Multivitamins are NOT a “waste of money”! Beware of flawed studies and biased conclusions!!!

Multivitamins are in the news again with the publication of 3 studies in the 12/17/13 issue of the Annals of Internal Medicine purporting to show that multivitamins do not prevent cognitive decline in men, do not reduce risk of heart disease in those who already have it and do not prevent heart disease and cancer, along with an accompanying editorial. These articles were reported on with headlines like “New Study: Daily Multivitamins, Supplements ‘A Waste Of Money.’” A sharply-worded editorial in the same issue titled
“Enough is enough: Stop Wasting Money on Vitamin and Mineral
Supplements,” stated “We believe that the case is closed — supplementing the diet of well-nourished adults with (most) mineral or vitamin supplements has no clear benefit and might even be harmful. These vitamins should not be used for chronic disease prevention. Enough is enough.”

However, as many researchers have stated, the case is FAR FROM CLOSED, in fact there is very good reason to believe, based on the preponderance of evidence, that it is wise for nearly every adult to take a good-quality multivitamin. This essay explains why.

Before doing so I would like to give some context.
I am a Family Practitioner certified by the American Board of Holistic Medicine who has been practicing for over 25 years in Soquel, CA. I have a special interest in nutrition and preventive medicine. In my spare time I volunteer on HealthTap, a website where people can ask questions of doctors. HealthTap gave me an award as the Top Family Physician in California in 2011 and Awarded me as the “Top Holistic Medical Practitioner” in the entire US in both the Winter and Summer of 2013. My fellow physicians on HealthTap have voted me to be the leading expert (among the 53,000+ physicians on HealthTap) in the U.S on Lyme Disease, Supplements, Herbal Supplements, Vitamin Deficiency, Vegetarian Diet and Vitamin C, as well as the 2nd leading expert on Vitamin D and Homeopathy. I invite readers here to visit me on HealthTap, where you can see my answers to hundreds of questions, at

https://www.healthtap.com/#experts/10003096/feed

While I enjoy participating on HealthTap, I was recently contacted by a fellow physician there who is quite upset that I still counsel people to take multivitamins despite the recent studies. I am thus writing this in response to him and the many others who have been fooled by the recent studies.

Before discussing the studies in the 12/17/13 Annals I want to discuss why it makes sense to take multivitamins. But one thing that I want to make very clear is, however beneficial vitamins may be, taking vitamins is never a good substitute for a healthy diet. It is always best to get our nutrients from food whenever possible. Given a choice between someone eating a healthy diet and taking no supplements and someone who eats an unhealthy diet (rich in junk food/fast food/GMO’s/sugar etc.) who takes hundreds of dollars of supplements I would say the person with no supplements but a healthy diet will likely experience far better health. But judicious use of supplements in addition to a healthy diet is the best choice for everyone.

One of the greatest reasons it is wise to take supplements is that most people do not have a particularly healthy diet. For example, there is a large body of evidence that eating Genetically Modified Food is unhealthy, but most of us eat it every day. The only way to be sure to avoid these hazardous “foods” is to eat only organic foods and only eat at restaurants that use only organic ingredients. I would estimate that less than 1% of the population does this (and, health-conscious as I am, I am not among that group). For a more detailed discussion of the hazards of eating GMO food see my essay “Why Eat Organic Food?’ at

https://drrandybaker.com/2013/04/22/organic-food-diet/

Those who say that vitamins are a waste of money seem to have the delusion that most people get adequate vitamins from their diets, so let’s examine the average American diet. The Standard American Diet (appropriately abbreviated SAD) is one of the main causes of our epidemics of obesity, cardiovascular disease, cancer, autoimmune disease and other chronic degenerative diseases. Some frightening facts about the Standard American Diet: Only 7% of calories consumed by Americans are from fruits and vegetables. Half of the vegetables are potatoes and half of those are chips and fries. 23% of the calories consumed by Americans are from white sugar and about 20% from white flour. (see
http://alaskaveg.org/SpookyFacts/SpookyFacts.pdf ).

Authorities have enumerated the DRI or Dietary Reference Intake levels for vitamins and minerals. This is similar to the RDA or Recommended Dietary Allowance. While many authorities feel that getting the DRI’s of nutrients is adequate for good health, it can be argued that they are far from perfect. The DRI’s are generally the level that will prevent an otherwise healthy person from having gross deficiency symptoms but do not apply to people who are ill, do not take into account the wide range of genetic variation of the population and do not reflect the amount of a nutrient that supplies optimal health. There are many cases where doses of vitamins and minerals far above the DRI’s have been shown to have therapeutic benefits. For a further discussion of DRI’s see

http://www.diet.com/g/dietary-reference-intakes

So, given that the DRI’s represent the minimum most people need for health, let’s look at how many Americans get the DRI’s of various nutrients from their diets.The source of this information is at

http://www.ars.usda.gov/Services/docs.htm?docid=11043

According to the US Dept. of Agriculture, only 24.9% of Americans get the DRI of Folate (which appears to lower risk of heart disease and cancer), only 14.1% get the DRI of Vit. E, 27.1% get the DRI of Calcium, 32% for Magnesium, 45.3 % for Vit A, 51.7 for Vit C, 58% for Zinc, 64.7% for B6, 65.7% for Iron, 69.3% for Copper, 70.1% for B12, 71.7 % for Vit B1. You can see the whole list at

http://www.ars.usda.gov/Services/docs.htm?docid=11043

In summary, over 2/3 of Americans are deficient in Folate, Vitamin E, Calcium & Magnesium and over 1/3 are deficient in Vitamins A, C and B6 as well as Zinc and Iron. Thus, these deficiencies are widespread and can have serious long-term consequences. Vitamin D deficiency, not measured by the USDA, is also extremely widespread, probably affecting most Americans who do not take at least 1000 iu/day in fall and winter months.

In 2002 the American Medical Association released a groundbreaking position paper published in the JAMA titled “Vitamins for Chronic Disease Prevention in Adults”
(http://jama.jamanetwork.com/article.aspx?articleid=195039)
Quoting from this review  “In the absence of specific predisposing conditions, a usual North American diet is sufficient to prevent overt vitamin deficiency diseases such as scurvy, pellagra, and beriberi. However, insufficient vitamin intake is apparently a cause of chronic diseases. Recent evidence has shown that suboptimal levels of vitamins, even well above those causing deficiency syndromes, are risk factors for chronic diseases such as cardiovascular disease, cancer, and osteoporosis. A large proportion of the general population is apparently at increased risk for this reason…

We recommend that all adults take one multivitamin daily. This practice is justified mainly by the known and suspected benefits of supplemental folate and vitamins B12, B6, and D in preventing cardiovascular disease, cancer, and osteoporosis and because multivitamins at that dose are safe and inexpensive.”

Now let’s examine the recent studies that lead some to conclude that multivitamins are “a waste of money.” Many of these conclusions are based on the Physician’s Health Study. This same study was in the news in Nov. of 2012 when it was claimed that this study showed multivitamins don’t prevent cardiovascular disease in men. The current conclusion from the same study is that multivitamins don’t prevent cognitive decline in men as they age.
I analyzed this same study in 11/12- see

https://drrandybaker.com/2012/11/11/vitamins-really-do-prevent-heart-disease-beware-of-bad-studies/

The criticisms I had then are the same I have now. The first thing to realize is that not all multivitamins are created equal. I will mostly quote much of my previous essay with a few minor changes.

It took quite a bit of searching to discover what the multivitamin used in this study was, as it is buried in the fine print. The multivitamin used was Centrum Silver. This is considered a perfectly adequate multivitamin by those with only cursory knowledge of nutrition, those who believe that the RDA is perfectly adequate, but for doctors who are knowledgeable about nutritional medicine it leaves a great deal to be desired.

Below is a list of the nutrients in the multivitamin used in this study:

Vitamin or Mineral Amount
Vitamin A (IU) 5000*
Vitamin C (mg) 60
Vitamin D (IU) 400
Vitamin E (IU) 45
Vitamin K (mcg) 10
Thiamin (mg) 1.5
Riboflavin (mg) 1.7
Niacin (mg) 20
Vitamin B6 (mg) 3
Folic Acid (mcg) 400
Vitamin B12 (mcg) 25
Biotin (mcg) 30
Pantothenic Acid (mg) 10
Calcium (mg) 200
Iron (mg) 4
Phosphorus (mg) 48
Iodine (mcg) 150
Magnesium (mg) 100
Zinc (mg) 15
Selenium (mcg) 20
Copper (mg) 2
Manganese (mg) 3.5
Chromium (mcg) 130
Molybdenum (mcg) 160
Chloride (mg) 72.6
Potassium (mg) 80
Boron (mcg) 150
Nickel (mcg) 5
Vanadium (mcg) 10

More detail as to the form of the vitamins/minerals and excipients is here: calcium carbonate, potassium chloride, dibasic calcium phosphate, magnesium oxide, ascorbic acid, microcrystalline cellulose, dl-alpha tocopheryl acetate, pregelatinized cornstarch and modified food starch.

Centrum Silver contains less than 2 percent of the following ingredients: acacia, ascorbyl palmitate, beta-carotene, bht, biotin, boric acid, calcium pantothenate, calcium stearate, cholecalciferol, chromium picolinate, citric acid, cornstarch, crospovidone, cupric sulfate and cyanocobalamin. More ingredients include FD&C blue no. 2 aluminum lake, FD&C red no. 40 aluminum lake and FD&C yellow no. 6 aluminum lake.

Further, Centrum Silver contains folic acid, gelatin, hydrogenated palm oil, hypromellose, lutein, lycopene, manganese sulfate, medium-chain triglycerides, niacinamide, nickelous sulfate, phytonadione, polyethylene glycol, polyvinyl alcohol, potassium iodide and pyridoxine hydrochloride. It also contains riboflavin, silicon dioxide, sodium ascorbate, sodium benzoate, sodium borate, sodium citrate, sodium metavanadate, sodium molybdate, sodium selenate, sorbic acid, sucrose, talc, thiamine mononitrate, titanium dioxide, tocopherols, tribasic calcium phosphate, vitamin A acetate and zinc oxide.

The amount of Vitamin C used in the study was 60 mg a day. I believe everyone should take a minimum of 500 mg twice a day to get the benefits of Vitamin C, and many people may need to take 5-10,000 mg a day in divided doses for optimal health. Taking a form of vitamin C known as  lypsospheric C is likely to be much more effective due to enhanced absorption, in which case 1,000 mg/day may be adequate for most. See http://www.livonlabs.com/
For more on the benefits of Vit C see

http://lpi.oregonstate.edu/infocenter/vitamins/vitaminC/  &

http://www.drpasswater.com/levy.htm

The 60 mg of Vitamin C used in this study likely has virtually no benefit in preventing heart disease (and no benefit in preventing cognitive decline).

Another key nutrient in preventing cardiovascular disease is Vitamin E. Everyone knows that cholesterol plays a role in heart disease. However, the role is a bit more complex than commonly thought. Cholesterol only causes problems if the wall of the arteries are damaged (via inflammation/oxidative stress in situations where Vitamin C levels are suboptimal) and if LDL cholesterol is oxidized, in which case the LDL will bind to or enter the arterial wall. Vitamin E prevents LDL cholesterol from being oxidized and also protects the arterial wall from oxidative stress.

This study used 45 IU of Vitamin E in the form of dl-alpha tocopherol, a synthetic form of Vit E that has been shown to be toxic in several previous research studies. Unlike synthetic E, which contains the synthetic chemical l-alpha tocopherol, natural E has only d-alpha
tocopherol as well as delta, beta and gamma tocopherols. Doses of 400-1200 units of natural E with mixed tocopherols have been proven to be highly effective in preventing heart disease. 45 units of synthetic E may do more harm than good! Taking only d-alpha tocopherol can lower our levels of gamma tocopherol which can have adverse health consequences, so even supplements with “natural E” that do not have mixed tocopherols may be harmful.

See http://www.healthy.net/scr/article.aspx?Id=557 for more on the research proving that Vit. E prevents heart disease.

Another key factor in the cause of heart disease (and preventing cognitive decline) is homocysteine, a toxic metabolite of the amino acid methionine. Vitamins B6, B12 and Folate have been shown to significantly lower homocysteine, reducing risk of both heart attack and stroke. The amount of B6 used in this study was a woefully inadequate 3 mg. A much more reasonable dose to reduce homocysteine is 25-50 mg. Many people may benefit even more from pyridoxal-5-phosphate, the activated form of B6. The form of B12 used in this study was 25 mcg of the cyanocobalamin form of B12. B12 is poorly absorbed by many, and cyanocobalamin is the least beneficial of the 3 common forms of B12. At least 1000 mcg of the methycobalamin form is advisable. While the 400 mcg dose of folic acid used is relatively reasonable, about one-half of the population has genetic difficulties converting folic acid to the active form, L-5-methyltetrahydrofolate (L-5-MTHF). There is also evidence that folic acid, a synthetic chemical, may increase risk of certain cancers including breast, prostate and colon. I thus advise taking at least 800 mcg of L-5-MTHF to prevent heart disease and stroke.

For more on homocysteine and heart health see

http://www.lef.org/protocols/heart_circulatory/homocysteine_reduction_01.htm

Vitamin D has also been shown to dramatically lower heart disease risk. A recent study done in Denmark involving more than 10,000 people found that those with the lowest levels of vitamin D experienced a 64 percent higher risk of heart attack, 57 percent higher risk of early death, 40 percent higher risk of ischemic heart disease and at least an 81 percent higher risk of death from heart disease. See

http://www.naturalnews.com/037372_vitamin_D_deficiency_cardiovascular_disease_risk.html

This study used the RDA of 400 IU of Vitamin D. However, to achieve optimal levels of  45-80 nanomoles per liter most adults need to take 5000-8000 IU/day of Vitamin D3.
It is also wise to take Vitamin K along with Vit. D for synergistic benefits.

Minerals can also be very helpful. Magnesium deficiency is extremely common and taking Magnesium has many proven benefits but Centrum Silver has only 100 mg of magnesium oxide, which is very poorly absorbed (approximately 4% absorbed). At least 200 mg of a well-absorbed form like taurate, citrate or glycinate would undoubtedly help more.

Selenium is also a useful antioxidant but the 20 mcg of sodium selenate is not nearly as beneficial as 100 mcg of selenium monomethionine might. 15 mg of zinc is reasonable but the zinc oxide form is, once again, relatively poorly absorbed compared to other forms of zinc.

Centrum silver also contains 4 mg of iron. This is, fortunately, a tiny amount, as iron is a pro-oxidant that is best avoided by all men and post-menopausal women as the evidence suggests that iron actually increases cardiovascular risk!

Added to the inadequacies of the quantities and forms of the nutrients in Centrum Silver, it also contains FD&C blue no. 2 aluminum lake, FD&C red no. 40 aluminum lake and FD&C yellow no. 6 aluminum lake, hydrogenated palm oil, polyethylene glycol, polyvinyl alcohol, sodium benzoate, pregelatinized cornstarch (undoubtedly of GMO origin), sucrose, talc and titanium dioxide, ingredients that I strongly recommend avoiding. Hydrogenated oils are among the greatest known risk factors for cardiovascular disease.
Aluminum in particular has been linked by many studies to Alzheimer’s disease. Giving a pill with 3 different aluminum-containing chemicals in an attempt to prevent cognitive decline is questionable at best!

As for the study “Oral High-Dose Multivitamins and Minerals After
Myocardial Infarction: A Randomized Trial” I have not yet learned the exact doses and vitamins used in this study but know that they gave only 100 iu of Vit D when, as discussed above, 5000 iu would be a much more reasonable dose. They also only gave 100 mcg of Vit B12, an inadequate dose for many due to its poor absorption. They also only gave the alpha tocopherol form of Vit E (I don’t know if it was natural or synthetic) and that is known to reduce levels of gamma tocopherol, which is probably more important in reducing cardiovascular disease. A study using mixed tocopherols would be more likely to show benefits.

Other flaws in this study include the fact that an astounding 46% of subjects discontinued the multivitamins during the study, making any conclusions questionable. Also, the group taking multivitamins had a higher rate of diabetes (which dramatically increases heart disease risk) than the control group, tending to bias the study against the treatment group.

In this study all subjects had already suffered a heart attack. They were only given vitamins for an average of 31 months (2 1/2 years). It is much easier to prevent than reverse heart disease and one might expect it would take a longer time to see clear benefits. Despite all of the above limitations, the group receiving vitamins had an 11% reduction in their primary endpoint (composite of time to death from any cause, heart attack, stroke, coronary revascularization or hospitalization for angina). This was not considered statistically significant but that may be a product of the size of the study and does not mean that multivitamins may not have been beneficial!

The third study in the 12/17 Annals was a review study titled “Vitamin and Mineral Supplements in the Primary Prevention of Cardiovascular Disease and Cancer: An Updated Systematic Evidence Review for the U.S. Preventive Services Task Force” which is available here:

http://annals.org/article.aspx?articleid=1767855

It concluded “Limited evidence supports any benefit from vitamin and mineral supplementation for the prevention of cancer or CVD. Two trials found a small, borderline-significant benefit from multivitamin supplements on cancer in men only and no effect on CVD.”
One of those 2 trials that found significant benefit for multivitamins preventing cancer is the same Physician’s Health Study using Centrum Silver that found little benefit in preventing cardiovascular disease and cognitive decline. That study showed an 8% reduction in cancer incidence and 12% reduction in cancer death after 11.2 years of follow-up. If there can be such good results using such a poor quality multivitamin I would expect much more impressive results with a good-quality multivitamin.

Another fine doctor who is also a friend and mentor, Alan Gaby, recently wrote an editorial in the Huffington Post commenting on the Annals editorial. His article is much more succinct than this one and he makes several good points that I have not because I want everyone reading this to read his fine article at

http://www.huffingtonpost.com/alan-r-gaby-md/vitamins-study_b_4481739.html

(PS in the few hours since I’ve posted this article WordPress tells me 75 people have read this post so far and only 1 of them has clicked on the link to Dr. Gaby’s article. It is REALLY worth taking a gander at it!)

Quoting Dr. Gaby “Multivitamin-mineral preparations have been shown in published research to have a wide range of benefits, including increasing energy and stress tolerance, improving pregnancy outcomes, decreasing infection rates, slowing bone loss, and improving cognitive function in schoolchildren. Some studies have also demonstrated protection against cardiovascular disease and cancer, although the evidence is conflicting. Furthermore, various individual nutrients or combinations of nutrients have been used successfully for the prevention and treatment of many other health conditions, including migraines, congestive heart failure, rheumatoid arthritis, kidney stones, diabetes, and depression.”

For another extensive critique of the Annals studies and editorial see http://bit.ly/18BeFJw
That article also discusses many studies that do show benefits of vitamin therapy.

A meta-analysis published in the Feb.-March 2013 issue of Psychosomatic Medicine, a peer-reviewed journal, titled “Effects of Vitamin and Mineral Supplementation on Stress, Mild Psychiatric Symptoms, and Mood in Nonclinical Samples: A Meta-Analysis” analyzed eight double-blind,placebo-controlled studies on the effects of multivitamins on aspects of mood in 1,292 men and women. Quoting http://bit.ly/1lu4AOU “When the research duo looked at trials that examined stress, supplemented subjects had a 65 percent lower risk of perceived stress compared to those that received a placebo. The analysis uncovered a 70 percent lower risk of mild psychiatric symptoms, a 68 percent lower risk of anxiety, a 73 percent reduction in experiencing fatigue and a 77.25 percent lower risk of confusion among supplemented participants. Happiness and decreased hostility levels were also likelier among supplement users in analyses of studies that analyzed these factors. Supplements that contained high doses of B vitamins tended to elicit greater benefits than those that had lower amounts.

“It is difficult to avoid the conclusion that the diets of the samples in the studies evaluated did not provide optimal nutrition,” the authors write. “The fact that there was a greater response to the supplements that offered doses higher than those suggested by RDAs calls into question whether RDAs or dietary reference values (DRVs) provide intakes that adequately meet the needs of the brain. The present findings also call into question the existing wisdom that, in industrialized societies, the consumption of diets containing sufficient energy and protein will naturally provide sufficient levels of micronutrients.”

“Multivitamin/mineral supplementation has a beneficial effect on many aspects of mood and mild psychiatric symptoms in healthy populations,” they conclude.

I find this study particularly significant because as a holistic practitioner it is clear that stress and anxiety are among the greatest and most common contributors to physical health problems, so any treatment that reduces stress and anxiety is certain to benefit our physical as well as our emotional health.

I could go on and on about the well-conducted studies that do show significant benefits of multivitamins but will limit myself to one more. This study,”Reduction in the Frequency of Arrhythmic Episodes in Patients with Paroxysmal Atrial Arrhythmia with a Vitamin/Essential Nutrient Supplementation Program,” was authored by Matthias Rath, M.D., Tatiana Kalinovsky, MSRN, and Aleksandra Niedzwiecki, Ph.D. and published in the Nov. 2005 issue of the peer-reviewed Journal of the American Nutraceutical Association. This double-blind placebo-controlled study showed very impressive reductions in cardiac arrhythmias in patients who took a multivitamin vs. a placebo. For a detailed report on this study see http://www4.dr-rath-foundation.org/pdf-files/arrhythmia_brochure.pdf

So is it reasonable to conclude that “the case is closed — supplementing the diet of well-nourished adults with (most) mineral or vitamin supplements has no clear benefit and might even be harmful. These vitamins should not be used for chronic disease prevention. Enough is enough.”?

I believe it is reasonable to conclude that incredibly inadequate/subtherapeutic doses of vitamins in poorly absorbed forms mixed with a variety of toxic excipients are mostly ineffective. I could have told you that before this study. It is also reasonable to conclude that the authors of the quoted editorial are either extremely misinformed and/or incredibly biased against supplements.
But, unfortunately, the message the general public is receiving is that “Vitamins are a waste of money” This is, as demonstrated, TOTALLY WRONG and I am concerned that the blind acceptance/uncritical reporting of studies like this will lead many people who are taking one of the many high quality multivitamins that do have reasonable doses and forms of these nutrients to stop taking them out of the mistaken belief that they have been shown to be ineffective. This would be tragic.

Addendum: If you have concluded that it is wise to take a multivitamin, you may wonder which one to take, as clearly some are MUCH better than others. There are many good choices and no single one is best for everyone. I advise looking for one that contains the L-5-MTHF form of folate as at least 40% of the population has difficulty converting folic acid to folate. I also advise choosing one that has the methylcobalamin or hydroxycobalamin forms of Vitamin B12 rather than the cyanocobalamin form. Ideally it should have relatively well-abosrbed forms of minerals. For example, if it has magnesium oxide I consider that a sign of a poor-quality vitamin, whereas if it has magnesium glycinate, taurate, malate, citrate or aspartate it is better quality. The best have natural Vitamin E with mixed tocopherols. I also like vitamins that have auxiliary nutrients such as Coenzyme Q10, Alpha Lipoic Acid, Lutein etc. I personally prefer capsules, are GMO-free and like those with minimal fillers, binders and excipients.
Some of my favorite multivitamins are UltraNutrient by Pure Encapsulations, Basic Nutrients (and other multivitamins) from Thorne Research and DFH Complete from Designs For Health. My favorite that is designed to take just one a day of is O.N.E. Multivitamin from Pure Encapsulations, though to make room for all the other important nutrients in it, it does not have calcium nor magnesium.
Some protein powders such as UltraClear by Thorne also contain all the ingredients of a multivitamin combined with protein and other nutrients.

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