Popping Vitamins Or Other Dietary Supplements?

I often get patients asking me if there's something they can take to recover faster (from their injury). Most of them seem to be taking some form vitamins or other dietary supplements already.

Have a look the next time you walk into a Guardian or Unity Pharmacy here. You’ll see lots of vitamins and supplements there for sale. Not to mention the few sales assistants who will tell you what you need to be taking.

In fact, earlier in April this year, The New York Times published an article on how older Americans are hooked on vitamins.

Do we really need to be taking any extra vitamins and supplements. I've written before why there is no evidence for taking glucosamine. If you're interested you can read more here.

This may seem as a shock for those of you who are already taking vitamins or any sort of dietary supplements. Many supposedly muscle building supplements make unproven claims and may even come with side effects.

In the journal article referenced below (Gliemann et al 2013), researchers found that resveratrol (an antioxidant found in red wine) actually limited the positive effects of cardiovascular exercise. It affects your VO2 max when taken daily in high concentrations.

Those of you who take fish oil supplements beware. There is evidence that men with high levels of the omega-3 fatty acid DHA in their blood (from the fish oil supplements) are at a higher risk of getting prostate cancer.

In fact, well known researcher Professor Pieter Cohen (who was sued by a supplement maker but Cohen won) said there are only two types of supplements. Those that are safe but don't work. And those that might work but have side effects, especially at higher than normal levels.

Most vitamins are in the first category. Taking a multivitamin daily will not harm you, but it usually won't help too much either. This is why major health organizations don't recommend supplements to healthy people.

Now don't get me wrong here, If you don't have enough Vitamin C, you can get scurvy. Without iron, you can become anemic. And if you don't get enough sunlight, you may need some Vitamin D. However, all three of the above can have negative effects at high doses. Same for Vitamin E and calcium.

Unless blood tests show that you're super deficient in a particular vitamin or mineral, there is no evidence that you should be popping those pills. Even so, it's better to be getting them from real food sources.

If you're an athlete, and you're taking antioxidants to boost recovery take note of what Dr Mari Carmen Gomez-Cabrera (who is a world leading researcher on anti-oxidants) published. The antioxidant pills that you pop suppresses the oxidative stress that signals to your body to adapt and get stronger. Meaning regular use of something seemingly mild and innocent like Vitamin C can actually block gains that you've trained so hard to get in your endurance boosting mitochondria (cells).

Dr Gomez-Cabrera suggests eating five servings of fruits and vegetables daily and you won't need to pop vitamin or other pills.

To put it bluntly, vitamins and other dietary supplements just plain useless or worse than useless. Of course you can still buy them and take them if you wish. You're just lining the pockets of those of manufacture and sell them.


References

Cohen P, Travis JC et al (2014). A Synthetic Stimulant Never Tested in Humans, 1,3- Dimethybutylamine (DBMA), Is Identified In Multiple Dietary Supplements.  7(1): 83-87. DOI: 10.1002/dta.1735.

Gliemann L, Friss J et al (2013). Resveratrol Blunts The Positive Effects Of Exercise Training On Cardiovascular Health In Aged Men. 591(20): 5047-5059. DOI: 10.1113/physiol.2013.258061.

Gomez-Cabrera MC, Domenech E et al (2008). Oral Administration Of Vitamin C decreases Muscle Mitochondria Biogenesis And Hampers Training-Induced Adaptations In Endurance Performance. Am J Clin Nutr. 87(1): 142-149. DOI: 10.1093/acjn/87.1.142.

PS -After I wrote the article, another patient who runs frequently asked about taking magnesium for muscle cramps. Read the article I wrote on what causes muscle cramps and save your money.

Fat Pad Most Painful In The Knee?

I had a patient who came to our clinic recently complaining that his MRI showed that his patella (knee cap) cartilage had "worn out" completely but he didn't have any pain prior to that. He had actually gone to do his MRI under his doctor's insistence for investigating something else.

His  MRI results was like in his words "opening a can of worms" telling him what's wrong with his knees and perhaps that's why he started having pain after that.

After his ranting, I had to explain very thoroughly about the structures in our knees that cause the most pain. The information I gave him was derived from an article published quite a while ago in the American Journal of Sports Medicine but still very relevant today.

The doctors in that study came up with a simple method to document the various sensations felt inside a single subject's knees one week apart. Right knee first, followed by the left a week later. (Note that the subject had no prior knee pain).

They would arthroscopically poke/ palpate (using a specially built spring loaded device) different structures inside the knee while video recording the procedure and record what the subject's response was. Force used was between 0 to 500 grams. All this done without intra articular anesthesia. Ouch! That must really hurt.

The doctors only injected local anesthesia at the portal site (incision). The first author inspected both knees arthroscopically. He asked the patient when he poked at different structures and graded the sensation as follows (0) no sensation; (1) was non painful awareness; (2) slight discomfort; (3) moderate discomfort and (4) severe pain. This was done with with a modifier of either accurate spatial localization (A) or poor spatial localization (B).

Ready for the results? They were exactly the same for both knees. Even though it was done one week apart.

Palpation of the patellar articular cartilage in the three under surfaces (central ridge, medial and lateral facets) resulted in no sensation, or a 0 score, even with a strongest force of 500 grams. Palpation of the odd facets elicited a score of 1B. Asymptomatic grade II or III chondromalacia (wearing out) of the central ridge was identified on both patellas of the subject!

Palpation of the articular cartilage surfaces of the femoral condyles, trochlea, and tibial plateaus at 500 g of force universally produced a sensation of 1B to 2B.

The sensation from the meniscus ranged from 1B on the inner rim of the meniscus to to 3B near the capsular margin.

Sensation from the  cruciate liagaments (Anterior, posterior cruciate ligaments) range from 1-2B in the mid-portion of the ligaments and 3-4B at the insertion sites.

Palpation of the suprapatellar pouch, capsule, and the medial and lateral retinacula produced a score of 3A to 4A (moderate to severe localized pain) at relatively low levels of force (about 100 g).

The most painful structures were the anterior synovium of the knee, the fat pad and the joint capsule - 4A.

The human knee can be very complex, especially our patellofemoral joint (patella and the femur). The three asymnetrical surfaces on the underside of the patella (or knee cap) has to work together with the femur as it accepts, transfers and dissipates loads between the bones.

We know from previous research that various structures in the knee send neurosensory signals (or messages) to the brain. It is theses signals that result in us feeling pain.

Even though my patient's patella cartilage had worn out (just like the subject) there shouldn't be any pain there as articular cartilage doesn't have any nerve supply. No nerve endings means it is unable to detect pain.

Even the ACL and meniscus wasn't really that sensitive to the poking. This observation may provide an explanation for the often poor localization of structural damage that many patients experience with a cruciate ligament or meniscal injury.

Now you know, worn out articular cartilage doesn't cause you pain. The pain you have is likely to come from other structures. And you definitely don't need to ingest any glucosamine too.


Reference

SF Dye, GL Vaupel and CC Dye (1998). Conscious Neurosensory Mapping Of The Internal Structures Of The Human Knee Without Intraarticular Anesthesia. AM J Sp Med. 26(6): 773-777. DOI: 10.1177/03635465980260060601.

black and white version

A Running And Glucosamine Article I Do Not Agree With

ST 240516

"The point of journalism is to tell the truth. It is not to improve society. There are facts and truths that feel regressive, but that doesn't matter. The point of journalism isn't to make everything better; it's to give people accurate information about how things are." Sebastian Junger.

I've never started an article with a quote before, but the above quote caught my eye and I feel it is only fair to give our patients and readers accurate information about how things are (even though I'm not a journalist. Don't get me wrong I'm not blaming the writer, I just want to present an evidence based view.

Not another running bashing article - that was my first thoughts glancing through the papers today "When running wears out the knees (ST 240516). This is under DocTalk on page B10.

I totally did not agree with the author on that. There is more than sufficient evidence to show that running does not wear out your knees.

The author's article also quoted studies saying that 35 percent of patients taking a regular dose  of 1500 mg of glucosamine sulphate daily can increase cartilage regeneration.

May I kindly draw your attention to a Cochrane review where authors showed that glucosamine was generally safe to ingest but does not help with pain. I've written about glucosamine back in 2010 and 2009. Go and have read if you're keen.


Reference

Townheed T, Maxwell L et al (2008). Glucosamine Therapy For Treating Osteoarthritis. Cochrane Database of Systematic Reviews. DOI: 10.1002/14651858.CDOO2946.pub2.

Glucosamine, Chondroitin & MSM

I've had many of my patients ask me if they need to be taking any supplements. Some even tell me they swear by their daily glucosamine and chondroitin pills -the 2 supplements favored by most runners. My patients were all really convinced the supplements worked until I tell them the published evidence.

In some earlier studies, there seemed to be some evidence supporting the use of glucosamine (but not chondroitin, or MSM etc). Yes, that means you do not need anything else in your tablet or pill except glucosamine. But most if not all of those studies were sponsored by the companies who made the tablets.

Based on recent studies however, researchers looked the effects of glucosamine and/ or chondroitin on joint spaces in the knees of 572 subjects with known (x-ray evidence) osteoarthritis in their knees. At the end of the 2 year follow up, there were essentially no differences between the subjects who received a placebo (or dummy) tablet and those who received glucosamine and/ or chondroitin. It was a double blinded study, meaning both researchers and subjects didn't know who were getting the dummy tablets and who were getting the real deal.

So what's my take on this. For all those who are currently taking them and feel that they work, please carry on. If not you may feel uneasy stopping anyway. For those who are thinking of starting, well, you have the evidence before you.

Have a look at much stronger evidence not to take glucosamine here.


Reference

Sawitzke AD, Shi H, Finco MF et al (2009). The Effect of Glocosamine and/ or Chondroitin Sulphate on the Progression of Knee Osteoarthritis. International Society of Sports Nutrition.