6th Annual Practitioner’s Guide to Dietary Supplements


A look at several dietary supplements that should be on the radars of health care practitioners.

Integrative Medicine: Moving from the Sidelines to Center Stage

By Jim LaValle, RPh, MS, CCN

When I first started out in pharmacy school in the late 1970s, there was not much acceptance of dietary supplements. The general consensus then was that vitamins made expensive urine.

That confused me because the more I learned about medicinal biochemistry and physiology, I realized that vitamins, minerals, and essential fatty acids were a requirement for proper metabolic function and health.

What made sense to me was that whether it is a drug, nutrient, chemical, or even an emotion, all of these could impact how a receptor or tissue would behave in the body. I was fortunate to be exposed to the nutraceutical movement that was going on in Europe in the 1980s. As I read on the research on botanicals and other natural products, it was clear to see the application of these types of agents to health.

I started a practice consulting with clients on how they could use natural products to optimize their health, help improve a condition they may have, and hopefully reduce their need for medications. And this body of experience led to my being able to write books and publish many journal articles, teach natural medicine in a university course, and extensively lecture at medical and pharmacy conferences of various types. The point being that I have been lecturing on natural therapeutics at a variety of medical venues for over 20 years now, and over the last few years, I have seen dramatically increased attendance at them by conventionally trained physicians.

What has happened? Could it be that dietary supplements and other natural therapies are actually starting to gain some acceptance in conventional medical circles?

A study called the “Life . . . Supplemented” Health Professionals Impact Study conducted by the Council for Responsible Nutrition in 2007 found that as many as 79% of physicians recommend some supplements to their patients. The supplements they were most likely to recommend were glucosamine/chondroitin for arthritis, omega-3s for heart health, supplements like calcium and vitamin D for bone health, and soluble fiber and plant sterols for helping to lower cholesterol.

I don’t have numbers of this type from 20 years ago, but I am confident that they would have been very low. In fact, my experience was that most physicians at that time told their patients not to take dietary supplements because they felt they were a waste of money and weren’t effective.

Today, we have a large number of practices adopting integrative therapies-so much so that we have things like the Consortium of Academic Health Centers for Integrative Medicine. In addition, there are more formal education opportunities available for health professionals on the use of dietary supplements and other complementary therapies. For example, I am an adjunct professor for a master’s degree in metabolic medicine being offered by the South Florida School of Medicine, and recently lectured in Vienna at an international medical congress on men’s health issues.

So things have changed, and it is largely because consumers have shown they want to use supplements as a first option for a variety of health concerns, like helping with cold and flu symptoms or helping to increase their energy. Consumer supplement sales as reported in journals like Nutrition Business Journal show that supplement sales have grown every year for the last couple of decades, even in slow economies. Sales in 2008 were $25.2 billion, and that was a 6.2% increase over the previous year. In fact, it’s been these types of numbers that caused medical associations to start paying more attention to the use of dietary supplements and which helped spur the National Institutes of Health to form the National Center for Complementary and Alternative Medicine and to start funding more research on the use of complementary therapies of different types (herbs, nutrients, acupuncture, and chelation therapy, to name a few.)

But I believe this growth couldn’t have happened if it hadn’t been for two things. First, there is a growing evidence base, studies on supplements showing how and why supplements of different types work-and physicians are seeing the results in their patients. Secondly, physicians see that people need help from supplements due to sobering dietary habits statistics. For example, the U.S. Centers for Disease Control in 2007 found that only 32% of teenagers ate two servings of fruit per day, and only 13% ate a daily vegetable serving.

Will supplements/natural therapies continue to play a significant role in the future of health? Because research on nutraceuticals of various types is taking place in unprecedented amounts, there is no doubt they will. Probiotics are a good example. Think about how much you are hearing and seeing on TV about probiotics now. It’s because companies are seeing the research on how important probiotics are to health, and they are trying to capitalize on it. This research helps physicians to understand nutraceuticals, why they are needed, and how they help. And, it drives even more consumer demand.

And ultimately, physicians are increasingly realizing that you can’t medicate your way out of diseases and conditions that are caused by poor nutrition and lifestyle. We need medications; they are extremely valuable for people who can’t or won’t use nutritional approaches or who don’t respond well enough with lifestyle measures. But in order to get ahead in the disease-state management equation, we need continued efforts to identify the most effective nutrition and lifestyle approaches.

There are still some barriers for physicians when it comes to the use of dietary supplements. There are ethical considerations, for example. Should doctors sell the supplements out of their offices? This is really the only way for physicians to be compensated for the time they take in counseling patients, and physicians feel more confident when they sell their own supplements because it allows them to control the quality of products their patients are using.

And office sales can be done ethically, but physicians will need guidelines to help in this area. In addition, because many insurance companies don’t reimburse for the use of supplements, there needs to be a way for physicians to allow cash sales while also providing services that are reimbursed. With the continued interest and demand, organizations can work together to provide the answers to these types of challenges, especially when the care is more cost effective and is improving health outcomes for people.

Natural therapies have gone by all kinds of names over the years: Holistic medicine, complementary medicine, alternative medicine, functional medicine, and now a newer term, integrative medicine, which stems from the fact that different complementary therapies (like nutrition supplements, acupuncture, and massage) are being integrated into medical care along with conventional medical care.

Integrative medicine is a term that people use, but what we are really talking about is just using good medicine. Integrative care is about delivering what people need for their health, whether it’s a medication, a nutrient, or an herbal extract that achieves a desired end-result most effectively.


James LaValle, RPh, MS, CCN, is a nationally recognized clinical pharmacist, author, educator, industry consultant, and clinical practitioner/pioneer in the field of natural therapeutics. He founded LaValle Metabolic Institute, an integrative medicine facility in Cincinnati, OH, and is the author of more than 20 books and e-books on natural medicine, including Cracking the Metabolic Code and Nutritional Cost of Drugs. He was named one of the “50 Most Influential Pharmacists” by American Druggist magazine and the 2011 Clinician of the Year by the Natural Products Association.


6th Annual Practitioner’s Guide to Dietary Supplements

Probiotics and Prebiotics

Background: Probiotics are “friendly” bacteria, more aptly described by the UN Food and Agriculture Organization and the World Health Organization as “live microorganisms which, when administered in adequate amounts, confer a health benefit to the host.” Growth of these friendly bacteria in the colon can be further stimulated by prebiotics, nondigestible food ingredients present in many of the world’s dietary fibers.

History of Use: While mainstream availability of commercial probiotics is relatively new, available strains are in no way limited. The Lactobacillus and Bifidobacterium families house the most common of probiotic strains. Prebiotic options are plentiful, too, with common types including galactooligosaccharides (GOS), inulin, and inulin-derived fructooligosaccharides (FOS).

Research: The precise mechanisms of probiotics are still being investigated, but it appears certain that probiotics can provide immunomodulating properties in a variety of ways. Limited clinical trials have yielded positive results with probiotics when used for gastroenteritis, antibiotic-associated diarrhea, stool health, and atopic dermatitis and allergies in children.

Conventional Wisdom: Still in its early years, probiotic research must rely on homogeneous experiment protocol to get more widespread approval. Positive studies are pumped out every week, but results can differ based on population, environment, dosage, and strain of probiotic material. Continued focus on strain-specific studies will drastically improve faith in probiotics.

Combination probiotic blends have demonstrated clinical potential too, but more research will determine whether mixtures are more beneficial than single strains.

Consumer Trends: Bacteria aren’t so bad once you realize the body houses at least 10 times more of these than actual human cells. This familiarity with bacteria, however, still needs to be communicated to the average household.

For consumers already informed about pre- and probiotics, yogurts and milk-based beverages provide some of the more popular carries for these ingredients. Notable brand names include PRE, Yakult, and Good Belly. Synbiotics, combination products of pre- and probiotics, already exist in the marketplace today.


Background: Curiosity around omega-3 fatty acids started in the 1970s, when researchers studying Greenland Inuits realized that these people had low rates of heart attack and high levels of omega-3 fatty acids in their blood. Omega-3 investigations have not slowed since then.

History of Use: Because of a lengthy history on the U.S. market, fish oil supplements are considered as having “grandfathered” market status. New commercial sources of omega-3s are providing market alternatives.

Research: Omega-3 research is largely led by the heart health category, which has remained a focus for centuries. In recent years, research has expanded to health factors including rheumatoid arthritis, neuroprotection, overall cognitive health, ocular health, and prenatal health. Ocular and prenatal health in particular have provided a sound argument for omega-3 DHA supplementation. Studies have shown that women with high DHA intake during pregnancy may see cognitive, immune, and allergenic improvements passed on to their offspring.

Conventional Wisdom: The average Westerner is full of omega-6, a fatty acid that can induce inflammation when intake is not controlled. Omega-3 can counter the inflammatory risk of omega-6. The likelihood that inflammatory problems in North America are a result of too much omega-6 and not enough omega-3 is being communicated more and more in the medical field and in food and supplement stores.

Consumer Trends: Omega-3 is without a doubt one of the most recognizable of what the USDA calls “accessory nutrients”-those not classified as vitamins or minerals, but which are understood as promoting optimal health.

Fish oil has maintained the top spot in the omega-3 market for most of its career, but new discoveries and marketing initiatives are yielding new players. As far as marine sources go, krill is now a proven competitor, and so is algae (a vegetarian/vegan alternative). Plant sources touted for high levels of omega-3 ALA include flaxseed (Linum usitatissimum), chia seed (Salvia hispanica), and sacha inchi seed (Plukenetia volubilis L.).

Based on a growing consumer interest in environmental sustainability and preserving fish populations, omega-3 suppliers now tout traceability and sustainability of their fishing practices. Marketing strategies often include environmental certifications and education about heavy metal contamination.

Better absorption rates and reduced fishy odors are also popular supplement selling points.

Saw Palmetto

Background: Saw palmetto (Serenoa repens) is derived from the ripe, partially dried berries of the dwarf palm tree.

History of Use: Native Americans are reported to have used this ingredient for “genitourinary disturbances.” Today’s humans primarily use it for the same area of health, in prostate and urinary support.

Due to its pungent taste, saw palmetto is now consumed as an extract, with various extraction methods suggesting that not all saw palmetto extracts are the same.

Research: The European Association of Urology cites research supporting saw palmetto use for nocturia. But while the unstoppable need to urinate at night has proved a mighty task for many men, most saw palmetto science targets another male health risk: benign prostate hyperplasia (BPH). BPH, or nonmalignant prostate enlargement, can lead to lower urinary tract symptoms (LUTS).

Numerous studies support saw palmetto’s use for reducing prostate volume and improving urinary flow in BPH-afflicted men, but negative studies have become apparent. The 2006 STEP study, a 2009 Cochrane study (analyzing results of 30 human clinicals), and a 2011 JAMA study have all cast gloom on saw palmetto research in mainstream media. It should be noted that the strength of each study, in  light of saw palmetto research as a whole, has been questioned for various reasons.

This year the FLUX study brought a bright light to the issue. In this placebo-free study, 120 men with mild to moderate LUTS saw improvements in several prostate scores after 24 months of saw palmetto use. Erectile function also improved for the average patient.

Conventional Wisdom: Positive research has been published on saw palmetto for men’s urinary health factors, but, as suggests above, the ingredient could benefit from more sufficiently controlled human trials.

Consumer Trends: A recent market share report from SPINS found that saw palmetto was the second most purchased herbal dietary supplement on U.S. food, drug, and mass market channels in 2010. At nearly $19 million in sales, saw palmetto was second only to cranberry. Few other ingredients have received such public attention for men’s health as has saw palmetto.


Background: One of North America’s most famed plant foods, cranberry (Vaccinium macrocarpon) has long found its way into the American diet as dried fruit, juice, sauce, and countless other modern manifestations. Cranberry is classified into several subgenus, including Vaccinium oxycoccus (European cranberry) and Vaccinium vitis-idaea (lingonberry), but much of modern research has centered in on the macrocarpon species (otherwise known as the American cranberry). Interest in this plant for potential healthful properties can be dated back to folklore, when American Indians are noted for having used the ingredient’s meat in poultices for treating wounds and its leaves for treating urinary disorder and diarrhea.

History of Use: As a juice or dietary supplement, cranberry consumption has become a popular, natural approach to combating urinary tract infection (UTI). Supplementing with cranberry to this effect is largely responsible for the continued success of the ingredient in food, beverage, and supplement markets.

Research: Cranberry research has honed in on UTI support, particularly in women. Due to natural anti-adhesion properties in cranberry, consumption of the fruit can reduce the amount of infectious bacteria that attaches to the inside of the bladder, thus causing infection. A wealth of research on this relationship supports cranberry’s use, but conflicting evidence does exist. Cranberry experts insist that the key to efficacy is in a cranberry’s active level of type A proanthocyanins (PACs). Type A PACs have been directly credited for cranberry anti-adhesion properties, and negative study results have, at times, been attributed to cranberry supplements that were too low in this important compound.

Conventional Wisdom: When it comes to UTI support, cranberry is popularly chosen as an alternative to antibiotic treatment. A 2011 study on 221 female UTI sufferers found that while antibiotic treatment was more effective than cranberry in reducing recurrence and extending delay of UTI, resistance to other antibiotics was increased with antibiotic use.

Consumer Trends: Cranberry remains one of the United States’ top-selling dietary supplements. A 2010 SPINS market report listed cranberry as the top selling herbal dietary supplement, generating over $35 million in natural and health foods channel revenue, up 15% from the previous year.

Vitamin K2, Vitamin D, and Calcium

Background: Vitamin D can be obtained from the sun and in two dietary forms: ergocalciferol (D2; derived from plant, yeast, or fungal sources) and cholecalciferol (D3; derived from sheep’s wool). Vitamin K2 is synthesized from meat, egg, and dairy products (as MK-4) or through a fermentation process of bacteria (as MK-7; also found in natto). Calcium can be sourced from plant, animal, and rock sources.

History of Use: Whereas calcium and vitamin D have seen action on dietary supplement, food, and beverage markets for years, vitamin K2 is a relatively new player.

Research: Uses of vitamin D and calcium, as they relate to bone health, are well established. But continuing research on vitamin K2  suggests that all three work in harmony. Vitamin K2’s ability to activate osteocalcin, a protein that transports calcium from blood to bones, effectively improves the utilization of dietary vitamin D and calcium for bone mineral density. An August 2011 study on postmenopausal women in Korea found that adding vitamin K2 to a program of vitamin D and calcium increased select bone mineral density and reduced unactivated osteocalcin. Studies continue to find that less unactivated osteocalcin is linked to better bone mineral status and reduced risk of bone fractures.

It should be noted that vitamin D sufficiency may be important to some other health factors, including cognitive function, cardiovascular health, and immune health.

Conventional Wisdom: Vitamin D deficiency remains a global issue, largely affecting the elderly, people with dark skin, and people living in climates with restricted sunlight.

While we all know the bone and dental benefits of calcium, consuming excessive calcium is believed to increase risk of heart attack and, depending on the source, maybe even kidney stone formation. Research on a link to cardiac troubles is especially increasing. It is this very risk that creates a platform for vitamin D, which synthesizes osteocalcin, and vitamin K, which activates osteocalcin so calcium can be transported away from the blood.

Consumer Trends: With high levels of fortification in milks, yogurts, and other dairy products, vitamin D and calcium remain at the top of consumers’ minds when it comes to bone health. Work is still to be done on educating consumers about the benefits of vitamin K2, but increasing approval for supplier ingredients in foods and beverages will bring the nutrient more attention.

Chondroitin Sulfate, Glucosamine, MSM

Background: Glucosamine and chondroitin sulfate are natural components of human cartilage. These compounds are commercially extracted from shellfish and from shark, bovine, porcine, and other cartilage sources, respectively. They are understood for their presence in naturally healthy cartilage, their importance in maintaining healthy cartilage, and even for a benefit of reducing the expression of cytokine mediators involved in cartilage degradation.

MSM is found naturally in plants, but only in amounts too small to be retrieved for use. It can be produced synthetically from dimethylsulfoxide, as the end result is nature-identical. This sulfur compound is believed to support joint health as a protein building block.

History of Use: Glucosamine and chondroitin sulfate have been commercially available for several decades. The two ingredients are often found together in formulas, and MSM is too becoming a common fit with these ingredients. The first GRAS-affirmed glucosamine ingredient came from Cargill in 2007. Other companies have received GRAS affirmation since then. Select companies have also obtained GRAS affirmation for chondroitin and MSM.

Research: Glucosamine and chondroitin have been the subject of numerous clinical trials; unfortunately, the results have varied. Most notably, the 2006 NIH-sponsored GAIT study on 1583 participants taking glucosamine, chondroitin, both ingredients, placebo, or an antiinflammatory drug found no overall benefit of either natural ingredient or combination over placebo or drug for pain scores.

On the other hand, a 2008 study found that glucosamine supplementation for 12 months or longer reduced need for joint replacement in an average of five years follow-up.

Clinical trials on MSM are few, but early results in randomized trials have shown promise, especially for knee osteoarthritis.

Conventional Wisdom and Consumer Trends: Glucosamine and chondroitin markets are victims of some big negative studies, but these items are still at the top of consumers’ minds when it comes to joint health. One aspect of glucosamine and chondroitin science that is not hotly debated is an excellent safety profile held by both. The MSM market is still maturing, but MSM is already found in many combination products with the two longstanding ingredients.

Lutein and Zeaxanthin

Background: Lutein and zeaxanthin are two carotenoids that provide yellow, orange, and red hues to the foods that contain them. Sources include carrots, egg yolk, and leafy greens (where those colors are covered up by the green of chlorophyll). In the body, lutein and zeaxanthin are found in especially high amounts in the retina, where they can reduce the amount of the sun’s blue light that enters and damages the eyes. Lutein and zeaxanthin occur together in nature.

History of Use: Lutein/zeaxanthin dietary supplements are commercially sourced from marigold flowers. They are reported to have been used safely in dietary supplements since the 1990s. FloraGLO lutein became the first lutein ingredient to receive GRAS status for use in certain foods back in 2001; since then, other companies have achieved GRAS status for their own lutein ingredients. Lutein is found naturally with amounts of zeaxanthin. The pair can also be used as natural colorants.

Research: Today there is a strong hope that lutein and zeaxanthin may reduce the risk of the world’s leading cause of blindness: age-related macular degeneration (AMD). Critics argue that results have not always favored lutein and zeaxanthin for a benefit here, but supporting studies continue to crop up. A meta-review published this September in the British Journal of Nutrition concluded that lutein and zeaxanthin intake, while not apparently linked to risk reduction in early AMD, do significantly reduce the risk of late-stage AMD. Another study published weeks later in the same journal pooled dietary intake levels of the nutrients in 1689 Finnish subjects. Compared to those in the lowest tertile of consumption, subjects in the highest tertile of lutein and zeaxanthin consumption saw over 40% reduced risk of nuclear cataract with either nutrient.  Incidence of cataract as it relates to this pair of carotenoids is also highly researched.

Conventional Wisdom:  One phrase has captivated the story of lutein and zeaxanthin for the last several years: AREDS 2. The Age-Related Eye Disease Study II (AREDS 2) is an NIH-funded multicenter study that could be a sink-or-swim story for these carotenoids. More than 4000 elderly subjects with AMD are participating in the study, which will assign patients to daily placebo, lutein-zeaxanthin, omega-3 DHA and EPA, or all nutrients, for five to six years. Initiated in 2008, the trial is still underway.

Consumer Trends: Lutein and zeaxanthin are found in many multivitamins. Standalone lutein/zeaxanthin products are growing in number.


Background: Coenzyme Q10 (CoQ10) is an antioxidant-like compound critical to ATP synthesis. It can be obtained through the diet from meat, fish, poultry, fruit, and vegetables, yet only in levels considered too low to have significant clinical effect. And so humans rely primarily on their body’s natural production of CoQ10.

History of Use: CoQ10 has been available as a supplement for many years, and this lipid-soluble compound is even appearing in foods and beverages. Common sources of CoQ10 come in the form of ubiquinone, but in 2006, Kaneka (Osaka, Japan) introduced a reduced-form of CoQ10 known as ubiquinol and now available for supplement, food, and beverage use. Ubiquinone must first turn into ubiquinol to work within the body; therefore, ubiquinol ingredients are seen as more immediately available CoQ10 sources.

Research: Research has demonstrated, first and foremost, the notion that we need CoQ10 to ward off chronic muscle pain, maintain energy, and keep our mitochondria in overall good shape. Studies have demonstrated CoQ10’s potential for supporting heart health through maintaining healthy cholesterol levels (often by lowering levels of oxidized LDL), regulating blood pressure, and even reducing risk of cardiac arrest in population studies. Research also supports the ingredient for periodontal health.

Consumer Trends: Dietary supplements remain the classic delivery system for CoQ10, but increasing GRAS status from CoQ10 suppliers is bringing CoQ10 to functional foods and beverages. Links to energy and muscle maintenance has CoQ10 receiving significant attention from elderly consumers and athletes.

Conventional Wisdom: Saving the most convincing research for last, CoQ10 is arguably best recognized as a nutrient we risk losing. Numerous trials suggest that CoQ10 stores deplete with age, with statin use, and in cases of chronic inflammation and muscle pain.

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