Thursday, August 11, 2011

Supplements - the good, the bad, and the downright awful.

Not all supplements (or medications) are created equal.

Choosing supplements is not easy. You have to ask yourself a few questions: Which supplement might be helpful or necessary for my health? Is there a difference between manufacturers of the same type of supplement? Is any one supplement safer than any others? Why are supplements not regulated in the United States?

Like most allopathic (western medicine) trained practitioners, after finishing my medical training, I was ignorant about the value of nutritional supplements, and especially about how to choose them. My interest and understanding about the value of supplements, and the vast differences in their quality, developed from listening to and learning from several highly respected Complementary and Alternative (CAM) health care practitioners. These practitioners took the time to try to educate me about this topic. Eventually, I developed more knowledge through my own reading and other educational activities.

Figuring out how to understand supplements and discern their quality has taken many years, a lot of research, and especially a lot of listening to really smart Integrative Medicine and CAM health care practitioners. The most important lesson I now understand is that all supplements differ in quality and efficacy. Well informed health care providers, natural stores, and natural pharmacies understand these differences. Furthermore, the quality of a supplement can range anywhere from terrible to excellent, and this difference usually depends on the quality of the manufacturer. Some manufacturers spend a lot of time, energy, and money to ensure that they are providing a high quality product to customers. Sadly, other companies simply don’t seem to care, being more interested in using the cheapest ingredients to maximize their profits, at the expense of uneducated consumers looking for help.

Why are supplements not regulated?

There are a number of reasons that supplements are not regulated by the United States government, but probably the most important reason is that, unlike the majority of  pharmaceutical medications, most supplements are rarely truly dangerous.

Pharmaceutical medications are highly concentrated chemicals engineered to have a profound effect on the body and they have many unwanted side effects that are known to cause potentially life threatening problems. Ironically, the desired effect from pharmaceutical medications is also a “side effect”, it just happens to be the side effect the pharmaceutical companies have created in order to potentially be helpful to their customers.

In contrast, many supplements are created from plant or earth elements (e.g. magnesium, calcium, manganese) that humans have used or been exposed to for thousands of years. In the case of vitamins (a western scientific discovery), they may be sourced from plant materials or created in a laboratory. Still they are generally safer than pharmaceuticals because they are part of normal human physiology and therefore necessary for proper biochemical and physiological functioning.

It is possibly to purchase empty capsules and add
supplements to them yourself, so that you can be sure
there are no binders, fillers, or other ingredients.
What are supplements and how were they developed?

Supplements include many different types of formulations. They may be sold as “vitamins or minerals” in which case they were originally developed and synthesized from some kind of plant source. Other supplements are basically just plants or their constituent parts (the leaves, stems, or roots) prepared in different ways. These will usually be ground into a powder and sold as such or they may be added to a tincture (mixed into a solvent like water or a small amount of alcohol) or they may even be enclosed in a gel cap or as a pill. Homeopathic preparations are derived from plants and earth elements but are significantly diluted in large volumes of water many, many times over.

Many supplements are developed and manufactured based on the historical knowledge of ancient cultures (e.g. Ayurveda from India, Chinese Medicine from China, or from an indigenous culture’s knowledge about local herbs and other remedies). The other main way that supplements are developed is through more recent knowledge developed in clinical research and science in the western world (e.g. vitamins, antioxidants, etc.). Today we are fortunate that many of these traditions and newer discoveries are able to be used together. Even more fortunate, both types of supplements can be tested by both clinicians and scientists, and the results of almost all of their research is available to all of us on the Internet, for our mutual benefit.

What makes an excellent supplement?

Is it any surprise that the most conscientious supplement manufacturers are those using the highest quality raw materials, free of harmful ingredients, thereby creating the best supplements available? They don’t use unnecessary or dangerous chemicals or ingredients just because it may be less expensive or faster to produce. They test their own products, even though it’s not required of them by law, and they choose ingredients that are known to be effective even if this costs more for them to produce. These manufacturers who care about the quality of their products, and the well being of patients who take them, put time, energy, and often a considerable amount of money into developing and manufacturing a better and safer product, and it shows in the safety and efficacy of the end result.

Generic Medications, “Generic” Supplements - What’s the real difference?

Anybody who walks through a supermarket is probably familiar with the concept of “generic” products. They are more colloquially called “knock off” products, which even have similar names and packaging. If you’ve ever felt adventurous enough to try these alternate versions, however, the difference becomes clear. Prescription drugs and supplements are no exception.

In a generic drug or supplement, the active ingredient is usually exactly the same dosage as the brand name product and the packaging may even look pretty similar, but the real difference is hidden in a place most people don’t think to look... the inactive ingredients.

In the case of pharmaceutical medications, it is these inactive ingredients that allow the distinction between the original (or trade named product) and it’s generic alternative. These inactive ingredients are the binders, fillers, and dyes used in their preparation. The goal is for the generic manufacturer to create a similarly effective product without it being an exact copy of the original.

In the case of supplements, similar concepts apply. While a supplement may not be regulated or even patent protected, manufacturers still use different quality of ingredient and inactive ingredients for many reasons.

What are all these “Inactive Ingredients” for?

When you look for a medication or supplement, you probably only call it by the “active ingredient” name (e.g. Amoxicillin, Tylenol, Vitamin D, Curcumin, etc.). However, there is much more that goes into these products than just the product name on the bottle might imply.

If most pharmaceutical medications were to contain only the “active ingredient(s)”, they would simply fall apart into a powder, be significantly less convenient to take, and many would taste quite unpleasant. A combination of several other ingredients go into making the solid “pill” to which we are accustomed. For instance, if a medication (or supplement)  is designed to be released slowly (e.g. timed release, extended release, continuous release, etc.), then there are chemicals added which are designed to break down slowly in our digestive system and allow the medication to release over a longer period of time, instead of all at once.

In the case of supplements (as well as pharmaceuticals) inactive ingredients should generally be avoided whenever possible. After all, every ingredient has some effect on the body...why increase your risk of side effects or other adverse events by using anything beyond what is absolutely necessary?

Fillers, Binders and Dyes, OH MY!

A comprehensive list of inactive ingredients would be massive, but they tend to fall into only a few categories which are pretty easy to understand.

Fillers - The active ingredients needed in many pharmaceutical medications are often in such tiny amounts that effectively handling them alone is impossible. Some pills would measure out to about the size of the head of a pin without “fillers”. Clearly, this kind of lilliputian product would be very difficult to get out of the bottle one dose at a time, even with tweezers and perfect eyesight. Fillers are used to, well, “fill out” space so that the active ingredient gets to a size that is more manageable for us to handle and take comfortably. Also, in these cases fillers allow the product manufacturer (or your compounding pharmacist) to ensure an exact dosage of medication.

In the case of pharmaceuticals, these fillers may be necessary, but in the case of supplements, these fillers are generally unnecessary because supplements tend to require a much larger amount of their active ingredients in order to be effective.

Binders - In addition, many medications and supplement ingredients may be naturally in a powder, crystalline, or liquid form. In order to make these into a solid pill, which most people are familiar with, manufacturers use “binding” materials to hold everything else (fillers, flavors, etc.) together. Binders can be wet or dry, depending on the specific properties of the active ingredients - Dry binders are generally mixed with the other ingredients and compacted under great force to create a solid mass. Wet binders are typically used when the other ingredients are mixed into a solution and form a wet mass that is then dried, granulated, and placed into a gelcap.

While binders may be desirable in some pharmaceutical medications, there is generally little reason to use them in the production of supplements and they should be avoided whenever possible.
Dyes make pills stand out, but they can also make you sick.

Dyes - The only real reason manufacturers add dyes to any product is to either make it look more attractive to consumers, or to make it look different enough from other pills so that patients can easily tell them apart. This may be a necessity for patients taking multiple pharmaceutical medications, where it is essential to be able to differentiate between them, but this is simply unnecessary when it comes to supplements.

As I mentioned, supplements usually have a much better safety profile than pharmaceuticals (i.e.the amount of active ingredient needed to make you ill is often a very large). Because of this, dyes are almost always unnecessary and they may be potentially harmful. For this reason they should almost always be kept out of supplements.

Remember, to get the pill that lovely shade of purple or yellow, manufacturers have to add artificial colorings. Many of these colorings have been shown to cause sensitization (developing an allergy to) and other harmful effects. One example of a harmful dye that, though heavily used and thought to be safe, turned out to be dangerous is Tartrazine (Yellow dye #5). Tartrazine, it turns out, not only colors products a brilliant shade of yellow, but also seems to cause hyperactivity and asthma. Several other dyes also demonstrate ill effects on people after some period of exposure and are therefore ill advised. Besides, do we really need our pills to be bright shades of purple, yellow, or red?

Flavoring - Nobody likes a nasty pill taste; it lingers in your mouth and you can taste it for hours. The artificial flavoring used in medications (and some supplements) is almost always unnecessary. Manufacturers can use a cellulose gelcap that keeps the medications away from our palates avoiding our exposure to these nasty flavors.

Even flavorings for pills that are designed to directly touch our tongue (e.g., sub-lingual medication that must dissolve under the tongue to be effective) usually taste sickeningly sweet. I find them much more unpleasant than just tasting the active ingredient alone. The reason they taste so weird is because of the combination of an already odd flavor, from the active ingredient, mixed with artificial sweeteners, which simply don't taste very good.

Artificial sweeteners and flavors are used instead of sugar because of potential adverse reactions of patients with diabetes, but they are unnecessary and potentially harmful. Flavoring for particularly nasty medications or supplements designed for children, or others who cannot swallow a gelcap, should be derived from real fruits or natural low glycemic sweeteners. Alternatively, the active ingredients (as a powder or liquid) can simply be mixed with a child’s favorite food (apple sauce, frozen desserts, honey, or mashed turnips (just kidding).

Manufacturing Byproducts - Most pills are made by machines and, as such, can contain residual manufacturing chemical byproducts.

One of the most common of these chemicals is magnesium stearate (both as a lubricant for pill machines and as one of the fillers used to make pills big enough to comfortably handle). Magnesium stearate, when used as a lubricant, can coat the medication and actually prevent the active ingredient from being absorbed completely by your body. You may also be interested in knowing that magnesium stearate is the main component of soap scum.

Lactose can be, and often is, used as a binder, applied as a shiny coating (to make tablets easier to swallow), or as an ingredient in a few timed/controlled release formulas. Though the amount of lactose in an average one of these pills is roughly 12.5 mg (about a thousand times less than an 8 ounce glass of milk) and far too low to affect most people, if you are sensitive to lactose, this could cause a reaction.

Any of these inactive ingredients can cause the medication or supplement to become less useful or even harmful. By preventing absorption, through unwanted side effects or by sensitization and/or allergy, these inactive ingredients should be minimized or excluded altogether whenever possible.

What are the alternatives?

Compounding pharmacies: When it comes to pharmaceutical medications there are usually few alternative other than asking your pharmacist to make you a custom preparation. Many of these pharmacies use very little in the way of binders and fillers, and almost always completely avoid dyes. When they mix a medication that needs a filler, they will generally use cellulose, where possible. Cellulose used for this purpose is generally non-toxic, safe, inert, and even provides us with a small amount of dietary fiber. Compounding pharmacies can also make you custom supplements, although this is rarely necessary.

High Quality Supplement Manufactures: The best supplement manufactures use a capsule (usually made of cellulose or gelatin) to hold the pure ingredient together and they add very little else. This means you can pull apart the two halves of the capsule and pour the contents onto your food or mix it into a drink. Alternatively, the manufacturer may provide the pure active ingredient (chemical, herb, etc.) as a powder that you can add to water or a smoothie. You can even prepare your own capsules by putting this powder into a gelcap yourself. (It may be important to note which type of capsule you get - cellulose is okay for vegetarians and vegans, but gelatin is not).

High quality supplements should come in capsules
made of cellulose or gelatin and contain pure ingredients.

Active Ingredients: Are they always safe and effective?

Raw materials that constitute the active ingredients in supplements (or even medications) may not be safe. They must be sourced from a reputable farmer, producer, or manufacturer. The best supplement companies (and the best pharmaceutical companies) choose the highest quality raw materials and only purchase them from reputable sources. A reputable source will never use pesticides or herbicides in growing their plants and they will avoid any potentially dangerous ingredients being introduced into their products.
If a product is sourced outside the USA, or other first world countries, there must be more skepticism about the quality of ingredients. These countries may produce excellent products but they may also produce dangerous products due to a laxity of laws regarding safety and oversight in their farming and manufacturing sectors. The best supplement manufacturers will know a lot about who supplies them with raw ingredients and if they are reputable and can be trusted.

Another issue with supplements is that some supplements may be ineffective. Effectiveness depends on the raw material being both bioavailable and having some effect on the body that research has shown to cause a positive effect in the body. Who wants to figure out which fraction of a type of supplement you need or want? I think it is easier to just choose a high quality manufacturer each time you purchase a supplement and then you rarely need to be concerned abou this problem.

In summary, the best manufacturers of supplements do what the best manufacturers of pharmaceuticals do; they buy (or make) the best raw materials, they test them thoroughly to ensure purity (no more and no less chemically), they follow the available research in order to use the most effective types of ingredients, and they provide the safest vehicle for them to be introduced into your body by using the safest and fewest binders, fillers, and other inactive ingredients.

Where do I buy my supplements and which manufacturers do I trust?

In my experience (at least in Canada and the United States), I have developed a hierarchy to where I can find and am willing to purchase supplements.

From lowest to highest:

  • Supermarkets and traditional drug stores - Usually carry the lowest quality (and least expensive) supplements, although you may occasionally find a decent product.
  • Specialty “Vitamin shops” - Mostly carry low to mediocre quality products, though they may also carry some trustworthy manufacturers.
  • Large scale natural stores (e.g. Whole Foods) - Carry a mix of good products mixed with many mediocre products. Usually, they have staff that have some knowledge of supplements and they may be able to offer some amount of education about product indications but, usually, not about quality.
  • Co-ops and small scale natural stores - Generally have good staff who know a fair amount about supplements. Quality ranges from mediocre to very good, with the occasional excellent product.
  • Large scale specialty natural pharmacies (often have a traditional pharmacy attached, e.g. Pharmaca in the United States) - They provide a significant amount of information and knowledge, but they carry a mix from good to excellent products. (In Europe, I have found that there are more of these types of pharmacies than in North America).
  • Small scale local natural pharmacies (usually traditional pharmacies also) - In Los Angeles, pharmacies like the Apothecary Pharmacy are an example. They offer good to excellent products, and may have a knowledgeable staff to assist you.
  • Natural Health Care Providers - Some are extremely knowledgeable about quality products and some less so. Because they are often permitted to sell supplements from their office, a conflict of interest may arise. Quality really depends on the individual practitioner, how much they need the extra income, their own efforts at researching quality products, and their commitment to their patients’ health.
  • Small Scale pharmacies specializing in natural products (may be associated with a traditional pharmacy) - An example of this is the Homeopathic Pharmacy in Santa Monica. They carry many excellent products and their staff is very knowledgeable (by the way, they have an online store).
  • And finally, the Internet - You can get just about anything through the Internet. Some companies are more trustworthy than others, but you pretty much need to know exactly what type of supplement and which manufacturers you want to purchase before you go to buy. As with everything on the Internet, quality information and products are mixed up with a lot of junk. If I were a patient, I would simply have no idea where to begin, so I always recommend knowing what type of supplement and which manufacturer you trust before you risk your money or your health.  
A word of advice about purchasing supplements: Even though I know a fair amount about supplements, I will not start using a supplement without the recommendation of a knowledgeable health care practitioner. In other words, as a patient, I do not recommend that you start any supplements without first obtaining a consultation with a respected Integrative Medicine or CAM health care provider. Since practitioners (Allopathic, Integrative, or CAM) may have limited knowledge pertaining to the quality of a given type of supplement, this is where asking for assistance from knowledgeable establishments, like the Homeopathic Pharmacy, can be particularly helpful.  

Just so you know, many cities (even large cities) may not have a single natural pharmacy. My son goes to college in Baltimore, Maryland in the United States, and my recent search for this kind of pharmacy in Baltimore and the surrounding area came up empty. Whole Foods and the local food co-ops were the only options for purchasing higher quality supplements. For those in smaller cities or towns, the only choice may be buying your supplements from your health care practitioner or online.

I hope that my road to a better understanding about supplements will help you to be able to choose products that are worth the investments of your money and that are valuable to your health. Below I am including the names of supplement companies that I trust and consider safe. Not all of their products are excellent, as each manufacturer has a range in the quality of their products, but I do trust them to be safe and generally of much higher quality than what is otherwise available on the market. This is by no means a comprehensive list. I know I am leaving out many excellent manufacturers, but I hope that this may help you to investigate these issues further for yourself and in consultation with your own health care practitioners. Please let me know your experience with supplements and/or supplement manufacturers that may have impressed you so that I can consider adding them to my list.


Supplement Companies I trust:

Thorne Research - Vitamins, minerals and many plant derived products.

Biotics Research - Vitamin, mineral, enzymes and hormone preparations.

Apex Energetics - Plant based preparations.

Researched Nutritionals - Transfer factors for immune system function.

Designs for Health - Vitamins, minerals and other preparations.

Nordic Naturals - Fish oils in liquid or gel caps. High quality manufacturer with significant testing to avoid heavy metals and winner of awards for quality.

Supreme Nutrition Products - Plant/herbal based supplements. Tested for potential effectiveness via Applied Kinesiology.

Montiff - For pure amino acid formulations

Ecological Formulas - Some specialty products. Website not available.

Pure Encapsulations - Some vitamins and minerals.

Standard Process - Plant / herbal based supplements

Homeopathic Companies

Heel - Homeopathy. Particularly known for Traumeel (a homeopathic preparation for traumatic physical injuries).

Essential Plant Oils (organic) / Aromatherapy

Veriditas Botanicals - For organic pure essential oils

Aura Cacia - For organic pure essential oils and aromatherapy products

Herbal Preparations:

Herb Pharm - For organic herbal preparations

Alternative Choices- For wildcrafted herbal preparations

Gaia Herbs - Plant / herbal based supplements

Eclectic Institute - Plant / herbal based supplements


New Directions Aromatics - A Canadian based company that stocks many organic pure essential oils and other ingredients to make your own skin care based products.

Santa Monica Homeopathic Pharmacy - not a manufacturer, but they stock many high quality products and supplements as well as a large variety of homeopathic preparations. The staff is very knowledgeable and will help you find quality products. - An Internet site that carries supplements and has some of the best prices I've seen on common supplements. - An Internet retailer that carries supplements that may be more difficult to find. They carry many quality manufacturers and I have found that their prices are generally competitive. An Internet retailer that carries some difficult to find products. I purchase from them occasionally and their prices seem better than many other sites. They also offer a rewards program.

Please note, there may be many other Internet sites that may be price competitive and that also offer difficult to find products. The reason I am including Pure Formulas and Healthy Designs is simply because I ordered from them on several occasions and I had good experiences (i.e. they send what I ordered in a timely fashion). I initially chose these retailers based on their inventory of difficult to find products and their competitive pricing, however, as I continue to compare Internet retailers product availability and prices these two sites have continued to earn my business by having decent prices as well as the products I am searching for. Unfortunately, like many Internet sites, the quality of their products and manufactures can vary, so please know specifically what you want before you go online to do your shopping. Please let me know if there are retailers in your area and/or online that have impressed you so that I can consider adding them to this list.

Researched and written by Dr. Rebecca Malamed, M.D. with assistance from Mr. Malcolm Potter.