each year on vitamins and supplements. Do these chemicals provide health benefits to us, or is the entire thing mostly a scam? The answer is that it is mostly a scam. With few exceptions, the best science demonstrates that virtually all vitamins and supplements are worthless, providing no benefit—and sometimes harming—the people who take them. To get our minds around the big vitamin and supplement swindle, we must first examine some of the excellent research which has been done, then analyze why these chemical products continue to be so aggressively sold and promoted, and finally sort out exactly what we should do to maintain optimal nutritional health.
Let’s start with fish oil supplements, also called omega-3 fatty acids. When I last wrote about this topic seven years ago, I recommended eating fish as a better alternative to taking these pills. However, I did point out that some research seemed to show a benefit from omega-3 fatty acid capsules. Since then, several additional studies have been done, including a few with thousands of patients, showing no benefit from fish oil supplements.
This is a common pattern in medicine. One or two poorly-conducted studies with just a few dozen patients suggest a benefit and everyone jumps on board. The recommendations come pouring in, along with the advertisements. Years later, large-scale, properly done randomized trials are conducted showing no benefit, but the old and now-discredited ideas persist for decades.
For example, in July the New England Journal of Medicine reported a study that included over 12,000 patients and went on for six years. These were individuals at high risk for heart disease and also either pre-diabetic or with adult-onset diabetes. There was zero benefit for patients taking fish oil capsules. Many of the earlier studies had far fewer patients. Other studies were not randomized trials. Some did not go on for as long. But this was a beautifully conducted trial showing that in these high risk patients, it was a waste of time to take fish oil.
In September, an article in the Journal of the American Medical Association pooled 20 different studies of fish oil with a total of 68,680 patients and found no benefit from fish oil supplements. Another study in 2010 randomized 4,837 patients who had already experienced a heart attack to receive fish oil supplemented margarine or placebo and showed no benefit to fish oil. Sure, a small study of 200 people here or there might show better outcomes, but with so few patients, sometimes that difference is just due to chance. However, when you study thousands of patients, you are more likely to get an accurate answer to your question.
There are several other large, ongoing randomized trials of fish oil. Until these trials come out, and unless they report a definite benefit, it is best not to bother with fish oil supplements. Just eat fish instead. The only patients who might consider fish oil are those who can’t eat fish or those who have had a heart attack and can’t take statin drugs. Healthy patients should not take these capsules, and people who eat fish several times per week should certainly not take them.
Vitamin E is another supplement that has been widely promoted for its health benefits. We hear that it is an “antioxidant” and can protect against cancer; no solid research supports this idea. What’s worse is a 2005 study which pooled the data from 19 different trials with a total of 136,000 patients showing that mortality was actually slightly higher in patients who took 400 IU or more of vitamin E daily. There are plenty of vitamin E supplements with 400 IU or more per capsule, including those from Walgreens, Rite Aid, and GNC.
Calcium is often promoted as being beneficial for osteoporosis. There is little evidence that this is the case. In the Women’s Health Initiative, 36,000 women were randomly assigned to take vitamin D and calcium or a placebo. There was only a slight difference in the risk of fracture, and this may have been due to chance. In that study, extra calcium caused more kidney stones and might have caused a few extra heart attacks as well. In June 2012, the British Heart Journal looked at a study of 24,000 patients and noted that people who took calcium supplements had double the risk of heart attack. Now, the heart attack risk has not been studied in the proper scientific fashion where we give 5,000 women calcium and 5,000 placebo and count the heart attacks over several years. Instead, we’ve looked back at research which was done studying other health outcomes, such as fractures, so the science is not as good; but when these sorts of harms are identified, it has to make us all think carefully about taking calcium. An argument could be made to limit calcium supplements to older women with severe osteoporosis and no history of heart attack. Fractures can be quite serious, especially in the elderly, but even a small potential risk of heart attack must give us pause.
Why should calcium supplements be harmful when eating foods rich in calcium is not? Well, you’ll find calcium in milk and cheese, of course, but also in beans, spinach, tofu, oranges, artichokes, canned salmon, and even lettuce. However, in none of these foods is the amount of calcium anywhere close to that in a couple of calcium pills. Typical calcium-rich foods have 100 mg to 300 mg of calcium per serving, whereas you could easily take 1,000 mg of calcium in a few Tums. Although it is speculation, it might be unhealthy for the body to take in so much calcium with one swallow, every day for years. We just don’t normally ingest calcium that way. Perhaps a study focusing only on calcium’s heart attack risk will show that calcium supplements are, in fact, totally safe, but until that study is performed, this is an area where caution is warranted.
Are there any vitamins we should take? Well, there is solid research showing that women who are considering getting pregnant should take folic acid. Also, if I draw your labs and see that you are low in a specific nutrient, such as vitamin D or iron, then a supplement is worthwhile. Vegans probably should take some additional vitamin B12, or at least have me check their B12 levels. Patients with a gastric bypass operation for obesity generally need to take some supplements. But for most everyone else, the widespread use of vitamins, calcium, fish oil, glucosamine, and other disproven chemicals such as saw palmetto, gingko biloba, and the like provide no benefit to patients and may cause harm.
Multivitamin supplements are very popular. Here you can get dozens of vitamins in one single pill. A recent study of 14,000 male physicians taking a multivitamin for many years showed no benefit in terms of the risk of heart disease. The study did suggest that just for men with a history of cancer, there was a slightly lower risk of a second cancer if they took multivitamins. However, there are some significant problems with the statistical approach used and I don’t think the evidence really supports vitamins in this setting.
In the face of ever-increasing scientific evidence that most vitamins and supplements are worthless or harmful, why is it that they remain so popular? I believe it is because these chemicals meet the needs of all parties involved—the people taking them, the people recommending them, and the people manufacturing them.
For people taking vitamins and supplements, these chemicals provide a psychological benefit. Call it the placebo effect or whatever, but we all want to be healthy. It is a cruel, scary world out there. The notion that all I have to do is pop a pill or two (or eight) every day and I’ll ward off cancer and heart disease is very reassuring. There is nothing wrong with wanting an easy solution to good health. Easy solutions are always preferable to difficult ones, except when they don’t work, as in this case. The fact is, some of our risks can’t be lowered no matter what we do. From a dietary perspective, eating healthy means eating in a way which is uncommon in our culture. Shopping in only 10% of the grocery store and rarely going to restaurants is tough. Avoiding cake, candy, ice cream, pasta, New York steak, french fries, and cheese is tougher. If it were possible to lower one’s risk of heart attack or cancer just by taking a vitamin, of course we should all do it, but this is a fiction.
There are easily half a million college freshmen
each year who are interested in becoming
physicians, but only about 16,000
end up in medical school.
For people recommending vitamins and supplements, a key advantage is that while these chemicals are mostly ineffective, their risks are small. Human beings, by our nature, like to visit healers, and we like to be healers ourselves. Your trainer at the gym, your hairdresser, your neighbor, your naturopath, and even your physician all have a desire to want to heal other people. It is quite heady to give medical advice. People hang on your every word. They write down what you say. They follow your directions. There are easily half a million college freshmen each year who are interested in becoming physicians, but only about 16,000 end up in medical school. This leaves a lot of people without an MD degree who want to serve as healers in some capacity in our society. Being able to “prescribe” vitamins is one avenue for non-MD types. Walk into any health food store and you will encounter a salesperson with no formal medical training who is delighted to give you authoritative-sounding advice based purely on fabrication; and this from someone who likely never even made it to college! Ask the guy or girl who helps with your exercise routine and a whole litany of senseless vitamin and supplement recommendations will come out, always delivered with an air of earnestness and confidence which belie the complete lack of science and knowledge underpinning their advice. As consumers, we should be highly skeptical, instead we are not. It is human nature to accept flawed information and lousy advice when it is delivered with an air of authority and professionalism. This is why, in the 2011 5th edition of the American Heritage Dictionary published by Houghton Mifflin, New York, the word “gullible” was omitted.
Of course, the manufacturers and sellers of vitamins and supplements find this to be an easy industry in which to be profitable. Unlike standard pharmaceuticals, these drugs are essentially unregulated. All sorts of unfounded health claims are offered up by the makers and sellers. When you compare the millions of dollars it can take to develop, test, gain FDA approval, and market a new pharmaceutical to the relative ease with which you can combine some supplements and sell them—no research, no FDA approval, no evidence of effectiveness ever needed—it’s no wonder that this is a huge industry with miles of shelf space in our nation’s drug stores invading our wallets at $14 billion each year. God bless any company that wants to make a profit and create jobs in our economy, but the invisible hand of capitalism must smite those companies who make products that drain resources and don’t really provide a benefit, like Venetian Blind sunglasses, baby tattoos, and most of the vitamins and supplements out there. The best way to get the correct amount of vitamins and supplements is to eat lots of fresh fruit and vegetables. Boring, I know. Patients must realize that there are thousands of chemicals in fruits and vegetables which are helpful to the body. The vitamins we have identified are only a tiny fraction of the various beneficial compounds found in these foods. Extracting just a few of these chemicals, calling them vitamins and packaging them in a pill, increasing the dosage ten or one-hundred fold, and then swallowing them is unlikely to provide major health benefits to us. Fresh fruits and vegetables are what we’ve been eating for millions of years, and our bodies are adapted to consume this sort of food. Chocolate cake and Big Macs are modern, toxic inventions of low nutritional value.
So save your time and money by passing on vitamins and supplements. Eat fruits and vegetables and a healthy protein source. Red meat is bad for us; it should not be consumed daily. Chicken and turkey are better, and fish probably even better yet. Some patients do not like any fish. Here is what I recommend for those folks. Skip breakfast and lunch, then visit one of the best seafood restaurants in the city, like AQUA on Pier 70 in Seattle or Seastar in Bellevue. Order the least fishy-tasting fish on the menu—halibut or scallops. Don’t eat any bread, soup, or salad beforehand. See how that goes.