Abraham Verghese
None-A-Day
Why your bottles of supplements and vitamins are a prescription for trouble.
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I keep long hours, and so what little TV I am aware of is the very-late-night stuff. There are so many people willing to sell you their patented get-rich schemes, which almost always involve real estate foreclosures and the like. Why share this secret at the incredible price of $49.99 (that’s three installments, of course) if it is such a moneymaker? You don’t see Bill Gates handing out Microsoft code. Surely it must be easier to get rich selling you the “system” to get rich than to go out and do it yourself. I will share with you a system not sold on TV. (I am dispensing it free—“shareware” if you like—but if you want to send me a check, that will be fine.) First, take out a full-page ad in your hometown paper. Make it dense with text, graphs, before-and-after pictures. Focus on words like “breakthrough,” “scientifically proven,” “all natural,” “secret,” and claim your product comes from sea coral, Asian herbs, or African forest vines. Choose a disorder for which medical science has no easy fix (hair loss, obesity, fatigue, chronic joint pain) or an attribute everyone wishes to have (more energy, better memory, younger-looking skin, admirable erections). Paste in testimonials from eminent doctors (the only thing you need to do is use the words “eminent doctor” before their name, and if their degree is in anthropology or English literature, that’s no problem); include excerpts from premier scientific “journals” (the simplest thing is to create your own), but don’t claim to cure, prevent, or diagnose; and leave an address for the readers to send a check. Scoff all you want at my scheme; the fact is that the persons behind each of those products are laughing all the way to the bank, while dispensing something that, if you are lucky, is no worse than cow poop.
Why would Congress hamstring the FDA and jeopardize your health and mine? Why, you ask, did Congress pass the Dietary Supplement Health and Education Act in 1994? Take a guess. For the greater good? Or because the supplement industry put on a huge and misleading campaign that scared us into thinking our access to vitamins and minerals was going to be taken away? Powerful senators and congressmen supported it, and the law passed. But the danger has become quite clear since 1994: The only way we are learning about toxic and undesirable effects is through poison centers and emergency rooms, if we learn about them at all, and it takes time for that information to be collected, connected, filtered, and for someone to say, “Wait a minute. Compound X is killing people!”
My friend Don Marcus, a distinguished rheumatologist and scientist who is a professor at Baylor College of Medicine, has a particular interest in this topic, perhaps because patients with chronic rheumatologic disorders are most at risk. He writes in the journal Obstetrics and Gynecology, “The consequences of this regulatory problem are illustrated by the damage caused by herbal weight loss preparations that contained ephedra and caffeine. It is estimated that 18,000 serious, adverse events and many deaths occurred before a ban on ephedra in herbal medicines went into effect in April 2004.” The fact that an herbal medicine has been around for a long time is no reassurance. We recently learned of hepatitis and liver failure caused by traditional herbals such as kava and comfrey and about renal failure caused by African folk medicines. Why only now? Don writes, “Many herbal medicines used for centuries, including species of birthwort used in obstetrics, contain aristolochic acids. … The toxicity of herbs that contain aristolochic acids was identified because of a cluster of over 104 cases of renal failure caused by an herbal weight loss preparation. Sporadic cases, which were identified subsequently, were not recognized in the past because of the latent period of months to years between ingestion of the herbal and development of renal failure or cancer.”
I have tended to not debate my patients over their supplements. As an infectious-diseases physician during the AIDS epidemic, I took care of large numbers of patients with HIV in Boston, then Tennessee, then Iowa, and then, for sixteen years, in Texas. In those earlier days, when we had so little to reverse the course of the disease, patients in droves tried this or that. Every week something new popped up—chelation, cat’s claw, mushrooms, various herbal teas. I said little. Why take away hope when I had so little to offer? I intervened once when poor parents who had already mortgaged their house to do chelation therapy for their son were selling their business to get “live cell” therapy in Mexico, when their son was at death’s door. I talked them out of it, and he died.
But of late, I do have this discussion with all my patients, because if I am to care for them, I have some obligation to protect them from a threat that keeps mounting. I ask them to bring in a list of everything they consume. (It’s amazing how often these herbals and supplements are not considered medicines.) I recommend a multivitamin a day, though even that might be excessive. With the water-soluble vitamins, at worst they get peed out. But certain vitamins, such as A, D, E, and K, are stored in our fat and stay around for a very long time; vitamin A in particular can cause liver damage. Some credible studies on vitamins and the prevention of cancer (vitamin E for lung cancer, for example) failed to show efficacy. Don’t get me wrong: Vitamins work great if you have scurvy or beriberi or night blindness or one of the many discrete conditions that represent true vitamin deficiencies. But unless you are pregnant or have had weight-loss surgery or have some other medical condition, you get your “essential” requirements without much effort.
I see if my patients and I can agree to set aside the words “dietary supplements” or “herbals” and look at everything they take as a drug. The word “herbal” is particularly misleading, as it implies being gentle and safe. Digitalis, atropine, and many chemotherapeutic drugs and poisons are also herbal. I see if we can agree that the active ingredients of “herbal” or “natural” medicines are still chemicals. The trouble is that an herbal supplement can contain hundreds of active chemicals, and the chances of interactions with other things you consume are high. A California Department of Health Services study in 1998 showed that a third of Asian patent medicines contained undisclosed drugs or heavy metals. Here is what else has been found in so-called herbal medicines: analgesics, diuretics, corticosteroids, alprazolam, fenfluramine, colchicine, caffeine. The most famous, or infamous, is PC-SPES, which was said to help prevent prostate cancer. It turned out that this pill contained female hormones, a blood thinner, and an anti-inflammatory medicine.
The Internet is a double-edged sword when used as the sole source of information, particularly because one is often being directed to a manufacturer’s home page, or else the information at a reputable Web site is taken directly from the manufacturer. One study found that 81 percent of retail sites made illegal health claims, and 52 percent omitted the required FDA disclaimer. But I am neither proscriptive nor prescriptive. My job is to help the patient negotiate this minefield. I tell him hope is great and so is faith, but let’s be sure to put our hope and faith in things that we know work or, at the very least, things we know don’t hurt us. The state and the feds need to step back in before we have another ephedra situation. Meanwhile, as your physician, I’ll do my best to protect you. No bull.
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