Effects of Different Fish Oil Types on Type 2 Diabetes Risk Factors in High-Risk Adults

Background and Rationale:

According to the International Diabetes Federation, about 590 million adults worldwide-or 1 in 9 adults-were living with diabetes in 2025, most of whom had type 2 diabetes (T2D). An additional 230 million adults (about 4 in 10) are unaware that they have diabetes and therefore remain undiagnosed. Diabetes substantially increases the risk of illness and death and has an impact comparable to aging approximately 15 years, making it a leading cause of disability and mortality worldwide.

Type 2 diabetes develops gradually as multiple risk factors accumulate over time, including unhealthy lifestyle habits and aging. These factors reduce the body's ability to produce insulin and/or respond effectively to insulin, a hormone that regulates blood sugar levels. As a result, blood sugar levels progressively rise and may eventually lead to a diagnosis of T2D.

Importantly, type 2 diabetes is preventable.

In people with T2D, elevated blood levels of apolipoprotein B (apoB) increase the risk of cardiovascular disease (apoB is a measure of the number of particles that carry "bad" cholesterol known as low density lipoproteins (LDL)). Traditionally, high apoB levels were considered a consequence of T2D. However, research from the principal investigator's laboratory has shown that high apoB levels may also contribute to the development of T2D.

This appears to occur because LDL particles can promote inflammation and impair the normal function of fat tissue. Poorly functioning fat tissue is associated with multiple metabolic abnormalities that increase the risk of both T2D and cardiovascular disease. Large population based studies confirmed that elevated blood apoB levels can predict the development of T2D many years before diagnosis.

Recent findings from the research team also indicate that 12 week supplementation with marine derived omega 3 fatty acids, EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid), can improve several risk factors for T2D, particularly in individuals with higher blood apoB levels. However, these data suggest that EPA and DHA may not provide identical benefits in reducing these risk factors.

Study Objective:

The overall aim of this study is to compare the effects of EPA versus DHA on major risk factors for T2D in adults with overweight or obesity and elevated blood apoB levels.

Study Design and Procedures:

After eligibility is confirmed, participants will visit the research institute (IRCM) for two baseline visits scheduled one week apart. During these visits, investigators will used specialized metabolic testing to:

1. Assess how participants' bodies process glucose and produce insulin using blood samples, and
2. Examine how participants' fat tissue responds to their own LDL using a small fat tissue biopsy.

Participants will then be randomly assigned to follow one of three interventions for 12 weeks: EPA, DHA or corn oil (placebo). At the end of the 12 week intervention, participants will return to the research institute to undergo the same assessments performed at baseline.

Data Analysis:

At the conclusion of the study, results from participants in each intervention group (EPA, DHA, and placebo) will be averaged and compared. This will allow researchers to determine the effects of EPA and DHA on key risk factors for T2D and to evaluate whether one omega 3 fatty acid is more effective than the other.

• Fish Oil (Dietary supplement): Four softgels of Carlson Elite EPA Gems taken orally per day (NPN 80079735, 1 g EPA/softgel)
• Fish Oil (Dietary supplement): Four softgels of Carlson Elite DHA Gems taken orally per day (NPN 80079736, 1 g DHA/softgel)
• Corn oil control (Dietary supplement): Four softgels of Carlson placebo taken orally per day (food-grade corn oil, 0 g EPA and DHA per softgel)

Primary outcomes

• Change from baseline to 12 weeks in the disposition index [12-weeks]: Disposition index calculated as first phase glucose-induced insulin secretion multiplied by insulin sensitivity measured during the Botnia clamp \[(ng C-peptide/mL)*(mg dextrose/kg/min)/(µU insulin/mL)\]

Secondary outcomes

• Change from baseline to 12 weeks in glucose-induced insulin secretion [12 weeks]: Glucose-induced insulin secretion measured by the Botnia clamp (ng C-peptide/mL)
• Change from baseline to 12 weeks in insulin sensitivity [12 weeks]: Insulin sensitivity measured by the Botnia clamp (mg dextrose/kg/min)/(uU insulin/mL)
• Change from baseline to 12 weeks in the oral disposition index [12 week]: Oral disposition index calculated as insulin secretion index (0-30 min) multiplied by insulin sensitivity index measured during an oral glucose tolerance test (arbitrary unit)
• Change from baseline to 12 weeks in low-density lipoprotein (LDL) size [12 weeks]: LDL size measured by Quantimetrix Lipoprint System (Å)
• Change from baseline to 12 weeks in LDL-induced white adipose tissue (WAT) inflammation [12 weeks]: LDL-induced WAT inflammation measured as WAT gene expression of a panel of pro- and anti-inflammatory mediators/markers (e.g. NLRP3, IL1B, MCP1, IL10, TREMs) by RT-qPCR. This will be measured after the incubation of participant WAT biopsies without or with their own LDL ex vivo.

Other outcomes

• Change from baseline to 12 weeks in LDL-induced WAT inflammation [12 weeks]: LDL-induced WAT inflammation measured as WAT secretion of a panel of pro- and anti-inflammatory mediators/markers (e.g. IL-1β, MCP1, IL10) by multiplex. This will be measured after the incubation of participant WAT biopsies without or with their own LDL ex vivo.

Sex: All, ages: 40 Years to 70 Years, accepts healthy volunteers

Inclusion Criteria:

Males and post-menopausal females:

* With a body mass index (BMI >25-40 kg/m2)
* Having confirmed menopausal status (FSH ≥ 30 U/l)
* Non-smokers (tobacco) or have quitted for over a year
* Low-moderate alcohol consumption: <7 alcoholic servings/ week
* Plasma apoB ≥1.05 g/L

Exclusion Criteria:

* Elevated risk of cardiovascular disease (≥ 20% of calculated Framingham Risk Score)
* Prior history of cardiovascular events (e.g. stroke, transient ischemic attack, myocardial infarction, angina, heart failure, arrhythmias, flutter, atrial …)
* Systolic blood pressure > 140 mmHg or diastolic blood pressure > 90 mmHg
* Diabetes or HbA1c ≥ 6.5%
* Reactive hypoglycaemia
* Prior history of cancer within the last 3 years or if lymph nodes were removed
* Thyroid disease - untreated or unstable Synthroid dose
* Severe renal dysfunction - eGFR < 30 mL/min/1.73 m²
* Hepatic dysfunction - AST/ALT > 3 times normal limit
* Anemia - Hb < 120 g/L in females and < 130 in males
* Bleeding disorders
* Blood coagulation problems (i.e. bleeding predisposition)
* Malabsorptive disease or surgeries (e.g. bariatric surgeries)
* Autoimmune and chronic inflammatory disease (i.e. celiac, inflammatory bowel, Graves, multiple sclerosis, psoriasis, rheumatoid arthritis, and lupus).
* Chronic diarrhea
* Cholecystectomy (e.g. removal of gall bladder)
* Sleep apnea
* Seizures
* Known history of difficulties accessing a vein
* Known history of vagal shock or loss of consciousness during blood withdrawal
* Concomitant medications (systemic corticosteroids; hypertension medication; anti-psychotic medications - psycho-active medication that promote weight gain; anticoagulant or anti-aggregates treatment (e.g. aspirin, NSAIDs, warfarin, coumadin..); systemic adrenergic agonists; weight-loss medication (e.g. GLP-1 agonists); lipid lowering medication (e.g. statins, anti-PCSK9); )
* Allergy to seafood/fish or corn oil
* Allergy to bovine gelatine or glycerine (softgel components)
* Allergy to Xylocaine (anesthesia used during fat tissue biopsy)
* Anticipated surgery or blood transfusion
* Known substance abuse
* Very high physical activity (> 5 hours of aerobic exercise per week)
* Already taking more than 1 gm of EPA and/or DHA supplementation per day
* Lack of compliance to the study requirements (i.e. not being fasting)
* Cancellation of the same scheduled testing visit more than once
* Lack of time to participate in the full length of the study (18-22 weeks)
* Other conditions deemed inappropriate by the study physician (e.g. difficulties in understanding/communicating in French or English)

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• May Faraj, P.Dt., Ph.D., Principal investigator, Institut de recherches cliniques de Montréal (IRCM)/ Université de Montréal