Core Four Supplements

I am often asked what I think about nutritional supplements.  As a doctor who specializes in a  more ”natural” form of medicine, it is fair to say that the use of supplements is a significant part of my medical armamentarium.   I use nutrition and directed supplementation in the care of my patients because I think that it is in their best interest.  I believe that this approach is safer than conventional allopathic drugs.  Certainly conventional drugs have a place in a comprehensive medical practice.  But in contrast to the treatment options offered by a “regular” doctor, the approach to rectify errant metabolic processes with a food or supplement is generally safer in the long run, and more lasting. 

 There are fewer side effects, drug interactions, and toxicities.  In this essay, we will develop the concept more fully of how a supplement can be utilized as a medicine that works to repair a damaged or deficient metabolic system.  This ultimately improves the patient’s symptoms  as our processes run more smoothly.
 
We have to remember that these medications are meant to by used in a  supplemental form.  Their use should augment and supplement, not replace, an ongoing path of wellness that is based in diet, exercise, and sound nutrition. 
 
But many of us, in spite of maintaining a clear head, following a good exercise regimen, balancing our hormones, choosing organic foods, and avoiding the numerous environmental toxins, may be in a state of nutritional depletion.  Our soils are deficient in essential minerals and so too is our food.  Throughout our lifetimes we have been subjected to numerous antibiotics and medications that have altered our gut microbiome.  Our nutritional status is altered by overuse, stress, and the constant need to rid our bodies of environmental toxins.  In short, we are metabolically tapped out and depleted.
 
Ideally nutritional deficiencies are measured through objective studies.  Laboratory tests can demonstrate if we are suffering from a shortage of the metabolic components required for our bodies to run smoothly.  I often equate a nutritional deficiency to a car that has a new muffler, gas tank, and engine, but one bad sparkplug.  The car will run, but not efficiently.  With a nutrient, food or mineral shortage our bodies display similar depreciations in performance.  When our body doesn’t run well, we develop what we refer to as “symptoms”.  The secret of functional medicine is to identify these deficiencies through careful history and analysis, then choose the best route of supplementation to replace the deficiency.  Ideally this is how supplement need is determined.  I recommend using testing to determine the deficiency, then matching the supplement with the results of the testing.
 
The practice of medicine when correctly applied is just that: a practice.  And practice over time makes perfect.  The skills required in medicine are no different from the 10,000 hours to make a dancer, musician or physicist.  Some of these things just take time. 
 
But to the observant medical practitioner, certain patterns begin to emerge through these hours.  The path through the forest, once more commonly traveled, starts to become clearer and more well known.  The sounds, smells and colors of the forest become more characteristic over time; they become more well defined and apparent.  So too are the associated sensory clues.  In this fashion the awareness of the nutritional and metabolic deficiencies attributed to a medical condition or spectrum of complaints (symptoms) develops more readily, slowly galvanizing in the practitioner’s consciousness. 
 
In the course of having taken many trips into the forest of health with my patients, I am finding that there are a few nutritional deficiencies that really stand out.  Often I suspect clinically that a certain biologic process is not functioning well.  I then obtain labs.  This correlation of clinical clues with the results of laboratory data has led me to observe that there are several common nutritional deficiencies that merit attention.
 
Four deficiencies stand out.  They are magnesium, fiber, Omega-three fats, and vitamin D.  Each will be covered separately in short paragraphs below.  Optimally these nutrients are measured.  But if you are not able to test and measure the following values, read on.  It may be that the “empiric” addition of these four supplements may change your life.
 
Magnesium, a positively charged ion, is probably my “favorite” supplement.  It is an essential co-factor in approximately 400 enzymatic reactions, so you can bet that it is pretty important to have normal levels and supplies for your cellular functioning.  Simply put, magnesium is the “warm blanket” for all biological reactions in the body.  It serves to stabilize electrical potentials across cell membranes, making nerves function more smoothly; it helps muscles to relax and remain pliable; it helps to relax the bowel, and is well known to be nature’s laxative, “milk-of-magnesia.”  Magnesium calms the brain, and ensures that the insulin receptor functions optimally to regulate our blood sugar.
 
I check red blood cell magnesium on all of my patients, and it is almost uniformly low.   However most people do not know how to supplement this important mineral correctly.   Across the board the doses being used are too low.  I recommend that my patients use about 500-1000 mg. daily of elemental magnesium.  Realize that a typical magnesium capsule contains both magnesium and its ionic salt: magnesium citrate, taurate, glycinate, citramate, malate, etc.  And in this salt, only about 1/4 to 1/5 is represented by the magnesium ion.  So a 600 mg capsule of magnesium citrate contains only about 100-150 mg of magnesium.  Do the math.  For adequate supplementation you will need at least 4-5 capsules.  Generally I am not concerned about a patient overdosing.   If your supplementation causes loose stools, you are probably using too much.  Dial back your dosing until the bowel consistency improves.
 
Omege-3 fatty acids are the important component of fish oils, cod liver oil, and products such as krill oil.  These polyunsaturated fats are essential for the correct functioning of every cell in your body as they are incorporated into the cellular membrane.  Cells that are deficient in omega-3 fats have compromised function; they are stiff and don’t allow the enzymes embedded in the cellular membrane to function correctly.  In the absence of these fats, the cell membrane is stiff and immobile.  Saturated fats, found in Hershey’s bars and lard, are solid at room temperature.  Omega-3 fats, found in salmon, allow that fish to swim flexibly and happily in 34 degree water.  Personally I prefer my cells to remain mobile and take on the characteristics of a salmon.  Disease and dysfunction results when your calls are made up only from the fats in a candy bar.
 
I can measure the ratios of different fats in a patient’s blood, but generally I don’t have to.  Across the board Americans, due to our Standard American Diet (SAD), are woefully deficient in these EFA’s, essential fatty acids.  Most of us require supplementation.  The specifics and fine points of the types of fatty acids merits an entire individual blog, but I can make the following recommendation.  To supplement well with fatty acids, you will need to spend a little money.  Don’t buy the cheap junk from Wal-Mart, even though the label may say “omega three fats.” Assuredly the product doesn’t contain what you need.  I recommend that for supplementation, without using high-dose fats to treat a specific medical condition, patients consume approximately one gram daily of the fats DHA and EPA.  Avoid any label that refers to “other” omega three fats.  And be cautious of the Omega-6 fatty acids, these are what our body uses to promote inflammation.   The best thing is to speak with a provider who understands the fine points.  When it comes to supplements, in particular fish oils, the devil is in the details.  If you are spending less than a dollar a day on your omega-three oils, you are probably doing more harm than good.
 
I strongly recommend the use of insoluble fiber with all of my patients- even the vegetarians.  Fiber is essential for the metabolism and health of the cells lining our intestines.  We can’t digest fiber (we’re not cows) but our intestinal bacteria can.  It is broken down by these bacteria to form compounds known as short chain fatty acids.  Additionally fiber helps to maintain water in the colon, and can be essential for a regular stool pattern.  Some think that there may be a mechanical action that scrapes diseased cells from the walls of the bowel.  Extensive evidence in the recent literature associates low fiber intake with colorectal disease and cancer.  Fiber is an essential part of my daily supplementation routine and has been for more than a decade.  I personally use a tablespoon daily of psyllium husk.  I tell my patients that I can set my watch by my morning stool patterns, and I believe that this results in large part from my daily fiber intake.  You should consider it too.
 
The final recommendation that I have for this blog is for all people to consider supplementing with vitamin D.  I cannot understate its importance, and its frequent deficiency in my patients.  Recent scientific literature has associated low vitamin D with….well…. just about everything.  The vitamin D receptor region (VDR) is a region found on about 10 percent, or about 2000, of our genes.  Attached to this promoter region, vitamin D effectively serves to “turn on” these genes.  So know your vitamin D level and supplement accordingly.  The laboratory range states that a normal range of vitamin D is from 30-100.  I think that 30 is too low.  I recommend that my patients try to maintain their levels between 50-70.   Here’s a tip.  Let’s say that your level is 30, and you want to get it to 70.  I suggest about 1000 IU daily for every ten points below your goal.  So 30 from 70 is 40, so I would start with 4000-5000 IU daily.
 
Is supplementation across the board required for all individuals?  Maybe my patient base self-selects, and I am seeing people’s nutritional deficiencies because we test for them.  But a significant proportion of my patients are not seeing me because of an illness, but for wellness.  They are wishing to optimize their health and longevity while generally feeling good already.  And this subset of kale-eating, mantra-chanting, and yoga-posing population is nutritionally deficient.   I know this because we test. 
 
Now imagine the degree of nutritional deficiencies of the remainder of our country.  These “big four” are a good start, with a significant “upside” and virtually non-existent risk and toxicity.  But to really do things right, I recommend a provider well versed in the complexity of the human body and spirit, the science and intricacies behind the testing, and the best supplement manufacturer, dosing and regimen required to correctly bring the body’s mechanics to a state of optimal function.