2. Ask the patient the following:
- the amounts (number of tablets or capsules) consumed per dose;
- the number of doses per day;
- the number of days dosed per week;
- how the dose is delivered (with or without food; if with food, before, during or after the meal);
- side-effects experienced.
3. Read all labels carefully.
- Determine the patient's daily dose (the number of reported tablets or capsules taken multiplied by the number of daily doses).
- Compare what the patient takes to the label and determine if the dose is correct. (It is not uncommon for the amounts on a label to be for more than one pill, or for patients to assume what is listed on a label is for only one pill. For example, a calcium product may state that five tablets provide 1,000 mg of calcium citrate. The patient may have been taking two tablets daily, thinking he or she was ingesting extra calcium, when, in fact, they were getting 60 percent less than the recommended label dose.)
- Determine the product's expiration date.
4. Use a reference text to rule out any contraindications with prescribed medication the patient currently uses.
5. Open each bottle and examine the contents.
- Are the capsules or tablets uniform in size and color?
- Is there evidence that the product is breaking down (cracks in the coating)?
- Determine if the smell is abnormal; if strong or foul smelling, ask the patient if the smell has changed with time.
6. Ask the patient where the products are stored.
- Is there a possible heat contamination for a product stored near the kitchen stove?
- Is there possible moisture contamination for a product stored in the bathroom?
7. If you suspect a product may not be fresh, whether expired or not, ask the patient:
- when the product was purchased;
- if the product could possibly have been exposed to unfavorable environmental conditions;
- if the size, color or uniformity of the capsules or tablets has changed since the date of purchase; and
- if he or she has ever felt a difference when using the product correctly.
Reasons Patients Use Supplements
My next step is to ask the patient why he or she uses the products. The most common reasons given are:
- general prevention or "insurance";
- prevention of a condition or disease that runs in the family;
- prevention of a condition or disease publicized by the media, or on advice of an untrained friend, acquaintance or family member;
- a noticeable difference is felt when the product is or is not taken;
- primary therapy for a diagnosed condition;
- complementary therapy (along with medication) for a diagnosed condition;
- primary therapy for an undiagnosed or self-diagnosed symptom complex.
Goals of Assessment
1. Rule out serious pathology - undiagnosed or misdiagnosed.
2. If the product is used as a primary therapy for a diagnosed condition, ensure that the patient:
- Knows the consequences of substituting the dietary supplement for prescription medication.
- Ingests the correct dose of the correct product (for a given condition) at the correct time, with a formula that is bioavailable, noncontaminated and not expired.
3. If the product is used as a complementary therapy with prescription medication, use a referenced text (PDR or Nutritional PDR) to ensure that the supplement does not interfere with the prescribed medication.
4. If the product is used as primary therapy for an undiagnosed or self-diagnosed symptom complex:
- Diagnose the condition, or refer to a qualified practitioner who can.
- If the diagnosed condition can be safely managed with dietary supplements, see 2b, below left.
5. If used for general prevention or prevention of a specific condition:
- Ensure the product is adequate for the desired needs.
- See 2b.
6. If used due to some form of media report, or advice from an untrained professional:
- Make sure what the patient is taking is really necessary.
- Refer to an appropriate allied professional, if indicated. (See 2b if use of the product is indeed warranted and supported with evidence-based literature.)
7. If a product is unnecessary, contraindicated, excessively dosed, or potentially harmful, causing imbalances with other nutrients or interactions with medications, do not hesitate to give appropriate counsel:
- Advise and recommend that the patient discontinue use immediately.
- Clearly document all recommendations in the chart notes.
When deciding if a new product or substance is worth recommending to a patient, verify the following:
- Human research has been conducted at the target group (age, sex, disease or condition, if applicable).
- The doses studied are the doses that are recommended.
- Forms of the product contain the same form of nutrient used in the study.
- The studies or trials are blinded.
- The funding is provided from neutral parties. (Product donations, if made, are done so with no strings attached.)
- The actual trials and published data were by investigators free of financial ties.
- Depending on your findings above, along with the patient's history (including family history and physical, including any observations of deficiency signs), recommend the following:
- Change the dose amount, timing or delivery (with or without meals).
- Discard expired, stale or possibly exposed products (especially if the patient states they are not working).
- Change brands if a product has been used for the proper time at the proper doses, but does not yield the desired effect. If a different brand of the same type of supplement (that you know is pure, fresh, and bioavailable) also fails, the patient is likely a nonresponder.
- For a nonresponder, check a reference text to see if there are other substances that may help the patient's condition.
- Do not hesitate to refer for a second opinion if you or the patient is uncomfortable with the diagnosis, recommendations, or response to therapy.
G. Douglas Andersen, DC, DACBSP, CCN
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