Monday, August 20, 2012

Multi (vitamin) verses

One of the questions that I always have to ask when I meet a new patient is "Are you taking any vitamins, supplements, or herbal products that are not prescribed by your provider?"  Quite frequently the answer I get is "No, should I?"  Unless there are specific health circumstances where I can recommend a specific supplement in a specific amount, my answer is usually no.  Let's talk about why.

Kyle Hill, who is a research fellow for the James Randi Educational Foundation, has already done an excellent post entitled "The Multi-Vitamin Fallacy."  Some of the highlights of his post include 1) Two recent large scale studies indicate there is no evidence for people to take multi's and there is also evidence pointing to increased health problems and toxicity, 2) There is no regulation on supplements so you might not actually be getting what you think you are, 3) people who take vitamins often engage in other healthier behaviors such as exercising regularly and not smoking, and 4) a multi-vitamin does not compare to the hundreds of active compounds found in fruits and vegetables.  So, in other words, people who take multi's because they don't eat fruits and vegetables are still not getting the benefit of eating them and their "additional insurance" isn't working.

Now, there are plenty of people who do acknowledge that they will not get the same benefits from a multi, so their next step is to find a supplement that in their mind actually contains ground up fruit and vegetables.  One of the more popular ones out there is a product called "Juice Plus."  This product is basically fruits and vegetables that are juiced, reduced to powders, fortified with a bit of extra fiber and enzymes, and then sold to the public through multi-level marketing.  The major selling point basically boils down to that we as busy people do not eat enough fruits and vegetables and after we start taking this product pretty much any health ailment that we suffer will somehow start to improve within a few days of taking this product.  Now if you are a skeptic that fact that this product is not ailment specific (i.e. is an all purpose cure) should start the warning bells in your head ringing.  So lets take a more detailed look at Juice Plus.

First of the recommendation that people eat 5-9 servings of fruit and vegetables per day was not to prevent vitamin deficiencies as you can get an adequate intake of various vitamins and minerals on far fewer servings. (Keep in mind that we get vitamins and minerals even when we eat protein sources as well, and as Kyle said in his article, our bodies are pretty efficient at using what we do get!).  The recommendation was to help people eat enough fiber and also to help people "fill up" on lower calorie nutrient dense foods and not fill up on higher calorie foods; in other words, more fruits and vegetables would hopefully translate into fewer fats and grains.  And guess what, just about any diet plan you look at from low carb to the Myplate has a fairly sizeable chunk of the plate as vegetables.  Barbara Rolls, a researcher at Penn State University, has actually published her research about using high nutrient/low calories foods to create a "bigger plate" that helps you eat fewer calories/carbs and still feel full.  Now, if you don't try to fill up on vegetables and instead try to do the Juice Plus, you probably won't get the same satiety value that vegetables provide and it will be that much easier for you to overeat on starches and other caloric dense foods.  So, would this help you with your weight?  Probably not, might even make overeating a little easier too.

One of the other reasons that I have seen people take juice plus is because they have an inflammatory bowel disease such as Chron's.  Typically someone with this condition cannot tolerate raw fruits and vegetables without severe pain and diarrhea.  Chances are they also bought into the idea that people need to eat their fruits and vegetables raw in order to obtain vitamins and minerals, but as I have covered in a previous post you can still get adequate amount and some vitamins and minerals are more bioavailable through cooking.  So, a person with IBD can still take in vegetables and fruits and just do their own cooking or juicing and still get what they need without pain.  On a related note, some people who have trouble with flatulence after consuming certain vegetables might be intrigued by the "enzymes" that are added to the Juice Plus.  Unfortunately, said enzymes do not survive the acidic environment of your stomach and so they won't help you absorb the vegetables better or prevent flatulence.  Once again, eating more vegetables cooked than raw, or learning that you can't tolerate certain vegetables, will help reduce the flatulence.

Also keep in mind that the Juice Plus does have fiber added back to it, but you wind up taking in only about 4 grams of fiber.  Typically, we are going to need more fiber than that to help maintain bowel regularity, so if someone is not eating enough fruit and vegetables, they may wind up trying to supplement their fiber intake via grain products or by taking fiber supplements.  If you wind up trying to supplement your fiber intake with more grain products, you will also be upping your caloric intake and probably going over your carb limit if you have diabetes or pre-diabetes.  In other words, that one cup of steamed broccoli gives you 5 grams of fiber, 55 calories, and only 6 gm net carbs, whereas that one piece of whole grain bread gives you only 3 grams of fiber, 100 calories, and 17 gm of net carbs.  And if you choose to use the fiber supplements, well then you are going to be spending more money in the long run too.

Oh, and speaking of money, you will also be spending on average about $300-$600 a year on the Juice Plus products.  In addition to whatever else you are spending on food.  Perhaps if the lack of evidence doesn't get you, the hit to your wallet will?

Are there some circumstances where supplements are a good idea?  Yes, there are. 
1) Vitamin B12: People who choose to follow a vegan diet should supplement with this vitamin as significant amounts are only found in animal products.  Some older adults also stop producing something called "intrinsic factor" in their stomachs and can't absorb B12 from foods.  People who have had part of their stomach removed for weight loss surgery or cancer, etc will also be unable to absorb sufficient B12 and will need to supplement.  Some people who have IBD will also require supplementation.  But like anything, supplementation will only benefit you if you have one of the above conditions or are KNOWN TO BE DEFICIENT.  A simple blood test can tell you whether or not you are deficient.

2) Vitamin D.  Our bodies can actually make an adequate amount of vitamin D through sun exposure for a mere 15-20 minutes per day, but some people might still be deficient.   SkepticRD works with a mostly elderly homebound population; these are people who don't get outdoors much and even if they did, chances are their ability to make vitamin D from sun exposure has diminished with age or because of other medical problems they might have.  Once we know a person's vitamin D levels are low we have to give them a large dose every week for 8-12 weeks and once their levels are back up to normal they usually require a maintenance dose of 1000-2000 IU per day.  Once a nurse asked me about vitamin-D foods, and I looked her in the eye and asked her if she wanted to start telling our patients to drink 10 cups of milk per day or eat roughly six cans of sardines per day.  She decided to promote safe sun exposure and enforce the prescribed supplement.  Younger people who have avoided sun eposure because of fear of skin cancer or aging might also have low vitamin D levels, but once again a simple blood test from your doctor can tell you whether or not you are deficient.

3) Omega-3 fats.  Omega-3 and omega-6 fats are essential fats, meaning that our bodies do not make these and we must get them from food.  If we get more omega-6 than omega-3 it tends to increase the risk for inflammation and therefore increase risk of heart disease among other things.  Pasture raised beef, game, other foraging animals, and wild caught fish will usually have a higher omega-3 content than feedlot raised beef, caged chicken, farm-raised fish, etc.  For people who do not have ready access to grass fed beef, etc. or choose not to pay a higher price per pound they might benefit from supplementing with omega-3 fish oil.  **Interesting story, when the "new" drugs for HIV/AIDS came on the scene people's life expectancy and quality of life grew--and it also tended to send their triglycerides through the roof.  Most of our lipid specialists would send them to me to help them change their diet but they would also have them taking 9-12 500 mg fish oil capsules per day (or more) to try to combat their elevated lipids.  I still remember the guy who would be sitting on his couch and look up to find both of his cats sitting right by his head.

4) Probiotics.  See this previous post on why that may not be a good idea except in certain circumstances.

5) What if I have a cold or flu and want to "boost my immune system?"  I have also addressed this before, but Mark Crislip does a most excellent job of explaining why that is not a good idea here.

Take home message--supplements will not make up for you not eating nutrient rich low calorie fruits and vegetables.  In a follow up post I plan to talk about the many excuses people give for not eating fruits and vegetables and how to combat them.


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  3. Just found this blog, I have a closed facebook group called crunchy skeptics and I'd love to have you in there since "diets" come up a lot. Just got into a juice plus fight today in person and found this.

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