Episode 9: Do nutritional supplements work? If so, which ones, and for whom?

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Take-Home Messages

·      Lifelong use of supplements to prevent an illness is very different from taking a supplement to treat a known deficiency or a specific symptom

·      The evidence does not support the use of most all supplements to prevent illness (with multi-vitamins being the exception where there is some evidence)

·      Supplements to treat a particular problem can be very helpful, especially if we do our N of 1 study in ourselves

Part One: Understanding Nutritional Supplements

• Various types of supplements:   Vitamins, Minerals, Herbals, Probiotics
• Most commonly used Supplements: Multivitamins, Omega-3s, Probiotics, Vitamin D, Calcium, Protein Powder, Psyllium
• We want to live long and well—taking a supplement may help us feel “agency” or that we are proactive in improving our health---even when the evidence does not support it.  

Part Two: the Supplement Industry Differs From Pharmaceuticals

• Licensed and prescribed drugs go through extensive testing/FDA oversight to demonstrate that they work and that they are safe
• Nutritional supplements are viewed as “food” and don’t have similar regulatory scrutiny
• Challenges: traditional drugs receive patents and can afford extensive clinical studies.  Nutritional supplements generally don’t have patents and can’t afford to conduct extensive research.  For this reason, most supplements have very little scientific evidence to support their benefits, even though their claims may suggest otherwise
• Real-Life Example: Critical Evaluation of Broccoli Sprout extract Study

Part Three: Evidence (mostly lacking) for Common Supplements

• Omega-3s: studies don’t show a reduction in heart disease or cardiac death; they may have a role for high blood triglycerides or for patients with rheumatoid arthritis (pain control) 
• Vitamins and Minerals: Minimal Impact on Disease Prevention except for a daily multi-vitamin which has supportive evidence that they may reduce cancer and cognitive decline
• Cognitive function: omega 3s and the MIND diet aren’t effective at slowing decline.
• Supplements for specific deficiencies or specific symptoms can be very helpful.  You can do your own “N of 1 Study” to see if they help you. Step 1: identify the problem (bowel irregularity, sleep…);  Step 2: choose a supplement and begin taking it; Step 3: re-assess after a few weeks.  If it helps, great.  If not, then likely best to stop.

Dr. Bobby’s regimen: a daily multivitamin, colace (for bowel regularity), and recently started Creatine for muscle strength.  I don’t take omega 3s, vitamin D calcium, magnesium, or pro-biotics.

Transcript

Dr. Bobby Dubois: 0:03

Hi, I'm Dr Bobby Dub ois and welcome to Live Long and Well, a podcast where we will talk about what you can do to live as long as possible and with as much energy and vigor that you wish. Together, we will explore what practical and evidence-supported steps you can take. Come join me on this very important journey and I hope that you feel empowered along the way. I'm a physician, ironman, triathlete and have published several hundred scientific studies. I'm honored to be your guide.

Dr. Bobby Dubois: 0:50

Today we're going to talk about a popular but often controversial topic nutritional supplements. Now, it's popular because a whole lot of Americans take them. It's controversial since there's often more passion than real evidence to support their use.

Dr. Bobby Dubois: 1:22

As listeners may know, my career focused on whether there's evidence to tell us what does and doesn't work in healthcare and, most importantly, for whom it helps or doesn't help. Now, that could be a surgical procedure. It could be a costly medication. As a physician, I care about patients and I want to help them, not hurt them, so it's very important for me to understand evidence, when it will help them and when it won't. As a scientist, I studied these issues and published over 180 peer-reviewed articles on them. So I approach supplements with this same mindset or perhaps some might say bias and I always ask myself these types of questions. Perhaps some might say bias, and I always ask myself these types of questions Is there evidence, good evidence, rigorous evidence that a particular supplement works, and for whom? Because it may work but it may not work for everyone, and if there isn't good evidence in people, I don't support their routine use, I don't use them, I don't talk to others about them. Now, evidence in animals or test-tubed studies in the lab are interesting, but by themselves aren't enough for me. Theories are great and there's lots of theories, and people build careers around theories, but I want to see that the supplement actually helps people, and so that's what I will focus on with you today and really on any topic that we will explore together.

Dr. Bobby Dubois: 2:57

As always, I want to begin with take-home messages First. I believe there's a really big difference between taking a supplement for the rest of your life to hopefully prevent big, important diseases like heart disease, cancer or mental decline. Now that's very different than taking a supplement for a known problem, like I have a tummy trouble and will Pepto-Bismol help me. That's a really different situation. Now, unfortunately, when we look at most supplements to prevent these long-term chronic diseases, the evidence is not very convincing that there's a lot of benefit. Now I like supplements to take care of a known problem, because you can quickly figure out if they're working, even if the evidence isn't absolutely convincing, and they are usually pretty safe. And so these are the take-home messages, and I will then flesh each and every one of them out.

Dr. Bobby Dubois: 4:05

Well, let's start with another point, which is a disclaimer. I am not a nutritionist, I'm not trained on food science, but I'm pretty good at looking at the evidence of what does and does not work. So the plan for this episode First, I'll review what supplements are and which are the most important ones that are commonly used today in the United States. Second, I will briefly describe the supplement industry and how it's different from the pharmaceutical industry and why it is that we don't have strong evidence for most products that they sell. And third, I'll talk about a few supplements not everyone, but just a few of the important ones and explore with you what we do and don't know about the evidence. As always, I will link these key studies in my show notes if you wish to look at them and, as always, I welcome your feedback on that. So let's get started.

Dr. Bobby Dubois: 5:12

Part one what are nutritional supplements? Can't have a full discussion without at least defining terms, so nutritional supplements fall into a number of categories. So nutritional supplements fall into a number of categories. They could be a vitamin like vitamin B12 or vitamin D or something like that. They could be a mineral that's also a different type of supplement, now. That could be calcium or magnesium or something like that. They could be an herbal like cumin that's a popular one you hear about. Or a supplement could be a probiotic to improve our gut health. Now, supplements are usually taken on a routine basis, meaning this is a good thing to improve my health and I'm going to take this every year for the rest of my life. But supplements can be taken for specific needs and we're certainly going to focus on that a little bit later.

Dr. Bobby Dubois: 6:07

The most commonly used supplements in the United States today is a routine multivitamin. Omega-3s are very, very popular Probiotics vitamin D, calcium, protein powder and psyllium, which is like Metamucil or one of those types of bowel agents. So those are the most commonly used ones. In America today, about half of us take at least one supplement and, as you know from either yourself or your friends, some people take a whole lot of them, no-transcript. Now, one of the really attractive appeal of supplements is that we all want to be proactive with our health and feel like we're doing something and that health and what happens to us isn't just a roulette game in Las Vegas. That, in fact, we want to feel we have agency and some sense of control. So taking a supplement gives us a sense we are doing something that will help our health, because that's important to almost all of us to have that feeling of agency.

Dr. Bobby Dubois: 7:32

Now there's a trio of challenges, though. So, on the one hand, we want to actively improve our health, and there's a lot of companies out there that want to make money on just that, and they respond to our desire to improve health, and they have really, really optimistic advertisements and spokespeople to help sell these supplements. And, as I'll get to in a few minutes, there aren't great incentives for supplement companies to do high-quality, rigorous research. Those research studies would be very expensive and, as we'll talk about in a moment, because you can't patent these, by and large, there's not the financial incentive to do wonderful studies. So end of part one. Let's flesh out some of these and get to understand what we do and don't know. So let me explain a little bit about the supplement industry. Look, I'm not an expert on the supplement industry. I spent a lot of time working with the pharmaceutical industry. I know that better, but I have a pretty good sense of what happens in the supplement world.

Dr. Bobby Dubois: 8:46

So pharmaceuticals your classic licensed drug by the FDA. They're highly regulated and the amount of evidence you need to get a drug through the FDA and approved and on the market is very high. And the FDA has very close oversight before any drug makes it to the market and they focus the FDA does on does this drug actually work and do the things that the drug company says they do, and is it safe for people to take? For that reason, on the nutritional side, the FDA has a very, very, very minor role. Before a supplement goes on the market, there's no requirement that safety studies or efficacy studies meaning does it work are done. So they don't approve. The FDA doesn't approve the claims for what a company might say that this will help reduce heart problems or anything else. Now, the FDA will look at safety issues after it's on the market, but they won't require rigorous studies to get on the market.

Dr. Bobby Dubois: 9:56

Now why is there such a difference between how the FDA approaches a typical medicine that a doctor might prescribe and a supplement? Well, the theory is that these are dietary supplements, not health aids. So this is food, and you can purchase any vegetable or fruit, basically that you want. There is no kind of FDA approval on what fruits and vegetables a market can sell. Now this is a little bit odd, because although these are dietary supplements, or viewed as such, we do take them for health reasons. We're hoping they might reduce heart disease or cognitive decline or cancer or something else.

Dr. Bobby Dubois: 10:40

In the pharmaceutical world, when you develop a drug, you can get a patent. That patent goes on for many, many years and because of that patent you can afford to do really detailed, rigorous clinical studies, and to bring a drug to market could cost a billion dollars or more, and so if you don't have a patent, you won't really want to do those kinds of studies. And that's exactly what happens in the nutritional world, because I could come out with a really wonderful pill that's for calcium or magnesium and I might study it and really understand who benefits and who doesn't. But somebody else from another company could basically come out with the same thing, because there isn't a patent on calcium or magnesium or vitamin D or something like that. So without that motivation of having a patent and being able to be exclusive, there just isn't the same incentives and therefore the studies that are done aren't as rigorous, aren't as big and aren't as believable. Do keep in mind there's a lot of money to be made in supplements and retailers probably make 30% to 50% on each and every bottle that's sold, make 30 to 50% on each and every bottle that's sold. Now what I've described here is a bit theoretical. So let me give you a real, live example of what a nutrition study might look like. Now they're not all going to look like this, but this will give you a sense of why I have some skepticism about many of the claims that are made.

Dr. Bobby Dubois: 12:22

So there was an article that came out recently and it was picked up in the press and it basically said that broccoli sprouts, the extract of broccoli sprouts, improved exercise performance. Hey, I would take some broccoli sprouts or an extract of broccoli sprouts if it helped me work out more and do better in a race. That sounds like a great thing and the theory is good that broccoli sprouts have antioxidants in them and we'll come to a little bit later what antioxidants are all about and that seems like a good thing. Antioxidants are good. Broccoli sprouts have them, so this might in fact help our exercise performance. And so they did an actual study.

Dr. Bobby Dubois: 13:03

But when you dig below the surface, you realize this study only had nine people in it. Nine people isn't enough really to tell anything. And they said well, your heart rate didn't go up as high when you did a standard amount of exercise. Well, that was only three-point difference. So for some people it didn't take the broccoli sprouts. Our heart rate went up to 187, and for the other people it was 184. And they said oh well, it improved how long you could work out before you got exhausted. Well, yes, but it was the difference between 401 minutes and 406 minutes. So tiny, tiny differences with only nine people. And then, of course, you read the description of the authors and the funding, and what you learned is that it was funded by the vegetable growers and that the authors have a patent pending for the broccoli sprout extract. So does this mean, because it was funded by vegetable growers and that the authors have a potential patent, that this can't be a valid study. No people can do good studies, but when there's only nine people the results are really tiny differences. But when there's only nine people the results are really tiny differences. Then I wonder and this is not atypical for studies. Obviously there's some supplement studies that are examined by the federal government or major research institutions, but for a lot of the things you hear about on the market, this type of broccoli study isn't all that surprising.

Dr. Bobby Dubois: 14:38

Okay, end of part two. On to part three. Is there evidence to support the use of these common supplements? Now, as I mentioned, and I'll say again because it's so important, I view supplements to prevent a disease really differently than supplements to handle a known problem. So, if you have constipation, metamucil or Colace or Psyllium would be considered a nutritional supplement and the beauty is you can know very quickly whether it helps you. It doesn't really matter what a large study says, it's what happens in you and you can tell that very quickly and if it doesn't work, you don't take it anymore. Now, more about this later.

Dr. Bobby Dubois: 15:23

But if you're taking a nutritional supplement to prevent a disease, well frankly you have to take that for decades and if there isn't really really strong evidence, I don't believe taking that supplement makes much sense. In my opinion, often what they claim greatly exceeds the evidence For most of these supplements. If there are any benefits, the amount is likely very small and that leads to an almost religious belief in some supplements that this is the answer. We have found it. By all means, I hope you trust what I share with you, but there's a website that you might want to look at. It's called examinecom and they tend to focus on supplements and they tend to pull together the evidence. So you could take a look at it for melatonin or whatever else you might have an interest in, and see what they come up with and see what they have on their website. So just another resource, and if something pops up in a headline, you could look at what they have about it and it might be helpful to you moving forward. So today I'm going to talk about a few supplements, but there's a lot more supplements we're not going to talk about today because we just don't have the time and we may bring those up in the future or, if you have an interest in any of them, reach out to me through my website, through Instagram, however you want.

Dr. Bobby Dubois: 16:59

So let's start with omega-3s because they're very popular. As I mentioned, it's one of the most commonly used supplements, and here's that word again antioxidants. So omega-3s have antioxidants. So what's an antioxidant? Without getting lost in the biochemical minutiae, an antioxidant helps stop damage to our cells. There are certain molecules that float around. They're called free radicals. That happens for a variety of different reasons and those free radical molecules can hurt our cells and an antioxidant basically stops those free radicals from doing that damage. So sounds like a really good thing. So taking an antioxidant sure seems like a good idea.

Dr. Bobby Dubois: 17:49

Another piece of this puzzle which got everybody excited about antioxidants and specifically omega-3s is that if you look around the world and you look at sort of epidemiologic studies, people who eat fish live longer and they have lower rates of heart disease. Fish has omega-3s, like anchovies or salmon or sardines. So if eating fish helps you, then taking the essence of fish, meaning these omega-3s, must be a good idea. The challenge and this happens over and over in observational studies when you actually test it out giving omega-3s as a supplement isn't the same thing as eating a fish, and eating a fish may not really be what's causing people to have less heart disease. It could be that those cultures that eat a lot of fish are also doing a lot of walking around and get a lot of exercise, or they have strong bonds with their family, or they're very good at sleeping every night. So what you observe doesn't necessarily mean that's the cause or that's the solution.

Dr. Bobby Dubois: 19:06

So there have been lots of randomized controlled trials, and a randomized controlled trial is basically you take a group of people and you randomly divide them into two groups, group A and group B. Group A gets supplements, say omega-3s, group B doesn't. And then you follow them over time, you measure certain things and then you ask the question well, did the omega-3s reduce heart disease? Did they reduce strokes? Did they reduce cognitive decline or cancer? That's a randomized controlled trial. That's really different than just I found a bunch of people who took omega-3s, I found a bunch of people who didn't and then figure out what happened to them. Then, another day, we'll talk about why that type of observational studies is so much less powerful than a randomized control trial. So there are two very large summaries of the evidence on omega-3s. One is called the Cochrane summary and that looked at 90 clinical trials or so and they found no benefit for heart disease. Similarly, the Mayo Clinic did a very large summary and again they found omega-3s did not prevent heart disease. Now you may run across a study or you may run across a headline that says there's benefit for heart disease, but really when you look at the totality of evidence because any one study may not give us the full answer the totality of evidence does not show a cardiovascular benefit. That's my interpretation of the literature. It's also the conclusions of these two very large and well-respected summaries.

Dr. Bobby Dubois: 20:53

So I mentioned earlier that supplements are very different if you're taking it for a specific problem that you have, not to prevent something, but for a problem you have. So for omega-3s, if you have high triglycerides, omega-3s can lower them. This isn't just to say, oh, if you take it for 30 years you won't get cancer or cognitive decline. You are going to take it because you have high triglycerides and you can measure it to see if it's making a difference. There's also some evidence that omega-3s help folks with rheumatoid arthritis, with discomfort Again something you can test. If you have rheumatoid arthritis, you try taking the omega-3s. If it improves the pain, great. If it doesn't, you stop Okay. So that's omega-3s.

Dr. Bobby Dubois: 21:45

What about vitamins and minerals? Do they reduce cardiovascular disease and cancer. Again, another big summary of 84 clinical trials. They looked at vitamin D, they looked at beta-carotene, they looked at vitamin E and there was really no benefit, and actually in some cases there was some increased risk. Where they did find some benefit was not on these individual items like vitamin D or beta carotene, but a simple, often viewed as boring multivitamin, a once-a-day vitamin that actually showed a small benefit in reducing cancer, and there's some data that a multivitamin might actually help you maintain cognitive function.

Dr. Bobby Dubois: 22:33

Many, many studies on vitamin D have shown that it doesn't protect muscle loss. It doesn't help your grip strength, it doesn't help you get up and about. Vitamin D is a really interesting one. Now, clearly, if you have a major vitamin D deficiency and it's affecting your bones, by all means vitamin D is a great thing, but if, again, you're using it to prevent disease, I just want to give you a sense of why it isn't. Just well, I'll take it, and if it helps, great, and if it doesn't, it doesn't.

Dr. Bobby Dubois: 23:05

Vitamin D is a double-edged sword. If you have bone issues, yes, vitamin D is very important in helping bones, and not that more is better. It's just that if you don't have enough vitamin D, you can have problems with bones, but vitamin D because it helps with calcification, and that's what bones are calcification it can also affect your arteries. So there was a randomized trial not long ago that looked at 36,000 people and some of those people got vitamin D and calcium and what they showed is, yeah, there was a small reduction in cancer mortality in the people who took the vitamin D and calcium, or mortality in the people who took the vitamin D and calcium, but there was an increase in cardiovascular mortality. Why we don't know for sure, but it could have been that that extra calcium and vitamin D caused some calcification in your coronary arteries and that led to cardiac problems.

Dr. Bobby Dubois: 24:04

Now, on the kind of vitamins, minerals and related area, there is some data and it's actually fairly good data that creatine may help with strength training. Just taking creatine powder and you don't exercise isn't going to make a difference, but there is data in the fitness literature that it may help strength training and improve your ability to grow muscle and to be able to lift more and more weight. There's also studies on cumin which are interesting. They've shown that it might lower an inflammatory thing in your blood called C-reactive protein, but we don't really know what that means. So just because you take cumin and it might lower this inflammatory marker, we don't know if it's going to make people feel better, if it's going to reduce the risk of cancer or heart disease.

Dr. Bobby Dubois: 24:56

And again, as I've mentioned, I don't focus on blood tests. I really really really focus on what does it do in people? So where do we go from here? What about supplements and cognitive decline? So, for cognitive decline, people have examined whether omega-3s can prevent that, and so there was a meta-analysis. This is again a summary of studies where they looked at 15 randomized controlled trials and the omega-3s didn't help cognitive decline. So we've talked before about the fact that omega-3s don't appear to help for heart disease standpoint. Now it appears they also don't help for cognitive decline.

Dr. Bobby Dubois: 25:48

Well, in the cognitive decline space, this isn't what I'm going to talk about now, isn't exactly about supplements, but it gives us some understanding. So this was a really, really important study and a really well done and a very large clinical trial where they compared a diet. Now it's called the MIND diet. It's called the MIND diet because they were hoping that this diet would help people's brains and brain health, and the MIND diet is kind of like the Mediterranean diet or the DASH diet, and that's basically. They put together foods that they thought from various previous studies might reduce the risk of dementia, like whole grains, leafy vegetables, nuts and beans and berries all the things that we think might help us and that you've also heard in various supplement advertisements. So this was a three-year study and they tested people for sort of brain health, cognitive function. But they also looked at their MRI scans in many of these people and what did they find? Made no difference. So if a diet rich in all of these what are supposed to be mind-oriented foods didn't help, it's likely the supplement based upon those same things isn't going to improve cognitive decline.

Dr. Bobby Dubois: 27:16

Now, exercise can help, blood pressure control can help, other things can help, but supplements appear not to be helpful. And if you hear from some advertisement that it's really helpful and been shown to prevent cognitive decline, I think you really want to ask what's the evidence? Was it done rigorously, and can I really believe it? Well, I mentioned earlier that I really do like supplements, but I like them not to prevent disease but if you actually have a known problem. So if you go to the doctor and the doctor tests your blood and he says, oh, your vitamin B12 levels are low and in fact it's causing some anemia, which might cause some fatigue for you. Well, of course, increasing your vitamin B12 level would be very important and a supplement could be very, very helpful, and people can get vitamin B12 deficient if they have something going on in their stomach that might cause them not to absorb it. Now where it gets a little tricky is if you do a blood test that shows a low level but you're not having any symptoms. Then it's a little tricky to know should you actually take the supplement.

Dr. Bobby Dubois: 28:28

But if your level is low and you're having symptoms, I think it's absolutely appropriate, wonderful and extremely helpful to consider a supplement that's specific to that, and supplements are great if you have a particular problem you want to address. So, if your bowels don't move regularly, of course Metamucil or psyllium is a supplement that can help you. We've talked in a previous one about caffeine. Well, if it helps you for doing your exercise regimen better, wonderful. If it keeps you alert, wonderful. And caffeine can also be viewed as a supplement. Many people take protein powder or protein supplements because they don't get enough in their diet, and that can be really helpful too, again, also in older adults, where we often may not get as much protein or we don't absorb it fully. And, as I alluded to earlier, creatine has been shown to improve strength training.

Dr. Bobby Dubois: 29:32

So the beauty of supplements for identified problems is that you can test it in yourself. Is that you can test it in yourself Our N of 1 study? How exciting we can do that. Again, remember what this N of 1 study, applied to a supplement, might look like, is the following. Step one assess your baseline issue. Is it that your vitamin B12 is low? Is it that your bowels aren't regular? Is it you're having difficulty building strength while you exercise? Is it a sleep issue, an anxiety issue? Is it a low energy issue? Okay, so identify what the problem is. Step one, and if you can quantify it number of hours of sleep or how often you move your bowels in a week great, the more you can quantify it, the better. There are questionnaires on the web for awful lot of things. You might find that.

Dr. Bobby Dubois: 30:24

Step two try a supplement. Step three see if it works for you. The beauty is this is only going to take a week, two weeks, maybe a month for you to figure this out. You're not taking a supplement for the rest of your life in the hope it will prevent a disease. A supplement for the rest of your life in the hope it will prevent a disease. You'll take it for a couple weeks and see if it helps you A wonderful use for a supplement and in a wonderful way for you to look at it.

Dr. Bobby Dubois: 30:52

All right, we're coming to the end, so I want to provide the take-home messages. First, supplements are really popular and a lot of money is spent on them. Second, taking a supplement gives us a feeling of agency, that we're actually doing something with our health. Third, there are many reasons why companies and supporters of them make very optimistic claims that exceed the evidence. Fourth, most supplements are pretty safe. So you got to think about do you want to take this for the rest of your life If it's to prevent disease? What are their costs and are there potentially some risks? So let me explain where I've netted out.

Dr. Bobby Dubois: 31:37

Having followed this area for a long time. There seems to be pretty good data that a daily multivitamin can potentially reduce the risk of cancer and cognitive decline. I don't believe that many of the other popular or advertised supplements have good evidence that they prevent major illnesses, but if you have a specific current problem. Absolutely try them and see For whatever it's worth. I take a multivitamin every day, I take colace to keep my bowels regular and I recently started creatine and it appears to be helping my exercise and my strength building program. So for the moment, I'll continue to take that. I don't take vitamin D, I don't take omega-3s, I don't take magnesium or any other nutritional supplement. So for whatever it's worth, that's what I do.

Dr. Bobby Dubois: 32:33

I hope that our discussion's been helpful. I've, as always, linked the key studies in the show notes. If you have any thoughts about this podcast or how I can improve them, or topics that you might have an interest in, let me know. I also will be sending out newsletters and if that's of interest, just go to my website and sign up drbobbylivelongandwellcom and you can also leave me messages there. So until next time, live long and well. Until next time, live long and well. Thanks so much for listening to Live Long and Well with Dr Bobby. If you want to continue this journey or want to receive my newsletter on practical and scientific ways to improve your health and longevity, please visit me at drbobbilivelongandwellcom.