Supplements: Vitamins are the source of life and health

Highlights:

• Vitamin A in the form of retinol is essential for collagen production, helping to reduce wrinkles and signs of aging
• Vitamin-B deficiency is associated with homocysteine elevations
• Fat-soluble vitamin K reduces triglycerides, is anti-inflammatory, and improves insulin sensitivity

Introduction

Supplementing vitamins has become ubiquitous, especially in developed countries. Their use is even more crucial in the elderly since seniors expend less energy, therefore, consume less food and, with it, also fewer micronutrients. It means that the use of supplements is widespread with the older population, being consumed by more than half of them. Meta-analysis of the trials of nutritional supplementation in all age groups and pathologies found benefits from supplementation. 

When it comes to vitamin supplements, it is vital to recommend your patients the correct one and their dosage, usage, and the optimal way to stack them. Let's look at the most common vitamins: A, B, C, D, E, and K, and how you may use them in your practice. The dosage is critical since "the more, the merrier" is not always valid with vitamins.

Have you known?

The word vitamin is derived from vitamine; the term was invented in 1912 by Polish biochemist Kazimierz Funk. It is composed of Latin "vita" (life) and "amine." When Funk isolated a complex of micronutrients essential to life, he presumed them to be amines. Later it turned out that not all those compounds are amines, and therefore was used without the final "e."(1)

Vitamin A

Retinol and dehydroretinol are the most significant members of the vitamin A group, and over half are made from carotenoids, such as beta carotene. This is one of the supplements whose dosage should be carefully advised: high levels of vitamin A are associated with osteoporosis and reduced bone mineral density. With daily intake exceeding 1500 μg of vitamin A, the risk of hip fracture doubled, compared with intake of 500 μg. It also increases the incidence of lung cancer in smokers (3). Vitamin A in the form of retinol is essential for collagen production, helping to reduce wrinkles and signs of aging. There may be a mitigation effect of vitamin A on age-related macular degeneration, the leading cause of blindness in seniors. 

It is one of the fat-soluble vitamins and therefore recommended to use after a meal containing fats. Other essential fat-soluble vitamins are D, E, K - which are also necessary to be included in the healthy stack for elderly people. Their dosage should be therefore more carefully considered, unlike water-soluble vitamins that can be taken with fewer precautions. Vitamin A natural sources are egg yolk or liver, and the recommended daily allowance (RDA) is 700 μg for females and 900 μg for males.

Vitamin B

Vitamin-B deficiency is associated with homocysteine elevations. Homocysteine was discovered in 1932 by Nobel laureate Vincent du Vigneaud, who described it as a toxic amino acid containing sulfur. Its elevated levels contribute to stroke and coronary heart disease (CHD). Homocysteine is also very well reduced with supplementation of B2 - riboflavin.

The combination of folate, vitamin B6 and B12 successfully lowers homocysteine levels and therefore decreases those risks. Raised homocysteine levels are also related to dementia, and folate (methylfolate) may improve this condition, as suggested by several trials (3).

Folate or vitamin B9 has a dual effect on cancer: decreasing the risk of several types, such as cancer of the colon, esophagus, or stomach, and increasing the growth of existing tumors. In the mouse model, folate suppresses cancer incidence but increases the growth whenever the tumor is developed (3).  

Vitamin B12 is the subject of many studies. More than 10% of American seniors are deficient since its absorption from food sources is complicated (B12 is not released from proteins to which it is bound). This also means that supplements (where the B12 is not protein-bound) may treat this malabsorption. The deficiency is a risk factor for bone loss (5), cognitive, psychiatric, and neurodegenerative diseases (3). The good news is that, unlike the majority of vitamins, B12 in high doses (10,000 times the recommended daily amount) is safe.These vitamins should always be supplemented in methylated forms, such as folate/methyl folate (not folic acid, the synthetic form), methylcobalamin (B12) - because of the genetic diversity of the MTHFR gene, and there are about 30-60% of people - who have some issues to metabolize them properly.

Another less known B vitamin that might be worthy for the elderly population is B10 - PABA - helping with the healthy tissues, skin, or might even help with greying hair. Another gripping member of the vitamin-B family, B3, is a precursor of NAD+, a classical coenzyme that mediates many redox reactions. NAD+ becomes limiting during aging, and its supplementation can improve age-associated pathophysiologies (6).

Biotin (B7) is another vitamin essential for healthy skin, hair and helps with weak nails. B6 is an essential cofactor for magnesium. The body needs it to create neurotransmitters like dopamine or serotonin - which are critical for inner motivation and feelings of contentment. In a nutshell, every elderly should take a good B-complex stack (methylated) to supply them with all the benefits we described above.

Vitamin C

One of the most used vitamins, C or ascorbic acid, protects from oxidative damage, is essential for immunity, and protects the skin from aging, with benefits increasing with dosing. Those benefits include

• Lowering of blood pressure and pulse rate
• Decreasing the frequency of colds with a daily dosage of 500 mg 
• Reducing the risk of developed advanced age-related macular degeneration
  

Vitamin C provides many benefits, with daily doses between 500 to 6000 mg, especially for the elderly (4). On the contrary, it does not affect cancer and cardiovascular diseases prevention (3). Its natural sources are common fruit and vegetables, from broccoli to citrus fruit. And for those vitamin-C aficionados, Kakadu plums contain 100x more of this vital compound than oranges.

Vitamin D

This hormone is manufactured in the skin, which depends on sun exposure (3). This fat-soluble vitamin improves bone density by helping absorb and retain phosphorus and calcium. Its deficiency increases the risk of falls and overall mortality, and on the contrary, its moderate doses decrease all-cause mortality, especially in older women (5). Like many other vitamins, it is deficient in half of the American patients (and a third of healthy adults) and needs to be supplemented, especially for seniors with little sun exposure (3).

Compared to placebo, a dose of 700 to 800 IU of vitamin D decreased hip fractures by 26% and nonvertebral fractures by 23%. Surprisingly, the fracture rate was not affected by calcium supplementing (3). The same dose also decreases the risk of fractures by about 20%. Studies suggest that double this dose may reduce the risk of colorectal cancer, and another one speculates about the protective role of vitamin D in cardiovascular disease. It could also lower blood pressure and decrease total mortality (3).

Since it is fat-soluble, its dosage should be carefully considered and serum 25(OH)D monitored. Hypercalcemia can occur at levels more than 300 ng/mL, toxicity with levels higher than 150 ng/mL. For patients with chronic granulomatous diseases, such as sarcoidosis, those levels are around 30 ng/mL. Natural supplementing consists of wild-caught salmon, canned sardines, or tuna in vitamin D fortified food, such as milk or juice. A semi-monthly trimestrial supplementation regimen may also replace daily dosage with the same preventive results. Vitamin D should always be taken after the meal, together with vitamin K2 (ideally a blend of different forms like MK7, MK4) to prevent calcification of arteries. 

Vitamin E

Some studies associate this fat-soluble antioxidant with a reduction of the risk of heart disease. A survey of more than five thousand Finnish men and women showed that a higher intake of vitamin E was associated with reduced coronary heart disease mortality while not preventing it. On the other hand, participants of another study were 21% more likely to be hospitalized with heart failure than those not taking vitamin E. Supplementing with vitamin E is therefore not supported by the American Heart Association to prevent cardiovascular disease. Vitamin E also slows cognitive decline and delays functional deterioration in Alzheimer patients but increases mortality in doses over 400 IU daily (3).

It is essential to choose the suitable form of vitamin E supplementation - synthetic alpha tocopherol acetate has only about 20% absorption of natural vitamin E. Natural E starts with D-Alpha - synthetic starts with DL-Alpha. Some also say an excessive vitamin E may develop prostate cancer (after supplementation with synthetic version). It is recommended to eat natural E complex with all four tocopherols and all four tocotrienols forms, ideally used together with 50 - 200  μg of selenium, with the maximum amount of 400 IU for men and 100-200 IU for women. Note: The problem of synthetic E is although they have the same chemical formula, they have different arrangements of atoms (seven synthetic variations do not occur in nature). Natural vitamin E may be found in nuts and seeds.

Vitamin K

This fat-soluble vitamin reduces triglycerides, is anti-inflammatory, improves insulin sensitivity (beneficial for diabetics). It also helps with bone mineral density, prevents bone fractures and osteoporosis (7). Its RDA is 120 μg for men and 90 μg for women and is covered by, for example, 100 g of romaine lettuce that contains 100 μg of vitamin K. Natural sources of vitamin K are green leafy vegetables, such as kale, Brussel sprouts, cauliflower or cabbage. To a smaller extent, it is also contained in fish, liver, eggs, or cereals. 

Conclusion

Vitamins play an essential role in preventing diseases, yet the population is dangerously deficient in many of them. Vitamin supplementation can be a very effective tool in your practice, especially for the elderly. It is always advised to determine the actual levels of different vitamins to optimize the supplementation program and take into consideration the fact if the vitamin is fat or water-soluble.

1. Potter, Jan M. Oral supplements in the elderly, Current Opinion in Clinical Nutrition and Metabolic Care: January 2001 - Volume 4 - Issue 1 - p 21-28
2. G Paolisso, S Sgambato, A Gambardella, G Pizza, P Tesauro, M Varricchio, F D'Onofrio, Daily magnesium supplements improve glucose handling in elderly subjects, The American Journal of Clinical Nutrition, Volume 55, Issue 6, June 1992, Pages 1161–1167, https://doi.org/10.1093/ajcn/55.6.1161
3. Robert Skully, MDa,b,c,d,e,*, Aroob Shanaah Saleh, MDa, Aging and the Effects of Vitamins and Supplements
4. Michael Janson, Orthomolecular medicine: the therapeutic use of dietary supplements for anti-aging
5. Anti-Aging Diet and Supplements: Fact or Fiction?, Jurga Adomaityte, Gerard Mullin and Adrian S. Dobs Nutr Clin Pract published online 25 September 2014 DOI: 10.1177/0884533614546889
6. Shin-ichiro Imai, Leonard Guarente,NAD+ and sirtuins in aging and disease, Trends in Cell Biology, Volume 24, Issue 8, 2014, Pages 464-471, ISSN 0962-8924, https://doi.org/10.1016/j.tcb.2014.04.002.
7. Shiraki M, Shiraki Y, Aoki C, Miura M. Vitamin K2 (menatetrenone) effectively prevents fractures and sustains lumbar bone mineral density in osteoporosis. J Bone Miner Res. 2000 Mar;15(3):515-21. doi: 10.1359/jbmr.2000.15.3.515. PMID: 10750566.