Is “Natural” Better? Myth Busting Supplements, Modern Medicine, and FDA Approval

Is "natural" always better when it comes to your health? In this episode of The Savvy Patient, Erin Stein and Dr. Gillian Goddard unpack what terms like "natural" and "unnatural" mean when it comes to the debate surrounding herbal remedies, pharmaceuticals, and dietary supplements. Tune in to learn about the history of plant medicine, the risks of unregulated supplements, how FDA approvals work, and how to safely evaluate what belongs in your medicine cabinet. Whether you take vitamins, supplements, or stick to prescription medications, tune in to learn how to evaluate efficacy and spot safety risks like a savvy patient!

We take a moment to remind you that while this is a medical discussion, it is not providing a diagnosis or treatment or any medical advice. The only way to get a diagnosis, treatment or medical advice for your particular condition is through a discussion with your doctor.

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Get your copy of The Hormone Loop by Dr. Gillian Goddard wherever books are sold.

This episode was produced and edited by Erin Stein. Music: “All We Live For (instrumental)” by Wolfclub licensed through Audiio.com. Intro and outro edited, and video created, by Ian Mayer. The Savvy Patient logo by Amanda Spielman.

TRANSCRIPT

00:00 Exploring Natural vs. Unnatural Remedies

03:52 The Historical Context of Plant-Based Medicines

07:45 The Science Behind Pharmaceuticals

11:45 The Risks of Herbal Remedies

15:49 The Role of Natural Ingredients in Modern Medicine

19:18 Understanding the Dangers of Natural Substances

22:54 Navigating Herbal Supplements and Medications

22:59 The Rigorous Process of FDA Drug Approval

26:33 Manufacturing and Quality Control in Pharmaceuticals

29:44 The Risks and Regulations of Herbal Supplements

39:27 Evaluating the Efficacy of Supplements

44:59 Understanding Vitamins and Their Regulation

Gillian Goddard: Welcome to the Savvy Patient.

Erin Stein: Welcome.

Gillian Goddard: Today is going to be fascinating. I feel like this is one where you and I come to this with a lot of different background.

Erin Stein: Yes, so today we're going to talk about what's natural and what's unnatural and what's good or bad about being natural or unnatural when it comes to medications and supplements.

Gillian Goddard: Remedies might be the word.

Erin Stein: Remedies, sure, treatments. My mother introduced homeopathic remedies and herbal remedies of various kinds, when I was a teenager, I guess, and so I have long used such things. Along with medications, I do not subscribe to one or the other exclusively.

Gillian Goddard: Whereas I grew up in a house where it was western medicine or western medicine, although recently my mother did—I did see that she had a bottle of Arnica in her medicine cabinet, so she's really like getting way out there now.

Erin Stein: Yeah, wow. All right, progressive. I will say my mother has a lot of issues with medications. There are a lot of medications she can't take that she has reactions to, and so I think that has continued to motivate her to seek out alternatives. But she was, I would argue, originally taken with the idea of things being more natural for your body versus unnatural for your body, right?

Gillian Goddard: Right. Which I think is the reason why a lot of people seek out herbal remedies, or alternatives to pharmaceutical products.

Erin Stein: Yes. There's a notion that if it is a plant and from the plant directly, that that is a more quote unquote “natural” thing to put in your body and that it will be gentler and some people feel it will be more effective because it's straight to the source, perhaps.

Gillian Goddard: Perhaps.

Erin Stein: And there is a lot of mistrust of medications—

Gillian Goddard: I think that's right.

Erin Stein: —some well-founded and some not. Both sides there. And this kind of plays into when we were talking about chemicals. You know, medications are seen as chemicals and chemicals are seen as bad because they're unnatural, they're human made, they are…

Gillian Goddard: Synthetic.

Erin Stein: Thank you. Synthetic. Somehow, it's not real. Like, it's not legitimate. And a lot of people like the idea of going backward in time to what people used to use before we had pharmaceuticals and the capability to formulate medications. They say, well, in whatever historical time period they chewed on some willow bark, for example.

Gillian Goddard: You can go back to almost any period of history prior to probably the late nineteenth and early twentieth century and find people using plant remedies. In fact, there's evidence that even pre-human people used plants as remedies. So certainly not a new idea.

Erin Stein: No. The idea of treating something is not the new idea. It's what was available and what is used to treat.

Gillian Goddard: Right.

Erin Stein: And I will say, fans of Outlander should be very familiar that, depending on the time period you're in, you use what's available. She uses herbal remedies in the past. Hospitals and pharmaceuticals forward in time.

Gillian Goddard: True. Ha ha ha.

Erin Stein: But if you pay attention, she is manipulating those herbs and plants to formulate more effective treatments out of them. You see how I'm segueing here?

Gillian Goddard: Mm, yes, yes, yes, yes. 

Erin Stein: The reality is that a lot of our pharmaceuticals, potentially half of FDA approved medications, are formulated based on plants, quote unquote “natural “sources.

Gillian Goddard: It's true. So many of the medications that we use in modern Western medicine were discovered in their original plant form and then refined to create the pharmaceutical product that gets sold on shelves. But it is true that so much of what we use was discovered by people who were, studying these plant remedies that people were using.

Erin Stein: Yes. And the other half of medications that are not derived from plant sources, what are those made out of?

Gillian Goddard: So those tend to be derived in a couple of different ways. Some of them are iterations on a theme, so the plant-derived medication is sort of the original, and then they iterated on that theme to something that maybe is similar but works better. Statins are a great example of this. The active ingredient in statins was originally discovered in red yeast rice, and it was the yeast, the fungi, that were actually making the statin compound. And you can still buy red yeast rice, and it still will act like a sort of weaker acting statin if you get a product that actually contains what it says it contains. It will lower your cholesterol somewhat, but basically what pharmaceutical companies did was make similar molecules that became more and more potent so you could take less and less of them to get the desired effect. The most commonly used statins now, which are atorvastatin, which was originally Lipitor, and rosuvastatin, which was Crestor, are some of the most recent statins that were developed in that line of research. That's one way that we get medicines that are not the direct compound that was found in plants. Another is animals. So, you know my favorite example of this is GLP1s. We discovered the basis for the very first GLP1, the compound exendin, in the venom of gila monsters, and then iterated on that theme to make all the GLP1s that are now available. And then the third is a reverse engineering process. And this is a little bit more modern, which is, we want to have this effect. And so, we're going to create a molecule that has this specific effect in the lab. A good example of this would be some of the new non-hormonal medications for hot flushes and night sweats. Basically, they discovered that there's a specific receptor in the temperature sensing centers of the brain in the hypothalamus, and estrogen acts on this receptor. So, they wanted something that would only act on this receptor and not necessarily act on other estrogen receptors in the body. And so, they created a molecule to do that. And there's actually these huge lists of patented molecules that exist and you can search the list for specific attributes that you are looking for to get potential candidates. And that's where a lot of pharmaceutical companies start making medicine.

Erin Stein: That's interesting. Animal sources–-arguably, also natural sources.

Gillian Goddard: Yes, yes. Although I don't think we would want to get bit by Gila monsters in order to lose weight or treat our diabetes. 

Erin Stein: No, I don't want that to happen, no. Pretty sure I don't want to pet one either. And then reverse engineering from what's happening in the body, also a kind of a natural start anyway.

Gillian Goddard: Well, I mean we are natural. Humans are natural.

Erin Stein: Funny how that works. This is the thing we're going to talk about. We have this idea that if you pick it straight out of the ground it's more natural, but why would that maybe not be so great?

Gillian Goddard: Yeah, absolutely.

Erin Stein: There's a couple of things. aspirin is from the bark of the willow tree, which people used to just chew on it or make teas, I think. But now we make aspirin out of it. And so yes, if you gnaw on some willow bark, it might have a small effect on a little bit of pain, but I don't trust what's on the willow bark from the tree in my backyard. I don't know what else I'm chewing and I don't know how much I'm getting in that chunk of bark that I'm chewing on.

Gillian Goddard: Yes. The other thing to know though about that is what's in the willow bark is salicylic acid. And so salicylic acid, you'll see in a lot of acne washes. 

Erin Stein: Yeah, I was just going to say, isn't that in my Clean and Clear?

Gillian Goddard: Yeah, it's in your acne wash. And the reason it's in your Clean and Clear is because it's an exfoliant. And so, you can imagine if you're taking an exfoliant and taking it orally, that it could have some unwanted effects. And indeed, salicylic acid on its own doesn't do well in the stomach. And that is part of the reason why they developed acetylsalicylic acid, which is a little bit easier for the stomach to tolerate, and then later they did things like coat it in buffering coatings. Bufferin is buffered aspirin that is going to be less irritating to the stomach. It made it easier to tolerate, among other things.

Erin Stein: Among other things. And morphine and codeine from opium, poppy flowers, is another thing. Clearly you can overdose on such things.

Gillian Goddard: Yes, a hundred percent, right?

Erin Stein: You don't want that to happen.

Gillian Goddard: And people used to do that with morphine and still do it with fentanyl, often because their street drugs are laced in it, but that's a topic for another day. 

Erin Stein: Opium's always been a problem. yeah.

Gillian Goddard: Opium has always been a problem from an addiction point of view.

Erin Stein: But it is a very powerful pain reliever.

Gillian Goddard: It is and there are many, many times when it is completely warranted to use it, to prevent people from being in pain temporarily, or at end of life. It has very important uses for pain management.

Erin Stein: So, there's two things that I see when I was looking up examples of this. Sometimes there are legitimate sources, you know, willow bark was used, sweet wormwood was used in Chinese medicine and now is a primary treatment for malaria. With these sources, there was something there there.

Gillian Goddard: There was.

Erin Stein: And they were able to turn it into a safer, more consistently dosed medication. But sometimes there's something that's not there there.

Gillian Goddard: Mm-hmm.

Erin Stein: Like wild yam.

Gillian Goddard: Yes. 

Erin Stein: Which many people have cited to me as a non-hormonal way to treat hormonal issues, to just rub some wild yam cream in certain places, and that's because people say it's a natural source of progesterone because it contains a chemical that can be turned into other hormones such as progesterone in a lab. But in the human body, it doesn't do that.

Gillian Goddard: Details.

Erin Stein: Details. Wild Yam doesn't do the thing people think it does. And while theoretically there's some basis for thinking it would, because they were able to do that in a lab, but they weren't able to do it in the human body. It doesn't work in the human body. It is not a natural remedy. It doesn't do shit.

Gillian Goddard: Correct. Here's the other thing to think about: we use plant sources to make pharmaceuticals sometimes. So, estradiol, which is the bioidentical form of estrogen that many women take in the form of an estrogen patch or estrogen gel, it is identical to the estrogen made in the ovaries. It starts as plants and they literally use plants to make it in many cases. They isolate and convert plant isoflavones into bioidentical estradiol.

Erin Stein: There you go, people. Plants.

Gillian Goddard: Here's the thing. Historically, people would find things that were really, really effective. And if they couldn't cultivate them, they could run into trouble. My favorite story about this is a plant called Silphium. Silphium was sort of a fennel-like plant and in the ancient world in Greece and Rome, they used it for all different kinds of things, in cooking, etc. But it was an incredibly effective contraceptive and abortifacient, incredibly effective. And so, they tried for many years to cultivate silphium as a as a crop because you know they wanted to be able to control their childbearing, go figure.

Erin Stein: Yep.

Gillian Goddard: And they never could actually get the plant to grow in a cultivated environment, and they used it to extinction.

Erin Stein: Ugh, those Greeks and Romans.

Gillian Goddard: Yeah, they literally ate so much of it that it was gone.

Erin Stein: It kind of fits with what we think we know of ancient Greek and Roman culture. The debauchery, the orgies…

Gillian Goddard: Yes. Yeah. The spas and the bath houses.

Erin Stein: They had a lot of use for this plant. I think that's fascinating.

Gillian Goddard: Yeah, it's one of my favorite stories about the ancient world.

Erin Stein: So, like all things, if we find something, we use it up.

Gillian Goddard: Yes, we use it up when it's in such high demand and then we have to turn to new things.

Erin Stein: This is a little bit of just fun trivia also this topic, because then we have things like penicillin.

Gillian Goddard: Mm, yes, the lab accident.

Erin Stein: Most of us have heard of this and learn about it in school at some point as being an incredible discovery.

Gillian Goddard: Yes, by accident. Somebody went on vacation, actually. And their plates got contaminated with mold and they…

Erin Stein: See? This is why you should take a vacation.

Gillian Goddard: That's right.

Erin Stein: Don't work too hard. Take a vacation.

Gillian Goddard: The petri dishes got contaminated with mold and when they came back the mold had kind of taken over the petri dishes, but in the places where the mold was growing, the bacteria were not and that was penicillin.

Erin Stein: But do we go around eating mold?

Gillian Goddard: I mean, I like blue cheese as much as the next person, but beyond that…

Erin Stein: Well, I guess there are some of you weirdos out there. I don't eat mold. But I don't think blue cheese treats bacterial infections.

Gillian Goddard: No, wrong kind of wrong kind of mold. Wrong kind of mold. And all the other -cillin antibiotics, so amoxicillin, etc., all those other antibiotics are iterations on the penicillin theme, which is why they end in the same ending. That's how we name medications.

Erin Stein: I would argue it's somewhat natural.

Gillian Goddard: Mm-hmm. Mm-hmm. And a good thing. Lots fewer people die from infections now that we have antibiotics.

Erin Stein: Yes, yes. The other one I wanted to mention was digoxin from the foxglove plant.

Gillian Goddard: Yep.

Erin Stein: And I like this because I feel like it's mentioned in novels all the time. People using foxglove for nefarious purposes usually in a novel.

Gillian Goddard: Yes, digoxin is an antiarrhythmic medication, one of the first medicines to treat heart rhythm problems. IT is still used today, although less so than it was even when I was in my training. Very effective medication.

Erin Stein: And there are other medications that are natural plants that are essentially poisons.

Gillian Goddard: Mmm. Yes, exactly. this is a total digression, but you know, what do we do if we don't digress?

Erin Stein: Sure, that's what we're doing here.

Gillian Goddard: One of the coolest things I've ever been to is the botanical gardens in Montreal. And they have an entire garden of poisonous plants. So, paclitaxel, I think is what you're getting at here. Paclitaxel was derived from the Pacific Yew tree, and it is a chemotherapeutic agent. When you have a blockage in an artery in your heart they will put in a little metal cage called a stent that sort of pushes the artery back open and keeps it open. And they are often impregnated with drugs to keep the cells of the artery wall from just growing over and re-closing the stent. And the original drug-eluting stents were paclitaxel-eluting because it kept the cells of the artery wall from growing, using the stent essentially as a scaffold.

Erin Stein: That was a lot of nerdy science that you just threw at us.

Gillian Goddard: That's what I'm here for, isn't it?

Erin Stein: Wow. I haven't been to the Montreal one, but I'm pretty sure I've seen at other botanical gardens, at least little sections of poisonous plants. 

Gillian Goddard: Yeah, this one's huge. They have like hemlock and cherries.

Erin Stein: Arsenic?

Gillian Goddard: Arsenic, yep. Well, cyanide comes from the pits of different tree fruit like cherries for example.

Erin Stein: Watch out for the tree fruit, people. Don't eat pits. That’s definitely been a plot in a murder novel. The cherry pits, for sure.

Gillian Goddard: Yes. The cherry pits, yes. The other thing is one that people eat all the time and don't think about, which is licorice and licorice root.

Erin Stein: You're either pro licorice or anti licorice as a flavor and not Twizzlers. We're talking black licorice.

Gillian Goddard: Yes. And like the real black licorice made with real licorice flavoring, not like Brach's black jellybeans or something like that, true licorice candy. Licorice root has a compound in it that acts like cortisol and it can give you Cushing Syndrome if you eat enough of it. It can act like cortisol, act like steroid and make you gain weight and give you diabetes and give you that round moon face if you eat enough of it. 

Erin Stein: How much do you have to eat?

Gillian Goddard: You know, this was always like a [medical] board question. It'd be like, you're seeing this patient and they're never from the United States. They're always from someplace else and they import licorice candy and they really, really like it. As a result, they have new diabetes and they're gaining weight and no one can figure out why and it turns out they're eating like licorice candy imported from someplace else and they're eating, huge amounts of it all day long. And this gets into the supplement versus medication versus going out into your backyard and pulling up a plant. If you look at adrenal support supplements, many of them do have licorice root in them. And so, you do have to be careful because you can have unintended consequences when you take supplements that contain botanicals that have real active ingredients.

Erin Stein: Yes. Again, some herbal things do have an effect and some herbal things don't. And the problem is you don't really know how much you're getting in your supplement. We'll get to that in a second. but you can overdose on these herbal supplements just because it's natural, if it is effective then it should be treated like medication and you shouldn't just take tons of it. Many people misguidedly equate natural with safer.

Gillian Goddard: That's right. And they don't think about the fact that they're herbal supplement might be interacting with a pharmaceutical medication that they are taking. So, an example of this is St. John's Wort, which is a botanical supplement used to treat depression, really does raise serotonin levels, and so does your SSRI. And so, if you're taking St. John's Wort and your SSRI, you can potentially get something called Serotonin Syndrome, having too much serotonin, which is also problematic.

Erin Stein: Yes, and I think I am not supposed to be taking that because of Tamoxifen. Like there's a list of herbal things that interact with tamoxifen. It's, number one, teasing out what might actually be effective versus not. And then if it is effective and you prefer to take that, you should still talk to a doctor about it.

Gillian Goddard: Exactly. Exactly. Exactly. I do have patients who take red yeast rice because they struggle to take statins, but they tell me about it, and we talk about which one they're taking, and we monitor their cholesterol with blood work to make sure it's having the desired effect.

Erin Stein: So, let's go into the FDA approved medication versus herbal supplement.

Gillian Goddard: FDA approved medications go through years of rigorous study. A new compound first gets studied in animal models to prove that it might be effective and to make sure it doesn't harm the animals. These studies are usually done in rats these days. There are lots of reasons why rats are the animal of choice. Mostly it has to do with their short generation length, the fact that we know how to genetically manipulate them if needed, and the fact that we can keep them relatively humanely in a small space. And for those who are squeamish about animal research, let me tell you the researchers who do this research are highly regulated by oversight boards. They're all kinds of requirements about how you keep lab animals and what will happen to them. And I will also tell you that the vast majority of modern medicines wouldn't exist without animal research. So, we should be grateful for the people who work to make that animal research as humane as possible because we really would not have a modern pharmaceutical industry without it. But after it goes through animal research, they do pilot studies in people, which are small studies, just to see if there's a there there. Then they have to do studies to prove that the drug is safe. Not just effective, but safe, and they have to figure out the different dosing. So, they give people different doses of the medicine to make sure that doses are safe and they record things like side effects and adverse events. And then finally, after they do all of that, they're required to do large what are called phase three trials. those studies are big, randomized control trials to show efficacy, to show that the medication is effective. They're placebo-controlled and they are often months to years in length and are very carefully monitored by people making sure that these studies are conducted in an ethical and rigorous way. And that is the data that gets submitted to the FDA, the phase three trial. And then these days, pretty much all new medications undergo what are called phase four trials, which are post-marketing trials. So, the drug is now approved by the FDA, it's on the market, and the company that is manufacturing it is still required to collect data, particularly to make sure that they're not seeing adverse events that weren't seen during the clinical trials and to make sure that there aren't longer term adverse events. So really the process of taking a drug from a botanical that is effective all the way through to marketing it is quite involved. And some of the medicines that we take now that were developed before and were kind of grandfathered into this system; like aspirin for example didn't undergo those types of trials but we now have more than a hundred years of people taking aspirin and we are pretty well aware of its benefits and risks. But the other thing that's different about pharmaceuticals is not just the process that it takes to bring them to market, but what happens when they start manufacturing them in bulk, which is that they have to be manufactured in factories both in the US and outside the US that are regulated by the FDA. The FDA actually has inspectors that go out to the manufacturing plants and does spot quality control checks to make sure that the factories are using best practices for cleanliness and to make sure that from one batch to the next, if you think that you're getting 81 milligrams of aspirin, you are in fact getting something fairly close, plus or minus 10%, to that 81 milligrams of aspirin. You have to show that you can consistently produce the same product with the same amount of active ingredient in it over and over and over again. And in fact, many, many, many, many, many drug recalls that occur have nothing to do with impurities getting in the medication or anything like that. It's that the pills or liquid or however the medication is given often doesn't have enough of the active ingredient in it. That is actually among the most common reasons why medications are recalled. 

Erin Stein: That's interesting. Obviously, safety and that people can take the medication without adverse effects is number one, but a key part of that process that I think gets glossed over easily is the dosage, figuring out what dose, A, has the effect you want it to have, and B, does not have any bad effects that you don't want it to have. And that is a huge part of the clinical trial process.

Gillian Goddard: It is, it is. And it is so, so important because you not only need to take a certain amount to get an effect, a lot of times there's a point at which you don't get more effect, but you do get more side effects. And so, finding that upper threshold of efficacy—you know, how effective is increasing the dose more and more and more—finding that upper threshold of efficacy is really important.

Erin Stein: Super important.

Gillian Goddard: When taking anything, supplement or medication, the decision you are making—and I don't think people think about it this way, but it is the decision you are making—is do the potential benefits to me outweigh the potential downsides to me? And the benefits being that the medicine or supplement is doing whatever it is you want it to do, and the downsides being, side effects and/or adverse events.

Erin Stein: Or poisoning yourself by taking too much. You can so easily take too much of things.

Gillian Goddard: A hundred percent. A hundred percent. Yes.

Erin Stein: So, herbal supplements. What's in them?

Gillian Goddard: Who knows? Probably not lead.

Erin Stein: I hope not. Hopefully not some asbestos.

Gillian Goddard: Yeah. The number one thing that herbal supplements are tested for is anything that foods are not supposed to contain. The FDA has minimum thresholds that you have to be below for certain impurities in foods because there's lots of naturally occurring things like arsenic and lead in soil where food is grown. 

Erin Stein: Yes. they are natural.

Gillian Goddard: They are, they are. So, you know, they're in food. And so, the FDA has thresholds and different states actually have different thresholds for how much of these naturally occurring compounds can be in food in order for the food to be safe. And because herbal supplements, all supplements, are regulated as food and not as medication, the main regulation around herbal supplements are that they not contain more than these minimum thresholds for certain things like lead, for example.

Erin Stein: If different states have different levels, I take that to mean some states have more stringent rules about what is in supplements.

Gillian Goddard: California has some of the most stringent rules. that is why you'll see now all of a sudden, they're finding lead in these products, and it's because California actually recently lowered the threshold for how much lead can be in a product to a very, very, very, very, very low level. but if you think about like a national manufacturer, if they're going to sell in California, they have to meet the California requirements. 

Erin Stein: Well, that was my question. Is it that requirement to be sold there or to be produced there?

Gillian Goddard: And so yeah, to be sold there. And so, most of these products are actually trying to meet the most stringent requirements because they want to be sold in California, which is, as you can imagine, quite a large market. But the FDA doesn't review any claims made by herbal supplement marketers and manufacturers. let me say that again. They don't review any claims made by supplement manufacturers. meanwhile, pharmaceutical manufacturers claims are very strictly regulated.

Erin Stein: I think it's worth pointing out that means if they say it does something, no one's checking to make sure it does that on a supplement.

Gillian Goddard: That's correct. If it's a supplement. If it's a pharmaceutical…

Erin Stein: They very much checked it.

Gillian Goddard: Yes, they very much checked it. And then they continue to watch for problems. They do not regulate herbal supplements claims of efficacy of the product being effective for any of the things that they say it's effective for. They don't actually regulate the composition of the herbal supplement, meaning they don't actually test to make sure that the herbal supplement contains what they say it contains. So, if you are buying a supplement that says it contains St. John's Wort, for example, it may or may not actually contain St. John's Wort. It may not. And it may not contain the amount that it says.

Erin Stein: Right. So, it may contain a little bit and some sawdust.

Gillian Goddard: Or it could contain way more. The other thing that the FDA does not do to the same degree is regulate the manufacturing process itself. You may have heard about food manufacturing companies having some pretty scary things going on in their factories because they haven't necessarily been inspected in a long time. Herbal supplement factories are regulated the way that food manufacturers are regulated, not the way pharmaceuticals are regulated, and they do not undergo the same kind of scrutiny.

Erin Stein: That is a major point to make, that the government spends more resources inspecting pharmaceutical production facilities than they do our food facilities.

Gillian Goddard: Yes, that is correct. Yes.

Erin Stein: That is disturbing.

Gillian Goddard: And true.

Erin Stein: And true. That just gives you a comparison. Like, if you trust the chicken you're buying at the grocery store, you should trust the prescription medication because it's been vetted a lot more and the quality control is higher.

Gillian Goddard: If you eat lunch meat, if you eat deli meat, for example, lots more scrutiny goes into pharmaceuticals. The other thing is that you just have to take a lot less of a pharmaceutical product because it contains the purest form of the active compound that they can make and they're actually often iterating on that to make it less and less all the time. So, for example, people take methylphenidate to treat ADHD, that is the active ingredient in Ritalin, is methylphenidate. And way back when somebody decided that at least for some people only one form of methylphenidate, the right-handed form, dexmethylphenidate, was more was more effective than giving people both left-handed and right-handed methylphenidate. And so, they started marketing dexmethylphenidate, which is marketed mostly as Focalin and Concerta. And so, people are refining these medications all the time so that you can take less [of the] active ingredient, but only the most effective active ingredient. And if you didn't understand my left-handed methylphenidate versus right-handed methylphenidate, I'm afraid you'll have to go back to chemistry class.

Erin Stein: Nope. No thank you. I'm going to take your word for it for now and someday we will do an episode about ADHD and then you can explain it better, maybe. But my high school chemistry class did not cover that. Or if it did, I've long forgotten. That's potentially more true.

Gillian Goddard: It's been a while.

Erin Stein: I really think this is so important because I just know there's some brains out there that are like, well, if I take three herbal supplement pills and it's the same amount of the plant or whatever that I'm getting in one pill of a pharmaceutical, what does it matter? I'm still getting the same amount.

Gillian Goddard: Well, what's making up the rest of those supplement pills?

Erin Stein: Well, that, but also, it's not a one to one. The form is different. The form has been refined to be more effective at a smaller amount and to minimize side effects, especially gastrointestinal issues would be my guess for a lot of these.

Gillian Goddard: Yes, and can I tell you how many people come into my office and they tell me they're having terrible stomach pain, and I ask them if they're taking any medications and they say no. And I ask them if they're taking any supplements and they give me a supplement list that's like twenty supplements long. In my brain, I am always like “ding ding ding ding ding ding ding.” 

Erin Stein: There's your stomach problem.

Gillian Goddard: There is your stomach problem because there's so much filler and cellulose and coatings and extra stuff in all those supplements that it's just irritating the hell out of your stomach.

Erin Stein: Well and potentially pesticides? Like here's the other thing. They are plants. Where are they growing these plants? How are they growing these plants?

Gillian Goddard: Well and again they are subject to the same regulations that food is subject to. So, they have the same restrictions around pesticide content as food does what pesticides can be used.

Erin Stein: Some of us have thoughts and feelings about how we regulate what's used on our food already. So those same thoughts and feelings will apply to a supplement.

Gillian Goddard: A hundred percent.

Erin Stein: Also, I see this in a micro way in my little, tiny garden that we have with some tomatoes and we have literally one zucchini and one cucumber now growing…You cannot control what's happening. There's weather, there's hot temperatures and cold temperatures, there's rain, then there's a drought. Then there's the soil you're using and the acidity or alkaline aspect of it. There's when you harvest it, how you treat the plant. Like there's so many elements to whether a plant produces food, let alone contains whatever the chemical compound is that you're growing it to use, the plant itself may or may not contain more or less of that depending on growing condition. And I don't think a lot of these places are testing the plant. They're just harvesting the plant and turning it into a supplement; however they're doing that. Right? 

Gillian Goddard: Yeah.

Erin Stein: So, some supplements do things, and you might want to take one.

Gillian Goddard: Some supplements do things. Some supplements do things that we don't have medications or pharmaceutical forms on offer.

Erin Stein: Such as?

Gillian Goddard: Aspirin is not a supplement. It's an over-the-counter medication. it's regulated, but not as much as a pharmaceutical is. Over-the-counter medicines are between food and pharmaceuticals. Closer to pharmaceuticals.

Erin Stein: Well, I think that's important I wasn't necessarily making that distinction between “prescription medications,” is what I would call it, instead of “pharmaceutical” versus “over the counter.” Although some over the counter medication used to be prescription.

Gillian Goddard: Many of them, yes. Allergy medicines are the best example of this. The allergy section of your CVS is full of medicines that used to be prescription only and now are available over the counter. And there's some things that have been grandfathered in. Aspirin and acetaminophen, which is Tylenol, were grandfathered in when the FDA started sort of their modern regulation of pharmaceuticals. So, they've always been available over the counter in the sort of modern medical era. but I’m thinking about supplements like iron. There are prescription-strength irons but they're really hard on people's stomachs so I almost always recommend an over-the-counter supplement because it's easier for people to tolerate. I'm thinking about magnesium supplements, calcium supplements, calcium… many are derived from natural sources. Calcium citrate like Os-Cal. It's from shells actually.

Erin Stein: I'm taking seashells, okay.

Gillian Goddard: Not whole!

Erin Stein: Should I just be at the beach licking seashells? Haha.

Gillian Goddard: Please don't do that. Please don't. There's lots of other stuff in those shells that is not calcium citrate. 

Erin Stein: They usually smell bad.

Gillian Goddard: They really do. Yeah, so there are times when your best option is a supplement and then what do you do about that? You try to go with a reputable brand.

Erin Stein: So, we're not saying all supplements are bad or that all supplements do nothing. We're saying you should research it and or talk to your doctor.

Gillian Goddard: That's the biggest thing is you should be talking to your doctor about whether it does what you think it does and whether it's appropriate for you and safe for you, whether it plays well with any medications and supplements that you are taking, and how to appropriately monitor it and its efficacy.

Erin Stein: Yes, and how would you evaluate a company that produces supplements to look for a more trustworthy producer, perhaps?

Gillian Goddard: There are third party groups that will go out and validate supplements. I think the best thing you can do is go with a reputable brand. There are a couple of brands that I do routinely recommend. I was just talking about calcium, and I mentioned Os-Cal, that's the brand, but all of the store brand versions of Oscal are made in the same factory as Os-Cal. So, you can go with a store brand. That's true of a lot of store brands, by the way. They're often manufactured on the same lines as the brand brand for over-the-counter products.

Erin Stein: So, like the CVS or Walgreens version of something?

Gillian Goddard: Yeah.

Erin Stein: Interesting.

Gillian Goddard: Yeah. I like Thorne, T H O R N E, as a supplement brand. For some supplements that are simpler supplements, I like Metagenics, which is a brand that you have to buy typically kind of through a doctor's website. But a lot of doctors have websites and usually if you just search Metagenics, you can find a portal through which to buy it. One of the things I don't like about their products is a lot of them contain a lot of different ingredients. And I think that usually with supplements simpler is better. But they do make a good magnesium supplement and a good B12 supplement.

Erin Stein: Well, I guess what I'm getting at is, how do you know they're good? Have you looked at how they manufacture it or their company practices or have you just used it, and seen patients tolerate it well?

Gillian Goddard: In the case of both Metagenics and Thorne, I've actually done some research into their manufacturing process. But also, then have seen, if you take red yeast rice from Thorne, I have seen people take it and their cholesterol goes down. So, both, like, the proof is in the pudding a little bit, but also there are specific brands where I've done a deeper dive into their manufacturing processes to be able to recommend them.

Erin Stein: You're essentially looking for quality assurance and independent verification.

Gillian Goddard: Yep. Exactly. Exactly.

Erin Stein: Every time we talk about supplements we also have to talk about vitamins. Vitamins are technically different.

Gillian Goddard: Not just technically, they are different. Vitamins are things that we need to consume because we cannot make them. We mostly get them as plant sources. So, this is all those B vitamins, B1, B2, B6, B12, Vitamin C, Vitamin D, E, Vitamin K.

Erin Stein: Yes. And when you're taking a vitamin as a pill or chewable or whatever, how is that manufactured and or overseen or not?

Gillian Goddard: As food unless it's a prescription vitamin. So, if you are taking a prescription vitamin D, there's a very specific type of vitamin D that's given as a prescription. That is regulated as a prescription. But here's an example. Fish oil. Fish oil lowers triglycerides. It is active and has been shown to have some benefits for people. There is both over-the-counter fish oil that people take, and there are a couple of brands of prescription fish oil that are more highly refined. And those prescription fish oils are regulated by the FDA as a pharmaceutical product and the fishy smelling capsules that you buy off the pharmacy shelf are regulated as food.

Erin Stein: Oh my god. Okay, so vitamins, essentially the same as supplements. Research the company, look at what's in them.

Gillian Goddard: Take them in the same way, in conjunction with a conversation with your doctor. Make sure you actually need them.

Erin Stein: Yes, and you mentioned what else might be in them. That's particularly true if you are a person who has allergies or sensitivities. Like lactose is actually in medications, both prescription and otherwise. So, it's worth looking at the ingredients in whatever it is, medication or supplement, actually.

Gillian Goddard: From a supplement point of view, my rule of thumb would be that you're looking for a short ingredient list.

Erin Stein: Yep. Well, this was complicated. I learned some new things. People are going to have questions about this.

Gillian Goddard: Absolutely. Send them on and we'll be sure to address them.

Erin Stein: I think natural is not automatically better or safer.

Gillian Goddard: Correct.

Erin Stein: It is checking on the efficacy and the dosage and the safety of what you are taking, 

Gillian Goddard: For you.

Erin Stein: …regardless of how you are taking it. Yes. And I'm going to argue that foraging for stuff in your backyard is probably not a safe way to medicate yourself.

Gillian Goddard: No, although it might make a good salad.

Erin Stein: I did in fact use several herbs out of my yard yesterday on dinner. Make yourself some peppermint tea. That's fine. But don't lower your cholesterol with the stuff from your backyard necessarily.

Gillian Goddard: Please don't. Please don't.

Erin Stein: Okay. Send us your questions. Good luck out there.