Fish, fishy, and fish adjacent

Why eat like an Inuit when you can pop a pill

In 1913, the people living on the northwest coast of Greenland were described as “probably the most exquisitely carnivorous people on earth¹.” They subsisted almost entirely on the meat of whales, seals, seabirds, and fish, of which the dominant species were halibut, capelin, and salmon. They ate almost no carbohydrates at all. And yet, they thrived.

More than half a century later, in 1971, researchers found that these same people had extremely low levels of heart disease, and no diabetes at all. Rather than engaging in collective hand-wringing about how people with such awful diets could possibly be so hale and hearty, the health of these “exquisitely carnivorous” people was attributed to just one part of their diet: fish. And so was born a new dietary trend.

People should eat more fish, we are told, specifically fatty fish like halibut and salmon. It is chock full of omega-3 fatty acids, notably the unmemorably named DHA (docosahexaenoic acid) and EPA (eicosapentaenoic acid). We are assured that these are good for our heart. Eat more cold-water fatty fish. You’ll be glad that you did.

Arctic char in Greenland. Photo by Dan Bach Kristensen for Getty.

Okay, but what about the people who live inland and don’t have easy access to fish? What about the people who just don’t like how fish tastes?

Enter: fish oil. It’s got all the benefits of fish, without any of the costs!

Reductionism is seductive—so easy, so smooth, so very quantifiable. Fish might be good for you, but what parts of the fish, and why? What if some parts of fish are bad for you? Are all species of fish equal, or all species of fatty fish? Wouldn’t you like to be able to titrate those benefits and know exactly what you’re getting? Do you want answers to these questions, like the modern person that you are, or do you want to live in the past, gorging yourself on fish and just hoping for the best?

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Ladies and gentlemen, step right up, step right up, and learn how to put your health back into your own hands. Come a little closer now, that’s right. Allow me to introduce to you the magical, magnificent (and marketable) cure that will finally bring you relief from your aches and pains. Have doctors ignored you, dismissed you, or left you to wallow in your own pain? Have you been left battered and bewildered at the doorsteps of the very professionals who say they want to help? Leave the disrespect behind, and the worry. Allow me to introduce you to fish oil! Fish oil is a space-age anti-inflammatory, combining the wisdom of the ancients with the most modern technology, allowing this precious substance to be harnessed at a low, low price that you will have to see to believe. Supplies are limited, however, so get yours today. Right now, I am authorized to provide a very special offer of two bottles for the price of one! That’s 100% off your second bottle! But wait—there’s more! Pay with cash, and we’ll throw in a third bottle for free. Absolutely free! Only you can take control of your health. If you don’t, nobody will. Have a twinge in your chest? Feeling weak in the knees? Worried about sudden death? Never fear. Fish oil is here!

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For a while there, the claims associated with fish oil were a marvel to behold²—fish oil has been proposed to help prevent schizophrenia and eye disease, ADHD and asthma. Still, there are some promising avenues to explore. If a diet high in fatty fish can help mitigate the risk of heart disease, why not isolate the property in the fish that is so helpful, package it, and sell it on its own!³ Shelf stability is awesome, after all. Fish oil is one of the most common dietary supplements taken in the United States. Eh, the fact that supplements themselves don’t seem to have the same heart healthy effects as eating actual fish shouldn’t stop you. Check out the reduction in pain and stiffness that you will experience on fish oil supplements if you have rheumatoid arthritis!⁴

So a diet rich in fatty fish is probably good for you, but attempts to isolate the valuable elements in fish resulted in supplements whose hype exceeded their promise. What’s an enterprising pharma company to do?

Photo credit: Maria Korneeva for Getty

Enter: Vascepa.

In November 2019, an article published in the Washington Post seemed to suggest that fish oil was being resurrected. “FDA panel endorses wider use of fish-oil drug to protect against heart problems,” the headline reads. But it turns out that the “fish-oil drug” in question is not the same thing as fish oil. The first two paragraphs of the article clarify:

A panel of experts unanimously recommended Thursday that the Food and Drug Administration allow wider use of a fish oil-based drug to treat people at high risk for heart attacks and strokes even when they are taking cholesterol-lowering drugs.

The 16-0 endorsement of the FDA advisory committee puts Dublin-based Amarin Corp. one step closer to widespread distribution of Vascepa, a drug the company has said could be worth billions of dollars annually. The FDA, which usually follows such guidance, could make a long-awaited final decision next month.

Fast forward to 2023, and find fish oil getting battered in the popular press. The same Washington Post that wrote excitedly about the “fish-oil drug” in 2019 now reports that “Marketers overstate fish oil claims for heart health, study shows,” and “Fish oil claims not supported by science.”

And yet Vascepa is going strong. The FDA did indeed approve its release, and now, the skilled marketers at Amarin Corp are working to distance themselves from the seedy underbelly of fish oil. That seedy underbelly isn’t all that seedy, of course, being merely the vague sense consumers increasingly have that maybe fish oil is not a miracle cure after all, and maybe, actually, just eating real fish once in a while is a better choice. But the marketers at Amarin, poor dears, have an even more difficult challenge than that, for the truth of Vascepa is that its only active ingredient is a slightly tweaked version of one of the two most recognized omega-3s in…fish oil. Remember DHA (docosahexaenoic acid) and EPA (eicosapentaenoic acid)? According to Vascepa’s website:

FDA-approved Vascepa is made up of one active ingredient: icosapent ethyl (IPE), which is an innovative form of eicosapentaenoic acid (EPA)

If “EPA” sounds familiar, that’s because it’s an omega-3 fatty acid. IPE is the only active ingredient in Vascepa and is considered the reason behind the significant CV benefits Vascepa can deliver.

Well gee, an uninformed person like myself might read that and think—if IPE provides such significant cardiovascular benefits, why not go ahead and take fish oil after all, which has a) the omega-3 that IPE is based on, a molecule doesn’t need to be synthesized in a lab and has never been suggested to be toxic, and b) contains DHA as well, another omega-3 which also sometimes seems to be associated with cardiovascular benefits.

Not so fast, buster. Some of the myriad reasons that that would be a bad thing to do are conveniently listed right here, also on the Vascepa website:

To summarize their argument: you should use Vascepa because the FDA says you should use Vascepa, as do some medical societies! Plus there’s this swell study⁵—funded by us!—that shows that our product is better than placebo at preventing heart damage. Oopsie though, we used a placebo that itself causes heart damage⁶. When people without conflicts of interest undertook a similar study,⁷ except that they used an actual placebo, all benefits of our delightful drug disappeared. Damn.

Reasons that the good people at Amarin would have you avoid fish oil supplements include that the FDA remains unconvinced, the American Heart Association isn’t in favor of supplements, and fish, from which fish oil comes, were never intended or approved to treat heart disease. They’re fish, after all, not medicine! You see, the only medicine that could possibly be effective is one that was created by people with a profit motive.

Note that there is no science backing up any of these claims. The one study they have was self-funded and used a toxic placebo, and every other reason they trot out is based on authority: trust us, because the FDA says so. Trust us, because the American Heart Association (AHA) says so. Trust us, because unspecified medical societies say so.

Science and medicine aren’t supposed to take marching orders from authority, ever, even actually trustworthy authorities. In addition, though, consider the obvious:

In a system where science is being bludgeoned to death and those who are witness to the crime either yell about it and are shoved into a corner, or remain silent and continue to collect their paychecks,

where the only “evidence” necessary to make scientific or medical claims is to refer to the recommendations of organizations (e.g. FDA, AHA) and publications (e.g. Science, Nature),

in an era when those same organizations and publications are strapped for cash and looking for new ways to stay afloat,

those organizations and publications will absolutely get gamed. They will become corrupt. They will get captured. And so they will remain in existence, sort of. Still draped in the aura and gravitas of their former reputations, they may look like the august sheep of old, but are very much wolves on the inside.

The real reasons that Amarin would have you use Vascepa are these: in 2021, Vascepa brought in over $550 million dollars net for Amarin in the United States, and Vascepa is the only product that Amarin makes. Once you know this, the story begins to make an easy, smooth, and so very quantifiable kind of sense.

An Inuit fisherman and dog sled driver in Qaanaaq, Greenland, chops halibut to feed to his hungry dogs. Photo by Justin Lewis, for Getty.

1. As cited in Bang, Dyerberg & Nielsen 1971. Plasma lipid and lipoprotein pattern in Greenlandic West-coast Eskimos. The Lancet, 297(7710): 1143-1146.

2. The site where this list came from, healthline.com, is awful. I would not rely on their analysis for anything.

3. To be fair, fish oil may also be a better companion than actual fish, or at least than their heads are. As has been widely accepted for years now, fish heads “can’t play baseball. They don’t wear sweaters. They’re not good dancers. They don’t play drums.”

4. This is a claim without citation on the Mayo Clinic’s website: “Studies suggest fish oil supplements might help reduce pain, improve morning stiffness and relieve joint tenderness in people with rheumatoid arthritis. While relief is often modest, it might be enough to reduce the need for anti-inflammatory medications.

5. REDUCE-IT trial, with toxic “placebo”: Bhatt et al 2019. Cardiovascular risk reduction with icosapent ethyl for hypertriglyceridemia. New England Journal of Medicine, 380(1): 11-22.

6. This means, among many other things, that the people who orchestrated the REDUCE-IT trial induced heart damage in their control group. Ridker et al 2022. Effects of randomized treatment with icosapent ethyl and a mineral oil comparator on interleukin-1β, interleukin-6, C-reactive protein, oxidized low-density lipoprotein cholesterol, homocysteine, lipoprotein (a), and lipoprotein-associated phospholipase A2: a REDUCE-IT Biomarker Substudy. Circulation, 146(5): 372-379.

7. STRENGTH trial, with actual placebo: Nicholls et al 2018. Assessment of omega‐3 carboxylic acids in statin‐treated patients with high levels of triglycerides and low levels of high‐density lipoprotein cholesterol: rationale and design of the STRENGTH trial. Clinical cardiology, 41(10): 1281-1288.