How Do Physicians Define Dietary Supplement Quality?

The rising use of dietary supplements and botanical medicines in clinics throughout the nation begs some important questions: How do medical practitioners define quality? What criteria do they consider when evaluating products to recommend to their patients? Are supplement companies adequately meeting the needs and preferences of the clinical community?

Holistic Primary Care’s 2018 practitioner survey gave us some insight into these issues.

The survey fielded last Winter, and generated responses from 469 practitioners, 33% of whom are conventionally trained MDs. Nearly two thirds (61%) dispense supplements in their practices, and 94% of those who do not dispense do recommend at least some supplements to patients. The 36-item survey included the following question:

In evaluating whether to introduce a new product or brand to your patients, how important are the following factors?

For each of 9 multiple choice answers, respondents could indicate whether that factor was “Decisive,” “Important but not decisive” or “Of minor importance.”

HPC Survey Decisive Supps Factors

The pattern of concerns was fairly consistent across practitioner subtypes, though there were a few interesting age differences.

Younger practitioners (age 30-40 yo) were surprisingly less likely (40% vs 61%). to cite GMO-free concerns than older ones (51-60 yo). They were also somewhat less likely to be concerned about Artificial Sweeteners (60% vs 77%). However younger respondents were more likely to be concerned about Dosage & Frequency issues (40% vs 25%) and Pricing (30% v 16%) than their older colleagues.

What Doctors Want

Robert SilvermanWhen assessing supplements, clinicians want a balance of solid science plus practical “Monday morning” applicability, says Robert Silverman, DC, director of the Westchester Integrative Health Center, and a popular lecturer on nutrition and functional medicine.

Dr. Silverman recently took an informal survey of some of his practitioner colleagues to find out what they look for in supplements, and what their unmet needs might be. Among the responses were:

  • Easy-to-swallow liquid formulas, especially for elderly patients and those experiencing “pill fatigue.”
  • Expanded sports support lines, especially for overzealous middle-aged marathoners and non-athletes who are just starting to exercise.
  • Gluten-free, Dairy-free, GMO-free products.
  • Compelling visual tools for patient education. Videos and easy-to-understand graphics can help patients understand what to take, and how to take it. This increases adherence and improves outcomes.
  • Fewer tablets or capsules, and intelligently designed formulas: Patient adherence is inversely proportional to complexity of a supplement regimen. Simpler is always better.
  • •Short format implementation protocols and online practitioner-education. Time is of the essence in any practice; clinicians want streamlined strategies. “We need algorithms. We need guidance,” said Dr. Silverman. And for different types of patients. “A woman who weighs 100 pounds is different from a man who weighs 270. Should each of them take the amount recommended on the label?”
  • •Social media and practice development support. Many functional medicine practitioners struggle to manage the various aspects of a non-insurance practice. Nutraceutical companies that help with that become valuable allies.

Dr. Silverman finds that practitioners’ needs regarding supplements vary depending on how deeply engaged they are in functional/holistic medicine. All say they want “science,” but they want it for different reasons.

Clinicians just learning about functional medicine generally want a few basic formulas to help resolve common chronic conditions they’re seeing every day. They need to develop confidence in functional medicine as a mode of practice, and in supplements as clinical tools. “They’re on the edge of the water, thinking about plunging in. They need to know what to use, how to use it, and who has good science.” But they don’t necessarily want an exhaustive treatise on liver detox or the most cutting-edge microbiome data; they want enough science to feel assured they are on the right path.

Then, there are practitioners who are partially engaged, who perhaps have “hybrid” practices where they still provide conventional allopathic care, but they are focusing more and more on nutrition and lifestyle. They are looking for more elaborate formulas and protocols for managing tough complex conditions. They may also gravitate toward brands that provide help with practice development.

And then, there are clinicians who are full-time, experienced functional or holistic practitioners. For them, supplements and herbs are not garnishes, but the therapeutic main course. They’re typically early-adopters who want the latest, most innovative formulas, and who like diving deeply into the data.

Quality Beyond the Products

For Jill Carnahan, MD, founder of Flatiron Functional Medicine, a thriving holistic practice in Lewisville, CO, the definition of “quality” goes far beyond a company’s commitment to analytical testing and clean products. Top companies—the ones she prefers—are fastidious about everything from packaging to customer service.

For her, supplements are not only vital clinical tools, they also represent upwards of 40% of her clinic’s total revenue. This cash stream makes possible the long, unrushed, in-depth office visits requiredJill CarnahanJill Carnahan, MD for the practice of functional medicine.

Features she looks for include:

  • Speedy fulfillment: “Fast, efficient, trouble-free ordering and shipping is key.”
  • Solid, yet eco-conscious packaging: “Sometimes we’ve gotten products that come damaged due to poor or inappropriate packaging. But eco-friendly packaging is also very important. We try to recycle as much as possible, and prefer companies that use recyclable materials.
  • Clear and detailed invoicing that includes specific product names, sizes, wholesale cost and recommended retail pricing.
  • Online ordering & autoshipping: “We buy from over 40 different companies, and carry over 600 SKUs (stock-keeping units). You can imagine my office manager going crazy trying to figure out how to order from whom. We like companies that make it easy for us.”
  • Reasonable minimums: Some companies require practitioners to purchase several dozen bottles at a time, which can be a deterrent for Carnahan. “If we have to order a minimum of 36 bottles, we may not try a new product because it will be a big waste if we don’t sell it.”
  • Professional and courteous customer service: High quality companies should have phone lines answered by real people well-trained in customer care and knowledgeable about the company. She tries to avoid brands that only provide a general “customer service” email as the only contact.

Product Innnovation

Carnahan’s patients typically have complex autoimmune disorders, environmental toxicities or both. She’s always looking for innovative companies that go beyond obvious product offerings and develop new products that meet their unmet needs.

One such issue is metabolic endotoxemia, caused by bacterial lipopolysaccharides (LPS) that cross a leaky gut mucosa into the blood. A number of nutraceuticals-- Quercetin, Curcumin, Sulphrophane, Resveratrol, EPA/DHA, Bifidobacteria and spore forming probiotics—can be helpful, but so far, no one has developed an easy-to-implement combination.

“If someone could put together a formulation bringing together these ingredients at the right dose levels to give the anti-LPS effect in the studies, it would solve a very big and very common problem.”

Dr. Carnahan said she would like to see further innovation in:

Detox Support Specific for Molds & Environmental Toxins: “I deal with a lot of mold and environmental toxicty. There are not a lot of good detox products for these patients. I don’t see a lot of cutting-edge innovation on the detox spectrum coming from big brands in the practitioner space. But it is a huge need.”

Sleep: Carnahan says many people with sleep problems try one type of product for a while, but then it stops working, so they go on to another, and eventually get frustrated. There’s room in the market for new and innovative sleep solutions.

Chronic pain: There’s a glaring need for good, clean, non-toxic natural products that can help attenuate chronic pain syndromes.

Keto /Low Carb Foods: “Keto” and low carb diets are very hot right now, and people are looking for easy, on-the-go meal replacements that taste good, provide lasting energy, and enable them to adhere to their regimens.

“I don’t prefer these to real food, but busy people really like them,” Carnahan says, adding that there’s room for innovation in that segment.

What Patients Want

Dr. Carnahan and her office staff routinely check in with patients about unmet needs. It’s part of the culture at Flatiron, one that demonstrates care and commitment. It also yields important insights.

Among her patients’ priorities are:

Larger sized bottles: “For many products, the standard size bottle is barely enough to get them through one month. This is especially true with antimicrobial herbal products like Allimed, Candibactin, or Candicidal, because they’re usually using 2 or 3 bottles per month on higher-dose protocols. Larger bottles would be very helpful.”

Auto-ship and re-purchase programs: “Patients want reminders. Amazon really has that down, with their Prime Pantry reminder system.” A model like that for top quality practitioner-recommended supplements would be a help, she says.

Samples: They’re extremely helpful especially for pain and sleep-focused products. Patients can find out within one or two doses whether a particular formula will work for them, before investing in a full bottle. Brands that provide samples are doing their practitioners—and the patients—a great service.

Untangling the Tangles

For Madiha Saeed, MD, a holistic family physician in Naperville, IL, and author of the popular book, The Holistic Rx, helping patients “untangle the tangle” around supplements is a constant challenge. In so many ways, supplements are important tools to help them “in their quest to take back the reins of their own health.” But too often people end up lost in,“a long and exhausting maze of aisles and aisles of supplements filled with promises and pitfalls.”

Madiha SaeedMadiha Saeed, MDSupplements are something of a conundrum, in her experience. At their best, they can be life-changing. But there are also many questionable products, and a fair amount of uncertainty, even for clinicians who’ve pursued education in nutrition and functional medicine.

She usually counsels her patients to keep it simple. And she values brands that echo the “keep it simple” philosophy.

“A large majority of chronic conditions can be helped with basic supplements like fish oil, magnesium, vitamin D, and probiotics. But as we start to venture outside of these basic supplements, we need to proceed with caution and knowledge to weed out the good from the bad.”

Dr. Saeed tries to steer patients to brands with demonstrated track records for compliance with good manufacturing practices (GMP); that use pharmaceutical grade production facilities and follow strict quality control measures. Whenever possible, she prefers products backed by meaningful clinical studies specific to those exact ingredients.

She tries to avoid products that contain dairy, sugar, soy, grains, additives, synthetic ingredients, colorings, known food allergens, or excessive binders, coatings, flavorings, “or anything that will disrupt the gut microbiome.” Organic ingredients are also a plus.

“I avoid “proprietary blends,” especially if they contain unneeded or questionable ingredients. And if it sounds like a miracle pill, I avoid it completely.”

The best supplements, Saeed says, are the ones that a patient will actually take.

So factors like cost, ease of use, and dosage also figure into her equation for evaluating products.

While supplements are important, and they’re certainly popular with her patients, Dr. Saeed tries to put them into proper perspective.

“Supplements cannot replace a healthy lifestyle. As a general rule, the better and more wholesome a patient’s diet, the fewer supplements he or she may need. Sometimes the art of simplicity is the solution to the puzzle of complexity.”

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