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April 13, 2000 (Philadelphia) -- If ordinary Americans end this week with more questions than answers about vitamins and supplements, take heart -- most physicians are just as confused.
Since the beginning of the year, there has been a flurry of papers and studies on vitamin and supplement use -- often with contradictory findings -- and just this week, the prestigious Institute of Medicine (IOM) released a report stating that antioxidants like vitamins C and E have no proven role in the prevention of disease. That report came a day after a report in a medical journal suggested that increasing vitamin C intake may protect women from gallbladder disease. No wonder confusion reigns.
After sorting through the headlines and the hype, John La Puma, MD, tells WebMD that the best advice for patients remains "eat healthy foods, not pills." La Puma spoke here at the annual meeting of a group that represents many of American's primary care physicians.
La Puma, who is medical director of the Cooking, Healthy Eating & Fitness (CHEF) Clinic in Elk Grove Village, Ill., says that the report from the IOM -- rather than adding to the confusion -- may help sort things out for both doctors and patients.
For example, the IOM report recommends changes in the recommended daily intake for vitamins C and E and selenium. "The original recommendations for vitamin C were based on the amount needed to prevent scurvy [weakening of bone and cartilage due to vitamin C deficiency]," says La Puma. He says that in modern America, scurvy is not the public health concern that it was 100 years ago. The IOM recommends increasing the levels to 75 milligrams per day for women and 90 milligrams per day for men. Additionally, the report says that smokers need an additional 35 milligrams per day. "Adding the recommendation for smokers is especially important" because smokers have increased damage that could be helped by antioxidants, La Puma says. He says, however, "I've never seen vitamin C sold in anything less than 250 milligrams, so this is what most patients will be taking."
The IOM suggests that vitamin E recommendations be increased to 15 milligrams per day for both men and women. It also changed the recommended intake for selenium to 55 micrograms per day.
La Puma says that instead of vitamins, he advises patients to get their vitamin C from "two handfuls of strawberries and their vitamin E from a quarter cup of almonds, which is actually a good handful of almonds. For selenium, I recommend taking two Brazil nuts a day. That's what I do."
While increasing the recommended daily intakes, the report also sets upper limits and warns that exceeding those limits may cause side effects. The recommended upper limit for vitamin C is 2,000 milligrams per day and for vitamin E is 1,000 milligrams, or 1,100 IU of vitamin E that's labeled "natural source vitamin E."
Many people think that if they take what are called mega-doses of vitamins, they will increase the benefit from the vitamin. Not so, says La Puma, because exceeding the recommended maximum for vitamin C can cause diarrhea, and mega-doses of vitamin E have been associated with excessive bleeding. La Puma says that he joins the IOM in opposing mega-dosing of vitamins.
Marianne Frieri, MD tells WebMD that she, too, thinks the IOM report is useful. Frieri, who attended the lecture by La Puma, says she has recently become interested in vitamin use after diagnosing hives "among some of my patients who were using mega-doses of vitamin C." She says, however, that recent studies have been somewhat confusing to sort through. Frieri is an associate professor of medicine and pathology at State University of New York, Stony Brook.
The IOM report also claims that there is no scientifically verifiable link between antioxidants and disease prevention. La Puma says he agrees with that finding.
La Puma, who is a medical ethicist as well as an internal medicine doctor, took a break from medicine for several years and attended cooking school. About five years ago, he returned to medicine but decided to combine his chef training with medicine. In his current practice, he "trains people how to cook healthy," he says. As a result, "I don't routinely recommend vitamin supplementation because I prefer that my patients eat healthy."
Physicians who do recommend supplements should, however, offer some guidance to patients, La Puma says. "First, don't buy vitamins containing iron. In the United States, there is no need to supplement iron. Second, always look for the USP stamp on the label. This is a voluntary organization that quantifies vitamin content. It is not as stringent as the FDA but it offers some protection. Third, buy vitamins that are made by manufacturers of ethical pharmaceuticals because these companies are more likely to be careful in the [manufacturing process]. ? And finally, if possible, buy vitamins and supplements from Germany because in Germany these products are more highly regulated."
For patients who are interested in learning ways to "eat healthy," La Puma has a few simple suggestions, including this basic advice: use smaller plates. He recommends buying nine-inch plates, or salad plates, and using them instead as dinner plates. "Then put a vegetable or fruit dish in the center of the plate. Put the meat alongside on a bread plate," he says.
He also teaches patients to cook "restaurant-style on weekends, making large quantities that are frozen for use during the week."
Finally, though, he says the key to health may lie in abandoning the notion of looking for health in the medicine cabinet.
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