A number of terms have been used to refer to supplements that cannot be classified as either herbal remedies or as vitamins or minerals. Often, they are referred to simply as "supplements," or they may be categorized as "nutritional supplements" or as "nutraceuticals," as used here.

Nutraceuticals may be synthesized to some degree by the body or may be compounds isolated from certain foods. Often, the claim is made that the body requires more of these compounds than it can synthesize itself under certain circumstances (e.g., taking certain medications, aging, depletion with a disease process). Nutraceuticals that the body can synthesize include phosphatidylserine, methylsulfonylmeth-ane (MSM), and S-adenosylmethionine (SAMe). Digestive enzymes (e.g., trypsin) and hormones (e.g., DHEA, melato-nin) are also popular products. Substances that are not necessarily synthesized by the body but nevertheless believed to play a useful physiologic role, such as citrus bioflavonoids and fructo-oligosaccharides, also fall into this category.

Data on overall sales and use of nutraceuticals are sparse. Measurement of nutraceutical consumption is complicated by their common incorporation into foods or multivitamins, which may then be referred to as "superfoods" or "megavitamins," based on these additions. Some nutraceuticals, such as lycopene and plant bioflavonoids, are natural compounds derived from fruits, vegetables, or grains.

When advising patients, it is often difficult to determine bioavailability when nutraceuticals are consumed orally. Health benefits are frequently attributed to nutraceuticals based only on in vitro data or a nutraceutical's known physiologic role, rather than based on evidence derived from randomized controlled trials (RCTs). Dosage of a given nutraceutical may be as variable among products as price. Table 52-6 lists a number of nutraceuticals, their uses, contraindications, and efficacy when available.

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