Emergency Department Visits for Adverse Events Related to Dietary Supplements
Published October 15, 2015
N Engl J Med 2015;373:1531-1540
DOI: 10.1056/NEJMsa1504267
Abstract
Background
Dietary supplements, such as herbal or complementary nutritional products and micronutrients (vitamins and minerals), are commonly used in the United States, yet national data on adverse effects are limited.
Methods
We used nationally representative surveillance data from 63 emergency departments obtained from 2004 through 2013 to describe visits to U.S. emergency departments because of adverse events related to dietary supplements.
Results
On the basis of 3667 cases, we estimated that 23,005 (95% confidence interval [CI], 18,611 to 27,398) emergency department visits per year were attributed to adverse events related to dietary supplements. These visits resulted in an estimated 2154 hospitalizations (95% CI, 1342 to 2967) annually. Such visits frequently involved young adults between the ages of 20 and 34 years (28.0% of visits; 95% CI, 25.1 to 30.8) and unsupervised children (21.2% of visits; 95% CI, 18.4 to 24.0). After the exclusion of unsupervised ingestion of dietary supplements by children, 65.9% (95% CI, 63.2 to 68.5) of emergency department visits for single-supplement–related adverse events involved herbal or complementary nutritional products; 31.8% (95% CI, 29.2 to 34.3) involved micronutrients. Herbal or complementary nutritional products for weight loss (25.5%; 95% CI, 23.1 to 27.9) and increased energy (10.0%; 95% CI, 8.0 to 11.9) were commonly implicated. Weight-loss or energy products caused 71.8% (95% CI, 67.6 to 76.1) of supplement-related adverse events involving palpitations, chest pain, or tachycardia, and 58.0% (95% CI, 52.2 to 63.7) involved persons 20 to 34 years of age. Among adults 65 years of age or older, choking or pill-induced dysphagia or globus caused 37.6% (95% CI, 29.1 to 46.2) of all emergency department visits for supplement-related adverse events; micronutrients were implicated in 83.1% (95% CI, 73.3 to 92.9) of these visits.
Conclusions
An estimated 23,000 emergency department visits in the United States every year are attributed to adverse events related to dietary supplements. Such visits commonly involve cardiovascular manifestations from weight-loss or energy products among young adults and swallowing problems, often associated with micronutrients, among older adults. (Funded by the Department of Health and Human Services.)
Herbals (botanical products), complementary nutritionals (e.g., amino acids), and micronutrients (vitamins and minerals) are all considered to be dietary supplements by the Dietary Supplement Health and Education Act of 1994.1 Although supplements cannot be marketed for the treatment or prevention of disease, they are often taken to address symptoms or illnesses, as well as to maintain or improve overall health.2 The estimated number of supplement products increased from 4000 in 19943 to more than 55,000 in 2012 (the most recent year for which data are publicly available),4 and approximately half of all adults in the United States report having used at least one dietary supplement in the past month.5 In 2007, out-of-pocket expenditures for herbal or complementary nutritional products reached $14.8 billion, one third of the out-of-pocket expenditures for prescription drugs.6
The Food and Drug Administration (FDA) is tasked with the oversight of dietary supplements; if a dietary supplement is found to be unsafe, the FDA can have the manufacturer remove the product from the market. However, the regulatory framework differs from that for prescription or over-the-counter pharmaceuticals. Manufacturers of dietary supplements containing ingredients that were introduced after October 15, 1994, are required to notify the FDA before marketing and to provide a rationale for the safety of the ingredients, such as historical use. However, neither safety testing nor FDA approval is required before the marketing of dietary supplements.7
Postmarketing reporting of adverse events by dietary-supplement manufacturers is required only for serious8 adverse events (e.g., those resulting in hospitalization, significant disability, or death), and voluntary reporting may substantially underestimate the adverse events associated with dietary supplements.9,10 Postmarketing regulatory actions to remove adulterated supplement products from the market have received public attention. From 2004 through 2012, more than 200 recalls were issued for dietary supplements containing unapproved regulated substances or impurities,11 and calls for changes in oversight have followed.4,12–18
The safety of dietary supplements that are not known to be adulterated remains poorly described,19 however. Data are lacking to quantify the frequency of adverse events associated with dietary supplements in the United States.4,20–24 We used nationally representative surveillance data to estimate the number of emergency department visits for adverse events related to dietary supplements and to identify the associated characteristics of the patients, products, and types of adverse events.
Methods
Data Collection
We estimated the number of emergency department visits for adverse events associated with dietary supplements in the United States using 10 years of data (from January 1, 2004, through December 31, 2013) from the 63 hospitals participating in the National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance (NEISS-CADES) project conducted by the Centers for Disease Control and Prevention (CDC), the FDA, and the Consumer Product Safety Commission. These hospitals make up a nationally representative probability sample drawn from all hospitals with at least six beds and 24-hour emergency departments (excluding psychiatric and penal institutions) in the United States and its territories, with four strata based on hospital size and a fifth stratum for pediatric hospitals.
Trained abstractors at each hospital reviewed the clinical records of every emergency department visit to identify physician-diagnosed adverse events and reported up to 2 implicated products and 10 concomitant products, as described previously.25 Abstractors also recorded narrative descriptions of the event, including preceding circumstances, physician diagnoses, testing, treatments administered in the emergency department or by emergency medical services, and patient outcome. Narrative data were coded with the use of the Medical Dictionary for Regulatory Activities (MedDRA), version 9.1. Since data collection is considered to be a public health surveillance activity, no approval from institutional ethics committees or review boards was required.26
Study Definitions
Cases were defined as emergency department visits for problems that the treating clinician explicitly attributed to the use of dietary supplements. This analysis included orally administered herbal or complementary nutritional products (including botanicals, microbial additives, and amino acids) and micronutrients (vitamins and minerals) but excluded products that are typically considered to be foods or drinks (e.g., energy drinks, herbal tea beverages). Additional products that are often used by consumers for complementary health but do not fall under the regulatory definition of dietary supplements (e.g., topically administered herbal or homeopathic products) were also included in the analysis. Herbal or complementary nutritional products were categorized according to common reasons for use. (For detailed definitions and specific products, see Tables S1 and S2 in the Supplementary Appendix, available with the full text of this article at NEJM.org.)
Adverse events were categorized as adverse reactions, allergic reactions, excess doses, unsupervised ingestion by children, or other events (e.g., choking). Cases involving death on the way to the emergency department or after arrival were excluded because death registration practices vary among participating hospitals, and details about event circumstances are often lacking. Visits involving intentional self-harm, drug abuse, therapeutic failures, nonadherence, or withdrawal were also excluded. The categorization of symptoms was based on MedDRA-coded narratives.
Statistical Analysis
The Consumer Product Safety Commission weighted cases of adverse events on the basis of the inverse probability of selection after adjustment for nonresponse and hospital nonparticipation and accounting for changes in the number of U.S. emergency department visits each year. We calculated national estimates as the sum of the number of cases multiplied by their respective weights and the corresponding 95% confidence intervals, using the SURVEYMEANS procedure in SAS software, version 9.3 (SAS Institute). Cumulative estimates and corresponding confidence intervals were divided by 10 to calculate average annual estimates and confidence intervals. We used the SURVEYFREQ procedure with the Rao–Scott modified chi-square test to assess differences in weighted proportions. We used SURVEYLOGISTIC and SURVEYREG procedures to assess linear trends in biennial estimates of emergency department visits. Biennial estimates were used to allow trend analyses to be conducted for categories of supplements associated with a small number of cases. We used intercensal estimates from the Census Bureau to calculate population rates. All analyses accounted for weighting and complex sample design. We considered that cumulative estimates of less than 1200, estimates that are based on fewer than 20 cases, or estimates with with coefficients of variation of more than 30% are statistically unreliable and are thus noted. Analyses of implicated products and symptoms were limited to cases in which a single dietary supplement product was implicated; unsupervised ingestions by children were analyzed separately.
Results
Supplement-Related Emergency Department Visits
On the basis of 3667 cases identified from 2004 through 2013, we calculated an average of 23,005 (95% confidence interval [CI], 18,611 to 27,398) emergency department visits for adverse events associated with dietary supplements annually and further estimated that these visits would result in an average of 2154 (95% CI, 1342 to 2967) hospitalizations annually (Table 1). In 88.3% of emergency department visits, clinicians attributed adverse events to only one supplement (as compared with multiple supplements). More than half of emergency department visits for supplement-related adverse events involved female patients. The mean age of patients who were treated for supplement-related adverse events was 32 years; more than a quarter (28.0%) of emergency department visits that were attributed to supplement-related adverse events involved persons 20 to 34 years of age. Persons 65 years of age or older were more likely to be hospitalized than were younger persons, with rates of 16.0% and 8.4%, respectively (P=0.003) (Table S3 in the Supplementary Appendix). One fifth of emergency department visits for supplement-related adverse events involved unsupervised ingestion by children.
Table 1
Products
Most emergency department visits for unsupervised ingestion of supplements by children involved a micronutrient product (61.9%; 95% CI, 56.5 to 67.3). The specific product categories that were most commonly implicated were multivitamins (33.6%; 95% CI, 29.0 to 38.3), iron (11.8%; 95% CI, 8.6 to 15.0), supplements for weight loss (10.4%; 95% CI, 7.8 to 13.1), and supplements for sleep, sedation, or anxiolysis (8.8%; 95% CI, 6.0 to 11.5).
After the exclusion of unsupervised ingestion by children, 65.9% of emergency department visits for supplement-related adverse events involved a single herbal or complementary nutritional product; 31.8% involved a single micronutrient product (Table 2). After the exclusion of unsupervised ingestion by children, a weight-loss product was implicated in 25.5% of emergency department visits and an energy product in 10.0% of such visits.
Table 2
According to Sex of Patients
Weight-loss products were implicated in an estimated 3399 (95% CI, 2618 to 4180) emergency department visits per year by female patients, almost three times the number of emergency department visits by male patients associated with these products (1223; 95% CI, 858 to 1588) (Figure 1). Of the total number of emergency department visits for supplement-related adverse events, weight-loss products were implicated in 30.4% (95% CI, 27.4 to 33.4) of such visits among female patients, as compared with 17.6% (95% CI, 14.3 to 20.9) among male patients. Sexual-enhancement products or bodybuilding products were implicated in 14.1% (95% CI, 10.5 to 17.7) of emergency department visits for supplement-related adverse events among male patients; there were too few cases among female patients to calculate a reliable estimate.
Figure 1
National Estimates of Emergency Department Visits for Adverse Events Associated with Dietary Supplements, According to Sex and Product Category (2004–2013).
Shown are the estimated number of emergency department visits per year, after the exclusion of unsupervised ingestion of dietary supplements by children, during a 10-year period. National estimates are based on fewer than 20 cases or have a coefficient of variation of more than 30% and may be statistically unreliable for the following combinations of product category and sex of the patient: sexual-enhancement products among women, bodybuilding products among women, and calcium among men.
According to Age of Patients
After the exclusion of unsupervised ingestion by children, micronutrients were implicated in two thirds of emergency department visits for supplement-related adverse events among children 4 years of age or younger (67.3%) and adults 65 years of age or older (62.7%) (Table S4 in the Supplementary Appendix). In contrast, herbal or complementary nutritional products were most commonly implicated among the other age groups.
Weight-loss products or energy products were implicated in more than half the emergency department visits for supplement-related adverse events among patients 5 to 19 years of age (51.2%; 95% CI, 44.2 to 58.3) and those 20 to 34 years of age (56.4%; 95% CI, 51.8 to 61.1) (Figure 2). Weight-loss products were implicated in 2661 (95% CI, 1995 to 3326) emergency department visits per year for supplement-related adverse events among patients 20 to 34 years of age, a number similar to that for visits associated with all other products combined among patients in each of the older age groups (Table S5 in Supplementary Appendix). Among adults 65 years of age or older, three specific micronutrients (iron, calcium, and potassium) were implicated in almost one third (29.9%; 95% CI, 24.9 to 35.0) of emergency department visits for supplement-related adverse events.
Figure 2
National Estimates of Emergency Department Visits for Adverse Events Associated with Dietary Supplements, According to Age Group and Product Category (2004–2013).
National estimates are based on fewer than 20 cases or have a coefficient of variation of more than 30% and may be statistically unreliable for the following combinations of age group and product category: weight loss (persons ≥65 years of age), energy (persons 50 to 64 years and ≥65 years of age), cardiovascular health or potassium (persons 5 to 19 years and 20 to 34 years of age), calcium (persons 5 to 19 years, 20 to 34 years, and 35 to 49 years of age), and iron (persons 5 to 19 years and 50 to 64 years of age).
Symptoms
Cardiac symptoms (palpitations, chest pain, or tachycardia) were the most common symptoms associated with weight-loss products (in 42.9% of patients) and energy products (in 46.0% of patients) (Table 3). Weight-loss or energy products were implicated in 71.8% (95% CI, 67.6 to 76.1) of all emergency department visits for supplement-related adverse events involving palpitations, chest pain, or tachycardia. Most of the visits for cardiac symptoms (58.0%; 95% CI, 52.2 to 63.7) involved persons 20 to 34 years of age. Cardiac symptoms were also commonly documented in emergency department visits attributed to bodybuilding products (49.8%; 95% CI, 34.5 to 65.0) and sexual-enhancement products (37.3%; 95% CI, 25.3 to 49.3). Most patients with palpitations, chest pain, or tachycardia associated with supplement-related adverse events were discharged from the emergency department (89.9%; 95% CI, 87.2 to 92.6).
Table 3
The most common adverse effects from most micronutrients (excluding iron, calcium, and potassium) were mild-to-moderate allergic reactions (40.6%) and swallowing problems (combination of choking and pill-induced dysphagia or globus, 41.0%; 95% CI, 32.4 to 49.7). Swallowing problems caused most emergency department visits involving calcium products (54.1%; 95% CI, 40.9 to 67.2), whereas abdominal symptoms (e.g., nausea, vomiting, and abdominal pain) were frequently associated with iron or potassium products.
Emergency department visits for supplement-induced swallowing problems were not common among patients 6 to 64 years of age (9.4%; 95% CI, 7.3 to 11.4) but were more common among those 65 years of age or older (37.6%; 95% CI, 29.1 to 46.2). Among older adults, 83.1% (95% CI, 73.3 to 92.9) of emergency department visits for supplement-induced swallowing problems involved micronutrients.
Trends over Time
The estimated number of emergency department visits for supplement-related adverse events was 20,517 (95% CI, 15,187 to 25,847) annually in 2004–2005 and 26,779 (95% CI, 21,703 to 31,854) annually in 2012–2013. However, after accounting for population increases, the incidence of emergency department visits for supplement-related adverse events did not significantly change during this period (P=0.09). There were no significant changes in the estimated numbers of emergency department visits for supplement-related adverse events associated with herbal or complementary nutritional products, micronutrients, weight-loss products, or energy products or for unsupervised ingestion of dietary supplements by children. However, emergency department visits for adverse events associated with micronutrients (excluding iron, calcium, and potassium) increased from 3212 (95% CI, 1930 to 4493) annually in 2004–2005 to 4578 (95% CI, 3397 to 5759) annually in 2012–2013 (P=0.03 after accounting for population increases).
Discussion
On the basis of reports from a nationally representative sample of emergency departments from 2004 through 2013, we estimated that dietary supplements were implicated in an average of 23,000 emergency department visits and 2000 hospitalizations annually. Although the numbers of emergency department visits and hospitalizations were less than 5% of the numbers that have been reported for pharmaceutical products previously,27 dietary supplements are regulated and marketed under the presumption of safety.
Although the incidence of emergency department visits for adverse drug events is reported to be low among young adults,27 more than one quarter (28%) of emergency department visits for supplement-related adverse events in our study involved young adults between the ages of 20 and 34 years. Weight-loss or energy products caused more than half these visits, commonly for cardiac symptoms (palpitations, chest pain, or tachycardia). Notably, cardiac symptoms were documented more frequently in emergency department visits for adverse events associated with weight loss (43%) and energy products (46%) than for prescription stimulants. In a previous study28 that used the same data source as the one used in our study, cardiac symptoms were documented in 23% of emergency department visits that were associated with prescription stimulants, which have label warnings for sympathomimetic adverse effects. Unlike over-the-counter or prescription medications, there are no requirements to identify adverse effects on dietary-supplement packaging. Clinicians could be encouraged to educate patients about potential cardiac effects from these products. However, since dietary-supplement histories are infrequently obtained,29–32 particularly among young adults,31 other opportunities for informing users of these potential adverse effects may be needed.
Unsupervised ingestions by children caused more than one fifth (21%) of all estimated emergency department visits for supplement-related adverse events, with almost two thirds involving micronutrients. Child-resistant packaging is not required for dietary supplements other than those containing iron,33 and despite such packaging, iron supplements were the second most commonly implicated type of supplement in unsupervised ingestion by children. Innovative safety packaging and targeted education on safe storage are potential interventions to reduce unsupervised ingestion of supplements by children.34
Among older adults, swallowing problems caused nearly 40% of emergency department visits for supplement-related adverse events, with micronutrients implicated in more than 80% of these visits. The FDA recommends limiting the size of pharmaceutical tablets to 22 mm and requires the reporting of tablet size and shape on abbreviated new-drug applications.35 However, there are no size recommendations or similar reporting requirements for dietary supplements. Large amounts or multiple types of micronutrients are often packaged in a single large pill, and many micronutrient products approaching or exceeding 22 mm are commercially available.36 Considerations for reducing the number of emergency department visits for swallowing problems include decreasing the size of supplement pills or using other delivery vehicles (e.g., liquids, gels, or powders), particularly for micronutrients for older adults, along with educating patients on methods for avoiding swallowing problems.
Limitations of our analysis should be noted. The number of emergency department visits attributed to supplement-related adverse events that we identified is probably an underestimation, since supplement use is underreported by patients, and physicians may not identify adverse events associated with supplements as often as they do those associated with pharmaceuticals.29–31,37 Physicians also may have more limited knowledge of interactions between prescription drugs and dietary supplements than they do interactions between prescription drugs. In addition, we did not collect data on emergency department visits associated with products that are generally considered to be foods or drinks by consumers but that may be considered to be dietary supplements under the Dietary Supplement Health and Education Act (e.g., energy drinks). However, it is also possible that emergency department physicians may incorrectly attribute certain symptoms to supplements, which could lead to overestimation.
The relatively wide confidence intervals around the reported national estimates indicate the precision limitations of using a relatively small, albeit representative, sample of hospitals. Sample size and design also prevent identification of differences among metropolitan areas, states, or regions. Nonetheless, population-based active surveillance can quantify adverse events better than voluntary reporting.10
A limited regulatory framework makes it challenging to accurately monitor the safety of supplements.18 It was not possible to calculate rates of emergency department visits for adverse events associated with supplements according to specific ingredient, product, or type, because data quantifying supplement use are extremely limited. Estimates of overall supplement use are available from national surveys, but studies have used varying categorizations, and most lack product-specific data.5,38 Identifying specific ingredients is also challenging because dietary supplements often contain multiple ingredients, and similarly named products can have different ingredients. For example, a product called Pro Clinical Hydroxycut Lose Weight lists 10 active ingredients, none of which are the three listed active ingredients in Hydroxycut Appetite Control.39
We categorized supplements on the basis of common reasons for use. In some cases, products were identified only by intended use (e.g., weight-lifting supplement). In other cases, specific products or ingredients were named, but because some products and ingredients are marketed for multiple uses (e.g., to improve energy and sexual performance), patients’ reasons for use might have differed from assigned categories.
In conclusion, we estimate that more than 23,000 emergency department visits annually in the United States from 2004 through 2013 were for adverse events associated with dietary supplements. Such visits commonly involved cardiovascular adverse effects from weight-loss or energy herbal products among young adults, unsupervised ingestion of micronutrients by children, and swallowing problems associated with micronutrients among older adults. These findings can help target interventions to reduce the risk of adverse events associated with the use of dietary supplements.
Notes
The findings and conclusions in this study are those of the authors and do not necessarily represent the official position of the CDC or the FDA.
Supported by the Department of Health and Human Services.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
We thank Dr. Lee M. Hampton, M.D. (medical officer for the CDC), and Ms. Kathleen Rose, R.N., B.S.N. (contractor for CDC), for their assistance with data acquisition and case review; and Herman Burney, M.S., Ray Colucci, R.N., and Joel Friedman, B.A., from the Consumer Product Safety Commission for their assistance with data acquisition.
Supplementary Material
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History
Published online: October 15, 2015
Published in issue: October 15, 2015
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From the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (A.I.G., N.S., M.C.L., D.S.B.), and Chenega Government Consulting (N.J.W.) — both in Atlanta; and the Center for Food Safety and Applied Nutrition and the Division of Public Health Informatics and Analytics (B.J.W., B.B.T.) and the Division of Dietary Supplement Programs (R.P.M.), Food and Drug Administration, College Park, MD.
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