Archive for the ‘supplements’ Category

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Which study should I believe?

Wednesday, October 26th, 2011

Vitamin E has this chemical structure

I just read the recent (Oct 12, 2011) JAMA article on "Vitamin E and the Risk of Prostate Cancer." It was a long-term, prospective, randomized study of 33,533 men followed in 427 study sites in the US, Canada and Puerto Rico. The investigators were from major academic centers, Duke, the Cleveland Clinic, Brigham and Woman's Hospital (e.g., Harvard) and the National Cancer Institute among them.

This was an impressive study of the effects of Vitamin E and/or selenium versus placebo that began in 2001 with the subjects being "relatively healthy men." Seven years after it began, in September 2008, the independent data and safety monitoring committee decided that the supplements should be stopped as there had been no positive results (reduction in prostate cancer detection) and futility analysis (a statistical tool) said the results were quite likely to be negative (more cases of prostate cancer). I hadn't heard of that term and found a medical website that discussed a number of reasons for ending a study prior to the intended date. I'll paste in the URL if you want to read a one-pager on what is called "interim analysis."

http://www.childrensmercy.org/stats/plan/interim.aspx

In this study, though the researchers stopped giving supplements and published an article (JAMA.2009;301(1):39–51) on the results to date, which showed a higher (but not statistically significant) number of cases of  prostate cancer in the groups receiving Vitamin E, selenium or both, they also continued following the patient group.

Prostatic cancer under the microscope

The later data, though July 5, 2011, was quite impressive. There was a 17% higher incidence of prostate cancer in the group taking Vitamin E. In most scientific studies a p-value of 0.05  is felt to be significant. That translates to a probability of 5% or less that whatever happened did so by chance. If the data calculates to a p- value of 0.01, there's a 1% chance this was a random occurrence. Here, after ~eleven years the p-value for Vitamin E increasing the chance a man was diagnosed with prostate cancer was 0,008. (I'll paste in a website that explains more of this stuff if you're remotely interested).   http://www.childrensmercy.org/stats/definitions/pvalue.htm

Why all the math and statistics?

Well, for starters, a few years back a large study showed the exact opposite, but in a highly selected group: men in Finland who were smokers. Another study, done with physicians as the subjects, showed no effect on the incidence of prostate cancer. A post by a physician harshly criticized the SELECT trial as part of a lengthy defense of supplements, but made sweeping pronouncements without supplying data or references to specific articles.

I read the articles, the blog post and the new study in detail. I know that medical research projects often come to conclusions that, a few years later, are "proven" incorrect. But I think this study was carefully done, had a clear-cut purpose in mind and included a large enough group of subjects that I'm going to believe its conclusions.

Plus I'm certainly not a Finnish smoker.

 

 

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Do I need to eat my words?

Wednesday, October 19th, 2011

Different choices for different ages

An old friend forwarded an article on vitamins yesterday, one that I read with special interest. It came from MedPage Today, an online medical news service for healthcare professionals that partners with the University of Pennsylvania School of Medicine to offer physicians continuing medical education credit (CME) for reading articles and then answering a few questions.

The article was titled "Vitamin Studies Spell Confusion for Patients" and extensively quoted Dr. David Katz fromYale's prevention research center. He is an adjunct Associate Professor at Yale's School of Medicine and an internationally renowned authority on nutrition. He comments that, based on the recent study I mentioned several posts ago, many clinicians say they've written off supplements for good.

Yet 50% of Americans take supplements; many take more than just a multivitamin.

Then Dr. Katz offers some caveats as I did, stating the Iowa study is "merely observational and can't prove cause and effect." He still recommends omega-3 fatty acids (AKA "fish oil") and vitamin D for most of his patients and adds calcium for women and prenatal vitamins and folic acid for pregnant women. otherwise he only uses vitamins when there are deficiencies.

A recent pole of clinicians found that 70% favor annual screening of specific vitamin levels to treat deficiencies. Which vitamins (and minerals) might be measured as part of an annual focused screening examination and whether medical insurance plans would cover such laboratory tests has not been delineated, as best I can find.

But I'm seventy, and articles from 2005 to 2010 in authoritative sources, talk about seniors needing much more B12, having multiple minor, but significant, vitamin deficiencies, and not eating well-balanced, healthy diets, even here in the United States, much less in other spots around the world. I'm lactase deficient and small-boned; do I need a calcium supplement?

clearly the best way to get your vitamins

I agree with Dr. Katz that eating a balanced diet would be a better answer, at least for those who are younger. The concept of "eating your colors," i.e., having multiple suit and vegetable dishes over the day which contain different phytochemicals as represented by the color of the food itself, makes great sense.

How many Americans do that at present or are likely to do that even if medical figures recommend such?

I regard this as an ongoing discussion. Dr. Katz is certainly correct in saying that vitamins have been shown to treat disease states, but not to prevent chronic disease. The surmise in the article in MedPage seems sound to me: vitamin isolates are less effective on their own and a full blend of antioxidants and phytochemicals (again, best found in those whole fresh fruits and vegetables, may be the key to obtaining maximum benefits.

This discussion is likely to go on and on, so I'll supply two URLs that may help you, in consultation with your own physician, make choices that are relevant to your nutritional status, age and degree of health.

http://www.uspharmacist.com/content/d/senior%20care/c/21981/

http://www.fda.gov/Food/DietarySupplements/ConsumerInformation/ucm110493.htm

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It's Yo-Yo time again

Wednesday, October 12th, 2011

take pills or eat right, is that the question?

 

 

 

 

A recent edition of The Wall Street Journal had an article titled "Supplements Offer Risks, Little Benefit, Study Says." It quoted a long-term study of Iowa women, uniform Caucasian and with a mean age of 61.6 in 1986 when the research began. This was not a prospective, randomized controlled trial (RCT), but a cohort study, i.e., a number of people grouped together for a particular reason.

When I Googled the original purpose of the research project I found the following statement:

The Iowa Women's Health Study (IWHS), started in 1986, is a cohort of 41,836 postmenopausal women aged 55-69 at baseline. The primary aims of the study were to:

1) Determine if the distribution of body fat (waist/hip) predicts incidence of chronic diseases, with the primary endpoints being total mortality, and incident cancers of the breast, endometrium, and ovaries, and

2) Determine to what degree diet and other lifestyle factors influence risk of chronic disease.

So who could resist this incredible pool of data?  I was intrigued to note the authors of this paper were from Finland, Minnesota, South Korea and Norway; three were PhDs and one had a Doctorate in Pharmacy + a Masters degree in Public Health. I somewhat doubt they were the originators of the IWHS.

I found other papers stemming from this study: one concluded that drinking lots of decaf coffee was associated with less type 2 Diabetes, another looked at rheumatoid arthritis, another at colon cancer incidence.

I renewed my long-expired membership in the American Medical Association this morning (it's very inexpensive for an older retired physician) in order to have access to the full article.These authors looked at vitamin and mineral supplement use in 38,772 of the women. I agree with their take on supplement use in general (it helps in those clearly deficient; the rest of us who take them do so in hope of preventing chronic diseases and lowering our risk of dying prematurely).

The data from numerous studies, in terms of mortality risk, has been inconclusive. There have only been a few RCTs (mostly looking at calcium supplementation and vitamin use) that have said it's good to take supplements. Others have said not only do they not help, they may harm.

I read the conflicting reports with a jaundiced eye, but this one has a lot of accumulated data and it's at least worth paying close attention to. The basic conclusions in this particular population set (white women in Iowa) were that calcium supplements are good, iron supplements are bad and the rest don't help.

There are a few, maybe more than a few caveats. This is an association, not a causation, although the authors tried to eliminate many of the possible differences between those who did and those who did not take supplements. The fact that this wasn't an RCT meant the two groups differed in a number of fundamental ways. This was not a study originally set up to test if supplements helped or hurt or neither.

Bottom line: the paper is impressive, but won't change my own use of supplements in any way

 

 

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Can there be long Life without Life?

Tuesday, August 30th, 2011

A "fountain with Youth" that's real

I was reading two articles, in our local paper last weekend when I realized I was channeling Yogi Berra and his famous quote, "It's déjà vu all over again. What's happened is a return to Herodotes, the Greek historian (5th century BCE) who told of a fountain in Ethiopia responsible for extraordinary lifespan and to Ponce de Leon, the Spanish explorer who traveled on Columbus' second voyage (1493) and described the Fountain of Youth, supposedly found in Florida.

Now we have a huge contingent of baby boomers (estimates in the 70 million range) who are about to reach 65 and don't want to grow or look older. The market for anti-aging remedies is currently about $80 billion a year and is expected to top $110 billion in the next four or five years. We live in a society that worships youth and many of our compatriots are being sold magic potions that some claim will prevent aging or at least most of its signs.

One of the articles had an amazing photo of Dr. Jeffrey S.Life, age 72, a body builder and author of a book titled The Life Plan: How Any Man Can Achieve Lasting Health, Great Sex and a Stronger, Leaner Body. You can buy this $26 book for $14.94 on Amazon, but I think I'll skip it.

Dr. Life's program includes diet, exercise and a healthy lifestyle; it also features, for at least some of his patients, injections of human growth hormone (at roughly $15,000 a year) plus testosterone.

The data on these hormone replacement regimens is, to say the least, not as rock solid as Dr. Life's toned torso. The NIH has a division called the National Institute On Aging (see link below), and the Geriatrician who heads this organization is solidly against widespread use of hormone replacement therapies.

http://www.nia.nih.gov/

What makes sense to me is exercising regularly, staying lean (or getting there) and stopping smoking. I noted that Dr Life's mentor died at age 69, a long ways short of my physician Dad's 94-year lifespan. Dad ran most days until his late 70s, stayed trim and quit smoking as a young doc when he realized he had three cigarettes going in three ashtrays in his three-room office.

lots of these out there

I think many baby boomers and others would like to find a magic bullet, a tonic or elixer that would allow them to eat what they want, do what they want and live to 100.

Until you show me a long-term, controlled study that points that way, I think we're as shy of the Fountain of Youth as we were in the days of Ponce de Leon or Herodotes.

Eat less and spend your money on a health club membership or a pair of running shoes instead.

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Should you take multivitamins?

Friday, July 29th, 2011

The best choice is on the right

Eight days ago The Wall Street Journal had an article with an intriguing title, "Multivitamins: Lots of Types, Lots of Label Confusion. The question was "do you really need a multivitamin?" and the answer was, "probably not, although much depends on your age, gender, diet and health.

I take a senior vitamin (I'm 70), 5,000 IU of vitamin D every other day, 500 milligrams of vitamin C and 2,500 micrograms of B12 a day. I also take another vitamin-containing capsule suggested by an ophthalmologist (as my Dad had macular degeneration and there's some data suggesting taking these vitamins plus zinc, selenium, copper, lutein and zeaxanthin can help prevent this disease).

The last two chemicals I mentioned are probably unfamiliar to most of you; but they're found naturally in your eyes, especially in the retina/macula. Zeaxanthin is the pigment that gives paprika  (made from bell peppers), corn, saffron, and many other plants their characteristic color.

The questions I asked myself for these vitamins today were firstly: what are the recommended daily allowances RDAs), the amount from food (and maybe added pills) that are sufficient to meet the nutrient requirements of nearly all (97-98%) healthy individuals in a group. And secondly: what are the tolerable upper intake (TUL) levels for these same vitamins.

Both these querys can be answered by looking at tables supplied by the Institute of Medicine (look at www.iom.edu). The IOM is an independent, nonprofit organization that works outside of government to provide unbiased and authoritative advice to decision makers and the public. It's been the health arm since 1970 of the National Academy of Science which itself was established by President Lincoln in 1863.

I'll just mention a few of the RDAs and TULs and stick to my age and gender. Remember B vitamins are water soluble, so for most of these there is no upper determined limit. Excess amounts should be excreted in the urine. That doesn't mean you can or should gulp an endless amount of these; to me it just means there is no data on adverse effects.

Vitamins that are fat soluble (A, D, E, and K for most of of us, CoQ10 for those who take this supplement {disclaimer: I know little about CoQ10 and have never taken it myself}), are different. Excess amounts may remain in the body and cause toxicity.

Vitmain C megadoses were advocated years ago by Linus Pauling (who won two Nobel prizes), but large, randomized clinical trials on the effects of high doses on the general population have never taken place and toxicity in some individuals taking high doses has been shown. The RDA for me is 75 mg/d and the TUL is 2,000.

I wondered if I were possibly pushing the upper limits of vitamin A intake, with 2,500 IU (international units) in my senior vitamin and 2,500 IU in the other multi I take, so I looked for the TUL and found it in IU format in the NIH's MedlinePlus website as 25,000 IUs.

Multivitamins are a $4.9 biilion/year industry, so I'd consult your own physician if you want to take them or any supplements.

 

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Vitamins & supplements: part 1

Tuesday, June 21st, 2011

The amazing mangosteen

I started reading the New York Times breaking news on my Kindle this morning and ran across a story titled "Support is Mutual for Senator and Utah Industry." The photo below the byline showed US Senator Orin Hatch at the HQ of one of his state's firms; this one puts out a $40 bottle of fruit juice. Well, that's a lot more than I usually pay (and I almost always buy fruit, not juice, anyway). But my interest was piqued, so I read the story and then did background research.

The fruit involved in the mangosteen, a name I vaguely remembered from my Air Force tour in the Philippines. It's been used in medicinal products in India and China for many years, but much more recently sold in mixed juice form in the United States with fairly incredible health claims (improves immunity, fights cancer, has anti-aging properties).

The Memorial Sloan-Kettering Cancer Center website says, "Despite claims by several marketers, the efficacy and safety of mangosteen products for cancer treatment in humans has not been established." They do mention that several small studies suggest it may be beneficial for halitosis, but also note at least one person who suffered a major side effect after prolonged use of mangosteen juice.

I was able to find a single randomized, double-blind, placebo-controlled trial that demonstrated some laboratory evidence of changes in immune function in a small group of 40 to 60-year-old  who took a mangosteen product that also contained multivitamins and "essential minerals" over a 30-day period. The study participants who got the combination product also felt their health improved.

So is this another expensive scam or will further study find we should all consider drinking mangosteen juice? Frankly I don't know, but I'd bet it's going to be hard to find out.

In March of this year, a Board Certified Family Practice physician who is now on the "mangosteen circuit" apparently spoke at the central Utah headquarters of the firm producing the miracle juice and claimed it had "anti-tumor," "anti-obesity," "anti-aging," "anti-fatigue," "antiviral," "antibiotic," and "anti-depressant" properties.

When asked how he knew the juice wasn't snake oil, he replied, "A company that is selling snake oil is not going to stay in business for 11 years and grow as fast as this company is growing."

That's strange. If I were asked a similar question I'd want to be able to show solid, evidence-based data generated by researchers who have no financial interest in the company.

sell very expensive juice with extensive but unproven health benefit claims

But the senator has apparently been the focal point for legislation that says nutritional supplement companies can bring out new products without FDA approval and make lots of general health claims without studies of safety or effectiveness.

Oh, and by the way, the New York Times mentioned that the doctor making all those sweeping statements has had his license to practice revoked on two occasions, for charges including prescribing excessive amounts of narcotics and for giving a weight-loss clinic signed, blank prescription forms.

He's not my idea of an ideal spokesperson.

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Post-exercise protein choices, part 1

Friday, June 17th, 2011

Maybe a few more pounds than this

I received a comment recently on one of my April 2011 posts asking if I still had the April edition of the Nutrition Action Health Letter (NAHL) published by the Center for Science in the Public Interest. My reader had lost her copy and wanted to know what protein supplement CSPI thought was reasonable. I found the info (it was creatine monohydrate with background research done by an associate professor at the University of Regina in Saskatchewan), emailed it to her and decided to review the whole topic in more depth.

I'm in the gym six or seven days a week for ~two hours or a tad more. I'm not trying to bulk up and never attempt the weights I see some of the really husky guys lifting.

As I walk in, I pass a lineup off supplements and see men especially, mixing up powders from large containers. I've never even considered the idea. I told my reader that the professor's credentials seemed reasonable, but she should ask her own physician before starting any supplements from a bottle. I also mentioned that I hard boil eggs, compost the yolks and eat the whites at meals that are otherwise low in protein.

But I reread the article in the April NAHL "Staying Strong: How exercise & diet can help preserve your muscles." The opening quote caught my eye. Miriam Nelson, the director of Tuft's Center on Physical Activity, Nutrition and Obesity Prevention said, "Muscle is the absolute centerpiece for being healthy, vital and independent as we grow older."

I turned seventy in April, so it made sense to pay attention to her. I'm already active and doing some "resistance training" as was recommended later in the article. I saw also quotes from Ben Hurley, a professor of kinesiology at the University of Maryland (and husband to Jane Hurley, an RD on the NAHL staff).

Hurley has been a longtime student of strength training AKA resitance or weight training and feels it is the mode of choice for preventing muscle loss.

Notice I said preventing loss of muscles, not muscle building. I see men in our gym who are only a few years younger than me and are still bulking up deliberately. The sixteen to twenty-year-old youngsters are presumably doing so to impress the young women or because their friends do so, but why do that at age sixty plus?

I actually bought Stonyfield Organic Oikos yogurt

But back to protein intake; experts like the woman who holds the Distinguished Chair in Geriatric Medicine at the University of Texas Medical Branch, Galveston, say we should consume 30 grams of protein soon after exercising and that smaller amounts won't work in older adults.

So that's four ounces of skinned chicken breast (170 calories) or my egg white plus some Greek yogurt (with twice the protein of regular yogurt). I'll try that a while and then comment on the idea.

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So let's talk about supplements

Tuesday, April 12th, 2011

You don't need supplements to build muscles

I'm in the gym at least six times a week when we're in town and I've noticed the establishment sells very large containers of protein powders and other muscle building supplements. Well, unlike some of the young men who are constantly working on free weights building up their upper body musculature, I spend at least an hour on a recumbent bike and then do stretches and five machines at moderate weights. What I don't do is lift free weights or gulp down large quantities of strange looking liquids that supposedly help to make you look like Charles Atlas or some Olympic weight lifter.

But both The Redbook article I mentioned in my last post and the Tufts Health&Nutrition Letter (sic) I got in the mail and eventually subscribed to mentioned other supplements in some detail. Redbook, after discussing four newish diet pills and their pros and cons, moved on to "natural" weight-loss pills, powders and liquids. They quoted studies and experts from Harvard and UC San Diego and referred readers to WebMD.com, which appears to be a reasonable public-access website for medical information (though it also carries lots of advertisements).

One caution from Dr. Michael Steelman (I Googled him and he's the only weight loss specialist to receive the national society's Bariatrician of the Year award twice and is now the editor of a peer review journal in the field) is that "Dietary-supplement companies aren't required to show clinical data on the safety and efficacy to the FDA, which means we have no idea whether they work or if they're safe."

The Tufts article mentions a "voluntary recall" in 2009  of 14 diet-aid products sold as Hydrocut. This is a combination of several active components including caffeine and green tea plus at least three other ingredients. When I traced the history of the product I found the manufacturer had been reported by the New York Times in 2003 as burying studies showing it was ineffective and covering up evidence of cardiac side effects.

Later on there were 23 reports of major side effects with one person ending up with a liver transplant (and at least 17 cases of liver damage reported in the American Journal of Gastroenterology).

Yet when I Googled the drug I found ads for it online today. The company just reformulated the product and put it back on the market.

I went back to the Redbook which next mentioned bitter orange extract. I found university physician comments and reviews saying it doesn't help dieters lose weight and has significant side effects. But you can find lots of ads for the drug.

Brew tea leaves or drink milk; don't take supplement pills

The only two substances that may be effective and reasonably safe are green tea extract and CLA, conjugated linoleic acid (found in dairy products). But a Harvard medical school obesity specialist recommends that the best way to use them for weight loss is to drink some green tea and some skim milk, not to buy the unregulated and often costly supplements you can find advertised online or in magazines.

"Caveat emptor," the Romans used to say; let the buyer beware.

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Diet pills and supplements, part one

Saturday, April 9th, 2011

Take two and call me in the morning

I've never used diet pills and have avoided supplements that are supposed to help you lose weight, but there's a great new article on them. It's in a distinctly non-medical source, but was as useful as the medical sites I found and the medical newsletters I received, so let's start there.

The article is in Redbook which I can state categorically I normally don't read. But I got in the mail yesterday, unsolicited, a health-related newsletter from a major university and saw an article in it on diet supplements and weight loss. That started my online search that circuitously led me to the Redbook article, also available online  at http://www.redbookmag.com/print-this/diet-pills-yl?page=all

The piece says it will update you on five of the newest diet pills (I counted four, but who's counting?). They walk through the pros and cons of orlistat, available OTC as Alli, which prevents digestion of a share of any fat you consume. The manufacturer of this drug did a study (I prefer totally independent sources) and found increased weight loss in subjects who took the med. What's the con? Well if you consume more fat than ~15 grams per meal, you can develop diarrhea and you may not absorb your daily vitamin intake as well (A, D, E, and K are fat-soluble).

The next drug is Merida (Silbutramine) which acts centrally, i.e., in the brain, altering two chemicals that tell you when you're full. It also can raise your blood pressure and has been assocaiated with strokes and heart attacks. This one is only for the obese or those seriously overweight with other rick factors (e.g., diabetes), is expensive and your healthcare insurance may not cover its cost.

Then there's a duo, Glucophage (metformin) and Byetta (exenatide) that are mostly used for diabetics with weight control problems. Therefore they are usually covered by insurance plans. They also can cause nausea and diarrhea, but have been effective in some fairly long-term studies.

I won't even start on the supplements in this post. What I do want to mention is that most of the medical specialists that Redbook consulted emphasize these drugs are not for the person who wants to lose five or ten pounds so they look good in party clothes or a swim suit. They're for the seriously overweight who preferably are under a doctor's care. And one medical expert said they only work if you are willing to make lifestyle changes.

Guess what? That means dieting and exercising.

 

 

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Fish or fish oil or neither?

Tuesday, March 1st, 2011

I read the Harvard Health Letter for March 2011 and then found a series of related medical articles and an interesting editorial. Let's start with the Harvard publication.It mentions four trials of fish oil supplements in people with pre-existing heart disease. None of those showed a positive effect in patients who are also on modern drug therapies.

Above the brief summary box was an longer commentary quoting Dr. Robert Eckel, the former president of the American Heart Association. He said "If you have heart disease, taking fish oil doesn't seem to replace eating fish." He also wrote the editorial I read in the journal Circulation. Dr. Eckel, who is on the staff of the Department of Medicine in the University of Colorado's medical school (down the road about 65 miles from me), carefully analyzed the four studies and concludes that prior evidence showing diets that include fish make sense, but taking fish oil supplements after you've had a heart attack doesn't.

A Mayo Clinic position paper I found online recommends eating one to two servings of fish a week and notes that fatty fishes, like salmon, herring and even tuna, are higher in the omega-3 fatty acids that may help. Talapia (which I've eaten twice this week) and catfish, are less likely to be heart healthy and any fish that's deep-fat fried may be bad for you.

What about those of us who haven't had clinical heart disease (yet)? Even the Harvard letter says fish oil may be okay for preventive therapy. But I'm not able to find good solid data to support this.

It seems true that populations that eat more fish, like the Inuit and some of the long-term participants in the Nurses' Health Study, were less likely to have a variety of severe heart disease issues (heart attacks, sudden death, heart rhythm problems). The unresolved question is whether they also had better health habits or genetics or other reasons for their diminished risk.

So from my point of view I'll continue taking my twice-a-day fish oil capsule. It's one that is third-party tested for heavy metals, PCBs and dioxins and the relative low dose of omega-3s (270 mg of EPA, 180 mg of DHA, 115 mg of other omega-3s) plus the addition of small doses of omega-9s and 6s seems more likely to help than harm

But I'm going to keep on eating fish, try some fatty fishes and watch the literature.

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