Vitamins verses Trust

Once-upon-a-time, when a patient said they were taking a vitamin, most doctors would simply shrug their shoulders and say, “well, I guess its OK, it couldn’t hurt.”   There was little research to judge the affect of vitamin supplements, so there was no reason to take a stand.  That is no longer true.  Now we have published data on many vitamins and we can say that for most people they do not work.  More importantly, there is increasing research that says manufactured, chemically synthesized nutriment compounds in a pill, can be deadly.

For this reason, I am likely to ask my patients if they are taking a vitamin and, if so, which fabricated additive and how much.  Therefore, I asked Bill, while he was in the office receiving chemotherapy for Hodgkin’s disease, what alternative therapies he was using.  When he informed me that he swallowed a multivitamin (MVI), large doses of Vitamins C and E, as well as a B complex preparation, I advised him to stop.  To my astonishment he responded, “Well, you only want me to do that because you make a lot of money on chemotherapy, and vitamins might put you out of business.”

Bill’s response, he lack of trust in my advice, disturbs me at several levels.  He fails to understand and does not wish to learn the present state of science regarding nutrition. In addition, there is a major problem regarding his perception of my motivations and therefore the veracity of my guidance.

Let us be clear; in the absence of malnutrition, malabsorption and a few uncommon medical conditions, there is absolutely no reason to take a multivitamin.  They do not prevent or fix anything.  Originally developed for starving populations and hungry soldiers during the Second World War, they have no place in a society with access to a broad range of foods. More importantly, there is increasing data that people taking a multivitamin may become less healthy.

Antioxidants such as Vitamin E, beta-carotene and probably high doses of Vitamin A, are harmful.  Supplemental doses of Vitamin C are useless and ultra-high dose Vitamin C, whether oral or IV, cannot be supported.  Excessive amounts of folic acid and B vitamins seem to do nothing.  Only vitamin D, with calcium, is of some benefit in women, and even that data is shakier than we would like.

I can accept that Bill has not learned this information, the 27 billion dollar-a-year American vitamin industry goes to great trouble to confuse good nutrition with artificially formulated tablets in pretty bottles.  Most people do not understand that vitamins are critical and fabulous, but only in their natural form.  Our bodies have spent millions of years learning how to gain value from an orange, apple or sweet potato. To think that a chemist in a lab is smarter than eons of evolution and can make super-nutrition in a pellet, is hubris, but I understand Bill’s confusion. Nonetheless, what does it say about our doctor-patient relationship if he does not trust me?

In New Jersey, our oncology practice is presently treating over 150,000 patients.  A dozen people in my family have had cancer. What kind of a monster would I have to be to deliberately ignore affective therapy, in order to make money?   Is it likely that the more that 35,000 members of the American Society for Clinical Oncology (ASCO), the dominant clinical cancer organization in the world, could keep the secret, if vitamins really worked?  Is it not more likely that if anyone had the cure, they would rush to the highest mountain, shout out the news and become the most famous (and rich) individual in health history?

So, if Bill does not trust my recommendations or motivation, why is he coming to see me at all?  I would surmise he feels trapped between getting state-of-the-science care and a distrust of that science.  As he watched the tumors grow, as he did his own research of his choices, he was limited to few alternatives. However, like anyone else in that position, he is not happy with how that decision process ended; sitting in an office with an IV dripping chemo into his arm.  I can empathize with his anger, fear and confusion; the feeling of being trapped.  Nonetheless, I have difficulty understanding why he does not see me as friend, as someone who has his back, rather than as a leach feeding off his suffering.

During our brief conversation in the chemo suite, which I finished by giving him a written review about the risks of vitamin supplements, I did not have time to dig deeper into his concerns.  If we are to continue together, I will need to understand his incentives, goals and how he makes decisions.  Otherwise, I am afraid his health will suffer because of mistakes, by him or me, born of poor communication.  Curing his cancer requires not only that he understand me, but that I trust him.


  • Liz
    Hang out on many cancer lists and you will find it eye opening. Clearly we need to teach more practical science in K-12. Sigh. 1) The "big bad pharma conspiracy" (eg they corner the market for profit shutting out any of the real cures, and these same folks forget that the seller of snake oil makes a mint; they don't care if it hurts us as long as they make a profit; along with forgetting if there really was a cure from carrots pharma would purify it, patent the purification and then make a fortune selling it) which with the very public information about the recall of just a tiny fraction of the drugs out there, combined with cognitive biases - especially the one where you over estimate the frequency of something when you hear about a rare event (recalling a drug), and you have some people question anything connected with FDA approved drugs. And of course when people talk about side effects that can be scary and so "natural and alternative" sound less scary as they are billed as gentler… and chemo is "harsh chemicals"… (see #2 below) 2) If it is natural it must be better and not hurt you… umm yeah radon, arsenic, night shade are all natural and can hurt or kill you… 3) If it is alternative it is a "family member" of natural, also see #1 above as big bad pharma is conspiring prevent the cure from coming to market 4) Diet will cure you as diet has hurt you; antioxidants will cure you, failure to take them is what caused your cancer to begin with (and the corollary for oncologists is talk with each and every patient about how high doses antioxidants can reduce the effectiveness some chemos since you want the "bad" cells to die) 5) Grasping at straws. Snake oil salesmen are very, very good at selling their wares as less toxic, will cure you, natural, etc. - they are good at not triggering common cancer fears and reassuring the ones you have already had triggered. They are selling hope; hope at a level that more honest and realistic oncologists will only offer up at the cure level if they are reasonably sure it is true. They also prey on cancer patients' fears (be they of losing their hair, side effects, of dying…). is a sad website to read in terms of the number of quacks out there and what they are selling. 6) Lack of understanding of basic science principles. Testimonials and "n's" of one do not prove anything. Give me an hour and I can create a great website, complete with testimonials and photos pulled off the web - not to mention you can only get the cure from me, and oh, by the way, I don't accept insurance (related to the big bad pharma theory is that insurance won't reimburse due to the far reaching influence of the evil pharma's preventing FDA approval, wanting to suppress the cure…). Besides dead people don't leave testimonials. If one, for example, is willing to accept that science has determined that a sentinel node biopsy is a good as removing all the nodes; that a lumpectomy (breast cancer) with radiation is as good as a mastectomy… then why are they unwilling to accept that chemo based in science is also better than carrot juice, coffee enemas, and infused "purified" urine (to name just a few snake oil options out there)? Science is like gravity - it works all the time, not just when you want it to. In fact gravity works even when you don't want it to (see America's Funniest Home Videos for some examples of that ). 7) Lack of knowledge about whatever cancer the person has, the treatments… along with information overload, fear, no understanding on how to separate out the garbage from the credible on the web (or in books, or TV…). With hundreds of thousands of pages coming up in a search, few look past the first few pages, few have enough knowledge to narrow is incredibly difficult to locate the credible information initially. It would be helpful if oncologists would hand out a list of websites that only have credible (and understandable at the 6th to 8th grade level) information. The list needs to be fairly long so they keep seeing the same credible things over and over. quackwatch needs to be on there too. 8) Yahoo groups support groups, online message boards… Some are better than others when it comes to keeping misinformation off. Many people on those lists ask what they should do, some of the ignorant suggest snake oil in the same post as the credible. People often can't tell the two apart and since it is now a "personal recommendation" tend to put more credibility in it. On some lists people are slammed for pointing out snake oil as "any decision you feel comfortable with is the one for you" (I was slammed and banned from one list for repeatedly countering snake oil with science and responding that no not every choice is the right one if you want to live). 9) On the vitamin subject we grew up being told to take our vitamins and it would make up for poor diet; all the publicity about how lack of this or that increases cancer risk, therefor some presume taking more is better… 10) Distrust of oncologist's information - one line of reasoning used by snake oil sales people is that oncologists make a fortune giving chemo so they have incentive to give it even if it does no good; doctors are in cahoots with the evil pharmas which either biases their judgement or they push chemo because of the profits (thus snake oil is better because snake oil sales people motives are "pure") 11) Somehow if something is in writing people tend to believe it more and there is a lot out there based on bunk that is comes up on the first search page of google and so when it is in contradiction with what you say AND you do not bring up what they are not telling you they found to tell them that info is wrong, you must be hiding something, be ignorant about this… and since you are giving them bad news and not reassuring them they WILL be cured, they would rather believe the snake oil sales people as they are promising what they want to hear… (add ignorance of even basic science and this compounds the problem). 12) Related to # 11, TV doctors pass out misinformation, PBS fundraisers and Dr. Oz, include some snake oil salesmen on their shows which gives them credibility. Celebrities spout garbage but their garbage gets a broad reach due to their celebrity status (and it if is in print it must be true)… So… if you'd like to get rich quick trade in both science based medicine and sell snake oil on the side. That should cover both bases for "the cure" LOL (NOT!)… Seriously though I think it would be really helpful for oncologist offices to hand out a list of websites (like an entire page full so people get hit with the same information on every site and it starts to sink in) of credible information. The brochures are too superficial and don't answer enough questions. I have a freaking PhD, read science and with each new cancer spent hours trying to make sure what I was looking at was credible when it wasn't a site connected with a comprehensive cancer center or the American Cancer Society… If I struggled with that with a new cancer, think how hard it can be for those who are years from school, forgotten any science they once knew, are overwhelmed and scared looking for cures...
    • Liz
      Opps - realized this also sounds like a slam of support lists - in fact it is not for the ones that stick to science (as a bunch do). The emotional support you can get on there is really helpful. The help with side effects of chemo in terms of what is "normal and usual" and what people haven't heard of so best call your onc is a common conversation (especially nausea, constipation, etc.). Also people give suggestions of things that help for side effects. For example I learned from one of those lists about how extended release Claritin D can help with neulasta bone pain. My oncologist hasn't mentioned it, I bought it up, he was of the opinion of can't hurt might help, I tried it and OMG the difference it made in the agony level. By the way, the "not brought it up" increases distrust in one's doctor for some. This lists also bring up treatments not mentioned by your oncologist which is a mixed bag as snake oil is mentioned too - but it was from a list I learned about rituxan bendamustine about 3 months before it because a standard of care, read up on it and asked about it - again not brought up by my oncologist - he generally will only discuss what is current standard of care and that man is ON the committee that determines that so why he didn't mention it to me as an option is beyond me - but stuff like this decreases trust too, rightly or wrongly. Of course the problem you mentioned is found in doctor offices beyond the specialty of oncology...
  • Stacy Snyder
    Dr. Salwitz , With deep respect I believe that you are unaware of the well designed studies that have shown benefits for vitamin therapies. Of course synthetic vitamins in well nourished individuals are of no benefit and full disclosure is necessary for physicians to treat effectively. Vitamin B6 can reduce the severity of Palmar-Plantar Erythrodysesthesia. May I send you some citations ? All best, Stacy Snyder
    • Liz
      Stacy - the problem is that many of the studies have mixed results or early studies show good results but then later, better designed studies show harm for some subset of people (or all people). My mom's vitamins that help prevent macular degeneration increase other issues - so it is a lesser of two evils situation. What he was taking about was piling on the the vitamins where, in this case, there was no discernible benefit and the preponderance of evidence is mounting that except in some cases, with specific diseases (like you mention above), many do no good and some do harm if taken in too large a quantity.
  • Mitch Silverman
    Another example of a study that shows a potential benefit of taking supplemental vit E in an elderly nursing home population. Submitted for your consideration: However, in a study of 450 Boston- area nursing home residents (average age: 85), those who were given 200 IU a day of vitamin E for one year had 20 percent fewer colds than those who were given a placebo. While that’s only a modest benefit, “colds in older people are a more serious problem than in younger people,” notes lead author Simin Nikbin Meydani.
  • Bridget
    When I was diagnosed with my first cancer, my primary physician encouraged me to add complex vitamin B and also vitamin D to my daily routine. Blood tests revealed that I was deficient in both in spite of eating a healthy diet of fresh vegetables, fruits, and some chicken and fish. As my cancer treatment went forward, none of the oncologists questioned the recommendation. Now, 4+ years beyond diagnosis #1, and 2 years beyond diagnosis #2, I still take my daily dose of vitamins while managing a good diet. This vitamin value question is one I will raise in my next visits with the oncology team as well as with my primary care doctor. On a personal note, seeing any of these physicians as my friends does not resonate with me. I look for competence, clarity of communication, and a sense of calm in the clinic, plus a clean environment. I suspect that each of them is so busy, that 'out of sight, out of mind' is the phrase that best describes their feelings for me. I always come prepared with my questions typed up, a list of anything I've read, and general thoughts about my state of well-being. And I always hope they're doing OK in their demanding fields of practice. But no, I don't see us as friends. Cancer has thrust us into a round of appointments and assessments, tins of Christmas cookies for them, and the continued hope of ongoing remission for me.
  • meyati
    I had a vitamin B deficiency twice. Rural, I ate tons of fresh fruit and veges that we grew-greens, corn, melons, cherries, peaches, apples. I had a B6 deficiency. In 2004, I had a B6 and a B12 deficiency.I ate well, I wasn't even anemic. I had a lot of CAT scans-no strokes, no mini-strokes, no Parkinsons, no brain cancer. They finally did lab work. The neurologist told me to go to Walmart and buy vitamin B6 and B12, as a multivitamin wouldn't have enough for me. Here in New Mexico, the doctors take Vitamin C and fish oil. I increased my Vitamin B and Folic Acid, and I went through radiation, and my lab work improved. When I saw my different oncologists last month, they asked me if I was still taking Folic Acid. The hematology oncologist said that he wished more patients took vitamin supplements. I'm glad that I have doctors with an open mind, and look at what works in their patients.
  • D Someya Reed
    Excellent comments here on an excellent post headlining an issue that many do not even think about. Liz...your detailed post is top notch, in my opinion. It is true for both sides that some vitamins have benefits for some things and some vitamins have either none or can be problematic to even toxic if taken to excess. Just like most anything. The one thing no one mentioned, unless I missed it, is that vitamins can be manufactured by good sources with good ingredients to bad sources with questionable to bad ingredients. This is not an indictment of any country or countries...bad, profit-driven motives occur in all countries. But I find it odd though not uncommon that Bill does not trust his oncologist based on profit-driven concerns yet trusts the vitamin industry which is also a profit-driven concern. Just because the profit dollars may be mathematically larger for an individual test or treatment vs. an individual bottle of multivitamins doesn't mean there is a greater profit margin for the oncologist. Would it make any difference to a "Bill" type patient if he knew (hypothetically, speaking) that the oncologist treatment has a 50% profit margin vs. a 100% profit margin for a bottle of vitamins. If this were true, who would be the more profit motivated provider? Are we basing trust on misconceptions of who's making the most money? Both providers would claim that each of them are trying to get you well. One of those things that makes you go....Hmmmm.
  • Penny H.
    I would agree with the article **for the most part**. (setting that off for emphasis) I would have liked the article a lot more, if Dr. S had put in that there are some things within the world of cancer where an oncologist is probably going to prescribe a supplement. Folic acid (1mg/day aka 1000 mcg/day) for autoimmune hemolytic anemia is one. In my case, it's cold agglutinin AIHA secondary to Waldenstrom's. First thing my hem/onc wrote was for me to take the folic acid and not depend on my diet (which, by the way is full of great veggies rich in said nutrient.) As my primary care reminds me ... it's best not to use absolutes when the subject is medicine ... there's a whole lot of gray that has to be taken into consideration.
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