Archive for the ‘Vitamins’ Category

Can Cod Liver Oil Improve Your Health?

Q: My neighbor swears by cod liver oil and says I should try it. Could it improve my health?

Drinking cod liver oil may help you if you happen to be deficient in either vitamin A or vitamin D. A type of fish oil, cod liver oil is a good source of the fat-soluble vitamins A and D. It also may contain Omega-3 essential fatty acids like other types of fish oil, helping ease achy joints and minor muscle aches.

Although it’s has been around a long time, cod liver oil didn’t start out as a medicine. It was originally a byproduct of the Norwegian fishing industry and commonly used to soften leather and as a hoof dressing for horses. Then in the 1800s German physicians discovered that cod liver oil cured children of rickets, a common disease at that time that caused serious bone deformities. It was also used successfully to treat joint aches, gout and “obstinate constipation”.

According to the United States Pharmacopeia (USP), Cod Liver Oil, USP is “a thin, oily liquid with a characteristic, slightly fishy odor and a definitely fishy taste” made by “steaming the livers of the Atlantic cod, then straining the oil that rises to the top of the vat or kettle”. Cod Liver Oil, USP lists 3 main ingredients: vitamin A, vitamin D and Omega-3 essential fatty acids.

By 1851, cod liver oil was declared “one of the most esteemed remedies currently available”. Doctors recommended it but children hated it and suggestions on how to improve the “fishy” taste of cod liver oil began to show up in medical and pharmacy references. The 19th edition of The United States Dispensary published in 1907 contains this advice for Cod Liver Oil, USP: “It may be taken alone or mixed with some vehicle calculated to conceal its taste and obviate nausea. Peppermint oil has been found to be helpful.” My favorite suggestion, taken from the same source, is to “chew a small piece of orange peel before and after taking the medicine.”

Cod liver oil may improve your health if your diet is low in either vitamin D or vitamin A. Vitamin D is essential to incorporate minerals such as calcium into new bone tissue. A nutritional deficiency of vitamin D causes rickets in children and osteomalacia in adults. In rickets, newly formed bone lacks minerals and is too soft, causing crooked bones and skeletal deformities. In adults, vitamin D deficiency causes weak bones, or osteomalacia. Deficiency of vitamin A can cause growth retardation, night blindness and an increased susceptibility to infections.

Each teaspoonful (5ml) of the official product of cod liver oil as Cod Liver Oil, USP contains 850 USP units of Vitamin A, 85 USP units of Vitamin D, and approximately 1 gram of Omega-3 essential fatty acids at a concentration similar to salmon oil.

The dose of cod liver oil recommended for children is one teaspoonful 3-4 times daily, and one tablespoonful (3 teaspoonfuls, or 15ml) 3-4 times a day for adults. Other formulations of cod liver oil besides the standard version contain extra vitamin A or D that’s been added by the manufacturer. The amount of Omega-3 fatty acids in cod liver oil varies, with formulas using Atlantic cod having the most and those from Pacific cod having little to none. It’s interesting that cod liver oil was considered helpful in chronic rheumatism (joint or muscle aches) because at least one product contained nearly the same concentration of Omega-3 fatty acids as today’s salmon oil supplements.

To reduce the prevalence of rickets in its children the United States began fortifying milk in the 1930’s with added vitamin A and D. Every 8 ounce serving of cow’s milk has 100 international units of Vitamin D which is 25% of its recommended daily intake and 150 units of vitamin A, which is 10% of its recommended daily intake. Today’s ready to eat cereals are also fortified with 10% of the recommended daily intake of both vitamins A and D. Rickets is now very rare in the United States.

Cod liver oil was one of the first effective vitamin supplements available, but thankfully there are more palatable options today to prevent deficiency of vitamin A and D. One tablet of either Centrum Silver® or Flintstones® chewable is today’s modern, and tastier, equivalent.

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Do You Need Vitamin E?

Q: How much Vitamin E should I take? Is natural Vitamin E any better than synthetic?

Vitamin E is a fat soluble vitamin that works as an antioxidant. An antioxidant helps protect your cells from damage by compounds called free radicals, which are produced by your body during metabolism. It was hoped that Vitamin E’s antioxidant action could decrease the risk of developing cancer, cataracts, heart disease and stroke, but in carefully designed clinical studies Vitamin E supplementation did not provide any benefit. In fact, Vitamin E supplementation was instead associated with an increased possibility of death, hemorrhagic stroke (stroke caused by bleeding into the brain) and prostate cancer.

How much Vitamin E do you need? According to the National Institutes for Health (the NIH), the recommended intake of Vitamin E for adults is 22.5 International Units (IU) daily. Although most Americans get about half that amount from their diet, Vitamin E deficiency is not very common. Vitamin E needs fat for it to be well absorbed, so eating a very low fat diet or having a disease that interferes with digestion or absorption of fat such as Crohn’s disease or cystic fibrosis can increase your risk of becoming deficient. Vitamin E deficiency may cause nerve and muscle damage with numbness in the arms and legs, muscle weakness, and vision problems. Vitamin E deficiency can also interfere with the effectiveness of your immune system.

Should you take a Vitamin E supplement? If most Americans get less than the recommended daily amount of Vitamin E in their diet, would taking it as a supplement make sense?

Most multivitamins  include 30 IU of Vitamin E as alpha-tocopherol, which is considered 100% of the daily requirement for adults by the NIH. High dose Vitamin E supplements of 400 IU contain over 13 times that amount. The most common forms of Vitamin E are alpha-tocopherol and gamma-tocopherol. Gamma-tocopherol is found in foods rich in Vitamin E, with nuts, seeds, oils and green leafy vegetables such as spinach and broccoli the best sources.

Vitamin E as alpha-tocopherol exists in higher concentrations in the body than its cousin gamma-tocopherol, and until recently was assumed to be responsible for Vitamin E’s antioxidant effects. That may not be the whole story. Recent research has uncovered evidence that the key to the antioxidant potency of Vitamin E is the level of gamma-tocopherol, not the amount of alpha-tocopherol in the tissues and blood. Taking a supplement of alpha-tocopherol will actually decrease the level of gamma-tocopherol and suppress Vitamin E’s beneficial antioxidant action. This may explain why alpha-tocopherol supplements have produced negative instead of positive results in controlled research studies.

One study that found high dose Vitamin E supplementation to be helpful was the Age-Related Eye Disease Study, or AREDS. A formula of 5 vitamins and minerals including Vitamin E 400 IU was used in the 5 year study. In the most severely affected study participants, the AREDS formulation of Vitamins A, C and E combined with zinc and copper showed a 25% decrease in the progression of age-related macular degeneration (AMD), a common cause of blindness in the elderly. Those with mild or no AMD did not notice any benefit, however.

Most Vitamin E supplements contain alpha-tocopherol as either the natural form (d-alpha-tocopherol) or synthetic form (dl-alpha tocopherol). The main difference between them is their potency. The natural (d-alpha-tocopherol) form is 1.5 times as potent as the synthetic (dl- alpha-tocopherol) form. Gamma-tocopherol Vitamin E supplements are now available but it’s too early to know if they can prevent  cancers, stroke or heart disease where the alpha-tocopherol form could not.

Unless you have age-related macular degeneration, taking a specific Vitamin E supplement is not only unnecessary but can cause bleeding problems, especially if you already take a blood thinner like warfarin, aspirin, or clopidogrel (Plavix®).  For More information about Vitamin E is available at http://ods.od.nih.gov/factsheets/VitaminE-QuickFacts.

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Taking Medicines On Time

As Jenny stepped on the bathroom scale she held her breath. If the glowing red numbers at her feet weren’t lying, she’d gained another pound!

Ten months ago the cramps and diarrhea of her Crohn’s disease were out of control so her rheumatologist at the Virginia Mason clinic in Seattle started her on a new medicine called prednisone. Taking it every day had solved her intestinal problems, but at a price: a raging appetite along with ballooning hips, puffy cheeks and sinking self-confidence.

They’d tried to cut her prednisone dose back several times but each time the cramps and bloody diarrhea came roaring back. Finally she’d had enough and went back to Virginia Mason to insist they take her off the prednisone no matter what before she turned into the Incredible Hulk.

Her doctor agreed. “But this time, before we try to taper it let’s move half of your prednisone dose to the evening first.”
“But I’m already taking the prednisone in the evening.”
“What? When did you start taking it in the evening?”
“I started taking it in the morning but it really upset my stomach so I ended up switching it to dinnertime instead.”
“No wonder we couldn’t get your prednisone dose down!”

Who knew taking a medicine at a certain time could be so important?

How about you? Are you taking your medicine at the “right” time? With some medicines it can make a big difference in how effective the medicine is or how much you are bothered with side effects. Some medicines should be taken on an empty stomach to help you absorb each dose, while others are best taken with food to avoid stomach upset. And a few medicines are more potent if taken at a particular time of day.

When instructed to take a medicine on an empty stomach you should take it at least 30 minutes before eating or 2-3 hours afterward. The thyroid replacement medicine levothyroxine and the stomach acid blocking medicine omeprazole work best if you take them first thing in the morning, about 30 minutes before breakfast.  With the bone building medicines alendronate (Fosamax®) or risendronate (Actonel®) even plain coffee can interfere with getting it into your body.

Most medicines should be taken with food. Stomach upset is the most common side effect reported by people taking medicine in clinical trials, where they keep track of every possible side effect. Unless told otherwise, it’s much easier on your stomach to take medicines with food, especially antibiotics, vitamins and minerals. Many antibiotics can cause nausea, cramps and vomiting if they’re all alone in your stomach. A common diabetes drug called metformin (Glucophage®) is notorious for causing nausea and diarrhea. The popular pain medicines naproxen (Aleve®) and ibuprofen (Motrin®) are very irritating to the stomach, causing cause stomach pain and even bleeding if taken without food or a full glass of water to dilute their irritating effect.

Some cholesterol medicines are more potent if you take them late in the day. Medicines like atorvastatin (Lipitor®) or simvastatin (Zocor®) called “statins” are examples of this. Statin medicines work by blocking the last step needed to make cholesterol, and because your body makes cholesterol at night, statin medicines drop your cholesterol better if you take them in the evening or at bedtime.

Why did Jenny have trouble tapering her prednisone when she took it in the evening? Your body makes an important hormone called cortisol. Cortisol helps you respond to stress, and you make more of it or less of it depending on how much is needed and how much is already in your body. If you take prednisone your body “sees” it as having extra cortisol around so it decreases the amount it makes the next day. As you continue on prednisone over time your body makes less and less cortisol, which can leave you vulnerable when you need large amounts of cortisol quickly to response to stress like a serious infection. When stopping prednisone it can take weeks to months for your body to recover from its lowered cortisol production.

Taking prednisone in the morning minimizes the impact it has on your own cortisol production, making it easier to taper the dose. After moving her prednisone dose from dinnertime to breakfast Jenny was finally able to get off it completely. And now she smiles when she sees the red glowing numbers on her scale each week.

What time is the best time for you to take your medicine?

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Vitamin D and Your Brain

Q: My doctor gave me a prescription for Vitamin D that I’ve taken once a week for the past few months. Now my doctor’s office called and said that I didn’t need another refill, but to continue taking it as a supplement. How much should I take?

Vitamin D plays an important role in maintaining the strength of your muscles and bones. We absorb Vitamin D from the foods we eat and our skin can make it when we are outside on a sunny day, but the form of Vitamin D in our food, in supplements, and in our skin is not yet active. Before it can help us, our kidneys must change that form of Vitamin D into an active one.

As we age our skin makes less Vitamin D from the sun and our kidneys become less efficient in changing it to its active form. Over 50% of elderly Americans are thought to have Vitamin D deficiency, which has been linked to muscle weakness, falling, and an increased risk of breast, prostate, pancreatic, colon and ovarian cancers.  Replenishing body stores of Vitamin D with supplementation has been shown to improve muscle strength and balance and decrease falls in elderly Americans by at least 20%.

New evidence published online in November 2014 in the journal Neurology links low levels of Vitamin D to the risk of developing dementia and Alzheimer disease. The Pro.V.A study followed 1927 generally healthy community dwelling elders, comparing blood levels of Vitamin D with their level of mental functioning. Those having a very low level of Vitamin D at the start of the study had a 122% higher risk of experiencing a decline in mental function over the 4.4 years of the study than those with adequate levels. Participants with low levels had a 55% increased risk of cognitive decline compared to the ones with adequate Vitamin D blood levels.

Unfortunately, it’s hard to get enough Vitamin D from just diet alone. The best source is fatty fish such as salmon, canned tuna and sardines, which have about 300 units of Vitamin D per 3.5 ounce serving. The next best source is fortified milk, with up to 100 units of Vitamin D. Milk was fortified in the United States beginning in the 1930s to combat rickets, a deficiency of Vitamin D in children that caused soft bones and deformed legs. One of the most memorable and concentrated sources of Vitamin D is cod liver oil, with 1300 units per tablespoon. (I’ll pass, thanks.)

Vitamin D is called the “Sunshine Vitamin” because our bodies generate it when our skin is exposed to UVB rays in direct sunlight. You are most likely to be deficient in Vitamin D if you are elderly, have dark skin, or spend very little time in the sun without wearing a sunscreen. Other causes of Vitamin D deficiency are linked to poor absorption of fat-soluble vitamins, such as having gastric bypass surgery, inflammatory bowel disease, or taking medicines like prednisone or the weight loss agent Alli®. Alli® is designed to block fat absorption in the gut, decreasing not just dietary fat absorption but also fat-soluble vitamins like Vitamins D and E.

Vitamin D comes in both prescription and non-prescription strengths. Three forms of Vitamin D are available: D2, called ergocalciferol, D3, called cholecalciferol, and calcitriol, which is the active form in our body. All 3 are available without a prescription from 400 up to 4000 units per capsule.  The best one to use for maintaining Vitamin D levels is D3, which is cholecalciferol.

If you are considered Vitamin D deficient prescription strength Vitamin D is given: one 50,000 units capsule once a week is usually prescribed for 6-8 weeks, followed by a maintenance dose of 1000 to 2000 units daily. After you have finished the 50,000 once weekly regimen of Vitamin D, if your blood test has come back up to normal you should be able to maintain it with 2,000 units a day from either sun, diet or supplements.

Most women over 50 years old should take a calcium supplement with at least 800 units Vitamin D daily to help their body absorb and use the calcium to strengthen their bones. If you already take a calcium supplement haven’t at least 800 units of Vitamin D, then 1000 units of additional Vitamin D as Vitamin D3 daily should be adequate. Choose Vitamin D3 (cholecalciferol) for best results.

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The Importance of Vitamin B12

One of my patients is a retired Marine. A few months ago he told me that he had been suffering from pains in his legs and feet for a couple of years. His doctor had tried several different pain medicines, but none of them really did much so he quit them all and just put up with it. Then he started taking a B vitamin with a lot of B12 in it, and to his amazement, within 3 days his feet and legs stopped hurting. It’s been over 6 months and the pain hasn’t come back. He’s decided to continue the vitamin, just to make sure.

Vitamin B12 is a water-soluble B vitamin that helps your body make new red blood cells , helps your nerves work, and prevents certain kinds of anemia. A deficiency in Vitamin B12 can show up as fatigue, weakness, depression or pain in your feet or hands.

According to the National Institutes of Health (NIH), Vitamin B12 is found mostly in animal proteins, such as fish, meat, poultry, eggs, milk, and milk products. Most healthy adults get enough Vitamin B12 in their diet; those who don’t either don’t get much animal protein in their diet or aren’t able to absorb Vitamin B12 very well.
Strict vegetarians may not get enough animal protein in their diet to satisfy the recommendation of 1 to 2 mcg daily of Vitamin B12. Others become deficient because they cannot absorb it very well, like the elderly, those who have had gastric bypass surgery and people who take certain medicines.

The most common cause of Vitamin B12 deficiency is not being able to absorb it. This can be due to a condition called atrophic gastritis, which affects 10-30% of the elderly. Atrophic gastritis interferes with the ability to absorb Vitamin B12 from your food because it decreases secretion of digestive juices such as gastric acid.
Our bodies only absorb about half the Vitamin B12 we get in our diet, which is usually attached to animal based protein like ground beef or chicken. Without enough stomach acid, your body can’t break down proteins and Vitamin B12 stays stuck to the protein.

Those who don’t absorb Vitamin B12 well may notice benefit from higher amounts of supplementation.
Medicines that can contribute to poor absorption and deficiency of Vitamin B12 include acid-reducing medicines such as Prilosec® (also known as omeprazole), Prevacid® (also known as lansoprazole), Protonix® or Nexium®. Older acid-blocking medicines which also impair absorption of Vitamin B12 include Zantac® (ranitidine), Pepcid® or Axid®. Metformin, a common pill for diabetes can also interfere with absorption of Vitamin B12.
Vitamin B12 contains cobalt and is available in several forms. The Vitamin B12 that is given as a shot is cyanocobalamin. Oral supplements are available as either cyanocobalamin, or methylcobalamin, and can be purchased without a prescription.

Most people who can absorb Vitamin B12 well only require 1 or 2 mcg daily. If you are over 70, take medicine for heartburn or an ulcer or have had gastric bypass surgery, you may need more than that. 1000-2000mcg daily of Vitamin B12 as an oral or a sublingual tablet can overcome poor absorption. Be sure to avoid the timed-release or long-acting products, because they may not be as well absorbed as the immediate release forms.
Since Vitamin B12 isn’t found in plant foods, if you are vegetarian the National Institutes of Heath suggests fortified breakfast cereals as an alternative source.

Vitamin B12 deficiency can be detected with a blood test. There are several ways to get more of the vitamin: monthly injections from your medical provider, tablets that you swallow and tablets that dissolve under your tongue. Your doctor or medical provider can advise you which would be best for you to take, and how much. There’s more information about Vitamin B12 at http://ods.od.nih.gov/factsheets/VitaminB12-QuickFacts/.

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Starting a Vitamin D Supplement

My doctor just called, and last week’s yearly blood work shows that I have a significant deficiency in Vitamin D. How did this happen? I suspect it’s something to do with having to take a prescription medicine that caused me an uncomfortable sun-related rash while enjoying myself watching a baseball game while on vacation in Florida. Since that painful incident I’ve become much more vigilant about staying out of the sun, but now I’m experiencing the results of that choice.

Vitamin D is a fat-soluble vitamin that is important in maintaining the strength of our muscles and bones. We get Vitamin D from diet, sun exposure, and supplements.

Vitamin D is called the “Sunshine Vitamin” because our bodies generate it when our skin is exposed to UVB rays in direct sunlight. You are most likely to be deficient in Vitamin D if you are elderly, have dark skin, or, like me for the past year and a half , spend little time outside in the sun without covering up or wearing sunscreen.

Vitamin D deficiency can also be from not being able to absorb fat-soluble vitamins, which can happen after having gastric bypass surgery, inflammatory bowel disease, or taking medicines like prednisone or the weight loss agent Alli®.

As we age, we’ll need more Vitamin D, because our skin is less able to make it from sun exposure and our kidneys become less efficient in changing it into its most active form. Although I’m only in my mid-fifties, I’m not alone in needing more Vitamin D. Over 50% of our elders in America are estimated to have Vitamin D deficiency, which has been linked to muscle weakness, falling, and an increased risk of breast, prostate, pancreatic, colon and ovarian cancers.  Replenishing body stores of Vitamin D with supplementation has been shown to improve muscle strength and balance and to decrease the incidence of falls in elderly Americans by at least 20%.

Unfortunately,as I found out, it’s hard to get enough Vitamin D from what you eat. The best dietary source is fatty fish such as salmon, canned tuna and sardines, which have about 300 units of Vitamin D per 3.5 ounce serving. The next best source is fortified milk, which has up to 100 units per cup of added Vitamin D. Milk was fortified in the United States beginning in the 1930s to combat rickets, a deficiency of Vitamin D in children that caused soft bones and deformed legs. One of the most memorable and concentrated sources of Vitamin D is cod liver oil, with 1300 units per tablespoon. Thanks, I’ll pass on that…

How did I find out I needed Vitamin D supplementation? By a blood test last week that measures 25-hydroxyvitamin D in the body. If the level is less than 30, you are considered Vitamin D deficient and a 8-12 week course of prescription Vitamin D supplementation at 50,000 units once weeky is usually prescribed, with a maintenance dose of 1000 to 2000 units daily after that. My Vitamin D level was only 13, and I have just started taking 50,000 units every week of a prescription of Vitamin D supplement.

Vitamin D supplements come in both prescription and non-prescription strengths. There are 3 forms of Vitamin D available: D2, called ergocalciferol, D3, called cholecalciferol, and calcitriol. These are available without a prescription in several strengths, from 400 up to 4000 units.  D3, also called cholecalciferol, is  best one at maintaining your Vitamin D.

I’ve just started taking 50,000 units of ergocalciferol ( Vitamin D2), every week for 12 weeks, after which I’ll get another blood test to see if I’ve responded to that. If my level hasn’t risen to at least 30, I’ll be repeating the weekly supplementation for another 12 weeks. Once I get back into the normal range, I should be able to maintain my level with about 2,000 units of D3 every day, from either sun, diet or supplements.

Because I need to continue taking the medicine that caused me the sun reaction in Florida, I’m probably stuck taking a Vitamin D supplement from now on. Most women over 50 years old should take a calcium supplement with at least 800 units Vitamin D daily anyway, to help their body use that calcium to strengthen their bones. Because I already take a calcium supplement containing 800 units of Vitamin D, eventually I’ll need at least 1000 units of additional Vitamin D as Vitamin D3 daily. Choosing Vitamin D3 (cholecalciferol)  for long term maintenance seems to maintain your levels better than taking Vitamin D2.

Dr. Louise Achey, Doctor of Pharmacy is a 30 year veteran of pharmacology. Please send questions and comments to www.AskDrLouise.com.

 

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