What do we really know about vitamins, supplements, and performance enhancers?

A 2016 Frontline special was highly critical of the vitamin and supplement industry, pointing out that it is largely unregulated, that supplements are not proven to be useful, and that some people have become quite ill or even died due to a supplement they were using.
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I actually agree with much of what they discussed on the show. The only thing I thought was a strange omission (given the topic) is that they never mentioned that we do have some independent third party testing for supplements, through ConsumerLab and LabDoor. Frontline also downplayed the known benefits of vitamins and herbs. For example, they never mentioned that in a 2012 research paper, 14,641 male physicians were randomized to receive a multivitamin or placebo, and followed over 10+ years. The group that took the vitamin had an 8% reduction in cancer.

So vitamins may be poorly regulated but they are worth looking into.

Moreover, contrary to Dr. Offit's assertion that most of us are getting enough vitamins, the US Department of Agriculture freely admits that most Americansdo not consume sufficient quantities of many vitamins. Right at the top of the list, only 46% of Americans consume enough vitamin A. 13% consume enough vitamin E. So, do you need to take vitamin supplements? How will you figure this out?


CLARITY IS POSSIBLE
I would like to help bring some clarity to the situation. That would take writing a book of course, but here are a few thoughts. I come at this from a very strict conventional medicine background. I practiced as a conventional family physician for 20 years (1987-2008) and during that time did not use or recommend any preventative vitamins.
When I “discovered” functional medicine, I decided to suspend disbelief and try the supplements recommended by Dr. Mark Hyman in The Ultramind Solution. I was really amazed to feel that they were helping me (that was not a scientific observation, but an intuitive one). I then joined a group of physicians who were all to some extent transitioning from conventional to functional medicine, and we formed a “lab group” so we could share our experiences with the myriad of new and unusual tests that we saw being used by alternative medical providers. Which ones were reliable? We really wanted to know. Having followed a flawed recipe for health during our time in conventional medicine, we were quite determined to figure out how to provide the best care for our patients.

WHAT ARE ALL THESE PILLS OUT THERE FOR?
I see five basic types of pills sold without a prescription:

1. One type involves substances our bodies already make, such as coenzyme Q10.
2. Another type involves substances that are not normally part of the body's biochemistry, but that we hope will modify the chemistry in a specific way. This is true for over-the-counter medications like antihistamines and anti-inflammatories, and substances derived from herbs and spices, like turmeric, cinnamon, Saint John’s Wort, rhodiola, red yeast rice, and many others.
3. There’s the category of "essential nutrients," which includes omega 3 and other fatty acids that are normally in food, but can be hard to get for some people.
4. There’s a group of substances I will call performance enhancers: these are designed to jolt the system, to make you lose weight, to build up muscle, or to increase sexual performance. These are the group of supplements one should never take because they are by far the most likely to result in injury or death. These supplements may actually contain unlabeled drugs, like Viagra or steroids, and they also may contain known toxins that may help temporarily but have been banned for being harmful.
5. Finally, there's vitamins, which are substances that are absolutely necessary and that our bodies usually cannot make. Most of these should be obtainable through food but there are three reasons why people may not have enough:

• They don’t eat the right foods
• Genetically, they need much more than can be obtained through food
• They have a condition that causes them to require a supplement

Over the last 5 years of training and practicing as a functional medicine physician (2010 to present) I have developed the following guidelines around vitamins and supplements.


RELIABLE TESTS
First there are some substances for which there are reliable tests. These include coenzyme Q10, vitamin D, vitamin B12 (though you need to check a methylmalonic acid, the B12 level is not sufficient) and other B vitamins (measured indirectly using the serum homocysteine – not perfect, but if too high, you know you need them – usually).
The reason to test and treat for these is that insufficiency either causes fatigue and difficulties with the immune system, or may cause a number of problems in the future. The most important issue is prevention of Alzheimer’s Disease. This is such a long latency disease that our main focus is prevention (though it can sometimes be reversed with a functional medicine approach). Proper vitamin levels may not be sufficient for prevention, but they provide some insurance.
There’s a few more nutrients I can test for reliably, including zinc, iron, selenium, and essential fatty acids, including long-chain fatty acids (omega 3s, omega 6s, arachidonic acid, etc.) and short chain fatty acids (made by beneficial bacteria).
Cholesterol is another nutrient we can measure. LDL cholesterol, often called “bad cholesterol”, is actually the building block for many critical structures: cell walls, myelin sheath for nerve cells, and steroid hormones like estrogen, testosterone, progesterone, cortisol, vitamin D and thyroid hormone. So how “bad” can it be? Well, there are many sizes of LDL, and it can be in a normal state, or an oxidized or glycated state, and each of these sizes and states matter to cardiovascular health. We can measure all these, and it’s not expensive, but it is often not done.


LESS RELIABLE TESTS
There are nutrients one can only hope to get a good handle on: these include vitamins A, C, E, and magnesium. It seems you can best measure these indirectly, by looking at levels of certain metabolite levels (body substances), or at damaged cell structures, like lipid peroxides and the level of 8-OH-deoxyguanosine, a cancer predictor.


UNRELIABLE TESTS
Finally there are nutrients that we really can’t measure. For example, there are many tests for iodine but none are reliable indicators of deficiency or sufficiency. I used to like the serum iodine but now I am not sure it’s the best way to go. Experts in the supplementation field recommend a careful trial of iodine rather than testing. 
Many tests attempt to quantify beneficial bacteria and I am not sure we are really getting a good picture from them. The situation is so complex, some won’t grow in culture, and the techniques for detecting them are imperfect. In research, arrays of beneficial bacteria seem to have a tantalizing story to tell but in individual patients, I can only make out very broad generalities. I actually like to look at their output (the short chain fatty acids they synthesize) better than their presence or absence. 
Calcium levels are available but they tell us more about abnormal hormonal conditions or dangerous cancer side effects than about dietary calcium sufficiency. Whether calcium sticks to bone or not seems to depend more on just about everything else: fruits and vegetables in the diet, level and type of exercise, gluten sensitivity, etc. Calcium is also important for cardiovascular health, and it is true that if you consume no dairy and few vegetables, you are likely to be deficient.


GAMING THE SYSTEM
I use just a few herbs because to me they are in the same general way of thinking as medications. They may be better suited to our body than manufactured chemicals, They may sometimes accomplish what medications can’t. But in general, they are not a root-cause solution.
I use some herbs that help reduce the impact of stress while someone is recovering from a long series of stressful events that have impacted the functioning of the adrenal glands. But along with these, I use stress reduction practices and tools to change how we respond to what bothers us.
I use turmeric or a combination of anti-inflammatory herbs to try to get someone off anti-inflammatory medications which can cause intestinal permeability (and a vicious circle of inflammation). I’m sure some people need to stay on turmeric, in certain situations where damage will not completely resolve.
I use red yeast rice when the harmful type of LDL cholesterol won’t resolve in spite of reasonable efforts with a functional medicine approach. There are many natural substances one can use to alleviate symptoms while we attempt to heal the underlying systems: inositol, N-acetyl cysteine, acetyl-l-carnitine, alpha lipoic acid, and many, many more. So many in fact that this is a significant problem with the first phase of functional medicine treatment: having to take so many pills. The goal is to get to a final minimum, or even to stop taking them altogether.


VITAMINS FOR HEALTHY PEOPLE
If you have no symptoms, no fatigue, no digestive issues, no joint pains (my three favorite symptoms to reverse!), no autoimmune disease, no strange neurological sensations, no mood or mind issues – should you still take a preventive vitamin?
There are two things you can do to answer this question:

1. See a functional medicine provider you trust for an assessment. Discuss your diet, your habits, your family history, get basic labs, and decide. The aim would be to avoid a long latency disease or an autoimmune disease that has not yet occurred.
2. Try a set of basic vitamins and take them for 3 months. Religiously. Keep track of any observations. Then decide: was it worth the effort and cost? You won’t really know what you might need, but you will have tried to figure something out.

DO VITAMINS/SUPPLEMENTS CONTAIN WHAT THEY CLAIM?
Here’s one last problem, in fact they sometimes don’t contain what they claim to contain. If you see a functional medicine provider, she will in fact tell you her favorite brands. Ask how she knows: does she read ConsumerLab or LabDoor? These are third party testing organizations that try to find out what is in vitamins and supplements, and whether they may be contaminated with lead (which can be a problem for herbs, for example). If you are on your own, you may have to get a subscription to ConsumerLab just long enough to figure out a specific set of vitamins and supplements.


MY FAVORITES
Well, my favorite types (because my favorite may depend on the condition):

• a multivitamin containing 5-L-methylfolate (not folic acid); and some vitamin A in retinol form
• additional vitamin D3 to a total of about 4,000 or 5,000 units for most people (know your level!)
• probiotics (at least 4 different strains each of Lactobacillus and Bifidobacter); 25 billion or so
• omega 3s (at least 1000 mg of EPA+DHA from the Supplement Facts label, and only if third party testing says they have no heavy metals and PCBs, and are not rancid, and they don’t give you the fish burps when you take them)

CONCLUSION
Why would Frontline present a documentary with such frightening headlines? Will supplements make you sick? If you avoid performance enhancers and get advice from a provider you trust, or use the resources that exist for assessing the adequacy and safety of vitamins and supplements, you would likely come out ahead. It’s not dangerous, but it does take some work to figure out. On the other hand, I hate to say it, but pharmaceutical companies have been trying to get the supplement industry regulated so they can take over. One problem they face is that the medications they promote themselves have very high rates of adverse effects: in 2009, the Drug Abuse Warning Network calculated that 50% of nearly 4.6 million drug-related emergency room visits were attributed to adverse reactions to medications taken as prescribed!! Dr. Paul Offit (interviewed on the Frontline documentary) is well aware of this, as his own Rotavirus vaccine is known to cause a very dangerous condition called "intussusception." But he is essentially employed by a pharmaceutical company that funds the “chair” he sits in and the Institute he created, and perhaps prefers to talk about the side effects of vitamins rather than the side effects of pharmaceuticals. We need to be careful what regulations are put in place, or only well-funded Big Pharma will be able to sell vitamins. The problem is that some of these pharmaceutical companies have a long history of hiding research findings and promoting their products without following regulations. So, yes, we need to fix the system we have, but let's be smart about it.


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REFERENCE
Gaziano J, Sesso HD, Christen WG, et al. Multivitamins in the Prevention of Cancer in Men: The Physicians' Health Study II Randomized Controlled Trial. JAMA. 2012;308(18):1871-1880. 

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