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We’re all citizens of the internet, which means we’ve likely all been served a supplement ad — for endometriosis or PCOS, for migraines or PMS, for low testosterone, better skin, or better sleep. Influencers hock herbs they call “nature’s Ozempic,” or a “natural detox,” or for “immune support.” Celebrities own supplement brands that they sell to their millions of followers on TikTok. One popular TikTok herbalist says she takes — and also sells — a liver detox supplement to “prep [her] body for pregnancy.” Sephora even has a cute little case designed to keep your supplements organized. Supplements are ubiquitous, and the marketing around them can be both authoritative and chummy, even confessional — personal promises that you can take control of your health.
But there’s a catch: Supplement makers don’t have to prove that their pill, tincture, powder or tea is either safe or effective. (By contrast, prescription and over-the-counter medications like Advil must show that they are both safe and effective before they ever go on the shelf.) In fact, the FDA doesn’t have the authority to test anything in any of those bottles at any point, unless there are official complaints and people get sick — but experts say that even then, the consequence is nothing more than a strongly worded letter.
That’s how a healthy 31-year-old woman wound up in Dr. Pieter Cohen’s office in Somerville, MA, with a set of alarming symptoms: She was oddly sleepy but her heart was racing and she couldn’t catch her breath. She was constantly nauseated and her fingers were spasming. She had just started taking a weight loss supplement called LipoFit Turbo and it turned out that — unbeknownst to her — those pills contained numerous pharmaceuticals according to the FDA, including metformin, a diabetes drug, and sibutramine, a controlled substance that is banned in the United States because it can cause heart problems. Supplements were also to blame when a 53-year-old woman’s left hand suddenly went numb, according to a case study in the Annals of Internal Medicine. She didn’t have any risk factors for cardiovascular disease, but she reportedly had a stroke because of a workout supplement she was taking called Jacked Power, which contained a variation of amphetamine, or speed.
These are not isolated incidents. About half of all Americans take a supplement, like a multivitamin, an herb, or a protein powder. In recent decades, the supplement market has boomed into an estimated 60-billion dollar industry, and rates of liver injury are increasing, in large part caused by overuse of supplements like turmeric pills that seem “natural” and benign but can be toxic to the liver in large doses.
The CDC found that supplements caused about 23,000 visits to the emergency room each year between 2004 and 2013, and that workout, weight loss, and sexual health supplements were the most risky — though even some of the most popular and safe vitamin supplements, like Vitamin D, can also be deadly in amounts much higher than the recommended allowance. We don’t know the full scope of the problem because no one tracks how many supplements are on the market or what they contain, and the CDC program that monitors supplement-related emergency room visits has just been cut by DOGE.
This apparent free-for-all is bad news for everyone, especially people who need a supplement, like the near 40% of girls and women under 21 who have low iron. Numerous studies have revealed that supplements often contain varying doses, not what is on the label. That’s a problem because some supplements do have evidence-based uses, like iron for a deficiency, folic acid for pregnant people, or melatonin for sleep. But because supplements aren’t regulated, a melatonin gummy that’s labeled five milligrams might contain zero melatonin. Or, one that’s labeled three milligrams might actually contain more than 10 milligrams.
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The mind-bending truth is that anyone can start selling pills that promise to make you feel better without any kind of expertise or proof. “Based on the rules in the United States, I could probably go and scoop dirt from my backyard, put it in a capsule and call it Dr. Gunter’s vaginal support,” says Dr. Jennifer Gunter, an OB-GYN and pain medicine physician. She’s kidding, but only a little. To understand supplement history, we have to travel way back in time, to an era before evidence-based medicine.
Supplements are like time capsules from an age before restrictions on ingredients or claims, before government regulation and randomized controlled trials. Back in the 1800s, medications were marketed directly to consumers, often using personal testimony and a money-back guarantee, much as supplements are peddled today.
There were cocaine toothache drops (“instantaneous cure!”), syrups for colicky babies that were basically straight alcohol, and Piso’s Tablets for the treatment of the diseases of women — like “ulceration of the womb” — which contained cannabis and chloroform. Headache remedies were often spiked with opium. The original Coca-Cola was sold as a tonic for nerves and headaches and was a favorite of the temperance movement because it was alcohol free — though it did contain cocaine.
Some of these medicines may have actually made a baby stop crying or dulled a headache, but they were also dangerous, and often did not even have an ingredient list, so people didn’t know what they were taking. Mrs. Winslow’s Soothing Syrup was advertised as a cure for teething pain, with a wholesome portrait of a mother in a white nightgown snuggling in bed with her two extremely calm small children. But the syrup contained morphine, which would certainly have made children sleepy but also killed some of them.
In 1906, after decades of medication-related deaths, people started to think that the government really needed to do something to ensure the safety of what Americans put into their bodies. “Maybe we shouldn't have people getting addicted to opium, and little old ladies taking cocaine. Maybe there's a place for regulation here,” says journalist Dan Hurley, who wrote the definitive book on the supplement industry, Natural Causes: Death, Lies, and Politics in America’s Vitamin and Herbal Supplement Industry.
The result was the 1906 Pure Food and Drugs Act, which mandated that medicines list the presence of drugs and alcohol on their label and ensure the accuracy of their claims. This was enough to put many snake oil companies out of business, because it turned out most people did not actually want to drug their children to sleep.
But, according to Hurley’s book, the Food and Drug Administration as we know it didn’t really get going until 1938, after an antibiotic was laced with antifreeze, causing the long and painful deaths of 107 people, most of them children. No one had bothered to test the medication for safety. After that, Congress passed a law requiring drugs to prove their safety to the FDA before going on the market. This was right on time, as pharmaceuticals were multiplying, including antibiotics and vaccines that could cure or prevent many of the diseases that had stalked humans for all of history.
Around the same time, the 13 dietary chemicals that we now call vitamins were discovered, and they inspired excitement and hope: Milk and flour started to be fortified with vitamins and minerals. Because these substances were originally isolated from foods, they were thought of as food or food additives, and were regulated that way, separately from drugs.
But by the 1980s, as Hurley reports, the vitamin and supplement industry had developed into one that would be recognizable today: pills and powders with big claims. Again, it took catastrophe for there to be any appetite for regulation: L-tryptophan is the amino acid found in turkey and milk that makes you sleepy. In the 1980s, it became the next big thing. Mainstream magazines called the amino acid a “natural” or even “magic” sleeping pill, one that could also help with pain, stress and PMS.
The problem was that, in some people, it also caused L-tryptophan eosinophilia-myalgia syndrome or EMS—excruciating muscle and nerve pain, fatigue, rashes, heart problems, paralysis and even death. By 1991, 1500 cases of EMS were reported to the FDA and 36 people had died. An investigation revealed that all the illnesses seemed to be linked back to one Japanese manufacturer, but it remains unclear what it was in those pills that may have caused the disease. (Despite this, L-tryptophan is now back on the market.)
At the time, David A. Kessler was the new head of the FDA, and this was a hinge moment, an opportunity: The L-tryptophan scandal was a perfect example of how out-of-control the supplement industry had become, and Kessler vowed to put regulations in place to prevent anything like it happening again.
But the supplement industry was determined to stop him, as detailed in a Frontline documentary called Supplements and Safety. Kessler wanted to restrict the claims on supplement packaging to those that the company could prove represented “significant scientific agreement.” For instance, there is significant scientific agreement that folic acid can prevent birth defects during pregnancy, but that level of evidence is extremely rare in the supplement world. And the claims are everything. Why else would anyone spend good money on a supplement, if not to “support immunity,” or to get “healthy skin,” or “super cleanse” your liver?
Faced with an existential threat, the industry launched an unprecedented lobbying campaign, according to the documentary. Pamphlets and ads whipped up panic: “Don’t let the FDA take your supplements away!” Congress got more letters about the proposed rules than they did protesting the Vietnam War. A widely run TV ad showed Mel Gibson in his bathrobe about to take his nightly vitamin when an armed swat team burst into his home to confiscate the pills and arrest him. As he’s cuffed, Gibson speaks to the camera, bewildered: ”Vitamin C, you know? Like in oranges?” Never mind that the FDA was never going to ban vitamins, but wanted to prevent misleading advertising about them.
The industry also mobilized one of their friends, Republican Senator Orrin Hatch, from Utah, a supplement hub. Herbalife International was Hatch’s third-largest donor for years, and other supplement companies also donated generously. At the time, Hatch’s son worked for a lobbying firm whose biggest clients were supplement manufacturers.
After two intense years of debate, lobbying and fearmongering, the FDA’s proposed regulation was dead. In its place was the Dietary Supplement Health and Education Act of 1994, a bipartisan bill sponsored by Hatch. It gave even wider leeway to supplements than they had had before, giving them special dispensation to bring products to the market that had never been shown to be beneficial, without any obligation to guarantee purity or safety.
“The law was designed by industry insiders to maximize profits,” says Dr. Pieter Cohen, an internal medicine physician and professor at Harvard University who studies the safety of supplements. The only compromise was the requirement for that familiar disclaimer: “This statement has not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.” Those two sentences are expected to do a lot of heavy lifting.
“Every other time people died, the FDA tightened regulations. Let's be sure it's safe and effective,” says Hurley. “This was the first time that instead they loosened regulations. It’s extraordinary.”
When the law went into effect in 1994, there were only about 4,000 products on the market. Now there are more than 100,000. Supplements have only become more popular, more profitable and globalized. “They thought they got the genie in the bottle and closed it. But the genie got back out, and now the genie is in charge of the FDA,” says Hurley.
All of this puts consumers in a difficult position. We can understand supplement history, but are supplements safe? Is there any safe way to take a supplement?
“It’s buyer beware,” says Gunter. If you see someone singing the praises of a supplement, figure out if they have a financial relationship to the product. That applies even if that person is a physician or other health professional. Gunter says that supplement companies can pay physicians tens of thousands of dollars a month to promote their product on social media. Jessica Knurick, a registered dietician who debunks online wellness claims, agrees, and she adds to be especially wary of fear-based language like “are you poisoning your kids?” In that case, she says “just keep on scrolling.”
But there are ways to protect yourself. First, find out if there is scientific evidence that the substance actually has any benefits. The National Institutes of Health’s Office of Dietary Supplements has fact sheets for many common supplements, summarizing the evidence on how each could be beneficial or risky.
And experts advise choosing products that have been certified by USP or NSF; these third-party testing organizations are also recommended by the Department of Defense for its service members, and their seal of approval helps ensure that what is on the label is actually in the bottle, and that the product is free of contaminants. “Otherwise, it’s a crapshoot,” says Cohen, who has conducted studies showing that many supplements don’t contain what they claim.
People reach for supplements in hopes of helping themselves live healthier, more comfortable lives. It’s an understandable urge — maybe even a universal one. That desire to take control can be especially acute for girls and women, whose health has been under-researched and whose concerns are often dismissed. But that’s what unethical supplement makers exploit. “They’re not closing that gap. They’re preying on it,” says Gunter. “The more people fall for that allure, the less they're going to be calling up their senator and going, what the fuck, dude? How come we don't have this basic science on our health?”
