Surviving the Supplement Aisle: Over the Counter Does Not Mean Safe

As you stroll through the supplement aisle of your grocery store, a sign catches your eye: “Medicines that Target Your symptoms.” The symptoms include everything from “canker sores” and “nerve pain” to “dry barking cough” and “fatigue and irritability due to overwork.” Underneath sit tiny blue bottles with minuscule amounts of substances that you can purchase for about $8-10. Your eyes move down the rest of the aisle: ashwagandha, N-Acetyl-L-Cysteine, activated charcoal, CoQ10, endless rows of alluring bottles with vibrant colors and well-laid out fonts. In the United States, these bottles will fly off the shelves, with over 70% of Americans taking a supplement (1). However, what you and many other consumers might not realize is that these supplements are not regulated by the Food and Drug Administration (FDA) and, in some cases, are harmful.

Before a drug can be brought to market, extensive tests are performed to determine the effectiveness and safety of the drug before it is prescribed. Safety needs to be scientifically examined, with risks and benefits analyzed. However, with supplements, there is no FDA requirement to determine safety before hitting the shelves. While a method for reporting injury does exist, this process occurs after harm has happened (2). Essentially, product testing is done in real-time on US consumers.

There is also shockingly little oversight in the accuracy of ingredients listed on a supplement’s bottle. In other words, a bottle advertising “250 mg of Vitamin C” may not actually contain 250 mg. It has been shown how easy it is for companies to falsify the actual contents of tablets you take daily. In 2015, the New York State attorney general’s office ran tests on high-selling supplements sold in Target, Walgreens, GNC, and Walmart and found that many of them contained cheap ingredients, including powdered rice, houseplants, and asparagus, and four out of five did not contain the ingredients promised on labels (3).

To make it more confusing, most vitamins and minerals have varying names for the same chemical structure. Caffeine can be listed as caffeine or hidden on a label as theine, mateine, or guaranine, depending on the source of origin. As one can imagine, this is misleading and makes it very difficult to make an informed decision about supplement use.

Everyone has a family member, friend, TV show, or TikTok video to reference for success stories of taking various supplements. While there may be benefits, the actual data behind commonly used supplements is not strong. While supplements are useful for specific diseases or patients with dietary deficiencies, they may not have the same effects for a healthy person who eats a balanced diet. In overuse, they can cause damage. For example, certain levels of aloe vera leaf powder, ashwagandha, vitamin D, vitamin A, and ginkgo biloba have been linked to liver injury. Ginger and garlic have been linked to excess bleeding, and creatine can cause kidney injury. Many other vitamins/minerals have been linked to gastrointestinal upset (1, 4, 5).

Despite limited data, many will still take supplements, optimistic that they will benefit their health. So, how do you survive the supplement aisle? Here are some tips:

• Be wary about claims made by companies to cure a disease or rapidly improve the quality of your life. If it sounds too good to be true, it probably is.
• Try not to take much more than the percentage of the recommended dose of vitamins/minerals. You probably don’t need that much. Especially if you have a well-balanced diet.
• Be especially careful when taking the fat-soluble vitamins: A, D, E, and K, which have significant toxicity.
• Some supplement companies have internal quality improvement systems. Look for labels on supplements that talk about self-review processes.
• Try to limit taking multiple types of supplements. If you are taking multiple supplements, carefully read labels to ensure that the same ingredients aren’t present in both to limit toxicity.
• If you take medications, including birth control, talk to your doctor before using supplements. Some supplements can interact with medicines making them either less effective or even toxic.
• Pay particular attention to substances that promote weight loss, energy gain, and muscle mass gain; these have frequently been found to have undisclosed ingredients by the FDA during investigations (1)
• Store your supplements away from children and pets.

Everyone wants to be healthy, energetic, and happy. However, health is a spectrum that varies from person to person. A supplement will likely not cure your symptoms, and it’s essential to be informed of the potential drawbacks of what we buy off the shelves. “Natural” does not always mean safe.

__________________________________________________________________________________________________________________

Dr. Christine Collins, MD

Dr. Christine Collins (left) is an Emergency Medicine resident at Cooper University Hospital in Camden, NJ. Following in the footsteps of Dr. Mazzarelli (Dr. Mazz), she completed a one month internship on The Michael Smerconish Program.

Dr. Rachel Haroz, MD

Dr. Rachel Haroz, MD FAACT (right) is Associate Professor in the Department of Emergency Medicine at Cooper Medical School of Rowan University, Division Head of Toxicology and Addiction Medicine and Medical Director for the Cooper Center for Healing. She helped build and now staffs the Center for Healing at Cooper University Hospital in Camden New Jersey, a substance use disorder clinic dedicated to treating patients with compassion and evidence based medicine and an integrated clinic for patients with HIV and substance use disorders.

__________________________________________________________________________________________________________________

1. Ronis MJJ, Pedersen KB, Watt J. Adverse Effects of Nutraceuticals and Dietary Supplements. Annu Rev Pharmacol Toxicol. 2018 Jan 6;58:583-601. doi: 10.1146/annurev-pharmtox-010617-052844. Epub 2017 Oct 6. PMID: 28992429; PMCID: PMC6380172.
2. Commissioner, Office of the. “FDA 101: Dietary Supplements.” U.S. Food and Drug Administration, FDA, https://www.fda.gov/consumers/consumer-updates/fda-101-dietary-supplements.
3. O’Connor, Anahad. “New York Attorney General Targets Supplements at Major Retailers.” The New York Times, The New York Times, 3 Feb. 2015, https://archive.nytimes.com/well.blogs.nytimes.com/2015/02/03/new-york-attorney-general-targets-supplements-at-major-retailers/.
4. Hudson A, Lopez E, Almalki AJ, Roe AL, Calderón AI. A Review of the Toxicity of Compounds Found in Herbal Dietary Supplements. Planta Med. 2018 Jul;84(9-10):613-626. doi: 10.1055/a-0605-3786. Epub 2018 Apr 19. PMID: 29672820.
5. AMA J Ethics. 2022;24(5):E410-418. doi: 10.1001/amajethics.2022.410.