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Article summary

  • The benefits of fish oil supplementation have been grossly overstated
  • Most of the studies showing fish oil benefits are short-term, lasting less than one year
  • The only fish oil study lasting more than four years showed an increase in heart disease and sudden death
  • Fish oil is highly unstable and vulnerable to oxidative damage
  • There’s no evidence that healthy people benefit from fish oil supplementation
  • Taking several grams of fish oil per day may be hazardous to your health

A new study was recently published showing that 3g/d of fish oil in patients with metabolic syndrome increased LDL levels and insulin resistance.

Unfortunately, I don’t read Portuguese so I can’t review the full-text. But this study isn’t alone in highlighting the potential risks of high-dose fish oil supplementation. Chris Masterjohn’s latest article on essential fatty acids, Precious yet Perilous, makes a compelling argument that fish oil supplementation – especially over the long-term – is not only not beneficial, but may be harmful.

This may come as a surprise to you, with all of the current media hoopla about the benefits of fish oil supplementation. Yet the vast majority of the studies done that have shown a benefit have been short-term, lasting less than one year. The only trial lasting more than four years, the DART 2 trial, showed that fish oil capsules actually increase the risk of heart disease and sudden death.

A 2004 Cochrane meta-analysis of trials lasting longer than six months suggests that the cardiovascular benefits of fish oil have been dramatically over-stated. They analyzed 79 trials overall, and pooled data from 48 trials that met their criteria. The only effect that could be distinguished from chance was a reduced risk of heart failure. Fish oil provided no reduction in total or cardiovascular mortality.

Too much fish oil can wreak havoc in your body

Omega-3 fatty acids are highly vulnerable to oxidative damage. When fat particles oxidize, they break down into smaller compounds, like malondialdehyde (MDA), that are dangerous because they damage proteins, DNA, and other important cellular structures.

A study by Mata et al demonstrated that oxidative damage increases as intake of omega-3 fat increases. The results of this study were summarized in the Perfect Health Diet, by Paul and Shou-Ching Jaminet:


Notice the clear increase in TBARS (a measure of oxidative damage of the LDL particle) with omega-3 fat. It’s important to note that this was only a 5-week trial. If it had gone on for longer than that, it’s likely the oxidative damage caused by omega-3 fats would have been even worse. This isn’t surprising if you understand the chemical composition of fats. Polyunsaturated fats (PUFA) are highly vulnerable to oxidative damage because they’re the only fatty acids that have two or more double bonds, and it’s the carbon that lies between the double bonds that is vulnerable to oxidation (as shown in the figure below):

diagram of chemical structure of EPA

Another thing worth noting, if you haven’t already, is that intake of saturated and monounsaturated fats does not increase oxidative damage by a significant amount. This is illustrated in both the table and the diagram above: saturated fats have no double bonds, which means they are well protected against oxidation. MUFA is slightly more vulnerable, since it does have one double bond, but not nearly as much as PUFA which has several double-bonds.

A randomized, double blind, placebo-controlled trial likewise showed that 6 grams per day of fish oil increased lipid peroxides and MDA in healthy men, regardless of whether they were supplemented with 900 IU of vitamin E. And consumption of fresh, non-oxidized DHA and EPA has been shown to increase markers of oxidative stress in rats.

Fish oil not as beneficial as commonly believed

To be fair, at least one review suggests that fish oil supplementation is beneficial in the short and even intermediate term. A recent meta-analysis of 11 trials lasting more than one year found that fish oil reduced the relative risk of cardiovascular death by 13 percent and the relative risk of death from any cause by 8 percent.

But the effect seen in this review was mostly due to the GISSI and DART-1 trials. They found that fish oil may prevent arrhythmia in patients with chronic heart failure and patients who have recently survived a heart attack.

However, there is no evidence that people other than those with arrhythmia and chronic heart failure benefit from taking fish oil or that doses higher than one gram of omega-3 fatty acids per day provide any benefit over smaller doses. And then there’s the rather disturbing result of the DART-2 trial, the only fish oil study lasting more than four years, showing an increase in heart disease and sudden death.

It’s logical to assume the effects of oxidative damage would take a while to manifest, and would increase as time goes on. That’s likely the reason we see some benefit in short- and intermediate-term studies (as n-3 displace n-6 in the tissues), but a declining and even opposite effect in the longer-term DART-2 trial (as increased total PUFA intake causes more oxidative damage).

The danger of reductionist thinking in nutritional research

The current fish oil craze highlights the danger of isolated nutrient studies, which unfortunately is the focus of nutritional research today. Kuipers et al. eloquently described the risks of this approach in a recent paper:

The fish oil fatty acids EPA and DHA (and their derivatives), vitamin D (1,25-dihydroxyvitamin D) and vitamin A (retinoic acid) are examples of nutrients that act in concert, while each of these has multiple actions(7,8).

Consequently, the criteria for establishing optimum nutrient intakes via randomised controlled trials (RCT) with single nutrients at a given dose and with a single end point have serious limitations. They are usually based upon poorly researched dose–response relationships, and typically ignore many possible nutrient interactions and metabolic interrelationships.

For instance, the adequate intake of linoleic acid (LA) to prevent LA deficiency depends on the concurrent intakes of α-linolenic acid (ALA), γ-LA and arachidonic acid (AA). Consequently, the nutritional balance on which our genome evolved is virtually impossible to determine using the reigning paradigm of ‘evidence-based medicine’ with RCT.

Interest in fish oil supplementation started with observations that the Inuit had almost no heart disease. It was assumed their high intake of marine oils produced this benefit. While this may be true, at least in part, what was overlooked is that the Inuit don’t consume marine oils in isolation. They eat them as part of a whole-food diet that also includes other nutrients which may help prevent the oxidative damage that otherwise occurs with such a high intake of fragile, n-3 PUFA.

It’s also important to note that there are many other traditional peoples, such as the Masai, the Tokelau, and the Kitavans, that are virtually free of heart disease but do not consume high amounts of marine oils. What these diets all share in common is not a large intake of omega-3 fats, but instead a complete absence of modern, refined foods.

Eat fish, not fish oil – cod liver oil excepted

That is why the best approach is to dramatically reduce intake of omega-6 fat, found in industrial seed oils and processed and refined foods, and then eat a nutrient-dense, whole-foods based diet that includes fatty fish, shellfish and organ meats. This mimics our ancestral diet and is the safest and most sane approach to meeting our omega-3 needs – which as Chris Masterjohn points out, are much lower than commonly assumed.

Some may ask why I continue to recommend fermented cod liver oil (FCLO), in light of everything I’ve shared in this article. There are a few reasons. First, I view FCLO as primarily a source of fat-soluble vitamins (A, D, K2 and E) – not EPA and DHA. Second, in the context of a nutrient-dense diet that excludes industrial seed oils and refined sugar, and is adequate in vitamin B6, biotin, calcium, magnesium and arachidonic acid, the risk of oxidative damage that may occur with 1g/d of cod liver oils is outweighed by the benefits of the fat-soluble vitamins.

So I still recommend eating fatty fish a couple times per week, and taking cod liver oil daily, presuming your diet is as I described above. What I don’t endorse is taking several grams per day of fish oil, especially for an extended period of time. Unfortunately this advice is becoming more and more common in the nutrition world.

More is not always better, despite our tendency to believe it is.

Note: As always, I’m open to discussion and dissenting views. But please don’t link to short-term studies on the efficacy of fish oil, because as I’ve explained in this article, it’s the long-term effects that we’re primarily concerned with. I’d be interested in seeing any studies longer than 2 years showing that 1) fish oil benefits extend beyond reducing arrhythmia in patients with chronic heart failure and patients who have recently survived a heart attack, 2) doses higher than 1g/d produce a larger benefit than doses of 1g/d, and (most importantly) 3) doses of >1g/d or higher do not increase the risk of heart disease or death

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fish oil graphic


Sorry, folks. Another long one. It was unavoidable, though, because I really did want this to be a “definitive guide” that covers all (or at least most) of the relevant issues involved with choosing a fish oil. Here’s a summary for the time-challenged:

  • There are seven important factors to consider when choosing a fish oil: purity, freshness, potency, nutrients, bioavailability, sustainability, and cost.
  • Not all fish oils are created equal. It’s essential to do your homework and make an informed choice. Many fish oils are oxidized or made with poor quality ingredients, and may actually cause health problems instead of solving them.
  • The potency of various products depends not only upon the levels of EPA and DHA, but also upon the molecular structure of the fats in the oil, which in turn affects absorption.
  • Natural fish oils are better absorbed than purified fish oils. Preliminary evidence suggests that krill oil (KO) may be better absorbed than fish oil, and anecdotal reports indicate that KO may be more effective for some than fish oil for reducing inflammation in some people.
  • Many fish oils are made from fish that are endangered. Choose products made from fish that are certified by organizations such as the Marine Stewardship Council.


So far in this series we’ve looked at why fish is superior to plant-based sources of omega-3. We’ve examined the importance of reducing consumption of omega-6 fats. We’ve considered how much omega-3 is needed to support health and treat disease. We’ve revealed that concerns about the safety of fish consumption have been overblown, and that eating fish regularly is not only safe, but incredibly beneficial. And in the previous article we compared the benefits of eating fish to taking fish oil.

In this final article of the series we’re going to take a closer look at fish oil. Fish oil has become wildly popular these days. Most people who are at least relatively health conscious understand that they need omega-3 in their diet, and are probably not getting enough from food (unless they eat a lot of fish).

Health care practitioners have caught on, too. I constantly hear both conventional and alternative practitioners telling their patients to take fish oil. In fact, I was listening to a podcast last week by one popular health and fitness guru in the paleo/primal world, and he advises his clients to take up to 20 grams of fish oil a day. That made me cringe.

Why? Because what most people – including health care practitioners – don’t seem to understand is that not all fish oils are created alike. There’s a tremendous difference in the ingredients, purity, freshness and therapeutic benefit of the fish oils available today. The supplement industry is rife with false claims and unsavory companies that are far more interested in profiting on the fish oil craze than they are in your health and well-being.

Recommending that people take up to 20g/d of fish oil without conveying the importance of choosing a high quality fish oil, and teaching them how to do that, is irresponsible and possibly dangerous. Taking 20g/d of a poor quality, oxidized fish oil could dramatically increase oxidative damage and inflammation – which is of course exactly the opposite of the desired effect.

In this article, I’ll focus more on dispelling common misconceptions about fish oil and helping you to choose the best product for your needs.

Factors to consider when buying fish oil

There are seven primary variables to be aware of when shopping for a fish oil:

  1. Purity. The oil must meet international standards for heavy metals, PCBs, dioxins and other contaminants. Many do not – even when they claim they do.
  2. Freshness. Omega-3 oils are susceptible to oxidation, which makes them rancid. Rancid oils are pro-inflammatory and contribute to the diseases you’re trying to relieve or prevent by taking fish oil in the first place!
  3. Potency. In order to have the desired anti-inflammatory effect, fish oil must contain an adequate amount of the long-chain omega-3 derivatives EPA and DHA. DHA is especially important.
  4. Nutrients. All fish oils contain some amount of EPA and DHA. However, fish liver oil (from cod, skate or shark) also contains naturally occurring fat-soluble vitamins that are difficult to obtain from foods.
  5. Bio-availability. The ability to absorb the beneficial components of fish oil is based on the molecular shape of the fatty acids. The more natural the structure the better.
  6. Sustainability: The fish should be harvested in a sustainable manner and species that are under threat should be avoided.
  7. Cost: the product must be relatively affordable to be practical for most people.


Many species of fish are known to concentrate toxic chemicals like heavy metals, PCBs, and dioxins which can cause serious disease, especially in children and developing fetuses. In a previous article I explained how these chemicals are typically not a concern when eating whole fish, because fish also contain selenium. Selenium binds to mercury and makes it unavailable to tissues, thus protecting against any damage it may cause.

And while fish constitute only 9% of our dietary intake of dioxins and PCBs, high doses of fish oils taken every day (as is often recommended) may raise this percentage significantly and expose us to undesirable levels of these toxins.

To address this, fish oil manufacturers use a process called molecular distillation to remove the toxins from the oil. When done correctly, molecular distillation is capable of reducing the toxins in fish oil to levels considered to be safe by the EPA and other agencies.

Although almost any fish oil manufacturer will tell you their product is free of these toxins, independent lab analyses tell a different story. Just last month (March, 2010), a lawsuit was filed in California court against the manufacturers of ten popular fish oils because they contained undisclosed and (possibly) unsafe levels of contaminants.

Unfortunately, this kind of deception is all too common in the supplement industry. That’s why it’s essential that you ask for something called a Certificate of Analysis (COA) from the manufacturer before you buy their product. A COA is an analysis performed by an independent lab to measure the ingredients of a product and confirm whether it lives up to the claims made by the manufacturer.

If the manufacturer won’t provide a COA, I start to get suspicious. This is standard practice in the industry and there’s no reason they shouldn’t be happy to show you theirs. Make sure that the independent lab they use is in fact independent and is preferably accredited, sponsored by a government agency, or has a solid reputation in the field.

This may seem like unnecessary paranoia, but when it comes to the possibility of ingesting powerful neurotoxins, it pays to do your homework.

In general, fish that are lower on the food chain like sardines and anchovies naturally have a lower concentration of contaminants. For this reason, it may be wise to look for a product made from these fish.

So what levels of these toxins are safe? As you might imagine, there is some disagreement on this question since there is no single governing body that determines acceptable levels. However, the standards that are most often followed by fish oil manufacturers are summarized in the table below.

fish oil toxin standards

* ppt = parts per trillion
* ppb = parts per billion

In a previous article we discussed selenium’s protective effect against mercury toxicity. If you are taking large doses of fish oil, and not eating any whole fish, it may be wise to ensure another regular source of selenium. Brazil nuts are by far the highest dietary source, with 1917mcg of selenium per 100g. (But they are also very high in n-6, so watch out!)


I have written extensively about the dangers of oxidized, rancid oils. They promote oxidative damage and increase inflammation, both of which are risk factors for nearly every modern disease. The more unsaturated an fat is, the more vulnerable it is to oxidation. Long-chain, omega-3 fats found in fish oil are the most unsaturated of the fats, and thus the most susceptible to being damaged.

This is why it’s absolutely crucial to ensure that the fish oil you select is fresh and not rancid. Once it has gone rancid, it will have the exact opposite effect on your body than you want it to.

The first thing to do is to check something called the “peroxide value” on the COA. This is a measure of rancidity reactions in the oil that have occurred during storage. and should be less than 5 meq/kg.

If this checks out, and you decide to order that product, break open a capsule once you receive it. There should be no “fishy” odors. They should smell like the ocean, but not like a rotten fish. They should also not have a strong lemon or lime scent, which could be an indicator that the manufacturer is trying to mask the rancidity.

A common misconception is that you can determine the quality of a fish oil by freezing it. The theory goes that if you freeze the oil and it is cloudy, it’s rancid. That is not the case. All fish contain saturated and monounsaturated fatty acids, albeit in small amounts. These fatty acids make the capsules appear cloudy when frozen in products that contain whole fish oil (i.e. Vital Choice’s Wild Salmon Oil).


This is another area surrounded by significant controversy. Some argue the levels of individual constituents in fish oil aren’t paramount. Scientists discovered the healthful effects of omega-3s by studying people with fish-heavy diets, before supplemental fish oil even existed. Clinical trials using supplemental fish oils over the past few decades have contained widely variable levels of both long-chain omega-3 derivatives (EPA and DHA), and not super-high concentrations of either or both.

However, due to poor conversion of ALA to EPA and DHA, unless you are eating fish it is very likely you are deficient in long-chain omega-3s.

Following this line of reasoning, the DHA content in particular of fish and fish oils does seem important if we wish to obtain the best possible therapeutic effect. Many recent studies demonstrating the anti-inflammatory potential of fish oil used a daily dosage of DHA in the range of 1-3 grams. What’s more, foods like salmon roe that have been prized by traditional cultures for their nourishing and healing effects contain large amounts of DHA. A single 6 oz. serving of salmon roe contains 1 g of DHA. (In fact, this would be the best way by far of supplementing with DHA if money were no object. (Unfortunately, wild salmon roe goes for about $28/serving.)

The suggested DHA dose will of course depend upon the condition being treated. If you have a chronic inflammatory condition (heart disease, arthritis, Crohn’s or ulcerative colitis, etc.) I would suggest taking between 1 and 2 grams per day. If you are taking it simply for health maintenance, 500 mg is probably sufficient.

Unfortunately, many fish oils do not have significant amounts of DHA. This means you’d have to take an impractically high number of capsules each day to obtain the therapeutic dose. This is not desirable, since all unsaturated oils (including fish oils) are subject to oxidative damage. We don’t want to take large quantities of them for this reason.

Remember to check the label and ensure that your product has approximately 200-300 mg of DHA per capsule. This will allow you to achieve the therapeutic dose by taking no more than 3 capsules twice a day.


All fish oils contain some amount of EPA and DHA, the long-chain omega-3 derivatives that provide the majority of the anti-inflammatory benefits seen in studies. However, fish liver oils (from cod, skate or shark) contain significant amounts of vitamins A and D in addition to EPA and DHA. Vitamins A and D are fat-soluble nutrients that are crucial to human health. Vitamin D, in particular, is difficult to obtain from commonly eaten foods – especially now that eating seafood carries a much higher risk of contamination with toxins.

Fermented cod liver oil is even more beneficial, because it contains vitamin K2. Vitamin K2 has been called “the missing nutrient” because it was only recently discovered, and many people are deficient in it.

It has been commonly believed that the benefits of vitamin K are limited to its role in blood clotting. Another popular misconception is that vitamins K1 and K2 are simply different forms of the same vitamin – with the same physiological functions.

New evidence, however, has confirmed that vitamin K2’s role in the body extends far beyond blood clotting to include protecting us from heart disease, ensuring healthy skin, forming strong bones, promoting brain function, supporting growth and development and helping to prevent cancer – to name a few.

Cod liver oil was traditionally processed by fermentation, which is likely to make it more absorbable and bio-available. Processing by fermentation also avoids the use of heat, which can damage the fragile fatty acids and cause fish oils to go rancid. Unfortunately, I am aware of only one company that sells fermented cod liver oil at this time (see below).


The ability to absorb the beneficial components of fish oil is based on the molecular shape of the fatty acids. In short, the more natural the structure and the less it is chemically altered, the better.

This is true for any nutrient, of course, and it explains why I am always in favor of obtaining nutrients from food or food-based sources when possible. Each additional step in processing from the natural state of a food to extract or isolate nutrients introduces the potential of damaging the nutrient, or changing it’s chemical form so that it’s more difficult to absorb or affects the body in a different way.

When it comes to fish oils, there are three forms currently available on the market:

  1. Natural triglyercide oil. This is what you get when you “squeeze” the whole fish and extract the natural oil from it. It is the closest to eating fish oil in its natural form, and is highly bioavailable. The drawback of this form is that, because it’s not concentrated, it usually has low levels of EPA and DHA. And because it isn’t purified, it can have high levels of contaminants such as heavy metals, PCBs, and dioxins.
  2. Ethyl ester oil. Occurs when natural triglyceride oil is concentrated and molecularly distilled to remove impurities. The ester form is still in a semi-natural state because it is the result of a process that naturally occurs in the body. The advantage to this form is that it can double or triple the levels of EPA and DHA.
  3. Synthetic triglyceride oil. This form occurs when natural triglycerides are converted to ethyl esters for concentration (as above), but then re-converted into synthetic triglycerides. The original position of the triglyceride’s carbon bonds change and the molecule’s overall structure is altered, which impacts the bioavailability of the oil.

Studies on absorption of the various types of fish oil suggest that, unsurprisingly, the natural triglyceride form is absorbed better than the ethyl ester form, which in turn is absorbed better than the synthetic triglyceride form.

One study by Lawson & Hughes in 1988 showed that 1 gram of EPA and 0.67 grams of DHA as natural triglycerides were absorbed 3.4 and 2.7 fold as well as the ethyl ester triglycerides.

In the previous article we saw that fish oils were better absorbed when taken with a high-fat meal. In another study by Lawson & Hughes later the same year, they showed that the absorption of EPA & DHA from natural triglycerides improved from 69% with a low-fat meal (8g total fat) to 90% with a high-fat meal (44g total fat). Absorption of both EPA and DHA from ethyl ester oils was increased three-fold from 20% with a low-fat meal to 60% with a high fat meal.

What about krill oil?

In addition to the three types of fish oil listed above, there is another type of oil that provides EPA & DHA: krill oil. Krill oil (KO) is extracted from Anarctic krill, Euphausia superba, a zooplankton crustacean rich in phospholipids carrying EPA and DHA. Krill oil also contains various potent antioxidants, including vitamins A & E, astaxanthin, and a novel flavonoid whose properties are not yet fully understood.

Krill oil has a unique biomolecular profile that distinguishes it from other fish oils. While EPA and DHA in fish oils comes in the form of triglycerides, the EPA and DHA is already incorporated into phospholipids, which facilitates the passage of the fatty acids through the intestinal wall. This increases the bioavailability of the EPA and DHA and improves absorption and assimilation.

Werner et al demonstrated essential fatty acids in the form of phospholipids were superior to essential fatty acids as triglycerides in significantly increasing the phospholipid concentrations of EPA and DHA in mice.

In a human study, Bunea et al compared the effect of krill oil and fish oil on blood lipids, specifically total cholesterol, triglycerides, LDL, and HDL. Krill oil was given at dosages of 1g/d, 1.5g/d, 2g/d or 3g/d, and fish oil was given at a single dose of 3g/d. The authors found the following:

  • KO at a daily dose of 1g, 1.5g, 2g or 3g achieved significant reductions of LDL of 32%, 36%, 37% and 39% respectively. Patients treated with 3g fish oil daily did not achieve a significant reduction in LDL.
  • HDL was significantly increased in all patients receiving KO. HDL increased 44% at 1g/d, 43% at 1.5g/d, 55% at 2g/d and 59% at 3g/d. Fish oil taken at 3g/d increased HDL by only 4%.
  • KO did not decrease triglycerides significantly at 1g and 1.5g. However, KO reduced triglycerides by 28% at 2g/d and 27% at 3g/d. Fish oil at 3g/d did not achieve a significant reduction of triglycerides.
  • Blood glucose levels were reduced by 6.3% in patients receiving 1g/d and 1.5g/d of KO, and 5.6% in patients receiving 2g/d and 3g/d of KO. A daily dose of 3g of fish oil reduced blood glucose by 3.3%.

Thus, in this study krill oil led to a significantly greater improvement in blood lipids compared to fish oil.

Note that the dosage of KO that obtained the best results, either 2g/d or 3g/d, is quite high. However, study participants received a maintenance dose of 0.5g/d for another 12 weeks after the therapeutic period of the study ended. These patients maintained the reductions in total cholesterol they attained in the study, and LDL, triglycerides and blood glucose were further reduced from baseline. There was a moderate decrease (of 3%) in HDL, but HDL was still significantly increased from baseline.

There is also unpublished research suggesting that 300 mg/d of KO reduces biochemical and subjective measures of inflammation and improves joint function and mobility in patients with rheumatoid arthritis (RA).

However, as this research is not published or peer-reviewed, and was sponsored by Neptune Technologies (the manufacturer of Neptune Krill Oil (NKO), I am cautious about interpreting its results.

So what does all of this information about bio-availability tell us?

  1. Taking fish oil capsules with a high-fat meal is essential to improve absorption of EPA and DH.
  2. Even when taken with a high-fat meal, ethyl ester oils are absorbed only 66% as well as natural triglyceride oils.
  3. Krill oil appears to significantly improve blood lipids when compared to fish oils, possibly because of its unique phospholipid structure.


The sustainability of fish oil production is difficult to gauge. Some oils are produced as a byproduct of fish harvesting, and manufacturers claim that they are simply making use of something that would normally be discarded. While this is certainly better than harvesting fish solely for their oil, it still supports harmful fishing practices.

The safest bet is to only use fish oil that is made from fish that are certified by MSF or a similar organization, such as the Environmental Defense Fund. Vital Choice Wild Salmon Oil is one example, as is Jarrow Max DHA (which is made from anchovies and sardines, both of which are generally regarded as safe to eat from an environmental standpoint).


I cover cost in the recommendations section below.


Note: I have no affiliation with any of these companies. These are simply the products I recommend based on my research. It’s very likely that there are other good products that I missed in my search. This is not an exhaustive list.

Which product you might choose from this list depends in large part upon what your goals are.

I have provided product recommendations in two different categories: baseline, and supplemental. Those wishing to to maintain health and ensure adequate nutrient intake should choose a product from the “baseline” category. Those who are dealing with a chronic inflammatory condition should also choose a product from the baseline category, but should consider adding a product from the “supplemental” category.

However, keep in mind that the absorption of the natural triglyceride oils (like the Wild Salmon Oil and Fermented Cod Liver Oil below) will be 1.5 times greater than the ethyl ester oils in the supplemental section. As a rule of thumb, all purified and molecularly distilled oils are ethyl esters.

This means you have to take 1.5 times as much of the ethyl ester oils to get the same dose of DHA that you’d get from the natural triglyceride oils. For example, Vital Choice Wild Salmon Oil has 220 mg DHA per serving. To get the same amount of DHA from Jarrow Max DHA, which is an ethyl ester oil, you’d have to take a serving that provides 333 mg of DHA.


Green Pastures Fermented Cod Liver Oil and Butter Oil Blend (GP FCLO)

Ingredients: about 270 mg omega-3 (about 139 mg EPA, 83 mg DHA), about 1,100 IU vitamin D, about 2,300 IU vitamin A. Values listed are approximate (see disadvantages).

Price: $47.00 for 120 capsules, 2 capsules per serving. $0.78/serving.

Advantages: a whole-food product in its natural form, rather than a supplement. Is relatively low in EPA & DHA compared to other products, but contains high levels of vitamin D, as well as vitamins A & K. The fat soluble vitamins A, D & K2 are important co-factors and likely improve the absorption and assimilation of EPA & DHA. Addition of grass-fed butter oil increases levels of K2. Cold-processed with fermentation, which means this is the least oxidized product available.

Disadvantages: levels of PCBs are posted on Green Pastures’ website here, but I’ve been unable to obtain information on heavy metals or dioxins. The EPA and DHA levels are what would be expected in a whole food product, but may not be high enough for a significant anti-inflammatory effect. Values for vitamins A, D, EPA and DHA are approximate and vary batch to batch due to fermentation processing method. Peroxide values are not provided, but because it is processed without heat they are likely to be very low.

Notes: because fermented cod liver oil contains vitamins A, D and K2 in addition to EPA and DHA, and because most people are deficient in some or all of these nutrients, this is currently the only product I recommend to everyone – patients, family and friends – regardless of their health status.

Vital Choice Wild Salmon Oil (VC WSO)

Ingredients: 600 mg of omega-3 (240 mg EPA, 220 mg DHA), 340 IU vitamin D, 2,060 IU vitamin A (per 3 1,000 mg softgels).

Price: $40 bottle, 180 capsules. 3 capsules/serving, $0.68/serving.

Advantages: processed without heat using micro-filtration, which retains naturally occurring vitamins A and D. Fatty acids are in their natural triglyceride form, which makes them more absorbable. Also contains astaxanthin, which protects the oil from oxidative damage and rancidity. Contains more EPA and DHA than GP FCLO. Nutrient levels are more consistent from batch to batch and certification is performed by independent, not-for-profit organization (NSF International).

Disadvantages: when compared to GP FCLO, does not have vitamin K2 and the dose of vitamin D is significantly lower. Otherwise no disadvantages.


Jarrow Max DHA

Ingredients: 600 mg of omega-3 (250 mg DHA, 36 mg EPA) per capsule; one capsule is one serving.

Price: $14.85 (at Vitacost) for 180 capsules. $0.08/serving.

Advantages: even after considering the differences in absorptions between Jarrow Max (an ethyl ester) and the two natural triglyceride oils listed above, Jarrow Max is significantly cheaper. It’s possible to get 1g/d of DHA for $0.32. Made with anchovies and sardines, both of which are naturally low in contaminants. Jarrow faxed me their certificate of analysis, which checked out fine. This is a good choice for those wishing a high-dose of DHA in addition to eating fish or taking one of the natural triglyceride oils above.

Disadvantages: has a 7:1 ratio of DHA to EPA. Although I believe DHA to be more beneficial than EPA, the research is mixed on this and some people report that they do better with EPA.

V-Pure Vegetarian DHA

Ingredients: 350 mg DHA, 50 mg EPA per serving, 2 capsules per serving.

Price: $21.95 for 60 capsules. $0.73 per serving.

Advantages: I received several emails from vegetarians asking me what I recommended they do to meet DHA needs. This is a DHA/EPA blend derived from marine algae, which is where oily fish get EPA & DHA in the first place. The algae in this product is organically grown and 100% free of toxins and contaminants. The capsules are quite small and can be easily swallowed.

Disadvantages: I haven’t seen much research on the marine-algae DHA/EPA blends. Although it’s plausible to assume their effects would be similar to fish oils, I’d like to see some studies backing that up. Likewise, I don’t know much about V-Pure as a company. Another potential issue is that the capsules have carrageenan in them, which has been shown to exacerbate intestinal inflammation in several studies. People with gut problems like IBS and IBD may want to avoid this product. Finally, at $0.73/serving this product is expensive. To get a therapeutic dose of 1g/d taking this alone, you’d have to take 9 capsules per day which be 4.5 bottles/month, or almost $100!

Tentatively Recommended

Neptune Krill Oil

Ingredients: 300 mg of omega-3 (90 mg DHA, 150 mg EPA) per serving, two capsules per serving.

Price: $16.86 for 60 capsules. $0.56/serving, 2 capsules per serving.

Advantages: KO has a unique phospholipid structure that appears to improve the absorption of EPA & DHA. At least one study suggests that KO is superior to fish oil in improving blood lipids. KO also contains vitamins E & A, as well as astaxanthin, an antioxidant claimed to be 10 times more potent than other carotenoids. KO capsules are much smaller than fish oil capsules, are easier to swallow, and many report they don’t cause the burping common with other fish oil capsules. Several anecdotal reports suggest that krill oil can be more effective than fish oil in reducing inflammation for some people.

Disadvantages: there are few studies demonstrating the effectiveness of KO, whereas fish oil has decades of research behind it. Most of the studies that do exist on KO were sponsored by Neptune, the largest manufacturer of KO. The dosages used in the study on KO and blood lipids were very high, and taking KO at those dosages would be expensive. (However, the therapeutic dose of 2-3g/d would only be necessary for 12 weeks, as the maintenance dose of 0.5g seemed to maintain the benefits attained during the therapeutic period.) The sustainability of krill harvesting is controversial.

The reason KO gets a tentative recommendation is that there’s still comparatively little research supporting its use, and because I am still uncertain about the environmental impact of harvesting the krill for the oil. If you have information to share on either of these questions, I’m all ears!

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vegetable oil poisonIn the last article we discussed the problems humans have converting omega-3 (n-3) fats from plant sources, such as flax seeds and walnuts, to the longer chain derivatives EPA and DHA. Since EPA and DHA (especially DHA) are responsible for the benefits omega-3 fats provide, and since EPA and DHA are only available in significant amounts in seafood, it follows that we should be consuming seafood on a regular basis.

But how much is enough? What does the research literature tell us about the levels of EPA and DHA needed to prevent disease and ensure proper physiological function?

I’m going to answer this question in detail in the next article. But before I do that, I need to make a crucial point: the question of how much omega-3 to eat depends in large part on how much omega-6 we eat.

Over the course of human evolution there has been a dramatic change in the ratio of omega-6 and omega-3 fats consumed in the diet. This change, perhaps more than any other dietary factor, has contributed to the epidemic of modern disease.

The historical ratio of omega-6 to omega-3

Throughout 4-5 million years of hominid evolution, diets were abundant in seafood and other sources of omega-3 long chain fatty acids (EPA & DHA), but relatively low in omega-6 seed oils.

Anthropological research suggests that our hunter-gatherer ancestors consumed omega-6 and omega-3 fats in a ratio of roughly 1:1. It also indicates that both ancient and modern hunter-gatherers were free of the modern inflammatory diseases, like heart disease, cancer, and diabetes, that are the primary causes of death and morbidity today.

At the onset of the industrial revolution (about 140 years ago), there was a marked shift in the ratio of n-6 to n-3 fatty acids in the diet. Consumption of n-6 fats increased at the expense of n-3 fats. This change was due to both the advent of the modern vegetable oil industry and the increased use of cereal grains as feed for domestic livestock (which in turn altered the fatty acid profile of meat that humans consumed).

The following chart lists the omega-6 and omega-3 content of various vegetable oils and foods:

efa content of oils

Vegetable oil consumption rose dramatically between the beginning and end of the 20th century, and this had an entirely predictable effect on the ratio of omega-6 to omega-3 fats in the American diet. Between 1935 and 1939, the ratio of n-6 to n-3 fatty acids was reported to be 8.4:1. From 1935 to 1985, this ratio increased to 10.3:1 (a 23% increase). Other calculations put the ratio as high as 12.4:1 in 1985. Today, estimates of the ratio range from an average of 10:1 to 20:1, with a ratio as high as 25:1 in some individuals.

In fact, Americans now get almost 20% of their calories from a single food source – soybean oil – with almost 9% of all calories from the omega-6 fat linoleic acid (LA) alone! (PDF)

This reveals that our average intake of n-6 fatty acids is between 10 and 25 times higher than evolutionary norms. The consequences of this dramatic shift cannot be underestimated.

Omega-6 competes with omega-3, and vice versa

As you may recall from the last article, n-6 and n-3 fatty acids compete for the same conversion enzymes. This means that the quantity of n-6 in the diet directly affects the conversion of n-3 ALA, found in plant foods, to long-chain n-3 EPA and DHA, which protect us from disease.

Several studies have shown that the biological availability and activity of n-6 fatty acids are inversely related to the concentration of of n-3 fatty acids in tissue. Studies have also shown that greater composition of EPA & DHA in membranes reduces the availability of AA for eicosanoid production. This is illustrated on the following graph, from a 1992 paper by Dr. William Landis:

percentage of n-6 and n-3 in tissue associated with

The graph shows the predicted concentration of n-6 in the tissue based on dietary intake of n-3. In the U.S. the average person’s tissue concentration of highly unsaturated n-6 fat is 75%. Since we get close to 10% of our calories from n-6, our tissue contains about as much n-6 as it possibly could. This creates a very inflammatory environment and goes a long way towards explaining why 4 in 10 people who die in the U.S. each year die of heart disease. (Note: the ratio of omega-6 to omega-3 matters, but so does the total amount of each.)

In plain english, what this means is that the more omega-3 fat you eat, the less omega-6 will be available to the tissues to produce inflammation. Omega-6 is pro-inflammatory, while omega-3 is neutral. A diet with a lot of omega-6 and not much omega-3 will increase inflammation. A diet of a lot of omega-3 and not much omega-6 will reduce inflammation.

Big Pharma is well aware of the effect of n-6 on inflammation. In fact, the way over-the-counter and prescription NSAIDs (ibuprofen, aspirin, Celebres, etc.) work is by reducing the formation of inflammatory compounds derived from n-6 fatty acids. (The same effect could be achieved by simply limiting dietary intake of n-6, as we will discuss below, but of course the drug companies don’t want you to know that. Less profit for them.)

As we discussed in the previous article, conversion of the short-chain n-3 alpha-linolenic acid (ALA), found in plant foods like flax and walnut, to DHA is extremely poor in most people. Part of the reason for that is that diets high in n-6 LA inhibit conversion of ALA to DHA. For example, one study demonstrated that an increase of LA consumption from 15g/d to 30g/d decreases ALA to DHA conversion by 40%.

Death by vegetable oil

So what are the consequences to human health of an n-6:n-3 ratio that is up to 25 times higher than it should be?

The short answer is that elevated n-6 intakes are associated with an increase in all inflammatory diseases – which is to say virtually all diseases. The list includes (but isn’t limited to):

  • cardiovascular disease
  • type 2 diabetes
  • obesity
  • metabolic syndrome
  • irritable bowel syndrome & inflammatory bowel disease
  • macular degeneration
  • rheumatoid arthritis
  • asthma
  • cancer
  • psychiatric disorders
  • autoimmune diseases

The relationship between intake n-6 fats and cardiovascular mortality is particularly striking. The following chart, from an article entitled Eicosanoids and Ischemic Heart Disease by Stephan Guyenet, clearly illustrates the correlation between a rising intake of n-6 and increased mortality from heart disease:

landis graph of hufa and mortality

As you can see, the USA is right up there at the top with the highest intake of n-6 fat and the greatest risk of death from heart disease.

On the other hand, several clinical studies have shown that decreasing the n-6:n-3 ratio protects against chronic, degenerative diseases. One study showed that replacing corn oil with olive oil and canola oil to reach an n-6:n-3 ratio of 4:1 led to a 70% decrease in total mortality. That is no small difference.

Joseph Hibbeln, a researcher at the National Institute of Health (NIH) who has published several papers on n-3 and n-6 intakes, didn’t mince words when he commented on the rising intake of n-6 in a recent paper:

The increases in world LA consumption over the past century may be considered a very large uncontrolled experiment that may have contributed to increased societal burdens of aggression, depression and cardiovascular mortality.

And those are just the conditions we have the strongest evidence for. It’s likely that the increase in n-6 consumption has played an equally significant role in the rise of nearly every inflammatory disease. Since it is now known that inflammation is involved in nearly all diseases, including obesity and metabolic syndrome, it’s hard to overstate the negative effects of too much omega-6 fat.

In the next article we’ll discuss three different methods for determining healthy intakes of n-3 that take background intake of n-6 into account.

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microscopeI recently came across two articles that I think you should read.

The first is over on Dr. William Davis’s blog, The Heart Scan. Dr. Davis reviews a study demonstrating that consumption of excess carbohydrate can raise cholesterol.

Now, if you’ve been reading my blog for a while you know that normal LDL cholesterol isn’t a risk factor for heart disease, right? So I am generally not concerned with what does or doesn’t raise cholesterol. However, there is a type of cholesterol that is a significant risk factor for heart disease: small, dense LDL cholesterol.

Small, dense LDL particles are more likely to become oxidized, and as I have explained in How to Increase Your Risk of Heart Disease, oxidized LDL is one of the strongest risk factors for heart disease we know of.

Dr. Davis clearly explains how eating too many carbs can increase your levels of small, dense LDL and he also explains why so many doctors and researchers don’t make this crucial connection. Check out the full article here.

The second article is on Dr. Barry Groves’ Second Opinions blog. He reviews a study which links consumption of linoleic acid to Inflammatory Bowel Disease (such as Crohn’s and Ulcerative Colitis) and Irritable Bowel Syndrome (IBS).

Linoleic acid is an omega-6 (n-6) essential fatty acid. “Essential” in this context means that humans can’t make it internally and need to eat it in the diet. However, we only need a tiny amount – about a teaspoonful per day – and eating too much of it can cause serious problems. Eating too much linoleic acid dramatically increases oxidized LDL cholesterol levels, which as I just explained in the last section significantly elevates our risk of heart disease. Linoleic acid is also pro-inflammatory, and inflammation is a major contributor to modern diseases like cancer, diabetes, heart disease and, you guessed it, Inflammatory Bowel Disease and Irritable Bowel Syndrome.

Tragically, linoleic acid has become one of the primary sources of calories in the American diet. Vegetable oils containing linoleic acid (such as soybean, corn, safflower, sunflower, cottonseed) are found in nearly all packaged and processed foods and all foods cooked in a restaurant. Almost all fried foods are extremely high in linoleic acid.

Is it any wonder, then, that Irritable Bowel Syndrome has reached such epidemic proportions? It is now the #2 leading cause for people missing work, behind only the common cold. It affects millions of people in the U.S. and abroad. There is no known “cure”, and the medications prescribed for it are largely ineffective.

This is yet another example of how toxic and harmful our modern diets are. If you want to avoid these conditions, eat traditional, saturated fats like butter, lard and coconut oil instead of industrially-processed vegetable oils. You’ll feel better, and you’ll enjoy your food a lot more too!

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codI’ve received several questions about the safety of cod liver oil (CLO) since the Vitamin D Council warned consumers about the ingestion of CLO due to concerns about potential vitamin A toxicity in their November bulletin.

Sally Fallon, president of the Weston A. Price Foundation, recently wrote a letter to members clarifying the issues raised by the Vitamin D council and exonerating cod liver oil.

If you’re having second thoughts about the health benefits of CLO, please read this and pass it on to anyone you know who currently takes or is considering taking cod liver oil.


Dear Members,

We are obliged to issue another official statement on cod liver oil after the November bulletin of the Vitamin D Council, which contains “an unprecedented warning about the ingestion of cod liver oil and resultant vitamin A toxicity.”

The warning accompanies a report on a review article co-authored by Dr. John Cannell, head of the Vitamin D Council, and fifteen other researchers, entitled “Cod Liver Oil, Vitamin A Toxicity, Frequent Respiratory Infections, and the Vitamin D Deficiency Epidemic” in the November issue of Annals of Otology, Rhinology and Laryngology.

Most of this paper is a review of studies showing the benefits of vitamin D in protecting against various illnesses, including respiratory infection. THIS PAPER DOES NOT PRESENT ANY INFORMATION WHATSOEVER INDICATING THAT COD LIVER OIL IS TOXIC, and, in fact, admits that vitamin A can significantly reduce the incidence of acute lower respiratory tract infections in Third World children.

A portion of the review article is an attempt to explain why a 2004 study providing 600 to 700 IU of vitamin D and 3,500 IU of vitamin A in the form of cod liver oil and a multivitamin failed to meaningfully reduce upper respiratory tract infections when studies from the 1930s found that cod liver oil could reduce the incidence of these infections by 30 to 50 percent. The authors of the recent commentary suggested that the older studies were more effective because cod liver oil in the 1930s contained much more vitamin D. They suggested that modern cod liver oil is low in vitamin D because the deodorization process removes the vitamin while manufacturers fortify the oil with only a fraction of the original amount. As an example, they cited cod liver oil made by Nordic Naturals, advertised as containing only “naturally occurring vitamins A and D,” which has only 3 to 60 IU of vitamin D per tablespoon but between 150 and 12,000 times as much vitamin A.

This conclusion is essentially the same as the conclusion reached by the Weston A. Price Foundation and the research of Chris Masterjohn; we have continually pointed out that vitamins A and D work together and that without vitamin D, vitamin A can be ineffective or even toxic. We do not recommend Nordic Naturals regular cod liver oil or any brand of cod liver oil that is low in vitamin D. But it is completely inappropriate to conclude from this 2004 study that cod liver oil is toxic because of its vitamin A content. Similar reviews could be put together showing the benefits of vitamin A and cod liver oil in numerous studies, including the studies from the 1930s. Obviously the solution is to use the type of cod liver oil that people took in the 1930s, which did not have most of the vitamin D removed by modern processing techniques.

Our recommendations for cod liver oil brands can be found here.

Healthy Skeptic note: I recommend either high-vitamin cod liver oil or fermented cod liver oil from Green Pasture and Wolf River Naturals.

The Vitamin D Council report claims that the vitamin A in cod liver oil is excessive and antagonizes vitamin D by inhibiting the binding of its active form to DNA and thus preventing its ability to regulate the expression of vitamin D-responsive genes.

Vitamins A and D are both precursors to active hormones that regulate the expression of genes. The body possesses certain enzymes that convert each of these in a two-step process to their active forms: vitamin A is converted to retinal and then to active retinoic acid while vitamin D is converted to calcidiol and then to active calcitriol. While directly consuming either retinoic acid or calcitriol would be unnatural, consuming vitamins A and D, together, as in cod liver oil, is perfectly natural. The enzymes involved in these conversions are responsible for producing incredibly powerful hormones and are therefore highly regulated.

In order for vitamin D to activate the expression of its target genes, it must bind to the vitamin D receptor (VDR) and then combine with the retinoid X receptor (RXR), which is activated by a particular form of vitamin A called 9-cis retinoic acid. RESEARCHERS FROM SPAIN RECENTLY SHOWED THAT VITAMIN D CAN ONLY EFFECTIVELY ACTIVATE TARGET GENES WHEN ITS PARTNER RECEPTOR IS ACTIVATED BY VITAMIN A.

In the ABSENCE OF VITAMIN A, molecules called “corepressors” bind to the VDR/RXR complex and PREVENT vitamin D from functioning.

The molecular biology of 9-cis¬ retinoic acid, however, is extremely complex, and this has led to some confusion. The RXR and its activator 9-cis retinoic acid partner up not only with the vitamin D receptor, but also with the receptors for steroid hormones, thyroid hormone, and most other nuclear receptors. In fact, if enough 9-cis retinoic acid is present, RXRs will even partner up with themselves. Ordinarily, this versatile form of vitamin A is gradually derived in small amounts from the larger pool of all-trans retinoic acid as needed. When scientists add large amounts of 9-cis retinoic acid to isolated cells, then, it may cause effects that smaller amounts naturally produced in the cell would not cause.

Researchers have shown, for example, that 9-cis retinoic acid interferes with the ability of vitamin D to stimulate the production of osteocalcin, a vitamin K-dependent protein involved in organizing the mineralized matrix of bone. This may have been because the excessive amount of 9-cis retinoic acid caused RXRs to pair up with themselves and thereby made these receptors unavailable to vitamin D. When scientists incubate cells with activated vitamin D and all-trans retinoic acid, ordinarily the source of 9¬-cis retinoic acid in the cell, the two hormones stimulate the production of osteocalcin with remarkable synergy.

More information on the interactions between vitamins A and D can be found in these articles:

Vitamin K2

Does Vitamin A Cause Osteoporosis?

Vitamin D Safety

The Spanish research demonstrating the necessity of 9-cis¬ retinoic acid for the functioning of the vitamin D receptor can be found here, and here:

In the December Vitamin D Council newsletter, Dr. Cannell further claims that consuming preformed vitamin A is “unnatural” and that the body highly regulates the conversion of carotenoids found in vegetables to vitamin A as needed. However, the enzymes that convert carotenoids to vitamin A are less critically maintained because they are unneeded when preformed vitamin A is provided in the diet-as it usually is. They are therefore, like the enzymes that convert essential fatty acids in plant oils to their elongated and desaturated forms, subject to variations in genetics, circumstantial health, and dietary and environmental influences.

Many factors can interfere with the conversion of carotenoids into vitamin A including thyroid problems, liver problems, diabetes and genetics. Babies and children convert carotenes very poorly if at all.

The statement that preformed vitamin A is unnatural is ludicrous in the light of what we know about traditional diets. The chief source of calories in the traditional Inuit diet, for example, is seal oil, which Weston Price found to be higher in vitamin A than cod liver oil. Fish heads, extremely rich in vitamin A, are a staple in the Japanese diet. Many cultures consume liver, often in high amounts-yet the authors of the review paper imply that liver is toxic. Tell that to the Frenchman enjoying his foie gras, the Englishman consuming liver and onions, or the South Sea Islander who submits to great danger to obtain shark liver for men and women, in order to ensure healthy children. The truth is that pre-formed vitamin A is more plentiful in traditional foods than vitamin D, yet politically correct nutrition insists that we must obtain vitamin A through the laborious process of converting carotenes.

More information on the conversion of carotenoids to vitamin A can be found in this article and this one: (see the section “Vitamin A Vagary”).

The Annals paper does not cite any studies showing toxic effects from cod liver oil, but Dr. Cannell cites one study in his December newsletter associating intake of cod liver oil with hypertensive disorders during pregnancy. Users of cod liver oil in this study had about twice the intake of vitamins A and D as non-users and eight times the intake of long-chain omega-3 fatty acids. The study found the most robust association with long-chain omega-3 fatty acids, which were associated with lower risk between 0.1 and 0.9 grams per day and higher risk above 0.9 grams per day. The authors suggested that the association with high blood pressure might be related to oxidative stress caused by a high intake of polyunsaturated fatty acids.

The abstract of the study can be found here:

The new Annals article offers nothing new to incriminate cod liver oil. It provides a well-written argument that vitamin D intakes need to be higher and incriminates only highly processed modern cod liver oils that have inadequate amounts of this critical nutrient. We recommend only high-vitamin cod liver oils that provide abundant vitamins A and D without an excess of polyunsaturated fatty acids.

As we pointed out in our last update on cod liver oil, during the first half of the century, cod liver oil was the focus of a worldwide health initiative. Parents were urged to give cod liver oil to their children by doctors, by government officials, by teachers and principals in schools, and even by their ministers in churches. A large portion of adults in America born before the Second World War received cod liver oil as children and this practice contributed to a high level of health, intelligence and physical development in those lucky enough to receive it. In many European countries, children received a daily ration of cod liver oil, especially during the war years. In the UK, for example, the government issued cod liver oil to all growing children until the early 1950s.

What has led to the demise of this obviously beneficial practice? Cod liver oil is a food; it can’t be patented, it can’t be created in a laboratory; it can’t create millions for the drug companies. So interest in this wonderful superfood has naturally waned. But if you are basing your dietary habits on the principles of healthy nutritional diets, don’t hesitate to include cod liver oil-our recommended brands of cod liver oil–as a healthy and natural food source of critical vitamins so lacking in modern diets.

Sally Fallon, President
The Weston A. Price Foundation

recommended links

  • Dr. Ron’s: a great place to purchase Blue Ice High Vitamin and Fermented Cod Liver oil.  I also like Dr. Ron’s line of additive-free supplements.

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