Tuesday, November 17, 2009

Malocclusion: Disease of Civilization, Part VI

Early Postnatal Face and Jaw Development

The face and jaws change more from birth to age four than at any other period of development after birth. At birth, infants have no teeth and their skull bones have not yet fused, allowing rapid growth. This period has a strong influence on the development of the jaws and face. The majority of malocclusions are established by the end this stage of development. Birth is the point at which the infant begins using its jaws and facial musculature in earnest.

The development of the jaws and face is very plastic, particularly during this period. Genes do not determine the absolute size or shape of any body structure. Genes carry the blueprint for all structures, and influence their size and shape, but structures develop relative to one another and in response to the forces applied to them during growth. This is how orthodontists can change tooth alignment and occlusion by applying force to the teeth and jaws.

Influences on Early Postnatal Face and Jaw Development

In 1987, Miriam H. Labbok and colleagues published a subset of the results of the National Health Interview survey (now called NHANES) in the American Journal of Preventive Medicine. Their article was provocatively titled "Does Breast-feeding Protect Against Malocclusion"? The study examined the occlusion of nearly 10,000 children, and interviewed the parents to determine the duration of breast feeding. Here's what they found:

The longer the infants were breastfed, the lower their likelihood of major malocclusion. The longest category was "greater than 12 months", in which the prevalence of malocclusion was less than half that of infants who were breastfed for three months or less. Hunter-gatherers and other non-industrial populations typically breastfeed for 2-4 years, but this is rare in affluent nations. Only two percent of the mothers in this study breastfed for longer than one year.

The prevalence and duration of breastfeeding have increased dramatically in the US since the 1970s, with the prevalence doubling between 1970 and 1980 (NHANES). The prevalence of malocclusion in the US has decreased somewhat in the last half-century, but is still very common (NHANES).

Several, but not all studies have found that infants who were breastfed have a smaller risk of malocclusion later in life (1, 2, 3). However, what has been more consistent is the association between non-nutritive sucking and malocclusion. Non-nutritive sucking (NNS) is when a child sucks on an object without getting calories out of it. This includes pacifier sucking, which is strongly associated with malocclusion*, and finger sucking, which is also associated to a lesser degree.

The longer a child engages in NNS, the higher his or her risk of malocclusion. The following graph is based on data from a study of nearly 700 children in Iowa (free full text). It charts the prevalence of three types of malocclusion (anterior open bite, posterior crossbite and excessive overjet) broken down by the duration of the NNS habit:

As you can see, there's a massive association. Children who sucked pacifiers or their fingers for more than four years had a 71 percent chance of having one of these three specific types of malocclusion, compared with 14 percent of children who sucked for less than a year. The association between NNS and malocclusion appeared after two years of NNS. Other studies have come to similar conclusions, including a 2006 literature review (1, 2, 3).

Bottle feeding, as opposed to direct breast feeding, is also associated with a higher risk of malocclusion (1, 2). One of the most important functions of breast feeding may be to displace NNS and bottle feeding. Hunter-gatherers and non-industrial cultures breast fed their children on demand, typically for 2-4 years, in addition to giving them solid food.

In my opinion, it's likely that NNS beyond two years of age, and bottle feeding to a lesser extent, cause a large proportion of the malocclusions in modern societies. Pacifier use seems to be particularly problematic, and finger sucking to a lesser degree.

How Do Breastfeeding, Bottle Feeding and NNS Affect Occlusion?

Since jaw development is influenced by the forces applied to them, it makes sense that the type of feeding during this period could have a major impact on occlusion. Children who have a prolonged pacifier habit are at high risk for open bite, a type of malocclusion in which the incisors don't come together when the jaws are closed. You can see a picture here. The teeth and jaws mold to the shape of the pacifier over time. This is because the growth patterns of bones respond to the forces that are applied to them. I suspect this is true for other parts of the skeleton as well.

Any force applied to the jaws that does not approximate the natural forces of breastfeeding or chewing and swallowing food, will put a child at risk of malocclusion during this period of his or her life. This includes NNS and bottle feeding. Pacifier sucking, finger sucking and bottle feeding promote patterns of muscular activity that result in weak jaw muscles and abnormal development of bony structures, whereas breastfeeding, chewing and swallowing strengthen jaw muscles and promote normal development (review article). This makes sense, because our species evolved in an environment where the breast and solid foods were the predominant objects that entered a child's mouth.

What Can We do About it?

In an ideal world (ideal for occlusion), mothers would breast feed on demand for 2-4 years, and introduce solid food about halfway through the first year, as our species has done since the beginning of time. For better or worse, we live in a different world than our ancestors, so this strategy will be difficult or impossible for many people. Are there any alternatives?

Parents like bottle feeding because it's convenient. Milk can be prepared in advance, the mother doesn't have to be present, feeding takes less time, and the parents can see exactly how much milk the child has consumed. One alternative to bottle feeding that's just as convenient is cup feeding. Cup feeding, as opposed to bottle feeding, promotes natural swallowing motions, which are important for correct development. The only study I found that examined the effect of cup feeding on occlusion found that cup-fed children developed fewer malocclusion and breathing problems than bottle-fed children.

Cup feeding has a long history of use. Several studies have found it to be safe and effective. It appears to be a good alternative to bottle feeding, that should not require any more time or effort.

What about pacifiers? Parents know that pacifiers make babies easier to manage, so they will be reluctant to give them up. Certain pacifier designs may be more detrimental than others. I came across the abstract of a study evaluating an "orthodontic pacifier" called the Dentistar, made by Novatex. The frequency of malocclusion was much lower in children who did not use a pacifier or used the Dentistar, than in those who used a more conventional pacifier. This study was funded by Novatex, but was conducted at Heinrich Heine University in Dusseldorf, Germany**. The pacifier has a spoon-like shape that allows normal tongue movement and exerts minimal pressure on the incisors. There may be other brands with a similar design.

The ideal is to avoid bottle feeding and pacifiers entirely. However, cup feeding and orthodontic pacifiers appear to be acceptable alternatives that minimize the risk of malocclusion during this critical developmental window.

* Particularly anterior open bite and posterior crossbite.

** I have no connection whatsoever to this company. I think the results of the trial are probably valid, but should be replicated.


ChristineGTaylor said...

There is a great new product that just won the PTPA award to gently wean a child off of a Pacifier-B-Gone.

Aaron Blaisdell said...

Thanks for the extremely informative post! I was fortunate that both my daughters did not use the pacifier much. But, my younger daughter breastfed for only the first 6 months, after which she was switched to the bottle (and is still on it at 14 months). I'll be keeping an eye on her orofacial development.

Dane Miller said...

Stephan, this series of blogs is absolutely incredible. I may end up printing it up for my dentist to check out and analyze as he loves this stuff. Keep up the good work and thanks for the great information.


Anna said...

Stephan, your series on malocclusions came at a great time for me, though I still wish I could roll back the clock 11 years. My son was a fantastic sleeper as an infant, toddler, and preschooler, thanks to that thumb and silky blankie he became attached to (he slept through the night starting at 7 weeks); consequently, we slept very well during his first years, too. I suspected his thumb sucking habit wasn't going to be great for his oral development, but as any parent knows, it's hard to disrupt anything that contributes to a happy and contented sleeping baby. Sigh.

And I weaned him to a cup at 10 months because by then his breast feeding had become merely a quick snack a few times a day, as by then he ate nearly as much food at meals as I did. And I had a tough time with breast-feeding for the first two months, which I eventually figured out was due to his tight lingual frenum, though he seemed not to suffer from it and gained quite well. At two months, his frenum must have stretched; he began to latch on properly so my discomfort decreased. So with that painful start, BF became something I became determined to do, and I had greater understanding of why some women give up (tight frenums are very common, but currently are rarely addressed or treated, in my experience, and according to Brian, Palmer, DDS). Had I understood then the oral development implications, I'm quite sure I would have continued BF much longer, even if only for "snacks". Of course, the pediatrician assured me that 10 months of BF provided the bulk of the benefits of BF for both my son and for myself (BF supposedly reduces risk of breast cancer). I'll also note that pediatricians seem to focus more on the nutrition and immune enhancing benefits of the breast milk itself (vs. formula), and don't yet seem to view delivering pumped breast milk from a bottle as not equivalent to suckling from the breast.

I guess I'm about to pay back that "bonus time" gained while my son was content and happy sucking his thumb, as we have just chosen an "orthotropic/orthopedic" oriented orthodontist 120 miles away to correct the resulting malocclusion. It's taken a long time to find an orthodontist that is as focused on the facial, oral, and naso-pharyngeal growth and development as on the cosmetic aspects of teeth straightening. This orthodontist's approach uses appliances that reinforce positive oral "habits" (closed mouth, lower jaw postioned forward) and proper resting oral posture (which reduces/eliminates the need to extract healthy teeth), which should lead to ample airways (and all the health benefits of proper breathing), ample room for secondary teeth eruption, and overall better facial proportion and development (strong jawline & chin, good cheekbones, and a handsome profile). Unlike conventional orthodontics (which these days requires little effort from the patient beyond keeping appts) this approach requires the active participation of the child and must be commenced early (as early as 7 yo) while there is still sufficient growth potential. As he is already 11 yo, we were almost too late in discovering this orthotropic approach, but the somewhat late eruption of his secondary teeth bought us some extra time. I think I'm getting it right this time.

Matt Stone said...

I never really thought of the potential to effect human facial development to be attributed to the malleability of the human face - as we are slow developers.

But I guess it really might be possible after all.

Bottle-feed a calf for example, and you won't get malocclusion. But I guess their development is so much more rapid they can't be compared to humans.

Guess I'll have to be less stubborn about thumb-sucking causing malocclusion from now on. Previously, I filed that under my "dumbest thing I've ever heard" category.

Next question is, what makes some kids suck thumbs and pacifiers? Is this really a natural thing, or some kind of malnutritive phenomenon?

In other words, can malnutrition lead to malocclusion in a roundabout way via causing children to constantly suck things?

Do other primates do this and suffer from malocclusion as a result?

Or perhaps does poor nutrition lead to softened facial bones, which allows thumb-sucking to actually alter facial structure when in a healthy child he/she could suck all day without causing structural changes?

Interesting questions indeed. Maybe by Malocclusion Part XX we'll have it all settled.

I suspect, seeing that Pottenger's cats had malocclusion, that thumb-sucking is still causally unrelated to malocclusion, but just a coincidental occurance.

Anna said...

I just thought of something else that might be significant, but perhaps not accounted for in teh data.

One trend I have noticed in recent years is that many parents, whether they breast feed or bottle feed their infants, often later employ prolonged use of "sippy" training cups, often well past the toddler and preschool age. These days sippy training cups aren't merely lidded cups with a small opening on one side of the rim to guide and slow flow rate while a child learns control; they are leak-resistant containers (bottles, actually) with very effective silicone seals in a straw or drinking spout, and consequently can be tossed about, dropped, and tossed in a gear bag, without fear of messy leaks r spills. I never liked the prolonged use of these cups because they simply don't train a child to manage fluids from an open container. Most older babies and toddlers can make the transition to open cups fairly quickly, given the opportunity, though of course there will be some spills and messes to clean along the way (I also think heavy sturdy glass tumblers "train" better than light, easy-to-tip unbreakable plastic tumblers). But the convenience and avoidance of messes with sippy cups that parents really like, probably also has unintended consequences beyond keeping a child untrained in table skills. I suspect the strong sucking action needed to open the very effective silicone seals probably is just as damaging as bottle feeding or NNS. And that's not even taking into account these sealed cups are often filled with carries-promoting contents like juice and are available all day for many young children.

Helen said...

Great post, Stephan!

I'm still breastfeeding my toddler twins, now almost 21 months, and so far, their occlusion seems great. It takes a lot of commitment to do this, so it's good to know it's having several benefits. (Secure attachment and good nutrition being others.) Children who are allowed to nurse long-term are also less likely to develop non-nutritive sucking habits, and mine seem pretty uninterested in this, except as an occasional diversion.

(My kids do use sippy cups, and I wonder about this, too, Anna.)

My occlusion was a mess and someday I will write out the saga of all the problems this has caused me. For one thing, it led to a narrower nasal passage, which, combined with chronic allergies, led to chronic mouth-breathing, which led to other dental/jaw problems, etc.

My brother and I were both bottle-fed (being adopted, not much choice back then, though there are creative alternatives nowadays, including induced lactation and the feeding methods you mentioned). He's got different genes than mine, but we also had different non-nutritive sucking habits. I sucked my thumb until I was four or five. He constantly had a pacifier in his mouth. Maybe it was our individual styles, but the thumb-sucking did me in, while he has not had any orthodontic problems (or allergies or mouth-breathing, gosh darn him).

This was in the late sixties, and I often wonder what the formula was like back then. I had a lot of digestive issues, too, which may have had to do with undiagnosed allergies to the formula (or resulting from leaky gut from using formula). I used to think formula must be better now, since they're adding DHA and all, but it's also possible that it was closer to cow's milk - e.g., a real food - back then. Based on my & my brother's experience (as well as that of others I know), I humbly submit that the IQ advantage of breastfeeding may be a red herring, or at least overstated (unless the formula is particularly lousy), but there are other considerable health consequences that can follow if you have a genetic susceptibility to them.

TanyaL said...

Anna, have you noticed that Brian Palmer's discussion of tongue tie, and how lower teeth can be crowded (that inward-pointing v-shape in the bottom teeth) or the high-arched palate that can go along with some tongue ties seems to correlate so well to Price's under-developed middle third of the face? And the heart-shaped, underdeveloped lower jaw? It sure looks related to me, different descriptions of the same phenomenon.

I've read good things about cranial-sacral therapy (from someone very experienced) in helping support proper oral-facial development. That's part of my plan for my kids, both have high, arched palates and my son's lower jaw is too small (and his tongue, while not classically tied, does not have normal mobility). I'm not suggesting it instead of your current plan, but maybe in addition.

R K @ Health Matters To Me said...

Absolutely awesome series, Stephan! Thanks so much for compliling this information and explaining it so well.

Unknown said...

I wonder how much influence the vitamn K2 content of breast milk has on jaw development, independent of the effects of nursing vs. bottles/NNS?

Richard Nikoley said...


"My occlusion was a mess and someday I will write out the saga of all the problems this has caused me. For one thing, it led to a narrower nasal passage, which, combined with chronic allergies, led to chronic mouth-breathing, which led to other dental/jaw problems, etc. "

I don't think I've ever read a better description of my own identical problems (now much improved from a paleo diet -- yet nothing I can do about the skinny nose & nasal passages).

I was on formula,

Richard Nikoley said...

I might mention one other thing. When I had "braces" as a kid, the ortho found that my front teeth were pushed out significantly because I was a "thruster" when I swallowed, i.e., my tongue would push hard against my front teeth and over time pushed them out and away.

To fix that, he installed sharp barbs on the inside of the hardware such that when I swallowed, I made a bloody mess of my tongue. It really worked, and worked fast to retrain my swallowing hardwire. It has been more than 30 years since I had them removed and my front teeth are still as straight as originally corrected.

Modern medicine can and does work wonders, too.

JM said...

Great post! I'm going to send it to someone who wrote an editorial in the local paper here in Australia that she didn't believe there were any benefits to breastfeeding past the first month or so and that the government should "stop trying to make mothers feel guilty" for using formula.

I think it's great to add other benefits to breastfeeding besides the usual immunity, allergies, digestive, IQ ones...the more support for it, the better.

FWIW, we're a child-led weaning household here. The first weaned herself at 3.5 years. My youngest is 18 months and still nursing happily.

Half Navajo said...

Other benefits for the woman from breastfeeding, they quickly go back to there normal wight in most instances!!


Anna said...

Breast milk is the ultimate "fast food" too, especially when away from home. Very convenient indeed and the price is right. And it doesn't take long to be able to feed relatively inconspicuously in public, either, at least until baby is easily distracted by the environment.

By 6 mos. post-partum, the 14 extra pounds from the pregnancy plus a few more had melted away from the pregnancy. Unfortunately, about the time Gabriel was weaned, I bought a bread machine and over the next 4 years I gained 5 pounds a year... :-( . Going to the gym when he started preschool didn't make a dent in the stored fat, but ditching the bread machine and eating low carb for 5 months melted it off easily .

Helen said...

Half-Navajo and Anna - Yes! I gained 85 pounds with twins (a lot of it was water I was retaining, but a lot wasn't), and it's all gone, and I'm still eating a ton of food.

And yeah, I don't think breastfeeding advocates push the "convenient" and "free" parts enough, especially to low-income women. Formula is extremely expensive and it's really a pain sterilizing bottles and all.

spughy said...

Great post - the only quibble I have with it is that cup-feeding is *really* difficult past the newborn stage, simply because babies like to grab things. They can certainly learn not to grab for it, but there's a period of several months of poor coordination regardless of intent that would be really messy and expensive to get through (not to mention heartbreaking if you're using breastmilk - it's hard work pumping it, seeing a full feed go flying - regularly - would make even the most dedicated mom switch to formula.

That having been said, cup feeding IS a great way of feeding a newborn who can't latch properly on the breast for some reason. Cup-feeding avoids the problem of nipple preference and makes the transition to full feeds at the breast much easier.

...And in my own experience, I was breastfed over a year and never had any degree of malocclusion (same for my two sisters), and my daughter breastfed for 3 years and has perfect teeth. She also never, ever sucked her thumb - honestly I think the comfort provided by extended breastfeeding makes it far less likely that a child would turn to a thumb or a pacifier for comfort. Of all the breastfed kids I know (upwards of 30 or 40) only 1 sucks her thumb, and 1 still uses a pacifier at 2.

Mark said...

Hi Stephan,
I've been asking around and I'd be curious to hear your thoughts. I went to a Crossfit sponsored Barry Sears seminar over the weekend. It was a good time but one thing he talked about that I've never of before was that monounsaturated fat should be favored over saturated fat because saturated fat activates the NF-kB pathway and therefore it is inflammatory for the body. Have you ever come across this? Kurt over at PaNu responded when I asked the same question by saying that the Zone is pseudoscience and that in Paleo times, natural fat breakdown was 50% sat 40% mono and 10% poly. I tend to agree with him on this but I thought it would be good to get as many smart peoples thoughts on this as possible. I don't want to give up my heavy cream or whole eggs or butter....the list just keeps going. Thanks!

Alex said...


You might want to keep an eye on your son's lingual frenum. I had a tight lingual frenum, and I didn't even know about it until I was in my 40s and my new dentist suggested I see an oral surgeon about the receding gums behind my lower front teeth. Gum grafts are rarely successful in that area, so the surgeon cut the lingual frenum on each side of the salivary duct to prevent further gum recession.

Anna said...

Thanks for the tip, Alex. That makes sense to me.

I thought it was curious that of the three conventional orthodontists (in our dental plan) that we consulted last year, none mentioned the frenum (labial or lingual) during the examination or treatment proposal. Of the three we consulted recently (who weren't in our dental plan - one semi-conventional who recommended a fixed Herbst appliance, one who uses/makes removable Crozat appliances, and the one we chose, who uses removeable BioBloc appliances), the latter two orthodontists both noted the frenums during their examination.

Dr. B G said...

OK Mark,

I have to respond. Sears is wrong and probably not up to date on the saturated fat literature. He's also wrong about carbs -- the zone is way too high carb (and I hate to say this -- but look at his double chin?) Robb Wolf agrees too if you read his threads.

Here are some great anti-inflammatory properties of butter (butyric acid, a short chain sat fat):
Involvement of different nuclear hormone receptors in butyrate-mediated inhibition of inducible NF kappa B signalling.
Schwab M, Reynders V, Loitsch S, Steinhilber D, Stein J, Schröder O.
Mol Immunol. 2007 Jul;44(15):3625-32. Epub 2007 May 22.

Role of nuclear hormone receptors in butyrate-mediated up-regulation of the antimicrobial peptide cathelicidin in epithelial colorectal cells.
Schwab M, Reynders V, Shastri Y, Loitsch S, Stein J, Schröder O.
Mol Immunol. 2007 Mar;44(8):2107-14. Epub 2006 Oct 19.

PPARgamma is a key target of butyrate-induced caspase-3 activation in the colorectal cancer cell line Caco-2.
Schwab M, Reynders V, Ulrich S, Zahn N, Stein J, Schröder O.
Apoptosis. 2006 Oct;11(10):1801-11.

I try to highlight more benefits here:

Sears is correct about many things (n-6/n-3 ratio goal 1.5-2.0 and consuming more n-3 to re-shift to treat chronic conditions, heart disease and cancer) but not the sat fat or carb intakes for modern man who had many in utero assualts, e.g. malocclusion that Stephan has highlighted wonderfully HERE.


Stephan Guyenet said...

Hi Matt,

I'm not sure what leads children to suck their fingers, but I suspect it may have something to do with reduced maternal contact/breast feeding.

Hi Amy,

It's very possible K2 plays a role during this period as well. K2-dependent proteins are active at the growing bone sutures.

Hi Spughy,

Thanks for your perspective; I can see how cup feeding might become more difficult after infancy.

Hi Mark,

I'm going to make Dr. Sears' statement more complete by adding "in rodents and cell culture". The fact is, it's never been demonstrated in a live human (that I've been able to find). But in mainstream nutrition science, the bar is so low for any data that indict saturated fat, that you don't actually need to show it causes inflammation in humans to say it does. What they're really focusing on is palmitic acid, which is 20-25% of mammal fat (including human body fat) and palm oil, but not much in coconut.

The only controlled studies I've found on fatty acids and inflammation in humans showed that trans fat, but not saturated fat, increases blood markers of inflammation. But their methods were not sensitive so it's an open question.

However, there are several indirect lines of evidence that sat fat does not contribute significantly to inflammation in humans. Cardiovascular disease appears to be an inflammatory disorder. The overwhelming number of prospective observational studies have found no connection between long-term SFA consumption and heart attack risk/atherosclerosis. The controlled trials, overall, have also failed to show a connection.

Another thing inflammation does is lower insulin sensitivity (NF-kB inhibits insulin signaling). The effect of SFA on insulin sensitivity in humans has been tested a number of times. Whereas high-lard diets rapidly induce a state of massive insulin resistance in rats, that doesn't happen in humans. Most studies have found no effect compared to MUFA or PUFA. The largest study found that insulin sensitivity of the SFA group was 15% lower.

To be fair, the other studies were not large enough to detect an effect this small so it's possible (but by no means certain) that SFA does slightly reduce insulin sensitivity in humans. But this has nothing to do with the massive insulin resistance you see in modern humans. The degree of insulin resistance possibly caused by SFA appears to be equivalent to what you get by drinking coffee (according to controlled trials on coffee consumption), but no one's mounting public health campaigns to stop coffee drinking. I think it's notable that saturated fat consumption has declined in the US as insulin resistance has increased.

So basically, if saturated fat causes inflammation at all, it's an effect so small that it's difficult to detect. I'll continue to follow the literature, but at this point I'm going to keep on eating the fat our species has always eaten: animal fat.

Mark said...

To Dr. B G and Stephan, thank you so much. This is what I was looking for. When people start throwing science stuff at me, I usually have to defer judgement because I'm not trained in bio-chem.
The thought didn't make sense to me because there weren't avocados (that many at least) or olive oil to feed Mr. Paleo. Also if Kurt at PaNu is correct, traditional animal meat is made up of 50% sat, 40% mono, and 10% poly.
I will go back to eating my saturated fat sources with some starch and meat while avoiding fruit (no more than 1 to 2 pieces a day), sugar, wheat, veggie oils, artificial sweeteners, and try to get some sleep while I'm at it. I will continue with my 2 tbsp of fish oil a day though, I think that has merit. Please let me know if you think otherwise. Thanks again.

Dr. B G said...

Thank you Stephan for all your succinct thoughts on the sat fat literature!!! Awesome!!

Mark -- I'd get my n3 only from the freshest, least rancid/oxidized fish oil (preferably from small, sustainable fish). I rarely get n3 from seafood any longer (though I love raw fish). Unfortunately seafood is so highly polluted from what I've read. If cats are in fact the 'canaries', then I now totally avoid seafood which appeared to immediately cause endocrine disruption in all 3 of my cats after introducing seafood soft/canned food to them (Hashimoto's in one, Grave's in 2). California uses the most flame retardants GLOBALLY. We are so retarded!! Seafood at the higher ends of the food chain appear to concentrate flame retardants, dioxins, mercury and many other heavy metals, etc.

Mark said...

Good point Dr. B G, I use Carlson's liquid fish oil. I think that's good.

Stephan Guyenet said...

Hi Mark,

In my opinion, 2 tablespoons of fish oil per day is an excessive amount. I believe it's best not to exceed one teaspoon per day, in the context of an otherwise healthy diet. Too much fish oil increases oxidative stress, LDL susceptibility to oxidation, and suppresses eicosanoid formation excessively.

Mark said...

Hi Stephan,
Thanks for your feedback, much appreciated. Couple of questions though.
So you would disagree with Robb Wolf who routinely suggests 0.5 g EPA/DHA per 10 lb of bodyweight? Sears also suggests at least one 1 tbsp per day or 2.5 g of EPA/DHA. My goal in dosing 2 tbsp is to help reverse insulin resistance (not sure how much I am but I was under the assumption that extra fish oil is better than too little and I still have small love handles) and to help balance the 6:3 ratio since I still eat grain fed meat (switching soon) and get some veggie oils through corn chips or taco shells during some meals. I know from your posts that it is ideal to not get these 0-6 oils at all but is it better to try and 'dilute' these out with higher fish oil intake instead of letting the ratio be higher with lower fish oil consumption?
1 tsp of Carlsons is 1,300 mg of DHA/EPA. If you think that is enough for me, 207 lbs roughly, I would definitely trust your judgement.

Anonymous said...

Wow, Stephan, as many others have previously noted, this whole series is simply fantastic! I have developed yet another passion/interest (as if I needed one...), dental anthropology! Someone should consider submitting a script of this and accompanying Weston A. Price documentation to PBS :-)

Purely anecdoctal of course but, due to social pressures at the time (I was born in 1973), I did not get breastfed. Based on the advice of our family doctor at the time, it was also suggested that I "seemed" hungry all the time (why no one figured out that this was because I was being fed formula is beyond me!!!) and that therefore, from the tender age of 4 and on, I was to be fed cereal, in the form of Pablum. Yummy soaked, whole-grain pablum at least you say... NO, OF COURSE NOT! Well, come my teenage years, I presented a severe overbite due to an underdevelopped mandibule. I had to undergo a pretty complicated jaw surgery, after having four perfectly healthy and very large molars pulled out, and my wisdom teeth were never allowed to come out, for fear of crowding due to lack of space following all this extensive surgical work.

Add to that the fact that I was also always hungry as a very, very active teenage boy eating a mostly high-carb diet, devoid of any good fats, and one begins to understand quite a few things...

Hmmm, I can't help but wonder now, "what if"...

Needless to say, our 1.5 year old son is still breasfeeding and hopefully, with all the good fats and nutrients that come from his nutrient-dense Weston A. Price-type diet, he will fare a bit better than I did!

Cheers to you my friend,

Stephan Guyenet said...

Hi Mark,

My opinion is that long-term consumption of large doses of fish oil probably has negative consequences. Few, if any, well-documented healthy cultures eat more fish fat than a teaspoon per day. I'm willing to be corrected if that statement is wrong, but I haven't come across any. The Inuit did eat more long-chain omega-3 than that, but they also ate nearly zero carb and were not optimally healthy in any case.

Mark said...

Thanks for your feedback, I will switch to one teaspoon a day while trying to be more Paleo. Your efforts are always appreciated!

trix said...

Thank you so much for this very interesting series.
I breastfed each of my 3 kids 2 to 3 yrs. They didn't need braces whereas I was not breastfed, and had a bunch of teeth pulled for braces. A few years ago an holistic dentist told me that my childhood orthodontist should have been shot for doing it that way. He said I will probably look older earlier than if I still had all my teeth.


Half Navajo said...

hey Lucy!!!

way to get it done right with your kids!!!

I have to say it again.. man this crap makes me over analyze my facial structure and teeth....mmmm....

good comments on the fish oil and saturated fats.


Monica said...

"I have to say it again.. man this crap makes me over analyze my facial structure and teeth....mmmm...."

Definitely. I had my four bicuspids and four third molars removed.

I was formula fed because my mom couldn't get me to latch on. I guess in 1975 there wasn't a whole lot of support or technology for breastfeeding. She told me she tried really hard but it just wasn't working.

Most people tell me I have a beautiful smile now, but the orthodontics were really painful (way worse than the extractions, and I was out of school 2 weeks for the wisdom tooth extractions). I wouldn't put my worst enemy through what I had to go through. And I wonder, too, what my face would look like with eight extra teeth in my mouth.

Adolfo David said...

About fish oil.

The most important thing is not fish oil amount per se, but EPA DHA amount. Most experts recommends 1 to 3 EPA DHA grams per day. Its not the same 1 tablespoon oh a very concentrated fish oil than a very poor cod liver oil. Personally I take 2 grams of EPA DHA per day. As any nutrient in excess is not good obviously. And everybody needs a minimum inflammation for optimal immune response.

Oxidation issue: If you take a fish oil rated with 5 stars by International Fish Oil Program, IFOS, oxidation is not a concern. Also you have in the market fish oils with sesame lignans which delete/avoid further oxidation probability of fish oil.

Gabriella Kadar said...

Harpseal oil capsules are available in Canada. Most of this is exported to Asia but it is available in Korean supermarkets and healthfood stores.

It is alleged that seal oil omega 3 ratios are better than fish for human consumption.

I'm not an expert on this subject.

However, the seal oil capsules are smaller and not enteric coated. There is also no 'fishy burp'.


The adverse consequences of lack of breastfeeding and poor nutrition on facial development is a public health disaster.

We do not live in a child friendly society. Sure it takes a village to raise a child, but it takes two tits to feed it.

Frank said...


could you please cite the studies that you told Mark about concerning SFA and Insulin resistance?

Well, as everyone else, this post series rocks.

Thanks a lot!!

pcm266 said...

I just wanted to express that I've truly enjoyed reading your posts about malocclusions. As an adult, who has gone through corrective surgery in September to correct an open bite, it was truly great to find new information on the subject.

You would not believe the things orthodontists say to patients, they seem to blame everything on genetics or lack any good answers when patients ask about these issues. For example, they tell me that my open-bite is caused by genes, whereas my parents did not have malocclusions. These things simply were not that common in my ancestry (who were mainly rural folk), so how does it become genetic all of a sudden?

I was breastfed till I was 13 months old, but I did suck on my finger as a child (to some extent).

Have you ever touched on the trendy topic of superfoods, or goji-berries especially? I am extremely skeptical about all these online stores selling such products and quoting dubious Chinese studies about the health benefits of these products. Have you ever tackled this topic, and would you ever consider looking into these things?

Anonymous said...

Excellent series, thank you. Might I recommend having the posts tagged as "Malocclusion" or something similar? It would be much easier then to link to the whole series.

Adolfo David said...

So curious, I think adding butter to a meal (low glycemic moderate protein in my case) suppresses my appetite a lot, really a lot.

lightcan said...

I would like to second Adolfo's point. We need to be clearer about fish oil quantities. A tablespoon says nothing about the content in omega 3. Chris Masterjohn recommends not going over 1% which means that if you eat 2000 kcal 2 grams of omega 3 is plenty. I suppose it depends on weight and height too. The other point is of course to stop taking it if you come down with a flu, for example, to let your body fight the inflammation.

I would like to add to the anecdotes about malocclusion. I have two kids, they were breastfed until they stopped themselves. The boy was breastfed for longer (13 months) he refused to take the bottle at around 8 months when he went to the creche (he didn't want any kind of cup either) and he didn't want a pacifier after 6 months, but he's the one who had an overbite at around 3. He's almost 5 now, it seems to be getting better. My daughter stopped breastfeeding at 7 months, drank formula from a bottle after that until 1, had a pacifier until the age of 3 and a half and she's fine from that point of view.
It could be less K2, but he seems to have stronger, wider teeth. Also, he had a tight frenum and there has been a lot of teeth grinding at night too.

Thank you Anna for all your information on orthodontics.

Stephan Guyenet said...

Hi Francois,

Here's a good review article from 2008 that discusses the clinical trials:


The thing I like about the trial is they only include studies that used reliable methods for measuring insulin sensitivity (as opposed to HOMA-IR). The thing that irritates me about it is they really focus on the one study that did find SFA decreases insulin sensitivity. The studies overall show no significant effect of SFA on insulin sensitivity. I'll be discussing that in a post at some point.

Hi Pete,

I don't think I've written about superfoods. As far as I'm concerned, the only superfoods you need are liver, greens and pastured butter. All those exotic berries are a waste of money. Did you know that goji berries grow in Europe? They call them wolfberries and no one eats them. Ah, the power of marketing.

Adolfo David said...

Umm about goji, here in Europe goji is famous among health conscious people. Every kind of berry like bluberries or blackberries is healthy dut to its polyphenols, obviously, and most probably goji is not worse or better. Liver? I would never take this high source of inflammatory arachidonic acid, when omega 3 enriched liver? :P Its boring being agree in all :)

LPaForLife said...


I can't eat liver because I can't stand the taste. I can eat many wierd things, but not liver. I have an alergic reaction when I eat butter. So am I doomed to bad nutrition?

Stephan Guyenet said...

Hi Adolfo,

Hmm. I never heard of them in France. They used the plants to make fences in the UK. Not many people ate them there, although a few did. I can't speak for all of Europe though, maybe people ate them more in some places.

Liver is the most nutritious food on earth by far, so I will always recommend it despite the AA. PUFA balance is important, but it's not the only factor.


Don't worry about the butter, you can always use cream (just kidding-- that's a quote from Julia Childs). As for the liver, you might be able to get some of the same things by eating other organs such as kidney, heart and sweetbreads. Chicken's eggs are good too.

Adolfo David said...

When I say here in Europe..I live in Madrid, spanish mediterranean coast and visit frequently Barcelona (all in Spain). Here you can find organic goji even in some big supermarkets where there are organic foods, diet products and similar. And I sell here nutritional supplements made in USA -and I am health journalist-, and many customers ask me about goji lol. Acai, noni, mangosteen are all in the same position of 'superfoods' as understood by customers-citizens. Since they have a lot of polyphenols I like them but I dont consider them a miracle or essential food or similar. I confess in my kitchen there is organic goji berries but I have so many foods in my kitchen! Superfood, interesting term, maybe for me fish oil (now I love also coconut oil lol), berries in general, brocoli and extra virgin olive oil, for me only then a long chain saturated fat like organic butter in fats field. Yeah, I have a very deep hatred to AA :)

Gabriella Kadar said...

Don't forget about oysters. They are probably also a good source of K2 and are definitely a great source of zinc.

I don't know if they are totally an alternative to liver but they are cultivated and not fed corn or soy.

Same goes for sea urchin. They are fed kelp which is also cultivated in cool ocean waters. Uni (raw sea urchin 'roe')is a great source of nutrients.

There are sustainably cultivated invertebrate alternatives to consuming mammalian flesh. If a person so chooses.

Low-Joe said...

Hi Stephan,

great post, as always.

Sorry, the following is bit oftopic.

Hi Adolfo,

do you still have any problems by eating food with a natural higher amount of AA, for example eggs & liver?

I’ve had written my experiences with eggs (AA) on this blog some time ago. A short summary: I’ve suffered from Crohn's disease (over 10 years). 3 years ago I started with Low Carb but I although reduced all polyunsaturated fats (Peat, Masterjohn), especially AA. So I didn’t eat eggs and liver only occasionally. After 2,5 years everything was fine, even the fistulas are cured completely. Then I started to reintroduce eggs (3 eggs per day). After 3 weeks the fistulas were inflamed again. SHOCK!!! That was always on LC. After that I decided to stop the egg consumption and to take some fish oil (3-4g daily, 1,2g DHA/EPA). 3-4 weeks after that, the fistulas were closed and cured. Several months later I decided to give the eggs a try again, because they are so nutritious, but now while taking some fish oil. 3 weeks later the fistulas were inflamed again.

After that I never eat an egg again, although I’m thinking that 3 eggs per day are not that much. After this 2,5 years on LC I decided to eat more carbs (because in my case the total amount of AA is very important, even on LC), like I do nowadays (about 200g/day from potatoes & sweet potatoes).

Some time later (after the egg consumption) I tried to eat liver (calf) on a regularly basis, that means 30-40g daily. Although while taking fish oil (3-4g daily, 1,2g DHA/EPA) the fistulas inflamed after 2-3 weeks. After that period I decided to take a little bit more fish oil (6g/day, 1,8g DHA/EPA) until the fistulas are closed and cured completely.

I know that pufas (tissue) have a long half life and that the total amount of AA on LC diet isn’t that important as on a normal high carb diet.
For example the following study: http://www.ncbi.nlm.nih.gov/pubmed/18046594?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=17

Or an article of Masterjohn:
“The fatty acid changes were somewhat surprising. The level of arachidonic acid (AA) actually increased on the low-carb diet. DHA increased, but EPA and other omega-3 fatty acids decreased. The AA:EPA ratio, then, increased, while inflammation decreased – quite the opposite of what conventional theory would predict. Decreases in inflammation had no meaningful correlation with weight loss, but were in fact correlated with the AA level and the AA:EPA ratio! Again, just the opposite of what conventional theory would predict.” (http://www.cholesterol-and-health.com/The_Cholesterol_Times-Issue-12.html)

I’m knowing al lot of studies like that, but my own experience is, that once somebody suffers from a chronically disease (in my own case crohn`s disease), it is better to eat a low AA diet (although while eating LC) and so a low polyunsaturated fat diet (but with some DHA).

As for my fat sources I’m only eating pastured butter and coconut oil, no other vegetable oils, and taking a little bit fish oil (although the total pufa content, omega 3 & 6, of my diet since the last 3 years never exceeded 3%). Beside the fact that I`m not able to eat such nutritious foods like eggs and liver on a regularly basis, I feel fine. My own experience is, that saturated fats are safe even or straightly by chronically diseases like crohn`s disease.

Lovely greetings from Germany @ all!

Low-Joe said...

I think it is very difficult to give an advice for everybody. Even such nutritious foods like eggs & liver could be problematic for some people (on an regularly daily basis and in higher amounts), but I although would them recommend. It is the same as glucose for diabetics. A healthy person could handle them whereas an unhealthy person has a big problem with the same amount. Before I suffered from crohn`s disease I eat a lot of sweets (really a lot, the same goes for wheat) and not much of arachidonic acid containing foods. In my opinion, the problems are not the foods which contain AA but rather the foods which lead to the disease (sugar, vegetable oils and may be wheat) where you can’t handle AA accurately.

A healthy person should eat eggs and liver regularly but some people may be do better with lower AA diet.

Adolfo David said...

Hi Low-Joe, I take omega 3-eggs, never liver. That reducing omega 6 and sugars is the most important step does not mean that AA food is not a concern in any way. I would suggest you to try another terrific antiinflamatory fat: extra virgin olive oil, which is full of polyphenols.

Stephan Guyenet said...

Hi Low-Joe,

Interesting, thanks for sharing your experience.

Heidi E. said...

Stephan, your site, among others has been a real savior for me. I discovered your site and Sally Fallon's Nourishing Traditions book at nearly the same time, coincidentally, and boy has my life changed.

I started to wonder about my daughter's teeth because they were decaying. She is nearly three now. We are still nursing, so of course her dentist tells me that the nursing at night is what is causing the decay and has been urging me to wean her. And that seemed just so bizarre to me. Her teeth and mouth seem well formed and well spaced, but the cavities!

Now I realize that it was her diet. She doesn't eat much refined sugar and we don't serve juice on a daily basis. But we were vegetarians. Until 2 months ago, I was a vegetarian for 20 years. And she was also. She eats a little meat now, and as much butter as I can get into her. She gets Cod Liver Oil every few days (still working on getting her to take it straight so I don't have to hide it in smoothies that she may or may not drink).

I can't change her diet as readily as I can change mine, so I will happily continue to nurse knowing I'm passing on some of the benefits of my new diet. And she doesn't show any signs of stopping. Hopefully we'll see improvements in her dental health.

To the poster above who doesn't like to eat liver--I loved it as a child and I have lost my taste for it now. I just started cutting up frozen beef liver into little "pills" and taking it with a glass of milk. I try for about an ounce of raw liver each day among the other dietary changes I've made.

While I can see that the Paleo/Primal diet is clearly optimal, I'm not sure we'll ever be there. We're slowing getting grains out of our diet, but cultural and financial restrictions are hard to get around.

I do have a question about the nursing vs. bottle feeding/pacifiers. Why, in layman's terms, doesn't breastfeeding cause the same oral problems as the artificial nipples? I've heard lots of advice to the contrary (so many "experts" out there!) and I'd like to be armed with some more information.

Heidi E.

Stephan Guyenet said...

Hi Heidi,

Glad you've made some positive changes, I hope your child's teeth improve.

Here's the theory of why breast feeding and bottle feeding are different.

Breast feeding and bottle feeding cause different patters of muscle activity in the mouth, and thus exert different forces on the surrounding bones. Breast feeding requires a peristaltic motion of the tongue that's similar to how an adult swallows (imagine a wave moving along the tongue as it pushes milk from the front to the back of the mouth-- you can feel it's the same motion your tongue makes when you swallow).

Bottle feeding requires a piston-like motion of the tongue that's different from normal swallowing, due to the different texture, shape and size of a plastic nipple, which does not approximate the texture, shape or size of a human breast. It creates a suction force in the mouth, creating inward pressure on the jaws that prevents them from broadening normally. This also leads to an increase in the height of the palate, constricting the sinus passages above.

Abnormal swallowing patterns are highly correlated with malocclusion. Breast feeding teaches a child the proper adult swallowing motion, whereas bottle feeding interferes with it.


Anna said...

Heidi E.

Take a look at retired dentist Brian Palmer's website on breast-feeding. He has excellent slices which illustrate how differently babies suck from a real nipple versus a simulated nipple.

Main page
The second page is on breast feeding and the importance to health.

Heidi E. said...

Oh excellent! Thank you for your quick response. That is indeed easy to understand and explain to others. When nursing in public, I often hear that continued nursing contributes to poor dental health.

It's hard not feel some guilt over my past nutritional "mistakes" with regard to my child's health, but at least I can feel a little redeemed knowing that child-led weaning is best for her.

Thanks again,
Heidi E.

Heidi E. said...

Oh, and thanks to you too, Anna!

Anna said...


We all make "mistakes" with our kids, so don't feel alone. Just hope that overall the right decisions get made and put into practice more often than the wrong ones. We mothers are often so prone to taking on guilt, not to mention the guilt that is heaped upon us by others.

It's also sometimes tough to know when to tune out what other people say about what we do and when there is some merit to consider (or at least learn more). I find my gut instincts haven't always been the best either, but I do think my "filter" for new information is getting better all the time. The timing isn't always right though - so much I wish I'd considered earlier.

I'm finding it helpful to separate issues from typical 20th-21st century perspectives and try to see things from other angles before arriving at a decision.

trix said...

For those of us who weren't raised on organ meats: try grinding liver, hearts, whatever organ meat and mixing it with ground beef (or grinding them all together) then using it as you would ground beef. No one will be able to tell. I wish I would have thought of that when my kids were little. I just started doing that...I've made meatballs, and chili that way. If anything the sauces were a bit richer.

Unknown said...


Do you have evidence that polyphenols have any benefits in vivo? Any longer term trials?

BJ said...

Question about liver. I believe I got the idea from this series or one of your others that liver was a good source of K2. I've been eating a decent amount of duck liver paste lately and plan on continuing with whatever the best butter I can buy is. The question is when I checked NutritionData.com on liver it said basically no vit K. I wonder if this is because their chart is actually K1 and not K2 for the liver types I've checked.

Haven't found of good source of other livers to cook for myself. I only really get it when we head out of Tampa on vacation in Vegas, San Fran, etc.

Stephan Guyenet said...

Hi Joseph,

Mammalian liver is a good source of long-chain menaquinones MK-7 through MK-10. It also contains some K1 and K2 MK-4, but not much of the latter. Chicken and goose liver is a good source of MK-4, especially foie gras which is very rich in it.

NutritionData is pretty good, but every now and then I see results I don't trust on it. Particularly when it comes to vitamins like K, that have several forms. You never know how they measured it or which forms they measured. This is a case where I trust the published papers more than NutritionData.

Stephan Guyenet said...

Duck liver is also likely to be a good source of MK-4.

Adolfo David said...

Sven, there are many studies in vivo, for example you have in HEALTH MYTHS EXPOSED 2nd edition by Shane Ellison and recommended by Weston Price Foundation members some citation about that some polyphenols are in vivo even more effective taken from supplements than from original natural source.

Probably polyphenols is one of the main reasons why veggies and fruits are in general so healthy.
"Antioxidant Activity of Tea Polyphenols In Vivo: Evidence from Animal Studies" Journal of Nutrition, october 2003

The Disease-Fighting Power of Polyphenols
By Laurie Barclay, MD


Gabriella Kadar said...

Nutritiondata.com is bizarrely out of date. FOr example: oysters....23 mg of cholesterol...... a food that is 'high in cholesterol'.

Ridiculous skewing of influence on readers based on empiric data.

As to K1, K2 nutritional analyses: nutritiondata.com has no K2 data whatsoever. Everything is based on phylloquinone content.

If you do a search on nutritiondata.com for any single 'ingredient' like oysters, you'll get a preferential presentation of canned or prepared foods.

I have not done any investigation, but I do wonder who is subsidizing or financing this website.

Anonymous said...

"Hunter-gatherers and other non-industrial populations typically breastfeed for 2-4 years, but this is rare in affluent nations. Only two percent of the mothers in this study breastfed for longer than one year."

"Does he want feeding? Does he? Shall Mummy get her breast out?"

"Mother, I'm 47 and a Chartered Accountant"

Seriously though I had a thought about thumb sucking (which I did). Maybe children who aren't getting sufficient nutrition are doing the "non-nutritious sucking" out of desperation, trying to get D3, K2 or some other missing ingredient by sucking everything they can find.