Dietary Supplement Practicum 2018: Meeting the Stakeholders–Meet the Watchdogs

so now we're going to meet three people who do something a little different in this space and I'm not going to introduce them with all of their credentials rather I'm going to ask each of them to do what our industry colleagues did what do you do in this space so the first of our speakers in this segment will be Laura McCleary who's from the Center for Science in the Public Interest what do you do Laura well hi there I am Laura McCleary and I'm a lawyer I've been doing public interest advocacy work mostly in the public health and good government spaces for 18 years and center for science of the public interest is an independent by which we mean we take no government donations or industry money a nonprofit organization and actually dice very supplements are I would say a very small part of our overall docket so you know here's a snapshot of some things that we do really we are an Innovation Lab to push for public health transformations that drive change so you are one of our achievements is coming to a restaurant near you or has AZ of several weeks ago calorie counts on menus that was really an effort that was led by us the ban of trans fat from the food supply and first its labeling was an effort that CSPI helped lead we led the fight for healthier school meals for children for school children and we do we use a mix of tactics and methods to achieve the changes that we seek everything from regulatory involvement to litigation in the courts on class-action claims around false and misleading products to legislation and of course public education a centerpiece of our work and our independence both is our nutrition action health newsletter this is a ten times a year publication it's very affordable I commend it to all of you it's it's a terrific magazine really reviews with rigor the science behind a lot of claims that float around in the food health and nutrition space and over the years we've done a lot to debunk and analyze the effectiveness of various types of dietary supplements so this is the work that I draw in as the regulatory lawyer thinking about what things we should bring to the public's attention which things we should bring to the Food and Drug Administration's attention about supplements one of these diabetes defense I'll talk about this a little bit later but it's you know in the area of unapproved drugs we have particular concerns so if there is a claim being made that a supplement you know counters the symptoms of diabetes or prevents some aspect of diabetes we are going to take a particular look at that most of the studies you'll see in this you can't read it up here you have the slides in the in the booklet we're actually underpowered to the outcome or found no effect and you do see these kinds of stories populating the web in particular cinnamon has magical properties I think a lot of this is that there's a lot of magical thinking around food in general and dietary supplements in particular we also tend to look at particular claims so the one that went the example in the other article on Prevagen for example for example the company touted the study but fail to disclose that the placebo was equally effective you know this is not unusual there's often slim or no evidence behind many of the claims and it's tricky from a regulatory perspective because the office of dietary supplement programs does attribute claims that are around an article a product that's being sold like as a supplement as imputed marketing but oftentimes what you have on the shelves are given that companies have gotten very savvy is you'll just have the bottle say Saint John's wort or cinnamon capsules or something and there's no claim at all and so therefore the consumer is then vulnerable to reading about on the web some separate marketing material that's off the label that may tout the benefits of a particular substance and yet it's very hard for FDA to make the enforcement case against the company this is another example of to nutrition action health newsletter articles that we published on on testosterone it's a three page article if you subscribe you'll get access to the full thing but the upshot was that while low testosterone is a legitimate medical condition of course that needs treatment in some cases that it's being oversold and that actually taking excess testosterone raises the some risk of cancer it's not totally clear on the probiotics you know the recommendation that came out of that was that they're oversold they don't need to be taken daily they can help with particular conditions and there's usually strains that have been identified as helping with particular things like while you're taking in antibiotics or if you have some kind of other infection and so you can take those particular things but that a lot of probiotics offer scant or little benefit maybe one day less of a cold for example I got involved personally in dietary supplements with a very dramatic case I read in the news dietary supplements had been part of my docket but in addition to sort of nutrition action during these publications and the 2013 Durbin bill that we had been involved in as well as the industry and trying to push for register product registration this issue came up in the news and I read the headlines just like everybody else I became immediately very concerned that pure powdered or in some cases highly concentrated liquid caffeine was being sold on the Internet it was sold at 99.9 percent concentrations a tablespoon in five pound bulk bags or two gallon jugs and a tablespoon could kill an adult a teaspoon could kill a child the proper dose was a thirty-second of a teaspoon which no one has the ability to measure at home and so we wrote a citizen petition and submitted it to the Food and Drug Administration these two young men our Logan Steiner and James Wade sweat we worked with their families who came to Washington on their own dime on multiple occasions to meet with lawmakers and publicize about the issue we had press conferences on the hill the FDA initially issued five warning letters to companies that we had identified as selling these products we did a spot check of the market within like six to nine months later I forget exactly the timing and there were still multiple availabilities of this product on the internet you could just get it so we ordered the product we took it up to the hill we had this kind of show-and-tell with reporters that we could still get these products even though the FDA had issued a warning letter there was also a third death that showed up in the medical literature where a person had taken a man had taken the caffeine and thrown it up all over the dashboard of his car and had went into cardiac arrest which is how you die from a caffeine overdose and there may have been a cult deaths that were showing up in the medical literature because if you take a high dose of caffeine and then are going to exercise or or you know jog outside or something and no one connects the substance with the heart attack if you had a normal autopsy for a heart attack you wouldn't be looking for caffeine levels in the blood so there could have been hardest at cases related to these products that just didn't show up because no one did a second autopsy specifically looking for caffeine levels just recently in April 2018 we were so heartened to see that the office of dietary supplement programs actually put out in a final guidance that these products are illegal or adulterated per se because they're if they're sold in an amount that's lethal to the end consumer if they're sold in bulk that even a scoop like a little scoop that came with the bag which is how they had been continued to be sold they said could be separated from the bag and would pose a danger and that's to Logan Steiners friend gave him some of the powdered caffeine and a little baggie separated from its original packaging so once these things are in circulation it's very hard and I think the trend is very concerning because what it shows is that there's a lot of bulk supplements that are kind of inputs to formulated supplements by the major brands and companies and those you can purchase directly from China or through bulk supplements websites here in the US and basically you're dealing with raw ingredients and they're uncut form and and so you know this is the FDA kind of pushing back on the ability to turn around and then make a profit by selling that we also in December put out as I said we're very concerned about unapproved drugs things that are marketed essentially to treat disease as dietary supplements and FDA has a guidance that says that they're going to prioritize enforcement of unapproved drugs because they pose as legitimate treatment for a medical condition in the case of opiate addiction there it are medically approved treatment protocols that are known to be effective for that condition few people have access to them some may not even know about them and so the temptation to then go to use a dietary supplement or not to have to go to a doctor that might be affiliated with your employment and admit to an addiction problem is very high so into that gap have rushed a number of as Duffy would say bad actors these are companies that were marketing opioid withdrawal AIDS in the dietary supplement marketplace some of which were sold on Amazon or Ebay and other places we wrote to the companies and when I say we I mean the grander we David sharp my colleague wrote them letters as CSPI you know do you have scientific studies showing that any of the ingredients in these products are effective for opiate addiction relief these are the responses we got back scientific studies are very costly so no we didn't bother we don't really have any scientific studies as such currently these are you know very common for the bad actors within the industry I would agree with the characterization that there are better and worse companies in this space there the problem is that the worst companies create a an atmosphere of consumer confusion and fraud sometimes outright fraud in January FDA and the Federal Trade Commission which we had also written to about the illegal marketing of this products and which has already brought several cases on the opioid dietary supplement claims took action we were pleased to see that they went out into the marketplace and found additional bad actors that we hadn't uncovered in our initial research and they issued a number of warning letters to those companies so that is the first step in an enforcement action I assume that the agencies will follow up and see whether in fact the companies have ceased selling those products in some cases the Department of Justice or FTC may go after the companies and seek aggressive kind of consumer penalties and even repayment of consumers who were defrauded obviously with a condition like opiate addiction it's life-threatening with other products what we see is that there's just widespread economically motivated adulteration which is lawyer speak for fraud in the case of Ginkgo we noticed that there was industry monograph pointing to widespread adulteration of Ginkgo products which is one of the top sellers among dietary supplements and that there was strong incentives to substitute other parts of the ginkgo tree or buckwheat for the allegedly active parts of ginkgo it's not a great supplement to begin with because there really isn't good evidence that it's effective for many of the things that patients may take it for like memory loss or muscle and joint benefits so we wrote FDA and enforcement letter saying these are adulterated it's kind of like that joke you know the food's terrible and there's not enough of it right these are adulterated and they're kind of ineffective so the some of those things led us to a recommendation to avoid to consumers to avoid ginkgo biloba supplements our priorities when we think about advocacy are first that we need to protect the public from acute risks like pure caffeine we've also worked on the tainted supplements that are you know tainted with often performance-enhancing amphetamines or that sort of thing for weight loss or from drug interactions we have a long-standing citizen petition to have a warning label on st. John's wort we're asked we're going to ask for the same thing on beta carotene because these have known drug interactions we also are concerned about unapproved drugs and then as a secondary concern we work on things that are about efficacy where we think consumers are being misled by an avalanche of claims these are a number of really in the weeds kinds of reforms but basically they'll add up to we think there should be some kind of mandated third party marked pre market oversight of safety and efficacy we recognize this as a fight that we lost in 1994 we think it's worth having another conversation with the industry about whether consumers and the industry really benefit from the current Wild West regulatory environment we also would back a registration system we think FDA needs more resources such as user fees and that in a number of areas FDA should enhance its regulatory oversight as just for new dietary ingredients that's the new dietary ingredients guidance in addition we think there should be a requirement for substantiation of claims that things are effective for the purposes claimed and that would sort of get out of the conundrum that Duffy had laid out which is how do you claim that something doesn't make you sick and that there should be ongoing prosecution where things actually pose a hazard thanks so much well thanks very much Laura Todd Cooperman is from ConsumerLab comm and has been a regular on our program for quite a number of years the only thing I need to watch out with Todd is that he always has so much he wants to say so I won't take any of your time as long as you promise not to take any more time than anybody else thank you it's always a pleasure to be here and thank you Paul's and Lisa for having me in an ODS I will try to get quickly to really where I want to go is to talk about some of the interesting things that we have been finding at ConsumerLab for those of you who are not aware ConsumerLab has been around for 19 years I'm a founder of the company we are basically people out people out there testing to see what's really in in supplements and other health and nutrition products and it's nice to see how the baton gets passed sometimes to the people at CSPI we we actually found some of those problems with the gingko which were recited into the policy work that that CSPI is doing from time to time again I'm going to try to skip through some of the earlier stuff since 1999 we've tested over 6000 products we put out a report every three weeks on another category of supplements we have about five or six categories always in testing and that represents about 850 different brands that we've tested from and we were supported primarily by seventy-seven thousand plus individual subscribers plus libraries and in other institutions that subscribe the consumer lab it's 42 dollars a year and also if anyone's not a subscriber I'm happy to give you a free access for 3 months we're gonna pass around a sign-up sheet which is what I do every year and we're happy to extend that to you we're in the news a lot just because our findings are quite interesting to a lot of people again I'm the founder I'm an MD our head of research is of mark Anderson who spoke here last year our 22 years experience in the dietary supplement area himself and an active member of the AOA C involved in developing protocols for testing supplements I'm so so you know why can't we just rely on the FDA and and good manufacturing practices with supplements well as you've been hearing for the last two days you can't because one the FDA doesn't approve supplements nor does it register supplements companies have to register but not not the products themselves email there are some lists now listings of products they're not registered good manufacturing practices if you actually look at them they can help but they really don't include a lot of meat a lot of teeth to them they don't include contamination limits they don't include ingredient identity parameters they don't include testing methods and as you know as you've heard you can use a very simple method and find that a product has a hundred percent of what it claims or you can use the right you know rigorous method and find that it has very little or none so manufacturers are the ones who get to determine these issues you know these parameters they are supposed to you know follow you know use good good science behind them but it is up to them so you are trusting the manufacturer and I in 2016 62% of the audits that were done of manufacturing facilities failed to pass all the criteria typically they for the reason that they were not specifying or verifying the identity of ingredients and we you can actually link to our there's a link there on our site you can actually see which companies pass or fail that that that audit we put we post that every year we'll be doing that in about a month again for 2017 so what do we do we do a lot of testing we put out product reviews on nearly every category of supplements out there about 10 to 40 products are included in each of those we also have the oldest quality certification program you may know that USP has one NSF has one we actually have the oldest and it's actually the only one to we freely publish our testing methods and criteria for passing we do some special tests specialty testing for academic researchers from time to time really just just to kind of help out but really our big push is really to inform the consumer and the healthcare provider as to really what's inside the bottle in these products we also spend a lot of time looking at the clinical literature because you can't just look you know just at the product as was mentioned before you know ginko we want to test the product we also want to tell our readers really what's the evidence for against what are the side effects where the drug interactions you know as bill was mentioning earlier we also answer a lot of questions from consumers we have over 500 questions answered on our website you your it'd be hard to miss us if you have a question about supplements and we don't pop up on Google we have an encyclopedia of natural products on the site giving more clinical information and also I realize I forgot to have on here but we also have our listing of recalls and warnings that come out every week and that's an archive that goes back over a dozen years and a newsletter that goes out to about a hundred and seventy hundred ninety thousand people now every twice a week with the latest updates these are just some examples of the categories that we cover interestingly this year we actually include tested CBD supplements even though they are technically illegal they are being widely sold we wanted to know what's in them apple cider vinegar I'll talk about that so it's not just a class you know the traditional you know fish oils and and and minerals and vitamins we're looking at all kinds of things we're gonna be testing a canned tuna fish and canned salmon shortly just because the evidence for fish oil itself has waned but the evidence for eating fish you know just gets stronger so we want to find products that actually have the omega-3s and are free of mercury etc so why do people care our members say you know I need to understand which supplements are best quality physicians and dietitians tell us I use your reports protect my patients and even the industry those who actually have come to get products tested through us and by the way it doesn't protect them from us not being able to test their products you know on our own but it gives us an opportunity to increase the number of products because our our real goal is to find good products for people you know who are looking to use them well so what does the industry say this is a VP of Marketing at a supplement distributor you know we're an independent organization that consumers trust to help them choose quality vitamins and supplements so what have we found well one out of every five supplements that we've tested has been found to have been of poor quality that's a little bit better than it was before had been one out of four it's nudging toward one out of five herbals have the highest failure rate 39% vitamins and minerals 20% multivitamins higher than that though because they're complex other supplements 18% and then other nutritional is about 25% so overall it's about 20 let's see 22% of the products we've selected if they have failed testing that's actually closer to yeah to one out of five so what do we find we find too little or no ingredient in some products too much ingredient and I'll show you an example of that where you're exceeding up or tolerable intake levels for certain nutrients inadequate labeling to describe ingredients poor quality ingredients spoilage of oils contaminations with heavy metals inadequate disintegration of pills unapproved label claims these are the kinds of things we're testing for we actually do just a little bit of testing in-house for disintegration making sure that pills break apart properly but we'd have to do so many types of tests that we found it's better to use experts in different areas of testing so if we get like a fish oil it may go out to one lab for PCBs and other ones for omega-3s and other ones for heavy metals etc so we're coordinating a lot of testing as well as doing some testing we select the products that we test for our reviews we purchase multiple samples at retail products can never be sent to us as I said pill disintegration testing is on an inside others are done out at other laboratories we publish the results all the results for the products that we buy and test on our own are published on our site for our members as I mentioned includes the latest clinical information consumer tips and we include in there any products that pass through our voluntary testing as well we publish as I said all our methods if you want to see how we tested and evaluated any product anyone is welcome to click that link and it'll show you how we how we test everything and I wanted to show you an example from our multivitamin report again for those of you who aren't familiar with what our reports look like and what we're providing here so this is from last year we do this report every two years on multivitamins it's an extensive report summary 46% of the multivitamins we test had failed the biggest problem was actually with gummy vitamins they are they are as it was mentioned earlier they are very difficult to make it I think it's very hard to control the quality in these and I'll show you some examples of the other kinds of problems that we're seeing with with the gummies we you know we start off with these reports with a lot of background about the clinical studies actually dr. Sasso is mentioned in the in his study with centrum was mentioned earlier what we test for what we found we then move on to talk about you know oh here's an example of disintegration you can see how this product even after 60 minutes post should break up break apart within 30 minutes even at 60 minutes we gave it a you know more time it still didn't break apart completely there should be nothing here at this point just as an example we show our kind of top picks for different categories of supplements but I want to get down to kind of the heart of our reports which was really here which is where we what we show in terms of the results for each product in terms of whether they were approved or not based on how they fared in our testing it doesn't mean they work we have other information about really what you should look for in terms of whether if something might work but here we're just showing from a quality perspective whether it had what it claimed and I'm gonna shoot down to as I said it was actually I mean like here's a gummy from Walgreens it claimed 400 milligrams of folic acid it had 500 750 7% as some of you know folic acid converts to folate at a higher rate than just to folate itself so that it's actually equal to about twelve hundred and eighty-seven dietary fully folate equivalence so you're going from what claimed to be 400 sorry I may have said milligrams micrograms and we're finding twelve hundred and eighty-seven so we're finding three times as much you know folate equivalence in this product the upper limit is a thousand so you're actually potentially doing yourself harm you know by taking this multivitamin this some more quick examples and and it's not every every gummy where we find the problem but we here's another one one hundred and seventy four percent we found a number to be off on their vitamin A levels this is a tablet that was off on on its folic acid and companies are allowed to and they should put in a little more than you know then it's necessary to make sure that it lasts through the expiration date but these are really it's in our opinion excessive now this go through and here's why diffusion I know we have a representative from from that company again wait Waymarsh more folic acid than claimed so 1382 dietary folate equivalents instead of I believe 400 here's another one there that one actually had what it claims so you can make a good gummy but I think it's very difficult I'm gonna jump out of this go back to the presentation so some other interesting recent findings that was as we was mentioned ginkgo biloba so four out of the ten supplements that we we purchased off the shelf were found to be did only four were approved I'm sorry six failed they were basically adulterated they were spiked with compounds from cheaper plants to make low quality ginkgo appear to be high quality in the way that herbal companies do this herbal suppliers is though they can take take a real herb squeeze it out basically you know get a good extract from it sell that keep the junk that's left over you know it's kind of like making coffee and selling the grounds and calling it coffee they'll throw back in maybe one compound that they know a test is looking for they're spiking it with that compound and then it'll pass whatever that test is that's looking for that single compound but if you're looking at the whole product you know the whole array of compounds it will fail testing and that's what that's what's going on with ginkgo one product actually had no more than 3% of the expected ginkgo compounds apple cider vinegar interestingly all good good news is all these vinegar bottles these were all fine they all had about 5 percent acetic acid plus compounds that indicated they were made from real Apple we also looked at these tablets that are being sold these because you know once something's out there there's going to be a pill so we've looked at these and what we found is that the amount of acetic acid which is probably what's really making these these products help people lose weight in two senses they're potentially upsetting their stomach with the acetic acid they don't have as much of an appetite and these pills have some acetic acid but you really have no idea how much is in there we found as little as four point four percent acetic acid to over 20 percent actually based on just the amount of powder was about over 30 percent turns out that if you sell a consumer product you know like Drano that that that has over 20 percent acetic acid it's supposed to be labeled a poison this product you know was not the company responded saying that well you know it's not a consumer product it's a dietary supplement it's exempt from that law my reading of the law is actually there's another place it says if you if you know there's a danger you have to in any event they did come back and agree the trait to change the labeling to add that you know you shouldn't separate this product this capsule you should take it with a lot of water take it with food so it is nice to see that there is some improvement in all of our reports you will see at the top of every report it'll state you know the back and forth between these companies so if they approached us we will we will also offer to send it to another laboratory if they'd like to have it tested you know almost every time it comes back finding what we found and it's not that the companies were really trying to do something bad they often just didn't know what they were doing last slide those and seal talked about earlier in terms of not actually being golden sealed you can see on the left this is real golden seal it has kind of a slight golden hue to it this is another one saying it's golden golden silver powder definitely not didn't have any berberine in it which is the key compound it's not yellow it's it would taste bitter which it didn't and so I could talk for a long time but I'm gonna stop and and again if you put your home on that list we will sign you up for a membership to consumer for three months thank you so now I'm gonna introduce James Hamlin and we're gonna do something just a little bit different with James's presentation then I asked him to kind of introduce himself and what he what he does and then I'm gonna interview him a little bit we'll see how that goes but James would you please start yeah so I don't have formal remarks I'm here representing all of journalism the entire profession but I want to represent that point of view which is a broad one I write for a general interest magazine that was founded in 1857 we cover the American idea I I came on to start the health section six years ago I left a radiology residency so I am an MD and I constantly question that decision but the but but it's been great and the reason I did it was so that I could meet people and tell stories and constantly learn about the world and be the Atlantic's motto is that we are of no party or click and that's that was really important to me that I not be tethered to any particular agenda or industry I still have the physicians code to do no harm I'm trying not to misinform people but I'm not Pro any particular not Pro regulation anti-regulation Pro big-government Pro supplement anti supplement I can take each story as it comes and try to shine a spotlight where we need to and to contextualize and to inform and to offer nuanced stories to our readers so I'd like to be here to be part of the discussion to offer that perspective and I'll talk to Paul now why don't you come on and sit down and I'm gonna maybe encourage you to particular eyes some of the things that you just said why are why did we ask you here to represent journalism which is essentially what you're doing yeah I mean I think that there you know there's a lot of misinformation on the internet and if you're a clinician you know a lot of people are coming to you having some idea of one thing that they read about one supplement and they don't know if it's true and when you trace it back it can often come from a third party that is definitely not at a disinterested party that is trying to sell the supplement or from even a physician who's selling both books that purport to inform people on a new diet plan and then also on their personal website selling supplements that are recommended in the book so it's really important that there journalism exists as an institution where you know that no one if you're seeing this at on the Atlantic on the New York Times Wall Street Journal you're reading this from someone who is not also taking money from any of the interested parties and is doing their best to simply cut through it all and as I get to be more and more nonsense on the internet you can at least go to these places and not trust everything that you read blindly but have a much higher threshold for thinking this is probably accurate this person is probably in good faith tried to give me the best information that they could what what have you written about supplements that I read no I've written and so much and I guess sort of there's a couple interesting things to know it like yeah it's so like I said I started the health section so I was covering everything that had to do with health we moved very quickly like when you're working with journalists it's the if you want to be involved be interviewed you know make contact information readily available make as much information available as you can make yourself accessible because people move real quickly and they're often working way out of their depth I mean there's something good to have reading a story by a journalist about caffeine supplements when that journalist is coming into this fresh and they don't really have a lot of background with caffeine supplements so you know they're gonna come they're gonna talk to people they're gonna make Civet this is a smart person who knows about science and you're gonna read their takeaway there's something nice about that as opposed to getting into getting a story from someone who's been covering the industry for twenty years and it has lots of biases and kind of probably didn't have that but but at the same time that means that that journalist who's coming in fresh needs probably has a few hours to talk to as many people and learn as much about this as they can you know especially if it's a news story so everything's not always gonna be perfect but the more that all of you can make yourselves available and be part of the conversation the better and then you have to that end I've written about pretty much every almost every kind of supplement yeah lots about caffeine lots about vitamins melatonin so tell me you mentioned caffeine a couple of times what what were you trying to learn what were you trying to convey to people about caffeine containing dietary supplements there's been a few different stories I have I really know that there's a company that was selling topical caffeine sprays interested people for a while so it's so kind of when there's a new product there's something that people are talking about I'll try to cut through mature this is accurate how much of it is not and I don't know there been yeah multiple different different sort of takes on it I guess caffeine is something that fascinates people because to so many people it's totally fine when you drink it in coffee in fact it's almost weird if you don't like drinking coffee and then it becomes very weird if you're spraying caffeine on your skin and even weirder if you're spraying it at other people they just and then just think about why that distinction should be and then why you should be thinking about one thing that is a supplement which which is a stimulant which can have seer the facts and why we regulate that as not pharmaceutical it's obviously come up a few times I think I don't know whether it was covered earlier but I did come in during patty joy stirs presentation and you expressed concern about the levels of caffeine exposure that warriors and their families are likely to be engaged in so it's and there have been regulatory efforts so what was what was your take on it was it that you were concerned about the health of people that they were not paying attention to the signals where you was there some other aspect of this that got your attention I think it's really easy and meeting of people who think about this stuff as much as all of you do to forget about the average level of literacy around supplements and I'm constantly confronted with that I'm readers write to me all the time and that does inform my work and a lot of people just have no idea that that anything they're buying from the store could be potentially less than a hundred percent exactly what it's labeled to be and that it won't definitely do exactly what the label implies that it will do and just constantly reminding people of that and then the duality of you know when people buy something when they need a prescription for it they tend to take that very seriously and follow the label to the tea and when it's something you can buy as much of as you want there seems to be no reason to not take as much as you want and so just reminding people this is not necessarily pure it's not necessarily good for you and you can overdo it more is not necessarily better those are probably three themes that people seem to want and need to be told again and again about different supplements so do you you're kind of leading to something that I was going to ask you about you get reactions to your stories and do you then does that lead to a conversation with with readers I wish it was more interactive I mean sort of use social media to try to make it not feel like you're just proclaiming things to people or decree like so we were talking about this earlier there's a lot of mistrust of journalists right now like 12 percent of Americans trust the media which is a term I don't like but like the the one group of people who have made it their job to just simply try to discern truth and convey it to people are very mistrusted right now and and part of that is this sort of elitism of just seeming like we know exactly how the world is and is supposed to be and I get that so I try to be interactive with people and be open-minded and say what we know and so we don't know and not try to be talking down to people as the definitive source on exactly how much vitamin D they should be taking or but at the same time not leaving it up to people to not implying that we we don't know anything because I'd want to just keep learning of communicating around sure yeah of course I'm interested it's so people I mean so many I think people who are really really drawn to supplements because they offer something that is and they can it helps them feel control most health solutions are about control and making sense of something that doesn't make sense to you especially when it's a serious diagnosis it's very rare that someone can be diagnosed with a cancer and they could say oh yeah well that makes sense that would happen to me you know and then and then you're just grasping for solutions and the medical establishment tends to be really rational about saying okay we can give you this king of chemo therapeutic agent there's a 70% chance it will increase your lifespan by this many years and you'll have these side-effects and then you can also go to the store and have something or read something on some blog about something that seems just absolutely perfect like almost no side effects relatively cheap and it cured this one person's kid so they offered that sort of even to rational people who or science minded to just say yeah I mean why would I not at least try it so I don't know I guess I think a lot about the the appeal of that and then how to not rob people of that effect by debunking it because I think there's value in that but then also accurately telling people you're probably wasting your money or possibly hurting yourself we can't possibly miss focusing your energy on something that is nonsense as opposed to emphasizing the things we do know that could be helping you you actually you used an interesting word there that I I think we've used in our own thinking about how consumers approach dietary supplements it's to take a little more active control of their own health sometimes it's in the context of maintaining health and that's a somewhat different circumstance from somebody who is seeking remediation of you used a potentially you know very strong a poor outlook for it in a disease state that's not going to get any better by itself my words to convey what you said but for the most part its consumers who are seeking health that are taking dietary supplements that's not everybody we we know there's no everybody in here but for those who are taking dietary supplements as part of a healthy pattern of health seeking behaviors d do you see them as a different kind of audience from the ones that you just described where there may be actively seeking solutions to acute problem yeah I think and that's probably most people who are going and reading New York Times general interest magazines about the latest supplements and whether they should be taking a multivitamin and whether something is going to be you know helping them prevent a heart attack later on you're not getting as many people who are looking but reading about there's their specific condition and that's part of the interesting thing about a general interest magazine you want things that are gonna be interested in most people not just to people with polycystic kidney disease so that's who we end up writing to most of the time and you could almost break it down further right like people who are just hoping to maintain the status quo and then people who are trying to improve themselves like in the case of military uses those are all supplements that are actually making you better at performing or promising to make you better at performing and yeah to this simple it's to the simple idea of maintaining status quo it's again very easy to sell people on the D on the idea that it's harmless it's you're not spending a ton of money worst case scenario you're flushing some vitamins down the toilet and I also like to remind the the psychology that we were always making trade-offs and that we're justifying things to ourselves and that when we do take a multivitamin it likely changes our calculus on how healthy we need to be in the rest of our lives and this is mostly I don't have a study off the top of my head but I didn't have a lot of anecdotes of people who will think they can take the multivitamin and eat pizza and if they didn't have that multivitamin then they might have ordered something healthier and so we we're not exactly comparing the exact same life plus or minus a multivitamin it's how does that change the psychology of the user that's a reasonable thing to say I'm looking at the clock only because I want I have a feeling that you may have stimulated some thoughts in our oh yeah I'd love to talk about whatever anybody's curious about so what I'm gonna do now is invite all three of the panelists from this session Laura mccleary Todd Cooperman and you to hang out here and take some questions from people in the audience and then we will end the day by having all six of you join us up front here and engage in further discussion so thanks a lot Jane [Applause] so we have an opportunity to talk to these folks first I see Duffy in the back with a question you ever saw from the media perspective I'm always curious you know we do our advertising review and we try to self-police there and it's often shocking at reputable organizations will take terrible advertising that's just clearly with claims that are too good to be true you know promising things that could not be substantiated I'm just wondering – do any of these newspapers do you ever hear them having policies in place that says you know we should not just take these people's money we should vet the claims a little bit yeah the critical thing about you guys probably mostly know this but the structure of any journalistic media organization is going to be such there's a thick firewall we don't even share any of the same space with people who have anything to do with advertising so I no journalist has any say in any of the ads that go into our magazine or onto our website if we see something that seems particularly egregious we're welcome to file a complaint or send it over to the this but it's a completely separate area of the business and it's it's meant to be that way and I know that they within Atlantic media they have standards and don't want to be misinforming people with any ad content I don't know exactly how those calculations are made at other places we certainly wouldn't run an ad that seemed to be you know doing harm for the world but I'm yeah I guess the important takeaway is that I have nothing to do with that and no journalist does and a lot of people think that's or don't understand that that's the case other questions from the audience or perhaps do you have questions for one another on the panel there's a lady in the back here all the way in the back yes and then the lady in front have you uh yeah this question is also for James what kind of sources do you use do you use like responsible journalism like our pubmed and cinahl for some of your sources when you're doing a story or do you what kind of sources do you use yeah I'm certainly not not irresponsible sources yeah so I just finished up my mph actually so now I feel like really good at vetting methodology so and and and statistics my have statisticians on call who I'll try to vet studies for with I'll try to you know I have higher thresholds for going for studies that are in bigger journals but I've seen terrible stuff published in JAMA and then in the journal and you just try to you know I have a network of people who I'll send it to and be like you have any time to look at the methodology on this like cuz probably I'm going to write something in a day and the people who can give me a comment or not always gonna be available we're always gonna feel like they can really dig into this study in order to say whether it's good or not so thankfully I'm able to do a lot of that myself and then the longer reported things yeah yeah you dig into often a lot of them getting you know one particular source and then find that they got all of their funding you know on this study and biotin from the egg council and like that's gonna cause a lot of problems and so it's not just about whether someone seems what they know what they're talking about but where there's their funding coming from and how is that going to appear to a reader yeah it's extremely complicated but the longer you're in journalism the more you get a good sense of who's trying to sell something and who's just trying to do science good one more thing folks um do you usually put in like recommended dosages that like the American Heart Association or at the FDA would recommend for a specific dietary supplement in your articles would probably be a little too granular okay thank you yeah there was another lady on the right hand side and then Naresh I'm a psychiatric nurse practitioner and what drove me here was my patients asking questions and I like y'all mentioned I have no idea how to how to answer them but also what you mentioned dr. Hamlin that I've had supplement companies approached me to sell their products online and it seems unethical to do that I'm glad to have these third-party organizations like ConsumerLab that I can now refer patients to but is there any ethical implication or legal implications for providers selling supplements hmm do you have any thoughts about that folks its regulated by your state medical board and its different state to state but do you have I mean as a person who is I would just find it anyone who's trying recommending something that they're also selling it's just really hard it's like not like your car salesman can't be honestly giving you information about that car but I wouldn't trust them as the definitive source on making you know are they really telling you everything that you need to know I would definitely you know go talk to other car dealers or other places and Rican sumer reports and find you know more objective outlets before recommending the recommendation of someone who's also selling the product not to say it can't happen symbiotically so you know there is a legitimate role for medical providers that are truly informed about the efficacy research and the risks and medical counter indications right to know about dietary supplements and to be able to inform their patients I think trainings like this are great for filling in some of those gaps but to become a full expert on you know everything the patient might ask you would be a big job and I think that level of medical knowledge varies widely among providers that's one end of the spectrum someone trying to provide legitimate medical advice is it worth it to spend your money probiotic for this medical condition for example to mention something that was we've done some research on you know and for vaginosis like that there are some strains that might be helpful but in general probably not worth your time and money as a sort of dietary daily habit but you know more troublingly there are so many examples of diet books or doctors who are also essentially running a supplement company and selling their name as part of that you know there's one that hits my Facebook feed with real regularity and the nutrition devices wackadoo and the supplements are like the third thing that they're selling you there's one that we're looking into right now where there's a guy who runs a gambling hotline and basically does tell a counseling for gambling addicts and then also sells a line of supplements that are supposed to help you stop gambling you know so there's a it's this it's snake oil right it's chicanery and that sort of thing it's been going on for a long time and it's just unfortunate that those kinds of practices are allowed to persist by a very loosey-goosey kind of regulatory infrastructure so I think there's a range of things that I think for those that latter category there are real ethical questions about whether the medical advice that they're providing – there are sensible patients is in conflict with their licensing complications Todd did you have any comments about this part of it and others turn off your microphones thank you yeah not in terms of the legality of selling it I defer to more experts on the law there but we do test those brands also the the professional brands they do tend to be higher quality not guaranteed though we do find problems from time to time they are a lot more expensive also so I mean as a physician I would I think it'd be better just recommend something that you know is is good and inexpensive you know then something that might be good and expensive so that just might two cents on that I would say also the multi-level marketing companies that are out there the the Nutrilite Amway USANA similar the product the products tend to be higher quality there but also just you know a lot more expensive nourish dr. Hamlin you look young MD are you taking any supplements I wondered when a question like that I'm 35 actually okay yeah I know I don't I don't take any any myself but I yeah I'm fortunate to have access to a good food system mhm good answer yes next to nourish yep so this question is for dr. Hamlin so I was raised in an area where people don't really trust science very much and so I get a lot of questions when I go back to visit my family about why science keeps changing like they read coffees good for you one day coffee is bad for you another day and as a researcher I understand why that happens but what do you think the role of the journalist is and trying to put the information that they're communicating in terms of the whole picture of what's been happening in the past and research this is like my favorite question I wrote I've written about this a few times with one story called new nutrition study changes nothing which kind of gets into this like extensively but there is there's a problem of the problem of the news cycle everyone wants something new everyone wants to be talking about whatever the thing is today and the editors and writers have to come in and have something new and a good story is something that changes your perspective right the challenge is what you already thought like no one needs to be told again oh also probably drinking water is better than drinking soda yet again today right we need something new when the new story would be out drinking soda not as bad as you thought like you know maybe maybe you don't need to be running like that is something that's indeed that's just a good story that's interesting so how do you square that with actually being a back that science moves like this like there is slow twists and turns to it but not something that's gonna engage like the whole big general interest audience so you can find lots of other ways to make stories interesting and good than trying to completely change someone's world view which is to highlight an element of it that people don't know enough about trying to highlight like the personal stories behind it trying to make it funny or entertaining in a way that's not necessarily like over-promising or scaring people and definitely not misinforming yet I could go on and on but that's like a main job of what I think of the mean thing I think about our job as being is contextualizing is like I'm gonna tell you about this new study that everyone's talking about today and I'm gonna put it in the context of thirty years of knowledge which have been building to this point and so this is not taken in isolation other questions Mary you had your I have my microphone on this is a good lead-in to something that I find challenging as both a performer of research as a provider counseling patients and as a person making my own individual choices it seems to me that there's a taxonomy or just where I could describe as a typical arc of a story for a dietary supplement and the first time it comes up it's terrible it's wonderful brilliant you'll find people who are cured of something then they look for a new story is after that's not a new story anymore then you start to see that negative stories come it's caused this much harm it's terrible and so I guess what I'm asking about is this bias or over interpreting both in the positive side but also in the negative side and I published something in the New England I mean in the Jama years ago and when we looked at the consumer extract from our study it left out a huge part of our results it only wants to talk about the negative results and and I'm finding that challenging that you know the assessment of risk is risk versus benefit risk versus opportunity personal choice how would you address that all of you in the word that you're doing keeping both ends of the spectrum alive without over-exaggerating either one so this issue that is that's a like a walkie er version of the last question in a way it's sort of you know and I think it it comes up with dietary supplements so as I said you know there's a lot of magical thinking people want a hat want to believe that you know this cinnamon that tastes good on their pop-tart is actually doing something really beneficial for their health but but it also is much about there's a lot of magical thinking nutrition right so there's all these trends and diet fads and also thinking and really as dr. Hamlin implies dietary advice hasn't changed much in the last 40 years it's basically you know eat more vegetables eat more whole grains don't avoid salt sugar and saturated fat and you've had a fight maybe over defining fat more precisely but but there there isn't there isn't sort of a there's a lot of savvy in among brands and among food manufacturers and among dietary supplement manufacturers about how to create that kind of mental permission for someone to go and take something that's just a little bit better for them and think of it as a health food so you know the example that I always uses veggie sticks that you have these little potato sticks and now my seventh when I go out to birthday parties for my seven-year-old they'll show up at the party cuz they're they wouldn't put a bowl of potato chips there but there's like a picture of spinach on the front of the package and there's like a dusting of spinach and they're sort of greenish so and now everyone can eat the veggie sticks it's cuz we want to eat the potato chips you know but we we don't want to also feel healthy and so there there's a brilliant sort of exploitation of that and then there's the rebound effect that was talked about whereas you know you eat something healthy and you think oh I could like it um indulge a little bit more so if I have my vote multivitamin how does that affect my overall diet quality this might I'm sorry to interrupt you but this might carry over a little bit into our broader discussion so what I'd like to do at this point is to thank and congratulate our speakers from this panel and then invite our other panelists from the previous session to come on up and we'll re-engage in some more discussion thank you [Applause]

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