About the Author
MARK A. MOYAD, MD, MPH, is the Jenkins/Pokemper director of complementary and alternative medicine at the University of Michigan Medical Center. He is the primary author of more than 130 medical journal articles on the subjects of lifestyle changes and supplements (more than any other expert) and has given more than 5,000 medical lectures to consumers and health care professionals. He lives in Ann Arbor, Michigan.
JANET LEE, LAc, has been writing about fitness, health, and nutrition for the last 20 years. She is also a licensed acupuncturist with a private practice in Los Angeles.
Excerpt. © Reprinted by permission. All rights reserved.
1
NAVIGATING THE SUPPLEMENT WORLD
MAYBE YOU CAME TO THIS BOOK because you'd like a better understanding of the supplements you're already taking. More likely, though, you're probably baffled and confused as to where to begin. The supplement world can be overwhelming, to say the least, but I am here to help.
Too often, in an attempt to navigate and make sense of the excess of choices, barrage of information, and varying opinions in the supplement market, consumers take the crowdsourcing approach: polling their friends to see what pills they're popping, doing an exhaustive Internet search, then heading to the store to stock up on a host of supplements.
I believe the days of dabbling in dietary supplements are over. Thousands of products debut every year and hundreds (sometimes thousands) of research studies come out every month, just in the areas of diet and supplements! If an "expert" is only dabbling part-time in this area but dishing out information to you, he is being reckless, especially since so many supplements are the equivalent of drugs.
I've been in the dietary supplement world for more than 30 years, and it is truly my passion. I don't just look at the bottom line in an abstract or at the conclusion or focus of one study. I go through a detailed, 70-point checklist (see page 461) of criteria to truly decipher whether anything can be gleaned from a study or a summary of studies. I draw on my own experience of working with patients on a daily basis. I take a hard look at specific conditions and ailments and deduce when a drug might work better than a supplement. When I have a question about the latest cancer treatment, I call an oncologist. When some of the world's top doctors have supplement questions, they call me.
I know the world of supplements can be complicated and convoluted. That's why I wrote this book as a guide to help you steer through it. Each year, just when I think I've heard every question, comment, or conspiracy theory about dietary supplements and nutrition recommendations, someone surprises me with a new one! So I'm giving you a small sampling of my responses to some common questions and declarations from the 5,000 lectures I've given in every corner of the world. I have also sprinkled some mythbusting information throughout, labeled as "FACT" or "FALSE," as well as some of my favorite factoids, labeled as "Moyad Fact" (which you'll find throughout the book). My hope is that this chapter will help you navigate and understand more clearly the massive world of supplements.
THE MIDDLE WAY
I use the excerpt below from The Teaching of Buddha to describe my approach to diet and lifestyle as well as supplements: Be educated but not extreme.
"To those who choose the path that leads to Enlightenment, there are two extremes that should be carefully avoided. First, there is the extreme of indulgence in the desires of the body. Second, there is the opposite extreme of ascetic discipline, torturing one's body and mind unreasonably."
BEFORE YOU BEGIN
"Why should I be taking supplements?"
You don't necessarily need to take a supplement if you're perfectly healthy, just like you wouldn't take a drug if you didn't have any health issues. If you do have a health condition, though, or you're at higher risk of a disease, such as heart disease or diabetes due to lifestyle or family history, you may want to consider taking a supplement just like you would consider taking a drug. What I've found over the last 30 years is that virtually all people have their own unique story that involves some health concern, large or small. In other words, almost everyone could potentially benefit from some type of supplement, even if it's something as simple as a multivitamin to reduce cancer or cataract risk.
"How are supplements different from drugs?"
To me, there is no difference between an effective supplement and a drug for a specific medical condition. Some of the most interesting supplements mimic the actions of pharmaceuticals, or vice versa (for example, red yeast rice extract versus statins for lowering cholesterol or capsaicin in low concentration versus the higher concentration prescription-only form for neuropathic pain). When a supplement works like an available drug, you should have more confidence in its ability to have a tangible effect (and, like drugs, not necessarily without side effects). In fact, many supplements sold in the United States are only available as drugs in other countries. (The over-the-counter supplement alpha-lipoic acid, to give you just one example, is sold as a prescription drug in parts of Europe and Asia.)
On the flip side, many drugs are derived from natural sources, including some of the biggest-selling drugs of all time: Cholesterol-lowering statins originally came from a fungus/yeast; metformin, used to treat diabetes, originates from the French lilac; and aspirin, a pain reliever and over-the- counter anti-heart attack pill, was created from willow bark. Bottom line: The difference between a drug and an effective supplement is only perception, not reality. I'm hoping this book will spur a change. Throughout, for each ailment and condition, I will give you the full answer: If a drug is more effective than a supplement in a specific situation, I have no problem saying so.
"Do I need an annual checkup to determine my supplement needs?"
Not necessarily, but you should have an annual discussion with a trusted doctor.
A research review of nine clinical trials, published in the Cochrane Database of Systematic Reviews, looked at 182,000 participants and found annual checkups did not improve health and often led to harmful or unnecessary tests. In fact, having an annual checkup did not appear to reduce the risk of hospitalization or disability, referrals to a specialist, or time missed from work. Sometimes when you're looking for a tractor in a haystack, you find a needle. In other words, even though you're typically being screened for "big" issues at a checkup, sometimes your doctor will find a small issue that you might then feel compelled to treat. Often, the benefits do not outweigh the negative side effects of treatment. This is why some cancer screening tests (prostate, breast, and thyroid, for example) are more controversial now. Let me give you an example: You go to the doctor for some complaint or maybe for an annual checkup. She notices that your PSA (prostate-specific antigen) levels are elevated, so she orders a biopsy. Then, she finds a small tumor in your prostate and now you're completely stressed out and anxious. You opt for treatment and endure significant side effects, including incontinence and erectile dysfunction. But it's very possible that the tumor, although malignant, would never have been fatal in the first place because they don't always grow to be life-threatening, and you would have been perfectly fine without treatment. In cases like these, the treatment is worse than the problem.
Of course, this doesn't mean you should never be tested for these cancers; screening saves lives. It just means many Americans are being overtested, which can lead to unnecessary procedures, prescriptions, and supplements. However, I am a fan of personalized risk assessment for anyone who's concerned about cardiovascular disease (see Chapter 2), so talk with your doctor about that.
"How do I know if a supplement will help or hurt me?"
People come up to me at lectures or in the clinic all the time to tell me that they read something negative about a supplement they're taking and are concerned but don't want to stop using it. One of the best ways to get to the bottom of any potential issue is to stop taking the supplement and see what happens. I call this the guinea pig effect. Likewise, one of the best ways to figure out if a supplement could help a condition is to start taking it at a low dosage.
"Should a ton of studies be done before a supplement is considered safe?"
I frequently recommend supplements that don't have large, randomized, double-blind placebo studies to back them up as long as they are inexpensive and safe; they have preliminary research for the condition in question and minimal side effects; and there are few other options (or those options are costly). For example, the research on vitamin B2 for migraine prevention is still preliminary, but it's impressive. The vitamin is dirt cheap and the side effects are negligible, so it's worth a try. The prescription options for migraines are expensive, have side effects, and don't always work. Plus, up to 50 percent of users have trouble functioning after taking them, so better alternatives are needed. This is the essence of benefit versus risk.
I would love to live in a world where every supplement fulfills all my research criteria (see the Appendix), but even conventional drugs don't work this way; it's part of the art of medicine. Few things in medicine come with a 100 percent assurance of effectiveness, so it comes down to probability and your willingness to accept a certain amount of risk to gain certain benefits.
"Are quality-control testing organizations useful?"
They can be. Both Consumer Reports and ConsumerLab.com tend to watch the supplement industry. ConsumerLab.com gets criticized for not being a "real" lab--they send out samples to reputable testing facilities--but I think they're providing a decent service.
The only problem I have with some of the quality-control testing labs in the United States, which will remain nameless, is that they are discriminatory. For example, these labs will not test sexual enhancement products, either because they have to do with sex (gasp!) or because of the sordid, negative associations they anticipate for getting in bed (pun intended) with these products. This is one of the largest categories within supplements! And they should all be allowed equal testing. Erectile dysfunction and female sexual dysfunction are real medical conditions that should be handled like any other, but instead the testing labs see them as stereotypes. I look forward to these labs being exposed for their at times discriminatory behavior.
"What's the difference between a dietary study and a dietary supplement study?"
I'll often see a dietary study referenced as support for a supplement or, more rarely, vice versa. A dietary study looks at the nutrients in certain foods, while a dietary supplement study looks at taking a specific supplement. You can't apply the conclusions about nutrients in the diet, say omega-3s or vitamin D, to the individual supplements. It's like comparing apples and tennis balls. For example, based on dietary studies, researchers believed beta-carotene was the active component in many plant foods that was reducing the risk of heart disease and cancer. But in several supplement studies of beta-carotene, people who took the pill ended up with an increased risk of lung cancer if they were current or possibly even former smokers, and in all the other trials, it showed no health benefit. (And there went hundreds of millions of dollars on clinical trial research!) Similarly, eating foods with selenium might reduce the risk of cancer, but taking selenium to prevent cancer has shown no benefit (and, again, it cost hundreds of millions of taxpayer dollars to show this).
The take-home message here is, if someone is selling you a supplement and referring to dietary studies with that ingredient, it proves nothing and it's likely a waste of your money. Always look at how the supplement itself has performed in clinical trials. As I was writing this section, I came across an "expert" on the Internet using studies of magnesium rich-food that showed a reduced risk of bone fractures and high blood pressure as a reason to buy a special magnesium supplement. And the beat goes on!
"The supplement business is a racket! There are huge quality control and safety issues!"
I hear this all the time. Those who bash dietary supplements across the board, claiming that drug-supplement interactions have reached epidemic proportions and quality control is nonexistent, just spread misinformation and panic. The biggest pill problem in the United States, by far, is death from an unintentional prescription drug overdose. And about 70 people die each day as a result of this, according to the latest report from the Centers for Disease Control and Prevention; that's more than 27,000 deaths per year and one every 19 minutes! Pain, antianxiety, and insomnia medications are most often to blame.
I have worked on supplement investigations where people have died, and it's always a tragedy, but those cases don't compare to the 70 people dying each day-- or the thousands of others who become seriously and dangerously addicted to these medicines. Yes, we need to drastically improve quality control in the supplement world, but let's put it in perspective, folks.
"Do I need blood testing to check for multiple nutrient deficiencies?"
There are clearly some cases in which you need a blood test if your doctor suspects a nutrient deficiency--say, with potassium, magnesium, iron, or vitamin B12-- especially when a drug increases the risk of one. (For example, the cancer drug Zytiga reduces blood potassium in many patients.) Iron blood testing for anemia is a gold standard for women with fatigue from excessive blood loss from menstruation, and B12 and magnesium testing may be warranted if you're on acid reflux medication long term.
Nutritional deficiency testing should always be handled on a case-by-case basis. Most people do not need a massive nutritional panel that looks at amino acids, vitamins, and minerals, where inevitably something shows up low and you're told you need a supplement to correct it. If your panel does reveal some deficiencies, always ask if correcting them (taking more of whatever nutrient is low) will produce a tangible, beneficial result. Let me explain: Hundreds of millions of dollars have been spent on studies looking at how high doses of vitamins B6 and B12 and folic acid affect a com£d in the blood called homocysteine, which experts believe is a marker for cardiovascular disease in most individuals. The Bs did, in fact, lower blood homocysteine levels, and supplement companies jumped on that. But after several decades, experts are realizing that lowering homocysteine doesn't really have much impact on heart health for most people. In other words, just because a blood test improves does not mean you will improve-- with the exception of the obvious ones, such as cholesterol and glucose.
Again, some individual tests are worthwhile, but the majority are absolute nonsense. Be leery about extensive blood panel tests for the following:
Amino acids
Antioxidants
B-complex vitamins
Fatty acids
Metabolites
Minerals
Vitamins
I often hear from people who have been dealing with celiac disease or Crohn's disease for years, both of which can impact nutrient absorption, or from those who've been on long-term extreme diets and are curious about possible nutrient deficiencies. If you're in a similar situation, please read the Bariatric Surgery section (see page 90), which lists a comprehensive panel of proven nutrient deficiency tests that can help you determine your own nutritional issues.
