Vitamins and Supplements

How much is too much?

Cecily Kelly, M.D.

Recommended vitamins/supplements

Pregnancy Osteoporosis High cholesterol

Cold Prevention/Treatment Weight Loss Supplements Miscellaneous

Topics to be covered

Overview

Survey done by the National Center for

Complementary and Alternative Medicine found that 4 in 10 adults had used “integrative therapy” in the past year

How much do we use?

Vitamins

Fat soluble Stored in fat globules It is possible to get too much-hypervitaminosis

Vitamins A,D,E,K

Water soluble

Too much Vitamin B Worsen diabetic neuropathy

Too much Vitamin C Loose money

Vitamins B and C

Vitamin Deficiencies

Occurs in alcoholics

due to malnourishment Heart failure Muscle wasting Peripheral nervous

system problems Problems with thinking

Beriberi-thiamine

Pellagra-niacin

Tiredness, muscle

weakness, joint and muscle aches, bleeding gums, rash on skin, loss of teeth

Scurvy-Vitamin C

Vitamin D-rickets

Not seen in developed world because of

Adequate supply of food Many fortified foods

Deficiencies

Fat soluble

Vitamin A-nausea, vomiting, headache, dizziness, blurred vision

Vitamin D-excess may cause cardiovascular problems

Vitamin E-increase bleeding problems Water Soluble

Vitamin C-laxative effect Vitamin B6-skin problems and peripheral

neuropathy

Too much?

Has found poor

evidence to recommend routine use of Vitamin A, D, or E, multivitamins with folic acid, or antioxidant combinations to reduce the risk of cardiovascular disease or cancer

United States Preventative Services Task Force

Pregnancy

Calcium

Keeps bones of mom and baby healthy 1,300 mg/day age 14-18 1,000 mg/day age 19-50

Folic acid Brain and spinal cord development 600 mcg/day

Iron Prevents anemia in mom and baby 27 mg/day

Vitamins in Pregnancy

US preventive services task force recommends

supplementation of 400mcg to 800mcg daily for all women capable of pregnancy

Folic Acid

Most pre-natal vitamins do not contain enough

calcium and expectant mothers must get additional calcium through diet or supplements

Calcium

Osteoporosis

Women 51-70 (Men over 70) recommended

1,200mg/day Two divided doses-body only able to absorb

approx 500mg at a time Do not take with medication for reflux like

prilosec, nexium, omeprazole Calcium citrate or calcium carbonate Take with vitamin D which helps absorption

Calcium

Eight ounces of yogurt-300mg One cup of milk-300mg 1.5 oz of cheese-300mg 8 oz of fortified OJ-300mg

Food Sources of Calcium

Adults < 70

600 IU/day Adults > 70

800 IU/day Helps us absorb calcium Also can get from the sun

Vitamin D

Sockeye Salmon-800 IU 3 oz can of tuna- 150 IU Vit D fortified milk- 80IU OJ fortified- 80 IU Fortified yogurt-80 IU

Food Sources of Vitamin D

People typically get 300mg of calcium from

their diet daily With the use of sunscreen, long hours spent

indoors, or people who live in the northern latitude, overall decreased sun exposure causes pts to not get enough Vitamin D

Do I get enough?

Colon cancer Kidney stones Obesity Hypertension Osteoporosis Bone fracture

What happens if I don’t get enough?

>2500mg/day may increase the risk of

hypercalcemia and kidney problems Kidney stones- >2150 mg/day in

postmenopausal women Avoid coral or dolomite (a kind of limestone)

because they can contain heavy metals like lead

How much is too much?

Omega-3

Essential fatty acid that we must get from our

diet Fish Salmon Tuna Halibut Nut oils

What is it?

Crucial for brain development Involved in growth and development Shown to decrease risk of heart disease Decrease inflammation

Why do I need it?

The American Heart Association recommends

two servings a week of fatty fish, such as: Mackerel Sardines Albacore Tuna Large Trout Salmon

How do I get it?

American Heart Association

Adults with no history of heart disease Fish two times a week

Adults with coronary heart disease 1 gram daily of EPA and DHA

Adults with high cholesterol levels 2-4 grams daily of EPA and DHA

And what if I don’t eat fish…

Do not take more than 3 grams without a

physician supervision Side effects include fish breath, gas, bloating,

belching, diarrhea Use with caution if you take a medication to thin

your blood or have a bleeding disorder- omega-3 supplements can increase your risk of bleeding

Get supplement from an established company that certifies that their products are free of contaminants like lead, heavy metals, mercury

How much is too much?

Cold Prevention

Prevention

Might help immune function Most evidence (8 studies)

suggests that even in doses of 1 gram a day does not prevent colds

Treatment “Some evidence” that taking

high doses may decrease sx duration by 1-1.5 days

Vitamin C

Prevention

Only in vitro evidence (in the lab) that it stops the growth of the common cold

No reliable evidence that it can prevent the cold in vivo (in humans)

Treatment 9-24 mg elemental zinc started within 24-48 hrs

of symptoms to reduce severity and duration of colds (6 studies)-take every 2-3 hrs while awake

Other studies show no effect (5 studies)

Zinc

Prevention

In vitro (in the lab) research suggests it stimulates immune system

In vivo (in people) studies for prevention against the common cold has “consistently been shown to be ineffective” (9 studies)

Treatment “Some preparations” may reduce

symptom severity and duration possibly by about 10%-30% Different species Best evidence with Echinacea

purpurea

Echinacea

Prevention

May have immunostimulant activity and antiviral

If taken between November and February may have one fewer cold episode than patients taking placebo

Garlic

Patients who have autoimmune disease such as RA

(rheumatoid arthritis or lupus) may do worse with the supplements that “stimulate” the immune system

Echinacea-Ragweed allergies should not use-cross allergy

Vitamin C-high doses may increase risk of side effects Zinc-nasal spray withdrawn from market due to

permanent anosmia (loss of sense of smell) Garlic-adverse effects like bad breath and body odor,

interaction with warfarin (coumadin) causing increase in risk of bleeding

How much is too much?

Promotional material “developed by a teacher

who was sick of catching colds in class” Contains vit C, vit E, vit A, zinc, echinacea No proof it can prevent or treat a cold Not recommended

What about Airborne?

American ginseng- maybe beneficial Probiotics-maybe beneficial for respiratory infection prevention-more in

children Panax ginseng-might have immunostimulant effects and protect against

colds and improve response to flu vaccine Vitamin E-some evidence that it might help the body build immune

response with vaccination Andrographis Astragalus Elderberry- possibly use in treating the flu-antiviral and immune system

changing effects Goldenseal Pau d’arco, bee propolis, wild indigo, boneset, Siberian ginseng,

larch arabinogalactan Teas-elderflower, rose hips, goldenseal, chamomile, peppermint, slippery

else, ginger, Mormon tea, linden flowers, meadowsweet

Others

Flu shot every year-Usually starts August-

March Hand washing or alcohol based hand gels

Hand washing-2 min with soap and water “Some evidence that alcohol based hand gels,

which have 62% ethyl alcohol, lower the amount of cold-causing viruses on fingers better than water.”2,3

So what can I do?

Weight Loss Supplements

Ephedra (aka Ma huang)

May also be bitter orange or country mallow Weight loss of 2lb/month Caffeine Adverse events shown in 50 trials-psychiatric,

autonomic, cardiovascular, GI symptoms Another review showed 87 reports of

hypertension, abnormal heart rhythm, heart attack, stroke, seizures

Ten events led to death, 13 permanent disability-9 of those were at the recommended dosage.

“Increase Energy Expenditure”

Sale was ban by FDA in April 2004

Chromium picolinate

Studies of chromium and obesity show no difference between study group and placebo

Kidney failure is sometimes related to doses of more than 1,000 mcg a day

Uncertain safety profile

“Modulate Carbohydrate Metabolism”

Forms of soluble fiber

Guar gum Relatively safe, also 11 trials with this vs placebo

showed no difference Glucomannan

Trials show moderate weight loss, but only 20-50 pts in each trial

Psyllium Improved glucose and cholesterol, no differences

in weight loss

“Increase Satiety”

Hydroxycitric acid Linoleic acid Green tea Licorice Pyruvate Vitamin B5 Andl-Carnitine Chitosan Dandelion Spirulina Guggul

Others

“If there is strong evidence for a product’s

quality, safety, and efficacy, it may be reasonable to recommend that product and closely monitor the patient.”

None of these supplements meet this criteria. Ephedra should be actively discouraged Due to lack of efficacy, patients are

discouraged from using: chitosan and guar gum

So what does my doctor say?

Exercise.

Eat a balanced diet.

Get plenty of rest.

Other Random Supplements/Vitamin

s

Prevention-MAYBE EFFECTIVE Treatment of bladder infections- NO EVIDENCE Cranberries are suppose to inhibit bacteria from

adhering to the bladder wall It has not been proven that taking “AZO cranberry”

can prevent bladder infections 300 mL/day of Ocean Spray Cranberry Juice cocktail, 500mg/day of Buckton Scott’s Cran-Max capsules 400mg/day of Cranactin cranberry caps

Cranberry Extract

Probiotic Generally considered to be beneficial because

it produces vitamin K, lactase, anti-microbial substances

Many uses, mainly used to treat antibiotic-associated diarrhea, acute infectious diarrhea, irritable bowel syndrome relief

Side effects: flatulence

Acidophilus

Treatment of knee osteoarthritis GAIT trial-1583 participants May help with patients with moderate to

severe pain-GAIT trial showed 79% if patients in treatment group had 20% reduction or greater of pain

1500 mg Glucosamine 1200 mg Chondroitin Side effects-upset stomach

Glucosamine/Chondroitin

Treatment of sleep disorders Decreases the time it takes for people with a

primary sleep disorder to fall asleep Safe for short term use Did not help with how efficient sleep was or

quality of sleep Not effective for patients with secondary sleep

disorder Side effects include nausea, headache,

dizziness, drowsiness

Melatonin

Treat depression, anxiety, sleep disorders Some scientific evidence that useful for short

term treatment of mild to moderate depression

Side effects: sensitivity to sunlight, anxiety, dry mouth, dizziness, GI problems, headache

Interacts with other medications

St. John’s Wort

Widely used for memory impairment, dementia, ringing

in the ears, claudication Study of 3000 patients followed for 6 years that were

age 75 or older took 240mg a day found gingko ineffective in Reducing incidence of high blood pressure and in lowering

blood pressure Slowing cognitive decline

Can increase bleeding risk Raw ginkgo seeds-seizures and death Headache, nausea, GI upset, diarrhea, dizziness,

allergies

Gingko Bilboa

Federal Regulation of Dietary Supplements

The regulation of dietary supplements is different than that of prescription medications No premarket review needed No prior approval by FDA before marketed Do not have to provide evidence to the FDA

before the product is marketed that their supplement is safe, although they are responsible for making sure that it is safe and that claims are not misleading

Purity of supplements is relative

“Natural” does not always mean safe or

healthy Tell your doctor about any supplements or

vitamins you are taking Interactions with coumadin St. John’s Wort decreases effectiveness of

certain prescription drugs

Things to remember

1. Prescriber’s Letter

Vit D and Calcium Document #270102 updated Dec 2010

Prenatal Vitamins Document #270216 Feb 2011

Cold and Flu Self-Study Course #09029 expires Aug, 2012

2. Widmer AF. Replace hand washing with use of a waterless alcohol hand rub ? Clin Infect Dis 2000; 31:136-43.3. Sattar SA, Abebe M, Bueti AJ, et al. Activity of an alcohol-based hand gel

against human adeno-rhino-, and rotaviruses using the gingerpad method. Infect Control Hosp Epidemiol 2000;21:516-9.

4. NIH:National Center for Complementary and Alternative Medicine: http://nccam.nih.gov

5. University of Maryland Medical Center: http://www.umm.edu/altmed/articles/omega-3-000316.htm

References

Questions?

Cecily H. Kelly, M.D.Office 830-372-3300

1350 Ashby St.Seguin