In a recent trial, placebo treatments were used in patients with persistent arm pain.1 There was a statistically significant reduction in pain for those taking the placebo pill. Subjects were told they would get either a placebo pill or an anti-depressant. Those given the pills were told about the potential side effects of anti-depressants and, not surprisingly, many experienced the side effects even though they were on the placebo. Subjects on placebo suffered from various symptoms including drowsiness, dry mouth, restlessness, dizziness, headaches, nightmares and others.
As a clinician, what you need to embrace is the fact that what you tell a patient about the expected outcomes of a given treatment, such as nutritional supplements, is likely to be an outcome that many patients will experience. In other words, if you give a patient a placebo detoxification supplement, and tell the patient they may experience a well-described detox reaction, many patients will experience the reaction even though they took nothing (a placebo). Clearly, what you tell a patient is part of their treatment program…the evidence is very supportive of this statement.
If you tell a patient that you found the most magical of supplements, and you give it to the appropriate patients, it is likely that many will experience what you say…at least in the short run. The placebo is now known to be a physiologic response; it can be measured with PET scans and other devices.2
So, clearly, we should view the placebo as a real thing. To me, it makes the most sense to couple the placebo with supplements that also have a real effect. Ask yourself the following question: Are my supplements real, or am I just helping to invoke a placebo response? This is a very real and important question to ask.
I want my supplements to have a real effect that is separate from the placebo, and we have evidence regarding several supplements that offer physiological benefits. However, for most supplements, there is absolutely no evidence that they do what is claimed by the supplying company. The most notorious supplements that fall into this category are detoxifying supplements. There is no way to measure toxicity, and so there is no way to determine if one is toxic and then less toxic…case closed. There is no debate on this one, just a lot of fluff.
If you are looking for a simple supplement program that is likely to benefit all patients, I suggest you utilize as your foundation a multivitamin/mineral, magnesium, and fish oil. Magnesium and fish oil are probably the best supported by evidence, from an epidemiological, experimental, and clinical perspective. And research is mounting which suggests that we should all take multivitamins. Recently, I wrote two chapters that review some of this evidence from the perspective of rehabilitation and soft tissue injuries, in which I explain that disease is essentially caused by inadequate adenosine triphosphate (ATP) synthesis, increased free radicals, and chronic eicosanoid and cytokine-mediated inflammation.3,4
Magnesium
Magnesium is needed for over 300 metabolic reactions, such as ATP synthesis, DNA repair, and antioxidant metabolism. Additionally, muscle tension increases with magnesium deficiency, and all components of connective tissue require magnesium. A deficiency of magnesium has been associated with an increase in the expression of enzymes involved in the inflammatory process such as phospholipase A2 (PLA2), cyclo-oxygenase (COX), and lypooxygenase (LOX), and an increase in the release of pro-inflammatory cytokines. Perhaps this is why magnesium deficiency is associated with diverse clinical manifestations, including sudden death, accelerated atherosclerosis, cardiovascular disease, hypertension, stroke, renal tubular disorders, osteoporosis, diabetes mellitus, headaches, asthma, preeclampsia, eclampsia, neurologic and even psychiatric conditions. Recent work by researchers from the Centers of Disease Control in Atlanta suggest that all adult Americans do not achieve the recommended level of daily magnesium. I would suggest taking a multivitamin mineral and about 400 mg of magnesium per day.3,4
Fish Oil
Even laypeople are learning about omega-3 fatty acids on television commercials. This one is straightforward. A reduction in omega-3 fatty acids and excessive omega-6 fatty acids leads to a state of chronic inflammation, which is expressed as an increase in pro-inflammatory eicosanoids, cytokines, and growth factors. Nearly every chronic disease has been linked to an n6-n3 imbalance. Taking about 1-3 grams of EPA/DHA from fish oil is a reasonable recommendation.3,4
Multivitamins
A famous toxicologist name Dr. Bruce Ames suggests that we all take a multivitamin/mineral as a metabolic tuneup.5,6 Other research suggests that multivitamins may protect against a variety of chronic diseases—the references illustrate the various conditions.7-17
Conclusion
Patients enter your office with various conditions. There is essentially no common condition that is caused by a specific nutrient, and there is definitely no condition caused by a deficiency in the latest multilevel marketing supplement. As patients present with their various problems, it is important to realize that most are caused by a pro-inflammatory state that is expressed as reduced ATP synthesis, increased free radical generation, and chronic inflammation.
To combat the pro-inflammatory state, we need to eat an anti-inflammatory diet, rich in fruits and vegetables, and take basic supplements. I suggest a multivitamin, magnesium, and fish oil.
If patients have joint pain, add glucosamine/chondroitin. If patients have osteoporosis, add hydroxyapatite. If patients fail to get adequate sun, add vitamin D. Simple is best, and the best is supported by evidence.
Dr. Seaman is the Clinical Chiropractic Consultant for Anabolic Laboratories, one of the first supplement manufacturers to service the chiropractic profession. He is on the postgraduate faculties of several chiropractic colleges, providing nutrition seminars that focus on the needs of the chiropractic patient. He is also a faculty member at Palmer College of Chiropractic Florida, where he teaches nutrition and subluxation theories. He can be reached by e-mail at [email protected].
References
1. Kaptchuk TJ et al. Sham device versus inert pill: randomized controlled trial of two placebo treatments. Brit Med J 2006; 332:391-97
2. Benedetti F et al. Neurobiological mechanisms of the placebo effect. J Neurosci 2005; 25:10390-10402
3. Seaman DR. Nutritional considerations for pain and inflammation. In Liebenson CL. Editor. Rehabilitation of the spine: a practitioner’s manual. Baltimore: Williams & Wilkins; 2006: p.728-740
4. Seaman DR. Nutritional considerations in the treatment of soft tissue injuries. In Hammer WI. Editor. Functional soft tissue examination and treatment by manual methods. 3rd ed. Boston: Jones and Bartlett; 2007
5. Ames BN. The metabolic tune-up: metabolic harmony and disease prevention. J Nutr 2003; 133:1544S-48S
6. Ames BN. Supplements and tuning up metabolism. J Nutr 2004; 134:3164S-68S
7. Fletcher RH, Fairfield KM. Vitamins for chronic disease prevention in adults: clinical applications. JAMA 2002; 287:3127-29
8. Cheng T et al. Effects of multinutrient supplementation on antioxidant defense systems in healthy human beings. J Nutr Biochem 2001; 12:388-395
9. McKay DL, Perrone G, Rasmussen H, Dallal G, Blumberg JB. Multivitamin/mineral supplementation improves plasma B-vitamin status and homocysteine concentration in healthy older adults consuming a folate-fortified diet. J Nutr 2000; 130:3090-96
10.McKay DL, Perrone G, Rasmussen H et al. The effects of a multivitamin/mineral supplement on micronutrient status, antioxidant capacity and cytokine production in healthy older adults consuming a fortified diet. J Am Coll Nutr. 2000; 19:613-21
11.Earnest CP, Wood KA, Church TS. Complex multivitamin supplementation improves homocysteine and resistance to LDL-C oxidation. J Am Coll Nutr 2003; 2:400-407
12.Chandra RK. Effect of vitamin and trace-element supplementation on cognitive function in elderly subjects. Nutrition 2001; 17:709-12
13.Holmquist C et al. Multivitamin supplements are inversely associated with risk of myocardial infarction in men and women – Stockholm Heart Epidemiology Program (SHEEP). J Nutr 2003; 133:2650-54
14.Giovannucci E et al. Multivitamin use, folate, and colon cancer in women in the Nurse’s Health Study. Ann Int Med 1998; 129:517-524
15.Willet WC [Professor of Epidemiology at Harvard. Goals for nutrition in the year 2000. CA Cancer J Clin 1999; 49:331-52
16.Mares-Perlman JA et al. Vitamin supplement use and incident cataracts in a population-based study. Arch Ophthalmol 2000; 118(11):1556-63
17.Suarez EC. Plasma interleukin-6 is associated with psychological coronary risk factors: moderation by use of multivitamin supplements. Brain Behav Immun 2003; 17(4):296-303