USPSTF: No benefit of beta carotene, vitamin E, multivitamins in CVD, cancer prevention
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The U.S. Preventive Services Task Force issued a recommendation statement against the use of beta carotene or vitamin E supplements for the prevention of CVD or cancer.
The recommendations in this statement, published in JAMA, are consistent with those of the 2014 USPSTF recommendation statement on vitamin, mineral and multivitamin supplements for the prevention of CVD and cancer.
“The USPSTF again concludes that the evidence is insufficient to assess the balance of benefits and harms of multivitamins and single- or paired-nutrient supplements (except beta carotene and vitamin E) for the prevention of cardiovascular disease or cancer. The USPSTF again recommends against the use of beta carotene or vitamin E supplements for the prevention of cardiovascular disease or cancer,” Carol M. Mangione, MD, MSPH, chief of the division of general internal medicine and health services research; Barbara A. Levey, MD, and Gerald S. Levey, MD, endowed chair in medicine; distinguished professor of medicine at the David Geffen School of Medicine at the University of California, Los Angeles; and chair of the USPSTF, and colleagues wrote.
Vitamin, mineral and multivitamin supplementation
The USPSTF rationale for this recommendation is as follows:
- there is adequate evidence that beta carotene supplements provide no benefit in the prevention of CVD or cancer;
- there is adequate evidence that vitamin E supplements provide no benefit in the prevention of CVD or cancer;
- evidence is inadequate regarding the benefits of supplementation with multivitamins for the prevention of CVD or cancer; and
- evidence is inadequate regarding the benefits of supplementation with single or paired nutrients, other than beta carotene and vitamin E, for the prevention of CVD or cancer.
The Task Force added that there exists adequate evidence that beta carotene may increase risk for lung cancer among those already at elevated risk.
There is also evidence that vitamin E causes and multivitamins may cause, at most, small harms; however, evidence is inadequate to discern the harms of supplementation with single or paired nutrients, according to the statement.
“Persons who have an acute or chronic illness may require additional vitamin, mineral, or multivitamin supplementation as part of management of their condition, which goes beyond supplementation for the prevention purposes addressed by this recommendation,” the USPSTF wrote. “In addition, the USPSTF clarified that persons who experience food insecurity are among the populations of interest for the research gap on whether the effects of vitamin, mineral, and multivitamin supplementation on cardiovascular disease and cancer outcomes differ across specific populations.”
The HHS and the American Heart Association both recommend healthy individuals receive adequate nutrition primarily from a variety of healthy foods and beverages, rather than supplements.
This USPSTF recommendation is intended to only apply to adults who are community-dwelling and nonpregnant, according to the statement. It does not apply to children, those who are pregnant, those who may become pregnant or individuals with a chronic illness, those who are hospitalized or those with a nutritional deficiency.
The USPSTF added that it separately recommends all individuals who are capable of or planning for pregnancy take a daily supplement of 0.4 to 0.8 mg of folic acid.
Please see the statement and supporting evidence document for complete details on this USPSTF recommendation.
‘Beyond wasted money ... a potentially harmful distraction’
In a related editorial, Jenny Jia, MD, MSc, instructor of medicine at the Northwestern University Feinberg School of Medicine, and colleagues discussed how vitamin and mineral supplements may represent a distraction from evidence-based CVD and cancer prevention strategies.
“The substantial marketing budget of the supplement industry generates interest, attention, and billions of dollars in revenue,” the authors of the editorial wrote. “Most people view supplements as, at worst, benign preventive products. However, in the U.S., dietary supplements are relatively unregulated and required to disclaim that health claims have ‘not been evaluated by the Food and Drug Administration’ and they are ‘not intended to diagnose, treat, cure, or prevent any disease.’”
“Beyond wasted money, the focus on supplements might be viewed as a potentially harmful distraction. Rather than focusing money, time, and attention on supplements, it would be better to emphasize lower-risk, higher-benefit activities,” the authors of the editorial wrote. “Health systems and health care professionals should focus on evidence-based preventive services recommended by the USPSTF, including controlling high blood pressure and behavioral counseling to encourage physical activity and a healthy diet.”
References:
- Conflict of Interest Disclosures. www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/conflict-interest-disclosures. Published in March 2022. Accessed on June 20, 2022.
- Jia J, et al. JAMA. 2022;doi:10.1001/jama.2022.9167.
- O’Connor EA, et al. JAMA. 2022;doi.10.1001/jama.2021.15650.
Perspective
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JoAnn E. Manson, MD, DrPH, MACP, FAHA
Vitamin and mineral supplements will never be a substitute for a healthful diet, and it's important that they not be perceived that way. The USPSTF did a comprehensive review of the literature, and I agree with their conclusion that there’s insufficient evidence to recommend vitamin and mineral supplements to prevent CVD or cancer, and that supplements of beta carotene and vitamin E should be avoided. I agree with the latter concerns because trials have shown an increased risk for lung cancer with beta carotene in smokers and an increased risk for hemorrhagic stroke with vitamin E.
Dietary supplements do serve a role during certain life stages, however. It’s important for women in pregnancy to take a prenatal vitamin and extra folic acid to prevent neural tube defects. Supplements can have a role in older adults as well, including taking extra vitamin B12 for pernicious anemia, vitamin D and calcium for bone health, and an antioxidant formulation for age-related macular degeneration. And patients with malabsorption conditions, at any age, will benefit from vitamin/mineral supplementation.
We found in our randomized trials of multivitamins that a multivitamin/multimineral supplement may have some benefits in older adults. We saw in our recent Cocoa Supplement and Multivitamin Outcomes Study (COSMOS) that older adults (above age 65) had a slower rate of cognitive decline with multivitamins than placebo (Baker LD, et al. www.CTAD2021.com) Additional research is needed to replicate these findings. We also saw in the Physicians Health Study II that multivitamins were linked to reduced risk for cancer (Gaziano JM, et al. JAMA. 2012;doi:10.1001/jama.2012.14641). Even the USPSTF report acknowledges that their meta-analysis of multivitamins showed a statistically significant 7% reduction in cancer incidence based on the 4 available trials, which were conducted largely in older adults.
We also saw in VITAL, our vitamin D and omega-3 trial, that vitamin D 2,000 IU per day led to a statistically significant 22% reduction in autoimmune diseases, as well as a close to 20% reduction in advanced cancer (Manson JE, et al. N Engl J Med. 2019;doi:10.1056/NEJMoa1809944; Hahn J, et al. BMJ. 2022;doi:10.1136/bmj-2021-066452; Chandler PD, et al. JAMA Netw Open. 2020;doi:10.1001/jamanetworkopen.2020.25850).
Although we and others have found certain benefits of multivitamins and vitamin D supplementation, a blanket recommendation to take vitamin or mineral supplements wouldn’t be warranted. Targeted use of supplements in certain high-risk groups, however, is appropriate, including specific life stages (as above), conditions associated with impaired absorption of vitamins and minerals, such as Crohn's disease, ulcerative colitis, celiac disease, and post-gastric bypass surgery, use of certain medications such as proton pump inhibitors or metformin that may interfere with absorption and/or metabolism of micronutrients, and other relevant conditions. However, the generally healthy population won’t have appreciable benefits from dietary supplements, and the focus should be on having a heart-healthy diet.
It’s also important to advise against mega-dosing of any dietary supplements, which can be associated with risks and toxicity. More is not necessarily better, and it can be worse.
Although it’s easier to pop a pill than to focus on a healthy diet, the complex array of phytochemicals, other nutrients, and fiber in unprocessed foods just can’t be packaged into a pill. And adding a dietary supplement to an unhealthy diet high in red meat, saturated fat, and processed food is not going to improve health. Whereas if instead you increase your intake of fruit, vegetables, whole grains, and fish, those foods will naturally replace the less healthy foods. There’s also concern that if you’re popping a pill that you misperceive as benefitting your health, you may become complacent about other lifestyle behaviors.
Overall, I agree with the USPSTF that vitamin and mineral supplements don’t have clear benefits for preventing CVD or cancer, and the focus should be instead on a healthy diet and healthy lifestyle practices.
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