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Dietary Supplements: A Framework for Evaluating Safety (Free Executive Summary) http://www.nap.edu/catalog/10882.html Free Executive Summary ISBN: 978-0-309-09110-7, 526 pages, 6x9, hardback (2005) This executive summary plus thousands more available at www.nap.edu. Dietary Supplements: A Framework for Evaluating Safety Committe on the Framework for Evaluating the Safety of the Dietary Supplements, National Research Council This free executive summary is provided by the National Academies as part of our mission to educate the world on issues of science, engineering, and health. If you are interested in reading the full book, please visit us online at http://www.nap.edu/catalog/10882.html . You may browse and search the full, authoritative version for free; you may also purchase a print or electronic version of the book. If you have questions or just want more information about the books published by the National Academies Press, please contact our customer service department toll-free at 888-624-8373. The growing consumer interest in health and fitness has expanded the market for a wide range of products, from yoga mats to the multiple dietary supplements now on the market. Supplements are popular, but are they safe? Many dietary supplements are probably safe when used as recommended. However, since 1994 when Congress decided that they should be regulated as if they were foods, they are assumed to be safe unless the Food and Drug Administration can demonstrate that they pose a significant risk to the consumer. But there are many types of products that qualify as dietary supplements, and the distinctions can become muddled and vague. Manufacturers are not legally required to provide specific information about safety before marketing their products. And the sales of supplements have been steadily increasing—all together, the various types now bring in almost $16 billion per year. Given these confounding factors, what kind of information can the Food and Drug Administration use to effectively regulate dietary supplements? This book provides a framework for evaluating dietary supplement safety and protecting the health of consumers. Copyright © National Academy of Sciences. All rights reserved. Unless otherwise indicated, all materials in this PDF file are copyrighted by the National Academy of Sciences. Distribution or copying is strictly prohibited without permission of the National Academies Press http://www.nap.edu/permissions/ Permission is granted for this material to be posted on a secure password-protected Web site. The content may not be posted on a public Web site.  Copyright © National Academy of Sciences. All rights reserved. This executive summary plus thousands more available at http://www.nap.edu Dietary Supplements: A Framework for Evaluating Safety http://books.nap.edu/catalog/10882.html 1 Consumer interest in health and self-care has expanded the market for a wide range of products, including dietary supplements. Total sales of dietary supplements have grown to over $18 billion per year. As with conventional foods, when used as recommended, many dietary supple- ments are probably safe. However, increased use of supplements and the broad spectrum of products that qualify as dietary supplements as defined by the Dietary Supplement Health and Education Act of 1994 (DSHEA) make the determination of risk to the health of the consumer, a sizeable task. In addition, the limitations imposed by DSHEA—that the Food and Drug Administration (FDA) determine what is unsafe without requiring that specific information on safety be presented by manufacturers prior to marketing or that manufacturers submit to the FDA any reports they have received on serious adverse events associated with dietary supplement use—serve to make the safety regulation of dietary supplements a sizeable challenge. THE COMMITTEE’S TASK FDA must approach evaluating the safety of dietary supplement ingre- dients in a manner that is cost effective and science based within this regulatory environment. In order to assist in developing such an approach, FDA turned to the Institute of Medicine and the National Research Council of the National Academies to provide a framework for evaluating the safety of dietary supplement ingredients. FDA requested that a committee of ex- perts (1) develop a proposed framework for categorizing and prioritizing Executive Summary Copyright © National Academy of Sciences. All rights reserved. This executive summary plus thousands more available at http://www.nap.edu Dietary Supplements: A Framework for Evaluating Safety http://books.nap.edu/catalog/10882.html 2 DIETARY SUPPLEMENTS dietary supplement ingredients sold in the United States based on safety issues, (2) describe a process for developing a system of scientific reviews, (3) utilize the proposed framework to develop at least six scientific reviews or monographs as prototypes, and (4) revise the framework based on com- ments received. The final Framework described in this report is the result of the committee’s deliberations over the last 30 months and comments received on the proposed framework issued in July 2002. This Framework includes guidance on considering the various categories of data, taking into consid- eration methods other expert bodies have used to categorize and review supplement safety issues. REGULATORY BACKGROUND Current regulatory approaches to the safety evaluation of dietary supplements in the United States are a product of several key pieces of legislation that span the twentieth century, culminating in the passage of DSHEA in 1994. Since the passage of the 1938 Federal Food, Drug, and Cosmetic Act (FDCA), FDA has wrestled with the most appropriate ap- proach to regulating dietary supplements and several attempts have been met with resistance by industry as well as by segments of the public. In 1958, the Food Additives Amendment to the FDCA defined food additives and provided that they must undergo a premarket approval pro- cess unless they were considered to be generally recognized as safe (GRAS) (Table ES-1). FDA subsequently attempted to regulate the botanical indus- try by alleging that individual botanical products were unapproved food additives; this approach was subsequently struck down by the courts, rec- ognizing that the applicability of the provisions of the FDCA to products containing a vitamin, mineral, or botanical ingredient (whether it was con- sidered a drug or a food, for example) depended on the product’s intended use, as determined usually by the labeling and advertising claims for the product. Congress acted further to delineate FDA’s authority by passing DSHEA in 1994. DSHEA established the first comprehensive definition of dietary supplements as legally equivalent to foods (Box ES-1). Most importantly, DSHEA established a regulatory framework for dietary supplements that defined FDA’s authority over these products. FDA bears the burden of proof in determining that a dietary supplement ingredient presents a “sig- nificant or unreasonable risk of illness or injury” (see Box ES-2) rather than being authorized by statute to require the manufacturer to provide data supporting its safety, as is authorized for substances added to foods 1 or for drugs. 1 Food ingredients not declared or listed as GRAS. Copyright © National Academy of Sciences. All rights reserved. This executive summary plus thousands more available at http://www.nap.edu Dietary Supplements: A Framework for Evaluating Safety http://books.nap.edu/catalog/10882.html EXECUTIVE SUMMARY 3 For new dietary ingredients (those not marketed in the United States prior to passage of DSHEA in 1994), manufacturers or distributors must notify FDA at least 75 days before introducing a dietary supplement ingre- dient and must provide FDA with the information that is the basis upon which the manufacturer 2 has concluded that dietary supplement or ingredi- ent will reasonably be expected to be safe. THE SAFETY FRAMEWORK FOR DIETARY SUPPLEMENTS The definition developed for a “framework” was based on review of other existing frameworks. The Framework consists of two components: (1) a process for prioritizing, evaluating, and describing available informa- tion to establish risk of harm, and (2) a set of science-based principles that serve as guidelines for evaluating risk to human health. For the Framework to be useful, FDA must have adequate resources for implementation. To be credible, it must be scientifically based and include guidelines for obtaining and integrating the totality of the information from many areas of science. Adequate staff with appropriate expertise must be available within FDA to administer the process and evaluate the informa- tion. The Framework described here (see Figure ES-1) characterizes the na- ture of the scientific evidence that FDA is likely to encounter and describes a process for organizing this evidence to assess where a dietary supplement ingredient 3 lies on a spectrum of concern. 4 As the level of concern in- creases, so does the potential for a “significant or unreasonable risk,” the standard warranting regulation under the FDCA, as amended by DSHEA. I. The Process Three major components comprise the process: • Signal detection • Initial review of available information • Integrative evaluation 2 The term manufacturer is used for simplicity, but the statutes related to dietary supple- ments refer to both manufacturers and distributors, which may or may not be the same for a given dietary supplement ingredient or product. 3 In order to be consistent with the FDA’s regulatory role, the definition of “dietary supple- ments” used is that of DSHEA (Box ES-1). 4 The use of the term “concern” denotes a need for further investigation and inquiry by FDA based on a relative level of interest arising from initial information. Copyright © National Academy of Sciences. All rights reserved. This executive summary plus thousands more available at http://www.nap.edu Dietary Supplements: A Framework for Evaluating Safety http://books.nap.edu/catalog/10882.html 4 DIETARY SUPPLEMENTS TABLE ES-1 Current Status of Foods, Food Additives, Drugs, and Dietary Supplements under the Food and Drug Administration (FDA) Regulations Dietary Supplements Containing “New” Containing Ingredients Ingredients Introduced after in Use prior DSHEA Conventional Status to DSHEA a (10/15/94) Foods b Premarket No No; FDA notification No e approval 75 days prior to sale required required; FDA has 3 options: (1) respond with objection, (2) respond with no objection, (3) not respond Postmarket No No No reporting or surveillance by industry required Burden of FDA must demonstrate FDA must demonstrate FDA must proof of significant or significant or demonstrate safety unreasonable risk of unreasonable risk of that food is harm to remove harm to prevent injurious to product from market product from being health to marketed remove product from market a DSHEA = Dietary Supplement and Health Education Act of 1994. b Here “conventional foods” refers to whole agricultural commodities. c This description applies to “new” drugs. Many over-the-counter drugs are regulated under FDA’s Over-the-Counter Drug Review procedures, which do not provide for post- marketing surveillance. d GRAS = generally recognized as safe (as defined by the 1958 Food Additives Amendment to Food, Drug, and Cosmetic Act). Copyright © National Academy of Sciences. All rights reserved. This executive summary plus thousands more available at http://www.nap.edu Dietary Supplements: A Framework for Evaluating Safety http://books.nap.edu/catalog/10882.html EXECUTIVE SUMMARY 5 Substances Added to Foods GRAS Notice (previously, GRAS d “Affirmation” Food Additive New Drugs c Pre-1958 Petition) Petition Yes No No; manufacturer Yes; with FDA voluntarily may approval becomes notify FDA of an approved food basis of self- additive declaration as GRAS f ; FDA will respond with letter of objection or no objection within 90 days Yes No No Rarely Manufacturer FDA conducts risk Manufacturer must Manufacturer must provides risk/ assessment to demonstrate present adequate benefit analysis determine if reasonable risk assessment to acceptable to FDA GRAS recognition certainty of no demonstrate should be harm for intended reasonable withdrawn use through certainty of no scientific harm for intended procedure or use history of use e In 2001 FDA proposed in the Federal Register (66:4706) a rule requiring marketers of food developed through biotechnology to notify the agency at least 120 days before commer- cial distribution and to provide information to demonstrate that the product is as safe as its conventional counterpart. f While the final regulations for the notification procedure are not yet published, the interim policy outlined by FDA in the proposed regulations invites interested persons who determine that a substance is GRAS to notify FDA of such GRAS determinations as described in the proposed regulation 21 C.F.R. § 170.36 (b) and (c). Copyright © National Academy of Sciences. All rights reserved. This executive summary plus thousands more available at http://www.nap.edu Dietary Supplements: A Framework for Evaluating Safety http://books.nap.edu/catalog/10882.html 6 DIETARY SUPPLEMENTS BOX ES-1 Legal Definition of a Dietary Supplement as Defined by the Dietary Supplement Health and Education Act of 1994 The term dietary supplement: (1) means a product (other than tobacco) intended to supplement the diet that bears or contains one or more of the following dietary ingredients: (A) a vitamin; (B) a mineral; (C) an herb or other botanical; (D) an amino acid; (E) a dietary substance for use by man to supplement the diet by increas- ing the total dietary intake; or (F) a concentrate, metabolite, constituent, extract, or combination of any ingredient described in clause (A), (B), (C), (D), or (E). Dietary supplements are further defined as products that are labeled as dietary supplements and are not represented for use as a conventional food or as a sole item of a meal or the diet. Supplements can be marketed for ingestion in a variety of dosage forms including capsule, powder, softgel, gelcap, tablet, liquid, or, in- deed, any other form so long as they are not represented as conventional foods or as sole items of a meal or of the diet (FDCA, as amended, § 402). Signal Detection Given the large number of dietary supplement ingredients and that dietary supplements are assumed to be safe in general, it is unlikely that FDA will have the resources or need to evaluate each ingredient uniformly. Thus it is assumed that some “signal” will indicate that an ingredient’s safety may need to be reviewed. When a signal is detected and the credibil- ity of the signal and its relationship to a serious adverse effect in humans is evaluated, it is up to FDA to decide to take the next step. Given the significant number of dietary supplement ingredients, FDA’s attention should focus on signals that indicate that a serious 5 health prob- lem may result due to ingestion of a dietary supplement ingredient. 5 Serious—any experience resulting in any of the following outcomes: death, a life-threaten- ing adverse experience, inpatient hospitalization or prolongation of existing hospitalization, a persistent or significant disability/incapacity, or a congenital anomaly/birth defect. Important medical events that may not result in death, be life-threatening, or require hospitalization may be considered serious when, based upon appropriate medical judgment, they may jeopardize the individual and may require medical or surgical intervention to prevent one of the out- comes previously listed (in accordance with 21 C.F.R. § 600.80 [2002] and 21 C.F.R. § 314.80 [2002]). Copyright © National Academy of Sciences. All rights reserved. This executive summary plus thousands more available at http://www.nap.edu Dietary Supplements: A Framework for Evaluating Safety http://books.nap.edu/catalog/10882.html EXECUTIVE SUMMARY 7 In contrast to reacting based on detecting a signal, FDA may decide to proactively initiate a review of a dietary supplement ingredient due to high prevalence of use in the general population, high level of use by a particu- larly vulnerable population, or other factors. One of the requirements of the study was to develop a framework that would include criteria for how the review of safety of dietary supplements BOX ES-2 Safety Standards for Dietary Supplements as Established by DSHEA Section 4. Safety of Dietary Supplements and Burden of Proof on FDA. DSHEA amends § 402 (21 U.S.C. 342) by adding the following: (f) (1) If it is a dietary supplement or contains a dietary ingredient that— (A) presents a significant or unreasonable risk of illness or injury under – (i) conditions of use recommended or suggested in labeling, or (ii) if no conditions of use are suggested or recommended in the labeling, under ordinary conditions of use; (B) is a new dietary ingredient for which there is inadequate information to provide reasonable assurance that such ingredient does not present a significant or unreasonable risk of illness or injury; (C) the Secretary declares to pose an imminent hazard to public health or safety, except that the authority to make such declaration shall not be delegated and the Secretary shall promptly after such a dec- laration initiate a proceeding in accordance with sections 554 and 556 of title 5, United States Code to affirm or withdraw the declara- tion; or (D) is or contains a dietary ingredient that renders it adulterated under paragraph [402](a)(1) under the conditions of use recommended or suggested in the labeling of such dietary supplement. In any proceeding under this paragraph, the United States shall bear the burden of proof on each element to show that a dietary supplement is adulterated. The court shall decide any issue under this paragraph on a de novo basis. (2) Before the Secretary may report to a United States attorney a violation of the paragraph (1)(A) for a civil proceeding, the person against whom such proceeding would be initiated shall be given appropriate notice and the opportunity to present views, orally and in writing, at least 10 days before such notice, with regard to such proceeding. SOURCE: FDCA, P.L. 75-717 § 402, as amended 21 U.S.C. § 342(f) (2001). Copyright © National Academy of Sciences. All rights reserved. This executive summary plus thousands more available at http://www.nap.edu Dietary Supplements: A Framework for Evaluating Safety http://books.nap.edu/catalog/10882.html 8 DIETARY SUPPLEMENTS FIGURE ES-1 Diagram of the three components of the Safety Framework: signal detection, identification of level of concern in an initial review, and integrative evaluation, as well as how these components feed into FDA’s decision to take action. Signal Detection Proactive Initiation Initial Review TAKE ACTION MONITOR Continue to Collect Data Concern Level Lower Higher Gather Data -Categories -Prevalence of Use -Use by Vulnerable Groups Draft Monograph Integrate Data Use Expert Advisory Committee Integrative Evaluation Concern Level Lower Higher Copyright © National Academy of Sciences. All rights reserved. This executive summary plus thousands more available at http://www.nap.edu Dietary Supplements: A Framework for Evaluating Safety http://books.nap.edu/catalog/10882.html EXECUTIVE SUMMARY 9 and ingredients should be prioritized. However, given the wide variety of dietary supplement ingredients available, the multiple forms of an ingredi- ent for sale (e.g., pills, concentrates, extracts), the voluntary and thus vary- ing nature of the data available on an ingredient, and the wide variety of adverse effects that are possible for dietary supplements and the depen- dence of such effects on exposure levels, a simple scheme for priority setting is not feasible nor scientifically defensible. Initial Review of Available Information The second component of the Framework is to conduct an initial re- view of available information. First, the nature of the information generat- ing the signal is examined to determine the appropriate level of concern regarding a risk to human health. This component is not envisioned as a detailed analysis of data, but rather as an assessment of the concern level warranted by the nature of the evidence (e.g., quality of the report, applica- bility to humans, route of exposure) and whether the information raises questions that require further examination. Second, some effort may be made to gather easily available data to place the detected signal in context; such additional information may come from many sources, including other categories of data. Thus this initial review of the signal information need not be limited to reviewing only the information associated with the signal. If reviewing the signal results in a moderate level of concern, data from other categories should be considered as well. Since it is assumed by DSHEA that dietary supplements are safe, there should be relatively few dietary supplement ingredients that will be catego- rized as of higher concern after the initial review and thus warrant further examination. This allows FDA to focus its efforts on the few dietary supple- ment ingredients that are strong candidates for regulation. Integrative Evaluation The third step of the Framework is conducting an integrative evalua- tion for those dietary supplement ingredients that are deemed to warrant further investigation based on the preliminary data reviewed in the second step. There are four aspects to the Integrative Evaluation component (see Figure ES-1): in-depth literature searching and reviewing, drafting of a safety monograph based on this information, integrating the available data into an analysis to complete the monograph, and possibly referring the draft monograph and accompanying information to an expert advisory committee for additional input prior to FDA determining whether to take regulatory action. [...]... Data Dietary supplements : a framework for evaluating safety / Committee on the Framework for Evaluating the Safety of Dietary Supplements, Food and Nutrition Board [and] Board on Life Sciences p ; cm Includes bibliographical references and index ISBN 0-309-09110-1 (hardcover) 1 Dietary supplements Evaluation 2 Dietary supplements Toxicology [DNLM: 1 United States Food and Drug Administration 2 Dietary. .. Evaluating Safety http://books.nap.edu/catalog/10882.html 18 DIETARY SUPPLEMENTS health New drugs are subject to premarket approval, yet DSHEA excludes all dietary supplements from this requirement despite the fact that they may possess biological activities similar to those found in medications, and survey data demonstrate that dietary supplements are used by consumers for medicinal purposes Further,... of dietary supplements make it difficult for the health of the American public to be adequately protected Copyright © National Academy of Sciences All rights reserved This executive summary plus thousands more available at http://www.nap.edu Dietary Supplements: A Framework for Evaluating Safety http://books.nap.edu/catalog/10882.html Committee on the Framework for Evaluating the Safety of Dietary Supplements. .. injury resulting from use of dietary supplements • A prospective, systematic monitoring and tracking mechanism for dietary supplement ingredients should be maintained and refined A prospective, systematic method for recording and monitoring the history of safety issues of specific dietary supplements is necessary to implement the Framework so that FDA can evaluate the safety of dietary supplement ingredients... more available at http://www.nap.edu Dietary Supplements: A Framework for Evaluating Safety http://books.nap.edu/catalog/10882.html Contents EXECUTIVE SUMMARY 1 1 INTRODUCTION AND BACKGROUND 19 Committee Charge, 21 General Background Information About Dietary Supplements, 22 References, 39 2 APPROACHES USED BY OTHERS AND EXISTING SAFETY FRAMEWORKS Resources on Dietary Supplements, 44 Consideration of Frameworks... formulation or processing of a dietary supplement ingredient is changed, it should be considered a new dietary ingredient and subject to regulatory oversight as such Many dietary supplement ingredients on the market today have new formulations and are produced through very different processes than related dietary supplement ingredients in traditional usage, or even other dietary supplement ingredients... THE SAFETY OF DIETARY SUPPLEMENTS Through the process of developing the Framework to evaluate the safety of dietary supplement ingredients, a number of legal and regulatory barriers were identified that hamper FDA’s ability to protect the public Copyright © National Academy of Sciences All rights reserved This executive summary plus thousands more available at http://www.nap.edu Dietary Supplements: ... http://www.nap.edu Dietary Supplements: A Framework for Evaluating Safety http://books.nap.edu/catalog/10882.html Copyright © National Academy of Sciences All rights reserved This executive summary plus thousands more available at http://www.nap.edu Dietary Supplements: A Framework for Evaluating Safety http://books.nap.edu/catalog/10882.html Preface The Committee on the Framework for Evaluating the Safety of Dietary. .. itself What follows in this report is a framework for prioritizing and evaluating the safety of dietary supplements based on existing information available to FDA and others This framework, the primary work of the committee, was developed in the context of the current law regulating dietary supplements, the Dietary Supplement Health and Education Act of 1994 (DSHEA) It has been nearly 10 years since... framework proposed, prototype monographs were developed for a variety of dietary supplement ingredients Copyright © National Academy of Sciences All rights reserved This executive summary plus thousands more available at http://www.nap.edu Dietary Supplements: A Framework for Evaluating Safety http://books.nap.edu/catalog/10882.html 14 DIETARY SUPPLEMENTS Significant changes made to the initial framework resulted . http://www.nap.edu Dietary Supplements: A Framework for Evaluating Safety http://books.nap.edu/catalog/10882.html 4 DIETARY SUPPLEMENTS TABLE ES-1 Current Status of Foods, Food Additives, Drugs, and Dietary Supplements. http://www.nap.edu Dietary Supplements: A Framework for Evaluating Safety http://books.nap.edu/catalog/10882.html 6 DIETARY SUPPLEMENTS BOX ES-1 Legal Definition of a Dietary Supplement as Defined by the Dietary. criteria for how the review of safety of dietary supplements BOX ES-2 Safety Standards for Dietary Supplements as Established by DSHEA Section 4. Safety of Dietary Supplements and Burden of Proof on