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Naturopathy vs. Science: Prenatal Vitamins

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This is another post in the naturopathy versus science series, where a naturopath’s medical advice is assessed against the scientific evidence. Today’s topic is brought to you by Toronto naturopath Shawna Darou, who recently published her evaluation of prenatal vitamins.

Vitamin supplementation is unnecessary for the vast majority of people. You wouldn’t know this walking through a drug store, where you’ll usually find an entire aisle packed with supplements. Alternative health providers like naturopaths tend to be strong supporters of supplementation, but this advice seems to be based mainly on the belief that “vitamins are magic” rather than good science. The best research hasn’t established a strong evidence base for taking  supplements. We definitely need vitamins in our diet to live. But that’s where we should be getting those vitamins – from our food, instead of from pills. If you eat a reasonable and balanced diet, and have no medical conditions that require special consideration, vitamin supplementation won’t offer meaningful health benefits. In the absence of any deficiency, vitamin supplements seem to be useless at best and harmful at worst.

That doesn’t mean vitamins are always useless or unnecessary. They can also have important science-based roles. Vitamin deficiencies can occur, and sometimes the consequences can be significant. Pregnancy is one example. Pregnant women may not obtain adequate amounts of nutrients like folate in their diet. Deficiencies are linked to major birth abnormalities: neural tube defects (NTDs). It is well-established that folic acid supplementation around the time of conception, and continued through pregnancy, can significantly reduce the risk of NTDs, and may reduce the risk of some other abnormalities as well. There are now widespread recommendations for folic acid supplementation in pregnancy. Because many pregnancies are unplanned, public health strategies have included fortifying food with folic acid, and this approach also seems to reduce birth defects in populations.

Folate is not the only deficiency possible in pregnancy. Pregnant women have higher requirements for calcium and iron. There’s also the need to ensure adequate amounts of vitamins A, the Bs, C, D, E and zinc. While these needs can potentially be met through diet, some guidelines recommend a multivitamin (and not just folic acid) because of the consequences of a deficiency and a lack of any real risks. And supplementation works. The most common maternal multivitamin (at least here in Canada) is Materna, though there are many competitors and lots of generics. Costs can be as low as $4-8 per month. Prenatal vitamins will usually contain 0.4mg to 1mg of folic acid – it’s the most essential ingredient. Most contain slightly higher amounts of calcium and iron than a typical daily multivitamin, along with modest amounts of other micronutrients. This formula helps pregnant women’s diets meet their nutritional requirements, reduces the risk of birth defects, and is a practice aligned with the best evidence.

Choosing a prenatal vitamin is normally a fairly straightforward matter: pick one, and take it daily, starting from when you begin to contemplate having a baby. I could find no guidelines that have established one brand of prenatal vitamin as superior, though some may be better tolerated than others. I usually suggest Materna (as it’s been used in clinical trials) but it’s expensive, so if cost is an issue, a store-brand product should be fine. (In Canada a prescription-only vitamin called PregVit is also popular.) With the exception of occasional reports of nausea and vomiting, most women have no problems finding a product they can tolerate and also afford. Beyond the basic prenatal vitamin brands, you’ll find other brands that are advertised as being superior for you and your baby’s growth. That’s why I read a recent blog post from a naturopath with interest, as she listed her preferred prenatal vitamins, and why.

What do naturopaths think of prenatal vitamins?

I first learned about naturopathy when I was a retail pharmacist in Toronto – Toronto has one of a handful of naturopathy schools in North America, so it’s not uncommon to meet patients that consult with them. I spent some of my time in that pharmacy helping patients source strange supplements, which sometimes cost hundreds of dollars per month. It was good for that pharmacy’s sales, but I was curious how naturopaths could always find conditions like food “intolerance”, pH “imbalances”, adrenal “fatigue”, and hormone “depletion” in their patients. I’d never heard of these conditions, and there was nothing in the medical literature that established they were real. It seemed the likelihood of being diagnosed with a condition like “candida overgrowth” was highly correlated with visiting a naturopath, as nearly every client was taking purgatives and avoiding bread, believing they were fighting some sort of a whole-body colonization of yeast that was widespread yet not detectable by medical science. The treatment, of course, was more supplements, sometimes combined with different forms of “detox” kits and some homeopathy.

Naturopaths consider themselves to be primary care providers comparable to medical doctors. Toronto naturopath Shawna Darou’s bio notes she “graduated from the Canadian College of Naturopathic Medicine (www.ccnm.edu ) at the top of her class and was the recipient of the prestigious Governor’s Medal of Excellence”, so presumably she’s an example of the advice you’d get from a typical Toronto naturopath. Her services advertised include women’s health and prenatal care, so I’d expect her to know what she’s talking about if she’s going to make recommendations about nutrition in pregnancy. There is a well-established evidence base to rely on, alongside dozens of guidelines and advice from groups like the Cochrane Collaboration.

The naturopath’s advice

Darou opens her post:

Choosing prenatal vitamins can be complicated, as the world of supplements is difficult to navigate. The two most popular prenatal vitamins are “Materna” and “Preg vit”, but I would like to show you why professional brands of supplements are far superior in both nutrient levels, and absorption. My current favourite prenatal vitamin is NFH brand “Prenatal SAP”, as they have integrated the most current research into their prenatal vitamin formula. Other great brands are Thorne Research, Douglas laboratories and Pure Encapsulations.

Perhaps not surprisingly, Darou’s website sells NFH Prenatal SAP. The same company also sells products to fight candida overgrowth and adrenal fatigue (both common naturopath-diagnosed conditions), which sends a signal about the credibility of the company, since candida overgrowth (as defined by naturopaths) and adrenal fatigue are both fake diseases.

Darou says she had four criteria for her selection:

  1. Nutrient levels – how much of each individual vitamin and mineral is in a daily dose?
  2. Absorbability of nutrients – are the vitamins and minerals found in their most absorbable form?
  3. Form of folate – folic acid or methylated folate? This is essential if you carry a defect in the MTHFR gene.
  4. Fillers and other additives. It’s amazing what you find when you read the fine print!

Darou has designed her own chart that compares the different brands.

Nutrient levels

Not surprisingly, more is better to Darou:

In a careful comparison between seven prenatal vitamins, I found that there is an enormous difference in the amount of basic nutrients, with the biggest discrepancy in B-vitamin levels. For example, vitamin B-5 levels range from 5 mg per day in PregVit to 100 mg per day in NFH’s Prenatal SAP. Overall, the professional lines (Pure Encapsulations, Douglas labs, Thorne Research and NFH) contained significantly higher levels of essential nutrients.

The most important nutrient in a prenatal vitamin is folic acid. Optimal levels of the others are not known, as there’s no evidence to suggest that additional amounts of the other B-vitamins or other ingredients offers any benefits at improving perinatal health. They’re unlikely to be harmful, however.

Absorbability

Darou criticizes three ingredients in multivitamins as being “cheap” (and presumably, inferior):

Calcium carbonate vs. calcium citrate: Darou prefers the citrate version, stating it is “more easily broken down and absorbed’. When given as single supplements, calcium citrate may cause less stomach upset than the carbonate version, but at the expense of larger tablets (citrate versions contain less elemental calcium). However, the amounts in multivitamins are all low, and when prenatal vitamins are taken with food, the choice of carbonate or citrate should not result in any meaningful differences.

Oxide forms of minerals vs. citrate forms (magnesium, zinc, copper): Darou states the oxide versions of minerals “have lower absorption, and can be irritating to the digestive tract, while the citrate forms have much better absorbability.” Even if correct, it doesn’t mean no absorption or that there are clinically meaningful differences. Again, this is a trivial difference without any meaningful impact on perinatal health.

Vitamin B12: cyanocobalamin vs. methylcobalamin: Darou states:

Cyanocobalamin is a synthetic form of vitamin B12 that does not exist in nature. When absorbed, it releases a cyanide molecule which is toxic and must be processed by the body. It is added to most multivitamins as it is significantly cheaper than the higher absorbed, more bioavailable form called methylcobalamin. All of the naturopathic lines of prenatal vitamins contain methylcobalamin.

Note the naturalistic fallacy – cyanocobalamin is not only unnatural, it releases cyanide! Vitamin B12 is a group of related compounds containing cobalt as the central ion. Cyanocobalamin is a version of B12 with a cyanide group. Darou doesn’t mention the fact that the amount of cyanide released from cyanocobalamin is insignificant to the body (and besides, cyanide is natural). She also doesn’t mention that cyanocobalamin is the version of B12 that is the most studied. There’s no published evidence that shows methylcobalamin is superior to cyanocobalamin as a prenatal supplement. B12 is widely believed to be some sort of energy panacea, but the science doesn’t support this claim. In your prenatal supplement, there’s no evidence demonstrating cyanocobalamin is inferior.

Forms of folate

Darou says:

…..up to 65% of women contain a defect in an enzyme called MTHFR which is essential in the absorption of folate. What this means is that ‘folic acid’, found in most prenatal vitamins may not be absorbed well for many women. I highly recommend folate supplements in the ‘methylated’ version which bypasses this step of absorption. Folate in the form of 5-MTHF (5-methyl tetra hydrofolate) is best.

The MTHFR deficiency has no effect on folic acid absorption (contrary to what Darou says) but rather its metabolism. Daroun recommends 5-methyl tetra hydrofolate another version of folic acid. While there is some preliminary evidence suggesting that MTHFR deficiency in the mother may increase the risk of NTDs, there isn’t any published evidence suggesting 5-methyl tetra hydrofolate is superior to folic acid in the prevention of NTDs. All of the large trials establishing the benefits of folate supplementation have used folic acid, so folic acid remains the preferred, evidence-based version of folate that should be used for the prevention of NTDs.

Tablet fillers and other additives: Not a bug, but a feature

Darou doesn’t like other ingredients in her supplements:

It is shocking to find the fillers and additives found in pharmacy brands of prenatal vitamins. For example Materna contains: BHT, corn starch, FD&C red #40, gelatin, lactose, mineral oil, polysorbate 80, sodium lauryl sulfate, soybean oil, titanium dioxide among others! Note that there are three key allergens here (corn, soy and lactose), and several toxic chemicals! PregVit vitamins are even worse in the fillers, containing ammonium hydroxide, D&C Red #27, FD&C Blue #1, FD&C Blue #2, FD&C Red #40, FD&C Yellow #6, PEG 3350, polyvinyl alcohol, propylene glycol, shellac glaze, sodium lauryl sulfate, talc and titanium dioxide!!

These ingredients are included in pharmaceuticals and vitamin supplements for one reason: to ensure the finished product is of high quality. A high quality product has a long shelf life, doesn’t smell bad, has consistent ingredient quality, is easy to swallow and then dissolves quickly and thoroughly, with the ingredients being absorbed quickly. A tablet manufactured without any excipients would likely disintegrate in the bottle or in a worst case scenario, fail to dissolve at all. Excipients are not harmful and actually improve the quality of the product, rather than weaken it. She doesn’t seem to understand that “the dose makes the poison” and the amounts in any product are deliberately there to ensure the final product is of high quality. In the absence of allergy, there are no harms, real or expected, from the excipients in supplements.

Conclusion

Darou paints a negative picture of conventional multivitamins using weak, and sometimes erroneous arguments, while subtly promoting a product and brand of vitamin that she happens to sells on her website. If you want a textbook example of a conflict of interest in health, here it is. Her recommendations are largely consistent with what I’ve seen from naturopaths before – limited scientific literacy that is filtered through a belief system, generating advice that can sometimes be reasonable but more often than not is inconsistent with the best medical evidence. The product Darou recommends is actually supported by weaker evidence that the products she recommends against. While the risks of these alternative (and much more expensive) multivitamins are relatively low, claims that they are superior to conventional (and more popular) multivitamins are not supported by good evidence. Women that need nutritional advice would be better advised to speak with health professionals that practice according to scientific standards, such as registered dieticians. You’ll be more likely to get reliable and most importantly, unbiased advice. The stakes are too high in pregnancy to rely on the advice of alternative medicine providers.

Photo from flickr user Thomas van Ardenne used under a CC licence.

Posted in: Naturopathy

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86 thoughts on “Naturopathy vs. Science: Prenatal Vitamins

  1. Calcium carbonate vs citrate: I was taught as a medical student and resident, and continue to teach now, that patients with low levels of gastric acid production (in particular, those taking proton pump inhibitors) should take calcium citrate, as calcium carbonate is poorly absorbed in the absence of acid. Do you know if there is evidence regarding this, or were my professors teaching through their collective hats?

    1. KayMarie says:

      I know that is the conventional wisdom, but not sure of the data.

      There is this meta-analysis but I think it is for standard issue humans, not specifically those with less stomach acid.

      http://www.ncbi.nlm.nih.gov/pubmed/11329115

      1. KayMarie says:

        Then I found this one that tends to relegate this to medical myth-land.

        http://www.ncbi.nlm.nih.gov/pubmed/22914054

        Although taking Calcium Carbonate with meals may have some importance.

  2. Nutritionprof says:

    It is true that low gastric acid may affect calcium citrate absorption (along with vitamin B12), but the article is on prenatal supplements. And unless there is a serious problem, eating food itself stimulates gastric acid production, which is part of the reason the directions are-to take with food.

    1. Bryan says:

      You’re right of course, but achlorhydria isn’t a prerogative of the elderly. Very low to no stomach acid certainly does occur among women of childbearing age, mostly due to pernicious anemia. I mention this because I wonder if it wouldn’t be harmful in such cases to use the “more bioavailable” methylfolate in stead of folic acid. People with pernicious anemia are incapable of using 5-methyltetrahydrofolate (methylfolate) due to their B12 deficiency, a phenomenon known as the “methylfolate trap”. This is why some advocate adding methylfolate to food in stead of folic acid, thus preventing any masking of megaloblastic anemia as a possible side effect of mandatory food fortification with folic acid. Folic acid doesn’t need B12 to be active as a provider of DNA-precursors. A pregnant woman with undetected pernicious anemia who took methylfolate wouldn’t get any protection from that against NTDs. The couple of micrograms of B12 present in a typical multivitamin wouldn’t prevent this, because in pernicious anemia on average only 1% of an oral dose gets absorbed by passive diffusion.

  3. M Welinder says:

    Maybe you can spell out in more detail how “D&C Red #27, FD&C Blue #1, FD&C Blue #2, FD&C Red #40, FD&C Yellow #6″ help “ensure the finished product is of high quality”.
    (Titanium dioxide might be there for colour too.)

    1. Scott Gavura says:

      Colors are primarily used in tablets and liquid formulations, though capsules can also be colored. One of the primary reasons for colorants is esthetics and patient acceptability. This may be a factor for women experiencing nausea and vomiting of pregnancy. Colorants also help patients and health professionals with product identification. Because the color is an integral part of the formulation it’s also a marker of the manufacturing quality control. Colorants can increase the stability of light-sensitive ingredients, maximizing the stability of the final dosage form and ensuring the active ingredients are delivered to the body reliably. Finally, discolored or mottled tablets are usually a sign of product quality issues or spoilage (e.g., due to improper storage).

    2. WilliamLawrenceUtridge says:

      Titanium dioxide is probably there to lighten colour, it’s opaque and white.

      The real question for me is “who cares if they are there?” There’s no evidence that they cause harm, particularly in the quantities found in these pills, and I see it as far more likely that the naturopath is fearmongering over “unnatural additives” a la the Food Babe.

      1. M Welinder says:

        > The real question for me is “who cares if they are there?”

        People with allergies. Less directly: anyone who is concerned that medication is made to look like candy.

        (Also, in the unrelated case of infant’s Advil: anyone who has to clean up the mess after a fuzzy baby smears it everywhere — who the heck decided to put a strong dye in such a medication?)

        The point is that the colouring has no function apart from addressing the fear that the customer will buy the competitor’s product because it is prettier. Scott mentioned light sensitivity, but quite frankly that is better solved by a proper pill bottle. He mentioned spoilage detection; in the factory that is utterly inadequate as quality control — sample and test is what you need — and in the home the sugar coating will tell you if they got wet

        1. muh chemicals says:

          Scott buried “product identification” a bit, but I think that alone justifies coloring medications. If I ran the FDA for a day, I’d ban “little white pills”; all medications approved for the elderly would now have to be in distinctive colors, distinctive shapes (e.g. Xanax bars), or clearly imprinted with their names.

        2. WilliamLawrenceUtridge says:

          Not quite just spoilage – differentating pills is also important, and mere shape and printing a name on it isn’t usually enough. House had a plot based on this.

          I know people imagine they are allergic to dyes (and that they cause hyperactivity, etc.) but how common are they? And I question whether anyone buys pills because of colour – mine are prescribed by a doctor, I have no real say in the specific brand. This is also one of the few instances where a compounding pharmacist performs a valuable function rather than merely adding to the cost.

          As for poisoning children, I would be interested to know whether changing the shape/colour would make kids less likely to eat them. Honestly don’t know, and given the things like child-proof caps, would it drop it from some tiny number of cases per year to an even tinier one? I’m more surprised by the fact that the coating of Advil tastes sweet to me – it literally is like candy in that regard.

          1. simba says:

            I have noticed, anecdotally, that American paracetamol and painkillers often have sweet coatings. I keep a bottle of them around for that reason. Friends were amazed that you could walk into a pharmacy and get a bottle of a hundred tablets (of various over-the-counter pain killers), it’s just not possible here.

            Where I’m from paracetamol can only be sold in sub-lethal amounts, and it tastes foul.

            1. Windriven says:

              “Where I’m from”

              Where is that, Simba? I thought that most nations were pretty loose with acetaminophen.

              1. simba says:

                Ireland. You can’t buy multiple packs of it unless a pharmacist is selling it to you, and I believe they cannot be sold in large-quantity packs (maximum of 12 tablets per pack for retail, 24 for pharmacy).

                Of course not everyone follows that…
                http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)60631-X/fulltext

            2. Thor says:

              In Germany today one can also only buy small otc packs of paracetamol and ibuprofen. For larger quantities, a prescription is necessary. Americans wouldn’t stand for it, but deaths from overdosing and overuse would be reduced.

              1. simba says:

                My friends when they enquired were told “This is America. You want to kill yourself, that’s your right. We don’t want to interfere.”

  4. Angora Rabbit says:

    An excellent article as always, Scott. If I can add, women who are planning or are pregnant should be sure not to overdose on vitamin A, because both excess and deficiency of its endpoint product, retinoic acid, can cause birth defects. For this reason we recommend that women take the Daily Recommended Intake for vitamin A and not more than this.

    Increased iron intake is also essential during pregnancy. This is because the infant’s iron burden must be delivered during the last trimester, to compensate for the low iron content of breast milk. The challenge here is that oral iron causes gut irritation and constipation, so compliance is understandably poor in women. But adequate iron is critical because gestational iron deficiency impairs fetal / postnatal brain development; search on Betsy Lozoff for details.

    Finally, the critical window for folate and neural tube defects is the periconceptual period, often before a women recognizes her pregnancy. Neural tube closure is completed by week 5 postconception. Waiting to take folate until second trimester misses this window; hence the reason for supplementing common foods with folate.

    And, of course, the single best thing a woman can do to help her baby reach its full potential, is to abstain from alcohol during pregnancy. We celebrate the Zero-For-Nine campaign on September 8 (9-9) to promote abstention during pregnancy. Many of us are studying the environmental and genetic factors that enhance alcohol’s prenatal damage. Because we cannot point to an individual’s personal risk, the best advice is to abstain.

    And take sufficient, but not excessive, perinatal vitamins and minerals. Remember that too many vitamins and minerals can have a great a risk for birth defects as too little. Stick with a reputable product and follow physician recommendations.

    1. Chris says:

      Back in the 1980s when I was working in a non-female profession I went to a couple of dinners of that combined all of the professional women’s groups (lawyers, engineers, scientists, doctors, etc).

      During one dinner the presentation was by a medical doctor on vitamin abuse. She included slides of deformed fetuses and babies from too much vitamin A. Not exactly the best choices for a dinner talk.

      Though a few years later I was sure to just take the prenatal vitamins prescribed by my doctor.

      1. Young CC Prof says:

        I’ve never seen human examples, but I did see rabbit babies with birth defects induced by too much pure Vitamin A. Most horrible thing I’ve ever seen in any biology textbook, IMHO. Including endoparasites.

    2. nu;tritionprof says:

      The beta carotene/vegetable form of vitamin A is fine for women to consume-excess will give them an orange color, but it is (so far as my textbooks show) non toxic. Unfortunately, many supplements use the animal form of vitamin A (the retinoids) which can be toxic.

  5. R Miller says:

    Sort of fascinating. The history of why pharmacy split from medicine is strongly rooted in the conflict of interest problem – making sure the people who prescribe do not dispense, and the people who dispense do not prescribe. I have to give naturopaths credit for their business savvy, they certainly found a way around.

    I guess alternative medicine means alternative ethics too.

    1. Derek Freyberg says:

      On the separation between prescribing and dispensing. I grew up in New Zealand, where there was that same separation, but spent some time in Japan in the early 1970s. There, in my experience, doctors dispensed what they prescribed, so your payment for the visit also included the cost of the medicine (hospitals, of course, had pharmacies). I didn’t see it as an issue, and it had the advantage of convenience – but then I wasn’t consulting naturopaths. But I believe that there is now a separation between prescribing and dispensing there too.

    2. Earthman says:

      “alternative medicine means alternative ethics”

      That is such a good quote! Must remember that one. Thanks

      1. stanmrak says:

        That’s not necessarily the derogatory assessment you intend. It’s not like the medical industry has such great ethics themselves. Just look at the long list of lawsuits they’ve lost recently, and the death count. We’ll start with Vioxx….

        1. WilliamLawrenceUtridge says:

          Sure stan, Big Pharma is evil. They practice deceptive marketing and research practices that actively harm the people who consume their products.

          How does that excuse naturopaths who make a direct profit from recommending the expensive vitamins they sell?

          Are you saying that naturopaths don’t have a conflict of interest until Pfizer resolves its research and business ethics? Why?

  6. Louis Miller says:

    Here is more vitamin and pregnancy woo- this time from an MD. Notice the link at the end to a vitamin store where she sells her own vitamins. Darou also has a store. They try to scare you about medicine so they can sell you their own products.

    http://www.huffingtonpost.com/kelly-brogan-md/vitamins-pregnancy_b_4495831.html

  7. Peter S says:

    “Daroun recommends 5-methyl tetra hydrofolate, more commonly known as folinic acid.”

    Minor correction. Folinic acid is 5-formyl tetrahydrofolate not 5-methyl tetrahydrofolate which is what she recommends.

    1. Scott Gavura says:

      Thanks for flagging that – I’ve updated the post.

      1. Peter S says:

        I only knew that from doing a lot of reading about supposed MTHFR “defects” — a very popular theory on the internet moslyt among non-MDs and patients but also some MDs, in which SNPs are blamed for a wide swath of what ails mankind. E.g.

        http://www.mthfrsupport.com/

  8. evilcyber says:

    “[...] while subtly promoting a product and brand of vitamin that she happens to sells on her website.”

    Who’d have thought? :)

    In my book, “naturopath” is synonymous with “charlatan.”

    1. Marc says:

      The most succinct was of putting it is one I learned right here on SBM:

      ND = Not a Doctor

  9. Thor says:

    It’s not just that CAM advocates for across the board vitamin, mineral and supplement use, often it must be a specific kind or formulation, allegedly enhancing absorbability and bioavailability. Amongst CAM, there is the widespread concept that conventional stuff is “bad”, less effective, or low quality (BigVitamin), and the “good” stuff is hand-crafted, designer versions promising more magical health results than their inferior relatives. These “enhanced” forms are usually more expensive and sold in-house by practitioners of various fields. A similarity is seen with the conventional/organic differentiation. Or to the No True Scotsman fallacy – stanmrak has often displayed this.
    “Well, of course there was no benefit, they didn’t take the right form of vitamin.
    My form, good. BigVit form, bad”.

    1. Peter S says:

      I always feel better knowing my supplements are organic, wild-crafted, food-state vegetarian sourced,, raw, all natural, and so on. Of course synthetics are ok when it comes to methyl b12 and methylfolate but I don’t see any contradictions, do you?

      1. Thor says:

        None whatsoever. “And so on” could include “food-grown” and “probiotic-cultered”. C’mon Peter, get with it – don’t you want to feel even better?

      2. josh says:

        I work in the supplement industry. Often times those “magical” naturopath vitamins are the same ones sold in stores just repackaged. Many Brands that sell only to practitioners sell the same, identical products just under two labels.
        For example
        http://www.nowfoods.com
        http://www.protocolforlife.com
        identical products, identical company.
        Foodstate and food grown are hilarious concepts. They take those regular, scary chemical vitamins, feed them to yeast, hydrolyze them and then sell them as fancy whole, food vitamins and people pay 4-5 times as much for them.
        Say what you will about the supplement industry, but man are they good are marketing and making money.

        1. Peter S says:

          Life Extension Foundation has superb marketing and pushes a lot of buttons. But when you look closely at all those footnotes they include in their articles, often they are to studies in some third world country of the effect of x on ten hamsters.

          The yeast thing is disturbing, I know that’s what companies like MegaFoods and Innate Response do for B vitamins anyhow that they advertise as foodstate. And the private labeling of the same product across many brands is very confusing.

      3. WilliamLawrenceUtridge says:

        Peter, it sounds like you’re simply describing food. And now I’m hungry.

  10. rork says:

    Thanks for very nice article (and informative comments).
    “believing they were fighting some sort of a whole-body colonization of yeast that was widespread yet not detectable by medical science” nearly made me injure myself laughing though. I’ll be more prepared in future.

  11. thurber says:

    On the subject of vitamins (though not the prenatal kind):

    I’m in somewhat of a quandary. My vitamin d levels are consistently low. About five years ago I was prescribed the once-a-week megadose of ergocalciferol. After a few weeks, I started having heart palpitations, I was urinating frequently, and I couldn’t sleep. I finally stopped taking them after a month or so.

    Now, my doctor wrote me another prescription. The script said “Vitamin D3″ but the pharmacist gave me a bottle of D2. I don’t know if this makes a difference.

    I get lots of sunshine, drink my milk, etc. but my blood level was 18.

    After my bad experience with the prescription-grade D, I really don’t want to do that again. And I don’t trust the over-the-counter supplements at all. I’ve read that traces of lead were found in vitamin D supplements.

    I’m curious what other commenters have to say on the topic of prescription vs. over-the-counter supplements.

    1. Thor says:

      Only a few pharmaceutical companies actually manufacture vitamins. They provide the bulk, raw ingredients. Regardless if they come from any of the dozens of companies represented in Whole Foods, your local naturopathist, by prescription at your local pharmacy (or on any drugstore shelf), they all come from BigPharma, (BigVit wing thereof).
      Then, individual companies make their own formulations/concoctions, ad infinitum, often adding dozens of other substances, like botanicals. The amount of vitamin product on the market (including online sources) is simply staggering.
      The supplement trade is capitalism at its best. Too bad its success is based on fluff.

    2. WilliamLawrenceUtridge says:

      I’m going to say “you should really talk to your doctor.”

  12. Daniel says:

    Is snark scientific? Is it proof of greater intelligence? Also, do sweeping generalizations make bias less of a liability? The very title of your post “naturopathic versus science” shows you’ve made up your mind from the get go, and the comments prove that the readers of this blog are, in some areas, reflexively cynical rather that thoughtfully skeptical.

    Naturopathic doctors aren’t perfect; on the other hand, the rate of patient harm and dozens of other transgressions are lower in my profession (I’m an N.D.), I assure you.

    Unfortunately, your readers are some of the smartest people around, and their responses here are proof of how deeply rooted biases are. And biases, I might remind you, impede science at every turn.

    1. R. Miller says:

      “Naturopathic doctors aren’t perfect; on the other hand, the rate of patient harm and dozens of other transgressions are lower in my profession (I’m an N.D.), I assure you.”

      Of course, when you deal primarily with fictional diseases, patients tend do reasonably well. How many cases of adrenal fatigue and chronic Lyme-disease progress into critical care situations?

      How about instead of complaining, you actually show what is wrong with the content and provide corrections with evidence.

    2. Harriet Hall says:

      As long as naturopathic schools teach homeopathy, naturopathy is properly described as “versus science.”
      The rate of harm from homeopathic remedies is zero because there is nothing in them. The rate of harm from substituting a placebo for an effective treatment may be small, but it certainly isn’t zero. The very fact of being a naturopath will continue to be a transgression against science and reason until they reject homeopathy and practice in accordance with scientific evidence. Everything naturopaths do that is good medical practice can be done just as well by MDs; there is no need for naturopathy.

    3. Windriven says:

      @Daniel-

      Sometimes reasonable people disagree; educated, logical, intelligent people. They can engage in reasoned discourse and, while they may never agree, they can part respecting the other’s perspective.

      Sometimes there are cretins who play at a subject without serious study, who pretend to science but neither respect it nor understand it, intellectual pygmies who wave their hands and invoke unseen and unseeable powers.

      These you fit with a drool cup and slap them hard on the back of the head when it starts to overflow. The rate of complications with NDs is certain to be lower than with physicians. You don’t treat serious conditions, you claim credit for regression to the mean, you play doctor without any depth of understanding.

      Take the Windriven Challenge, assh0le: name the top 10 most serious medical conditions that naturopathy has mastered, the ones where hands down, naturopathy has transformed the human condition. Then I’ll name my 10 for scientific medicine.

      Put up or crawl back in your little storefront and shut your face.

    4. Thor says:

      I’ve made up my mind, about naturopathy at least, because I know what it is.
      I’ve seen it up close and personal. You can’t keep such an open mind that your brains fall out, as the saying goes.

      “Reflexively cynical” = “You’re hurting my feelings by your strong, educated and forthright opinions about my magic fairy potions and procedures”.

      “Thoughtfully skeptical” = “Even though concepts of homeopathy and acupuncture are a bit hard for my science-based mind to grasp, I welcome your ideas to the table, as it is best to consider all sides and perspectives”.

    5. Marc says:

      Dr. Hall beat me to it, but when your nostrums have no effects at all, you will have a lower incidence of negative effects

    6. Peter S says:

      My experience with NDs was as pathetic as my experience with acupuncture and chiropractic. Two different highly recommended practitioners, two completely different sets of recommendations for my pain/anxiety/fatigue issues including “liquid serotonin” (yes there is such a thing), some homeopathic thing or other, pea protein, some super special (and outrageously expensive) form of magnesium, and I don’t recall what else now. None of it, of course, helped. At least neither diagnosed me with some fake disease, I can be thankful for that I guess.

    7. Jann Bellamy says:

      “Bias” is a preconceived opinion that is not based on reason or actual experience. This post is one of a series by Scott Gavura (see link in post) in which he deconstructs naturopathic practice as described in the naturopath’s own words, not some preconceived notion of how they practice. He goes through each element of naturopathic treatment and, in painstaking detail, demonstrates its deficiencies by showing how the naturopath deviated from the available evidence, or, in some cases, showed an appalling lack of basic scientific knowledge or biomedical ethics. That hardly fits the definition of “bias.”
      It is ironic that you chose the term “bias,” as the naturopath’s conclusion in this case is a textbook example of confirmation bias.

    8. KayMarie says:

      <blockquote?Is snark scientific?

      It isn’t a required part of the scientific method but it does seem to be a part of many scientists narrowly focused sick and twisted sense of humor. I’m looking at you people who named genes Sonic Hedgehog and Son of Bithorax.

      reflexively cynical rather that thoughtfully skeptical

      Or previously researched a subject and since no new data is being presented no new hypothesis testing is required.

      If I’ve looked at something 100 times and besides having no new information the 101st thing that should change my mind this time is the exact same as #’s 2, 4, 6, 8, 12, 13, 15, 16,17, 22, 25, 34, 56, 67, 77, 78, 79, 81, 84, and 99. Do I really have to completely dismantle an entire data set and reanalyze the statement from scratch, again? Because if I don’t I’m cynical. If I open my skull too many times my brains fall out.

      At least SBM will change the treatments because of new data (like changed how ulcers are treated once H. pylori was proven). The only change I’ve seen in most natural treatments/naturopathic treatments in my years on earth is they have a new fad name for the cause of all lack of wellness or a new MLM has a new juice it has to sell before it runs out of people to enroll as distributors.

    9. WilliamLawrenceUtridge says:

      Hi Daniel, any comments about Scott’s actual analysis of the unscientific nature of this one naturopath’s comments?

      Can you describe the scientific nature of the core dogma of naturopathy, specifically that “vital energy exists and can be manipulated”?

      Please feel free to submit a guest post supporting the scientific nature of this naturopath’s beliefs about prenatal vitamins, since you appear to believe such beliefs exist.

      on the other hand, the rate of patient harm and dozens of other transgressions are lower in my profession (I’m an N.D.), I assure you.

      Three points:

      1) Your word and assurances are insufficient; I require proof
      2) Have you considered that your profession’s lack of harms is due to the inert nature of much of your materia medica?
      3) Have you considered the lower rate of transgressions might be due to the tiny number of naturopaths compared to the much larger number of medical doctors? Also, Michael Wilson.

      Unfortunately, your readers are some of the smartest people around, and their responses here are proof of how deeply rooted biases are. And biases, I might remind you, impede science at every turn.

      Sure, but when you’re practicing a profession that isn’t really concerned with the scientific method, you’re not really in a position to lecture, are you?

      All skeptics want is an even playing field – prove that your interventions work, in humans, using randomized, controlled clinical trials, before you sell your products and services to the public. Why is this so objectionable to you?

    10. Andrey Pavlov says:

      Unfortunately, your readers are some of the smartest people around, and their responses here are proof of how deeply rooted biases are.

      You should take a moment to realize that you are looking in a mirror.

  13. Gerald M. Rittenberg says:

    A general comment re science & naturopathy, etc.: Cleveland Clinic has opened a Chinese Herbal Therapy Clinic (see link) thus furthering the integration of pseudoscience into clinical medicine under the aegis of a prestigious academic institution. Hopefully, this will receive the scrutiny from science based medicine practitioners it warrants.

    http://my.clevelandclinic.org/media_relations/library/2014/2014-3-5-cleveland-clinic-among-first-in-the-us-to-open-hospital-based-chinese-herbal-therapy-clinic.aspx

    1. Sanity:) says:

      I thought too much science was bad for medicine?

      Remember when doctors supported the tobacco industry?

      What is needed is a system where front and back end that are in communications both having the same power.

      1. WilliamLawrenceUtridge says:

        Remember when doctors supported the tobacco industry?

        Remember how doctors discovered cigarettes caused lung cancer and this led to massive public health campaigns that reduced smoking rates? Remember when lung cancer incidence peaked, then started dropping, continuing to do so year-after-year, because of doctors?

        I don’t, because when the whole thing started, I hadn’t even been born.

        Maybe pick your examples a little more recently than that. Most doctors these days agree that smoking is bad for you.

        What is needed is a system where front and back end that are in communications both having the same power.

        Gee, great idea, what about we also cured cancer, brought about world peace, eliminated poverty and created a source of limitless clean energy?

        Saying what is needed is easy. Saying how to bring it about, getting buy-in and executing it…little more difficult.

      2. Chris says:

        Remember when tobacco companies paid actors to pretend to be doctors? It seemed that the research coming out just after WWII showed smoking was dangerous, and the tobacco companies did not like that:
        http://tobacco.stanford.edu/tobacco_main/index.php

  14. Sanity:) says:

    “conflict of interest in health”
    This is everywhere in healthcare, the FDA, DEA, AMA, even here and sadly even my guru Dr. Oz is conflicted.

    1. WilliamLawrenceUtridge says:

      Get a new guru, Oz is far more motivated by increasing his audience share than he is by producing good information. Unless you think treating lying “psychics” like Jon Edwards as therapists is a good idea.

  15. Gerald says:

    Thanks for the correction.

  16. Stephen S. Rodrigues, MD says:

    “where a naturopath’s medical advice is assessed against the scientific evidence.”

    Evidence is evidence the issues is how valid it is and the intent of the scientist or the collector of the data. The confirming the conclusion with further study. That’s science!

    Also the word or person “naturopath” is not synonymous with stupid or unethical.
    And “science” is not synonymous with intelligent, correct, precision or ethical.
    Factor in experience, intent and factor out any conflicting interest => That’s better science!

    1. n brownlee says:

      “Factor in experience, intent”

      That is, exactly and by definition, NOT science.

      1. He who collects the raw data in a laboratory to be used to formulate concepts, conclusions and therapies is called evidence. The validity of evidence has to be weighed on the who collected, why they collected, for what cause etc. So without sound evidence all conclusions are fuzzy.

        The science you referring to are the pure sciences, like physics, math chemistry and chemistry. Once a human idea infects the equations then the value drops significantly.

    2. Windriven says:

      “Evidence is evidence the issues is how valid it is and the intent of the scientist or the collector of the data.”

      What does the intent of the scientist have to do with the strength of the evidence? And the last paragraph is a dogs breakfast of non sequitur and inanity.

      1. KayMarie says:

        I will say that I know of situations where a scientist’s intent was to confirm their bias and deliberately searched for one strain that did what they wanted and then only mentioned that strain rather than the other dozens of strains they tested before finding the one that did what they wanted.

        So intent sometimes does play a role in occasional cases of fraud or bias. It always, eventually, comes to light with replication by other scientists.

        Although if he meant it in the conspiracy theory way of anyone who doesn’t agree with my pet hypothesis is obviously bought off, then its just a standard anti-science attack. If you really follow the evidence you have to let all the data lead you, not just the stuff you like or made up.

        1. @kaymarie
          Where did you come from with all of your understanding of science?
          You are spot on, Evidence is the raw material to be used to formulate the concepts for testing, confirmation and retesting.

          Let’s stick to science and leave the innuendoes, blame, shaming and attacks for the group thinkers.

          @wind
          The strength of the evidence has zero to do one who collected it but has 100% to do with how well it holds up to the many tests of time.

          Great philosophers say, don’t believe me, other and yourself – until it is so.

          1. WilliamLawrenceUtridge says:

            You are spot on, Evidence is the raw material to be used to formulate the concepts for testing, confirmation and retesting.

            Great. Can you explain why you reject the science and evidence regarding acupuncture when it contradicts your experience?

            Let’s stick to science and leave the innuendoes, blame, shaming and attacks for the group thinkers.

            That’s funny coming from the guy who keeps insulting the people who disagree with him, and demanding they ignore the evidence in favor of your pre-existing conclusions. I suggest the first group thinkers we attack are CAM proponents who feel justified in selling their nonsense before it is found to be effective.

            The strength of the evidence has zero to do one who collected it but has 100% to do with how well it holds up to the many tests of time.

            That’s exactly wrong. The strength of the evidence determines whether it will stand the test of time, and a large part of the strength of the evidence is careful controls being more valuable than experience. The strength of the evidence is primarily in how it is collected.

            Great philosophers say, don’t believe me, other and yourself – until it is so.

            Two things about philosophers:

            1) They are usually pretty indifferent to empirical evidence, making them useful as theorists of science but useless as actual scientists.

            2) We had philosophers for thousands of years, it’s only once people stopped philosophizing and started testing their premises that technology and medicine progressed in such a remarkable fashion.

          2. Windriven says:

            Steve, you say one thing, I call you on it, then you say something unrelated as if it is somehow profound.

            Dude, I’m beginning to wonder if you have 52 in your deck. Are you on drugs?

    3. WilliamLawrenceUtridge says:

      Also the word or person “naturopath” is not synonymous with stupid or unethical.

      Nobody says it was – it’s just considered synonymous with “wrong”. The entire model and belief system behind naturopathy is based on something that was shown unnecessary several centuries ago, and they certainly don’t help by adopting treatment methods that have consistently failed upon empirical testing.

      And “science” is not synonymous with intelligent, correct, precision or ethical.
      Factor in experience, intent and factor out any conflicting interest => That’s better science

      All true, but your implication – that science is corrupt and your alternative of “whatever I believe in” is right – is fundamentally wrong.

      Science is a public method of gathering and analyzing information, informed by previously-existing knowledge. That’s it.

      1. Stephen S. Rodrigues, MD says:

        “All true” yes all that I just said is true.

        Good job working

        1. Jopari says:

          What a case of cherry picking.

          If you can’t understand what was said, don’t respond until you do.

  17. Spectator says:

    This industry is pretty convincing. I fell for the food-based vitamin thing for a while, until I stopped taking vitamin supplements exc where I had a specific need as determined by my MD.

    It certainly sounds reasonable:
    Premise: “Vitamins outside of food are not where your body expected them, so they’re not absorbed”.
    Fix: Attach the vitamins to a bit of food (the yeast grown thing). Trust us, we’re honest health-conscious types.

    While I’m now not sure what the “food-grown” vitamin actually is as compared to the other stuff, I won’t take their claims at face value.
    Nor will I buy their expensive products, unless they’re shown to be necessary.

    1. Peter S says:

      Who wouldn’t feel good after reading this. Kinda begs the question though, why not just eat the damn foods in the first place??

      Deeper Connections with Food: FoodState Nutrients™

      At INNATE Response™, we care about doing things the right way – we never take shortcuts, and we never compromise on quality or things that matter. This is why we make our own FoodState Nutrients™ from scratch in our state-of-the-art facility in New Hampshire.

      ?FoodState Nutrients™ are made with fresh and local foods. We use local and organic fruits and vegetables, like blueberries, broccoli, oranges and carrots, that are frozen at harvest to preserve the full range of phytonutrients. We use food, not fillers, in all of our formulas. Our connection to the whole foods we use extends far beyond the food crate delivered to our back door; we seek to nurture the relationships with the people who care for our food, supporting organic and independent family farms across the country. We know we are getting the highest-quality whole food ingredients while supporting rural communities and the land.”

      1. KayMarie says:

        Because of the various myths that the food the average consumer can buy can’t possibly be good enough to do you any good in amounts a human can actually consume.

        How we survived on the amount of food a person can actually eat before industrialization….its a mystery. :-)

    2. WilliamLawrenceUtridge says:

      Nor will I buy their expensive products, unless they’re shown to be necessary.

      Even if proven necessary – you don’t need expensive products. The molecules are identical, irrespective coming from a $40 bottle or a $4 bottle.

  18. Kayla says:

    What a timely article! I have recently started prenatal vitamins in anticipation of trying for a baby in a few months.

    I have been concerned about the MTHFR issue though. It seems that if you do have this mutation (and my research shows that’s about 15% of Caucasians), you do need to take L-5-MTHF because you won’t get the benefit from folic acid, and thus experience a higher risk of NTDs. As I understand it, if you have recurrent miscarriages, your OB will test you for MTHFR and may then prescribe a high does of folic acid or L-5-MTHF to help with future pregnancies.

    NTDs are quite serious, and I have zero interest in enduring “recurrent” miscarriages when a simple blood test could reveal information that might prevent them, so I intend at my preconception checkup (with a hospital OB) next week to ask for this blood test to be sure; and I’ve been taking L-5-MTHF along with my prenatal vitamin (which contains folic acid) just in case.

    As you noted, there are a lot of quacks out there talking about MTHFR, so I am really interested in what you have to say about this.

    1. Peter S says:

      I do hope you are able to get a good answer from a responsible doctor. After I tested positive for one of the common MTHFR mutations I spent a lot of time online researching it and it was difficult to navigate especially some of the alarmist websites and patient forums blaming MTHFR SNPs for all that ails mankind; it seemed to be the CAM world’s latest universal culprit. There seems to be an emerging industry of people, mostly non MDs of course, who will interpret your SNPs and, surprise, recommend the right slew of supplements to address them.

      E.g.

      http://www.mthfrsupport.com/our-team/

      I would stay away from these sorts of people although I understand and appreciate the fear they can instill.

  19. Heather says:

    I was hoping this article would have discussed DHA and iodine in prenatal vitamins. I am a pharmacist as well as a new mom and these are the 2 ingredients that differ the most between brand and generic prenatals that I’ve seen. Stuart is the most famous/popular brand name, but is pretty expensive, especially if taken preconception through lactation.

    When taking my prenatal vitamin, I just went with a generic version (containing 0.8 mg folic acid, iron, calcium, and the usual vitamins). My MD only recommended that I take enough folic acid, but did not endorse any brand.

    My sister’s OB recommended taking a supplement with DHA. This is found in the branded products, but very few generics. What does the evidence say about DHA supplementation? I’m not a big fish eater, and many pregnant women cut back on their fish consumption anyway due to concerns about mercury.

    Finally, I’ve also seen articles discussing that pregnant women may not be getting enough iodine due to more salt being consumed in processed foods as opposed to iodized salt. Some prenatals contain potassium iodine and some don’t. Grr, why can’t there be some sort of standardization for what must be in a prenatal?

    Anyway, I’d appreciate any input. I’m a regular reader of this blog and would value your opinions.

    1. KayMarie says:

      Here is a 2013 review of DHA http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3602397/

      Sounds like we are at that emerging information stage where you can be certain it is important, but the data for exactly how much is needed hasn’t been worked out yet so they can’t really add it to the standard list of what has to be in a prenatal.

      http://www.ncbi.nlm.nih.gov/pubmed/19088150 gives the recommended amount of iodine, you could check how much iodized salt you use and see if you really need more than what you get in your diet.

    2. Peter S says:

      Sardines are rich in omega 3s and being far down the food chain are very low in mercury from what I have read. Also, seaweed is very rich in iodine; for example just a little bit of dulse has multiples of the RDA. Note this is just based on study I am not a medical professional.

  20. Heather says:

    Yeah, it’s recommended that I get 290 mcg/day of iodine (lactating). I just don’t see how I could be getting that without supplementation. The only time I used iodized salt is occasionally at work. I guess I’m going to have to go buy some potassium iodide supplements to take with my generic prenatals.

    I’ll probably go with 150 mcg (as potassium iodide) based on this NEJM letter , which is also what I’ve seen in the OTC prenatal vitamins that contain KI.

    http://www.nejm.org/doi/full/10.1056/NEJMc0807851

    I just wish I had thought about before I got pregnant instead 18 months later! Now that I’m thinking about it, I see stuff everywhere talking about inadequate iodine intake. Thanks for the input.

  21. Angora Rabbit says:

    Hi Heather,

    I think we’ll never know the answer about DHA and how much is beneficial because I don’t believe the study can ethically be done. The animal data were sufficiently encouraging that the producers began adding it (and EPA) to formulas, and they are not willing to risk a legal threats potentially posed by removing it, let alone market share. I think the data are sufficiently encouraging that intake of EPA and DHA is warranted; if you use fish, just make sure it is not a source with high mercury.

    Regarding iodine, milk also contributes more than one thinks because many dairies and farmers use iodine-based cleaners to sterilize the equipment and udders (honestly, the flotsam I’ve acquired over the years…). Other good sources are seafood in general, seaweed (yum!). Other good sources can be veggies, meats and eggs. Watch foods that contain goiterogens, which inhibit thyroid hormone synthesis, and are found in raw cabbage, turnips, bamboo shoots, cassava, sweet potatoes, and millet. Cooking destroys them, hurrah!

  22. Ariann says:

    Just a correction – pregnant women do not have a higher requirement for calcium than other pre-menopausal women, although lactating women do.

    http://lpi.oregonstate.edu/infocenter/lifestages/pregnancyandlactation/

    “Although 200-250 mg/day of calcium is transferred to the fetus, primarily in the last trimester, dietary intake requirements of calcium are not increased due to maternal physiological adaptations. ”

    In general, micronutrient RDIs during pregnancy are more similar to than different from RDIs when not pregnant.

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