Supplements: Bittersweet pills?

From supermarkets and chemists to specialty health and wellbeing stores, our marketplace has been inundated with vitamins and supplements which, when taken regularly, are purported to propel us into a state of optimal health. Available in a number of sizes, shapes, flavours, and forms — capsules, tablets, powders, chewables, softgels, and liquids — these products and the burgeoning industry they represent are the subject of both accolades and disparagement. On one hand they are revered for safeguarding us from the perils of modern-day living; poor diets, sedentary lifestyles, and largely indoor existences. On the other, they are deemed unnecessary and potentially harmful.

Despite the scepticism surrounding the industry, there is no disputing that it’s on the rise. Market research company Future Market Insights calculated the global dietary supplements market revenue to be US$123.3 billion in 2015, and forecasts that it will more than double to US$252.1 billion by 2025. This corroborates information provided by the CEO of Australian-based supplement and wellness company Swisse, Radek Sali, who says: "The industry is turning over around AU$3.5 billion annually in Australia alone. That’s expected to grow to AU$4.6 billion over the next
three years."

Asked why he believes the industry is growing at such a rapid pace, Radek points to the fact that health and wellbeing has become aspirational; something that everyone wants to attain. "I think there’s a rising consumer understanding around wellness," he says, "and wellness is something that we all strive for. Our lives are precious; we want to live as long as we possibly can, which means doing the right things for our bodies. Exercising, having a good state of mind, and choosing the right nutrition — including supplementation — all add up to better health outcomes."

"Our lives are precious; we want to live as long as we possibly can, which means doing the right things for our bodies." – Radek Sali

However, this is only one view in what is a very fractious debate. Dr Rachael A Dunlop, a Senior Scientist from the Institute for Ethnomedicine in the US, has interpreted the industry’s growth entirely differently. Beyond simply being drawn to the promise of wellness, Rachael believes that the industry is growing so quickly because consumers are enticed by the promise of a magic pill; a ‘get healthy quick’ cure-all that supplants the fundamental problems typically causing ill-health; things like diet and exercise. "The promises of the supplement industry are extremely seductive," she explains. "You’ll look younger, skinnier, and have more energy; all the things many of us want. But in a time poor world, and where otherwise significant effort is involved, we’d rather take the easy way out."

Of course, this so-called ‘easy way’ is not without risk. In many instances supplements simply don’t do what they claim to and, in more extreme cases, have been known to cause harm.

Global Standards

One of the largest problems when evaluating the safety of supplements, is that each country in the world regulates its own industry. While there is an overwhelming trend for under-regulation, there are huge discrepancies from one country to the next. For instance, in the UK supplements are considered to be foods, and are consequently regulated by the Food Standards Agency and the Department of Health (FSADH). Therefore, unless a medical claim is made by the manufacturer, supplements aren’t subject to the same stringent regulatory process that the UK’s Medicines and Healthcare Regulatory Agency apply to medicines.

Similarly, in the US supplements are regulated under the Dietary Supplement Health and Education Act, a branch of the Federal Food, Drug and Cosmetic Act. This means that the onus is largely on supplement manufacturers to self-regulate, as they are not required to obtain approval from the Food and Drug Administration (FDA) before marketing dietary supplements. The FDA’s website states: "Before a firm markets a dietary supplement, the firm is responsible for ensuring that: the products it manufactures or distributes are safe; any claims made about the products are not false or misleading; and, the products comply with the Federal Food, Drug, and Cosmetic
Act and FDA regulations in all other respects."

Conversely, in Australia supplements are considered to be complementary medicines, and as such are regulated by the Therapeutic Goods Administration (TGA). However, when labelling products, the TGA divides medicines into two categories; Aust L and Aust R. While Aust R medicines include prescriptions and over-the-counter medicines, which are checked against safety and quality criteria, the majority of supplements fall into the Aust L category, which is far less tightly regulated. When it comes to Aust L products, the onus is again on the manufacturer to certify that they have only used pre-approved low-risk ingredients, and evidence is not required by the TGA.

"The TGA is known as a paper tiger because it has no teeth," says Rachael. "Manufacturers are required to state they hold evidence for the product’s use and benefits, but are not required to present such evidence before it is licensed. Not to mention the standards of evidence can be very tenuous, such as ‘used in antiquity’, which merely requires companies to say that a product has been ‘used by the ancient xyz African hill tribe for generations’ and they get a listing for their product.

"Furthermore, the system is reactive not pro-active, relying on people to complain rather than the TGA conducting its own investigations. Often when products are deemed to breach regulations, the TGA still don’t enforce directives, because the cost to prosecute is regularly greater than the fine."

Despite these pitfalls, Australia’s supplement regulation is heralded as being one of the best in the world. "All supplements manufactured in Australia are manufactured as a therapeutic product, so they’re subject to the same scrutiny as drug medicine," explains Radek. "Only Canada has a similar system; the rest of the world legislate the manufacture of products under food standard. So if you’re not buying a product from a plant that’s manufactured under TGA or the Canadian equivalent, you’re going to be buying a product manufactured in a food grade plant, which doesn’t require as stringent testing and cleaning as a drug plant."

Online Markets

The inconsistency in global standards combined with an increasingly digital marketplace exacerbates the potential risk factor of supplements. Not only are the regulatory standards of products bought online unclear, but there is also a large market for imitation and illegal products to be sold online. "Some supplements have been found to be contaminated with drugs such as steroids, or even heavy metals, and these are not something you want to be unknowingly consuming," says Rachael.

Recently there has been a spate of health complications that have arisen from the consumption of weight-loss products containing green tea extract. In 2014, the American College of Gastroenterology released findings that green tea catechins could be toxic and cause liver failure. Despite this, weight-loss supplements containing green tea extract continue to be sold online. Earlier this year, an otherwise healthy 27-year-old man in Australia had to have an emergency liver transplant after consuming a protein powder containing green tea extract that he’d bought online.

However, as Radek points out, most retail consumption — including the purchase of supplements — is trending towards online markets, and there are legal avenues providing for the online sale of supplements. "Currently there is a process where you can sell online as long as you are registered in the original country of sale," he says. "Swisse is the number one brand for selling online into China, and we also trade in the UK, Holland, Italy, and Singapore; and all of those countries have different regulations in place for supplements."

"Supplements by definition are drugs, thus they are capable of interacting
with other medication people may already be taking."- Professor Rachael A Dunlop

Contraindications

The majority of people who take vitamins and supplements self-medicate, believing that there’s little or no danger in taking complementary medicines. However, there are certain people who face a higher risk from the side effects of supplements, including people taking other medications, people recovering from surgery, pregnant and breastfeeding women, people undergoing cancer treatment, and children.

"Supplements by definition are drugs," says Rachael, "thus they are capable of interacting with other medication people may already be taking. This can either reduce the efficacy of the drug or increase it, potentially causing toxicity and adverse events. People generally self-diagnose the supplements they need and are also unlikely to reveal their supplement use to their doctor, and
this can make for a potentially
disastrous situation."

Do you need them?

There are two schools of thought when it comes to taking supplements. The first is that, on account of our poor diets and lifestyles, the majority of us struggle to meet basic dietary requirements and should therefore take supplements as a precautionary measure. "These days It’s pretty hard
to find someone without some sort of dietary deficiency," says Radek. "According to the Australian Bureau of Statistics, more than 90 per cent of people don’t eat enough fruit and vegetables, so everyone should take a multivitamin in order to ensure that they’re at least getting their basic nutritional needs met."

On the other hand, there is a strong argument that, unless diagnosed with a nutritional deficiency, the majority of us don’t require supplements. "There are certainly benefits to taking supplements if you have been diagnosed by a doctor and are being prescribed a pharmaceutical-grade product," explains Rachael. "Otherwise, if you have a pretty balanced diet, then you’re probably just creating expensive urine."

Fresh is best

It’s the position of the American Dietetic Association that the best nutritional strategy for promoting optimal health and wellness is to choose a wide variety of foods.

This view is supported by Dr Trent Watson, accredited practising dietitian and spokesperson for the Dietitians Association of Australia who, in conversation with independent consumer advocacy group Choice, says: "In the western world, even those not following such great diets are usually getting adequate nutrition, and it’s not necessary to take multivitamins for general health."

Additionally, there are several benefits that real food has over supplements. For instance, food contains fibre and polyphenols, which have been proven to help prevent degenerative diseases such as cancer and cardiovascular disease. Whole foods also contain a range of vitamins and nutrients in different forms, which are beneficial when it comes to the ability of the body to absorb certain nutrients. As an example, many forms of calcium exist in different types of foods, and — because calcium is better absorbed in conjunction with substances like proteins and vitamin D — foods remain the best source of calcium when compared to supplements.