Monday, January 21, 2013

The Practice of Dietary Supplementation

      There is much truth in Hippocrates words, “food is thy medicine,” but sometimes, a little dietary supplementation can be of benefit in preventing and treating some medical conditions.  It is also advocated by the Academy of Nutrition and Dietetics that there are times when dietary supplementation can be deemed beneficial in patient care.  Recently, the DPG group Dietitians in Integrative and Functional Medicine held a webinar entitled, “The Science, Art and Practice of Dietary Supplementation.”   The speaker during the event, Ms. Mary Beth Augustine, RD, CDN is a  Senior Integrative Nutritionist with Beth Israel Hospital in New York.  She shared her knowledge and expertise in choosing supplements wisely and appropriately to help enhance patient care.    Of utmost importance it is necessary to seek dietary supplements that are safe and reliable. 
     The FDA defines a dietary supplement as any product that is taken by mouth and contains a dietary ingredient that supplements the diet.  The dietary ingredient can be a vitamin, mineral, herb, amino acid, metabolite or enzyme.   The world of dietary supplements is not strongly regulated by the FDA which can pose problems for consumers.   Luckily, there are resources and techniques that can be used to locate the best quality dietary supplements available for your patient.   Additionally, some companies voluntarily partake in the FDA regulatory auditing system called Current Good Manufacturing Practices (cGMP) where their products are subjected to testing for quality, identity, strength and purity.  It should be noted on the dietary supplements label that it undergoes such testing.  If the vendor does not provide such testing for it’s products, you may present them with a sample audit form that they may fill out to your qualifications.  Integrative Medicine-A Clinicians Journal or ICMJ pieced together such a form that can be used for this purpose. It is also beneficial to obtain proof of evidence for product, raw material and stability testing of the supplement.  Another venue to investigate is which analyzes these substances in their laboratory and reports their findings on their website.
     Ethical considerations are especially important in deciding whether to recommend a supplement or not.   Would the supplement cause more harm than good? With the high costs of supplements, is it justifiable to recommend such a product to your patient? Of course, it would be prudent to review evidence based medicine information on dietary supplements you are considering recommending.  The Natural Medicine comprehensive internet database provides a wealth of information on different herbs/botanicals from uses to safety considerations.  They also provide knowledge on the scientific evidence supporting or disputing the uses of the herb for medicinal purposes.   Ms. Mary Beth Augustine did encourage attendees to not solely rely on the western scientific analytical method of deciding whether a supplement would be appropriate or not.  She notes that, “practice based wisdom,” is also an essential tool in the decision making process.   Also, the patient should be actively involved in deciding on supplement usage.  As the speaker noted, there is a paradigm shift in the way health care practitioners are relating to their patients.  Patients’ are becoming more involved in the decision making process.  Therefore, it is suggested Dietitians review the research and discuss findings with their clients and allow their clients to make the final decisions on what to take or not to take. 
     In educating patients on the different dietary supplements that may be useful for their medical condition, it is always important to stress that there is always an assumption of risk no matter how safe the dietary supplement appears to be.   For instance, it was previously thought that St. John’s Wort was very safe to take but it has recently been found to interact with protease inhibitor drugs.   It is also necessary to provide start and stop dates.  An example given during the webinar was a patient who had been taking vitamin B6 supplements for years and developed neuropathy leaving practitioners to question whether it was excess vitamin B6 or diabetes that resulted in the patient’s condition.  It is advisable to start with the lowest effective dose for a supplement and increase as tolerated/needed.  And when documenting dietary supplement usages, do not use words like treat or diagnose such language is intended for physicians only.  Structure and function claims are better suited for documentation of these medicinal products by Dietitians.  For instance, “feverfew _______(optimizes, enhances, supports, aids, maximizes)  treatment of migraine headaches.”
     Overall, dietary supplementation can be a useful addition in a patient’s medical treatment plan.  Diet changes should always be the first step in the process and dietary supplements can be added as deemed appropriate.  It is essential that safety, purity and integrity of the product be confirmed and specific brand names associated with these supplements should be provided to clients.  It is also the Dietitians responsibility to adequately educate the patient on the risks involved with the supplement and document appropriately.