Current regulatory guidelines and resources to support research of dietary supplements in the United States

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.

Osteoarthritis: Insights into Diagnosis, Pathophysiology, Therapeutic Avenues, and the Potential of Natural Extracts

Osteoarthritis (OA) stands as a prevalent and progressively debilitating clinical condition globally, impacting joint structures and leading to their gradual deterioration through inflammatory mechanisms. While both non-modifiable and modifiable factors contribute to its onset, numerous aspects of OA pathophysiology remain elusive despite considerable research strides. Presently, diagnosis heavily relies on clinician expertise and meticulous differential diagnosis to exclude other joint-affecting conditions. Therapeutic approaches for OA predominantly focus on patient education for self-management alongside tailored exercise regimens, often complemented by various pharmacological interventions primarily targeting pain alleviation. However, pharmacological treatments typically exhibit short-term efficacy and local and/or systemic side effects, with prosthetic surgery being the ultimate resolution in severe cases. Thus, exploring the potential integration or substitution of conventional drug therapies with natural compounds and extracts emerges as a promising frontier in enhancing OA management. These alternatives offer improved safety profiles and possess the potential to target specific dysregulated pathways implicated in OA pathogenesis, thereby presenting a holistic approach to address the condition's complexities.

Therapeutic Effect of Natural Products and Dietary Supplements on Aflatoxin-Induced Nephropathy

Aflatoxins are harmful natural contaminants found in foods and are known to be hepatotoxic. However, recent studies have linked chronic consumption of aflatoxins to nephrotoxicity in both animals and humans. Here, we conducted a systematic review of active compounds, crude extracts, herbal formulations, and probiotics against aflatoxin-induced renal dysfunction, highlighting their mechanisms of action in both in vitro and in vivo studies. The natural products and dietary supplements discussed in this study alleviated aflatoxin-induced renal oxidative stress, inflammation, tissue damage, and markers of renal function, mostly in animal models. Therefore, the information provided in this review may improve the management of kidney disease associated with aflatoxin exposure and potentially aid in animal feed supplementation. However, future research is warranted to translate the outcomes of this study into clinical use in kidney patients.

Exploring Therapeutic Digestive Enzyme Landscape in India: Current Evidence, Profit Motives, Regulations, and Future Perspectives

This analysis critically examines the profit-driven marketing of digestive enzymes as over-the-counter (OTC) supplements in the context of India, expressing ethical concerns regarding pharmaceutical companies prioritizing financial gain over genuine public health needs within the lucrative OTC supplement market. The review delves into various enzymes, their mechanisms of action, uses, adverse drug reactions, and provides evidence from various studies. The research method involves the exploration of profit-driven strategies employed by pharmaceutical companies, addressing regulatory challenges, investigating the gap between dietary supplements and pharmaceutical drugs, and emphasizing the impact of direct-to-consumer advertising on self-diagnosis and overuse. Additionally, the study reviews various e-pharmacy platforms in India, assessing formulations and pricing. Key findings highlight the diverse formulations on these platforms, exposing insights into cost variations and indicating a regulatory gap that necessitates a comprehensive re-evaluation by Indian and international authorities. The analysis emphasizes the influence of direct-to-consumer advertising on behavior and potential health risks, raising ethical concerns about oversimplified health claims that overlook the necessity for individualized treatment plans. In conclusion, the study underscores the ethical complexity of prioritizing profit over public health and advocates for regulatory re-evaluation, exploring broader implications such as cultural influences and alternative therapies. The evolving landscape, featuring plant-based and microbe-derived alternatives, is presented as transformative, particularly in conditions like celiac disease.

Neonatal Opioid Withdrawal Syndrome Following Prenatal Use of Supplements Containing Tianeptine

Tianeptine is an opioid receptor agonist that is prescribed as an antidepressant in many countries. In the United States, tianeptine is not approved for medical use because of its potential for abuse and addiction. Nonetheless, products containing tianeptine are easily obtainable and are marketed as dietary supplements. There are increasing reports of adverse effects and fatal toxicities resulting from tianeptine use among adolescents and adults. This emerging public health threat could escalate the opioid epidemic and drive increased newborn perinatal exposure. The impact of in utero exposure to tianeptine has not been studied, and to our knowledge, the authors of only 1 report have documented possible neonatal effects. Here, we describe a case of chronic prenatal exposure to tianeptine in the setting of maternal dependence on dietary supplements. This infant developed signs of severe withdrawal shortly after birth that were refractory to treatment with oral phenobarbital but responded to subsequent oral morphine therapy. On further questioning, the mother revealed the use of a tianeptine-containing dietary supplement. We did not perform confirmatory toxicology testing because tianeptine is not assayed by usual urine drug screening tests. For infants with clinical signs of opioid withdrawal without known etiology, we suggest that the maternal interview should inquire about the use of neurotropic over-the-counter drugs.

Non-targeted chemical analysis of consumer botanical products labeled as blue cohosh (Caulophyllum thalictroides), goldenseal (Hydrastis canadensis), or yohimbe bark (Pausinystalia yohimbe) by NMR and MS

Consumers have unprecedented access to botanical dietary supplements through online retailers, making it difficult to ensure product quality and authenticity. Therefore, methods to survey and compare chemical compositions across botanical products are needed. Nuclear magnetic resonance (NMR) spectroscopy and non-targeted mass spectrometry (MS) were used to chemically analyze commercial products labeled as containing one of three botanicals: blue cohosh, goldenseal, and yohimbe bark. Aqueous and organic phase extracts were prepared and analyzed in tandem with NMR followed by MS. We processed the non-targeted data using multivariate statistics to analyze the compositional similarity across extracts. In each case, there were several product outliers that were identified using principal component analysis (PCA). Evaluation of select known constituents proved useful to contextualize PCA subgroups, which in some cases supported or refuted product authenticity. The NMR and MS data reached similar conclusions independently but were also complementary.

Irradiated and radioactively contaminated foods: Analysis of EU RASFF notifications from 1997 to 2022

Food irradiation technique is an authorized tool used on a commercial scale in many countries to preserve different types of foodstuffs from deterioration caused by microorganisms, insects, and metabolic activity to prolong their shelf life without leaving any residual effect on processed foods, unlike preservatives and pesticides. This study was carried out to analyse the EU Rapid Alert System for Food and Feed (RASFF) notifications on food radiation from 1997 to 2022 in order to identify the most frequently reported products, their origin countries and associated reasons for notification, as well as the most notifying countries, product categories, notification classification, risk decisions, and actions taken. A total of 488 notifications were recorded during this time period. China was the most frequently notified origin country, accounting for 19.88% of all notifications, followed by the United States (11.68%), Russia (7.99%), Vietnam (7.17%), and Poland (5.53%). The top notified product categories were "dietetic foods, food supplements, and fortified foods" (37.09%), followed by fruits and vegetables (23.16%), herbs and spices (8.81%), and prepared dishes and snacks (5.53%). The top 5 notified products were food supplements (25.00%), mushrooms (20.70%), noodles (7.58%), tea (4.51%), and spices (3.69%). The four main reasons for food radiation notifications were unauthorized irradiation (57.58%), too high levels of radioactivity (22.34%), unlabeled irradiation (19.47%), and unauthorized facilities (14.96%). Too many notifications included more than one reason for the notification. Out of 109 notifications related to too-high levels of radioactivity (up to 10755 Bq/kg), 101 were due to the presence of 137Cs, 134Cs, 60Co, and 48Cd in mushrooms, mainly originating from Poland (25), Bulgaria (24), Ukraine (15), and Belarus (12). Such studies provide the necessary data to ensure food safety and encourage countries to implement comprehensive procedures to protect consumers health.

Hepatotoxicity due to dietary supplements: state-of-the-art, gaps and perspectives

Food supplements are products intended to complement the normal diet and consist of concentrated sources of nutrients or other substances with a nutritional or physiological effect. Although they are generally considered safe if the manufacturer's recommendations are followed, many of them have shown hepatotoxic properties. This can cause many diseases (e.g. steatohepatitis and cirrhosis) characterized by progressive damage and malfunction of the liver that in the long term can lead to death. A review of the literature was carried out to elucidate which dietary supplements have been associated with cases of hepatotoxicity in recent years, with emphasis on those relevant to the consumer and the new trends (e.g. cannabidiol). It has been reported that the supplements described as hepatotoxic are mainly of botanical origin (e.g. green tea or turmeric) and those used in sports (mainly anabolic androgenic steroids). There is a great variability of compounds described as causing liver damage, although sometimes it is not possible to identify them, because they are contaminants or adulterants of the products. In addition, the prevalence of toxic effects after the administration of supplements is difficult to define due to underreporting and the lack of specific studies. Globally regarding hepatotoxicity of dietary supplements, there is a paucity of well-conducted clinical trials on the efficacy of these compounds and the frequency of related liver damage, as the use of these products is largely uncontrolled.

Role of Nutritional Supplements in Sport, Exercise and Health

Health promotion requires good nutrition and an adequate lifestyle, which together contribute to people's well-being [...].

Major Gaps in Understanding Dietary Supplement Use in Health and Disease

Precise dietary assessment is critical for accurate exposure classification in nutritional research, typically aimed at understanding how diet relates to health. Dietary supplement (DS) use is widespread and represents a considerable source of nutrients. However, few studies have compared the best methods to measure DSs. Our literature review on the relative validity and reproducibility of DS instruments in the United States [e.g., product inventories, questionnaires, and 24-h dietary recalls (24HR)] identified five studies that examined validity (n = 5) and/or reproducibility (n = 4). No gold standard reference method exists for validating DS use; thus, each study's investigators chose the reference instrument used to measure validity. Self-administered questionnaires agreed well with 24HR and inventory methods when comparing the prevalence of commonly used DSs. The inventory method captured nutrient amounts more accurately than the other methods. Reproducibility (over 3 months to 2.4 years) of prevalence of use estimates on the questionnaires was acceptable for common DSs. Given the limited body of research on measurement error in DS assessment, only tentative conclusions on these DS instruments can be drawn at present. Further research is critical to advancing knowledge in DS assessment for research and monitoring purposes.

Supplements for Lipid Lowering: What Does the Evidence Show?

PURPOSE

In this review, the regulation, proposed hypolipidemic mechanism, and efficacy of common dietary supplements (DSs) marketed for cardiovascular health are discussed.

RECENT FINDINGS

Data demonstrate modest but inconsistent lipid-lowering effects with common DSs such as probiotics, soluble fibers, plant sterols, green tea, berberine, guggul, niacin, and garlic. Furthermore, data is limited regarding turmeric, hawthorn, and cinnamon. Red yeast rice has shown to be a beneficial DS, but its safety and efficacy are dependent upon its production quality and monacolin K content, respectively. Finally, soy proteins and omega-3 fatty acid-rich foods can have significant health benefits if used to displace other animal products as part of a healthier diet. Despite the rising use of DSs, data demonstrate unpredictable results. Patients should be educated on the difference between these DSs and evidence-based lipid-lowering medications proven to improve cardiovascular outcomes.

Effect of educational intervention on knowledge and attitude about the role of vitamins, minerals and nutraceuticals in COVID-19 and other disorders among medical and nursing undergraduates of a tertiary care teaching hospital

PURPOSE

There must be a perfect balance between Food and Dietary supplements (DS) to ensure optimal well-being. The purpose of this study was to evaluate the impact of a webinar on the change in knowledge and attitude about the role of vitamins, minerals and DS among medical and nursing undergraduates so that they could bring about a positive change in popular practices, as well-informed Health Care Professionals (HCPs).

MATERIALS AND METHODS

The study was a cross-sectional analytical study comprising 12 knowledge and 11 attitude questions administered to medical and nursing undergraduates with the help of semi-structured and pre-validated google form both before and after a webinar explaining the role of key nutrients and also the evidence and recommendations surrounding DS. Data were analyzed using STATA.12 to assess the impact of the webinar.

RESULTS

There were 415 participants, with 265 medical and 150 nursing students. There was a significant improvement both in the knowledge (4.95 (±1.45), 7.76 (±1.69) and attitude scores (pre-webinar mean score 31.8 (±5.57) post-webinar mean score 27.7 (±4.90))of the participants after the webinar. An overall positive correlation before the webinar changed to a more significant negative correlation, indicating a positive impact of the webinar (0.0054-0.0701).

CONCLUSION

The study suggests that continuing education informing various HCPs and undergraduate students about the absolute necessity of a diet rich in nutrients, vitamins, minerals, and probiotics is the need of the hour. Additionally, the efficacy and safety concerns, appropriate indications and dosages of various DS should be adequately stressed so that informed decisions can be made. Such training programs might have a far-reaching impact on the nutrition choices of the population at large.

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.

Assessment of Physicochemical Parameters and Contaminants in Herbal Dietary Supplements Used in the Treatment of Inflammatory Bowel Disease

Inflammatory bowel disease is a complex disorder characterized by chronic gastrointestinal inflammation. Thus, patients prefer to use herbal dietary supplements containing turmeric, Indian frankincense, green chiretta, and black pepper in an attempt to cope better with their chronic condition. The dietary supplements' dosage forms and herbal ingredients were assessed in terms of the products' physicochemical parameters (weight uniformity, friability, disintegration, rupture test, tablet's breaking force, and powder flowability) in view of the USP-NF requirements. In addition, contaminants such as organic solvents and ethylene oxide were evaluated using gas chromatography. Assessment of gluten via an Enzyme-Linked Immunosorbent Assay was also performed. Most of the products met USP requirements. The high average weight of one multicomponent tablet sample with a high breaking force value can explain the observed negative results of the disintegration test. A total of 26% of samples tested positive for gluten, but the most alarming fact is that the ethylene oxide levels found in two samples were up to 30 times higher than the EU limit. Accordingly, dietary supplement quality control is of fundamental importance.

Quantitative Bioactivity Signatures of Dietary Supplements and Natural Products

Dietary supplements and natural products are often marketed as safe and effective alternatives to conventional drugs, but their safety and efficacy are not well regulated. To address the lack of scientific data in these areas, we assembled a collection of Dietary Supplements and Natural Products (DSNP), as well as Traditional Chinese Medicinal (TCM) plant extracts. These collections were then profiled in a series of in vitro high-throughput screening assays, including a liver cytochrome p450 enzyme panel, CAR/PXR signaling pathways, and P-glycoprotein (P-gp) transporter assay activities. This pipeline facilitated the interrogation of natural product-drug interaction (NaPDI) through prominent metabolizing pathways. In addition, we compared the activity profiles of the DSNP/TCM substances with those of an approved drug collection (the NCATS Pharmaceutical Collection or NPC). Many of the approved drugs have well-annotated mechanisms of action (MOAs), while the MOAs for most of the DSNP and TCM samples remain unknown. Based on the premise that compounds with similar activity profiles tend to share similar targets or MOA, we clustered the library activity profiles to identify overlap with the NPC to predict the MOAs of the DSNP/TCM substances. Our results suggest that many of these substances may have significant bioactivity and potential toxicity, and they provide a starting point for further research on their clinical relevance.

Prevalence of dietary supplement use and knowledge, attitudes, practice (KAP) and associated factors in student population: A cross-sectional study

Dietary supplements (DSs) intake has been increasing worldwide despite no consensus evidence for the efficacy and safety of disease prevention, control, or treatment in nutrient-replete populations. This study aimed to determine the prevalence of DSs use, knowledge, attitude, and practice (KAP) and associated factors among university students in Jordan. A national cross-sectional study was carried over across universities in Jordan. Participants completed a valid and reliable online questionnaire (Cronbach's alpha = 0.802 and correlation coefficients between 0.72 and 0.26). Univariate analyses were used to determine the relationship between variables. Multivariable regression was carried out to identify significant factors contributing DSs usage. A total of 448 university students completed the study (73.7% females). More than half of the students used DSs (60.9%), with single-nutrient ingredient supplements being the most commonly used type. The primary motivators were maintaining health and most students reported no side effects associated with consumption. The results revealed poor knowledge, a negative attitude towards DSs usage among all participants, even non-users, and high-risk practices among the DSs users. Normal weight and overweight individuals were more likely to use DSs (OR:2.88, 95%CI:1.61-5.16, OR:1.95, 95%CI:1.01-3.79, respectively). Low and medium-family income categories were more likely to use DSs than those in the high-income category (OR: 0.04, 95%CI: 0.02-0.07, OR: 0.06, 95CI:0.03-0.11, respectively). Undergraduate students were more likely to use DSs than postgraduate students (OR:5.56, 95%CI:3.19-9.69). In this study, a high prevalence of DSs use was highlighted. The results suggest that nutrition education is required to improve awareness of DSs and to promote safe practices.

Have safety and efficacy assessments of bioactives come of age?

This article describes why the safety and efficacy assessment of non-nutrient bioactives for reducing chronic disease risk is so complicated, especially for dietary supplements and traditional medicines. Scientists, regulators, and the public have different and sometimes opposing perspectives about bioactives. Drug, food, and traditional medicine models used for bioactive safety assessment are based on different assumptions and use different processes. Efficacy assessment is seldom based on clinical trials of boactives' effects in reducing chronic disease risk. It usually consists of application of quality assurance measures and evaluation of label claims and commercial speech about ingredients or products to ensure conformity to regulations. Harmonization of safety and efficacy assessment on a global basis is difficult because of differences within and between regulatory systems. The recommendations provided may open the way for bioactives to play a larger health role in the future, fill gaps in data needed for crafting authoritative dietary guidance on intakes, and speed harmonization of global standards.

Potential Use of Quercus dalechampii Ten. and Q. frainetto Ten. Barks Extracts as Antimicrobial, Enzyme Inhibitory, Antioxidant and Cytotoxic Agents

The bark resulted as a by-product after different Quercus sp. processing is a valuable alternative source of phenolic compounds (mainly tannins). Hence, the focus of the present work was to obtain eight extracts from the rhytidome of the less-studied Q. dalechampii and Q. frainetto and characterize them in terms of chemical and bioactive profiles. Ultrasound and microwave-assisted extraction methods were used for the preparation of the extracts. Total phenolic and tannin contents were assessed through classic spectrophotometric methods, while several individual phenolic compounds were identified and quantified using UPLC-PDA. Antioxidant, enzyme-inhibitory, antibacterial, and cytotoxic activities were tested using in vitro assays; additionally being evaluated was the ability of the extracts to inhibit the adherence of MRSA to suture wires. The UPLC analysis confirmed the presence of gallic acid, catechin, taxifolin, vanillic acid, epicatechin, and caffeic acid. The results showed that tested extracts were able to exert cytotoxic effects, at 6% and 3% concentrations, on confluent cells. The tested solutions inhibit α-glucosidase activity and the antibacterial potential suggested a mild to moderate effect against the Gram-positive strains. Overall, the obtained results revealed rich phenolic and tannin contents for the extracts obtained from both species through microwave-assisted extraction, probably responsible for their mild antibacterial and cytotoxic effects.

Green Solid-Phase (Micro)Extraction of Andrographolides’ from Human Plasma Samples Followed by UHPLC-DAD-QqQ-MS/MS Analysis

Since inflammatory bowel disease is a progressive disease, optimal treatment early in the disease course is paramount. Still, the use of conventional drugs is accompanied by side effects. The herbal therapies for gastrointestinal disorders are traditionally widespread in Asia, while in Western countries have been adopted in recent years. Andrographis paniculata is a herbaceous plant used in anti-inflammatory treatment. To improve its clinical application, an analytical method with the potential to define a relationship between dose and plasma concentration of active ingredients is prerequisite. Considering the increasing demand for eco-friendly bioanalytical methods, our research aimed to implement new sample preparation technique microextraction by packed sorbent for extraction of marker compounds of A. paniculata from plasma. This green procedure using polymeric sorbent based on the poly (styrene-divinylbenzene) allowed miniaturization of sample volume (100 µL), decrease in consumption of solvents, and high recovery (92–98%). A highly selective and sensitive reversed-phase ultrahigh-performance liquid chromatography method has been developed and validated. The newest greenness assessment software AGREE calculator was used for evaluation of the method’s environmental performance. It suggests that our method conforms to the eco-friendly conditions (score 0.8). The sample preparation was identified as weak point of the bioanalytical methods which highlights the importance of microextraction.

Dietary supplement mislabelling: case study on selected slimming products by developing a green isocratic HPLC method for their quality control

Nowadays, a huge population consumes Dietary supplements for losing weight. Products are often claimed as botanical blends, yet they aren't necessarily safe. Misleading labels are also very common. Thus, validated analytical methods for a wide range of slimming compounds are highly needed. Herein, we present a simple HPLC/PDA method for the quantitation of seven popular slimming ingredients. Studied compounds were Caffeine, Raspberry Ketone, trans-Resveratrol, p-Synephrine, p-Octopamine, p-Hordenine and 2-phenethylamine. After optimization, separation was carried out on a C18 column and mobile phase was a mixture of Acetonitrile:Water containing 0.1% phosphoric acid (50:50, %v/v). The last compound was eluted at 9.76 min. Separation was efficient showing baseline- separated symmetric peaks, without using any gradient programs, organic mobile phase modifiers or modified stationary phases. Method validation was done following ICH guidelines. Calibration curves were linear over wide concentration ranges and calculated LOD values were in the range 0.02-0.09 µg/mL. Method greenness was assessed using Analytical Eco-scale, GAPI and AGREE metric tools. Further, four random sample products purchased from online supplement stores were assayed. Results proved some mislabeling actions. To support our findings, standard addition was carried out and average % recoveries were 96.67 - 101.44% with standard deviation ≤ 2.83 between measurements.

Science and claims of the arena of food bioactives: comparison of drugs, nutrients, supplements, and nutraceuticals

The scientific community and lay press are participating in a heated debate over the usefulness of food bioactives when used as dietary supplements. This debate often ignores hard scientific evidence and the outcomes of proper research in either direction. Some propose that health claims should be awarded based on classic pharmacological parameters of efficacy and safety. Others suggest that a botanical history of their safe use and basic biological evidence in support of their effects should suffice to allow their marketing. The current regulatory impasse does not help solve this conundrum. It is time for scientists, regulators, and legislators to open an epistemological debate on the appropriateness of using classic pharmacological methods for substances that do not share the usual drug profiles and which are, consequently, difficult to study in humans.

Historical Aspects of Herbal Use and Comparison of Current Regulations of Herbal Products between Mexico, Canada and the United States of America

Increased life expectancy and high costs of medicines and medical care have led to the use of herbal products. However, these items may contain toxic compounds that have an impact on public health. We will focus on the regulatory aspects and differences of these products marketed in the North American region (USA-Mexico-Canada) from government websites and selected literature. Mexico has an ancestral tradition of using plants for the treatment, improvement, and maintenance of human health as compared with Canada and the USA Currently, the use of herbal products in this region has a regulatory framework. The legal framework in these three countries is related to their history, idiosyncrasies, socio-economic and cultural aspects. Therefore, there are different public policies for herbal products consumed in the region. Mexico has a more specific classification of these products. In Canada, all herbal products are classified as natural health products and the safety and efficacy must be scientifically proven. In the USA, the development of botanical drugs is very recent. In particular, both herbal products classified as food supplements in Mexico and dietary supplements in the USA may have risks in both safety and efficacy.

Multivitamins in the prevention of cancer and cardiovascular disease: the COcoa Supplement and Multivitamin Outcomes Study (COSMOS) randomized clinical trial

BACKGROUND

Although older adults commonly take multivitamin-multimineral (MVM) supplements to promote health, evidence on the use of daily MVMs on invasive cancer is limited.

OBJECTIVES

The study objective was to determine if a daily MVM decreases total invasive cancer among older adults.

METHODS

We performed a randomized, double-blind, placebo-controlled, 2-by-2 factorial trial of a daily MVM and cocoa extract for prevention of cancer and cardiovascular disease (CVD) among 21,442 US adults (12,666 women aged ≥65 y and 8776 men aged ≥60 y) free of major CVD and recently diagnosed cancer. The intervention phase was from June 2015 through December 2020. This article reports on the MVM intervention. Participants were randomly assigned to daily MVM or placebo. The primary outcome was total invasive cancer, excluding nonmelanoma skin cancer. Secondary outcomes included major site-specific cancers, total CVD, all-cause mortality, and total cancer risk among those with a baseline history of cancer.

RESULTS

During a median follow-up of 3.6 y, invasive cancer occurred in 518 participants in the MVM group and 535 participants in the placebo group (HR: 0.97; 95% CI: 0.86, 1.09; P = 0.57). We observed no significant effect of a daily MVM on breast cancer (HR: 1.06; 95% CI: 0.79, 1.42) or colorectal cancer (HR: 1.30; 95% CI: 0.80, 2.12). We observed a protective effect of a daily MVM on lung cancer (HR: 0.62; 95% CI: 0.42, 0.92). The composite CVD outcome occurred in 429 participants in the MVM group and 437 participants in the placebo group (HR: 0.98; 95% CI: 0.86, 1.12). MVM use did not significantly affect all-cause mortality (HR: 0.93; 95% CI: 0.81, 1.08). There were no safety concerns.

CONCLUSIONS

A daily MVM supplement, compared with placebo, did not significantly reduce the incidence of total cancer among older men and women. Future studies are needed to determine the effects of MVMs on other aging-related outcomes among older adults. This trial is registered at www.clinicaltrials.gov as NCT02422745.

Practical, Evidence-Based Approaches to Nutritional Modifications to Reduce Atherosclerotic Cardiovascular Disease: An American Society For Preventive Cardiology Clinical Practice Statement

Despite numerous advances in all areas of cardiovascular care, cardiovascular disease (CVD) is the leading cause of death in the United States (US). There is compelling evidence that interventions to improve diet are effective in cardiovascular disease prevention. This clinical practice statement emphasizes the importance of evidence-based dietary patterns in the prevention of atherosclerotic cardiovascular disease (ASCVD), and ASCVD risk factors, including hyperlipidemia, hypertension, diabetes, and obesity. A diet consisting predominantly of fruits, vegetables, legumes, nuts, seeds, plant protein and fatty fish is optimal for the prevention of ASCVD. Consuming more of these foods, while reducing consumption of foods with saturated fat, dietary cholesterol, salt, refined grain, and ultra-processed food intake are the common components of a healthful dietary pattern. Dietary recommendations for special populations including pediatrics, older persons, and nutrition and social determinants of health for ASCVD prevention are discussed.

Dietary Supplements Use among Athletes in Lebanon: Knowledge, Attitudes, Practices, and Correlates

Athletes are under the utmost pressure to reach excellence in their performance and achieve the desired outcomes in competitions, prompting them to use dietary supplements. Given the threats to both health and eligibility, it is crucial to observe the prevalence, sources of information, knowledge, attitudes, and practices (KAPs) among Lebanese athletes practicing their sports for at least two years. In the present paper, a cross-sectional study is performed using the snowball sampling method, in which a self-administered KAP questionnaire is used to collect data from 455 athletes (mean age: 27.4 ± 7.9 years; men: 73.1%) participating in four sports categories (ball games, combat sports, endurance sports, and weightlifting). Among the Lebanese athletes, the prevalence of dietary supplement (DS) use was 74%, where half of them had predominately used sports supplements. Athletes in Lebanon heavily rely on coaches (74%) and online sources, including webpages and social media (64%), as key information sources for DSs. The findings suggest that significant proportions of athletes show knowledge deficits and unsatisfactory attitudes towards multiple aspects related to supplementation. Moreover, education and sports type modulate the use of DSs among athletes. Furthermore, 34% reported using supplements without a recommendation from specialists, and 69% admitted to not reading the supplement's nutrition facts. This study urges the need for the regulation of concerned authorities and education programs to help overcome the existing challenges.

Quantification of tocochromanols in vitamin E dietary supplements by instrumental thin-layer chromatography

A variety of vitamin E dietary supplement capsules (DSC) based on different natural oils or synthesis products are currently found on the market whose vitamin contents need to be controlled before and after marketing. Here, we present an instrumental thin-layer chromatography (TLC) method which allows a direct determination of all tocopherols (T) and tocotrienols (T3) as well as α-tocopherol acetate simultaneously in one run with short analysis time. For this purpose, contents of the DSC were extracted, applied on silica gel 60 plates, and developed with n-hexane/ethyl acetate/acetic acid, 90:10:2 (v/v/v) as mobile phase. The UV scan of the plate at 293 nm was used for quantification based on the peak height. Following the scan, the plate was treated with 10% sulphuric acid in methanol which led to characteristic yellow-to-brown colouring of the tocochromanol spots which allowed to distinguish tocochromanols from matrix components with similar Rf values. In most cases, determined vitamin E contents matched well with the information listed on the label of the investigated DSC samples. The method is fast, easy to perform and gently treats the analytes as it requires no thermal treatment prior to quantification, which makes it suitable as a screening method.

Do Multivitamin/Mineral Dietary Supplements for Young Children Fill Critical Nutrient Gaps?

BACKGROUND

Nearly a third of young US children take multivitamin/mineral (MVM) dietary supplements, yet it is unclear how formulations compare with requirements.

OBJECTIVE

Describe the number and amounts of micronutrients contained in MVMs for young children and compare suggested amounts on product labels to micronutrient requirements.

DESIGN

Cross-sectional.

SETTING

All 288 MVMs on the market in the United States in the National Institutes of Health's Dietary Supplement Label Database in 2018 labeled for children 1 to <4 years old.

MAIN OUTCOME MEASURES

Number of MVM products and amounts per day of micronutrients in each product suggested on labels compared with requirements represented by age-appropriate Daily Values (DV). Micronutrients of public health concern identified by the Dietary Guidelines for Americans (DGA) 2015-2020 (DGA 2015) and DGA 2020-2025 (DGA 2020) or those of concern for exceeding the upper tolerable intake levels.

STATISTICAL ANALYSES

Number of products and percent DV per day provided by each micronutrient in each product.

RESULTS

The 288 MVMs contained a mean of 10.1 ± 2.27 vitamins and 4.59 ± 2.27 minerals. The most common were, in rank order, vitamins C, A, D, E, B6, B12; zinc, biotin, pantothenic acid, iodine, and folic acid. For micronutrients denoted by the DGA 2015 and DGA 2020 of public health concern, 56% of the 281 products containing vitamin D, 4% of the 144 with calcium, and none of the 60 containing potassium provided at least half of the DV. The upper tolerable intake level was exceeded by 49% of 197 products with folic acid, 17% of 283 with vitamin A, and 14% of 264 with zinc. Most MVMs contained many of 16 other vitamins and minerals identified in national surveys as already abundant in children's diets.

CONCLUSIONS

A reexamination of the amounts and types of micronutrients in MVMs might consider formulations that better fill critical gaps in intakes and avoid excess.

Analytical strategies to determine the labelling accuracy and economically-motivated adulteration of "natural" dietary supplements in the marketplace: Turmeric case study

Turmeric has faced authenticity issues as instances of economic-adulterations to reduce the cost. We used carbon-14 and HPLC analyses as complementary methods to verify "all-natural" label claims of commercial dietary supplements containing turmeric ingredients. A high percentage of curcumin-to-curcuminoids value was used as an indicator to imply the presence of synthetic curcumin. However, using the HPLC method alone did not provide direct evidence of curcuminoids' natural origin, whereas using only the carbon-14 method cannot test for potency label claims and determine which constituent(s) contain ¹⁴C radiocarbon. By analyzing results from both methods, a significant correlation between the percentage of curcumin-to-curcuminoids and % biobased carbon (Pearson's r = -0.875, p < 0.001) indicated that synthetic curcumin was greatly attributed to determined synthetic ingredients. Only four out of the 14 samples analyzed supported authentic label claims. This orthogonal testing strategy showed its potential for the quality control of turmeric products.

Prevalence and characteristics of multivitamin-multimineral (MVMM) use among Saudi populations in Riyadh, Saudi Arabia: A cross-sectional study

ABSTRACT

Use of multivitamin multimineral (MVMM) preparations is prevalent and growing worldwide, contributing to major health expenditure. Minimal literature on prevalence and characteristics of MVMM use is available from Saudi Arabia.The study was conducted to determine the prevalence and characteristics of MVMM use among Saudi population in Riyadh, Saudi Arabia.A cross-sectional study was conducted at 6 shopping malls located in the different regions of Riyadh city for 6 months from February 01, 2019, to July 31, 2019. A well-structured English questionnaire was developed, translated into Arabic language, and validated by the experts. A pertinent inclusion and exclusion criteria were established. After having informed consent to be included in the study, the printed copies of the questionnaire were distributed among the participants using a convenient sampling technique. The data were collected and analyzed using SPSS version 24. Descriptive statistics were presented as numbers, percentages, means, and standard deviations. A P value of ≤.05 and 95% confidence intervals were used to report the statistical significance.Out of 1200 surveys distributed, 1105 were returned by the participants (response rate 92%). Prevalence of MVMM supplements use turned out to be 47%. The study revealed statistically significant association between MVMM use and gender, marital status, education, regular exercise, smoking, following special diet, and eating fruits and vegetables (P ≤ .05). Majority of the participants used MVMM on daily basis (57.9%), and hospital prescriptions (57.9%) were the most common reason of MVMM use. Majority of the participants used MVMM for diet supplements (32.2%), health promotion (29.4%), and treatment of disease (16%).The MVMM use is prevalent in Saudi population, warranting sound regulatory policies for their judicial use and increase awareness about the benefits and side effects of dietary supplements.

The Role of Pharmaceutical Scientists in the Formation of a Healthy Lifestyle as a Value Orientation

This article focuses on the role pharmaceutical scientists play in achieving social well-being, in particular in the formation of a healthy lifestyle as a value orientation among students and the public in historical retrospect. The following set of research methods was used: a general scientific method, and a historical (chronological, logico-historical, retrospective), personalized, empirical method (including the questioning of pharmaceutical interns and the analytical processing of questionnaires). The territorial boundaries of the study cover Slobozhanshchyna, a historical and geographical region centered in Kharkiv. The educational activities of Slobozhanshchyna’s pharmaceutical scientists during the 19th and early-20th centuries, as well as in the modern period, are presented. Attention is drawn to the fact that the role of pharmaceutical scientists in forming the environment for the development of a harmonious, spiritually and physically developed personality in historical retrospect is important. It is noted that the founders of pharmaceutical education in Ukraine initiated educational activity as a means for promoting the formation of a healthy lifestyle in the educational space and outside of the Imperial Kharkov University. The changes in the public and educational activities recommended for forming a healthy lifestyle among Slobozhanshchyna’s medical scientists and naturalists during the Imperial era have been generalized. The analysis of the research sources and questionnaires of pharmaceutical interns allowed us to assert that, in modern times, Slobozhanshchyna’s pharmaceutical scientists are trying to organize socially useful activities, taking into account the best achievements of the founders of pharmaceutical education in Ukraine. The “orientation to a healthy lifestyle of representatives of the institution of higher pharmaceutical education” has been proposed. This includes the adoption of a set of material, social, and spiritual benefits and ideals considered to be objects of purpose in the pursuit of a healthy lifestyle by employees and students (i.e., part of the implementation of the mission of the University), and using these as tools to meet the needs of both university representatives and ordinary citizens. This article contains a number of factors that mediated the formation of a healthy lifestyle as a value orientation of an individual, including: (a) the circumstances of the individual’s life (the conditions of education of the individual); (b) the individual’s consciousness reflecting the general and specific conditions of their personality formation; (c) the motivation of the real behavior mediated by the subject’s activities. The presence of these factors was identified as typical for the health-saving educational environment. This article provides recommendations regarding the following measures for the organization and effective promotion of a healthy lifestyle by modern pharmaceutical scientists: provide an opportunity to study the peculiarities of the organization of educational activities by scientists of the past to students and specialists in the pharmaceutical field; open museum expositions devoted to the problem of healthcare; conduct master class lectures and educational events devoted to the problem of forming a comprehensively developed personality; involve students in joint research on the problem of active longevity; provide informational support to educators and the public through scientific and popular science publications; conduct awareness-raising work with the population in order to create a health-saving environment.

Dietary supplements intake during the second wave of COVID-19 pandemic: A multinational Middle Eastern study

Introduction

Despite the controversy about the benefits of dietary supplements in treating or preventing COVID-19, their use has increased worldwide even with the introduction of relevant vaccines. Thus, this study aimed to investigate the perception of the Middle Eastern Arab public of dietary supplements as prophylactic or therapeutic agents against COVID-19, and their consumption during the second wave of the COVID-19 pandemic.

Methods

A validated, pilot tested online survey was distributed through social networking platforms in Lebanon, the Kingdom of Saudi Arabia, Palestine, Jordan, and the United Arab Emirates. Responses underwent various statistical analyses.

Results

A total of 2,100 responses were included. Around 44% of participants reported changes in their dietary behavior during COVID-19, and 70% believed that healthy habits may prevent the infection. Moreover, 21% believed that dietary supplements surely protect against COVID-19 and 45% thought they aid in treating it. Users of supplements during the second wave of the pandemic counted for 47%, who declared they were influenced by the media, healthcare providers, or close contacts. Most used supplements included Vitamins C and D and zinc. Only 34% of participants read supplement leaflets. The use of supplements was significantly correlated with being female and exercising, as revealed by the odds ratio and logistic regression analysis.

Conclusions

In line with other areas of the world, the use of dietary supplements in the Middle East against COVID-19 is not evidence-based. Competent health authorities should play their role in spreading sound awareness among the public regarding this issue.

Perspective on Improving the Relevance, Rigor, and Reproducibility of Botanical Clinical Trials: Lessons Learned From Turmeric Trials

Plant-derived compounds, without doubt, can have significant medicinal effects since many notable drugs in use today, such as morphine or taxol, were first isolated from botanical sources. When an isolated and purified phytochemical is developed as a pharmaceutical, the uniformity and appropriate use of the product are well defined. Less clear are the benefits and best use of plant-based dietary supplements or other formulations since these products, unlike traditional drugs, are chemically complex and variable in composition, even if derived from a single plant source. This perspective will summarize key points-including the premise of ethnobotanical and preclinical evidence, pharmacokinetics, metabolism, and safety-inherent and unique to the study of botanical dietary supplements to be considered when planning or evaluating botanical clinical trials. Market forces and regulatory frameworks also affect clinical trial design since in the United States, for example, botanical dietary supplements cannot be marketed for disease treatment and submission of information on safety or efficacy is not required. Specific challenges are thus readily apparent both for consumers comparing available products for purchase, as well as for commercially sponsored vs. independent researchers planning clinical trials to evaluate medicinal effects of botanicals. Turmeric dietary supplements, a top selling botanical in the United States and focus of over 400 clinical trials to date, will be used throughout to illustrate both the promise and pitfalls associated with the clinical evaluation of botanicals.

Quality control of dietary supplements: An economic green spectrofluorimetric assay of Raspberry ketone and its application to weight variation testing

Although Dietary supplements are readily accessible and extensively used worldwide, they are inadequately regulated and consumers are victims of manufacturers' fraud. Thus, quality regulations are required to ensure safety of products available to the public. We propose the first native spectrofluorimetric quality control assay of raspberry ketone, a popular dietary supplement ingredient for weight loss. This work relies on the constant wavelength synchronous scan of the Raspberry Ketone native fluorescence, overcoming the demerits of conventional excitation/ emission spectra. For the best measurement conditions, several parameters were optimized including Δλ value, diluting solvent, medium pH and the effect of surfactants/ macromolecules. In aqueous medium (Δλ = 110 nm), a linear relationship exists between synchronous fluorescence intensity at peak maximum 405.6 nm and solution concentration in the range 300-1500 ng/mL. Method sensitivity was recorded with LOD and LOQ values 60.63 and 183.72 ng/mL; respectively. Validation was done in accordance to International Conference on Harmonization (ICH) guidelines. This simple procedure was successfully applied to the analysis of Raspberry Ketone in commercially available dietary supplement capsules with average recovery 98.67% ± 1.74 and further extended to weight variation testing following the official United States Pharmacopeial (USP) guidelines. Finally, green assessment was done using the ''Analytical Eco-scale'' tool. The total score was 89/100 points revealing excellent greenness of our proposal. Our proposal is simple, eco-friendly and cheap. It can be conveniently adopted for routine quality control practices especially in developing countries.

Omega-3 Fatty Acid Dietary Supplements Consumed During Pregnancy and Lactation and Child Neurodevelopment: A Systematic Review

BACKGROUND

Maternal nutrition during pregnancy and lactation has profound effects on the development and lifelong health of the child. Long-chain PUFAs are particularly important for myelination and the development of vision during the perinatal period.

OBJECTIVES

We conducted a systematic review to examine the relationship between supplementation with omega-3 fatty acids during pregnancy and/or lactation and neurodevelopment in children, to inform the Scientific Report of the 2020 Dietary Guidelines Advisory Committee.

METHODS

We identified articles on omega-3 fatty acid supplementation in pregnant and lactating women that included measures of neurodevelopment in their children (0-18 y) by searching PubMed, CENTRAL, Embase, and CINAHL Plus. After dual screening articles for inclusion, we qualitatively synthesized and graded the strength of evidence using pre-established criteria for assessing risk of bias, consistency, directness, precision, and generalizability.

RESULTS

We included 33 articles from 15 randomized controlled trials (RCTs) and 1 prospective cohort study. Of the 8 RCTs that delivered omega-3 fatty acid dietary supplements during pregnancy alone (200-2200 mg/d DHA and 0-1100 mg/d EPA for approximately 20 wk), 5 studies reported ≥1 finding that supplementation improved measures of cognitive development in the infant or child by 6%-11% (P < 0.05), but all 8 studies also reported ≥1 nonsignificant (P > 0.05) result. There was inconsistent or insufficient evidence for other outcomes (language, social-emotional, physical, motor, or visual development; academic performance; risks of attention deficit disorder, attention-deficit/hyperactivity disorder, autism spectrum disorder, anxiety, or depression) and for supplementation during lactation or both pregnancy and lactation. Populations with a lower socioeconomic status and adolescents were underrepresented and studies lacked racial and ethnic diversity.

CONCLUSIONS

Limited evidence suggests that omega-3 fatty acid supplementation during pregnancy may result in favorable cognitive development in the child. There was insufficient evidence to evaluate the effects of omega-3 fatty acid supplementation during pregnancy and/or lactation on other developmental outcomes.

Trends in packaging material for food products: historical background, current scenario, and future prospects

The commercial demand for food products and dietary supplements has increased drastically in the last few decades. The packed food products and nutritional supplements have made a profound impact on the modern human lifestyle. Since ancient times, storage and long-term use of food products remain a significant challenge for humans. There are different parameters for the evaluation of food products and dietary supplements broadly categorized as quality control and quality assurance. On an average million tons of food, materials get spoiled daily worldwide due to lack of storage and transportation point out packaging systems inequalities. To ensure the quality of packed food products and nutritional supplements among available measures, packaging remained an important event and had been refined from time to time to provide a standard. Over a period, the packaging industry has evolved using modern technology from the conventional methods of new generation packaging, including glass, wood, and paper to most new biodegradable materials. The ancient pattern of packaging; manual packaging has been taken over by an automated system of packing, resulting in enhanced output with minimal chance of damage to valuable products for humanity. The article will emphasize new insights into current packaging system not only provide the quality of these products but also in aiming new heights beyond conventional technologies and consumer opinions. In the present study, we have given more emphasis on novel methods of packaging, the packaging materials, quality of packed products, and their impacts of food products on the environment.

Peer-to-Peer Social Media Communication About Dietary Supplements Used for Weight Loss and Sports Performance Among Military Personnel: Pilot Content Analysis of 11 Years of Posts on Reddit

Background

Over 60% of military personnel in the United States currently use dietary supplements. Two types of dietary supplements, weight loss and sports performance (WLSP) supplements, are commonly used by military personnel despite the associated serious adverse effects such as dehydration and stroke.

Objective

To understand peer-to-peer communication about WLSP supplements among military personnel, we conducted a pilot study using the social media website, Reddit.

Methods

A total of 64 relevant posts and 243 comments from 2009 to 2019 were collected from 6 military subreddits. The posts were coded for year of posting, subreddit, and content consistent with the following themes: resources about supplement safety and regulation, discernability of supplement use through drug testing, serious adverse effects, brand names or identifiers, and reasons for supplement use.

Results

A primary concern posted by personnel who used supplements was uncertainty about the supplements that were not detectable on a drug test. Supplements to improve workout performance were the most frequently used.

Conclusions

Our pilot study suggests that military personnel may seek out peer advice about WLSP supplements on Reddit and spread misinformation about the safety and effectiveness of these products through this platform. Future directions for the monitoring of WLSP supplement use in military personnel are discussed.

Chemical Composition, Diuretic, and Antityrosinase Activity of Traditionally Used Romanian Cerasorum stipites

Cherry stems (CS) represent a by-product intensively used in Eastern European countries as a traditional remedy for urinary tract disorders. Ethnopharmacological evidences sustain the use of CS as aqueous preparations (infusion and decoction), but few data were previously reported about phytochemical profile and pharmacological potential of CS hydroalcoholic extracts. In this regard, we aimed to evaluate the phenolic profile, in vitro antioxidant and tyrosinase inhibitory potential, and in vivo diuretic activity of 70% hydroethanolic cherry stems extract and cherry stems decoction (CSD). LC-DAD-ESI/MSⁿ analysis revealed the presence of flavonoid-type compounds as main constituents for both preparations, especially flavanones (naringenin glycosides). Antioxidant activity evaluated through DPPH, ABTS, and FRAP methods was superior for cherry stems extract, probably due to the presence of phenolic-derived compounds in higher amounts than CSD. On the other hand, tyrosinase inhibitory potential and diuretic effect exerted by CSD were stronger, highlighting that other types of hydrophilic secondary metabolites are responsible for this bioactivity. Overall, our findings indicate that CS preparations could be used as promising mild diuretic agents and encourage further investigations regarding the correlation between their chemical composition and bioactive potential.

A Comparison of Current Regulatory Frameworks for Nutraceuticals in Australia, Canada, Japan, and the United States

The nutraceutical market is growing and the demand for products is increasing. Consumers are looking for cheaper alternatives to prescription medications as well as health products to supplement their dietary intake on a regular basis. Many countries classify these products into different categories based on their health claims. The purpose of this review is to compare and contrast the differences of regulatory frameworks in countries of similar status in regard to nutraceutical products: vitamins, minerals, herbal supplements, and probiotics. This review also takes into consideration the aspects of nutraceutical safety in relation to government regulations. It is evident that further discussion is indicated with regard to the harmonization of nutraceutical product regulation in a global context in order to promote and protect public health. This literature review selected 27 documents for a review using a systematic search of internet databases and search engines including PUBMED and Google Scholar. These documents were reviewed and synthesized for data relating to nutraceutical regulation within the four different countries of focus. Outcomes included information on safety and toxicity, drug interactions, classification of products, and regulatory processes for nutraceutical product approval in each country.

An Approach to Investigate Content-Related Quality of Nutraceuticals Used by Slovenian Consumers: A Case Study with Folate and Vitamin D Supplements

A predisposition for the efficiency of nutraceuticals is that the product contains a sufficient quantity of a vitamin. Several studies have highlighted different quality issues. Our objective was to investigate whether the contents of the vitamins in selected types of food supplements were in accordance with labeling. We focused on two types of food supplements where content-related quality issues could result in public health risks: food supplements for supplementation with (a) folic acid (as 5-methyltetrahydrofolate (5-MTHF)) in pregnancy and (b) with vitamin D in the general population. The study was done on supplements from the global supply that are typically used by Slovenian consumers. We sampled one production batch of 30 different food supplements-six and 24 samples with 5-MTHF and cholecalciferol, respectively. We found samples with vitamin contents outside the 80-150% tolerance interval in both sets. Particularly, 5-MTHF was found to be more problematic, probably due to its lower stability. This study shows the need for better quality control. Quality control is needed during both the manufacturing process and product shelf lifetimes. Content quality should be also subject to external controls by authorities. Voluntarily quality control schemes would also enable consumers to identify products of sufficient quality.

Analysis of the clinical characteristics of insulin autoimmune syndrome induced by alpha-lipoic acid

WHAT IS KNOWN AND OBJECTIVE

Alpha-lipoic acid (ALA) is widely used as a dietary supplement and antiageing agent. Insulin autoimmune syndrome (IAS) is the most serious adverse reaction reported with the use of ALA. The purpose of this study was to explore the clinical characteristics of ALA-induced IAS and provide a scientific reference for clinical diagnosis, treatment and prevention.

METHODS

We collected literature on IAS cases induced by ALA for retrospective analysis in Chinese and English.

RESULTS AND DISCUSSION

The median age of 37 patients (28 females and 9 males) was 61 years (range 32-82). The symptoms occurred at night and in the early morning (60.7%), in the late postprandial period (50.0%) or after fasting (35.7%), within hours in some patients and up to 2 months in others after stopping ALA or during medication treatment. Autonomic nervous system symptoms (81.1%) and neurological hypoglycaemia (64.9%) are the main clinical manifestations of hypoglycaemia. The blood glucose concentration at the onset of hypoglycaemia was 2.19 mmol/L (median, range 1.09-3.52), the insulin concentration was ≥100 μIU/ml (94.6%), and the C-peptide concentration was ≤20 ng/ml (83.3%). Testing for IgG insulin autoantibodies (IAAs) was positive in 37 patients. Pancreatic imaging was unremarkable on computed tomography (CT), magnetic resonance imaging (MRI) and abdominal sonography. Hypoglycaemia disappeared within 5 days to 8 months after withdrawing ALA alone or using corticosteroid treatment. IAA turned negative in 7 months (median; range 2-36). Follow-up showed no recurrent hypoglycaemic episodes at 7.25 months (median; range 1-36).

WHAT IS NEW AND CONCLUSION

ALA-induced IAS is a clinically rare autoimmune disease with hypoglycaemia that occurs during medication treatment or after drug withdrawal that should be treated promptly.

Trends in Nutrient- and Non-Nutrient-Containing Dietary Supplement Use among US Children from 1999 to 2016

OBJECTIVES

To characterize dietary supplement use among US children, including product type, motivations, user characteristics, and trends over time with a primary focus on non-vitamin/non-mineral dietary supplements (NVNM).

STUDY DESIGN

Overall, NVNM, and vitamin and/or mineral dietary supplement only (VM-only) use; motivations for use; and trends in use over time were examined in children (≤19 years of age) using the National Health and Nutrition Examination Survey 1999-2016 data (n = 42 510).

RESULTS

Between 1999 and 2016, overall dietary supplement and VM-only dietary supplement use among all children remained relatively stable at ∼30%; yet, NVNM dietary supplement use increased from 2.9% to 6.4%, mainly due to increased use of omega-3 polyunsaturated fatty acids. NVNM use was greater in boys than in girls (3.9% vs 3.3%), and greater in older children than in younger children (Ptrend < .0001), the opposite of what was observed with VM-only dietary supplement use. Although both user groups shared 2 primary motivations, both motivations were reported by a significantly greater percent of vitamin and/or mineral dietary supplement users vs NVNM users: to maintain health (38.7% vs 23.1%) and to improve health (33.1% vs 22.6%). NVNM users were much more likely to use dietary supplement for relaxation, stress, and sleep; for mental health; and for colon and bowel health.

CONCLUSIONS

Although the prevalence of any dietary supplement and VM-only dietary supplement use among US children has both remained stable, the prevalence of NVNM use has increased substantially over time. Yet, NVNM use remains relatively low overall. NVNM use exhibited different patterns by sex, age, and motivations when compared with vitamin and/or mineral dietary supplement use. Despite increasing NVNM use, high-quality evidence supporting their use is lacking, especially in children.

Recent advances in the applications of nano-agrochemicals for sustainable agricultural development

Modern agricultural practices have triggered the process of agricultural pollution. This process can cause the degradation of eco-systems, land, and environment owing to the modern-day by-products of agriculture. The substantial use of chemical fertilizers, pesticides, and, contaminated water for irrigation cause further damage to agriculture. The current scenario of the agriculture and food sector has therefore become unsustainable. Nanotechnology has provided innovative and resourceful frontiers to the agriculture sector by contributing practical applications in conventional agricultural ways and practices. There is a large possibility that agri-nanotechnology can have a significant impact on the sustainable agriculture and crop growth. Recent research has shown the potential of nanotechnology in improving the agriculture sector by enhancing the efficiency of agricultural inputs and providing solutions to agricultural problems for improving food productivity and security. The prospective use of nanoscale agrochemicals such as nanofertilizers, nanopesticides, nanosensors, and nanoformulations in agriculture has transformed traditional agro-practices, making them more sustainable and efficient. However, the application of these nano-products in real field situations raises concern about nanomaterial safety, exposure levels, and toxicological repercussions to the environment and human health. The present review gives an insight into recent advancements in nanotechnology-based agrochemicals that have revolutionized the agriculture sector. Further, the implementation barriers related to the nanomaterial use in agriculture, their commercialization potential, and the need for policy regulations to assess possible nano-agricultural risks are also discussed.

Dietary Supplements: Knowledge and Adverse Event Reporting Practices of Department of Defense Health Care Providers

INTRODUCTION

The purpose of the study was to assess the knowledge of dietary supplements (DS) and adverse event (AE) reporting practices of the Department of Defense health care providers. AEs related to use of DS are not uncommon. However, it is estimated that less than 2% of AEs are reported. This is problematic given the Food and Drug Administration relies on AE reports to identify and ultimately remove unsafe products from the market. Inadequate reporting of AE puts all DS users at risk.

MATERIALS AND METHODS

Cross-sectional design was used. Electronic surveys were sent to the Department of Defense health care professionals (HCPs) and Emergency Medicine (EM) physicians asking questions about practices regarding DS and AE knowledge and reporting behaviors. The surveys were open for 5 months. During this period of time, HCPs received three email reminders following the initial email to enhance participation. The computer package IBM SPSS version 25 software (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 21.0, Armonk, New York) was used for statistical analysis. Frequency distributions of the responses were analyzed.

RESULTS

Of the 1,700 surveyed, 270 HCPs and 68 EM physicians completed the surveys. At least 39% of HCPs reported never receiving formal DS training. Seventy-two percent of HCPs reported asking their patients about the use of DS. However, when asked if they knew where to report an AE, only 40% of HCPs knew where to report an AE and only 38% knew how to report an AE. Of the EM physicians, only 38% asked their patients about DS. However, a majority (78%) reported that they had encountered an AE. EM physicians also reported they lacked knowledge regarding where (87%) and how (87%) to report AE.

CONCLUSIONS

It is clear that physician and nonphysician HCPs would benefit from additional training about DS and how and where to report suspected AE. Providing regular training on risks, common AE, and how and where to report an AE would help fill the knowledge gap in the ever-changing DS industry. Addressing these issues and coming up with a solution to integrating AE reporting into clinical care could improve health care practices and increase AE reporting to the Food and Drug Administration, which would have a beneficial impact on patient care, public safety, and mission readiness.