The high cost of staying well

Vitamins don't come cheap, and the cost of an upmarket supplement can be as much as six times that of the cheaper brands. But what, exactly, are you getting for your money? Catherine Nixey investigates

It used to be so simple: limes stopped your teeth falling out; cod liver oil stopped your legs going bendy and an apple a day kept the doctor away. Then along came Linus Pauling and all health broke loose.

It used to be so simple: limes stopped your teeth falling out; cod liver oil stopped your legs going bendy and an apple a day kept the doctor away. Then along came Linus Pauling and all health broke loose.

In the 1960s, Pauling became convinced that high doses of vitamin C acted as a prophylactic and even a cure for colds and cancer. Chemists started selling the vitamin as Linus Powder and a revolution began. An alphabet of supplements subsequently appeared in shops: A, B, C and D. Then more arrived: alpha carotene, beta carotene, omega 3, along with large swathes of the periodic table such as iron, zinc, calcium.

There are myriad variations in combination, concentration and format - liquids, pills and now even sprays are all common. And, in addition to the obvious differences, there are seemingly random differences in price: a supplement containing the same dosage of vitamin C can vary as much as six times in price depending on which brand you buy; the higher priced one insidiously suggesting inferiority of the cheaper. How can the unwary shopper tell which is better?

"You can't," says Dr Fred Kavalier, doctor and health writer. "I don't think we have any way of knowing how effective a vitamin is by looking at the bottle or the price. It is quite possible that more expensive vitamins are produced to a lower standard than the cheaper ones, and that very cheap vitamins are produced to a very high standard. But there is absolutely no way of telling by looking at the bottle or the price."

Is it possible that you are getting a better quality of vitamin or iron? Patrick Holford, founder of the Institute for Optimum Nutrition, thinks not. "Vitamin C is vitamin C. You might pay a different amount for a different concentration, but otherwise the price should be the same." And aside from a little atomic tinkering it is hard to see how you might be getting a different kind of iron.

Perhaps one of the most confusing purchases for consumers is multivitamin and minerals. With so many ingredients listed, how do you know which one to choose? And will an expensive brand be more likely to give you the nutrients you need?

Not necessarilly, believes Patrick Holford. What you should look for is the presence of particular vitamins and minerals. A good multivitamin will contain the B vitamins and folic acid, which together may help protect against a range of diseases including cancer and strokes. The most important minerals, believes Holford, are iron, magnesium, zinc, selenium and chromium. "The last two are often omitted from multivitamin packs," he says, even though modern diets are known to be deficient in immune-boosting selenium.

"The other thing to look at is the dosage. The RDA figures often differ widely from optimum amounts," he argues. "In general, the optimum level of B vitamins is five to ten times more than the RDA." But though doses will vary between brands, price is not a reliable indicator of quality.

Colette Phillips, a spokesperson for Boots, says that price variations shouldn't be arbitrary. "If you are paying more for a supplement it should be because you are getting something for your money. Prices of supplements do vary, but it is usually because a vitamin is combined with something else - another vitamin perhaps or a mineral, or because it is in a more innovative format, like a spray, that is more expensive to produce."

But it was certainly not always the case that price reflected product. In 2001 it was discovered that several vitamin manufacturers had been supplementing their financial health with a Europe-wide price-fixing cartel. When the European Commission uncovered the cartel they fined the industry a record £543m, with Hoffmann-La Roche, manufactures of Sanatogen, paying the largest share: £289m. The Consumers Association felt that this would have had an indirect effect on the price of vitamins in Britain. After the cartel was terminated manufacturers saw their earnings from the sale of vitamin C drop by half, from £150m to a considerably more sickly £75m.

Is it possible that the more expensive vitamins might be more expensive because they have some other quality - perhaps they are more easily taken up by your body? Rory Collins, Professor of Medicine and Epidemiology at Oxford University, thinks not. "The body readily absorbs vitamins into the blood from food and from pills." But vitamins in excess of the body's needs are not kept. "These vitamin supplements are chiefly excreted in the urine. It has been said that Americans have the richest urine in the world, because they consume a lot of expensive vitamins and then just pee them out."

And it seems unlikely there is much placebo effect in the belief that a more expensive version does more good: "In principle you might get a placebo effect but it seems an expensive way of going about doing it," says Professor Collins. "There is no good evidence that any vitamin supplements are effective. So if you are going to waste your money on these unproven vitamins, you may as well waste less money on the cheaper ones."

Professor Collins is a world expert on vitamins. "We ran one of the largest studies of vitamins for the prevention of heart disease and cancer called The Heart Protection Study. We studied 20,000 people in Britain over a six or seven year period. We failed to show any effect whatsoever of vitamin E, C or beta carotene on cancer, vascular disease or indeed any other disease.The vitamins and minerals that people get in their diet in most western populations appear to be adequate. There is no evidence that adding to this produces any worthwhile benefit."

And interestingly a 1994 study showed supplement taking was in fact highest among respondents who were "educated, had a normal body mass index, engaged in exercise, were non-smokers, and ate a diet lower in fat and higher in fruits and vegetables" - in other words people who were extremely unlikely to be vitamin deficient.

But the idea that vitamins benefit your health is refelected in their huge sales. Surely it cannot be entirely mistaken?

"There is certainly no doubt that if you are deficient in particular vitamins then you do get terrible diseases," says Dr Kay-Tee Khaw, of Cambridge University. "Certain supplements are very beneficial to certain people - vitamin D for those who live in sunless climes like ours, or folic acid for women who are intending to get pregnant. And of course vitamin supplements are essential for those who are seriously deficient in a certain vitamin, such as iron supplements for anaemia sufferers.

"But there is no good evidence that taking vitamin C supplements has any benefit. Blood levels of vitamin C are a very good marker of dietary habits. Humans cannot make vitamin C for ourselves; we can only get it from fruit and vegetables. And so although high levels of vitamin C correlate with good health and low levels of cancer and cardiovascular disease there is no good evidence it is the vitamin C that is causing the good health. There is a lot more in fruit and vegetables than vitamins."

In 2001 Dr Khaw published a study which found that a 50g daily increase in foods that were rich in vitamin C cut the death rate from cardiovascular disease and other diseases by 20 per cent. Food high in vitamins is nothing more complicated than a banana or an orange.

WHO TAKES WHAT AND WHY?

Annalisa Barbieri Health and lifestyle writer

I take a multivitamin recommended for breastfeeding mothers, then other vitamins depending on what's going on. I'm currently taking zinc to boost my immune system, which is taking a battering as I am a new mum.

Patrick Holford Founder of the Institute for Optimum Nutrition

I take vitamin pills every day. I take a daily multivitamin, 2g vitamin C supplement, an essential fat supplement and an antioxidant complex. They are definitely worth taking.

Dr Edouard Josse GP

I don't take multivitamins because eating a balanced diet is sufficient. But I take folates to reduce the risk of cardiovascular diseases. I take vitamin C when I have a cold, although this is unsubstantiated by medical evidence.

Professor Rory Collins Department of Medicine and ...pidemiology, Oxford University

Yes, I do take vitamins every day - I take them in my diet. But I don't take supplements, no. If you eat a reasonable diet they are just a waste of money.

How much you are paying for your healthy living

VITAMIN C

Tesco Own Brand chewable 60 tablets 500mg £1.99 (3.3p a tablet)

Boots Own Brand chewable 60 tablets 500mg £3.10 (5.1p a tablet)

Redoxon Slow Release 40 tablets 500mg £7.49 (18.7p a tablet)

MULTIVITAMINS

Asda own brand 44p for 30 tablets (1.5p per tablet)

Boots Complete multivitamin and mineral formulation 90 tablets £4.49 (5p per tablet)

Centrum Complete multivitamin and mineral formula 100 tablets £12.29 (12.3p per tablet)