Nutritional supplements: the snacks of the Pharma industry

I had a very interesting journey to my clinic yesterday. I was accompanied by a gentleman who had a medical issue which he wanted to discuss with me.  I usually nap during this ride, but yesterday’s conversation was interesting. As part of the discussion about his health issue, I had the opportunity to look at his prescription. It was a long one with 7 medicines listed one below the other in an uncharacteristic clean and readable handwriting.  Of the 7, 3 were pertinent to his medical condition and the other four were nutritional supplements of various kinds. One was a multi vitamin, one contained various fatty acids including omega three, one contained some amino acids and Vitamin B12, and another one had some herbal supplements with whose names I am not familiar. When I see such prescriptions, I do not know what to say. I stay silent.  But the problem arises when the person asks me for my opinion on the tablets. This gentleman asked me that exact question. I thought a lot, hmmm..ed and uhhh..ed a bit and said, “You are taking some tablets which do not cause harm but are also not essential for your health”. He replied that he is spending around 1000 rupees each month just on these tablets. I was quite certain that the 4 supplements had cost him more than the three important pills that he was taking for his health condition. When I told him that the nutritional supplements are not essential and the research evidence to support their use in the disease condition that he has is very flaky, I could see confusion and disbelief in his eyes. He did not say anything after that, but I am sure he was going through a lot of confusion regarding why he is spending so much money on some medicines which are not of much use to him. 

He got down in a place just before where I had to go and we said out goodbyes. After that, I got thinking if what I did was right. Firstly, I haven’t read up recently about dietary supplements and role of vitamin supplementation in health. So the information I provided him was a few years old. I was asking myself whether I should I have read up more before I told him that. Secondly, I was not in a therapeutic doctor-patient relationship with this man. I am not his doctor. He spoke very highly of his physician who wrote all these medicines for him. Did I do wrong by planting the seeds of doubts in this man’s mind about the physician whom he seemed to trust a lot? Was it worth it, given that the supplements were not harmful? Maybe I should have just said, “please check with your doctor whether you need all these supplements. Tell him about your cost concerns. Have a discussion with him.” Thirdly, would the doctor entertain such a discussion? I felt bad that I got carried away because I was having company during the lengthy journey, and had an opportunity to give a ‘lecture’ about things I ‘knew’! 

 

I have been thinking about dietary supplements since that time. This is not the first time I am seeing a prescription that has more supplements in it than active medicines to help correct the disease process. I also have colleagues who routinely supplement Vitamin tablets and injections to patients.  The incessant requests, and often demands from patients, for “sattu maathirai” / “sattu oosi” (Tamil for tablets and injections for strength) are familiar for all doctors. Nutritional supplement pills and injections have become the cultural motifs of healing. I know both doctors and patients who criticize prescriptions that do not contain supplements. Once, I had a lawyer couple in my clinic with a good practice and from an affluent background. I wrote a prescription for knee arthritis for the wife. They went to the pharmacy and the husband rushed back with the prescription and said, “Doctor, I think by mistake you left out the vitamin tablet.” They saw it as a mistake! 

 

I came home last night and read up on the current updates on nutritional supplements. I spent a few hours going through literature from abroad and from India and I thought it is important to write about this. There seems to be no role for routine nutritional supplementation for healthy adults, or even for those with well controlled chronic conditions like diabetes or hypertension. Large scale studies have consistently shown that there is no difference in any outcomes such as diabetes, hypertension, heart attacks, heart failure, cancers or any chronic conditions between people who received these supplements and those who did not.

 

Doctors prescribe Vitamin D for people with bone and joint problems. It is common to see calcium and vitamin D being prescribed for arthritis of joints. Vitamin D does improve bone health and prevents risk of falls. But they have no role in pain reduction in uncomplicated joint pain. It is useful to supplement calcium and vitamin D for women after menopause and those with some forms of bone disorders. But there is no role for it to reduce joint pains or body pains. Master health check up protocols in many private and government hospitals today routinely test for Vitamin D levels in the blood and correct it if it is low. There is no evidence for any benefit of this testing either. 

 

Vitamin C is prescribed by many doctors for faster recovery from fevers, colds and infections. There is theoretical benefit that this may work. But studies showed that if you give Vitamin C the cold gets cured in 7 days and without it in one week! Jokes apart, Vitamin C is not a very useful one for faster recovery from infections. Vitamin A, beta carotene, Vitamin C, Vitamin E have all been described as anti-oxidants. There has been a lot of noise about anti-oxidant supplements to prevent cancers and heart diseases. Large scale studies have shown that these are useless. They do not prevent cancer or heart disease. 

 

The most popular vitamin supplementation in both the private and public sector practice in India is Vitamin B complex. Becosules, and Neurobion Forte, are the most prescribed brands. They contain several of the B complex vitamins. I know practitioners who vouch for its effectiveness in a wide variety of clinical conditions. Some routinely prescribe it for body aches and pains. When I was an intern in a government medical college, I was taught about this popular “KKK Syndrome”. The KKK is brief for “Kai Kaal Kodaichal” (aches and pains in the hands and legs). I was taught to prescribe BCT (B Complex Tablet) for this condition. I believed that to be a medical treatment till after medical school when I realized that it is only a placebo. I worked briefly in the psychiatry department of CMC Vellore as part of my training and that was when I understood the importance of medical unexplained somatic symptoms (KKK Syndrome) and how psychological conflicts can manifest as bodily symptoms. But BCT is ubiquitous in clinical prescriptions, especially in primary care. There have been instances in our pharmacy when we faced delays in the supply chain of our drugs, the only medicine which we are always worried about is BCT, because it would always get exhausted even when we have buffer stock of other fast-moving drugs. Vitamin B complex is useful in some clinical conditions. Folate, one of the B complex vitamins, must be supplemented during pregnancy as it prevents an anomaly in the baby called neural tube defect. Vegetarians and vegans tend to have diets deficient in Vitamin B12. So they may require routine supplementation. There is also a recommendation to routinely check Vitamin B 12 blood levels among vegetarians, vegan, elderly and those with ulcer disease in their stomach. If the Vitamin B12 blood levels are low, they will require supplementation. But there is no role for Vitamin B complex in unexplained aches and pain, tiredness, fatigue etc. Especially in people like the gentleman whom I was talking to or the lawyer couple, who have a fairly good quality diet, who consume fruits and vegetables regularly, there is no benefit from such Vitamin B complex supplementation.

 

For patients at risk for vitamin deficiency, such as those with alcohol use disorder, poor-quality diets with low fruit and vegetable intake (which is true of many people in a low resource setting), malabsorption, a history of weight loss bariatric surgery, or some genetic problems of metabolism, as well as those being treated with hemodialysis or parenteral nutrition, multivitamin supplementation is essential. But in otherwise healthy people who have adequate dietary intake and no risk factors for inadequate vitamin status, guidelines world over suggest not taking multivitamin supplementation because of insufficient evidence of benefit. One interesting clause added by these guidelines caught my eye and confirmed my belief. I quote it here, “However, we also do not strongly discourage patients who wish to take multivitamins due to their own belief systems, as long as there is no absolute contraindication for an individual patient.” 

 

After reading all this and thinking about the travel conversation, I thought that for people like that gentleman, it is a matter of relative priority and what that man believes he needs for getting better. But how many of these beliefs are thrust by market forces with a profit motive, and how many of these are uninfluenced beliefs? If a doctor plants several multivitamins in a naïve patient’s prescription and gives them reason to believe that it will make them better, is that a genuine belief system? If I routinely pump Injection Neurobion into the body of an uninformed patient and make them believe that is what is giving them vital force to function, am I not reinforcing a false belief? After planting such misinformed beliefs and false notions, am I not hiding behind “the patient can do what they believe is right”? The nutritional supplements are to the pharma industry as snacks are to the food industry. Nice to have, but not necessary! I slept peacefully with the reassurance that my practice of not filling patients’ prescriptions with supplements is not outdated or misinformed!