Earlier this week, an article came out in the Business Insider regarding the lack of safety and efficacy related to all vitamin supplementation. The headline bemoans the very idea of supplementing with vitamins, righteously proclaiming, “we never should have started this” alluding, not so subtly, to the risk of developing cancer by taking any supplement. The article then goes on to quote a variety of studies, varying from observational studies to randomized controlled trials, on various vitamins. Fair credence is given to the size of studies quoted, types of study, and publication journal. It paints a grim picture of the entire supplement industry, seemingly with fair cause. Upon further investigation of the article, referenced studies, as well as context, it became apparent that in order to have a meaningful and necessary evaluation about this multi-million dollar industry, we need to be talking about the same thing so we aren't continually comparing apples to oranges. Of course, my own experience predisposes me to an inherent bias, just as a reader of this site, or a writer for a business magazine. Fortunately, my experience also affords me insights into the details of this industry; and as the saying goes “the devil is in the details”. The aim of this article then, is not to dismiss such articles as yet another case of “haters hating”, rather as any good scientist will attest, you must engage, validate, and validate again until you can shift results of a study from correlation to causation. Criticism of this review is not that it questions the validity and current model of vitamin access, rather that it fails to provide context, delineate between different uses, types, and dosages of vitamins, nor does the article standardize outcomes. All together this broad stroke analysis yields a reductionist conclusion that all vitamins, at all times are bad and/or useless.
Isn’t it interesting that a google search can yield two articles one saying vitamin B12 is good, the other saying vitamin B12 bad. This case of “alternative facts” is not always the result of false claims, instead both can be true in the right context, with a whole gamut factors that influence whether it’s “good” or “bad”. There seems to be a movement towards simplifying inherently complex matters. In this simplification, we lose details, details that can shift our understanding significantly. By categorizing all vitamins and natural supplements as the same, as well as their safety profiles, we are doing a disservice to the consumer. Depending on the condition and the vitamin in question, the duration of a supplement, dosage form, source of raw materials, delivery method and dose of a vitamin or supplement can vary significantly. All this is to say not all supplements are created equal! Some supplements do not need to be taken long-term, such as vitamin A, and should be discontinued after a specific period. Other supplements, such as iron, benefit from a baseline measurement of status to prevent overdosing. Some vitamins are ineffective with genetic mutations, or if they are in the wrong form. Benefit and safety are determined by the condition, form, and usage.
Some of the risks associated with inappropriate use of supplements are minor, while others can be significant; akin to the variability between over the counter and prescription drugs. These parameters of use have been identified for many vitamins (perhaps the breadth of knowledge is not as large as it is for pharmaceutical drugs, but it is growing exponentially); just because the use is specific does not negate the benefits that are available. Some of these benefits are therapeutic in nature, while other benefits are related to the maintenance of normal physiological functions. This approach requires us to shift our understanding of why we use supplements. If using supplements is an attempt at a silver bullet approach, essentially replacing pharmaceutical drugs with “natural” options only, then it will be misguided. Vitamin supplementation for prevention is present to restore physiological homeostasis no more, no less. The need for supplements is valid in certain situations, especially when the physiological mechanisms of the vitamin is well characterized; supplementation can have predictable upstream and downstream effects limiting risks. For instance, if you are depleted of vitamin D, in the winter, causing your immune system to suffer, supplementation, with the right vitamin D supplement, in the right dose, will restore this. The degree of supplementation required depends on the degree of depletion – one size does not fit all. What about therapeutic applications, you may ask – where the goal is not homeostasis, rather pushing one biochemical pathway over another? That's when we get into “therapeutic approaches” and the use of vitamins in this capacity should be subject to the same scrutiny and regulations proportional to its health impact. For example, “healthy” volunteers using a face cream with collagen for wrinkles does not have the same potential for health benefits and risks as taking vitamin A for scarring. So we really need to ask ourselves the following;
- What are we asking from our supplements?
- Is the form we are getting it in appropriate to answer the above question?
As the article accurately describes, the inception of modern
vitamin supplementation arose during a time when access to whole foods was limited, thus the incidence of vitamin deficiency was much more prevalent. However, the assumption that this is no longer an issue is simply not true, and ignores a number of key determinants to health. Vitamin deficiencies still exist. This is not only due to our dietary choices (what we eat), but also our dietary options (the quality of what we can access).We also need to consider the soil quality, GMO’s, modern farming practices, toxic load, and cost of natural/organic foods. Further deficiencies arise from the rise in incidence of many chronic conditions and drug use that impair nutrient absorption. For example, vegetarians who do not eat red meat are missing a significant food source of vitamin B12, which is involved in red blood cell production; this deficiency can lead to a megaloblastic anemia. Supplementation in these individuals is much more likely to be appropriate. The article does not delineate between appropriate use and inappropriate use of supplements. Study design must also consider if it is an appropriate use of the vitamin given the baseline status of subjects. In order to draw accurate conclusions – what was the vitamin status of the individual at the beginning of the study? What was the compliance with treatment? What other medications or conditions would alter the metabolism of the supplement? What form was given and how much?
It is also important to consider that many assumptions are made from observational studies. While these studies are not without their benefits, their results are simply correlations, and causation is in no way established because we cannot control for other factors that may contribute to the incidence of lung cancer, for example. This same argument can be made for outlining the benefits of natural supplements – the trends have to be substantiated with additional more rigorous study methods. The more rigorous we are with the literature, the more confidently we can manufacture products that reflect this.
One can see how easily individuals who are self-prescribing, can inappropriately take vitamins and supplements. It is important to note that this article was written by an American author, speaking to the regulatory climate in the United States, which does not evaluate the claims that are being made by companies on their natural health products. Many countries such as Canada, Australia, and European Union, do in fact have regulatory bodies that determine what can and cannot be said regarding the health benefits of many products. While these regulated systems are certainly not perfect, they provide a framework for a more appropriate understanding of what supplementation can do for you.
The conclusion drawn from the article denounce the use of any vitamins, but perhaps the message that the studies offer is much more to the fact that health products are not the benign products we once thought they were. They carry both significant benefits and risks when improperly used. Ultimately, it will require a 3 tier approach to ensuring these health products are safe for public use:
- Research and regulation: High quality research studies need to be conducted and findings validated. Standardizing the forms, dosages, and outcomes of vitamins is imperative as it compares apples to apples and allows researchers to come up with innovative solutions to problems. Then regulatory bodies need to ensure that products that use this research are not extrapolating without due cause. This is where misleading marketing becomes dangerous, as it promotes inappropriate use. When companies are beholden to consumers and regulatory bodies, public safety is prioritized.
- As industry leaders, it behooves product makers to ensure they are transparent and honest about their supplements and their benefits. Poor manufacturing practices, whereby multiple unlisted ingredients are added, poor or toxic forms, and a lack of quality control parameters, endangers consumers.
- Consumer education is imperative in self-care product model for natural products. Understanding why they are taking a supplement and what the impacts are will empower them to make better decisions about their health. Further, seeking assistance from trained healthcare advisors, who can modify a protocol to fit their needs, limits adverse reactions as a holistic approach is taken. That means you don’t throw the kitchen sink at the problem and hope for the best- rather you have a specific targeted treatment with a clear start and end point.
Rather than fear mongering with scandalous headlines that do not accurately represent valuable concerns, these articles would incite dialogue that is more meaningful, if results were discussed without extrapolating these results. As an industry we can certainly do better, similarly so can the reporting on this industry.