Like many scary health scenarios where patients seek some modicum of influence, the COVID-19 pandemic has led to patient demand for “immune-boosting” dietary supplements. Toilet paper wasn’t the only essential item being limited by stores; bottles of zinc and vitamin C flew off the shelves as consumers stocked up. The role of vitamin D in COVID-19 has been conflated and deflated depending on the study-du-jour. And of the eight “drugs” in President Trump’s top-of-the line treatment, three of them were natural products. The medical professional has, for the most part, dismissed vitamins as nothing more than “expensive pee.” But as an integrative medicine physician examining the data, I urge my colleagues to take a more thoughtful approach to supplement recommendations and consider whether unconscious biases are influencing how you counsel patients.

Bias #1: If it mattered, I would have learned it in medical school

The entire spectrum of vitamins and minerals was covered in a one-hour pharmacology class during my first year of medical school. I’d summarize my knowledge by graduation as having memorized the four fat-soluble vitamins for the Step 1 exam, knowing that mixing vitamin K and warfarin was a no-no, and that magnesium deficient patients got mag sulfate IV boluses. The vast majority of medical schools are sorely deficient when it comes to meeting recommendations for nutrition education, and residents and practicing physicians woefully unprepared to answer even the most basic of questions. It wasn’t until my integrative medicine training that I did a deeper dive into nutrition, and gained a true appreciation for how vital micronutrients are to human health. 

Bias #2: The false glamour of pharmaceutical drugs and FDA approval

Dietary supplements are often dismissed as ineffective, unregulated, and unsafe. The FDA and FTC do provide oversight over dietary supplements as a category separate from drugs and food. Certainly, pharmaceutical drugs undergo thorough multi-phase investigations prior to FDA approval, while under the Dietary Supplement Health and Education Act of 1994 dietary supplements can be sold with providing proof of efficacy or safety. While research is being done to better define best practices around supplements, lack of funding by pharma companies and NIH grants makes progress lag. And while certain categories of dietary supplements — notably weight loss, sexual performance, bodybuilding, and brain boosters — have a higher risk of adulteration and harm, a review of the FDA Adverse Event Reporting System Public Dashboard through the third quarter of 2020 shows a total of 1,670,783 drug reports, of which dietary supplements account for only 119. 

Bias #3: We can get everything we need from our diet

If all my patients ate a perfectly curated diet, full of plants from soil replete with nutrients, whole grains and legumes, healthy proteins — not too much or little — then maybe, just maybe, I would feel comfortable without additional support. But even my most motivated of patients, even those fortunate patients with private chefs and nutritionists on call, at best meet those standards 75 percent of the time. Heck — I teach culinary medicine, and I don’t eat well enough to feel I’m getting all my nutrients through food. Add on all the confounding factors like significant nutrient deficiencies caused by prescription medications; National Health and Nutrition Examination Survey data showing anywhere from 39 to 94 percent of Americans fail to get recommended daily intakes of multiple vitamins; issues of malabsorption and poor digestion, and the general public confusion about what even constitutes a healthy diet, and the possible people who warrant a pass on supplements diminishes significantly.

Bias #4: If I can’t see it, it doesn’t exist

The importance of vitamins was first appreciated through the classic descriptions of clinical deficiency such as scurvy, beri-beri, and rickets. Most clinicians these days, having failed to see a wayward sailor whose gums are bleeding, make the assumption that the primary purpose of a vitamin is to prevent a deficiency state and, consequently, unless patients exhibit specific signs of deficiency, they by default are replete. In reality, micronutrients have myriad functions, and even marginal depletion may cause impaired biochemical function and even functional problems affecting metabolic, immunological, or cognitive pathways. 

Bias #5: Don’t ask, don’t tell

The typical lab evaluation for patients with symptoms like fatigue, joint pain, or neuropathy can run into the thousands of dollars once specialized autoimmune and other biomarkers are added. But other than a B12 and vitamin D level, most of the vitamins and minerals are ignored. I recently saw a 39-year-old woman with stage 3 colon cancer for an integrative consultation to help support her through the upcoming rigorous regimen of chemo and radiation. She followed a fairly balanced vegetarian diet and wasn’t on any medications, but her labs revealed a ferritin of 6.3, B12 130, vitamin D 17 — all major deficiencies. Her fatigue, previously attributed to stress due to her cancer diagnosis, improved with iron infusions and B12 shots, as did her resilience through her treatment. 

Bias #6: The illusion of scientific rigor

Oftentimes when a published study concludes that a dietary supplement failed to show benefit, the medical field jumps on the bandwagon shouting, “See, supplements are just a waste of money!” And existing research has raised concerns, such as increased risk of lung cancer in smokers who take high dose beta-carotene, and excess calcium supplements and mortality. At the same time, it’s a mistake to generalize one negative study to all populations and health conditions. The recent negative data about fish oil and cardiovascular outcomes should not be construed to either mean that previous meta-analyses showing reduced myocardial infarction were wrong, or extrapolated to suggest fish oil has no role in other conditions where benefits have been shown such as inflammatory rheumatic conditions. Taking that leap is like stopping the use of insulin for diabetes because it didn’t work for treating hyperlipidemia. Don’t let a predetermined bias against non-pharm options lead to an all or nothing approach. 

Just as we shouldn’t promote unwarranted use of vitamins and minerals, we should be equally on guard against bias against their use at all. If a patient needs pharmaceuticals, consider how those are impacting specific micronutrients and consider monitoring at a follow-up visit, before problems manifest. If a person’s diet isn’t optimal, consider at the minimum a basic good quality multivitamin/mineral support. If your patient has complaints of persistent symptoms despite a negative workup, consider the possibility of nutrient deficiencies. Combine a high index of suspicion with these relatively low-cost, low-risk preventive approaches to avoid missing deficiencies that might compromise health. At the minimum, please don’t mislead your patients by calling it “posh piss” when their well-being is at stake.

Melinda Ring is an internal medicine physician.

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