Buyer Beware — The Dangers of Surfing for Supplements
By Jasmin Ilkay, MPH, RD
Today’s Dietitian
Vol. 8 No. 5 P. 40

Sure, shopping online is convenient, but when it comes to purchasing health products, is it safe? Educate your clients about the possible hazards before they go surfing for supplements.

The Internet is the most influential source of health information today. An estimated 97 million adults use the Internet to look for health-related materials, and studies show that consumers are paying attention to what they are finding. In a Harris Interactive survey, 70% of respondents reported that information found online has influenced their healthcare treatment.1 Many studies confirm an increased trend in complementary and alternative medicine use, including the use of dietary supplements. While the Internet has allowed for consumers to have increased access to dietary supplements, how do they know whether they are safe or whether they even work?

The difficulty in finding scientific support for supplement use, coupled with misguided thoughts about government regulation, puts consumers at a disadvantage. Many people are misinformed about the extent of the government’s role in regulating dietary supplements. A Harris Interactive, Inc. Health Care telephone survey conducted in October 2002 confirmed this. Of the 1,010 people surveyed, most participants believed the following:

• Supplements are supposed to be approved by a government agency.

• Manufacturers are not allowed to make claims for the safety and effectiveness of dietary supplements unless there is solid scientific evidence supporting them.

• Manufacturers are required to include warnings about the potential side effects or dangers in taking certain dietary supplements.

Unfortunately, these beliefs are far from the truth, and the regulation of dietary supplement companies on the Internet are the least trustworthy.

Federal Regulation
Internet regulation for the sale of dietary supplements is under the jurisdiction of the Federal Trade Commission (FTC) and the FDA. The FDA is responsible for regulating claims on product labeling while the FTC is responsible for advertising claims. Although the Internet is subject to the same regulation as any other media, monitoring and enforcing the laws is very complicated. Currently, the FDA and FTC are engaged in discussions on how to apply each agency’s authority in the sale of dietary supplements on the Internet.2 The passage of the Dietary Supplement Health Education Act of 1994 (DSHEA) is partly to blame for the insufficient regulation of dietary supplements.

More than one decade ago, there was much discourse concerning the future of dietary supplements. Consumers were concerned about their access to dietary supplements; Congress was reviewing its role as a regulatory agency; and all the while, researchers were discovering and confirming numerous health-promoting properties of dietary supplements. At the same time, a campaign was launched advocating consumer freedom in purchasing dietary supplements. This campaign, primarily facilitated by the supplement and health food industries, led to the passing of DSHEA.

DSHEA defines dietary supplements as “products that are intended to supplement the diet and contain one or more of the following ingredients: a vitamin, a mineral, an herb or other botanical, an amino acid, a dietary substance that supplements the diet by increasing total daily intake, or a concentrate, metabolite, constituent, or combination of these ingredients.”3 Dietary supplements should be taken orally in the form of a pill, capsule, tablet, or liquid and are labeled on the front panel as being a dietary supplement. This broad definition paved the growth for today’s now multibillion-dollar dietary supplement industry. Even with strict marketing and labeling guidelines, under DSHEA, the FDA does not have the necessary resources or authority to ensure that all dietary supplements are safe and effective.

Supplements with ingredients that were marketed before passage of DSHEA are not regulated for safety and labeling before they hit the market. They are presumed to be safe due to the long history of their use by consumers. Supplement manufacturers releasing a product with a new dietary ingredient (after October 15, 1994) must notify the FDA at least 75 days before marketing the product (but it is still put on the shelves!). Even though notification is required, the FDA is still responsible for showing that a dietary supplement is unsafe before it can restrict its use. Unfortunately, in the case of ephedra, it took 155 deaths and dozens of heart attacks and strokes before it was pulled off shelves (but it has again shown up on the Internet since its ban).

The lack of government regulation, as required by DSHEA, further impedes the already difficult task of regulating dietary supplements on the Internet. There are many barriers to monitoring supplement companies on the Internet. Many of these companies re-create and remove Web sites and change their company name, making it challenging to enforce federal and state laws. Other sites provide links to more Web pages, making investigating difficult and complex. There are also jurisdictional challenges due to regulatory and enforcement issues across state, federal, and international lines.3 Regulating false label and advertising claims by dietary supplement companies on the Internet appears to be the most difficult.

Erroneous Claims Confirmed
A recent study assessed information and claims on the Internet for eight common herbal products (ginkgo biloba, St. John's wort, echinacea, ginseng, garlic, saw palmetto, kava kava, and valerian root). A total of 273 (81%) of the 338 retail Web sites reviewed made one or more health claims; of these, 149 (55%) claimed to treat, prevent, diagnose, or cure specific diseases. More than one half of the sites containing a health claim omitted the standard federal disclaimer. It was also found that nonretail sites were more likely than retail sites to include literature references.4

Another study published in 2002 reviewed 61 Web sites located by searching for “herbs” and “cancer cure.” Of the commercial sites surveyed, 92% discussed prevention, 89% mentioned treatment, and 58% promised a cure for taking the herbal supplement.5

These studies confirm that a vast number of supplement companies make erroneous claims on the Internet. If these claims were put on a product’s label in a store, they would be taken off the shelves. These marketing tactics pose a potential danger for consumers wishing to make purchases online. Below are some tips that consumers can follow to make their Internet research and purchasing safer.3,6

1. Be careful of Web sites that claim to treat, prevent, or cure any disease.

2. Remember that Web sites can't make claims that a dietary supplement will have an effect on any structure or function of the body when the claims are not substantiated.

3. Beware of Web sites that recommend foregoing conventional treatments such as surgery or chemotherapy.

4. Be leary of claims to treat certain medical conditions that are prominent in the news (such as bird flu).

5. Always contact a qualified and supportive healthcare provider before using a dietary supplement.

6. Many Web sites reference studies that are flawed and rarely include reports citing negative effects.

7. Look for ingredients in products with the USP notation, which indicates the manufacturer followed standards established by the U.S. Pharmacopoeia (USP).

8. Be leary of Web sites that fail to provide a company name, address, phone number, or other contact information.

9. Remember that customer testimonials are often undocumented and are not a substitute for scientific proof.

Benefits of Using the Internet
If done safely, shopping online has numerous conveniences. Many people report that they use the Internet to get better prices, increased variety, and privacy. Before the advent of the Internet, “those in more rural communities may have had limited access to many products that only were available in specialty health food stores,” says Suzanne Dixon, MPH, MS, RD, founder and director of Cancer Nutrition Info, LLC (CancerNutritionInfo.com). “As well, consumers may be less likely to purchase additional products that would be recommended by a health food salesperson,” she adds.

Disadvantages to Using the Internet
As mentioned, Web sites are not allowed to advertise that a certain supplement can cure, treat, or prevent a disease. Yet, research has shown that fraudulent claims are made by many companies, especially internationally. Combating the large amounts of false nutrition and dietary supplement information is one reason Dixon created CancerNutritionInfo.com. It provides up-to-date, comprehensive, and scientifically sound information about nutrition and cancer for both patients and professionals. Dixon counseled many patients who wanted to substitute special diets and intensive dietary supplement regimens for necessary medical treatments.

The amount of false information posted on the Web poses a potential threat to consumers’ health. Many companies mislead consumers about the effectiveness of certain supplements. Some dietary supplement companies go as far as telling patients to forgo medical treatments such as surgery and chemotherapy. People also need to be aware that some supplements contain harmful ingredients and have the potential to interact with certain medications.

The Dietitian’s Role
Dietitians play a large role in educating the public about the safety and efficacy of dietary supplements. They are often confronted with clients who want to know whether they should take dietary supplements to enhance their health or prevent certain diseases. Yet, new supplements are being introduced and researched so rapidly that it’s difficult to stay abreast of current information. Additionally, many dietitians may be unaware of the resources available to get quick and reliable information about dietary supplements, especially in regard to nonvitamin and nonmineral supplements.

Fortunately, there are many Web sites available that do provide reliable information. Most importantly, beware of sites that make false claims, advertise products, and/or those that lack a reference list. The following list, contributed in part by Dixon, includes examples of Web sites that provide reliable information on dietary supplements:

• CancerNutritionInfo.com: This site provides information on diets, nutrition programs, supplements, and herbs that reportedly help patients who have cancer. There is limited free access and an option for a free trial. A subscription is required for full access. http://cancernutritioninfo.com

• Longwood Herbal Task Force (LHTF): The LHTF was organized by the faculty, staff, and students of Children’s Hospital Boston, Massachusetts College of Pharmacy and Health Sciences, and Dana-Farber Cancer Institute to learn more and teach other clinicians about herbs and dietary supplements. The Web site includes book reviews, databases, and detailed monographs. Access is free. www.longwoodherbal.org

• National Center for Complementary and Alternative Medicine (NCCAM): NCCAM is one of 27 institutes that make up the National Institutes of Health. Includes short fact sheets for a variety of popular dietary supplements. Access is free. http://nccam.nih.gov/health/supplements.htm

• Natural Medicines Comprehensive Database: This site provides up-to-date information on natural medicines, herbs, and dietary supplements that are popularly used in the Western world. The site is maintained by pharmacists, dietitians, physicians, and pharmacologists. A subscription is needed for access to the Web site’s information. www.naturaldatabase.com

• SupplementWatch.com: This site consists of a network of health professionals dedicated to educating people about the pros and cons of dietary supplements. Access is free. www.supplementwatch.com

• University of Maryland Medical Center: The University of Maryland Medical Center provides information about alternative and complementary medicine and brief summaries about dietary supplements. Access is free. www.umm.edu

In addition to learning where to go for reliable information, dietitians must understand how to approach clients about whether they should take a particular supplement. Dixon was confronted with this daily while working as a cancer nutrition specialist and epidemiologist at the University of Michigan Comprehensive Cancer Center and the Josephine Ford Cancer Center in Detroit. Many of her patients were frustrated by the lack of reliable information available for using dietary supplements and she wanted to help them make educated decisions. “Many patients who are open to alternative treatments also desire to have more control over their health. They want to help themselves, not harm themselves,” she says. Patients often confide in dietitians about their supplement use, and helping them make informed decisions is an important part of a dietitian’s job. Below are some tips from Dixon to help dietitians do just that:

• Complete a brief literature review. There may be a study of a specific supplement of interest.

• Investigate possible drug interactions. If some information is difficult to interpret, ask coworkers or peers, such as a pharmacologist or pharmacist, for assistance.

• If a dietary supplement is considered unsafe, present the information to the patient immediately and explain that safety is the most important factor in determining which supplements may be worth trying.

• If a dietary supplement appears safe, keep a detailed record as part of the clinical chart tracking intake and any noted changes in health or side effects. Ask the patient to keep a record as well.

• Conduct in-services to educate other practitioners about the trend in patient care and define your role as a dietitian. Include a discussion of your role in helping patients sort through the confusing information on dietary supplements.

“Present the information that you find, but enhance the patient’s control by letting them make the final decision,” Dixon advises. It’s imperative to give patients the power of choice. Otherwise, they may not be honest with their healthcare providers regarding complementary and alternative treatments they are using.

The advent of the Internet has allowed consumers increased access to health information and dietary supplements. While this has allowed for consumers to take more control of their healthcare, it also poses a serious health threat. Many supplement companies misrepresent their products’ efficacy and safety. Consumers need to arm themselves with good information from various reliable resources and talk to their healthcare providers about taking any dietary supplement beyond a multivitamin.

— Jasmin Ilkay, MPH, RD, is a freelance writer who specializes in nutrition topics such as dietary supplements, weight management, eating disorders, sports nutrition, and diabetes. She has a private nutrition consulting practice in Claremont, Calif.

References
1. RAND Health. Proceed with Caution: A Report on the Quality of Health Information on the Internet. May 2001. Available at: http://www.kaisernetwork.org/health_cast/uploaded_files/ProceedWithCautionCompleteStudy.pdf. Accessed February 2006.

2. U.S. Food and Drug Administration. Answers to Stakeholders’ Questions: FOODS. Available at: http://www.fda.gov/oc/fdama/fdamawebcast/stakeholdersquestions/foods.html. Accessed February 2006.

3. U.S. Food and Drug Administration. Use Caution Buying Medical Products Online. Available at: http://www.fda.gov/fdac/features/2005/105_buy.html. Accessed February 2006.

4. Morris CA, Avorn J. Internet marketing of herbal products. JAMA. 2003;290(11):1505-1509.

5. Bonakdar RA. Herbal cancer cures on the Web: Noncompliance with The Dietary Supplement Health and Education Act. Fam Med. 2002;34(7):522-527.

6. Bren L. Agencies Team Up in War Against Internet Health Fraud — FDA, FTC, state, and Canadian agencies investigate fraudulent health claims. FDA Consumer. September-October 2001.