Fatty liver is a common problem in women with PCOS. In this study, EPA, an omega-3 fatty acid and a fish oil, was shown to improve the symptoms of nonalcoholic steatohepatitis (fatty liver). EPA is the fish oil that you cannot get when you rely on vegan sources of omega-3's--it's not in flax, and it's not in marine algae. Some research shows that when you've eaten enough marine algae to completely saturate your tissues, what's left can be used to make EPA, but it's not the way of getting it that the body prefers.
This is important to understand, because the vast majority of foods that are labeled as supplemented with omega-3 fatty acids either contain ALA (primarily in the form of flax) or DHA (primarily from marine algae).
The other advantage to eating fish is, that if you've put a fillet on your plate, you've likely removed another (fattier) kind of protein. That's the positive double whammy you get in seafood choices.
In my training I was always encouraged to develop good negotiation skills. In other words, if a client didn't like a certain food, to have a few other options up my sleeve that would provide equivalent nutritional value. Only when I got into omega-3 chemistry, inflammation, and PCOS, did I realize that in this one crucial area, I would have to dig my heels in and advocate that this essential nutrient was simply non-negotiable: if you don't eat fish, you miss out on total health.
Over the weekend I had an animated discussion with another dietitian who was adamant that her clients (mainly with eating disorders) simply were not going to accept this. I told her they simply would not achieve total health…and possibly total recovery. I got some resistance, but hopefully at some point this colleague will come to understand that we're here to guide our clients where they have the potential to go. We're not here to tell them what they want to hear, with the hopes that somehow health will just magically appear.
Tanaka N, Sano K, Horiuchi A, Tanaka E, Kiyosawa K, Aoyama T. Highly Purified Eicosapentaenoic Acid Treatment Improves Nonalcoholic Steatohepatitis. J Clin Gastroenterol. 2008 Apr;42(4):413-418.
This is to address some great questions about fish oil that Katie sent in.
Katie asked: after reading about fish oil and its obvious benefits, I finally bought some Carlson Super Omega-3 Fish Oil Concentrate soft gels yesterday at Whole Foods.
I have several questions I have tried to get answered via this site and the Internet, but can't seem to find clear answers, so I am throwing them out here, in hopes you can help.
1. The bottle says"Each Carlson Super Omega — 3 soft gel contains 1000 mg (1 gram) of a special concentrate of fish body oils from deep, cold-water fish which are especially rich in the important Omega-3's EPA and DHA." However, the Supplemental Facts read EPA 300 mg DHA 200 mg Other Omega-3's 100mg. I believe that adds up to 600mg. Right? There is no mention of the other 400 mg. Where are they? I'm very confused about this. Can you explain this to me? There is also Natural Vitamin E — 10 IU…incase that means something.
2. How many pills/mg am I supposed to take? I read between 1000 mg and 3000 mg. Which makes me confused again because even though the bottle says 1000 mg in each pill I can only find 600 of them! I want to make sure that I am taking enough, but not taking too much! How much do you take? Also, do I work up to that or just dive in?
3. Last question…is there anything else I should be taking with the fish oil? I know that sometimes if you take something you need to supplement with something else. Is that the case here?
Thank you in advance for your advice and information!
My response: Katie, these are really great questions and something that I am often asked by my clients. Here's the scoop:
1. The dosage on the ingredient list can indeed be very confusing and frankly I believe it is a way in which some supplement companies try to give the impression that you are getting a better product with higher potency, but it can be misleading. When the label states something like…"contains 1000 mg marine oil", you are not getting the complete information.
The critical ingredients and the amounts you need to know about are — how much EPA (eicosapentanoic acid) and DHA (docosahexaenoic acid) are contained in each capsule.
EPA and DHA have been shown to support healthy functioning of the cardiovascular, immune, gastrointestinal, and musculoskeletal systems. EPA is also an excellent anti-inflammatory and helpful in conditions such as insulin resistance, diabetes and auto-immune related inflammation.
DHA is an important factor for those with PCOS as it supports many aspects of health including pregnancy, fetal development, and healthy neurological function.
The other"marine lipids" are simply the total fat of the fish, where the EPA and DHA are the active portions of that fat. It is the"actives" that are providing the therapeutic value. The vitamin E in the capsules is for preservative purposes and helps prevent rancidity of the fat.
2. Regarding the dosage you should take, that is a harder question to answer because it will depend on what you are trying to target. Those with PCOS should be targeting anywhere from 500 — 1000 mg. DHA. So you need to know how much DHA is in each cap, for example if the capsule has only 200mg. of DHA, you'll need to take 3 of them to get approximately 500mg. You can then work up to a higher dose, always start with the lower dose and work your way up. Sometimes it is easier to get a liquid version that is high potency versus taking handfuls of pills to achieve the same dose.
I do not recommend that you take a liquid fish oil that is derived from Cod Liver Oil as the source as it usually has a high amount of Vitamin A and it is possible to get toxic doses of vitamin A. Another thing to note is that in a combination EPA/DHA cap, the dosage EPA will usually be higher than the amount of DHA, that is no problem. The EPA will only be of additional benefit.
Don't hesitate consulting with a registered dietitian knowledgeable both in PCOS and supplements in order to have your supplementation tailored to your specific health needs — remember we are all different, with unique physiology, medical history and requirements.
3. Fish Oil does not have to be taken with anything else to enhance its function. It can be taken all at once, with meals, between meals — it is very flexible this way.
Here are a couple of additional tips:
- if you tend to"burp" back fish oil, make sure to buy a brand that comes in an"enterically coated capsule", they might cost a few cents more, but it's worth it. - refrigerate your fish oil to protect it and this also can help reduce"burp back". - contributes to creating beautiful, healthy skin.
One last fun fact about fish oil. Most of it actually comes from the southern hemisphere not as you might think from the deep waters off Norway!
Here's to fish oil!
Carmina McGee, MS, RD, LE Ventura, California 805.816.2629 info@carminamcgee.com
Way back when I first started studying omega-3 chemistry, I put together a list of DHA contents of a variety of seafoods. I was recently asked for a copy of that list, and since the list was not complete the first time I did it, I decided to update it.
I noticed when looking at the latest list that there were two significant changes: Over half of the seafood given the"green light" are farmed. Meaning we need to be more open to eating farmed fish and better manage our ocean farming habits. Secondly, as a consumer it is also important to know what fishing method was used. Some are sustainable, some are not.
The list below is based off of the Monterey Bay Aquarium Seafood Watch list, most recently updated January 11. As much as I advocate for all of you to eat more fish, I want to be sure that I do my part to encourage responsible use of the ocean's resources. So the only options included on this list are the"green light", or most sustainable options. If you don't see it there, it didn't get a green light. The (F) in front of an item denotes"farmed".
I'll update this from time to time so you all can keep current. I used the national list, but you can also find more specific regional lists at the same website. The downloadable wallet cards or iPhone application are great to keep with you so that you can always make better choices when you're grocery shopping or eating out.
Bottom line, any seafood has omega-3's. Even if they're not as high as what is found in salmon, every time you eat fish, you're not eating a meat higher in saturated fat. There's a"double whammy" benefit over and above that simple DHA.
Hope this inspires you to think when buying or ordering your seafood!
Milligrams of EPA/DHA/total omega-3 per 100 gram (3.5 cooked ounces)
I was asked by one of our readers (who happens to also be my dear cousin Susan), if there was anywhere on the Internet, a checklist for vegetarians to follow to be sure their diet is complete. Her pretty exhaustive research found nothing really practical for meal planning.
So in response to that, and knowing that a very high percentage of our own readers are vegetarian, I put something together. Please let us know if it needs refining or detail, so that we can make this as practical as it can possibly be.
There are five main things to attend to. All of them are important, but I ordered them in the way I look at them when planning a vegetarian meal for myself.
1. What is my protein source and how much of it do I need to truly give me enough protein?
Here are your goals based on the number of calories you eat. This will make 30% of your calories protein, which will help to fight insulin resistance.
2. Where is my vitamin D coming from, and have I had enough? You will have to make a very conscious effort to get enough of this vitamin. With regard to whole foods, mushrooms are pretty much the only vitamin D-containing food. With regard to vegan milk alternatives, beware. Most are so low in protein, they are more accurately thought of as juices rather than milks. If you choose to drink them you will need to find other ways to meet criteria nu,ber one above. I blogged about this in detail not too long ago.
3. Are my fats healthy? If your definition of vegan is primarily not eating meat, and you are eating a lot of packaged, processed, prepared, or baked food…be extra sure you are not inadvertently letting the pro-inflammatory fats sneak in. Remember, they tend to begin with the letters"s" and" c" — soybean, safflower, sunflower, sesame, corn, cottonseed. (Canola is the exception.). Vegans are often blindsided here with salad dressings, baked goods, cookies, and chops. Read your labels--as much as I love Whole Foods, their entire snack food aisle only has a handful of choices you can bring home if you follow this rule! Good fats include olive and organic canola.
4. Am I getting DHA and EPA (marine omega-3)? Yes, flax, green veggies, and other foods contain omega-3, but the conversion rate is not high. You will need to find a marine algae supplement to be sure your intake of these two essential fatty acids is adequate. InCYSTer Chris Marquette found one that is not genetically modified; look for it next time you shop.
5. Am I getting enough fruits and vegetables? Ideally, these should be the vast majority of what you eat. I am surprised at how many vegans I know who do not like vegetables! You should be aiming for 2-3 1/2 cup servings PER MEAL. Beware of juicing; it is a great way to get in large volumes of fruits and vegetables…BUT…the carbohydrate to protein ratio is not going to help reduce insulin resistance. Make a smoothie out of your juice with your favorite protein powder.
Of course, you can take supplements to make up many of these deficiencies…but if your solution in more than one of these categories is a supplement, I challenge you to consider why you do what you do. The true definition of a vegan is someone WHO MEETS THEIR DAILY NUTRITIONAL NEEDS without using animal-based food to make it happen. If all you have done is remove animals from your diet, you are simply a picky or misinformed eater.
Women with PCOS tend to have higher risk pregancies. A risk that is pretty well acknowledged is gestational diabetes. However, the rate of pre-eclampsia is also higher in cysters. Did you know diet can help you reduce your risk?
Researchers analyzed the diets of women with pre-eclampsia and gestational hypertension to see if any specific nutrients were correlated with these problems. The specific nutrients they looked at were: calcium, omega-3 and omega-6-6 fatty acids, trans fatty acids, magnesium, folate, and vitamins C, D, and E. There was a slight reduction in risk of pre-eclampsia in women with a higher intake of omega-3 fatty acids.
Omega-3 fatty acids, especially DHA and EPA, are two essential items you should include in your"Healthy Pre-pregnancy, Pregnancy, and Nursing Toolbox".
Boomsma CM, Eijkemans MJ, Hughes EG, Visser GH, Fauser BC, Macklon NS. A meta-analysis of pregnancy outcomes in women with polycystic ovary syndrome. Hum Reprod Update. 2006 Nov-Dec;12(6):673-83.
Oken E, Ning Y, Rifas Shiman SL, Rich Edwards JW, Olsen SF, Gillman MW. Diet during pregnancy and risk of preeclampsia or gestational hypertension. Ann Epidemiol 2007 Sep;17(9):663-8.
Many of the women I work with are vegan vegetarians. Which means when it comes to increasing omega-3 intake, they tend to want to go heavy on flax, hoping it will make up for not eating fish. It simply doesn't work this way…in ways that are very important to PCOS.
When different groups of rats are given ALA (the primary omega-3 in flax), EPA and DHA (the primary omega-3's in fish oil), EPA and DHA lowered glucose and insulin levels about 35-38% greater than did ALA. Insulin sensitivy improved by 60% in the fish oil groups compared to the ALA groups.
Bottom line, if you really, really want to get better, and you're not currently eating fish, or using a fish or marine algae supplement, you may want to seriously consider adding one of those to what you're doing. It's pretty non-negotiable, we need DHA and EPA to properly function as human beings.
Andersen G, Harnack K, Erbersdobler HF, Somoza V. Dietary eicosapentaenoic acid and docosahexaenoic acid are more effective than alpha-linolenic acid in improving insulin sensitivity in rats. Ann Nutr Metab. 2008;52(3):250-6. Epub 2008 Jun 19.
I just received an email from a client who noticed that every time she added flaxseed oil to her diet, she started to wheeze. We checked online, and sure enough, some people can be allergic to flaxseed. Here are some of the common symptoms of flaxseed allergy.
For anyone who is trying to increase their omega-3's, this can pose a challenge, since the vast majority of foods in the grocery store labeled as omega-3 supplemented contain flaxseed as the omega-3 source. If it turns out you are a flax-allergic person, be extra sure you read those labels!
ALA, the primary omega-3 in flaxseed oil, is not a substitute for fish oil; it has completely different and essential functions. A good way to think of it is that EPA and DHA from fish oil provide the"meat" of the structure of your brain and nerve cells, while ALA acts kind of like"rustproofing", keeping all that DHA and EPA in place that you worked so hard to get in the diet. They both need each other present in order for maximum effectiveness.
Here are some ideas for getting more omega-3's in the diet.
1. Other foods containing ALA include
Broccoli Brussels sprouts Cabbage Canola oil Edamame Kale Parsley Pecans Pumpkin seeds Spinach Spring greens Tempeh Tofu
One reason I have not included walnuts, which are typically the first vegetarian food recommended to increase omega-3 intake, is that the omega-6 content is so high that it is mathematically impossible to improve an omega-6 to omega-3 ratio when using them. I love walnuts and think they have some great nutritional benefits for PCOS, but in the rare and special case of a flaxseed allergy, it may not be a food that you would want to eat in large quantities. (I'm working on a pro-walnut post for a later date for you curious types!) Here are some practical ways to incorporate the foods above into your diet.
1. Know your nuts! The nuts with (a) the best omega-3 levels and (2) the best overall ratios of healthy to unhealthy fats include: macadamia, hazelnut, pecan, pine, and pistachio. Those are the nuts you should be using with the most frequency in your snacking and cooking. If you like nut-encrusted fish and pesto sauce…you're in luck! You can also throw nuts in your coffee grinder to make nut powders, which can be added to waffles, pancakes, baked goods, smoothies, and salad dressings. They'll give your creations a little bit of a gourmet twist!
2. Use shredded cabbage in your tacos instead of shredded lettuce. That's how they do it in Mexico…and it's the perfect topping for a fish taco!
3. Get in the habit of throwing a handful of dark greens--kale, spinach, parsley--into your smoothies. You won't even taste them.
4. Pumpkin seeds, like nuts, are easily added to trail mix, thrown on salads, soups, and hot cereals, and ground to include in your encrustings.
5. Cook with canola oil.
6. I've included the three types of soybean that are not tough on thyroid--edamame, tofu, and tempeh. Edamame is a fun snack when popped out of the shell, tofu and tempeh can be the basis for a meatless meal.
7. If you like pesto, you may want to try chimichurri, another parsley-based sauce that I call"South American pesto". It is wonderful on grilled meats and easy to make! I've seen ready made varieties in the grocery store.
8. Be extra careful about omega-6 fatty acids. The less of those in your diet, the less omega-3 you will need to counter their inflammatory influence. For review, except for canola, which is ok, minimize your use of oils beginning with the letters"s" and"c"…safflower, sunflower, soybean, corn, cottonseed. (The reason soy as a food is ok while soybean oil is not, is because the ratio of omega-6 jumps up when you extract and use only the fat and do not buffer it with the meat of the soybean.)
Here are a couple of recipes for you, one for chimicurri sauce, and one for a tasty squash/kale/whole wheat lasagna I tested out this week.
It just takes a little creative thinking to find ways around a flaxseed allergy. Hopefully some of the suggesstions I'm providing turn out to be favorites in your home!
Spinach Kale Whole Wheat Lasagna (from Sunset Magazine, February 2008)
Note: I couldn't find whole wheat lasagna noodles in my store so I bought whole wheat egg noodles and layered them with the other ingredients to make a casserole. It was great! Prep and Cook Time: about 2 hours. Notes: You can assemble and chill the lasagna a day ahead, but add 10 to 15 minutes to the baking time. You can also freeze the lasagna, wrapped well in plastic wrap, for up to 1 month and bake it frozen (add 1 1/4 hours to the oven time).
Yield Makes 8 servings
Ingredients 4 tablespoons olive oil, divided 1 medium red onion, peeled and sliced 3 peeled garlic cloves (1 minced, 2 left whole) 2 cans (14 oz. each) crushed tomatoes 1 teaspoon dried oregano About 1 tsp. each salt and freshly ground black pepper, divided 6 cups (about 2 lbs.) butternut squash, peeled and cut into 1/2-in. cubes 1/2 tsp. dried thyme 1 pound Lacinato kale (often sold as dinosaur or Tuscan kale) 9 whole-wheat lasagna noodles (about 8 oz.) (Often, whole wheat pastas are made with flax…be sure to read your labels!)1 container (15 oz.) part-skim-milk ricotta cheese 1/8 teaspoon ground nutmeg 2 cups shredded mozzarella cheese, divided
Preparation 1. Preheat oven to 400°. Heat 2 tbsp. olive oil in a 2- to 3-qt. pot over medium heat. Add onion and minced garlic; cook, stirring occasionally, until onion is soft and translucent, 5 minutes. Add tomatoes, oregano, and 1/2 tsp. each salt and pepper. Reduce heat and simmer until thick and flavors are combined, about 30 minutes. Set aside.
2. While sauce is cooking, in a 12- by 15-in. baking pan, sprinkle squash with thyme, remaining olive oil, and salt and pepper to taste. Add garlic cloves and toss squash mixture to coat with oil. Bake until soft, 10 to 15 minutes. Meanwhile, bring 3 qts. salted water to a boil in a large pot.
3. Reduce oven temperature to 350°. Transfer squash and garlic to a food processor and purée until smooth.
4. Tear kale leaves from center ribs and discard ribs. Boil leaves until soft, 5 to 8 minutes. Drain; let cool. Squeeze out as much water as possible and chop finely.
5. In the same pot, bring another 3 qts. salted water to a boil. Add noodles and cook until tender to the bite, about 10 minutes. Drain; rinse with cold water.
6. In a bowl, mix ricotta, nutmeg, 1 cup mozzarella, and remaining 1/2 tsp. each salt and pepper.
7. Coat the bottom of a 9- by 13-in. pan with 1/3 of tomato sauce (about 1 1/2 cups). Lay 3 noodles in a single layer over sauce. Top noodles with squash, spreading evenly. Sprinkle 1/2 of kale evenly over squash. Arrange 3 more noodles on kale and top with ricotta, spreading evenly. Top with remaining kale and noodles. Cover noodles with remaining tomato sauce and sprinkle with remaining 1 cup mozzarella.
8. Bake lasagna until juices are bubbling and cheese is melted, about 30 minutes. Let stand 10 minutes before slicing.
Grilled Halibut with Chimichurri Sauce from Epicurious.com
1/3 cup extra-virgin olive oil 1/4 cup fresh lemon juice 1 tablespoon water 1 tablespoon minced garlic 1 tablespoon minced shallot 3/4 teaaspoon hot red-pepper flakes 3/4 cup chopped flat-leaf parsley 4 (6- to 8-ounce) halibut steaks (3/4 to 1 inch thick) 1 tablespoon vegetable oil print a shopping list for this recipe
Preparation
Whisk together olive oil, lemon juice, water, garlic, shallot, red-pepper flakes, and 1/2 tsp each of salt and pepper until salt has dissolved. Stir in parsley. Let chimichurri stand 20 minutes.
Meanwhile, prepare grill for direct-heat cooking over medium-hot charcoal (medium heat for gas).
Pat fish dry, then brush with vegetable oil and sprinkle with 1/2 tsp salt and 1/4 tsp pepper (total).
Oil grill rack, then grill fish, covered only if using a gas grill, turning once, until just cooked through, 8 to 10 minutes total.
Serve fish drizzled with some of chimichurri; serve remainder on the side.
Cooks' notes: ·Halibut can be cooked in a hot oiled large (2-burner) ridged grill pan over medium heat. ·Chimichurri can be made 1 hour ahead and kept, covered, at room temperature.
Last night I had a consultation with a client who is in her mid 50's. She doesn't officially have PCOS, but she has many of the symptoms, and I believe if she were younger, trying to have children, she might have the diagnosis. What is really interesting about this case is that this woman was born 2 months prematurely and spent several weeks in a neonatal intensive care unit before being able to go home. This was long before this was commonplace.
A very high percentage of my clients were born prematurely. This is a huge risk factor because it is during the last trimester of pregnancy that the brain and nervous system does the majority of its development. When the baby's nervous system is forced to grow and develop in an unfamiliar and unnatural…and stressful…environment, it just can't thrive like a nervous system that is at home in the womb.
Secondly, inside momma, there is at least a little bit of exposure to nutrients that are needed for this development. Outside the womb, we can do our best, but we can never completely replicate nature. In the case of my client, her intensive care stay happened long before we even knew much of this, and before omega-3 fatty acids were added to the feedings of babies in intensive care units. So my client, essentially, has been playing catch up at least since the day she was born.
A recent study confirmed what I just described, and what I've been teaching for several years. In a study comparing 28 babies categorized as"small for gestational age", 28 babies whose weight was statistically normal, and 56 normal-weight babies. An additional comparison was made between 60 premature babies, 20 of which were"small for gestational age" and 40 whose weight was normal.
Preterm babies seemed to have higher levels of building blocks of essential fatty acids, but the important omegas that they needed were not there, indicating that something about preterm birth may impair the conversion process. Term, normal weight babies had higher levels of DHA (one of those essential omegas), and higher ratios of endpoint to building block compounds. This suggested that the term babies were better able to convert building blocks into active omega-3's.
Term but small babies had higher levels of eicosapentaenoic acid, which is an intermediate in the conversion, meaning perhaps that lower weight babies also have important metabolic differences.
So, it seems, there are two important goals: (1) keep that baby in utero as long as possible, and (2) don't get so caught up in your pregnancy weight gain that you restrict your baby's development. Goal #1, interestingly, has been shown to be more achievable in mothers who consume adequate omega-3s! Goal #2 is a little more challenging, especially if you are being managed for gestational diabetes and your weight is being more closely monitored. That's when quality or what you do eat becomes important. It's going to be hard to get enough omega-3's, optimize your baby's weight gain, and keep your insulin function under control, if your focus is not on nutritionally dense foods that give you a bang for your buck.
That's why inCYST works so hard to train its professionals. They love to do this work, and they would love to help you figure it out!
Agostoni C, Marangoni F, Stival G, Gatelli I, Pinto F, Risé P, Giovannini M, Galli C, Riva E. Whole Blood Fatty Acid Composition Differs in Term Vs Mildly Preterm Infants: Small Vs Matched Appropriate For Gestational Age. Pediatr Res. 2008 Apr 3.
