To Depend Upon Multivitamins and Supplements -- Or Not

The best way to get the vitamins, minerals, and other nutrients you need isn’t with a shopping spree at your local drugstore. It’s from food.  WebMD

"Digestion slows down during sleep, so taking your nutrient supplement late at night would not be associated with an efficient absorption."
"Fluid intake is especially important for the disintegration of the supplement tablet or capsule and for dissolution of water-soluble nutrients such as vitamin C and B vitamins."
Jeffrey Blumberg, professor of nutrition science and policy, Tufts University, Boston

"Multivitamins tend to do best when taken earlier in the day, as the B vitamins in them might stimulate metabolism and brain function too much for a relaxing evening or before bed."
Neil Levin, clinical nutritionist, NOW Foods

The issue is multivitamins, and who should take them along with other dietary supplements. Expert reaction is mixed, but mostly on the side of recommending supplements only for people with specific conditions; pregnant women for one group, prescribed folic acid to reduce risk of neural tube defects; children in developing countries where diets fail to provide sufficient vitamin A and iron.

Otherwise, according to recent studies insufficient evidence has been found to recommend multivitamin supplements to the healthy, average individual who eats a varied whole-food diet. On the other hand, taking too much of certain vitamins can be harmful. So, no, healthy people with a varied diet really have no need for dietary supplements such as multivitamins.

Of course the supplement industry, valued an an estimated $128 billion in yearly sales globally respectfully begs to disagree. And a 2011-2012 U.S. National Health and Nutrition Examination Survey saw 52 percent of respondents reporting the use of dietary supplements, a percentage of participation remaining unchanged from a similar 1990-2000 survey.

There is a useful place for supplements as a complement in nutritional intake for those with certain deficiencies who require help in meeting needed nutrient intake on a daily basis. For those who meet this criteria, those supplements should be taken regularly at certain times of the day that are both convenient and which promotes optimal absorption.

Debate around taking vitamins in the morning or at night confuses some people, but experts in the field agree that morning is the best time for multivitamin intake, along with any B vitamins. The timing should be consistent and the supplements or vitamins should be kept in a visible place to remind to take them, same time of day, every day. Vitamins and supplements are often prescribed for older people.

Most supplements are best taken with food with a view to reducing stomach upset, and to stimulate digestion and improve absorption. Iron, magnesium and fish oil supplements most commonly may cause digestive upset taken on an empty stomach. Fat-soluble vitamins A, D, E and K are absorbed better with a meal or snack containing a teaspoon of fat (almond butter, avocado) , as does a multivitamin containing those vitamins.

Preliminary research suggests that taking probiotics with a meal or 30 minutes before a meal could produce better effects than taking them after eating. It is elementary that hydration while taking a supplement or multivitamin is essential. Certain types of minerals change the "take with food" equation where chelated mineral supplements can be taken without food.

Chelation refers to a mineral bound to an acid so there is no reliance on stomach acid to break down the mineral. Nutrient duos include vitamin D to boost calcium absorption and vitamin C to boost iron absorption; these nutrients should be taken simultaneously through supplements or even better with whole food sources; iron supplements taken with a glass of iron juice for example, where vitamin C boosts the iron.

Calcium supplements should ideally be taken at a different meal than iron supplements or multivitamins since calcium can affect the body's absorption of iron, zinc and magnesium. The body absorbs calcium more effectively taken at 600 milligrams or less. Fiber should be taken at a different time from other supplements and medications to avoid interference with absorption.

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Calcium. “There really should be no reason that people should be calcium deficient,” says Angel Planells, a dietitian from Seattle. Known for the role it plays in making your bones stronger, calcium is found in dairy products like milk and yogurt. Women -- especially those who are likely to have osteoporosis -- may think about taking calcium supplements. But talk to your doctor first.
Vitamin D. This nutrient, made by the body from sunshine, helps you take in calcium and phosphorus, so it’s key for healthy bones and teeth. Older adults don’t make it as well, so supplements can help make you less likely to have bone loss and broken bones.
Vitamin B12. This is important for keeping blood cells and nerve cells healthy. Aging affects how well you take in and use B12 from foods, so if you’re over 50, it’s probably best to get your B12 from supplements and B12-fortified foods like cereals, as well as foods that are rich in it, like meat, low-fat dairy, and fish.
Folate. This helps prevent anemia. Spinach, beans, peas, oranges, fortified cereals, and enriched breads can have it.
B6. This helps your metabolism and immune system. You can get it in fortified cereals and soy products, as well as organ meats and whole grains.
Your body also needs these:
Vitamin C. Oranges, right? (And red and green bell peppers, along with other vegetables and fruits.) It may help protect you from cataracts, help wound healing, and possibly lower your odds of having certain kinds of cancer.

Magnesium. Among other things, it helps keep your blood pressure and blood sugar levels steady. It’s also good for your bones. You can get it from nuts, spinach, and dairy products, and it’s used to fortify some breakfast cereals. Experts aren’t sure how well it works as a supplement.
And here are some popular items you can find in the supplements aisle that you might talk with your doctor about:
Probiotics. Gut health is also very important for your immune system. Some studies show that probiotics -- living organisms like those found in yogurt -- help prevent some types of diarrhea and ease symptoms of irritable bowel syndrome.
Coenzyme Q10. Also called coQ10, this is made naturally in your body and found in most body tissues. It may help your immune system work better.
Melatonin. A hormone released mostly at night, it’s believed to help you fall asleep. The science on it is promising.
Fish oil. The American Heart Association recommends at least two servings a week of salmon and other types of fish with omega-3 fatty acids. In supplement form, though, no studies have shown that it protects against heart disease. Omega-3s also may help with symptoms of rheumatoid arthritis.

WebMD Feature, John Donovan --  Reviewed by Neha Pathak, MD on January 03, 2019

To Vitaminize Oneself -- or Not

"We take multiple different ones [supplemental vitamins], in combination with whatever prescription drugs we might also be taking."
"We've bought into the idea that these products are simultaneously miraculous and entirely safe."
"Wrapped in with all of that is the desire for longevity . . . to just feel good."
"It gets tricky to determine which ones [vitamins] have good science behind them and which don't."
Catherine Price, journalist, writer, Philadelphia

"What's the best available evidence? Is there good evidence that taking these things helps or improves outcomes?"
"There is very good evidence. People have studied this over and over and over again. And in otherwise healthy people, [vitamin supplementation] appears to do virtually nothing."
"It's not a definitive thing that they definitely increase mortality [people using antioxidant supplements]. But they shouldn't even have a hint of increasing mortality, because the whole point of taking them is to live healthier and longer."
"I don't have any skin in this game. I wish they worked. Who wouldn't?"
"It's a two-edged sword. They might think, 'I guess I don't need to eat properly anymore, because I'm taking these vitamins'."
"The best way to get your nutrients is through foods. If there's one [supplement] that has at least some evidence for benefit -- and likely no harm, unless used in mega-doses -- you could go ahead and take some calcium and vitamin D. But choose the least expensive you can find. And don't get too neurotic about it."
James McCormack, professor, faculty of pharmaceutical sciences, University of British Columbia

"B12 is another one that, as we get older, we may not be able to get sufficient food sources of."
"I don't think there's any evidence that an older person needs more vitamins [unless a specific health problem requiring supplemental nutrients exists]."
"I think people don't understand that they just take the supplements to be sure they are getting enough."
Stephanie Atkinson, professor, department of pediatrics, McMaster University

"There are the classic tea-and-toasters, where people [elderly retired on fixed incomes] are just having essentially tea and white bread with not much on it."
"Those are the people at really high risk for nutritional insufficiency."
"It's the purified capsules that really haven't shown to be beneficial [as opposed to an adequate, balanced diet]. Probably because there are multiple nutrients present in food, and recapitulating exactly which ones might be the best is kind of a false hope."
Dr. Mark Tarnopolsky, expert, neuromuscular diseases, McMaster University, Hamilton

A recent University of Alberta research team's goal studying whether there was evidence to support the belief that vitamin D substantially improves health outcomes, its devoted use reducing falls, fractures, rheumatoid arthritis, cancer and risk of early death led them to the conclusion that calcium-absorption vitamin D does have some benefit in the prevention of fractures and falls, but marginally. Of a study group of 45 to 57 people using vitamin D and calcium daily over a decade, one only would benefit from fracture avoidance. Additionally a small reduction in mortality risk was found in people aged 70 and older.      
Most people do not need to take vitamin supplements,  but in some situations, taking the pills may provide health benefits.  Image: Thinkstock

In searching for reliable scientific evidence to support the use of vitamin D supplements in the prevention of cancer, respiratory infections or rheumatoid arthritis or for the maintenance of mental well-being "no other effects are proven", the researchers stated. What they did discover was that on the evidence mega-doses of vitamin D could presage unexpected outcomes, inclusive of a potential increased risk of early death; now that's mind-fixing.

According to Statistics Canada, about 16 million Canadians, representing almost 50 percent of the entire population, made use of at least one nutritional supplement -- while in the U.S., dietary supplements are known to represent a $36-billion industry, amply demonstrating the generalized trust in the power of vitamins and dietary supplements for enhanced health and longevity. It isn't just vitamin D, of course, but the belief in marketing claims that antioxidants or omega 3s are hugely beneficial, burden our lives as well in the thought that they are disease-preventives and guard against premature death.

In genuine instances of vitamin deficiencies, the most common of which is scurvy or rickets, vitamin supplementation has proven to be hugely effective; in fact there are thirteen vitamins that the human body does require, to live healthily, that become confused in people's minds with the add-ons that are in fact, redundant if people consume a wide range of whole foods in moderation. Health Canada informs us that a balanced diet is capable of providing all the nutrients required to sustain good health for most people.

And it is people age 50 and up who most benefit from taking additional vitamin D. A 'moderate' daily dose of under 800 IU of vitamin D daily in combination with about 500 mg of calcium results in a reduction in fractures, osteoporosis, so that Health Canada cites a maximum daily dosage of vitamin D age 50 and up to be 4,000 IU as long as the users speak to their family doctor before embarking on regular supplemental use. The older we get the less able we are to synthesize vitamin D from exposure to the sun. And in northern climates like Canada's, winter exposure to sun diminishes our vitamin D intake.

B12 on the other hand is necessary to ensure normal nerve function and healthy red blood cells. Pernicious anemia can result from low levels of B12, a blood disorder causing fatigue and mental imbalance in thought and concentration. Again, it is older people whose absorption of B12 from foods becomes impaired, and even more so in the presence of regular antacid use. The propensity is of people geared feel that if the use of a vitamin is recommended, then perhaps increasing the dosage would be even more beneficial.

Yet the body can be overtaxed when people indulge in the belief that more is better, when it results in issues such as hypercalcemia; abnormal calcium levels in the blood as a result of taking excessive amounts of vitamin D. Too much vitamin A intake has been linked to bone loss, on the other hand, along with an increase in hip fractures. Dr. McCormack emphasizes that no absolute and consistent evidence can be relied upon that vitamin supplements will benefit healthy people.

Studies published in the journal Annals of Internal Medicine in 2013 found:

• taking a daily multivitamin for 12 years failed to slow cognitive decline in male physicians age 65 and older;
• high doses of multivitamins and minerals did not associate with reduced risk of a second heart attack, stroke or hospitalization for angina in people age 50 and older with previous myocardial infarction;
• a review involving over 400,000 community groups randomly assigned to multivitamin supplements or single or paired vitamins discovered no clear evidence of a beneficial effect on cardiovascular disease, cancer or death from any cause.

On the other hand, an Iowa Women's Health Study found that multivitamin use was associated with a 2.4 percent increased absolute risk in mortality when 39,000 older women were studied. The Cochrane collaboration produced a 2012 report on antioxidants covering 78 randomized trials in which 300,000 people were studied to find no evidence exists in support of the use of antioxidant supplements to prolong life. Those using antioxidant supplements, in fact, were found to be marginally likelier [1.03 times as likely] to die early as opposed to those not using these supplements for it seems that beta-carotene and possibly vitamin E and A appear to increase mortality while vitamin C or selenium do not.

Credit: © ISTOCKPHOTO.COM/MARCEL NIJHUIS

The Sunshine Vitamin

"This sun-phobic atmosphere has been promoted for so long. But the abstinence recommendation of not being exposed to one direct ray of sunlight for your entire life defies good logic."
"There is good evidence that the lower the latitude that you live [in the Northern Hemisphere], the lower your risk for high blood pressure, having a heart attack, multiple sclerosis, Type I diabetes, infectious diseases, cognitive dysfunction, and the list goes on."
"You essentially [your body] make no vitamin D before 9 a.m. and after 4 p.m. or 5 p.m., even if  you're at the equator with the sun shining brightly."
"Its just like everything else in life. You have to do it [exposure to the sun's rays] in moderation. And you need to understand the consequences of what you're doing."
Dr. Michael Holick, endocrinologist, Boston University Medical Center

For decades medical authorities have been warning people to stay out of the sun; have no direct sun contact, use Vitamin D supplements to obtain the requisite daily Vitamin D. At one time people were regularly exposed to direct sunlight throughout the course of their daily lives. The Industrial Revolution had the increasing effect of producing soot and smog and before long city landscapes were clouded with particulate matter to the extent that little sunlight penetrated. Children began presenting with rickets, and doctors across the Western world realized that lack of sun had warped growing bones.

The curative powers of the sun and of fresh air were noted by the ancients. The father of medicine, Hippocrates, treated various ailments with a regimen of direct sun exposure. In the late 19th Century, sunshine was prescribed as a treatment for tuberculosis, among other diseases. More latterly, the risk of skin cancer has led the medical community to warn people of the risks inherent in direct, prolonged exposure to the sun. But the key here is 'prolonged' exposure, not limited exposure. Any kind of exposure, however brief, was decried as too risky.

But although Vitamin D has been industrially added as a vital supplement to all manner of foods, most notably dairy products, research reveals that there are a myriad of benefits derived from direct sun exposure. Chemical changes occur when photons in sun penetration of the skin  takes place. The sun influences the creation of nitric oxide, causing blood vessels to relax, lowering blood pressure. Skin cells stimulated by UV radiation produce other hormones to modulate the immune system, and to produce beta-endorphin, making us feel good in sunlight.

Dr. Holick, specializing in vitamin D, sees the value in supplementation, but he also stresses that sun exposure is a requirement for optimum health outcomes. He explains that avoiding the sun may raise risk of other diseases like breast cancer, heart disease and colon cancer. His book, The UV Advantage: The Medical Breakthrough That Shows How to Harness the Power of the Sun for Your Health, recommends people receive five to ten minutes of direct exposure to the sun at least two to three times weekly.

He is a professor of medicine, physiology and biophysics at Boston University. And he also acts as the director of the Heliotherapy, Light, and Skin Research Center at the medical centre of the university. Many of his colleagues, long accustomed to warning patients off sun exposure under the fear that even minute exposure can damage DNA are yet to accept Dr. Holick's arguments fully.

A study out of the UK where light-skinned people were exposed to simulated sunlight produced an interesting effect. "There was some DNA damage, but what was remarkable was that at the end of the study, it looked like there were mechanisms at play to help correct the DNA damage", Dr. Holick pointed out.

Two studies from the Journal of the National Cancer Institute reported that those with daily sun exposure experienced a lower risk of non-Hodgkins' lymphoma. As well, survival rates were increased for patients with early-stage melanoma.

Even while the sun is associated with damage to the epidermis, small doses in exposure appear to effectively heal skin problems, as Dr. Bobby Buka, a dermatologist in New York points out. Inflammatory skin conditions like psoriasis, eczema and acne can be seen to improve when people are exposed to UV radiation for limited periods of time.

Vitamin A Deficiency and Cognition

"We have known for some time there is less vitamin A in the blood of people with Alzheimer's compared with people who have normal cognitive function. What we didn't know was how important it could be in early childhood development."
"Vitamin deficiency during pregnancy is much more harmful [to the fetus] than a vitamin deficiency later in life."
"If you give vitamin A supplements in the first month or two of life, you can reprogram the brain and restore most of the cognitive function. If you wait two months, the supplements don't work as well."
"The World Health Organization report says there are 250 million preschoolers in the world with vitamin A deficiency. In developing countries, vitamin A deficiency is quite common and likely affects many pregnant women."
Weihong Song, Canada Research Chair, Alzheimer's disease, University of British Columbia

New research shows that mice deprived of vitamin A in the womb may have higher levels of beta amyloid (here shown as plaque in the brain of an Alzheimer's patient). Medical News Today

In 2015, international researchers discovered a link between vitamin D deficiency and the onset and development of Alzheimer's and dementia, by studying and observing over one thousand, six hundred seniors for a period of six years. It is estimated that between 40 and 75 percent of all adults are deficient in vitamin D, representing a group of secosteroids responsible for the absorption of calcium, iron, magnesium, phosphate and zinc. Essentially vitamin D has a hormonal action.

Only a few foods confer the benefits of vitamin D, though the human body absorbs it through exposure to sunlight. Most people require the use of vitamin D supplements to boost the body's critical store.

Now, researchers at the University of British Columbia in Vancouver have published a study appearing in the journal Acta Neuropathologica, pointing out that vitamin A deficiency may trigger Alzheimer's disease late in life. Even mild vitamin A deficiency in animal models had the effect of increasing production of amyloid beta, protein fragments which form plaques in the brain. People with Alzheimer's suffer from amyloid plaques which smother and in time kill neurons as dementia steadily advances.

A new study has found that mice deprived of vitamin A before birth are more likely to develop symptoms of Alzheimer's disease. (Robert F. Bukaty/The Associated Press)

Gene mutations and environmental factors over a prolonged period of time cause Alzheimer's disease. Mice engineered with a mutated human gene to render them susceptible to Alzheimer's were used in this laboratory study which discovered that fetal malnutrition leads to learning problems that will last a lifetime. Deprived of vitamin A through their mother's diet, fetal mice performed poorly on tests of learning and memory when they reached adulthood.

And this was so irrespective of their being exposed to a normal diet directly post-birth.

Dr. Song and his research collaborators at the Children's Hospital of Chongqung Medical University in China "rescued" brain function in mice with vitamin A supplements applied directly after birth.

Brain health in the developing world and in remote parts of China and elsewhere in the world where food choices are limited, point out why those not obtaining sufficient vitamin A in the diet severely compromises cognitive health. Vitamin A can be found in fish and in brightly coloured fruits and vegetables, all of which may be in short supply in deprived areas where lack of essential foods and fruits deprive people of vitamin A.

"We have known for some time there is less vitamin A in the blood of people with Alzheimer's compared with people who have normal cognitive function," said researcher Weihong Song. "What we didn't know was how important it could be in early childhood development." Martin Dee / Vancouver Sun

The Wonder Vitamin and the Sun

Vitamin D has been latterly rediscovered as a wonder substance, an element -- a neuroregulatory hormone -- about whose full potential there is still much to be known, but which helps us to be healthy human specimens. People who live in the northern hemisphere have been shown to have insufficient amounts of that vital vitamin in their systems, since exposure to the sun is critical to to ability of all living creatures to produce vitamin D.

It is the healing vitamin. There is not yet complete consensus on its absolute, complete potential to make us healthy, but it has demonstrated an almost miraculous capacity to ease depression, increase healthy bones structure, improve brain function, enhance the health of hearts, and even possibly to prevent cancer.

Vitamin D is a fat-soluble vitamin that is naturally present in very few foods, added to others, and available as a dietary supplement. It is also produced endogenously when ultraviolet rays from sunlight strike the skin and trigger vitamin D synthesis. Vitamin D obtained from sun exposure, food, and supplements is biologically inert and must undergo two hydroxylations in the body for activation. The first occurs in the liver and converts vitamin D to 25-hydroxyvitamin D [25(OH)D], also known as calcidiol. The second occurs primarily in the kidney and forms the physiologically active 1,25-dihydroxyvitamin D [1,25(OH)₂D], also known as calcitriol [1].
Vitamin D promotes calcium absorption in the gut and maintains adequate serum calcium and phosphate concentrations to enable normal mineralization of bone and to prevent hypocalcemic tetany. It is also needed for bone growth and bone remodeling by osteoblasts and osteoclasts [1,2]. Without sufficient vitamin D, bones can become thin, brittle, or misshapen. Vitamin D sufficiency prevents rickets in children and osteomalacia in adults [1]. Together with calcium, vitamin D also helps protect older adults from osteoporosis.

 

When the sun withdraws seasonally many people experience wild mood swings, depression and no small extent of irritability. It's called 'seasonal affective disorder', affecting mood-susceptible people during the winter months. The health benefits attributed by science to vitamin D are unparalleled by any other vitamin. Its health and healing properties were known in ancient times, when exposure to the sun was known to treat epilepsy, paralysis, asthma, jaundice, bladder and colon diseases and obesity.

Sun exposure was indicated in the treatment and relief of scurvy and rickets in the 1700s, when sailors in particular onboard vessels for prolonged periods of time suffered from the lack of food known to aid in the production of vitamin D. It's how the British acquired the sobriquet 'Limey' because of the penchant for the British Navy to stow limes aboard, known to fend off scurvy onset. Sailors, infamously, began to experience brittle bones, their teeth would fall out and they would become ill from lack of vitamin D.

Without our exposure to the sun all living things would expire. In the late 1920s sun therapy was set aside when penicillin was discovered, followed by science discovering antibiotics used in the treatment of so many ailments that previously increased sun exposure was prescribed for. A wide variety of illnesses, from bacterial infection such as anthrax, cholera and dysentery, to tuberculosis. The influence of Florence Nightingale was responsible for hospitals at the turn of the century increasing window space to maximize sunlight exposure.

Direct exposure to sunlight for 15 to 30 minutes in midday is required for the absorption and storage of vitamin D, leading to good health. That exposure should be increased the further north one lives. It is not absorbed through glass, but only through direct rays of the sun in the out-of-doors. During World War I, sun therapy was used to treat wounds and prevent tetanus and gangrene from setting in. Sun therapy was used in the treatment of skin diseases, the nervous system, circulatory system, and ear, nose and throat ailments.

Fear of prolonged exposure to the sun at peak sunlight  hours during the day has led people to be warned they must use sun block. Sunscreen is fine once the required daily exposure to the sun has been achieved. Too prolonged exposure without sun block on t he other hand can have a determinedly deleterious effect on the skin, from burning to premature ageing and some forms of cancers.

A diet high in produce helps build up an internal sunscreen as it were, lowering sunburn opportunities. Alternatives to the use of sun block such as light, white body-covering cotton clothing and hats to cover the skin at peak sunlight hours works as well. An antioxidant-rich diet is another invaluable assist.

Recommended Dietary Allowances (RDAs) for Vitamin D [1]

Age	Male	Female	Pregnancy	Lactation
0–12 months*	400 IU (10 mcg)	400 IU (10 mcg)
1–13 years	600 IU (15 mcg)	600 IU (15 mcg)
14–18 years	600 IU (15 mcg)	600 IU (15 mcg)	600 IU (15 mcg)	600 IU (15 mcg)
19–50 years	600 IU (15 mcg)	600 IU (15 mcg)	600 IU (15 mcg)	600 IU (15 mcg)
51–70 years	600 IU (15 mcg)	600 IU (15 mcg)
>70 years	800 IU (20 mcg)	800 IU (20 mcg)

* Adequate Intake (AI)

Sources of Vitamin D

Food
Very few foods in nature contain vitamin D. The flesh of fatty fish (such as salmon, tuna, and mackerel) and fish liver oils are among the best sources [1,11]. Small amounts of vitamin D are found in beef liver, cheese, and egg yolks. Vitamin D in these foods is primarily in the form of vitamin D₃ and its metabolite 25(OH)D₃ [12]. Some mushrooms provide vitamin D₂ in variable amounts [13,14]. Mushrooms with enhanced levels of vitamin D₂ from being exposed to ultraviolet light under controlled conditions are also available.