Supplements: can you get everything you need with a balanced diet? - by Dr Nina Bailey BSc, MSc, PhD, RNutr

This Sunday's blog is written by Dr Nina Bailey from Igennus. Nina is a leading expert in marine fatty acids and their role in health and disease. Here she discusses supplements and if they are absolutely necessary for maintaining your health and preventing disease.

Headlines like this constantly pop up on social media and can leave many of us confused and unsure about the pros and cons of supplementation.  As with many of the headlines we read, the complete ‘story’ is rarely told, the ‘facts’ often distorted or, in some cases (depending on the author/source), can be simply untrue.  As with most things in life, there are two sides to every story.  We are often told that supplements (omega-3, multivitamins, minerals and so on) are simply a waste of money, and as a nutrition scientist I both agree and disagreewith this statement.

I do agree that not all supplements are formulated for efficacy (and hence will not be effective) and that there will of course be some individuals who, because of their diet and lifestyle or current health situation (note that I don’t say ‘choices’, which I will expand on later!), don’t need to supplement. Mostly, I disagree because we cannot make sweeping statements that appear to apply to the whole of the population!  We are all unique, and the nutrient requirements of one person will differ quite significantly from the next depending on their general lifestyle, their working habits, activity levels and sleep status. Do they drink regularly? Do they smoke? Are they under stress at work or home?  The simple fact is that no two people are the same, or lead the same life, and so of course there will be individuals who require additional nutrients or micronutrients at certain points or stages in their lives.  If the products they take are expertly formulated to deliver safe, viable doses, in forms that are known to be both bioavailable and effective, then the health benefits are unquestionable.   What we often hear from so-called ‘experts’, however, is that a balanced diet allows us to obtain the nutrients we need so avoids the need for supplements!

Just eat food!

So, can we really get all the nutrients we need from our diet? Absolutely!  We should indeed be able to sustain ourselves with the nutrients we require for everyday function via the food we choose to eat!  But wait, before we actually ditch our pot of multivitamins and minerals or fish oil supplement, let’s just take a moment to look at what is considered to be a balanced diet and, importantly, some of the factors that may (or may not) influence our ability to maintain a nutrient-rich variety of foods.

A diet that promotes health and prevents disease is one that contains an abundance of natural, unprocessed, seasonal, organic, fresh whole plant foods; a broad range of wild, grass-fed or pastured organic animal proteins; plus an array of ‘good’ fats.  If this is your diet (and has been for decades), then thumbs up to you, as it’s highly likely that your vitamin and mineral levels, along with your omega-3s, are nicely optimised.  But wait: you work long hours in the city, commute an hour each way, you find time to work out twice weekly yet survive on less than 7 hours sleep at night!  Okay, so now we need to look again, as it’s highly likely that some aspects of your life may be exerting a high level of emotional and physical stress on certain metabolic pathways (not even to mention the impact of likely unavoidable factors such as pollution).  With stress there is inflammation and with inflammation we are at a higher risk of developing poor health.  You may (or may not) feel generally ‘healthy’ (so you get a bit tired at times and perhaps get the odd cold, but nothing more than that)  but the inner workings may (invisibly) disagree.

It may not be that you are nutrient deficient per se, but you may need more nutrient[s] than someone eating a similar diet but who has less of an inflammation-encouraging stress burden than you do! The key thing to take on board here is that we and our life situations are all different and so are our nutrient requirements. This way of thinking is the focus of personalised nutrition, which concentrates on the individual rather than the population as a whole, whose standard guidelines tell us that we should all be consuming ‘X’ amount of vitamins or ‘Y’ amount of calcium, regardless of age, sex, activity levels or even stress!  Eating more nutrient-rich foods may be the answer on an individual basis or, alternatively, we could move to supplementation.  But here is the crux of the matter, because taking a poorly formulated supplement may well cause your body more harm than good.   Unless your product is formulated using carefully selected, highly bioavailable, body-ready nutrients in doses that aim to support (not overload) the numerous metabolic and cellular processes that occur on a continuous basis, then you may as well not bother.

Let us look back to headlines published by the Daily Mail in 2016, where it stated that calcium supplements ‘dramatically increase risk of heart attacks’ but without clarifying that it is the type of calcium that was the issue. Given that the majority of calcium supplements contain calcium in the carbonate form (aka limestone) it is actually not surprising that this form of calcium builds up in the arteries (rock is terribly hard to digest and absorb…).   In addition, supplements are not foods, and should not [in terms of how we ‘dose’] be treated as such, yet consumption guidance on many calcium supplements means that individuals are taking  a large dose, all at once, that the body is simply unable to process.    In contrast, taking naturally-derived calcium [such as algae-sourced, pre-digested] over the day as a split-dose will lead to calcium accumulation within the bones (where you need it) and not the arteries, with significant benefits to bone mineral density, which is generally the purpose of taking a calcium supplement. (Kaats et al., 2011)

So what is the perfect diet?

This is a subject close to my heart and while the jury is out on defining a recognised, validated diet that meets the requirements of the whole population (simply because it is unlikely to exist), you can read about how to optimise your diet to give you the best possible nutrient-dense ingredients to reduce the risk of chronic disease here.    It’s also recognised by experts in nutrition that it’s not about how much of a food we eat, but more about focusing on the quality of the foods we consume. For example, it’s well established that food budgets can lower the nutritional adequacy of an individual’s diet.  Indeed, people’s food choice and diet variety of foods integral to a healthy diet (i.e. fruit, vegetables, fish) can be perceived as a luxury, with healthier alternatives (organic, grass-fed and so on) to common foods often carrying a price premium, making them essentially unachievable for some.  While many of us may wish to follow a perceived nutrient-rich, balanced diet, various economic ‘barriers’ can be influential on our dietary choices.  It is, for example, estimated that half of the weekly income is needed for a person on income support to eat a healthy diet, while the considerably higher cost of therapeutic diets places an even greater burden on older people with limited incomes. (Conklin et al., 2013) Thus I highlight the importance of my earlier comment about an individual’s diet and lifestyle situation rather than their diet and lifestyle choice as it is well established that socio-economic factors will influence how well a person will, or can, eat. (Maguire & Monsivais 2015) The assumption that we are all (or could be) consuming a balanced diet is therefore not feasible and supplementation may well be a convenient (and more affordable) option for many.  What is clear is that while we are consistently reminded of the benefits of a balanced diet, the figures for diet-related chronic diseases would suggest that the majority of us are non-compliant!

Diet related disease

In 2006-07, poor-diet-related ill health cost the NHS in the UK £5.8 billion, (Scarborough et al., 2011) and 10 years on, that figure has undoubtedly continued to grow.  Diabetes and obesity are key diseases that lead to other diet-related chronic diseases and it is well accepted that nutritional strategies that focus on the prevention of obesity and diabetes can reduce the prevalence of other major chronic diseases. In addition, cancer, cardiovascular disease, liver disease, kidney disease, digestive disease, and mental illness are consequences as well as causes of other diet-related chronic diseases.  All diseases have multifactorial causes, and most result from decreased antioxidant status, increased inflammatory status, impaired carbohydrate/lipid/one-carbon metabolism, impaired functioning of neurons and DNA transcription, hypertension, and/or modified gut flora. (Fardet & Boirie 2013)  Thus, it can be said that increasing antioxidant status, decreasing inflammation and/or supporting the complex systems that influence health via diet (and/or supplementation) can only aid in reducing disease risk.

Some studies suggest that supplements like vitamins and antioxidant can be harmful, so are supplements actually safe?

When used appropriately, yes, supplements are safe.  What is ‘appropriately’ I hear you ask?  When we read negative headlines it’s always worth looking at the source of the information behind them.  What is clear from many dietary intervention studies is that many nutrients work synergistically and that when given in very high doses, there is indeed a potential for them to cause problems by disrupting nutrient pathways.  Nutrients are not drugs, and should not be treated as such in research trials.  The antioxidant vitamin E, for example, is a popular antioxidant that has been associated with a reduced risk of cancer, yet a study published in 2011 found that the risk of prostate cancer actually increased among the men taking vitamin E compared to the men taking a placebo.  Scary stuff and you could easily think that this therefore makes vitamin E supplementation a bad idea for everyone – right?  Not so!  Let’s look more closely at some of the facts in this case.    Firstly, the trial used a synthetic vitamin E, a mixture of eight a-tocopherol stereoisomers in equal amounts (stereoisomers are molecules that have the same molecular formula but their atoms have a different arrangement).  Only one of these stereoisomers, (12.5% of the total mixture), was RRR- or d-a-tocopherol, the natural form.  A number of studies have shown significant differences between natural-source and synthetic vitamin E.  They have also shown that natural-source vitamin E is more efficiently used by the body than its synthetic counterpart and that the body has a preference for natural-source vitamin E over synthetic vitamin E.  (Burton et al., 1998) Had this trial used naturally-derived vitamin E the outcome may well have been very different.  Indeed, other trials have reported that both dietary and supplemental (as natural α-tocopherol) vitamin E are not only inversely associated with prostate cancer risk (high levels/high intake offer protection) but may also contribute to improved prostate cancer survival in those men with the disease. (Watters et al., 2009)

Secondly, when we give high doses of a single antioxidant such as vitamin E to an individual who may already be low in antioxidants, this can have the potential to cause vitamin E to become a pro-oxidant with the capacity to increase inflammation and therefore have health-negative outcomes; it is useful, therefore, to understand how antioxidants actually ‘work’ and the factors that influence their actions.  Antioxidants act to stabilise free radicals usually by donating an electron, hydrogen or other chemical group that, essentially, calms the free radical down and stops it going on the rampage.  However, depleted antioxidants have the capacity to become pro-oxidants thereby ‘switching teams’ to become free radicals themselves unless another antioxidant (such as CoQ10, lipoic acid or vitamin C) steps in to donate one of its electrons, thus converting vitamin E back from a pro-oxidant to an antioxidant.  So – numerous antioxidants act together, essentially working as a tag team to keep the body free from free radicals;  however, if someone hasn’t been eating their veggies, they may be low in antioxidants and so dumping a high-dose vitamin E into the mix may cause a rise in the pro-oxidant version.  Therefore rather than supplementing with single antioxidants, it is more effective to supplement with a mix so they have the capacity to recycle each other.  The antioxidant story is a complex subject that was recently clarified by fellow nutritionist Sophie Tully and you can read more about the pros and cons of taking antioxidant supplements and how to optimise the benefits for you rather than the population on a general level here.

Choosing the right supplement

It’s a minefield out there! For a consumer, the variety of supplements in health shops, online, or even in supermarkets can be overwhelming. I’m going to use my own experience of involvement in­­­­­ supplement formulation to illustrate the importance of awareness of the choices to be made in doing so:  the focus is to ensure the efficacy and safety of formulas. Uptake and retention of nutrients is optimised by taking measures to overcome bioavailability issues, by using only the most effective ‘body-ready’ forms, or pre-methylated forms of vitamins and minerals.  We incorporate a slow release matrix into our tablets and we actively encourage split-dosing to ensure all-day coverage. We also do not believe in overloading the body with excessive ‘mega’ doses that the body does not need or simply cannot absorb in one dose. The majority of water-soluble nutrients are simply not needed in mega-amounts for an effect and can (such as in the case of folic acid) come with undesired contraindications.  Sometimes the body will simply excrete any excess it does not need or cannot absorb in one dose. For example, with nutrients such as B12 and vitamin C, absorption is far better when the nutrient is delivered at smaller doses at a sustained rate because the transport systems responsible for their uptake quickly become saturated.  This means that as the dose increases, the absorption rate decreases and the majority of the nutrient will simply pass though the body unabsorbed – this is wasteful and financially unacceptable.  In addition, we use vitamin B12 as methylcobalamin(rather than the cheaper poorly absorbed cyanocobalamin form) for enhanced uptake. We use Quatrefolic® which is the body-ready form of folate, as [6S]-5-methyltetrahydrofolate, while most standard supplements contain synthetic folic acid. Incidentally, the article I am responding to referred to the use of folic acid as desirable during pregnancy; I would point out that folic acid is now being updated to folate by many supplement manufacturers because of issues around impaired folic acid metabolism and the role this plays in the development of neural tube defects (such as spina bifida).   We also choose the active form of riboflavin, riboflavin-5-phosphate.  Similarly, vitamin B6 is pyridoxal-5-phosphate, the only form of B6 with cofactor activity.    Taking such important considerations as bioavailability and dose frequency into account, safe supplements are formulated with the aim of delivering unprecedented yet cost-effective health benefits – otherwise what is the point?

Summary

Supplements may not be for everyone, but if we base the argument for not supplementing on the utopian notion that we can obtain all the vitamins and minerals we need from a balanced diet, then it’s highly likely that the majority of us would benefit from a micronutrient top-up!  In addition, given the growing burden that dietary-related chronic diseases are having on our NHS system, it is evident that nutrient deficiencies (= increased nutrient demands) are rife.  It is also evident that with an increasing market, not all supplements will be equal in terms of safety and efficacy and that purchasing from a reputable healthcare company with a team of experienced, and highly qualified nutrition scientists (who are also practising nutrition practitioners) behind the development of their products will ensure that you are in the safest hands possible when choosing products aimed at optimising health. If you’re interested, here is the link to The Independent’s article What vitamins should I take, which prompted this article.

References

Burton GW, Traber MG, Acuff RV, Walters DN, Kayden H, Hughes L, Ingold KU. Human plasma and tissue alpha-tocopherol concentrations in response to supplementation with deuterated natural and synthetic vitamin E.

Am J Clin Nutr. 1998 Apr;67(4):669-84.

Conklin AI, Maguire ER, Monsivais P. Economic determinants of diet in older adults: systematic review. J Epidemiol Community Health. 2013 Sep;67(9):721-7

Fardet A, Boirie Y. Associations between diet-related diseases and impaired physiological mechanisms: a holistic approach based on meta-analyses to identify targets for preventive nutrition. Nutr Rev. 2013 Oct;71(10):643-56.

http://www.dailymail.co.uk/health/article-3834828/Calcium-supplements-dramatically-increase-risk-heart-attacks.html#ixzz4obrK7XZV

Kaats GR, Preuss HG, Croft HA, Keith SC, Keith PL. A comparative effectiveness study of bone density changes in women over 40 following three bone health plans containing variations of the same novel plant-sourced calcium. Int J Med Sci. 2011 Mar 2;8(3):180-91.

Maguire ER, Monsivais P. Socio-economic dietary inequalities in UK adults: an updated picture of key food groups and nutrients from national surveillance data. Br J Nutr. 2015 Jan 14;113(1):181-9.

Scarborough P, Bhatnagar P, Wickramasinghe KK, Allender S, Foster C, Rayner M. The economic burden of ill health due to diet, physical inactivity, smoking, alcohol and obesity in the UK: an update to 2006-07 NHS costs. J Public Health (Oxf). 2011 Dec;33(4):527-35.
Watters JL, Gail MH, Weinstein SJ, Virtamo J, Albanes D. Associations between alpha-tocopherol, beta-carotene, and retinol and prostate cancer survival. Cancer Res. 2009 May 1;69(9):3833-41.