What Supplements Does an Evidence-Based GYN Take?

When you have no skin in the supplement game...

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Sometimes, it feels like social media is rapidly becoming one big supplement ad. In addition to traditional ads, there are soft sales from doctors and other healthcare professionals who clearly profit from the supplements because they are either selling their own product or they are sharing discount codes, often something like #GynoApproved. Some may not be directly financially profiting; they are just posting about them to ride the popularity of supplements on social media as they know the posts and videos they create about the topic get more attention and views, which drives followers that are most definitely a currency. So many healthcare providers are trying to get in on the menopause gold rush that it’s become a supplement minefield.  Unlike some doctors who base their supplement choices on less rigorous evidence, I demand that supplements actually have some proven benefits. For example, I am not a rodent; I am a human woman, so rat studies aren’t going to sway me. I also don’t want low-quality studies or studies published in questionable journals. I demand the same evidence from supplements as I do from pharmaceuticals because I’m worth it.

I don’t typically like discussing what I do because it's an anecdote, but since I frequently get this request, I thought I would explain the reasoning behind what I take or mostly don’t take. This doesn't mean that you should do what I do, but perhaps you might be interested in how I think about it. But remember, I am using lots of *I* words here.

Before we go any further, I have an entire section of The Vajenda dedicated to supplements, and it’s called Supplements & Such (very creative, I know…insert eye roll emoji). There, you can find information on how I group supplements (this is an important primer), the backstory behind the lack of legislation for supplements in the United States, and reviews of different products, to name just a few of the topics. 

In this post, I’m writing about supplements for generally healthy people, meaning for primary prevention. There are some evidence-based reasons to take supplements for primary prevention that I won’t discuss here because they don't apply to me. For example, I'm not trying to get pregnant, so I don't need a folic acid supplement. I also have no idea about the literature for professional athletes/bodybuilders, so what I write here may not apply.

The following is my answer to someone asking what supplements I, a reasonably physically active and healthy woman in her 50s, take for preventative health care. 

Here’s my list:

Vitamin D, 1,000 IU, and I do this reluctantly because studies have consistently failed to show significant benefit from routine supplementation (excluding people with true vitamin D deficiency). There is a lot of bias and shoddy science among the biggest promoters of the supposed low vitamin D epidemic, and there is a good summary here in the New York Times for anyone interested. The latest Endocrine Society guidelines recommend against routine supplementation for people ages 50-70 years (my age group) for those who can get 600 IU a day from their diet. The VITAL study showed no benefit from Vitamin D supplementation in reducing fractures with or without calcium. I had my vitamin D level tested after I broke my ribs as part of the workup, and my level was barely normal by the new cut-off: I was 23 ng/ml, and normal is ≥ 20 ng/ml (50 mmol/l). Because my level is barely normal and I have osteopenia, my endocrinologist persuaded me to take it. I was conflicted because vitamin D supplements don't tend to increase bone density in clinical trials, except for those with very low baseline levels of < 12 ng/ml (<30 nmol/L). Some data shows people with higher levels tend to have better bone health, but there are lots of confounders. There is likely no downside to taking 1,000 IU a day. I take Nature Made, which is third-party verified and cheap. 

Is This Really a Supplement? Maybe, kind of?

Protein: At the Menopause Society meeting, we were quoted that women should consume 1.2 g/kg of protein daily, but I think there is enough evidence to suggest that 1.6 g/kg is a better target, especially when combined with resistance training. Diet-wise, I struggle the most here. For me, 1.6 g/kg is about 125 g a day, but when I first started tracking protein, I was in the 60-70 g/day range, which was eye-opening and showed the benefit of at least checking once or twice. It has taken time and dedicated effort to restructure my diet accordingly. I’ve reached the 100-105 g range, and recently, I have surpassed 120 g fairly consistently. I sometimes make smoothies with skyr (Icelandic yogurt) and protein powder (I use Simply Tera’s Whey Powder, vanilla because every other protein powder tastes disgusting to me), and I find Barebells protein bars extremely palatable, as well as Fairfield protein shakes and Ensure Max 30 g Protein shakes, so I guess you could loosely call those supplements (the Ensure also has 650 mg of calcium!). Protein bars and these shakes are also great for travel as they don’t have to be refrigerated. I’ve been playing around with some high-protein flours and now have a few recipes for higher-protein dinner rolls and pizza crusts, and look, getting an extra five or more grams of protein from something I love is a win-win. If people are interested, I will post some of my high-protein recipe modifications. 

Here are some of the most common supplements that I get asked about that I do NOT take:

Calcium: The recommendation in the United States is 1,200 mg a day for women over age 50, and I get between 800-1,200 mg a day. Calcium absorption is believed to reduce with age, partly due to lower vitamin D, but I'm taking that, so it shouldn't be an issue. There aren’t good studies showing that calcium supplementation reduces fractures for people eating a typical diet. In the Women’s Health Initiative, calcium combined with vitamin D did not significantly reduce hip or wrist fractures compared with placebo. While there were some beneficial changes in a few markers of bone health, these were not statistically significant. Admittedly, the WHI may not apply to me as this study was postmenopausal women at typical risk of fracture, and I'm at higher risk, but other data suggests that calcium supplements only provide about a 1% increase in bone density, which is limited to the first year of use. There is also a small but definite increased risk of kidney stones with a calcium supplement, an extra 5 cases per 10,000 women per year. While this is a small increase in risk, I have one kidney, and a kidney stone would be a bigger deal for me. Also, if I took a calcium supplement for 30 years, at five extra stones a year, that means when I’m 88, I would have had a 1.5% lifetime risk of a calcium supplement-induced kidney stone. The general consensus is that it’s best to get calcium from a diet, but if there is a dietary requirement shortfall, make up the remainder with a supplement. How do I get to 800-1,200 mg? I have a lot of milk, coconut and soy milk with added calcium, feta cheese, and skyr or yogurt. I often have a glass of So Delicious Coconut Milk when I walk in the door. I like the taste; it only has 45 calories, and it adds 130 mg of calcium to my diet. I cook rice in it as well, and it just gives it a hint of coconut.

Collagen: There is no good data supporting collagen supplements for muscle or bone health, which would be my primary concern. While low-quality data supports it for skin health, the data is, well, lower-quality, so it’s not enough for me to bother with. I’m sticking with sunscreen and Retin-A, which have a lot of quality evidence. 

Creatine: This may show a very small benefit for the muscles, but the effect is less for older people, and even for younger people, the benefit is likely so slight that it’s probably not clinically significant. Here’s part of a conclusion from a recent meta-analysis: 

A pooled analysis of the current data suggests that creatine supplementation promotes a small increase in skeletal muscle hypertrophy in both the upper and lower body musculature when combined with a regimented resistance training program. Those considering creatine supplementation for the goal of regional muscle hypertrophy should consider the practical significance of the small magnitude of effect. Furthermore, young adults appear to derive a greater hypertrophic benefit compared to older individuals, but the magnitude of this difference is relatively modest, calling into question the practical relevance of this finding

I’ve heard a lot of chatter recently about creatine supplements for memory, but the data here is weak, and I’m not going to take something daily that has a weak effect when there are many things with great data for brain health (see this post). Like most people, I am busy, and I don’t want to waste money, time, and energy on interventions with little supporting proof. When a supplement reaches a threshold that makes it into guidelines for the prevention of dementia, then I’ll consider it. Until then, I will stick with robust science.  

Fiber: I consistently get > 25 g of fiber a day, so I don’t supplement here. For those who can’t get to that goal or who are struggling with constipation, psyllium husk is the winner, hands down. You can get that from Metamucil or one of my favorite cereals, Bran Buds. There is no reason to waste your money on expensive, designer fiber supplements. 

Omega-3 fatty Acids: the VITAL trial probably gives us the best data here, and the conclusion from the paper is, “supplementation with n−3 fatty acids did not result in a lower incidence than placebo of the primary end points of major cardiovascular events (a composite of myocardial infarction, stroke, or death from cardiovascular causes) and invasive cancer of any type.” While some people wonder if people who don’t eat any fish might benefit from an omega-3 supplement, I don’t think the data is very robust. Also, I make a pretty concerted effort to have fatty fish twice a week. I asked Dr. Danielle Belardo about the benefits of omega-3 supplements for people who don’t eat fish, as she is a preventative cardiologist and a vegan, and she says there is no good evidence to support supplementation for heart health, even for those who don’t eat fish. In fact, she told me that a “healthful plant-based diet does not demonstrate lower omega levels as compared with omnivores.” There may be benefits with a purified form of EPA for people with elevated triglycerides and who also have diabetes or who have coronary artery disease, but that’s not the situation we are discussing here. 

Final thoughts…

I really do my best to get all my nutrition from my food because that seems to be the one consistent message in every study. It’s a simple idea but not easy to execute, and I think that’s important to recognize. I also have a super supportive husband who does more than 50% of the grocery shopping and cooking, and that helps a lot. And I have my easy backups, like protein shakes or high-fiber Mission tortillas (18 g of fiber and 5 g of protein, not bad!), and Kodiak Cakes Protein cakes (pancake mix) to help fill in the gaps. 

(I have no sponsorships with any of the food items that I have mentioned; I am just sharing what I like because I have benefited so much from others sharing what they like with me.) 

I love this quote from the Harvard Health Blog, as it sums this all up quite well:

How food, and its component molecules, affect the body is largely a mystery. That makes the use of supplements for anything other than treating a deficiency questionable.

Gunter’s corollary is that many people are looking to capitalize on this mystery, especially for women in menopause.

References

1. Bouillon, R., Manousaki, D., Rosen, C. et al. The health effects of vitamin D supplementation: evidence from human studies. Nat Rev Endocrinol 18, 96–110 (2022). https://doi.org/10.1038/s41574-021-00593-z

2. Marie B Demay, Anastassios G Pittas, Daniel D Bikle, Dima L Diab, Mairead E Kiely, Marise Lazaretti-Castro, Paul Lips, Deborah M Mitchell, M Hassan Murad, Shelley Powers, Sudhaker D Rao, Robert Scragg, John A Tayek, Amy M Valent, Judith M E Walsh, Christopher R McCartney, Vitamin D for the Prevention of Disease: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 109, Issue 8, August 2024, Pages 1907–1947, https://doi.org/10.1210/clinem/dgae290

3. US Preventive Services Task Force; Grossman DC, Curry SJ, Owens DK, Barry MJ, Caughey AB, Davidson KW, Doubeni CA, Epling JW Jr, Kemper AR, Krist AH, Kubik M, Landefeld S, Mangione CM, Silverstein M, Simon MA, Tseng CW. Vitamin D, Calcium, or Combined Supplementation for the Primary Prevention of Fractures in Community-Dwelling Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2018 Apr 17;319(15):1592-1599. doi: 10.1001/jama.2018.3185. PMID: 29677309.

4. Manson JE, Crandall CJ, Rossouw JE, et al. The Women’s Health Initiative Randomized Trials and Clinical Practice: A Review. JAMA. 2024;331(20):1748–1760. doi:10.1001/jama.2024.6542

5. Livingston G, Huntley J, Liu KY, et al. Dementia prevention, intervention, and care: 2024 report of the Lancet standing Commission. The Lancet 2024, July 31. 

6. LeBoff MS, Chou SH, Ratliff KA, et al. Supplemental vitamin D and incident fractures in midlife and older adults. N Engl J Med 2022;387:299-309.

7. Manson JE, Cook NR, Lee IM, et al., on behalf of the VITAL Research Group. Marine n−3 Fatty Acids and Prevention of Cardiovascular Disease and Cancer. N Engl J Med 2019;380:23-32.

8. Omega-3 fatty Acids, Fact Sheets for Health Professionals, NIH https://ods.od.nih.gov/factsheets/Omega3FattyAcids-HealthProfessional/#:~:text=The%20AHA%20does%20not%20recommend,and%20those%20with%20preexisting%20CVD.

9. McMorris T, Hale BJ, Pine BS, Williams TB. Creatine supplementation research fails to support the theoretical basis for an effect on cognition: Evidence from a systematic review. Behav Brain Res. 2024 May 28;466:114982. doi: 10.1016/j.bbr.2024.114982. Epub 2024 Apr 4. PMID: 38582412.

10. Avgerinos KI, Spyrou N, Bougioukas KI, Kapogiannis D. Effects of creatine supplementation on cognitive function of healthy individuals: A systematic review of randomized controlled trials. Exp Gerontol. 2018 Jul 15;108:166-173. doi: 10.1016/j.exger.2018.04.013. Epub 2018 Apr 25. PMID: 29704637; PMCID: PMC6093191.

11. Prokopidis K, Giannos P, Triantafyllidis KK, Kechagias KS, Forbes SC, Candow DG. Effects of creatine supplementation on memory in healthy individuals: a systematic review and meta-analysis of randomized controlled trials. Nutr Rev. 2023 Mar 10;81(4):416-427. doi: 10.1093/nutrit/nuac064. PMID: 35984306; PMCID: PMC9999677.

12. Nunes E. A., Colenso-Semple L., McKellar S. R., Yau T., Ali M. U., Fitzpatrick-Lewis D., Sherifali D., Gaudichon C., Tomé D., Atherton P. J., Robles M. C., Naranjo-Modad S., Braun M., Landi F., and Phillips S. M. (2022) Systematic review and meta-analysis of protein intake to support muscle mass and function in healthy adults, Journal of Cachexia, Sarcopenia and Muscle, 13, 795–810, https://doi.org/10.1002/jcsm.12922