A Few Thoughts About Supplements

Thanks to Dr. Nathan for bringing our attention to an article in the New York Times on 1/5/2018 titled, “How to Counter the Circus of Pseudoscience,” by Lisa Pryor, a medical doctor and author of “A Small Book About Drugs.” It might lend some insight into the struggles we physicians have with saying yes or no to supplements that our patients ask about.

There are several major points made by Dr. Pryor, mostly revolving around the need to question science and keep learning. We must recognize our own shortcomings and be aware that our knowledge base is something less than 100% regarding optimal medical treatments.

“Most doctors, especially the good ones, are acutely aware of the limits of their knowledge. I have learned from those much more experienced and qualified than me that humility is something to be cultivated over time, not lost.”

As physicians, our recommendations for treatment are “evidence-based”. As we have discussed in earlier articles, we depend on randomized controlled trials to compare different treatments and decide which is best in a certain situation for a particular patient. As a result of ongoing research, practices change as new evidence emerges.

“Guidelines are revised, advice is reversed — on blood pressure, diet, hormone replacement, opioid prescribing. This can be immensely frustrating for patients, even though it is what we must do to provide the best possible treatment.”

Another point Dr. Pryor makes is that other practitioners may strongly advocate for treatments that have no scientific basis. Her argument is that the less one knows about evidence-based medicine, the more easily one can be persuaded that an alternative treatment is useful. The passion with which these products are ‘prescribed’ makes it more likely that the client or customer will buy them. As non-prescription supplements, they are not regulated and are not held to the same standards of proof of effectiveness that prescription drugs are. And there is no quality control between one bottle and the next. The supplements sold in a practitioner’s office are usually quite expensive, to the benefit of the practitioner who is both recommending and selling them. Be aware that naturopath doctors are not medical doctors. Here’s more on that specialty.

My main concern about these situations is that these practitioners don’t know what they don’t know. In other words, they can easily be waiting for alternative treatments to work without doing appropriate workup for something that might be a medical problem that warrants other treatment, sooner rather than later.

“In the face of this circus, we doctors must hold tight to evidence. We must hold tight to our doubt, our knowledge of our fallibility as individuals and as a profession, knowing that humility is a strength, not a weakness. … But we must also as a profession engage in the public conversations about health, including on social media, along with our colleagues in allied health fields. If we do not, the discussion will be dominated by the passionately uninformed, who build trust only to sell false cures. And we must listen to patients, as we are taught to do, showing care and understanding. We must take on the difficult challenge of inspiring and motivating with the truth.”

To help me sort out some of the products my patients tell me they’ve bought, I sometimes access the National Center for Comprehensive and Integrative Health (NCCIH, at nccih.nih.gov), which is one of 27 divisions of NIH. The mission of NCCIH is to define, through scientific investigation, the usefulness and safety of complementary and integrative health interventions.

For instance, biotin is something I am frequently asked about. Check out the information NCCIH posts, in this particular case from medlineplus.gov.

My patients have recently receiving recommendations for peppermint oil from their GI specialists. Here’s some info on that. 

And maybe you’ve heard that medications that are used to treat reflux, called proton pump inhibitors (PPIs) may lower magnesium. Here’s some info about that – with some tips about checking your magnesium level, increasing magnesium intake in your foods, watching your kidney function, and possibly using magnesium to decrease migraine headaches.

Here’s a word of advice, or two: Be Skeptical. Medical doctors don’t have a problem with over-the-counter supplements in general, as long as there’s some proof that they work. And it’s best if your doctor knows about the supplements that you’re taking. Sometimes they can account for problems you’re having, such as nausea, dizziness or constipation. Interestingly, I’ve recently read that in those taking high doses of biotin, thyroid tests might be affected.

There are times that my experience with a supplement makes me believe it may work even when there’s no proof that it does. What do I do then? I tell my patients they should try it … but there’s no proof that it works. If it works for them, fine; otherwise, they can stop it.

Tell all your health care providers about any complementary or integrative health approaches you use. Give them a full picture of what you do to manage your health. This will help ensure coordinated and safe care. Most competent M.D.s would be interested in answering your questions regarding treatments that they prescribe. Expect the same of any other professionals you trust with your health. It’s the most valuable asset you have!