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It's Time to Tell Our Patients to Stop Their Vitamin Supplements

October 17, 2012

Paul E. Sax, M.D.

Paul E. Sax, M.D., is director of the HIV Program and Division of Infectious Diseases at Brigham and Women's Hospital in Boston.

Over in JAMA, there's a large study out today that (yet again) failed to demonstrate a benefit of vitamins.

Over 3000 patients with HIV in Tanzania were randomized to receive either high-dose or standard-dose multivitamin supplementation, in addition to "HAART" (ugh). Though the study was planned for 24 months, it was stopped early by the Data Safety and Monitoring Board due to a higher rate of LFT abnormalities in the high-dose vitamin group. Not only that, the sickest patients -- those with BMI < 16 -- seemed to do even worse on the mega-dose, with a higher risk of death that almost reached statistical significance (relative risk 1.36; 95% CI, 0.93-1.98; p=.11).

One could quibble with the generalizability of the results to current standard of care in well-resourced areas -- for example, the most common regimen was d4T, 3TC, and nevirapine, used in nearly 60% -- but it's hard to imagine how this makes the results less convincing. After all, one would expect that vitamin supplementation would be more important in settings where malnutrition and advanced HIV disease are highly prevalent.

So what should we do?

I've been keeping quiet with my patients who insist on taking handfuls of vitamins, despite their having access to real food and nothing at all to suggest dietary insufficiency. With this study, however, I will strongly encourage them to save their money -- the only people benefiting from their daily intake are those in the $27-billion dollar/year vitamin industry.

Paul Sax is Clinical Director of Infectious Diseases at Brigham and Women's Hospital. His blog HIV and ID Observations is part of Journal Watch, where he is Editor-in-Chief of Journal Watch AIDS Clinical Care.

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Journal Watch is a publication of the Massachusetts Medical Society.
 
See Also
An Introduction to Dietary Supplements for People Living With HIV/AIDS

Reader Comments:

Comment by: Scott (Seattle) Sat., Nov. 3, 2012 at 10:59 pm EDT
Please Dr.Sax get re-educated on suppliments.Stop listening to pharma-based and funded studies.
HIV positive need suppliments especially if they have chosen not to be on HAART.Jury may still be out on mega-supplimentation but basic suppliments help most of us on HAART.
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Comment by: G. MCarter (Brooklyn, NY) Thu., Nov. 1, 2012 at 8:56 am EDT
I too find this a peculiar conclusion. First, the "high dose" arm some might consider subtherapeutic. Second, the intervention contained only a few vitamins (Bs, C, E), no minerals (like selenium) or vitamin D. Third, the fact that ALT (liver enzymes) were increased (mostly between 40 and 200) is probably more due to malnutrition among people with BMI under 16 in the study, nearly all of whom were on liver-toxic meds like stavudine or efavirenz. Fourth, the putatively high-dose intervention helped offset neuropathy--probably more important than marginal ALT increases! That said, supplements need to be high quality (many are) and as some commenters here have noted they can be beneficial (I've seen this and personally experienced it as a person living with Hep C) but also can be problematic. Patient-centered and holistic still applies and claiming a "generalizability" to all people living with HIV from this study with this intervention in this population is imprudent.
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Comment by: R. McCormick (RWC, CA USA) Wed., Oct. 31, 2012 at 2:19 am EDT
oh please. I've been HIV POZ longer than you've been a doctor. My own doctor and I have done many tests.. I go off my supplements and my blood work looks like crap, I go back on them and they are stabilized. And just what do you suggest, with our current food supply filled with high doses of sugar, sodium and fake crap, GMO's and poor soil producing poor quality fruits and vegetables, that we supplement out systems with. Not to mention the TOXICITY that the HIV drugs create in the body. Supplements, if taken correctly and good quality (NOT CENTRUM, give me a break) WILL help to detox the body, provided needed nutrients and help off set certain side effects. I take Ashwagandha to keep my heart from palpitating after I take my meds. It's known as an adaptogen. It DOES work. Please do you homework and stop peddling that doctors know it all, they don't. Stop trying to give supplements a bad name. Your not educated enough to make that call.
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Comment by: Luke (Toronto) Mon., Oct. 22, 2012 at 6:36 pm EDT
I'm shocked & dissappointed by this but maybe it's not such a surprise after all. I've been taking supplements including herbs on & off for 10 years & what I've found is that my problem symptoms always get worse which is consistent with this article. I'm begining to think that anything you take to enhance your health also enhances the strength of your medication making the meds far too strong for your body. It's always the same thing wheather I'm taking B complex or alpha lipoic acid or rhodiola: first the mouth dries out because of diminished salivary flow leading to oral inflammation & thrush with the nice breath, that's shortly followed by poor digestion which is, best of all, accompanied by depression & fatigue. Yes, being poz for over 15 years is really s**tty I'm learning. Do we really have to accept life with acidic blood? If raising the body's ph to an optimal alkaline level makes the medication 2 or 3 (or more) times as strong then why not reduce the medication? This way one could theoreticaly have the best of both worlds: optimal ph & effective medication. I would never do this on my own, nobody should. I have to ask an expert about this.
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Comment by: Edward (Fort Lauderdale) Mon., Oct. 22, 2012 at 2:58 pm EDT
This is not true. I believe heavy dosing may be dangerous. Why do doctor's prescribe Vitamins like Vit. D? 5-HTP, Acidophilis, L-Arginine, Apple Pectin, Fish Oil and Vit. D are just a short list of examples of supplements that have an obvious and proven effect on my health. 5-Htp does make me calmer and therefore putting me in a better mood. Acidophilis helps me with gas. L-Arginine has several obvious vascular benefits. Apple Pectin is the only thing that works for me and loose stools. Once supplementing with Fish Oil and Vit. D. a favorable blood work level readings were obvious. Many vitamins we take don't present these "obvious" benefits, so we assume it's all a waste. It all depends on what we take and good absorbtion. Many probably don't work, but to write it off as a waste of time and money just seems ignorant escpecially when your using many misleading limited studies. Next time you have loose stools take Apple Pectin, then tell me I'm wrong.
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Replies to this comment:
Comment by: Myles Helfand (TheBody.com) Wed., Oct. 24, 2012 at 7:45 pm EDT
Keep in mind that Dr. Sax is referring to people who take "handfuls of vitamins" despite having "nothing at all to suggest dietary insufficiency." He's not suggesting that all people with HIV stop taking all vitamins and supplements, period. He's suggesting that, if our bloodwork is totally fine and there are no problem areas that can be helped with supplements, there are better uses for our money than taking a whole bunch of assorted vitamins because we feel they'll protect us.

To use two of your examples, Edward: If you're one of those precious few folks who don't have a vitamin D deficiency, taking vitamin D doesn't really serve a purpose. If your lipid levels are fine, you don't really need to consider fish oil.

It's our liver's job to filter out much of the stuff our body doesn't want or need. This study suggests that, if we're popping too many supplements that our body just doesn't need, we may actually be forcing our livers to work harder to filter all of that extra stuff out, which may cause long-term damage. It's an important reminder that, just like pretty much *anything* we put into our bodies, supplements aren't always an automatic good.


Comment by: Bill (NC) Fri., Oct. 19, 2012 at 10:13 am EDT
If I take multivitamins or drink Boost or Ensure my face breaks out in a rash. This started after I started my meds. My IDS told me that I did not need to take them and that they actually were putting a strain on my liver since it processes them.
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Comment by: Dominic (Auckland, New Zealand) Fri., Oct. 19, 2012 at 9:42 am EDT
Er, can we have some serious analysis on this, please?

For years I've been heeding the advice of Experts on The Body that I should take a multi-vitamin+mineral tablet per day, just to be sure I get all the vitamins and minerals my body needs to fight HIV. I remember that selenium is one of the minerals that it's been said is particularly needed. And I imagine that my one multi-vit+mineral per day equates to the "standard dose" referred to in the article.

So Paul Sax says he is now strongly encouraging people not to buy such supplements?

Please, we need a balanced view on this.

Editors, can you get a concensus of medical opinion, please, from medical experts?
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Comment by: Divine (Singapore) Fri., Oct. 19, 2012 at 4:35 am EDT
Hello, I am living with HIV in Singapore. I have many friends with HIV who are taking a multi-vitamin as well as other health supplements like omega oil and evening primrose oil. Does this mean they should stop taking the supplements as well? What about HIV patients who are not on HAART yet, can they continue to take their vitamins?
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Comment by: karmachi (Philadelphia) Thu., Oct. 18, 2012 at 10:52 pm EDT
I make my own electrolyte and protein drinks from scratch. For probiotics , I eat cocoanut yogurt.
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Comment by: John (Philadelphia, PA) Thu., Oct. 18, 2012 at 1:45 pm EDT
Have you seen this (also in JAMA http://jama.jamanetwork.com/article.aspx?articleid=1380451):

Multivitamins in the Prevention of Cancer in Men
The Physicians' Health Study II Randomized Controlled Trial

Conclusion: In this large prevention trial of male physicians, daily multivitamin supplementation modestly but significantly reduced the risk of total cancer.

Any thoughts about how this would apply in the US among people living with HIV?

John
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Comment by: mike m. (PA) Thu., Oct. 18, 2012 at 1:02 pm EDT
I know for myself each time I begin what I believe is a supplementation protocol that is promoted by many to increase health and well being in HIV'ers something goes out of whack whether it be liver enzymes, kidney function, RBC's, etc. I think for me and perhaps for many others with all things being equal in regards to proper diet and on medication regimen any excess burden on the organs specifically those with long term HAART history can have detrimental effects. Like anything perhaps depends on so many other variables though.
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