Healthy Food & Healthy Living by Dr. Ayala

Do vitamins and supplements really promote wellness?

How many vitamin bottles adorn your counter? Many Americans have quite a collection. Almost 80 percent of Americans report consuming daily supplements. The vitamin and supplement 50 billion industry spends 900 million on advertising. The barriers to entry into this lucrative business are low: the makers and marketers never had to prove efficacy, do not need FDA approval, and carefully crafted health and vigor declarations – that fall just a tad short from health claims – are exaggerated if not outright misleading, yet are legal. The vitamin and supplement industry receives very little oversight.

People are naturally concerned about filling nutritional gaps in their diet. People would also like to optimize their health and fitness. The vitamin and supplement marketing messages fall on receptive ears because who could say no to effortless prevention, enhancement, beauty and stamina. 

Vitamins and supplement additives are clearly useful for correcting vitamin and mineral deficiencies. Vegan diets, for instance, don’t contain enough if any B12 and need supplementation with this vitamin. Folic acid and iron supplementation is recommended during pregnancy – folic acid supplementation is proven to reduce the incidence of neural tube defects, and folic acid is advised for anyone pregnant or planning a pregnancy.

What about the rest of us?

Updated recommendations published by the US Preventive Services Task Force, an independent volunteer group of national experts in prevention and evidence-based medicine, sorted through the vitamin and supplement scientific data. The recommendations follow a systematic review of 84 studies, among them an additional 52 new studies since the previous review.

For healthy adults who are not pregnant, and not diagnosed with a deficiency, the US Preventive Services Task Force states that “current evidence is insufficient to assess the balance of benefits and harms of the use of multivitamin supplements, single supplements, or most paired supplements for the prevention of cardiovascular disease or cancer.”

The task force specifically recommends avoiding beta carotene (possible increased risk of heart disease and lung cancer) and vitamin E supplements. 

As to multivitamins: there’s “insufficient” evidence, the task force concludes.

The appeal of the pill

In a new editorial in JAMA scientists from Northwestern University support the new recommendations.

The authors start with the well supported fact that “eating fruits and vegetables is associated with decreased cardiovascular disease and cancer risk.” It’s reasonable to assume that if key components of the fruits and vegetables can be extracted and compacted into a pill these pills would do the same, at lesser effort and expense.

Alas, fruits and vegetables can’t be mimicked by a pill, as plants contain a myriad of compounds: besides the known vitamins and minerals, also fiber, phytochemicals, and many more micronutrients, working in concert. We (that includes the microbes living within us) have co-evolved with plants and are adapted to metabolize these foods. 

What’s the harm?

If it won’t help, it can’t hurt, is what many say as they pop in a bunch of vitamins.

The task force begs to differ.

As mentioned above, there was increased risk of lung cancer among smokers who took beta carotene supplements. Taking vitamin A may reduce bone density. Vitamin D supplementation can cause high blood levels of calcium and kidney stones. 

Beyond that, supplements are a waste of money and  – even worse – squandered attention, states the Northwestern physicians editorial, led by Jeffrey Linder, MD. “Rather than focusing money, time, and attention on supplements, it would be better to emphasize lower-risk, higher-benefit activities. Individual, public health, public policy, and civic efforts should focus on supporting people in regular preventive care, following a healthful diet, getting exercise, maintaining a healthy weight, and avoiding smoking.”

Real food is the best source of nutrients, and plant foods are more than the sum of their known nutrients. Decades of controlled studies of vitamin and mineral supplementation have been largely disappointing.

Although eating well and exercising isn’t always easy, the multivitamin and supplement “insurance policy” may be standing in your way to committing to improving your diet.

Dr. Ayala

Are you in denial about overeating and your weight?

Denial is a powerful coping mechanism. When it comes to eating and weight issues many of us seem to be living in ignorant bliss. 

In much the same way many of us believe ourselves to be above average drivers, studies show that weight misperception is widespread. People don’t recognize overweight in themselves or in their loved ones, and even health professionals fail to identify overweight and obesity when just observing a patient. 

About 48 percent of overweight men and 23 percent overweight women considered themselves about the right weight in a study including about 16,000 people, and even among obese people only about 10 percent were aware of the extent of the extra weight they carried. About 8% of obese adults considered themselves to be "about the right weight” in another study.

We often don’t see the expanding weight on ourselves, and we don’t see it in our own kids: A meta analysis of more than 64,000 kids shows that 50 percent of parents did not identify that their kids were overweight or obese, and seriously underestimated their kids' weight status.

It may be that our eyes have acclimated to heavier bodies because so many of us are now overweight. Looking at mid 20th century footage of the movie-star-thin general public from that era surprises us, and contrasts clearly with our two-thirds-overweight/obese population. 

We’re unaware of how much we eat

We not only see ourselves as smaller than we actually are, we also underestimate how much we eat. Intake tends to be underreported by 10-40 percent according to a recent review of 59 studies, which compares people’s reports of intake to objective measures of the calories people need to eat to maintain weight (energy expenditure measured by doubly labeled water, which is the gold standard for assessing how many calories are spent).

Calorie undercounts are widespread, but studies show that overweight and obese people undercount to a greater extent.

Calories expenditure, however, is related to body mass – the larger you are the more calories you need, regardless of physical activity.

A new study including 221 people compared reported caloric intake with objective measures of energy expenditure using doubly labeled water, and also compared it to body size.

Overall, underreporting was very significant, and by as much as 1000 calories a day – had that been true people would be losing weight rather than staying the same weight or gaining some.

Obese people underreported caloric intake by as much as 42 percent. More active people also tended to underreport by almost as much: 41 percent. In comparison, thinner and more active people underreported – but by less.

But when you take into consideration body size and therefore resting energy expenditure, the absolute discrepancy between reported caloric intake and expenditure was equal: thinner people under-reported calorie intake less, but their caloric need is lower, therefore the absolute discrepancy between actual intake and caloric need was about the same.

Dietary patterns rather than calorie counts

Given the tediousness of counting calories, and the inaccuracy our self-assessed intakes, eating while counting perhaps isn’t serving us well. Regardless of the reasons why we tend to imagine we’re eating less and better than we actually are, our self deception allows us to gain weight over time.

The authors suggest that perhaps focusing on obesity-risky foods, such as high energy density foods, ultra-processed foods, foods with low fiber that cause little satiety, and sugary beverages, might better serve as dietary guidelines. Recommending a dietary pattern rather that focusing on specific foods and quantities can help curb overeating, especially since most of us are only partially aware of ourselves doing it.

Denial, again, is a natural coping mechanism, but it’s especially un-useful when interventions such as healthier eating and activity habits could have helped turn the tide.

Dr. Ayala