Weighing alternative remedies
■ With 53% of Americans using dietary supplements, discussing such products should be part of primary care, doctors say. Physicians offer tips on addressing the subject.
By Christine S. Moyer — Posted Feb. 20, 2012
Patients frequently come to family physician Walt Larimore, MD, with questions about whether cocktails of herbs, metabolites and vitamins will improve their health.
So he wasn't surprised when a patient recently asked if taking cinnamon could cure her type 2 diabetes.
Uncertain of the answer, he researched the supplement's effectiveness online with the patient and determined that cinnamon probably would be ineffective in treating her condition.
Two decades ago, that patient's question might have seemed absurd. But today, with more than half of U.S. adults using dietary supplements, discussing alternative medicines during office visits is a common part of primary care.
The Food and Drug Administration defines a dietary supplement as any product taken by mouth that contains an ingredient intended to supplement a person's diet but is not represented as a sole item of the diet. Such products usually come in capsules, liquids, nutrition bars, powders and tablets. They must contain appropriate labeling and at least one dietary ingredient. Those ingredients include amino acids, herbs and vitamins, the FDA said.
Dr. Larimore, who practices in Colorado Springs, Colo., is among the health professionals who are noticing an uptick in patients who take supplements or have questions about them. Fifty-three percent of U.S. adults reported using at least one dietary supplement in 2003-06, up from 42% between 1988 and 1994, according to the latest data from the Centers for Disease Control and Prevention.
Contributing to that rise: patients becoming more involved in their care; the high cost of prescription drugs, which leads some people to seek natural alternatives; and an aging population searching for remedies to chronic illnesses, physicians say. Also spurring the public's interest are the large number of studies in the past two decades on the health benefits of products such as calcium, fish oil and vitamin D.
"People often assume that natural products are safer" than prescription drugs, but that's not true, said Dr. Larimore, medical director of Mission Medical Clinic of Colorado Springs, a faith-based nonprofit organization. "What's critical for health professionals and the public to understand is that supplements are essentially unregulated in the United States."
Under the Dietary Supplement Health and Education Act of 1994, supplement manufacturers or distributors -- not the FDA -- are responsible for ensuring that their products are safe and their health claims accurate. Once a supplement is on shelves, the FDA can restrict its use or remove it if the agency proves that the product is unsafe.
Conventional drug products such as prescription medications cannot be released to the public until the FDA confirms that they are safe and effective for their intended uses.
Complicating matters is that supplements often contain ingredients that might appear benign but can interact with one another and prescription medications, said Richard D. Kelley, MD, a family physician in Austin, Texas. As a result, patients commonly experience allergic reactions and significantly elevated blood pressure, Dr. Kelley said. In more extreme cases, supplement use can lead to liver damage, profound anxiety and death.
Just as concerning to health professionals is the fact that supplements often have quality problems. For example, they may be contaminated with lead, cadmium or other heavy metals, said ConsumerLab.com. The New York-based nonprofit provides independent test results on nutrition products for consumers and health professionals.
Doctors may have limited office time and minimal training to discuss with patients the potential dangers of supplements. Another challenge is that scientific findings seem to change on the medical benefits of using supplements.
But health professionals say it is primary care physicians' duty to be educated on supplements and to talk to patients about use of such products. "Patients look to us to be the one to help guide them" in managing their health, said Dana Simpler, MD, a Baltimore internist. "If the primary care physician doesn't do it, who will?"
Talking to patients about supplements
About 40% of adults 20 and older take multivitamins/multiminerals, the most commonly used dietary supplements among adults, the CDC said. Other substances also are widely used by adults. For instance, 37% reported taking fish oil, omega 3 or DHA in the past 30 days, said a 2007 study by the CDC's National Center for Health Statistics. Also commonly used were glucosamine and echinacea (20%), flaxseed oil or pills (16%) and ginseng (14%).
Dr. Simpler monitors her patients' use by mailing them a questionnaire before their annual exam that asks for a list of all prescriptions, over-the-counter substances and supplements they take. She asks patients to bring the questionnaire to their appointment.
Other doctors have a staff member ask patients before an office visit what prescription medications and natural products they take.
Regardless of how the details are gathered, physicians need to find out what supplements their patients use, according to American Medical Association policy. The AMA recommends that doctors routinely inquire about patients' use of alternative or unconventional therapies and educate themselves and their patients on the latest data.
Knowing about a patient's supplement use recently helped Dr. Larimore get an individual's hyperthyroidism under control. After a discussion with the patient, he learned that she was taking thyroid medicine, a multivitamin, calcium and vitamin D, all at breakfast.
"All of a sudden it was clear," he said. "You can't take thyroid medication with calcium, because the [supplement] will absorb it."
He added, "If you don't know [what your patient is taking] you're potentially dead in the water."
An analysis of 101 adult primary care patients who use supplements and prescription medicine found that 14 were at risk of having at least one drug-supplement interaction, some of which were considered serious. The data were released in August 2008 in the book Advances in Patient Safety: New Directions and Alternative Approaches, published by the Agency for Healthcare Research and Quality.
Dr. Kelley sees several patients each month whose health is impacted negatively by a supplement. He often identifies the problem because the individual's blood pressure is significantly higher than his or her normal levels. Among the possible causes is a drug-supplement interaction, he said.
Dr. Kelley asks such patients why they are using the particular product and informs them of the potential dangers. He tells them, "You're having an adverse effect with this. You need to stop taking it, because it's not benefiting you."
To prevent supplement-related complications, Cleveland internist Raul Seballos, MD, tries to help patients find ways to achieve their health goals without taking the natural products. Dr. Seballos, vice chair of preventive medicine at Cleveland Clinic, asks patients if they sleep at least eight hours, exercise a minimum of 150 minutes a week and manage their stress levels well.
"All these issues need to be addressed before you take supplements," he tells patients. "Supplements are not answers to these issues."
Dr. Seballos also evaluates the need for a supplement. For example, if his female patients can get 1,200 milligrams of calcium naturally, he often recommends they not take calcium supplements, because the products have been linked to an increased risk of health problems.
Physicians agree that patients usually are receptive to polite suggestions on ways to manage their health without using supplements. "It's not like people want to take handfuls of pills every day. What they want is good health," Dr. Simpler said.
Determining the risks
Recent data show that regular use of certain supplements might increase one's risk of death. Older women who used at least one common supplement, such as a multivitamin or iron, were more likely to die during a study period of 19 years than those who did not take the products. That was the finding of a study of more than 38,000 women in the Oct. 10, 2011, Archives of Internal Medicine.
To stay abreast of the frequently changing data on supplements, Dr. Seballos encourages doctors to subscribe to one or two reputable journals that are relevant to their specialty and read the publications regularly.
Dr. Larimore said physicians can access dependable websites to find information on the health benefits and risks of supplements. Some commonly used sites among doctors include those of the Office of Dietary Supplements, the National Center for Complementary and Alternative Medicine, and ConsumerLab.com.
Some doctors recommend supplements -- but only after carefully weighing the benefits and consequences. Dr. Kelley sometimes suggests chromium, because he encourages patients to do resistance training, and the supplement has been shown to help preserve lean muscle.
But he does not promote many natural products. Throughout his career, Dr. Kelley has treated patients for severe reactions to supplements, including tachyarrhythmia.
"I haven't been able to attribute a patient's improved health to supplements," he said. "But I've definitely seen the downside of it."