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How much is too much? Cecily Kelly, M.D. Topics to be covered Recommended vitamins/supplements Pregnancy Osteoporosis High cholesterol Cold Prevention/Treatment Weight Loss Supplements Miscellaneous Overview How much do we use? Survey done by the National Center for Complementary and Alternative Medicine found that 4 in 10 adults had used “integrative therapy” in the past year Vitamins Vitamins A,D,E,K Fat soluble Stored in fat globules It is possible to get too much-hypervitaminosis Vitamins B and C Water soluble Too much Vitamin B Worsen diabetic neuropathy Too much Vitamin C Loose money Vitamin Deficiencies Beriberi-thiamine Occurs in alcoholics due to malnourishment Heart failure Muscle wasting Peripheral nervous system problems Problems with thinking Pellagra-niacin Scurvy-Vitamin C Tiredness, muscle weakness, joint and muscle aches, bleeding gums, rash on skin, loss of teeth Vitamin D-rickets Deficiencies Not seen in developed world because of Adequate supply of food Many fortified foods Too much? Fat soluble Vitamin A-nausea, vomiting, headache, dizziness, blurred vision Vitamin D-excess may cause cardiovascular problems Vitamin E-increase bleeding problems Water Soluble Vitamin C-laxative effect Vitamin B6-skin problems and peripheral neuropathy United States Preventative Services Task Force Has found poor evidence to recommend routine use of Vitamin A, D, or E, multivitamins with folic acid, or antioxidant combinations to reduce the risk of cardiovascular disease or cancer Pregnancy Vitamins in Pregnancy Calcium Keeps bones of mom and baby healthy 1,300 mg/day age 14-18 1,000 mg/day age 19-50 Folic acid Brain and spinal cord development 600 mcg/day Iron Prevents anemia in mom and baby 27 mg/day Folic Acid US preventive services task force recommends supplementation of 400mcg to 800mcg daily for all women capable of pregnancy Calcium Most pre-natal vitamins do not contain enough calcium and expectant mothers must get additional calcium through diet or supplements Osteoporosis Calcium Women 51-70 (Men over 70) recommended 1,200mg/day Two divided doses-body only able to absorb approx 500mg at a time Do not take with medication for reflux like prilosec, nexium, omeprazole Calcium citrate or calcium carbonate Take with vitamin D which helps absorption Food Sources of Calcium Eight ounces of yogurt-300mg One cup of milk-300mg 1.5 oz of cheese-300mg 8 oz of fortified OJ-300mg Vitamin D Adults < 70 600 IU/day Adults > 70 800 IU/day Helps us absorb calcium Also can get from the sun Food Sources of Vitamin D Sockeye Salmon-800 IU 3 oz can of tuna- 150 IU Vit D fortified milk- 80IU OJ fortified- 80 IU Fortified yogurt-80 IU Do I get enough? People typically get 300mg of calcium from their diet daily With the use of sunscreen, long hours spent indoors, or people who live in the northern latitude, overall decreased sun exposure causes pts to not get enough Vitamin D What happens if I don’t get enough? Colon cancer Kidney stones Obesity Hypertension Osteoporosis Bone fracture How much is too much? >2500mg/day may increase the risk of hypercalcemia and kidney problems Kidney stones- >2150 mg/day in postmenopausal women Avoid coral or dolomite (a kind of limestone) because they can contain heavy metals like lead Omega-3 What is it? Essential fatty acid that we must get from our diet Fish Salmon Tuna Halibut Nut oils Why do I need it? Crucial for brain development Involved in growth and development Shown to decrease risk of heart disease Decrease inflammation How do I get it? The American Heart Association recommends two servings a week of fatty fish, such as: Mackerel Sardines Albacore Tuna Large Trout Salmon And what if I don’t eat fish… American Heart Association Adults with no history of heart disease Fish two times a week Adults with coronary heart disease 1 gram daily of EPA and DHA Adults with high cholesterol levels 2-4 grams daily of EPA and DHA How much is too much? Do not take more than 3 grams without a physician supervision Side effects include fish breath, gas, bloating, belching, diarrhea Use with caution if you take a medication to thin your blood or have a bleeding disorder- omega-3 supplements can increase your risk of bleeding Get supplement from an established company that certifies that their products are free of contaminants like lead, heavy metals, mercury Cold Prevention Vitamin C Prevention Might help immune function Most evidence (8 studies) suggests that even in doses of 1 gram a day does not prevent colds Treatment “Some evidence” that taking high doses may decrease sx duration by 1-1.5 days Zinc Prevention Only in vitro evidence (in the lab) that it stops the growth of the common cold No reliable evidence that it can prevent the cold in vivo (in humans) Treatment 9-24 mg elemental zinc started within 24-48 hrs of symptoms to reduce severity and duration of colds (6 studies)-take every 2-3 hrs while awake Other studies show no effect (5 studies) Prevention Echinacea In vitro (in the lab) research suggests it stimulates immune system In vivo (in people) studies for prevention against the common cold has “consistently been shown to be ineffective” (9 studies) Treatment “Some preparations” may reduce symptom severity and duration possibly by about 10%-30% Different species Best evidence with Echinacea purpurea Garlic Prevention May have immunostimulant activity and antiviral If taken between November and February may have one fewer cold episode than patients taking placebo How much is too much? Patients who have autoimmune disease such as RA (rheumatoid arthritis or lupus) may do worse with the supplements that “stimulate” the immune system Echinacea-Ragweed allergies should not use-cross allergy Vitamin C-high doses may increase risk of side effects Zinc-nasal spray withdrawn from market due to permanent anosmia (loss of sense of smell) Garlic-adverse effects like bad breath and body odor, interaction with warfarin (coumadin) causing increase in risk of bleeding What about Airborne? Promotional material “developed by a teacher who was sick of catching colds in class” Contains vit C, vit E, vit A, zinc, echinacea No proof it can prevent or treat a cold Not recommended Others American ginseng- maybe beneficial Probiotics-maybe beneficial for respiratory infection prevention-more in children Panax ginseng-might have immunostimulant effects and protect against colds and improve response to flu vaccine Vitamin E-some evidence that it might help the body build immune response with vaccination Andrographis Astragalus Elderberry- possibly use in treating the flu-antiviral and immune system changing effects Goldenseal Pau d’arco, bee propolis, wild indigo, boneset, Siberian ginseng, larch arabinogalactan Teas-elderflower, rose hips, goldenseal, chamomile, peppermint, slippery else, ginger, Mormon tea, linden flowers, meadowsweet So what can I do? Flu shot every year-Usually starts August-March Hand washing or alcohol based hand gels Hand washing-2 min with soap and water “Some evidence that alcohol based hand gels, which have 62% ethyl alcohol, lower the amount of coldcausing viruses on fingers better than water.”2,3 Weight Loss Supplements “Increase Energy Expenditure” Ephedra (aka Ma huang) May also be bitter orange or country mallow Weight loss of 2lb/month Caffeine Adverse events shown in 50 trials-psychiatric, autonomic, cardiovascular, GI symptoms Another review showed 87 reports of hypertension, abnormal heart rhythm, heart attack, stroke, seizures Ten events led to death, 13 permanent disability-9 of those were at the recommended dosage. Sale was ban by FDA in April 2004 “Modulate Carbohydrate Metabolism” Chromium picolinate Studies of chromium and obesity show no difference between study group and placebo Kidney failure is sometimes related to doses of more than 1,000 mcg a day Uncertain safety profile “Increase Satiety” Forms of soluble fiber Guar gum Relatively safe, also 11 trials with this vs placebo showed no difference Glucomannan Trials show moderate weight loss, but only 20-50 pts in each trial Psyllium Improved glucose and cholesterol, no differences in weight loss Hydroxycitric acid Linoleic acid Green tea Licorice Pyruvate Vitamin B5 Andl-Carnitine Chitosan Dandelion Spirulina Guggul Others So what does my doctor say? “If there is strong evidence for a product’s quality, safety, and efficacy, it may be reasonable to recommend that product and closely monitor the patient.” None of these supplements meet this criteria. Ephedra should be actively discouraged Due to lack of efficacy, patients are discouraged from using: chitosan and guar gum Exercise. Eat a balanced diet. Get plenty of rest. Other Random Supplements/Vitamins Cranberry Extract Prevention-MAYBE EFFECTIVE Treatment of bladder infections- NO EVIDENCE Cranberries are suppose to inhibit bacteria from adhering to the bladder wall It has not been proven that taking “AZO cranberry” can prevent bladder infections 300 mL/day of Ocean Spray Cranberry Juice cocktail, 500mg/day of Buckton Scott’s Cran-Max capsules 400mg/day of Cranactin cranberry caps Acidophilus Probiotic Generally considered to be beneficial because it produces vitamin K, lactase, anti-microbial substances Many uses, mainly used to treat antibiotic-associated diarrhea, acute infectious diarrhea, irritable bowel syndrome relief Side effects: flatulence Glucosamine/Chondroitin Treatment of knee osteoarthritis GAIT trial-1583 participants May help with patients with moderate to severe pain-GAIT trial showed 79% if patients in treatment group had 20% reduction or greater of pain 1500 mg Glucosamine 1200 mg Chondroitin Side effects-upset stomach Melatonin Treatment of sleep disorders Decreases the time it takes for people with a primary sleep disorder to fall asleep Safe for short term use Did not help with how efficient sleep was or quality of sleep Not effective for patients with secondary sleep disorder Side effects include nausea, headache, dizziness, drowsiness St. John’s Wort Treat depression, anxiety, sleep disorders Some scientific evidence that useful for short term treatment of mild to moderate depression Side effects: sensitivity to sunlight, anxiety, dry mouth, dizziness, GI problems, headache Interacts with other medications Gingko Bilboa Widely used for memory impairment, dementia, ringing in the ears, claudication Study of 3000 patients followed for 6 years that were age 75 or older took 240mg a day found gingko ineffective in Reducing incidence of high blood pressure and in lowering blood pressure Slowing cognitive decline Can increase bleeding risk Raw ginkgo seeds-seizures and death Headache, nausea, GI upset, diarrhea, dizziness, allergies Federal Regulation of Dietary Supplements The regulation of dietary supplements is different than that of prescription medications No premarket review needed No prior approval by FDA before marketed Do not have to provide evidence to the FDA before the product is marketed that their supplement is safe, although they are responsible for making sure that it is safe and that claims are not misleading Purity of supplements is relative Things to remember “Natural” does not always mean safe or healthy Tell your doctor about any supplements or vitamins you are taking Interactions with coumadin St. John’s Wort decreases effectiveness of certain prescription drugs References 1. Prescriber’s Letter Vit D and Calcium Document #270102 updated Dec 2010 Prenatal Vitamins Document #270216 Feb 2011 Cold and Flu 2. 3. 4. 5. Self-Study Course #09029 expires Aug, 2012 Widmer AF. Replace hand washing with use of a waterless alcohol hand rub ? Clin Infect Dis 2000; 31:136-43. Sattar SA, Abebe M, Bueti AJ, et al. Activity of an alcohol-based hand gel against human adeno-rhino-, and rotaviruses using the gingerpad method. Infect Control Hosp Epidemiol 2000;21:516-9. NIH:National Center for Complementary and Alternative Medicine: http://nccam.nih.gov University of Maryland Medical Center: http://www.umm.edu/altmed/articles/omega-3-000316.htm Cecily H. Kelly, M.D. Office 830-372-3300 1350 Ashby St. Seguin
