No More Fish Oil (Inflammation, Asthma, and Gastritis)

Update: I didn’t notice any benefits from discontinuing fish oil, and I feel better on my regular supplemental dose (about 3g/day). My latest thinking is that fish oil may calm down an overactivated immune system via increasing IL-10, and that this may be helpful not only for asthma but for any number of conditions where tissues can get “stuck” in an inflammatory state.

Fish oil has been good to me. It was the first supplement that I noticed reduced my asthma symptoms, over fifteen years ago. Along with dietary changes, supplemental vitamin D, and evening primrose oil, I used 2-4 grams of fish oil per day, and for the most part stayed asthma free.

Eventually, for whatever reasons, my asthma went away. Occasionally I still notice a small amount of lung tightness, but these days I can breathe easily even if I don’t follow a strict diet or take inflammation-suppressing supplements. Maybe my immune system changed, or maybe my lung microbiota changed. Whatever the reasons, I’m grateful. Constant lung tightness caused by inflammation really sucked, and inhaled corticosteroids messed with my moods so much that I couldn’t use them (I felt suicidal).

Recently I stopped taking fish oil, as I suspected it might be aggravating my gastritis symptoms. I’ve recovered very slowly from painful stomach inflammation initially triggered by a stomach bug over eighteen months ago. I still have minor intermittent symptoms (sensations of heat or coolness), but I also have days where I feel completely normal, and I can drink moderate amounts of wine and coffee, as well as eat spicy food, citrus fruits, and other potential gastritis triggers without any digestive issues or increased pain. One of the things that was still triggering flares, I realized very recently, was supplemental fish oil.

My diagnosis (via endoscopy) was reactive chemical gastropathy, the kind generally caused by NSAID, COX enzyme-inhibiting medications like ibuprofen. I was relieved by this diagnosis (no ulcers, cancer, or precancerous changes) but also confused, since I’d used NSAIDs very infrequently, and not at all since having stomach pain. Even after this diagnosis I continued to suspect that my gut biome was out of whack, even though I tested negative for H. pylori (via blood test and endoscopic biopsy), and was free of symptoms typically associated with dysbiosis (such as nausea, bloating, burping, poor digestion, excessive gas, low stomach acid, etc.). After a few months of recovery my only remaining symptoms were heat, burning, or pain around my ribcage or back (I did have other digestive symptoms initially, and also the whole time I was using PPIs, but a few months after I weaned off acid blockers my digestion pretty much returned to normal).

I recently watched a Chris Masterjohn video that shed some light on the issue.

Around 5:40 Masterjohn points out that ingesting high levels of EPA (one of the fatty acids found in fish oil, along with DHA) can have the same effects as taking anti-inflammatory drugs (NSAIDs).

That statement hit me like a ton of bricks. No wonder I’d been recovering so slowly!

Large amounts of supplemental fish oil, like NSAIDs, inhibit COX enzyme activity. The COX enzymes are responsible for transforming dietary fatty acids into various prostaglandins, some of which (PGE2) protect the stomach in various ways (decreasing gastric acid output, increasing bicarbonate to neutralize acid in the duodenum, etc.). Some anti-ulcer drugs, such as misoprostol, work by directly emulating specific prostaglandins.

In addition to fish oil, many herbs and medicinal plants also inhibit the COX-2 enzyme, including turmeric, resveratrol, pycnogenol, ginkgo, and ginger (here’s a long list of COX-2 inhibitors on selfhacked.com). While moderate COX-2 inhibition is helpful for reducing joint pain and preventing cancer, recent research indicates that COX-2 (as well as COX-1) is essential for “maintenance of mucosal integrity and ulcer healing.”

I suspect that my asthma-suppressing protocol of anti-inflammatory foods and supplements (fish oil, turmeric, boswellia, etc.), along with stress, may have weakened my stomach lining over time, eventually resulting in increased vulnerability to stomach bugs, alcohol, caffeine, etc. Early on, when I was first having stomach pain, I mentioned to my GP that I was taking both fish oil and turmeric. She recommended that I continue both (specifically because of their anti-inflammatory properties). But it turns out that stomach inflammation can’t be treated the same as joint or muscle inflammation. Aspirin and ibuprofen (like fish oil and turmeric) are anti-inflammatory, but they also can cause gastritis and/or peptic ulcers. My GP may have assumed that fish oil and turmeric were okay because they don’t suppress the COX-1 enzyme, only COX-2. Except that’s not true; fish oil suppresses both COX-1 and COX-2. And as referenced above, COX-2 is also necessary for gastric protection and recovery. Fish oil is fairly similar to aspirin in its effects: it thins the blood and it inhibits COX. And, like aspirin, high or frequent doses can tear up your stomach.

This is not to say fish oil, turmeric, ginger, etc. can’t be gastroprotective. Fish oil can suppress H. pylori. Ginger suppresses gastric acid secretion and also inhibits h. pylori, as does turmeric. My guess is that moderate culinary use of both ginger and turmeric probably does more good than harm, even for people with dodgy stomach linings, but using either plant in concentrated pill/supplement/extract form may over-suppress COX-2, potentially aggravating gastric problems.

Ultimately, when using a supplement (or even deciding whether to include a food in your diet, or not) you have to go with how it makes you feel. Scientific research and traditional healing practices might point you in the right direction, but different studies can produce conflicting results. For example, there are compounds in aloe vera (often used to treat gastritis) that both stimulate and inhibit prostaglandin synthesis. Some drugs and medicinal plants might provide short-term relief but slow down long-term healing. In other cases relieving pain (via acid suppression, stomach coating agents, or increased prostaglandin synthesis) might indicate or coincide with actual healing (not just mask symptoms).

Fatty Acids and Prostaglandin Pathways

Over a year ago I came across some research that indicated higher intakes of linoleic acid may increase PGE2 secretion, reduce gastric acid, and protect the stomach. For awhile I tried eating more walnuts and sunflower seeds (both high in linoleic acid), but it didn’t seem to help much. In animal studies, arachidonic acid (which is a direct precursor of PGE2) had a greater gastroprotective effect than linoleic acid.

The relationship between fatty acids and prostaglandin production is complex, as indicated by this chart:Arachidonic acid is found in egg yolks, liver, chicken, and other animal products, or can be manufactured by the body from linoleic acid, given the right nutritional factors and enzymes. PGE2, which protects the stomach, is made from arachidonic acid, via cyclo-oxygenase (COX). This chart labels series 2 prostaglandins as “unfavorable,” but in terms of stomach lining integrity, the opposite is true in most cases (adequate PGE2 is required for mucosal integrity).

In terms of balancing omega-3 and omega-6 fatty acids, it’s probable I’ve gone too far in the omega-3 direction. Going forward I’ll continue to eat fatty fish such as salmon and sardines, but I’ll stop taking fish oil and cod liver oil, and I’ll eat more foods that contain arachidonic acid, such as whole eggs, liver, and chicken.

I’ll probably continue taking evening primrose oil which contains GLA. This can be synthesized into DGLA (via the elongase enzyme) and then into PGE1 (again, via COX). PGE1 is a beneficial prostaglandin in terms of preventing asthma, reducing blood pressure, etc.

Fatty acids and prostaglandins are only part of how the stomach protects itself. Animal studies indicate that the stomach can become tolerant to NSAID use (probably via increased blood flow), even with near complete prostaglandin suppression. But I do think it’s likely that taking supplemental fish oil and anti-inflammatory herbs has slowed down my healing process, and maybe contributed to my stomach problems in the first place.

There are also foods that upregulate COX-2 in the stomach lining, which can accelerate gastric healing (including ulcers). Ellagic acid, found primarily in strawberries and walnuts, but also in other berries, grapes, and pomegranates, has this effect. A metabolite of ellagic acid, urolithin A, is also protective against IBD.

A “Good” Diet is a Moving Target

It’s a good feeling when you have a health program “dialed in.” You’re feeling good and you know, more or less, what you need to do to keep feeling good, in terms of diet, supplements, exercise, sleep, social life, life purpose, etc.

But the one constant in life is change. What worked for me for years was a high-fat, low-carb, mostly-Paleo diet, combined with vitamin D and fish oil supplementation. This worked great for getting rid of lung inflammation, but in the long term it may have weakened my stomach lining.

So now I’m adjusting, increasing complex carbs and reducing fats, increasing cooked vegetables (especially broccoli and greens), reducing vitamin D (which, at high doses, can raise serum calcium levels and increase gastric acid secretion), cutting out the fish oil, and moderately increasing my intake of arachidonic acid from food sources. I’m also experimenting with a wide range of supplements that may contribute to gastric healing and long-term stomach protection (collagen hydrolysate, vitamin K2, l-glutamine, co-enzyme Q10, zinc carnosine, n-acetyl cysteine, buffered vitamin C, vitamin E, and medicinal mushrooms such as cordyceps and Lion’s Mane).

Fighting Non-Existent H. Pylori

It’s unfortunate that when you search for “gastritis” on the internet, most of the information that is returned concerns research or remedies for fighting H. pylori infection. Yet there are a significant number of gastritis cases in which H. pylori isn’t a causative factor (especially in the United States — infection rates here are low). Worse, many of the natural remedies for reducing H. pylori (including fish oil, turmeric, ginger, black seed, etc.) also inhibit COX and may slow down gastric healing.

There are a huge number of factors that can weaken or irritate the stomach lining, including stress, NSAID use, infection (from h. pylori, viruses, etc.), dysbiosis (the stomach has its own acid resistant microbiota), food intolerances (gluten and dairy, primarily), alcohol abuse, too much coffee, too much spicy or acidic food, smoking, gallbladder problems, iron overload, nutritional deficiencies, and genetic factors. But in most cases, a visit to the doctor’s office will result in recommendation to take proton pump inhibitors, with little discussion of why the stomach might be vulnerable to injury in the first place.

The lack of answers from my doctors, combined with the huge bias of internet information toward dealing with H. pylori infection, pointed me in the wrong direction in terms of healing, and I think many people may be in the same boat.

Healing Protocol for Chemical/Reactive Gastritis?

I’m hesitant to attempt any kind of healing protocol for gastritis, for a number of reasons:

• I’m not fully recovered, and it has taken me a long time to get where I am.
• I’m not a doctor or a naturopath — I don’t have any formal medical training.
• There are so many possible causes of gastritis — some interventions could help some people but hurt others (such as the use of betaine Hcl or d-limonene, which can improve digestion, but can hurt like hell if your stomach lining is damaged).

That said, some common sense measures will probably be helpful for most people, such as eating slowly, chewing well, eating smaller meals, meditating, reducing stress, getting enough sleep, and avoiding irritating foods and beverages (which vary from person to person, but might include alcohol, coffee, spicy food, acidic foods such as citrus and tomatoes, milk products, and/or gluten).

PPIs are prescribed very liberally by most doctors, but in hindsight I wonder if using an H2 blocker such as ranitidine (Zantac) would have been just as effective for my initial recovery (when I was in near-constant pain and couldn’t sleep through the night because of stomach pain). Using omeprazole did provide some relief at first, but long-term PPI use leads to anxiety, nutritional deficiencies, kidney disease, and increases the chance of stomach cancer. In about 50% of people (including myself), stopping PPIs leads to intense rebound symptoms. My GP explicitly and incorrectly told me that tapering off wasn’t necessary, which led to a great deal of pain, and probably a net negative in terms of my healing. Taking PPIs is preferable to dying from a bleeding ulcer, but for non-ulcer gastropathy the risks may outweigh the benefits. This seems especially true considering very few people appear to recover from gastritis after a short course of PPIs (at least that’s my take from reading various forums).

My general approach to healing, until now, has been to reduce alcohol and caffeine, reduce spicy and acidic foods, and to increase various gastroprotective factors via the supplements I mentioned above. For short-term pain relief and acid reduction I’ve primarily used slippery elm mixed with water, herbal teas (fennel seed, chamomile, ginger), and sometimes aloe vera juice or black licorice. Melatonin also has gastroprotective properties, and supplementing in small doses (<1mg) at night may accelerate healing (melatonin has a very similar chemical structure to omeprazole). Some of the herbs I use also suppress COX-2, but they also provide relief by reducing gastric acid (even with natural remedies, there’s always a trade-off).

It’s too early to say if stopping fish oil is going to be a huge help. I’ll report back if I notice significant changes.

Onward

Hopefully I can get to the point where I feel 100% recovered, but even if not, my quality of life is very high right now, and I feel grateful for being in reasonably good health. It’s amazing how chronic pain can readjust your life priorities. In a way it has been a gift. Having been through the wringer, I feel more focussed than ever on friendship, family, contribution, creativity, and my spiritual core.

If you are struggling with similar issues, hopefully this post is helpful. I’m posting it as public for now, but at some point I may put it behind my Patreon wall; I don’t want to be known as “the gastritis guy” any more than I wanted to be known as “the hair regrowth guy” or “the asthma guy.” But I do feel compelled to share what I’ve learned so far.

Feel free to comment or ask questions.