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ABSTRACT
Despite almost 25 y of fish oil supplementation (FS) research in athletes and widespread use by the athletic community, no systematic reviews of FS
in athletes have been conducted. The objectives of this systematic review are to: 1) provide a summary of the effect of FS on the athlete’s physiology,
health, and performance; 2) report on the quality of the evidence; 3) document any side effects as reported in the athlete research; 4) discuss any
risks associated with FS use; and 5) provide guidance for FS use and highlight gaps for future research. Electronic databases (PubMed, Embase, Web
of Science, Google Scholar) were searched up until April 2019. Only randomized placebo-controlled trials (RCTs) in athletes, assessing the effect of
FS on a health, physiological/biochemical, or performance variable were included. Of the 137 papers identified through searches, 32 met inclusion
criteria for final analysis. Athletes varied in classification from recreational to elite, and from Olympic to professional sports. Mean age for participants
was 24.9 ± 4.5 y, with 70% of RCTs in males. We report consistent effects for FS on reaction time, mood, cardiovascular dynamics in cyclists, skeletal
muscle recovery, the proinflammatory cytokine TNF-α, and postexercise NO responses. No clear effects on endurance performance, lung function,
muscle force, or training adaptation were evident. Methodological quality, applying the PEDro scale, ranged from 6 to a maximum of 11, with only 4
RCTs reporting effect sizes. Few negative outcomes were reported. We report various effects for FS on the athlete’s physiology; the most consistent
findings were on the central nervous system, cardiovascular system, proinflammatory cytokines, and skeletal muscle. We provide recommendations
for future research and discuss the potential risks with FS use. Adv Nutr 2020;11:1300–1314.
Keywords: performance, injury, inflammation, mood state, recovery, DHA, EPA, exercise
1300 Copyright
C The Author(s) on behalf of the American Society for Nutrition 2020. Adv Nutr 2020;11:1300–1314; doi: https://doi.org/10.1093/advances/nmaa050.
for the respective fatty acids. EPA and DHA have been re- within the electronic databases were conducted under each
ported to have differential effects on the antioxidant systems of the following specific terms—cognition, performance,
and anabolic-catabolic pathways in skeletal muscle (3, 4). injury, recovery, adaptation, skeletal muscle, muscle sore-
Moreover, EPA has inhibitory effects on cyclooxygenase- ness, endurance, strength—and the following methods were
2 expression, and metabolism of arachidonic acid (an n– applied to the searches: in PubMed, MESH headings were
6 fatty acid) (5). Furthermore, EPA is the precursor for 3- used and combined, whereas in Embase, Emtree was used
series prostanoids and 5-series leukotrienes (eicosanoids), with the expansion of the subject search term with the
whereas DHA is the precursor for protectins and maresins, subject added to query builder. Reference lists of individual
with both fatty acids producing the anti-inflammatory and study publications and reviews were consulted for additional
proresolving, aptly named, resolvins (5). studies. The publication abstracts and titles were screened
Case studies have demonstrated that elite athletes use FS individually to ensure removal of studies not meeting the
(6, 7). A review focusing on nutritional recovery strategies in inclusion/exclusion criteria. If there was any doubt over
team sports athletes concluded there was emerging evidence article inclusion or exclusion, the article was obtained in full
Lewis et al.
Żebroswka et Cycling Competitive Male participants ↑NO at rest and 3 1320 EPA Not measured Endothelium
al. (31) n = 13 postexercise 880 DHA independent
vasodilatation,
peak power, TGs,
LDL and HDL
cholesterol, total
cholesterol, HR,
SBP, DBP, glycerol,
TAS, PWV
Filaire et al. (32) Judo Elite Male participants ↓TGs, ↑MDA at rest 6 600 EPA Not measured GPx
n = 20 only, ↑MDA, 400 DHA
Rmax, CDmax
post-ex, ↑NO
post-ex
Filaire et al. (33) Judo Elite Male participants ↑MDA, Rmax, 6 600 EPA Not measured
n = 28 CDmax at rest, 400 DHA
and ↓post-ex Vitamin C, vitamin
E, β-carotene
Filaire et al. (33) Judo Elite Male participants ↑MDA, Rmax, 6 600 EPA Not measured
n = 28 CDmax at rest 400 DHA
and post-ex, ↑NO
post-ex
McAnulty et al. Cycling Competitive Male and female ↑F2-isoprostane 6 2000 EPA ↑Plasma DHA (55.8%),
(34) participants post-ex 400 DHA EPA (61.5%)
n = 48
McAnulty et al. Cycling Competitive Male and female Prevented 6 2000 EPA ↑Plasma DHA (95.3%),
(34) participants F2-isoprostane 400 DHA EPA (77.8%)
n = 48 ↑post-ex Vitamins, minerals,
antxs
McAnulty et al. Cycling Competitive Male and female Prevented 2 220 EPA Not measured ORAC, ferric-reducing
(35) participants F2-isoprostane 180 DHA ability of plasma
n = 39 ↑post-ex Vitamin C, EGCG,
quercetin, B
vitamins
Martorell et al. Soccer Semiprofessional Male participants ↑RBC SOD and GRd 5 d/wk for 8 1140 DHA ↑RBC DHA (26.4%) RBC MDA, carbonyl
(36) n = 15 activity, ↓GPx wk CHO, proteins, index,
almonds nitrotryosine, CAT
Ghiasvand et al. Basketball Well-trained Male participants Resting: ↑MDA 6 2000 EPA Not measured No change TNF-α
(19) n = 34
1
CAT, catalase; CDmax, maximum amount of conjugated dienes; CHO, ; DBP, diastolic blood pressure; EGCG, epigallocatechin 3-gallate; GPx, glutathione peroxidase; GRd, glutathione reductase; HR, heart rate; MDA, malondialdehyde;
ORAC, oxygen radical absorption capacity; post-ex, ; PWV, pulse wave velocity; Rmax, maximum rate of oxidation during the propagating chain reaction; SBP, systolic blood pressure; SOD, superoxide dismutase; TAS, ; TG, triglyceride.
2
All nonsignificant findings for the effects of FS.
Andrade et al. (37) Swimmers Elite Male participants Resting: ↑PBMC, ↓plasma 6 950 EPA ↑Plasma total ω-3 fatty PBMC TNF-α, IL-2, IL-4,
n = 20 PGE2 , ↓IFN-γ 500 DHA acids (45.4%), EPA cortisol, insulin
(196%), DHA (96%)
Delfan et al. (38) Paddlers Elite Male participants Resting PBMCs: ↓TNF-α, 4 2400 EPA Not measured IL-4, Th1/Th2 ratio
n = 22 ↓IL-1β, ↑IL-6, ↑IL-10, 1200 DHA
↓IFN-γ
Santos et al. (39) Marathon Competitive Male participants Resting: ↑lymphocyte 8.5 300 EPA Not measured Lymphocyte death.
n = 21 proliferation; ↓IL-2, 1500 DHA Postrace lymphocyte:
↓TNF-α, ↓IL-10 IL-2, IL-4, TNF-α, IL-10
Postrace: ↑lymphocyte
proliferation
Nieman et al. (40) Cyclists Competitive Male and female 6 2000 EPA ↑Plasma EPA (311%), DHA Total blood leukocytes, CK,
participants n = 23 400 DHA (40%) CRP, ratio sIgA:protein,
myeloperoxidase, IL-6,
IL-8, IL-1Ra, endurance
performance
Da Boit et al. (41) Athletic, Recreational Male and female ↓Total number of 16 550 EPA Not measured URTI incidence, severity
nonspecific participants n = 30 symptom days 550 DHA and duration of URTI,
Whey protein, vitamin visits to medical doctor,
D sIgA conc. and secretion
rate
Capó et al. (42, 43) Soccer Semiprofessional Male participants ↓Post-ex MIP1-α. Post-ex 5 d/wk for 8 wk 1140 DHA ↑RBC DHA (36%) Oxidative damage in
n = 15 LPS-stimulated PBMCs: CHO, proteins, PBMCs, ROS production
↓TNF-α, ↓IL-6, ↓TLR-4 almonds by PBMCs. Resting and
protein concentrations postexercise plasma:
↑PBMCs UCP-3, ↓GPx IL-2, IL-4, IL-6, IL-8, IL-10,
VEGF, IFN-γ , TNF-α,
IL-1α, IL-1β, TNF-β, EGF,
IL-5, IL-15, MCP-1,
GMCSF
Capó et al. (44) Soccer Semiprofessional Male participants Resting: neutrophil gene 5 d/wk for 8 wk 1140 DHA ↑RBC DHA (36%) Neutrophils: nitrate, nitrite;
n = 15 expression (IL-8, NFκB); CHO, proteins, NO; MPO, TNF-α, gene
↑neutrophil total MPO, almonds expression (COX2,
↑neutrophil total CAT TNF-α, MPO)
activity
Nieman et al. (45) Cyclists Competitive Male and female Resting: serum ↓CRP, 24 d 400 EPA Not measured Plasma IL-10, IL-1Ra, TNF-α,
participants n = 39 plasma IL-6, total 400 DHA CK, MCP, MPO, sIgA
leukocytes, EGCG, quercetin protein, HSP-70
↓granulocyte oxidative
burst
Ghiasvand et al. Basketball Well-trained Male participants Resting: ↓IL-6, ↑GPx 6 2000 EPA Not measured No change GPx in
(19) n = 34 EPA-only group
Vitamin E +/−
1
CAT, catalase; CHO, carbohydrate; CK, creatine kinase; COX, cycloxygenase; CRP, C-reactive protein; EGCG, epigallocatechin 3-gallate; EGF, epidermal growth factor; GMCSF, granulocyte macrophage colony-stimulating factor; GPx, glutathione peroxidase;
HSP, heat-shock protein; MCP, monocyte chemotactic protein; MIP, macrophage inflammatory protein; MPO, myeloperoxidase; PBMC, peripheral blood mononuclear cell; ROS, reactive oxygen species; sIgA, salivary immunoglobulin A; TG, triglyceride; Th1/2; T helper
cell 1/2; TLR, toll-like receptor; UCP, mitochondrial uncoupling protein; URTI, upper respiratory tract illness; VEGF, vascular endothelial growth factor.
2
All nonsignificant findings for the effects of FS.
Lewis et al.
Mood and
Sex and cognition and Cardiovascular Physical Dosing period, Active treatment, ω-3 biomarker
Author Sport Athlete status sample size skill and respiratory Skeletal/muscle Biomarkers performance wk mg/d response to FS No effect for FS2
Jakeman et al. Athletes Recreational Male >Recovery of CMJ <1 7500 EPA Not measured Muscle soreness,
(46) participants 500 DHA CK, IL-6
n = 27
Lewis et al. (47) Summer Competitive Male ↓Fatigue (% drop 3 375 EPA Plasma EPA↑ MVC, squat jump,
Olympic sports participants Wingate power), 510 DHA (65.8%), DHA no CMJ, back
n = 31 ↑VL EMG Vitamin D change squat, push-ups,
endurance
performance
(time trial)
Black et al. (48) Rugby Professional- Male ↓Fatigue, ↑sleep ↓Muscle soreness ↑Mean CMJ peak 5 1102 EPA Plasma ω-3 fatty
elite participants quality force 1102 DHA acids(240%)↑
n = 20 Whey PRO,
CHO, vitamin D
Philpott et al. Soccer Competitive Male Muscle soreness ↓ ↓CK conc. 6 1102 EPA Blood ω-3 fatty CRP, MVC, soccer
(49) participants 1102 DHA acids↑ (58%) passing test,
n = 30 Whey PRO, yo-yo level 2
CHO, vitamin D test
Gravina et al. Soccer Competitive Male and female ↑Anaerobic 4 4900 EPA Blood ω-3 fatty Respiratory
(50) participants endurance 1400 DHA acids↑ (100%) function (FEV1,
n = 26 (enhanced FVC), MVC,
training effect) 20-m sprints,
vertical jump
height, yo-yo
level 1 test
Raastad et al. Soccer Professional- Male ↓TGs 10 1600 EPA Plasma EPA V̇O2 max, running
(51) elite participants 1004 DHA (175%), DHA speed at
n = 28 (40%) ↑ anaerobic
threshold, run
time to
exhaustion
Buckley et al. Aussie Rules Professional- Male ↓DBP, ↓sub-max ↓TGs 5 360 EPA RBC EPA (116%) Run time to
(52) elite participants exercise HR 1560 DHA DHA (100%), exhaustion,
n = 25 ↑total n–3 V̇O2 /running
(74%) economy
Oliver et al. (53) American Competitive Male ↓NFL 27 2000–6000 DHA ↑Plasma DHA
football participants (98–99.9%),
n = 81 dose
dependent
Mavrogenis et All sports Recreational Male ↓Pain ↑Activity 32 d 3000 EPA Not measured
al. (54) participants 2112 DHA
n = 31 Vitamins and
minerals, GLA
1 CHO, carbohydrate; CK, creatine kinase; CMJ, counter movement jump; CRP, C-reactive protein; DBP, diastolic blood pressure; EMG, electromyography recording from vastus lateralis; FEV1, forced expiratory volume in 1 s; FVC, forced vital capacity; GLA, γ -linolenic acid; HR, heart rate;
MVC, maximum voluntary contraction; NFL, neurofilament light; PRO,; TG, triglyceride; VL, vastus lateralis; V̇O2 max, maximum oxygen uptake.
2 All nonsignificant findings for the effects of FS.
Sex and sample Mood, cognition, Immune and Cardiovascular Physical Dosing period, Active treatment, ω-3 biomarker
Author Sport Athlete status size and skill inflammation and respiratory Skeletal/muscle Biomarkers performance wk mg/d response to FS No effect for FS2
Raastad et al. (51) Soccer Professional-elite Male participants ↓TGs 10 1600 EPA ↑Plasma EPA V̇O2 max, running
n = 28 1004 DHA (175%), DHA speed at
(40%) anaerobic
threshold, run
time to
exhaustion
Buckley et al. (52) Aussie Rules Professional-elite Male participants ↓DBP, ↓sub-max ↓TGs 5 360 EPA ↑RBC EPA (116%) Run time to
n = 25 exercise HR 1560 DHA DHA (100%), exhaustion,
total n–3 (74%) V̇O2 /running
economy
Hingley et al. (55) Runners and Well-trained, Male participants ↓Sub-max V̇O2 8 140 EPA ↑OM3I: 4.5% to 6% Endurance
cyclists recreational n = 26 during 5-min 560 DHA performance
cycling time trial (time-trial),
Wingate, MVC
Peoples et al. (56) Cyclists Competitive Male participants ↓Exercise HR, 8 800 EPA ↑RBC DHA
n = 16 ↑cycling economy 2400 DHA (41.4%), total
(↓sub-max V̇O2 ) n–3 (24.3%),
Żebroswka et al. Cyclists Competitive Male participants ↑V̇O2 max (+5%), ↑NO at rest, 3 1320 EPA Not measured Endothelium
(31) n = 13 FMD (%) postexercise, 880 DHA independent
↑glucose and FFA vasodilatation,
at rest peak power,
TGs, LDL and
HDL cholesterol,
total
cholesterol, HR,
SBP, DBP,
glycerol, TAS,
BM, PWV
Fontani et al. (57) Athletics Recreational Male and female ↑Vigor, attention, ↓Homocysteine 5 1600 EPA ↓AA/EPA
participants ↓reaction time, 800 DHA
n = 33 anger, anxiety,
depression
Fontani et al. (58) Karate Competitive Male and female ↑POMS, ↓reaction 3 4800 EPA Not measured
participants time 2400 DHA
n = 18 Policosanol
Guzmán et al. (59) Soccer Professional-elite Female ↓Complex 4 3500 DHA Not measured
participants reaction time
n = 34
Black et al. (48) Rugby Professional-elite Male participants ↓Fatigue, ↑sleep ↓Muscle soreness ↑Mean CMJ peak 5 1102 EPA ↑Plasma ω-3 fatty
n = 20 quality force 1102 DHA acids (240%)
Whey PRO,
CHO, vitamin D
Mickleborough et Endurance sports Competitive Male and female ↓Urinary LTE4 and Improved lung 3 3200 EPA ↑Neutrophil EPA
al. (60) participants ↓9α11β-PGF2 ; function (FEV1) 2200 DHA (1206%), but no
n = 20 ↓plasma LTB4, change DHA
TNF-α, IL-1β
Tartibian et al. (61) Wrestling Recreational Male participants ↑FEV1, ↑FVC, ↑VC, 12 180 EPA Not measured FEV1% and FIV1%
n = 40 ↑MVV, ↑FEF25–75, 120 DHA
↑FIV1
Gravina et al. (50) Soccer Competitive Male and female ↑Anaerobic 4 4900 EPA ↑Blood ω-3 fatty Respiratory
participants endurance 1400 DHA acids (100%) function (FEV1,
n = 26 FVC), MVC,
20-m sprints,
vertical jump
height, yo-yo
level 1 test
1 AA,; BM,; CHO, carbohydrate; CMJ, counter movement jump; DBP, diastolic blood pressure; FEF, forced expiratory flow from 25% to 75%; FEV1, forced expiratory volume in 1 s; FFA, free fatty acid; FIV1, forced inspiratory volume in 1 s; FMD, flow mediated dilation; FVC, forced vital capacity;
n n
FIGURE 1 Flow diagram of study selection criteria. RCT, randomized controlled trial.
Data synthesis and extraction provide a summary of both the significant and nonsignificant
A meta-analysis was not conducted due to the heterogeneity findings.
across studies and the variety of outcomes reported. Data
extraction captured information relating to: 1) study design
(e.g., randomized, placebo-controlled trial); 2) sample char- Subject characteristics
acteristics (e.g., age, sample size, sex, sport, athlete status); 3) The majority of investigations (n = 22) studied men only.
health and performance variables (e.g., mood, cognition and Nine RCTs included participants of both sexes, and one
skill, cardiovascular and respiratory, skeletal muscle, immune RCT included women only. The mean age for participants in
and inflammation, biomarkers, physical performance); 4) the FS and placebo groups across the RCTs was 24.9 ± 4.5
fish oil dose and dosing period; 5) additions to the fish oil y; 1 RCT failed to report the age of the participants (53).
(e.g., vitamin D, vitamin E, etc.); 6) measurement of n–3 Athletes varied in classification, from recreational (e.g., non-
fatty acid biomarkers (e.g., plasma EPA and DHA); and 7) competitive) to elite (referring to a professional or national-
nonsignificant effects and findings. level competitive standard) and from a range of summer
Olympic sports (e.g., judo, swimming, cycling, marathon)
and professional sports (i.e., American football, soccer, rugby,
Australian Rules football, and basketball) (Tables 1–4).
Results
Study selection and sports
We identified a total of 137 papers using our search strategy, Methodological quality and risk of bias
of which 32 RCTs (level of evidence 1B) met the inclusion The methodological quality of the RCTs, applying the PEDro
criteria (Figure 1). The mean sample size of included studies scale (maximum score obtainable 11), ranged from a score
was 27 participants (range: 15–81 participants). of 6 (2 studies) to a maximum of 11 (1 study), with an
The 32 RCTs were grouped into the following areas (some average score of 9. Of the 32 RCTs included, 25 (75%)
studies represented twice): oxidative stress only (n = 5); were double-blind in design, 7 (20%) were single-blind,
immunity, inflammation, and oxidative stress (n = 10); and 3 incorporated a crossover design with a wash-out
muscle recovery (n = 5); team sports and training adaptation period ranging from 2 wk to 35 d (31, 57, 60). A major
(n = 5); cardiovascular physiology (n = 5); cognition and methodological flaw affecting 28 of the 32 RCTs (88%), was
mood state (n = 4); respiratory health (n = 2); and injury that the size of the treatment effect (i.e., effect sizes) was not
related (n = 2) (Tables 1–4). Only significant findings are reported. Sponsorship and research funding by the fish oil
reported in the results and discussed. However, Tables 1–4 industry was clearly reported in 7 RCTs.