Bio and photo in April 2019

Practical Nutritional Supplement De-Prescribing

By Dr. Douglas Lobay, BSc, ND

I attended the University of British Columbia Therapeutics Initiative Course: Bringing Best Evidence to Clinicians in October 2018 at Surrey Memorial Hospital. It was a wonderful course; it was honest and sharp in its evaluation of drug-based therapy. It presented many popular contemporary prescription practices and evaluated them with the keen precision of a razor’s edge. It used empirical evidence and the power of statistics to cut through the pharmaceutical chaff and present the truth about certain drugs. As Mark Twain once said, “There are three kinds of lies: lies, damned lies and statistics.”

The course provided algorithms to help get people off unnecessary poly-pharmacy.^1,2 It showed ways to help decrease and stop certain drugs including anti-depressants, anti-anxiety drugs, anti-cholinergics, anti-psychotics, and proton-pump inhibitors.^3-5 It gave practical examples and videos of real patients. Although it was funny to watch at the time, it was also sad in retrospect. It is bittersweet to think that we live in a society that has seen incredible advances in medicine and the treatment of disease. And yet, we are overwhelmed by a culture of addiction to the power of unnecessary pills. By the end of the day I was thinking about my practice and the over-use of vitamin and nutritional supplements.

Draga was a listless Slavic lady who frequently stopped by my office with punctuality of a Swiss clock. She spent a lot of time in health food stores and read a lot of health magazines. She was constantly bringing in different vitamins and nutritional supplements that she had just purchased. She wanted my opinion to see if they were okay to take or not. Many times, I lost track and inventory of what supplements she was taking and for what purpose. She occasionally made appointments to do a nutritional supplement review and update. I must admit that after several years of this folly I had developed a simple and quick method of analysis for her. She would stop by the office with a bag of her new supplements. She would show me what she had purchased, and I would have a quick scan of the products. I would then give her a thumbs up, thumbs down, or thumbs sideways for the relevancy and possible effectiveness of what she was going to take.

John was an old Russian gentleman who came to my office one day with a badly swollen and obviously infected finger. He had been pruning his roses when one of the thorns lanced his outstretched finger. I said that we needed to lance the appendage and give him some antibiotics to take. He said obstinately no. I paused and there was silence. He brought out his briefcase and opened it. There in its interior was every vitamin from a to z in alphabetical order. He was a big believer in Earl Mindell and the Vitamin Bible. John told me that Earl Mindell recommended this and that vitamin for his condition, and he was going to cure it naturally. I said I would give some natural antibiotics. He vehemently said no. He thanked me and went on his way back to Kootenays. I later heard that he was later hospitalized and was treated for sepsis.

Olivia was an eloquent English lady struggling with cancer. She had exhausted conventional medical therapy unsuccessfully. She was taking a plethora of vitamins and nutritional supplements from at least five different clinics. She was feeling ill and nauseous most of the time. I did an inventory of her daily nutritional supplement regime and discovered she was taking upwards of 50 different pills per day. In addition, I reviewed what pharmaceutical medicines she was taking and for what purpose. After a period of willful deliberation, I revised and reduced her list of supplements and medicines to a more manageable number. Her nausea reduced, and she felt some better.

Sophia was a vibrant German lady suffering from chronic insomnia. She had tried an innumerable of nutritional supplements that were supposed to help improve sleep. She was also taking several pharmaceutical medications that were supposed to induce and maintain sleep. She was routinely mixing different supplements, herbs, and drugs for her intractable insomnia. I did a vitamin, nutrient, and drug inventory of what she was and had been taking and what stuff she currently had at home. I helped her reduce her list of supplement intake in the hope of minimizing duplicity and side effects. She still suffers with bouts of insomnia but doesn’t feel overwhelmed or hopeless in terms of nutritional interventions.

I reflected back on my practice of nutritional medicine. It seemed I was spending an inordinate amount of energy and time on nutritional supplement de-prescribing. It appeared to me that many ill-informed and well-intentioned individuals were taking too many vitamins, minerals, and other nutritional supplements in the hopes of curing their ailments and achieving optimal health. Many people would read something in a health magazine or on the internet and become persuaded that they needed to take this supplement. Long ago I stopped reading over-the-counter lay health nutritional magazines. If I believed everything I read, I probably would be taking a whole whack of stuff. I pondered this conundrum and became convinced there was some method to this madness. I believe there is a logical and systematic way to review nutritional supplement intake and make simple and practical suggestions to manage daily intake.

Here are some simple and practical things I’ve learned about taking vitamins and nutritional supplements. Obviously, they won’t apply to everybody and there are exceptions to the rules. Keep things simple and don’t get over-whelmed. Take a multiple vitamin and mineral supplement and/or a B-complex before taking an individual vitamin or nutritional supplement. There may be times when you need an individual vitamin or mineral or have a health condition where it is recommended. If low in food calcium intake, take a moderate amount of a calcium supplement. If low in magnesium food intake, you can add a magnesium supplement. If taken together, a 2 to 1 ratio of calcium to magnesium is recommended for most people. If vitamin D is a concern, you can take supplement vitamin D, especially if there is no sunshine or you have a condition where it is required. Vitamin C and/or vitamin E, especially naturally sourced, may be recommended for a specific health condition. If you think you need an individual B-vitamin, like B12, try it for a while and see if notice a benefit. This same advice may be true for other individual vitamin and minerals. Fish oils may be recommended, especially if you don’t consume fish more than three times per week. Probiotics may be recommended, especially if you don’t consume probiotic foods or have a condition whereby your intestinal micro-flora is reduced. Other nutritional supplements may be recommended and/or consumed in addition to your core program if indicated.

If you are trying an individual nutritional supplement for a specific condition, try it for a while and see if it helps. Do not just blindly consume it continuously without a re-evaluation. I am surprised at how many people take a supplement that was recommended years ago. They take it usually on blind faith and are not even sure it if does anything. Don’t be afraid to cut things out and eliminate them for a while. I usually have a day off and don’t take any vitamin or nutritional supplements on one day of the week, usually Sunday. Remember to have a logical core program of vitamins and nutritional supplements to begin with.

To recapitulate: take a core group of vitamin, mineral and nutritional supplements, perhaps consisting of a decent multiple vitamin and mineral supplement, possibly extra calcium, magnesium and vitamin D and possibly the antioxidant vitamins C and E. Additional nutritional supplements such as fish oils and probiotics may be recommended as part of a core program. Obviously, the addition of other individual nutrients and/or supplements may be based on a specific health condition or a unique individual requirement. Re-evaluate your nutritional supplement intake periodically to see if you are achieving your goals. Read labels and try not to duplicate things. And, sometimes I recommend a nutritional supplement detox, whereby you don’t take anything for a while.

I often tell patients, if they are taking more supplements that the sum of the number of their fingers and toes, they are taking too much stuff. Remember, the old adage, “if it sounds too good to be true, it probably is.” In summary, keep your nutritional supplement program simple, logical, and practical.

References

1. Scott IA, Le Couteur DG. Physicians need to take the lead in deprescribing. Intern Med J. 2015 Mar;45(3):352-6.

2. Sharma M, et al. Polypharmacy and potentially inappropriate medication use in geriatric oncology. J Geriatr Oncol. 2016 Sep;7(5):346-53.

3. Salahudeen MS. Deprescribing medications in older people: a narrative review. Drugs Today (Barc). 2018 Aug;54(8):489-498.

4. Reeve E, et al. Deprescribing: A narrative review of the evidence and practical recommendations for recognizing opportunities and taking action. Eur J Intern Med. 2017 Mar;38:3-11.

5. Farrell B, et al. Methodology for Developing Deprescribing Guidelines: Using Evidence and GRADE to Guide Recommendations for Deprescribing. PLoS One. 2016 Aug 12;11(8):e0161248.