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Popular Dietary SupplementsPopular Dietary SupplementsHelp or Hype?Help or Hype?

Popular Dietary SupplementsPopular Dietary SupplementsHelp or Hype?Help or Hype?

Ellen Coleman, RD, MA, MPHEllen Coleman, RD, MA, MPH

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Prevalence of UsePrevalence of UsePrevalence of UsePrevalence of Use

59% take supplements regularly59% take supplements regularly 46% take multiple vitamin/mineral46% take multiple vitamin/mineral 35% take single vitamins35% take single vitamins 15% take herbs15% take herbs 8% take specialty supplements (SAM-e, 8% take specialty supplements (SAM-e,

glucosamine)glucosamine)

59% take supplements regularly59% take supplements regularly 46% take multiple vitamin/mineral46% take multiple vitamin/mineral 35% take single vitamins35% take single vitamins 15% take herbs15% take herbs 8% take specialty supplements (SAM-e, 8% take specialty supplements (SAM-e,

glucosamine)glucosamine)

2001 Harris Survey 2001 Harris Survey

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Reasons for UseReasons for Use

Improved health and well being: Feel better = 72% Prevent illness = 67% Treat illness = 51% Live longer = 50% Increase muscle mass = 37% Weight management = 12%

Improved health and well being: Feel better = 72% Prevent illness = 67% Treat illness = 51% Live longer = 50% Increase muscle mass = 37% Weight management = 12%

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Reasons for UseReasons for UseReasons for UseReasons for Use

Other:Other: Specific health reason = 36%Specific health reason = 36% Sports nutrition = 24%Sports nutrition = 24% Recommended by doctor = 33%Recommended by doctor = 33%

2001 Harris Survey;www.supplementinfo.org2001 Harris Survey;www.supplementinfo.org

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Knowledge of SupplementsKnowledge of SupplementsKnowledge of SupplementsKnowledge of Supplements

Many don’t understand supplement action:Many don’t understand supplement action: 58% indicate calcium only needed by 58% indicate calcium only needed by

postmenopausal women postmenopausal women 41% indicate primary reason for iron is to 41% indicate primary reason for iron is to

increase energyincrease energy

92%92% consult physician regarding Rx drugs consult physician regarding Rx drugs

49% 49% consult physician regarding supplementsconsult physician regarding supplements

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Supplement SalesSupplement SalesNutrition Business JournalNutrition Business JournalSupplement SalesSupplement SalesNutrition Business JournalNutrition Business Journal

Exceeded Exceeded $16.8$16.8 billionbillion in 2000; in 2000;

1/31/3 of of $49.5 billion$49.5 billion US nutrition industry US nutrition industry Vitamins = 35% market share Vitamins = 35% market share Herbs = 25% market share Herbs = 25% market share Specialty = 10% market shareSpecialty = 10% market share Sports nutrition = 9% market shareSports nutrition = 9% market share Minerals = 8% market share (Ca++ biggest)Minerals = 8% market share (Ca++ biggest)

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U.S. Dietary Supplement SalesU.S. Dietary Supplement SalesU.S. Dietary Supplement SalesU.S. Dietary Supplement Sales

0

5

10

15

20

25

2000 2001 2002 2003 2004 2005

Sales in billionsSales in billionsSales in billionsSales in billions

Nutrition Business JournalNutrition Business Journal

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Vitamins for AdultsVitamins for AdultsVitamins for AdultsVitamins for Adults

Elderly, vegans, alcoholics, and patients Elderly, vegans, alcoholics, and patients with malabsorption at higher risk of with malabsorption at higher risk of inadequate intake or absorptioninadequate intake or absorption

General population has suboptimal intake General population has suboptimal intake Low levels of folic acid, vitamin B6 and Low levels of folic acid, vitamin B6 and

B12 are risk factor for CHD, neural tube B12 are risk factor for CHD, neural tube defects, and colon and breast cancerdefects, and colon and breast cancer

JAMA. 287:3116-3126, 2002JAMA. 287:3116-3126, 2002

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Vitamins for AdultsVitamins for AdultsVitamins for AdultsVitamins for Adults

Low levels of vitamin D contribute to Low levels of vitamin D contribute to osteopenia and fracturesosteopenia and fractures

Low levels of antioxidant vitamins A, C, Low levels of antioxidant vitamins A, C, and E may increase risk of several chronic and E may increase risk of several chronic diseasesdiseases

““Pending strong evidence of effectiveness Pending strong evidence of effectiveness from randomized trials, it appears prudent from randomized trials, it appears prudent for all adults to take vitamin supplements”for all adults to take vitamin supplements”

JAMA. 287:3127-3129, 2002JAMA. 287:3127-3129, 2002

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Popular Herbal SupplementsPopular Herbal SupplementsPopular Herbal SupplementsPopular Herbal Supplements

SoySoy Green teaGreen tea ValerianValerian Saw palmettoSaw palmetto EphedraEphedra

GuaranaGuarana Black cohoshBlack cohosh Milk thistleMilk thistle Grape seed extractGrape seed extract Red cloverRed clover

Nutrition Business JournalNutrition Business Journal

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EphedrineEphedrineEphedrineEphedrine

CNS stimulant and decongestantCNS stimulant and decongestant Structurally similar to amphetaminesStructurally similar to amphetamines Increases heart rate and blood pressureIncreases heart rate and blood pressure May promote body fat loss; improve May promote body fat loss; improve

anaerobic and aerobic performanceanaerobic and aerobic performance Ma Huang, Ephedra Sinica, Sida Cordifolia Ma Huang, Ephedra Sinica, Sida Cordifolia

contain ephedrinecontain ephedrine

CNS stimulant and decongestantCNS stimulant and decongestant Structurally similar to amphetaminesStructurally similar to amphetamines Increases heart rate and blood pressureIncreases heart rate and blood pressure May promote body fat loss; improve May promote body fat loss; improve

anaerobic and aerobic performanceanaerobic and aerobic performance Ma Huang, Ephedra Sinica, Sida Cordifolia Ma Huang, Ephedra Sinica, Sida Cordifolia

contain ephedrinecontain ephedrine

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EphedrineEphedrine

Side effects: GI Side effects: GI distress, dizziness, distress, dizziness, headache, irregular headache, irregular pulse, heart attack, pulse, heart attack, stroke, seizure, stroke, seizure, psychosis and deathpsychosis and death

Variable potency, poor Variable potency, poor quality control, quality control, banned substancebanned substance

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CaffeineCaffeineCaffeineCaffeine

CNS stimulant CNS stimulant epinephrine levels epinephrine levels 3 to 6 mg of caffeine/kg 1 hour before 3 to 6 mg of caffeine/kg 1 hour before

exercise may improve enduranceexercise may improve endurance Does not promote body fat lossDoes not promote body fat loss Guarana, Kola nut, Mate, Red Bull, No-Guarana, Kola nut, Mate, Red Bull, No-

Doze, Vivarin contain caffeineDoze, Vivarin contain caffeine

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CaffeineCaffeineCaffeineCaffeine

Side effects: Side effects: diuresis, nausea, diuresis, nausea, muscle tremor, muscle tremor, palpitations and palpitations and headacheheadache

Caffeine increases Caffeine increases effects of ephedrineeffects of ephedrine

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ECA StackECA Stack

ECA Stack is a ECA Stack is a popular performance popular performance and weight loss and weight loss supplementsupplement

Typical ingredients:Typical ingredients:30 mg of ephedrine30 mg of ephedrine100 mg of caffeine100 mg of caffeine300 mg of aspirin300 mg of aspirin

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SynephrineSynephrineSynephrineSynephrine

CNS stimulant similar to caffeine and CNS stimulant similar to caffeine and ephedrineephedrine

Doesn’t appear to have same negative CNS Doesn’t appear to have same negative CNS effects as ephedrineeffects as ephedrine

Effectiveness for weight loss is over-stated; Effectiveness for weight loss is over-stated; raises blood pressure in animalsraises blood pressure in animals

Citrus Aurantium contains synephrineCitrus Aurantium contains synephrine

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Green Tea ExtractGreen Tea ExtractGreen Tea ExtractGreen Tea Extract

Mild thermogenic effect: high content of Mild thermogenic effect: high content of catechin-polyphenols (EGCG) + caffeinecatechin-polyphenols (EGCG) + caffeine

Catechin-polyphenols Catechin-polyphenols norepinephrine norepinephrine levels (levels (↓ ↓ norepinephrine breakdown)norepinephrine breakdown)

Green tea extract (90 mg ECGC; 50 mg Green tea extract (90 mg ECGC; 50 mg caffeine) caffeine) energy expenditure by 4% and energy expenditure by 4% and fat use compared to caffeine + placebofat use compared to caffeine + placebo

Am J Clin Nutr.. 70:1040-1045, 1999Am J Clin Nutr.. 70:1040-1045, 1999

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Grape Seed ExtractGrape Seed ExtractGrape Seed ExtractGrape Seed Extract

Flavonoids (proanthocyanidins) potent anti-Flavonoids (proanthocyanidins) potent anti-oxidants and free-radical scavengers oxidants and free-radical scavengers

May inhibit destruction of collagen May inhibit destruction of collagen structures; enhance blood vessel integritystructures; enhance blood vessel integrity

In vitro and animal studies suggest reduced In vitro and animal studies suggest reduced risk of cancer and cardiovascular diseaserisk of cancer and cardiovascular disease

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Black CohoshBlack CohoshBlack CohoshBlack Cohosh

Contains triterpene glycosides and appears Contains triterpene glycosides and appears to have an estrogen-like action to have an estrogen-like action

Binds to estrogen receptors and suppresses Binds to estrogen receptors and suppresses luteinizing hormoneluteinizing hormone

Standardized extracts: positive effects on Standardized extracts: positive effects on menopausal/post menopausal complaintsmenopausal/post menopausal complaints

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SAMeSAMeSAMeSAMe

S-adenosyl-L-methionine donates methyl S-adenosyl-L-methionine donates methyl groups to proteins, nucleic acids, hormones groups to proteins, nucleic acids, hormones neurotransmitters, membrane phospholipidsneurotransmitters, membrane phospholipids

May be helpful for the treatment of May be helpful for the treatment of depression (by affecting neurotransmitters) depression (by affecting neurotransmitters) and arthritis (by stimulating cartilage and arthritis (by stimulating cartilage growth and repair)growth and repair)

Hardy et al. AHRQ. October 2002Hardy et al. AHRQ. October 2002

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Soy IsolfavonesSoy IsolfavonesSoy IsolfavonesSoy Isolfavones

Isoflavones exert weak estrogenic activityIsoflavones exert weak estrogenic activity May help treat menopausal symptomsMay help treat menopausal symptoms Conflicting research whether isoflavones Conflicting research whether isoflavones

inhibit estrogen dependent breast cancer inhibit estrogen dependent breast cancer and reduce bone loss from osteoporosisand reduce bone loss from osteoporosis

May reduce risk of CHD by reducing LDL May reduce risk of CHD by reducing LDL cholesterol and platelet aggregationcholesterol and platelet aggregation

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Milk ThistleMilk ThistleMilk ThistleMilk Thistle

Contains liver-protective substances Contains liver-protective substances collectively designated silymarin collectively designated silymarin

Silymarin blocks entry of toxic substances Silymarin blocks entry of toxic substances into liver cell membranesinto liver cell membranes

Stimulates protein synthesis; accelerates Stimulates protein synthesis; accelerates regeneration and production of new cellsregeneration and production of new cells

Germany: supportive treatment for toxic Germany: supportive treatment for toxic liver damage + inflammatory liver diseaseliver damage + inflammatory liver disease

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Saw PalmettoSaw PalmettoSaw PalmettoSaw Palmetto

Appears to have anti-inflammatory and Appears to have anti-inflammatory and mild antiandrogenic (anti-male hormone) mild antiandrogenic (anti-male hormone) effectseffects

Used for benign prostatic hypertrophy in Used for benign prostatic hypertrophy in EuropeEurope

Relieves symptoms of enlarged prostrate; Relieves symptoms of enlarged prostrate; does not reduce enlargementdoes not reduce enlargement

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EchinaceaEchinaceaEchinaceaEchinacea

Used to fight upper respiratory infectionsUsed to fight upper respiratory infections Increases number of immune cells in blood Increases number of immune cells in blood Enhances cell’s ability to destroy harmful Enhances cell’s ability to destroy harmful

bacteria; inhibits replication of virusesbacteria; inhibits replication of viruses Recent study: no benefit for treatment of Recent study: no benefit for treatment of

cold cold Ann Intern Med. 137:939-946, 2002Ann Intern Med. 137:939-946, 2002

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KavaKavaKavaKava

Used to relieve stress, anxiety, and tensionUsed to relieve stress, anxiety, and tension CNS depressant and has anesthetic effects CNS depressant and has anesthetic effects Used as social drink in some cultures Used as social drink in some cultures Associated with liver injury including Associated with liver injury including

hepatitis, cirrhosis, and liver failurehepatitis, cirrhosis, and liver failurewww.cfsan.fda.gov/~dms/addskava.htmlwww.cfsan.fda.gov/~dms/addskava.html

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ValerianValerian

Used to promote sleep due to mild sedating Used to promote sleep due to mild sedating and tranquilizing effectsand tranquilizing effects

Appears to depress brain centers and Appears to depress brain centers and directly relax smooth muscledirectly relax smooth muscle

Documented CNS depressant activity may Documented CNS depressant activity may potentiate existing sedative therapypotentiate existing sedative therapy

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St John’s WortSt John’s Wort

Used to relieve depression; “herbal Prozac”Used to relieve depression; “herbal Prozac” Appears to increase serotonin Appears to increase serotonin Conflicting research whether helpful for Conflicting research whether helpful for

depression; self-treating can be harmfuldepression; self-treating can be harmful Interacts with many drugs: Interacts with many drugs: ↓ effectiveness ↓ effectiveness

ofof cyclosporin, indinavir, digoxin, warfarin cyclosporin, indinavir, digoxin, warfarin

JAMA. 287:1807-1814, 2002JAMA. 287:1807-1814, 2002JAMA. 286:208-216, 2001JAMA. 286:208-216, 2001

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GinkgoGinkgo

Used to improve memory + concentration, Used to improve memory + concentration, especially in older peopleespecially in older people

Promotes vasodilation; enhances blood flowPromotes vasodilation; enhances blood flow May aid leg circulation in people with May aid leg circulation in people with

peripheral vascular diseaseperipheral vascular disease May interact with Rx medications and May interact with Rx medications and

supplements that thin the bloodsupplements that thin the bloodJAMA. 286:208-216, 2001JAMA. 286:208-216, 2001

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CreatineCreatine

Increases Cr and CP content in muscles Increases Cr and CP content in muscles May improve high-power performance May improve high-power performance <<30 30

seconds and delay onset of fatigueseconds and delay onset of fatigue Increases body mass by ~ 3 to 7 lbsIncreases body mass by ~ 3 to 7 lbs Loading: 20-25 g/day for 5 to 7 daysLoading: 20-25 g/day for 5 to 7 days Maintenance: 2-5 g/dayMaintenance: 2-5 g/day

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CreatineCreatine

Side effects: weight Side effects: weight gaingain

Athletes using Athletes using creatine creatine mustmust drink drink adequate fluidsadequate fluids

Lack of long-term Lack of long-term safety datasafety data

Med Sci Sports Exerc. Med Sci Sports Exerc. 32:706-717, 200032:706-717, 2000

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CreatineCreatine

May alter balance and May alter balance and agilityagility

““Anabolic” products Anabolic” products containing creatine containing creatine may also contain may also contain banned substancesbanned substances

IOC Nutritional IOC Nutritional Supplements Study, 2002Supplements Study, 2002

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GlucosamineGlucosamineGlucosamineGlucosamine

Plays a role in maintenance and repair of Plays a role in maintenance and repair of cartilagecartilage

Stimulates cartilage cells to synthesize Stimulates cartilage cells to synthesize cartilage building-blocks – glycoproteins cartilage building-blocks – glycoproteins and glycosaminoglycans and glycosaminoglycans

May have anti-inflammatory action by May have anti-inflammatory action by inhibiting proteolytic enzymes that inhibiting proteolytic enzymes that contribute to cartilage breakdowncontribute to cartilage breakdown

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GlucosamineGlucosamine

Most effective for Most effective for early arthritis, less for early arthritis, less for severe arthritissevere arthritis

Appears safe, more Appears safe, more research needed for research needed for effectivenesseffectiveness

1.5 g/day in divided 1.5 g/day in divided dosesdoses

JAMA. 283:1469-1475, 2000JAMA. 283:1469-1475, 2000JAMA. 283:1483-1484, 2000JAMA. 283:1483-1484, 2000

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ProteinProtein

Requirements:Requirements: Strength athletes:Strength athletes:

1.6 – 1.7 g/kg/day1.6 – 1.7 g/kg/day Endurance athletes: Endurance athletes:

1.2 – 1.4 g/kg/day 1.2 – 1.4 g/kg/day

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ProteinProtein

To gain 1 lb of muscle:To gain 1 lb of muscle: 3,500 calories3,500 calories 100 g protein100 g protein

To gain 1 lb in a weekTo gain 1 lb in a week 500 extra calories per 500 extra calories per

dayday 14 extra g protein per 14 extra g protein per

dayday

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ProteinProtein

Excess protein (over 2 g/kg/day) not Excess protein (over 2 g/kg/day) not incorporated into muscle – increases amino incorporated into muscle – increases amino acid oxidationacid oxidation

Adequate calorie intake = ample protein Adequate calorie intake = ample protein intakeintake

Protein supplements are convenient but not Protein supplements are convenient but not superior to dietary proteinsuperior to dietary protein

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““After testing positive for nandrolone, After testing positive for nandrolone, Fritz Aanes suffers two heartbreaks..”Fritz Aanes suffers two heartbreaks..”

Lost the bronze medalLost the bronze medal Banned for two years Banned for two years

from competitionfrom competition Protested drug testProtested drug test Denied taking steroidsDenied taking steroids Lab confirmed dietary Lab confirmed dietary

supplement contained supplement contained nandrolone – not listed nandrolone – not listed on labelon label

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Evaluating SupplementsEvaluating SupplementsEvaluating SupplementsEvaluating Supplements

What claims are made for the product?What claims are made for the product? What are the product’s ingredients? What are the product’s ingredients? Is the product safe?Is the product safe? Is the product effective?Is the product effective? Does the product contain substances banned Does the product contain substances banned

by athletic organizations?by athletic organizations? Is the product affordable?Is the product affordable?

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Choosing a SupplementChoosing a SupplementChoosing a SupplementChoosing a Supplement

Products that have USP (United States Products that have USP (United States Pharmacopeia) on the supplement labelPharmacopeia) on the supplement label

Products eligible for ConsumerLab seal of Products eligible for ConsumerLab seal of approval – www.consumerlab.com approval – www.consumerlab.com

Nationally known food and drug companies Nationally known food and drug companies with tight manufacturing controls with tight manufacturing controls

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Choosing a SupplementChoosing a SupplementChoosing a SupplementChoosing a Supplement

Supplement label should provide Supplement label should provide appropriate and accurate information appropriate and accurate information

Be wary if statements are unclear or label Be wary if statements are unclear or label makes preposterous claimsmakes preposterous claims

Avoid products with claims that sound too Avoid products with claims that sound too good to be truegood to be true

No dietary supplement can guarantee No dietary supplement can guarantee optimum performance or healthoptimum performance or health

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FDA – Evaluating Supplement FDA – Evaluating Supplement Information on InternetInformation on Internet

FDA – Evaluating Supplement FDA – Evaluating Supplement Information on InternetInformation on Internet

Look for sites run by government, university, or Look for sites run by government, university, or reputable medical/health associationreputable medical/health association

Is site’s purpose to educate or sell product?Is site’s purpose to educate or sell product? Is site’s information supported by research and Is site’s information supported by research and

cited in PubMed?cited in PubMed? Think twice about chasing the latest headline: Think twice about chasing the latest headline:

science advances by small steps and slowly science advances by small steps and slowly building towards consensusbuilding towards consensus

http://www.cfsan.fda.gov/~dms/ds-savvy.htmlhttp://www.cfsan.fda.gov/~dms/ds-savvy.html

Look for sites run by government, university, or Look for sites run by government, university, or reputable medical/health associationreputable medical/health association

Is site’s purpose to educate or sell product?Is site’s purpose to educate or sell product? Is site’s information supported by research and Is site’s information supported by research and

cited in PubMed?cited in PubMed? Think twice about chasing the latest headline: Think twice about chasing the latest headline:

science advances by small steps and slowly science advances by small steps and slowly building towards consensusbuilding towards consensus

http://www.cfsan.fda.gov/~dms/ds-savvy.htmlhttp://www.cfsan.fda.gov/~dms/ds-savvy.html

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Final ThoughtsFinal ThoughtsFinal ThoughtsFinal Thoughts

By definition, a supplement is a substance By definition, a supplement is a substance to augment the dietto augment the diet

Promote proven dietary strategies for Promote proven dietary strategies for athletic performance, weight loss, and athletic performance, weight loss, and healthhealth

Educate consumers on potential Educate consumers on potential benefits/risks of dietary supplements and benefits/risks of dietary supplements and lack of quality controllack of quality control

By definition, a supplement is a substance By definition, a supplement is a substance to augment the dietto augment the diet

Promote proven dietary strategies for Promote proven dietary strategies for athletic performance, weight loss, and athletic performance, weight loss, and healthhealth

Educate consumers on potential Educate consumers on potential benefits/risks of dietary supplements and benefits/risks of dietary supplements and lack of quality controllack of quality control