658. This Is Your Brain on Supplements

If you ever watch TV or use the internet, you've probably seen advertisements for products

that are supposed to help your focus improve your memory and prevent the cognitive effects

of aging.

Our brains are incredible, but memory can get complicated.

That's why we created new NERIVA memory 3D.

Alpha brain is one of the most important supplements that I've ever found, ever in my life.

It's not the most important one, and the one that I cherish the most.

I started noticing the clarity wasn't there, that I needed, and that was frustrating.

I'd seen many commercials about Previgen, and I thought, why not give it a try?

Want to know why there are so many of these ads?

Apparently because they work.

Around 60% of US adults take at least one dietary supplement, the most common being

a multivitamin.

Brain supplements are one of the fastest growing segments of the market.

It has doubled over the past seven years, and it's projected to double again in the next

seven to around $25 billion a year.

We asked Freconomics Radio listeners to tell us what they take and why.

I take a bunch of supplements in the morning, but specifically for brain health, I take

krill oil, and I also take creatine powder.

After listening to a parenting podcast, I started taking coline, which is for fetal

brain development, but also adults can take it for memory.

The one brain supplement I take is omega-3 fish oil.

I take it once a day.

Currently I'm taking 20 to 25 grams of creatine a day for cognitive benefits.

I take a good amount of fish oil every day.

It takes three tablespoons of MCT oil every day.

My father-in-law is taking magnesium 3 and 8.

He has Parkinson's, and we're trying to retain some of his mental clarity.

I've been taking NAC, that's short for N acetylcystine, often on for several years.

The reason I take it is because I found a really interesting article on PubMed about

how it reduces obsessive and compulsive behavior, and it cured my sweet tooth.

It makes me feel sort of calm and less impulsive.

In case you're wondering, these supplements are not regulated by the Food and Drug Administration,

the way that pharmaceuticals are, both prescription and over-the-counter pharma products.

That is thanks to the Dietary Supplement Health and Education Act, or Dishay, which

President Clinton signed in 1994.

Dishay treats supplements as a type of food, not as drugs.

Many of them are made from plants or other natural matter.

Does this guarantee that they're safe?

Well, consider that hemlock is also natural, so are rice and anthrax.

Okay, but do these brain supplements at least work?

Today, on the show, we kick off a month-long series we're calling the Freakonomics Radio

Guide to Getting Better.

We will start by trying to understand the brain supplement industry.

You can imagine in an industry that has absolutely zero oversight and regulation, it's truly

the Wild West.

And we will look at the scientific evidence.

For instance, on a scale of 0 to 10, how effective are brain supplements at preventing cognitive

decline?

I'm really struggling between 0 and 1.

This is your brain on supplements, and it starts now.

This is Freakonomics Radio, the podcast that explores the hidden side of everything,

with your host, Stephen Dubner.

We're going to speak about supplements today with not one, not two, but three physicians.

Let's start with Peter Atia.

He wrote the best-selling book Outlive, The Science and Art of Longevity, and he makes

a Peter Atia Drive podcast.

He did his medical training at Stanford and Johns Hopkins, and today he runs a high-end

boutique medical practice.

We have some patients, Stephen, that come into our practice, and I kid you not.

They have a supplement list of, I mean, I've seen people come in with a hundred items

on their list.

My practice is pretty small.

I only see 75 patients.

It's a virtual practice, except for some of the evaluation we do at our facility in Austin,

Texas, where we have people come out at least once a year for a two-day expansive exercise

testing.

We're not providing primary care.

We're really just applying this medicine 3.0 playbook.

I assume you're fairly expensive, yes?

Yes.

All right.

Define medicine 3.0 for me.

I would define it as a type of medicine that focuses equally on the pursuit of lengthening

life as it does on reducing the decline of health span, and also takes a more personalized

approach based on all the best available evidence.

The five main domains of medicine 3.0 exercise, nutrition, sleep, emotional health, and exogenous

molecules, assuming that exogenous molecules are at least close to equal importance of

the others.

How do you think about that category, not for yourself as a human or as an investor or

as a podcaster, but as a physician, particularly?

It really depends on the situation.

There are some people for whom the drugs and supplements or hormones really play a minor

role, and then there are other scenarios whereby there are the difference between life

and death.

The person has hypertension, high blood pressure that is otherwise just completely recalcitrant

to the normal measures of weight loss and exercise.

Being able to use a drug to lower their blood pressure is going to have a dramatic impact

on the risk of heart disease and stroke.

And for other people, you're going to get 90% of the lift out of the other four levers.

I want to talk mostly about supplements, particularly brain supplements or what are at

least advertised as brain supplements.

The supplement industry and these measurements are all a little murky, but the supplement

industry is now estimated to be at around $45 billion a year in the US.

What do you make of that figure?

My intuition is that the majority of that money would be just as well flushed down a toilet.

Because why?

I think at best, most supplements are unhelpful and some of them are probably harmful, not

because of malice, but just incompetence on the part of the people who are making them.

Harmful on what dimensions and in what way?

Is it a dosing issue?

Is it a component issue of the supplements?

I think there's two ways in which this can occur.

The first is when an active ingredient is there, but it's in a much, much higher quantity

than it should be.

Obviously, you can have the opposite problem, which is equally likely or maybe more likely

where it's in a significantly lower level than what they're telling you.

In which case, it's just a homeopathic useless treatment.

But then, of course, you have the problem where impurities show up, most notably heavy metals.

You think you're buying melatonin and what you're getting is melatonin with lead or something

like that.

A recent consumer reports analysis of protein powders and shakes found that two-thirds of them

contained more lead in a single serving than you should consume in a day.

In some cases, more than 10 times as much.

How does this kind of contamination happen?

There's no testing by the FDA of supplements before they arrive on store shelves.

And that is Peter Cohen.

He's a professor at Harvard Medical School and a physician at the Cambridge Health Alliance,

where he also runs the Supplement Research Program.

Science magazine wants to scribe Cohen as a mix of Indiana Jones and Sherlock Holmes

in the supplement world.

He and his colleagues collaborate with research labs all over the world.

There's been a lot of questions over the decades about the quality of products, in part

because of studies like ours demonstrating that everything is not exactly as it might

appear on the label.

Cohen and his colleagues once found an unapproved and fetamin-like stimulant in several weight-loss

supplements, and they published their findings.

One of the supplement makers sued Cohen for libel, claiming $200 million in damages.

The case went to trial.

The jury found in Cohen's favor, but the week-long trial, he later said, put my family

through the ringer.

If it strikes you as unfair, or at least unfortunate, the scientific researcher finds himself in

a situation like that.

Well you may want to go back and listen to an episode we made a few months ago, number

647, about the degree to which the United States is a lawyerly society.

Whenever there is money to be made, there will be lawyers to protect the money makers,

and there is a lot of money being made in supplements.

Since the passage of Dechet in 1994, the number of supplements on the market has grown

from around 4,000 to 90,000, and none of them, remember, are getting any kind of health

agency approval.

It's basically completely unpredictable, what you're getting.

There are some nonprofit organizations that review manufacturing practices, and run some

tests before supplements go to market, but these are not mandatory reviews.

The manufacturer has to opt in, and the testing is limited.

These groups are only looking at the chemical compounds found in the supplement, and are

not making any assessment of the health claims, or structure function claims, or you name

it.

I don't know of a single organization that's doing that in any sort of accurate way.

You know, taking a look at the labels, and saying, is this truthful, or is this supported

by salt signs?

If you had to say on a scale of 0 to 10, how reliable would you say that the claims, the

medical, nutritional claims about supplements in total are?

Yeah, I mean, it's very distorted, and I'm really struggling between 0 and 1.

I don't know if I can do fractions, but it would be somewhere there.

In the first year of the Second Trump administration, there have been substantial shifts in food

and drug policy, and in public health policy.

In some cases, there's more regulation, in some cases, less.

There have also been cuts to scientific funding and staffing, including at the CDC, the centers

for disease control, so all of these targets are moving.

The FDA does regulate what a manufacturer can write on a supplement label, and the FTC,

the Federal Trade Commission, does regulate advertising and marketing.

For instance, a supplement manufacturer cannot claim that their product can diagnose treat

cure or prevent any disease, but if you have a good copywriter or a good AI and a good

lawyer to approve the copy, the English language can be quite pliable.

As long as the manufacturer avoids mentioning a specific disease, like Alzheimer's disease,

they can suggest that their product has that health benefit, the same one that anyone

with Alzheimer's disease or with a loved one with Alzheimer's disease would be thinking

about.

The manufacturer, if we were manufacturer supplements, could promote our product as if it maintains

a healthy memory or preserves healthy memory or memory boosting.

All of these are legal claims, even if your product has never been studied in humans

at all.

Let's say there is a supplement that promotes itself as being good for your brain, and there's

a similar pharmaceutical product with similar claims.

What's the difference in how those claims are arrived at?

You've already explained how under Dishay that the first doesn't have to really have any

data.

What about for the pharmaceutical version?

Yeah, the pharmaceutical is completely a different situation.

In order for a pharmaceutical to make a claim, it would have to have been approved by

the FDA.

Large clinical trials need to be conducted.

The FDA needs to first approve the pharmaceutical for human use.

When they do that, they'll also be clear on what the approved uses are, and traditionally

manufacturers have been required to stick with the claims that they had originally got

approval for.

Beyond that, they couldn't comment on the use of their drug.

I'd like to ask you a very naive question, but why is it that we're a country that has

an FDA, Food and Drug Administration, and an FTC, Federal Trade Commission?

If I'm a pharmaceutical firm and I want to sell my drug, then I need to go through a long

established standard, which is problematic in many ways.

We all know that.

There's a lot of advocacy for change in many directions there, but there is a standard.

If I'm a different kind of entrepreneur and I want to sell a supplement, let's say,

it is essentially making identical claims to the pharmaceutical about brain health, memory

health, retaining cognitive function, and so on.

There's not much inspection.

There's not much guarantee of consistency or even ingredients.

The odds are very good that I'll manufacture in China, by the way.

I can make these similar claims and sell them on the open market and the FDA and the FTC

don't touch it.

I literally just don't understand how that makes sense.

Am I naive?

Am I stupid?

Am I missing something?

What's going on?

No, you've got it completely correct.

How a manufacturer can look at it is if they have some compound they want to sell as

some health compound, they just need to decide which is the more profitable route.

It might be that doing large randomized control trials and then having proprietary control

over it and being able to have the stamp of approval with FDA as prescription drug and

then being able to sell that globally will be the most profitable.

But if they think that that might not be a good use of resources, then exactly take the

second path that you mentioned and go directly to market just tone down the claims and start

selling it online as a dietary supplement.

Peter Cohen and his colleagues at the Supplement Research Program are not the only people

concerned with supplement safety and efficacy.

The NIH has an office of dietary supplements that publishes fact sheets about supplements.

The U.S. Department of Defense runs a program called Operation Supplements Safety, turns

out that military members take more supplements than civilians and examine.com, a subscription

website, publishes up-to-date supplement research.

But with 90,000 different supplements on the market, there is a real scarcity of good

data.

And that can have serious consequences.

We have thousands of patients who end up in emergency departments to the adverse effects

of supplements every year in the States.

Who keeps the records on that?

Well, it was recently shut down.

The research that looks at how many people end up in emergency departments is based on a

series of Sentinel emergency departments that was set up and operated in part by the CDC.

And the collection of that data could also detect adverse effects of dietary supplements.

So that was the only representative way to take a look and get an estimate of how many

people are actually ending up in emergency departments.

I'm looking at the data now.

It says it an estimated 23,000 emergency department visits annually in the U.S. from dietary supplement

adverse effects.

I feel bad for those 23,000 people.

So that's relatively tiny, yeah?

Yeah.

Compared to the number of people who are being misled about the claims in dietary supplements

absolutely.

I mean, how would that compare to alcohol overuse in ERs?

Yes.

The difference is that tobacco alcohol gun violence.

In those situations, no one is using those products to improve their health.

So here we have situations where there's no information for consumers that they're going

to find about the risks of these products and they're taking that to improve their health.

And then to end up in the emergency department, tens of thousands or hospitalized, that's

serious.

So hearing Peter Cohen talk about the problems with supplements, you might think that he is

anti-supplement, but you'd be wrong.

I couldn't practice good medicine without them.

And remember, is also a primary care physician.

I recommend supplements to my patients all the time.

These are vitamins and mineral supplements or combinations of those.

And they're key to medical care.

Just name your top, whatever five or ten vitamins and minerals that you prescribe.

Multivitamin, vitamin D, calcium that's often combined with vitamin D, iron's grade, and

I'm showing my favorites.

Indeed, for some people with vitamin deficiencies, supplements can be critical.

Here is one of our listeners, Danielle Douglas.

Hi, as a 44-year-old emergency medicine physician, my brain needed to be a Ferrari and

not a Toyota, and it wasn't anymore.

I was doing everything right or so I thought.

But as I worked in the busiest ER in San Diego County during a COVID pandemic, homeschooled

three children and worked out like a triathlete to cope with all the stress.

My nutrient stores were depleted, and cortisol levels completely strained.

Through lab testing, I realized my stress vitamins and minerals like magnesium and B vitamins

were in the toilet.

Fortunately, through supplementation with GMP NSF certified supplements and obtaining them

through well-vetted distributors, I was able to get my brain back to functioning at

optimum levels.

A lot of the listeners we heard from say they're using creatine to boost their brain power.

Here's Peter Cohen.

Yeah.

So, creatine is not really part of medical care, but it's something that can help a specific

type of athletic performance.

If one's doing repetitive weight lifting, for example, taking creatine can slightly

improve one's ability to recover in between sets.

Now, while that is well-established, creatine is often marketed as if it'll have some

sort of cognitive benefits, and there's no robust data whatsoever to support that claim.

Has anyone tried that you know of?

With creatine, I believe there's been a few small studies.

And usually, when you have just a few small studies, you can publish the ones that look promising.

But with creatine, even the very small studies are not suggestive enough.

Okay?

What about colline?

Colline makes a little more sense, because it's a precursor of acetylcholine, and that's

something that gets low in Alzheimer's disease.

So it makes some sense that let's put something that can get converted in the body and something

that you might be deficient in when you have memory loss.

But with colline, I know of no studies that have demonstrated all that giving colline

will improve memory or function.

How about Ginkgo, and I'd love you to get into the Ginkgo evaluation of memory study,

if you could?

Ginkgo, below, but has been carefully investigated, because it was probably the leading botanical

supplement that was thought to potentially have cognitive benefits or prevent memory loss.

And this idea goes back probably thousands of years, right?

Absolutely.

Chinese and others have been using that.

So a lot of NIH funds has been spent on trying to understand, you know, can Ginkgo,

below, but preserve or improve memory, and the studies are negative, basically, there's

no difference between Ginkgo, below, and placebo.

The nice thing for a supplement manufacturer, though, is that you can take a study like

that that definitively is shown that Ginkgo, below, but does not prevent memory loss.

And completely ignore it when it comes to your label.

So then you can just put Ginkgo, below, but into your supplement, and then sell it as

memory enhancement.

This is how crazy the current advertising, marketing, environment is.

There's just a disconnect between how supplements can be promoted and the proven benefits.

And that's because the law basically gives manufacturers a pathway to communicate just

about any health benefit to consumers without having to demonstrate anything that their

product actually works or even have studied their product in humans.

What about omega-3s?

Yeah.

So with omega-3, what's very interesting is that in cohort studies, a group of people who

have diets are very rich in omega-3, a lot of fatty fish and other omega-3 foods, there's

a lower incidence of Alzheimer's disease in those populations.

So it's a natural fight, but in this situation with omega-3, it has been saying, I believe

up to five years in duration and no benefit of omega-3 supplementation to improve cognitive

function.

What does that say about the difference between ingesting an ingredient that's naturally

occurring in a food versus a supplement version rate?

It probably says a lot because this reductionist approach to nutrition might not be the most

beneficial.

So if we're just reducing herring to its omega-3 content, there's a lot of other things

going on, exciting things when it comes to herring.

Talk about that.

Is it about the cell structure?

Is it about the other components?

What are the exciting things in herring?

You know, I'm not a herring analytical chemist expert, but I would assume that if we took

a deep dive into the chemistry of herring, we would find thousands of different compounds.

Some of those would be fascinating to study, and they're all combined together.

With food, there's also the tradition of how we eat it, right?

Like, with the herring, how is it preserved?

Is it in vinegar or the sugar?

And how do those preservatives affect either positively or negatively our health?

And then, of course, what are we putting the herring on, right?

So a lot's going on there, but you're a herring fan from a nutritional perspective.

Oh, yeah.

Definitely.

I think the more fish we can get in our diet, the better.

Can you talk for just a minute about the relationship between modern supplement taking,

especially botanicals and things like that, and the development of medicines generally?

How do you think about knowing what's valuable and what's not from the natural world versus

the pharmaceutical world?

I think that what we've learned from decades of high quality studies is that it's really

the details that matter.

It's not so much the origin of something to come from a lab or to come from a plant.

It's what are the precise components in that health product?

If there's more than one, what's the ratio of those?

If there's one, precisely how much there is, how is that ingredient or ingredients absorbed

into the body?

And then, once that's standardized, we can understand its health effects.

There is no clear distinction between pharmaceutical drugs and botanical preparations.

Red yeast rice is a great example.

Red yeast rice is a fermented rice product, kind of like making beer, you come by yeast

with rice and make red yeast rice.

And one of the fermentation byproducts, there's a compound called monocolon, K.

And that compound is precisely the same chemical as low of a stat, which is a stat and drug.

That's a perfect example of this overlap between precisely the same chemical.

And we've done research on a similar plant alkaloid like that, called colantamine, where

it's found in plants and has been part of some traditional botanical remnants of those

plants out.

And it's also isolated, synthesized, and used as pharmaceutical drugs.

So there's no real distinction between these, but I would say that unless you're standardizing

the production of something, you really can't understand its long-term health effects.

This is a subtle but important point that Cohen is making.

Drugs that have gained FDA approval, including over-the-counter drugs like ibuprofen, fall

into what is called evidence-based medicine.

Many supplements, meanwhile, fall into what you might call gossip-based medicine.

You may hear from a friend that a certain supplement worked great for them, but you don't

know what else they're taking.

You don't really know what it did for them, and remember the placebo effect is powerful.

You also don't know if maybe ten other friends took the same supplement and found that it

didn't help, or maybe even harmed them.

Even and nutrition science are hard enough even when you have good data.

With supplements, it can be hard to even know the dose you're getting.

The drug that Cohen mentioned a minute ago, Galantamine, is an FDA-approved prescription

treatment for mild to moderate dementia caused by Alzheimer's.

According to the FDA, Galantamine isn't legally supposed to be sold as a dietary supplement,

but it is as a non-prescription treatment for memory retention and cognitive function.

Peter Cohen and his colleagues analyzed pharmaceutical versions of the drug, versus several

supplement versions.

They found that the pharma versions were properly labeled.

They contained between 98 and 104 percent of the quantity listed on the labels.

In other words, what it says is what you get.

The supplement versions, meanwhile, ranged from less than 2 percent to 110 percent of

the quantity listed on the label, and they found that a third of the supplements were contaminated

with bacteria associated with gastrointestinal illness.

So if you are in favor of supplements, you might like to move them into the evidence-based

realm.

Coming up after the break is that going to happen.

I'm Stephen Dubner.

This is the Freakonomics Radio Guide to Getting Better, we'll be right back.

So the Physician Peter Cohen is skeptical of many dietary supplements, but he does use

some in taking care of his patients.

The Physician Peter Atia is also skeptical, and he too makes room for exceptions.

There are a handful of supplements that I take, and by extension, there are a handful

of supplements that many of our patients take.

Name them.

I think for most people, magnesium is a really logical choice.

There are different forms that you can take magnesium in.

You can take it in a form that is really rapidly absorbed.

You can take it in a form that is very slowly absorbed, and they actually achieved totally

different things.

So we don't consider those mutually exclusive.

There's also a form that is bound to another molecule that enables transfer across the

blood brain barrier, and there's reasonable, though, because it's only a supplement.

It's not subject to the same level of testing, but there's reasonable evidence that it's

got some protection in the brain and augments sleep.

So you have three completely different types of magnesium, and I think there's benefit

in all three of those.

I think another supplement that makes sense for almost everybody is creatine monohydrate.

There's physical advantage.

There's cognitive advantages to that.

Are they massive?

No, they're not massive, but you always have to weigh the cost, both economic and risk

of taking something to the potential benefit.

And so if you do it on an ROI basis, I actually think creatine makes a ton of sense.

I would say those are probably the two closest supplements that I would put in the almost

no-brainer camp.

I would put EPA and DHA, which are the two omega-3 fatty acids found in fatty fish.

Maybe 90% of people, 80% of people probably don't consume enough fatty fish to achieve the

levels that we believe.

And when I say we, I don't mean me personally.

I mean, the epidemiologists and people who study this, that we think produce the optimal

levels of cardiovascular and brain health.

And so for most people, myself included, taking a high quality EPA and DHA supplement is

a great way to supplement the amount of fish we eat.

Maybe another one I would throw in there is for jet lag.

I think melatonin can be very helpful, not a fan of it at all for daily use,

because it does seem to down-regulate endogenous production of melatonin.

But when you're hopping in my experience more than six or seven hours of a time zone,

melatonin can be a wonderful tool to help reset circadian rhythm,

along with another supplement that I only use during those periods, which is called

phosphatidyl serine.

Phosphatidyl serine suppresses cortisol output from the adrenal glands,

and also is just a fantastic tool when you're trying to go to bed.

When you describe cognitive advantages to some of these supplements,

how would you assess the evidence for those advantages compared to the evidence of

some pharmaceutical, maybe it's a GLP1 agonist that we hear a lot about these days?

How does one body of evidence compare to the next?

Oh, it's not even close, Stephen. The advantage that we would have when assessing the benefits

of a GLP1 agonist are so much more because the studies are so much larger, there's so much more robust.

It's interesting that you brought up GLP1s because everybody understands the efficacy that these

drugs have when it comes to weight loss and type two diabetes. But there are all sorts of subanalyses

that are looking at other questions. How does this drug stack up in patients with heart failure?

How does this drug stack up in patients with MCI or mild cognitive impairment?

It is that indication of MCI that I think is the most interesting right now because the

jugular question is not does a person who is obese overweight or have type two diabetes who takes

this drug and therefore emuliorates those conditions? Does that improve MCI? The answer is

obviously yes, it does because anything that takes weight off and improves insulin sensitivity

improves cognitive function. The more important question and the multi-billion dollar question is

independent of the weight loss and the improving insulin sensitivity do these things improve

cognition. And if the answer to that is yes, we would elevate this drug from its current status into

the pantheon of what we call zero protective agents, right? Something that is actually targeting some

of the fundamental metrics of aging and not doing it circuitously through weight loss or insulin

sensitivity, all of which are important, but they're very distinct questions. What is your sense

based on what you've read and learned so far about the mechanisms by which there's a cognitive

boost to the GLP ones? We actually recently did a podcast on that about twice a year we do a podcast

called what is it called? I think we call it proven promising fuzzy nonsense like we basically

take a bunch of drugs and supplements and run them through our framework and put them into five

categories. So GLP ones came out in that assessment as promising and promising is a high bar for us

like we're sticklers and where I landed on that Stephen was the data look pretty good at the moment

but the definitive study still hasn't been done. I don't see any evidence that a person with normal

cognition, normal risk factors, insulin sensitive and of normal weight would benefit from them.

So if you were to think about comparing what is known on the market today as brain supplements or

supplements that offer cognitive benefits of some kind, if you compare that whole kind of murky

pool of supplements to the cognitive benefit effects of GLP ones, how do you think about those two

pools of treatments differently? So these are spoken about in very different circles. The discussion

that you and I are having about GLP ones is the discussion that's happening with physicians

and scientists and these are really interesting questions. I don't pay that much attention to the

podcast sphere, but in podcast land, we're really talking about biohacking and those people are

talking about everything from lion's mane to beeswax to all sorts of god knows what there's virtually

no overlap in those discussions that I can see. I've spent a lot of time looking at both of these

things and from where I sit and have no bias because I couldn't care less. I'm just interested in

what works. I think that there's potentially a signal there on the GLP one side. My intuition,

though, is it is not a cognitive enhancer? It is something that prevents decline in the susceptible

individual. So when we think about brain function and especially brain supplements, it seems to be

mostly older people who are concerned about improving or stopping the loss of memory or maybe

for stalling Alzheimer's and things like that. But as you're not talking about the relationship

between cognitive function and physical function, I wonder if you can talk a bit about what's included

in cognitive function as you see it as a physician primarily. What's the relationship between cognitive

function and mental health? What's the relationship between cognitive function, not just memory, but

things like decision making and so on? We think of cognitive function broadly in terms of executive

function, which would include decision making, memory, which is both short and long term and then

there are lots of subtypes of memory, visual spatial memory, etc. And then processing speed.

Those are the three pillars of cognition and they can all be measured. Unfortunately, we don't have

great off-the-shelf ways to measure this. There aren't like amazing apps that do this, but a really

good clinician who's well versed in how to do cognitive testing can measure and assess your

performance on those domains. We still have to accept the fact that as we age our cognitive

performance declines just as our physical performance does. So my VO2 max is getting lower by decade,

my muscle mass, my strength, these are decreasing by decade, and so too is my cognitive performance.

So then the question becomes what can I do to offset that? What I really want people to understand

is all the supplement stuff you're doing is a little bit of rearranging the deck chairs on

the Titanic. You earn the right to worry about that stuff. Once you have the stuff that provides 90%

of cognitive function taken care of and that's going to come down to sleep, exercise, nutrition,

intellectual and social engagement, and learning. These are the pillars of maintaining cognitive

function. And if you never took a supplement for the rest of your life, but you adhered to

maximizing your participation on those domains, you would be incredible.

So you said that a lot of the spending on supplements is equivalent to flushing the money

down the toilet. You, however, are an investor in a couple companies that make supplements, yes?

Yes. These include Element and AG1, both which are pretty well known. Walk me through those,

start with Element. Describe what it is and why you invest in it. And I assume that it's not

in the category of supplements that you'd be better off flushing your money down the toilet,

correct? Correct. So Element is a company that makes an electrolyte drink. It's effectively

sodium chloride salt with flavoring. This was actually a topic I was never really interested in

until four years ago when I had a couple of repeated bouts of lightheadedness,

including one that resulted in a really significant face plant that required multiple stitches to

a bunch of lacerations across my face. And when I got home, this happened while I was traveling,

and my doctor took my blood pressure and sort of confirmed what I had always known,

which is I had sort of low blood pressure. And it was exacerbated by things like traveling,

or for example, if I gave blood or if I was exercising a lot, the obvious solution to that is

to hydrate more. And that got me really deep down the rabbit hole of hydration. I basically bought

every product on the market. And the one that I liked that I found palatable enough was Element.

I reached out to the founder of the company and made a small investment. And I want to be clear,

I don't think there's anything magical about any electrolyte drink. What you're really trying to

do is identify a way that you can easily deliver something on a frequent basis. And so what you're

titrating towards is compliance at the lowest cost. If I were to drink more water and put more

salt on my food, I could achieve a similar benefit. Yeah. So why not do that? It's just going to be

much harder to be compliant than to take a little simple pack, throw it in my bottle every time I

go to the gym, which is every day. And then what about AG1? Same thing. What is it? How did you get

involved in it? What does it do for you? AG1 is effectively a slightly overkilled multivitamin

that combines a whole bunch of nutrients that you would otherwise be getting if you're eating a

great diet that's well balanced. So I think of it as kind of a belt and suspenders for me,

because I don't know, maybe four days a week, Steven, I can hit the metrics and I'm eating

a really great diet. And on the days I don't, I'm totally fine overdoing it a little bit and

making sure I have a little bit more. So how do you think about the difference between

getting these ingredients or nutrients into your body via food versus via supplement?

I think it entirely depends on which supplement we're talking about. And therefore it's case-by-case.

For sodium, I don't think it matters if you're putting salt on your food versus consuming sodium

and something else. Provided you're not consuming a bunch of other junk with it. For the fruits and

vegetables and the phytochemicals and things like that that you're trying to replace, I would say you

are assuredly better off getting it in food because by definition, if you're consuming it in food,

you're getting a ton of fiber and you're getting water as well. And you can't replace the fiber

in a supplement at nearly the same efficacy. If we were going to talk about protein, I would say

the same thing. I think you're always better off getting your protein in food, but I'm sitting

here supplementing protein with a protein shake or a protein bar most days. Because otherwise,

I'm just not going to hit my protein target. So the answer I think is it's usually better

to achieve these things in food. And for some people, life is straightforward enough that they can

always do that. My patients live in the real world. And despite their luxuries, even most of them

have a hard time day in and day out hitting their targets. And I know that if my patients have to

rely on supplementation here and there, probably most people do. One of the things I always tell

somebody is, you know, make sure anybody who's selling you anything has a really clear

line of conflict disclosures around. You've mentioned a couple of things that I'm involved in. And

my patients are very clear on where my conflicts are. And we're not actually selling anything to

anybody. So I was thinking it's important that people understand that that you have to be aware

of the doctor you go to see who turns around and sells you an unlimited supply of supplements.

Coming up after the break, where is the FDA heading with supplement regulation? I'm Steven

Dubner. This is Frekenomics Radio. We'll be right back.

When you think about brain supplements, you're really thinking about the brain and the brain as much

as we love it and appreciate it. The fact is, we really don't know it all that well. It reminds me

of the ocean. It's right there in front of us. We use it all the time, but there is still

so much to learn. So where do most people learn about brain function and brain supplements?

When we asked Frekenomics Radio listeners where they get their information, the results were

pretty much what you would expect. A wide-ranging blend of physician advice, reading podcasts,

social media, friends, and friends of friends, online. On Instagram, there are roughly 12

million posts with the hashtag Supplements. There are millions more on TikTok. For Peter Tia,

this is frustrating. Let's be honest, our species is becoming lazier and lazier. If I sat here

and gave you an hour-long dissertation on how much I could improve your brain health by exercising,

and then you heard some guy talk for 30 seconds on a TikTok video about how you could take this

pill. Most people just want the pill. They don't have the time, energy, or desire to kick the

tires on it and realize that stuff at Tia was talking about is going to make like a 50% improvement

in my cognition. And what this other guy's talking about is going to do nothing, but he sounds

better and it's easier. And here again is Peter Cohen, the Sherlock Holmes of the supplement world.

It does seem like the current social media environment makes it very difficult

to get accurate and useful tips and advice to stay at the forefront. But this isn't just a problem

that started with TikTok. I'm sort of reminded of the evolution of the Dr. Oz show. Dr. Mehmet Oz is

a cardiothoracic surgeon who now runs the Centers for Medicare and Medicaid Services. He got his

start on Big Time TV as a recurring guest on the Oprah Winfrey show. I think if we were to have

access to those early tapes on Oprah, I think is advice when I spawn on terrific. Increase your

vegetables, get more exercise, avoid empty calories, you name it. But then something happens when

you need to produce a show or more a week in your audience is growing and growing and advertisers

want more and more and more and more. And it's hard to say every day, like get some more exercise,

eat some more fruits and vegetables, do more home cooking. In 2011, the Dr. Oz show was preparing

an episode about the HCG diet. HCG is short for human-chorianic gonadotropin, which is a hormone

produced by women during pregnancy. For the diet, patients take HCG and eat only 500 calories a day.

That is roughly one-fourth the daily calories recommended for a typical adult woman.

When he did his show on that, he asked me to come as a guest. And I assumed it was going to be a show

that was going to be about debunking this weight loss practice. And instead, I felt a bit ambushed

because I remember one of these weight loss docs came out of her stretch limo with multiple

patients outside the studio. And the whole show was then designed to say, hey, you know,

maybe there's something there, maybe you should give it a try. What did you say? Did you just say,

well, I haven't seen any evidence at this works and therefore we should go slow or were you

a little bit more aggressive than that? I forget what I actually said because I was so surprised by

that situation. But I might have said something like, if you starve yourself, you will lose weight

in starving yourself for a diet is not healthy. That can lead to a call stone formation,

a lot of other problems. So I don't recommend this. I remember that there were two patients who had

actually suffered some sort of adverse effects after they had started this HCG diet. But instead

of being next to us on stage, they were out in the audience. But I do remember that I chatted

with them, connected with them and commiserated with them as the show was going on.

Now, what you're describing is something that I've observed for a long time. I mean,

it's probably been happening since the history of humankind, which is that the bolder predictions,

positive or negative are the ones that tend to get our attention. It could be in the realm of

politics, CNN or Fox News or MSNBC. And if I come on and say, you know, this and that about the end

of the Republic or fascism, I'm going to likely be considered a good and spicy guest and I will

be invited back. However, Peter Cohen comes on there and says, well, yeah, if you starve yourself,

you're going to lose weight. I'm guessing you weren't invited back at least as an advocate of

that kind of thing, correct? Correct. On the HCG circuit. Reach out to me again.

The FDA has approved HCG as a prescription drug to treat female infertility and some other

conditions. Companies that sell it as an over-the-counter weight loss remedy have received warning

letters from the FDA and the FTC. Warning letters are one way the FDA tries to exert its regulatory

reach over supplements and make them more reliable. Peter Cohen has some other ideas.

There are some very thoughtful ways that we could improve the quality of these products.

If the political will was there, we could also quickly get a handle on the health claims.

So the idea that's been floated around is to have an FDA registry of legal permitted

dietary supplement products. For example, if a product label came to the FDA and it contained

ingredients that were not legal supplement ingredients, the FDA would simply not post it.

If there were suspicious things, maybe the FDA could require additional testing or maybe the

FDA could require additional testing of all products before they posted it on their website

by a high-quality third party. If there was political will, they could say, listen, we're not

going to put any health claims on our website that are not supported by science. And then

requiring that that's the only information that can be available on the label. If you were to do

that, then consumers could make more accurate decisions about what to put in their body.

So what direction do you see the political will moving in at this moment?

Yeah, just the opposite. The manufacturers are advocating for more ability to make more

health claims and somehow to figure out a way to get the FDA's name on the label so the

health claim actually looks vetted by the FDA. And how does that intersect with what you know about

the worldview of Bobby Kennedy, Jr. That would be very consistent with minor standing of how he's,

you know, perceived supplements as if this whole world of supplements is beneficial in the whole

world of pharmaceuticals is poisoning us. And that's nonsense since there's no real distinction

between these two categories at all. Accepted lower burden of proof in one case, right, exactly.

But on the other hand, what I've been hearing is that supplement manufacturers particularly have

been chagrinned by the lack of movement in that direction so far in the second Trump administration

is it coming and we just haven't seen it yet or is it maybe not coming? Well, I think part of

the problem for the manufacturer's get excited is that they have had it so good for so many years.

They've basically had a situation where the FDA has not been forcing the minimal bits of the law

that do exist that they could go after some particularly hazardous products or they could go after

adulterated products. And the FDA seems to be about choosing enforcement discretion,

which is their way of saying we're just not going to enforce the law for years.

Is that really the FDA's position? To find out, we called up one last physician,

Marty McCarrie, Commissioner of the FDA. McCarrie has been on Frekenomics Radio a few times in

the past. He was a surgical director and health policy scholar at Johns Hopkins. He's also written

a few books, including blind spots when medicine gets it wrong and what it means for our health.

Running the FDA is his first job in government. I asked him now about a proposed change to what is

called the grass standard or generally recognized as safe, which applies to food and dietary supplements

because remember the FDA treats supplements as a category of food, not medicine.

Yeah, we've announced that we are challenging the grass standard, which basically says food

companies can put a new chemical in food if they generally recognize it as safe. And we're saying,

look, guilty until proven innocent, you have to show us that something is safe if you want to add a

newly engineered chemical into the US food supply that children are going to eat.

So the supplement market that's really exploding and it is remarkable to me how unregulated

that industry is. I wonder what your position is on that and whether you think the FDA should be

doing more. We have to look at all of it. We have to look at every aspect. Now, for example,

we know that if you drink a canisota, the caffeine can have a slight positive impact on your

short-term memory. Now, are we going to crack down on a social media influencer who says,

you know, that I drank this caffeinated drink to help me with my memory? We have to prioritize

what is safeguarding the public versus what's simply cracking down for cracking down sake.

And so we've got to look at all of it and then come up with a priority list of where to start.

It turns out that the FDA's priority list is pretty long. So next time on the show, we will cover as

much of that as we can. The FDA today is not going to be an FDA in a receive-only mode. We're not

going to be stingy librarians. We're going to go into the pipeline, find out what sounds promising

and bring that to the forefront. That's next time on the show, a full conversation with

Commissioner McCary. Until then, take care of yourself. And if you can, someone else too.

And if you found this episode useful or interesting, please tell a friend about Freakonomics Radio.

That is the single best way to support our show. You can also leave a rating or review on your

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Stitcher and Rendbud Radio. You can find our entire archive on any podcast app, also at Freakonomics.com,

where we publish transcripts and show notes. This episode was produced by Alina Coleman,

with help from Dalvin Abouaje and edited by Gabriel Roth. It was mixed by Jasmine Klinger with

help from Jeremy Johnston. We also had recording help from Bill Pollock. Special thanks to all

our listeners who shared their firsthand supplement experience. The Freakonomics Radio Network

staff also includes Augusta Chapman, Eleanor Osborne, Ellen Franklin,

Elsa Hernandez, Alaria Montenacort, Theo Jacobs, and Zach Lipinski. Our theme song is Mr.

Fortune by the hitchhikers and our composer is Luis Guerra.

So wait a minute. You're saying the New York Times has you for nutrition tips. You said,

make your own chicken stock and granola, and they just cut the granola part.

Nope, they cut both. They said, we want you to stick to the area that your expertise on.

What's your supplement tip? But the reason they said that was because they don't like

granola tip. The Freakonomics Radio Network, the hidden side of everything.

Stitcher.