Vitamins – a waste of money or victims of bad science?

by Patrick Holford

One New Year tradition, along with wondering how you could have spent so much on so little, is making healthy resolutions which may involve some sort of supplement. As a nutritional therapist I’ve been helping people for years to handle chronic disorders and stay healthier by recommending specific nutritional supplements based on risk, coupled with substantial changes in people’s diet. There’s plenty of evidence it benefits people but there’s lots we still don’t know and new well-conducted research is always welcome.

However another long standing tradition is the regular publication of studies that don’t help to clarify anything. They claim to have found that certain supplements are ineffective and possibly dangerous, leading to news stories about deadly or at least unnecessary vitamins and expensive urine. I don’t object to negative conclusions – they can be very useful – but these widely publicised studies are invariably done with little understanding of nutrition and their headline-worthy conclusions often bear little relation to what they actually found.

Two classic examples of these toxic studies came out just before Christmas, both published simultaneously in the same journal, presumably for maximum impact. One investigated whether multivitamins could prevent dementia, the other whether they could reduce cardiovascular risk in people with a history of heart disease. No one who knows about nutrition or who is interested in adding to our knowledge of what works and what doesn’t would have conducted either of these poorly conceived trials.

Vitamins can slow brain shrinkage

Why try to prevent dementia by giving a fairly low-dose multi-vitamin when there is already a very good randomised trial showing that it is possible to slow down brain shrinkage and memory loss, the two hallmarks of Alzheimer’s, by giving high doses of B vitamins to those at risk. That’s about half the population over 65.

Giving multivitamins to heart disease patients, who are also on a range of powerful drugs, is equally ignorant. The informed approach would be to use specific supplements known to benefit heart disease on patients who were deficient. For example, giving B vitamins to those with raised levels of the amino acid homocysteine, which is a marker for heart disease, or antioxidants to those with a high level of oxidative stress.

The studies were published in the Annals of Internal Medicine [1] which ran an editorial that provided the scare headlines but which didn’t remotely reflect what the studies actually found, as will become clear. The key part read: “Antioxidants, folic acid, and B vitamins are harmful or ineffective for chronic disease prevention, and further large prevention trials are no longer justified. Most supplements do not prevent chronic disease or death, their use is not justified, and they should be avoided.”

This is pure prejudice totally disconnected from the results of the trials. These were trials of “multivitamins” and as such tell you nothing about ‘most’ supplements – just the ones on trial. They also came up with no evidence of harm and the cardiovascular trial was not about preventing heart disease (primary prevention), but only reducing further harm once it has developed (secondary prevention).

The study ran into big trouble

So what did these studies actually show? The first was a sub-group of a larger trial. Patients aged 50 or older who had had a heart attack within the previous six weeks were given a multivitamin supplements, at quite high doses or a placebo[2] There were 1708 people at the start of the trial which was intended to see if the vitamins reduced various consequences of heart disease (primary endpoints) such as death, repeated heart attacks , stroke, coronary revascularization, or hospitalization for angina.

But the study ran into big trouble. The patients were meant to take the supplements for at least 3 years but half of them (46%) failed to keep taking the vitamins for that long and 17% dropped out completely. In the end there were just 400 patients in the vitamin group and 426 in the placebo group. The primary endpoint(s) occurred in 27% of patients taking vitamins and 30% of patients taking placebos.  Without any treatment you would expect 30% to have one of those cardiac events, so 3% fewer of those on vitamins had them. That’s actually a 10% reduction or a potentially life-saving benefit for one in ten.

However the small size of the trial, made worse by the fact that so many people had stopped taking the vitamins or dropped out, meant that this result couldn’t tell you anything useful at all. Trials have to be a certain size to make sure (technically known as “powered”) that the result didn’t happen by chance.  This study was originally powered to detect a 25% reduction in risk so the official ‘statistical’ conclusion was that there was no difference between the risk between those taking the vitamins and a placebo. The positive trend, however, indicates that the trial should be repeated with enough participants to detect a 10% reduction in risk.

Patrick Holford

Patrick Holford

Patrick Holford is a nutrition expert specialising in mental health. In 1984 he founded the Institute for Optimum Nutrition. He is director of the Food for the Brain Foundation, and it's outpatient clinic, the Brain Bio Centre. He is author of 36 books, including the best-selling Optimum Nutrition Bible and, together with Jerome Burne, Food is Better Medicine than Drugs and 10 Secrets of Healthy Ageing.
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  • Patrick Holford! That’s such a shame. I was starting to like it here.

    • Editorial

      I’d just ask you to read it. Patrick certainly has his detractors but he knows a lot about vitamins and what would be sensible ways to test them and what wouldn’t. Let’s not start off down the ad hominem route. Be really interested to hear your response to what he actually writes.

  • I too have had doubts about some of Mr Holford’s advice in recent years – although I bought a couple of his books before I had stumbled across Gary Taubes’ “The Diet Delusion”.

    However, from what little I know his advice in the present article is spot on. It certainly seems to jibe with Dr Malcolm Kendrick’s views, for which I have the greatest respect.

    • We certainly should try to avoid “ad hominem” arguments. Not only for all the well-known reasons, but also because it seems to me that in the present state of nutrition science it seems unlikely that anyone at all has the whole truth and nothing but the truth. What is important is for us all to work together, as far as possible, and try to fit together the various pieces of the giant nutrition jigsaw.

      • Editorial

        Absolutely and without wanting to go down the conspiracy route it is the case that powerful commercial interests are involved in studies on diet- see Hannah Sutter’s recent article here on SACN. As for supplements pharmaceutical companies readiness to do whatever it takes to protect the bottom line – set out in Melayna Lamb’s post on clinical trials last week – would suggest they probably aren’t reluctant to muddy the water. And that’s quite apart from the fact that evaluating diet and lifestyle interventions is a lot trickier than testing a single drug.

  • Jerome, I can see where Eve and Tom are coming from, Jerome. Patrick can invoke mixed receptions amongst people. But his discussion of homocysteine, B vitamins, heart disease and Alzheimers is highly pertinent because homocysteine is an important link in the chain that joins ’cause and effect’ in these matters. Yes, and I think he is right to intimate we do not get objective and unbiased studies involving vitamin trials and why.

    Homocysteine is an important in the puzzle of chromic disease. In the test kit of diagnostics homocysteine testing can be a reliable indicator of background and lingering oxidative stress. But levels is homocysteine is influenced by several factors. High homocysteine levels can point to nutritional deficiencies and stresses, but there can be alternate nutritional factors at work, and high homocysteine can be induced by factors not directly related to nutrition. As ‘markers’ go homocysteine reliably informs something is wrong, but since several factors can bear upon homocysteine, cortisol being one, and so despite it’s reliability as a risk factor homocysteine lacks specificity in ability to point to underlying cause(s).

    So Patrick is correct to imply supplementation with B vitamins could be prudent, and that the evidential support may be imperfect, but although Patrick’s primary focus is nutrition, compromised nutrition is likely not the only lifestyle or environmental risk factor that has capacity to raise homocysteine levels. Actually the association homocysteine levels may have with cortisol levels links several generally well accepted risk factors with process, but it also points to the involvement of at least two additional potential risk factors that have hitherto been overlooked.

    Part of the difficulty is that informed people, Patrick included, can suggest protocols for treatment ahead of a real understanding of what factors (causes) actually give rise to the need for treatment in the first place. The virtue (or lack of it) in any prospective treatment(s) becomes a lot clearer if the action of the proposed treatment can be cross-referenced against an identified process linking cause with effect.

    In heart disease addressing elevated levels of homocysteine in the most natural ways possible is a way of diminishing atherogenic pressures that lead to atherosclerosis (and arteriosclerosis) and the general package we term’ CVD’ or ‘heart disease’.

    The capacity of cholesterol to potentate the process of atherogenesis still has not been established. In contrast the atherogenic properties, or capacity to potentate atherogenic process, of homocysteine and oxidised cholesterol is supported by evidence. And both homocysteine and insulin are implicated as risk factors for Alzheimers.

    Homocysteine, and oxidised cholesterols, of which ‘cholestane triol’ is one, deserve to get more air time and column inches. Credit to Patrick for his contribution to the process.

  • What irony from a man who has spent years selling the dam things!

  • Aidan Goggins

    I’ve read two rebuttals to these studies.

    The first from Dr Alan Gaby, a US doctor who received his undergraduate degree from Yale University, his M.S. in biochemistry from Emory University, and his M.D. from the University of Maryland. He is past-president of the American Holistic Medical Association and gave expert testimony to the White House Commission on Complementary and Alternative Medicine and has written numerous scientific papers in the field of nutritional medicine. So, quite the authority!

    The second, this article here from Patrick Holford.

    Whilst Patrick’s and my own philosophies are probably best illustrated as a Venn diagram, reading both articles, I can indubitably state that Patrick has presented a far more relevant, thought provoking, and scientifically qualified and rigorous discussion on why we should not discount vitamin use.

    It is a shame if anyone dismisses this piece right off the bat instead of considering the merits of the content presented. I, for one, found many valid and well presented points.

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