Volume 14, January 1999
Dietary Supplements: An Important Component of
Alternative Medicine Curricula
To the Editor:—
We commend the initiative by Milan and col-
leagues on teaching residents about acupuncture, chiropractic,
massage therapy, and homeopathy.
The popularity and respect-
ability of complementary/alternative medicine (CAM) in the
United States have grown considerably over the past few years.
This trend has already been recognized by the National Institutes
of Health, and Wetzel et al. recently reported in JAMA that up to
64% of American medical schools offer courses or selected topics
on the subject.
However, as physicians working in a large geriat-
ric practice, we care for a segment of the population with unique
patterns of CAM utilization. In our experience, elderly patients
are much more likely to use alternative supplements like vita-
mins, herbs, and other natural products than to use alternative
systems like acupuncture or chiropractic. Given the increasing
geriatric population, we believe that a CAM curriculum should in-
volve a component on such supplements.
The quality and quantity of scientific evidence supporting
the use of some of these supplements have increased steadily
over recent years. For example, the use of St. John’s wort for the
treatment of depression and related disorders is widespread in
certain European countries and has been extensively re-
The use of garlic in the management of hypercholes-
terolemia and mild hypertension is being studied both in the
United States and abroad, albeit with mixed results.
been investigated as a therapeutic approach in patients with
and peripheral vascular disease. Although
none of these supplements has obtained FDA approval as yet,
they are frequently used by patients in our geriatric practice. Part
of our role as health care providers is to be aware of the potential
efficacy and complications of compounds used by our patients
and to be able to provide appropriate counseling. This awareness
and training should begin in medical school.—
Jose Ness, MD,
Cynthia Pan, MD,
Department of Geriatrics, Mount Sinai Hospital,
New York City, N.Y.
1. Milan FB, Landau C, Murphy DR, et al. Teaching residents about
complementary and alternative medicine in the United States. J
Gen Intern Med. 1998;13:562–7.
2. Wetzel MS, Eisenberg DM, Kaptchuk TK. Courses involving comple-
mentary and alternative medicine at US medical schools. JAMA.
3. Linde K, Ramirez G, Mulrow CD, Pauls A, Weidenhammer W, Mel-
chart D. St. John’s wort for depression—an overview and meta-
analysis of randomized clinical trials. BMJ. 1996;313:253–8.
4. Silagy C, Neil A. Garlic as a lipid-lowering agent—a meta-analysis.
J R Colls Physicians Lond. 1994;28:39–45.
5. Le Bars PL, Katz MM, Berman, N, Itil TM, Freedman AM, for the
North American EGB Study Group. A placebo-controlled, double
blind, randomized trial of an extract of ginkgo biloba for dementia.
—Drs. Ness and Pan are entirely correct that the use
of herbal and other “dietary supplements” has increased expo-
nentially in many segments of the population, including the geri-
atric population. The over-the-counter sale of such supplements
is a billion-dollar industry with sales increasing by 25%
They are also correct that the scientific evidence to evaluate the
efficacy and safety of herbal supplements is steadily increasing.
The recent availability of the translated Komission E Papers from
Germany is a valuable addition. Given that botanicals are not
patentable, companies lack the opportunity to recoup the costs of
investigations necessary for FDA approval ($140 million to $500
million). Therefore, those expensive but critically important double-
blind, randomized, controlled trials will most likely be few and far
The absence of herbal medicine from our curriculum in
complementary/alternative medicine does not reflect a lack of
recognition on our part of the importance of this area. Rather, it
reflects a lack of access to an experienced and credentialed
teacher. Herbal medicine is practiced largely by patients them-
selves. There is currently not an organized field of practice with
standardized education or licensure. There are a few
from varying backgrounds with interest and self-acquired exper-
tise. Unfortunately, we have not yet found anyone locally to offer
such a course in our curriculum. We agree with Drs. Ness and
Pan that the need for clinicians to have at least a general under-
standing of herbal medicine and knowledge of potential interac-
tions with pharmaceuticals is especially great in the geriatric
population. We hope that we will be able to add this to our curric-
ulum in the near future.—
, MD, C
Division of General Internal Medicine, Rhode Island Hospital,