The Importance of the Omega-6/Omega-3
Fatty Acid Ratio in Cardiovascular Disease
and Other Chronic Diseases
ARTEMIS P. SIMOPOULOS1
The Center for Genetics, Nutrition and Health, Washington, DC 20009
Several sources of information suggest that human beings
evolved on a diet with a ratio of omega-6 to omega-3 essential
fatty acids (EFA) of ; ;1 whereas in Western diets the ratio is 15/1–
16.7/1. Western diets are deficient in omega-3 fatty acids, and
have excessive amounts of omega-6 fatty acids compared with
the diet on which human beings evolved and their genetic
patterns were established. Excessive amounts of omega-6
polyunsaturated fatty acids (PUFA) and a very high omega-6/
omega-3 ratio, as is found in today’s Western diets, promote the
pathogenesis of many diseases, including cardiovascular dis-
ease, cancer, and inflammatory and autoimmune diseases,
whereas increased levels of omega-3 PUFA (a lower omega-6/
omega-3 ratio), exert suppressive effects. In the secondary
prevention of cardiovascular disease, a ratio of 4/1 was
associated with a 70% decrease in total mortality. A ratio of
2.5/1 reduced rectal cell proliferation in patients with colorectal
cancer, whereas a ratio of 4/1 with the same amount of omega-3
PUFA had no effect. The lower omega-6/omega-3 ratio in women
with breast cancer was associated with decreased risk. A ratio of
2–3/1 suppressed inflammation in patients with rheumatoid
arthritis, and a ratio of 5/1 had a beneficial effect on patients
with asthma, whereas a ratio of 10/1 had adverse consequences.
These studies indicate that the optimal ratio may vary with the
disease under consideration. This is consistent with the fact that
chronic diseases are multigenic and multifactorial. Therefore, it
is quite possible that the therapeutic dose of omega-3 fatty acids
will depend on the degree of severity of disease resulting from
the genetic predisposition. A lower ratio of omega-6/omega-3
fatty acids is more desirable in reducing the risk of many of the
chronic diseases of high prevalence in Western societies, as well
as in the developing countries. Exp Biol Med 233:674–688, 2008
Key words: balanced omega-6/omega-3 ratio; dietary omega-3 fatty
acids; inflammation; cardiovascular disease; chronic diseases; diet-
The interaction of genetics and environment, nature,
and nurture is the foundation for all health and disease. In
the last two decades, using the techniques of molecular
biology, it has been shown that genetic factors determine
susceptibility to disease and environmental factors deter-
mine which genetically susceptible individuals will be
affected (1–6). Nutrition is an environmental factor of major
importance. Using the tools of molecular biology and
genetics, research is defining the mechanisms by which
genes influence nutrient absorption, metabolism and ex-
cretion, taste perception, and degree of satiation; and the
mechanisms by which nutrients influence gene expression.
Whereas major changes have taken place in our diet over the
past 10,000 years since the beginning of the Agricultural
Revolution, our genes have not changed. The spontaneous
mutation rate for nuclear DNA is estimated at 0.5% per
million years. Therefore, over the past 10,000 years there
has been time for very little change in our genes, perhaps
0.005%. In fact, our genes today are very similar to the
genes of our ancestors during the Paleolithic period 40,000
years ago, at which time our genetic profile was established
(7). Humans today live in a nutritional environment that
differs from that for which our genetic constitution was
selected. Studies on the evolutionary aspects of diet indicate
that major changes have taken place in our diet, particularly
in the type and amount of essential fatty acids and in the
antioxidant content of foods (7–11) (Fig. 1).
Today industrialized societies are characterized by 1) an
1To whom correspondence should be addressed at The Center for Genetics, Nutrition
and Health, 2001 S Street, NW, Suite 530, Washington, DC 20009. E-mail:
Copyright ? 2008 by the Society for Experimental Biology and Medicine
increase in energy intake and decrease in energy expendi-
ture; 2) an increase in saturated fat, omega-6 fatty acids and
trans fatty acids, and a decrease in omega-3 fatty acid
intake; 3) a decrease in complex carbohydrates and fiber; 4)
an increase in cereal grains and a decrease in fruits and
vegetables; and 5) a decrease in protein, antioxidants and
calcium intake (7, 9, 12–15) (Tables 1 and 2). The increase
in trans fatty acids is detrimental to health as shown in
Table 3 (17). In addition, trans fatty acids interfere with the
desaturation and elongation of both omega-6 and omega-3
fatty acids, thus further decreasing the amount of arach-
idonic acid, eicosapentaenoic acid and docosahexaenoic
acid availability for human metabolism (18).
The beneficial health effects of omega-3 fatty acids,
eicosapentaenoic acid (EPA) and docosahexaenoic acid
(DHA) were described first in the Greenland Eskimos who
consumed a high seafood diet and had low rates of coronary
heart disease, asthma, type 1 diabetes mellitus, and multiple
sclerosis. Since that observation, the beneficial health effects
of omega-3 fatty acids have been extended to include
benefits related to cancer, inflammatory bowel disease,
rheumatoid arthritis, and psoriasis (19).
Whereas evolutionary maladaptation leads to reproduc-
tive restriction (or differential fertility), the rapid changes in
our diet, particularly the last 150 years, are potent promoters
of chronic diseases such as atherosclerosis, essential hyper-
tension, obesity, diabetes, arthritis and other autoimmune
diseases, and many cancers, especially cancer of the breast
(20), colon (21), and prostate (22). In addition to diet,
sedentary lifestyles and exposure to noxious substances
interact with genetically controlled biochemical processes
leading to chronic disease.
In this review, I discuss the importance of the balance
of omega-6 and omega-3 essential fatty acids in the
prevention and treatment of coronary artery disease, hyper-
tension, diabetes, arthritis, osteoporosis, other inflammatory
and autoimmune disorders, cancer and mental health, and
the mechanisms involved.
Figure 1. Hypothetical scheme of fat, fatty acid (x6, x3, trans and total) intake (as percent of calories from fat) and intake of vitamins E and C
(mg/d). Data were extrapolated from cross-sectional analyses of contemporary hunter-gatherer populations and from longitudinal observations
and their putative changes during the preceding 100 years (9).
Acid Intake in the Late Paleolithic Period (g/d)a,b,c
Estimated Omega-3 and Omega-6 Fatty
Ratios of x6/x3
aData from Eaton et al. (13).
bAssuming an energy intake of 35:65 of animal:plant sources.
cLA, linoleic acid; ALA, linolenic acid; AA, arachidonic acid; EPA,
eicosapentaenoic acid; DTA, docosatetranoic acid; DPA, docosa-
pentaenoic acid; DHA, docosahexaenoic acid.
OMEGA-6/OMEGA-3 FATTY ACID RATIO 675
Imbalance of Omega-6/Omega-3
Food technology and agribusiness provided the eco-
nomic stimulus that dominated the changes in the food
supply (23, 24). From per capita quantities of foods
available for consumption in the U.S. national food supply
in 1985, the amount of EPA is reported to be about 50 mg
per capita/day and the amount of DHA is 80 mg per capita/
day. The two main sources are fish and poultry (25). It has
been estimated that the present Western diet is ‘‘deficient’’ in
omega-3 fatty acids with a ratio of omega-6 to omega-3 of
15–20/1, instead of 1/1 as is the case with wild animals and
presumably human beings (7–11, 13, 26–28) (Table 4).
Before the 1940s cod-liver oil was ingested mainly by
children as a source of vitamin A and vitamin D with the
usual dose being a teaspoon. Once these vitamins were
synthesized, consumption of cod-liver oil was drastically
decreased, contributing further to the decrease of EPA and
DHA intake. Table 5 shows ethnic differences in fatty acid
concentrations in thrombocyte phospholipids, the ratios of
omega-6/omega-3 fatty acids, and percentage of all deaths
from cardiovascular disease (16).
An absolute and relative change of omega-6/omega-3 in
the food supply of Western societies has occurred over the
last 150 years. A balance existed between omega-6 and
omega-3 for millions of years during the long evolutionary
history of the genus Homo, and genetic changes occurred
partly in response to these dietary influences. During
evolution, omega-3 fatty acids were found in all foods
consumed: meat, wild plants, eggs, fish, nuts and berries
(29–38). Studies by Cordain et al. (39) on wild animals
confirm the original observations of Crawford and Sinclair
et al. (27,40). However, rapid dietary changes over short
periods of time as have occurred over the past 100–150 yr is
a totally new phenomenon in human evolution (13, 15, 41–
43) (Table 6).
Biological Effects and the Omega-6/Omega-3 Ratio
There are two classes of essential fatty acids (EFA),
omega-6 and omega-3. The distinction between omega-6
and omega-3 fatty acids is based on the location of the first
double bond, counting from the methyl end of the fatty acid
molecule. In the omega-6 fatty acids, the first double bond is
between the 6th and 7th carbon atoms and for the omega-3
fatty acids the first double bond is between the 3rd and 4th
Table 2.Late Paleolithic and Currently Recommended Nutrient Composition for Americans
FNB-IOM 1989 recommendationsa
FNB-IOM 2005 recommendationsb
Total dietary energy, (%)
Ascorbic acid (mg)
aModified from Eaton et al. (13).
bData from DRI Tables on the internet: http://www.iom.edu/CMS/3788/4574.aspx
cP/S, polyunsaturated to saturated fat.
Table 3.Adverse Effects of Trans Fatty Acidsa
Decrease or inhibit
Decrease or inhibit incorporation of other fatty acids into
Decrease high-density lipoprotein (HDL)
Inhibit delta-6 desaturase (interfere with elongation and
desaturation of essential fatty acids)
Decrease serum testosterone (in male rats)
Cross the placenta and decrease birth weight (in humans)
Low-density lipoprotein (LDL)
Lipoprotein (a) [Lp(a)]
Cholesterol transfer protein (CTP)
Abnormal morphology of sperm (in male rats)
aModified from reference 17.
Acids in the Late Paleolithic Period and in Current
Western Diets (United States) (g/d)a
Ratios of Dietary Omega-6:Omega-3 Fatty
aLA, linoleic acid; ALA, linolenic acid; AA, arachidonic acid; EPA,
eicosapentaenoic acid; DTA, docosatetranoic acid; DPA, docosa-
pentaenoic acid; DHA, docosahexaenoic acid. Reprinted with
permission from reference (15).
carbon atoms. Monounsaturates are represented by oleic
acid, an omega-9 fatty acid, which can be synthesized by all
mammals including humans. Its double bond is between the
9th and 10th carbon atoms.
Omega-6 and omega-3 fatty acids are essential because
humans, like all mammals, cannot make them and must
obtain them in their diet. Omega-6 fatty acids are
represented by linoleic acid (LA; 18:2x6) and omega-3
fatty acids by a-linolenic acid (ALA; 18:3x3). LA is
plentiful in nature and is found in the seeds of most plants
except for coconut, cocoa, and palm. ALA on the other hand
is found in the chloroplasts of green leafy vegetables, and in
the seeds of flax, rape, chia, perilla and in walnuts. Both
EFA are metabolized to longer-chain fatty acids of 20 and
22 carbon atoms. LA is metabolized to arachidonic acid
(AA; 20:4x6), and LNA to EPA (20:5x3) and DHA
(22:6x3), increasing the chain length and degree of
unsaturation by adding extra double bonds to the carboxyl
end of the fatty acid molecule (Fig. 2).
Humans and other mammals, except for carnivores such
as lions, can convert LA to AA and ALA to EPA and DHA,
but it is slow (44). This conversion was shown by using
deuterated ALA (45). There is competition between omega-
6 and omega-3 fatty acids for the desaturation enzymes.
However, both D-4 and D-6 desaturases prefer omega-3 to
omega-6 fatty acids (44, 46, 47). But, a high LA intake
interferes with the desaturation and elongation of ALA (45,
48). Trans fatty acids interfere with the desaturation and
elongation of both LA and ALA. D-6 desaturase is the
limiting enzyme and there is some evidence that it decreases
with age (44). Premature infants (49), hypertensive individ-
uals (50), and some diabetics (51) are limited in their ability
to make EPA and DHA from ALA. These findings are
important and need to be considered when making dietary
recommendations. EPA and DHA are found in the oils of
fish, particularly fatty fish. AA is found predominantly in the
phospholipids of grain-fed animals and eggs.
LA, ALA, and their long-chain derivatives are important
components of animal and plant cell membranes. In
mammals and birds, the n-3 fatty acids are distributed
selectively among lipid classes. ALA is found in triglycer-
ides, in cholesteryl esters, and in very small amounts in
phospholipids. EPA is found in cholesteryl esters, triglycer-
ides, and phospholipids. DHA is found mostly in phospho-
lipids. In mammals, including humans, the cerebral cortex,
retina, and testis and sperm are particularly rich in DHA.
DHA is one of the most abundant components of the brain’s
structural lipids. DHA, like EPA, can be derived only from
direct ingestion or by synthesis from dietary EPA or ALA.
Mammalian cells cannot convert omega-6 to omega-3
fatty acids because they lack the converting enzyme, omega-
3 desaturase. LA, the parent omega-6 fatty acid, and ALA,
the parent omega-3 fatty acid, and their long-chain
derivatives are important components of animal and plant
cell membranes (Fig. 2). These two classes of EFA are not
interconvertible, are metabolically and functionally distinct,
and often have important opposing physiological functions.
When humans ingest fish or fish oil, the EPA and DHA
from the diet partially replace the omega-6 fatty acids,
especially AA, in the membranes of probably all cells, but
especially in the membranes of platelets, erythrocytes,
neutrophils, monocytes, and liver cells (reviewed in
references 8, 52). Whereas cellular proteins are genetically
determined, the polyunsaturated fatty acid (PUFA) compo-
sition of cell membranes is to a great extent dependent on
the dietary intake. AA and EPA are the parent compounds
for eicosanoid production (8) (Tables 7–8, Fig. 3).
Because of the increased amounts of omega-6 fatty
acids in the Western diet, the eicosanoid metabolic products
from AA, specifically prostaglandins, thromboxanes, leuko-
trienes, hydroxy fatty acids, and lipoxins, are formed in
larger quantities than those formed from omega-3 fatty
acids, specifically EPA (8). The eicosanoids from AA are
biologically active in very small quantities and, if they are
formed in large amounts, they contribute to the formation of
thrombus and atheromas; to allergic and inflammatory
disorders, particularly in susceptible people; and to
proliferation of cells. Thus, a diet rich in omega-6 fatty
acids shifts the physiological state to one that is prothrom-
botic and proaggregatory, with increases in blood viscosity,
vasospasm, and vasocontriction and decreases in bleeding
time. Bleeding time is decreased in groups of patients with
hypercholesterolemia, hyperlipoproteinemia, myocardial in-
trations in Thrombocyte Phospholipids and Percentage
of All Deaths from Cardiovascular Diseasea
Ethnic Differences in Fatty Acid Concen-
Arachidonic acid (20:4x6)
Ratio of x6/x3
aData modified from reference 16.
Table 6. Omega-6:Omega-3 Ratios in Various
Greece prior to 1960
Current India, rural
Current United Kingdom and
Current United States
Current India, urban
OMEGA-6/OMEGA-3 FATTY ACID RATIO677
farction, other forms of atherosclerotic disease, and diabetes
(obesity and hypertriglyceridemia). Bleeding time is longer
in women than in men and longer in young than in old
people. There are ethnic differences in bleeding time that
appear to be related to diet.
Linoleic Acid Increases Low-Density Lipopro-
tein Oxidation and Severity of Coronary Athero-
sclerosis. Oxidative modification increases the
atherogenicity of low-density lipoprotein (LDL) cholesterol.
Oxidized LDL is taken up by scavenger receptors that do
not recognize unmodified LDL leading to foam cell
formation. Diets enriched with LA increase the LA content
of LDL and its susceptibility to oxidation (53, 54). Reaven
et al. (55) showed that a LA-enriched diet especially affects
oxidation of small, dense LDL. Louheranta et al. (56)
showed that as the percent of energy intake from LA
increased from the lower quartile 2.9% to the highest 6.4%
so did the LDL oxidation. In their study, the average energy
from LA was 4.6%. In another small cross-sectional study,
enhanced susceptibility of LDL to oxidize was associated
with severity of coronary atherosclerosis (57).
Linoleic Acid Inhibits Eicosapentaenoic Acid
Incorporation from Dietary Fish Oil Supplements in
Human Subjects. Cleland et al. showed that LA inhibits
EPA incorporation from dietary fish oil supplements in
human subjects (58). Thirty healthy male subjects were
randomly allocated into one of two treatment groups. One
group was on a high LA and low saturated fatty acid diet,
whereas the other group was on a low LA and low saturated
fat diet. The difference in the low LA and low saturated fatty
acid diet was made up with monounsaturated fatty acids
(olive oil). After a 3-week run-in period, the subjects
consumed a fish oil supplement containing 1.6 g EPA and
0.32 g DHA per day. After four weeks of fish oil
Figure 2. Elongation and desaturation of omega-6 and omega-3 polyunsaturated fatty acids.
supplementation, the incorporation of EPA in neutrophil
membrane phospholipids was highest in the lowest LA
group, indicating that the ingestion of omega-6 fatty acids
within the diet is an important determinant of EPA
incorporation into neutrophil membranes. This study also
shows that monounsaturated fatty acids, in this case olive
oil, do not interfere with EPA incorporation.
Decreasing Linoleic Acid with Constant a-
Linolenic Acid in Dietary Fats Increases (Omega-
3) Eicosapentaenoic Acid in Plasma Phospholipids
in Healthy Men. Liou et al. carried out a study in which
decreasing levels of LA with constant ALA led to increases
of EPA in plasma phospholipids in healthy men (59). The
omega-6/omega-3 dietary ratio varied between 10/1 to 4/0
of LA/ALA. It is unfortunate that the authors did not have a
lower ratio of 2–1/1 omega-6/omega-3, which is closer to
the ratio on which humans evolved. At a ratio of 1/1,
Zampelas et al. showed a decrease in C-reactive protein
(CRP), which Liou et al. at a ratio of 4/1 did not show (60).
A Lower Omega-6/Omega-3 Ratio as Part of a
Mediterranean Diet Decreases Vascular Endothe-
lial Growth Factor. Ambring et al. studied the ratio of
serum phospholipid omega-6 to omega-3 fatty acids, the
number of leukocytes and platelets, and vascular endothelial
growth factor (VEGF) in healthy subjects on an ordinary
Swedish diet and on a Mediterranean-inspired diet that was
high in fish and flaxseed oil (61). This is a very interesting
and important study, because it clearly showed that the serum
phospholipid ratio of omega-6/omega-3 fatty acids was
substantially lowered after the Mediterranean diet versus the
Swedish diet. The omega-6/omega-3 ratio was 4.72 6 0.19
on the Swedish diet and 2.60 6 0.19 on the Mediterranean
diet (P , 0.0001). There was no change in CRP or
interleukin-6 (IL-6), but the total number of leukocytes was
10% lower after the Mediterranean diet, the total number of
platelets was 15% lower, and so was the serum VEGF, 206
6 25 pg/mL versus 237 6 30 on the Swedish diet (P ¼
0.0014). The authors concluded that ‘‘A Mediterranean-
inspired diet reduces the number of platelets and leukocytes
and VEGF concentrations in healthy subjects. This may be
linked to higher serum concentrations of omega-3 fatty acids,
which promote a favorable composition of phospholipids.’’
These findings are consistent with our studies on the
traditional diet of Greece prior to 1960 that was rich in
ALA, EPA and DHA and balanced in the omega-6/omega-3
ratio, which distinguished it from other Mediterranean diets
(62, 63), by being similar in the omega-6/omega-3 ratio to
the diet on which human beings evolved (7–13, 26–28).
As the Omega-6/Omega-3 Ratio Decreases, So
Does the Platelet Aggregation. Freese et al. compared
the effects of two diets rich in monounsaturated fatty acids,
differing in their LA/ALA ratio on platelet aggregation in
human volunteers (64). Both diets were similar in saturated,
monounsaturated and polyunsaturated fatty acids. The
results showed that platelet aggregation in vitro decreases
as the ratio of LA/ALA decreases in diets rich in
monounsaturated fatty acids.
The higher the ratio of omega-6/omega-3 fatty acids in
platelet phospholipids, the higher the death rate from
cardiovascular disease (16). Excessive amounts of omega-
6 PUFA and a very high omega-6/omega-3 ratio, as is found
in today’s Western diets, promote the pathogenesis of many
diseases, including cardiovascular disease, cancer, and
inflammatory and autoimmune diseases, whereas increased
levels of omega-3 PUFA (a lower omega-6/omega-3 ratio),
exert suppressive effects (65).
Plasma Omega-6/Omega-3 Ratio and Inflamma-
tory Markers. Ferrucci et al. studied the relationship of
plasma PUFA to circulating inflammatory markers in 1123
persons aged 20–98 years in a community-based sample
(66). The total omega-3 fatty acids were independently
associated with lower levels of pro-inflammatory markers
[IL-6, IL-1ra, tumor necrosis factor-a (TNFa), CRP], and
higher anti-inflammatory markers [soluble IL-6r, IL-10,
transforming growth factor-a (TGFa)] independent of
confounders. The omega-6/omega-3 ratio was a strong
negative correlate of IL-10. The authors concluded,
‘‘Omega-3 fatty acids are beneficial in patients affected by
diseases characterized by active inflammation.’’
The Balance of Omega-6/Omega-3 Fatty Acids Is
Important for Health: The Evidence from Gene
Further support for the need to balance the omega-6/
omega-3 EFA comes from the studies of Kang et al. (67,
68), which clearly show the ability of both normal rat
cardiomyocytes and human breast cancer cells in culture to
form all the omega-3’s from omega-6 fatty acids when fed
the cDNA encoding omega-3 fatty acid desaturase obtained
from the roundworm Caenorhabditis elegans (C. elegans).
The omega-3 desaturase efficiently and quickly converted
the omega-6 fatty acids that were fed to the cardiomyocytes
in culture to the corresponding omega-3 fatty acids. Thus,
Table 7.Effects of Ingestion of EPA and DHA from
Fish or Fish Oil
Decreased production of prostaglandin E2(PGE2)
A decrease in thromboxane A2, a potent platelet aggregator
A decrease in leukotriene B4formation, an inducer of
inflammation, and a powerful inducer of leukocyte
chemotaxis and adherence
An increase in thromboxane A3, a weak platelet aggregator
and weak vasoconstrictor
An increase in prostacyclin PGI3, leading to an overall
increase in total prostacyclin by increasing PGI3without
a decrease in PGI2, both PGI2and PGI3are active
vasodilators and inhibitors of platelet aggregation
An increase in leukotriene B5, a weak inducer of
inflammation and a weak chemotactic agent
OMEGA-6/OMEGA-3 FATTY ACID RATIO 679
omega-6 LA was converted to omega-3 ALA and AA was
converted to EPA, so that at equilibrium, the ratio of omega-
6 to omega-3 PUFA was close to 1/1. Further studies
demonstrated that the cancer cells expressing the omega-3
desaturase underwent apoptotic death whereas the control
cancer cells with a high omega-6/omega-3 ratio continued to
proliferate (69). More recently, Kang, et al. showed that
transgenic mice and pigs expressing the C. elegans fat-1
gene encoding an omega-3 fatty acid desaturase are capable
of producing omega-3 from omega-6 fatty acids, leading to
enrichment of omega-3 fatty acids with reduced levels of
omega-6 fatty acids in almost all organs and tissues,
including muscles and milk, with no need of dietary omega-
3 fatty acid supply (70–72). This discovery provides a
unique tool and new opportunities for omega-3 research,
and raises the potential of production of fat-1 transgenic
livestock as a new and ideal source of omega-3 fatty acids to
meet the human nutritional needs. Furthermore, the trans-
genic mouse model is being used widely by scientists for the
study of chronic diseases and for the study of mechanisms
of the beneficial effects of omega-3 fatty acids (73).
Omega-3 Fatty Acids and Gene Expression
Previous studies have shown that fatty acids released
from membrane phospholipids by cellular phospholipases,
or made available to the cell from the diet or other aspects of
the extracellular environment, are important cell signaling
molecules. They can act as second messengers or substitute
for the classical second messengers of the inositide
phospholipid and the cyclic AMP signal transduction
pathways. They can also act as modulator molecules
mediating responses of the cell to extracellular signals.
Recently it has been shown that fatty acids rapidly and
directly alter the transcription of specific genes (74). In the
case of genes involved in inflammation, such as IL-1b, EPA
and DHA suppress IL-1b mRNA whereas AA does not, and
the same effect appears in studies on growth-related early
response gene expression and growth factor (74). In the case
of vascular cell adhesion molecule (VCAM), AA has a
modest suppressing effect relative to DHA. The latter
situation may explain the protective effect of fish oil toward
colonic carcinogenesis, since EPA and DHA did not
stimulate protein kinase C. PUFA regulation of gene
expression extends beyond the liver and includes genes
Table 8. Effects of Omega-3 Fatty Acids on Factors Involved in the Pathophysiology of Atherosclerosis and
FactorFunction Effect of n-3 fatty acid
Arachidonic acidEicosanoid precursor; aggregates platelets; stimulates
white blood cells
Platelet aggregation; vasoconstriction; increase of
Prevent platelet aggregation; vasodilation; increase cAMP
Neutrophil chemoattractant; increase of intracellular Caþþ
A member of the acute phase response; and a blood
Increase endogenous fibrinolysis
Activates platelets and white blood cells
Chemoattractant and mitogen for smooth muscles and
Cellular damage; enhance LDL uptake via scavenger
pathway; stimulate arachidonic acid metabolism
Stimulate eicosanoid formation
Stimulate neutrophil O2free radical formation; stimulate
lymphocyte proliferation; stimulate PAF; express
intercellular adhesion molecule-1 on endothelial cells;
inhibit plasminogen activator, thus, procoagulants
Stimulates the synthesis of all acute phase proteins
involved in the inflammatory response: C-reactive
protein; serum amyloid A; fibrinogen; a1-chymotrypsin;
An acute phase reactant and an independent risk factor
for cardiovascular disease
Reduces arterial vasoconstrictor response
Tissue plasminogen activator
Platelet activating factor (PAF)
Platelet-derived growth factor
Oxygen free radicals
Interleukin 1 and tumor
C-reactive protein (CRP)#
Increases sensitivity to insulin
Related to LDL and HDL level
Decreases the risk for coronary heart disease
Lipoprotein(a) is a genetically determined protein that
has atherogenic and thrombogenic properties
Contribute to postprandial lipemia Triglycerides and chylomicrons
such as adipocyte glucose transporter-4, lymphocyte
stearoyl-CoA desaturase 2 in the brain, peripheral mono-
cytes (IL-1b, and VCAM-1) and platelets [platelet derived
growth factor (PDGF)]. Whereas some of the transcriptional
effects of PUFA appear to be mediated by eicosanoids, the
PUFA suppression of lipogenic and glycolytic genes is
independent of eicosanoid synthesis, and appears to involve
a nuclear mechanism directly modified by PUFA.
Linoleic Acid and Arachidonic Acid Increase
Atherogenesis: Evidence from Diet-Gene Interac-
tions: Genetic Variation and Omega-6 and Omega-
3 Fatty Acid Intake in the Risk for Cardiovascular
As discussed above, leukotrienes are inflammatory
mediators generated from AA by the enzyme 5-lipoxyge-
nase. Since atherosclerosis involves arterial inflammation,
Dwyer et al. hypothesized that a polymorphism in the 5-
lipoxygenase gene promoter could relate to atherosclerosis
in humans, and that this effect could interact with the dietary
intake of competing 5-lipoxygenase substrates (75). The
study consisted of 470 healthy middle-aged women and
men from the Los Angeles Atherosclerosis study, randomly
sampled. The investigators determined 5-lipoxygenase (5-
LO) genotypes, carotid-artery intima-media thickness,
markers of inflammation, CRP, IL-6, dietary AA, EPA,
DHA, LA, and ALA with the use of six 24-hour recalls of
food intake. The results showed that 5-LO variant genotypes
were found in 6.0% of the cohort. Mean intima-media
thickness adjusted for age, sex, height and racial or ethnic
group was increased by 80 6 19 lm from among the
carriers of two variant alleles as compared with the carrier of
the common (wild-type) allele. In multivariate analysis, the
increase in intima-media thickness among carriers of two
variant alleles (62 lm, P , 0.001) was similar in this cohort
to that associated with diabetes (64 lm, P , 0.01) the
strongest common cardiovascular risk factor. Increased
dietary AA significantly enhanced the apparent atherogenic
effect of genotype, whereas increased dietary intake of
omega-3 fatty acids EPA and DHA blunted this effect.
Furthermore, the plasma level of CRP of two variant alleles
was increased by a factor of 2, as compared with that among
carriers of the common allele. Thus, genetic variation of 5-
LO identifies a subpopulation with increased risk for
atherosclerosis. The diet-gene interaction further suggests
that dietary omega-6 fatty acids promote, whereas marine
omega-3 fatty acids EPA and DHA inhibit leukotriene-
Figure 3. Oxidative metabolism of arachidonic acid and eicosapentaenoic acid by the cyclooxygenase and 5-lipoxygenase pathways. 5-
HPETE denotes 5-hydroperoxyeicosatetranoic acid and 5-HPEPE denotes 5-hydroxyeicosapentaenoic acid.
OMEGA-6/OMEGA-3 FATTY ACID RATIO681
mediated inflammation that leads to atherosclerosis in this
The prevalence of variant genotypes did differ across
racial and ethnic groups with higher prevalence among
Asians or Pacific Islanders (19.4%), blacks (24.0%) and
other racial or ethnic groups (18.2%) than among Hispanic
subjects (3.6%) and non-Hispanic whites (3.1%). Increased
intima-media thickness was significantly associated with
intake of both AA and LA among carriers of the two variant
alleles, but not among carriers of the common alleles. In
contrast, the intake of marine omega-3 fatty acids was
significantly and inversely associated with intima-media
thickness only among carriers of the two variant alleles.
Diet-gene interactions were specific to these fatty acids and
were not observed for dietary intake of monounsaturated,
saturated fat, or other measured fatty acids. The study
constitutes evidence that genetic variation in an inflamma-
tory pathway—in this case the leukotriene pathway—can
trigger atherogenesis in humans. These findings could lead
to new dietary and targeted molecular approaches for the
prevention and treatment of cardiovascular disease accord-
ing to genotype, particularly in the populations of non-
European descent (6).
Clinical Intervention Studies and the Omega-6/
Omega-3 EFA Balance
The Lyon Heart Study was a dietary intervention study
in which a modified diet of Crete (the experimental diet)
was compared with the prudent diet or Step I American
Heart Association Diet (the control diet) (76–79). The
experimental diet provided a ratio of LA to ALA of 4/1.
This ratio was achieved by substituting olive oil and canola
(oil) margarine for corn oil. Since olive oil is low in LA
whereas corn oil is high, 8% and 61% respectively, the ALA
incorporation into cell membranes was increased in the low
LA diet. Cleland et al. (58) have shown that olive oil
increases the incorporation of omega-3 fatty acids whereas
the LA from corn oil competes. In the Lyon Heart Study, the
ratio of 4/1 of LA/ALA led to a 70% decrease in total
mortality at the end of two years (76).
The Gruppo Italiano per lo Studio della Sopravvivenza
nell’Infarto miocardico (GISSI) Prevenzione Trial partic-
ipants were on a traditional Italian diet plus 850–882 mg of
omega-3 fatty acids at a ratio of 2/1 EPA to DHA (80). The
supplemented group had a decrease in sudden cardiac death
by 45%. Although there are no dietary data on total intake
for omega-6 and omega-3 fatty acids, the difference in
sudden death is most likely due to the increase of EPA and
DHA and a decrease of AA in cell membrane phospholi-
pids. Prostaglandins derived from AA are proarrhythmic,
whereas the corresponding prostaglandins from EPA are not
(81). In the Diet and Reinfarction Trial (DART), Burr et al.
reported a decrease in sudden death in the group that
received fish advice or took fish oil supplements relative to
the group that did not (82). Similar results have been
obtained by Singh et al. (83, 84). Except for the Lyon Heart
Study, most of the cardiovascular disease omega-3 fatty
acids supplementation trials did not attempt to modify the
consumption of other fat components, and specifically did
not seek to reduce the intake of omega-6 fatty acids despite
the fact that there is convincing support for such studies.
The differences in the omega-6/omega-3 ratio in the
background diets and the dose of EPA and DHA could be
an important factor in studies with conflicting results in
intervention trials on the role of EPA and DHA in patients
with ventricular arrhythmias in which a beneficial effect was
shown by Leaf et al. (85) but not by Raitt et al. (86).
Yokoyama et al. investigated the effects of EPA on
major coronary events in hypercholesterolemic patients in a
randomized open label, blinded analysis (87). Patients were
randomly assigned to receive either 1800 mg of EPA with
statin or statin only in a 5-year follow up. The results
showed that EPA is a promising treatment for prevention of
major coronary events, and especially nonfatal coronary
events, in Japanese hypercholesterolemic patients. This is a
very important finding because the Japanese already have a
high fish intake. These findings further support the data
from the study by Iso et al. that showed, compared with a
modest fish intake of once a week or about 20 g/d, a higher
intake was associated with substantially reduced risk of
coronary heart disease, primarily nonfatal cardiac events,
among middle aged persons (88).
The importance of balancing the LA (omega-6) to ALA
(omega-3) ratio was shown in a randomized, controlled, 3-
diet, 3-period crossover study in which 22 hypercholester-
olemic subjects were assigned to 3 experimental diets: a diet
high in ALA (ALA diet; 6.5% of energy) a diet high in LA
(LA diet; 12.6% of energy), and an average American diet
(AAD) for 6 weeks (89). Serum IL-6, IL-1b, and TNF-a
concentrations and the production of IL-6, IL-1b, and TNF-
a by peripheral blood mononuclear cells (PBMCs) were
measured. The ratio of omega-6/omega-3 was 10/1 in AAD,
4.1/1 in the LA diet and 2/1 in the ALA diet. The results
showed that on the ALA diet, IL-6, IL-1b, and TNF-a
production by PBMCs and serum TNF-a concentrations
were lower (P , 0.05 and P , 0.08 respectively) than with
the LA diet or AAD. PBMC production of TNF-a was
inversely correlated with ALA (P ¼ 0.07) and with
eicosapentaenoic acid (P ¼ 0.03) concentrations in PBMC
lipids with the ALA diet. Changes in serum ALA were
inversely correlated with changes in TNF-a produced by
PBMCs (P , 0.05). In this study the increased intake of
dietary ALA elicited anti-inflammatory effects by inhibiting
IL-6, IL-1b, and TNF-a production in cultured PBMCs.
Changes in PBMC ALA and EPA derived from ALA are
associated with beneficial changes in TNF-a release. The
cardioprotective effects of ALA are mediated in part by a
reduction in the production of inflammatory cytokines, IL-6,
IL-1b, and TNF-a (60, 90). Other studies, in which the ratio
of LA/ALA was not balanced, failed to decrease CRP or IL-
6, IL-1b, or TNF-a (91), leading to wrong conclusions that
LA is not inflammatory, despite the fact that it has been
shown by Toborek et al. in 2002 (92). These results are
important because they strongly suggest that the ALA intake
at a ratio of 1–2/1—which is simple to implement, as shown
by Paschos et al. (90) and Zampelas et al. (60)—could lead
to an anti-inflammatory state, which is beneficial to health
and reduce the risk for heart disease beyond that achieved
from lower LDL concentrations alone.
Studies carried out in India indicate that the higher ratio
of 18:2x6 to 18:3x3 equaling 20/1 in their food supply led
to increases in the prevalence of non-insulin diabetes
mellitus (NIDDM) in the population, whereas a diet with
a ratio of 6/1 prevented the increase in NIDDM (93).
James and Cleland have reported beneficial effects in
patients with rheumatoid arthritis (94) and Broughton has
shown beneficial effects in patients with asthma by
changing the background diet (95). James and Cleland
evaluated the potential use of omega-3 fatty acids within a
dietary framework of an omega-6/omega-3 ratio of 3–4/1 by
supplying 4 gm of EPAþDHA and using flaxseed oil rich in
ALA. In their studies, the addition of 4 gm EPA and DHA
in the diet produced a substantial inhibition of production of
IL-1b and TNFa when mononuclear cell levels of EPA were
equal or greater than 1.5% of total cell phospholipid fatty
acids which correlated with a plasma phospholipid EPA
level equal to or greater than 3.2%. These studies suggest
the potential for complementarity between drug therapy and
dietary choices that increased intake of omega-3 fatty acids
and decreased intake of omega-6 fatty acids may lead to
drug-sparing effects. Therefore, future studies need to
address the fat composition of the background diet, and
the issue of concurrent drug use. A diet rich in omega-3
fatty acids and poor in omega-6 fatty acids provides the
appropriate background biochemical environment in which
Asthma is a mediator driven inflammatory process in
the lungs and the most common chronic condition in
childhood. The leukotrienes and prostaglandins are impli-
cated in the inflammatory cascade that occurs in asthmatic
airways. There is evidence of airway inflammation even in
newly diagnosed asthma patients within 2–12 months after
their first symptoms (96). Among the cells involved in
asthma are mast cells, macrophages, eosinophils, and
lymphocytes. The inflammatory mediators include cyto-
kines and growth factors (peptide mediators) as well as the
eicosanoids, which are the products of AA metabolism,
which are important mediators in the underlying inflamma-
tory mechanisms of asthma (Table 8; Fig. 3). Leukotrienes
and prostaglandins appear to have the greatest relevance to
the pathogenesis of asthma. The leukotrienes are potent
inducers of bronchospasm, airway edema, mucus secretion,
and inflammatory cell migration, all of which are important
to the asthmatic symptomatology. Broughton et al. (95)
studied the effect of omega-3 fatty acids at a ratio of omega-
6/omega-3 of 10/1 to 5/1 in an asthmatic population in
ameliorating methacholine-induced respiratory distress.
With low omega-3 ingestion, methacholine-induced respi-
ratory distress increased. With high omega-3 fatty acid
ingestion, alterations in urinary 5-series leukotriene ex-
cretion predicted treatment efficacy and a dose change in
.40% of the test subjects (responders) whereas the non-
responders had a further loss in respiratory capacity. A
urinary ratio of 4-series to 5-series of ,1 induced by
omega-3 fatty acid ingestion may predict respiratory benefit.
Bartram et al. (97, 98) carried out two human studies in
which fish oil supplementation was given in order to
suppress rectal epithelial cell proliferation and prostaglandin
E2(PGE2) biosynthesis. This was achieved when the dietary
omega-6/omega-3 ratio was 2.5/1 but not with the same
absolute level of fish oil intake and an omega-6/omega-3
ratio of 4/1. More recently, Maillard et al. reported their
results on a case control study (99). They determined
omega-3 and omega-6 fatty acids in breast adipose tissue
and relative risk of breast cancer. They concluded, ‘‘Our
data based on fatty acid levels in breast adipose tissue
(which reflect dietary intake) suggest a protective effect of
omega-3 fatty acids on breast cancer risk and support the
hypothesis that the balance between omega-3 and omega-6
fatty acids plays a role in breast cancer.’’ In a case-control
study in Shanghai, China on the relationship between fatty
acids and breast cancer, Shannon et al. concluded, ‘‘Our
results support a positive effect of omega-3 fatty acids on
breast cancer risk and provide additional evidence for the
importance of evaluating the ratio of fatty acids when
evaluating diet and breast cancer risk (20).’’
Osteoporosis represents a major challenge to health
care services, particularly with increases in the elderly
population worldwide. Bone mineral accrual during child-
hood and adolescence plays a vital role in preventing
osteoporosis. The identification of factors influencing peak
bone mass is important for the prevention of osteoporosis
and related fractures. Genetic factors are responsible for
about 70% of the variance in bone mass (100, 101). Other
factors include nutrition, physical activity, and body mass
index (BMI) (102). Animal studies have shown that dietary
intake of long-chain omega-3 fatty acids may influence both
bone formation and bone resorption (103, 104) and an
increase in periosteal bone formation (105, 106).
The dietary ratio of omega-6/omega-3 fatty acids and
bone mineral density in older adults was studied in the
Rancho Bernardo Study by Weiss et al. (107). The study
was carried out in 1532 community-dwelling men and
women aged 45–90 years, between 1988 and 1992. The
average intake of total omega-3 fatty acids was 1.3 g/d and
the average ratio of total omega-6/omega-3 fatty acids was
8.4 in men and 7.9 in women. There was a significant
inverse association between the ratio of dietary LA to ALA
and bone mineral density (BMD) at the hip in 642 men, 564
women not using hormone therapy, and 326 women using
hormone therapy. The results were independent of age, body
mass index, and lifestyle factors. An increasing ratio of total
dietary omega-6/omega-3 fatty acids was also significant
OMEGA-6/OMEGA-3 FATTY ACID RATIO683
and independently associated with lower BMD at the hip in
all women and at the spine in women not using hormone
therapy. Thus, the relative amounts of dietary omega-6 and
omega-3 fatty acids may play a vital role in preserving
skeletal integrity of old age.
The study by Hogstrom et al. is unique in that it
measured serum fatty acid concentrations rather than use a
dietary recall questionnaire to determine fatty acid intake
(108). The aim of the 8-year prospective and retrospective
study was to investigate a possible role of fatty acids in bone
accumulation and the attainment of peak bone mass in
young postpubertal men. Key findings show a positive
association between omega-3 fatty acids and BMD of the
total body and spine, and the accumulation of BMD at the
spine between 16 and 22 years of age in the cohort of
healthy young men. This study is the first to examine the
association between individual PUFAs, BMD, and bone
mineral accrual. In summary, BMD of the total body
measured at 22 years of age showed a significant negative
correlation with serum concentrations of oleic acid and
monounsaturated fatty acids, and a significant positive
correlation with DHA and omega-3 fatty acids. BMD of the
spine measured at 22 years of age showed a positive
association with DHA and omega-3 fatty acids. Changes in
BMD of the spine between 16 and 22 years of age showed a
positive association with DHA and omega-3 fatty acids, and
a negative association with the omega-6/omega-3 ratio
The study by Hogstrom et al. (108) adds to the growing
body of evidence that omega-3 fatty acids are beneficial to
bone health. Animal models have suggested that omega-3
fatty acids may attenuate postmenopausal bone loss.
Ovariectomized mice fed a diet high in fish oil had
significantly less bone loss at the femur and lumbar
vertebrae than did ovariectomized mice fed a diet high in
omega-6 fatty acids (109). In vitro models using a
preosteoblastic cell line, MC3T3-E1, indicated a greater
production of the bone-formation markers alkaline phos-
phatase and osteocalcin after 48 hours of treatment with
EPA than after treatment with ALA (110).
Omega-3 fatty acids play an important role in health
and disease and favorably affect skeletal growth. The
attainment of peak bone mass in adolescence and the
prevention of age-related osteoporosis are potential positive
effects of omega-3 fatty acids.
Psychologic stress in humans induces the production of
proinflammatory cytokines such as interferon gamma
(IFNc), TNFa, IL-6 and IL-1. An imbalance of omega-6
and omega-3 PUFA in the peripheral blood causes an
overproduction of proinflammatory cytokines. There is
evidence that changes in fatty acid composition are involved
in the pathophysiology of major depression (111). Changes
in serotonin (5-HT) receptor number and function caused by
changes in PUFA provide the theoretical rationale connect-
ing fatty acids with the current receptor and neurotransmitter
theories of depression (112–116). The increased C20:4x6/
C20:5x3 ratio and the imbalance in the omega-6/omega-3
PUFA ratio in major depression may be related to the
increased production of proinflammatory cytokines and
eicosanoids in that illness (114). There are a number of
studies evaluating the therapeutic effect of EPA and DHA in
major depression. Stoll and colleagues have shown that
EPA and DHA prolong remission, that is, reduce the risk of
relapse in patients with bipolar disorder (117, 118).
Kiecolt-Glaser et al. studied depressive symptoms,
omega-6/omega-3 fatty acid ratio and inflammation in older
adults (119). As the dietary ratio of omega-6/omega-3
increased, the depressive symptoms, TNF-a, IL-6, and IL-6
soluble receptor (sIL-6r) increased. The authors concluded
that diets with a high omega-6/omega-3 ratio may enhance
the risk for both depression and inflammatory diseases.
Dry eye syndrome (DES) is one of the most prevalent
conditions. Inflammation of the lacrimal gland, the
meibomian gland, and the ocular surface plays a significant
role in DES (120, 121). Increased concentration of
inflammatory cytokines, such as IL-1, IL-6, and TNFa
have been found in tear film in patients with DES (122).
Miljanovic et al. investigated the relation of dietary intake
of omega-3 fatty acids and the ratio of omega-6 to omega-3
with DES incidence in a large population of women
participating in the Women’s Health Study (123). A higher
ratio of omega-6/omega-3 consumption was associated with
a significantly increased risk of DES (OR: 2.51; 95% CI:
1.13, 5.58) for .15:1 versus ,4.1 (P for trend ¼ 0.01).
These results suggest that a higher dietary intake of omega-3
fatty acids is associated with a decreased incidence of DES
in women and a high omega-6/omega-3 ratio is associated
with a greater risk.
Age-related macular degeneration (AMD) is the leading
cause of vision loss among people 65 and older. Both AMD
and cardiovascular disease share similar modifiable factors
(124–128). Fish intake has been reported to have protective
properties in lowering the risk of AMD (129–133),
especially when LA intake was low (129, 130). In a study
involving twins, Seddon et al. showed that fish consumption
and omega-3 fatty acid intake reduce the risk of AMD
whereas cigarette smoking increases the risk for AMD
Conclusions and Recommendations
Western diets are characterized by high omega-6 and
low omega-3 fatty acid intake, whereas during the
Paleolithic period when human’s genetic profile was
established, there was a balance between omega-6 and
omega-3 fatty acids. Therefore, humans today live in a
nutritional environment that differs from that for which our
genetic constitution was selected.
The balance of omega-6/omega-3 fatty acids is an
important determinant in decreasing the risk for coronary
heart disease, both in the primary and secondary prevention
of coronary heart disease.
Increased dietary intake of LA leads to oxidation of
LDL, platelet aggregation, and interferes with the incorpo-
ration of EPA and DHA in cell membrane phospholipids.
Both omega-6 and omega-3 fatty acids influence gene
expression. EPA and DHA have the most potent anti-
inflammatory effects. Inflammation is at the base of many
chronic diseases, including coronary heart disease, diabetes,
arthritis, cancer, osteoporosis, mental health, dry eye disease
and age-related macular degeneration. Dietary intake of
omega-3 fatty acids may prevent the development of
disease, particularly in persons with genetic variation, as
for example in individuals with genetic variants at the 5-LO
and the development of coronary heart disease.
Chronic diseases are multigenic and multifactorial. It is
quite possible that the therapeutic dose of omega-3 fatty
acids will depend on the degree or severity of disease
resulting from the genetic predisposition.
In carrying out clinical intervention trials, it is essential
to increase the omega-3 and decrease the omega-6 fatty acid
intake in order to have a balanced omega-6 and omega-3
intake in the background diet. Both the dietary intake and
plasma levels should be determined before and after the
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