Supplementary materials for Deane et al, “Omega 3 and …
Supplementary materials for Deane et al, “Omega 3 and polyunsaturated fat for prevention of depression and anxiety”. Contents TOC \o "1-3" \h \z \u Supplementary materials for Deane et al, “Omega 3 and polyunsaturated fat for prevention of depression and anxiety”. PAGEREF _Toc22138764 \h 1Supplementary Text 1. Results section in greater detail PAGEREF _Toc22138765 \h 3Characteristics of included studies PAGEREF _Toc22138766 \h 3Does increasing omega-3, omega-6 or total PUFA alter risk of depression or anxiety? PAGEREF _Toc22138767 \h 3Supplementary Table 1. Brief characteristics of included studies PAGEREF _Toc22138768 \h 7Supplementary Table 2. High vs low long-chain omega 3 (primary outcomes) PAGEREF _Toc22138769 \h 11Supplementary Table 3: GRADE assessment: Summary of findings for effects of long-chain omega-3 (LCn3) on depression and anxiety PAGEREF _Toc22138770 \h 15Supplementary Table 4. High vs low ALA (primary outcomes) PAGEREF _Toc22138771 \h 18Supplementary Table 5. High vs low total PUFA (primary outcomes) PAGEREF _Toc22138772 \h 19Supplementary Table 6: GRADE assessment: Summary of findings for effects of total PUFA on depression and anxiety PAGEREF _Toc22138773 \h 20Supplementary Table 7: GRADE assessment: Summary of findings for effects of ALA on depression and anxiety PAGEREF _Toc22138774 \h 22Supplementary Table 8. High vs low long-chain omega 3 (secondary outcomes) PAGEREF _Toc22138775 \h 24Supplementary Table 9. High vs low ALA (secondary outcomes) PAGEREF _Toc22138776 \h 25Supplementary Table 10. Characteristics of ongoing trials that appear to have assessed relevant outcomes for this review PAGEREF _Toc22138777 \h 26Supplementary Figure 1. Study flow diagram. PAGEREF _Toc22138778 \h 32Supplementary Figure 2. Meta-analysis of effects of higher LCn3 vs lower LCn3 on risk of depression symptoms, sub-grouped by LCn3 dose. PAGEREF _Toc22138779 \h 33Supplementary Figure 3. Meta-analysis of effects of higher LCn3 vs lower LCn3 on risk of depression symptoms, sub-grouped by EPA dose. PAGEREF _Toc22138780 \h 34Supplementary Figure 4. Meta-analysis of effects of higher LCn3 vs lower LCn3 on risk of depression symptoms, sub-grouped by DHA dose. PAGEREF _Toc22138781 \h 35Supplementary Figure 5. Funnel plot of the analysis of effects of higher LCn3 vs lower LCn3 on risk of depression. PAGEREF _Toc22138782 \h 36Supplementary Figure 6. Meta-analysis of effects of higher LCn3 vs lower LCn3 on depression symptoms, analysed using SMD, sub-grouped by LCn3 dose. PAGEREF _Toc22138783 \h 37Supplementary Figure 7. Meta-analysis of effects of higher LCn3 vs lower LCn3 on depression symptoms, analysed using SMD, sub-grouped by EPA dose. PAGEREF _Toc22138784 \h 38Supplementary Figure 8. Meta-analysis of effects of higher LCn3 vs lower LCn3 on depression symptoms, analysed using SMD, sub-grouped by DHA dose. PAGEREF _Toc22138785 \h 39Supplementary Figure 9. Funnel plot of the analysis of effects of higher LCn3 vs lower LCn3 on depression symptoms, using SMD, sub-grouped by depression rating scale. PAGEREF _Toc22138786 \h 40Supplementary Figure 10. Forest plot of trials randomising to higher vs lower LCn3 intake and assessing depression symptoms (on a continuous scale) in those without depression at baseline, subgrouping by scale and displayed in native scales. For meta-analysis data were combined using SMD (not shown, SMD 0.01, 95% CI -0.06 to 0.07, I2 46%). PAGEREF _Toc22138787 \h 41Acknowledgements: PAGEREF _Toc22138788 \h 42Supplementary References PAGEREF _Toc22138789 \h 43Supplementary Text 1. Results section in greater detailCharacteristics of included studiesCharacteristics of included studies and risk of bias are shown in Supplementary Table 1 and in more detail in our database paper ADDIN EN.CITE <EndNote><Cite><Author>Hooper</Author><Year>2019</Year><RecNum>21697</RecNum><DisplayText>(1)</DisplayText><record><rec-number>21697</rec-number><foreign-keys><key app="EN" db-id="52z90aw5jrvss5e5e0evfss4aatttfd5fs0t" timestamp="1541241884">21697</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hooper, Lee</author><author>Abdelhamid, Asmaa</author><author>Brainard, Julii</author><author>Deane, Katherine H. O.</author><author>Song, Fujian</author></authors></contributors><titles><title>Creation of a database to assess effects of omega-3, omega-6 and total polyunsaturated fats on health: database and methodology for a set of reviews</title><secondary-title>BMJ Open </secondary-title></titles><periodical><full-title>BMJ Open</full-title><abbr-1>BMJ Open</abbr-1></periodical><pages>e029554</pages><volume>9</volume><number>5</number><dates><year>2019</year></dates><urls><related-urls><url>: 10.1136/bmjopen-2019-029554</electronic-resource-num></record></Cite></EndNote>(1), risk of bias is itemised by domain for each study in Figure 1, flow diagram for this review in Supplementary Figure 1. The 32 RCTs (33 comparisons) randomised 46,467 participants, of which twelve were judged to be at low summary risk of bias PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Lcm9taG91dDwvQXV0aG9yPjxZZWFyPjIwMTA8L1llYXI+
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ADDIN EN.CITE.DATA (2-14), including twelve LCn3 comparisons, and the single ALA assessment (Figure 1). Thirty trialsaG9vYixZYXNlci4gRW5kb2NyaW5vbG9neSBhbmQgTWV0YWJvbGlzbSBSZXNlYXJjaCBDZW50ZXIs
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ADDIN EN.CITE.DATA (2, 34) (4837 participants, these participants were part of a factorial trial so also included in an LCn3 trial) and one assessed effects of higher total PUFA ADDIN EN.CITE <EndNote><Cite><Author>Estruch</Author><Year>2018</Year><RecNum>18084</RecNum><DisplayText>(35)</DisplayText><record><rec-number>18084</rec-number><foreign-keys><key app="EN" db-id="52z90aw5jrvss5e5e0evfss4aatttfd5fs0t" timestamp="1530303952">18084</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Estruch, R.</author><author>Ros, E.</author><author>Salas-Salvadó, J.</author><author>Covas, M.</author><author>Corella, D.</author><author>Arós F et, a l</author></authors></contributors><titles><title>Retraction and republication: Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013; 368:1279-90</title><secondary-title>New England Journal of Medicine</secondary-title></titles><periodical><full-title>New England Journal of Medicine</full-title><abbr-1>N Engl J Med</abbr-1><abbr-2>NEJM</abbr-2><abbr-3>The New England Journal of Medicine</abbr-3></periodical><pages>25-25</pages><volume>378</volume><dates><year>2018</year></dates><urls></urls></record></Cite></EndNote>(35) (4997 participants). We found no trials assessing effects of omega-6 fatty acids on depression or anxiety. Fourteen RCTs assessed risk of serious depression symptoms, seventeen depression symptoms (assessed as a continuous measure in those without depression at baseline), one severity of depression in people with depression at baseline and five assessed anxiety. Participants were recruited with chronic illness or risk factors in 17 trials (6 with CVD, 3 diabetes or impaired glucose tolerance, 1 dyslipidaemia or hypertension, 2 with Huntingdon’s disease, 1 each with multiple sclerosis, non-alcoholic fatty liver disease, macular degeneration, Parkinson’s disease or colorectal tumours), memory deficit, cognitive impairment or Alzheimer’s disease in 6 trials, mental health problems in 4 trials (two with schizophrenia, 1 young people at high risk of psychotic disorders, 1 mild to moderate depression), and healthy participants in 5 trials. Of the 31 LCn3 trials, most gave supplementary capsules or medicinal oils, but two used supplemental foods (enriched margarine and fish sausages) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Lcm9taG91dDwvQXV0aG9yPjxZZWFyPjIwMTA8L1llYXI+
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ADDIN EN.CITE.DATA (2), and the PUFA trial dietary advice plus nuts. ADDIN EN.CITE <EndNote><Cite><Author>Estruch</Author><Year>2018</Year><RecNum>18084</RecNum><DisplayText>(35)</DisplayText><record><rec-number>18084</rec-number><foreign-keys><key app="EN" db-id="52z90aw5jrvss5e5e0evfss4aatttfd5fs0t" timestamp="1530303952">18084</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Estruch, R.</author><author>Ros, E.</author><author>Salas-Salvadó, J.</author><author>Covas, M.</author><author>Corella, D.</author><author>Arós F et, a l</author></authors></contributors><titles><title>Retraction and republication: Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013; 368:1279-90</title><secondary-title>New England Journal of Medicine</secondary-title></titles><periodical><full-title>New England Journal of Medicine</full-title><abbr-1>N Engl J Med</abbr-1><abbr-2>NEJM</abbr-2><abbr-3>The New England Journal of Medicine</abbr-3></periodical><pages>25-25</pages><volume>378</volume><dates><year>2018</year></dates><urls></urls></record></Cite></EndNote>(35) LCn3 doses ranged from 300mg/d PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UYWphbGl6YWRla2hvb2I8L0F1dGhvcj48WWVhcj4yMDEx
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ADDIN EN.CITE.DATA (30), with 12 trial arms assessing doses of ≤1000mg/d, 13 arms >1000 to ≤2000mg/d, and seven arms doses of >2000mg/d EPA+DHA (one trial was unclear PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UdXR0bGU8L0F1dGhvcj48WWVhcj4yMDA4PC9ZZWFyPjxS
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dXJsPjwvcmVsYXRlZC11cmxzPjwvdXJscz48L3JlY29yZD48L0NpdGU+PC9FbmROb3RlPgB=
ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UdXR0bGU8L0F1dGhvcj48WWVhcj4yMDA4PC9ZZWFyPjxS
ZWNOdW0+MTYyODc8L1JlY051bT48RGlzcGxheVRleHQ+KDMyKTwvRGlzcGxheVRleHQ+PHJlY29y
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dGVydmVudGlvbiBhZnRlciBmaXJzdCBteW9jYXJkaWFsIGluZmFyY3Rpb24gKGZyb20gVGhlIEhl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bCBvZiBjYXJkaW9sb2d5PC9hYmJyLTM+PC9hbHQtcGVyaW9kaWNhbD48cGFnZXM+MTUyMy0xNTMw
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ZGl0aW9uPk5PVCBJTiBGSUxFPC9yZXByaW50LWVkaXRpb24+PGtleXdvcmRzPjxrZXl3b3JkPkNv
bmZpZGVuY2UgSW50ZXJ2YWxzICpEaWV0LEZhdC1SZXN0cmljdGVkL210IFtNZXRob2RzXSAqRGll
dCxNZWRpdGVycmFuZWFuIERpc2Vhc2UtRnJlZSBTdXJ2aXZhbCBGZW1hbGUgRm9sbG93LVVwIFN0
dWRpZXMgSHVtYW5zIE1hbGUgTWlkZGxlIEFnZWQgKk15b2NhcmRpYWwgSW5mYXJjdGlvbi9kaCBb
RGlldCBUaGVyYXB5XSBNeW9jYXJkaWFsIEluZmFyY3Rpb24vZXAgW0VwaWRlbWlvbG9neV0gT2Rk
cyBSYXRpbyBSZXRyb3NwZWN0aXZlIFM8L2tleXdvcmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+PHllYXI+
MjAwODwveWVhcj48L2RhdGVzPjxpc2JuPjAwMDItOTE0OTwvaXNibj48d29yay10eXBlPmh0dHA6
Ly9keC5kb2kub3JnLzEwLjEwMTYvai5hbWpjYXJkLjIwMDguMDEuMDM4O0NvbXBhcmF0aXZlIFN0
dWR5IFJhbmRvbWl6ZWQgQ29udHJvbGxlZCBUcmlhbCBSZXNlYXJjaCBTdXBwb3J0LCBOb24tVS5T
LiBHb3YmYXBvczt0PC93b3JrLXR5cGU+PHVybHM+PHJlbGF0ZWQtdXJscz48dXJsPmh0dHA6Ly9v
dmlkc3Aub3ZpZC5jb20vb3ZpZHdlYi5jZ2k/VD1KUyZhbXA7Q1NDPVkmYW1wO05FV1M9TiZhbXA7
UEFHRT1mdWxsdGV4dCZhbXA7RD1tZWQ1JmFtcDtBTj0xODQ4OTkyN2h0dHA6Ly9zZngudWNsLmFj
LnVrL3NmeF9sb2NhbD9zaWQ9T1ZJRDptZWRsaW5lJmFtcDtpZD1wbWlkOjE4NDg5OTI3JmFtcDtp
ZD1kb2k6MTAuMTAxNiUyRmouYW1qY2FyZC4yMDA4LjAxLjAzOCZhbXA7aXNzbj0wMDAyLTkxNDkm
YW1wO2lzYm49JmFtcDt2b2x1bWU9MTAxJmFtcDtpc3N1ZT0xMSZhbXA7c3BhZ2U9MTUyMyZhbXA7
cGFnZXM9MTUyMy0zMCZhbXA7ZGF0ZT0yMDA4JmFtcDt0aXRsZT1BbWVyaWNhbitKb3VybmFsK29m
K0NhcmRpb2xvZ3kmYW1wO2F0aXRsZT1Db21wYXJpc29uK29mK2xvdy1mYXQrdmVyc3VzK01lZGl0
ZXJyYW5lYW4tc3R5bGUrZGlldGFyeStpbnRlcnZlbnRpb24rYWZ0ZXIrZmlyc3QrbXlvY2FyZGlh
bCtpbmZhcmN0aW9uKyUyOGZyb20rVGhlK0hlYXJ0K0luc3RpdHV0ZStvZitTcG9rYW5lK0RpZXQr
SW50ZXJ2ZW50aW9uK2FuZCtFdmFsdWF0aW9uK1RyaWFsJTI5LiZhbXA7YXVsYXN0PVR1dHRsZTwv
dXJsPjwvcmVsYXRlZC11cmxzPjwvdXJscz48L3JlY29yZD48L0NpdGU+PC9FbmROb3RlPgB=
ADDIN EN.CITE.DATA (32), two trials included two arms with different doses PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5WYW4gRGUgUmVzdDwvQXV0aG9yPjxZZWFyPjIwMDg8L1ll
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ADDIN EN.CITE.DATA (12, 24)). Ratios of EPA to DHA varied, doses of EPA ranged from 96 to 2250mg/d, DHA from 120 to 1720mg/d. Seven RCTs randomised at least 1000 participants PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Lcm9taG91dDwvQXV0aG9yPjxZZWFyPjIwMTA8L1llYXI+
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ADDIN EN.CITE.DATA (2) and total PUFA ADDIN EN.CITE <EndNote><Cite><Author>Estruch</Author><Year>2018</Year><RecNum>18084</RecNum><DisplayText>(35)</DisplayText><record><rec-number>18084</rec-number><foreign-keys><key app="EN" db-id="52z90aw5jrvss5e5e0evfss4aatttfd5fs0t" timestamp="1530303952">18084</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Estruch, R.</author><author>Ros, E.</author><author>Salas-Salvadó, J.</author><author>Covas, M.</author><author>Corella, D.</author><author>Arós F et, a l</author></authors></contributors><titles><title>Retraction and republication: Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013; 368:1279-90</title><secondary-title>New England Journal of Medicine</secondary-title></titles><periodical><full-title>New England Journal of Medicine</full-title><abbr-1>N Engl J Med</abbr-1><abbr-2>NEJM</abbr-2><abbr-3>The New England Journal of Medicine</abbr-3></periodical><pages>25-25</pages><volume>378</volume><dates><year>2018</year></dates><urls></urls></record></Cite></EndNote>(35). Control groups received olive, corn or sunflower oils, other fats, other 'inert' or ill-defined substances, different dietary advice, foods without omega-3 enrichment, or nothing. Trial authors provided some response to attempted contact for 16 trials. Does increasing omega-3, omega-6 or total PUFA alter risk of depression or anxiety?Key evidence is provided in the three GRADE tables summarising evidence on effects of LCn3, ALA and total PUFA on primary outcomes (Supplementary Tables 3, 6 and 7), in forest plots showing meta-analyses (Figures 2 and 3, Supplementary Figures 2-4, 6-8 and 10) and funnel plots (Supplementary Figures 5 and 9). Risk of depression symptomsThirteen RCTs randomised 26,528 participants to higher vs lower LCn3 and reported on 1355 people found to have symptoms of depression (RR 1.01, 95% CI 0.92 to 1.10, I2 0%, 5% incidence, Figure 2). In these trials mean LCn3 dose was 1.4g/d (SD 0.9), median dose was 0.95g/d (range 0.4 to 3.4), mean trial duration was 24.2 months (SD 25.1), median duration was 12 months (range 6 to 89 months). The four largest trials tended to be longer but lower dose than average. This lack of effect of LCn3 on risk of depression did not differ in sensitivity analyses by risk of bias, fixed effects or study size, though retaining only trials with good compliance suggested increased risk of depression diagnosis with increased LCn3 (RR 1.16, 95% CI 0.99 to 1.36, I2 0%, Supplementary Table 2). Over 90% of meta-analytic weight came from three trials that assessed depression using the Center for Epidemiologic Studies Depression Scale (CESD, score ≥16PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DaGV3PC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (36-38). Similarly there were no clearly missing data (although several of the ongoing trials detailed in Supplementary Table 10 would be expected to have finished by the start of 2017, so might be considered to constitute missing data, non-publication is most likely to equate to minimal effect sizes so would be likely to confirm rather than change our findings). The similarity of the random- and fixed-effects meta-analyses, which weight small studies differently (random effects: RR 1.01, 95% CI 0.92 to 1.10; fixed-effects: RR 1.02, 95% CI 0.93 to 1.12) also suggest that little small study bias is present. ADDIN EN.CITE <EndNote><Cite><Author>Page</Author><Year>2019</Year><RecNum>22162</RecNum><DisplayText>(39)</DisplayText><record><rec-number>22162</rec-number><foreign-keys><key app="EN" db-id="52z90aw5jrvss5e5e0evfss4aatttfd5fs0t" timestamp="1565082516">22162</key></foreign-keys><ref-type name="Book Section">5</ref-type><contributors><authors><author>Page, M.J.</author><author>Higgins, J. P. T.</author><author>Sterne, J. A. C.</author></authors><secondary-authors><author>HIggins, J.P.T.</author><author>Thomas, J.</author><author>Chandler, J.</author><author>Cumpston, M.</author><author>Li, T.</author><author>Page, M. J.</author><author>Welch, V. A. </author></secondary-authors></contributors><titles><title>Chapter 13: Assessing risk of bias due to missing results in a synthesis. Draft version (29 Janaury 2019) for inclusion in</title><secondary-title>Cochrane Handbook for Systematic Reviews of Interventions</secondary-title></titles><dates><year>2019</year></dates><pub-location>London</pub-location><publisher>Cochrane</publisher><urls></urls></record></Cite></EndNote>(39) Subgrouping by intervention type, replacement nutrients, and LCn3 dose did not suggest important differences by subgroup, but subgrouping by baseline depression risk suggested increased depression risk in healthy adults with increased LCn3, and little or no effect in those with serious illnesses (no trials recruited participants with current depression or where ≥50% took antidepressants, Supplementary Table 2). As pre-specified LCn3 dose subgroupings did not divide included trials effectively, post-hoc we re-ran more even LCn3 dose subgroupings, and subgroupings by EPA and DHA dose. There was no suggestion of LCn3 dose effects (test for subgroup differences p=0.98), EPA (p=0.13) or DHA (p=0.87) effects, Supplementary Figures 2-4. GRADE assessment suggests that increasing LCn3 probably has little or no effect on risk of depression symptoms (moderate-quality evidence, downgraded once for imprecision, Supplementary Table 3).Data were very limited from trials of ALA (RR 1.11, 95% CI 0.67 to 1.84, 1 trial, 59 people found to have depression symptoms (GDS-15 score >10), not altered in any sensitivity analysis, ALA dose 2g/d, trial duration 40 months, Figure 2 and Supplementary Table 4) and total PUFA (RR 0.75, 95% CI 0.54 to 1.03, 1 trial, 147 depression diagnoses – assessed via diagnosis by usual physician and reported by participants at study follow-up or reported habitual use of antidepressant drugs, total PUFA dose unclear, median duration 56 months, Figure 2 and Supplementary Table 5), and we found no data from trials of omega-6 (Figure 2). GRADE suggests that increasing ALA may increase the risk of depression symptoms very slightly (NNH 1000, low-quality evidence, downgraded twice for imprecision) and effects of increasing total PUFA on risk of depression symptoms are unclear as the evidence is of very low-quality (downgraded once each for risk of bias, indirectness and inconsistency, Supplementary Tables 6 and 7).Depression severity and remission (in those with existing depression). A single small trial assessed effects of 1.1g/d LCn3 for 6 months in poor Iranian men with mild or moderate depression symptoms at baseline (GDS-15 mean 7.2).PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UYWphbGl6YWRla2hvb2I8L0F1dGhvcj48WWVhcj4yMDEx
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ADDIN EN.CITE.DATA (29), some of whom were depressed at baseline, and reported on remission, suggesting more remission in those on higher LCn3 (Supplementary Table 2). GRADE assessment suggests that effects of increasing LCn3 on depression severity was unclear as the evidence was of very low-quality (downgraded once each for risk of bias, indirectness and imprecision), and effects of increasing LCn3 on risk of remission in depression is unclear as the evidence was of very low-quality (downgraded once for risk of bias and twice for indirectness, Supplementary Table 3). No trials of ALA, omega-6 or total PUFA included participants with depression at baseline. Depression symptoms assessed on a continuous scale (in those not selected for depression at baseline)Fifteen RCTs assessing depression symptoms on several scales (lower scores indicated less depression) were meta-analysed using SMD suggesting little or no effect of increased LCn3 (SMD 0.01, 95% CI -0.06 to 0.07, I2 46%, mean LCn3 dose 1.2g/d, SD 0.6, median LCn3 dose 1.1g/d, range 0.3 to 2.4g/d, mean trial duration 18 months, SD 21, median duration 6 months, range 6 to 75 months, Supplementary Table 2). In the subgroup of seven trials that assessed depression using the Geriatric Depression Scale (GDS, short form scores from 0 to 15, 0-4 indicating no depression, 5-10 mild depression and 11+ severe depression) the mean difference with increased LCn3 was 0.03 (95% CI -0.10 to 0.16, I2 35%, 8307 participants, mean control group GDS 3.4, mean dose 1.0g/d, SD 0.6, mean duration 17 months, SD 18, median duration 6 months, range 6 to 48 months). There was no effect in any sensitivity analysis, and no differences between subgroups except for subgrouping by duration and depression scale. There was a suggestion of some benefit of LCn3 to depression severity in trials of up to 24 months, no effect in trials of 24 to <48 months, and some harm in trials of at least 48 months. In the single trials using Hamilton, Self-rating and Calgary Depression Scales increasing LCn3 appeared to reduce depression scores (Supplementary Table 2). Post-hoc dose subgrouping using updated cut-offs did not suggest dose effects for LCn3 (test for subgroup differences p=0.36), EPA (p=0.50) or DHA (p=0.23), Supplementary Figures 6-8). There was some evidence of small study bias. Data from two trials PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SYXVjaDwvQXV0aG9yPjxZZWFyPjIwMTA8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (6, 15, 28), and the funnel plot suggests trials showing worsening of depression severity with increased LCn3 may be missing (Supplementary Figure 9). This suggestion of small study bias was confirmed by Egger’s test for small study effects (p=0.029). If such studies were added into the analysis the SMD would tend to increase, suggesting some worsening of depression from increasing LCn3. However, the similarity of the random- and fixed-effects meta-analyses, which weight small studies differently (random effects: SMD 0.01, 95% CI -0.06 to 0.07; fixed-effects: SMD 0.02, 95% CI -0.02 to 0.06) suggest that the small study bias is not a very large problem. ADDIN EN.CITE <EndNote><Cite><Author>Page</Author><Year>2019</Year><RecNum>22162</RecNum><DisplayText>(39)</DisplayText><record><rec-number>22162</rec-number><foreign-keys><key app="EN" db-id="52z90aw5jrvss5e5e0evfss4aatttfd5fs0t" timestamp="1565082516">22162</key></foreign-keys><ref-type name="Book Section">5</ref-type><contributors><authors><author>Page, M.J.</author><author>Higgins, J. P. T.</author><author>Sterne, J. A. C.</author></authors><secondary-authors><author>HIggins, J.P.T.</author><author>Thomas, J.</author><author>Chandler, J.</author><author>Cumpston, M.</author><author>Li, T.</author><author>Page, M. J.</author><author>Welch, V. A. </author></secondary-authors></contributors><titles><title>Chapter 13: Assessing risk of bias due to missing results in a synthesis. Draft version (29 Janaury 2019) for inclusion in</title><secondary-title>Cochrane Handbook for Systematic Reviews of Interventions</secondary-title></titles><dates><year>2019</year></dates><pub-location>London</pub-location><publisher>Cochrane</publisher><urls></urls></record></Cite></EndNote>(39) Overall we believe that the effect of small study bias is small. GRADE assessment suggests that increasing LCn3 probably has little or no effect on depression symptoms (moderate-quality evidence, downgraded once for publication bias, Supplementary Table 3).A single large trial assessed effects of increasing ALA by 2g/d over 40 months on depression symptoms found little or no effect on the GDS (MD -0.02, 95% CI -0.14 to 0.10, 4068 participants, unaltered in sensitivity analyses, Supplementary Table 4). We found no data on effects of omega-6 or total PUFA on depression symptoms. GRADE assessment suggests that increasing ALA may have little or no effect on the severity of depression (low-quality evidence, downgraded once each for imprecision and risk of bias, Supplementary Table 7).Anxiety incidence and remission. One study at low summary risk of bias provided data on effects of 0.84g/d LCn3 on risk of anxiety symptoms over 74 months, with only 12 evenly distributed cases in 15480 participants (RR 1.00, 95% CI 0.32 to 3.10) ADDIN EN.CITE <EndNote><Cite><Author>ASCEND Study Collaborative Group</Author><Year>2018</Year><RecNum>21701</RecNum><DisplayText>(4)</DisplayText><record><rec-number>21701</rec-number><foreign-keys><key app="EN" db-id="52z90aw5jrvss5e5e0evfss4aatttfd5fs0t" timestamp="1542140629">21701</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>ASCEND Study Collaborative Group,</author></authors></contributors><titles><title>Effects of n?3 Fatty Acid Supplements in Diabetes Mellitus</title><secondary-title>New England Journal of Medicine</secondary-title></titles><periodical><full-title>New England Journal of Medicine</full-title><abbr-1>N Engl J Med</abbr-1><abbr-2>NEJM</abbr-2><abbr-3>The New England Journal of Medicine</abbr-3></periodical><pages>1540-1550</pages><volume>379</volume><number>16</number><dates><year>2018</year><pub-dates><date>2018/10/18</date></pub-dates></dates><publisher>Massachusetts Medical Society</publisher><isbn>0028-4793</isbn><urls><related-urls><url>;(4), none on remission. No studies provided data on effects of ALA, omega-6 or total PUFA on anxiety incidence or remission. Anxiety symptoms assessed on continuous scales (in those not selected for anxiety at baseline)Five studies assessed effects of increasing LCn3 on anxiety symptoms using four different scales (SMD 0.15, 95% CI 0.05 to 0.26, I2 0%, 1378 participants, mean does 1.4g/d, SD 0.7, median dose 1.1g/d, range 0.5 to 2.4g/d LCn3, mean trial duration 26 months, SD 30, median 6 months, range 6 to 35 months, Supplementary Figure 10). No included studies were at low summary risk of bias, but other sensitivity analyses reflected the main analysis. Subgrouping and funnel plots were not attempted as there were too few trials, we are not aware of missing data. No trials of ALA, omega-6 or total PUFA reported on anxiety symptoms. GRADE assessment suggests that increasing LCn3 probably has little or no effect on anxiety symptoms (moderate-quality evidence, downgraded once for risk of bias, Supplementary Table 3).Effects of LCn3 vs omega-6We assessed effects of LCn3 vs omega-6 to help understand whether omega-3 is helpful, while omega-6 is harmful. If this were the case we would expect to see a greater effect of LCn3 when it replaces omega-6. There was no indication that effects of replacing omega-6 with LCn3 differed from replacement of any other dietary component for depression incidence or severity (Supplementary Table 2). Secondary outcomesWe found no outcome data on effects of increasing LCn3 on social participation, psychosis, self-harm, costs or fidelity of the intervention. Data on quality of life, carer stress, suicidality, adverse events, drop outs and drop outs due to adverse events are reported in Supplementary Table 8. 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ADDIN EN.CITE.DATA (41)). Drawing conclusions simply on statistical significance of the SMD analyses, one trial suggested improvements in the Life Satisfaction Index with higher LCn3, but another did not suggest changes in SF-36 mental or physical components. Caregiver burden was assessed in two trials, suggesting a reduction in caregiver burden in one small trial, but no change in emotional or economic burden in another. There were no important differences in acceptability of LCn3 or its control when assessed through dropouts, and no effect of increasing LCn3 on dropouts due to adverse effects. Adverse events reported by at least 4 trials suggested no effect on gastrointestinal side effects, respiratory or nervous systems, an increased risk of urogenital problems and bleeding, and reduced risk of skin problems with increased LCn3 but these are based on few reports. We have formally systematically reviewed effects of omega-3, omega-6 and total PUFA on cancer, diabetes, cognition, inflammatory bowel disease, cardiovascular disease, functional outcomes, mortality, adiposity and lipids in sister reviews. PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BYmRlbGhhbWlkPC9BdXRob3I+PFllYXI+MjAxODwvWWVh
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ADDIN EN.CITE.DATA (1, 42-49)There was little or no effect of being randomised to increased ALA on gastrointestinal side effects, but fewer dropouts due to adverse side effects (Supplementary Table 9). Trials of omega-6 and total PUFA did not provide data on secondary outcomes. Ongoing trialsWe identified eleven ongoing trials of polyunsaturated fats that appear likely to have assessed depression or anxiety outcomes (detailed in Supplementary Table 10). Some are overdue for publication and may constitute missing data, others are due to complete and be published over the next few years. Supplementary Table 1. Brief characteristics of included studies StudyPopulation, countryIntervention ComparisonParticipants randomisedTrial DurationAlphaOmega – Kromhout 2010 ALAPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Lcm9taG91dDwvQXV0aG9yPjxZZWFyPjIwMTA8L1llYXI+
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ADDIN EN.CITE.DATA (3)50-85 year olds at high risk of progression to advanced age-related macular degeneration, USAEPA & DHA supplement, 0.65g/d EPA & 0.35 g/d DHALCn3 vs nil2157 int, 2046 cont5 yearsASCEND 2018 ADDIN EN.CITE <EndNote><Cite><Author>ASCEND Study Collaborative Group</Author><Year>2018</Year><RecNum>21701</RecNum><DisplayText>(4)</DisplayText><record><rec-number>21701</rec-number><foreign-keys><key app="EN" db-id="52z90aw5jrvss5e5e0evfss4aatttfd5fs0t" timestamp="1542140629">21701</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>ASCEND Study Collaborative Group,</author></authors></contributors><titles><title>Effects of n?3 Fatty Acid Supplements in Diabetes Mellitus</title><secondary-title>New England Journal of Medicine</secondary-title></titles><periodical><full-title>New England Journal of Medicine</full-title><abbr-1>N Engl J Med</abbr-1><abbr-2>NEJM</abbr-2><abbr-3>The New England Journal of Medicine</abbr-3></periodical><pages>1540-1550</pages><volume>379</volume><number>16</number><dates><year>2018</year><pub-dates><date>2018/10/18</date></pub-dates></dates><publisher>Massachusetts Medical Society</publisher><isbn>0028-4793</isbn><urls><related-urls><url>;(4)Patients with diabetes, without apparent vascular disease, UKEPA & DHA supplement, 0.46g/d EPA & 0.38 g/d DHALCn3 vs MUFA7740 int, 7740 cont7.4 yearsChiu 2008PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DaGl1PC9BdXRob3I+PFllYXI+MjAwODwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA (50)Men treated for angina, UKDietary fish advice or EPA supplement, 2.4 g/week EPA LCn3 vs nil1571 int, 1543 cont3-9 yearsDerosa 2016 ADDIN EN.CITE <EndNote><Cite><Author>Derosa</Author><Year>2016</Year><RecNum>18382</RecNum><DisplayText>(5)</DisplayText><record><rec-number>18382</rec-number><foreign-keys><key app="EN" db-id="52z90aw5jrvss5e5e0evfss4aatttfd5fs0t" timestamp="1530304135">18382</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Derosa, G.</author><author>Cicero, A. F.</author><author>D'Angelo, A.</author><author>Borghi, C.</author><author>Maffioli, P.</author></authors></contributors><titles><title>Effects of n-3 PUFAs on fasting plasma glucose and insulin resistance in patients with impaired fasting glucose or impaired glucose tolerance</title><secondary-title>BioFactors</secondary-title></titles><periodical><full-title>BioFactors (Oxford, England)</full-title><abbr-1>BioFactors</abbr-1></periodical><pages>316-322</pages><volume>42</volume><number>3</number><dates><year>2016</year></dates><urls></urls></record></Cite></EndNote>(5)Overweight/obese Caucasians with impaired fasting glucose (IFG) or impaired glucose tolerance (IGT), ItalyEPA & DHA supplement, 0.83g/d EPA & 1.57 g/d DHALCn3 vs non-fat138 int, 143 cont1.5 yearsDIPP – Tokudome 2015PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ub2t1ZG9tZTwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+
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ADDIN EN.CITE.DATA (19)People with non-alcoholic steatohepatitis (NASH) & non-alcoholic fatty liver disease (NAFLD), USAEPA supplement, 0.9 g/d EPA LCn3 vs unclear86 int, 82 cont1 yearEPOCH – Danthiir 2011 ADDIN EN.CITE <EndNote><Cite><Author>Danthiir</Author><Year>2014</Year><RecNum>18314</RecNum><DisplayText>(6)</DisplayText><record><rec-number>18314</rec-number><foreign-keys><key app="EN" db-id="52z90aw5jrvss5e5e0evfss4aatttfd5fs0t" timestamp="1530304097">18314</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Danthiir, V.</author><author>Hosking, D.</author><author>Burns, N. R.</author><author>Wilson, C.</author><author>Nettelbeck, T.</author><author>Calvaresi, E.</author><author>et, a l</author></authors></contributors><titles><title>Cognitive performance in older adults is inversely associated with fish consumption but not erythrocyte membrane n-3 fatty acids</title><secondary-title>The Journal of nutrition</secondary-title></titles><periodical><full-title>Journal of Nutrition</full-title><abbr-1>J Nutr</abbr-1><abbr-2>The journal of nutrition</abbr-2></periodical><pages>311-320</pages><volume>144</volume><number>3</number><dates><year>2014</year></dates><urls></urls></record></Cite></EndNote>(6)Healthy older adults with no cognitive impairment, AustraliaEPA & DHA supplement, 0.6 g/d EPA & 1.72 g/d DHALCn3 vs MUFA195 int, 196 cont1.5 yearsFerreira 2015PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GZXJyZWlyYTwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+
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ADDIN EN.CITE.DATA (20)Adults with Huntington's disease, 6 European countriesEPA supplement, 2.0 g/d EPA LCn3 vs unclear147 int, 143 cont0.5 yearsHashimoto 2016 ADDIN EN.CITE <EndNote><Cite><Author>Hashimoto</Author><Year>2016</Year><RecNum>20223</RecNum><DisplayText>(21)</DisplayText><record><rec-number>20223</rec-number><foreign-keys><key app="EN" db-id="52z90aw5jrvss5e5e0evfss4aatttfd5fs0t" timestamp="1530355534">20223</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hashimoto, M.</author><author>Kato, S.</author><author>Tanabe, Y.</author><author>Katakura, M.</author><author>Mamun, A. A.</author><author>Ohno, M.</author><author>et, a l</author></authors></contributors><titles><title>Beneficial effects of dietary docosahexaenoic acid intervention on cognitive function and mental health of the oldest elderly in Japanese care facilities and nursing homes</title><secondary-title>Geriatrics & Gerontology International</secondary-title></titles><periodical><full-title>Geriatrics and Gerontology International</full-title><abbr-1>Geriatr Gerontol Int</abbr-1><abbr-2>Geriatrics & Gerontology International</abbr-2></periodical><pages>330-337</pages><volume>17</volume><number>2</number><dates><year>2016</year></dates><urls></urls></record></Cite></EndNote>(21)Healthy older people, JapanEPA & DHA supplement, 0.18 g/d EPA & 0.81 g/d DHALCn3 vs MUFA43 int, 32 cont1 yearJackson 2016 ADDIN EN.CITE <EndNote><Cite><Author>Jackson</Author><Year>2016</Year><RecNum>20220</RecNum><DisplayText>(22)</DisplayText><record><rec-number>20220</rec-number><foreign-keys><key app="EN" db-id="52z90aw5jrvss5e5e0evfss4aatttfd5fs0t" timestamp="1530355532">20220</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jackson, P. A.</author><author>Forster, J. S.</author><author>Bell, J. G.</author><author>Dick, J. R.</author><author>Younger, I.</author><author>Kennedy, D. O.</author></authors></contributors><titles><title>DHA Supplementation Alone or in Combination with Other Nutrients Does not Modulate Cerebral Hemodynamics or Cognitive Function in Healthy Older Adults</title><secondary-title>Nutrients</secondary-title></titles><periodical><full-title>Nutrients</full-title></periodical><pages>86-86</pages><volume>8</volume><dates><year>2016</year></dates><urls></urls></record></Cite></EndNote>(22)Healthy adults with subjective memory deficit, UKEPA & DHA supplement, 0.13 g/d EPA & 0.90 g/d DHALCn3 vs MUFA33 int, 32 cont0.5 yearsLee 2012PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MZWU8L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA (23)People aged ≥60 years, low to middle socioeconomic status, MalaysiaEPA & DHA supplement, 0.15 g/d EPA & 0.43 g/d DHALCn3 vs n618 int, 18 cont1 yearMAPT – Vellas 2017 ADDIN EN.CITE <EndNote><Cite><Author>Andrieu</Author><Year>2017</Year><RecNum>21994</RecNum><DisplayText>(14)</DisplayText><record><rec-number>21994</rec-number><foreign-keys><key app="EN" db-id="52z90aw5jrvss5e5e0evfss4aatttfd5fs0t" timestamp="1550077986">21994</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Andrieu, Sandrine</author><author>Guyonnet, Sophie</author><author>Coley, Nicola</author><author>Cantet, Christelle</author><author>Bonnefoy, Marc</author><author>Bordes, Serge</author><author>Bories, Lawrence</author><author>Cufi, Marie-No?lle</author><author>Dantoine, Thierry</author><author>Dartigues, Jean-Fran?ois</author><author>Desclaux, Fran?oise</author><author>Gabelle, Audrey</author><author>Gasnier, Yannick</author><author>Pesce, Alain</author><author>Sudres, Kristel</author><author>Touchon, Jacques</author><author>Robert, Philippe</author><author>Rouaud, Olivier</author><author>Legrand, Philippe</author><author>Payoux, Pierre</author><author>Caubere, Jean-Paul</author><author>Weiner, Michael</author><author>Carrié, Isabelle</author><author>Ousset, Pierre-Jean</author><author>Vellas, Bruno</author></authors></contributors><titles><title>Effect of long-term omega 3 polyunsaturated fatty acid supplementation with or without multidomain intervention on cognitive function in elderly adults with memory complaints (MAPT): a randomised, placebo-controlled trial</title><secondary-title>The Lancet Neurology</secondary-title></titles><periodical><full-title>The Lancet Neurology</full-title><abbr-1>Lancet Neurol</abbr-1><abbr-2>The Lancet. Neurology</abbr-2></periodical><pages>377-389</pages><volume>16</volume><number>5</number><dates><year>2017</year></dates><publisher>Elsevier</publisher><isbn>1474-4422</isbn><urls><related-urls><url>(17)30040-6</url></related-urls></urls><electronic-resource-num>DOI: 10.1016/S1474-4422(17)30040-6</electronic-resource-num><access-date>2019/02/13</access-date></record></Cite></EndNote>(14)People aged ≥70 years with memory complaint, IADL limitation or slow gait speed, France & MonacoEPA & DHA supplement, 0.23 g/d EPA & 0.80 g/d DHALCn3 vs non-fat840 int, 840 cont3 yearsMEMO – Van de Rest 2008PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5WYW4gRGUgUmVzdDwvQXV0aG9yPjxZZWFyPjIwMDg8L1ll
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ADDIN EN.CITE.DATA (8)Healthy older people with subjective memory complaints, USADHA supplement, 0.90 g/d DHALCn3 vs n6242 int, 243 cont0.5 yearsNEURAPRO – McGorry 2017 ADDIN EN.CITE <EndNote><Cite><Author>McGorry</Author><Year>2017</Year><RecNum>20311</RecNum><DisplayText>(25)</DisplayText><record><rec-number>20311</rec-number><foreign-keys><key app="EN" db-id="52z90aw5jrvss5e5e0evfss4aatttfd5fs0t" timestamp="1530355575">20311</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>McGorry, P. D.</author><author>Nelson, B.</author><author>Markulev, C.</author><author>Yuen, H. P.</author><author>Sch?fer, M. R.</author><author>Mossaheb, N.</author><author>et, a l</author></authors></contributors><titles><title>Effect of ω-3 Polyunsaturated Fatty Acids in Young People at Ultrahigh Risk for Psychotic Disorders: The NEURAPRO Randomized Clinical Trial</title><secondary-title>JAMA Psychiatry</secondary-title></titles><periodical><full-title>JAMA Psychiatry</full-title></periodical><pages>19-27</pages><volume>74</volume><number>1</number><dates><year>2017</year></dates><urls></urls></record></Cite></EndNote>(25)Young people at ultra-high risk for psychotic disorders, Australia, Switzerland, Germany, China, Austria, Singapore, NetherlandsEPA & DHA supplement, 0.84 g/d EPA & 0.56 g/d DHALCn3 vs non-fat153 int, 151 cont0.5 yearsOFAMS – Torkildsen 2012PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ub3JraWxkc2VuPC9BdXRob3I+PFllYXI+MjAxMjwvWWVh
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ADDIN EN.CITE.DATA (11)Healthy cognitively normal adults aged 70-79, UKEPA & DHA supplement, 0.20 g/d EPA & 0.50 g/d DHALCn3 vs MUFA434 int, 433 cont1 yearPalma 2015 ADDIN EN.CITE <EndNote><Cite><Author>Palma</Author><Year>2015</Year><RecNum>19900</RecNum><DisplayText>(28)</DisplayText><record><rec-number>19900</rec-number><foreign-keys><key app="EN" db-id="52z90aw5jrvss5e5e0evfss4aatttfd5fs0t" timestamp="1530355369">19900</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Palma, C.</author></authors></contributors><titles><title>Omega 3 fatty acids supplementation in Schizophrenia</title><secondary-title>European Archives of Psychiatry and Clinical Neuroscience</secondary-title></titles><periodical><full-title>European Archives of Psychiatry & Clinical Neuroscience</full-title><abbr-1>Eur Arch Psychiatry Clin Neurosci</abbr-1><abbr-2>European Archives of Psychiatry and Clinical Neuroscience</abbr-2></periodical><pages>S122-S122</pages><volume>265</volume><number>Supplement 1</number><dates><year>2015</year></dates><urls></urls></record></Cite></EndNote>(28)People with schizophrenia, SpainEPA & DHA supplement, 0.84 g/d EPA & 0.47 g/d DHALCn3 vs nil30 int, 30 cont1 yearPomponi 2014PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Qb21wb25pPC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48
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ADDIN EN.CITE.DATA (12)Older people with mild cognitive impairment & few comorbidities, AustraliaEPA & DHA supplement, 1.67 g/d EPA & 0.16 g/d DHA or 0.4 g/d EPA & 1.55 g/d DHALCn3 vs n636 int, 18 cont0.5 yearsSUFOLOM3 – Galan 2010PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYWxhbjwvQXV0aG9yPjxZZWFyPjIwMTA8L1llYXI+PFJl
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYWxhbjwvQXV0aG9yPjxZZWFyPjIwMTA8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (13)People with a history of MI, unstable angina or ischemic stroke, FranceEPA & DHA supplement, 0.4 g/d EPA & 0.2 g/d DHALCn3 vs non-fat1248 int, 1253 cont4 yearsTajalizadekhoob 2011PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UYWphbGl6YWRla2hvb2I8L0F1dGhvcj48WWVhcj4yMDEx
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ADDIN EN.CITE.DATA (32)Survivors of recent first myocardial infarction, USALCn3 dietary advice, dose unclear LCn3 vs mixed fat51 int, 50 cont2 yearsTREND-HD 2008 ADDIN EN.CITE <EndNote><Cite><Author>Huntington Study</Author><Year>2008</Year><RecNum>7143</RecNum><DisplayText>(33)</DisplayText><record><rec-number>7143</rec-number><foreign-keys><key app="EN" db-id="52z90aw5jrvss5e5e0evfss4aatttfd5fs0t" timestamp="1530213368">7143</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Huntington Study Group,</author></authors></contributors><titles><title>Randomized controlled trial of ethyl-eicosapentaenoic acid in Huntington disease: the TREND-HD study</title><secondary-title>Archives of Neurology</secondary-title><alt-title>Arch Neurol</alt-title></titles><periodical><full-title>Archives of Neurology</full-title><abbr-1>Arch Neurol</abbr-1></periodical><alt-periodical><full-title>Archives of Neurology</full-title><abbr-1>Arch Neurol</abbr-1></alt-periodical><pages>1582-1589</pages><volume>65</volume><number>12</number><reprint-edition>NOT IN FILE</reprint-edition><keywords><keyword>Adult Analysis of Variance Canada Double-Blind Method *Eicosapentaenoic Acid/aa [Analogs & Derivatives] Eicosapentaenoic Acid/tu [Therapeutic Use] Female Follow-Up Studies Humans *Huntington Disease/dt [Drug Therapy] Huntington Disease/ge [Genetics] *Hu</keyword></keywords><dates><year>2008</year></dates><isbn>1538-3687</isbn><work-type> Trial Multicenter Study Randomized Controlled Trial Research Support, Non-U.S. Gov't</work-type><urls><related-urls><url>;(33)People with Huntington's disease, USA & CanadaEPA supplement, 0.95 g/d EPALCn3 vs non-fat158 int, 158 cont0.5 yearsSupplementary Table 2. High vs low long-chain omega 3 (primary outcomes)Outcome (test for subgroup differences)SA or SubgroupStudiesParticipantsEffect Estimate (Risk Ratio, M-H, Random, 95% CI)*I2, %Risk of depression symptomsMain13265281.01 [0.92, 1.10]0Summary risk of bias (SA)6246181.05 [0.90, 1.22]33Fixed effects (SA)13265281.02 [0.93, 1.12](Risk Ratio, M-H, Fixed, 95% CI)0Compliance (SA)572101.16 [0.99, 1.36]0Larger trials (≥100 randomised, SA)12264361.01 [0.92, 1.10]0Intervention type, subgrouping (p=0.68)Dietary advice11014.90 [0.24, 99.66]-Supplemental foods140680.98 [0.59, 1.63]-?Supplement or capsule10221541.00 [0.92, 1.10]0?Any combination12052.91 [0.12, 70.71]-Replacement, subgrouping (p=0.10)n3 vs SFA00Not estimable-n3 vs MUFA5224561.16 [0.99, 1.36]0n3 vs n627550.99 [0.10, 9.43]0n3 vs non-fat, nil or low n3633170.94 [0.84, 1.05]0Dose, subgroup (p=0.68)LCn3 ≤150mg/d00Not estimable-LCn3 >150 to ≤250mg/d00Not estimable-LCn3 >250 to ≤400mg/d140680.98 [0.59, 1.63]-LCn3 >400 to ≤2400mg/d10216961.00 [0.92, 1.10]0LCn3 >2.4 to ≤4.4g/d16632.99 [0.12, 73.16]-LCn3 >4.4g/d00Not estimable-Duration, subgroup (p=0.12)Duration 6 to <12 months413611.15 [0.63, 2.11]0Duration 12 to <24 months433311.18 [1.00, 1.40]0Duration 24 to <48 months343741.05 [0.64, 1.73]0Duration ≥48months2174620.93 [0.83, 1.04]0Depression risk, subgroup (p=0.03)Previous or current depression00Not estimable-Other serious illness10252780.97 [0.88, 1.07]0Healthy312501.35 [1.02, 1.79]0Antidepressant use, subgroupantidepressants used00Not estimable-no antidepressant use13265281.01 [0.92, 1.10]0Depression severity (participants have depression at baseline)Main, assessed using GDS (Geriatric Depression Score)161-0.94 [-2.27, 0.39]MD (IV, Random, 95% CI)-Low summary risk of bias (SA)00Not estimable-Fixed effects (SA)161-0.94 [-2.27, 0.39]MD (IV, Random, 95% CI)-Compliance (SA)161-0.94 [-2.27, 0.39]MD (IV, Random, 95% CI)-Larger trials (≥100 randomised, SA)00Not estimable-Depression symptoms (in those without depression at baseline)main 1599080.01 [-0.06, 0.07]SMD (IV, Random, 95% CI)46Low summary risk of bias (SA)680440.00 [-0.08, 0.08]SMD (IV, Random, 95% CI)62Fixed effects (SA)1599080.02 [-0.02, 0.06]SMD (IV, Fixed, 95% CI)46Compliance (SA)117832-0.01 [-0.10, 0.07]SMD (IV, Random, 95% CI)56Larger trials (≥100 randomised, SA)1096970.03 [-0.01, 0.07]SMD (IV, Random, 95% CI)0Assessment scale(p=0.02 in SMD analysis)Note: all available studies used for each subgroupGDS (Geriatric Depression Scale)783070.03 [-0.10, 0.16]MD (IV, Random, 95% CI)35MADRS (Montgomery–?sberg Depression Rating Scale)3698-0.12 [-0.61, 0.37]MD (IV, Random, 95% CI)0HAM-D (Hamilton Depression Scale) 124-2.70 [-6.34, 0.94]MD (IV, Random, 95% CI)-HADS (Hospital Anxiety & Depression Scale); depression subscore 14490.30 [-0.21, 0.81]MD (IV, Random, 95% CI)-GHQ (General Health Questionnaire); depression subscore12180.03 [-0.26, 0.32]MD (IV, Random, 95% CI)-SDS (Self-rating Depression Scale) 148-3.96 [-7.85, -0.07]MD (IV, Random, 95% CI)-CDS (Calgary Depression Scale for Schizophrenia) 171-1.58 [-2.66, -0.50]MD (IV, Random, 95% CI)-Derogatis tool 13921.55 [-0.42, 3.52]MD (IV, Random, 95% CI)-Intervention type, subgroup (p=0.28)?Dietary advice00Not estimable-Supplemental foods24116-0.03 [-0.15, 0.08]SMD (IV, Random, 95% CI)58Supplement or capsule1254000.00 [-0.08, 0.09]SMD (IV, Random, 95% CI)43Any combination13920.16 [-0.04, 0.35]SMD (IV, Random, 95% CI)-Replacement, subgrouping (p=0.15)n3 vs SFA00Not estimable-n3 vs MUFA54704-0.05 [-0.17, 0.07]SMD (IV, Random, 95% CI)61n3 vs n661152-0.09 [-0.30, 0.13]SMD (IV, Random, 95% CI)56n3 vs non-fat, nil or low n3440520.06 [0.00, 0.12]SMD (IV, Random, 95% CI)0Dose, subgrouping (p=0.81)LCn3 ≤150mg/d00Not estimableSMD (IV, Random, 95% CI)-LCn3 >150 to ≤250mg/d00Not estimableSMD (IV, Random, 95% CI)-LCn3 >250 to ≤400mg/d14068-0.01 [-0.08, 0.06]SMD (IV, Random, 95% CI)-LCn3 >400 to ≤2400mg/d1458400.00 [-0.08, 0.09]SMD (IV, Random, 95% CI)48LCn3 >2.4 to ≤4.4g/d00Not estimable-LCn3 >4.4g/d00Not estimable-Duration, subgrouping (p=0.02)Duration 6 to <12months81481-0.11 [-0.28, 0.07]SMD (IV, Random, 95% CI)58Duration 12 to <24 months283-0.51 [-0.95, -0.06]SMD (IV, Random, 95% CI)0Duration 24 to <48months359520.01 [-0.04, 0.06]SMD (IV, Random, 95% CI)0Duration ≥48months223920.08 [0.00, 0.16]SMD (IV, Random, 95% CI)0Depression risk, subgrouping (p=0.36)Previous or current depression161-0.35 [-0.86, 0.15]SMD (IV, Random, 95% CI)-Other serious illness1190770.01 [-0.06, 0.07]SMD (IV, Random, 95% CI)47Healthy4831-0.05 [-0.30, 0.21]SMD (IV, Random, 95% CI)55Antidepressant use, subgroupingantidepressants used00Not estimable-no antidepressants used1599080.01 [-0.06, 0.07]SMD (IV, Random, 95% CI)46Depression remission50% reduction HAM-D 1248.00 [1.17, 54.50]SMD (IV, Random, 95% CI)-Summary risk of bias (SA)00Not estimable-Compliance (SA)00Not estimable-Larger trials (≥100 randomised, SA)00Not estimable-Risk of anxiety symptomsMain1154801.00 [0.32, 3.10]-Low summary risk of bias (SA)1154801.00 [0.32, 3.10]-Fixed effects (SA)1154801.00 [0.32, 3.10]-Compliance (SA)00Not estimable-Larger trials (≥100 randomised, SA)1154801.00 [0.32, 3.10]-Anxiety remission50% reduction00Not estimable-Anxiety severity (participants have anxiety at baseline)00Not estimable-Anxiety symptoms (participants without anxiety at baseline)Main513780.15 [0.05, 0.26]SMD (IV, Random, 95% CI)0Summary risk of bias (SA)00Not estimable-Fixed effects (SA)513780.15 [0.05, 0.26]SMD (IV, Fixed, 95% CI)0Compliance (SA)39620.14 [0.01, 0.27]SMD (IV, Random, 95% CI)0Larger trials (≥100 randomised, SA)413540.16 [0.05, 0.27]SMD (IV, Random, 95% CI)0Assessment scale(p=0.72 in SMD analysis)HARS (Hamilton Anxiety Rating Scale)124-1.20 [-5.58, 3.18] MD (IV, Random, 95% CI)-HADS (Hospital Anxiety & Depression Scale) -Anxiety27440.43 [0.06, 0.79]MD (IV, Random, 95% CI)0GHQ (General Health Questionnaire) - Anxiety12180.24 [-0.55, 1.03]MD (IV, Random, 95% CI)-Derogatis Stress Profile13921.94 [0.04, 3.84]MD (IV, Random, 95% CI)-Supplementary Table 3: GRADE assessment: Summary of findings for effects of long-chain omega-3 (LCn3) on depression and anxietyPatient or population: People at any baseline risk of depression and anxiety Setting: Trials of at least 6 months duration of LCn3 in any country or context Intervention: Higher LCn3 intakeComparison: lower LCn3 intake OutcomesAnticipated absolute effects* (95% CI) Relative effect(95% CI) № of participants (studies) Certainty of the evidence(GRADE) CommentsRisk with low LCn3 (primary outcomes)Risk with High LCn3Risk of depression symptoms51 per 1,000 51 per 1,000(47 to 56) RR 1.01(0.92 to 1.10) 26528(13 RCTs) ????MODERATE a,b,c,d,eIncreasing LCn3 probably has little or no effect on depression diagnosis. Downgraded once for imprecision. Depression severity in those with depression at baseline assessed with: GDS (Geriatric Depression Scale) The mean depression severity in those with depression at baseline was 7.2 GDS score The mean depression severity in those with depression at baseline in the intervention group was 0.94 GDS score lower (2.27 lower to 0.39 higher) - 61(1 RCT) ????VERY LOW f,g,hThe effect of increasing LCn3 on depression severity is unclear as the evidence is of very low quality. Downgraded once each for risk of bias, indirectness and imprecision. Depression remissionassessed with: 50% reduction in HAM-D 83 per 1,000 667 per 1,000(97 to 1,000) RR 8.00(1.17 to 54.50) 24(1 RCT) ????VERY LOW i,j,kThe effect of increasing LCn3 on risk of remission in depression is unclear as the evidence is of very low quality. Downgraded once for risk of bias and twice for indirectness. Depression symptoms (in those without depression at baseline)- - - 9908(15 RCTs) ????MODERATE b,c,l,m,nIncreasing LCn3 probably has little or no effect on depression symptoms in people without depression at baseline. Downgraded once for publication bias. Risk of anxiety symptoms1 per 1,000 1 per 1,000(0 to 2) RR 1.00(0.32 to 3.10) 15480(1 RCT) ????VERY LOW o,p,qThe effect of increasing LCn3 on anxiety incidence is unclear as the evidence is of very low quality. Downgraded once for indirectness and twice for imprecision. Anxiety severity (in those with anxiety at baseline) Not pooled Not pooled not pooled(0 RCTs) - We found no studies that assessed effects of LCn3 on severity of anxiety in those with anxiety at baseline. Anxiety remission (50% reduction) not pooled not pooled not pooled (0 RCTs) - We found no studies that assessed effects of LCn3 on anxiety remission. Anxiety symptoms (in those without anxiety at baseline) - - - 1378(5 RCTs) ????MODERATE b,r,s,tIncreasing LCn3 probably has little or no effect on anxiety symptoms in those without anxiety at baseline. Downgraded once for risk of bias. *The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio; MD: Mean difference; SMD: Standardised mean difference GRADE Working Group grades of evidenceHigh certainty: We are very confident that the true effect lies close to that of the estimate of the effectModerate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially differentLow certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effectVery low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect Explanationsa. Risk of bias: Main analysis and most sensitivity analyses suggest little or no effect, but limiting to trials at low risk of compliance problems suggests increased risk of depression with increased LCn3. Not downgraded. b. Inconsistency: I2 <50%, not downgraded. c. Indirectness: men and women with a variety of baseline health conditions included, from several regions of the world. Not downgraded d. Imprecision: 95% confidence intervals include increased risk of depression with more LCn3. Downgraded once. e. Publication bias: funnel plot appears symmetrical, we are not aware of missing data. Not downgraded f. Risk of bias: the single study was not at low summary risk of bias. Downgraded once. g. Indirectness: Single trial assessing 61 Iranian men, women and other countries not represented. Downgraded once. h. Imprecision: 95% CI includes both important benefits and some harm. Downgraded once. i. Risk of bias: the single trial was not at low summary risk of bias. Downgraded once. j. Indirectness: single trial in 24 Italians with Parkinson's Disease. Downgraded twice. k. Imprecision: Although there were only 8 events, the 95% CI included only benefits. Not downgraded. l. Risk of bias: effect did not differ in trials at low summary risk of bias, or in other sensitivity analyses. Not downgraded. m. Imprecision: 95% CI included only little or no effect. Not downgraded. n. Publication bias: Funnel plot suggests that some small studies with higher SMDs may be missing. Adding these back would tend to suggest slightly worse outcomes with LCn3. Downgraded once. o. Risk of bias: the single study was at large and at low summary risk of bias. Not downgraded. p. Indirectness: the single trial was conducted in UK diabetics. Downgraded once. q. Imprecision: the 95% CI included both important harms and important benefits. Downgraded twice. r. Risk of bias: no included trials were at low summary risk of bias. Downgraded once. s. Indirectness: included men and women with a variety of health conditions, though mainly from Europe. Not downgraded. t. Imprecision: 95% CI included only little or no effect. Not downgraded. Supplementary Table 4. High vs low ALA (primary outcomes)OutcomeSA or SubgroupStudiesParticipantsEffect Estimate (Risk Ratio, M-H, Random, 95% CI)*Risk of depression symptomsMain 140681.11 [0.67, 1.84]Summary risk of bias (SA)140681.11 [0.67, 1.84]Fixed effects (SA)140681.11 [0.67, 1.84](Risk Ratio, M-H, Fixed, 95% CI)Compliance (SA)140681.11 [0.67, 1.84]Larger trials (≥100 randomised, SA)140681.11 [0.67, 1.84]Depression symptoms (in those without depression at baseline)Main, GDS 14068-0.02 [-0.14, 0.10] MD (IV, Random, 95% CI)Summary risk of bias (SA)14068-0.02 [-0.14, 0.10] MD (IV, Random, 95% CI)Fixed effects (SA)14068-0.02 [-0.12, 0.09] MD (IV, Fixed, 95% CI)Compliance (SA)14068-0.02 [-0.14, 0.10] MD (IV, Random, 95% CI)Larger trials (≥100 randomised, SA)14068-0.02 [-0.14, 0.10] MD (IV, Random, 95% CI)Depression remissionMain 00Not estimableRisk of anxiety symptomsSymptomatic00Not estimableAnxiety symptoms00Not estimableAnxiety remission50% reduction00Not estimableSupplementary Table 5. High vs low total PUFA (primary outcomes) OutcomeSA or SubgroupStudiesParticipantsEffect Estimate (Risk Ratio, M-H, Random, 95% CI)*Risk of depression symptomsMain 127390.75 [0.54, 1.03]Summary risk of bias (SA)00Not estimableFixed effects (SA)127390.75 [0.54, 1.03](Risk Ratio, M-H, Fixed, 95% CI)Compliance (SA)00Not estimableLarger trials (≥100 randomised, SA)127390.75 [0.54, 1.03]Depression symptoms (in those without depression at baseline)Main 00Not estimableDepression remissionMain 00Not estimableRisk of anxiety symptomsSymptomatic00Not estimableAnxiety symptomsMain 00Not estimableAnxiety remission50% reduction00Not estimableSupplementary Table 6: GRADE assessment: Summary of findings for effects of total PUFA on depression and anxietyPatient or population: People at any baseline risk of depression and anxiety Setting: Trials of at least 6 months duration in any country or context Intervention: Higher total PUFA intakeComparison: lower total PUFA intakeOutcomesAnticipated absolute effects* (95% CI) Relative effect(95% CI) № of participants (studies) Certainty of the evidence(GRADE) CommentsRisk with lower total PUFARisk with higher total PUFARisk of depression symptoms61 per 1,000 46 per 1,000(33 to 63) RR 0.75(0.54 to 1.03) 2739(1 RCT) ????VERY LOW a b cWe are uncertain of the effect of increasing total PUFA as the evidence is of very low-quality. Downgraded once each for risk of bias, inconsistency and indirectness.Depression severity - (0 RCTs) -No RCTs assessed this outcome.Depression remission (50% reduction) (0 RCTs) - No RCTs assessed this outcome. Depression symptoms (in those without depression at baseline)(0 RCTs)-No RCTs assessed this outcome.Risk of anxiety symptoms(0 RCTs) - No RCTs assessed this outcome. Anxiety severity - - (0 RCTs) - No RCTs assessed this outcome. Anxiety remission (50% reduction) (0 RCTs) - No RCTs assessed this outcome. Anxiety symptoms(0 RCTs)-No RCTs assessed this outcome.*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio; MD: Mean difference; SMD: Standardised mean difference GRADE Working Group grades of evidenceHigh certainty: We are very confident that the true effect lies close to that of the estimate of the effectModerate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially differentLow certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effectVery low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect ExplanationsRisk of bias: the included study was not at low summary risk of bias (or at low risk for compliance). Downgraded once. Inconsistency: only one trial, downgraded once. Indirectness: the single trial that provided data for this assessment compared increased nut intake (high in PUFA) with increased olive oil intake (high in MUFA). However, nuts are also rich sources of many vitamins and minerals including magnesium, selenium, zinc and B vitamins, so it is unclear whether the decrease in depression risk is due to PUFA or other dietary components. Supplementary Table 7: GRADE assessment: Summary of findings for effects of ALA on depression and anxietyPatient or population: People at any baseline risk of depression and anxiety Setting: Trials of at least 6 months duration of ALA in any country or context Intervention: Higher ALA intakeComparison: lower ALA intakeOutcomesAnticipated absolute effects* (95% CI) Relative effect(95% CI) № of participants (studies) Certainty of the evidence(GRADE) CommentsRisk with lower ALARisk with Higher ALARisk of depression symptoms14 per 1,000 15 per 1,000(9 to 25) RR 1.11(0.67 to 1.84) 4068(1 RCT) ????LOW aIncreasing ALA may increase the risk of diagnosis of depression very slightly, NNH 1000. Downgraded twice for imprecision.Depression severity in those with depression at baselinenot pooled-(0 RCTs)-No RCTs assessed this outcome.Depression remission (50% reduction) not pooled not pooled not pooled (0 RCTs) - No RCTs assessed this outcome. Depression symptoms (in those without depression at baseline) - assessed with GDS (Geriatric Depression Scale)The mean GDS at baseline was 1.49 The mean GDS in the intervention group was -0.02 lower (0.14 lower to 0.10 higher)- 4068(1 RCT) ????LOW b,cIncreasing ALA may have little or no effect on depression symptoms. Downgraded for imprecision and risk of bias. Risk of anxiety symptomsnot pooled not pooled not pooled (0 RCTs) - No RCTs assessed this outcome. Anxiety severity in those with anxiety at baselinenot pooled - - (0 RCTs) - No RCTs assessed this outcome. Anxiety remission (50% reduction) not pooled not pooled not pooled (0 RCTs) - No RCTs assessed this outcome. Anxiety symptoms in those without anxiety at baselinenot pooled-(0 RCTs)-No RCTs assessed this outcome.*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio; MD: Mean difference; SMD: Standardised mean difference GRADE Working Group grades of evidenceHigh certainty: We are very confident that the true effect lies close to that of the estimate of the effectModerate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially differentLow certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effectVery low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect Explanationsa. Imprecision: 95% CI include both important harms and important benefits. Downgraded twice. b. Risk of bias: the included study was not at low summary risk of bias (or at low risk for compliance). Downgraded once. c. Imprecision: 95% CI included benefit of over 10% improvement in GDS score. Downgraded once. Supplementary Table 8. High vs low long-chain omega 3 (secondary outcomes)OutcomeSubgroupStudiesParticipantsStatistical MethodEffect EstimateSocial participation00Mean Difference (IV, Random, 95% CI)Not estimableQuality of life measures?Life satisfaction index (LSI) 1352Mean Difference (IV, Random, 95% CI)1.10 [0.14, 2.06]SF36 - mental 191Mean Difference (IV, Random, 95% CI)-0.60 [-3.10, 1.90]SF36 - physical 191Mean Difference (IV, Random, 95% CI)1.10 [-2.12, 4.32]Carer stressCaregiver burden (Zarit Burden Interview) 148Mean Difference (IV, Random, 95% CI)-3.49 [-7.02, 0.04]Emotional overload1174Mean Difference (IV, Random, 95% CI)0.00 [-0.91, 0.91]Economic overload1174Mean Difference (IV, Random, 95% CI)-0.20 [-0.56, 0.16]Healthcare and patient costs00Mean Difference (IV, Random, 95% CI)Not estimablePsychosis, suicidality, suicide or self-harmSuicide316433Risk Ratio (M-H, Random, 95% CI)0.99 [0.13, 7.73]Fidelity00Mean Difference (IV, Random, 95% CI)Not estimableAdverse eventsAny GI side effect 1211609Risk Ratio (M-H, Random, 95% CI)0.95 [0.80, 1.12]?Nausea 3651Risk Ratio (M-H, Random, 95% CI)1.14 [0.64, 2.05]Abdominal pain or discomfort 3271Risk Ratio (M-H, Random, 95% CI)1.03 [0.11, 9.21]Diarrhoea 3849Risk Ratio (M-H, Random, 95% CI)0.65 [0.43, 1.00]?Malignancy 12081Risk Ratio (M-H, Random, 95% CI)0.22 [0.15, 0.32]Urogenital system 43063Risk Ratio (M-H, Random, 95% CI)1.11 [0.83, 1.48]Respiratory system 53577Risk Ratio (M-H, Random, 95% CI)1.01 [0.61, 1.66]Musculoskeletal disorders32997Risk Ratio (M-H, Random, 95% CI)0.73 [0.45, 1.18]Falls or injuries 32687Risk Ratio (M-H, Random, 95% CI)1.52 [0.88, 2.62]Cardiovascular system 32971Risk Ratio (M-H, Random, 95% CI)1.19 [0.83, 1.68]Bleeding 43290Risk Ratio (M-H, Random, 95% CI)1.35 [0.82, 2.20]Skin problems (itching, rashes) 46831Risk Ratio (M-H, Random, 95% CI)0.80 [0.49, 1.32]Infections 22905Risk Ratio (M-H, Random, 95% CI)0.90 [0.77, 1.06]Brain and Nervous System 63834Risk Ratio (M-H, Random, 95% CI)0.97 [0.80, 1.17]Headache or worsening migraine 3651Risk Ratio (M-H, Random, 95% CI)0.77 [0.33, 1.82]Insomnia or fatigue 3712Risk Ratio (M-H, Random, 95% CI)1.11 [0.71, 1.73]Sense organs 22905Risk Ratio (M-H, Random, 95% CI)0.96 [0.70, 1.31]Hormonal 22385Risk Ratio (M-H, Random, 95% CI)1.11 [0.73, 1.70]Drop outs115654Risk Ratio (M-H, Random, 95% CI)0.94 [0.82, 1.09]Dropouts due to adverse events64976Risk Ratio (M-H, Random, 95% CI)0.99 [0.69, 1.42]Supplementary Table 9. High vs low ALA (secondary outcomes) OutcomeStudiesParticipants Statistical MethodEffect EstimateAny gastrointestinal side effect12433Risk Ratio (M-H, Random, 95% CI)0.93 [0.38, 2.28]Dropouts due to adverse events12433Risk Ratio (M-H, Random, 95% CI)0.89 [0.47, 1.65]Supplementary Table 10. Characteristics of ongoing trials that appear to have assessed relevant outcomes for this reviewBeyond Aging Project PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Db2NrYXluZTwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+
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ADDIN EN.CITE.DATA (51)Study nameThe Beyond Ageing Project Phase 2: A selective prevention trial using novel pharmacotherapies in an older age cohort at risk for depressionMethodsRCTParticipantsOlder adults (60+ years) at risk of depression (K-10 score ranging from 16-29) who initially participated in the first Beyond Ageing ProjectInterventionsEach for 12 months:Arm 1: omega-3 (4 capsules, total 2g/d: 1200mg EPA and 800mg DHA) and placebo microcrystalline cellulose (1 capsule)Arm 2: paraffin oil placebo (4 capsules) and sertraline hydrochloride (1 capsule, 50mg)Arm 3: paraffin oil placebo (4 capsules) and placebo microcrystalline cellulose (1 capsule)OutcomesPrimary: depressive symptoms (PHQ-9)Secondary: cognitive decline, MMSE, brain metabolism, hippocampal volume, anxiety (GAD-7), disability (WHODAS-II), sleeping problems (PSQI), exercise (Active Australian Survey)Starting dateRegistered on Trials Registry: 12 Jan 2010Study start date: June 2011Study completion date est: Main results expected in 2017Contact informationIan Hickie (PI), Brain and Mind Centre, University of Sydney, ian.hickie@sydney.adu.auNotesACTRN12610000032055Cai 2017 ADDIN EN.CITE <EndNote><Cite><Author>Cai</Author><Year>2017</Year><RecNum>20012</RecNum><DisplayText>(52)</DisplayText><record><rec-number>20012</rec-number><foreign-keys><key app="EN" db-id="52z90aw5jrvss5e5e0evfss4aatttfd5fs0t" timestamp="1530355421">20012</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cai, S.</author><author>Coates, A. M.</author><author>Buckley, J. D.</author><author>Berry, N. M.</author><author>Burres, L.</author><author>Beltrame, J.</author><author>Howe, P. R. C.</author><author>Schrader, G.</author></authors></contributors><titles><title>There is No Association Between the Omega-3 Index and Depressive Symptomsin Patients With Heart Disease Who Are Low Fish Consumers</title><secondary-title>Heart, Lung and Circulation</secondary-title></titles><periodical><full-title>Heart, Lung & Circulation</full-title><abbr-1>Heart Lung Circ</abbr-1><abbr-2>Heart, Lung and Circulation</abbr-2></periodical><pages>276-284</pages><volume>26</volume><dates><year>2017</year></dates><urls></urls></record></Cite></EndNote>(52)Study nameOmega-3 fatty acid supplementation for symptoms of depression in patients with cardiovascular diseaseMethodsRCT, parallel groups. Both the participants and the researchers were blinded to whether they were in the fish oil or placebo groups.Participants91 patients (65 males and 26 females, mean age 59.2 (10.3) years) with heart disease and depressive symptoms (Center for Epidemiological Studies Depression Scale, CES-D) and low fish/fish oil intakes.InterventionsIntervention: Four 1 gram capsules of eicosapentaenoic acid (EPA)-rich fish oil per day for 6 months. Each capsule will contain 500mg of eicosapentaenoic acid (EPA) and 25 mg of docosahexaenoic acid (DHA).Placebo: Four 1 gram capsules of soybean/corn oil per day for 6 months. Each capsule will contain 500mg of soybean oil and 500 mg of corn oil.OutcomesPrimary: Depression (Hamilton Rating Scale For Depression)Secondary: Quality of Life (Short Form (SF)-36)Angina frequency (Seattle Angina Questionnaire)Degree of change in vasodilator function assessed by flow mediated dilatation (FMD) in the brachial arteryChanges in cerebral blood flow measured by transcranial Doppler ultrasoundStarting dateParticipants were recruited in 2009-2013. Trial was registered 1/12/2008Contact informationAlison Coates, School of Health Sciences, Alliance for Research in Exercise, Nutrition and Activity, Sansom Institute for Health Research, University of South Australia, PO Box 2471, Adelaide, South Australia. Alison.coates@unisa.edu.auNotesACTRN12608000598381The authors confirm that the main outcomes are still being analysed.Chiang Chiu 2010 ?Study nameThe Assessment for the Effects of Health Products on Depression and Cognitive Function: Fish Oil in Patients With Late-life DepressionMethodsRCT, parallel groups, double-blindParticipantsOlder people with major depressionInterventionsIntervention: three capsules of n-3 fatty acids. Each capsule included 600mg eicosapentanoic acid (20:5n-3), 400 mg of docosahexanoic acid (22:6n-3), tertiary-butylhydroquinone 0.2 mg/g and tocopherols 2 mg/g.Placebo: three identical capsules per day. All capsules included olive oil.OutcomesRecurrence of depressionChange of cognitive functionStarting dateStudy start date: May 2007Study Completion Date: September 2010Contact informationChih-Chiang Chiu, Department of Psychiatry, Taipei City Psychiatric Center, Taipei City Hospital, No. 309, Sungde Road, Taipei 110, Taiwan.Email: chiu@NotesNCT01235533DO Health ?Study nameVitamin D3- Omega3- Home Exercise- Healthy Ageing and Lengevity Trial (DO-HEALTH)MethodsRCTParticipantsCommunity dwelling adults 70 years and older, 50% of seniors enrolled based on a fall in the year before enrollmentInterventionsEach for 3 years:Arm 1: omega 3 (1g/d, ratio EPA:DHA = 1:2) and vitamin D3 (2000 IU/d) capsules and strength home exercise (3x30 mins/week)Arm 2: omega 3 (1g/d, ratio EPA:DHA = 1:2) and vitamin D3 (2000 IU/d) capsules and flexibility home exercise (3x30 mins/week)Arm 3: omega 3 (1g/d, ratio EPA:DHA = 1:2) and placebo capsules and strength home exercise (3x30 mins/week)Arm 4: omega 3 (1g/d, ratio EPA:DHA = 1:2) and placebo capsules and flexibility home exercise (3x30 mins/week)Arm 5: placebo and vitamin D3 (2000 IU/d) capsules and strength home exercise (3x30 mins/week)Arm 6: placebo and vitamin D3 (2000 IU/d) capsules and flexibility home exercise (3x30 mins/week)Arm 7: placebo and placebo capsules and strength home exercise (3x30 mins/week)Arm 8: placebo and placebo capsules and flexibility home exercise (3x30 mins/week)OutcomesPrimary: non-vertebral fractures, functional decline, blood pressure, cognitive decline, rate of any infectionSecondary: other fractures, falls, pain in knee osteoarthritis, musculoskeletal changes, gastro-intestinal symptoms, mental and oral health, quality of life, life-expectancy, cardiovascular events, cancer, glucose measures, cost-benefit. All endpoints supported by a DO-HEALTH biomarker studyStarting dateRegistered on Trials Registry: 6 Dec 2012Study start date: Dec 2012Study completion date est: Nov 2017Contact informationHeike Bischoff-Ferrari (PI), Centre on Aging and Mobility, University of ZurichNotesNCT01745263EudraCT: 2012-001249-41do-health.euInTrePad ?Study nameIntervention of Testosterone & Fish Oil for the Prevention of Alzheimer's Disease: InTrePadMethodsRCTParticipantsPiB-PET (Pittsburgh compound B) positive men aged 60 years and over with Subjective Memory ComplaintsInterventionsEach for 56 weeks:Arm 1: DHA capsules (1720mg/d) and testosterone undecanoate (intramuscular injection 1000mg/4ml every 8 weeks)Arm 2: placebo DHA and testosterone undecanoate (intramuscular injection 1000mg/4ml every 8 weeks)Arm 3: placebo DHA and placebo testosteroneOutcomesPrimary: PiB scoreSecondary: neuropsychological, mood and daily functioning questionnaires, beta amyloid levels, fluorodeoxyglucose to assess brain glucose metabolism, inflammatory and oxidative biomarkers, hippocampal volume, quality of life, safety and tolerability of treatmentStarting dateRegistered on Trials Registry: 14 Jan 2013Study start date: 28 Feb 2013Study completion date est: unclearContact informationRalph Martins (PI), Sir James McCusker Alzheimer's Disease Research Unit, Hollywood Medical Centre, Nedlands, Australia, r.martins@ecu.edu.auNotesACTRN12613000034730Ralph Martins written to in 2016- no responseIrish Omega-3 NCT02848469 ?Study nameIrish Omega-3 StudyMethodsRCT, 2 arms (LCn3 vs placebo), 6 monthsParticipantsParticipants at ultra high risk of psychosis (aged 13 to 45 years)InterventionsInt: 200ml juice drink including 1g EPA and 1g DHACont: 200ml juice drink without omega 3 (no fish taste in either)OutcomesPrimary: transition to psychosisSecondary: fatty acid changesStarting dateRegistered on Trials Registry: 25 July 2016Study start date: Sept 2013Estimated study completion date: February 2018Contact informationM Rooney (PI), University College CorkNotesNCT02848469n-3 for Vascular Cognitive Aging-NCT01953705 ? ADDIN EN.CITE <EndNote><Cite><Author>Bowman</Author><Year>2019</Year><RecNum>22147</RecNum><DisplayText>(53)</DisplayText><record><rec-number>22147</rec-number><foreign-keys><key app="EN" db-id="52z90aw5jrvss5e5e0evfss4aatttfd5fs0t" timestamp="1564739742">22147</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Bowman, L. Gene</author><author>Silbert, C. Lisa</author><author>Dodge, H. Hiroko</author><author>Lahna, David</author><author>Hagen, Kirsten</author><author>Murchison, F. Charles</author><author>Howieson, Diane</author><author>Kaye, Jeffrey</author><author>Quinn, F. Joseph</author><author>Shinto, Lynne</author></authors></contributors><titles><title>Randomized Trial of Marine n-3 Polyunsaturated Fatty Acids for the Prevention of Cerebral Small Vessel Disease and Inflammation in Aging (PUFA Trial): Rationale, Design and Baseline Results</title><secondary-title>Nutrients</secondary-title></titles><periodical><full-title>Nutrients</full-title></periodical><volume>11</volume><number>4</number><keywords><keyword>white matter hyperintensities</keyword><keyword>cognitive decline</keyword><keyword>vascular cognitive impairment</keyword><keyword>executive function</keyword><keyword>eicosapentaenoic acid</keyword><keyword>docosahexaenoic acid</keyword><keyword>neuroimaging</keyword><keyword>MRI</keyword><keyword>elderly</keyword></keywords><dates><year>2019</year></dates><isbn>2072-6643</isbn><urls></urls><electronic-resource-num>DOI: 10.3390/nu11040735</electronic-resource-num></record></Cite></EndNote>(53)Study namen-3 PUFA for Vascular Cognitive AgingMethodsRCTParticipantsOlder adults (80 years and older) at high risk for cognitive decline and dementia of Alzheimer's typeInterventionsEach for 3 years:Arm 1: omega 3 fish oil (1.65g/d EPA+DHA)Arm 2: soybean oil placebo (1.65g/d)OutcomesPrimary: total cerebral white matter volumeSecondary: biomarkers of endothelial health, total brain atrophy, medial temporal lobe atrophy, ventricular expansion, trail making test part B, digit symbol WAIS-R, cerebral blood flow, fractional anisotropy within frontal gyriStarting dateRegistered on Trials Registry: 24 Sept 2013Study start date: May 2014Study completion date est: March 2019Contact informationAlena Borgatti, borgatti@ohsu.edu; James Dursch, dursch@ohsu.edu; Gene Bowman and Lynne Shinto (PIs), Oregon Health and Science UniversityNotesNCT01953705NAYAB Qurashi 2017 ADDIN EN.CITE <EndNote><Cite><Author>Qurashi</Author><Year>2017</Year><RecNum>22158</RecNum><DisplayText>(54)</DisplayText><record><rec-number>22158</rec-number><foreign-keys><key app="EN" db-id="52z90aw5jrvss5e5e0evfss4aatttfd5fs0t" timestamp="1565004134">22158</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Qurashi, Inti</author><author>Chaudhry, Imran B.</author><author>Khoso, Ameer B.</author><author>Farooque, Sana</author><author>Lane, Steve</author><author>Husain, Mohammad Omair</author><author>Chu, Simon</author><author>Sarginson, Jane</author><author>Hamarani, Munir</author><author>Naqvi, Haider A.</author><author>Razzaque, Bushra</author><author>Minhas, Fareed A.</author><author>Yung, Alison R.</author><author>Deakin, J. F. W.</author><author>Husain, Nusrat</author></authors></contributors><titles><title>A randomised, double-blind, placebo-controlled trial of minocycline and/or omega-3 fatty acids added to treatment as usual for at-risk mental states (NAYAB): study protocol</title><secondary-title>Trials</secondary-title></titles><periodical><full-title>Trials</full-title></periodical><pages>524</pages><volume>18</volume><number>1</number><dates><year>2017</year><pub-dates><date>2017/11/09</date></pub-dates></dates><isbn>1745-6215</isbn><urls><related-urls><url>: 10.1186/s13063-017-2275-y</electronic-resource-num></record></Cite></EndNote>(54)?Study nameMinocycline and/or omega-3 fatty acids added to treatment as usual for at-risk mental states (NAYAB)MethodsRCT (2x2)ParticipantsPeople aged 16 to 35 years with at-risk mental state (ARM)InterventionsEach for 6 months:Intervention: 1.2 g/day concentrated marine fish oil (2 capsules/d together providing 720 mg/d EPA & 480 mg/d DHA)Control: matched soft gel capsules, content unclearBoth plus or minus minocycline tablet (2x2)OutcomesPrimary: transition to psychotic disorderSecondary: severity of depression symptoms (Montgomery-?sberg Depression Rating Scale, MADRS), ARMS symptoms, social and occupational function, cognitive scores, medication, adverse effectsStarting dateRegistered on Trials Registry: October 2015Study start date: October 2015Study completion date est: December 2018Contact informationInti Qurashi, Manchester University, Inti.Qurashi@merseycare.nhs.ukNotesNCT02569307Phosphatidylserine for Mild Cognitive Impairment?Study nameInvestigating a phosphatidylserine based dietary approach for the management of mild cognitive impairmentMethodsRCTParticipantsPeople with mild cognitive impairment (MCI) aged 65 to 85 yearsInterventionsEach for 24 months:Arm 1: phosphatidylserine omega 3 (DHA enriched)Arm 2: placebo cellulose capsulesOutcomesPrimary: selective reminding test (SRT)Secondary: mini mental state examination (MMSE), neurological battery test (NBT), dementia (DSM-4 criteria), mini sleep questionnaire (MSQ), Hamilton Anxiety rating scale (HAM-A), safety and adverse eventsStarting dateRegistered on Trials Registry: 6 Aug 2014Study start date: Sept 2014Study completion date est: Sept 2019Contact informationNadia Niemerzyanski, nadiaN@; Yael Richter, yaelr@NotesNCT02211560Terminated due to difficulties in participant recruitment – not known whether results exist for those participatingStoll 2001 ?Study nameOmega 3 fatty acids in bipolar disorder prophylaxisMethodsRCTParticipantsPeople aged 18 to 65 with bipolar disorderInterventionsEach for 12 months:Arm 1: omega 3Arm 2: placeboOutcomesProphylactic efficacyStarting dateTrial Registration entry: 2 Feb 2001Trial start date: July 2000Estimated study completion: July 2004Contact informationAndrew Stoll, Mclean HospitalNotesNCT00010868The PI, Andrew Stoll, appears to have been struck off the medical register in Massachusetts in 2011 (Commonwealth of Massachusetts Board of Registration in Medicine, Adjudicatory Case number 2011-026) so it has not been possible to contact him and no publication of results has been foundVITAL-DEP 2018 ADDIN EN.CITE <EndNote><Cite><Author>Okereke</Author><Year>2018</Year><RecNum>22159</RecNum><DisplayText>(55)</DisplayText><record><rec-number>22159</rec-number><foreign-keys><key app="EN" db-id="52z90aw5jrvss5e5e0evfss4aatttfd5fs0t" timestamp="1565006636">22159</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Okereke, Olivia I.</author><author>Reynolds, Charles F., III</author><author>Mischoulon, David</author><author>Chang, Grace</author><author>Cook, Nancy R.</author><author>Copeland, Trisha</author><author>Friedenberg, Georgina</author><author>Buring, Julie E.</author><author>Manson, JoAnn E.</author></authors></contributors><titles><title>The VITamin D and OmegA-3 TriaL-Depression Endpoint Prevention (VITAL-DEP): Rationale and design of a large-scale ancillary study evaluating vitamin D and marine omega-3 fatty acid supplements for prevention of late-life depression</title><secondary-title>Contemporary Clinical Trials</secondary-title></titles><periodical><full-title>Contemporary Clinical Trials</full-title><abbr-1>Contemp Clin Trials</abbr-1></periodical><pages>133-145</pages><volume>68</volume><dates><year>2018</year></dates><publisher>Elsevier</publisher><isbn>1551-7144</isbn><urls><related-urls><url>: 10.1016/t.2018.02.017</electronic-resource-num><access-date>2019/08/05</access-date></record></Cite></EndNote>(55) ?Study nameThe VITamin D and OmegA-3 TriaL - Depression Endpoint Prevention (VITAL-DEP)MethodsRCTParticipantsMulti-ethnic population of apparently healthy adults (men 50 years plus, women 55 years plus) without cancer, cardiovascular disease or depression at baselineInterventionsEach for mean 5 years:Arm 1: omega 3 (Omacor fish oil, EPA+DHA 1g/d: 465mg EPA; 375mg DHA) and placeboArm 2: placebo and vitamin D3 (1/d, 2000IU)Arm 3: omega 3 (Omacor fish oil, EPA+DHA 1g/d: 465mg EPA; 375mg DHA) and vitamin D3 (1/d, 2000IU)Arm 4: placebo and placeboOutcomesPatient Health Questionnaire 8 (PHQ8), other self-reported depression measures and health service use measures related to depression (plus additional measures in participants at high risk of depression)Starting dateTrial Registration entry: 1 Oct 2012Trial start date: July 2010Estimated study completion: May 2020Contact informationOlivia I. Okereke, MD, SM, Principal Investigator, Brigham and Women's Hospital, Brigham and Women's HospitalNotesNCT01696435Supplementary Figure 1. Study flow diagram. Supplementary Figure 2. Meta-analysis of effects of higher LCn3 vs lower LCn3 on risk of depression symptoms, sub-grouped by LCn3 dose. Supplementary Figure 3. Meta-analysis of effects of higher LCn3 vs lower LCn3 on risk of depression symptoms, sub-grouped by EPA dose. Supplementary Figure 4. Meta-analysis of effects of higher LCn3 vs lower LCn3 on risk of depression symptoms, sub-grouped by DHA dose. Supplementary Figure 5. Funnel plot of the analysis of effects of higher LCn3 vs lower LCn3 on risk of depression.Supplementary Figure 6. Meta-analysis of effects of higher LCn3 vs lower LCn3 on depression symptoms, analysed using SMD, sub-grouped by LCn3 dose. Supplementary Figure 7. Meta-analysis of effects of higher LCn3 vs lower LCn3 on depression symptoms, analysed using SMD, sub-grouped by EPA dose. Supplementary Figure 8. Meta-analysis of effects of higher LCn3 vs lower LCn3 on depression symptoms, analysed using SMD, sub-grouped by DHA dose. Supplementary Figure 9. Funnel plot of the analysis of effects of higher LCn3 vs lower LCn3 on depression symptoms, using SMD, sub-grouped by depression rating scale. Supplementary Figure 10. Forest plot of trials randomising to higher vs lower LCn3 intake and assessing depression symptoms (on a continuous scale) in those without depression at baseline, subgrouping by scale and displayed in native scales. For meta-analysis data were combined using SMD (not shown, SMD 0.01, 95% CI -0.06 to 0.07, I2 46%). Acknowledgements: This review is one of a set of reviews conducted by the PUFAH group. The Polyunsaturated Fats and Health (PUFAH) group includes Asmaa Abdelhamid1, Sarah Ajabnoor1, Faye Alabdulghafoor1, Lena Alkhudairy2, Priti Biswas3, Julii Brainard1, Charlene Bridges4, Tracey J Brown1, Katherine Deane3, Daisy Donaldson1, Sarah Hanson3, Lee Hooper1, Oluseyi Florence Jimoh1, Nicole Martin4, Alex O’Brien1, Karen Rees, Lena Alkhudairy2, Fujian Song1, Gabrielle Thorpe3, Xia Wang1 and Lauren Winstanley1. 1Norwich Medical School, University of East Anglia2Warwick Medical School, University of Warwick3 School of Health Sciences, University of East Anglia4Cochrane Heart Group, University College LondonSupplementary References ADDIN EN.REFLIST 1.Hooper L, Abdelhamid A, Brainard J, Deane KHO, Song F. Creation of a database to assess effects of omega-3, omega-6 and total polyunsaturated fats on health: database and methodology for a set of reviews. BMJ Open. 2019; 9(5): e029554. 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