Advising patients who use dietary supplements

Public use of dietary supplements is quite prevalent, with an estimated 1 of 5 patients using such substances in an effort to maintain or promote their health. Despite their popularity, patients and physicians are often unaware of the limited regulation of these products as well as their potential risks and benefits. Lack of physician knowledge in these areas has the potential to strain the doctor-patient relationship. In this review, we present a 6-step approach to advising patients who are considering use of dietary supplements. Our framework includes a discussion of regulatory issues, efficacy and safety, potential supplement-drug interactions, and monitoring for adverse events and therapeutic effects.     

Sixty percent of patients with rheumatoid arthritis in Japan have used dietary supplements or health foods

We conducted a survey on the use of dietary supplements and health foods (DS/HF) in definite rheumatoid arthritis (RA) patients treated by RA specialists. Among 296 patients (male 48, female 248), 179 patients (60.5%) had experience of DS/HF use. Prevalence of DS/HF use was significantly higher in female than in male patients (63.7% versus 43.8%). Overall, patients who have used DS/HF were significantly younger than those who have not used; it was particularly notable in female patients. The proportion of current users was significantly higher in those less than 5 years from diagnosis than those who had been diagnosed for 5 years or more. Products of herbs or algae (44.1%) and components of cartilage (40.8%) were the most popular DS/HF. Primary sources of product information were family members or friends (56.4%) and advertisements in the mass media (34.1%). Of the users, 73.7% did not disclose DS/HF use to their physicians. The users expected alleviation of the symptoms (35.2%) and improvement of health (34.6%). However, 59.2% of the users were unsure of the benefits. In conclusion, physicians should be aware of the high prevalence of DS/HF usage in patients with RA in Japan.     

Online Sources of Herbal Product Information

Herbal products are commonly used to treat clinical conditions and are often purchased online without the supervision of a healthcare provider. The use of herbals remains controversial because of widespread exaggerated claims of clinical efficacy and safety. We conducted an online search of 13 common herbals (including black cohosh, echinacea, garlic, ginkgo, ginseng, green tea, kava, saw palmetto, and St John's wort) and reviewed the top 50 Web sites for each using a Google search. We analyzed clinical claims, warnings, and other safety information. A total of 1179 Web sites were examined. Less than 8% of retail sites provided information regarding potential adverse effects, drug interactions, and other safety information; only 10.5% recommended consultation with a healthcare professional. Less than 3% cited scientific literature to accompany their claims. Key safety information is still lacking from many online sources of herbal information. Certain nonretail site types may be more reliable, but physicians and other healthcare professionals should be aware of the variable quality of these sites to help patients make more informed decisions.     

Lack of herbal supplement characterization in published randomized controlled trials

PURPOSE: Herbal supplements in the United States and abroad have poor quality control and high content variability. We assessed the extent to which recently published randomized controlled trials of herbal supplements characterized and verified the content of the supplement under study. METHODS: We identified all MEDLINE-indexed English language randomized controlled trials evaluating single-herb preparations of echinacea, garlic, ginkgo, saw palmetto, or St. John's wort that were published between January 1, 2000, and February 9, 2004. From each article we extracted information characterizing the herbal supplement studied. RESULTS: Of 81 randomized controlled trials meeting inclusion criteria, 12 (15%) reported performing tests to quantify actual contents, and 3 (4%) provided adequate data to compare actual with expected content values of at least one chemical constituent. In those 3 studies, actual content varied between 80% and 113% of expected values. Studies of higher overall quality (Jadad score > or =3) performed testing somewhat less frequently (5/54; 9%) than those with lower Jadad scores (7/27; 26%) (P = .09). CONCLUSION: Documented characterization of herbal supplements in published randomized controlled trials is inadequate. Investigators may be unaware of the extent to which herbal quality-control issues may detract from the value of otherwise well-designed clinical trials. The scientific and clinical utility of future herbal randomized controlled trials would be enhanced if authors provided evidence that the herbal products studied were of high quality.     

Acute liver failure caused by 'fat burners' and dietary supplements: a case report and literature review

Globally, people are struggling with obesity. Many effective, nonconventional methods of weight reduction, such as herbal and natural dietary supplements, are increasingly being sought. Fat burners are believed to raise metabolism, burn more calories and hasten fat loss. Despite patient perceptions that herbal remedies are free of adverse effects, some supplements are associated with severe hepatotoxicity. The present report describes a young healthy woman who presented with fulminant hepatic failure requiring emergent liver transplantation caused by a dietary supplement and fat burner containing usnic acid, green tea and guggul tree extracts. Thorough investigation, including histopathological examination, revealed no other cause of hepatotoxicity. The present case adds to the increasing number of reports of hepatotoxicity associated with dietary supplements containing usnic acid, and highlights that herbal extracts from green tea or guggul tree may not be free of adverse effects. Until these products are more closely regulated and their advertising better scrutinized, physicians and patients should become more familiar with herbal products that are commonly used as weight loss supplements and recognize those that are potentially harmful.     

Use of dietary supplements and natural remedies increased dramatically during the 1990s

OBJECTIVES: To estimate the prevalence and trends in dietary supplement and natural remedy use in Sweden during the 1980s and 1990s. DESIGN: Three nationally representative, cross-sectional surveys conducted in 1980-81, 1988-89 and 1996-97 were used for analysis. In face-to-face interviews participants reported consumption of dietary supplements and natural remedies during the previous 2 weeks. SETTING: Sweden. SUBJECTS: The samples consisted totally of 38 594 adults aged 16-84 years (14 642 in the 1980-81 survey, 12 391 in the 1988-89 survey and 11 561 in the 1996-97 survey). Main outcome measures. Changes in prevalence of dietary supplement and natural remedy users between 1980 and 1997. RESULTS: The 70% increase in the prevalence of dietary supplement users amongst both men and women [odds ratio (OR), 1.7; 95% confidence interval (CI), 1.6-1.9, OR, 1.7; 95% CI, 1.5-1.8, respectively] occurred mainly between 1988-89 and 1996-97. The increase in the prevalence of natural remedy users was even more dramatic - more than threefold in men (OR, 3.3; 95% CI, 2.9-4.0) and almost threefold in women (OR, 2.6; 95% CI, 2.3-2.9) - and the systematic increase started already in the 1980s. The increase was observed in all age groups and in all socio-economic groups, except for farmers. In 1996-97 the prevalence of dietary supplement users was 22% amongst men and 33% amongst women, and of natural remedies 7 and 14%, respectively. CONCLUSIONS: During the last two decades, the use of dietary supplements and natural remedies amongst the adult Swedish population has dramatically increased.     

Nutritional risks and deficiencies pre and post bariatric surgery: Recommendations for optimal dietary management

ObjectiveThis paper aims to summarise the key recommendations from the most recent literature, to support Chinese bariatric surgeons and their multidisciplinary teams in the optimal nutritional management of their patients. There is a growing body of evidence that recognises the risk of untreated nutritional deficiencies pre and post bariatric surgery. This paper will focus on the most prevalent and catastrophic of nutritional consequences.Nutritional workup prior to surgery, in addition to postoperative nutrition follow up is highly desirable to avoid complications associated with restrictive diets and large variations in body mass ^[1]. Dietetic counselling to address presurgical nutritional deficiencies, appropriate use of presurgical Very Low-Calorie Diets (VLCD), postsurgical dietary protocol and adequate supplementation is prudent. Ensuring that patients are informed and prepared for the postsurgical restrictive dietary changes and lifestyle modifications is critical for long term success. Furthermore, longer term dietetic follow up can also monitor patient dietary compliance to avoid the extremes of nutritional deficiency. ConclusionsPre and post bariatric nutritional screening and long term nutritional follow up in addition to adherence to a life-long nutritional supplementation regimen, is critical for successful post-operative outcomes.     

Correlation between serum advanced glycation end products and dietary intake of advanced glycation end products estimated from home cooking and food frequency questionnaires

Background & aimsTo our knowledge the association between dietary advanced glycation end-products (dAGEs) and cardiometabolic disease is limited. Our aim was to examine the association between dAGEs and serum concentration of carboxymethyl-lysine (CML) or soluble receptor advanced glycation end-products (sRAGEs), and to assess the difference on dAGEs and circulating AGEs according to lifestyle and biochemical measures.Methods and results52 overweight or obese adults diagnosed with type 2 diabetes were included in this cross-sectional analysis. dAGEs were estimated from a Food Frequency Questionnaire (FFQ) or from a FFQ + Home Cooking Frequency Questionnaire (HCFQ). Serum concentrations of CML and sRAGEs were measured by ELISA. Correlation tests were used to analyze the association between dAGEs derived from the FFQ or FFQ + HCFQ and concentrations of CML or sRAGEs. Demographic characteristics, lifestyle factors and biochemical measures were analyzed according to sRAGEs and dAGEs using student t-test and ANCOVA.A significant inverse association was found between serum sRAGEs and dAGEs estimated using the FFQ + HCFQ (r = −0.36, p = 0.010), whereas no association was found for dAGEs derived from the FFQ alone. No association was observed between CML and dAGEs. dAGEs intake estimated from the FFQ + HCFQ was significantly higher among younger and male participants, and in those with higher BMI, higher Hb1Ac levels, longer time with type 2 diabetes, lower adherence to Mediterranean diet, and higher use of culinary techniques that generate more AGEs (all p values p < 0.05).ConclusionsThese results show knowledge on culinary techniques is relevant to derive the association between dAGEs intake and cardiometabolic risk factors.     

Agreement between patient report and medical record review for medications used for rheumatoid arthritis: The accuracy of self‐reported medication information in patient registries

Objective

With the growth in patient registries in rheumatic disease research, it is important to validate the collected information. We examined the convergent validity of self‐reported medication use for rheumatoid arthritis (RA).

Methods

In the setting of the Brigham Rheumatoid Arthritis Sequential Study (BRASS), a large registry of patients with RA, we examined the agreement between patients' self‐report of current and past RA medication use and information from medical records. For a sample of patients in BRASS, these 2 sources of information were compared using the kappa statistic as well as the percent agreement.

Results

The 91 patients selected for assessment were typical of a prevalent RA cohort: >80% were women and the mean disease duration was 16 years. The agreement for current medication use was excellent, ranging from 0.71 for sulfasalazine to 0.96 for methotrexate. However, for past medication use agreement was lower, ranging from 0.13 for methotrexate to 0.74 for aurothioglucose. The weighted kappa for cumulative oral glucocorticoid dose was 0.67.

Conclusion

Self‐report of current medication use and cumulative oral glucocorticoid dose appears to have moderate to excellent validity. However, self‐report of past medication use may not be valid.     

Significance of cow's milk protein antibodies as risk factor for childhood IDDM: interactions with dietary cow's milk intake and HLA-DQB1 genotype

Summary Dietary factors are suspected to play an aetiological role in the development of insulin-dependent diabetes mellitus (IDDM). We analysed cow's milk formula, betalactoglobulin, and bovine serum albumin antibodies by an enzyme-linked immunoassay in unselected children with newly diagnosed IDDM and in their non-diabetic siblings and enquired about infant feeding practices by questionnaire. Among 410 diabetic sibling pairs matched for age and sex, by logistic regression analysis – including overall duration of breast-feeding, age at introduction of dairy products, recent consumption of cow's milk and HLA-DQB1 genotype (“high/moderate” vs “low/decreased” risk of IDDM) – bovine serum albumin IgG antibody levels (OR 2.12, 95 %CI 1.25–3.57) and genetic risk (OR 3.81, 95 %CI 2.43–5.17) were positively associated with IDDM; cow's milk formula IgM antibodies were inversely associated with the risk of IDDM (OR 0.50, 95 %CI 0.29–0.87). Of the diabetic sibling pairs, 42 were identical for HLA-DQB1 alleles associated with IDDM risk or protection (DQB1^*0201, *0301, ^*0302 and *0602/03). In these 42 pairs, children with IDDM had higher median levels of bovine serum albumin IgG, of betalactoglobulin IgG, and of cow's milk formula IgG and IgA antibodies than the non-diabetic siblings (p < 0.05). In conclusion, children with IDDM have higher levels of cow's milk protein antibodies than their HLA-DQB1-matched sibling controls, and these high levels of antibodies are independent risk markers for IDDM. [Diabetologia (1998) 41: 72–78] Received: 13 June 1997 and in revised form: 26 August 1997