Balancing the Risks and Benefits of Vitamin C Supplements

Mainstream medicine has long had a healthy skepticism of dietary supplements, extending to the present day with commentaries like “Enough is enough.” In an essay entitled “Battling quackery,” however, published in the Archives of Internal Medicine, it’s argued that we may have gone too far in our supplement bashing, as evidenced by our “uncritical acceptance” of supposed toxicities; the surprisingly “angry, scornful tone” found in medical texts using words like “careless,” “useless,” “indefensible,” “wasteful,” and “insidious”; and ignoring evidence of possible benefit.

“To illustrate the uncritical acceptance of bad news” about supplements, the authors discussed the “well-known” concept that high-dose vitamin C can cause kidney stones, as I highlight in my video Do Vitamin C Supplements Prevent Colds but Cause Kidney Stones? Just because something is well-known in medicine, however, doesn’t mean it’s necessarily true. In fact, the authors couldn’t find a single, reported case.

We’ve known that vitamin C is turned into oxalates in the body, and, if the level of oxalates in the urine gets too high, stones can form, but, even at 4,000 mg of vitamin C a day, which is like a couple gallons’ worth of orange juice, urinary oxalates may not get very high, as you can see at 1:10 in my video. Of course, there may be the rare individuals who have an increased capacity for this conversion into oxalates, so a theoretical risk of kidney stones with high-dose vitamin C supplements was raised in a letter printed in a medical journal back in 1973.

When the theoretical risk was discussed in the medical literature, however, the researchers made it sound as if it were an established phenomenon: “Excessive intake of vitamin C may also be associated with the formation of oxalate stones.” Sounds less like a theoretical risk and more like an established phenomenon, right? That statement had seven citations supposedly suggesting an association between excessive vitamin-C intake and the formation of oxalate kidney stones. Let’s look at the cited sources, which you can see from 1:47 in my video. One reference is the letter about the theoretical risk, which is legitimate, but another listed citation, titled “Jaundice following the administration of niacin,” has nothing to do with either vitamin C or kidney stones. What’s more, the other five citations are just references to books. That may be acceptable if the books cited primary research themselves, but, instead, there was a kind of circular logic, where the books just cite other books citing that theoretical risk letter again. So, while it looks as if there’s a lot of evidence, they’re all just expressing this opinion with no new data.

By that time, there actually were studies that followed populations of people taking vitamin C supplements and found no increased kidney stone risk among men, then later, the same was shown in women. So, you can understand the frustration of the authors of “Battling quackery” commentary that vitamin-C supplements appeared to be unfairly villainized.

The irony is that we now know that vitamin-C supplements do indeed appear to increase kidney stone risk. The same population of men referenced above was followed further out, and men taking vitamin-C supplements did in fact end up with higher risk. This has since been confirmed in a second study, though also of men. We don’t yet know if women are similarly at risk, though there has now also been a case reported of a child running into problems.

What does doubling of risk mean exactly in this context? Those taking a thousand milligrams or so of vitamin C a day may have a 1-in-300 chance of getting a kidney stone every year, instead of a 1-in-600 chance. One in 300 “is not an insignificant risk,” as kidney stones can be really painful, so researchers concluded that since there are no benefits and some risk, it’s better to stay away.

But there are benefits. Taking vitamin C just when you get a cold doesn’t seem to help, and although regular supplement users don’t seem to get fewer colds, when they do get sick, they don’t get as sick and get better about 10 percent faster. And, those under extreme physical stress may cut their cold risk in half. So, it’s really up to each individual to balance the potential common cold benefit with the potential kidney stone risk.


What about intravenous vitamin C? I’ve got a whole video series on that, including:

If you’re not taking vitamin C supplements for pharmacological effects and just want to know how many vitamin C-rich fruits and vegetables to eat every day, check out my video What Is the Optimal Vitamin C Intake?.

Is there anything we can put into our mouth that really might help prevent colds? These videos will point you in the right direction:

And, if you’re interested in learning about the most important steps you can take to prevent and treat kidney stones, look no further than my videos How to Prevent Kidney Stones with Diet and How to Treat Kidney Stones with Diet.

What about high-oxalate vegetables such as rhubarb, spinach, beet greens and swiss chard? I’d encourage a moderation in intake. If you’re going to take my advice to ideally eat cups of dark green leafy vegetables a day I’d recommend sticking with other greens such as kale or collards.

In health,
Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live presentations:

Is It Healthier to be Happier?

More than 60 years ago, the World Health Organization defined health as a “state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” Just because you’re not depressed doesn’t necessarily mean you’re happy. But, if you look in the medical literature, there are 20 times more studies published on health and depression than there are on health and happiness. In recent years, though, research on positive psychology has emerged, and we’re now asking what we can do to increase our success, functioning, and happiness. Although these are all inherently good in themselves, what about the question I address in my video Are Happier People Actually Healthier?

“There is growing evidence that positive psychological well-being is associated with reduced risk of physical illness,” but it’s not surprising that healthier people are happier than sick people. “The intriguing issue is whether psychological well-being protects against future illness or inhibits the progression of chronic disease.” To figure out which came first, you’d have to get more than just a snapshot in time. You would need prospective studies, meaning studies that go forward over time, to see if people who start out happier do, in fact, live longer. A review of such studies indeed “suggests that positive psychological well-being has a favorable effect on survival in both healthy and diseased populations.”

Not so fast.

Yes, positive states may be associated with less stress, less inflammation, and more resilience to infection. But, positive well-being may also be accompanied by a healthy lifestyle that itself reduces the risk of disease. Happy people tend to smoke less, exercise more, drink less alcohol, and sleep better. So, maybe happiness leads to health only indirectly. The apparent protective effect of positive psychological well-being, however, persists even after controlling for all these healthy behaviors. This means that even at the same level of smoking, drinking, exercising, and sleeping, happier people still seem to live longer.

Ideally, to establish cause-and-effect definitively, we’d do an interventional trial, in which participants would be assigned at random to different mood levels and tracked for health outcomes. It’s rarely feasible or ethical to randomly make some people’s lives miserable to see what happens, but if you pay people enough you can do experiments like the one whose objective stated: “It has been hypothesized that people who typically report experiencing negative emotions are at greater risk for disease and those who typically report positive emotions are at less risk.” Researchers tested this using the common cold virus. Three hundred and thirty-four healthy volunteers were assessed for how happy, pleased, and relaxed they were, or how anxious, hostile, and depressed. Subsequently, they were given nasal drops containing cold rhinoviruses to see who would be more likely to come down with the cold. Who would let someone drip viruses into their nose? Someone paid $800, that’s who!

Now, just because you get exposed to a virus doesn’t mean you automatically get sick. We have an immune system that can fight it off, even if the virus is dripped right into our nose. But, whose immune system fights better?

In one-third of the bummed out folks, their immune systems failed to fight off the virus and they came down with a cold. But only about one in five got a cold in the happy group. Could it be that those with positive emotions slept better, got more exercise, or had lower stress? No. It appears that even after controlling for the healthy practices and levels of stress hormones, happier people still appear to have healthier immune systems and a greater resistance to developing the common cold.

It also works with the flu. When researchers repeated the study with the flu virus, increased positive emotions were associated with decreased verified illness rates, just like in their earlier study on colds. These results indicate that feeling vigorous, calm, and happy may play a more important role in health than previously thought.


Okay, so if happiness improves health, how do we improve happiness? That’s the subject of my video Which Foods Increase Happiness?.

I’m as guilty as the rest of my colleagues for focusing on mental illness rather than mental health (though my Laughter as Medicine video is a rare exception). It’s a consequence of what’s out there in the medical literature, though I’ll make a special effort to highlight new studies in this area as they’re published. I do, however, have a number of videos on preventing and treating negative mood states, such as depression and anxiety:

What about psychiatric medications? See my videos Do Antidepressant Drugs Really Work?, Exercise vs. Drugs for Depression, and Saffron vs. Prozac.

Interested in other ways to improve our immune system? Check out Using the Produce Aisle to Boost Immunity.

In health,
Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live, year-in-review presentations:

What to Eat to Boost Immunity

What we eat—or don’t eat—can affect our immune system. In my video Using the Produce Aisle to Boost Immune Function I profile a study conducted to determine the effect of the consumption of brightly colored vegetables on the immune system. For the first two weeks, the subjects ate basically no fruits and veggies. Then, they drank one and a half cups of tomato juice every day for two weeks, followed by two weeks of carrot juice, and then two weeks of spinach powder. Within just two weeks of a fruit- and veggie-deficient diet, immune function plummeted. However, just one and a half cups of tomato juice a day brought subjects back from the ashes. It didn’t take five servings a day—just one tall glass of tomato juice produced results. The carrot juice alone didn’t seem to help as well, however, nor did the powder equivalent of about one serving of spinach. This tells me two things: how remarkably we can affect our immune function with simple dietary decisions and, not all veggies are alike.

When this study was repeated looking at other immune markers, the tomato versus carrot appeared more evenly matched. There is one family of vegetables, however, that we definitely don’t want to miss out on. Inflammation and leaky gut can occur all because of an absence in our diet of AHR ligands—in other words, cruciferous vegetables, including cabbage, collards, cauliflower, kale, Brussels sprouts, and broccoli.

Do people who eat healthier actually get sick less? Those who eat more fruits and vegetables appear to have a lower risk of getting an upper respiratory tract infection like the common cold, whether they’re otherwise vegetarian or not. Even just one added apple a day may help keep the doctor away. The common cold is usually so innocuous, though, so why not test against something stronger?

Researchers have also looked at more serious respiratory infections like influenza. Studying the relationship between various risk factors and influenza-related hospitalizations in the United States, they found that a 5 percent increase in the prevalence of obesity was associated with a 6 percent increase in hospitalization rate. Physical inactivity had worse outcomes, resulting in a 7 percent increase in hospitalizations. Low fruit and vegetable consumption, however, had the most impact, increasing flu-related hospitalization rates by 8 percent.

The common cold isn’t always innocuous, though. For instance, a cold during the first trimester of pregnancy is associated with a number of birth defects, including anencephaly, one of the worst, which causes a fatal malformation of the brain. More recent data suggest that the cold-related fever is the real culprit, as anti-fever drugs appear able to prevent the possible birth defects caused by the common cold.

It’s best, of course, not to get sick in the first place. One thousand women and their diets were followed before and during pregnancy. It was found that “[w]omen who consume more fruits and vegetables have a moderate reduction in risk of [upper respiratory tract infection] during pregnancy, and this benefit appears to be derived from both fruits and vegetables instead of either alone.” Whole fruits and vegetables provide a natural balance of all sorts of things that may improve our immune function in a “complementary, combined or synergistic manner that could account for the protective effect observed from high consumption of both fruits and vegetables”—or maybe that’s the only way they got enough in their diet. The women who appeared protected in this study were eating nearly nine servings of fruits and vegetables a day, compared with only five servings of fruits or four of veggies. This suggests that the arbitrary five- or six-a-day minimum may be insufficient for effective immune function.

For example, in one famous study, elderly individuals were randomized into groups that ate either five servings of fruit and veggies a day or two servings a day. The five-a-day group showed an 80 percent improved antibody response to their pneumonia vaccination compared to the two-a-day group. Even though only about 30 percent (12 out of 40 people) of the five-a-day group reached their target levels of servings, they still did six times better than the two-a-day group. But maybe eight, nine, or ten servings a day would have worked even better.


Need a reminder about what those protective Ah receptors are? See The Broccoli Receptor: Our First Line of Defense and Counteracting the Effects of Dioxins Through Diet.

What’s the best way to prepare broccoli? Check out these videos:

In late pregnancy, however, women can overdo it. See Caution: Anti-Inflammatory Foods in the Third Trimester.

What else can we do to lower our risk of upper respiratory tract infections? See:

Also be sure to check out my video, Are Happier People Actually Healthier?, which compares people’s resistance to having the common cold virus dripped into their nostrils.

In health,
Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live, year-in-review presentations: