Omega-3 Oils: Applications in Functional Foods

durability.

Preface

The growing awareness regarding nutritional properties of edible oils has prompted a great deal of research in the development of new sources of edible oils with more healthful compositions. Besides playing an important role in food processing and nutrition, lipids are essential components of many metabolic functions and this is particularly true for omega-3 fatty acids such as eicosapentaenoic acid (EPA) and (DHA). The role of essential fatty acids in nutritional and disease prevention, particularly, omega-3 fatty acids have been studied in numerous health applications. As the general population grows older, formulation and composition profiles of edible fats and oils have become more specialized and the need for novel sources of omega-3 fats has also increased. The general awareness of the health benefits of omega-3 fatty acids is reflected by the growth in consumption of omega-3 fats either as dietary supplements or in fortified foods. EPA is generally associated with cardiovascular protection, and has been reported to have strong anti-inflammatory, anti-thrombotic, anti-arrhythmic, and anti-atherogenic. DHA on the other hand is generally related with cell structures and has been found to be particularly important in neurologically related metabolism, such as brain and retina development and function, and has become an important nutrient in prenatal and post-natal nutrition for mother and children.

This book addresses the role omega-3 plays in general in health and disease. Some chapters review the latest clinical evidence on the impact of n-3 PUFA consumption on prevalent human diseases such as inflammation related illnesses in general and cardiovascular disease in particular. These reviews emphasize preferentially on selected meta-analyses and some chapters are actually original data to demonstrate the beneficial effects of long chain omega-3s. When processing omega-3 oils, it is important and precautions have to be taken to minimize conditions that can destroy the nutritional properties of the omega-3s and generation of unwanted fishy taste and aroma making the oil and food products unacceptable for consumption. The book also examines the different aspects of processing fish oil and other omega-3 fats taking into account issues such as preservation of the nutritional properties, the essential fatty acids, and how fats interact with other components and nutrients in food products in a focused and coordinated manner. Lastly but not least important, this book also explains different methods to deliver omega-3 to the consumer, either through food fortification, nutritional supplements, and also newly developed pharmaceutical products. Including methods used in the protection of the oil against oxidation and techniques of incorporation into foods.

Ernesto M. Hernandez and Masashi Hosokawa

1

Omega-3 Fatty Acids in Health and Disease

Fereidoon Shahidi,     Department of Biochemistry, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada

Introduction

The omega-3 (n-3) fatty acids belong to the family of polyunsaturated fatty acids (PUFAs) with three or more double bonds with the first unsaturation site occurring on the third carbon from the methyl end group. The location of the first unsaturation site dictates the biological activity of the molecules involved. Other double bonds are positioned in a methylene-interrupted manner with respect to the first and subsequent double bonds. Omega-6 fatty acids constitute another family of PUFAs; the first member of this family is linoleic acid (LA, 18:2n-6).

The first member of the omega-3 family and the parent molecule in this series is alpha-linolenic acid (ALA, 18:3n-3), which is abundant in flaxseed oil and is also present in canola, soybean, and walnut oils, among other commodities. Meanwhile, stearidonic acid (18:4n-3) has been detected in viable amounts in several species of algae, fungi, and animal tissues, as well as seeds of Echium (Boraginaceae). It has also been produced in soybean transgenitically. The other important omega-3 fatty acids, namely eicosapentaenoic acid (EPA, 20:5n-3), docosahexaneoic acid (DHA, 22:6n-3), and to a lesser extent, docosapentaenoic acid (DPA, 22:5n-3), are found in high amounts in certain algal species and in marine oils, primarily those from the body of fatty fish species such as herring and mackerel, the liver of lean white fish such as cod and halibut, and the blubber of marine mammals such as whales and seals. These important all cis omega-3 oils may also be recovered from processing by-products of wild catch and aquaculture fisheries (Shahidi, 2007; Zhong et al., 2007). While alpha-linolenic acid may be metabolized in the body via a series of desaturation and elongation reactions (Fig. 1.1), the production of long-chain omega-3 PUFA from ALA is limited and may vary from 1 to 5% (Shahidi & Finley, 2001). This is because conversion of ALA to stearidonic acid (SA, 18:4n-3) via the action of DELTA-6 desaturase is the slowest and thus the rate-determining step. This enzyme may be impaired and its activity reduced owing to aging, disease condition, lifestyle factors, micronutrient deficiency, or to use of certain drugs. Thus, adequate dietary intake of long-chain PUFA is generally recommended to maintain health and reduce disease risk. The fatty acid composition of selected plant, algal, and animal sources of omega-3 fatty acids are summarized in Table 1.A.

Table 1.A

Fatty Acid Composition of Omega-3 Oils.a

aSeal blubber oil contains 12.2% of 20:1 and 2.0% of 22:1.

Fig. 1.1 The n-6 and n-3 fatty acids and their metabolites. Abbreviations: EFA, essential fatty acids; LA, linoleic acid; ALA, α-linolenic acid; GLA, γ-linolenic acid; SA, stearidonic acid; PG, prostaglandin; DGLA, dihomo-γ-linolenic acid; ETA, eicosatetraenoic acid; AA, arachidonic acid; EPA, eicosapentaenoic acid; DPA, docosapentaenoic acid; DHA, docosahexaenoic acid.

Omega-3 Fatty Acids in Food and Daily Intake Requirements

As it was noted, plant sources of omega-3 oils provide ALA, which may promote health. However, the importance of omega-3 fatty acids is often ascribed to the long-chain PUFAs, especially EPA and DHA. The total content of EPA and DHA in various fish varies and depends on the type of fish and their habitat. The proportion of omega-3 fatty acids in fish muscle is higher in fatty fish such as herring, mackerel, and salmon than in lean fish such as cod, flounder, haddock, perch, and halibut (Table 1.B). Meanwhile, shellfish such as crab (0.3%–0.4%), shrimp (0.2%–0.5%), and lobster (0.3%–0.4%) have low levels of omega-3 fatty acids, and mollusks may also contain low levels of omega-3 fatty acids (e.g., squid, scallops, oysters, and mussels, 0.2%–0.6%) or no omega-3 fatty acids (abalone and some species of clam) (Shahidi, 2006; 2007; Barrow & Shahidi, 2008).

Table 1.B

Content (g/100g) of Omega-3 Fatty Acids (EPA + DHA)a in Selected Fish.

aEPA, eicosapentaenoic acid; DHA, docosahexaenoic acid.

The total recommended daily intake of EPA and DHA is age-dependent. It should be up to 1.5 g for children 1–8 years old, 2.0 g for 9–13 years old, and 2.5 g for 14–18 years old; this value may reach up to 3.0 g/day for adults, depending on the purpose and type of studies conducted. Owing to the oxidizability of such oils, their supplementation with antioxidants such as vitamin E is recommended. However, most suppliers of fish oil capsules generally add vitamin E to their products in order to arrest oxidative processes; this would also address the increasing need of the body on antioxidants because of consumption of highly unsaturated lipids which would otherwise cause oxidative stress. Although manufacturers as well as consumers of dietary supplements may use alpha-tocopherol, mainly d-alpha-tocopherol, manufacturers of omega-3 capsules often use mixed tocopherols from soybean oil-refining deodorizer-distillate, which is rich in gamma-tocopherol, as a source of vitamin E for stabilizing the oil because gamma-tocopherol is a much more effective antioxidant than alpha-tocopherol in vitro and hence it better protects the oil from oxidative deterioration.

In order to take advantage of omega-3 fatty acids, there has been a surge in the retail market in the appearance of fortified foods as well as a myriad of dietary supplements containing omega-3 fatty acids—occasionally ALA, but mainly EPA and DHA (Shahidi, 2006). Although use of such oils has traditionally been restricted owing to their instability and flavor reversion, availability of stabilized products such as microencapsulated and coacervated marine oils have allowed manufacturers to offer a variety of products. These include cereal-based products such as crackers, bars, bread, and pasta; dairy-based products such as milk, yogurt, and specialty dairy-based drinks; and juices, such as orange juice, as well as other commodities. Table 1.C summarizes the types of products in which omega-3 oils may be used for fortification and/or enrichment purposes. In addition, candies, pastries, and other confectionary products containing omega-3 fatty acids have appeared. Furthermore, meat products and even seafoods have been fortified in test markets and in product development. These formulated commodities either use microencapsulated and coacervated marine oils and do not release their content until it reaches the gastrointestinal tract or employ stabilized omega-3 oils by using sophisticated refining techniques and powerful antioxidants.

Table 1.C

Different Classes of Food Products Enriched with Omega-3 Fatty Acids.

For therapeutic purposes, concentrates of omega-3 fatty acids—for example, up to 75% omega-3 content, or even capsules containing pure omega-3 fatty acids—may be used for certain health conditions. The concentrates may be in the ethyl ester form or as triacylglycerols, reconstituted to appear as natural or true-to-nature. Commercially available concentrates may contain equal amounts of EPA and DHA, or predominantly EPA or DHA, depending on the end use. Procedures used for concentration of omega-3 fatty acids are varied and are beyond the mandate of this brief overview (Shahidi & Wanasundara, 1998).

Omega-3 Fatty Acids in Health and Disease

Marine oils and their omega-3 fatty acids provide the best example of functional food ingredients and nutraceuticals that may serve as a continuum for their perceived and demonstrated health benefits. Thus, they may prevent ailments caused by their deficiency, such as those encountered in the body, and secondly they aid in reducing disease risk, and thirdly they act as therapeutic agents in treating certain diseases or conditions.

A large body of literature provides information about the health benefits of omega-3 fatty acids, mainly those arising from EPA and DHA. EPA and DHA serve as building blocks of cells in vital organs, particularly those with electrical activity such as the brain, the heart, and the eye, and also are important for normal growth and development (Shahidi & Miraliakbari, 2004; 2005). Therefore, adequate intake of omega-3 fatty acids by pregnant and lactating women is encouraged in order to address the need of the fetus or the infant for these essential components that are necessary for the development of the retina and the brain. Whereas most studies have examined the health benefits of EPA and DHA, research on DPA is rather limited because this fatty acid occurs in minor amounts in seafoods and marine oils. However, DPA, which is found in relatively high abundance in blubber of marine mammals such as seal blubber oil, may play a major role in health promotion and disease prevention (Kanayasu-Toyoda et al., 1996). It is worth noting that ALA supplementation increased the concentration of ALA, EPA, and DPA (but not DHA) in breast milk lipids (Francois et al., 2003).

As mentioned earlier, DHA is an important component of the brain, and studies have clearly indicated that infant formulas devoid of omega-3 fatty acids may adversely affect the intelligence quotient, verbal skill, and general performance of the infants when compared with mother’s milk that is rich in omega-3 fatty acids. It has also been shown that omega-3 fatty acids are important in addressing attention deficit/hyperactivity disorder, dyslexia, mental health issues, depression, schizophrenia, and memory problems as seen in Alzheimer’s disease and dementia, as well as in certain respiratory disorders.

With respect to heart health and associated benefits, omega-3 fatty acids are important in providing a myriad of benefits. These benefits are ascribed to their effect in reducing the risk of stroke and heart disease; reducing blood thickness and blood pressure; reducing the risk of blood clotting and hardening of the arteries; providing relaxation to blood vessels; reducing the level of triacylglycerols; and finally protecting against arrhythmia, ventricular tachycardia, and fibrillation. The latter two effects have been fully documented in the existing literature.

In addition, omega-3 fatty acids may have a positive effect on patients with type-2 diabetes and those with inflammatory disorders, including arthritis and bowel problems, such as Crohn’s disease, among others. Skin disorders are also often alleviated, and the shine of the hair (or fur in animals) is improved by consumption of omega-3 fatty acids. Fish oils may also increase low-density lipoprotein (LDL) cholesterol concentration in the body. It is therefore beneficial to use garlic and/or garlic extracts or phytosterols together with fish oils in multicomponent products in order to take advantage of the cumulative effect of such mixed products. Omega-3 oils may also be useful in the treatment of certain types of cancer and mental disorders and could affect gene expression. A cursory account of these health benefits and influence on gene expression is provided in the following section.

Omega-3 Fatty Acids and Cardiovascular Disease

Cardiovascular disease is the common term for all diseases that affect the heart and the circulatory system, including ischemic heart disease, non-ischemic myocardial heart disease, hypertensive heart disease, and valvular heart disease. It is the leading cause of death in the western societies (de Lorgeril et al., 2002) and has been linked to the high fat intake, particularly saturated fat, common in western diets (Dolocek & Granditis, 1991). The hallmark of cardiovascular disease is cardiac dysfunction, which in most cases is caused by hypertension due to the narrowing of large arteries with atheromatous plaques, or the total occlusion of coronary arteries (thrombus) caused by atheromatous blockages leading to myocardial tissue necrosis. Both conditions reduce the heart’s ability to pump blood and can result in either chronic or sudden heart failure.

It is well known that regular consumption of fatty fish or fish oils containing n-3 long-chain PUFA lowers the rate of incidence and death from cardiovascular heart disease (Albert et al., 2002; Hu et al., 2002). The cardioprotective effects of marine oils were first postulated in the 1950s based on cross-cultural studies done on Greenland Inuits and Danish settlers of Greenland (Sinclair, 1956). These studies demonstrated that the Greenland Inuits had a significantly lower incidence of heart disease compared to the Danish settlers, despite their comparable fat intakes (40% of caloric intake) and a higher intake of dietary cholesterol. This anomaly was referred to as the ‘Eskimo Paradox’ (Bang et al., 1980). Epidemiological studies carried out in the 1970s suggested a strong correlation between the low incidence of coronary heart disease in Greenland Inuits and their high consumption of fish and marine mammals, both being rich in long chain n-3 fatty acids (Fischer & Weber, 1984). Other cross-cultural epidemiological studies among coastal Japanese and Alaskan populations lend further support to these findings, showing inverse relationships between long chain n-3 PUFA intake and cardiovascular disease (Hirai et al., 1989; Davidson et al., 1993).

Although the biochemical basis for cardioprotective effects of n-3 PUFAs remains unknown, it may be multifactorial and could collectively result in anti-arrhythmic, anti-atherogenic and decreased platelet reactivity/aggregation (anti-thrombotic). Investigations on the link between fish oils and cardiovascular disease in both animal and human models have concluded that this effect may be mediated by substrate competition between n-3 PUFA and arachidonic acid (AA, 20:4n-6) for cyclooxygenase (COX) enzymes that produce prostaglandins and thromboxanes. Competition between n-3 PUFA and AA could result in positive health benefits because a) n-3 fatty acids inhibit the production of AA through substrate competition for the DELTA-6 desaturase, b) long chain n-3 PUFA compete with AA for incorporation into the sn-2 position of membrane phospholipids thereby reducing membrane AA levels (Siess et al., 1980), and c) eicosanoids produced from EPA have anti-inflammatory and anti-aggregatory effects, for example increasing the membrane EPA/AA ratio shifts eicosanoid production from the pro-aggregatory eicosanoids PGI2 and TXA2 towards the anti-aggregatory TXA3 in platelets (Coker & Parratt, 1985) and PGI3 in endothelial cells (Fischer & Weber, 1984). These actions would result in vasodilation and decreased platelet aggregation, both having anti-thrombotic effects.

The potential anti-arrhythmic properties of n-3 PUFAs, such as ALA, EPA, and DHA, have been examined in animal models. In one such study, intravenous infusion of either fish oil or pure n-3 fatty acids in exercising dogs before an experimentally induced coronary artery obstruction reduced sudden cardiac death by preventing ventricular fibrillation (Billmann et al., 2000). The mechanisms of the antiarrhythmic effects of n-3 PUFAs have been further explored using spontaneously contracting cultured cardiac myocytes isolated from rats (Kang & Leaf, 2000). The cultured rat myocytes were induced to fibrillation using various toxic agents such as ouabain, beta-adrenergic agonists, and high Ca²+ concentrations added to the bathing medium. EPA and DHA added at low doses of 5–15 mu mol/L in the bathing medium inhibited the expected fibrillation when the toxic agents were added to the media (de Lorgeril et al., 1998). Interestingly, when the added EPA and DPA were removed from the culture media using delipidated bovine serum albumin, the cultured myocytes returned to fibrillation. Thus, n-3 PUFAs at low concentrations are able to modulate the activity of specific ion channels in myocardial sarcolemma.

One of the most effective ways to protect the myocardium from ischemic/reperfusion injury is by inhibition of the transmembrane Na+/H+ antiport exchanger. This transmembrane antiport system maintains the myocardial cell’s pH, but during ischemia this system paradoxically participates in cell necrosis. The importance of transmembrane Na+/H+ antiport exchanger in ischemic heart disease was shown in a clinical trial using a specific Na+/H+ exchange inhibitor caporide (Theroux et al., 2000). The inhibitor showed a potential benefit in reducing the risk of cardiac death as long as it was taken prior to the ischemic event (Amusquivar et al., 2000). It has recently been shown that EPA and DHA at concentrations of 25–100 mu M inhibited the Na÷/H+ antiport exchanger in isolated cardiomyocytes and, thus, could protect the myocardium from arrhythmias and cell death during ischemic events. This effect was limited to long chain n-3 fatty acids, as LA and ALA showed no significant effects on the Na+/H+ exchanger (Goel et al., 2002). Although the role of ALA in the prevention of arrhythmia caused by ischemia or during reperfusion remains unclear, the metabolic conversion of ALA to EPA is thought to mediate any of the cardioprotective effects of ALA, and at least one study using a canine model revealed cardioprotective effects with ALA (Chaudry et al., 1994).

The diet and reinfarction trial (DART) was the earliest controlled trial that examined the effects of dietary intervention in the secondary prevention of myocardial infarction (Burr et al., 1989). The study included 2033 Welsh men who had recovered from an earlier heart attack and were allocated to one of two groups that received or did not receive advice on each of three dietary factors, namely reduced fat intake and an increased ratio of polyunsaturated to saturated fat, increased intake of fatty fish, and increased consumption of cereal fiber. The results of this landmark trial revealed that men receiving at least 2 fatty fish meals per week (200–400 g of fish meat or 1.5 g fish oil per day through supplement) had a 29% reduction in fatal heart attack risk, which was apparent after 4 months of intervention, when compared to the non-fish consuming groups, but there was no significant reduction in the incidence of non-fatal heart attacks. The results of this study strongly suggest that marine n-3 fatty acids have a specific antiarrhythmic effect rather than anti-atherogenic or anti-thombotic effects (Burr et al., 1989).

The GISSI (1999), or Gruppo Italiano per lo Studio della Sopravvienenza nell ‘Infarto Miocardio Prevenzione, study was initiated in 1993 and carried out over 3.5 years. This multicentered trial was conducted in Italy (172 centres) and included 11,324 patients who had suffered a heart attack less than 3 months prior to recruitment. Just as in the DART study (Thun et al., 1991), the GISSI Prevenzione study revealed that marine n-3 fatty acid intake conferred early and progressive risk reductions for cardiovascular disease.

The Lyon Diet Heart Study (de Lorgeril et al., 1998) conducted in France was one of the earliest intervention trials (with 204 control subjects and 219 experimental subjects), making the hypothesis that a Mediterranean diet high in ALA could reduce the relative risk of cardiovascular events and/or death in previous heart attack victims. After 1 year of study, total cardiovascular events were reduced from 34.7% in the control group to 24.5% in the fish oil group and 28% in the mustard oil group (Narayanan et al., 2001).

Omega-3 Fatty Acids and Inflammatory Diseases

Chronic inflammation associated with diseases such as inflammatory bowel disease, psoriasis, atherosclerosis, and rheumatoid arthritis may be caused or attenuated by alterations of normal cytokine pathways resulting in cytokine overproduction. Many anti-inflammatory pharmacotherapies have been developed to inhibit the production of pro-inflammatory cytokines. Omega-3 fatty acids may be used in the treatment and/or management of inflammatory diseases because they alter the cytokine biosynthesis (Wanasundara & Shahidi, 1997).

Arachidonic-acid-derived cytokines have proinflammatory actions in-vivo, whereas those derived from EPA are significantly less proinflammatory (Shoda et al., 1995; Bagga et al., 2003). Studies investigating the effects of n-3 PUFAs on ex-vivo cytokine production by leukocytes is an active area of research, but these studies have produced inconsistent results. Mantzioris et al. (2000) showed a 20% decrease in ex-vivo IL-1 beta production in healthy men after 4 weeks of supplementation with 1.8 g of fish oil per day, demonstrating that n-3 PUFAs affect cytokine production by leukocytes, but this study was not a controlled trial. Results of a recent placebo-based, double-blind, parallel study involving 150 healthy men and women aged 25–72 years who were supplemented with ALA or fish oil revealed no significant differences in ex-vivo cytokine production (TNF-alpha, IL-6, IL-1beta and IL 10) between the placebo and intervention groups after 6 months of supplementation (Kew et al., 2003). However, they did show that monocytes had significantly increased levels of ALA in participants supplemented with α-linolenic acid, and increased monocyte EPA and DHA levels in those given fish oil. Both n-3 groups also had lowered monocyte AA levels compared to the control group, which might lead to decreased synthesis of the pro-inflammatory LTB4 in-vivo (Tilley & Maurice, 2002). Although the mechanisms by which n-3 fatty acids suppress the production of inflammatory cytokines are unknown, the suppression of inflammatory eicosanoid production by EPA is likely to be involved.

Inflammatory bowel disease (IBD) is a general term for chronic inflammatory diseases of the gastrointestinal tract and mainly includes ulcerative colitis and Crohn’s disease. The incidence of ulcerative colitis and Crohn’s disease is higher and rising in Western countries compared to Asian countries, and epidemiological studies have attributed this trend to high intake of saturated and n-6 PUFA in typical western diets (Shoda et al., 1996).

The effects of n-3 fatty acid supplementation in IBD have been studied using many animal models. Thus, the effects of perilla oil (n-3, alinolenic acid rich), fish oil (n-3 long chain fatty acid rich), and safflower oil (n-6 fatty acid rich) supplementation on ulcer formation and pro-inflammatory cytokine production in rats have been examined. These results suggest that ALA may be superior to EPA and DHA for controlling intestinal inflammation in experimentally induced Crohn’s disease, but the authors could not rule out the possibility of synergistic effects between n-3 fatty acids and other bioactives in perilla oil (Shoda et al., 1995). Nieto et al. (2002) used the trinitrobenzenesulfonic acid model to study the effects of n-3 fatty acid supplementation on ultrastructural and histological changes during experimentally induced ulcerative colitis in rats and revealed that rats given an n-3 fatty acid rich diet had significantly less macroscopic and microscopic colonic damage when compared to both the n-6 group and the n-6 plus n-3 group. In addition, the n-3 group had significantly lower inflammatory marker levels when compared to both other groups, which strongly suggest that n-3 fatty acids are therapeutic, whereas n-6 fatty acids exacerbate experimentally induced ulcerative colitis. Another model study uses 4% acetic acid feeding to induce IBD. Thus, using this model, rats given a fish oil (EPA) enriched diet for 6 weeks after treatment had improved intestinal function and considerably less histologic injury compared to rats given low n-3 fatty acid diets after treatment, demonstrating that n-3 PUFAs, especially EPA, have protective effects against acetic acid induced colitis (Empey et al., 1991).

Although animal models provide strong evidence for the protective effects of n-3 fatty acids against induced IBD, such models may not accurately portray the human etiology of this disease since it is induced using noxious chemicals. Several epidemiological studies have shown an inverse relationship between n-3 fatty acid intake and the risk of IBD. In addition, some intervention studies have shown that n-3 fatty acid supplementation is an effective therapeutic means to manage these diseases (Alsan & Triadafilopoulos, 1993). A 24-year study showed that the Greenlandic people who consumed a diet rich in marine-derived n-3 fatty acids exhibited a significantly lower incidence of inflammatory bowel disease when compared to Western populations. Furthermore, the incidence of Crohn’s disease and dietary habits among Japanese men and women over a 19-year period was examined (Shoda et al., 1996). This study showed that individuals with lower dietary n-6/n-3 ratios were 21% less likely to suffer from Crohn’s disease (RR 0.79). IBD sometimes exhibits alternating relapses and remissions, and some clinical studies have investigated the potential of n-3 fatty acids to prolong periods of remission. Belluzzi et al. (1996) carried out a double blind, placebo-based study to investigate the effects of 2.7 g per day of fish oil supplements in 78 patients with Crohn’s disease who were at high risk for relapse as assessed by the Crohn’s Disease Activity Index. After one year, 59% of patients in the fish oil group remained in remission (23 out of 39) compared to 26% in the placebo group (10 out of 39). Further analysis revealed the difference in relapse rate between the two groups to be due to fish oil supplementation only; cigarette smoking, gender, previous surgery, age, and duration of the disease did not affect the likelihood of relapse. In addition, examination of blood for indicators of inflammation (serum as–acid glycoprotein, serum a2-globulin) revealed that the fish oil group had a significant decrease in all inflammatory markers assayed compared to the control group after one year.

Not all studies have supported the therapeutic effects of n-3 fatty acids in inflammatory bowel disease sufferers. For example, Lorenz-Meyer et al. (1996) performed a double-blind, placebo-based trial on 204 Crohn’s disease patients in remission to study the effects of highly concentrated n-3 PUFAs on the maintenance of remission over a 12-month period. At the end of this trial there was no difference between the n-3 and the control groups; specifically, 30% of patients in both groups remained in remission. However, at the end of this study it was noticed that the n-3 group required less drug therapy (prednisolone) to manage the disease compared to the control group. This result implies that n-3 fatty acid supplementation may be somewhat helpful in the treatment of Crohn’s disease. A recent clinical trial by Middleton et al. (2002) of 63 ulcerative colitis patients studied the effects of a combination of fish- and plant-derived n-3 fatty acids on disease remission. After 12 months, duration of remission was not significantly different (P:0.05) between groups (n-3 group: 55% remained in remission, control group: 38% remained in remission). Based on these results, although there was a 17% increase in disease remission in the n-3 group, Middleton et al. (2002) were unable to support the therapeutic benefits of n-3 fatty acid supplementation. The insignificant effects of n-3 fatty acids may be due to the relatively low doses of n-3 fatty acids used in the study (1.9 g total).

There is a wealth of evidence both supporting and refuting the therapeutic potential of n-3 fatty acids for inflammatory bowel diseases. The conflicting results are most likely due to differences in study size, duration, source of n-3 fatty acids, and the amount of n-3 fatty acids provided. Therefore, more animal studies are needed to develop a comprehensive biochemical basis for the theorized effects of n-3 fatty acid supplementation in the treatment of inflammatory bowel diseases.

The effects of n-3 fatty acid supplementation in patients with arthritis, particularly rheumatoid arthritis, have been investigated and the effects of manipulating dietary fat intake on clinical outcomes in patients with rheumatoid arthritis have been examined (Kremer et al., 1985). The n-3 group reported noticeable reduction in morning stiffness and number of tender joints. The beneficial results were attributed to the intervention regimen conducted on the n-3 supplemented group by this group. Volker et al. (2000) carried out a randomized, placebo-based, double-blind clinical study to determine the effects of fish oil supplementation on clinical variables. After 15 weeks of supplementation, there was a significant improvement (p<0.02) in the clinical status of patients in the n-3 group compared to the placebo group. Although trials by Kremer et al. (1985) and Volker et al. (2000) do provide evidence about therapeutic benefits for n-3 fatty acid supplementation in rheumatoid arthritis, neither of these clinical trials were long-term studies, lasting 12 and 15 weeks, respectively. Geusens et al. (1994) studied the long-term effects of n-3 fatty acid supplementation in patients with active rheumatoid arthritis in a 12-month double-blind, randomized study. Ninety subjects who did not receive dietary interventions were supplemented daily with either 2.6 g of fish oil, or 1.3 g of fish oil and 3 g of olive oil, or 6 g of olive oil. After a 12-month supplementation period only the fish oil group (2.6 g per day) exhibited significant clinical improvements in both the patient’s evaluation of pain and the physician’s assessment of pain. In addition, a significant number of patients in this group had reduced antirheumatic medication use throughout the 12-month trial.

No significant improvements occurred in the combined fish and olive oil group or in the olive oil only group, implying that the observed therapeutic benefits of fish oil supplementation in patients with rheumatoid arthritis were dose dependent, with doses less than 2.6 g per day being ineffective.

Considerable evidence from in vitro and human studies suggest that n-3 fatty acids serve as effective therapeutic agents for the management of inflammatory arthritic diseases, but the biochemical basis for these observations are not well understood. However, it is likely that n-3 fatty acids exert their antiarthritic affects through modulation of inflammatory cytokine production. More in-depth knowledge of the roles of cytokines in inflammatory arthritic diseases is needed to understand how n-3 fatty acids influence this disease. Also, more long term and large-scale intervention studies investigating the effects of n-3 fatty acid supplementation on arthritis symptoms are needed in order to strengthen the proposed inverse relationship between n-3 fatty acids and inflammatory arthritic diseases. Several human studies have investigated the immunosuppressive effects of n-3 fatty acids in transplant patients. Thus, the effects of fish oil supplementation on kidney transplant acceptance and renal function was examined (Homan van der Heide et al., 1993). After 1 year there was an overall improvement of renal function in the fish oil supplemented group. The total number of rejection episodes was lower in the fish oil group compared to the control, as was mean arterial blood pressure. The observed hemodynamic and immunomodulatory effects of fish oil were speculated to be due to a shift away from the vasoactive and proinflammatory AA eicosanoids to EPA derived eicosanoids. However, a similar but more sophisticated study by Hernândez et al. (2002) investigated the effects of fish oil supplementation (6 g per day) on kidney function and kidney rejection rate, as well as on proinflammatory cytokine production in 86 kidney transplant patients. After 12 months no differences were observed in the above parameters between the n-3 group (fish oil, experimental group) and the control group (6 g per day of soybean oil). However, this study may have been complicated by the choice of soybean oil as the placebo fatty acid source because soybean oil contains approximately 8% ALA, which may reduce the significance of differences between the experimental and the control groups.

Studies on animals and humans investigating the potential immunosuppressive effects of postoperative n-3 PUFA supplementation in organ transplant patients have been inconsistent, possibly due to the existing differences in study design such as amounts and sources of fatty acid supplements, the duration of study, and the type of organ transplant surgery studied. More clinical trials are needed to clearly support the beneficial effects of n-3 fatty acid immunonutrition in organ transplant