CEimpact Podcast

Should You Take a Multivitamin?

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1 out of 3 adult Americans take a daily multivitamin. On this episode of GameChangers, we discuss a recent study which examined whether daily multivitamin use extends life or prevents common causes of death.
 
The GameChanger
The study found no evidence that daily multivitamin use reduced death from common conditions such as heart disease or cancer.
 
Guest
Geoff Wall, PharmD, BCPS, FCCP, BCGP
Professor of Pharmacy Practice, Drake University
Internal Medicine/Critical Care, UnityPoint Health

Jake Galdo, PharmD, MBA, BCPS, BCGP
CEO, Seguridad


References
Multi-Vitamin Study
NIH Press Release

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CPE Information
 
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Discuss the use of multivitamins.
2. Identify implications for healthy patients considering multivitamin use.



0.05 CEU/0.5 Hr
UAN: 0107-0000-24-226-H01-P
Initial release date: 07/22/2024
Expiration date: 07/22/2025
Additional CPE details can be found here.

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Speaker 1:

Hey, ce Plan members From CE Impact. This is Game Changers. I'm your host, jen Moulton, and today I have with me two regular contributors, Doctors Geoff Wall and Jake Galdo. Welcome to both of you.

Speaker 2:

Hello.

Speaker 1:

Howdy. Today's topic, I can imagine, may be a bit controversial for some of you listening. I'd even put myself in that bucket, potentially potentially because I have so many questions, and that is why we're going to take a look at this as a bit of a point counterpoint so we can really delve into what the latest evidence shows. And the evidence that we're referring to is the study that was published in JAMA related to the efficacy of multivitamins in otherwise healthy people. So, given that one out of three Americans take a multivitamin, this study truly impacts a lot of people. So, jeff, let's start with you. What's really the background of the study?

Speaker 3:

So, as you point out, the supplement industry in the United States, and actually probably worldwide, is a multi-billion dollar industry, and while I think there's certainly patients who benefit from stuff, I think there's a lot of questions surrounding especially largely healthy people taking supplements.

Speaker 3:

So I mean people who don't necessarily have any other disease. States or other comorbidities who are taking a multivitamin for a variety of reasons. States or other comorbidities who are taking a multivitamin, you know, for a variety of reasons, right, you know, they heard that. You know that it makes you live longer, or you know they are afraid that they don't get enough vitamins in your diet, or you know, whatever I mean, there's, I think, a million reasons why largely healthy Americans would take supplements, right? So I think that's the key piece. But what we're missing with nearly all of these supplements is decent randomized control trial data actually showing benefit. Now, part of that, of course, is that who is going to pay for these studies? The companies that produce supplements. Even if they had the money and they usually don't why would they do a randomized control trial that may show their study? Their product is ineffective, right? You know, as the current rules show, all they have to do according to the FDA is just put a little sticker on the back of their bottle that says you know, this product has not been evaluated by the FDA to diagnose or treat a disease and they're good to go right. So there's really no financial incentive, I don't think, for most companies to do randomized control trials, and the other piece, of course, is if they were to find a benefit. There's 87 other companies out there who make the exact same supplement. So again, it's hard for them to say, well, our particular brand of vitamin D is better than all their other ones. So it gets kind of tricky, and so most of the evidence that's been done by this has been done by federal organizations, the NIH, stuff like that, and so the study that you're referring to is fairly hot off the press just late June here in JAMA, and it did cause a bit of, I think, a late media stir, excuse me, because of kind of the headline in it, which was that multivitamins increase mortality in patients taking them.

Speaker 3:

Now, you know that's a clickbait title if I've ever heard one, and I think we really need to talk about the study itself. The authors in the paper point out that you know as recently as 2022, the US Preventative Service Task Force, which is really the nationwide task force of physicians and other healthcare professionals that talk about preventative services, including screening and stuff like that. Also talk about drugs. They've recommended, for example, that the vast majority of Americans don't need to take a daily aspirin for cardio protection, because it causes more harm than good. In 2022, this same group said, we really can't tell you whether a daily multivitamin in healthy people is harmful or helpful. Basically, and that's because the studies just weren't very well done.

Speaker 3:

Now, a study on mortality is going to be very challenging for multivitamins because you're going to have to follow patients for 15, 20 years and, of course, no study is going to do that. So, rather than do an RCT, probably the most practical way to do a study like this is to do a large retrospective study. But again, the problem with retrospective studies is the confounders. Right, you know, okay, well, you know, we found this, but did you confound? Did you take into account the smoking status of the patients who took multivitamins versus those who didn't, their age, their weight, you know, et cetera, a million other factors, socioeconomic status there's a million things which affect health, of course, right. So any study that that is going to be published.

Speaker 3:

Looking at at mortality in patients who are taking a multivitamin A is, just by its very nature, going to have a confounding with it. But this study, I think, did as good a job as you possibly could do to deal with this those conf compounders, and here's how they did it. Basically, they note that this is a question that needs to be answered. They also note that the vast majority of Americans probably get most of the recommended daily allowance in their diet. I mean, certainly there are people who have either food insecurity or anything along those lines, but it's important to note that in America we do actually vitamin fortify a large number of our foods, right? So like, if you eat, you know, wonder Bread, for example, it's actually fortified with several vitamins and iron. Even so, you know, it's certainly possible for you to get your RDA of stuff, even if you're not a big vegetable lover, right? But you know. Again, that's the question is is it? Does a daily multivitamin improve longevity?

Speaker 3:

So to get the number of patients to figure that out, they had to take data from three very large, very fairly older cohort studies that have gone on for years and years and years to try and answer this question. And even though it's probably going to make our listeners ears glaze over is. I think we need to talk a little bit about the three studies. They pulled their cohort fund and the first was the AARP Diet and Health Study and this study was started in 1995. And it was basically just a questionnaire study that then they followed patients over time to take a look at certain disease states they developed and again they tried to take a look at what risk factors would put these patients in this AARP study at risk. And so they looked at diabetes, mi, stroke, end-stage kidney disease as well as a couple of other things. And then they also in this study they actually looked in a questionnaire they asked about multivitamin use. So they were able to take that data and split it into those who did take report daily multivitamin use and those who didn't.

Speaker 3:

The PLCO study was the second study they looked at. It was a randomized cancer screening study that enrolled about 150,000 patients between 1993 and 2001. And again it's the same thing. They wanted to take a look at what risk factors people would have for cancer and at the entry point of the study they did ask about multivitamin use as well. And then finally, a little closer to home for I think for you and me, jen, anyway is the AHS study, which enrolled about 55,000 people who work with pesticides, with their pesticide applicators and their spouses, and they wanted to take a look at development of cardiovascular disease and as well as cancer you might imagine, for pesticide producers. And they also asked about multivitamin use. The vast majority of these patients were in Iowa and North Carolina. They kind of moved all three of these patients up into one gigantic cohort of patients and when that was all said and done they had 390,000 participants that they had enough data to pull whether they were taking a multivitamin or not a day and have enough to take a look. They had been followed along to take a look at outcomes as far as mortality.

Speaker 3:

As I said before, any study like this is going to have 12 million confounders right, they're never going to get all of them, but reading through the study, I think they did as good as they possibly could to account for, you know, gender, age, race, ethnicity, education level, smoking status, bmi, marital status, physical activity level, alcohol intake, coffee intake, an overall healthy eating index, et cetera, et cetera, et cetera, and again, we could probably spend 20 minutes just talking about the multiple confounders they did, and then taking these confounders and putting them to a pretty complex statistical model that basically accounted for all these in a regression analysis that they kind of took a look at whether they were on a multivitamin and others, and then dealt with and tried to account for all these different confounders Also to make sure that they were taking a look at time bias. I thought they did a good job in saying, okay, we're going to look at mortality at different cut points. So they looked at mortality at five years, five to 10 years and then after 10 years of that baseline multivitamin assessment. Now, of course, there's no way for them to assess whether people continue to be on multivitamins, which is one of the big strikes of the study. Right At the beginning of the study, yeah, I took a multivitamin a day. Did they take it five years after that? That again, 390,000 patients split it between these three studies and this average age was 57, about half and half male and female, et cetera, et cetera.

Speaker 3:

And in the final pooled analysis, which again all they were looking at was mortality, they found that daily multivitamin users had a higher risk of mortality than non-users.

Speaker 3:

It was about a 5% excess risk and it did just reach statistical significance. But yeah, it was statistically significant and it was associated with a hazard ratio basically of 1.04, so about a 4% to 5% increased risk of mortality. When they broke it down by cancer, heart disease, you know all that the numbers were very similar. But, as you might imagine, as you took patients out of the cohort you were losing power, so it lost statistical significance. That was the big issue. And then when they did multiple redos of the analysis, taking a look at again that zero to five years, five to 10 years, when they took a look at again that zero to five years, five to 10 years, when they took a look at individual cohorts, et cetera, et cetera, they found pretty much the same number. They either didn't find a statistical benefit or they found in some cases actually a slight increase in mortality, basically. So of course the media has taken this and ran with it and said and that's where I think it's kind of clickbaity.

Speaker 3:

Well, the vitamins kill you. Well, no, they don't kill you. Again, this is a retrospective cohort study, so they did a good job dealing with as much of the confounders as possible. But this is hypothesis generating. It is not hypothesis proving.

Speaker 3:

I think what you can really take away from the study is for generally healthy patients, patients who don't have a lot of other reasons to maybe take individual vitamins, there seems to be little benefit to taking a multivitamin a day. It just doesn't seem to give you any longevity benefit. Now, that may not be why you're taking multivitamins. You may be taking multivitamins for a wide variety of other things and some of them may be important to some people and not important to other people. My girls take vitamin A and C a lot of times because they want to improve how their hair looks, you know. So I mean, you know again, that's, you know that's not a mortality benefit, but I, you know that seems to work for them. I guess that's fine. They certainly don't have any side effects that they told me about it. I think the big side effect has been my wallet depletion, anyway. So that's, I mean, I think that's kind of the study.

Speaker 3:

It's certainly what authors discussed and basically said you know this is what we found. It's certainly, you know, even if we parse it down to individual races, individual genders, individual ages and you know all sorts of stuff, they basically found the same thing no benefit, largely in healthy patients. And the editorial list talked about this paper and that accompanying issue basically said this is probably the best data we're ever going to get on this, but it doesn't mean that you should just never recommend multivitamins ever. There are definitely patients who may benefit from that and there are patients where it may harm them, and I think, as pharmacists and other providers, we need to be able to discuss that, and so that's something to keep in mind.

Speaker 3:

And the other thing that I know Jake's going to talk about is you know, it's probably you know the best way to refocus nutrition interventions on food rather than supplements, because that is probably the best way humans, you know, get their vitamins is not through a pill, but vegetables and cereal grains and things along those lines. So I think that's one of the key points we need to take away from the lab. I don't think we need to say stop your multivitamin, it kills people, you know sort of thing. So what do you think, jen, jake?

Speaker 2:

I'm going to jump in because I have a lot of thoughts on this. I've been jotting down some things to react to Geoff, a lot of thoughts on this. I've been jotting down some things to react to Jeff, and I want to start with the first part, which is what the heck are we talking about in the sense of why do we even think about multivitamins? And this began in the great year of 1832, and I'm making the number up when pirates roamed the earth. Right, because we're talking about scurvy. That's really where this is coming from. We had pirates. They didn't have vitamin C, they got scurvy. So then we were like, oh, we got to get them some vitamin C.

Speaker 2:

And so we start saying, well, maybe we should take vitamin C as a supplement, maybe we're worried about rickets, maybe we're worried about this or that, all the things that we don't really hear about anymore. And we don't hear about it anymore because it's in our food. And so I think the overarching theme here is that, yes, vitamins are important, but we've kind of addressed them in modern society, and so, you know, there is a little bit of a tongue in cheek here and I'm really scared to put this out into the universe. In some way it reminds me of vaccines. We don't hear about polio anymore because we cured it. So now we don't get vaccinated and now, all of a sudden, we have polio again, right, is it? We don't have scurry, we don't have rickets because we've effectively cured it, and now we're going to go on the other extreme side of things and we're going to start seeing rickets again.

Speaker 3:

You know it's funny that you mentioned that, because I actually had probably the first and only case of scurvy I've ever seen in my life. It was just before the pandemic 2018, 2019. And it was exactly what you said. It was a patient who basically was homeless, had zero access to food and somehow just did not get enough vitamin C in their diet and started complaining of gum bleeding and bleeding in the joints and I didn't catch it and no one on our team caught it until we had gotten I forget what subspecialty and he's like yeah, this is scurvy.

Speaker 3:

And I think we all looked at each other and went what In the 21st century in America? Yep, it can happen.

Speaker 2:

So I'm sure that's a barely underused ICD-10, but it probably doesn't exist, right? Yes, I'm sure it is. Yes. So I want to catch us in this kind of conversation with what are we treating? Why are we treating it? So there's like this aspect of it. Then that gets into the second part, which is health equity.

Speaker 2:

And the fact that you just talked about a patient case that was homeless is just on the nose about health disparities, right? Because we're sitting here and we're saying what's the harm of a multivitamin? And, jeff, you made the joke about your wallet Well, the homeless person doesn't have the wallet that can get harmed, and then that's why they have curvy. So I do think that as much as we say, oh, there's nothing wrong with it, there is something wrong with it. There's a cost to it. And then it's really sad when you think about these disparities and you consider that the people that can afford the multivitamin are the ones that don't necessarily need it because they have the food. Those that cannot afford the multivitamins are the ones that don't have access to food. So you know, it's the haves and have-nots all over again in this type of environment. But with that all said, I think that the takeaway still is I don't need multivitamins. The takeaway is I'm worried about scurvy because of my diet. Let me take a multivitamin or, better yet, let me just take vitamin C, you know.

Speaker 2:

I also think it's kind of interesting that you said who would fund this. No one has money for it. It's a $50 billion industry. There's money here, right, and? And when you you'd made the joke, my, my multivitamin is better than your multivitamin. All that reminded me about is when we took some old drugs, I don't know, like colchicine, and rebranded them after a study and said my drug is better because it was studied. So, like dear life science, vitamin makers, like there's a role for you to actually do a study because you might be able to say my multivitamin is better, and then we have data, which I think is helpful.

Speaker 2:

Ultimately, though, I feel like this really gets into the role of the pharmacist and the pharmacy team and the community health worker for understanding these disparities right, and that one of the things that we do when we dispense drugs it's the right patient gets the right drug at the right dose, at the right route for the right reason. You know that there's not the right time or something right. I always had a six right. To me it's the right. Reason the indication that is what we've always been taught. Like reason the indication that is what we've always been taught.

Speaker 2:

That is the first thing we look at when addressing medication-related issues. It is us being interventionist and so I would almost argue what is my indication for multivitamins? There isn't one, it's gone. What is my indication for vitamin B12? Patients on metformin and ADA guidelines stipulate that if you're on metformin, you need B12 supplementation. There is an indication for the drug period and I think if we approach all products pharmaceutical vitamins, dietary supplements, anything in that perspective, then I think we can address a lot of misuse, but also have emphasis on the role of the pharmacy team in addressing appropriateness of care.

Speaker 3:

And you know, as you point out, I completely agree that. You know, I think, as pharmacists in particular, because of course we're the ones who get you know, hey, you know, I read on this thing that you're supposed to take this. Can you point me in the direction of that? I mean, I think, yeah, you know, it's easy to say, you know aisle three, you know sort of thing, but you know to say, well, you know, why do you want to take this? Well, because you know, this dude on TikTok told me I need to do it. Okay, well, you know, first of all, first of all, don't get your medical information from TikTok. But second of all, you know, let's talk a little bit about you know why you might want to take this and you know is, is there any benefit or are you just spending money for no reason? Now, if someone says, well, I just want to spend my money for no reason, okay, you know, most of these things are pretty harmless. If you, if, again, if you can tolerate the wallet depletion, that's your business, you know.

Speaker 3:

But I think that we need to be frank with patients and say you know, you know the the healthy patient comes up and says you know. Hey, I heard probiotics are really good for gut health so I'd like to take a probiotic and it's just like well, what do you mean? Good for gut health? I know I have a lot of diarrhea, okay, well, I'm not really sure probiotics are really indicated for that. Right, if you can afford it, it's probably not going to hurt you If you're immunocompromised. No-transcript vitamin E, you know, in patients who are at risk for falls For a long time, we said take extra vitamin D because it helps patients, you know, decrease the risk of falls. More recent studies suggest not only does it not do that, it may increase the risk of falls. So you know there are populations where harm actually beyond wallet depletion can actually occur in these patients. So you know asking those questions is important. And then, jake, I know you want to talk a little bit about drug induced or drug induced.

Speaker 2:

You know vitamin depletion and there's several examples of that or drug-induced vitamin depletion, and there's several examples of that we're credited to. To your point about drug-depleted, nutrition-depleted medications and things like metformin, that I always go to because.

Speaker 2:

I really like that as our example. The end statement of the study was that the study found no evidence that daily multivitamin consumption reduced the risk of death from conditions such as heart disease or cancer. Right, fantastic, diabetes, right, oh yeah, yeah, right. And there are other diseases that are not listed. There are other things that go into this. So I think that this is just adding to the ongoing body of evidence.

Speaker 2:

But again, I err on the fact that we are interventionists. We identify and resolve medication-related problems in pharmacies and our community health workers identify and resolve health-related social needs, and so through that combination we can look at this and say what are the right drugs for the right person, and I think that that's the end-all be-all. And sometimes it just might be a multivitamin. I had a really old patient that would come in and the store that we were at is a more affluent store in a neighborhood and our sister location was in a less affluent area. So in our location I had the little old man that came in from his house, walked through the neighborhood, came in and he would buy his like $50 THC vitamin. That's what he wanted, that's what he was able to afford. That gave him peace of mind, but there is mind health and his physiological and his mental health benefited from a $50 a month vitamin Sure and there's value to that.

Speaker 3:

Yeah, no, there's no doubt about that. And again, you know it's certainly not to you know again, if a person feels that they're getting a subjective or objective benefit from taking a multivitamin day, again, you know, there's no, there's no real harms associated with it except wallet depletion. So, yeah, you know, that's always been kind of my take on things, like, yeah, there's not a lot of data, you know, at a population level. If you personally want to give this a shot, yeah, terrific, you know, try it for a month, try it for two months, see what you think. You know, I think that's certainly reasonable to say too.

Speaker 3:

And, and you know, I think the other piece too, of course, like so many things, is, you know, you pointed out, you know there's a lot of, you know, branded multivitamins as opposed to the cheap store multivitamins. And of course, you know pointing out that you can. You know the cheap vitamin A and the cheap multivitamin that's still, you know, goes through a rigorous process is the same as the expensive, you know, time release vitamin A. I totally agree with that as well. So, yeah, I mean, you know patients like supplements because it feels like they, it gives them some control over their own health, instead of a doctor. Tell them you must take this for your high blood pressure. You know they go, you know. Okay, wait, you know what. I'm going to take care of this.

Speaker 1:

Yeah, well, I think you know. I think too. I think the reason that this is such a nebulous topic is because there isn't a lot of data. So back to your point, jeff. You know there does need to be more evidence, but there is some evidence out there and I think that people in this space would probably point to that. But to your point too.

Speaker 1:

I think you know a multivitamin is sort of like just throwing it all out there, whereas if you're low on vitamin D, as an example, like that's something targeted. So I think that's maybe the conversation too that pharmacists can have with patients is why are you taking it? I think you said that, like if you wanna just throw money out there and somebody told you on TikTok, great, but really, why are you taking it? Like, what is the reason? And a multivitamin is similar to you know, it's why I tell everybody.

Speaker 1:

You know, if everybody's like oh, I'm congested, what do I take for that? I've got this drug that has like five things in it and I'm like okay, well, you don't have a cough, you don't have. You know, like those multiple products that are in those over the counter just make me crazy, because everything should just be. You know you usually have like one or two symptoms, not five all at once. So it's similar to a multivitamin. I think that you know if you're really targeting something, let's spend your money there, versus a multivitamin which has a ton of stuff in it that you don't need. So I think maybe that is that's a conversation to have with patients as well. Yeah, absolutely.

Speaker 3:

And again you know, yeah, I have an older patient with macular degeneration. Yeah, here's some beta carotene and vitamin C and vitamin E. Yeah, there's good studies showing that it helps. I have a patient with osteopenia osteoporosis. Yeah, you probably should go ahead and be on calcium and vitamin D. Even if you drank a lot of milk, you should probably be on both of those. So, yes, I mean targeting those things I think are very important.

Speaker 1:

Yeah, and I think too, as pharmacists, you know, we just don't know a lot about that stuff, because a lot of times people, like you said, are going to, like you know, a health nutrition store or a big box store and, you know, just grabbing it, and so they don't often come to you as the pharmacist to ask those questions. Or even in the hospital, when you see med lists, you know, like just asking some of those questions and trying to delve into it. I think it's really important for us to understand why people are doing, you know what they're doing, what their true end goal is, so that we can really guide them on how best to spend their money.

Speaker 3:

Yeah, I've made this joke many times. Many of my friends and family knows that. Yeah, nothing irritates me more than when, you know, a little old lady walks into GNC at the mall and some high school you know, grad, you know attempts to tell her oh, well, you have diabetes Well this is what you need. It's like uh-huh yeah.

Speaker 1:

But I think we've let it happen too, you know. I mean people don't think to come to a pharmacist to ask those questions, because sometimes we don't know the answer and so we just say like aisle three, you know. So I think it is important to know what the you know, what are the questions to ask them and what are the recommendations. I mean, we need to have that in our back pocket, or they're going to go to GNC. Well, any last comments. I think we've kind of covered all the multivitamin angles, Jake. Anything else to wrap up?

Speaker 2:

No, I think you know everything that you and Jeff just said about GNC or other locations and thinking about it just boils down to medication indication, and I think that that's the mantra that we should have, and medication is dietary supplements, and so that should be inclusive in our conversation, absolutely.

Speaker 1:

A hundred percent, yeah, and I think because of this study. You know it is getting media press, so patients will have questions and they want your opinion as the medication therapy expert. So hopefully we've given you some tools to be able to answer those questions. If you are a CE plan member, don't forget to claim your CE credit for this episode, and if you know others who could benefit from this conversation, please be sure to pass along this podcast as well. And that is it for this week. So thank you again, jeff and Jake, for joining us on this topic. As always, everyone, have a great week and keep learning. We'll talk to you next week.

Speaker 4:

Thanks for listening in. Claim your CE credit by clicking on the link in the show notes and check out CE Impact's other education at CEImpactcom, where we curate the most important information in pharmacy and medicine to deliver straight to you. Join today to connect your learning to practice.