PODCAST: Are Supplements Helpful? Harmful? A Waste of Money?

TODD: Just to start off, let's talk about the landscape generally here. When we first approached you about this, your reaction was, “Hooooooo wee!” Why that reaction?

DR. SEPTIMUS: Well, because I think that this is a really important topic. And I think it's important that reliable sources like Houston Methodist address something that is being addressed — whether we like it or not — in popular social media. And it's a topic that can be harmful in the wrong hands. It's a topic that is leading to literally billions of dollars of expenditures by patients. And it's a place where I feel like people really need — and deserve — accurate information and deserve to know when we don't know the answer.

TODD: So, you also said in that email response, “It's controversial.” Who’s it controversial among? Doctors versus their patients or among doctors?

DR. SEPTIMUS: Yes. To all of that. It's a controversial subject because it is visceral, meaning that people have very emotional responses to the use of supplements. It's also controversial because you have a number of health care practitioners who are profiting on supplements and who are profiting on people who are desperate to find what they call natural answers to things. And, so, you have a country of individuals who are pushing these supplements who have what sound like official titles and, you know, that people trust. And then, on the flip side, you have a real lack of information in the traditional medical community because there is a lot of research on many supplements, and most health care practitioners don't receive the education that they should in medical school about nutrition supplements and other, you know, what used to be termed complementary medicine, now termed — by most people — integrative medicine. And the final thing that I would add is that there's a growing and very prominent community — the functional medicine community — that is very strongly advocating for the use of many supplements. And there are a lot of really positive things about the functional medicine community. There are a lot of people in the allopathic or traditional medical community who just think we need to ignore functional medicine. I disagree with that. I think there are a lot of aspects of functional medicine that we should listen to and pay attention to because they're clearly filling a need in some patients. It's just that the answer to fulfilling that need is not necessarily to throw a bucket of supplements at people.

[Music being to play to signal a brief interjection in the interview]

ZACH: If Dr. Septimus’ use of the term functional medicine didn't ring a bell, don't worry. It didn't for anyone here either. I'm familiar with fringe medicine, alternative medicine, holistic medicine, complementary medicine and integrative medicine. But this was the first I'd ever heard of functional medicine. So, we did some research. It turns out the field, or the name, dates to 1990, when a doctor created the concept to address growing health problems associated with chronic disease. The Institute for Functional Medicine, which oversees training of functional medicine doctors, calls the model, “an individualized, patient centered, science-based approach that empowers patients and practitioners to work together to address the underlying causes of disease and promote optimal wellness.” To us, that sounded a lot like what you hear in holistic and alternative medicine, which is why some critics call functional medicine just rebranding. But one thing that distinguishes functional medicine from alternative medicine is that its practitioners generally come from conventional medicine — some MDs, some osteopaths, some dieticians and nutritionists, behavioral therapists, physician assistants. Houston Methodist has one such doctor. The Cleveland Clinic and George Washington University have whole centers for functional medicine. The Cleveland Clinic became the first such academic one in 2014. Another thing that distinguishes functional medicine from most alternative medicine is that its practitioners don't use exotic therapies, like acupuncture, or homeopathy or crystals. They corporate modalities such as nutrigenomics, which looks at the interaction between nutrients in an individual's genes. Diet is huge and supplements can be part of that, which is why Dr. Septimus mentioned the field. For all that, functional medicine seems just as controversial as other alternative medicines. Its Wikipedia entry is entirely critical. For instance, it describes the field as a form of, “alternative medicine that encompasses a number of unproven and disproven methods and treatments,” and describes the centers at Cleveland Clinic and George Washington as, “unfortunate examples of pseudoscientific quackery infiltrating medical academia.” Though Dr. Septimus mentions some positives about functional medicine, he's also pretty skeptical. When we got back to him to learn more about the field, he noted that he finds offensive the claim that functional medicine restores health by addressing the root cause of disease. Its implication being that doctors like him just treat symptoms. He also says there's little evidence to back up much of what they practice and notes that some things they talk a lot about — leaky gut and adrenal fatigue, for instance — don't even exist as conditions. In any event, it's still a pretty fledgling field. The Institute for Functional Medicine says it's certified more than a thousand practitioners now, including a little more than 100 in Texas and about 25 in the Greater Houston Area. If you're intrigued enough to want to find one, the institute's website has a search function for practitioners in your area.

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TODD: Just Googling the topic, I came across an AMA article that mentioned that there are more than 90,000 supplements out there. Can anyone make sense of all that?

DR. SEPTIMUS: Well, I mean, if you think about the way that the popular media approaches, quote unquote, natural cures, you can imagine that any time anybody can put something into a pill and call it natural, it's going to have some appeal to a certain group of people. And there's a lot of money to be made by doing so. So, you probably have dozens of different magnesium supplements, for example. So, think about the potential for putting different, you know, pharmaceutical products together — because that's what these are, they’re drugs — and make money off of it. And you can see why there would be tens of thousands. I'm surprised it's only 90,000. I would think it would be far more. And the final piece of this is that, a few decades ago, Congress passed a law that exempted the supplement industry from FDA regulation. So, as opposed to an allopathic product like blood pressure medicine [which] has to go through an FDA approval process, the supplement industry is not subject to that. So, any Tom, Dick or Harry can put out a supplement and call it natural as long as they put a stamp on the bottle that says, “This product is not intended to treat, diagnose or cure any medical condition.” If you look at any supplement, that's on every single bottle and that all goes back to that law that Congress passed.

TODD: So, is that a problem that it's not? Is it not that it's not regulated? I mean, is there a solution to that?

DR. SEPTIMUS: In answer to your first question, is it a problem: I think it's an enormous problem. The first thing that we learn in medical school is "primum non nocere,” which means, “first, do no harm.” And when I talk to patients about the FDA approval process — because there's a lot of mistrust out there with the FDA — I say, look, you know, yes, there are some products that need to be pulled from the market. In my, you know, 20-year career, there have been multiple things that have been pulled off the market. But the way we know that they need to be pulled off the market is the monitoring. There's no monitoring of supplements of any degree. And, so, when you have a product on the market that's being marketed heavily and that people are spending billions of dollars on — that has never gone through basic safety testing — that, to me, is a major problem. How do we change it? The only way to change it is for the Congress to change the law again. And I don't see that happening any time soon. So, while we have a situation that's potentially dangerous, there are potential ways to make sure that at least the supplement that you're taking…and I'm not against, by the way, all supplements. There are many — or not many, but there's a handful of — supplements that I do recommend to patients for the right reasons. You have to make sure that they contain whatever the bottle says they do. Seems very basic, but it's actually not the case a lot of times. And B, that they're not contaminated with anything. And, so, what I recommend to patients is that they use third party verification to ensure any supplement that they take has with it what it says it has in it, and that it's not contaminated. And I have several sources that that I give patients to find those safety measures.

TODD: But you think there are probably lots of stuff out there that is contaminated and that is doing harm to people?

DR. SEPTIMUS: I don't think, I know. As far back as, I think, ten years ago, Consumer Reports did a review, for example, of protein powders. You know, you think protein powders, those are not supplements. Actually, they are. You know, it's taking substance and sticking it in a powder and then, you know, marketing it to people. And they found that half of the protein powders that they researched were contaminated with heavy metals. I think we can all agree that you don't want to take heavy metals into your body. So that's just one example you can go to. One of the websites that I recommend people consider is ConsumerLab. ConsumerLab reviews all kinds of different supplements. And you can go to, for example, vitamin D and they'll have reviewed dozens of vitamin D supplements. And you can see which ones passed, meaning — it doesn't mean that the vitamin D helps people — all it means is that it has what it says it has in it and it's not contaminated. And then it'll list all the supplements that flunked, and you'd be shocked at the things that they have found in the supplements. Consumer Reports has done this with other things as well. It's scary, quite frankly.

TODD: So, our listeners could go to the Consumer Reports and find a list of these if they want to.

DR. SEPTIMUS: So, Consumer Reports, you have to be a subscriber, and they've only done a couple of articles on this. The website that regularly reviews in an independent lab is called ConsumerLab. All one word — I don't remember if it's consumerlab.org or consumerlab.com, but they do third party reviews. And then the other good resources: If you see a supplement or a nutraceutical that has a stamp on it that says USP, that's a third-party lab. And most, for example, Nature Made is one brand that most — but not all — of its pills have been third party verified by USP. And there's another stamp that you can see that's NSF. Those are two that if you see that on the bottle, at least, you know, it's been third party verified to have what it says it has in it.

TODD: So, if you get one of those and you take it as recommended — you don't overtake it — can you assume that it's safe?

DR. SEPTIMUS: No. Those only tell you that the bottle is correct — that it has what it says it has. It does not necessarily tell you that a supplement is safe. And this goes back to that law that Congress passed. The first step in the FDA approval process for traditional medications is not “Does it work?” The first step is, “Is it safe?” The phase one clinical trials. And, so, what happens, for example, with nutraceutical and supplements is that something can make, you know, get a USP verification, even if it's not a safe product because it has not been tested for safety. All that USP or NSF or ConsumerLab are looking for is does this have what the bottle says it has without contaminants.

TODD: Is there much research going on into this stuff at this point? It seems like it's hard to do research on stuff that's touted for sort of general healthy aging over the course of time. And B, since these products are already on the market, that there's not a real financial incentive for someone to do them.

DR. SEPTIMUS: Well — and this is the traditional argument from the naturopathic and functional medicine community, is that pharmaceutical companies are not driven to do the research. And, so, they're trying to hide it from you because they don't want you taking natural supplements. They want you taking their drugs. In fact, the NIH and other organizations have spent billions of dollars studying supplements. The one that's probably the best studied is fish oil. For example, fish oil has been exhaustively studied and exhaustively — exhaust…exhaustively — fish has been studied exhaustively. Calcium supplements have been studied extensively. Vitamin E, vitamin A, vitamin D, selenium. There are there many, many, many supplements that have been the subject of major clinical trials. And with almost no exceptions, all of them fail to show a benefit. And, so, it's not true that there's not been any studies. It's just that there have not been a lot of studies that have actually shown a benefit. And that doesn't work in favor of supplement makers. So, they don't want to talk about that.

TODD: I know you said earlier that there's a few that you recommend, but do you generally think that they're a waste of people's money?

DR. SEPTIMUS: Yes. To expound on that, just briefly, fish oils are the greatest example. So, there was a preliminary study in — I believe — the late 80s, called the GISSI heart failure study that showed a reduction in some cardiovascular outcomes in patients who took fish oil. And, so hence, there has been an explosive interest in fish oil supplements, both in the over-the-counter industry. And in the pharmaceutical community there have been two FDA approved fish oil products. Almost without exception — there's one exception to it, but almost without exception — the studies have failed. And in fact, there's a suggestion now, based on all the years of clinical data we have, that if you take high dose omega three fatty acid supplements, which is what's in fish oil, you actually have an increased risk of cardiac arrhythmias. And it's a great example of what happens when you actually look deep into this. There's a lot of theoretical kind of mechanistic explanation. “Oh, here's why zinc helps you when you have the flu.” But then when you actually study it, it doesn't work. And that's the story of the pharmaceutical industry. I think the number is something like one in ten or one in 100 pharmaceutical products actually make it to phase three clinical trials. And the reason is that most stuff that mechanistically should work doesn't in the human body, because the human body is so much more complicated. And, over the course of the last ten years, we've had increasing evidence that omega three fatty acids — fish oils — don't have clinical benefit. And, yet, the spending on fish oil supplements continues to go up. It's a perplexing thing about our human nature that we feel like it's natural, we feel like it should work, and so we don't pay attention to the clinical data showing it doesn't work.

TODD: In your mind, there's consensus on that? I mean, I can Google fish oil and I will see articles by doctors, some with PhDs, talking about all the benefits of fish oil and citing some studies.

DR. SEPTIMUS: So, there have been — here and there — studies showing certain benefits or certain off-target effects. For example, there's some people who say that it helps with dry eyes. There's some people who say it helps with joint pain. But, when you look — en masse — at the clinical data, you know, the gold standard of clinical research is randomized controlled trials, and when you look at the data, it's just staring you in the face again. With a very specific exception of one particular fish oil product called Icosapent ethyl, fish oil supplements have no benefit. And, like I said, it's amazing the spending on fish oil supplements continues to go up and people continue to just refuse to believe the data because they have this practically religious fervor of belief in it. But you have to believe the data. You know, it's not like it's one clinical study. So, people — like what you're referencing — they'll reference the one or the two clinical trials that show what they want it to show, that it's beneficial. But then they don't pay attention to the dozens of other trials that don't show benefit.

[Music begins to play to signal a brief interjection in the interview]

ZACH: Most Americans likely take the easy availability of nutritional supplements for granted. But, in the 1990s, concern about an imminent FDA crackdown caused such fear among advocates that one organization produced a television commercial in which Mel Gibson portrayed a citizen being handcuffed and arrested in his home on charges of possessing a bottle of vitamin C. Of course, when the FDA did issue regulations, it merely barred the labeling of supplements with health claims that hadn't been proved truthful and scientifically valid. But it was clear that the fears about what the agency might do touched a nerve among the then estimated 75 million Americans who took supplements. In the years since the Dietary Supplement Health and Education Act was passed into law in 1994, the industry has exploded. At last count, the National Center for Health Statistics found that over 50% of all adults in America have used a supplement in the past 30 days. The center used data from 2017 and 2018, but more recent polls suggest this figure is closer to over 70%. When did supplement usage start? Probably the mid-twentieth century. Vitamins and minerals came first, the result of researchers synthesizing and isolating vitamins and minerals, which are needed by the body. Doctors started to recommend them to patients and companies beginning to produce multi vitamins around the same time. Protein supplements touted by bodybuilding advocates also became popular in the 1970s. In the 1990s, more people started to turn to herbs and dietary supplements because of the increasing modernization of agriculture and heavy availability of prepackaged food lacking nutrients. The anti-aging movement led by one guru, who takes 100 a day, turned people on to a host of new supplements they hoped would extend their lives. The pandemic made believers of still more people. And, by the way, here's how that 1994 act defines supplements: “A product other than tobacco intended to supplement the diet that bears or contains one or more of the following dietary ingredients: a vitamin, a mineral, an herb or other botanical, an amino acid, a dietary substance for use by man to supplement the diet by increasing the total dietary intake or a concentrate metabolite, constituent extract or combination of any ingredient described.” The bottom line is supplements aren't going away. By 2020, the global nutritional supplement industry was said to be worth over $140 billion, nearly 40 billion of that within the United States by the end of the decade. Some projections call for the market to grow anywhere from 200 to $350 billion.

[Music ends, commercial plays and sound effect signals mid-episode reaction segment with Zach and Todd]

ZACH: It's funny, I do remember that commercial with Mel Gibson, of all people, being arrested for having vitamins. I was a kid, but I just remember — it's such a bizarre thing. It was almost like a Saturday Night Live commercial. So, the absurdity of it all, right?

TODD: Right. Yes. It was very over-the-top, kind of wild, very dramatic. He had the FDA agents forcibly taking him, handcuffing him — and him pleading with them, “It's just vitamin C!”

ZACH: Amazing. You know, to that point, I'm thinking back to my own, you know, vitamin supplement journey, right. And you're a kid, your parents have you take your Flintstones chewable and things like that. And then you get older. I'm like, well, I better just take a multivitamin every day. And sometimes I forget it and sometimes I don't. And, occasionally, I'll try something like a fish oil, like I mentioned earlier. But outside of that, I just really haven't had any trigger points or identified anything like, oh, I really need to start taking this for myself. But — just for the listeners for like a brief flyover — what are the reasons why you take supplements, like the specific things you're taking them for in your own personal life.

TODD: Sure. I take some for heart issues — not that I have any, but my forebears, when they went, they all went by heart-related matters. So, I take things like CoQ10 and niacin, which are touted to have some beneficial effect on the heart. I don't eat dairy products, as I mentioned, so I take supplements that are good for bone health. I take fish oil, some things with anti-inflammatory properties. But just generally things that are touted to help aging.

ZACH: And is it you just kind of get in the habit of like, I'm taking X amount of pills each day and it's just part of your routine.

TODD: Yeah, just before I go to bed at night, I take one of about seven or eight.

ZACH: Okay. So, you're not, like carrying around the pills with you all day. It's more of a nightly ritual. 

TODD: Right, right.

ZACH: Okay, so, yeah, that's something I could maybe see myself doing. I would just be intimidated by, like, the whole, you know, the Monday, Tuesday, Wednesday, Thursday, the seven pills…which time do I take it, that kind of thing.

TODD: Yeah. No, it's just kind of a routine just before I go to bed.

ZACH: Okay.

TODD: I'll take them. By the way, about multivitamins...

ZACH: Yeah.

TODD: That's…I don't want to use the word controversial, but there's not a lot of agreement between doctors. A lot of doctors will say the studies about them show that there's no benefit from them. But you still get a lot of doctors who recommend their patients take them.

ZACH: Interesting. I would think that that would be one of the least controversial things — the standard multivitamin, right?

TODD: Yeah. I think they're viewed by some doctors as just kind of a good insurance policy, in case you're not getting everything you need from your diet. But doctors who are more skeptical say the studies just don't show any benefit from them.

ZACH: To that point, you know, everybody's diet is different, right? You can't…a doctor when he sees you, I mean, yeah, it's like, “Hey, what did you have today or something?” Unless you have a serious, you know, condition where like, hey, you shouldn't be eating X, Y or Z, they really don't know what your everyday thing is. So that security blanket, if you will, of the multivitamin makes sense that the people recommend that they're for filling in the gaps or whatever random dietary deficiencies you might have just because of your habits.

TODD: Right. That's the thinking anyway. And I'm sure not just by doctors, but by people who take them. So, it's a good deal for the multivitamin industry.

[Sound effect signals return to interview]

TODD: Let me speak for supplements, because I take some and would be open to taking others. For instance, my father suffered from BPH, so I see that in my future. If I could find something for that, I would love to take it. I know there are some supplements out there. I'm not taking anything now, but if someone ever said, “Oh that would actually help.” I would be eager to do that. And I think people generally sort of think that this can promote healthy aging, that they can maybe reduce their risk of certain things. Is there something wrong with that thinking?

DR. SEPTIMUS: So, that's the brilliance of the way that supplements have been advertised. And it's the brilliance of the way that certain practitioners have advertised their cash-pay practices. A lot of their practices are anti-aging, and a lot of their practices focus on, again, this idea that there's something, quote unquote natural that you can use. And my argument is not that people should not take supplements. My argument is that we have to have clinical data to support their safety first and then that they work second. So, BPH is actually a really good example. When I was in medical school in the nineties, there was a ton of interest in saw palmetto. We know for sure saw palmetto is safe. Actually, that's one of the supplements that, if you find a third-party verified saw palmetto, is not going to hurt you. It's been studied extensively. But guess what? It's also not going to help, and that's been shown in trial after trial. And yet men spend millions of dollars on saw palmetto every year. And now it's actually evolved. So, you actually will see now the supplements that are, quote, prostate health or men's health. And, you know, so they've broadened out from just saw palmetto and added a bunch of other things into the supplement. But that's a great example, actually. And a lot of people, for example, will take a multivitamin that they look at as an insurance policy. Multivitamins have been studied. They've been shown to not be harmful. So, do I have a problem with people taking multivitamins? No. But I tell them get a third-party verified supplement; make sure that it's both age and gender specific; and recognize that if you eat a balanced, healthy diet and there's nothing wrong with your digestive tract and you're not taking any medicines that prevent you from absorbing nutrients normally, you're probably wasting your money. But, again, it's probably not hurting you either. That's the first bar, for me, that I feel like people have to cross.

TODD: So, that's not one of the ones you recommend.

DR. SEPTIMUS: Which one? Saw palmetto?

TODD: No, multivitamins.

DR. SEPTIMUS: I have a lot of patients in whom I do recommend a multivitamin. So, you know, you probably heard of this class of drugs called proton pump inhibitors. They're one of the most commonly prescribed medications on the planet. They are strong antacid medicines. Well, when you alter the acidity of your stomach, you are not going to absorb nutrients normally. And that is a situation — and I have a lot of patients who are on these drugs from their specialist — so I'll have all of them take a multivitamin, because I look at it as an insurance policy to help them absorb their vitamin B12 and their magnesium and other, you know, micronutrients that, because they have adjusted their digestive tract, they may not. I also have a lot of patients that have had what's called bariatric surgery, the gastric bypass, the gastric sleeve. Those patients absolutely need nutritional support with additional — not just a multivitamin — but sometimes with other vitamins as well. So, there are definite roles for multivitamins and other vitamin and mineral supplements depending on the situation.

TODD: Do your patients ask a lot about supplementation? I mean, is that a big interest to many patients? And, also, do you fear that a lot of your patients are taking them without your knowing it?

DR. SEPTIMUS: Fear is not the right word. We do try really hard to push patients to tell us if they're taking supplements. And what I try to tell people is: Please know there's no judgment here. Even if I disagree with you, it's your body. And, so, you can choose what to put in it. But I have to know what you're putting in your body in order for me to make sure that I'm treating you appropriately. So, we very strongly encourage people to tell us what they're taking and try to create that safe space for that discussion. And I think most of my patients are honest with me about what they're taking. Again, it's not a fear. I don't fear that my patients are taking supplements. I know they're taking supplements.

TODD: But taking them without telling you?

DR. SEPTIMUS: Oftentimes people start themselves on these things and they come in for their wellness exam or they come in for follow up on their, you know, blood pressure and there's a new supplement on there. They usually do not call me or send me a chart message before they start it. I find out about it afterwards.

TODD: Do you ever see people that are taking like 25 of them or so?

DR. SEPTIMUS: Of course. I actually have many patients that see functional and integrative medicine practitioners, and I work with those practitioners. So, I have a lot of patients that are taking a lot of supplements that — even though I may not think that's doing them good — I've worked with these other practitioners to make sure at least what they're taking is safe. And, so, I think we can find common ground there.

TODD: You mentioned you recommend some.

DR. SEPTIMUS: The one that I probably recommend the most is magnesium. Magnesium has some natural muscle stabilizing properties and also is a natural sleep aid. So, I will very commonly use a couple hundred milligrams of magnesium as a first line agent to help people who are having insomnia or who are having muscle aches. There are three well-known types of magnesium available over the counter: magnesium oxide, magnesium glycinate and magnesium citrate. Unfortunately, the most commonly used is magnesium oxide, which you barely even absorb. It mostly just causes diarrhea. But magnesium glycinate, which is a chelating magnesium, is very well absorbed and does not tend to cause the gastrointestinal distress. So, that's the one that I recommend the most. Magnesium citrate is kind of somewhere in between.

TODD: Does it matter if it's tablet, capsule, gel? Do you absorb better...

DR. SEPTIMUS: Most magnesium oxide is tablets. Most magnesium citrate is gel caps. And most magnesium glycinate is a capsule, where the chelating magnesium is in little pellets inside it. So, it just depends on the formulation.

TODD: Don't we absorb from capsules better than tablets?

DR. SEPTIMUS: It depends on the formulation of the drug. It just depends. Magnesium glycinate is the best absorbed of the three. It's also the hardest to find of the three, although it's becoming more and more easy to find. I mentioned multivitamins. I use [them] extensively in patients who are taking certain medicines or have certain medical problems. And, another really good example, it's very common is metformin. Anyone who takes metformin for diabetes or for insulin resistance needs to be on a multivitamin. I will tell you, the supplement that I have the most interest in right now is turmeric. And the reason is that the Indian community has been using turmeric, actual turmeric, as a curative — similar to the way that, you know, for example, the Chinese community uses green tea — for generations. I have Indian medical partners and friends who talk about that, when they were kids, if they were sick, they got yellow milk. Which was, you know, milk with turmeric in it. And it is currently being studied for natural anti-inflammatory properties. And there are even some studies looking at it as an anti-cancer agent because of the reduction in inflammation. It clearly is safe. You know, again, that's always my first bar. And because it has these clear anti-inflammatory properties, I find it as a safe alternative to giving patients what's called NSAIDs, which are a powerful class of medicine to reduce joint pain and that type of thing. And that's — medicines like Aleve and ibuprofen and there are much more powerful versions of that that are prescriptions — so, if I have a choice, again, between something that I know is not harmful and that has clear anti-inflammatory properties and I can give that instead of something like an ibuprofen or Aleve that has some very clear disadvantages, it's not as powerful but I will frequently reach for that in my tool kit.

TODD: For just people with inflammation issues?

DR. SEPTIMUS: People who have joint pains would be the most common thing. Let let's try this. You had someone who comes in and he says, “I'm taking two Aleve twice a day and I have been for five years.” You know, because, “if I don't take that, I can't get out of bed.” And it's starting to irritate their kidneys or they're starting to have liver issues. Well, if I can reduce their dose of their, you know, Aleve by 50% by giving them turmeric, that's a much safer alternative, in my opinion.

TODD: But what I read is that like disease generally is all about inflammation. How about taking turmeric generally? Just as that, it's a good tonic because it's anti-inflammatory.

DR. SEPTIMUS: So, we're getting a little out of evidence-based medicine a little bit into what I call the woo woo. But I don't think that that is unfounded. I am a big believer in the idea that very many things in medicine relate to inflammation, and I think — even more basic than that — it's actually insulin resistance. And, so, I advise people to go on anti-inflammatory diets, which basically means get all the sugar and refined and processed foods out of your diet and, you know, turmeric — again, we don't have any evidence that it's doing anything positive in that situation — but again, we know it's safe. So, do I have a problem with people doing that? No, not at all. And it's one of the only things that I would say that about — is that, you know, if you want to take it for general anti-inflammatory properties, I think we have enough evidence that it's safe.

TODD: If they're going to do it, is it a good idea to kind of cycle in and out of it? That if you take it every day, at some point it's going to lose effectiveness? So, stop for a while and start up again?

DR. SEPTIMUS: I don't think so. If you look at a diet from the Indian subcontinent, it's rich in all kinds of spices that we don't generally have in our Western diet. And they, you know, that population tends to get turmeric on a regular basis for their entire lives, and we don't see any adverse effects from that. And so I see no reason to cycle in and out.

TODD: Yeah, I didn't mean so much adverse effects as you might get more benefit from stopping and starting.

DR. SEPTIMUS: I don't know of any evidence to that effect, but it's not something that I think has probably been studied either.

TODD: Any other supplements that you like or are there any that you have a strong feeling against that are popular?

DR. SEPTIMUS: Sure. I think there are a couple of things that are very important for people to realize. Again, one of them is that this idea that just because something mechanistically might work doesn't mean that it will work. The second is that just because epidemiologically something looks like it's going to work doesn't mean it will. And the reason I preface what I'm saying is that, I mean, I give you a couple of examples of this. So, one was, you know, when I was in medical school, there was epidemiologic data that people who had higher selenium levels had lower risk of prostate cancer. So, at the VA, they did a study and showed that if you supplement veterans with selenium, that it does nothing to reduce your risk of prostate cancer. But — oh, by the way — it has an off-target effect that it increases your risk for diabetes. Calcium supplements are something that, with some very specific exceptions — for example, if someone's had gastric bypass or other nutritional problems — calcium supplements have not been shown to reduce fracture. They have been shown in one study to increase bone density, but they've never been shown to reduce fractures. And they are, in my opinion, definitively associated with an increased risk of coronary calcification. So, I tell patients I would much rather that you avoid the increase in heart disease and find other ways to build bone than take a calcium supplement.

TODD: Taking them with magnesium doesn't help you better absorb it into your bones, if you take it with magnesium?

DR. SEPTIMUS: There's no long-term data to prove or disprove that. But what we know — definitively — is that if you get calcium through food, that it's safe. And, so, my postmenopausal women, I want them to get 1500 milligrams of calcium a day, but I want them to do it with diet. And even if you don't eat dairy, there's plenty of places to get calcium that is nondairy. And, again, you can have some extreme diets that are exceptions to these rules. So, for example, if you're a vegan there, it may be much more difficult for you depending on your constraints to get certain nutritional items. And, so, you may need to take certain supplements. For example, vegans have to take vitamin B12 because they cannot get vitamin B12 if you don't eat any meat products. But calcium…I have a hard time making the case for people taking it with or without magnesium.

TODD: Well, anything else you want to add?

DR. SEPTIMUS: I think that the one clear take-home message is that if you're interested in taking supplements, that it's really important that you discuss it with your physician when you do so. And if your physician's not willing to engage in the discussion and address your concerns, maybe you don't have the right partnership. Just because I disagree with what my patients do, doesn't mean that I won't work with them. No one's going to agree with everything that their patients do. And, so, I think it's really important to recognize that because these supplements are drugs — there's nothing natural about taking a pill that, you know, has something that's quote unquote natural in it. If it was natural, it would be in its natural form, not in a pill. And, so, partner with your physician or your health care provider to make sure that what you're doing is safe. And then one final thing, I'll tell you it. You know, I actually spent a month of medical school in China. And in China, there are, of course, a number of traditional Chinese medicine practitioners, and they have their own pharmacies. And when you go to a traditional Chinese pharmacy, or at least this was in the late nineties, your doctor might prescribe you a tea or a sav and the traditional Chinese pharmacist would actually make you the tea or make you the sav from the, you know, whatever plant the traditional Chinese physician was recommending. And I see that as so different from when you go to Whole Foods and buy a tablet that says it's got resveratrol and green tea extract in it. That's not the same thing. So, even if you are a really strong believer in, you know, traditional Eastern medicine, what a lot of people are calling traditional eastern medicine in the United States is not.

TODD: I think that's all I have. I've enjoyed this chat. It's been very enlightening for me.

DR. SEPTIMUS: It was fun.

TODD: I appreciate you taking your time with us.

DR. SEPTIMUS: Absolutely. My pleasure.

[End of the interview]