Optimizing Metabolism

by Ingrid Kohlstadt MD, MPH

Maps, Not Menus:

Navigating Dietary Supplements

Introduction

As the name dietary supplement suggests, nutrients are often viewed as a menu category placed somewhere among desserts, coffee, and digestifs (bitters). Partly because of this select-from-the-menu approach, dietary supplements range from dangerous but legal performance-enhancers to vitamins proven to reduce birth defects in offspring. Reports on dietary supplement safety and benefits are commensurately all over the map. Unfortunately this approach leaves consumers and their practitioners to wade through the options. This Townsend Letter column presents a cartographic approach to selecting dietary supplements.

Dietary Supplements for the Right Reasons

The name “dietary supplements” implies something to aid the body when food alone can’t do the job. But in what situation isn’t diet enough to meet the body’s needs? Phrased differently, when should supplements be on the menu? There are many appropriate uses, but inappropriate uses are quite common. In the following five examples, dietary supplements are neither the preferred first course of action, nor the first course on a menu.

1. Writing checks that the body can’t cash

If you take all the dietary supplements together, not singling out those associated with physician recommendations, many are to help people stay awake too long or do better at sports than their bodies are conditioned for. There’s nothing healthful about flogging the body to squeeze an extra drop of adrenaline.

Rather – Put stress-management first.

2. Trying to undo the effects of poor selections made earlier on the menu.

Studies validate that dietary supplements rescue people from the full-blown effects of greasy spoon choices. Dietary supplements then become enablers, permitting people to knowingly make unhealthful food selections free of the discomfort which would otherwise follow.

Rather – Emphasize that this diet needs change more than supplementation.

3. Eating food stripped of its nutrients, often without the person eating it aware that the food has been mishandled in this way.

Modern agriculture, food processing and food preparation are well documented to reduce the nutrient value of foods or make the foods more difficult to digest, leading to nutrient losses.

Rather – Congress could do a lot in this area, but until then, help patients become more savvy shoppers in the current buyer-be-extra-aware environment.

4. Diets with multiple restrictions

Although we as a society have access to a broader array of foods than most any society before us, we also have new and often complicated food restrictions. Take the child with lactose intolerance whose classmate has a nut allergy at a school with a Kosher dairy lunch policy. There aren’t many ways to pack a balanced lunch.

Rather – Before reaching for the processed, sweetened protein supplement bars, encourage dialogue with the school, innovate with the parents, and taste-test with the student.

5. Undetected food allergies and intolerances

Food allergies and intolerances play into lots of ill health. Dietary supplements may treat some of the symptoms but aren’t the way to extinguish the inflammatory fire.

Rather – Focusing on diagnosing and removing the offending foods, will be the more effective approach, possibly in combination with dietary supplements.

Maps Versus Menus

Despite the list above, I recommend dietary supplements of some kind to most of my patients. The difference is that I don’t put dietary supplements on a menu, as if serving them at a restaurant. I use them in the chart (map) room, to navigate my patients to the shores of health.

For me the phrase “patient chart” is literal and makes the new term “electronic medical record” feel anemic. This distinction may seem esoteric, but I find it to be practical both for patient interactions and as the editor of medical nutrition books. So allow me to elaborate with a narrative.

Inspiration’s breath blew icy down my winter coat on an early March day when spring felt invincible yet still far away. I ducked into a gallery opening mostly as a way to stay warm. Then I saw the ancient way-finders – two rooms of maps from 1400s, documents older than the printing press. Each cartographic masterpiece was created from the map-maker’s spatial, temporal and religious perspective and emanates a “world view.” The cartographer’s geographic location is central, disproportionately large, and usually the most detailed, as if bearing a red dot and the words “YOU ARE HERE.”

As I listen to my patients, examine them and look at the results of recent blood work, in my mind I am placing them on a medical map. Where is their “YOU ARE HERE?” I try to locate the coordinates that mark their biggest health challenges.

Another striking aspect of the maps is their varied orientation. For example, in some maps from Christian cartographers east is on top in anticipation of the resurrection. Maps from China orient north, not because of magnetism but because of the relative location of the emperor’s throne. While I was a station doctor in Antarctica my world turned upside down, as suggested in the news-clip “Kohlstadt rises to the bottom.”

Experience can be a tough teacher when we assume north is up. I now make an extra effort to understand my patients’ orientation. By that I mean, finding out how they define wellness and how and if they plan to get there. For some patients reorientation is necessary before I can fully help chart their course.

The Map-Maker’s Menu

Giving directions from my location won’t help someone at another point on the map. However, as a nutrition physician I am frequently polled with the question, “What supplements do you take, Doc?” The question has tasked me to develop maps for menu-seekers. My responses sound like these examples.

• Make sure your body has the needed nutrients to optimize blood pH. For some people that may involve taking a dietary supplement.

• Plants and people have grown up together. Eat as much turmeric as if you live in India, as many olive-phytonutrients as do the Greeks, and as much garlic as if Count Dracula is coming this Halloween (this amount has not been quantified). Supplements can help us fully use plant food for health.

• Be a union leader: Support your microbial workforce. Especially during infections and when using antibiotics, a suitable probiotic can be useful.

• Fiber is not classified as a nutrient; however our natural food during infancy contains more fiber-like oligosaccharides than nutrients. Compelling research places fiber among the most beneficial dietary changes for most people in our society. The benefits hold even when dietary supplements are used to achieve the recommended fiber intake.

• The Map Approach Can Clarify the Latest Headlines

Some of my patients are understandably suffering from a form of whiplash caused by reading the headlines. One report says take calcium and the other says not to. One says eat eggs as a protein source the other advising avoiding cholesterol-laden. One says no salt the other says that you need salt. I couldn’t imagine ordering from such a confusing menu!

A map approach allows me to help patients see past the headlines and take off the cervical collar. Calcium may not be as important as overall mineral status and eating enough alkalinizing foods. Eggs are a source of protein the body can use more readily than meat to repair damaged protein and the cholesterol risk can be minimized by hard-boiling eggs from grass-fed chickens. Most of us choose too much sodium (salt) and too little potassium and magnesium. Yet if you run marathons, use saunas or travel to the tropics that same “bad” salt could save your life.

The Map Approach Makes Blood Tests More Meaningful

Dietary supplements alter metabolic lab test results. When dietary supplements are menu selections, their use tends to be sporadic and probably less often reported to health care practitioners. Since metabolic blood tests are used to inform medication selection and dosing, sporadic, unreported use of dietary supplements (even when they are beneficial) poses risks. These risks could be minimized with a map-making approach where the patient-practitioner team charts the clinical course.

A New Mapping Tool

How about going nutritional geocaching? If you are, consider making Advancing Medicine with Food and Nutrients, 2nd edition, part of your portable navigating system. In this recent book, which I edited, 70 authors provide clinical cartographic experience. The book’s not only for explorers. The chapters are organized by common disease entities and contain summary “menus” of disease-specific nutrient recommendations.

Ingrid Kohlstadt, MD, MPH, FACN, FACPM, is the founder of INGRIDients Inc., where she has edited Advancing Medicine with Food and Nutrients, 2nd edition (CRC Press; 2012). On the faculty of Johns Hopkins Bloomberg School of Public Health, Dr. Kohlstadt is researching an approach to leverage nutrition more fully in disease prevention.