Food vs Supplements. Is it that simple?
The food and supplement debate is more nuanced than:
you either have medically identified deficiency (think rickets and vitamin C); OR
this supplement/probiotic will make me ... less fatigued, fix my gut, fix my sore joints, deal with my hormone/immune/autoimmune problem.
Just because you're not obviously deficient in a specific nutrient or mineral doesn't mean that something isn't going awry with your body. Similarly, a supplement isn't enough for long term benefits.
While I am a conservative prescriber and user of supplements compared to other practitioners — always doing my best to use a food first approach — a food only approach may be impractical for some.
Consider a mother who is two years post-partum, has breastfed for much of that time and whose child has developed colic. This mother has changed their own eating patterns, continues to have poor sleep, and works part time. Is it any wonder given what we know about how the body preferences nutrition in breastmilk and the mothers altered habits that she has developed reflux, nutrient deficiencies (even mild ones) and anxiety. As the gut, brain and immune system interact it is, I believe, unreasonable to think that this ‘super’ woman will make sufficient food and lifestyle changes to see the benefits needed to stay well in the short term. To give this stressed and depleted mother time to get eating, sleeping and digesting back on track, supplements can provide additional support.
Given our: stressful lifestyles, soil nutrient depletion, often sedentary work, lack of sleep, out of season eating and low grade environmental toxins, it isn't surprising that our level of nutrient absorption might be compromised. If you suffer from acid reflux, IBS, IBD it is almost certain that you are not adequately breaking down and absorbing a range of water and fat soluble vitamins and minerals. Even without obvious digestive complaints or absolute deficiencies this can lead to problems like:
painful or prolonged periods;
fatigue;
anemia;
anxiety and depression;
inflammation and pain; and
issues with immunity including food sensitivities, colds, skin changes and potential worsening of autoimmunity.
This is a big topic to chew on and most people are aware that there is more to the picture than just a) Food and b) Supplements.
Lets consider then, the goal of using food as medicine + targeted supplementation
A holistic approach:
If you are struggling with any chronic lifestyle condition or a hormonal/immune problem then an evidence based approach to food and supplements would look like this:
Consider your current diet.
Consider your current working and living conditions - including stress and stress perception; exposures to environmental toxins.
Identify where food and lifestyle changes can help immediately. ie. cutting down on coffee, eliminating key gut irritants, reducing exposure to other environmental impacts, stress reduction measures. This is a process and rarely happens in one go. Sometimes you might only make one or two changes and come back to this weeks, months or years later.
Consider further changes to diet that target deficiencies identified by pathology or functional tests. Often instead of taking loads of supplements we can work out which specific vegetables and foods can impact your health condition. Examples include:
Limiting brussel sprouts, cabbage, broccoli and cauliflower which are goitrogenic foods that interfere with iodine uptake in the thyroid worsening hypothyroid conditions.
Managing protein intake for kidney function; and
Modulating FODMAPS or using an elimination diet for food sensitivities and autoimmune conditions.
Identifying genetic variants that prevent adequate uptake of some nutrients or the likelihood of cognitive decline and improving the intake of foods and cofactors that can assist.
This step is often trial and error as your response can be individual. For some the response is rapid and for others may take some time. It's at this point that I consider whether more personalised nutrition via Metabolic Balance may be suited to you.
After ruling out what is likely to be disrupting biochemical processes and removing it; building specific foods (+quantities where possible) and lifestyle changes into the diet and routines, it's possible to identify targeted supplements that can assist.
An Evidence based approach
Below are just a few examples of an evidence base for targeted supplementation. I.e. there has been a tangible benefit obtained, often by measuring biomarkers for nutritional status (blood/urine etc) or via the causal link between supplement intake and measurable health outcomes (when accounting for other health variables).
A Meta-analysis considering evidence from 25 Randomised Control Trials (the gold standard for nutrition evidence) found a protective effect of Vitamin D supplementation for the reduction of acute respiratory illness risk1.
A double-blind placebo controlled study with 92 youths found statistically significant improvements in the concentration levels of ADHD sufferers after 12 week Omega 3 supplementation2
A Meta-analysis considering data for 2028 people found a 3-month programme of Magnesium supplementation (370mg/day) statistically reduced blood pressure levels.
When it comes to the evidence for supplements I always try to find those that have moderate to strong evidence for them. However, food and supplements often work synergistically and therefore it can be hard to always find random controlled trials. What do I consider in these cases? If a supplement (or food for that matter) has cell line, animal and small human trials or even large epidemiological (these are population based) studies that have consistent scaled results where researchers have been able to identify the potential mechanism of how they work across all of these types of studies then I will also consider these supplements or foods as therapeutic.
I never want you to be taking supplements long term and hoping for the best.
** If you have used proton pump inhibitors for acid reflux issues, you will likely have ongoing digestive issues and mild to moderate nutrient deficiencies. Supplemental support is recommended in the short to medium term in this instance.
** If you have chronic gut conditions such as IBS, IBD and coeliac disease your digestive process are definitely impacted. Following pathology, supplemental support is recommended in this instance depending on the length of your illness.
** If you have gut or gut related immune issues such as endometriosis, painful periods, PCOS or Autoimmune conditions digestive processes are impacted and inflammation is prevalent. Supplementation for either the medium to long term is recommended.
Long term dietary support is essential for all of these conditions.
Supplement quality
It’s worth considering the type of supplementation being used and whether they are synthetic or food state formulas? Where possible, if we can derive our supplements from food state sources rather than those manufactured in a lab, the body is more readily able to identify and use these substances.
In addition, it’s useful to establish the purity of ingredients used in supplementation, for example, by checking that omega 3 is derived from non-polluted fish sources, free from Mercury, PCBs and other contaminants.
TAKE-AWAYS :
Always start with a food first approach. This needn't be about elimination and should definitely be about 'what else can you include?’.
Have the nutritional basics in place - nutrient dense whole foods with a focus on fibre, prominent vitamins and minerals, omega 3 and adequate hydration.
Consider personalising this approach depending on your health goals i.e. increase prebiotics (fibre in food that improves our good bacterial populations + the molecules they produce) and fermented foods for improving IBS symptoms; OR improving the intake of leafy greens at volumes sufficient to provide magnesium and anti-inflammatory molecules to assist with blood pressure and joint pain.
Consider targeted supplementation that is open to review as you change and optimise your diet and lifestyle.
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REFERENCES
1. Martineau AR, Jolliffe DA, Hooper RL, et al. Vitamin D supplementation to prevent acute respiratory tract infections: Systematic review and meta-analysis of individual participant data. BMJ. 2017. doi:10.1136/bmj.i6583
2. Chang JPC, Su KP, Mondelli V, et al. High-dose eicosapentaenoic acid (EPA) improves attention and vigilance in children and adolescents with attention deficit hyperactivity disorder (ADHD) and low endogenous EPA levels. Transl Psychiatry. 2019. doi:10.1038/s41398-019-0633-0
3. Rosique-Esteban, N., Guasch-Ferré, M., Hernández-Alonso, P., & Salas-Salvadó, J. (2018). Dietary Magnesium and Cardiovascular Disease: A Review with Emphasis in Epidemiological Studies. Nutrients, 10(2), 168. https://doi.org/10.3390/nu10020168
(Written in conjunction with @juliaebbens)