To Take or Not to Take: Supplements?

“So tell me what kind of medicines you are taking?” I looked at my patient across the desk while she pulled out a long list.

“Vitamin E, Vitamin B12, Vitamin D, multivitamin, Zinc, Acai Berry, Coenzyme Q10, fish oil, Selenium, flaxseed, calcium, ginseng, rhubarb…” She proceeded to pull up multiple bottles that soon filled the desk.

“Do you smoke?” I asked as I wrote down her information.

“Yes, 1 pack a day.“

“For how many years?“

She shifted uncomfortably in her chair. “At least 30 years.“

This patient encounter left me unsettled. The number one question in my mind was, “Why would someone take at least 18 supplements designed to improve her health, while regularly inhaling toxins from cigarettes over 30 years?” Does that make any sense?

My patient eventually told me that it was much easier to take the supplements and vitamins than it was to try to quit smoking cigarettes. I agreed that quitting smoking is very difficult, but I told her that in the end, she would be much better off putting her efforts towards stopping smoking than in ingesting multiple vitamins and pills which do not have scientific proof supporting any health benefits from taking them.

In fact, in daily medical practice, patients often ask about the value of taking supplements.

Over the last year, there have been some notable studies published on calcium, Vitamin D and fish oil. Some of these new recommendations are controversial as they may contradict earlier published studies. What should you personally take for supplements? The best approach is always to speak with your personal physician about supplements so that he or she can tailor your regimen to your individual needs.

CALCIUM: Two publications this year have influenced my advice to patients on calcium supplementation. The medical establishment has always recommended calcium supplementation to help osteoporosis prevention and treatment. In February 2013, the U.S. Preventive Task Force (USPTF) issued a summary statement after reviewing research stating that in postmenopausal women, there is no evidence to support taking less than 1000 mg of calcium and 400 IU of Vitamin D3 a day, as those levels do not help prevent fracture and may raise the risk of kidney stones. A large study from Sweden reported that women with total calcium intake below 600 mg a day or above 1400 mg a day had higher rates of death from all causes, death from cardiovascular cause and death from ischemic heart disease. There was no increase in the rates of death from stroke.

The take home message? It does not seem to be of benefit to take low dose calcium supplements or Vitamin D3; however there is likely harm in taking over 1400 mg of total calcium intake a day. So if you combine the view of both sources, one might conclude that you can get 1000 mg to 1399 mg a day of calcium to decrease the cardiovascular risk and possibly help bone health. However, keep in mind that this would include all calcium sources, including food. This is a helpful link to amount of calcium in common foods: www.ucsfhealth.org/education/calcium_content_of_selected_foods/

The caveat is that all the women in the Swedish study were Swedish, which may not be representative of all women.

VITAMIN D: As reviewed above, the USPTF stated that taking less than 400 mg of Vitamin D3 a day in postmenopausal women did not help prevent fractures. So what about taking more than 400 mg of Vitamin D3 a day? Their guidelines did not apply to women with osteoporosis or for those with documented Vitamin D deficiency. Most experts are recommending at least Vitamin D3 1000 IU once a day to those with osteoporosis or Vitamin D deficiency, but often doctors prescribe even more.

In recent studies, it turns out than up to 75% of Americans may be deficient in Vitamin D. This number seems to be rising, and researchers blame that on the increased use of sunscreen with SPF (sun protection factor) which blocks UV light that manufactures Vitamin D in the skin, less sunshine exposure, and lack of Vitamin D containing foods in the diet. African Americans and people with more melanin in the skin also have lower levels of Vitamin D in the blood because melanin blocks absorption of Vitamin D in the skin. www.scientificamerican.com/article.cfm?id=vitamin-d-deficiency-united-states

Severe deficiency of Vitamin D can cause rickets in children, which is “soft bone syndrome” and results in bony deformities such as bowed legs. Vitamin D deficiency in adults can lead to osteomalacia, which causes weak bones and decreased muscle strength.

Possible benefits of having adequate levels of Vitamin D based on recent studies:

1. a lower risk of uterine fibroids;
2. decreased blood pressure;
3. decreased risk of multiple sclerosis.


So, what do I recommend for patients? If the patient has osteoporosis or Vitamin D deficiency, I recommend taking at least 1000 IU of Vitamin D3 daily. If the patient has very low levels of Vitamin D, I will prescribe higher doses. If the patient does not have a high risk for skin cancer, I recommend 10 minutes of sunlight without sunblock 2-3 times a week to boost Vitamin D levels.

Omega 3 fatty acids: For many years and many observational studies, populations that eat foods high in omega 3 fatty acids, which are the unsaturated fats in fatty fish (such as salmon), have lower rates of heart disease. Omega 3 fatty acids can lower triglyceride levels, and a prescription drug, Lovaza, which lowers triglycerides, is actually high dose fish oil. Cardiologists often tell patients to increase fish in their diet or supplement with omega 3 fatty acids.

In 2012, a large scientific study was published which analyzed 14 studies on omega 3 supplementation in patients who already had heart disease. Supplementation with omega-3 fatty acids did not reduce the risk of overall cardiovascular events, all-cause mortality, sudden cardiac death, myocardial infarction, congestive heart failure, or transient ischemic attack and stroke. 

What is the bottom line? Many researchers recommend trying to get omega 3 fatty acids from eating fish, instead of taking pills. This is mainly because if you are eating fish instead of other things, you are likely to be decreasing your red meat consumption, which is healthier in the long term.

What happened to my patient? 6 months after I had the conversation with her about vitamins/supplements and smoking, she developed a cough and headache. Unfortunately she was diagnosed with metastatic lung cancer and died in hospice. This sad example illustrates that the power of supplements cannot stop the power of cigarettes to cause cancer.

All of the studies above still support the notion that there is no substitute for living well. Eating well, exercising regularly and sleeping at least 7 hours a night. There are no shortcuts for those things.