Everyone Needs a multivitamin, Renegade Endurance Radio Episode 37
In this episode I review what the research says about whether we are getting enough vitamins and minerals and talk about how I’ve come to think that everyone probably needs to take a high quality multivitamin.
Theme music courtesy of soundotcom.com
Resources Mentioned in This Episode
The index disease for calcium is osteoporosis
Disease latency for osteoporosis is long because even with zero calcium intake, bone cannot be torn down fast enough to produce depletion in less than several years
Unabsorbed calcium binds with food, oxalates, and unabsorbed fatty and bile acids. It reduces the absorption of oxalates and decreases the risk of calcium oxalate kidney stones.
Calcium also reduces the cancer-promoting activity of the unabsorbed fatty and bile acids in the colon. Intestinal oxalate binding produces and immediate benefit. Calcium oxalate kidney stones would be considered a short-latency calcium deficiency disease, contrasted with the anti-cancer effect being a long-latency phenomenon.
Both of the above effects are an important feature of deficiency diseases that may not have been fully evident with something like beriberi (short latency disease). Low calcium intake just uncovers the propensity of stone formation.
These all illustrate that any morbidity with the above would not occur if calcium intake were higher and thus reflects nutritional deficiency. Such morbidities should be classified as deficiency diseases.
The index disease for vitamin D is rickets.
Impaired calcium absorption produced by vitamin D deficiency should produce osteoporosis (as it does when calcium is low due to low intake), only recently has impaired calcium absorption been considered part of the picture of vitamin D deficiency disease.
In terms of low vitamin D, those with low concentrations (no matter the cause) are less able to make calcitrol in amounts sufficient to reduce oncogenesis. So although circulating calcitrol concentrations may be normal in vitamin D deficiency states, tissue concentrations (which are dependent on substrate vitamin D concentrations may be low)
Prostate cancer incidence and mortality are inversely associated with solar UV radiation and serum vitamin D concentrations
Current reference ranges of vitamin D are considered “normal” only because a person does not have rickets or osteomalacia.
A table in the study shows that the amounts of calcium, vitamin D, and folic acid needed to prevent the associated index disease are often the same as or above the intake needed to prevent the nonindex disease (or deficiency symptoms).
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why you should take a multivitamin
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This week I wanted to dive into the topic of multi vitamins because I feel like there are two main categories of people when it comes to multivitamins - those who think you should take them and those who think they are a waste of money. I tend to fall somewhere in the middle, but as I went to look at the research that was available on multivitamins while I was writing the notes for this episode, I think I’m sliding more towards the camp of everyone should take a multivitamin.
First I want to clarify that taking a multivitamin or any supplement is absolutely 100% not a substitute for eating a solid diet full of whole, nutrient dense foods. That is hands down the best way to get all the vitamins and minerals you need. Because there are a lot of phytonutrients found in plants and whole foods that we have no idea about and we don’t know what benefit they have or how they interact with other nutrients. So while you may think that eating an orange and taking a vitamin C supplement are the same thing, they are not. You get a much greater benefit from the orange than the supplement. But even if you’re eating a healthy diet, studies show that it’s virtually impossible to get adequate amounts of all of the necessary nutrients just from food. One recent paper reported that large populations of people in the US had intakes that were below the requirement for a variety of nutrients.
35% of people don’t get enough Vitamin A
31% don’t get enough vitamin C
74% don’t get enough vitamin D
67% don’t get enough vitamin E
39% don’t get enough calcium
46% don’t get enough magnesium
They also found that 0% of people got enough potassium (that’s a big deal), 8% got enough choline, and 33% got enough vitamin K.
This means that what’s called “micronutrient sufficiency” is not being achieved through food in a huge portion of the population.
There is a whole host of reasons why we aren’t getting adequate micronutrients from our food. To really dive into this topic could be a whole podcast episode in itself, so I’m only going to mention a few things. First, the average American is simply not eating enough of the right foods. Go into any grocery store and you see that most of it is taken up with processed foods full of artificial ingredients. And while yes, many of them are fortified with certain nutrients, not being deficient is very different than having enough for health, we’ll talk about that idea more in a minute. Fruits and vegetables are the main source of vitamins, and it is recommended that we all get at least 5 servings daily (I recommend more like 9, but 5 is a great place to start). But a recent survey showed that only about 30% of the population actually meets this goal.
The plants and animals that we eat have fewer micronutrients than they used to. There are many reasons for this - nutrient depleted soil, pesticides, and breeding for specific traits like taste and sugar content of fruit over nutrients. So chances are that even if you are eating a nutrient-dense whole foods diet, you may still be deficient or not entirely sufficient in many of these nutrients.
One of the big problems with suboptimal levels of vitamins (and this includes levels that are above the level of deficiency) is that it contributes to an increased risk of chronic disease, especially cancer, cardiovascular disease, and osteoporosis. An article from the Journal of the American Medical Association states that measurements of vitamin levels for abnormality are not a reliable guide for this form of deficiency. The example that they use is supplementing folate in elderly patients decreased their homocystine levels (a metabolite that typically indicates deficiency of B6, B12, or folate) even though their serum folate levels were normal.
To say that supplementing when you are not deficient does not provide a benefit is contradictory. There is randomized clinical trial data (often considered the strongest form of evidence) showing that folate during the first trimester of pregnancy reduces the risk of neural tube defects in infants and the same with calcium reducing the risk of fractures in elderly women with otsteoporosis.
Folate supplementation in many cereals and grains only increases folate by about 100mcg, so this is still not enough for many people to get the recommended 400mcg per day. Food preparation also decreases the vitamin content of food, so keeping food hot for longer than 2 hours causes a 10% or greater loss of vitamin C, folate, and B6. These same vitamins are also lost during chilling storage, and reheating. So, even though you might be eating enough of a certain food to think that you’re getting adequate intake of certain vitamins, if you are cooking, chilling, and reheating your food, chances are that you are getting much less than you think you are.
Vitamin supplementation is NOT an appropriate substitute for a good diet. So the first line of defense against micronutrient deficiency is a solid diet.
That being said, after reading a few studies it seems like it’s generally a good idea for most people to take a multivitamin regardless of the quality of their diet.
One study concluded that supplementation with a multivitamin formulated at about 100% of daily value can decrease the prevalence of suboptimal vitamin status and improve micronutrient status to levels associated with reduced risk for several chronic diseases. Another concluded that micronutrient sufficiency is not being achieved through food solutions for several essential vitamins and minerals and that the use of age and gender specific multivitamin/multimineral supplements may serve as a practical means to increase micronutrient status without increasing intakes above the upper limit.
There are many clinical trials that have demonstrated the benefits of multivitamin and multimineral supplementation, and it has been shown to not only improve nutritional status and decrease risk for chronic diseases, but also has been shown to improve mood, alleviate migraines, improve immune function and infectious disease outcomes in the elderly, reduce morbidity and mortality in patients with HIV infections, decrease PMS symptoms, improve symptoms of bipolar disorder, decrease violence and antisocial behavior in children, and improve intelligence in kids.
Another reason why I think that there is resistance among many in the medical community to adopt a widespread recommendation to multivitamins is because the nutrient sufficiency of a population tends to be determined (at least on a broad level) by the absence of what are called “short latency” diseases such as rickets, scurvy, and beriberi. One study I read on this topic stated that the long-latency disorders that afflict the human race today, such as cancer, cardiovascular disease, and central nervous system degeneration, constitute a field that from the standpoint of clinical nutrition is left largely to nutritional quacks. Discerning the extent to which nutrition may play a role in such disorders, positive or negatives, is probably the principal challenge facing nutritional science today.
This paper also states that there is a bias towards short-latency disease and a tendency to link individual nutrients to single diseases as well as a single disease mechanism. So vitamin D deficiency has been linked to rickets, iodine has been linked to goiter, etc. The presumption has been that if the intake of the nutrient is sufficient to prevent the expression of the index disease for that specific nutrient, then the the intake of that same nutrient must also be sufficient for overall wellbeing.
But probably the most profound statement is in regards to vitamin D, but also carries over to any nutrient, is that the vitamin D requirements are aimed at preventing stage-3 deficiency (which in this case is rickets or osteomalacia) and there is still the presumption that if you do not have rickets or osteomalacia then you have sufficient vitamin D. It then goes on to discuss that increasing serum vitamin D levels from 50 nmol/L to 80 nmol/L (both values are in the normal reference range for labs) improves calcium absorption efficiency by nearly two-thirds and reduces osteoporotic fracture risk by one-third.
This also gets into the idea that recommended daily intakes are kind of junk because their goal is to make sure that you don’t get any of these short-latency diseases and not for you to be optimally healthy. I’m not sure how that’s even really a good policy, I get that we want to prevent disease, but why the focus on the bare minimum? I’m sure there’s some sort of political agenda here, or maybe it’s meant to keep the entire medical industry in business...but whatever the reason is, I’m sure it’s not a good one.
So my conclusion from reading all of this is that we all need to start taking a multivitamin. Inevitably the next question you’re going to ask me is “which one should I take?” Before I dive into that, I want to mention that one of the studies I referenced earlier said that they were not aware of any evidence that various multivitamins differ in bioavailability because of the way they were formulated. This particular study was written in 2002 so I’m not sure what the availability of whole foods based multivitamins were at that time. Either way, I wanted to share what the evidence says, but then also say that I disagree with that statement.
what should you look for in a multivitamin?
I prefer capsules over tablets, you can shove a lot of stuff in to relatively small space with a tablet, but they tend to be harder to digest and full of binders and questionable things that keep them together. It also takes longer to break them down in your gut because of the way they are packed together.
Capsules break down much more easily, which is important because most of your nutrient absorption takes place in your small intestine and if you have a giant tablet that takes hours to break down, that may not happen in your small intestine...which means expensive pee.
If you find a capsule based multivitamin, chances are that it will require you to take multiple capsules because you can’t fit as much stuff into a capsule as you can a tablet. However, I’ve found that the expensive pee problem is greatly reduced with a multiple capsule dose multi-vitamin. It’s also possible that this means twice a day dosing, so once in the morning and once in the evening. But be careful if you chose to go that route because if your vitamin contains B vitamins, you may find yourself having trouble sleeping.
Your multivitamin should also not contain any gross fillers such as magnesium stearate. The only purpose of this form of magnesium is to help the ingredients go through the manufacturing equipment faster, so it saves the manufacturer money while also decreasing the absorption rate of some of the nutrients in your vitamin.
Something like calcium laurate is a better option because it serves the same purpose but does not simultaneously inhibit absorption. This no gross filler requirement also means that it is free from wheat, corn, gluten, yeast, artificial colors, sweeteners, flavors, and lactose.
If you’re an athlete you need to make sure that your vitamin doesn’t have any banned ingredients in it. There’s a certification called NSF for sport which ensures via third party verification that it is free from any banned ingredients. This is something that I actually just learned about, I listened to a couple of interviews with olympic athletes who said that they were actually scared to take any sort of vitamin, supplement, or even protein powder for fear of it containing something that would get them banned from competition.
If you’re really concerned about this, look for the TGA certification, this is the Australian Therapeutic Goods Administrations inspection and certification which is conducted at a pharmaceutical level standard. There are very few companies in the US that have this certification, so it’s probably not worth the trouble for most people to find a vitamin that is TGA certified.
There are also some nutrients that you need to make sure are in your multivitamin in the right forms and adequate amounts.
The first is vitamin D. The 200-400IU of vitamin D is pathetic. That’s, as we’ve already discussed, barely enough to keep a kid from getting rickets and definitely not enough to support optimal health. And if you live in a place where there’s not a lot of sun or you are in a northern climate where it’s hard for your body to make vitamin D from the sun for most of the year, you need more. I’d prefer 2000IU or more of vitamin D, but since that’s hard to find with optimal amounts of other nutrients, vitamin D is the one supplement that I think most people should take in addition to their multi. When you look for a vitamin D supplement, you also want it to have vitamin K2 in order to make sure that you are actually absorbing the D.
You also need to make sure that your vitamin has vitamin B6, B12, and B2 in the correct forms. For B6 that’s pyridoxal 5’-phosphate (or P5P). With B12 you want methylcobalamin and for B2 you want riboflavin 5’-phosphate. You also want to make sure that the folate in your vitamin is NOT folic acid, and it’s even better if it’s methyltetrahydrofolate.
Minerals are also tricky because by themselves they are not well absorbed so they need to be bound to something else. Look for chelated forms of calcium, magnesium, copper, zinc, manganese, chromium, and molybdenum. It will say something like zinc picolonate or magnesium bisglycinate on the label instead of just the mineral. I’ve also seen them listed as “zinc amino acid chelate.”
I also typically like a whole-foods based multivitmain, because despite what the study I mentioned earlier says, I think that they are better absorbed. I have found that there is less of the expensive pee phenomenon with whole foods based multis. My favorite brand is Garden of Life. It satisfies most of my requirements (but not all). If you are interested in learning what other brands I recommend, I use FullScript, for an online dispensary. When you create a free account there you can see my favorites as well as check out their whole catalog. You’ll also get 10% off all of your orders!