#340 – AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need

We discuss:

• Overview of episode topics [1:45];
• How Peter evaluates patients’ supplement regimens, and common misconceptions about supplements vs. pharmaceuticals [3:00];
• A framework for evaluating supplements [6:15];
• Evaluating creatine: purpose of supplementation, dosing, and mechanism of action [10:00];
• Creatine: proven benefits for muscle performance, potential cognitive benefits, and why women may benefit more [15:15];
• Creatine: risk vs. reward, kidney concerns, and choosing the right supplement [18:45];
• Evaluating fish oil: its primary purpose as a supplement and how to track levels [20:45];
• Fish oil: how omega-3s impact inflammation, heart health, and brain function, and the strengths and limitations of current research [26:30];
• Fish oil: the risks of supplementation, guidance on selecting high-quality products, and how to determine whether supplementation is appropriate [37:30];
• Evaluating vitamin D: understanding deficiency and optimal levels [45:15];
• Vitamin D: role in bone health, immune function, potential longevity impact, and biomarker limitations [51:15];
• Vitamin D: efficacy, safety, and balancing risk vs. reward [58:15];
• Evaluating B vitamins: function, consequences of deficiency, and key biomarkers to assess whether supplementation is necessary [1:02:15];
• B vitamins: risks for CVD and dementia associated with deficiency, and limited evidence for general population supplementation [1:07:15];
• Evaluating ashwagandha: background, uses, and mechanism of action [1:15:30];
• Ashwagandha: current evidence for its effects on sleep, stress, and anxiety [1:19:15];
• Ashwagandha: evaluating supplement quality, safety profile, and the risk-reward balance [1:22:15];
• The importance of using a structured evaluation framework to assess any supplement [1:26:30]; and
• More.

Show Notes

Overview of episode topics [1:45]

Main topic: Supplements

• The challenge with the topic of supplements is that it’s so variable person to person – a variety of supplements and doses 
• Today, Peter has instead decided to explain a framework for how one should think about supplements 
• Additionally, Peter will go through case studies of a variety of supplements to talk through it and allow listeners to then be able to apply it in their own life
• Peter will go through case studies for:
  • Creatine
  • fish oil
  • vitamin D
  • B vitamins
  • ashwagandha

How Peter evaluates patients’ supplement regimens, and common misconceptions about supplements vs. pharmaceuticals [3:00]

Assessing Patients’ Supplement Use

• When patients enter the practice, their full medical history is gathered, including:
  • Prescription medications
  • Over-the-counter supplements
  • Hormones
  • Any other exogenous molecules they consume
• There is a wide range in supplement usage among patients:
  • Some take absolutely nothing—no prescription medications or supplements.
  • Others take no medications but have a supplement list that is two pages long.
  • Most patients fall somewhere in between.
• The mental model for evaluation:
  • Supplements are analyzed using a process similar to how the kidney filters glucose, sodium, and potassium:
  • Everything is “dumped out” first, and then the question is asked: What should be added back in?
  • This doesn’t mean literally stopping everything, but it serves as a thought process for analysis.

Patients Often Don’t Know Why They Take Certain Supplements

• Many patients don’t have a clear reason for why they are taking certain supplements.
• Common responses when asked why they take a supplement:
  • “I saw someone on Instagram talking about it.”
  • “A doctor recommended it years ago, but I don’t remember why.”
• This lack of clarity reinforces the need for a structured evaluation framework.

The Misconception About “Natural” Supplements vs. Pharmaceuticals

• Some patients strongly prefer supplements over medications and express views such as:
  • “I don’t believe in taking medicine—only natural supplements.”
• Peter’s response: There is a difference between supplements and pharmaceuticals, but patients should truly understand that difference instead of making assumptions.
  • The key distinction is regulation, not necessarily effectiveness or safety.

Regulatory Differences Between Supplements & Pharmaceuticals

• Supplements:
  • Not regulated by the FDA in the same way as pharmaceuticals.
  • Are generally classified as “GRAS” (Generally Regarded as Safe) by the FDA.
  • The process for determining safety is not rigorous and lacks formal oversight.
• Pharmaceuticals:
  • While not perfect, they undergo a more stringent approval process.
  • Must clear regulatory hurdles before being prescribed.

Overlapping Ingredients Between Supplements & Pharmaceuticals

• Some supplements contain active ingredients found in prescription drugs.
• Example: Red rice yeast vs. Statins
  • Some patients refuse to take a statin (e.g., pravastatin) to lower ApoB.
  • However, they are comfortable taking red rice yeast, not realizing that:
    • High doses of red rice yeast function similarly to a modest dose of pravastatin.
• Key lesson: The natural vs. pharmaceutical distinction is often misleading, and all molecules should be evaluated through the same lens.

Purpose of the Framework Discussion

• The goal is to analyze supplements objectively rather than emotionally or ideologically.
• Today’s discussion focuses on over-the-counter supplements because:
  • It’s the most common area of patient confusion.
  • It is harder to evaluate compared to pharmaceuticals due to lack of regulation.
• The framework being introduced will help patients critically assess any supplement they take.

A framework for evaluating supplements [6:15]

Introduction to the Supplement Evaluation Framework

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