The AMA Crosses the Line

August 2002 | Health Conscious

The AMA Crosses the Line

by Rebecca Ephraim, RD, CCN

Where has the American Medical Association (AMA) been? I had to roll my eyes as I read the "Scientific Review" in the AMA’s powerful publication arm, Journal of the American Medical Association (JAMA), which suggests everybody should be taking a daily multivitamin. The article, entitled "Vitamins for Chronic Disease Prevention in Adults," appeared in the June 19 edition of JAMA; the article’s gist was subsequently splashed across newspapers and heralded on TV and radio news programs across the country.

The article, written by two Harvard-affiliated M.D.s, reviews a large body of research that ultimately promotes the use of vitamin supplements for many segments of the population. It shows that vitamin supplements benefit those at risk for chronic illnesses such as heart disease, cancer, and osteoporosis as well as the untold numbers of people who have nutrient-absorption problems. So the benefits cover just about everybody! And the authors admit as much in the commentary that follows the article, in which they say, "We recommend that all adults take one multivitamin daily."

My initial reaction was, "It’s about time!" The JAMA cited references from 152 scientific sources. Interestingly, one-third of them were published either before or during 1995. And another 69 were published before the year 2000. So the fact of the matter is, this article could have been written with ample supporting evidence well before we clicked into the 2000s. In addition, 13 of the studies cited in the JAMA article appeared during the 1980s or earlier — one was published in 1976.

From my nutrition reading and coursework, I’m acutely aware that there has been scientific evidence in support of vitamin supplementation dating back to the 1950s and earlier. But why the AMA and its journal have chosen not to communicate this information until now remains a mystery to me, especially as a growing number of Americans — about half the population — now regularly uses supplements.

I knew that Annette Dickinson, Ph.D., an expert on the benefits of vitamins and minerals, could provide some insight. She is the vice president of scientific and regulatory affairs for the Council for Responsible Nutrition (CRN), a trade association of dietary-supplement manufacturers. She may represent the interests of supplement makers, but her depth and scientific bent have made her a well-respected name in the field of nutrition overall. She was a member of the FDA’s Food Advisory Committee, was appointed by President Clinton to the Commission on Dietary Supplement Labels, and is author of Optimal Nutrition for Good Health.

Moreover, Dr. Dickinson was a steadfast advocate of responsible nutritional supplementation long before her thirty-year involvement with CRN. As a child, her mother was a strong believer in the peace of mind that vitamin supplements offer — and that was well in advance of the huge body of solid scientific evidence available today. "I always thought they [supplements] represented a rational approach to a kind of insurance given the fact that survey after survey shows that hardly anybody gets everything they need from diet alone," she says. "My philosophy is and always has been that it’s better to get nutrients from supplements plus diet than to go short. It just seems to me an eminently logical proposition."

Without a doubt, the JAMA commentary represents a turnaround from the antivitamin stance the publication has historically supported. However, this is not very impressive to Dr. Dickinson, who calls it a "small" watershed. Her lukewarm reaction is based on the wishy-washy advice printed on the "JAMA Patient Page" accompanying the JAMA articles, which is for doctors to copy and distribute to their patients. She notes that the patient page says nothing about recommending a daily multivitamin. Indeed, the only reference is this: "The best way to get vitamins is from whole foods — fruits, grains, vegetables, dairy products, and lean meat. However, taking a daily multivitamin supplement will also ensure adequate amounts of the important vitamins."

Hardly a trumpeting endorsement. Dr. Dickinson laments, "I think they still are not accepting the evidence or recommendations that would make sense based on what’s presented [in the Scientific Review and commentary]. I think they’re still holding back very significantly, but it is a step forward and I hope it will be the first of others."

So back to why Dr. Dickinson believes it’s taking so long for JAMA to come around on the supplements issue. An argument that should not be used, she says, is a supposed scheme by pharmaceutical companies to suppress the use of nutritional supplements. "I don’t subscribe to that view. Many of the major supplement makers are pharmaceutical companies. [For example] Wyeth, which is a giant pharmaceutical company, also makes Centrum. Bayer, also an enormous pharmaceutical company, is the maker of One-A-Day. [Conversely] many of the lesser-known supplement makers also produce over-the-counter drugs, or in some cases, pharmaceutical drugs."

Dr. Dickinson blames the AMA’s foot-dragging on an entrenched mindset. She says there’s a mistaken tendency among medical doctors to hold nutritional supplements to the same standard as pharmaceuticals. Physicians are taught that drug use can cause significant adverse side effects and that diagnostic testing should be performed to assess a person’s needs before prescribing medication. Yet Dr. Dickinson says testing people for nutritional supplements is expensive, usually not covered by health insurance, and unnecessary, since vitamins and other supplements have an enduring safety record. In fact, testing for vitamin deficiencies is more expensive than simply buying a year’s supply of multivitamins! Besides, there’s ample evidence that vitamin supplements are health-supporting for the general population.

Another obstacle to an out-and-out supplement endorsement, she says, is that the "[conventional] medical community generally is skeptical of so-called‘personal intervention.’" As a result, it has historically discouraged the idea that one should take responsibility for one’s own health apart from getting a physician’s care.

Lastly, Dr. Dickinson believes there is a political agenda that snakes through this issue. "I think both the dietetics community and the medical community have been slow to acknowledge that there’s anything less than perfect about either the American diet, the form that it takes, the way that people actually eat, and the fact there are actual health consequences of those habits." In other words, a lot of the food products on the market are nutrient deficient and, overall, Americans are not making good food choices. To compound the problem, as a society, we’re exercise slugs, which means we need fewer calories. And Dickinson argues that the fewer calories we take in, the harder it is to squeeze in the nutrients we need. Hence, nutritional supplements cover a lot of sins.

Only one-third of the M.D.s in this country belong to the AMA (down from 75 percent in the 1970s). So the AMA can hardly serve as the voice representing the majority of the nation’s M.D.s. Among other issues, the AMA’s resistance to change may offer the key to why so few physicians align themselves with their professional organization. Yet when the AMA — or its medical journal — speaks, the nation’s mainstream media make it Big News, as if the AMA’s pronouncements signal a turning point in how consumers will conduct themselves with regard to health issues. However, with millions of Americans already popping vitamins — either on their own or upon the recommendation of their enlightened health practitioner — JAMA‘s audience may simply be those M.D.s who need to catch up on a subject about which the majority of Americans are already informed.

Disclaimer: This column is for information only and no part of its contents should be construed as medical advice, diagnosis, recommendation or endorsement by Ms. Ephraim.