Biological Trace Element Research

, Volume 125, Issue 1, pp 1–12 | Cite as

Clinical and Analytical Toxicology of Dietary Supplements: A Case Study and a Review of the Literature

  • Gijsbert B. van der Voet
  • Andrey Sarafanov
  • Todor I. Todorov
  • Jose A. Centeno
  • Wayne B. Jonas
  • John A. Ives
  • Florabel G. Mullick


The use of dietary supplements has grown dramatically in the last decade. A large number of dietary and herbal supplements escape regulatory and quality control; components of these preparations are poisonous and may contain, among other toxins, heavy metals. Uncontrolled use of dietary and herbal supplements by special populations, such as the military, may therefore pose a health risk. Clinical symptoms are not always properly attributed to dietary supplements; patients often do not mention supplement use to their health care provider. Therefore, a health risk estimate is hard to make on either the individual or the population level. The literature on this issue was reviewed and discussed in the light of a representative clinical–chemical case study. This case study was performed on a host of preparations that were used by one single individual in the military. Both essential (chromium, copper, zinc, and iron) and poisonous (arsenic, lead, and nickel) trace elements were determined using inductively coupled plasma combined with optical emission spectrometry (ICP–OES) or with mass spectrometry (ICP–MS). Arsenic and lead were detected at exposure levels associated with health risks. These health risks were detected predominantly in hormone-containing supplements and the herbs and botanicals used for performance enhancement. To the extent that this is a representative sample, there is an underestimation of supplement use and supplement risk in the US military, if not in the general population. Since clinical symptoms may be attributed to other causes and, unless patients are specifically asked, health care providers may not be aware of their patients’ use of dietary supplements, a strong support of laboratory diagnostics, such as a toxicological screening of blood or urine, is required. In addition, screening of the preparations themselves may be advised.


Dietary supplements Herbal supplements Adverse effects Clinical toxicology Laboratory diagnosis Toxicology screening Quality control Essential metals Poisonous metals Arsenic Lead 


  1. 1.
    Yetley EA (2007) Multivitamin and multimineral dietary supplements: definitions, characterization, bioavailability, and drug interactions. Am J Clin Nutrition 85:269S–276SGoogle Scholar
  2. 2.
    Bent S (2008) Herbal medicine in the United States: review of efficacy, safety, and regulation: Grand Rounds at University of California, San Francisco Medical Center. J Gen Intern Med (April 16, Epub ahead of print)Google Scholar
  3. 3.
    Office of Nutritional Products, Labeling and Dietary Supplements (ONPLDS), Food and Drug Administration (FDA). Website: (accessed April 23, 2008)
  4. 4.
    Office of Dietary Supplements (ODS), National Institutes of Health (NIH). Website (accessed April 23, 2008)
  5. 5.
    National Center for Complementary and Alternative medicine (NCCAM), National Institutes of Health (NIH).Website (accessed April 23, 2008)
  6. 6.
    Kaufman DW, Kelly JP, Rosenberg L, Anderson TE, Mitchell AA (2002) Recent patterns of medication use in the ambulatory adult population of the United States: the Slone survey. JAMA 297:337–344CrossRefGoogle Scholar
  7. 7.
    Kelly JP, Kaufman DW, Kelly K, Rosenberg L, Anderson TE, Mitchell AA (2005) Recent trends in the use of herbal and other natural products. Arch of Intern Med 165:281–286CrossRefGoogle Scholar
  8. 8.
    Timbo BB, Ross MP, McCarthy PV, Lin C-TJ (2006) Dietary supplements in a national survey: prevalence of use and reports of adverse events. J Am Diet Assoc 106:1966–1974PubMedCrossRefGoogle Scholar
  9. 9.
    Haller CA (2006) Clinical approach to adverse events and interactions related to herbal and dietary supplements. Clin Toxicol 44:605–610CrossRefGoogle Scholar
  10. 10.
    Ko R (2006) Safety of ethnic & imported herbal and dietary supplements. Clin Toxicol 44:611–616CrossRefGoogle Scholar
  11. 11.
    Izzo AA, Ernst E (2001) Interactions between herbal medicines and prescribed drugs. Drugs 61:2163–2175PubMedCrossRefGoogle Scholar
  12. 12.
    Hu Z, Yang X, Ho PC, Chan SY, Heng PW, Chan E, Duan W, Koh HL, Zhou S (2005) Herb–drug interactions: a literature review. Drugs 65:1239–1282PubMedCrossRefGoogle Scholar
  13. 13.
    Chavez ML, Jordan MA, Chavez PI (2006) Evidence-based drug-herbal interactions. Life Sci 78:2146–2157PubMedCrossRefGoogle Scholar
  14. 14.
    Gardiner P, Phillips R, Shaugnessy AE (2008) Herbal and dietary supplement–drug interactions in patients with chronic illnesses. Am Fam Physician 77:73–78PubMedGoogle Scholar
  15. 15.
    Sood A, Sood R, Brinker FJ, Mann R, Loehrer LL, Wahner-Roedler DL (2008) Potential for interactions between dietary supplements and prescription medications. Am J Med 121:207–211PubMedCrossRefGoogle Scholar
  16. 16.
    The Directorate of Health Promotion and Wellness (DHPW) (US Army Center for Health Promotion and Preventive Medicine (USACHPPM). Website: (accessed April 23, 2008)
  17. 17.
    Corum SJC (2004) Dietary supplement use in the military: do army health care providers know enough ? Army Medical Department Journal PB 8-04-1,2,3 (January–March), 36–38. Website: (accessed April 23, 2008)
  18. 18.
    Dietary Reference Intakes: Recommended Intakes for Individuals (DRI Tables). Food and Nutrition Information Center (FNIC) United States Department of Agriculture (USDA). Website: (accessed April 23, 2008)
  19. 19.
    Toxicological profile for lead (2005) Agency for Toxic Substances & Disease Registry (ATSDR). Website: (accessed April 23, 2008)
  20. 20.
    Ernst E (2002) Toxic heavy metals and undeclared drugs in Asian herbal medicines. Trends Pharmacol Sci 23:136–139PubMedCrossRefGoogle Scholar
  21. 21.
    Toxicological profile for arsenic (2005) Agency for Toxic Substances & Disease Registry (ATSDR). Website: (accessed April 23, 2008)
  22. 22.
    Sadovsky R, Collins N, Tighe AP, Brunton SA, Safeer R (2008). Patient use of dietary supplements: a clinician’s perspective. Curr Med Res Opin (March 17, Epub ahead of print)Google Scholar
  23. 23.
    Ashar BH, Rowland-Seymour A (2008) Advising patients who use dietary supplements. Am J Med 121:91–97PubMedCrossRefGoogle Scholar

Copyright information

© Humana Press Inc. 2008

Authors and Affiliations

  • Gijsbert B. van der Voet
    • 1
  • Andrey Sarafanov
    • 1
  • Todor I. Todorov
    • 2
  • Jose A. Centeno
    • 1
  • Wayne B. Jonas
    • 3
  • John A. Ives
    • 3
  • Florabel G. Mullick
    • 1
  1. 1.Division of Biophysical Toxicology, Department of Environmental and Infectious Disease SciencesArmed Forces Institute of PathologyWashingtonUSA
  2. 2.Crustal Imaging and Characterization TeamUS Geological SurveyLakewoodUSA
  3. 3.Samueli Institute for Information BiologyAlexandriaUSA

Personalised recommendations