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Vitamins and Mortality

The discovery of various vitamins – essential micronutrients that cause disease when deficient – was one of the great advances of modern scientific medicine. This knowledge also led to several highly successful public health campaigns, such as vitamin-D supplementation to prevent rickets.

Today vitamins have a deserved reputation for being an important part of overall health. However, their reputation has gone beyond the science and taken on almost mythical proportions. Perhaps it is due to aggressive marketing from the supplement industry, perhaps recent generations have grown up being told by their parents thousands of times how important it is to take their vitamins, or eat vitamin-rich food. Culture also plays a role – Popeye eating spinach to make himself super strong is an example this pervasive message.

Regardless of the cause, the general feeling is that vitamins are all good – they are not only important for health, they promote health. Many people take vitamin supplements on the idea that more is better, or for nutritional “insurance” to make sure they are getting enough of every vitamin.

The problem with deeply embedded cultural beliefs is that people make decisions based upon assumptions that everyone “knows,” rather than making evidence-based risk vs benefit decisions. This phenomenon is exacerbated when the industry is able to make aggressive health claims without requiring any scientific evidence to back up those claims (as is the case in the US since DSHEA was passed in 1994).

It is therefore important to shatter the pedestal on which vitamins have been placed, to bring them down to the level of scientific evidence. The good news is, there is a ton of research on vitamins, which continue to be the subject of much new research. Each year, therefore, the risks and benefits of vitamins become more clear. One recent study which is getting much press adds to this body of knowledge about vitamins.

In the latest issue of The Archives of Internal Medicine is a population based observational study looking at health outcomes and vitamin use as part of the larger Iowa Women’s Health Study. The authors looked at 38,772 older women and asked them to self-report their vitamin use. This is a long term study and their vitamin use was reports in 1986, 1997, and 2004, and mortality was followed through 2008. They found a small but statistically significant increase in mortality for those taking multivitamins, B6, folic acid, iron, copper, magnesium and zinc. There was also a small decrease in mortality for those taking calcium.

The strength of this study is that it is large with a long term follow up. There are many weaknesses, however. Vitamin use was self-reported. Further, this is a correlational study only. Therefore possible confounding factors could not be controlled for. For example, it is possible that women who have an underlying health issue that increases their mortality were more likely to take vitamins or to report taking vitamins.In fact, other studies suggest there is such a “sick-user effect” with vitamins.

It is therefore not possible from this study to draw any conclusions about cause and effect – that vitamin use increases mortality. But it does provide a cautionary reminder that it is not reasonable to assume that vitamin supplementation is without any risk. We still need to follow the evidence for the use of specific vitamins at specific doses for specific conditions and outcomes.

Conclusion

As is typical of observational studies, the results are somewhat mixed, depending upon the details of how such studies are conducted. There are also many variables to consider – which vitamins and which doses in which populations with what health conditions. There is therefore a great deal of noise in the data. I do not think we can conclude that the vitamins listed above actually increase risk of mortality. But neither can we conclude that there is any health benefit for routine supplementation. Years of research have failed to provide such evidence, and the mixed results we are seeing is consistent with there being no or only a small effect.

Based upon the totality of evidence the best current recommendation is to have a well-rounded diet with sufficient fruits and vegetables, which should be able to provide most people with all the micronutrients they require. There is no evidence to support routine supplementation. There is also reason to avoid taking megadoses of vitamins, as this can cause toxicity, and even short of toxicity the evidence becomes more compelling at higher doses of the risks of supplementation.

But there are also many situations in which targeted supplementation is evidence-based and appropriate. There is increasing evidence to support the use of vitamin D supplementation for many populations. Many elderly have borderline or  low B12 levels, which correlates with dementia. Pregnant women should take prenanatal vitamins. (To give just a few examples.)

Vitamins are just like any other health care intervention – they have potential risks and benefits and it is best to follow the evidence. For most people the best advice is to ask your primary health care provider which supplements, if any, you should take. Recommendations should be based upon specific health conditions and blood tests to measure levels of vitamins, so that specific deficiencies can be appropriately targeted.

Posted in: Nutrition

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112 thoughts on “Vitamins and Mortality

  1. pasulj says:

    Well put Steve!! I am constantly trying to explain this very point to patients.

  2. Thanks for the info on the ‘sick user effect.’ I am not familiar with that one yet. I would guess that there is both a healthy user effect going on, a sick user effect going on, plus the deleterious impact of vitamins themselves, as has been noted in randomized controlled trials (which should strongly serve to limit those two biases).

  3. marilynmann says:

    Of possible interest, a randomized controlled trial found that vitamin E increases the risk of prostate cancer. In the current issue of JAMA.
    Klein, et al. Vitamin E and the Risk of Prostate Cancer. JAMA. 2011;306(14):1549-1556.
    http://jama.ama-assn.org/content/306/14/1549.short

  4. daijiyobu says:

    And there’s also that great N=1 study called “Gary Null Almost Kills Himself” via hypervitaminosis.

    -r.c.

  5. LovleAnjel says:

    When I saw this study I thought “Sick people up their vitamin intake.” Good that the sick-user effect is getting attention. It’s important to separate that from side effects of the vitamins.

  6. ConspicuousCarl says:

    Just before coming here today, I noticed this report about vitamin E possibly causing prostate cancer:
    http://www.foxnews.com/health/2011/10/11/study-finds-vitamin-e-may-increase-risk-prostate-cancer/?test=latestnews

    I don’t have access to the full paper (JAMA) to get any info on the structure or controls, if any.

    However, here are some perfect quotes:

    Klein said. “People think of vitamins as innocuous substances, but in fact, that’s not true. They’re active agents; they’re part of our normal physiology and getting too much of things that are normal for us can sometimes be harmful.”

    Dr. David Samadi, a Fox News Medical A-Team member and chief of robotics and minimally invasive surgery at Mount Sinai School of Medicine in New York City agreed. “We now have a better understanding of the relationship between vitamin E and prostate cancer. Their key finding…is the reason I am so cautious of prescribing alternative medicines.We should base our practice off of evidence-based clinical trials.

  7. ConspicuousCarl says:

    Also, isn’t the “sick patient effect” what is already called “confounding by indication”?

  8. JPZ says:

    @Steven Novella

    Thank you for the thoughtful review of the recent Iowa Women’s Health Study article. You raise some important points about the study design. At least three other large cohort studies have found no correlation between multivitamin-mineral use and all cause mortality. The n=182,099 Multiethnic Cohort Study found no association between multivitamin supplement use and all-cause mortality (Am J Epidemiol. 2011 Apr 15;173(8):906-14). A study in Washington state (n = 77,719) also found no increase in mortality and a decrease in CVD risk with multivitamin use (Am J Epidemiol. 2009 Aug 15;170(4):472-83). The Women’s Health Initiative (n = 68,132) found no association between multivitamin use and mortality in post-menopausal women (Arch Intern Med. 2009 Feb 9;169(3):294-304). I am disappointed that this study got sensationalized, but that seems to be how the news cycle works in this day and age.

  9. Quill says:

    I think this bears repeating:

    Vitamins are just like any other health care intervention – they have potential risks and benefits and it is best to follow the evidence. For most people the best advice is to ask your primary health care provider which supplements, if any, you should take. Recommendations should be based upon specific health conditions and blood tests to measure levels of vitamins, so that specific deficiencies can be appropriately targeted.

    That really is concise and easily comprehended advice. It’s not about the mystery, the marketing and the latest miraculous substance being sold by anybody. It is a straightforward thing, based on one’s own situation and what has been shown to work.

  10. tmac57 says:

    This may sound like a comical question,but I wonder,in all sincerity;since some of these vitamin pills are quite large,is there any indication that they are responsible for significant amounts of choking deaths or injury? I am always wary when I have to swallow pills that are large.

  11. LovleAnjel says:

    @tmac57

    That’s a good question. I did a quick Peb Med search and this was what I could find:

    http://www.ncbi.nlm.nih.gov/pubmed/1329494

    Pills which contain guar gum can cause obstruction at several different parts of the digestive tract.

  12. Harriet Hall says:

    Choking deaths from pills? I would think they are VERY rare, but here’s a report of one in a child:
    http://www.downtownexpress.com/de_146/tribecaboydies.html

  13. marilynmann says:

    @ConspicuousCarl and anyone else who is interested in the Vitamin E study: I just noticed that JAMA is making the full text of the study available to nonsubscribers.

    http://jama.ama-assn.org/content/306/14/1549.full

    The study was a randomized controlled trial with 4 arms: selenium, vitamin E, both selenium and vitamin E and placebo.

  14. Jan Willem Nienhuys says:

    I quote:

    In multivariable adjusted proportional hazards regression models, the use of multivitamins (hazard ratio, 1.06; 95% CI, 1.02-1.10; absolute risk increase, 2.4%),

    and from
    http://news.yahoo.com/vitamins-may-increase-womens-risk-dying-research-finds-212402256.html

    For example, of the 12,769 women in the study who took a daily multivitamin, 40.8 percent had died by the end of 2008, whereas 39.8 percent of the 10,161 women who hadn’t taken a daily multivitamin had died.

    So, in the first place 15,842 women are left out in this analysis. Moreover, calculating from my head (square root of 10,000 x 0,4 x 0,5 is sqrt 2400 is about 50 i.e. 0,5%. of 10,000) the difference of 1% is hardly twice the standard error in both these two subsets. If I consider this 12,769+10,161 women to be the total universe I get p=0.064 one-tailed (uncorrected for multiple comparisons), and I don’t believe that including a kind of between group of 15,842 is going to give an improvement.

    Note how a difference of 1% (40,8% – 39,8%) is changed into an “absolute risk increase” of 2,4% by comparing it to 40.8 % rather than 100%. Then another trick is used to blow it up until a hazard that is 6% more than the neutral value of 1.

    Maybe I don’t understand the miracles of “multivariable adjusted proportional hazards” too well. Compared to the total (38,772) group and the total time of about 25 years it means 3 deaths per year more in the ‘vitamin group’, and 2 deaths per year less in the ‘no-vitamin’ group, and 1 death per year less in in the unmentioned group of 15,842 women. Maybe it’s the sick user effect, but for now I think that it only becomes ‘statistically significant’ if you apply some kind of trick.

    Is there any M.D. that can explain the statistics used to me?

  15. pmoran says:

    Today vitamins have a deserved reputation for being an important part of overall health. However, their reputation has gone beyond the science and taken on almost mythical proportions. Perhaps it is due to aggressive marketing from the supplement industry, perhaps recent generations have grown up being told by their parents thousands of times how important it is to take their vitamins, or eat vitamin-rich food. Culture also plays a role – Popeye eating spinach to make him super strong is an example this pervasive message.

    The basic practice of supplementation derives from the mainstream.

    Some here will remember the “tonics” commonly employed by doctors at least up to the middle of the last century. Latterly they usually contained iron and vitamins and they served as a “pick-me-up” for just about any vague complaint, as they still do today within CAM.

  16. ConspicuousCarl says:

    marilynmann,

    Thanks! I failed to be inquisitive and I didn’t even bother to check before assuming it was unavailable.

    That looks like a monster of a study. 35k patients including randomized placebos.

    That was using 400 units of vitamin E, which is well above the RDA I found on the NIH website (22 IU for most adults). However, Amazon.com is overflowing with 400-IU pills and 1000-IU is available if you look for it.

    Enjoy your cancer, hippies.

  17. tmac57 says:

    pmoran- I am old enough to remember ads for Geritol,which had a tag line as a cure for “iron-poor tired blood”. They got into trouble with the US FTC,and were heavily fined (heavy for that era) in 1973.It was an iron supplement with B vitamins (and 12% alcohol for medicinal purposes). It is still sold as a tonic and a brand of multivitamin,though I haven’t seen ads for it in years.

  18. tmac57 says:

    ConspicuousCarl-

    That was using 400 units of vitamin E, which is well above the RDA I found on the NIH website (22 IU for most adults). However, Amazon.com is overflowing with 400-IU pills and 1000-IU is available if you look for it.

    Enjoy your cancer, hippies.

    Ouch!!! That’s pretty harsh Carl.

  19. BillyJoe says:

    “When I saw this study I thought “Sick people up their vitamin intake.” ”

    When I saw this study I thought “so much for all those health nuts consuming extra vitamins”.
    In other words, it could be either: sick people taking vitamins or healthy people trying to get an edge by taking vitamins.

  20. JPZ says:

    @ConspicuousCarl

    “Enjoy your cancer, hippies.”

    Seriously??? These are clinical trial subjects who volunteered so that you could be enlightened! Or perhaps you are talking about the 23% of Americans 60 and older who take 400 IU or more of vitamin E daily? I’m sure there are more than a few Republicans in that population segment.

    @everyone

    If I can return to the science, the vitamin E used in this study was all-rac alpha-tocopherol acetate – the synthetic form which is composed of eight isomers. And, all-rac vitamin E is 45% as potent as RRR-alpha tocopherol, the naturally occuring form. This means that to get 400 IU vitamin E activity, they had to give more than 800 mg of all-rac vitamin E. Four of the all-rac vitamin E isomers have no vitamin E activity but are not inert. The metabolism is different (http://www.ncbi.nlm.nih.gov/pubmed/9804189), and there have been a few intervention trials that found different effects based on the form used (http://www.nap.edu/openbook.php?record_id=9810&page=224).

    It is a little odd that vitamin E alone increases incidence but vitamin E + selenium did not. There was a non-significant increase in incidence in the selenium group, and there was a significant interaction effect between the two. I am guessing that the lower end of the 95% CI (HR, 1.17; 99% CI, 1.004-1.36; P = .008) was like a golfball waiting for the wind to push it into the hole.

    No other form of cancer was increased; no increase in heart disease or diabetes; nor in all cause mortality. The paper reported the only significant negative outcome even after ten years of 400IU/day. I thought it was important to point out the lack of collateral damage from the treatment, but it may also provide insights into the hype. This big, expensive study would have reported no effect of vitamin E or selenium on any health outcome. Luckily, the lower limit of their 95%CI crept barely over the 1.0 finishing line (1.004 – who reports three significant digits? Not the authors EXCEPT for this one number). The day was saved even if the study had to become a one trick pony.

    Two other large vitamin E intervention trials found a 35% risk reduction (ATBC) or no effect (PHS II). The paper does a pretty good job of laying out the differences between the studies.

    My final point is more of a question. What is the clinical signigicance of increasing the risk of prostate cancer cases by 1.6 per 1000 person-years once you take into account the age of the men (fewer person-years left after 60), the long period of exposure needed (the vitamin E line starts to diverge at 4 years but only reaches significance at 10 years), and the risk of actually getting a prostate cancer that will need to be treated?

  21. Well now point is what vitamin will affect in negative way and in positive way as well. Vitamin E has got negative affect on prostate cancer and vitamin b and d has got positive affect on sexual health,, what should be considerd now,, survey always tell us something and somethinig,, but we should remember that any consumption in limit can never harm you.

    To read more about vitamins and its relation on sexual health… go to http://www.genericpharmacyrx.net/blog

  22. ConspicuousCarl says:

    JPZ on 13 Oct 2011 at 2:13 am

    @ConspicuousCarl

    “Enjoy your cancer, hippies.”

    Seriously??? These are clinical trial subjects who volunteered so that you could be enlightened! Or perhaps you are talking about the 23% of Americans 60 and older who take 400 IU or more of vitamin E daily? I’m sure there are more than a few Republicans in that population segment.

    Yeah, as TMAC said it was pretty harsh. Not really a nice thing for me to say, and I apologize to any decent people out there who had to read it.

    However, I will insist that you think a bit harder and realize that “hippies” was obviously supposed to refer to misguided health nuts who OD on every vitamin and other supplement they can think of, not clinical volunteers or any other people who take things as instructed by doctors.

  23. Conspicuous Carl “However, I will insist that you think a bit harder and realize that “hippies” was obviously supposed to refer to misguided health nuts who OD on every vitamin and other supplement they can think of, not clinical volunteers or any other people who take things as instructed by doctors.”

    When my MIL was getting treatment for lymphoma she was in a support group for her type of cancer. The support group had a nurse practitioner come in to talk about nutrition. Apparently she suggested all sorts of supplements to help support the cancer treatment and prevent return to the cancer. MY MIL seemed unimpressed, I think feeling that it all seemed to complicated, expensive and unproven. But it seems likely to me that other in the group would have followed the NP’s directions vigorously. Why? Not because they are silly hippies looking for some sort of health edge. More probably because they are very scared and they want to do anything they can to decrease their odds of a pretty awful death.

    It sounded like you were directing your comment to ALL folks who take high dose vitamins without explicit directions from their doctor. Even if you were only talking about the so called health nuts, it’s still mighty low to gloat over anyone getting cancer.

  24. tmac57 says:

    micheleinmichigan-

    Even if you were only talking about the so called health nuts, it’s still mighty low to gloat over anyone getting cancer.

    Exactly!
    Concerning your MIL’s experience in the cancer support group,I have seen that 1st hand,as I participated in a caregivers support group,and my wife was in a parallel cancer support group.That organization (which I will not identify) is generally a wonderful resource for support,and is 100% free; supported by donations,but the amount of woo that we encountered there was disturbing.
    Along with speakers who were from top notch cancer facilities giving science based information,they had all manner of CAM people (you name it,it was there) presenting dubious modalities.And the discussions in the groups themselves were full of misinformation about mainstream treatments and downright fraudulent scams.I got into trouble more than once with the facilitator by challenging things such as the Royal Rife machine,to anti-vax propaganda (these were things brought up by the participants,not the facilitator).
    This could be a whole separate topic for SBM to tackle.

  25. ConspicuousCarl says:

    You are all correct on the second point as well and I extend my apology to those people. I really didn’t mean it seriously, which is not a proper attitude to have in regards to the subject anyway.

  26. CarolM says:

    hippies” was obviously supposed to refer to misguided health nuts who OD on every vitamin and other supplement they can think of,

    Hippies, shmippies. My mother went all-in with vitamins around 1971 after reading a couple Adele Davis books. She went nuts with the stuff, like a religion. Every time I visited there was a new Miracle Supplement, including Selenium for a spell, also Niacin, Lecithin, Papaya Enzymes, etc. I couldn’t keep up and did’t try. Her brother and SIL also went nuts, and these are all WWII generation folks. It’s been routine with that gen for decades now.

    I always suspected it was a substitute for what they should have been doing – quitting smoking, losing weight, and exercising. My mother finally did quit smoking after a DIL confronted her about it while being lectured on raw milk or whatever. But my mom never really got active again, due to weight and knee problems.

    But she is still alive at 93, albeit with dementia, so what can I say?

  27. JPZ says:

    @ConspicuousCarl

    “You are all correct on the second point as well and I extend my apology to those people. I really didn’t mean it seriously, which is not a proper attitude to have in regards to the subject anyway.”

    One of the only points I have found in favor of “intelligent design” is how perfectly our foot can fit in our own mouths. ;) We all get passionate about an issue sometimes and stumble over how to express it. And, I’ll share my own COI behind my response – my mother was an actual flower-child/hippie and the only supplement she has ever used was the calcium/vitamin D her internist recommended.

  28. JPZ says:

    @ JWN or TILITS or anyone else with a strong stats background

    “My final point is more of a question. What is the clinical signigicance of increasing the risk of prostate cancer cases by 1.6 per 1000 person-years once you take into account the age of the men (fewer person-years left after 60), the long period of exposure needed (the vitamin E line starts to diverge at 4 years but only reaches significance at 10 years), and the risk of actually getting a prostate cancer that will need to be treated?”

    I am quite curious about how this particular figure permutates once you take into account population specific effect modifiers. I minored in Epidemiology in grad school (enough stats to usually work out this kind of question), but it seems that I am having some sort of mental block.

    US census estimates average male life span of 76 years in 2010. VIt E exposure time until incidence is 10 years. NCI estimates 1-in-7 chance of contracting prostate cancer between ages of 60-80. About 66% of prostate cancers are latent (slow growing) (Wikipedia, so take with a grain of salt).

  29. @ConspicuiousCarl, Thanks, I always admire someone who’s willing to rethink a comment. I hope I will be as gracious when it’s my turn.

  30. tmac57, yes, I get the impression many health condition support groups can be a blessing and a curse. Hard to know how to balance the good and the bad.

  31. qetzal says:

    @JPZ

    You may be correct that the claimed link between vitamin E and prostate cancer is either an artifact or clinically irrelevant. Even so, that only means the study suggests no detectable effect of vitamin E at all. So why take it?

  32. Jan Neinhuys asked:
    “Is there any M.D. that can explain the statistics used to me?”

    Jan, with that blog comment, you should be explaining the sttistics to the doctors. They need some help:

    Donna M. Windish; Stephen J. Huot; Michael L. Green. Medicine Residents’ Understanding of the Biostatistics and Results in the Medical Literature. JAMA. 2007;298(9):1010-1022.

  33. tmac57: yes, geritol is still around, and still has 12% alcohol.

    the alcohol is, incidentally, the secret ingredient in a lot of the old remedies from the ‘snake oil salesman’ of days gone by.

    now you know why the snake oil salesman could attract a crowd: the ppl would have a legit, medicalized, legitimized reason to take a nip.

    have things changed?

  34. JPZ says:

    @qetzal

    I actually worked on vitamin E and heart health research back in the turn of the century. The preliminary data and small scale clinical studies with biomarkers were all great. The dietary supplement industry really talked up the potential for vitamin E as an antioxidant that may be important in heart health. The story was pretty good when you could bring up LDL-oxidation and all. The sales of vitamin E shot up, and we invested in more research including providing vitamin E for large clinical trials (I was in the group that suggested 400 IU for the SELECT trial – my old company made the capsules).

    The first trial that told me vitamin E may not work for heart disease was GISSI-Prevenzione. Just like competing academics, we talked about study design flaws and characteristics of the “right” intervention study. Then the “right” studies got done, and the preponderance of evidence was that vitamin E did very little for heart disease. Today (and for some years now), I wouldn’t recommend that people take vitamin E to prevent heart attacks.

    There are other indications for vitamin E: huge doses for slowing Alzheimer’s progression or lower doses for slowing AMD progression. There is not large body of data to support these uses, but both conditions are incurable and there are a few good quality clinical trials to support its use.

  35. JPZ says:

    @everyone

    Another comment on the Murusu and SELECT trials from an industry colleague of mine (https://www.economist.com/users/mi-mcburney/comments). His main points and style differ from mine.

    Mortamins?

    Oct 13th 2011 6:24 GMT.

    Nutrients are not drugs. Vitamins are essential for health. Without adequate nutrition, people will die. With proper nutrition, people will not live forever. But, we still need an adequate intake of essential nutrients.

    The Mursu study was an epidemiologic study. Using statistics, the authors attempted to peel away confoundation from many co-related behaviors – supplement usage, dietary behaviors, use of alcohol, andn the list goes on. 81% of these women were regularly using dietary supplements. And good for them because these women were consuming <3 servings of fruit, <4 servings of vegetables, and 90% of Americans are not consuming the RDA for vitamin E. According to the Institute of Medicine experts, people do need to be consuming more vitamin E. This will require supplementation since few foods are rich sources of vitamin E and even fewer are fortified/enriched. It is prudent to modestly supplement to ensure a vitamin E intake which meets recommended daily amounts (15 mg/d for those over 14y)

    For more information on these studies, and others, please go to http://TalkingNutrition.dsm.com, follow @dsmnutrition on twitter, or like http://www.facebook.com/TalkingNutritionDSM. For the record, DSM is the world’s largest manufacturer of vitamins which are sold to food, pharmaceutical, dietary supplement, and formula companies who integrate them into consumer products.

    Michael I McBurney, PhD
    Head of Scientific Affairs, DSM Nutritional Products

  36. JPZ says:

    @Moderators

    I’m sorry, but I do not know where else to ask. This is the first comment I have made that has “awaited moderation.” How does that work? Being as there was no obscenity nor insults within, I would like a little guidance.

  37. nybgrus says:

    @JPZ:

    If it had 3 or more hyperlinks in it that will lead to moderation automatically.

  38. JPZ says:

    @nybgrus

    Thank you! It had three exactly. I was worried I had violated a rule somewhere.

  39. cloudskimmer says:

    Thanks for the article, Steve; I’ve been wanting to read some intelligent commentary since the study appeared in the newspaper.

    When I was a kid, we were sometimes given a multivitamin, and I remember them as being about the size of an aspirin tablet, coated, and relatively easy to swallow; perhaps my memory is fading but the ones today seem much larger. In the days before DSHEA, weren’t they required by the FDA to contain what the label said? One reason I’m not interested in taking them these days–aside from anything in the most recent study–is that, thanks to DSHEA, I have no confidence that the pill inside contains what the label indicates. After all there is no regulatory body that insures quality, and unless the pills kill someone, the FDA cannot take any action against the manufacturer. Are vitamins found on the shelf in a drug store any more reliable than any of the other supplements located nearby? Even if my doctor advises some extra vitamin, such as vitamin D, how can I be sure that the pill contains what the label says it does?

  40. Jeff says:

    Here’s one recent study which found that baseline users of dietary supplements had a 48% reduced risk of cancer mortality and 42% lower all-cause mortality.

    The Main Stream Media tends to ignore studies showing a benefit from supplements. Their principal interest is in sensationalizing those studies, no matter how weak, which show supplements to be worthless and/or harmful.

  41. Jeff says:

    Typo in previous post: should be mainstream media (two words, not three).

    @cloudskimmer: Actually, thanks to DSHEA we now have Dietary Supplement Good Manufacturing Practices. These regulations address your concerns about quality, content, and labeling.

  42. tmac57 says:

    Jeff-

    The Main Stream Media tends to ignore studies showing a benefit from supplements.

    This strikes me as obviously false. I see headlines in the news constantly touting new research that claims some benefits for various substances or supplements.But you also see news that show negative effects leading people to believe that scientists don’t really know anything.
    The problem is in indiscriminate reporting of poor research or small preliminary studies,and interpretation of the data that go beyond what it actually shows. The Main Stream Media does do a bad job of science reporting for sure,but I think it errs in both positive and negative directions.

  43. LovleAnjel says:

    @Jeff

    The regulations you cite were never a part of DSHEA, they are in response to it. DSHEA was passed in 1994. These regulations were passed in 2007.

  44. JPZ says:

    @cloudskimmer

    The label claims on a dietary supplement are in fact regulated (http://www.fda.gov/Food/DietarySupplements/DietarySupplementLabeling/default.htm) as are the manufacturing quality standards (http://www.fda.gov/Food/DietarySupplements/GuidanceComplianceRegulatoryInformation/RegulationsLaws/ucm110858.htm#fr). A company can break the law and have a product that does not meet label claims, but that does not mean the product is not regulated.

    For vitamins and minerals, meeting label claims is easy. For herbs, there is generally no “standard of identity” statute, so you can get ripped off by an irresponsible company putting an herb’s leaves in the product when the roots are the effective component (or something like that). In these cases, it is better to look for herbs meeting voluntary quality standards (e.g. contains Ginko biloba with a minimum of 30% gingkosides) or labels touting clinical trials run on the EXACT formulation in the box.

    Store brands are generally manufactured by one of the big supplement companies like Pharmavite, so the quality is generally good (although I did once buy a store brand multivitamin-mineral that caused me a great deal of gastric pain until I figured out the mineral mix used high bioavailability forms that also had the worst side effect profile when the pill is not coated).

    And, as nearly everyone here can tell you (and I agree), there is no pre-market requirement for manufacturers to prove efficacy – which needs to change.

    As for small versus big pills, standard One a Day used to have much smaller pills than standard Centrum. Usually, the difference is in the calcium-phosphorus content.

  45. Jeff says:

    @LovleAnjel:
    DSHEA authorized the FDA to come up with a set of regulations governing the manufacture of supplements. It took the FDA 13 years to finally give us the current GMPs. This explains:
    http://www.fdaimports.com/industries/dietary_supplements/good_manufacturing_practices.php

  46. Jeff says:

    JPZ: Most people take supplements for prevention and better health, not to treat a specific condition. It might be many years before the tocotrienol form of vitamin E is ever proven to “cure” a specific disease. Do you think consumers should therefore be denied access to it?

    A more recent review found tocotrienols to be useful in the treatment of Metabolic Syndrome (PMID 21774781).

  47. JPZ says:

    @Jeff

    You are putting words into my mouth and asking leading questions. If you know the basis and finer points of DSHEA, I imagine that you already know the answers.

    My own position is that consumers should expect a supplement to do what it says it does, and they should have a reasonable expectation of safety. I believe safety and efficacy should be based in science. The details beyond these core values are open to intelligent interpretation and thoughtful debate.

  48. nybgrus says:

    @jeff:

    Really? That’s the study you cite to try and say supplements aren’t “worthless and/or harmful?”

    Lets see, just from the freakin’ pubmed abstract:

    After adjustment for potential confounders, neither any vitamin/mineral supplementation nor multivitamin supplementation at baseline was statistically significantly associated with cancer, cardiovascular, or all-cause mortality

    [emphasis mine]

    So they couldn’t even find an association let alone causation. Of course, you are honing in on the second line about antioxidant supplements showing a decrease in cancer and all-cause mortality. Of course the CI’s are very wide and come very close to 1, so I am pretty dubious about the claim, but you just casually drop the link and say a 42% and 48% reduction, never mind the CI going from 72% to 3%, nor the conclusion of the abstract itself:

    Based on limited numbers of users and cases, this cohort study suggests that supplementation of antioxidant vitamins might possibly reduce cancer and all-cause mortality.

    [emphasis mine]

    Yes, very strong study you cite there Jeff. Amazing how that evil mainstream media and us horribel anti-supplement folk claim that supplements are mostly worthless.

  49. JPZ says:

    @Jeff

    I provide the best scientific evidence I can for nutritional product efficacy on SBM. nybgrus, Harriet Hall, and others cut me no slack on the quality of my science nor my interpretations. I appreciate the scrutiny – it makes me try harder to express the science better. I also appreciate your providing a reference to support your statement (it is more common that commentators do not). The better your science, the stronger your voice here (at least I hope so LOL).

  50. nybgrus says:

    @JPZ:

    I cut you no slack, but you also approach the topic from intellectual honesty and a scientific base. You don’t try and pawn off BS studies and one-off results as actually being meaningful. And over time, I think we’ve learned that we agree on most things and only disagree on some finer points and admittedly gray areas and our not-terribly-different worldview means I would advocate one way and you another in those cases. And yet, unlike Jeff, I somehow find myself respecting your opinion and look forward to reading your understanding. I actually learn something and am challenged myself.

    Jeff could learn a thing or two from that.

  51. JPZ says:

    @Moderators

    OK, my post that was intended to share another nutrition industry perspective posted on The Economist website and linked to this discussion was blocked after Moderator review (it seems). I respect the fact that this is your blog, but could I please respectfully request, guidelines as to what I can and cannot share in this community?

    1. Harriet Hall says:

      @JPZ. Your comment was not blocked. I think it just got overlooked. It has now been approved.

  52. JPZ says:

    Thank you, Harriet.

  53. stanmrak says:

    I’m amazed that this study would even be mentioned on a site like this. It wouldn’t even pass as a high school science project, and it’s being discussed seriously? It only demonstrates how little is known here about nutrition.

    “For most people the best advice is to ask your primary health care provider which supplements, if any, you should take.”

    Really? Ask a person who got almost no nutritional education in medical school about nutrition?

  54. stanmrak says:

    I assumed by “primary healthcare provider” you meant a MD. There are good sources for this type of information in the “healthcare” profession, but doctors are not them!

  55. JPZ says:

    @StanMrak

    OK, your first three sentences were a complete facepalm, so I will ignore those.

    The second part I will address. Steven Novella’s review of the multivitamin-mineral supplements and mortality study was quite good. My comment on his review only supported his statements by quoting three additional large trials with no increase in mortality. Whether by training, osmosis or other means, my impression is that he has at least a working knowledge of the science of nutrition. You can read my other comments here and decide for yourself whether I am qualified to evaluate someone’s understanding of nutrition.

    Steven’s viewpoint about physicians providing advice on dietary supplements is consistent with his other viewpoints expressed here. If I understand that viewpoint correctly (please correct me if I am wrong, Steven), it is more about physicians taking responsiblity to address dietary supplements and other health practices so that patients do not fill the void with non-scientific beliefs. I personally think most physicians need more training in nutrition before they can perform well in that particular role, but I also commonly see comments here about physicians referring patients to dieticians when in doubt. I realize only 1 out of 4 US medical schools make a significant effort to teach nutrition (http://www.aafp.org/online/en/home/publications/news/news-now/resident-student-focus/20101020nutritioneduc.html), but progress is being made including online and continuing ed options.

  56. nybgrus says:

    my prediction is that stanmrak is one of those that significantly overblows the import of diet and nutrition in human health. Nutritional education is deficient in medical training, I won’t argue it isn’t. However, it not nearly as deficient as many think. Those that are so convinced it is lacking so severely are almost always those who think that eating diet [XXX] will prevent/cure diseases [ABCD] (and ABCD are not vitamin/nutrient deficiency diseases, of course. They are usually cancer or chronic pain syndromes or something like that). So to them, the gap seems enormous because they are vastly overinflating the top end.

    Furthermore, those that tend to get all uppity about the nutrition thing confuse an understanding of nutrition with the ability to recommend specific diets to patients. For example, I may know a patient is lacking in nutrient [X] but I may not be particularly able to recommend a specific diet to remedy that. Of course, that is where dieticians come in – teaching people how to eat well is important, but not exactly in the purview of a physician.

    The gulf is much smaller than people like stanmrak believe.

  57. stanmrak says:

    You’re right – I think that diet and nutrition contribute more to human health than drugs do. I wonder how thoroughly this study would have been discredited here if the conclusions were the opposite? The truth is that this study is laughably incompetent, bordering on fraudulent, and anyone who gives it any credence is a fool.

  58. nybgrus says:

    You’re right

    Thanks.

    The rest is gobbledy gook, so I’ll just leave it at that.

  59. Chris says:

    nybgrus, he is a supplement shill:
    http://www.selfgrowth.com/experts/stan_mrak

  60. JPZ says:

    @Chris

    I suppose I could be considered a supplement shill as well, but I am terribly conservative in that I expect efficacy and safety to be based on science. But I take no offense at your characterization of Stan Mrak.

    @nybgrus

    The thing about calling Dunning-Kruger on someone is that it is a pretty rude assessment of their knowledge, and it leaves them with little defense to counter. If you don’t know what you don’t know, how can you then say you know it? My unfortunate assessment is that the current weaknesses in overall medical education and physician knowledge about nutrition (aside from heart health and diabetes), leads to a Dunning-Kruger effect in most attendings, i.e. the feeling that I know enough physiology and endocrinology to fill in the gaps to understand nutrition. In Australia where you are training, it may be different. I base this assessment on my Ph.D. in nutritional sciences and working in 100+ clinics around the US running nutrition clinical trials. Many physicians train themselves to be outstanding experts in nutrition – I can attest to that! But that overweening confidence to say that one can evaluate the health benefit of a nutritional intervention based on extracting vague knowledge from limited training is a recipe for hubris. Steven’s review of this study is an example of a physician who has taken at least some extra step. My sincere apologies if I am coming across as a self-important jerk.

    @StanMrak

    Well, thanks for the second facepalm. My interest in your insights declines with every baseless post like that. Consider your audience and what it might take to appeal to their understanding. Or, you can come across like that fanatical, screaming maniac on the street corner who forces everyone to walk on the other side of the street. Your choice.

  61. Chris says:

    Well, JPZ, I only did it for the irony factor.

  62. nybgrus says:

    @Chris:

    Thanks for the link. I didn’t need to look it up – I’ve gotten good at sniffing them out. But hey, he lists Gary Null, Joe Mercola, and Mike Adams as some of his “expert mentors.” That says pretty much all I need to know.

    @JPZ:

    First off, I would not consider you or call you a supplement shill. If I have ever come across as implying that, a thousand apologies.

    As for you comment – honestly, maybe I am just not reading it right, but I am not sure what exactly the point is. And/or perhaps my understanding of Dunning-Kruger is not quite right either. Obviously one cannot know what one does not know. However, from my understanding of it D-K is the further assumption that you do know the extent of it. For me, all those unknowns rarely trip me up – I may not know exactly what I don’t know, but I do know that there is a lot I don’t know so I am always open to hearing something new or contradictory.

    As a prime example, just a few weeks back a classmate of mine was doing a presentation on nephrotic syndrome. She posed the question “What causes edema in nephrotic syndrome.” The immediate answer (which was mine as well) was that the loss of protein leads to hypoalbuminemia and a net transcapillary loss of oncotic pressure which leads to excess fluid in the interstitium. She replied that was, in fact, incorrect. Everyone in the room immediately began an uproar. However, despite the fact that until that very moment I myself had been certain that was the mechanism I quieted everyone and asked my classmate to proceed with her explanation. I listened to everything she had to say, found it interesting and compelling, did a quick search on Up To Date, and changed my understanding.

    See, to me, D-K would have been the uproar – “No! I know what the mechanism is.” Had she been wrong I would have corrected her. But I wasn’t about to predict she would be wrong just because my preconceived understanding was counter to what she was saying.

    But I digress. In regards to nutrition specifically, I would think that the teaching is relatively on par over here (good or bad as that may be). My point was not that nutrition education is good enough – I am the first to admit it is not. We could certainly bolster that. But merely that how bad it is is indeed blown out of proportion.

    But the education on nutrition is difficult. What are you supposed to teach? Take VitD for example. Obviously we know the basic functions and we know what hypovitaminosis would lead to. And thanks to Gary Null we know what massively acute hypervitamonisis would do as well. But how do we define “normal” and at what levels do we supplement? Evolution does not mold us to have “perfect” levels of anything – good enough will suffice. So if we do the standard metric of “normal” which is designed to capture the values of 95% of a non-diseased population, not only are we missing 5% of “normal” but we are making the assumption that the levels of a non-diseased person are optimal (since that is what we often equate “normal” with). From my readings on the topic, it seems that VitD has many more functions, particularly in cancer, than we had previously imagined. And it also seems to me that indeed “normal” is sub-optimal – at least in many cases. But then, how do we determine optimal? And how do we ensure that translates across populations? How do we detect subtle negative effects, either in subsets of a population or in other deleterious effects before undescribed since we’ve never had, let alone studied, a population with “optimal” VitD levels? So who do we suggest supplements their diet? And what is the best way to supplement?

    I am certain you appreciate the import of such questions and would be the first to say that a scientific study would be the best way to find those answers. But you also know of the practical limitations of that. And of course, the VitD example translates to basically every other foodstuff molecule we can and do imbibe. Folks like Stan Mrak would have us believe that more is better, especially of some things, and not of others. But that is pure guesswork. You know my stance is that the safe and more often correct choice is to avoid supplementation of any kind unless there is a clear indication for it – and that is something we are taught in medical school.

    Otherwise, I might take VitD (how much? how often?) for decades of my life in the hopes of improving my cancer risk profile and myriad other things as well. And then some subtle and very unlikely pathology occurs because I increased the likelihood of that through my supplementation. One may argue that the odds of that happening are very low – but so is an individual’s likelihood of getting cancer in the first place. And history has shown us that unexpected effects – besides being unexpected – are also very common. So do you risk the known or the unknown? One could also argue that VitD is overall very safe (Jeff comes to mind here) and I would agree. But what about all the myriad other supplements out there? How does one decide which “safe” one to take? Or which combination? And of course – how much?

    That is why I think that most “supplements” should be taken off the market and that proving some sort of efficacy AND safety before marketing is necessary – I think you and I are mostly in agreement on that. But when it comes to nutritional advice (and I am blanking on who said it originally but Dr. Hall mentioned it in a post of her’s some time back) – eat lightly, not too much fats, with good variety, and plenty of fruit and veg. Anything beyond that and you step off into the realm of guesswork and make evidence free assertions along the way.

    So I hope I don’t come off as someone who has the overweening hubris to evaluate a health benefit from esoteric biochemical knowledge. Everything I have just written was to demonstrate that I think that is exactly impossible. But that is a double-edged sword. It also means that I cannot advocate for supplementation oustide of a clinically recognizable and defined deficiency. All I am saying is that the preponderance of data demonstrate that such willy-nilly supplementation most likely does exactly nothing – or that at least the small benefits are balanced out by small detriments. So until I have some robust data to demonstrate I should recommend a nutritional intervention from something outside of such clinical deficiencies I won’t because I don’t think I can.

  63. Jeff says:

    From my readings on the topic, it seems that VitD has many more functions, particularly in cancer, than we had previously imagined. And it also seems to me that indeed “normal” is sub-optimal – at least in many cases. But then, how do we determine optimal?

    Chris, here’s one VitD study which tries to answer your question:

    Markedly Higher Vitamin D Intake Needed to Reduce Cancer Risk, Researchers Say

  64. nybgrus says:

    Well, problem solved then, huh Jeff? BTW, I am not Chris, though our names are similar so I can understand the confusion.

    Thanks for the link, but it says nothing I don’t already know, nor does it address my post. Nice of you to surface when I invoke your name though. I’ll keep that in mind for the future.

  65. Jeff says:

    @Nybgrus: My apologies for getting the names wrong. You also said:

    my prediction is that stanmrak is one of those that significantly overblows the import of diet and nutrition in human health.

    I would argue that research into fields like epigenetics is proving that diet and nutrition can have a profound effect on human health. Studies like this one show how diet can influence how genes are expressed.

  66. squirrelelite says:

    @Jeff,

    Your researchers have a more recent study in publication.

    Pubmed ID 21868542

    The abstract states:

    Low serum levels of 25-hydroxyvitamin D [25(OH)D] have been associated with a high risk of breast cancer. Since publication of the most current meta-analysis of 25(OH)D and breast cancer risk, two new nested case-control studies have emerged.
    MATERIALS AND METHODS:

    A PubMed search for all case-control studies on risk of breast cancer by 25(OH)D concentration identified 11 eligible studies. Data from all 11 studies were combined in order to calculate the pooled odds ratio of the highest vs. lowest quantile of 25(OH)D across all studies.
    RESULTS:

    The overall Peto odds ratio summarizing the estimated risk in the highest compared to the lowest quantile across all 11 studies was 0.61 (95% confidence interval 0.47, 0.80).
    CONCLUSION:

    This study supports the hypothesis that higher serum 25(OH)D levels reduce the risk of breast cancer. According to the review of observational studies, a serum 25(OH)D level of 47 ng/ml was associated with a 50% lower risk of breast cancer

    So, it’s an updated meta-analysis of 11 studies (size and quality unknown since I don’t have access to the article details).

    Without a closer look at the details, it’s hard to guess how well supported that recommendation really is.

    But, a few questions occur to me.

    How many people overall were tracking in those survey studies and for how long and at what level of supplementation?

    In particular, how many were at a standard level of supplementation (600 IU/day), an increased level (2000 IU/day like I am taking at my doctor’s suggestion) and the maximum level they noted (10,000 IU/day)?

    How many breast cancers and other cancers were reported in those groups?

    As an illustration, a change from 8 cancers in the standard group to 6 cancers in the 2000 IU group to 4 cancers in the 10,000 IU group would give a 50% reduction in the risk (about what they claimed). But, would that really be significant and would it be worth supplementing at the low end of the toxic range (10,000-40,000 IU)???

    I also looked up the current recommendations for Vitamin D.

    http://ods.od.nih.gov/factsheets/vitamind

    That recommendation notes that there may be a confounding factor in those serum Vitamin D levels.

    Considerable variability exists among the various assays available (the two most common methods being antibody based and liquid chromatography based) and among laboratories that conduct the analyses [1,7,8].

    It also discusses the benefits and risks of Vitamin D supplementation with regard to cancer.

    Laboratory and animal evidence as well as epidemiologic data suggest that vitamin D status could affect cancer risk. Strong biological and mechanistic bases indicate that vitamin D plays a role in the prevention of colon, prostate, and breast cancers. Emerging epidemiologic data suggest that vitamin D may have a protective effect against colon cancer, but the data are not as strong for a protective effect against prostate and breast cancer, and are variable for cancers at other sites [1,46,47]. Studies do not consistently show a protective or no effect, however. One study of Finnish smokers, for example, found that subjects in the highest quintile of baseline vitamin D status had a threefold higher risk of developing pancreatic cancer [48]. A recent review found an increased risk of pancreatic cancer associated with high levels of serum 25(OH)D (≥100 nmol/L or ≥40 ng/mL) [49].

    And it avoids a definitive recommendation for Vitamin D supplementation to reduce the risk of cancer and only concludes

    Further research is needed to determine whether vitamin D inadequacy in particular increases cancer risk, whether greater exposure to the nutrient is protective, and whether some individuals could be at increased risk of cancer because of vitamin D exposure [46,55]. Taken together, however, studies to date do not support a role for vitamin D, with or without calcium, in reducing the risk of cancer [1].

  67. JPZ says:

    @Chris

    Dang, I failed my hipster test! ;)

    @nybgrus

    Yep, what I wrote was pretty much impossible to follow. I can look at it now and see the stream of consciousness, but the words make no sense. I took your comment about “understanding of nutrition” and ended up commenting on a half-dozen other things. Mia culpa.

    The Dunning-Krueger mention was incorrectly tied to your assertion that you may have an understanding of nutrition but not the ability to create the appropriate diet to correct nutritional problems. But, Dunning-Krueger doesn’t even apply to you given your appropriately phrased comment. It only applies when I make a different extrapolation, i.e. if a medical student or physician in the US asserts that they understand nutrition, odds are 3:1 against that being true – unless they have made a special effort to study beyond their training. I’ve run into a lot of physicians who make this assertion, but, based on my training and expertise, they don’t know what they don’t know, e.g. one OB/GYN was convinced that lactation made a woman iron deficient through loss of iron in breast milk. So, taking objective data on medical school nutrition education and my subjective experience encountering frequent individual hubris, I pulled a Dunning-Krueger mention out of my hat. I think I should have opted for the rabbit.

    In terms of what to teach, there is a lot of authoritative material to draw upon. The 1985 IOM report that started setting a standard for nutrition education (http://www.nap.edu/openbook.php?record_id=597). Current, direct online education from the University of North Carolina (http://www.nutritioninmedicine.net/neppphp/NeppPortal.php) created by physicians who are nutrition experts (and some Ph.D.s sprinkled in for flavor). A good article on specific medical school success stories and lots of other info from 2010 (http://pen.sagepub.com/content/34/6_suppl/40S.full.pdf+html). There have been some great symposia too, but I haven’t checked if you can access those without a subscription.

    I still think of this study every time someone goes overboard talking about vitamin D being non-toxic (http://ajph.aphapublications.org/cgi/reprint/85/5/656.pdf). If I remember the story rights, it seems some small dairy had a kickback scheme going on with a vitamin D supplier where the dairy was massively overbuying vitamin D and dumping it all in the milk.

  68. JPZ says:

    @nybgrus and Chris

    OK, I have a reply on the way, but I forgot about the 3 links rule (I gave several examples about medical nutrition education info). We’ll see when it gets out of moderation.

  69. JPZ says:

    [I just figured out how to do this. You'll just have to wait for the links.]

    @Chris

    Dang, I failed my hipster test! ;)

    @nybgrus

    Yep, what I wrote was pretty much impossible to follow. I can look at it now and see the stream of consciousness, but the words make no sense. I took your comment about “understanding of nutrition” and ended up commenting on a half-dozen other things. Mia culpa.

    The Dunning-Krueger mention was incorrectly tied to your assertion that you may have an understanding of nutrition but not the ability to create the appropriate diet to correct nutritional problems. But, Dunning-Krueger doesn’t even apply to you given your appropriately phrased comment. It only applies when I make a different extrapolation, i.e. if a medical student or physician in the US asserts that they understand nutrition, odds are 3:1 against that being true – unless they have made a special effort to study beyond their training. I’ve run into a lot of physicians who make this assertion, but, based on my training and expertise, they don’t know what they don’t know, e.g. one OB/GYN was convinced that lactation made a woman iron deficient through loss of iron in breast milk. So, taking objective data on medical school nutrition education and my subjective experience encountering frequent individual hubris, I pulled a Dunning-Krueger mention out of my hat. I think I should have opted for the rabbit.

    In terms of what to teach, there is a lot of authoritative material to draw upon. The 1985 IOM report that started setting a standard for nutrition education (link). Current, direct online education from the University of North Carolina (link) created by physicians who are nutrition experts (and some Ph.D.s sprinkled in for flavor). A good article on specific medical school success stories and lots of other info from 2010 (link). There have been some great symposia too, but I haven’t checked if you can access those without a subscription.

    I still think of this study every time someone goes overboard talking about vitamin D being non-toxic (link). If I remember the story rights, it seems some small dairy had a kickback scheme going on with a vitamin D supplier where the dairy was massively overbuying vitamin D and dumping it all in the milk.

  70. Chris says:

    JPZ, I used it because he has been known to pull the “Pharma Shill Gambit.”

    I also noticed you have something he does not: an mind open to new information.

    (I wonder what kind of answer you’d get from Gary Null about Vitamin D being non-toxic? Oh, never mind, it is a beautiful fall day and I am going to go get some Vit D naturally, and hopefully without burning.)

  71. nybgrus says:

    @JPZ:

    Phew! I am glad that I wasn’t missing something glaring. As I said, I respect your posts and opinion, and so when you start pulling D-K out at me, I have to sit there and reflect… and I just couldn’t quite put my finger on it. Thank you for acknowledging that my comment was not D-K worthy, since I do try and think carefully about what I say and write and how I do it as well.

    @Jeff:

    Once again, the point is missed. As Squirrelelite pointed out, it is much more complex than “Me take VitD. Me no get cancer.” (And BTW, Squirrelelite I don’t have institutional access to that article either so sorry but I can’t help there). The point of my entire post was that yes, VitD does seem to have some interesting and potentially useful anti-cancer effects. But it almost certainly has other effects we haven’t yet been able to suss out. And note that the studies follow serum levels of VitD – how does that translate to oral dosages? That WILL vary from person to person and formulation to formulation. And what is the absolute risk reduction? Is an NNT of 1000 worth it if the risk for, say, ureteric calculi increased such that NNH is 100? How do you stratify risk for people more likely to be stone formers? How do you identify those more likely to be stone formers? And then toss in a maybe increased risk of pancreatic cancer? Let me tell you, if I decreased my absolute risk of breast, prostate, and colon cancer at the expense of increasing pancreatic cancer – I would choose NOT to take the intervention. Prostate and colon I can get check ups for. Prostate is a disease of old age and absolute risk is low and the course is usually indolent – if I were to get prostate cancer after 65 chances are much greater I’d die with it than from it. Colon cancer – I’ll be getting my regular colonoscopies, thank you. And breast? That is such a wonderfully survivable cancer I put that as a feather in the cap of modern medical science. But give me pancreatic cancer and I am dead inside of 12 months. No thank you.

    The point I have been trying to make is that willy nilly supplementation, even in the face of studies showing a cancer benefit is not cut and dried like you wish to make it out to be. An article in sciencedaily doesn’t change that.

    And as for the whole greens and 9p21 effect…. hardly surprising to me. They haven’t demonstrated that the greens interact on an epigenetic or proteomic level. They have demonstrated that eating healthy and being healthier can mitigate some of the genetic predispositions for CV disease. To me that is hardly newsworthy. The problem is that many people, like yourself, take that and extend it out much further than the data warrants. And do note, my diet “advice” if you will, is basically exactly in line with the study. But neither you nor I can say anything more than that without making evidence free assertions, most of which aren’t supported by logic and biological plausibility.

  72. squirrelelite says:

    @nybgrus,

    Thanks for a more clear and articulate statement of the viewpoint I think we both share.

    I was also struck by Jeff’s statement that “diet and nutrition can have a profound effect on human health.”

    As I thought about it over the last day, I realized that the word “profound” sounds significant but is actually very vague.

    Certainly diet and nutrition (and other lifestyle factors like exercise) are important in preventing or controlling conditions like cardiovascular disease and type II diabetes. But, once you get a disease like cancer, that profound effect becomes a lot less profound. As an illustrative anecdote (not evidence), I will always think of my sister-in-law. She was diagnosed with an aggressive form of renal cell carcinoma almost two years ago. She tried a combination of dietary changes including an organic vegan diet and was very concerned about the acid-base diet effect stuff that Robert Young espouses. She was also drinking Essiac tea and had a friend who kept her supplied with homeopathic remedies.

    She had one round of chemotherapy which reduced the size of her tumor but not enough to make it operable. She didn’t tolerate the side effects of the chemotherapy and decided not to undergo another round.

    The chemotherapy at least had a measurable effect on her condition. But, if any of those other interventions had a “profound” effect on her cancer, we couldn’t detect it. I think in the last few weeks of her life even she had realized all these interventions weren’t really helping her. She died about six months after her cancer was diagnosed.

    I also second your thoughts about colon cancer. My father was diagnosed during a colonoscopy about six years ago. There were actually two different types of cancer cells detected. He underwent the full round of chemotherapy and radiation treatments and seems to be cancer free now. At least he is alive and generally well now. I have had two colonoscopies (both negative) and will be due for another one in another year or so.

    But, today I need to get to work early so I can get my flu shot!

  73. Jeff says:

    @squirrelelite: I’m no fan of homeopathy, vegan diets, or Robert O. Young’s PH theories, But there is research showing certain natural compounds could be useful for the prevention or treatment of cancer:

    Epigenetic Changes Induced by Curcumin and Other Natural Compounds

  74. Jeff “diet and nutrition can have a profound effect on human health”

    Certainly, aid workers are projecting that 800,000 children may die from famine in the Horn of Africa.

    How much are Americans spending on vitamins that are useless or unproven each year? Is it possible that money could be better spent on proven diet and nutrition remedies (otherwise known as “food” and “clean water”) that will save lives.

    I’m all for folks eating balanced meals and even taking vitamins when there is good evidence it will help them.

    But beyond that… really? We should spend bunches of money on supplements in the hopes of maybe, possibly, preventing cancer when we are 65, instead of taking that cash and sending it to someone who may starve, or putting it into education or something else meaningful? Who knows, that kid you feed or educate may be one who comes up with a kick-ass treatment or solid preventative method for cancer someday.

    Okay, that was my vent.

  75. JPZ says:

    @Jeff

    “I’m no fan of homeopathy, vegan diets, or Robert O. Young’s PH theories, But there is research showing certain natural compounds could be useful for the prevention or treatment of cancer:”

    Then accept the data in context – especially cancer-related findings. A study that links a nutrient to a mechanism that might be used by various cancers does not mean it prevents cancer (possible syllogism fallacy). An epidemiological study showing a correlation between intake of a nutrient does not mean it prevents cancer (correlation proves causation fallacy). There are many interesting leads for anti-cancer nutritional products, but few actual clinical trials proving efficacy.

    Epigenetics is a fascinating and complex field. Where once we focused on feeding methyl-donors (e.g. folate) to methylate (block) the promoters of cancer promoting genes, now we worry about hypermethylating promoters on cancer suppressing genes. That is a massive oversimplification, but it does illustrate the dangers of assuming early scientific findings are sufficiently complete to recommend nutritional modifications.

  76. JPZ says:

    OOPS

    “An epidemiological study showing a correlation between intake of a nutrient AND CERTAIN TYPES OF CANCER does not mean it prevents…”

  77. Jeff says:

    JPZ: I did not mean to imply that one study proves a single nutrient (like curcumin) prevents cancer. But there does seem to be sufficient evidence for interested consumers to consider supplementation.

  78. JPZ says:

    @squirrelelite and nybgrus

    I am starting to understand the frustration with Jeff’s responses.

    @Jeff

    OK, having an effect on ten mechanisms (many with dubious connections to cancer) does not mean that the nutritional product has anticancer effects. Tens of thousand drug candidates a year show efficacy on a disease mechanism but never make it out of animal studies. Mechanisms that sound all “sciency” do not equal efficacy.

    A PubMed search on “curcumin” and “clinical trial” turned up 55 references – mostly unrelated to our discussion (pharmacokinetics, reviews, etc.). All clinical trials I could find were open-label (no control group) and most often used 8 g curcumin/day – equivalent to 267 g/d tumeric (3% curcumin – http://www.ncbi.nlm.nih.gov/pubmed/17044766). The drop out rate was pretty high due to GI complications in some studies, and the efficacy was either expressed as biomarkers (i.e. not actually testing the anti-cancer effects) or had very modest preventative effects (e.g. slower increase in abberant crypt cells – you still get cancer, it just takes a little longer). The data are a little better on using curcumin for stomach upset (http://www.nlm.nih.gov/medlineplus/druginfo/natural/662.html).

    The very pro-dietary supplement Linus Pauling Institute at Oregon State University did a reasonably good review of the data and found insufficient evidence to support use of curcumin at this time (http://lpi.oregonstate.edu/infocenter/phytochemicals/curcumin/). You quoted a webpage at Life Extension Foundation on curcumin. They sell a 400 mg capsule curcumin product with 60 capsules at $28.50 for the bottle. At 20 capsules a day to get 8g/d (the dose most often studied), that is going to run you $9.50/day for something they told you is supported by lots of evidence. Or, you could take less curcumin and hope (yes, only hope) that an untested dose isn’t sub-clinical for cancer prevention.

    THAT is why you have to be careful where you get your information.

  79. nybgrus says:

    @squirrelelite:

    Thanks for the kind words. And I am very sorry to hear about your SIL.

    You make a good comment on the use of “profound.” Makes me think of the creationist use of “kind” – vague enough to fit whatever you need when you need it.

    And yeah, colon cancer is imminently curable if caught early. I am glad to hear your father is doing well after his cancer. I worry about my SO’s father though – he is at prime risk and absolutely refuses to get a colonoscopy. My holiday time will be spent working carefully and diligently to try and convince him.

    @michelle:

    Also very good points. It reminds me of this classmate I have. She is pretty daffy and honestly I have serious doubts as to her ability to pass the upcoming USMLE we have to take. She was a psych major in her undergrad and wants to go into psychiatry (nothing wrong with that). But she also thinks that an excellent project to spend time and resources on would be to go to the most severely stricken developing countries and give them psychological counseling because, as it turns out, depression and other psychiatric disease is the 6th or 7th leading burden of care in such regions. Somehow getting out there and giving them resources for clean water, clean and regular supplies of food, and basic medicines doesn’t seem very important to her. She is absolutely convinced her idea is better. I joke around after some beers with others classmates about how much sense it makes to counsel people about the grief of losing a child from diarrhea, instead of giving them clean water and antibiotics to prevent the death in the first place. As they say, when you have a hammer everything looks like a nail.

    @Jeff:

    What exactly are you arguing for? Nobody is trying to take away your turmeric. I believe I’ve even said it before – I actually cook with it rather often.

    And nobody is trying to say we shouldn’t research more or even that it would be a bad thing to advise patients to add into their diet. But if you are talking about concentrating it to enable taking mega-doses, you are far ahead of safe recommendations. The fact that it has been demonstrated to actually work on an epigenetic level means it very likely will have pretty significant effects on gene expression. You have no idea what that would lead to in very large quantities. Neither do I. But messing around with epigenetics gets you to levels of complexity that would make me nervous to do without a lot more knowledge and data on it – specifically good clinical trials.

    Furthermore, this falls well into the realm of pharmocognosy and even then, as a single example does not justify the entirety of the supplementation market. I keep making broad points using specific examples to support my stance and my claims. You keep coming in, dropping a tiny line with a single bit of good evidence (sometimes), and expect that to comment on the greater conversation? I’m not sure what your tack or your point is…..

  80. tmac57 says:

    Overheard at dinner:
    “There are thousands of studies out there showing that natural substances could be useful in medicine,but no one wants to spend money studying them because they can’t make a profit!”
    Hmmmmm?

  81. nybgrus says:

    @JPZ:

    Yes, you are indeed seeing the frustration. I haven’t even done the in depth searches you just did in regard to curcumin. But I know enough about the way such things tend to work that I can still speak intelligently on the topic. You further hammered in the specific details – but I was attempting to discuss the overarching ideas here. Every specific example is just that – an example of the bigger story.

    But thank you very much for demonstrating, yet again, that for every tidbit that seems promising and interesting that Jeff feels is so “profound” digging deeper demonstrates my point quite nicely.

    Well, the first years are just about to finish the last exam of the year and there are some jugs of beer to be purchased in celebration so I shall be off. I look forward to more specific examples that miss the point from Jeff, more excellent analysis by JPZ, and more insight from squirrelelite when I return :-D

  82. JPZ says:

    @Jeff

    nybgrus said, “I keep making broad points using specific examples to support my stance and my claims. You keep coming in, dropping a tiny line with a single bit of good evidence (sometimes), and expect that to comment on the greater conversation?”

    nybgrus said it very well. You may benefit from thinking on the big picture. Or, if your assertions are based on beliefs that do not require scientific substantiation, then it really doesn’t help you or I to have this discussion. Beliefs and faith are individual experiences, and challenging faith only reinforces it.

    @everyone

    Is there a term for expressing one’s controversial beliefs in groups in order to solicit negative feedback that reinforces your beliefs? It is so common online (and elsewhere) that I would be surprised if it was not a defined behavior.

  83. nybgrus says:

    @JPZ:

    Thanks for the kind words again.

    I believe the word you are looking for is troll. Perhaps there is a better one that I am unaware of though… anyone else know a good one?

  84. Jeff says:

    JPZ: I agree with your characterization of the post from The Linus Pauling Institute. Here’s a more recent review:

    Curcumin as a therapeutic agent: the evidence from in vitro, animal and human studies

    It does mention a multicenter, randomised,
    double-blind, controlled trial using curcumin.

    The review concludes:

    Its non-toxicity and good tolerability in human
    subjects, in combination with strong promising results from
    cell line, animal and early human clinical studies, support
    the ongoing research and development of curcumin as a
    preventive and disease-modifying agent.

    Of course much more research is needed to prove if curcumin could treat or prevent any condition, including cancer. I merely stated that enough data exists for the interested consumer to consider supplementing with it.

  85. Jeff says:

    Incidentally, Life Extension Foundation has posted takedowns on both the Iowa Women’s Health Study and the SELECT VitE/Selenium Study. I won’t use links in case the filter holds them up. Those interested can copy and paste these:

    1. LEF.ORG: Findings from Flawed Study Used To
    Discredit Multivitamin/Mineral Supplements

    2. LEF.ORG: Synthetic Alpha Tocopherol
    Shown to Increase Prostate Cancer Risk

  86. Chris says:

    I have mostly seen tumeric/curcumin being studied as a chemotherapy agent, not as food for cancer:

    Curcumin: A review of anti-cancer properties and therapeutic activity in head and neck squamous cell carcinoma.
    Wilken R, Veena MS, Wang MB, Srivatsan ES.
    Mol Cancer. 2011 Feb 7;10:12. Review.

    A quote from that free online article:

    Curcumin has demonstrated in vivo growth suppressive effects on head and neck squamous cell carcinoma using nude mouse xenograft models. The lipophilic nature of curcumin and relative insolubility in aqueous solutions, combined with short half life and low bioavailability following oral administration has presented a significant challenge in developing an effective delivery system for its use as a chemotherapeutic agent.

  87. @JPZ and nybrgus, how about “cyber-martyr”? in the sense of one who intentionally elicits mistreatment in order to further a cause, online. Possibly “devotee” or “disciple” would be appropriate. Of course every time a SBM reader goes over to AoA to state a contrary position on vaccines they could be doing the same thing.

    warning off topic, my apologies

    @nybrgus, I don’t want to be ungrateful for you general support of my comment, AND I do agree that one has to prioritize essentials such as food, water, etc in a crisis situation, but I’m surprised that you friend could not make a good case for increased psychiatric care in developing countries. Please relay a couple of hints to her from me.

    someplace to start – http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1489826/

    the just of it…

    “The fact that mental disorders are among the top ten causes of disability in Africa and the rest of the world, and that their contribution to the overall burden of disease is going to rise, makes a strong case for giving them the attention and resources they need. Policy makers need to stress the cost-benefit ratio of treating persons with mental illness and making them active participants in national economic activities.”

    Me here

    Consider that around 1% of any population will have schizophrenia, 2.6*% bipolar disorder, these are folks who, left untreated, will often place increased demandas upon security personnel, emergency medical personnel, as well as family members and will be able to contribute far less to society or the care of their children.

    This could lead one to consider that children who are placed in orphanages or live on the streets in developing countries (or foster care and streets here at home) have a disproportionately high risk of having a family history of mental illness. This suggests that increasing mental health services may decrease demands to care for homeless children, lower crime rates (from street children and the adults they grow into) and increase those children’s health/education outcomes.

    I’m sure there’s more, but the general idea is that one can not build a stable society purely by providing essentials in a crisis, at some point, to prevent future crisis, one needs to build a stable health infrastructure. Mental health care is an important part of that infrastructure.

    My apologies if I’m coming across soapboxy, my family history is in play here.

  88. Jeff says:

    I think JPZ might find agreement with Dr. Mark Hyman’s excellent post on supplement use by participants of the Iowa Wommen’s Health Study:

    http://www.huffingtonpost.com/dr-mark-hyman/vitamin-dangers_b_1018430.html

  89. JPZ says:

    @nybgrus and micheleinmichigan

    Thanks for the leads! Its called the martyr complex (http://en.wikipedia.org/wiki/Martyr_complex).

  90. damn, in my previous post it should be “gist of it” not “just of it”. I hate it when I unintentionally torture the English language.

  91. nybgrus says:

    martyr complex…. yeah, that fits.

    @michele:

    My intent was not to say that psychological care is not important – it most certainly is. But in a situation of limited resources (money, supplies, and manpower) why would you focus on a project that will have such a limited and transient effect size? The essentials are exactly that – essential. And if you look at developed nations, you will find that the burden of disease from psych issues is higher on the list than in developing nations. That is because Maslow’s hierarchy of needs has been met, and those can take precedence. I personally think that the state of mental care in developed nations is deplorable. But in those countries where having a stable water supply that won’t make you severely ill or kill you, that is not only a priority, but much of the psychological burden will be decreased at the same time. I’ll also add (since in re-reading it wasn’t particularly clear) that she wasn’t talking about providing anti-psychotics to schizophrenics. She was referring to purely psychological counseling (like CBT and coping techniques) to enable people to deal with the horrible conditions in which they live. But honestly, even if she were talking about anti-psychotics, I would still rate that as a very low priority in these situations. Providing mosquito netting and education about malaria, which affects 300,000,000 people in Africa and leads to 1,000,000 deaths per year (mostly in children) is simply a more effective use of resources.

  92. nybrgus “I’ll also add (since in re-reading it wasn’t particularly clear) that she wasn’t talking about providing anti-psychotics to schizophrenics. She was referring to purely psychological counseling (like CBT and coping techniques) to enable people to deal with the horrible conditions in which they live.”

    Actually, I figured that, which is why I thought she needed a hint. :)

    “Providing mosquito netting and education about malaria, which affects 300,000,000 people in Africa and leads to 1,000,000 deaths per year (mostly in children) is simply a more effective use of resources”

    Oh well, this is the point were you have to start looking at actual numbers, which I don’t have the time or talent to do. Certainly one should not choose anti-psychotics over mosquito nets. But the seriously mentally ill seldom wait around politely until one can work them into the budget. You worked in a hospital, I’m sure you’ve experienced that. The question is can one lower the burden on police, emergency medical care and child care budgets by increasing effective mental health services to the seriously mentally ill in developing nations? I suspect one could, so this ends up being a win-win in the budget, manpower, resources department. But there might be evidence to the contrary…

  93. JPZ says:

    @nybgrus

    Maslow’s hierarchy of needs is exactly what crossed my mind the first time you mentioned this idea. Have you shared it with your schoolmate?

    @micheleinmichigan

    Actually, as I was reading your comments I was agreeing with you in a different context. The need for mental health care among former child soldiers is going to trump a whole lot of other needs because the level of dysfunction can be so high. The number of men I saw passed out drunk in the streets of rural Guatemala would argue that a good alcohol treatment program would do more to improve the community than one year of a vitamin A supplementation program (hard as it is for me to admit that professionally). But in some place like Darfur, I don’t see bringing a mental health professional into that kind of dangerous situation until safety, food, water and shelter are covered. After the situation is stabilized, bring in LOTS of mental health professionals because those people have been traumatized. As for the individual with serious mental illness who should be treated before they are a threat to themselves and others in their 3rd world community, I don’t have an answer. Countries with 30% HIV/AIDS+ rates among pregnant women can’t find the pennies a day (Indian knock-off but potent meds) needed to stop transmission to her child. Bad situations exist, and they aren’t fair.

  94. nybgrus says:

    @michele/JPZ:

    I don’t broach much with this particular classmate. She once got into an argument with a friend of mine who is a 1st year and stated that parasympathetics arose from the thoracolumbar regions and that Horner’s syndrome can only arise from a Pancoast tumor. Both are verifiably wrong. But she insisted that my first year friend (who was recently elected to take over my role as Academic Officer) should shut up and listen to her because she was a second year and knew better. This was only about 6 weeks ago. Hence my concern that she may not even pass the USMLE we have to take in 2 months.

    And yes, I completely agree that mental health care would be very important and useful. And in fact, I would argue that better outcomes would be achieved by combining both “sorts” of interventions, if you will. The problem is that good mental health care is hard, time consuming, and expensive. That is why we don’t have anything one could remotely consider to be good MH care in the states (well, that and the stigma associated with it). And yeah, I have worked in a hospital – ER specifically – and seen exactly what happens to people with genuine mental illness and it really is very sad.

    So on a theoretical basis, I fully agree with you – and JPZ makes a very good point about the child soldiers and other incredible abuses these people suffer. But I am looking at things from a pragmatic standpoint in terms of what can actually be done and, well, “bang for the buck” if you will. Rolling out a CBT program, which will inevitably be extremely limited, poorly supported, cost a lot in manpower and money, and be extremely difficult logistically to roll out to large populations is just not as useful as basic medical needs and infrastructure. All I am saying is one has to walk before they can run.

    But in looking at developed nations, even ones like Sweden that have amazing health care including MH, we can see practical examples of how difficult it is to enact good MH care where infrastructure and stability exists. That’s all I am really saying in this complete (but interesting) tangent. :-D

  95. JPZ, good examples on the former child soldiers and substance abuse in Guatemala. I do think it’s important to clarify that I am talking generally about developing nations, not specifically regions in the midst of armed conflicts or crisis famine.

    What I saying is that there is a point were untreated mental illness consumes more resources and/or creates more risks (for example by increasing HIV or HEP transmission rates and the risks of the development of AZT resistant strains of HIV due to non-adherence.) than the cost of treating the patient for mental illness.

    Of course life isn’t fair or smart for that matter. We often end up focusing on the problem in front of us, regardless of the real cost or risks of a less visible problem. I just figure it doesn’t hurt to take a step back and consider what those real costs and risks might be, particularly if it helps me to set aside something frivolous (a $3 latte habit or a supplement that has very little evidence of being useful in the short or long term) so that I might contribute to something important.

    My apologies for the off topic comments.

    What I really want to know JPZ is if you agree with that Hyman article that Jeff posted. There’s a point were Hyman observes that obesity and malnutrition are linked in the U.S., due to the consumption of calorie dense nutrient poor foods. He seems to use this as an argument for supplementation.

  96. JPZ says:

    @nybgrus

    “Rolling out a CBT program, which will inevitably be extremely limited, poorly supported, cost a lot in manpower and money, and be extremely difficult logistically to roll out to large populations is just not as useful as basic medical needs and infrastructure”

    I should have clarified since it would be extremely difficult to roll out CBT as the treatment of choice in any of these situations. In Guatemala, perhaps an Alcoholics Anonymous model would work well and would cost nothing. As for child soldiers, I saw a version of play therapy being applied (“These children never had a childhood.”) in what was also their school. I think there were some costs for additional staffing. I think there are ways to address some mental health needs in these settings, but maybe not the majority.

    @micheleinmichigan

    Oddly enough, I remember discussing this concept in 1995 based on some Cuban data that indirectly hinted at this effect. But, yes, obesity is associated with higher rates of iron and vitamin D deficiency as well as a condition called sarcopenic obesity (muscle wasting more or less). It seems common sense right now when you frame it as people getting fat from eating junk food, but back in 1995, people laughed at the thought because they believed eating more low-quality food would still add up to sufficient nutrient intake due to volume. On an anecdotal note, a friend of mine teaches at a community college in Washington, and she has all of her students fill out a dietary analysis at the beginning of the year. She showed me some of the aggregate data after several years, and I was shocked at how strong the link between obesity and inadequate nutrient intake stood out.

  97. JPZ – the first time I heard about something similar was in Kazakhstan. We adopted my daughter from an orphanage when she was one. She was somewhat small on the growth charts, but she was sort of cubby. Our coordinator and the embassy doctor both pointed out that the kids from the orphanage were often kinda cubby (not obese) but anemic. That they were given a lot of cheap food (that was all the orphanage could afford) of low nutritional value. It wasn’t “junk food”, but porridge and bread just doesn’t offer the full spectrum of nutrients, also, not much outdoor time.

    Our ped’s test did show anemia, so she took polyvisol for awhile. The thing that amazed me was how hungry she was. She would eat anything we gave her and she ate more than I did. This was followed by a big growth spurt. I always wonder if the hunger was nutrient cravings or more psychological. Can’t really tell. She’s a healthy size now

    Regardless, I’m inclined to think the answer to malnutrition caused by diet (not something like pernicious anemia) should be treated with a change in diet when possible. Not taking supplements with your junk food.

  98. @nybgrus, Thanks for considering my arguments. here’s a link to an article about a small clinic in South Africa that supports HIV patients with mental illness. You might find it interesting. http://www.plusnews.org/report.aspx?ReportId=78476

  99. JPZ says:

    @micheleinmichigan

    “Not taking supplements with your junk food.”

    I don’t imagine that scenario happens all that often – kind of like alcoholics taking supplements proven to protect the liver or smokers using antioxidants. The obese person has developed very poor eating habits over some time. If they work with a dietician to improve their eating habits, they are still potentially starting out with one or more nutrient deficiencies. Some deficiencies take many months to resolve by diet alone, and the obese person is unlikely to be fully compliant with the better diet for some period of time. I feel a multivitamin-mineral supplement is appropriate in this case, perhaps with additional single nutrient supplements (iron, vitamin D, etc.) until those deficiencies are corrected. Even after those deficiencies are corrected and the dietary patterns improve, it may be prudent to continue a multivitamin-mineral supplement. If they fall back into poor eating habits for a week along the way (not at all unusual), other nutrients tend to deplete in a matter of days (e.g. vitamin C) and a multivitamin-mineral supplement would appropriately smooth over such irregularities. Perhaps that is a bit pro-supplement in tone, but I hope well within scientific support.

  100. nybgrus says:

    @michele:

    Of course. I am always open to new viewpoints and modifying my stance and thoughts based on the evidence. I don’t think we were too far off in our thoughts to begin with. But you do raise the very good point about actual DALYs associated and the downstream effects. To me that indicates that there may be very good reason to implement programs that offer both basic needs and psychological counseling in some sense. What I was (and still am) against is the rolling out of a psychological program separate and indepedent from other basic interventions. I really don’t think that would be particularly effective. But you do make a good point for investigating the inclusion of some psychological care in health and infrastructure teams.

    I’ll read the article when I get a chance. I have 9 or so friends coming over soon since we are doing full make-up for the Brisbane Zombie Walk and will be indisposed for the day. Appropriately enough it is a fund raiser for the brain institute :-D

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