There’s no doubt about it: We’re pill-popping people. There are pills for when we’re sick, pills for when we’re healthy, and pills for when we’re just not sure. Our medicine cabinets have become “junk drawers,” stuffed full of half-filled bottles just in case we need them down the road.
Why are we so dependent on pills for everything? It’s all about the easy fix. No time to eat nutritiously? No problem, just take a multivitamin. Feeling the sniffles? Run for the vitamin C. But will these help? The vitamin and supplement industry has made every effort to convince you they will. I worry that a blind belief in these treatments might keep you from doing the things that can truly help your health. But if these supplements aren’t improving your health, wouldn’t your money be better spent on something that has been proven to do so, like a gym membership or more healthful food? I think so.
While advancements in drug development have saved countless lives, drugs can be incredibly dangerous if used by the wrong people or in the wrong way. And far too often they are. So many questions surround even over-the-counter medications. Are all painkillers created equal? Are generics as good as name brands? If there’s a chance aspirin can stave off serious conditions such as cancer, heart disease, and stroke, shouldn’t we all just take it? In this chapter, you’ll learn what you need to do to make the best choices for you. You’ll learn the critical questions you need to ask before you pop any pill.
The old days of “take two and call me in the morning” are over—or should be. All medications have risks and it’s important that you be aware of them. Even over-the-counter painkillers, if overused, can cause serious injury or death. The truth is that when it comes to medicines, one size does not fit all.
There is perhaps no more ubiquitous bottle in the American home than the one that holds the multivitamins. According to a 2011 report by the CDC, about 40 percent of American adults take one daily. My friend is one of them. He lives on a diet of frozen dinners and candy. No fresh vegetables, no fruits. When I tell him I’m concerned about his health, he says not to worry; he takes a multivitamin every day. To him it’s a kind of health insurance. When I questioned that approach, he got pretty darn defensive. For believers, taking multivitamins is a sensitive subject. They feel they are doing something critically important for their health. When I tell friends I have never taken a multivitamin, they’re shocked. Surely as a doctor, I should be more responsible about my health, they say. I reply that I get my vitamins through eating a balanced diet, but it’s clear they just don’t believe me.
Why are Americans spending billions of dollars on multivitamins every year? Probably several reasons. Since you were little you’ve been told to take your vitamins and in fact, vitamins are essential for life. Vitamin C deficiency causes scurvy, niacin deficiency causes pellagra, vitamin A deficiency can lead to blindness, and vitamin D deficiency causes rickets. No one wants to be vitamin-deficient. The big questions are whether having extra vitamins is a good thing and whether getting vitamins through pills is equivalent to getting them from your food. Also, are multivitamins really as important to your health as advertisements would lead you to believe? The current science suggests that the answer to this question is probably not.
Most of the evidence suggests that taking a multivitamin won’t help you live any longer than not taking one. Many studies have tried to sort this out and most are observational studies or association studies, the same type of studies I talked about in the question about whether having a drink a day is good for you. These studies look at a group of people over time to see whether those who took vitamins had better or worse health outcomes. Their results vary widely; some show slight benefits, but others show increased risks of death.
An expert panel convened in 2006 to give advice to the NIH on the research supporting vitamins for the prevention of chronic disease. They concluded that the present evidence was “insufficient to recommend either for or against the use” of multivitamins. The U.S. Preventive Services Task Force reached the same conclusion. That’s a bit surprising given the enthusiasm so many people have for them and the advertising that suggests they are absolutely essential for maintaining health. If vitamins are so vital, why is it so hard to show a benefit to your health?
Although I don’t support general use of multivitamins and supplements, I am a big fan of eating a diet rich in vitamins and other nutrients. I worry that divorcing these vitamins from the foods from which they naturally come implies that they are somehow just as, if not more, effective in pill form. Additionally, although some vitamins taken in excess are simply eliminated in the urine, many vitamins taken in high doses have been shown to be harmful. The good news is that your body stores vitamins to be used at times when they aren’t available in your diet. As long as you are eating a balanced diet most of the time, you should get enough.
It is pretty easy to find someone who will tell you that you need to take more vitamins. For a segment on Good Morning America, I went on two popular vitamin websites to see what they would try to sell me. To set the stage, I repeat, I eat a very healthful diet. As a family we eat a wide variety of foods and plenty of fruits and vegetables every day. I have no chronic medical conditions and thankfully, no family history of early heart disease. Both sites felt I needed to do a lot more. One site recommended I take a daily antioxidant, a daily multivitamin, B-50, vitamin C, omega-3 fatty acids, and a special supplement! The cost: $600 per year. Another website had similar recommendations: Vitamin C, calcium, fish oil with vitamin E, magnesium, vitamin D, super B, milk thistle, and a multivitamin! Their price: $624 per year. Think about that. Even with my concerted effort to eat a balanced diet, vitamin companies still suggest that I need to spend more than $600 in supplements. Just imagine what the recommendation would be for someone a little less conscientious. It could easily go into the four figures. You could be doing so many other things with that money!
I don’t want to go on a rant here, but there is more pseudoscience attached to the vitamin and supplement industry than just about anywhere in health care. It is an industry that needs more effective governmental oversight to protect the public.
We spend billions of dollars on multivitamins every year. Take the money you are spending on them and put it toward eating more servings of healthy fruits and vegetables. It’s not only a more straightforward approach to the vitamins and minerals you need, but it can be a tastier one, too.
I hate getting a cold. Who doesn’t? As a pediatrician, I have had more than most adults. It never fails: I’ll be looking into the back of a sick child’s throat and he’ll take that moment to hit me with a major sneeze or cough. That’s it! A few days later I feel the early signs and I know I’ll be a bit miserable for the next week or so. Just like you, I sure wish there was something I could do when I know I’ve been exposed, or during the peak season, to prevent colds from happening. Unfortunately, there is no magic bullet.
There’s enough mythology around cold prevention and treatment to fill an entire book. One of the most popular theories—that excess vitamin C wards off colds—goes back more than forty years, to Linus Pauling, a two-time Nobel Prize–winning biologist, who began promoting supplemental vitamin C for the prevention of colds. Since then, scores of studies have concluded that regular use of vitamin C does not reduce the frequency of colds in the general population.
Some people like the “just in case” approach to health care. That’s where you say, “I’ll take it just in case.” I am not a fan of that tactic, for many reasons. First, relying on treatments that haven’t been proven to work can lead to confusion as to what is based on science and what is based on faith. Better to make decisions based on evidence. While there are some studies that show that adults who take at least 200 mg of vitamin C every day have slightly shorter colds (less than twelve hours shorter), that’s not enough of a lure for me to take it throughout cold season. For those of you who are attracted to those ever so slightly shorter colds, and are willing to take pills every day “just in case,” there is some good news. Vitamin C is relatively safe at low doses. If you keep your intake in the lower range, I don’t think you are doing any harm—even if studies suggest you aren’t doing much good. What your body doesn’t use will be excreted in your urine.
What about taking vitamin C after you get a cold, to diminish its length or intensity? I can’t tell you how many people at work rush for their emergency mega-doses of vitamin C when they get a cold. Sorry, but there is only bad news in that department. Taking vitamin C after the cold starts doesn’t work.
As frustrating as it is, there really is no pill to prevent the common cold. Taking vitamin C religiously won’t prevent the common cold, though it might shorten it just a little bit. Taking vitamin C after a cold has started doesn’t do a thing. Best to focus on trying to prevent a cold in the first place.
It used to be, “An apple a day keeps the doctor away.” Now it seems like aspirin has pushed the beloved ruby icon of health aside.
During my training, the chairman of the pediatric department gave me a great piece of advice. He said, “You never want to be the first one to adopt a new therapy… but you also don’t want to be the last.” You don’t want to be first, because when new drugs come on the market or new treatments are implemented, there is less understanding of what their serious side effects and long-term consequences might be. New treatments all look fantastic until they are tried on millions of people. All too often, after further evaluation, products that once seemed promising are found not to be helpful, and sometimes are actually harmful. On the flip side, you don’t want to be last, because in doing so you may deny your patients innovative treatments that have proven their worth. Bridging this dichotomy of informed decision making drives much of my approach to medicine. The goal is to be skeptical of new treatments but open to being convinced.
We’ve all heard the advice somewhere: Take a baby aspirin every day to lessen the risk of heart attack or stroke. It’s tantalizingly easy to follow. After all, aspirin is available over-the-counter, is universally known, and has been used by nearly everyone at one time or another. Additionally, we hear all the time about how more Americans die from heart disease than from any other illness. Stroke is not that far behind.
The temptation to take a daily baby aspirin, without a doctor’s advice, might not seem like such a bad idea. After all, everyone’s doing it—and how bad can a baby aspirin be? But take it from this doctor: You should resist. Even though aspirin is an over-the-counter drug, it still is a medicine that has potentially serious side effects. To protect your health, never take any drug, even one that seems as innocuous as aspirin, without fully knowing the potential risks. For people at high risk of heart disease or who already have cardiovascular disease, the potential benefits will outweigh the risks—not necessarily so for someone with a different health profile.
To understand the trade-offs, you need to know a bit about why heart attacks and strokes happen and how aspirin works. Heart attacks and strokes can be caused by clots that form in critical arteries and block blood flow. When this happens in an artery supplying blood to your heart, you have a heart attack; when it happens in an artery providing blood to your brain, you have a stroke. Aspirin has a number of actions but works primarily by reducing clot formation in these arteries. It inhibits the actions of platelets, cellular components in your blood that are an important part of clotting. Normally, when there is a nick in a blood vessel, proteins in your blood work together with platelets to plug the leak. When aspirin is in your system, platelets don’t stick together as well. This can help prevent heart attacks and strokes because clots not only form in response to nicks in blood vessels; they also occur when blood vessels are damaged by anything, including atherosclerotic plaques seen in people with high cholesterol. This is the good news.
Now for the bad. While no one wants clots to block critical arteries feeding your heart and brain, there are many times that you do want clots to form, for instance when you are bleeding. If clots don’t form or form slowly, you run the risk of prolonged bleeding. There’s also a chance for a “double whammy.” Aspirin can irritate your stomach lining, which can cause bleeding and then can interfere with the clot-forming to make the bleeding stop. On rare occasions the amount of bleeding in the gastrointestinal tract can be large, even fatal. In addition, bleeding can occur in other places. If clotting is impaired and bleeding occurs in the brain, taking aspirin can actually cause a stroke.
So how do you weigh your benefits and risks? If you have had a previous heart attack or a stroke due to a blockage in an artery, most doctors will recommend that you take a daily baby aspirin. The evidence is pretty strong that it can lower your chance of having a recurrent event. It gets murkier if you have never had a problem. A recent study in the Journal of the American Medical Association analyzed data from Italy on more than three hundred thousand people taking aspirin to prevent a first heart attack or stroke. They found that the number of cardiovascular events prevented was about the same as the number of episodes of major bleeding caused by the aspirin. In light of these risks, the American Heart Association recommends aspirin only for people who are at high risk of having a heart attack. The U.S. Preventive Services Task Force (USPSTF), the government advisory group that looks at this sort of thing, recommends an aspirin for men ages forty-five to seventy-nine and women ages fifty-five to seventy-nine when the potential benefits outweigh the potential harm due to gastrointestinal bleeding.
Right now there is also growing evidence that daily aspirin use reduces both the occurrence of colonic polyps, the precursors to colon cancer, and the occurrence of colon cancer itself. However, the evidence that it actually reduces deaths from colon cancer is more limited, with some studies showing a benefit and others not. In those studies that do show a benefit, the benefit is small. So why the differences in these studies? Well, most polyps do not go on to become cancers, and polyps picked up by routine colon cancer screening can be removed so that they never have a chance to cause a problem. So what if aspirin prevents something that would not have harmed you?
Just as for heart disease and stroke, you have to ask yourself, what is your risk of getting colon cancer compared with the risks from taking an aspirin? The USPSTF reviewed this issue back in 2007. It found that the benefits of daily aspirin use for the prevention of cancer did not outweigh the risks for people with an average chance of developing colon cancer, as well as those with a family history of colon cancer. While there have been quite a number of studies published since 2007, there hasn’t been anything that convinces me that routinely taking aspirin for colon cancer prevention makes sense. Better approach: Get regular, recommended colon cancer screenings, such as a colonoscopy. If you have already had colon cancer, you fall into a different risk group altogether.
Who could have guessed that a decision about something as seemingly simple as taking a daily aspirin could be so controversial? Bottom line is that aspirin is not for everyone. Even though it’s sold over the counter, it is a real drug with real side effects. For those who have had a heart attack in the past, it can really be a lifesaver. However, if you don’t need it, don’t take it. Before starting on aspirin or any nonprescribed drug, have an open conversation with your doctor about risk, benefit, and how to view the trade-offs.
I have to admit it. I am a bit of a brand-name snob. I have my favorite brand of soap, corn flakes, ice cream, sneakers, and jeans. For some reason, I am not very excited about buying store brands for any of these. I guess the marketing has gotten to me. I know what I want—or at least I have been convinced that I do by the millions of dollars in advertisements.
So I’m not surprised that you may be hesitant about giving up your brand-name drug for the generic equivalent. The pharmaceutical industry spends billions of dollars on advertisements every year to build their market and brand loyalty. How can the store version do the same thing as the expensive stuff? It doesn’t always look the same. The size and color are different and it may not even the taste the same. How many times have you played mental Ping-Pong, glancing at the side-by-side over-the-counter pain relievers, one brand name, one store brand, wondering whether it’s worth paying the extra few dollars for the brand-name version? Surely, there’s a reason that the “no-name” box is cheaper. After all, why would anyone pay more for the same product? Turns out, there’s no good reason to.
The generic forms of drugs can save you potentially thousands of dollars a year without affecting your health. Here’s why. The FDA requires that generic drugs be chemically identical and be as safe and effective as their brand-name counterparts. While they might not look exactly the same, they must have the same active chemicals. The company making the generic drug must do studies to show the FDA that the same amount of the drug gets into your bloodstream, meaning it will work the same.
There is a reason why generic drugs cost so much less than the brand-name ones. When drug companies develop a new product, they bear the costs of years of research and development in order to bring it to market. Because of these huge investments, manufacturers are rewarded with patent protection for twenty years. The patent protects the manufacturer’s investment in the drug by giving the manufacturer exclusive rights to sell the drug during the life of the patent. Once the patent expires, other manufacturers can apply to the FDA for approval to market a generic version of the product. These manufacturers don’t need to pay for research, development, or marketing, so their costs are much, much lower. When several companies get approval to manufacture generics, competition drives the price down further.
According to the FDA, nearly 80 percent of prescriptions filled in the United States are for generic drugs. That percentage is expected to grow as many popular medications continue to come off patent. In just one year big-ticket drugs including Lipitor for high cholesterol, Plavix for preventing blood clots, Lexapro for depression, and Singulair for asthma went generic.
Surprisingly, brand-name manufacturers frequently make generic versions of their own or other brand-name drugs. For example, Pfizer, the maker of the cholesterol-lowering drug Lipitor, was also the manufacturer of the first generic clone! The manufacturer may also make slight changes in the formulation (how much drug per pill, how a drug is absorbed) as a means of trying to extend their patent protection and safeguard their share of the market. Even after a patent expires, the brand-name manufacturer often continues to advertise their version, hoping you will still perceive its superiority and be willing to pay more for it. There is no legitimacy to this marketing ploy, but like much direct-to-consumer advertising of drugs, it is quite effective.
You can feel secure about getting the same quality and saving money by buying generic versions of a drug. You’ll be getting the same benefits but at less cost.
Here’s a pop quiz. What do the following have in common: A bad case of poison ivy, the flu, a sprained ankle, and menstrual cramps? Give up? They are all conditions that lead us to buy medications that end up being used a few times before being forgotten and pushed to the back of wherever you keep your drugs, typically the medicine cabinet. As they sit and sit, another thing happens. They pass their expiration dates, leaving you with that big dilemma when you need them again: Do you throw them away and buy new ones, or do you risk it and use them anyway?
This uncertainty is the reason for many after-hours calls. Some patients wonder if the drugs are still effective; others fear they could be dangerous. With food we’ve been conditioned to think if it’s expired, it’s time to get rid of it. I don’t know anyone who would think of drinking milk two weeks after its stamped date, let alone a year or two! Luckily, there is an extensive body of research looking into the safety of using drugs after their expiration dates. It agrees that, in most cases, prescription and over-the-counter drugs remain safe and effective long after those printed dates.
Here’s why. To protect the public, beginning in 1979 drug companies were legally required to put a date that their drug would still be good on the package. Herein lies the major distinction: The FDA did not require a date to indicate when the drug would theoretically start to “go bad,” nor did it require drug companies to test for that. The drug companies just needed to provide a date for which they would guarantee that the medication would still be good. For most drugs, the pharmaceutical companies assigned a relatively arbitrary and short time frame—generally two to three years. Manufacturers claimed that the longer they needed to keep drugs on hand to continue to test their efficacy, the more costs they would have to pass on to consumers. Given this, they chose very conservative dates for expiration.
This subject of drug longevity is one I know well. For four of the years I worked at the CDC, I was responsible for the Strategic National Stockpile. Few people realize that the government has amassed a huge collection of critical antibiotics, vaccines, and other drugs to be used in the event of public health emergencies. We’ve been lucky and most haven’t been needed, so they sit in waiting. The drugs in the stockpile are worth billions of dollars, so the government does not want to discard them unless it has to. As part of our country’s Shelf Life Extension Program, drugs are periodically tested for potency and safety. These tests have shown that most of the drugs remain effective for many years longer than would be expected based on expiration dates.
The general public’s knowledge of this program’s findings is very limited. I found this out firsthand when I went knocking on doors and looking into people’s medicine cabinets for a “Doc at the Door” segment on Good Morning America. Let me tell you, you really get to know someone after seeing what’s in his medicine cabinet! There was one thing all the people I spoke to had in common. They were all unsure how to manage their medicines, and much of their confusion stemmed from not knowing when to keep and when to discard prescription and over-the-counter medications.
Drug companies are in business to make money. It’s in their best interest for you to frequently replenish medications, even when they are still effective. When it comes to deciding what to use and what not to use after the expiration date, here’s my advice:
• For critical medications (heart drugs, blood pressure medications, etc.) stick to the expiration dates. If you are being prescribed correctly, you shouldn’t come near to approaching the typical one-year date.
• For non-liquid over-the-counter medications being stored in a cool, dark place, don’t worry about the expiration dates.
• For antibiotics, it’s a good idea to stick to the expiration date, too. Some antibiotics lose potency over time or if improperly stored. When prescribed a course of antibiotics, finish them! If you have an old container of antibiotics, get rid of them properly. If you are given antibiotics to use sporadically for prevention of a urinary tract infection, discard them when they reach the expiration date.
• For liquids, I’d stick close to the expiration date. They tend to degrade faster than pills.
• For all medications, if the appearance or the smell of the medicine has changed, throw it out.
This issue is so confusing, it’s enough to give you a headache. We have been conditioned to believe that “expiration date” actually means the date after which something is no longer good. Fortunately, for most drugs, that is not the case. Their expiration dates only guarantee that a medication is good on that date, even if it’s just as likely to still be effective five years past that date. Unless the regulations on this change (and I see nothing to suggest that they will), you need to follow your personal risk tolerance. But I bet if you follow my simple rules, you will be making fewer late-night trips to the drugstore.
When my wife has a headache or a fever, she always says, “I’m going to take some aspirin.” She doesn’t mean she is actually going to take an aspirin. It is just the word she and many other people use for a pain or fever reliever. When we were kids that was what we took. Now there are choices. Acetaminophen (Tylenol and generics) gained popularity throughout the 1960s and ibuprofen (Motrin, Advil, and generics) became available over the counter in 1984.
So when you have a headache, fever, or aches and pains, which one do you take and does it matter? Are all pain and fever relievers equal?
They are not. Each drug works in a different way and has different strengths and side effects that you need to know about. If you learn the basics, it’s easy to reach for the right one for what ails you. If you’re treating a particular medical condition, like arthritis or migraines, have your doctor go over them with you to see what will be best for you.
Here are the basics:
Aspirin: Aspirin is a member of a class of drugs called nonsteroidal anti-inflammatory drugs, or NSAIDs. These drugs work in part by blocking the production of prostaglandins, chemicals in your body that regulate inflammation, fever, and pain. Aspirin is also used for the prevention of heart disease in high-risk people and in the treatment of heart attacks, strokes, and a number of joint disorders. Like all drugs in this class, it can cause indigestion, heartburn, and ulcers. Because aspirin has been linked to Reye’s syndrome, a serious and sometimes fatal illness in children, it shouldn’t be given to any child younger than nineteen years old unless directed to by a doctor. Another caution: Aspirin interferes with how your blood clots. That makes it good for preventing clotting in your heart vessels, but dangerous if you are prone to bleeding.
Ibuprofen: Like aspirin, ibuprofen is also an NSAID. It is very useful for treating muscle pain, body aches, and fever and is often used for menstrual cramps. NSAIDs are quite safe when used for short periods of time, but extended use has been linked to an increased risk of stomach bleeding, heart attack, stroke, and kidney failure. It’s best to take this drug after you’ve had something to eat to reduce any stomach distress. As with any NSAID, don’t take it for more than ten days without checking with your doctor.
Acetaminophen: Like ibuprofen, acetaminophen lowers fever and reduces pain. However, it is not an NSAID and doesn’t reduce inflammation, so is not recommended for body aches and pains from overworked muscles. What I really like about this drug is that it is easy on the stomach, so it does not need to be taken with food. There’s a big warning with acetaminophen, though. In large doses it is very toxic to the liver. For adults, never take more than 3,000 mg (3 grams) in a single day. It actually is pretty easy to reach this limit. Extra-strength products contain 500 mg per tablet or capsule, so if you take two every six hours, you will reach the limit. You have to be very careful because quite a number of over-the-counter cold, flu, and sleep products also contain acetaminophen in combination with other drugs. Because of this, always read the label to make sure you aren’t taking in too much. Another caveat: If you have liver disease or have more than three drinks per day, stay away from this drug!
Generally, my advice for adults relates to preference. Over time you may find that you tolerate or get relief from one of these drugs more than the others. If you have any medical conditions, talk to your doctor about which medication is best for you. For example, ibuprofen can interfere with the heart-protective benefits of aspirin.
Here’s a brief recommendation and overview by symptom.
Fever: Acetaminophen or ibuprofen. One advantage of ibuprofen is that the dosing is every eight hours versus every six hours for acetaminophen. A number of systematic reviews in children show a benefit of ibuprofen over acetaminophen for fever relief.
Headache: Acetaminophen or ibuprofen. I like the side-effect profile of acetaminophen better than for the NSAIDs as long as you pay attention to the dose. Otherwise either of these is fine. There are some studies that show that caffeine adds to the relief from these drugs. I’d be careful, though, since caffeine withdrawal is also a cause of headaches.
Muscle aches and pains, menstrual cramps: Ibuprofen. The anti-inflammatory properties of this drug make it my favorite.
Hangover: Ibuprofen or aspirin. Remember that acetaminophen is toxic to the liver. If you’ve been drinking too much, give your liver a break and use one of these other drugs.
Pain and fever relievers are not created equal. Know the side effects and the benefits of each. Also make sure to use caution when using them with other over-the-counter multipurpose medications to make sure you aren’t taking more than the daily recommended dose. Even though these are not prescription drugs, there are risks from taking too much of them.
Walk through any health food store and you’ll see shelves lined with various herbal supplements. We’ve all heard the claims: Echinacea supports your immune system, gingko improves memory, raspberry ketones help you lose weight. In my clinical practice, I always get questions about “natural” supplements. I get it. We all want to feel better when we’re sick and want to prevent illness. There’s always a friend who doesn’t trust conventional medicine and is suspicious of the pharmaceutical industry but swears by something alternative. Plus, there’s comfort in the word herbal. After all, aren’t herbal remedies natural? That should make them safe and good for you, shouldn’t it?
When it comes to herbal supplements, safe is not something that should come to mind. In fact, to me, herbal supplements are some of the scariest remedies out there because they are, in essence, self-regulated.
I don’t have anything against looking to nature for cures. Many drugs used in conventional medicine are derived from plants and herbs. However, before these drugs are marketed, pharmaceutical companies are required to do safety studies and conduct clinical trials to show that they are effective. As a doctor and scientist, that just makes sense to me. Look to the natural world for potential treatments, then assess them scientifically for effectiveness. I wish that were true for supplements.
When you take an herbal supplement or remedy, you have no way of knowing what the active (druglike) ingredients are or whether the amount contained in two similar products is the same. You have no way of knowing whether the claims on the label have been tested and proven, unlike when you take a prescribed drug that meets FDA standards.
Shocked? I was when I first started looking into this. The most incredible thing to me is that this was a deliberate decision by Congress. In 1994, they basically said to the FDA, the agency entrusted with ensuring a safe and effective drug supply, “hands off the vitamin and supplement industry.” They passed the Dietary Supplement Health and Education Act (DSHEA). This legislation placed dietary supplements in a special category under the general umbrella of “foods” instead. Under the DSHEA, the manufacturer became responsible for ensuring that its products are safe before they are marketed. According to the FDA, “Unlike drug products that must be proven safe and effective for their intended use before marketing, there are no provisions in the law for FDA to ‘approve’ dietary supplements for safety or effectiveness before they reach the consumer.” The FDA adds, “Unlike drugs, supplements are not intended to treat, diagnose, prevent, or cure diseases.” That means supplements cannot make claims, such as “reduces arthritic pain” or “treats heart disease.” Per the FDA, these claims can only legitimately be made for drugs.
Surprised? That is because the advertising for supplements frequently walks a fine line. A supplement can purport to support a strong immune system rather than claim to prevent colds. It can claim to promote weight loss rather than to treat obesity. Pick up any supplement and you will see an asterisk on the label. If you have really good vision you will read the tiny disclaimer that says that the claims on the label “have not been evaluated by the FDA.”
To add insult to injury, under DSHEA, once the product is marketed, the FDA has to prove that a dietary supplement is “unsafe” before it can take action to restrict the product’s use or force its removal from the marketplace. Talk about a sweet deal! Supplements are a multibillion-dollar business. Whose lawyers do you think are going to win most of those fights? Manufacturers are entrusted to “verify” that their products are safe and not make any misleading claims about their medical benefits.
Let’s look at the über-popular herbal supplement Airborne, marketed to prevent colds. In 2008, it had to shell out over $23 million to settle a class-action lawsuit brought against the company for false advertising. A report on Good Morning America revealed that what Airborne claimed was a double-blind, placebo-controlled study by a company specializing in clinical trial management was really conducted by two guys with no medical degrees. The company ceased referring to its product as a cold remedy and removed those claims from the box, now choosing to say it can help support your immune system. Somehow I don’t think it is the only supplement manufacturer that might have fudged a thing or two.
Echinacea, another popular herbal remedy touted for preventing and treating colds, has also shown inconsistent scientific basis for those claims. A 2005 study in the New England Journal of Medicine found no benefits from echinacea for rhinovirus (colds) over placebo. In 2009, Cochrane, an independent health care review system, examined sixteen controlled clinical trials comparing different echinacea preparations for preventing and treating common colds. There was no evidence that it prevented colds. Other studies looked at whether it shortened the duration or decreased the severity of the symptoms once a cold was contracted compared with a placebo. Some studies showed that preparations based on the herb of Echinacea purpurea might provide some benefits for cold relief in adults, but none in children. The problem with relying too much on these results is the inconsistency from product to product. Various supplement manufacturers use different species of the herb, different parts of the plant, and different manufacturing processes, so any potential benefits could differ from one brand to another.
So what should you do if you use supplements? The first thing is to find out if what you are using is safe. Some supplements can increase or decrease the effectiveness of medications you are currently taking. Talk to your doctor about this. In the meantime, visit the NIH website on Complementary and Alternative Medicine. There you will find great information on the effectiveness of supplements and potential dangers. As a physician, I want to see scientific evidence before I recommend anything to my patients. You should demand the same standards for any product you put in your body.
Buyer beware! Being dependent on supplements isn’t good for your health or your pocketbook. Most herbal supplements have not been tested scientifically to see if they work and the claims you see on the label have not been independently evaluated. Just because something is “natural” does not mean it is safe.
Picture this: A back alley, a junkie slumped over behind a Dumpster, dead from heroin. That is the image of a drug overdose that I, and I think many others, have from movies and news reports. However, the rising problem of drug abuse looks much different from what we might expect. Instead of strung-out addicts, think soccer moms, colleagues at work, and high school and college students. Think about legal prescription drugs. The United States is facing an epidemic of prescription pain medication abuse. In 2007, prescription narcotic painkillers were involved in more unintentional overdose deaths than heroin and cocaine combined! Even more disturbing, in 2009, for the first time in the thirty years that the government has been tracking drug-induced deaths, drug overdoses and the effects of long-term drug abuse killed more people than motor vehicle accidents.
It might start innocently enough, with nagging back pain that keeps you from getting to work. Maybe it’s insomnia that you can’t seem to beat. Or you just need a little oomph to get that big project done. One or two pills turn into a few more, and before you realize it, you can’t get through the day or night without them. Drugs commonly involved in unintentional deaths include pain relievers, tranquilizers, antidepressants, stimulants, and sedatives. You may recognize the names: OxyContin, Vicodin, Xanax, all commonly abused, highly addictive prescription drugs.
This epidemic affects all ages. The National Institute on Drug Abuse (NIDA) reported that in 2009, sixteen million Americans ages twelve and older had taken a prescription pain reliever, tranquilizer, stimulant, or sedative for nonmedical purposes at least once in the year prior to being surveyed. For many, use begins in high school. As teens become adults, the rates continue to rise. While we tend to think of drug abuse and overdose as the plague of youth, the forty-five-to-fifty-four-year-old age group had the highest rate of unintentional drug overdoses.
Why is prescription drug abuse so common? Largely because the use of these drugs does not carry the same stigma as the use of illicit drugs. Many people feel that because doctors prescribe them, they must be safe to take. And once you have a prescription drug problem, getting drugs isn’t hard. More than half of all prescription drug users get them from family and friends, not physicians. Others learn how to scam the system to get drugs. It can be very difficult for doctors to tell whether a patient has significant pain for which a narcotic pain reliever might be warranted or is just trying to get drugs. Many doctors are undertrained in pain management or don’t take the time to prescribe properly.
Prescription drugs aren’t the only problem. Just because you don’t need a prescription for over-the-counter (OTC) painkillers, it doesn’t mean they are universally safe. While OTC painkillers like acetaminophen (Tylenol), aspirin, and ibuprofen (Motrin) lack the addictive potential of powerful prescription pain medications, they pose serious health risks if misused. An unintentional overdose of acetaminophen can seriously damage your liver and even cause death.
Pain relievers are commonly found in other medications as well, making it easy to ingest more than intended. Acetaminophen poisoning is now the most common cause of acute liver failure in the United States. The risk of overdose has become so significant that companies such as Johnson & Johnson, makers of Tylenol, reduced the recommended daily dose from eight pills (4,000 mg) to six pills (3,000 mg) to protect users from accidental overdoses. Ten thousand milligrams can destroy your liver.
Take this example, which shows how easy it can be to get into trouble: You have the flu and feel achy, feverish, and congested. You wake up feeling terrible so you pop two extra-strength acetaminophen tablets for pain relief. That’s 1,000 mg. The package says you can take six tablets over the course of the day, which you eagerly do, for a total of 3,000 mg. You also take an OTC multisymptom cold and flu medication, such as Dayquil, to help with the congestion and flu symptoms. This product also contains acetaminophen. The instructions say you can take four doses in twenty-four hours, so over the course of the day you take a total of eight tablets. That’s another 2,600 mg of acetaminophen. Then to help you sleep, you take NyQuil. One dose contains 650 mg of acetaminophen. You might not realize it, but by simply taking common cold and fever medications, you have consumed almost 7,000 mg of acetaminophen. This is more than twice what is recommended and for some, could be a toxic dose. When you’re feeling bad as it is, you may not think to calculate all the milligrams you’ve taken over the day, but they keep adding up. Acetaminophen is even found in prescription painkillers, such as Percocet and Vicodin. If you start with acetaminophen to control your discomfort and end up taking something stronger because you still need relief, you could be setting yourself up for trouble.
Now is also a good time to go through your medicine cabinet and make sure you don’t unintentionally become someone’s drug supplier. When I was in my thirties, I had multiple episodes of severe back pain, which finally led me to have surgery. Over the course of five years I was prescribed muscle relaxants and narcotic pain pills. When one drug wouldn’t work, I would get a stronger one. Over the years, I built up quite a pharmacy in my closet, loaded with addictive and potentially dangerous drugs. It wasn’t until I had someone coming to stay with us who I knew had a prescription drug problem that I went through my medications and discarded them properly. Don’t wait until it is too late. Take a look—you may be surprised at what you find.
Addiction and deaths from prescription pain relievers are skyrocketing. Occasional use can lead to dependence and addiction. Never take medication that has not been prescribed for you and make sure you understand how to take your medications safely. Use caution when using OTC medications as well. Always know what is in the medicines you are taking, and be aware of the safe limits for these drugs. They can also be deadly.
One of our good friends, Don, is the picture of health. Although he just celebrated his sixtieth birthday, he barely looks a day over forty. It’s no wonder; playing competitive ice hockey several times a week for decades has left him slim and fit. Looking at him, few could imagine Don’s been fighting high cholesterol and heart disease for much of his life. He’s not alone. Today, the most common cause of death in America for both men and women is heart disease. Of the many risk factors, one of the most important is high cholesterol.
So where does most of this cholesterol come from? Surprisingly, it’s not from your diet. Your body manufactures cholesterol and uses it widely: To form the walls of your cells; to produce the hormones that send signals throughout your body, including vitamin D, estrogen, and testosterone; and to help you digest your food. You could not live without cholesterol. The amount of cholesterol measured in your blood is a balance between what you make, what you eat, and what you get rid of. High-density lipoprotein (HDL), also known as good cholesterol, is involved in transporting cholesterol back to your liver for elimination. It is a good marker for how well you get rid of cholesterol. Low-density lipoprotein (LDL), also known as bad cholesterol, is linked to a buildup of cholesterol in your blood and the formation of plaques in your arteries. These plaques—a combination of cholesterol, calcium, platelets, and other material—can block your arteries and cause a heart attack or stroke. A high blood level of LDL cholesterol is a risk factor for heart disease, whereas a high level of HDL cholesterol is a marker for protection from heart disease.
There has been much interest in drugs that can lower your LDL cholesterol, as well as those that can raise your HDL cholesterol. So far, drug therapy to raise your HDL cholesterol has not been very promising. Drugs that have been able to do so haven’t been shown to reduce the risk of heart disease or save lives. It is a different story for statins, drugs that reduce LDL cholesterol. Statins block the production of cholesterol and may even help reabsorb cholesterol in plaques that have already formed. For people who have heart disease or who are at great risk of having a heart attack, statins are an important treatment tool. The popularity of these drugs is almost unrivaled; millions of Americans take them daily. That includes Don, whose father died from heart disease at a young age and who is genetically disposed to having high cholesterol, which can’t be controlled through exercise or diet. For Don and others like him, it’s amazing how well they work. But for others whose situations are less definitive, whether to automatically use statins is less clear. Sure, they can lower LDL cholesterol in anyone, but is that necessarily the way to go?
Let’s look at my wife, Jeanne, for example. She follows all the rules: Rarely eats high saturated-fat foods, exercises almost every day, and has never smoked. However, she also has a family history of high cholesterol. No matter what she does in terms of diet and exercise, her body keeps her LDL and total cholesterol a little on the high side. Fortunately, she also has a high level of HDL cholesterol. I was curious to see if she might benefit from a statin. This year after she got her results from her blood work, I sat down and calculated her risk for heart disease. You should do it, too, using this tool: www.nhlbi.nih.gov/guidelines/cholesterol/atglance.htm.
There’s a list of risk factors: First, do you already have atherosclerotic disease (plaques in your arteries)? This could include a history of angina (chest pain), blockages in the arteries in your neck, or poor circulation to your hands and feet. For my wife the answer was a resounding “no” to all of these. Second, if you don’t already have diseased arteries, do you have big risk factors for heart disease such as: Smoking, high blood pressure, low HDL cholesterol, a family history of early heart disease (in a male, close relative under fifty-five years; in a female, close relative under sixty-five years), and age (if you are a man, are you over forty-five years; if a woman, over fifty-five years)? Again, for Jeanne, the answers were no to all of these. Next, I used a special calculator to predict her risk of having a heart attack or dying from heart disease within the next ten years. This is called your Framingham Risk Score (hp2010.nhlbihin.net/atpIII/calculator.asp?usertype=prof). I know this sounds complicated, but if you try it, you’ll see it isn’t.
Using this tool, Jeanne’s ten-year risk of having a heart attack or dying of heart disease is only 1 percent, even with her elevated cholesterol levels. In cases like Jeanne’s, you should weigh the benefits of statins against the possible side effects. Although a statin might lower that risk of heart disease even further, when the potential benefits of a treatment are small, you really need to look at risks. For statins, the side effects are rare but include muscle pain or inflammation, confusion, and an increased risk of developing diabetes. If you truly have heart disease or are at great risk for heart disease, the benefits of the drug would likely outweigh these risks. However, if you are at low risk for heart disease to begin with, why take a drug for the rest of your life that could have any potential side effects?
One more point about statins bears mentioning because you may hear a lot about it. There is mounting evidence that among the main benefits of statin therapy is not just the reduction in bad cholesterol, it is its role in reducing inflammation in your blood vessels. Inflammation in your blood vessels creates a setting for plaque to form. If you reduce inflammation, there will be less plaque. Less plaque means fewer blockages of your arteries. This may help to explain why in some studies, statins reduce the risk of heart disease even in patients who don’t have very high cholesterol. Inflammation can be measured by a blood test called the C-reactive protein and more doctors are checking this as well, as a means to prevent heart disease. By the way, Jeanne had hers measured, too—it was also low. By either approach, standard heart disease risk or inflammation, the balance for her and for many others with elevated cholesterol levels would not support taking a statin.
Statins are not for everyone. While the benefits of statins may seem like a slam dunk, particularly considering the high prevalence of heart-related deaths, there is still considerable controversy over whether they are suitable for all people regardless of heart disease risk. If you are at high risk of dying of heart disease or stroke, then there is great benefit in taking a medicine that significantly lowers that risk. If you are not at great risk of dying from heart attack or stroke, who cares if a drug lowers your cholesterol and risk even further?
It is hard to think of a class of medications that has a more checkered and disturbing history than hormone therapy in women. Beginning in the 1960s estrogens and then combination estrogen and progesterone products were marketed to women to treat the symptoms of menopause—then considered a disease—and to prevent its alleged consequences: heart disease, Alzheimer’s disease, and osteoporosis.
Never has a drug seen such widespread acceptance based on such flimsy medical evidence. It wasn’t until high-quality randomized, double-blinded controlled trials were conducted that the truth became known. For most women, the risks from using menopausal hormone therapy far outweighed the benefits.
As anyone who has lived through or lived with someone going through menopause knows, it’s not easy. As levels of estrogen and progesterone decrease, the body goes through a multitude of unpleasant changes. For many women—and for many years—hormone therapy (formerly called hormone replacement therapy) was a godsend when it came to dealing with the unwelcome side effects of menopause.
Generally speaking, hormone therapy involves artificial supplementation with hormones that decline at the time of menopause. In addition to addressing bothersome hot flashes and night sweats—two of the most common complaints associated with menopause—hormone therapy also deals with some of the vaginal symptoms of menopause, such as dryness and itching, and may reduce the risk for hip fractures.
Initial studies found other benefits. Women who took hormone therapy were less likely to develop heart disease and dementia. However, these studies were quite misleading. Women were not randomly assigned to take these drugs; instead researchers looked at the outcomes for women who chose to take them and compared them to women who chose not to. In the case of hormone therapy, prescribing information for some products indicated that women with heart disease should not take them. It was no surprise, therefore, that fewer women taking the drugs had heart disease.
It wasn’t until randomized controlled trials were conducted that the truth was shown. The Women’s Health Initiative study, or WHI for short, is perhaps the most well known study to reveal these risks. This study enrolled more than 160,000 postmenopausal women between fifty and seventy-nine years of age between 1993 and 1998 and was designed to quantify the benefits of hormone therapy in the realm of cardiovascular disease.
Instead the WHI study delivered a devastating one-two punch to hormone therapy. Not only was the risk of coronary heart disease found to be 29 percent higher in women taking hormone therapy when compared to the placebo group; the risk of breast cancer was 26 percent higher in women taking the medication. Only modest reductions were seen in the rates of colorectal cancer and hip fractures in women taking hormone therapy—not nearly enough to offset the harm.
Despite this large-scale study and later ones that have similar findings, the debate over whether hormone therapy increases the risk of chronic disease continues. Some are looking to see if there are subgroups of women for whom the drugs are safe and effective. Others call into question the methods used in the large controlled drug trials.
The U.S. Preventive Services Task Force (USPSTF) has issued recommendations that are quite clear. They recommend against the use of hormone therapy for the prevention of chronic disease of any kind, including heart disease or fractures. They found that while hormone therapy decreased the risk of fractures and colon cancer, it increased the risk of stroke, gallbladder disease, urinary incontinence, dementia, blood clots, and breast cancer. The trade-off was just not worth it. This is in keeping with the recommendations of many other medical societies. The USPSTF did not address the use of hormone therapy for treating severe menopausal symptoms.
Many women continue to take these drugs despite studies that suggest health risks, primarily because they see these drugs as their best option for dealing with severe symptoms of menopause. The FDA still approves of the use of hormone therapy for treating menopausal symptoms and for the prevention of osteoporosis. However, the agency recommends that they be used at the lowest effective dose and for as short a period as possible.
The weight of the evidence overwhelmingly demonstrates that hormone therapy poses health risks to postmenopausal women and should not be used for the prevention of any chronic disease. Women with severe menopausal symptoms should ask their doctor about other options for relief, such as low-dose estrogen creams for vaginal symptoms. Some women find they can control some symptoms through yoga and other relaxation techniques. Dressing in layers and keeping your bedroom cool can help with hot flashes. If you can’t find comfort any other way, use hormone therapy as briefly as you can.
You’ve all heard the adage “A picture is worth a thousand words.” Nowhere is that more true than the ubiquitous “Got Milk” campaign. Seeing the thin, white mustache above a celebrity’s mouth symbolizes the benefits of drinking milk. For most people that means recognizing the importance of calcium in your diet.
Calcium is a critical component of our bones and is very important for bone strength. Vitamin D is an important regulator of calcium absorption from the intestine. In growing bones, extreme deficiencies of calcium and vitamin D can lead to rickets. In adults it can cause bone demineralization and, in some people, osteoporosis.
Osteoporosis is a condition marked by severe thinning of the bones and an increased risk for fractures. It is seen primarily in elderly postmenopausal women. Roughly one-half of all postmenopausal women will have a fracture due to osteoporosis at some point in their lives. The big fracture everyone worries about is of the hip. For older women and men, a hip fracture can be a life-altering and life-ending experience. It is an event that can render previously active people immobile for months, and it can impact their quality of life forever. A third of men who have a hip fracture are dead within a year.
Conventional wisdom would suggest that, if your bones are brittle from too little mineralization, increasing the intake of calcium would help. This principle, in fact, is the basis for the massive sale of calcium supplements—one of the most popular on the market today. According to the CDC, 61 percent of women older than sixty take calcium supplements. Unfortunately, the evidence is pretty inconclusive that taking calcium and vitamin D supplements leads to improved bone health. The USPSTF has suggested that, for now at least, the evidence is too shaky to recommend the use of calcium supplements, with or without vitamin D. A review of the randomized controlled trials found little benefit, though the quality of studies in terms of the amount and types of supplements used varied. They concluded that daily supplementation with 400 IU (international units) of vitamin D and 1,000 mg of calcium did not reduce fractures due to osteoporosis.
America’s love affair with calcium supplementation is emblematic of its love affair with supplements in general. Many people accept on faith that supplements will improve health. More often when formal studies are done, supplements have been shown to cause harm. Getting too much calcium increases your risk of kidney stones—not a large increase in risk, but an increase nonetheless. More concerning are several studies linking calcium supplementation to a small but real increase in heart attacks and strokes. The theory is that taking large doses of calcium leads to the calcium being deposited not just in your bones, but also in the plaques that are forming in your coronary arteries. The larger the plaque, the more likely it is to block blood flow to your heart and brain. Unlike dietary calcium, which is absorbed slowly, supplements give your body a large amount of calcium all at once.
The better approach is to get the calcium you need from your diet throughout the day, to allow it to be absorbed slowly. The National Osteoporosis Foundation (NOF), an industry-supported advocacy group, also endorses food as the best source of calcium. Eating a diet that includes dairy products and leafy green vegetables, in addition to calcium-fortified foods, easily allows you to reach your daily goals. The Institute of Medicine has laid out recommendations for calcium intake. For healthy adults, the recommended intake is 1,000 to 1,200 mg per day. With a little bit of planning, it isn’t that hard to do. Foods rich in calcium include low-fat or nonfat milk, yogurt, cheese, sardines, salmon, broccoli, and dark leafy vegetables such as kale, in addition to calcium-fortified orange juice and cereals. Start your day with a combination of these foods and you’ll quickly be at your recommended intake. The NOF also cautions against getting more calcium than you need through supplements, citing the lack of any additional benefits and warning of possible risks.
When it comes to preventing weakened bones, calcium supplementation may not be as useful as you think. Try to get the calcium you need from your diet. It isn’t the same as getting it through pills.
I bet if I asked a roomful of people where they stored their medicine, 99 percent, if not more, would say in the bathroom medicine cabinet. After all, that’s what it’s for, isn’t it? I actually turned this question around and sprung it on unsuspecting residents in a northern New Jersey neighborhood for a “Doc at your Door” segment. Going door to door, I asked them if I could look in their medicine cabinets—in the name of better health. They were all overflowing with medications. Every single person was shocked when I said that the bathroom is the worst place to store both prescription and over-the-counter drugs.
Of all the rooms in your house, the bathroom is the most hot and humid. Just picture a typical morning: Steamy showers, warm water fogging up your bathroom mirror as you shave. Guess what makes medications disintegrate and lose their effectiveness the fastest? Excessive moisture and heat! We all put medicine there but we shouldn’t. To protect your drugs’ efficacy and longevity, they should be stored in a cool, dry place away from bright light. The back of a linen cabinet, a bedroom shelf, or a kitchen cabinet (away from the sink, stove, and direct sunlight) are all better suited. I like to organize mine in Tupperware-type boxes so I can easily pull them out to find what I’m looking for.
No matter where you decide to house them, make sure all medication is kept out of the reach of children or in a locked cabinet. According to the CDC, each year more than seventy thousand children are seen in the emergency room due to unintentional poisonings. More than 80 percent of the cases involved unsupervised children getting into medicines. Even vitamins, which children confuse with candy, should be kept in a safe place where they can’t access them.
This is especially important when you are visiting others. One of the riskiest situations for young children happens every holiday season when Grandma and Grandpa come to visit. Often elderly people keep their medications in pill organizers. These are great tools to help you to remember to take your medications and they are easy to open, which for people with arthritis can be a real benefit. However, if little kids are around, these pill organizers can be deadly. To see for myself how risky this could be, I conducted a totally unscientific experiment for Good Morning America. I assembled a group of six incredibly adorable children, two to four years old. First I gave them a variety of pill organizers and asked them to show me how fast they could open them. All six got them open; one three-year-old little girl had hers open in just ten seconds. Next I gave them easy-open prescription bottles like the kind often given to the elderly. Four out of the six kids got into these in less than thirty seconds. Finally, I gave them each a child-resistant pill container. None of the children could open it.
The lessons are clear. Even if your own children are out of the house, when grandchildren or visitors come, make sure to safely store your and their medication out of sight. If you use easy-open pill containers, remember that these can be incredibly dangerous around children. For your everyday medications: Keep them cool, keep them dark, and keep them all locked up.
It seems like the bathroom is the most practical place to keep medications, since we often take them when we wake up or before bed, but dry, cool areas really are the best place to store them. Use bathroom cabinets for first aid items and health and beauty supplies that are not affected by heat and moisture. Most importantly, keep all medications out of the reach of children, whether you are at home or visiting.