Nutritional Supplements

[MUSIC] This is Mayo Clinic Talks, a curated weekly podcast for physicians and health care providers. I'm your host, Darrell Chutka, a general internist at Mayo Clinic in Rochester, Minnesota. Nutritional supplements are very popular with our patients. They're supposed to provide benefits that may not be present in our typical diet. Consumers by supplements because they're readily available, relatively low cost, and they believe that supplements will help them achieve various health benefits. Patients often assume that supplements are completely safe, yet some can cause significant health issues, especially when taken in higher doses. Some have the potential to interact with various prescription medications. So are their nutritional supplements our patients should be taking? Which ones are potentially harmful, and how safe are these products, and do they have any regulatory oversight? These are some of the questions I'll be asking my guest, Dr. Andrew J.Gam, Director of Sports Medicine Research at the Mayo Clinic as we discuss nutritional supplements. You're listening to Mayo Clinic Talks. And we're welcome, and thank you for joining me today. Well, what are some of the more commonly used nutritional supplements that our patients could be using today? Usually across multiple demographics, we still see multivitamins tend to be kind of the more commonly used dietary supplements. So whether it's younger adults, older adults, anything that kind of fits into that multivitamin or isolated vitamin and mineral compounds, again tend to be the more popular of kind of all the supplement categories that a lot of individuals are taking. We sometimes see people, again, maybe focus on something like vitamin D because they maybe heard that in the weather months we don't get as much of that from sunlight exposure. So that tends to be one that is maybe more seasonal. And then similarly with maybe some older adult patients or populations we might see things like calcium or again vitamin D would kind of come into the picture there for musculoskeletal health or maybe some age-specific conditions that they've been told should maybe explore some of those supplements to see if it might help, but just kind of broadly speaking, multivitamins tend to be the most popular. And I see a lot of calcium and vitamin D being taken by my patients, but again, it's an older practice. I would imagine younger patients are more into the sports nutritional supplements, is that right? Yeah, so if we even include like energy promoting you know ingredients or dietary supplements in there, those are very popular of recent. And so sometimes their energy drinks, sometimes their pre-workouts or now we're starting to see caffeine added to all kinds of different things. Sometimes for performance related reasons, sometimes just because we're not sleeping enough so our bones kind of walking around tired and needs a boost to caffeine and then protein would be another one to fit in there for more of our active populations or patients to try to help get more protein in the diet, either promote or maintain lean body mass and kind of get the recovery benefits. Why do you think supplement use has become so widespread and popular? I think it's kind of a combination of reasons. I think marketing and social media exposure is probably one of the top just because of the, I don't want to say false promises, but there's definitely a lot of allure and upside that a lot of patients I think are maybe gravitate towards when they see the marketing or hear the marketing claims of take x, y and z and it could fix all your problems or this is kind of the missing ingredient in your diet. And if you you know buy this supplement, it's going to again fix not only that issue, but sometimes they're even marketed as like a panacea visc and again manage all of your conditions or right, all of them that you might be having in reality that's really far from the truth. There's definitely some situations where dietary supplements can be helpful, especially if there's kind of an identified deficiency in the diet or if a person maybe is on a restrictive diet or has eliminated certain groups of foods altogether, then usually there's kind of an indication where a dietary supplement probably would be a good idea and and could maybe help correct whatever the known deficiency is or you know help manage some of the issues that may have come from it, but rarely do we see the kind of glorified benefits actually come to fruition with most supplements on the market. They are very heavily marketed and it seems like they often market towards conditions that we really can't correct, you know, problem-sleeping, low energy, trouble with their memory and they use a lot of testimonials so we don't really have to prove a lot if you believe what you're hearing, these things can pretty much take care of almost any problem anybody has. They tend to use a lot of science-y like terminology so again it might sound true when you hear some of these claims or what I think happens a lot is there's a lot of over extrapolation where again if we kind of look at the structure of function claims of some isolated ingredients the companies aren't necessarily lying in terms of what that ingredient or product may be able to do but in reality unless that person is deficient with that ingredient or compound just taking it isn't always something to make all their problems necessarily go away. There's oftentimes a lot of other usually what I refer to just kind of low hanging fruit kind of lifestyle changes that likely would make a much more profound impact on their overall kind of health and wellness. As you even said just better managing your sleep maybe getting more physical activity in opting for just more nutrient dense foods altogether so kind of more of a well balanced diet. Oftentimes if you're addressing those that's going to give you much more of a general benefit than any other specific supplement you know may offer and again going back to the marketing I think it's just people maybe gravitate towards a simpler option of I just got to take this small capsular pill and that's a lot easier than working out every day going to the grocery or cooking my own meals being diligent about going to bed at a respectable time and kind of getting on a regular sleep schedule like those things take commitment and consistency and that's hard to fit into a busy life schedule so if a simple supplement can be an easier option there it kind of makes sense why people might explore that but again unfortunately it's it's the other things that probably give them more of a benefit. Do you think there any out there that our patients really should be taking? Again it kind of comes down to the specific situation so in my experience oftentimes if people do have a specific dietary restriction where again maybe they're lactose intolerant or they're vegetarian or whatever the kind of reason being if they're restricting you know major categories of foods then chances are they they might well in fact have a nutrient deficiency that a dietary supplement could offer a good alternative for them to just get more of that ingredient kind of in the diet on a daily basis. You know even one for example that we see more in our sports medicine practice here is iron deficiency anemia and sometimes it's a combination of maybe that athlete just doesn't get a lot of iron in the diet but oftentimes it's coupled with the fact that they might be a female athlete or a highly trained endurance athlete and kind of all of those factors together make the more predisposed to that iron deficiency anemia condition and supplementing with iron is a pretty tried and true method to kind of correct that deficiency and kind of help them restore normal iron levels within the blood and and kind of similar conditions like that where even as we alluded to earlier with older adult populations musculoskeletal health tends to be a concern so maybe supplement with vitamin D or calcium can be effective strategies to help just maintain bone marrow density as individuals age and might help promote some resiliency against falls fractures and some of those known risks with that specific population so that's where I kind of try to dig into a little bit more of what age are you or what's your diet look like and then kind of taking things a little further to identify if there is in fact a need or an underlying condition that could be a good use case for where certain dietary supplements could come into play. Well Andrew we both live in the Midwest and you know we get vitamin D from some dairy products and a sunlight exposure and where we live we might get sunlight exposure under skin for maybe a couple months of the year if we're if we're lucky so I see vitamin D is probably the most common supplement in my patients take but you know I have to admit I think I see more patients taking too much vitamin D they're not enough you need about four to eight hundred units per day and you can find supplements of vitamin D of a thousand five thousand ten thousand units and the bottles just take one daily and these patients are getting way too much vitamin D and it's it's a fat soluble vitamin so it's not like vitamin C where it leaves your body if you take too much. Yeah just as you said there I think that's the important detail is those fats soluble vitamins are one where we can take too much of and they are stored within the body and over time that could reach toxic levels if people are taking kind of mega doses of some of those ingredients and and I think that's kind of the concern with with a lot of supplements is there can be too much of a good thing even the water soluble vitamins and then other supplements where they just have well beyond the recommended daily allowance where it's 10,000% of your daily requirement. Sometimes we'll see it in like five hour energy drinks or some of the real concentrated shots or our high dose potency supplements where again those can be risky if people are taking those every day and certainly if they're taking more than the recommended serving size, the risk of reaching some of those toxicity levels is going to go up quite a bit in those situations. Sure. I saw a woman few years ago who was concerned because she looked up on the internet that why was she turning orange and she was convinced she had liver disease and then she did she looked like the great pumpkin. I mean she was orange but her liver tests were all normal and as I explore to nutrition she was taking huge amount of caratuse and she had hypercarotenemia. Boy she didn't look like a pumpkin. Well other than too much of some nutritional supplements, are there some high risk supplements out there that patients can get old of? Yeah I would say going back to some of those energy promoting products those tend to be ones that have higher rates of what we consider adulteration where there's either illegal or non-approved compounds added to some of those products and who knows definitively of why that's the case. My suspicion is that it kind of makes people feel like that product is working more especially if it's intended to increase energy levels, alertness and focus. If they're adding illegal stimulant compounds to those products people are probably going to get a jolt of energy and it's because they're taking different and fed to mean like compounds or derivatives of those and yeah it might make them feel good temporarily but there's certainly some known risk and health effects to you know they come with some of those different ingredients. So those are ones specifically that are usually on kind of higher risk lists of pre-workouts or even some of weight loss promoting products because they too tend to have different stimulant like compounds in there to help promote fat burning or increase metabolic rate and those can again have some pretty strong health risks associated with them. Again, if people are taking it daily and then one of the newer ones that we've seen kind of in the last couple of years is cratum and then even one of the derivatives of cratum, the 70H compound that has some opioid-like effects that are pretty dangerous if taken especially the lack of regulation associated with those two particular products and so that's one I wouldn't be surprised if it becomes a controlled substance here in the next couple of years or is not able to be sold at least over the counter because that's one where there's a lot of health risks associated with it as well. So those are ones that tend to be kind of more higher risk types of products and again a lot of times it's because of who knows definitively what's in them, what the amount is and whether or not there's some adulterant mixed in there. Are there some supplements out there that are highly likely to interact with some of our prescription medications that we should know about? Yeah, there are a few St. John's Whart is one in particular that can have some kind of counteracting effects with certain medications, vitamin K, even some of the omega-3s so different fish oil products sometimes can have interference effects with blood clotting and so sometimes post-surgery or procedures that's kind of recommended that people stop taking any kind of fish oil or omega-3 type products in a few days I think after surgical cases and then the challenge is a lot of the herbal supplements and kind of proprietary blends. I don't think we definitively know what the interference effect may or may not be there and so sometimes it's probably safest if you're trying to new medication maybe just stopping some of those types of products until we have more data to know definitively if there is that interference effect with medications. The other one that it's not necessarily interfering with the medication but two supplements that sometimes can interfere with one another is vitamin C and iron absorption so sometimes if someone is taking iron it's recommended to take it at separate times of the day from vitamin C so that you don't compromise the absorption of it into the bloodstream. Andrew, you mentioned regulations. Are these products regulated? Is there any oversight of these supplements? In the U.S the FDA does regulate the dietary supplement industry and so there's a specific act of Congress the Dishae Act or Dietary Supplement Health and Education Act that kind of initiate a lot of the policies regarding how dietary supplements are regulated, marketed, the different ingredients that can be included in some of those products. I would say the limitation of that is there's not as much pre-market regulation as we see in the pharmaceutical industry so not a lot of dietary supplement products have been clinically studied to know definitively if that ingredient is safe to consume especially in that combination of the other ingredients that might be in a multi-ingredient blended product. So there again are some limitations in terms of the pre-market side of it but post-market surveillance is again overseen by the FDA and they have a pretty extensive list I guess of ingredients or products that have needed to be banned or ceasing the cisletters sent to companies asking them to reformulate before putting back on the market and so there is a long list of those that is usually publicly available that people could go and search and find some of those companies, brands, ingredients that are on that FDA warning list of those particular products and then globally it kind of depends so each country sometimes has their own way at which supplements are regulated. Nowadays with the internet you can buy things from across the world so you could certainly buy products or ingredients that are manufactured in another country and they may or may not align with the same US dietary regulations or the same policies that we have so there's definitely some challenges there to know how things differ or the same in terms of like the global dietary supplement market. So just to kind of plug some of our own research is I was asked to join an author group that has global representations so there's about 48 authors on this and there were a couple authors from each of major countries around the world and we were all asked to kind of write a section to highlight how our country regulates dietary supplements and then we put this massive review article together. It's currently out in pure review right now but hopefully within a couple of months that can become published but again what it does is it outlines each country's regulations and policies regarding dietary supplements and it just kind of highlights some of the more in-depth I guess regulation policies and then other countries that may not have any and so it's a little bit more of the wild wild west there so it'll be an interesting article to kind of see out in the literature and just kind of document how that policy and regulation does differ across the world. Yeah well consumers assume that supplements contain the exact amount of active ingredients that the label says I have heard that there's a fair amount of variability even within one bottle of active ingredient in one tablet versus another I don't know if that's true or not. It can be so what I usually advise patients to is when it comes to selecting a dietary supplement brand altogether is trying to find a company that subscribes to some kind of third-party testing meaning another company in organization has tested that product they've reviewed the supplement facts label and then kind of confirm what's in the canister reflects what's in the label in terms of the actual ingredients the amount of the ingredient included in there and then that third party would would kind of approve it and then include it on that list and so if you're buying dietary supplements that are made by those companies that have again that third-party seal of approval on there you can put a lot more faith in that product knowing that again it's been evaluated it's been confirmed that what's in the canister reflects what's in the label and then also there's no illegal compounds or for athletes there's no band substances in that particular supplement as well so that's usually where I steer people first is trying to find those types of products that have that third-party verification on it to again get that extra assurance because otherwise there's no way to definitively know I would never recommend products that don't have that third-party because I'm taking a gamble myself unless someone actually goes and tests it in a lab we don't really know what's in some of those products are there actually prescription-grade nutritional supplements can we write a prescription for some of these things there are in select use cases so there's even some high dose omega-3 or fish oil type products that are kind of medical grade similarly with going back to the vitamin D you can get vitamin D shots sometimes for a high dose if someone's really deficient or there's kind of a specific medical reason why someone would benefit from getting that a high dose 10,000 I use type of injection versus 4 to 800 I use a day so there are a few instances there where there's more medical grade usually higher potency type supplement ingredients that are available I will occasionally have a patient who is taking a large number of these supplements I think the record for me is something like 56 or 57, not sure how they even had time to get that many capsules and tablets in. But if you've got any tips for clinicians who are seeing patients taking many supplements, we really see no clear clinical indication. I would just kind of ask them, you know, why, you know, why are they taking them? What are they striving to get out of it? And just trying to dig a little bit deeper and then maybe even explain to that patient that most of these haven't been studied and most of the benefits aren't really clinically supported. And then I would imagine in that case, they're probably spending hundreds if not a thousand dollars a month potentially on that kind of dietary supplement regimen. So that's probably more than they're spending on groceries and kind of food alone when in reality, they'd probably get the same if not quite a bit more benefits from just eating the healthier diet, more variety in the diet. I would just keep inquiring about why that many supplement ingredients and then, you know, in sports medicine, I pretty much have my list of about five supplements that these are probably the only ones that are worth considering taking for more physical performance type benefits. And beyond that, you're kind of just wasting your money and there's not really a lot of upside to including more than around my kind of short list of, again, supplements that have consistently been shown to offer some of those benefits. But then at the same time, been showing to be safe and kind of appropriate to use for those individuals. And then even going back to our topic earlier, concerned about taking too much. So unless people are getting labs to kind of confirm that they're deficient in any particular ingredient, again, there's no real need to add more in there. And if anything, there could be more hard and good to come from that if you're just blindly taking high dosages of some of these ingredients. So my philosophy is kind of assess, don't guess, you know, if you're unsure about something to get lab work done to confirm if you're deficient or not, before just jumping in and taking 50 plus supplement ingredients and hoping that's going to fix all your problems. Yeah. I know there are cases where we see maybe a lab abnormality or a symptom that we can't explain in a patient and they're taking several nutritional supplements and I encourage them to stop to see if that could be the cause. And what I've discovered is the more nutritional supplements an individual takes, the harder it is to get them to stop even one of them. You know, somebody taking two or three, there's usually no problem in them stopping for a little bit, but boy, they are really adamant about taking their supplements when they're taking that many. I kind of have stolen the phrase polypharmacy where people might be taking multiple medications that sometimes interfere with one another or cause compounding issues when those are, you know, medically indicated or they're kind of needed to manage conditions, but in the supplement space, those are all kind of self-induced. If you kind of are in this poly supplementation situation where again, you're taking 15, 20 different products, they have overlapping ingredient profiles. And now, all of a sudden, you're getting five to 10 times the recommended allowances for some of those ingredients. And you've again kind of created your own problem just because you're under the belief that more might be better or all these different supplements you hear about are good. And so you just kind of blindly taking them for no other reason. Yeah. Well, Andrew, you've given us some really good information on nutritional supplements. Can you summarize our discussion maybe with two or three key points? I would say when it comes to most dietary supplements, a lot of the ones that we see on the market really don't offer the benefits or kind of the magic solutions that we tend to hear about and when it comes to the marketing of those products. But at the same time, there are situations or individuals that can benefit from dietary supplements. So if they're on restrictive diets or even just kind of a picky eater, I guess, and not really eating a well-balanced diet where they're getting a variety of nutrient dense foods, fruits and vegetables, then again, certain dietary supplement ingredients can be helpful and can be beneficial or even seasonal changes. As we said, vitamin D in the winter time certainly be warranted in some parts of the world. And lastly, I usually would recommend, again, opting for products or brands that subscribe to third-party testing and verification just to make sure the quality of supplements that you're taking is high and knowing definitively what's in the canister of the product reflects what's on the label. And again, knowing you're not taking anything dangerous or potentially illegal if you're an athlete. We've been discussing nutritional supplements with Dr. Andrew J.M. An exercise physiologist and director of sports medicine research at the Mayo Clinic. Andrew, thank you so much for sharing your knowledge with us today. Absolutely. Thank you. You can now listen to several hundred different medical topics developed for primary care providers on Mayo Clinic Talks Podcasts. Find them at ce.mail.edu or your favorite podcasting app. If you've enjoyed Mayo Clinic Talks Podcasts, please follow us. We're honored to have you as a listener and invite you to tune in again next week. Stay well.