Unconscious biases against vitamins and supplements [PODCAST]

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“Like many scary health scenarios where patients seek some modicum of influence, the COVID-19 pandemic has led to patient demand for ‘immune-boosting’ dietary supplements. Toilet paper wasn’t the only essential item being limited by stores; bottles of zinc and vitamin C flew off the shelves as consumers stocked up. The role of vitamin D in COVID-19 has been conflated and deflated depending on the study-du-jour. And of the eight ‘drugs’ in President Trump’s top-of-the line treatment, three of them were natural products. The medical professional has, for the most part, dismissed vitamins as nothing more than ‘expensive pee.’ But as an integrative medicine physician examining the data, I urge my colleagues to take a more thoughtful approach to supplement recommendations and consider whether unconscious biases are influencing how you counsel patients.”

Melinda Ring is an integrative medicine physician.

She shares her story and discusses her KevinMD article, “6 unconscious biases against vitamins and supplements.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Melinda Ring. She is an integrative medicine physician, and she wrote the KevinMD article “6 unconscious biases against vitamins and supplements.” Melinda, welcome to the show.

Melinda Ring: Yeah, thanks so much for having me.

Kevin Pho: We’ll get into the article in a little bit, but first off, can you share your story and journey to where you are today?

Melinda Ring: So I’d say I grew up with an interesting perspective on health and medicine. My dad’s a pathologist, and when I was growing up, I used to go with him on the weekends to help him out with autopsies. When we would do that, I obviously got a really strong connection to the body and how it changed in death, but also this profound sense of what else was missing, that there was something other than the physical, you can call it spirit, that also changed between life and death.

And then in college, I started out majoring in Buddhism and Eastern religion, and then halfway through switched to cellular and molecular biology, just kind of continuing this East-West path. After completing my internal medicine residency at the University of Chicago, I did an integrative medicine fellowship, and since then, I’ve been on my way. Since 2007, I’ve served as director of the Osher Center for Integrative Medicine at Northwestern University, where I see patients and teach and do research, and really, I’m trying to push the needle forward on integrative health.

Kevin Pho: Now, tell us a little bit more about your practice, some typical cases that you see, and perhaps a typical workday.

Melinda Ring: Well, my workday is pretty varied. I like to do a lot of things, so I do quite a bit of teaching, teaching culinary medicine and teaching integrative medicine, trying to train that next generation of health providers to know about those things.

In my clinical practice, I only do consults at this time, and so I get referrals from physicians where their patients are seeking things other than conventional biomedicine, or things to help complement what they’re doing with their other care. So a lot of people come looking for things like which natural product they should be taking, what diet is the right diet for them, and what other things from other healing traditions, like traditional Chinese medicine, Ayurveda, and mind-body practices, might help complement their care and help them get to their goal. So it’s a really rewarding practice. I see patients with all conditions, and those interested in prevention, or just, again, trying to feel better.

Kevin Pho: Now, what are the most common conditions that other physicians would send patients to you for?

Melinda Ring: Well, my practice is very heavily women’s health-based, and I specialize in hormonal disorders. So I do see a lot of women who are having perimenopausal issues and thyroid-type concerns, where they’re just not feeling like they used to. But there are also, I mean, everything from oncology patients who are trying to mitigate some of the side effects that they may have from chemotherapy and radiation, and patients with conditions like fibromyalgia, chronic fatigue, and other things that our usual care just isn’t that good at treating. And so a lot of people will come and get referred by their physicians where they feel like they’re just out of answers: Are there other things that can give them hope that they might feel better?

Kevin Pho: All right, let’s transition now into the KevinMD article that you wrote. It’s titled “6 unconscious biases against vitamins and supplements.” Now, for those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of why you decided to write it?

Melinda Ring: Yeah, sure. So I teach quite a bit about, and include in my clinical practice quite a bit about, natural products, and one of the most common themes that I hear from my patients is that they have been told by their doctors that there’s no need to take dietary supplements, that they’re dangerous, that they’re always adulterated, that they’re not regulated, that there’s no need to take supplements, that you can get everything through your diet. And so I was just moved to try to bring awareness to our medical community about some of the biggest myths that are out there about dietary supplements that they just may not be aware of.

Kevin Pho: All right, so what would you say are some of those most common myths?

Melinda Ring: Yeah, so the ones that I went through in the article: The first one was, “If it mattered, I would have learned it in medical school.” We know that nutrition, natural products, and these sorts of things, there’s just not enough time given to them in medicine. I probably had, at most, an hour lecture on vitamins and supplements. That’s due to the pressures of how much we have to learn in medical school, but I think it leads to this feeling that then it doesn’t matter to somebody’s health.

The second one is this false glamor of pharmaceutical drugs and FDA approval. This is, again, something that’s heard a lot, like, “Oh, dietary supplements are unregulated.” But in fact, there is regulation through an act called the DSHEA Act, which is the Dietary Supplement Health and Education Act, and through it, there is FDA and FTC oversight of natural products. Now, it is very different, and it’s considered at a different level than pharmaceuticals or even over-the-counter drugs. You don’t need the phase one and phase two trials before dietary supplements are put on the market. But in fact, there is regulation, and there is research happening that shows the benefits of some of these things. So that is number two.

The third one is a big one, and that is, “We can get everything we need from our diet, so we don’t need dietary supplements or vitamins or anything.” I don’t know about you, I mean, I teach about this stuff, and I try to practice what I preach, but I know my diet is far from perfect. Studies like those from NHANES, which is the National Health and Nutrition Examination Survey in our country, show that up to 94 percent of Americans fail to get the recommended daily intake of certain nutrients. And so I think, again, this idea that if you eat a healthy diet, you don’t need supplementation is just a huge fallacy, and we’re doing our patients a disservice. On top of that is the fact that so many of our pharmaceutical agents deplete the body of these nutrients, and that so many people have digestive issues and may not be absorbing them well. I think it’s the rare person who actually is getting everything they need through their diet.

The fourth bias is, “If I can’t see it, it doesn’t exist.” I have not had a patient walk in my door with scurvy or rickets. And so there is kind of this idea that, well, if somebody doesn’t have these overt symptoms of nutrient deficiency, there’s not a problem. But we know that, even if you think about something like iron deficiency anemia or iron deficiency, there can be iron deficiency before there is anemia. It’s a process. It’s not like we go from being fine to being not fine. The reality is that some of those earlier deficiencies, before there is a full clinical manifestation, can still wreak havoc on the biochemical processes. These nutrients act as cofactors in our enzyme reactions and other things. And so again, I think this idea that if you don’t have the classic syndrome, there’s not a problem, is another myth.

The fifth bias is “Don’t ask, don’t tell.” This is just the reality that, again, we are more prone to send our patients for expensive tests, evaluations, and procedures than to do something slightly beyond the normal, typical evaluation for deficiencies. I think probably vitamin D has gotten popular to check. B12 will get thrown in there when somebody complains of fatigue, or an iron panel, but that’s pretty much it. We have so many more vitamins and minerals that can be checked. And so I think sometimes going a little bit deeper can really help uncover problems. I see it all the time.

And then the last one is the illusion of scientific rigor. This is not only an issue with dietary supplements, but what I see happen is that a study will get published, “Fish oil is not good for X disease,” and then this gets blown up in the news or in medicine as, “Therefore, there is no benefit to fish oil,” which then discards the data that shows that fish oil has been shown to be helpful for, for example, rheumatoid arthritis and ulcerative colitis. And so there is this idea that we have to learn not to generalize one scientific finding to all disease, all patients.

So those were the ones that I went through in that article, and hopefully it helps open some minds to the fact that it’s worth taking another look at natural products and dietary supplements for our patients.

Kevin Pho: One of the areas of pushback that I get whenever I talk about supplements, I guess, relates to your sixth bias, the one about scientific rigor, and how some supplements don’t have that gold standard of randomized, double-blind, controlled studies that back up a lot of these supplements. Now, what are your thoughts on that, and can you comment on that line of criticism that I often hear about?

Melinda Ring: Just historically, let’s say, natural products have been used in many cultures for thousands of years, and I think the double-blind, placebo-controlled trial is what we should be doing for many of these natural products. Compared to, let’s say, suggesting that a patient go get a massage or meditate, there is an inherently greater risk associated with using natural products. They’re active agents; that’s why we think they work, but that means they can also cause harm.

It is a problem in the field that, because many times these products cannot be patented, we don’t have the big engines of pharmaceutical companies behind funding the studies like we do with our usual medications. That doesn’t mean they shouldn’t be done, but it is the reality. The NIH division, the NCCIH, National Center for Complementary and Integrative Health, is one of the organizations that is helping fund some of that research, but we do have a long way to go. So I don’t disagree with the fact that we need more research in this area. I think that is true.

However, there should also be a recognition that oftentimes, when you’re using these supplements, the inherent risk is so much less than with the pharmaceutical drugs that we use. I put this in my article: If you look at the reports on reported harms through the FDA Adverse Event Reporting System, there are almost 2 million adverse drug reports, and out of those, less than 200 were related to dietary supplements. So I think, yes, we need more data, and we should stop blowing up the potential risk, because it is relatively low compared to the pharmaceutical drugs that we recommend to our patients.

Kevin Pho: When you discuss integrative medicine in articles like this, in general, do you get any pushback from your non-integrative medicine physician colleagues?

Melinda Ring: I have been called unscientific or anti-scientific by some of these kinds of Quackwatch agencies, so yes, I have certainly been on the receiving end of that. I think, again, those are from people and organizations that are just anti-any change to the current standard of practice.

For the most part, all of my patients are referred by physicians, and the reality is, I think as most physicians go through their practice, they start to see that there is a lot still missing in medicine to provide the care that our patients need. And so more and more, I see doctors as patients. My referrals for patients come from other physicians in cardiology, oncology, etc. I think in integrative medicine, as long as we can bridge that language and help realize that there is science behind what we’re doing, that there is thought behind what we’re doing, and that it is always with the goal of taking the best care of patients, hopefully integrative medicine will gain greater acceptance and will overcome some of that negative view.

Kevin Pho: You work for an academic medical center, and I know other academic medical centers also have integrative medicine departments, like the Cleveland Clinic and Duke, for instance. Now, do you see this becoming more of a trend going forward, where traditional academic medical centers are partnering or starting up their own integrative medicine divisions?

Melinda Ring: I frankly think we’ve reached that tipping point. Northwestern is a member, and I’m a member, of the Academic Consortium for Integrative Medicine and Health, which is the corollary to, say, the ACP for internal medicine. And so it is the organization that represents academic centers with integrative medicine programs. There are well over 70 organizations that are part of that, so really, most major academic centers across the country have integrative medicine available in some form or another.

A lot of integrative medicine is practiced in the community. For me, it’s been a choice to stay within academic medicine because I think we need to create change from within medicine. And yeah, I think we’re going to see it more and more, and hopefully that’s going to help increase its acceptance as a valid form of care.

Kevin Pho: We’re talking to Melinda Ring. She is an integrative medicine physician, and she wrote the KevinMD article “6 unconscious biases against vitamins and supplements.” Melinda, for those primary care clinicians who may be listening to this podcast, when should we start thinking about integrative medicine approaches when we see patients in the exam room? Are there any specific conditions that should lead us to that integrative medicine approach? Should we refer healthy patients to integrative medicine? So what are some common scenarios where we in primary care should think about an integrative medicine solution?

Melinda Ring: I am personally biased. I think every patient can benefit from an integrative medicine approach. The goal, frankly, in the field is that most integrative medicine will just become part of medicine. So if, for example, a supplement works or acupuncture works, it should be part of standard treatment plans, and all primary care doctors should be comfortable doing that.

At this point, I would encourage primary care and specialist physicians to identify others, physicians in the community that they do feel comfortable collaborating with. And then for those patients where, number one, the patient’s expressing an interest, where the primary care physician doesn’t feel comfortable, they’re saying, “Well, the patient’s asking me about using valerian root, and I have no idea because we never covered that in medical school.” If a patient’s expressing interest, it’s a great idea to get an integrative physician involved so that the care can be overseen. We know patients are going to use these things. Let’s have them use them safely and with good oversight.

The second area is those areas that I talked about where we just don’t have good pharmaceutical or interventional approaches, things like irritable bowel syndrome, chronic fatigue, fibromyalgia, and chronic pain syndromes. Let’s move away from opioids and pain medications to trying to help patients. And then certainly, when patients express any interest in holistic approaches, it’s great to have a resource in your own community where you feel comfortable referring a patient, rather than them having to seek it out on their own.

And I will say, I will encourage people: There are now integrative medicine trainings for faculty. There are conferences available on nutrition, on dietary supplements, or just on integrative medicine in general. So go for your continuing medical education and learn more about it yourself so that you feel more confident either incorporating it or making appropriate referrals.

Kevin Pho: Now, you’re internal medicine-trained, but there are a lot of integrative medicine clinicians with significantly less training or more variable training. So when looking for an integrative medicine clinician, what kind of qualifications should we be looking out for?

Melinda Ring: So integrative medicine is considered, number one, a fellowship-level training. So realistically, if they have completed an integrative medicine fellowship, they have already completed their primary training, whether it’s pediatrics, family medicine, surgery, or emergency medicine, and then gone on to do integrative medicine training. Unfortunately, there are people in the community who will label themselves as integrative or functional medicine without having done a full fellowship training.

And so I would say that there is now a board certification for integrative medicine. I’m actually on the board of the board, which is the American Board of Integrative Medicine. That’s offered through the organization ABPS. And so looking for a board-certified integrative medicine physician guarantees that they at least meet a certain level of quality, knowledge, ethics, etc., and have completed a fellowship training.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Melinda Ring: Well, my take-home message is this. I would say, as the Zen monk Suzuki said, “In the beginner’s mind there are many possibilities, but in the expert’s mind there are few.” Where there is so much divisiveness in the world, we don’t need to be on different sides within medicine. I think if we can all let go of ego a bit and allow ourselves to be curious, and come with this idea of the beginner’s mind, the idea of first listening without preconceived notions and judgments, we will do a better job of healing ourselves and our patients.

Kevin Pho: Melinda, thank you so much for sharing your time and insight, and thanks again for being on the show.

Melinda Ring: Thanks so much, Kevin.

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