Complementary and alternative medicine Medicine Science Skepticism/critical thinking

From dietary supplements to the emergency room

If there’s one thing I’ve been consistent about, it’s that, however ridiculous all the other woo I routinely discuss here is—homeopathy, reiki, reflexology, I’m talking to you and your friends—herbal medicine and supplements might have value because they might have a physiological effect that is beneficial in treating or preventing disease. Of course, if that’s the case, it’s because the herb or supplement contains chemicals that act as drugs. They’re “dirty” drugs in that they are mixed with all sorts of other substances in the herb or supplement that might or might not have effects, which means that different lots of the herbs or supplements often have different activity, but they are drugs nonetheless. That’s why, for instance, doctors don’t tell patients to chew on foxglove leaves when they want a patient to get digoxin. Digoxin is a powerful drug with a relatively narrow “therapeutic window,” meaning that the difference between the levels of the drug in the blood needed for therapeutic effect are not very far from toxic levels; so predictable, reliable drug content is essential. I just learned a while ago that within the living memory of some older physicians digoxin actually was prescribed as crude extracts, which was very difficult and dangerous, hence the necessity of purification. In other cases, (such as Artemisinin, for which Youyou Tu was recently awarded the Nobel Prize in Physiology or Medicine), crude plant extracts do not contain sufficient quantities of the active component, necessitating its isolation, purification, and, in some cases, chemical modification to increase its absorption, stability, or activity.

One thing that proponents of herbal medicine and supplements often forget, though, is that if herbs or supplements can have potentially beneficial effects (albeit difficult to regulate effects due to the crude, impure nature of the extracts often used) because they contain drugs, then herbs and supplements can also produce adverse events, again, because they contain drugs. You can overdose on herbs and supplements. This point was recently reinforced by a new study by Geller et al published yesterday in the New England Journal of Medicine (NEJM), entitled Emergency Department Visits for Adverse Events Related to Dietary Supplements. It was carried out by investigators from the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, and Chenega Government Consulting; and the Center for Food Safety and Applied Nutrition and the Division of Public Health Informatics and Analytics and the Division of Dietary Supplement Programs, Food and Drug Administration. The title pretty much tells you what the study is about, and what the study is about is that dietary supplements cause a lot of visits to the emergency room every year, 23,005 (95% confidence interval [CI], 18,611 to 27,398) emergency department visits per year can be attributed to adverse events related to dietary supplements.

Let’s back it up a minute before I get into the study more. In the US, dietary supplements are regulated by the FDA (or, more appropriately, barely regulated by the FDA) under the Dietary Supplement Health and Education Act of 1994 (DSHEA), which is one of the worst laws ever passed or, as Peter Lipson calls it, a travesty of a mockery of a sham. Basically, supplements are considered more food than medicine and regulated as such. They can’t be marketed for the treatment or prevention of disease (i.e. drug claims), but can make so-called “structure-function” claims (i.e., “boosts the immune system”). The problem is, what constitutes a “drug claim” compared to a “structure-function” claim remains fairly vague. Even after the FDA issued rules in 2000 that banned explicit claims that a product treats or prevents disease, there’s still considerable wiggle room, and enforcement isn’t exactly what I would call robust. In the meantime, supplement hawkers have cleverly used the Internet to circulate claims for these products that aren’t necessarily on the packages or in the package inserts. As Geller et al note:

Although supplements cannot be marketed for the treatment or prevention of disease, they are often taken to address symptoms or illnesses, as well as to maintain or improve overall health. The estimated number of supplement products increased from 4000 in 19943 to more than 55,000 in 2012 (the most recent year for which data are publicly available), and approximately half of all adults in the United States report having used at least one dietary supplement in the past month.5 In 2007, out-of-pocket expenditures for herbal or complementary nutritional products reached $14.8 billion, one third of the out-of-pocket expenditures for prescription drugs.6

We know supplements are big industry here in the US. Indeed, for whatever reason, Utah has become the state where the supplement industry is most concentrated, and as a result its politicians strongly support supplements. Senator Orrin Hatch (R-UT) has long been in the pocket of the supplement industry and is its most friendly lapdog and powerful defender. Rising star Representative Jason Chaffetz (R-UT), whom you might have heard about recently as a long shot candidate for Speaker of the House in the wake of John Boehner’s resignation and the implosion of Kevin McCarthy’s (R-CA) candidacy, has over the last few years been vying to outdo Hatch in demonstrating his fealty to the supplement industry. It’s not just Utah politicians, though. There is the Congressional Dietary Supplement Caucus, which is bipartisan and has members from all over the country. It includes the aforementioned Chaffetz and Hatch, as well as Sen. Darrell Issa (R-CA), Rep. Frank Pallone (D-NJ), and Rep. Tom Cotton (R-AR). Thanks to the power of the supplement industry, thus far every attempt to tighten regulation of supplements since 1994 has failed. For example, in 2010, facing a primary challenge from the Tea Party, after having championed a bill to give the FDA more power to regulate dietary supplements, Sen. John McCain (R-AZ) caved because he decided that he couldn’t be perceived as being in favor of more government regulation.

As a result of the lack of regulation of dietary supplements, manufacturers and advocates make all sorts of de facto health claims for supplements such as that they can prevent or treat cancer and the like. FDA enforcement is sporadic and directed at only the most egregious, most immediately dangerous cases. Meanwhile, advocates, using the exaggeration of “food as medicine,” continue to sell their products, many of which are scary substances manufactured under scary conditions, even though there is a distinct paucity of evidence for their usefulness.

The result is what we see in this study. Postmarketing reporting of adverse events from supplements by manufacturers is only required for the most serious events (e.g., those resulting in hospitalization, significant disability, or death), while voluntary reporting almost certainly greatly underestimates the incidence of adverse events. So Geller et al decided to use a national surveillance database to estimate the number of adverse events attributable to supplements that result in visits to the emergency room. They used the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance (NEISS-CADES) project conducted by the CDC, the FDA, and the Consumer Product Safety Commission. There are 63 hospitals participating in the project that make up a nationally representative probability sample drawn from all hospitals with at least six beds and 24-hour emergency departments with four strata based on hospital size and a fifth stratum for pediatric hospitals. Cases were identified thusly:

Trained abstractors at each hospital reviewed the clinical records of every emergency department visit to identify physician-diagnosed adverse events and reported up to 2 implicated products and 10 concomitant products, as described previously. Abstractors also recorded narrative descriptions of the event, including preceding circumstances, physician diagnoses, testing, treatments administered in the emergency department or by emergency medical services, and patient outcome. Narrative data were coded with the use of the Medical Dictionary for Regulatory Activities (MedDRA), version 9.1.

Geller et al looked at a ten year period from 2004 to 2013 for cases:

Cases were defined as emergency department visits for problems that the treating clinician explicitly attributed to the use of dietary supplements. This analysis included orally administered herbal or complementary nutritional products (including botanicals, microbial additives, and amino acids) and micronutrients (vitamins and minerals) but excluded products that are typically considered to be foods or drinks (e.g., energy drinks, herbal tea beverages). Additional products that are often used by consumers for complementary health but do not fall under the regulatory definition of dietary supplements (e.g., topically administered herbal or homeopathic products) were also included in the analysis. Herbal or complementary nutritional products were categorized according to common reasons for use…

Adverse events were categorized as adverse reactions, allergic reactions, excess doses, unsupervised ingestion by children, or other events (e.g., choking). Cases involving death on the way to the emergency department or after arrival were excluded because death registration practices vary among participating hospitals, and details about event circumstances are often lacking. Visits involving intentional self-harm, drug abuse, therapeutic failures, nonadherence, or withdrawal were also excluded. The categorization of symptoms was based on MedDRA-coded narratives.

When the analysis was done, on the basis of 3.667 cases identified in the database, Geller et al calculated an average of 23,005 emergency room visits for adverse events related to supplements and further estimated a 2,154 yearly hospitalizations. In the vast majority of these cases (88.3%), doctors attributed the adverse event to only one supplement, and the mean age of patients was 32 years, with more than a quarter of the visits due to patients between 20 and 34 years of age. Not surprisingly, people older than 65 were nearly twice as likely to be hospitalized. One-fifth of the visits involved unsupervised ingestion of supplements by children. (So, parents, lock your supplements up the way you do with your prescription and over-the-counter drugs.) There’s a nice graph in the article that boils down a lot of information in a very compact package, including age of patients and what the product category was:

The age distribution of adverse events due to dietary supplements
The age distribution of adverse events due to dietary supplements

Not surprisingly, in younger patients weight loss supplements were by far the largest category of supplements that caused adverse events. Similarly, not surprisingly, cardiac symptoms were the most common symptom associated with weight-loss products (42.9% of patients), and weight-loss or energy products were implicated in 71.8% of all ER visits for supplement-related adverse events involving palpitations, chest pain, or tachycardia. These were young people, too, the vast majority between 20 and 34 years old. Interestingly, among patients under 6 and 65 or older, swallowing problems caused a significant number of the ER visits. I don’t find that too surprising, given the horse pill-sized capsules many supplements are often sold in. Calcium supplements were the worst offenders.

It’s rather an odd coincidence that a couple of days before this study was published, the story of NBA star Lamar Odom’s fight for his life after taking large quantities of “herbal Viagra” in a Nevada brothel hit the news in a big way. It should be noted, however, that Odom had also apparently been using cocaine and drinking Cognac; so it’s difficult to know what the cause of his collapse was for sure, although it certainly could have been a combination of whatever was in the herbal product plus the cocaine, plus whatever else he was taking (and, according to E! News, he was taking a lot). Whatever the case, Odom is, by many reports, in bad shape, with reporting that failure of four organs, is on dialysis, and has suffered multiple small strokes. How many of these medical reports are true (considering the source) or not, the prognosis of multiorgan failure is very, very bad.

Whether the ten or more tablets of “herbal Viagra” that Odom took had anything to do with his condition or it was the cocaine, Cognac, and other drugs he was doing that landed him hear death, this NEJM study is yet more evidence that there are real consequences to the DSHEA and letting supplements be sold with, in essence, almost no regulation. Odom, if the herbs were the main reason for his collapse, would just be an extreme case.

By Orac

Orac is the nom de blog of a humble surgeon/scientist who has an ego just big enough to delude himself that someone, somewhere might actually give a rodent's posterior about his copious verbal meanderings, but just barely small enough to admit to himself that few probably will. That surgeon is otherwise known as David Gorski.

That this particular surgeon has chosen his nom de blog based on a rather cranky and arrogant computer shaped like a clear box of blinking lights that he originally encountered when he became a fan of a 35 year old British SF television show whose special effects were renowned for their BBC/Doctor Who-style low budget look, but whose stories nonetheless resulted in some of the best, most innovative science fiction ever televised, should tell you nearly all that you need to know about Orac. (That, and the length of the preceding sentence.)

DISCLAIMER:: The various written meanderings here are the opinions of Orac and Orac alone, written on his own time. They should never be construed as representing the opinions of any other person or entity, especially Orac's cancer center, department of surgery, medical school, or university. Also note that Orac is nonpartisan; he is more than willing to criticize the statements of anyone, regardless of of political leanings, if that anyone advocates pseudoscience or quackery. Finally, medical commentary is not to be construed in any way as medical advice.

To contact Orac: [email protected]

148 replies on “From dietary supplements to the emergency room”

23,005 (95% confidence interval [CI], 18,611 to 27,398) emergency department visits per year can be attributed to adverse events related to dietary supplements.

Being free of side-effects and risk of overdosage is one of the main supposed advantage, if not the main advantage of “natural” alt-med over “mainstream” medicine.
Well, so much for that.

In a previous thread, a drive-by poster left the usual accusation of mainstream medicine doing plenty of harm. In a pot, meet kettle way, allow me to bounce its words, properly edited, back at alt-med proponents:

Supplement medicine IS quackery, pure & simple. Until they begin archiving the perhaps millions of iatrogenic incidences that occur each year, we will never know just how big the scam really is.

Although I would moderate this by saying that there may be legitimate uses of real food supplements (vitamins and minerals in case of deficiencies, by example). So it is not full quackery from top to bottom. Close enough, unfortunately.

Thank you for sharing your expertise so tirelessly, Orac! Your blog and others helps this cancer patient keep hold of her temper when someone recommends woo with a “works for me” testimony. They mean well, I don’t need to make enemies, and I know I can’t change their minds. (I believe we need more science education in the grades and high school to reverse this in future generations.)
You are doing good in the world.

When I first saw the title of this post, my immediate assumption was that it would be about the Odom case. I’d heard some mention of his taking an herbal supplement that allegedly mimics a certain medication (the name of which has a tendency to trip spam filters on blogs that allow comments). But according to this study, it’s a widespread problem, and the only two factors distinguishing Odom from the rest of that crowd are (1) he’s moderately famous and (2) it’s an extreme case.

One of the idiots I survey gets around the rules by saying that customers can look up what the product “can do” ( i.e. look through his materials or other woo-drenched lit) -btw- he and several of his faithful became ill on one of his products which was overloaded with vitamin D – one died IIRC.

The usual spiel is that -unlike meds, supplements have NO harmful effects.

I also recall that ephedra was implicated in quite a few cardiac events years ago.

I can hardly wait for the woo-meisters’ reactions to the study.

One of the idiots I survey gets around the rules by saying that customers can look up what the product “can do” ( i.e. look through his materials or other woo-drenched lit)

IANAL, but if that’s a valid legal workaround, then it’s turtles all the way down. He’s making certain claims in his marketing materials. I don’t see how the material being on the web, as opposed to a radio or TV commercial, makes a difference.

Ephedra isn’t the only example. I’m having a vague recollection of something called fen-phen (I’m not sure of the exact spelling), but I don’t have time to look it up right now.

Fen-phen was the combination of fenfluramine/phentermine, both prescription medications, used together for weight loss, and they worked very well together. Fenfluramine and related drugs that were also used with phentermine cause pulmonary hypertension and valvular heart disease. They were pulled from the market back in the ’80s. Phentermine is, however, not implicated in those effects.

@ Eric Lund:

That’s how it works:
he refers people to written and SPOKEN materials- some of which occurs during his endless, droning daily internet radio/ radio shows- he reads off vaguely related studies, about say, cinnamon and vamps off on his own drift and then ,then sells a product with cinnamon ( or broccoli, grape, olive oil, red fruits, nuts, grains, phytonutrients etc.). Thus, it may not be a single *instance* but a global impression acquired by regular listeners. A legal case I suppose would have to go over hundreds of hours of material and put together thousands of hints and innuendo. People who study memory know how you can manipulate what listeners THINK they heard HOWEVER he lacks cautious speech and self-monitoring so I think that he HAS made claims for specific foods and nutrients. He has quite a few lawyers to guide him though.

@Denice #6:

I can hardly wait for the woo-meisters’ reactions to the study.

They’ll probably crow about how few admissions were caused by homeopathic remedies compared to… gah, forget it. You can all take it from there.

It’s very likely that the products that Lamar Odom was taking were made in China, a major center for allegedly herbal products that contain actual prescription-requiring pharmaceuticals.
I can’t help but shake my head at the people who wouldn’t buy food products from China because of all the adulteration/contamination scandals around them, but somehow think that capsules from China are somehow immune from that kind of thing. “But it’s Chinese herbs!” was bad news coming from my patients, and it has not gone away in the years since.
I think they must have a mental image of Chinese herbals coming from an enigmatically wise Chinese graybeard in a dark little shop full of strange things in jars and chests of tiny drawers. Bad news, folks – that wise old man is DEAD for years. Your Chinese herbs were bottled by his grandson in a factory with smokestacks, noisy machines, and a rail siding, while he rides around in his Mercedes picking up prostitutes and bribing Party officials, if he and his factory are really in China at all, and not in New Jersey.
It’s time to let the wise old herb doctor go to his rest once and for all.

If you want to get a feel for the response of at least some anti-vaccine people, Dr Pan posted this article here:

Basically it’s along the line of “more people are hospitalized by drugs” and “don’t tell me what to put into my body.”

I would suggest that people who want to claim they do their own research pay attention when new information comes out.

Sometimes the issues on RI have at least ≤i>some plausible scientific controversy, or at least require a bit of scientific sophistication to understand why certain practices are problematic…

And sometimes the wrong-ness at hand is just so blatant you feel the human race is doomed if this sh!t can be allowed to go on…

If supplements can have potentially beneficial effects because they contain drugs, then they can also produce adverse events because they contain drugs.

I’m utterly freaked-out Orac has to write that, because it’s so f-ing obvious AND so blithely ignored by greed-heads exploiting the gullible. Call me cynical, but I can’t believe supplement-slingers and their tools in government “forget” this. I have to conclude they know it, and just don’t care. (I also don’t believe anyone who has ever started an MLM ‘business’ has had any illusions that they’re not running a Ponzi scam.)

I cannot chalk up ‘supplements are food, not drugs’ or ‘food and drugs are mututally exclusive, so food shouldn’t be regulated’ to stupidity, only to… well… evil.

The sad case of Lamar Odom may be useful in getting this study some pub, but it isn’t really relevant. Odom had serious emotional problems, and was headed for self-destruction by any available means. Regulating supplements wouldn’t have saved him. But sports are full of wide-spread supplement abuse. A lot of jocks – including plenty of otherwise ‘normal’ high-school kids – got seriously screwed-up on andro. When one magic pill gets whacked down, two more pop up to replace it. Just win, baby!

I’ve been asking myself why magical thinking is so pervasive, and on a recent SBM thread I noted that magical claims have always been at the heart of virtually all advertising of mass-marketed products. Perhaps little-known fact: the earliest class of products to employ the methods of advertising-as-we-know-it were patent medicines.

But i’m also recalling the way ‘science’ was presented to the public in my youth (I was born 1953, and stuff from previous decades was till in circulation). ‘Science’ was depicted as uber-magic – fulfilling the promises of the magicians and alchemists because ‘it actually works!’ ‘Science’ would provide a simple and easy solution for everything. Need to clean house? The Jetson’s-like automated system that will do it all with one push of a button is just around the corner! Got a health issue? No problem. If we don’t already have a pill that will fix you right up, it’ll be here before you know it! Want to be better than nature made you? ‘Science’ will provide a simple solution for that, too! (Check the early enthusiasm for LSD…)

(Not that any actual working scientists bought that line. But they weren’t writing the copy,)

The critical scholarship on advertising has long grappled with the fact that advertising continues to work despite the fact products can’t and don’t live up to the magical claims made for them. Why don’t people realize the claims are bogus, and just stop paying attention to the hype? The most common explanation: the fears and desires ad claims address are so deep, the general idea of their accessibility so reinforced by the whole sphere of ubiquitous promotion, that when any individual purchase fails its promise and leads to buyers remorse, the default mental path back to optimism is to go buy something else! (There’s probably also a bit of woo-style blaming – if the magic didn’t work for you, it must be your fault. But, hey, don’t give up! The shelves are full of options, try again!)

Of course, some Libertarian is thinking none of this justifies regulation. Consumers will make rational choices; free enterprise regulates itself; under the invisible hand of the bad will fail and the good prevail. Except most buying decisions aren’t rational. Except all kinds of bogus-claim-backed products have sold well for decades and decades. Except even if bad products eventually fail in the market, people die first. Think we don’t need regulation? Google ‘Tris’ and then STFU.

However gullible the public may be to the magic promises of supplements, we do have a goverment that makes laws and creates regulations to protect its citizens. To anyone tasked with that, that supplements are drugs and should be regulated as such would seem to be a no-brainer. So why doesn’t that happen? Who has the motive, and the power, to stand in the way? If we were just talking about the woo-ish supplement makers in Utah, websites like NN, and assorted MLM scammers, we could imagine that if the Tea Party loses their grip on Congress we could get some sensible reform. But there are big supplement sections in virtually every store that has a pharmacy counter – Target, WalMart, Walgreens, CVS. And with CVS positioning itself to take over a huge chunk of primary care with it’s in-store ‘clinics’, I wouldn’t bet on progress no matter who gets elected to what.

As far as supplements go, I’m feeling SBM’s identification with Sisyphus might be too optimistic. At least Sisyphus moved the rock.

@#6, et alia

I am sure that it will be cooked as “look how few ER visits are prompted by our products compared to standard drugs.” There may also be a sauce of “and these people did not follow directions for our natural, harmless stuff.” Victim blaming and tu quoque. I will not be surprised to see attacks on the CDC and authors as being pharma shills.

I receive FDA updates all the time as part of my job. Many of these updates concern supplements with hidden drug content.

Many of these hidden drugs are banned in the US. I really wonder if these drugs are naturally present in the supplement or if naturally present they are at the strength found in the supplement.

I would think that many of these hidden drug ingredients are placed in the supplement so it has some semblance of acting the way statements say it will.

Of course usually when I see the words “supplements to improve your health or cure something” the first thing I do is protect my wallet.

@14–it’s already happened, in the NPR article that covered this study–they gave quite a lot of spacetime to a Naturopath who used it all on this sort of ‘damage control’:

Oh, yes. I expect a raft of posts and articles on quack websites arguing exactly the same thing. I’m guessing it’s already started; I just haven’t seen them yet.

I can hardly wait for the woo-meisters’ reactions to the study.

It was done by the CDC and the FDA and is therefore tainted. Big Pharma garble garble garble!

This swedish study was mentioned in sweden’s tv I saw. Googling got this:

Antioxidants were fed to mice -> “they developed twice as many tumors in their lymph nodes, a hallmark of the spread of cancer—a process called metastasis.”
Supplements (with antioxidants) protect cancer cells.

Iron in supplements maybe dangerous to heart. In 80’s iron was included in supplement pills here. Later (in 90’s) they sold them without iron, this all – of course – in silence. Because of some heart attacks.., I think.

Old Rockin’ [email protected]:

I can’t help but shake my head at the people who wouldn’t buy food products from China because of all the adulteration/contamination scandals around them, but somehow think that capsules from China are somehow immune from that kind of thing.

Would these be the same people that like to complain on Facebook about how much the gubmint is watching them?

As awful as all the woo associated with supplements is, some are useful vitamin and mineral supplements which correct deficiencies and may be useful in treating some conditions.

But the other issue is that problem, ie 23,000 ER visits is dwarfed by the problems associated with conventional meds. 103,000 individuals are hospitalized annually in the United States for NSAID-related serious gastrointestinal complications at a cost in excess of two billion dollars and I recall that during the hearings on Vioxx, it was estimated that there may be as many as 15,000 deaths a year linked to NSAIDs. Look at the problems with prescription pain med overdoses.

In context, the problems with supplements is dwarfed by those associated with conventional medicine.

And, right on schedule (actually, later than I had expected), we have just the misguided argument we were talking about in the comments a couple of hours ago.

@ MrrKATT,

I’ve heard about those problems and warnings about high dosage vitamin E and Omega 3 fish oils. Of course, you’ve probably heard about high dose Calcium and possible heart events.

So far I haven’t heard any response form the usual suspects BUT I imagine that they’ll either compare the numbers to the 700 000 deaths** “caused” by SBM or say that Big Pharma fixed the studies ( since we all know that studies in scientific journals aren’t to be trusted because of ghost writers, fixed data, thrown out studies and paid advertising by pharma.
Woo-meisters only trust their own studies or what their fave journals publish- i.e. the really awful rags they read..

** I believe that the number has settled around 700K despite much variation over the years.

Wow. No mention of the 1000,000 deaths per year from pharmaceuticals.

I agree that most supplements are inappropriate. but there are some that have merit:

Vitamin D

Neem has a very unique molecule called Azadirachtin. This is a highly complex molecule that would be very expensive to synthesize in any significant amount. Plants synthesize many useful chemicals for us. Please do not discount this simple fact.

Ha ha!
I answered MrrKATT prior to Mr Murray’s comment.

No, I’m not psychic but I am sickeningly familiar with my area

In context, the problems with supplements is dwarfed by those associated with conventional medicine.

So, these supplements should get a pass?

Your Chinese herbs were bottled by his grandson in a factory with smokestacks, noisy machines, and a rail siding, while he rides around in his Mercedes picking up prostitutes and bribing Party officials, if he and his factory are really in China at all, and not in New Jersey.

This. The same folks who are so worried about the provenance of their organic vegetables (and free-range chickens, for the non-vegetarians in the group) will consume supplements without giving them anywhere near the same degree of scrutiny. How do we know that the contents of the package bear more than coincidental resemblance to the contents claimed on the label?

The last comment about the factory location also raises an interesting point. If the supplements are being imported, then in principle Customs can spot-check the merchandise to make sure it’s not a smuggling operation–granted, they probably don’t do that often, but if they got a tip about somebody’s imported Nonsenseoleum herbal supplement containing actual drugs that aren’t supposed to be imported, they might take a look. But if the product is actually being manufactured in the US, then ICE is out of the loop, and unless the manufacturer is stupid enough to give the authorities grounds for a search warrant, it is likely to go undetected.

Either way, as you note, the manufacturer is pulling in money like their worst caricatures of Big Pharma.

it was estimated that there may be as many as 15,000 deaths a year linked to NSAIDs

Ah, the passive voice! Is there nothing it can’t accomplish that can’t be accomplished by it?

Apparently the “herbal Viagra” that Lamar Odom took contained actual Viagra, which was not listed on the label.

@ shay #27

You can’t be accused of hoisting a logical fallacy if you don’t make a claim, which may be why E. Murray didn’t bother to attempt drawing any sort of conclusion. Because it would have been really dumb.

I agree that most supplements are inappropriate. but there are some that have merit:
Neem has a very unique molecule called Azadirachtin.

You’re recommending a supplement as appropriate because it contains a powerful pesticide?

I agree that most supplements are inappropriate. but there are some that have merit:

Having looked up Epazote I can believe that people might take it occasionally if they do not like the predictability and controlled dosages of prescription vermifuges. However, I struggle to imagine the conditions for which it would be appropriate as a *regular* dietary supplement, except perhaps delusory parasitosis.

herr doktor bimler beat me to it on the question of neem and azadirachtin. Way back in 2008 or earlier, I reviewed the scientific literature on neem and concluded that it was not safe for human ingestion. Yet, today, I see dietary supplements containing the leaves or extracts thereof.

The Council for Responsible Nutrition has was weighed in on the study in NEJM with a positive slant:

“The results of this study reinforce that dietary supplements are safe products, particularly when put into context with the number of people—over 150 million Americans—who take dietary supplements every year. To put this projected number of 23,000 annual emergency room (ER) visits into context, we estimate that far less than one tenth of one percent of dietary supplement users experience an emergency room visit annually. That percentage becomes even smaller when you eliminate the products that are not dietary supplements and exclude the ER visits that resulted from eye drops, ear drops, and other OTC and non-dietary supplement products inaccurately included by the researchers to make their projections for dietary supplements.”

For another take on the study, see:

That percentage becomes even smaller when you eliminate the products that are not dietary supplements

Other than that, Mrs. Lincoln, how was the play?

I also smell a No True Scotsman in that: if it sends lots of people to the emergency room, then it can’t be a dietary supplement. I can understand their argument that eye drops and ear drops aren’t dietary supplements, but they are on shakier ground with anything intended for oral consumption.

Speaking of the ER, probly the 10th confirmed case of Influenza-b this week only in mine.

“I also smell a No True Scotsman in that: if it sends lots of people to the emergency room, then it can’t be a dietary supplement.”

And if it’s actually a dietary supplement that was involved, the victims clearly were Doing It Wrong.*

*oddly, alties never seem to extend this argument to prescription drug reactions/overdoses.

The whole “conventional medicine causes more ER visits” meme is a red herring.
As in: The average number of Americans shot to death by toddlers runs to about one per week. This is vastly overshadowed by the number shot to death by adolescents and adults. So let’s not worry about leaving the .357 loaded and off safety around the rugrats, because we might need it in a hurry to defend against those far more dangerous gangbangers and home invaders.
Which brings me ’round to “has” at #21. The people who worry about the gummint and the black helicopters don’t buy Chinese products if they can help it anyway, ’cause socialists and all like that. The folk I was thinking of are more to the other side of the spectrum, the ones who buy cage-free Bolivian sea salt.

The “but pharmaceuticals are worse” argument is about like saying that since armed robbery is so horrible, picking pockets and tax fraud should be legalized.

Why such resistance to the idea of putting your supposedly innocuous supplements in a child-resistant bottle? What would be wrong with making smaller calcium supplements so elderly people didn’t choke on them?

[email protected]

Why such resistance to the idea of putting your supposedly innocuous supplements in a child-resistant bottle? What would be wrong with making smaller calcium supplements so elderly people didn’t choke on them?

More regulation = less profit

I get why Bug Supplement doesn’t want to but what’s up with all the hostility from the alt med fanboys/girls? Do they feel attacked and this is how they defend themselves? Is this just how people react when you shine a light on something they’d rather not acknowledge?

The people who worry about the gummint and the black helicopters don’t buy Chinese products if they can help it anyway, ’cause socialists and all like that.

Assumes facts not in evidence, namely that the black helicopter crowd is worried about such details as logical consistency. They’ll happily buy it from Wal-Mart if Wal-Mart stocks it. And we all know that Wal-Mart is interested in keeping the price low–they don’t care whether the factory is in New Jersey, Oxfordshire, or Guangdong, as long as they can get the product cheap. Even the black helicopter types who do care enough to check the sourcing claimed on the package are likely to take the package’s word for it–they don’t stop to think that a supplement manufacturer who is not entirely honest about the product’s benefits may be less than scrupulously honest about the sourcing of the product. Admittedly, that’s because it doesn’t occur to them that the claims about the product might not be accurate.

Natural products as a treatment for disease tend to be unreliable.

Even the use of citrus fruits as a treatment for scurvy was unreliable before Vitamin C was isolated.

Which of the following are known to have or supply a “daily” intake requirement for humans?
Which are known to have properties well outside of foodstuffs?
– Vitamin D
– Epazote
– Neem

ephedra, opium, hashish, nux vomica, …

Why should it be legal to market any product as a dietary supplement if it has or supplies no known requirement in diet? I think you could make a better case for formaldehyde as a dietary supplement than azadirachtin as one.

Does anyone happen to know the current most-used drug in legitimate medicine that is actually extracted from a plant rather than synthesized?
I guessing that in relatively recent history it was morphine and derivatives, but now?
Outside of legit medicine, it’s gotta be yeast pee.

@doug #48: As defined by the FDA, although not one and the same by function, a dietary supplement (DS) may include essential nutrients. My personal bone of contention is with the term “nutritional supplements” which is widely applied by marketers to any and ALL dietary supplements. Short of any established nutrient, how can they be nutritional? And don’t even get me started on “phytonutrients”! Marketers adopted that one because it sounds ‘greener’ than phytochemicals, regardless of the fact that a phytonutrient is a substance required by plants, but not necessarily people. And then there’s “functional foods”, defined by the Food and Nutrition Board of the Institute of Medicine in 1994 – the same year as the enactment of the Dietary Supplement Health and Education Act (DSHEA) – as “any food or food ingredient that may provide a health benefit beyond the traditional nutrients it contains.” When that benefit is the prevention or treatment of disease, no matter what manufacturers, marketers, naturopaths, herbalists, “nutritionists”, quacks, and members of U.S. congress may be dreaming or scheming, the food or its active constituent, whether added to foods as an ingredient or not, becomes a crude drug, but a drug nonetheless. Whereas science and history rightly use the term drug, it just doesn’t sit well with marketers.

@doug #50: If you narrow that to prescription rather than OTC drugs, my first guess would be paclitaxel.

That would be booze, a chemical waste excreted by the yeast cell to avoid poisoning itself. It has the side benefit of suppressing growth of bacteria, which sometimes fight back with acetic acid.

Articles such as this are annoying and misleading because the author paints with a broad brush and indicts vitamins along with “supplements” in general, some of which, such as weight-loss products, can indeed cause harm.

The NEJM article stated, in reference to ER visits: “Such
visits commonly involve cardiovascular manifestations from weight-loss or energy products among young adults and swallowing problems, often associated with micronutrients, among older adults”.

Okay, but let’s not crucify vitamins because some elderly people have difficulty swallowing large tablets, which of course could be chopped up into smaller pieces, or capsules could be ingested, which are easier to swallow.

You are obviously part of conventional medicine, “Orac”, so I am not surprised that you are practically trashing all supplements. I’ve taken vitamins and other supplements for 53 years… with no adverse reactions. I do not take any drugs, nor do I have any need for such. I do not even wear reading glasses at the age of 70, despite all of the books that I have written and a lifetime of extensive use of my eyes.

I am unaffected by such nonsensical articles or blog posts but young people might be influenced and that thought disturbs me. If any young people, in particular, are reading my comments, many scientific studies have been conducted, including at places like Harvard, which have showed the value of certain supplements for specific purposes. Do your own research. Read research articles in respected journals.

herr doktor [email protected]:

it was estimated that there may be as many as 15,000 deaths a year linked to NSAIDs

Ah, the passive voice! Is there nothing it can’t accomplish that can’t be accomplished by it?

Indeed. It’s like a kitten turd on your rug.

I’ve been working on a presentation on most popular toxic plants in our gardens and let me put it this way – I already have 25 very popular plants and the list is by no means conclusive. And quite a lot of them contain substances that extracted, purified and then syntethized are powerful medication (colchicine, digoxin, atropine, to name but a few). Hopefully, the presentation will disabuse at least a few people of the notion that natural and plant-derived equals safe.

I was thinking the “animal, vegetable, mineral” thing when I counted yeast as plants.
My ol’ Biology 529.04 (special topics in biology, mycology) prof would disapprove. There was a man man fond of a mug of dilute yeast pee.

@ Alia:

There are quite a few internet sites that list “plants not to have at home if you have a cat’ / ” outdoor plants that are deadly to cats”.

Alia, do you have black henbane on your list?
I have no idea how widely it is still grown as an ornamental. Where I live, and in many places, it appears on noxious weed lists. I rather like it, in no small part because of the appearance of the seed pods. It doesn’t seem very invasive here. I seems to do OK on recently disturbed soil, then gets choked out by native plants.

@HDB #34

Your comment immediately made me think of those parents who think their kid’s autism is caused by a parasite infection – I suppose you could say they have a sort of delusional parasitosis by proxy. Obviously no responsible MD is going to give them a prescription antihelmintic, so it makes sense that they would seek out “natural” alternatives. I wonder if Epizote is going to be the new MMS, now that the FDA is finally starting to crack down on the latter.

If Big Supplement can’t be bothered to sell small-enough vitamin and calcium supplements, I will indict them. The defenders of “complementary” medicine shout about incorrect dosages of prescription drugs; they don’t shrug and say “pills can be cut” and “smaller dosages could be given.”

The marketers of dangerous energy drinks and crap homeopathic nostrums have spent a couple of decades working to give their products an aura of reality and utility by grouping their “supplements” with vitamin D capsules, One result is that people assume energy drinks are safe because they believe vitamin A is always safe. A doctor might be able to get an answer to “are you using any vitamins or supplements,” but it will be in terms of the marketing-promoted idea of a “supplement.” If those companies want to work to repeal the DSHEA, and make it clear that B vitamins and calcium citrate are in fact different from energy drinks, coneflower extracts, and so on, I will applaud. But until then, they don’t get to do a “no true Scotsman” in which a “supplement” means “those expensive pills, and only those expensive pills, that have not been called into question in the last fortnight.”

@Denice Walter – yes, I’ve seen several such lists and I generally consult them when buying plants for my home, but this presentation is more general, not only about cats. And there are also a lot of myths over there, like a very popular story about a kid becomming severely ill after drinking water in which lilies-of-the-valley had stood. As it turns out, it’s just an urban legend and anyway, as a friend of mine assured me, such water tastes horrible, so you would never ever drink a whole glass.

@doug – yes, I mention black henbane. Over here it’s not an ornamental plant as such but it’s a popular weed and many people may have it in their gardens just because it happened to sprout there.

I always thought that nutritional supplement was just another name for dessert.

The county board disapproves of team-building activities on the county’s time, so we re-named our quarterly pot-lucks “nutritional conferences.”

There’s a certain symmetry in that fungi makes alcohol which makes me a fun guy.

…MAKE alcohol…
Either too much or not enough of the nutritional supplement Old No. 7.

@ Alia # 66
I did drink lily of the valley water once. Someone couldn’t find a vase so they used a glass and later on they removed the flowers… and it tasted normal enough as I got halfway through the glass before mom started freaking out. Nothing happened, though.

Some 30 years ago, a bunch of scientists went through the claims made about medicinal plants and the results were published in a lovely herbary. Most of the stuff was reclassified as either ‘poisonous as hell’ or ‘obsolete, doesn’t work as claimed’. The authors listed useful uses for various plants – those 30 years back, cigarettes made of some goddamn poisonous evil were used to treat asthma, for example (I’d prefer asthma to smoking anything, thankyouverymuch) but I don’t know a MD in the right specialty and old enough to tell me more… I’d stick to inhalatory steroids, thankyouverymuch.

@ kultakutri:

I seem to recall vaguely that herbalists recommend smoking
– an old “Indian” herb- lobelia- for asthma AND
– smoking herbal substances which act like atropine ( not sure which herbs)
Neither seems particularly appealing.

Personally, a natural health advocate once told me, unsolicited of course, to throw my father’s meds away and try herbs for heart failure- esp hawthorne and foxglove. Needless to say, I didn’t.

@Alia #58: You might want to include kidney beans (Phaseolus vulgaris L.), which you may have noticed in most books on poisonous plants. Then there’s goji or wolfberries (Lycium barbarum L.), which in some individuals will cause severe allergic reactions, including raised rashes and severe gastric disturbances, regardless of whether they are certified organic or not.

@Alia #58: For those who juice apples, it may be useful to note that half a teaspoonful of the seeds is enough to kill an infant.

@ Dangerous Bacon
Vitamin supplements have been used for about as long as I have been living (i.e., a very long time) and only in the past several years have questions been raised about their value and safety. Undoubtedly some of these people have agendas and certainly some writers are Big Pharma shills (one writer for has repeatedly been accused of being such).

Vitamin supplements used in a judicious manner are quite safe. Indeed, the second source you gave stated “taking the correct dosage was harmless”. However, there is no such thing as a “correct dosage” because needs vary across individuals. Football players enduring two-a-day practices in extreme summer heat will have nutrient needs far greater than the needs of a 90 year-old sedentary person.

The idea of an RDA was developed during World War II with the objective of preventing disease. It has nothing to do with nutrient levels that are needed to achieve optimal health.

You first source is a blog article written by a PhD student who mentioned the Iowa Women’s Health Study. That study was flawed and the flaws have been pointed out in various sources, including this one.

I could write much more but I have neither the time nor the inclination to do so.

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