Survey of Advertising for Nutritional

Supplements in Health and

Bodybuilding Magazines
Rossanne M. Philen, MD, MS; Diana I. Ortiz; Steven B. Auerbach, MD;

Henry Falk, MD

The use of food supplements by the general public is poorly quantified, and little information on this subject is available in the medical literature. We surveyed
12 recent issues of popular health and bodybuilding magazines (1) to quantify
the number of advertisements for food supplements, the number of products
advertised, and the number and type of ingredients in these products; (2) to
identify the purported health benefits of these products; and (3) as a preliminary
effort to identify areas for future research. We counted 89 brands, 311 products,
and 235 unique ingredients, the most frequent of which were unspecified amino
acids; the most frequently promoted health benefit was muscle growth. We also
found many unusual or unidentifiable ingredients, and 22.2% of the products
had no ingredients listed in their advertisements. Health professionals may not
be aware of how popular food supplements are or of a particular supplement's
potential effects or side effects. In addition, patients may be reluctant to discuss
their use of these products with traditional medical practitioners. We recommend
that routine history taking include specific questions about patients' use of food
supplements and that any possible adverse effects or side effects be reported
to public health authorities.
(JAMA. 1992;268:1008-1011)

TWO recent

public health problems in

volving tryptophan-associated eosinophilia-myalgia syndrome and adverse ef
fects associated with use of - -hydroxybutyric acid highlighted the widespread
use of legal and illegal food supplement
products and the potential hazards in
volved.1"9 Although tryptophan and -y-hydroxybutyric acid occur naturally in hu
mans, both were taken in quantities
much larger than required by the body,
From the Division of Environmental Hazards and
Health Effects, National Center for Environmental
Health and Injury Control, Centers for Disease Control,
Atlanta, Ga (Drs Philen, Auerbach, and Falk), and Departamento de Ciencias y Technolog\l=i'\a,Universidad
del Turabo, University Station, Puerto Rico (Ms Ortiz).
Reprint requests to Division of Environmental Hazards and Health Effects (F28), National Center for Environmental Health and Injury Control, Centers for Disease Control, 1600 Clifton Road, NE, Atlanta, GA30333

(Dr Philen).

both were taken for their pharmacologie

effects, and both were synthetically man
ufactured (advertised claims notwith
standing). Although consumers may use
these products for their pharmaceutical
properties, they may not consider food
supplements as drugs, and physicians
may not routinely elicit a history oftheir
use.

The proportion of the population that

food supplement products is un
known, and there is little information in
the medical literature on this subject.10
We hypothesized that these products
might be popular among health-conscious
persons or those who purchase health and
uses

bodybuilding magazines. Therefore, as a

preliminary step to quantifying the types
offood supplement products available and
to identify potential areas for future re
search, we surveyed health and body
building magazines to determine the ex-

tent of advertising for these

well

products as

the number and type of ingredi

ents used in these products.
as

METHODS
We purchased a single issue of each of
12 health or bodybuilding magazines

published during June, July, or August

1991, at local Atlanta, Ga, area super
markets, bookstores, and card shops (Ta
ble 1). One copy of each health or body
building magazine available was pur
chased at each store, without repeating
titles. Thus, magazines used in the study
were selected by the stores and not by
the investigators. We reviewed each
magazine page by page for advertise
ments for food supplement products and

tabulated any advertised as tablets, cap

sules, or powders. No liquid supplement
products were included.
Information in each advertisement in
cluding manufacturer, brand name, prod
uct name, all advertised ingredients, ben
efits attributed to consuming the prod
uct, dosage information, and the tele
phone number and address of the
manufacturer or distributor (when avail
able) was entered into a computerized
database.
Using this information, we determined
the number of products advertised, the
number of unique ingredients in all ad
vertised products, and the number of
times any ingredient was mentioned in
any advertisement. We then categorized
these data into major groups of ingre
dients and products and also categorized
the purported health benefits or effects
of the products.
We attempted to identify the known
toxic properties of the ingredients by
reviewing several chemistry, biochem-

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istry, pharmacology, medical, and her

bal textbooks as well as by searching
through~'MMEDLINE, Toxline, and PoisIndex.11 Ingredients that did not fit

into

readily

or that could not be

identified were included in the

category

miscellaneous

category.

RESULTS

Using 12 magazines as our source, we

counted 89 companies, 311 products, 235

unique ingredients, and 914 instances
when ingredients were mentioned. Only
242 products (77.8%) listed ingredients,
and we sorted those 914 instances when
ingredients were mentioned into 15 cat
egories (Table 2). A mean of 26 products
were advertised in each magazine.
In our survey, we found that amino
acids were the most frequently men
tioned ingredients (198 [21.7%] of 914
instances when ingredients were men
tioned), and 104 (33.4%) of 311 products
included one or more amino acids as an
ingredient. In 56 (53.8%) of the 104 prod
ucts, one or more amino acids were spec
ified; 63 products (60.6%) contained un
specified amino acids. (Percentages to
tal more than 100% since 15 products
listed both specific and nonspecific amino
acids as ingredients.) Tryptophan was
advertised as an ingredient in one prod
uct (which did not list a company name
or address), although products contain
ing tryptophan were recalled at the re
quest of the Food and Drug Admin
istration (FDA) in November 1989
because of their association with eosinophilia-myalgia syndrome. The tryp
tophan dosage in this product was
1000 mg, which suggests that the tryp
tophan is manufactured.
Many products were promoted for
muscle growth and enhanced strength,
and steroid-type ingredients were ad
vertised as being in 28 (9%) of 311 prod
ucts. With the exception of ecdysterone,
the named sterols were all plant deriv
atives: -sitosterol, campesterol, diosgenin, fucosterol, and stigmasterol.
Ecdysterone is an insect hormone with
no known use in humans, and the rec
ommended dosage was 1000 mg per dose.
Diosgenin is found in yams, and phar
maceutical companies have used it to
manufacture progesterone and corti
sone.25 The most frequently specified in
gredients are listed in Table 3.

Although some ingredients were not

mentioned frequently in advertisements,

they are unusual enough to deserve spe
cial mention. For example, the prescrip
tion medication levodopa was listed as
an ingredient in one product, without
any information on dosage or side ef
fects. A few products included were ad
vertised as having glandular material
such as adrenal, hypothalamus, and neo-

1.Magazines Surveyed tor Food Supple

Advertisements, Study of Food Supplement
Advertisements, 1991

Table
ment

Frequently Mentioned Ingredients

by Specific Name, Study of Food Supplement Ad
vertising, 1991
Table 3.Most

Date

Title
Better Nutrition for

Today's Living
Bodybuilding Lifestyles
Bodypower Plus
Diet and Lifestyle
Fitness Plus
Flex
Ironman

Muscle and Fitness

Muscle Mag International
Muscle Training Illustrated
Natural Physique
Women's Physique World

No. (%) of
Instances When

June 1991

July 1991

June 1991

June/July
July
July
July
July
August
July

1991
1991
1991
1991
1991
1991
1991
June 1991
Summer 1991

Amino

Ingredient
acids (not specified)

Chromium
Branched-chain amino acids
Minerals (not specified)
Vitamins (not specified)
Boron
Inosine
Smilax
Carnltine
Dibencozide
Gamma oryzanol

Ginseng
2.Principal Categories of 914 Instances
Ingredients Were Mentioned in Advertised
Products, Study of Food Supplement Advertise

Ingredients Were

Mentioned

(n=914)
(4.4)
(3.3)
27 (3.0)
26 (2.8)
26 (2.8)
22 (2.4)
20 (2.2)
40
30

18(2.0)
18(2.0)
18(2.0)
17 (1.9)
16(1.8)

Table
When

ments, 1991

Category

of

Ingredient

Amino acids
Miscellaneous
Herbs
Vitamins
Trace minerals
Minerals

Steroids
Protein
Fats

Enzymes

Glands

Carbohydrates

Over-the-counter medication
Bacteria

Prescription medication

natal

No.

(%) of Mentions
198(21.7)
175(19.1)
130(14.2)
105(11.5)
69 (7.5)
47(5.1)
39 (4.3)
36 (3.9)
36 (3.9)
23 (2.5)
23 (2.5)
21 (2.3)
7 (0.8)
4 (0.4)
1 (0.1)

pituitary hypothalamus

concen

trate, without indicating the origin of

this material. Also advertised were in

gredients to which we could find no ref
erences in the medical literature: conch
grass, muira puama, or uva ursi. We
found references to one product only in
The American Journal of Chinese Med
icine: dong quai was referred to as an
herbal "tonic for women."26 In a bro
chure we obtained at a health food store,
one advertised ingredient, gotu kola, was
listed as an "herbal tonic"11; the same
brochure listed "nettle herb" as a "di

etary supplement."

No health effect was mentioned for 90

products (28.9%), and the most fre

quently advertised health effect was
muscle growth, a claim made for 59
(19.0%) of the 311 products. The most
commonly claimed health effects are

listed in Table 4.
In 221 (24.2%) of 914 instances when

specific ingredients were mentioned,

dosage information was also provided;
66 (29.9%) of 221 were dosages for amino
acids, more than for any other ingredi
ent. The doses for amino acids ranged
from 350 mg for some single amino acids
to 40 000 mg of unspecified amino acids.
The dose for folie acid in one product
was 10 mg, although the US recom
mended daily allowance for this vitamin

4.Principal Effects Attributed to 311 Food

Supplement Products, Study of Food Supplement
Table

Advertisements, 1991
No.

(%) of

311 Products
Effect
Muscle growth
Increased testosterone levels
Nutritional supplement
Energy enhancer
Fat reduction
Increased strength
Growth hormone releaser
No effect listed
Other effects
Total

Claiming Effect
59(19.0)
27 (8.7)
21 (6.8)

17(5.5)

15(4.8)
(3.8)
(2.6)
90 (28.9)
62(19.9)
12
8

311

is 400 v^>mmmm>fn one twenty-fifth

the amount in one dose of this product.
Most ingredients for which dosages were
given in the advertisements were items
for which no recommended daily allow
ance has been established.

COMMENT
As part of taking a routine medical
history, standard medical practice re

quires physicians

to

question patients

the use of medications and drugs.

Patients may hesitate, however, to dis
close their use of food supplement prod
ucts for several reasons: they may not
consider that these items are drugs, or
they may not wish to admit to tradi
tional medical practitioners that they
use alternative or nontraditional forms
of treatment for their disorders or that
they use products that are intended for
such questionable effects as testoster
one enhancement or supplementation.
In our survey, we found that plant and
insect steroids were included in 9% of
products advertised. Despite intensive
literature surveys, we could find no infor
mation on the effects on humans of con
suming these plant and insect steroids.
Several investigators, however, have ex
amined various aspects of ecdysterone's
effects on rats and other species.28'31
Canthaxanthin, a synthetic non-pro
vitamin A carotenoid, is frequently in
gested for skin-tanning purposes and
on

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advertised as being in two products

for which no purported effects were
given. One death due to aplastic anemia
has been reported in an individual who
used this product, although it is not clear
that canthaxanthin use was the cause of
death.32 For another product, hydran
gea was listed as an ingredient. The
leaves and buds of hydrangeas are
known to contain cyanogenic glycosides
and may induce cyanide poisoning if con
sumed.13*1238
Although for most ingredients, includ
ing vitamins, doses were not given in
the advertisements, the dose of folie acid
in one product was 25 times the US
recommended daily allowance of 400 g.
Products that contain more than 1 mg of
folie acid are treated as drugs under
existing regulations, and high levels of
folie acid may mask symptoms of per
nicious anemia, which could potentially
lead to irreversible neurologic damage.14
In a 1987 report, the American Medical
Association (AMA) divided vitamin
preparations into two categories: vita
mins used as therapeutic agents and vi
tamins used as dietary supplements.33
The AMA recommended (1) that vita
mins used as dietary supplements be no
more than 50% to 150% of the recom
mended daily allowance and (2) that vi
tamins used as therapeutic agents not
exceed two to 10 times the recommended
daily allowance and that such vitamins
"should be recommended by a physician
according to specific medical indica
tions."33 Clearly, the preparation con
taining 10 mg of folie acid far exceeds
these recommendations.
Though this survey does not quantify
actual product use, it does assess what
types of supplement products are avail
able to the public and what effects (if
any) these products are advertised to
have. The results described here illus
trate that a wide variety of food sup
plement products are readily available
to the public and that many of these
contain ingredients on which informa
tion is not readily available. Food sup
plement products are easily obtained
through mail order, health food stores,
drug stores, and specialty nutrition
stores. Despite their widespread avail
ability, we could find no toxicological
information for humans on 139 ingredi
ents (59%), although we did extensive
literature searches. Usually, in the ad
vertisements for these products, little,
if any, mention was made of possible
side effects or of conditions that con
traindcate their use (such as pregnancy,
hypertension, or thyroid disease); such
warnings are often mentioned on nonprescription medications. Recommended
dosages were rarely mentioned in the
advertisements, and the amount of each
was

ingredient was seldom noted.

Advertisers of these products

diseases such
were

not reticent in their claims. Phrases such

as "the most potent alternatives to an

abolic steroids

legally available"34 or
"outperforms anything legal"35,36 were
common. Readers were urged to pur
chase products before "upcoming Ho
meopathic and FDA regulations make
[Product Name] a prescription only
item."35 Products were openly adver
tised as being as strong as or stronger
than testosterone and as being more ef
ficient at increasing muscle size. Some
advertisers openly attempted to circum
vent regulations intended to prevent
false or misleading claims by making
statements such as the following:
our ads for [Product Name]
caused such a stir that even the FDA thought
they sounded too good to be true. As a result
they've asked us to stop making all health
claims for [Product Name]. They contend that
such claims make [Product Name] a drug!!!
What claims specifically? Things like test
osterone booster, growth hormone releaser,
anabolic activator, incredible gains in lean
muscle mass, energy enhancer, fat burner...
and so on... We determined that if we took all
health claims off the label and prominently la
beled it a "food supplement" that would be
okay. The [Product Name] we now sell is the
exact same formula you all have come to love.
Except now it is officially a "food supplement."
It still contains Dibencozide, Yohimbe, Smilax, Boron, Gamma Oryzanol, Arginine Pyro
glutamate, Chromium, Carnitine, Transferulic Acid, Saw Palmetto, Orchic, Germanium,
PAK, CoQIO, Lipoic Acid, Mexican Wild Yam
and a lot more.37

Unfortunately

Although this advertisement may be

in compliance with the letter of the law,
it appears to be an attempt to circumvent
the applicable regulations. Such at
tempts are not always successful, and the
advertisement cited could potentially be
found illegal as an implied claim.
Adolescents may be particularly vul
nerable to these advertising claims.
Mirkin found that many adolescent ath
letes take nutritional supplements in
the hope that these will improve their
athletic performance.38 In a survey of
163 adolescents, Amos found that the
adolescents' beliefs about what supple
ments could do and their reasons for
using the supplements showed them to
have misconceptions and uncertainties
regarding these products.10
Although our report focuses on gen
eral health and bodybuilding maga
zines, persons taking supplements for
other reasons may be as vulnerable to
advertising claims as adolescents. In
particular, persons with chronic dis
eases such as arthritis, those with
poorly understood syndromes such as
chronic fatigue syndrome or premen
strual syndrome, or those with terminal

as some cancers

particularly susceptible

may be

the alleged
health benefits of nutritional sup
plements. These products may also be
used by individuals for symptoms such
to

insomnia, digestive discomforts,

"nerves," or for the promotion of gen

as

eral well-being. The claims of beneficial

health effects made for many of these
products are based only tenuously, if at
all, on information from peer-reviewed
research. Products are promoted to the
public as being "natural" and "organic,"
when in fact most ingredients in these
products are from manufactured or
chemically derived sources.
Our findings on nutritional supple
ment products, their ingredients, and
availability are intended to serve as a
preliminary assessment of a problem
that is poorly documented in the medi
cal literature. Future work in this area
should be directed at quantifying nutri
tional supplement use, identifying and
characterizing nutritional supplement
users, and evaluating the effects of

supplements on heavy users.

We emphasize to practitioners that
(1) food supplement items are readily
available to the public; (2) judging by the
quantity of advertisements, the types of
supplement items listed here, as well as
many others, are consumed by a sizable
number of patients; (3) many ingredi
ents are not readily identifiable, and
even for those that are identifiable, all
potential effects or side effects may not
be known; (4) supplement users may
combine two or more products and may
set their own dosage regimens; and (5)
unanticipated effects may occur as hap
pened in the case of tryptophanassociated eosinophilia-myalgia syn
drome.
We also urge physicians and other
health professionals to routinely ask
questions on the use of supplement
products when taking their patients'
history and, when appropriate, to con
sider potential ill effects of these prod
ucts when making a differential diagno
sis. The FDA has traditionally treated
nutritional supplements as foods. These
products are not evaluated for safety by
the FDA as drugs are.39 Therefore, re
porting adverse effects of supplement
products to appropriate public health
authorities, such as state or local health
departments, could be instrumental (1)
in preventing or attenuating any future
outbreaks similar to that of eosino
philia-myalgia syndrome or (2) in iden
tifying and characterizing unknown or
unanticipated side effects of these prod
ucts and stimulating further research in
this area.
We thank Sonya Smith and Elizabeth C. Tomlinson,

MPP, for their assistance with data collection.

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