My strategy is to tell them to stop all vitamins which have been shown to increase mortality, heart failure, stroke, or MI - including vitamins E, A, C, Zn, selenium, folic acid, B6, and magnesium. I let them keep the benign ones but tell them they are generating expensive toilet water. I tell them statins were derived from yeast (it's true) and aspirin from willow bark (again largely true). I don't tell them warfarin is rat poison (they all know that) but I do say it was derived from sweet clover. ACE inhibitors were derived from snake venom (Bothrops spp), but I don't mention that. So natural (vitamin) vs drug (synthetic) is a false distinction.

Please comment on last years JACC article on CHF and COq10.

I wonder how much the decreasing incidence of heart disease in Europe as you go from North to South is due to the increasing adherence to the mediterranean diet and how much is due to the increasing levels of sunshine. It may be that it is not enough to eat a mediterranean diet, maybe you have to eat it  in the mediterranean!

What we should be telling our patients is how to get their vitamins from FOOD !!!  Once again, the lack of physician training in nutrition comes into play here.  Getting the B complex of vitamins from whole grains is the way to go rather than in concentrated supplement form.  By the way, we should take note that in a recent article in Annals of Internal Medicine ( a journal that I believe should qualify as evidence-based), the use of vitamins B6, B9, and B12 were shown to have significant benefit in the a prevention of Age-Related Macular Degeneration; therefore, we can't say that there is NO good evidence in this regard as is suggested by Dr. Bilazarian.  Finally, 10 minutes every other day of unrestricted sunlight to the face, neck, and upper torso will more than supply the needed amount of Vitamin (D3).  There is no danger of dermal toxicity with this amount of exposure.

Whatever advice is given to patients, it is particularly important to avoid the old saw "You get all the vitamins you need from a well-balanced diet."  Patients have tumbled to the circular reasoning in that statement.  And more importantly perhaps, they are inundated with information about how unbalanced the typical diet is.  And the clever "expensive urine" comment doesn't help as the typical response, most often not spoken, is "What do I care how expensive my urine is as long as I live a long, healthy life?"  Perhaps DGN's advice is the best model for counseling.  Tell them what is known about supplements to avoid based on scientifically valid studies, which are OK and supported by scientific study and acknowledge that our knowledge of the majority must await further study.

Take a look at the vast amount of literature at http://www.vitamindcouncil.org/.

 

The study in JAMA was ridiculous in that they gave a year's worth of vitamin D in one day ? 500,000 IU. 

The Registered Dietitian (R.D.)is the recommended "go-to" resource for addressing the issues of vitamins and supplements. The adequacy of a client's eating pattern can first be assessed,  and recommendations can be made for a "food approach" to healthy lifestyle.  Dietary suppplements such as multivitamins, Vit D, Calcium, fish oils and special needs supplements can be discussed and considered in the context of the client's personal regimen.  It would be very worthwhile to secure a reputable RD for your practice.

As a health writer who has been interviewing integrative docs for 30 years, I think that physicians who have no knowledge of nutritional/supplement therapy along with legitimate doubts should attend nutritional med conferences and learn first hand how this approach plays out in actual clinical settings. To say that B vitamins should not be used, in an age where poor diet is the rule and not the exception, seems ludicrous to me.  I have talked to too many doctors over the years who have used B factors with great healing benefits.  Niacin, for instance, was found to reduce cholesterol and raise HDl 55 years ago.  B6 is a remarkable substance for carpal tunnel.  And these are dosages in the mega range.  Many of the nutrition docs have been at their trade for decades and have much to offer.

Some comments here are misinformed. The grain supply is now fortified with folic acid and my lab won't even let me order RBC folate levels anymore because deficiency has become so rare (except in alcoholics and malnourished patients who eat nothing). Therefore, except in pregnancy or demonstrated folic acid deficiency (which is now rare), there is no need to take THIS B vitamin. Second, pyridoxine for carpal tunnel syndrome in mega doses (vitamin B6) will only aggravate neuropathy not mitigate it. It has been known for many years that high doses of pyridoxine cause peripheral neuropathies. Therefore, the recommendation of the previous correspondent is nonesensical. The treatment of CTS is rest, splits, physiotherapy, ergonomic modification and if all else fails NSAIDs and surgical release. 

There is virtually no evidence to recommend vitamin C for anyone except constant skiers at high risk for colds (see the recent cochrane review of randomized trials). Same now goes for selenium and vitamin E for preventing prostate cancer and dementia. All of these theories which were once cherished have now been debunked. I could go on and on ... vitamin A causes lung cancer in smokers, vitamin E replenishment causes heart failure and increased mortality, etc, etc.

As they say, show me the "money". In this case, evidence. 

Carpal tunnel and vitamin B6, circa 2007 systematic review:

 Clin Rehabil. 2007 Apr;21(4):299-314.

A systematic review of conservative treatment of carpal tunnel syndrome.

Piazzini DB, Aprile I, Ferrara PE, Bertolini C, Tonali P, Maggi L, Rabini A, Piantelli S, Padua L.

Department of Physical Medicine and Rehabilitation, Catholic University, Rome, Italy.

My experiences in the past 24 years as a Registered Dietitian (RD) has included so many individuals who needed advice on vitamin and supplement use... the most troubling patients have been the ones who use or don't use vitamins religiously.Nutrition is a science, like medicine, and not a belief system.  Anyone who recommends exactly the same treatments for everyone has missed the point.  Each patient needs to be evaluated by their diet--averaged over a period of time, by their family history and personal history of health and disease.  At that point it is clearer what they might need.  Many patients can meet their nutritional needs by eating foods, especially if they know a variety of foods that will provide the nutrients they need.  A Registered Dietitian with plenty of experience evaluating diets and on interviewing skills to get enough information from the patient and the family would be such an asset to determining actual needs--and reevaluating that patient's needs as they change over time.Except in cases of frank deficiency I rarely can tell a patient whether they should continue or avoid specific vitamins.  It takes extra time, but to give a thorough answer, I really need to know much more about the patient and the supplements they consume by brand to be able to guide them.  It’s guidance for that period of time, but they need to be re-evaluated as they change, and/or as time passes.

 

How sad?  Doctors think processed foods can provide all the nutrients that are needed?  The National Cancer Institute conducted a study and found 5 servings of fruits and veges did not reduce cancer or heart disease rates.  Recall this?  Not a single person is sufficient in vitamin C who doesn't take supplements!  Optimal blood levels, which reduce histamine and activate white blood cells, are achieved by taking 500 mg vitamin C 4-5 times a day.  The absence of scurvy does not indivate adequacy. 

Vitamins that increase mortality?  Do physicians fall for pseodo-science?  If no, then why do you all prescribe statin drugs that only work 3% of the time (1 in 70 users avert a non-mortal heart attack over 5-years), and has a side-effect ratio that exceeds any alleged benefits?  And you dare criticize vitamin pills? 

About 4 in 10 adults are deficient in B12 (serum test will not reveal this, only a therapeutic challenge will uncover the problem).  How many of your patients walk in and out of your office with burning feet, short-term memory loss, fatigue, back aches, all related to a shortage of B12?  Common multivitamins won't supply enough B12 to remedy the problem (doctors are supposed to know this).  It takes ~300 mcg of methylcobalamin to remedy this form of anemia (only 1% of oral B12 is absorbed).

Don't throw flawed studies in my face.  Recent study said folic acid is of no benefit in preventing heart attacks.  OK.  But it IS beneficial in fighting mental depression, and is required for DNA repair.  How much folic acid are your patients getting who don't eat green leafy vegetables?   

Absolutely!  As an Exercise Physiologist in a hospital based cardiac rehab program, I work alongside a number of very experienced, knowledgeable and skilled Registered Dieticians, and see the value daily of the the practice you speak of. Almost everyone has an an opinion on appropriate nutrition, whether based on media reports, Canada's Food guide, the internet or other sources. 

The amount of education these professionals provide on both general evidence based nutrition and on individualized programs tailored to the patient is enormous, and the patience they exhibit in dealing with entrenched ideas and practices is incredible.

The question is how to incorporate this into regular practice? Most folk don't experience access to RDNs on a regular basis.  Most have never even met one once, let alone know the difference between a Personal Trainer handing out nutrition advice and a RDN who knows the literature/evidence and how to apply it. 

This is where physician referrals might help fill the gap. Most GP's don't have the time necessary to investigate indiviual eating habits, nor the background to quickly identify strategies to optimize a heathly diet - relative to a RDN who does it daily.  

I believe it behooves physicians to include RDNs in their network of recommended professionals to support their patients efforts attain and maintain a healthy lifestyle. .

As an R.D. I constantly review literature for studies validating many health claims and suggestions for the public.  I am not aware of the studies you are referring to.

I think this is a helpful forum for discussion, and sharing of information.  I frequently use the PDR for Nutrition Supplements to evaluate if a supplement might be harmful for an individual, and also the consumerlabs website to see why people tell me they are taking a product and whether the brands pass the safety tests they run.  

I would be genuinely interested in some of the sources you find useful, it's obviously a topic with so many opinions and results to evaluate.  Any information you can share would be appreciated.  

 

NOT POSSIBLE! Gettting what you need nutritionally from food is would be great if it were possible. I've researched and studied the connections between health and nutrition for nearly 40 years. What I've learned is the mineral content in our food is severely deminished. At one time a single apple provided 50% of the RDA of iron ... today you need to eat 26 apples to get the same. Yes, one apple today provides only 1/50th of the RDA of iron. Understand, while plants can and do manufacture vitamins and other nutrients, they do not and can not manufacture minerals. Minerals must come from the soil. Between farming practices and errosion the soil is over 85% depleted (according to the USDA). NOTE: This is true even if eating organic. You are correct that the best and likely only source of minerals (mega, trace, ultra-trace) our bodies can assimilate is from real food. The challenge is how do I eat the necessary 26 apples and 45 bowls of spinach a day? I've used a food source for nearly 15 years and seen a tremendous difference in my health, the health of my family and friends. I now work with the company so don't want to plug it here - but if you have an interest, it would be a pleasure to share the info with you. The company has offered this through doctors & health practitioners and lay people for over 25 years.