July 4, 2024 • 42 mins
Can multivitamins extend your lifespan or are they just giving you "expensive urine"? Join Josh and Adam in this Dr Journal Club podcast episode as they dive into a revealing JAMA Network Open study, exploring the true impact of multivitamin use on mortality risk. With 30% of the population regularly consuming these supplements, understanding their real benefits and potential harms is crucial.
In this episode, we break down the study's analysis of data from three prospective US cohorts to answer whether multivitamins truly prevent all-cause mortality, cancer, and cardiovascular disease.
Tune in for a critical evaluation of this popular health practice and see if multivitamins are truly worth the hype.
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2820369
Learn more and become a member at www.DrJournalClub.com
Check out our complete offerings of NANCEAC-approved Continuing Education Courses.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Introducer (00:02):
Welcome to the Dr Journal Club podcast, the show
that goes under the hood ofevidence-based integrative
medicine.
We review recent researcharticles, interview
evidence-based medicine thoughtleaders and discuss the
challenges and opportunities ofintegrating evidence-based and
integrative medicine.
Continue your learning afterthe show at www.
(00:24):
d rjournalclub.
com.
Dr. Joshua Goldenberg (00:31):
Please bear in mind that this is for
educational and entertainmentpurposes only.
Talk to your doctor beforemaking any medical decisions,
changes, etc.
Everything we're talking aboutthat's to teach you guys stuff
and have fun.
We are not your doctors.
Also, we would love to answeryour specific questions on
drjournalclub.
com.
You can post questions andcomments for specific videos,
(00:55):
but go ahead and email usdirectly at josh at
drjournalclub.
com.
That's josh at drjournalclub.
com.
Send us your listener questionsand we will discuss it on our
pod.
Hello and welcome to another DrJournal Club podcast with your
host, josh and Adam, your heroesand sidekicks for
(01:18):
evidence-based review andcritical evaluation of the
medical literature, of themedical literature.
And what's the?
You have?
Adam's got this like hoodie onand what is the character in
Beavis and Butthead that alwayshas their like like?
(01:41):
I am Gornolio, that's like theimpression that I'm getting, but
we are competent leaders in theintegrative, evidence-based
medicine field, ladies andgentlemen, so do not worry about
our side banter.
Okay, today we are going to betalking about an article out of
JAMA Network, the open sisterjournal or child journal from
JAMA on multivitamin use.
You always know it's importantwhen I get independent emails
(02:02):
from both my parents saying youshould talk about this on Dr
Journal Club.
And then we got a few emails aswell from other providers.
I think this must have hit themedia waves pretty, pretty hard.
How about you?
And then I think youindependently sent it to me also
.
So it's kind of all over thenews.
Dr. Adam Sadowski (02:20):
Yeah, I have email subscriptions to like new
england journal of medicine andjama, and then I think within
jama I also subscribe to notonly the open, because the open
the reason why it's called openis open access, so you don't
need institutional there's.
They're all anyone can readthem for free, which is awesome,
um, and there's someinteresting articles in there
(02:41):
and they kind of cover a varietyof topics.
But then there there's JAMAproper, jama internal medicine
and JAMA cardiology.
Those are the other threewithin JAMA that I look at.
Sometimes I have free articlesin there that I have access to.
Other times I don't have muchluck getting access to full,
full articles, usually the um,like the main headliner articles
(03:06):
like the big um, the big what'sthe term?
Um landmark trials aretypically free um, which is good
.
Yeah, those are the ones that II care more about.
A lot of the other side stuffare like super, super, super
niche stuff, um, that aren'treally clinically relevant to me
but would be interesting from aresearch standpoint, usually
(03:27):
require institutional access.
That I don't have.
So that's usually how I'mstaying up to date on stuff is I
just constantly get these likeemail things and whenever I go
for a walk in the morning, it'susually what I'm doing is going
through like email, social media, listening to podcasts, that
kind of stuff, and then, whenI'm looking through my email,
stuff will come through.
I'll look at it, and then Iusually spam your phone with
(03:50):
like 400 different articles thatwe need to read.
Yes, and that's how this onecame up, actually, yeah, that
works pretty well.
Dr. Joshua Goldenberg (03:58):
I mean, it's kind of like a little
anecdote around disseminationand science.
Like when you write grants, youalways have to have a
dissemination section and thereshould really be one in journal
articles too, and I mean this ishow this information gets
disseminated, right, it's likeyou've got podcasts and
subscriptions.
I'm hearing stuff from my momLike this is how this
information gets out there andchanges practice, right, because
(04:20):
now we're talking about it andit's an important part of
science.
I think there's a couple areasin science that are finally
getting appropriate recognition.
One is patient and publicinvolvement.
It's like now a requiredsection.
Like if you just submit to BMJ,for example, or any of their
sister articles, journals, youhave to say how the public or
(04:41):
patients were involved.
Our grant going in next weekhas a whole section on how we're
involving the public and peoplewith lived experience.
And then the other isdissemination.
It's like, okay, you can do thescience, but you don't just
like submit your article andwalk away.
Like there's someresponsibility here in you
getting the word out andchanging practice, which I think
(05:01):
in general is a good thing.
Dr. Adam Sadowski (05:04):
Yeah, I'd agree, I'd agree.
Dr. Joshua Goldenberg (05:06):
Okay, cool.
So, uh, with multiple attackson this one, we've heard from
everybody, so we're going to doit.
Um, so this is the multivitaminuse and mortality risk in three
prospective US cohorts, andMichelle will get you the link
for that.
Um, this was a sort ofcombination cohort study across
(05:28):
three different cohorts.
Do you want to walk us throughthe methods, or how should we
parse this one?
Dr. Adam Sadowski (05:33):
Yeah, so just for like background.
Basically everybody knows aboutmultivitamins at this point,
going all the way back to theFlintstone times, when people
had a Flintstone gummies whichwere absolutely disgusting.
Dr. Joshua Goldenberg (05:45):
I remember those times.
Dr. Adam Sadowski (05:46):
To now evolving into these, like really
gummies these delectablegummies Addicting, yeah, that
are basically just candy withsome vitamin C in it.
Yeah, but it's importantbecause a lot of people take
multivitamins for whateverreason.
I'm sure that really it's kindof pertinent to everybody.
(06:07):
It seems like everybody,whenever they visit the doctor,
will say, oh, I'm not takinganything, but I do take a multi,
and great or whatever.
And about 30% of the populationis using some sort of regular
multivitamin or using amultivitamin on a regular basis.
Dr. Joshua Goldenberg (06:24):
Yeah, that's a lot.
That's one in regular basis.
Dr. Adam Sadowski (06:25):
Yeah, that's a lot, that's one, one in three
people, yeah, and some of thethe issues with regards to the
data looking uh at, you know,are multivitamins beneficial or
not?
Um, is the issue of confoundingwhere, uh, a lot of people who
are using multivitamins arealready healthy to begin with,
so it's kind of hard todetermine whether or not they're
even getting benefit to theiruse outside of, you know, not
(06:51):
being in a deficient state, sootherwise generally healthy,
well-rounded diet, you know,non-smokers, et cetera, et
cetera.
Typically, the people who areusing multivitamins are
typically healthy, and sothere's this idea of the healthy
user effect.
And then, conversely, you havepeople who are not in good
(07:12):
health, who suddenly have acoming to Jesus moment perhaps,
and then we'll start takingmultivitamins, sort of like as
an entrance to wanting to live ahealthier lifestyle and view a
multivitamin as this healthything to do, and so we'll start
supplementing with amultivitamin.
(07:33):
And so we don't really know, orit's not that we don't know,
it's just that the evidence ispretty mixed.
The United States PreventiveServices Task Force has pretty
much made the recommendationthat if you're otherwise a
healthy individual, there'sreally no need for a
multivitamin supplementation forthe purposes of preventing
death, because in the UnitedStates, everything is basically
(07:57):
fortified, and so, even if youdon't have the best diet, having
a true nutritional deficiencynot to be confused with
insufficiency is pretty rare.
There's not many people in theUnited States who are walking
around with, let's say, ricketsor scurvy.
Dr. Joshua Goldenberg (08:15):
Not anymore.
Dr. Adam Sadowski (08:16):
Whereas, yeah , not anymore.
And so you know, when it comesto using a multivitamin in
getting physiologic excess towhat you're already getting on a
daily basis, is there any sortof actual benefit to that in
people who are otherwise healthy?
Um, and just using amultivitamin in preventing uh
(08:37):
all cause mortality, cancer,cardiovascular disease.
Dr. Joshua Goldenberg (08:40):
Right.
Dr. Adam Sadowski (08:41):
And that's that's what the paper is looking
at.
Dr. Joshua Goldenberg (08:43):
Yeah, exactly, and I think the so
there's a couple, a couplethings.
So, yeah, I love that healthyuser, sick user effect
discussion, justmethodologically.
Sometimes that sick user effectyou know we might call that
like reverse causation, bias,right?
So remember, so observationalstudies, which is what this is.
You know, association does notequal causation.
(09:05):
That's why we love randomized,controlled trials.
But when you have anassociation, instead of thinking
that A is driving B so like themultivitamin is driving the
disease outcome, like you're notdying as much, it may actually
be that B is driving A andthat's why they're associated.
So the sick user effect is,essentially they have a and
that's driving their use ofvitamins because they have this
(09:26):
belief that it's healthy and itwill help them.
So you'll see that association,but it's because of the reverse
causation.
So, anyway, so just neatmethodological stuff.
I would also say that.
So this is looking at mortalityand people usually take it, as
I've heard people say, likequote unquote insurance to make
sure they're getting everythingthat they need, and the argument
would be well, okay, like weshould be seeing some health
(09:48):
benefits here, and so thisquestion is really on a
mortality level.
Are we seeing a difference withlong follow up?
Dr. Adam Sadowski (09:55):
They also did look at heart disease and
cerebral vascular accidents.
Dr. Joshua Goldenberg (09:59):
Did they look at those as separate
outcomes or death because of?
Dr. Adam Sadowski (10:04):
That is a good question.
I think they did death becauseof, and they also looked at
all-cause mortality, so they didseparate it out.
Dr. Joshua Goldenberg (10:11):
Yeah, but they're not looking at MIs or
other diseases short of death.
So I guess, just trying toforeshadow counter arguments,
one might be, you know, okay,well, maybe it's not leading to
a change in death but maybe ithas other benefits or wellness
outcomes or things like that.
But we'll well, that'sforeshadowing, so we'll get to
that.
So I think you set that upreally really well.
(10:32):
Some of the oh so, what are theissues?
So the big issues with this isyou need large cohorts of people
to be able to see these sortsof outcomes with statistical
significance.
You need long follow-up,because the argument is like,
okay, you take a multivitaminfor six months, like you know,
if you'd have a randomizedcontrol trial or something like
that, like yes, that's ideal,but you're not going to study
(10:52):
them for 30 years and that's thetype of follow-up you might
need to see these types ofoutcomes.
So you need these largeobservational studies.
So one issue is lag time effectand so you need large cohorts
with multi-decade follow-up,which is what the study is
trying to do.
And the other is this you know,like you said, the healthy user
and sick data to be able tostratify by other markers of
(11:14):
health and separate that out asa variable or do multivariate
adjustments?
Do we still see this effect?
So when you have these largecohorts, you could do that type
(11:37):
of statistical magic or voodoo,depending on who you're talking
to.
Depending on who you're talkingto and then from a sick user
effect, they also did thisclever thing where they excluded
everyone at the beginning attheir baseline levels, who had
cancer, diabetes, any of thesemajor diseases, because of the
fear of the sick user effect.
So really they limited theircohorts to people that were
(11:59):
going in, like you said, healthy, and then looking at their self
reportreport of multivitaminuse and the development of death
.
And then the last thing is well, what if people change over
time?
You know their multivitamin use, or if they develop diabetes in
the middle there, and thenthat's what's driving their
multivitamin use.
So they did have somesequential time data from these
(12:22):
cohorts about people'smultivitamin use over time, not
very nuanced and detailed, Ithink it was like every few
years or five years or decadesor something like that, but they
had something time-linked wherethey can kind of update that as
well.
So the neat thing is thatthere's big questions about
multivitamins, studyingmultivitamins, and so they
(12:43):
thought, hey, with this approach.
With these techniques, we mightbe able to address some of
these issues.
Dr. Adam Sadowski (12:48):
Yeah, and I think we also have to remember
that, when it comes to thesekind of studies, something that
we have to take into account isthe fact that a lot of it is
self-reported, and so you knowyou're relying on people saying
yes, I take a multivitamin everyday, or I only take it every
three days, and so the accuracyor the precision within that is
pretty poor, so we do have totake that into account as a
(13:09):
limitation.
Dr. Joshua Goldenberg (13:10):
And it doesn't speak to the quality of
the multivitamin either.
Right, it's just asking someoneif they take a multivitamin
every day or not.
Dr. Adam Sadowski (13:18):
Yeah, you know, if you were to take
someone randomly off the streetand just say how many times a
week do you eat burritos?
Dr. Joshua Goldenberg (13:30):
I don't think the answer is going to be
very accurate.
Right, and you don't know ifthey had whole foods, made that
at home burritos versus going toTaco Bell three times a day.
Right, and so it's somewhatanalogous here is that there's
no quality metric here.
Dr. Adam Sadowski (13:37):
But, but does that matter?
Remember when we talked aboutthat before?
Dr. Joshua Goldenberg (13:42):
Well, so that's the question, right?
So we're just sort of saying soyou know.
So, dr, I am going to tell youthat it doesn't matter.
It's all expensive urine, andthis proves it.
And I'm just playing devil'sadvocate and saying that this is
not measuring quality, right?
So this is just asking peopleif they have a multivitamin and
(14:04):
then trying to associate thatanswer with death.
Yeah, yeah, okay, we're coolwith that.
Dr. Adam Sadowski (14:12):
We'll just move along so we'll move along.
Dr. Joshua Goldenberg (14:15):
Okay, we're not cool with that, but
it's a detente.
Okay, go ahead yeah.
Dr. Adam Sadowski (14:19):
So in this study they had three cohorts for
a total of just shy of 400,000participants, so they had about
34,000 deaths for a total ofjust under 8 million person-year
follow-ups.
So one way to look at that isif I had 8 million people in a
(14:41):
study and followed them for oneyear, or if I had one person who
I followed for 8 million years.
Dr. Joshua Goldenberg (14:49):
You're now just falling apart here.
Dr. Adam Sadowski (14:50):
Yeah, yeah, it's a lot, it's a a lot, it's a
lot of data basically we havewe have a lot of follow-up data
that you can't get from arandomized control, trial or
other study types.
So this is this is sort of thebenefit of doing these large
prospective cohort studiesalthough there's a lot of
limitations from them, you canget a lot of good data from them
(15:12):
.
And then if get a lot of gooddata from them, and then if you
look at the confidence intervals, because of the high number of
participants and the longfollow-up, the confidence
intervals tend to be a lot, muchmore narrow, which is usually
reassuring.
Dr. Joshua Goldenberg (15:25):
No, so that's the point.
It's like we talked about.
For this sort of researchquestion, you really are going
to need multi-decade follow-up,and that's where these cohorts
come in with all limitations.
So did we say so?
These are three cohorts, soit's the NIH, aarp Diet and
Health Study Cohort, the PLCOCancer Screening Trial Cohort
(15:48):
and the Agricultural HealthStudy Cohort, I believe, the
latter of which is like a cohortof pesticide applicators.
So I had a big question aboutapplicability and external
validity with these cohorts, butit's something that we need to
kind of consider.
They did look at thedifferences between cohorts to
see if there were any obviousdifferences and didn't seem to
(16:10):
see it.
But these are the people inthis, this study.
Dr. Adam Sadowski (16:16):
Yeah, and the PLCO was the prostate, lung,
colon, ovarian cancer screeningtrial cohort and that goes back
to.
All of these go back to theearly to mid nineties.
So the NIH AARP health studycohort goes back to 1995.
The PLCO cohort goes back to1993.
And then the AHS, theAgricultural Health Survey, goes
(16:38):
back to 1993.
Why they didn't include, likethe nurse's health study or you
know, some of these other largewell-known cohort studies kind
of remains elusive.
I'm sure the data there has gotto exist.
Dr. Joshua Goldenberg (16:55):
You'd think so.
Dr. Adam Sadowski (16:57):
I would be hard-pressed if it doesn't.
Dr. Joshua Goldenberg (16:59):
It did seem like a random selection of
cohorts.
I mean, I've seen the NIH AARPall the time in lots of studies.
I've never seen a study on thisagricultural health cohort or
the secondary analysis of PLCOcancer screening cohort either.
Dr. Adam Sadowski (17:14):
I'm wondering if that agricultural health
study was trying to tap intolike a more rural patient
population base.
Dr. Joshua Goldenberg (17:21):
Maybe it would be nice to have had some
justification.
Maybe that's what we'restruggling with here is why were
they not?
Why are they not the author'snot justifying the selection?
Is this just pragmatic, likethis is what they had buddies in
that could get access to, orwas this chosen for specific
reasons?
Because I'm left scratching myhead as to why these cards were
(17:44):
chosen and if they wereappropriate and if it's
applicable to the larger USpopulation, and I wouldn't have
these questions if they had agood rationale for their
selection, which they don't seemto explain.
Dr. Adam Sadowski (17:55):
Yeah, because if we look at the NIH AARP
cohort, those individuals were50 to 71 years of age.
Dr. Joshua Goldenberg (18:02):
Right.
Dr. Adam Sadowski (18:03):
Yep, they lived in one to two metro areas
or in six different states, butthey didn't specify which states
.
They were excluded from datacollection in this study if they
provided answers through aproxy.
So let's say you know, you askthe individual, do you use a
multivitamin?
And then their brother answersfor them.
(18:23):
If they died before receivingthis questionnaire, which is
pretty obvious exclusionarycriteria If they had cancer,
some sort of major adversecardiovascular event, diabetes
or end-stage renal disease atbaseline, or if they had cancer,
some sort of major adversecardiovascular event, diabetes
or end stage renal disease atbaseline, or if they had
basically implausible caloricintake not necessarily
implausible, but just excess.
And I mean that's importantbecause if you're, one could
(18:45):
assume that if you're eatingcaloric excess then you're going
to be sort of physiologicallyoverachieving on nutrients that
would be available in amultivitamin.
Theoretically, now, you couldbe eating just like caloric
excess from like lots and lotsand lots of soda.
But they did apply thatexclusionary criteria to, I
(19:07):
think to all of the studiesanyway.
And then any of the cohortsthat had missing covariates that
they were interested in werealso excluded.
The PLCO was done at 10different centers.
The ages there at baseline were54 to 74.
They excluded data from thereIf participants died at baseline
(19:31):
collection for this particularstudy, if they had missing
outcomes on at least eightdifferent responses for the
questionnaires that they wereinterested in and then for the
AHS.
These were individuals who wereat least 18 years of age that
were pesticide applicators,living in Iowa and Northern
Carolina.
Dr. Joshua Goldenberg (19:52):
Yeah, interesting.
Again, would have loved to seea rationale for the selection of
these cohorts.
For the most part the censoringI was okay with.
Again, they censored the peoplewith these major conditions on
purpose to avoid I believe againit's not explained to avoid
this sick user effect.
And I and the caloric, like theextreme caloric intake we've
(20:16):
seen stuff like that before,sort of these, and you kind of
tried to explain itmythologically and I think also
it's sometimes used as a qualitymetric, like they're just not
reporting things properly ifit's this extreme, but they
don't really define what extrememeans, which is, again, maybe
that's in a supplement somewhere, but I don't see it here.
So, yeah, so I mean, for themost part I'm okay, but just a
(20:39):
lot of questions about theselection of the population here
that I think a couple sentencesexplanation would have put my
mind at ease.
Otherwise I'm okay with it.
Look, the thing is we don't dothis for money.
This is pro bono and, quitehonestly, the mothership kind of
ekes it out every month or so,right?
(21:00):
So we do this because we careabout this, we think it's
important, we think thatintegrating evidence-based
medicine and integrativemedicine is essential and there
just aren't other resources outthere.
The moment we find somethingthat does it better, we'll
probably drop it.
We're busy folks, but right nowthis is what's out there.
Unfortunately, that's it, andso we're going to keep on
fighting that good fight.
(21:21):
And if you believe in that, ifyou believe in intellectual
honesty in the profession andintegrative medicine and being
an integrative provider andbringing that into the
integrative space, please helpus, and you can help us by
becoming a member on Dr JournalClub.
If you're in need of continuingeducation credits, take our
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We have ethics courses,pharmacy courses, general
(21:43):
courses.
Interact with us on socialmedia, listen to the podcast,
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These are all ways that you cansort of help support the cause.
Okay, so with those caveats,shall we jump into the next
section exposure assessment.
Dr. Adam Sadowski (22:10):
Yeah, so basically they looked at people
who were non-users ofmultivitamins versus daily users
and which kind of I kind oflike it makes the data a little
bit cleaner because you'reyou're more likely if someone's
like an actual daily user,they're more likely to be a
daily user than someone who'slike infrequently using.
Then you're trying to quantifyokay, well, how, how often are
you taking it?
right and then they also defined, like you said earlier, that it
was all, it was all causemortality, but the death from
(22:31):
specifically, cancer, heartdisease and strokes.
And then they looked at thecovariates of age, sex, race,
ethnicity, education, smokingstatus, bmi, marital status,
physical activity, alcohol,coffee, healthy eating index,
family history of cancer and useof other supplements.
Dr. Joshua Goldenberg (22:51):
Yeah, and this is important for the
healthy user effect.
So we've been dealing with thesick user effect by censoring
people with disease at baselineand by looking at these
surrogates for healthy users,like healthy eating index we've
talked about that before alcoholintake, physical activity, bmi.
(23:11):
In theory, they're going to beusing this to try to control for
those potential confounders, sothat's why that is particularly
interesting.
And then, of course, they havethree different cohorts, so
they're somewhat measured indifferent ways and so, again, it
has to be harmonized acrossthese cohorts before they can do
their analysis.
Dr. Adam Sadowski (23:29):
Yep, yep, yep , yep.
Dr. Joshua Goldenberg (23:30):
Cool.
Dr. Adam Sadowski (23:31):
And then, when they looked at their
analysis, they did bothindividual analyses and pooled
analyses, where the pooledanalyses was the main outcome of
interest.
Dr. Joshua Goldenberg (23:40):
Pooled across all three cohorts Yep.
Dr. Adam Sadowski (23:43):
Exactly.
So they individualized themacross each individual cohort.
So you have three differentcohorts.
So they did one analysis waslet's just look at each cohort
individually.
We had three different cohorts.
So they did one analysis waslet's just look at each cohort
individually.
And then they also said OK,well, now let's do what we
really care about, which ispooling all the data together
and analyzing that.
So we combined all threecohorts.
Dr. Joshua Goldenberg (24:00):
Yes, this is.
There's some interesting stuffhere and it's complicated stats
even for us.
But there's a few things that Idid want to touch on.
So one is so they have threedifferent cohorts, right I did
want to touch on.
So one is so they have threedifferent cohorts, right, and
they claim that they didindividual analysis on each
individual cohort and that itwas similar enough that they
(24:22):
then pooled them.
But they don't show unless Imissed it, they don't show any
evidence of that or say whatsimilar means.
They also say there's lowbetween-study heterogeneity.
Again, I don't see any highsquare statistic or rationale
and that is their rationale forpooling them.
And when they say pooling them,they actually mean a
meta-analysis, which is rare.
(24:43):
Normally we're used to seeingmeta-analyses after attached to
a systematic review.
This is a meta-analysisattached to three cohorts.
It isn't unprecedented, ithappens and it can be kosher.
But they also they did a fixedeffects meta-analysis, which is
very rarely done.
Usually you do random effects.
Fixed effects assumes that theintervention and everything else
(25:06):
is exactly the same and theonly difference that you're
dealing with in themeta-analysis is the size of the
samples, is the size of thestudies.
There's basically nostatistical or mathematical
input from the heterogeneitycomponent, whereas random
effects assumes you're gettingan average of different
(25:28):
populations and different typesof interventions and doses and
therefore is more conservative,has wider confidence intervals,
not less impressive p-values,because it makes these
assumptions and it incorporatesthe assumed reasonable
heterogeneity in a populationlike that.
So you have to be careful.
Fixed effects are going to likeover-argue p-values and stuff
like that and be overly precise.
(25:49):
And I don't see how they getaway with saying that you've got
three different cohorts acrossvery different populations,
people just saying they take amultivitamin you have no idea
what type of multivitamin, whatthe dose of the multivitamins
were and getting away with doinga fixed effects meta-analysis
on that.
So maybe I am missing somethingand if you're a statistician
(26:11):
please call in and correct me.
But that was a little.
I'm not saying it's a red flag,I'm just saying sort of like
the cohort selection.
I was left scratching my headand would have liked some
explanation as to the rationalefor that, because that did not
seem like how I would look atthat.
Anyway right.
Dr. Adam Sadowski (26:30):
Yeah, no, it was.
Dr. Joshua Goldenberg (26:31):
It was a little confusing yeah, okay, so
they, so they.
But for let's say, let's, let'sassume, for the sake of
argument, playing devil'sadvocate, it was okay to pull
these cohorts and that it wasokay to use fixed effects, and
so now we're going to talk aboutthe results that they found
when they did that.
Yeah, yeah, brought myattention is that we're talking
(27:07):
about I think I said threedecades earlier, but really
we're talking about a medianfollow-up of, you know, 23, 21,
almost 24 years across all thecohorts.
We're talking about 23 and ahalf years median follow-up, so
it is still a lot of follow-uptime and anything else from
(27:28):
baseline, besides what we'vetalked about before, about
describing those cohorts thatyou wanted to touch on.
Dr. Adam Sadowski (27:33):
I mean the average age basically was 62.
And, excuse me, the median agewas 62.
Dr. Joshua Goldenberg (27:41):
At baseline, right?
So I think that's relevant too.
This is an older, these areolder folks, and you know, it's
not too surprising that the AARPcohort in there as well, right?
So you have to be what?
50 to even be a member of theAARP.
So, yeah, so this is.
Dr. Adam Sadowski (27:56):
this is a population that's skewing older
already with a with ainterquartile range of 57 to 66.
So I mean, it's still likemiddle of the road patient
population, that these are themajority of patients who are
going to be being seen from likea primary care status.
And you know, you kind of wantthe data, I would feel like on
on people who are at higher riskfor, for you know, death anyway
(28:19):
because, um, if you have ayounger cohort and you're and
you're following them, then evenharder, yeah.
Yeah, it would be harder totrack the data that you're
trying to evaluate, and so thiswould actually help if there was
an effect with use ofmultivitamins to show you know
again, if we think about, likeour absolute risk, those who are
(28:41):
at higher risk for things.
If there's a higher risk, youwould expect the intervention to
provide more benefit thansomeone who's at you know a
primordial risk or primaryprevention risk standpoint.
Dr. Joshua Goldenberg (28:54):
Yeah, and then that's so.
That's true and fair and Idon't have a huge issue, just to
note that it's an older cohort.
And then the other thing Iwanted to point out is the HEI
score.
I know we kind of ragged on HEIbefore as like it's an
imperfect measure of healthyeating, but it's sort of what we
have and commonly used.
So it's a scale of zero to 100.
(29:16):
And in here in these cohortsthe average and this seemed
mostly consistent across thedifferent cohorts it looks like
the AHS which went with the AHSthat was the agricultural one
has a little bit of a lowerhealthy eating index but for the
(29:37):
most part they're scoring inthe 60s and I believe 100 score
is considered the best andreflects sort of that 100%
alignment with major you know,common dietary recommendations
in the United States.
So they're in that 60 to 70range on average as far as
(29:58):
healthy eating.
Dr. Adam Sadowski (29:59):
And we also are kind of seeing a healthy
user effect where, compared tothose who are not using
multivitamin, they're morelikely.
Individuals who are usingmultivitamins are more likely to
use other supplements ingeneral, have a lower BMI,
better diet quality, less use oftobacco products, etc.
Etc.
Dr. Joshua Goldenberg (30:20):
Yeah, so that's exactly the point, right?
I think now that they have thislevel data on people's diet and
their BMI and their physicalactivity and supplement use, in
theory they can try to controlfor that and just look for
residual effects ofmultivitamins.
And we we had a analogous issue.
What was one of the papers wedid I forget what it was
(30:43):
studying which looked at the oh,it was ultra processed foods
and tried to separate that outfrom the HEI and we, argued, had
a pretty hard time doing that.
But this is their attempt ofbasically saying you know, let's
make sure that it's not justthe fact that people that eat
healthy are taking multivitaminsand we're seeing the effect
(31:03):
because they're eating healthy.
Right, right, right, right,okay cool.
Dr. Adam Sadowski (31:07):
So let's get into the sort of the meat and
potatoes of it and I think right, right, okay, cool.
So let's get into the sort ofthe meat and potatoes of it and
I think, yeah, let's do the funstuff.
I think the best way to kind ofpresent this is talk about the
well they split it up as towhat's called fp1 and fp2, so
follow-up period one andfollow-up period two, where
follow-up period one was yearsof follow-up between years one
(31:29):
through 12, and then follow-upperiod two was beyond 12 years,
and I feel like beyond 12 yearsis a little bit more of the data
that we should kind of focus inon because it's more long-term
from that standpoint.
But we will discuss both.
Dr. Joshua Goldenberg (31:46):
Okay, yep Gotcha.
Alrighty, okay, okay, yep,gotcha.
Dr. Adam Sadowski (31:48):
Alrighty, okay.
So when it comes to mortality,there was a 4% increased risk in
individuals using dailymultivitamins compared to
non-users, and that hazard ratiowas 1.04 with a confidence
(32:09):
interval of 1.02 to 1.07.
So a 4% increased risk ranginganywhere from 2% to 7%, but that
was limited to years 1 through12.
Once we extended out beyond 12years, that was no longer
statistically significant andalthough the point estimate
didn't change at 4%, theconfidence interval was much
wider and ranged from 0.99, so a1% benefit in reducing the risk
(32:35):
to 1.08, so across thatthreshold of 1.
And so it was anywhere from 1%protective to 8%, increasing the
risk of mortality, and that wasall-cause mortality.
When we look at heart disease,cancer and stroke across neither
(32:56):
, across none of the FP2 timepoints was there.
Basically everything wasconsistent, right For FP2, there
was no statisticallysignificant differences between
the two for heart disease,cardiovascular disease or cancer
.
Dr. Joshua Goldenberg (33:08):
From death, from those things.
Right, right, yeah, correct.
Dr. Adam Sadowski (33:12):
But when?
And then, when we look at heartdisease, there was a 6%
increase risk which ranged from1% to 11%, isolated to the first
follow-up period for the first12 years, which is consistent
with the mortality data.
Dr. Joshua Goldenberg (33:27):
So I wonder if, if this was done as a
random effects meta-analysis,that confidence interval would
have been wider, and even thatstatistically significant
increased risk would also not bestatistically significant.
So I'm curious about that, butI think the take-home is.
What is clear, though, isthere's definitely is no signal
for benefit.
The question is, you know, isthere actually a signal for harm
(33:49):
or not?
I'm not sure, but certainlythere does not seem to be a
signal for benefit.
Would you?
How would you take that?
Dr. Adam Sadowski (33:58):
Yeah.
Dr. Joshua Goldenberg (33:59):
Okay.
Dr. Adam Sadowski (34:00):
Yeah, I'd agree, and again, that that
signal for harm is only in the,in the short term, and it's
really really small.
Dr. Joshua Goldenberg (34:07):
Right, exactly, and really close to
losing significance if thoseconfidence intervals got a bit
wider.
So I'm a little suspicious.
But yeah, okay, cool, and theydon't have a good argument.
I mean, I guess you could comeup with some mechanism as much
as you love, mechanism of how itcould cause harm, but certainly
we're not seeing a signal forbenefit there.
Okay, excellent, I think that'sthe main take home.
(34:29):
Is there anything else that youwanted to talk about as far as
the overall results, or shouldwe jump into sort of that
discussion piece?
Dr. Adam Sadowski (34:41):
No, I was going to jump into the
discussion piece and just saythat you know, this is yet again
some more evidence that'sconsistent with prior evidence
showing no benefit of, you know,multivitamin supplementation or
super physiologic doses ofvarious nutrients for otherwise
healthy individuals.
It's consistent with the USPSTFrecommendation.
(35:03):
It's consistent with a priorrandomized control trial.
Dr. Joshua Goldenberg (35:06):
Looking at this and so yeah, I mean the
data is the data looking at thisand so, yeah, I mean I, the
data is the data.
Yeah, the data is the data.
I think that I would agree withthe few caveats I think I said
before, which is, you know, thisis sort of interesting cohort
selection.
I'm not sure what to make of it,I'm not sure what to make of
the choice of meta analysis type, and but I certainly don't see
(35:31):
a signal of benefit.
But then again, I would saythere's no metric here for the
quality or dose in themultivitamins, simply looking
for an association betweenpeople saying they take a
multivitamin every day and thendying over the next few decades.
So I think that is a faircriticism.
That being said, it's going tobe a very challenging study and
(35:55):
probably impossible to answerthat question, because you would
need 30-year cohorts with dataon the quality and type of
multivitamin and then somestatement about what actually is
considered a high quality thateveryone agrees on and all of
those things, and then you'dhave even more of an issue of a
healthy user effect for peoplethat are seeking out specific
(36:18):
high quality multivitamins asopposed to grabbing something
off the shelf.
So I don't know how you woulddo that study, but I think it is
fair to argue that however thatquestion is still open, based
on this study.
Dr. Adam Sadowski (36:30):
I don't know if I agree because and again it
goes back to the idea of priors.
So you know, we already havequite a bit of evidence showing
that there's a lack of benefit,you know.
So we have consistency in thatstandpoint.
We can only work with through,or we can only work with what we
have, and what we have for themost part, is pointing towards
(36:55):
no benefit.
And then to say, to rationalize, saying, oh well, I'm using a
high quality supplement and youknow, these cohorts don't
pertain to my person, my patient.
Therefore, this is actually,you know, a reason to recommend,
you know, iv nutrients or thisfancy multivitamin.
(37:19):
I don't think you can make thatargument, and it goes back to
that idea of priors that we'vetalked about before, where you
really need to have a reallygood case and strong evidence to
suggest why you're making thatrecommendation over what has
already been established in theliterature.
Dr. Joshua Goldenberg (37:38):
Yeah, and to bolster your side of this,
thank you To steel man, you abit here.
It would be one thing for me tosay, well, you can't really
answer this specific question,but what's the harm?
And as long as you do, informconsent.
Dr. Adam Sadowski (37:54):
Well, we also have evidence of harm right
Well exactly.
Dr. Joshua Goldenberg (37:57):
So that's my point is that even though
we've been saying maybe we havesome questions about that harm
signal, there is a harm signalnow, right, like that is out
there in the literature and it'sit's, you know, it's, it's,
it's there and so and it's aboutdeath.
It's not about like belly aches, right.
So I think that balanceargument changes to where it's
(38:17):
say okay, well, maybe you canhand wave and say it's not a
perfect study and dah, dah, dah,dah and whatever is.
And you have, you have goodarguments about that, whatever
is argument.
And when you just say no, basta, we're done.
You commonly bring up withvitamin D, for example, but even
that shifts if you've got asignal of harm, if you've got
questions about the signal ofharm.
So I don't know, man, Actually,on retrospect, maybe I'm
(38:40):
leaning into your camp a littlebit and just saying not only am
I not going to startrecommending Maltese, maybe we
even ask people to stop.
I don't know, it's not medicaladvice, we're just talking about
research and implications, butI think the argument about
shifting that onus is a good one.
Dr. Adam Sadowski (38:59):
Yep, and so far from what we've looked at on
this podcast, it looks like theShilajit so far has been the
only thing that has panned out.
Dr. Joshua Goldenberg (39:09):
Shilajit is the clear winner.
Dr. Adam Sadowski (39:11):
Knee osteoarthritis.
Dr. Joshua Goldenberg (39:13):
No curcumin.
For what was it?
Curcumin for functionaldyspepsia?
But then a new study came outbasically showing a harm signal
with curcumin in liver disease.
We're going to have to look atthat.
Liver failure we're going tohave to look at that study next
week I think.
But yeah, interesting,interesting stuff.
But there are very few things inour rarefied list, the Dr
(39:35):
Journal Club list, of largemagnitude, high quality evidence
that things work.
And so what's our running list?
Probiotics for necrotizing,necrotizing colitis.
We've got maybe semaglutide wedon't actually know if that's
true and apparently withoutlooking it up, we've got Vi
semaglutide we don't actuallyknow if that's true and and
apparently without looking it up, we've got um viagra, according
to you.
And then what was the other onewe did last time?
(39:57):
Oh yeah, e-cigs.
E-cigs seems to have super highevidence with a large magnitude
of effect as well.
So what's the world coming tome?
But don't do the multivitamins.
What it's like this?
This is the strangest finalconclusion.
You, we should be doing e-cigsand Viagra and jump on the
semaglutide bad wagon, but don'tdo the multivitamin.
Is this really where we want toleave our listeners after today
(40:18):
?
Dr. Adam Sadowski (40:18):
we're here for a fun time, not a long time
we should leave it at that,alright.
Dr. Joshua Goldenberg (40:25):
Dear listeners, thank you for putting
up with us and we will see younext week.
If you enjoy this podcast,chances are that one of your
listeners.
Thank you for putting up withus and we will see you next week
.
If you enjoy this podcast,chances are that one of your
colleagues and friends probablywould as well.
Please do us a favor and letthem know about the podcast and,
if you have a little bit ofextra time, even just a few
seconds, if you could rate usand review us on Apple podcast
or any other distributor, itwould be greatly appreciated.
(40:48):
It would mean a lot to us andhelp get the word out to other
people that would really enjoyour content.
Thank you.
Hey y'all y'all.
This is.
Josh.
DrYou know we talked about some
really interesting stuff today.
I think one of the things we'regoing to do that's relevant.
There is a course we have on DrJournal Club called the EBM
Boot Camp.
That's really meant forclinicians to sort of help them
understand how to criticallyevaluate the literature, etc.
(41:09):
Etc.
Some of the things that we'vebeen talking about today.
Go ahead and check out the shownotes link.
We're going to link to itdirectly.
I think it might be of interest.
Don't forget to follow us onsocial and interact with us on
social media at DrJournalClub.
Drjournalclub on Twitter, we'reon Facebook, we're on LinkedIn,
etc.
Etc.
So please reach out to us.
We always love to talk to ourfans and our listeners.
(41:32):
If you have any specificquestions you'd like to ask us
about research, evidence, beinga clinician, etc.
Don't hesitate to ask.
And then, of course, if youhave any topics that you'd like
us to cover on the pod, pleaselet us know as well.
Introducer (41:47):
Thank you for listening to the Doctor Journal
Club podcast, the show that goesunder the hood of
evidence-based integrativemedicine.
We review recent researcharticles, interview
evidence-based medicine thoughtleaders and discuss the
challenges and opportunities ofintegrating evidence-based and
integrative medicine.
Be sure to visit www.
drjournalclub.
com to learn more.
Welcome to the Dr Journal Club podcast, the show
that goes under the hood ofevidence-based integrative
medicine.
We review recent researcharticles, interview
evidence-based medicine thoughtleaders and discuss the
challenges and opportunities ofintegrating evidence-based and
integrative medicine.
Continue your learning afterthe show at www.
(00:24):
d rjournalclub.
com.
Dr. Joshua Goldenberg (00:31):
Please bear in mind that this is for
educational and entertainmentpurposes only.
Talk to your doctor beforemaking any medical decisions,
changes, etc.
Everything we're talking aboutthat's to teach you guys stuff
and have fun.
We are not your doctors.
Also, we would love to answeryour specific questions on
drjournalclub.
com.
You can post questions andcomments for specific videos,
(00:55):
but go ahead and email usdirectly at josh at
drjournalclub.
com.
That's josh at drjournalclub.
com.
Send us your listener questionsand we will discuss it on our
pod.
Hello and welcome to another DrJournal Club podcast with your
host, josh and Adam, your heroesand sidekicks for
(01:18):
evidence-based review andcritical evaluation of the
medical literature, of themedical literature.
And what's the?
You have?
Adam's got this like hoodie onand what is the character in
Beavis and Butthead that alwayshas their like like?
(01:41):
I am Gornolio, that's like theimpression that I'm getting, but
we are competent leaders in theintegrative, evidence-based
medicine field, ladies andgentlemen, so do not worry about
our side banter.
Okay, today we are going to betalking about an article out of
JAMA Network, the open sisterjournal or child journal from
JAMA on multivitamin use.
You always know it's importantwhen I get independent emails
(02:02):
from both my parents saying youshould talk about this on Dr
Journal Club.
And then we got a few emails aswell from other providers.
I think this must have hit themedia waves pretty, pretty hard.
How about you?
And then I think youindependently sent it to me also
.
So it's kind of all over thenews.
Dr. Adam Sadowski (02:20):
Yeah, I have email subscriptions to like new
england journal of medicine andjama, and then I think within
jama I also subscribe to notonly the open, because the open
the reason why it's called openis open access, so you don't
need institutional there's.
They're all anyone can readthem for free, which is awesome,
um, and there's someinteresting articles in there
(02:41):
and they kind of cover a varietyof topics.
But then there there's JAMAproper, jama internal medicine
and JAMA cardiology.
Those are the other threewithin JAMA that I look at.
Sometimes I have free articlesin there that I have access to.
Other times I don't have muchluck getting access to full,
full articles, usually the um,like the main headliner articles
(03:06):
like the big um, the big what'sthe term?
Um landmark trials aretypically free um, which is good
.
Yeah, those are the ones that II care more about.
A lot of the other side stuffare like super, super, super
niche stuff, um, that aren'treally clinically relevant to me
but would be interesting from aresearch standpoint, usually
(03:27):
require institutional access.
That I don't have.
So that's usually how I'mstaying up to date on stuff is I
just constantly get these likeemail things and whenever I go
for a walk in the morning, it'susually what I'm doing is going
through like email, social media, listening to podcasts, that
kind of stuff, and then, whenI'm looking through my email,
stuff will come through.
I'll look at it, and then Iusually spam your phone with
(03:50):
like 400 different articles thatwe need to read.
Yes, and that's how this onecame up, actually, yeah, that
works pretty well.
Dr. Joshua Goldenberg (03:58):
I mean, it's kind of like a little
anecdote around disseminationand science.
Like when you write grants, youalways have to have a
dissemination section and thereshould really be one in journal
articles too, and I mean this ishow this information gets
disseminated, right, it's likeyou've got podcasts and
subscriptions.
I'm hearing stuff from my momLike this is how this
information gets out there andchanges practice, right, because
(04:20):
now we're talking about it andit's an important part of
science.
I think there's a couple areasin science that are finally
getting appropriate recognition.
One is patient and publicinvolvement.
It's like now a requiredsection.
Like if you just submit to BMJ,for example, or any of their
sister articles, journals, youhave to say how the public or
(04:41):
patients were involved.
Our grant going in next weekhas a whole section on how we're
involving the public and peoplewith lived experience.
And then the other isdissemination.
It's like, okay, you can do thescience, but you don't just
like submit your article andwalk away.
Like there's someresponsibility here in you
getting the word out andchanging practice, which I think
(05:01):
in general is a good thing.
Dr. Adam Sadowski (05:04):
Yeah, I'd agree, I'd agree.
Dr. Joshua Goldenberg (05:06):
Okay, cool.
So, uh, with multiple attackson this one, we've heard from
everybody, so we're going to doit.
Um, so this is the multivitaminuse and mortality risk in three
prospective US cohorts, andMichelle will get you the link
for that.
Um, this was a sort ofcombination cohort study across
(05:28):
three different cohorts.
Do you want to walk us throughthe methods, or how should we
parse this one?
Dr. Adam Sadowski (05:33):
Yeah, so just for like background.
Basically everybody knows aboutmultivitamins at this point,
going all the way back to theFlintstone times, when people
had a Flintstone gummies whichwere absolutely disgusting.
Dr. Joshua Goldenberg (05:45):
I remember those times.
Dr. Adam Sadowski (05:46):
To now evolving into these, like really
gummies these delectablegummies Addicting, yeah, that
are basically just candy withsome vitamin C in it.
Yeah, but it's importantbecause a lot of people take
multivitamins for whateverreason.
I'm sure that really it's kindof pertinent to everybody.
(06:07):
It seems like everybody,whenever they visit the doctor,
will say, oh, I'm not takinganything, but I do take a multi,
and great or whatever.
And about 30% of the populationis using some sort of regular
multivitamin or using amultivitamin on a regular basis.
Dr. Joshua Goldenberg (06:24):
Yeah, that's a lot.
That's one in regular basis.
Dr. Adam Sadowski (06:25):
Yeah, that's a lot, that's one, one in three
people, yeah, and some of thethe issues with regards to the
data looking uh at, you know,are multivitamins beneficial or
not?
Um, is the issue of confoundingwhere, uh, a lot of people who
are using multivitamins arealready healthy to begin with,
so it's kind of hard todetermine whether or not they're
even getting benefit to theiruse outside of, you know, not
(06:51):
being in a deficient state, sootherwise generally healthy,
well-rounded diet, you know,non-smokers, et cetera, et
cetera.
Typically, the people who areusing multivitamins are
typically healthy, and sothere's this idea of the healthy
user effect.
And then, conversely, you havepeople who are not in good
(07:12):
health, who suddenly have acoming to Jesus moment perhaps,
and then we'll start takingmultivitamins, sort of like as
an entrance to wanting to live ahealthier lifestyle and view a
multivitamin as this healthything to do, and so we'll start
supplementing with amultivitamin.
(07:33):
And so we don't really know, orit's not that we don't know,
it's just that the evidence ispretty mixed.
The United States PreventiveServices Task Force has pretty
much made the recommendationthat if you're otherwise a
healthy individual, there'sreally no need for a
multivitamin supplementation forthe purposes of preventing
death, because in the UnitedStates, everything is basically
(07:57):
fortified, and so, even if youdon't have the best diet, having
a true nutritional deficiencynot to be confused with
insufficiency is pretty rare.
There's not many people in theUnited States who are walking
around with, let's say, ricketsor scurvy.
Dr. Joshua Goldenberg (08:15):
Not anymore.
Dr. Adam Sadowski (08:16):
Whereas, yeah , not anymore.
And so you know, when it comesto using a multivitamin in
getting physiologic excess towhat you're already getting on a
daily basis, is there any sortof actual benefit to that in
people who are otherwise healthy?
Um, and just using amultivitamin in preventing uh
(08:37):
all cause mortality, cancer,cardiovascular disease.
Dr. Joshua Goldenberg (08:40):
Right.
Dr. Adam Sadowski (08:41):
And that's that's what the paper is looking
at.
Dr. Joshua Goldenberg (08:43):
Yeah, exactly, and I think the so
there's a couple, a couplethings.
So, yeah, I love that healthyuser, sick user effect
discussion, justmethodologically.
Sometimes that sick user effectyou know we might call that
like reverse causation, bias,right?
So remember, so observationalstudies, which is what this is.
You know, association does notequal causation.
(09:05):
That's why we love randomized,controlled trials.
But when you have anassociation, instead of thinking
that A is driving B so like themultivitamin is driving the
disease outcome, like you're notdying as much, it may actually
be that B is driving A andthat's why they're associated.
So the sick user effect is,essentially they have a and
that's driving their use ofvitamins because they have this
(09:26):
belief that it's healthy and itwill help them.
So you'll see that association,but it's because of the reverse
causation.
So, anyway, so just neatmethodological stuff.
I would also say that.
So this is looking at mortalityand people usually take it, as
I've heard people say, likequote unquote insurance to make
sure they're getting everythingthat they need, and the argument
would be well, okay, like weshould be seeing some health
(09:48):
benefits here, and so thisquestion is really on a
mortality level.
Are we seeing a difference withlong follow up?
Dr. Adam Sadowski (09:55):
They also did look at heart disease and
cerebral vascular accidents.
Dr. Joshua Goldenberg (09:59):
Did they look at those as separate
outcomes or death because of?
Dr. Adam Sadowski (10:04):
That is a good question.
I think they did death becauseof, and they also looked at
all-cause mortality, so they didseparate it out.
Dr. Joshua Goldenberg (10:11):
Yeah, but they're not looking at MIs or
other diseases short of death.
So I guess, just trying toforeshadow counter arguments,
one might be, you know, okay,well, maybe it's not leading to
a change in death but maybe ithas other benefits or wellness
outcomes or things like that.
But we'll well, that'sforeshadowing, so we'll get to
that.
So I think you set that upreally really well.
(10:32):
Some of the oh so, what are theissues?
So the big issues with this isyou need large cohorts of people
to be able to see these sortsof outcomes with statistical
significance.
You need long follow-up,because the argument is like,
okay, you take a multivitaminfor six months, like you know,
if you'd have a randomizedcontrol trial or something like
that, like yes, that's ideal,but you're not going to study
(10:52):
them for 30 years and that's thetype of follow-up you might
need to see these types ofoutcomes.
So you need these largeobservational studies.
So one issue is lag time effectand so you need large cohorts
with multi-decade follow-up,which is what the study is
trying to do.
And the other is this you know,like you said, the healthy user
and sick data to be able tostratify by other markers of
(11:14):
health and separate that out asa variable or do multivariate
adjustments?
Do we still see this effect?
So when you have these largecohorts, you could do that type
(11:37):
of statistical magic or voodoo,depending on who you're talking
to.
Depending on who you're talkingto and then from a sick user
effect, they also did thisclever thing where they excluded
everyone at the beginning attheir baseline levels, who had
cancer, diabetes, any of thesemajor diseases, because of the
fear of the sick user effect.
So really they limited theircohorts to people that were
(11:59):
going in, like you said, healthy, and then looking at their self
reportreport of multivitaminuse and the development of death
.
And then the last thing is well, what if people change over
time?
You know their multivitamin use, or if they develop diabetes in
the middle there, and thenthat's what's driving their
multivitamin use.
So they did have somesequential time data from these
(12:22):
cohorts about people'smultivitamin use over time, not
very nuanced and detailed, Ithink it was like every few
years or five years or decadesor something like that, but they
had something time-linked wherethey can kind of update that as
well.
So the neat thing is thatthere's big questions about
multivitamins, studyingmultivitamins, and so they
(12:43):
thought, hey, with this approach.
With these techniques, we mightbe able to address some of
these issues.
Dr. Adam Sadowski (12:48):
Yeah, and I think we also have to remember
that, when it comes to thesekind of studies, something that
we have to take into account isthe fact that a lot of it is
self-reported, and so you knowyou're relying on people saying
yes, I take a multivitamin everyday, or I only take it every
three days, and so the accuracyor the precision within that is
pretty poor, so we do have totake that into account as a
(13:09):
limitation.
Dr. Joshua Goldenberg (13:10):
And it doesn't speak to the quality of
the multivitamin either.
Right, it's just asking someoneif they take a multivitamin
every day or not.
Dr. Adam Sadowski (13:18):
Yeah, you know, if you were to take
someone randomly off the streetand just say how many times a
week do you eat burritos?
Dr. Joshua Goldenberg (13:30):
I don't think the answer is going to be
very accurate.
Right, and you don't know ifthey had whole foods, made that
at home burritos versus going toTaco Bell three times a day.
Right, and so it's somewhatanalogous here is that there's
no quality metric here.
Dr. Adam Sadowski (13:37):
But, but does that matter?
Remember when we talked aboutthat before?
Dr. Joshua Goldenberg (13:42):
Well, so that's the question, right?
So we're just sort of saying soyou know.
So, dr, I am going to tell youthat it doesn't matter.
It's all expensive urine, andthis proves it.
And I'm just playing devil'sadvocate and saying that this is
not measuring quality, right?
So this is just asking peopleif they have a multivitamin and
(14:04):
then trying to associate thatanswer with death.
Yeah, yeah, okay, we're coolwith that.
Dr. Adam Sadowski (14:12):
We'll just move along so we'll move along.
Dr. Joshua Goldenberg (14:15):
Okay, we're not cool with that, but
it's a detente.
Okay, go ahead yeah.
Dr. Adam Sadowski (14:19):
So in this study they had three cohorts for
a total of just shy of 400,000participants, so they had about
34,000 deaths for a total ofjust under 8 million person-year
follow-ups.
So one way to look at that isif I had 8 million people in a
(14:41):
study and followed them for oneyear, or if I had one person who
I followed for 8 million years.
Dr. Joshua Goldenberg (14:49):
You're now just falling apart here.
Dr. Adam Sadowski (14:50):
Yeah, yeah, it's a lot, it's a a lot, it's a
lot of data basically we havewe have a lot of follow-up data
that you can't get from arandomized control, trial or
other study types.
So this is this is sort of thebenefit of doing these large
prospective cohort studiesalthough there's a lot of
limitations from them, you canget a lot of good data from them
(15:12):
.
And then if get a lot of gooddata from them, and then if you
look at the confidence intervals, because of the high number of
participants and the longfollow-up, the confidence
intervals tend to be a lot, muchmore narrow, which is usually
reassuring.
Dr. Joshua Goldenberg (15:25):
No, so that's the point.
It's like we talked about.
For this sort of researchquestion, you really are going
to need multi-decade follow-up,and that's where these cohorts
come in with all limitations.
So did we say so?
These are three cohorts, soit's the NIH, aarp Diet and
Health Study Cohort, the PLCOCancer Screening Trial Cohort
(15:48):
and the Agricultural HealthStudy Cohort, I believe, the
latter of which is like a cohortof pesticide applicators.
So I had a big question aboutapplicability and external
validity with these cohorts, butit's something that we need to
kind of consider.
They did look at thedifferences between cohorts to
see if there were any obviousdifferences and didn't seem to
(16:10):
see it.
But these are the people inthis, this study.
Dr. Adam Sadowski (16:16):
Yeah, and the PLCO was the prostate, lung,
colon, ovarian cancer screeningtrial cohort and that goes back
to.
All of these go back to theearly to mid nineties.
So the NIH AARP health studycohort goes back to 1995.
The PLCO cohort goes back to1993.
And then the AHS, theAgricultural Health Survey, goes
(16:38):
back to 1993.
Why they didn't include, likethe nurse's health study or you
know, some of these other largewell-known cohort studies kind
of remains elusive.
I'm sure the data there has gotto exist.
Dr. Joshua Goldenberg (16:55):
You'd think so.
Dr. Adam Sadowski (16:57):
I would be hard-pressed if it doesn't.
Dr. Joshua Goldenberg (16:59):
It did seem like a random selection of
cohorts.
I mean, I've seen the NIH AARPall the time in lots of studies.
I've never seen a study on thisagricultural health cohort or
the secondary analysis of PLCOcancer screening cohort either.
Dr. Adam Sadowski (17:14):
I'm wondering if that agricultural health
study was trying to tap intolike a more rural patient
population base.
Dr. Joshua Goldenberg (17:21):
Maybe it would be nice to have had some
justification.
Maybe that's what we'restruggling with here is why were
they not?
Why are they not the author'snot justifying the selection?
Is this just pragmatic, likethis is what they had buddies in
that could get access to, orwas this chosen for specific
reasons?
Because I'm left scratching myhead as to why these cards were
(17:44):
chosen and if they wereappropriate and if it's
applicable to the larger USpopulation, and I wouldn't have
these questions if they had agood rationale for their
selection, which they don't seemto explain.
Dr. Adam Sadowski (17:55):
Yeah, because if we look at the NIH AARP
cohort, those individuals were50 to 71 years of age.
Dr. Joshua Goldenberg (18:02):
Right.
Dr. Adam Sadowski (18:03):
Yep, they lived in one to two metro areas
or in six different states, butthey didn't specify which states
.
They were excluded from datacollection in this study if they
provided answers through aproxy.
So let's say you know, you askthe individual, do you use a
multivitamin?
And then their brother answersfor them.
(18:23):
If they died before receivingthis questionnaire, which is
pretty obvious exclusionarycriteria If they had cancer,
some sort of major adversecardiovascular event, diabetes
or end-stage renal disease atbaseline, or if they had cancer,
some sort of major adversecardiovascular event, diabetes
or end stage renal disease atbaseline, or if they had
basically implausible caloricintake not necessarily
implausible, but just excess.
And I mean that's importantbecause if you're, one could
(18:45):
assume that if you're eatingcaloric excess then you're going
to be sort of physiologicallyoverachieving on nutrients that
would be available in amultivitamin.
Theoretically, now, you couldbe eating just like caloric
excess from like lots and lotsand lots of soda.
But they did apply thatexclusionary criteria to, I
(19:07):
think to all of the studiesanyway.
And then any of the cohortsthat had missing covariates that
they were interested in werealso excluded.
The PLCO was done at 10different centers.
The ages there at baseline were54 to 74.
They excluded data from thereIf participants died at baseline
(19:31):
collection for this particularstudy, if they had missing
outcomes on at least eightdifferent responses for the
questionnaires that they wereinterested in and then for the
AHS.
These were individuals who wereat least 18 years of age that
were pesticide applicators,living in Iowa and Northern
Carolina.
Dr. Joshua Goldenberg (19:52):
Yeah, interesting.
Again, would have loved to seea rationale for the selection of
these cohorts.
For the most part the censoringI was okay with.
Again, they censored the peoplewith these major conditions on
purpose to avoid I believe againit's not explained to avoid
this sick user effect.
And I and the caloric, like theextreme caloric intake we've
(20:16):
seen stuff like that before,sort of these, and you kind of
tried to explain itmythologically and I think also
it's sometimes used as a qualitymetric, like they're just not
reporting things properly ifit's this extreme, but they
don't really define what extrememeans, which is, again, maybe
that's in a supplement somewhere, but I don't see it here.
So, yeah, so I mean, for themost part I'm okay, but just a
(20:39):
lot of questions about theselection of the population here
that I think a couple sentencesexplanation would have put my
mind at ease.
Otherwise I'm okay with it.
Look, the thing is we don't dothis for money.
This is pro bono and, quitehonestly, the mothership kind of
ekes it out every month or so,right?
(21:00):
So we do this because we careabout this, we think it's
important, we think thatintegrating evidence-based
medicine and integrativemedicine is essential and there
just aren't other resources outthere.
The moment we find somethingthat does it better, we'll
probably drop it.
We're busy folks, but right nowthis is what's out there.
Unfortunately, that's it, andso we're going to keep on
fighting that good fight.
(21:21):
And if you believe in that, ifyou believe in intellectual
honesty in the profession andintegrative medicine and being
an integrative provider andbringing that into the
integrative space, please helpus, and you can help us by
becoming a member on Dr JournalClub.
If you're in need of continuingeducation credits, take our
NANSEAC approved courses.
We have ethics courses,pharmacy courses, general
(21:43):
courses.
Interact with us on socialmedia, listen to the podcast,
rate our podcast, tell yourfriends.
These are all ways that you cansort of help support the cause.
Okay, so with those caveats,shall we jump into the next
section exposure assessment.
Dr. Adam Sadowski (22:10):
Yeah, so basically they looked at people
who were non-users ofmultivitamins versus daily users
and which kind of I kind oflike it makes the data a little
bit cleaner because you'reyou're more likely if someone's
like an actual daily user,they're more likely to be a
daily user than someone who'slike infrequently using.
Then you're trying to quantifyokay, well, how, how often are
you taking it?
right and then they also defined, like you said earlier, that it
was all, it was all causemortality, but the death from
(22:31):
specifically, cancer, heartdisease and strokes.
And then they looked at thecovariates of age, sex, race,
ethnicity, education, smokingstatus, bmi, marital status,
physical activity, alcohol,coffee, healthy eating index,
family history of cancer and useof other supplements.
Dr. Joshua Goldenberg (22:51):
Yeah, and this is important for the
healthy user effect.
So we've been dealing with thesick user effect by censoring
people with disease at baselineand by looking at these
surrogates for healthy users,like healthy eating index we've
talked about that before alcoholintake, physical activity, bmi.
(23:11):
In theory, they're going to beusing this to try to control for
those potential confounders, sothat's why that is particularly
interesting.
And then, of course, they havethree different cohorts, so
they're somewhat measured indifferent ways and so, again, it
has to be harmonized acrossthese cohorts before they can do
their analysis.
Dr. Adam Sadowski (23:29):
Yep, yep, yep , yep.
Dr. Joshua Goldenberg (23:30):
Cool.
Dr. Adam Sadowski (23:31):
And then, when they looked at their
analysis, they did bothindividual analyses and pooled
analyses, where the pooledanalyses was the main outcome of
interest.
Dr. Joshua Goldenberg (23:40):
Pooled across all three cohorts Yep.
Dr. Adam Sadowski (23:43):
Exactly.
So they individualized themacross each individual cohort.
So you have three differentcohorts.
So they did one analysis waslet's just look at each cohort
individually.
We had three different cohorts.
So they did one analysis waslet's just look at each cohort
individually.
And then they also said OK,well, now let's do what we
really care about, which ispooling all the data together
and analyzing that.
So we combined all threecohorts.
Dr. Joshua Goldenberg (24:00):
Yes, this is.
There's some interesting stuffhere and it's complicated stats
even for us.
But there's a few things that Idid want to touch on.
So one is so they have threedifferent cohorts, right I did
want to touch on.
So one is so they have threedifferent cohorts, right, and
they claim that they didindividual analysis on each
individual cohort and that itwas similar enough that they
(24:22):
then pooled them.
But they don't show unless Imissed it, they don't show any
evidence of that or say whatsimilar means.
They also say there's lowbetween-study heterogeneity.
Again, I don't see any highsquare statistic or rationale
and that is their rationale forpooling them.
And when they say pooling them,they actually mean a
meta-analysis, which is rare.
(24:43):
Normally we're used to seeingmeta-analyses after attached to
a systematic review.
This is a meta-analysisattached to three cohorts.
It isn't unprecedented, ithappens and it can be kosher.
But they also they did a fixedeffects meta-analysis, which is
very rarely done.
Usually you do random effects.
Fixed effects assumes that theintervention and everything else
(25:06):
is exactly the same and theonly difference that you're
dealing with in themeta-analysis is the size of the
samples, is the size of thestudies.
There's basically nostatistical or mathematical
input from the heterogeneitycomponent, whereas random
effects assumes you're gettingan average of different
(25:28):
populations and different typesof interventions and doses and
therefore is more conservative,has wider confidence intervals,
not less impressive p-values,because it makes these
assumptions and it incorporatesthe assumed reasonable
heterogeneity in a populationlike that.
So you have to be careful.
Fixed effects are going to likeover-argue p-values and stuff
like that and be overly precise.
(25:49):
And I don't see how they getaway with saying that you've got
three different cohorts acrossvery different populations,
people just saying they take amultivitamin you have no idea
what type of multivitamin, whatthe dose of the multivitamins
were and getting away with doinga fixed effects meta-analysis
on that.
So maybe I am missing somethingand if you're a statistician
(26:11):
please call in and correct me.
But that was a little.
I'm not saying it's a red flag,I'm just saying sort of like
the cohort selection.
I was left scratching my headand would have liked some
explanation as to the rationalefor that, because that did not
seem like how I would look atthat.
Anyway right.
Dr. Adam Sadowski (26:30):
Yeah, no, it was.
Dr. Joshua Goldenberg (26:31):
It was a little confusing yeah, okay, so
they, so they.
But for let's say, let's, let'sassume, for the sake of
argument, playing devil'sadvocate, it was okay to pull
these cohorts and that it wasokay to use fixed effects, and
so now we're going to talk aboutthe results that they found
when they did that.
Yeah, yeah, brought myattention is that we're talking
(27:07):
about I think I said threedecades earlier, but really
we're talking about a medianfollow-up of, you know, 23, 21,
almost 24 years across all thecohorts.
We're talking about 23 and ahalf years median follow-up, so
it is still a lot of follow-uptime and anything else from
(27:28):
baseline, besides what we'vetalked about before, about
describing those cohorts thatyou wanted to touch on.
Dr. Adam Sadowski (27:33):
I mean the average age basically was 62.
And, excuse me, the median agewas 62.
Dr. Joshua Goldenberg (27:41):
At baseline, right?
So I think that's relevant too.
This is an older, these areolder folks, and you know, it's
not too surprising that the AARPcohort in there as well, right?
So you have to be what?
50 to even be a member of theAARP.
So, yeah, so this is.
Dr. Adam Sadowski (27:56):
this is a population that's skewing older
already with a with ainterquartile range of 57 to 66.
So I mean, it's still likemiddle of the road patient
population, that these are themajority of patients who are
going to be being seen from likea primary care status.
And you know, you kind of wantthe data, I would feel like on
on people who are at higher riskfor, for you know, death anyway
(28:19):
because, um, if you have ayounger cohort and you're and
you're following them, then evenharder, yeah.
Yeah, it would be harder totrack the data that you're
trying to evaluate, and so thiswould actually help if there was
an effect with use ofmultivitamins to show you know
again, if we think about, likeour absolute risk, those who are
(28:41):
at higher risk for things.
If there's a higher risk, youwould expect the intervention to
provide more benefit thansomeone who's at you know a
primordial risk or primaryprevention risk standpoint.
Dr. Joshua Goldenberg (28:54):
Yeah, and then that's so.
That's true and fair and Idon't have a huge issue, just to
note that it's an older cohort.
And then the other thing Iwanted to point out is the HEI
score.
I know we kind of ragged on HEIbefore as like it's an
imperfect measure of healthyeating, but it's sort of what we
have and commonly used.
So it's a scale of zero to 100.
(29:16):
And in here in these cohortsthe average and this seemed
mostly consistent across thedifferent cohorts it looks like
the AHS which went with the AHSthat was the agricultural one
has a little bit of a lowerhealthy eating index but for the
(29:37):
most part they're scoring inthe 60s and I believe 100 score
is considered the best andreflects sort of that 100%
alignment with major you know,common dietary recommendations
in the United States.
So they're in that 60 to 70range on average as far as
(29:58):
healthy eating.
Dr. Adam Sadowski (29:59):
And we also are kind of seeing a healthy
user effect where, compared tothose who are not using
multivitamin, they're morelikely.
Individuals who are usingmultivitamins are more likely to
use other supplements ingeneral, have a lower BMI,
better diet quality, less use oftobacco products, etc.
Etc.
Dr. Joshua Goldenberg (30:20):
Yeah, so that's exactly the point, right?
I think now that they have thislevel data on people's diet and
their BMI and their physicalactivity and supplement use, in
theory they can try to controlfor that and just look for
residual effects ofmultivitamins.
And we we had a analogous issue.
What was one of the papers wedid I forget what it was
(30:43):
studying which looked at the oh,it was ultra processed foods
and tried to separate that outfrom the HEI and we, argued, had
a pretty hard time doing that.
But this is their attempt ofbasically saying you know, let's
make sure that it's not justthe fact that people that eat
healthy are taking multivitaminsand we're seeing the effect
(31:03):
because they're eating healthy.
Right, right, right, right,okay cool.
Dr. Adam Sadowski (31:07):
So let's get into the sort of the meat and
potatoes of it and I think right, right, okay, cool.
So let's get into the sort ofthe meat and potatoes of it and
I think, yeah, let's do the funstuff.
I think the best way to kind ofpresent this is talk about the
well they split it up as towhat's called fp1 and fp2, so
follow-up period one andfollow-up period two, where
follow-up period one was yearsof follow-up between years one
(31:29):
through 12, and then follow-upperiod two was beyond 12 years,
and I feel like beyond 12 yearsis a little bit more of the data
that we should kind of focus inon because it's more long-term
from that standpoint.
But we will discuss both.
Dr. Joshua Goldenberg (31:46):
Okay, yep Gotcha.
Alrighty, okay, okay, yep,gotcha.
Dr. Adam Sadowski (31:48):
Alrighty, okay.
So when it comes to mortality,there was a 4% increased risk in
individuals using dailymultivitamins compared to
non-users, and that hazard ratiowas 1.04 with a confidence
(32:09):
interval of 1.02 to 1.07.
So a 4% increased risk ranginganywhere from 2% to 7%, but that
was limited to years 1 through12.
Once we extended out beyond 12years, that was no longer
statistically significant andalthough the point estimate
didn't change at 4%, theconfidence interval was much
wider and ranged from 0.99, so a1% benefit in reducing the risk
(32:35):
to 1.08, so across thatthreshold of 1.
And so it was anywhere from 1%protective to 8%, increasing the
risk of mortality, and that wasall-cause mortality.
When we look at heart disease,cancer and stroke across neither
(32:56):
, across none of the FP2 timepoints was there.
Basically everything wasconsistent, right For FP2, there
was no statisticallysignificant differences between
the two for heart disease,cardiovascular disease or cancer
.
Dr. Joshua Goldenberg (33:08):
From death, from those things.
Right, right, yeah, correct.
Dr. Adam Sadowski (33:12):
But when?
And then, when we look at heartdisease, there was a 6%
increase risk which ranged from1% to 11%, isolated to the first
follow-up period for the first12 years, which is consistent
with the mortality data.
Dr. Joshua Goldenberg (33:27):
So I wonder if, if this was done as a
random effects meta-analysis,that confidence interval would
have been wider, and even thatstatistically significant
increased risk would also not bestatistically significant.
So I'm curious about that, butI think the take-home is.
What is clear, though, isthere's definitely is no signal
for benefit.
The question is, you know, isthere actually a signal for harm
(33:49):
or not?
I'm not sure, but certainlythere does not seem to be a
signal for benefit.
Would you?
How would you take that?
Dr. Adam Sadowski (33:58):
Yeah.
Dr. Joshua Goldenberg (33:59):
Okay.
Dr. Adam Sadowski (34:00):
Yeah, I'd agree, and again, that that
signal for harm is only in the,in the short term, and it's
really really small.
Dr. Joshua Goldenberg (34:07):
Right, exactly, and really close to
losing significance if thoseconfidence intervals got a bit
wider.
So I'm a little suspicious.
But yeah, okay, cool, and theydon't have a good argument.
I mean, I guess you could comeup with some mechanism as much
as you love, mechanism of how itcould cause harm, but certainly
we're not seeing a signal forbenefit there.
Okay, excellent, I think that'sthe main take home.
(34:29):
Is there anything else that youwanted to talk about as far as
the overall results, or shouldwe jump into sort of that
discussion piece?
Dr. Adam Sadowski (34:41):
No, I was going to jump into the
discussion piece and just saythat you know, this is yet again
some more evidence that'sconsistent with prior evidence
showing no benefit of, you know,multivitamin supplementation or
super physiologic doses ofvarious nutrients for otherwise
healthy individuals.
It's consistent with the USPSTFrecommendation.
(35:03):
It's consistent with a priorrandomized control trial.
Dr. Joshua Goldenberg (35:06):
Looking at this and so yeah, I mean the
data is the data looking at thisand so, yeah, I mean I, the
data is the data.
Yeah, the data is the data.
I think that I would agree withthe few caveats I think I said
before, which is, you know, thisis sort of interesting cohort
selection.
I'm not sure what to make of it,I'm not sure what to make of
the choice of meta analysis type, and but I certainly don't see
(35:31):
a signal of benefit.
But then again, I would saythere's no metric here for the
quality or dose in themultivitamins, simply looking
for an association betweenpeople saying they take a
multivitamin every day and thendying over the next few decades.
So I think that is a faircriticism.
That being said, it's going tobe a very challenging study and
(35:55):
probably impossible to answerthat question, because you would
need 30-year cohorts with dataon the quality and type of
multivitamin and then somestatement about what actually is
considered a high quality thateveryone agrees on and all of
those things, and then you'dhave even more of an issue of a
healthy user effect for peoplethat are seeking out specific
(36:18):
high quality multivitamins asopposed to grabbing something
off the shelf.
So I don't know how you woulddo that study, but I think it is
fair to argue that however thatquestion is still open, based
on this study.
Dr. Adam Sadowski (36:30):
I don't know if I agree because and again it
goes back to the idea of priors.
So you know, we already havequite a bit of evidence showing
that there's a lack of benefit,you know.
So we have consistency in thatstandpoint.
We can only work with through,or we can only work with what we
have, and what we have for themost part, is pointing towards
(36:55):
no benefit.
And then to say, to rationalize, saying, oh well, I'm using a
high quality supplement and youknow, these cohorts don't
pertain to my person, my patient.
Therefore, this is actually,you know, a reason to recommend,
you know, iv nutrients or thisfancy multivitamin.
(37:19):
I don't think you can make thatargument, and it goes back to
that idea of priors that we'vetalked about before, where you
really need to have a reallygood case and strong evidence to
suggest why you're making thatrecommendation over what has
already been established in theliterature.
Dr. Joshua Goldenberg (37:38):
Yeah, and to bolster your side of this,
thank you To steel man, you abit here.
It would be one thing for me tosay, well, you can't really
answer this specific question,but what's the harm?
And as long as you do, informconsent.
Dr. Adam Sadowski (37:54):
Well, we also have evidence of harm right
Well exactly.
Dr. Joshua Goldenberg (37:57):
So that's my point is that even though
we've been saying maybe we havesome questions about that harm
signal, there is a harm signalnow, right, like that is out
there in the literature and it'sit's, you know, it's, it's,
it's there and so and it's aboutdeath.
It's not about like belly aches, right.
So I think that balanceargument changes to where it's
(38:17):
say okay, well, maybe you canhand wave and say it's not a
perfect study and dah, dah, dah,dah and whatever is.
And you have, you have goodarguments about that, whatever
is argument.
And when you just say no, basta, we're done.
You commonly bring up withvitamin D, for example, but even
that shifts if you've got asignal of harm, if you've got
questions about the signal ofharm.
So I don't know, man, Actually,on retrospect, maybe I'm
(38:40):
leaning into your camp a littlebit and just saying not only am
I not going to startrecommending Maltese, maybe we
even ask people to stop.
I don't know, it's not medicaladvice, we're just talking about
research and implications, butI think the argument about
shifting that onus is a good one.
Dr. Adam Sadowski (38:59):
Yep, and so far from what we've looked at on
this podcast, it looks like theShilajit so far has been the
only thing that has panned out.
Dr. Joshua Goldenberg (39:09):
Shilajit is the clear winner.
Dr. Adam Sadowski (39:11):
Knee osteoarthritis.
Dr. Joshua Goldenberg (39:13):
No curcumin.
For what was it?
Curcumin for functionaldyspepsia?
But then a new study came outbasically showing a harm signal
with curcumin in liver disease.
We're going to have to look atthat.
Liver failure we're going tohave to look at that study next
week I think.
But yeah, interesting,interesting stuff.
But there are very few things inour rarefied list, the Dr
(39:35):
Journal Club list, of largemagnitude, high quality evidence
that things work.
And so what's our running list?
Probiotics for necrotizing,necrotizing colitis.
We've got maybe semaglutide wedon't actually know if that's
true and apparently withoutlooking it up, we've got Vi
semaglutide we don't actuallyknow if that's true and and
apparently without looking it up, we've got um viagra, according
to you.
And then what was the other onewe did last time?
(39:57):
Oh yeah, e-cigs.
E-cigs seems to have super highevidence with a large magnitude
of effect as well.
So what's the world coming tome?
But don't do the multivitamins.
What it's like this?
This is the strangest finalconclusion.
You, we should be doing e-cigsand Viagra and jump on the
semaglutide bad wagon, but don'tdo the multivitamin.
Is this really where we want toleave our listeners after today
(40:18):
?
Dr. Adam Sadowski (40:18):
we're here for a fun time, not a long time
we should leave it at that,alright.
Dr. Joshua Goldenberg (40:25):
Dear listeners, thank you for putting
up with us and we will see younext week.
If you enjoy this podcast,chances are that one of your
listeners.
Thank you for putting up withus and we will see you next week
.
If you enjoy this podcast,chances are that one of your
colleagues and friends probablywould as well.
Please do us a favor and letthem know about the podcast and,
if you have a little bit ofextra time, even just a few
seconds, if you could rate usand review us on Apple podcast
or any other distributor, itwould be greatly appreciated.
(40:48):
It would mean a lot to us andhelp get the word out to other
people that would really enjoyour content.
Thank you.
Hey y'all y'all.
This is.
Josh.
DrYou know we talked about some
really interesting stuff today.
I think one of the things we'regoing to do that's relevant.
There is a course we have on DrJournal Club called the EBM
Boot Camp.
That's really meant forclinicians to sort of help them
understand how to criticallyevaluate the literature, etc.
(41:09):
Etc.
Some of the things that we'vebeen talking about today.
Go ahead and check out the shownotes link.
We're going to link to itdirectly.
I think it might be of interest.
Don't forget to follow us onsocial and interact with us on
social media at DrJournalClub.
Drjournalclub on Twitter, we'reon Facebook, we're on LinkedIn,
etc.
Etc.
So please reach out to us.
We always love to talk to ourfans and our listeners.
(41:32):
If you have any specificquestions you'd like to ask us
about research, evidence, beinga clinician, etc.
Don't hesitate to ask.
And then, of course, if youhave any topics that you'd like
us to cover on the pod, pleaselet us know as well.
Introducer (41:47):
Thank you for listening to the Doctor Journal
Club podcast, the show that goesunder the hood of
evidence-based integrativemedicine.
We review recent researcharticles, interview
evidence-based medicine thoughtleaders and discuss the
challenges and opportunities ofintegrating evidence-based and
integrative medicine.
Be sure to visit www.
drjournalclub.
com to learn more.
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