It was terrifying. They kept trying to comfort me by telling me they had the best surgeons. But they also said that I needed a new liver and that my body might reject it. – Christopher Herrera
Christopher Herrera, a 17-year-old teenager, had arrived at the Texas Children’s Hospital emergency room almost like a Martian. Not with a space shuttle, but with a yellow face, eyes and chest described by doctors as being close to the golden colour of a marker. He was severely jaundiced. In adolescents, jaundice, the external sign of liver disease, can have a variety of causes, from viral hepatitis, parasitic infections, autoimmune diseases, malignancies, diseases without a direct and obvious link to the liver (such as ulcerative colitis) to all kinds of substances that are toxic to the liver, such as alcohol, paracetamol or certain poisonous mushrooms.
In Christopher’s case, however, the cause was surprising: a dietary supplement based on a tea extract was to blame. The young, overweight high school student had bought it, attracted by the promise on the label and in the ads that the natural product “burned fat”. In his case, the effects were unexpected: his liver was so badly damaged that he had to be placed on a waiting list for a liver transplant. Fortunately, the doctors managed to save his life, but there were unavoidable personal costs: Christopher can no longer play football or any other sports, he has to be careful with physical effort and everything that could put undue pressure on the new organ, and he has to go to the doctor every month for an assessment of his health and liver function.
Even if few have heard about it, Christopher Herrera’s case is unique only if one considers the young man’s age and some other personal circumstances. Otherwise, the victims of “harmless” food supplements are far more numerous than many of us realise. Sometimes the negative effects are less intense. Other times, and fortunately much less often, the outcome is fatal. However, people are attracted to the promise of a “wonder pill”. Most of them are like lottery players: they only lose money. Others end up like many players of the infamous Russian roulette: they lose everything.
Supplements for all seasons
Are these promises fulfilled in the life of the consumer of food supplements or are they just beautifully packaged and professionally advertised illusions?
Since a year has four seasons, the “experts” that peddle supplements tend to pills promote different pills depending on the season. Is it winter? “As physical exercise is not a priority for most of us during winter, and a sedentary lifestyle is ubiquitous, food supplements give the body the energy it needs to be fit.” Is spring on its way? Then allergies are coming too. “If we suffer from severe allergies, then the vitamins our bodies take from food may not be enough. Therefore, we need nutritional supplements.” Then, as those who have rid themselves of spring allergies enter summer (thanks to food supplements, no doubt) other dangers lurk around their health. “Have you ever thought that dietary supplements can help you stay healthy in the summer?” The famous Dr. Oz himself recommends three such supplements. And after the summer, the leaves of the trees fall, the day gets shorter, we see less of the sun, and the cold returns. “That is why, every autumn it is advisable to enrich your diet with food supplements, which re-vitaminise and re-mineralise your body, so that the immune system becomes unbeatable again.”
In this way, the circle closes: there are supplements for all seasons. All are full of promises. Some are explicit, trumpeted in advertisements convincingly presented by actors who play the role of ordinary and modest people, claiming that the advertised supplements saved them from otherwise incurable suffering. Other such promises are implicit, born in the mind of the consumer who is convinced that the power of nature, concentrated in a tablet—and possibly the mastery of the manufacturer who has carefully selected the best plants—can only bring health and abundant life. Are these promises fulfilled in the life of the consumer of food supplements, or are they just beautifully packaged and professionally advertised illusions?
The benefits of dietary supplements
Here’s a simple test. Do those who regularly consume dietary supplements live longer than those who do not? If we were to follow the recommendations presented above, the answer should undoubtedly be yes. Many studies have attempted to answer this question.
In 2007, a prestigious American medical journal published an article summarising the results of previous research on antioxidant supplements, which the popular literature often claims to be true guardians of life. Authors identified 68 randomised clinical trials with over 230,000 participants.
Drawing on the data, the authors found that when both good quality and methodologically questionable studies were analysed, the conclusion was that supplements are harmless: they neither harm nor benefit their users. They do not prolong life, but they do not shorten it either. In other words, they have no effect on mortality. No difference was found between those who take dietary supplements with antioxidants and those who do not.
When only methodologically rigorous studies were included in the calculations, a slight increase in mortality was observed among consumers of antioxidant supplements (47 studies, with a total of over 180,000 participants). Among the antioxidants, it is worth mentioning that beta-carotene (pro-vitamin A, the orange substance in carrots), vitamin A and vitamin E, alone or in combination, increased mortality. In contrast, vitamin C had no positive or negative influence on mortality. This study was not without methodological limitations, but the data are relatively convincing that these supplements do not significantly influence the health of those consuming them.
At the end of 2013, another meta-analysis was published, which evaluated all studies on the effect of vitamins and minerals on the prevention of cancer and cardiovascular disease (in total, over 400,000 participants were included in these studies). The conclusion? Two large studies (27,658 participants) indicated a slightly lower risk of cancer in men who used multi-vitamin pills. One of the two studies also included women, but no benefit was observed.
An analysis of methodologically-sound studies bringing together almost 325,000 participants on the effect of vitamins A, C, D, and E, beta-carotene, folic acid, selenium or calcium, showed neither a reduction nor an increase in risks. Beta-carotene increases the risk of lung cancer mortality in smokers, an effect known for a relatively long time and which is paradoxical because it has long been thought that beta-carotene, with its antioxidant properties, should reduce the risk of lung cancer, because smoking triggers the formation of free radicals (which beta-carotene is supposed to neutralise).
In addition to their very low effectiveness in prolonging or improving the quality of life, there are at least two general problems related to the quality of food supplements. Firstly, quality is sorely lacking in many supplements, given that there are no detailed standards regarding their production.
The US Food and Drug Administration (FDA) has identified food supplement production units where pills were contaminated with feces and rodent urine.
In the US, in 2003, the analysis of a sample of “Ayurvedic” food supplements in Boston showed that 20% of them contained unacceptable amounts of lead, mercury or arsenic. Second, there are often considerable discrepancies between the text on the label and the contents of the box. In 2008, two food supplements were withdrawn from the US market because the selenium content (which, in small quantities, is beneficial to the body) was 200 times higher than what was stated on the label. The consumers of these supplements experienced hair loss, muscle cramps, joint pain, fatigue and rashes.
Also impressive is the number of alleged weight loss dietary supplements (many of them plant-based) in which, almost systematically, considerable amounts of synthetic derivatives have been detected, especially sibutramine and phenolphthalein. Sibutramine was the active substance in a weight loss medicine which was withdrawn from the market because it was determined that the risks outweighed the benefits. Between 2008 and 2009, more than 70 such counterfeit supplements were identified in the United States. Since then, every few weeks, the FDA continues to issue public warnings against 3-6 counterfeit food supplements with synthetic ingredients. Counterfeiting cases have also been reported in Europe and other parts of the world. In Romania, some “weight loss supplements”, originating in China, have been found not only to be contaminated with sibutramine and phenolphthalein, but also affected by many other quality problems.
Should we use supplements daily?
It is a distinguishing trait of the medical field that there are at least two opinions on almost every question within it. In November 2013, The Wall Street Journal asked a number of medical professionals this question: “Do you recommend vitamin supplements to healthy people?” The only one who answered promptly and categorically “Yes” is Fred Hassan, a chemist by profession, former leader of several pharmaceutical companies and currently CEO of a large company that manufactures contact lenses. Four were more cautious, recommending at most one multivitamin per day, vitamin D in some people, or using them only on the advice of a doctor. Everyone else was rather skeptical.
“With one exception—folic acid for women planning a pregnancy—healthy people taking vitamin supplements should be informed that they are paying good money for a placebo effect.” (Gurpreet Dhaliwal, professor of medicine at the University of California).
“No. A balanced diet is all we need.” (Murali Doraiswamy, professor of psychiatry and medicine at Duke University Medical Center).
“It is much more beneficial for individuals to focus on healthy eating. A balanced diet can provide all the nutrients the body needs.” (David Blumenthal, president and CEO of a New York NGO involved in philanthropic support for access to treatment nationwide).
“Stop buying vitamin supplements, take the money you save every month and do something that will really help you feel better—buy a massage session.” (Rita Redberg, Professor of Medicine and Cardiology at the University from California).
“Maybe we should spend less on bottled supplements and more in the fruit and vegetable section of our stores or, better yet, our gardens.” (Carol Cassella, doctor and writer).
Most of the opinions above are therefore congruent with the impressive amount of data which proves that, except for some people, such as pregnant women or people on a strictly vegetarian (vegan) diet, these “wonder pills” have little or no effect on the duration or quality of life.
Robert Ancuceanu, PhD, is a professor in the Faculty of Pharmacy at the Carol Davila University of Medicine and Pharmacy in Bucharest, Romania.