Supplements are supplemental

I get asked often about supplements both by patients in my practice and by social acquaintances. There are a couple of canned answers I give if I am in a hurry, but they usually revolve around four fundamental thoughts that I have about supplements.

1) The first is that supplements in my mind are classified in the same categories as prescription medications. 

•  In my mind, supplements, herbals, recreational drugs, over the counter drugs, and prescription medications are all chemicals we put in our bodies at relatively low doses to deliver a desired effect. They all have risk and benefit profiles, interactions with other medications, and side effect profiles that need to be monitored. To put it more directly, supplements are not exempt from the gauntlet of rigorous questions I pose to every drug: "Should I be on this?", "Is this safe?", "What is this really adding to my health?", "How can I get the desired effect in another way?", "Is the cost really worth it?"

• While the complex history of why supplements and drugs became different categories and fell into different regulatory frameworks is beyond the scope of this entry, know that it is fascinating.

• Many people think that supplements are benign. This is definitely not the case. Take for example the paper by Omenn et al. 1996. They found that supplementing men that smoked with beta carotene and vitamin A caused the following:

  • - a 28% increased relative risk of lung cancer of HR 1.28 (95%CI 1.04 to 1.57; P0.02)

  • an 18% increased likelihood of death in general. HR 1.18 (95%CI 1.02 to 1.37) 

  • a 46% increased likelihood of death from lung cancer. HR 1.46 (95%CI 1.07 to 2.00)

  • I referenced this paper in a recent post LINK TO POST. Additional here is a LINK TO PAPER

2) Don’t think that supplements can out compete a bad diet.

• And an analogy I like to use is to compare 'taking supplements to save a bad diet' to "using Valentine's Day to save a marriage that you've put no effort into the rest of the year'.

• It just wont work.

3) Most supplements might be an indication of health user bias and simply represent a good proxy for superior general self care.

• I really like Michael Pollan's approach of, "be the kind of person who takes supplements". That is, the supplements themselves might actually do minimal to nothing to help you, but they can represent the fact that you’re investing time, energy, thought, and resources into your health as evidenced by the purchase of supplements. 

• We can think of taking supplements similar to the 'vegan red herring'. Let me explain. Multiple observational studies show that vegans live longer and healthier lives compared to individuals on the standard American diet... So should we all conclude that we should all become vegan? Not so fast. It is incredibly difficult to disentangle the benefits of the vegan diet alone from the other healthy lifestyle practices that vegans often practice. Vegans are less likely to smoke, they are almost uniformly wealthier, they eat less processed foods, they are more likely to meditate and do yoga, more likely to go to the doctor, and more likely to do almost any behavior considered healthy compared to the standard American. Thus, veganism might be a proxy for health; a positive prognostic indicator of health indicative of all the other health behaviors integrated together as opposed to the vegan diet being the actual behavior driving the health itself. In reality, it is likely a mix of both. So too with supplements. 

• Marion Nestle nails this sentiment when she writes in her book "Food Politics" that, "... Taking supplements is a health behavior that "tracks" with other characteristics that predict food health. People who take supplements are less likely to smoke cigarettes or abuse alcohol and are more likely to follow dietary recommendations and to exercise; they are also more likely to be educated, financially well off, and - no surprise - healthier."

• To learn more Michael Pollan's book "In Defense Of Food" and Marion Nestle's book "Food Politics" are must reads.

4) I don't think supplement companies are evil, but their sole purpose in existing is to turn financial profit; indicating that their incentives might not align with yours.

• We exist in a semi-regulated free market economy. To survive here one must be aware of the predator and prey relationship and be able to navigate it adeptly. Can a supplement company both make profit AND do so by delivering incredibly high quality chemicals that actually improve their customers health? Yes, and I believe many do operate in this good faith effort. This is the ideal outcome. However, I am not being cynical when I say that if a company has to choose, the profits come first. No margin, no mission || No employment, no existence. 

In the end supplements are not a magic bullet. They are a potential tool in the health arsenal, but don’t bring a knife to a gun fight. You can't depend on supplements for everything. There are so many more potent levers to pull when it comes to drastically improving your health and longevity. Use supplements wisely and know that you have to be your own advocate in this wild west of a market.