An overview of herb and dietary supplement efficacy, safety and government regulations in the United States with suggested improvements. Part 1 of 5 series

Natural Product Use Among Veterans with Chronic Pain: A Qualitative Study of Attitudes and Communication with Healthcare Providers

BACKGROUND

Despite mixed evidence regarding the safety and efficacy of natural products, many are marketed for pain and related symptoms. Use of these products is prevalent among veterans, who have disproportionately high rates of chronic pain. To date, however, there is limited research on veterans' beliefs and attitudes about natural products and their communication with healthcare providers about their natural product use.

OBJECTIVE

To explore how veterans experiencing chronic pain make decisions about natural product use, to investigate veterans' beliefs about the safety and efficacy of these products, and to examine veterans' experiences discussing natural products with their providers.

DESIGN

Qualitative sub-study conducted as a supplement to a pragmatic randomized controlled trial for chronic pain management.

PARTICIPANTS

Twenty veterans experiencing chronic pain who reported using natural products for pain management or related health concerns.

APPROACH

Qualitative interviews with veterans were conducted over the phone and audio-recorded. Interviews were guided by an original semi-structured interview guide and qualitative data were analyzed using a template-based rapid analysis technique.

KEY RESULTS

Veterans with chronic pain may perceive natural products as safer than pharmaceutical products and may prefer to use natural products. Talking with providers about natural products is important to veterans, who would like information regarding the safety and potential for interaction of natural products with pharmaceutical products. However, veterans were frequently disappointed with these conversations. Veterans felt their providers demonstrated biases against natural products, which negatively impacted patient-provider relationships.

CONCLUSIONS

Veterans wish to have more productive conversations with providers about natural products. They value providers' open-mindedness towards natural products and transparency about limitations in their knowledge. Suggestions for how providers and healthcare systems might better support veterans interested in natural products are discussed.

Mitigating Traumatic Brain Injury: A Narrative Review of Supplementation and Dietary Protocols

Traumatic brain injuries (TBIs) constitute a significant public health issue and a major source of disability and death in the United States and worldwide. TBIs are strongly associated with high morbidity and mortality rates, resulting in a host of negative health outcomes and long-term complications and placing a heavy financial burden on healthcare systems. One promising avenue for the prevention and treatment of brain injuries is the design of TBI-specific supplementation and dietary protocols centred around nutraceuticals and biochemical compounds whose mechanisms of action have been shown to interfere with, and potentially alleviate, some of the neurophysiological processes triggered by TBI. For example, evidence suggests that creatine monohydrate and omega-3 fatty acids (DHA and EPA) help decrease inflammation, reduce neural damage and maintain adequate energy supply to the brain following injury. Similarly, melatonin supplementation may improve some of the sleep disturbances often experienced post-TBI. The scope of this narrative review is to summarise the available literature on the neuroprotective effects of selected nutrients in the context of TBI-related outcomes and provide an evidence-based overview of supplementation and dietary protocols that may be considered in individuals affected by-or at high risk for-concussion and more severe head traumas. Prophylactic and/or therapeutic compounds under investigation include creatine monohydrate, omega-3 fatty acids, BCAAs, riboflavin, choline, magnesium, berry anthocyanins, Boswellia serrata, enzogenol, N-Acetylcysteine and melatonin. Results from this analysis are also placed in the context of assessing and addressing important health-related and physiological parameters in the peri-impact period such as premorbid nutrient and metabolic health status, blood glucose regulation and thermoregulation following injury, caffeine consumption and sleep behaviours. As clinical evidence in this research field is rapidly emerging, a comprehensive approach including appropriate nutritional interventions has the potential to mitigate some of the physical, neurological, and emotional damage inflicted by TBIs, promote timely and effective recovery, and inform policymakers in the development of prevention strategies.

Kratom: a primer for pain physicians

PURPOSE OF REVIEW

Kratom is used commonly in the United States, usually to mitigate pain, opioid withdrawal, or fatigue. A comprehensive discussion on kratom, tailored to pain management physicians, is needed, given its associated risks and potential interactions.

RECENT FINDINGS

Kratom and its main metabolites, mitragynine and 7-OH-mitragynine, bind to a variety of receptors including mu opioid receptors. Still, kratom cannot be described as a classic opioid. Kratom has been utilized without FDA approval as an alternative to traditional medications for opioid use disorder and opioid withdrawal. Lower doses of kratom typically cause opioid-like effects while higher doses can have sedating effects. Tolerance, dependence and withdrawal still occur, although kratom withdrawal appears to be more moderate than opioid withdrawal. Contamination with heavy metals and biological toxins is concerning and there is potential for serious complications, including seizures and death.

SUMMARY

The use of kratom as an opioid-sparing alternative as a part of a multimodal pain regimen is not without significant risks. It is of utmost importance for pain physicians to be aware of the risks and adverse effects associated with kratom use.

Bitter yet beneficial: The dual role of dietary alkaloids in managing diabetes and enhancing cognitive function

With the rising prevalence of diabetes and its association with cognitive impairment, interest in the use of dietary alkaloids and other natural products has grown significantly. Understanding how these compounds manage diabetic cognitive dysfunction (DCD) is crucial. This comprehensive review explores the etiology of DCD and the effects of alkaloids in foods and dietary supplements that have been investigated as DCD therapies. Data on how dietary alkaloids like berberine, trigonelline, caffeine, capsaicin, 1-deoxynojirimycin, nuciferine, neferine, aegeline, tetramethylpyrazine, piperine, and others regulate cognition in diabetic disorders were collected from PubMed, Research Gate, Web of Science, Science Direct, and other relevant databases. Dietary alkaloids could improve memory in behavioral models and modulate the mechanisms underlying the cognitive benefits of these compounds, including their effects on glucose metabolism, gut microbiota, vasculopathy, neuroinflammation, and oxidative stress. Evidence suggests that dietary alkaloids hold promise for improving cognition in diabetic patients and could open exciting avenues for future research in diabetes management.

Association between genetically proxied glucosamine and risk of cancer and non-neoplastic disease: A Mendelian randomization study

Introduction

Observational investigations have examined the impact of glucosamine use on the risk of cancer and non-neoplastic diseases. However, the findings from these studies face limitations arising from confounding variables, reverse causation, and conflicting reports. Consequently, the establishment of a causal relationship between habitual glucosamine consumption and the risk of cancer and non-neoplastic diseases necessitates further investigation.

Methods

For Mendelian randomization (MR) investigation, we opted to employ single-nucleotide polymorphisms (SNPs) as instruments that exhibit robust associations with habitual glucosamine consumption. We obtained the corresponding effect estimates of these SNPs on the risk of cancer and non-neoplastic diseases by extracting summary data for genetic instruments linked to 49 varied cancer types amounting to 378,284 cases and 533,969 controls, as well as 20 non-neoplastic diseases encompassing 292,270 cases and 842,829 controls. Apart from the primary analysis utilizing inverse-variance weighted MR, we conducted two supplementary approaches to account for potential pleiotropy (MR-Egger and weighted median) and assessed their respective MR estimates. Furthermore, the results of the leave-one-out analysis revealed that there were no outlying instruments.

Results

Our results suggest divergence from accepted biological understanding, suggesting that genetically predicted glucosamine utilization may be linked to an increased vulnerability to specific illnesses, as evidenced by increased odds ratios and confidence intervals (95% CI) for diseases, such as malignant neoplasm of the eye and adnexa (2.47 [1.34-4.55]), benign neoplasm of the liver/bile ducts (2.12 [1.32-3.43]), benign neoplasm of the larynx (2.01 [1.36-2.96]), melanoma (1.74 [1.17-2.59]), follicular lymphoma (1.50 [1.06-2.11]), autoimmune thyroiditis (2.47 [1.49-4.08]), and autoimmune hyperthyroidism (1.93 [1.17-3.18]). In contrast to prior observational research, our genetic investigations demonstrate a positive correlation between habitual glucosamine consumption and an elevated risk of sigmoid colon cancer, lung adenocarcinoma, and benign neoplasm of the thyroid gland.

Conclusion

Casting doubt on the purported purely beneficial association between glucosamine ingestion and prevention of neoplastic and non-neoplastic diseases, habitual glucosamine ingestion exhibits dichotomous effects on disease outcomes. Endorsing the habitual consumption of glucosamine as a preventative measure against neoplastic and non-neoplastic diseases cannot be supported.

Development of a screener to assess athlete risk behavior of not using third-party tested nutritional supplements

Introduction

The aim of this cross-sectional study was to develop an algorithm to predict athletes use of third-party tested (TPT) supplements. Therefore, a nutritional supplement questionnaire was used with a section about self-reported TPT supplement use.

Methods

Outcomes were randomly assigned to a training dataset to identify predictors using logistic regression models, or a cross-validation dataset. Training data were used to develop an algorithm with a score from 0 to 100 predicting use or non-use of TPT nutritional supplements.

Results

A total of n = 410 NCAA Division I student-athletes (age: 21.4 ± 1.6 years, 53% female, from >20 sports) were included. Then n = 320 were randomly selected, of which 34% (n = 109) of users consistently reported that all supplements they used were TPT. Analyses resulted in a 10-item algorithm associated with use or non-use of TPT. Risk quadrants provided the best fit for classifying low vs. high risk toward inconsistent TPT-use resulting in a cut-off ≥60% (χ2(4) = 61.26, P < 0.001), with reasonable AUC 0.78. There was a significant association for TPT use (yes/no) and risk behavior (low vs. high) defined from the algorithm (χ2(1)=58.6, P < 0.001). The algorithm had a high sensitivity, classifying 89% of non-TPT users correctly, while having a low specificity, classifying 49% of TPT-users correctly. This was confirmed by cross-validation (n = 34), reporting a high sensitivity (83%), despite a lower AUC (0.61).

Discussion

The algorithm classifies high-risk inconsistent TPT-users with reasonable accuracy, but lacks the specificity to classify consistent users at low risk. This approach should be useful in identifying athletes that would benefit from additional counseling.

In vitro anti-HIV, cytotoxicity and nutritional analysis of Trianthema portulacastrum L. (Aizoaceae)

The development of antiretroviral therapy has brought a tremendous relief to the world as it minimizes mortality, reduces HIV transmission, and suppresses progression in infected patients. However, the orthodox antiretroviral therapy is faced with limitations which have necessitated a continuous search for more novel plant-based antiviral compounds, which can bypass the existing barriers created by drug resistance and target more viral proteins. Despite the edibility and enormous pharmacological benefits of T. portulacastrum, little is known about its nutrient profiles and potential use as a natural source of antiviral drug. This study focuses on the full feed analysis and anti-HIV potential of two biotypes of T. portulacastrum. Ethanolic extracts of both biotypes of T. portulacastrum (T01 and T02) had significant inhibitory effects on the level of replication of the HIV-1. Both extracts induced the inhibition of at least 50% of the HIV-1 viral load at considerably low IC50 values of 1.757 mg/mL (T01) and 1.205 mg/mL (T02) which is comparable to the AZT standard. The protein composition ranged between 8.63-22.69%; fat (1.84-4.33%); moisture (7.89-9.04%); fibre (23.84-49.98%); and carbohydrate content (38.54-70.14%). Mineral contents of tested T. portulacastrum varied considerably in different parts of the plant. Nitrogen N mineral ranged between 13.8-36.3 mg/g; sodium Na (2.0-14.0 mg/g); potassium K (14.0-82.0 mg/g); magnesium Mg (2.8-7.1 mg/g); calcium Ca (9.1-24.7 mg/g); phosphorus P (1.3-3.6 mg/g); iron Fe (193.5-984.0 ppm); zinc Zn (42.5-96.0 ppm); manganese Mn (28.5-167.5 ppm); and copper Cu (2.0-8.5 ppm). These mineral values are comparable or higher than values quoted for common vegetables, suggesting that T. portulacastrum is a nutrient-dense vegetable that could provide alternative sources of antiviral nutrients to HIV-infected individuals. Further studies are recommended to unravel key metabolites responsible for high nutrient profiles and antiretroviral effects in T. portulacastrum.

Trends in Coprescription Among Taiwanese Children from 2002 to 2012

Purpose

Coprescription means that patients use different prescription medications at the same time, which can lead to polypharmacy and subsequent complications. In Taiwan, prescriptions can be ordered by Western physicians, traditional Chinese physicians and dentists. It is essential to disclose the trends in coprescription to prevent possible polypharmacy among children.

Patients and Methods

We used the Longitudinal Health Insurance Database 2000 in Taiwan. Children <18 years old who had coprescription from 2002 to 2012 are included. The odds ratio and 95% confidence interval are estimated by a logistic regression model to evaluate the correlation between basic characteristics and coprescription.

Results

A total of 44,801 children are included in the analysis. The numbers of children with coprescription and the numbers of coprescriptions ordered for children increased with calendar years. Children aged 3-5 year and 6-8 years constituted the majority of coprescriptions, while those aged <3 years constituted the minority of coprescriptions. Compared to those in the Western medication-alone group, aged 3-5 years and children who lived in central and southern Taiwan are more likely to have coprescription.

Conclusion

Coprescription among Taiwanese children is not uncommon. Healthcare providers, policymakers and parents should be aware of the real coprescription situation among the children.

Vanillin serves as a potential substitute for chemical chelator desferal in iron-overloaded mice

PURPOSE

Iron toxicity occurs under iron-overloaded settings, such as a high iron diet and blood transfusion, and damages important organs. Vanillin has been proven to have potential iron chelation capability. Given the negative effects of commonly used iron chelators like deferoxamine (DFO), we sought to examine the iron chelation potency of vanillin and evaluate its potential effect in the treatment of iron overload-related disorders.

METHODS

42 male NMRI mice were prepared for this purpose, and except for the negative control group, iron overload conditions were generated in them by injecting iron. Then normal saline (as a control), vanillin, and DFO (n = 7) were subsequently given to iron-overloaded mice. In the following, the activity of antioxidant enzymes catalase and superoxide dismutase were measured in the blood serum, brain, kidney, spleen, lung, and liver tissues of mice. Furthermore, the level of lipid peroxidation was determined by measuring the amount of malondialdehyde. Also, Perl's and H&E staining were used to examine the physiopathology changes of tissues.

FINDINGS

Vanillin, a natural antioxidant compound, outperformed deferoxamine, a chemical iron chelator. Along with a decrease in iron content, the activity of catalase and superoxide dismutase enhanced in the iron-overloaded groups that were treated with vanillin. The level of lipid peroxidation was also declined in the iron-overloaded mice receiving vanillin.

CONCLUSION

Vanillin can be used as a suitable substitute for chemical chelators with fewer side effects and equivalent efficiency. We encourage the use of this compound as a natural iron chelator following performing additional safety and efficacy studies.

Ashwagandha-induced liver injury-A case series from India and literature review

BACKGROUND

Ashwagandha herb is commonly used in Ayurveda and a "fad" dietary supplement for a host of indications based on low levels of evidence. Recently, ashwagandha was implicated in multiple reports of herb-induced liver injury (HILI), mainly from the United States. We present the first, and currently largest, series of ashwagandha-HILI from multiple centers in India.

METHODS

We retrospectively analyzed the respective institutional electronic medical records for ashwagandha-HILI. Patients consuming ashwagandha as part of multiherbal formulations or along with other known hepatotoxic supplements or medicines were excluded. All patients underwent a detailed diagnostic workup to exclude competing causes reasonably. Where possible, the implicated herbal formulation was retrieved and subjected to chemical analysis.

RESULTS

Out of 23 patients with liver injury from ashwagandha (January 2019 to December 2022), we report 8 patients with single-ingredient formulation-related HILI. Study cohort was male predominant, and cholestatic hepatitis was the commonest presentation. Five patients had underlying chronic liver disease; 3 presented with acute-on-chronic liver failure, and all 3 died on follow-up. In others, the liver injury was prolonged, nonetheless self-limiting. Liver biopsy revealed cholestatic features predominantly with hepatocellular necrosis and lymphocyte/eosinophil predominant portal-based inflammation. One patient progressed to chronic HILI. Chemical analysis revealed only natural phytochemicals without adulteration or contamination.

CONCLUSIONS

Ashwagandha-HILI presents with cholestatic hepatitis and can lead to the syndrome of acute-on-chronic liver failure with high mortality in those with pre-existing liver disease. Educating the public on avoiding the use of potentially toxic and unrecommended herbal supplements can help mitigate the avoidable liver disease burden in the community.

Prevalence of adulteration in dietary supplements and recommendations for safe supplement practices in sport

The prevalence of dietary supplement use among athletes continues to rise with 60-80% of athletes often reporting current or previous use of dietary supplements. While select dietary ingredients have been shown to improve acute performance and enhance training adaptations over time, it is important to still consider the risk vs. reward for athletes before opting to consume a dietary supplement. Previous work has indicated that certain dietary supplements may pose risks for inadvertent doping, may be susceptible to mislabelling, could be banned by certain governing bodies of sport, or pose health risks for certain populations. The purpose of the current narrative review is to summarize the prevalence of adulteration in dietary sport supplement products, outline the risks of inadvertent doping for athletes, and highlight best practices regarding safe supplementation strategies. Analytical studies have found anywhere from 14 to 50% of samples analyzed from dietary supplement products have tested positive for anabolic agents or other prohibited substances. It is important for the consumer to adhere to safe supplementation strategies, which include following serving size recommendations, cross-referencing ingredient profiles with the list of prohibited substances, choosing quality products that have been verified by a third-party certification program, and being cognizant of consuming multiple dietary supplement products with overlapping ingredient profiles. Once these practices have been considered, it is reasonable for an athlete to utilize dietary supplements as a strategy to optimize performance and health, with a low risk of failing a drug test (adverse analytical finding) and experiencing adverse events.

A Global Overview of Dietary Supplements: Regulation, Market Trends, Usage during the COVID-19 Pandemic, and Health Effects

Over the last 20 years, the use of dietary supplements (DS) has continued to grow in many countries. Due to the public health crisis brought on by the COVID-19 pandemic and amidst fears regarding COVID-19 vaccines and their low supply in many regions of the world, there has been a marked interest in the use of DS as alternative means of protecting against and treating this emerging disease, as well as boosting the immune system and minimizing the risk of inflammation. Despite a lack of evidence to suggest their efficacy, a surge in the sales of DS has been reported in many parts of the world. Questions have also been raised about the health effects associated with DS due to their increased use during the health crisis. Numerous scientific studies have demonstrated their beneficial properties as well as some adverse and even toxic effects. In addition, given the current global interest in this issue, a review is needed to establish the status of dietary supplements before and during the health crisis. The aim of this review is to summarize the current evidence on the impact of dietary supplements on the incidence of the COVID-19 pandemic, as well as their regulation and associated market trends. First, we provide an overview of DS, including a comprehensive review of the legislative and regulatory aspects of DS in the USA, China, the EU, and Algeria. Second, we describe the prevalence of the most commonly consumed DS and their efficacy as a prophylactic modality in the era of COVID-19. Additionally, we examine the structure and size of the DS market in the countries that predominantly produce and import them, its global market trend, and the impact of the COVID-19 pandemic on market growth. Finally, in this review, we also discuss the profile of DS users.

Athletes Perceived Level of Risk Associated with Botanical Food Supplement Use and Their Sources of Information

Athletes should carefully consider the use of botanical food supplements (BFSs) given the current lack of substantiation for botanical nutrition and health claims under EU and UK food laws. In addition, athletes may be at an increased risk of doping violations and other adverse outcomes potentially associated with BFS use; however, little is known about athletes' intake, knowledge, or perceptions in relation to BFS use. An online cross-sectional survey of n = 217 elite and amateur athletes living on the island of Ireland was conducted using Qualtrics XM to assess intake, knowledge, attitudes, and perceptions. General food supplements (FSs) were reported by approximately 60% of the study cohort, and 16% of the supplements reported were categorized as BFS. The most frequently consumed BFSs were turmeric/curcumin (14%), Ashwagandha (10%), and Beetroot extract (8%). A higher proportion of amateur athletes would source information about BFSs from less credible sources, such as fellow athletes, or from internet sources or their coach, compared to elite athletes. Those who sourced information about botanicals from fellow athletes (p = 0.03) or the internet (p = 0.02) reported a lower perceived level of risks associated with BFS use. This study therefore suggests that amateur athletes may be more likely to source information from less credible sources compared to elite athletes who may have more access to nutrition professionals and their knowledge/advice. This may have potential adverse implications for amateur athletes, e.g., Gaelic games players, who are included within the doping testing pool but who may not have access to evidence-based nutrition advice.

Universal Training Precautions: A Review of Evidence and Recommendations for Prevention of Exercise-Related Injury, Illness, and Death in Warfighters and Athletes

Facing pressure to train for victory, warfighters and athletes encounter numerous health risks that are directly related to their regular physical training. The concept of universal training precautions (UTPs) signifies universal processes designed to prevent unnecessary bodily harm, including injury, illness, and death, during physical training programs. Although no formal guidelines exist for collectively implementing a defined set of UTPs to address a broad scope of exercise-related health risks, recommendations and guidelines have been published relating to preventing sudden death during high school sports and collegiate conditioning sessions. A long list of critical topics must be considered as UTPs, including physical fitness factors, transition-period accommodation, hydration, environmental factors and acclimatization, appropriate recovery, use of medications and dietary supplements, and importantly, leadership. In this article, we outline in detail, with corresponding Strength of Recommendation Taxonomy ratings, what should be considered universal recommendations to minimize the risk of warfighters and athletes coming to harm when participating in group physical activities.

Association between Consumption of Dietary Supplements and Chronic Kidney Disease Prevalence: Results of the Korean Nationwide Population-Based Survey

Despite the enormous global market of dietary supplements, the impact of dietary supplements on kidney disease is still unclear. Based on the National Health and Nutrition Examination Survey from 2015 to 2017, this study evaluated the association between dietary supplement and chronic kidney disease (CKD) in 13,271 Korean adults. Among the dietary supplements, vitamin and mineral intake was the highest at 61.41%, followed by omega-3 fatty acids at 11.85%, and ginseng at 7.99%. The prevalence of CKD was significantly higher in those who consumed amino acids and proteins, ginseng and red ginseng, and herbal medicine (plant extract)-berries than in those who did not. Conversely, patients who consumed probiotic supplements had a significantly lower prevalence of CKD than those who did not. In the population without CKD risk factors or history of CKD, the prevalence of CKD was high in the group consuming ginseng and red ginseng. After adjusting for covariates, the herbal medicine (plant extract)-berry group showed an independent association with CKD incidence. In conclusion, it is suggested that dietary supplements may affect kidney function. Further large-scale cohort studies are required to elucidate the exact effects of each dietary supplement on CKD.

Off the Beaten Path: Caring for People Engaging in Potentially Unsafe Low Evidence Therapies

Palliative care clinicians regularly care for patients with serious illnesses, many of whom are engaging in the use of complementary and alternative medicine (CAM) either alone or along with conventional medical therapies. A subset of these patients may be engaging in therapies that have little or no evidence for efficacy and carry significant potential risks to their health. These therapies, however, may carry a great deal of significance for the patient and family for whom conventional medicine has failed or is otherwise deemed untenable. Dismissing such therapies as "quackery" risks alienating patients and damaging or even severing a therapeutic relationship. When faced with patients who are engaging in potentially unsafe low-evidence therapies (PULETs), clinicians themselves may experience a great deal of moral distress when deciding how to balance supporting the hope PULETs may represent with the principles of nonmaleficence and autonomy. In this article, we will review the definition of PULETs and distinguish them from most CAM therapies. Drawing upon existing writings in the CAM literature, we will then review a framework to evaluate the relative risk/benefit ratio of such therapies followed by a review of the ethical and legal aspects of care. Finally, utilizing existing principles and tools in emotion-based communication, we present a communication approach to foster continued collaboration and care for patients who engage in PULETs.

Omics as a Tool to Help Determine the Effectiveness of Supplements

There has been considerable interest in dietary supplements in the last two decades. Companies are releasing new specifics at an alarming pace, while dietary supplements are one of the less-studied substances released for public consumption. However, access to state-of-the-art and high-throughput techniques, such as the ones used in omics, make it possible to check the impact of a substance on human transcriptome or proteome and provide answers to whether its use is reasonable and beneficial. In this review, the main domains of omics are briefly introduced. The review focuses on the three most widely used omics techniques: NGS, LC-MS, NMR, and their usefulness in studying dietary supplements. Examples of studies are described for some of the most commonly supplemented substances, such as vitamins: D, E, A, and plant extracts: resveratrol, green tea, ginseng, and curcumin extract. Techniques used in omics have proven to be useful in studying dietary supplements. NGS techniques are helpful in identifying pathways that change upon supplementation and determining polymorphisms or conditions that qualify for the necessity of a given supplementation. LC-MS techniques are used to establish the serum content of supplemented a compound and its effects on metabolites. Both LC-MS and NMR help establish the actual composition of a compound, its primary and secondary metabolites, and its potential toxicity. Moreover, NMR techniques determine what conditions affect the effectiveness of supplementation.

Hepatotoxicity due to herbal dietary supplements: Past, present and the future

Dietary supplements (DS) constitute a widely used group of products comprising vitamin, mineral, and botanical extract formulations. DS of botanical or herbal origins (HDS) comprise nearly 30% of all DS and are presented on the market either as single plant extracts or multi-extract-containing products. Despite generally safe toxicological profiles of most products currently present on the market, rising cases of liver injury caused by HDS - mostly by multi-ingredient and adulterated products - are of particular concern. Here we discuss the most prominent historical cases of HDS-induced hepatotoxicty - from Ephedra to Hydroxycut and OxyELITE Pro-NF, as well as products with suspected hepatotoxicity that are either currently on or are entering the market. We further provide discussion on overcoming the existing challenges with HDS-linked hepatotoxicity by introduction of advanced in silico, in vitro, in vivo, and microphysiological system approaches to address the matter of safety of those products before they reach the market.

Comparison of nutritional supplements for glycemic control in type 2 diabetes: A systematic review and network meta-analysis of randomized trials

AIMS

Direct and indirect evidence were combined in this systematic-review and network meta-analysis (NMA) to assess and compare the effect of nutritional supplements on glycemic control, and rank the supplements accordingly.

METHODS

PubMed, Scopus, and Web of Science were searched up to April 2021. We included randomized controlled trials that investigated the effect of vitamins D, C, and E, magnesium, zinc, calcium, selenium, and omega-3 on at least one glycemic marker, including glycated hemoglobin (HbA1c), fasting blood sugar (FBS), homeostasis model assessment-estimated insulin resistance (HOMA-IR), HOMA-B, and insulin, in adults with type 2 diabetes. To estimate effectiveness of supplements, a random-effects NMA in the Bayesian framework was applied. To assess risk of bias, Cochrane Collaboration Tool was used.

RESULTS

Analysis of 178 studies indicated that zinc, vitamin D, omega-3, vitamin C, and vitamin E were effective in reducing HbA1c with low certainty. For reduction of FBS, zinc, vitamin D, and vitamin C, and for HOMA-IR, vitamin D were effective with low certainty. None of the supplements were effective in the reduction of insulin and HOMA-B with low certainty. After excluding poor-quality studies, only vitamin D was significantly effective in reducing all of the markers. Consistently, when the analysis was restricted to studies with a duration of ≥12-weeks, vitamin D reduced HbA1c, FBS, and HOMA-IR.

CONCLUSIONS

Vitamin D supplementation was more effective compared to other supplements in improving HbA1c, FBS, and HOMA-IR, albeit with low certainty of evidence. This result was confirmed by low-risk of bias studies.

REGISTRATION

CRD42021240691.

Bioactive nutraceutical ligands and their efficiency to chelate elemental iron of varying dynamic oxidation states to mitigate associated clinical conditions

The natural bioactive or nutraceuticals exhibit several health benefits, including anti-inflammatory, anti-cancer, metal chelation, antiviral, and antimicrobial activity. The inherent limitation of nutraceuticals or bioactive ligand(s) in terms of poor pharmacokinetic and other physicochemical properties affects their overall therapeutic efficiency. The excess of iron in the physiological compartments and its varying dynamic oxidation state [Fe(II) and Fe(III)] precipitates various clinical conditions such as non-transferrin bound iron (NTBI), labile iron pool (LIP), ferroptosis, cancer, etc. Though several natural bioactive ligands are proposed to chelate iron, the efficiency of bioactive ligands is limited due to poor bioavailability, denticity, and other related physicochemical properties. The present review provides insight into the relevance of studying the dynamic oxidation state of iron(II) and iron(III) in the physiological compartments and its clinical significance for selecting diagnostics and therapeutic regimes. We suggested a three-pronged approach, i.e., diagnosis, selection of therapeutic regime (natural bioactive), and integration of novel drug delivery systems (NDDS) or nanotechnology-based principles. This systematic approach improves the overall therapeutic efficiency of natural iron chelators to manage iron overload-related clinical conditions.

Discovering novel drug-supplement interactions using SuppKG generated from the biomedical literature

Objective:

Develop a novel methodology to create a comprehensive knowledge graph (SuppKG) to represent a domain with limited coverage in the Unified Medical Language System (UMLS), specifically dietary supplement (DS) information for discovering drug-supplement interactions (DSI), by leveraging biomedical natural language processing (NLP) technologies and a DS domain terminology.

Materials and Methods:

We created SemRepDS (an extension of an NLP tool, SemRep), capable of extracting semantic relations from abstracts by leveraging a DS-specific terminology (iDISK) containing 28,884 DS terms not found in the UMLS. PubMed abstracts were processed using SemRepDS to generate semantic relations, which were then filtered using a PubMedBERT model to remove incorrect relations before generating SuppKG. Two discovery pathways were applied to SuppKG to identify potential DSIs, which are then compared with an existing DSI database and also evaluated by medical professionals for mechanistic plausibility.

Results:

SemRepDS returned 158.5% more DS entities and 206.9% more DS relations than SemRep. The fine-tuned PubMedBERT model (significantly outperformed other machine learning and BERT models) obtained an F1 score of 0.8605 and removed 43.86% of semantic relations, improving the precision of the relations by 26.4% over pre-filtering. SuppKG consists of 56,635 nodes and 595,222 directed edges with 2,928 DS-specific nodes and 164,738 edges. Manual review of findings identified 182 of 250 (72.8%) proposed DS-Gene-Drug and 77 of 100 (77%) proposed DS-Gene1-Function-Gene2-Drug pathways to be mechanistically plausible.

Discussion:

With added DS terminology to the UMLS, SemRepDS has the capability to find more DS-specific semantic relationships from PubMed than SemRep. The utility of the resulting SuppKG was demonstrated using discovery patterns to find novel DSIs.

Conclusion:

For the domain with limited coverage in the traditional terminology (e.g., UMLS), we demonstrated an approach to leverage domain terminology and improve existing NLP tools to generate a more comprehensive knowledge graph for the downstream task. Even this study focuses on DSI, the method may be adapted to other domains.

Aphrodisiac Performance of Bioactive Compounds from Mimosa pudica Linn.: In Silico Molecular Docking and Dynamics Simulation Approach

Plants and their derived molecules have been traditionally used to manage numerous pathological complications, including male erectile dysfunction (ED). Mimosa pudica Linn. commonly referred to as the touch-me-not plant, and its extract are important sources of new lead molecules in drug discovery research. The main goal of this study was to predict highly effective molecules from M. pudica Linn. for reaching and maintaining penile erection before and during sexual intercourse through in silico molecular docking and dynamics simulation tools. A total of 28 bioactive molecules were identified from this target plant through public repositories, and their chemical structures were drawn using Chemsketch software. Graph theoretical network principles were applied to identify the ideal target (phosphodiesterase type 5) and rebuild the network to visualize the responsible signaling genes, proteins, and enzymes. The 28 identified bioactive molecules were docked against the phosphodiesterase type 5 (PDE5) enzyme and compared with the standard PDE5 inhibitor (sildenafil). Pharmacokinetics (ADME), toxicity, and several physicochemical properties of bioactive molecules were assessed to confirm their drug-likeness property. Molecular dynamics (MD) simulation modeling was performed to investigate the stability of PDE5–ligand complexes. Four bioactive molecules (Bufadienolide (−12.30 kcal mol⁻¹), Stigmasterol (−11.40 kcal mol⁻¹), Isovitexin (−11.20 kcal mol⁻¹), and Apigetrin (−11.20 kcal mol⁻¹)) showed the top binding affinities with the PDE5 enzyme, much more powerful than the standard PDE5 inhibitor (−9.80 kcal mol⁻¹). The four top binding bioactive molecules were further validated for a stable binding affinity with the PDE5 enzyme and conformation during the MD simulation period as compared to the apoprotein and standard PDE5 inhibitor complexes. Further, the four top binding bioactive molecules demonstrated significant drug-likeness characteristics with lower toxicity profiles. According to the findings, the four top binding molecules may be used as potent and safe PDE5 inhibitors and could potentially be used in the treatment of ED.

Reduction of iron toxicity in the heart of iron-overloaded mice with natural compounds

BACKGROUND

Iron-overload is one of the risk factors in susceptible individuals. Iron-overload causes complications such as diastolic dysfunction, arrhythmias, ventricular dilation, and systolic dysfunction in the heart. Therefore, particular care is needed for those who need blood transfusions or patients with underlying heart diseases.

PURPOSE

In this study, we examined the ability of six compounds, hesperidin, coumarin, caffeic acid, ferulic acid, and vanillin, to reduce the effects of iron-overdose in the heart of iron-overloaded mice.

METHODS

For this purpose, 84 mice were prepared and except for the control group, iron-overload conditions were created in them by injecting iron. The hearts of mice were then harvested and the activities of the antioxidant enzymes catalase and superoxide dismutase were evaluated. Additionally, the amount of lipid peroxidation was measured by assessing the quantity of malondialdehyde. The physiopathology of cardiac tissue was considered by Perl's and H&E staining.

RESULTS

According to the results, almost all natural compounds showed better performance than desferal, as an iron chelator chemical. Meanwhile, hesperidin, vanillin, and ferulic acid were the best antioxidant compounds and were able to improve the activity of antioxidant enzymes by reducing the amount of deposited iron.

CONCLUSION

We recommend the use of the above compounds as natural iron chelators after completing additional studies.

Nutraceuticals and Diet Supplements in Crohn's Disease: A General Overview of the Most Promising Approaches in the Clinic

Crohn's disease (CD) is a chronic inflammatory gastrointestinal disorder requiring lifelong medications. The currently approved drugs for CD are associated with relevant side effects and several studies suggest an increased use of nutraceuticals among CD patients, seeking for what is perceived as a more "natural" approach in controlling this highly morbid condition. Nutraceuticals are foods or foods' components with beneficial health properties that could aid in CD treatment for their anti-inflammatory, analgesic and immunoregulatory activities that come along with safety, high tolerability, easy availability and affordability. Depending on their biological effect, nutraceuticals' support could be employed in different subsets of CD patients, both those with active disease, as adjunctive immunomodulatory therapies, and/or in quiescent disease to provide symptomatic relief in patients with residual functional symptoms. Despite the increasing interest of the general public, both limited research and lack of education from healthcare professionals regarding their real clinical effectiveness account for the increasing number of patients turning to unconventional sources. Professionals should recognize their widespread use and the evidence base for or against their efficacy to properly counsel IBD patients. Overall, nutraceuticals appear to be safe complements to conventional therapies; nonetheless, little quality evidence supports a positive impact on underlying inflammatory activity.

Adverse effects associated with use of specific dietary supplements: The US Military Dietary Supplement Use Study

Dietary supplements (DSs) are used by 50% of Americans and 70% of United States military service members (SMs); some have adverse effects (AEs). This cross-sectional investigation examined AEs associated with specific DSs. A stratified random sample of SMs from the Air Force, Army, Marine Corps, and Navy was obtained. Volunteers completed a questionnaire reporting AEs for 96 generic and 62 specific DSs. The highest prevalence (≥1 AE) in specific DS categories was 35% prohormones, 33% weight loss supplements, 26% pre/post workout supplements, 14% herbal products, 12% multivitamin/multiminerals, 11% protein/amino acids, 9% muscle building supplements, 7% other DSs, 6% joint health products, and 5% individual vitamins/minerals. Specific DSs of concern (with proportion reporting AEs) included: Libido Max® (35%), Hydroxycut Hardcore® (33%), OxyElite® (33%), Roxylean® (31%), Growth Factor 9® (30%), Super HD® (29%), Hydroxycut Advanced® (29%), Lipo 6® (28%), The Ripper® (27%), Test Booster® (27%), Xenadrine Xtreme Thermogenic® (27%), C4 Extreme® (26%), and C4 Origional® (25%). Products marketed for weight loss, use before/after workout, and prohormones had the highest AE prevalence. DSs can contain substances with independent/additive AEs and/or interact with other ingredients or prescribed medications. Methods described here could provide a continuous surveillance system detecting dangerous DSs entering the market.

Coprescription Trends in Western Medicine, Chinese Herbal Medicine and Dental Medicine among Older Adults in Taiwan from 1997 to 2013

BACKGROUND

Coprescription is a potential medical problem for older adults that could induce polypharmacy and subsequent complications. In Taiwan, Chinese herbal medicine (CHM) is popular among the older adults. Investigating the coprescription trends in Western medicine, CHM and dental medicine is important to avoid possible polypharmacy.

METHODS

We analyzed data from the Longitudinal Health Insurance Database 2000 (LHID 2000) in Taiwan. Patients ≥ 60 years old who received coprescription of Western medicine, CHM and drugs for dental care from 1997 to 2013 were included. The odds ratio (OR) and 95% confidence interval (95% CI) were estimated by a logistic regression model for evaluating the correlation between baseline characteristics and coprescription.

RESULTS

A total of 266,034 patients were included for the analysis. Most patients receiving coprescriptions lived in the northern Taiwan and with a monthly income lower than 20,000 new Taiwan dollars. The trends in older adults using Western medicine alone or CHM alone decreased over time, but the cohort using dental medicine alone had the opposite result. Decreased trends in coprescription with age were noted. The trends in the proportion of coprescription and the number of days of coprescription increased with the calendar year. Increased trends in the proportion of patients with coprescription were also found, except for the cohort of patients who used both Western medicine and CHM. Patients who were female, and aged 70-79 years were prone to receive coprescription.

CONCLUSIONS

Coprescription in older patients is not uncommon in Taiwan. Healthcare providers and policymakers should be aware of the complex coprescription pattern in the older adults.

Suplementy diety – specyficzna żywność

Rynek suplementów diety rozwija się bardzo dynamicznie, co ma związek z rozpowszechnieniem tej kategorii produktów w środkach masowego przekazu, stosunkowo bezproblemową procedurą wprowadzenia na polski rynek oraz powszechną dostępnością (można je nabyć w aptece, sklepach zielarskich, spożywczych oraz w Internecie). Z definicji suplementy mają być uzupełnieniem diety, zaliczają się do żywności oraz nie mogą wykazywać działania leczniczego. Ich postać, która została ustawowo określona, może być wizualnie identyczna z postacią farmaceutyczną produktów leczniczych, co może wprowadzać konsumentów w błąd, jeżeli nie wiedzą, jak rozróżniać te dwie grupy. Polska legislacja nie uwzględnia żadnych wymogów dotyczących parametrów technologicznych czy właściwości fizycznych gotowych produktów. Na bezpieczeństwo stosowania suplementów diety, oprócz ich jakości i rzeczywistej zawartości deklarowanych składników, składa się również ewentualna obecność zanieczyszczeń i niedozwolonych substancji dodatkowych. Wybiórcza kontrola rynku oraz brak szczegółowych wytycznych dotyczących parametrów postaci suplementów daje znaczną dowolność producentom, jednocześnie umożliwia wprowadzenie na rynek produktów o wątpliwej jakości, które mogą zagrażać konsumentom, będąc całkowicie pozbawionymi działania prozdrowotnego. Ze względu na rosnące zainteresowanie tą grupą produktów przez konsumentów, przedstawiono w pracy sytuację prawną suplementów diety na polskim rynku, odnosząc się także do legislacji europejskiej i amerykańskiej. Omówiono procedurę wprowadzania na rynek, podstawowe wytyczne stawiane tej grupie produktów, wskazania do stosowania oraz aspekty związane z bezpieczeństwem i zagrożeniami wynikającymi ze stosowania suplementów diety.

Complementary and Alternative Therapies for Weight Loss: A Narrative Review

Despite various strategies, overweight and obesity problems are still increasingly prevalent worldwide with serious health outcomes. Consequently, the continuous demand for more effective, safe and acceptable therapies for reducing body weight is also escalating—including complementary and alternative therapies (CATs). The aim of this review is to provide a summary of the most commonly- and recently-used CATs, with evaluation of their safety and efficacy for weight loss. Electronic scientific databases such as Scopus, PubMed and EBSCO Host were explored for articles that reported CATs for overweight and obesity treatment from 2015 to December 2019. Only systematic reviews, meta-analysis and randomized controlled trials (RCTs) published in English were included. Studies whereby CATs were not utilized for reducing body weight were excluded. Eight systematic reviews and meta-analyses and 11 additional RCTs with 765 participants (50.2% overweight and 49.8% obese) related to hypnotherapy, acupuncture and dietary supplements met the inclusion criteria. Their results suggested that spirulina, chitosan, probiotic, EPA + DHA, vitamin D, fiber, and herbal extract supplementation may all provide small reductions in body weight (ranging from 1-10 kg). Interestingly, hypnotherapy and acupuncture reported significantly greater reduction in body weight compared with placebo (p < 0.001 and p < 0.0001, respectively). Nonetheless, the evidence is still relatively limited and not encouraging to provide a definitive conclusion due to the methodological shortcomings and the presence of adverse events in chitosan and fiber supplementation. Hence, studies of this nature need to be further replicated and improved to corroborate the efficacy and safety of the CATs to combat weight issues.

Community-Based Survey Exploring Use of the Dietary Supplement Creatine by Adult Non-Athletes

Creatine is classified as a “sports supplement”, but it also has health benefits. The purpose of this study was to assess use of creatine as a dietary supplement in adult non-athletes. Three hundred ninety-nine adults (19–89 years) completed an online survey. Among the respondents, 77% (n = 307) were regularly active, including participation in weightlifting (34%), running (34%), and cycling (21%). Twenty-eight percent (n = 111) reported use of creatine with an average dose of 6.4 ± 4.5 g. Daily creatine use was reported by 45%, and 38% reported using creatine 2–6 times weekly. Primary sources of information about creatine were trainers/coaches (29%), friends/family (32%), and internet (28%). Forty percent (n = 44) of creatine users were female. When compared by age, 46% of young, 32% of midlife, and 6% of old respondents reported creatine use with no differences in dose or frequency. Young and midlife respondents reported primarily trainers/coaches, friends/family, and internet as sources of information about creatine, but old respondents limited their sources to friends/family and fitness magazines. Although creatine is widely used by adult non-athletes who regularly exercise, dietitians and other healthcare providers are not the primary source of information. Fitness trainers can appropriately provide guidance and education regarding safe and effective use of creatine.

Spotlight on the Compositional Quality of Probiotic Formulations Marketed Worldwide

On the worldwide market, a great number of probiotic formulations are available to consumers as drugs, dietary supplements, and functional foods. For exerting their beneficial effects on host health, these preparations should contain a sufficient amount of the indicated living microbes and be pathogen-free to be safe. Therefore, the contained microbial species and their amount until product expiry are required to be accurately reported on the labels. While commercial formulations licensed as drugs are subjected to rigorous quality controls, less stringent regulations are generally applied to preparations categorized as dietary supplements and functional foods. Many reports indicated that the content of several probiotic formulations does not always correspond to the label claims in terms of microbial identification, number of living organisms, and purity, highlighting the requirement for more stringent quality controls by manufacturers. The main focus of this review is to provide an in-depth overview of the microbiological quality of probiotic formulations commercialized worldwide. Many incongruences in the compositional quality of some probiotic formulations available on the worldwide market were highlighted. Even if manufacturers carry at least some of the responsibility for these inconsistencies, studies that analyze probiotic products should be conducted following recommended and up-to-date methodologies.

Fish Oil for Inflammatory Bowel Disease: Panacea or Placebo?

Dietary supplements have increasingly gained popularity over the years not only to replete micronutrient deficiencies but for their use in treatment of disease. The popularity of dietary supplements for inflammatory bowel diseases (IBD) arises from their perceived ease of use, potential disease-modifying benefits, and perceived safety. Overall, randomized controlled trials have not consistently shown a benefit of fish oil for the maintenance of remission with Crohn's disease. The inconsistency of these findings highlights the need for more studies that are powered to clarify the context in which omega-3 fatty acids might have a role in the treatment algorithm of IBD.

Use of Molecular Methods to Authenticate Animal Species and Tissue in Bovine Liver Dietary Supplements

Dietary supplements containing bovine (subfamily Bovinae) liver are susceptible to fraud due to their high value and the lack of modern detection methods available for processed animal tissues. The objective of this research was to use molecular methods to authenticate dietary supplements claiming to contain bovine liver or beef liver through the verification of animal species and tissue type. A total of 53 bovine/beef liver dietary supplements were purchased from online sources. The presence of liver was verified with reverse transcription and real-time PCR testing for microRNA-122 (miR-122), which is highly expressed in liver tissue. Multiplex real-time PCR targeting domestic cattle (Bos taurus), horse (Equus caballus), sheep (Ovis aries), and pork (Sus scrofa) was used to verify species. Samples that failed species identification with multiplex real-time PCR underwent DNA mini-barcoding. Overall, bovine species were detected in 48/53 liver supplements: 35 samples were confirmed as domestic cattle with multiplex real-time PCR and an additional 13 samples were confirmed as domestic cattle or Bos spp. with DNA mini-barcoding. One of these samples was also positive for sheep/lamb, which was declared on the label. One product contained undeclared pork in addition to beef. MiR-122 was detected in 51 out of 53 supplements, suggesting the presence of liver. While this study demonstrates the potential use of tissue-specific microRNAs in verifying tissues in dietary supplements, more research is needed to evaluate the specificity of these markers.

Herbal Supplements: Precautions and Safe Use

The Food and Drug Administration (FDA) classifies herbal preparations as food supplements. New herbal supplements and products are not governed by the strict FDA drug approval process and there is no premarket approval required. The FDA prohibits manufacturers and distributors from marketing adulterated or misbranded products but does not rigorously define safe practices. Scientific evidence related to herbal supplements is limited. Herbal supplements have been associated with adverse reactions and herbal-drug interactions. Information and precautions for 20 common herbal supplements, including St. John's wort, ginseng, echinacea, and ginkgo, are reviewed. Resources for consumers and health care professionals are highlighted.

Authentication of Hedyotis products by adaptor ligation-mediated PCR and metabarcoding

DNA barcoding is a widely used tool for species identification and authentication. However, it may not be applicable to highly processed herbal products due to severe DNA fragmentation. The emergence of DNA metabarcoding provides an alternative way to solve the problem. In this study, we are the first to combine the use of adaptor ligation-mediated PCR method and metabarcoding to reveal species identities in herbal products. As an illustration, we applied the method on three Hedyotis herbal products collected from China and Thailand. Results showed that H. diffusa and H. corymbosa were present in the products which were consistent with their label claims. Our study indicated that the adaptor ligation-mediated PCR with metabarcoding approach is useful for authentication of highly processed herbal products.

Use of Dietary Supplements in Pediatric Liver Disease and Transplantation

BACKGROUND

Dietary supplements are frequently used by healthy individuals and those with chronic medical conditions but may cause damage to the liver. The aim of this study was to examine the prevalence and attitudes of dietary supplement use, and the frequency of disclosure to healthcare providers among parents/caregivers for children with chronic liver disease.

METHODS

We developed an anonymous survey for parents/caregivers of children (<18 years old) with chronic liver disease or liver transplant recipients and distributed the survey through social media groups organized around pediatric liver diseases.

RESULTS

The survey was completed by 101 parents/caregivers (48 without transplant and 53 posttransplant).Among respondents, 87% agreed they would use dietary supplements to help their child, but parents/caregivers of transplant recipients were less likely to consider use (77% vs 98%; P = 0.01). In the past 12 months, 83% reported dietary supplement use including 47% who used nonvitamin/mineral supplements. In two-thirds of parents/caregivers, use was initiated by their personal belief. Although 77% of respondents disclosed their use to their liver team, disclosure varied depending on the supplement with no individual that used cannabinoid products disclosing the use.

CONCLUSIONS

Dietary supplements are frequently used by children with liver disease and may exceed use in other pediatric conditions. Though most parents report use to their liver team, disclosure may vary depending on the specific supplement. Providers should take extra measures to review use of supplements with their patients and work to develop trust with their families to obtain accurate disclosure of use.

Extraction of Cyproheptadine as Potent Appetizing Stimulant in Herbal Supplements by Efficient Carbon Nitride Nanosheets as Dispersive Solid Phase Extraction Adsorbent

Background: Application of natural-based herbal medicine is on a growing trend in some countries and people prefer to use plant-originated drugs rather than chemical-based ones. The present study describes an interesting sample preparation method for extraction and determination of cyproheptadine in herbal supplements as appetizing stimulant by using carbon nitride nanosheets as dispersive solid phase extraction method coupled with HPLCUV. Methods: Various techniques used for characterization of adsorbent such as: Infrared spectroscopy (IR), scanning electron microscopy (SEM), Zeta potential analysis and powder X-ray diffraction (XRD). Optimization of the important extraction parameters were conducted by one parameter-at-a time method. Next, method validation was carried out. Results: The optimized cyproheptadine extraction parameters were introduced and under optimized conditions the method presented a good linearity in the concentration range of 300-2000 ng/g. The limit of detection (LOD) was 100 ng/g for the introduced method. Conclusion: Quantitative analysis of fifteen real samples (Tablets or capsules) by proposed method confirmed the illegal presence of cyproheptadine in herbal appetizing stimulants supplements of the markets.

Is it safe to consume traditional medicinal plants during pregnancy?

The popularity of natural medicine is growing worldwide. Unlike conventional licensed medicines, herbal medicine practices are usually not supported by effectiveness, efficacy, or safety studies, which raise concerns about potential risks involved in their usage, particularly in high-risk patients such as pregnant women where teratogenicity is a concern. Despite a lack of science-based evidence, the use of herbal products for the management of pregnancy-associated challenges is common, due to the common notion that they are free of toxic effects and adverse reactions because they are "natural." The lack of concern about utilizing herbal remedies during pregnancy is strengthened by the lack of regulation in most countries for their marketing. However, plant-based remedies are not free of adverse reactions. Medicinal plants and herbal remedies contain substances that can be toxic to the human body and the fetus. Potential effects of indiscriminate use of medicinal plants are embryotoxicity, teratogenic, and abortifacient effects. Some plant constituents can cross the placenta and reach the fetus. Phytochemicals and their metabolites are known to induce stimulation of uterine contraction and hormone imbalance that could result in abortion. The alterations to the hormonal profile can affect conception, induce teratogenic activity, and halt the pregnancy or produce a congenital malformation. Due to the wide range of modes of action of phytochemicals, some medicinal plants may be safe to use during certain trimesters of pregnancy and harmful at other stages. This manuscript reviews available scientific information concerning potential health hazards associated with the consumption of herbal medicines during pregnancy, highlighting those herbs that should be avoided due to their potential abortifacient and/or teratogenic activity. We focused on plants that were tested by preclinical studies, and studies of these plants are summarized. Common therapeutic use of these herbs, estimated effects, toxicological effects, and animal studies of these plants is summarized. The literature reviewed suggests that consumption of the following medicinal plants should be avoided during pregnancy: Abrus precatorius, Achyranthes aspera, Ailanthus excelsa, Aloe vera, Aristolochia indica, Areca catechu, Bambusa vulgaris, Cassia occidentalis, Cicer arietinum, Cimicifuga racemose, Dolichandrone falcate, Ginkgo biloba, Hydrastis canadensis, Indigofera trifoliate, Lavandula latifolia, Maytenus ilicifolia, Momordica cymbalaria, Moringa oleifera, Musa rosacea, Oxalis corniculate, Phytolacca dodecandra, Plumeria rubra, Ricinus communis, Ruta graveolens, Stachys lavandulifolia, Senna alata, Trigonella foenum-graecum, Vitus agnus-castus, and Valeriana officinalis.

Daily supplementation with aronia melanocarpa (chokeberry) reduces blood pressure and cholesterol: a meta analysis of controlled clinical trials

BACKGROUND & OBJECTIVES

Cardiovascular disease is a leading cause of morbidity and mortality in the United States. Dietary supplements, such as those rich in antioxidants, have the potential to improve markers of cardiovascular health, but little is known about the total effect of these supplements. The purpose of this analysis is to identify the effect size of supplementation with aronia berry extracts and to evaluate how age may influence these effects.

METHODS

This analysis included a literature review of controlled trials evaluating the effects of daily aronia berry supplementation for an average of 6-8 weeks on the outcomes of total cholesterol and blood pressure. Three distinct analyses were conducted: systolic blood pressure, diastolic blood pressure, and total cholesterol. The moderator of age was evaluated for each of the three outcome measures.

RESULTS & CONCLUSION

Daily supplementation with aronia berry extracts for 6-8 weeks significantly reduces systolic blood pressure, which is a key risk factor for cardiovascular disease, as well as total cholesterol. These effects are most significant in adults over the age of 50 years. Supplementation with aronia berry is a safe and effective way to reduce total cholesterol and systolic blood pressure, with even larger effects among adults over the age of 50 years.

Use of Dietary Supplements in Living Kidney Donors: A Critical Review

Dietary supplement use is high among US adults, with the intention by users to promote overall health and wellness. Kidney donors, who are selected based on their overall good health and wellness, can have high utilization rates of dietary supplements. We provide a framework for the evaluation of living kidney donors and use of dietary supplements. In this review, dietary supplements will include any orally administered dietary or complementary nutritional products, but excluding micronutrients (vitamins and minerals), food, and cannabis. Use of dietary supplements can influence metabolic parameters that mask future risk for chronic illness such as diabetes and hypertension. Dietary supplements can also alter bleeding risk, anesthesia and analgesic efficacy, and safety in a perioperative period. Finally, postdonation monitoring of kidney function and risk for supplement-related nephrotoxicity should be part of a kidney donor educational process. For practitioners evaluating a potential kidney donor, we provide a list of the most commonly used herbal supplements and the effects on evaluation in a predonation, perioperative donation, and postoperative donation phase. Finally, we provide recommendations for best practices for integration into a comprehensive care plan for kidney donors during all stages of evaluation. We recommend avoidance of dietary supplements in a kidney donor population, although there is a paucity of data that identifies true harm. Rather, associations, known mechanisms of action, and common sense suggest that we avoid use in this population.

Nutritional and medical food therapies for diabetic retinopathy

Diabetic retinopathy (DR) is a form of microangiopathy. Reducing oxidative stress in the mitochondria and cell membranes decreases ischemic injury and end-organ damage to the retina. New approaches are needed, which reduce the risk and improve the outcomes of DR while complementing current therapeutic approaches. Homocysteine (Hcy) elevation and oxidative stress are potential therapeutic targets in DR. Common genetic polymorphisms such as those of methylenetetrahydrofolate reductase (MTHFR), increase Hcy and DR risk and severity. Patients with DR have high incidences of deficiencies of crucial vitamins, minerals, and related compounds, which also lead to elevation of Hcy and oxidative stress. Addressing the effects of the MTHFR polymorphism and addressing comorbid deficiencies and insufficiencies reduce the impact and severity of the disease. This approach provides safe and simple strategies that support conventional care and improve outcomes. Suboptimal vitamin co-factor availability also impairs the release of neurotrophic and neuroprotective growth factors. Collectively, this accounts for variability in presentation and response of DR to conventional therapy. Fortunately, there are straightforward recommendations for addressing these issues and supporting traditional treatment plans. We have reviewed the literature for nutritional interventions that support conventional therapies to reduce disease risk and severity. Optimal combinations of vitamins B1, B2, B6, L-methylfolate, methylcobalamin (B12), C, D, natural vitamin E complex, lutein, zeaxanthin, alpha-lipoic acid, and n-acetylcysteine are identified for protecting the retina and choroid. Certain medical foods have been successfully used as therapy for retinopathy. Recommendations based on this review and our clinical experience are developed for clinicians to use to support conventional therapy for DR. DR from both type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) have similar retinal findings and responses to nutritional therapies.

Toxicity studies of a gum guggul extract formulation administered by gavage to Sprague Dawley (Hsd:Sprague Dawley SD) rats and B6C3F1/N mice

Gum guggul extracts (GGEs) are botanical preparations derived from the oleoresin of the Commiphora mukul tree. The preparations are traditionally used in Ayurvedic medicine to treat hyperlipidemia, obesity, diabetes, atherosclerosis, and inflammatory conditions such as arthritis. In the United States, GGEs are marketed as dietary supplements. GGE toxicity was evaluated due to widespread human exposure through increasing dietary supplement use, demonstrated metabolic and hormone-altering effects, and a lack of available information to adequately assess safe use in humans. Male and female Sprague Dawley (Hsd:Sprague Dawley SD) rats and B6C3F1/N mice were administered a GGE formulation in corn oil by gavage for 28 days or 3 months. Oral gavage was chosen as the route of exposure for these studies because human exposure primarily occurs by ingestion of encapsulated GGE supplements. (Abstract Abridged).