Energy balance, macronutrients, micronutrients and meal timing all have their place in a well- rounded training program, but where do supplements fit in?
During our assessment process, we often find that people focus on aspects of their nutrition that don’t have a high return on investment relative to others. An example is someone who is trying to gain strength and focuses primarily on good food quality. Although food quality is an important tool, it may not be the most effective tool for gaining strength. Proper energy balance creates a greater physiological response than maximizing the micronutrient quantity from a high-quality diet.
The same goes for supplements. Too often we see people delving into the intricacies of supplements when previous stages of nutrition have not been applied. Of course each client is individual; however, we are looking for a tool that will create:
- The greatest physiological impact
- In the least amount of time
- With the least psychological resistance
The muscle and strength pyramid is a very useful tool created by Eric Helms of 3DMJ that illustrates this concept. If we are trying to lose fat and have not mastered energy balance, then supplements will be simply ineffective in creating fat loss.
Below are the six supplements that Central Athlete stands behind. The last thing we want to do is recommend a supplement that isn’t a sure thing. These are our criteria:
- Data volume—How many studies have been researched?
- Data age—Sometimes studies come out that show positive effects of a particular supplement. However, after continued research, further effects are teased out and it becomes apparent that the initial effects may have been the placebo effect or statistical error. This recently happened to citrulline malate, which didn’t make our list.
- Data consensus—There needs to be a preponderance of scientific research that supports its efficacy.
- Real world feedback—Have actual athletes used these supplements and experienced positive benefits?
It should mentioned that we recommend against buying from Amazon, discount retailers or local health food stores. The products from Amazon come from unauthorized resellers and could be counterfeit or expired. Many supplements need to be refrigerated, which resellers often ignore. Purchasing medical-grade supplements directly from the manufacturer or our online store follows all manufacturer shipping and storage best practices.
Obviously, cheaper doesn’t mean better. Discount brands have lower doses of ingredients per serving. For example, four capsules of Kirkland fish oil equals the same dosage as one capsule from the top medical-grade fish oils. Are you willing to take up to twelve capsules per day instead of three?
Scouring the shelves at your local health food store for the right product is often a nightmare that often leads you to settle for “close enough.” Find a method that allows you to purchase the ideal products you need, when you need them, curated by a health professional.
Healthy body composition, skeletal muscle repair, appetite reduction
Description—Whole foods are always preferential to supplements and processed foods. However, consuming adequate daily protein and optimizing nutrition during the post-workout window is imperative for creating favorable body composition changes, as well as recovering from training. Whey protein supplements can help fill this gap.
Benefits—Whey protein powder has been demonstrated to decrease fat mass, increase lean mass, synthesize protein, address insulin sensitivity and reduce appetite.
Dosing—A great starting point is one gram per pound of bodyweight. If you weigh 180 pounds, that means 180 grams of protein per day as a minimum requirement. Although protein synthesis drops off after a certain quantity of protein, emphasizing protein as part of a balanced diet seems to be advisable given the current research. More specifically, 75-125% of body weight is an appropriate goal for the majority of people. Use whey protein powder to fill the gap in meeting this requirement if you are not able to meet your individual protein needs through whole food sources.
Longevity, vitality, immune function
Description—What are probiotics? To address this question, some definitions are required. "Dys" means “faulty” and bios mean “life and growth.” Generally the terms refer to the imbalance in the bacterial flora of the intestine. A condition without any dysbiosis is eubiosis. This, however, would more appropriately be termed utopia. Reduction of the dysbiosis is known as probiosis. We finally arrive at probiotics. Probiotic means "to promote life.” The ingestion of the probiotic living organism will improve microbial balance in the intestine. Significant numbers of scientific reports are being written by doctors, professors and researchers linking the benefits of probiotic bacteria (friendly bacteria) in the defense against many common, rare and even mysterious maladies such as SARS and West Nile disease. The vast majority of contemporary microbiologists and medical researchers agree that a shortage of probiotic bacteria in the gastrointestinal tract is the underlying cause of premature aging and more than 90% of all diseases.
Benefits—The benefits of taking probiotics seem to vary from immunity to general longevity to improvements in gastrointestinal function. New research indicates that people who are overweight or obese have an altered microbiome relative to their skinny peers.
Dosing—According to Dr. Dixon Thom, Founder of the Center of Biological Medicine in Scottsdale, Arizona, probiotics are so crucial due to the sterile and homogenized nature of our food/produce that they should be administered from one year preconception to death. Dosing depends upon the strain and should be rotated each time you finish a previous strain. Some of the common strains are L. (lactobacillus) Acidophilus, L. Bifidus (bifidum), L. Bulgaricus, as well as other key members of the Lactobacillus family, such as L.Brevis, L.Caseii, L.Causasicus, L.Delbruekeii, L.Fermenti, L.Heleveticus, L.Lactis, L.Leichmannii and L.Plantarum.
Bone structure support, mood, immunity, fat loss, hormonal health
Description—Vitamin D is the number one vitamin deficiency in the United States. Mounting evidence suggests that vitamin D deficiency could be linked to several chronic diseases, including cardiovascular disease and cancer. Due to the cheap cost of Vitamin D supplements, Vitamin D is building a reputation as the single most efficient supplement that has been researched.
Dosing—The RDA for vitamin D is roughly 400-800 IU, and the optimal level is roughly 2,000 IU minimum. The only people who do not need to concern themselves with vitamin D are those who live in the tropics and have frequent sun exposure with bare skin (wearing a t-shirt and shorts is not enough). The recommended daily allowance for Vitamin D is currently set at 400-800IU/day, but this is too low for adults to raise levels where all cause mortality drops 50% (40-60 ng/dl). The safe upper limit in the United States is 2,000IU/day, while in Canada it is 4,000IU/day. Research suggests that the true safe upper limit is 10,000IU/day. For moderate supplementation, a 1,000-2,000IU dose of vitamin D3 is sufficient to meet the needs of most of the population. This is the lowest effective dose range. Higher doses, based on bodyweight, are in the range of 20-80IU/kg daily. Vitamin D3 supplementation (cholecalciferol) is recommended over D2 supplementation (ergocalciferol), since D3 is used more effectively in the body. Vitamin D should be taken daily, with meals or a source of fat, like fish oil. To clarify, you have to first figure out the difference. So, if labs come in at 28 ng/dl, and you want to raise to 50 ng/dl, then you subtract 28 from 50. Then you take that number, 22, multiply by 100, 2200. So dose would be 2200 iu/day. Again, this is theory, take precaution and refer out if unsure. 100 iu/day, raises 25-OHD 1 ng/mL in 3-6 months. That's Dr. Thom’s recommendation and a conservative approach. Regardless of the method, the key with Vitamin D is to retest consistently. 40-60 ng/mL is the sweet spot.
Benefits—The benefits of raising vitamin D levels to 40-60 ng/dl are broad yet are correlated to decreasing all cause mortality by 50% in Western populations. This may be even more beneficial for lower educated individuals, Blacks, Hispanics and people who live in higher latitudes. The benefits range from decreased risk of falls to improvements in hormonal profiles as well as body composition improvements.
Lean body mass, power output, hormonal support
Description—Creatine is one of the most extensively studied supplements and is naturally found in diets, specifically in animal-based protein. Creatine supplementation has been utilized primarily for athletic improvements over the last several decades; however, there may be more breadth to the addition of creatine supplementation for various avatars.
Dosing—Creatine monohydrate can be supplemented through a loading protocol. To start loading, take 0.3g/kg body weight for 5-7 days, then follow with a minimum daily 0.03g/kg dose either for three weeks (if cycling) or indefinitely without requiring another load. For the average person, these doses tend to result in 20g taken during the loading phase and around 2g taken daily henceforth, although many users take 5g daily due to the low price of creatine and possibly more benefits; higher doses may be prudent for those with a high amount of muscle mass and high activity levels. There are many different forms of creatine available on the market, but creatine monohydrate is the cheapest and most effective form of creatine. Micronized creatine is easier to dissolve in water, which may make it easier to supplement. Creatine is usually taken daily. Side-effects related to dosing are nausea, cramping and diarrhea. These occur either when creatine is not taken with liquids or when too much of a dose is taken acutely, and can be attenuated by taking creatine with food.
Benefits—Creatine has been noted to have benefits ranging from increased skeletal muscle mass to improvements in power as well as hormonal benefits.
Lean body mass, recovery
Description—The inclusion of carbohydrate supplements can be utilized in various athletic and performance scenarios. For athletes seeking performance, it's essential to fuel and refuel appropriately. Many people "know" they must refuel after a hard bout of training, but a lot of folks do it without accuracy.
Dosing—Dosing is dependentup on the individual and various frameworks are used to determine the ideal intake.
Body weight formula
0.8g/kg carbohydrate. At 2.2lbs per kg, for a 165lb (75 kg) athlete this works to 60g carbs.
Body Fat % based formula - Now keep in mind, these are very general guidelines; while they do take weight and body fat percentages (which is an indirect inverse measure of insulin sensitivity), it doesn't really account for the type of training.
Post Training Fuel Male
-above 12% - 10g carb
-8-12% - 25g carb
-below 8% - 40g carb
Post Training Fuel Female
-above 16% - 10g carb
-12-14% - 20g carb
-below 12% - 30g carb
Type of training
CNS dominant sessions will require less PWO carbs, and more PWO protein (think 5x5 deadlift). 1:1 ratio of carbohydrates to protein.
Cellular dominant sessions will require less protein, and more carbohydrate. (think 10km run). 4:1 ratio of carbohydrates to protein.
CNS/Cellular sessions (true mixed modality). I hate the term, highly inaccurate, but people get it: "heavy metcon" require both HIGH carb + protein. 2:1 ratio of carbohydrates to protein.
Example: 32 y/o male, 5'9, 180lbs, 7% BF.
Metabolic only (cellular) it will be 30g/120g P/C.
If it is strength only (CNS), it will be 50g/60g P/C.
If it combines both strength and metabolic (CNS/Cellular) in the same session it will be 60g/120g P/C.
Keep in mind these are the numbers that work for THIS athlete. The example is used to stress the variances in sessions.
Benefits—The benefits of carbohydrate supplementation depend on the individual and what they are looking to accomplish. There is a growing body of research, for example, that carbohydrate supplementation can not only improve recovery but can also support athletes performing high-volume resistance training as well as skeletal muscle gains.
Energy, fat burning, strength benefits, euphoria
Description—Caffeine is a powerful stimulant, and it can be used to improve physical strength and endurance. It is classified as a nootropic because it sensitizes neurons and provides mental stimulation.
Dosing—Caffeine dosages should be tailored to individuals. If you are new to caffeine supplements, start with a 100mg dose. Typically, 200mg of caffeine is used for fat-burning supplementation, while acute strength increases occur at higher doses, 500mg and above. Researchers tend to use a dosage range of 4-6mg/kg bodyweight.
Benefits—Many of caffeine’s effects, including fat burning, strength benefits and euphoria, are subject to tolerance, and may not occur in people used to caffeine, no matter how large the dose is.
General health, fat loss, brain function
Description—Fish oil is a common term used to refer to two kinds of omega-3 fatty acids: eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). These omega-3 fats are usually found in fish, animal products and phytoplankton. Fish oil is recommended as a source of these omega-3 fats as they are the cheapest and most common source of them.
Dosing—Fish oil doses vary depending on the goal of supplementation. For general health, 250mg of combined EPA and DHA is the minimum dose and can be obtained via fish intake. The American Heart Association recommends 1g daily. If the goal of supplementation is to reduce soreness, a 6g dose, spread over the course of a day, will be effective. Pregnant women should increase their intake of DHA by at least 200mg a day, as long as there is no risk of elevated mercury levels.
Benefits—Fish oil provides a variety of benefits when supplemented, particularly when the ratio of omega-3 and omega-6 fatty acids in the body is almost equal (1:1). The average diet (red meat, eggs, and so forth) are high in omega-6 fatty acids, which is why fish oil is recommended (to balance the ratio). A ratio of roughly 1:1 is associated with healthier blood vessels, a lower lipid count and a reduced risk for plaque buildup. Fish oil can also decrease the risk of diabetes and several forms of cancer, including breast cancer.
When it comes to your own personal health and fitness journey, understanding what makes the most sense for you and your personalized needs can be overwhelming and confusing with the amount of information available at your fingertips.
At Central Athlete we ensure that each person walks away with a plan that leaves them feeling empowered instead of overwhelmed. Interested in learning more about personalized fitness? Click the link at the bottom of this article to learn more!
Benefit—Decreased fat mass - Inclusion of dietary protein in the diet above the recommended daily intake appears to aid in the process of fat loss during hypocaloric diets (eating less than required to sustain body weight). There is currently no demonstrated benefit with whey protein over other protein sources.
Benefit—Increased lean mass - Protein in general increases lean mass, but there is not a significant body of evidence to support whey protein as being more effective than other protein sources.
Benefit—Increased muscle protein synthesis - Whey protein appears to increase muscle protein synthesis to a higher degree than other protein sources acutely, although over prolonged supplementation, it seems comparable in potency.
Benefit—Increased insulin sensitivity - Whey protein has been noted to increase insulin sensitivity to a larger degree than casein when consumed by obese persons as part of a fat loss diet; it has not yet demonstrated an insulin sensitizing effect in lean athletes.
Benefit—Reduced appetite - Appears to reduce appetite (common to all protein sources), but its superiority over other protein sources is not yet demonstrated.
Plummer, N. Probiotics, essential fatty acids and antioxidants in health and disease. Presented in 2. Portland, Oregon, February 26-27, 2000. Seroyal (1-630-227-9827).
Byrnes, S. Probiotics: the good bacteria within. Healthy & Natural Journal. 1999; Dec. 31.
Trenev, N. Probiotics: first line of defense against a food supply done haywire. JANA. 1998;1(2): 37-39.
Torkos, S. Clinical implications for antibiotic and probiotic therapies. International Journal of Integrative Medicine. 1999;1(1): 14-17.
Cantanzaro, J. A., Green, L. Microbial ecology and dysbiosis in human medicine. Alternative Medicine Review. 1997;2(3): 202-208.
Anderson, J. Acidophilus-why your intestines need this friendly bacteria. Alternative Medicine. 1996;26: 72-76.
Ginsberg, D. I., Drapeau, C., Jensen, G. S. Probiotic bacteria and the immune system. JANA. 2000;3(2):44-50.
Honma, N. On effects of lactic acid bacteria. Part I. Biological significance. New Medicines and Clinics. 1986;35 (12):2687-2695.
Chaitow, L., Trenev, N. Probiotics. Thorson Publishing Group, Northamptonshire England, 1990.
Mackie, R., Gaskins, H. Gastrointestinal microbial ecology. Science and Medicine. 1999;Nov/Dec: 18-27.
Lennart, C. Probiotics: the link between health and disease. Positive Health. 1998; Dec. 31.
Mitsuoka, T. Intestinal Bacteria and Health. Harcourt Brace Jovanovich, Japan, Tokyo, 1978.
Hughes, V.L. Microbiologic characteristics of Lactobacillus products used for colonization of the vagina. Obstet Gynecol. 1990;75:244-248.
Benefit—Decreased risk of falls - The risk of falls in the elderly (and subsequently, the rate of bone fractures) appears to be significantly reduced with Vitamin D supplementation at 700 IU or greater, with most research in the 700-1000 IU range. Lower doses do not appear effective, and a greater protective effect appears to exist alongside calcium supplementation (and possibly Vitamin K supplementation).
Benefit—Decreased risk of cardiovascular disease risk - There appears to be less risk of cardiovascular disease and related cardiovascular complications with supplementation of 1,000 IU of Vitamin D or higher serum levels of Vitamin D. The degree of prevention is borderline significant overall.
Benefit—Decreased bone fracture risk - A decrease in bone fracture risk (nonvertebral and hip) appears to exist when supplemental doses of Vitamin D3 are taken above 800 IU, with this protective effect being highly correlated with the improvement in functionality and fall reduction risk
Benefit—Decreased blood pressure - Both correlational and intervention studies note that higher cohorts of serum Vitamin D have lower blood pressure than lower cohorts, establishing a role for Vitamin D in blood pressure reduction. The magnitude of reduction is small, around 5mm Hg systolic, and likely not potent enough to be a reference therapy.
Benefit—Decreased fat mass - Mixed effects on overweight/obese persons, but it appears that normalizing a deficiency may aid fat loss in persons of higher body weight. Insufficient evidence to suggest the role of Vitamin D in lean persons.
Benefit—Decreased all cause mortality - Cohorts of people with higher serum Vitamin D appear to die less frequently than cohorts with less serum Vitamin D; this may be heavily influenced by reducing falls in the elderly (reduction of falls and subsequent hospitalizations reducing death rates).
Benefit—Increase insulin sensitivity - Improvements in insulin sensitivity can occur secondary to increasing pancreatic insulin secretion.
Benefit—Increased testosterone - An increase in testosterone has been noted in men with 3,332 IU of Vitamin D over the course of a year.
Benefit—Increased power output - Creatine is the reference compound for power improvement, with numbers from one meta-analysis to assess potency being "Able to result in an increase of 12-20% in strength, and able to effect a 12-26% increase in power following a training regiment using creatine monohydrate.” There does appear to be a high degree of variability, which is correlated with the amount of creatine reaching muscle tissue. There does not appear to be much difference between trained and untrained persons. An acute study noted an increase in peak torque by 33.4% and reduction in the time to reach peak torque by 54.7%; this is perhaps useful as comparison.
Benefit—Increased lean mass - Does appear to have inherent lean mass building properties, but a large amount of research is confounded with water weight gains (difficult to assess potency).
Benefit—Increased weight - Appears to have a large effect on increasing overall weight due to water retention in persons who respond to creatine supplementation. Degree of increase is variable.
Benefit—Increased anaerobic running capacity - Appears to increase anaerobic cardiovascular capacity, not to a remarkable degree however.
Benefit—Increased testosterone - Degree of testosterone spike is not overly notable, although it appears to be present.
Benefit— Increased fatigue resistance - Small degree of fatigue reduction during exercise, but appears unreliable.
Benefit—Increased muscular endurance - Somewhat effective.
Benefit—Decreased blood glucose - The spike in blood glucose following a meal may be reduced in the range of 11-22% following creatine supplementation, with no apparent influence on fasting blood glucose.
Benefit—Decreased fatigue - In the fatigue experienced by children subject to tramautic brain injury, frequency of fatigue is reduced from 90% down to 10% with 400mg/kg oral ingestion daily. Fatigue is also reduced to a lesser degree in sleep deprivation.
Benefit—Increased bone mineral density - Limited evidence in favor of improvements in bone mineral density with creatine supplementation.
Studies - https://examine.com/rubric/effects/view/16/Bone%20Mineral%20Density/all/
Benefit - Increased VO2 Max - Improvements in VO2 max are not wholly reliable, and appear to be low in magnitude.
Studies - https://examine.com/rubric/effects/view/16/VO2%20max/all/
Benefit - Decreased DNA damage - Appears to reduce exercise-induced DNA damage; practical relevance unknown but potentially promising for cancer prevention.
Benefit - Decrease of symptoms of osteoarthritis - Appeared to increase functionality, although not to a remarkable degree.
Benefit - Increased cognition - Appears to be reliable in increasing cognition in vegetarians, but is based on limited evidence and not yet compared to a reference drug.
Benefit - Increased glycemic control - Appears to be somewhat effective in diabetics for improving glycemic control.
Benefit - Decreased depression - Notable and due to seeming to be related to serotonin and augmenting SSRI therapy, and appears to have a gender difference (efficacy in females) which needs to be explored more.
Benefit - Decreased symptoms of sleep deprivation - The cognitive dysfunction associated with prolonged sleep deprivation can be attenuated with creatine loading prior to said sleep deprivation, but this is to a small degree.
Benefit - Increased functionality in elderly or injured - Possibly an effect, but the less reliable effects of creatine in the older population (which seem to respond less) seems to manifest here.
Benefit - Growth hormone - Creatine is able to suppress growth hormone secretion during exercise when loaded (up to 35%) and to a lesser degree during maintenance (5% or less) while creatine at rest can spike growth hormone up to 83+/-45%. This bidirectional effect is similar to Arginine supplementation.
Benefit - Increased alertness - Increases in alertness tend to be during sleep deprivation or stress, rather than outright increases in alertness. Not overly potent.
Benefit - Subjective well-being - The influence of creatine on well-being and general happiness is usually dependent on it treating a disease state; there does not appear to be a per se benefit to well being.
Studies - https://examine.com/rubric/effects/view/16/Subjective%20Well-being/all/
Carbohydrate supplementation and resistance training - https://www.ncbi.nlm.nih.gov/pubmed/12580676
The effect of a carbohydrate and protein supplement on resistance exercise performance, hormonal response and muscle damage - https://www.ncbi.nlm.nih.gov/pubmed/17530986
Effect of various ratios of carbohydrate-protein supplementation on resistance exercise-induced muscle damage - https://www.ncbi.nlm.nih.gov/pubmed/22525650
Effects of liquid carbohydrate/essential amino acid ingestion on acute hormonal response during a single bout of resistance exercise in untrained men - https://www.ncbi.nlm.nih.gov/pubmed/16472979
Hormonal response to carbohydrate supplementation at rest and after resistance exercise - https://www.ncbi.nlm.nih.gov/pubmed/18562774
Benefit - Appears to benefit anaerobic cardiovascular exercise, perhaps due to combination antifatigue effects and increasing power output.
Benefit - There appears to be a reliable and significant increase in power output (both weight lifting as well as cycle ergometer measurements) in both trained and sedentary persons with doses of caffeine exceeding 5mg/kg, assuming the subject is not caffeine tolerant. Tolerance, or lower doses of caffeine, are not as effective.
Benefit - An increase in aerobic exercise capacity is noted with caffeine, possibly secondary to increased free fatty acids and adrenaline.
Benefit - There may be an acute increase in blood glucose when caffeine is paired with a carbohydrate containing meal, but long term ingestion of caffeine does not appear to adversely influence glucose (only acutely).
Benefit - Tends to increase blood pressure more than it doesn't, which is in part due to caffeine tolerance (naive users experiencing increases in blood pressure at higher rates) or genetics; the increase in blood pressure tends to be transient and low in magnitude.
Benefit - In general, cortisol appears to be increased at high doses of caffeine; lower doses may not have an effect.
Benefit - An increase in fat oxidation appears to be apparent (assessed via increased serum glycerol and free fatty acids) which is thought to be secondary to increases in adrenaline.
Benefit - An increase in heart rate is noted, but not wholly consistent. It appears to affect those with lower caffeine tolerance or high overdoses of caffeine.
Benefit - A decrease in insulin sensitivity is noted acutely when caffeine is taken alongside carbohydrates, thought to be secondary to reducing glucose deposition.
Benefit - Seems to increase lactate production during exercise when caffeine is acutely preloaded.
Benefit - Although the effects are somewhat unreliable, there appears to be a reduction in the rate of perceived exertion associated with caffeine ingestion.
Benefit - Although the overall effect is unreliable and context dependent, caffeine appears to improve reaction time.
Benefit - A very small (usually 12%) increase is noted in trained athletes consuming caffeine above 250mg prior to exercise, this may be dependent on exercise as studies without exercise fail to find alterations in testosterone. This increase in unlikely to lead to significant testosterone-like effects.
Benefit - There appears to be an increase in training volume (overall work performed during a workout) associated with caffeine ingestion relative to placebo, extending to both weightlifting and anaerobic cardiovascular exercise.
Benefit - Overall, highly mixed effects effects of caffeine on memory. It appears to increase spatial/perceptual memory and reduce working memory (perhaps secondary to overstimulation).
Benefit - Caffeine is reliable and effective in increasing the state of wakefulness and suppressing sedation.
Benefit - An increase in blood flow (flow mediated vasodilation) has been noted with caffeine.
Benefit - Decrease in fatigue have been noted during exercise and during low strenuous physical exercise.
Benefit - Mixed effects on metabolic rate following acute doses of caffeine.
Benefit - Appears to be an increase in oxygen uptake with caffeine consumption, may be related to the increase in metabolic rate.
Benefit - May increase subjective well being and mood state, possibly secondary to reducing fatigue or from catecholamines.
Benefit - Increases in heat production following caffeine consumption have been noted.
Benefit - In men, there does not appear to be a significant suppressive effect of caffeine on appetite.
Benefit - Fish oil, both EPA and DHA, are reference drugs for the purpose of reducing triglycerides with highly reliable reductions in the range of 15-30% (higher reductions seen in persons with higher baseline triglycerides).
Benefit - Fish oil supplementation has been noted to be comparable to pharmaceutical drugs (fluoxetine) in majorly depressed persons, but this may be the only cohort that experiences a reduction of depression. There is insufficient evidence to support a reduction of depressive symptoms in persons with minor depression (ie. not diagnosed major depressive disorder).
Benefit - The decrease in symptoms of lupus as assessed by SLAM-R and BILAG at times reaches up to 50% symptom reduction and tends to exceed 30%, and the first pilot studies noted remission in all subjects (although they have not been replicated since). Oddly, benefit may come from lower doses (160mg EPA and 140mg DHA) with higher doses conferring less benefit.