Safety in Supplements: Ensuring the Highest Quality for Your Patient
By Christopher Oswald, DC, CNS
Supplement quality should be a very big concern to all doctors of chiropractic. You may have recently seen an article exposing the dangers of supplement use. Yes, there are supplements that are not of the highest quality, but there are several standards that you can look for to put you at ease about whether the supplement that you are recommending will contain exactly what the label states and be safe for your patients. In 1994, the Dietary Supplement Health and Education Act (DHSEA) was passed as a measure to promote and protect public health. The act describes who is subject to current Good Manufacturing Practices (cGMP); if you manufacture, package, label, hold or import dietary supplements you are bound by this DSHEA to follow cGMPs. Following cGMPs is the most basic tenet of what a company within the dietary supplement industry must do to comply with DSHEA, but there are manufacturers and distributors that go much farther in ensuring the quality of the products you are providing to your patients.
The cGMPs dictate that you must put your procedures and work instructions in writing and then you must follow them. In addition, cGMPs require testing of the finished product. By doing this, the company is able to produce a standardized product with the same results every time a new batch is created. To ensure the company is following cGMP standards, a third party audit can be performed by any number of agencies including NSF International, USP (U.S. Pharmacopeial Convention, NPA (Natural Products Association), and the TGA (Therapeutic Goods Administration). Companies with the highest regard for quality pride themselves on their standards and a high level of self regulation by receiving certification of their procedures through these third party agencies.
In the dietary supplement industry, the FDA is more reactive than proactive when dealing with specific products. The manufacturer is tasked with ensuring that the product is safe for human use and the FDA will not step in until there is a complaint or problem with one of the company's products. This is why it is important to use companies that are dedicated to making a product that is tested in multiple stages throughout production for potency, purity and identity. This testing to ensure product quality requires testing for the identity of the raw materials and having a qualified laboratory test the finished product for: identity; microbial and heavy metal contaminants; pesticides and herbicides; other chemical contaminants, such as aflatoxins or melamine; and for overall potency. This information can be requested from manufacturers by asking for a certificate of analysis (CoA) for the specific product in question. It is important that the company not only tests its products, but that it is also using the most appropriate tests in analyzing their products. Many companies also go far beyond the minimal testing requirements stated by cGMPs in an effort to produce the highest quality product. A manufacturer that uses high pressure liquid chromatography (HPLC) to ensure they know exactly what is in their products, is more reliable than a company that just takes the word of the raw material supplier for product identity.
Know What You Recommend
In my practice, I know that giving contaminated supplements to my patients could potentially aggravate existing conditions or present new ones, so I need to know exactly what I am recommending to my patients in order to provide an accurate prognosis. This is why I scrutinize each and every brand that I provide within my practice prior to usage by my patients. In order to do so, I request a third party CoA of each of the company's products that I plan to offer, as well as a record of the testing performed on the raw materials prior to being prepared into tablet, capsule, gel, liquid or powder form. It is important to not just assess the final product, but also to know the quality of the raw materials. If there are impurities in the raw material, do you even want to take the chance with them ending up in the finished product? Requesting this information can be a very time consuming process, let alone analyzing the data that is sent to you. However, the confidence you gain knowing you are recommending the best is worth every effort.
Self regulation within the nutritional supplement industry has become paramount to distinguish the best from the rest. There are distributors of dietary supplements that hold quality in the highest regard and have developed their own programs that do all the work of verifying the quality of brands for you. To reduce the time spent gathering and analyzing information, you can instead choose to work with a distributor or program that has done this part for you. Of course, prior to relying on any program that ensures quality, I would recommend that you first take the time to evaluate their processes to make sure they meet your standards. Once you understand how they go about validating quality, and you trust their process, it will be very easy to screen the brands you want to recommend for product quality.
Ensure Safety and Quality
If you are recommending dietary supplements to patients in your practice, it is your duty to ensure that whatever they are taking is safe and of the highest quality. If patients are not given any guidance and go to the local superstore to grab what you recommended, can you guarantee that the product is safe and the label accurately represents the contents? I know that if I sent a patient somewhere with a recommendation to follow and they purchased a contaminated supplement and were hurt, I would be devastated. Would I be liable? That is something for the lawyers to work out, but I do know I can prevent this by facilitating patient access to dietary supplements of the highest quality.
The best way to ensure that your patients are using quality supplements is to provide this service within your practice. By offering supplements through your practice, it provides access to professional product lines that are not available to the retail market and are, many times, the most pure and highest quality options available. Facilitating your patient's access to these kinds of products in a convenient way through your office supports a commitment to providing the best quality healthcare to your patients.
If you say your patients will only pay for the least expensive supplement, well, that may not be true. The Nutrition Business Journal's 2012 report on the global supplement and nutrition industry shows that from 2009 to 2010 there was a 4.4% increase in dietary supplement sales in the midst of a major recession. Even more significant is that practitioner sales increased at a higher rate over this same time period. In my opinion, these numbers point to the fact that patients are willing to spend a bit more on a supplement from a trusted source to ensure they are getting a safe and quality product.
It seems that dietary supplements are in the news more and more often; unfortunately the news is many times negative due to the fact the supplement in question had very low quality, contaminants, heavy metals or one of the many other things that might compromise the integrity of a quality dietary supplement. It has become evident to me that it is my responsibility to know exactly what is in the products that I recommend my patients to take. This goes much farther than just reading the label or calling the company with a couple questions. When you do contact a company about the quality of their supplements, if they are not gladly providing you with documentation of the quality of their products and manufacturing practices, I would start to look for another company that prides themselves in their self regulation and transparency of their quality practices.
Christopher Oswald, DC, CNS, is currently a medical educator on staff with Emerson Ecologics, the home of the Emerson Quality Program, as well as a 2007 graduate of Northwestern Health Sciences University. Upon graduating, he went into private practice with a focus on using functional medicine to approach tissue health, adrenal health, GI health, weight loss and optimizing sports performance. Along the way, Dr. Oswald learned how to successfully combine supplement sales within a chiropractic practice. He can be reached at