Quality Supplements: serving sizes, standards, and your questions answered

Over the last 20 years, natural products and supplements have grown immensely in popularity (10). It seems for any ailment there is a supplement that has been said to help. Unfortunately, there is very limited regulation on these products, and the FDA is only able to remove supplements from the market once they have already caused harm. When doing a simple search for Calcium on Amazon, the results span roughly 7 pages, so how do you know what is a trustworthy and high quality product? The answer seems to be in third party testing.

Benefits of supplementation

Supplementation can be incredibly beneficial to those with chronic illness or a deficiency. 

Disease may respond well to dietary supplements as supplements have been shown to be incredibly powerful medicines and possibly even enhance the effects of medications (5). But this is HIGHLY dependent on the medication, on the supplement, on the individual, and on the disease state. Not to mention the dosages of ingestible products and the weight of the individual. 

As an example, Coenzyme Q10 (CoQ10) has been mostly studied for its reduction in oxidative stress in the body, such as ameliorating *dyslipidemia, hypertension (14, 15). The proper dosage still needs to be studied further as no conclusions were made about an optimal amount, though most studies look at anywhere from 100-200 mg/day doses.

A lot of the time the actual recommended amounts of a nutrition/dietary supplement are in place to prevent a deficiency, not to encourage optimal health (12).  This is leading to health professionals becoming more informed about the benefits (and risks) of supplementation, as well as recognising when it may or may not be appropriate to recommend one.

*dyslipidemia: imbalance of lipids in the body

According to the National Center for Complementary and Integrative Health, the most used products by adults in the US are:

  1. Fish oil or Omega E supplements
  2. Glucosamine
  3. Probiotics/Prebiotics 
  4. Melatonin 
  5. Coenzyme Q10
  6. Echinacea
  7. Cranberry
  8. Garlic supplements
  9. Ginseng
  10.  Ginkgo biloba

Are multivitamins Beneficial

There are mixed opinions if multivitamins are beneficial and actually improve health. In 2018 a consensus panel report determined that vitamins can be beneficial if they contain micronutrients that a person is not adequately consuming (13). For example, a strict vegan individual who takes zero nutritional supplements may be at risk of vitamin B12, zinc, and iron deficiency. 

 

At the same time, some individuals require higher than normal intakes and may need more than the daily recommended value, like folic acid or iron for pregnant women. Others may have absorption issues and require supplements in a form other than a pill or through food, like for those who have a history of bariatric surgery and may benefit from a sublingual vitamin B addition. 

 

The consensus did agree that there does not seem to be sufficient evidence in consuming a daily multivitamin with the aim of chronic disease prevention (like cancer and cardiovascular disease) (13).

 

Alexa, our founder, says “I’ve worked with individuals who compared their health before and after taking multivitamins every day. Some didn’t notice anything at all, others noticed better quality hair and nails, or more energy. It depends where an individual may be deficient, or if they are indeed getting all of their nutrition from food. I’m a food first kind of gal, but if you know that you don’t get enough of certain food groups (like animal products if you’re a strict vegan) then supplementation can be super beneficial”.

Safety of supplements

The US Food & Drug Administration (FDA) regulates dietary supplements as food, not as drugs. Dietary supplements often have high amounts of ingredients with strong biological effects, so it’s best to check with your healthcare professional before starting any supplements. Trusted healthcare professionals to speak to regarding safe supplementation include your physician, nurse or nurse practitioner, pharmacist, or registered dietitian.

Here’s some more information straight from the FDA webpage:

  • The FDA does NOT have the authority to approve dietary supplements for safety and effectiveness, or to approve their labeling, before the supplements are sold to the public.
  • Under the FD&C Act, it is the responsibility of dietary supplement companies to ensure their products meet the safety standards for dietary supplements and are not otherwise in violation of the law.
  • Dietary supplement labels are required to have nutrition information in the form of a Supplement Facts label that includes the serving size, the number of servings per container, a listing of all dietary ingredients in the product, and the amount per serving of those ingredients. They also must have a statement on the front of the product identifying it as a “dietary supplement” or similar descriptive term (e.g., “herbal supplement” or “calcium supplement”).

Since the FDA is only able to remove products from the market once they are unsafe (2), it is up to the consumer to do their research to ensure they are purchasing a safe product. Since there are so many products on the market and products are continuously being added to the market, the FDA cannot take action until a patient reports harm caused by a product (2). 

 

Back when the law came into action in 1994, there were 4,000 products on the market. In 2000, 29,000 products were on the market (11), so the FDA does not have the bandwidth to regulate all products. 


Some reasons that products have been pulled from shelves are microbial and heavy metal contamination, adulteration, substituting herbs and false ingredients listed on labels. Companies continue to use substances that have been banned in the US, with some companies using intentional contamination. The worst offenders are weight loss and muscle-building supplements and are more likely to be contaminated (1). One example is the FDA’s ban of Ephedra in 2004. According to the National Center for Complementary and Integrative Health, Ephedra was added to weight loss supplements and was associated with heart attack, seizure, stroke and sudden death. It affected those taking both low and high doses and as a result companies were no longer able to use it in their supplements in the US.

what does the "serving size" mean on supplements?

A serving size is NOT a recommended serving. They are based on how much people actually consume, not what they should consume. So when it comes to supplements, you will likely see a serving size with instructions on how much to take. This could be based on research and what has been used in some studies. This can be risky, because oftentimes research uses high doses to induce an effect (or an attempt to induce an effect) of what they are studying. Not all research can be inferred to all populations – just the ones being studied (for example, studies on pregnant women should not be inferred to teenage males). 

 

An example I can think of is a popular supplement with instructions to take on an empty stomach. I would guess this is to ensure the water soluble vitamins are all absorbed without potential interferences from food in the stomach. BUT, this supplement also contained minerals that may induce nausea on an empty stomach. 

 

Alexa points out “Not everyone will need to or should take the “serving suggestion” on the back of a supplement bottle. If you eat healthy, and vary your food intake, taking the entire dose of a supplement may not provide any additional benefits, and could even give you too much to where you’re now consuming harmfully high doses. It’s best to work with your healthcare professional to see where you’re deficient and by how much”. 

Additives

Additives may be necessary for shelf life, binding ingredients together, or to improve the texture/colour/taste. Some of these additives may contain allergens, like soy, or ingredients that certain religious groups or vegans avoid, like animal gelatin. It is important to read the ingredients list of supplements before consuming.

third party testing

Since the FDA does not determine safety of a supplement before it hits the market, companies have begun to offer third party testing to ensure a safe product. In order to be considered a third party, the organisation must have no involvement with the design and implementation of the product being tested.  

 

All of the companies offering third party testing have their own quality assurance programs, accreditation, and use labs with proper certification. The third party company must disclose what substances they have tested for in a product and can only put testing labels on the products that have actually been tested. Third party testing helps keep the consumer healthy and helps prevent them from purchasing a product that is not safe for consumption. 

 

In order to determine if a supplement has been third party tested, it should have a stamp on the bottle of the certification or can be searched on the NSF website. The NSF screens for 280 banned substances, offering athletes confidence when purchasing their supplements. Other third party testing seals include: USP, BSCG, and ConsumerLab.

bottom line

For the most part, people are able to consume their body’s required vitamins and minerals through a balanced diet and not everyone needs additional supplementation. 

As an example, a vitamin like vitamin D may be difficult for the body to synthesize during winter months and supplementation may be needed. 

Supplements can be incredibly beneficial for overall health and specific concerns, but when not taken under the care of a doctor or registered dietitian, they can be dangerous. 

Certain supplements like Vitamin A can become toxic if over consumed. 

Getting your blood tested to see if you may be at risk of nutritional deficiencies can be incredibly beneficial in deciding if a supplement is right for you.

And remember, it is illegal in the United States for supplements to tout that they treat or cure a disease. They can say that it reduces the risk of XYZ.

Stay connected and join The Better Balanced Community

this post was co-written by nutrition student enthusiast, Ashley Lyons

references

  1. Mathews NM. Prohibited Contaminants in Dietary Supplements. Sports Health. 2018 Jan/Feb;10(1):19-30. doi: 10.1177/1941738117727736. Epub 2017 Aug 29. PMID: 28850291; PMCID: PMC5753965.

  1. White CM. Dietary Supplements Pose Real Dangers to Patients. Ann Pharmacother. 2020 Aug;54(8):815-819. doi: 10.1177/1060028019900504. Epub 2020 Jan 24. PMID: 31973570.

  1. Eichner AK, Coyles J, Fedoruk M, Maxey TD, Lenaghan RA, Novitzky J, Lindsey AT, Deuster PA. Essential Features of Third-Party Certification Programs for Dietary Supplements: A Consensus Statement. Curr Sports Med Rep. 2019 May;18(5):178-182. doi: 10.1249/JSR.0000000000000595. PMID: 31082891.

  1. Vento KA, Wardenaar FC. Third-Party Testing Nutritional Supplement Knowledge, Attitudes, and Use Among an NCAA I Collegiate Student-Athlete Population. Front Sports Act Living. 2020 Sep 15;2:115. doi: 10.3389/fspor.2020.00115. PMID: 33345104; PMCID: PMC7739801.

  1. Massey PB. Dietary supplements. Med Clin North Am. 2002 Jan;86(1):127-47. doi: 10.1016/s0025-7125(03)00076-2. PMID: 11795085.

  1. Basch EM, Servoss JC, Tedrow UB. Safety assurances for dietary supplements policy issues and new research paradigms. J Herb Pharmacother. 2005;5(1):3-15. PMID: 16093231.

  1. Sarma N, Upton R, Rose U, Guo DA, Marles R, Khan I, Giancaspro G. Pharmacopeial Standards for the Quality Control of Botanical Dietary Supplements in the United States. J Diet Suppl. 2021 Oct 26:1-20. doi: 10.1080/19390211.2021.1990171. Epub ahead of print. PMID: 34699287.

  1. Chen F, Du M, Blumberg JB, Ho Chui KK, Ruan M, Rogers G, Shan Z, Zeng L, Zhang FF. Association Among Dietary Supplement Use, Nutrient Intake, and Mortality Among U.S. Adults: A Cohort Study. Ann Intern Med. 2019 May 7;170(9):604-613. doi: 10.7326/M18-2478. Epub 2019 Apr 9. PMID: 30959527; PMCID: PMC6736694.

  1. Lentjes MAH. The balance between food and dietary supplements in the general population. Proc Nutr Soc. 2019 Feb;78(1):97-109. doi: 10.1017/S0029665118002525. Epub 2018 Oct 30. PMID: 30375305; PMCID: PMC6366563.

  2. Saldanha LG, Dwyer JT, Bailen RA, Andrews KW, Betz JW, Chang HF, Costello RB, Ershow AG, Goshorn J, Hardy CJ, Coates PM. Characteristics and Challenges of Dietary Supplement Databases Derived from Label Information. J Nutr. 2018 Aug 1;148(suppl_2):1422S-1427S. doi: 10.1093/jn/nxy103. PMID: 31505680; PMCID: PMC6857608.

  3. Dwyer JT, Coates PM, Smith MJ. Dietary Supplements: Regulatory Challenges and Research Resources. Nutrients. 2018 Jan 4;10(1):41. doi: 10.3390/nu10010041. PMID: 29300341; PMCID: PMC5793269.

  4. Coppens P. The Importance of Food Supplements for Public Health and Well-Being. World Rev Nutr Diet. 2020;121:66-72. doi: 10.1159/000507524. Epub 2020 Oct 6. PMID: 33502375.

  5. Blumberg, J. (2018, April). The Use of Multivitamin/Multimineral Supplements: A Modified Delphi Consensus Panel Report. ScienceDirect, 40(4). https://www.sciencedirect.com/science/article/pii/S0149291818300894

  6. Gutierrez-Mariscal FM, Arenas-de Larriva AP, Limia-Perez L, Romero-Cabrera JL, Yubero-Serrano EM, López-Miranda J. Coenzyme Q10Supplementation for the Reduction of Oxidative Stress: Clinical Implications in the Treatment of Chronic Diseases. Int J Mol Sci. 2020 Oct 23;21(21):7870. doi: 10.3390/ijms21217870. PMID: 33114148; PMCID: PMC7660335.

  7. Digiesi, V., et al. “Coenzyme Q10 in essential hypertension.” Molecular aspects of medicine 15 (1994): s257-s263.

16. Skoracka, Kinga, et al. “Female Fertility and the Nutritional Approach: The Most Essential Aspects.” Advances in Nutrition 12.6 (2021): 2372-2386.

Tagged , ,