Gunter's Guide to Supplements

You Deserve Informed Consent

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A while back I put a call out for questions, and the biggest bucket of requests was about supplements. That led to me writing more posts about supplements and more… so I felt it was time to organize them so they were easier to find. In this subsection of The Vajenda, you’ll find a table of contents (this post) and my posts about vitamins, minerals, probiotics, vaginal products, and a whole host of special mixes, as well as background information about legislation or lack thereof (in the United States anyway). And, of course, plenty of information about risks. If the supplement industry isn’t going to provide you with informed consent, then I’m stepping up!

Most of the supplements you’ll read about here are understudied; for some, the data amounts to little more than a hypothesis. Sometimes people think to themselves, well, I want to be cutting edge, so I’m okay trying something new, but it’s important not to confuse a novel hypothesis for cutting-edge. Cutting-edge therapy is my 20-year-old son having open heart surgery where a valve was replaced without needing a blood transfusion and being able to walk a mile just two weeks later. The surgery, multiple post-operative protocols, and even the choice of valves weren’t just an idea his surgeon dreamed up; his cutting-edge therapy was the tip of a massive research iceberg that started with many intriguing hypotheses.

Many intriguing hypotheses don’t pan out. For example, delaying the introduction of peanuts until age three used to be the recommendation to reduce peanut allergies. The hypothesis was that the immune system would be more mature and better able to handle peanuts. That seems like a sound hypothesis, but when it was actually studied, the reverse was true. The early introduction of peanuts significantly reduced the risk of allergies, and the recommendation changed as a result. 

Medicine is littered with incredible harm from so-called disruptive or novel medications and interventions that were never evaluated appropriately. The Rely tampon is a classic example (unstudied super absorbent material led to toxic shock syndrome and some deaths), there is the medication thalidomide (unstudied in pregnancy, which led to miscarriages and severe birth deformities), and the Dalkon shield (inadequately studied IUD, which led to severe infections and some deaths), and many more. It’s important not to confuse “cutting edge” with inadequately studied products quickly foisted on people courtesy of unfettered capitalism. And it’s equally as important to note how many of these unstudied/inadequately studied products and medications were meant for women.

With supplements, it’s hard to know the dangers because there is so little research, so in many cases, the waters are essentially uncharted. For example, supplements are a growing cause of liver failure, and supplement adulteration, often with pharmaceuticals or even completely novel drugs, is a real concern. There is also microbial contamination, and many supplements don’t contain the amount of active ingredient that the label claims. For example, in a study published in JAMA (2024), researchers looked at the accuracy of labeling for products containing galantamine, a medication used to treat dementia (primarily Alzheimer's disease), but it has some off-label indications as well. Galantamine offered a unique opportunity to compare the accuracy of labeling for a prescription product versus a supplement, as galantamine is available as both a prescription (regulated) and as a supplement (unregulated). With the regulated prescription (generics were chosen), the amount of galantamine in the pills was between 97.5% and 104.2% of the amount indicated on the label, which is not an uncommon margin of error, and there was no bacterial contamination. However, with the unregulated, over-the-counter supplement version, the amount of galantamine ranged from less than 2% to as much as 110% percent of what was printed on the label, and only one product contained what is claimed with the same margin of error as the prescription products. In addition, three or 30% of the supplements were contaminated with genes for the enterotoxin produced by Bacillus cereus sensu stricto, which is a cause of food poisoning.

People often mistakenly think I am pro-Big Pharma. I am not. I am pro-regulation, as study after study shows us that when regulations don’t exist, people suffer. 

What about third-party validation? While it may help, especially when it comes to identifying contaminants or adulteration, it may not guarantee the product contains the amount of product that it claims. You can read more about that in this post on prenatal vitamins. 

We also don’t know how supplements might negatively affect the body or interact with other medications. For example, turmeric/curcumin interferes with iron metabolism and can cause iron deficiency. How many other supplements negatively affect a different bodily function?

It’s not wrong to try a supplement that isn’t recommended in any guideline. It’s your body and your choice. What is wrong is for a medical provider, coach, or person with a supplement store to misrepresent supplements as being “science-backed,” “doctor-approved,” or “expert-recommended” when quality studies supporting effectiveness and safety are lacking. And it’s wrong not to inform you of the risks. You can make an informed choice only when you are given accurate information. Consider two ways information about chasteberry for PMS could be presented:

The first is from a woman’s health company that just happens to sell chasteberry:

Widely recommended by women’s health experts, chasteberry helps to relieve mood swings and headaches, lowers stress levels, reduces sleep disruptions, and lessens feelings of fatigue.  In addition, chasteberry reduces breast tenderness during PMS and significantly helps in managing cyclical mastalgia.

Versus how I describe the data on chasteberry:

Chasteberry or Vitex agnus-castus, also known as vitex. The hypothesis is that it might help PMS by stimulating dopamine receptors, which may affect levels of prolactin and progesterone levels. There have been 13 or so studies worth evaluating, but unfortunately, they are all low to moderate quality. While there was a suggestion of benefit, the quality of the studies and the different preparations used makes conclusions impossible. Using chasteberry for PMS is best described as exploratory, and experts agree that it can’t be recommended without further study. It does not appear as a recommended therapy in any major guideline for PMS. There haven’t been major safety signals that we are aware of, but as it is understudied, we can’t fully inform about risks. If you decide to take this product, you should be aware that supplements are not tested to prove they contain what they claim, and there are increasing reports of supplements that have been adulterated with pharmaceuticals, even antidepressants. In addition, supplements are a growing cause of liver failure. If you decide you want to try chasteberry, do not choose a product that mentions the term “proprietary blend,” and look for one with a seal indicating third-party testing, such as USP Verified.

If you were to decide to take chasteberry for PMS based on the first advice, you would be making an uninformed choice. But you wouldn’t realize that because you wouldn’t know that you hadn’t been given enough information to make an informed choice. On the other hand, deciding to take chasteberry when you know the data is low quality would be an informed choice. It’s easy to see why people might be attracted to the more optimistic but much less informative, and in my opinion unethical, first presentation.

But Dr. Gunter, you’re just not open-minded to holistic/Eastern/alternative/cutting-edge medicine. 

This is a straw woman argument. I am actually very open-minded to all kinds of approaches to medicine WHEN they are backed by quality research. But the truth is most supplements fail to meet even basic benchmarks for efficacy, and many are of questionable safety, and some don’t even contain what they claim. Let me pose the question that people should be asking. Why are those who manufacture, sell, and promote supplements closed-minded to validating that their “ancient” and/or “natural” remedies actually work by rigorously testing them vs. placebos? I believe women DESERVE science, and unlike many who sell supplements, I am not interested in lowering my medical standards for a buck. Actually, it’s more like millions of bucks. The answer to a history of research neglect isn’t to foist understudied, unregulated products on women. That is exploiting the gaps in medicine, not closing them. 

But Big Pharma won’t study natural products! 

Untrue. Many pharmaceuticals are based on compounds found in nature because nature is filled with bioactive chemicals: digoxin from foxglove; ergotamine, from a mycotoxin from a mold that grows on rye; and paclitaxel, a chemotherapy drug from the bark of the Pacific yew tree, to name but a few. Sometimes, a natural product is used (meaning found in nature), but often, compounds are tweaked to make them more suitable (usually more active and/or less toxic), and sometimes, even completely synthetic versions are produced. 

There are many advantages to making a compound synthetically. For example, the availability of some raw products, such as soybeans destined to be used to make estradiol and progesterone, can be impacted by the weather. Or the weather might affect the concentration of the bioactive compound from season to season. Also, natural compounds can be contaminated with lead or other substances from the soil. When a compound can be made in a lab, those issues don’t exist. 

The NIH also spends taxpayer dollars researching natural substances. For example, at least $150 million of US taxpayer money has been spent studying curcumin, and yet we still don’t have definitive data about its benefits.

Do you know who doesn’t spend much money studying these products? The supplement industry. It’s not as if they don’t have the cash. In 2023, Americans spent about $45 billion on supplements, and worldwide, that number is about $177 billion. To be clear, there is no incentive to study these products. If you are already legally selling your product and making money hand over fist, doing a proper study might just find data showing your product is no better than a placebo or that it causes harm. Why risk a study that could end your profits? 

With that preamble, here is Gunter’s Guide to Supplements and Such. As I write about more products, I’ll add them to the Table of Contents below with a hyperlink. If you have specific products you’d like me to write about, leave the request in the comments! And as always, the information here is not individual medical advice.

Gunter’s Guide to Supplements and Such

The Basics

***START HERE*** -> What is a supplement anyway? This post breaks down the basics of the different types of products. Really, read this first because there are some cases where supplements are indicated, and the language can be confusing (which the industry counts on)

The Death-Strewn Backstory of Big Supplement, how we got here (in the United States)

My Open-Minded Approach to Alternative Medicine. Really!

Homeopathic remedies, do you know what they are? Many people do not. Read this post before taking any.

Supplement companies often use podcasts to gain influence. An important read about advertising and using trusted podcasters to whitewash supplements.

The Money

The Money in Menopause Supplements.  I created my own supplement to show how much someone can make selling supplements and how easy it is.

Avenir Nutrition, a company that makes a useless product that glorifies binge drinking, is making millions in sales. Read about their cash claims here. It seems that cultivating a large, engaged following on social media can be wildly profitable. 

Adulteration and Contamination

Lead poisoning in Ayurvedic Medicine. It’s a huge issue.

Mislabeling and dangerous ingredients in sports enhancers. One product even contained a compound that has NEVER BEEN TESTED IN HUMANS (yes, I am shouting).

Products

Hangovers/Alcohol/Liver

The Liver Shield, a supplement that claims to support the liver and help you recover from drinking.

Z-Biotics. A product that claims it can prevent hangovers.

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Magnesium

And Osteoporosis

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Menopause

Dr. Kellyann & ME Peri plus Menopause, promoted by Drew Barrymore 

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Menstrual-Related Concerns

Castor Oil Packs for Menstrual Pain

Flo vitamins for PMS 

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Probiotics

Can probiotics prevent osteoporosis?

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Pregnancy

Mislabeling of prenatal vitamins. This is one of the most pressing reasons we need legislation because prenatal vitamins are among the few medically recommended supplements.

Folic acid: Why you need a prenatal vitamin with folic acid and not “natural” folate or methylfolate. Most designer prenatal vitamins do not have folic acid! 

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Vaginal Products

Vaginal boric acid, this is one of those products that is taken advantage of as it does have a legitimate use for two conditions. However, it is inappropriately promoted to balance the vaginal pH, which it cannot do. 

References

Tucker J, Fischer T, Upjohn L, Mazzera D, Kumar M. Unapproved Pharmaceutical Ingredients Included in Dietary Supplements Associated With US Food and Drug Administration Warnings. JAMA Netw Open. 2018;1(6):e183337. doi:10.1001/jamanetworkopen.2018.3337

Ghabril, M, Ma J, Patidar K, et. al. Eight‐Fold Increase in Dietary Supplement–Related Liver Failure Leading to Transplant Waitlisting Over the Last Quarter Century in the United States. Liver Transplantation 28(2):p 169-179, February 2022. | DOI: 10.1002/lt.26246

Cohen PA, Jacobs B, Van Hoorde K, Vanhee C. Accuracy of Labeling of Galantamine Generic Drugs and Dietary Supplements. JAMA. 2024;331(11):974–976. doi:10.1001/jama.2024.0328

Csupor D, Lantos T, Hegyi P, et. al. Vitex agnus-castus in premenstrual syndrome: A meta-analysis of double-blind randomised controlled trials. Complement Ther Med. 2019 Dec;47:102190. doi: 10.1016/j.ctim.2019.08.024. Epub 2019 Aug 30. PMID: 31780016.