“The average consumer has no way of determining which supplement is free of contaminants and which isn’t.”

By Abby Ellin, September 18, 2008, The New York Times – LIKE many people these days, Lori Potter, a 50-year-old massage therapist living on Kauai, Hawaii, has explored alternative healing for everything from headaches to skin problems. So when she wanted to boost her immune system and lower her stress levels a few years ago, she made an appointment with a visiting practitioner of ayurveda, a medical system that originated in India thousands of years ago and has gained wide popularity in the United States.

He prescribed herbal supplements, which he tested himself for impurities, to help boost her immunity. Soon, Ms. Potter said, she felt more energetic and her digestion was better. After two years, the practitioner stopped visiting the island, and she has not taken any supplements since, she said, because she has not met any practitioners she trusts.

“You never know what’s really in these supplements,” she said. “This is serious stuff, and you can’t just take them without knowing the source.”

Ms. Potter may be right to be wary. A report in the Aug. 27 issue of The Journal of the American Medical Association found that nearly 21 percent of 193 ayurvedic herbal supplements bought online, produced in both, India and the United States, contained lead, mercury or arsenic. Almost all of the products were sold through American Web sites. “Some manufacturers advertised that they test for metals, and their products still had them,” said Dr. Robert B. Saper, assistant professor at the Boston University School of Medicine and lead author of the study. The average consumer, he said, “has no way of determining which supplement is free of contaminants and which isn’t.”

No one knows the exact numbers of arsenic, mercury or lead poisoning illnesses in the United States related to ayurvedic medicine. Dr. Saper estimated that there have been 80 cases since 1978, but he believes that is just the “tip of the iceberg.” In 2005, the Centers for Disease Control and Prevention reported a total of 12 cases of lead poisoning associated with ayurvedic products in Texas, New Hampshire, Massachusetts, New York State and California.

While the Western medical community may be concerned about Dr. Saper’s findings, many ayurvedic practitioners and holistic health centers are less so. Of the dozen spas, wellness centers and practitioners contacted for this article, all said they stood behind their products. Some suppliers said they believed that the levels of heavy metals in their ayurvedic products were no greater than in many Food and Drug Administration-approved medicines.

Kevin Casey, the chief of Banyan Botanicals, a maker of ayurvedic products in Ashland, Ore., sells three items — mahasudarshan, shilajit and kanchanar guggulu — that are on Dr. Saper’s list of contaminated supplements.

After the study came out, Mr. Casey said, some of his 15,000 clients, who include practitioners and consumers, called. He said he alleviated their fears after he explained that his products are sent to outside laboratories, and they meet “the standards that we adhere to.”

He added that sales had not suffered since the study, which has “created a dialogue — people are talking about it and understanding that there is the presence of heavy metals, but it doesn’t mean it’s toxic or dangerous.”

Dr. Saper disagreed. Even with relatively low levels of lead in the bloodstream, he said, “a person can be relatively asymptomatic but the lead can still impact their I.Q. It can reduce their cognitive function and increase blood pressure.”

Michael McGuffin, president of the American Herbal Products Association, a trade group, said that eliminating every trace of arsenic, mercury or lead from products was not a reasonable goal. “If it was, we’d have to find an entirely new food supply,” he said.

Many Americans get their first taste of ayurveda at spas. A 2006 survey from the International Spa Association reported that about 31 percent of United States spas offer ayurvedic medicine, usually limited to hot oil massages and facials. But some spas with ayurvedic practitioners, including Exhale in Santa Monica, Calif.; the Chopra Center for Well-Being in Carlsbad, Calif., and Manhattan; and the Ayurvedic Rejuvenation and Wellness Center in Manhattan, also recommend that some clients take herbal supplements to boost their immune systems and alleviate everything from depression to acne.

Dawne Burrowes, the director of the Ayurvedic Rejuvenation and Wellness Center, said she bought supplements from manufacturers such as Banyan Botanicals, which has been in business for 12 years. The Chopra Center buys some goods from Bazaar of India, an importer of herbal and ayurvedic products in Berkeley, Calif., and the source of 17 products that Dr. Saper found contained lead, mercury or arsenic.

Dr. David Simon, the medical director of the Chopra Center for Well-Being, said he was satisfied that Bazaar of India sends its products to an independent laboratory and that the herbs they recommend are free from toxic levels of heavy metals.

John Shahani, the ayurvedic practitioner at Exhale Spa in Santa Monica, took a similar position. Two products sold at the spa made by Balance Ayurvedic Products (AyurRelief and GlucoRite) were found by Dr. Saper to contain lead, but Mr. Shahani, who is technical director of Balance, said that he had the products tested by American laboratories and was not worried about their safety. “We know everything that goes into our products,” he said, adding that he has certificates from the labs to ensure that the products are lead-free.

Kush Khanna, the president of Bazaar of India, defended the safety of the 17 products that Dr. Saper listed. All of the items, said Mr. Khanna in an e-mail message, have levels of contaminants below the safety levels recommended by the World Health Organization.

Mr. Khanna declined to explain why some, but not all, of the offending products are no longer on his Web site. He said business had not suffered since the study was released.

The F.D.A. does not specify maximum acceptable concentrations or daily dose limits for contaminants in dietary supplements. Instead, the onus is on the manufacturer to ensure that its products are safe. What’s more, there are no universally accepted standards for herbal supplements. The Food and Agricultural Organization/World Health Organization Joint Expert Committee on Food Additives Secretariat recommends that a 70-kilogram, or 154-pound, person consume no more than 250 micrograms of lead, 50 micrograms of mercury and 150 micrograms of arsenic per day.

The National Sanitation Foundation International Dietary Supplement Standard, which certifies dietary supplements and ingredients for purity, suggests a daily limit of 20 micrograms of lead, 20 for mercury and 10 for arsenic. California Proposition 65 has limits of 0.5 microgram of lead per day and 10 micrograms of arsenic per day. (There are currently no guidelines for mercury.) But, as Wynn Werner, president of the National Ayurvedic Medical Association pointed out, California does not prohibit sales of these products, but “rather requires a specific warning to the consumer if a product contains these elements above its limits.” None of the tainted supplements in Dr. Saper’s study met the standards for lead set forth by California Proposition 65.

In fact, the presence of metals in certain ayurvedic products may be intentional. An ancient form of ayurveda called “rasa shastra” involves fusing organic and mineral compounds — including pearl, gold, diamonds, copper and mercury — into a medicine and then purifying it into what is believed to be a safe and ingestible form. But the rasa shastra products in Dr. Saper’s study contained the highest levels of mercury, arsenic and lead — as much as 10,000 times over the recommended limits.

Symptoms of lead poisoning, according to Dr. Saper, can include abdominal pain, lethargy, impaired cognition, constipation and anemia.

Earlier this year, a woman named Frances Gaskell experienced some of these symptoms after taking Garbhapal Ras, an herbal supplement geared toward pregnant women, and filed a lawsuit in the Federal District Court for the Southern District of Iowa against the manufacturer, Maharishi Ayurveda Products, which is based in India but distributes its products in the United States. According to the lawsuit, her blood levels were over 20 times the level considered safe by the Centers for Disease Control, said her lawyer.

Her case may be among the most extreme, but some spas are wary. Dr. Marguerite Barnett, a plastic surgeon, owns the Mandala Med-Spa in Sarasota, Fla. A few years ago she added ayurvedic massages to her treatments, but she does not have an in-house ayurvedic practitioner, nor will she sell herbs or supplements. “I am not being negative toward ayurvedic medicine in general — it has a lot to offer — but we do have to raise questions about the purity of the products being used,” she said.

Regardless, some are convinced that the benefits outweigh any pitfalls. In her 20’s, Gina Simo, now 39 and a full-time mother, suffered from a terrible case of cystic acne. Dermatologists were not able to help her, so she went to the Pratima Ayurvedic Skincare Spa Clinic in Manhattan, run by Pratima Raichur. After three months of dietary changes and herbal supplements, the pimples had disappeared. Ms. Simo is undeterred by results of Dr. Saper’s study, still visits the spa and even gives her 18-month-old daughter supplements for colds and skin allergies. “I just feel so much safer with herbs than with quote-unquote medicine.”


FORBES.COM – By Matthew Herper, September 17, 2008 – Amgen’s most important experimental drug, for osteoporosis, beat expectations about both its effectiveness and its safety in a 7,808-patient study, potentially giving the drug maker a much-needed hit.

The would-be treatment, denosumab, prevented fractures much better than placebo. Results were in line with existing therapies. Researchers had worried the drug might increase infection rates or the risk of cancer, but clear differences did not emerge.

“This drug seems quite excellent and comparable to other drugs,” says Loren Wissner Greene, co-director of the osteoporosis center at NYU Langone Medical Center, although she still wants to see more evidence that it doesn’t increase cancer risk. BioMedTracker, an institutional research service, increased its estimate of the probability that denosumab will be approved by 3%, to 77%.

Geoffrey Porges of Sanford C. Bernstein wrote in a note to investors that the drug’s prospects will come down to a “cost vs. value trade-off” as it competes with cheap generics in the $7 billion market for osteoporosis drugs.

“I think it’s going to be a first-line drug,” says Ethel Siris, a Columbia University osteoporosis specialist who co-authored the study. She said the safety concerns were “reassuring” and argued that denosumab would be more appealing than other drugs because it is a twice-a-year shot; most women do not reap the benefits of osteoporosis drugs simply because they don’t take them consistently.

Shares of Amgen rose 4% to $65. The data were presented at the annual meeting of the Association of Bone and Mineral Research and released via a filing with the Securities and Exchange Commission. Hopes for the bone drug have pushed Amgen shares to a new high as investors are optimistic denosumab can help the company overcome several years of disappointments.

Amgen’s status as the biggest biotechnology company is based largely on four drugs used to boost blood-cell production. Two of them, Epogen and Aranesp, saw their combined sales drop 8% to $6 billion last year on safety worries that caused doctors to limit their dosages. Newer drugs haven’t taken off; Monday, Amgen sold two of its lowest sellers and licensed a third for a mere $130 million.

Denosumab is the first result of a new research effort of Amgen research chief Roger Perlmutter, who until 2001 led basic research at Merck.

It has gone through a 15-year journey from the time Amgen pathologist David Lacey discovered a bone-boosting protein called OPG in mice that had super-dense bones. OPG boosts bone production by blocking another protein, called the RANK ligand. Denosumab mimics OPG by blocking the RANK ligand, too.

Amgen announced in July that denosumab beat placebo in reducing the risk of three categories of fractures: those in the spine, those in the hip and those in other parts of the body. The company also said that there were no statistically significant differences in infection or cancer. The question for investors has been how well denosumab stacks up to other drugs and whether there are even hints of side effects.

But investors also want to know how the denosumab results stack up to other osteoporosis studies and will be looking for statistically significant hints of side effects.

Particularly important is how denosumab, a twice-a-year shot, compares to Merck’s Fosamax, a once-a-week pill that is available as a $50-a-month generic. Another crucial competitor is Reclast, from Novartis, which is given once yearly as a 15-minute intravenous infusion.

Denosumab reduced spine fractures by 68%, more than the 47% reported for Fosamax and 70% for Reclast. It reduced hip fractures by 40%, compared to 51% for Fosamax and 41% for Reclast, and other types of fractures by 20%, compared to 20% for Fosamax and 25% for Reclast. (The clinical trial results for Fosamax and Reclast are courtesy of Deutsche Bank.)

The results are particularly striking given that Reclast was tested on far sicker patients who were at much higher risk for broken bones than those who were given denosumab. But scientist usually dismiss comparisons of drugs from different clinical trials. “It’s a mistake to compare head-to-head,” warns Siris.

In a head-to-head study with Fosamax presented yesterday, patients on denosumab had denser bones, but the study was too small to assess fracture risk.

In the 7,800-patient study, 2.4% of denosumab patients developed cancer, compared to 2% on placebo. Serious infections were 4.1% versus 3.4% for placebo, but the results were not statistically significant.

There is hope that denosumab will turn out to be safer than the older drugs. On a conference call before the data were released, analysts at Deutsche Bank noted that the Food and Drug Administration had approved one bisphosphonate, Actonel from P&G, even though there were more cancers in patients taking the drug than on a placebo; experts thought the cancer risk was due to chance because the studies were deemed too short in duration for a drug to cause cancer.

But no entirely new bisphosphonate has been approved since the withdrawal of Merck’s Vioxx in 2004 led to a tougher climate for experimental drugs. Earlier this month, a clinical trial showed an increase in the number of patients dying of cancer when taking the cholesterol drug Vytorin from Merck and Schering-Plough. A top statistician said that the drug wasn’t causing cancer deaths, but two editorials in The New England Journal of Medicine argued that such a risk could not be ruled out.

“I just don’t see anything there,” says Siris. “You’re going to see minor differences in numbers, but I think they’re chance findings.” Willard Deer, Amgen’s international chief medical officer, says the side effects appear “balanced” with placebo. “We will continue to look for every needle in the haystack,” Deer says.

Will the successful results lead to big sales? A survey of the published research of five Wall Street analysts revealed no consensus on what hurdles denosumab has to clear in order to become a blockbuster. One difficulty is cost. Denosumab is expected to cost at least $1,000 per year, the same as Reclast, which is 20 times more than generic Fosamax.

Bernstein’s Porges has written that it may prove difficult to convince insurers to let doctors and patients try the drug unless its effectiveness and safety far outstrip that of Fosamax. Analysts at S.G. Cowen warn against comparing denosumab data to the results for other drugs. They say that so long as it is safe, the medicine is likely to become the first choice for patients for whom Fosamax proves ineffective or intolerable because of side effects like heartburn.

A big question is how easy the drug will be for doctors to give, Siris argues. If it costs $1,000 a year, stocking such an expensive medicine might prove a challenge for some physicians. This is a bigger problem for Reclast, she notes, because the drug has to be given at special infusion centers.

But she thinks one of Amgen’s biggest problems will be making sure doctors have the drug in their offices, in order to give it to their patients. “It has to be available to patients in an easy way,” she says.

Tiny target: A new targeted nano carrier selectively brings a cancer-killing drug to the mitochondria, the drug’s subcellular site of action. In these fluorescent images, yellow indicates that the drug is inside the mitochondria. Cell nuclei are stained blue.
Credit: Volkmar Weissig

Researchers find a new way to precisely target cancer drugs

By Katherine Bourzac, September 18, 2008, MIT Technology Review – Most drugs work by affecting a particular organelle within cells, but it’s difficult to get a therapeutic compound to the right place inside a cell. Now researchers have succeeded in targeting a cancer-killing drug to a part of the cell called the mitochondrion by packaging it in a nano carrier. The highly targeted version of the drug increased its efficacy in tests in mice, even at relatively low doses, shrinking tumors and extending survival.

Over the past several years, researchers have had great success using antibodies and other molecules to target drugs to cells of particular tissue types. But once a drug gets inside the right cell, it’s easy for it to get lost. Drugs are tiny compared with cells, and their charge, weight, and tendency to interact with water all determine where in the cell a drug ends up. “You have to design it such that it finds its way,” says Volkmar Weissig, a professor of pharmacology at the Midwestern University College of Pharmacy, in Glendale, AZ, who developed the new targeted therapy with Vladimir Torchillin, director of the Center for Pharmaceutical Biotechnology and Nanomedicine, at Northeastern University, in Boston.

Subcellular targeting “is one of the biggest promises nanotechnology offers,” says Jerry Lee, a project manager at the National Cancer Institute’s Alliance for Nanotechnology in Cancer. The new research, he says, “offers early proof of concept of being able to target not only to cancer cells, but to pick and choose where in the cell to target.”

Weissig and Torchillin developed a nano carrier to deliver a drug called ceramide to the mitochondria of cancer cells. The researchers enclosed ceramide within a sphere of lipids similar to those in many drug-delivery systems. This lipid envelope, which is too large to pass through the walls of healthy blood vessels, has a tendency to passively accumulate in tumors. (Tumor blood vessels have large gaps that allow the lipid-coated drugs in.) In order to actively target the drug to its subcellular site of activity, Weissig and Torchillin decorated the lipid envelopes with a molecule known to accumulate in the mitochondria.

In animal tests, the approach shows good efficacy, says Joseph DeSimone, a professor of chemistry and chemical engineering at the University of North Carolina at Chapel Hill. DeSimone is taking a different approach to intracellular targeting: he recently found that it’s possible to control where in the cell nanoparticles accumulate by varying their shape. Overall, he says, “methods for accessing intracellular targets are extremely important to pursue.”

Unhealthy mitochondria play a role in obesity and many diseases, including diabetes and degenerative diseases of the nervous system and muscle. And in theory, the nano-carrier system could be used to carry a wide variety of drugs to the mitochondria, says Weissig. However, since the carrier relies on leaky blood vessels to get to its target cells, it’s not likely to be used to treat a wide variety of other diseases. Inflammatory diseases like arthritis, which also causes leaky blood vessels, are another possible application.

The nano-carrier technology was recently licensed by Telomolecular, a company in Rancho Cordoba, CA. Weissig says that the company will use it to develop an anticancer drug that works in the mitochondria. Although the system was proved using ceramide, Telomolecular will test other cancer drugs as well, says Weissig.

September 18, 2009, The New York Times — A long-awaited federal study of an X-ray alternative to the dreaded colonoscopy confirms its effectiveness at spotting most cancers, although it was far from perfect.

Medicare is already considering paying for this cheaper, less intrusive option that could persuade more people to get screened for colon cancer. And some experts believe the new method may boost the 50 percent screening rate for a cancer that is the country’s second biggest killer.

”We’re talking about for the first time really screening the population,” said Dr. Carl Jaffe, an imaging expert at the National Cancer Institute who was not involved in the research.

In the new study, the largest of its kind, the so-called ”virtual colonoscopy” identified nine out of 10 people who had cancers and large growths seen by regular colonoscopies.

But there were flaws, too. Among them: The radiologists sometimes misread the X-ray, leading them to spot polyps that weren’t there. That led to unnecessary follow-up testing.

The X-ray test’s real value may be in showing who really needs a regular colonoscopy — it was better at ruling cancer out than it was at detecting it, suggests the report in Thursday’s New England Journal of Medicine.

Colorectal cancer will claim about 50,000 lives this year. The point of screening, widely recommended at age 50, is to find growths before they turn cancerous.

The gold standard is colonoscopy, in which a long, thin tube equipped with a small video camera is snaked through the large intestine to view the lining. Any growth can be removed during the procedure.

It involves sedation and a missed day of work, not to mention preparation that uses pills or liquids to clean out the bowel.

The study focused on CT colonography, also known as virtual colonoscopy. It’s a super X-ray of the colon that is quicker, cheaper and easier on the patient than traditional colonoscopies.

It too requires the bowel clean-out and has a potentially serious drawback — radiation.

Colonoscopies cost up to $3,000. The X-ray test costs $300 to $800; most insurers don’t cover it so far, but Medicare is considering it.

Insurers likely will weigh the new study heavily in their coverage decisions, said Dr. Durado Brooks, who oversees colorectal and prostate cancer programs at the American Cancer Society.

Preliminary, unpublished data from the new study already helped persuade the cancer society and others to put out guidelines in March that added virtual colonoscopy and a stool DNA test to the recommended arsenal of screenings for colon cancer, Brooks said.

In the new study, both the standard colonoscopy and the X-ray test were given to 2,531 people at 15 U.S. medical centers.

The scans showed large growths in about one in six people, although some were false alarms not confirmed by colonoscopy.

Of the patients with growths verified by colonoscopy, 90 percent were flagged through the X-ray scans.

”That’s very good news,” said Dr. C. Daniel Johnson, the lead author of the study. He is a researcher at the Mayo Clinic campus in Scottsdale, Ariz., with financial ties to one virtual colonoscopy company, GE Healthcare.

Back to the false alarms — only one in four of those patients diagnosed with a growth actually had one, noted Dr. Robert Fletcher, a retired Harvard Medical School professor who wrote an editorial accompanying the study. He is a paid consultant for a company that makes a DNA screening test for colon cancer.

Some additional drawbacks to virtual colonoscopy:

–In about one in six of the patients, the X-ray found abnormalities outside the colon that led doctors to recommend additional testing or care. Some of those discoveries may be life-threatening, but others are not and investigation of them may prove expensive and hard on the patient, Fletcher wrote.

–The X-ray tests are not as good at colonoscopy at detecting flat growths on the colon wall that are more likely to be cancerous than the more familiar knobby polyps, according to other researchers.

–Virtual colonoscopies, currently recommended every five years, expose people to repeated doses of radiation. It’s half the dose of a standard CT exam, but the cumulative effects are not yet known. Colonoscopy is only recommended every 10 years.

”These concerns do not rule out CT colonography as a screening test but they need to be considered,” Fletcher wrote.

The study was not designed to look at whether the screenings prevented deaths.


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Editorial, The New York Times, September 18, 2008 – The newer drugs for treating schizophrenia have come under such a cloud in recent years that it’s no surprise to learn of another setback: they work no better than an older, less expensive drug in children and adolescents for whom they are heavily prescribed.

It is another disturbing example of how aggressive marketing can propel drugs to blockbuster sales even though they are no more effective, and possibly more risky, than older versions.

A government-supported study delivered the bad news this week about Zyprexa, made by Eli Lilly, and Risperdal, made by Janssen. When introduced in the 1990s, these drugs were supposed to be an advance over earlier antipsychotics because they reduced such side effects as uncontrolled shaking or tremors. But they were very expensive, and they came with their own side effects, notably rapid weight gain.

A major study in 2005, sponsored by the National Institute of Mental Health, found that several newer antipsychotics were no better than an older and far cheaper drug in treating schizophrenia in adults. Now the new study, sponsored by the same agency, has found similar results in a small eight-week trial in 116 youngsters between 8 and 19 years old.

The study found no clear differences between Zyprexa, Risperdal and an older medication in relieving the symptoms of schizophrenia. But there were clear differences in side effects.

Youngsters taking Zyprexa gained about 13 pounds on average and those on Risperdal about 8 pounds. Both groups experienced changes in cholesterol and insulin levels that can increase the risk of diabetes. Youngsters taking the older drug did not gain weight and had little in the way of metabolic changes.

Parents, psychiatrists and other physicians will need to rethink whether the newer antipsychotics should still be deemed the first line of treatment for most youngsters. Many might do better on an older drug.

The newer drugs were heavily promoted for adults and became widely used before they were tested against an earlier, cheaper version. So great was the confidence in their superiority that doctors even prescribed them for children. The belated realization that such confidence was misplaced suggests that new drugs should be tested against older versions at the start, before vigorous marketing campaigns make them best sellers.

Fish and fish oil: Good for most folks, but not everyone

Harvard Medical School – September 18, 2008 – Research done since the 1990s shows beyond all doubt that you can lower your risk for the most serious diseases of our time by following a healthy diet. Healthy eating, based on this new science, can ward off 25% of all cancers and, combined with exercising regularly and not smoking, can prevent possibly 90% of cases of type 2 diabetes.

What’s so special about fish or the oil extracted from it? In addition to being an excellent source of protein, fish tends to be rich in the healthful omega-3 fats our bodies need but can’t make. The two omega-3s we get from seafood are eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). A third type, alpha-linolenic acid (ALA), is found in many plants.

Omega-3 fats help the heart’s lower chambers (ventricles) maintain a steady beat and guard against potentially deadly erratic rhythms. They ease inflammation and help prevent the formation of dangerous clots in the bloodstream. Omega-3 fats also lower triglycerides, the most common type of fat-carrying particle in the bloodstream.

In 2002, the American Heart Association recommended that people with coronary artery disease take fish oil. Its reasoning was sound. At the time, solid research showed that eating fish or, for some people, taking fish oil, helped protect against dying of heart disease.

Since then, studies have generally supported the benefits of eating more fish or taking fish oil. Yet some research has raised a red flag about whether people with severe angina, seriously compromised heart function, or potentially lethal ventricular rhythms should eat a lot of fish or take fish oil.

Refining the prescription

A European trial tested the impact of eating oily fish at least twice a week or taking fish oil among men with easily provoked severe angina. Surprisingly, those who got more omega-3s were more likely to have died of heart disease during the several-year study.

Another note of caution came from trials of fish oil for folks prone to potentially deadly disturbed rhythms in the ventricles, notably ventricular tachycardia and ventricular fibrillation. Most people who experience one of these and live to tell about it get an implanted cardioverter-defibrillator (ICD) to detect and halt these arrhythmias. In one trial, people with an ICD who took high-dose fish oil had more episodes of ventricular tachycardia or fibrillation than those taking a placebo. In two similar trials, fish oil prevented ventricular arrhythmias in one and had no harm or benefit in another.

Experiments by Dr. Alexander Leaf (emeritus professor of clinical medicine at Harvard Medical School) and his colleagues show that omega-3 fats prevent potentially fatal rhythms by suppressing the function of hyperexcitable cells that live in scar tissue or in heart muscle that doesn’t get enough oxygen. That’s great when there’s plenty of healthy heart tissue. But what about when these hyperexcitable cells are responsible for the lion’s share of cardiac function, such as in people with severe angina or other conditions in which the heart is chronically deprived of oxygen? Stifling them with fish oil could conceivably snuff out the heartbeat, explains Dr. Leaf.

Recasting recommendations

A single recommendation on fish and fish oil can’t cover all the bases, but here’s what you should know:

Even though you can buy fish oil without a prescription, talk with your doctor first before taking it.

Yellow light. Go easy on fish and avoid fish oil if you have hard-to-control angina, severe heart failure, or an ICD. Ongoing research could modify that advice, but for now it’s a prudent approach.

Go fish. Everyone else could benefit from eating fish, preferably fatty fish like salmon, sardines, mackerel, and trout, twice a week. It can help keep a seemingly healthy heart in good shape, and protect one that may be in trouble. Baked or broiled fish is best; deep-fried, fast-food fish doesn’t count. On non-fish days, have a handful of walnuts or ground flaxseeds, use flaxseed or canola oil, or try some tofu, all good sources of alpha-linolenic acid.

Try oil. If you have one or more narrowed coronary arteries, have had bypass surgery or angioplasty, or had a heart attack, and your heart function is good, try to get 1 gram of DHA plus EPA daily. In Europe, doctors routinely prescribe fish oil for heart attack survivors. American doctors are more reluctant to follow the American Heart Association’s recommendation.

High triglycerides. Taking 2 to 4 grams of EPA plus DHA a day can help control high triglycerides.

Practical matters

Taking fish oil may be cheaper than eating fish, but it isn’t nearly as pleasant. Gulping down the large capsules can be difficult, and some people don’t like the fishy aftertaste or belches. Freezing the capsules can help.

Fish oil is free of mercury and other contaminants found in some fish. Over-the-counter supplements aren’t closely regulated by the FDA, so you don’t always know what you are getting. For vegetarians, V-Pure capsules contain EPA and DHA extracted from algae, which is where fish get them. The best way to get omega-3 fats, though, is to eat oily fish. It’s better for you than red meat, and is far tastier than a capsule.

For more information on nutrition and your health, order our Special Health Report, Healthy Eating: A guide to the new nutrition, at