Medicine For People!

April 2011: Multiple Vitamins Part I


The Pills We Take

Convulsions in the Nursery

Little Joey looked fine at birth - ten fingers, ten toes, breathed right away. Everyone sighed in relief, and mother fell peacefully asleep in her room. But two hours later -- trouble. Little Joey began to convulse. The neonatal team administered anticonvulsants, but the medicine did not help. They tried the second-line anticonvulsants. No luck. They made another call to the pediatric neurologist, who thought a moment and then ordered 100 milligrams of intravenous vitamin B6. The younger nurses looked at each other askance, but the afternoon supervisor shook her head. "No questions. Call the pharmacy and let's get it up here."

The supervisor remembered hearing of a similar situation, a convulsing child for whom no medication worked. Only vitamin B6 did the trick. Such children don't come along frequently1, but this might be one. Sure enough, five minutes after the infusion Little Joey relaxed quietly into his crib. He'd had the misfortune to be born with a genetic variant of the enzyme (an enzyme is a biochemical reaction accelerator) called glutamic acid decarboxylase (GAD). His brain could produce GAD just as fast as yours, but it was a variant GAD and could not produce normal amounts of brain-calming gamma-aminobutyric acid (GABA). Without adequate GABA, little Joey was fated to convulse.

Your brain requires a normal amount of vitamin B6 for its GAD to make adequate GABA, but Little Joey's GAD and consequently his brain only worked correctly when flooded with vitamin B6.

Micronutrient Needs

I tell you about Little Joey as example of something I've learned over the years. Different people need different amounts of each micronutrient. Micronutrients are substances we require in small amounts in order to stay healthy. Most micronutrients are vitamins and minerals. See a full list.

For some years, I've been one of those who recommended "fail-safe" doses of essential vitamins and minerals, doses that would meet any conceivable need. Now I conclude that is overkill. Micronutrient needs vary so much between individuals. We can't all pop the same vitamins and get the same results. In this newsletter, I will give you some background for understanding these needs. In our following newsletter, I will get down to brass tacks and make recommendations.

Adequate Nutrition Defined

We use several terms to describe adequate amounts of such nutrients: The RDI, the EAR, and "Enough." The RDI and EAR are quantities set by the Food and Nutrition Board of the Institute of Medicine Here's what they mean.

EAR, the Estimated Average Requirement, is the lowest measure for what we need. These requirements come from a compilation of scientific studies and are designed to satisfy the need of 50 percent of people. For vitamin B6, the EAR for adults is 1.1 milligram per day. By definition, if everyone in your family obtains 1.1 milligram of vitamin B6 daily, half of the family will get enough, and half will obtain too little.

RDI stands for Reference Daily Intake. You're probably more familiar with the term Recommended Dietary Allowance2 (RDA), which has been replaced by RDI. Recognizing that some individuals, like Little Joey, have unusually high requirements for any given micronutrient, but that most people do not, the RDI identifies the amount of the micronutrient required by 97.5 percent of healthy individuals.

Enough - when we move from populations to individuals, then the concept of "enough" comes in. Enough is what you, as an individual, require to function well and be healthy. For two or three percent of the healthy population, the RDI - by definition - is not enough. In the case of vitamin B6, the RDI is 1.3 to 1.7 milligrams. People with acute or chronic illness are not considered when setting the RDI, and these people often require greater amounts, 10 milligrams per day in the case of people on kidney dialysis, for example. And a very few people, like Little Joey, require a lot more. He is going to convulse unless he gets between 50 and 200 milligrams each day.3

Micronutrient Deficiency: Quiet and Common

If we all consumed the RDI for every micronutrient, most of us would get what we need. However, since the 1970s, the National Health and Nutrition Examination Survey by the Centers for Disease Control has consistently found that, for every nutrient surveyed, a surprising number of people consume too little.

Micronutrient Deficiency

Source: Proceedings of the National Academy of Science November 21, 2006 Vol 103 no 47, pg 17589-17594

This table shows that over nine of 10 people fail to obtain even the EAR (Estimated Average Requirement) for vitamin E. Remember, the EAR is the amount that satisfies only the half of the population with the lowest needs and is much less than the RDI.

Whether we look at the general population as in the table above, or at specific groups, we still find deficiencies. About 9 percent of children are deficient in iron.4 Adults on weight loss diets consumed the RDI for only 12 of 27 essential micronutrients. To quote the study "Six micronutrients (vitamin B7, vitamin D, vitamin E, chromium, iodine and molybdenum) were identified as consistently low or nonexistent in all four diet plans."5

Why Don't Deficiencies Show?

When you look at the people around you, most seem to do well despite their deficiencies. Why, you intelligently ask, do we not see people falling over on the sidewalk from vitamin deficiency? The answer is that we borrow against tomorrow. If we are short of vitamin E or some other micronutrient, available supplies are prioritized to keep us right-side-up and walking. But there is a long term price to pay. Pregnant women miscarry with insufficient vitamin E. With many micronutrient deficiencies, maintenance and repair get short-changed, leading to premature aging.6 Our physiologic systems work very similarly to our governments. When resources are short, they go where they are most needed, and maintenance of infrastructure is left for later.

Help! - What Do I do?

The best solution to the deficiency problem is to eat a nutrient-rich diet. Examples of nutrient rich foods are whole grains, fresh vegetables and fruits, nuts (except peanuts), and small amounts of dairy, fish, poultry, and beef. In other words, you might eat a breakfast of oatmeal with fresh fruit, a lunch of bean soup and salad and a supper of fresh fish or chicken breast with two vegetable side-dishes. Snack on fruits or nuts. These foods give you lots of micronutrients per calorie.

A nutrition-poor diet, on the other hand, is high in fats and calories, low in magnesium, bioflavonoids, carotenoids, minerals and vitamins. An example of a nutrient poor diet would be packaged cereal7 for breakfast, a "fast food" lunch, and pizza and a token salad for supper.

We can test for nutrient levels in your system. In our office, we routinely measure a few micronutrients such as iron (tested by a ferritin level), vitamin D, and potassium. However, to test every nutrient would cost over $5,000 dollars.8 Imagine you had to pay that much to discover how much fluid was in your automobile transmission, brake system, oil system, cooling system, and wiper fluid reservoir. It would make more sense just to buy a quart of each fluid and pour it into each filling-pipe each year. Sure, some systems would already be close to full, and the quart would run out onto the ground, but at least you would be assured you wouldn't run short over the coming year.

Likewise, if we cannot be sure we are getting enough micronutrients, can we just take large amounts extra to be sure? I wish it were that simple! Next month I will explain why I've changed my mind about recommending fail-safe doses of vitamins as a preventive measure. Meanwhile, enjoy a nutrient-rich diet and the good health that goes with it!


1 Estimates of the incidence of such seizures varies, from 1 in 20,000 births in Germany to 1 in almost 400,000 births in the Netherlands.

2 Daily requirement for pyridoxine supplements in chronic renal failure. Kopple JD, Mercurio K, Blumenkrantz MJ, Jones MR, Tallos J, Roberts C, Card B, Saltzman R, Casciato DA, Swendseid ME. Kidney Int. 1981 May;19(5):694-704.

Vitamin B6 deficiency was evaluated in 37 patients with chronic renal failure and in 71 patients undergoing maintenance hemodialysis (HD) or intermittent peritoneal dialysis (PD). Vitamin B6 deficiency was assessed by the in vitro activity of erythrocyte glutamic pyruvic transaminase (EGPT), without (basal) and with (stimulated) the addition of pyridoxal-5-phosphate to the assay, and the EGPT index (stimulated activity ./. basal activity). Basal and stimulated EGPT activities were below normal in the HD patients, and the EGPT index was increased in each group of patients, indicating vitamin B6 deficiency. Supplemental pyridoxine hydrochloride was given to 30 HD patients who received 1.25 to 50 mg/day (37 studies), 6 PD patients who were given 1.25 or 2.5 mg/day (7 studies), and 8 nondialyzed patients with mild to severe renal failure who received 2.5 mg/ day. In all HD patients, 10 or 50 mg/day of pyridoxine hydrochloride rapidly corrected the abnormal EGPT index and maintained normal values; with supplements of 5.0 mg/day or less, the index was often abnormal, particularly in those who were septic or taking pyridoxine antagonists. In PD patients and nondialyzed patients with renal failure, 2.5 mg/day of pyridoxine hydrochloride was inadequate to correct rapidly the abnormal index in all patients. These findings suggest that HD patients should receive 10 mg/day of supplemental pyridoxine hydrochloride (8.2 mg/day pyridoxine). PD patients and patients with chronic renal failure should receive about 5.0 mg/day of supplemental pyridoxine hydrochloride (4.1 mg/day pyridoxine). When sepsis intervenes or vitamin B6 antagonists are taken, 10 mg/day of pyridoxine hydrochloride may be a safer supplement for all patients.

5 J Int Soc Sports Nutr. 2010 Jun 10;7:24. Prevalence of micronutrient deficiency in popular diet plans.

Calton JB. Department of Nutritional Research and Education, Calton Nutrition, North Venice, FL, USA.


BACKGROUND: Research has shown micronutrient deficiency to be scientifically linked to a higher risk of overweight/obesity and other dangerous and debilitating diseases. With more than two-thirds of the U.S. population overweight or obese, and research showing that one-third are on a diet at any given time, a need existed to determine whether current popular diet plans could protect followers from micronutrient deficiency by providing the minimum levels of 27 micronutrients, as determined by the U.S. Food and Drug Administrations (FDA) Reference Daily Intake (RDI) guidelines.

METHODS: Suggested daily menus from four popular diet plans (Atkins for Life diet, The South Beach Diet, the DASH diet, the DASH diet) were evaluated. Calorie and micronutrient content of each ingredient, in each meal, were determined by using food composition data from the U.S. Department of Agriculture Nutrient Database for Standard Reference. The results were evaluated for sufficiency and total calories and deficient micronutrients were identified. The diet plans that did not meet 100% sufficiency by RDI guidelines for each of the 27 micronutrients were re-analyzed; (1) to identify a micronutrient sufficient calorie intake for all 27 micronutrients, and (2) to identify a second micronutrient sufficient calorie intake when consistently low or nonexistent micronutrients were removed from the sufficiency requirement.

RESULTS: Analysis determined that each of the four popular diet plans failed to provide minimum RDI sufficiency for all 27 micronutrients analyzed. The four diet plans, on average, were found to be RDI sufficient in (11.75 +/- 2.02; mean +/- SEM) of the analyzed 27 micronutrients and contain (1748.25 +/- 209.57) kcal. Further analysis of the four diets found that an average calorie intake of (27,575 +/- 4660.72) would be required to achieve sufficiency in all 27 micronutrients. Six micronutrients (vitamin B7, vitamin D, vitamin E, chromium, iodine and molybdenum) were identified as consistently low or nonexistent in all four diet plans. These six micronutrients were removed from the sufficiency requirement and additional analysis of the four diets was conducted. It was determined that an average calorie content of (3,475 +/- 543.81) would be required to reach 100% sufficiency in the remaining 21 micronutrients.

CONCLUSION: These findings are significant and indicate that an individual following a popular diet plan as suggested, with food alone, has a high likelihood of becoming micronutrient deficient; a state shown to be scientifically linked to an increased risk for many dangerous and debilitating health conditions and diseases.

6 PNAS _ November 21, 2006 _ vol. 103 _ no. 47 _ 17589-17594

7 They may add ten or so vitamins to the cereal, but this comes nowhere close to the micronutrients in whole foods.

8 As an example of this cost, the standard test for vitamin B12 costs $79, but doesn't always identify vitamin B12 deficiency. A more thorough analysis costs about $340. Multiply that by twenty to thirty vitamins and minerals and you've got a not insignificant expense.



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Medicine for People! is published by Douwe Rienstra, MD at Port Townsend, Washington.