Introduction
Nutritional medicine involves the use of vitamin and mineral supplements, usually given orally, in the form of tablets or liquids. In order for any living organism to function adequately, there are a whole series of trace elements such as zinc, magnesium and chromium and a number of vitamins usually described by letters of the alphabet (A to E) that are essential. Their absence leads to disease, an observation first noted by James Lind in 1753. He was a naval physician who observed that sailors on long voyages, and therefore without fresh fruit and vegetables, developed scurvy.

This deficiency illness could kill a significant proportion of the crew on a long voyage, consequently significantly debilitating the navy’s ability to fight or even man their ships of discovery. Lind observed that the addition of lime juice to the sailor’s diet could prevent scurvy. Vitamin C itself, however, was not chemically isolated until the 20th Century. A whole series of specific nutritional deficiency diseases such as pellagra and beriberi (both deficiency diseases of the Vitamin B group) were carefully documented, and their cause isolated, in the 1920s and 30s.

As a consequence, the dietary recommendations made by most Western governments tend to be more focused on the specific intakes that avoid deficiency rather than those which promote optimal health. While we are almost invariably certain about the nutritional requirements that are needed to avoid illness, there is often little information, and indeed much argument in the nutritional world, about the doses of nutritional supplements required to sustain optimal health, particularly in a high state of nutritional demand, for instance during a disease process or when an individual is undergoing unusual physical or mental demands such as competitive sport.

This is perhaps illustrated by the differences that exist in Reference Nutrient Intakes (RNI) between the United States and the United Kingdom, almost uniformly the RNIs in the US are higher than those in the UK in spite of the fact that the Ministry for Agriculture, Fisheries and Food (MAFF) has recently increased its recommended RNI for the UK population. This shows how much of the average UK population falls below the recommended intakes. This suggests a somewhat worrying picture. While we certainly eat enough to suffer from increasing rates of obesity, a significant minority are probably simultaneously suffering from nutritional deficiencies. This is probably associated with the rise of high fat, high carbohydrate and low nutrient value junk food in association with the increased industrialisation of farming tending to produce products with relatively lower levels of trace elements and vitamins.

What should nutritional medicine be used for?
Nutritional medicine has a whole range of applications that span both conventional and complementary medicine. There are those who would argue that everyone needs to take regular nutritional supplements on a daily basis, which others suggest that nutritional supplements are only needed in states of proven deficiency such as an iron deficiency anaemia. Certainly, nutritional supplements can be effectively used as agents that modify disease processes.

For instance, there is sound evidence that zinc taken orally, if you are suffering from colds or flu, will shorten the duration of the illness and improve symptoms. Increasing the consumption of polyunsaturated fatty acids, usually derived either from plants or more commonly fish oils can be of real benefit in reducing the levels of harmful fats in the blood, controlling and modifying the inflammation experience by patients with rheumatoid arthritis and even help symptoms and reducing relapse rates in inflammatory bowel disease such as ulcerative colitis and Crohn’s.

Studies suggest that Vitamin C probably does treat (although it does not prevent) colds and Vitamin B6 is of value in premenstrual syndrome and possibly autism, while Vitamin E may be of value for patients with angina. We also know that folic acid, taken before and during pregnancy, will reduce the rate of spina bifida. In general, the intake of folic acid in most westernised industrial nations falls well below the recommended nutritional intake; one American study suggested that most adults were only taking half the RNI for folate as part of their regular daily diet.

Nutritional medicine, therefore, can be very important in the treatment and prevention of a variety of problems. The recommendations made by some nutritionalists frequently involve quite complex and expensive supplement regimes. Many people claim benefit from such approaches, and indeed they may be of genuine benefit. However, as is the case with the practical application of many aspects of complementary medicine, we are often unclear about the scientific validity of the very specific recommendations that may be made by some practitioners.

Who prescribes supplements?
The majority of people taking nutritional supplements will do so on the basis of advice from health magazines, a friend, or perhaps someone in a health food shop or pharmacy that may sell various nutritional supplements. Many people will already be taking cod liver oil or glucosamine for their arthritis and menopausal women frequently take extra calcium in order to avoid osteoporosis. The majority of nutritional supplements are therefore self-prescribed.

Nutritional supplements may also be used as part of the treatment regimes prescribed by a whole variety of complementary practitioners, including herbalists, homoeopaths, osteopaths and chiropractors. Some therapists specialise in the investigation and prescription of nutritional supplements, in particular those who are members of the British Association of Nutritional Therapists, Registered Naturopaths and medically qualified doctors who are members of the British Society for Allergy, Environmental and Nutritional Medicine (BSAENM).

Is it Safe?
There has recently been a lot of discussion about the safety of nutritional supplements. There is no doubt that some nutritional supplements taken in high doses can produce adverse reactions. For instance, extra Vitamin A is certainly not recommended in pregnancy as it may cause abnormalities in the foetus. High doses of Vitamin C can cause diarrhoea. In general terms nutritional supplements taken over 2 or 3 months are very, very unlikely to cause adverse reactions. However, supplements taken over a long period of time, such as B6 for premenstrual syndrome have, in a very small number of cases, been reported to cause nerve damage.

This has usually involved very high doses, far higher doses than those usually recommended by responsible nutritional therapists. Excessive doses of zinc and selenium have been reported in some instances to suppress the immune system and there has also been a suggestion that prolonged use of evening primrose oil may make some forms of epilepsy slightly worse. However, it is important to stress that in general nutritional supplements are very safe. There have, for instance, been no reported deaths due to nutritional supplementation in the United Kingdom, a situation that is dramatically different to that from the prescription of anti-inflammatories for arthritis.

[Dr. Georgiou is a qualified Clinical Nutritionist with an honours degree in the Biological Sciences, a 3-year Diploma in Nutritional Medicine, is a Metabolic Typing Consultant and is a member of the British Association of Nutritional Therapists].

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