I remember during medical school that more than one of my faculty used to have a regularly repeated crack that the only thing that taking vitamin supplements could do for you was to produce expensive pee. My first year in medical school was nearly thirty years ago now; so it's been a long time. During the nearly three decades since I first entered medical school, I have yet to see any evidence to persuade me otherwise. If you eat a well-rounded diet, you don't need vitamin supplementation. Of course, none of that stops the supplement manufacturers from trying to convince us that taking multivitamins and various single vitamin supplements is absolutely critical for health and that they can even cure diseases. There's even a form of alternative medicine quackery whose basic premise is that, if a little bit of vitamins is good, a lot more is better. That branch of quackery is known as orthomolecular medicine.
So it was with some amusement that I watched the festivities this week as the Annals of Internal Medicine published multiple studies and an editorial taking the supplement industry to task. The editorial, entitled Enough Is Enough: Stop Wasting Money on Vitamin and Mineral Supplements, was unusually blunt and harsh for a peer-reviewed journal, so much so that it provoked news stories with headlines like How the vitamin industrial complex swindled America:
Questions about the health benefits of vitamin supplements have been percolating in the medical establishment for decades — even as the multivitamin industry has grown to a multi-billion powerhouse in the U.S. This week, the respected journal the Annals of Internal Medicine put its well-heeled foot down."We believe that the case is closed — supplementing the diet of well-nourished adults with (most) mineral or vitamin supplements has no clear benefit and might even be harmful," the journal said in an editorial. "These vitamins should not be used for chronic disease prevention. Enough is enough."
Here's Dr. Edgar Miller of Johns Hopkins Bloomberg School of Public Health, one of the editorial's five co-authors: "What will protect you is if you spend the money on fruits, vegetables, nuts, beans, low fat dairy, things like that," Miller tells CBS News. "Exercising would probably be a better use of the money." The only exceptions are folic acid for pregnant women and, possibly, vitamin D — the studies are mixed on its benefits and risks.
And, from the editorial itself:
Other reviews and guidelines that have appraised the role of vitamin and mineral supplements in primary or secondary prevention of chronic disease have consistently found null results or possible harms (5, 6). Evidence involving tens of thousands of people randomly assigned in many clinical trials shows that -carotene, vitamin E, and possibly high doses of vitamin A supplements increase mortality (6, 7) and that other antioxidants (6), folic acid and B vitamins (8), and multivitamin supplements (1, 5) have no clear benefit.
Despite sobering evidence of no benefit or possible U.S. adults from 30% between 1988 to 1994 to 39% between 2003 to 2006, while overall use of dietary supplements increased from 42% to 53% (9). Longitudinal and secular trends show a steady increase in multivitamin supplement use and a decline in use of some individual supplements, such as -carotene and vitamin E. The decline in use of -carotene and vitamin E supplements followed reports of adverse outcomes in lung cancer and all-cause mortality, respectively. In contrast, sales of multivitamins and other supplements have not been affected by major studies with null results, and the U.S. supplement industry continues to grow, reaching $28 billion in annual sales in 2010. Similar trends have been observed in the United Kingdom and in other European countries.
The large body of accumulated evidence has important public health and clinical implications. Evidence is sufficient to advise against routine supplementation, and we should translate null and negative findings into action. The message is simple: Most supplements do not prevent chronic disease or death, their use is not justified, and they should be avoided. This message is especially true for the general population with no clear evidence of micronutrient deficiencies, who represent most supplement users in the United States and in other countries (9).
So what are the studies that led to this amazingly honest and scientifically justified? They consist of two good studies and the only part of a bad study that I believe. I'll explain. First up is a randomized study out of Brigham and Women's Hospital in Boston that examined the question of whether vitamin supplementation can improve cognition in older men. It's known as the Physicians' Health Study II (PHS II), which is a large-scale, randomized, double-blind, placebo-controlled trial testing the long term effects of multivitamins in the prevention of chronic disease. The study presented here is a substudy of the main study looking at cognitive function. The study has a 2 x 2 x 2 x 2 factorial design and tests vitamin E, β-carotene, ascorbic acid, and a multivitamin in male physicians aged 50 or older. Randomization occurred back in 1997, and, when all was said and done, after continuing participants from PHS I were joined by newer recruits, there were 2,980 subjects receiving multivitamin and 2,967 receiving placebo. Endpoints were assessed using the Telephone Interview for Cognitive Status (TICS), which is a telephone adaptation of the Mini-Mental State Examination (26); immediate and delayed recalls of the East Boston Memory Test (EBMT) to assess verbal memory; the delayed recall of a 10-word list in the TICS to test verbal memory; and a category fluency task. The primary prespecified outcome of the cognitive substudy was a composite score of global cognition (i.e., an average of all cognitive tests). Investigators created the composite global score by standardizing results of each cognitive test using Z scores and averaging them. Because verbal memory is strongly associated with risk for Alzheimer disease, investigators also assessed a secondary outcome of a verbal memory composite score.
To make a long story short, the results of this study, too, were resoundingly negative. There was no statistically significant effect on any of the outcomes measured, and in fact none of them even came close to being statistically significant. Given the number of outcomes examined, that in itself is about as negative a study as negative can be. This left the poor investigators scrambling to explain their negative results. (Remember, no one does a test this large expecting it to be completely negative like this.) They go on and on about how maybe because these were all highly educated men, effect sizes were much smaller and how they were all in general adequately nourished. Of course, that's exactly the point. For normal, adequately nourished people, vitamin and mineral supplementation produces no detectable benefits in general. It's only for certain targeted nutritional deficiencies where supplementation can help, and in some cases nutritional supplementation can be harmful.
The next study is a systematic review of the evidence with respect to whether multivitamin supplementation has an effect on all cause mortality, cancer, and cardiovascular disease by the U.S Preventative Services Task Force, the same group that reevaluated screening mammography guidelines four years ago. Basically, the USPSTF reviewed three primary prevention trials of multivitamin supplements and 24 trials of single or paired vitamins that randomly assigned more than 400,000 subjects. The studies were found using a search of MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Database of Abstracts of Reviews of Effects, which encompassed the time period from January 2005 to 29 January 2013, supplemented with manual searches. Two investigators independently selected and reviewed fair- and good-quality trials for benefit and fair- and good-quality trials and observational studies for harms. Only studies that were conducted among community-dwelling adult subjects in developed countries who were not malnourished and had no chronic disease were included.
If you look at the Forest plots in Figures 2 and 3, which examine the unadjusted relative risk for cardiovascular disease and cancer, respectively, at the longest followup, you'll see that they are about as overwhelmingly negative as can be, with virtually all the studies having error bars that overlap zero. (Unfortunately, this is the only article that's not behind a pay wall; so you can look at the Forest plot yourself. The results for cardiovascular disease were particularly negative. For cancer, there was a study suggesting selenium and calcium might have protective effects against cancer, while there was one suggesting that folic acid supplementation might increase the risk of cancer. All of these studies' effects were barely statistically significant, and the rest were all consistent with the null hypothesis; i.e., no effect. This led the USPSTF reviewers to conclude that "results of vitamin supplementation trials have been disappointing at best, despite having a solid mechanistic basis," further stating that they found no evidence that nutritional doses of vitamins or minerals on cardiovascular disease, cancer, or all-cause mortality.
Finally, the third study is the most infamous of all, the Trial to Assess Chelation Therapy (TACT) study. Regular readers will recall that I've written about this one many times as a misbegotten and unethical waste of $30 million of taxpayer money. You probably only recall this study as testing chelation therapy as a treatment for cardiovascular disease, but recall that it was a 2 x 2 factorial design that tested these groups:
- Chelation plus high oral high dose vitamin and mineral supplement
- Chelation placebo plus oral high dose vitamin and mineral supplement
- Chelation plus oral high dose vitamin and mineral supplement placebo
- Chelation placebo plus oral high dose vitamin and mineral supplement placebo
This allowed Gervasio Lamas, MD, a professor of clinical medicine at the Columbia University Division of Cardiology and now Chairman of Medicine at Mount Sinai Medical Center, who is the PI of TACT, to look at whether high dose vitamin and mineral supplementation had any effect on cardiovascular disease. Recall that the original results of the study showed no benefit in any individual endpoint from the witches' brew of chelation therapy with or without high dose vitamin supplementation. For the composite endpoint used, there was similarly no benefit in everyone except one group: Diabetics. As I put it, normally this sort of finding would lead to the recommendation that chelation therapy should not be used in anyone without diabetes because the best evidence we have from TACT is that it's resoundingly ineffective. Also, as I explained, the "benefit" observed in diabetics is likely due to confounders. Perhaps I'll have to write about that further, as, seeking to divide the study into as many MPUs (minimal publishable units) as possible, Lamas recently published a paper on the diabetics in TACT.
In the meantime, I'll remain "shrill and brutish" about TACT and point out that the most recent MPU from TACT found nothing even resembling a statistically significant effect of the high dose vitamin supplementation on the same composite endpoint consisting of time to death from any cause, reinfarction, stroke, coronary revascularization, or hospitalization for angina, or any of the individual endpoints. This left Lamas lamenting that you can't conclude for sure much of anything because so many patients either didn't adhere to the regimen or dropped out of the trial. Nearly half the patients discontinued the vitamin therapy, and 17% withdrew from the study. Still, this MPU from TACT is about as negative as negative can be.
None of this is surprising.
Of course, the supplement industry is large and has powerful advocates; so its allies were not going to take this lying down. The responses are at best disingenuous and, in one case, hilariously over the top. For instance, Cara Welch, Sr VP of Scientific & Regulatory Affairs for Natural Products Association (NPA), says:
The intention of supplements is to supplement the diet. Don’t expect supplements to cure the common cold or prevent cancer, but they are part of the puzzle of a healthy lifestyle.
In the same article, Steve Mister, President and CEO of the Council for Responsible Nutrition (CRN), laments:
The editorial demonstrates a close-minded, one-sided approach that attempts to dismiss even the proven benefits of vitamins and minerals. It’s a shame for consumers that the authors refuse to recognize the real-life need for vitamin and mineral supplementation, living in a fairy-tale world that makes the inaccurate assumption that we’re all eating healthy diets and getting everything we need from food alone. We would not suggest that vitamin supplements are a panacea for preventing chronic disease, but we hope the authors would agree that there is an appropriate place for supplements. Given that government research repeatedly demonstrates that the typical consumer diet is falling short on critical nutrients, vitamin supplements are an appropriate option to meet those needs.
Hilariously, on the same page is a sponsored link claiming that a supplement called Immmuno-LP20 can stimulate the immune system and fight off colds and infections. 'Nuff said. Well, almost. These two spokespersons are being disingenuous at best and at worst are lying. Of course, the supplement industry claims all sorts of health benefits for vitamin supplementation that go beyond just claiming they are a "part of the puzzle of a healthy lifestyle." I've lost track of how many times I've seen such claims.
My favorite response, however, comes from—you guessed it!—Mike Adams. No one—and I mean no one—brings home the crazy like Mike, and this is no exception. He was quick off the mark to post a characteristic rant of his, Mainstream media attacks multivitamins in yet another example of quack science catapulted into the news by pharma interests. It's replete with cries of "pharma shill!" and dire insinuations of conspiracy to suppress "natural" cures. You really have to read the whole thing. If you're a connoisseur of crankery, as I am, you won't regret it, as it's enormously entertaining in the way that only Mike Adams can be.
The key objections that Adams has to the entire series of articles in Annals are quite predictable, and involve the aforementioned conspiracies and everyone being in the pay of big pharma. Oh, and let's not forget the alleged "double standard":
The answer is because this scrutiny is reserved solely for nutritional supplements. In today's distorted system of quack medicine, junk science and pro-pharma propaganda, medications never have to be proven effective to be promoted and hyped. There is no scientific evidence whatsoever, for example, that chemotherapy prevents the progression of cancer (chemo actually causes more cancer), or that statin drugs enhance lifespan. There is no evidence whatsoever that ADHD drugs create healthy children or that antidepressants cure depression. Yet all these drugs are heavily hyped by medical journal (i.e. "drug journals") and the mainstream media without regard for their disastrous lack of efficacy and safety.
Excuse me a minute, while I wipe the flecks of spittle off of my glasses. So intense is Adams' crazy that they're flying out of my computer screen as I read his screed. Of course, I've addressed many of these very topics, particularly how chemotherapy actually does work, contrary to Adams' lies, does work. In any case, this is a classic case of projection, because the real double standard is with respect to supplements. Thanks to the DSHEA of 1994, the law that hamstrings the FDA with respect to regulating health claims about supplements, supplements are regulated as food, not medicine, which means that the standards are lower, and antivaccinationists can even get away with claiming an industrial chelator is a nutritional supplement, at least for a while. All we're left with, then, are claims by Adams that no drug has ever reversed any disease? Really? Antibiotics do a damned good job of curing pneumonia and numerous other bacterial infections. Chemotherapy can cure some cancers. Adams also angrily dismisses any sort of disease management, such as the use of antihypertensive drugs, as not "curing" the condition, which is besides the point. Until there is a "cure," management is often quite helpful. How many millions of people have avoided heart attacks and strokes because cheap antihypertensives keep their blood pressure under control? How many diabetics haven't lost limbs or vision because of glucose control due to insulin or oral hypoglycemic medicines? Adams posits a false dichotomy, where either a treatment completely reverses a disease process or it's useless. Sorry, but things are not black and white.
Perhaps the most hilarious part of Adams' "argument," such as it is, is this:
To make sure these multivitamin studies fail to produce positive results, these studies are universally structured so that they are based on cheap, low-grade, synthetic vitamins and inorganic minerals. Not coincidentally, these brands of low-grade multivitamins are actually manufactured by companies owned by pharmaceutical interests. They really do have a financial incentive to make multivitamins look bad, and so their multivitamin formulations are intentionally designed to fail.
Which makes no sense. Pharma makes lots of money selling supplements, and the cost of developing vitamin supplements is nowhere near what it takes to develop a new drug, as the massive clinical studies needed to win FDA approval aren't necessary. Supplements are thus nearly pure profit, which is why drug companies and large commercial interests have jumped into the business. As usual, Adams is completely wrong. If anything, pharmaceutical companies have every incentive to want the studies published in Annals to be positive studies, because that would translate into increased sales and increased profits. Hilariously, one of the supplements used in these studies, the Centrum Silver used in PHS II, is manufactured by Pfizer, and, as Scott Gavura points out, the vitamin combinations used in TACT were chosen by naturopaths and "natural" health practitioners themselves. Do you really think Pfizer wants a study concluding that taking its Centrum Silver does no good for seniors? Oh, and Adams' Pinto analogy made me almost spit up my coffee on my MacBook Pro as I typed this. Read it for yourself. You won't regret it. Probably.
Basically, the hilarious thing is that Adams' whine boils down to the naturalistic fallacy, namely the claim that nutrients derived naturally from food products is better. Ironically, that's exactly what the editorial in Annals said in essence, namely that for most people in developed countries who are adequately nourished through food (who, by the way, make up the vast majority of supplement users), vitamin and mineral supplements are unnecessary and do not prevent chronic disease. The message from the evil medical cabal portrayed by Adams is to get your nutrition from your food. The evil medical cabal also recommends elsewhere to consume a diet high in vegetables and fruits.
I can't help but finish by noting another thing Adams says:
If you want to take supplements, invest in high-end, quality supplements based on food concentrates or food extracts. Nutrients derived from real food tend to be far healthier than synthetic nutrients.
Again, that's exactly what the editorial says, that nutrients derived from real food are good enough such that supplementation is unnecessary. However, note the first part of what Adams says: Invest in "high-end" supplements. Those "high-end" supplements are also the highest profit supplements. I'm guessing that's going to be the next supplement cabal retort to science: Don't use those cheap, pharma-produced supplements. They aren't the real supplements. Use our high-end, natural supplements instead. They're the real deal.
Next step: Continue to profit!
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I love this one from the industry hack:
Ummmm ... this was a study that followed, uh, actual people? Who eat, like, whatever they eat? Who aren't being fed carefully balanced diets as part of the study?
Sometimes upspeak is just the thing.
The editorial demonstrates a close-minded, one-sided approach that attempts to dismiss even the proven benefits of vitamins and minerals.
Take your protein pills and put your helmet on, Mr. Mister. (Sorry for the mixed musical metaphor.) That whole paragraph is a steaming mass of [citation needed].
While I can't rebut this from the perspective of being a scientist, I can in a way by using a tool that many scientists will use, and that is observation. My observation come from many years of owning and running a restaurant, so its fair to say I've seen a lot of people eat, what they are willing to spend to eat healthier, how they react to us promoting how we are trying to use healthier ingredients, Etc.
People will talk a good game about wanting to "eat healthier" but their actions prove otherwise. Now I have no way to correlate this with who was or who wasn't using supplements, but based on just the total sample of my customer base, a high percentage of people do not care all that much about making sure they are eating healthy. On the other hand, many of them, based on reactions we see to the way we would offer healthier options, know they should be eating better. So to me the bottom line is, to attack supplements saying, "oh people should just eat healthy" is overly simplistic and misses the point. People do not want to eat healthy, for all kinds of reasons, and many of them will take supplements as a way to counterbalance that.
Mike Adams must be a master of selective reading because he and Dr. Edgar Miller vote promote a healthy diet, but since the latter's recommendation didn't also include massive doses of organic, all natural vitamins from food concentrates I see how he'd miss that.
If "nutrients from real food are good enough that such supplementation is unnecessary" they have an additional ruse:
they sell 'real foods' - freeze-dried organic GMO-free fruits and vegetables ( see Natural New 'store') and dried vegetable/ fruit/ herb powders ( see Gary Null.com) as well as "healthy" candy bars, "superfoods" and other arcane exotica ( berries, nuts, roots, herbs).
I'm sure that they'll also hawk supplements for "health and beauty" or "anti-aging".
BUT they're still shrieking about how the entrenched powers-that-be will do anything to discourage "healthy living" so that the medical mafia will profit off of suffering and disease.
It's just their way. But I do hear a hint of desperation lately.
Oh goodie.
"I'm purposedly selling a bad product so my customers will stop trusting my concurrent across the street"
Yep. Looks like a sound business model.
I was tickled to recently see a TV ad for Centrum Silver, loudly proclaiming that it was the vitamin used in large national study! Since this ad came out AFTER the the Annals article,no mention was made the results of that study...
Purely for entertainment value, I listed a variety of foods/ quasi-foods currently available from the aforementioned woo-ful websites:
camu camu powder, spirulina, chlorella, cacao, coconut, mangosteen, maca, turmeric, Himalayan salt, spices, probiotics, protein powders, chia seeds, freeze-dried organics, herbal tinctures, energy bars, raw foods ( nuts, fruits, corn) AND heirloom seeds for 'growing your own': NN
Cruciferous Stuff, Fiber Stuff, Garyade ( sports drink), Green Stuff, Greens and Grains, Heavenly Aloe ( drink), Muscle Stuff, Pain Stuff, Power Berry Blast, Red Stuff, Red Stuff Original, Ultimate Lifetime Diet Shake, Coco Magic Bars: GN
Both also offer skin and hair care products and dentifrices.
PLUS other crap.
I agree with nearly everything in this post, but as I pointed out at SBM too, the PHS II study found evidence that low-dose multivitamin reduces cancer incidence compared to placebo, though the effect is rather small:
HR 0.92; 95% CI, 0.86-0.998; P = .04
http://www.ncbi.nlm.nih.gov/pubmed/23162860
I have seen (vague) complaints about their methods for adjusting that HR estimate, unadjusted is claimed to be RR = 0.94 (95% CI 0.87 to 1.003).
Note: this doesn't factor in costs (of pills, hassle, other problems besides cancer), and I feel it's likely that you could have spent the money on better diet and gotten even more benefit (I have no data though, so be suspicious, and intending people to eat better is different than actually getting them to do so). Also note these are just older male doctors, not general public.
Speaking of other problems, overall mortality got HR = 0.94 (95% CI 0.88 to 1.02). Since I started not very biased toward supplement being ineffective, I am now somewhat biased in favor of the supplement helping. Maybe worth more studies is my conclusion, but they'll need to be massive, like this one. Small effect for vast numbers of people, if that happens, just might be found to be worth something. We'll need careful costing out to determine if it is worth it.
I don't take supplements for myself, but I do give my kids their Flintstones. Since these studies are focused on adults, does anyone know of any studies showing benefits or the lack of benefits, for children's supplements?
BUT they’re still shrieking about how the entrenched powers-that-be will do anything to discourage “healthy living” so that the medical mafia will profit off of suffering and disease.
That was my first thought when all of this came out, as well. Another set of science-based studies showing that, yes, in some instances, eating decently is better than taking a pill. But because it's a pill that Mikey peddles, suddenly his usual caterwauling about lifestyle being more effective than pharmaceuticals does a complete 180.
People do not want to eat healthy, for all kinds of reasons, and many of them will take supplements as a way to counterbalance that.
Palindrom @ #1.
@ Roadstergal:
In truth, they've both been selling foods/ quasi foods for quite a while but these products are ALSO means to avoid eating a balanced diet-
people make poor choices and then down a few supplements, candy bars or smoothies made with superfoods or Stuff (tm).
Alt med ideas of a balanced diet however cannot be fulfilled by most normal mortals- GMO-free, organic, vegan, raw etc etc etc and don't resemble SB dietary guidelines.
As opposed to ... ?
Incidentally, I think this is a fairly unhelpful thing to say. People, particularly ones of the worried well sort, will, not entirely unreasonably, will ask themselves how they'd know their diets are well-rounded enough, and some of them will conclude that taking supplements is a sensible precaution. It doesn't help that the deluge of more-or-less sensible nutritional claims in the media is apt to leave anyone not expert in the subject bewildered as to what constitutes a healthy or rounded diet.
Since, as palindrom observes, the typical American's diet - unhealthy as it's widely considered to be - is evidently well-rounded enough, it might be more helpful to say "If you eat at least as well as the average guy at McDonald's, you don't need vitamin supplements", or something to that effect. Get the point across that one doesn't need to eat particularly well to do without supplements, just not to eat way worse than average.
This is my shocked face. -_-
I totally agree with you that people should eat real food rather than relying on long-term vitamin supplements - though this too seems to be objectionable to some strains of scientism - but to be entirely fair you should have noted that the PHS II study that showed no cognitive benefit of vitamin use previously reported a modest but statistically significant reduction in cancer rates associated with vitamin use.
I'm assuming the answer will be "no", but is there any shred of evidence that in the general case "synthetic" vitamins are any different from "natural" ones?
Is it just the naturalistic fallacy, again?
(I recall one vitamin, perhaps one of the Ds, had a synthetic form that was not the same chemical as the natural form, and that might have made some difference.
But that's not the general case, as far as I know - and equally if the synthesis was altered - more expensively! - to produce the same chemical rather than a notionally-equivalent one, I'd expect identical results...)
@ Sigivald: Good website for you to find information about Vitamins and Supplements; the NIH-ODS (Office of Dietary Supplements):
http://ods.od.nih.gov/search.aspx?zoom_query=vitamin%20d
Why, when the USPSTF review of studies, including if I recall correctly, PHS I, came to a negative conclusion with respect to supplements and cancer?
The intention of supplements is to supplement the diet. Don’t expect supplements to cure the common cold or prevent cancer, but they are part of the puzzle of a healthy lifestyle.
Actually, no...the puzzle is complete for most people without them.
@13 Andreas Johansson
Err, if you read Mikey's screed carefully he's advocating "organic minerals" a few paragraphs further down. I wonder who is supplier is?
I’m assuming the answer will be “no”, but is there any shred of evidence that in the general case “synthetic” vitamins are any different from “natural” ones?
My intuition is also that the general answer to your question is "no", though as you note, there are specific exceptions.
Minerals are a different story. Take chlorine, for instance: it can be an ion with charge state -1 (which is the form in which the body prefers it), or it can be in molecules where it has 1, 3, 4, 5, or 7 covalent bonds (most if not all of which are poisonous). Other trace elements may have several different charge or bonding states, especially those outside the alkali and alkaline earth metals (the left two columns of the periodic table). I don't know for sure if this is the case, but I can envision some of those elements being absorbable in some states (particularly the ones occurring in food) but not others (which may be what the supplements are providing). The latter would tend to give you expensive feces as well as expensive urine.
Additionally, some vitamins (C and the B vitamins, particularly) are water soluble, which means that if you consume more in a given period than your body can absorb, the excess goes out the urethra. Other vitamins (A and D) are fat-soluble, so you can buffer those to some extent, but there are also limits there: it's possible to die from an overdose of fat-soluble vitamins (as in other things, the dose makes the poison).
No need to flush your expensive, multivitamin-laden urine down the toilet - recycle it!
Devotees of "urine therapy" can benefit multiple times from the same dose of vitamins, plus absorbing all that other goodness from their liquid bodily waste.
I'm really pissed off (sorry) at having missed the latest World Conference On Urine Therapy. Too bad the shrill, brutish allopaths succeeded in scrubbing any mention of it from the mainstream media.
This injustice will one day pass.
http://www.sandiegoreader.com/events/2013/nov/13/65780/
Orac @19: "Why, when the USPSTF review of studies, including if I recall correctly, PHS I, came to a negative conclusion with respect to supplements and cancer?"
Not sure it's as negative as folks think.
From that paper:
"When SU.VI.MAX's findings in men were pooled with the PHS-II results, the unadjusted relative risk for all cancer incidence was reduced over 10 years of follow-up (unadjusted pooled relative risk, 0.93 [CI, 0.87 to 0.99])."
Also "We found a statistically significant protective effect from multivitamin supplementation when we pooled data for men in these 2 trials. The borderline significance level in both studies and the lack of an effect in women in SU.VI.MAX suggest we should not try to overgeneralize these results. "
The SU.VI.MAX study actually found a significant sex by treatment interaction - not so easy to do cause power for testing an interaction is low compared to main effects.
I certainly agree with not overgeneralize though.
I'd argue they aren't being Bayesian enough too. What's our prior on the chance of less cancer or all-cause mortality in men?
Concerns were initially mentioned in #9 and #16.
I'll add:
Guys, eat more vegetables, the women might be beating us that way.
Just a theory. I have others: HSP27 (aka HSPB1) is estrogen responsive, higher in womens tissues, and why some think they get less esophagus cancer.
Warning to self and others: It's easy to come up with just-so stories after peeking at the data. Famous method of self-delusion.
Although not entirely negative, it's s a pretty negative study. We're talking super borderline statistical significance here. For example, for all cancer sites in Appendix Table II, the 95% confidence interval for the adjusted RR was 0.82 to 0.998. I've never seen a confidence interval in a clinical study get that close to including 1.0 without actually including 1.0. All the other confidence intervals encompassed 1.0.
Personally, I think of these trials the way a clinician does, rather than a statistician, because statistically significant does, particularly when it's so borderline, does not necessarily mean clinically significant. This is the classic example of a study that barely achieves statistical significance (and really, really, barely) for its result, which is almost certainly not clinically significant. Add the Bayesian treatment in, and this is almost certainly a negative study.
Rich @3:
Most people don't eat at restaurants all the time. If someone is thinking of the restaurant meal as a treat, they may well go for the rich sauces that they don't make at home, followed by a nice big dessert. But the person who had that big dinner out probably didn't have similar breakfast and lunch that day.
If I just want a salad, I usually make it myself at home; I'm much better at making a mixed green salad than at making something with a complicated sauce that requires careful timing.
That said, I am glad restaurants have salads on the menu: sometimes I'm out at a restaurant for the company, or suddenly realize it's past my lunch time and I need to eat something right away, and why not a salad?
Vicki, you are right on. Not only that, but expensive. If I'm spending money to go out, I'm going to be a little more indulgent. That's not to say some people don't eat like that all day, but for me, a restaurant is a treat. Sometimes I'm indulgent at home, but it's certainly not the norm.
the 95% confidence interval for the adjusted RR was 0.82 to 0.998
Keep in mind that the choice of 95% confidence as the marker of significance is conventional. There is a good reason for that choice in research involving human subjects, namely that it is often difficult to get a big enough sample size that the research team can use a more stringent test of confidence, such as 99% confidence, or the 5σ confidence level typically demanded in particle physics experiments--the physicists use that level because (1) they can and (2) there are documented cases of effects which appeared significant at levels between 3σ and 5σ but disappeared when examined at the 5σ level. But the 95% significance cutoff (known to physics types as 2σ) comes with the risk of an occasional false positive. With a sufficiently large sample size, a research team could justify using a more stringent significance test (I don't know whether this is true for the study in question), and with the null hypothesis lying just outside the 95% confidence interval, I would not be surprised if a more stringent test (assuming it is justified) would fail to exclude the null hypothesis.
Orac: "Why, when the USPSTF review of studies, including if I recall correctly, PHS I, came to a negative conclusion with respect to supplements and cancer?"
Because when the same study reports that an intervention has a statistically significant effect on one disease and zero observable effect on another, touting one of those results as definitive and rejecting the other as meaningless is hard to justify by purely logical criteria.
I agree that "generally well nourished" is a poor choice of words. Many people do not believe that their diet is particularly healthy, and in fact most people don't eat all that healthy a lot of the time. You hear, "You don't need vitamins if you just eat right!" and you start thinking about how you've only had one serving of veggies yesterday and no fruit at all, and about that piece of cake after lunch, and your hands inch towards the vitamin bottle.
However, what the evidence shows is not that some theoretical ideal diet keeps people healthy, but that the typical real-world American diet provides adequate micro-nutrients. The stuff we're doing wrong is eating too many total calories, not enough fiber, and too much fat, salt and sugar. Vitamin pills aren't going to make up for any of that, unfortunately!
(Or, of course, you can be a conspiracy theorist and believe that the RDAs are way way too low, or that the soil is depleted and veggies have no vitamins left in them.)
“ If you eat a well-rounded diet, you don’t need vitamin supplementation.”
The vitamin crowd will jump on this and only smile at your “ignorance”. They confuse well-rounded, meaning to eat a variety of foods, with HEALTHY ,a term becoming almost as useless as “natural”.
Even if people eat a standard diet and are fat, they are not likely to be vitamin deficient, nor would they be any “healthier” if they take vitamins. It’s almost reasonable to state that no matter how poorly you eat, vitamins won’t substitute for changing your ways. It’s rather like weight loss--you will get just as fat on organic chips if you eat them all the time.
If you eat poorly, start eating better. What’s so hard about that?
@Young CC Prof
Thanks, that's good to know. I have an unfortunate tendency to fall back on the typical grad student "ramen and frozen pizza" diet, so I've often wondered if the whole "you don't need vitamins if you're eating a balanced diet" thing applies to me.
Long-term vegans may exhaust their stores of B-12 in a decade or so and do need some form of supplementation. No mention is made of the specific content/composition of these older physicians' diets, only that it is presumed to be normal. Statistically, then, five to ten percent might be expected to have a purely plant-based diet that needs extra B-12. I'm skeptical of any generalization that isn't fairly detailed about what this presumed "normal" diet consists of.
Well, damn. It seems I've fallen for causation-correlation fallacy, fooled by regression to the mean, and maybe the placebo effect.
I have relatives with pernicious anaemia so we (my doc and I) keep an eye on it. Four years ago my doc said my B12 levels were borderline low, and I should take a supplement like Centrum Silver. Next two blood tests my levels were normal again.
Fortunately, I haven't wasted too much money. I usually don't bother taking them, and only take them for a couple of days when I'm feeling unusually tired (or more regularly when I have blood tests coming up--kind of like cramming for a test and I'm sure as equally uneffective). After a couple of days of taking pills, I feel good again.
I'll repeat: Damn. Thought it was actually doing something for me even though I was aware of sample size of n=1, cognitive biases, etc. I broke Fenyman's First Principle of Science. "You must not fool yourself....and you are the easiest person to fool".
Think I'll go home, stare at myself in the mirror, and repeat myself a third time.
Incidentally, not a vegetarian either. Eat fish and chicken, turkey, although I don't eat red meat unless it comes as spicy sausage with pineapple and red peppers on a pizza.
AND straight from the horse's mouth:**
Gary Null takes on the study
( @ progressiveradionetwork.com/ garynullshow/ yesterday/ 2 minutes in-24 minutes) also shown as an article
Exhibiting rather pressured speech, he discussed the two "flawed studies" which were most likely funded by so-called consumer groups which can be traced back to pharma.
They have "grievous methological flaws"; the research is "reprehensible" and "gutteral science"- " a perversion of science" due to many "design flaws" - the adherence rate, the drop out rate, a weak questionaire that relies upon recollection- unlike his own "47 clinical studies with 40,000 subjects". The studies used low doses of inferior supplements- unlike his own spectacular products.
He has been able to find a multiple of studies that show that supplements work against cognitive decline and CVD.
Thousands of them.
Shame on the publication's editiors, shame of the NYT/ Washington Post editors etc. He challenges them: he calls for a boycott for supporting such "gutteral science".***
** I know, I know, I shouldn't associate an innocent animal with such material
*** quoted verbatim, twice.
@Dan J. Andrews
I'm sure no one here would want you to disregard your doctor's advice to take a supplement for a known vitamin deficiency. What's being addressed here is the question of whether taking a multi "just to be safe" improves health outcomes for people without any vitamin deficiencies.
I actually should be supplementing my diet- despite eating a fairly healthy variety of food, I continually test as near anemic. Women tend to lose iron pretty quickly.
Was there not a recent study showing that people who consumed vitamin supplements had slightly worse health than baseline?
I'd be most interested to see the mortality rate of consumers of anything with a name including "Quantuum" with the general population.
@ Spectator:
Yes. There have also been studies involving risks associated with separate nutrients like beta carotene, one component of b complex, calcium, omega 3 etc. I think Harriet Hall wrrote about this a few months ago @ SBM.
@ PGP:
It will be better in 20 years. Trust me.
@Denice.
Yep, that's when you can stop taking iron and start the hormone replacement therapy
@ Shay:
Believe it or not, I don't take any meds. Oh, OTC allergy and sinus meds as needed. I never took iron either.
I'm not sure these studies are talking about someone who takes a single one-a-day multivitamin each day. I agree, they are probably wasting their money, but I don't really feel the consequences are earth-shaking.
It's the megadoses, massive pill-popping, and taking stuff that is just plain weird that concern me. That, and the high incidence of contamination and adulteration in supplements, makes supplementation a game of Russian roulette for the people who brag of taking 40, 80, 100 or more supplements per day.
DW @37
I think you have the wrong end of the horse there.
DW @3
Wouldn't that pay havoc with the "vital life essence" of the food-like substances? I haven't heard of the archeologists finding any Blackfoot freeze driers at the Head Smashed In* buffalo jump site.
*Named after an early Darwin award winner who sheltered under a ledge to watch the bison fall past him. Unfortunately he leaned a little to far out and was found under a heap of Bison with his head smashed in.
@Spectator:
Here it is! See Scott Gavura @ SBM today- he links to Mursu et al, The Iowa Women's Health Study, wherein older women who took supplements had an increased mortality rate. There is also the Harriet Hall piece, a few months ago.
@ Militant Agnostic:
Ha!
Not sure about the vital life essences of arcane food-like substances and COLD ( suspended animation, perhaps?)
BUT we all *know* that any temperatures above 115 degrees F will kill the vital essence so drying or cooking has to be at low temps.
ALSO we can't forget that a plant-based diet is high in ORAC ( not THAT Orac) and phyto-nutrients ( sometimes called "fido-nutrients" by lazy-mouthed woo-meisters- good for your pets too!) i.e. Nature's own Pharmacopaeia !
I can't help but think of that line "Cows eat plants. I eat cows."
@Politicalguineapig: If you always test as "near-anemic" you should ask your practitioner if you might have thalassemia-beta minor, which my wife has. They kept trying to supplement her all through her childhood, without success. "Thal minors" are perfectly adapted clinically to their near-anemic red cell counts, and taking extra iron will do no good and can raise body iron storage to toxic levels. If your counts persist on the low side despite supplementation you may want to consult a hematologist.
I am a rare woman who was never anemic, not even while pregnant (which was a surprise - I had rather severe hyperemesis from 6 weeks until 24 hours post-partum). Though I dutifully take prescriptions, I have a general dislike of taking pills, and every supplement I was sometimes tempted to try and all the "cures" Mr Woo has purchased for me never were taken more than a few doses before I mostly forgot them.
I found it interesting that the chelation study had so much trouble with continued compliance by study participants. I have to wonder if it was the length of the study or possible side effects to the chelation or supplements. I know that iron supplements almost always make me nauseous, and a few other types of supplements have treated me similarly.
Mr Health Ranger and his marketing - fascinating (and you have to wonder if this was a planned response from the beginning if the results weren't helpful). "It isn't that you don't need supplements! You just need to buy my supplements.
I too agree that we need to drop the "well rounded diet," for the very flaw a commenter made above, imagining that the typical diet isn't good enough so you should take them just in case. But that's absolutely false.
The proper advice is: Don't take any supplements or multivitamins unless your doctor specifically tells you to, period.
he calls for a boycott for supporting such “gutteral science”
Was it performed by Klingons or something?
I have taken supplements twice in my life. The first time as a teenager full of acne angst and the supplement was Vitamin A. Yes I was aware that in large doses Vitamin A is toxic and was careful not to overdose.
It didn't work.
The next time was when I was undergoing R CHOP 21 for Diffuse large B cell Lymphoma. It was a multi-vitamin and mineral supplement and I checked with my hematologist before taking it. I only took half the recommended dose and did not take it during chemo week. While I cannot say it worked I did not suffer from mouth ulcers or constipation which is common in people receiving R CHOP. I did however suffer all the other usual side effects like nausea, hair loss and fatigue. If I ever have to go through it again I would take the supplements.
Other than that I would prefer to get my vitamins and minerals from the food I eat. It definitely more enjoyable than swallowing pills.
A couple of comments (okay, three... so a threesome of comments):
1) Vitamins may be supplements, but when alternatives (where did the term "woo" come from, anyway? I don't want to use a term I don't understand if someone can explain it... woo as in romance or win over?) talk about taking upwards of 150 supplements a day, they are not talking about vitamins (mostly). Things like mistletoe extract, cannabis oil, scorpion venom, and many, many varieties of herbs come in supplement form. Many cancer patients take a shotgun approach and just take them all hoping something will do something. I've noticed some confusion with some in the comments of various posts on here about why someone would take so many vitamins. They aren't taking vitamins (mostly). I realize that this post isn't really about this, but I did want to clarify since just using the word "supplement" can cause confusion when it's referencing multivitamins and has another meaning in the alternate therapy realm.
By the way, Tumeric (mentioned somewhere above) contains curcurmin (a widely used anti-cancer supplement even for those using conventional therapies) and has been shown to have some anti-cancer properties in legitimate studies, so watch what you're calling snake oil.
2) Too much Vitamin D can lower your mortality according to several studies
I don't have a link to the studies. Just to the blog that posted transcripts from them. There is a sweet spot where not even Vitamin D lowers mortality, enough raises it, and too much lowers it again (kind of like Vitamin D and the three bears. You want the dose that's "Just right.")
Here is the blog post (an honest blog by a woman pursuing alternate therapies and regretting her decision because they didn't work... she posts lots of scientific studies on her blog):
http://bisforbananascisforcancer.wordpress.com/2013/11/27/supplement-vi…
3) This little gem was from the same blog:
http://www.dailymail.co.uk/health/article-1263787/Do-multivitamin-pills…–says-study.html
An excerpt:
"Experts from the Karolinska Institute in Stockholm, Sweden, tracked more than 35,000 women aged between 49 and 83 over a ten-year period.
They found those who regularly took multivitamins were 19 per cent more likely to have developed a breast tumour.”
So, yes, taking vitamins in supplemental form can even be harmful.
My dad had kidney failure his doctors said from taking too much Omega 3 fish oil. He almost died. Once he stopped taking it, he was fine. He was taking a LOT! He almost OD'd on vitamins! Imagine that.
Orac@26:
I'd love to wager on whether estimated HR is bigger or smaller than 1 on the next studies like PHS II for older US men. I'd be giving odds around 5 to 1 in favor of HR<1. True HR=.97 would matter since we are talking about millions of people.
Eric Lund@29: this is not arm-chair quest for truth, this is gambling. Two kinds of errors are possible, and making either of them means killing people.
I took B-complex for a couple of months, to go with the B12 injections after being diagnosed with pernicious anemia. Patient support groups online advocate that everyone on B12 therapy should do so, because "all B-vitamins work closely together". I stopped taking them when I couldn't find any reliable evidence supporting that B12 deficiency is treated more effectively when B-complex is added. Never noticed any difference.
Even if someone had a coexisting deficiency in say B1 or B3, B12 would still treat any symptoms of B12 deficiency. Someone with B1 or B3 deficiency would develop beriberi or pellagra, not pernicious anemia. So exactly how closely do B-vitamins work together anyway? It's not as if B12 cannot be used by your body if you lack sufficient B1 or B3. It's different when you have coexisting folate deficiency, but that would call for supplementing with folic acid, not B-complex.
@ Mary ( quite contrary):
"Woo" suggests the exclamation a person vocalises upon seeing or hearing something truly amazing - "OOooo!" or "Woooo!" as well as the eerie sound of a theramin in ancient sci fi films- hinting of mystery and otherworldliness.
I think that the concept of "wooing" the mark is also apropo.
I personally visualise woo as a viscous, oleogelatinous near-liquid that seeps and flows into imaginable any nook and cranny and which is nearly impossible impossible to wash off. Think of malarial swamps and industrially contaminated quagmires.
"I keep my finger on the pulse of woo-
and am always careful to wash my hands afterwards".
EDIT
into every imaginable nook and cranny and whichis nearly impossible to wash off..
@Mary,
I think the reason that turmeric is often lumped in with snake oil is that naturopaths and other alties have jumped on it as a cure all without any convincing evidence that it actually is.
True, there are some preliminary studies that suggest it has anti-cancer and anti-inflammatory properties, but they mostly seem to be in mouse models, which doesn't always translate well to humans. In addition, even if curcumin (the main active ingredient in turmeric) is effective against cancers in humans, it's rather likely that the dosage required to maintain the effect will be much larger than what's found naturally in turmeric, so eating one tablespoon of it a day is probably not going to do anything for you. Finally, curcumin is not very water soluble and easily broken down in your system, so even if you eat a bunch of it, most of it is probably going to do diddlysquat.
So in essence, more research into curcumin is good and may yield some useful drugs in the future, but eating a bunch of turmeric is highly unlikely to do anything other than making your food taste better.
If you sit and gnaw on a turmeric root, that's true, but if you eat it with fat - like in a traditional curry - it is far more bioavailable. There have been studies showing oral cancer prevention in betel-chewing humans with leukoplakia as well as some sort of hamster. It's hard to prove the benefits of eating traditional real-food diets in humans; you can do epidemiological studies until the cows come home, and pair them with animal studies showing benefits for plant after plant, but people can still say none of it is "rigorous" because you did not have genetically similar humans raised in cages and compelled to eat the Standard American Diet vs. the SAD plus one botanical at a time. Yet, all else being equal, age-adjusted rates of cancer and other chronic diseases simply are lower in people who eat traditional diets rich in plant foods.
ORD: Thanks for the advice; I hope you don't mind, but I'm saving that post to my word processor for posterity.
Thanks for the non sequitur. How did they get the hamsters to chew the quid? Do you mean this?
People are eating betel now? P. betel or A. catechu?
I know how to make curry. If you're using a tablespoon or more of turmeric per serving, you don't.
Do you have evidence of this?
Uh-oh. Wait, what?
@Dangerous Bacon #23
EWWWWW! I had heard this practice existed, but really really didn't want confirmation.
EWWWWW!
(people are weird)
@ Denise #56
Okay, that makes sense, but it seems like it would apply more to the blindly indoctrinated true believer. You know, the ones that say things like "Chemo doesn't work" and "Big Pharma doesn't want us to find a cure."
Unless the "woo" is the therapy and not the user.
I've run across "open-minded tryers" of alternative therapies who have more of an attitude like "Well, chemo didn't work for me so I think I'll try this now. Oh, that didn't work either." They allow the skeptic in them to be honest about the results (think Steve Jobs), whereas the woo true believers are dogmatic. These dogmatic types usually do not have solid tumors that are still growing to prove to them that the woo doesn't work, from what I have seen. They usually have surgery and then turn to woo rather than adjuvant chemo where the success or lack of success of the therapy is unprovable (unless there is a recurrence!).
Real stage IV cancer patients who turn to woo as a last resort tend to not be dogmatic. It's a hail Mary.
Anyway, thank you for the explanation.
My understanding is that the volk etymology traces it back to James Randi, doubled as "woo woo." I think I've found it attested into the 1970s and not from Randi, but I don't have the vigor to repeat the exercise at the moment.
@Indigo-fire
Oh, well if you're going to use the word "cure," then yes it's a "woo." For the most part, from what I"ve seen, only surgery is truly curative and sometimes chemo can be for some kinds of tumors/cancers.
But lowering your chances of recurrence after treatment is another thing. For instance, nobody thinks Vitamin D can shrink a solid tumor, but studies have shown that it can decrease the chance of recurrence with some types of cancer. This is the interest in curcurmin, also.
If a patient has gone through treatment at a stage lower than IV, they will often look for anything they can to prevent it from coming back. Some fall into the woo trap and take all kinds of crazy things and do juicing, acupuncture, supplements, etc. They believe they are fighting their cancer on all fronts. If it doesn't come back, it "worked!" And there is no convincing them otherwise.
But science-minded (or trusting?) patients will look for real evidence that something does help. From what I've heard, there is some evidence that curcurmin can reduce the risk of recurrence (and yes, you are recommended to take it with fat), but I haven't researched it too heavily at this point myself.
OK, I lied. G—— is apparently going to make me use Julian dates this time around.
You're just a shill for Big Farmer.
@ herr doktor bimler #51:
I KNEW that my comment would get someone to riff upon that ( either German or Klingon was my guess).
Research has shown that the effectiveness of placebos is proportional to how much people pay for them.
Narad -- Julian dates?
Right now it's 245647.4802
Ach. I meant 2456647.4802. Dropped a digit. But now it's almost .4811.
When Yogi Berra was asked "What time is it, Yogi?" he is said to have replied, "You mean, right now?"
@Jane at # 59
IANAD, but studies showing benefits of using spices with food pop up frequently in the news. Yeah, newspapers != reliable reporting on science, but that's what I have to work with.
I've never read anywhere that refined foods or a habit of eat all you want and pack it on are roads to health. While a decent diet obviously won't prevent _all_ disease (or the Pilgrims would not have left us cemeteries full of young children) it's hard to believe that we're just more sophisticated diesel engines which run equally well on almost any grade of fuel*.
*Which is not literally true. Many diesels can't use biodiesel, etc.
And yet another data point on supplements of all stripes (not to mention another DSHEA slam):
http://www.nytimes.com/2013/12/22/us/spike-in-harm-to-liver-is-tied-to-…
Essentially Jane is saying to eat more plants because they might have good stuff in it so just eat more plants and shut up.
Stu -- I'm up with that, as long as chocolate counts as a vegetable.
Of course they do! So do steaks and cheeseburgers.
Oh, and especially Impossibly Easy Cheeseburger Pies. Yum.
I always get annoyed when told by strangers to "eat more/less X". More/less than what? Than what I currently do? They don't know how much celery I eat, so how do they presume to tell me whether I get the right amount? Than what the average person does? Just where do I find out that?
Andreas -- the spousal unit had an episode the week before Christmas that scared the hell out of all of us, since he was manifesting four of the five signs of a stroke.
Thankfully, it turned out to be a migraine, something that runs in the males in his family. But it didn't help that as I was looking for information on strokes that the treatment advice was usually lifestyle related. Don't smoke, get some exercise, keep your weight down etc. and of course he doesn't smoke, he's very fit and physically active, his weight is well within parameters for a man of his height, etc etc.
In the words of Mark Twain, he was a sinking ship with no ballast to throw overboard.
There's an old Punch cartoon from the 30s or 40s in which a doctor is prescribing life-style changes to a patient, and becoming increasingly distraught because however extreme and spartan his recommendations become, they are irrelevant because the patient's habits are already so austere and virtuous.
In the final frames the doctor -- about to collapse in exasperation -- insists that the patient should embark on a long bracing holiday in the Outer Hebrides, which the patient dismisses with the blithe announcement that he already lives there.
Sometimes there is truth in labelling:
from packages of cough drops *from Switzerland* -
called "Menthol Fresh Cough Suppressant Throat Drops" and " Green Tea with Echinacea Cough Supressant Throat Drops" each with lovely illustrations of varrious herbs...
BUT each has an active ingredient ( Menthol) listed and as "INACTIVE ingredients" ( my bolding)-
"aspertame, extracts of eucalyptus and a R----- herb miixture ( elder, horehound, hyssop, lemon balm,linden flowers, mallow, peppermint, sage, thyme, wold thyme) etc AND
aspertame, citirc acid, echinacea, green tea, peppermint and a R------ herb mixture ( same as above) etc"., respectively.
Don't think I bought this.
That is, WILD thyme.
I should think people would be lining up for the chance at a wild thyme....
Homonyms are waste of thyme.
If you've got the money, honey....
I'm only coming if Denice brings parsley, sage and rosemary, too.
So you're all meeting at Scarborough Fair?
One of my favourite folk songs to sing is "The wild mountain thyme", but the Kipper Family's version is better…
Obvious HTML fail, and obligatory request for a preview/edit function.
Kipper Family lyric
@sheepmilker: there was a performer at the New York Ren Faire who did lovely parodies of songs; her "Wild Mountain Crime" is wonderful