Product quality is a high priority for dietary supplement users. Manufacturers are well aware of that fact.
Many brands claim they provide top quality formulas, made in pharmaceutical-grade production plants, with strict adherence to federally-defined Good Manufacturing Practices (GMPs).
Generally speaking, these claims are true, based on site visits Holistic Primary Care has made to leading brands in both the direct-to-consumer and practitioner-only nutraceutical sectors.
Manufacturers have their own ideas about what constitutes top-quality. But as more healthcare professionals bring supplements into the mainstream of clinical practice, the question of how practitioners define quality becomes increasingly important.
What criteria do clinicians consider when evaluating products on behalf of their patients? Are supplement companies adequately meeting the needs and preferences of the clinical community?
Holistic Primary Care’s 2019 practitioner survey gave us some insight.
The survey fielded last Winter, and generated responses from 360 practitioners, 32% of whom are conventionally trained MDs. More than two thirds (65%) dispense supplements in their practices, and 91% of those who don’t dispense are recommending some supplements to patients. Nearly all (95%) take supplements themselves.
The 49-item survey included the following question:
In evaluating whether to introduce a new product or brand to your patients, how important are the following factors?
For each of 10 multiple choice answers, respondents could indicate whether that factor was “Decisive,” “Important but not decisive” or “Of little importance.”
The top five most decisive factors among our respondents were: Free of Heavy Metals (90%), Free of Artificial Sweeteners (75%), Allergen-Free (69%), GMO-Free (67%); and Dosage Form/Frequency (43%).
What Doctors Want
The pattern of decisive criteria was fairly consistent across practitioner subtypes. In general, clinicians—regardless of background training or age—want to feel confident that the products they recommend are safe, free of toxins, artificial additives, and genetically-modified ingredients.
But there were some notable differences between younger and older practitioners.
Younger practitioners (age 30-40 yo) are much more sensitive to Dosage Form & Frequency; 75% of them identified this as a decisive factor, versus only 43% of those in the 51-60 age bracket. They are also much more concerned about prices, with 50% considering price a decisive factor, versus only 28% in the older segment.
Younger respondents are somewhat more concerned about ingredient sources, with 25% identifying US-Only Ingredients as a decisive issue, versus just 8% in the older group.
The written comments indicate that when evaluating product quality, practitioners are thinking far beyond the basic ingredient lists.
“Inactive ingredients are crucial in my decision,” wrote one respondent, who stressed a strong preference for products free of all forms of sugar, alcohols, colorings, and additives.
Packaging is also important. As one respondent noted, “I am starting to look at brands that use glass bottles instead of plastic.”
Robert Silverman, DC, director of the Westchester Integrative Health Center, and a popular lecturer on nutrition and functional medicine, has been conducting informal research among his integrative medicine colleagues to learn more about what they look for in supplements. He’s found a number of common themes:
- Easy-to-swallow liquid formulas, especially for elderly patients and those experiencing “pill fatigue.”
- Expanded sports support lines, especially products targeting over-zealous middle-aged marathoners and non-athletes who are just starting to exercise.
- Gluten-free, Dairy-free, GMO-free products.
- Compelling visual tools for patient education. Clinicians want videos and easy-to-understand graphics that help patients understand what to take, and how to take it. This increases adherence and improves outcomes.
- Intelligent formulas with fewer tablets or capsules. Patient adherence is inversely proportional to the complexity of the regimen. The more pills or capsules, and the more times per day, the less likely it is that patients will stay with the program. Simpler is always better.
- Easy implementation protocols and online education. Time is of the essence in any practice. Clinicians want streamlined strategies for different types of patients. “A woman who weighs 100 pounds is different from a man who weighs 270. Should each of them take the amount recommended on the label?”
- Social media and practice development support. Many functional medicine practitioners struggle with practice management. Nutraceutical companies that help with that become valuable allies.
Quality Goes Beyond the Products
For Jill Carnahan, MD, founder of Flatiron Functional Medicine, a thriving holistic practice in Lewisville, CO, the definition of “quality” goes far beyond a company’s actual products. Top companies—the ones she prefers—are fastidious about everything from packaging to customer service.
For her, supplements are not only vital clinical tools, they represent over 40% of her clinic’s total revenue. This cash stream makes possible the long, unrushed, in-depth office visits needed to care for people with complex, longstanding chronic conditions.
Features she looks for include:
- Speedy fulfillment: “Fast, efficient, trouble-free ordering and shipping is key.”
- Solid, yet eco-conscious packaging: “Sometimes we’ve gotten products that come damaged due to poor or inappropriate packaging. But eco-friendly packaging is also very important. We try to recycle as much as possible, and prefer companies that use recyclable materials.”
- Clear and detailed invoicing: Carnahan wants the invoices to give specific product names, sizes, wholesale cost, and recommended retail pricing.
- Online ordering & autoshipping: “We buy from over 40 different companies, and carry over 600 SKUs (stock-keeping units). You can imagine my office manager going crazy trying to figure out how to order from whom. We like companies that make it easy for us.”
- Reasonable minimums: Some companies require practitioners to purchase several dozen bottles at a time. That’s a deterrent for Carnahan. “If we have to order a minimum of 36 bottles, we may not try a new product because it will be a big waste if we don’t sell it.”
- Professional and courteous customer service: High quality companies should have phone lines answered by knowledgeable, well-trained customer care professionals. Carnahan avoids brands that only provide a general “customer service” email as the sole contact.
What Patients Want
A nutraceutical or herbal product is only as good as a patient’s willingness to take it. Dr. Carnahan and her team frequently check in with patients about the products they’re taking. This is part of the culture in her practice, and it yields important insights.
Larger sized bottles: “For many products, the standard size bottle is barely enough to get them through one month. This is especially true with antimicrobial herbal products like Allimed, Candibactin, or Candicidal, because they’re usually using 2 or 3 bottles per month on higher-dose protocols. Larger bottles would be very helpful.”
Auto-ship and re-purchase programs: “Patients want reminders. Amazon really has that down, with their Prime Pantry reminder system.” A model like that for top quality practitioner-only supplements would be a help.
Samples: Product samples are extremely helpful especially for pain and sleep products. Patients can find out quickly whether a particular formula will work for them, before investing in a full bottle. Brands that provide samples do practitioners and their patients a great service.
Adam Perlman, MD, Director of Integrative Medicine and Wellbeing at the Mayo Clinic Florida, and former head of Duke Integrative Medicine, agrees on the importance of samples.
“Say I want to help a patient with gut healing, and I recommend a product which is a big tub of stuff, and it costs like $75 or $80. And the patient gets it home and finds out she hates the pineapple flavor! It can be a real problem.”
Modern online shopping has created extremely high patient expectations. “With Zappos, if you bought a pair of shoes online and you don’t like them, you can just throw them back in the box and return them. But how are we, at a medical clinic, supposed to deal with that when someone doesn’t like the supplements they buy from us? I need to manage those patient expectation issues, and I need help.”
Perlman, who is leading the development of an entirely new integrative health program at Mayo’s massive Jacksonville campus, says product samples are an invaluable aid in averting potentially difficult situations.
The Mayo center is in its earliest developmental stages and not yet set up for dispensing supplements. But Perlman says he and his colleagues are already having discussions about product quality, brand selection, ethics, and logistics of clinic-based dispensing.
Mayo’s three campuses—in Rochester, MN, Scottsdale, AZ, and Jacksonville, FL—are destination centers for people with serious, complex medical conditions. For integrative medicine to work there, it has to deliver both clinical and fiscal value.
Working within a world-renowned mainstream institution like this presents unique challenges for supplement-savvy physicians like Dr. Perlman and his integrative colleagues. They have experience with supplements, but most other Mayo doctors do not.
Perlman says he evaluates supplement quality through the lens of Mayo’s “Three Shields”—a set of core values that guide everything at the clinics.
“I say, ‘How does this address our three shields? How does it improve our clinical care of our patients? How does it contribute to the research that helps inform and heal people? How does it help educate patients and providers?’”
When assessing products, Perlman looks for:
- Science that is specific to the branded product. “That’s very important. We know that different formulations of the same ingredient can be very different when used in practice.”
- Product-specific studies from academic institutions or third parties other than the product’s manufacturer.
- Clear information about potential safety concerns, drug interactions, and possible side effects patients may experience.
“We all know that these issues exist. Be open about it. Put it in perspective. We write (prescriptions) for drugs that interact with other drugs all the time. This is no different. Just because something interacts with the CYP450 enzyme system doesn’t mean it is dangerous. We want to be able to talk intelligently about the products we recommend.”