When Supplements Really Work, Part II: The Right Fit for Your Fitness
HHN: In Part I of this series, "When Supplements Really Work: Supplements Perform Like Drugs," you suggest that readers consider taking the multivitamin Centrum Silver, since in a strong clinical trial it was shown to prevent cancer and cataracts even in very healthy people. However, the ingredients, per the label, include modified corn starch, the preservative BHT, various colorings (Blue 2 Lake, Red 40 Lake, Yellow 40 Lake), and hydrogenated palm oil. Have there been scientific studies of other multivitamins without such ingredients?
MM: Unfortunately, no other product has been tested against a placebo in 14,000+ individuals for more than 11 years. Centrum was also shown in other large studies of men and women to prevent eye disease (cataracts).
No other multivitamin can match these numbers or quality or safety based on this scientific study, though some people will say otherwise. Almost every month when I give a lecture, a representative from another multivitamin company approaches me, angrily insisting that his/her product has more research compared to Centrum Silver. I ask to see the research, and in more than five years I’ve never received that piece of mail.
Like you, I am not happy that Centrum and many other high profile brands contain the ingredients you mention. But I also believe I have a moral and ethical obligation to inform the public of what was used successfully in the largest multivitamin clinical trial in medical history. I understand why someone might not want to take Centrum Silver. That’s also why my book lists all the ingredients and the dosages used in the clinical trial. If you want to buy something else, you can try to seek out a cleaner product with similar ingredients and a safety record.
But keep this in mind: I report on Centrum and other supplements that have an impressive clinical study behind them because every other product is guesswork."The drugs that have had the most impressive research in clinical trials are the drugs we use today. So why not purchase the exact product used in the most impressive clinical trial for a dietary supplement?"My simple rule of thumb is, «Let's reward the research!» In the drug world, the drugs that have had the most impressive research in clinical trials—Viagra, Prilosec, Lipitor, etc—are the drugs we know and use today, because they have the best odds of working in each of us. So, why not purchase the exact product used in the most impressive clinical trial for a dietary supplement?
As another example, the Mayo clinic and 40 other medical centers did a large clinical trial of a low-cost American ginseng product, Wisconsin ginseng, supplied by the Ginseng Board of Wisconsin, and found it to be significantly more effective than placebo in reducing cancer-related fatigue (CRF). Wisconsin ginseng can be found at the Ginseng Board’s website. The product has good quality control and is fairly moderate to low cost compared to other ginsengs.
Using the original study formula for a particular treatment also reduces the chances of your becoming a guinea pig because of an untested toxicity with a new concoction.
HHN: If a supplement company makes its own version of a product that has been shown to work, why doesn’t it test that product?
MM: There is no monetary reward for a supplement company that researches its own version of a pill, but considerable reward in copycatting the product of a company that did the research."There is no monetary reward for a supplement company that researches its own version of a pill, but considerable reward in copycatting the product of a company that did the research."The company that copycats the supplement will then in some cases tell consumers that their product has 10 — 50 clinical trials, but only the ingredients in the product, and not the product itself, have the clinical research. Many such companies will charge you even more for someone else’s research. It’s a kind of bait and switch.
HHN: Understood. That said, after a certain period of time, pharmaceutical companies lose their exclusive rights to sell their drug and generic versions become available. Wouldn’t that be comparable to someone finding the exact same ingredients and concentrations in a different and perhaps cleaner dietary supplement? And if that’s the case, why not purchase the supplement without toxic fillers?
MM: When a drug becomes generic, or an over-the counter generic, then the customer is still purchasing the exact same original ingredients used in the clinical trial that showed efficacy and safety. For example, if I might benefit from an anti-allergy medication that contains a single ingredient of efficacy, "loratidine," I may buy the generic one from CVS or Walgreens. In this instance I am not only buying the ingredient but the insurance, because if something goes wrong there is accountability or liability.
Now, if you try to mimic Centrum Silver precisely in order to get to the same end points found in the clinical trial, that’s not easy, because there are 30 or so ingredients, various forms of nutrients utilized, and dosages to consider. And unlike the case of generic drugs, if something goes horribly wrong, there’s no accountability for this formula with the other supplement company.
In addition, there is this very important question to consider:"Do you know for sure that what this other company claims about its clean product is true?"Do you know for sure that what this other company claims about its clean product is true? Have you researched this sufficiently to be confident that what this company states is in the product is in fact there, at the promised concentration levels, and without other unwanted, undisclosed ingredients?
If you can find a cleaner product that almost mirrors Centrum Silver with some safety and efficacy research, that’s a solid choice. Something also tells me that if Centrum does not clean up their products, the next generation is going to hit them where it hurts. My kid’s generation is demanding greener products, and companies will have to change to survive or thrive. Look at all the changes happening in the fast food industry just in the past 6 months: Almost every chain is being forced to clean up some aspect of its food, from artificial colors to antibiotics. This is just starting. It’s beautiful!
Investigating Supplement Quality and Safety
HHN: How can supplement consumers best investigate the quality and safety of their brands and products?
MM: I suggest approaching this like car sales—a salesperson can say "this car is the best," but many of us read what Consumer Reports or another established objective organization says about its safety record before purchasing it. Product research is standard in consumer education today, so why treat something you are going to ingest any differently?
So, before I take a supplement that wasn’t studied in the clinical trial, I want to know its contents have been tested and verified by an independent third party. And I would much rather take a supplement whose bottle contains an NSF label, meaning it passed the independent organization NSF International’s testing and certification process—arguably the world’s best quality control testing, because they audit the manufacturer every 6 months—than a supplement that the manufacturer alone promotes as clean."I want an independent third party to verify that what’s on the supplement label is in the package, no more no less."NSF certification of a particular product verifies both accuracy and purity: that what’s on the supplement label is in the package, no more no less, so for example if it says "gluten-free," it is; and that the product doesn’t contain unsafe levels of contaminants. The reason you never hear any more about a U.S. Olympic athlete, NFL, NHL or Major League Baseball player getting in trouble with supplements—unless it’s deliberate cheating elsewhere—is because they all use NSF-certified sport products that do not contain banned substances. For a list of their certified dietary supplements, visit the NSF online database.
I will also trust dietary supplements labeled as certified by the U.S. Pharmacopeial Convention (USP), a scientific nonprofit that offers independent verification services as well. USP is second best in my opinion, because its testers audit once a year or more.
And when companies aren’t willing to invest the money to demonstrate that what they promise is what the customer gets, I tend to become skeptical and think, "Where else are they cutting corners and trying to save a buck?"
HHN: From an HHN review, it seems that many supplement brands aren’t NSF or USP tested, and USP doesn’t provide a list of the supplements it has verified on its website. Are there other means of checking the reliability of brands readers may use?
Another resource you can try is the supplement company’s website. Look for its quality control statement, which explains how it assures quality control of products. Every once in a while you might find a company that is third-party certified but doesn’t state this on the label. For example, one such company says only on its website: "Our facilities are registered as GMP compliant by NSF International and are audited by this third-party certifying organization twice a year, in addition to routine FDA inspections."
Lastly, don’t be afraid to contact the supplement company and ask what their current quality control standards are and if they have third-party oversight. The good companies will not shy away from these answers.
Just be careful. Relying solely on a company’s messaging can be misleading."Certain companies have touted their products as now being BPA-free—true enough, but some of the companies just substituted BPA with a compound that’s equally controversial."For instance, certain companies have touted their products as now being BPA-free—true enough, but some of the companies just substituted BPA with a compound that’s equally controversial. A supplement company’s claim that its product is "natural" means nothing. Arsenic, lead, mercury, and tobacco are "natural," but I don’t want them in my supplements.
HHN: Are there particular brands you’ve researched vis a vis quality-control testing and have come to count on for that quality?
MM: It’s my job not to favor brands. I go into every situation with objectivity and a "prove-it-to- me" stance. And as we’ve discussed, I typically choose the supplement that shined in the clinical research for preventing or treating a particular condition or disease, because that is also the product that had to demonstrate safety or at least generate some knowledge of the expected minor and major side effects.
The quality of that research is also very important. Published clinical trials can run the gamut from good to bad. It’s essential to be able to read between the lines of the study. To help consumers analyze and assess the study literature, the last chapter of The Supplement Handbook contains my easily understandable medical research checklist, which some health care professionals are now using to teach clinicians and researchers.
HHN: Is it important to select supplements based on how optimally their nutrients will be absorbed in the body, as some health writers and supplement companies advise?
MM: There is what sounds good and logical, but then there is the definitive research. Just because you might absorb a nutrient better does not mean you will in fact be better until that has been proven. It turns out that when blood levels are measured, some of the cheaper supplements absorb just fine.
There’s an analogy I like to use: "If in Detroit Tiger Stadium you hit a baseball 500 feet, it’s called a home run,"Pills in the body work by a threshold effect. You do not need massive absorption but some absorption for impact."but if in Tiger Stadium you hit that baseball 500 miles, that is, into Canada, it still counts as a home run." In other words, pills in the body work by a threshold effect; you do not need massive absorption but some absorption for impact. It’s kind of like asking whether it’s better to run 5 or 5.2 miles a day.
So, when people recommend a particular brand because of absorption, ask first if they have a conflict of interest and second, what evidence they have to prove their product works better than a cheaper product. What specific diseases or conditions have been prevented or treated with that pill based on what scientific studies? And is there a head-to-head absorption study that proves a clinical difference?
Bottom line: I don’t worry about absorption, but about results. The most important issues are efficacy and safety—how a supplement or pill changes the way you feel and/or changes the clinical endpoint of a condition or disease. This is the standard by which drugs are moving toward, and supplements should do the same.
Best Form To Take
HHN: What does the research have to say about supplement efficacy depending upon its form—tablet, capsule, liquid?
MM: The answer is similar to what you find in the drug world: Form is much less important than compliance. Compliance is always the biggest issue, and everything else a distant second.
In short, the research shows us that pill-taking never becomes routine. After a few years, most folks get bored or simply forget to consistently take their drugs—even if they are life-saving!
Here’s one example: The initial results of the Women’s Health Initiative, the world’s largest clinical trial of calcium and vitamin D to prevent bone loss and hip fractures, first indicated that the supplements did not work."After a few years, most folks get bored or simply forget to consistently take their drugs—even if they are life-saving!"However, a secondary look at the trial showed that those women who took the 1000 mg of calcium carbonate with 400 IUs of vitamin D3 80% or more of the time for seven years had a nearly 30% reduction in hip fractures compared to the women on placebos! And, by the way, the researchers used very cheap brands of calcium and vitamin D, the Os-Cal® brand from GSK.
The message is clear: The best supplement form is the form that will allow for your best compliance.
With a Meal?
HHN: Regarding another aspect of forgetfulness: If the directions indicate that a supplement should be consumed "with a meal" and a person forgets, what is the "X-minute window of opportunity" after the meal during which the supplement will still be well- absorbed?
MM: Most of this research on taking drugs and supplements with a meal has been based on lowering side effects rather than making or breaking clinical changes or endpoints."Much of the time, when supplement directions say to take with a meal, it’s to reduce gastrointestinal side effects and to improve compliance and memory."In other words, much of the time when the directions say "with a meal," it’s to reduce gastrointestinal side effects and to improve compliance and memory, because remembering that you need to take a pill is often tied to or associated with meals. In some cases, such as with iron supplements and osteoporosis drugs, you do get slightly better absorption without meals, but taking iron with meals is still good enough and reduces stomachaches to boot. Interestingly, researchers found that taking the type-2 diabetes drug metformin with food reduces its absorption but increases patient compliance—and, as a result, taking metformin during a meal did a better job of lowering patients' overall diabetes risk.
I find that many people get too caught up in the minutiae or specifics of how to take their pills, which just cranks up their anxiety and redirects their focus away from what really matters: consistent compliance. So my advice is: Take your pills primarily at the time of day when you can best remember to take them.
HHN: Typically, how long do dietary supplements work within the body? Might supplementing every other day or some other regimen be sufficient for people who have the discipline to maintain a consistent alternate schedule?
MM: Unfortunately, we know much more about pharmacology in the drug world than we do in the supplement arena. We don’t know the half-life of many supplements because the research hasn’t been adequate. With calcium and vitamin D, the Women’s Health Initiative study showed us that taking the combination 6−7 days a week got the best results. In another trial, the Women’s Health Study, Vitamin E was ingested every other day instead of daily, and showed no overall impact on cardiovascular risk. Research shows that the half-life of the active ingredient in red yeast rice is only a few hours, so daily consumption is important to continue its cholesterol-lowering effects.
To date, the majority of positive dietary supplement trials have tested daily consumption. And for now, all we can do is to copy the exact way folks took the supplements in the clinical studies that got us to take them.
HHN: What are the vital takeaways readers should keep foremost in mind when navigating the supplement universe?
MM: 3 points:
1Dietary supplements are like drugs. Take the ones that have been shown in clinical studies to help the conditions you have, and expect results. There is nothing natural about taking any pills, so take them only when the benefit outweighs the risk.2Never allow yourself to be placed on any supplement without knowing the exact dosage range, side effects, worse-case and best-case scenarios, impact on heart health, accountability/reputation of the company and its safety/quality control, best measured by independent, third-party testing.3Always challenge yourself and the supplement by taking on heart-healthy habits first: exercising regularly, eating a healthy diet, eliminating tobacco exposure, and maintaining healthy weight, blood pressure, blood sugar, and cholesterol levels. Accomplishing all seven of these, without taking any supplements, will increase your odds by 80 to 90% of living to age 85 or longer with no or little physical or mental disability. No dietary supplement or drug has been shown to match these effects, or has even come close.When Supplements Really Work. Selecting reliable brands. Click To Tweetby