Tag Archives: supplements

Vitamin C – More than you care to know about it!

Toronto naturopathic doctors

Recently, a patient asked me about a specific vitamin C product, basically whether it was worth paying a premium for.

In order to offer them the most accurate answer I could, I decided to confirm a few facts before replying, and ended up going down bit of a rabbit hole.

Vitamin C (ascorbic acid) is a an often over-looked (probably owing to it’s ubiquitous nature), but very valuable nutrient, protecting against heart disease and cancer; and supporting immune system activity and eye health, but where we use it most is in recovery from tissue healing (e.g., disc injury, sports injuries, etc.).

How much vitamin C should I take daily?

At this writing, the recommended daily allowance (RDA) for vitamin C is 60 mg daily, an amount that can be consumed by eating a single orange.

That said, experts disagree that this an optimal daily intake. Most vitamin C supplements offer 1000 mg per dose, and in the recent past, recommendations of 5000 or 6000 mg daily were not unusual.

For optimal vitamin C levels, research demonstrates that complete plasma (“blood”) saturation (i.e., the blood is as full as it can be) of vitamin C occurs at doses of 1000 mg daily.

White blood cells (i.e., cells of the immune system) were vitamin C saturated at even lower doses of 100 mg daily.

Should I take my vitamin C all at once?

No. Much of the vitamin C taken in a 1000 mg  capsule will be excreted in the urine.

At doses of 100 mg, no vitamin C is excreted in the urine (i.e., your body “keeps”, and presumably uses, it all).

At doses of 500 mg, bioavailability (i.e., the amount that enters the blood)  begins to decline.

This suggests, in order to not “waste” your vitamin C supplement, you should separate your intake into doses of less than 500 mg.

Importantly, slow-release vitamin C, which theoretically would allow for more complete absorption of higher doses of vitamin C, resulted in 50% lower absorption of 1000 mg of vitamin C in at least one study.

Ultimately, after at least one month of supplementation, users of both slow-release and regular vitamin C had equal blood vitamin C levels, but clearly, added cost for “slow-releasing” is not warranted.

How about “buffered” vitamin C?

Persons finding they experience digestive upset when using vitamin C are often directed to use “buffered” vitamin C products – mineral salts of ascorbic acid (e.g., calcium ascorbate), which are less acidic, and therefore thought to be less” irritating”.

There is little scientific support for this assertion.

Importantly, at the 1000 mg discussed above, the common digestive side effect of diarrhea, which may be mistakenly attributed to the acidic nature of vitamin C, is unlikely to occur.

How about vitamin C products combining bioflavenoids?

Bioflavenoids are plant chemicals that act as antioxidants, and are reputed to improve absorption of vitamin C.

Although they do add value to a product that is used for the purpose of antioxidant action, the research does not support that the vitamin C absorption of that product will be increased.

Sum it up, Egghead!

Vitamin C, take:

  • 1000 mg daily
  • In doses of approximately 400 mg (although practically, 500 mg is likely the closest dose you will be able to source)
  • Theoretically, having vitamin C with food may increase bioavailability (decrease “waste”)
  • Slow-release capsules, and bioflavenoids-added formulas do not improve vitamin C absorption

References

Zelman KM. Benefits of vitamin C [Internet]. WebMD. [cited 2018 Sep 14]. Available at: https://www.webmd.com/diet/features/the-benefits-of-vitamin-c#1.

Vitamin C [Internet]. Government of Canada. [cited 2018 Sep 14]. Available at: https://www.canada.ca/en/health-canada/services/nutrients/vitamin-c.html.

Oranges, raw, Florida, nutrition facts and calories [Internet]. SelfNutritionData. [cited 2018 Sep 14]. Available at: https://nutritiondata.self.com/facts/fruits-and-fruit-juices/1969/2.

Levine M, Conrey-Cantilena C, Yank Y, Welch RW, Washko PW, Dhariwal KR et al. Vitamin C pharmacokinetics in healthy volunteers: evidence for a recommended dietary allowance. Proc Natl Acad Sci USA [Internet]. 1996 Apr 16 [cited 2018 Sep 14];93(8):3704–3709. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC39676/.

Oregon State University. Linus Pauling Institute [Internet]. Supplemental forms. [cited 2018 Sep 14]. Available at: https://lpi.oregonstate.edu/mic/vitamins/vitamin-C/supplemental-forms.

– Jonah Lusis, ND

 

Posted: 2018 Sep 14

Should Children Use a Multi-Vitamin?

Toronto Naturopathic Doctors

This is an article I wrote for EcoParent Magazine’s Fall 2017 Issue. It hasn’t been posted Online, but I’ve posted it here!

After I submitted it, I was contacted by the editor and asked for a few changes – apparently some of the magazines advertisers were manufacturers of vitamins, and their products don’t meet the standards I suggest in my article. For the print version, we edited out sections of the article, including some relevant quality suggestions (I didn’t object to the edits because EcoParent are friends, and I’m not interested in putting them in a tough spot).

Anyway, below is the article in it’s entirety, including “all the names”.

Jonah Lusis, ND

Should Children Use a Multi-Vitamin/Mineral?

Too many years ago, while as a student working in a health store in Toronto, I was asked by the storeowner to offer customers samples of a children’s multi-vitamin/mineral.

I did so, unaware at the time that the issue was so controversial! More than one parent indignantly declined, declaring that their pediatrician claimed children did not require nutritional supplementation.

Were their pediatricians right?

Let me preface this discussion by disclosing that I am not a “supplements naturopath” – my modus operandi is to focus on correcting a patient’s lifestyle, but I am not averse to supplementation, particularly if on consideration of available evidence it is indicated.

The intent of multi-vitamin/mineral use is to compensate for nutritional shortcomings in a persons diet.

The obvious first question is: Is a child consuming all the nutrients they require from the food they are eating?

A 2006 report prepared by the Region of Waterloo Public Health and the University of Waterloo determined that 68% of grade six students in the Waterloo Region of Ontario were not meeting the Canada’s Food Guide to Healthy Eating guidelines for fruit and vegetable consumption. The same study found that consumption of “meat and alternatives” (e.g., tofu) was inadequate in 46% of students, an important factor in the associated findings of inadequate intake of iron and zinc, in 11% and 31% of students, respectively1.

Another study determined that 0% of (adult) subjects were able to meet their micronutrient (i.e., vitamins and minerals) Recommended Daily Allowances (RDA’s) through diet alone2.

Canada’s Food Guide to Healthy Eating, which does not offer the most up-to-date nutritional guidelines (in my opinion, better guidelines are available here) recommends children younger than 13 years of age eat:

  • 4 to 6 servings of vegetables and fruit daily (low, in my opinion)
  • 1 to 2 servings of meat and meat alternatives daily3.

Does your child meet these guidelines? If not, consider supplementing their diet with a multi-vitamin/mineral.

Any multi-?

As with all things in life, quality in nutritional supplements is wide-ranging, and as a rule, you get what you pay for.

There are a wide range of factors that determine the quality any nutritional supplement. For example:

  • Does the product contain the full spectrum of nutrients required for health, and in adequate quantities?
  • Minerals and vitamins are available in differing forms (e.g., magnesium carbonate may result in net loss of magnesium from the body; compared to magnesium glycinate, which is more efficiently absorbed and better tolerated4). Does the product contain well-absorbed, well-tolerated, optimally bioactive forms of nutrients?
  • Certain nutrients (e.g., vitamin A, iron), consumed in excess, are potentially toxic. Does the product contain excessive amounts of potentially toxic nutrients?

The Comparative Guide to Nutritional Supplements™ assesses and rates over 1’300 multi-vitamin/minerals quality on the above, and 14 other criteria, offering a score out of five stars. The majority of “cheap”, “store brands” earned very poor ratings (“one star” representing a fairly typical score)4.

A review of the ingredients list of Flintstones™ Complete Chewables Multivitamins reveals:

  • An absence of minerals except calcium and iron (e.g., magnesium, selenium, zinc).
  • Calcium in the relatively lower-quality calcium carbonate form4.
  • Folate in the form of folic acid, which may increase risk of colon cancer5.
  • B12 in the relatively inferior cyanocobalamin form (compared to the methylcobalamin), which requires depletion of stores of other important nutrients for absorption6.
  • Vitamin E in the synthetic, poorly bioactive d/l-alpha tocopherol form (as opposed to d-alpha tocopherol, which is absorbed at two times the rate4).

Also important to consider are the non-therapeutic ingredients. The #1 Brand Choice of Canadian Pediatricians also:

  • Appears to contain quite a bit of sugar. The exact amount of sugar is not included on the label, but confectioner’s sugar, corn syrup solids (which are 100% sugar) and dextrose monohydrate (sugar) are three of the first seven ingredients listed.
  • Contains sorbitol which may cause digestive upset.
  • Contains several food colorings, including Red 40 and Yellow 6, both of which contain the carcinogen benzidine7.

Many reviewing the ingredient list will note that I did not include aspartame, the most plentiful ingredient listed, as a point of concern. Although controversial, the current scientific evidence suggests that aspartame is safe for human consumption8.

What about the risks I’ve heard about?

Over the past decade or so, several studies9 have been published that have demonstrated a correlation between multi-vitamin/mineral use and rates of cancer development.

Although receiving much publicity, the relationship is between is these is weak, statistically not such that a causal relationship is the appropriate conclusion (an analogy may be if it was noted that persons taller than 180 cm had very slightly higher cancer rates, it would be incorrect to draw the conclusion that being tall causes cancer).

The Bottom Line

Take the time to learn and understand how be consistently eating a balanced, nutrient-rich diet, including what constitutes food serving sizes.

Keep a food journal to determine of your routine allows you to consistently offer your child a healthy, balanced diet (and as importantly, do they eat it).

If you are concerned that your child is not eating in a way that ensures adequate nutrition, use a multi-vitamin/mineral – there is very little to support that using nutritional supplements to correct nutritional deficiencies (as opposed to using “mega-doses” of nutrients) is harmful (even the authors of studies arriving at conclusions critical of multi-vitamin/mineral use concede their use is indicated to correct nutritional deficiencies10).

To find a high-quality multi-vitamin/mineral for your child:

  • Shop for a “children’s” multi-vitamin/mineral, which will include potentially toxic nutrients in amounts appropriate for children’s smaller bodies
  • Visit a health store for a higher-quality range of options than a national drug or grocery store chains
  • Be willing to invest in a quality product – even a seemingly expensive product will typically amount to approximately $1.00 daily

References

  1. Hanning R, Toews J. Food and physical activity behaviours of grade 6 students in Waterloo Region. Region of Waterloo: Population Health Research Group; 2007. [cited 2017 Apr 29]. Available from: http://chd.region.waterloo.on.ca/en/researchResourcesPublications/resources/Grade6lifestyle_report.pdf.
  2. Misner B. Food alone may not provide sufficient micronutrients for preventing deficiency. Journal of the International Society of Sports Nutrition [Internet]. 2006 Jun 5 [cited 2017 Apr 29]. Available from: https://jissn.biomedcentral.com/articles/10.1186/1550-2783-3-1-51.
  3. Health Canada [Internet]. Ottawa How much food should you need every day. [cited 2017 Apr 29] Available from: http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/basics-base/quantit-eng.php.
  4. MacWilliam L. Comparative guide to nutritional supplements™. 5th professional ed. Northern Dimension Publishing; 2014. pp. 53-72, 90-103.
  5. Mason JB, Dickstein A, Jacques PF, Haggarty P, Selhub J, Dallal G et al. A temporal association between folic acid fortification and an increase in colorectal cancer rates may Be illuminating important biological principles: a hypothesis. Cancer Epidemiol Biomarkers Prev July 1 2007 (16) (7) 1325-1329; DOI:10.1158/1055-9965.EPI-07-0329.
  6. Obeid R, Fedosov SN, Nexo E. Cobalamin coenzyme forms are not likely to be superior to cyano- and hydroxyl-cobalamin in prevention or treatment of cobalamin deficiency. Molecular Nutrition & Food Research. 2015;59(7):1364-1372. doi:10.1002/mnfr.201500019.
  7. Potera C. Diet and nutrition: the artificial food dye blues. Environmental Health Perspectives. 2010;118(10):A428.
  8. Arnarson A. Aspartame: good or bad. Authority Nutrition: An Evidence-based Approach [Internet]. [cited 2017 Apr 29]. Available from: https://authoritynutrition.com/aspartame-good-or-bad/.
  9. Mursu J, Robien K, Harnack LJ, Park K, Jacobs DR. Dietary supplements and mortality in older women: the Iowa Women’s Health Study. Archives of internal medicine. 2011;171(18):1625-1633. doi:10.1001/archinternmed.2011.445.
  10. Guallar E, Stranges S, Mulrow C, Appel LJ, Miller ER. Enough is enough: stop wasting money on vitamin and mineral supplements. Ann Intern Med. 2013;159:850-851. doi: 10.7326/0003-4819-159-12-201312170-00011.

 

 

Is It Worth It to Spend More on Nutritional Supplements?

Toronto Naturopathic Doctor

When I started writing this, the intent was to quickly summarize a conversation I’ve had on a number of occasions with patients trying to make educated decisions when choosing nutritional supplements and botanical medicines, but it turned into a bit of a manifesto.

There is a huge difference in the level of quality between a “professional grade” nutritional supplement or botanical medicine, and products sold at most national drug stores, Costco®, etc.

To offer a sense of perspective, The Comparative Guide to Nutritional Supplements evaluates multi-vitamins/minerals on a range of standards, including some of the topics discussed below, and awards each product a rating. In the 3rd edition of the Guide, Douglas Laboratories® UltraPreventative® X earned a rating of 95.4 (of a possible 100), and Jamieson™ Power Vitamins for Men rating was 3.51.

The bottom line: you get what you pay for.

For those with stuff to do, here’s a summary of what I discuss below in detail:

  1. Raw materials – More potent raw materials result in a more effective end products
  2. Nutrient form and absoption – Vitamins and minerals are available in a range of forms, some cheaper and some more expensive for manufacturers. Does the product use well-absorbed, potent forms of each nutrient?
  3. Manufacturing quality – High-quality manufacturers take extra steps throughout the development and production process to guarantee quality of the end product. Has the product been manufactured in such a way that quality ingredients maintain their potency and absorbability?
  4. Formulation – Is the “recipe” for the product developed by someone with actual clinical experience, or is it simply a haphazard “sum of it’s parts”?
  5. Non-medicinal additives – Does the product contain undesirable (even toxic) ingredients as fillers, flavouring agents, etc.?
  6. Dosage and potency – Although cheaper at time of purchase, does low product potency result in having to use many doses daily to obtain meaningful amounts of nutrients?

For those with less stuff to do, read on!

Whenever I have a new patient intake appointment, part of process of gathering complete information includes not only identifying what other treatments a patient may have used in the past or are presently using, and with what amount of success, but if nutritional supplements are being used, who are the manufacturers?

This is important information for me to have, because there is a wide range in quality between nutritional supplements.

Unfortunately, nutritional supplements are not regulated particularly rigorously. The main emphasis of regulation is safety, and reliability of advertising claims (i.e., “This product cures cancer” is not an allowable claim for a product to make unless they can provide scientific evidence of this fact). Importantly, product efficacy (unless the manufacturer is making specific health claims about their product) is not a consideration.

Individual pharmaceutical drugs each have a very specific chemical composition. If choosing to use a “generic” version of the drug, rigorous standards guarantee that the amount of active ingredients and the rate at which the drug is absorbed into the body are the same as the original. This provides some assurance that quite similar performance can be expected2.

The actual quality between two, for example fish oil products, can vary widely – a low-quality fish oil product and a high-quality fish oil product are really, the same in name only.

Not achieving the desired health results with the use of a low-quality nutritional supplement or botanical medicine does not necessarily mean that the specific nutrients or herbs are not potentially helpful to that patient, it may indicate they are using an ineffective product.

These are some of the differences between high-quality nutritional supplements and botanical medicines and their low-quality counterparts:

Raw Materials

Unlike generic and brand name pharmaceuticals, there is no “standard” starting point for nutritional supplements and botanical medicines.

Botanical medicine tinctures (those bad-tasting liquid medicines sold in amber bottles) are prepared by macerating (soaking) plant materials in a solvent (usually alcohol). The proportion of plant to alcohol, by weight, is usually included on the label, and gives the user a sense of how potent the medicine is. Only some companies use dried herbs (as opposed to “fresh/wet” herbs) as their raw material: dried herb = lower weight = more herb used in the tincture = more concentrated plant medicine.

A second example is standardization of ingredients. In many cases, the specific chemical responsible for a desired action in a plant is known. For example, important ingredients in the therapeutic effect of St. John’s Wort are chemicals in the hypericin family3. Products including St. John’s Wort should therefore include known, consistent amounts of hypericin in each dose.

Lastly, again in the realm of botanical medicines: how were ingredients grown? Agricultural research has demonstrated that organically grown/raised produce is more nutrient dense than it’s conventional counterparts4. It follows that organically grown plants will yield more potent botanical medicines – does a manufacturer use organically grown raw materials?

Nutrient Form and Absorbtion

Minerals (e.g., calcium, magnesium, zinc) are absorbed into the body attached to acids, for example amino acids or other organic acids (e.g., magnesium carbonate – the carbonate is added for magnesium absoption).

The efficiency of absorption of a particular mineral is greatly influenced by the organic acid it is bound to. Inorganic mineral salts are less expensive to use in production, but offer poor nutritional value, under some conditions potentially causing net loss of a particular mineral from the body5. Magnesium carbonate or magnesium glycinate? One is cheaper, but not necessarily the better value.

Forms of nutrients are not only relevant in nutrient absorption. Alpha-tocopherol is the most common form of vitamin E used in nutritional supplements. It is available in a natural, d-alpha tocopherol form, and a synthetic d/l-alpha tocopherol form. The synthetic form is less expensive for manufacturers to source, but is also less bioavailable, and has only half the biological activity of the natural form of vitamin E5. Which form do you think Costco®’s Kirkland Signature™ brand vitamins use?

Manufacturing Quality

Raw materials aside, a company’s manufacturing standards can result in wide differences in quality of end products.

Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are the key active ingredients in fish oil products, and are concentrated in fish oil supplements by a process called “esterification” (EPA and DHA do not naturally occur in fish in the concentrations found in higher-quality fish oil supplements).

For optimal absoption in the body, however, the EPA and DHA should be “un-esterified” back into their natural, “triglyceride” form, which increases absoption by some 70%6. An “esterified” fish oil product may appear to be very concentrated, but will not ultimately offer the benefits a well-manufactured, “triglyceride form” product will, information not available on a product label.

In general, manufacturers who are quality focused will “go the extra mile” to ensure their products offer maximum benefit (and protect their reputation):

  • Metagenics® performs clinical trials on many of their products (most nutritional supplements are simply a combination of nutrients that have been identified as having some effect in a particular health condition, but the final combination/product itself is not evaluated).
  • MediHerb®7 and Douglas Laboratories®1 use a process called liquid chromatography to confirm potency of end products.

Formulation

In some cases, particularly in the case of botanical medicines, the formulation (recipe) plays as important a role in the effectiveness of the medicine as the specific medicinal ingredients included. Much like a recipe, which is more than the sum of it’s parts, a successful botanical medicine will often include herbs that act as “synergists”, plants that do not include chemicals acting directly on the primary health concern, but that increase the effect of the other plants included in the formula (e.g., cayenne acts as a circulatory stimulant, which when included in a formula can increase rate of delivery of other chemicals in an herbal medicine).

Both Viriditas Herbal Products and MediHerb® products are created by herbalists having decades of compounding experience. Can this be said of all brands?

Non-Medicinal Additives

Nutritional supplements include more than nutrients alone, in fact, in many cases the medicinal ingredients are less than the “other” ingredients. Are the “other” ingredients desirable or undesirable?

High-quality products will often have included “helpful” substances, for example vitamin E, an anti-oxidant, added to a fish oil product to prevent naturally occurring rancidity of any oil.

In contrast, Flintstones™ Complete Chewables Multivitamins include as “non-therapeutic” ingredients:

  • Aspartame (safe8, but none-the-less controversial) as it’s most plentiful ingredient
  • Sugar as three of the first seven ingredients (labeled as confectioner’s sugar, corn syrup solids, dextrose monohydrate)
  • Sorbitol, which may cause digestive upset
  • Several food colorings, including Red 40 and Yellow 6, both of which contain the carcinogen benzidine9

Potency, Dosage and Amount Needed for Effect

Sometimes the actual cost of a product is hidden in the dosage required for benefit.

For example, the “standard” daily dose recommended for many higher quality fish oil products offers, in the neighbourhood of 1’500 mg of combined EPA and DHA in each dose, the generally recommended “meaningful” dose for these recognized by experts10.

One capsule of 1000 mg Kirkland Signature™ Fish Oil contains 250 mg of combined EPA and DHA, a minimal dose11, 12, meaning one would have to take six capsules daily to meet the requirement for the “meaningful” recommended dose. (The label on the Kirkland Signature™ Fish Oil further suggests swallowing the capsules with water, which will reduce absorption of fat-soluble chemicals).

The bottom line (again): you get what you pay for.

The above is likely daunting. Even to person such as myself for whom this is my “job”, conversations with manufacturer’s representatives are often frustrating, like comparing apples to oranges: is a liquid fish oil including an anti-oxidant to prevent rancidity preferable to a fish oil in a supposedly more stable capsule form? It’s a rabbit hole (that you can continue down if you want to learn more about fish oil quality issues).

Self-serving as this may sound, my best advice is to trust your naturopathic doctor.

Although obviously a source of income for our office, the items in our dispensary are a quality-control mechanism for us, and selected after hundreds of hours of education, research and product meetings.

Or at the very least, don’t buy on price alone.

Good luck!

Jonah Lusis, ND

References

  1. MacWilliam L. Comparative guide to nutritional supplements™. 3rd professional ed. Northern Dimensions Publishing; 2003. pp. 68, 111, 117.
  2. US Food and Drug Administration [Internet]. Facts about generic drugs. [cited 2017 May 10]. Available from: https://www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/understandinggenericdrugs/ucm167991.ht.
  3. Drugs.com [Internet]. St. John’s Wort. [cited 2017 May 10]. Available from: https://www.drugs.com/npp/st-john-s-wort.html.
  4. Średnicka-Tober D, Barański M, Seal CJ, et al. Higher PUFA and n-3 PUFA, conjugated linoleic acid, α-tocopherol and iron, but lower iodine and selenium concentrations in organic milk: a systematic literature review and meta- and redundancy analyses. The British Journal of Nutrition. 2016;115(6):1043-1060. doi:10.1017/S0007114516000349.
  5. MacWilliam L. Comparative guide to nutritional supplements™. 5th professional ed. Northern Dimension Publishing; 2014. pp. 54-7.
  6. Dyerberg J, Madsen P, Moller JM, Aardestrup I, Schmidt EB. Bioavailability of marine n-3 fatty acid formulations. Prostaglandins Leukot Essent Fatty Acids. 2010 Sep;83(3):137–141.
  7. MediHerb [Internet]. Quality assurance of herbs. [cited 2017 May 10]. Available from: http://www.mediherb.com/about-us/quality-assurance.aspx.
  8. Arnarson A. Aspartame: good or bad. Authority Nutrition: An Evidence-based Approach [Internet]. [cited 2017 May 10]. Available from: https://authoritynutrition.com/aspartame-good-or-bad/.
  9. Potera C. Diet and nutrition: the artificial food dye blues. Environmental Health Perspectives. 2010;118(10):A428.
  10. Burford-Mason A. Using nutritional supplements in practice part 2 – recap and update. Nutrition for Docs 2009; 2009 May 30-31; Toronto, ON: Ontario Society of Physicians for Complementary Medicine and The Complementary Medicine Section, Ontario Medical Association; 2009.
  11. Hjalmarsdottir F. How much omega-3 should you take per day? Authority Nutrition: An Evidence-based Approach [Internet]. [cited 2017 May 10]. Available from: https://authoritynutrition.com/how-much-omega-3/.
  12. Mayo Clinic [Internet]. Omega-3 fatty acids, fish oil, alpha-linolenic acid. [cited 2017 May 10]. Available from: http://www.mayoclinic.org/drugs-supplements/omega-3-fatty-acids-fish-oil-alpha-linolenic-acid/dosing/hrb-20059372.

 

Posted: 2017 May 10