On February 3rd, the New York Times released an article, New York Attorney General Targets Supplements at Major Retailers, in which they found that four of five herbal supplements did not contain the herb they purported to. The supplements came from four national retailers: GNC’s Herbal Plus, Target’s Up & Up, Walgreens’ Finest Nutrition, and Walmart’s Spring Valley. Even most of the garlic supplements didn’t contain garlic – a component that would seem rather unchallenging to obtain.

A reader asked me to weigh in on whether this has any ramifications for the supplements vegans are recommended.

In my recent Interview with Talk to a Doc, I talked about how vegans do not necessarily need to take supplement pills since there are other ways to obtain recommended nutrients. That said, it’s often easier and more convenient, and some might argue even more American to just take a pill!

So what does this NY Attorney General report mean for those of us taking supplements? In most cases, the controversy over what’s in supplements is about herbal supplements that are supposed to have medicinal effects rather than for vitamins and minerals. Even so, I’d be hesitant to rely on the exposed companies even for vitamins and minerals.

You can trust that supplements with the U.S. Pharmacopeia’s USP Verified symbol have what the label indicates. But getting the USP Verified symbol is expensive and so most smaller companies don’t go through the process.

While I can’t know for sure, I have no reason to doubt the supplement brands I generally take (Whole Foods, Trader Joe’s) or the supplements popular in the vegan community such as VegLife, Deva, Vitashine, or Opti3.

I recently did a 30-minute interview with Katya Trent of Wellness with Katya: Talk To A Doc.

We mainly discussed whether vegans need to take supplements.

Towards the end of the interview, I said that vegans can get all the nutrients they need without taking supplements. I should have clarified that this is based on three assumptions:

1. You’re getting vitamin B12 through fortified foods.

2. You’re getting enough sunlight to make adequate vitamin D or that you’re eating UV-treated mushrooms with large amounts of vitamin D.

3. You’re getting enough short chain omega-3 fatty acids from plant foods and that your body is converting enough to the long chain DHA. The jury is still out on whether vegans, especially older vegans, need a direct source of DHA (more info).

If you listen, I hope you enjoy it!

After posting the article Cadmium Levels in Vegans, Zinc Supplements and Alzheimer’s Disease, Ginny Messina let me know that there is a concern about cadmium contamination of zinc supplements.

I researched the issue and added the following section to VeganHealth.org’s article Cadmium:

In 2001, Krone et al tested six zinc supplements from Seattle area health food stores to see if they contained cadmium (1). According to the authors, “Because the chemical properties of [zinc] and cadmium (Cd) are so similar, these two elements invariably occur together in nature.”

They found that the single zinc supplements had very low levels of cadmium whereas the multi-mineral supplements had enough that taking the RDA of zinc would provide up to 2 µg of cadmium (20% of the daily limit recommended by the US Federal Drug Administration (FDA)). It also happens that three of the supplements with low levels of cadmium were in the form of zinc gluconate whereas none of the multi-mineral preparations were the gluconate form. So, it could be that zinc gluconate is unlikely to have much cadmium or that single zinc supplements are unlikely.

According to their website, the supplement manufacturer Kirkman, from Oregon, does a rigorous job testing their supplements for contamination of cadmium and other impurities (more info). They also have an article on their site, Cadmium: A Serious Heavy Metal and Topic. They ship outside the United States.

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References

1. Krone CA, Wyse EJ, Ely JT. Cadmium in zinc-containing mineral supplements. Int J Food Sci Nutr. 2001 Jul;52(4):379-82. | link

In 2010, I wrote about a meta-analysis on calcium supplements and cardiovascular disease, Calcium Supplements: Are They Safe? The association with heart disease was limited to people who started out with a dietary calcium intake of 700 mg/day or more (not including the supplements). Then in 2011, I noted a study on supplement use in older women that found a link between calcium supplements and a lower risk of mortality (Supplement Safety).

Since I recommend that vegans get their calcium levels up to at least 700 mg and preferably the DRI (1,000 mg for adults under 50; 1,200 mg for adults over 50) by whatever means necessary (greens, fortified foods, or supplements), I try to keep track of this research as closely as I can. In February, results from two different studies looking at calcium supplements and cardiovascular disease were reported.

One study was from the USA and followed people aged 50 to 71 at baseline for 12 years (1). No association between cardiovascular disease deaths and calcium intake was found for women. For men, calcium supplements of 400 to 1,000 mg/day was associated with an increased risk of cardiovascular death, but was just barely statistically significant. But supplements of more than 1,000 mg/day were associated with a highly significant increase in cardiovascular mortality:

When the numbers were stratified for smoking, there was a strong trend towards the risk being mainly in current smokers. The average user of supplements for men had a dietary calcium intake (not including supplements) of 815 mg. So once you figure in another 400 to 1,000+ mg of supplemental calcium, their intakes were anywhere from the DRI to about 50% higher than the DRI.

The second study was from Sweden, on older women (2). All-cause mortality for dietary calcium (not including supplements) was a U-shaped curve, with both low calcium and high calcium associated with an increase in mortality:

The findings were similar, but even stronger for cardiovascular disease, and were also very similar for dietary plus supplemental calcium.

One thing to consider for this Swedish study is that 1,400 mg of non-supplemental calcium would indicate a pretty high dairy intake. If you assume 300 mg per serving of dairy, that’s at least 3 servings of dairy per day (on top of the calcium they might be getting from other foods). The results did not adjust for dairy product intake so it’s possible that dairy of 3 servings (or more) per day could have caused the increase in cardiovascular deaths.

While it’s not yet clear what is going on here, my conclusion remains that vegans should aim for at least 700 to 1,000 mg/d (or 700 to 1,200 mg/d if over 50) from foods or supplements, but that you should not go much above that.

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References

1. Xiao Q, Murphy RA, Houston DK, Harris TB, Chow W, Park Y. Dietary and Supplemental Calcium Intake and Cardiovascular Disease Mortality: The National Institutes of Health–AARP Diet and Health Study. JAMA Intern Med. 2013;():1-8. | link

2. Michaëlsson K, Melhus H, Warensjö Lemming E, Wolk A, Byberg L. Long term
calcium intake and rates of all cause and cardiovascular mortality: community
based prospective longitudinal cohort study. BMJ. 2013 Feb 12;346:f228. | link

Question:

What B12 Supplement Should I Take?

Answer:

I get this question all the time, so I finally decided to write up a blog post to point people to.

Cyanocobalamin

Cyanocobalamin is the most common form of B12 supplement and is the form found in fortified foods. It doesn’t occur much in nature, but it is the most stable form of vitamin B12, and the cheapest. It has been the most studied form and has consistently been shown to be effective. Unless there are extenuating circumstances, I recommend that people take cyanocobalamin as their B12 supplement.

Cyanocobalamin contains a molecule of cyanide, but the amount of cyanide in cyanocobalamin supplements is so small as to be physiologically insignificant (more info).

Some people have cyanide metabolism defects, and they should not take cyanocobalamin. If you are asking yourself right now if you might be one of those people, you can assume the chances are close to zero.

People with cyanide poisoning should not take cyanocobalamin. If you have not previously suspected that you might have cyanide poisoning, then you can assume you don’t have it.

People with chronic kidney problems should probably take a non-cyanocobalamin form of B12 (more info).

Finally, cigarette smokers might want to take a non-cyanocobalamin form of vitamin B12 as they can build up cyanide in their system. This is theoretical – I have never come across a vegan cigarette smoker who reported vitamin B12 deficiency based on taking cyanocobalamin and the Institute of Medicine has concluded that “The effect of smoking on the B12 requirement thus appears to be negligible (1).” (More info.)

Methylcobalamin & Adenosylcobalamin

Methylcobalamin is one of the two co-enzyme forms of vitamin B12, the other being adenosylcobalamin (known by many other names, including “dibencozide”). When I first got into the B12 issue, dibencozide was all the rage, now it’s methylcobalamin for some reason. The two forms have different functions in the body and both are necessary (more info).

Methylcobalamin is promoted by some alternative health practitioners and the supplement industry as superior to cyanocobalamin, primarily because it is a co-enzyme form of vitamin B12.

Based on many studies and case reports in the scientific literature in which cyanocobalamin has successfully cured vitamin B12 deficiency, it appears that the body can convert cyanocobalamin into methylcobalamin without any problem. The body also has to convert methylcobalamin or cyanocobalamin into adenosylcobalamin for B12 to carry out all of its functions. (A fourth form of vitamin B12, hydroxocobalamin, is the form typically found in animal products and B12 injections; it must also be converted into the co-enzyme forms.)

But is there any harm in taking methylcobalamin over cyanocobalamin? Probably not, but methylcobalamin is thought not to be as stable as cyanocobalamin and therefore higher doses are recommended, a minimum of 1,000 µg per day. Recommendations for cyanocobalamin are much lower (more info).

Some people with chronic fatigue report getting more relief from adenosylcobalamin than either methylcobalamin or cyanocobalamin (more info), while other people report feeling better only when taking both co-enzyme forms (adenosyl- and methyl-).

Cyanocobalamin supplements are ubiquitous, cheap, and well-studied, while methyl and adenosyl are much more of an unknown entity. Unless you have a good reason to be using them, I recommend cyanocobalamin.

Living Food Vitamin B12

Some companies claim to have a natural, living, plant, or raw source of vitamin B12. The B12 can come from seaweed or other unstated sources. Unless a label lists the source of vitamin B12 as cyanocobalamin, methylcobalamin, adenosylcobalamin, or hydroxocobalamin, I would not rely on it.

Specific Brands of Vitamin B12

I do not have recommendations regarding any specific brands of vitamin B12 supplements. As far as cyanocobalamin goes, I assume all sublingual or chewable tablets to be effective. I do not have an opinion on B12 skin patches or sprays.

As far as methylcobalamin supplements, as I stated above, I’m not as confident about them, and I have no opinion on any specific brand name.

Are B12 Supplements Vegan?

Yes. (More info.)

References

1. Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. Washington, DC: National Academy Press; 2000.

Question (edited for clarity):

It is always explicitly recommended that Vitamin B12 tablets should be dissolved under the tongue (aka “sublingual”). I wonder if that is also true for other minerals and vitamins of special concern to vegetarians, such as iron and vitamin D2? If not, why is this the case with vitamin B12?

Answer:

I have always told people who asked about sublingual B12 that there was no evidence, of which I was aware, that sublingual was any better than just chewing. Despite this, until today, I had been recommending sublingual in my Step 1 Recommendations, which are geared towards people who have not recently had a reliable source of B12. I have recommended sublingual as a precaution just in case it was more effective. In recent years, I have been more diligent about trying not to recommend anything just to be prudent unless specifically stating that is why I am recommending it. This suggestion for sublingual (versus just oral) was a remnant left over from previous times.

Still, I did not know whether sublingual was better than oral until I got this question and decided to check in on the research. As it turned out, there was a study as long ago as 2003. Yikes! I guess I hadn’t checked in quite a long time.

The 2003 study compared 500 µg per day via the sublingual and oral routes. The results were that sublingual was absolutely no better than oral B12 at raising vitamin B12 levels or improving B12 activity (as measured by homocysteine and methylmalonic acid levels). The report did not specifically state whether the tablets were chewed or not (I assume that they were swallowed whole). So now I’m not sure I should even suggest that the tablets be chewed, but because other studies have shown a benefit to chewing, I will leave that in my recommendations.

As for other vitamins and minerals, I have never checked into the research on taking them via the sublingual route, but my sense is that there would not be any benefit. It might even be dangerous to try this with iron given that it is a pro-oxidant and probably should not be held in constant contact with your tissues.

Reference

Sharabi A, Cohen E, Sulkes J, Garty M. Replacement therapy for vitamin B12 deficiency: comparison between the sublingual and oral route. Br J Clin Pharmacol. 2003 Dec;56(6):635-8. | link

Harvard School of Public Health: Nutrition Insurance Policy: A Daily Multivitamin

From the article:

“Looking at all the evidence—from epidemiological studies on diet and health, to biochemical studies on the minute mechanisms of disease—the potential health benefits of taking a standard daily multivitamin appear to outweigh the potential risks for most people.”

They reference the Iowa Women’s Health Study which I blogged about on October 11.

(Note: I am not able to recommend or assess any particular brand of multivitamin.)

A new report on the safety of supplement use in older women has been released from the Iowa Women’s Health Study (1).

The study tracked women 55 to 69 years old, almost entirely white, for an average of 19 years. After adjusting for age, education, place of residence, diabetes, high blood pressure, body mass index, waist to hip ratio, hormone replacement therapy, physical activity, smoking, energy, alcohol, saturated fatty acids, whole grain products, fruits, and vegetables, they found the following:

– Multivitamins were associated with a 6% increase in mortality (1.06, 1.02-1.10).

– Iron (1.10, 1.03-1.17) and copper (1.45, 1.20-1.75) were associated with an increased risk for mortality.

– Vitamin B6 (1.10, 1.01-1.21), folic acid (1.15, 1.00-1.32), magnesium (1.08 1.01-1.15), and zinc (1.08, 1.01-1.15), were all associated with a borderline statistically significant increased risk of mortality.

– Vitamin A, beta-carotene, vitamin B complex, vitamin C, vitamin D, vitamin E, and selenium supplements were not associated with an increase in mortality.

– Calcium supplements were associated with a decreased risk of mortality (0.91, 0.88-0.94).

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There was not a lot of data on amounts, except for iron and calcium. The groups with an increased risk of mortality from iron were taking fairly hefty amounts of iron, with the biggest risks associated with 50 to > 400 mg/day! That is a lot of iron ‒ the RDA for women 51 to 70 years old is 8 mg.

The levels of calcium associated with the reduced risk of mortality were basically anything less than 1,300 mg per day.

The authors summed up their findings with, “In conclusion, in this large prospective cohort of older women, we found that most dietary supplements were unrelated to total mortality rate. However, several commonly used dietary vitamin and mineral supplements were associated with increased total mortality rate, most strongly supplemental iron; calcium showed some evidence of lower risk.”

This study is just one piece to a very large puzzle, and I would not take it to mean anything conclusive. If you look at the entire body of research, results regarding supplements have been quite mixed and this tends to make me think they do not have a strong effect on mortality one way or the other, although there is still more to be learned.

One thing I would take away from this study is that it is further evidence that people should not take iron supplements, especially more than the RDA, unless under the guidance of a physician.

As for vegans, studying supplements in terms of their ability to decrease or increase mortality in a population that does not have acute deficiencies is not the same as for people whose diets are significantly lower than the DRIs for particular nutrients. This study would not give me any reason to change my recommendations.

Reference

1. Mursu J, Robien K, Harnack LJ, Park K, Jacobs DR. Dietary Supplements and Mortality Rate in Older Women: The Iowa Women’s Health Study. Arch Intern Med. 2011;171(18):1625-1633.   |   Link

Ginny has once again set the record straight with her article, Vitamins B12 and D: Monitoring versus Supplementing.

I would merely add that if you are going to the doctor to get tests done anyway, it wouldn’t hurt to add vitamin D to the panel just to know where it is.

Bill Clinton, are you listening?!

Happy New Year!

I have a couple of quick things which might be of interest:

1. After reading that QuasiVegan was taking taurine and feeling great, I decided to do some experimenting on myself. I have been taking 1,000 mg of taurine per day for a week. I don’t feel any different – not that I was feeling bad to begin with, but you never know.

A few years ago I tried a similar experiment with carnitine and I noticed myself feeling slightly worse. Also a few years ago, I tried taking methylcobalamin (a form of vitamin B12) rather than cyanocobalamin and felt nothing after going through an entire bottle over the course of a few weeks.

2. Over the holidays I talked to another vegan who was feeling very fatigued, got her D levels tested and they were low, started taking vitamin D, and now feels much better.

I’m not suggesting that how one feels is the best way to determine if taking a supplement is healthy or not, but it might be able to indicate if you had a severe deficiency.