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August 19, 2019

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A beginner’s guide to dietary supplements


Are you consuming enough of what does a body good?

Recent surveys and studies suggest the majority of Americans are missing the mark for at least one essential vitamin or mineral. That lack seldom leads to a full-blown deficiency, but it plays a role in the bigger picture of an individual’s health.

“Three-fourths of all Americans are taking some sort of supplement, the most common being a multivitamin,” said Duffy MacKay, a licensed naturopathic doctor and senior vice president of scientific and regulatory affairs with the Council for Responsible Nutrition, a leading trade association of the booming supplement industry in the U.S. “People don’t exactly know what they are short on.”

According to the latest “Dietary Guidelines for Americans”, vitamin D, calcium, potassium and fiber top the list. Since the 1940s, supplements have been sold as an answer to nutrition gaps, and consumers are buying the probiotics, fish oils and proprietary blends promising to make us whole.

Those promises need attention.

Council for Responsible Nutrition 2016 Survey on Dietary Supplements

• 71% of American adults — more than 170 million people — take supplements. Women were a greater share than men, with 77% represented vs. 65%.

• 75% of American adults take a multivitamin, followed in popularity by vitamin D (37%), vitamin C (34%) and Calcium (29%).

• The majority of supplement users are motivated by overall health and wellness benefits, followed by the desire for more energy and to fill nutrient gaps.

The U.S. Food and Drug Administration is tasked with ensuring the safety of what we consume, especially when it comes to controlled substances. But in 1994, supplements were federally classified as “food”, meaning oversight and enforcement would be much less stringent. It wasn’t until December 2015 that the FDA created a standalone Office of Dietary Supplement Programs, augmenting the research-based Office of Dietary Supplements within the National Institutes of Health, and elevating the mission to protect public health by rooting out products that pose some risk.

However, a Los Angeles Times column by consumer-affairs watchdog David Lazarus suggested that the already small budget of the new FDA office — reportedly less than $5 million to police a $37 billion industry — was threatened under President Donald Trump. If the funding cuts Trump proposed for the Department of Health and Human Services manifest, Lazarus wrote, “it’s almost a sure thing that people increasingly will be at greater risk when it comes to the safety and effectiveness of over-the-counter supplements.”

Damon McCune, director of UNLV’s Didactic Program for Nutrition and Dietetics, says there are probably tens of thousands of products on the market. “That number is fluid,” he said, “and I imagine changes every day.”

That’s because it’s relatively easy to bring supplements to commercial shelves, and consumers tend to be quick to trust the packaging. Until a stronger system is established for evaluating and enforcing supplement efficacy and safety, the public must arm itself with information.


    • A variety of unique fruits and vegetables can be found beautifully displayed at the International Marketplace located at 5000 S. Decatur in Las Vegas on January 28, 2013.

      A variety of unique fruits and vegetables can be found beautifully displayed at the International Marketplace located at 5000 S. Decatur in Las Vegas on January 28, 2013.


      Dietary guidelines have changed over the years, from the Food Guide Pyramid to MyPlate.

      • The Center for Health and the Global Environment at Harvard says nutrient retention is maximized when food is minimally processed and doesn’t have to travel very far.

      • Food with color, especially bold color, contains more healthy phytochemicals, Prevention magazine reported. Also: bigger isn’t better when it comes to nutrient density.

      • A 2013 study published in the journal PLOS ONE showed cooking vegetables upped nutrient density, and beans won for nutrition per penny.

      “The U.S. Department of Agriculture has done a lot of good research,” said Crystal Petrello, a registered dietitian and past-president of the Nevada Academy of Nutrition and Dietetics. She says that while people might get recommended amounts of protein, the produce portion of a balanced diet is where they falter. “People should be getting between nine and 11 servings of fruits and vegetables a day. The average person gets one or two servings,” Petrello said. “And they consider spaghetti sauce or ketchup as part of that.”

      Clinical research and common sense support the idea that a diet packed with fresh, nutrient-rich foods helps stave off debilitating conditions such as heart disease and diabetes. “Investing” in fruits and veggies gives the most bang for your buck, Petrello said, adding that people should limit added sugar. Because the better the diet, the less need to supplement it.

      Since 2011, the federal government has provided a personalized tool called MyPlate, which uses a person’s age, sex, height, weight and activity level to calculate a diet plan. Using its Daily Checklist, you can enter your details and download the corresponding guide to food-group and calorie targets within these categories: protein, grain, fruits, vegetables, dairy.

      With the help of two nutrition experts, Harvard Medical School compiled a list of foods dense in vitamins and minerals relative to the number of calories per serving: avocados, baked potatoes, bell peppers, Brussels sprouts, eggs, fish (cod, halibut, salmon, scallops, shrimp, tuna), fruit (cantaloupe, papaya, raspberries, strawberries), grains (barley, brown rice, oats, quinoa), greens (chard, collard greens, kale, mustard greens, spinach), lean meat (beef, lamb, venison), legumes (garbanzo, kidney, navy and pinto beans, lentils, peas), low-fat yogurt, mushrooms (cremini, shiitake), nuts (almonds, cashews, peanuts), poultry (chicken, turkey), seeds (flax, pumpkin, sesame, sunflower), sweet potatoes.


      According to the Dietary Supplement Health and Education Act of 1994, in order to be identified as a dietary supplement, a product must:

      1. Enhance the human diet

      2. Contain one or more dietary ingredients

      3. Be taken orally in whatever form

      The Consumer Healthcare Products Association defines a “dietary ingredient” as any of the following: vitamins, minerals, herbs and other botanicals, amino acids, enzymes and potentially beneficial bacteria or yeasts. But supplements aren’t just about promoting health by filling in nutritional gaps or fortifying stores of particular vitamins and minerals. Some products advertise better mental, athletic or sexual performance. They might be natural, single-source extracts from plants or animal tissues, or targeted blends with chemically altered natural materials and others that are entirely synthetic.

      How are supplements regulated?

      “It’s a misconception that the industry isn’t regulated,” said Damon McCune, head of UNLV’s Didactic Program for Nutrition and Dietetics. “It is regulated, just very poorly.” Dietary supplements are jointly regulated by the Food and Drug Administration and the Federal Trade Commission.

      • FDA: Supplements don’t need FDA approval before going to market, though companies must notify the agency of their product information and intent to sell. The onus is on the FDA to investigate products and manufacturing facilities and prove something isn’t safe in order to restrict use or remove items from shelves. “(Supplements) go through a more rigorous process than food inspection and a less rigorous one than drugs,” said the Council for Responsible Nutrition’s Duffy MacKay. Unlike prescription medications, supplements may only make claims about health broadly (though some companies break that rule), or about nutrient content or specific functions.

      In its own effort to engage companies in bringing supplements to a level of consistent quality, the Council for Responsible Nutrition built a self-regulatory registry called the Supplement Online Wellness Library to “help create a rich and more complete picture of the marketplace for regulators, retailers and industry.”

      • FTC: The FTC tracks responsibility in advertising claims. If it comes down on a supplement brand for having misleading practices, MacKay said, it sends a message throughout the industry that encourages other companies to get in compliance. But with limited resources and so many supplements to watch, matters get complicated. Among factors making regulation more difficult is abundant misinformation on the internet, MacKay says. “Just remember there are no magic bullets or quick fixes ...”

      Proven supplements work well for ...

      Can I take too much of a vitamin or mineral?

      From Carol Haggans, registered dietitian and consultant for the National Institutes of Health’s Office of Dietary Supplements:

      “It is possible to overdose. ... All vitamins and minerals have a recommended intake, which is the amount people should strive to get from foods — and, if needed, dietary supplements — each day.”

      “Vitamin A is one nutrient that can cause serious problems at high doses, including birth defects if a woman is pregnant. Iron can also be toxic at high intakes. Even some of the B-vitamins can cause problems at high doses.”

      “Some vitamins, like B12, do not have an upper limit because they have not been found to be toxic at high doses. But even if there is no upper limit, consuming more than the recommended amount doesn’t necessarily have any benefit.”

      Early in her journey to becoming a registered dietitian, Crystal Petrello said, she was obstinate when it came to incorporating supplements.

      “I saw it as a snake-oil industry, and people were spending so much money,” she said.

      But after working in the nutrition field, her mind was changed about the potential of certain products. She says she has experienced the benefits of supplements, though dietitians and even supplement-industry officials agree the approach to better health should be “food first.”

      “There is a magic we don’t understand when it comes to eating food,” said Dr. Duffy MacKay, a licensed naturopathic physician and senior vice president of scientific and regulatory affairs for trade group the Council for Responsible Nutrition. “Some cool stuff happens when you eat a salad.”

      Carol Haggans, a registered dietitian and consultant for the Office of Dietary Supplements at the National Institutes of Health, said it is possible to get all essential nutrients by eating a nutritious variety of foods, though there are exceptions.

      “For example, all women who might become pregnant should get 400 micrograms of folic acid a day from either fortified foods or dietary supplements,” she said. “And men and women over 50 should get the recommended amounts of vitamin B12 from fortified foods or dietary supplements, because they might have trouble absorbing the vitamin B12 that is naturally present in food.” According to the NIH, scientific evidence backs some supplement use for overall health, such as taking calcium and vitamin D to fortify bones.

      Damon McCune, who directs UNLV’s Didactic Program in Nutrition and Dietetics, said that while there are legitimate cases for taking supplements, consumers too often don’t consult physicians and dietitians about potential benefits and harmful interactions with other over-the-counter products or prescription medications. He also said food provides trace nutrients that supplements can’t, and that people jump to them too quickly without considering dietary changes that might pack more nutrition at a lower cost.

      “The first thing people get wrong is that an overwhelming number don’t need supplements. People use supplements in place of food,” McCune said. “They are marketed so well that people go to them first.”

      MacKay disagrees. He said studies have shown that supplement users already engage in healthy habits, from regulating their diets to staying away from cigarettes. “I’m not going to be popular for saying this, but I’ve heard this statement from the dietitian community forever,” he said. “People aren’t using supplements to offset terrible habits. That’s a myth.”

      He further asserted that even the most health-conscious eaters might miss important nutrients. “We all travel, get stressed and eat birthday cake,” he said. “A multivitamin is a good insurance policy.”

      Most people aren’t aware of their nutrient intake on a level specific enough to inform what needs supplementing, so conversations with a dietitian are a way to get started. Once you’ve created a food log and broken down your diet, you can apply Dietary Reference Intakes recommended by the Institute of Medicine’s Food and Nutrition Board.


      The most glaring cautionary tale in the supplement world might be ephedra. Products containing the plant’s ephedrine alkaloids were marketed for weight loss and athletic performance, but the Food and Drug Administration banned the ingredient in 2004 after it was linked to heart problems and strokes. According to the Mayo Clinic, more than 800 reports of serious toxicity were collected by the FDA, including more than 22 deaths. Yet some related extracts not included in the ban are still sold.

      Weight loss and bodybuilding remain “high-risk” supplement categories, though they’re overshadowed by a newer one: sexual enhancement.

      In 2013, a study was published by the Journal of the American Medical Association that looked at all FDA Class I recalls — “those for which there is a reasonable probability that the use of or exposure to a product will cause serious adverse health consequences or death” — from 2004 to 2012. Researchers found that 51 percent were dietary supplements. Sexual enhancement products were the most common offender, followed by those purported to bulk up or slim down the body.

      All of these supplement recalls were rooted in “unapproved active pharmaceutical ingredients,” also known as hidden drugs.

      “These ingredients, generally undeclared in the labeling, can pose considerable dangers to consumers,” read a 2010 FDA letter to manufacturers of dietary supplements.

      That same year, a report to Congress from the Government Accountability Office found that nearly all herbal supplements it tested had trace amounts of contaminants such as lead, mercury, cadmium, arsenic or pesticide. While heavy metals were within safe limits, 40 percent of the products tested contained enough pesticide to exceed the legal limit, according to The New York Times, which also flagged “illegal health claims” related to Alzheimer’s disease, cancer and diabetes.

      The Council for Responsible Nutrition works to warn consumers, says the trade group’s senior vice president of scientific and regulatory affairs, Duffy MacKay, but there is a prevailing lack of research into many manufacturer claims.

      MacKay says one positive example is probiotics, live bacterial cultures believed to support gut health. It’s a juggernaut of a trend, so companies are incentivized to invest in study-backed development.

      The stalwarts of the vitamin aisle have significant market share, partly because they’re familiar enough for consumers to trust their value.

      “Calcium and vitamin D are important for keeping bones strong and reducing bone loss; folic acid decreases the risk of certain birth defects, and omega-3 fatty acids from fish oils might help some people with heart disease,” says registered dietitian and National Institutes of Health consultant Carol Haggans. “Other supplements need more study.”

      15 supplement ingredients to avoid

      Consumer Reports’ ongoing series, The Truth About Supplements, is “reviewing the research and talking with medical experts to find out whether common supplements live up to their marketing hype and whether they are safe to take.” As part of that effort, a March report listed 15 ingredients to “always avoid,” as they can cause organ damage, cancer and cardiac arrest. “Moreover,” the report read, “our experts agree that none of these supplement ingredients provide sufficient health benefits to justify the risk.”

      The 15 that made the list were: aconite, caffeine powder, chaparral, coltsfoot, comfrey, germander, greater celandine, green tea extract powder, kava, lobelia, methylsynephrine, pennyroyal oil, red yeast rice, usnic acid, yohimbe.


      Damon McCune with UNLV’s nutrition and dietetics program said anyone could claim the title of “nutritionist,” so seek out a registered dietitian trained to adhere to certain standards.

      But keep in mind that credentials aren’t a guarantee of sound advice. Whether you’re dealing with a dietitian or a medical doctor, McCune said it’s OK to get a second opinion if it doesn’t feel right, especially in the age of Dr. Oz. Mehmet Oz is a cardiothoracic surgeon with a leadership position in Columbia University’s medical school — and a network talk show themed around health and wellness. Oz has been criticized for featuring “miracle” products that in some cases have been discredited (in 2014 he was brought before Congress to answer for giving viewers false hopes, and the following year a group of prominent physicians called for his firing from Columbia).

      “Don’t always take it as gospel,” McCune said. “There should be a high level of responsibility on the consumer. People need to learn to be more savvy.”

      Tips for choosing products

      1. The fewer ingredients, the better.

      2. If provided daily percentages are way above federal guidelines, be wary.

      3. If a supplement lists a “proprietary blend,” unapproved substances may be hiding.

      4. When choosing a multivitamin, tailor it to your age, gender and other characteristics (such as pregnancy) to ensure the mix of ingredients suits your needs.

      5. Understanding ingredient lists is one thing. Recognizing the marks of vetted products is another. Third-party verifications are available through organizations such as, Informed-Choice, U.S. Pharmacopeial Convention and Good Manufacturing Practice. Companies have to pay for their services, and some forego the option. “They conduct tests on dietary supplements to check for things such as contaminants, potency and absorption,” said National Institutes of Health consultant Carol Haggans. “These programs provide assurance that a supplement was properly manufactured, that it contains the ingredients listed on the label and that it does not contain harmful levels of contaminants — though these organizations do not test the product to determine whether or not it is actually effective.”

      6. Try Google Scholar to check out research firsthand. “And read multiple articles,” McCune said. “Don’t just read one that supports what you want to hear and ignore the 10 others that say the opposite.”

      7. Registered dietitian Crystal Petrello recommends the similar resource Examine and the NIH’s Natural Medicines Comprehensive Database. “Just because it says it’s natural doesn’t mean it’s safe,” Petrello said. “Arsenic is natural.”

      Watch for interactions and report any issues

      Interactions: Consumers should always check with their doctors to make sure they’re not introducing something that could harm them depending on what they already take, prescription or over-the-counter. The Mayo Clinic offers an online database listing known interactions with 40 common supplements, from acidophilus to zinc.

      Recalls: This FDA site logs recalls, market withdrawals and safety alerts. If you experience adverse effects after taking a supplement, you can report it to the FDA through its MedWatch portal.

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