New thoughts on B12, omega 3 & Multivitamin replacement

Here are some thoughts on B12 0mega 3, zinc and a variety of other nutrients that are components of a multivitamin tablet.

Top Line recommendations

1. Magnesium Taurate 300 mg at bedtime [1 capsule]
2. Zinc citrate 30 mg at bedtime [Pure brand = 1 capsule]
3. B12 oral spray 2000 mcg daily.[Better You B12 boost]
4. Centrum Silver Adult Over 50: 1 daily.
5. Vegan Omega 3 4G daily [Nutravita brand = 2 capsules]

B12 a common deficiency over 50

Prevalence

A sizable portion of over 50s are B12 deficient [ Estimates are 30-40% over 50].

High risk: the elderly, metformin users[1], PPI takers [eg omeprazole for acid reflux], vegans and those with high folate diets or folate supplementation. We certainly don’t want to limit folate consumption because folate is in itself dementia-protective and if you wish to be vegan that is fine but B12 has to be maintained!

Why does it matter?

David Spence wrote “Metabolic vitamin B12 deficiency: a missed opportunity to prevent dementia and stroke“[[2]]. This a well-researched case for replacement. Critically, it is frequently missed; is easily treated; and contributes importantly to cognitive decline and stroke in older people.

A recent review [[3]] stated ‘systematic review suggests that supplementation of B Complex vitamins, especially folic acid, may have a positive effect on delaying and preventing the risk of cognitive decline’ They highlight B1 [thiamin/e] B12 and folate.

Yahn et al say in another review: “Clinical data from our literature review strongly suggest that a deficiency in vitamin B12 is a risk factor for ischemic stroke and worsens outcome. [[4]]

There is a clear mechanism whereby B12 deficiency involves processes that lead to Alzheimer’s Disease.[[5]]

Measurement?

There are some difficulties in interpretation of serum B12 measurements [serum levels do not reflect intracellular levels in all cases]: measuring B12 plus Homocysteine plus MMA measurement gives a clearer picture.

However, many authorities accept simple B12 measurement as a reasonable screening test.

Pragmatism

If you are over 50 and especially if you fall into one of the special risk categories. then get tested and if that isn’t possible take B12 pragmatically to ensure adequate biological function. There are no established risks to B12 and any excess you don’t need gets out in your urine. Expert discussion of limited epidemiological evidence of a small increase in colorectal cancer when B12 levels are very high reassuringly suggests that this does not demonstrate B12 causing cancer: more likely that the cancer is causing the raised B12.

What treatment? 

Oral B12 is as effective as intramuscular injection [[6]]. A dose of 1000 mcg daily as a spray or a sublingual tablet is recommended in Canada and Scandinavia [7] The ranges quoted are from 500-2000 mcg. Given missed days, complete safety [no risk of overdose] and significantly reduced absorption in older individuals [ Vitamin B12 intake recommendations in Australia and the United States assume an average estimated absorption rate of 50% of the vitamin from food[8], while the European Food Safety Authority assumes 40% .

I recommend using 1000 mcg daily at 50 and in anyone over 60 increase to 2000mcg. The spray I use is 1200mcg/ squirt so I take 2 a day.

Zinc & Magnesium – major players

Zinc is critical for immunity and most over 50s are not getting enough in their diet.

“People 60 years and older generally have zinc intakes below 50% of the recommended daily allowance on a given day. Causes involved: altered intestinal absorption, inadequate chewing, psychosocial factors, drugs interactions, altered subcellular processes”[[9]].

Specific additional benefits. 

In numerous studies, zinc supplementation has been found to improve blood pressure, glucose, and LDL cholesterol serum level [[10]]. There is a significant improvement in all lipid measurements [the study was in patients with T2DM] who take 30-50mg Zinc daily. NB not zinc sulphate which is poorly absorbed [[11]].

To repeat: I have mentioned in another InfoSheet that many over 50s are magnesium deficient and advise 600mg at nightime using Mg Taurate which is highly absorbed [Tom Oliver brand], or Mg. glycinate or citrate but NOT oxide. It has to be an organic compound not an inorganic salt. There is no way to get adequate dosage through the skin.

Omega 3 fatty acids – no longer a fishy story

Omega 3’s are technically N3 -PUFA’s.

There are several health benefits. They reduce inflammation and strengthen the immune system [[12]], are beneficial in the treatment of inflammatory bowel disease [[13]], and rheumatoid arthritis [[14]], are under investigation for their therapeutic potential in multiple sclerosis. There is evidence of modest benefit in osteoarthritis at a dose of 4G daily[[15]. They have cardioprotective effects. The US National Institutes of Health have a Nutrition department. Their conclusions about omega-3s and CVD are in an NIH Fact Sheet [[16]]. This states:

“Research indicates all types of seafood promote heart health. Fish oil and other omega-3 supplements lower triglyceride levels and might reduce the risk of some cardiovascular endpoints, especially among people with low dietary omega-3 intakes. Evidence of a protective effect for omega-3 supplementation is stronger for people with existing coronary heart disease than for healthy individuals”.

‘Adequate’ intake would be 3 meals of fatty fish a week or an awfully large consumption of flaxseed oil. The benefit is always going to be greater for those at highest risk but for over 50’s any benefit is good and will be sustained over many years after establishing the habit or regular consumption

In 2004, the US FDA approved a health claim for conventional foods and dietary supplements that contain EPA and DHA [92]. This health claim states, “Supportive but not conclusive research shows that consumption of EPA and DHA omega-3 fatty acids may reduce the risk of coronary heart disease.” FDA also specifies that the labels of dietary supplements should not recommend a daily intake of EPA and DHA higher than 2g [[17]]. This refers to general supplementation over all ages and is not because of any hazard. Where omega 3 is used specifically and medically to lower raised triglycerides then a 4g dose is allowed. I believe this is a safe dose in the over 50’s.

There are no known hazards apart from an interaction with old fashioned anticoagulants.

Prospective studies and three new meta-analyses suggest that fish or n-3 PUFA intake are associated with a reduction in development of mild cognitive decline and Alzheimer's disease. Supplementation with docosahexaenoic acid (DHA) in randomized controlled trials (RCTs) in those with mild cognitive impairment showed benefit on cognitive decline. In cognitively healthy individuals with clinical coronary artery disease 3.36 G daily slowed cognitive ageing by 2.5 years [[18]].

Type of preparation

Fish oil can deteriorate with prolonged storage or exposure to light. Some people find they dislike the fishy aftertaste. Fish oil may contain mercury and Cod liver oil contains vitamin A so overdosage with this form of omega 3 may be toxic. As all fish derive their omega 3’s originally from eating algae alga oil is a good alternative with no fishy overtones. Also suitable for vegans and no risk of mercury or Vit. A overdosage [theoretical]. [I take Nutravita Vegan Omega 3 – Amazon. I capsule daily is 2G]. In the USA, Ovega is a reputable brand but others may be available.

What dose?

You must choose to take either 2G or 4G daily. I have opted for 4G,personally  because that dose has been used in most recent studies.

Multivitamin tablets – back in favour.

There has been hot debate for years about the value of taking a multivitamin. To some extent it depends on what is in the pill. You need to avoid those containing iron which is only needed for menstruating women. The main issue has been the lack of evidence of benefit. The recent COSMOS-Mind study [[19]] provides the first evidence of a positive effect on cognition of a multivitamin taken over a 3 year period. The product used was the Centrum Silver, Adult over 50 preparation. [Other Centrum Products are NOT identical – so take this one as nobody knows which component was the useful one].  There was no benefit on cardiovascular disease [[20]].

This preparation also contains the right dose of thiamine [mentioned above].

References

[1] Infante M, Leoni M, Caprio M, Fabbri A. Long-term metformin therapy and vitamin B12 deficiency: An association to bear in mind. World J Diabetes. 2021 Jul 15;12(7):916-931. doi: 10.4239/wjd.v12.i7.916. PMID: 34326945; PMCID: PMC8311483.

[2] Spence JD. Metabolic vitamin B12 deficiency: a missed opportunity to prevent dementia and stroke. Nutr Res. 2016 Feb;36(2):109-16. doi: 10.1016/j.nutres.2015.10.003. Epub 2015 Oct 21. PMID: 26597770.

[3] Gil Martínez V, Avedillo Salas A, Santander Ballestín S. Vitamin Supplementation and Dementia: A Systematic Review. Nutrients. 2022 Feb 28;14(5):1033. doi: 10.3390/nu14051033. PMID: 35268010; PMCID: PMC8912288.

[4] Yahn GB, Abato JE, Jadavji NM. Role of vitamin B12 deficiency in ischemic stroke risk and outcome. Neural Regen Res. 2021 Mar;16(3):470-474. doi: 10.4103/1673-5374.291381. PMID: 32985467; PMCID: PMC7996019.

[5] Lauer AA, Grimm HS, Apel B, Golobrodska N, Kruse L, Ratanski E, Schulten N, Schwarze L, Slawik T, Sperlich S, Vohla A, Grimm MOW. Mechanistic Link between Vitamin B12 and Alzheimer's Disease. Biomolecules. 2022 Jan 14;12(1):129. doi: 10.3390/biom12010129. PMID: 35053277; PMCID: PMC8774227.

[6] Wang H., Li L., Qin L. L., Song Y., Vidal-Alaball J., Liu T. H. (2018). Oral vitamin B 12 versus intramuscular vitamin B 12 for vitamin B 12 deficiency. Cochrane Database Syst. Rev. 3 (33), CD004655. 10.1002/14651858.cd004655.pub3

[7] Wentworth B. J., Copland A. P. (2018). Revisiting vitamin B12 deficiency: A clinician’s guide for the 21st century. Pract. Gastroenterol. 182, 29.

[8]  Institute of Medicine . Dietary Reference Intakes: The Essential Guide to Nutrient Requirements. The National Academies Press; Washington, DC, USA: 2006.

[9] Mocchegiani E, Romeo J, Malavolta M, Costarelli L, Giacconi R, Diaz LE, Marcos A. Zinc: dietary intake and impact of supplementation on immune function in elderly. Age (Dordr). 2013 Jun;35(3):839-60. doi: 10.1007/s11357-011-9377-3. Epub 2012 Jan 6. PMID: 22222917; PMCID: PMC3636409.

[10] Olechnowicz J, Tinkov A, Skalny A, Suliburska J. Zinc status is associated with inflammation, oxidative stress, lipid, and glucose metabolism. J Physiol Sci. 2018 Jan;68(1):19-31. doi: 10.1007/s12576-017-0571-7. Epub 2017 Sep 30. PMID: 28965330; PMCID: PMC5754376.

[11] Heidari Seyedmahalleh M, Montazer M, Ebrahimpour-Koujan S, Azadbakht L. The Effect of Zinc Supplementation on Lipid Profiles in Patients with Type 2 Diabetes Mellitus: A Systematic Review and Dose-Response Meta-Analysis of Randomized Clinical Trials. Adv Nutr. 2023 Nov;14(6):1374-1388. doi: 10.1016/j.advnut.2023.08.006. Epub 2023 Aug 19. PMID: 37604307; PMCID: PMC10721485.

[12] Innes JK, Calder PC. Omega-6 fatty acids and inflammation. Prostaglandins Leukot Essent Fatty Acids 2018;132:41–8. 

[13] Ungaro F, Rubbino F, Danese S, D’Alessio S. Actors and Factors in the Resolution of Intestinal Inflammation: Lipid Mediators As a New Approach to Therapy in Inflammatory Bowel Diseases. Front Immunol 2017;8:1331

[14] Kostoglou-Athanassiou I, Athanassiou L, Athanassiou P. The Effect of Omega-3 Fatty Acids on Rheumatoid Arthritis. Mediterr J Rheumatol. 2020 Jun 30;31(2):190-194. doi: 10.31138/mjr.31.2.190. PMID: 32676556; PMCID: PMC7362115.

[15] Stonehouse W., Benassi-Evans B., Bednarz J., Vincent A.D., Hall S., Hill C.L. Krill Oil Improved Osteoarthritic Knee Pain in Adults with Mild to Moderate Knee Osteoarthritis: A 6-Month Multicenter, Randomized, Double-Blind, Placebo-Controlled Trial. Am. J. Clin. Nutr. 2022:nqac125. doi: 10.1093/ajcn/nqac125

[16] https://ods.od.nih.gov/factsheets/Omega3FattyAcids-HealthProfessional/#en92

[17] U.S. Food and Drug Administration. Summary of qualified health claims subject to enforcement discretion.2014.

[18] Welty FK. Omega-3 fatty acids and cognitive function. Curr Opin Lipidol. 2023 Feb 1;34(1):12-21. doi: 10.1097/MOL.0000000000000862. Epub 2022 Nov 25. PMID: 36637075.

[19] Baker LD, Manson JE, Rapp SR, Sesso HD, Gaussoin SA, Shumaker SA, Espeland MA. Effects of cocoa extract and a multivitamin on cognitive function: A randomized clinical trial. Alzheimers Dement. 2023 Apr;19(4):1308-1319. doi: 10.1002/alz.12767. Epub 2022 Sep 14. PMID: 36102337; PMCID: PMC10011015.

[20] Jenkins DJA, Spence JD, Giovannucci EL, Kim YI, Josse RG, Vieth R, Sahye-Pudaruth S, Paquette M, Patel D, Blanco Mejia S, Viguiliouk E, Nishi SK, Kavanagh M, Tsirakis T, Kendall CWC, Pichika SC, Sievenpiper JL. Supplemental Vitamins and Minerals for Cardiovascular Disease Prevention and Treatment: JACC Focus Seminar. J Am Coll Cardiol. 2021 Feb 2;77(4):423-436. doi: 10.1016/j.jacc.2020.09.619. PMID: 33509399.