Omega-3s vs. Omega-6s: Balancing the Scale for Optimal Health in Clinical Practice

Nutrition advice is ubiquitous in our current culture, and every dietary trend promises to be the path to optimal health. Patients need to seek knowledgeable professionals with evidence-based answers to their health questions about omega-6 and omega-3 fatty acids and inflammatory health.

Omega-3 and omega-6 fatty acids each have their roles in physiologic functioning, yet with considerable overlap. Omega-3s are widely touted for their anti-inflammatory properties and benefits for heart health. We find them in fatty fish, flaxseeds, chia seeds, and walnuts. Omega-6 fatty acids are found in processed foods, vegetable oils, and seed oils, so they are ubiquitous in the modern Western diet. While they do play important roles in various organ systems, too many omega-6 fatty acids can be harmful. 

High levels of omega-6 fatty acids, especially higher ratios of omega-6 fatty acids to omega-3 fatty acids, fuel inflammation and worsen chronic disease risk. Balancing the intake of omega-6 fatty acids to omega-3 fatty acids is imperative to overall health.

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Understanding Omega-3 and Omega-6 Fatty Acids

Fatty acids are a crucial component of cell membranes, with specific duties in function, signaling, and metabolic roles. In particular, omega-3 and omega-6 fatty acids are essential polyunsaturated fats with important roles in overall health. Omega-3 fatty acids include alpha-linolenic acid (ALA), eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA). The roles of omega-3 fatty acids are in cognitive functioning, vision, and cardiovascular health. EPA and DHA exhibit anti-inflammatory properties, reducing the risk of many chronic diseases, like heart disease and osteoarthritis. While ALA can serve as a precursor to EPA and DHA, the body is inefficient at converting ALA to EPA and DHA, so it is ever more important to obtain omega-3 fatty acids from foods.

Omega-6 fatty acids include linoleic acid (LA) and arachidonic acid (AA). They also serve important, but different, functions than omega-3 fatty acids. Overall, omega-6s aid with blood clotting, muscle contraction, and immune response. AA makes up a substantial amount of the phospholipids in the brain, liver, skeletal muscles, platelets, and immune regulatory cells. The other omega-6 fatty acid, LA, also has significant roles in skin integrity. LA is a main component of ceramides, which make up at least 50% of the lipid-rich extracellular matrix in the skin, which is imperative in controlling skin permeability–controlling what comes in and what goes out.

ALA (the omega-3 fatty acid) and LA (the omega-6 fatty acid) are both essential fatty acids, which the body cannot make but instead must obtain from the diet. They are present in the highest concentrations in a variety of plant-based foods and a handful of animal products. ALA is found in high concentrations in pumpkin seeds and walnuts. LA is found in seeds, vegetable and seed oils, nuts, and eggs. The other omega-3 fatty acids (EPA and DHA), which must come from foods, are found in fatty fish, nuts, seeds, and oils. 

The Omega-6 to Omega-3 Ratio: Implications for Health

The relationship between omega-3 and omega-6 fatty acids is nuanced. While they are each beneficial, the ratio of omega-3 fatty acids to omega-6 fatty acids adds a level of complexity to understanding the two types. While a moderated intake of omega-6 fatty acids has been shown to have anti-inflammatory effects and reduce the risk of cardiovascular disease, higher intakes of omega-6 fatty acids and an imbalance of omega-3 fatty acids as compared to omega-6s are known to increase the risk of inflammatory-driven chronic illnesses like heart disease, metabolic syndrome, obesity, autoimmune diseases, and more.

Before the food revolution, using natural, non-synthetic, and processed foods, people typically ate a fairly balanced ratio of these omega-6 and omega-3 fatty acids, in ranges anywhere from 1:1 to 4:1. However, the modern food supply has led to a substantial rise in omega-6 fatty acids in the Western world, now with a ratio of about 20:1. The health consequences have been paramount. While a higher than recommended intake of omega-6 fatty acids increases the risk of proinflammatory conditions, diets high in omega-3 fatty acids are antiinflammatory, actually protecting against cardiovascular disease, metabolic syndrome, and other inflammatory-mediated health problems.

There is a direct association between the omega-6 to omega-3 ratio and many health outcomes. A lower omega-6 to omega-3 ratio is associated with fewer adverse cardiovascular events, like heart attack and stroke. Reducing omega-6 dominance improves inflammatory markers, cholesterol profiles, insulin sensitivity, and overall health profile.

Consequences of Imbalance: Omega-6 Dominance

The modern food supply consists of an abundance of processed foods and vegetable oils, which has predisposed to a shift in the balance of dietary omega-6 to omega-3 fatty acids. With this shift has come significant health implications. Omega-6 dominance, with a higher omega-6 to omega-3 ratio, is linked to several adverse health outcomes, including cardiovascular disease, metabolic syndrome, and other proinflammatory conditions.

Arachidonic acid (the common omega-6 fatty acid) is a precursor for pro-inflammatory molecules like prostaglandins and leukotrienes. High levels of these inflammatory molecules promote endothelial dysfunction, platelet clumping, and arterial narrowing. This significantly increases the risk of developing atherosclerotic plaque and heart disease leading to heart attack and strokes.

Omega-6 dominance also causes dyslipidemia or unfavorable cholesterol profiles. Elevated levels of unhealthy low-density lipoprotein cholesterol (LDL-C) and low levels of cardioprotective high-density lipoprotein cholesterol (HDL-C) increase the risk of atherosclerosis and heart disease even more.

Metabolic syndrome is another risk of a high omega-6 to omega-3 ratio. Metabolic syndrome is a constellation of proinflammatory health conditions, including obesity, insulin resistance, dyslipidemia, and high blood pressure. Chronic inflammation is a major driver in insulin resistance, as a result of both chronically high insulin levels and poor insulin signaling. This further exacerbates the weight gain, metabolic dysregulation, and abdominal adiposity that characterize metabolic syndrome.

A high omega-6 to omega-3 ratio also promotes the development of other proinflammatory conditions, through the increased proinflammatory cytokines from high levels of omega-6 fatty acids. Conditions such as autoimmune diseases, inflammatory bowel diseases, and asthma are known to result from immune dysregulation and not only are more likely to occur but are also more likely to be exacerbated by omega-6 dominance. 

Strategies for Achieving Balance in Clinical Practice

As the intake of processed foods remains at an all-time high, and as obesity and metabolic dysfunction are more common year-over-year, healthcare professionals have an urgent responsibility to guide patients toward a more balanced omega-6 to omega-3 ratio. This can be achieved by both dietary modifications and supplementation, both of which should be personalized to each patient, based on their health concerns and risk factors. 

Several dietary strategies can help patients improve the omega-6 to omega-3 ratio of the foods they eat. Selecting whole, real foods, as close to their natural state as possible, while avoiding processed foods, is a vital first step. This helps eliminate vegetable and seed oils and other proinflammatory fats, and it also helps include more healthy fats, which is the next important step. Choosing healthy fats, like nuts, olive oils, avocados, fatty fish, chia seeds, and flax seeds helps increase the intake of antiinflammatory omega-3 fatty acids, thus reducing the risk of adverse cardiovascular events and other inflammatory-mediated conditions.

Despite dietary modifications, many patients struggle to consume sufficient omega-3 fatty acids. This is where supplementation of EPA and DHA omega-3 fatty acids may be beneficial. Utilizing a functional medicine approach allows for personalized nutrition plans, which can be tailored to each patient’s specific risk factors and health conditions. For example, patients who have existing high levels of inflammation likely require a more substantial change in their dietary patterns to ensure high levels of omega-3 fatty acids to help lower inflammation. In contrast, patients who already regularly consume some omega-3 fatty acids may be able to make small swaps to optimize their nutrition. Personalized nutrition plans also allow for consideration of food preferences, lifestyle factors, and health goals, which helps promote overall adherence and patient success.

Omega-3 Supplementation: Clinical Guidelines

Despite dietary modifications, many patients struggle to consume sufficient omega-3 fatty acids. This is where supplementation of EPA and DHA omega-3 fatty acids may be beneficial. Several formulations of omega-3 supplements are available, including encapsulated triglyceride fish oil and emulsified fish oil. Emulsified fish oil not only promotes better patient adherence through its improved palatability, but it also appears to have better absorption. 

Algal oil is a vegan alternative omega-3 supplement to fish oil. It still offers bioavailable omega-3 fatty acids but is suitable for those following a vegan diet and generally for those with fish or seafood allergies. Cod liver oil is another alternative, and its origin is liver, as the name suggests. It is high in fat-soluble vitamins A and D. Krill oil offers another option for omega-3s, but it carries ethical and sustainability concerns, as krill are fewer in number and less available.

High-dose fish oil (total daily doses 4 grams or more) has been shown to reduce moderate-to-severe elevations in triglycerides and is even more effective when combined with dietary modifications and lifestyle changes. In patients without elevated triglycerides or significant dyslipidemia, fish oil doses of 1 to 4 grams per day may improve cardiovascular health. However, it is important to note that supplementing with omega-3s has not been shown to lower cardiovascular disease risk and is not recommended for the prevention of heart disease.

Monitoring and Adjusting Treatment Plans

Several assessment tools are available to assess fatty acid health status and monitor changes over time. Regular laboratory monitoring of patients' fatty acid profiles helps adapt and optimize individual treatment plans. Monitoring fatty acid levels over time shows both healthcare providers and patients the effectiveness of dietary interventions, supplementation, and lifestyle modifications, which have two important functions: suggesting any necessary treatment changes and encouraging patients to continue treatment adherence.

Comprehensive fatty acid profiles evaluate not only levels of essential (ALA, LA) and non-essential (EPA, DHA, AA) fatty acids but also other fatty acids (saturated fats, trans fats, and more), cytokines, and eicosanoids, and important fatty acid ratios and indices. These fatty acid profiles are immensely helpful in a health deep-dive, for a comprehensive functional medicine assessment of current health. 

More simplified omega-3 and omega-6 fatty acid testing are also available, especially as follow-up testing, to demonstrate changes in these key markers. Monitoring fatty acid levels over time is similar to monitoring labs like lipid panels and glycosylated hemoglobin levels. It allows healthcare providers and patients to see how dietary and other treatment changes directly impact fatty acid levels over time.

Although inflammatory markers are non-specific, they correlate well with omega-3 fatty acid status. Helpful inflammatory markers include erythrocyte sedimentation rate, high-sensitivity C-reactive protein, interleukin-6, and other cytokines and eicosanoids. These inflammatory markers generally have an inverse relationship with omega-3 fatty acid status, such that lower systemic inflammatory markers are associated with improved omega-3 fatty acid profiles.

Challenges in Dietary Modification and Compliance

Many common challenges and barriers to dietary modifications and adherence act as barriers to overall good health. From inadequate patient and clinician education to deeply rooted dietary habits and preferences, to limited access and availability to healthy foods, overcoming these common challenges and barriers requires concerted effort with a multifaceted approach to address deeper underlying problems.

Improving patient and clinician education is a huge project, but it is essential to dietary modifications and behavior changes. Understanding how processed foods contribute to inflammation through proinflammatory components like a high amount of omega-6 fatty acids is much more likely to encourage lasting dietary modifications than a simple list of “good and bad foods.” Furthermore, misconceptions and misinformation abound in the world of nutrition, so much so that it is impossible to refute each one. However, educating just one patient at a time can dramatically improve their overall health.

Culture plays a significant role in dietary habits and preferences, especially what is learned and experienced in childhood. While education can help change these to an extent, modifying dietary habits and preferences requires that patients remove some emotional connections with less healthy foods. When you add in less availability of healthy foods, whether it be in rural areas with lower socioeconomic status or in the hustle and bustle of eating on-the-go restaurant foods, changing our food supply (removing the majority of processed foods) is imperative to improve the availability of healthy foods.

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Key Takeaways

Recognizing the importance of balancing the intake of omega-6 and omega-3 fatty acids is the first step in understanding overall inflammatory health. While omega-3 fatty acids are vital for everyone to consume, some patients benefit from even higher amounts, to address or prevent specific health conditions. Using a functional medicine approach to overall health, healthcare professionals should offer personalized nutrition plans to help patients achieve the optimal omega-6 and omega-3 fatty acid balance and to track these fatty acid and inflammation levels over time, making necessary adjustments and refinements along the way.