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Recommended vitamins/supplements
Pregnancy Osteoporosis High cholesterol
Cold Prevention/Treatment Weight Loss Supplements Miscellaneous
Topics to be covered
Survey done by the National Center for
Complementary and Alternative Medicine found that 4 in 10 adults had used “integrative therapy” in the past year
How much do we use?
Water soluble
Too much Vitamin B Worsen diabetic neuropathy
Too much Vitamin C Loose money
Vitamins B and C
Occurs in alcoholics
due to malnourishment Heart failure Muscle wasting Peripheral nervous
system problems Problems with thinking
Beriberi-thiamine
Tiredness, muscle
weakness, joint and muscle aches, bleeding gums, rash on skin, loss of teeth
Scurvy-Vitamin C
Fat soluble
Vitamin A-nausea, vomiting, headache, dizziness, blurred vision
Vitamin D-excess may cause cardiovascular problems
Vitamin E-increase bleeding problems Water Soluble
Vitamin C-laxative effect Vitamin B6-skin problems and peripheral
neuropathy
Too much?
Has found poor
evidence to recommend routine use of Vitamin A, D, or E, multivitamins with folic acid, or antioxidant combinations to reduce the risk of cardiovascular disease or cancer
United States Preventative Services Task Force
Calcium
Keeps bones of mom and baby healthy 1,300 mg/day age 14-18 1,000 mg/day age 19-50
Folic acid Brain and spinal cord development 600 mcg/day
Iron Prevents anemia in mom and baby 27 mg/day
Vitamins in Pregnancy
US preventive services task force recommends
supplementation of 400mcg to 800mcg daily for all women capable of pregnancy
Folic Acid
Most pre-natal vitamins do not contain enough
calcium and expectant mothers must get additional calcium through diet or supplements
Calcium
Women 51-70 (Men over 70) recommended
1,200mg/day Two divided doses-body only able to absorb
approx 500mg at a time Do not take with medication for reflux like
prilosec, nexium, omeprazole Calcium citrate or calcium carbonate Take with vitamin D which helps absorption
Calcium
Eight ounces of yogurt-300mg One cup of milk-300mg 1.5 oz of cheese-300mg 8 oz of fortified OJ-300mg
Food Sources of Calcium
Adults < 70
600 IU/day Adults > 70
800 IU/day Helps us absorb calcium Also can get from the sun
Vitamin D
Sockeye Salmon-800 IU 3 oz can of tuna- 150 IU Vit D fortified milk- 80IU OJ fortified- 80 IU Fortified yogurt-80 IU
Food Sources of Vitamin D
People typically get 300mg of calcium from
their diet daily With the use of sunscreen, long hours spent
indoors, or people who live in the northern latitude, overall decreased sun exposure causes pts to not get enough Vitamin D
Do I get enough?
Colon cancer Kidney stones Obesity Hypertension Osteoporosis Bone fracture
What happens if I don’t get enough?
>2500mg/day may increase the risk of
hypercalcemia and kidney problems Kidney stones- >2150 mg/day in
postmenopausal women Avoid coral or dolomite (a kind of limestone)
because they can contain heavy metals like lead
How much is too much?
Crucial for brain development Involved in growth and development Shown to decrease risk of heart disease Decrease inflammation
Why do I need it?
The American Heart Association recommends
two servings a week of fatty fish, such as: Mackerel Sardines Albacore Tuna Large Trout Salmon
How do I get it?
American Heart Association
Adults with no history of heart disease Fish two times a week
Adults with coronary heart disease 1 gram daily of EPA and DHA
Adults with high cholesterol levels 2-4 grams daily of EPA and DHA
And what if I don’t eat fish…
Do not take more than 3 grams without a
physician supervision Side effects include fish breath, gas, bloating,
belching, diarrhea Use with caution if you take a medication to thin
your blood or have a bleeding disorder- omega-3 supplements can increase your risk of bleeding
Get supplement from an established company that certifies that their products are free of contaminants like lead, heavy metals, mercury
How much is too much?
Prevention
Might help immune function Most evidence (8 studies)
suggests that even in doses of 1 gram a day does not prevent colds
Treatment “Some evidence” that taking
high doses may decrease sx duration by 1-1.5 days
Vitamin C
Prevention
Only in vitro evidence (in the lab) that it stops the growth of the common cold
No reliable evidence that it can prevent the cold in vivo (in humans)
Treatment 9-24 mg elemental zinc started within 24-48 hrs
of symptoms to reduce severity and duration of colds (6 studies)-take every 2-3 hrs while awake
Other studies show no effect (5 studies)
Zinc
Prevention
In vitro (in the lab) research suggests it stimulates immune system
In vivo (in people) studies for prevention against the common cold has “consistently been shown to be ineffective” (9 studies)
Treatment “Some preparations” may reduce
symptom severity and duration possibly by about 10%-30% Different species Best evidence with Echinacea
purpurea
Echinacea
Prevention
May have immunostimulant activity and antiviral
If taken between November and February may have one fewer cold episode than patients taking placebo
Garlic
Patients who have autoimmune disease such as RA
(rheumatoid arthritis or lupus) may do worse with the supplements that “stimulate” the immune system
Echinacea-Ragweed allergies should not use-cross allergy
Vitamin C-high doses may increase risk of side effects Zinc-nasal spray withdrawn from market due to
permanent anosmia (loss of sense of smell) Garlic-adverse effects like bad breath and body odor,
interaction with warfarin (coumadin) causing increase in risk of bleeding
How much is too much?
Promotional material “developed by a teacher
who was sick of catching colds in class” Contains vit C, vit E, vit A, zinc, echinacea No proof it can prevent or treat a cold Not recommended
What about Airborne?
American ginseng- maybe beneficial Probiotics-maybe beneficial for respiratory infection prevention-more in
children Panax ginseng-might have immunostimulant effects and protect against
colds and improve response to flu vaccine Vitamin E-some evidence that it might help the body build immune
response with vaccination Andrographis Astragalus Elderberry- possibly use in treating the flu-antiviral and immune system
changing effects Goldenseal Pau d’arco, bee propolis, wild indigo, boneset, Siberian ginseng,
larch arabinogalactan Teas-elderflower, rose hips, goldenseal, chamomile, peppermint, slippery
else, ginger, Mormon tea, linden flowers, meadowsweet
Others
Flu shot every year-Usually starts August-
March Hand washing or alcohol based hand gels
Hand washing-2 min with soap and water “Some evidence that alcohol based hand gels,
which have 62% ethyl alcohol, lower the amount of cold-causing viruses on fingers better than water.”2,3
So what can I do?
Ephedra (aka Ma huang)
May also be bitter orange or country mallow Weight loss of 2lb/month Caffeine Adverse events shown in 50 trials-psychiatric,
autonomic, cardiovascular, GI symptoms Another review showed 87 reports of
hypertension, abnormal heart rhythm, heart attack, stroke, seizures
Ten events led to death, 13 permanent disability-9 of those were at the recommended dosage.
“Increase Energy Expenditure”
Chromium picolinate
Studies of chromium and obesity show no difference between study group and placebo
Kidney failure is sometimes related to doses of more than 1,000 mcg a day
Uncertain safety profile
“Modulate Carbohydrate Metabolism”
Forms of soluble fiber
Guar gum Relatively safe, also 11 trials with this vs placebo
showed no difference Glucomannan
Trials show moderate weight loss, but only 20-50 pts in each trial
Psyllium Improved glucose and cholesterol, no differences
in weight loss
“Increase Satiety”
Hydroxycitric acid Linoleic acid Green tea Licorice Pyruvate Vitamin B5 Andl-Carnitine Chitosan Dandelion Spirulina Guggul
Others
“If there is strong evidence for a product’s
quality, safety, and efficacy, it may be reasonable to recommend that product and closely monitor the patient.”
None of these supplements meet this criteria. Ephedra should be actively discouraged Due to lack of efficacy, patients are
discouraged from using: chitosan and guar gum
So what does my doctor say?
Prevention-MAYBE EFFECTIVE Treatment of bladder infections- NO EVIDENCE Cranberries are suppose to inhibit bacteria from
adhering to the bladder wall It has not been proven that taking “AZO cranberry”
can prevent bladder infections 300 mL/day of Ocean Spray Cranberry Juice cocktail, 500mg/day of Buckton Scott’s Cran-Max capsules 400mg/day of Cranactin cranberry caps
Cranberry Extract
Probiotic Generally considered to be beneficial because
it produces vitamin K, lactase, anti-microbial substances
Many uses, mainly used to treat antibiotic-associated diarrhea, acute infectious diarrhea, irritable bowel syndrome relief
Side effects: flatulence
Acidophilus
Treatment of knee osteoarthritis GAIT trial-1583 participants May help with patients with moderate to
severe pain-GAIT trial showed 79% if patients in treatment group had 20% reduction or greater of pain
1500 mg Glucosamine 1200 mg Chondroitin Side effects-upset stomach
Glucosamine/Chondroitin
Treatment of sleep disorders Decreases the time it takes for people with a
primary sleep disorder to fall asleep Safe for short term use Did not help with how efficient sleep was or
quality of sleep Not effective for patients with secondary sleep
disorder Side effects include nausea, headache,
dizziness, drowsiness
Melatonin
Treat depression, anxiety, sleep disorders Some scientific evidence that useful for short
term treatment of mild to moderate depression
Side effects: sensitivity to sunlight, anxiety, dry mouth, dizziness, GI problems, headache
Interacts with other medications
St. John’s Wort
Widely used for memory impairment, dementia, ringing
in the ears, claudication Study of 3000 patients followed for 6 years that were
age 75 or older took 240mg a day found gingko ineffective in Reducing incidence of high blood pressure and in lowering
blood pressure Slowing cognitive decline
Can increase bleeding risk Raw ginkgo seeds-seizures and death Headache, nausea, GI upset, diarrhea, dizziness,
allergies
Gingko Bilboa
Federal Regulation of Dietary Supplements
The regulation of dietary supplements is different than that of prescription medications No premarket review needed No prior approval by FDA before marketed Do not have to provide evidence to the FDA
before the product is marketed that their supplement is safe, although they are responsible for making sure that it is safe and that claims are not misleading
Purity of supplements is relative
“Natural” does not always mean safe or
healthy Tell your doctor about any supplements or
vitamins you are taking Interactions with coumadin St. John’s Wort decreases effectiveness of
certain prescription drugs
Things to remember
1. Prescriber’s Letter
Vit D and Calcium Document #270102 updated Dec 2010
Prenatal Vitamins Document #270216 Feb 2011
Cold and Flu Self-Study Course #09029 expires Aug, 2012
2. Widmer AF. Replace hand washing with use of a waterless alcohol hand rub ? Clin Infect Dis 2000; 31:136-43.3. Sattar SA, Abebe M, Bueti AJ, et al. Activity of an alcohol-based hand gel
against human adeno-rhino-, and rotaviruses using the gingerpad method. Infect Control Hosp Epidemiol 2000;21:516-9.
4. NIH:National Center for Complementary and Alternative Medicine: http://nccam.nih.gov
5. University of Maryland Medical Center: http://www.umm.edu/altmed/articles/omega-3-000316.htm
References