On vitamins
Larry Hoover
(c) 1996
First published June 1996 in THE TOWNSEND LETTER FOR DOCTORS AND PATIENTS
Reprinted with permission by the Author and The Townsend Letter
The Vitamin Paradigm Wars
I have been involved in megavitamin controversies from 1955 when with two
colleagues we [1] published our paper showing that niacin lowered total
cholesterol levels. This was quickly confirmed because Dr. W. B. Parsons,
Jr[2] . It was easy to measure cholesterol levels. Dr Parsons is one of the
most knowledgeable and experienced internists in the use of niacin to lower
cholesterol levels. But after we[3] published a much more comprehensive
paper where we concluded: (1) that the addition of niacin or niacinamide in
large doses was therapeutic for acute and non deteriorated schizophrenics;
(2) was not therapeutic for chronic patients, our involvement in controversy
became massive, until today even though every study using the same type of
patients, the same methods and the same regimen, has corroborated our
findings.
The conclusions reached by Dr. E. Cameron and Linus Pauling[4] on the
beneficial effect of ascorbic acid on the outcome of terminal cancer was
just as forcefully rejected by the cancer establishment. The main reason for
the non acceptance of the Vale of Leven's conclusions and for the non
acceptance of our psychiatric findings is very simple. We are just now
beginning to emerge from the vitamins-as-prevention paradigm into the
vitamins-as-treatment paradigm. Psychiatry is simply ten or more years
behind the rest of the medical sciences.
The Five Stages of Vitamin Discovery and Use
Machlin[5] divided the history of the vitamins into five periods. The first
phase was present from 1500 B.C. to about 1900 A.D. when it was empirically
observed that certain foods prevented some diseases. Egyptians used liver to
prevent night blindness. Central American Indians used specially treated and
cooked corn to prevent pellagra for several thousand years.
The second period started about 1890 and continued until about 1910. During
this period the relationship between the lack of certain foods and disease
became established. Thus polished rice was proven to cause beri beri. Of
course, if brown rice had remained the staple food of the Japanese Navy
there would have been no problem and no discovery of thiamin as a vitamin.
During the first period it became recognized that altering the natural food
supply would produce disease. This lesson is still imperfectly understood by
most modern societies.
The third phase from 1900 to 1948 was the golden age of vitamin discovery,
isolation and synthesis of vitamins. The fourth phase from 1933 began with
the first commercial synthesis of vitamin C and continues today. These four
phases comprise the vitamin-as-prevention paradigm. This paradigm became so
firmly established that only now is it beginning to weaken by the onslaught
of new information.
The fifth phase is the recognition of health effects beyond prevention and
new biochemical functions. It is the vitamin-as-treatment paradigm. It is
beginning to enter the medical profession, has not yet been accepted by the
medical schools which remain many years behind in the teaching of nutrition
and is still tightly held by dietitians and many nutritionists, especially
those working for institutions.
The introduction of this last phase is credited by Machlin to our paper in
1955 which showed that megadoses of nicotinic acid decreased total
cholesterol, the decrease being relatively greater the higher the initial
blood level. He wrote, "I somewhat arbitrarily started the fifth period with
the report in 1955 of the cholesterol-lowering effect of niacin, which is a
well-accepted response of the vitamin that has nothing to do with its
coenzyme role and is a clear health effect beyond preventing the deficiency
disease pellagra". I had concluded many years ago that this early report
would be one of the most important findings which would take us into the
modern paradigm. It is the first vitamin to be approved for megadose use by
FDA, for lowering cholesterol, but it could also be used for any other
indication including the schizophrenias.
The Vitamin-as-Prevention Paradigm
This paradigm is described by the following rules or beliefs:
) That vitamins are catalysts and therefore are needed in very small doses
since they can be recycled almost indefinitely.
)That they are needed only to prevent deficiency disease i.e. diseases
caused by a deficiency of these vitamins. Thiamin is needed to prevent beri
beri, nicotinic acid is needed to prevent pellagra and vitamin C is needed
to prevent scurvy.
It therefore follows that any use of vitamins which disobeys these rules is
not indicated and has by many medical societies been considered unethical
practice or malpractice. If they are needed only in small doses the use of
large doses must be forbidden. If they are used only to prevent disease, any
use to treat other disease must be forbidden.
For these reasons regulatory daily requirement were developed as a guide to
society and to the professions. They are invariably small doses based upon
this paradigm and upon very little real hard evidence of their practicality
and usefulness. The prevention paradigm adherents presented a hard and
secure front against those who would break its rules by enforcing the view
that large doses were never needed, that they were potentially dangerous
(these dangers were never clearly defined and related to dose level, and the
height of sarcasm thrown against vitamins-as-treatment physicians was that
the only thing vitamins would do is to enrich the urine and the waters into
which that urine ran. Just a few months ago a physician attacked some of my
views in a popular medical journal by claiming that the waters around
Victoria must be rich in vitamin C. If I had retorted I would have added
that this is better than enriching them with antibiotics, tranquilizers,
antidepressants and the thousands of drugs which now enrich the waters. A
physician friend and colleague lost his medical licence in Saskatchewan. One
of the charges against him was that he gave a patient intravenous ascorbic
acid. Another was that he diagnosed a patient schizophrenic with the help of
a test developed by Humphry Osmond and I called the HOD[6] test. This is a
very helpful perceptual test which yields probability levels for the
presence of schizophrenia.
Vitamin-as-Treatment Paradigm
This paradigm contains the following new rules, based upon a good deal of
evidence:
) That optimum doses should be used in both prevention and treatment and
that these doses vary from very small to very large, i.e. into the
megavitamin range. For example to prevent pellagra one needs about 10
milligrams of nicotinic acid daily, but to prevent the symptoms of chronic
pellagra from recurring one will need close to 1000 mg daily. There is no
optimum doses for the whole population. It depends upon age, sex, type of
illness, type of stress, i.e. upon the individual. We will have to determine
the optimum levels for schizophrenics, for depressions, for the arthritides,
for lupus, for cancer and so on. This is well described by Roger Williams[7]
in his classic works on biochemical individuality.
) That vitamins may have activity which appears to be unrelated to their
properties as vitamins. This was a very difficult concept to accept but the
introduction of the word antioxidants struck a responsive chord and many
physicians who were terribly fearful of using vitamins had no compunction
against using the same vitamins an antioxidants. This fits in with the
increasingly popular view that hyper oxidation, the formation of free
radicals, is basic in the pathology of a large number of conditions
including cancer, senility and so on.
The Assault on the Vitamin-as-Prevention Paradigm
This began about 55 years ago with the report by the American
pellagrologists that chronic pellagra could not be treated except by very
large doses of nicotinic acid; they used 600 mg daily. It was also shown
that dogs kept on the pellagra- producing diet for a long time no longer
responded to small doses of this vitamin. They had become dependent and
needed much larger doses.
The next assault on this paradigm arose from the classic studies of William
Kaufman[8] who reported in two books before 1950 the marked therapeutic
benefit to arthritics by giving them multigram doses of vitamin B-3 daily.
But this important work was ignored and hardly any physicians are aware it
was ever done.
The next attack came from a different direction, from the work of Drs.
Wilfred and Evan Shute[9] of Ontario who showed that large doses of vitamin
E given for adequate periods of time were very helpful in treating coronary
disease, burns, and were useful in prevention. They were not ignored. They
were almost destroyed by a medical profession which was completely unaware
of the importance of their work, did not believe vitamin E was a vitamin and
knew with absolute certainty that their work was useless. The Shute Clinic,
still in existence, treated over 30,000 patients from all over North
America. The agenda of the few attempts to repeat their work was to show how
useless vitamin E was. Today the major studies[10] which have confirmed this
early work still consistently refuse to acknowledge the prior work of these
great pioneers, as if the idea had sprung freshly minted from their own
foreheads when they launched the Harvard Vitamin E studies. Had the Shutes'
findings been taken seriously in 1960, think of enormous saving of human
health, the enormous decrease in human misery and the enormous financial
saving over the past 35 years.
In the early Fifties, Dr. Fred Klenner began his work on megadoses of
vitamin C. He used doses up to 100 grams per day orally or intravenously. In
clinical reports he recorded the excellent response he saw when it was given
in large doses. He reported, for example, that patients given vitamin C
would suffer no residual defects from their polio. A controlled study in
England on 70 children, half given vitamin C and half given placebo showed
that none of the treated cases developed any paralysis while up to 20
percent of the untreated group did[11] . This study was not published
because the Salk Vaccine had just been developed and no one was interested
in vitamins. Dr. Klenner's work was ignored.
However, only after Linus Pauling entered the field with his classic report
to Science in 1968 did the use of megadoses of vitamins receive major world
attention. The public and a few scientists were immediately attracted to his
conclusions world wide, while the medical profession as a block dumped all
over him. Their main objection apparently was that he did not have an M.D.
Dr. Pauling became interested in vitamins about the time he had decided to
retire. He had won his second unshared Nobel Prize and was getting tired and
frustrated by the opposition to his work for peace. He had made a few
powerful enemies including Senator McCarthy of anti communist fame, and
Joseph Stalin of communist fame who considered his views on the atom
directly opposed to communist theory. At a meeting in New York in 1966, both
Dr. Irwin Stone and I met Dr. Pauling for the first time. Dr. Stone had
assembled a large collection of vitamin C papers (he hated the word vitamin
C and preferred the more correct term ascorbic acid). Dr. Stone first used
the word megavitamin and the word hypoascorbemia. He considered scurvy, not
a deficiency disease, but a metabolic error. I urged him to publish his
review of ascorbic acid which he did several years later[12] . Irwin heard
Dr. Pauling state that he wished he could live another 25 years because
science was making so many interesting discoveries. Dr. Stone wrote to him
and told him he could achieve his goal if he would take vitamin C in
megadoses. Dr. Pauling tried it out, was convinced because he felt so much
better, and lived another 30 years.
The major impetus given by Linus Pauling to the megadose concept of vitamin
C stimulated by Irwin Stone has finally thrown this vitamin into public and
medical acceptance. Many years ago Linus Pauling concluded that people
taking ascorbic acid would live longer[13] . All the information we have
about ascorbic acid lead to this conclusion. It is therefore very helpful to
actually see what it can do in practice for the final test is the practical
one - does it work? In fact, it does. Dr. James Enstrom[14] , School of
Public Health, University of California at Los Angeles analyzed a ten year
study of 11,348 people, aged 25 to 74. Men who consumed at least 300 mg of
ascorbic acid suffered 41 percent fewer deaths during that period compared
with men who took only 50 mg, in their food. They lived on the average 6
years longer. For women the results were not as striking. This amount of
ascorbic acid can not be obtained from the diet alone and shows that
supplements are essential. Had they used gram doses daily, I think the
results would have been more striking.
Dr. A.G. Brox[15] and colleagues at McGill University found that two grams
of ascorbic acid daily, successfully treated 7 out of 11 patients with
idiopathic thrombocytopenic purpura (ITP). They had all been sick more than
two months and had not responded to adrenocorticosteroids. Three had had
splenectomies. Four had failed additional treatment including the current
usual treatments. Their report had been rejected by the New England Journal
of Medicine, I think, because they were then involved in a dispute with
Linus Pauling. They had refused to advise him whether a rebuttal letter
answering the Mayo cancer and ascorbic acid studies he had submitted would
be published until he threatened them with legal action. Then they rejected
it. I have one patient now with ITP on ascorbic acid who has been well over
five years, but only as long as she remains on her ascorbic acid. If she
discontinues it, her platelet count begins to sink within a few weeks.
Linus Pauling[16] carried the orthomolecular concepts into the field of
cancer and again stirred up a hornets nest of hostility. For a good
discussion of his work see Hoffer[17] . But I am totally convinced he was
correct. His many scientific reports were very impressive. My studies with
Pauling[18] on 660 cancer patients beginning in 1978 are confirmatory.
The first major attention to megadoses of vitamins followed our report of
the effect of nicotinic acid on cholesterol, not because we had reported it
but because it was promptly confirmed by the Mayo Clinic. I had been invited
by the Mayo Foundation to give them a series of lectures on schizophrenia.
During a dinner I told their chief of psychiatry about the effect of
nicotinic acid on cholesterol. He passed it on to the chief of medicine in
the presence of his senior resident Dr. W. B. Parsons Jr[19] . Dr Parsons is
one of the pre-eminant experts in the use of megadoses of nicotinic acid.
The work was then taken up by Dr. E. Boyle, then with the National Institute
of Health, and later by the Coronary Drug Study which eventually established
nicotinic acid as the treatment of choice for hypercholesterolemia. It is
also by and large the cheapest and safest.
During that time Humphry Osmond and I published our second book, "How To
Live With Schizophrenia"[20] . A California patient[21] had recovered on
orthomolecular treatment having failed the best California could offer over
four years. Her father was so grateful he decided to educate every physician
in his community. He did so by handing out copies of our book. One of them
came into the hands of a psychiatrist. Dr. Pauling and Ava visited her one
afternoon, and Dr. Pauling saw the book on her coffee table. He began to
read it, borrowed it, and finished it by morning. He went to bed still
thinking of retiring and he arose the next day determined that he would not
and would enter this new field of megavitamin therapy. He was intrigued by
the large doses of vitamin B-3 we were using with safety. This led to his
Science report[22] and to his amazing contribution to the theory of
meganutrient therapy, in the use of vitamin C for viral and other
infections, for his very recent contribution to the cholesterol problem and
heart disease. Dr. Pauling made the greatest individual contribution toward
the overthrow of the old paradigm and its replacement by the newer, more
accurate, and useful one.
Megavitamin therapy was ignored by medicine at large and was vilified by
psychiatry. Only after Dr. Pauling entered the fray did the major profession
take notice, and then it too became very hostile and critical especially
after Dr. Pauling's first book on the common cold appeared. The National
Institute of Mental Health funded a study in New Jersey under the direction
of Dr. Wittenborn, a research psychologist. They had first approached a
psychiatrist in St. Louis, who agreed to do the study if I would be a
consultant. So the NIMH turned to New Jersey. The Wittenborn study was
double blind and was an attempt to repeat our original double blind
controlled studies started a decade before. Dr. Wittenborn in his first
report found that there was no difference between the placebo and the
treated group. We had claimed that it worked best for early or acute
patients and did not by itself help the very chronic ones. The
Wittenborn[23] study was primarily on these chronic cases. Later Dr.
Wittenborn re-analyzed his results by pulling out the early cases as we had
done, and in his second report he showed that he got the same results that
we had. His first report was greeted with shouts of enthusiasm from NIMH and
later by the American Psychiatric Association when they did their task force
report on Megavitamins and Orthomolecular Psychiatry. His second report was
greeted by a cold silence and may have cost him any further support. His
second paper was never referred to by the critics of megavitamin therapy.
The American Psychiatric Association called Humphry Osmond and me before
their Committee on Ethics because I had published the California paper.
After a vigorous half-day debate over 20 years ago in Washington they told
us they would let us have their decision in a few weeks. We are still
waiting. However, they effectively killed interest in the use of vitamins
for treating schizophrenia when they issued their irresponsible and flawed
report[24] . The APA bears major responsibility for preventing the
introduction of a treatment which would have saved millions of patients from
the ravages of chronic schizophrenia. Just as the APA was once captured by
psychoanalysis, it is now captured by tranquilizers.
Folic acid is another safe water soluble vitamin. It has been used in doses
up to 15 mg daily. There has been a report that this dose caused
gastrointestinal disturbances but in another study with the same dose this
was not seen. Most patients do not need more than 5 mg. Recently it has been
proven that women will give birth to babies with spina bifida and similar
neural tube defects (NTD) much less frequently if they take supplemental
folic acid, 1 mg per day. I generally recommend 5 mg daily. Dr.
Smithells[25] in 1982 showed that giving pregnant women extra folic acid
decreased the incidence of NTD's. Before that he had measured the red cell
folate and white cell vitamin C levels of mothers who had babies with NTD's
and found they were lower in both. It was thus known since 1981 that a
multivitamin preparation containing folic acid would decrease the birth of
these damaged babies.
The immediate reaction to the original findings was one of strong disbelief
and hostility, and the establishment refused to advise women to take folic
acid until the requisite number of double blind experiments were done. At
last they are satisfied 11 years later, culminating with a report in J.
American Med Ass in 1989. Folic acid provided protection for most causes of
the defect. Even in women with a family history, the frequency of babies
with the defects was more than five times greater - 18 per 1000 against 3.5
per 1000, in women who did not take the vitamin in the first six weeks of
pregnancy. How many babies could have been saved by such a simple solution?
Even if the original findings had been wrong, what harm would it have done
to have advised them immediately about this very important finding? I was
astonished in 1981 at the vehemence of the reaction by physicians and
nutritionists, and I am still astonished. The recent studies showed that
folic acid decreased NTD's by 75 percent. If all the other vitamins were
used as well I am certain that figure would be closer to 100 percent.
I can not recall in the past 40 years a single female patient of mine on
vitamins giving birth to any child with a congenital defect. I have been
able to advise them all that they not only would not harm their developing
baby by taking vitamins, but that their chances of giving birth to a
defective child would be greatly diminished. I was frequently asked this by
my patients who had been told by their doctors that they must stop all their
vitamins while pregnant. They looked upon vitamins as toxic drugs. I am
still asked the same question for the same reason today.
However, governments can learn and respond. It is now official that pregnant
women should take extra folic acid in order to prevent spina bifida and
other birth defects. The U.S. Public Health Service has issued the following
advisory: "In order to reduce the frequency of NTD's (neural-tube defects)
and their resulting disability, the United States Public Health Service
recommends that: All women of childbearing age capable of becoming pregnant
should consume 0.4 mg of folic acid per day for the purpose of reducing
their risk of having a pregnancy affected with spina bifida or other NTD's".
This amount will not be provided by most diets and requires supplementation.
Apparently the US Public Health Service is considering fortifying bread with
folic acid. Folic acid is destroyed by heat but some will survive.
In USA about 25,000 babies are born each year with spina bifida. In Canada
it has been estimated that each of these children will have cost about
$40,000 by the time they are 14 years of age. Giving women folic acid early
in their pregnancy would have avoided perhaps 3/4 of these births. Over ten
years, while the cautious scientists were discussing whether folic acid was
safe enough and was effective, 250,000 children were born at a total cost of
10 billion dollars (over ten years). Folic acid for pennies per day could
have saved the United States public 7.5 billions dollars over this ten year
period. The saving in public health dollars will be enormous. The waste in
this long delay is inexcusable, since folic acid is totally safe and could
have been given to all pregnant women over ten years ago. This is the costs
of inactivity, of the conservative stance of the profession when it comes to
the super safe vitamins.
Conclusion
The vitamins-as-treatment paradigm is developing very rapidly and will
absorb the vitamin-as-prevention paradigm which is no longer needed.
Vitamins are important nutrients which will be used in optimum doses, small
or large, for conditions which are responsive whether or not they are
considered to be vitamin deficiency diseases. Only the fossilized physicians
who have been the most powerful antagonists of the newer medicine still
adhere to the old, totally inadequate paradigm. But there are still
physicians who question whether vitamin B-3 is the correct treatment for
pellagra. They will still promote their old ideas and will bolster them by
manufacturing toxicities. As a rule, when there are no toxicities, it is
simple to invent them, such as vitamin C causes kidney stones, or damages
the liver, or interferes with the treatment of diabetes and so on. Every
month I hear about new toxicities which totally surprise and delight me
because they indicate how imaginative my colleagues can be.
A. Hoffer, M.D, Ph.D.
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