Let’s face it: every company in the practitioner channel claims to have the finest quality products, made with the cleanest ingredients made in state-of-the-art manufacturing facilities to pharmaceutical standards. Terms like “purity,” “traceability,” and “sustainably sourced” are de rigueur on product labels and detail sheets.

The “quality proposition” is all the rage across the supplement industry these days, and especially so in the practitioner channel. And that’s a good thing.

But with the rising use of dietary supplements and botanical medicines in clinics across the country, it is very important to ask, how do medical practitioners themselves define quality? 

What criteria do they consider when evaluating products to recommend to their patients? Are supplement companies adequately meeting the needs and preferences of clinicians and their patients? Where are the unmet needs? Holistic Primary Care’s 2018 practitioner survey provides some insight.

The survey fielded last winter, and generated responses from 469 practitioners, 33% of whom are conventionally trained MDs. Nearly two thirds (61%) dispense supplements in their practices, and 94% of those who don’t dispense do recommend at least some supplements to patients. The 36-item survey included the following question: “In evaluating whether to introduce a new product or brand to your patients, how important are the following factors?”

For each of nine multiple choice answers, respondents could choose whether that factor was “Decisive,” “Important but not decisive” or “Of minor importance.”
Here are the criteria, ranked from most to least decisive:

• Free of heavy metals (75% decisive; 24% important; 1% of minor importance)
• Free of artificial sweeteners (71% decisive; 27% important; 2% of minor importance)
• GMO-free (60% decisive; 35% important; 5% of minor importance)
• Allergen-free (56% decisive; 42% important; 2% of minor importance)
• Practitioner-only status (38% decisive; 40% important; 22% minor importance)
• Dosage form & frequency (34% decisive; 57% important; 18% minor importance)
• 3rd party seals (USP, NSF, CRN, etc.) (27% decisive; 55% important; 18% of minor importance)
• Price (23% decisive; 71% important; 6% of minor importance)
• U.S.-only ingredients (7% decisive; 47% important; 46% of minor importance)

The pattern of concerns was fairly consistent across practitioner subtypes, though there were a few curious age differences. Younger practitioners (age 30-40 years) were surprisingly less likely to cite GMO-free concerns than 50-60 year olds (40% vs 61%). They were also less likely to care about artificial sweeteners (60% vs 77%).

However, younger respondents were more likely to cite dosage & frequency issues (40% vs 25%) and pricing (30% vs 16%) as decisive factors.

What Doctors Want
For busy practitioners, the definition of product quality goes far beyond what’s actually in the tablets or capsules. It encompasses everything from the science behind the formulations to the diligence of the customer service team.

Doctors want a balance of solid science plus practical “Monday morning” applicability, said Robert Silverman, DC, director of the Westchester Integrative Health Center. Speaking at HPC’s 2018 Practitioner Channel Forum, Dr. Silverman shared findings from an informal survey of some of his practitioner colleagues. Dr. Silverman asked dozens of doctors what they look for in supplements, and what their unmet needs might be. Among the responses were:

• Easy-to-swallow liquid formulas, especially for elderly patients and those experiencing “pill fatigue.”
• Expanded sports support lines, especially for overzealous middle-aged Iron Men (and women), and non-athletes who are suddenly driven to overdo it on their workouts.
• Gluten-free, dairy-free, GMO-free products.
• Compelling patient education tools. Videos and easy-to-understand graphics can help patients understand what to take, and how to take it. This increases adherence and improves outcomes. Keep in mind that doctors—even the holistic ones—don’t have a lot of teaching time with patients.
• Fewer tablets or capsules, and intelligently designed formulas. Adherence is inversely proportional to complexity of a supplement regimen. Simpler is always better.
• Short format implementation protocols. Time is of the essence in any practice; clinicians want streamlined strategies. “We need algorithms. We need guidance,” said Dr. Silverman, and for different types of patients. “A woman who weighs 100 pounds is different from a man who weighs 270. Should each of them take the amount recommended on the label?” How is an ordinary doctor supposed to know?
• Social media and practice development support. Many functional medicine practitioners struggle to manage the various aspects of a non-insurance practice. Nutraceutical companies that help with things like social media marketing and patient acquisition can become valuable allies.

Science … But How Much?
Every doctor will say, “I want to see the data” to support the use of a particular supplement. Likewise, every company will say that its formulas are “science-backed” or “evidence-based.”
But Dr. Silverman has found that doctors want science for different reasons, depending on how deeply engaged they are in functional/holistic medicine. It is very important to understand their psychology.

Those in the early stages of learning generally want science for reassurance. They want to know about a few basic formulas to help resolve common chronic conditions they’re seeing every day. They need to develop confidence in functional medicine as a mode of practice, and in supplements as clinical tools. “Science” is what gives them permission to feel that their interest in supplements is not “quackery.”

“They’re on the edge of the water, thinking about plunging in. They need to know what to use, how to use it,” Dr. Silverman said. But they don’t necessarily want an exhaustive treatise on liver detox pathways or the most cutting-edge microbiome data. They want enough science to feel assured they are on the right path.

Then there are practitioners who are partially engaged. These are the folks who have “hybrid” practices where they still provide conventional allopathic care, but they also incorporate nutrition and lifestyle change. They want formulas and protocols for managing tough complex conditions, and they want to understand the science behind these protocols. 

Then there are the full-time experienced functional or holistic practitioners. For them, supplements and herbs are the therapeutic main course, not a side dish. They want the latest, most innovative formulas, and they like diving deeply into the data. For them, the science helps in refining their patient care and improving their clinical outcomes.

Quality Beyond the Products
For Jill Carnahan, MD, founder of Flatiron Functional Medicine, a thriving holistic practice in Lewisville, CO, the definition of “quality” goes far beyond a company’s commitment to analytical testing and clean products. Speaking at the TPC Forum, Dr. Carnahan said her preferred companies are fastidious about everything from packaging to customer service.

Supplements are not only vital clinical tools in her practice, they also represent upward of 40% of her total revenue. This cash stream makes possible the long, unrushed, in-depth office visits that her patients value.

When evaluating supplement vendors, she looks for:

• Speedy fulfillment: “Fast, efficient, trouble-free ordering and shipping is key.”
• Solid, yet eco-conscious packaging: “Sometimes we’ve gotten products that come damaged due to poor or inappropriate packaging. But eco-friendly packaging is also very important. We try to recycle as much as possible, and prefer companies that use recyclable materials.”
• Clear and detailed invoicing that includes specific product names, sizes, wholesale cost, and recommended
• retail pricing.
• Online ordering & auto-shipping: “We buy from over 40 different companies, and carry over 600 SKUs. You can imagine my office manager going crazy trying to figure out how to order what from whom. We like companies that make it easy for us.”
• Reasonable minimums: Some companies require practitioners to purchase several dozen bottles at a time, which can be a deterrent for Dr. Carnahan. “If we have to order a minimum of 36 bottles, we may not try a new product because it will be a big waste if we don’t sell it.”
• Professional and courteous customer service: High-quality companies should staff their phone lines with real people well-trained in customer care and knowledgeable about the company. Dr. Carnahan avoids brands that only provide a general “customer service” e-mail as the only contact.

Product Innovation
Dr. Carnahan treats a lot of patients with complex autoimmune disorders, environmental toxicities, or both. She’s always looking for innovative companies that go beyond obvious product offerings and develop new products that meet their unmet needs.

One such issue is metabolic endotoxemia, caused by bacterial lipopolysaccharides (LPS) that cross a leaky gut mucosa into the blood. A number of nutraceuticals—quercetin, curcumin, sulforaphane, resveratrol, EPA/DHA, Bifidobacteria and spore-forming probiotics—can be helpful for this condition. But, so far, no one has developed an easy-to-implement combination.

“If someone could put together a formulation bringing together these ingredients at the right dose levels to give the anti-LPS effect in the studies, it would solve a very big and very common problem.”

Dr. Carnahan said she would like to see further innovation in:

• Detox support specific for mold: “I deal with a lot of mold and environmental toxicity. There are not a lot of good detox products for these patients. I don’t see a lot of cutting-edge innovation on the detox spectrum coming from big brands in the practitioner space. But it is a huge need.”
• Sleep: Dr. Carnahan said many people with sleep problems try one type of product for a while, but then it stops working, so they go on to another, and eventually get frustrated. There’s room in the market for new and innovative sleep solutions.
• Chronic pain: There’s a glaring need for good, clean, non-toxic natural products that can help attenuate chronic pain.
• Keto/low-carb foods: “Keto” and low-carb diets are very hot right now, and people are looking for easy, on-the-go meal replacements that taste good, provide lasting energy, and enable them to adhere to their regimens.  “I don’t prefer these to real food, but busy people really like them,” Dr. Carnahan said, adding that there’s room for innovation in that segment.

What Patients Want
Dr. Carnahan and her office staff routinely check in with patients about unmet health needs. It’s part of the culture at Flatiron, one that demonstrates care and commitment. It also yields important insights. Among her patients’ priorities are:

• Larger-sized bottles: “For many products, the standard size bottle is barely enough to get them through one month. This is especially true with antimicrobial herbal products like Allimed, Candibactin, or Candicidal, because they’re usually using two or three bottles per month on higher-dose protocols. Larger bottles would be very helpful.”
• Auto-ship and re-purchase programs: “Patients want reminders. Amazon really has that down, with their Prime Pantry reminder system.” A model like that for top quality practitioner-recommended supplements would be a help, she said.
• Samples: They’re extremely helpful especially for pain and sleep-focused products. Patients can find out within one or two doses whether a particular formula will work for them, before investing in a full bottle. Brands that provide samples are doing their practitioners—and patients—a great service.

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Erik Goldman
Holistic Primary Care

Erik Goldman is co-founder and editor of Holistic Primary Care: News for Health & Healing, a quarterly medical publication reaching about 60,000 physicians and other healthcare professionals nationwide. He is also co-producer of the Practitioner Channel Forum, the nation’s leading conference focused on opportunities and challenges in the practitioner segment of the dietary supplement industry.