Chronic Disease Management - Herbs and Supplements

so welcome everyone thank you for coming my name is Kathy Dennehy I'm one of the associate clinical professor x' in the School of Pharmacy I've been practicing at UCSF now for about 12 years and gave my very first presentation on herbs and supplements back in 1997 so after that point in time after that talk it was I gave it actually at a national meeting I kept getting requests from people to do more talks on herbs and supplements and very steadily it became an area of expertise for me so much of the information that I'm going to present to you today is really sort of a summarization of evidence at least in regards to the supplements that we're going to discuss it's a summarization of clinical evidence that is currently available to either support or refute claims that are made by some of the more popular dietary supplements so this is an overview of what I'm going to discuss with you today we're gonna talk a little bit about how the products are regulated and how that's different from other prescription and over-the-counter products we're gonna talk about just overall statistics regarding who's using these products and why they're being used hazards that can result from dietary supplement use and look at just the top six selling products and finally information resources so that when you have questions or when you know if your health care provider if you have patients that have questions or family members that have questions resources that you can go to to help answer you know the questions as they come up so I want to start out with just a little bit of historical information because I think it's really interesting to look at how we've sort of come full circle in our use specifically really of plants as medicines if you look back at the very first pharmacopoeias that were discovered back in 1500 BC this is Ebers papyrus that pharmacopoeia was based on all plant based medicines and when you look at the use of plants for medicines today plants attribute about 25 percent of the drugs that we use and a larger percent 50 percent of the products that we use drug based products that we use come from natural sources so this could be microorganisms animal based plant base but overall just a very large proportion of the drugs that we use coming from natural resources and and that's an important fact because if we look also at you know the richest sources of our natural resources many of these are our rainforests and you know it's quite frightening that it's estimated that about 50,000 species of plants and animals and microorganisms are lost per year due to deforestation in rainforests so it's definitely an area where you see a big pharma and also you see the National Cancer Institute coming in and trying to preserve you know these rainforests and looking at them now as a resource and tool for future drug discovery I'm overall there is a very large population of individuals on the earth who use plants as medicines World Health Organization estimates that at about 80% with majority in developing countries well when we look at how these products are regulated it is quite different than how prescription drugs and non prescription drugs are regulated and you often hear at least I often hear people say things like oh well dietary supplements you know healthcare providers might say dietary supplements well I don't recommend them because they're not regulated well they are regulated they're just not regulated in the same way as prescription and over-the-counter drug products but they are regulated and they are regulated by the FDA but the regulation that's in place which is called the dietary supplement health and education Act which was passed in 1994 unfortunately creates certain certain loopholes that can cause problems when it comes to product content and product safety and product purity so if you think about a drug product drugs true drugs like over-the-counter drugs and prescription drugs are governed under the FDA Center for Drug Evaluation and Research supplement products are regulated under the Center for Food Safety and applied nutrition so they're regulated under the same Center that regulates food products they're not regulated under the center that regulates drug products drug products before they're marketed to you as a consumer have to prove that they're both safe and efficacious there has to be a you know an abundance almost of literature to support that they're safe and efficacious before the FDA says ok you get the stamp of approval and now you can market your drug to the public for dietary supplements it's different because they don't have to prove that their product is safe to the FDA before they market it they do they are responsible however the manufacturer is responsible for assuming the burden of safety so that that's where it's a little bit different in terms of efficacy they also don't have to submit proof of efficacy to the FDA before they market a product they really don't even need to notify the FDA that they're marketing the product other than the fact that after they market it if they're if the product has a structure function claim they need to notify the FDA within 30 days that they've made a structure-function claim but overall if they're marketing a product they don't have to tell the FDA that they're marketing the product and so the burden of efficacy again falls to the manufacturer because the FDA does say that you cannot market something that has claims that are either false or misleading so the claims that they make you know are meant to be truthful they should be truthful but the oversight of that can be somewhat difficult because once it's on the market the FDA can't take it off the market unless they can actually prove that the product is unsafe there are only certain types of claims that dietary supplements can make the ones that are actually FDA approved are health claims and nutrient content claims so to give you an example of what a health claim is it relates to food substance or a dietary ingredient to a health condition or a disease an example here would be a diet low in sodium may decrease the risk of high blood pressure another one might be a diet high in folate can decrease the risk of neural tube defects and these are all claims that the government has said you know basically the manufacturer has submitted enough literature scientific to support so that the FDA says yes there is enough scientific support and we will okay that claim and you can put that on your label some of the more recent ones where related to cancer one that says a diet rich in selenium may decrease the risk of cancer and that was getting batted back and forth because the FDA was saying well you know we don't have conclusive evidence so we're not going to pass that health claim so what they ended up doing was they they ended up saying okay you know we'll give we'll let you put the claim on the label because there is data there but after you state that selenium may be beneficial for reducing certain types of cancer you also have to say a statement that says that the FDA has determined this evidence is limited and not conclusive and so the FDA statement has to directly follow the health claim statement so those are examples of health claims and nutrient content claims these typically appear on food products and usually they are in relation to products that have an established percent daily value so you might find a vitamin that says it's high potency or you might find a food product that says it's low in saturated fat so those types of descriptions there are FDA qualifications for being able to put those on your product there is a certain qualification for how much saturated fat is considered to be low in saturated fat and there's a certain content of multivitamins that you know the content of the multi or the vitamins in the multivitamin that have to be present in order for you to determine that it's high potency so those are FDA approved claims structure-function claims again are not FDA approved but you do have to notify the FDA within 30 days after the product has already been marketed of the claim that you have made and that claim is then looked at by the Federal Trade Commission who governs those and again most importantly that the manufacturer is the one that's responsible for determining that the claim is not false or misleading that there's no proof that actually has to actually be shown before that product reaches the market it's really in the manufacturers hands to substantiate that and this sort of just lists some examples of types of structure function claims that that exist importantly when you look at structure function claims they also have to be accompanied by this FDA disclaimer and I'm sure many of you in watching television or in reading ads and magazines have come across nutraceutical products that either on television it's usually in really really tiny print at the very bottom of the screen but also in ads that can be the same thing it has to be there it doesn't have to be in bold print but it does have to say that it hasn't been evaluated by the FDA and it's not intended to diagnose treat cure or prevent any disease when you think about disease claims and structure-function claims sometimes there's a bit of a gray zone where if you're a consumer it's really hard to tell if a product is making a structure-function claim or a disease claim so I put together a little list here and I thought I would quiz you to see if you could recognize which ones were disease claims in which ones were structure-function claims so this first one improves absent-mindedness and importantly i also want to remind you the definition of structure-function is that the supplement is intended to maintain normal healthy structures and functions of the body that's the definition of what a structure function claim is so improves absent-mindedness what does that sound like does that sound like a structure function claim or disease claim okay so it's mix I heard some people say disease I heard some people say structure function this actually does qualify as a structure function claim the reason why is because absent-mindedness cannot be linked conclusively with a certain disease it's not considered completely characteristic of a disease like Alzheimer's improves memory lost associated with aging this is also structure function and the reason why is because you're maintaining a normal healthy process the process is aging memory loss occurs with aging so that's a normal process and this is something that's intended to supplement that normal process improves senile dementia this one's pretty obvious that's a disease claim reduces cholesterol disease claim maintains normal cholesterol a structure function because you're maintaining a normal normal healthy cholesterol relieves stress and frustration that's pretty ambiguous but it is a structure function claim and leaves crayons and edema associated with menstruation this one you might initial you your first inclination might be to say that this is a disease claim but in actuality the FDA has defined processes of menstruation and menopause as being normal healthy processes so it's actually okay to say this because this is a structure function claim because menstruation is a normal healthy process if you said something like prevents bone fragility in postmenopausal women that would actually be a disease claim because preventing bone fragility implies that this is something that would be useful for osteoporosis so so again it's a real fine line it's not always so easy to tell these are some other requirements of labeling for supplements you have to state the name of the product importantly there are certain products out there specifically plant products that have two names they have the plant name like chasteberry and then they have the Latin genus and species name which is Vitus agnus castus so if you're not someone who's familiar with the Latin name you may go out and be looking at products and you go what is this vitex agnus castus on the back of this what is this and you know unless you know that this was chase berry you might not know what that is so anytime you go out and you're you're looking to buy at least a plant-based diet airy supplement it's a really good idea to also know what the Latin genus and species name is for the product that you're looking for and you can just see I'm not going to read all these to you but importantly name and place of business and manufacture that is important because obviously if there's some sort of problem with the product you want to be able to contact the manufacturer products that are purchased solely over the internet you know may or may not have that on the on the container and when you go to contact the manufacturer the website may be gone so I always advise people to purchase products you know from large chains or large nutraceutical distributors preferably from a place you can actually walk into versus a distant internet site that you may not be able to you know you may not even know where that site is actually set up the word dietary supplement has to be on the package and finally importantly also cautionary statements are not required so even if a manufacturer has had cases let's say of livered toxicity that may be you know I've had two cases of liver toxicity that have been reported to me as possibly being associated with my prop product I don't actually I'm not really required to put that on my label so I don't have to state that if I have a product that I know potentially lowers blood sugar I don't have to state that it could interact with diabetes medications or that it could lower sugar in patients who have diabetes so cautionary statements are also left at the discretion of the manufacturer unless there's some FDA enforcement saying you have to put this cautionary statement on your product there's also something called a supplement facts panel supplement facts panels are very similar to the facts panels you see on food products they list your serving size what's in your serving size the amount in terms of weight a percent daily value this is usually from vitamins and minerals if a percent daily value actually exists and also if the blend is proprietary the ingredients of that proprietary blend so this is an example here of a supplement facts panel this is actually a whole example of a dietary supplement in this case it's jin-sang it states that it's ginseng down here it actually tells you that it's oriental ginseng it's a powdered root so it tells you the part of the plant it says oriental ginseng so this if they were to use the plant name it would be panax ginseng tells you how much is in it any other sort of ingredients or fillers who the company and manufacturers the statement on this is when you need to perform your best take ginseng and then the FDA disclaimer here if this was a proprietary blend and I know that everyone in this audience has seen proprietary blends you know basically what they do is they will give you you know it'll say one capsule contains a thousand milligrams or whatever the total milligrams is in their proprietary blend and then they'll say our product contains maybe it contains echinacea ginseng zinc and you know another may be a vitamin or something so for a proprietary blend the problem that I have as a pharmacist is that I actually don't know how many milligrams of echinacea is in the thousand milligrams I just know that echinacea you have to listen in order of the most prevalent to the least prevalent so echinacea is the most prevalent ingredient in the proprietary blend but I don't know how many milligrams is actually in it because you're only telling me it's a thousand milligrams of this collective group of compounds so when you look at clinical studies for ginseng or echinacea you realize that the pharmacologic effect is based on a certain dose or amount so if you don't have a therapeutic amount of that plant or chemical you know supplement in it you're not going to see that effect from it so so that's the problem that I have with proprietary blends is I feel like there's information that I would like to know that is not present so overall the take-home message here as a consumer is really that when it comes to purity and potency it's the manufacturers responsibility to assure that prior to 1997 there was actually no standards that the FDA had developed for supplement manufacturers to adhere to when it came to how they were going to manufacture their products to to make sure that they were pure and you know had what they had in it in 2007 this new legislation was passed which you can see and for larger companies hasn't really even come into effect yet large companies have to comply by June 2008 smaller companies have up until 2010 or 2009 depending on their size to comply but overall the legislation that was passed they called it the Good Manufacturing Practices supplement standards and so this was their attempt at stating that we expect you as a supplement manufacturer to have certain standards in place that you're going to use to assure that what it says on the label is actually what's in the bottle so that's new I mean it's ELISA step in the right direction how they're going to enforce this I don't know that's going to be difficult but at least there you know is a statement saying that this is what we expect of you and if you know obviously if they find that a company is not meeting that expectation then they can you know issue a product recall to that manufacturer for that product I know this is a little bit blurry but I just kind of wanted to give you an example of problems with product content and this was a published in the Los Angeles Times and they basically took an independent testing lab and went out and tested ten different manufacturers brands of st. John's wort and they tested them based on their labeled concentration of a chemical compound called hypericin which at the time when this was done was considered the number one constituent that you had to have in a st. John's wort product for efficacy for depression now we know that that's actually a different compound but um but the point is is that all of these products on their label says our product contains this amount of this chemical compound hypericin and when the independent testing lab went and tested the product and they tested three different products from each manufacturer so this is a cumulative mean score here but over all three of these manufacturers here here and here you know had about 50% or less of the labeled amount and interestingly two of them had even more than what was anticipated but the point is is that there's a lot of variability here and you know whether it's having too little or having too much you really just want it to have just that amount you would really like for this to be a hundred percent a hundred percent 100% 100% in the ideal world and there are tools out there to help you find those manufacturers who you know where product testing has been done and where they have indeed met their labelled claim sorry labeled claims related to content and I'll get to that towards the end of my presentation but this is just an illustration for you of problems illustrating problems with product content that has existed over time by leaving the content and the manufacturing processes at the discretion of the manufacturer so the term standardization you may have heard this term standard you know the product is standardized I sell ginko and my product is standardized to contain 24% flavo and glycosides so what does that mean what is standardization and if a product isn't standardized is that bad standardization really truthfully I've only seen it in relation to herbal products which makes sense because when you're standardizing something you're standardizing it to a chemical compound or a group of chemical compounds that are thought to contribute to the pharmacology or efficacy of the product we don't really know for most plants what the chemical compounds are that make them efficacious because they haven't been that well researched for the most commonly used plants we do have information related to that and so you will see standardized markers on products like ginkgo and garlic you may or may not see them on a product like echinacea because it hasn't been conclusively shown that any particular grouping of chemicals you know at this concentration leads to efficacy in terms of you know treating common cold so standardization will only exist if the chemicals have been researched and if they've been found to be meaningful to the efficacy of the product and I've listed some examples down below here now importantly if I went out and bought a melatonin product or a glucosamine product or a coenzyme q10 product those are not going to have a standardization to a certain chemical compound because it is only one chemical it should all be 100% melatonin are 100% glucosamine sulfate or 100% coenzyme q-10 it's different from a plant which has numerous chemical compounds in it and you know trying to find a standardization then to the chemical group in that plant that is meaningful to the efficacy and lastly again just pointing out again that the efficacy and safety is really also for the most part in the hands of the manufacturer because the claims cannot be false or misleading but they don't have to submit proof that it actually does what it's stated to do and the safety issue is left to the hands of the manufacturer as well there is one exception to this and it is if a manufacturer is marketing a product that contains what's called a new dietary ingredient and so a new dietary ingredient is an ingredient that has never before been marketed prior to the passage of the dietary supplement health and education Act so most products have been most plants and supplement compounds have already most of them have already reached the market but if it was a new plant product that had never been marketed before they would have to submit evidence of some safety to the FDA before the FDA would allow them to market that the caveat here is that if I'm the manufacturer how do I know if my product is a new dietary ingredient is there some master list of products and ingredients that were marketed prior to October of 1994 No no they don't actually yeah no there is no there's no master compendium of products ingredients marketed prior to 1994 so it's really left up to the discretion of the of the supplement manufacturer again whether or not their product qualifies as having a new dietary ingredient new legislation that also is really important to us as consumers is just the issue of safety and I know that probably almost all of you did hear about the concerns over you know when the whole thing with ephedra when a federal products were pulled from the market and it had to do with the fact that they were causing stroke or heart problems in some patients or elevations and blood pressure and it wasn't until the FDA received a number of these case reports and enough of them that they go oh my gosh like this is the same product and it's the same chemical ephedra that's involved with a number of these incidences we better look into this and when they did they said you know this is this is a hazard this could really hurt people and that's when they pulled it from the market so the FDA can only pull something from the market if they can prove that it's unsafe that's the only way that they can pull it they have to prove it's unsafe so the burden of proof is on them in this case that's how a federal was removed from the market now the manufacturer prior to the passage of this the end of 2007 had no obligation to report adverse events that were reported to them even if they were serious even if there were deaths they did not have to tell the FDA that these were taking place so as it turned out and I think the company was metabolise if I'm not mistaken that that particular product had when the FDA actually contacted them had quite a few events that they had been keeping record of but had just never forwarded those adverse event reports to the FDA so now the FDA came up with new legislation again designed to protect us a little bit more which says that as a manufacturer if you have an adverse event that falls under the category of serious you have to report it to the FDA and by definition by definition of serious it's got to pull it out here serious is defined as death life-threatening experience hospital admission disability birth defect or medical or surgical intervention required so there's a very strict definition that applies to that if I get other case reports of you know a lot of people just having you know migraine headaches with my product I don't actually have to report those unless it requires them to go see a doctor for it in which case it would you know if it was a hospital ated to a hospital admission I would have to report it and they also have to maintain now their records for six years so there's a requirement now for maintenance of adverse effect reporting all right so I'm going to move forward and just talk a little bit you know these are sort of obvious things why are patients using these products well certainly you know in California we're we're a very healthy state for the most part I think there's other states that actually rank above us in terms of health and preventive medicine but we're still pretty healthy you know most mostly worried we have good weather we get out there we try to exercise we try to do things that you know eat right take vitamins or minerals you know if we know that our diet isn't the best and so overall we're trying to maintain kind of a well-balanced healthy lifestyle and so you know being an active participant in that if you felt that a supplement would would contribute to that is one of the reasons people take these products there also is you know various folks who just don't you know they've lost faith in the Western medicine system they really prefer using more alternative practices or alternative medicine or they don't like the attitude of Western practitioners towards alternative medicine and there's just a list here a lot of different natural implies safe and healthy is also another one that it that is common you know the example I always use is you know poison oak is natural but you don't want to eat it so not everything that's natural is safe and healthy this is actually a survey where it was published in the archives of internal medicine and it looked at what were the what were the attitudes or thoughts of people who use dietary supplements as compared to people who did not use dietary supplements and the primary rationale for use was to improve overall health and well-being a subset about 36 percent thought it would help them to live longer users were more likely to believe that the product was beneficial for a broad array of medical conditions and most of them would consider using a supplement if they were terminally ill users would continue to use these products 71% would even if the FDA said it wasn't effective for that indication that they would continue to use it irregardless of the FDA stating that it doesn't work for that about 50 percent felt that their health care provider was prejudiced against they're using dietary supplements and 44 percent said they felt their doctor knew little to nothing about dietary supplements so this is one this is a problem obviously because you know really important as a pharmacist as a nurse as a health care provider to know and be able to screen for interactions with not only other medications but also with conditions that you may have so it is important to disclose that information the largest survey we have unfortunately is about 6 years old it's the 2002 National Health Interview Survey they surveyed about 30,000 Americans and they asked them specifically regarding their use of non vitamin non mineral supplements and the reason that that's important is because when you look overall at the class of supplements the number one selling products are vitamins and minerals and then it goes to the next product that's not a vitamin or mineral I believe is glucosamine that has the highest sales based on I think 2006 statistics but here you can see that about one in five reported using a non vitamin non mineral supplement and that users were more likely to be women in their peri and postmenopausal years college-educated living on the west coast that almost defines me just a little shy of forty five but but it you know interesting statistics a majority of patients are people who took this survey I shouldn't say patients a majority of adults didn't tell their health care provider and those folks also were taking prescription drugs at the same time so that's a concerning statistic and this is just a listing here of the types of conditions that were most commonly being treated with the most prevalent being cold and flu type symptoms this is a summary of the top-selling products from this list today we're going to talk about echinacea ginseng ginkgo glucosamine st. John's wort and fish oil and now I'm just gonna switch back a little bit and talk about other hazards that can occur with dietary supplement products and one of them has to do with unintentional in many cases plant substitution this can happen let's say if you're someone who goes out I'm sure you've seen in the news case reports of people who went out to harvest mushrooms and they accidentally didn't pick the right ones and they got the Amanita mushrooms and ended up with liver toxicity because the whole family had mushroom soup for dinner or something like that so that's an example of mistaken identity so it can happen when you're out there harvesting your own herbs to brew as a tea there's cases of you know digitalis poisoning that's a cardiac type medication that's actually used and people who harvested foxglove instead of the herb that they thought they were getting and there's also case reports by manufacturers who've accidentally you know put plants into their product that they thought was echinacea but it turned out to be a totally different plant that looked like echinacea so it's important to know what what's in your product adulteration or contamination can occur either intentionally or unintentionally sometimes in the manufacturing process depending on how the product is manufactured some of the heavy metals used you know to either grind up the herb or grind up the supplement can end up in the product itself so here's an example of this was a survey done published in the New England Journal of Medicine where they looked at 260 Asian patent medications from California retail herbal stores and found that 32% D had undeclared pharmaceuticals or heavy metals in them so that was concerning this gives you an example this is a little bit more recent this release just came out I think this was like in the past year there's always products that are being recalled constantly you can go to the FDA's website WWF da govt look under the link for dietary supplements and you can actually find products you know that have been recalled products that have contained contaminants products that are being given warnings or citations for making claims that are either disease claims or just misleading or false claims so this is a product this came out of a manufacturing plant in Florida and it said and it was for male enhancement see a lot of those on the television now and it said the legendary super pill is no longer a myth infinitely more effective than other sexual enhancement products and it turned out that this product contained compounds that were viagra like so basically sort of prescription drug like compounds that were derivatives of viagra so this product was then asked the FDA said you need to remove this product from the market another product that the FDA asked to be removed from the market this manufacturer was in California and they were marketing a product called Zen Chi for persons who had high blood sugar and this product contained prescription glyburide Fenne Foreman which are prescription drugs that are used to treat diabetes this was a mail-order product it can only be purchased by telephone or over the Internet but on the website when it was up it said the product had no side effects no toxic FDA approved and 97% effective so you know big warnings here FDA approved you know not FDA approved if you're saying that it lowers sugar because that's a disease claim no side effects if you're taking a supplement for an efficacious purpose it's makes sense pharmacologically that if you take too much of it it can also have a side effect so and then 97% effective that would potentially make it more effective than prescription drugs that are out on the market so if it sounds too good to be true always beware the other thing that I always that I was find interesting about this it's not it's not really even grammatically correct so I don't know how much faith I would put in that statement and finally direct toxicities direct toxicities again happened based on the pharmacology of the product and it's just an extension going from here's what it does for efficacy and if we go over that line now we're into the toxicity area and you may or may not have seen there was a case actually very very recently of this gentleman I don't know where he lived but he would they called him the Smurf man and it was it was I swear it was like three months ago on Good Morning America he was in there with Matt Lauer and getting interviewed and Nancy Snyderman came in and gave gave her information on colloidal silver but overall unfortunately certain side effects are not reversible with many drugs and many supplements they are you're having stomach upset you stopped taking the product the stomach upset goes away you had an elevation in your liver enzymes you stopped taking the product the side effects go away in this case unfortunately with colloidal silver if you use too much of it it can contribute to this discoloration of your skin which makes your skin appear kind of bluish gray and that's permanent that doesn't go away even when you stop using the product other cases direct toxicity there's some rare cases that have been reported for black cohosh and green tea extract this green tea extract is different from green tea that you drink as a tea so don't freak out because I drink green tea too and really enjoy it and it has a lot of health benefits but this green tea extract is a very defined concentrated alcoholic extract of green tea mainly in products that were being used for weight loss and it was about 14 cases that were reported whereas for the black cohosh it was about 40 cases that were reported but given how widely used black cohosh is you know it's very difficult if you don't do product analysis it's very difficult to contribute an effect to to the actual supplement and it's very hard to know if it's even causing that because in randomized control trials it hasn't shown to affect liver enzymes over the course of three months of use the last hazards that I'm gonna talk about our hazards related to interactions and how do we know if something interacts well in some cases we do because we have literature to support that the number one herb then actually the number one interaction offender Bar None with supplements is Saint John's wort and it affects a group of enzymes in the liver that metabolize a lot of different medications it also affects a drug transport protein that affects drug concentrations of digoxin so overall this particular herb can reduce the efficacy of other medications not all medications some medications can read there's cases of reduced efficacy of birth control pills resulting in unwanted pregnancy case reports of reducing serum levels of cyclosporine resulting in a graft rejection and someone who had had a transplant lower levels of an antiretroviral called indinavir and digoxin and there's there's a list it goes it goes on from here but there's a lot of different drugs that it can affect and the message that I tend to give when it comes to st. John's wort because it is a you know really good herb when it comes to mild to moderate depression the message that I give is don't take it you know first of all don't take it unless you've had your depression diagnosed by a physician first of all and you're in agreement as to the severity of it but also but also just don't don't take it if you're taking medications that are really essential to your health so if I'm someone who's taking drugs for cancer or HIV or those types of conditions where you know these drugs are really essential to making sure that I stay healthy I probably wouldn't want to take st. John's wort because of the risk of drug interactions there are cases of herbs that have herbs and supplements that have additive or opposing effects so that all that means is that the pharmacology of the product is similar to let's say a prescription drug that you're taking so if I take st. John's wort and I take paxil for my depression there are case reports of reactions of when the levels of serotonin in the body go too high there's case reports of you know one case report of someone who took kava kava with xanax and had sort of a left lethargic semi-comatose kind of reaction to that so when you have herbs or supplements that have pharmacology that's similar to prescription drug pharmacology they can be additive and they can also be opposing so theoretically there's no case reports of this yet but theoretically it's advised that if you're someone who takes echinacea and you have an autoimmune disorder let's say you have lupus or you have rheumatoid arthritis not to take echinacea in combination because it could affect your disease or if I'm someone who's taking immune suppressants taking something that's an immune enhancer may not be the wisest decision again when we get to the end of this talk I'm going to give you the resources drug information resources to help you research these types of questions so when they come up you can have something to to go to because there's so many different questions that can arise and finally just Hazards introduced by the consumer these are these are either individuals who choose to use alternative dietary supplement treatments in of standard medical treatments that may have more more proof of efficacy for a condition or at least be someone who either intentionally or accidentally over supplements one of the most common things that I see I work in a anticoagulation coumadin clinic a half day a week and you know when I get patients who come in with their prescription bottles or with their you know supplement bottles and there's like five different supplement bottles and they all have vitamin A you know a hundred percent of the daily value but collectively now they've got five hundred percent of the daily value but they don't think about that because you know they all have different names or they're using them for different reasons so you need to actually look at what's in the products that you're taking and go if this has got a hundred percent and this has got a hundred percent and this has got a hundred percent and that's all the same thing am i over supplementing and is there a problem with that you know is it something where the body will just naturally eliminate that from your body if you are over supplementing or is it something where you could have possible side effects in terms of the the products today we're gonna talk about ginkgo biloba first this is one of the oldest living trees in the world it's highly resistant to pollution so it's found in many different cities historically the ginkgo biloba fossils actually date back about 200 million years that's how old it is so it truly is one of the oldest living trees on the face of the planet and the supplement form is prepared from the leaves of the plant there are some standardized markers to which this is standardized and I've listed them here for you so when you go and if you're purchasing a product like this you know what to look for on the label if I was going out and buying this product for myself I would be looking for these these things that I've listed here I would be looking for the content of Flavin glycosides as 24% terpene lactones as 6% and I would be looking for an extract ratio that falls somewhere between 50 to one so that means that 50 parts of the leaf are used to prepare one part of the extract so those are just things that you should look for on the package labeling these are some of the things that it's been studied for and by far the most commonly studied indication is for cognitive insufficiency or dementia the other leader here in terms of clinical trial support is for peripheral arterial occlusive disease or poor circulation or blood flow to the legs and actually improving pain free walking distance and I'm not going to show you those trials today for pain free walking distance but we will talk about the trials for dementia everything that I've listed under the other category here are things that have you know there may be one trial there may be two trials but overall it's really inconclusive and for the stuff it's inconclusive in general I don't recommend going out and using it for these things you know I guess if it's not going to hurt you you could try it but but overall just letting you know that there's not a lot of clinical support at this time for everything listed under the other category when you look at what is involved with Alzheimer's disease there are certain things taking place in the pathophysiology so you have higher levels of oxidation you have low levels of a neurotransmitter called acetylcholine you have a presence of amyloid beta fibrils which form plaques in the brain that cause neuron degeneration and when you look at ginkgos mechanism you can see how it could be beneficial for this you can see that it has blood thinning effects antiplatelet effects it's a it's an antioxidant it helps to dilate blood vessels and at least in the test tube or in vitro it's been shown to enhance levels of or decrease amyloid beta fibril aggregation and in animal models to increase levels of acetylcholine in terms of clinical support I tend to look at systematic reviews and meta-analysis because this is a real easy way to pull together the bulk of the information that's been published and usually if it's something like what's called a Cochrane review the Cochrane review does very evidence-based reviews they tend to look at only randomized trials or you know very specific criteria for what they include so in this case was a review looking at ginkgo for dementia or cognitive impairment and they included 33 randomized double-blind placebo-controlled trials the longest of which was a year in length and what they observed was overall they found significant small but significant improvements in both cognition activities of daily living and even with some doses for the clinicians assessment of global improvement overall however when you look at how strong of an effect we're seeing and you compare it to other Cochrane reviews of a drug class called cholinesterase inhibitors so these are drugs like aricept which is done as a pill exelon which is Reva stig mean and razza dine which Glan to mean these are prescription drugs that are all pretty much the leaders in treating Alzheimer's disease they're sort of the first line treatment options and when you when you compare the level of improvement in cognition seen with ginkgo as compared to these other drug compounds that the level of improvement is still smaller so just putting in a perspective in terms of there is an effect but it's certainly not as big as what you're gonna see with a prescription drug so the guided in GE M studies this is sort of the direction what's on the horizon you want to know what you're gonna hear about in 2010 you're gonna hear about the results of these trials and these are trials looking at can using ginkgo biloba prevent or delay the onset of Alzheimer's disease in individuals who are coming to the doctor and presenting for the first time with some you know complaints of cognitive function problems and very large sample size you know up to 5,000 patients over the age of 70 that they're using a standardized ginkgo biloba extract that's been used in other clinical trials so that's good they're using a dose that's been substantiated based on the Cochrane review which is good and they have good study design randomized double-blind placebo-controlled study designs so I'll be really interested to see what these results show see in healthy persons so the bad news is that it really doesn't look like it does anything for people who are healthy and who don't have any sort of you know any sort of it's a word I'm looking for any sort of I want to say predilection but I don't even know if that's quite the right I don't even know if that is a word predication maybe that's what Alzheimer's disease or cognitive impairment so these are these were all done in healthy adults there were some studies and healthy seniors that showed improvement in maybe one or two memory tests but they were looking at like ten memory tests and they go oh well here's ten memory tests but they did show an improvement in this one so there must be an effect so that's sort of selectively picking out results in trying to highlight the benefit in this case there were things related to long-term memory storage and that test was involving you know having them remember a series of names and and also retrieval and delayed recognition and recall which basically means I would say to use something like bread pencil rabbit fish and then ten minutes later I'd say well what were the four words that I said earlier so that's the kind of delayed recognition recall we're talking about in healthy young adults same same thing no consistent effect really no consistent effect with either of these groups so I do not recommend it for healthy individuals who don't have some sort of cognitive impairment in terms of side effects it's a relatively safe herb to use it does not have a whole lot of side effects because it can have antiplatelet effects you don't want to use it in combination with things like warfarin which is a blood thinner or with other antiplatelet drugs because it can there have been a few cases of bleeding side effects you also want to be careful anytime you have an herb or a supplement that has antiplatelet effects you want to discontinue using it about a week before if you have a surgery that's coming up I also said avoid using in patients with a history of seizure disorder this really has to do with some case reports of seizures that were reported but the reality is is that it's really the ginkgo nut and not the ginkgo leaf that has a neurotoxin in it that's been linked to seizures and you might go oh my gosh gingko nuts linked to seizures the ginkgo you know the neurotoxin and gingko nuts well it's it's really uncooked gingko nuts because you know cooked gingko nuts are really kind of a delicacy in China and they're eaten all the time quite safely so it's uncooked gingko nuts do you have a neurotoxin that has caused case reports of seizures and it's thought that maybe in these reports involving ginkgo leaf preparation it might even have been a contaminant that was present and there is one case of a sedative reaction and someone who combined ginkgo with a sedative medication called trazadone but pharmacologically ginkgo doesn't have sedative effects so this one I sort of I don't put a lot of weight into it just because pharmacologically it doesn't add up and then no product analysis was done so it's real hard to say for sure if it was the ginkgo that was the cause this is a summary slide I put it in here mainly for you just to have information regarding how much you should take if there's an equivalent to the products the European products that have been studied in clinical trials and in general how much literature do we have in terms of length of effect and the longest trial that was done with ginkgo was a year so we don't know how efficacious it would be beyond that the next product I'm going to talk about is st. John's wort this is something where the above-ground parts of the plant are used for mild to moderate depression again anything listed under other is something that should not be seriously entertained for clinical uses because it has not doesn't have enough clinical support at this time products do carry a standardization and in this case they might say they're standardized to 0.3% high pierson or 5% hyperforin it's really the hyper furan though that seems to be the most important chemical compound because hyperforin by itself in addition to the extract in its entire entirety increases serum levels of norepinephrine dopamine and serotonin 5-ht means serotonin and overall when you look at the Cochrane information or meta-analysis what we see is that this was a meta-analysis done in 2005 that had 26 trials which compared Saint John's wort to placebo and showed that it was more efficacious than placebo 14 trials comparing Saint John's wort to either a tricyclic antidepressant which is sort of the older group that's what I was taught when I was in pharmacy school and then you had all the newer ones which are the called the SSRIs which are your pack souls and your prozac's and citalopram and those kinds of drugs seven comparisons to st. John's wort with SSRIs seven comparisons with tricyclics all showing equivalent efficacy so some pretty good support here for st. John's wort from mild to moderate depression caveat is most most of the comparative trials did not have a placebo arm so really the gold standard what you want to see is you want to see the herb you want to see the drug and you want to see a placebo arm so we know how much of this is a placebo response only three of three trials actually to date that have been published have had that so that's one caveat and the other caveat is that the longest clinical trial to date was only 12 weeks so we don't have any information in terms of long-term efficacy data side effect wise again we mentioned the drug interactions that occur with this particular herb not to use it for pharmacologic reasons in combination with antidepressants at least not without the supervision of your doctor because there are also case reports of something called serotonin syndrome which was having a higher than a high level of serotonin in the bloodstream causing adverse effects there have been some case reports of sort of a mood enhancement or mania and agitation hypomania and finally photosensitivity which typically occurs at doses that are two to four times the recommended dose and interestingly were initially observed in animals that were grazing on st. John's wort and they noticed that these cows and sheeps were getting sunburned so for st. John's wort it is a good idea to wear you know sun protection eye protection when you're using it and again here's a summary slide just giving you information about dosing standardization and also us equivalence of European products and now I'm going to flip over to ginseng this is actually a picture of American ginseng there's a American ginseng is also called panic skinca phileas it's actually the root of the plant that we're most interested in in this case not the leaves and you can see that there's a bunch of different types of ginseng that's marketed the ones that you're most likely to come in contact with as you go into a pharmacy or into a you know a nutraceutical distributor like GNC or something like that or the the top two Chinese are Korean ginseng and American ginseng and the others aren't really as prevalent also the top two are the ones that have been most commonly studied so it is the root of the plant that is used the actual word for panax ginseng comes from the Greek word panacea which is for cure-all and the Chinese word Jen Shen I hope I don't know if I'm pronouncing that right which means likeness of man so what this really abstracts to is a cure-all for man and that's kind of how it's used it's an adaptogen or it's touted as an adaptogen now some problems with the ginseng industry have cropped up over time one of the problems is that it really takes about four to five years for a good ginseng root to mature to the point where it has enough Jennsen asides in it but also that it's reached a reproductive capacity so that it can make other ginseng plants before it's pulled that's important because if you don't wait long enough you're gonna have you know you're not going to have enough to incent asides in your product the other problem is that because it takes so long to mature there have been some problems with over harvesting and in 2003 the world health organization listed panax ginseng as an endangered species due to over harvesting so in some cultures the wild variety is preferred to something that's cultivated it's thought to be more potent or more efficacious and so because of that there is this concern about wild ginseng an endangerment of wild ginseng also it has led to some problems with cost and also content with ginseng products there was this one analysis done a while ago but it was done by the College Philadelphia College of Pharmacy and science and they looked at 54 ginseng products and 25% had no ginseng 60% had sub-therapeutic amounts so again this goes to the problems that we've seen in the past with content being assured of the content based on what's on the label hopefully these new standards that are coming forth are gonna help are encouraged at least manufacturers to meet their labeling claims but again I'm going to give you a resource that's going to help you to know where to look for manufacturers that do meet those labeling content claims in terms of standardization its vengeance enta sites that the product is standardized to four to seven percent and pharmacologically there are a lot of different things that have been observed but there are 32 different incentive sides you know in a root product so a lot of these pharmacologic tests have involved one or more of these gen set asides being pulled out and analyzed and then the effect has been reported so collectively you know it's very difficult to say collectively that these are all the effects that you would see if you used ginseng in terms of how it's used clinically the ones where I put double stars so you can see here cold preventive anti-cancer lowering postprandial which means after eating sugar iNDOT and persons with diabetes those are really the three that have the best clinical support the other three you know the adaptogenic claims that improvement in mood and cognition the enhancement of physical performance really have not met with success I would say in clinical trials it just hasn't been those claims cannot be upheld by the literature that's been published in those areas so the direction that we're looking in now is you know ginseng as an immune enhancer almost like echinacea its efficacy in cancer and its efficacy in terms of you know could it be something that would be beneficial for persons with diabetes and the clinical trials that I'm going to show you really relate to immune enhancement and this was a study here that was a study done in 227 patients it was a randomized double-blind placebo-controlled trial and they used a standardized ginseng panax ginseng product called jinsana which is available in almost any grocery store so jinsana or placebo in combination with a flu shot and what they found was that at 12 weeks there were far fewer cases of flu that were reported in the people who had been taking jinsana with their flu shot as opposed to people who were taking placebo and jinsana well this study was published in 1996 and little had been published since but recently there's been this interest now in ginkgo for its immune enhancing properties and you can kind of see this growth in publications 2004 2005 2006 where we have 3 3 new clinical trials that also support this role 2 of these trials were again this in this case they were using a different species of ginseng the American ginseng not the panax ginseng that I reported in the last trial so these were using an American ginseng extract for four months in combination with the flu shot as compared to placebo and the flu shot and in seniors senior citizens two of these trials reported significant reductions in cold frequency and one of the two also found a reduction in cold duration in healthy adults it didn't have as robust in effect and this this other study here was not done in conjunction with flu shots so basically it was just giving American ginseng or placebo for four months and looking at the incidence of colds in people who tended to have frequent you know frequent colds and they didn't find any difference in the number of people who developed one cold over the course of four months but they did find a significant reduction in those who developed two or more colds at four months that there were fewer colds lesser severity and people who developed two or more colds over four months in the ginseng group so overall some pretty good preliminary evidence here saying that ginseng might have a nice little anti cold type effect side effects from ginseng we know that ginseng has a chemical group in the plant called methylxanthines methylxanthines are also structurally related to caffeine and this could be wide there are some case reports of agitation and excitation sort of a stimulatory type response that's been observed with ginseng there's also case reports of people who have had prior bipolar and schizophrenic schizophrenia who've taken ginseng and then had problems with that excitability manic type behavior there are some case reports of hormonal type side effects break through vaginal bleeding breast tenderness breast pain and finally the effects that I mentioned on blood sugar so to be careful if you're someone who's using this and have a history of diabetes that it could lower your sugars in terms of drug drug interactions it also has antiplatelet effects similar to ginkgo so we don't want to use it in combination with coumadin or other blood thinners and then because it may have an immune enhancing effect kind of like echinacea now we have to consider the same theoretical contraindications which would be don't use it if you have an autoimmune disorder or if you're taking immune suppressants and overall this is the dosing that's been used in clinical trials that Jensen is a very popular product of the Chinese varietal dosing is 200 to 4 100 milligrams a day of that or the crude root which is 2 grams a day echinacea is the next product I'm going to talk about there is a variety of different plant species out there the one that you should be most familiar with is the echinacea purpurea the above-ground parts because this is the one that's been shown to have evidence of efficacy and cold treatment trials overall in terms of cold treatment trials this was a meta-analysis that was done they basically included only trials that used echinacea as a single ingredient and only used it for natural development of colds not for trials that inoculated people with a virus to make the cold happen and they found a total of 16 trials and overall for prevention they didn't find a benefit three of the trials didn't show a benefit for prevention but of the 16 treatment trials a majority showed a benefit and those that did show a benefit most commonly involved the above-ground parts of echinacea purpurea in this fresh-pressed juice formulation so that was the most efficacious product so overall what they concluded is that there's some evidence of efficacy for the above-ground parts of echinacea purpurea in the early treatment of colds and for prevention that's not you know it's not supported right now by the literature and species other than echinacea purpurea is also not supported at this time and use in children is not supported at this time side-effect wise the worst side effect is bad taste if you can tolerate the taste and the frequency of the dosing you're a ok there is a slightly higher incidence of rash in children so that is something where you'd want to be careful and this I've just included again as a dosing slide so you know how it's dosed and the product that was used and contraindications again for people who have a history of immune disorders the question was how did it work what did it actually do and it did both it actually did symptoms and it also decreased the duration the cold duration and if this is something that you are interested in I want to point out that there is another meta-analysis that I didn't include here it was published in The Lancet in July of 2007 which reported a 58% reduction of developing a cold and a reduction in duration of 1.25 days using echinacea products but they included all different products they included inoculation trials as well as natural cold development trials um glucosamine is an amino sugar it's naturally found in our cartilage cells it's something that's used as a building block for something called proteoglycans which are present in our cells it comes as a variety of formulations three different salt formulations glucosamine sulfate is the one that's been studied the most and really has sort of the evidence to support it these products typically are made from extractions of chitin so chitin is something that comes from shellfish you don't have to be worried if you have a seafood allergy because it's actually the meat of the shellfish that causes the allergic reaction not the exoskeleton or chitin the cartilage you know it protects our bones it provides the cushioning it's made up of these different chemical groups cartilage cells protein water proteoglycans and it's really the proteoglycans where glucosamine is used as a building block osteoarthritis you basically have a breakdown of the cartilage taking place trauma to the bone inflammation and pain that occurs because of that in terms of how glucosamine works it does have antioxidant effects anti-inflammatory effects it does increase the production of proteoglycans synthesis and decreases the activity of enzymes that would otherwise damage structural proteins it's also been shown that the sulfur groups specific to glucosamine sulfate may be important for this bone mineralization process which may be why glucosamine sulfate is a preferred formulation notice however that all of these are in vitro which means these are occurred in the test tube we can't substantiate these effects in humans in terms of efficacy the Cochrane review says summative ly that it works if you're using glucosamine sulfate for improving pain and improving function comparisons to nonsteroidals which are things like ibuprofen there was two trials that showed that glucosamine was superior in pain relief for than the nonsteroidals and two that showed that it was equivalent in efficacy and there was also a couple of trials that were three years in length that showed a slowing of progression of osteoarthritis there's a publication that came out recently as a follow-up to this trial where they not only looked at three years but they extended it out for people who wish to continue up to seven years and showed a decrease in hip hip replacement as well and in the group that was using the glucosamine so overall this looks pretty good some caveats are that you know there's there's a few caveats that go along with this the product that was most commonly studied was a product not available in the United States of glucosamine sulfate and what about 65% of these trials involve that one brand and if you actually took that brand out of the out of the out of the you know analysis it didn't have an effect on pain or functional scores so there was a question of well you know is it something related to this particular product or you know not we're not real sure the largest trial to date was this gait trial the interesting thing was that it had five different arms so it had a glucosamine arm a chondroitin arm a combination glucosamine chondroitin arm a prescription drug arm for celebrex and a placebo arm and it was for knee osteoarthritis and they were looking at six months who had achieved a 20% reduction in knee pain and in this study it was only the celebrex arm that showed a significant improvement as compared to placebo but this interesting thing is you can see that the response rate in the placebo group is quite large much larger than observed in most trials of knee osteoarthritis with it usually it's around 30% so this is very large and so you know even the celebrex had a hard time being superior to a 60% let's see of a response rate they did find when they looked at patients who had moderate to severe pain specifically that the combination was actually statistically significantly superior to placebo so overall glucosamine certainly in my opinion worth a trial if you've got osteoarthritis if I were to recommend it I would recommend the glucosamine sulfate product I say go ahead and you know try it as a three-month trial see if you notice a difference if you're not noticing a benefit stop using it if you are noticing a benefit great you know continue using it the dosing is listed here for you it's typically given as a once daily dose 1500 milligrams and initially where there was some concern that because it has a sugar as part of its structure that it might be bad for diabetics those that's been pretty much been dispelled it's actually been studied in diabetics and not shown to have an effect significantly in glucose levels the last herb I'm going to talk about is fish oil and by far I also label this label this particular supplement as the jack-of-all-trades because it has so many areas where I can't I swear to you I could like run on for a day about the benefits of fish you know eating more fish and fish oil products because they've shown benefits in so many different areas overall in the United States we don't consume enough you can see here the ratio of omega-6 now a mega 6 fatty acids these are all essential fatty acids so the body doesn't make these we have to get these from an outside source and omega-6 fatty acids we can tend to consume more of those than omega 3 fatty acids which are like the fish products you can see the ratio of Arkan sumption compared to you know Greenland Eskimos that's the mainstay of their diet is fish so they have a one to one ratio but we've also observed in epidemiologic trials that there's a higher risk of cardiovascular disease a higher risk of depressive disorders a higher risk of inflammatory disorders when you have this higher ratio of omega-6 to omega-3 dietary intake or in populations that consume more fish they have a decreased level of these types of disorders in terms of the sources one of the questions I'm often asked is what's the best source the best source is dietary fish that really is the best source if you can eat two to three servings of fish a week that's fantastic you know I'm not a big user of pills I don't often recommend pills if you're a woman who's pregnant and you want to use it you know the pill formulation limits the the mercury exposure there's negligible amounts of mercury and omega-3 fatty acid fish oil supplements so so that's a healthy way to go for that the reason why we're using them is because we want to enhance our levels of these two compounds DHA and EPA overall there's other sources for omega-3 fatty acids you may have heard of flaxseed or flaxseed oil very popular it contains a precursor called alpha linoleic acid this is a precursor which eventually goes on to form EPA the problem is is that it's not real efficient in doing that less than five to ten percent of ala ends up getting converted into EPA and two to five percent is converted into DHA so you have to consume a lot more the other thing that's interesting is that there are epidemiologic trials showing that supplementation actually not supplementation but rather a higher intake a higher level of alpha linoleic acid has been associated with and it's not it's not for sure these are epidemiologic trials so it's not like this equals that it's there's some literature out there which suggests that there may be an association that's what I'm trying to get at between higher levels of alpha linoleic acid and prostate cancer and also higher levels of alpha and linoleic acid and macular degeneration so the recommendation right now is to not use a la oils in men who have a history for prostate disease but rather to recommend fish and fish oil supplements which have both been shown to cause reductions in macular degeneration and in prostate cancer so the fish and the fish oil is the way you you want to go at least for for those two conditions overall the benefits are very broad so we know that it reduces triglycerides there's actually an FDA approved fish oil product called ohmic or that's been approved for reducing very high triglyceride levels it's cardioprotective it reduces the incidence of heart attack even if you've never had a first heart attack if you have had a first heart attack it decreases the incidence of having a second heart attack so the American Heart Association has also put their stamp of approval on recommending that people increase their intake of fish and fish products depression it has some benefits in clinical trials as an add-on therapy for depression there is about 17 trials looking at it as a treatment for rheumatoid arthritis which have shown improvements in pain relief in pregnancy it's been shown to have benefits in terms of increasing the length of gestation increasing birth weight in babies having better visual acuity and children and also most recently and this is a study that just came out in Lance at 2007 that when they followed the this is something that came out of the UK but when they followed the children of women who had consumed fish products versus women who didn't consume any that there was better communication skills better fine motor skills better pro-social behavior in those children of those women who were using fish products or fish in general in their diet side effect wise it doesn't have a whole lot of side effects may cause some GI disturbance it does have antiplatelet effects so this is another product that we want to be careful if you're someone who uses coumadin or blood thinners also the dosing depends on what you're trying to - you know remedy if you're taking it for triglyceride reduction the dosing is much higher than if you're trying to use it to prevent you know heart disease because you're at a higher risk for heart disease so the dosing here is very specific to different different areas and you should just take a look at that if you're someone who wishes to use fish or fish oil products I do want to say that just to put it in perspective if you were to eat a 3 to 4 ounce serving of herring or salmon the amount of EPA and DHA that you would get is about 1.6 grams in that serving and that if you're gonna eat something like tuna or cod or catfish in a 3 to 4 ounce serving would only have 200 to 300 milligrams of those EPA and DHA question great question is this farmed or wild it's a it's a very good question the amounts the amounts are different depending on if it's farmed or wild so you will have different amounts of omega-3 fatty acids usually it's higher in wild than it is in farmed higher amounts of those omega-3 fatty acids but in order you know in general would I recommend there's there's certain there are certain websites that will kind of lay it out for you these are the fishes these the amounts of EPA and DHA that they have per 3 to 4 ounce serving and I can share that with you after after the talk if you're interested in that ok so let's move on to the last pieces which shouldn't take more than about five minutes and they have to do with general recommendations and how to search for information if you're asked a question or if you want to know you got a family member who wants to take this first thing is I always say purchase it from a big distributor why because the big distributors have more to lose if there's a problem make sure that the product has the common things you'd see on a normal bottle a lot number an expiration date the manufacturer's name and address I say avoid products with a long list of ingredients but the reason I say that it's not a it's not a absolute it really is more that again goes back to this whole have the proprietary blend and not really knowing if there's a you know if it's a proprietary blend how much of each individual ingredient is in that here's where here's where in terms of resources that are available to you consumer lab is probably one of my number one picks for consumers if you're interested in getting information about there are three different labs if you will that do testing on these products consumer lab goes out and just test products they don't manufacturer doesn't ask them to test their product they just go out and test products they go this month we're gonna test melatonin and they go out and they take about 20 different manufacturers brands of melatonin and test them for purity they test them for potency they test them for product dissolution meaning will the tablet dissolve in your stomach acid and and then they basically give it a stamp of approval if it meets all those things often they find that certain manufacturers products don't and so then they say we don't recommend this getting access to this you can actually access it it's WW ConsumerLab comm it's actually one of the next slides I'm going to show you right here ConsumerLab comm but the benefit of this website it only costs I think $30 a year to be a member and you get access to their product testing you get access to a ton of good information that is referenced evidence-based and referenced about herb and supplement products so there's monographs in there where you can read about products and they also post health advisories so for example that one product that had a viagra derivative honest is something that was posted on consumer lab the information related to the USP recommending warning labels for liver problems related to black cohosh and green tea extract was reported on ConsumerLab comm so they have a lot of good information and it's it's at a reasonable price the other symbols the NSF symbols and the USP symbols also appear on products if the manufacturer has requested they come in and test their products so this is a little different you know here I'm contacting them and saying come in and test my products I really want to be able to put your seal of approval on my on my on all my products and if they go in and they test it and they verify the same things content no contaminants good manufacturing practices USP also tests again for dissolution then they will get the stamp of approval and they can put it on their on their product in terms of reliable resources outside of consumer lab if you're looking at something on the internet or if you're looking at an advertisement you determine who's making the statement you know a lot of products are sold solely based on testimonials if you you know if you if you actually look at where consumers get information about supplement products it is typically the number one sources are things like friends advertisements family and you know where doctors and pharmacists fall we're like down there at about ten percent so you know the people who are supposed to be giving you the balanced information evidence-based wise are not being utilized as resources so it's very much based on advertisements word-of-mouth testimonials and so you have to you know if you're gonna go out and use one of these products you have to go out and and determine is it efficacious so read about it you know go to consumer lab calm you know there's other references natural medicines comprehensive database this is this was actually they did studies looking at what's what's the most reliable number one reference for dietary supplement information I use this all the time and that's because I'm constantly getting questions about products and some of them I don't even like I've never even heard of them and I go to natural medicines comprehensive databases and it's in there and I'm you know they have evidence-based information comes as an online format and also a book format I'm a big fan of online in general in terms of information because it gets updated as soon as you get a book it's often outdated right and then it does rank the effectiveness of the claims the is going to be more expensive though than ConsumerLab and finally natural standard which you know really has emerged over the last five years as being a very reputable evidence-based resource not only for consumers but also for health care providers and this is their website here WWN actual standard comm and you can log on to that and get information and I don't know if they I think they require a subscription as well but I don't know how much it is but they do a real good job as well in defining efficacy so if you get asked the question these are just things you want to avoid if it sounds too good to be true stay away from it that's really what this slide says and finally you know tell your tell your doctor if you're taking these products if you have a side-effect report it to the MedWatch program at the FDA website I say don't use them in children pregnant or lactating women because they're really most of these products have not been sufficiently studied in these groups and the risks sometimes you know outweighs the the benefit and that's that's kind of the bottom line it's just that we're still in a state now where we can't guarantee content we can't guarantee that the products gonna work you know but it is important that you still tell your doctor and and there are resources out there now for you to look at so if someone asks you know does this work for this or which manufacturer is the best for a melatonin product I would if that was asked to me I would go to the consumer lab website and I would see what products has been tested I might look at the USP website and see if they've you know got verified products that they've tested so that's how I you know you can find a manufacturer and then regarding information about efficacy or drug interactions you're gonna have to stick to the you know consumer lab natural standard natural medicines database those are really the three big ones in terms of finding fact-based information so I'm really sorry I went over I went over by about 10 minutes so but I really hope that you walk away with some good information

Channel: University of California Television (UCTV)

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Keywords: Herbal, medicine, supplements, alternative

Id: WwWoaMs31ME

Length: 89min 26sec (5366 seconds)

Published: Wed May 28 2008