Are multi-vitamins & minerals worth it?

Multivitamins

I get asked this question a lot. Should we be using multivitamins? Are they worth worth your MEF (money, effort, focus)??  Here's my encapsulated view of the world of multivitamin/minerals (further known as multis).

The Overview Multi-vitamins/minerals are not going to save you from a bad diet. Good food is foundational. Multis are there  to act as supportive operatives for the nutrients in the food that you eat. If you eat crappy food, not only will you eventually feel the effects of not getting the value from your diet, you won't have the nutrition for the multis to add their support.

Next question: Then if we eat well, do we really need a multi?

This depends on what you think the definition of eating well is. Since I'm the one writing this and I spend most of my working hours focused on food and nutrition, I'll ask you to follow my lead on what constitutes a high quality, nutrient-rich diet.
If on a close-to-daily basis, you get:

  • 6 - 10 servings of vegetables (serving: 1/2 cup hard veg, 2 cups leafy greens)
  • 4 - 6 servings of lean or plant based protein
  • 3 servings of fresh or frozen fruits
  • some nuts and seeds
  • some good fat at each meal
  • and, 3 servings of fatty fish per week

...then maybe you don't need a multi. Probably you'd be better with a few targeted nutrients for your specific body needs. On this one, all I can say is, work with an experienced nutritionist or naturopathic doctor to determine what those needs are. For those who know that they don't eat an optimum diet, a multi vitamin mineral can be helpful support.

Next question: If I'm going to use a multi, are some better than others?

Maybe the only question I can answer with a resounding 'yes'.

Question: What should I look for when choosing a multi? Here are the most important factors to consider:

Absorption: One-a-days are estimated to generally lead to a 10 - 20% absorption under ideal digestive conditions, i.e. we may absorb that much of what is on the label - more of some nutrients, less of others, depending on what your body needs. The intestinal tract is designed for absorption of food, it is not meant to lap up highly concentrated inorganic materials such as a blend of synthetic vitamins and minerals. For that reason, a lot of it doesn't pass through your intestinal wall. The better multis are the ones that are in: 1/ food-based form 2/ powders or liquids 3/ multiple tablets or capsules per day. In this case, you'll get more from your multi if you take smaller amounts, more frequently - like one or two with each meal. If you know you won't do it more than once per day, I would still recommend the smaller amount of a higher quality multi over a one-a-day, which I never recommend.

Marketing: The supplement industry is like all others, it's a business. The bottom line is profit. If you buy a cheap multi, you can guarantee it was cheaply made. Also if you buy one that has a massive marketing campaign, you can be sure that most of the dollars went to the marketing, not the quality of the ingredients. To make things just a little more confusing, consider that pharma and supp companies will latch onto nutritional buzz words such as 'antioxidants', 'omega 3', 'anti-aging' and put just enough nutrient in their bottle to be able to use it on the label, but not enough to give it much effect in the body. Is it broken down into men's, women's, over 50? Although there are some minor reasons to separate them out, note that mostly it's marketing. Anything that is in a women's multi that would actually be specific to a woman is usually contained in such a small amount to be negligible. Same for men. The good nutrients in a good multi will be good for both. As a couple, you can buy one for both of you, unless you really feel a lot better seeing your gender on the label. If your mind likes what its taking, it may have better benefits. Don't underestimate the placebo effect.

Effectiveness Although the research on multis is limited (see references below for more on the reasons for this), those of us in the nutritional field have come to accept that there are particular forms of vitamins and minerals that seem to work better. Although there is not full agreement on this, you will see clinical lines reflecting what practitioners want in their supplements. In part, this comes from experience  in the field (i.e. observing what actually works for our clients), from investigations into the natural forms of substances and what makes biochemical sense (even if it isn't fully double-blind placebo controlled). Having research to back up our hypotheses is a good thing, but it cannot always be done with an effectiveness that makes useful conclusions viable, and there is more to our relationship with food and nutrients than just what can be shown in research. When we're looking more closely at vitamins, there are co-factor forms that may prove to be more effective for a percentage of the population. Folic acid is an example. The natural form of this vitamin that is found in nature and our bodies is folate. A particular form of folate called 5-methyltetrahydrofolate (5-MTHF) can be used directly by the body for a crucial detoxification process called remethylation, (which will ultimately effect heart and brain health). Folic acid, the more common form found in multis, has to go through a conversion to be used by the body. In those of us who have a genetic or acquired inability to do the conversion, 5-MTHF will be the only way to go. There are more useable forms of most of the B vitamins, Vitamin E, K, and preferred forms of C, D, and A. Is it worth the extra money for every person to pay for these co-factor forms? Not necessarily. But for the person who needs the added support, the difference will be significant. And if you're not sure, you'll have to weigh out the cost against the potential increase in effectiveness.   In the case of minerals, they have to be bound to something else to stabilize them (they are always bound in nature). Usually it is an organic acid, a salt or a protein. Glysinates, citrates, amino-acid chelates, piccolinates, aspartate are a few of the binders that seem to have a higher bio-availability. I would suggest avoiding anything that is bound to carbonate (as in Calcium Carbonate) as we need a lot of stomach acid to break it down, which may or may not be available, so why take the chance. Also oxides (as in Magnesium Oxide) tend to do a good job of being released in the colon but they do not readily pass through the intestinal wall to get into the bloodstream. If a multi doesn't mention what the minerals are bound to, don't buy it - you can guarantee what they don't say, they would rather you don't know. Also, look for elemental amounts of minerals to get a clearer sense of how much of the actual mineral is in it. For example if it says 500 mg. Calcium Carbonate, 350 mg. is likely the carbonate and 150 mg. is the calcium. The elemental amount tells you how much of the mineral you're actually getting.

Recommendations

First recommendations are for the professional lines that I use cuz they are what I like best. You may be able to order it online or not. If you really want these and don't otherwise have access, feel free to drop me a line at tzabia@foodcoach.ca - we'll have a short conversation so I can determine if these would be good for you, and if so, you can order them through my online dispensary.

Restorative Formulations Metabolic Nutrition - 1/4 scoop 1 - 2X /day

Douglas Labs Ultra Preventative X - 2 tablets at each meal

If you are seeking multis available in retail stores, I would suggest a few:

AOR Multi Basics 3 - ideally take one with each meal, 3X per day.

Healthforce Vitamineral Green - although not a multi as we usually think about it, it is a concentrated source of foods from land and sea that contain a rich concentration of nutrients in bioavailable form. In powder or capsules.

Negative Research

This section is for those of you who may recall, and are curious about the media attention in December 2013 that focused on negative research re: the value of multi-vitamins  Enough Is Enough: Stop Wasting Money on Vitamin and Mineral Supplements , with the statement "Most supplements do not prevent chronic disease or death, their use is not justified, and they should be avoided." Makes for good news, but it wasn't backed by particularly rigorous studies.

In one of the research studies, 5947 male physicians, 65 years or older were followed for 4 years with one group taking a low dose multi and the other placebo. Their conclusion was that in this demographic, "long-term use of a daily multivitamin did not provide cognitive benefits."
Here are the limitations of the study which makes it a challenge to get on board with their conclusions:

1. Poor adherence criteria - the participants only needed to take their multi (or placebo) two thirds of the time. That means that on an annual basis, they could have missed taking it for four months. Even taking good quality multis occasionally will not produce any benefits worth noting. It is akin to only eating vegetables on some days. Can it benefit? Yes, but it won't benefit enough to transmit to changes in long term health. The participants in the study were inconsistent in their use.

2. They relied on participant recollection rather than bottle return (which is considered the higher standard for information collection in a study like this). Expecting a busy person (in this case, doctors) to remember how often they take something is just not reliable science.

3. They used a low dose multi. Decades of research on individual nutrients in pill form have shown benefits in a multitude of areas of health. The key is larger doses taken consistently over an extended period of time. Usually these are doses that are higher than you will find in a one-a-day multi. Smaller doses can have a smaller effect, but not enough to reverse degeneration. For that, therapeutic doses are needed. These studies were counting on small doses of potentially low-quality synthetic multis to make a big difference in long-term cognitive health.

4. Some cognitive benefits despite the low dose. The results were not clinically significant, but despite the quality, quantity and lack of adherence, there were still small benefits as opposed to none.

In the other study, 1708 patients, men and women, aged 50 years and older who had a heart attack at least 6 weeks earlier, were monitored for 4.5 years with one group on a multi-vitamin, multi-mineral. Their conclusion was "high-dose oral multi-vitamins and multi-minerals did not statistically significantly reduce cardiovascular events in patients after MI (myocardial infarction) who received standard medications. However, this conclusion is tempered by the non-adherence rate."

Problems:

1. As mentioned in their statement, there was poor compliance. 46% of participants in the multi-vitamin group quit taking it.

2. There was a low dose of heart protective Vitamins D and B12.

3. The multi contained only one form of Vitamin E, rather than the full complex which has heart protective effects.

4. There were more diabetic patients in the multi-vitamin group than in the control group. That makes for more complex physiological outcomes.

In addition to these studies, the article reviewed other research that showed either no benefits, or potential harm from supplementation use. In most, there is a particular demographic that was involved that limited these conclusions when relating it to the larger population. In addition, there are many studies to counteract these conclusions. I have some of them listed in my references below.

References

http://lpi.oregonstate.edu/infocenter/vitamins.html https://www.onnit.com/academy/multivitamin-researchers-case-is-closed-because-i-said-so/ http://ajcn.nutrition.org/content/85/1/269S.long

Gaziano JM, Sesso HD, Christen WG, et al. Multivitamins in the prevention of cancer in men: the Physicians' Health Study II randomized controlled trial.JAMA : the Journal of the American Medical Association. Nov 14 2012;308(18):1871-1880.

Grodstein F, O'Brien J, Kang JH, et al. Long-Term Multivitamin Supplementation and Cognitive Function in Men: The Physicians' Health Study II. Annals of Internal Medicine.2013;159(12).

Harris E, Macpherson H, Vitetta L, Kirk J, Sali A, Pipingas A. Effects of a multivitamin, mineral and herbal supplement on cognition and blood biomarkers in older men: a randomised, placebo-controlled trial. Human Psychopharmacology. Jul 2012;27(4):370-377.

Haskell CF, Robertson B, Jones E, et al. Effects of a multi-vitamin/mineral supplement on cognitive function and fatigue during extended multi-tasking. Human Psychopharmacology.Aug 2010;25(6):448-461.

Hunt, Sara and Groff, James, Advanced Nutrition and Human Metabolism, West Publishing Company, 1990.

Kushi LH, Folsom AR, Prineas RJ, Mink PJ, Wu Y, Bostick RM. Dietary antioxidant vitamins and death from coronary heart disease in postmenopausal women. The New England Journal of Medicine. May 2 1996;334(18):1156-1162.

Lamas GA, Boineau R, Goertz C, et al. Oral High-Dose Multivitamins and Minerals After Myocardial Infarction. Annals of Internal Medicine. 2013;159(12).

Li K, Kaaks R, Linseisen J, Rohrmann S. Vitamin/mineral supplementation and cancer, cardiovascular, and all-cause mortality in a German prospective cohort (EPIC-Heidelberg).European Journal of Nutrition. Jun 2012;51(4):407-413.

Sardesai VM. Role of antioxidants in health maintenance. Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. Feb 1995;10(1):19-25.

Sesso HD, Christen WG, Bubes V, Smith JP, MacFadyen J, Schvartz M, . . . Gaziano JM. Multivitamins in the prevention of cardiovascular disease in men: the Physicians' Health Study II randomized controlled trial. JAMA : the journal of the American Medical Association. Nov 7 2012;308(17): 1751-1760.

Smith AD, Smith SM, de Jager CA, et al. Homocysteine-lowering by B vitamins slows the rate of accelerated brain atrophy in mild cognitive impairment: a randomized controlled trial.PloS One. 2010;5(9):e12244.