Table Talk 020

Melody00:29

All right. Welcome back to the Table Talk podcast. So I have Lauren Castle who is a pharmacist here in Ohio. Dr. Lauren Castle, I should say. And then Dr. Megan Morrison, who is in Texas. Welcome to you, both, both of you have been on the podcast before.

So I'm so thankful that you're coming back today to talk about a really important topic and that is choosing quality supplements. So you all know if you've been on Instagram, on Facebook, watching TV, that the ads for supplements, new food supplement type products, just continue and continue to grow.

And about half the adult us population takes one or more supplements regularly, and we spend more than 35 billion on these products each year. So the question is, which products should we take? How do we know if what we are taking is quality. And the reason these questions are coming up is that the US food and drug administration has had some warnings recently on numerous dietary supplements, containing undeclared or unapproved, potentially pharmaceutical ingredients.

And so when we start to have these conversations with our patients, we have to remind that the food and drug administration does not evaluate the effectiveness, safety, or quality of dietary supplements or the ingredients in them before they enter the marketplace. And so this comes from an act actually back in 1994, called the dietary supplement, health and education act, and dietary supplements are classified as a category of food that aren't subject to the pre-market safety and effectiveness testing required by the FDA for drugs.

So they can. Action against adulterated or misbranded product. So if the product is labeled incorrectly, the wrong thing is in it but only after it goes to market. So this is different from the drug and pharmaceutical process, where they have to approve these things before it goes to market.

And even at this point, we're not still not testing for safety and efficacy with supplements. We're just looking to make sure postmarketing if they have what they say they have in them and they, you know, they can take that action. And so the FDA does track dietary supplements reported by consumers and customers.

You can also report safety concerns or outcomes with the US health and human services, safety reporting. But it's important to realize that the products that we have, there's no guarantee that it has the amount that it claims to. And that's really why we talk a lot about quality and finding companies that we can see their data on quality.

And we can look at that ourselves as providers and even patients have access to, to make sure that we have the right amount of ingredient from batch to batch and really working with a provider to make sure you're taking the right amount of something. If you're taking something for a therapeutic purpose or you're taking something because you have a low nutrient level that you know about, you wanna make sure you're getting the right amount and the right thing.

And, and that's really why we're here talking about this today. So, certainly the FDA requires that manufacturing companies adhere to current good manufacturing practices, which are intended to make sure the quality and safety of these products, but compliance really isn't always enforced in that category.

Certain companies pride themselves on their compliance in those categories and other companies it's not as enforced. So I think as we see more and more of this come to market and consumers learn more and more about this companies are being more transparent with this information, which is great. And so we have moved a long way.

Megan, why don't you just give us a little background to why we're even talking about this and some of the studies that they have had on these products and maybe not fulfilling what exactly we thought they were.

Megan03:59

And supplements and they can be very important to somebody's health journey. Along with, you know, everything else, we talk about diet and exercise and all that good stuff, but there have been a lot of studies done on supplements and supplement companies. And the ingredients contained, or maybe not contained in those products.

So I wanted to just highlight one study. It was published back in 2018 in Jamma, and it looked at adult rated dietary supplements. So supplements that contained unapproved ingredients, from 2007 to 2016. So there were 776 adult rated dietary supplements,

FDA had identified. And I do wanna point out most of the, the categories that the most of these supplements fall under are sexual enhancement supplements, weight loss, or muscle building. It's definitely not necessarily like those are the biggest categories that they looked at and they found like 45% sexual enhancement drugs, almost 41% weight loss 12% muscle building had one unapproved ingredient in that product. And we talk about this because some of those ingredients were actual drugs that they were finding in these products and those can definitely interact with other supplements or prescription medications that a patient's on.

And so it's super important to be aware of that. And, you know, I think something we, we wanna mention too, we're not talking about this to scare people out of supplements, cuz like I said, they can be very important and helpful to many people, but just to be aware. I talk a lot about personal care products and the stuff on the shelves.

Maybe isn't the best quality, same thing with supplements. You know, we think a lot of us think we go into our local pharmacy and everything on the shelfs there safe. So it's just good to be aware of, of this issue. And we will talk about ways to make sure that you are choosing safer supplements.

Melody06:18

Awesome.

Yeah. There's been multiple studies like this, where the they've gone in and tested the products and the products didn't have the amount they had in them and they didn't like Megan said had different things in them than they were labeled for. And so certainly that can be dangerous, especially when we're talking about adding drugs to a supplement that isn't intended to be a drug and not knowing those potential ingredients.

So I think especially when it comes to choosing things just off the shelf, this is a really important conversation to have with your pharmacist. So Lauren comes from a, I've done a little bit of retail work in my background. Megan has as well, but Lauren has the most retail experience as far as being the pharmacist behind the counter, that community pharmacists, that you have access to ask these questions to.

So Lauren, talk to us about what is your typical conversation. Someone comes up and asks. They wanna supplement for X, Y, Z. What conversation are you having with them? If you're at a store that maybe doesn't stock professional brands that we're used to recommending, how do you have that conversation?

Lauren07:17

Absolutely so supplements, obviously there are tons of different brands, whether it's brand names you might be familiar with, you see advertised on TV. There's store brands that are generic, you know, kind of knockoff versions of those brand names. And more and more, I mean, the supplements that you see in your typical retail pharmacy have definitely been changing over the years.

And a lot of it has been because of some of these studies that have come out. So, you know, I think we talked about how in this one particular study in Jamma, it was a lot of these sexual enhancement, weight loss, and muscle building supplements. So a lot of those categories in particular are marketed on the internet.

Right? Like, yes, we might carry a few of those things in your typical retail store for weight loss or muscle building, but they're gonna be things that are more like creatine supplements or protein supplements for weight loss. There's actually really pretty limited supplements that most stores might carry.

I mean, you might have some diuretic type products or potentially some herbal supplements, something like green tea or things like that. And then really for those sexual enhancement supplements. I mean, most pharmacies are gonna have maybe some nitric oxide, boosters, things like that. But a lot of those categories are ones that you're gonna find like on the internet being marketed.

And so it's especially difficult to vouch for the quality of those products when they're only sold online. And they're not going through a large retailer that is doing at least the bare minimum in terms of looking at the quality of the products. Right? Because, there was a report that had come out a couple years back.

It was, I think, after this initial study, still a few years ago that talked about how some of the major chains, actually had some products on their shelves that didn't exactly have the ingredients listed or might have had others. Now, granted, they were not quite as serious of allegations as compared to some of these things, having prescription ingredients in them, but it might have been something like an herbal product that said it contained curcumin or turmeric.

Maybe it also had some ginger in it. And that wasn't actually disclosed on the label because when they're doing this manufacturing, sometimes in the plants, they might not have the best quality control and that's how sometimes things can get adulterated.

So you definitely have to think about that. You know, think about the source of where you're getting these products. If you are in your typical pharmacy, most of the products should have at least some level of guarantee in terms of the quality on them. But there's a couple different organizations that basically have third party testing and these products and these supplements can actually have certifications.

So you might see things on the label like USP, which is United States Pharmacopia. That's sort of the gold standard. Some of the bigger brands will actually have USP certification. So that's a great seal to look for. You can also see something like NSF which is basically for sports supplements, especially we'll have this since there are such strict regulations around drug testing. Athletes in particular have to be really careful to make sure that any supplements they're using don't have contaminants in them that could flag a drug screen.

Another organization is called Consumer Lab. And so Consumer Lab does third party testing as well.

And then the last couple of organizations you might see are something like UL, which is Underwriters Laboratories. Or some more specific groups like international fish oil standards as well as band substances control groups. So certifications can be a great way to kind of just do a quick check on the quality.

Even if they don't have one of these, is there something else that's on the product that says the quality is guaranteed or that they have any type of other testing or standardization that the product goes through.

So next, what I like to look for whenever someone is asking about a product, particularly in a retail store, is there's really, as you're looking at the label, two main sections that you can look at.

The first one is the actual nutrition label that is going to be the supplement fax label. And so that's gonna tell you what the active ingredients are. But before we even dive into that, I really like to look at the inactive ingredients because that's gonna tell you more so right off the bat. If these products are containing things like fillers or synthetic ingredients that really are going to kind of dilute down the value of the supplement that you are looking at.

And so there could be a number of things in a product such as artificial colors. If it says red dyes or yellow dyes, it could have artificial flavors or artificial sweeteners. Those are all things that we tell you to avoid in your food, but yet, in trying to eat this healthy diet, you might be loading up on a bunch of supplements that have.

The same ingredients that we're trying to avoid in our food. So that's the first step. And of course, things like gummy vitamins and chewables, and all of that have become really popular over the last few years. Lauren I know. And so it's not to say that you can't use a gummy vitamin because there's actually even differences between cleaner brands that produce gummy vitamin supplements versus other brands that are gonna be full of artificial colors and I love the flavors.

Melody13:03

The the apple cider vinegar ones and like, well, love the fact that like you're taking it to like improve your weight or things like that. And then it's got sugar in it.

So it's just sort of like a contrast.

Lauren13:15

Yes, exactly. So ultimately when you're looking at something like a gummy vitamin, most of them have between two to five grams of sugar in just like two gummies. And so for some of these things especially if it's one that you're taking like an apple cider gummy multiple times a day, potentially with every meal, you're adding in upwards of 10 to 20 grams of sugar in a day.

And that's if you're just taking one supplement, if you source all of your supplements through gummies then ultimately, I mean, you could be eating handfuls of these things. And it's really gonna add up. So when possible, you know, the gummies are really not the ideal form. There's also a lot of potential.

Melody13:58

I had one supplement that was actually like a whole foods based gummy, but it gave me cavities. And then I stopped doing that. I haven't had a cavity since. But it's partially just, I mean, you could brush your teeth afterwards. Yes. But depending on how rigidy your teeth are and all of that, it can make a difference.

Lauren14:15

Yeah, so the gummies are, are a little problematic in a number of ways. But outside of that, even if we're not looking at gummies, you might be looking at a tablet versus a capsule form. Generally speaking, the tablets have to have a lot more binders and ingredients to hold them together.

Whereas capsules can be a little bit cleaner in that you might just have a simple gelatin or plant-based capsule and the active ingredients can go right inside of there. But some of the different fillers that you might see or additives you might see are things like cellulose, steric acid, gelatin, soybean oil, maltodextrin, potassium sorbate, silicone dioxide, citric acid, soil lessen, sorbital.

So some of these different things, magnesium steroid is a really common additive. A lot of these additives are considered as like what the FDA would call generally recognized as safe, meaning that in really small quantities, they're supposedly safe, right? They're not going to be immediately toxic, but by the same token, something like titanium dioxide, which is typically used to make a supplement more of a pure white color.

So maybe it doesn't look like it's brown, it's supposed to make it look better. That's something that's currently in the news right now because of the lawsuit that someone is filing against Skittles. Because they're saying that, you know, yes, there's tiny amounts of titanium dioxide in them, but when you eat Skittles on a regular basis and you're eating large quantities of it, that is adding up.

And so the same thing goes for a supplement. You might have just a tiny amount of titanium dioxide that's in that supplement, but if it's something you're taking every day, if it's in multiple of the brands that you're taking and you're taking it for potentially long term, that little tiny amount is something that can really add up.

So that's why we really wanna start with looking at those inactive ingredients to see is this even a product that's worth looking at? What's actually in it in terms of the active ingredients, because if it's full of junk, then it's not gonna be a great way to get those active ingredients. And then secondly, you also wanna look for things like allergens, right?

Because for a lot of people, especially on their functional medicine journey, they might be going through different types of elimination, diets. And so things like milk, eggs, fish, even shellfish in some types of calcium supplements or collagen supplements could be problematic. Same thing with tree nuts.

If there's any type of oils or things like that, that are in there. And then of course, wheat as well, can be in certain products. So lots of different allergens to look for as well and allergens are supposed to be very clearly disclosed on the label. So that should be a little bit easier to look for.

And then after that, you can get into looking at the actual ingredients themselves as far as active ingredients. And so of course you wanna make sure that we're looking for, active ingredients that are going to work for you. And so from a functional standpoint, we often talk about making sure that the active ingredients are truly active in their active forms.

Right? So one example might be vitamin D. Comes in different forms, right? So there's vitamin D two, which is sort of the precursor of the vitamin D3, that is actually the active form. And so for a lot of patients, when their doctor writes a prescription for D2, they're taking that, but then their body has to go and convert that to an active form of D3.

And so why not just take the D3, that's going to already be.

Same thing goes for things like B12, right? So Siano Cobain is the most common form of B12 that's in most supplements, but for a lot of patients, they have difficulty converting that into a more active form such as methylcobalamin. And then also the body potentially has to detoxify that cyanide molecule that the actual B vitamin is bound to.

And so again, from a safety standpoint, the cyan Ballin is of course approved. So it's, it's not that they're saying this is toxic in and of itself, but again, when you think about taking really high doses for really long periods of time, is there a better option that your body is going to be able to process and use such as a methylcobalamin. But at the same time, supplements are something that should truly be tailored and individualized because for some people that maybe are really sensitive to their methylation pathways, a methyl vitamin might actually not be great.

So they might actually struggle if they're using certain type of B vitamin that's methylated, or whether it's folic acid versus a methyl folate versus a folenic acid. It's all gonna be really unique to that individual person. And so some of these other types of vitamins, you might not even be able to find in your regular grocery store or pharmacy.

So something like a hydroxycobalamin or a felenic acid, those are much harder to come across. And that's where sometimes you might have to really seek out these professional quality supplements so that you can get exactly what you need for your individual body and your individual health needs. And so that's where I think PharmToTable comes in.

We've got some great options that Melody can kind of expand on in terms of finding the right supplements for you.

Melody20:06

Yeah. We could have a whole conversation probably about methylation and all of those things, but we're probably not prepared to talk about that today, but then there's all this also this case of like over methylation.

So we just take all these methylated vitamins, the potential for carcinogen process to start happening in the body. If we've got too much methylation, it's such a balance. And the scary part is that people could be just overdosing on a lot of this stuff and essentially we're disrupting the balance or the homeostasis in their body.

Another example I think, you know, is good to point out is that you may not actually it's Lauren pointed out the vitamin examples, but when it comes to herbs, sometimes certain parts of an herb are the part that is studied and has the active ingredient or even certain types. So like cinnamon, for example, there's multiple different species of cinnamon.

Some that have shown data in reducing blood sugar and some that have not. So if I just buy a cinnamon supplement, I'm not necessarily knowing if that is the right one. And so that's where knowing what you're looking for, working with a clinician that knows about it, whether it's an herbalist, a pharmacist, a integrative specialist, someone that's actually got the data, knows which product to choose that's gonna have.

And again, we can't say that this particular product treats a specific illness, because it's not a drug. We can't say that that's, it's not labeled as a drug, but we can say that we have data for, selon cinnamon to do X, Y, Z, or data shows that Sayon cinnamon at this dose did X, Y, Z. So sometimes patients might even consume that, or I've heard people say, oh, add a teaspoon of cinnamon to your oatmeal, to lower your blood sugars.

And while that's great, I'm always a food first advocate, that teaspoon of cinnamon probably is not getting absorbed well enough to hit the doses that we need in order for our blood sugars to reduce like in some of those studies. So I think just knowing like what dose you're getting does the company that you're working with have data that shows it gets absorbed, cuz if it's just stained in your stomach and your intestines and you're getting rid of it, it might not even be doing the job that you're wanting it to do.

I think there's a caveat with the whole tumeric conversation, because originally we thought we had to drive tumeric into the bloodstream through all these liposomal pathways. And then we're learning more about how tumeric actually has some anti-inflammatory benefits in the gut. So maybe it doesn't need to be driven into the bloodstream to actually have the effect.

And so that's really where we have to follow the research. If we're gonna be buying these things, taking these things, we have to sort of see what research we have that shows and what product and the same thing comes with probiotics. Probiotics are a billion dollar industry more as, or more of the supplement industry.

And if we don't pick the strains that actually have data to show that they actually do the effects, then we might not be actually getting any value from that supplement that we're taking and paying for. So working with a provider is super important and we do have visits actually purposefully designed to help you choose the best supplements.

So this is not a full functional medicine consult, but we do collect some information to find out what you're interest in and as far as selecting supplements, and determining those appropriate supplements for you. So it's only $50 a visit and it's called our brief supplement consult.

And that visit again is we're gonna ask you some basic questions about what you would like to do with your health, what your past medical history is, what drugs you take, cuz that's so important to selecting supplements. If there's any nutrient or herbal drug interactions, we wanna make sure we're watching out for those.

And then you'll meet with a pharmacist for a brief encounter. And then they'll come up with a plan for you as far making supplement recommendations. If you wanna dive deeper where you want lab testing, you want to look at your gut microbiome. You wanna look at your hormones. You wanna look at your nutrient levels.

We could potentially order some nutrient type things based on those supplement encounters. But I think that is probably best fit for a wellness visit or a functional medicine. So when we need to go deeper into lab work and, and evaluating that lab work, it takes a little bit more expansive amount of time.

So certainly with those patients, we're also gonna individualize their supplement regimen, but you've already know you've got labs for D or you've got labs for other nutrients or reasons you wanna take other nutrients and you just wanna make sure you're on the right track. You're choosing the best product.

Then certainly sign up for that appointment and we'd be happy to help steer you towards those products that we know are from reputable sources. Anything else you guys wanna add to this conversation? I know it's such a huge industry and really trying to help patients navigate those questions.

I guess I'll ask each of you this, if you were standing, talking to patients at the pharmacy counter, anything else that would come to mind besides like looking, I mean, certainly half the, the things on the shelves might go away just by looking at that inactive ingredient list like Lauren, talked about, but are there core nutrients that we would maybe need from supplementation in your mind, in, in traditional US population?

Lauren24:50

Yeah, I can definitely tackle that question. So, most people, in an ideal world, we would get all of our nutrients and vitamins and minerals from the food that we eat. But unfortunately it can be really challenging to eat a balanced diet and to get every single vitamin mineral that we need every single day.

The most common deficiencies that I see are number one, vitamin D mm-hmm , especially for those of us living in Ohio, Texas might have a little bit easier time getting that vitamin D from the sunlight. But for a lot of people, vitamin D is definitely an area that they can be deficient in. And , like we said, it's great to get it from either food or from sunlight, but if your levels are low, sometimes it can take that supplement to really help get it back in balance faster.

And so that's something you can test for and actually know where your level is at and know if you need to supplement. So that would be one.

Melody25:51

I would say to that with the vitamin D conversation. The first time I ever tested my vitamin D it was like 13 or something like that low. And I just think like, based on all the research I've seen and everything, just all the things in my health that have improved.

I mean, certainly it's not like the magic bullet for everything, but I mean, I used to get sick three or four times a year and get everything my kids had and all of that. And like, once you get your vitamin D level to a certain place, it really helps so much with your immune function. I mean, we've seen the data with vitamin D and COVID and all of that too, but it's just such an important level.

And I know there's lots of controversies associated with it that we don't have to time to dig into today too. But it's really an important hormone to keep it's actually a hormone, as well as, because our body can make it as well as an external nutrient. But, certainly I agree, a hundred percent that Americans and people across the world need to make sure their D levels are adequate.

Lauren26:43

Yeah, I think the second that I see most commonly is magnesium. So magnesium is another one that can be a little tricky to get from our food sources. And because it's used in so many different functions within the body, a lot of people can be deficient in this. And have really noticeable symptoms.

So if you're getting things like muscle cramping, if you're getting anxiety, if you have trouble sleeping, lots of different reasons that you might be low in magnesium. And magnesium's another one where there's so many different forms and formulations, it can be really tricky to figure out which one's right for you.

Most of the supplements you see on the store shelves are probably magnesium oxide, which is the most poorly absorbed. So you might want to look at which magnesium you might need. So a saturate form can be really great for if you're someone that tends to be more constipated, because it really can help with that problem.

If you're looking for more of like a glycinate form can be more of a calming form of magnesium that can be absorbed well. Same thing with a three in eight form also really great for sleep or for anxiety. So magnesium's probably another one that I see a lot of people are low in. You can also even get it in topical form so you can get it in a spray or a cream and actually apply it to new areas that might be

Melody28:03

sore ever spray it on freshly shaven lakes. Don't matter. It is the most terrible experience.

Lauren28:11

yes, yes.

Melody28:13

So bad. I was like, oh my goodness. I try to rinse it off and it doesn't come off anyways.

Lauren28:18

That's a, a great pharmacist tip. Same thing with epsom salt baths actually happening magnesium in them as well. And so you can absorb it that way. So lots of great ways to get your magnesium in.

So I think those are probably my main two. And then number three would be omega threes. Again, really hard to get from food, especially if you're someone that doesn't eat a lot of fatty fish or potentially healthy grass fed beef, things like that. If you're more on the plant based vegan, vegetarian side, getting an omega 3s is, very, very challenging, and you most likely will need to supplement with an algae based form of omega 3s.

Which you can get, but that's another one that the quality does matter. A good fish oil really shouldn't smell or taste fishy, that kind of indicates that it might be more rancid. So you can get good quality fish oils in a lot of different forms too.

I have a really hard time in taking big capsules, the trick is to actually take a bite of food, chew your food really, really, really well to the point that you're ready to swallow, chew it like three more times and then put the supplement in your mouth and swallow it. The, you know what we call a bolus of food that actually can help to get those down.

There's some brands that even make emulsified versions of fish oil liquid, that taste great. So the mango one, if you struggle with that, that can be a good tip. So I think those are my top three. And then I would just add in B vitamins as well.

Again, depending on your genetics, you may need to supplement with some B vitamins and also depending on your diet, again, if you're a vegan, supplementing with a little B12, it's gonna be super important to make sure that you are getting that particular nutrient, in your diet.

Melody30:06

Yeah. And potentially iron too, depending on how much, how well of an iron absorber you are specific to the vegan vegetarian population.

Lauren30:12

So, yeah, iron. Definitely one for that population to consider. Can be a little tricky for others that are trying to supplement with it. It's not always well tolerated.

Mm-hmm. Another one that you might want to test your levels, um, and kind of do a deep dive to determine if you need to be supplementing with iron or not.

Melody30:31

Yeah. Thankfully, fair shell, which is like a registered trademark type of iron actually does really well with absorption and doesn't cause constipation or nausea, like the other kind.

So I find that that one is really well absorbed even, and tolerated even by like pregnant women, that need to supplement with iron. So a lot of you can hear us talking about a lot of these like patient specific reasons. We might use one thing over another thing. The point is you should work with a provider, help get help in figuring out this process, cuz otherwise you're gonna spend.

I don't even know how many thousands of dollars trying out things that might not even provide you the benefit that you're looking for. So really tailoring that regimen to the data and to your needs.

And that can really help you save money. So while it seems like some of these higher quality products may be more expensive, in reality, you might be using less than you would've needed to do that cheaper quality product.

So you're gonna get a bigger bang for your buck, essentially.

Thanks for joining our Table Talk podcast, choosing quality supplements.

And as always, you can find us at PharmToTable. PHARMTOTABLE.life L I F E. And if you're looking to book a supplement, consult that brief supplement consult that we discussed, you can click make an appointment, and that will lead you to the page where you can select your state.

And from there you can click on a provider and find the provider in your state that you wanna work with and book that appointment. So if you have any questions or concerns, there's also a chat box now on our website that you can message us if you're having any issues with booking that supplement consult.

So looking forward to seeing many of you soon, thank you.

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