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Supplements

So, you’re thinking about taking a supplement. Maybe your doctor advised you to take something specific; maybe you read an article about the benefits of a vitamin; maybe a friend told you about a positive experience. Or maybe you’re just wondering what’s out there and whether you could take something that would benefit your health. There are tens of thousands of supplements on the American market. Even if you know you’re looking for something specific, there are often multiple brands and formulations to choose from. Where to begin? The first thing I’d advise anyone to do when deciding whether to take a supplement at all, or which one in which dose, is to ask a doctor or your medical care team. Some supplements can interact badly with medications, or have serious side effects for some people. Even if a supplement label says “natural,” that does not necessarily mean “safe.”

Market research company NPD conducted a study that found that the people who were tracked only came close to meeting the government’s MyPlate daily nutritional recommendations on 2% of days. Clearly, as a country, we are falling short of best nutritional practices for good health. Eating a balanced diet is understood to be the best way to achieve good nutritional health. Supplements can only do what their name says: add to something else. The supplement itself can’t do the heavy lifting in your life or take the place of smart food and lifestyle choices, medical care, or appropriate medications. If, however, you know that you have a deficiency in a certain area, or fall into a population that is known to need more of a given nutrient than a balanced diet can provide, supplementation might be just what you need to make up that difference. The Academy of Nutrition and Dietetics (A.N.D.) recognizes certain groups of people as being likely to need dietary supplements: people who are pregnant or nursing, strict vegetarians, people with food allergies or intolerances, senior citizens, and those with diseases such as cancer, or kidney, cardiovascular, or bone disease.
The Food and Drug Administration (FDA) defines a dietary supplement as “a product taken by mouth that contains a ‘dietary ingredient’ intended to supplement the diet. The ‘dietary ingredients’ in these products may include: vitamins, minerals, herbs or other botanicals, amino acids, and substances such as enzymes, organ tissues, glandulars, and metabolites.” (http://www.fda.gov/Food/DietarySupplements/QADietarySupplements/ucm191930.htm) For all supplements, it’s important to note that the FDA does not have a hand in assessing the validity of any claims the manufacturer makes. There may be a disconnect between the reality and the public’s beliefs and desires regarding the FDA’s role in the supplement industry: “According to a 2002 Harris Poll, over half of adults who responded to the poll believe that dietary supplements are regulated by the government,” and, “when consumers were asked about government involvement in supplement regulation, 81% believed that the FDA should regulate and test for the safety of dietary supplements before they enter the market” (http://archive.law.fsu.edu/journals/transnational/vol20/mason.pdf). This, however, is not how the process actually works. I’ll elaborate on that when I talk about supplement regulation later in this article.

Supplements, by definition in the American market, cannot claim to diagnose, cure, mitigate, treat, or prevent a disease. And since supplements are not required by law to be tested for safety or effectiveness, it is important for the conscientious consumer to do research on the products they’re considering. You can also look for a seal of approval on the label on a product. Several independent organizations offer a seal of approval. The NIH cautions that these do not indicate that the product is safe or effective; they do indicate that the product contains the ingredients it claims to include, that it was safely manufactured, and that it does not contain harmful levels of contaminants.

The website Information Is Beautiful has an interactive visualization of how much scientific evidence exists backing up popular supplements. I highly recommend checking this out, at http://www.informationisbeautiful.net/play/snake-oil-supplements/. Note that each bubble represents that supplement for treating a particular condition—not all conditions it might be used for. For that reason, some supplements are shown in multiple bubbles on the chart. You can click through from any given bubble to a website with information on the study it represents. This is worth doing: I found at least one linked study containing an update that the study has been withdrawn until further research is conducted.

Caveat Emptor
In a February 2015 study in which supplements from several major chain retailers were tested, the majority were found either to not contain the active ingredient they claimed to have, or to have contaminants.

At Willy Street Co-op, General Merchandise Category Manager Angela Pohlman gave me an overview of the procedures used to determine what supplements go on our shelves. She says, “The vast majority of the new supplements that come in are through reps and brokers that we have good relationships with and trust, [and] they tend to only bring us products they know we would be comfortable with. We look for certifications such as USDA Organic, Non GMO Project-verified, Fair Trade (where possible, pretty rare for supplements), and Good Manufacturing Practices (GMP). We give preference to things made in the USA, Canada, and Europe (Canada and Europe in particular are highly regarded in their supplement standards), transparency (companies that give information willingly and proudly about their processes/sources) and to independent businesses.” When you’re shopping at the Co-op, feel free to ask a staff member if you have any questions about brands. If you’re interested in doing your own research, the FDA recommends asking the following questions to a manufacturer to help you assess quality:

  1. What information does the firm have to substantiate the claims made for the product? Be aware that sometimes firms supply so-called “proof” of their claims by citing undocumented reports from satisfied consumers, or graphs and charts that could be mistaken for well conducted scientific research.
  2. Does the firm have information to share about tests it has conducted on the safety or efficacy of the ingredients in the product?
  3. Does the firm follow good manufacturing practices and have a quality control system in place to determine if the product actually contains what is stated on the label and is free of contaminants?
  4. Has the firm received any adverse events reports from consumers using their products? (http://www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/LabelingNutrition/ucm064928.htm)

If you want to do research on supplements, browse the library or bookstore—but make sure, particularly at the library, that you’re getting the most recent edition of any book! Research on supplements can change and evolve quickly. Angela recommends Prescription for Nutritional Healing by Phyllis A. Balch, CNC, which, as of the time of writing, is on its fifth edition, published in 2010. Even more recently, The Supplement Handbook by Mark Moyad, MD, MPH, with Janet Lee, was published in 2014.

In the latter book, the author advises that consumers be wary of the use of dietary studies to justify the use of supplements. “A dietary study looks at the nutrients in certain foods, while a dietary supplement study looks at taking a specific supplement. You can’t apply the conclusions about nutrients in the diet, say omega-3s or vitamin D, to the individual supplements. It’s like comparing apples and tennis balls…[for example,] eating foods with selenium might reduce the risk of cancer, but taking selenium to prevent cancer has shown no benefit...Always look at how the supplement itself has performed in clinical trials.” (p. 7)

History of Dietary Supplements
Scurvy is likely the best-known example of the consequence of a vitamin deficiency. Long before anyone knew what a vitamin was,sailors who had poor access to a balanced diet would suffer from bleeding gums, wounds that didn’t heal, fatigue, and eventual death from bleeding. We now know that scurvy is the result of a vitamin C deficiency. Over the course of history, the cure for scurvy—ingestion of certain citrus fruits, particularly lemons —was discovered and forgotten repeatedly, until vitamin C was properly identified in the 20th century.

Vitamins are defined as essential organic compounds that cannot be synthesized solely by the body: they must be obtained from some other source, typically food. Vitamin D, however, can be synthesized in the skin when exposed to sunlight; and vitamin K can be synthesized by intestinal microflora (http://www.ift.org/knowledge-center/read-ift-publications/science-reports/scientific-status-summaries/dietary-supplements.aspx).

The term “vitamine” (yes, it originally had an “e!”) was coined in 1912 by Casimir Funk. In 1929, the Nobel prize was awarded to two people: Christiaan Eijkman, who showed that adding bran “polishings” back into white rice eliminated the disease known as beriberi, caused by a vitamin B1 deficiency; and Gowland Hopkins, who isolated the amino acid known as tryptophan and demonstrated its importance in nutrition. (www.nobelprize.org/nobel_prizes/themes/medicine/carpenter/). Starting in the mid-1930s, consumers could buy vitamin supplements.

What’s a mineral?
Vitamins and minerals are often mentioned in the same breath, but they are not the same. Minerals, more accurately known as “dietary elements,” are chemical elements required by living organisms aside from the elements that naturally occur in common organic molecules (en.wikipedia.org/wiki/Dietary_element). Humans need at least twenty dietary elements, ranging from sodium to potassium to copper to chlorine.

Whole Food Supplements
Rather than synthesizing or isolating the compounds as in conventional supplements, whole food supplements use actual food ingredients in the attempt to move closer to the known benefits of consuming a whole food. The idea is that ingesting the complex compounds surrounding the vitamin rather than just the vitamin on its own might help the active ingredient be better recognized and absorbed by the body, similarly to when you consume fresh food.

Herbal/Botanical Supplements
Herbal medicine is simply the practice of using plants, or their parts, as dietary supplements. These include plants as diverse as echinacea, St. John’s Wort, turmeric, garlic, and ginger. Rather than seeking to fill a vitamin or mineral deficiency, these supplements aim to support health with regard to specific conditions, though it’s still important to remember that they are not FDA-approved to diagnose, cure, mitigate, treat, or prevent any disease. The Information is Beautiful chart mentioned above includes studies on many herbal remedies if you’re interested in learning more about the research being done on these sorts of supplements.

For an interactive timeline of botanical medicine throughout history, check out http://www.takingcharge.csh.umn.edu/activities/interactive-history-botanicals.

DSHEA
The supplements industry in the US has more than quintupled sales since 1994 (http://archive.law.fsu.edu/journals/transnational/vol20/mason.pdf). This was the year the climate for supplements changed dramatically. Whether the change was for better or for worse depends on who you ask. The Dietary Supplement Health and Education Act, better known as DSHEA, passed in 1994, created a new framework for the regulation of supplements. DSHEA is the reason supplements do not need FDA approval before they go on the market; the exception is when there is a “new dietary ingredient,” which requires review for safety. Under DSHEA, manufacturers themselves are responsible for determining that their products are safe and that the claims they make are substantiated by evidence. (http://www.fda.gov/Food/DietarySupplements/QADietarySupplements/ucm191930.htm) Essentially, this ensures that there are no requirements for pre-market testing of supplements for safety or effectiveness. (http://archive.law.fsu.edu/journals/transnational/vol20/mason.pdf) This act is generally considered to be very industry-friendly, meaning that consumers have many options, but also that the atmosphere is very much one of “buyer beware.”

The Dietary Supplement and Nonprescription Drug Consumer Protection Act was enacted in 2006. This requires manufacturers of dietary supplements and non-prescription drugs to report serious adverse events caused by their products to the FDA. It also requires manufacturers to include a phone number or address on their product labels so consumers are able to contact them.

Global Policy and Regulations
What Americans call dietary supplements are known by different names in the eyes of the law in other countries: in the EU, they’re referred to as “nutraceuticals” and “functional foods;” in Canada, “natural health products;” in Japan, “foods for specified health use” (FOSHU); in Australia, they fall under the umbrella of “complementary medicines;” in Russia, “biologically active dietary supplements” (BADS). The ways in which they’re regulated also varies from country to country. In Australia, they’re regulated the same as medications. In Japan, the Ministry of Health and Welfare must approve each supplement after receiving scientific evidence supporting the claims the manufacturer is making. In the EU, there is a comprehensive list of approved vitamins and minerals that can be added to supplements. If a substance is not already on the permitted list, it must be approved by the European Commission first. In short: if you live outside the US or if you’re going to be traveling, consider looking into the supplement regulations in the area before making an assessment about whether to buy a product.

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