No, You Still Don’t Need Vitamin D Supplements!

The NY Times this week ran a story under the headline “Am I Getting Enough Vitamin D During the Winter?” I’ll give you one guess how they answered that one.

Yes, the days are at their shortest right now. (The shortest day of the year will be Wednesday, December 21.) And yes, your body synthesizes vitamin D when you’re out in the sun, so you make less of it this time of year.

You also get vitamin D from a variety of foods. The Times story quoted a skin cancer expert from NYU School of Medicine, Dr. Deborah Sarnoff from, who said “you don’t need to get it [vitamin D] from sunshine.”

So you don’t need to run out and take vitamin D supplements. as I pointed out emphatically in a column I wrote back in August, and in several earlier columns too. Scientists have conducted multiple major studies of vitamin D supplements, as I wrote before, and those studies–involving thousands of subjects and running for many years–showed that

• Vitamin D supplements do not improve bone density, and they do not reduce the risk of osteoporosis.
• Vitamin D supplements don’t prevent heart disease, weight gain, mood disorders, multiple sclerosis, or metabolic disorders.
• Vitamin D supplements (in the most recent study, involving 26,000 men and women followed for more than five years) don’t do anything to prevent bone fractures.

But the NY Times reporter (Rachel Peachman) really wanted to recommend supplements, it appears. She apparently wasn’t able to get a doctor to say that, so instead she quoted a dietitian nutritionist, who provided the quote, saying “Especially as we’re entering the winter months, most people would benefit from taking a supplement.”

Not surprisingly, the Times doesn’t quote an actual study that supports this recommendation, because that’s not what the science says. (To be fair, the dietitian also included some caveats, which are paraphrased in the article, including the point that “it’s difficult to suggest one blanket recommendation for everyone.”)

So no, NY Times, most people wouldn’t benefit from taking a supplement. As Drs. Steven Cummings and Clifford Rosen wrote last summer in the New England Journal of Medicine, “providers should stop screening for 25-hydroxyvitamin D levels or recommending vitamin D supplements, and people should stop taking vitamin D supplements to prevent major diseases or extend life.” And as five of my Hopkins colleagues wrote in a 2013 review in The Annals of Internal Medicine, “stop wasting money on vitamin and mineral supplements.” The science just doesn’t support it.

Cummings and Rosen also pointed out that more than 10 million blood tests for vitamin D levels are conducted in the US each year, with the vast, vast majority of these being unnecessary. These tests aren’t free, and our costly health care system doesn’t need the extra burden.

Finally, let me offer a caveat that I’ve written before: although routine supplementation is worthless and megadoses of vitamins can be harmful, if you think you have a vitamin deficiency, consult with your doctor. Serious vitamin deficiencies might be the result of other health problems that your doctor can help you address, and treatments for specific conditions or diseases may include vitamins.

For Pete's Sake, Stop Taking Vitamin D Supplements!

Way back in 2014, I wrote a column about vitamin D supplements, explaining that they don’t work. I added vitamin D to my previous list, the Top 5 Vitamins That You Should Not Take, to create a list of 6 useless vitamin supplements.

Together, these two columns had well over 1,000,000 views. And yet it seems the message didn’t get through. Well, now a massive new study published in the New England Journal of Medicine reports that I was right all along: taking vitamin D pills isn't good for you. Let’s review the findings, shall we?

In 2014, I wrote about two studies, both published in The Lancet. The first paper, a massive review of 462 other studies, concluded that taking supplemental vitamin D did not help to prevent heart disease, weight gain, mood disorders, multiple sclerosis, and metabolic disorders, all of which had been linked to lower vitamin D. Nope, they said: it appears that low levels of vitamin D are a result of bad health, not the cause.

Ah, you might be thinking, but vitamin D is mostly about bone health, right? Well, the second study that I wrote about in 2014 looked precisely at that question. That paper concluded that vitamin D supplements do not improve bone density, and they do not reduce the risk of osteoporosis.

In other words, vitamin D supplements are a complete waste of money.

Nonetheless, people keep taking vitamin D, and doctors in the U.S. continue to recommend it (based on published guidelines that urgently need revision), on a very large scale.

So now we’ve spent millions of dollars on a huge new trial, which followed nearly 26,000 men and women for more than 5 years, to see if vitamin D supplements would do anything to prevent bone fractures. (And by “we” I mean U.S. taxpayers, who funded this study through grants from the National Institutes of Health.)

The result: people who took vitamin D had exactly the same risk of bone fractures as those who didn’t. It didn’t matter how much vitamin D they took, nor did it help if they also took supplemental calcium at 1200 mg per day. And it didn’t help people who had relatively low levels of vitamin D either. Taking vitamin D supplements just didn’t make any difference to anyone.

So we should stop taking vitamin D–but there’s more. In an editorial accompanying the new study, Steven Cummings and Clifford Rosen point out that “More than 10 million serum 25-hydroxyvitamin D tests are performed annually in the United States.” These tests add costs to our already exorbitant health care system, and they don’t provide patients with any benefit.

Cummings and Rosen put it bluntly: “providers should stop screening for 25-hydroxyvitamin D levels or recommending vitamin D supplements, and people should stop taking vitamin D supplements to prevent major diseases or extend life.” Or as my Hopkins Eliseo Guallar, Lawrence Appel, and Edgar Miller wrote back in 2013, “Enough is enough: stop wasting money on vitamin and mineral supplements.”

At the top of this article I mentioned that my list of useless vitamin supplements has 6 vitamins on it, so here they are:

1. Vitamin C
2. Vitamin A and beta carotene
3. Vitamin E
4. Vitamin B6
5. Multi-vitamins
6. Vitamin D

If you want to know the science behind the other 5, take a look at my column on The Top Five Vitamins You Should Not Take.

Finally, I should point out that although routine supplementation is worthless and megadoses of vitamins can be harmful, if you think you have a vitamin deficiency, consult with your doctor. Serious vitamin deficiencies might be the result of other health problems that your doctor can help you address, and treatments for specific conditions or diseases may include vitamins.

No, megadoses of vitamin C won't cure a coronavirus infection

The world is awash in treatments for COVID-19, the illness caused by coronavirus. Or at least that's what you might think if you just searched the internet.

The truth is, we don't yet have any effective treatments for COVID-19, although thousands of scientists are working furiously to try to create them.

Today we'll look at just one of the supposed treatments, which is being actively promoted on social media and many websites: vitamin C.

For those who don't want to read further, I'll start with the conclusion: vitamin C won't help to prevent or to treat coronavirus infection. I wish we had such a simple solution, but we don't.

Now let's back up a bit. Why would anyone think that vitamin C might be effective in treating this terrible virus? Vitamin C is an essential nutrient, and we all need it, but most people get plenty of vitamin C in their normal diet. As I've written before, taking vitamin C supplements is unnecessary but probably harmless, although megadoses carry the risk of kidney stones.

The modern craze with vitamin C started with Linus Pauling, a brilliant chemist and a Nobel Prize winner. Late in his career, he wrote a book promoting vitamin C as a miracle cure for many illnesses, including the common cold (which is caused by a virus). He had very little good evidence for this belief, but his promotion of vitamin C led to hundreds of studies testing his hypothesis. The bottom line: vitamin C doesn't work at preventing or curing the common cold. (See Paul Offit's book if you want more details on this and many other "miracle" cures.)

But wait, someone might object: haven't some of those vitamin C studies (as in this review paper) shown a benefit against the common cold? Well yes, but when you run hundreds of studies of a treatment that doesn't work, this is what happens: negative studies are hard to get published, but positive studies are easier. Run enough studies, and a few of them, merely by chance, will show a small positive effect. That's what we've seen with vitamin C.

Today, though, everyone is looking for a cure for COVID-19, and not surprisingly, many people (even some doctors) are claiming vitamin C is the answer. I've seen Twitter users explain, very confidently, that you just need to take 12,000 mg of vitamin C and you'll get better. This website comes right out and states that high-dose vitamin C will cure coronavirus, based on a widely-shared video from a doctor in China. (I won't provide the link because it has already done enough damage.)

It's almost impossible to disprove a claim that a treatment works. For example, I could claim that ginger snap cookies helps to prevent coronavirus infection. That's right! Ginger snaps, made with real ginger, which seems to have magical curative properties. If you object, I could demand that you prove me wrong–but the onus is on me, as the one making the claim, to first provide some genuine evidence. We haven't seen anything like that for vitamin C.

We need well-controlled experiments to know with any confidence that a treatment works. Some doctors at Wuhan University have started a trial of vitamin C to see if it has any benefits for COVID-19, but results won't be available for many months. I'm skeptical, but at least they're approaching the question the right way.

Dozens of studies of new treatments for COVID19 are being launched right now, with remarkable speed due to the urgency of the pandemic.The WHO has just launched trials of the 4 most promising existing drugs (which don't include vitamin C, I should add). To obtain a believable, positive result, we need to see evidence that a carefully administered treatment provides a significant benefit over what we're doing now–which is little more than supportive care, unfortunately.

Meanwhile, we'll have to wait and hope that one of the plausible efforts currently under way will yield an effective treatment. We've been down this road too many times with vitamin C, though, and the chances that it will have any effect are, based on past experience, close to zero.

Conspiracy theories and snake oil, the perfect pair

Why on earth would people rely on a conspiracy theorist, someone with only a high school education, for medical or health advice? And yet, some people do.

Alex Jones, the far-right conspiracy theorist who runs the Infowars radio program and website, was temporarily suspended by Twitter this week, following bans by Apple, YouTube, and Facebook. These social media companies banned him for repeatedly violating their rules about hate speech and inciting violence. Among other notorious claims, Jones has falsely claimed that children murdered in the mass shooting in Sandy Hook were just actors and that their parents faked their deaths.

What many people don't know, though, is that Jones also runs a dietary supplement business from his Infowars site. Despite reports that Jones' supplements are little more than "overpriced, mundane vitamins," his supplement sales seem to be quite profitable–so much so, in fact, that Buzzfeed reported that the supplement business "largely funds Jones' highly controversial Infowars media empire."

I was curious to see what Jones was selling, so I looked at his Infowars web store. It features an array of products with names like:

• Brain Force Plus
• Super Male Vitality
• The Real Red Pill, DNA Force, and more

Each of these products is marketed with breathless claims for what it can do, including testimonials from Jones himself. For example, Brain Force Plus claims to "supercharge your state of mind," and Jones plugs it with this quote:

"This is what I take before a hard-hitting show. I absolutely love it, and the crew does too. This stuff is over the top powerful!"

Well then. Never mind that Brain Force is really just a collection of herbal extracts and vitamin B-12, none of them proven to "supercharge" your mind or any other body part.

In a similar vein, Jones hypes Super Male Vitality with this claim:

"This product works so well for me that I actually had to stop taking it before I go on air or else I would want to do hours and hours of overdrive with complete focus on the topics at hand."

From the name, you might guess that Super Male Vitality has something to do with testosterone, and the website does state that it "may help support normal testosterone levels in men." What's in it? A collection of plant extracts, none of them proven to maintain or increase testosterone or to have any actual medical benefit.

Of course, if you follow the asterisks on both of these pages and read further down, you'll see that

"These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease."

This statement is the standard disclaimer that supplement manufacturers make in order to avoid FDA oversight. There's no actual scientific evidence (and Jones's Infowars pages don't attempt to cite any) that these products do what the text on the very same page says they do. You just have to take Jones' word for it.

This is pure snake oil. That shouldn't be surprising, not coming from a man who has accused grieving parents of faking their children's deaths, and who claims the U.S. government was behind the 9/11 attacks. It's hard to understand why anyone believes any of the outrageous claims this guy makes, and especially bewildering that people who trust him to advise them on health and diet. His supplements aren't even a good buy, as Buzzfeed reported a year ago. All I can say is, caveat emptor.

Another dietary supplement to avoid: calcium

Despite the claims on the package, these

pills don't give you strong bones.

Dietary supplements and vitamins are a multi-billion dollar business, driven by heavy advertising and constant promises that supplements will somehow make you healthier. For most people, vitamins and other dietary supplements are useless, and when taken in large quantities they can even be harmful. (See my article, "The Top Six Vitamins You Should Not Take" for specifics.)

Now we can add another supplement to the list of those that you shouldn't take: calcium. Calcium supplements are often sold on the promise that they strengthen your bones or prevent osteoporosis. Given that calcium is a major component of our bones, it seems sensible to assume that extra calcium might help strengthen them.

What seems sensible, though, doesn't always turn out to be true. A large new study published recently in the Journal of the American Heart Association shows that taking supplemental calcium leads to an increased risk of heart disease, by increasing the calcification of your arteries. That's a bad outcome.

The new study, led by John J.B. Anderson of UNC Chapel Hill and Erin Michos at Johns Hopkins University, looked at changes in coronary artery calcification over a 10-year period in 2,742 adults. Calcification of the arteries is strongly associated with heart attacks and other life-threatening events; basically, a calcified artery is a dangerously unhealthy artery.

The study found some surprising results that seem at first to be contradictory: people who simply consumed the most calcium through their diet had a slightly lower risk of calcification of the arteries - about 27% lower than the group with the lowest amount of dietary calcium. However, people who took calcium supplements had a 22% higher risk of calcification.

Why are calcium supplements harmful when dietary calcium seems healthful? The authors explained:

"Little of the additional calcium provided by calcium supplements, however, is incorporated in bone by adults."

In other words, if you just take a pill of concentrated calcium, your body can't handle it, and some of it seems to end up in the linings of your arteries, where it makes them rigid and contributes to cardiovascular disease. So rather than strengthening your bones, supplemental calcium might "strengthen" your arteries, but in a bad way. As the study explains:

"Rather than promoting bone health, excess calcium from the diet and supplements is postulated to accrue in vascular tissues." 

You don't want more calcium in your arteries. That's too bad for supplement makers, whose claims that calcium supplements "promote healthy bones" (as claimed, for example, by Nature's Way "bone formula" calcium pills) are just not supported by science. You can, though, get plenty of calcium by eating these calcium-rich foods:

1. Cheese
2. Yogurt
3. Milk
4. Sardines
5. Leafy greens such as spinach, kale, broccoli rabe, and bok choy

So if you're concerned about osteoporosis or just general bone health, skip the pills, save your money–and protect your heart–by eating a calcium-rich diet instead.

How to treat the flu: a shopping guide

Flu season is upon us, and your local pharmacy may feature special displays with products claiming to cure or treat the flu (which is caused by the influenza virus). The array of products, and the claims featured on their packaging, can be bewildering. Which of them should you buy? Here is a quick guide. (Spoiler: if you want to know what really works, skip to the end.)

This photo from a local RiteAid shows their display of "alternative" treatments. Let's consider a few of them.

Alternative pills that claim to treat the flu. 

1. Across the top we have vitamin C drops, helpfully labelled "Defense" in large letters. You might think these would defend you against the flu virus, but you'd be wrong. Vitamin C has no effect whatsoever on the flu, and it doesn't prevent colds either. People have been taking it for decades, but popularity is no substitute for evidence.

2. The shelves include 11 different formulations of Airborne, with the phrase "helps support your immune system" prominently displayed. Does this product help your immune system fight off the flu? Not even a tiny bit. Airborne is nothing more than an overpriced vitamin supplement (including vitamin C), and it's on the shelf because of clever and misleading marketing. Back in 2008, Airborne settled a $23.3 million lawsuit over false advertising, which was filed because they called their product a "miracle cold buster." After the lawsuit, they simply re-labeled it as an "immune booster," which is vague enough that they've been getting away with this claim ever since. Save your money.
3. Several of the products here, notably Zicam, are basically sugar pills supplemented with zinc. Some time ago, there was preliminary evidence that zinc might reduce the duration of a cold, but there was never any evidence that it could work for the flu. (Aside: colds are caused by completely different viruses.) Once scientists looked at it a little harder, they discovered that zinc doesn't work for colds either, as I explained in a 2012 column. Zicam is marketed as homeopathic, a clever ploy that allows it to escape government regulation. Their marketing constantly dances around what is permitted, usually by claiming it provides "immune support." Sound familiar?

Very expensive sugar pills.

4. On the bottom shelf you might notice Oscillococcinum, a homeopathic remedy that is just a sugar pill. Oscillo's claims to treat anything are almost laughably ridiculous: its "active" ingredient is supposed to be an extract from the heart and liver of a duck, which is then diluted until even that ingredient is no longer present.  As you can see in the close-up picture here, it's not cheap: $31 for 30 pills.
The box also claims that it "reduces duration and severity of flu symptoms," a completely false claim. The FDA has issued warning letters about this before, pointing out that "These products have not been approved or otherwise authorized by FDA for use in the diagnosis, mitigation, prevention, treatment (including treatment of symptoms), or cure of the H1N1 Flu Virus." Apparently the manufacturers of Oscillo (and the numerous places that sell it) are just ignoring the FDA.

These are just the "alternative" treatments. Most pharmacies have an even larger selection of flu treatments with real medicine in them. Here's a photo from the same RiteAid, right next to the alt-med selections.  

Medicines that try to treat the flu.

The selection here includes pills and liquids in many shapes and sizes, and all of them have active ingredients that do indeed have some effects. But they don't actually treat the flu itself: instead, they treat some of the symptoms, such as pain and congestion. None of them work very well, although those that contain ibuprofen or acetaminophen do help reduce pain.

So what does work? The latest medical science offers only two options:
1. Vaccination. Get your flu shot! The flu vaccine isn't perfect, and it varies in efficacy from year to year, but it usually provides some protection. In the best years it can reduce your chance of getting the flu by 75% or more. It's far better to avoid getting the flu in the first place.

2. Oseltamavir (Tamiflu), available only by prescription, is the only anti-viral medication that has been shown to have some effectiveness against the flu. It's not great, but it can reduce the severity of symptoms and maybe shorten the duration of the illness by about 1 day. You have to see a doctor to get it, which means taking your (sick) child or self to a doctor's office and exposing other people to the flu. 

The bottom line: none of the treatments that you can buy without a prescription will cure the flu. The "alternative" treatments are completely useless, and the real medicines might help a little bit with symptom control. 

Your best choice, by far, is the flu vaccine. Unfortunately, the internet is filled with misinformation such as claims that the vaccine doesn't work, or that it can give you the flu, or (worst of all) the utterly discredited notion that preservatives in the vaccine cause autism. Some of the anti-vaccine nonsense has even been promoted by presidential candidates, namely Donald Trump, Ben Carson, and Jill Stein. By spreading these false stories, Trump and Stein are doing real harm to the public health.

Flu advice from a future doctor.

Finally, I want to give props to RiteAid for trying to get people vaccinated. In front of the same store at which I took these pictures were two large signs saying "Get your flu shot today." Inside the store, they had a special table with science-based information about the flu vaccine, which featured artwork from local children (one of them shown here) encouraging other kids to get vaccinated. Well done.

The top five cold remedies that do not work

A cure for the cold, from ThadGuy.com

One of my daughters caught a cold last week, and now she's given it to me. We’re giving ourselves the best treatment known to science: rest. But to judge from the products offered at our pharmacies, you’d think there were dozens of options to treat a cold. In local pharmacies and in the medicines aisle at my local grocery store, I’ve found row after row of colorful packages, claiming to relieve cold symptoms, shorten the duration of the common cold,” and more. 

Some of these medications actually do treat symptoms, but none of them cure a cold. But mixed among them—sometimes side-by-side with real medicines—I found several products that don’t work at all. 

How can a drug manufacturer get away with this? Simple: the products that don’t work are either supplements or homeopathic products. The manufacturers of both these types of “medicines” have successfully lobbied Congress to pass laws that exempt them from FDA regulation. Supposedly they aren’t allowed to make direct claims to cure or treat disease, but unless you read the wording on their packages very carefully, you’d never notice. (Note to older adults: bring your reading glasses to the pharmacy section!) 

Most important for consumers: if a treatment says it’s homeopathic, then its ingredients do not have to be shown effective. “Homeopathic” simply means that the ingredients are listed on the Homeopathic Pharmacopoeia, a list maintained by homeopaths themselves. And if it contains supplements or vitamins, they too are exempted from regulation by the FDA, under a law known as DSHEA. 

So next time you go searching for something to take for your cold, or for your child’s cold, here are the top 5 cold remedies you should not buy:

1. Zicam is a zinc-based remedy. Zinc is tricky, because there is some evidence to suggest that taking zinc right at the onset of a cold might shorten its duration a little bit, from 7 days to 6. But as Dr. Terence Davidson from UC San Diego explained, if you look at the more rigorous studies, the effect vanishes. Zinc turns out to have some worrisome side effects, too. Zicam's nasal spray and gel versions were linked to a serious loss of the sense of smell (anosmia), which led the FDA to issue a warning letter in 2009. Zicam responded by withdrawing the product for a time, but their website now says “A clinical link between the Zicam® products and anosmia was not established.“ Strictly speaking, this is correct, but there have been published reports suggesting a link, such as this one from 2009.*

Zicam’s website makes the misleading claim that “All of our Zicam® products are regulated by the FDA.” This is a common ploy of homeopathic drugmakers, claiming the FDA regulates them because the FDA could step in (as they've already done with Zicam) if consumers are being harmed. Unlike real drugs, though, Zicam has not been evaluated by the FDA for effectiveness or safety.

2. Airborne. You can find this in the cold remedy section many pharmacies (I did), but Airborne doesn’t cure anything. It’s a cleverly marketed vitamin supplement with no scientific support for any health benefits. How do they get away with it? Actually, Airborne paid $23 million back in 2008 to settle a class-action lawsuit over its advertising. They had been calling Airborne a “miracle cold buster.” According to the Center for Science in the Public Interest’s David Schardt, 

“Airborne is basically an overpriced, run-of-the-mill vitamin pill that’s been cleverly, but deceptively, marketed.”

After the lawsuit, Airborne modified their packaging, which now claims only that it “helps support your immune system.” This is one of those vague claims that supplement makers love, because it doesn't really mean anything. Airborne's products also now include a disclaimer that

 “These products are not intended to diagnose, treat, cure, or prevent any disease.”  

So what the heck are they doing in the “cold medicines” section of the store?

3. Coldcalm is a homeopathic preparation sold by Boiron, one of the world’s largest manufacturers of homeopathic remedies (including Oscillococcinum, an almost laughably ineffective flu remedy). It claims on the package to relieve cold symptoms. What’s in it? A dog’s breakfast of homeopathic ingredients, including belladonna, about which NIH says, 

“Belladonna is UNSAFE when taken by mouth. It contains chemicals that can be toxic.” 

Another ingredient is pulsatilla, which “is highly toxic, and produces cardiogenic toxins and oxytoxins which slow the heart in humans.” Neither belladonna nor pulsatilla relieves cold symptoms.

Being homeopathic, these ingredients are highly dilute, but I think I’ll pass on Coldcalm.

4. Umcka. Umcka is another homeopathic preparation that claims to “shorten the duration of common cold” and “reduce severity of cold symptoms.” Sounds pretty good—if only it were true. Umcka’s active ingredient is a plant extract called pelargonium sidoides, an African geranium. Interestingly, there have been a few experiments on this extract, some of which showed a small positive effect. However, a review of these studies reported that their quality was “very low," that all of them were conducted by Umcka itself, and that all of them were conducted in the same region of Russia. And remember: homeopathic preparations are so dilute that they contain little, and sometimes none, of the active ingredient.

5. Antibiotics. Okay, these are real medicine, and you can’t buy them over the counter at your pharmacy. But Americans take them in huge quantities to treat the common cold. The problem is, antibiotics don’t work for colds.

When my daughter told her friends she had a cold, they wanted to know why she didn’t go to the doctor. Of course, doctors can’t do anything about a cold, and going to a doctor’s office just puts other patients at risk. My daughter knows this. But her friends were astonished to hear that we never take her to the doctor for a cold. It turns out that most of them had been to doctors many times for colds, often coming away with a prescription for antibiotics. 

Antibiotics treat bacterial infections, not viruses. Taking antibiotics unnecessarily can be bad for you: besides wiping out your gut flora, it increases the risk that bacteria will develop drug resistance. Perhaps if we changed the name to "antibacterials," doctors would stop prescribing them for viruses.

I found Zicam, Airborne, Umcka, and Coldcalm for sale at Walgreens and Walmart. CVS and RiteAid don’t carry Umcka (good for them!) but do sell the others.

When you get a cold, you develop immunity to it and you won’t catch it again.We keep getting colds because they're caused by more than 100 different viruses, most of them nasty little buggers that continually circulate in our population. Each time you catch a cold, you’re getting a brand new one. The only consolation is that once you’re over it, you won’t get that one again.

So if you get a cold this winter, save your money. Stay home, rest and drink plenty of fluids. And I have it on good authority that there is one treatment for the common cold that’s inexpensive, widely available, and really, really works: chicken soup.

*In response to my inquiry, Zicam's manufacturer, Matrixx Initiatives, sent me some additional information. They pointed out that subsequent studies have not supported a link between Zicam and anosmia (loss of the sense of smell), and also that they permanently discontinued Zicam intranasal gel products ("Cold Remedy Nasal Gel and Cold Remedy Gel Swabs) in 2009, "despite the absence of any credible scientific data pointing to a potential link." They also argue that "the efficacy of zinc-based formulations is primarily a function of bioavailable dose" and that "Zicam products are formulated to ensure availability of the zinc." Arguing in favor of Zicam's benefits, they pointed to several studies that I'd already read, and I remain unconvinced and, as I pointed out above, Matrixx does not have to prove efficacy to the FDA because they are selling Zicam as a homeopathic preparation, which allows them to avoid FDA regulation.

Internet quack Joe Mercola is worried. Dr. Oz to the rescue!

Dr. Oz interviews Joe Mercola on his show.

After a series of studies showing that vitamins and supplements are usually a waste of money, including my recent article on the top 6 vitamins you shouldn’t take, internet supplement salesman Joe Mercola is worried.  He should be: his Internet-driven empire is largely based on sales of vitamins and supplements, for which his claims range from merely implausible to dangerously untrue, including:

• Himalayan salt is far better for you than regular salt. Coincidentally, Mercola sells the good salt.
• Vitamin D is "the new silver bullet for cancer." No, it's not.  Not even a little bit.
• Homeopathy cured a boy of autism. Of course Mercola doesn't provide any proof of this, only a testimonial.  This is not even remotely plausible, since homeopathic preparations are just sugar pills.

I could provide many more examples, but this should be enough to demonstrate that I'm not making this stuff up.

Mercola is also one of the loudest voices and worst offenders in the anti-vaccine movement. Among other misinformation, he claims that the hepatitis vaccine causes autism, and his website urges people to use his supplements instead of getting vaccinated.

So how do I know Mercola is worried? He's appearing on the Dr. Oz Show on Monday, February 10 (the day after I'm writing this) to talk about multivitamins. Apparently his 10 minute segment wasn't enough, so he posted an article on his website with the "Information I couldn't share" on Dr. Oz's show.

Does the article explain why multivitamins are actually good for you?  Well, no. Most of the article is a big red herring, in which he argues that supplements should not be regulated as drugs, because "we have all the regulations we need." Then he contradicts himself and says that the FDA already regulates supplements. (It doesn't - or to be more precise, the FDA does not require supplement makers to prove their products work. It can only step in if the products start to kill people. This is what Mercola calls regulation.) Besides, he says, supplements are harmless. As evidence, he cites a press release from a pseudoscientific organization that claims "no deaths from supplements in 27 years."

Not surprisingly, Mercola doesn't cite any actual science to support his claims. In contrast, several very large studies in major medical journals, cited in my own columns last month and last October, show that routine supplementation with multivitamins, especially with the megadoses that many people take, can indeed cause genuine harm. Those same studies showed that if you don't have a deficiency, there's simply no benefit to taking most vitamins.  Mercola's response is to cite opinion pieces from his own website that simply assert, without any evidence, that the studies are wrong.

In other words, Mercola's response is "Oh yeah?" He then goes off on a tangent and launches an irrelevant ad hominem attack on noted vaccine expert Dr. Paul Offit.

Why has Dr. Oz repeatedly had Joe Mercola on his show? This is a tough one. Does Oz believe that autism is caused by vaccines, something Mercola has claimed repeatedly over the years?  Does he understand that Mercola's anti-vaccination campaign leads to genuine harm? Does he know that the FDA has repeatedly issued warnings to Mercola to demand that he stop making false claims about his vitamins and supplements, as Chicago Magazine reported?

Or does Dr. Oz keep inviting Mercola back because he knows Mercola has a big audience that will increase his own viewership?

Despite my past criticism of Dr. Oz, I still think he has a better grasp of science than Joe Mercola. He also reassures viewers constantly that he doesn't sell the products that appear on his show. And yet Oz is giving a platform to someone who makes huge profits selling products based on unproven claims. By having Mercola on his show, Oz is giving him free publicity and helping him sell those same products. And whether or not Oz agrees with Mercola, he is helping to give credibility to Mercola's wildly inaccurate and dangerous anti-vaccine claims.

The top 6 vitamins and supplements you shouldn’t take

The evidence against supplements continues to pile up.

Recently I created a list of The Top 5 Vitamins You Shouldn’t Take. Now I’m expanding that list to include vitamin D, which is taken by almost half of older adults. Now, two new studies in latest issue of The Lancet show that most of these people are wasting their money.

The first study is a large review by Philippe Autier and colleagues, who found that taking supplemental vitamin D has no effect on a wide range of diseases and conditions. After looking at over 450 studies, the authors conclude:

“The absence of an effect of vitamin D supplementation on disease occurrence, severity, and clinical course leads to the hypothesis that variations [in vitamin D levels] would essentially be a result, and not a cause, of ill health.”

So it appears that we’ve been getting cause and effect backwards, at least as far as vitamin D is concerned. Autier looked at non-skeletal disorders, including heart disease, weight gain, mood disorders, multiple sclerosis, and metabolic disorders, all of which have been linked to lower vitamin D. In trial after trial, supplemental vitamin D had no beneficial effect on any of these conditions. Autier et al concluded that:

“associations between 25(OH)D and health disorders … are not causal. Low 25(OH)D [vitamin D] could be the result of inflammatory processes involved in disease.”

Instead, the researchers found, in study after study, that low vitamin D was the result of poor health, not the cause.

The Autier study didn’t look at the biggest supposed benefit of vitamin D: protection against osteoporosis. We’ve long known that vitamin D is associated with bone health. Fortunately, in the same issue of The Lancet, Ian Reid and colleagues looked closely at this question. They reviewed 23 studies with 4082 participants, all designed to determine at whether supplemental vitamin D improves bone density. Their findings? It doesn’t help. They concluded:

“Continuing widespread use of vitamin D for osteoporosis prevention in community-dwelling adults without specific risk factors for vitamin D deficiency seems to be inappropriate.”

Vitamin D supplements, to put it plainly, are a waste of money.

(For those concerned about osteoporosis, the widely used drug alendronate (Fosamax®), has been shown to increase bone density by about 5%, as explained in a 2011 article by Dr. Sundeep Khosia. But Fosamax has side effects.)

It’s pretty easy to get enough vitamin D in a normal diet. Or, as Dr. Mark Gillinov explained in the Huffington Post last week, just 10 minutes of sunlight gives you about 4 times your daily recommended vitamin D requirement.

So here's my expanded list of the Top Six Vitamins You Shouldn’t Take, with the newest entrant at the end:

1. Vitamin C
2. Vitamin A and beta carotene
3. Vitamin E
4. Vitamin B6
5. Multi-vitamins
6. Vitamin D

You can read more about the first five in the original list.

What’s left? Well, if you don’t have a deficiency, there’s no reason to take any supplemental vitamins at all.  As my Hopkins colleagues Eliseo Guallar, Lawrence Appel, and Edgar Miller wrote last month in the Annals of Internal Medicine : “Enough is enough: stop wasting money on vitamin and mineral supplements.”  As they wrote, after looking at three more large studies just published last month,

"most supplements do not prevent chronic disease or death, their use is not justified, and they should be avoided."

Save your money. Or better yet, if you must spend it, buy a bit more fresh fruit. You'll be healthier for it.

Five vitamins you shouldn't take

I used to take vitamin supplements almost every day. Taking vitamins seems like a good idea: after all, we know that vitamins are essential for life, and vitamin deficiencies can definitely hurt you.  I always thought that vitamins were an inexpensive way to get a little bit healthier.

Millions of Americans apparently agree with me. Close to half of the population in the U.S. takes vitamins, with multi-vitamins being the most popular.*  Vitamins are sold in virtually every grocery store, ranging from mega-markets like Wegmans to the organic Whole Foods chain.

The vitamin and supplements industry, which is immensely profitable, relies on the intuition that if a little bit of something is good for you, a bit more can't hurt.  Right?

Wrong.  If you don't have a serious vitamin deficiency, taking supplemental vitamins doesn't provide any benefit, in almost all cases that have been studied.  What's even more surprising is this: routinely taking mega-doses of vitamins might actually harm you.

So here are the top 5 vitamins that you should not take (unless your doctor recommends it):

1. Vitamin C.  Perhaps the most popular single vitamin supplement, vitamin C occurs in plentiful amounts in many fresh fruits and vegetables.  In the early days of global exploration, sailors often died from scurvy, caused by the lack of vitamin C.  Way back in the 1700's, Scottish doctor James Lind famously conducted an experiment that proved that citrus fruit cured scurvy, although vitamin C itself wasn't discovered until the 1930s.

Vitamin C gained its current popularity through the woefully misguided efforts of Linus Pauling, who published a book in 1970 recommending mega-doses of C to prevent the common cold. Although Pauling was a brilliant chemist (and Nobel laureate), he was completely wrong about vitamin C, as Paul Offit explains in detail in his new book, "Do You Believe in Magic?"

Vitamin C doesn't prevent or cure colds.  This question has been studied exhaustively: a review in 2005 covering 50 years worth of research concluded that

"the lack of effect ... throws doubt on the utility of this wide practice."  

Although Vitamin C is generally safe, megadoses of 2000 mg or more can increase the risk of kidney stones, which can be excruciatingly painful.

2. Vitamin A and beta carotene. Vitamins A, C, and E are all anti-oxidants, which have been promoted for their supposed anti-cancer properties.  The evidence doesn't support this: for example, in a large study supported by the National Cancer Institute*, smokers who took vitamin A were more likely to get lung cancer than those who didn't.

Vitamin A plays an important role in vision, but too much vitamin A can be toxic, causing multiple serious side effects. Perhaps the most famous cases of vitamin A toxicity occurred in early polar explorers, who ate the livers of their sled dogs, not realizing that the livers had excessively high amounts of vitamin A.  Antarctic explorer Douglas Mawson barely survived, and his companions died, probably of vitamin A poisoning.

3. Vitamin E. Long touted as an anti-cancer agent, vitamin E is a very popular supplement.  A large study last year, of 35,533 men, looked at vitamin E and the risk of prostate cancer. The authors found that the risk of cancer increased for men taking vitamin E.  In an even larger review done at Johns Hopkins University, Edgar Miller and Lawrence Appel found that the overall risk of death was higher in people who took vitamin E.  The Mayo Clinic summarizes the evidence this way:

"Evidence suggests that regular use of high-dose vitamin E may increase the risk of death from all causes by a small amount." 

4. Vitamin B6.  The B vitamins, including B6 and B12, are present in many foods, and deficiencies are rare.  But taking B6 supplements for a long time can be harmful, as NIH's website explains*:

"People almost never get too much vitamin B6 from food. But taking high levels of vitamin B6 from supplements for a year or longer can cause severe nerve damage, leading people to lose control of their bodily movements."

5. Multi-vitamins. This is the big one. With nearly 40% of Americans taking a multi-vitamin, they must be good for you, right? But a huge study that I wrote about last year, looking at 38,772 women over 25 years, found that the overall risk of death increased with long-term use of multivitamins, vitamin B6, folic acid, iron, magnesium, zinc, and copper.  Death, one must admit, is a pretty bad outcome.

On the evidence, supplementing your diet with any of these 5 vitamins carries little or no benefit, and may cause you harm.  This is why we do science, people. Our intuitions aren't always right: just because a little bit of something is good for you does not mean that a lot of it is even better.

Vitamins don't "boost your immune system," they don't promote joint health, they don't reduce stress, and they don't help prevent colds or other common ailments.

So what should one do?  Ignore the marketing, and treat supplements like you would any other medicine: take them with caution.  If you are taking regular vitamin supplements, or thinking about it, ask your doctor before doing so.

And by the way, 100 grams of spinach has healthy amounts of vitamins A, C, E, K, several B vitamins, and essential minerals including iron and calcium.

So ditch the vitamins and eat your spinach.  Or blueberries.  Blueberries are great.

[*The statistics and references used in this article were collected, in part, by the U.S. Centers for Disease Control, the U.S. Department of Agriculture, and the National Institutes of Health, all of which are currently shut down due to the stubborn actions of a minority of Representatives in the U.S. Congress.  Thanks, Congress!]

Multivitamins and cancer: a mixed bag

A major new study published this week in the Journal of the American Medical Association (JAMA)  came to the surprising conclusion that

"daily multivitamin supplementation modestly but significantly reduced the risk of total cancer."

The report included some caveats, such as the fact that all 14,641 participants were healthy male physicians.

But the result is still surprising, because other recent studies, some of them even larger, have concluded that vitamin supplements do not provide any significant health benefits.  On the contrary, some studies found that supplements could actually be harmful.  As I wrote last year, a very large study of 38,772 older women, who were followed for 25 years, showed that the risk of death INCREASED with long-term use of multivitamins, vitamin B6, folic acid, iron, magnesium, zinc, and copper.  That's death, not just cancer.  The authors of that study, Jaakko Mursu and colleagues, concluded that there is

"little justification for the general and widespread use of dietary supplements."

The new study, PHS II (Physicians' Health Study II) looked at overall death rates as well as cancer, and found that men on a daily multivitamin had fewer deaths, but too few to be statistically significant.

So we have a large study in men showing that multivitamins seem to reduce overall cancer, and maybe even death, but an even larger study in women showing the opposite effect.

A second study from last year, in 35,533 men, looked at vitamin E and selenium supplements. That study, also published in JAMA, found that risk of cancer INCREASED for men taking vitamin E, selenium, or both.

The media reports aren't helping to clarify things.  The NY Times proclaimed "Multivitamin use linked to lowered cancer risk, and the Wall St. Journal reported that "Multivitamin cuts cancer risk, large study finds."  Bloomberg News went right for the business angle, announcing that "Pfizer multivitamin reduces cancer 8% in men, study finds."

Compared to Bloomberg news, Pfizer's own website was remarkably restrained, saying only

"Centrum Silver was part of the recently published landmark study evaluating the long-term benefits of multivitamins."  

No claims about reducing the risk of cancer - surprisingly, the independent media made far stronger statements than Pfizer.  Not true of supplement manufacturer GNC, which was flashing a pop-up headline that "Taking a daily multivitamin could cut cancer risk", linking to a news article at the Boston Herald.

So what do we make of this new study?  Are multivitamins good for you after all?

The new JAMA study appears to be very well done.  It's a double-blind, placebo-controlled study in which half of the physicians received a daily multivitamin, Centrum Silver, and half received a placebo.  The participants didn't know if the pill they were taking was a vitamin or a sugar pill.  The authors report some minor conflicts of interest, but none of them work for or received major funding from Pfizer (PFE, the manufacturer of Centrum).  So how to explain the seeming contradiction with two larger studies published only a year ago?

To answer this question, we must look at the details of the study itself.  This study looked at 21 different types of cancer risk.  For most cancers - colon cancer, prostate cancer, lung cancer, pancreatic cancer, lymphoma, leukemia, melanoma, and others - multivitamins did not provide a benefit.  But when all the numbers were added up, the effect was just large enough to be "significant", at a level of p=0.04.  More on that in a moment.

Here are the raw numbers: among the 7,317 men who took a daily multivitamin, there were 1,290 cases of cancer over the 11-year study.  Among the 7,324 men who took a placebo pill, there were 1,379 cases.  That's about 1.2% more - far less than the 8% reported by Bloomberg News. The statistical analysis showed that this difference had a p-value of 0.04, a result the authors considered significant. When the authors looked only at men with no history of cancer, the effect was smaller, and not statistically significant.

One explanation of the new finding is that the effects were indeed due to chance. Let's look at that p-value of 0.04. In much of the scientific literature, any p-value below 0.05 is considered "significant," but this has been widely criticized, in part because it encourages binary "true, false" thinking that is not the way scientists actually think. Also, the "0.05 threshold actually represents evidence much weaker than the number "0.05" suggests. A back-of-the-envelope Bayesian calculation shows that if the cancer-preventing power of multivitamins was a 50:50 proposition before this study, then after this study there is still a 10-26% chance that the cancer prevention claim is wrong. If we thought that prior evidence made this effect less than 50:50, (say 25:75), then the study has roughly a 25-50% chance of being wrong.* Either way, I won't be stocking up on Centrum Silver anytime soon.

Looking at this small effect, and at the contradictory results from other studies, neurologist Steven Novella writes in his blog that

"About the only thing we can say with a high degree of confidence is that there is no large risk or benefit from taking a multivitamin. There may be a small benefit, no benefit, or even a small harm."

That's a good summary.  So should men take a multivitamin?  Well, it's your money, but if you don't have a vitamin deficiency, it's probably not worth it.  Should women?  The evidence still says no.

*Thanks to Stanford biostatistician Steven Goodman (formerly of Johns Hopkins University) for crunching some numbers to produce Bayes factors.

Don't take your vitamins

We've known for a long time that vitamins are good for you. Perhaps the best example is vitamin C, which completely cures scurvy, a disease that has plagued mankind for millenia. (It was described by Hippocrates some 2400 years ago.) Scottish doctor James Lind described how to cure scurvy with citrus fruit back in 1753, but it wasn't until 1932 that scientists Albert Szent-Gyorgyi and Charles Glen King identified vitamin C as the essential nutrient behind the cure for scurvy. (Szent-Gyorgi gave vitamin C the name ascorbic acid because of its anti-scurvy properties.)

Many other vitamins and micronutrients are required for good health, such as vitamins B and D, iron, folic acid, calcium, and potassium. Deficiencies in these vitamins cause all sorts of diseases, some of them very serious.

So it seems intuitively obvious that if a little bit of these nutrients is good for you, then a lot should be even better. Right? This intuition is the basis for the a huge and powerful nutritional supplements industry, which makes billions of dollars each year selling multi-vitamins and high-dose supplements in a bewildering variety.

The problem is, our intuition is wrong. Two separate studies published this past week, involving tens of thousands of subjects, showed that high doses of vitamins and supplements, rather than being helpful, can sometimes kill you.

In the first study, Jaakko Mursu and colleagues have been following 38,772 older women since 1986. The women in the study, whose average age was 62 back in 1986, have reported their use of multivitamins and supplements for the past 25 years. The news was not good: the risk of death INCREASED with long term use of multivitamins, vitamin B6, folic acid, iron, magnesium, zinc, and copper. The risk of death only decreased with the use of calcium. They also noted that in other studies, calcium had the opposite effect.

The authors concluded that there's

"little justification for the general and widespread use of dietary supplements,"

and the story was widely reported as showing that supplements are risky (Wall St. Journal) and unnecessary (New Zealand Herald).

In the second study, Eric Klein and colleagues studied 35,533 men over the past 10 years, looking at whether vitamin E or selenium would decrease the risk of prostate cancer. Both supplements have been claimed to have benefits, so the researchers randomly divided the subjects into four groups, giving them daily doses of (1) vitamin E only, (2) selenium only, (3) vitamin E and selenium, and (4) nothing (in the form of placebo pills).

The result: the risk of cancer INCREASED for the men taking vitamin E, selenium, or both. Although the increased risk is small, it is abundantly clear that neither of these supplements is helpful against prostate cancer.

Not surprisingly, the supplements industry hasn't taken this news lying down. The Council for Responsible Nutrition is an industry lobbying group representing the supplements industry (don't be fooled by the name). They released a statement by their vice president, Duffy MacKay (a naturopath, which is a form of quackery I'll have to treat separately in the future), grasping at the fact that, in the study, the increased risk of cancer from vitamin E plus selenium wasn't quite as big as the increase from vitamin E alone.

"This reinforces the theory that vitamins work synergistically," said MacKay.

Aha! So if I take even more supplements, perhaps my risk of cancer will go up only an eensy-teensy bit?

The Council released a second statement about the study on multivitamins, saying

"CRN maintains that nutrients may be robbed of their beneficial effects when viewed as if they were pharmaceutical agents, with scientists looking to isolate those effects, good or bad."

I see... so the benefits of supplements will disappear if we treat them as drugs: wouldn't that include taking vitamins and supplements as pills?

The supplements industry (Big Supp?), which is largely unregulated, has a darker side too: countless hucksters, many operating primarily through the Internet, who are making a fortune selling overpriced supplements (and advice on how to use them) that they claim will cure cancer, diabetes, and a host of other diseases. These include internet quack Mike Adams, who posted a response to this week's studies on his Nature News website, claiming:

"Recent attack on vitamins a fabricated scare campaign."

In Adams' response, he starts by arguing that the American Medical Association"has a long and sordid history of openly attacking vitamins and nutrition," a bizarre claim that has nothing to do with the study results even if it were true (it's not). He goes on to claim that the

"study data were ALTERED!"

(the all-caps is his) and

"voodoo statistics [were] used to alter the outcome."

I looked at the numbers he extracted from the paper to support these claims, and he failed - badly - to understand the data. Apparently for Mike Adams, statistics that he doesn't understand are just "voodoo."

So I'm afraid the news boils down to this: eat lots of fruit and vegetables, and a balanced diet, and you'll get all the micronutrients and vitamins you need. Supplements are only needed if you have a demonstrable deficiency. For most people, multivitamins and other supplements are a waste of money, and they might even be harmful. But hey, apples are in season right now, and spinach can be kind of tasty if you prepare it properly.