1 s2.0 S0002916523055235 Main

Download as pdf or txt
Download as pdf or txt
You are on page 1of 10

See corresponding editorial on page 909.

DHA supplementation improved both memory and reaction time in


healthy young adults: a randomized controlled trial1–3
Welma Stonehouse, Cathryn A Conlon, John Podd, Stephen R Hill, Anne M Minihane, Crystal Haskell, and David Kennedy

ABSTRACT havior, including changes in learning, memory, auditory, and ol-


Background: Docosahexaenoic acid (DHA) is important for brain factory responses (3). Despite DHA’s critical role in brain
function, and its status is dependent on dietary intakes. Therefore, function, the capacity to synthesize DHA de novo is limited in
individuals who consume diets low in omega-3 (n23) polyunsatu- mammals, and its consumption through the diet ensures an ade-
rated fatty acids may cognitively benefit from DHA supplementa- quate supply for neuronal function (1). A large proportion of the
tion. Sex and apolipoprotein E genotype (APOE) affect cognition New Zealand population [w30% (6)] do not, or rarely, consume
and may modulate the response to DHA supplementation. seafood (ie, the major dietary source of DHA), which could po-
Objectives: We investigated whether a DHA supplement improves tentially affect cognitive function. Research on the efficacy of
cognitive performance in healthy young adults and whether sex and DHA, in terms of its effects on cognitive function in humans, by
APOE modulate the response. using randomized controlled trials (RCTs) has focused on either
Design: Healthy adults (n = 176; age range: 18–45 y; nonsmoking end of the life cycle and shown improvements in children with
and with a low intake of DHA) completed a 6-mo randomized, learning disorders (7, 8) and inconsistent effects in older adults
placebo-controlled, double-blind intervention in which they con- during age-related cognitive decline (9–11). There is a lack of
sumed 1.16 g DHA/d or a placebo. Cognitive performance was robust evidence to assess the effect of DHA supplementation on
assessed by using a computerized cognitive test battery. For all tests, cognitive performance in younger healthy adults; to our knowl-
z scores were calculated and clustered into cognitive domains as edge, only 5 trials have been conducted, each with considerable
follows: episodic and working memory, attention, reaction time design limitations, including small sample sizes (12–14), short
(RT) of episodic and working memory, and attention and processing durations (12–16), and a lack of placebo control (13).
speed. ANCOVA was conducted with sex and APOE as independent
Although the physiologic basis is poorly understood, signifi-
variables.
cant sex differences with regard to cognitive performance have
Results: RTs of episodic and working memory improved with DHA
been shown (17, 18). Event-related potential and fMRI studies
compared with placebo [mean difference (95% CI): 20.18 SD
have shown sex differences in the pattern of brain activation (19,
(20.33, 20.03 SD) (P = 0.02) and 20.36 SD (20.58, 20.14 SD)
20). Therefore, it is likely that the response in cognitive per-
(P = 0.002), respectively]. Sex 3 treatment interactions occurred
formance to DHA supplementation may be modulated by sex.
for episodic memory (P = 0.006) and the RT of working memory
(P = 0.03). Compared with the placebo, DHA improved episodic
However, to our knowledge, none of the RCTs that investigated
memory in women [0.28 SD (0.08, 0.48 SD); P = 0.006] and RTs of the effect of DHA supplementation on cognitive function has
working memory in men [20.60 SD (20.95, 20.25 SD); P = examined sex interactions.
0.001]. APOE did not affect cognitive function, but there were some 1
From the Institute of Food, Nutrition and Human Health, Massey Uni-
indications of APOE 3 sex 3 treatment interactions.
versity, Auckland, New Zealand (WS and CAC); the School of Psychology,
Conclusions: DHA supplementation improved memory and the RT Massey University, Palmerston North, New Zealand (JP and SRH); the De-
of memory in healthy, young adults whose habitual diets were low in partment of Nutrition, Norwich Medical School, University of East Anglia,
DHA. The response was modulated by sex. This trial was registered Norwich, United Kingdom (AMM); and the Brain, Performance and Nutri-
at the New Zealand Clinical Trials Registry (http://www.anzctr.org. tion Research Centre, Department of Psychology, Northumbria University,
au/default.aspx) as ACTRN12610000212055. Am J Clin Nutr Newcastle, United Kingdom (CH and DK).
2
2013;97:1134–43. Supported by grants from the Massey University Research Fund, Neuro-
logical Foundation of New Zealand, and Oakley Mental Health Research
Fund. The DHA and placebo supplements were supplied by Efamol Ltd
INTRODUCTION (Surrey, United Kingdom) and Health & Herbs International Ltd (Albany,
The long-chain (LC)4 omega (n23) PUFA DHA is the domi- New Zealand).
3
nant n23 PUFA in the brain. DHA performs structural functions Address correspondence to W Stonehouse, Institute of Food, Nutrition
and Human Health, Massey University, Private Bag 102 904, North Shore
and influences numerous neuronal and glial cell processes (1–3).
City, 0745, Auckland, New Zealand. E-mail: [email protected].
DHA has been shown to accumulate in areas of the brain involved 4
Abbreviations used: AA, arachidonic acid; CRT, choice reaction time;
in memory and attention such as the cerebral cortex and hippo- LC, long chain; RCT, randomized controlled trial; RT, reaction time.
campus (4, 5), and animal studies have shown that deficiency in Received October 12, 2012. Accepted for publication January 16, 2013.
brain DHA has critical effects on neuronal development and be- First published online March 20, 2013; doi: 10.3945/ajcn.112.053371.

1134 Am J Clin Nutr 2013;97:1134–43. Printed in USA. Ó 2013 American Society for Nutrition
OMEGA-3 DHA AND COGNITIVE PERFORMANCE 1135
Apolipoprotein E genotype (APOE) is a major genetic risk sules/d. DHA capsules provided 1.16 g DHA/d and 0.17 g EPA/d,
factor for Alzheimer’s disease with carriers of the APOE4 allelic and placebo capsules contained high–oleic acid sunflower oil.
variant (w25% of whites) at several-fold increased risk (21, 22). Fatty acid profiles of treatments are summarized in Table 1. The
Although the evidence is controversial, it is likely that the dosage of DHA was chosen to be physiologically relevant and
APOE4 allele also affects cognitive performance in cognitively achievable through diet (equivalent to w2–3 portions oily fish/wk),
healthy adults (23). Some studies showed poorer performance and the duration of 6 mo was chosen to ensure saturation of the
on cognitive tasks in healthy adult APOE4 carriers (23), whereas tissues with DHA. Erythrocyte DHA levels which have been
other studies showed no difference (24) or even better perfor- shown to correlate with brain tissue levels (36), reach a plateau
mance (25, 26) compared with APOE4 noncarriers. Structural after 6 mo (37). Placebo and treatment capsules were identical in
and functional neurologic changes are seen in APOE4 carriers size and shape. Capsules were provided in identical opaque drug
decades before the appearance of any cognitive or clinical containers that were coded and distributed by staff from Health
symptoms (27–30). Prospective and some intervention studies & Herbs International Ltd according to the randomization
have shown APOE-modulating effects on the relation between scheme. Both research staff and participants were blind as to
LC n23 PUFAs and cognitive function, although the results which participants received DHA or placebo treatments until after
have been controversial (10, 31–34). data analysis. Participants were requested to consume capsules
The primary aim of the study was to investigate whether a high- with a meal and to store capsules in the fridge.
DHA supplement for 6 mo would improve memory (episodic and General demographic information, including ethnicity, level of
working memory), attention, reaction times (RTs) of memory and education, and first language, was obtained by using a structured
attention, and processing speed in young, healthy adults (age questionnaire. Cognitive assessments, fasting blood samples, and
range: 18–45 y) whose habitual diets were low in DHA. A sec- anthropometric measurements were obtained at baseline and after
ondary aim was to investigate whether sex and APOE would 6 mo. Participants were requested not to consume any fatty fish or
modulate the response to the intervention. fish-oil supplements (other than those provided) and to maintain
their normal daily routine (eating pattern, physical activity, and
SUBJECTS AND METHODS
alcohol consumption) for the duration of the study. Participants
kept weekly diaries to record the consumption of DHA or placebo
This dietary intervention (http://www.anzctr.org.au; capsules, seafood (type and amount), and any deviations from the
ACTRN12610000212055) was conducted at Massey Uni- study protocol (eg, illness and use of medication or other nutri-
versity’s Albany campus (New Zealand) between March and tional supplements). The average weekly consumption of seafood
December 2010 according to the guidelines of the Declaration of portions was calculated from diaries and categorized into fatty,
Helsinki. Ethical approval for the trial was obtained from the medium-fat, and low-fat sources (as previously described). Treat-
Massey University Human Ethics Committee (Southern A; ref- ment compliance was determined by using a combination of weekly
erence 10/07), and written informed consent was obtained from diary records, pill-counting of leftover capsules, and analysis of
all participants. erythrocyte LC n23 PUFA levels which is a valid biomarker for
the intake of LC n23 PUFA (37).
Participants At the end of the study, each participant completed a computer-
A total of 228 adults (83 men and 145 women), aged 18–45 y, based tolerance questionnaire adapted from Freeman and Sinha (38).
were recruited in Auckland, New Zealand. Inclusion criteria for
participants were no known major medical condition or disease Blood sample collection and assays
and not taking medication for any condition or disease, non-
EDTA blood was collected. The EDTA buffy coat (white
smoking, low habitual intake of LC n23 PUFAs (less than w200
blood cell–rich layer) was used for the extraction of DNA for
mg EPA + DHA/wk), no consumption of fish-oil supplements
APOE analysis. Erythrocytes were washed 3 times with saline
over the past 6 mo, no allergies to seafood, and not pregnant or
(0.9% NaCl) for fatty acid analysis. Analysis of APOE were
lactating. LC n23 PUFA intake was estimated by asking potential
carried out by Canterbury Health Laboratories, which is fully
participants to record the frequency of habitual consumption of
seafood. Seafood was categorized into fatty (greater than w1 g
n23/100 g), medium-fat (w0.5–1 g n23/100g), and low-fat (less TABLE 1
Fatty acid composition (g/2.25-g daily dosage) of DHA and placebo
than w0.5 g n23/100 g) sources (35), and frequency options
capsules1
included never, 1, 2, or 3 times/mo, and 1, 2, or .23/wk.
Fatty acids DHA capsules Placebo capsules
Study design Palmitic acid (16:0) 0.02 0.09
Stearic acid (18:0) 0.07 0.06
A randomized, placebo-controlled, double-blind study design
Oleic acid (18:1n29) 0.13 1.61
was used. Volunteers who met eligibility criteria were randomly Linoleic acid (18:2n26) 0.02 0.12
assigned to one of 2 groups (ie, the DHA or placebo groups) for Arachidonic acid (20:4n26) 0.05 ,0.01
a period of 6 mo. The random allocation was done by stratified EPA (20:5n23) 0.17 0.02
random assignment on the basis of sex and age. The randomi- DPA2 (22:5n23) 0.06 ,0.01
zation scheme was generated by using the website Randomi- DHA (22:6n23) 1.16 0.02
zation.com (http://www.randomization.com). DHA and placebo 1
Only fatty acids that were detected at $1% of total fatty acids for
capsules were supplied by Efamol Ltd and Health & Herbs In- either active or placebo capsules are shown.
2
ternational Ltd. Treatment was provided as three 750-mg cap- DPA, docosapentaenoic acid.
1136 STONEHOUSE ET AL

accredited with International Accreditation New Zealand to cognitive domains and tasks were assessed: episodic memory
International Organization for Standardization 15189, by using (immediate and delayed word recall, delayed word recognition,
polymerase chain reaction as described by Hixson and Vernier and delayed picture recognition), working memory (n-back,
(39). Erythrocyte fatty acids were analyzed by using a Shimadzu Corsi blocks, and a letter-number sequencing task), attention
gas chromatograph 2010 ported to a gas chromatograph mass [Stroop test, choice reaction time (CRT), and digit vigilance]; and
spectrometer-QT2010 (Shimadzu Corp) as previously described processing speed (finding As task).
(40). Briefly, a 200-mL solution of 83 mmol/L heptadecanoic The accuracy (percentage of correct responses made) for all
acid 17:0 (S . 98%) as an internal standard that contained tests and RTs (in ms) (only for n-back, word and picture rec-
butylated hydroxytoluene (150 mmol/L) dissolved in methanol ognition, Stroop, CRT, and digit vigilance) were assessed. See
was added to 50 mL erythrocytes followed by 1 mL methanolic online supplementary material under “Supplemental data” in the
HCL (3N). Samples were vortexed and incubated for 4 h at online issue for detailed descriptions of tasks.
908C. After cooling to room temperature, fatty acid methyl es- The cognitive testing was conducted under rigorously con-
ters were extracted by adding 2 mL hexane followed by thor- trolled conditions (see online supplementary material under
ough mixing. The hexane phase that contained fatty acid methyl “Supplemental data” in the online issue). In brief, assessments at
esters was recovered after centrifugation, dried under nitrogen, baseline and end were performed at a similar time of day (be-
resuspended with 100 mL hexane, and transferred to a gas tween 0700 and 1000). On the day before tests, participants were
chromatography vial of which 1 mL was injected onto the gas instructed not to consume alcohol, take recreational drugs, or
chromatography–mass spectrometer via split injection (split undertake any unusual sporting activities, to have a good night’s
ratio of 1:10). The capillary column used was an Rtx-2330 sleep, and not be overly stressed. These aspects were confirmed
(30 m 3 0.25 mm; Restek). Mass spectrometer conditions were before participants were allowed to commence assessments.
as follows: ion source temperature, 2358C; interface tempera- Participants arrived at the research unit fasted from food or
ture, 2508C; and ionization voltage, 70 eV. The injector tem- stimulants (caffeine and alcohol), except for water, for $10 h. A
perature was 2508C. Helium gas was used as the carrier gas at standard breakfast was provided before the commencement of
a flow rate of 0.77 mL/min. An initial oven temperature of 708C cognitive tests. Environmental factors such as noise and tem-
was maintained for 3.0 min, allowed to increase to 1558C at perature were controlled to avoid any distraction during tests.
a rate of 258C/min, held for 6.0 min, increased to 1758C at a rate All assessments were carried out on 5 standardized computers,
of 38C/min, held for 3.0 min, increased to 2058C at a rate of 38C/ with the same computer used by individual participants at
min, and finally increased to 2208C at a rate of 88C/min and held baseline and end assessments. Participants were instructed on
for 2.0 min. The total time for each run was 36 min. The total the procedure for the administration of the cognitive battery and
spectrum of erythrocyte fatty acids in the samples were identi- undertook a training session before administration of the full
fied and quantified and are expressed as the weight percentage of battery of tests at baseline and end assessments.
total fatty acids. CVs for EPA and DHA assays were 2.7% and
3.6%, respectively. The CV for the DHA assay was 4%.
Statistical analysis
The sample-size calculation was based on a difference in
Analysis of supplements z score of 0.5 for memory domains and proved a statistical
Oxidation levels of supplements during the 6-mo duration of the power equal to 0.8 and an a level of 0.05 (2 tailed) (G*Power
study were analyzed by measuring the peroxide and anisidine 3.1.2) (47). The minimum sample size required was 32 partic-
values by using the American Oil Chemists’ Society Official ipants per treatment and sex group. To test for sex 3 treatment
Method Cd8-53 with modifications and the American Oil and APOE 3 treatment interactions, a total sample size of 179
Chemists’ Society Official Method Cd18-90, respectively (41). provided 80% power to detect a medium effect size f of 0.25
Oxidation levels were below maximum permitted levels. The fatty (equivalent to a treatment effect of 0.5 SD) at an a level of 0.05
acid content of the capsules were analyzed by using a Shimadzu (G*Power 3.1.2) (47).
GC-17A gas chromatograph equipped with a flame-ionization Descriptive and comparison statistics (independent t test,
detector as previously described (42). 2 tailed) of baseline characteristics were based on all participants
randomly assigned to treatment groups. Baseline characteristics
of dropouts and participants who completed the study were
Cognitive assessment compared, and dropouts did not differ from study completers.
Cognitive function was assessed with the Computerized The primary analysis was carried out on all participants for
Mental Performance Assessment System (Northumbria Univer- whom baseline and end data were available irrespective of the
sity), which has previously been shown to be sensitive to nutri- level of compliance or protocol violations. The analysis was
tional interventions (43, 44). The following 2 additional tasks were carried out on 7 cognitive domains, including sex (men compared
included; the finding As task from the Kit of Factor-Referenced with. women) and APOE (APOE4 carriers compared with
Cognitive Tests (45) and the letter-number sequencing task, which noncarriers) as independent variables (28 tests). Changes to
is a subtest of the Wechsler Adult Intelligence Scale III In- cognitive domains during the treatment period between DHA
telligence test (46). Cognitive tasks used were all standard tasks of and placebo groups were assessed by using ANCOVA models to
cognitive function that have previously been shown to increase adjust for baseline cognitive-function test scores and other co-
activation of the frontal cortex (15), which is the area of the brain variates as follows: education, first language (English compared
associated with the accumulation of DHA, memory, and attention with other), age, and baseline DHA concentrations. Sex and
(4, 5). The battery of tests took w1 h to administer. The following APOE were added to the model as independent variables to test
OMEGA-3 DHA AND COGNITIVE PERFORMANCE 1137
for sex 3 treatment, APOE 3 treatment, and APOE 3 sex 3 RT of attention ¼ðzRT Stroop test
treatment interactions. þ zRT choice RT þ zRT digit vigilance ÞO3 ð6Þ
For all cognitive outcomes, z scores were calculated by
pooling baseline and 6-mo data as previously described (9).
z scores were clustered into cognitive domains as follows:
Processing speed ¼ zfinding As ð7Þ
Memory ¼ðzimmediate word recall þ zdelayed word recall
þ zdelayed word recognition þ zdelayed picture recognition ÞO4 ð1Þ
Statistical analyses were performed with IBM SPSS statistics
software (version 20; IBM Corp).
Working memory ¼ðznback þ zCorsi blocks
þ zletternumber sequencing task ÞO3 ð2Þ RESULTS
The flow of participants through the study is summarized in
Figure 1. Of 228 participants who were randomly assigned to
treatments, 52 subjects were lost to follow-up or discontinued the
Attention ¼ ðzStroop test þ zCRT þ zdigit vigilance ÞO3 ð3Þ intervention for various reasons (n = 30 in the DHA group; n = 22
in the placebo group) (Figure 1). The final analysis was conducted
in 176 participants [n = 85 in the DHA group (33 men and 52
women); n = 91 in the placebo group (33 men and 58 women)]
for whom baseline and end data were available irrespective of the
RT of memory ¼ðzRT delayedword recognition
level of compliance or protocol violations.
þ zRT delayedpicture recognition ÞO2 ð4Þ Baseline characteristics of subjects are summarized in Table
2. Participants were mostly European, had English as their first
language, and were highly educated (most having tertiary
qualifications). DHA and placebo groups did not differ with
RT of working memory ¼ zRT nback ð5Þ regard to baseline characteristics (Table 2) or cognitive tests

FIGURE 1. Participant flow through the study.


1138 STONEHOUSE ET AL
TABLE 2 following cognitive tasks: delayed picture recognition [mean
Baseline characteristics by randomly assigned treatment groups difference (95% CI): 1.23% (0.04%, 2.42%); P = 0.04], delayed
DHA Placebo word recognition [2.56% (0.01%, 5.11%); P = 0.049], finding
Variables (n = 115) (n = 113) P1 As task [6.58 (3.23, 9.94); P , 0.001], and delayed word recall
[3.97% (0.33%, 7.61%); P = 0.03] (data not shown). No sig-
M/F (n) 43/72 40/73 0.75
Age (y) 33.4 6 7.762 33.2 6 7.90 0.82
nificant differences were seen between men and women for any
Ethnicity (%) NA3 other cognitive tasks (data not shown).
European 78.2 80.9 Dropouts did not differ from the participants who completed
Maori/Pacific 5.5 0 the study for any baseline characteristics (data not shown) except
Asian 14.5 13.6 for age. Dropouts were 2.76 y (95% CI: 0.35, 5.18 y) younger
Other 1.8 5.5 than participants were who completed the study (mean 6 SD:
English as first 86 81 0.27 31.2 6 7.97 compared with 33.9 6 7.7 y, respectively; P =
language (%)
0.03).
Education (%) NA3
No qualifications 0 1
The median (25, 75 percentile) consumption of seafood over the
Secondary school 30 26 duration of the trial was 1.08 portions/wk (0.43, 2.15 portions/wk),
Tertiary 70 74 of which only 0.01 portions/wk (0, 0.07 portions/wk) were from
BMI (kg/m2) 25.7 6 4.89 24.9 6 4.63 0.21 fatty seafood sources. Treatment groups did not differ with regard
APOE4 carriers (n = 176) 29 (34) 25 (28) 0.41 to seafood intake (P = 0.44).
[n (%)]4 Compliance rates were 87.0 6 14.3% compared with 88.8 6
1
Values were derived by using an independent t or chi-square test 13.3% in DHA and placebo groups, respectively, and did not
(2 tailed). differ significantly. A significant increase in erythrocyte DHA
2
Mean 6 SD (all such values). levels compared with the placebo of 2.7% (95% CI: 2.37%,
3
NA, chi-square test was not appropriate; .20% cells have expected 3.03%) of total fatty acids confirmed compliance to the DHA
counts ,5. treatment (Table 3). Erythrocyte EPA and the n23 index in-
4
APOE analyses were available only for participants who completed
creased, whereas docosapentaenoic acid, arachidonic acid (AA),
the 6-mo intervention.
AA:EPA ratio, and AA:DHA ratio decreased significantly with
DHA compared with placebo treatment (P , 0.001). Neither
scores (see Table 1 under “Supplemental data” in the online men compared with women nor APOE4 carriers compared with
issue). A significant sex 3 treatment interaction was seen for the noncarriers differed with regard to baseline erythrocyte fatty
first language. The DHA group contained a greater proportion of acid levels or changes in erythrocyte fatty acid levels in response
men whose first language was English than did the placebo to treatments (data not shown).
group (88% compared with 68%, respectively; P = 0.02). Effects of treatment on the cognitive-function domains are
However, all participants had a good knowledge of English. Of summarized in Table 4. See Table 2 under “Supplemental data”
the 176 participants who completed the study, 31% of subjects in the online issue for a summary of the results of individual
were carriers of the APOE4 allele (43 E3/E4, 5 E4/E4, and 6 cognitive-function tests. A significant effect of sex 3 treatment
E2/E4) and 69% of subjects were noncarriers (103 E3/E3 and 19 interaction (P = 0.01) was seen for episodic memory. Although
E2/E3). At baseline, women scored higher than men did on the no effects were seen in men, episodic memory improved

TABLE 3
Changes within and between treatments in erythrocyte arachidonic acid, long-chain omega-3 fatty acids, and omega-3 index from baseline to 6 mo1
DHA Placebo DHA compared
(n = 83) (n = 90) with placebo

Variables Baseline 6 mo Change2 Baseline 6 mo Change Difference3 P

AA (percentage of 11.2 6 1.63 4


10.4 6 1.45 20.88 6 1.15 11.2 6 1.70 11.2 6 1.73 0.01 6 1.29 20.89 (21.26, 20.52) ,0.001
total fatty acids)
EPA (percentage of 0.61 6 0.34 0.81 6 0.41 0.20 6 0.22 0.54 6 0.31 0.52 6 0.31 20.01 6 0.25 0.21 (0.14, 0.28) ,0.001
total fatty acids)
DPA (percentage of 2.81 6 0.77 2.48 6 0.85 20.33 6 0.73 2.71 6 0.81 2.70 6 0.88 20.01 6 0.60 20.32 (20.52, 20.12) 0.002
total fatty acids)
DHA (percentage of 5.28 6 1.35 7.91 6 1.65 2.62 6 1.27 5.06 6 1.76 4.98 6 1.60 20.08 6 0.88 2.70 (2.37, 3.03) ,0.001
total fatty acids)
AA:EPA 23.1 6 12.9 15.2 6 6.38 27.84 6 11.6 23.3 6 9.59 23.8 6 9.92 0.53 6 9.62 28.37 (25.06, 211.7) ,0.001
AA:DHA 2.30 6 0.84 1.37 6 0.38 20.93 6 0.62 2.51 6 1.0 2.53 6 1.02 0.02 6 0.45 20.95 (21.11, 20.79) ,0.001
Omega-3 index (%) 5.89 6 1.42 8.72 6 1.72 2.82 6 1.34 5.59 6 1.90 5.50 6 1.72 20.09 6 0.98 2.92 (2.56, 3.27) ,0.001
1
Includes only participants with erythrocyte fatty acid analysis at baseline and 6 mo. Men and women did not differ, and therefore, only results of total
treatment groups are presented. P values were derived by using independent t test (2 tailed). AA, arachidonic acid (20:4n26); DHA, 22:6n23; DPA,
docosapentaenoic acid (22:5n23); EPA, 20:5n23; omega-3 index, percentage of EPA + DHA of total erythrocyte fatty acids.
2
Baseline and 6-mo values differed significantly within treatment (P , 0.001; dependent t test, 2 tailed).
3
All values are means; 95% CIs in parentheses.
4
Mean 6 SD (all such values).
TABLE 4
Changes within and between treatments in cognitive-function test z scores from baseline to 6 mo1
DHA (n = 85) Placebo (n = 91) DHA compared with placebo

P-treatment P-sex 3 P-APOE 3


Variables Baseline 6 mo Change Baseline 6 mo Change Difference effect treatment treatment
Episodic memory
Total 20.06 6 0.762 0.19 6 0.63 0.26 (0.14, 0.38)3,4 20.14 6 0.71 0.07 6 0.68 0.21 (0.09, 0.32)4 0.05 (20.11, 0.22) 0.52 0.01 0.39
Men 20.21 6 0.82 20.002 6 0.74 0.15 (20.04, 0.34) 20.23 6 0.73 0.18 6 0.66 0.32 (0.14, 0.50)4 20.17 (20.43, 0.09) 0.20 — —
Women 0.04 6 0.71 0.31 6 0.52 0.37 (0.23, 0.51)4 20.09 6 0.70 0.01 6 0.69 0.09 (20.05, 0.23) 0.28 (0.08, 0.48) 0.01 — —
RT5 of episodic
memory
Total 0.04 6 0.95 20.19 6 0.72 20.28 (20.39, 20.17)4 0.14 6 0.94 0.01 6 0.89 20.10 (20.20, 0.01)4 20.18 (20.33, 20.03) 0.02 0.81 0.87
Working memory
Total 20.07 6 0.76 0.15 6 0.62 0.22 (0.11, 0.32)4 20.09 6 0.74 0.01 6 0.79 0.12 (0.01, 0.22)4 0.10 (20.04, 0.25) 0.17 0.37 0.46
RT of working
memory
Total 0.10 6 1.01 20.33 6 0.82 20.51 (20.66, 20.35)4 0.20 6 1.09 0.01 6 0.99 20.15 (20.30, 0.00)4 20.36 (20.58, 20.14) 0.002 0.03 0.78
Men 0.06 6 1.03 20.50 6 0.74 20.66 (20.90, 20.41)4 0.16 6 1.07 0.11 6 1.02 20.06 (20.31, 20.19) 20.60 (20.95, 20.25) 0.001 — —
Women 0.31 6 1.01 20.22 6 0.85 20.36 (20.55, 20.17)4 0.23 6 1.11 20.05 6 0.98 20.24 (20.43, 20.06)4 20.12 (20.38, 0.15) 0.39 — —
Attention
Total 0.06 6 0.57 0.06 6 0.55 0.06 (20.08, 0.20) 20.06 6 0.62 20.02 6 0.70 20.04 (20.18, 0.10) 0.10 (20.10, 0.30) 0.32 0.14 0.51
RT of attention
Total 20.09 6 0.75 20.03 6 0.76 0.07 (20.04, 0.17) 0.00 6 0.77 0.01 6 0.74 0.02 (20.08, 0.13) 0.04 (20.11, 0.19) 0.59 0.22 0.80
Processing speed
4 4
Total 20.11 6 1.03 0.19 6 1.15 0.27 (0.14, 0.40) 20.23 6 0.83 0.16 6 0.93 0.38 (0.25, 0.50) 20.11 (20.29, 0.07) 0.24 0.13 0.65
OMEGA-3 DHA AND COGNITIVE PERFORMANCE

1
Includes only participants with cognitive-function scores at baseline and 6 mo. The DHA group included 33 men and 52 women. The placebo group included 33 men and 58 women. A decrease in the
reaction time of cognitive tasks indicates an improvement. P values were derived by using ANCOVA (adjusted for baseline cognitive function score, baseline DHA concentrations, first language, age, and
education). Sex and APOE were added as independent variables to test for sex 3 treatment and APOE 3 treatment interactions.
2
Mean 6 SD (all such values).
3
Mean; 95% CI in parentheses (all such values). All values were adjusted for baseline cognitive function z score, baseline DHA concentrations, first language, age, and education.
4
Baseline and 6-mo z scores differed significantly within treatment (P , 0.05; dependent t test, 2 tailed).
5
RT, reaction time.
1139
1140 STONEHOUSE ET AL

significantly (by 0.28 SDs) in women who consumed DHA


compared with women who consumed the placebo. This im-
provement equated to correctly remembering or recognizing
approximately one more word or picture compared with the
placebo group.
The RT of episodic memory improved significantly after DHA
treatment irrespective of sex, and the DHA group responded
faster (by 0.18 SDs) to these tasks than the placebo group did.
DHA did not significantly affect the working memory domain,
but the RT of working memory improved significantly (by 0.36
SDs) in the DHA group compared with the placebo group. A
significant sex 3 treatment interaction was also seen (P = 0.03).
Although RTs improved numerically for both sexes after DHA
compared with placebo treatment, this improvement was only
significant in men (by 0.6 SDs). This result equated to men in
the DHA group having completed the working memory task
223 ms (2354, 292.4 ms) (20%) faster than did men in the pla-
cebo group.
No significant effects of DHA were seen on attention or the RT
of attention. However, there was limited room for improvement
on the accuracy of attention tasks with baseline scores on at-
tention tasks .96% (CRT .97%, digit vigilance .96%, and
Stroop test .97%) (see Table 2 under “Supplemental data” in
the online issue).
The processing speed did not differ significantly between DHA
and placebo groups.
APOE4 carriers and noncarriers did not differ at baseline with
regard to cognitive domains. APOE status did not affect treat-
ment responses on any cognitive domains (Table 4). Because no FIGURE 2. Adjusted mean (95% CI) changes in z scores from baseline to
effects of APOE 3 treatment interaction were observed, results end in RT for working memory (A) and attention (B) in male APOE4
carriers compared with noncarriers who consumed DHA compared with
stratified by APOE groups are not presented. APOE 3 sex 3 a placebo (APOE4: DHA, n = 11; placebo, n = 7; APOE4 noncarriers:
treatment interactions were observed for RTs of working DHA, n = 22; placebo, n = 26). A decrease in RT indicates an
memory (P = 0.02) and attention (P = 0.005). Both male APOE4 improvement. 1P values indicate differences between DHA and placebo
carriers and noncarriers who received DHA showed improve- groups within APOE groups and were derived by using ANCOVA
(adjusted for baseline RT, baseline DHA concentrations, first language,
ments in the RT of working memory compared with those in the age, and education). APOE 3 sex 3 treatment interaction: RT for
placebo group, but the effect was considerably greater in APOE4 working memory, P = 0.02; RT for attention, P = 0.005. RT, reaction time.
carriers [mean (95% CI) differences between treatments were
21.19 SD (21.89, 20.50 SD) (P = 0.001) in APOE4 carriers
and 20.42 SD (20.81, 20.02 SD) (P = 0.04) in APOE4 non- improved the RT of episodic memory, whereas the accuracy of
carriers] ((Figure 2A). The large effect in APOE4 carriers was episodic memory was improved in women, and the RT of working
due to both improvements in the DHA group and a worsening of memory was improved in men. APOE did not have an effect on
performance in the placebo group. A similar effect was seen in changes in cognitive function in response to DHA supplemen-
male APOE4 carriers for RTs of attention (Figure 2B) with an tation, but there was some indication that, when stratified by sex,
improvement in the DHA group and worsening in the placebo APOE may have modulated effects on RTs of working memory
group, which resulted in a significant difference between groups and attention. Because the study did not have sufficient statis-
[mean (95% CI): 20.80 SD (21.27, 20.33 SD) (P = 0.005]. tical power to investigate this interaction, these effects are only
The RT of attention was not affected in APOE4 noncarriers. preliminary. No conclusions could be drawn regarding the effect
With regard to side effects, a significantly greater proportion of of DHA on the accuracy of attention because of ceiling effects in
participants in the DHA-treatment group reported burping and test performance. The processing speed was not affected by
unpleasant breath [burping: 49% compared with 22%, re- DHA supplementation.
spectively (P , 0.001); unpleasant breath: 39% compared with The few RCTs undertaken in healthy young adults have failed
18%, respectively ( P = 0.001); chi-square test], but the effects to show any effects of LC n23 PUFAs on episodic or working
were rated as minor (1 and 2 on a scale from 1 to 10). memory (12, 14–16), RTs of memory (14, 15), attention (14,
15), or processing speed (16). However, none of these studies
examined sex interactions. The failure to examine sex in-
DISCUSSION teractions may have led to inaccurate conclusions because if
This study showed, for the first time to our knowledge, that a sex dimorphism exists, the combination of sexes may have
DHA supplementation improved memory and RTs of memory in cancelled out or dilute any potential effects. Some studies used
healthy young adults whose habitual diet was low in DHA, and small dosages (12, 15) or had small sample sizes (12–14), and
sex modulated the response. DHA supplementation significantly all studies were of relatively short duration, with a range from 4
OMEGA-3 DHA AND COGNITIVE PERFORMANCE 1141
to 12 wk (12–16). A duration .12 wk and, on the basis of the gional brain atrophy (50, 51). Surprisingly, young (20–35-y-old)
current study, $6 mo may be needed to achieve measurable APOE4 carriers have been shown to perform better on cognitive
effects on cognitive function in adults. All of these limitations tasks than noncarriers have (25, 26) and showed increased brain
were overcome in the current study; the intervention period was activation in the frontal and temporal regions during memory
of adequate duration (6 mo), a relatively large DHA dosage was tasks (28).
used, although such a level can be achieved by dietary changes, To our knowledge, the current study is the first to examine the
and the study had sufficient statistical power to investigate in- cognitive response to DHA supplementation in younger adults
teraction effects of sex and APOE. The comprehensive battery according to APOE We saw no evidence for a differential cog-
of cognitive tests have previously been shown to be sensitive to nitive performance with DHA treatment. Although no effect of
nutrition interventions and were performed under rigorous the APOE4 allele carrier status was observed for the responses
standardized conditions that reduced variation because of envi- in the group as a whole, the data were strongly suggestive of sex
ronmental factors (48). A limitation was the lack of statistical dimorphisms. There was some indication that, when stratified by
power to investigate APOE interactions stratified by sex. sex, improvements in RTs of working memory and attention
The increased consumption of DHA in the current study with DHA compared with placebo were more pronounced in
resulted in an increase of 2.6% of total fatty acids in erythrocyte male APOE4 carriers than in noncarriers. The effects were due
DHA levels and also lowered AA:DHA and AA:EPA ratios, to both improved scores in the DHA group and worsening scores
which may have contributed to the cognitive improvements in the placebo group. This novel finding of a potentially greater
shown in the study by altering membrane fluidity and decreased effect of DHA in RTs of memory and attention in male APOE4
production of proinflammatory eicosanoids (1, 3). DHA is likely carriers requires additional investigation, and the biological
to affect brain function by several possible mechanisms as basis for the interaction needs to be investigated.
previously reviewed (1–3). Its incorporation into the neuronal More-robust RCTs that are long enough ($6 mo) and take into
membrane lipid bilayer is essential for neuroplasticity, the pro- account the habitual intake of LC n23 PUFAs are needed to
motion of neurogenesis, neurite outgrowth and synaptogenesis, confirm the findings of this study and to determine the most
and the maintenance of membrane fluidity and membrane pro- effective dosage of DHA for optimal cognitive function. It is
tein function, which, in turn, affects the speed of signal trans- important that any future trials of DHA on cognitive function
duction, neurotransmission (1–3), and regulation of brain stratify for sex, and this should be planned into the study design
glucose uptake (49). DHA has also been shown to reduce the from the start so that sex-stratified random assignment and re-
vascular tone, which is likely to increase cerebral blood flow cruitment of sufficient numbers of men and women is ensured.
during cognitive tasks (14). Unesterified DHA, which is released Future trials that investigate the effects of APOE should ensure
from the sn2 position of phosphoglycerides by phospholipase a sufficient statistical power to investigate the effects of APOE
A2 is likely to influence inflammation via a variety of mecha- stratified by sex.
nisms, including the downregulation of inflammatory cytokine In conclusion, DHA supplementation improved memory and
production and by acting as a precursor of the docosanoid family RTs of memory in healthy young adults whose habitual diet was
of compounds (neuroprotectins and resolvins) that resolve low in DHA and sex modulated the response to DHA supple-
neuroinflammation and inhibit oxidative stress-induced neuronal mentation. APOE did not modulate the response to treatment in
apoptosis (1, 3). the group as a whole, but there was some indication that, when
Memory domains were affected differently by DHA supple- stratified by sex, APOE may have resulted in greater improve-
mentation in men and women. In women, episodic memory ments in RTs in male APOE4 carriers, but this needs to be
improved, whereas in men, RTs of working memory improved confirmed in future studies. These memory-related cognitive
compared with in the placebo group. Sex differences in cognitive domains are the building blocks of more-complex cognitive
test performance may be explained by the use of different functions or behaviors that are common in everyday life (20,
problem-solving strategies by men and women as indicated by 48). Thus, young healthy adults may cognitively benefit from an
differences in the functional organization of the brain when increased consumption of DHA.
performing memory tasks (19, 20).
We thank all supporting staff and participants in the study.
The APOE4 allele, which was carried by 31% of participants The authors’ responsibilities were as follows—WS: was the main author
in the current study, is the major common genetic risk factor for of the manuscript, designed the research (project conception, development of
Alzheimer’s disease (21, 22) with an w3- and 15-fold increase the overall research plan, and study oversight), conducted the research
in risk in APOE3/E4 and APOE4/E4 individuals relative to the (hands-on conduct of the research and data collection), performed statistical
wild-type genotype (21). Although the physiologic basis is un- analyses, and had primary responsibility for the final content of the manu-
known, there have been reports that the cognitive response to LC script; CAC: designed the research (project conception, development of the
n23 PUFAs may be APOE dependent. Improvements in atten- overall research plan, and study oversight), conducted the research (hands-on
tion in .65-y-olds were seen only in APOE4 carriers (10), conduct of the research and data collection), analyzed cognitive data, criti-
whereas Quinn et al (32) showed improvements in cognitive cally revised the manuscript, and approved of the final version of the man-
uscript; JP and SRH: designed the research (project conception and
function only in APOE4 noncarriers with Alzheimer’s disease.
development of the overall research plan), critically revised the manuscript,
Evidence for the role of APOE4 in the young adult brain is still
and approved the final version of the manuscript; AMM: provided significant
emerging, but structural and functional neurologic changes advice regarding all aspects related to APOE analysis, interpretation of
are seen in APOE4 carriers decades before the appearance of APOE data, and contribution to the writing up of these aspects in the man-
any cognitive or clinical symptoms (27–30). APOE4 in young uscript, critically revised the manuscript, and approved the final version of
adults is associated with abnormally low rates of glucose me- the manuscript; CH: designed the computerized cognitive test battery and
tabolism that occurs as early as in 20–39-y-olds (30) and re- provided advice regarding the analysis of cognitive data, critically revised
1142 STONEHOUSE ET AL
the manuscript, and approved of the final version of the manuscript; and DK: 20. Speck O, Ernst T, Braun J, Koch C, Miller E, Chang L. Gender dif-
designed the computerized cognitive test battery, critically revised the man- ferences in the functional organization of the brain for working
uscript, and approved of the final version of the manuscript. DK has pre- memory. Neuroreport 2000;11:2581–5.
viously received funding from Efamol, Martek, and Ginsana SA for DHA 21. Bertram L, McQueen MB, Mullin K, Blacker D, Tanzi RE. Systematic
research. WS, CAC, JP, SRH, AMM, and CH had no conflicts of interest. meta-analyses of Alzheimer disease genetic association studies: the
AlzGene database. Nat Genet 2007;39:17–23.
22. FarrerLA, Cupples LA, Haines JL, Hyman B, Kukull WA, Mayeux R,
Myers RH, Pericak-Vance MA, Risch N, van Duijn CM. Effects of age,
REFERENCES sex, and ethnicity on the association between apolipoprotein E genotype
1. Horrocks LA, Farooqui AA. Docosahexaenoic acid in the diet: its and Alzheimer disease - a meta-analysis. JAMA 1997;278:1349–56.
importance in maintenance and restoration of neural membrane func- 23. Wisdom NM, Callahan JL, Hawkins KA. The effects of apolipoprotein
tion. Prostaglandins Leukot Essent Fatty Acids 2004;70:361–72. E on non-impaired cognitive functioning: a meta-analysis. Neurobiol
2. Innis SM. Dietary (n23) fatty acids and brain development. J Nutr Aging 2011;32:63–74.
2007;137:855–9. 24. Jorm AF, Mather KA, Butterworth P, Anstey KJ, Christensen H,
3. Tassoni D, Kaur G, Weisinger RS, Sinclair AJ. The role of eicosanoids Easteal S. APOE genotype and cognitive functioning in a large age-
in the brain. Asia Pac J Clin Nutr 2008;17:220–8. stratified population sample. Neuropsychology 2007;21:1–8.
4. Chung WL, Chen JJ, Su HM. Fish oil supplementation of control and 25. Alexander DM, Williams LM, Gatt JM, Dobson-Stone C, Kuan SA,
(n23) fatty acid-deficient male rats enhances reference and working Todd EG, Schofield PR, Cooper NJ, Gordon E. The contribution of
memory performance and increases brain regional docosahexaenoic apolipoprotein E alleles on cognitive performance and dynamic neural
acid levels. J Nutr 2008;138:1165–71. activity over six decades. Biol Psychol 2007;75:229–38.
5. Gamoh S, Hashimoto M, Sugioka K, Hossain MS, Hata N, Misawa Y, 26. Mondadori CRA, de Quervain DJF, Buchmann A, Mustovic H,
Masumura S. Chronic administration of docosahexaenoic acid im- Wollmer MA, Schmidt CF, Boesiger P, Hock C, Nitsch RM, Pa-
proves reference memory-related learning ability in young rats. Neu- passotiropoulos A, et al. Better memory and neural efficiency in
roscience 1999;93:237–41. young apolipoprotein E epsilon 4 carriers. Cereb Cortex 2007;17:
6. University of Otago. Ministry of health. a focus on nutrition: key 1934–47.
findings of the 2008/2009 New Zealand Adult Nutrition Survey. Wel- 27. Dennis NA, Browndyke JN, Stokes J, Need A, Buke JR, Welsh-
lington: Ministry of Health, 2011. Bohmer KA, Cabeza R. Temporal lobe functional activity and con-
7. Richardson AJ, Montgomery P. The Oxford-Durham study: a randomized, nectivity in young adult APOE epsilon 4 carriers. Alzheimers Dement
controlled trial of dietary supplementation with fatty acids in children with 2010;6:303–11.
developmental coordination disorder. Pediatrics 2005;115:1360–6. 28. Filippini N, Ebmeier KP, MacIntosh BJ, Trachtenberg AJ, Frisoni GB,
8. Sinn N, Bryan J, Wilson C. Cognitive effects of polyunsaturated fatty Wilcock GK, Beckmann CF, Smith SM, Matthews PM, Mackay CE.
acids in children with attention deficit hyperactivity disorder symp- Differential effects of the APOE genotype on brain function across the
toms: a randomised controlled trial. Prostaglandins Leukot Essent Fatty lifespan. Neuroimage 2011;54:602–10.
Acids 2008;78:311–26. 29. Filippini N, MacIntosh BJ, Hough MG, Goodwin GM, Frisoni GB,
9. Dangour AD, Allen E, Elbourne D, Fasey N, Fletcher AE, Hardy P, Smith SM, Matthews PM, Beckmann CF, Mackay CE. Distinct patterns
Holder GE, Knight R, Letley L, Richards M, et al. Effect of 2-y n23 of brain activity in young carriers of the APOE-epsilon 4 allele. Proc
long-chain polyunsaturated fatty acid supplementation on cognitive Natl Acad Sci USA 2009;106:7209–14.
function in older people: a randomized, double-blind, controlled trial. 30. Reiman EM, Chen KW, Alexander GE, Caselli RJ, Bandy D, Osborne
Am J Clin Nutr 2010;91:1725–32. D, Saunders AM, Hardy J. Functional brain abnormalities in young
10. van de Rest O, Geleijnse JM, Kok FJ, van Staveren WA, Dullemeijer C, adults at genetic risk for late-onset Alzheimer’s dementia. Proc Natl
Olderikkert MG, Beekman AT, de Groot CP. Effect of fish oil on Acad Sci USA 2004;101:284–9.
cognitive performance in older subjects - a randomized, controlled 31. Barberger-Gateau P, Raffaitin C, Letenneur L, Berr C, Tzourio C,
trial. Neurology 2008;71:430–8. Dartigues JF, Alperovitch A. Dietary patterns and risk of dementia - the
11. Yurko-Mauro K, McCarthy D, Rom D, Nelson EB, Ryan AS, Three-City cohort study. Neurology 2007;69:1921–30.
Blackwell A, Salem N Jr, Stedman M. Beneficial effects of doco- 32. Quinn JF, Raman R, Thomas RG, Yurko-Mauro K, Nelson EB, Van
sahexaenoic acid on cognition in age-related cognitive decline. Dyck C, Galvin JE, Emond J, Jack CR, Weiner M, et al. Docosahex-
Alzheimers Dement 2010;6:456–64.
aenoic acid supplementation and cognitive decline in Alzheimer dis-
12. Antypa N, Van der Does AJW, Smelt AHM, Rogers RD. Omega-3 fatty
ease a randomized trial. JAMA 2010;304:1903–11.
acids (fish-oil) and depression-related cognition in healthy volunteers.
33. Samieri C, Feart C, Proust-Lima C, Peuchant E, Dartigues JF, Amieva
J Psychopharmacol 2009;23:831–40.
H, Barberger-Gateau P. Omega-3 fatty acids and cognitive decline:
13. Fontani G, Corradeschi F, Felici A, Alfatti F, Migliorini S, Lodi L.
modulation by ApoEe4 allele and depression. Neurobiol Aging 2011
Cognitive and physiological effects of Omega-3 polyunsaturated fatty
acid supplementation in healthy subjects. Eur J Clin Invest 2005; 32:2317.e13–22.
35:691–9. 34. Whalley LJ, Deary IJ, Starr JM, Wahle KW, Rance KA, Bourne VJ,
14. Jackson PA, Reay JL, Scholey AB, Kennedy DO. DHA-rich oil Fox HC. n23 Fatty acid erythrocyte membrane content, APOE
modulates the cerebral haemodynamic response to cognitive tasks in varepsilon4, and cognitive variation: an observational follow-up
healthy young adults: a near IR spectroscopy pilot study. Br J Nutr study in late adulthood. Am J Clin Nutr 2008;87:449–54.
2012;107:1093–8. 35. The New Zealand Institute for Plant & Food Research, New Zealand
15. Jackson PA, Deary ME, Reay JL, Scholey AB, Kennedy DO. No effect Ministry of Health. New Zealand FOODfiles 2010. Palmerston North,
of 12 weeks’ supplementation with 1 g DHA-rich or EPA-rich fish oil New Zealand. The New Zealand Institute for Plant & Food Research
on cognitive function or mood in healthy young adults aged 18-35 Ltd, 2010.
years. Br J Nutr 2012;107:1232–43. 36. Kuratko CN, Salem N. Biomarkers of DHA status. Prostaglandins
16. Rogers PJ, Appleton KM, Kessler D, Peters TJ, Gunnell D, Hayward Leukot Essent Fatty Acids 2009;81:111–8.
RC, Heatherley SV, Christian LM, McNaughton SA, Ness AR. No 37. Katan MB, Deslypere JP, van Birgelen AP, Penders M, Zegwaard M.
effect of n23 long-chain polyunsaturated fatty acid (EPA and DHA) Kinetics of the incorporation of dietary fatty acids into serum choles-
supplementation on depressed mood and cognitive function: a rando- teryl esters, erythrocyte membranes, and adipose tissue: an 18-month
mised controlled trial. Br J Nutr 2008;99:421–31. controlled study. J Lipid Res 1997;38:2012–22.
17. Duff SJ, Hampson E. A sex difference on a novel spatial working 38. Freeman MP, Sinha P. Tolerability of omega-3 fatty acid supplements
memory task in humans. Brain Cogn 2001;47:470–93. in perinatal women. Prostaglandins Leukot Essent Fatty Acids 2007;
18. Herlitz A, Rehnman J. Sex differences in episodic memory. Curr Dir 77:203–8.
Psychol Sci 2008;17:52–6. 39. Hixson JE, Vernier DT. Restriction isotyping of human apolipoprotein-E by
19. Guillem F, Mograss M. Gender differences in memory processing: gene amplification and cleavage with HHAI. J Lipid Res 1990;31:545–8.
evidence from event-related potentials to faces. Brain Cogn 2005;57: 40. Stonehouse W, Kruger A, Smuts CM, Loots DT, Wentzel-Viljoen E,
84–92. Vorster HH. Plasma polyunsaturated fatty acids and liver enzymes in
OMEGA-3 DHA AND COGNITIVE PERFORMANCE 1143
HIV-infected subjects: the Prospective Urban and Rural Epidemiology 46. Wechsler D. WAIS-III administration and scoring manual. San Antonio,
(PURE) Study. Am J Clin Nutr 2010;91:729–35. CA: Psychological Corporation, 1997.
41. Society AOCs. Official methods and recommended practice of the 47. Faul F, Erdfelder E, Lang AG, Buchner AG. *Power 3: a flexible
American Oil Chemists’ Society. 5th ed. Champaign, IL: AOCS Press, statistical power analysis program for the social, behavioral, and bio-
1993. medical sciences. Behav Res Methods 2007;39:175–91.
42. Sukhija P, Palmquist D. Rapid method for determination of total fatty 48. Schmitt JAJ, Benton D, Kallus KW. General methodological consid-
acid content and composition of feedstuffs and feces. J Agric Food erations for the assessment of nutritional influences on human cogni-
Chem 1988;204:608–1. tive functions. Eur J Nutr 2005;44:459–64.
43. Kennedy DO, Haskell CF. Cerebral blood flow and behavioural effects 49. Cunnane SC, Plourde M, Pifferi F, Begin M, Feart C, Barberger-Gateau
of caffeine in habitual and non-habitual consumers of caffeine: a near P. Fish, docosahexaenoic acid and Alzheimer’s disease. Prog Lipid Res
infrared spectroscopy study. Biol Psychol 2011;86:298–306. 2009;48:239–56.
44. Kennedy DO, Veasey R, Watson A, Dodd F, Jones E, Maggini S, 50. den Heijer T, Oudkerk M, Launer LJ, van Duijn CM, Hofman A,
Haskell CF. Effects of high-dose B vitamin complex with vitamin C Breteler MM. Hippocampal, amygdalar, and global brain atrophy in
and minerals on subjective mood and performance in healthy males. different apolipoprotein E genotypes. Neurology 2002;59:746–8.
Psychopharmacology (Berl) 2010;211:55–68. 51. Wishart HA, Saykin AJ, McAllister TW, Rabin LA, McDonald BC,
45. Ekstrom RB, French JW, Harman HH, Dermen D. Manual for kit of Flashman LA, Roth RM, Mamourian AC, Tsongalis GJ, Rhodes CH.
factor-referenced cognitive tests. Pinceton, NJ: Educational Testing Regional brain atrophy in cognitively intact adults with a single APOE
Service, 1976. epsilon 4 allele. Neurology 2006;67:1221–4.

You might also like