Health & Wellness

The Supplement Maze

By Deborah Eck, RD, LD, CNSC
Eating well with multiple sclerosis can be a challenge. There is so much information about food and supplements that are said to help with MS. It often leaves one asking, “Where do I begin?”
Part of the confusion starts with advice from well-meaning family and friends, media, and health food stores, which can have an influence on the decisions you make. MS is sometimes lumped into the pile with other health and diet concerns that are more publicized, like diabetes, high blood pressure, obesity, and cancer. MS is different and should be treated as such. 
Next, it’s important to know the “red flags” of junk science in order to weed out the nonsense. Junk science will make claims that sound too good to be true. Anything that promises a quick fix, gives severe warnings from the results of a single study, makes recommendations from studies done without peer reviews, draws simplistic conclusions, or makes recommendations to sell a product should be suspected of “junk science.”
It’s comforting to know we have high quality food available to us in the United States. We should be able to get all the vitamins and minerals from our food if we consume three balanced meals a day.  However, many people are still concerned their diets may be suboptimal in some micronutrients. A complete multivitamin found at your local drug or grocery store can help bridge the gap. But before we discuss what you should do, let’s explore some of the things you should not do.
What to Avoid
Nutritional supplements come in the form of megadose vitamins, minerals, and herbs that are not regulated by the FDA. You can buy them over the counter without a prescription. Beware of taking single-dose vitamins and minerals (greater than 100 percent of the dietary reference intakes, or DRI’s), and/or herbs in large amounts.  This is generally unnecessary and can be dangerous if self-prescribed.
This point is critical because many supplements like vitamins E and C act as antioxidants, which among other important functions, boost the immune system. Antioxidants can be favorable for some people; however, MS is thought to be a disease of an overactive immune system. Consuming high doses of substances that boost the immune system even more is not recommended with MS. Large doses are not advised if one is taking other prescribed medications under the advice of a cardiologist for heart disease, because vitamins E and C can thin the blood.
Consuming 30-40 IU of synthetic vitamin E daily is a good idea if you are taking fish oil supplements. You can get this amount daily in a generic complete multivitamin. Many single-dose supplements greatly exceed this amount (800 to 1000 IU per dose) so be sure to select those that fall within the recommended range. If you really feel you would benefit from taking additional vitamin E, find one that provides 100 to 200 IU daily.
High doses of other vitamins can antagonize your immune-modulating, immunosuppressive therapies used to manage MS. Supplements that stimulate the immune system should be avoided in high doses. Those include selenium, zinc, B1, B2, folic acid,  B6, vitamin A, biotin, magnesium, copper, and manganese. The effectiveness of these is not supported by studies in MS.
Much Ado about D
Vitamin D helps with calcium absorption and works to prevent osteoporosis, which is common in people with MS. Some studies have found that 75 to 80 percent of people with MS have low vitamin D levels. While there has been much speculation about the relationship between MS and vitamin D, the role it plays in the disease has not been determined.
The current recommendation for the general population is 400 IU daily from birth through adolescence, 200 IU for adults under 50, 400 IU daily for people 50 to 70, and 600 IU for those over 70. 
However, for the person with MS, some doctors are prescribing as much as 50,000 to 100,000 units by mouth weekly and monitoring the levels. Your doctor will decide what is best for you. If you are interested in taking vitamin D, first get your blood serum levels checked; you might already be deficient and need aggressive replacement. More studies need to be done to determine the upper limit of vitamin D intake in order to achieve therapeutic benefit in MS patients. High amounts are not recommended for people with kidney disease, so be sure to discuss your vitamin D plan with your physician first. 
Herbal Remedies to Avoid
As with vitamins, herbal supplements may stimulate the immune system; not a good idea with MS. Echinacea, ginseng, CoQ10, gingko biloba, DHEA, and garlic may decrease the effectiveness of your primary medication used to manage MS. Keep in mind there are no peer-reviewed clinical studies with regard to MS to support the use of these supplements.
St. John’s Wort in particular should be avoided if you are taking any prescribed medications until you consult your physician for further advice. St. John’s Wort can activate several enzymes which may ultimately lead to decreasing the serum availability of many different prescribed medications that may be prescribed by your doctor. Result: your medication doesn’t work as well as it should.   Finally – you guessed it – there are no studies supporting the use of St. John’s Wort with MS.
What to do, what to do?
As with introducing anything new that may affect your health, seek your physician’s advice. Your doctor will prescribe single doses of vitamins if your blood lab values show a deficiency and will monitor you to determine if or when discontinuing the supplement is appropriate. Your physician can best address your specific health concerns. Beyond that, a licensed or certified registered dietitian can integrate your supplements into a solid and sound nutritional plan.
Some general tips include:
1)  Start with a complete multivitamin each day. Don’t get fancy or spend a lot of money! A generic complete multivitamin from a large-scale manufacturer is all you need. Beware of fillers. Read labels to make sure of actual vitamin content. 
2)  Consider taking a calcium supplement with vitamin D, once or twice a day, depending on the number of dairy servings you consume daily.  Generally 1000 to1200 mg of calcium and 800 to 1000 IU of vitamin D daily is considered safe for most adults. Calcium supplements have 500 to 600 mg calcium and 100 to 200 IU vitamin D per day. The addition of 400 IU vitamin D will bring you to 800 to 1000 IU daily of vitamin D. 
3)  Choose a fish oil supplement that contains a small amount of vitamin E in each dose from a large-scale manufacturer. Peer-reviewed studies seem to approve of Omega-3 fatty acids and haven’t indicated that they should be avoided. The FDA considers 1 to 3 grams daily safe.
Many supplements are available, too many to list. Some are harmful, many are of no benefit, most are expensive. More research is needed in this area and it's coming. In the meantime, always give a written list of all your supplements to your doctor, pharmacist, and dietitian. They can help you sort through them and make a plan that is safe and healthful for you!
Deborah Eck, RD, LD, CNSC is a registered and licensed dietitian in the state of Kentucky. She is also board-certified in enteral and parenteral nutrition support. She is currently the Chief Clinical Dietitian at Norton Brownsboro Hospital in Louisville, KY. She has a 20-year long special interest in the nutritional management of multiple sclerosis and has worked alongside the Louisville Comprehensive Care MS Center of Louisville, KY to support its mission to educate patients, families, and the medical community about treatment options and emerging research in the management of MS.
(Last reviewed 7/2010)