• According to the National Center for Complimentary and Alternative Medicine (NCCAM), a dietary supplement can be a vitamin, a mineral, an herb or other botanical, an amino acid, or other such substances or their constituents.
• The FDA regulates dietary supplements under a different set of regulations than those covering conventional foods and drug products and has not made full use of oversight power despite its “oversight” by the industry-friendly 1994 Dietary Supplement Health and Education Act (DSHEA).
• Manufacturers and distributors of dietary supplements are not required to demonstrate safety and effectiveness and we have all heard the adds saying “its against the law for companies to claim that any supplement can prevent, treat, or cure any disease.” 

To supplement, or not

In the US more than half of the adult population have taken supplements to lose weight, stay healthy and avoid prescription drugs and to improve both physical and sexual performance. Unfortunately, people may have a false sense of safety with so-called ‘natural’ treatments. The incredible rise of dietary supplement use (vitamins, minerals, herbs, or other plants extracts) in the 21th century represents the ability of marketing to create a “health halo” particularly around vitamins, despite the absence of scientific usefulness. The supplement and vitamin industry is big business and in 2009, we spent $26.7 billion on supplements, according to the Nutrition Business Journal, a trade publication. There is now a growing resurgence in supplements with celebrity endorsements extolling the virtues of cleanses and “detoxing” juices.

Not without risk?

A healthy nutrition pattern, regular exercise and no smoking  is the best way to achieve health -based on the evidence. Dietary supplements, may actually do more harm than good. Paradoxically there is evidence of increased risk of developing health problems such as cancer and heart disease. Taking more than the recommended dosage beta carotene, for instance, a supplement advertised as a boost to the immune system was found to increase the risk of developing lung cancer and heart disease by up to 20%. There are findings suggesting that additional calcium may be related to a number of cancers and increased heart attacks.

A 2013 study from the National Institutes of Health suggested there is an increased risk of heart attack, stroke or other cardiovascular diseases from taking calcium supplements for men only; while other studies suggest there is an increased risk for both men and women. One thing is clear, there is a reasonable degree of uncertainty about how much calcium is too much. Of interest, two large dietary studies that compared how patients over 50 years of age fared when instructed to consume higher versus lower levels of calcium on bone health were negative: none provided any evidence that calcium intake is associated with fracture risk and the effect of calcium from diet or supplements on bone mineral density showed a  minimal 1 to 2 percent increase detected but had no meaningful impact on fracture risk. The jury is still out about harm with extra calcium but there remains very little evidence of any benefit for those without a deficiency.

The same is found with most other supplements.

• An analysis of 24 studies and two trials evaluated the role of vitamin supplements for the prevention of chronic diseases and involved more than 350,000 people and found little evidence that vitamin and mineral supplementation impacted the risk for a number of chronic health conditions, including cancer. (Annals of Internal Medicine in 2013). In the absence of sufficient scientific evidence, many people choose to use multivitamin supplements to prevent cancer.

However, we can agree that it remains unproven whether multivitamin supplement use for the healthy population or patients with cancer is beneficial or harmful. According to the Mayo Clinic dietary guidelines recommend supplements — or fortified foods — in the following situations:

• Women who may become pregnant should get 400 micrograms a day of folic acid from fortified foods or supplements, in addition to eating foods that naturally contain folate.
• Women who are pregnant should take a prenatal vitamin that includes iron or a separate iron supplement.
• Adults age 50 or older should eat foods fortified with vitamin B-12, such as fortified cereals, or take a multivitamin that contains B-12 or a separate B-12 supplement.
• Adults age 65 and older who do not live in assisted living or nursing homes should take 800 international units (IU) of vitamin D daily to reduce the risk of falls.

Dietary supplements (vitamins or iron) also may be appropriate if you fit in one of the following categories:

• Poor nutritional status: don’t eat well or consume less than 1,600 calories a day.
• Vegan or a vegetarian who eats a limited variety of foods.
• Fish intolerance and do not obtain two to three servings of fish a week -especially if there is known heart disease.
• A woman who experiences heavy bleeding during your menstrual period.
• A medical condition that affects how your body absorbs or uses nutrients, such as chronic diarrhea, food allergies, food intolerance, or a disease of the liver, gallbladder, intestines or pancreas.
• Prior surgery on your digestive tract and are not able to digest and absorb nutrients properly.

Example of supplement-drug  interaction

Potentially serious or life-threatening interactions between some supplements and medication are well known. Most significant interactions are with anticoagulants, cardiovascular medications, oral diabetes drugs, and antiretrovirals used in HIV. Some of the more important supplement-drug interactions are as follows:

• St. John’s wort is the leading complementary and alternative treatment for depression in the United States. This over-the-counter natural supplement can be dangerous and with important drug interactions that may reduce the concentration of numerous drugs in the body, including antidepressants, oral contraceptives, blood thinners, cancer chemotherapy and blood pressure medications, resulting in impaired effectiveness and sometimes treatment failure. Major life-threatening events have been reported as a result of this supplement potential to increase the effectiveness of some blood thinners (anticoagulants) and cardiovascular medications with disastrous complications. St. John’s wort may interact with medications used to treat depression or other mood disorders, including tricyclic antidepressants, SSRIs and monoamine oxidase inhibitors (MAOIs). Taking St. John’s wort with antidepressant medications can increase the chance of side-effects and could potentially lead to a particularly dangerous condition called serotonin syndrome (related to too much serotonin with symptoms that range from mild (shivering and diarrhea) to severe (muscle rigidity, fever and seizures). Serotonin syndrome is also a possible side effect increased by the interaction of St. John’s wort with cough medicines that contains dextromethorphan. St. John’s wort may reduce levels of some drugs in the body, making them less effective such as allergy medications (antihistamins) such as: Loratadine (Claritin), Cetirizine (Zyrtec) and Fexofenadine (Allegra). A possible life-threatening effect St. John’s wort is of concern for kidney, liver and heart transplant patients. The effectiveness of the anti-rejection medication called Cyclosporine can be seriously reduced and case reports of failure of liver, or kidney transplants and death as a result of St. John’s wort interaction use are well appreciated. Some heart patients must use the drug called digoxin (Lanoxin) to control heart rhythm and treat heart failure and any loss of this drugs effectiveness as a result of St. John’s wort can be clinically important. Similarly, for those with HIV a loss of effectiveness of antiretroviral medications (protease inhibitors and non-nucleoside reverse transcriptase inhibitors) in combination with St. John’s wort may lead to treatment failure.
• Gingko is a common supplement with an increased bleeding due to interactions with the powerful blood thinner warfarin (Coumadin) is possible with ginkgo, garlic, and ginseng. An increased bleeding risk (including intracranial hemorrhage) as a result of a gingko interaction with some anti-inflammatory drugs like ibuprofen (Motrin), naproxen (Aleve), or aspirin. Given the narrow therapeutic index of warfarin, the anticoagulation status in patients must be monitored frequently and for those who take dietary supplements big swings in the degree of anticoagulation (as measured by the Protime test) is a concern.

Detox, anyone?

Celebrity Gwyneth Paltrow endorses a “detox” charcoal lemonade drink marketed as one of best juice cleanses. The product has activated charcoal, “alkali” water and is sweetened with cane sugar and represents a pure marketing campaign against make-believe toxins. Medical detoxification to rid the body of real toxins is a life-saving therapy often used in a real medical emergency situation. Activated charcoal is used by physicians in emergency poisoning cases at much larger doses and is not without its problems. Activated charcoal can also bind a number of vitamins: ascorbic acid (vitamin C), niacin (vitamin B3), pyridoxine (vitamin B6), thiamine (vitamin B1) and biotin so buyer beware especially if you “detox” regularly. The 2016 Goop Detox endorsed by Paltrow is a set of recipes and guidelines with special “dust” to help “undo everything that was done to your body during the overindulgent holiday season.” We wish there really was a quick fix -but a healthy lifestyle -is just that -you got to go out and walk more, not smoke and follow a healthy nutrition pattern.Medical detoxification to rid the body of real toxins is a life-saving therapy often used in a real medical emergency situation. Activated charcoal is used by physicians in emergency poisoning cases at much larger doses and is not without its problems. Activated charcoal can also bind a number of vitamins: ascorbic acid (vitamin C), niacin (vitamin B3), pyridoxine (vitamin B6), thiamine (vitamin B1) and biotin so buyer beware especially if you “detox” regularly. The 2016 Goop Detox endorsed by  Paltrow is a set of recipes and guidelines with special “dust” to help “undo everything that was done to your body during the overindulgent holiday season.” We wish there really was a quick fix -but a healthy lifestyle -is just that -you got to go out and walk more, not smoke and follow a healthy nutrition pattern.

Alkaline water

Alkaline water with a high pH (ionized) has health claims to boost metabolism, provide more energy and help absorb nutrients better and even slow the aging process. Excess “acidity” measured by checking urine pH is believed by some alternative practitioners and naturopaths to be related to a long list of conditions: cancer, heart diseases, arthritis, kidney stones, gallstones and osteoporosis. The “solution” according to some is to consume a special alkaline diet and “alkaline” water, and supplements. Unfortunately, nothing is more painful than the death of an illusion. The human body maintains a fairly consistent pH balance (homeostasis) with a blood pH of about 7.4. Urine pH can not be used to measure blood pH and manipulating urine pH to deal with medical conditions as a result of “excess acidity” is fiction. There are no high quality studies that support the broad reaching health claims.

Summary

Some nutritional supplements and vitamins certainly have a place to treat specific nutritional deficiencies. Most importantly tell your doctor of any and all dietary supplement use. This is very important prior to any  “routine surgery” given some potentially important supplement interactions and particularly  bleeding risk.

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