Dietary Supplements

Dietary Supplements

•  Majority  of  adults  in  US  take  1+  dietary  supplement  either  every  day  or  occasionally  

•  May  include  vitamins,  minerals,  herbals,  botanicals,  amino  acids,  enzymes,  others  

•  Can  be  in  tablet,  capsule,  powder,  drink,  energy  bar  forms  

Na#onal  Ins#tutes  of  Health,  Office  of  Dietary  Supplements,  Dietary  Supplements:  What  You  Need  to  Know,  2011  

Supplement Sales

 Dietary  supplement  sales  in  the  US  are  $22.5  billion  per  year  (2006)  

Source:  Natural  Products  Founda#on’s  Dietary  Supplement  Informa#on  Bureau,  2009.  Image:  Jose  Paolo  S.  Borromeo  

 

European Union

•  EU  Food  Supplement’s  DirecMve  of  2002  •  Establishes  purity  criteria  •  Must  be  proven  safe  before  sale  •  Must  be  labeled  “this  is  not  a  medicinal  

product”  if  similar  to  medicinal  product  

United States

•  Dietary  Supplement  Health  and  EducaMon  Act  of  1994  (DSHEA)  

•  Includes  vitamins,  minerals,  herbs,  botanicals  (except  tobacco),  amino  acid  or  combinaMon  of  any  of  these  used  to  supplement  the  diet  

•  Regulated  as  a  category  of  foods,  not  drugs  •  Don’t  have  to  prove  efficacy  or  safety  before  sale  –  

FDA  regulates  aYerwards  if  safety  issues  arise  •  Enforcement  is  spoZy,  industry  largely  unregulated  

Dietary Supplement Facts Panel

Quality

•  Quality  standards  exist  –  although  may  be  quesMonably  reinforced  

•  IdenMty,  purity,  strength,  composiMon  •  Independent,  extra-­‐governmental  

organizaMons  may  add  addiMonal  quality  tesMng:  U.S.  Pharmacopeia,  ConsumerLab,  NSF  InternaMonal  

Concerns

•  May  contain  trace  amounts  of  lead  and  other  contaminants  

•  May  displace  income  that  could  otherwise  be  used  for  Rx  drugs  and  healthy  foods  

•  Users  do  not  always  disclose  to  pracMMoners;  pracMMoners  do  not  always  ask  about  supps  

•  Herbals  can  contain  dozens  of  compounds  and  acMve  ingredients  may  not  be  known  

Supplement Savvy

•  “Natural”  means  nothing  •  “High-­‐potency”,  “pharmacy-­‐grade”,  

“prescripMon-­‐strength”  •  Self-­‐diagnosing  is  harmful  •  More  expensive  supplements  ≠  beZer  quality  •  Some  may  interact  with  prescripMon  and  

over-­‐the-­‐counter  medicaMons  

Contraindications

•  Vitamin  K  can  reduce  ability  of  blood  thinner  Coumadin  to  prevent  blood  from  clofng  

•  St.  John’s  wort  can  expedite  breakdown  of  many  drugs  –  including  oral  contracepMves  and  anMdepressants  –  and  reduce  effecMveness  

•  AnMoxidants  such  as  vitamins  C  and  E  may  reduce  effecMveness  of  certain  chemo  therapies  

Na#onal  Ins#tutes  of  Health,  Office  of  Dietary  Supplements,  Dietary  Supplements:  What  You  Need  to  Know,  2011  

IOM Tolerable Upper Intake Levels Nutrient UL Nutrient UL

Vitamin A 3,000 mcg Iron 45 mg

Vitamin C 2,000 mg Magnesium 350 mg

Vitamin D 100 mcg Manganese 11 mg

Vitamin B6 100 mg Molybdenum 2,000 mcg

Vitamin E 1,000 mg Niacin (Vitamin B3) 35 mg

Calcium 2,000 mg Phosphorus 4,000 mg

Choline 3,500 mg Selenium 400 mg

Copper 10,000 mcg Zinc 40 mg

Folate (Vitamin B9) 1,000 mcg No UL for: thiamin, riboflavin, pantothenic acid, biotin, vitamin B12, vitamin K, chromium or carotenoids

Claim: “Promotes joint health” •  “Joint  health”  =  $800  mil/annual  sales  •  Glucosamine  &  chondroiton  –  mostly  negaMve  results  •  2006,  Glucosamine/ChondroiMn  ArthriMs  IntervenMon  Trial  

(GAIT)  found  no  clear  benefit  for  most  paMents  •  2009,  RTC  found  glucosamine  +  chondroiMn  no  more  

effecMve  than  placebo  to  slow  carMlage  damage  from  OA  •  2010,  Norwegian  researchers  tested  glucosamine  for  

chronic  LBP  &  degeneraMve  lumbar  OA,  no  significant  difference  between  glucosamine  &  placebo  

NEJM  2006  Feb  23;354(8):795-­‐808;  JAMA  2010  Jul  7;304(1):45-­‐52  

Claim: “Improves memory, focus” Ginkgo  EvaluaMon  of  Memory  (GEM)    •  Randomized,  double-­‐blind,  placebo-­‐controlled  trial  of  

3,069  people  age  72-­‐96  at  6  academic  medical  centers  •  Twice-­‐daily  doses  of  120  mg  ginkgo  extract  did  no  beZer  

than  placebo  to  slow  cogniMve  decline  over  6  years  •  Earlier  GEM  findings:  debunked  benefit  against  

Alzheimer’s  &  demenMa  •  DeKosky,  UVA  author,  “I’ve  got  no  good  reason  to  suggest  

you  conMnue  to  take  it  beyond  your  own  blind  faith”  

JAMA  2009  Dec  23;302(24):2663-­‐70;  JAMA  2008  Nov  19;300(19)2253-­‐62.  

Claim: “Prevents aging” •  Resveratrol:  anMoxidant  found  in  red  wine  •  Appears  to  inhibit  enzymes  that  regulate  cell  energy  •  2006,  Improves  health  &  longevity  of  overweight,  aged  mice    •  2008,  May  slow  age-­‐related  deterioraMon  and  funcMonal  decline  of  

mice  on  a  standard  diet  –  doesn’t  increase  longevity  when  started  at  middle  age  

•  Clinical  studies  of  resveratrol  in  humans  use  1  g/day  =  667  boZles  of  red  wine  

•  Long-­‐term  effects  &  safety  are  unknown  •  Great  example  of  exploiMng  preliminary  animal  study  data  for  

profit  before  science  unquesMonably  can  prove  benefits  

Cell  Metab  2008  Aug;8(2):157-­‐68;    

Who May Need a Supplement? Group   Why?  

Dieters   <1600  kcal  per  day  may  benefit  from  vitamin/mineral  supplement  

Vegans,  no  dairy   Vitamin  B12,  calcium  and  vitamin  D  

Infants,  children   Fluoride,  vitamin  D,  iron  

Pregnant  women   400  mcg  folic  acid  from  forMfied  foods  or  supplements;  prenatal  vitamins  

Older  adults   Vitamin  B12  (gastriMs,  decreased  IF  producMon),  calcium  and  vitamin  D  

Darker  skin   Vitamin  D  

CigareZe  smokers   Vitamin  C  –  helps  prevent  cigareZe  smoke-­‐induced  oxidaMve  damage  

Alcohol  abusers   B  vitamins  –  alcohol  inhibits  B  vitamin  absorpMon  and  metabolism  

MedicaMon   Many  medicaMons  may  interfere  with  normal  vitamin/mineral  metabolism  

In Summary •  Just  because  you  don’t  need  a  prescripMon  doesn’t  mean  a  

supplement  is  harmless  •  Don’t  waste  Mme  and  money  on  supplements  if  you  don’t  

need  to  •  Changing  diet  and  exercise  paZerns  IS  harder  than  

popping  a  supplement  pill  •  Most  individuals  can  obtain  all  nutrients  from  foods  alone  •  When  supplements  are  indicated,  they  should  be  taken  

with  cauMon  and  under  the  supervision  of  a  qualified  medical  professional    

For More Information •  Office  of  Dietary  Supplements,  Dietary  Supplement  Fact  Sheets:  

hZp://ods.od.nih.gov/factsheets/list-­‐all/    •  UC  Berkeley,  Berkeley  Wellness  LeZer  Dietary  Supplements  

Guide:  hZp://www.wellnessleZer.com/ucberkeley/best-­‐of-­‐wellness/dietary-­‐supplements-­‐guide/    

•  MedlinePlus,  Herbal  Medicine:  hZp://www.nlm.nih.gov/medlineplus/herbalmedicine.html    

•  NCCAM,  Using  Dietary  Supplements  Wisely:  hZp://www.nccam.nih.gov/health/supplements/wiseuse.htm