Imagine the following scenario: A patient enters the doctor's office with a bag chock-full of dietary supplements reported to help maintain a healthy blood pressure. It's a supplement maker's dream, and a scenario that is becoming increasingly real for many physicians. While some caregivers are still apt to recommend purging the supplements in the rubbish bin, increasingly cardiologists are so open to the idea that they will recommend supplements to their patients. So why the, ahem, change of heart?

As patients educate themselves about dietary supplements, so must clinicians. "It's largely patient driven, and fueled significantly by the Internet," says Catherine Ulbricht, PharmD, a senior attending pharmacist at Massachusetts General Hospital and chief editor for Natural Standard Research Collaboration and Journal of Dietary Supplements.

In 2008, nearly three-quarters of heart specialists surveyed recommended some form of dietary supplements to their patients, according to "Use of dietary supplementsby cardiologists, dermatologists and orthopedists" (Nutrition Journal, March 2011). Cardiologists from the study recommended supplements for the purposes of lowering cholesterol, maintaining healthy cholesterol, and general heart health. Cardiologists are also likely to take supplements for themselves for general health, said the study authors, who at the time worked for the supplements trade group Council for Responsible Nutrition.

Supplement sales for cardiovascular health reflect the shift in attitudes. According to SPINS, in combined channels Natural and Food/Drug/Mass, sales rose 5.6 percent from Sept. 2010 to Sept. 2011. The most significant increase in sales came from the conventional channel, rising from $353 million to $376 million in the same time period, representing a 6.3% increase, as compared to 0.6% in the natural channel (figures exclude Walmart and Whole Foods).

Ulbricht says that, early on, many clinicians didn't want to know about supplements or alternative therapies. She says patients were not allowed to take them during in-patient care and some weren't thinking ahead to the fact that once a patient checked out of the hospital, they would likely go back to using them. "Like it or not, we need to be educated on natural products," she says, "foster open communication between providers and patients, and stop perpetuating 'white-coat syndrome'."

This change in attitude is largely from a new kind of physician. "The shift is about taking care of the whole person," says Mimi Guarneri, MD of Scripps Center for Integrative Medicine and author of The Heart Speaks (Touchstone, Jan. 2006). "This new breed of physician is as comfortable prescribing nutraceuticals as they are pharmaceuticals," she says. Guarneri believes that even the term alternative care is misleading because it implies something out the ordinary. Integrative better reflects the type of care that should be offered. "It's about what you need, when you need it," she says, which can mean nutritional food, nutraceuticals, supplements and/or pharmaceuticals.

The biggest obstacle that prevents clinicians from accepting alternative care, as a viable option, was and can be a lack of scientific evidence, says Ulbricht. "Clinicians were raised on evidence-based medicine," she says, "so it was important for supplement companies to speak their language and invest in the type of science clinicians recognize and accept."

That is finally happening, she says. At Natural Standard Research Collaboration, a peer review and rating service of scientific studies for alternative medicine, Ulbricht says she has seen the quality of science for alternative-care options improve dramatically over the last ten years (see more about Natural Standard in sidebar).

The problem with supplements

This heartfelt love-fest does not mean that the dietary supplement industry doesn't get physicians' hearts racing, or at least cause a little heartburn. There are still issues to work out. "When manufacturers don't standardize the ingredients in their products, don't follow GMPs, don't provide safety information or lack substantial scientific evidence to support claims, this adds liability issues," says Ulbricht. "Healthcare providers will shy away from these products opting for FDA-approved and regulated therapies."

Guarneri would like to see the industry invest more in clinical research, and not just studies of 40 people, she wants to see more studies involving 4,000 people. She believes that since products are selling without such studies, there is no incentive to pay for research of that magnitude. "I encourage the industry to look at some of the companies that are standing up and investing in this level of research," Guarneri says.

Another issue is education. "Many schools don't adequately train practitioners of the future on these therapies so understandably they don't feel comfortable discussing nor recommending them to their patients," says Ulbricht. "The industry needs to align with government and academic agencies to help educate caregivers."

Cardiologists agree. Annette Dickinson, PhD, and Andrew Shao, PhD, authors of the Nutrition Journal study, found that professional journals and clinical studies were physicians most trusted source for reliable information about dietary supplements. A majority had not received any formal training. Two in three physicians said they are interested in Continuing Medical Education (CME) regarding these products, and would like more information on potential interactions with pharmaceuticals; how to counsel patients about dietary supplements; and medical, legal and ethical issues relating to dietary supplements. "It's important for the industry to not only fund research, but to educate caregivers at medical conferences so they aren't just getting information from the pharmaceutical companies," says Guarneri.

Ulbricht has seen at Massachusetts. General Hospital, "Students and health care providers are demanding to learn this subject. It's no longer us against them," she says.

What are they prescribing?

Supplements that are leading the way for their role in cardiovascular health are fish oils and essential fatty acids and coenzyme Q10. In the Nutrition Journal study, 69 percent of cardiologists surveyed agreed with the statement, "Adults with a family history of heart disease should consider taking dietary supplements containing omega-3 fatty acids/fish oil."

An even more recently, a study review found the level of peer-reviewed cardiovascular research and alternative options is so strong that physicians should recognize that the treatment of hypertension is no longer limited solely to prescription drugs. The study, Nondrug Interventions for Treatment of Hypertension (Sept. 2011, Journal of Clinical Hypertension), said that although the first-line of treatment should be pharmaceutical therapies combined with lifestyle factors (low-salt, high-fiber, DASH diet), an alternative approach could be useful for patients who are reluctant to solely take prescription medications.

The study called out CoQ10 as the leading supplement recommendation, citing that CoQ10 may reduce standing blood pressure by as much as 16 mm Hg. The study authors, John Bisognano, MD, professor of Medicine and director of Outpatient Cardiology at the University of Rochester Medical Center and Kevin Woolf, MD, a cardiology fellow at the center, also reviewed supplements like vitamin D, fish oil, folate, garlic, and potassium for small but statistically significant drops in blood pressure. They also reviewed herbal remedies, acupuncture, meditation, as well as biofeedback and implantable devises to reduce blood pressure. The authors reiterated that any of these options should be considered on a patient-by-patient basis and should not be recommended as a one-size-fits all approach to blood pressure management.

Doctor Rx: Strong evidence base

Natural Standard rates various alternative therapies for their effectiveness based on evidence-based research. Here is a short list of ingredients that show strong levels of scientific evidence for cardiovascular preventative health, according to Natural Standard.

Grade: A Strong Scientific Evidence for Cardiac Secondary Prevention and Related Conditions