Weekend Roundup: Caveat Emptor on Nutraceuticals
Navigating the murky and unregulated world of fad diets and supplements
This weekend I wanted to dive into a topic that is broadly applicable to both human and veterinary medicine: The >$60 billion dollar global supplement industry. Millions of people—and increasingly their pets—take supplements. For some supplements, this might have some modest benefits; for many others, it is likely no more than a harmless, albeit expensive, placebo. But this industry is a largely unregulated Wild West, and there is risk of harm through products not containing what they claim, adulteration, and supplements that cause serious drug interactions (for example, St. John’s wort), to name only a few issues. Below are several articles and a humorous video from John Oliver on how to navigate nutraceuticals and supplements, and I close out the post with my thoughts on best practices for any supplement.
22 Out of 25 Melatonin Products Were Mislabeled, Study Finds
Like many people, I have occasional trouble sleeping. Is this potentially related to chronic anxiety and excess caffeine intact? Who’s to say? ¯\_(ツ)_/¯
Over the years, I’ve tried melatonin and CBD with varying success. Melatonin in particular has been helpful for adjusting to different timezones as I’ve traveled outside the country (one of the few actual medical indications). So I took note when I saw this recent disturbing story in the New York Times (emphasis mine):
A team of researchers analyzed 25 melatonin gummy products from different brands and found that 22 contained different amounts of melatonin than what was listed on their labels; one contained only 74 percent of the advertised amount of melatonin, while another had 347 percent of the labeled amount. Yet another product contained no detectable melatonin at all.
Researchers tested gummies from only a single bottle of each product, so it’s possible that the amount of melatonin varied from batch to batch. But the findings point to a staggering discrepancy between the amount of melatonin consumers think they’re ingesting and how much they might actually take, said Dr. Pieter Cohen, an associate professor at Harvard Medical School and the lead author of the paper.
“You are at the mercy of the dietary supplement industry,” Dr. Cohen said.
As the article points out, an accurately labeled 3 mg melatonin product is still hundreds or thousands of times the normal amount of the hormone produced in the brain at night to facilitate sleep. High doses can contribute to hangover-like morning drowsiness or other side effects, and a product that actually contains more than the labeled amount will only exacerbate this problem.
Dr. Oz and Nutritional Supplements: Last Week Tonight with John Oliver (HBO)
Few people can take a complex, potentially boring and/or infuriating technical topic and turn it into comedy gold that is also educational better than John Oliver. Think of him as a funnier, British, Bill Nye that loves profanity. This segment from his show “Last Week Tonight” uses the now largely disgraced Dr. Oz as the punching bag entry point to discussing the bigger issues and bad incentives with the US supplement industry, including how powerful lobbying groups buy-off politicians and block regulation, even in the face of deaths.
CBD: What you need to know about its uses and efficacy
Like I mentioned above, I occasionally take CBD for sleep and anxiety. CBD, or cannabidiol, has become the miracle supplement du jour in people and animals, touted as a cure-all for almost anything that ails you—pain, insomnia, anxiety; whatever you’ve got, someone out there is claiming CBD can help. Before I started, I went down a rabbit hole of reading about the potential uses and side effect profile. I ultimately decided it had a favorable cost-benefit ratio, and I seem to tolerate it well.
Some of the popularity of CBD is likely a spillover effect from increasing acceptance (and de-scheduling) of cannabinoids including Epidiolex, a concentrated preparation of CBD that was approved by the FDA in 2018 to treat epilepsy. Studies in dogs have shown it may have benefits for seizures and osteoarthritis. While most studies suggest CBD is well-tolerated in dogs, this article from the Cornell University College of Veterinary Medicine provides a great summary of the potential risks of CBD pet products (again, emphasis and parenthetical mine):
No standard therapeutic dose has been established at this time, and since many products are made without standards, you can’t always be sure exactly how much of the active ingredient is present in different batches of cannabinoid products anyway.
Wakshlag was the lead author on a study that evaluated 29 CBD products for pets and found heavy metal contamination in four of the products (EJF: including lead!). The research team determined that two products had no cannabinoids in them. Of the remaining products, only 10 were measured to have a total cannabinoid concentration that was within 10% of the amount that they claimed to have on their label.
Studies done with CBD have shown that it can affect liver enzymes, specifically cytochrome P450s and alkaline phosphatase, both of which are involved in the metabolism of many medications.
This means that there is a risk that using CBD in combination with other drugs will cause them to interact and change how the medications perform. It may also affect the prescribed or recommended dosages. So, while you may be able to pick up CBD treats at the store, you need to check with your veterinarian before giving them to your dog. The most common side effects noted by owners were an increase in appetite and sedation.
If you are interested in CBD for your pets, ask your veterinarian for their guidance and check the labels to make sure there are no other active ingredients or potentially toxic additives (see below). The best products (sometimes more expensive) will follow Good Manufacturing Practices (GMP) and have available Certificates of Analysis (CoA).
Pit bull–type breeds with dilated cardiomyopathy eating nontraditional diets improve after diet change (2015–2022)
Moving from dietary supplements to diet itself, one of the hottest topics in veterinary nutrition has been the rift between companies like Blue Buffalo that use aggressive (and often emotionally manipulative and misleading) marketing to push non-traditional, frequently grain-free, diets as superior to those produced by large, established pet food companies like Purina and Hill’s. This has taken on greater urgency in the last few years as many of these diets have been associated with a rise in the previously rare disease Dilated Cardiomyopathy (DCM) and associated heart failure. The FDA has been investigating and released a series of updates on their ongoing findings. While the specific nutritional cause has not been definitively identified, a brand new study in the Journal of the American Veterinary Medical Association published a few weeks ago finds that pitbull dogs with DCM on non-traditional diets had substantial improvements in cardiac function when they switched to a more traditional dog food:
ABSTRACT
Objective: To compare signalment, clinical signs, diet, echocardiographic findings, and outcome for pit bull-type breeds diagnosed between 2015 and 2022 with dilated cardiomyopathy (DCM) or with DCM diagnosed by a cardiologist but that did not meet all study echocardiographic criteria (DCM-C).
Animals: 91 dogs with DCM and 11 dogs with DCM-C.
Procedures: Data were collected on clinical findings, echocardiographic measurements, and diet at the time of diagnosis (for 76/91 dogs); echocardiographic changes; and survival.
Results: For dogs with diet information available for time of diagnosis, 64/76 (84%) dogs were eating nontraditional commercial diets, while 12/76 (16%) were eating traditional commercial diets. There were few differences between diet groups at baseline, with congestive heart failure and arrhythmias common in both groups. Thirty-four dogs with known baseline diet and diet change status had follow-up echocardiograms between 60 and 1,076 days later (traditional diet, n = 7; nontraditional diet that changed diets, 27; and nontraditional diet group without diet change, 0). Dogs in the nontraditional diet group that changed diets had a significantly greater decrease in normalized left ventricular diameter (diastolic, P = .02; systolic, P = .048) and the left atrium-to-aorta ratio (P = .002) and a significantly greater increase in fractional shortening (P = .02) compared to dogs eating traditional diets. Dogs eating nontraditional diets with diet change (n = 45; P < .001) and dogs eating traditional diets (12; P < .001) had a significantly longer survival time compared to dogs eating nontraditional diets without diet change (4). Dogs with DCM-C also had significant echocardiographic improvements after diet change.
Clinical relevance: Congestive heart failure and arrhythmias were common in pit bull-type breeds with DCM. Those eating nontraditional diets that changed diets had significant improvements in echocardiographic measurements after diet change.
ASPCA vitamin and supplement toxicity and safety
Finally, I want to close with a few resources from the ASPCA Animal Poison Control Center about which common vitamin and supplements can be toxic to pets. While something like a multivitamin may seem harmless, things like iron and Vitamin D actually have a fairly narrow index of safety. A short list of some of the most problematic supplements and additives includes:
Alpha lipoic acid (aka thioctic acid)
5 hydroxytryptophan (5 HTP)
Caffeine (guarana, green tea) / coffee extracts
Citrus aurantium (synephrine)
Ephedra (ma huang)
Fluoride
Iron
Vitamin D
Xylitol
Yohimbine
Best Practices
In conclusion, here are my recommendations for approaching any new supplement or nutraceutical:
Look to see if there are any clinical studies in animals (not test tubes or in vitro)
The best search engine for biomedical and life sciences studies is Pubmed
Check if any of the authors have affiliations with the company selling the product
If yes, this doesn’t automatically disqualify the study, but it should introduce a lot of skepticism
Make sure the journal is credible! There are many journals, and some are predatory, allowing anyone to publish for money with little to no peer review standards. Here are some of the most reputable for vetmed*
Journal of the American Veterinary Medical Association
American Journal of Veterinary Research
Journal of Veterinary Internal Medicine
Journal of the American Animal Hospital Association
Journal of Feline Medicine & Surgery
Veterinary Record
Frontiers in Veterinary Science
*This is not a comprehensive list, and many smaller, niche journals for the various subspecialties are not included here
Some examples of reliable sources for human medical information include the Mayo Clinic and the Cleveland Clinic pages on drugs and supplements
For supplements, buy products with a certificate of analysis that follow Good Manufacturing Practices (GMP)
When in doubt, ask your vet or doctor!
Great article, thanks!