A couple of weeks ago I had a woman approach me at the pharmacy counter asking about chromium supplementation for blood sugar control.
She told me that her blood sugar levels were higher than they should be and that she would really like to get off of metformin because she “doesn’t like taking drugs”.
My first step was to ask her about her diet and lifestyle. Turns out she infrequently exercises, has high stress levels, gets poor sleep, and her diet is high in processed foods and carbohydrates with low fiber and minimal vegetables. I suggested we optimize these things as a way to possibly get off of metformin rather than immediately adding chromium.
Not sold on lifestyle changes and seeking a quick fix, she still wanted more information on chromium, so I obliged and informed her of the evidence for effectiveness and safety as well as the warnings and precautions, side effects and drug interactions. It was this piece that got her attention. She was surprised to hear that a natural health product could have just as many side effects as a doctor prescribed pharmaceutical.
Now that I had her attention, we discussed some lifestyle changes and the possibility of seeing a health coach to help her with implementing them. She left educated and ready to make a change.
A common scenario
Working in community pharmacy, this is a scenario that plays out often for me.
Patient doesn’t want to take drug >>> Patient also doesn’t want to change lifestyle >>>Patient seeks alternative. >>> Shiny natural alternative to drug presented by natural health company promises results >>> Patient asks me about said product.
This phenomenon of swapping pharmaceuticals for natural alternatives is called “Green Pharmacy” and it is becoming increasingly common as the wellness economy booms globally. Worth 3.7 Trillion in 2015, the wellness economy saw growth of 800 Billion in just 3 years to a value of 4.5 Trillion in 2018 (21).
But you’re a functional medicine pharmacist. Shouldn’t you be happy about this?
While i am pleased to see health and wellness is becoming more top of mind globally, I still have some criticisms of green pharmacy.
Reasons I try to avoid green pharmacy:
wellness companies are still for profit companies
Just because wellness companies are selling natural products, doesn’t mean they aren’t out here to make money. Companies that make natural health products have massive marketing departments just like any other for profit company. Furthermore, while pharmaceutical prices are set by strict standards and there are limits to the profit a pharmacy can make off of them, natural health products are not subject to the same standards. The price of a supplement is based on whatever profit the seller can get away with.
They are still a bandaid solution
Natural health products are limited in the same way as pharmaceuticals in that they do not address the root cause of dysfunction. I go easier on vitamins because they are at times needed to address nutritional deficiencies, but if they are needed for more than just a short time, you have not addressed the cause of the deficiency.
Just because they are natural doesn’t mean they are without side effects
People are often surprised to hear the laundry list of side effects I rattle off for a natural health product, expecting this to only be the case for pharmaceuticals. But natural health products can have just as many, if not more side effects than pharmaceuticals. Take chromium for example which can cause cognitive and motor disruptions at common over the counter doses (22).
The world of natural health product data is murky with respect to:
What the product actually contains
Since 2004, HealthCanada has instituted the Natural and Non-prescription Health Products Directorate, aimed at ensuring that the natural health products available to Canadians meet safety, efficacy and quality standards (23) . Prior to this directorate it was much more difficult to be sure that products were labelled properly. But even since this directorate came to be, Health Canada continues to find products laced with bona fide pharmaceuticals. Take Rhino 7 Platinum 5000 for example which was marketed as a natural erectile dysfunction option but found to contain sildenafil, the active ingredient in viagra, as recently as September 2019 (24). For this reason it is important to vet natural health products carefully yourself or purchase them from someone you trust has vetted them.
Safety and efficacy data
Though the financial incentives of the wellness economy have led to a great deal more research in recent years, historically good quality research on natural health products has been lacking. As a result we often see conflicting efficacy data with a multitude of small studies of varying quality. With respect to safety, we do not have the same post marketing surveillance of natural health products that we do with pharmaceuticals so in the absence of individual practitioner clinical experience it is hard to be sure of long term safety. When we look at the data available for chromium we see that the FDA suggests 200mcg daily is safe for up to 6 months. Beyond that we do not have good quality data showing it is safe (22).
Drug interactions
Again, compared to pharmaceuticals which are dispensed through pharmacy software and subject to interaction checks each time, natural health products often fly under the radar. Patients either will not report using them to their health care providers, or they will have an interaction check done once with their pharmacist and then forget about it, not bothering to check upon subsequent medication changes.
How do i use natural health products in my practise
The world of natural health products is far from perfect, but they can still be used safely and effectively to help achieve health outcomes. As a pharmacist, I simply apply the same framework that I use to evaluate pharmaceuticals. I’ve discussed this framework at length in a previous blog, but I will now apply it to natural health products.
Necessary:
First thing is first: do we really need this product? Can we address the problem with lifestyle interventions instead? Or maybe it isn’t even a lifestyle issue. I had one patient ask me about a liver support product because her liver enzymes were up. A quick look at her medications list revealed that she was taking an antibiotic called minocycline for acne, which can increase liver enzymes (25). Instead of starting her on this new product, I faxed her doctor to inform them of the issue.
Effective:
Is this product going to be effective for the patient? What data do we have showing efficacy? Are the studies of sufficient quality? How many studies do we have?
Safe:
What sort of safety data do we have overall? Are there any interactions with other medications the patient is taking? How long have these things been studied? How long can we anticipate the patient will take this for?
Adherence:
Is the patient going to be able to take the product as it was studied? What if the studies used massive doses multiple times a day? Are they going to be able to afford that?
proceed with caution and always ask your pharmacist
I hope that this article has provided you with a more balanced perspective on natural health products. As with a great deal of functional medicine topics, the truth lies somewhere in the middle of two opposing views. Natural health products are not all quackery, and they are not a panacea either. When in doubt, always ask your pharmacist!
References
As always, references can be found here.
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