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Rapid Responses: Rapid Responses published:
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Vitamin drops for infants and children still required
- Ann Hobbiss, Deborah Wyles, Community Dietitian for Bradford NHS Hospitals Trust. (26 July 2002)
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Jejunization of the ileum masks malabsorption.
- Joseph W. Arabasz MD PC (27 July 2002)
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Multivitamins are beneficial for age related macular degeneration
- Andrew J Lotery (27 July 2002)
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Lost expertise
- Gurli Bagnall (27 July 2002)
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Am I missing something ?
- Stuart W Dwyer (27 July 2002)
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No evidence??
- david derauf (29 July 2002)
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Re: No evidence??
- Godfrey P. Oakley (29 July 2002)
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Colon Cancer Risk Reduced by Multivitamins
- Thomas F. Heston (30 July 2002)
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Vitamins, Health and Scientific Research
- Luis Vitetta, Avni Sali (Head of School), Charles Barbaro (Senior Research Associate). (30 July 2002)
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Consumption of multivitamin tablets
- Bo O Norberg (31 July 2002)
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Homocysteine as biomarker justifies daily multivitamin recommendation
- Eddie Vos (1 August 2002)
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Vitamin E unconvincing?
- Keith A Grimaldi (6 August 2002)
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Ann Hobbiss, Public Health Nutritionist University of Bradford, BD9 4JL., Deborah Wyles, Community Dietitian for Bradford NHS Hospitals Trust.
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Dear editor, David Bender provides sensible advice regarding the need for vitamin supplements in adults. However, he neglects to reiterate the need for infants and children to receive vitamin drops from age one to five years. The Committee on Medical Aspects of Food recommend that welfare vitamin drops containing vitamin A and D are given to children unless adequate vitamin intake can be assured (1). In particular, infants and children living in Northern latitudes of the UK, those from traditional Asian Islamic communities, those that were pre-term with small vitamin stores, and any child who is on a restricted diet or a poor eater will need supplementation. Given that ricketts is still apparent in some communities in the UK, GPs need to be reminded that these are free to parents who have eligibility to free prescriptions. Committee on Medical Aspects of Food - 'Weaning and weaning diet'. Department of Health report on health and social subjects No.45.1994:Sationery Office. |
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Joseph W. Arabasz MD PC, Private Practice Denver, Colorado USA
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Dear BMJ and Dr. David A. Bender, I hope this note finds you well. I am pleased that the subject of appropriate use of nutritional supplementation is up for discussion, starting with your article on whether or not a daily multiple vitamin pill is really necessary. I have a reference from a Physician in the Caribbean who feels that a regular diet doesn't really replace the multiple nutritional losses that occur with a significant disease such as Tropical Sprue. The implication is, of course, that Pharmacologic doses of vitamins and nutrients might be necessary to overcome nutritional deficits that could be so large as to eventually cause increased Morbitiy and Mortality in humans. Furthermore, the nutritional losses may be so great as to prevent the gut from repairing itself. It appears that the ileum may hypertrophy and actually reabsorb fluid so that the symptom of gross diarrhea isn't present. Since there are few active absorption sites in the ileum, however, the nutrients that are usually absorbed in the duodum may still be deficient. In addition to a significant and deadly Tropical Sprue, which could have a Mortality rate of up to 30%, a Leaky Gut Syndrome may occur when the gastrointestinal tract doesn't have the proper nutritional source of energy and vitamins, etc. to repair itself. The substrate of choice for enterocytes is Glutamine, the essential/non-essential amino acid, meaning that the human body usually makes enough of this amino acid in health to meet bodily requirements, but in illness, especially recurrent illness, or the prolonged NPO state, the body doesn't produce enough and Glutamine must then be supplemented either intravenously or orally. Surgical patients kept on prolonged hyperalimentation without Glutamine supplementation developed villous atrophy of the dudenum and were prone to develop gram negative sepsis. Once Glutamine was added to the hyperal solution, the patients got well. Glutamine also happens to be only one enzyme away from an excitatory amino acid neurotransmitter in the brain, making it possible that a deficiency of Glutamine secondary to an unrequieted and/or recurrent disease in the gut, makes it possible that a Glutamine deficiency might be one of the causative etiologies of the Chronic Fatigue Syndrome. The fact that interferon levels have been noted to be extremely low in patients with a Malabsorption Syndrome is important in that The Chronic Fatigue Syndrome is also known as the Post Viral Syndrome. The persistent presence of only a mildly aggressive virus may be due to the fact that interferon levels are quite low in the patient. It is my opinion that Tropical Sprue is a much more widely distributed disease on our planet than previously thought; quite possibly the same might be said of the Leaky Gut Syndrome. Therefore, I think that a daily multiple vitamin may be quite necessary in people who have nutritional deficiencies, especially when Fatigue or diarrhea are or have been present. I would also speculate that this matter should be looked into further, since the clinical picture and response might be more important than analysis of serum vitamin levels. I have been quite pleased with your BMJ articles; keep up the good work. I find articles to be excellent food for thought. Cordially, Joseph W. Arabasz MD Past Division Chairman, Anesthesiology, Cook County Hospital, Chicago, Ill. Past Chairman, Respiratory Therapy, Cook County Hospital, Chicago, Ill. Diplomate ABA Mensa PO Box 6939 Denver, Colorado 80206 USA | |||
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Andrew J Lotery, Assistant Professor of Ophthalmology University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242
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Sir, Dr Bender states that regarding multivitamins, “supplements will probably do us no good-apart from folic acid taken periconceptually and, possibly, vitamin D by elderly people”. He fails to note that a recent prospective multi-center study demonstrated that a combination of vitamin C, vitamin E, beta carotene and zinc significantly reduced the progression of age related macular degeneration (AMD) (1). This is a significant oversight as AMD is a major health problem. It is the commonest cause of blindness in the elderly in the Western world with up to a third of the population over the age of seventy affected to some degree (2). It is therefore important to disseminate the information that specific multivitamins, as used in this study, will help a very significant proportion of the elderly population. References: (1) A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta carotene, and zinc for age-related macular degeneration and vision loss: AREDS report no. 8. Arch Ophthalmol. 2001 Oct;119(10):1417-36. (2) Klaver CC, Assink JJ, van Leeuwen R, Wolfs RC, Vingerling JR, Stijnen T, Hofman A, de Jong PT. Incidence and progression rates of age-related maculopathy: the Rotterdam Study. Invest Ophthalmol Vis Sci. 2001 Sep;42(10):2237-41. Conflict of interest: none |
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Gurli Bagnall, Patients' Rights Campaigner
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Nutritional deficiencies do not happen only in those with a poor diet. Malabsorption occurs in some instances, and certain medications are known to block the proper utilisation of various nutrients. David A Bender, senior lecturer in biochemistry, makes the comment: “Some 20-30% of the population in developed countries take a daily vitamin supplement. Does it do them any good?” He goes on to discuss the pros and cons of supplements in cancer and heart disease, but what about other signs and symptoms of nutritional deficiency? The causes are rarely investigated and the routinely prescribed, temporary patch-up pharmaceuticals, do not address them. How many patients complaining of feeling tired and depressed are ever tested for iron or B Complex before antidepressants are prescribed? A look at the finger nails alone, may give the answer. Are there longitudinal ridges? Are they thin and splitting or flattened and brittle? Look for white spots on the nails of a person who complains of a loss of taste and smell. These signs and symptoms indicate a zinc deficiency. Dry, red, scaly spots on the skin may be caused by low manganese. Does the patient have muscles cramps, fast pulse and excessive sweating? Anxiety or depression are most commonly diagnosed, but in fact, the patient may simply be low in magnesium. Premature grey hair, sore tongue, palpitations, hair loss, fatigue, irritability and behavioural disorders will not be eased by CBT and psychotropic drugs if they are caused by a low level of folic acid. These are just a few of the deficiencies a family doctor in our grandparents time would have considered before anything else. Today, patients complaining of the same, are generally misdiagnosed or labelled a non-diseased nuisance. Iatrogenic consequences are frequently the result, so who can wonder at why so many turn to supplements? We know that the wrong fuel in a motor will cause damage; that herbivores need plant food, and that carnivores eat meat. Why has the medical profession forgotten that the human body only works efficiently if it receives the correct fuel? Gurli Bagnall, Patients' Rights Campaigner, New Zealand |
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Stuart W Dwyer, Medical Practitioner Grahamstown, South Africa, 6140
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To quote from this article: "There is clear epidemiological evidence that people with a high plasma concentration of vitamin E are less at risk from cardiovascular disease. The Cambridge heart antioxidant study showed a reduction in non-fatal but not in fatal myocardial infarctions.4 While the benefits from reducing non-fatal infarctions are obvious, this is hardly convincing evidence of the benefits of vitamin E supplementation." This seems like convincing evidence to me, or am I missing something...? | |||
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david derauf, Clinical Assistant Professor KKVHC, Honolulu, Hawaii 96819
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While a word of caution from time to time is certainly in order for our vitamin crazed world, the statement :" there is no evidence yet from controlled trials whether or not this ( folic acid) will reduce cardiovascular disease or cancer" can not go without challenge. the first data suggests otherwise, as was shown by Schnyder G et al. "Decreased rate of coronary restenosis after lowering of plasma homocysteine levels." NEJM 2001 Nov;345(22):1593-1600. One study does not allow conclusions, but there is some evidence. |
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Godfrey P. Oakley, Visiting Professor of Epidemiology Rollins School of Public Health, 1518 Clifton Road NE Atlanta , GA 30322
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Yes, there is even more RCT data. Mark and colleagues reported reduction in stroke mortality in an RCT that included supplemental folic acid, B12 and B6. (1) This is the first RCT that I know of that showed a positive effect between a folic acid containing supplement and reduction in CVD. (2) Godfrey Oakley, MD, MSPM 1. Mark SD, Wang W, Fraumeni JF, et al. Lowered risks of hypertension and cerebrovascular disease after vitamin/mineral supplementation: the Linxian Nutrition Intervention Trial. American Journal of Epidemiology 1996; 143:658-64. 2. Oakley GP. Inertia on folic acid fortification: Public health malpractice. Teratology 2002; 66:44-54. |
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Thomas F. Heston, Editor, Medjournal.com Kellogg, Idaho 83837 USA
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To the Editor: The editorial discounting the benefits of multivitamin supplementation by David A Bender (1) contained several disturbing statements, such as the comment that the Cambridge heart antioxidant study (2) showed "hardly convincing evidence of the benefits of vitamin E supplementation." Bender admits that there was a reduction found in nonfatal heart attacks, but for some reason simply dismisses this benefit without justification. Perhaps the most glaring omission was the lack of discussion of several trials showing the benefits of multivitamin supplementation on reducing the risk of colon cancer. The Cancer Prevention Study II cohort of 806 397 US men and women found a modest reduction in colon cancer mortality among moderate to heavy drinkers taking a multivitamin containing folic acid (3). Another prospective cohort study of 88 758 women over a 16 year follow-up period found that supplementation with a folate containing multivitamin reduced the risk of colon cancer (4). In women taking supplementation with a folate containing multivitamin, the relative risk of colon cancer after 15 years compared to those not taking a supplement was 0.25 [CI 0.13 to 0.51] (5). Yet another study of 251 men and 193 women with colon cancer matched against 233 men and 194 women in the Seattle metropolitan area also found that multivitamin supplementation was associated with a significantly reduced risk of colon cancer. This study was significant in that the hypothesis of a causative association was strengthened by the finding of a significant trend between increasing multivitamin supplementation and a decreased risk of colon cancer (6). In addition to the association with a reduced risk of colon cancer, there is a large body of research showing mental health benefits. For example, the finding that prison inmates behave better when they take supplements with vitamins, minerals, and essential fatty acids (7). Overall, Bender's conclusions cannot be justified because they were made using incomplete information and an unjustified dismissal of significant health benefits. Given the large number of trials showing an inverse association between multivitamin supplementation and colon cancer, as well as other health benefits, at this point in time it is more reasonable to support the use of multivitamin supplementation than to discount its usefulness. Thomas F. Heston, MD, FAAFP Conflicts of Interest: none REFERENCES
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Luis Vitetta, Director of Research GSIMedicine, Swinburne University,9 Frederick St, Hawthorn, Victoria, Australia, 3122., Avni Sali (Head of School), Charles Barbaro (Senior Research Associate).
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To the Editor. As Dr Bender rightly points out, recently the American Medical Association's recommendations included that all adults take multivitamins daily.(1) Numerous well conducted cell culture, animal and human studies agree with this notion.(2) Yet Dr Bender still questions the validity of the review. This may in part be due to the conflicting nature generated by the results of human studies. Dr Bender has failed to point out that the failure of some intervention studies to show a result in favor of multivitamins may largely be due to the lack of consideration for scientific rationales developed from laboratory and epidemiological studies. For example, in a recent randomised controlled trial of vitamin E supplementation and macular degeneration, it was concluded that vitamin E was not protective.(3) This is hardly surprising, a plethora of published data indicates that vitamins are organic substances that work in tandem with other micronutrients and not as singular entities, as has been previously shown in cell proliferation studies in humans.(4) Further in another recent study by the Heart Protection Collaborative Study Group recently published in the Lancet(5) a multivitamin mixture was ineffective in affording protection. In this study, it is most probable that the critical stages of endothelial damage to blood vessels or the stages associated with tumour initiation and promotion, those stages that antioxidants have been shown to inhibit, could have been significantly surpassed. Once again a deficit to consider a proper scientific rationale, namely that multivitamins were not designed to reverse an adverse health event such as long standing vascular disease. Once a neural tube defect has occurred for example, no substantial supplementation with folic acid could reverse that outcome. Traditionally we have been brought up on teachings that nutritional deficiencies can lead to vitamin deficits which can then result in disease. We have also traditionally warned and cautioned for good reasons that excess intake of certain vitamins such as vitamins A and D can have serious deleterious effects. Whilst this is true evidence is now accumulating that over active lifestyles with excess tobacco, alcohol and stressful like events can significantly deplete vitamin absorption from food sources.(1,2) We agree with others here in particular Drs Dwyer and Oakley, good evidence based research is available. The current evidence is that regular supplementation will do no harm.(1,5) Regular supplementation could be beneficial.(1,2). Further studies based on sound scientific rationales from laboratory and epidemiological data are warranted though. References 1. Fletcher RH, Fairfield KM. Vitamins for chronic disease prevention in adults: clinical applications. JAMA. 2002; 287(23):3127-9. 2. Prasad KN, Che Pradad K. Cancer prevention studies and recommendations. In: Fight Cancer with Vitamins and Supplements. Healing Arts Press Vermont 2001, Pp 91-98. 3. Taylor HR, Tikellis G, et al. Vitamin E supplementation and macular degeneration: randomised controlled trial. BMJ. 2002; 325(7354):11. 4. Paganelli GM, Biasco G, et al. Effect of vitamin A, C, and E supplementation on rectal cell proliferation in patients with colorectal adenomas. J Natl Cancer Inst. 1992;84(1):47-51. 5. MRC/BHF Heart Protection Study of antioxidant vitamin supplementation in 20 536 high-risk individuals: a randomised placebo-controlled trial. Heart Protection Study Collaborative Group. Lancet 2002; 360 (9326): 23- 33. |
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Bo O Norberg, Dept Int Med, Univ Hosp, SE-90185 Umeå, Sweden
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Editor – Dr Bender correctly emphasises that multivitamin supplements are probably useless, except D vitamin for osteoporosis, and folic acid before pregnancy.1 I would like to add that cobalamain and folate supplements also may be considered in persons above 70 years of age due to a high prevalence of malabsorption and malnutrition concerning these micronutrients in elderly people. 2 Bo Norberg associate professor Department of Internal Medicine, University Hospital of Northern Sweden, SE-90185 Umeå, Sweden bo.norberg@vll.se 1Bender DA. Daily doses of multivitamin tablets. Regular consumption will probably do no good, with a few exceptions. BMJ 2002;325:173-4 2Norberg B. Supplements - certainly [editorial]! Rondel 2002; 12. URL: http://www.rondellen.net |
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Eddie Vos, maintains site http://www.health-heart.org Montreal Qc Canada
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Editor–While the editorial on multivitamin use by D.A. Bender (1) acknowledges elevated homocysteine (Hcy) as potential risk in cardiovascular disease (CVD), he concludes: "... unless our intake is inadequate as a result of a poor diet then supplements will probably do us no good -apart from folic acid taken periconceptually and, possibly, vitamin D by elderly people." One of Dr. Bender's 2 criteria for determining optimum nutritional intake is via biomarkers but he ignores that higher than minimal Hcy constitutes effectively our best, if not only, biomarker for general sub- optimal nutrition in individuals and populations. Hcy reduction involves at least the following nutrients: B2, B6, B12, folacin, choline, betaine, zinc and magnesium. In fact, a high quality multivitamin / mineral containing most of these players will reduce Hcy in just about anybody. Since these nutrients cannot be obtained from a single "food group" Hcy is by far the best biomarker for nutritional status. High Hcy (and/or high Hcy thiolactone, its possibly more deleterious dehydrate) is thus more than an easily lowered risk factor for CVD, cancer, dementia and other diseases, it is our best biomarker for multiple micro-nutrient intakes. Serum Hcy increases with age (2) and with reduced nutrient intakes and Hcy has been firmly linked to CVD risk (3), as well as to dementia and Alzheimer's disease in the Framingham Study -with a doubled risk after >/=8 years, in the >14 micromol/L at baseline group (2). High mean serum Hcy levels of ~17.5 micromol/L were found in frail elderly Dutch (4), values not inconsistent with those in the Framingham population where, encouragingly, in each age group low values of <6 micromol/L occurred, even in 90 - 94 year olds despite a group mean of 26.6 micromol/L. An Irish study reported a 57% incidence of a mutation (non wild-type) affecting Hcy metabolism via just 1 of the enzymes requiring nutrients and vitamins to function effectively (5). The question "to multivitamin supplement or not to supplement" should be answered considering their near zero toxicity, considering high Hcy levels that are the rule and not the exception (2, 4) and considering emerging understandings of wide-spread genetic/nutritional factors inhibiting Hcy metabolism (5). There may be no "satisfactory" multivitamin intervention studies (1) but these may well be impossible if not unethical. However, the Hcy literature is massive (~4 new studies/day) and overwhelmingly points in the direction of benefit -and no harm. Few approaches in prevention are as low-cost and low-risk as over-the-counter multivitamins. If the Framingham Study methodology can serve as guide for "cholesterol management", its Hcy arm should similarly guide potential reduction of CVD, cancer, dementia and Alzheimer's disease risks via "Hcy management", i.e. the recommendation of multivitamin use for nearly everyone. As opposed to, for example, statin drugs and aspirin, no-iron U.S. multivitamin/mineral supplements with average ~9x RDA/RDI/DV amounts of 6 of 8 B vitamins are sold in 6 month supply bottles without child proof caps. For this reason and others, nutrients and drugs should not be judged by the same standards. The argument that lowering Hcy by ~30% with non-prescription supplements should not be recommended because of lack of studies is unfortunate since multivitamins should ease the strain of drug interventions to normalise biomarkers that may well be less deleterious than homocysteine and its derivatives. Eddie Vos (no competing interests, with thanks for his input to KS McCully MD (3), the scientist who gave us the Hcy theory) ref: 1. Bender DA. Daily doses of multivitamin tablets. BMJ 2002;(325):173-4 (July 27) ref. 2. Seshadri S, Beiser A, Selhub J et al. Plasma homocysteine as a risk factor for dementia and Alzheimer's disease. N Engl J Med 2002;346(7):476-83 ref 3. McCully KS. Chemical pathology of homocysteine (part I) Atherogenesis. Ann Clin & Lab Sci 1993;23(6):477-93 ref. 4. de Jong N, Chin A Paw MJ, de Groot LC et al. Nutrient-dense foods and exercise in frail elderly: effects on B vitamins, homocysteine, methylmalonic acid, and neuropsychological functioning. Am J Clin Nutr 2001;73(2):338-46 ref. 5. McNulty H, McKinley MC, Wilson B et al. Impaired functioning of thermolabile methylenetetrahydrofolate reductase is dependent on riboflavin status: implications for riboflavin requirements. Am J Clin Nutr 2002;76:436-441 |
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Keith A Grimaldi, Chief Scientist Sciona PO9 1HS
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Did I read this right: There is clear epidemiological evidence that people with a high plasma concentration of vitamin E are less at risk from cardiovascular disease. The Cambridge heart antioxidant study showed a reduction in non- fatal but not in fatal myocardial infarctions. While the benefits from reducing non-fatal infarctions are obvious, this is hardly convincing evidence of the benefits of vitamin E supplementation. ?? |
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