Influence of the dietary supplement health and education act on consumer beliefs about the safety and effectiveness of dietary supplements

A Behaviourally Informed Approach to Reducing the Risk of Inadvertent Anti-doping Rule Violations from Supplement Use

For many reasons, athletes' use of supplements is highly prevalent across sports and competitive levels, despite the risk of these products containing a substance on the World Anti-Doping Agency Prohibited List. Contravening anti-doping rules through supplement use could have serious consequences for competitive athletes (e.g., ineligibility from major competitions, loss of medals and funding) due to the principle of strict liability. Indiscriminate supplement use also poses a risk to athlete health. To reduce the possibility of ingesting a supplement containing prohibited substances, independent quality assurance and certification programs have been established (e.g., Informed Sport). However, these programs do not completely eliminate risk, leading to some anti-doping organisations promoting a 'just say no' to supplements stance. Yet, this approach can be problematic as a small number of supplements may be necessary for athletes to consume, in certain situations. Recognising that athletes will continue to use these heavily marketed products, this narrative review describes a theoretically underpinned and systematic approach to preventing inadvertent doping by considering the barriers to and enablers of athlete adherence to risk minimisation supplement use guidelines (RMSUG). By outlining a conceptual shift towards a behaviourally informed approach, this review serves to stimulate the development of multifaceted interventions to prevent inadvertent doping through supplement use. Recognising that risk-minimised supplement use involves a myriad of behaviours, the problem of inadvertent doping through supplement use is framed, and research appraised, through the lens of the Behaviour Change Wheel.

Nutritional Supplement and Dietary Interventions as a Prophylaxis or Treatment of Sub-Concussive Repetitive Head Impact and Mild Traumatic Brain Injury: A Systematic Review

Mild traumatic brain injury (mTBI) affects 42 to 56 million individuals worldwide annually. Even more individuals are affected by sub-concussive repetitive head impacts (SRHIs). Such injuries may result in significant acute and chronic symptoms. A study of how individuals may adjust or augment their nutritional and dietary habits to prevent cumulative neurotrauma and promote post-injury recovery is necessary. The objective of the current study is to systematically review nutritional and dietary interventions for neurotrauma prevention and mTBI recovery to direct clinical decision-making and identify future areas of research. This systematic review, without a specified time-period, was performed in PubMed, Scopus, Cochrane, CINAHL, and Web of Science followed by a manual search of references. Search strings were generated by a research librarian. Studies were included if they: 1) investigate human subjects with mTBI or SRHI; 2) investigate a supplement/ingredient of dietary supplement sold in the U.S. or dietary intervention without classification as a drug or prohibitive statement against use by the U.S. Food and Drug Administration (FDA); 3) assess a quantifiable outcome; and 4) are published in English in a peer-reviewed journal with an accessible full-length article. Studies were excluded if: 1) the study included non-mTBI or SRHI subjects (e.g., moderate/severe TBI, stroke); 2) mTBI is not assessed separately from moderate/severe mTBI; or 3) the studies that required intracranial hemorrhage. Fifteen studies from 12 unique subject populations met inclusion and exclusion criteria. A total of 1139 mTBI or SRHI subjects were enrolled across intervention arms in the study populations. A total of eight intervention were studied. Omega-3 fatty acid (n-3FA), melatonin, and Pinus radiata were the only interventions examined in multiple studies. Studies included 10 randomized-control trials, three prospective observational studies, and two retrospective observational studies. Seven of the 15 studies had a low risk of bias. Eleven studies reported benefit of the intervention. Strongest evidence supports n-3FA utility for neurotrauma prevention in athletes exposed to SRHI. Both Pinus radiata and melatonin may have benefit for persistent post-concussion symptoms; however, additional multi-center studies are necessary prior to making a definitive conclusion on these supplements' efficacy. Future studies should continue to assess both novel interventions and additional interventions examined in this review to bring additional evidence to the burgeoning field of nutritional and dietary interventions for SRHI and mTBI.

Dietary Supplements: A Gateway to Doping?

Dietary supplements are widely used among athletes, but many may be unaware of the potential for unintentional doping, especially considering that supplements can often be contaminated with prohibited substances. The reason behind the widespread use of dietary supplements among athletes is often cited as being for the purposes of enhancing health or performance. However, many athletes turn to unreliable sources of information, and often lack knowledge of dietary supplement regulations. The aim of this narrative review is to explore the current research surrounding the psychological constructs (such as norms, attitudes, and beliefs) related to dietary supplement use among athletes that may lead to inadvertent doping. This review also covers possible programme structures that may be effective at preventing inadvertent doping.

A content analysis of marketing on the packages of dietary supplements for weight loss and muscle building

•

Weight loss dietary supplement packages have a high prevalence of marketing claims.

•

Such claims are potentially misleading and lack scientific evidence.

•

Products with the FDA disclaimers and warnings displayed more claims on average.

•

FDA disclaimers and warnings are never displayed on the front of the package.

Most dietary supplements for weight loss and muscle growth lack scientific evidence in support of product claims and contain ingredients that can be harmful to health. Many people, however, still use these products. This paper aims to address a gap in the knowledge of the number and types of marketing claims appearing on dietary supplements for weight loss and muscle building and how they relate to the presence of an FDA disclaimer. We identified all products (n = 110) found in the weight loss and muscle building section of three stores (a pharmacy, supermarket, and superstore) in the Boston, MA area during 2013. We performed a content analysis to assess the presence of marketing claims displayed on product packaging, including claims about weight loss, safety, quality, and scientific evidence. Warnings and the FDA disclaimer were also coded. We found that, on average, products displayed 6.5 claims. Among weight loss- and muscle building- related claims, claims about reducing weight, BMI, or body fat were most common (60.9%), followed by protein claims (40.0%). Nearly half of the products made claims that scientific research supported product use. Products with the FDA disclaimer (53.6%) or a warning for vulnerable populations (56.4%) had a higher average number of claims compared to products without the disclaimer or warning (p < 0.001). Dietary supplements for weight loss and muscle building displayed many marketing claims promising weight loss despite a lack of scientific evidence that such products can be used safely and effectively. Greater FDA regulation of these marketing claims are needed.

Determinants of Knowledge About Dietary Supplements Among Polish Internet Users: Nationwide Cross-sectional Study

Background

An accurate understanding of dietary supplements (DS) is a prerequisite for informed decisions regarding their intake. However, there is a need for studies on this understanding among the public based on validated research tools.

Objective

This study aims to assess the knowledge about DS among Polish internet users with no medical education and to identify its determinants and design an appropriate predictive model.

Methods

The study protocol was prospectively registered with a statistical analysis plan. Polish users of a web-based health service and a social networking service were administered a survey consisting of the recently developed questionnaire on knowledge about DS, the questionnaire on trust in advertising DS, the beliefs about medicines questionnaire, and several other health-related single-item measures and sociodemographic questions. The results were subjected to general linear modeling.

Results

A total of 6273 participants were included. Of the 17 yes or no questions in the questionnaire of knowledge about DS, the mean number of correct responses was 9.0 (95% CI 8.9-9.1). Health service users performed worse than social networking users by 2.3 points (95% CI 2.1-2.5) in an analysis adjusted for potential confounders. Internet users had fewer true beliefs about DS if they presented higher trust in their advertising (adjusted β=−.37; 95% CI −.39 to −.34), used DS (adjusted β=−.14; 95% CI −.17 to −.12), experienced their positive effect (adjusted β=−.16; 95% CI −.18 to −.13), were older or younger than 35 years (adjusted β=−.14; 95% CI −.17 to −.12), expressed interest in the topic of DS (adjusted β=−.10; 95% CI −.13 to −.08), reported getting information about the products from friends (adjusted β=−.13; 95% CI −.15 to −.11), and believed that medicines are harmful (adjusted β=−.12; 95% CI −.15 to −.10). The proposed 5-predictor model could explain 31.2% of the variance in knowledge about DS. The model appeared resistant to overfitting and was able to forecast most of the observed associations.

Conclusions

Polish internet users with no medical education exhibit some false beliefs regarding DS. Trusting the advertising of DS appears to conflict with knowledge about them. There is an urgent need for effective web-based educational campaigns on DS and the promotion of advertising literacy. After the proposed predictive model is externally validated, it may help identify the least informed target audience.

Do Dietary Supplements Improve Perceived Health Well-Being? Evidence from Korea

This study analyzes the self-reported intake of dietary supplements (DS) and their effects on perceived health well-being from a survey with 1210 adult respondents in Korea. To account for selectivity bias from observable confounders, we use a propensity score matching (PSM) model. Our findings show that demographics, health concerns, family history of disease, frequency of hospital visits, and regular exercise are positively associated with intake of DS among consumers. Results from PSM show that the intake of DS leads to significant improvements in perceived health well-being among DS takers relative to DS non-takers regardless of gender, urban residence, having self-reported diseases or not. The paper concludes with implications for policies that promote intake of DS in Korea.

The ITS region provides a reliable DNA barcode for identifying reishi/lingzhi (Ganoderma) from herbal supplements

The dietary supplement industry is rapidly growing yet, a recent study revealed that up to 60% of supplements may have substituted ingredients, some of which can be harmful contaminants or additives. When ingredients cannot be verified morphologically or biochemically, DNA barcoding complemented with a molecular phylogenetic analysis can be a powerful method for species authentication. We employed a molecular phylogenetic analysis for species authentication of the commonly used fungal supplement, reishi (Ganoderma lingzhi), by amplifying and sequencing the nuclear ribosomal internal transcribed spacer regions (ITS) with genus-specific primers. PCR of six powdered samples and one dried sample all sold as G. lucidum representing independent suppliers produced single, strong amplification products in the expected size-range for Ganoderma. Both best-hit BLAST and molecular phylogenetic analyses clearly identified the presence of G. lingzhi DNA in all seven herbal supplements. We detected variation in the ITS sequences among our samples, but all herbal supplement samples fall within a large clade of G. lingzhi ITS sequences. ITS-based phylogenetic analysis is a successful and cost-effective method for DNA-based species authentication that could be used in the herbal supplement industry for this and other fungal and plant species that are otherwise difficult to identify.

Outcome Expectancies, Health Information Seeking, and Cancer Beliefs Associated with Multivitamin/Mineral Use in a National Sample, HINTS-FDA 2015

BACKGROUND

Dietary supplements, including multivitamins/minerals, are commonly reported by adults, yet little is known about multivitamin/mineral use in relation to information seeking, cancer-specific outcome expectancies, and cancer beliefs.

OBJECTIVE

To examine the relationship of heath information seeking, beliefs about cancer, and outcome expectancies with multivitamin/mineral use within a national sample.

DESIGN

A secondary analysis of data collected by The Health Information National Trends Survey (HINTS) and the US Food and Drug Administration (FDA) (HINTS-FDA 2015) was conducted. HINTS-FDA 2015 evaluated information seeking, beliefs about cancer, and health behaviors and was a self-administered, two-stage mail survey sent to a random sample of US postal addresses stratified by county smoking rates.

PARTICIPANTS

Adult household residents were invited to participate, resulting in a 33% response rate (n=3,738).

MAIN OUTCOME MEASURES

Participants self-reported use of multivitamin/mineral products.

STATISTICAL ANALYSES

Adjusting for covariates (demographics, single-ingredient and herbal supplement use) weighted stepwise binary logistic regression was used to examine correlates of self-reported multivitamin/mineral use.

RESULTS

Intake was associated with less than a high school education, having health insurance, and single-ingredient and herbal supplement use. Trust in health organizations (odds ratio [OR]=1.67, P<0.001) and the expectancy that cancer could be avoided with dietary supplements (OR=1.76, P<0.001) correlated with use. Agreement that supplements labeled as "anticarcinogenic" could treat (OR=3.07, P<0.001) or prevent cancer (OR=6.06, P<0.001) correlated with multivitamin/mineral use. Fatalistic beliefs (P<0.001) and negative information-seeking experiences (P<0.001) were associated with slightly lower odds of use.

CONCLUSIONS

Despite leading health organizations' discouragement of dietary supplements for cancer prevention, this study found that trust in health organizations and outcome expectancies were associated with multivitamin/mineral use. This divergence presents a need to explore how dietary supplement evidence based recommendations can be translated and disseminated for the public.

Effects of Nutritional Supplements and Dietary Interventions on Cardiovascular Outcomes: An Umbrella Review and Evidence Map

BACKGROUND

The role of nutritional supplements and dietary interventions in preventing mortality and cardiovascular disease (CVD) outcomes is unclear.

PURPOSE

To examine evidence about the effects of nutritional supplements and dietary interventions on mortality and cardiovascular outcomes in adults.

DATA SOURCES

PubMed, CINAHL, and the Cochrane Library from inception until March 2019; ClinicalTrials.gov (10 March 2019); journal Web sites; and reference lists.

STUDY SELECTION

English-language, randomized controlled trials (RCTs) and meta-analyses of RCTs that assessed the effects of nutritional supplements or dietary interventions on all-cause mortality or cardiovascular outcomes, such as death, myocardial infarction, stroke, and coronary heart disease.

DATA EXTRACTION

Two independent investigators abstracted data, assessed the quality of evidence, and rated the certainty of evidence.

DATA SYNTHESIS

Nine systematic reviews and 4 new RCTs were selected that encompassed a total of 277 trials, 24 interventions, and 992 129 participants. A total of 105 meta-analyses were generated. There was moderate-certainty evidence that reduced salt intake decreased the risk for all-cause mortality in normotensive participants (risk ratio [RR], 0.90 [95% CI, 0.85 to 0.95]) and cardiovascular mortality in hypertensive participants (RR, 0.67 [CI, 0.46 to 0.99]). Low-certainty evidence showed that omega-3 long-chain polyunsaturated fatty acid (LC-PUFA) was associated with reduced risk for myocardial infarction (RR, 0.92 [CI, 0.85 to 0.99]) and coronary heart disease (RR, 0.93 [CI, 0.89 to 0.98]). Folic acid was associated with lower risk for stroke (RR, 0.80 [CI, 0.67 to 0.96]; low certainty), whereas calcium plus vitamin D increased the risk for stroke (RR, 1.17 [CI, 1.05 to 1.30]; moderate certainty). Other nutritional supplements, such as vitamin B6, vitamin A, multivitamins, antioxidants, and iron and dietary interventions, such as reduced fat intake, had no significant effect on mortality or cardiovascular disease outcomes (very low- to moderate-certainty evidence).

LIMITATIONS

Suboptimal quality and certainty of evidence.

CONCLUSION

Reduced salt intake, omega-3 LC-PUFA use, and folate supplementation could reduce risk for some cardiovascular outcomes in adults. Combined calcium plus vitamin D might increase risk for stroke.

PRIMARY FUNDING SOURCE

None.

Knowledge about dietary supplements and trust in advertising them: Development and validation of the questionnaires and preliminary results of the association between the constructs

BACKGROUND

Despite offering little overall benefit and emerging concerns about their safety, dietary supplements have become increasingly popular. Trust in advertising them may contribute to high confidence in dietary supplements in public opinion.

AIM

To develop and validate a screening questionnaire intended for the general public regarding knowledge about dietary supplements and a questionnaire on trust in advertising dietary supplements, and to identify the association between these constructs.

MATERIALS AND METHODS

The development and validation of the measures was overseen by the panels of experts. The conceptual frameworks of the constructs were scientifically well grounded. A set of semi-structured interviews and anonymous web-based surveys was performed. The final questionnaire was applied to 220 non-medically educated people and 121 medically educated people.

RESULTS

A 17-item questionnaire on knowledge about dietary supplements and eight-item questionnaire on trust in advertising dietary supplements were developed. The measures presented satisfactory proof of validity, however, the psychometric properties of the questionnaire on knowledge were modest. Both the knowledge about dietary supplements in the study group and trust in advertising them were low. A significant negative relationship was found between knowledge about dietary supplements and trust in advertising them among the general public (Pearson's r = -0.42, 95%CI: -0.52 to -0.30, p<0.0001). This association was especially pronounced in people who reported not taking dietary supplements (Pearson's r = -0.61, 95%CI: -0.76 to -0.39, p<0.0001).

CONCLUSIONS

The extensive advertising of dietary supplements appears to be in conflict with promoting evidence-based knowledge about them, which raises substantial concerns for the public health. The results of the study are only preliminary and require further confirmation and exploration.

Identifying the "Mushroom of Immortality": Assessing the Ganoderma Species Composition in Commercial Reishi Products

Species of Ganoderma, commonly called reishi (in Japan) or lingzhi (in China), have been used in traditional medicine for thousands of years, and their use has gained interest from pharmaceutical industries in recent years. Globally, the taxonomy of Ganoderma species is chaotic, and the taxon name Ganoderma lucidum has been used for most laccate (shiny) Ganoderma species. However, it is now known that G. lucidum sensu stricto has a limited native distribution in Europe and some parts of China. It is likely that differences in the quality and quantity of medicinally relevant chemicals occur among Ganoderma species. To determine what species are being sold in commercially available products, twenty manufactured products (e.g., pills, tablets, teas, etc.) and seventeen grow your own (GYO) kits labeled as containing G. lucidum were analyzed. DNA was extracted, and the internal transcribed spacer (ITS) region and translation elongation factor 1-alpha (tef1α) were sequenced with specific fungal primers. The majority (93%) of the manufactured reishi products and almost half of the GYO kits were identified as Ganoderma lingzhi. G. lingzhi is native to Asia and is the most widely cultivated and studied taxon for medicinal use. Illumina MiSeq sequencing of the ITS1 region was performed to determine if multiple Ganoderma species were present. None of the manufactured products tested contained G. lucidum sensu stricto, and it was detected in only one GYO kit. G. lingzhi was detected in most products, but other Ganoderma species were also present, including G. applanatum, G. australe, G. gibbosum, G. sessile, and G. sinense. Our results indicate that the content of these products vary and that better labeling is needed to inform consumers before these products are ingested or marketed as medicine. Of the 17 GYO kits tested, 11 kits contained Ganoderma taxa that are not native to the United States. If fruiting bodies of exotic Ganoderma taxa are cultivated, these GYO kits will likely end up in the environment. The effects of these exotic species to natural ecosystems needs investigation.

Dietary supplement use, perceptions, and associated lifestyle behaviors in undergraduate college students, student-athletes, and ROTC cadets

OBJECTIVE

To identify the prevalence of dietary supplement (DS) use, perceptions of DS efficacy, and lifestyle behaviors of DS users and non-users.

PARTICIPANTS

Undergraduate students, student-athletes, and ROTC cadets at a Midwestern University between September 2014 and January 2015.

METHODS

A cross-sectional online survey was administered. Analysis included descriptive statistics, chi-square, and independent sample t-tests.

RESULTS

At least 50% of respondents from each group reported DS use. Users generally reported favorable perceptions of efficacy. Undergraduate student DS users reported more exercise and more healthful dietary habits compared to non-users; however, nearly 72% of undergraduates who reported tobacco use also reported DS use. Less significant differences were observed in the student-athlete and cadet samples.

CONCLUSIONS

DS use is common on college campuses, and many DS users report favorable perceptions of efficacy. With the exception of tobacco use, collegiate DS users generally report lifestyles that are as healthy or healthier than non-users.

Equine dietary supplements: an insight into their use and perceptions in the Irish equine industry

Background

Nutritional supplements are frequently used by horse owners/caregivers to supplement their horse(s) diets. Some work has been done to identify the types of supplements fed and the reasons for doing so; however, this has been predominantly disciple-specific and with little focus on participants’ perceptions of supplement testing and regulation. The aim of this study was to gain an insight into the use and perceptions of equine dietary supplements in the Irish equestrian industry.

Methods

An online survey was designed to ascertain the following information: demographics, types of supplements fed and reasons for use, factors that influenced respondents’ choice of supplement, where advice was sought and perceptions of testing and regulation of equine supplements

Results

The survey yielded 134 responses, 70% non-professionals and 30% professionals. A greater percentage of professionals included supplements in their horse(s) diets (98%) compared to non-professionals (86%). Almost 70% of professionals fed more than two supplements, whereas 80% of non-professionals reported to feed only one supplement. Joint supplements were most commonly fed by all respondents (22%) followed by calming supplements (13%). The enhancement of performance (35%) and prevention of joint disorders (34%) were the most common reasons reported by respondents for using a supplement. Over 53% of respondents sought advice on choosing a supplement from their feed merchant, followed by their veterinarian (46%). Veterinary recommendation was given as the most influential factor when choosing a supplement by 90% of respondents, followed by cost (69%). Most (93%) respondents thought that feed supplements had to meet legal standards, with each batch analysed for quality (72%) and the supplement tested on horses before being launched on to the market (92%).

Conclusion

This study has identified the main types of supplements used in the Irish equestrian industry along with the reasons for their use. However, it has also highlighted major misperceptions in how supplements are tested before being launched for sale and further work on this aspect of the findings would be beneficial.

Proportionality in Public Health Regulation: The Case of Dietary Supplements

The idea that the degree of infringement public health interventions have on individual rights should be proportional to the degree of expected benefits has emerged as an influential principle in public health ethics and policy. While proportionality makes sense in theory, it may be difficult to implement in practice, due to the inherent conflict between individual rights and the common good underlying the principle. To apply the proportionality principle to a decision of policy, one must still find a reasonable way of balancing these competing values in light of the available options and empirical evidence. In this article, I consider how the proportionality principle applies to the regulation of dietary supplements and examine some critiques of the current oversight system. I argue that it may be difficult maintain proportional oversight because the risks of dietary supplements vary considerably. Strengthening the regulations may therefore promote an appropriate level of regulation in some cases but lead to overregulation in others.

Dietary Supplement Adverse Event Report Data From the FDA Center for Food Safety and Applied Nutrition Adverse Event Reporting System (CAERS), 2004-2013

Background: The Food and Drug Administration (FDA)’s Center for Food Safety and Applied Nutrition (CFSAN) oversees the safety of the nation’s foods, dietary supplements, and cosmetic products. Objective: To present a descriptive analysis of the 2004-2013 dietary supplement adverse event report (AER) data from CAERS and evaluate the 2006 Dietary Supplements and Nonprescription Drug Consumer Protection Act as pertaining to dietary supplements adverse events reporting. Methods: We queried CAERS for data from the 2004-2013 AERs specifying at least 1 suspected dietary supplement product. We extracted the product name(s), the symptom(s) reported, age, sex, and serious adverse event outcomes. We examined time trends for mandatory and voluntary reporting and performed analysis using SAS v9.4 and R v3.3.0 software. Results: Of the total AERs (n = 15 430) received from January 1, 2004, through December 31, 2013, indicating at least 1 suspected dietary supplement product, 66.9% were mandatory, 32.2% were voluntary, and 0.9% were both mandatory and voluntary. Reported serious outcomes included death, life-threatening conditions, hospitalizations, congenital anomalies/birth defects and events requiring interventions to prevent permanent impairments (5.1%). The dietary supplement adverse event reporting rate in the United States was estimated at ~2% based on CAERS data. Conclusions: This study characterizes CAERS dietary supplement adverse event data for the 2004-2013 period and estimates a reporting rate of 2% for dietary supplement adverse events based on CAERS data. The findings show that the 2006 Dietary Supplements and Nonprescription Drug Consumer Protection Act had a substantial impact on the reporting of adverse events.

Mandatory disclaimers on dietary supplements do not reliably communicate the intended issues

Some efforts by the government to regulate the promotional statements of pharmaceutical manufacturers have recently been found unconstitutional under the First Amendment, which has been interpreted to protect commercial as well as personal speech. As an alternative means of protecting patients from unreliable marketing claims, courts have proposed that the Food and Drug Administration could add disclaimers to promotional messages that discuss off-label, or unapproved, uses. We conducted a systematic review of studies of the disclaimers currently required for dietary supplements, to assess how well disclaimers inform consumers' health choices. A few small studies reported a modest impact of disclaimers on consumers' attitudes about dietary supplements, but larger and more rigorous studies generally revealed that many consumers were unaware of a disclaimer or reported that it did not affect their perceptions of a product. The available evidence indicates that replacing government restrictions on pharmaceutical marketing with potentially ineffective disclaimers will be an inadequate way of informing patients about the efficacy and safety of drugs, and it risks returning the United States to a previous era when inappropriate marketing claims about prescription drugs proliferated and contributed to the inappropriate use of those products.

Consumers' perceptions of the dietary supplement health and education act: implications and recommendations

In 1994, the United States Congress passed the Dietary Supplement Health and Education Act (DSHEA). The regulatory framework for dietary supplements created by DSHEA has led to significant misperceptions regarding consumers' understanding of the safety and efficacy of supplements. Research shows that consumers erroneously believe that: (1) supplements are approved by the government, (2) supplements have been tested for safety and effectiveness, (3) the content of supplements is analyzed, and (4) manufacturers are required to disclose known adverse effects to consumers. Furthermore, labelling requirements that are intended to provide transparency to consumers are relatively ineffective. The following four recommendations are offered for reforming DSHEA: (1) only allow structure-function claims that are supported by research evidence, (2) require manufacturers to list known adverse effects on the labels of dietary supplements, (3) require that the Food and Drug Administration analyzes the content of dietary supplements and (4) restrict the definition of dietary ingredients. These recommendations would bring DSHEA to more closely align with consumer expectations regarding the regulation of dietary supplements and would likely provide a safer landscape for the use of supplements. Copyright © 2015 John Wiley & Sons, Ltd.

Knowledge About E-Cigarette Constituents and Regulation: Results From a National Survey of U.S. Young Adults

OBJECTIVES

To examine young adults' knowledge of e-cigarette constituents and regulation and its association with product use and self-reported exposure to marketing.

METHODS

Young adults (18-34 years, N = 1,247) from a U.S. web panel were surveyed in March 2014. Using multinomial logistic regressions, self-reported exposure to marketing was examined as a predictor of whether participants responded correctly (reference category), incorrectly, or "don't know" to four knowledge items-whether e-cigarettes contain nicotine, contain toxic chemicals, are regulated by government for safety, and are regulated for use as a cessation aid. Analyses adjusted for demographics and smoking status and were weighted to match the U.S. young adult population.

RESULTS

Most respondents did not know if e-cigarettes, contain toxic chemicals (48%), are regulated for safety (61%), and are regulated as cessation aids (68%); fewer than 37% answered all of these items correctly. Current users of e-cigarettes (past 30 days) had a lower likelihood of being incorrect about safety testing (p = .006) and being regulated as a cessation aid (p = .017). Higher exposure to e-cigarette marketing was associated with a lower likelihood of responding "don't know" than being correct, and with a higher likelihood of being incorrect as opposed to correct about e-cigarettes containing nicotine.

CONCLUSIONS

Knowledge about e-cigarette constituents and regulation was low among young adults, who are the largest consumer group for these products. Interventions, such as warning labels or information campaigns, may be necessary to educate and correct misinformation about these products.

Common use of dietary supplements for bipolar disorder: a naturalistic, self-reported study

Background

Dietary supplements are taken by about half of Americans. Knowledge of dietary supplement use is important because they may interact with prescription drugs or other supplements, cause adverse reactions including psychiatric symptoms, or contain inherently toxic ingredients or contaminants. This study explores the use of dietary supplements by patients with bipolar disorder in the US.

Methods

Data were obtained from an ongoing, naturalistic study of patients with bipolar disorder who received pharmacological treatment as usual. The patients self-reported their daily mood, sleep, and medications taken, including all drugs prescribed for bipolar disorder or that the patient felt impacted their mood. These included other prescribed drugs, over-the-counter drugs and dietary supplements. Drugs that received premarketing approval from the FDA were not included as dietary supplements. Patient demographics and daily medication use were characterized.

Results

Data were available from 348 patients in the US who returned a mean 249.5 days of data. In addition to prescribed psychiatric drugs, 101 of the 348 patients (29 %) used a dietary supplement for at least 7 days and 69 (20 %) used a supplement long term (for at least 50 % of days). Of the 101 supplement users, 72 (71.3 %) took one supplement daily. The 101 patients tried over 40 different supplements, and the long-term users took 19 different supplements. The most commonly taken supplements for both groups were fish oil, B vitamins, melatonin, and multivitamins. Patients using supplements were more likely to be white (p < 0.001), older (p = 0.009), and ill for more years (p = 0.025).

Conclusions

Many patients with bipolar disorder use dietary supplements in addition to prescribed drugs. Physicians should obtain detailed information about all dietary supplements taken by patients with bipolar disorder.

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

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

Consumer attitudes toward dietary supplements consumption

Purpose

– Drawing on a socio-cognitive model, the theory of planned behaviour (TPB), the aim of this paper is to investigate whether the effects of social cognition on intention to consume dietary supplements moderate by health motivation.

Design/methodology/approach

– This study was carried out using a cross-sectional survey approach. Subjects comprised 438 undergraduate students from six universities in Malaysia.

Findings

– Given strong support for the extended TPB's application to dietary supplements consumption provided by the study, it seems feasible that desirable changes in attitude, social norms, and perceptions of control might lead to corresponding changes in behavioural intention. The empirical findings, which are based on multi-group analysis, show that the strength of the relationships between informational influence, consumer attitude, and their intention to consume dietary supplements are strongly influenced by health motivation.

Practical implications

– This research sets the ground for stakeholders in the healthcare and pharmaceutical sectors to improve their understanding of what drives dietary supplements consumption. Armed with this knowledge, marketers and health professionals could plan and execute their marketing strategies and health interventions more effectively.

Originality/value

– The core contribution lies in an important extension of social cognitive model by incorporating the moderating effect of health motivation. This study demonstrates the measurement validity and predictive efficacy of the proposed integrative model which can be used as a promising framework to examine other preventive health behaviours.

Herbal products in pregnancy: experimental studies and clinical reports

The aim of this work is to provide an update from an overview of the literature of the most frequently consumed herbal remedies during pregnancy, both alone and concomitantly with prescribed medications and particularly on their side effects to the mother and fetus. We have also analyzed some of the adverse interactions that may occur due to concomitant use of herbal and pharmaceutical products during pregnancy. Herbal remedies are not evaluated according to the same standards as pharmaceuticals, and in the USA some of it are not licensed but sold as food supplements. There is a lack of basic knowledge on the part of both clinicians and patients as to the indications for use and safety of herbal medicines used in pregnancy and lactation. If 'traditional use' is the only available information, the pregnant woman should be made aware of this to enable her to make an informed decision concerning potential use.

The regulation of dietary supplements in the United States: advocating for a reasonable approach, protecting patient safety, and the role of nursing

Many Americans report using dietary supplements (DS) and there is evidence that the use of such products is increasing. Under the current regulatory system DS are not tested for safety or effectiveness, as with over the counter and prescription drugs, and the Food and Drug Administration (FDA) has limited authority to protect Americans from potential harm. DS in the United States have become a major public health and patient safety issue with injuries, illnesses, and deaths attributed to their use. Efforts in congress to legislate safer regulations have been met with limited success, in part because of the lobbying efforts of the DS industry. Although there is near consensus in the literature and among stakeholder government agencies that a modified FDA role is needed, resolving the issue requires a multifaceted approach. Along with political and legislative action, effort must be made to increase the American public's knowledge of DS.

More Is Not Always Better: Intuitions About Effective Public Policy Can Lead to Unintended Consequences

Public policy decisions often appear based on an assumption that providing more options, more information, and greater decision-making autonomy to consumers will produce better outcomes. We examine reasons why this "more-is-better" approach exists based on the psychological literature. Although better outcomes can result from informed consumer choice, we argue that more options, information, and autonomy can also lead to unintended negative consequences. We use mostly health-related policies and guidelines from the United States and elsewhere as exemplars. We consider various psychological mechanisms that cause these unintended consequences including cognitive overload, affect, and anticipated regret, information salience and availability, and trust in governments as authoritative information providers. We also point toward potential solutions based on psychological research that may reduce the negative unintended consequences of a "more-is-better" approach.