COMMENTARY

Pricey Pee: Time to Regulate Vitamin and Dietary Supplements

Melissa Walton-Shirley, MD

Disclosures

July 18, 2018

Despite a lack of proven benefit and an association with harm in some studies, the obsession with vitamins and dietary supplements continues to fuel a multi–billion-dollar industry. In the United States alone, the supplement market was almost $30 billion in 2015. The global dietary supplement market is projected to reach $278 billion by 2024. Yet a review paper titled "Supplemental Vitamins and Minerals for CVD Prevention and Treatment" found no benefit for supplementation with multivitamin, vitamins C and D, calcium, β-carotene, or selenium.[1]

Furthermore, some antioxidant combinations (at least two of vitamins A, C, and E; β-carotene; selenium;  and zinc) and extended-release niacin were associated with an increase in all-cause mortality. A more recent meta-analysis in Circulation: Cardiovascular Quality and Outcomes concluded that multivitamins do not prevent cardiovascular disease (CVD).[2]  

Similarly, a JAMA publication found no benefit of omega-3 fatty acid supplementation on CVD risk,[3] yet Americans continue to love their fish oil pills.

Negative Data, Negative Impact

A US Food and Drug Administration (FDA) warning that biotin may interfere with lab test results is the only news to have had any real impact on supplement use by my patients. Despite its interference with troponin I, brain natriuretic peptide, and thyroid assays (affecting our ability to diagnose heart attack, heart failure, or thyroid disease), my patients have lamented, "But what am I going to do about my hair and my nails?" Thankfully, most of them get it and have thrown their potentially harmful biotin in the trash. That's not the case for vitamins C and E and other cocktails that continue to show up frequently on medication lists.

I sometimes find it helpful to explain to patients that anything in a bottle isn't natural, that early death and disease are perfectly natural occurrences, and that preventing them often requires "unnatural" approaches, such as surgery and FDA-regulated medications.

I advocate for truly natural approaches that are not found in the aisles of a "health food" store, such as the Mediterranean diet and walking. We should make an exception for pregnant women, who should follow evidence-based  recommendations for supplementation as directed by their obstetricians.[4]

Conversations with patients might be more productive if we understand that the obsession with alternative medication use is multifactorial. It can stem from a patient's need to exercise more control over treatment regimens, concerns with immediate availability or affordability of a treatment,  the influence of word of mouth, subjugation to false advertising, and the impact of true-true and unrelated outcomes.

Sometimes the patient has experienced or witnessed what they perceive to be (or what may indeed be) a bad outcome with traditional medicine.

Then, there are the mainstream-medicine haters who still find their way into hospitals and physicians' offices. It's that rare patient with arms crossed and lack of eye contact who decries that "all medications kill patients" while "supplements are harmless." Sometimes they are convinced that physicians directly profit from the prescriptions they write. The best we can do is to acknowledge that there are risks and benefits to every aspect of medicine and reassure the patient we will do our best to provide good, thoughtful care and take time to address their concerns. We should also take seriously the adverse outcomes that result from hospital-associated mistakes and the side effects of approved pharmaceuticals. Despite our best efforts, some patients will remain unconvinced.

Squirrel Extract and Others

A patient once brought two large paper bags of daily supplements to an office visit. Each of the 50 compounds was meant to ward off a specific disease. None had prevented her cardiomyopathy with a left ventricular ejection fraction of 30%. A patient dying of prostate cancer never saw the irony in continuing his decade-long habit of taking scores of multicolored tablets and capsules nightly. One patient with coronary artery disease stopped all of his prescribed medications in favor of a popular line of supplements, resulting in a thyroid-stimulating hormone level of 60 mIU/L, a blood pressure of 150/90 mm Hg, and a serum total cholesterol of 270 mg/dL.

Another patient with a history of supraventricular tachycardia brought powdered squirrel extract to the office. It had been ground up and placed in a tiny glass bottle that was corked and made ready for sale by the local iridologist. Anyone can go online and buy supplements that claim to grow hair, increase penis size, reduce wrinkles, and promote longevity. Anyone can become a vendor.

Imagine what could be accomplished if the monies spent on worthless supplements were used on high-quality foods, exercise equipment, dental care, health screening, and educating our children. Instead, patients are filling their toilets with very expensive urine and placing their faith in worthless and sometimes dangerous promises in a bottle.

It's time our medical societies and the FDA took a firmer stand on supplements. It won't change all minds, but the majority of patients are reasonable individuals capable of making informed decisions. With the advent of the electronic health record and the need to feed the hamster wheel of medicine with relative value units, we have less and less time with patients in the office setting. Incorrect assumptions regarding the benefits of alternative therapies and supplements are going uncorrected while folklore and hype continue to flourish.  We need a national campaign that addresses these issues because prevention of harm is just as much a part of medicine as is curing disease.

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