The survey, conducted under the auspices of Fairleigh Dickinson University, was funded by the pharmaceutical company Amarin, a prescription form of omega-3s, and so concentrated on that category. The survey posed questions to a pool of 200 physicians, with 50 of those being cardiologists, and 150 pharmacists, split evenly between those who work at chain stores or independent pharmacies.
Among the questions the survey asked of these healthcare professionals was an open-ended question that plumbed the depth of their knowledge about the differences between dietary supplements and drugs. Among physicians, 21% said supplements “are not regulated by the FDA,” while more than a quarter (28%) of pharmacists agreed with that statement. 14% of doctors and 15% of pharmacists said they didn’t know what the difference was, and 17% of doctors said there was “no difference.” This was the sole area in which pharmacists seemed to have more knowledge of supplements than their MD peers; only 2% of pharmacists agreed with that statement.
The lack of specific nutrition education in medical school curriculums has often been noted. While it's a failing that seems to be slowly changing, many physicians practicing today received their primary medical education years ago. It’s notable that few if any MDs or medical groups have stepped forward to defend the dietary supplement industry against what many within the business perceive as an unfair attack on the part of the NYAG.
This same education gap exists among pharmacists, which in some ways is even more troubling. Pharmacists, after all, are focused specifically on substances that can be injected or ingested that will positively affect health outcomes. But in the past, most pharmacy school curriculums focused entirely on pharmaceuticals to the exclusion of all else.
Phil Berce is the owner of Good Value Pharmacy, a four-store chain in southeastern Wisconsin. Berce received his training at the University of Wisconsin in the early ‘80s and so represents an age range of pharmacists who are in a decision making capacity within the industry. When asked how much nutrition information he received when getting his pharmacy degree, Berce was quick to answer:
“None. The explosion of dietary supplements during my career has been absolutely incredible. It wasn’t even close to that when I was in school. Yes, we studied the basic vitamins. But the benefits of something like omega-3s was not even something we talked about back in 1982.”
Rick Kingston is a clinical professor of pharmacy at the University of Minnesota and president of regulatory and scientific affairs at SafetyCall International, a consulting firm that works with many dietary supplement firms on questions of adverse event reporting, toxicology and management of recalls. Kingston said the quality of nutritional information provided to students these days is better than in Berce’s time, but still has a long way to go.
“I think it could still be greatly improved. Even though additional questions on nutrients have been added to board exams, they are primarily looking at the 10 or 15 top selling supplements. Things like glucosamine or omega-3s,” Kingston said.
Kingston said that even if the will existed to include more nutrition information in pharmacy school curriculums, the effort is complicated by the huge number of drugs on the market.
“The sheer volume of information that must be absorbed about drugs is a factor,” Kingston said.
Kingston said that even though a pharmacy education is supposed to be a fact- and science-based endeavor, superstition and hearsay still can creep in. Some of the beginning portions of his elective class on dietary supplements must be devoted to dispelling myths.
“They hear constantly from their other professors or older clinicians that dietary supplements are not regulated. They hear from their mentors or they hear it from the media. They hear it so often that they start to believe it. So I have to help them understand the differences between the categories of products,” he said.
Vague link to data
It requires a mind shift that is difficult to achieve within a single elective course, Kingston said. The total of the rest of the students’ training is on tightly defined substances with (for the most part) defined modes of action affecting specific chemical pathways. With supplements, students are confronted with often multiple ingredient products with usually unspecified modes of action whose manufacturers for regulatory reasons can’t be completely forthright about the data behind the formulas.
“For a mainstream pharmaceutical there is a direct link between a product and the supporting data for that product. As a pharmacist you’re trained to look for specific indications and for obvious reasons dietary supplements aren’t labeled that way.
“There is a lot of good primary literature on dietary supplements out there but it requires a search. For practicing pharmacists there are so many different medications that they have to stay on top of,” Kingston said.
Quality perception problem
Berce said in his experience pharmacists will educate themselves on the aspects of their business that are important to them. Berce sells nutritionals in his pharmacies, and some of his independent peers do even more, basing as much as 50% of their business on dietary supplements or other nutritionals. So reaching out to pharmacists who are seeking to expand their knowledge could be an opportunity for the industry. But the persistent question of quality is a complicating factor for the greater acceptance of dietary supplements in the pharmacy sector, Berce believes.
“The quality in supplements has been hit or miss. One of the problems has been cheap nutritionals on the market. (The NYAG affair) brings up the problem of lack of uniform standards in nutrition. If one goes with a reputable manufacturer, and there are a bunch of them, I feel more comfortable. A manufacturer that says, we use these manufacturing processes from raw material to final product, that gives me a lot more confidence. It’s not just about a cheap product,” Berce said.