Fortification, supplementation, and medication

During the last year, there has been a turbulent debate in Europe and Sweden about free trade with vitamins and minerals, i.e. micronutrients and trace elements. "No one has ever died of micronutrients", was the message from the micronutrient industry in a dirty lobby campaign against EU officials, Swedish officials, and journalists. The message was spiced with lies, insinuations and insults. Iron, for example, is easily overdosed. In 1999, four persons died in Sweden due to chronic iron intoxication (hemochromatosis).

The micronutrient field is extremely complex (1-3). For practical use, it is essential to discriminate between fortification, supplementation, and medication. Fortification is the addition to ordinary food (e.g. cereals) of a fraction of the recommended daily dose of one or more micronutrients. Supplementation is the addition of the recommended daily dose of one or more micronutrients as a pill or some other non-food preparation (capsule, solution, mixture) for healthy people. Medication implies treatment of overt deficiency and diseases; higher doses are usually required in the first stage of treatment.

In the natural state, micronutrients often provide commodities in short supply. Man is to some degree adapted for shortage but not for abundance. The chronic iron intoxication (hemochromatosis) provides a practical illustration. It is reasonable to assume, that the same model applies to other micronutrients with slow excretion. In Sweden, most micronutrient pills contain the recommended daily dose of vitamin A and vitamin D. Furthermore, the dose of vitamin E in micronutrient pills often exceeds the recommended daily dose by an order of magnitude, ten times the recommended dose. It is suggested that the doses of the vitamins mentioned should be reduced to 25% of recommended daily dose; pills are not the only source of micronutrients in the ordinary diet of healthy people.

The significance of micronutrients was detected during the last century due to specific deficiencies in specific populations. The vitamins serve usually as coenzymes or hormones, not as fuel. Excess micronutrients are considered to provide no excess benefits for the consumer, just as excess calories do not provide excess energy. Since most micronutrients may be toxic in excess amounts, a varied and cautious fortification of food offers principal advantages over supplementation (cf 4). However, fortification and supplementation are insufficient for women in fertile age and people over 70 concerning cobalamin and folate. A relative deficiency may lead to spontaneous abortions, neural tube defects and, in the elderly, nerve cell disturbances, anemia, and atrophia of mucous membranes.

In Sweden, there is an extensive experience with oral high-dose cobalamin and oral high-dose folic acid in the treatment of deficiency states (cf 5). These vitamins appear to be safe for medication with pharmacological doses. The oral maintenance dose of cobalamin is usually 1-2 mg daily. The oral maintenance dose of folic acid is usually 5 mg daily. The doses of remission treatment are often twice the maintenance doses mentioned. Swedish physicians feel that these doses are efficient and safe.

Bo Norberg

1. Basu TK, Temple NJ, Garg ML. Antioxidants in human health and disease. CABI Publishing, Oxon (UK), 1999
2. Schurmann K, Klassen HG, Hages M, Prinz-Langenohl R, Pietzik K, Bieslaski HK. Bioavailability of oral vitamins, minerals and trace elements. Drug Res 1997; 47(4):369-380
3. Willet WC, Stampfer MJ. What vitamins should I be taking, doctor? N Engl J Med 2001; 345(25):1819-24
4. Hägglöf M. Superstition of supplementations [culture]! Rondel 2002; 11. URL: http://www.rondellen.net
5. Norberg B. Oral high-dose cyanocobalamin – a contagious concept [editorial]! Rondel 2001; 8. URL: http://www.rondellen.net

Published April 8, 2002