Expensive Urine or Effective Triage?

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Victor Herbert, the outspoken Harvard nutrition scientist, was quoted by the United States well read Time magazine in a famous 1992 cover story about nutrition as saying that vitamins just gave one “expensive urine.”

This one liner has acted as a simple rebuke to the consumption of additional nutrients as food supplements – or at least the water soluble ones. It is repeated by the medical community wedded to the model that food will supply all we require, and by the skeptics who seek an easy one liner to dismiss thousands of research papers that contradict this simplistic and invalid statement.

Whilst the consumption of healthy, nutrient dense food is an absolute requirement of health, there are many incidences where this may not be enough; from poor food choice to unique gene related requirements. As scientific research has moved forward in the last two decades so has the understanding of the value of additional nutrients in a dose beyond the minimum required to avoid gross nutrient deficient diseases.

So is it important for everyone to take vitamin supplements, megadoses, or to up your levels of antioxidants? The answer may well be a resounding YES.

In the summer of 2002, Harvard Medical School scientists, Dr’s Kathleen Fairfield and Robert Fletcher, reviewed the data and concluded that all North Americans should be taking a multi-nutrient supplement as a preventative measure.[1] They published their findings and the recommendation to take a multi-nutrient supplement in the prestigious Journal of the American Medical Association. No such study has been conducted in the UK but eating patterns and lifestyles are very similar.

They concluded:

Some groups of patients are at higher risk for vitamin deficiency and suboptimal vitamin status. Many physicians may be unaware of common food sources of vitamins or unsure which vitamins they should recommend for their patients. Vitamin excess is possible with supplementation, particularly for fat-soluble vitamins. Inadequate intake of several vitamins has been linked to chronic diseases, including coronary heart disease, cancer, and osteoporosis.

This report followed a paper in the New England Journal of Medicine that also suggests the relative low cost of regular multi-nutrient supplement consumption is a valuable preventative health measure.[2] In another recent survey looking at lifestyle strategies employed by the medical profession, 72% of physicians and 89% of nurses questioned used dietary supplements regularly, occasionally, or seasonally.[3]

1000435950-150x150Those who discard the multi-nutrient advice often point to the availability of the required vitamins and minerals in a diet containing a large variety of foods, particularly fruits and vegetables. This is fundamentally true, but ignores the reality that many Britons and Europeans do not consume the recommended daily intake of fruits and vegetables. In addition, it does not address the recent research indicating a declining nutrient content of produce in international farming practice and especially in the UK as described in the Composition of Foods by McCance and Widdowson. There are also extensive differences in the antioxidant qualities of differing foods and supplements and incorrect selection will diminish their health value.[4]

Dr. David Heber of the UCLA Centre for Human Nutrition recently suggested that consumers think of the basic four supplements – a multivitamin, extra vitamin C, extra vitamin E, and calcium – as an integral part of their diet in addition to the four basic food groups.

Effective Triage

PNAS-Nov-21-2006A more contemporary view of micro-nutrient supplementation has been proposed by Dr Bruce Ames, one of the world’s most quoted and published scientists. He argues that the body operates on a short term view only using a ‘triage approach’ to essential utilisation:[5]

Triage – from the French word ‘trier’ meaning to sort, separate, or select – works in A&E and battlefield situations when doctors prioritise treatments depending on the probable survival of the wounded

It is literally all about living for today. By understanding that Nature favours survival today over tomorrow, a theory that vitamin inadequacy is behind the rise in chronic diseases “makes sense… and it is almost certainly going to be right,” says Dr Bruce Ames.

By appreciating that natural selection favours short-term survival over the long-term, Prof Ames’ hypothesised that our short-term survival is achieved by prioritising the allocation of scarce micro-nutrients. In other words, to stop us falling over from a lack of iron in the heart, for example, iron is pulled from non-essential sources within the body.

The triage theory is a way of measuring the insidious damage going on over time and supplies a unifying framework explaining why a crop of diseases associated with aging is emerging for so many micro-nutrients.[6]


conclusion1-150x150The ‘expensive urine’ dismissal fails to understand that the provision of essential vitamins and minerals as well as fatty acids will be apportioned on a daily basis by the body to meet immediate needs, these will fluctuate and demands will vary. Excluding valuable micro-nutrients for the potential perception of useless daily excretion may yet prove to be the worst long-term health advice ever given.

Poor nutrition has been linked to an increased risk of many diseases, including cancer, heart disease, and diabetes. The human diet requires both macro-nutrients, which are the main source of calories, and micro-nutrients (≈40 essential minerals, vitamins, and other biochemicals), which are required for virtually all metabolic and developmental processes. The leading dietary sources of energy in the Western world are abundant in carbohydrates and fats[7] but deficient in micro-nutrients (i.e., they are energy-dense and nutrient-poor).[8]

Clinical Education holds the view that based on this, as well as extensive additional research that consuming a high quality multi vitamin and mineral supplement as an addition to your sound dietary choices will decrease your risk of developing  a nutrient-insufficiency condition which may take years off your life and life off those remaining years.


[1] Fairfield KM, Fletcher RH. Vitamins for chronic disease prevention in adults: scientific review. JAMA. 2002 Jun 19;287(23):3116-26. View Abstract

[2] Willett WC, Stampfer MJ. Clinical practice. What vitamins should I be taking, doctor? N Engl J Med. 2001 Dec 20;345(25):1819-24. View Abstract

[3] Dickinson A, Boyon N, Shao A. Physicians and nurses use and recommend dietary supplements: report of a survey. Nutr J. 2009 Jul 1;8:29. View Abstract

[4] Carlsen MH, Halvorsen BL, Holte K, Bohn SK, Dragland S, Sampson L, Willey C,Senoo H, Umezono Y, Sanada C, Barikmo IE, Berhe N, Willett WC, Phillips KM, Jacobs DR Jr, Blomhoff R. The total antioxidant content of more than 3100 foods, beverages, spices, herbs supplements used worldwide. Nutr J. 2010 Jan 22;9(1):3. [Epub ahead of print] View Abstract

[5] Ames BN Low micronutrient intake may accelerate the degenerative diseases of aging through allocation of scarce micronutrients by triage. Proc Natl Acad Sci U S A. 2006 Nov 21;103(47):17589-94. View Full Paper

[6] McCann JC, Ames BN Vitamin K, an example of triage theory: is micronutrient inadequacy linked to diseases of aging?J Clin Nutr. 2009 Oct;90(4):889-907. View Abstract

[7] Block G(2004) J Food Composition Anal 17:439–447.View Data

[8] Kant AK. Consumption of energy-dense, nutrient-poor foods by adult Americans: nutritional and health implications. The third National Health and Nutrition Examination Survey, 1988-1994.Am J Clin Nutr. 2000 Oct;72(4):929-36. View Abstract


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