Nutritional Supplements for Diabetes Sold on the Internet

Business or Health Promotion?

Loredana Covolo; Michela Capelli; Elisabetta Ceretti; Donatella Feretti; Luigi Caimi; Umberto Gelatti

BMC Public Health. 2013;13(777)

Conclusion

In conclusion, easy internet access to NSs lacking adequate medical information and strong scientific evidence is a public health concern, mainly considering that a misleading information could lead to an improper prevention especially in healthy people and improper management of a disease in people suffering from diabetes. It is necessary to develop appropriate and reliable information to enable consumers to make an informed decision about the product prior to purchasing it. Furthermore, health care providers should be more informed about these widely used products. It is also evident that more research to validate the efficacy and safety of these NSs is called for.

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Abbreviations
ALA: Alpha lipoic acid; NHANES: National Health and Nutrition Examination Survey; NIH-ODS: National Institute of Health Office of Dietary Supplements; NS: Nutritional supplement; FDA: Food and Drug Administration; MA: Meta-analysis; RCT: Randomized controlled trial; SR: Systematic review; T2D: Type 2 diabetes.

Authors' contributions
The article was conceived by all authors. LC took responsibility for drafting the article. MC and LC carried out the Web search and interpreting of the data. EC, DF, LC and UG had a substantial role in critical revision. All the authors have given their final approval of the version for publication.

Acknowledgements
The authors gratefully acknowledge "Quality and Technology Assessment, Governance and Communication Strategies in Health Systems" Study and Research Centre - University of Brescia, Viale Europa 11, 25123 Brescia, Italy for the support.

Table 1. Characteristics of nutritional supplements sales websites included in the study
Company	URL*	Website location	Nutritional supplement	Health Professional contact suggested	FDA disclaimer†	Scientific references	Testimonials
Type II Free	https://www.typefreediabetes.com	USA-New York	Glucocin	No	No	No	No
Xtendlife	https://www.xtend-life.com	USA-Georgia	Diabet-Eze	Yes	No‡	Yes	Yes
ADW American Diabetes wholesale	https://www.americandiabeteswholesale.com	USA-Florida	Diachieve Sugar Defense	No	No	Yes	Yes
Green Turtle Bay Vitamin Company	https://www.energywave.com	USA-Winsconsin	Diabetiks	Yes	Yes	No	Yes
Native Remedies	https://www.nativeremedies.com	USA-Texas	Insulate Plus	No	No	Yes	Yes
Heart, Diabetes & Weight Loss	https://www.vagnini.com	USA-Texas	AGE Essential Defence	No	No	No	No
NutriVera Naturals	https://www.nutrivera.com	USA-Minnesota	Alpha Betic	Yes	Yes	No	No
Optimum Diabetics	https://www.optimumdiabetics.com	USA-Texas	Optimum Diabetics	Yes	Yes	No	Yes
Get Healthy Again	https://www.gethealthyagain.com	USA-Florida	Custom Elixir D	No	No	No	No
Nutrient Synergy, Inc.	https://www.nutrientsynergy.com	USA-Florida	Nepretin	Yes	No§	No	Yes

*latest access on 20th April 2012 †FDA disclaimer: "This statement has not been evaluated by the FDA. This product is not intended to diagnose, treat, cure, or prevent any disease" ‡the statement that the product is not a diabetes medication replacement is contained in the FAQ section. §the statement was not complete.

Table 2. Characteristics of references retrieved on the websites selling nutritional supplements
Nutritional supplement	Ingredient	N° of references	N° of relevant references*	Publication date of relevant references
Glucocin
	Biotin	19	2	1990
	Magnesium	26	2	1998
	Chromium	26	10	from 1987 to 2000
	Momordica c.	3	1	2007
	Gymnema s.	3	–	–
	Camellia s.	27	–	–
Diachieve
Sugar Defense	†	23	3	1997/1999/2000
Insulate Plus
	Chromium	2	1	1990
	Gymnema s.	1	–	–
	Vaccinium m.	2	1	1997

*studies carried out on humans and regarding diabetes, –The studies regarded the entire product and not the single ingredient

Table 3. Dosage recommended for nutritional supplements (NSs) offered by the companies online and dosage tested
Ingredient	N° of websites on which the dosage was specified/websites selling the relative NS	Dosage per day (mg) indicated in the website	Dosage tested (mg)	Reference
Alpha Lypoic Acid	1/6	600	300	Ansar et al., 2011 [14]
			600	de Oliveira, 2011 [15]
			600/1200/1800	Bartlett, 2008 [16]
			600/1200/1800	Lee, 2011 [17]
Gymnema sylvestre	1/6	2700	400	Leach, 2007 [18]
Magnesium	3/5	300 (2 websites)	365	Mooren, 2011[19]
Magnesium	3/5	768 (1 website)	291.6 – 745.2	Bartlett, 2008 [17]
Chromium	2/5	0.3	0.02 – 1	Bartlett, 2008 [16]
		0.66	0.04	Sharma, 2011[20]
			0.5	Kròl, 2011[21]
			0.5 – 1	Ali, 2011[22]
			1	Cefalu, 2010 [23]
Zinc	3/4	15	10	Shidfar et al., 2010 [24]
		54	30	Bartlett, 2008 [16]
		78	50	Hussain, 2006 [25]
Camellia sinensis	2/4	40	150 – 600	Neyestani, 2010 [26]
Camellia sinensis	2/4	1800	375 – 750	MacKenzie, 2007 [27]
Biotin	2/3	0.2	2	Albarracin, 2008 [28]
			2	Geohas, 2007 [29]
			5	Revilla-Monsalve, 2006 [30]
Momordica charantia	1/3	2700	1000	Ooi, 2010 [31]
Momordica charantia	1/3	2700	500–2000	Fuangchan, 2011[32]
Trigonella foenum-graecum	0/3	–	2800	Losso, 2009 [33]
Vaccinium myrtillus	1/3	100	–	–