Damned If You Do, Damned If You Don’t: Vitamins, Global Province Letter, 12 June 2013

Vitamins, minerals and other supplements won't compensate for a poor diet, but they can help fill nutritional gaps in a good one.  -- Dr. Andrew Weil

Flipfloppers. A dietitian of our acquaintance, certainly the one we always most respected, always laughed roundly at nutritionists and doctors who opined about food matters. “Today’s truth is tomorrow's lie," she would say. "What’s gospel at the moment will become the devil’s own words, before you can even say 'Jack Robinson.'"

We find she’s right. Especially when it come to vitamins, with the medical community perfectly divided between those who love them, those who find them ineffective, and those who think they are even bad for you.  Probably one should take a few, stay away from those that are obviously dangerous, but never take any vitamin in excess.  The prevailing view about them changes with some regularity, usually based on very irregular evidence.

So, at once, we both laugh at and take seriously Paul Offit's "Don’t Take Your Vitamins"  which appeared in the New York Times, Sunday Review, p. 4.  He would wean you off your pills faster than Nancy Reagan (the "Just Say No" lady).  Head of the infectious disease division of Children's Hospital of Philadelphia, he winds up his polemic against vitamin supplements with: "As a result, consumers don't know that taking megavitamins could increase their risk of cancer and heart disease and shorten their lives; they don’t know that they have been suffering too much of a good thing for too long."  He is one of many alarmist physicians now warning the world to proceed with caution amidst the vitamin frenzy. 

Querying Experts and the Common Man. Well, we have already been out to the healthcare professionals, to the self appointed experts, and to a few commonsense folks about vitamins. Here is what some of them had to say. They're hesitant, not anxious to put any stakes in the sand.

Airline Pilot Who Always Cuts to the Chase. He finds that there is so little research that one cannot even reach a firm hypothesis. "Vitamins are a semi-enigma. Very few double blind studies exist because they are not patentable, thus no money (other than the supplement manufacturers).
The Danish study mentioned in the Op-Ed piece is one of the few. An adjunct group in the HATS trial faired poorly on the niacin, c and e combo.
Speaking of niacin, if you are taking it to lower app b or LDL- P great, but there are ZERO demonstrated benefits to its HDL-C raising effect, probably because it only changes HDL-C not HDL-P or Apo A-1"

Nutritionist Recommends Restraint and Lots of Healthy Foods.  "I would agree with everything in this article. It has long been recognized that antioxidant supplements (particularly vitamins C and E) do not produce the positive health effects that earlier proponents suggested they would, and that high dose antioxidant supplements may protect abnormal cells from targeted destruction, among other things. I tell people determined to take a multi to limit it to one that has around 100% of the Daily Value for all it's components, except for vitamin D. People may need more of it. It's easy enough to get a 25-hydroxyvitamin D test to see exactly how much any individual needs above and beyond the DV. I always recommend at least 800-1000 iu's, which some multi's may contain.

I generally don't recommend men take calcium because of potential concern about calcification of the arteries leading to heart disease (unless recommended by an MD), and in women recommend they limit their supplemental calcium to 500 mg and try to get the rest from food unless told otherwise by their doctor.

On that note, unfortunately many doctors don't know much about nutrition, but some people are lucky and find one who does. Mostly, I think, aside from vitamin D, and maybe fish oil, supplements serve as distractions from the real work people need to be doing with their diet, which is to eat less animal foods, and more fruits, vegetables, unrefined grains, nuts, seeds, beans and heart healthy oils. Doing this takes a lot more effort than popping a pill."

Chief Executive of Healthcare Firm Detects a Broad Medical Consensus. "The physician consensus seems to be that folks above the Mason Dixon Line find it difficult to get enough Vitamin D...so many prescribe Vitamin D. A lot of physicians also prescribe calcium. Other than those two nutritional items...on which there appears to be a modest consensus, we are left with the theories of individual physicians."

A Very Thorough South American Physician Who Practices International Medicine. Just like the wonderful Roman satirist Horace, he advocates moderation and more moderation.  But he is not skeptical about modest use of vitamins. "Interesting article but incomplete from my perspective. Vitamins are just a large group of molecules that can modify in one or more ways certain biochemical reactions. Some are innocuous, others may cause problems, and others are not well known. They mostly come from foods. Only minute amounts are needed, however, deficiencies are quite common. Grossly, about 20% have significant deficiencies based on my own experience since I measure most of them in several of my patients.

I would suggest not to take vitamin A since it may change the epithelium of several organs including the eye and teratogenesis in pregnant women, vitamin K since it may induce clots, and vitamin E which has been thought to increase in all cases mortality and prostate cancer.

Niacin supplementation is not necessary. Niacin seems to do everything right. It lowers triglycerides, lowers LDL, raises HDL, lowers total cholesterol, lowers C-reactive protein, and increases the beneficial large HDL particles. These facts lead people to think that niacin reduces cardiovascular risk and has been recommended by physicians for a long time. However, it is not the case. The negative results of the expensive NIHsponsored 3,414 patient AIM-HIGH (Atherothrombosis Intervention in Metabolic Syndrome with Low HDL Cholesterol/High Triglycerides and Impact on Global Health Outcomes) trial came as a cold surprise. In AIM-HIGH, randomization to Niacin extended release 1.5 to 2.0 g daily in patients on background Simvastatin plus or minus Ezetimibe, had no impact on major cardiovascular events (NEJM 2011,365:2255). The final nail in Niacin's coffin was placed in December 2012 when Merck announced preliminary negative results of the massive phase III Health Protection Study-2 HSP2-THRIVE trial, in which nearly 26,000 subjects with cardiovascular disease and/or diabetes in the United Kingdom, Scandinavia, and China were randomized to Niacin Extended Release 2 g plus the anti-flushing agent Laropiprant daily or placebo on top of background therapy with Simvastatin plus or minus Ezetimibe. During 3.9 years of prospective follow-up, Niacin boosted HDL levels by 17% and reduced LDL by 20%, but it had no impact on endpoint cardiovascular events and it was associated to an increased risk of serious adverse events (Merck press release). In particular, individuals on Niacin experienced a 20 to 35% increase rate of infections, internal bleeding, and myopathy. There is no evidence supported by any randomized double blind controlled trial at the present time that a patient should be on Niacin to reduce cardiovascular risk.

Vitamin C should be taken in modest amounts. Vitamin C is a cofactor in several important enzymatic reactions. Most of these involve the proper synthesis of collagen, an essential protein that provides structural stability to most tissues and organs. In particular, ascorbic acid is essential for the hydroxylation of proline and lysine groups in the collagen molecule. Hydroxylation allows the collagen molecules to both arrange themselves in triple helix structure and to form cross-links among themselves which provides tensile strength. Vitamin C deficiency causes fragility of tissues expressed as spontaneous bruising, arthralgias or joint aches, nosebleeds, among others. Vitamin C is neither synthesized nor stored in the body. Thus, constant supply from meals such as fresh fruits and vegetables is essential to maintain proper levels. Overdose of vitamin C may cause oxalate kidney stones. 

Vitamin B12 or cyanocobalamin should be taken in modest amounts. B12 is an important cofactor in the metabolism of multiple organs and systems. It has a critical role in the production of red blood cells by the bone marrow, and in preserving an adequate structure and function of both the central nervous system and peripheral nerves. Deficiency of vitamin B12 is associated with fatigue, anemia, cognitive deficits, functional brain and cerebellar disorders, numbness, muscle weakness. Methylmalonic acid and homocysteine are specific metabolic markers and sensitive indicators of functional Vitamin B12 status. Correlation studies between these metabolic markers suggest that optimal Vitamin B12 level should be higher than 500 pg/ml. This is above what we see in most individuals. This vitamin does not cause overdose since it is eliminated by the body. However, in those with renal insufficiency it may cause intoxication by accumulation of cyanide, a component of vitamin B12.

Vitamin D should be taken in modest amounts. Adequate vitamin D level in serum seems to be 45 ng/ml or higher which is higher than what we often find in most individuals. This molecule has a pivotal role in maintaining the normal function of many systems and organs including bone, retina, brain, heart, muscle, skin, and immune cells including those with antitumor activity. Cognitive function, retina integrity, and bone resistance to fractures correlate with vitamin D in a dose dependent manner. In fact, vitamin D serum levels >30 ng/ml correlate to significant cognitive function protection, levels >38 ng/ml correlate to significant reduction in macular degeneration of the retina, and levels >45 ng/ml correlate to a 25 to 50% risk reduction in bone fractures. Vitamin D is mostly produced by the skin when exposed to ultraviolet light from the sun. However, due to the high latitude where most of us live, in addition to our lifestyle that keeps us indoors or covered by clothes, sun exposure is sub optimal for inducing the skin to generate adequate amounts of vitamin D. It is to be noted that Vitamin D has a half-life in serum of about 3 months for which adequate sun exposure or supplementation should be ongoing. Physicians try to discourage sun exposure because of its association to some forms of skin cancers and photoaging.

Folic acid should be taken in modest amounts. Foliate is an important cofactor in the metabolism of multiple organs and systems such as bone marrow, central nervous system and peripheral nerves. Inadequate status of Foliate has important health consequences such as fatigue, anemia, cognitive deficits, functional brain and cerebellar disorders, numbness, muscle weakness. Low foliate concentrations increase a woman’s risk for having an offspring with a neural tube defect. Homocysteine is a sensitive functional marker of inadequate intracellular foliate concentrations. Correlation studies between these metabolic molecules suggest that optimal Foliate levels should be higher than 15 mg/ml. Most individuals have lower values. Foliate has a half life of about 3 months."

Old Crusty Friend in the Philippines Who Has Been Around the Horn a Few Times and is a Vitamin D Enthusiast. "Any article that pretends to discuss the pros and cons of vitamin usage and fails to mention Vitamin D has to be suspect.

If one were to eliminate all vitamin supplements, the very last one to drop would be that for D3. It is free to us from the sun, and is perhaps the most important to our immune system and our cellular functions; BUT I think that nearly all people on the planet are deficient in this vitamin (actually a hormone).

I am told by people that those who live near the equator surely are not deficient. Like people in the Philippines? B.S. Wrong.. They do not want to get browner or blacker. They cover up from the sun. Long sleeves. Parasols. etc.

America? Who gets out in the sun anymore, unless slathered with SPF of about a gazillion and cancer producing chemicals?

Everybody is deficient in Vit D, and all the rest of the talk is basically palaver. Your vit D3 blood levels should be well over 50; idiot doctors tell you that you are OK with a level of about 30. But that is pure crap, like much of what doctors spew out about something they never studied before: nutrition."

Blind Leading the Blind.  Reading between the lines, we can tell that nobody knows that much about vitamins—where they help, where they hurt, what makes them more effective, what happens when different vitamins are given side by side, why they act differently with different human subjects, etc. etc.  The studies are few, small, and incomplete.

We can sense that generally a few vitamins can't hurt you, but too many may.  And we can intuit that some of them, at least, have limited good effects. As our population ages, we probably have greater numbers of people with vitamin deficiencies.  It behooves science to step into the vacuum and figure out how to put the body in balance.  But that has not happened yet: an average aging Joe must cook up his own remedies, magic, and schemes to keep himself alive as time makes it harder for him to replenish his body or get rid of his wastes.  As Desiderius Erasmus quipped, “In the land of the blind, the one-eyed man is king."

P.S.  We have long said that if you let your life be dictated by half truths, most likely you will be half living. Eventually we will get around to adding this to our section on Dictums.

P.P.S.  We think it is fair to say that we spend too much money on packaged vitamins and the like.  And not enough money on things that are relatively free. For instance, turmeric and other spices are pretty helpful, but only a handful of us use them as seasoning.



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