How safe are commonly used vitamins and minerals?

Dietary supplements are natural health products used to supplement the diet, such as vitamins, minerals, amino acids, enzymes and plant extracts. Although these products are more complementary medicines, they are usually referred to as dietary supplement by consumers whose intention is to augment their diet rather than treat disease. 

One reason for the persistent popularity of vitamins and minerals is the perception that they are harmless. There are many potential harms or potential adverse effects but, unlike conventional medicines, manufacturers of vitamins and minerals are not required to present extensive documentation about safety.

Marketing of vitamins and minerals is generally based on their claimed benefits with little, if any, mention of their potential harms. Consumer information leaflets are not provided, and few dietary supplements carry warnings of potential adverse effects on their packaging. Nonetheless, there are well‑recognised harms from the ingredients of dietary supplements, especially when taken in high doses.

Some of the commonly used vitamins and minerals and their potential adverse effects.

Vitamin A (Retinol)

Ingestion of >300,000 IU may result in acute toxicity. Chronic toxicity (hypervitaminosis) is associated with doses >10,000 IU/day. Symptoms of chronic hypervitaminosis A include skin desquamation, liver impairment, loss of vision and severe intracranial hypertension.

Vitamin B3 (Niacin or Nicotinic acid)

Taking high doses of vitamin B3 are commonly associated with peripheral vasodilation (expansion of blood vessels) causing skin flushing, burning sensation, pruritus and hypotension. Vasodilation may also occur in the eye resulting in reversible toxic cystoid macular oedema.

Vitamin B6 (Pyridoxine)

At doses ≥200 mg/day of vitamin B6 have been associated with severe sensory peripheral neuropathies. Risk often arises from multiple products being taken all containing pyridoxine.

Vitamin C (Ascorbic acid)

At very high doses, Vitamin C is associated with precipitation of cysteine, urate or oxalate kidney stones, especially in people with a predisposition for kidney stones. Vitamin C may reduce effectiveness of antineoplastic drugs such as vincristine, doxorubicin, methotrexate, cisplatin and imatinib in cancer patients.

Vitamin D (Colecalciferol)

Very high doses of Vitamin D may cause hypercalcaemia (increase quantity od calcium), with symptoms from thirst and polyuria to seizures, coma and death. High intermittent doses of vitamin D have been associated with increased risk of falls and fracture in the elderly.

Vitamin E (Alpha-tocopherol)

Very high doses of Vitamin E shows antiplatelet effect and increased risk of haemorrhagic stroke reported.

Calcium

Carbonate salt of calcium can cause gastric reflux and constipation. High‑dose calcium may induce vascular and soft tissue calcification, hypercalciuria, kidney stones and secondary hypoparathyroidism. Interferes with absorption of magnesium, iron and zinc if taken simultaneously, and can reduce absorption of many other drugs e.g. levothyroxine, tetracyclines.

Magnesium

High doses often result in diarrhoea, nausea and abdominal cramping due to the osmotic effect. Like other divalent cations, magnesium may chelate and reduce absorption of other minerals or medicines such as tetracyclines.

Zinc

Zinc is often associated with altered or impaired taste and smell. Intranasal zinc can cause anosmia. Doses ≥80 mg/day in clinical trials were associated with adverse prostate effects.

Selenium

Associated with acute and chronic toxicity. Signs of chronic high‑dose ‘selenosis’ are hair and nail loss or brittleness, lesions of the skin and nervous system, nausea, diarrhoea, skin rashes, mottled teeth, fatigue and mood irritability.

Vitamins and minerals are generally used safely when prescribed in medical settings for the treatment or prevention of deficiency states and other appropriate conditions. For example, vitamin B3 is used for hyperlipidaemias and folic acid is used in pregnancy to prevent birth defects (e.g. anencephaly, spina bifida). The key to the safety of vitamins and minerals is the prescribed dose, which is usually derived from research demonstrating that the benefits outweigh the harms. This is often not the case when consumers are self‑medicating with products purchased on the open market, as consideration is rarely given to the effective or safe dose.

 

Vitamin D and COVID-19

Vitamin D is important for bone, muscle and dental health but there has been no strong evidence to show that taking vitamin D supplements will make you less susceptible to COVID-19.

During the COVID-19 pandemic, many countries have been spending more time indoors than usual, because of the restrictions in place to limit transmission of the virus.

In addition to reducing the spread of COVID-19, restrictions have also helped slow down the spread of many common infectious diseases including influenza (flu). However, there are health-related drawbacks to spending less time outside.

International health authorities have been concerned that reduced exposure to sunlight has left some people vulnerable to a vitamin D deficiency.

Vitamin D is important for bone, muscle and dental health. Some recent reports have also suggested that vitamin D levels may influence risk of COVID-19 infection and severity.

What is vitamin D?

Vitamin D is an essential vitamin that helps to regulate calcium in your body, which is why it’s so important for bone health.

The source of most vitamins needed by humans come from the foods we eat. Vitamin D is different from other vitamins because it is produced when our skin is exposed to the sun (which is why it is sometime called the ‘sunshine’ vitamin). Only 10% of our vitamin D supply comes from food, like egg yolks and mushrooms, or from fish that have a lot of fatty tissue such as salmon and herring.

What does vitamin D do?

Vitamin D has an important role in helping the body absorb calcium. Calcium helps to keep our bones, muscles and teeth healthy and strong.

Throughout pregnancy, having good vitamin D levels is important for a baby’s bone development.

There is also some evidence that vitamin D plays a role in our immune responses, which researchers are trying to understand.

One clue that suggests a link between vitamin D and immunity is the presence of vitamin D receptors on the surface of human immune cells. Receptors are like a lock in a door that can only be turned with the ‘right key’. Opening the lock causes actions to occur that can change how a cell behaves. Some researchers believe that having vitamin D receptors on almost all of our immune cells means that vitamin D is able to ‘unlock’ a response in those cells and so influence our immune system activities.

Can vitamin D supplements protect me from COVID-19 infection?

Having enough vitamin D is important for your overall well being, and after your health is crucial during this time. However, taking supplements (including vitamin D) to prevent COVID-19 infection is not supported by any clinical evidence.

The best ways to avoid infection with the SARS-CoV-2 virus are to practice good hand hygiene and physical distancing, and to keep following restrictions and recommendations from the federal and state or territory departments of health.

Some international studies have reported that people who died after being diagnosed with COVID-19 tended to have low levels of vitamin D. Many of those people were older and had age-related health issues or other conditions before they contracted coronavirus. A review of available data by the National Institute of Clinical Excellence in the UK has concluded that age and health status – not vitamin D levels – made these people more vulnerable to poor health outcomes after being infected with COVID-19.

One group of research scientists from the UK said that it’s 'plausible' a person with low levels of vitamin D could be more susceptible to a COVID-19 infection, because of vitamin D’s role in our immune system, but a direct link has not been established. 

What happens if vitamin D levels in the body are too low?

It is well established that low levels of vitamin D can contribute to bones becoming more fragile and prone to breaking due to loss of bone mineral density. In mild cases, this is known as osteopenia. In more severe cases, this is known as osteoporosis, which occurs when your bones lose calcium and other minerals at a rate that’s too fast for your body to replace. 

Vitamin D deficiency in older people is also linked to poorer muscle strength and increased risk of falls.

In children, low vitamin D could lead to weak and soft bones that don’t form the way they should. This disease is called rickets. In adults, a softening of the bones is called osteomalacia.

How can one get vitamin D?

The best natural source of vitamin D is when skin is exposed to the sun’s Ultra Violet rays. 

As described previously, small amounts of vitamin D can also be obtained from food such as oily fish and eggs, but food can only make up a small portion of your daily requirement.

Some people may not be able to spend enough time in the sun or may not be able to produce vitamin D easily. Health professionals may recommend vitamin D supplements after considering individual circumstances, including whether vitamin D deficiency is present and how severe it is.

How do I know if I have a vitamin D deficiency?

Some people are more likely to have low vitamin D levels due to physical, medical or environmental factors. They include:

• - people who wear concealing clothing
• - people who spend long hours indoors due to their occupation or their health conditions, - including those who are housebound or living in institutions, such as aged care facilities
• - older adults
• - people with certain medical conditions such as obesity or malabsorption
• - young children born to a person who was vitamin D-deficient while pregnant.

PAIN: WHY IS IT GOOD?

WHAT IS PAIN 

Pain is a way that the brain alerts the body to potential danger. It can be experienced in many different ways, from mild discomfort to severe and constant pain. 

There are also many different treatments for managing pain.

WHY IS PAIN GOOD?

When a person feels pain because they have been injured, it is meant to alert the person that there is damage, and that they need to do something, such as fix the injury or move away from the cause of the damage.

The brain helps to make those decisions, based on information about what is happening to the person. The brain decides whether the body is in danger, whether the body needs protecting, and what needs to be done.

Usually the brain gets it right deciding what type and level of pain to feel, and what to do to protect the body from any further harm.

For example, a sprained ankle hurts to walk on, so limping or using crutches are appropriate responses. Touching a hot stove will cause a reflex that removes the body part quickly before too much damage can occur, and make the person more careful around the stove to avoid further injuries.

Some other times, a decision (by the brain) is not straightforward. A person damages their back but feels leg pain (this is called referred pain) or someone has an arm or leg amputated, but still experiences pain there (this is called phantom limb pain).

Another example is chronic non-cancer pain. In this type of pain, changes to the nervous system make the brain overprotective and the body excessively sensitive to what is happening around it. This increased sensitivity interprets the information as pain.

Types of pain

A common way to categorise pain is by the length of time a person has been feeling it.

Acute pain

Acute pain starts suddenly and tends to be short-lived. It can range from mild to severe and can have many different causes. Usually it happens as a normal response to damage. The term 'acute' means that it lasts for a few moments, days or weeks.

Acute pain is a warning that damage has occurred to your body, that you need to protect the damaged area, and seek help to address the cause. Acute pain usually reduces or goes away as the damage to the body heals.

Acute pain can be caused by different conditions including injuries and diseases.

The best way to treat acute pain will depend on what type of pain it is and what has caused it. Common treatments can be physical – such as using heat or cold to reduce the pain or taking medicines for the relief of short-term pain. Learning about the pain can also help a person to understand it better and may be a useful part of treatment.

Chronic pain

Chronic pain is pain that lasts more than 3 months or longer than expected for healing after surgery, injury or a condition. The cause may also be unknown. It is sometimes called 'persistent pain'.

Chronic pain can be caused by an ongoing condition, such as nerve pain or migraine, among others. 

Sometimes chronic pain occurs after a person has had acute pain, but the original cause of the acute pain no longer exists. This can be frustrating for the person experiencing the pain. It can also be challenging to treat the chronic pain that has now taken over.

Pain conditions

Pain can be a symptom in many conditions. Correct diagnosis and management of pain varies for different pain conditions.

Managing pain

Living with pain, whether it is acute or chronic, can be challenging. There is no one-size-fits-all approach to the management of pain.

Different treatments may be recommended by medical experts. These treatments may include:

• Simple treatments: such as using a heat or cold pack.
• Physical treatments: such as massage and mobilisation.
• Psychological treatments: such as cognitive behavioural therapy (CBT) or cognitive behavioural-based interventions, hypnosis, relaxation, meditation, mindfulness, acceptance and commitment therapies, psychoanalytic and psychodynamic therapies.
• Medications:such as paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs) and if required, opioids.
• Invasive procedures: such as nerve blocks (a pain reliever medicine injected towards a nerve), radiofrequency neurotomy (use of heat to temporarily turn off a nerve’s ability to send pain signals).

Which treatments are best?

In general, treating the cause of the pain is best wherever possible. If pain itself is the target of management, treatments other than invasive procedures can be tried first to provide pain relief.

In many cases, pain relief is best achieved with a combination of treatments. For example, if someone has acute low back pain (and the cause is not a serious condition such as infection or cancer), medical experts recommend starting with a combination of:

• learning about the nature of pain
• reassurance that many people recover rapidly
• self-managing the symptoms, such as by putting a heat pack on the painful area, and
• staying active and avoiding bed rest.

For chronic pain not related to cancer, medical experts recommend similar treatments to those for low back pain. They also add:

1. psychological and mind-body treatments that address underlying thoughts, feelings, emotions and behaviours about pain,
2. mindfulness and relaxation, and
3. medicines such as paracetamol and NSAIDs.

If someone feels pain for longer than expected, or if different treatments have been tried but are not really helping, they should talk to a health professional.

Medicines for pain

Treating the cause of the pain if there is one (for example a broken bone) should be the main goal, many people will also take some kind of pain reliever medicine.

What is a pain reliever?

Pain relievers are medicines that work on the body's nervous system to reduce the feeling of pain. They are also known as analgesics and pain relief medicines. People also use the term ‘pain killer’, but this is not accurate and can set up unrealistic expectations about a medicine.

Pain relievers have different active ingredients. It's important to know what these are and which one(s) you are taking, particularly if you are taking more than one medicine.

Many pain relievers can be bought over the counter without prescription. These include paracetamol, and non-steroidal anti-inflammatory medicines (NSAIDs) such as ibuprofen, aspirin and diclofenac.

Medicines for the relief of short-term pain

Active ingredients are what make medicines work. Many pain medicines have the same active ingredient but different brand names. Knowing the active ingredients in your medicines is important so that you don’t take too much of one type of medicine. Active ingredients in common pain medicines include:

• paracetamol 
  
• aspirin 
  
• ibuprofen 
  
• diclofenac
  
• piroxicam

All these over-the-counter medicines can be used for mild to moderate pain relief, such as headache and period pain. Paracetamol, aspirin and ibuprofen can also reduce fever. Aspirin, ibuprofen and diclofenac are all members of a class of medicines called ‘non-steroidal anti-inflammatory drugs’ (NSAIDs), which can be used to reduce inflammation or swelling (in conditions like arthritis, and muscle and bone injuries).

For stronger pain, a combination of paracetamol and ibuprofen may be an appropriate option.

The medicines listed above are commonly used for the relief of short-term pain. They are also often combined with other active ingredients in medicines to treat conditions other than pain, such as cold and flu. It can be dangerous taking these active ingredients (in one medicine or in several different medicines) over a long period of time, or in doses higher than recommended.

Talk to your health professionals about pain relief.

Your doctor or pharmacist can help you make a decision on the best pain medicine for you. They can help you understand:

• the brand name and active ingredients
  
• how to take the medicine
  
• the expected benefits of the medicine
  
• the possible side effects of the medicine
  
• other treatment options.
  

The Consumer Medicine Information (CMI), often inside the medicine packet or box, is designed to inform you about prescription and pharmacist-only medicines.

Managing reflux and heartburn

What is GERD?

Gastro-esophageal reflux disease (GERD) is defined as reflux or heartburn symptoms that are: frequent (two or more times per week) or severe and significantly impact on your life.

Reflux occurs when stomach acid leaks from the stomach and moves up into the esophagus (food passage). Sometimes you can feel the stomach acid coming up into your mouth causing a sour, unpleasant taste. You may also have a burning chest pain or discomfort after eating, called heartburn.

How is GERD diagnosed?

GERD is diagnosed based on symptoms – frequent or severe reflux or heartburn.

If you also have any of the following, your health professional may refer you for an examination called an endoscopy to determine whether there is another cause of your symptoms:

• difficulty in swallowing
• painful swallowing
• unexpected weight loss
• persistent vomiting
• dark, tarry or sticky feces.
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How is GERD managed?

Making some lifestyle changes, such as avoiding certain foods and drinks that may trigger your reflux, can often help reduce reflux symptoms.

If you have mild and infrequent symptoms, these changes may be all that you need.

If you have GERD, your health professional may prescribe a 4–8-weeks course of a medicine called a proton pump inhibitor (PPI). A PPI reduces the amount of acid produced in the stomach and is effective at treating reflux symptoms.

A PPI medicine is taken once a day 30–60 minutes before a meal.

• If you mostly have symptoms during the day, you should take the PPI before breakfast.
• If you mostly have symptoms at night, you should take the PPI before your evening meal.

Lifestyle changes for GERD

Making changes to your lifestyle may help reduce your reflux symptoms, even while you are taking medicine for GERD. Not all changes will work for all people. Your health professional can help you to decide what may work best for you.

Changes that could be helpful include:

1.    Losing weight- If your health professional suggests this is necessary – even modest               weight loss can help, and studies have shown that overweight people experience a                  greater relief from symptoms the more weight they lose.

2.    Stopping smoking – A study of people taking a regular medicine for reflux found that            stopping smoking almost halved the severity of their reflux symptoms; the improvements        were mostly among people of normal weight

3.    Cutting back on alcohol – Alcohol may trigger reflux symptoms in some people.

4.    Avoiding certain foods and drinks that trigger your reflux symptoms – Examples           include fatty foods, chocolate, spicy foods and coffee; different people find different foods        and drinks trigger their symptoms, so only avoid those that affect you so that you don’t           restrict your diet unnecessarily

5.    Raising the head of your bed, sleeping on a wedge pillow or wedging up your                mattress by 20 cm – This can help if you have reflux symptoms at night and they disrupt        your sleep

6.    Avoiding lying down after eating

7.    Eating smaller meals

8.    Avoiding eating 2–3 hours before bedtime

9.    Avoiding eating before vigorous exercise.

Reducing or stopping treatment

After completing an initial course of PPIs, many people can reduce the amount of medicine they take and still maintain control of their symptoms. Up to 6 out of 10 people can also stop taking PPIs without their symptoms returning.

For these reasons, your health professional may ask you to return for a review after you have completed your initial course of treatment. If your symptoms are well controlled, your health professional may suggest trying to reduce your PPI medicine by:

• i.   lowering your PPI dose
• ii.  taking your PPI on alternate days
• iii. taking your PPI only when you get symptoms
• iv. stopping your PPI.

Some people with GERD need to continue taking PPIs over a longer period. Also, there are other conditions you may have that need ongoing PPI treatment.

Remember that lifestyle changes remain an important part of managing GERD. After you have stopped taking a PPI, lifestyle changes become even more important in controlling your reflux symptoms.

Rebound acid hypersecretion

If PPIs are stopped suddenly, reflux symptoms may return for around 4–5 days because of what is known as rebound acid hypersecretion. This occurs when the stomach has become used to a PPI and starts producing more acid. Some over-the-counter medicines can help relieve symptoms while the stomach readjusts to no longer needing a PPI.

To reduce the risk of rebound acid hypersecretion, your health professional may ask you to gradually lower your PPI dose before stopping. This may mean taking a lower dose of PPI medicine, or taking it only on alternate days. Your reflux symptoms may change over time, so the dose of PPI you need may also change. Your health professional can help you to manage this.

Do PPIs have side effects?

PPIs have been used for many years by millions of people. If they are used appropriately, the benefits of taking these medicines are greater than the possible risk of side effects.

Some common side effects include headache, nausea, vomiting and diarrhoea.

Researchers have studied possible more serious side effects of taking PPIs, including kidney disorders (acute interstitial nephritis), bone fractures, certain infections (Clostridium difficile infection), low magnesium, low vitamin B12 and pneumonia. However, from these studies it was not clear whether PPIs were the cause of these side effects.

Even though it is not clear if PPIs can cause such serious side effects, it is not a good idea to stay on any medicine for longer than you need to. If your GERD is under control, ask your health professional whether you can make a plan to lower your dose or stop your PPI medicine.