“To all my little Hulkamaniacs, say your prayers, take your vitamins and you will never go wrong.” Hulk Hogan
As a confirmed supplement taker, it struck me some time ago that I should really make more effort to understand what I'm taking and why and whether I'm doing it in such a way that my body gains maximum benefit.
I always suspected that swallowing a handful of vitamins and minerals with the orange juice every morning was possibly swallowing a whole lot of advertising propaganda at the same time. Yet still I did it (and forgot the orange juice too) because as someone with both HIV and neuropathy, I felt that my immune system was continually under attack and therefore needed boosting with supplements to enable it to fight off the unknown and unexpected.
However, I wonder if most people supplement their vitamins because they feel they should and not because of specific medical advice. Furthermore, when you read an article about the latest supplement claiming to help your particular problem, you're tempted to add it to your existing list.
It was almost a cliché in the early eighties that desperate people trying to survive with HIV were taking twenty to thirty supplements a day and that seemed shocking then. However, that feeling that you're somehow letting your system down unless you use supplements hasn't gone away and is actively fed by the supplement industry, the media and by the internet. Perhaps more worryingly, it is stronger than the underlying and unsettling feeling that you may actually be overdoing it! Hmm! Hints of addictive behaviour maybe! In my case I've just always felt that I needed someone to tell me how to supplement sensibly instead of leaving me to my own devices. Am I the only one? I somehow don't think so.
The problem is, despite that nagging feeling that I should really be more responsible both with my wallet and with what I throw down my throat, I still do it every day! I have a few medical problems for which there are no cures and I suspect it's a slightly panicked response to that. Eventually, my conscience pricked me enough to do some research to try to find out what really is necessary and what the best means of taking vitamins actually is. What I discovered was a maze of differing opinions concerning which vitamins are useful for what; when they should be taken and most importantly, what dosage strengths are recommended. The industry behind supplements has mushroomed and that has led to conflicting opinions as to what is truth and what is plainly lies, ad-speak and hot air.
What follows is a summary of what most experts have found (you will always discover doctors and nutritionists who disagree with various points). However, the only way an ordinary person, without a nutritional science degree but with HIV-related problems can plot his or her way through the vitamin obstacle course is to take the consensus opinion and trust that it's not going to do you any harm. Before you take any action however, you do need to talk to as many medical experts as possible and do your own research. Your HIV-specialist should probably be the primary advice giver -- you don't want to be taking anything that will compromise your HIV-medication (we all know about St. John's Wort and grapefruit for instance!)
The Harvard nutritionist Victor Herbert's famous Time magazine quote in 1992 that vitamins just give you "expensive urine", has stuck in many people's minds. However, sales figures since then would beg to differ, as would the American Food and Drug Administration, which to cite just one example, began requiring Folic acid (a form of vitamin B) to be added to grain products only four years later. That single smart move quickly prevented a worrying rise in cases of spina bifida in babies, caused by mothers not receiving enough folate in their diet and undoubtedly saved lives. Cases like this convinced more and more people that boosting their vitamin levels was a good idea.
According to the American Journal of Preventative Medicine, more than half of all Americans use vitamins or supplements and according to the Hartman Group, (a natural products marketing firm) they spend more than five billion dollars each year in the process! Whilst these astounding statistics are probably reasonably accurate for most developed countries, the rest of the world may regard the idea with some cynicism -- the cost and availability alone will make it prohibitive for many populations.
I wonder if the statistics are even higher for people living with HIV; though again, it may depend on their demographic. Whether it's somewhat of a western luxury or not, the fact is that vitamin supplementation is here to stay and shows no sign of slowing down. So what's the truth behind the hype?
Why Do People Living With HIV Need Vitamin Supplements?
One of today's buzz words is 'micronutrients'. These are basically vitamins, minerals and anti-oxidants and although we don't require large amounts, they are essential for good health. As the body goes through its normal daily functions, the necessary chemical reactions in cells are 'fed' by micronutrients. However, many people living with HIV need more, or supplemented, micronutrients to support cells damaged by the virus and to bolster the immune system.
Another problem for people with HIV is getting the correct amount of nutrients via their diet. The virus itself and certainly the medication can affect your metabolism which in turn prevents proper absorption of micronutrients. Apart from this, lack of appetite, diarrhoea and sickness, plus possible liver, kidney and intestinal problems can block essential intake of vitamins, anti-oxidants and minerals. It's not surprising then that the immune system is even further compromised.
The most common deficiencies in HIV+ people include vitamins A, E, and B-complex (B1, B2, riboflavin, niacin, B3, B6, B12, B9 and folic acid), leading to various immune system related conditions and of course for readers of this blog, neuropathy. Some studies have concluded that micronutrient deficiencies can even lead to lower CD4 counts but this is not universally accepted.
So What Are Vitamins and What Do They Do?
There are basically two sorts of vitamins and they are categorised according to how they're transported through the body. The body cannot manufacture vitamins itself (with the exceptions of vitamin D, which is manufactured by the body on exposure to sunlight; and vitamin K, which is created by bacteria in the intestine) and cannot survive without them.
Water-soluble vitamins are carried around your system by water. They need to be replenished daily because you lose them through fluids like sweat and urine.
They're mainly the B-vitamins: folic acid, biotin, pantothenic acid, thiamine (B1), niacin (B3), pyridoxine (B6) and cyanocobalamin (B12) and vitamin C.
Fat-soluble vitamins are carried by fats found in the blood stream. Since fat stores vitamins better than water, it's not so important if the daily dose is interrupted. These vitamins include, A (retinol), D (calciferol), E and K. However, overdosing with these vitamins can lead to a build-up of toxic levels. They're much harder for the body to dispose of through urination and that's why many doctors and nutritionists give out warnings.
Water-soluble vitamins (B, C, folic acid), are found in meat, fish, fruit, vegetables and whole grains and you should eat foods containing these every day. Over-cooking also destroys them, so it's always better to grill or steam rather than boiling. As I've already mentioned, many people with HIV have trouble eating normally and that's where supplementation comes in.
Fat-soluble vitamins (A, D, E, and K), are generally found in meat and meat products, animal fat and vegetable oils, dairy products and fish.
n.b.: This article is not going into the subject of minerals but it is important to remember that vitamins and minerals are two completely different things. In general, minerals help vitamins to work properly. Just for reference, the most important minerals are: calcium, iron, magnesium, iodine, copper, phosphorus, manganese, chromium, selenium and zinc. The last two are frequently recommended for people with HIV but they are not vitamins.
But What Do Vitamins Actually Do?
Vitamins are essential for good health and people whose immune systems are compromised do need to maintain a normal level of vitamins daily in their system.
Vitamin A is the body tissue vitamin; helping to maintain and develop skin and bone. It also helps with vision, the functioning of the nervous system, reproduction and growth.
The B vitamins increase fat production along with proteins and carbohydrates and assist with metabolism, building red blood cells and maintaining the protective sheathes of the nerves (especially relevant for neuropathy patients).
Vitamin C is definitely an aid for immune system performance, helping to heal wounds as well as forming tissues, cells, bones and teeth.
Vitamin E protects the membranes on the outside of cells and therefore assists the immune system in fighting off illness.
Vitamin K is necessary for blood clotting at wound sites.
The following two sections, are probably the ones of most interest to most people and for that I apologise for the amount of information you had to wade through to get to this point. Although we want to know when to take these supplements and which daily dose is the right one; I always want to know what it is I take and what it's supposed to do. This is not so easy when researching HIV medications but is much easier with vitamins.
When Should We Take Them for the Best Effect?
For many people living with HIV, their daily routine revolves around the time of day they take their HIV medications. It may be necessary to adjust your supplement intake accordingly but never the other way round -- your ARV intake is of prime importance.
Instructions on vitamin bottles can sometimes be so small; you need a magnifying glass to be able to read them. This is generally because of the amount of legally required information but that doesn't make it any easier for the user. Many people look at the recommended daily dose and take everything at the same time and when it's most convenient. However, this can lead to mal-absorption and thus a waste of your money.
Studies seem to show that concentrated man-made vitamins (the most commonly found on the supermarket shelves) need to actually bond with real food vitamins in order to be properly absorbed by the body. Just drinking water and popping vitamins may be a diet option but won't be maintaining your health the way you hope it will.
Another problem is the sheer variety of opinions amongst the medical and nutritional professions. I've tried to bring together the most often recommended times for taking vitamins but you will always find contradictions. The human body metabolizes food at different rates and times for different people. Some people metabolize slowly in the mornings and faster at the end of the day and for others it's the opposite. Hard and fast rules are difficult to prove then.
Most people start with a multi-vitamin. The general opinion is that the best time to take it is in the morning, within a half hour of a healthy, protein and fruit breakfast, (eggs, milk and an apple for instance). Busy people will see this as an unrealistic scenario, as they buy their sandwich and coffee to go in the bus or car to work but we have to try don't we! If you forget in the morning, it's best to wait until lunch, or the first substantial food intake, so that the multi-vitamin is properly digested and breaks down with your food.
Single vitamin supplements have their own "best times" and again, opinions differ according to what you read.
Most nutritionists state that vitamin Bs, vitamin B-complexes, vitamin C and vitamin E should be taken in the morning, with some food, so that you can best benefit from their energy giving properties.
If you then take your vitamin D (and necessary calcium) with the next meal, you won't have problems with the absorption of the calcium. Most multivitamins contain iron and iron can clash with the calcium, leading to poor absorption of both. Minerals such as calcium and magnesium (plus vitamin D) are natural muscle relaxants and can also be taken before going to bed.
Vitamins A, D, E and K should preferably be taken with foods containing fat or oil, so that they can form "micelles" to allow absorption (a handful of nuts is one option).
Although rare, some doctors advise taking vitamin supplements on an empty stomach because they feel the body will absorb the nutrients better. Vitamin C is not one of them because it is so quickly flushed out of the body. Vitamin C actually only lasts a few hours in the bloodstream, so should really be repeated two or three times a day but it's not a good idea to take it last thing in the evening because of its stimulant properties. Taking vitamins on an empty stomach can also cause heartburn and indigestion problems. If that's the case, it may be better to open up the capsules or grind the tablets and blend them into a smoothy.
Some nutritionists also advise taking vitamins on an empty stomach but with specific instructions that they should be chewed. Some think that a chewed tablet is far better than one swallowed whole. Again, the grinding into a drink option may be more appealing.
In general, most sources advise taking vitamins with, or just after food and the science seems to bear that out but as already mentioned, other experts think differently. Some people may be finding eating solid food difficult enough but still need the vitamin intake. It's best to take advice and then see what works for you.
What Is the Recommended Daily Dosage?
Another controversial topic is how much of each vitamin you need to supplement. Many people take their multi-vitamin and then take other vitamins at recommended daily dosages separately, forgetting that they've already ingested a substantial amount of their daily intake in the multi-vitamin. This can lead to health problems as well as being a waste of money.
Recommended daily intakes (RDI) are not an exact science. Your particular health problem may require larger doses of particular vitamins to help with your deficiency and you will possibly see different RDIs on every different brand. Multi-vitamins can be bewildering when you try to work out exactly how much they contain. It's a bit of a minefield and isn't helped by the various acronyms which almost nobody understands. Here's a short list of some of the nutritional values to help you make your decisions.
RDI: recommended daily intake (it is illegal in Canada for instance to print RDIs on a vitamin bottle, maybe for a good reason.)
RDA: Recommended Dietary Allowances
DV: daily value
RE: retinol equivalents
Mg: milligram (nutrients are expressed in a variety of units)
Ug (or mcg): microgram (for instance 0.5 mg is the same as 500 ug)
IU: international units
Unfortunately there's not enough room here to explain how you convert milligrams to IU, or what the other equivalents may be and some state that it's just not possible because they represent different values. Searching the internet may not make it any clearer; it's very complicated. What we can do is compare the same label descriptions between different makes but even that is risky because what some companies claim is both not accurate and in no way comparable with others, or an international standard. Besides that, the difference between synthetic and "natural" vitamins is very significant. If any industry required urgent regulation, it's this one!
However, as vitamin users we have to make a judgement somewhere, or just not use them at all. After searching through many nutritional websites, the following recommendations from the European Union are at the bottom end of the scale in comparison with most others but again, every individual is different and your health status and age may require different daily intakes. The link that follows refers to the United States FDA and Canadian recommendations, which are slightly different in some cases. It is also not my job to recommend any sort of vitamin dosage to other people; that would be irresponsible. Apart from this, these are recommended daily intakes for normal, healthy people and we are not. It's very difficult knowing what's best but your doctor should be able to advise you.
Vitamin A: 800 mcg
Vitamin B1: 1.4 mg
Vitamin B2: 1.6 mg
Vitamin B12: 2 mcg
Vitamin C: 60 mg
Vitamin D: 5 mcg
Vitamin E: 10 mg
Folic Acid: 200 mcg
What follows are a few general tips that most reputable sites offer regarding vitamins and although they may go without saying, they're worth bearing in mind.
Cost is always an issue and generally, synthetic supplements are cheaper than organic and subject to aggressive marketing because they have a substantial market share to fight over. However, as mentioned earlier, you need to be more careful with how you take them in order to get optimum benefit.
Try to buy the best quality for the price you can afford.
Check expiry dates on boxes or bottles and store your vitamins in a cool place.
Buy cold-pressed capsules rather than tablets as they tend to be more easily absorbed than pills or tablets.
Vitamin supplements are rarely strictly regulated and it can be difficult to tell whether you're getting what the label claims, so it may be wise to confine your purchases to reputable brands.
Never buy vitamins online unless you can clearly verify their street address, phone number, e-mail address and refund policy.
Be wary of "extras" like gingko, ginseng or green tea in multi-vitamins. There is little evidence that the amounts provided have any meaningful effect.
Watch out of claims like, "high potency, super, complete or all natural" which may just be advertising jargon with no intrinsic meaning. Studies have shown that there is little difference between basic brands and those with extravagant claims. "Let the buyer beware" very much applies to this branch of the health industry.
We are a vulnerable group of people. We have health problems which can't be cured and sometimes the side effects of the illness, or the medication used to treat it can leave us looking for any relief, anywhere. It's human nature but we have to use our common sense and try to make decisions supported by expert advice and careful research. An unregulated industry can persuade you to swallow anything but people living with HIV and other diseases like neuropathy have learned to be sceptical of exaggerated promises and claims. It's only logical that we should be cautious with what we put into our bodies.