A guide to nutritional supplements. Dr. Louise Gagné Saskatoon Community Clinic

Transcription

1 A guide to nutritional supplements

2 Nutritional supplements: a multibillion dollar industry 71% of Canadians regularly take vitamins, minerals, herbal products, homeopathic medicines, etc

3 Problems with over the counter supplements May not contain any of the substance(s) listed on the label May be contaminated with heavy metals, pharmaceutical drugs, pesticides, etc May be poorly labeled E.g. each serving of 6 capsules provides E.g. there may be no information given about common allergens, gluten, etc May be prohibitively expensive

4 Natural Health Products Directorate The Natural Health Products Directorate was established in 2004 as a branch of Health Canada Its mandate is to ensure that all Canadians have ready access to natural health products that are safe, effective and of high quality, while respecting freedom of choice and philosophical and cultural diversity.

5 NHP Product Licensing NHPs supported by sufficient evidence will be issued a Product Licence along with a Natural Product Number (NPN) or Homeopathic Medicine Number (DIN- HM) which must appear on the label.

6 Natural Health Products Directorate There have been over 42,000 applications for product licenses since 2004 Thus far, 25,919 licenses have been issued There a no plans for routine on site inspections or random quality control testing for off the shelf products Consumer complaints will be investigated

7 Good manufacturing practice Premises must be clean and orderly Personnel must be qualified Quality assurance must approve all operational procedures and investigate complaints Good sanitation and record keeping Product specifications must be available Every lot must be tested for conformance with specifications

8 Issues to consider Will the supplement offer health benefits? Are there health risks to taking the supplement? Is the supplement of good quality? Is it well absorbed and utilized by the body? Are the benefits of the supplement worth the cost? Is there a cheaper way to obtain these same nutrients/phytochemicals/probiotics?

9 Potential harm: vitamin C In a recent study, people who took high dose vitamin C (1000mg/d) had a 25% higher risk of developing cataracts than in those who did not use supplements. The risk increased by 38% in women 65yr. On the other hand, previous studies have linked higher blood levels of vitamin C with a lower risk of cataracts Bottom line: obtaining vitamin C primarily from foods appears to be best

10 Getting vitamin C from foods Excellent sources of vitamin C include: parsley, broccoli, bell pepper, strawberries, oranges, lemon juice, papaya, cauliflower, kale, mustard greens, and Brussels sprouts.

11 Potential harm: vitamin E HOPE-TOO study found that 400IU vitamin E per day did not protect against heart disease and actually increased the risk of heart failure Vitamin E supplements may increase the risk of death from hemorrhagic stroke Other studies have found lower risk of heart disease with higher intake of vitamin E both from food and supplements

12 Vitamin E as found in whole foods versus supplements/food additives In whole foods, vitamin E exists as a combination of 8 different compounds: α, β, δ, γ tocopherols and α, β, δ, γ tocotrienols Only synthetic or natural forms of alphatocopherol are added to foods. Most of the vitamin E added to multivitamins and used in individual vitamin E capsules is alpha-tocopherol

13 Getting vitamin E from foods Excellent sources of vitamin E include: sunflower seeds, almonds, olives, wheat germ oil, sunflower oil, safflower oil, spinach, mustard greens, chard, turnip greens.

14 Potential harm: beta carotene In a large cancer prevention trial, smokers who took beta carotene as a supplement had an increased risk of lung cancer and increased overall mortality On the other hand, consumption of beta carotene from fruits and vegetables is associated with a lower risk of lung cancer

15 Getting beta carotene from foods Food sources of beta-carotene include sweet potatoes, carrots, kale, spinach, turnip greens, winter squash, collard greens, cilantro and fresh thyme.

16 Potential harm: high dose B vitamins High dose B vitamins (folic acid 2.5mg, B6 25mg, B mcg) have been found to increase the risk of heart attack, stroke and overall mortality in patients with type 1 and 2 diabetes. On the other hand, we know that there are multiple benefits from getting adequate amounts of folic acid, vitamin B12 and vitamin B6 in the diet

17 Getting B vitamins from foods B vitamins (except B12) are found in a wide spectrum of plant foods such as: leafy greens, vegetables, nuts, seeds and whole grains as well as in meat, milk, eggs B12 is naturally found only found in animal foods, such as, meat, cheese, milk, yogurt and cheese B12 may also be obtained in some fortified vegetarian foods

18 Whole food diets Eating a whole food diet is a good way to obtain all essential nutrients (other than vitamin D) Whole foods are nutrient dense

19 Examples of whole foods 1. Whole grains: wheat berries, brown rice, quinoa, millet, corn and products made from whole grains 2. Legumes: kidney beans, pinto beans, garbanzo beans, navy beans, etc 3. Nuts: walnuts, pine nuts, pecans, almonds, cashews, etc 4. Eggs, cheese, yogurt, milk, tofu, soymilk 5. Unprocessed beef, lamb, chicken, turkey & fish

20 Whole foods versus nutrients Whole foods are complex mixtures of proteins, fats, carbohydrates, vitamins, minerals, enzymes, phytochemicals, fiber, water and possibly other as yet unknown constituents. Studies repeatedly find that whole foods have actions that are different from their isolated constituents

21 Carrots Carrots contain over 100 phytochemicals and other substances including: aesculetin, apegenin, arachidonic acid, p-hydroxybenzoic acid, caffeic acid, chlorogenic acid, chlorophyll, chrysin, cinnamic acid, p-coumaric acid, eugenol, ferulic acid, geraniol, beta-ionone, kaempherol, limonene, linalool, linolenic acid, luteolin, methionine, myristicin, oleic acid, alphapinene, psoralen, 5-methocypsoralen, quercetin, quercitrin, beta-sitosterol, stigmasterol, umbelliferone, vanillic acid, etc

22 Carrots Carrots also contain: B vitamins (B6, thiamine, folic acid), beta-carotene, vitamin C, magnesium, vitamin E, vitamin D2, potassium, copper, calcium, glutathione, iron, manganese, phosphorus, sulfur, calcium pectate (a type of pectin fiber)

23 More about carrots There are several hundred different varieties of carrots available in six different colors The nutritional content of a carrot varies according to the variety, the soil type and quality, growing conditions, harvesting methods, storage and transportation, processing, cooking methods, etc

24 Supplements Multivitamins Vitamin D Calcium Essential fatty acids Probiotics Fiber

25 Why take a multivitamin? May fill in gaps in the diet May lower the risk of chronic disease

26 Multivitamins When taken prior to and during pregnancy, multivitamins can decrease the risk of congenital heart defects, some childhood cancers and preterm birth Multivitamins taken for 3 months prior to pregnancy have been found to eliminate the increased risk of birth defects in children born to diabetic mothers

27 Multivitamin use in childhood The American Academy of Pediatrics recommends a multivitamin for: Children from low income families Children with poor eating habits Children with chronic diseases such as cystic fibrosis Children enrolled in weight management programs Children consuming vegetarian diets without adequate dairy products

28 Multivitamins May need to be used consistently for many years in order to see benefits In the Nurses Health Study, multivitamin use was associated with a significantly lower risk of colon cancer (RR 0.25), but only after 15 years of regular use

29 Multivitamins & myocardial infarction Swedish study (AJCN) Healthy women (with no history of heart disease) were found to have a 40% lower risk of MI after taking a one-a-day multivitamin for > 5 yrs In the Nurses health study, multivitamin use was associated with a 24% lower risk of heart disease

30 What to look for in a multivitamin Beta carotene (or mixed carotenoids) B s: thiamine, riboflavin, niacinamide, pyridoxine, folic acid, B12, biotin, pantothenic acid Vitamin C mg Vitamin D3: at least 400 IU Vitamin E (d-alpha tocopherol) 15 IU (or mixed tocopherols/tocotrienols) Minerals: zinc & copper (ratio of 10:1), iodine, chromium, selenium, calcium, magnesium +/- Iron for adolescent girls, pregnant women, female cross country runners

31 What multivitamins do not provide Protein Fiber Essential fatty acids Phytochemicals (sometimes present in miniscule amounts) Usually inadequate amounts of calcium and vitamin D

32 Centrum Covers your core vitamin and mineral needs Vitamins Vitamin A 1000 IU, Beta-Carotene 3000 IU, Vitamin E 25 IU, Vitamin C 90 mg, Folic Acid 0.4 mg, Vitamin B mg, Vitamin B2 3.2 mg, Niacin 15 mg, Vitamin B6 3 mg, Vitamin B12 14 mcg, Vitamin D 400 IU, Biotin 45 mcg, Pantothenic Acid 10 mg Minerals Calcium 175 mg, Phosphorus 125 mg, Iodine 0.15 mg, Iron 10 mg, Magnesium 50 mg, Copper 2 mg Other Ingredients Lutein 250 mcg

33 Lutein & zeaxanthin Richest sources are cooked leafy greens. Lutein and zeaxanthin are currently being studied in the AREDS 2 trial - a study looking at ways to reduce the risk of age related macular degeneration

34 Vitamin D We evolved to obtain most of the vitamin D we need from sun exposure, however, most people have inadequate sun exposure vitamin D cannot be made from the sun from Oct-Mar Many people are vitamin D deficient All people living at our latitude (52 N) should be taking vitamin D supplements from October until March. Many people require supplementation all year around. Vitamin D supplements are very inexpensive

35 Sources of vitamin D Foods: Fatty fish, mushrooms, egg yolks Fortified foods: milk, breakfast cereals, soymilk, butter Supplements: fish liver oils, multivitamins, vitamin D

36 Vitamin D supplementation Vitamin D3: at least 1000 IU/day for adults Formulations: liquid, drops, tablets/capsules Take with meals, since it is fat soluble From October 1-March 30 most people need ~ 2000 IU/day From April 1- September 30, depending on outdoor exposure, IU/day Check 25(OH)D level to assess status

37 Calcium RDA (total intake from foods + supplements) Adults age 19-50: 1000 mg/d Adolescents: 1300 mg/d, People over age 50: 1200 mg/d Good sources: dairy products, sardines, canned salmon, leafy greens (kale, collards), broccoli, tofu (especially if it is made with calcium chloride), almonds, sesame seeds/sesame tahini, seaweed (dulse, nori, kombu), fortified orange juice and fortified soy milk.

38 Estimating calcium intake General diet ~ 250 mg Dairy products 1 cup milk = 300mg ½ cup yogurt = 120mg 1 oz cheese = 200mg (a small cube or the size of 4 dice) Non dairy foods rich in calcium: Sardines ½ tin ~ 300mg Tofu (calcium sulfate) 1/3 package ~ 300mg Fortified foods 1 cup fortified orange juice = 300 mg 1 cup fortified soy milk = ~100 mg (shake well) Supplements

39 Types of calcium supplements Formulations: powders, tablets, liquid, capsules, chewable Calcium citrate is well absorbed and can be taken anytime (with or without food) is relatively expensive Calcium carbonate less well absorbed-requires adequate gastric acid and must be taken with meals Relatively inexpensive Take calcium in divided doses if > 500 mg/day

40 Natural sources Coral calcium: unsustainable source, may contain environmental contaminants, no proven benefits over other types of calcium supplements Dolomite or oyster shell calcium: may be contaminated with heavy metals and other environmental contaminants

41 Calcium/magnesium Since many people s diets are also low in magnesium, this combination makes sense Usually 2:1 or 1:1 (calcium:magnesium) Calcium tends to be constipating Magnesium tends to act as a mild laxative

42 Calcium absorption Remember that vitamin D is required for adequate calcium absorption Calcium is better absorbed in the presence of adequate gastric acid or with vitamin C containing foods/supplements

43 Essential fatty acids Most western diets are overloaded with omega 6 fats and lacking in omega 3 s To correct this imbalance: cut down on consumption of omega 6 s and eat more omega 3 s Plant sources of omega 3 s (alpha-linolenic acid): flax, walnuts, hemp, canola, chia Animal sources: fatty cold water fish (EPA & DHA) salmon, sardines, herring, mackerel, black cod, halibut

44 EPA & DHA Average intake in Canada = mg/d The Canada Food Guide recommends at least 150 gram of fish per week (5.3 oz) and does not specify the type of fish to eat Jackfish (pike) contains ~ 0.1 grams of EPA+DHA per 100 grams (3.5 oz) fish Wild chinook salmon contains ~ 1.5 grams of EPA + DHA per 100 grams (3.5 oz) fish

45 Fish oils (omega 3 s) EPA + DHA mg/day with meals Molecularly distilled, high potency Check consumer lab or IFOS (International Fish Oil Standards) program ( ) IFOS: Labeling, contaminants (mercury, PCB s, dioxins, furans), heavy metals (arsenic, lead, cadmium) & oxidative tests

46 Reading fish oil labels Ingredients: purified deep sea fish oil (from anchovies and sardines), soft gel capsule (gelatin, water, glycerin, natural lemon oil), natural lemon oil, d-alpha tocopherol, rosemary extract Two 1000 mg Soft Gels Contain: EPA: 650 mg DHA: 450 mg Other Omega-3s: 180 mg Vitamin E: 30 IU

47 3-6-9 fatty acid supplements Ingredients: purified deep sea fish oil (from anchovies and sardines), soft gel capsule (gelatin, water, glycerin, natural lemon oil), borage oil, natural lemon oil, d-alpha tocopherol, rosemary extract Two 1000 mg Soft Gels Contain: EPA: 270 mg DHA: 180 mg Other Omega-3s: 115 mg GLA: 66 mg OA: 160 mg Vitamin E: 30 IU

48 Fish liver oils Supplement Facts Serving Size: 1 Softgel Vitamin A (from Cod Liver Oil) 2500 IU Vitamin D3 (from Cod Liver Oil) 270 IU Each serving may also provide the following naturally occurring amounts of Omega-3 Fatty Acids: Eicosapentaenoic Acid (EPA) 45mg Docosahexaenoic Acid (DHA) 60 mg

49 Prebiotics and probiotics Prebiotic: "a non-digestible food ingredient that beneficially affects the host by selectively stimulating the growth and/or activity of one or a limited number of bacteria in the colon." Probiotic: a preparation containing live bacteria (e.g. lactobacilli) that is used to restore beneficial bacteria to the body

50 Probiotics May be useful in: inflammatory bowel disease, recurrent bladder infection, vaginitis May also help to prevent: allergies, asthma, certain cancers Quality problems: dead bacteria, pathogens Quantity problems: 1-5 billion/day may not be effective Ingredients: often contain dairy

51 What to look for: GMP NHP number Bacterial count Probiotics Beneficial bacteria may be obtained from yogurt that is labeled as having live bacterial cultures Other foods that can provide beneficial bacteria: kefir, sauerkraut, miso, tempeh (fermented soy product)

52 Probiotics Usually contain a variety or organisms including strains of lactobacilli and bifidobacteria Ideal bacterial count is not clear Some products contain only 1 billion organisms per capsule VSL #3 contains 450 billion per packet Bacteria must be able to survive the acidic stomach environment and establish themselves in the intestine Take with meals.

53 B complex Often sold in the form of stress tabs containing all of the B vitamins plus vitamin C Often very high dose There should not be any need for a B complex supplement if a whole foods diet is eaten and/or a good quality multivitamin is being taken

54 Vitamin C The most commonly used supplement Tissues are saturated at mg Water soluble vitamin, so it has been thought to have low toxicity, but may cause GI upset, diarrhea and increased risk of kidney stones (high doses), other harmful effects??? Easy to obtain adequate amounts from the diet May lessen the duration and symptoms of the common cold

55 Fiber supplements Fiber supplements should always be taken with 1-2 cups of water or other fluid Large amounts of fiber may interfere with the absorption of some minerals (calcium, magnesium zinc and iron) & medications A sudden increase in fiber may cause gas and bloating. Fiber should be increased gradually.

56 Fiber supplements Increase dietary soluble fiber and/or add a soluble fiber supplement to lower glycemic index of a meal or to lower cholesterol Examples: Metamucil (psyllium), Benefiber Increase insoluble fiber from the diet or add supplemental insoluble fiber to help alleviate constipation Examples: bran, bran bars/wafers Eating more fruits, vegetables, legumes and whole grains will increase both soluble and insoluble fiber

57 Core supplements Vitamin D: at least 1000 IU/d (with meals) A good balanced multivitamin (with meals) Additional calcium/magnesium as needed Essential fatty acids, especially omega 3 s if fatty fish is not eaten ~ 4 times per week

58 The foundation of health Whole foods diet supplying all of the essential nutrients, plus and phytonutrients and fiber. Regular daily physical exercise Strong social/community supports See the book: Healthy at 100 by John Robbins Great web site