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Vitamins and Supplements. How much is too much? Cecily Kelly, M.D. Topics to be covered. Recommended vitamins/supplements Pregnancy Osteoporosis High cholesterol Cold Prevention/Treatment Weight Loss Supplements Miscellaneous. Overview. How much do we use?.

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Vitamins and supplements

Vitamins and Supplements

How much is too much?

Cecily Kelly, M.D.

Topics to be covered
Topics to be covered

  • Recommended vitamins/supplements

    • Pregnancy

    • Osteoporosis

    • High cholesterol

  • Cold Prevention/Treatment

  • Weight Loss Supplements

  • Miscellaneous

How much do we use
How much do we use?

  • Survey done by the National Center for Complementary and Alternative Medicine found that 4 in 10 adults had used “integrative therapy” in the past year

Vitamins a d e k
Vitamins A,D,E,K

  • Fat soluble

  • Stored in fat globules

  • It is possible to get too much-hypervitaminosis

Vitamins b and c
Vitamins B and C

  • Water soluble

  • Too much Vitamin B

    • Worsen diabetic neuropathy

  • Too much Vitamin C

    • Loose money

Beriberi thiamine

  • Occurs in alcoholics due to malnourishment

  • Heart failure

  • Muscle wasting

  • Peripheral nervous system problems

  • Problems with thinking

Scurvy vitamin c
Scurvy-Vitamin C

  • Tiredness, muscle weakness, joint and muscle aches, bleeding gums, rash on skin, loss of teeth


  • Not seen in developed world because of

    • Adequate supply of food

    • Many fortified foods

Too much
Too much?

  • Fat soluble

    • Vitamin A-nausea, vomiting, headache, dizziness, blurred vision

    • Vitamin D-excess may cause cardiovascular problems

    • Vitamin E-increase bleeding problems

  • Water Soluble

    • Vitamin C-laxative effect

    • Vitamin B6-skin problems and peripheral neuropathy

United states preventative services task force
United States Preventative Services Task Force

  • Has found poor evidence to recommend routine use of Vitamin A, D, or E, multivitamins with folic acid, or antioxidant combinations to reduce the risk of cardiovascular disease or cancer

Vitamins in pregnancy
Vitamins in Pregnancy

  • Calcium

    • Keeps bones of mom and baby healthy

    • 1,300 mg/day age 14-18

    • 1,000 mg/day age 19-50

  • Folic acid

    • Brain and spinal cord development

    • 600 mcg/day

  • Iron

    • Prevents anemia in mom and baby

    • 27 mg/day

Folic acid
Folic Acid

  • US preventive services task force recommends supplementation of 400mcg to 800mcg daily for all women capable of pregnancy


  • Most pre-natal vitamins do not contain enough calcium and expectant mothers must get additional calcium through diet or supplements


  • Women 51-70 (Men over 70) recommended 1,200mg/day

    • Two divided doses-body only able to absorb approx 500mg at a time

    • Do not take with medication for reflux like prilosec, nexium, omeprazole

    • Calcium citrate or calcium carbonate

    • Take with vitamin D which helps absorption

Food sources of calcium
Food Sources of Calcium

  • Eight ounces of yogurt-300mg

  • One cup of milk-300mg

  • 1.5 oz of cheese-300mg

  • 8 oz of fortified OJ-300mg

Vitamin d
Vitamin D

  • Adults < 70

    • 600 IU/day

  • Adults > 70

    • 800 IU/day

  • Helps us absorb calcium

  • Also can get from the sun

Food sources of vitamin d
Food Sources of Vitamin D

  • Sockeye Salmon-800 IU

  • 3 oz can of tuna- 150 IU

  • Vit D fortified milk- 80IU

  • OJ fortified- 80 IU

  • Fortified yogurt-80 IU

Do i get enough
Do I get enough?

  • People typically get 300mg of calcium from their diet daily

  • With the use of sunscreen, long hours spent indoors, or people who live in the northern latitude, overall decreased sun exposure causes pts to not get enough Vitamin D

What happens if i don t get enough
What happens if I don’t get enough?

  • Colon cancer

  • Kidney stones

  • Obesity

  • Hypertension

  • Osteoporosis

  • Bone fracture

How much is too much
How much is too much?

  • >2500mg/day may increase the risk of hypercalcemia and kidney problems

  • Kidney stones- >2150 mg/day in postmenopausal women

  • Avoid coral or dolomite (a kind of limestone) because they can contain heavy metals like lead

What is it
What is it?

  • Essential fatty acid that we must get from our diet

    • Fish

    • Salmon

    • Tuna

    • Halibut

    • Nut oils

Why do i need it
Why do I need it?

  • Crucial for brain development

  • Involved in growth and development

  • Shown to decrease risk of heart disease

  • Decrease inflammation

How do i get it
How do I get it?

  • The American Heart Association recommends two servings a week of fatty fish, such as:

    • Mackerel

    • Sardines

    • Albacore Tuna

    • Large Trout

    • Salmon

And what if i don t eat fish
And what if I don’t eat fish…

  • American Heart Association

    • Adults with no history of heart disease

      • Fish two times a week

    • Adults with coronary heart disease

      • 1 gram daily of EPA and DHA

    • Adults with high cholesterol levels

      • 2-4 grams daily of EPA and DHA

How much is too much1
How much is too much?

  • Do not take more than 3 grams without a physician supervision

  • Side effects include fish breath, gas, bloating, belching, diarrhea

  • Use with caution if you take a medication to thin your blood or have a bleeding disorder- omega-3 supplements can increase your risk of bleeding

  • Get supplement from an established company that certifies that their products are free of contaminants like lead, heavy metals, mercury

Vitamin c
Vitamin C

  • Prevention

    • Might help immune function

    • Most evidence (8 studies) suggests that even in doses of 1 gram a day does not prevent colds

  • Treatment

    • “Some evidence” that taking high doses may decrease sx duration by 1-1.5 days

Vitamins and supplements

  • Prevention

    • Only in vitro evidence (in the lab) that it stops the growth of the common cold

    • No reliable evidence that it can prevent the cold in vivo (in humans)

  • Treatment

    • 9-24 mg elemental zinc started within 24-48 hrs of symptoms to reduce severity and duration of colds (6 studies)-take every 2-3 hrs while awake

    • Other studies show no effect (5 studies)


  • Prevention

    • In vitro (in the lab) research suggests it stimulates immune system

    • In vivo (in people) studies for prevention against the common cold has “consistently been shown to be ineffective” (9 studies)

  • Treatment

    • “Some preparations” may reduce symptom severity and duration possibly by about 10%-30%

      • Different species

      • Best evidence with Echinacea purpurea


  • Prevention

    • May have immunostimulant activity and antiviral

    • If taken between November and February may have one fewer cold episode than patients taking placebo

How much is too much2
How much is too much?

  • Patients who have autoimmune disease such as RA (rheumatoid arthritis or lupus) may do worse with the supplements that “stimulate” the immune system

  • Echinacea-Ragweed allergies should not use-cross allergy

  • Vitamin C-high doses may increase risk of side effects

  • Zinc-nasal spray withdrawn from market due to permanent anosmia (loss of sense of smell)

  • Garlic-adverse effects like bad breath and body odor, interaction with warfarin (coumadin) causing increase in risk of bleeding

What about airborne
What about Airborne?

  • Promotional material “developed by a teacher who was sick of catching colds in class”

  • Contains vit C, vit E, vit A, zinc, echinacea

  • No proof it can prevent or treat a cold

  • Not recommended


  • American ginseng- maybe beneficial

  • Probiotics-maybe beneficial for respiratory infection prevention-more in children

  • Panaxginseng-might have immunostimulant effects and protect against colds and improve response to flu vaccine

  • Vitamin E-some evidence that it might help the body build immune response with vaccination

  • Andrographis

  • Astragalus

  • Elderberry- possibly use in treating the flu-antiviral and immune system changing effects

  • Goldenseal

  • Pau d’arco, bee propolis, wild indigo, boneset, Siberian ginseng, larch arabinogalactan

  • Teas-elderflower, rose hips, goldenseal, chamomile, peppermint, slippery else, ginger, Mormon tea, linden flowers, meadowsweet

So what can i do
So what can I do?

  • Flu shot every year-Usually starts August-March

  • Hand washing or alcohol based hand gels

    • Hand washing-2 min with soap and water

    • “Some evidence that alcohol based hand gels, which have 62% ethyl alcohol, lower the amount of cold-causing viruses on fingers better than water.”2,3

Increase energy expenditure
“Increase Energy Expenditure”

  • Ephedra (aka Ma huang)

    • May also be bitter orange or country mallow

    • Weight loss of 2lb/month

    • Caffeine

    • Adverse events shown in 50 trials-psychiatric, autonomic, cardiovascular, GI symptoms

    • Another review showed 87 reports of hypertension, abnormal heart rhythm, heart attack, stroke, seizures

    • Ten events led to death, 13 permanent disability-9 of those were at the recommended dosage.

Modulate carbohydrate metabolism
“Modulate Carbohydrate Metabolism”

  • Chromium picolinate

    • Studies of chromium and obesity show no difference between study group and placebo

    • Kidney failure is sometimes related to doses of more than 1,000 mcg a day

    • Uncertain safety profile

Increase satiety
“Increase Satiety”

  • Forms of soluble fiber

    • Guar gum

      • Relatively safe, also 11 trials with this vs placebo showed no difference

    • Glucomannan

      • Trials show moderate weight loss, but only 20-50 pts in each trial

    • Psyllium

      • Improved glucose and cholesterol, no differences in weight loss


  • Hydroxycitric acid

  • Linoleic acid

  • Green tea

  • Licorice

  • Pyruvate

  • Vitamin B5

  • Andl-Carnitine

  • Chitosan

  • Dandelion

  • Spirulina

  • Guggul

So what does my doctor say
So what does my doctor say?

  • “If there is strong evidence for a product’s quality, safety, and efficacy, it may be reasonable to recommend that product and closely monitor the patient.”

  • None of these supplements meet this criteria.

  • Ephedra should be actively discouraged

  • Due to lack of efficacy, patients are discouraged from using: chitosan and guar gum

Exercise eat a balanced diet get plenty of rest
Exercise.Eat a balanced diet.Get plenty of rest.

Cranberry extract
Cranberry Extract

  • Prevention-MAYBE EFFECTIVE

  • Treatment of bladder infections- NO EVIDENCE

  • Cranberries are suppose to inhibit bacteria from adhering to the bladder wall

  • It has not been proven that taking “AZO cranberry” can prevent bladder infections

    • 300 mL/day of Ocean Spray Cranberry Juice cocktail,

    • 500mg/day of Buckton Scott’s Cran-Max capsules

    • 400mg/day of Cranactin cranberry caps


  • Probiotic

  • Generally considered to be beneficial because it produces vitamin K, lactase, anti-microbial substances

  • Many uses, mainly used to treat antibiotic-associated diarrhea, acute infectious diarrhea, irritable bowel syndrome relief

  • Side effects: flatulence

Glucosamine chondroitin

  • Treatment of knee osteoarthritis

  • GAIT trial-1583 participants

  • May help with patients with moderate to severe pain-GAIT trial showed 79% if patients in treatment group had 20% reduction or greater of pain

  • 1500 mg Glucosamine

  • 1200 mg Chondroitin

  • Side effects-upset stomach


  • Treatment of sleep disorders

  • Decreases the time it takes for people with a primary sleep disorder to fall asleep

  • Safe for short term use

  • Did not help with how efficient sleep was or quality of sleep

  • Not effective for patients with secondary sleep disorder

  • Side effects include nausea, headache, dizziness, drowsiness

St john s wort
St. John’s Wort

  • Treat depression, anxiety, sleep disorders

  • Some scientific evidence that useful for short term treatment of mild to moderate depression

  • Side effects: sensitivity to sunlight, anxiety, dry mouth, dizziness, GI problems, headache

  • Interacts with other medications

Gingko bilboa
Gingko Bilboa

  • Widely used for memory impairment, dementia, ringing in the ears, claudication

  • Study of 3000 patients followed for 6 years that were age 75 or older took 240mg a day found gingko ineffective in

    • Reducing incidence of high blood pressure and in lowering blood pressure

    • Slowing cognitive decline

  • Can increase bleeding risk

  • Raw ginkgo seeds-seizures and death

  • Headache, nausea, GI upset, diarrhea, dizziness, allergies

Federal regulation of dietary supplements
Federal Regulation of Dietary Supplements

  • The regulation of dietary supplements is different than that of prescription medications

    • No premarket review needed

    • No prior approval by FDA before marketed

    • Do not have to provide evidence to the FDA before the product is marketed that their supplement is safe, although they are responsible for making sure that it is safe and that claims are not misleading

    • Purity of supplements is relative

Things to remember
Things to remember

  • “Natural” does not always mean safe or healthy

  • Tell your doctor about any supplements or vitamins you are taking

    • Interactions with coumadin

    • St. John’s Wort decreases effectiveness of certain prescription drugs


1. Prescriber’s Letter

  • Vit D and Calcium

    • Document #270102 updated Dec 2010

  • Prenatal Vitamins

    • Document #270216 Feb 2011

  • Cold and Flu

    • Self-Study Course #09029 expires Aug, 2012

      2. Widmer AF. Replace hand washing with use of a waterless

      alcohol hand rub ? Clin Infect Dis 2000; 31:136-43.

  • Sattar SA, Abebe M, Bueti AJ, et al. Activity of an alcohol-based hand gel against human adeno-rhino-, and rotaviruses using the gingerpad method. Infect Control HospEpidemiol 2000;21:516-9.

  • NIH:National Center for Complementary and Alternative Medicine:

  • University of Maryland Medical Center:

  • Questions


    Cecily H. Kelly, M.D.

    Office 830-372-3300

    1350 Ashby St.