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**Lowering Cholesterol and Triglycerides with Omega-3 and Probiotics Supplementation: A Case Study** &#x200B; **TL;DR** Ingestion of Omega-3 fish oil and probiotics (live microorganisms that improve gut function) was correlated with my mom lowering her cholesterol levels from 301 mg/dL to 266 mg/dL (LDL vs HDL breakdown) \[yes, we realize that it is still high\] within five months and her triglyceride levels from 313 mg/dL to 116 mg/dL within three months. These results are supported by recently-published scientific literature exploring the potential of probiotics to treat hypercholesterolemia and omega-3 oil to treat hypertriglyceridemia. She used the following over-the-counter products: PRN Omega-3 fish oil (2668mg/serving) every day and VSL #3 probiotics (112.5 billion CFU) every other day from Costco’s pharmacy. &#x200B; **Backstory** Hyperlipidemia runs in my family. Both my parents and grandparents, as well as most of my aunts and uncles, have a serum (found in the blood) lipid that is elevated (cholesterol/triglycerides/both). My 67-year-old mom, Kim, has struggled with high cholesterol and high triglycerides for \~4 years. Her stats: (Height: 5’1/2”, 153.7cm) (Weight: \~109lbs, \~49.4kg). She has no systemic diseases or illnesses besides osteoarthritis in her knees and takes no prescription medications. Despite maintaining a healthy diet (\~1200 kCal/day with sufficient nutrients and lots of vegetables/fiber), healthy/steady body weight, and regular cardiovascular and resistance exercise, her cholesterol levels remained elevated. For most of 2017, we experimented with a fully plant-based diet, and even then her lipid levels did not improve. Though she had high cholesterol, Kim chose lifestyle changes over taking a statin to avoid the side effects. In March 2018 she obtained a blood test with “very high” triglycerides (313 mg/dL) and started taking a daily dose of high-quality omega-3 (2668 mg). Three months later, after receiving her July 2018 blood test, her triglycerides dropped a staggering 197 points, reaching 116 mg/dL (within normal range). After her July 2018 blood test, Kim started taking a probiotic along with her omega-3’s. When the results of her subsequent blood test in December 2018 came in, her total cholesterol levels dropped an incredible 35 points, from 301 mg/dL to 266mg/dL (HDL vs. LDL ratio depicted on graph along with further explanation below). Graph of total serum cholesterol: [https://imgur.com/a/5AS6TPW](https://imgur.com/a/5AS6TPW) &#x200B; **Post Highlights** Products I Used * PRN Omega-3 Oil (2668 mg) every day * VSL #3 Probiotic (112.5 billion CFU) every other day Products I’m Adding * Nature’s Way Primadophilus Reuteri Probiotic (5 billion CFU) every other day * Dr. Tobias GutMeister Prebiotic every other day How to find/take omega-3 oils * Look for oil with DHA and EPA, not ALA (unless you are a strict vegan/vegetarian). * Approximately 2 EPA: 1 DHA ratio. * The brand matters!! Make sure the oil is triglyceride (TG) or re-esterified triglyceride (rTG) form (NOT in ethyl-ester form). You might have to contact the manufacturer directly to ask. * Do not exceed 3000mg per day How to find/take probiotics * Look for one with at least *lactobacillus acidophilus* and *bifidobacterium* strains. For possibly extra efficacy, find a separate supplement that contains the *lactobacillus reuteri* strain. * Buy a refrigerated probiotic for maximum effectiveness. * Eat lots of fruits and veggies (prebiotics) to feed the probiotics and promote their growth. * CFU count: higher=better until you reach 100 billion CFU Side effects * For healthy individuals: Probably nothing, maybe some stomach discomfort while it gets used to the new supplements. * For individuals with serious illnesses or immune system deficiency: Not a good idea. &#x200B; **Brief Science Breakdown** High triglycerides and high cholesterol have long been identified as risk factors for cardiovascular disease by the American Heart Association. Consequently, statin drugs are often prescribed to patients whose lipid levels are out of the normal range. However, these drugs can be accompanied by uncomfortable side effects (WebMD, FDA.gov). Recent scientific publications have demonstrated that over-the-counter Omega-3 and probiotic supplements may effectively reduce lipid levels with much fewer potential adverse effects. The first supplement my mom took was a marine omega-3 by PRN in March 2018 (2668 total mg per day). Adequate amounts of omega-3 supplementation (3-4g) could reduce triglyceride levels by 20%-50% (Musa-Veloso 2010). They could also lead to an HDL (“good cholesterol”) increase (Harris 1989). However, as a side effect, LDL (“bad cholesterol”) levels may also rise as VLDL is converted to LDL (Huff 1989). This result was exemplified in my mom’s case, as her triglyceride levels dropped by 63%, HDL levels rose by 25%, and LDL level spiked up 35% after her first stint of omega-3 supplementation. Then we began her probiotic regimen. Several clinical trials have shown that ingestion of a probiotic reduced total serum cholesterol by a statistically significant amount and was especially effective in people who are in the “high cholesterol” range (>240 mg/dL). So far, the most common strains (forms of bacteria) that have demonstrated effectiveness are: *lactobacillus acidophilus, bifidobacterium,*and *lactobacillus reuteri* (Shimizu 2015, Xiao 2003, Guo 2011). After ingesting *l. acidophilus* and *bifidobacterium* in the VSL #3 supplement, my mom’s total serum cholesterol decreased by 12% with a large drop in LDL (-17%) compared to HDL (-5%) as shown in her December 2018 lipid panel. Her triglycerides also increased by 26% but this was probably because she took a trip to Australia in November 2018 and ate at a calorie surplus, consuming an increased amount of saturated fats, simple carbohydrates, animal products, and total calories per day without exercise. Graph of LDL vs. HDL breakdown: [https://imgur.com/a/t7MSloV](https://imgur.com/a/t7MSloV) &#x200B; **How to Choose an Omega-3 Oil** What is an Omega-3 Supplement? “Omega-3” is a blanket term for a type of polyunsaturated fatty acid with a distinct chemical structure composition. This blanket covers ALA (found in plants) and DHA & DPA & EPA (found in marine life). Unfortunately, we cannot synthesize these fatty acids in our bodies so we have to eat them. In addition, our bodies need to convert ALA to a DHA & DPA & EPA so it is a less metabolically efficient form of omega-3 (Surette 2008). Ingesting these omega-3 fatty acids have been shown to improve lipid levels, which are risk factors for cardiovascular disease (Jacobson 2008). How do Omega-3’s Work? When we ingest omega-3’s, they are absorbed into the cellular membrane of all of our tissues. There, they fulfill a variety of roles, namely reducing the inflammation processes (immune system in attack mode) in our bodies (Surette 2008). This inflammation reduction indirectly leads to a wide variety of beneficial effects. The Manufacturing Method Matters (avoid ethyl-ester formulations!) Omega-3 supplements are sold in different formulations that are not equally effective and pure. The **triglyceride \[TG\]**and **re-esterified triglyceride \[rTG\]** forms are absorbed most readily whereas ethyl-ester formulations are very poorly absorbed (Madsen 2010). **It is important to verify with the manufacturer that the oil is NOT in ethyl ester form. Don’t be fooled by the term “high-potency”!** The re-esterified form is supposedly the purest form because all of the toxins are removed by that stage of processing (PRN website). I decided to go with PRN’s oil \[2668mg Omega-3, 1680mg EPA, 560mg DHA) because it is rTG and has been recently clinically proven to treat dry-eye symptoms, indicating that the body absorbs/utilizes it (Epitropoulos 2016). Some Reputable Products: * PRN Dry Eye Omega Benefits * OmegaVia Fish Oil * Minami Nutrition Platinum * OmegaVia Fish Oil * Nordic Naturals Ultimate Omega * Eagle Eye Sciences Icelandic Blue Omega * Real Dose Nutrition Super Critical Omega &#x200B; **How to Choose a Probiotic** What is a probiotic? According to the International Scientific Association for Probiotics and Prebiotics, a probiotic consists of “live microorganisms that, when administered in adequate amounts, confer a health benefit on the host (Hill 2014). How do probiotics work? Although probiotics have been shown to confer health benefits, we do not yet fully understand the mechanisms by which they operate. What we do know is that they colonize our intestinal tracts and promote our intestinal health which, in turn, leads to various beneficial effects for our bodies depending on the strain (Bermudez-Brito 2012). We also know that probiotics need to “feed on” prebiotics (in the form of dietary fiber) to survive and proliferate (Tsai 2019). \[A prime example of a prebiotic is Quaker oatmeal. It is a “heart healthy” food because it may lower cholesterol through increasing your dietary fiber intake by 3-4 grams per serving.\] That’s one of the many reasons why consuming fruits and vegetables is so important!! The Strain of Bacteria Matters The efficacy (effectiveness/potency) of probiotics depends on the strains (types) of bacteria in them and health condition that you want to target (Sniffen 2018). So far, the most efficacious probiotic strains for hyperlipidemia are: *lactobacillus acidophilus, bifidobacterium,* and *lactobacillus reuteri* (Shimizu 2015, Xiao 2003). Therefore, for the objective of lowering serum lipid levels, you should look out for supplements that contain these specific strains. Room temperature or refrigerated? (Refrigerate both kinds after opening). Probiotics stored at room temperature (dried) tend to be cheaper because of lower manufacturing costs. However, the drying process decreases the bacterial viability because it has adverse effects on cell membrane and protein structure integrity (Dianawati 2016). Therefore, your best bet is going with a probiotic supplement that is stored at lower temperatures. Dosage \[C.F.U (Colony Forming Units)\]. There is no conclusive “best dose” for probiotics yet. Some study results suggest that there is a “threshold” for effectiveness, but they do not agree on what the threshold is--and it might differ between individuals. The study designs are also not rigorous enough to reach a solid conclusion as they often combine probiotic strains into the same dose groups (Sniffen 2018). So, based on my anecdotal evidence, more=better. &#x200B; **Side Effects** Possible Side Effects of Consuming Fish Oil * According to the FDA, consumption of omega-3 fish oil should not exceed 3000mg per person per day \[mg/p/d\] to avoid these potential adverse effects: fluctuations in glycemic control (>4500 mg/p/d), increased bleeding tendencies (reduced blood clotting from cuts) (>3000mg/p/d), and elevation in LDL cholesterol (>3000mg/p/d) (federalregister.gov). However, most of these claims are from older studies in the 1990s and have not been proven since then (Surette 2008). All of the Omega-3 supplements I’ve seen are <3000mg per serving anyways. * Mild Gastrointestinal issues: Fishy taste in mouth, fishy breath/burps, upset stomach, loose stools, nausea (WebMd) \*\*\*Re-esterified triglyceride (rTG) omega-3 supplements have the least gastrointestinal side effects (Epitropoulos (2016) + I can vouch for that\*\*\* Possible Side Effects of Consuming Probiotics (for healthy individuals) * Mild Gastrointestinal issues (Most common): Temporary increase in gas, bloating, constipation, and thirst (Healthline) * Allergic response (Rare): Usually mild. However, in the super rare case, anaphylaxis is serious! Be careful! Possible Side Effects of Consuming Probiotics (for unhealthy individuals with immune system deficiencies) * Sepsis, localized infection, opportunistic infection, metabolic disturbances, allergic response, and horizontally-transferred antibiotic resistance to other pathogens (Kothari 2018). **Bottom Line: If you do not have a serious illness or allergy to omega-3’s and probiotics, consuming less than 3000mg of Omega-3 and 1 serving of probiotics won’t cause problems.** &#x200B; &#x200B; **Additional Thoughts** Plan Going Forward Kim is feeling great and looking forward! We are going to continue this supplement regimen and document the results of her next blood test in March 2019. Until then, she is going to further reduce her simple carbohydrate intake, cutting out most sugars. I have also added two supplements to her probiotic regimen: 1. Primadophilus Reuteri Probiotic (5 billion CFU) by Nature’s Way 2. GutMeister Prebiotic by Dr. Tobias My Impressions on the Current Research * More scientific articles were published towards the end of 2018 on the topic of probiotics and blood lipid levels so I’ll be checking those out. It is definitely gaining interest, especially since the results are so promising. * All of the research I found was conducted internationally. It would be nice to see researchers in America jump on this topic as we probably have the worst diet in the globe and can use the data for our obesity epidemic. Final thoughts * If you’ve made it this far, thanks for reading! I hope that you learned some useful information and can now take some action to improve your health or help someone with theirs by spreading the knowledge. I believe that being informed is the first step to improvement. Anyone could be a citizen scientist. * I also firmly believe that we should raise awareness about preventive care and move towards it. This means questioning the status quo, engaging in discourse about it, and promoting research into more natural, alternative treatments with fewer side effects. * There is no “magic pill” for anything. Being healthy is a holistic endeavor and if your diet, lifestyle, or mental health is off-balance...do something about it! It’s a journey that anyone can start on, at any time, no matter where your genetics put you on the starting line. * Every body is different. There is no guarantee that a therapy will be as effective on any two people. * Probiotics need fruits and veggies to be effective, so eat your plants! * Good luck to whoever gives this a try! You have my best wishes. Please consult a physician beforehand just in case you are an extremely rare case that has an adverse reaction. * I am not affiliated with any of the aforementioned brands in any way. I just want to release some beneficial information to those who need it. Pass it on! &#x200B; **References** Shoutout to all of the amazing scientists who research nutrition! Thank you for all the work you continue to do to advance our knowledge and make this world a healthier place. 1. Musa-Veloso K, Binns MA, Kocenas AC, Poon T, Elliot JA, Rice H, Oppedal-Olsen H, Lloyd H, Lemke S (2010). Long-chain omega-3 fatty acids eicosapentaenoic acid and docosahexaenoic acid dose-dependently reduce fasting serum triglycerides. Nutr Rev. 2010 Mar;68(3):155-67. doi: 10.1111/j.1753-4887.2010.00272.x. 2. Harris WS (1989). Fish oils and plasma lipid and lipoprotein metabolism in humans: a critical review. J Lipid Res. 1989 Jun;30(6):785-807. 3. Huff MW, Telford DE (1989). Dietary fish oil increases conversion of very low density lipoprotein apoprotein B to low density lipoprotein. Arteriosclerosis. 1989 Jan-Feb;9(1):58-66. 4. Shimizu M, Hashiguchi M, Shiga T, Tamura H-o, Mochizuki M (2015) Meta-Analysis: Effects of Probiotic Supplementation on Lipid Profiles in Normal to Mildly Hypercholesterolemic Individuals. PLoS ONE 10(10): e0139795. doi:10.1371/journal.pone.0139795 5. Xiao JZ, Kondo S, Takahashi N, Miyaji K, Oshida K, Hiramatsu A, Iwatsuki K, Kokubo S, Hosono A (2003). Effects of milk products fermented by Bifidobacterium longum on blood lipids in rats and healthy adult male volunteers.J Dairy Sci. 2003 Jul;86(7):2452-61. 6. Guo Z, Liu XM, Zhang QX, Shen Z, Tian FW, Zhang H, Sun ZH, Zhang HP, Chen W (2011). Influence of consumption of probiotics on the plasma lipid profile: a meta-analysis of randomised controlled trials. Nutr Metab Cardiovasc Dis. 2011 Nov;21(11):844-50. doi: 10.1016/j.numecd.2011.04.008. 7. Hill C, Guarner F, Reid G, Gibson GR, Merenstein DJ, Pot B, Morelli L, Canani RB, Flint HJ, Salminen S, Calder PC, Sanders ME (2014). Expert consensus document. The International Scientific Association for Probiotics and Prebiotics consensus statement on the scope and appropriate use of the term probiotic. Nat Rev Gastroenterol Hepatol. 2014 Aug;11(8):506-14. doi: 10.1038/nrgastro.2014.66. Epub 2014 Jun 10. 8. Bermudez-Brito M, Plaza-Díaz J, Muñoz-Quezada S, Gómez-Llorente C, Gil A (2012). Probiotic mechanisms of action. Ann Nutr Metab. 2012;61(2):160-74. doi: 10.1159/000342079. Epub 2012 Oct 2. 9. Tsai YL, Lin TL, Chang CJ, Wu TR, Lai WF, Lu CC, Lai HC (2019). Probiotics, prebiotics and amelioration of diseases. J Biomed Sci. 2019 Jan 4;26(1):3. doi: 10.1186/s12929-018-0493-6. 10. Sniffen JC, McFarland LV, Evans CT, Goldstein EJC (2018). Choosing an appropriate probiotic product for your patient: An evidence-based practical guide. PLoS One. 2018 Dec 26;13(12):e0209205. doi: 10.1371/journal.pone.0209205. eCollection 2018. 11. Dianawati D, Mishra V, Shah NP (2016). Survival of Microencapsulated Probiotic Bacteria after Processing and during Storage: A Review. Crit Rev Food Sci Nutr. 2016 Jul 26;56(10):1685-716. doi: 10.1080/10408398.2013.798779. 12. Surette ME (2008). The science behind dietary omega-3 fatty acids. CMAJ. 2008 Jan 15;178(2):177-80. doi: 10.1503/cmaj.071356. 13. Jacobson TA. Role of n–3 fatty acids in the treatment of hypertriglyceridemia and cardiovascular disease. Am J Clin Nutr 2008;87:1981S–90S \[Suppl.\]. 14. Epitropoulos AT, Donnenfeld ED, Shah ZA, Holland EJ, Gross M, Faulkner WJ, Matossian C, Lane SS, Toyos M, Bucci FA Jr, Perry HD (2016). Effect of Oral Re-esterified Omega-3 Nutritional Supplementation on Dry Eyes. Cornea. 2016 Sep;35(9):1185-91. doi: 10.1097/ICO.0000000000000940. 15. Dyerberg J, Madsen P, Møller JM, Aardestrup I, Schmidt EB (2010). Bioavailability of marine n-3 fatty acid formulations. Prostaglandins Leukot Essent Fatty Acids. 2010 Sep;83(3):137-41. doi: 10.1016/j.plefa.2010.06.007. 16. Department of Health and Human Services. US Food and Drug Administration.Substances affirmed as generally recognized as safe: menhaden oil. Washington:Federal Register; 1997. 1997;62:30751–7 (21 CFR Part 184 \[Docket No. 86G-0289\]). Available: [http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=1997\_register&docid=fr05jn97-5](http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=1997_register&docid=fr05jn97-5) (accessed 2007 Nov 26). 17. Kothari D, Patel S, Kim SK (2018). Probiotic supplements might not be universally-effective and safe: A review. Biomed Pharmacother. 2018 Dec 28;111:537-547. doi: 10.1016/j.biopha.2018.12.104. Picture of us for our stamp of approval: [https://imgur.com/a/aVGmcZ2](https://imgur.com/a/aVGmcZ2)