We all know the internet has a lot to say, especially when it comes to medicine and health. But you know, as I've been on the internet lately, it seems like supplements have become a particular fascination.

Top 10 supplements you should be taking. Supplements I love that you may not know about and might want to try.

They're often touted as something close to miracle drugs.

Something else I take every single day is my Inositol. This has done incredible things for my hormone balance. I also take B12 every single as well as vitamin C. A lot of clinical evidence that supplementing with something called methylfolate can be very, very effective at treating anxiety and even effective at treating depression.

I'm sure you realize this: you gotta be careful. And keep in mind, just about everyone is trying to make a buck off of you every time you're going on the internet and doing a Google search for any kind of health condition. So let's talk about supplements today. What can they do? What can't they do? What do we really know about supplements? How good is the data? And how can you even know for sure what you're actually buying? To be honest, the answer to that last question, you really kind of can't. And that's because of a 1994 law called the Dietary Supplement Health and Education Act, DSHEA. We're gonna talk more about this in the podcast, but here's an explanation of what it is from the Food and Drug Administration's YouTube channel.

'DSHEA defines dietary supplements as a category of foods, so they must comply with requirements that apply to food as well as the dietary supplement-specific requirements. Unlike prescription drugs, FDA does not have the authority to approve dietary supplements or their labeling before products are introduced to the market.

So the law basically allowed manufacturers to sell untested pills and powders as long as they didn't claim the product would treat or cure a disease. Now, since it was passed, everything changed. Annual industry revenues grew from 4 billion to 70 billion. So today, I'm gonna ask supplement safety advocate, Dr. Pieter Cohen, for some help. Help in navigating the risks and rewards of supplements. Dr. Cohen is an associate professor of medicine at Harvard Medical School and a general internist at Cambridge Health Alliance, where he leads the supplement research program. I'm Dr. Sanjay Gupta, CNN's chief medical correspondent. This is Chasing Life. How did you get interested in the world of supplements?

So I first got interested because of my patients. So I'm a primary care doc and take care of patients outside of Boston here in Somerville. When I started out in practice, I wasn't really focused on supplements at all. In fact, I just thought they were expensive placebos, really, that people were using on their own and didn't really affect medical care. That really changed over the years because I started to see that my patients were getting harmed by these weight loss pills from Brazil. When we took a closer dive, the harm was that patients would have panic attacks or end up in the hospital with damaged or kidneys. When we looked at the contents of the pills, I was struck by how pharmaceutical drugs that had never been approved here in the States were ending up in these pills and then my patients were taking them and experiencing harm. So it was that experience that led my interest into this area of what are patients doing on their own and how might that be harming them.

You're talking about pills in this case that were imported from another country, Brazil in this case. Were you seeing the same stuff ultimately in pills that were purchased in the United States?

Right. So I actually thought this was just a problem of weight loss pills from Brazil, but it was within the community here in Boston. And we were publishing and working on getting the word out about it, going to local churches, talking to the community. It was at that time that I got a call from the FDA. And the FDA told me, you know, Pieter, what you're seeing in Boston with these imported weight loss pills from Brazil is a pattern that we're seeing across the country in weight loss dietary supplements.

Let me just back up for one second and ask for some definitions, some basics here. The word supplement typically means to add, you know, whatever it may be. Is there an accepted definition of supplement when it comes to the medical world?

What we're talking about here are things called dietary supplements, and it doesn't really have any meaning beyond the legal term. So basically, when the law was passed that regulates supplements, the law that was passed in 1994, that defined this term, dietary supplement. It's really a legal term defined by Congress.

The law in 1994, DSHEA, I think you're talking about. First of all, what is that law? And I think the perception often is that there is not a lot of regulation around supplements. So what is the regulation?

Supplements fall under DSHEA, this 1994 law.

And what does that stand for again?

Dietary Supplement Health and Education Act of 1994. And DSHEA is the current framework that all dietary supplements are sold in. Now that law in 1994 was initially being designed to better regulate vitamins and minerals. What unfortunately happened, unfortunately in my opinion, was that that same structure was expanded to include botanicals, all nature botanicles, many different types of extracts, like let's say a cow thyroid extract. Live microorganisms like both bacteria and yeast that are sold as probiotics, protein powders, amino acids, all this was lumped together. Under that same framework that was being created to regulate vitamins and minerals, and all of them were called dietary supplements or dietary ingredients.

If you think about a prescription medicine, I think people are pretty confident that it's gone through these clinical trials of safety and efficacy and things like that. What about with dietary supplements? What can the public reasonably expect if they say that this supplement has been regulated?

'Yeah, I think we have a false impression of what regulation means. So the regulations really kick in after the fact. The FDA is in the position of looking for problems out in the marketplace after supplements are being sold, and then working to try to identify the products, which is incredibly difficult, because they don't have a effective system to detect harms, and then to try to remove those dangerous products. While those regulations exist for practical purposes, it's companies selling us whatever they choose to declare and identify as a dietary supplement. They have rules about- certain manufacturing rules. The plant needs to be sterile, for example, but it's not like a FDA inspector checks the plant, ensures it's sterile before supplements are sold on the marketplace. So everything's retrospective after these products are already on the marketplace.

So someone can come up with a supplement, start to sell it, to the public. I mean, a person could go to a store, pay with a credit card, buy something like this. And unless, as you're saying, it's found to cause some sort of harm, or if the manufacturing facility is found to not be abiding by good manufacturing practices, in retrospect, a lot of people could take it before it might be potentially withdrawn from the market.

Correct.

That sounds like a pretty scary system.

It's a system that emphasizes access and minimizes the assurances of safety, or at least leaves safety in the manufacturer's court.

Let me ask you, just as a person who's very focused on his health, and I know you are as well, how many people do you think or what percentage of the population do you think need supplements?

My thinking is that, and this is how I practice in my primary care practice, is that unless a person has trouble, a disease that either inhibits absorption of ingredients in the intestines, or is likely to do so in the future, those are patients who I do think need multivitamins and other vitamins. My clinical experience is that regardless of how people are eating, as long as people are not on a highly restrictive diet, that they are gonna get sufficient vitamins and minerals. So even if they're eating mainly manufactured or processed foods, or they're growing everything in their own garden, because of supplement supplementation, I'm not seeing serious vitamin deficiencies in my practice. So I'm not recommending that patients take multivitamins routinely.

So, just to be clear, what are some of the conditions you're talking about where someone may not be absorbing?

Well, a very common thing would be if someone's had a stomach surgery, like gastric bypass surgery, part of the stomach is removed. And in that situation, they're not able to absorb all the vitamins when they're eating.

Things like gluten sensitivities as well with stuff like that fall into that category.

Absolutely. If you have untreated celiac disease or untreated gluten sensitivity, what that's going to do is jam up the mechanism there in the stomach to absorb the vitamins. But once it's treated, if someone is avoiding gluten and their celiac diseases are well controlled, it's certainly reasonable to continue a multivitamin, but it might not be necessary.

But what about the safety issue again, though? Are multivitamins generally considered safe, then? Or do you sort of lump them together with some of your same concerns about supplements overall?

'No, I consider multivitamins to be safe. There have been very unusual cases. There was a case years ago in which people were being harmed by multivitamins. And it turned out that one of the heavy metals was very high levels because of a very serious manufacturing problem. Like very high-levels, like a thousand times what it should have been.

Wow.

'And patients' hair was falling out, people were getting very sick, visiting the doctors. You know, we're talking about like, very small number of products over decades. The great majority of multivitamins are safe and the clinical trials have demonstrated that they won't harm you. So that's why I don't clump them with the categories what I would, I term high-risk dietary supplements, which are more likely to be risky to have.

Weight loss supplements, some of the herbals, things like that, you'd put in the higher risk category.

You got it. Some of the sports supplements and some of the sexual enhancement supplements as well.

You made this comment to me last time we spoke, again, that even if you had a sort of standard American diet, and we're talking about maybe eating fast food from time to time, cereals, things like that, the way that food is fortified, maybe not like this all over the world, but at least in the United States, that for the vast majority of people, again, unless they've had some sort of intestinal surgery or something like that they're probably not going to need supplements. I remember you saying that, and it really stuck out to me, like even bread is fortified. You may say, look, I'm not eating a salad every day, but I am eating a standard American diet. So for the most part, while that may not be the healthiest in terms of supplementation, I shouldn't necessarily need anything.

That's precisely the reason why I don't think the majority of adults need multivitamins. Because if you're cooking everything from lots of fruits and vegetables in your own kitchen, or you're buying those breads, milk, cereals that are available everywhere, you're gonna be getting the vitamins you need, unless you have very restricted diet or one of those health conditions we were talking about earlier.

You've been at this for a long time. Do you take supplements?

I don't. But if my doctor recommended I should, I would start.

And your doctor would recommend, because they would look at Pieter's lifestyle and say, hey, you're probably not getting enough of X, Y, or Z.

Right. Let's say I was diagnosed with a condition that was interfering with my absorption, and my doc recommended I should take a multivitamin. I certainly would take one.

So if you sort of extend that argument, if you look at something like vitamin D, for example, people who may have gotten their vitamin D levels checked, found to be deficient, they're asked then to take supplementation, and then you hear varying doses, 1,000 milligrams, 2,000, 4,000. How good is the data then if you're trying to figure out dosing or whether to take something at all?

Yeah, I think that's a good point. I think it's something that's evolving and it's not, there hasn't been much attention to study that. A recent example of this is really with iron supplementation. So, when I was in medical school, if someone was deficient in iron, we would recommend they take an iron supplement morning and iron supplement night and do that indefinitely until their iron stores came back up. More recently, a few years ago, there was a small study, but one that strongly suggested that all that iron was actually interfering with absorption iron. So it would be better to take iron one day, not to take it the next day, and then to take the other day. So just take one pill every other day, and that's become more the standard of care recently of routinely repleting iron deficiencies, actually greatly decreasing the amount of iron. That's an example of, and that study is just, that's not based on a tremendous amount of data. And that just goes to show us how little this area is researched and how much more we do need research in this area to better understand what would be the best approach to repleting vitamin levels at different levels, but also with people with different conditions. They might require different regimens and different dosages, and then that's not well studied.

It does seem like the manufacturers, as you were sort of alluding to, they would prefer you take more of their product, obviously, and if the data is not required from a regulatory standpoint, will we ever have that data? I mean, who's going to fund those sorts of trials if the date is not required and people actually would prefer to sell as much of their product in the first place as possible?

'I think you're getting at a core concern I have with the current regulatory framework that really inhibits us moving forward. It's that there is no incentive for manufacturers to conduct carefully done clinical trials. One thing we haven't talked about yet is that one other part of the law is that supplements can claim to have health effects without it being proven in humans. Since you can do that without doing a clinical trial, what's the incentive to invest in all that money, millions of dollars to do a clinical trail? The only potential outcome is negative because if you're right, you were already advertising it as it was beneficial to your health and all you did was to prove that your claim is correct. But more likely, it's- turns out it doesn't really work like you had hoped it did, and all that money is wasted, and then you've got a problem. But the good news, I guess, is that you can still keep on selling it as if it does work, even when the studies come out negative.

'But that seems like a huge problem, though, because you do hear these outlandish claims. And I think people who are well-intentioned, you know, I think that's part of what has driven the use of supplementation, which seemed to increase even more so during the pandemic as people wanted to take greater control of their health, is that they read a claim that this is going to cure your back pain. It's going to help you live longer. It's gonna, whatever, and they believe it, understandably. And yet there's no accountability for those claims. And even when it comes to harm, it's only after the fact. So not only may it not work, could potentially harm you and you have just bought this product with your credit card from a legitimate looking store. Again, that seems problematic, especially when you're doing it in pursuit of good health.

I absolutely agree. And one of the problems with supplements compared to traditional foods is that when we buy a traditional food, we're using all our senses to try to determine if we should put this into our body. So when we buy broccoli, if it's yellow, if it is mushy, if its getting soft and smells bad, we're like, mm, yes it's broccoli, but no thank you. And the thing about supplements is they're in those capsules. Usually, they're closed off, right? There's no smell. And unfortunately, given the regulatory framework that we have here in the States, we can't be assured of the quality of that powder, and we also can't assured of those health benefits that are written on the box.

We're gonna take a quick break here, but when we come back, we're gonna look at some popular supplements that could be sitting in your cabinet right now. So it is a little bit buyer beware or a lot buyer be aware when it comes to these things? I did a deep dive on a few supplements because I was very interested in the use of certain supplements for pain specifically. So for example, the four that I came up with for pain potentially CoQ10, which helps seemingly with mitochondrial function, which can help with the sort of pain that one might develop after intense workouts or even with statins. Sometimes if you're taking a cholesterol lowering medication it can cause these muscle aches. There seem to be pretty good data, to me at least, on the use of CoQ10 for that. Is that something you've heard of?

I've definitely heard of it. My take is that the totality of the evidence does not suggest that's the case to me. So I don't recommend it to my patients. But it's a great example of what we're talking about, which is that an educated consumer should be able to take CoQ10 if they wish to, to try to treat pain after working out or when they're taking their cholesterol medication. I think that that makes perfect sense, just because my assessment of it is that I'm not convinced that it works. I don't think that should limit consumers and my patients from trying it if they'd like to.

Fair, I think that's a really sensible approach. I think as physicians, we probably have some obligation to make sure patients aren't harming themselves. But beyond that, who am I to say that, look, that didn't work for you, even if they say it did. But again, getting to this point, and I think you've said this already, Pieter, but the totality of evidence for many of these things is just not going to be great. And to take it a step further, it may never be great because there's no requirement for that evidence to be rate. If you're looking for great evidence to do or not do something, when it comes to supplements, you may not find it.

I agree. And I also agree that the placebo effect is something that we should take very seriously. If someone is taking something that's safe and it's helping them function better, be more relaxed, have less pain, regardless if we can understand it, biomedically or not, I definitely think that should be encouraged.

'The four that I was talking about I'm just gonna name them. You don't have to- because again I don't think there's gonna be great evidence behind these but there was better evidence in my estimation than there was around a lot of other things specifically with regard to pain. So CoQ10 as I mentioned. Magnesium, which I thought was really interesting magnesium I saw for lower back pain, which I thought had decent evidence behind it. Turmeric was another one and then willow bark which probably should be no surprise because it has some of the same active ingredients as aspirin, salicylic acid. So those were the four. But again, I think this is such an important point. If you're looking for great evidence behind any of these things, you're probably not going to find it and you may never find it unless the regulatory framework changes and that evidence starts to become required.

'Yeah, one thing we haven't talked about yet is that there's no manufacturing standards for how something's prepared. So let's say willow bark has been used for hundreds of years for pain in a traditional medicine practice and in that practice though there would be a specific way to prepare the bark before it's consumed by humans. So it wouldn't just be like willy-nilly, there's going to be a very specific process. How is the bark treated first? Is it dried? What's that liquid that's used? Is it water or is it a different solvent? Do you drink it as a tea? Do you then boil it down or somehow isolate or distill it? And all of this would be standardized in traditional medicine practice, allowing for willow bark to be effective for the reason that it's being used. So it's important for consumers to understand that buying commercial willow bark dietary supplements in the United States, there's no requirement that any standard practice here is used. The only requirement is that a manufacturer make up the steps that they use. They write it down like a recipe and they keep it in their factory. And they do that same thing every time they do every batch. So it's, there is a perfect example of how I believe our regulatory framework doesn't allow us to channel the potential benefits of the botanicals because we've lost all the standardization that's required to make high quality botanicals.

'If I was a very well-intentioned supplement maker, I wanted to put out really good supplements because I felt like they could be helpful, like how would I convince someone like you that this is a good supplement?

'Yeah, well, fortunately, we do have a workaround. And how it generally works today is there's a few companies that the manufacturer that you could hire to do a deep dive into your practice. So two examples that I'm big fans of, USP, US Pharmacopeia, and NSF. NSF I've collaborated with on many research studies and-

National Science Foundation?

'No, it's just NSF International. You probably have many things at home from your dishwasher to pipes in your house-

Got it.

'-they're tested by NSF. They run an excellent dietary supplement testing program. And both those groups do deep dives into the quality of manufacturing. So a manufacturer would pay one of those two groups, for example, and they would take a look. They'd look at the manufacturing, they'd look the original. Ingredients that are coming in that at the end of the line when consumers are going in to purchase this online or in a store, that the label accurately represents what's in the product. So if a company is spending that kind of money to ask an external group like NSF or USP to analyze every step of the process, that's what would make me comfortable that what's on the label is in the product. However, with a few caveats. One is that manufacturing process. This isn't assuring that it's made in a traditional way. It's just saying it's in the way that the company thinks it's being made. And the other thing is those claims. If you say something's good for gut health or will boost your immunity, those claims are not assessed by these companies. The companies are just looking at, is the powder in the bottle the same as what's on the label? That's a very good start. But obviously we would need more accurate information about the claims and ideally the manufacturing process. So how do I go about finding the brand of willow bark extract that is going to be accurately labeled? Here's my tips. Number one is go to one of those two companies or non-profits websites and they on their website will list all the supplements that they have certified.

That's good to know.

So you find their dietary supplement certification section and you look at willow bark. Are there any willow bark supplements that have been certified by either of those two? Then you go purchase that individual brand. Other tips, sometimes, unfortunately, you might be looking for an ingredient that hasn't been certified. So the next best thing I would recommend if you can't find something that is certified by one of those two programs or other. There are some other high quality programs, particularly in the sports supplement field. But if you can't find something, then my recommendation would be to purchase supplements only with one ingredient on the label. And that makes no health claims. If you want to try willow bark extract and you can find any that are NSF or USP, I'd recommend going to a retailer you trust. And purchasing something that just lists willow bark extract on the label and does not say anything about pain or anything else, then try that.

Yeah, that makes sense. A retailer you trust with Amazon? I mean, would you find reputable products on Amazon?

Absolutely. But do I trust Amazon to have vetted the products so that I know that every product on Amazon is refuge at all? Absolutely not. Amazon has tried to put into place some safety factors, but my understanding from multiple different studies, including our own from my colleagues, some of which we've bought on Amazon, is that for reasons that we don't know exactly for why, that program is not really working that well. It is possible that it's because those certifications that are required are very easy, maybe to find online and fabricate.

So you, you're not a supplement taker. Have you ever, I mean, ever tried it? Or have you ever been curious about trying some or melatonin? My kids take melatonin, for example, or ashwagandha. That's another one that's gotten a lot of steam lately.

'Everything I know about the manufacturing of it concerns me, so I can't be assured of what I'm getting. I think I would be more self-willed and curious and experimentational if I had a sense that I could get precisely the same formulation that's been studied in trials that are beneficial. And outside of vitamins and minerals, I don't have that assurance.

Pieter, I always learn a lot from you. I really appreciate it. It's a complicated field. And again, I have a lot of sympathy for the folks who are probably listening to a podcast like this because I think most people are genuinely in pursuit of good health. So hopefully this helps people navigate through that. Thanks for your time. That was my conversation with Dr. Pieter Cohen. Thanks so much for listening. Chasing Life is a production of CNN Audio. Our podcast is produced by Eryn Mathewson, Jennifer Lai, Grace Walker, Lori Galarreta, Jesse Remedios, Sofia Sanchez, Kyra Dahring, and Madeleine Thompson. Andrea Kane is our medical writer. Our senior producer is Dan Bloom. Amanda Sealy is our showrunner. Dan Dzula is our technical director. And the executive producer of CNN Audio is Steve Lickteig. With support from Jamus Andrest, Jon Dianora, Alex Manasseri, Robert Mathers, Leni Steinhardt, Nicole Pesaru, and Lisa Namerow. Special thanks to Ben Tinker and Nadia Kunang of CNN Health, and Wendy Brundige.