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Evelyn Tribole, MS, RD

www.EvelynTribole.com
Etribole@gmail.com

Dietary Management of Inflammatory Bowel Disease

Crohn’s disease and chronic ulcerative colitis are two diseases


that are together classified as inflammatory bowel disease (IBD),
and result in an inflammation of the intestines.

During an “attack” symptoms may include abdominal pain,


nausea and vomiting, frequent bowel movements, diarrhea, weight loss, dehydration,
anemia and fever. These factors contribute to a loss of appetite in many individuals.

In addition, IBD, particularly Crohn's disease, is often associated with poor digestion and
absorption of dietary protein, fat, carbohydrates, water, and a wide variety of vitamins
and minerals. Thus, much of what a person eats may never really get into the body.
Therefore, while dietary habits do not cause the disease, they do play a crucial role in
managing it.

While there is not one “IBD diet” for everyone, you can work with your registered
dietitian to develop an eating plan that will help manage symptoms during the acute
phases of a flare up, help determine what types of foods may exacerbate symptoms, and
help resume a healthy eating plan that will promote recovery during “remissions.”

Basic Diet Tips to Help Manage IBD:


• Eat small, frequent meals and snacks instead of just a few large meals. Even during a
flare up, eating adequate high protein foods such as lean meats, fish, poultry and eggs
(or egg substitutes) may help relieve IBD symptoms.
• Don’t skip meals – this may cause pain and bloating when you finally do eat.
• Eat slowy – take small bites and chew food well.
• Drink plenty of fluids – especially water - to keep your body hydrated (which can be
a challenge during vomiting and diarrhea episodes) and prevent constipation.
• Take vitamin and/or mineral supplements as recommended by your doctor.
• When IBD is under control, try foods that are high in fiber. You might find that
cooked vegetables more tolerable than raw. High fiber foods include:
o Whole grain breads, bagels, buns, pasta
o Bran cereals
o Whole grains like barley, corn, brown rice, quinoa
o Dried fruits, berries, oranges, apples and pears (with skins)
o Green, leafy vegetables
• During a flare up, limit high fiber foods to help minimize symptoms.
• Limit gas-producing foods such as cruciferous vegetables (broccoli, cabbage,
cauliflower, Brussels sprouts); dried peas, beans, legumes and lentils; onions, chives,
peppers and carbonated beverages.
• If you are lactose intolerant, avoid lactose-containing (dairy) foods or try soy-based
alternatives, lactase enzymes and lactase pretreated foods.

1100 Quail Street, #111, Newport Beach, CA 92660  949-654-9904


Evelyn Tribole, MS, RD
www.EvelynTribole.com
Etribole@gmail.com

• Use pre-digested nutritional drinks (elemental diet) as recommended by your


registered dietitian to give your bowel a rest and replenish lost nutrients.
• Avoid alcohol and caffeine as these stimulate the intestines.
• Sugar alcohols, such as sorbitol (sweetener used in foods) may cause diarrhea and
bloating.
• If you develop gas and diarrhea after eating fatty or greasy foods, then limit these
foods in your diet: butter, margarine, mayonnaise, salad dressing, oil, high fat meats
and dairy products, skin of poultry, fried foods, etc.

Nutrient Deficiencies Found in Some Patients with IBD

• Calcium
• Cyanocobalamin (vitamin B12)
• Folic acid
• Magnesium
• Niacin (vitamin B3)
• Thiamine (vitamin B1)
• Vitamin D
• Vitamin K
• Zinc

New Nutritional Therapies Being Explored

• Omega-3/Omega-6 Fats
• Prebiotics such as psyllium (a complex carbohydrate)
• Probiotics – lactobacillus preparations and live-culture yogurt
• Psyllium
• Indian frankincense (Boswellia serrata) contains the anti-inflammatory agents
boswellic acid and alpha-boswellic acid. There's preliminary clinical research that
taking 350 mg Indian frankincense gum resin three times daily might induce
remission of ulcerative colitis. This is promising, but it's too soon to recommend
Indian frankincense for treating patients with active ulcerative colitis.
• Wheatgrass (Elytrigia repens) juice. There's preliminary clinical evidence that
wheatgrass juice might help reduce rectal bleeding and abdominal pain in patients
with active ulcerative colitis.

1100 Quail Street, #111, Newport Beach, CA 92660  949-654-9904


Evelyn Tribole, MS, RD
www.EvelynTribole.com
Etribole@gmail.com

Supplements that Might Worsen IBD Symptoms

These supplements might increase intestinal motility, resulting in a laxative effect.

Supplement Contains
Alder buckthorn anthraglycosides which have a laxative effect
Aloe latex anthraquinones which have a laxative effect
Cascara anthraglycosides which have a laxative effect
Castor oil Has stimulant laxative effects
European buckthorn anthraquinones which have a laxative effect
Fo-ti anthraquinones which have a laxative effect
Rhubarb anthraquinones which have a laxative effect
Senna anthraquinones which have a laxative effect

Caution
There have been rare cases of pathogenic colonization involving Lactobacillus in
severely immunocompromised patients. To be safe, patients on conventional
immunosuppressants should avoid probiotics.

Tip
Take antibiotics and bacterial probiotics, separately, by at least 2 hours. Theoretically,
simultaneously taking antibiotics might kill a significant number of the live organisms.

References:

Crohn’s and Colitis Foundation of America. Diet and nutrition. Available at:
http://www.ccfa.org/info/diet?LMI=4.2

Diet and nutrition, Living with Crohn’s. Remicade: Infliximab. Available at:
http://www.remicade.com/crohns/crohns_lifestyle/crohns_diet.jsp

Tsang, G. Nutrition & health: Inflammatory bowel disease IBD diet (Crohn’s diet).
Available at: http://www.healthcastle.com/ibd-diet.shtml

1100 Quail Street, #111, Newport Beach, CA 92660  949-654-9904


Consumer Information and Education
Provided by your
Health Care Professional
Based on
Natural Medicines Comprehensive Database

BLOND PSYLLIUM
What other names is the product known by?
Blond Plantago, Blonde Psyllium, Che Qian Zi, Dietary Fiber, Englishman's Foot,
Indian Plantago, Isabgola, Isabgul, Ispagol, Pale Psyllium, Plantaginis Ovatae Semen,
Plantaginis Ovatae Testa, Plantago decumbens, Plantago fastigiata, Plantago insularis,
Plantago ispaghula, Plantago ovata, Ispaghula, Psyllium, Psyllium husk, Sand Plantain,
Spogel.

What is it?
Blond psyllium is an herb. The seed and the seed husk are used to make medicine.

Is it Effective?
Natural Medicines Comprehensive Database rates effectiveness based on scientific
evidence according to the following scale: Effective, Likely Effective, Possibly
Effective, Possibly Ineffective, Likely Ineffective, Ineffective, and Insufficient Evidence
to Rate.

The effectiveness ratings for BLOND PSYLLIUM are as follows:


Effective for...

Relieving constipation and softening stools.

Likely Effective for...

Lowering cholesterol in people with high cholesterol.

Possibly Effective for...

Diarrhea.
Irritable bowel syndrome (IBS).
Lowering blood sugar after eating a meal in people with diabetes (type 2).
Preventing the relapse of ulcerative colitis.
High blood pressure.
Hemorrhoids.
Treating side effects of a drug called Orlistat (Xenical, Alli).

Possibly Ineffective for...

Serious kidney disease.


Skin growths in the large intestine and rectum (colorectal adenoma).

Insufficient Evidence to Rate Effectiveness for...

Preventing fat redistribution syndrome in people with HIV disease, some types
of cancer and skin conditions, and other conditions.

How does it work?


The husks of the psyllium seed absorb water and form a large mass. In people with
constipation, this mass stimulates the bowel to move. In people with diarrhea, it can
slow down the bowel and reduce bowel movements.

Are there safety concerns?


Blond psyllium is safe for most people when taken with plenty of fluids. Drink at least
8 ounces of fluids for every 3-5 grams of husk or 7 grams of seed. In some people,
blond psyllium might cause gas, stomach pain, diarrhea, constipation, and nausea. It
has also been linked to reports of headache, backache, runny nose, cough, and sinus
problems.

Some people can have an allergic response to blond psyllium with symptoms such as
inflamed nasal passages, sneezing, inflamed mucous membranes of the eyelids, hives,
and asthma. Some people can also become sensitized to psyllium through occupational
exposure or repeated ingestion of psyllium. Discontinue using blond psyllium and seek
medical attention immediately if you develop symptoms such as flushing, severe
itching, shortness of breath, wheezing, swelling of the face or body, chest and throat
tightness, or loss of consciousness.

Do not take blond psyllium if:

You have difficulty swallowing.


You have bowel or intestinal problems such as impaction, obstruction, spasms,
or other bowel problems.
You are scheduled for surgery in the next two weeks.

Are there any interactions with medications?


Carbamazepine (Tegretol)
Interaction Rating = Moderate Be cautious with this combination.
Talk with your health provider.
Blond psyllium contains large amounts of fiber. Fiber can decrease how much
carbamazepine (Tegretol) the body absorbs. By decreasing how much carbamazepine
(Tegretol) the body absorbs blond psyllium might decrease the effectiveness of
carbamazepine (Tegretol).

Digoxin (Lanoxin)
Interaction Rating = Minor Be watchful with this combination.
Talk with your health provider.
Blond psyllium is high in fiber. Fiber can decrease the absorption and decrease the
effectiveness of digoxin (Lanoxin). As a general rule, any medications taken by mouth
should be taken one hour before or four hours after black psyllium to prevent this
interaction.

Ethinyl estradiol
Interaction Rating = Minor Be watchful with this combination.
Talk with your health provider.
Ethinyl estradiol is a form of estrogen that's in some estrogen products and birth
control pills. Some people worry that psyllium can decrease how much ethinyl
estradiol the body absorbs. But it is unlikely that psyllium will significantly affect
ethinyl estradiol absorption.

Lithium
Interaction Rating = Moderate Be cautious with this combination.
Talk with your health provider.
Blond psyllium contains large amounts of fiber. Fiber can decrease how much lithium
the body absorbs. Taking lithium along with blond psyllium might decrease the
effectiveness of lithium. To avoid his interaction take blond psyllium at least one hour
after lithium.

Medications for diabetes (Antidiabetes drugs)


Interaction Rating = Moderate Be cautious with this combination.
Talk with your health provider.
Blond psyllium might decrease blood sugar by decreasing the absorption of sugars
from food. Diabetes medications are also used to lower blood sugar. Taking blond
psyllium with diabetes medications might cause your blood sugar to be too low.
Monitor your blood sugar closely. The dose of your diabetes medication might need to
be changed.

Some medications used for diabetes include glimepiride (Amaryl), glyburide (DiaBeta,
Evelyn Tribole, MS, RD
www.EvelynTribole.com
Etribole@gmail.com
Vitamin D

Chief Functions
▪ Regulates absorption and use of calcium and phosphorus for
development of bones and teeth
▪ Aids in maintenance of healthy nervous and muscular systems by
regulating blood calcium levels
▪ Aids in calcium absorption from intestines and deposition of
calcium in bones/teeth
▪ Prevents excessive urinary loss of calcium and phosphorus
▪ Stimulates maturation of cells and proper formation of skeleton
▪ Helps with maintenance of bones in ears for hearing
▪ Essential for mineral homeostasis

Possible benefits
▪ Insulin—may aid in function of insulin, therefore possibly aiding in regulation of blood glucose
▪ Cancer—might aid in prevention or treatment of cancer by altering growth of cells
▪ Immunity—might assist function, thereby helping defend against infection
▪ Dialysis patients—might improve zinc status

Deficiency symptoms
▪ Osteomalacia (adults)
▪ Rickets (children)
▪ Inadequate mineralization of the bone, leading to malformed bones
▪ Deafness

Stability
▪ Stable to heat and oxidation
▪ Destroyed by excess ultraviolet irradiation

Nutrient-nutrient reactions and absorption


▪ Vitamin A is synthesized in the skin and also absorbed in the small intestine from foods
containing vitamin D
▪ For adequate absorption of vitamin D in the diet, at least 10% of calories must come from fat,
because vitamin D is a fat-soluble vitamin
▪ Conversion of active vitamin D takes place in the liver
▪ Vitamin D is stored in the liver, skin, brain, bones, and other tissues
▪ Cadmium can block the production of vitamin D in the skin
▪ Sunblock with a SPF of 8 or higher prevents vitamin D synthesis
▪ Clouds, smoke, smog, heavy clothing, window glass, and screens decrease vitamin D synthesis
▪ Pantothenic acid (B5) is necessary for the synthesis of vitamin D in the skin

Dietary sources
▪ Fortified milk Cod liver oil Liver
▪ Cheese Butter Eggs
▪ Cream Fatty fish Oysters

1100 Quail Street, #111, Newport Beach, CA 92660  949-654-9904


Evelyn Tribole, MS, RD
www.EvelynTribole.com
Etribole@gmail.com

Groups at highest risk for deficiency


▪ Dark-skinned children
▪ Infants who are breastfed for a prolonged time with no supplementation
▪ Children with inadequate intake of fortified vitamin D milk
▪ Children on anticonvulsant therapy for epilepsy
▪ Persons with intestinal malabsorption
▪ Females who have had multiple pregnancies and have breastfed with little exposure to the sun
▪ Women with a low calcium intake

Other facts
▪ Vitamin D exists in two forms, D2 (ergocalciferol) and D3 (cholecalciferol)
▪ D2 is the supplemental form of vitamin D
▪ D3 is the naturally occurring form of vitamin D, found in foods and manufactured in the skin
with exposure to sunlight
▪ Light-skinned people require 10-15 minutes/day of sun exposure for complete vitamin
synthesis
▪ Dark-skinned people require 3 hours/day of sun exposure for complete vitamin synthesis
▪ Persons with limited exposure to sunlight may require a vitamin D supplement
▪ Toxicity can not occur from too much exposure to the sun
▪ If an infant is breastfed and not exposed to sunlight, a daily supplement of 5-7.5 mcg or 200-
300 IU is recommended
▪ Fortified foods are the major dietary source of vitamin D

Lab Test
25-hydroxy-vitamin D

References
Sizer F, Whitney E. Nutrition Concepts and Controversies. 11th ed. Belmont, CA: Thomson &
Wadsworth; 2008:219-259.

Somer E. The Essential Guide to Vitamins and Minerals. New York, NY: Harper Collins
Publishers; 1992:1-65, 224-246, 287-293.

Schlenker E, Long S. Essentials of Nutrition and Diet Therapy. 9th ed. St Louis, MO: Mosby
Elsevier; 2007:107-144.

US Dept of Agriculture, National Agricultural Library, Food and Nutrition Information Center.
Dietary Reference Intakes: vitamins. Available at:
http://fnic.nal.usda.gov/nal_display/index.php?info_center=4&tax_level=3&tax_subject=256&to
pic_id=1342&level3_id=5140. Accessed July 28, 2008.

1100 Quail Street, #111, Newport Beach, CA 92660  949-654-9904


Evelyn Tribole, MS, RD
www.EvelynTribole.com
Etribole@gmail.com
Folic Acid
(folacin, folate)

Chief functions
▪ Required to make all new cells
▪ Involved in synthesis of DNA, red blood cells, and protein
▪ Acts with vitamin B12 in the production of hemoglobin
▪ Required for practically all biochemical reactions involving one-
carbon transfers
▪ Functions metabolically as a coenzyme

Possible benefits
Heart disease—when folate is in short supply, it is not possible to complete the conversion of
methionine to cysteine, and homocysteine accumulates in the blood; high blood levels of
homocysteine lead to atherosclerosis, adding to risk for cardiovascular disease and stroke

Deficiency symptoms
▪ Impaired cell division
▪ Alterations of protein synthesis
▪ Abnormal digestive function
▪ Immune and nervous system depression
▪ Mental confusion
▪ Fainting
▪ Poor growth
▪ Smooth red tongue

Stability
▪ Unstable to heat and oxidation
▪ Up to 50% lost in preparation, processing, and storage

Nutrient-nutrient reactions and absorption


▪ Converted to its active form in the body with the help of vitamin B12, niacin, and vitamin C
▪ Absorbed directly from small intestine
▪ Absorption of folate becomes more efficient when folate status is low
▪ Small amount of folate is stored in liver and other tissues
▪ An acid environment is required to release folate from its food source and enable its absorption
▪ Absorption of folate depends on its source—approximately 50% of folate occurring naturally in
plant foods is absorbed, compared with 85% of the folic acid added to fortified foods

Dietary sources
▪ Best—green leafy vegetables, brewer’s yeast, liver, and fortified cereals
▪ Other—citrus fruits (especially orange juice), beets, broccoli, wheat bran, other whole grains,
and tomatoes

1100 Quail Street, #111, Newport Beach, CA 92660  949-654-9904


Evelyn Tribole, MS, RD
www.EvelynTribole.com
Etribole@gmail.com

Groups at highest risk for deficiency


• Patients with ulcerative colitis have difficulty absorbing folate. Sulfasalazine can worsen the
problem because it also inhibits absorption of folic acid in the intestine
▪ People who abuse alcohol
▪ Individuals who take certain medications (aspirin and its relatives, anticonvulsants,
Sulfasalazine and oral contraceptives)
▪ Patients with impaired absorption (ie, gastric bypass)
▪ Persons in stressful situations (ie, disease, exercise, etc)

Other facts
▪ DRI for infants and children are based on body weight and the folic acid content of breast milk
▪ 3 mcg/kg of body weight or 100 mcg/day prevents folate deficiency anemia
▪ Folate deficiency is the most common vitamin deficiency
▪ Macrocytic anemia (red blood cell volume >100 milliliters) is caused by folate or B12
deficiency
▪ Deficiency limits cell function, and affects growth and repair of cells and tissues
▪ Inadequate intake of folic acid is linked with the risk of neural tube defects in a fetus during
pregnancy; in 1989, the US Food and Drug Administration ordered all manufacturers of
enriched grain products (breads, cereals, rice, and pasta) to fortify these products with folic
acid
▪ Because supplementation with folic acid began, the incidence of neural tube defects has
dropped by 25%, even in women who have no prenatal care
▪ The amount of folacin in vitamin supplements is limited to 400 mcg to prevent masking of B12
deficiency

References
Sizer F, Whitney E. Nutrition Concepts and Controversies. 11th ed. Belmont, CA: Thomson &
Wadsworth; 2008:219-259.

Somer E. The Essential Guide to Vitamins and Minerals. New York, NY: Harper Collins
Publishers; 1992:1-65, 224-246, 287-293.

Schlenker E, Long S. Essentials of Nutrition and Diet Therapy. 9th ed. St Louis, MO: Mosby
Elsevier; 2007:107-144.

US Dept of Agriculture, National Agricultural Library, Food and Nutrition Information Center.
Dietary Reference Intakes: vitamins. Available at:
http://fnic.nal.usda.gov/nal_display/index.php?info_center=4&tax_level=3&tax_subject=256&to
pic_id=1342&level3_id=5140. Accessed July 28, 2008.

1100 Quail Street, #111, Newport Beach, CA 92660  949-654-9904


Evelyn Tribole, MS, RD
www.EvelynTribole.com
Etribole@gmail.com

Probiotics & Prebiotics

More than 400 types of microorganisms are in your gastrointestinal


tract. Some of these microorganisms are healthy and others are
unhealthy. The healthy bacteria in your gut help to digest food, and
synthesize some vitamins and essential fatty acids. Probiotics are live
microbes that help to improve the balance.

Benefits Of Probiotics
Probiotics allow the healthy bacteria to thrive. They also:
▪ Synthesize vitamins (particularly the B vitamins)
▪ Improve immunity (approximately 60% of your immune cells are found in the intestine)
▪ Decrease allergies (particularly in regard to skin reaction, such as dermatitis or eczema)
▪ May decrease the risk of developing dental caries
▪ May speed recovery from bacterial vaginosis
▪ May lessen the problems associated with inflammatory bowel disease (particularly related to
pouchitis or ulcerative colitis) and irritable bowel syndrome
▪ Seem to help people with lactose intolerance digest dairy products more easily
▪ May improve cholesterol levels
▪ May decrease the risk of colon cancer
▪ May help people suffering from diarrhea associated with antibiotic usage or acute illness

Foods Containing Probiotics


Pasteurization kills probiotics, but many fermented-food manufacturers add them back into the
food. No strict labeling guidelines exist for probiotic-containing foods at this time. The dose
needed for probiotics varies widely, depended on type and formulation. The following foods
contain probiotics:
▪ Yogurt ▪ Buttermilk ▪ Miso
▪ Cottage cheese ▪ Fresh sauerkraut ▪ Kefir
▪ Soy sauce ▪ Tempeh

Benefits Of Prebiotics
Prebiotics are nondigestible substances that feed the probiotics, helping them to thrive in the
gastrointestinal tract. Not all probiotics consumed will survive; it is important to consume
prebiotics with probiotics.

Prebiotics release short-chain fatty acids, which decrease the pH of the colon and, thereby,
enhance mineral absorption, particularly calcium, iron, and magnesium, possibly decreasing the
risk of osteoporosis development. This decrease in pH also leads to the decreased survival of
some pathogenic bacteria. Prebiotics may decrease cholesterol levels and reduce the risk of colon
cancer, as well. Some forms of prebiotics aid in the relief of constipation. Different strains of
prebiotics provide different health benefits.

1100 Quail Street, #111, Newport Beach, CA 92660  949-654-9904


Evelyn Tribole, MS, RD
www.EvelynTribole.com
Etribole@gmail.com

Foods Containing Prebiotics


▪ Flax ▪Oatmeal ▪ Honey
▪ Jerusalem artichoke ▪ Onion ▪ Bananas
▪ Wheat ▪ Garlic ▪ Leafy greens
▪ Barley ▪ Leeks ▪Berries
▪ Rye ▪ Legumes ▪Asparagus

Best Sources Of Probiotics Or Prebiotics


Use this chart to identify the best sources of probiotics or prebiotics for a variety of conditions:

Condition Recommended Probiotics/Prebiotics


Diarrhea from antibiotic usage Lactobacillus rhamnosus GG
Saccharomyces boulardii
Enterococcus faecium
Streptococcus thermophilus
Bacillus clausii
Lactibacillus acidophilus
Irritable bowel syndrome Lactobacillus plantarum
Bifidobacterium infantis
Lactobacillus rhamnosus GG
Vaginal yeast infection Lactobacillus acidophilus
Weakened immunity Lactobacillus rhamnosus
Lactobacillus plantarum
Lactobacillus salivarius
Bifidobacterium bifidum
Lactose indigestion Lactobacillus bulgaricus
Streptococcus thermophilus
Constipation (prebiotics) Lactulose
Oligofructose

Resistant Starch
Resistant starch helps to feed probiotics, similarly to prebiotics. Resistant starch is found in
cooked starchy products, such as hot cereals, and unripe fruit, such as bananas that are still firm
to the touch. On food labels, resistant starch is referred to as starch, modified food starch, corn
starch, or maltodextrin.

Probiotic And Prebiotic Supplements


Only live microorganisms are classified as probiotics; avoid any that are not live. Prebiotics are
consumed in different ways, including:
▪ Sprinkled on food
▪ Stirred into liquid
▪ Taken in capsule form
▪ Purchased in prebiotic-fortified foods and beverages, such as sports drinks

1100 Quail Street, #111, Newport Beach, CA 92660  949-654-9904


Evelyn Tribole, MS, RD
www.EvelynTribole.com
Etribole@gmail.com

Restrictions
Individuals who are immunocompromised or have compromised gut integrity should only use
these products under the advisement of a doctor.

References And Recommended Readings


International Food Information Council. Functional foods fact sheet: Probiotics and prebiotics.
Available at: http://www.ific.org/publications/factsheets/preprobioticsfs.cfm. Accessed July 8,
2008.

World Gastroenterology Organisation. World Gastroenterology Organisation Practice


Guidelines: probiotics and prebiotics. Available at:
http://www.worldgastroenterology.org/assets/downloads/en/pdf/guidelines/19_probiotics_prebiot
ics.pdf. Accessed July 8, 2008.

Roberfroid MB. Am J Clin Nutr [serial online]. 2000;71:1682S-1687S. Probiotics and prebiotics:
are they functional foods? Available at: http://www.ajcn.org/cgi/content/full/71/6/1682S.
Accessed July 8, 2008.

Douglas LC, Sanders ME. Probiotics and prebiotics in dietetics practice. J Am Diet Assoc.
2008;108:510-521.

1100 Quail Street, #111, Newport Beach, CA 92660  949-654-9904


EVELYN TRIBOLE, MS, RD Page 1 6/3/09 Page 1 of 3

How Much Fish Oil?


By Evelyn Tribole, MS, RD
There are literally hundreds of studies on the various conditions in which fish oil may be helpful (from basic health
to stress reduction). Yet, there is little consensus among the experts as to which omega-3 fatty acid (particularly,
EPA and DHA) is providing the benefit let alone the effective amount. While it may seem that the scientists can’t
make up their minds, the problems usually lie with the study design, making it difficult to assess effectiveness, not to
mention the right dose. Here are a few common reasons there are conflicting results on omega-3 studies:
• Failure to evaluate or account for the background diet: including the amounts of omega-3 and omega-6 fats eaten.
• Few direct comparisons of different sources, doses and ratios of fatty acids
• Failure to use biomarkers to assure compliance of supplement.
The gold standard for studies is the randomized double-blind design, in which neither researcher nor subject know who is getting the omega-3
or placebo. But even some of these controlled trials suffer from the study design limitations described above. That said, the following charts
list amounts of fish oil recommended for particular conditions. When there is not a clear dose, the range of effective doses used in studies is
provided. Unless otherwise stated, the doses on the charts to follow, are combined totals for EPA + DHA. One gram is equivalent to 1000
milligrams. Keep in mind that a one gram capsule of fish oil is not 100% EPA/DHA. Remember to always check with your physician before
taking fish oil, especially in amounts exceeding 3000 milligrams (the level deemed Generally Recognized as Safe by the FDA).
Baseline Recommendations for Health
International guidelines were published in 2000, by a respected group of fatty-acid scientists, from a meeting organized by the International
for the Study of Fatty Acids and Lipids (ISSFAL). You can meet these levels by eating an average of 10 ounces of fatty fish per week.
Age EPA + DHA (combined) EPA minimum DHA minimum
milligrams milligrams milligrams
2-3 years old 433 145 145
4-6 years old 600 200 200
7 years and over (including adults) 650 220 220
Pregnant or Breastfeeding 650 220 300

lFrom: Tribole. E. Ultimate Omega-3 Diet.(2007) McGraw-Hill: Ny, NY


EVELYN TRIBOLE, MS, RD Page 2 6/3/09 Page 2 of 3

“Official” Recommendations by Scientific Organizations


These fish oil recommendations are issued by scientific organizations, based on expert review committees.
Condition EPA + DHA Organization Source
Hypertriglyceridemia 2-4 g/day Am. Heart Association Kris-Etherton.Circulation. Circulation. 2002 Nov 19;106(21):2747-57.

Heart Disease 1g/day Am. Heart Association Kris-Etherton.Circulation. Circulation. 2002 Nov 19;106(21):2747-57.

Patients w/ Mood, Impulse- 1 g/ day Am. Psychiatric Assoc. Freeman MP et al.Omega-3 fatty acids: evidence basis for treatment and future
Control or Psychotic Disorders. research in psychiatry.J Clin Psychiatry. 2006 Dec;67(12):1954-67.
Mood Disorders 1-9 g/day Am. Psychiatric Assoc Freeman MP et al. 2006 Dec;67(12):1954-67.

Conclusion of Meta-Analysis Scientific Review Papers


These health conditions treated by fish oil are the results of a systematic review process of several studies, which conclude with a specified
dose. (Meta-analysis is a process in which studies are identified based on strict criteria and then evaluated for effectiveness).
Condition Fish Oil Dose/day Comments Source
(EPA + DHA)
3.7 g Reviewed 124 trials and of these, 36 studies fulfilled Geleijnse J et al. Blood pressure response to fish oil
scientific criteria (including randomized placebo- supplementation: metaregression analysis of
randomized trials. J of Hypertension. 2002;20(8):
controlled design). There was a significant reduction in
Hypertension 1493-1499.
blood pressure, usually with a high dose. Notably, one
(high blood
of the studies used a small dose of 180 mg(EPA + Theobald H E, et al. Low-dose docosahexaenoic
pressure) acid lowers diastolic blood pressure in middle-aged
DHA)/day, which effectively lowered blood pressure. A
new study (not included above), found that 700mg of men and women. J Nutr. 2007;137(4):973-8.
DHA lowered blood pressure in healthy adults.
Pain: joint >2.7 g Reviewed 24 studies, and of these 17 studies met Goldberg RJ et al. A meta-analysis of the analgesic
pain from scientific criteria, (randomized placebo-controlled effects of omega-3 polyunsaturated fatty acid
supplementation for inflammatory joint pain.
PMS, Irritable trials). Supplementation reduced pain in patients with Pain.2007;129(1):210-223.
Bowel or joint pain from inflammatory bowel disease, rheumatoid DOI:10.1016/j.pain.2007.01.020)
rheumatoid arthritis or dysmenorrhea, resulting in less pain meds
arthritis. (NSAID’s) taken.
2.7-6 g There have been at least 14 published randomized Stamp LK et al. Diet and Rheumatoid Arthritis: A
controlled trials of fish oil in RA. Fish oil reduced RA Review of the Literature. Seminars in Arthritis and
Rheumatoid Rheumatism. 2005;352: 77-94.
symptoms in a dose dependent manner. Omega-3 Cleland , LG. Fish Oil: What the Prescriber Needs to
arthritis (RA)
supplementation with a diet low in Arachidonic Acid Know . Arthritis Research and Therapy. 2006;
(potent omega-6) results in greater improvement. 8:202.

lFrom: Tribole. E. Ultimate Omega-3 Diet.(2007) McGraw-Hill: Ny, NY


EVELYN TRIBOLE, MS, RD Page 3 6/3/09 Page 3 of 3

Promising Scientific Studies


While more research is need for these health conditions ameliorated by fish oil, enough studies exist that it merited a scientific review
process, yet there are not enough data/studies to recommend a specific dose.
Condition Age (years) Fish Oil Dose per day Comments Source
(EPA + DHA)
Crohn’s Adults 2.7-5.6 grams 12 randomized placebo Calder P. Recommendations for
Disease/Inflammatory controlled studies showed a Therapeutics and Prevention: n–3
Bowel Disease benefit, including longer Polyunsaturated fatty acids,
remissions. inflammation, and inflammatory
diseases. Am. J Clinical Nutr.
2006; 83(6):S1505-1519S.
Crohn’s/ 5-16 400 mg EPA + 200 Omega-3s prevented relapse in a Romano, C et al. Usefulness of ω-3 fatty acid
Irritable Bowel Disease mg DHA double-blind study on children with supplementation in addition to mesalazine in
Crohn’s disease.Notably, the fish oil maintaining remission in pediatric Crohn’s
group had fewer relapses by 61% at disease: A double-blind, randomized, placebo-
the end of one year. Whereas, 95% of controlled study. World J Gastro.2005;
the kids receiving just standard 11(45): 7118-7121.
medications relapsed by the first
month.

lFrom: Tribole. E. Ultimate Omega-3 Diet.(2007) McGraw-Hill: Ny, NY