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Vitamins and supplements

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Matt Smith:

Welcome to a La Trobe University podcast. I would be your host Matt Smith. With me today is Adjunct Senior Lecturer Ken Harvey from the School of Public Health. You're here today to talk to me about vitamins, how society is treating them, how we should be treating them… we've had a case recently where it's been compared in the media to the Coke and fries kind of mentality of, if we go to a pharmacist, the pharmacist was being encouraged to upsell us on our prescription medication with some vitamins as well, and is upsell the right way to put that sort of deal?

Ken Harvey:

As you say, it was promoted as the Coke and fries deal, it was going to make a lot of extra money for pharmacists, but it raised real questions about ethics. I mean, first of all, the evidence for doing this deal was not good. I mean, yes, it's true that you can get diarrhoea with some antibiotics, especially broad spectrum antibiotics, there's some evidence that taking probiotics or lactobacilli in some people, and in some studies, can help, but it's not recommended across the board, it's not without risk. These are live organisms and indeed in immunosuppressed patients, they have invaded and caused problems. And the evidence for some of the other stuff was equally dubious. I mean, it's true that taking blood pressure medication can sometimes lower some minerals, but that's rare that people come in to real problems with that, and if it's suspected by the pharmacist, then the answer is to send the patient back to the doctor, get some blood tests, confirm it, and then yes, a supplement might be indicated. So it was an interesting deal which created a lot of angst in the community in which really the two conflicting roles of a pharmacist – one as a professional adviser and one as a small businessman to make money came into clear conflict, and to their credit that deal was actually abandoned because of criticism.

Matt Smith:

Yeah. I found a large part of it as well – it would have been a violation of the trust that the public puts into a pharmacist – we see them as somebody of authority who knows what they're doing and knows what they're talking about.

Ken Harvey:

Yes, and indeed that's true. Pharmacists are well educated in terms of drug use. They can give good advice about drug interactions and potential problems, and if patients are having problems with medication, then it's quite reasonable that they go back and talk to the pharmacist who, if necessary, can refer them back to their doctor. And I noticed that there's a Readers' Digest I think assessment in which they came out at about number four or five in the trusted professions. And that's I think quite appropriate, but clearly deals like this do conflict with that trusted authority image, and people have pointed out it's not just on selling things, some of the things in the pharmacist's shop that they sell, ear candles, homeopathic medications, a lot of other complementary medicines that are not evidence based, again call into conflict this trusted advice. Now again, let me say that many of the best pharmacists either don't stock that sort of rubbish or if they do stock it, they'll give good advice if a customer asks about it, but not all do that. And as I say, this is a real dilemma for the pharmacy profession. I might add that the medical profession has been in a similar situation in the past. There was a deal done with a prescribing software company and pharmaceutical companies, which put advertisements to the latest and most expensive drugs flashing up in the face of doctors in their prescribing software on their computer, all day every day, and clearly this was an equal problem, and caused a lot of controversy. And ultimately again, that deal was abandoned, and now, quite rightly, the code of conduct of Medicines Australia, which is the prescription drug organisation, says no pharmaceutical advertisements allowed in software. And I would hope that similar ethical concerns will be taken on by the Complementary Medicine Health Care Council of Australia, which is the body that is responsible for complementary medicine manufacturers. In fact they have got a code of conduct – it's very weak and it does need strengthening along these lines.

Matt Smith:

I read an article recently – it was a Time magazine article – in which the reporter spent five months using vitamins, 22 tablets a day, at the end of it, it had no effect. He was medically monitored throughout the entire process and it didn't really have an effect – it didn't improve things for him and he actually put on weight. Are vitamins something that we actually need, or is it something that we think we need?

Ken Harvey:

Well, it's something that we are prompted to need by a lot of advertising pressures. Look, in practice, what we need is a balanced diet. We need fruit and we need vegetables and we need to eat sensibly, and if you do that, you have absolutely no need for vitamin supplements at all. Now, having said that, yes, there are some elderly patients in nursing homes for example, or perhaps with poor diets, who could benefit from a particular vitamin supplement. That's something that again should be discussed with their doctor. There is no need for routine vitamin supplementation and indeed, the increasing evidence is that it can be harmful. For example, new studies have shown that males taking doses of Vitamin E which have been recommended by the industry, have slightly more problems of prostate cancer. There's been other studies showing that women taking multiple vitamins again perhaps have a slightly increased incidence of death, so these things are not without risk. People think that because they're natural they're harmless, but that's not necessarily so, especially when they're taken in much larger doses than you would normally get from a diet. So no, no, I think the clear evidence is that we should just stick to eating properly and restrict our supplements to if there is a real problem with a diet, which sometimes does happen with the elderly or the aged, people living alone. Clearly the push for vitamins is driven by promotion, and there's lots of very clever, subtle promotion out there implying that you're too busy to eat properly, therefore have a multi vitamin. If you're too busy to eat properly, there's no evidence that taking an expensive vitamin will help. The most it does is change the colour of your urine. What you need to do is get a better diet. And there's again lots of advertisements as we know in which cricketers, sporting enthusiasts and others swear by the fact that taking this vitamin daily has helped to improve their performance. I'd like to know exactly how much money they were paid to make that. It's clearly cash for comment, and again should just be taken with a grain of salt. People are being paid to say these things. Why should you take any notice of them?

Matt Smith:

What would be an ideal situation out of this then? Is it better public education on what vitamins do and when you would need them, or is it better regulation of the industry?

Ken Harvey:

Well, I think we need both really. And also, to be fair, there are structural problems in the sense that not everyone can afford a good diet. That regrettably, junk food is cheaper than good fruit and vegetables, and certainly when you get out into the country, get out into rural and isolated Australia, where the costs of transporting fruit and vegetables are high, it can be difficult to have a good diet, but again that's not an answer for having vitamin supplements. So going back to your question, I'd like to see less hype about vitamins and complementary medicines and indeed, there is a lot of concern about the over-promotion and the claims being made that lack substance and the Parliamentary Secretary for Health has got a number of reports on her desk at the moment suggesting that advertising arrangements need to be tightened, that sponsors that make claims that lack a foundation should have sanctions that hurt, and that at the moment the sanctions are weak or non-existent, so regulation I think does need to be strengthened, advertising and health promotion does need to be strengthened, giving the messages as I say, that diet is the appropriate thing. I think we've got to look at some of the underlying problems. People have suggested more recently, for example, that OK, what about a fat tax on things that are unhealthy for us, and use that money to subsidise things that are good, like fruit and vegetables, and I think this concept of trying to make the right choices, the easy choices, and the affordable choices, I mean, that's basic public health philosophy. We could do more there.

Matt Smith:

What do you think about the fat tax? I know that it's come into play in a few of the Northern European countries I believe.

Ken Harvey:

Yes, Denmark in particular I think has just introduced it. Denmark has got quite a high incidence of cardiac-vascular disease. I think it's not so much because of the obesity, although it's a problem in most countries now, I think their particular concern was they had a higher rate of heart disease than other countries and certainly there's a good correlation of eating too much of certain sorts of fats and heart disease – it clogs up your arteries and you get heart attacks and nasty things. I think that was the prime driver, but the widespread obesity epidemic and the rise of non-communicable diseases that are associated with that – diseases like heart attacks, diabetes, for example, which are all related to obesity and being overweight, that's made us think a lot in the public health arena about how to cope with these things, and clearly, education is one thing, and good information is the getting of wisdom, but we all know there's a lot of things we know we shouldn't do, but we do, because they're easy to do, they're nice to do, and again, it gets back to making the right choices, healthy choices, the easy choices and degrees of regulation, tax, financial incentives, can all help there. So I think the fat tax is certainly something to be looked at. I understand that it was put up as one of the propositions on our preventative health task force but the government understandably has not embraced that at the moment. They've got a lot of other problems. But I think as part of a package, and again we know in trying to improve people's health you shouldn't just be restrictive and punitive, it's information, it's incentives, and finally, it's sanctions that carry the day, but down the track we've got to look again at fat taxes and using that money to subsidise more healthier products.

Matt Smith:

At some point though it takes the trust away from the consumer. It says that the people can't be trusted to be responsible for their own health.

Ken Harvey:

Oh, look, I disagree with that. I mean, this is the nanny state argument. For example, look at gambling. We know that large amounts of distress is caused by a relatively small proportion of problem gamblers, and yet they are specifically targeted by the gambling industry. What's more, the gambling industry specifically targets lower socio-economic suburbs to put most of their machines in. And of course, as I've said, advertising and promotion is all designed to encourage unhealthy activities which are financially rewarding for those that are encouraging them. So I won't have it that it's just a matter of individual decisions, as some of our right-wing neo-conservatives say. If there's a push for unhealthy behaviour, if it's pushed by large amounts of money from vested interests of industry, then I think it's up to society to counter that. We have accepted those concepts, I mean, the seat belt legislation has got up, you can't smoke now, in this room or in enclosed spaces or restaurants – those sorts of restrictive changes have been accepted by the community on the basis of good information provided, that this was to help to all, that individual behaviour can cause problems for other people, and under those circumstances, I think, looking at legislative and restrictive solutions, in combination with the incentives and everything else, and information, is important.

Matt Smith:

Now lastly, if I could get some free health advice from you. I have high blood pressure and am on daily medication for that. Should I be taking vitamin supplements?

Ken Harvey:

The answer is no. Don't take anything extra recommended by your pharmacist to make extra money. Talk to the doctor, talk to the pharmacist. I mean, the crucial question is, what is the evidence that taking something routinely with my prescription medication will relieve an alleged side effect. And what are the downsides? And certainly a lot of elderly patients take a lot of drugs, blood pressure drugs, lipid lowering drugs… for a pharmacist to add on an extra three or four medications, presents a big burden to the patients, not just in cost, but in terms of compliance, remembering what to take, how to take it, it shouldn't be done.

Matt Smith:

Ken Harvey, thanks for your time today.

Ken Harvey:

Thanks.