Dietary supplements, including vitamins, minerals, amino acids, and botanicals,1 are increasingly popular primary and adjunctive therapies initiated to enhance well-being, improve health, or prevent exacerbations or worsening of signs and symptoms associated with established chronic illnesses.1 These therapies are frequently self-prescribed upon recommendations from friends or family, with little to no guidance from health care providers, in part because lay people often equate the descriptor "natural" with safe and benign. It is not uncommon for people to begin supplement therapies on the basis of information from catalogs, websites, store sales flyers, and advertisements.
Supplement usage is often not fully shared by patients with providers during health encounters. Some clients take so many supplements that they are uncomfortable sharing the information with the health care team. Others prefer to avoid writing lengthy lists on health forms or participating in prolonged discussions about a collection of pills and capsules that they believe are irrelevant to the actual medical encounter. The following exemplars have been crafted to represent fairly typical encounters occurring during recent health assessment activities. These exemplars offer opportunities to showcase high-frequency occurrences that typify the challenges associated with developing an accurate medication/supplement profile of patients.
* During the assessment encounter, the elderly female is asked by the nurse practitioner, "What medications and supplements do you currently take? The client provides a list that she describes as "up-to-date" and "complete." The nurse practitioner follows up by asking, "Do you take any other vitamins or supplements?" The client shares that she takes "some," but they are not prescribed by the doctor and she does not have them on the list. When pressed by the nurse practitioner, the client reluctantly agrees to bring out the supplements but expresses frustration that they are only vitamins. With additional encouragement, the client brings a shoebox of supplements to the table. Supplements include Co-Q 10 200 mg; glucosamine-chondroitin with hyaluronic acid, MSM, and vitamin D3 1000 IU; cranberry extract 450 mg; vitamin D 2000 IU, soft chew calcium 500 mg, vitamin D 500 IU, and vitamin K 40 [mu]g (twice daily); biotin 10 000 [mu]g; melatonin 5 mg (occasional use for sleep); AREDS (age-related eye disease study) formula pills; and, a multivitamin for adults older than 50 years containing vitamin D3 800 IU and calcium 300 mg.
* A client provides his list of medications and also shares his pill bottles. He reviews the finalized list and verifies its accuracy. Toward the end of the interview, the nurse practitioner suggests that the client discuss aspirin therapy with his primary care physician during his upcoming visit. The client states, "Oh. I do take that but it is only a baby aspirin. I have it upstairs next to my bed." The client shares that he started it on his own because his wife was told to take it. He acknowledges that he did not think that the aspirin "was that big of a deal."
* A client shares that he is prescribed atorvastatin 40 mg of tablet once daily for a diagnosis of mixed hyperlipidemia. He reports that he "hates taking this medicine" because he has heard that some people experience "really bad muscle aches and liver problems." As a result of his concerns, he recently started red yeast rice 1200 mg with a garlic 1000 mg soft gel capsule daily in addition to the prescribed statin. He did not discuss these dietary supplements with his health care team, despite a recent visit with his primary care provider. The client notes that there is a lot of information on the web about how these supplements can help him stop his atorvastatin therapy and "get off this stuff." "I'd rather be on something natural!"
These vignettes exemplify several immediate concerns, including some issues related to the specific types of self-administered supplements. The first vignette demonstrates vitamin D3 oversupplementation. Several of the supplements in this vignette contribute to prolonged clotting times, potentially a concern with scheduled health screenings or prescription drug interactions. The soft chew supplement with vitamin K could potentially influence drug-to-drug interactions, depending upon future prescriptions. Low-dose aspirin was not recommended or prescribed in the second vignette; however, the client determined that it was probably a "good idea" to take the aspirin because his wife was taking it. Low-dose aspirin therapy is associated with gastrointestinal irritation and bleeding risks. Drug-to-drug interactions may also occur with aspirin therapy. The third health encounter is concerning because of the client's decision to combine a prescribed statin medication with red yeast rice, without alerting his primary care provider or specialist. Although red yeast rice may offer opportunity for improving hyperlipidemia, adding this supplement to his daily regimen should be a decision made in consultation with his providers to avoid failing to recognize adverse effects and drug-to-drug interactions.
The vignettes share important commonalities. Each client failed to discuss or notify his or her provider of the decision to begin dietary supplement therapy, often despite a recent evaluation that included a medication/supplement history or verification process. In each vignette, the client decided to begin supplements on the basis of family or friend experiences or advice and, at times, on the basis of information gleaned from websites. Particularly concerning is each client's casual approach to these various tablets and capsules, perhaps appropriately labeled as supplement nonchalance that is often influenced by supplement naivete.
Supplement nonchalance and naivete affect all age groups. Supplement usage type is influenced by age and developmental level. Many middle-aged adults and seniors use supplements, often in wide variety. Supplement use and naivete are international phenomena and include risks not only associated with the supplement itself but also with its manufacturing.2-4 Cohen5 describes contaminated dietary supplements as American roulette. Cohen reports that some supplements contain hazardous materials whereas others are produced with pharmaceutical analogues to avoid Federal Drug Administration (FDA) detection or patent infringement lawsuits, specifically, supplements designed for sexual performance, weight loss, and muscle building. Supplements are not regulated by the FDA and only those designated as unsafe by the FDA can be removed from the market. Many consumers incorrectly believe that supplements are not only safe, but also regulated as medications.6
Published literature and professional anecdotes offer many examples of adverse events, near-miss reactions, toxicities, and other negative health consequences associated with supplement dosing. Popular dietary supplements that are of particular note are those associated with weight loss and energy, particularly when self-administered by people with comorbidities that are influenced by stimulants. Some weight-loss and energy supplements influence or mimic thyroid hormone actions, leading to problems with thyrotoxicosis and associated cardiac complications.7 Sexual performance is another common concern, and opportunities to purchase sexually-enhancing supplements are plentiful and unregulated with public health risks related to adverse psychological effects and addictions.8 Sexual performance supplements have also been associated with atypical optic neuropathy.9 There are wide-ranging injuries linked to supplement use, including many reports of liver damage and failure.3,4,10 Some reports suggest that supplements may be harmful in the presence of cancers.11
RECOGNIZE THAT DIETARY SUPPLEMENTS ARE HERE TO STAY
There are opportunities to incorporate dietary supplements into health plans. Complementary and integrative health is popular, and providers need to be familiar with user-friendly, evidence-based, free, and easily accessible resources both for professional consultation and lay person referrals. It is likely that as the number of people with chronic illnesses increases, including cardiovascular and metabolic diseases and conditions associated with aging, dietary supplement usage will also increase. Shane-McWhorter12 reports that large numbers of people living with diabetes use supplements, many on a daily basis. This popularity, influenced by the high cost of traditional medication therapy and provider office copays, is responsible for an enormous dietary supplement revenue stream with no indications of future decline.12 Providers need to recognize that dietary supplements are mainstream and here to stay.
REMEDYING SUPPLEMENT NONCHALANCE AND NAIVETE
Health professionals should consider their obligations to patients regarding healthy use of dietary supplements. It is critically important to address both the nonchalant approach to supplements and naivete associated with risks that include potential adverse events and drug-to-drug interactions. Provider responsibilities include a comprehensive assessment of dietary supplement usage using plain language questions and, at times, if needed, repeating these questions at several points during each and every health history interview. Health professionals must make certain that patients understand that prescribed and nonprescribed medications and supplements should be included in the health history.
Providers may want to consider a "brown bag" practice policy that requires patients to bring all medications and supplements to each health care encounter, with a clearly shared explanation as to why doing so is critically important to health outcomes. Care contracts that specify client responsibilities related to full disclosure of dietary supplements and over-the-counter medications as part of the patient-provider relationship may also help to showcase the importance of this information. Including health care students and new providers in activities that illustrate safety concerns with dietary supplements when incorrectly used may also help to increase provider expertise and awareness and contribute to a positive ripple effect across practice settings.
As clients are exposed to a consistently shared message about potential risks of dietary supplements, particularly when used unbeknownst to the provider, and the importance of a comprehensive medication profile that includes all types of supplements and over-the-counter medications, supplement nonchalance and supplement naivete may be replaced with well-informed vigilance and safer self-care expertise.
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