Page 86 - JSOM Spring 2021

reported in a small group of athletes. In subjects under du- The European Food Safety Authority has deemed that intakes
104
ress, Giles et al. found that anger and confusion remained sta- of up to 5g/d EPA+DHA are safe and “do not appear to in-
ble in the FOS group but did not have an effect on fatigue. crease the risk of spontaneous bleeding episodes or bleeding
112
Conversely, Black et al. reported that FOS led to a likely mod- complications. . . .” Even in perioperative settings, compel-
118
erate beneficial effect on subjective feelings of fatigue in pro- ling evidence suggests that FOS does not significantly increase
fessional athletes. However, the effect on other mood states bleeding. A systematic review of 52 studies found that FOS
70
was deemed trivial. Similarly, two previous studies found that did not increase bleeding during or after surgery. Similar
119
self-reported mental fatigue was significantly less in the FOS findings were reported after cardiac surgery. Also, FOS does
120
groups. 109,110 However, in both studies, other mood states were not increase bleeding even with concurrent aspirin or warfarin
not affected. use. Given the lack of evidence in clinical populations, FOS
121
should not pose any bleeding risks to healthy adults, such as
athletes or SOF personnel.
Overall: Cognitive Outcomes
As illustrated in Table 3, prophylaxis FOS attenuates markers Dietary Supplement Quality
of head trauma and likely reduces the severity of TBI. The Since polyunsaturated fats (e.g., FOS) are highly unstable and
latter finding still needs confirmatory human research. Related susceptible to oxidation, there are concerns regarding the EPA
to cognitive performance, FOS may improve reaction time and and DHA quantity and quality of commercial FOS. A recent
perceived mental fatigue. However, it is unclear if FOS effects study compared the EPA, DHA, and EPA+DHA content to
other mood states, attention, or vigilance. the actual measured amount of various FOS and found that
the amounts of EPA, DHA, and EPA+DHA claimed were 99–
TABLE 3 Applications of FOS for Special Operators: Cognitive 106%, 79–99%, and 91–103%, respectively. Another anal-
122
Protection and Performance ysis reported similar results in commercially available FOS. 123
Context Application
Cognitive Protection Regarding oxidation, FOS has generally been shown to meet
Mild TBI • FOS consistently reduces TBI occurrence specifications. A robust analysis of over 2000 tests determined
and severity in animal models that the majority of commercially available FOS have accept-
• Although not conclusive, based on two able levels of oxidation. Using globally sourced FOS sam-
124
case studies and one trial, FOS may exert
protective effects before and after mild ples, De Boer et al. found that 86–98% of FOS were within
TBI/concussion oxidation compliance. 125
Cognitive Performance
Reaction time • FOS likely improves reaction time in young Adverse Events
adults and athletes Of the studies included in a recent systematic review, only one
15
Attention/Vigilance • FOS most likely does not influence trial reported minor adverse effects of FOS. The side effects
attentional control and vigilance were mild and included complaints such as poor taste and
Mood • FOS improves subjective mental fatigue minor gastrointestinal symptoms. They concluded that FOS
• It is unclear if FOS improves other “appears to be safe in athletes.” Another review conducted by
measures of mood (vigor, anger, anxiety, a military expert panel determined FOS to be safe with infre-
confusion, etc.) quent adverse events. 101
FOS = fish oil supplementation; TBI = traumatic brain injury.
Future Investigations
Safety
Despite the large body of evidence available on FOS, none of
Since SOF personnel use dietary supplements at a higher rate the reported trials used a SOF population in physiological or
than conventional military forces and the general public, they psychological stress experienced during SUSOPS. To establish
may be at a greater risk of adverse events from inappropriate the efficacy of FOS in the SOF community, future investiga-
use or poor manufacturing and, exclusively related to FOS, an tions should be conducted in SOF personnel under training
increase risk of bleeding. 114 duress. Other considerations include using a FOS protocol to
establish a dose-response relationship, using a low omega-6
Bleeding PUFA placebo (coconut oil or high-oleic safflower/sunflower
During SUSOPS, SOF personnel are at risk of sustaining oil), preloading for at least 4 weeks, and equating protein in-
life-threatening injuries. As such, consuming substances that take across groups.
could increase bleeding would be inappropriate, if not, grossly
contraindicated. For example, in an analysis of SOF deaths Conclusion
from 2001 to 2004, 94% of potentially survivable injuries
were related to hemorrhage. Platelets function to enhance Fish oil supplementation has multiple physical and cognitive
115
blood clotting during wound healing. Since omega-3 PUFAs performance applications for SOF personnel. Due to the fa-
have been shown to reduce platelet aggregation, it is plausible vorable safety profile and potential benefits, FOS of 2–3g/d to
to suggest that this may increase bleeding time. 116 improve SOF personnel’s skeletal muscle and cognitive perfor-
mance seems reasonable and in agreement with the evidence.
In a publication from the “Nutritional Armor” conference This is especially true for those that consume less than three
and expert panel, Hamazaki et al. determined that 3g/d EP- servings per week of fatty fish. While results from previous
A+DHA was safe for military populations and that “this find- trials can be extrapolated to a garrison military population,
ing cannot be interpreted to mean that taking more than 3g of the findings have limited generalizability for SOF personnel
omega-3 PUFAs (EPA/DHA) per day could be deleterious.” during SUSOPS. As such, future FOS investigations should
117

82 | JSOM Volume 21, Edition 1 / Spring 2021