Stop All Supplements? The Four Filters That (ALL) Doctors and Patients Need
Dear Citizen Scientist,
I’m here to call a timeout on the American healthcare playground. I need those from the holistic and integrative medicine community and those from traditional medicine’s “ivory towers” to huddle up.
Supplements and medications both have a place in helping our number one priority – our patients. And we need to stop throwing each other under the bus over such things.
One of my favourite patients recently felt like a monkey in the healthcare middle, and I’m trying to use her frustrations to help close the gap between my colleagues. My VIP walked into my office holding a stack of paperwork from her recent hospitalization, with a recommendation highlighted at the top that said “stop all supplements.” If you’re a practitioner or recently been a patient, I’m sure you can smell what I’m stepping into.
My 70 year old patient had just flown back from a world-renowned medical institution, where after five days of testing she was left without answers for her chronic fatigue. Despite tens of thousands of dollars on consults and studies from the Pulmonary, Cardiology, Neurology and Internal Medicine departments at the treating out-of-state hospital, she was back in my office, where her Irritable Bowel Syndrome was cured, asking for direction. Her arms were crossed. Her brow was furrowed. And she had reason to be skeptical after reading her discharge paperwork.
At issue were the following statements from the esteemed medical institution, read on.
“Consumers often equate natural with safe. Patients should know that any supplement powerful enough to exert a positive effect on health also may be powerful enough to exert a negative effect.”
I agree with this, however serious negative side effects from ingested or topical supplements are far less common than those from prescription medications. Take a look at the FDA’s Adverse Event Reporting System (FAERS)’s Public Dashboard sometime. The FDA has reviewed over a million deaths linked to prescription drugs.
Supplements contain active ingredients that may interfere with prescription medications and may have adverse effects.”
This is true. Most commonly, supplements can reduce the body’s ability to break down a prescription drug. Doctors are not flying blind here any longer however. We now have a well-established, growing list of supplements that should prompt a practitioner to make an adjustment in dosage of a given medication (see Natural Medicine’s).
“Vitamins and supplements are not regulated, nor studied as rigorously as prescription medications… there can be significant concerns regarding the purity of these products.”
This is one of the greatest challenges we in the integrative medicine community face. The market has tiers – like handbags in Southeast Asia. If you need convincing look at documentaries like Bigger, Faster, Stronger, and publications like the 2015 New York State Attorney General’s report accusing four major retailers of mislabeling and falsely advertising supplements.
And there are other studies highlighting a lack of what is called “pharmacovigilance” in the supplement industry. The only study my patient was given by the hospital was from 2013 that showed less than half the herbal products tested had the actual active ingredient listed on the label.
It’s no longer a secret that there are supplements and there are medical-grade supplements. Too often, studies, news reports and hospital-based doctors are lumping them all together. Medical nutrient/supplement companies (eg. Xymogen, Orthomolecular, Perque) are often run by former Big Pharma employees who meet or beat pharmacovigilance standards of their previous employers.
“There may be unknown interactions (with prescription drugs) with components of supplements that cannot be screened for at this time.”
This isn’t entirely true. There is a newer service now to help evaluate supplement-drug interactions, check out Natural Medicines. And there are other third-party services like examine.com that are critically analyzing and reporting on over 10,000 human supplement studies. We’re beyond the era of supplement ignorance that I experienced in medical school.
“People can often get enough nutrition through their diet to keep nutrients in a normal range.”
I agree it is possible – but, under some rather strict conditions:
- The patient doesn’t have (stress-related) low hydrocholoric acid.
- The patient is eating 4-6 servings of multi-colored vegetables per day.
- The patient’s gut biome hasn’t been ravaged by multiple antibiotics, or the Standard American Diet.
- The patient is tracking their dietary intake and getting a broad metabolic blood panel drawn every 4- 6 months.
- The patient is chewing their food twenty times before swallowing.
- The patient is having healthy bowel movements twice per day.
- The patient doesn’t take multiple nutrient-leaching prescription drugs.
It is the rare American who – in the second half of life – can get optimal cellular level nutrition through their diet alone and without taking supplements.
Medical Nutrition Consults are Complicated
B12 is a great example. With age the small intestine’s ability to sense and absorb B12 drops off. Additionally, hydrochloric acid, needed at optimal levels to absorb B12, drops off with age (stress often reduces gut acid also). Lastly, “normal” serum B12 ranges – as defined by major academic centre’s – continue to increase on a regular basis. We had a patient last week with a normal serum B12 (1100pg/mL) whose hot flashes went away when she stopped her B12 injections. Her system was happier with a B12 closer to 700 pg/mL. We are all still learning, aren’t we?
System Based Doctors Can Help My Cause
Before you declare the “ivory tower” the enemy, let me share the good that their consultation provided for my patient. I diagnosed anemia in my patient months ago, and started her on iron (60 mg of ferrous bis-glycinate). In the stacks of lab tests done at the hospital they noted that my patient’s ferritin had dropped below 50 ng/mL and therefore she should consider supplementing with more iron.
I ran an additional iron panel to corroborate the findings and decided to up her iron dose, with the goal of reducing her (RLS) restless leg medication. I also, however, decided to increase her daily vitamin C dose from 1 gram to 3 grams per day to aid in iron absorption. The hospital’s comments were neither for or against vitamin C: “it doesn’t reduce risk of common colds and may cause diarrhea.” The hospital also encouraged our patient to change the timing of her gut support formulas so that psyllium did not interfere with the absorption of her narcolepsy medications.
I know many other practitioners and patients are dealing with a similar situation, and here’s what I want us all to remember. We are in this together. If those at the major hospitals had it all figured out, we in the integrative medicine space wouldn’t be experiencing a growing number of patient inquiries. Likewise, if we integrative practitioners cracked all the codes on chronic diseases we wouldn’t have patients flying off to visit out-of-state hospitals. Those practitioners and patients in the hospital setting, as well as those in the community, need to apply a four-filter
N-R-P-S challenge to every prescribed medication and supplement:
N = NEED: Is there a true need and how do we assess that?
R = RISK: What is the risk for side effects and what references can be used to assess this risk?
P = PURITY: How can we assure purity of a drug or supplement?
S = SUCCESS: How do we measure success with a medication or supplement? (Is there value?)
In The End, We Compromised
My patient and I put her list of supplements up on my wipe board and ran each of them through the N-R-P-S filter. Together we decided on a stream-lined version of her regimen that emphasized off-setting any negative side effects that her statin might be causing. She admitted that she was omitting some supplements to appease her other doctors, and for now I’m okay with that.
It is easy for me to be critical of the hospital for over-looking the association between CoQ10 deficiency and muscle weakness in statin users. Just as it was easy for the hospital to be critical about my low iron dosage and ill-timed psyllium fiber. For the patients sake can we say “so what?” The bottom line is better attention to detail and better patient care when our efforts are taken together.
If hospital and community-based practitioners keep patients as their number one priority. And patients step up to be more engaged in their healthcare research. And we all keep the N-R-P-S filter present, active and growing, while humbly acknowledging the unknowns on both sides of the treatment aisle. Then we will see medicine accelerate like never before. I have hope.
A Resource from Harvard that can help facilitate the N-R-P-S Filter:
Harvard Health: Making Sense of Vitamins and Minerals