COMMENTARY

Three Myths About Dietary Supplements … and How Knowing the Right Answers Is Good for Your Integrative Medicine Practice Loren Israelsen; Frank Lampe

Abstract The use of safe and beneficial dietary supplements remains an important part of your patients’ healthy lifestyle—and supplements are likely an important part of your integrative medicine practice. Although issues surrounding potency, ingredient identification, adulteration, and the enforcement of existing laws are legitimate concerns for medical professionals and consumers, the responsible industry is actively working to raise quality standards for its products through a number of self-regulatory measures. These include education about and adoption of additional quality assurance initiatives, such as GMPs for botanical ingredients; better supply-chain management; adoption

Loren Israelsen is president, and Frank Lampe is vice president, of Communications & Industry Relations for the United Natural Products Alliance (UNPA), an international trade association representing many leading natural products, dietary supplement, functional food, scientific and technology, and related service companies that share a commitment to provide consumers with natural health products of superior quality, benefit, and reliability. For more information, visit http://www.unpa.com.

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ietary supplements have been in the news a lot for the last couple of years, and for the most part, the news has not been positive. Accusations of fraudulent and unsafe products and repeated cries that the industry is unregulated, promulgated by a number of mostly reputable media and scientific sources, permeate the headlines. Yet the industry, valued at $37 billion in 2015,1 enjoys solid, sustainable growth as more and more consumers continue to take charge of their own health and well-being, aided by an expanding body of research showing the benefits of a healthy diet, exercise, and proper dietary intake. Questions, based on the perception that the US Food and Drug Administration (FDA), the agency responsible for the regulation of dietary supplements, isn’t doing its job, abound in these negative reports. In response, a number of states’ attorneys general have chosen to pursue enforcement actions of their own 20

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of improved identification and testing methodologies; an industry-wide product registry; the use of accredited third-party certifications and seals; and initiatives to promote widespread membership in the industry’s trade associations, which is a reliable indicator of a company’s support of and adherence to strict quality guidelines. Also, industry support of appropriate enforcement actions against problem players and products from the US Food and Drug Administration (FDA), the Federal Trade Commission (FTC), and states’ attorneys general continues in an effort to rid the market of unsafe and mislabeled products.

against the industry. In February of 2015, the New York attorney general, Eric Schneiderman, opened a scientifically incompetent investigation against 8 botanical products sold at 4 leading retailers,2 claiming that the products, most of which were extracts of botanicals, didn’t contain what was on the label and were adulterated with a number of other substances, including substances known to cause allergic reactions. Schneiderman’s methodology of choice was DNA barcode testing, part of a suite of emerging DNA technologies that is revolutionizing all areas of species identification, including anthropology, genealogy, forensics, medicine, and law enforcement. It is not inconceivable to imagine that in the not-too-distant future, all plant and animal life on Earth will be sampled and catalogued, creating an unparalleled database representing the essence of matter. But as with many emerging technologies, the viability of its application, in this case for botanical extracts and finished dietary supplement products, is a work in progress. Schneiderman’s use of DNA barcode testing on botanical extracts exposed its limitations as well as problems with its quantitative— and not qualitative—results. At issue for the use of DNA testing for botanical extracts are a lack of validated reference standards; problems with low quality or fractured DNA (an expected result from the extraction process); the inability to identify plant parts; and potential cross-contamination in the laboratory. In Israelsen—Dietary Supplement Myths

March of 2015, four of the industry’s trade associations commissioned a widely distributed white paper3 that discussed “the capabilities and limitations of DNA barcoding for botanical dietary supplement authentication to inform assessments of the applicability and accuracy of DNA test results,” provided guidance on how to perform DNA barcoding properly, and offered a critique of the methodology used by the New York attorney general. Sadly, the flaws inherent in Attorney General Schneiderman’s methodology didn’t seem to concern him, his staff, or a number of mainstream media outlets, specifically the New York Times,4 which led a credibility assault on the dietary supplement industry. But once the 24-hour news cycle had ended, few of these media chose to question the testing methodology or the inaccurate findings of Schneiderman’s “investigation.” The attorney general’s investigation was discredited in articles in Forbes5 and the New Yorker.6 More than a year later, however, there has been no closure for 3 of the 4 retailers implicated and the products implicated remain off the shelves of those stores as the case remains “under investigation.” In light of all of the negative press—much of it unwarranted and inaccurate—American consumers and many patients of integrative medical professionals may be questioning the integrity and safety of the supplement brands they see on store shelves—and on the shelves of medical dispensaries. In response, we present the following 3 myths about dietary supplements and the facts behind those myths, which, we hope, will lead to measured and thoughtful discussions about a highly complex and important topic. Myth 1: Dietary Supplements Are Unregulated Contrary to what consumers are likely to read in mainstream media, dietary supplements are subject to a host of regulations as promulgated by the FDA under the Code of Federal Regulations, Title 21, of the Food, Drug and Cosmetic Act7 and as amended by the passage of the Dietary Supplement Health and Education Act8 (DSHEA) in 1994, which created a new regulatory framework for the safety and labeling of dietary supplements as a category of foods—and not drugs— that are “intended to supplement the diet.” The DSHEA was passed by unanimous consent of US Congress, and for the first time it created a legal definition for dietary supplements as a separate class of products and created the structure that determined how the FDA regulates the industry. This regulatory structure includes: 1. The labeling of dietary supplements. 2. Good manufacturing practices (GMPs). 3. Premarket notification for new dietary ingredients. 4. Control of/approval over structure/function claims. 5. Manufacturing facility and equipment inspection, including specific record-keeping requirements. 6. Enforcement of all of the above, including the issuance of warning letters and injunctions, to Israelsen—Dietary Supplement Myths

remove from the market illegal products and to sanction dietary supplements companies and facilities that are out of compliance with the law. 7. Creation of the Office of Dietary Supplements within the National Institutes of Health. Upon signing the DSHEA into law, President Bill Clinton said: After several years of intense efforts, manufacturers, experts in nutrition, and legislators, acting in a conscientious alliance with consumers at the grassroots level, have moved successfully to bring common sense to the treatment of dietary supplements under regulation and law.

When observers look at a supposed lack of supplement regulation, it’s instructive to note that it took legislation from Congress, at the urging of the dietary supplement industry, to force the FDA to create GMP regulations, more than 10 years after the DSHEA was passed into law. And contrary to most media perceptions, the supplement industry has repeatedly worked to support regulations, as seen by its support for the passage of the Dietary Supplement and Nonprescription Drug Consumer Protection Act9 in 2006 that created the serious adverse event reporting system now in use. In addition, dietary ingredients are further regulated under the Food Safety Modernization Act (FSMA),10 which was signed into law by President Barack Obama in January 2011. A point of criticism about the DSHEA is that it distinguishes between “old” and “new” dietary ingredients. As with many other categories of products, including foods and medical devices, when a new law is passed, consideration has to be made for existing products on the market—also called “grandfathering.” In many cases, a presumption of safety is made based on long history of use and no evidence of adverse events—and this was the case for dietary ingredients sold in the marketplace prior to October 1994. Under the DSHEA, new ingredients are treated differently and do require a premarket safety notification to the FDA. This process is referred to as a New Dietary Ingredient Notification. In this way, both existing market realities and recognition that new dietary ingredients should be treated differently were addressed in the law. The FDA has the power to remove products from the marketplace when it finds them to be unsafe and has done so when needed. In addition, the ingredients contained in most supplements are not patentable, which greatly reduces the economic incentives needed to conduct the premarket testing that all patentable drugs, with their promise of tremendous profits, are required to undergo. Yet this testing has not stemmed the number of deaths each year from prescription drugs, including those from prescription drug overdoses, estimated at 28 000 in 2014 alone, according to a Centers for Disease Control and Prevention study.11 Of course, no new law is perfect, and the DSHEA is no exception. Since its passage 22 years ago, it has held up Integrative Medicine • Vol. 15, No. 3 • June 2016

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remarkably well, with no amendments, yet viable areas of concern have emerged. These issues are currently being addressed by industry, although it’s also accurate to say that the actions by New York Attorney General Schneiderman have been a motivator for some of these changes. Issues of note are as follows: 1. Manufacturer and product registry: Currently, under provisions of the Bioterrorism Act of 2002 and the FSMA, all food companies—including dietary supplement manufacturers and ingredient suppliers— must register with the FDA. Thus, the FDA has the largest and most complete database of companies doing business in this marketplace. But the agency does not share this information, making it difficult for consumers and the media to research companies and products. A supplement label database that is available to consumers, compiled by the National Institutes of Health,12 has partially resolved this issue, but it is voluntary and incomplete. As this article went to press, 4 of the industry trade associations are collaboratively working to either join an existing database or create a new one that would likely require participation as a condition of membership. 2. Third-party certification of GMPs: Although the FDA regularly inspects manufacturing facilities for GMPs, among other requirements, its resources to inspect the majority of facilities in the United States and worldwide is limited. Wide adaption of credible third-party certification, as offered by NSF International, USP, UL, and others, will lead to better quality supplements as well as greater confidence in the products by medical practitioners and consumers. 3. Unlike its provisions for dietary supplements, the DSHEA did not provide for GMPs for botanicals. The FDA could have created subset GMPs but did not, leaving industry botanical ingredients suppliers on their own to create suitable manufacturing practices. In addition, when the FDA finally published Section 111, the GMPs for dietary supplements, it chose to exclude dietary ingredients, because of the objections of the industry. The consequence of these decisions was that the industry faced disconnection between GMPs for finished dietary supplement products and ingredients, creating a “hole” in the regulation of the botanicals and supplement supply chain. However, both of these issues have largely been resolved through the passage of the FSMA, which addresses and mandates stringent “farm-to-shelf ” supply chain controls, documentation, and management for both food and supplement ingredients, including botanicals. An effort begun in 2015 by the industry to create botanical “GMPs,” with a focus on agricultural and harvesting best practices, is ongoing. 22

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Regarding enforcement of the industry, when critics argue that the law does not provide enough oversight of the industry, even the FDA has stated that it has adequate regulatory authority in place for it to properly regulate the dietary supplement industry.13 The FDA’s biggest impediment to more robust enforcement measures has been a lack of resources—and Congress has repeatedly chosen to not increase budgets for the FDA to enforce the DSHEA. But it’s important to note that responsible supplement companies support and encourage robust enforcement measures by the FDA, the Federal Trade Commission (FTC), and the Department of Justice against noncompliant products, including those companies targeted at a joint Department of Justice press conference14 in November 2015. The elevation of the FDA’s Division of Dietary Supplements to an Office15 in December 2015, which industry publicly supported, is indicative that the agency will seek additional resources and is engaged and intent on actively regulating the industry. Myth 2: Dietary Supplements Are Not Safe More than 68% of US adults consume dietary supplements16 to support their health and well-being. With extremely few adverse events as reported by both government and industry data, supplements are actually one of the safer product categories on the market. Notwithstanding, reputable scientific journals have repeated the myth that supplements are broadly unsafe, ostensibly because of a lack of the premarket approval that is required for drugs. As stated earlier, supplements largely derived from foods or that include food use should not be required to adhere to the same strict standards as a drug or pharmaceutical with clear physiological effect that is often a synthetically created chemical and that has no clear history of safe use in the marketplace. As an example of this bias within the scientific community, a peer-reviewed study in the New England Journal of Medicine17 in October 2015, which received plenty of media attention, estimated that 23 000 emergency room (ER) visits, characterized by the study authors as “adverse events” between 2004 and 2013, were the result of issues with dietary supplements. But the article failed to mention that the study included an unknown number of over-the-counter drugs, topical creams, and other confounding factors. Speaking at an educational briefing held in December 2015 that was sponsored by the bipartisan Congressional Dietary Supplement Caucus18 in Washington, DC, Rick Kingston, PharmD, a clinical professor at the University of Minnesota, College of Pharmacy, and an adjunct professor at the National Center for Natural Product Research at the University of Mississippi, noted that the study had many additional shortfalls, including the fact that “not all emergency room visits are created equal in terms of level of severity or seriousness.” Kingston observed that “in Israelsen—Dietary Supplement Myths

almost 90 percent of the heart-related ER visits, the patients were discharged from the ER and sent home.” Kingston pointed out that more than 20% of ER visits cited in the article involved “unsupervised ingestion by children, and although a concern, supplement ingestions by children often require no treatment and result in no adverse effects despite the child being evaluated in an emergency department.” He further noted that among older adults, pill-induced swallowing problems led to more than one-third of the ER visits, which is something that the industry can help evaluate and address. Another 10% of the overall visits were from excessive doses. When looking at total emergency room visits per year, dietary supplements, even at the inflated estimate of 23 000 within a 10-year period, represent 0.017% of all visits. By comparison, pharmaceutical drugs—as prescribed by medical doctors—resulted in 731 000 ER visits per year. Despite a proven safety record and widespread use by consumers, the responsible industry is burdened by repeated claims that a number of the products do not contain the amounts of ingredients listed on the labels (or contain too much of the ingredient) or are adulterated with lesser quality and less expensive ingredients—or worse, that they are adulterated with undeclared active pharmaceutical ingredients (see Myth 3, later in this article). Reports from independent testing firms, such as consumerlab.com, have shown that label claims about potency don’t always reflect what’s in the bottle. The certification programs discussed earlier in this article— and the certification seals from reputable certifiers on the labels of supplement products, help ensure that the products do indeed meet label claims. Until the FDA, which routinely tests supplement products, has the resources to broaden its testing, consumers and medical practitioners are encouraged to purchase products with legitimate certification labels. A second issue is economic adulteration. This occurs when a manufacturer or an ingredient supplier purposefully substitutes a less-expensive ingredient for an active one. This practice is not exclusive to dietary supplements, of course, as it has been going on in commerce for thousands of years and is the source for the well-known phrase caveat emptor, Latin for “buyer beware.” In dietary supplements, such substitutions include inert materials, such as maltodextrin, for example, to bulk up weight, or the use of a different, lower-cost ingredient or even a different species of the listed plant that can pass commonly used identification tests. Examples include the adulteration of ginkgo with rutin/quercetin from buckwheat, coenzyme Q10 with idebenone, and saw palmetto with palm oil.19 The issue is widespread enough that the American Botanical Council (ABC), in partnership with the American Herbal Pharmacopeia (AHP) and the National Center for Natural Products Research (NCNPR) at the University of Mississippi and with wide financial support from industry, has created the ABC-AHP-NCNPR Botanical Adulterant Program,20 to educate stakeholders about the issue. The intention of the program Israelsen—Dietary Supplement Myths

… is to confirm the extent of adulteration in the United States and global markets, determine which official or unofficial analytical methods are currently available to help detect the presence (or absence) of a suspected or known adulterant, and to provide comment and guidance on the relative strengths and/or weaknesses of differing analytical methods.

To date, the program has issued 5 adulteration reports and 3 laboratory guidance documents to help stem the accidental or purposeful adulteration of botanical ingredients. The industry is also in the process of expanding transparency about its ingredients through a number of initiatives designed to improve supply-chain integrity. Some of these initiatives are part of the FSMA discussed elsewhere in this article and include adoption of increased facility inspections; heightened, targeted ingredient testing; and the use of innovative track-and-trace systems that record in real time the source, location, and status of all dietary ingredients. Myth 3: Products With Unapproved Drugs Are Dietary Supplements It must be repeated that the large majority of supplement companies are responsible, follow the law, and produce high-quality products that serve consumer needs. Yet it’s a common misperception that is repeated over and over again in media (as well as by regulators) that products containing undeclared or adulterated active pharmaceutical ingredients (APIs) are dangerous “dietary supplements.” In fact, these products—even though they are labeled as dietary supplements—are legally classified as unapproved new drugs,21 or more commonly, “illegal, tainted products being sold as dietary supplements.”23 The distinction is crucial as these products are the ones most often responsible for negative press as well as serious safety concerns for consumers, because these products are often spiked with APIs that have been withdrawn from the market or that may be present at doses far beyond recommended levels. Weight loss, sports nutrition, and sexual enhancement products are the leading categories where such adulteration is most likely to take place. The old adage, “If it sounds too good to be true, it probably is,” applies here, because “dietary supplements” offering fast or drug-like results are, in fact, most often mislabeled drugs and should be avoided by consumers. The DSHEA was passed prior to the wide use of and could not foresee the widespread sales channel that developed for supplements on the Internet, which created opportunities for an almost anonymous selling environment, making enforcement much more challenging. Nor did the DSHEA see the explosion of overseas ingredient sourcing, particularly from China. Previously, most products were sold via various retail and practitioner channels and by multilevel marketing associates with ingredients sold to the brand holders or contract manufacturers by a relatively small handful of suppliers and importers. With the staggering growth of the industry since 1994, the demand for ingredients has mushroomed as has the supply chain, leading to dishonest Integrative Medicine • Vol. 15, No. 3 • June 2016

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supply sources and creating consumer fraud and deception. Although the task of identifying and removing problem products ultimately falls on the shoulders of an underresourced FDA and the self-regulatory efforts of the industry, the issue of adulterated products has caught the attention of a handful of states’ attorneys general, as mentioned previously. In addition to its support for resources for the FDA, the responsible industry has expanded its outreach to the attorneys general and their staffs in key states in a concerted effort to educate them about the value of quality supplementation as part of a healthy lifestyle and the economic effect of a mature and “clean” industry, inform them about the regulatory provisions already in place at the national level, provide them with information and resources, and help them shift their focus toward noncompliant companies and unsafe products. In addition, the industry is working to take action against the deceptive, false, and misleading advertising claims of products by noncompliant companies through 2 efforts: a joint effort created by the Council for Responsible Nutrition Foundation and the National Advertising Division23 and a separate effort sponsored by the Natural Products Foundation’s “Truth in Advertising” program,24 which in 2013, reviewed 275 advertising cases and mailed 150 warning letters to companies responsible for marketing dietary supplements with illegal drug and disease claims. Conclusion The use of safe and beneficial dietary supplements remains an important part of your patients’ healthy lifestyle—and supplements are likely an important part of your integrative medicine practice. Although issues surrounding potency, ingredient identification, adulteration, and the enforcement of existing laws are legitimate concerns for medical professionals and consumers, the responsible industry is actively working to raise quality standards for its products through a number of self-regulatory measures. These include education about and adoption of additional quality assurance initiatives, such as GMPs for botanical ingredients; better supply-chain management; adoption of improved identification and testing methodologies; an industry-wide product registry; the use of accredited thirdparty certifications and seals; and initiatives to promote widespread membership in the industry’s trade associations, which is a reliable indicator of a company’s support of and adherence to strict quality guidelines. Also, industry support of appropriate enforcement actions against problem players and products from the FDA, the FTC, and states’ attorneys general continues in an effort to rid the market of unsafe and mislabeled products. References

1. Bradley J. NBJ: ‘The US supplement industry is $37 billion, not $12 billion.’ Nutraingredients USA Web site. http://www.nutraingredients-usa.com/ Markets/NBJ-The-US-supplement-industry-is-37-billion-not-12-billion. Published June 1, 2015. Accessed June 7, 2016.

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2. New York State Office of the Attorney General. A.G. Schneiderman asks major retailers to halt sales of certain herbal supplements as DNA tests fail to detect plant materials listed on majority of products tested. http://www.ag.ny.gov/ press-release/ag-schneiderman-asks-major-retailers-halt-sales-certain-herbalsupplements-dna-tests.Published February 3, 2015. Accessed June 8, 2016. 3. Harbaugh D, Mishler B, Neal-Kababick J, Brown P. The capabilities and limitations of dna barcoding of botanical dietary supplements. United Natural Product Alliance Web site. https://unpa.com/assets/news_resource/ asset/76/The_Capabilities_and_Limitations_of_DNA_Testing_FINAL_310-2015.pdf. Published March 2015. Accessed June 8, 2016. 4. O’Connor A. New York attorney general targets supplements at major retailers. New York Times Web site. http://well.blogs.nytimes.com/2015/02/03/new-yorkattorney-general-targets-supplements-at-major-retailers/?hp&action=click&pgt ype=Homepage&module=a-lede-package-region®ion=top-news&WT. nav=top-news&_r=1. Published February 3, 2015. Accessed June 8, 2016. 5. Morrell A. Did The NY AG flub its testing in herbal supplement smackdown? Forbes Web site. http://www.forbes.com/sites/alexmorrell/2015/03/14/didthe-ny-ag-flub-its-testing-in-herbal-supplement-smackdown/. Published March 14, 2015. Accessed June 8, 2016. 6. Twilley N. How not to test a dietary supplement. New Yorker Web site. http:// www.newyorker.com/tech/elements/dna-barcoding-new-york-dietarysupplement. Published February 10, 2015. Accessed June 8, 2016. 7. US Food and Drug Administration. CFR – Code of Federal Regulations Title 21.http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/cfrsearch. cfm?cfrpart=111. Updated August 21, 2015. Accessed June 8, 2016. 8. National Institutes of Health. Dietary Supplement Health and Education Act of 1994. https://ods.od.nih.gov/About/DSHEA_Wording.aspx. Published October 25, 1994. Accessed June 8, 2016. 9. US Food and Drug Administration. Dietary Supplement and Nonprescription Drug Consumer Protection Act. http://www.fda.gov/RegulatoryInformation/ Legislation/SignificantAmendmentstotheFDCAct/ucm148035.htm. Published December 22, 2006. Accessed June 8, 2016. 10. US Food and Drug Administration. FDA Food Safety Modernization Act. http://www.fda.gov/Food/GuidanceRegulation/FSMA/. Updated February 25, 2016. Accessed June 8, 2016. 11. Centers for Disease Control and Prevention. Injury prevention & control: Opioid overdose. http://www.cdc.gov/drugoverdose/data/. Updated March 14, 2016. Accessed June 8, 2016. 12. National Institutes of Health. National Institutes of Health Office of Dietary Supplements dietary supplement label database. http://www.dsld.nlm.nih. gov/dsld/. Updated December 2015. Accessed June 8, 2016. 13. US Food and Drug Administration. The regulation of dietary supplements: A review of consumer safeguards. http://www.fda.gov/newsevents/testimony/ ucm112576.htm. Updated July 22, 2009. Accessed June 8, 2016. 14. US Department of Justice. Justice Department and federal partners announce enforcement actions of dietary supplement cases. https://www.justice.gov/opa/ pr/justice-department-and-federal-partners-announce-enforcement-actionsdietary-supplement-cases. Updated January 22, 2016. Accessed June 8, 2016. 15. US Food and Drug Administration. FDA creates the Office of Dietary Supplement Programs and announces new nutrition office leadership. http:// www.fda.gov/Food/NewsEvents/ConstituentUpdates/ucm478303.htm Published December 21, 2015. Accessed June 8, 2016. 16. Council for Responsible Nutrition. The CRN consumer survey on dietary supplements: 2014. http://www.crnusa.org/CRNconsumersurvey/2014/. Published October 30, 2014. Accessed June 8, 2016. 17. Geller A, Shehab N, Weidle N, et al. Emergency department visits for adverse events related to dietary supplements. N Engl J Med. 2015; 373(16):1531-1540. 18. Council for Responsible Nutrition. Product safety expert debunks research questioning the safety of dietary supplements at congressional briefing. http:// www.crnusa.org/CRNPR15-DSC-ProductSafety121115.html. Published December 11, 2015. Accessed June 8, 2016. 19. Obermeyer W. economically motivated adulteration in the dietary supplement marketplace (PowerPoint). US Food and Drug Administration Web site. www. fda.gov/downloads/newsevents/meetingsconferencesworkshops/ucm163645. ppt. Published June 1, 2009. Accessed June 8, 2016. 20. American Botanical Council. The ABC-AHP-NCNPR Botanical Adulterant Program. http://cms.herbalgram.org/BAP/index.html?ts=1459182280&signa ture=4201a716a30689d1246c5f684d1be80b. Accessed June 8, 2016. 21. Hamburg M. Letter to manufacturers of dietary supplements. US Food and Drug Administration Web site. http://www.fda.gov/downloads/Drugs/ResourcesForYou/ Consumers/BuyingUsingMedicineSafely/MedicationHealthFraud/UCM236985. pdf. Published December 15, 2010. Acccessed June 8, 2016. 22. American Herbal Products Association. FDA enforces against tainted products masquerading as supplements. KeepSupplementsClean Web site. http://www. keepsupplementsclean.org/. Published 2011. Accessed June 8, 2016. 23. Council for Responsible Nutrition. Industry self-regulation program. http:// www.crnusa.org/NAD/. Published 2006. Accessed June 8, 2016. 24. Natural Products Foundation. Truth in advertising expands education outreach. http://www.naturalproductsfoundation.org/index.php?src=news&srctype=detail& category=News&refno=75. Published December 11, 2013. Accessed June 8, 2016.

Israelsen—Dietary Supplement Myths

Three Myths About Dietary Supplements … and How Knowing the Right Answers Is Good for Your Integrative Medicine Practice.

The use of safe and beneficial dietary supplements remains an important part of your patients' healthy lifestyle-and supplements are likely an importa...
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