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Introduction: It was a long, difficult, and confusing road that lead me to the conclusion that as a person with diabetes (type I for 45 years), I should take vitamin, mineral, and trace element (micronutrient) supplements daily. My educational background, like that of most other health care providers, did not include much clinical information about the need for micronutrients. Most of the information presented concerned biochemical effects (the effects of vitamins on the chemical reactions of cells) or deficiency states due to an unbalanced diet. I can remember my professor summarizing vitamin use by saying "the vast majority of people in the United States don't need to take daily vitamin supplements, as long as they consume well-balanced and nutritious meals each day." He also emphasized the lack of long-term clinical studies about micronutrient supplementation. My professor categorized the people who probably needed supplements as: children during growth stages, pregnant and lactating women, elderly patients, individuals with specific vitamin deficiencies, patients with chronic conditions, alcoholics, individuals under stress, and those who did not follow a well-balanced diet. I added up all the people in these categories and realized that a relatively high percentage of the total US population might need daily supplements.
Over the past 25 years I have collected an extensive file on various subtopics relating to diabetes, its treatments, and its complications. In 1988, I noticed my file on micronutrients expanding at an impressive rate. By 1990, my file had grown from about four inches to over four feet wide. Periodically I would review the files and subcategorize them into various vitamin, mineral, and trace element files. One day I finally decided to read all the information I had gathered. It was then I realized that much of what I had been taught about vitamins, and the conclusions that I had reached, might be wrong. There are some excellent articles published in very respectable medical journals that specifically link diabetes and certain vitamin deficiencies, as well as identify some micronutrients that may have a positive impact on the disease. Reading these articles, however, I also saw very real information gaps; more studies need to be done. I tried discussing vitamin education with other health care providers and realized very little time is spent on this topic in most professional programs. Most people teaching these programs don't review the literature in depth, and there's a general "anti-vitamin supplement bias." Very little government or corporate funding is available for vitamin research; consequently, the controversy surrounding daily supplementation of micronutrients will rage for many years to come.
Recent studies show some benefits to daily supplementation, especially with "antioxidant type vitamins." A five-year study involving almost 30,000 peasants from rural China discovered that vitamin E, betacarotene, and selenium supplements seem to reduce cancer deaths by 13% and all other deaths by 9%. Unfortunately, I believe most health care providers feel guilty about recommending vitamin supplements because of the way they were trained, precluding an objective review of study reports and other literature involving these compounds. In simpler terms, nutrition ignorance can breed nutrition arrogance. The problem is that two individuals, one wanting to believe in supplementation and the other thinking it unnecessary, can review the same medical literature in detail and come to completely different conclusions. People become confused by the hybridization of science and rumor that infects both sides of the supplement controversy.
The Case for Supplements
Although individuals need over 50 vitamins, minerals, and trace elements each day, only 17 of them have official recommended daily allowances (RDA's). Futhermore, the RDA's are estimates designed to prevent vitamin deficiencies, not provide optimum doses, and are sometimes based on a tiny number of test individuals with no chronic conditions. Many PhD's, MD's, and micronutrient specialists note that there can be significant differences between a vitamin's recommended daily allowance and its optimal/therapeutic dose. A good example is niacin, whose RDA is approximately 20 mg, but whose therapeutic dose can be up to seven grams (7,000 mg) per day (used to help lower cholesterol levels in patients with hyper-lipidemia) [Advisory Board-Niacin is contraindicated in people with diabetes for the treatment of lipid disorders. Niacin increases insulin resistance and reduces insulin sensitivity by about 30%. Niacin can induce overt diabetes in people who have impaired glucose tolerance, and can change well controled diabetes into uncontrolled diabetes.-Dr. Nancy Bohannon, MD]. Some studies have shown that high doses of certain vitamins will actually reduce the incidence of disease. Antioxidants, including vitamin E, betacarotene, vitamin C, selenium, and zinc, have proven effective in lowering the rate of cardiovascular disease and certain cancers when given in higher-than-RDA doses.
Another facet of the supplementation controversy concerns the "healthy, normal diet." How many people do you know follow a healthy, normal diet? One study showed that 25% of the US population do not eat vegetables, and 43% don't eat fruit, on any given day. Only 9% of the people studied ate the recommended five servings of fruits and vegetables on a daily basis. Many of the required vitamins and minerals are found in food like liver, but who can recommend eating liver, with its high cholesterol content, on a regular basis? Dairy products may be high in calcium and certain vitamins, but they are also high in calories, saturated fat, and cholesterol. Even vegetables aren't sacrosanct. Modern food processing, storage, transportation, and refrigeration techniques insure that the produce on your table is anywhere from three to twenty-four weeks old. Since the chemical stability of many vitamins and micronutrients is very fragile after a plant has been harvested, the nutritional value of some foods may be lowered by virtue of time, preservation, and processing. When you add the people who don't eat a balanced diet to the list of people who should supplement, you can see that a large portion of the US population probably needs daily vitamin supplements.
Numerous articles have concluded that individuals with diabetes who have elevated blood sugar levels do not absorb micronutrients and often have an excess excretion of vitamins and minerals through the urine. For example, many articles have documented that individuals with diabetes have low blood levels of vitamin C. Isn't it logical to conclude, just to be on the safe side, that a person with diabetes should take daily supplements of vitamin C? It's established fact that many individuals with diabetes lose magnesium through urine, eat a magnesium-light diet, and don't always absorb the magnesium they do eat. Shouldn't these people be identified and given magnesium supplements? Recent literature has documented the impact of vitamin E on patients with diabetes, not to mention its effects as an antioxidant free radical scavenger, increasing life expectancy. Conclusions, anyone?
The Case for Research
The concept of "diabetes and micronutrients" has some historical similarities to the concept of "chronic hyperglycemia causing diabetes complications." Even though many animal, human and short term studies were conducted showing that complications were due to increased blood glucose levels, only a small minority of health care providers encouraged their patients to try normalizing their blood sugars. It took the results of the DCCT to get many people to follow what seemed to be a very obvious and logical treatment. With diabetes and micronutrients we have a lot of information, but we don't have the large-scale, long-term study proving that a precise dose of vitamins, minerals, and trace elements will make a significant difference. The sad fact is that we will probably never have such definitive results. As with the concept of "sustained hyperglycemia inducing complications," we have animal and human studies on micronutrients and diabetes and can make some logical conclusions, but even the studies we have usually summarize by stating that more studies are needed. This results in more confusion and controversy-bummer.
One of my major concerns is that many health care professionals have been trained to scorn vitamin supplementation. Anyone recommending supplementation is considered some type of charlatan or quack. The real problem, however, is most health care providers do not evaluate their patient's micronutrient status, their diet, or their needs. Many of the diabetes patient assessments I've seen don't even mention these concerns. In addition, there are more than 40 therapeutic classes of drugs that cause micronutrient depletion or interfere with micronutrient status, most notably the thiazide diuretics and corticosteroid medications. We also know that water softeners will deplete many minerals from the water system-magnesium, for example. I've been in the health care system for many years, and nobody has ever asked about or monitored my drug therapy regarding micronutrients, nor has anybody been in any way concerned about it.
The Warning Flags
Now that I've listed some of the reasons I think many patients with diabetes should supplement micronutrients daily, I want to wave a warning flag or two. First of all, a person who decides to take vitamins should make sure they take vitamins in an intelligent and, most importantly, safe manner. Secondly, it's true that there are some charlatans out there who will lead people to believe that vitamins are some kind of miraculous cure for chronic conditions. There are documented cases in which people quit taking insulin after being told that some micronutrient or other natural product, i.e.: bee pollen, would handle the person's diabetes. I am aware of no micronutrients that cure diabetes or significantly affect blood sugar levels. Some terms to watch out for that are often associated with unproven nutritional remedies include: orthomolecular, ecological, alternative, holistic, unorthodox, metabolic, unconventional, and non-toxic. On the other hand, there are micronutrients that people can take on a daily basis which might help prevent some problems.
I think there is a part of all of us that wants to believe there is some magic product out there that will make us feel better, live longer, and reduce the chances of developing complications. Any reasonable person who understands diabetes at all knows that diet, exercise, drug therapy, and knowledge through self-monitoring of blood glucose levels are the essential ingredients to diabetes care. On the other hand, after reviewing all the literature, the bottom line is that I have decided to take daily supplements of vitamins. I take all of the vitamins, minerals, and trace elements known to benefit people in amounts at least equal to the RDA's. There are certain vitamins, such as vitamins C and E, betacarotene, and magnesium, which I take in large doses because I believe they will do me no harm and might be beneficial in preventing some problems.
When looking at micronutrients in diabetes there is great controversy regarding supplementation. I'm a reasonable, scientifically trained, intelligent person, and I have looked at this controversy, and the studies, and the lack of attention given to this subject, and I have decided that micronutrient supplementation may do me a great deal of good. Psychologically, it was difficult for me to come to this conclusion, but I feel good about it. There is emerging evidence that individuals with diabetes should take daily micronutrient supplements, and I am not the type of person who will wait 20 years for the final, established study before I take vitamins on a daily basis.
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