Lancaster Physician Fall 2021 - 23

FALL 2021
But for all the expense put into these supplements,
there is little to no data suggesting
actual benefits. In some cases, people may be
increasing their health risks by consuming them,
not to mention the harm to their wallets. In
fact, the United States Preventive Services Task
Force recently released an updated Draft Recommendation
Statement with a D (discourage the
use) recommendation against beta carotene and
vitamin E, and an I (insufficient evidence to recommend)
recommendation regarding general
multivitamins and single or paired nutritional
supplements. Those recommendations apply
to community dwelling, non-pregnant adults.
The draft evidence review analyzed 78 trials
(n=694,084) and showed a statistically significant
increase in cardiovascular mortality and
lung cancer with use of beta carotene, both
with and without vitamin A. Vitamin E was
clearly shown to provide no benefit for allcause
mortality and cancer. Evidence was more
ambiguous and not statistically significant for
general multivitamins, vitamin A, vitamin C,
calcium (without vitamin D), and selenium
for their ability to prevent mortality, cancer, or
cardiovascular disease. Some associations with
hip fracture (vitamin A), hemorrhagic stroke
(vitamin E), and kidney stones (vitamin C,
calcium) were suggested.
Vitamin B supplements (often marketed as
" Super B " or " B complex " ) are commonly used
by patients as well. Sometimes people use them
because they feel they will get more energy from
them. In other cases, people take them because
they want to self-treat a neuropathy, or they
feel it will improve cognition. A 2017 review
of studies showed that while the B vitamins
lowered homocysteine, they did not improve
cognition. There is no indication to treat anemia
with B12 outside of known deficiency of
B12, and a Choosing Wisely article from the
AAFP showed no benefit of B vitamins for
neuropathy if there is not a B deficiency. In
fact, vitamin B6 can actually cause neuropathy
when going above physiologic levels. I have
seen many patients, who were taking B vitamin
supplements, with a B6 level at three to four
times the physiologic range.
With all the negative and neutral evidence, is
there any evidence of supplements or vitamins
that was considered beneficial? In studies with
and without calcium, Vitamin D supplementation
has been seen to produce a lower risk
of cancer mortality, and there's a non-statistically
significant trend showing lower all-cause
mortality. A caveat should be noted here; no
trial evaluating large bolus doses of vitamin D
(24,000, 50,000, 500,000 units) has shown
benefit, and some have shown an increased
falls risk using these very high doses. Our population's
vitamin D levels may be a little lower
here in the northeast, especially as we attempt
to prevent the effects of the sun on our skin.
But if supplements are felt necessary, averaging
around 1000 units daily of D3 is likely most
appropriate. Multiple studies have suggested
an association between lower vitamin D and a
higher risk for COVID and its complications.
However, data is still lacking as to whether
supplementing with vitamin D is effective as a
prevention or treatment. It is likely not harmful
at this point, when given in reasonable doses.
Folic acid supplementation is strongly recommended
for women of childbearing age,
using a dose of 400 to 800 mcg. In the past, 4
mg was recommended for women previously
giving birth to children with neural tube defects
to prevent recurrence, but evidence has called
this practice into question.
Finally, many patients avail themselves to a
long list of other herbal and alternative supplements.
They bring this information to their
physician, wanting to know if these options
are safe and effective to treat the conditions for
which they are using them. A longer description
about benefits and risks of these supplements is
beyond the scope of this article. Often, we may
be inclined to tell patients what we know off
the top of our head, what we have heard from
other patients, or that we don't know enough
to guide them one way or another. But we can
do a better service for our patients by being
more informed about what they are interested
in taking. The Natural Medicine Comprehensive
Database is the most complete database
I am aware of for information on the herbal
supplements. It includes levels of effectiveness
for a variety of conditions, reasons people would
use them, safety, side effects, drug interactions,
condition interactions, and more. A subscription
to this service allows all this information to be
at your fingertips. But once a supplement may
be deemed useful for a certain condition, we
LANCASTER 23
PHYSICIAN
also need to keep in mind whether the specific
manufacturer is reliable, as the regulation of these
is far less than prescription drugs. Consumerlabs.
com and labdoor.com are both sites that can be
used to get more information.
Patients are asking about vitamins and supplements
more than ever. We need to be the place
where they can get trustworthy information
about what's out there, or they will get it from
somewhere else. In the meantime, let's also
keep reminding them of the best way to keep
themselves in good health and helping them set
goals for healthy eating and increased exercise,
as well as quality sleep. There is no substitute
for these, and people will start feeling better
quickly as they start to engage.
SOURCES AND REFERENCES:
https://www.nccih.nih.gov/
research/research-results/
americans-spend-30-billion-a-year-outofpocket-on-complementary-health-approaches
https://www.crnusa.org/newsroom/
dietary-supplement-use-reaches-all-time-high
https://www.uspreventiveservicestaskforce.org/
uspstf/draft-recommendation/vitamin-supplementation-to-prevent-cvd-and-cancer-preventive-medication#fullrecommendationstart
https://pubmed.ncbi.nlm.nih.gov/28248558/
https://www.aafp.org/afp/recommendations/viewRecommendation.
htm?recommendationId=334
https://www.uspreventiveservicestaskforce.org/
uspstf/recommendation/folic-acid-for-the-prevention-of-neural-tube-defects-preventive-medication
https://pubmed.ncbi.nlm.nih.gov
/30134243/#:~:text=An%20example%20is%20
the%20decades%27%20old%20practice%20
of,findings%20from%20a%20randomized%20
clinical%20trial%20in%201991.

http://www.labdoor.com https://www.nccih.nih.gov/ https://www.crnusa.org/newsroom/ https://www.uspreventiveservicestaskforce.org/ https://pubmed.ncbi.nlm.nih.gov/28248558/ https://www.aafp.org/afp/recommendations/viewRecommendation.htm?recommendationId=334 https://www.aafp.org/afp/recommendations/viewRecommendation.htm?recommendationId=334 https://www.aafp.org/afp/recommendations/viewRecommendation.htm?recommendationId=334 https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/folic-acid-for-the-prevention-of-neural-tube-defects-preventive-medication https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/folic-acid-for-the-prevention-of-neural-tube-defects-preventive-medication https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/folic-acid-for-the-prevention-of-neural-tube-defects-preventive-medication https://pubmed.ncbi.nlm.nih.gov

Lancaster Physician Fall 2021

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