WHOLE HEALTH: CHANGE THE CONVERSATION

Advancing Skills in the Delivery of Personalized, Proactive, Patient-Driven Care

This document has been written for clinicians. The content was developed by the Integrative Medicine

Program, Department of Family Medicine, University of Wisconsin-Madison School of Medicine and Public

Health in cooperation with Pacific Institute for Research and Evaluation, under contract to the Office of

Patient Centered Care and Cultural Transformation, Veterans Health Administration.

Information is organized according to the diagram above, the Components of Proactive Health and Well-Being.

While conventional treatments may be covered to some degree, the focus is on other areas of Whole Health

that are less likely to be covered elsewhere and may be less familiar to most readers. There is no intention to

dismiss what conventional care has to offer. Rather, you are encouraged to learn more about other

approaches and how they may be used to complement conventional care. The ultimate decision to use a

given approach should be based on many factors, including patient preferences, clinician comfort level,

efficacy data, safety, and accessibility. No one approach is right for everyone; personalizing care is of

fundamental importance.

Dietary Supplements: An Overview Educational Overview

VHA Office of Patient Centered Care and Cultural Transformation Page 1 of 14

WHOLE HEALTH: CHANGE THE CONVERSATION Dietary Supplements: An Overview

Educational Overview

Vignette: Frederick Frederick is a 51-year old Air Force Veteran who is completely perplexed about the meaning on the packaging for several products that he recently purchased to help him with his “GI reflex.” He wants to take licorice but is not sure it is safe or what the right dose would be. He is also concerned because he has hypertension and “early diabetes.” He takes hydrochlorothiazide, lisinopril, and metformin and does not want to take anything that will interact with his medications. Conversations with health food store employees and knowledgeable relatives led him to also start a multi-vitamin, omega-3s, ginkgo, bilberry, and coenzyme Q10. His regimen is expensive and he is wondering about its usefulness. As you collaborate with Frederick on a Personal Health Plan (PHP), which supplements do you counsel him to continue or stop taking? What are the correct doses? Side effects? Reliable brands? What should he look for on a label that would indicate quality products?

Statistics about Supplement Use and Why They Are Used

20% of the U.S. population regularly uses nonvitamin, nonmineral dietary supplements.1,2

Recent estimates are that approximately 20% of the U.S. population regularly uses nonvitamin, nonmineral dietary supplements.1,2 The prevalence of herbal medicine use by some ethnic and cultural groups in the United States may be even higher; one meta-analysis found that 4-100% (mean 30%) of Latinos living in the United States regularly use herbals.3 People in the United States spend more than $5.5 billion yearly on thousands of different dietary supplements; the top botanical products purchased are cranberry, garlic, saw palmetto, soy, flax, turmeric, aloe, wheat/barley grass, spirulina, and ginkgo.4 The most popular non-herbal supplements include omega-3’s and glucosamine.1 The reasons for the use of dietary supplements vary by demographic, but one national survey found that dietary supplements used were for head/chest colds (29.8% of survey respondents), musculoskeletal conditions (16.4%), stomach or intestinal illness (10.6%), anxiety/depression (5.5%), insomnia (4.8%), headache (4.2%), menopause (2.7%), cholesterol (2.6%), and recurring pain (2.0%).1 The Healthcare Analysis Information Group (HAIG), which surveyed 141 consolidated VA systems about complementary and alternative medicine (CAM) use, reported that 48 of the respondents supported the use of dietary/nutritional supplements.5 Another ten facilities specifically allowed for the prescription of herbal supplements. Half of the facilities where herbal supplements were prescribed followed a process whereby a Clinical Executive Board reviewed herbal supplement providers and granted them prescribing privileges.

WHOLE HEALTH: CHANGE THE CONVERSATION Educational Overview: Dietary Supplements

VHA Office of Patient Centered Care and Cultural Transformation

Page 2 of 14

Legislation As a result of the 1994 Dietary Supplement Health and Education Act (DSHEA, often pronounced “de shay”) dietary supplements are legally considered foods, not pharmaceuticals.6 Regulation as foods mandates specific labeling requirements (see below) and an emphasis on post-release surveillance. It is primarily after the appearance in the marketplace that products are monitored for safety and label claim violations; this is in stark contrast to the pharmaceutical regulatory climate in the United States, where there are several phases of testing prior to a product being allowed for sale to the public. As a result of this, regulations have been established about what is allowed on dietary supplement labels; knowledge of this will help health care practitioners to better counsel patients and ensure that they are purchasing quality and effective products. The definition of dietary supplement, as per Congress’ wording in DSHEA and from what is listed on the FDA website, is “…a product taken by mouth that contains a ‘dietary ingredient’ intended to supplement the diet. The ‘dietary ingredients’ in these products may include: vitamins, minerals, herbs or other botanicals, amino acids, and substances such as enzymes, organ tissues, glandulars, and metabolites.” There is a lot of general advice available on the FDA website (www.fda.gov), under the categories of “Food” or “Dietary Supplements”), as well as on the website for the Office of Dietary Supplements through the National Institutes of Health (http://ods.od.nih.gov/).

Types of Supplements The legislated definitions for dietary supplements are broad, and, as a result, there are many types of dietary supplements available for sale in the market. Examples are tablets, capsules, softgels, gelcaps, liquids, or powders. Even some foods, such as bars and drinks, can be considered dietary supplements depending on the quantity of the ingredients and their intended purpose, though it can be difficult to tell which products are technically foods and which are dietary supplements. If a manufacturer has researched its product adequately and accurately, the label will guide the consumer about the appropriate use of the product. A clinician, however, may decide to become involved in this analysis in order to answer patient questions, providing an expert opinion about a company’s claims. The best and most effective type of supplement varies.7 For example, some plants are more often used in raw form, such as an infusion made from peppermint (Mentha x piperita) leaves. Infusions are a common form for aromatic plants (many in the mint, or Lamiaceae, plant family), and/or ones whose preparation involves delicate plant parts such as leaves or flowers. Woody, thicker plant parts usually require a decoction, a type of preparation where the plant is boiled in water for a specified amount of time in order to extract the physiologically-active phytochemicals. Tinctures, an alcohol or glycerin extraction, is a common supplement type. These extractions have an extended shelf life, and are appropriate for any plant whose phytochemicals may not be particularly soluble in water.

WHOLE HEALTH: CHANGE THE CONVERSATION Educational Overview: Dietary Supplements

VHA Office of Patient Centered Care and Cultural Transformation

Page 3 of 14

Standardized extracts, usually sold in a capsule form, are common and used by clinicians for a few main reasons. First, some clinicians focus their use of supplements on this type as they are often the ones studied in randomized, controlled trials. Many sources list the patented, standardized extracts that have been subjected to such research.8 Other supplements, notoriously adulterated because of their rarity or high cost, are often used in a standardized form that has been quality tested by a third party testing organization. Finally, in some cases the raw, whole plant is unsafe and needs to be processed and sold as a standardized extract. One example of this is butterbur (Petasites hybridus), studied in clinical trials for migraine prophylaxis or the treatment of allergic rhinitis. In the raw, unprocessed form, butterbur contains pyrrolizidine alkaloids, hepatotoxic compounds which need to be removed before this plant can be safely used.

Supplement Safety: Adverse Effects and Interactions with Pharmaceuticals Throughout the Whole Health Online Course, whenever supplements are mentioned, you will see the following reminder, referring you back to this module:

The regulation of dietary supplements (DS) contrasts with that for pharmaceuticals. For example, DS are treated technically as foods, and as such are monitored after they reach the shelves of grocery stores, pharmacies, and health food stores; pharmaceuticals are required to undergo layers of testing prior to sale to the public. This creates a potential lag in the appearance of adverse effects and the removal of a particular DS from public availability. It also puts the burden of proof of safety on DS consumers and prescribers, creating an important role for health care providers in ensuring that they are being appropriately and safely used. Not only does any DS have the potential to cause an adverse effect (as with any ingested substance, pharmaceuticals included), but it is important to be aware of DS interactions with foods, other DS, and pharmaceuticals. As much as it is important for a clinician to determine the efficacy of dietary supplements for a given patient’s health risks or problems, it is crucial to assess dietary supplements for their safety. The two main areas of safety involved are adverse effects, including the appropriateness of use in children or pregnant or lactating women, and possible adverse supplement-pharmaceutical or supplement-supplement interactions.

Note: Please see the module on Dietary Supplements for more information about how to determine whether or not a specific supplement is appropriate for a given individual. Supplements are not regulated with the same degree of oversight as medications, and it is important that clinicians keep this in mind. Products vary greatly in terms of accuracy of labeling, presence of adulterants, and the legitimacy of claims made by the manufacturer.

WHOLE HEALTH: CHANGE THE CONVERSATION Educational Overview: Dietary Supplements

VHA Office of Patient Centered Care and Cultural Transformation

Page 4 of 14

Information about adverse effects of dietary supplements exists in most, if not all, of the information sources listed below and in the accompanying clinical tools for this module. In many cases, dietary supplements have not been assessed for their safety in certain patient populations, such as children or pregnant/lactating women; in such cases, it is prudent to avoid using such products until more definitive safety data surfaces. It is important for all health care providers to know that DS quality may vary, an issue illustrated by some recent reports of disparity between DS label claims and product content, as determined by laboratory analysis. Just as providers should assure that a given DS has a low likelihood for adverse effects or interactions in a given patient, the quality of products being used by patients or recommended by providers should be assured. This can be done by reviewing the rating of a particular brand by a third-party certifier, such as one of the following9:

NSF International (http://www.nsf.org/) Natural Products Association (http://www.npainfo.org/) ConsumerLab (https://www.consumerlab.com/) The U.S. Pharmacopeia (USP) (http://www.usp.org/)

These groups use laboratory analyses independent of DS companies to determine the accuracy of label claims, and the presence of adulterants or contaminants.10 Some dietary supplements contain compounds that have been deemed unsafe; again, another reason to learn about specific products and avoid ones that may be unsafe. Examples are products that contain ephedrine, now banned by the FDA due to adverse cardiovascular effects, or any plant that contains the hepatotoxic, carcinogenic pyrrolizidine alkaloids. Two common plants that contain these compounds are butterbur (Petasites hybridus) and comfrey (Symphytum officinale). Some extracts, such as Petadolex for butterbur, have these compounds removed and are presumed safe for consumption, but it always behooves the clinician and consumer to assure themselves that any particular product is free of harmful constituents. Supplement-pharmaceutical interactions are another aspect of dietary supplement safety. Dietary supplements may affect the absorption or metabolism of other substances, whether they are other dietary supplements or pharmaceuticals. This interaction may be as simple as the decreased absorption that takes place with co-administration of calcium or fiber products and pharmaceuticals. Related to this, many demulcent plants—one example is slippery elm (Ulmus fulva) root bark powder—contain polysaccharides, which may bind compounds in the lumen of the intestinal tract inhibiting their absorption. Other interactions are mediated through the liver’s cytochrome enzyme system (cP450, or CYP). Such interactions may lead to increased or decreased levels of the co-administered products, depending on whether or not the enzyme system is enhanced or inhibited, respectively. One well-known example of this effect occurs with St. John’s wort (Hypericum perforatum), which increases the activity of the CYP3A4 enzyme, leading to a decrease in

WHOLE HEALTH: CHANGE THE CONVERSATION Educational Overview: Dietary Supplements

VHA Office of Patient Centered Care and Cultural Transformation

Page 5 of 14

efficacy of cyclosporine, oral contraceptive pills, and selective serotonin reuptake inhibitors, to name a few, which are also metabolized in that cytochrome system. From the standpoint of pharmaceuticals, the anticoagulant drug, warfarin, is an important example of a medication that interacts with a number of different supplements. Phytochemicals, such as the terpene lactones and flavonol glycosides in Ginkgo biloba, have the potential to augment warfarin’s anti-coagulation effects and increase bleeding risk. The databases and books listed in this module provide comprehensive information about adverse effects and interactions for the DSs available in the United States. Health care providers should make a habit of checking their patients’ DSs in these databases in order to assure safety and efficacy. As more and more people are taking more and more dietary supplements, the phenomenon of “polyherbacy”, or the ingestion of numerous dietary supplements on a daily basis, raises the possibility of supplement-supplement interactions just as for supplement-pharmaceutical interactions. Many sources now detail the known dietary supplement interactions. Online subscription databases each have a section on this topic, and this regularly-updated feature, or a similar source, should be a part of every clinician’s dietary supplement prescribing practice. In addition, some books and articles have focused on the details about dietary supplement interactions. Three examples are:

Brinker F. Herb Contraindications and Drug Interactions Plus Herbal Adjuncts With Medicines; Fourth Edition. Eclectic Institute; 2010.

Sood A, Sood R, Brinker FJ, Mann R, Loehrer LL, Wahner-Roedler DL. Potential for interactions between dietary supplements and prescription medications. Am J Med. 2008 Mar;121(3):207-211.

Stargrove MB. Herb, Nutrient, and Drug Interactions: Clinical Implications and Therapeutic Strategies. Mosby Elsevier; St. Louis: 2008.

Mindful Awareness Moment

Dietary Supplements

Pause for a moment to ask yourself a few questions related to dietary supplements: 1. What dietary supplements do you take yourself, if any? 2. What informed your choice of which supplements to take (or not)? Was your

decision informed by research findings? Colleagues? Friends? Personal experience? Experiences described by your patients?

3. How important is it to you to be able to counsel your patients about dietary supplements? Why?

WHOLE HEALTH: CHANGE THE CONVERSATION Educational Overview: Dietary Supplements

VHA Office of Patient Centered Care and Cultural Transformation

Page 6 of 14

Label Reading A dietary supplement label serves several purposes. Ideally, it conveys information to the consumer relevant to the safe and effective use of the product. Also, it needs to conform to government regulations and legal requirements. Finally, a clinician can use the label of a dietary supplement in conversations with a patient about use, dosing, and product quality. Relevant to the above-mentioned purposes of a dietary supplement label, it is important to know that there are three main types of statements allowed by the U.S. Food and Drug Administration (FDA). These are detailed on the FDA website www.fda.gov.11 Of note, the Federal Trade Commission may become involved in dietary supplement label limits and requirements if issues surrounding advertising develop. Structure/function claims One of the allowable statements on a label is called a structure/function claim, which describes how a product promotes wellness related to a structural part or function of the body. No mention is allowed related to the diagnosis, prevention, treatment or cure of any specific disease, and a disclaimer to this effect has to be on the label. Examples of structure function claims are “builds strong bones”, “maintains cell integrity”, “promotes immune function,” or “supports heart health.”12 Nutrient content claims Nutrient content claims use terms such as high, low, free, more, reduced, and lite to describe the amount of a compound in a product. These claims may also include percentage claims if no Daily Value percentage exists. The FDA’s Food Labeling Guide (http://www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/LabelingNutrition/ucm2006828.htm) lists what nutrients and their content claims are allowable. Health claims Health claims are the most stringent and evidence-based phrases allowable on a dietary supplement label. A petition is made through one of three methods of scientific review (NLEA Authorized Health Claim, a Health Claim Based on Authoritative Statements, and Qualified Health Claims). These differ primarily in the strength of the evidence for the claim and the source of the claim which might come from the scientific literature, a scientific body, a governmental organization, etc. Once approved, a statement can be placed on the label. An example of an approved health claim, based on significant scientific agreement, is “Healthful diets with adequate folate may reduce a woman's risk of having a child with a brain or spinal cord defect,” whereas a qualified health claim, based on some preliminary evidence, is “Supportive but not conclusive research shows that consumption of EPA and DHA omega-3 fatty acids may reduce the risk of coronary heart disease. One serving of [Name of the supplement] provides [Number] grams of EPA and DHA omega-3 fatty acids.”

WHOLE HEALTH: CHANGE THE CONVERSATION Educational Overview: Dietary Supplements

VHA Office of Patient Centered Care and Cultural Transformation

Page 7 of 14

These claims may come to the attention of a clinician when discussing particular products with a patient. In many cases, vague phrasing prompts the clinician to provide more specific counseling about the efficacy and safety of a dietary supplement in a given clinical scenario. Other requirements Other requirements from the FDA include a descriptive name (including a statement that it is a "supplement”); the name and place of business of the manufacturer, packer, or distributor; contact information for reporting adverse effects; net contents of the product; and a “Supplement Facts" panel which lists a serving size, a complete list of ingredients, and the percent daily value (%DV) of relevant ingredients. Reviewing a particular label for these characteristics can help clinicians, patients and consumers to begin to get an idea about the quality of a dietary supplement. Beyond these generalities, determining what should be on a supplement label depends on the specific dietary supplement involved. Clinicians can help patients effectively use dietary supplements by first being up-to-date on the evidence supporting the use of various nutrients by a given demographic. Calcium intake recommendations are a good example. Recommendations from scientific research are based on a patient’s gender, age, and risk factors, and are usually stated in elemental calcium. Some nuances from the medical literature are surfacing and would be available to clinicians doing a basic search on medical databases. For example, one might find that no more than 500 milligrams of elemental calcium should be taken in any one dose, and that generally calcium carbonate is reasonably absorbed when taken with meals (taking advantage of stomach acid) except in low acid environments when preliminary data indicates calcium citrate may be slightly better absorbed. Putting this all together, then, a clinician will want to tailor calcium product recommendations depending on each patient, paying attention to the form, dose, and elemental calcium amounts listed on the back (as opposed to total calcium compound (i.e. calcium carbonate, calcium citrate, etc.). This approach can be applied to any other specific dietary supplement.

Tailor recommendations for a given supplement to the individual patient. Note not only their weight, age, and gender, but also what else they are taking, how different supplements and medications might interact with one another, and how important taking a given supplement is to them. Being aware of how much they are spending on dietary supplements relative to their income is also important.

Labeling specific to herbal medicines Beyond the general dietary supplement label requirements as mentioned above that also apply to botanically-based products, there are some labeling practices specific to plants. For example, all herbal medicine labels should mention the Latin scientific name for a plant, including the Genus and species, or any variety of subspecies. For example, no longer is

WHOLE HEALTH: CHANGE THE CONVERSATION Educational Overview: Dietary Supplements

VHA Office of Patient Centered Care and Cultural Transformation

Page 8 of 14

“echinacea” sufficient to adequately critique an herbal medicine product containing that plant; there are three distinct species of echinacea (Echinacea purpurea, Echinacea pallida, Echinacea pallida var. angustifolia) that are used medicinally, and they have unique efficacy profiles. It is important for health care providers to be specific in their prescribing in order to focus on the species (in this case, Echinacea purpurea) with the best evidence for medicinal action. Furthermore, every herbal medicine label should list the plant part being used, correlating it with the physiological condition being treated. It should be clear whether or not the roots, stem, flowers, leaves, and/or some other plant parts were used. One example of why this is important is stinging nettle (Urtica dioica); the root is used for benign prostatic hypertrophy, but the leaf is used as an anti-inflammatory for conditions like arthritis and allergic rhinitis. In addition, various botanical medicine types (tinctures, capsules, infusions, etc.) will have unique label information. All tinctures should detail the strength or ratio, expressed as kilogram of herb to liters of solvent, or ounce to ounce. These are mostly in the range of 1:2-1:5. The percentage of alcohol or glycerin used in making the tincture needs to be listed. These two pieces of information allow the calculation of the exact amount of plant in each dose, especially important in plants with narrow therapeutic indices. An example for Panax ginseng root is “1:2 dry root to extract ratio in 23-29% grain alcohol.” Every kilogram of the root was dissolved in 2 liters (or every gram was dissolved in 2 milliliters). For standardized extracts, the label should list the marker compound(s) and percentage standardization. Such detail allows equilibrating prescribing practices with clinical trial dosing, or comparing two different products. An example of the information that should be present in a standardized extract of Ginkgo biloba is a “50:1 standardized extract containing 6% terpene lactones and 24% flavonol glycosides.” The ginkgo was dissolved in a solvent, and then the solvent was removed to concentrate the herb while retaining the same percentages by weight of the standardization compounds.

WHOLE HEALTH: CHANGE THE CONVERSATION Educational Overview: Dietary Supplements

VHA Office of Patient Centered Care and Cultural Transformation

Page 9 of 14

SUMMARY: A CHECKLIST TO ASSESS LABEL ADEQUACY

• Is the dietary supplement correctly and completely identified? o Consider form and dose o Consider the specific needs for botanical products

• Does it have a correctly labeled claim statement? o Is there a structure/function claim, and, if so, the necessary disclaimer? o Is there a health claim, and, if so, is it one of the legally-allowable ones as per

the FDA website? o Is there no claim at all?

• Is the company’s contact information clearly and completely listed? • Is there a “Supplement Facts” section on the label, with all active and inactive

ingredients listed? For more information, see the following clinical tools:

• Top Supplements for Every Clinician to Know • How to Read a Dietary Supplement Label • Dietary Supplement Information Resources • Choosing an Effective and Safe Dietary Supplement

Dietary Supplement Quality Because of how dietary supplements are regulated, there are more unknowns when it comes to quality for supplements than for pharmaceuticals. Recent legislation mandating that dietary supplement companies adhere to Good Manufacturing Practices (GMP) has improved the situation. The GMP regulations involve a detailed series of requirements to ensure the purity, quality, strength, and composition of dietary supplements, some of which is achieved by inspections of the manufacturing facilities. Also, the presence of third-party certification services, and corresponding labeling, has helped to steer consumers to quality products. For example, The U.S. Pharmacopeia (www.uspverified.org) tests products and ingredients for identification, strength, purity, and quality, in addition to providing some basic education tools online for consumers, patients, and health care practitioners. The USP symbol is starting to show up on some products, verifying that they have passed this level of inspection. Another company, ConsumerLab (www.consumerlab.com), has two programs, one that is voluntary (where businesses apply for certification and are then tested) and the other non-voluntary (where products are chosen from retail shelves for testing). Information is available on a subscription service, although some information is provided free of charge for consumers on their website.

WHOLE HEALTH: CHANGE THE CONVERSATION Educational Overview: Dietary Supplements

VHA Office of Patient Centered Care and Cultural Transformation

Page 10 of 14

Back to Frederick Frederick was pleasantly surprised that his clinician was able to advise him about his dietary supplements. His clinician took a few minutes, using the ECHO (Efficacy, Cost, Harms, Opinions) approach described in the Introduction to Complementary Approaches module, to briefly discuss each of Frederick’s supplements with him.13 They also reviewed the labels on each of his supplements together.

Frederick was pleased to confirm that licorice might indeed help his gastroesophageal reflux, and agreed to use the form without glycyrrhizin (deglycyrrhizinated licorice, or DGL), which would be much less likely to raise his blood pressure.

Frederick elected to continue the multivitamin, given that it is challenging for him to eat the variety of healthy foods he would like, and his clinician was concerned about him getting enough vitamin D3 from skin exposure to the sun.

Frederick will continue his omega-3 supplement. He suspects it helps his aches and pains, and it seems to have reduced his triglyceride levels. A review of the label and a cross-check with the ConsumerLab online database is reassuring to his clinician that the product appeared to provide an adequate dose and was free of contaminants.

Frederick will stop the coenzyme Q-10. While some patients find this useful for boosting energy or assisting with muscle pain related to statin medications, he is not taking a statin, and it has not seemed to make a difference for any of his other symptoms. Furthermore, it has been too expensive for him to take routinely, since he is paying for it out-of-pocket.

Frederick also elected to hold off on the bilberry. He was taking it for night vision but was told by his clinician that it had not proven in the research to be useful for this indication.

Frederick plans to continue his ginkgo, because he feels it helps him think more clearly. He is aware that ginkgo might increase his risk of bleeding slightly, but he feels the benefits outweigh the risks. A label review of the product he is taking indicates that the product is a standardized extract of Egb761, the same formulation used in most of the ginkgo clinical trials. He will take the same dose used in those trials.

Frederick’s clinician does a review of Frederick’s final list of both supplements and pharmaceuticals, to verify there are no potential supplement-pharmaceutical interactions. Reassured, Frederick agrees to check in before starting any other supplements, and he will follow up in two to three months.

Where to Learn More Numerous sources are available for further investigation into the clinical use of dietary supplements. The main categories of dietary supplement resources are web-based resources, both free and subscription-based resources, and print-based resources, the

WHOLE HEALTH: CHANGE THE CONVERSATION Educational Overview: Dietary Supplements

VHA Office of Patient Centered Care and Cultural Transformation

Page 11 of 14

latter including books and scientific journals. Some of each of these categories is listed below, but the clinician is encouraged to explore other resources mentioned at conferences, by medical librarians, or through their own searches, in order to find sources most relevant and useful to their own patients and practices.

Dietary Supplements: An Overview Clinical Tools

Top Supplements for Every Clinician to Know How to Read a Dietary Supplement Label Dietary Supplement Information Resources Choosing an Effective and Safe Dietary Supplement

Web-Based Resources Web-based resources may provide a variety of information relevant to the clinician, including evidence for/against dietary supplement use, dietary supplement dosing and safety, patient education sheets, and in-depth monographs.

Subscription web sources

HerbMed

www.herbmed.org

Natural Medicines Comprehensive Database

www.naturaldatabase.com

Natural Standard Research Collaboration

www.naturalstandard.com

ConsumerLab - evaluates different products in terms of whether they contain the contents they list on their packaging

www.consumerlab.com

Free web sources

Longwood Herbal Task Force (http://www.longwoodherbal.org/) National Center for Complementary and Alternative Medicine

http://nccam.nih.gov/health/atoz.htm

Office of Dietary Supplements (http://ods.od.nih.gov/) University of Wisconsin Integrative Medicine

(http://www.fammed.wisc.edu/integrative/supplement-samplers)

World Health Organization monographs

(http://apps.who.int/medicinedocs/en/d/Js2200e/)

WHOLE HEALTH: CHANGE THE CONVERSATION Educational Overview: Dietary Supplements

VHA Office of Patient Centered Care and Cultural Transformation

Page 12 of 14

Books

Blumenthal M (ed). The ABC Clinical Guide to Herbs. Austin, TX: American Botanical

Council; 2003 Bonakdar RA (ed). The H.E.R.B.A.L. Guide: Dietary Supplement Resources for the

Clinician. Philadelphia; Lippincott Williams & Wilkins; 2010 Johnson RL, Foster S, Low Dog T, Kiefer D. National Geographic Guide to Medicinal

Herbs. Washington D.C.; National Geographic: 2010 Mills S, Bone K. Principles and Practice of Phytotherapy: Modern Herbal Medicine.

Edinburgh, England: Churchill Livingstone; 2000 Schulz V, Hänsel R, Blumenthal M, Tyler VE. Rational Phytotherapy. Berlin: Springer-

Verlag; 2004 Mason P. Dietary Supplements. Fourth Edition. Pharmaceutical Products Press; 2011 PDR for Nonprescription Drugs, Dietary Supplements, and Herbs. Physician Desk

Reference Inc.; 2011

Journals

Economic Botany HerbalGram Journal of Ethnopharmacology Journal of Herbal Pharmacotherapy

This educational overview was written by David Kiefer, MD, Clinical Assistant Professor, Department of Family Medicine, University of Wisconsin-Madison School of Medicine and Public Health and Assistant Clinical Professor of Medicine, Arizona Center for Integrative Medicine, University of Arizona.

Whole Health: Change the Conversation Website

Interested in learning more about Whole Health? Browse our website for information on personal and professional care.

http://projects.hsl.wisc.edu/SERVICE/index.php

WHOLE HEALTH: CHANGE THE CONVERSATION Educational Overview: Dietary Supplements

VHA Office of Patient Centered Care and Cultural Transformation

Page 13 of 14

References 1. Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among

adults and children: United States, 2007. National health statistics reports. 2008(12):1-23.

2. Gardiner P, Graham R, Legedza AT, Ahn AC, Eisenberg DM, Phillips RS. Factors associated with herbal therapy use by adults in the United States. Altern Ther Health Med. 2007;13(2):22-29.

3. Gardiner P, Whelan J, White LF, Filippelli AC, Bharmal N, Kaptchuk TJ. A systematic review of the prevalence of herb usage among racial/ethnic minorities in the United States. Journal of immigrant and minority health / Center for Minority Public Health. 2013;15(4):817-828.

4. Lindstrom A, Ooyen C, Lynch ME, Blumenthal M. Herb supplement sales increase 5.5% in 2012: herbal supplement sales rise for 9th consecutive year; turmeric sales jump 40% in natural channel. HerbalGram. 2013(99):60-65.

5. Healthcare Analysis and Information Group (HAIG). 2011 Complementary and alternative medicine survey. September 2011. Department of Veterans Affairs, Veterans Health Administration. http://shfwire.com/files/pdfs/2011CAM_FinalReport.pdf. Accessed February 10, 2014.

6. U.S. Food and Drug Administration. Dietary Supplement Health and Education Act of 1994. U.S. Food and Drug Administration website. http://www.fda.gov/regulatoryinformation/legislation/federalfooddrugandcosmeticactfdcact/significantamendmentstothefdcact/ucm148003.htm. Accessed June 8, 2014.

7. Mills S, Bone K. Principles and Practice of Phytotherapy: Modern Herbal Medicine. Edinburgh; New York: Churchill Livingstone; 2000.

8. Blumenthal M, Brinckmann J, Wollschlaeger B. The ABC Clinical Guide to Herbs. Austin, TX: American Botanical Council; 2003.

9. Blumenthal M. Identifying High Quality Herbal Dietary Supplements: A Discussion of Issues About Quality and Clinical Reliability. Scripps Conference on Dietary Supplements; 2006.

10. Whybark M. Third-party evaluation programs for the quality of dietary supplements. HerbalGram. 2004(64):30-33.

11. U.S. Food and Drug Administration. Dietary Supplement Labeling Guide: Chapter VI. Claims. U.S. Food and Drug Administration website. http://www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/DietarySupplements/ucm070613.htm. Accessed October 20, 2013.

12. Gastelu G. Structure/Function Claims Overview. SupplementFacts.com website. http://www.supplementfacts.com/struc_func_claims_overview.htm. Accessed August 2, 2014.

13. Natural Medicines Comprehensive Database. http://naturaldatabase.therapeuticresearch.com/home.aspx?cs=&s=ND. Accessed June 8, 2014.