their connection with type 2 diabetes were not a part of this study — although the study acknowledges the role of omega-3 fatty acids in lowering triglyceride levels.

The larger recommendation appears also to be against omega-3 in general as the study does not mention the role of omega-3 in reducing the rate of heart disease. It is a contentious topic, nonetheless, connected with type 2 diabetes.

The focus on glucose metabolism might be inadequate to provide a recommendation against the consumption of omega-3, given the plethora of scientifically proven health benefits that long-chain fatty acids have. This begs the question whether health benefits of omega -3 should be studied with respect to type 2 diabetes alone. This begs a further question whether type 2 diabetes should be viewed in isolation to obesity, hypertension and cardiovascular diseases?

Critical analysis of the omega-3 study

Our body requires two types of essential fatty acids; they are the n-6 fatty acids (omega-6) and n-3 (omega-3) fatty acids and it must be provided through our diet. The reason these fatty acids are essential is that mammals are unable to produce them in their body, unlike plants. Among these, omega-3 fatty acids particularly have multiple proven health benefits.

Omega-3 fatty acids are of three types of alpha-linolenic acid (ALA), eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). ALA is found in plant sources such as avocados and walnuts. EPA and DHA are found primarily in animal sources, the only plant sources that have EPA and DHA are seaweed, krill, and algae. Hence, supplementing omega-3 fatty acids through your diet is essential. Unfortunately, fatty fish rich in omega-3 is not always available on a regular basis to the vast majority of people who live in landlocked areas. Hence, fish oil supplementation is crucial not only from a health angle but also from the ease of access perspective.

Omega-3s have multiple health benefits that are backed by science. They play an important role in brain and eye health as DHA alone accounts for 40% of the PUFA in your brain and 60% in your eye[II]D Tassoni, G Kaur, RS Weisinger, AJ Sinclair’s The role of eicosanoids in the brain. Asia Pac. J. Clin. Nutr. 2008;17:220–228.. Omega-3s are linked to improved eye health and they prevent macular degeneration, which is the number one cause for blindness in the world[III]Bénédicte M. J. Merle; Pascale Benlian; Nathalie Puche; Ana Bassols; Cécile Delcourt; Eric H. Souied Circulating omega-3 Fatty Acids and Neovascular Age-Related Macular Degeneration Investigative Ophthalmology & Visual Science March 2014, Vol.55, 2010-2019. doi:10.1167/iovs.14-1391.

The paper published in the BMJ explores the worldwide epidemic of type 2 diabetes, which affects 400 million adults worldwide and costs a staggering $800 billion[IV]Omega-3, omega-6, and total dietary polyunsaturated fat for prevention and treatment of type 2 diabetes mellitus: systematic review and meta-analysis of randomised controlled trials in BMJ 2019;366:l4697. Previously, effects of omega-3 on type 2 diabetes had remained inconclusive although the reduction in triglyceride levels from anywhere between 15%-30%  is more conclusive[V]Cazzola R1, Russo-Volpe S, Miles EA, Rees D, Banerjee T, Roynette CE, Wells SJ, Goua M, Wahle KW, Calder PC, Cestaro B Age- and dose-dependent effects of an eicosapentaenoic acid-rich oil on cardiovascular risk factors in healthy male subjects Atherosclerosis. 2007 Jul;193(1):159-67. Epub 2006 Aug 1.

In this study, the researchers from the University of East Anglia conducted randomised trials to measure the effect of increasing the dosage of PUFA fats on glucose metabolism [VI]Omega-3, omega-6, and total dietary polyunsaturated fat for prevention and treatment of type 2 diabetes mellitus: systematic review and meta-analysis of randomised controlled trials in BMJ 2019;366:l4697. American Heart Association recommends supplements for adults not eating sufficient oily fish. Now, for countries with large populations like the US, India and China, it is very unlikely that the entire populace would have ready access to oily fish on a regular basis. The Global Burden of Disease data suggest that our consumption of omega-3 fatty acids is below the recommended level[VII]GBD 2016 Risk Factors Collaborators. Global, regional, and national comparative risk assessment of 84 behavioral, environmental and occupational, and metabolic risks or clusters of risks, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet2017;390:1345-422. doi:10.1016/S0140-6736(17)32366-8 pmid:2891911.

The study ran 83 randomised controlled trials covering 1,21,070 participants[VIII]Omega-3, omega-6, and total dietary polyunsaturated fat for prevention and treatment of type 2 diabetes mellitus: systematic review and meta-analysis of randomised controlled trials in BMJ 2019;366:l4697. Half of the participants were in Europe. Now, it should be noted that the study does not mention what the omega-3 consumption of the participants was in the first place and whether they were at or above the recommended levels.

Supplementation with omega-3 might not help people who already obtain at an adequate level of omega-3 from their diet but can this conclusion be applied to a worldwide general population?

While making recommendations for diabetes, it should be noted there is no one factor that contributes to the ailment. Hence, expecting omega-3 as a panacea is rather strange. Omega-3 supplementation has a host of health benefits as discussed above —particularly in lowering the blood triglyceride level deserves a closer look.

Essential fatty acid, its role in lowering triglycerides & countering metabolic syndrome

High triglyceride levels are not the cause of type 2 diabetes. However, if you have high triglycerides, it is an indication of insulin resistance and is likely to indicate a pre-diabetic condition. High triglycerides are associated with metabolic syndrome — a condition in which obesity, high blood pressure and high blood sugar occur together to increase your risk of cardiovascular diseases. Hence, addressing triglyceride levels using a combination of a healthy diet and exercise is crucial to ensuring a metabolic syndrome and avoiding indirectly type 2 diabetes in the future.

Earlier, chronic diseases were individually assessed; now a complex interdisciplinary approach is considered a better option to address chronic diseases. Therefore, viewing type 2 diabetes as an exclusive disease while ignoring metabolic syndrome is a rather myopic view of addressing the disease. We should question whether omega-3 supplementation is part of a healthy diet or not and whether it has a role in reducing the risk of chronic diseases.

Such a study has not been done for the first time. A similar study found no significant changes in glucose metabolism due to increased omega-3 consumption but did observe improved insulin sensitivity[IX]Cai Chen,  Yan Yang,  Xuefeng Yu, 3 Shuhong Hu, and Shiying Shao Association between omega‐3 fatty acids consumption and the risk of type 2 diabetes: A meta‐analysis of cohort studies J Diabetes Investig. 2017 Jul; 8(4): 480–488, Published online 2017 Feb 3.

Should you discontinue the consumption of omega-3?

First, let us look at a few studies where they found the effect of fish oils to lower diabetes among Asians[X]Cai Chen,  Yan Yang,  Xuefeng Yu, 3 Shuhong Hu, and Shiying Shao Association between omega‐3 fatty acids consumption and the risk of type 2 diabetes: A meta‐analysis of cohort studies J Diabetes Investig. 2017 Jul; 8(4): 480–488, Published online 2017 Feb 3. Though these studies were carried out over a relatively shorter period of 12 weeks, they tend to reach an important observation that omega-3 can help at an early stage intervention than for patients who already have type 2 diabetes. But what should a person who is diabetic or has elevated levels of blood sugar do?

Well, the answer is firstly not to expect fish oil capsules to magically lower diabetes. Tackling diabetes requires a proper healthy diet free of processed foods and addressing the underlying hormonal imbalance. Most diabetes researchers across the world do agree that diabetes can be countered with an appropriate diet and exercise regime. Second, after assessing the multitude of benefits that fish oil possesses, one should make it a part of a healthy diet, as the data suggest there are more people in the world who do not meet the recommended daily requirements.

To conclude, viewing dietary advice based on one study is a rather risky proposition. Hence, even if you accept the results of this research, there is no reason to avoid or move away from omega-3 supplements in view of their positive effects on health.

References   [ + ]

I, IV, VI, VIII. Omega-3, omega-6, and total dietary polyunsaturated fat for prevention and treatment of type 2 diabetes mellitus: systematic review and meta-analysis of randomised controlled trials in BMJ 2019;366:l4697
II. D Tassoni, G Kaur, RS Weisinger, AJ Sinclair’s The role of eicosanoids in the brain. Asia Pac. J. Clin. Nutr. 2008;17:220–228.
III. Bénédicte M. J. Merle; Pascale Benlian; Nathalie Puche; Ana Bassols; Cécile Delcourt; Eric H. Souied Circulating omega-3 Fatty Acids and Neovascular Age-Related Macular Degeneration Investigative Ophthalmology & Visual Science March 2014, Vol.55, 2010-2019. doi:10.1167/iovs.14-1391
V. Cazzola R1, Russo-Volpe S, Miles EA, Rees D, Banerjee T, Roynette CE, Wells SJ, Goua M, Wahle KW, Calder PC, Cestaro B Age- and dose-dependent effects of an eicosapentaenoic acid-rich oil on cardiovascular risk factors in healthy male subjects Atherosclerosis. 2007 Jul;193(1):159-67. Epub 2006 Aug 1
VII. GBD 2016 Risk Factors Collaborators. Global, regional, and national comparative risk assessment of 84 behavioral, environmental and occupational, and metabolic risks or clusters of risks, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet2017;390:1345-422. doi:10.1016/S0140-6736(17)32366-8 pmid:2891911
IX, X. Cai Chen,  Yan Yang,  Xuefeng Yu, 3 Shuhong Hu, and Shiying Shao Association between omega‐3 fatty acids consumption and the risk of type 2 diabetes: A meta‐analysis of cohort studies J Diabetes Investig. 2017 Jul; 8(4): 480–488, Published online 2017 Feb 3
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