When I started writing this, the intent was to quickly summarize a conversation I’ve had on a number of occasions with patients trying to make educated decisions when choosing nutritional supplements and botanical medicines, but it turned into a bit of a manifesto.
There is a huge difference in the level of quality between a “professional grade” nutritional supplement or botanical medicine, and products sold at most national drug stores, Costco®, etc.
To offer a sense of perspective, The Comparative Guide to Nutritional Supplements evaluates multi-vitamins/minerals on a range of standards, including some of the topics discussed below, and awards each product a rating. In the 3rd edition of the Guide, Douglas Laboratories® UltraPreventative® X earned a rating of 95.4 (of a possible 100), and Jamieson™ Power Vitamins for Men rating was 3.51.
The bottom line: you get what you pay for.
Whenever I have a new patient intake appointment, part of process of gathering complete information includes not only identifying what other treatments a patient may have used in the past or are presently using, and with what amount of success, but if nutritional supplements are being used, who are the manufacturers?
This is important information for me to have, because there is a wide range in quality between nutritional supplements.
Unfortunately, nutritional supplements are not regulated particularly rigorously. The main emphasis of regulation is safety, and reliability of advertising claims (i.e., “This product cures cancer” is not an allowable claim for a product to make unless they can provide scientific evidence of this fact). Importantly, product efficacy (unless the manufacturer is making specific health claims about their product) is not a consideration.
Individual pharmaceutical drugs each have a very specific chemical composition. If choosing to use a “generic” version of the drug, rigorous standards guarantee that the amount of active ingredients and the rate at which the drug is absorbed into the body are the same as the original. This provides some assurance that quite similar performance can be expected2.
The actual quality between two, for example fish oil products, can vary widely – a low-quality fish oil product and a high-quality fish oil product are really, the same in name only.
Not achieving the desired health results with the use of a low-quality nutritional supplement or botanical medicine does not necessarily mean that the specific nutrients or herbs are not potentially helpful to that patient, it may indicate they are using an ineffective product.
These are some of the differences between high-quality nutritional supplements and botanical medicines and their low-quality counterparts:
Unlike generic and brand name pharmaceuticals, there is no “standard” starting point for nutritional supplements and botanical medicines.
Botanical medicine tinctures (those bad-tasting liquid medicines sold in amber bottles) are prepared by macerating (soaking) plant materials in a solvent (usually alcohol). The proportion of plant to alcohol, by weight, is usually included on the label, and gives the user a sense of how potent the medicine is. Only some companies use dried herbs (as opposed to “fresh/wet” herbs) as their raw material: dried herb = lower weight = more herb used in the tincture = more concentrated plant medicine.
A second example is standardization of ingredients. In many cases, the specific chemical responsible for a desired action in a plant is known. For example, important ingredients in the therapeutic effect of St. John’s Wort are chemicals in the hypericin family3. Products including St. John’s Wort should therefore include known, consistent amounts of hypericin in each dose.
Lastly, again in the realm of botanical medicines: how were ingredients grown? Agricultural research has demonstrated that organically grown/raised produce is more nutrient dense than it’s conventional counterparts4. It follows that organically grown plants will yield more potent botanical medicines – does a manufacturer use organically grown raw materials?
Minerals (e.g., calcium, magnesium, zinc) are absorbed into the body attached to acids, for example amino acids or other organic acids (e.g., magnesium carbonate – the carbonate is added for magnesium absoption).
The efficiency of absorption of a particular mineral is greatly influenced by the organic acid it is bound to. Inorganic mineral salts are less expensive to use in production, but offer poor nutritional value, under some conditions potentially causing net loss of a particular mineral from the body5. Magnesium carbonate or magnesium glycinate? One is cheaper, but not necessarily the better value.
Forms of nutrients are not only relevant in nutrient absorption. Alpha-tocopherol is the most common form of vitamin E used in nutritional supplements. It is available in a natural, d-alpha tocopherol form, and a synthetic d/l-alpha tocopherol form. The synthetic form is less expensive for manufacturers to source, but is also less bioavailable, and has only half the biological activity of the natural form of vitamin E5. Which form do you think Costco®’s Kirkland Signature™ brand vitamins use?
Raw materials aside, a company’s manufacturing standards can result in wide differences in quality of end products.
Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are the key active ingredients in fish oil products, and are concentrated in fish oil supplements by a process called “esterification” (EPA and DHA do not naturally occur in fish in the concentrations found in higher-quality fish oil supplements).
For optimal absoption in the body, however, the EPA and DHA should be “un-esterified” back into their natural, “triglyceride” form, which increases absoption by some 70%6. An “esterified” fish oil product may appear to be very concentrated, but will not ultimately offer the benefits a well-manufactured, “triglyceride form” product will, information not available on a product label.
In general, manufacturers who are quality focused will “go the extra mile” to ensure their products offer maximum benefit (and protect their reputation):
In some cases, particularly in the case of botanical medicines, the formulation (recipe) plays as important a role in the effectiveness of the medicine as the specific medicinal ingredients included. Much like a recipe, which is more than the sum of it’s parts, a successful botanical medicine will often include herbs that act as “synergists”, plants that do not include chemicals acting directly on the primary health concern, but that increase the effect of the other plants included in the formula (e.g., cayenne acts as a circulatory stimulant, which when included in a formula can increase rate of delivery of other chemicals in an herbal medicine).
Both Viriditas Herbal Products and MediHerb® products are created by herbalists having decades of compounding experience. Can this be said of all brands?
Nutritional supplements include more than nutrients alone, in fact, in many cases the medicinal ingredients are less than the “other” ingredients. Are the “other” ingredients desirable or undesirable?
High-quality products will often have included “helpful” substances, for example vitamin E, an anti-oxidant, added to a fish oil product to prevent naturally occurring rancidity of any oil.
In contrast, Flintstones™ Complete Chewables Multivitamins include as “non-therapeutic” ingredients:
Sometimes the actual cost of a product is hidden in the dosage required for benefit.
For example, the “standard” daily dose recommended for many higher quality fish oil products offers, in the neighbourhood of 1’500 mg of combined EPA and DHA in each dose, the generally recommended “meaningful” dose for these recognized by experts10.
One capsule of 1000 mg Kirkland Signature™ Fish Oil contains 250 mg of combined EPA and DHA, a minimal dose11, 12, meaning one would have to take six capsules daily to meet the requirement for the “meaningful” recommended dose. (The label on the Kirkland Signature™ Fish Oil further suggests swallowing the capsules with water, which will reduce absorption of fat-soluble chemicals).
The above is likely daunting. Even to person such as myself for whom this is my “job”, conversations with manufacturer’s representatives are often frustrating, like comparing apples to oranges: is a liquid fish oil including an anti-oxidant to prevent rancidity preferable to a fish oil in a supposedly more stable capsule form? It’s a rabbit hole (that you can continue down if you want to learn more about fish oil quality issues).
Although obviously a source of income for our office, the items in our dispensary are a quality-control mechanism for us, and selected after hundreds of hours of education, research and product meetings.
Or at the very least, don’t buy on price alone.
Posted: 2017 May 10