In a column and subsequent communication in Elle* magazine, a well-known writer from the National Institutes of Health wrote a column about a recent study by Dr. Salim Yusuf and colleagues from Hamilton, Ontario, published in The New England Journal of Medicine, in which over 9000 individuals over 55 years of age were studied. These patients already had diabetes or ongoing heart disease, and at least one other risk factor for a heart attack or stroke. They were treated for four to six years with 400 IU of vitamin E or placebo. The vitamin E treatment did not decrease the number of subjects who had a heart attack of stroke. These subjects were very high-risk individuals in whom extensive, and perhaps irreversible, damage already had occurred.

I took exception to this column and popular press reports, which interpreted this study as having shown that vitamin E does not protect the heart. This interpretation led the reader to believe that vitamin E supplements are not useful as a health benefit for the heart. The study showed no such finding, and had no bearing on whether or not vitamin E supplements are useful in healthy, non-damaged, individuals who are not at extraordinarily high risk for a heart attack or stroke. The scientific evidence is overwhelming that anti-oxidant supplementation is beneficial, particularly in a preventive fashion, before extensive damage has occurred. I wrote a letter to the editor, which was published, but was extensively edited to remove my objection to the over-interpretation of the scientific findings.

In response, the columnist did not address the issue of applicability of this vitamin E study for the average readers of a popular woman's magazine. Rather, she pointed out that some anti-oxidants, such as beta-carotene supplements, can increase the risk for some cancers in some groups of patients. This is well known. Beta-carotene, vitamin A, and selenium, to name a few supplements, when taken in excessive amounts, can indeed have dangerous side effects. However, this has nothing to do with the usefulness of vitamin E, which has been shown in some studies to be safe in daily doses of 1600 IU or more.

A final comment by the columnist in response to my edited letter was particularly provocative, and reflected a very conservative view of anti-oxidants. She stated, "Some investigators believe that vitamins may exert their protective effects when consumed as part of a healthy diet rather than as pills."

Required intake of anti-oxidants vs. beneficial levels of intake
Although a healthy diet with lots of fruits and vegetables is a good start, both for anti-oxidants and for basic nutrition, I do not agree that diet alone is adequate for optimal benefits of anti-oxidants. The Federal Dietary Guidelines establish a minimum standard for levels of intake needed to protect against vitamin deficiencies. These guidelines differ considerably from therapeutic or optimal intake of anti-oxidants for the average adult.

A safe and reasonable adult daily intake of anti-oxidants for a beneficial protective effect against free radical damage is at least 1000 mg of vitamin C, 400 IU of vitamin E, and 200 micrograms of selenium. With a high intake of the right fruits and vegetables in the diet (e.g. oranges or juice, strawberries, other berries, broccoli, kiwis, guavas), it is possible to reach the 500-1000 mg level of vitamin C per day; but a concerted effort with full knowledge of the vitamin C content of the fruits and vegetables must be made. It is highly unlikely for one to obtain an optimal intake of vitamin E in the diet. The average American takes in under 20 IU of vitamin E in the diet, and most food processing removes vitamin E from foods in which it originally was found. Oils rich in vitamin E often are high in dangerous polyunsaturated fats that contribute to atherosclerosis and other damage.

Selenium is present in meats, some seafood, and some nuts, grains, and vegetables. However, because of the variability of the selenium content in the soil in which grains and vegetables are grown, it is unlikely that most Americans get an optimal intake of selenium.

The diets of most individuals do not obtain optimal amounts of the highly beneficial anti-oxidants such as pycnogenol, grape seed extract, and coenzyme Q10. One certainly can obtain bioflavonoids from consumption of a diet high in vegetables and fruits, along with red wine or grape juice, but optimal levels are unlikely to be consumed. In addition, in refined foods, bioflavonoids are usually removed because of their bitter taste.

Should anti-oxidant supplements be considered?
We are left with the original question: Can the diet provide adequate anti-oxidant intake, or should supplements be considered? If adequate is defined as enough to protect against gross vitamin deficiencies, dietary intake probably is adequate. A diet high in fruits and vegetables (the exception rather than the rule in the U.S.) can provide a good start towards anti-oxidant benefits and the blocking of some of the damage done by free radicals. However, for optimal anti-oxidant protection, optimal health, and the best chances of protecting against diseases and damage related to free radicals, a resounding endorsement of anti-oxidant supplements is needed.

This author is strongly convinced of the value of anti-oxidant supplements, based on interpretation of the scientific literature, and uses the following supplements daily:

Vitamin C: 1000 mg
Vitamin E (mixed tocopherols): 800 IU
Selenium: 200 micrograms
Coenzyme Q10: 60 mg
Grape Seed Extract: 200 mg

It is necessary to pay attention to daily intake of some of the supplements, especially selenium. Excessive intake (e.g., more than 500 micrograms per day) can be damaging, and should not be taken. Optimal nutrition and supplements require a commitment to daily consistency, and a process of education regarding the best sources, amounts, and uses of the foods and supplements. However, the benefits may be realized in added years of good health down the road.

David Felten, MD, PhD, is founding Director of the Center for Neuroimmunology and Professor of Pathology and Human Anatomy and Professor of Neurology at Loma Linda University School of Medicine in Loma Linda California. He is an internationally known researcher whose contributions helped to establish the field of psychoneuroimmunology.

© 2000 David L. Felten, M.D., Ph.D.

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