Chester County Medicine Winter 2020 - 12

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FISH OIL: Use or Not
BY MIAN JAN, M.D., CHAIRMAN, DEPARTMENT OF MEDICINE PENN MEDICINE CHESTER COUNTY HOSPITAL,
AND
ASAD ALI, A MEDICAL STUDENT AT NOVA SOUTHEASTERN UNIVERSITY FLORIDA

A

triglyceride is a lipid composed of a glycerol molecule
plus three fatty acids hence the tri-prefix which means
three and thus triglycerides. These molecules are held
together by high energy ester bonds which account for the efficient
energy storing capacity of fat. Metabolically triglycerides store the
most amount of energy per unit, 9 kcals per gram. This might
sound like a good thing; however, elevated triglycerides have been
associated with an increased risk of cardiovascular disease. Where
does fat come from? Our bodies follow a simple formula, if energy
in is greater than energy out then there is an increased production
of fat, and triglycerides are one form of fat. (Fig. 1) That is why
diet, exercise, and in some cases medical management are key in
keeping triglycerides within normal limits.

Figure 1
Figure 1: From the American College of Cardiology (ACC)
- a metabolic map showing how a high sugar/high fat western
diet impacts cardiometabolic risk. There are four main associations
with a high sugar/high fat diet:
1. Increased reactivity of brain's regions associated with reward.
2. Reshaping of the gut microbiome.
3. Increased consumption of high glycemic index
carbohydrates.
4. Increased saturated fats, and added sugar.

12 CHESTER COUNT Y Medicine | WINTER 2020

All of these associations are further linked to up-regulation of
fat production and can lead to hyperlipidemia which can increase
cardiometabolic risk.
There are three main molecules patients should be concerned
about in regards to how triglycerides impact their cardiovascular
health: low-density lipoproteins (LDL), high-density lipoproteins
(HDL), and very low-density lipoproteins (VLDL). LDL and
VLDL have been colloquially termed 'bad cholesterol', while
HDL has been termed 'good cholesterol'. These cholesterol derived
molecules are used to transport triglycerides throughout the
body. Having hyperlipidemia can lead to hypercholesterolemia.
Historically, hypercholesterolemia has been treated with a variety
of medications - of which statins are the most common. Statins
work by inhibiting the enzyme HMG-CoA Reductase which is
instrumental in the metabolic production of cholesterol, the main
precursor for fat transport in the body.
The American College of Cardiology (ACC) defines a patient
to be at very high risk of atherosclerotic cardiovascular disease
(ASCVD) if they have had a history of multiple ASCVD events
or have 1 major event accompanied by several risk factors. Major
events include recent acute coronary syndrome (within 12
months), myocardial infarction, ischemic stroke, and symptomatic
peripheral artery disease. Risk Factors include: age >/= 65,
heterozygous familial hypercholesterolemia, CABG or PCI outside
of ASCVD event, diabetes mellitus, hypertension, chronic kidney
disease, history of smoking, persistently elevated LDL above or
equal to 100 mg/dL despite statin use, or history of congestive
heart failure. If a patient is at a very high risk of an ASCVD event,
the ACC recommends adding ezetimibe to maximal statin therapy
if LDL is greater than 70 mg/dL.
One of the most studied supplements for reducing cholesterol
and improving heart health has been omega-3 fatty acids, the
primary ingredient in fish oil supplements. Fish oil is readily
available for many patients over the counter and is a commonly
taken supplement among the general population. Previously,
the American Heart Association (AHA) had recommended
that patients with coronary heart disease (CHD) should take


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Chester County Medicine Winter 2020

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