Trends in Supplement Use Family Physicians Role

Key Points

• Under DSHEA, supplements are regulated differently from pharmaceuticals, with less governmental safety monitoring.

• The use of supplements is widespread.

• Patients should be encouraged to list their supplements whenever they are asked to list their medications.

• Patients may not always discuss supplement use with their health care providers.

The National Health Information Survey (NHIS) gathered data on complementary and alternative (or integrative) medicine (CAM) use and found that 17.7% of 23,393 adults and 3.9% of 9417 children had used nonvitamin, nonmineral natural products in the past 12 months (Barnes et al., 2008). Supplements have become a familiar sight in pharmacies, health food stores, and supermarkets. They are also widely available online, and many food products have them as added ingredients. The sheer number of available products and advertising claims can lead to confusion for patients and health care professionals alike.

Advising patients regarding supplement use can be challenging. Product safety and standardization are often variable. Research may be of poor quality or difficult to interpret. Supplement-drug interactions and other adverse effects are an ever-present concern. Furthermore, most physicians have received little formal teaching about supplements, and becoming familiar with the many popular products can seem daunting.

Despite these challenges, it is vital that family physicians have a working knowledge of appropriate supplement use. Although large numbers of people take supplements, many believe it is not useful to share this information with their physician. The 2002 NHIS found that only one third of the estimated 38 million American adults who use supplements were likely to report doing so to their physician. Disclosure rates were found to be lowest among males, younger adults, minorities, and less frequent users of Western medical care (Kennedy et al., 2008). Results from multiple public surveys, including telephone surveys of more than 2200 people, revealed that almost half of regular supplement users believed that their physicians were prejudiced against supplement use. About 44% thought their physicians had limited knowledge about such products (Blendon et al., 2001).

Specifically asking about herb and other supplement use when gathering a patient history is essential, given that patients may not always volunteer this information. Helping patients make choices regarding supplement use often involves negotiation. Of 1196 supplement users, 66% stated that they would keep taking the supplement they were taking most often, even if the U.S. Food and Drug Administration (FDA) reported it as ineffective (Blendon et al., 2001). People who take supplements often value their independence in making health care decisions, and many have spent much time researching various products online. Table 52-1 summarizes findings

Table 52-1 Main Reasons Patients Use Dietary Supplements

Kennedy (2007)* (n = 23,393 adults)

ConsumerLab.comf (n = 3226)

Kaufman et al.f (n = 2590)

1. Back pain

1. General health (67%)

1. 'To supplement the diet" (45%)

2. Neck pain

2. Colds (53%)

2. General health (16%)

3. Joint pain (5.2%)

3. Osteoarthritis (39%)

3. Arthritis (7%)

4. Arthritis (3.5%)

4. Energy enhancement (37%)

4. Memory impairment (6%)

5. Anxiety (2.8%)

5. Cholesterol control (29%)

5. Energy (5%)

6. Cholesterol (2.1%)

6. Cancer prevention (28%)

6. Immune system enhancement (5%)

7. Head/chest cold (2.0%)

7. Allergies (27%)

7. Other joint issues (4%)

8. Other musculoskeletal conditions (1.8%)

8. Weight management (25%)

8. Sleep aid (3%)

9. Severe headache or migraine (1.6%)

9. Prostate problems (3%)

As often occurs with complementary and alternative/integrative medicine (CAM) modalities, use is most common for disorders (often chronic) that Western medical approaches may not be able to treat as safely or effectively.

^National Health Information Survey of reasons for CAM use in general, 2008.

tin 2002 study on reasons for supplement use, 54% of respondents indicated they were taking supplements for four or more simultaneous conditions. Respondents could give multiple reasons for taking supplements. Respondents were users of the ConsumerLab.com website and likely high-frequency herb users.

¿Results are based on a 2002 telephone survey of why people take supplements. The definition of "supplement" used for respondents excluded vitamins and minerals; 25% answered either "don't know" or "no reason specified" when asked about supplement use. Respondents could give multiple reasons for taking supplements.

on the reasons people give for taking dietary supplements. Many supplements have been used for thousands of years, and for some patients, this alone constitutes evidence that supplements are safe and beneficial. Native Americans had medicinal uses for more than 2500 different plant species (Moerman, 1998), and various "supplements" have been used as part of traditional medical practices in most cultures throughout history. In the United States before 1930, herbs constituted a significant proportion of the remedies listed in the United States Pharmacopeia (Blumenthal, 2003).

Only in recent decades have more scientifically based studies of supplement efficacy and safety been conducted. With the development of the National Center for Complementary and Alternative Medicine (NCCAM) in October 1998 within the National Institutes of Health (NIH), supplement research funding in the United States has grown dramatically. In other countries, groups such as the European Scientific Cooperative on Phytomedicines (ESCOP, www.escop.com) and Edzard Ernst's team at the University of Exeter have been gathering and analyzing data from hundreds of well-designed randomized trials. It is no longer legitimate during a patient encounter to make sweeping statements discouraging supplement use because, "We just don't know enough about them." To state that all supplements are dangerous is just as inaccurate as claiming, as many manufacturers do, that dietary supplements are consistently safe and effective. Some supplements have shown great promise in helping to prevent or treat various illnesses. Others have been proven harmful enough that their use should be discouraged. Ideally, physicians should be as informed and actively involved in patients' decisions regarding dietary supplements as they are with their decisions regarding prescription medications. Box 52-1 offers guidelines for discussing supplements with patients.

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