Chen Ching-wen, born in 1974, works at the Chang Gung Biotechnology Company. Due to her busy schedule she doesn't have much time to eat properly and thus relies on various dietary supplements to maintain her health. Each day she takes one of the array of products which she keeps lined up on her desk: primrose oil, CoQ10, green tea extract, Chinese caterpillar fungus, glossy ganoderma (Ganoderma lucidum), and blue-green algae (cyanobacteria). "After taking these products I find that my skin is healthier and I have more energy," claims Chen, who feels that spending an average of NT$2-3000 a month for good health is a bargain.

Mrs. Li is 40 years old and has never gone in for exercise or special diets, yet her refrigerator is chock full of all sorts of dietary supplements, including vitamins, grape seeds, chitosan, and glossy ganoderma; there are even a few whose names and effects she has forgotten. Although she has spent a lot of money on these products in the hope of increased health, she's never actually made the effort to thoroughly try them out. Instead, after taking a new product for a few days, she tosses the remainder into the fridge and forgets about it, as if the fact that she spent some money to buy it is enough to guarantee its benefits. "Even though I'm not very conscientious about taking them, I still can't resist buying them," admits Mrs. Li.

Most people take or have taken dietary supplements. How about you?

A proper diet is more fundamental than medicine. Do modern nutritional supplements embody the traditional maxim "good food is good medicine"?

The fitness fad

"Red wine is good for the heart." "Chocolate improves brain functioning." "Coffee helps guard against cardiovascular disease." We've all heard such one-sided and misleading information. Medical research published one day is routinely contradicted the next, leaving people at a loss as to what to believe.

Take water intake, for example. For some time now the health benefits of increased water consumption have been widely publicized, but not everyone agrees.

"Increasing water intake without a good reason is a mistake," says Professor Chiang Wen-chang of the Institute of Food Science and Technology at National Taiwan University (NTU). With water, it's not a matter of the more you drink the better. Drinking too much water only increases the load on the heart and kidneys, and can result in edema. "A healthy person who weighs 60 kilograms and gets an average amount of exercise needs about two liters of water per day. When you take into consideration the water content of the food you eat, the eight large glasses of water (a typical coffee mug holds about 300 milliliters) per day recommended in the past is simply excessive."

Despite the wide range of opinions regarding just what constitutes a healthy diet, it's widely believed that modern diets are unbalanced and lacking in nutrition and result in a deterioration of physiological functions. In this kind of environment the existence of an array of dietary supplements boasting special nutritional and medicinal properties comes as no surprise. The stress of the increasing pace of life and environmental degradation only serves to increase the prevalence of such products.

Nattokinase, glossy ganoderma, shark cartilage, blue-green algae, lecithin, grape seeds, probiotics, garlic oil, golden root (Rhodiola rosea, also known as arctic root), and CoQ10. These are just a few of the plethora of dietary supplements being churned out by manufacturers all too eager to bring out new products and stimulate demand. The pace of change is so quick that new products are put on the market even before consumers become familiar with the old ones.

"Taiwan is the window on the Chinese market place," asserts Yang Yao-ming, president of the Health Food Association of the ROC. Because it has a sufficiently large population and a relatively high average income, Taiwan is seen as an ideal test market for nutritional supplements. Add to this the penchant the Taiwanese have for anything new, and you have a perfect guinea pig for testing the latest nutritional supplements.

A good example is nattokinase, at present one of the hottest selling nutritional supplements.

The glutinous silky matter inside of natto (a traditional Japanese dish made from fermented soybeans) is known as nattokinase. As with the kinase in yams, this enzyme is believed to have the ability to dissolve blood clots. Its extract was first successfully manufactured in Japan, and over the past two years this nutritional supplement has quickly become the most popular anti-thrombogenic in Taiwan. The average price is over NT$10 per capsule.

Another rising star in the nutritional supplement market is Pueraria mirifica powder, commonly referred to as wild kudzu root. Originally an element of traditional Thai cuisine, it became an instant sensation when it began to be sold in Japan and Taiwan recently. Like green papayas, it is said to stimulate the growth of breast cells. It remains a hot seller despite the cost--a bottle of 60 capsules costs nearly NT$1,000.

Yet the average consumer may not be aware that the above-mentioned products are not considered "health foods"; at best they can be called "dietary supplements." Dietary supplements don't require certification from the Department of Health (DOH), there are laws which prohibit making claims as to their health benefits, and they can only be sold as ordinary food products.

Effectiveness versus curative effect

Is there any difference between "health foods" and "dietary supplements"?

Formulated by the DOH in 1999, the Health Food Control Act defines a health food as "a food product which promotes good health." The phrase "promotes good health" means that it improves health and lessens the risk of illness and disease. Moreover, there must be substantial scientific proof of any such benefits, but such effects should not fall into the category of medical treatment.

Simply put, health foods promote good health, but they don't have a curative effect.

From the time that "health food" was given a legal definition, only products which have been approved by the DOH's Bureau of Food Safety and given a seal of approval can be called "health food" and advertised as having health-enhancing effects. Moreover, nutritional supplements which have not received such approval cannot be advertised as having health-promoting effects. Violators can be fined up to NT$2 million.

Even though the DOH aims to safeguard public health and regulate the health food market by verifying the safety and effectiveness of health foods, over the past eight years since the Health Food Control Act was enacted only 88 products have been given verification. This falls far behind the number of products approved in Japan (over 600) and China (over 3,000).

Taking a quick glance at the health foods which have been approved by the DOH, one may be surprised to discover that 70% are ordinary foodstuffs such as chicken extract, yoghurt, tea, oats, and cooking oil--a far cry from the encapsulated extracts that most people associate with the term "health food."

Yang Yao-ming, president of the Health Food Association of the ROC, estimates that there are over 2000 nutritional supplements on the market in Taiwan which have not yet been approved. According to the Fair Trade Commission and the Industrial Technology Research Institute, annual sales of nutritional supplements in Taiwan amount to NT$25 billion, but the industry itself estimates that the total is closer to NT$40 billion.

Only products which have been given the "health food" seal of approval by the government should be considered as having health-enhancing effects. Consumers should try to select products which display this seal.

Health food versus supplements

Why don't the manufacturers of "dietary supplements" apply to have their products approved as "health foods"?

"Most manufacturers consider the approval threshold to be too high," says Hsieh Ting-hung of the DOH's Bureau of Food Safety. It takes about half a year to process the average application. Even after a product is proven to be safe and effective, any advertisements are subject to strict regulations.

"The main reason is that the manufacturers are unwilling to spend money for testing," says Yang Yao-ming. It takes between one and two years to test one product, and the cost runs between NT$2 million and NT$4 million. Considering that most nutritional supplements in Taiwan only remain popular for about two years, most manufacturers believe that getting verification for their products is not economically viable.

Moreover, the range of therapeutic effects tested by the DOH is quite limited. At present only 11 effects are being tested, including gastrointestinal tract health, regulation of blood cholesterol, dental health, regulation of blood sugar, delaying senility, liver protection, and reducing fatigue.

According to Hsieh Ting-hung, the number of therapeutic effects being tested remains limited due the delicate, complex and interconnected nature of the functions of the human body. Thus, any misuse or abuse of the word "health" can result in the consumer being seriously misled.

Take enhancing male sexual capability as an example. Whether or not increasing sexual capability belongs to the category of health protection has yet to be decided, so products which claim to have such effects are not being tested. Due to concerns about harmful side effects, even products which can be used to treat cancer are not being tested, since the agents used to control the growth of cancerous cells typically harm normal, healthy cells. This being the case, how can such products be rashly approved when it's not possible to carry out more thorough testing on animals and humans?

Contrary to what most people might expect, most of the health foods approved by the DOH are ordinary food products, and not costly health tonics.

Traps to avoid

Despite the fact that explicit claims as to health-enhancing effects are prohibited, nutritional supplements can already be found in every home, largely due to the wide exposure they receive from such channels as direct marketing, television shopping programs, over-the-counter pharmacies, hypermarkets, and underground radio stations, not to mention health product websites such as "Slimall." Hence consumers of dietary supplements need to be wary of a few potential traps:

Trap one: The product may not have the same effect as its ingredients

Professor Chiang Wen-chang of NTU's Institute of Food Science and Technology points out that the amount of active ingredients in some dietary supplements on the market is too small to have an effect. There are also some products using substandard ingredients, and some which are ineffective due to the influence of other ingredients.

Taking garlic oil as an example, even though garlic does contain active ingredients which are effective in lowering cholesterol and preventing cardiovascular disease, it can easily lose its effectiveness due to oxidation caused by prolonged exposure to air or high temperatures during the extraction process. So just how effective is a garlic extract capsule? Perhaps even the consumer himself is unclear.

Another example is lecithin. Purported to lower cholesterol and enhance brain functioning, it is made from either soybeans or egg yolks. Lecithin made from soybean extract is less pure and has less effect than that made from egg yolk. But lecithin made from egg yolk has to be swallowed along with the egg fat, so how can it be effective in reducing cholesterol?

It's no wonder that Chen Chao-tzu, director of the pharmaceutical department at the Koo Foundation Sun Yat-Sen Cancer Center, says, "Lecithin has no medicinal effects, and as a food it's too costly; it's like spending money on calories!"

Trap two: "Natural" is not by definition better

Most people blindly believe that natural is better. So as long as a product is labeled as natural, the average consumer believes that it is less harmful, more easily digested, and that it won't result in the accumulation of toxins in the organs. In fact, this is not the case.

"The human body doesn't have the capacity to distinguish between natural and chemical compounds," claims Chen Chao-tzu. Actually, what you need to pay attention to when buying nutritional supplements are the product's purity and the inclusion of any harmful substances; whether or not it's natural is secondary. For example, last November, the Consumers Foundation discovered that some Agaricus blazei they tested had absorbed heavy metals, long-term consumption of which could lead to heavy metal poisoning.

"In this area, it's up to the business community to exercise caution and carefully select their sources," says Yang Yao-ming. The question of the efficacy of dietary supplements can be put aside for the moment, but the issue of safety is imperative. In other words, "a product should contain the ingredients it's labeled as having, and nothing else." While the Health Food Association of the ROC hopes to protect consumers and take responsibility for the verification of product safety, the results are not clear. Up till now, less than ten of the products whose manufacturers have voluntarily applied have been give approval by the association.

Trap three: Solve one problem, create another

In general, dietary supplements contain minimal amounts of active ingredients, and can't cause any serious harm unless taken in huge quantities. Nonetheless, for every advantage there is a corresponding disadvantage, something the discerning consumer needs to consider.

For example, taking deep-sea fish oil on a daily basis can reduce triglyceride, act as an antithrombin, and help prevent paralysis. Yet, according to Chen Chao-tzu, large doses of fish oil can lead to a low level of thrombocytes, slower blood clotting, and alterations in lipoproteins. Then if you happen to get injured and bleed, your blood may not be able to clot and stop the bleeding. Thus, the American Heart Association suggests that fish oil should only be taken if advised by a physician, and even then regular monitoring is necessary.

Furthermore, since everybody has a different physical constitution, it's important not to habitually go in for the latest dietary fads. Take, for instance, the current clam essence craze. Although it's purported to increase one's energy, it's not suitable for everyone, since it's high in purine (a substance which the liver metabolizes into uric acid). For somebody whose medical history includes gout, not only does clam essence do no good, it can even exacerbate the gout.

Trap four: If you don't follow the directions, benefits are lost

Because dietary supplements, unlike ordinary food products, contain large amounts of special ingredients, they must be taken with care. Take green tea extract, for example. It contains large amounts of catechin and is praised as an antioxidant and for its ability to increase physical energy, but it should not be consumed along with certain other products.

"Green tea extract is able to reduce oxidation, but if taken together with other nutritional supplements or medicines it can cancel out their effects. It's like what practitioners of traditional Chinese medicine say, 'Mung beans can cancel out the effects of medicine, and so shouldn't be taken together with medicine,'" says Kao Chi-chen, director of the business department of Chang Gung Biotechnology Company.

Another example is grape seeds. They only have an effect if eaten on an empty stomach, since food proteins make them difficult to digest. Eating grape seeds after a meal can be useless.

Trap five: Beware of products whose claimed health effects change over time

In order to appear novel, many dietary supplements are hastily put on the market without first being properly tested. If later found to be ineffective, a new selling point may be used to promote the product. Sometimes, when a product fails to gain approval for medicinal use, the manufacturer decides it will be better to settle for second best, and markets it as a dietary supplement instead.

Take shark cartilage for example. Based on the belief that sharks are immune to cancer and that shark cartilage contains a substance which suppresses the growth of new blood vessels, shark cartilage began to be promoted as having the ability to control cancer. But when clinical testing failed to substantiate such claims, shark cartilage began to be marketed as being effective for improving the health of joints.

Then there is chitosan, which purportedly combines with fat in the large intestine. At first it was marketed for its ability to reduce cholesterol, improve digestion, and help one lose weight. But later, when it was found that the human body has a very limited capacity to assimilate chitosan, and that its slimming effects are negligible, chitosan began to be promoted as a product which might be able to relieve arthritis.

Some nutritional supplements are in fashion for a time, and then their effects slowly fade from public consciousness.

For example, grape seeds are high in proanthocyanidines and supposedly effective in combating senility. They unexpectedly became a hot item for a time, only to lose their appeal. "It's not easy to ward off senility," says Yang Yao-ming. Postponing the onset of senility is a good idea, but one misconception needs to be dispelled. Good health is a long-term undertaking, but many consumers are only interested in getting quick results. It is unrealistic to think that taking some nutritional supplement for a few months is enough to ensure a lifetime of good health.

Contrary to what most people might expect, most of the health foods approved by the DOH are ordinary food products, and not costly health tonics.

Good food is good medicine

With nutritional supplements being all the rage, not joining the craze might seem like throwing away the elixir of life when it's already in the palm of your hand. But according to NTU's Professor Chiang Wen-chang, "Food and drink are most fundamental." Three square meals and a balanced diet is the best way to maintain good health. Eating haphazardly while placing one's hopes for good health in dietary supplements and health foods is losing sight of what is most important.

"Health food is a practical application of the maxim 'good food is good medicine,'" says Chiang Wen-chang. In addition to advocating three meals a day and warning against blindly following dietary fads, he also recognizes that nutritional supplements do have some benefit. Nevertheless, he warns that consumers need to be aware of what they are lacking, what needs replenishing. "Good health is each person's responsibility."

Despite the abundance of rumors and anecdotal evidence, ultimately nutritional supplements have not undergone the same stringent clinical testing as pharmaceutical products, and thus there is no guarantee as to their effectiveness to alleviate symptoms. It's still necessary to see the doctor when ill, and believing in a product's efficacy is not sufficient reason to postpone seeking medical advice.

Most people today do not enjoy perfect health. When faced with the questions of whether or not to take dietary supplements, what to take, and how to take it, making your own judgment is essential!

Originally grown in Brazil and Peru, due to its high content of macro-molecular polysaccharides the Agaricus blazei mushroom has recently become a highly popular nutritional supplement all over the world. But since it absorbs heavy metals during its growing process, consumers need to select it carefully.