Messaging and Multivitamin Use: Rethinking the “It Can’t Hurt” Philosophy

Abstract

Fifty-two percent of American adults report use of a dietary supplement, most commonly for improved health and disease prevention. However, literature supporting such use is inconsistent. Many providers suggest that the addition of a multivitamin “couldn’t hurt,” but this messaging may promote unintentional consequences including a shift of emphasis on intake of healthy foods to nutrient supplements and a neglected opportunity to discuss the profound benefits of a healthy diet. Potential implications of such messaging and recommendations for counseling are described.

‘A common adage among health care professionals is the idea that the use of multivitamins “does not, would not, or cannot hurt.’

Data from the 2011 to 2014 NHANES (National Health and Nutrition Examination Survey) survey found that over half (52%) of all US adults report regular use of dietary supplements and 32% of adults report regular use of multivitamin-mineral (MVM) supplements, specifically. ¹ Among the most common reasons for using supplements is to improve overall health, supplement the diet, and prevent health problems. ² The data to support the preventive health benefits, specifically prevention of chronic illness including cardiovascular disease (CVD) and cancer, are insufficient. ³ And yet, many supplements are promoted to prevent these conditions. ⁴ Additionally, many health care professionals recommend dietary supplements to their patients. ⁵

A common adage among health care professionals is the idea that the use of multivitamins “does not, would not, or cannot hurt.” This philosophy is supported by published literature, which finds long-term use of MVM supplements “safe” (without serious adverse effects). ⁶ But safety may not be the only harm that promoting MVM supplementation gives rise to.

As addressed in the Offringa review, health behavior messaging is important and there are potential implications to the way health professionals discuss use of MVM supplements, especially as it relates to the idea that it “wouldn’t hurt” to add one to a patient’s regimen. ⁷ Potential unrecognized risks of such messaging will be described below and recommendations for counseling on MVM supplements is provided.

Shifting Emphasis of Food to Supplements

The message that multivitamin use for disease prevention “doesn’t hurt” is problematic. When used without clarification of the limited available supporting evidence, this messaging insinuates a positive effect for patients and may take the place of a discussion about the benefits of a healthy diet. By using the words “it wouldn’t hurt” as opposed to “it may not be helpful,” there is a suggestion of benefit as opposed to a question of utility. It is difficult enough for patients to navigate the marketing language of dietary supplements, and providers should promulgate clear messaging about the usefulness of such products. The phrase “it wouldn’t hurt” has the potential to shift the emphasis from obtaining adequate nutrition through healthy foods to obtaining nutrition through supplementation. That consuming a diet high in saturated fats, sugars, and salt can be redeemed through use of a supplement. To not strive for a varied, healthful intake because a MVM supplement can fill the nutrient gaps.

Unfortunately, this idea has not held up in nutrition studies.^8,9 Conclusions from systematic reviews including the US Preventive Services Task Force guidelines agree that there is insufficient evidence to recommend for or against use of MVM supplements for the prevention of chronic diseases such as CVD and cancer in otherwise healthy patients.^3,10 So while many well-intentioned health care professionals suggest MVM supplementation “wouldn’t hurt” as a means to say “it’s probably safe but we aren’t sure it provides any benefit,” it would be better to include a more detailed explanation so that patients are aware of the limited efficacy data and not left to assume otherwise. Better yet, providers should use the opportunity to discuss the preventive benefits of a healthy diet.

Food Versus Supplements: Burden of Proof

While the literature evaluating the usefulness of MVM supplements in the prevention of death and disease is conflicting, the data supporting the beneficial effects of diet on health are not. In fact, poor diet is recognized as the leading cause of death and disability in the United States, and the World Health Organization predicts that by 2020, two thirds of disease worldwide will exist because of a poor lifestyle.^11-13 A large body of consistent evidence suggests eating a healthy diet can prevent, delay, or even reverse CVD, hypertension, hyperlipidemia, diabetes, and certain cancers.^14-19 The effect of such intake is rapid and profound.

When patients seek options for decreasing their risk for chronic illness, it is imperative that health care providers discuss the benefits of a healthy diet. The phrase “it wouldn’t hurt” to add a MVM supplement for prevention diminishes the opportunity to promote the time-tested intervention of healthy eating. An intervention which touts far more convincing evidence than any supplement.

A Change in Messaging

Because 52% of Americans are using dietary supplements, there are numerous opportunities to provide counseling on the utility of and alternatives to such products for disease prevention. Counseling should occur when a patient seeks guidance on the use of a MVM supplement, but also when a multivitamin is observed on a medication list or mentioned in the medication reconciliation process.

Health care providers should refrain from suggesting to patients that the addition of a MVM supplement “wouldn’t hurt.” Counseling on the use of MVM supplements first requires ascertaining the reason for use. There are segments of the population, for example, pregnant or lactating women, that stand to benefit from supplementation. However, a patient who is seeking a supplement to prevent chronic disease or who hopes to obtain their nutrients from supplements in place of healthful foods needs clear messaging about the limitations of such use. Various health organizations agree there is insufficient data to recommend dietary supplements for the prevention of chronic disease:

• The American Cancer Society suggests that current evidence does not support the use of dietary supplements for cancer. ²⁰

• The American Heart Association recommends that nutrients should be consumed through food, rather than supplementation, to prevent heart disease in healthy persons. ²¹

• The Academy of Nutrition and Dietetics state that there is no evidence to support that MVM supplements are effective in preventing chronic disease. ²²

The “it couldn’t hurt” messaging insinuates that patients may achieve health gains by using supplements, oftentimes in place of healthful food choices or in spite of poor food choices. Phrases such as “it may not be helpful” could be used instead so that the lack of concrete support is apparent. The “it couldn’t hurt” messaging also diminishes the opportunity to talk instead about the clear and consistent evidence that supports the profound health benefits of a nutritious diet. Providers should leverage these conversations to discuss with patients the benefits of diet, current eating patterns, and strategies for improved intake.