Vitamins and Other Supplements: An Update

We are often asked about various vitamins and supplements and when important information becomes available, we try to make blog posts to update everyone.  We’ve also decided to summarize some of our thoughts about supplements and this is the result of that effort.  As always, the opinions expressed here are general recommendations and we always encourage a conversation with your physician before you make any changes to previously recommended treatments.

Multivitamins

There is general agreement among physicians that a well-balanced diet provides adequate vitamins and minerals required to maintain health and prevent diseases. Over half of Americans report that they regularly take dietary supplements in an effort to improve their health.  Unfortunately, no studies have documented any benefit from multivitamin supplementation in healthy adults and safety concerns have been raised.

Specific vitamins and supplements

We do not recommend routine supplementation with vitamins A, C, E, folic acid or beta-carotene.

Taking antioxidant vitamins (such as vitamin C and vitamin E) has been promoted as beneficial in prevention of colds, heart attack, stroke and cancer. Unfortunately, none of these illnesses are prevented by taking vitamins. And worse yet, evidence has accumulated that antioxidant vitamins can be harmful. 

A remarkable study from Norway published in the New England Journal of Medicine in 2006 rebuffed prior theories that heart attacks could be prevented by antioxidant vitamins and was among the first to raise concerns that these might actually increase heart attack and stroke risk. 

Supplemental beta-carotene, vitamin A and vitamin E may increase risk of death according to a recent JAMA review.  

A study published in the Proceedings of the National Academy of Sciences demonstrated that taking supplemental vitamin C and vitamin E eliminated one of the major benefits of exercise in healthy men (in this case, the body’s ability to respond to insulin). We described this study in detail in a prior post.

There is no evidence that vitamin E is effective in preventing Alzheimer’s disease or other types of dementia.

A recent review of 67 studies (involving over 230,000 participants) concluded that vitamin C (alone or in combination with other vitamins) did not lower mortality. The same review concluded that vitamin E supplementation (as well as supplementation with vitamin A and beta-carotene) may increase mortality significantly.  

A recent study published in the Archives of Internal Medicine also concluded that the “more is better” approach is not necessarily the best.  They concluded that for adult women, multivitamins, vitamin B₆, folic acid, iron, magnesium, zinc and copper all increased mortality in and that calcium supplementation decreased overall risk.

A study published in the Journal of the American Medical Association this month also concluded that men who took 400 IU of vitamin E were 17% more likely to develop prostate cancer over 7 years than were those who did not take vitamin E.  An earlier study concluded that vitamin E supplementation increased the risk of death in men.

Earlier studies in smokers found that beta-carotene supplements increased lung cancer risk and the trace mineral selenium has been linked to an increased risk of non-melanoma skin cancer in women and men.

The exceptions

Deficiencies of vitamins B₁₂ and D are linked to many health problems and when low levels are found in lab testing, we often recommend supplementation.  Also, most American adults should probably take a calcium supplement. 

It is very clear that vitamin D is important for bone health (to prevent osteoporosis). Recently, data have suggested that adequate vitamin D levels may also decrease the risk of falling, and prevent colon polyps and cancer and heart attack and may facilitate weight loss in those who are overweight. We’ve reviewed this data and while it’s unlikely that vitamin D is magic, it does seem to be important. Over-the-counter vitamin D supplementation is reasonable for average-risk patients who have a mild vitamin D insufficiency, but a much higher dose (prescription strength) supplement is probably more appropriate in patients at risk for osteoporosis or those with severe deficiency.

Low levels of vitamin B12 can cause anemia and damage to the brain and nerve cells. Symptoms of nerve damage may be present before anemia. They can include numbness or tingling in the fingers and toes, poor balance and coordination, forgetfulness, depression, confusion, difficulty thinking and concentrating, impaired judgment and poor control of impulses, a decreased ability to sense vibration, ringing in the ears (tinnitus), and dementia, a decline in mental abilities that is severe enough to interfere with daily life.

The Bottom Line

With the few exceptions above, vitamin supplements are unnecessary and potentially harmful.  A well-balanced diet coupled with daily exercise is the closest thing to a magic pill for good health.

Written by: Drs. Martin, Schrader and Yates

Don't Cancel Your Mammogram Yet

As you’ve certainly heard or read, the USPSTF (United States Preventive Services Task Force) has issued updated guidelines for breast cancer screening. Here’s a summary of those recommendations and our comments.

Summary of USPSTF Recommendations

• The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. The USPSTF recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is at least moderate certainty that the net benefit is small.

• The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

• The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

• The USPSTF recommends against teaching breast self-examination (BSE). The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.

• The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

• The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

Summary of American Cancer Society Recommendations

• Yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health.

• Clinical breast exam (CBE) should be part of a periodic health exam, about every 3 years for women in their 20s and 30s and every year for women 40 and over.

• Women should know how their breasts normally feel and report any breast change promptly to their health care providers. Breast self-exam (BSE) is an option for women starting in their 20s.

• Women at high risk (greater than 20% lifetime risk) should get an MRI and a mammogram every year. Women at moderately increased risk (15% to 20% lifetime risk) should talk with their doctors about the benefits and limitations of adding MRI screening to their yearly mammogram. Yearly MRI screening is not recommended for women whose lifetime risk of breast cancer is less than 15%.

Phil Evans, a professor of radiology at the University of Texas Southwestern Medical Center and president of the Society for Breast Imaging, says he was "shocked" by the changes. "There's a ton of scientific data in this country and others on screening that shows a significant benefit for women between 40 and 49 to be screened," he says. (Quoted in the Wall Street Journal)

It is important to note that the American Cancer Society and other groups have not changed their recommendations (which uniformly include teaching breast self examination and routine mammography). Dr. Schrader, Dr. Bond and I will review the evidence supporting these changes as it becomes available, but for now we believe that it is premature to change screening procedures.

Comments / Posted by Scott W. Yates, MD, MBA, MS, FACP

Preventing Flu: What Works

From Airborne to vitamin D, the truth behind preventative measures and treatments.

In 2004, People magazine interviewed Dr. Peter Katona, an associate clinical professor of infectious diseases at the David Geffen School of Medicine at UCLA, about a money-making dietary supplement called Airborne.

The small tablets, then being marketed as a handy cold prevention and treatment remedy, are chock-full of vitamins, herbs and minerals and fizz once placed in water.

Katona gave a frank opinion, calling the over-the-counter supplement a "waste of money." The actor Kevin Costner, on the other hand, gave a brief but glowing review and confessed to stashing them on his private plane.

"Who do you think readers listened to?" says Katona, with a laugh.

In Depth: Cold/Flu Products To Try, And Toss

Katona's assessment was reinforced last December when Airborne agreed to pay up to $30 million to settle a class-action lawsuit. The Federal Trade Commission, which announced the settlement, said Airborne lacked "competent and reliable scientific evidence to support the claims."

Airborne is still on the shelves--with a slightly different marketing claim that it supports the immune system--but that doesn't make the product any more effective.

Though Americans spent $4.6 billion on cough, cold and sore throat remedies in 2008, in fact there are only a handful of scientifically proven preventions and treatments for viruses that cause the cold and flu, and none of them involve excess doses of vitamins. Instead, public health officials and physicians have a more common-sense approach, including avoiding sick people, getting vaccinated for the seasonal and H1N1 flues, managing symptoms with reliable medications like an anti-inflammatory or decongestant, and seeking treatment for the flu within the first 48 hours of flu symptom onset.

Prevention and Treatment Myths

Still, this doesn't stop sufferers from relying on a host of ineffective treatments. Like Dr. Katona, emergency physician Dr. Frank McGeorge often deals with patients who rely on remedies that lack scientific proof until their symptoms worsen and they have to see a health care professional.

McGeorge, a Detroit-Mich.-based spokesman for the American College of Emergency Physicians, says a lot of patients often take vitamins like echinacea, zinc and vitamin C once they get sick. While research on the use of the herb echinacea to treat colds and flues is still ongoing, many studies--including two funded by the government--have found no benefit.

Similarly, there's not enough scientific evidence to demonstrate that zinc and vitamin C are powerful weapons against the cold and flu. On the contrary, both can be harmful in excessive doses. Earlier this year, the Food and Drug Administration warned consumers that the homeopathic cold-treatment nasal spray Zicam, which contains the mineral zinc, had been linked to a loss of smell in more than 100 people since 1999. McGeorge also advises against regularly taking more than 500 milligrams of vitamin C per day. Doing so over a long period of time may be harmful; excess vitamin C can cause severe diarrhea.

"There are very intelligent, well-grounded people who swear by this stuff," says McGeorge, referring to vitamin supplements and homeopathic remedies. "My problem is that people taking these [products] sometimes ignore things that will really help them and instead choose voodoo medicine."

Getting Smart About the Cold and Flu

Instead, McGeorge would prefer patients to practice cold and flu prevention by washing their hands, avoiding sick people, staying healthy and, for the flu, getting vaccinated. This year that means obtaining both the seasonal flu vaccine and the H1N1 vaccine. The second vaccine is particularly important for high-risk patients like pregnant women and young children.

Controlling uncomfortable symptoms of either the cold or flu can be done with over-the-counter medications like ibuprofen, an anti-inflammatory that reduces fever and pain; a decongestant, which relieves swollen tissue in the nose; or an antihistamine, which minimizes sneezing, runny nose and coughing. And staying hydrated, which helps keep mucus moist and easy to clear from the nose, will do more to help the body heal than any alternative or homeopathic remedy.

Dr. Norman Edelman, chief medical officer at the American Lung Association, says an effective cold and flu prevention strategy should also include a healthy diet, exercise and plenty of sleep. Following these guidelines will help support the immune system, though Edelman stresses that minor slip-ups, like missing an hour or two of exercise during the week, won't severely compromise one's natural defenses.

And if you've been unfortunate enough to catch a cold or flu, Edelman has a final recommendation: be considerate of others.

"Cancel that trip to grandma's or don't go to work," he says. "If you're sick and spread it to someone else, that's an impolite thing to do."

Cold/Flu Products To Try, And Toss

Echinacea

Some who use this herb to shorten the duration of a cold or treat its symptoms say that it's effective, and at least one study of 95 people made a similar observation. Yet many studies, including two funded by the government, have found no benefit. The National Center for Complimentary and Alternative Health, a division of the National Institutes of Health, is continuing to study the use of Echinacea in treating upper respiratory infections and in supporting the immune system.

Vitamin C

There is no conclusive evidence to support vitamin C as a cold prevention or treatment remedy, according to the National Institute of Allergy and Infectious Diseases. Several controlled studies have been conducted, but the data on whether or not vitamin C reduces the severity or duration of symptoms is unclear. In fact, taking more than 500 milligrams of vitamin C daily over a long period of time may be harmful; excess vitamin C can cause severe diarrhea.

Consider Vitamin D

If there is a supplement you might consider taking this winter, says Dr. Edelman, it is vitamin D. Recent research has demonstrated an association between vitamin D deficiency and cardiovascular disease and increased risk of the common cold. It's easy to get sufficient levels of vitamin D--which the body processes when it's exposed to the sun's UV-B rays--during the summer months but more difficult throughout winter. Research on the use of vitamin D to protect against the cold is still ongoing; discuss the appropriate dose with your physician.

Tamiflu and Relenza

Practicing prevention doesn't guarantee immunity; for those who do come down with the flu, McGeorge recommends seeing a health care professional within the first 48 hours. That's a critical window of time during which a doctor can prescribe the antiviral medications Tamiflu or Relenza, both of which have been shown to shorten the course of the flu.

From Yahoo Health by Rebecca Ruiz

Reviewed/Posted by: M Keith Schrader, MD

Life expectancy lagging in the United States

Consider the following and then ask yourself why the United States has the same life expectancy as Cuba and Slovenia.

Best, Worst Countries for Life Expectancy

Japan has the world’s greatest life expectancy, and it’s more than twice the life expectancy in Sierra Leone.

That’s according to a new report, World Health Statistics 2009, issued by the World Health Organization.

The report shows that children younger than 5 account for nearly 20% of the world’s deaths, and that child mortality is a major reason for the wide range in life expectancy amount countries.

The World Health Organization’s new report is based on data from 2007, the most recent year for which global life expectancy statistics are available.

The report shows that 14 countries had life expectancies of at least 81 years. Here are those countries, along with their life expectancy for babies born in 2007:

Japan: 83

Australia, Iceland, Italy, San Marino: 82

Andorra, France, Israel, Monaco, New Zealand, Norway, Singapore, Spain, Sweden: 81

At the other end of the life expectancy spectrum, 15 countries had life expectancy below age 50. Here are those countries and their life expectancy for babies born in 2007:

Sierra Leone: 41

Afghanistan: 42

Lesotho, Zimbabwe: 45

Chad, Zambia: 46

Central African Republic, Guinea-Bissau, Mozambique, Swaziland, Uganda: 48

Burkina Faso, Burundi, Mali, Nigeria: 49

In the U.S., life expectancy for a baby born in 2007 is 78 year. Chile, Cuba, Denmark, Kuwait, Slovenia, and the United Arab Emirates share that same life expectancy.

Think you’re healthy?

Don’t answer too quickly. Even though we’re bombarded with health and fitness information, on average American adults still don’t get it.

Researchers at the Medical University of South Carolina compared two large-scale studies covering the period 1988 to 2006 and found the percentage of adults with a body mass index (BMI) greater than 30 rose from 28 percent to 36 percent.

The number of people exercising three times a week or more fell from 53 percent to 43 percent, while the number of people eating five portions of fruit and vegetables a day fell by nearly 40 percent.

The Bottom Line: As Americans, our sedentary, overfed, and indulgent lifestyle trumps our world-class health care system.

From WebMD and World Health Organization: “World Health Statistics, 2009.”
Comments / Posted by M. Keith Schrader, MD