Docosahexaenoic Acid

What Is It?

Docosahexaenoic acid, or DHA, is one of the major dietary omega-3 fatty acids (n-3 polyunsaturated fatty acids, or PUFAs) commonly found in fatty fish, meat, and fish oils$^{1,2}$. It is metabolically derived from alpha-linolenic acid (ALA), and much of the health benefits attributed to ALA are actually physiologically mediated by DHA and a related omega-3 fatty acid, called eicosapentaenoic acid (EPA)$^3$. DHA has been studied in vitro (cell lines), in vivo (animal models), and in clinical studies for its role in neurological, vascular, and metabolic health$^4$, and is considered particularly important during brain development in childhood$^5$. Within the human body, DHA is most abundant in the retina of the eye and is considered critical for proper visual function$^6$. Numerous clinical trials have demonstrated the potential efficacy of DHA in cancer prevention and treatment, as well as identified its benefits for patients undergoing chemotherapy, as it improves treatment- and cancer-related outcomes like nutritional status$^7$, bone resorption$^8$, and weight loss$^9$. With regards to its cancer-fighting activity, DHA has been shown to inhibit inflammatory pathways$^{10}$, upregulate antioxidant activity$^{11}$, and induce cancer cell death$^{12}$, supporting its role as an important anticancer nutrient.

What Are Its Other Names?

Docosahexaenoic acid is most commonly referred to as DHA, but it may also be referred to as doconexent, cervonic acid, deconexento, docosahexaenoate, doconexentum, or doxonexent$^{13}$. Its chemical name, based on IUPAC standards, is (4Z,7Z,10Z,13Z,16Z,19Z)-docosa-4,7,10,13,16,19-hexaenoic acid$^{13}$. Studies on omega-3 fatty acids often refer to DHA in addition to its precursor ALA and another omega-3 fatty acid called eicosapentaenoic acid.

What Foods Have It?

DHA is typically sourced from fish oil, fish, lamb, or beef$^{1,2}$. Wild fish are considered a better source of DHA, since marine fish feed on plankton rich in omega-3 fatty acids$^1$, whereas farmed fish tend to feed on cereals rich in omega-6 fatty acids, which may counteract the health benefits of DHA$^2$. It is important to know that the ratio of omega-6 to omega-3 fatty acids in the diet is more important than the absolute values of omega-3 fatty acids, and a high omega-6:omega-3 ratio is associated with inflammatory processes and related diseases like cancer, Alzheimer’s, and autoimmune diseases$^1$. A diet high in omega-3 fatty acids must thus be accompanied by a diet low in processed and fried foods, which are rich in omega-6 fatty acids. Note that a plant-based diet is completely deficient in DHA$^1$, and endogenous production of DHA from ALA is fairly low$^{11}$ (1% conversion$^{14}$), so it is recommended to consume DHA directly from fish oils or fish to reap the benefits of this nutrient. 

What Are Its Main Benefits?

Cancer Prevention and Treatment DHA has been demonstrated through clinical trials and observational studies to reduce the risk of developing prostate$^4$, colorectal$^{15}$, lung$^4$, and breast cancer$^{16}$, as well as alleviating the side effects of cancer treatment such as neuropathy, weight loss, and anemia$^{17}$.

Cancer Prevention Frequent consumption of fish, regardless of cooking method, was associated with a reduced risk of developing lung cancer in an observational study in Japanese men$^{18}$. Increased fish consumption was also correlated with a decreased risk of prostate cancer in Swedish men by inhibiting the formation of pro-inflammatory signaling molecules called eicosanoids$^{19}$. In fact, Swedish men who ate no fish had double or triple the risk of developing prostate cancer than those who ate moderate or high amounts of fish$^{19}$. High plasma levels of DHA are associated with a reduced risk of breast cancer$^{19}$, and DHA and EPA have been reported to decrease the incidence of breast cancer in a dose-dependent manner$^{20}$. Other studies have shown an inverse relationship between omega-3 fatty acids and colorectal cancer risk, but only in men$^{15}$. Lastly, two clinical trials, mainly investigating DHA in conjunction with EPA (in the form of fish oil), have demonstrated that 4.1 g/day EPA and 3.6 g/day DHA or a combination of 3.25 g/day DHA and EPA could reduce the risk of developing colorectal cancer in patients with sporadic adenomatous colorectal polyps$^{21}$, and breast cancer in peri/postmenopausal women$^{22}$. The details for these trials can be found in the section titled “Summary of Data”, below. Cancer Treatment Aside from cancer prevention, DHA has been shown to significantly improve the efficacy and tolerability of traditional cancer therapy. In a small phase II trial, 1.8 g/day DHA was given to 25 metastatic breast cancer patients undergoing chemotherapy, and it was found to increase disease-free survival and slightly reduce treatment-associated toxicities, including anemia, thrombopenia (low platelet count), and gastrointestinal issues$^{23}$. Similarly, 1.04 g DHA and 0.19 g EPA given to breast cancer patients undergoing paclitaxel treatment was found to reduce the incidence of treatment-related nerve damage (neuropathy)$^{24}$. In 33 patients with inoperable non-small cell lung cancer, a 66-day treatment of 4 capsules of 510 mg EPA and 340 mg DHA led to increases in body weight and improvements in antioxidant and anti-inflammatory status (patients had markedly reduced levels of C-reactive protein and IL-6, two major pro-inflammatory molecules)$^{25}$. Lastly, a pilot study on 38 postmenopausal breast cancer survivors investigated a treatment of 4 g of EPA and DHA daily for 3 months and found that it could reduce bone resorption (bone loss), although the researchers acknowledged that longer-term studies are needed$^{26}$. Protecting Cardiovascular Health DHA, as an omega-3 fatty acid, has highly beneficial cardioprotective effects as it reduces the risk of arrhythmias (abnormal heart rhythms) and alters the production of molecules called prostaglandins, thus improving platelet and vascular function$^{16}$. The Mediterranean and Eskimo diets, which are high in marine-derived fats$^{5}$, have been noted in observational studies and clinical trials to reduce the risk of major adverse cardiovascular outcomes$^{27}$. Similarly, higher plasma DHA levels were associated with a lower risk of fatal coronary heart disease, as concluded in a study pooling several cohort studies with nearly 45,000 individuals$^{28}$. The DART trial noted that consuming fish oil twice a week significantly reduced mortality in heart attack survivors$^{29}$, and similar results were observed in the GISSI study, which showed that 850 mg/ day of DHA and EPA in a 2:1 ratio led to a significant reduction in cardiovascular mortality in post-heart attack patients$^{30}$ and that 1 g/day of DHA and EPA provided some reduction in mortality in patients with heart failure$^{31}$. In individuals with blood triglyceride levels above 150 mg/dL, taking 3.4-4 g/day of EPA and/ or DHA was shown to reduce these levels by around 29%$^{32}$, and in individuals with metabolic syndrome, DHA administration alongside EPA for 6 months led to reduced serum levels of LDL-cholesterol and triglycerides$^{33}$. Lastly, women who consumed fish more than once a week had half the age-adjusted risk of having a stroke compared to women who consumed no fish, demonstrating the great potential of DHA to protect cardiovascular health$^{34}$. However, it is essential to note that many medications used to treat cardiovascular diseases, such as anti-coagulants, blood thinners, and blood pressure medications, are known to react with fish oil supplements and cause dangerous side effects. Thus, you should always consult a healthcare provider before changing your diet or taking new supplements$^{51}$. Countering Inflammation and Autoimmune Disorders The numerous health benefits of DHA can be linked to its profound capacity to counter inflammation. With the global rise in the prevalence of inflammatory disorders, linked to increased consumption of pro-inflammatory omega-6 fatty acids$^{11}$, exploring the anti-inflammatory role of DHA in the diet is highly important. Clinically, DHA and EPA are both used as adjuvant immunosuppressants to treat rheumatoid arthritis or inflammatory bowel disease, as they are primarily inflammatory diseases$^{15}$. Cell studies have shown that DHA can directly suppress NF-kB10, which is a transcription factor involved in the expression of many pro-inflammatory genes. In the body, DHA is metabolized to produce anti-inflammatory lipid mediators called protectins and maresins, which contribute to countering inflammation in the body$^{11}$. Similarly to EPA, DHA inhibits the production of pro-inflammatory cytokines by acting as an alternative substrate for certain enzymes that normally produce pro-inflammatory signaling molecules called eicosanoids$^{15}$. Overall, DHA contributes to a more anti-inflammatory state in the body, which is important in both preventing and treating numerous inflammation-related diseases. Promoting Neurological Development and Alleviating Neurological Disorders DHA comprises the main component of membrane phospholipids in the brain, and high fetal DHA levels are considered critical for neurological health and protection from schizophrenia, Huntington’s Disease, and high blood pressure$^{4}$. Intake of omega-3 fatty acids like DHA has been associated with improved symptoms of depression and overall cognitive health. In patients with Parkinson’s Disease, treatment with 800 mg of DHA and 290 mg of EPA daily for 6 months vastly improved their depression symptoms compared to the placebo group$^{35}$, and DHA and EPA seem to work synergistically to alleviate depression$^{1}$. Similarly, DHA has been found to reduce the risk of all-cause dementia and Alzheimer’s disease$^{4}$, and in a 2-year study on cognitively healthy elders, treatment with 500 mg of DHA and 200 mg of EPA was associated with no progressive decline in cognitive function$^{36}$. It is worth noting that patients with major depressive disorder (MDD) and bipolar disorder (BD) are DHA-deficient relative to healthy controls$^{37}$, and a study on around 2000 elderly people found that high consumption of fish is associated with better cognitive performance in a dose-dependent manner$^{38}$, providing support for DHA’s critical role in neurological health.

What Are Its Main Drawbacks?

N.B: the drawbacks associated with DHA are similar to those associated with EPA, so this section can also be found in the review about EPA as an anticancer nutrient. Dietary intake of DHA from animal sources is necessary, since de novo synthesis (i.e. from your body producing it) is inefficient$^{11}$, and plant-based foods do not contain DHA$^{1}$. Further, the studies on its health benefits have some inconsistent data due to the influence of genetics, the baseline plasma ratio of omega-6 fatty acids to omega-3 fatty acids, and the particular source of DHA (which impacts its bioavailability, meaning the proportion of DHA that exerts biological activity in the body)$^{4}$. Lastly, absolute intake of omega-3 fatty acids seems not to be as important as the omega-6 to omega-3 ratio in the diet – thus, intake of DHA must be done alongside a diet low in omega-6 fatty acids (typically found in refined vegetable oils and foods cooked in vegetable oils)$^{5}$. DHA and fish oil supplements may also have harmful interactions with several common medications used to treat cardiovascular disease (such as blood thinners, anti-coagulants, and blood pressure medications), and should be avoided in some individuals taking these medications$^{51}$.

What Are Its Mechanisms of Action?

1. Inducing Cancer Cell Apoptosis: Cell line studies have shown that DHA can trigger the activation of programmed cell death, or apoptosis, in multiple types of cancer cells. In human upper gastrointestinal cancer cells, a combination of DHA and paclitaxel (chemotherapy drug) was found to induce apoptosis and suppress long-term cell survival$^{12}$. In murine leukemia cells, DHA was found to reduce cell viability and increase cancer cell sensitivity to destruction by cytotoxic T lymphocytes$^{39}$ (immune cells that usually aid in clearing cancer cells), and in human liver cancer cells (HepG2) transplanted in mice, DHA treatment led to increased apoptosis and reduced tumor growth$^{40}$. Regarding the precise mechanisms through which DHA induces cancer apoptosis, it has been suggested that it works by activating caspases-3 and -9, which are critical to apoptotic pathways, increasing the ratio of Bax to Bcl-2, which are pro- and anti-apoptotic proteins, respectively, and disrupting the membrane potential of cancer cell mitochondria$^{41}$.
2. Inhibiting Cancer Cell Cycle Progression and Viability: DHA has been shown to inhibit the viability and proliferation capacity of various cancer cells in vitro and in mouse models. When added to SW480 human colon cancer cells, 0-20 µg/mL of DHA for 48-120 hours (in conjunction with EPA) led to markedly reduced cell viability, with the effect most pronounced at 72 hours$^{42}$. Furthermore, DHA downregulates a particular signaling pathway known as the Wnt/β-catenin signaling pathway, which normally upregulates the expression of proteins involved in cell cycle progression, called cyclins$^{41}$. DHA inhibits this pathway and subsequently inhibits cancer cell proliferation and tumorigenesis, and this was demonstrated in breast cancer cells in vitro (MCF-7 human breast cancer cells) and in vivo (4T1 mouse breast cells)$^{43}$. In another study on MCF-7 breast cancer cells, DHA administration was found to reduce the cells’ capacity for migration and invasion as well as their expression of MMP-2, which is a matrix metalloprotease critical to cancer spread$^{44}$.  Furthermore, by inhibiting the expression of Granzyme B, DHA inhibits a process called the epithelial-to-mesenchymal transition, which is critical to cancer migration and metastasis, as shown in human colorectal cells$^{45}$.
3. Blocking Cancer-Promoting Inflammatory Pathways: Through inhibiting various pathways involved in inflammation, DHA can suppress cancer initiation and progression. DHA can either directly inhibit the activation of NF-kB, which usually promotes the expression of pro-inflammatory genes, or prevent its activation by upregulating the intracellular levels of glutathione, which counters oxidative stress$^{11}$ (implicated in cancer progression)$^{46}$. DHA also inhibits the expression of pro-inflammatory genes like IL-1, COX-2, and iNOS in macrophages$^{14}$ – the expression of these genes is the mechanism through which macrophages contribute to tumor-promoting inflammation$^{47}$. Furthermore, when tissues are under stress, DHA becomes oxidized to resolvin D$^{11}$, which, as the name suggests, contributes to resolving inflammation in the body through down-regulating NF-kB48. Plus, when DHA gets incorporated into cell membranes, it reduces the expression of toll-like receptors, which are involved in activating NF-kB inflammatory pathways$^{14}$. Altogether, the inhibition of inflammation can prevent tumor formation and cancer progression. Regarding the receptors involved, similarly to EPA, DHA can bind to peroxisome proliferator-activated receptors-alpha and -gamma (PPAR), which bind to and form a heterodimer with the retinoid X receptor (RXR). This heterodimer translocates to the nucleus, where it binds to particular DNA regions called peroxisome-proliferator responsive elements (PPRE) and inhibits the expression of NF-kB and pro-inflammatory genes$^{14}$.

What Are Typical Doses and Durations?

Generally, the Food and Agricultural Organization (FAO) and World Health Organization (WHO) recommend a combined daily intake of EPA and DHA of at least 250 mg, which should be raised to 1-1.5 g for individuals with cardiovascular disease risk factors or high blood triglyceride levels$^{11}$. Consuming 2-3 servings of oily fish a week, accounting for 500 mg/day1, meets the minimum recommended intake of EPA and DHA$^{11}$. To minimize the burden of chronic disease, 1000-2000 mg (1-2g) of EPA and DHA daily is recommended$^{1}$. With regards to cancer prevention, no minimum has been established to our knowledge, but clinical trials that found efficacy for cancer prevention have used 3.6 g of DHA with 4.1 g EPA daily for 12 weeks (showing reduced rectal cell proliferation)$^{21}$ and 3.25 g/day combined EPA and DHA for 6 months (showing reductions in biomarkers associated with breast cancer risk)$^{22}$, among other ranges of doses and durations. Details for each study can be found in the section below. Lastly, it has been suggested that 600 mg to 3.6 g of omega-3 supplementation alongside conventional cancer therapies like radiotherapy or chemotherapy may help reduce the risk of toxicity and enhance patient survival rates$^{49}$. Daily intake of EPA and DHA (1.5 g/ day) for long periods of time could also alleviate the risk of cancer cachexia, one systematic analysis found$^{50}$.

Summary of Data

Cancer Prevention A total of 10 randomized clinical trials that investigated DHA as a cancer-preventative nutrient were identified on PubMed. The data from the trials is summarized below:

📄 Detailed DHA cancer prevention human clinical trial study notes analyzed by Anticancer.ca Cancer Treatment A total of 8 randomized clinical trials that investigated DHA as a cancer-treating nutrient were identified on PubMed. The data from the trials is summarized below:

📄 Detailed DHA cancer treatment human clinical trial study notes analyzed by Anticancer.ca Treating Other Outcomes of Cancer A total of 23 randomized clinical trials that investigated DHA as a nutrient alleviating other outcomes like nutritional status, bone resorption, and general inflammation during cancer or cancer treatment were identified on PubMed. The data from the trials is summarized below:

📄 Detailed DHA other outcomes human clinical trial study notes analyzed by Anticancer.ca

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• Docosahexaenoic Acid
• What Is It?
• What Are Its Other Names?
• What Foods Have It?
• What Are Its Main Benefits?
• What Are Its Main Drawbacks?
• What Are Its Mechanisms of Action?
• What Are Typical Doses and Durations?
• Summary of Data
• References
• About This Article
• Disclaimer