Multivitamins are one of the most commonly consumed supplements in the United States, taken by at least one-third of the population (J Nutr. 2011;141(2):261-266). We are bombarded by vitamin advertising. Yet we hear so much conflicting information about them from physicians and marketers. Are they beneficial or are they detrimental? At least with multivitamins, I will attempt to address these questions with several studies.

The quick and dirty answer is that it appears to depend on the demographics utilizing them and also the content of the multivitamins themselves. So the real question becomes, who should and who should not be taking them? There are studies that have been done on men and women looking at mortality risk and chronic diseases, such as cancer and age-related macular degeneration.

Cancer benefit in men

The Physicians’ Health Study II is the only well-designed, randomized, double-blinded, placebo-controlled trial (RCT), the gold standard of studies, to date that looks at multivitamins. This study was published in JAMA and indicates that multivitamins may be beneficial for men to prevent the overall risk of cancer (JAMA online Oct. 17, 2012). The results showed that men who took a daily multivitamin were 8 percent less likely to develop cancer overall compared to the placebo group. Even though this is a modest effect, the results were statistically significant.

For those who did have cancer, there was also a trend toward reduction in cancer mortality of 12 percent, but it did not reach the threshold of statistical significance. When they analyzed cancers individually, such as prostate and colorectal cancers, there was no difference with the placebo group. The duration of the study was considered substantially long at 11 years. The demographics included 14,641 healthy male U.S. physicians who were at least 50 years old. The multivitamin used in the study was Centrum Silver.

It may be well worth the effort for men over the age of 50 to take a multivitamin, since it is an easy way to reduce the risk of a broad category of chronic diseases, including cancer that is difficult to treat in many circumstances. The authors stressed that this should not replace a good diet and exercise, which are more likely to have larger beneficial effects on cancer.

Cancer effect for postmenopausal women

In the Women’s Health Initiative, a large observational study, there was neither an increase nor a decrease in the risk of cancer with multivitamins (Arch Intern Med. 2009(3);169:294-304). Does this mean that multivitamins don’t have the same effect in women? Not necessarily.

The design of each of the two studies was different. The previous study was a randomized controlled trial comparing a group of males who took a multivitamin to those who took a placebo, whereas this study was large, but observational — participants were observed over time — and thus is not as well designed. Therefore, the Physicians’ Health Study II had a better design and more definitive results. Interestingly, the authors of this study concluded that diet, with an emphasis on fruits and vegetables, and exercise are more beneficial than a multivitamin. This conclusion is a similar to the previous study.

Mortality effect for postmenopausal women

For postmenopausal women, taking a multivitamin may be detrimental. There was an increased risk of mortality of 6 percent in women taking a multivitamin which, though modest, is still statistically significant, according to the Iowa Women’s Health Study (Arch Intern Med. 2011;171(18):1625-1633).

However, according to this study, copper was found to have a 45 percent increased risk of mortality in postmenopausal women. I described this study in more detail in my Oct. 25, 2011 article.
So why do I mention this study? To emphasize the fact that, though this is a large observational study like the Women’s Health Initiative, it is not as well designed, nor are the results as definitive as a RCT like the Physician’s Health Study II mentioned above. For instance, I could not find details about the dose of copper nor whether one standard multivitamin was used.

Regardless, there needs to be a RCT to determine if multivitamins are harmful in postmenopausal women. What I might suggest is that postmenopausal women think twice about taking the multivitamin in the Physician’s Health Study II, since it contained copper. It is important to ask your doctor whether multivitamins are appropriate for you and, if so, which one.

Age-related macular degeneration (AMD) and multivitamins

A multivitamin was shown to be beneficial in preventing the progression of AMD to advanced stage disease. This was a well-designed RCT called the AREDS study (Arch Ophthalmol. 2001;119:1417-1436). The results showed a significant 28 percent reduction in risk of worsening disease in patients between the ages of 55 and 80 years old. The study’s duration was 6.3 years. The multivitamin used contained a combination of vitamin C (500 mg), vitamin E (400 IU), beta carotene (15 mg), zinc (80 mg) and copper (2 mg).

This multivitamin combination also prevented visual acuity loss by 27 percent. These results are impressive, since advanced AMD is the leading cause of central vision loss in patients 65 years and older (Arch Ophthalmol. 1998;116(5):653-658). The study’s conclusion suggests that patients with AMD take this multivitamin combination as long as they don’t have contraindications, such as smoking. Before starting this type of multivitamin, please consult an ophthalmologist.

To review or summarize, multivitamins in the right population have substantial risk reduction effects, such as in cancer with men. However, benefits may be dependent on the population, for with postmenopausal women, multivitamins may actually increase the risk of mortality. They may also depend on the multivitamin’s composition — not all multivitamins are created equal. For example, a certain combination of elements is beneficial for macular degeneration, not just any multivitamin. Thus, one size does not fit all. And remember, a supplement is just that, it should supplement a healthy diet.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management.  For further information, go to the website www.medicalcompassmd.com and/or consult your personal physician.

In last week’s article on fall risk, I briefly mentioned cataracts as a contributor. Cataracts, the nuclear type, reduce visual acuity in an insidious process. What is important about cataracts is that they affect so many Americans, and their incidence is rising. Well, as it turns out, cataract surgery may not only reduce the risk of falls and hip fracture but, at the same time, pressure in the eye.
A diet rich in carotenoids may also prevent the occurrence of cataracts, whereas statins may have the reverse effect by increasing risk.

Cataract surgery and hip fracture

In a recent study, elderly cataract patients who underwent surgery were significantly less likely to experience a hip fracture during a year of follow-up than those who did not have surgery (JAMA. 2012;308:493-501). This was a retrospective (backward-looking) observational study, and its size was considerable, with over one million patients 65 and older. The results showed a 16 percent reduction in the risk of hip fractures overall. Those who were older — between 80 and 84 — had the most to gain, with a 28 percent reduction in hip fracture risk.

The reason for the increased fall risk and subsequent hip fracture risk in those with cataracts is the decrease in visual acuity and depth perception and the reduction in visual field that accompanies cataracts (J Am Geriatr Soc. 2009 Oct;57(10):1825-1832). As we know, hip fractures have tremendous impact on the ability of elderly patients to remain independent. Thus, avoiding them is the best strategy, since many of these patients do not regain their prior mobility.

Cataract surgery and intraocular pressure

Yet another benefit of cataract surgery is the potential reduction in intraocular pressure (IOP). Why is intraocular pressure (pressure within the eye) important? High IOP has been associated with an increased risk of glaucoma. A comparative case series (looking at those with and without cataract surgery) utilizing data from the Ocular Hypertension Treatment Study showed that those cataract patients with ocular hypertension (higher than normal pressure in the eye) who underwent cataract surgery saw an immediate reduction in IOP (Ophthalmology. 2012;119:1826-1831). This effect lasted at least three years. The removal of the cataract lowered the IOP by 16.5 percent from 23.9 mm Hg to 19.8 mm Hg. This would be close to the lower end of pressure reduction goals in glaucoma treatments, 20 to 40 percent. Therefore, cataract surgery may be synergistic with traditional glaucoma treatment.

Cataract surgery and macular degeneration risk

In a May 15, 2011 article, I wrote about a study that suggested cataract surgery increased the risk of progression of age-related macular degeneration (AMD). However, this may not be the case after all. There is conflicting evidence from a second study. Rather than increasing AMD risk, cataract surgery may uncover underlying AMD pathology that is hidden because the cataract obfuscates the view of the retina (back of the eye) (Arch Ophthalmol. 2009;127:1412-1419). The study’s strengths were the use color retinal photographs and fluorescein angiography (dye in blood vessels of eye), both very thorough approaches.

Cataract prevention with dietary carotenoids

Diet may play a significant role in prevention of cataracts. In the Women’s Health Initiative Observational Study, carotenoids, specifically lutein and zeaxanthin, seem to decrease cataract risk by 23 percent in women with high blood levels, compared to those with low blood levels (Arch Ophthalmol. 2008;126(3):354-364). In fact, those in the highest quintile (the top 20 percent) had an even more dramatic 32 percent risk reduction when compared to those in the bottom quintile (the lowest 20 percent). As the authors commented, it may not have been just lutein and zeaxanthin. There are more than 600 carotenoids, but these were the ones measured in the study. Some of the foods that are high in carotenoids include carrots, spinach, kale, apricots and mango, according to the USDA. Interestingly, half a cup of one of the first three on a daily basis will far exceed the recommended daily allowance. Thus, it takes a modest consistency in dietary carotenoids to see a reduction in risk.

Vitamin C effect

The impact of vitamin C on cataract risk may depend on the duration of daily consumption. In other words, 10 years seems to be the critical duration needed to see an effect. According to one study, those participants who took 500mg of vitamin C supplements for 10 or more years saw a 77 percent reduction in risk (Am J Clin Nutr. 1997 Oct;66(4):911-916). However, only very few women achieved this goal in the study, demonstrating how difficult it is to maintain supplementation for a 10-year period.

Those who took vitamin C for fewer than 10 years saw no effect in prevention of cataracts. In the well-designed AREDS study, a randomized controlled trial, the gold standard of studies, those who received 500 vitamin C supplements along with other supplements did not show any cataract risk reduction, compared to those who did not receive these supplements. There were 4,757 patients involved in the study with duration of 6.3 years of daily supplement consumption. Therefore, I would not rush to take vitamin C as a cataract preventative.

Statin use

Statins have both positive and negative effects, and the effect on the eyes is negative. In the Waterloo Eye Study with over 6,000 participants, those patients taking statins were at a 57 percent increased the risk of cataracts (Optom Vis Sci 2012;89:1165-1171). Diabetes patients saw an increased risk of cataracts as well. And in diabetes patients, statins seem to increase the rate at which cataracts occurred. The authors surmise that this is because higher levels of cholesterol may be needed for the development of epithelial (outer layer) cells and transparency of the lens. This process may be blocked with the use of statins. Before considering discontinuing statins, it is important to weigh the risks with the benefits.

Thus, if you have diminished vision, it may be due to cataracts. It is important to consult an ophthalmologist for cataract surgery, which can reduce your risks of falls, hip fractures and intraocular pressure. For those who do not have cataracts, a diet rich in carotenoids may significantly reduce the risk of occurrence.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management.  For further information, go to the website www.medicalcompassmd.com and/or consult your personal physician.

Falling is not a big deal when you are young, but that changes with age. Most of us have seen the commercial where the woman has fallen and can’t get up. Although this commercial has been mocked, for older adults, falling can be seriously debilitating or cause life-threatening complications. In a study, 24 percent of people over the age of 71 who had at least one fall experienced reduced quality of life (J Gerontol A Biol Sci Med Sci. 1998;53A(2):M112-M119).

In a survey, 80 percent of women said they preferred death over the risk of a “bad” hip fracture from a fall that would cause loss of independence and nursing home admission (BMJ. 2000;320(7231):341-345). Unfortunately, falls in those over age 65 are quite common, with 30 to 40 percent falling annually (Clin Geriatr Med. 2002;18(2):141-158).

Now that I have your attention, what increases the risk of falls and what can we do to prevent them? When we think of the risk, we think of making the home safer by, for example, making sure that there are no loose rugs or by providing adequate lighting. But the potential causes and prevention go far beyond these steps. The factors that increase risk include chronic diseases, such as osteoarthritis, Parkinson’s, dementia, atrial fibrillation, AMD and cataracts, as well as obesity and medications.

Medication’s impact

Many patients over the age of 65 are on blood pressure medications. It turns out that diuretics (water pills) may increase the risk of falls. In a case-control study (those with high blood pressure compared to those without), nursing home patients who newly started diuretics or had their dose increased had a significant twofold increased risk of fall, especially the first day (Pharmacoepidemiol Drug Saf. 2012 May;21(5):560-563). Loop diuretics, such as Lasix (furosemide), had the most damaging effects on risk.

The authors recommend close surveillance of elderly patients for at least two days when initiating diuretic medications to treat high blood pressure. High blood pressure can be effectively treated with lifestyle modifications, such as an antioxidant-rich diet like the DASH diet that focuses on fruit, vegetables and low saturated fat (Circulation. 2010;122:A18589).

Chronic diseases

Those with osteoarthritis (OA), especially of the knee, are more likely to fall. This makes sense, since it is more difficult to walk with OA. In the GLOW study, a prospective (forward-looking) study involving postmenopausal women, those with OA had a 27 percent greater risk of falling, compared with those who didn’t have the disease (Ann Rheum Dis. online June 23, 2012). There was also a 21 percent increased risk of fracture that occurred, as well. Over 50,000 women with a mean age of 68 participated in the study. I recommend reading my article on the treatment and prevention of OA from July 10 for more details.

Obesity effect

We tend to associate falls and fractures with elderly patients who are gaunt and frail. However, it turns out that obesity increases the risk of falls. In an observational study, there was a linear relationship between obesity and fall risk (J Am Geriatr Soc. 2012 Jan;60(1):124-129). In other words, as patients increased their BMI, their fall risk went up proportionally.

Even more interesting, the risk of fracture increased with increasing BMI associated with obesity. Just a reminder that obesity is a BMI of 30 kg/m2 or over. According to the authors, the reason for obesity’s effect is that people who are obese have difficulty with balance. In this study, underweight patients did not have an increase in falls. To treat obesity, lifestyle modifications have shown significant results. And as you decrease weight and inflammation, it also helps to treat osteoarthritis.

Vitamin D

Although it is not surprising that vitamin D helps to prevent falls, since this supplement strengthens bones and muscle in the elderly, dose and frequency are determining factors of whether it is beneficial or detrimental. In a randomized controlled trial (RCT), the gold standard of studies, annual oral doses of 500,000 IUs of vitamin D3 actually increased the risk of falls and fracture in elderly patients, 15 percent and 26 percent respectively (JAMA. 2010;303:1815-1822).

However, when given on a daily basis, vitamin D does what we have come to expect, decreases the risk of falls and fractures with the appropriate dose. In a secondary analysis of a RCT, it was the lower doses of 200 IUs, 400 IUs and 600 IUs that were ineffective, while the higher dose of 800 IUs taken daily showed a large, statistically significant 72 percent reduction in the risk of falls (J Am Geriatr Soc. 2007;55(2):234-239).

The difference between this and the previous study on vitamin D was the frequency and dosing regimen. Hence, taking vitamin D is an easy and very efficient way to reduce falls and fractures in the elderly. Many elderly are deficient in vitamin D and should have their blood levels checked. Regardless of the results, they should receive at least 800 IUs of vitamin D — if not more — on a daily basis. This will either maintain or improve blood levels of vitamin D.

Exercise

In a RCT, exercise in women with a mean age of 65 increased the bone mineral density (BMD) of the spine by 77 percent compared to a control group, which had a 66 percent reduction in BMD. In other words, the women developed stronger bones with increased exercise. The trial design looked at the exercise group, which focused on increased exercise intensity, and compared it to a control group with low-intensity and low-frequency exercise. This translated into a significant reduction in fall risk for the exercise group.

We should be aware of the risk factors for falls. Complications from falls are the leading cause of mortality in older adults. This is not something to be taken lightly. Fortunately, many of the risk factors are modifiable with lifestyle changes, including a nutrient-dense diet, vitamin D supplementation and increased exercise.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management.  For further information, go to the website www.medicalcompassmd.com and/or consult your personal physician.