Sorting Out Supplements
Updated: Nov 10, 2018
A common question we encounter in our daily practice is “what supplements should I be taking?” There is no straightforward answer to this question as it really depends on your age, diet, and specific health issues, but I will try and narrow it down a bit. I also want to preface things by saying that it is best to get the majority of your vitamins, minerals, and nutrients through whole, unprocessed foods. Unfortunately, today’s soil is seriously lacking in nutrients due to modern intensive agricultural methods. Each successive generation of fruits and vegetables is nutritionally less robust than the last. A study in 2004 demonstrated that the protein, calcium, potassium, iron, and vitamins B2 (riboflavin) and C content for 43 different fruits and vegetables had declined from 1950 to 1999 (1). Kind of depressing, no?
Keeping that in mind, here are a few of the common supplements that we get asked about and often recommend to our patients.
I generally do not recommend a multivitamin every one of my patients. Many think that taking one will make up for a less than optimal diet. Sorry to break it to you, but nothing replaces the vitamins, minerals, antioxidants, and other beneficial compounds that you get from eating whole, unprocessed foods (even ones that are grown in somewhat depleted soil). Further more, there is a lack of clear scientific evidence that multivitamins reduce the frequency of sickness and doctor’s visits, and taking them has not been shown to be cost effective (2). They may, however be helpful in patient’s who have undergone gastric bypass surgery and in the elderly (who’s diet is often that of tea and toast) (3). I also recommend a prenatal multivitamin in my patients who are trying to conceive or who are already pregnant.
While women are at higher risk of iron deficiency because of the regular blood loss associated with menstruation, most people do not need routine iron supplementation. Not to mention that iron supplements can cause a lot of stomach issues. I always recommend that patients have iron deficiency confirmed through blood work prior to starting a supplement. Iron can be obtained through diet rich in dark leafy vegetables, fortified whole grains, and lean meats. Clams, oysters, beef, and chicken contain a highly absorbable form of iron called “heme” iron, whereas plant foods contain a poorly absorbable form called “nonheme” iron. A few other tricks to increase iron absorption: avoid consuming substances that impair iron absorption (such as tea, coffee, dairy, supplemental calcium, and supplemental zinc) along with your meals, cook with a cast iron skillet, and consume iron rich foods along with foods that are rich in vitamin C (or take a 250mg vitamin C supplement).
Similar to iron, I usually don’t recommend B12 supplements for patients without confirming first that they have a deficiency. That being said, a supplement with the recommended RDA (2.4mcg in most individuals, 2.6mcg in those who are pregnant) is not harmful, especially in vegetarians and people who do not get much animal products in their diet. A high dose supplement (ie. 1000mcg) is suggested only when there is a confirmed deficiency. Food sources of vitamin B12 include poultry, eggs, and milk.
Vitamin D is a supplement that I take myself and recommend to a lot of my patients. Not only does it help maintain bone health, it has been shown to be inversely related to all-cause mortality (death from all causes) including from cardiovascular disease, respiratory disease, and cancer (4). Vitamin D deficiency is quite widespread and research suggests that it has much broader role in disease prevention than originally thought. A comprehensive article discussing vitamin D and health can be found here. I recommend that my patients get at least 1000 IU of vitamin D3 a day, especially those that do not spend much time outdoors in the sun and post-menopausal females. Those with vitamin D deficiency often require much higher doses.
Assuming you are getting enough calcium through dietary sources, there is usually not a need to supplement. The RDA for calcium for most individuals is 1000mg (1200mg for post-menopausal females). This can be reached through approximately 3 servings of dairy products a day (1cup of milk, 1 cup of yogurt, and 1.5 oz of cheese all equal 1 serving). If you are vegetarian or are choosing to avoid dairy because of its potential impact on digestive function and inflammatory disorders, you can meet your quota through foods such as kale, broccoli, tofu, and fortified soy milk. With the exception of soy and fortified products, these foods typically contain a lot less calcium per serving than dairy-based foods- even more reason to get your 7+ servings of fruits and vegetables a day! Taking a supplement then topping it off with some calcium rich foods is another option, however I usually do not recommend taking any more than 500mg of calcium through supplements. There is some controversy surrounding the safety of calcium supplementation in regards to its possible relationship to cardiovascular risk, however intake within the normal recommended range has not been shown to be associated with cardiovascular risk in otherwise healthy adults (5).
When it comes to bone health, I usually caution my patients against over focusing on calcium intake and calcium supplementation. Vitamins D and K are also vital to the maintenance of skeletal strength and consuming a variety of whole foods and fruits and vegetables (usually along with a vitamin D supplement) ensures that you are getting adequate amounts of these bone building nutrients. Check out this article for a more in-depth at this topic.
Omega-3 Fatty Acids (fish oil)–
Fish oil supplements have taken the nutritional stage over the last decade. While studies in the early 2000s demonstrated that omega-3 PUFAs (polyunsaturated fatty acids) reduced the risk of cardiovascular disease outcomes and all-cause mortality, more recent research has failed to show a beneficial effect (6). This does not mean that they are ineffective, only ineffective in the context that they were tested. Evidence does, however, support the consumption of at least 2 servings of fatty fish a week (for example salmon, trout, tuna, and mackerel). Omega-3 supplementation is therefore a reasonable alternative for those who do not consume fish. I also usually recommend omega-3 supplements to patients with high cholesterol, especially high triglycerides (7). While the evidence isn’t clear for a beneficial effect, there is certainly no harm. For general health I usually recommend a supplement containing 1000mg of combined EPA and DHA. Higher doses in the realm of 4-5gm per day are recommended for patients with elevated triglycerides. I personally try and get my omega-3’s through regular consumption of fish and walnuts, however I do top that off with a supplement. Even if their exact effect on cholesterol is questionable, omega-3 fatty acids are anti-inflammatory (8). Given that cardiovascular disease is, at its core, an inflammatory condition, it makes sense to consume them as part of a heart healthy diet.
The reality is that this is a huge topic and this list is by no means all-inclusive. That being said, these are the top supplements that come up in conversation with our patients. If you are signed up for our newsletter you will also be receiving a weekly installment in our “Supplement Series,” a multi-part series highlighting various supplements that we ourselves use on a regular basis. And if you aren’t yet signed up, head to our main page and subscribe before you miss out! Last but not least, if there any specific supplements you are wondering about, please feel free to comment below on this post or send us an email!
Continue to follow your gut,