Nutritional Supplement Regimens - Karima Hirani MD MPH - Holistic and Alternative Medicine Doctor

Do you need to take supplements?

Supplements cannot take the place of healthy diet. However, a growing amount of research suggests that a daily multivitamin provides a useful complement to a healthy diet (Willett & Stampfer, 2001, see references at end of page). In addition to ensuring an adequate intake of essential nutrients, a daily multivitamin is associated with lower risk of cardiovascular disease, colon cancer, and breast cancer (Willett & Stampfer, 2001). While all individuals may benefit from the use of a daily multivitamin, individuals most likely to benefit include women who might become pregnant, persons who regularly consume 1-2 alcoholic drinks per day, the elderly, vegans, and poor urban residents who do not eat a healthy diet (Willett & Stampfer, 2001).

What does the RDA or DRI tell you?

The Recommended Dietary Allowance (RDA) provides information about the appropriate level of a nutrient that meets the needs of practically all healthy individuals in the general population (Bland et al., 1999). In general, the RDA tends to err on the side of being low in order to meet 100% of the government standards (Bland et al., 1999). The Dietary Recommended Intakes (DRI) were established to provide additional information, such as upper limits and recommendations for adequate intakes when there is insufficient data to determine the RDA (Mertz, 2000). The study of required intakes is complicated by variations in levels of consumption of natural food sources, variations in nutrient content of the same foods, and nutrient interactions (Mertz, 2000; Willett & Stampfer, 2001). Thus, lack of data has required RDA and DRI committees to use a significant amount of judgment in choosing between a range of intakes (Mertz, 2000). Furthermore, since the RDA and DRI recommendations establish levels for the general population, they do not account for differences in individual biochemical requirements, nor do they establish optimal intake for individuals experiencing an illness or environmental stressors (Bland et al., 1999).

How much of a supplement should you take?

Information provided by the RDA and DRI levels can provide a starting point, but are inadequate for therapeutic doses or levels required to ameliorate symptoms. Depending your your medical history and other complicating factors such as your diet, I will work with you to determine (and subsequently adjust) your individual optimal daily dose, which will also change over time. For your information, we have provided a list of vitamins and minerals summarized by individual vitamins and minerals, including physiologic functions of the nutrient, selected natural food sources, adverse effects of severe deficiency, potential therapeutic uses of increased intake, and toxic effects of excess intake. It is hoped that the reader will use this information to consider the use of a particular nutrient. To determine your individual needs more specifically, we can discuss your needs during your next follow up visit. Also remember that our office offers specialty testing for nutritional deficiencies, immune surveillance, or other conditions that may alter the recommended supplement intake for you. This information is for education use only and does not subsitute for the supervision of a physician. Please do not start or stop any current medications without the advise from a physician.

Also included is information about the preferred form of a nutrient that will increase its bioavailability, as well as a proposed scheduled for taking the supplements. The schedule accounts for the various interactions between nutrients. For example, calcium blocks the ability to absorb zinc, iron and copper (Galland & Buchman, 1988). Zinc and iron interfere with each other’s absorption (Galland & Buchman, 1988). Phosphorous interferes with calcium absorption (Bland et al., 1999). For practical purposes, you may want to buy a multivitamin that ignores these and other interactions. However, using this information to consider the optimal timing of intake as well as most bioavailable form, you may buy additional supplements to meet your individual needs. For example, a woman may buy a multivitamin that she takes in the morning, but buy an additional bioavailable form of calcium to take in the evening.

Partial Listing of Vitamin and Mineral Supplements

Fat Soluble Vitamins	Water Soluble Vitamins	Minerals
Vitamin A Vitamin D Vitamin E Vitamin K	B1 (Thiamin) B2 (Riboflavin) B3 (Niacin) B6 (Pyridoxine) B12 (Cobalamin) B5 (Pantothenic Acid) Folate Biotin Vitamin C (Ascorbic Acid)	Boron Calcium Chromium Copper Iron Magnesium Manganese Molybdenum Phosporus Selenium Zinc

Vitamin A

(includes Provitamin A carotenoids that are dietary precursors of Retinol)

Functions:: Required for normal vision, gene expression, reproduction, embryonic development and immune function.
Selected Food Sources:: Liver, greens, carrots, apricots, sweet potatoes, dairy products, fish.
Adverse Effects Of Severe Deficiency:: Skin lesions, night blindness, dry eyes.
Potential Therapeutic Uses:: Gastric ulcer.
Toxic Effects Of Excess:: Specific birth defects, liver toxicity, hip fractures. Note: Toxic effects are observed with excess supplemental intake of preformed Vitamin A (Retinol) only. Adverse effects are not associated with supplemental intake of Provitamin A carotenoids. Individuals particularly susceptible to adverse effects of high intake of preformed Vitamin A include pregnant women, individuals with high alcohol intake, preexisting liver disease, hyperlipidemia, severe protein malnutrition, or women taking oral contraceptives.

Vitamin D (Calciferol)

Functions:: Maintains serum calcium and phosphorous concentrations.
Selected Food Sources:: Fish e.g. sardines, salmon, tuna, shrimp), sunflower seeds, liver, eggs, fortified milk products.
Adverse Effects Of Severe Deficiency:: Rickets characterized by malformation of the skeleton in children, and osteomalacia in adults.
Potential Therapeutic Uses:: Psoriasis, mood regulation during the winter, additional Vitamin D may be needed by patients on glucocorticoid therapy.
Toxic Effects Of Excess:: Hypercalcemia (high calcium in the blood), fatigue, headache, nausea, vomiting.
See Also:: Dr. Hirani Vitamin D Page

Vitamin E (alpha-tocopherol)

Functions:: Major function appears to be as a non-specific chain-breaking antioxidant.
Selected Food Sources:: Vegetable oils, unprocessed cereal grains, nuts (e.g. sunflower seeds, almonds), fruits, vegetables, meats, wheat germ, spinach, oatmeal, bran.
Adverse Effects Of Severe Deficiency:: Symptoms nonspecific and rare.
Potential Therapeutic Uses:: Myocardial infarction, intermittent claudication, premenstrual syndrome, dysmenorrhea, epilepsy, osteoarthritis. Note: A growing amount of evidence suggests that a Vitamin E supplement in a dose of 400 IU is likely to be beneficial to middle-aged and older individuals who are at increased risk of coronary disease (Willett & Stampfer, 2001).
Toxic Effects Of Excess:: Increases anticoagulant activity and may cause hemorrhagic toxicity. Note: Patients on anticoagulant therapy should be monitored when taking Vitamin E supplements. Also Vitamine E may be associated with increased blood pressure in individuals with hypertension.

Vitamin K

Functions:: Coenzyme during the synthesis of many proteins involved in blood clotting and bone metabolism.
Selected Food Sources:: Greens (e.g. broccoli, lettuce, spinach), cabbage, liver, cheese, butter.
Adverse Effects Of Severe Deficiency:: Rare but can occur in newborns causing easy bruisability.
Potential Therapeutic Uses:: Osteoporosis.
Toxic Effects Of Excess:: None known to date. Note: May affect clotting. Patients on anticoagulant therapy should be monitored when taking Vitamin K supplements.

B1 (Thiamin, Aneurin)

Functions:: Coenzyme in the metabolism of carbohydrates and branched-chain amino acids.
Selected Food Sources:: Yeast (e.g. bread products), whole grains and cereals, nuts (e.g. sunflower, pine, peanuts).
Adverse Effects Of Severe Deficiency:: Classic symptoms of beriberi including anorexia, weight loss, decreased attention, numbness and tingling, neurologic signs. Beriberi is most common in individuals with cirrhosis of the liver.
Potential Therapeutic Uses:: Extra thiamin may be needed by persons treated with hemodialysis, peritoneal dialysis, or those with malabsorption syndrome.
Toxic Effects Of Excess:: None known to date. Note: Chemically sensitive patients and those with yeast sensitivity may have adverse reactions.

B2 (Riboflavin)

Functions:: Coenzyme in numerous redox reactions.
Selected Food Sources:: Yeast (e.g. bread products), organ meats, almonds, wheat germ, wild rice, milk.
Adverse Effects Of Severe Deficiency:: Rare. Associated with corneal vascularization, dermatitis, cracked corners of the mouth, red swollen tongue.
Potential Therapeutic Uses:: Migraines (prevention of recurrence).
Toxic Effects Of Excess:: None known to date.

B3 (Niacin- includes Niacinamide and derivatives)

Functions:: Coenzyme or cosubstrate in many biological reduction and oxidation reactions, so needed for energy metabolism.
Selected Food Sources:: Yeast (e.g. bread products), rice bran, wheat bran, peanuts, meat, fish, poultry.
Adverse Effects Of Severe Deficiency:: Pellagra characterized by diarrhea, dermatitis, dementia and death. Early symptoms include anorexia, weakness, insomnia, red swollen tongue, stomatitis, numbness, vertigo.
Potential Therapeutic Uses:: Osteoarthritis, Diabetes mellitus, Acne vulgaris (topical gel) Note: Extra niacin may be needed by persons treated with hemodialysis, peritoneal dialysis, or those with malabsorption syndrome.
Toxic Effects Of Excess:: Flushing, GI distress, hepatitis, increased homocysteine levels

B6 (includes Pyridoxal, Pyridoxine, Pyridoxamine, 5'-phosphatases)

Functions:: Coenzyme in the metabolism of amino acids, glycogen and sphingoid bases.
Selected Food Sources:: Fortified cereals, sunflower seeds, wheat germ, tuna, organ meats, soybeans and products.
Adverse Effects Of Severe Deficiency:: Central nervous system changes, abnormal ECG, hyperirritability, convulsive seizures. Usually associated with cirrhosis of the liver or specific drugs (e.g. D-penicillamine).
Potential Therapeutic Uses:: Premenstrual syndrome, attention deficit-hyperactivity disorder, depression, asthma, nausea and vomiting during pregnancy, monosodium glutamate intolerance.
Toxic Effects Of Excess:: Suppression of lactation, increased liver enzymes, sensory neuropathy, memory impairment.

B12 (Cobalamin)

Functions:: Coenzyme in nucleic metabolisms. Also prevents megaloblastic anemia.
Selected Food Sources:: Meat, fish, eggs, cheese, fortified cereals.
Adverse Effects Of Severe Deficiency:: Sore tongue, paresthesis of the extremities, weakness, neurological changes, megaloblastic anemia, bone marrow changes. Note: Individuals at higher risk may have gastric achlorhydria, decreased secretion of or antibodies to intrinsic factor, impaired pancreatic function, dysfunction or surgical removal of distal ileum.
Potential Therapeutic Uses:: Fatigue, some neurological disorders (e.g. Bell's Palsy, Trigeminal Neuralgia), asthma. Note: Since 10-30% of older people malabsorb food-bound vitamin B12, it is advisable for individuals older than age 50 to meet their RDA through supplements or fortified foods.
Toxic Effects Of Excess:: None known to date.

Pantothenic Acid (B5)

Functions:: Coenzyme in fatty acid metabolism.
Selected Food Sources:: Yeast, organ meats, mushrooms, soybeans, split peas, fish, eggs, meat, potatoes, oats, cereals.
Potential Therapeutic Uses:: Constipation (using D-panthenol), rheumatoid arthritis. Additional intake may be needed by those taking isoniazid or dopamine.
Toxic Effects Of Excess:: None known to date.

Folate (Folic acid, Folacin, Pteroylpolyglutamates)

Functions:: Coenzyme in the metabolism of nucleic and amino acids. Also prevents megaloblastic anemia.
Selected Food Sources:: Yeast (e.g. bread products), black eye peas, soy and other beans, enriched cereals, dark leafy vegetables (e.g. spinach, kale).
Adverse Effects Of Severe Deficiency:: Megaloblastic anemia, red swollen tongue, altered intestinal function, birth defects.
Potential Therapeutic Uses:: Reduced neural-tube defects if taken during pregnancy, cardiovascular disease, colon cancer, breast cancer, cervical dysplasia, depression, gingivitis (taken as a mouthwash). Note: Numerous randomized controlled trials have shown that folic acid supplementation during pregnancy is associated with a reduced risk of neural-tube defects (Willett & Stampfer, 2001). In addition, substantial evidence suggests that higher intake is associated with lower risk of cardiovascular disease, colon cancer, and breast cancer (Willett & Stampfer, 2001).
Toxic Effects Of Excess:: Irritability, hostility, insomnia, GI problems.

Biotin

Functions:: Coenzyme in the synthesis of fat, glycogen and amino acids.
Selected Food Sources:: Yeast, liver, soybeans, rice, egg yolk.
Adverse Effects Of Severe Deficiency:: Rare. Can be caused by intake of raw eggs with avidin, which inactivates biotin, or long-term antibiotics.
Potential Therapeutic Uses:
Toxic Effects Of Excess:: None known to date.

Vitamin C (Ascorbic acid, Dehydroascorbic acid)

Functions:: Cofactor for reactions requiring reduced copper or iron metalloenzyme. Also functions as a protective antioxidant.
Selected Food Sources:: Guavas, citrus fruits, tomatoes, brussel sprouts, brocolli, cauliflower, strawberries.
Adverse Effects Of Severe Deficiency:: Scurvy characterized by abnormal hairs, failure of wounds to heal, defects in tooth formation, easy brusing, gingivitis, anemia.
Potential Therapeutic Uses:: Acute viral infections, atherosclerosis, hypertension, asthma, depression. Note: excess vitamin c (35 mg/d) is recommended for smokers, and should be considered by nonsmokers who are regularly exposed to tobacco.
Toxic Effects Of Excess:: GI distress, kidney stones, excess iron absorption. Note: caution recommended in particular for individuals with advanced renal disease or glucose-6-phosphate deficiency.

Boron

Functions:: No clear biological function in humans.
Selected Food Sources:: Fruits and vegetables if soil contains adequate levels.
Potential Therapeutic Uses:: Osteoarthritis
Toxic Effects Of Excess:: Nausea, vomiting, diarrhea, dermatitis, lethargy. Also reproductive and developmental effects found in animal studies.

Calcium

Functions:: Essential role in blood clotting, muscle contraction, nerve transmission, and bone and tooth formation.
Selected Food Sources:: Kelp, dairy (e.g. milk, cheese, yogurt), greens, corn tortillas with lime, nuts (e.g. almonds, brazil).
Adverse Effects Of Severe Deficiency:: Demineralization of the bone, parethesias (feeling of pins and needles), tetany, rickets. Mild to moderate deficiency common in women and vegetarians.
Potential Therapeutic Uses:: Osteoporosis, colon cancer, hypercholesterolemia, hypertriglyceridemia, prevention of preeclampsia, premenstrual syndrome. Note: Numerous double-blind studies support the use of calcium supplementation for the prevention and treatment of osteoporosis (Gaby & Wright, 2001).
Toxic Effects Of Excess:: Generally well-regulated. However, excess may result in constipation, kidney stones, hypercalcemia, milk alkali syndrome, or renal insufficiency.

Chromium

Functions:: Helps to maintain normal blood glucose levels.
Selected Food Sources:: Meats, whole wheat, wheat bran, rye bread, cereals, fresh chili, oysters.
Potential Therapeutic Uses:: Diabetes mellitus, reactive hypoglycemia, hyperlipidemia.
Toxic Effects Of Excess:: Chronic renal failure.

Copper

Functions:: Component of enzymes in iron metabolism.
Selected Food Sources:: Oysters, nuts (e.g. brazil, almonds, hazelnuts, walnuts, pecans), split peas, organ meats.
Adverse Effects Of Severe Deficiency:: Anemia, depigmentation, connective tissue and skeletal abnormalities.
Potential Therapeutic Uses:: Osteoporosis, rheumatoid arthritis (as copper bracelet).
Toxic Effects Of Excess:: GI distress, liver damage. Note: individuals with Wilson's disease, Indian childhood cirrhosis and idiopathic copper toxicosis are at increased risk of adverse effects from excess copper intake.

Iron

Functions:: Component of hemoglobin and numerous enzymes. Prevents microcytic hypochromic anemia.
Selected Food Sources:: Kelp, fruit (e.g. prunes, raisins), seeds (e.g. pumpkin, squash, sunflower), fortified breads and grains ( non-heme iron sources), meat and poultry (heme iron sources).
Adverse Effects Of Severe Deficiency:: Anemia, fatigue, tachycardia (fast heart rate), shortness of breath upon exertion.
Potential Therapeutic Uses:: Iron deficiency anemia. Note: Iron is the most common nutritional deficiency in the world. Individuals at high risk include premenopausal women and those consuming a vegetarian diet.
Toxic Effects Of Excess:: GI distress, liver disease, growth retardation (>3mg/kg/d in children who are not iron deficient). Note: Individuals who consume alcohol are at increased risk of hemosiderosis and hemachromatosis.

Magnesium

Functions:: Cofactor for enzyme systems.
Selected Food Sources:: Kelp, wheat, nuts (e.g. almonds, cashews, brazil), buckwheat, millet, rye, tofu.
Adverse Effects Of Severe Deficiency:: Neuromuscular excitability, muscle spasm, parethesias, tetany. Increased risk if diarrhea, alcoholism, or fat malabsorption.
Potential Therapeutic Uses:: Fatigue including chronic fatigue syndrome, symptoms associated with mitral valve prolapse, cardiovascular disease, asthma, migraines, premenstrual syndrome, urinary symptoms (frequency, urge incontinence, nocturia), diabetes, chronic obstructive pulmonary disease, pregnancy-related complications, hypertension, alcohol withdrawl.
Toxic Effects Of Excess:: Osmotic diarrhea. Note: Higher risk of toxicity in the elderly or others with poor renal function.

Manganese

Functions:: Involved in the formation of bone, as well as in enzymes involved in amino acid, cholesterol, and carbohydrate metabolism.
Selected Food Sources:: Nuts (e.g. pecans, Brazil, almonds), whole grains (e.g. barley, rye, wheat), split peas, spinach.
Adverse Effects Of Severe Deficiency:: Pigmentary changes in hair, dermatitis, prolonged blood clotting time.
Toxic Effects Of Excess:: Neurotoxicity Note: Because manganese in drinking water and supplements may be more bioavailable than manganese from food, caution should be taken when using manganese supplements. In addition, individuals with liver disease may be distinctly susceptible to the adverse effects of excess manganese intake.

Molybdenum

Functions:: Cofactor for enzymes involved in catabolism of sulfur amino acids, purines and pyridines.
Selected Food Sources:: Lentils, beef liver, split peas, cauliflower, green peas, wheat germ, spinach, brown rice, nuts
Adverse Effects Of Severe Deficiency:: Rare.
Toxic Effects Of Excess:: Reproductive effects, gout-like symptoms. Note: Individuals who are deficient in dietary copper intake or have some dysfunction in copper metabolism that makes them copper-deficient could be at increased risk of molybdenum toxicity.

Phosphorus

Functions:: Maintenance of pH. Storage and transfer of energy and nucleotide synthesis.
Selected Food Sources:: Milk, yogurt, ice cream, cheese, peas, meat, eggs, sodas, fast food.
Adverse Effects Of Severe Deficiency:: Rare. Hypophosphatemia can occur if starving, in diabetic ketoacidosis, patients receiving high glucose IV, or chronic use of aluminum-containing antacids.
Toxic Effects Of Excess:: Metastatic calcification, skeletal porosity, decreased calcium levels.

Selenium

Functions:: Defense against oxidative stress and regulation of thyroid hormone action.
Selected Food Sources:: Butter, seafood (e.g. smoked herring, scallops, lobster, shrimp), wheat germ, brazil nuts.
Adverse Effects Of Severe Deficiency:: Rare.
Potential Therapeutic Uses:: Cancer prevention, rheumatoid arthritis.
Toxic Effects Of Excess:: Hair and nail brittleness and loss.

Zinc

Functions:: Component of multiple enzymes and proteins. Involved in the regulation of gene expression.
Selected Food Sources:: Fresh oysters, ginger root, ground round steak, lamb chops, pecans, dry split peas, brazil nuts.
Adverse Effects Of Severe Deficiency:: Impaired growth, wound healing, dry scaly skin.
Potential Therapeutic Uses:: Acne vulgaris, colds (zinc gluconate lozenges), rheumatoid arthritis, psoriatic arthritis, gastic ulcer, macular degeneration, improved immune function in patients with cancer and aids, growth retardation, anorexia nervosa.
Toxic Effects Of Excess:: Reduced copper levels.

References

Bland, J., Costarella, L., Levin, B., Liska, D., Lukaczer, D., Schiltz, B., & Schmidt, M. (1999). Clinical Nutrition: A Functional Approach. Gig Harbor, Washington: The Institute for Functional Medicine.

Gaby, A., & Wright, J. (2001). Nutrient Therapeutics : Nutrition Seminars.

Galland, L., & Buchman, D. D. (1988). Superimmunity for Kids. New York: Dell Publishing.

Mertz, W. (2000). Three Decades of Dietary Recommendations. Nutrition Reviews, 58(10), 324-331.

Willett, W., & Stampfer, M. (2001). What vitamins should I be taking, Doctor? New England Journal of Medicine, 345(25), 1819-1824.

Additional references were used for selected food sources (Bland et al., 1999; Galland & Buchman, 1988), potential therapeutic uses (Gaby & Wright, 2001), and toxic effects (Bland et al., 1999; Willett & Stampfer, 2001). Unless otherwise indicated, therapeutic uses are preliminary findings from one or more randomized, controlled, and/or double-blind studies. For more information regarding appropriate therapeutic doses for your condition, please arrange a consultation.