Lancaster Physician Summer 2019 - 20

L A N C A S T E R M E D I C A L S O C I E T Y.O R G

Healthy Communities

benefits as antioxidants in foods. In fact, highdose antioxidant supplements generally do no
good and may cause harm (Pham-huy, He, &
Pham-huy, 2008). Halliwell (2013) calls our
attention to the lack of evidence to support
a benefit in high consumption of nutritional
antioxidants for the protection against disease in
persons without deficiencies. Knowledge gaps
also exist in adequately assessing the benefits in
special populations. For example, while there
is some research on vitamin E's role in the
progression of dementia, it is not conclusive
(Halliwell, 2013). However, in the same vein
of disease prevention, the evidence is more in
favor of consumption versus supplementation.
The key to the usefulness of antioxidants may
be in the synergy of their naturally occurring
form, alongside the importance of lifestyle
interventions. It is also important to note that
antioxidant supplements can act as pro-oxidants
and actually become oxidative stress inducers
when taken at levels significantly above the recommended dietary intakes (Halliwell, 2013).
WHO SHOULD I CONSIDER A
DIETARY SUPPLEMENT?
With a lack of strong evidence supporting
the advantages of supplements, physicians must
weigh the possible benefits against the risks
when recommending their use. Considering
supplement users are more likely to be female,
older, physically active adults who consume
a healthier diet, usage may be a marker for a
healthy lifestyle. Therefore, an irony exists, the
most common users are often the ones who
need supplements the least. Furthermore, it's
important to remember that supplement labels
fail to note if they exceed the recommended
upper limit (UL) of a nutrient. American adults
do not exceed the ULs from foods alone, only
with supplements.
Populations that clinicians may want to
evaluate the need for targeted, short-term,
supportive supplementation include:
* Patients with poor nutrient intakes
from food
* Those consuming low-calorie diets
* Those avoiding specific groups of foods
(e.g., vegans)

* Patients with medical conditions that
impair digestion, absorption, or use of
nutrients
* Older adults may benefit from B12
Professional Organizations recommendations
for supplement use:
* AAP: infants & vitamin D
* AAP: children who have an inadequate
appetite, suffer abuse, follow fad diets, have
anorexia, follow special diets for obesity
* AND: poor nutrient intakes from diet
alone, low-calorie diets, avoid certain foods
* AHA: EPA & DHA for heart disease or
triglyceride lowering
WHAT TO LOOK FOR IN A
SUPPLEMENT
The FDA does not approve supplements
nor register them. While good manufacturing
practices (GMPs) are required, they are set by
the manufacturer and do not set contamination
limits, ingredient identity parameters, and
testing methods. In fact, 54 percent of GMP
inspections in FY 2018 resulted in citations of
infractions, most commonly for identification
of ingredient issues. Common problems with
supplements include:
Too little or no ingredient
Too much ingredient
Inadequate labeling to
describe ingredient
Poor quality ingredient
Spoilage of oils
Contamination with heavy metals
Inadequate disintegration of pills
Unapproved label claims
Stick with reputable brands that have
been evaluated by third-party labs for safety,
authenticity, and effectiveness. Be cautious
with products that have "proprietary blends."
Consider using ConsumerLab.com (nominal
annual subscription) for up-to-date product
reviews, testing, and quality certifications.

LANCASTER

20

PHYSICIAN

FINAL THOUGHTS
There are a few key points here to consider
when evaluating the potential micronutrient
status of patients. Do labs illustrate the presence
or absence of micronutrient deficiencies or
metabolic barriers? What, if any, genomic information is available? What nutrient depletions
may be occurring as a result of medication use?
It is necessary to conduct a thorough review
of history, medications, dietary intakes, and
comorbidities. The current common theme of
personalization in nutritional recommendations
pertain in this area too, as there may be some
instances where micronutrients, particularly
antioxidant support through supplementation,
may be indicated. Therefore, choice of the
correct form, dose, standardization, product,
and timing of a supplement is paramount.
However, based on the current body
evidence, these more conservative recommendations will be in order:
Consume a diet that naturally provides
antioxidants, one that is nutrient dense but
not calorically dense. Support consumption
of brightly colored fruits, vegetables, and
whole grains.
Focus on supporting an antioxidant lifestyle-get plenty of exercise. Refrain from
tobacco use, limit alcohol, reduce stress,
get proper rest, and avoid processed and
poor-quality foods.
In closing, examples such as this only serve to
remind clinicians of the need to stay up to date
with current research, consider your patient's
"big picture," and target your interventions to
meet the needs/goals of the individual. The
shared decision-making process for supplement
use is best achieved with the guidance of a
knowledgeable dietitian nutritionist.


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Lancaster Physician Summer 2019

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