How Should We Teach Nutrition to Health Care Professionals?

Abstract

Nutritional deficiencies are rampant throughout the world. Health care professionals have a unique responsibility and opportunity to help their patients understand the critical impact of nutrition on health. While nutritional supplements are of great clinical benefit, they are not a substitute for eating healthfully. In this editorial I discuss ways to think about nutritional medicine and priorities for educating health care professionals.

Introduction

For the past 3 years, I have been teaching natural medicine in Russia. Few people are aware that the first translation of my book Textbook of Natural Medicine was into Russian over 20 years ago. Recently, I was asked to cover vitamins. Frustratingly, I was only allocated a meager 3 hours and 20 minutes to cover the 13 vitamins. Very challenging since, for example, my vitamin D lecture alone is 90 minutes long and textbooks are available for each vitamin. I realized for the limited time available I needed to focus on what is most important from a clinical perspective. The simplest approach would be to teach the biochemistry of vitamins—this can be easily found in any nutrition textbook.

Not so available in textbooks is the perspective of 50 years of hard-earned experience studying, practicing, and teaching nutritional medicine. I have personally tried and cared for patients using virtually every diet theory (SAD [standard American diet], vegan, vegetarian, lacto/ovo vegetarian, pescatarian, pure water fasts of 1-30 days, intermittent fasting, etc). I have read many books and textbooks on nutrition, reviewed tens of thousands of research articles, and studied or attended lectures on vitamin/mega-vitamin therapy from giants in the field such as Paul Anderson, ND; Sid Baker, MD; John Bastyr, ND, DC; Jeff Bland, PhD; Alan Gaby, MD; Abram Hoffer, MD; Michael Murray, ND; Linus Pauling, PhD; Jonathan Wright, MD; and many others. I apologize to these others I have learned from for not mentioning them. With this background in mind, I have some thoughts on what actually worked, where we got sidetracked, and what we need to teach those who want to practice nutritional medicine, which I consider to be vitally important.

The Medicalization and Industrialization of Nutritional Supplements Got Us Off Track

If you’ve not read my Unimportant Molecules editorial (IMCJ 20.4), I suggest finding a copy. In this editorial I outline how misplaced concreteness made us overly confident of limited research on single molecules. Worse, very often these single molecules were chosen based on animal research or manufacturing convenience. In that editorial I discuss how most of the discovery of nutrients was distorted by the early stage of our understanding of biochemistry and the limited technology available 100 years ago when much of the work was done.

Most of the best research on the clinical importance of vitamins has come from epidemiological studies of the foods being eating and subsequent assertion that the benefits seen were due to specific nutrients. The beta-carotene, lung cancer, and cigarette smoking debacle is a profound example of the fundamental problem with this approach. The epidemiological research found an inverse correlation between blood level of beta-carotene and various cancers, especially those of the lungs. Based on this, several clinical trials studied the effect of giving beta-carotene to smokers with the expectation the intervention would decrease the risk of lung cancer. To everyone’s great surprise, the supplementation actually increased their risk of lung cancer.¹ A number of reasons for this have been proposed. Those which make the most sense to me are the reduction of other carotenoids when excessive amounts of beta-carotene are consumed and that beta-carotene upregulates CYP1A1, which plays an important role in activation of carcinogens to more active forms in order to facilitate later conjugation in Phase II.² I quote this particular study since it shows that the dietary flavonoid quercetin mitigates this effect. The clear message: supplementing with isolated beta-carotene can be a problem, while beta-carotene in the context of foods which contain quercetin mitigates this effect so there is a net benefit.

There is No Substitute for a Diet of Diverse, Organically Grown Whole Foods

Food fads are just that—does not matter the theory or prestige of the proponent(s), all success appears to depend upon eating diverse real foods rich in nutrients and low in metal and chemical contaminants. I’ve cared for vitally healthy vegans, but also children who were failing to thrive because their emaciated vegan mothers were unwilling to recognize the need to address the limitations of their diets. I’ve seen heavy meat eaters with no apparent health problems dragged into my office by concerned wives (sorry about the apparent gender bias—but never once had a husband drag in his wife), while most others came in for hypertension, cancer, kidney stones, etc.

In virtually every case, I found that the quality of the food and the individual’s unique biochemistry are far more important than the particular diet theory the person follows. Our bodies are remarkably adaptable, as long as the critical nutrients are available. To be clear, the best health is achieved when the diet strategy complements a person’s unique biochemistry. But this is more a matter of fine-tuning which does not matter if the food is of poor quality—low in nutrients and high in toxins. I’ve had many conversations with “biohackers” where they extolled the benefits of their strategy. My first question is whether they eat organically. Virtually always the answer is “no,” at which point I start educating them on how the quality of the foods—or lack thereof—will swamp the potential benefits of their strategy.

There is no substitute for nutrient-rich, uncontaminated food.

Just Because a Vitamin Deficiency Caused a Disease Does Not Mean Replenishing the Missing Nutrients will Reverse the Disease

I have been giving this concept a lot of thought recently. I’ll not spend much space here since I plan to cover in a future editorial. A great example is vitamin D and multiple sclerosis (MS). Many studies show clear correlation between vitamin D deficiency and incidence of MS.³ However, properly controlled vitamin D intervention studies show limited or no benefit.⁴ Please be clear, there are many examples of reversal of a disease by replenishing the nutrient deficiencies that caused the disease—vitamin D (with calcium and vitamin K2) is hugely beneficial in osteoporosis. But there are also many where this is not the case.

Vitamin Supplementation Is Immensely Beneficial—When Appropriate

Therapeutic nutrition is of enormous benefit for our patients and sophisticated vitamin supplementation is an important clinical tool. The Table lists the areas where I think nutritional supplements are indicated.

Table.

Indications for Nutritional Supplementation

Multivitamin and mineral at modest dosages to ensure all bases are covered For special circumstances, e.g., living in a polluted city To address genetic susceptibilities, e.g., VDR receptor deficit For specific clinical purposes, e.g., promoting immune function during an infection

Abbreviation: VDR, vitamin D receptor.

I recommend a good quality, modest dosage, multivitamin and mineral supplement. I have looked at a lot of actual patient diets and run some of them through software tools to determine the levels of nutrients in diets people actually consume. While a carefully designed diet can theoretically achieve adequate levels of all nutrients (according to recommended daily intakes [RDIs]), the high levels of metals and chemicals in the environment increases nutrient needs beyond what can be achieved by food alone. These toxins either directly destroy nutrients or compete with them for enzyme systems, cell signaling, epigenetic modulation, etc. Figure 1 shows how blood lead increases the need for several B vitamins and how the synergistic effects of toxins combined with deficiencies results in increased risk of health-damaging hyperhomocysteinemia.

Figure 1.

Synergistic effects of blood lead levels and B-vitamin deficiencies increasing homocysteine levels.⁵ Subjects with the lowest quartile of blood lead and each micronutrient (A, folate; B, vitamin B6; and C, vitamin B12) less than the median were used as a reference. Q1: first quartile; Q2: second quartile; Q3: third quartile; Q4: fourth quartile.

However, who wants just adequate? There are serious problems with the RDIs and other “approved” standards. Figure 2 shows the huge discrepancy between “adequate” intake of nutrients according to blood levels vs measures of physiological function. As can be seen, while only 4% in this study were deficient in vitamin B12 according to serum levels, 17% to 19% were functionally deficient according to metabolites that increase when vitamin B12 levels are inadequate.

Figure 2.

Functional Measures of Vitamin B12 Are More Accurate Than Serum Levels⁸

Much of the inconsistency between blood levels of a nutrient and physiological measures is due to biochemical individuality. Emerging research is clearly documenting huge genetic variations in nutrient needs. For example, considerable research shows that people with VDR polymorphisms require higher intake of vitamin D. Worse, having dysfunctional VDR polymorphisms plus low levels of vitamin D substantially increases risk of not just the obvious osteoporosis, but a surprisingly diverse range of diseases from polycystic ovary syndrome (PCOS) to even thalassemia.^6,7

Although virtually all the nutrition research is on preventing or treating disease, equally important is achieving optimal physiological function. For example, one of the key strategies for longevity is maintaining mitochondrial function. Species’ longevity is directly proportional to their ability to protect their mitochondria. Figure 3 shows this well.

Figure 3.

Mitochondrial DNA Damage Inversely Associated with Species Longevity¹¹

There is a lot of animal research showing that antioxidants decrease mitochondrial damage and increase longevity. We need collaborating human research.

Optimal health depends upon optimal levels of all the important nutrients in the context of biochemical individuality and environmental challenges. This is simply not possible just from food.

Finally, there are many ways to use supplements for specific clinical purposes. For example, the length and severity of the common cold are improved by using zinc lozenges.⁹ Another example is IV use of vitamin C to reduce mortality in sepsis.¹⁰

Conclusion

Good health depends upon eating a diverse range of real, organically grown, and uncontaminated foods. Nutritional supplements are of immense clinical value, when indicated. The most effective clinicians are able to:

• Facilitate patients making a commitment to healthful eating

• Deeply understand the uniqueness of each person’s biochemistry and how to use nutritional supplements to optimize their physiological function

• Recognize when disease or environmental stressors require extra amounts of key nutrients

I believe this describes the readers of IMCJ.

Biography

Joseph Pizzorno, ND; Editor in Chief, IMCJ; co-author, Textbook of Natural Medicine; Founding President, Bastyr University; Chair, Board of Directors, Institute for Functional Medicine.