An Apple A Day

If you read about vitamin supplements you must be confused.  Actually, it would be hard not to be. Vitamins are, by definition, essential to health.  Studies of hundreds of millions of people confirm that truth. However, a rash of recent studies have linked taking vitamin supplements to higher rates of a variety of diseases, especially cancer.  What’s up?

The fundamental problem is bad research.  This bad research is the consequence of poor understanding, plus the difficulties inherent in designing and conduct nutritional studies that apply to the real world.  The best examples of the faults in these nutritional studies are probably those dealing with folic acid and vitamin E.  

Many studies show that dietary folic acid reduces the risk of many diseases, particularly cancer.  The prevention of congenital spinal malformations is the main reason our food supply has been fortified with folic acid for decades.  Surveys of the American population show that this approach works.  That is the simple part.  The confusing part is that some studies have shown an increased risk of cancer with folic acid supplementation, while others have shown that folic acid lowers the risk of the very same cancers.

As many of you have heard me explain following your own blood testing, nearly 20% of us have a genetic inability to convert folic acid to its metabolically active form.  Those individuals among us need to take a special form of folate.  If they take the common, most widely available kind of folic acid, not only does it not help, it seems to cause problems consistent with the unhappy research findings. After MERCK, which holds a patent on this form of folic acid, allowed others to use it, I had it added to my multiple vitamin.  Very few multiple vitamins contain this form of folic acid, as it is more expensive.  Two months ago I read an editorial in a major medical journal wherein a couple of prominent experts pointed out that negative studies on folic acid in diabetics had neglected to address this issue.  Their opinion, with which I am in complete agreement, was that these studies were fundamentally flawed and almost certainly drawing incorrect conclusions as a consequence.

Vitamin E has also taken a lot of heat due, to a similar lack of understanding.  Most of the vitamin E you can buy in supplements comes as alpha tocopherol.  Unless you are a chemist, your brain won’t want to swallow that word or distinguish it from beta, gamma, delta or any other tocopherols.  It is not even that simple, because even with all of those tocopherols, an additional class of compounds called tocotrienols are part of the Vitamin E family and seem to be important.  Food contains all of these compounds, and it appears that alpha tocopherol might be the least important of all.  As one vitamin E researcher wrote, “taking a mixture of vitamin E that resembles what is in our diet would be the most prudent supplement to take”.  I would amend that statement to read, “taking a mixture of vitamin E that resembles what would be in an ideal diet and considers your individual needs, would be the most prudent supplement to take”.

A recent survey concluded that very few Americans were low on any vitamins or minerals.  While that got significant media attention, the fact that hundreds of studies have shown the opposite, did not.  Many of those studies actually measured body levels.  That is especially important as estimates from dietary records are woefully misleading.  Dietary records are infamously different from the truth of what people really do eat.  On top of that, absorption varies tremendously from person to person and even time to time for the same person.

Thankfully, there is evidence that some who write about and study nutrition are thinking more clearly.  The “experts” are becoming more expert.  Also, those with a better understanding are getting at least some attention for their criticisms.

Positive evidence of the benefits of dietary supplementation continues to accumulate (of course).  Recent studies have shown that the brains of people of all ages, from young children to elderly adults, function better beginning just days after starting to take a multiple vitamin.  The same holds true of omega-3 supplements. In an example of the complexity of nutrient interaction, vitamin E lowers the rate of prostate cancer but only when taken along with selenium.

Bottom line-

Think critically -  If something is vital, many of us need it.

Don’t forget the food – A vitamin pill cannot entirely replace good food.  

Don’t go crazy -  Take moderate amounts of nutrients as a safety net.

Go crazy if YOU need to -  Some people, especially when ill, need much more.

Vitamins vary – Cheap forms of nutrients cost less, but they are usually a waste of money and can be harmful

The widely disseminated comments of many organizations and authorities would lead one to believe that any possible linkage between vaccination and autism has been entirely disproven.  That is not so.  The theory that there might be a connection is biologically plausible.  One of the most consistent biological abnormalities among children with autism is their limited ability to detoxify heavy metals. It would be a real possibility then that repeated doses of a heavy metal like the mercury preservative, which had been used in nearly all vaccines, would lead to autism in some individuals.  However, a theoretical possibility means just a hair more than nothing.  A newly published study supports the view that there may well be a connection between vaccinations and autism.

The authors of this study analyzed nationwide data to investigate the connection between total vaccination exposure, autism and speech or language impairment (SLI).  Other studies have typically looked for associations between autism and some specific immunization.  When the intent of an investigation is to test the theory that some component, present in many vaccines, might be an autism-causing factor, the design of this study, utilizing the sum of vaccination exposure, makes much more sense.

These researchers took into account the potential confusion created by the timing of vaccine and diagnosis of autism or SLI.  Autism begins before age 2 but is typically diagnosed years later. If vaccinations were causative, those first two years are when the child would have received them.  So, these researchers used total vaccination exposures up to two years of age.  Accounting for the delay in diagnosis, they used the rates of autism and SLI at age 8 for their analysis.  Because the effect would become evident in individuals 6 years after their exposure, researchers compared rates of vaccinations in 1999 with autism/SLI rates 6 years later (2005). They then analyzed these data, controlling for known and suspected autism risk factors.  They also performed statistical tests for potentially confounding health conditions and access to medical care (which might lead to higher rates of diagnosis), finding that these factors did not influence the rates of autism and SLI.

These researchers identified what we call a linear dose-response.  For every 1% increase in vaccination rates there was a 1.7% increase in the number of children having either autism or speech/language impairment.  This study does not prove that childhood vaccinations cause autism.  It does prove that the issue is unresolved and that caution about all vaccinations is warranted.

Thimerosol, the standard mercury preservative formerly used in childhood immunizations, is the preservative in flu shots.  As the institutional authorities of conventional medicine push childhood vaccination for flu, despite little research support of effectiveness, these findings suggest that we might be perpetuating a problem.  Dropping thimerosol from vaccines was an excellent idea.  Why would it be okay to give it to our children in a different shot?

It is nice to report good news. In this case, the good news is that a recent study of prostate cancer found that drinking coffee reduced risk.

It is always essential to view dietary studies skeptically. There are so many reasons they can be misunderstood, or just plain wrong. The world is too complicated to neatly study it. It is very difficult and ethically dubious to conduct ideally controlled dietary research. A little story about such presumptions might help.

One day a student in the homeopathy class I used to teach in the UCSF medical school inadvertently dramatized the assumptions one can make about research overlooking the requirements of studies in the real world. Seeking to discredit my research credentials, he belligerently demanded to know where my lab was. I pointed out that, despite the advantages to science, people just do not like being locked up in cages for the convenience of scientists.

Wild humans, living in their natural environment, have an annoying habit of eating a variety of mixed up food items with such unpredictability that their eating patterns seem almost whimsical. It is as if they actually select what they eat based upon some internal preference or external appearance. They/we are then extremely poor experimental subjects. I hope he went into basic sciences research or had some humanistically transformative experience. He did apologize, so there is hope for his wizened soul.

Although still far from certain, the most reliable research data comes from intervention studies. One group of people, exactly the same as another group, is treated differently and watched to see what happens. Yes, this is potentially every bit as creepy as the medical student’s thoughtless question. Studies of the long-term effects of dietary differences are essentially impossible. Would you volunteer for a study where someone else would tell you what you could and could not eat for a decade or two?

Despite the inevitable weaknesses, this study is relatively compelling. That is because the effect was proportional to the amount of coffee consumed. In other words, a bit of coffee reduced the risk, while a lot of coffee reduced risk a lot. Six cups a day (not unusual in Scandinavia where the study took place) reduced the risk of developing of prostate cancer by 20% and the death rate from prostate cancer by 60%. Coffee would seem then to prevent the worst forms of prostate cancer.

As the risk reduction persisted when the coffee was decaf, the most likely anti-cancer effect is the antioxidants in the coffee. Now, if that theory holds water (sorry), a cup or two of Mediterranean coffee, which typically has 50x higher levels of antioxidants then the coffee most of us drink, should have really powerful effects. It would also be a more tolerable means to achieve the results. Six cups of coffee a day would have me bouncing off the ceiling, not just the walls. Other studies, including studies of high blood pressure and Alzheimer’s, suggest that coffee has benefits beyond the buzz and flavor desired by so many. The blood pressure study specifically considered Mediterranean-style coffee (finely ground coffee heated in water short of boiling temperatures), which is very different from the coffee most of us drink. Due to the uncertainties of such research, the complexity of compounds in “coffee” and the fact that many people react badly to some types of coffee, further study is warranted. Unlike most medical research, I am sure that recruiting subjects will not be a problem!

Forgive me for rattling on about vitamin D, but it is VERY important. The latest news is even more important than usual, and it is notable for at least three reasons, maybe four, if we count the fact that Mother’s Day is fast approaching.

The most meaningful studies are designed as interventional trials, where people are divided into groups, each receiving different treatments, and then their responses analyzed statistically to determine if the treatment had any effect. This study was designed in that way, with women who were pregnant for 12 weeks or more randomly assigned to receive either 400, 2,000 or 4,000 iu of vitamin D a day. Researchers then tracked their risk of major complications of pregnancy, including premature labor, premature birth and infections. The highest dose of vitamin D, 4,000 iu/day, was clearly associated with the lowest rate of complications.

First, this is important because pregnancy complications are serious and common.

Secondly, because showing that doing something has an effect demonstrates cause not just association.

FInally, given official warnings that taking 2,000 iu/day of vitamin D is the safe upper limit, I am impressed that they were able to get the study approved. Human Subjects Committees at research institutions are mandated to block research that endangers the subjects of the trial. For example, 15 years ago, when I conducted the first national survey of alternative medical instruction in US medical schools and family practice residency programs, the Human Subjects Committee at UCSF refused to allow me to resend questionnaires to schools that did not respond to the first one, as they felt that I would be harming them by such a request. Seriously. Thankfully, the particular HSC involved in this case was courageous enough to approve this vitamin D study. As such research is needed and human subjects committee can be ridiculously conservative, this is not a minor event. I find that most patients need well more than the “safe limit” of 2,000 to bring their blood levels up to normal. This “safe limit” is completely wrong and unscientific. It must be changed, and the sooner the better.

A classic study was recently released warning heart patients to avoid essentially all herbal medicines. One commentator recommended that instead of buying herbs patients should save their money and “buy a pair of shoes”. As this publication walks all over herbal medicine with callous regard, the shoes seem to be on the other pair of feet. As the “study” is at best extremely poor, a better use of the shoes might be to deliver a kick to the backsides of the authors of the report and the editorial board of the journal that published it.

Having read several articles about the study, I have yet to find any data contained in the study. That is bizarre. Reviewing the complexities of the data obtained, especially how they were obtained, almost always tells me if the study is decent, in this case the absence of data in the commentary articles is even more revealing. The articles simply gush warning phrases and lists of “dangerous” herbs.

Reading between the lines, this “study” is apparently really just a warning that many patients with heart disease use herbs and take prescription medication at the same time and they can interact with one another. Okay, go on.

Of course prescription medications and herbs can interact. Research has shown that for decades and common sense told us the same right from the beginning. How can two things directly effect the same organ and not interact in some way? At the same time, the authors regurgitate conventional hype about interactions, overlooking considerable research evidence that contradicts those “old doctors tales” as for example, garlic and blood thinning medication.

Instead of this Chicken Little overreaction, a better use of medical journal pages would have been to urge physicians to learn about common herbs and ask patients about their use of herbs. You should be reminded that using prescription medication means you have to be careful about other things you might take and that you should purchase herbs that have been tested for purity, potency and identity.