Editorial
           Dietary supplements: improving education is not enough
           Worldwide demand for dietary supplements sky-                   health-care provider. The benefits of involving a 
           rocketed at the beginning of the COVID-19 pandemic;  health-care professional in the decision to take dietary                                            
           some countries reported sales increases of more than  supplements are immense and must be encouraged                                                    oung/
           50% in March, 2020, compared with the same period  because of the less obvious risks and harms associated.                                              ates Y
           the previous year, and the market continues to grow.            Some dietary supplements can aggravate IBD—eg, if                                       Sherry YScience Photo Library
           Concerns about vaccine safety and hopes of boosting  they contain lactose or artificial colours. Oral iron has  For more on global sales 
           immune function against COVID-19 propelled people  known gastrointestinal side-effects such as nausea  increases see Pharma Nutrition 
           to turn to dietary supplements, despite insufficient data to    and diarrhoea; it can also mask signs of serious 2021; 18: 100282
                                                                                                                                          For more on COVID-19’s effects 
           support recommendations for this purpose. In response           gastrointestinal disease such as dark stools. Interactions  on uptake of supplements see 
           to concerns about public health and safety, the US Food         with other prescribed medications can be dangerous,  https://ods.od.nih.gov/
                                                                                                                                          factsheets/COVID19-
           and Drug Administration (FDA) launched Supplement               causing major drug–drug interactions. In addition, some  HealthProfessional/
           Your Knowledge on June 2, 2022, an education initiative         people, such as those with liver disease, can have life-       For the FDA Supplement Your 
           aimed at helping people make informed decisions about           threatening complications from seemingly innocuous  Knowledge initiative see 
                                                                                                                                          https://www.fda.gov/food/
           taking dietary supplements. The initiative explains the  supplements such as vitamin A or green tea extract.                   information-consumers-using-
           laws around the industry, highlighting the risks associated       Dietary supplements are not allowed to be marketed  dietary-supplements/
                                                                                                                                          supplement-your-knowledge
           with dietary supplements and the importance of involving        in the USA as a treatment, prevention, or cure for any  For more on new dietary 
           health-care professionals.                                      disease, but illegal marketing is a huge problem that  ingredients notifications 
                                                                                                                                          received by the FDA see https://
             Regulations for dietary supplements vary worldwide  the FDA has not adequately addressed. Fraudulent  www.fda.gov/media/127746/
           but are perhaps most controversial and stimulate the  health claims target the most vulnerable and can delay  download
           greatest debate in the USA. In 1994, when the dietary  people receiving appropriate treatment. Thousands of  For more on drug–drug 
                                                                                                                                          interactions and liver disease 
           supplement industry was worth an estimated US$4 billion         products have been found to be incorrectly labelled—           see https://britishlivertrust.org.
           and encompassed approximately 4000 products, the  even containing hidden toxic ingredients.  Weight  uk/information-and-support/
                                                                                                                                          living-with-a-liver-condition/
           US Congress passed the Dietary Supplement Health and            loss supplements in particular receive a lot of illegal  diet-and-liver-disease/
           Education Act (DSHEA). Under DSHEA, the FDA is not  marketing, with hundreds of products found to contain  complementary-and-alternative-
                                                                                                                                          medicines-cam/
           authorised to approve dietary supplements for safety and        dangerous agents such as sibutramine or dinitrophenol,  For more on incorrect labelling 
           effectiveness before marketing and instead relies on post-      which can result in serious health complications or  of products see N Engl J Med 
                                                                                                                                          2022; published online May 18. 
           market surveillance to remove unsafe and illegal products.      death. In a previous Editorial we discussed liver injury  https://www.doi.org/10.1056/
           The US market is now worth an estimated $55 billion,  related to dietary supplements; by one US analysis, the  NEJMp2205675
           with as many as 80 000 products; as a result, the FDA  proportion of drug-induced acute liver failure caused by  For more on weight loss 
                                                                                                                                          supplements containing 
           has struggled to keep up. Manufacturers are required  these agents increased from 2·9% to 24·1% in 25 years.                   dangerous ingredients see 
           to submit a pre-market notification to the FDA before             We welcome the new FDA education initiative, but  https://www.fda.gov/drugs/
                                                                                                                                          medication-health-fraud/
           introducing new dietary ingredients, yet loopholes in  it is only a small step towards improving the safety of  tainted-weight-loss-products
           the law mean that many new ingredients are introduced           dietary supplements for consumers. Increasing awareness  For our previous Editorial see 
                                                                                                                                          Editorial Lancet Gastroenterol 
           without any safety evaluation, thus failing to protect  of the importance of joint decision making between  Hepatol 2018; 3: 343
           consumers against harmful products. In 2019, the FDA  consumer and health-care professionals is an essential  For more on numbers of liver 
           estimated that more than 4600 notifications for new  step, but shifting the focus of accountability for safety  injury related to dietary 
                                                                                                                                          supplements in the US see 
           dietary ingredients should have been submitted since  should not be the aim. Trust in US public health bodies  Liver Transpl 2022; 28: 169–79
           DSHEA’s enactment; however, at the time of reporting,  is low, with one 2021 poll reporting almost a quarter of  For more on mistrust of the FDA 
                                                                                                                                          see https://cdn1.sph.harvard.
           they had only received just over 1100.                          Americans having little or no trust in the FDA; therefore,  edu/wp-content/uploads/
             Although there is poor evidence of a benefit for  whether the initiative will have the desired effect is  sites/94/2021/05/RWJF-Harvard-
           dietary supplements for most people with a healthy,  questionable. Illegal marketing of dietary supplements  Report_FINAL-051321.pdf
           balanced diet, they are crucial for people with dietary  is unacceptable, and major legislative change is required 
           deficiencies or at-risk populations. For example, people        to restore public trust and ensure products only contain 
           with inflammatory bowel disease (IBD) or pancreatic  approved, safe ingredients before they ever reach the 
           dysfunction might be prescribed vitamins by their  market.  ■ The Lancet Gastroenterology & Hepatology
           www.thelancet.com/gastrohep   Vol 7   August 2022                                                                                                 689