Transcript Vitamins and Supplements

How much is too much?
Cecily Kelly, M.D.
Topics to be covered

 Recommended vitamins/supplements
 Pregnancy
 Osteoporosis
 High cholesterol
 Cold Prevention/Treatment
 Weight Loss Supplements
 Miscellaneous
Overview

How much do we use?

 Survey done by the National Center for
Complementary and Alternative Medicine found
that 4 in 10 adults had used “integrative therapy” in
the past year
Vitamins

Vitamins A,D,E,K

 Fat soluble
 Stored in fat globules
 It is possible to get too much-hypervitaminosis
Vitamins B and C

 Water soluble
 Too much Vitamin B
 Worsen diabetic neuropathy
 Too much Vitamin C
 Loose money
Vitamin Deficiencies

Beriberi-thiamine

 Occurs in alcoholics due to
malnourishment
 Heart failure
 Muscle wasting
 Peripheral nervous system
problems
 Problems with thinking
Pellagra-niacin

Scurvy-Vitamin C

 Tiredness, muscle weakness,
joint and muscle aches,
bleeding gums, rash on skin,
loss of teeth
Vitamin D-rickets

Deficiencies

 Not seen in developed world because of
 Adequate supply of food
 Many fortified foods
Too much?

 Fat soluble
 Vitamin A-nausea, vomiting, headache, dizziness,
blurred vision
 Vitamin D-excess may cause cardiovascular problems
 Vitamin E-increase bleeding problems
 Water Soluble
 Vitamin C-laxative effect
 Vitamin B6-skin problems and peripheral neuropathy
United States Preventative
Services Task Force

 Has found poor evidence to
recommend routine use of
Vitamin A, D, or E,
multivitamins with folic
acid, or antioxidant
combinations to reduce the
risk of cardiovascular
disease or cancer
Pregnancy

Vitamins in Pregnancy

 Calcium
 Keeps bones of mom and baby healthy
 1,300 mg/day age 14-18
 1,000 mg/day age 19-50
 Folic acid
 Brain and spinal cord development
 600 mcg/day
 Iron
 Prevents anemia in mom and baby
 27 mg/day
Folic Acid

 US preventive services task force recommends
supplementation of 400mcg to 800mcg daily for all
women capable of pregnancy
Calcium

 Most pre-natal vitamins do not contain enough
calcium and expectant mothers must get additional
calcium through diet or supplements
Osteoporosis

Calcium

 Women 51-70 (Men over 70) recommended
1,200mg/day
 Two divided doses-body only able to absorb approx
500mg at a time
 Do not take with medication for reflux like prilosec,
nexium, omeprazole
 Calcium citrate or calcium carbonate
 Take with vitamin D which helps absorption
Food Sources of Calcium

 Eight ounces of yogurt-300mg
 One cup of milk-300mg
 1.5 oz of cheese-300mg
 8 oz of fortified OJ-300mg
Vitamin D

 Adults < 70
 600 IU/day
 Adults > 70
 800 IU/day
 Helps us absorb calcium
 Also can get from the sun
Food Sources of Vitamin D

 Sockeye Salmon-800 IU
 3 oz can of tuna- 150 IU
 Vit D fortified milk- 80IU
 OJ fortified- 80 IU
 Fortified yogurt-80 IU
Do I get enough?

 People typically get 300mg of calcium from their diet
daily
 With the use of sunscreen, long hours spent indoors,
or people who live in the northern latitude, overall
decreased sun exposure causes pts to not get enough
Vitamin D
What happens if I don’t get
enough?

 Colon cancer
 Kidney stones
 Obesity
 Hypertension
 Osteoporosis
 Bone fracture
How much is too much?

 >2500mg/day may increase the risk of
hypercalcemia and kidney problems
 Kidney stones- >2150 mg/day in postmenopausal
women
 Avoid coral or dolomite (a kind of limestone)
because they can contain heavy metals like lead
Omega-3

What is it?

 Essential fatty acid that we must get from our diet





Fish
Salmon
Tuna
Halibut
Nut oils
Why do I need it?

 Crucial for brain development
 Involved in growth and development
 Shown to decrease risk of heart disease
 Decrease inflammation
How do I get it?

 The American Heart Association recommends two
servings a week of fatty fish, such as:





Mackerel
Sardines
Albacore Tuna
Large Trout
Salmon
And what if I don’t eat fish…

 American Heart Association
 Adults with no history of heart disease
 Fish two times a week
 Adults with coronary heart disease
 1 gram daily of EPA and DHA
 Adults with high cholesterol levels
 2-4 grams daily of EPA and DHA
How much is too much?

 Do not take more than 3 grams without a physician
supervision
 Side effects include fish breath, gas, bloating,
belching, diarrhea
 Use with caution if you take a medication to thin
your blood or have a bleeding disorder- omega-3
supplements can increase your risk of bleeding
 Get supplement from an established company that
certifies that their products are free of contaminants
like lead, heavy metals, mercury
Cold Prevention

Vitamin C

 Prevention
 Might help immune function
 Most evidence (8 studies) suggests
that even in doses of 1 gram a day
does not prevent colds
 Treatment
 “Some evidence” that taking high
doses may decrease sx duration
by 1-1.5 days
Zinc

 Prevention
 Only in vitro evidence (in the lab) that it stops the
growth of the common cold
 No reliable evidence that it can prevent the cold in
vivo (in humans)
 Treatment
 9-24 mg elemental zinc started within 24-48 hrs of
symptoms to reduce severity and duration of colds (6
studies)-take every 2-3 hrs while awake
 Other studies show no effect (5 studies)
 Prevention
Echinacea

 In vitro (in the lab) research suggests
it stimulates immune system
 In vivo (in people) studies for
prevention against the common cold
has “consistently been shown to be
ineffective” (9 studies)
 Treatment
 “Some preparations” may reduce
symptom severity and duration
possibly by about 10%-30%
 Different species
 Best evidence with Echinacea purpurea
Garlic

 Prevention
 May have immunostimulant activity and antiviral
 If taken between November and February may have
one fewer cold episode than patients taking placebo
How much is too much?

 Patients who have autoimmune disease such as RA
(rheumatoid arthritis or lupus) may do worse with the
supplements that “stimulate” the immune system
 Echinacea-Ragweed allergies should not use-cross allergy
 Vitamin C-high doses may increase risk of side effects
 Zinc-nasal spray withdrawn from market due to
permanent anosmia (loss of sense of smell)
 Garlic-adverse effects like bad breath and body odor,
interaction with warfarin (coumadin) causing increase in
risk of bleeding
What about Airborne?

 Promotional material “developed by a teacher who
was sick of catching colds in class”
 Contains vit C, vit E, vit A, zinc, echinacea
 No proof it can prevent or treat a cold
 Not recommended
Others

 American ginseng- maybe beneficial
 Probiotics-maybe beneficial for respiratory infection prevention-more in
children
 Panax ginseng-might have immunostimulant effects and protect against
colds and improve response to flu vaccine
 Vitamin E-some evidence that it might help the body build immune
response with vaccination
 Andrographis
 Astragalus
 Elderberry- possibly use in treating the flu-antiviral and immune system
changing effects
 Goldenseal
 Pau d’arco, bee propolis, wild indigo, boneset, Siberian ginseng, larch
arabinogalactan
 Teas-elderflower, rose hips, goldenseal, chamomile, peppermint, slippery
else, ginger, Mormon tea, linden flowers, meadowsweet
So what can I do?

 Flu shot every year-Usually starts August-March
 Hand washing or alcohol based hand gels
 Hand washing-2 min with soap and water
 “Some evidence that alcohol based hand gels, which
have 62% ethyl alcohol, lower the amount of coldcausing viruses on fingers better than water.”2,3
Weight Loss
Supplements

“Increase Energy
Expenditure”

 Ephedra (aka Ma huang)
May also be bitter orange or country mallow
Weight loss of 2lb/month
Caffeine
Adverse events shown in 50 trials-psychiatric,
autonomic, cardiovascular, GI symptoms
 Another review showed 87 reports of hypertension,
abnormal heart rhythm, heart attack, stroke, seizures
 Ten events led to death, 13 permanent disability-9 of
those were at the recommended dosage.




Sale was ban by FDA in
April 2004

“Modulate Carbohydrate
Metabolism”

 Chromium picolinate
 Studies of chromium and obesity show no difference
between study group and placebo
 Kidney failure is sometimes related to doses of more
than 1,000 mcg a day
 Uncertain safety profile
“Increase Satiety”

 Forms of soluble fiber
 Guar gum
 Relatively safe, also 11 trials with this vs placebo showed
no difference
 Glucomannan
 Trials show moderate weight loss, but only 20-50 pts in
each trial
 Psyllium
 Improved glucose and cholesterol, no differences in
weight loss











Hydroxycitric acid
Linoleic acid
Green tea
Licorice
Pyruvate
Vitamin B5
Andl-Carnitine
Chitosan
Dandelion
Spirulina
Guggul
Others

So what does my doctor
say?

 “If there is strong evidence for a product’s quality,
safety, and efficacy, it may be reasonable to
recommend that product and closely monitor the
patient.”
 None of these supplements meet this criteria.
 Ephedra should be actively discouraged
 Due to lack of efficacy, patients are discouraged from
using: chitosan and guar gum
Exercise.
Eat a balanced
diet.
Get plenty of rest.
Other Random
Supplements/Vitamins

Cranberry Extract

 Prevention-MAYBE EFFECTIVE
 Treatment of bladder infections- NO EVIDENCE
 Cranberries are suppose to inhibit bacteria from
adhering to the bladder wall
 It has not been proven that taking “AZO cranberry”
can prevent bladder infections
 300 mL/day of Ocean Spray Cranberry Juice cocktail,
 500mg/day of Buckton Scott’s Cran-Max capsules
 400mg/day of Cranactin cranberry caps
Acidophilus

 Probiotic
 Generally considered to be beneficial because it
produces vitamin K, lactase, anti-microbial
substances
 Many uses, mainly used to treat antibiotic-associated
diarrhea, acute infectious diarrhea, irritable bowel
syndrome relief
 Side effects: flatulence
Glucosamine/Chondroitin

 Treatment of knee osteoarthritis
 GAIT trial-1583 participants
 May help with patients with moderate to severe
pain-GAIT trial showed 79% if patients in treatment
group had 20% reduction or greater of pain
 1500 mg Glucosamine
 1200 mg Chondroitin
 Side effects-upset stomach
Melatonin

 Treatment of sleep disorders
 Decreases the time it takes for people with a primary
sleep disorder to fall asleep
 Safe for short term use
 Did not help with how efficient sleep was or quality
of sleep
 Not effective for patients with secondary sleep
disorder
 Side effects include nausea, headache, dizziness,
drowsiness
St. John’s Wort

 Treat depression, anxiety, sleep disorders
 Some scientific evidence that useful for short term
treatment of mild to moderate depression
 Side effects: sensitivity to sunlight, anxiety, dry
mouth, dizziness, GI problems, headache
 Interacts with other medications
Gingko Bilboa

 Widely used for memory impairment, dementia, ringing
in the ears, claudication
 Study of 3000 patients followed for 6 years that were age
75 or older took 240mg a day found gingko ineffective in
 Reducing incidence of high blood pressure and in lowering
blood pressure
 Slowing cognitive decline
 Can increase bleeding risk
 Raw ginkgo seeds-seizures and death
 Headache, nausea, GI upset, diarrhea, dizziness, allergies
Federal Regulation of Dietary
Supplements

 The regulation of dietary supplements is different
than that of prescription medications
 No premarket review needed
 No prior approval by FDA before marketed
 Do not have to provide evidence to the FDA before the
product is marketed that their supplement is safe,
although they are responsible for making sure that it is
safe and that claims are not misleading
 Purity of supplements is relative
Things to remember

 “Natural” does not always mean safe or healthy
 Tell your doctor about any supplements or vitamins
you are taking
 Interactions with coumadin
 St. John’s Wort decreases effectiveness of certain
prescription drugs
References

1. Prescriber’s Letter
 Vit D and Calcium

Document #270102 updated Dec 2010
 Prenatal Vitamins

Document #270216 Feb 2011
 Cold and Flu

2.
3.
4.
5.
Self-Study Course #09029 expires Aug, 2012
Widmer AF. Replace hand washing with use of a waterless
alcohol hand rub ? Clin Infect Dis 2000; 31:136-43.
Sattar SA, Abebe M, Bueti AJ, et al. Activity of an alcohol-based hand gel
against human adeno-rhino-, and rotaviruses using the gingerpad
method. Infect Control Hosp Epidemiol 2000;21:516-9.
NIH:National Center for Complementary and Alternative Medicine:
http://nccam.nih.gov
University of Maryland Medical Center:
http://www.umm.edu/altmed/articles/omega-3-000316.htm
Cecily H. Kelly, M.D.
Office 830-372-3300
1350 Ashby St.
Seguin