Column: What Supplements Should You Take?

[Column written by Dr. Annabel Fountain]

Every year, $35 billion is spent by Americans on vitamins, minerals, botanicals and other supplements. Is this multi-billion dollar industry selling snake oil? Thank you again to Olivia Benyak-Pitcher for assisting me with this article. Olivia is a pharmacist who owns and operates My Pharmacy in Charities House on Point Finger Road.

As discussed in part one of this two-part article, all components of the immune system [barriers, cells, healthy bacteria and the microbiome, processes and chemicals] work together to fight disease.

One of the problems when it comes to making recommendations about herbs and supplements is that there aren’t a lot of good studies. The pharmaceutical industry wants us all to take medicines and doesn’t invest in research into more natural remedies. This means that the evidence to support use of vitamins and minerals is often not as robust as that produced to support use of drugs.

Be careful when you’re buying supplements, especially if ordering them online. Because supplements are not categorized as drugs or food, they’re often not regulated by the Food and Drug Administration [FDA] in the U.S. Unless the bottle carries the USP seal or other varification that provides standards, a supplement may not be what it says it is or do what it says it does.

There are certain vitamins, minerals, herbs, and other substances that have been shown to improve immune response and potentially protect against illness. Those which have been best studied are: Vitamin D [discussed in part 1 of this article], Vitamin C, zinc, probiotics and B vitamins.

What’s really important to understand about most of the studies is that only those who were deficient at baseline saw a significant improvement in outcomes when given a supplement.

Zinc is the second most abundant trace element in the body after iron. It is a component of DNA. It is mostly found in animal proteins but can also be found in grains. Zinc has been shown to protect against respiratory tract infections and reduce the duration of the common cold. Up to 30% of older people have zinc deficiency. Most of the large studies on zinc deficiency have been done in the developing world.

Pharmacist’s advice: As long as you don’t take more than 40mg of zinc per day, taking zinc long term is usually safe. Different forms of zinc have diverse ways of affecting your body. To boost your immune system, a good, cost-effective form is zinc-gluconate which is often used in cold remedies. Zinc picolinate is more easily absorbed but is a little bit more expensive. Zinc supplements are best taken on an empty stomach [at least 1 hour before or 2 hours after meals].

Caution: Taking zinc for an extended period of time or in a high dose [more than 30mg pure or elemental zinc a day], can lead to depletion of copper and iron. Zinc supplements are relatively safe taken along with other medications, except for certain antibiotics such as ciprofloxacin or minocycline. The diuretic amiloride can increase the amount of zinc in the body causing overdose of zinc if zinc is taken at the same time.

Vitamin C has been studied quite well. A Cochrane review showed that regularly taking vitamin C supplements reduced common cold occurrence in individuals under high physical stress, including marathon runners and soldiers, by up to 50%. In 2017 and 2018, Journals of Critical Care showed that high dose intravenous vitamin C treatment significantly improved symptoms in people with severe infections, including sepsis and acute respiratory distress syndrome [ARDS] resulting from viral infections. This is the complication that occurs in COVID-19 and some centres are using IV vitamin C in severe COVID-19 infection.

Vitamin C deficiency used to be called scurvy and the use of citrus fruits in British sailors to prevent it is why the English were called Limeys!

Pharmacist’s advice: The recommended daily dose of Vitamin C, also known as ascorbic acid, is about 75-90 mg. Vitamin C is water-soluble, and readily available in many natural food sources. Any excess is not stored but excreted in the urine. If we decide to supplement, a 1000mg sustained release preparation is sufficient. Calcium ascorbate well-absorbed and gentle on the stomach.

Caution: Under normal circumstances, the maximum daily recommended amount for vitamin C is 2,000 mg. People with chronic liver or kidney conditions, gout, or a history of calcium-oxalate kidney stones should take no more than 1000 mg a day.

Vitamin C is quite safe to use with other medications, but high doses may decrease the effectiveness of warfarin and can also decrease how quickly the body breaks down acetaminophen [Tylenol] and aspirin.

Pro-biotics are live microorganisms that may be able to help prevent and treat some illnesses. They come either as foods that naturally contain microorganisisms [live yoghurt, kombucha, kimchi], or supplement pills that contain live active bacteria and yeast.

We are still learning about the microbiome but research is showing that certain combinations of microorganisms in the gut are associated with more or less disease. There are even studies that look at the effect of faecal transplants [yes, you heard that right!] where faecal bacteria and other microbes are transferred from a healthy individual into another individual. This has shown to be effective in treating C diff [Clostridium difficiles] infection and may be more effective that antibiotics. Ongoing studies are looking at transferring gut bacteria from slim people to obese individuals to see if the overweight subjects lose weight.

This is a fascinating area of developing research. It is postulated that manipulation of the components of our microbiome could prevent disease, enhance immune function, increase energy, improve memory, relieve the symptoms of irritable bowel syndrome and speed recovery of an upset stomach.

The way they work to improve health may be by interactions with other gut flora, production of certain organic acids such as lactic acid, and synthesis of vitamin K and most of the water‐soluble B vitamins [biotin, cobalamin, folates, nicotinic acid, pantothenic acid, pyridoxine, riboflavin, and thiamine] in humans.

Pharmacist’s advice: The gut microbiome and its impact on the health of the host is a relatively new area of scientific research. We don’t know if the intake of only a few specific artificially selected strains has any significant long-term impact on our health, although it is agreed probiotic food has many health benefits. I recommend that you try to support your microbiome with fermented food, plenty of vegetables and regular exercise.

If you decide to take probiotics in a pill form chose one that has Lactobacillus Rhamnosus Gg, Lactobacillus Paracasei and Lactobacillus Acidophilus. Take your probiotics shortly before food.

Caution: Although probiotics are generally safe to use, it is recommended to avoid probiotics in short-gut syndrome [use with caution]; in severe immunocompromised conditions and in small intestinal bacterial overgrowth [SIBO].

Others supplements which are less well studied are: Black elderberry, echinacea, medicinal mushrooms, Astralagus, selenium, garlic, Andrographis, Garlic, licorice, pelargonium sidoides, curcumin [turmeric], propolis. Dr Pitcher has found Elderberry and Echinacea to be particularly helpful.

Elderberry: is the dark purple berry from the European elder tree. It contains antioxidants, it is a good source of vitamin C and fibre so is generally nutritious. It also may support heart health by reducing blood cholesterol and inflammation.

Certain phytochemicals in the elderberry inhibit the early stages of a viral infection by blocking key viral proteins responsible for both the viral attachment and entry into the host cells. It is also effective at inhibiting viral propagation at later stages of influenza [flu] when the cells are already infected with the virus.

Most of the research has only been conducted in a lab setting and not tested extensively in humans. Further large-scale studies are still needed.

How to use it: Elderberry juice syrup, lozenges or capsules containing 175 mg of elderberry extract taken within 48 hours of the first symptoms seem to relieve flu symptoms and reduce the length of time the flu lasts. Most products recommend taking it four times daily for 3-5 days.

Relief seems to occur within 2 to 4 days of treatment for most people. Continuous use longer than 12 weeks is not recommended because of the lack of data on impact on immune system on the long term.

Caution: Consuming the raw berries, the seed, the bark and the leaf can be unsafe because the plant can contain a substance that releases cyanide in some circumstances. However, commercial preparations and cooked berries do not contain cyanide and only when overdosed can cause mild gastrointestinal side effects.

Elderberry might cause the immune system to become more active, and this could increase the symptoms of autoimmune diseases so avoid elderberry if you have one of these conditions. For the same reason, it may decrease the effectiveness of immunosuppressant medications.

Make sure the product you choose contains standardized elderberry juice. When given to children care should be taken regarding the proper dosing.

Echinacea: is a group of flowering plants used worldwide as a popular herbal remedy. They’re linked to many health benefits, such as reduced inflammation, improved immunity, lower blood sugar levels, relief from migraines and alleviating anxiety.

A series of experiments have demonstrated that Echinacea extract activates the white blood cells of the immune system. Taking Echinacea may lower the risk of developing colds by more than 50% and shorten the duration of colds by one and a half days. Again, most studies are limited, especially in humans.

How to take it: Echinacea products are highly variable, which makes it hard to set a standard recommended dosage. The dosages vary with the form of echinacea you’re using. Try to purchase echinacea products from trusted brands and follow the instructions on the label.

Although it is considered safe and well tolerated, it is worth keeping in mind that these recommendations are for short-term use [8 weeks] as Echinacea’s long-term effects on the body are still relatively unknown.

Caution: As Echinacea appears to stimulate the immune system, people with autoimmune disorders or people taking immunosuppressive drugs should avoid it or consult their doctors before taking it. For similar reasons people on regular medications that modulate the immune system [like corticosteroids] should avoid taking Echinacea preparations at the same time.

We hope that this two-part article has helped you to better understand the complexities of your immune system. Good nutrition and physical activity are most important for maintaining your health but there are some supplements that can help so we shared those that have the best evidence to support their use.

- Dr Annabel Fountain is a Bermudian physician who is board certified in Endocrinology, Diabetes and Internal Medicine. In 2018, Dr Fountain was awarded Fellowship of the Royal College of Physicians. She is the Owner/Medical Director of Fountain Medical Group. Dr Fountain offers the following Endocrinology services, Diabetes Prevention, Education and Management, Thyroid Disease – Hypothyroidism, Hyperthyroidism, Nodules and Cancer, Obesity and Weight management, Disorders of Calcium and Bone including Osteoporosis, Hypertension and Cholesterol disorders, Adrenal and Pituitary Disease, Infertility and Menopause, Other glandular disorders. Dr Fountain is available for telemedicine appointments during the COVID-19 isolation recommendations. Please call your primary care physician for a referral or 232-2027 to make an appointment.

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