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Supplement Your
Dietary Supplement IQ
Chris D’Adamo, Ph.D. Assistant Professor
Department of Family & Community Medicine
Department of Epidemiology & Public Health
Director of Research Center for Integrative Medicine
Presentation Outline
Overview of Dietary Supplements
Definition
Regulation
Supplements to Generally Consider
Multivitamin
Vitamin D
Omega-3 Fatty Acids
Probiotics
Supplements to Avoid
Potential for tainting with pharmaceuticals
Presentation Outline
Supplement & Drug Interactions
Supplements for Special Situations
People taking statins, beta-blockers, acid-blocking drugs
Vegetarians
Pregnant women
Evidence-Informed Supplements for Specific Concerns
Joint Health
Digestion
Checklist: Informed Supplement Consumer
Immune System
Heart Health
Liver Health
Depression
Sleep
Dietary Supplements Defined
What is a dietary supplement?
1994 Dietary Supplement Health and Education Act (DSHEA)
A product (other than tobacco) intended to supplement diet
Contains one or more dietary ingredients and taken orally
Vitamins, minerals, herbs or other botanicals, amino acids
Vitamins Minerals Herbs Amino Acids
Immune System
Regulation of Dietary Supplements
Federal Regulation of Dietary Supplements
Food and Drug Administration (FDA)
Supplements regulated as food
Pre-DSHEA assumed safe, post-DSHEA provide safety evidence
Labeling and claims requirements
Ingredient names & amounts, directions for use, no health claims, etc.
2007 Good Manufacturing Practices (GMP)
Quality standards for manufacturing, preparation, storage, facility
Federal Trade Commission (FTC)
Regulate marketing of supplements
Regulation of Dietary Supplements
Federal Regulation of Dietary Supplements
No universal regulation of supplement content
“Don’t know what you’re getting”… in many cases, true!
Many dietary supplement companies hire 3rd party
laboratories for product purity certification
Contains specified ingredients
No contaminants
Dissolves properly
GMP compliant
Some 3rd party labs better than others
NSF-certified gold standard
Supplements to Consider
Multivitamin: Overview
Most common dietary supplement
33% of Americans take multivitamin
Usually contain at least 13 vitamins &
15 minerals most important to nutrition
How multivitamins are used Generally capsule or tablet orally once per day
Powders, liquids, multiple daily doses less common
Best taken with meal
Many of nutrients lipid-soluble, need fat for absorption
Multivitamin: Types
RDI-centric
RDI of most important vitamins/minerals
Reference Daily Intake – replaced RDA in 1997
Prevent micronutrient deficiency in most people
"% Daily Value" on food & supplement labels
Widely available
Higher potency
Exceeds RDI for many vitamins/minerals
Why? RDI prevent deficiency disease…
not to promote optimal health!
Higher in vitamin D, B-vitamins, vitamin C, etc.
Health stores, clinical practices, Amazon, etc.
Multivitamin: Favorable Research Improves nutritional status
2000 Journal of American College of Nutrition, 2009 European Journal Clinical Nutrition
Reduces risk of birth defects 2001 Epidemiology, 2002 Epidemiology, 2002 Pediatrics, 2003 Pediatrics
Associated with weight loss & decrease in body-fat % 2010 International Journal of Obesity Research
Reduced risk of macular degeneration & cataracts 2007 American Journal of Clinical Nutrition, 2008 Ophthalmology
Reduces risk of heart attack 2010 American Journal of Clinical Nutrition
Reduces risk of colon cancer 2002 Cancer Epidemiology, Biomarkers, & Prevention
Reduces risk of all-cause mortality and cancer mortality 2011 European Journal of Nutrition
Multivitamin: Unfavorable Research
No benefit in some studies
No reduction in risk of cancer or cardiovascular disease 2009 Archives of Internal Medicine
No reduction in risk of breast cancer 2010 Public Health Nutrition, 2010 American Journal of Clinical Nutrition
Slight increase in non-cancer, non-CVD mortality
Lots of media coverage… but study flawed and over-interpreted
2011 Archives of Internal Medicine
Direct conflict with 2011 European Journal of Nutrition Study!
Multivitamin: Recommendations
Does brand make a difference? YES!
Cheap brands use cheap vitamin/mineral forms
Affects absorption and effectiveness
Natural vitamin forms better absorbed than synthetic
Natural vitamin E twice absorption of synthetic
Certain vitamin forms more effective than others
Vitamin D3 superior to vitamin D2
Certain mineral binding salts better absorbed than others
Magnesium citrate much better absorption than magnesium oxide
Multivitamin: Recommendations
How to choose a good brand?
www.multivitaminguide.org Ranking based on: composition, bioavailability, synergistic effect, potency
101 of most common multivitamins in United States
Comparative Guide to Nutritional Supplements Lyle MacWilliam, biochemist, commissioned by Canadian Minister of Health
Scientific analysis of 510 multivitamins available in United States & Canada
Multivitamin: Recommendations
Multivitamin: Recommendations
Quality is key! Consult rankings Whole-food based multivitamins also good choice
Synergy between hundreds of food components!
Always consume with meal Important fat-soluble nutrients
Poor absorption in absence of fat
Be an informed consumer! Choose/avoid the following… Vit E: d-alpha tocopherol (natural) NOT dl-alpha tocopherol (synthetic)
Vit E: look for "mixed tocopherols" and/or "gamma tocopherol"
Vitamin D3 NOT vitamin D2
Methylcobalamin form of B12 NOT cynacobalamin form of B12
Avoid oxide binding salts (magnesium citrate NOT magnesium oxide)
Avoid iron for men and postmenopausal women
Vitamin D: Overview
A uniquely important vitamin
Hormone-like activity (secosteroid)
Controls expression of over 200 genes
Vitamin D active in most biological systems
Musculoskeletal system
Classically emphasized role
Endocrine system
Nervous system
Cardiovascular system
Digestive system
Immune system
Vitamin D: Sources
Sun exposure
UVB light converted to vitamin D3 in skin
D3 transported to liver, metabolized to 25(OH)D Also called calcidiol… measured most vitamin D blood tests
25(OH)D converted to calcitriol in kidneys Calcium metabolism… remaining calcitriol & calcidiol → health benefits
20,000 international units (IU) from 30 minutes sun exposure Only spring and summer if north of Atlanta
Limited amount from foods D3 from oily fish, eggs, butter, cheese, fortified milk/cereals
Vitamin D fat-soluble… needs fat for absorption
10-100 IU: depending upon source
Supplements deliver much higher doses… up to 5,000+ IU per pill
Vitamin D: Reference Daily Intake
Current RDI varies
Up to age 50: 200 IU
Age 51-70: 400 IU
70 and older: 600 IU
Amount to prevent vitamin D deficiency
Rickets Softening of bones → deformities, fractures, etc.
Most common in children… rare in United States
Also occurs in adults… called osteomalacia
Amount to prevent chronic disease… much higher!
Call to substantially increase RDI to at least 1,000 IU
Explosion in vitamin D research
Vitamin D: Favorable Research Prevents bone disorders (osteoporosis, fractures, etc.)
2009 Cochrane Systematic Database Review
Reduced risk of cancers (breast, colon, prostate, etc.) 2004 American Journal of Clinical Nutrition, 2009 Cancer Epidemiology
Improved survival among colorectal cancer patients 2012 Cancer Epidemiology, Biomarkers and Prevention
Reduced risk and better control of diabetes 2010 Diabetes, Obesity, & Metabolism, 2010 Diabetes Care
Reduced risk of obesity 2010 Obesity, 2010 Diabetes, 2009 Journal of American Dietetic Association
Help weight loss & improve cardiovascular risk factors 2012 British Journal of Nutrition
Reduced risk of cardiovascular disease 2009 Archives of Internal Medicine, 2010 American Journal of Cardiology
Vitamin D: Favorable Research
Improve depression & Seasonal Affective Disorder 2008 Journal of Internal Medicine, 1999 Journal of Nutrition, Health, & Aging
Reduced risk of Crohn’s disease, rheumatoid arthritis,
multiple sclerosis and other auto-immune disorders 2010 Journal of Rheumatology, 2007 American Journal of Clinical Nutrition
Stimulate immune system to prevent infection 2010 American Journal of Clinical Nutrition
Decreased risk of all-cause mortality 2008 Archives of Internal Medicine
Vitamin D: Unfavorable Research
Vitamin D supplementation not beneficial in some trials
Breast cancer – 2009 Breast Cancer Research and Treatment
Heart attack – 2007 Circulation Between 200 – 400 IU vitamin D used… very low dose
No risks of high serum vitamin D in observational studies
Unless extremely high concentrations over 100 ng/mL Increased risk of atrial fibrillation “excess” 25(OH) D > 100 ng/mL
Vitamin D increases calcium absorption… too much calcium in blood?
No evidence of harm from typical vitamin D supplements
Fat-soluble, but safe at even at very high intake Acute D3 toxicity intake ≈ 176,000,000 IU… 440,000 400 IU capsules
Only toxic cases manufacturing mistakes (extremely rare)
Vitamin D: Recommendations
Convincing evidence: recommend 25(OH)D test to everyone!
Vitamin D inadequacy extremely common
Between 36-100% depending on group, 2006 Mayo Clinic Proceedings
Supplementation most important for people who…
Live north of Atlanta (in fall & winter)
Cannot synthesize from sun
Have darker skin tone
Less efficient synthesis in skin
Older adults
Greater risk of osteoporosis & other chronic diseases
Avoid sun or wear sunscreen
Most vitamin D from sun exposure
Have low serum 25(OH)D
Everyone should have vitamin D tested… inexpensive and major risk-factor!
Vitamin D: Recommendations
Not much difference by price or brand
Gel capsule preferable to tablet
Vitamin D fat-soluble… better absorption
Take with food
Vitamin D fat-soluble
Vitamin D3 preferable to D2
D3 (cholecalciferol) more effective than D2 (ergocalficerol) 2004 Clinical Endocrinology & Metabolism
Serum 25(OH)D target range ≈ 40 ng/mL (100 nmol/L)
More research needed for optimal threshold… most people low!
Omega-3 Fats: Overview
Class of polyunsaturated fatty acids (PUFA)
Common structure (C=C in n-3 position)
Three nutritionally important omega-3 fats
Alpha-linolenic acid (ALA)
One of two essential fatty acids
“Short-chain”… converts to “long-chain”
Eicosapentaenoic acid (EPA)
Long-chain omega-3
Docosahexaenoic acid (DHA)
Long-chain omega-3
Health benefits of EPA and DHA most studied
Precursor to eicosanoids… anti-inflammatory effects
Omega-3 Fats: Sources
Vary by type of omega-3
ALA
Nuts, seeds, vegetables Flax seed, chia seed, walnuts, leafy greens
EPA/DHA
Oily fish Salmon, sardines, mackerel, tuna, etc.
Other animal products Depends on animal's diet… grass-fed beef and pastured eggs
Seaweed Generally DHA only
Fortified foods Milk, yogurt, cereals, etc.
Omega-3 Fats: Rationale
Standard American Diet ("SAD") low in Omega-3
Evolved on diet with ≈ even omega-6:omega-3 (1:1)
"Paleo-style diet" - Fish, grass-fed meat, vegetables, fruits, etc.
Both omega-6 & omega-3 necessary
Linoleic acid (omega-6) an EFA
Imbalance affects inflammatory cascade… especially if too much omega-6
Standard American Diet…
20:1 omega-6:omega-3!
MUCH higher in many cases
Recent changes… industrialization of food supply
Grain-fed beef, soybean oil, corn oil, etc.
Thought to play role in auto-immune & inflammatory conditions
Omega-3 Fats: Favorable Research
More clinical research than any vitamins All studies below RCT’s or reviews of RCT’s
Improved many auto-immune conditions Rheumatoid arthritis, Irritable Bowel Syndrome, asthma, etc.
2009 Cochrane Systematic Review, 2005 Nutrition, 2000 American Journal
of Clinical Nutrition, 2000 European Respiratory Journal
Reduced blood pressure 2002 Journal of Hypertension
Lowers triglycerides 2009 Nutrition and Health
Decreased cardiovascular disease events and mortality 2006 American Journal of Clinical Nutrition, 2008 British Medical Journal,
2009 Clinical Cardiology, 2009 Annals of Internal Medicine
Omega-3 Fats: Favorable Research
Helps treat depression 2009 & 2010 Journal of American College of Nutrition
Helps manage bipolar disorder 2009 European Journal of Clinical Nutrition
Prevention of psychotic disorder among high-risk 2010 Archives of General Psychiatry
Reduction in ADHD symptoms 2009 Journal of Attention Disorders
Decreased cognitive decline in older adults 2011 Journal of Nutrition, Aging, and Health
Omega-3 Fats: Unfavorable Research
Some clinical trials found no benefit
ADHD
2001 Journal of Pediatrics
Cognitive performance
2008 Neurology
Schizophrenia
2001 American Journal of Psychiatry
No clinical studies showing harm
But be aware of potential interaction with anticoagulants
Omega-3 Fats: Recommendations
Convincing evidence: recommend to most people
Not recommended for people on anticoagulant drugs
Coumadin, etc.
Omega-3 supplements can thin blood
Most important for people who…
Don’t eat fatty, cold-water fish
Vegetarians/vegans… ALA poorly converted to EPA/DHA
Flounder, catfish, etc. no omega-3
Have autoimmune or chronic inflammatory conditions
Have high triglycerides or are at high risk for heart disease
Eat Standard American Diet
Omega-3 Fats: Recommendations
Supplement with ALA or DHA/EPA? Flaxseed oil (ALA) vs. fish oil (EPA/DHA)
Fish oil superior to flaxseed oil ALA conversion to EPA/DHA very poor!
Only 8 to 20% ALA converted to EPA/DHA
2008 Nutrition Reviews
Most omega-3 benefits from EPA/DHA
Krill oil another good source of EPA/DHA
If vegetarian/vegan
Consider algae-based omega-3 supplement
Probiotics: Overview
Probiotics defined: World Health Organization
“Live micro-organisms… administered in adequate
amounts, confer beneficial health effect on the host”
Probiotics can be bacteria or yeasts
Bacteria much more abundant… bigger role in health
Primarily colonize or transiently act in gastrointestinal tract
Why are gut bacteria important?
Over 100 trillion bacteria in gut
Ten times amount of cells in human body!
500 different species of bacteria in gut
Critical role in metabolism and immune system
Probiotics: Important Varieties
Three classifications of probiotics
Genus – broadest
Species – more specific
Strain – most specific
Most probiotic supplements classified by genus & species only
Lactobacillus
One of most common bacterial genera in gut
Convert lactose & other sugars to lactic acid
Can help some with lactose intolerance
Acidic environment inhibits harmful bacteria
Over 100 species
Indicated by L. _______
Some of most important: L. acidophilus, L. casei, L. reuteri, L. brevis
Probiotics: Important Varieties
Bifidobacterium
Another common bacterial genera in gut
Inhibit pathogenic bacteria
Competes for resources & produces lactic acid
29 species identified
Indicated by B. _______
Some of most important: B. longum, B. breve, B. animalis
Saccharomyces
Common fungal genus in gut
Most yeast damage gut, e.g. Candida Albicans
Some species compete with pathogens
Indicated by S. _______
S. Boulardii prevents/treats GI disorders
Probiotics: Dietary Sources
Fermented foods
Component of most traditional diets
Asian
Miso and natto Fermented beans/grains… often soy
L. acidophilus (miso) & B. natto (natto)
Kimchi Fermented cabbage, radishes, etc.
L. kimchii
Kombucha Fermented tea
S. cerevisiae
Probiotics: Dietary Sources
European
Yogurt Fermented dairy
Cow, goat, sheep milk
L. bulgaricus & Streptococcus thermophilus
Kefir Also fermented dairy
More probiotic species than yogurt
L. rhamnosus, B. longum, S. florentinus, etc.
Sauerkraut Fermented cabbage
L. plantarum, L. mesenteroides, etc.
Probiotics: Dietary Sources
African
Ogi Fermented grains… often corn
L. brevis, L. acidophilus, etc.
Currently in United States…
Primarily yogurt
Traditional products available health food stores Kefir, kimchi, kombucha, etc.
Probiotics: Supplement Rationale
Americans consume few fermented foods!
Commercial yogurt not optimal source
Often high in sugar… feeds yeast & pathogens
Relatively low bacterial count
100 million lactic acid bacteria per serving… 100 trillion bacteria in gut
Probiotics: Favorable Research
Most clinical research of all dietary supplements
All clinical trials or reviews of clinical trials
Major species listed for each outcome
Regulates bowel function
Effective against diarrhea… especially antibiotic-associated
L. rhamnosus GG, S. Boulardii, L. Bulgaricus and many others
2012 Journal of American Medical Association
Effective against constipation
B. lactis, L. casei
2010 World Journal of Gastroenterology
Probiotics: Favorable Research
Effective treatment for some Inflammatory Bowel Disease
Ulcerative Colitis
B. Animalis, B. Breve, L. Acidophilus and combinations
2010 Proceedings of the Nutrition Society, 2010 Annals of Pharmacotherapy
Crohn’s Disease
Evidence not as convincing… some success with L. Rhamnosus
2009 Current Pharmaceutical Design
Effective treatment for Irritable Bowel Syndrome L. Acidophilus, B. Breve, B. Bifidum, S. Boulardii and combinations
2010 Journal of Nutrition
Probiotics: Favorable Research
Effective treatment for other autoimmune conditions
Eczema and allergic rhinitis
L. Acidophilus, B. Lactis, L. Sakei
2010 American Journal of Clinical Dermatology, 2010 Pediatric Pulmonology
Improve immunity in healthy individuals
Reduces risk of common cold
L. paracasei, L. plantarum, L. Bulgaricus
Younger adults
2010 European Journal of Nutrition
Older adults
2010 British Journal of Nutrition
Probiotics: Unfavorable Research
Ineffective in some trials for certain conditions
Crohn’s Disease
2008 Digestive Disease and Sciences
Pancreatitis (feeding tube)
2008 Lancet
No evidence of harm from oral probiotic supplementation
Not necessarily harmless… more research needed
Probiotics: Recommendations
Recommend to people eating Standard American Diet
Usually not necessary if consume variety of fermented foods
Don’t typically need to take on an ongoing basis
Cycle on and off occasionally... few times a year or specific situations
Most important for people who…
HAVE BEEN ON ANTIBIOTICS!
Critical to replenish flora & prevent side-effects
Have digestive problems and/or food intolerances
Will be travelling out of the country
Prevent diarrheal disorders
Have an autoimmune condition
Are at high risk for infections
Especially useful during flu season
Probiotics: Recommendations
Core product: contains genus & species variety
Especially Lactobacillus & Bifidobacterium
Occasionally rotate products for increased variety
Specific conditions: single-species okay
S. boulardii, L. GG, etc. for diarrhea
Choose high potency products
At least 5 billion colony forming units (CFU)
≥ 10 billion preferable… especially after antibiotics
Many products contain over 100 billion CFU
Remember… 100 trillion bacteria in gut!
Probiotics: Recommendations
Choose refrigerated product during summer
Probiotics die if exposed to high temperatures
Refrigerating extends life & assures potency
Choose products that specify strain
Most specify genus and species
Best products also specify strain!
Choose products supported by research
Probiotic supplements vary tremendously
Trust those supported by research
Company can point to studies
Supplements to Avoid
Supplements to Avoid
Most supplements safe… but some may pose risk
Especially products tainted with pharmaceuticals
Three classes of supplements most likely to be tainted
Weight-loss supplements Not likely to be effective long-term
Cannot replace healthy diet & exercise habits
Often stimulant-based… contraindications?
Especially among overweight
Some products tainted with sibutramine
Active ingredient in Reductil (withdrawn by FDA)
Increases blood pressure, pulse, potential risk for CVD events
http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsin
gMedicineSafely/MedicationHealthFraud/ucm234592.htm
Supplements to Avoid
Sexual-enhancement supplements
Some products tainted with tadalafil or sildenafil
Active ingredients in Cialis and Viagra
Can interact with nitrates to cause low blood pressure
http://www.fda.gov/Drugs/ResourcesForYou/Consumers/Buying
UsingMedicineSafely/MedicationHealthFraud/ucm234539.htm
Bodybuilding supplements Some products tainted with anabolic steroids
Often marketed as containing “steroid-like” components
Have caused liver or kidney problems
http://www.fda.gov/Drugs/ResourcesForYou/Consumers/Buying
UsingMedicineSafely/MedicationHealthFraud/ucm234539.htm
Tainted products rare… but can pose health risk!
Supplement and Drug Interactions
Supplements and Drug Interactions
St. John’s Wort and Antidepressants Synergy: increased risk of serotonin syndrome
Red Yeast Rice and Statins Synergy: increased risk of muscle & liver problems
Calcium/magnesium/zinc and Antibiotics Reduced absorption: antibiotic may not work as well
Ginkgo Biloba and Anticoagulants Increased bleeding risk
Fish Oil and Anticoagulants Increased bleeding risk
Supplements for Special Situations
Supplements for Special Situations
Coenzyme Q10 for people on statins or beta-blockers
aka “CoQ10”
These medications deplete CoQ10
Coenzyme Q10 supplementation recommended
2006 Annals of Pharmacotherapy
Also good idea to take with Red Yeast Rice
Why is supplementing with CoQ10 important?
Critical in muscle function… particularly heart
Reduces cardiovascular disease risk and blood pressure
2007 Nutrition Review & 2006 Journal of Cardiac Failure
Reduces statin-induced muscle myopathy
2007 American Journal of Cardiology
Supplements for Special Situations
Vitamin B12 for people on stomach acid-blockers
Prilosec, Zantac, antacids, etc.
These medications deplete vitamin B12
Reduced stomach acid to absorb B12
Why is vitamin B12 important?
Help metabolize protein, fat, and carbohydrates
Low levels → fatigue, depression, neurological damage
Low concentrations associated with Alzheimer’s disease
2010 Neurology
Supplementation lowers homocysteine
2008 Proceedings of Nutrition Society
Supplementation reduces cognitive decline
2012 American Journal of Clinical Nutrition
Supplements for Special Situations
B-vitamins and zinc for vegetarians
Especially B12 for vegans
Vegetarian diets typically low in these nutrients
2002 American Journal of Clinical Nutrition
Folic acid for pregnant women
Deficiency can cause neural tube defects
Supplementation prevents neural tube defects
2009 Annals of Internal Medicine
Can often be obtained in quality multivitamin
Evidence-Informed Supplementation
for Specific Health Concerns
Popular Supplements: Joint Health
Glucosamine & Chondroitin 2006 New England Journal of Medicine
Methylsulfuromethane (MSM) 2006 Osteoarthritis and Cartilage
Hyaluronic Acid 2008 Nutrition Journal
Turmeric 2006 Arthritis and Rheumatism
Ginger 2001 Arthritis and Rheumatism
Popular Supplements: Digestion
General Digestive Support
Digestive Enzymes Broad-spectrum plant-based (preferable)
Animal-based
Pancreatin
2009 Alimentary Pharmacology & Therapeutics
Acid-reflux… tapering off acid-blocking medications
Deglycyrrhizinated Licorice (DGL) 2001 Hospital Practice
Aloe Vera Typically juice
Popular Supplements: Immune System
Echinacea 2006 Cochrane Database Systematic Review
Vitamin C 2010 Journal of International Medical Research
Vitamin D 2010 Nutrition
Zinc 2011 Cochrane Database Systematic Review
Probiotics 2006 Journal of Clinical Gastroenterology
Mushroom extracts 2012 Medicine and Sports Science
Popular Supplements: Heart Health
Red Yeast Rice 2010 American Journal of Cardiology
Fish Oil 2009 Annals of Internal Medicine
Coenzyme Q10 2007 European Heart Journal
Vitamin D 2009 Archives of Internal Medicine
Popular Supplements: Liver Health
Milk Thistle 2008 Annals of Hepatology
N-Acetyl Cysteine (NAC) 2005 Clinical Therapeutics
S-Adenosyl Methionine (SAM-e) 2007 Hepatology
Turmeric 2009 Liver International
Popular Supplements: Depression
St. John’s Wort 2008 Cochrane Database Systematic Review
Fish Oil 2010 Journal of Clinical Psychiatry
S-Adenosyl methionine (SAM-e) 2002 International Journal of Psychopharmacology
Popular Supplements: Sleep
Melatonin 2004 Journal of Clinical Endocrinology & Metabolism
Valerian Root 2006 American Journal of Medicine
5-Hydroxytryptophan (5-HTP) 2000 Alternative Medicine Review
Checklist: Informed Supplement Consumer
□ No interactions with other drugs/supplement
- Talk to healthcare professional and consult literature
□ No outrageous label claims
- Especially weight loss, sexual, bodybuilding products
□ Carefully read all ingredients on label
- Consider content, quality, source of ingredients
- Some forms of vitamins, minerals, etc. better than others
- Look for strains on probiotics
Checklist: Informed Supplement Consumer
□ Seek 3rd party verification certificate
- Sign of commitment to product quality
- NSF “Gold Standard” of product quality
□ Choose brands supported by
peer-reviewed research
- Ultimate sign of commitment to product quality!
- Companies not required to conduct research…
provides consumers & healthcare professionals
with evidence the supplement works
