Advising patients who use dietary supplements

Comparison between the American and the European Systems of Monitoring Adverse Effects of Dietary Supplements and Their Usefulness on the Polish Market

Many Polish patients do not inform physicians about supplements they use in addition to prescribed medicines. This may be because they consider dietary supplements as being rather natural products that cannot cause health problems. Although dietary supplements may produce side effects, Poland's food safety system and medical statistics do not recognise the necessity of reporting such cases. However, a different approach is observed in France and the United States where adverse effects of food supplements as well as drugs are reported. The aim of this study was to determine the need for creating in Poland a general model of a register monitoring dietary supplements and their adverse effects. In order to achieve this goal, a detailed comparison between the American and European monitoring systems was made. It showed the relationship between negative symptoms caused by specific components in supplements and t profiles of patients who reported side effects. Additionally, it was found that there is a real risk associated with side effects caused by dietary supplements. Therefore, it necessary to establish in Poland a special system for recording such cases as it should be beneficial to patients, including polypragmatic patients.

Nutraceuticals and dietary supplements: Disparities in usage and potential for harm

Background: The use of nutraceuticals and dietary supplements has a complex history. Aim: This work seeks to discuss the current state of nutraceuticals and dietary supplements, with a particular focus on the ambiguity of these terms, their current usage, potential harms, roles within the healthcare system, and associated disparities. Methods: This work reviews recent literature spanning the history of nutraceuticals and expands upon recommendations made by previous authors. Results: While a substantial portion of the United States population consumes these substances, their safety profiles are rarely well characterized. Taking a broad definition of these terms paints a picture of harmless use by a population that is middle-aged, educated, and white. However, focusing on specific substances reveals concerning disparities in race, ethnicity, income, physical health, and health literacy. This is of particular concern when looking at the side effects of these supplements both in isolation and due to drug-supplement interactions. Conclusions: In this work, the authors build upon the recommendations of others to propose ways in which physicians and healthcare systems can work to reduce the disproportionate harms of these substances on historically marginalized groups.

Determination of the Awareness about and Need for Health Support Pharmacies as the Provider of Consultation Service about Nutrition Education and Diet-Related Health Promotion by Health Professionals in Japan

Health support pharmacies (HSPs) have been established as a new category of pharmacies in Japan. In addition to prescriptions, HSPs provide several health services, including consultations on diet/nutrition, health foods, and nursing care. Therefore, not only individuals receiving medications but also community residents should have access to HSPs. However, it is unclear whether people are aware of HSPs. Thus, the purpose of this study was to assess the awareness about HSPs and determine the need for their services. To this end, we conducted an online cross-sectional questionnaire survey in 10,000 Japanese adults. Approximately 60.2% of the participants were aware of family pharmacies/pharmacists, and 21.8% of these participants had a family pharmacy/pharmacist. Meanwhile, 2.6% of the participants were aware of HSPs, while 9.2% of the participants had only heard of HSPs. Awareness of HSPs was higher among men and younger individuals than among women and older generations. In addition, only 7.2% of the participants were aware of the location of the HSP in their area of residence. At the time at which this survey was conducted, only 3.5% of the participants were using HSP services, and half of them did not perceive the merits of using these services. However, 44.4% of the participants wished to avail themselves of HSP services in the future, and this desire increased with age. Half of the participants wished to use services that were associated with drugs, and the need for other services, such as consultations on diet/nutrition or health foods, was low. In conclusion, there was low awareness about HSPs among the survey participants. However, from our findings, we gathered that if individuals are aware of HSPs, they will wish to use HSP services. To improve healthy life expectancy, it is important to increase awareness about HSPs and their number.

Self-Perceived Health and Chronic Conditions Among Users of Supplements With and Without Botanical Ingredients: Findings from the 2009-2014 National Health and Nutrition Examination Survey

The objective of this research was to investigate associations among self-reported health status, chronic conditions, and use of dietary supplements containing botanicals and describe reasons for use among U.S. adult supplement users. This was a cross-sectional analysis using data from the 2009-2014 National Health and Nutrition Examination Survey (NHANES). Supplement information was collected with a 30-day recall interview. Self-reported general health status and doctor-informed diagnoses of chronic conditions were assessed using a health status questionnaire. We used weighted multivariate logistic regressions to assess associations between supplement use and perceived health and number of chronic conditions. Participants were 16,958 non-institutionalized U.S. adults aged 20 years and older. Adults with excellent or very good self-perceived health were more likely to use botanical supplements than adults with good perceived health (adjusted odds ratio [aOR], 1.48; 95% confidence interval [CI], 1.28-1.74). Adults with three or more chronic conditions were more likely to report using botanical supplements than adults with no chronic conditions (aOR, 1.49; 95% CI, 1.13-1.69). The most frequently reported reasons for both non-botanical and botanical supplements use were "personal choice or influenced by advertisements or word of mouth," "improve health," and "specific health conditions" (93.3%, 84.2%, and 64.7%, respectively). While perceptions of health are more positive among adults using botanical supplements, chronic conditions and reasons for botanical supplements use related to personal choice, improving health, or addressing specific conditions were more likely. Differentiating botanical supplements from other complementary and integrative therapies may be useful for facilitating a deeper understanding of the reasons.

St John's wort for depression: scoping review about perceptions and use by general practitioners in clinical practice

BACKGROUND

Extracts of Hypericum perforatum, more commonly known as St John's wort (SJW), have good evidence for treating depression. The herb is easily accessible and widely used by consumers, although it has potential for interaction with other medicines. Consumers' use of SJW is often not discussed with their general practitioners (GPs). It is unclear how GPs perceive use of SJW in practice and the implications for consumers and pharmacists.

OBJECTIVE

Explore GPs' perception of SJW use in practice.

METHODS

Scoping review.

KEY FINDINGS

Few studies explore GPs' perceptions of SJW for depression, but they appear to recommend it infrequently, except in Germany. Reasons for limited use in practice include lack of knowledge, particularly regarding which preparations and dosages have trial evidence, and lack of standardisation of active ingredients. Guidelines either do not mention SJW or advise against its use.

CONCLUSIONS

Consumers drive SJW use but often do not disclose to their GPs, which is concerning due to issues about safety. Pharmacists could play an important role here. Improved education about SJW is required for both GPs and consumers, including the need for communication between them and their pharmacists. Lack of adoption of evidence-based therapy for depression should be explored further.

Alternative remedies for insomnia: a proposed method for personalized therapeutic trials

Insomnia is a common symptom, with chronic insomnia being diagnosed in 5-10% of adults. Although many insomnia patients use prescription therapy for insomnia, the health benefits remain uncertain and adverse risks remain a concern. While similar effectiveness and risk concerns exist for herbal remedies, many individuals turn to such alternatives to prescriptions for insomnia. Like prescription hypnotics, herbal remedies that have undergone clinical testing often show subjective sleep improvements that exceed objective measures, which may relate to interindividual heterogeneity and/or placebo effects. Response heterogeneity can undermine traditional randomized trial approaches, which in some fields has prompted a shift toward stratified trials based on genotype or phenotype, or the so-called n-of-1 method of testing placebo versus active drug in within-person alternating blocks. We reviewed six independent compendiums of herbal agents to assemble a group of over 70 reported to benefit sleep. To bridge the gap between the unfeasible expectation of formal evidence in this space and the reality of common self-medication by those with insomnia, we propose a method for guided self-testing that overcomes certain operational barriers related to inter- and intraindividual sources of phenotypic variability. Patient-chosen outcomes drive a general statistical model that allows personalized self-assessment that can augment the open-label nature of routine practice. The potential advantages of this method include flexibility to implement for other (nonherbal) insomnia interventions.

Too little, too late: ineffective regulation of dietary supplements in the United States

Millions of people in the United States consume dietary supplements hoping to maintain or improve their health; however, extensive research has failed to demonstrate the efficacy of numerous supplements in disease prevention. In addition, concerns about the safety of routine and high-dose supplementation have been raised. The Food and Drug Administration regulates dietary supplement quality, safety, and labeling, and the Federal Trade Commission monitors advertisements and marketing; still, vast enforcement challenges remain, and optimal governmental oversight has not been achieved. If the composition and quality of ingredients cannot be reliably ensured, the validity of research on dietary supplements is questionable. Moreover, the health of the US public is put at risk.

Provider and patient expectations for dietary supplement discussions

BACKGROUND

Dietary supplement use in the United States is common. Patients can procure supplements without a prescription, and often do not disclose supplement use to their healthcare providers. Providers and patients may be uncertain about what would be appropriate or helpful in discussions of supplements during routine office visits.

OBJECTIVE

To explore provider and patient expectations for discussions of dietary supplements.

DESIGN

Semi-structured interviews were conducted with a purposeful sample of healthcare providers from three specialties and their patients who reported taking supplements.

PARTICIPANTS

Thirty-five outpatient providers (14 primary care, six integrative medicine, and 15 complementary and alternative medicine (CAM) providers) and 107 of their patients.

APPROACH

Qualitative analysis of transcripts using grounded theory and iterative review.

RESULTS

Both providers and patients raised twelve common topics about dietary supplements that they felt were important to discuss during office visits, such as: supplements taken; supplement risks (interactions, safety/harm, side effects/adverse events); treatment benefits; efficacy; alternative treatments; and patient expectations/preferences for treatment. Some topics were mentioned more frequently by providers than patients, such as how to take, reason for taking, and evidence for use. Providers raised several topics that were mentioned infrequently by patients. Supplement costs and regulations were not brought up by any patients, even though consideration of these topics could influence patient decisions to take supplements. Complementary healthcare providers brought up topics not mentioned by primary care providers, such as the importance of supplement brands and supplement mega-dosing.

CONCLUSIONS

Patients and providers have concordant views about the need to discuss patient supplement use and ensure patient safety. Patients may undervalue, be unaware of, or discount information about cost or regulations that could affect their decision-making about supplement use. Future studies could examine the value, acceptability, and influence of a more comprehensive approach to discussions to help patients appropriately evaluate supplements.

Nutritional supplements for diabetes sold on the internet: business or health promotion?

Background

Diabetes is one of the most widespread chronic disease. Although many medications are available for the treatment and prevention of diabetes, many people turn to nutritional supplements (NSs). In these years, the online sales have contributed to the growth of use of nutritional supplement. The aim of the research was to investigate the type of information provided by sales websites on NSs, and analyse the existence of scientific evidence about some of the most common ingredients found in available NSs for diabetes.

Methods

A web search was conducted in April 2012 to identify web sites selling NSs in the treatment of diabetes using Google, Yahoo and Bing! and the key word used was “diabetes nutritional supplements”. Website content was evaluated for the quality of information available to consumers and for the presence of a complete list of ingredients in the first NS suggested by the site. Subsequently, in order to analyze the scientific evidence on the efficacy of these supplements a PubMed search was carried out on the ingredients that were shared in at least 3 nutritional supplements.

Results

A total of 10 websites selling NSs were selected. Only half of the websites had a Food and Drug Administration disclaimer and 40% declared clearly that the NS offered was not a substitute for proper medication. A total of 10 NS ingredients were searched for on PubMed. Systematic reviews, meta-analyses or randomized control trials were present for all the ingredients except one. Most of the studies, however, were of poor quality and/or the results were conflicting.

Conclusions

Easy internet access to NSs lacking in adequate medical information and strong scientific evidence is a matter of public health concern, mainly considering that a misleading information could lead to an improper prevention both in healthy people and people suffering from diabetes. There is a clear need for more trials to assess the efficacy and safety of these NSs, better quality control of websites, more informed physicians and greater public awareness of these widely used products.

Physician-patient communication about dietary supplements

OBJECTIVE

Describe the content and frequency of provider-patient dietary supplement discussions during primary care office visits.

METHODS

Inductive content analysis of 1477 transcribed audio-recorded office visits to 102 primary care providers was combined with patient and provider surveys. Encounters were collected in Los Angeles, CA (2009-2010), geographically diverse practice settings across the United States (2004-2005), and Sacramento, CA (1998-1999).

RESULTS

Providers discussed 738 dietary supplements during encounters with 357 patients (24.2% of all encounters in the data). They mentioned: (1) reason for taking the supplement for 46.5% of dietary supplements; (2) how to take the supplement for 28.2%; (3) potential risks for 17.3%; (4) supplement effectiveness for 16.7%; and (5) supplement cost or affordability for 4.2%. Of these five topics, a mean of 1.13 (SD=1.2) topics were discussed for each supplement. More topics were reviewed for non-vitamin non-mineral supplements (mean 1.47 (SD=1.2)) than for vitamin/mineral supplements (mean 0.99 (SD=1.1); p<0.001).

CONCLUSION

While discussions about supplements are occurring, it is clear that more discussion might be needed to inform patient decisions about supplement use.

PRACTICE IMPLICATIONS

Physicians could more frequently address topics that may influence patient dietary supplement use, such as the risks, effectiveness, and costs of supplements.

Long chain omega-3 dietary supplements: a review of the National Library of Medicine Herbal Supplement Database

BACKGROUND

Dietary fish oil supplements are increasingly used as an alternative to prescription-grade omega-3 fatty acids (P-OM3) for the treatment of hypertriglyceridemia. The content of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in these supplement products varies widely and may result in a suboptimal response. The aim of this study was to review marketed fish oil supplements and to develop a reference for clinicians to compare products.

METHODS

The National Library of Medicine Herbal Supplement Database was systematically searched using fish oil, EPA, DHA, and omega-3 fatty acid as search terms. Daily doses needed to achieve the Food and Drug Administration (FDA)-approved dose (RxDose) (3,360 mg of combined EPA and DHA) were calculated from the milligrams of EPA and DHA per serving, and suggested retail prices were used to calculate monthly cost of each product. A "usage criteria" was set to highlight products at the RxDose with a monthly cost of <$50, daily servings <8, daily amount of vitamins A and D less than or equal to the U.S. Dietary Reference Intake upper limit defined as 10,000 and 4,000 IU, respectively, and if the product was U.S. Pharmacopeia verified.

RESULTS

A total of 163 products were identified, and 102 nonliquid and liquid products met our entry criteria. The median amount of EPA and DHA per serving in the nonliquid products was 216 mg and 200 mg, respectively, and the median number of servings at the RxDose was 11.2 at a median monthly cost of $63.49. The median amount of EPA (460 mg) and DHA (400 mg) per serving in the liquid products was higher than the nonliquid products. Thus, the median number of servings at the RxDose was only 3.6 teaspoons and the median monthly cost of $13.60. Only 22% of products met our "usage criteria."

CONCLUSIONS

The amount of EPA and DHA per recommended serving in these products was highly variable. Clinicians should heighten their scrutiny in terms of selection of the appropriate product.

Readability of patient and health care professional targeted dietary supplement leaflets used for diabetes and chronic fatigue syndrome

OBJECTIVES

The purpose of this study was to assess readability of patient and health care professional targeted dietary supplement (DS) leaflets used for diabetes mellitus (DM) and chronic fatigue syndrome (CFS) with a novel measurement tool and Flesch-Kincaid Grade Level (FKGL).

METHODS

Patient and professional leaflets for DS used to treat DM and CFS from the Natural Medicines Comprehensive Database (NMCD) and Natural Standard (NS) databases were evaluated. Leaflets were analyzed using FKGL and the author-developed health information readability analyzer (HIReA). HIReA integrates lexical, semantic, syntactic, cohesion, and style features and yields values of -1 (very hard) to 1 (very easy).

RESULTS

Patient-targeted leaflets substantially exceeded the consensus readability level (6th grade) as assessed by both FKGL (grade 13.0767) and HIReA (-0.2360). Professional leaflets were similarly more difficult to read as scored by HIReA (-0.7065) and FKGL (grade 14.7429). Most and least difficult-to-read sections in patient leaflets (NS/NMCD) were Related Terms (-0.8863)/Other Names (-0.8146), and Safety Concerns (0.0821)/Scientific Evidence (0.0629), respectively. Overall, leaflets in NS (-0.5721) were more difficult to read than those in NMCD (-0.3704). These differences appeared to be less pronounced when FKGL was used to assess the readability, indicating its lack of preciseness.

CONCLUSIONS

Readability for patient targeted DS leaflets is far more difficult than recommended levels. HIReA is a more precise method to measure readability than FKGL. The disparity between targeted levels of readability and measured levels may contribute to a lack of understanding by patients, with a resulting negative impact on adherence and outcomes.

Clinical and analytical toxicology of dietary supplements: a case study and a review of the literature

The use of dietary supplements has grown dramatically in the last decade. A large number of dietary and herbal supplements escape regulatory and quality control; components of these preparations are poisonous and may contain, among other toxins, heavy metals. Uncontrolled use of dietary and herbal supplements by special populations, such as the military, may therefore pose a health risk. Clinical symptoms are not always properly attributed to dietary supplements; patients often do not mention supplement use to their health care provider. Therefore, a health risk estimate is hard to make on either the individual or the population level. The literature on this issue was reviewed and discussed in the light of a representative clinical-chemical case study. This case study was performed on a host of preparations that were used by one single individual in the military. Both essential (chromium, copper, zinc, and iron) and poisonous (arsenic, lead, and nickel) trace elements were determined using inductively coupled plasma combined with optical emission spectrometry (ICP-OES) or with mass spectrometry (ICP-MS). Arsenic and lead were detected at exposure levels associated with health risks. These health risks were detected predominantly in hormone-containing supplements and the herbs and botanicals used for performance enhancement. To the extent that this is a representative sample, there is an underestimation of supplement use and supplement risk in the US military, if not in the general population. Since clinical symptoms may be attributed to other causes and, unless patients are specifically asked, health care providers may not be aware of their patients' use of dietary supplements, a strong support of laboratory diagnostics, such as a toxicological screening of blood or urine, is required. In addition, screening of the preparations themselves may be advised.