Supplement Your Dietary Supplement IQ

research at the Center for Integrative Medicine and very excited to be presenting a wealth of information today I one of my favorite topics which is dietary supplements and we're gonna do first is give you just kind of a broad overview on the topic you know actually defining what supplements are getting into the issue of how they're regulated then delve into the topic of some supplement you want to consider which follows Marx talked very nicely because it's most of the ones that he recommends for his patients but then we're gonna look and flip it over a little bit look at those that are a good idea to avoid then just very briefly get into the important topic of supplement and drug interactions look at some specific situations where supplementation is essential and then take a very quick look at some specific concerns okay that people take supplements for where there's good evidence supporting that and then I'll tie it all together with an informed supplement consumer checklist so the ultimate goal today is not only to kind of inform you on what supplements might be beneficial for your health but also to give you a discriminating eye to product quality because as you'll see today supplements are not all created equal okay there's very big difference based on quality of concerns that I'll kind of help you navigate today okay so let's define them first so dietary supplement was defined by the 1994 dietary supplement health and education act or Touche as it's often known as a product other than tobacco make that clear intended to supplement the diet and it contains one or more dietary ingredients that are taken orally so for instance I don't know skin creams that have vitamins or minerals in it would not be considered a dietary supplement has to be taken orally and there are four categories are vitamins minerals herbs or other botanicals and amino acids and when I've got up here in the picture are examples from each of these categories that have some good evidence in supporting immune system health now as far as regulation goes this is an area where there's a lot of confusion a lot of misconceptions so a lot of times people will tell you supplements aren't regulated at all it's not true actually they're regulated by both the FDA and the FTC but where some of the confusion is is that they're regulated as foods by the FDA and not as drugs thus those ingredients that you know we're offered before that Desha that I've mentioned on the previous slide are assumed safe those that are after touche you have to provide safety evidence so there's also a variety of labeling and claims requirements and more recently in 2007 instituted Good Manufacturing Practices GMP s which a quality standards for manufacturing preparation facility hygiene and so on and then you've got the FTC which regulates the marketing so these sort of ridiculous claims you see sometimes they monitor those but where they confusion lies and this is one thing we'll talk about quite a bit today is that there's no Universal regulation of supplement content right so you may hear a lot of times you don't know what you're getting and there's some validity to that all right a lot of times you know is really in the bottle what's on the label that's the big question and in order to resolve that that issue what many dietary supplement companies do and I would say what the good ones do is hire third-party labs to you know certify that the products are pure for all kinds of things so to make sure that it contains what it says it contains one that there no contaminants importantly it dissolves properly there's GMP compliant and so on now with that being said some third-party labs are clearly better than others and I've got a couple up here that are good so the NSF for instance many people consider to be the gold standard in terms of third-party lab verification okay so with no further ado how many of you just before we get really get into this stuff how many of you take a supplement of some sort Wow okay that's pretty much every hand in the room including mine that's a little bit of a self-selected group here I'd say but most people do okay so data is shown that most Americans take at least one dietary supplement and we're going to talk about those that are a good idea and it sort of follows in again marks very very closely in many ways so the first of which is a multivitamin so this is the most common dietary supplement and what they usually do is contain at least 13 of the vitamins and 15 of the minerals that are most important to human nutrition so you know again most of us are probably taken when we know how they're taking it's easy to take a capsule or tablet once per day and it is really best taken with a meal and there's a reason if they suggest doing that is that a lot of the nutrients that are within it or fat soluble so they need some fat to be absorbed optimally there are basically two classes you've got your RTI's centric vitamins these are the ones that have a hundred percent of everything on the label and basically you know the RDI many of you probably know it as the RDA these are the values that are needed to prevent micronutrient deficiency in most people and that's key okay now I'll talk about in this in the next category so again these are the percent daily values when you look at any food label these are the the RTI's then you've got higher potency in my opinion higher quality products that exceed the RDI for many key vitamins and minerals so again why would you want to do this if it's you know if it's hundred percent at seven percent right well that hundred percent is the amount to prevent nutrient deficiencies not chronic does not to prevent crop diseases so that's the real issue in the United States and most developed countries today is chronic disease and these RTI is just really aren't cutting it so these are typically dosed higher and important vitamin D B vitamins and vitamin C and others these are not quite as widely available as the RTI eccentric might be but any go to any health food store in many clinical practices people so people offer these and find pretty much anything on Amazon so you can find them there as well okay and for all the research I got to present today you don't need to writing this stuff down I'm happy to send the slides to anybody who requests and I've got my email address at the very end so we're gonna take kind of a 30,000 foot view and not get it to me the details of these studies but you know we know there's these micronutrient deficiencies that are rampant so there's enough research out there that shows that multivitamins do a pretty good job of improving nutritional status that's kind of their main purpose okay also strong evidence that they reduce the risk of birth defects and this is probably the folic acid folate that they contain then there's a smattering of evidence for a whole host of other sort of outcomes I think most notably was a study that came out a few years ago that found a reduced risk of all-cause mortality and cancer mortality so it's pretty solid evidence I would say for multivitamins that said they're not a cure for everything you know that I could prevent everything there have been a number of negative findings or no findings and in fact you know what I think is interesting and what what people find so confusing about research is that study that I mentioned on the previous slide as far as you know reducing all cause mortality about a week later another study came out and said they found the exact opposite okay and I think there are some issues made a lot of media coverage so I think there's some issues with that that particular study a lot of flaws I think that were there but that said you know the evidence is not universally supportive and I think a big part of that comes down to the quality of the products that were used in the studies so that leads to a question that I get constantly which is why I have it in bold type italicized an exclamation point you know this product brand make a difference yes it does okay so there's a tremendous tremendous difference in quality between products and as we'll see on the next slide you basically get what you pay for all right so the cheap brands use cheaper vitamin and mineral forms and this adversely affects the absorption and effectiveness of the product so I won't get into too much of the details here but we know that natural forms of vitamins are typically better absorbed synthetic that's in binding salt so let's take magnesium for example you'll see magnesium citrate who's better than magnesium oxide so that's the second part of a mineral so there's a big difference in product quality so you know we can only do so much today how do you sort of make these make this determination on your own there are some good resources out there one of my favorite is multivitamin guide org and this is a pretty comprehensive ranking of over a hundred of the most common multivitamins United States probably my top resource very you know very solid stuff then you've got the comparative guides nutritional supplements which is even more comprehensive that's 14 metrics of product quality and look there were 500 vitamins on here just a few of the things these are the factors they consider in their rankings so you know I think a picture tells a thousand words and this kind of sums it up again you basically get what you pay for all right so a lot of the cheaper products that you find everywhere just aren't particularly effective right so they'll kill the messenger that's just the way it is all right so as far as recommendations go again quality is key you want to take a look at these rankings and not just what's what's there so if there's something is a product that you're interested in that's not on these rankings look at the tenants and principals that are in the rankings to help you make that determination all right now something that you know III have had an interest in whole food based multivitamins recently you've probably seen in stores I don't know how they you know they don't rank quite as highly as some of the others on there but I like those because you know there's there's synergy between food components there's hundreds of components and food beyond just the vitamins and minerals that we've identified so I like those and again you always want to consume with a meal for the for the purpose as I mentioned earlier to make sure that you're going to get maximum absorption with the fat and lastly I've got a little kind of mini checklist here for you to help make you you know give you a discriminating eye and being a foreign consumer so got a few few points here the first of which is is vitamin E so I don't have this up here just because that's what I did my doctoral work on but it gives you a very simple way to find out what products are good or not so look on the label for D alpha tocopheryl which is the natural form as opposed to DL alpha tocopherol which is a synthetic form which is which is absorbed much less efficiently the natural form also with the topic of vitamin E look for it to say mixed tocopherols or gamma tocopherol on a label okay again I think if you do just these two things that's gonna cover most good multivitamin so the rest of stuff kind of takes care of itself you got stuff like vitamin d3 the methyl cobalamin form of vitamin b12 and mark mentioned in his presentation about methylated folic acids a good thing to find in products as well and avoiding those oxide binding salts which I mentioned before so this last point the last bullet point that I have up here this is not really a reflection of product quality just something that people want to keep in mind so men and postmenopausal women don't have as much need for iron and I would probably stay away from that because they're not losing it with their blood and unless you give blood regularly lots of dietary sources so something just to keep in mind and many products are iron free that kind of cater to this fact okay so moving on to the ever important vitamin D so this is indeed a uniquely important vitamin it has hormone like activity and controls the expression of over 200 genes right so we typically think of vitae or have thought of vitamin D for its role in the musculoskeletal system bones teeth that kind of stuff but it's involved in basically every biological system in the body and unlike most of the supplements were going to talk about today vitamin D is many of you know I'm sure we get primarily from the Sun so I'm not gonna get into too much of the other details on the physiology of this but it involves the skin kidneys and liver and we get about 20,000 IU from 30 minutes of sun exposure during the spring and summer months and that's a key as well because those of us live in this area if you're north of Atlanta so I'm gonna say Jacksonville something in that in that region you're not going to get any in the fall in winter even if you're out there you know sunbathing and around you know in December it's just the angle of Sun is not sufficient so that when you combine the fact that it's not in many foods as is part of the rationale for supplementing with it so it isn't some things oily finished eggs butter you've got a few the sources here but it's in relatively small amounts maybe 10 100 maybe 200 IU but you think about what we get from the Sun 20,000 you know it does does kind of make a case for supplementation particularly in the fall bunch of months so I mentioned the RTI's in a previous slide like they do for all nutrients they vary depending upon stage of life and so on but again that's really gonna drive this home today this is just the amount to prevent deficiency diseases in this case rickets and thankfully is not a big issue United States or other developed countries what is a big issues chronic disease and the levels to prevent that are likely much higher so there's been a call in the public health community the medical community the nutrition community to increase the Rd eyes to at least a thousand IU if higher and this is due to the explosion of research on the subject and we'll delve a little bit into this right now so it's very well-established that vitamin D prevents bone disorders fractures osteoporosis that kind of stuff but there's also this wealth of evidence that it's involved in other disease processes cancers for instance diabetes obesity cardiovascular disease risk factors and cardiovascular disease itself so again you know when you control the expression of over 200 genes you're going to be involved in a lot of different disease processes okay now what I think's really interesting with this is some of the evidence that can help improve depression and seasonal affective disorder so in fact many people think that seasonal affective disorder may be a manifestation of vitamin D deficiency you're not outside woopsie you're not outside you're not getting the Sun and thus this could be contributing to that problem you've got the impact on autoimmune diseases just general immunity to prevent colds and flus and then finally you got a decrease risk of all-cause mortality okay so you know as with most studies not all the evidence is positive there have been a number of trials where vitamin D supplementation was not beneficial although many would argue and I'm among them that the doses used in these were too low so many of these suppon trials including the ones I've got here used between 2 and 400 IU and again that's like a you know it's a drop of water in the ocean and with respect to to how much we really need so but we need to be mindful of getting too much of any vitamin and the good news with these that there do not appear to be many risks with it okay so the only circumstances under which there appears to be problems is when the concentrations are really really high in the blood right over 100 nanograms familiar and this is something that you just don't really see much I've talked to my colleagues in clinical practice so you'd have to be taking a heck of a lot of vitamin D to get that level and it usually involves kidney liver some kind of dysfunction that lets that happen so and then looking at the vitamin D supplement trials are no rodents of harm but it is fat soluble so generally speaking you want to be mindful of not getting too much of fat soluble nutrients so they accumulate in the fat cause problems good news with D is unlike maybe vitamin A retinol or buddy some of the others is that the acute d3 toxicity level is extraordinarily high so 176 million IU just to kind of put this into context that would be four hundred forty thousand foreign I you capsule a day so it's it's very unlikely to happen and there have been some toxic cases typically and manufacturing of milk or supplements you know where they perhaps would have two hundred IU in the label but in the product they actually had two hundred million IU so these aren't small mistakes it's a very safe very safe vitamin okay so that said well I think there's a lot of benefit vitamin D it's tough to make blanket recommendations on how much people could take because we're all different levels and our blood are all different and as such I think they're strong enough evidence to recommend that people get a vitamin D blood test okay 25 hydroxy D how many of you have had a vitamin D blood test oh good all right that's a little it's more hands-on I expect that's good to see okay because the problem is you can be doing things right healthy and feel great but have low levels of vitamin D vitamin D inadequacies extremely extremely common up to 100% depending upon the subgroup so that said the people for whom vitamin D supplementation is most important are those of us that live north of Atlanta in the fall and winter people of darker skin tone because again the synthesis starts in the skin and it's less efficient for darker skin tone older adults because of the risk of bone diseases and disorders you know your hylia phobes that you know completely avoid the sun at all costs again that's where we get most of our vitamin D from and then finally and most importantly those that have low serum vitamin D so this is something again I think everyone should get tested alright good news is for those of us are on a budget there's not much difference by price or brand unlike multis and some of the other things we'll talk about today as long as you're getting one that's in a gel capsule so vitamin d is fat soluble and when in some evidence shows that when it's in a gel capsule to draw it a little bit better i want to take with food vitamin d3 which is the supplement form is actually better than the prescription form of vitamin d2 so that's good news most products on the market contain d3 and then finally there's a lot of discussion debate however you will on this last thing but you know you want to get your your your target rate somewhere in the area of about 40 nano grams per milliliter or 100 animals per liter okay so make sure you look at the units if you get your test we need more research to find the optimal threshold but again this stands to support the the thinking that you know you want to get a vitamin D blood test before you start taking it or whatever you happen to be right now and then adjust and see where you are after you've been taking the supplement or a while some people need to take more than others okay just give in their liver and kidney function and so on so that's a vitamin D the next supplement that I think most people should consider are they make of three fats okay most of us have heard about these it's just a class of polyunsaturated fatty acids and three of which are thought to be nutritionally important these are ala which then converts to EPA and DHA and it's really the health benefits of EPA and DHA that have been most studied okay this is where the anti-inflammatory action of the omega-3 fatty acids primarily occurs now unlike vitamin D lots of dietary sources of Omega threes ala comes primarily from plant sources so your nuts seeds and some vegetables and so on flaxseed is a particularly dense source of ala chia seed which is becoming pretty popular these days as well and then EPA and DHA we classically think of probably the most rich source is oily fish so salmon my personal favorite of sardines which I eat by the temple mackerel these kind of fishes have this kind of fish have quite a bit of EPA and DHA now other animal products can too so but depending upon what you what the add animals Eaton's we heard we're not just what we eat we are what we eat ate okay so this is where your grass-fed beef and pasture pasture-raised eggs and come in rich sources of epa and DHA so we don't need a whole lot of seaweed in this country you know this typically has the DHA form only but it's as rich source of that then you've got fortified foods that would add these things because think you know the food industry is recognizing that people people are recognizing that omega-3 is good for them so you have that in foods as well okay so why should we consider selling with us and not just eating it well in fact is the standard American diet which is fittingly often called the sad diet is very low in omega-3 if we look at human beings I'm very of evolutionary biology if you look at how we have evolved over the course of several million years primarily on a diet that had an even omega-6 to omega-3 ratio one to one and so you're kind of paleo style eating comes in now that said we need both omega-6 and omega-3 but the problem is when we get way too much omega-6 which most people are doing it creates you know contributes this inflammatory cascade that causes so many issues so we'll put this out the audience now again we evolved on a one-to-one ratio most people think this is optimal what do you think the standard American diet ratio be of 6 to 3 perfect yeah here you go 20 to 1 ok but you know if any of you seen supersize me Morgan Spurlock was probably I don't know 20,000 to 1 and sadly people are doing this those that are subsiding only on fast-food you basically know I'm mega 3 lots of mega 6 so and this is due to the changes in our food supply you know get grain fed beef which is high in omega-6 low and mega 3 you've got soybean oil and corn oil and everything so this is really thought to be a big contributor to this epidemic of autoimmune and inflammatory conditions ok so lots of research here right and more than any of the vitamins so all the studies that I've got cited here that she could take a look at in more detail in the you know at some other point these are all randomized controlled trials or systematic reviews of randomized controlled trials so very strong evidence that omega-3 fats can benefit a variety of autoimmune conditions all right for everything from rheumatoid arthritis to IBS to asthma and again it's a sort of this anti-inflammatory action that they have the contributes then there's strong evidence for cardiovascular disease risk factors such as blood pressure fried lissa rides in particular very very potent at luring those and perhaps most importantly they have decreased risk of cardiovascular events and mortality so that's something that much of most of the statin drugs can't claim so mega threes are very powerful for heart disease what the story didn't stop there okay again I'm really interested in this whole cognitive emotional spectrum and you know mega threes are helpful treating depression and bipolar disorder psychotic disorder ADHD you know a lot of thinking it's evolved with that and then it has been shown to reduce cognitive decline in older adults so again it's acting in a variety of way in a variety of places okay now not all the clinical trials have been beneficial and it's typically in the space of some of these complicated conditions multifactorial things like ADHD and overall cognitive performance where there are a lot of inputs and there are no clinical studies showing harm though but that said I think you know we need to be cognizant that these make it three fastest some others thin the blood so there's potential for interaction with anticoagulants so those of you in clinical practice or happened to be on these drugs should keep that in mind okay so as far as the recommendations go and I think there's pretty strong evidence that most people could benefit from an omega-3 supplement provided if you're on anticoagulant drug that you watch out you know you communicated your position on that but I think their most important for people who aren't eating this fatty Coldwater fish so not everybody is eating two tins of sardines a day like I am okay and you know for those that that particular vegetarians or vegans that avoid fish should be should be aware of this because ala is very poorly converted TPA and DHA where most of the action is and for the Flay of fish fans out here sorry those kind of white light fish are not good sources of omega-3 so and then people with autoimmune or chronic inflammatory conditions could benefit and have benefited in research for mega three supplementation people would have high triglycerides or at high risk for heart disease and those were just eating this crappy stay on American diet okay all these people it's special important all right so the question that I get most of omega-3 fats is you know should I something with Fox heat oil or fish oil I think the evidence is pretty clear that fish oil is superior all right so again that that conversion of ala epa and DHA is very poor eight to twenty percent of its converted to epa and DHA and in men it's even that's kind of a lower inspection that eight percent or so and most of those benefits are coming from epa and DHA so krill oil has become pretty popular that's another good source it has some other advantages perhaps even over fish oil and but if someone is vegetarian or vegan you know there are options out there there algae based omega-3 supplements that can get too thick and not get you good and they get very fat all right so the last broad category that we'll look at today are probiotics and this is probably the most complicated one we'll spend the most time on because unlike the other supplement and that plays a role on kind of how they're handled and so on so the World Health Organization to find them as live microorganisms which administered an adequate amounts confer beneficial health effects on the host so probiotics can be bacteria or yeast right and what they do is primarily on the GI tract via the colonizing or acting in a transient manner depending upon the species and strain so why is this action in the gut important well just looking at sheer volume there were 100 trillion bacteria in the gut and I think most people are surprised to hear this is ten times the amount of cells in our body so I always question you know who's really the host and who's the guest so you know there's a lot of them there's over 500 species of bacteria in the gut probably some we don't even know about yet and they play an absolutely essential role metabolism and immune system just just to start probably many many other things okay now it's important that we first established how these are classified because this is important when you're choosing the probiotic supplement so there are three classifications the genus is the broadest the species is more specific and the strain is the most specific okay and mo probox up and see fine on shelves are classified by the genus and species only but really good ones that we'll look at in a little while will also specify the stream and just looking at a few you know of these genera which is the plural of genus if you were wondering we'll start with lactobacillus so the way that this one works and you've probably heard of this is to convert lactose and other sugars into lactic acid so this is why many people have lactose issues lactose intolerance can handle yogurt for instance but not milk that's because the lactobacillus species that are in it help you know consume that lactose and make the product easier to digest and what this does is it it creates an acidic environment that's helpful inhibiting harmful bacteria lots of different species and we look at your supplement or yogurt or kefir or whatever it may be it's indicated by an L dot alright so that just means it's it's from the lactobacillus genus then you have your Bifidobacterium which is another very common genus and about 29 space species of these that are often in probiotic supplements so these are the ones that are abbreviated by a B dot and then final last one we'll look at is the Saccharomyces so this is actually a yeast alright so I think a lot of us are aware that yeast typically aren't a good thing particularly yeast or fungal overgrowth Candida albicans for instance is one that we hear a lot about that said there's some you know nutrition is rarely ever that simple or that Piper wait you know there are some that are beneficial and for instance s Boyardee is one that prevents and treats diarrhea and GI disorders so this gives you kind of these are kind of the three big genera okay so there are lots of dietary sources of these too and if you look at traditional diets from across the world they contain some fermented foods and this is something that's becoming pretty popular among health-conscious people and I love this kind of stuff and you know if you look at basically every culture in the world there was some source of fermented food and they're eating so looking at Asia cultures in Japan for instance miso and natto were basically omnipresent how many of you tried not to that's the stringy looking stuff on that the right anyone yeah yeah well it's in a quiet I ate it it's it's an acquired taste and probably an odour that you never acquire it's it's an it's a but it was a part of a part of Japanese cuisine and still is to this day I think got kimchi which I think a lot of people have tried now in Korean cultures kombucha tea which is also when it's become really popular got those those bottles there that that you see in a lot of stores nowadays you can also make your own many people do it's not hard to do in European cultures it was primarily fermented dairy so yogurt but we all know about that it's two species that constitute that kefir you know we're starting to see in more and more grocery stores it's it's basically amped up yogurt in many ways it's got more probiotic species than yogurt then you got sauerkraut so it's not just you know the cabbage with vinegar okay real sauerkraut as you see what these guys are doing here was either in a vat of some sort people would often have a barrel in their basement with cabbage and then let the kind of the bacteria provide that vinegary taste so again these are all sources of different probiotic species and you can see the different names up here right see if you're eating a variety of things you're getting a variety of probiotics in your diet African cultures – oh gee I think it's pronounced fermented grains so across the world these are things that people were eating the United States it's primarily yogurt you've got your healthy and you know health enthusiasts like us that are probably trying to keep her kimchi kombucha even natto in some instances that you could find health food stores but problem is on the grand scheme on a big scale most people aren't consuming these things and it's yogurt typically and if we look at a typical yogurt product labels I've got up here look at the sugar count alright 47 grams I mean I think this is one of the biggest like sort of stealth health threats is yerba got to read these labels the problem with that is is that it feeds the pathogenic bacteria so you're almost worse off and you if you were not eating any yogurt or probiotic species at all and again you know I talked about the drop of water in the ocean for vitamin D I'd say even more so with yogurt you know again there's 100 million lactic acid bacteria per serving 100 trillion bacteria in the gut so for someone that has some some GI issues or whatever the case may be you know you really need to think about something with probiotics all right so as far as the research goes this is probably that the field in which there's the most research of all dietary supplements all the studies that I'm citing here are clinical trials were reviews of clinical trials and I've got the species listed for each of the outcomes as well so the most classic use of probiotics is for bowel function okay it's effective against diarrhea and constipation so it works on kind of both ends of the spectrum so it can be very helpful in regulating this is you know for those of you that are in the you know healthcare professionals particularly effective for antibiotic associated diarrhea it's an effective treatment for some forms of inflammatory bowel disease so all sort of colitis you you see for instance there's good evidence that can help with that Crohn's disease the evidence is a little bit more mixed some positive studies some with no findings very clear for people theater well bowel syndrome that probiotics can be helpful but again that's not really where the story ends I mean looking beyond the gut you know we know that these bacteria plays such a profound role in their immune system and not surprisingly then probiotics can be an effective treatment for other arm end conditions so eczema that was good research for that lots and lots of anecdotal stories to seasonal allergies and what I think is probably most interesting of all is the fact that you can improve the immunity of healthy people you know worrying off risk of common cold for instance with probiotic supplementation so really cool stuff okay so you know there's some studies that didn't find a benefit again Crohn's disease is one where the evidence is kind of mixed pancreatitis there was a high-profile study about this that increased actually increased mortality although that was when it was administered through a feeding tube and people who were very sick so there's no evidence of harm in any study from oral probiotic supplementation that said it's not necessarily harmless it's just you know ultimately we're going to have more studies that that uh that determine so recommendations clearly people ganna let standard American diet that aren't consuming the kefir the kimchi that kind of stuff that said people typically don't need to take these on an ongoing basis you know tend to cycle on and off a few times a year or for specific situations would be very important to supplement and these are some of them so again you got my all caps italics exclamation point people on antibiotics no-brainer slam-dunk you know these these broad-spectrum will deplete not just the bad bacteria but the good ones as well so it's critical to replenish the floor and prevent side effects like diarrhea France's good evidence that people have digestive problems or food intolerances can really benefit from probiotic supplementation when it comes to prophylaxis if you're traveling out a country where you know exposed to different kinds of things you can help prevent iReal disorders people with autoimmune diseases again we saw eczema allergies those types of things and for people that are high risk of infections so I usually bump mine up a little bit during cold and flu season alright so when you're looking for a core product you run on one find one that has a variety of different genus and species okay especially lactobacillus and Bifidobacterium alright you may want to rotate products for increased variety again there are hundreds of different species in our gut so it's a good idea to do some rotation that said you know there there is kind of a time and place for the the single species products you know for Dyer es we already air lactobacillus GG for instance can be pretty effective but for most part you want to look for those that have a variety of species and again choosing high potency products is important if you see something it's got it that's in the millions it's not going to do much even the low billions see that I think five 10 billion at least if not more especially after antibiotics again keep in mind they're a hundred trillion bacteria in the gut so let's remember that scale all right on now in terms of giving you a discriminating eye for quality it's very important points here all right so during the summer in particular perhaps all year you want to choose a refrigerated product we talked about probiotics are alive and thus they can die and one of the ways that they died it was when they're exposed to heat you know when they're being shipped in these in these trucks so by refrigerating it extends life and it assures the potency of the product I mentioned before too typically most supplements will just have the genus and species you want to choose products that specify the strain it's a sign of quality typically and so we take a look at this product for instance it's got the strains listed so these are typically your best products and then lastly the probiotics there are so many different species so many different combinations look for products that are supported by research ok and the company can typically point to the studies that they've done but this will give you an idea if someone just says they're taking probiotics and what does that mean there's so many different species out there so many different products that look for ones that have research supporting their efficacy all right so we've talked about the good supplements now let's talk about bad ones you do Enterprise before we get into this is that most supplements are safe okay safety is not the big issue for me a lot of times it's product quality and content but there are some that pose a risk and it's typically when they're tainted with pharmaceuticals and there are three classes of supplements that are most likely to be tainted first of which are the weight loss supplements got problems with these for a couple reasons first of which is they're they're not likely to be effective long-term all right people think they can take venture burn and I can do whatever you want move around at all just doesn't work that way but I think even more disconcerting as a fact that these are often stimulant based and some of which have been tainted you know they've got a link here that the coentrão some of these that have been tainted with drugs that have removed from from the market because of safety concerns risking you know raising the risk of cardiovascular disease events so typically I think these are bad just conceptually but also they can have some health risks okay then you've got your sexual enhancement supplement and just take a look at the label on this one I mean that it black aunt with Chinese lettering and that's doing whatever you know that that just doesn't pass the common sense test and the issue that these is is or several many people will take these when their doctors told them that they have to avoid because there are nitrates and they couldn't take cialis or viagra or one of those types of things but some of these you know products have been tainted with these things and thus can contribute to really low blood pressure so something to avoid and then find out the bodybuilding supplements and I do to be clear that this is not you know include whey protein which is a good supplement that has a lot of good research behind it what I'm referring to more of those that talk about having steroid like components and the reason they say this is they offer and contain steroids okay and this is cause liver kidney problems again looking at the label or just you know fire and just you know it creasing testosterone these kind of things I just you know a lot of this is common sense but these are these are areas that you want to want to have exercise some caution so there are the rarity I'd say they're exception not the rule but definitely be aware these kind of things alright so but supplement drug interactions have one slide on this we could spend a couple hours talking about this what I've done instead is point you to some resources okay there's a covers and a number of good books on this subject where if you're a clinician or if you're taking a bunch of herbs and drugs and if you want to learn more I would you know look at look into these books but I did want to kind of give you some representative examples the first of which our products were their synergy with drugs so st. John's wort is an effective antidepressant there's Cochrane reviews on that that that show that it works well so if you're taking that with an antidepressant you know you get the synergy and you get a little bit too much of what you're looking to accomplish same thing goes with red yeast rice it's effective at lowering cholesterol you take that with a statin you know you can get an increased risk of muscle and liver problems so you get that synergy then conversely you've got the opposite kind of thing where absorption can be reduced you have competition so with some of the minerals antibiotics this is pretty well understood if you are an antibiotic look at the label might say avoid calcium and these types of things then you've got just general interaction so I mentioned fish oil and anticoagulants ginkgo would be another one too so a lot of these good anti-inflammatory products for cumin turmeric ginger thin the blood and as such if someone's donated coagulants there's the you know risk of interaction but if you're says in this subject any of these books would be great I'm going to talk about a few special situations that are of critical importance first of which is coenzyme q10 for people on statins or beta blockers and to me it's just such a travesty that so many people are taking these drugs and not taking cook u10 it's very clear from the research evidence that both of these particularly statins deplete coq10 and I'm not going to get too much into the science behind this but coq10 is essential for muscle function particularly out of the heart so you're taking these drugs to protect your heart but at the same time it's depleting a nutrient that is essential for heart function so this you know any of you that are healthcare professionals are taking these things I can't aside the strongly enough so Marc talked a little about the problem of stomach acid blockers or prilosec zantac antacids that people often take like candy you know these are not benign they're known to deplete vitamin b12 for instance so it's a again everyone who's taken these should be taken to b12 supplement probably should be thinking about how to get off the drugs and we'll talk about that on a couple slides because there are other issues to increased risk of HP Lorre infections so these are not the benign sort of I'll just take it once the Larry the Cable Guy remember that guy there's commercial now for prilosec you can eat whatever you want if you take that take it it just doesn't it's it's bad advice but for those that are on them now you know you really want to make sure that you get b12 supplement to prevent the problems okay so a couple more people on vegetarian or vegan diets especially vitamin b12 I think people recognize that fact but these diets are typically not always but typically low in these nutrients and then finally flow cassadee for pregnant women I should say the methylated form would be preferable the story that you heard about is is quite accurate and was said but you know you want to there's very strong evidence that these can prevent on neural tube defects now you can usually get these don't need to take this separately if you get a good high quality multivitamin you're gonna get a good amount there okay so we'll kind of quickly go through this part so that can save some time for questions but again these are kind of what I've gone through thus far our supplements that are good for just most people consider but people have problems and people take supplements for those problems and we're gonna look at a few of those that have good evidence so joint health is one of the most common reasons that people take supplements and you know I'd say glucosamine chondroitin has been study for a long time very strong evidence behind it I think a good glucosamine chondroitin product you know I take it prophylactically and I haven't been an athlete that I want to keep my joints healthy and and and working well and pain-free as they are now so I think a coachmen chondroitin is a great one there's some other ones as well I could see turmeric on here for a lot of things okay then digestion so this is one of the most common reason that people in our clinical practice are taking supplements and for general digestive support I think a broad spectrum plant-based digestive enzymes a great idea helps a lot of people with you know bloating gas those types of things and it you know the reason I've got plant-based on there is that they tend to survive the stomach acid better than the animal-based ones so that's a good idea and then you know as far as after the reflux goes common problem and for those that are tapering off acid blocking medications you get this horrible kind of rebound effect so some ways to kind of work around that would be DGL after all these years I still don't want to pronounce the day so we'll just say DGL you chew their little kind of tablets that Lawson jizz that you chew that can be very helpful and drinking aloe vera juice is another one as well that can during that sort of tapering process all right the immune system there's just an abundance of evidence for four supplements that can improve immune function zinc has some of the strongest evidence there's a Cochrane systematic review that showed benefits for zinc and preventing both the int both the frequency of colds but also the duration severity and the same goes for a lot of these other supplements too you know when it comes cold what I feel like I've been exposed or if I feel like a little since coming on I should take a mix of these things and knock on wood I've had pretty good success with it heart health again red yeast rice is for people that are looking to avoid statins red East rice is effective product and lots of evidence shows that it can lower lipids of course you get your fish oil cookie tan and vitamin D as well okay for liver health is something that they've been brewing not quite as common but still worth mentioning milk thistle is a great product so anyone who has elevated liver enzymes this is something where there's some good evidence again you got turmeric on the list it's a great one depression Anna mentioned it before st. John's wort is an effective product for depression you know it's multifactorial I think I'd look into other lifestyle stuff too but it's helpful fish oil can be and then Sammy which you saw in the previous slide too is another it's good evidence for alleviating depression and then sleep so this is an areas a lot of concern melatonin is is you know some have evidence for this is typically what I would take if I need to adjust to a time zone or just have some help sleeping valerian has another one melatonin is interesting thing too we're just kind of scratching the surface with respect to all the many things that that does it's the sleep hormone so when lights turn off you start to promote more melatonin but it's also an effective antioxidant that has all other kinds of effects all right so we're going to close before we take some questions on giving you just an overall kind of checklist on how to become an informed supplement consumer how to have that discriminating eye and choose high quality products so first thing is first things first you should make sure that what you're taking will not interact with other drugs or supplements that you're taking so you want to talk to your healthcare professional but let's we also have to be realistic you know that they may not know so you got to do your own homework on this one you can get one of those books resources so you know you have to do some digging on your own again avoiding outrageous label claims it saddens me to see people will kind of fall hook line and sinker for some of this marketing I mean taking this one for instance me if you think dream body taking that it's going to give you a dream body you know I don't know what to tell you it just it doesn't think it's not that simple and this is especially true for those weight loss sexual function products and bodybuilding products that you probably want to avoid anyway and then very importantly to read all the ingredients on the label alright just don't read the front carefully consider the content quality and source of the ingredients so giving you a couple pointers on on some things to look for because again these are not all created equally and you know you really want to take a close look at the labels and finally it's something that I think is important is to seek reputable companies that have done research and have have had third-party labs come in and say hey you know this is legit so there are party verification certificates or something and I think you should you should require just a sign of commitment to product quality okay they don't have to do this companies don't have to do it but I think anything you're going to consume you want to make sure that it's been certified it's pure no contaminants that's got you know in the bottle what's on the label then finally choosing brands supported by research again I think this is the ultimate sign of product quality and you know the companies don't have to do this but it provides us you know the consumers and health care professionals with evidence that the supplement works and you know we've got some exhibitors out here today and we carefully vetted all of them and they are doing research that was one of the things that I wanted to make sure that people are familiar with us are doing research on their products to make sure they work so these are some tools I'm happy to take some questions and you know we'll go from there so yes so the the – for those who didn't hear the first questions about red East rice it is actually what the statins were initially derived from so it's something I would recommend people actually take a coq10 product while they're taking the ready to rice it works but I think the same precautions should go for that the second was about iodide which you know again it's it's as we're all getting towards our sea salt and you know I get the pink Himalayan sea salt you're not getting it from that now it is in plenty of vegetables green vegetables that kind of stuff especially sea vegetables but it's it is something that we you know people need to be mindful yes yeah there are that's one that's a little bit less clear so hormone supplementation something that you typically won't want to work with a good physician on that there are supplements out there like DHEA that that act on hormones melatonin actually does two it is it hormone but you know that's one that's where I kind of say exercise caution you'd want to get blood work and make sure where you are and get it while you take a supplement so but there are okay yes well it's an area near and dear to my heart did my doctoral work in that area I think antioxidants are good but they can be bad so if you have too much of them they actually could be pro oxidant so it's think that what nutrition usually the kind of tipping point and then things get bad so I prefer for that kind of thing ty to get it in a good multi your first of all to get it from your diet so real high level just taking a vitamin E supplement for instance even though we found it to be effective that vitamin E blood levels to prevent against physical function and cognitive decline i I'm not typically crazy about single antioxidant supplements because again they can go pro oxidant it's we don't really know where that level is so yes rip on you yeah that's fine it yeah you don't really need that much so in avocado we plenty and even less even half an avocado a quarter an avocado so doesn't need a whole a huge fatty meal to get it just some to help yes that's a great question so can everyone hear the questions okay so the question was a probiotic and antibiotic should you wait until the course of antibiotics is over or should you take it during I think what most people recommend is actually to take it during but space it away from your antibiotic by a couple hours okay so you'd say you take the antibiotic in the morning take probiotics to spaced a few hours away from that if you take at the same time it's gonna kill a lot of the probiotic but you also want to prevent you know not wait for the the side-effects wait for the diarrhea to happen you want to kind of prophylactically so I think it's a good idea to take the probiotic with antibody just based a couple hours away so yes today hair growth well biotin is one that people often use for that a lot of the stuff that actually helps with joint health helps with hair as well so it's all kind of about collagen so a lot of these same things I don't take MSM now but when I did I found myself almost having to shave twice a day because it would make it makes things happen so fast nails as well so think hair skin and nails typically the same products they're gonna help with joints will help with that yeah it's uh it's hyaluronic acid has a very high molecular weight but there are some that have a lower molecular weight so this is what a lot of times people have the osteoarthritis they'll get hyaluronic acid injections in their knee some hyaluronic acid supplements can be helpful too but it just needs to be a little molecular weight why don't we take I'm sorry been wearing this side won't you go with the scarf well I mean I think I mean diet comes first so for people that are healthy I think the main three or four that I talked about first is probably all you need if you have these other other issues you know if you're not able to get it through other lifestyle practices then you know you guess you could either deal with hit or take a drug or something but it it I'm generally a food first type person but you know for these types of issues you know I think just one thing you want to look for and I've seen this with people I work with redundancy and ingredients so make sure if you've taken a bunch of supplements you're not getting a whole lot of the same thing in them so just a quick point for you see in a lot of supplement something called bio pairing does anyone know it's a black pepper extract that supplement companies put in to improve the absorption it's a very good job of that but if you're taking 12 supplements or whatever it is and you got bio parrying and ten of them that's not a good thing so I think trying to be a minimalist and cut down to what you really need is the key so yes right so they said that sexually we'll take one more for the surgeon say prebiotics are very important too so you know they they do feed the you can get a lot of those so some of the I call shenanigans though so fructooligosaccharides and any one or two that you look at I prefer I think it's better if people to get the fibers in their diet that feed them and we'll take one more question will go in the very back there yep I understand that there sometimes are gastric side effect with I think it's the Droid what do you recommend and can you talk Tibet I don't think that's a it's it's it may be for some people I mean everyone's physiology is a little bit different that's not unless you were taking massive doses I have heard about that anecdotally it's typically the research hasn't shown that to be a big a real big problem but if it were I would probably just cut back on a little bit maybe try another brand and see if you get the same thing because they're fillers often in supplements too so okay well that that's that's it and if anyone wants to to contact me thank you thank you very much send me an email and I can send you the slides joy the rest of the conference you

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