Medicine For People!

June 2011: Multiple Vitamins Part III




Multiple Vitamins Part III

Yes or No?

You'll frequently see doctors argue for and against daily vitamins. Should you, like many of our patients, go out and buy the vitamin that that someone says may prevent heart disease or preserve the brain? Many gulp down a handful of supplements every day, figuring taking the pills might help and can't hurt. Or should you listen to the doctors who say that since supplements are unregulated and the science is sketchy, best just to avoid them. Which approach is better? This month's newsletter aims to give you some guidelines and tools to answer those questions.

Beyond the Multiple Vitamin

First, your health depends not just on the micronutrients that will fit into a capsule or two, but on other nutrients that won't.

Here are the important ones, but first let me repeat the mantra of this series – food is best. Yes, supplements can help, they can even be vital to health. Still, having a good diet composed of fresh vegetables, fruit, beans and grains provides nutrients in a way that pills can never match. This is the foundation of good health, and far more important than anything that follows.

  • Fiber feeds the bacteria in our intestine. These bacteria affect our health. We and our bacteria evolved in a very different dietary world. Some people, but not all, with arthritis, colon disease, gas, fatigue, diarrhea or constipation suffer because of an unhealthy intestinal bacterial community. A review1 of over 30,000 deaths showed between a reduction of between 25 and 59 percent in the death rate in those consuming more fiber. Best is food that, frankly, is going to take a little chewing time, such as fresh fruits, vegetables, and grains. There's precious little fiber in a hamburger, a pizza, a coke, and a bag of chips.

  • For many Americans, the modern diet runs low in omega-3 fatty acids, especially EPA and DHA. These reduce the inflammatory component of arthritis and seem to benefit people with certain cancers and heart disease. This will require two high-potency capsules or two teaspoons of fish oil.

  • Magnesium stores run low in about a third of Americans, cannot be detected by measuring blood magnesium, and can result in headache, irregular heartbeat, high blood pressure, muscle cramps and other symptoms. An excess of magnesium can cause diarrhea. If you are low, it'll take up to four capsules a day to replace, capsules that'll have no room for anything else. If you have any of these symptoms, consult your healthcare provider about whether magnesium could help you and how to obtain enough.

  • In our northwest clime, most of us can use extra vitamin D. Multiple vitamins made for a national market often do not suffice here. Unless you're about to move to a very sunny climate, you need to talk to your doctor about vitamin D.

Multiple Vitamins: Where's the Science?

To outline the groundwork of our previous newsletters, I've included this section with links.

Individual Differences

We humans don't just look different from each other—we each have an individual metabolism with, sometimes, dramatic results.

Government Standards

Because these individual variations in needs, government recommendations for vitamin and mineral intakes do not suffice for the majority of people.

Sometimes Nutrients Can Help, Sometimes They Can Harm

While you need to read the studies with a careful eye , supplements can worse

Important Groups: Pregnant Women, the Chronically Ill, and Children

With this information, we gave rules for particular groups .

Individual Considerations

How to Read the Label—the RDI

Assuming you're already careful with what's on your dinner plate, a good place to start considering a multiple vitamin is by reading the label.

On the label, you'll find percentages of the daily intake supplied. The USDA has set levels of nutrient intake called Reference Daily Intake (the RDI) that will satisfy the needs of 97.5 percent of normal people. To be safe, an RDI must not hurt anyone, and is set, purposely, to be to too low for some people rather than too high. Almost certainly the percentages on the label you read will be all over the map. There are some good reasons for this.

For example, the amount of folic acid in a pre-natal vitamin will equal or exceed the RDI because higher amounts of folic acid reduce the risk of birth defects, so you can expect to see at least 100 percent of the RDI on the label. (Always be sure to take vitamin B12 with folic acid. Taking either alone can damage the nervous system.)

Then again, manufacturers often include amounts of vitamin B12 far in excess of the RDI because up to half of older people absorb the vitamin poorly. The only danger from excess vitamin B12 is when it is taken without folic acid, but multivitamins already contain that, so no worries. And if you want to push vitamin B12 into someone who absorbs it poorly, you need a hefty dose.

Potassium works just the other way. Yes, potassium stores run low in about a third of Americans, are poorly detected by measuring blood potassium, and can result in irregular heartbeat, high blood pressure, muscle cramps and other symptoms. But because an excess of potassium will kill us and we obtain varying amounts from our food, the amount of potassium in every vitamin is usually less than 10 percent of the RDI. Replacing potassium in those who are low requires your doctor's help and is beyond the ability of a multiple vitamin to influence.

Therefore, because there are over twenty essential micronutrients, an infinite variety of people who will take them, and a constantly evolving understanding of nutrition, I can't tell you exactly what percentage of each nutrient should be in your pill. Some manufacturers have put considerable thought into their products, and other manufacturers have not. So how do you choose?

How Vendors Compete

Vitamin vendors compete on price, quality, or hype.

Competition by Price

Consumer Reports bought a selection of multiple vitamins and tested to see what was in them2. They found that, by this measure, some of the Big Box labels provided the most value for the dollar-- with Costco's Kirkland brand, Walmart's Equate, and Dollar General's Healthsense topping the list at about a dollar a month.

Competition by Hype

The angles used to push vitamins defy imagination. I'll just say I've chased down enough claims and found them bogus that I am jaded. Currently the rage seems to be that the vitamins are “plant based.” Such vitamins hold no health advantage over any other kind of vitamins. If you want “plant based”, eat your spinach.

Competition by Quality

Some companies compete by quality. Thorne Research, for example, sells into an international market under certification of the Australian Therapeutic Goods Administration, chosen because most countries accept those standards as definitive. Other companies position themselves as premium companies, some with justification, most without.Without visiting the factory (I visited Thorne's), you can sometimes tell if the manufacturer aims at quality by checking the form of the vitamin or mineral on the label. Many vitamins and minerals exist in several forms with varying costs. The downside, of course, is that labels can be inaccurate.

More economical, less bioavailable, often adequate

Expensive, either safer in larger amounts or more bioavailable


Mixed carotenoids

Magnesium oxide

Magnesium chelate, citrate, or malate


d-alpha-tocopherol or mixed tocopherols. The more gamma- and delta-tocopherol listed, the better.

Riboflavin (vitamin B2)

Riboflavin-5-phosphate (active form of vitamin B2)

Pyridoxine (vitamin B6)

Pyridoxine -5-phosphate (active form of vitamin B6)

Cyanocobalamin (Vitamin B12)

Methylcobalamin or adenosylcobalamin (active forms of vitamin B12)

Folate or Folic acid

5-methyltetrahydrofolate (the biologic form used in your body)

Magnesium stearate: a usually harmless flow agent you'll find in every economy vitamin.

Magnesium stearate: not required to be listed on the label, so often it isn't. But if listed, a sign of a high-volume, low-cost operation.


An inexpensive vitamin including ingredients from the left hand column can be a useful multiple vitamin. But a vitamin claiming a premium price without ingredients meeting standards from the right hand column is not a good buy.

Magnesium stearate is a flow agent used to speed operation of the encapsulation machinery (it has a soapy texture). If you find that vitamins upset your stomach, it may be the magnesium stearate.

What Should NOT Be in your Multiple Vitamin

Iron: Men over the age of twenty, and women past menopause may suffer adverse consequences from iron supplementation, so should avoid it unless prescribed.

Examples of the Above Principles Put Into Practice

Choice of supplement should always be based on your individual situation – your age, your health, and your financial resources. Here are some examples of rational vitamin regimens.

  • Marty is a forty year old man with no health problems. He takes Costco's Kirkland brand daily vitamin and 2000 units of vitamin D daily.

  • Janet is a 59 year old practicing lawyer with high cholesterol, strong family history of heart disease, and adequate disposable income. She takes three capsules of Thorne's Basic Nutrients V as a basic daily vitamin, with an extra 2000 units of vitamin D. To keep her musculoskeletal system in shape for the long haul, she adds two teaspoons of cod liver oil and 1500 milligrams of glucosamine daily. To protect her heart, she takes 750 milligrams of niacin twice a day (along with a statin), and of course the cod liver oil does no harm here either.) Finally, being a professional woman and having carefully read our series on brain aging, she asked her doctor to prescribe one 300 milligram lithium capsule daily, and she takes two capsules of Neurochondria, a brain preservation supplement, twice a day.

  • Mary, a 32 year old mother of two and part-time fitness instructor, takes a pre-natal vitamin with iron, standard fare for any woman with the potential for pregnancy. Every morning to prevent constipation she also takes one tablespoon of a fiber supplement in a glass of water..

  • Ralph, 65 and unemployed, is looking for work to augment his small Medicare check. More money goes toward his mortgage than towards his vegetable supply. He takes Walmart's Equate multiple vitamin to fortify his pasta and tuna diet.

  • Simon doesn't like pills in general, but he knows that recovery from acute illness can require increased amounts of vitamin A, thiamine, and folic acid. He keeps a multiple vitamin on hand and takes it only if he is ill.

  • Anne's friends recommended a plant-based vitamin supplement for her six-month old. She decided instead to call her child's doctor's nurse to see what they suggested. She learned that plant-based supplements can contain allergens or contaminants which may pose a danger to an infant's immature immune system. Mary decided to stick with breast milk and a liquid vitamin D supplement for the first year or two.

My Recommendation for You

If you have cancer, are pregnant, or are deciding for an infant or child, ask your doctor. Otherwise, review the information in these newsletters, take into account your age, state of health and risk factors. Avoid marketplace hype. Remember, supplements are secondary; food is first. Unless you have a specific condition that requires a specific supplement, given the choice where to put your dollars, fresh vegetables and fruits, whole grains and beans trump vitamin pills. If you can afford both, so much the better. More information here.

Ignore the Media See-Saw

Within a week two after you read this newsletter, you're will likely see at least three news pieces about vitamins. Don't assume the writer has actually read the research they are reporting on. Rarely do they know how to. Experts and researchers often have a commercial agenda. The tricks they can use to mislead you (and your doctor) multiply like the Hydra's head. I often spend hours studying and checking scientific references – just scanning the abstract does not tell you much. Keep your eye on Medicine for People! We'll help keep you on an even keel.


Which fruits and vegetables are worth paying the “organic” price premium for? Which aren't? This guide to the Clean Fifteen and the Dirty Dozen appeared on the clinic Facebook page. Check us out for unique shorts about health and medicine.


1 Dietary Fiber Intake and Mortality in the NIH-AARP Diet and Health Study
Archives of Internal Medicine (02/14/11) Park, Yikyung; Subar, Amy F.; Hollenbeck, Albert; et al.

New research suggests that dietary fiber may reduce the risk of death from cardiovascular, infectious, and respiratory diseases. Scientists looked at dietary fiber intake and its relation to total mortality and death from specific causes in the NIH-AARP Diet and Health Study. Over an average nine years of follow-up, there were 20,126 deaths identified in men and 11,330 deaths in women. For both sexes, dietary fiber intake was associated with a significantly lowered risk of total death. Dietary fiber intake reduced the risk of death related to cardiovascular, infectious, and respiratory diseases by 24 percent to 56 percent in men and 34 percent to 59 percent in women. In men, researchers noted an inverse association between dietary fiber intake and cancer death. And for both sexes, dietary fiber from grains only was inversely related to total and cause-specific death in both men and women.

2 Consumer Reports, September 2010, page 21-23.



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Medicine for People! is published by Douwe Rienstra, MD at Port Townsend, Washington.