Four Good Reasons to Take a Multivitamin

I do not know how many times I have been asked the question "why should I take a multivitamin?" - but today I am going to share some of the answers with you. This blog post started off as one on immunity. I have had a lot of people asking me lately what they can do to boost their immunity. They seem surprised when I mention taking a daily multivitamin. The following list is by no means an exhaustive list of reasons why you should take a multivitamin, but I think it is some good reasons.

1. Experts agree that we don't get enough nutrition from our food. In the perfect world, all your essential vitamins and minerals would come from the foods you eat every day. You would eat a nutrient dense, modest calorie diet, not worry about weight gain, and feel confident that food was meeting your needs. That is not the world we live in. There is more data than I can cite that clearly shows our diets (even those of us who watch what we eat carefully) tend to be nutrient poor. More often, they are calorie rich AND nutrient poor, which is why we simultaneously have increasing obesity and poor nutrition. In 2001, researchers from the Harvard School of Public Health writing in the New England Journal of Medicine said the following:  "Given the greater likelihood of benefit than harm, and considering the low cost, we conclude that a daily multivitamin makes sense for most adults. Substantial data suggests that higher intakes of folic acid, vitamin B6, vitamin B12, and vitamin D will benefit many people, and a multivitamin will ensure adequate intake of other vitamins." (1)  The following year, researchers from Harvard Medical School, wrote in the Journal of the American Medical Association: "Most people do not consume an optimal amount of all vitamins by diet alone.  Pending strong evidence of effectiveness from randomized trials, it appears prudent for all adults to take vitamin supplements." (2)
2. Taking a multivitamin is good for immunity.  There has been a great deal of research looking at the the use of basic nutrition in the form of a multivitamin for preventing infection and improving immunity.  The vast majority of studies have been done in the over-65 population, because nutritional status tends to decrease and community acquired infections (like the flu and pneumonia) tend to increase and become more deadly as we age.  The findings are almost 100% positive.  Again, far too many studies to cite, but if you search Google Scholar for "multivitamin and immunity" you'll find plenty of good reading material.  What about in the non-elderly?  In a study published in 2003, researchers gave a daily multivitamin to adults aged 45-64 and found that the rates of infection and days of lost work were significantly less in those taking a multivitamin compared to those taking a placebo. (3)  
3. Taking a multivitamin may help you to control your appetite.  Two studies published in November 2007 in the British Journal of Nutrition indicate that taking a multivitamin and mineral supplement may assist in weight management. The first study reported on a survey of survey of 267 men and 320 women aged 20 to 65. (4) The survey found that in men regularly taking a dietary supplement weighed less, had less body fat, and lower BMI than those who did not. Women reported similar results, as well as generally reduced appetite.  In the second study, obese patients were placed on a low calorie diet and either given a multivitamin or placebo. (5) While both groups lost weight equally, those taking the multivitamin reported significantly reduced hunger both between and after meals.  What should this tell us? Our metabolism is driven by nutrients - vitamins and minerals are the cofactors that make all the reactions work. When we lack these nutrients, things just don’t work as well. Moreover, a basic reason we eat is to get the nutrients we need. When the body doesn’t get enough of what it needs, one thing it does is make you feel hungry so you will eat more to get those nutrients.
4. It might make your cells younger.  Let's face it, most of us either want to stay young or be younger.  Most of the focus these days on "anti-aging" is on cosmetic procedures.  You can lift, inject, color, and tighten whatever you want, but that does not change anything but what you see in the mirror.  Research published earlier this year from the National Institute of Environmental Health Sciences found that the cells of multivitamin users were biologically younger than those of non-users. (6) As we age, a piece of DNA called a telomere that resides at the end of your chromosomes gets shorter.  When the telomere is finally "consumed" the cell dies (a process called apoptosis).  Thus telomere length is often looked at a a measurement of cellular age.  This particular study looked at the cells of 586 women aged between 35 and 74.  Multivitamin users had, on average, telomeres that were 5% longer than those of non-users of the same age.

Even if you think you eat really well, taking a multivitamin is a sensible health insurance policy for most adults.  I also think it's a good idea for kids, but perhaps we will leave that for a separate blog post.  I think the hardest thing for most people who have never supplemented before is simply getting started and making this part of your routine.  Here are two ideas to help you get in the habit of taking a vitamin.  First, put them where you will see them every day.  Inside your medicine cabinet is usually not that place.  I suggest setting the bottle of multivitamins by your toothpaste or on the desk in your office (or one in each place).  Second, set a reminder for yourself.  Most of us carry a PDA or cell phone these days.  Set a daily alarm to chime at the time when you want to take your vitamins.  You probably won't need to do this forever, but it can be a great tool when you are trying to make this a new habit.

In Health,


Dr. Jacques


References:
(1) Willett WC, Stampfer MJ. Clinical practice. What vitamins should I be taking, doctor?  N Engl J Med. 2001 Dec 20;345(25):1819-24.

(2) Fletcher RH, Fairfield KM.  Vitamins for chronic disease prevention in adults.  JAMA 2002; 287:3127-312. 

(3) Barringer TA, Kirk JK, Santaniello AC, Foley KL, Michielutte R. Effect of a multivitamin and mineral supplement on infection and quality of life. A randomized, double-blind, placebo-controlled trial.  Ann Intern Med. 2003 Mar 4;138(5):365-71.

(4)(5) G.C. Major, E. Doucet, M. Jacqmain, M. St-Onge, C. Bouchard, and A. Tremblay. Multivitamin and dietary supplements, body weight and appetite: results from a cross-sectional and a randomised double-blind placebo-controlled study. Br J Nutr. 2007 Nov 1;:1-11

(6) Xu Q, Parks CG, DeRoo LA, Cawthorn LM, Sandler DP, Chen H.  Multivitamin use and telomere length in women. Am J Clin Nutr. 2009 Jun;89(6):1857-63.

Why I don't like flax oil as a source of Omega-3

I know right off that some people will read this post and disagree heartily with what I am about to write. I love discussion - especially when it can be well supported by research - so if you have comments, please leave them!

I get asked a lot of questions about the best supplemental sources of Omega-3 fatty acids. Omega-3 fatty acids are essential fatty aids or EFAs. As the word essential implies, this group of fats are a requirement for normal health and cellular function. The body cannot make these fats itself, so it must – as with essential vitamins and minerals – obtain them from an outside source such as a food or a dietary supplement. Technically speaking, there are only two EFAs: the Omega-6 fatty acid Linoleic Acid (LA) and the Omega-3 fatty acid Alpha Linolenic Acid (ALA). From these, the body can derive the other four essential fatty acids: Gamma Linolenic Acid (GLA), Eicosapentaenoic Acid (EPA), Docosahexaenoic Acid (DHA), and Arachadonic Acid (AA). These four can also be ingested pre-formed.

Flax seed oil is an outstanding source of the Omega-3 fatty acids ALA. Other good sources are canola, pumpkin, walnut oils. The issue at hand is that most people are supplementing these things (versus using the food - like eating walnuts or pumpkin seeds) to obtain a specific health benefit. Virtually all the good research associated with health associated claims is directly related to EPA and DHA from fish oils. There is not substantial evidence that ALA alone from sources such as flax or canola has any of these effects, despite the fact that the body can create EPA and DHA from ALA.

Why? This may be because the ability to convert ALA to EPA and DHA can be impaired by a variety of factors including a diet high in the Omega-6 fatty acid Linoleic Acid (LA), trans-fats, and saturated fats, alcohol intake; deficiencies (even sub-clinical) of niacin (B3), vitamin B6, vitamin C, zinc or magnesium; diabetes and insulin resistance. Scientific studies report the human conversion of ALA to EPA and DHA to be between 0.2 (1) and 15 percent (2). That is incredibly inefficient. This blog recently discussed the new paper from the Journal of the American College of Cardiology that recommended 500mg per day of Omega 3 (specifically from EPA and DHA) for the prevention of heart disease (Omega 3 Updates, 27 Aug 2009). Assuming that you were doing a great job of converting your ALA, you would need to take over 3,300 mg (3.3 grams) of flax oil to get the equivalent of one 500mg fish oil capsule. If you are at the low end...well, you do the math.

Furthermore, ALA converts almost entirely to EPA (3) and minimally to DHA (which gives the greatest benefits for the brain). Therefore, for health benefits attributed to EPA and/or DHA, foods or products containing these preformed fatty acids should be the preferred source.

And I don't want to completely knock flax. The seeds are a great source of ALA, fiber, and lignan - which may have some of its own health benefits. Flax seeds or meal an excellent addition to muffins, pancakes, or other foods where they can nicely boost nutritional content. But if you want the health benefits of EPA and DHA, eat fatty fish or take fish oil.


References:
1) Pawlosky RJ, Hibbeln JR, Novotny JA, et al. Physiological compartmental analysis of alpha-linolenic acid metabolism in adult humans. J Lipid Res. 2001; 42: 1257–1265.
2) Emken EA, Adlof RO, Gulley RM. Dietary linoleic acid influences desaturation and acylation of deuterium-labeled linoleic and linolenic acids in young adult males. Biochim Biophys Acta. 1994; 1213: 277–288.
3) Mantzioris E, Cleland LG, Gibson RA, et al. Biochemical effects of a diet containing foods enriched with n-3 fatty acids. Am J Clin Nutr 2000;72:42-48.

Hoodia for Weight Loss

When I put out a call for ingredients that people wanted more information about I was not expecting to get questions on Hoodia. In the world of natural products for weight loss, ingredients come and go - there is always a "hot" trend" - and Hoodia really hit that status 3 or 4 years ago.

Nonetheless, I got more requests to talk about Hoodia than anything else, so here we go.

First, some history. Hoodia, primarily the species Hoodia gordonii, is a traditional plant of Southern Africa. The San people of the Kalahari Desert would eat this plant to ease thirst and hunger when they were traveling, and short on readily available food sources. Literature also suggests that the San found Hoodia to be helpful for indigestion and other mild GI complaints.

In the 1960s, the Council for Scientific and Industrial Research (CSIR) took an interest in Hoodia and other indigenous plants for their possible medicinal properties. CSIR later contracted with a British pharmaceutical company called Phytopharm LTD to continue the investigation of Hoodia as a drug for appetite suppression. Phytopharm isolated a compound called p57, which they felt was the active ingredient responsible for the appetite-suppressing qualities of the plant. They licensed this to pharmaceutical giant Pfizer in 1998. Pfizer dropped the product after early clinical trials for vague reasons. Reports/rumours later circulated that the levels of Hoodia required to suppress appetite in rats and dogs was extremely large and produced severe liver damage. It may have also caused kidney damage. (You can read about that here, but remember, most of this is not validated: Hoodia Report from Fatnews)

Take two. After the failed attempt with Pfizer, whatever the reasons, Phytopharm entered into a contract with Unilever. Unilever was researching p57 as an addition to its popular SlimFast line of diet products. After 4 years of research, Unilever followed Pfizer and dropped p57 in late 2008. The publicity following this split often quoted executives from Unilever as saying that "clinical study concluded that Hoodia could not meet Unilever’s safety and efficacy standards." (read more here: Hoodia Finds Life After Unilever)

But wait, you ask, Hasn't Hoodia been available as a dietary supplement for years?? Yes it has. Concurrent to all this negotiation over the patented p57 (this patent expires in 2017, by the way), the natural products industry (reeling from the loss of Ephedra in 2004) jumped all over Hoodia as a traditional weight loss ingredient - and this created another set of problems.

Hoodia has long been acknowledged by the Convention on International Trade in Endangered Species (CITES), as a fragile species. It is apparently slow growing and hard to harvest. When it began to boom in popularity two things happened: 1) you had a lot of plant poaching - literally people stealing the herb to sell - and 2) you had a lot of product showing up here in the US that probably was not Hoodia at all (read more about fake Hoodia here: Fake Hoodia Fears Easing as Market Stabilizes). Fortunately, for the past few years, this seems to be improving. Methods for farming Hoodia have improved as have methods for identifying the genuine ingredient.

So what is the good news? Those who have practiced traditional herbal medicine will tell you that when you take a plant that has had a long history of being used for "condition x", try to isolate a chemical out of it and then expect the same results, you may not get what you are looking for. There are many great examples of this such as hypericin from St John's Wort and lobeline from Lobelia inflata. The San people ate whole Hoodia, not p57. But you can't patent the plant...

So if you are going to use Hoodia as part of your weight management strategy, you are actually likely to be better off with the whole plant extracts that are present in dietary supplements and not the isolated p57 - at least until if/when research proves otherwise. Also if you are going to take Hoodia, take a certified product - for example Naturex's HoodiaPure® - or others with CITES certification.

In Health,

Dr. Jacques

CNN Review of Natural Cholesterol-lowering Substances

Often, natural products coverage in the mainstream media makes me want to cringe. They seem to go after or highlight the most sensational things they can find, which I believe contributes to consumer confusion about the safety and efficacy of natural products.

Sometimes, however, they do a good job, and I think these efforts should be encouraged and highlighted. There are a lot of people worried about their cholesterol - and with so many products from drugs to foods marketed at consumers, it can be hard to understand the choices.

While this article does not discuss all the options, it does highlight the currently available research on many of the more popular natural ingredients used in "heart health" products.

For those of you who are interested in this topic, here is the CNN article:
http://www.cnn.com/2009/HEALTH/08/20/cholesterol.lowering.supplements/

Omega-3 Updates

It seems like omega-3 fatty acids are competing with vitamin D for "most famous nutrient" award this year. There has been so much research published this year on these nutrients that it's almost more confusing for the public.

There have been several newsworthy pieces on omega-3 fats lately that have generated enough email to my in-box that I think they are worth blogging about.

1) In this study - Plasma n-3 polyunsaturated fatty acids are negatively associated with obesity - published in the British Journal of Nutrition, researchers examined blood levels of omega-3 fats in 124 people of varying body mass index (BMI). They found that, in general, people with higher BMIs (those who weighed more) had lower levels of omega-3 that those with lower BMIs. Most of the questions I have received are from people who want to know if this studying is saying that taking more omega-3 will cause you to weight less. There is no data yet to support that. However, there are other profound health benefits of these fats that make including them in your diet or taking them in a supplement worthwhile. Keep in mind that an average serving of salmon can have 2 or more grams of omega-3 - so those in the very high fish intake group may have been getting levels well above those shown to be health-supportive.

2) A study (Long-chain omega-3 fatty acids, fish intake, and the risk of type 2 diabetes mellitus) that hit the news more recently followed the health of 195,204 US adults for 14 to 18 years. Part of what researchers tracked was intake of fish and other sources of essential fatty acids. During the course of the study, 9380 people developed type 2 diabetes. Intake of fish and other essential fats was not associated with a reduced risk for developing diabetes. Actually, the highest intakes of fish (5 times or more per week), were associated with a 20% INCREASED risk. The researchers called this "modest". I do not call that modest. There is other research indicating that in those with diabetes or at risk for diabetes high intakes of omega-3 may elevate blood sugars. I think that until we know more, we should caution people against high intakes if omega-3 fats, and encourage the modest intakes that are associated with so many health benefits.

3) This leads me to the final story on this topic. A new review published in the Journal of the American College of Cardiology looked at studies involving approximately 40,000 people. They concluded that overwhelming evidence suggests that for prevention of heart disease, everyone should take 500 mg per day of omega-3 fatty acids as EPA and DHA (eicosapentanoic acid and docosahexanoic acid - the omega-3s from fish). For those with a known risk for heart disease, they suggest a higher dose of 800 to 1000 mg/day is well-supported by research. To read more on this review, click here: Omega-3 review: Half a gram needed for heart benefits.

So the conclusions for now:
Omega-3 fatty acids are important for good health. They have been shown to support the health and development of the brain and the eye, and we know they modulate inflammation, benefit the skin, joints, hormone balance and more. It does not, however, appear that they help you lose weight - but you never know what future studies might show. Levels of 500 to 1000 mg are appropriate for those who are looking to prevent heart disease. Very high intakes seem to increase the risk for diabetes - so until we know more, go for moderation. My final added advice - if you are relying on fish as your main source of omega-3, please seek clean sources. Fatty fish like salmon and tuna are often contaminated with pesticides, herbicides, and heavy metals that accumulate in your body and are truly harmful. Here is a great list of fish rated by average mercury levels: NRDC Fish List

In Health,

Dr. Jacques

Gut Bugs

I used to always tell my patients "you are more like a bagel than a roll of bread." This was not commentary on their doughiness, but rather a not-very-elegant analogy of the human body.

Most people think of the outside of their body as what they can see - their skin. But really, the passage from your mouth at one end to your anus at the other is a long, continuous tube, that is really part of your outside. For anything to truly get inside of you - your food, drinks, medication, some infections, etc - it has to be allowed through this barrier.

When we think about nutrition, we mostly tend to think about what we put in - vitamins, minerals, protein, water - but we often don't stop to think about the complexity of how these things actually get from our digestive system into us. Part of the equation is the complex ecosystem of "gut bugs" - our intestinal microflora that resides in the digestive system.

The whole field of probiotics (microflora that you can supplement), and the study of intestinal microflora in general, has exploded in recent years. The more we learn about these organisms, the more we seem to learn that our relationship with them is very important to health - for nutrition, immunity, and much more. It also seems at the moment that the more we know, the less we know - the number of strains of flora is now dizzying, and understanding which are good, which are bad, which are right for what purposes is becoming increasingly complex.

That said, the research that is pouring in these days is fascinating. Here are two recent studies that I think are very worthy of noting:

The first shows that a daily supplement of Lactobacillus and Bifidobacterium strains (the two most commonly supplemented probiotics) may reduce the incidence of cold and flu-like symptoms in children by 50 per cent. This is a very nice practical study. It has long been known that some probiotics can benefit immunity, but to actually have some data showing that it can reduce the incidence of common infections by half is great news for lots of parents with kids going back to school right now. Click here to read a good news story on the study: Probiotics may reduce cold and flu symptoms for children.

The second is also a study indicating increased immune protection from a probiotic. In this study indicates that probiotics may protect against toxoplasmosis. This is a parasite that can be carried by house cats. This is early research, but very interesting. This parasite infects more than a billion people worldwide - so if future research shows this to be effective prevention, that is good news for a lot of people! To read more about this story, click here: Could probiotics protect us from gut parasites?


I am sure that I will have many future posts about probiotics. For now, I think it is one of the things that most people should consider taking on a daily basis. Our natural flora can be disrupted by so many things: our diet, medications like antibiotics or steroids, infections - and these "friendly" bugs support our health in critical ways, many of which we are only beginning to understand. The greatest risk from supplements is really taking something that is "dead" - meaning that the probiotics in the supplement are no longer viable to be able to take hold and populate the digestive system. So pay a little more for quality - it's worth it.

In Health,

Dr. Jacques


References
A >G.J. Leyer, S .Li, M.E. Mubasher, C. Reifer, A.C. Ouwehand. Probiotic Effects on Cold and Influenza-Like Symptom Incidence and Duration in Children. Pediatrics 2009, Volume 124: e172-e179.

A. Benson, R. Pifer, C.L. Behrendt, L.V. Hooper, F. Yarovinsky. Gut Commensal Bacteria Direct a Protective Immune Response against Toxoplasma gondii. Cell Host & Microbe. 20 August 2009, Volume 6, Issue 2, Pages 187-196.

Vinegar for Weight Loss

I get a lot of questions about natural ingredients for weight loss. One thing that I will do with this blog is review as many of them as I can with a particular focus on reviewing the available research. Apparently, there was a recent piece that appeared on WebMD about cider vinegar for weight loss. I have had several questions on this since the article appeared. (To read the original piece, click here.)

Apple cider vinegar has been touted as a cure-all for everything from digestive ailments to rheumatism. Hippocrates, the “Father of Medicine” reportedly gave it to patients as a healing tonic in 400 BC. To the best estimates of modern-day herbalists, apple cider vinegar first appeared in weight loss remedies in the 1970s – although modern proponents claim that this was the secret weight loss cure of Ancient Egypt. The secret recipe that started the modern-day trend was a blend of Apple Cider Vinegar, kelp (seaweed), lecithin, and vitamin B6. The story was that the lecithin emulsified fat, iodine in the kelp increased thyroid function (speeding up metabolism), B6 somehow metabolized the freed fat, and the vinegar would then breakdown or dissolve the fat and accelerate metabolism. Other theories have tied weight loss benefits of Apple Cider Vinegar to increased detoxification or improved pH.

Is there any actual evidence that Apple Cider Vinegar can help you lose weight? Not much. I did find a study done in Egypt in 2001 that showed that mice given a high dose of Apple Cider Vinegar for 4 weeks had significant weight loss compared to those on a controlled diet. However, the vinegar-eating mice also had pretty significant damage to their livers, stomachs, and small intestines – including erosion of the lining of the stomach and intestines (ie, ulcers) and changes in the cells of the liver. Not good for the mice. The study that was discussed in the WebMD article was also done in mice fed a diet high in vinegar for 6 weeks. They did not lose weight, but researchers reported that the vinegar "inhibited the accumulation of body fat." So what we really have to date is some less than spectacular data in mice.

Somehow, people always want to take these kinds of animal studies and transform them into the next great miracle cure for obesity. So what about studies in humans? A small study conducted in 2005 on 12 adults found that subjects who consumed 2 tablespoons of vinegar with a meal of bread reported less hunger after their meal. The same researcher later conducted a study in 13 adults and found when subjects used an oil and vinegar dressing with a meal of potatoes, they had lower post-meal blood sugars and a healthier insulin response. Finally, one study from 2004 gave a dose of 2 tablespoons of vinegar to 15 adults before lunch and dinner for 4 weeks. Compared to placebo, the vinegar group lost an average of 2 pounds over 4 weeks.

While these small trials are interesting, they do not look at big enough numbers to be significant and they do not address other issues of health. I have found one case report of a woman who suffered an acid burn in her esophagus from taking Apple Cider Vinegar tablets - she apparently did not lose weight. As part of the follow up to that case, investigators tested many products and found that some of them were so acidic (containing acetic acid levels over 20%) that they were in the range that the Consumer Product Safety Commission considers poisonous to humans.

Overall, Apple Cider Vinegar has some very good and valid uses. You can use it in salad dressing, it makes a great addition to marinades or to tenderize meat, you can clean gold jewelry with it, and you can use it as a natural weed killer in your garden. But as a weight loss agent, it has not yet been shown to be effective, and it could be harmful. Future more rigorous studies in humans might show doses that have both good safety and health benefits. For now, proceed with caution.

References:

Mohamed el-OA, Mohamed SM, Mohamed KA. The effect of cider vinegar on some nutritional and physiological parameters in mice. J Egypt Public Health Assoc. 2001;76(1-2):17-36.

Hill L. L., Woodruff L. H., Foote J. C., Barreto-Alcoba M. Esophageal Injury by Apple Cider Vinegar Tablets and Subsequent Evaluation of Products. JADA; 105(7): 1141-1144 (July 2005).

Ostman E, Granfeldt Y, Persson L, et al. Vinegar supplementation lowers glucose and insulin responses and increases satiety after a bread meal in healthy subjects. European Journal of Clinical Nutrition, 2005;59;983-988.

Leeman M, Ostman E, Bjorck I. Vinegar dressing and cold storage of potatoes lowers postprandial glycaemic andinsulinaemic responses in healthy subjects. European Journal of Clinical Nutrition, 2005

Johnston CS, Kim CM, Buller AJ. Vinegar improves insulin sensitivity to a high-carbohydrate meal in subjects with insulin resistance or type 2 diabetes. Diabetes Care, 2004;27:281-282.