In this lecture, we're going to look at Dietary Supplements.

To be fair, this is just a brief scratching of the surface for a very large and complex topic. But I do want to point out just a couple of concerns about safety and appropriate use of Dietary Supplements. Dietary supplements are certainly a big business. In the US the majority of Americans consume a dietary supplement, either every day or somewhat regularly. These can include things like vitamins and minerals, amino acids and enzymes and they might be taken in tablet form, capsule form, powder form, even in energy bar form. The point is that these are things that are supplemental to the foods that we eat. While It's difficult to estimate exactly how much people spend on supplements. One group estimates that in the United States we spend almost 23 billion dollars a year on dietary supplements and related products. Products. The situation in the European Union is a little bit different than that of the United States. In the EU, a lot of the supplement-based information and consumer information is derived from the EU Food Supplement's Directive of 2002. This was a directive that established purity criteria. And in the EU, one of the major differences between the situation in the US. Is that, in the EU, supplements have to be proven safe before they can be sold to the general public. In the EU, products have to be labeled. This is not a medicinal product. If it is similar to a medicinal product. In the U.S. things are a little bit different. Supplement regulation and the governance of supplement sales is loosely directed by what was called DSHEA and that's the Dietary Supplement Health and Education Act of 1994. The original intent of this piece of legislation was that the governments in the U.S. wanted to start to reign in and to regulate and legislate to some degree, the growing interest in and sales of dietary supplements, so the DSHEA Act

defined supplements in the U.S. as a vitamin, a mineral. An herb or a botanical, except for tobacco. An amino acid, or a combination of any of those that are used in supplementation to the diet. Supplements in the US are regulated as a category of foods. And not of drugs. What's interesting about the United States scenario, is that supplements do not have to be proven. As either effective or being safe, before being sold. So you or I, essentially if we wanted to get in the supplement business could start selling supplements tomorrow over the counter without really doing any leg work to prove that it was safe or even that what we said was in the bottle, was in the bottle. Enforcement in the US is at best spotty and the industry is still largely And regulated. The DSHEA Act in the United States Regulations say that if you're going to sell a supplement, it has to have a supplement facts panel on it. So this is one that you might see. it tells you amount per serving in this column and then what the percent of the daily value is. So this supplement here, it might be some sort of multivitamin supplement. It's a pretty good supplement. Because you can see that for the majority of the nutrients, it's close, providing close to 100% of the recommended value. What's a problem though is that with some supplements, you see things like 1,000, or 2,000, 3,000% of your daily value. We tend in the United States to live in a society where people think, huh, if 100% is good, 1,000%. It must be ten times as good. But that certainly not the case with supplements. These are very very concentrated sources of vitamins and minerals and in some people with some conditions at different metabolic situations could actually prove very dangerous to be taking very high levels of this over the counter product. One thing that you want to be concerned about as a consumer is the quality of the dietary supplement if you do choose to purchase them. In the US, quality standards exists, although questionably reinforced, the

identity, the purity, the strength, the composition of the active ingredient in the dietary supplement that you are taking may not entirely known. In the U.S. there are independent extra-govenemental organizations that add additionally quality testing. So you sometimes see labels listed on the supplement that say that they have been proving to be safe, or this is a pure product, or this meets the industry standards. And it's a third party non governmental group. That provides that seal of purity or whatever but often times or all the time the supplement manufactures do have to pay for that, so its not something that US government mandates but many supplement companies do employ. There are certainly concerns about taking certain dietary supplements. There is the possibility that some of them might contain lead or other contaminants. They may in certain populations displace income that could otherwise be used for prescription drugs. In the U.S. we're talking, primarily about the older population. There are certainly unscrupulous manufacturers out there, who target and market directly to, older people on limited incomes. If you have x amount of dollars a month to spend, and you need to buy healthy food, you may need to buy prescription drugs Drugs. For most of these people, you should not be spending what limited amount of income they have on dietary supplements that haven't been proven to be safe, or effective. One situation that we're starting to pay more attention to in the healthcare environment, is the fact that users of supplements don't always disclose them to their healthcare Healthcare practitioners. Part of the problem is that many healthcare practitioners, they don't ask what types of supplements you use. They might ask you about all the drugs that you're on, prescription drugs, but they don't ask you about your supplements. So it is important that if you do take dietary supplements and go to the doctor

or the clinic to your healthcare practitioner, that you mention the dietary supplements that you're on. Because many of them can be contraindicated with other parts of your medical. Treatment for example medicines that you might be taking would not be advisable to be taking other supplements at the same time. The herbal supplements that some people take. contain dozen of compounds and active ingredients that may not be known. So especially in pregnancy and for people on multiple medications say when in doubt you leave the herbal supplements out. A few more things to help make you a savvy supplement user. Keep in mind that the word, natural, means nothing. You see natural posted all over foods and supplements, and other health care products. In the United States, there's no regulation for using the word, natural. Some other terms that are somewhat misleading, purposely misleading. Are things like high potency, pharmacy grade, or prescription strength. You might buy a supplement that's more expensive, because it says it's of the highest pharmacy grade. It's kind of an ironic statement. Where, in the United States, supplements are sold over the counter. So you don't need a prescription strength version of it, and there's no definitions for these terms as well. Self diagnosing yourself with a problem and taking and taking a supplement if you're having a health condition is a harmful practice. More expensive supplement do not equate to better quality. And again, some over the counter supplements may have various dangerous potential interactions. And are contraindicated with many types of prescription medications. Some examples of contraindications. Vitamin K. Vitamin K is a supplement. Reduces your ability of your blood thinner to work. So if you're on the blood thinner drug, Coumadin. That's helping prevent your blood from clotting. And you take a high dose of vitamin K,

which promotes blood clotting. Those two things don't work together. Saint John's Wort can expedite the breakdown of many drugs. There are many documented cases. While it's not certainly an epidemic. But individuals who are taking oral contraception, or antidepressants. They started taking Saint John's Wort. And they had the opposite of the intended. Effect. The contraception is not effective, the antidepressents are not effective. Antioxidants like vitamin C and vitamin E have been shown to reduce the effectiveness of certain chemotherapy therapies. In the United States there are tolable upper intake levels set by the Institute of Medicine for certain vitamins and minerals. Well, there are not ULs, upper limits, for all of the vitamins and minerals. But for the ones that you do see listed here in this table, it's a godo idea to pay attention to them. Because what it means, is that if you regularly go above this tolerable upper intake level, you could potentially be putting yourself at risk. Because there is science that shows, as very high levels. Above the UL. These certain vitamins and minerals can prove harmful. Let's look at a number of different claims that certain supplements make. And see whether or not they really have any bearing. Or whether or not they're true. Sometimes, you see products that claim to, quote unquote, promote joint health. What does that mean? Well, joint health supplements are big business. In the US there's roughly 800 million dollars in joint health supplement sales per year. And most of that has to do with the supplements glucosamine and chondroiton which you see sold or marketed together. Which to be honest have mostly negative results in very large-scale studies that have been done. To test whether or not they help with, joint health. One of the most well-known studies, was the GAIT trial; glucosamine, chondroitin, and arthritis intervention trial of 2006. Which, bottom line, found no clear

benefit, for most people taking these products. In the, in the majority of these studies, any of the benefit that was realized, was attributable, to the placebo effect. In 2009, there was a random Randomized study that showed glucosamine and chondroitin were no more effective than the placebo was to slow cartilage damage from osteoarthritis. And again in 2010 there was a different study done by a group of Norwegian researchers who tested glucosamine for chronic low back pain and degenerative lumbar osteoarthritis and found that there was no significant difference between glucosamine and placebo. So at the end of the day glucosamine is not or hasn't been proven to be harmful, but it certainly has been proven not to help improve joint pain. Another claim you sometimes see supplements that advertise or say that there going to improve your memory or your focus, in the U.S. Americans spend about 250 million dollars per year on these products. Is it worth it? Or are they wasting their money. The largest study done, and one of the supplements that's used primarily for memory and for focus, is the study, or is using the supplement gingko. There was a large scale study done called the GEM trial. Gingko Evaluation of Memory. And in this study, it was a randomized study. Double blind, placebo controlled, and looked at over 3,000 people. who were age 72 to 96, at 6 different academic medical centers. They were given either twice daily doses of 120 milligrams of ginkgo extract, or they were in a placebo group. And at the end of the 6 year trial the researchers found that those that were taking the ginkgo had no remarkable or no not much less cognitive decline then the placebo group did. Earlier gem findings have debunked. The benefit of gingko against Alzheimer's and Dementia. And according to the author of one of these studies from the University of Virginia. He say's I, and he as a researcher said this, have got no good reason to suggest that you continue to take gingko beyond Beyond your own blind faith.

So essentially we're spending 250 million dollars year on products that are marketed to help our memory, and we can show absolutely no scientific data that these products actually work. Again, they haven't been proven to be harmful for you, but as is the case with most supplements, they're a pretty big waste of money. The last claim that we'll look at are those which prevent aging. Isn't that what we all want? To live a nice, full, longer life. Well, eating a good diet and exercising regularly is a lot of work. Can I just buy a product to help prevent my aging? In the U.S. again, about 250 million dollars a year is spent. On these products. One of the primary ingredients in these anti-aging property er products that you see marketed is called resveratrol. And resveratrol is an anti-oxidant compound foud in red wine. It appears to inhibit enzymes that regulate cell energy. In 2006, there was a study done that got everyone excited about Resveratrol. It showed an improvement in health and longevity of overweight, aged mice. Now, in 2008, another study came out that said, it may help to slow age-related deterioration and functional decline of mice on a standardized diet. It doesn't increase longevity, when started at middle age. Now, one of the problems with these studies about Resveratrol, is that, we are humans, and they are mice. And animal study outcomes don't always extrapolate perfectly, to human populations. Another issue, is that, the clinical studies of Resveratrol, would equate to, the amount of Resveratrol that they were using in a study, 1 g a day, is roughly equivalent To 667 bottles of red wine. So it's, of course, not realistic for humans to be consuming that level of resveratrol from the naturally occuring sources in our diet, which would be redwine. So, manufacturers, what they love to do, is to extract that compound and put it into a supplement and sell you that. So, of course, you wouldn't get the harmful effects of all of that red wine. But really, at the end of the day, there have been no studies done that prove the

long term Efficacy or safety of Resveratrol. This is perfect example of the exploitation of preliminary animal study data done for profit long before the science has unquestionably proven that this is safe or effective for using humans. To be honest, the majority of supplements that are sold are not necessary, and they tend to be a big waste of money, and in come cases, can be dangerous. But there are certainly groups for which dietary supplements are important. Who might need a supplement and why? People who diet heavily, who are on very calorie restricted diets they probably need to include a multivitamin or mineral supplement. People who are vegans or consume no animal products. They need vitamin B12 supplements. As the only appreciable source of vitamin B12 in the diet comes from animal foods. If you don't consume dairy, you might need to consider a calcium supplement. Infants and children. If you in an area with no fluoridation in your water, they may need a fluoride supplement. And for those that don't spend the lot of time out of doors, they may require a vitamin D supplement. Pregnant women are advised to get 400 micrograms of folic acid a day from either prenatal vitamins or fortified foods or supplements. Older adults may require supplemental vitamin B12. What happens when you get older is that your body produces less hydrochloric acid and one of the components of hydrochloric acid is something called intrinsic factor. Intrinsic factor helps your body to vitamin B12, so when you get older, even if you're eating animal foods with vitamin B12 in them, your body might not be as effectively absorbing that B12 as you did when you were younger. Darker skinned individuals may need vitamin D supplements as you require more exposure to UV light. With an, if you have dark skin, than if you have light skin, in order to produce, or to activate the right amount of Vitamin D in your body. People who smoke cigarettes have higher Vitamin C needs, people who have used alcohol have higher B Vitamin needs, and

individuals that are on certain type of medications, many medications interfere with normal vitamin and mineral metabolism. Metabolism, and you may require vitamin and mineral supplements there. So, it's not to say that all supplements are a waste of time or money or are harmful. Cause there are certainly groups for whom dietary supplements are helpful. In summary, just becasue you don't need a prescritpion to buy a dietary supplement, doesn't mean that a supplement is necessarily harmless. For most of these products, don't waste your time and your money if you don't need to. It is true that changing your diet and excersizing regularly is harder, than popping a supplement pill. And to be honest, most individuals can, and should be obtaining all of the appropriate vitamins and minerals that they need from foods and shouldn't rely on a supplement to help fill in the gap. When supplements are indicated, they should be taken with caution. And only under the supervision of a qualified medical professional. If you're interested in learning more, I would encourage you to look at some of these websites, to learn a little bit more about dietary supplements. As well as their safety and their efficacy.