**EP237: Are Supplements Good or Bad?** **Dr. Warwick:** Welcome to Dr. Warwick's podcast channel. I am Warwick, a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. I believe educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love. Hi, my name is Dr. Warwick Bishop, and welcome to my podcast and videocast station. Thank you for joining me. Today, I thought I'd talk a little bit about supplements. Patients often raise questions about supplements: what they can take, what they should take, and they also let me know what they are taking. To a large degree, there's a fair bit of confusion around supplements, and I thought I'd touch on that because it comes up with significant frequency. The supplement and vitamin industry is massive, and many people are involved both in the sales and distribution. Of course, there are many customers, and I think it's really important to stop and reflect on where they fit in, how they fit in, and what they might be for you. Often, we'll see literature popping up in the popular press, but also in the medical literature, telling us that a certain supplement, vitamin, coenzyme, or whatever it might be, hasn't been shown to be beneficial. I think this is often a cause for pause. In recent times, there's been some work on vitamin D that suggested it didn't offer any upside in the research trials that they did. Similarly, there's been work with fish oil that didn't show any benefit. So, let's just tease that out a little bit because I think it's important to understand actually what these trials are saying and therefore not potentially throw out the baby with the bathwater. Let's dwell on the fish oil reports. There was a study that looked at a good number of patients, and I've referred to it in a previous podcast. It was done over a number of years. They took relatively well people, actually, and gave them one gram of fish oil a day. At the end of the study period, which was about five years off the top of my head, they didn't show any outcome benefit statistically for the people who took the fish oil. Now, I think we have to be mindful that there are a few questions to ask before we leap to the conclusion that fish oil is no good. First of all, could those people have been fit and well enough such that their diets already included enough omega-3 oil, meaning that supplementing with more may not have had an impact on their absolute levels or improved them beyond where they already were? Possible. Is it possible that one gram a day is not a therapeutic dose? Maybe we need much more than that. Certainly, if you had a large piece of salmon, you'd find about 30 plus percent of the weight of that salmon. Your 200 grams of salmon fillet will contain significant amounts of oil. So, we're talking grams of oil—10, 20, 30, 40 grams of oil in a serve. One gram a day may have been really an inadequate dose. We also know that people with certain conditions, for example, people with very high-risk coronary artery disease with high triglyceride levels, have been shown to benefit clearly, statistically, without question, on really high doses of fish oil. In particular, EPA (eicosapentaenoic acid), which is one of the sub-fractions of the marine triglycerides in a standard fish oil capsule, and DHA (docosahexaenoic acid) is the other. Interestingly then, perhaps fish oil isn't a dud after all, and it's more about who will get a benefit from it and what dose we should be using. Should we be using a complex of all marine triglycerides, EPA and DHA, or should we be using specific marine triglycerides, only EPA or only DHA? Well, I don't think we have the answers. One of the complexities around the way we evaluate supplements is that, of course, none of these things in a medical environment in a human being operate in isolation. I had a real realization about this relatively recently. My son, as a 17-year-old teenager, was producing, as you would expect, huge amounts of testosterone because that's what teenage boys do. He was also eating everything in the house, so his nutrition was really pumped up, and he was surfing up to three or four hours at a time. His exercise was way up there. Now, during the time that his testosterone was up, his eating was maximized, and his exercise was maximized. You guessed it—he built muscle and lost weight. So, he looked strong and lean, as you would expect. However, the question then is, what if he didn't have the nutritional component of that? What if he didn't do the exercise? What if it was just testosterone alone? The point I'm trying to make is that often we need all ingredients to get the recipe outcome that we desire. I don't think you could make a cake with just flour. It needs eggs, water, and other bits and pieces. You need all these ingredients together, and I think that one of our failings—and it's one of the difficulties, actually—is that we can't evaluate the holistic impact of different supplements. Therefore, we don't know exactly how they fit in, and it might be that the fish oil studies I referred to before required other dietary or exercise-related contributors to generate an appropriate outcome. It does make some sense that perhaps some supplements are beneficial, and we probably need to think about who that could be for and why. Certainly, there is an endless number of supplements available, and if you look at any vitamin store, you'll be overwhelmed with everything that should be able to help you. So, where do you start? I had the chance to read a book relatively recently by Stephen Sinatra, a medical doctor in the United States, a cardiologist, in fact, with a significant interest and passion for supplementation and holistic medicine. His feeling for his patients, particularly with cardiac-related issues, is that there are four major supplements he would recommend on a regular basis for maximal cardiac health. These are for people who may have high blood pressure, may have irregular rhythms, may have cardiac failure, or may even have ischemic heart disease. The supplements that Dr. Sinatra recommends are: 1. Coenzyme Q10. You've probably heard of that. It's not a bad agent to be given with statins for all sorts of good reasons. 2. L-carnitine, which helps in fatty acid transport into the mitochondria. 3. D-ribose, which is a sugar and one of the building blocks for the energy system that we require. 4. Magnesium, which helps in a catalytic way to many of the processes—over 200 processes in our body—and is also good for leg cramps. So, magnesium, D-ribose, L-carnitine, and coenzyme Q10 for people with heart-related issues, certainly based on the research produced within the book by Dr. Sinatra called *The Sinatra Solution*, seem like not a bad combination of agents to at least try and assess for yourself if they're beneficial. In my own practice, I take coenzyme Q10 from time to time. I take vitamin K2 during wintertime, vitamin D. I try to exercise regularly. I try to eat a low-carb diet with lots of greens and plenty of good protein. I also take good doses of fish oil. My feeling is if you are going to take fish oil, you probably do need a decent dose if it's going to count. But I have to say all these things are, to a degree, based on trying to tie together where the evidence is, and getting clear answers in randomized double-blind control trials may never be possible. So, supplements, I reckon, are a fascinating space. People do ask about them. I know people take them. I think there's a real requirement to think about where they might fit in and what might be useful. Of course, one of the issues I didn't touch on that is important is the quality of the supplement that you acquire. Try to access it through your local vitamin store and seek advice there or through a reputable dealer online. I'm going to wish you the very best. If you've got any queries or questions or even any ideas for future podcasts, drop us a note. Until next time, I hope you live as well as possible for as long as possible. Take care and bye for now. You have been listening to another podcast from Dr. Warwick. 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