Survey of Advertising for NutritionalSupplements in Health andBodybuilding MagazinesRossanne M. Philen, MD, MS; Diana I. Ortiz; Steven B. Auerbach, MD; Henry Falk, MD

The use of food supplements by the general public is poorly quantified, and lit-tle information on this subject is available in the medical literature. We surveyed12 recent issues of popular health and bodybuilding magazines (1) to quantifythe number of advertisements for food supplements, the number of productsadvertised, and the number and type of ingredients in these products; (2) toidentify the purported health benefits of these products; and (3) as a preliminaryeffort to identify areas for future research. We counted 89 brands, 311 products,and 235 unique ingredients, the most frequent of which were unspecified aminoacids; the most frequently promoted health benefit was muscle growth. We alsofound many unusual or unidentifiable ingredients, and 22.2% of the productshad no ingredients listed in their advertisements. Health professionals may notbe aware of how popular food supplements are or of a particular supplement'spotential effects or side effects. In addition, patients may be reluctant to discusstheir use of these products with traditional medical practitioners. We recommendthat routine history taking include specific questions about patients' use of foodsupplements and that any possible adverse effects or side effects be reportedto public health authorities.

(JAMA. 1992;268:1008-1011)

TWO recent public health problems involving tryptophan-associated eosino-philia-myalgia syndrome and adverse effects associated with use of

- -hydroxy-butyric acid highlighted the widespreaduse of legal and illegal food supplementproducts and the potential hazards involved.1"9 Although tryptophan and -y-hy-droxybutyric acid occur naturally in humans, both were taken in quantitiesmuch larger than required by the body,

From the Division of Environmental Hazards andHealth Effects, National Center for EnvironmentalHealth and Injury Control, Centers for Disease Control,Atlanta, Ga (Drs Philen, Auerbach, and Falk), and De-partamento de Ciencias y Technolog\l=i'\a,Universidaddel Turabo, University Station, Puerto Rico (Ms Ortiz).

Reprint requests to Division of Environmental Haz-ards and Health Effects (F28), National Center for En-vironmental Health and Injury Control, Centers for Dis-ease Control, 1600 Clifton Road, NE, Atlanta, GA30333(Dr Philen).

both were taken for their pharmacologieeffects, and both were synthetically manufactured (advertised claims notwithstanding). Although consumers may usethese products for their pharmaceuticalproperties, they may not consider foodsupplements as drugs, and physiciansmay not routinely elicit a history oftheiruse.

The proportion of the population thatuses food supplement products is unknown, and there is little information inthe medical literature on this subject.10We hypothesized that these productsmight be popular among health-consciouspersons or those who purchase health andbodybuilding magazines. Therefore, as apreliminary step to quantifying the typesoffood supplement products available andto identify potential areas for future research, we surveyed health and bodybuilding magazines to determine the ex-

tent of advertising for these products aswell as the number and type of ingredients used in these products.METHODS

We purchased a single issue of each of12 health or bodybuilding magazinespublished during June, July, or August1991, at local Atlanta, Ga, area supermarkets, bookstores, and card shops (Table 1). One copy of each health or bodybuilding magazine available was purchased at each store, without repeatingtitles. Thus, magazines used in the studywere selected by the stores and not bythe investigators. We reviewed eachmagazine page by page for advertisements for food supplement products andtabulated any advertised as tablets, capsules, or powders. No liquid supplementproducts were included.

Information in each advertisement including manufacturer, brand name, product name, all advertised ingredients, benefits attributed to consuming the product, dosage information, and the telephone number and address of themanufacturer or distributor (when available) was entered into a computerizeddatabase.

Using this information, we determinedthe number of products advertised, thenumber of unique ingredients in all advertised products, and the number oftimes any ingredient was mentioned inany advertisement. We then categorizedthese data into major groups of ingredients and products and also categorizedthe purported health benefits or effectsof the products.

We attempted to identify the knowntoxic properties of the ingredients byreviewing several chemistry, biochem-

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istry, pharmacology, medical, and herbal textbooks as well as by searchingthrough MEDLINE, Toxline, and Pois-Index.11 ~'M Ingredients that did not fitinto a category or that could not bereadily identified were included in themiscellaneous category.RESULTS

Using 12 magazines as our source, wecounted 89 companies, 311 products, 235unique ingredients, and 914 instanceswhen ingredients were mentioned. Only242 products (77.8%) listed ingredients,and we sorted those 914 instances wheningredients were mentioned into 15 categories (Table 2). A mean of 26 productswere advertised in each magazine.

In our survey, we found that aminoacids were the most frequently mentioned ingredients (198 [21.7%] of 914instances when ingredients were mentioned), and 104 (33.4%) of 311 productsincluded one or more amino acids as aningredient. In 56 (53.8%) of the 104 products, one or more amino acids were specified; 63 products (60.6%) contained unspecified amino acids. (Percentages total more than 100% since 15 productslisted both specific and nonspecific aminoacids as ingredients.) Tryptophan wasadvertised as an ingredient in one product (which did not list a company nameor address), although products containing tryptophan were recalled at the request of the Food and Drug Administration (FDA) in November 1989because of their association with eosino-philia-myalgia syndrome. The tryptophan dosage in this product was1000 mg, which suggests that the tryptophan is manufactured.

Many products were promoted formuscle growth and enhanced strength,and steroid-type ingredients were advertised as being in 28 (9%) of 311 products. With the exception ofecdysterone,the named sterols were all plant derivatives: -sitosterol, campesterol, dios-genin, fucosterol, and stigmasterol.Ecdysterone is an insect hormone withno known use in humans, and the recommended dosage was 1000 mg per dose.Diosgenin is found in yams, and pharmaceutical companies have used it tomanufacture progesterone and cortisone.25 The most frequently specified ingredients are listed in Table 3.

Although some ingredients were notmentioned frequently in advertisements,they are unusual enough to deserve special mention. For example, the prescription medication levodopa was listed asan ingredient in one product, withoutany information on dosage or side effects. A few products included were advertised as having glandular materialsuch as adrenal, hypothalamus, and neo-

Table 1.Magazines Surveyed tor Food Supplement Advertisements, Study of Food SupplementAdvertisements, 1991

Title DateBetter Nutrition for Today's Living June 1991Bodybuilding Lifestyles July 1991Bodypower Plus June 1991Diet and Lifestyle June/July 1991Fitness Plus July 1991Flex July 1991Ironman July 1991Muscle and Fitness July 1991Muscle Mag International August 1991Muscle Training Illustrated July 1991Natural Physique June 1991Women's Physique World Summer 1991

Table 2.Principal Categories of 914 InstancesWhen Ingredients Were Mentioned in AdvertisedProducts, Study of Food Supplement Advertisements, 1991

Category of Ingredient No. (%) of MentionsAmino acids 198(21.7)Miscellaneous 175(19.1)Herbs 130(14.2)Vitamins 105(11.5)Trace minerals 69 (7.5)Minerals 47(5.1)Steroids 39 (4.3)Protein 36 (3.9)Fats 36 (3.9)Enzymes 23 (2.5)Glands 23 (2.5)Carbohydrates 21 (2.3)Over-the-counter medication 7 (0.8)Bacteria 4 (0.4)Prescription medication 1 (0.1)

natal pituitary hypothalamus concentrate, without indicating the origin ofthis material. Also advertised were ingredients to which we could find no references in the medical literature: conchgrass, muira puama, or uva ursi. Wefound references to one product only inThe American Journal ofChinese Medicine: dong quai was referred to as anherbal "tonic for women."26 In a brochure we obtained at a health food store,one advertised ingredient, gotu kola, waslisted as an "herbal tonic"11; the samebrochure listed "nettle herb" as a "dietary supplement."

No health effect was mentioned for 90products (28.9%), and the most frequently advertised health effect wasmuscle growth, a claim made for 59(19.0%) of the 311 products. The mostcommonly claimed health effects arelisted in Table 4.

In 221 (24.2%) of 914 instances whenspecific ingredients were mentioned,dosage information was also provided;66 (29.9%) of221 were dosages for aminoacids, more than for any other ingredient. The doses for amino acids rangedfrom 350 mg for some single amino acidsto 40 000 mg of unspecified amino acids.The dose for folie acid in one productwas 10 mg, although the US recommended daily allowance for this vitamin

Table 3.Most Frequently Mentioned Ingredientsby Specific Name, Study of Food Supplement Advertising, 1991

No. (%) ofInstances WhenIngredients Were

Ingredient Mentioned (n=914)Amino acids (not specified) 40 (4.4)Chromium 30 (3.3)Branched-chain amino acids 27 (3.0)Minerals (not specified) 26 (2.8)Vitamins (not specified) 26 (2.8)Boron 22 (2.4)Inosine 20 (2.2)Smilax 18(2.0)Carnltine 18(2.0)Dibencozide 18(2.0)Gamma oryzanol 17 (1.9)Ginseng 16(1.8)

Table 4.Principal Effects Attributed to 311 FoodSupplement Products, Study of Food SupplementAdvertisements, 1991

No. (%) of311 Products

Effect Claiming EffectMuscle growth 59(19.0)Increased testosterone levels 27 (8.7)Nutritional supplement 21 (6.8)Energy enhancer 17(5.5)Fat reduction 15(4.8)Increased strength 12 (3.8)Growth hormone releaser 8 (2.6)No effect listed 90 (28.9)Other effects 62(19.9)Total 311

is 400 v^>mmmm>fn one twenty-fifththe amount in one dose of this product.Most ingredients for which dosages weregiven in the advertisements were itemsfor which no recommended daily allowance has been established.COMMENT

As part of taking a routine medicalhistory, standard medical practice requires physicians to question patientson the use of medications and drugs.Patients may hesitate, however, to disclose their use of food supplement products for several reasons: they may notconsider that these items are drugs, orthey may not wish to admit to traditional medical practitioners that theyuse alternative or nontraditional formsof treatment for their disorders or thatthey use products that are intended forsuch questionable effects as testosterone enhancement or supplementation.

In our survey, we found that plant andinsect steroids were included in 9% ofproducts advertised. Despite intensiveliterature surveys, we could find no information on the effects on humans of consuming these plant and insect steroids.Several investigators, however, have examined various aspects of ecdysterone'seffects on rats and other species.28'31

Canthaxanthin, a synthetic non-provitamin A carotenoid, is frequently ingested for skin-tanning purposes and

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was advertised as being in two productsfor which no purported effects weregiven. One death due to aplastic anemiahas been reported in an individual whoused this product, although it is not clearthat canthaxanthin use was the cause ofdeath.32 For another product, hydrangea was listed as an ingredient. Theleaves and buds of hydrangeas areknown to contain cyanogenic glycosidesand may induce cyanide poisoning if consumed.13*1238

Although for most ingredients, including vitamins, doses were not given inthe advertisements, the dose of folie acidin one product was 25 times the USrecommended daily allowance of 400 g.Products that contain more than 1 mg offolie acid are treated as drugs underexisting regulations, and high levels offolie acid may mask symptoms of pernicious anemia, which could potentiallylead to irreversible neurologic damage.14In a 1987 report, the American MedicalAssociation (AMA) divided vitaminpreparations into two categories: vitamins used as therapeutic agents and vitamins used as dietary supplements.33The AMA recommended (1) that vitamins used as dietary supplements be nomore than 50% to 150% of the recommended daily allowance and (2) that vitamins used as therapeutic agents notexceed two to 10 times the recommendeddaily allowance and that such vitamins"should be recommended by a physicianaccording to specific medical indications."33 Clearly, the preparation containing 10 mg of folie acid far exceedsthese recommendations.

Though this survey does not quantifyactual product use, it does assess whattypes of supplement products are available to the public and what effects (ifany) these products are advertised tohave. The results described here illustrate that a wide variety of food supplement products are readily availableto the public and that many of thesecontain ingredients on which information is not readily available. Food supplement products are easily obtainedthrough mail order, health food stores,drug stores, and specialty nutritionstores. Despite their widespread availability, we could find no toxicologicalinformation for humans on 139 ingredients (59%), although we did extensiveliterature searches. Usually, in the advertisements for these products, little,if any, mention was made of possibleside effects or of conditions that contraindcate their use (such as pregnancy,hypertension, or thyroid disease); suchwarnings are often mentioned on non-prescription medications. Recommendeddosages were rarely mentioned in theadvertisements, and the amount of each

ingredient was seldom noted.Advertisers of these products were

not reticent in their claims. Phrases suchas "the most potent alternatives to anabolic steroids legally available"34 or"outperforms anything legal"35,36 werecommon. Readers were urged to purchase products before "upcoming Homeopathic and FDA regulations make[Product Name] a prescription onlyitem."35 Products were openly advertised as being as strong as or strongerthan testosterone and as being more efficient at increasing muscle size. Someadvertisers openly attempted to circumvent regulations intended to preventfalse or misleading claims by makingstatements such as the following:Unfortunately our ads for [Product Name]caused such a stir that even the FDA thoughtthey sounded too good to be true. As a resultthey've asked us to stop making all healthclaims for [Product Name]. They contend thatsuch claims make [Product Name] a drug!!!What claims specifically? Things like

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testosterone booster, growth hormone releaser,anabolic activator, incredible gains in leanmuscle mass, energy enhancer, fat burner...and so on... We determined that ifwe took allhealth claims off the label and prominently labeled it a "food supplement"

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that would beokay. The [Product Name] we now sell is theexact same formula you all have come to love.Except now it is officially a "food supplement."It still contains Dibencozide, Yohimbe, Smi-lax, Boron, Gamma Oryzanol, Arginine Pyroglutamate, Chromium, Carnitine, Transferu-lic Acid, Saw Palmetto, Orchic, Germanium,PAK, CoQIO, Lipoic Acid, Mexican Wild Yamand a lot more.37

Although this advertisement may bein compliance with the letter of the law,it appears to be an attempt to circumventthe applicable regulations. Such attempts are not always successful, and theadvertisement cited could potentially befound illegal as an implied claim.

Adolescents may be particularly vulnerable to these advertising claims.Mirkin found that many adolescent athletes take nutritional supplements inthe hope that these will improve theirathletic performance.38 In a survey of163 adolescents, Amos found that theadolescents' beliefs about what supplements could do and their reasons forusing the supplements showed them tohave misconceptions and uncertaintiesregarding these products.10

Although our report focuses on general health and bodybuilding magazines, persons taking supplements forother reasons may be as vulnerable toadvertising claims as adolescents. Inparticular, persons with chronic diseases such as arthritis, those withpoorly understood syndromes such aschronic fatigue syndrome or premenstrual syndrome, or those with terminal

diseases such as some cancers may beparticularly susceptible to the allegedhealth benefits of nutritional supplements. These products may also beused by individuals for symptoms suchas insomnia, digestive discomforts,"nerves," or for the promotion of general well-being. The claims of beneficialhealth effects made for many of theseproducts are based only tenuously, if atall, on information from peer-reviewedresearch. Products are promoted to thepublic as being "natural" and "organic,"when in fact most ingredients in theseproducts are from manufactured orchemically derived sources.

Our findings on nutritional supplement products, their ingredients, andavailability are intended to serve as apreliminary assessment of a problemthat is poorly documented in the medical literature. Future work in this areashould be directed at quantifying nutritional supplement use, identifying andcharacterizing nutritional supplementusers, and evaluating the effects ofsupplements on heavy users.

We emphasize to practitioners that(1) food supplement items are readilyavailable to the public; (2) judging by thequantity ofadvertisements, the types ofsupplement items listed here, as well asmany others, are consumed by a sizablenumber of patients; (3) many ingredients are not readily identifiable, andeven for those that are identifiable, allpotential effects or side effects may notbe known; (4) supplement users maycombine two or more products and mayset their own dosage regimens; and (5)unanticipated effects may occur as happened in the case of tryptophan-associated eosinophilia-myalgia syndrome.

We also urge physicians and otherhealth professionals to routinely askquestions on the use of supplementproducts when taking their patients'history and, when appropriate, to consider potential ill effects of these products when making a differential diagnosis. The FDA has traditionally treatednutritional supplements as foods. Theseproducts are not evaluated for safety bythe FDA as drugs are.39 Therefore, reporting adverse effects of supplementproducts to appropriate public healthauthorities, such as state or local healthdepartments, could be instrumental (1)in preventing or attenuating any futureoutbreaks similar to that of eosinophilia-myalgia syndrome or (2) in identifying and characterizing unknown orunanticipated side effects of these products and stimulating further research inthis area.

We thank Sonya Smith and Elizabeth C. Tomlin-son, MPP, for their assistance with data collection.

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