Everett Clinic family medicine physicians, Dr. Luis Enriquez and Dr. Subathra Selvaraj, contributed to the Herald's "First, consider the ‘what” and ‘why’ of supplements."
A stroll through the vitamin and supplement aisle can be overwhelming. Bottles promise almost everything: preventing the common cold, improving brain health and building muscle. It’s a smorgasbord of pills, powders and gummy vitamins.
How do we determine what is safe, effective and worth the investment?
“Based on research, most people eating a general, American diet really don’t need extra supplements and vitamins,” says Dr. Luis Enriquez, family medicine at The Everett Clinic. “We mostly get what we need from our diets. That’s true even for people who don’t necessarily eat the healthiest diets.”
Dietary guidelines published for 2015-2020 by the federal departments of Agriculture and Health and Human Services advise us to meet our nutritional needs primarily with food.
“Food first,” says Sonya Angelone, registered dietitian, nutritionist and spokesperson for the Academy of Nutrition and Dietetics. “Food has other health benefits and synergistic qualities that help absorption (of vitamins and minerals).”
The general recommendation is to grab an orange over popping a vitamin C pill. However, medical experts and the U.S. dietary guidelines agree there are case in which vitamins and supplements can be beneficial — as long as we choose wisely and safely.
Who needs bottled nutrients?
The first and most important step is consulting someone knowledgeable about your diet, lifestyle, medical history and prescription medications.
“An expert can help make informed recommendations and navigate land mines. It may even take a few visits to maximize the benefits,” Angelone says.
Certain groups of people have specific needs, which may warrant supplements.
According to Enriquez, women who are planning or already pregnant are often advised to increase folic acid. Studies indicate it helps reduces birth defects affecting a baby’s spinal cord. Additionally, a multivitamin may benefit individuals with celiac or Crohn’s disease, which affect digestion and can hinder absorption of nutrients.
“Some people follow special diets, such as vegetarians and vegans,” Angelone points out. And that requires research to make sure their diets are adequate. “For example,” she says, “you might need to watch vitamin D levels if you’re not eating dairy products.”
Vitamin D is found in fish, eggs and milk. The body also generates it via sunlight. Vitamin D deficiency is more common in regions low on sunshine — like ours.
“Everyone in the Pacific Northwest seems to be low in vitamin D at some point,” Enriquez says. “Taking a supplement at a healthy dose might not be a bad idea and could help with fatigue and mood issues.”
Vitamin D also helps the body absorb and retain calcium and phosphorus, which supports strong bones. In 2008, the American Academy of Pediatrics specifically recommended an increase in vitamin D for infants, children and adolescents.
Families might want to talk about vitamin D with their doctor, given the pediatricians’ recommendation, says Coty Navarro, lead nutritionist for Snohomish Health District’s Women, Infants and Children program.
The right approach to taking vitamins?
Parents are sometimes concerned that children — particularly picky eaters — need multivitamins. Consult a pediatrician if you’re concerned, Navarro advises, but this is not often a long-term problem.
“Look at your kids’ diets over the course of time, what they ate during the entire week,” she says. “Vitamins and minerals stay in the body, so don’t be too hard on yourself if your kids don’t eat all their vegetables on a certain day.”
Treat vitamins and supplements as you would a prescription medication. Follow dosing recommendations, expiration dates and fully understand what you are taking and why.
“It is very important to tell your doctor what you’re taking,” says Dr. Subathra Selvaraj, who practices family medicine with The Everett Clinic.
“Vitamins processed in commercial forms include additives and fillers that cause allergic reactions, such as rashes and diarrhea, in some people. For us to find what’s causing that, patients need to tell us everything.”
Vitamins and supplements can also impede prescription medications. Even if it is all a patient is taking, strictly adhere to recommended dosages.
“Most every vitamin has a toxicity symptom,” Angelone says. “Any vitamin you take will cause problems if you take too much. Even vitamin C in too high of a dose can cause diarrhea.”
Testing vitamin levels remains less precise than most people realize, which makes it all the more important to follow recommendations.
“There is still a lot that is unknown regarding safe amounts,” Enriquez says. “There are some safe recommendations for daily amounts that are helpful rather than harmful. But in terms of exact blood levels, there is still a lot we don’t know beyond the ballpark range.”
Expert advice also helps to ensure you get the full benefits needed and desired. Common knowledge categorizes vitamins into simple classifications, but most vitamins have many subsets.
“Inexpensive options aren’t always the best form,” Angelone says.
“For example, there are eight different forms of vitamin E you need in order to get the true benefits. Most over-the-counter ones only have one, synthetic form of vitamin E, which isn’t as well absorbed.”
What you don’t know can harm you
Do not assume a supplement is safe just because it reached retail shelves. The the U.S. Food and Drug Administration does not have the same regulatory oversight of supplements that it has over prescription medications.
The FDA definition of dietary supplements includes vitamins, minerals, herbs, botanicals and amino acids. According to Lyndsay Meyer, FDA spokesperson, the supplement market is currently a $30 billion to $40 billion industry with upward of 85,000 products. In comparison, the FDA team overseeing dietary supplements has a budget of less than $5 million and no more than two dozen people.
“The FDA does not have pre-market approval of dietary supplements,” Meyer says.
Furthermore, labeling regulations contain concerning loopholes. Companies cannot claim a product is intended to treat, diagnose, prevent or cure a disease.
However, they can claim a supplement affects the “structure or function” of something the body does naturally. For example, a general claim of “helping support brain health” is allowable.
In the last decade, Meyer recalls only one mandatory recall of a dietary supplement the FDA deemed unsafe. Beyond the FDA’s limited scope regarding safety, Meyer points out that the agency “doesn’t even touch effectiveness.”
“People think that they can go into the store and buy a supplement off the shelf and certainly the FDA looked at it ahead of time for safety and effectiveness. That’s not the case,” Meyer says.
“It’s important to be aware because there can be serious issues, says Neal Malik, assistant professor at Bastyr University. “There are reports of meal-replacement supplements contaminated with lead and sports supplements containing anabolic steroids. Some protein supplements may or may not even contain any protein at all.”
Since 2011, the FDA has 700 instances on file in which products marketed as supplements contained pharmaceutical drugs — some banned outright, even by doctor prescription.
“We found one instance of an herbal product intended for sexual enhancement which contained Viagra, Cialis and Prozac in three times the amount that a doctor would prescribe,” Meyer says.
While there are meager safety or quality-control guarantees, there are some precautions consumers can take. Many professionals, including Angelone, steer patients away from online ordering, where it can be harder to determine origin and authenticity.
“Individuals can also check the supplement bottle. Look for the USP label. That means the product is at least tested for some level of quality by the U.S.
Pharmacopeial Convention,” Malik advises. “If that’s not there, look for the NSF International mark. Both are third parties that independently test supplements for quality assurance.”
Meyer strongly encourages the public and health-care providers to report all adverse reactions directly to the FDA. Manufacturers are not required to submit all complaints to the FDA.
“Every report is reviewed by an appropriate medical officer in the FDA. It can take as few as one or two well-documented instances to set off a signal that prompts the agency into action,” Meyer says.