Supplements vs Medicines

Some people believe supplements are “natural” and therefore feel comfortable to take them whilst some of the same peoole are suspicious of modern medicines and worry about taking them. Some of those who are the most skeptical of modern medicines and reject them, are in contrast very trusting of alternative medicines including supplements, vitamins or in some cases simply changing our diet.

Some people will accept claims about these alternative treatments without any evidence to support them, whilst some of the same people will reject claims about medicines despite clear scientific evidence. 

It is also true that some people who accept the validity of medical science are also a little too zealous and reject the idea of supplements, special diets, or vitamin pills being of any use at all for anyone.

I would like in this article to try and steer a middle course.

For full disclosure I am a fully trained medical doctor. And I have also worked for many years designing, running, interpreting, and communicating the results of clinical trials. I am qualified in pharmaceutical medicine as well as in psychiatry which helps inform some of the comments below about placebo and nocebo. Now I don’t say all that to say you can’t disagree with me, but just to help you see the expertise I do bring to the table on this matter.

Unfortunately even after almost two years of pandemic it remains the case that my medical qualifications, the fact that I am a scientist, means that some people will reject what I say as hopelessly biased, and somehow corrupted by the pharmaceutical corporate complex. I hope you will see that is not the case

To begin with, I think we need to blur the boundaries a bit between so called “natural” remedies and medicines. For example, a number of modern medicines start off by us finding something in a plant or other biological entity that we then purify and maybe learn to synthesise. One good example that springs to my mind of this is aspirin which is found in willow tree bark (white willow).

Secondly let’s look specifically at vitamins. In fact doctors often prescribe vitamins if someone’s levels are low or to prevent them becoming low. The tablets are then manufactured in a similar process to medicines snd I think many would consider them to be medicines. When an alternative health care provider is prescribing the very same thing that a qualified medical doctor might be prescribing is it really alternative?

Also supplements are not necessarily safe or entirely natural. In fact some of them are frankly dangerous. Apricot seeds for example can kill due to the cyanide they release in the body!

I am not anti supplements altogether but I do think we need to have our eyes open. There are substances in our foods and supplements that have pharmacological properties. What I mean by that is that these compounds act like medicines in our bodies. In other words there are either receptors in our bodies that get stimulated or blocked by them, or there is some other more indirect effect.

An example of an indirect effect would be the way some medicines and indeed some supplements can affect the balance of our bowel bacteria. This can sometimes be for good but it can also be for bad. Our bowel bacteria themselves release substances that find their way into our blood and influence our bodies, crucially this includes neurotransmitters that affect the way we think and feel. So apparently a huge part of the carb craving many people feel is related to the neurotransmitters released by some of these bacteria as they urge the body to feed them in a way they like!

Among some alternative medicine practitioners there is a dismissive attitude to evidence based medicine and to clinical trials. I think this is as unfortunate as any doctor who is dismissive of the potential value of us altering our diets and/or taking supplements judiciously.

What is clinical research? How Randomised Controlled Trials show us what works 

Clinical research is invaluable and it actually helps us see what does and what does not work.

In my view we should be much more confident about choosing to take an evidence based medicine than we are about taking a supplement that has not gone through trials.

I don’t often trumpet my own background in comments like this. But I am an expert on clinical trials. And they are complex and expensive vital tools.

For anyone who doesn’t know a randomised controlled trial is the top level of evidence. Also you can pool the results of several trials in a systematic review and meta analysis (a statistical tool) which gives even stronger evidence

The idea is simple. We recruit a group of patients with a set of criteria that aims to reduce some of the other variables but then we rely on randomisation to automatically spread other variables between the groups. One such variable might well be what supplements someone is taking. So at the point of randomisation some in each group might be taking supplements in addition to the trial medicine and some might not. Hopefully randomisation would spread those people evenly between the groups so any effects of the supplements would be cancelled out between the two groups. This is why in a clinical trial they do not usually want you to start taking supplements during treatment as that might effect the results.

The patient groups as I say are selected randomly and one group is given the drug and other either an older drug or a placebo. Sometimes there may be three or more groups so one gets the new drug, one the old one and another placebo (an inactive tablet). Obviously ethics comes into the design of studies as for example if someone is clearly in need of cancer treatment for example it would be wrong to give them nothing or a placebo.

Now when we then follow up the patients in a clinical trial we can look at differences between the two groups. Whilst some differences may indeed be due to chance, we can use clever statistics that identify what the likelihood is a specific difference we see is due to chance. Some may have seen a statement like p=0.05 in a clinical paper. That is a way of expressing the probability that the difference is due to chance. We tend to use 0.05 as a cut off for registering medicines. It means that there is a 5% chance the difference we’ve seen is due to chance alone. Sometimes trials will have results that have a p value of as low as 0.001 or lower. That means there is a 0.1% probability the result is due to chance or in other words if you run the same trial 1000 times chance would through up the results just once.

Think of it this way. If you toss a coin (which in a way randomisation is very much like) then you’d get a 50/50 chance of a head or a tail. Each time you toss that coin you reduce the chance that you get the same result. To get six heads in a row is probably something none of us have ever or will ever see. But in theory it could happen. It would happen with a probability of 0.5×0.5×0.5×0.5×0.5×0.5 which comes to less than p=0.001. Ie less than one in a thousand attempts someone would throw a head six times in a row.

So for example anyone who questions the treatment effect of some modern medicines is really saying they think it’s more likely to throw six heads in a row tossing a coin than that the drug actually works. This seems rather unlikely and so I do think we should all learn to value and accept clinical trials and their results. We do not need to be suspicious of them just because they are run by pharma companies as these trials are highly regulated.

Of course the vast majority of supplements are never going to be put through the rigour of a clinical trial as they cost so much to run. And so we simply can never be as confident that a supplement works as we are that a medicine works.

What about when there is no evidence?

To be absolutely fair the the absence of evidence is not evidence of absence.

So if we were to consider an example supplement that has never been studied in this way, we are not really able to say that we are sure it works. But that doesn’t mean we can say that we are sure it doesn’t work. This is a mistake many doctors and those who are confident to believe in science make.

An example of this fallacy that as there is not yet clear evidence which shows that Covid19 antibody levels in the blood predicts for sure whether or not you are likely to die if you are infected. But that doesn’t mean that we know that it is not relevant what your level is. It remains highly likely that the higher the level of antibodies the more likely you are to be protected. As a result of the lack of firm evidence, however, some doctors say don’t bother checking your antibodies level after a vaccine even if you have a blood cancer or other immune cause. But the full body of data for all other disease shows us that antibodies are good things and that they generally prevent disease or lessen its severity. So it is very reasonable to assume that the higher your antibody level the safer you are. And so far the clinical data is emerging that supports that idea.

Such reasoning is analogous to the way many think about vitamins. Since we know vitamins do us good let’s take higher doses in the hope it does us more good. Now this may be true for some vitamins and for some people. But that may well be becuse that individual who benefits does so because they were actually deficient in the vitamin. I take daily vitamin D because early in my disease someone did a blood level and it was very low which is quite common in those of us with blood cancer and we believe may even be part of the reason we get sick.

But it may well be that with some vitamins when we get to a certain level taking more will make no difference as we already have enough. And if we ran a proper clinical trial what we might find was that the people taking real extra vitamins and the people taking placebo extra vitamins (i.e. a tablet that has no active ingredients) BOTH reported feeling better. This would be due to the so called placebo affect. Which actually isn’t necessarily a BAD thing. If we believe are doing something about a problem we face and we trust a powerful figure who advises us to do something or ingest something our powerful minds release something called “hope”. That hope makes us look for a positive change and when we look for something positive we often notice it. And so we feel better. In fact it’s remarkable how much improvement we can sometimes make to our symptoms by this placebo effect.

Some people would go so far as to say placebo is the best studied medical intervention of all! Some doctors even advocate telling the patient they are giving them a placebo. It is remarkable how this works. As one example if you tell someone they’ve drunk a cup of caffeinated Tea but it’s really decaf the very same receptors in the Brain for caffeine light up! Yes that’s right. Your body thinks it has taken in caffeine because if all the associations between that taste and the experience of taking caffeine and it reacts as if it has taken caffeine.

In truth a proportion of the effectiveness of any medicine is due to this placebo effect. The classic example we also talk about is over the counter pain relief. Almost all of us have taken a pain pill and felt almost immediately better. But the truth is the drug in the pain pill takes longer than that to get into our system! We have actually used the placebo effect.

So if someone believes a supplement or vitamin or indeed a prescribed medicine will work then it’s much more likely it will. Even if there are no biological changes going on.

So going back to our vitamins it’s possible thet in some cases taking extra vitamins might not be needed biologically but might psychologically help us. It isn’t always simply the case that more is better. And if we go back to our antibodies illustration in fact the monoclonal antibody studies show us something interesting. If someone was making their own antibodies at a reasonable level giving them monoclonal man made antibodies didn’t help. But if like many of us they weren’t making antibodies of their own it will often be life saving.

So more isn’t always better.

And in fact more can simply mean more toxicity.

And this is an important point. Since many supplements probably in reality DO act in a similar way to medicines they also have side effects like Medicines. So we need to be aware of this.

One example is the use of green tea in blood cancer patients. At least one clinical study showed a clear benefit of this. But to get the benefit the dose required produced raised liver enzymes in many patients. This means the “natural” green tea extract was actually acting like a medicine and in this case damaging the liver. If that damage is detected early it’s not a problem as stopping the supplement allows the liver to recover. But if it hadn’t been detected thst could lead to more serious liver damage.

So a supplement someone takes is most likely not to have been proven to work like a medicine has. So that is one reason to be less confident about taking it.

It also hasn’t been tested for side effects. Going back to our clinical trials we look for not just positive differences between the groups but also negative ones. If a certain side effect happens more often in the drug group than the placebo group we conclude that the drug causes it.

So when you take a supplement you can’t be sure it doesn’t have side effects either.

But terrible side effects also happen in the placebo group of clinical trials. This is due to chance or what some call the nocebo effect where taking something you expect to have bad effects means you experience those effects.

A Classic example of this would be if you enrol someone into a trial and tell them if they get the drug they may feel nauseous since they don’t know if they are taking the drug or the placebo they may well get nauseous even on the placebo.

So sometimes we take a drug or supplement and the side effect we feel may not be caused by that drug or supplement.

Also since some supplements are really untested medicines then they may well interact with other medicines. This can be a major problem in some cases. And of course drugs interact with other drugs too. So the cocktails of proven drugs with unproven supplements has the potential of causing all kinds of chaos in our bodies.

Sometimes two drugs or supplements might cancel each other out. Or sometimes they might make each other work too well and lead to a severe side effect.

Finally the manufacture of licensed medicines is very carefully regulated and controlled. Factories are inspected. Tests are done on the end product. And we batch label them so thst if something unusual happens it is possible to recall the batch which might be faulty somehow.

There is zero regulation on the manufacture of supplements. You might be buying something that has zero of the ingredients you are looking for and instead has something toxic in it. This is a major issue. And it’s why you need to be very carful how you source supplements you want to use. It’s a bit like when as a kid my dad warned me not to eat mushrooms I picked wild. He explained thst only experts know which type of mushrooms are poisonous and which are not.

So to summarise, I am not against supplements or changes to diet. But I think we should be much less confident in them than we are in medicines that have been properly tested and not the other way round.

Just because a substance is natural doesn’t mean it works, and in fact it might do serious damage to us either directly or by interacting with another medicine or supplement we are taking.

I do believe that supplements can be helpful for sure. My issue is my cynicism and lack of faith, if you like. So I tend both for supplements and medicines not to expect much improvement and guess what….I don’t see much improvement! One of my mainstream doctors actually recently advised me to try a specific supplement that they felt might help my energy levels. I can’t remember what one it was now. But I dutifully bought it from as reputable a company as I could (and actually here is something that I wish we could have more clarity on how to know WHICH is a good company….) and dutifully tried it….and unfortunately it didn’t work for me. Not to say it might not work for others either. 

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