“What is there that is not poison? All things are poison and nothing (is) without poison. Solely the dose determines that a thing is not a poison.”
– Paracelsus (1493-1541)
As I mentioned at the end of the last installment, it was my intention in this issue to focus on Abraham’s position on the Wolff-Chaikoff effect. However, recent discussions with many of you on the subject of iodine supplementation has led me to conclude that, after spending over a year examining iodine research though my own eyes as well as the eyes of Abraham and the world’s foremost iodine researchers, it is time to step back for a bit and ponder some “big picture” thoughts in terms of what it all means from a clinical, patient management perspective. In taking this time to detach myself from the minutia inherent to the research world, my focus on the “big picture” easily led me to what seems to be, based on your comments, the major clinical concern. Can milligram dosing of supplemental iodine cause side effects and adverse reactions? Because of your ongoing and very necessary concern about this question, I am going to devote this installment of the series to this issue. In contrast, to typical discussions in this series, though, I will not be presenting a parade of studies that prove milligram dosing of iodine will cause adverse effects with some individuals. Why? I have already done this in previous installments, yet the controversy and passions still persist.
Because of this I am going to approach the controversy from a different perspective. First, I am going to discuss why the possibility that milligram dosing of iodine might cause adverse effects in some individuals has aroused such intense passions on both sides. Second, I am also going to widen my perspective by exploring the idea that, as suggested by Paracelsus, everything on earth under the right circumstances will cause adverse reactions. Finally, I am going to present some thoughts and ideas as to why we in the clinical nutrition community have such a difficult time dealing with this reality.
SOME “BIG PICTURE” THOUGHTS ON ABRAHAM’S ATTITUDES ON IODINE RELATED SIDE EFFECTS
As I mentioned, after examining iodine research from the point of view of Abraham and others for over a year now as well as from your point of view via your feedback, it appears that the main clinical controversy that is first and foremost in the minds of most of us is the risk of significant adverse, thyroid-related effects of milligram dosing of supplemental iodine for significant segments of the population. Of course, as suggested by Paracelsus above, anything at a certain dose will cause adverse effects in someone. However, as I have tried to point out so far in this series, Abraham seems to suggest that iodine is exempt from this scenario, being safe for everyone at virtually any dose up to 50 -100 mg per day, an amount that is several thousand percent higher than RDA levels. Other than his personal assurance and limited clinical research, what proof does he offer that his position is correct? Based on my examination of his writings that you have been reading over the past year, it appears to me that research-based proof offered by Abraham can be distilled down to two key assertions. First, the Japanese have been ingesting approximately 12 mg per day of iodine on average (Which means many Japanese have been ingesting amounts that are considerably higher) for generations with no ill-effects whatsoever. As I hope I conveyed to you in the segment of this series in which I explored both Abraham’s references and the research performed by others in relation to this issue, it appears that Abraham’s beliefs about the Japanese experience with dietary iodine is in error.
The second assertion is that the Wolff-Chaikoff effect not only is non-existent but represents a plot by “medical iodophobes” to keep daily intake of iodine for the average American at levels no higher than 150 mcg. In the last issue I explored both the impact of iodine on thyroid function in general and specifically in relationship to the Wolff-Chaikoff effect, looking through the eyes of researchers publishing in peer reviewed journals. In the next issue I will begin to explore the Wolff-Chaikoff effect through Abraham’s eyes as described in his written commentaries on the subject. Specifically, I will explore his position with particular focus on his references. For me, the quality of the references will be particularly important since, as I demonstrated in the last segment, all of the peer reviewed publications I have read on the subject seem to agree that the Wolff-Chaikoff effect, indeed, exists. If it appears that Abraham’s position on the Wolff-Chaikoff effect is in error, then I feel we must conclude that Abraham’s assertion that supplementation of iodine is totally safe for everyone at virtually any dose up to 50 – 100 mg per day is also in error.
SOME “BIG PICTURE” THOUGHTS ON ATTITUDES TOWARD SUPPLEMENTATION OF NATURAL SUBSTANCES
Now, I would like to share with you some “big picture” thoughts on my attitudes about Abraham in general that have come from spending over a year examining his writings on iodine. In addition, I would like to share my thoughts on others who have and continue to passionately promote therapeutic use of natural substances. During the last several months my attitude towards Abraham and his writings on iodine have gone through an evolution that I have never really experienced with any other newsletter series. As you saw, I began with a stance of being highly suspicious and contentious. However, as I hope you also have seen, my position has evolved from one that is primarily suspicious and highly contentious to one that is infinitely more complex, where admiration and distaste exist synonymously. Because of this complexity about which I will elaborate shortly, I would like to frame my thoughts on this complexity with my observations about the ways advocacy and opposition towards supplementation in general has waxed and waned over the years in this country. In doing so, I hope to demonstrate that Abraham is not an isolated radical heretic but part of an ongoing, interwoven movement in clinical nutrition that displays characteristics that deserve our admiration and appreciation and characteristics that warrant a reaction of fear and suspicion.
If you examine the history of nutrient research, you will often find that discovery of nutrients such as vitamin C, B vitamins, etc. shed new light on the reasons for human sickness. In turn, since human sickness at the time of the discovery of these nutrients was so profoundly involved with deficiency of these nutrients, i.e., scurvy, pellagra, etc., supplementation of these nutrients led to tremendous improvements in health. As I am sure we would all agree, use of nutritional supplementation in these instances carries little controversy. However, researchers and authors that followed often would portray these nutrients in ways that were much more controversial. First, they suggested that supplementation of these nutrients could have a positive impact on health beyond correction of deficiency related diseases. While this portrayal is more controversial than the first, I would hope we can all agree that a large body of research documents that this position has merit. However, the second portrayal, in my opinion, does not only deserve the label “controversial” but also deserves the label “suspicious.” Why? Many who have made the claims stated above do not stop there. In contrast, both in the past and now, they have very passionately and very vocally suggested that, because these micronutrients come from “natural” sources and are an integral part of human physiology, they can be granted an exemption from the basic dose/response laws of nature. In turn, because of this belief that natural substances are exempt from dose/response laws, these individuals feel we can rightfully claim that many natural substances have attained the status of a panacea in that most people who ingest these substances will receive some sort of benefit and no one, no matter how unique and unusual his or her biochemical and physiologic profile may be, will suffer any sort of negative reaction no matter high or low the dose. What are these dose/response laws from which natural substances, according to many in the nutritional community, are exempt? As suggested at the beginning of this newsletter, probably the most important was most eloquently described by Paracelsus approximately 500 years ago. Because of the eloquence used by Paracelsus to define this incredibly important concept, I would like to present the quote again, as published in Casarett and Doull’s Toxicology: The Basic Science of Poisons, Fifth Edition (1):
“What is there that is not poison? All things are poison and nothing (is) without poison. Solely the dose determines that a thing is not a poison.”
As suggested by Paraselsus, the laws of dose/response indicate that everything will be harmful at a certain amount, including air and water. To further illustrate this important aspect of substance administration, consider water. I am sure that no one will deny that water is essential to the health of virtually all living beings, including humans. However, cases of water intoxication leading to fatal hyponatremia have been reported (2, 3). Of course, you might counter this argument by rightfully pointing out that the studies I have mentioned involved extremely high amounts of water being used under very unusual circumstances. Therefore, my example does not apply to the “average” patient we see clinically on a daily basis. In turn, my reply to this is to ask another question that might be more relevant to our circumstances as clinicians. In certain populations, could water, at doses typically consumed, create adverse effects? To answer this question, consider two scenarios. What would happen if a patient who, for reasons such as stroke, throat cancer, or other debilitating diseases, lost the ability to swallow? Could ingestion of a glass of water cause aspiration into the lung with potentially serious consequences? Hopefully, we can all agree that the answer is obvious. Next, consider the recommendation to go swimming in a pool on a hot summer day. Certainly I would assume most of us would agree that this would be an excellent recommendation for the average patient. However, is it a wise recommendation for all patients? To answer this question, consider the wisdom of this recommendation when advising quadriplegic patients. Thus, no matter how much we would like to believe those in the nutritional community who passionately and sometimes fanatically want to convince us that a certain nutritional substance has attained a status of a form of panacea in that it can be ingested in virtually any amount by anyone regardless of his or her health status without any risk of adverse sequelae, the fact remains that there is absolutely no evidence that this is true, not only with nutrients but for virtually every substance known to man.
Other than misleading consumers, do those who make panacea-like claims for nutritional supplements create other issues that may not be in the best interest of those who either use or recommend nutritional supplements? Unfortunately, yes. As we all know, in this country one of our favorite pastimes is trying to “take down” people who put themselves on pedestals, particularly when ascent to the pedestal is based on information that is not entirely truthful. Do we see a similar scenario when certain individuals in the nutritional community ascend pedestals by very publicly and very brashly proclaiming the discovery of a new, “natural” substance that cures everybody and harms nobody, no matter what the dose? Absolutely!! Given how easily it is to scientifically prove that any claims of panacea are false, publishing papers that take promoters of nutritional supplements off of their undeserved, self-proclaimed position on the pedestal has become an increasingly favorite pursuit by many of the primary researchers of the world. Interestingly, though, contrary to the belief of many in the nutritional community, I find that, after reading these papers, rarely do they seem to suggest that the researchers have a personal vendetta against what they were researching. In contrast, the text in most of these papers, at least to me, suggests that the researchers are doing their best to find truth. Fortunately, the truth does not take great intelligence or intricate methodology to discover. What is the truth? The substance being investigated, like so many before it, falls far short of the “Holy Grail”-like claims that some are making. Of course, I do readily acknowledge that, even today, some bias against nutritional supplements does still exist among certain researchers and certain peer review committees that decide what papers will be published in high profile scientific journals. Nevertheless, even though methodology may be less than ideal in some of these papers, I do feel that the vast majority of these papers do easily prove what we may not want to hear but need to hear: A nutritional supplement that can function as a panacea has yet to be discovered for the simple reason that, as Paracelsus noted 500 years ago, every substance on earth, at a certain dose, has the potential for creating adverse effects in every life form on earth.
Of course, you might assume that people who read these papers would welcome the idea that some of the most learned researchers in the world have affirmed the inherent logic that, like everything else in our environment, natural substances, at any given dose, have the potential for creating positive effects in some people and negative effects in others. For, by having this valuable information, we will be better able to choose both dosage and recipient carefully so that benefit/risk ratio can be as high as possible. In turn, we can now use this substance in a cautiously confident manner knowing that we have used research intelligently to maximize the possibility of benefit and minimize the possibility of adverse effect. Unfortunately, as the mass media and Internet suggest, a large fraction of the people who feel it is their business to comment and critique on these studies rarely react in such a fashion. In contrast, reactions can often be divided into two primary, occasionally fanatic camps. The first camp, often labeled “supplement haters,” or words to that effect, concludes that, since proof of the obvious now exists that a supplemented substance is not really totally innocuous at any dosage in any person no matter what his or her unique genetic, biochemical, and physiologic profile may be, the public must now be warned that ingestion in any amount by any person is no longer advisable. Ironically, the passion that drives this group all too often blinds them to the fact that, in the vast majority of scenarios, the “anti-panacea” suggestion that these substances harm everyone no matter what the dose is just as ludicrous as the “panacea” suggestion that they harm no one no matter what the dose.
The second group, often labeled as “supplement lovers,” or words to that effect, react very differently to these studies, using words like:
- “FDA conspiracy”
- “Drug company conspiracy”
- “The journals are puppets of the drug companies”
- “Researchers are nothing more than prejudiced idiots ‘on the take’ from the drug companies.”
Again, I want to make it clear that I do believe that some prejudice towards natural substances still exists among researchers and journal editors. However, is this prejudice widespread enough today to warrant these types of sweeping generalizations? I believe no. Why? The biggest reason is that, in the health care industry, as in most industries in this country, “money talks.” How does it talk in the case of supplements? Two ways. First, the supplement industry, while not as large as the drug industry, is now a multi-billion dollar industry that now wields a good amount of clout in many decision-making circles throughout the country. The second and, to me, the most important, is that many of the highest selling nutrients are manufactured by drug companies. For example, Hoffman LaRoche produces a large portion of the world’s supply of ascorbic acid. In turn, this has led to a tremendous increase in funding for nutritional research. While I recognize that this amount of funding cannot match the amount devoted to drug research, I do believe that the amount is now high enough to prevent the major medical journals from prejudicially publishing only negative studies on nutrition and rejecting the positive ones. If you still have doubts that I am correct, I challenge you to search the table of contents for the past year of journals such as New England Journal of Medicine, JAMA, or Lancet. I can assure you that you will find at least one positive study on nutrition.
I find it both unfortunate and, as a proud member of the supplement industry, somewhat embarrassing that so many of my peers seem to reflexively react in a sometimes obviously paranoid manner to every study that reaffirms the simple truth that we do not produce panaceas. To me, the simple fact is that not every negative study on supplements is a product of a dark conspiracy to destroy the supplement industry. Furthermore, if a conspiracy does exist that has a goal to force us to only state the absolute truth about everything we sell, I say bring it on. I have enough confidence in the truth about everything I sell that I, with all my heart, believe I can make a successful living in this industry without having to try to convince all of you that the Holy Grail can be found deep within the bowels of our warehouse.
What is the end product of this seemingly never ending, all too public war of words between these two factions who seem more intent on winning than publicizing the truth that supplemental natural substances will help many and adversely affect others? A frustrated and confused public that gets so tired of hearing and reading contradictory statements of “fact,” that they begin to reject what we offer all together. Given the fact that I have been in this industry over 20 years trying to tell the truth and still can say that I make enough to maintain my business, feed my family, and pay the mortgage, I believe that the truth is a viable and, more than ever, the best marketing tool. Hopefully, at a time in the not too distant future, before the public gives up on us all together, the warring factions I have described will discover this.
MY CURRENT POSITION ON ABRAHAM AND HIS PUBLICATIONS
Initially, as I mentioned, I was hesitant to give any credibility to Abraham. Why? Interestingly, the fact that his attitudes on iodine supplementation differed so significantly from what I had learned about iodine previously had little to do with my initial beliefs about the man. In contrast, my negativity had more to do with three factors. First, I felt then and even more so now that, after having read several of their papers, the anti-iodine researchers whose work gained popularity in the middle decades of the 20th century were not evil, Darth Vader-like “medical iodophobes” as suggested by Abraham. In contrast, they were well intentioned investigators doing the best they could with the knowledge and technology available to them at that time to improve patient health. Second, I found Abraham’s stream of consciousness writing style, which would probably have both peer reviewed journal reviewers and high school English grammarians screaming in frustration, very hard to follow. The third factor, though, was probably most instrumental in making me want to, initially, completely reject Abraham’s credibility. To me, it seemed that Abraham was making the same tragic mistake that so many in our field have made before. He seemed to be driven to once again elevate supplemental iodine to the rarified status of panacea in that virtually everyone, with or without evaluation to determine need, would benefit from doses that are thousands of times higher than the RDA with absolutely no risks of any side effects whatsoever.
Now, as I mentioned, having taken over a year to evaluate Abraham’s writings, his references, plus the work of other iodine researchers, I am finding that my attitude towards Abraham has transformed into one that is infinitely more complex than the one I held initially.
Abraham’s position that use of supplemental iodine in clinical nutrition has been vastly under appreciated – As I hope you have seen in this series, a very large body of research suggests that iodine is not only vital to optimal thyroid function but vital to optimal function of a host of other organ systems such as the female breast. In addition, many papers affirm Abraham’s contention that doses higher than RDA levels can be beneficial for many patients with few side effects. Therefore, I feel very thankful that Abraham has led us to a more full appreciation of the idea that iodine nutriture needs to be evaluated not just when thyroid function is being considered but when virtually all aspects of nutritionally oriented care of ailing patients is being considered.
Abraham’s contention that researchers such as Wolff, who discovered and publicized side effects of iodine supplementation, were evil, “medical iodophobes” who were conspiring to remove supplemental iodine from the armamentarium of health care professionals – Having now read several of the papers written by Wolff and others that Abraham references as proof of the inherent evil and “medical iodophobic” intentions of these researchers, I continue to stand with my original contention that Abraham is another one in the lineage of “supplement lovers” mentioned above who passionately desire to restore certain nutrients to what they feel is a rightful place on the panacea pedestal. However, am I totally absolving Wolff from blame on this issue? Absolutely not!! After reading his key papers on iodine and thyroid function, which I will be reviewing, I feel he is a combination of two types of people I just described. On one hand, I feel Wolff performed an admirable role as a primary researcher by doing his best to remove iodine from the undeserved panacea pedestal upon which iodine was placed by many clinicians in the early part of the 20th century. For, as you will see from a paper published in 1930, 18 years before Wolff’s first publications, many patients at that time, contrary to the nostalgic descriptions by Abraham, were experiencing significant side effects with the iodine doses being administered so freely during the early 20th century.
On the other hand, Wolff appeared to perform a less than admirable role as one of the “supplement haters” described above in suggesting that, since some patients react negatively to milligram dosing of iodine, no one should ingest more than 150 mcg per day. Therefore, in my opinion, Wolff was most assuredly wrong in trying to remove milligram doses of iodine from the repertoire of clinicians in this country simply because some patients experience the transient reduction in thyroid hormone production called the Wolff-Chaikoff effect.
In resorting to name calling in the form of “medical iodophobe,” though, has Abraham taken the best route to negate the damage done by Wolff? As we have learned from Michael Holick and his brilliant and witty writings on recommendations for high dose vitamin D, I think Abraham could have done better. To me, the research supporting the use of milligram doses of iodine in certain patients is, as I hope I have demonstrated, so strong that name calling really was never necessary to get our attention that changes needed to be made.
SOME “BIG PICTURE” THOUGHTS SPECIFIC TO IODINE RELATED SIDE EFFECTS
In concluding these “big picture” thoughts on Abraham and milligram dosing of iodine, I would like to share some “big picture” thoughts on nutrient side effects. As I mentioned, based on dose/response laws plus genetic, biochemical, and physiological uniquenesses shared by everyone, adverse reactions are inevitable at certain doses, no matter what the substance. However, on the whole, one of the saving graces of nutritional supplements is that, most often, the worst possible case scenario in terms of side effects is not all that bad, especially when compared with other options that are often employed in health care. For example, very often the worst possible case scenario with high doses of niacin is flushing, which generally ceases fairly quickly. However, as I have suggested in this series, iodine is a notable exception among nutrients. While, as I have described, the Wolf-Chaikoff effect is transient, often lasting no more than 1-2 days, others prone to either genetically or environmentally induced hypo- or hyperthyroidism, sometimes fare much worse with milligram dosing of iodine, as I have also described in this series. Furthermore, anecdotal reports from you have affirmed that a small but significant group of patients will experience sometimes severe reactions. Interestingly, I have heard some discount the significance of these reactions using some very imaginative rationalizations. For example, I have heard some discount adverse effects by stating that these effects only last a short time. To me, if I put myself in the shoes of the patient, a severe reaction that only lasts a day is still a severe reaction that should be avoided if at all possible. I have heard others discount sometimes severe side effects by rationalizing that they are actually beneficial byproducts of bromide or fluoride detoxification. My response to this is twofold. First, based on feedback from many of you plus my examination of published research papers, I believe the idea that supplemental iodine can be used to eliminate bromide and fluoride from the body has merit. In turn, I will explore this fascinating aspect of clinical iodine utilization in a future installment of this series. However, my second response is to paraphrase a statement attributed to Jeffrey Bland who noted that there is no such thing as a “good” detox reaction where it is beneficial to get sick in order to get well. Bland points out that the true physiology of detox reactions makes it clear that they are inherently detrimental to health and should be avoided if at all possible.
Given the sometimes severe reactions to milligram doses of iodine that are much greater than what is typically seen with high dose micronutrient administration, I feel it behooves us to take extra precautions and only use milligram doses of iodine intelligently as part of an overall customized, functional medicine based supplemental and lifestyle modification program to reduce even remote risks of adverse effects to levels that are as low as possible. For, another “saving grace” of the fact that we employ substances naturally found in the body is that we have the ability to optimize some of the physiologic and biochemical imbalances that make some people more prone to adverse reactions in the first place. Or, to use the water analogy I employed earlier, it is true that a person who cannot swim is more likely to drown. However, while avoiding water all together may certainly be a good solution to this problem, is it the best? I hope that we can all agree that the best solution in this instance is swim lessons. However, getting back to that quadriplegic I discussed, even though he or she also has an identical case presentation of an inability to swim, swim lessons probably will not be the best solution. In contrast, minimal exposure to water is probably the best option.
As I have discussed, a healthy patient, due to the fact that he or she is genetically programmed to easily adapt to the large variations in the levels of iodine found in our environment, will rarely experience iodine induced side effects, even at very high doses. However, we, by and large, deal on a daily basis with sick people who, due to environmental factors such as chemical toxins and inflammation, have lost this ability to adapt. As I have mentioned, this loss of adaptive capacity can be more specifically defined by the fact that in certain patients, a combination of genetic propensity plus certain environmental stressors has adversely affected function of the sodium/iodide symporter (NIS), which is the primary regulator of iodine transport into the thyroid. In this situation, as with the water scenario I just described, is the best solution to avoid iodine or to create better tolerance through optimization of NIS function? Hopefully, we can all agree that the latter is best, unless creating better tolerance, as with the quadriplegic, is not possible. Then, recommendations of milligram dosing of iodine are clearly inappropriate. This type of thinking, which I feel neither Wolff nor Abraham optimally emphasized, represents, to me, the true answer to the iodine quandary. The statements these authors have used that suggest either no one or everyone should ingest milligram doses of iodine only confuse and cause needless suffering either because iodine was never used when its use was appropriate or was used when use was clearly inappropriate.
In contrast, I feel an intelligent way to optimize the chance of benefits from supplemental iodine while minimizing the risk of side effects is the following:
- Admit that the risk of iodine induced side effects is real but will vary in intensity based on each patient’s unique genetic, physiologic, and biochemical profile.
- Evaluate for the level of risk by determining the presence of factors such as chemical toxicity and inflammation that increase risk.
- Optimize patient function in those areas determined to be increasing the risk of iodine induced adverse effects.
- Then, and only then, employ supplemental iodine in amounts that are necessary to optimally compliment the rest of the program being used to restore patient health.
As I will be discussing in a future segment, there are practitioners who are using milligram dosing in this fashion and have reduced the risk of side effects to virtually nil, even in chronically ill patients who you might feel are at relatively high risk.
As I mentioned, in the next installment I will examine Abraham’s very unique stance on the Wolff-Chaikoff effect.
Moss Nutrition Report #221 – 06/01/2008 – PDF Version
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- Garigan TP & Ristedt DE. Death from hyponatremia as a result of acute water intoxication in an Army basic trainee. Mil Med. 1999;164(3):234-8.
- Ophir E et al. Water intoxication – a dangerous condition in labor and delivery rooms. Obstet Gynecol Surv. 2007;62(11):731-8.