How to Choose a Supplement

On June 19, 2002, the Journal of The American Medical Association (JAMA) contained a scientific review article by R.H. Fletcher, MD, MSc, and K.M. Fairfeld, MD, DrPH, which addressed the current debate regarding the use of vitamin supplements and the prevention of chronic disease in adults. After reviewing the body of evidence on this controversial subject, the researchers advised their medical colleagues that the use of vitamin supplements is a prudent intervention in the fight against many chronic degenerative diseases.

The researchers stated that vitamin deficiency syndromes such as scurvy and beriberi are uncommon in Western societies. However, suboptimal intake of some vitamins, even above levels causing classic vitamin deficiency, is a risk factor for chronic diseases. This scenario is common in the general population, especially the elderly.

To many of us this was a breath of fresh air after decades of skepticism from the medical community. But, starting supplements is not simply a matter of rushing down to the mega-mart for brand “X” of vitamins. There are many, many pitfalls in taking supplements.

First of all, 25-50% of supplements are bogus, not even containing the ingredients listed, or so poorly prepared they are not well absorbed. To begin your search, look for a brand that has GMP, USP, or ISO 9000 type of certification. This means that the ingredients listed are truly in the product, and it has been tested for purity and safety.

Next, look for a broad spectrum supplement that includes all the necessary vitamins and minerals, anti-oxidants, and plant nutrients, with a specific list of ingredients. The key is getting the right ingredients in the right amounts. This should include nutrients that support the health of heart, bone, brain, liver, and eyes. It should also provide support for methylation, and defense against glycation, oxidation and inflammation (more later on these).

Avoid the inorganic mineral forms including carbonate, oxide, sulphate and phosphate. Do include mineral forms such as citrate, malate, succinate, aspartate and alpha-ketoglutarate. For example, calcium carbonate is bad, calcium citrate is good. The bad mineral forms are super cheap to make, poorly absorbed, and can even cause lower levels of other minerals. These cheap mineral salts are better laxatives than supplements!

Choose a form of Vitamin E that is the natural d-alpha-tocopherol with at least half gamma-tocopherol or mixed-tocopherols. Many studies have suggested that vitamin E supplementation increases the risk of prostate cancer – these poorly designed studies used only one of the eight forms of vitamin E which we know causes a deficiency in one of those other eight forms, the gamma-tocopherol portion, one of the most important anti-cancer forms of vitamin E.

The best form of Vitamin D, other than sunshine, is D3 or cholecalciferol. We should really check a blood level on Vitamin D to accurately determine the right amount to take.

Avoid potential toxicities. Don’t take more than 5000 IU of Vitamin A unless in the form of beta-carotene which will convert as much as needed to Vitamin A. Don’t supplement iron unless menstruating or directed by a physician.

Last is the issue of purity. Many supplements are contaminated with heavy metals such as mercury or lead. For example, calcium from oyster shells usually contains high levels of heavy metals. Unfortunately, our oceans are laden with these metals, and while good for a hard oyster shell, they are certainly bad for us! So, just because something is “natural” doesn’t guarantee it is good.

Our best nutrition is certainly through diet. We are designed to get 6-8 servings of fresh fruit & vegetables daily.   The truth is that 90% of Americans don’t get even 5 servings daily. 90% of us! Even with a lot of effort, this is hard to do. Furthermore, because of synthetic fertilizers and lack of crop rotations, the typical leaf of lettuce doesn’t have the nutrients we think it does. It is a fact that organic gardening produces safer, more nutritious produce.

So, who should take supplements? Not the red wine drinking, berry eating, organic gardening, mostly vegetarian salmon fisherman living in the pristine wilderness! Seriously, we all should.

Control of Oxidation

Because we live on planet earth we oxidize. Much like a piece of rusting metal the process of oxidation slowly damages our DNA and cellular functions. Oxidation is arguably the driving force behind the degenerative diseases of aging including heart disease, cancer and dementia, as well as being implicit in autoimmune diseases, chronic fatigue and fibromyalgia. Even depression, autism and schizophrenia are known to have links to oxidation. Essentially we age due to oxidation.

What is Oxidation ?

Mostly, the body generates oxidation in the process of producing energy. Cellular respiration is the process by which we convert nutrients into water and carbon dioxide, in the presence of oxygen, releasing energy. This energy production occurs deep in our cells in the mitochondria, the “generators” of cellular energy. Along the way, packets of energy called “electrons” are passed along a complex chain of chemical steps, eventually producing an energy storehouse known at adenosine-triphosphate (ATP). As these electrons are passed along, some chemicals give up electrons, which is oxidation, and some accept electrons, which is reduction. This constant reduction-oxidation (redox) process is“cellular respiration”. The energy stored as ATP is later used to power the bodily functions.

Problems begin when some of these electrons escape the normal chain of events and react with ambient oxygen, creating toxic oxygen free radicals. Oxygen is truly the “fire of life” and loves to accept electrons. These oxygen radicals are very unstable and aggressively react with other molecules in the cell. Like sparks flying out of a fire, the free radicals damage whatever is in the immediate area. Sometimes this is the cell wall, or critical enzymes and proteins in the cell, or even the cellular DNA.

There are also free radicals that come from outside our body, such as hydrocarbons, pesticides, smog, cigarette smoke and metals like lead and mercury.

Anti-oxidants donate an electron to neutralize and “snuff out” free radicals. The anti-oxidant sacrifices itself as it then becomes oxidized and it must be replenished. We have a tremendous built in system of anti-oxidants and get many more through our diet. Our “built-in” anti-oxidant systems fade with normal aging and our diets are not providing the amounts of anti-oxidants necessary to prevent oxidative damage. Once the process of oxidation begins to overwhelm our ability to stop it, the damage begins, and along with it the process of degenerative diseases and aging.

Anti-oxidants like glutathione, super-oxide dismutase (SOD) and n-acetyl-cysteine (NAC) are made within our bodies, while others must be obtained through diet, such as vitamins A, C, E as well as the many bioflavonoids from fruit and vegetable sources. Minerals like selenium, manganese, copper and zinc are not anti-oxidants but are a vital part of the systems.

It is critical to appreciate that anti-oxidants work in different parts of the body. For example, CoEnzyme Q works deep in the mitochondria helping with the electron transfers. Vitamin E and pomegranate are two that love fats and work well in fat-areas like cell membranes and cholesterol plaque. Vitamin C and glutathione love water and work in the fluid portions of the cell.

Anti-oxidants also work in different ways. CoQ is an anti-oxidant, but it also regenerates Vitamin E. Alpha-lipoic acid regenerates Vitamin C which then regenerates Vitamin E. Vitamin C and E along with selenium help Vitamin A to function properly.

All this interaction between anti-oxidants underscores a very important concept in supplementation – they work together! Getting a broad spectrum of nutrients, like that found in nature, is an essential part of supplementation.

Balancing glutathione and methylation

Glutathione is our most potent cellular anti-oxidant and is made primarily from an amino acid called cysteine, which we get through foods such as meat, eggs, garlic, onions, broccoli and red peppers.

Methylation is another supremely important process in the body that has a profound influence on hundreds of systems including oxidation control. Methylation helps us regulate proper gene expression, suppress viruses, and remove heavy metals.   Methylation is even known to regulate DNA damage that is caused by environmental stressors.

It is here that glutathione and methylation intersect and things gets really interesting. The body has a choice to either produce more glutathione or to support methylation reactions. Too little glutathione and we can’t fight free radicals and oxidative damage. Too little methylation and many viruses and genes will not be properly regulated. A chemical called homocysteine lies at the heart of this intersection and the B vitamins play a role in making certain the body can satisfy both pathways.

Homocysteine is made from the essential amino-acid methionine, after methionine donates a methyl group to support other reactions in the body. Homocysteine can then either donate its cysteine toward creating a glutathione molecule, or it can be recycled back to methionine in order to support methylation.

Essential B vitamins

Once you have the raw material to make glutathione or to methylate, you need cofactors vitamin B12 and folate to complete the processes. Vitamin B12, specifically the active methyl-cobalamin form, donates a methyl to recycle homocysteine back to methionine. In turn, methyl-folate is the only substance that can then donate a methyl to recycle cobalamin back to the all-important methyl-cobalamin.

Recent research has found that many people have a genetic variant that does not allow them to recycle homocysteine, but, by giving these people high levels of B12 about 80% of them can over-ride this defect. About 20% of people with this defect need to utilize another pathway to recycle homocysteine and for these people we use tri-methyl-glycine as a methyl donor. High levels of homocysteine are associated with increases in vascular disease.

Many people don’t get enough B12 in their diet. The only dietary sources are from meat, eggs and dairy and the rest of vitamin B12 is made by the bacteria that reside in our gut. Vegetarians need to insure adequate B12 intake. Taking probiotics to replenish the good bacteria in the gut may help with B12 production.

It gets even more complicated by the fact that many people do not activate the b12 and folate in their systems. The B12 in our diet or in most vitamins is cyano-cobalamin and is not active. It has to be converted in the liver to methyl-cobalamin and adenosyl-cobalamin. Measuring a B-vitamin by-product in the urine called MMA can determine if you are making enough active B12.

In our clinic we administer intra-venous infusions of glutathione and activated methyl-cobalamin and observe significant improvements in people with memory loss, dementia, auto-immune diseases and chronic fatigue. Also, the newer forms of active methylated B-complexes are available in better supplements.

Control of Inflammation

Inflammation plays a necessary role in our health but is also the real culprit behind most diseases of aging, including heart disease, diabetes, cancer and dementia. If you struggle with weight gain, fatigue, insomnia or mood swings then inflammation is likely playing a role. Take a closer look at how inflammation can be good or bad and how to control it.

Acute inflammation is part of our normal defense mechanism that helps kill invading pathogens and keep us healthy. The classic signs of rubor (red), calor (warm), tumor (swollen) and dolor (pain) are familiar to anyone that has ever sprained an ankle or had a skin infection. Again, this is part of how the body fights infection or cleans up and repairs damaged body parts. Acute inflammation is a good thing.

Chronic inflammation, however, is not good. It’s a sneaky process, silently damaging our arteries, nerves and organs. It will also suppress the immune system and promote the growth of cancers. Blood markers, such as C-Reactive Protein (CRP) are good for measuring chronic inflammation. High levels of CRP are associated with more heart disease and high CRP levels are found in diseases such as Alzheimer’s, diabetes and cancers.  The single most effective way to lower inflammation in the body is to lose excess weight.

Dietary fats and inflammation

The type of fat we eat will increase or decrease inflammation. There are two fatty-acids that humans can’t make thus they are “essential” and we must get them through our diet. These essential fatty acids are called omega-6 and omega-3. Omega-6 oils increase inflammation, while Omega-3 oils decrease inflammation. The balance of these two oils is critical and how they control inflammation very interesting…

Omega-6 oils (Linoleic Acid), are found in red meat, egg yolk and shellfish. They break down to a chemical called Arachodonic Acid (AA), which then breaks down by three different pathways to produce inflammation proming chemicals. You may recognize the names of these chemicals as prostaglandins, leukotrienes, and thromboxanes.

Medications such as ibuprofen, naproxen, and Celebrex work by stopping the breakdown of AA to these inflammation causing chemicals. However, with these medications you also risk side effects of gastric ulcers, kidney strain, high blood pressure and even increased risk of heart attack and stroke. Several have been removed from the market due to tens of thousands of deaths.

Fortunately, many natural supplements are also very effective at stopping these inflammatory chemicals from being made without the common side effects. Just a few examples include curcumin which is the active ingredient from the herbal turmeric plant, a form of vitamin E called gamma-tocopherol, an extract called boswellia which comes from the same African trees from which frankincense is derived, and pycnogel from French maritime pine bark.

Omega-3 oils are found in foods such as fish, flax, pumpkin seeds and canola oils. Alpha-Lineoleic Acid, (ALA) is the main omega-3 and it breaks down to the “good oils” known as EPA (eicosapentanoic acid) and DHA (docosahexanoic acid) which then break down to ANTI-inflammatory chemicals. Fish and krill are much more efficient at providing the EPA and DHA directly so I recommend these in supplement form and focus on including the plant sources of ALA in my diet. Omega-3 oils will actually down-regulated the omega-6 pathway which is yet one more way they will combat inflammation.

So, here’s the rub. We are supposed to get a 2:1 ratio of omega-6 to omega-3 oils in our diet and thus a balance of inflammatory versus anti-inflammatory chemicals in the body. But in America we get about a 20:1 ratio of omega-6 to omega-3. Cut back on omega-6 and increase omega-3 in your diet.

Supplement with a good quality fish oil or flaxseed capsule.   Flax is great, but about 1/3 as potent of a source than fish oil for EPA/DHA oils. Flaxseed meal is delicious added into cereals, oatmeal, etc. You should get 1000mg/day of the active EPA/DHA for prevention, 2000mg/day if you have heart disease. We use doses in this range to lower triglycerides, lower CRP, and increase the size of LDL cholesterol particles (a good thing). My favorite suppliers are Douglas Labs, Life Extension or Nordic Naturals.

Sugar and high glycemic foods will activate the omega-6 pathway leading to more inflammation. So will insulin, and if you are diabetic or overweight you make more insulin. Get your carbohydrate calories from fresh fruit and vegetables that are chocked full of anti-inflammatory compounds. If we combine excess omega-6 oils with 20-50 times the refined sugar our ancestors ate, plenty of high-glycemic foods, then add a dash of insulin we really have a recipe for inflammation and disease!

Grass fed animals, harvested while on fresh green grass, have a much higher omega-3 fat content. Same for milk from grass fed dairy and eggs from free-range poultry. Wild game, such as venison or buffalo has much higher omega-3 levels. Consider that our ancestors ate lean meat, wild game, and lots more fish. They also had little to no sugar and no processed foods laden with omega-6 oils.

Picking the Right Product

Now we are down to picking a specific product.  In this series we reviewed how to check labels for reputable products, what mineral forms to avoid, and a few general points about the type of vitamin ingredients.  We also focused on the role of oxidation and inflammation causing or contributing to multiple diseases and aspects of aging.

Let’s start by choosing a broad spectrum multi-vitamin that includes all the necessary vitamins and minerals, anti-oxidants, and plant nutrients, with a specific list of ingredients. This should include nutrients that support the health of heart, bone, brain, liver, and eyes. It should also provide support for methylation and defense against oxidation and inflammation.

There are many variations between multi-vitamins but in general the better brands will have well thought out ingredient lists with fairly standardized amounts and types of each ingredient.  I endorse numerous brands that my patients are taking, with my personal favorites coming from Douglas Labs or Life Extension.

Note that most multi-vitamins will not have enough vitamin D or K since these are fat-soluble and potentially toxic if getting too much – thus most vitamin blends will err on the side of low doses with vitamin D and K.

Get a blood level for total vitamin D and take enough of the D3 form to get blood levels at least above 50 nmol/liter, with 70-100 ideal and over 150 potentially too much. Doses from 2000 to 5000 units/day are typical and I suggest checking blood levels every 6 months until levels are stable in the ideal range.

Recent research has uncovered the fact that most of us are not getting enough vitamin K, much of which is actually made by the “good” bacteria that live in our gut. Vitamin K is well known to help clot blood but also plays a role in causing calcium to deposit into healthy bone and stay out of the arteries. The K2 form seems to have the most research showing artery benefits with doses of 45 mcg/day. A blended vitamin K with K1 and the two subtypes of K2 may be a good way to go.

My favorite multi-vitamin is called Ultra-Preventive “X” or the “EZ Swallow” from Douglas Labs. As stated in their product sheet it “has been carefully developed to contain the right proportions of vitamins, minerals, trace elements, and other nutrients without danger of toxic build-up or other side effects. Each ingredient is selected in consideration of its absorbability, competitive relationship with other nutrients, allergenic potential, and long- term safety. Certain nutrients such as beta-carotene, vitamin C, vitamin E, and B-complex vitamins are included in high-potency amounts because of the vital roles they play in antioxidant protection, energy production, the maintenance of healthy blood cells, the nervous system, hormonal balance, and more. Minerals and trace elements are provided in their safest and most bioavailable forms.”  The organic fruit and vegetable blend adds components that squelch inflammation, help control oxidation and provide for methylation and detoxification.

I like the very broad spectrum multi-vitamin rather than trying to piece-meal a dozen different bottles of various supplements. The comprehensive and well thought out ingredients are typically a better blend than the sometimes hodge-podge approach of taking a “little of this and a little of that”. I like the simplicity of one product covering so much ground and providing a strong “foundation” from which to logically add other more targeted supplements. This approach is also the most cost effective.

What Else?

After considering a multi-vitamin what else makes sense to supplement? As noted above, a separate vitamin D and K is usually warranted. Omega-3 oil is another basic for all to consider and 1-2 caps/day is usually sufficient. Whether or not to take further supplements from here depends on what the more specific goals might be.

For general wellness and anti-aging I would add things that help with cellular energy and detoxification. A chelator of heavy metals is not a bad idea. Some supplements down-regulate cancer promoting and inflammation promoting genes while others increase telomere length of genes, which is likely to extend the age span.

If you have a specific condition or strong family history for certain diseases then you might want to add extra “disease-specific” support. I usually recommend these type of supplements after emphasizing how the right multi-vitamin should be added first.

For heart health, high blood pressure and artery disease consider Neo40 which helps increase nitric oxide production.  Other various cardiovascular support might include pomegranate, syntrinol, policosanol, niacin, hawthorne, coleus and modified whey protein extracts. We measure extensive cardiac risk factor blood panels and target these various supplements to specific markers that need better control.

With cancer there are lots of recommendations.  I suggest getting a good resource guide such as Dr Keith Block’s book “Life Over Cancer” or “Defeat Cancer – 15 Doctors of Integrative and Naturopathic Medicine Tell You How” by Connie Strasheim. It is overwhelming the amount of data supporting various supplements for treating and preventing cancer and having a reputable guide is prudent.  Our Cancer Protocol is a good starting point when consider cancer treatments.

Arthritis is a very common condition and supplements can combat inflammation while providing support for healthy cartilage and joint lubrication.  Glucosamine / chondroitin / collagen products can help stimulate healthy cartilage. Cetyl-Myristoleate is a dynamite supplement that helps with joint lubrication and modulates inflammation.  Consider curcumin, boswellia, pycnogenol, etc to help control inflammation and avoid NSAIDs if possible.

Neurologic problems such as dementia, memory loss, and peripheral nerve issues can benefit from things that support neurotransmitter production, lower inflammation, and protect the delicate myelin sheaths that cover and protect our nerves. Many amino acids and herbal products are available to support neurologic health. The recently studied pyrroloquinoline quinone (PQQ) is a novel compound that some consider being a newly discovered vitamin that has been shown in human studies to improve mental processing.   Alpha glycerylphosphoryl choline (alpha GPC) may support memory and neurological function.

Your first medicine is nutrition. Taking supplements is not intended to replace a healthy diet that should be chocked full of raw, preferably organic, fruits and vegetables, balanced with lean meats and anti-inflammatory fats. However, there is a case to be made for a logical and calculated supplement regimen. If you are going to consider taking supplements then perhaps this article will help you evaluate and choose wisely. As with any supplement or over-the-counter medication I encourage you to inform your doctor and your pharmacist of your choices, particularly if you are taking prescription medications.


Author

Scott Rollins, MD, is Board Certified with the American Board of Family Practice and the American Board of Anti-Aging and Regenerative Medicine.  He specializes in bioidentical hormone replacement for men and women, thyroid and adrenal disorders, fibromyalgia and other complex medical conditions.  He is founder and medical director of the Integrative Medicine Center of Western Colorado (www.imcwc.com) and Bellezza Laser Aesthetics (www.bellezzalaser.com).   Call (970) 245-6911 for an appointment or more information.

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