Liver problems linked to supplement use are on the rise

I have written or posted several articles on healthcare issues. For your convenience, I have provided a series of links at the bottom of these articles.

In the last 30 years, our collective relationship with supplements has morphed into a full-blown obsession: More than half of adults in the United States today take supplements to “treat” nearly every health issue or psychological woe under the sun. TikTok creators guzzle berberine to “speed up” their metabolism, celebrities swallow sea moss for gut health, and biohackers pop metformin for longevity.

Supplements may seem like a shortcut to a better mood or ripped physique, but emerging evidence suggests these compounds can harm more than help. Over the last quarter century, scientists have seen a stark rise in liver injury and liver failure linked to supplement use. Patients are showing up to clinics with less severe side effects, too, including mood swings, gastrointestinal issues, fatigue, kidney stones, hair loss, and high blood pressure.

Behind this troubling trend are three key factors: the rise of supplements containing especially toxic compounds, harmful drug interactions, and a phenomenon known as “megadosing,” or taking well beyond the recommended limit.

“Everyone is searching for the magic bullet and the elixir of youth— something that’s very easy to be popped as a pill to slow down the aging process or prevent chronic disease,” says JoAnn Manson, a physician, epidemiologist and endocrinologist at Brigham and Women’s Hospital in Massachusetts and a professor at Harvard Medical School.

Eighty-four percent of consumers are confident these products are safe and effective. However, most of the tens of thousands of supplements on the market have not been tested for efficacy or safety. “It’s a Wild West out there, so buyer beware,” Manson warns.

The (limited) benefits of supplements

Humans have harnessed botanicals, herbs, plants, minerals, and metals to treat illness or improve general well-being for thousands of years.

But now, ingredients that were once steeped in ancient wisdom fill pharmacy shelves and social media feeds—often in the form of tablets, capsules, soft gels, powders, bars, gummies, and liquids.

“We have a global diet-related disease crisis and people are really sick, broken and suffering,” says Dariush Mozaffarian, cardiologist and dean of the Tufts Friedman School of Nutrition Science and Policy.

Patient polls suggest 52 percent of individuals in the United States feel their symptoms are “ignored, dismissed, or not believed” when seeking medical treatment. The traditional Western medical system is “failing them,” Mozaffarian adds, so many turn to natural “do-it-yourself” medicine, which often includes supplements.

For certain health conditions, deficiencies, and life stages, targeted supplementation can be beneficial. Pregnant women take folic acid to prevent birth defects, while older people often benefit from additional B12. Evidence suggests omega-3s can support heart health and probiotics can relieve irritable bowel syndrome.

Scores of studies support these uses, but the majority of other claims don’t live up to the hype.

“There is no compelling data that herbal supplements are needed to maintain general health,” says Marwan Ghabril, a hepatologist and professor of medicine at Indiana University School of Medicine. “It gets trickier to come up with a one-size-fits-all answer when individuals are trying to address a specific malady or therapeutic intent.”

For most people, taking common dietary supplements at the recommended dose is safe and doesn’t pose serious health risks. They’ll simply make “expensive urine,” Mozaffarian says.

When to beware of supplements

As the supplement industry has grown to meteoric heights, so have the downstream side effects: 2022 estimates suggest supplements may cause up to 43 percent of drug-induced liver injury in the United States and 19 percent of drug-induced acute liver failure that put people on the transplant list. This is a massive uptick—an eight-fold increase—over 25 years.

Recent media reports spotlight patients ending up in the emergency room with yellow eyes, abdominal pain, fatigue—symptoms of liver failure linked to supplement intake, even from reportedly “clinically-validated” brands.

Certain supplements have been linked to these effects, including green tea extract, often found in weight-loss supplements or metabolism “boosters;” bodybuilding supplements sometimes tainted with anabolic steroids; and multi-ingredient nutritional supplements used for a range of purposes from hair growth to mental health.

These ingredients are common: In 2024, researchers found that 15 million Americans take compounds known to be toxic to the liver: turmeric, ashwagandha, black cohosh, garcinia cambogia, green tea, and red yeast rice.

“While things like simple vitamins and minerals are generally okay, with some points of caution [niacin can be hepatotoxic in high doses], I would generally avoid anything with herbal or botanical ingredients,” Ghabril says.

These offending agents impact health in myriad ways: Green tea extract can inflame the liver, while bodybuilding supplements can slow or stall bile fluid. Multi-ingredient supplements are trickier to study health-wise, as it’s difficult for scientists to isolate their active components.

Mislabeling and adulteration run rampant across the supplement industry, too, making it challenging to pinpoint side effects. Users often mix and match supplements with multiple bioactive ingredients, sometimes taking them at super-high doses or with other drugs, while manufacturers swap in cheaper ingredients to lower costs.

In rare cases, analyses have revealed supplements contaminated with heavy metals like lead and arsenic, synthetic drugs, bacteria, yeast and fungi—agents which are linked to dementia, infection, brittle bones, and appendicitis, especially in the elderly or those with compromised immune function.

Bigger doses aren’t better for you

Megadosing, when consumers take micronutrients exceeding the recommended dietary allowance or more than advised by their health provider, is also risky—especially when the compound is fat-soluble and builds up in the body.

“When it comes to supplements, higher doesn’t necessarily mean better,” Mozaffarian says.

High doses of vitamins can interfere with the body’s normal processes, Mozaffarian explains, leading to side effects like gastrointestinal symptoms, headaches, heart palpitations, or insomnia. Women may be especially vulnerable to the toxic effects of megadosing due to smaller body sizes and differences in metabolism and immune function.

Importantly, reactions are also based on individual genes or immune systems, Ghabril explains. Green tea extract might be totally fine for one person yet cause serious harm for another.

“The evidence is clear that herbal and dietary supplements can cause liver injury just like prescription drugs can,” Ghabril says. “There is a clear unmet need for our population’s well-being and safety when it comes to their marketing and use.”

How to choose a better supplement

How did it get to be this way? For one, the FDA doesn’t regulate dietary supplements in the same way as it does prescription or over-the-counter drugs. Supplement-makers don’t have to prove their products are safe or effective before entering the market. That means consumers can’t be sure what’s in the bottle or exactly how it might affect them.

“It’s really unfortunate that, in the U.S., supplement companies can make millions of dollars in profits without testing their agents,” Mozaffarian says. “We should require them to use some portion of their profits to show that their products work.”

With over 80,000 unique products sold, it’s challenging to distinguish high-quality products from low. But Manson and Ghabril direct consumers to draw on trusted resources such as the NIH Office of Dietary Supplements or LiverTox database.

If you are considering taking supplements, Manson, Ghabril, and Mozaffarian all say: Talk to your doctor, source supplements from a reputable provider with third-party testing, avoid megadosing, cross-check any potential drug interactions or contaminations, and don’t expect a miracle.

“Supplements can’t substitute for a balanced diet and healthy lifestyle factors like exercise and sleep,” Manson says.

And that’s ultimately the real key to improving your health. “The magic formula for a long, healthy life is well-known: a healthy diet of minimally-processed foods, mostly plants, plenty of exercise, sleep, low stress, avoidance of drugs, and meaning in life,” Mozaffarian says. “We need to get our vitamins from food.”

These core tenets may not seem as sexy as the ‘miracle-in-a bottle’ supplements, but they work, he adds.

5 things you should know before trusting that supplement

What if you could take one pill and suddenly have more energy, better skin, and a healthier heart? That’s the promise that beckons every time I walk by the supplements aisle at my local drugstore—filled with fish oil capules, jugs of collagen powder, magnesium chews, and every letter of vitamin under the sun.

It’s tempting. So it’s no wonder that supplements are projected to balloon to a $200-billion global industry by 2025.

But I’ve always had a healthy dose of skepticism about how much any of these supplements can really do and whether they’re worth the cost. These are some of the insights from our previous reporting on supplements—with the very important caveat that you should always consult your doctor first about health decisions.

1) Supplements aren’t strictly regulated.

Nearly every story we’ve published about supplements hits on one key point: The U.S. Food and Drug Administration doesn’t regulate dietary supplements in the same way as it does food and drugs—meaning companies don’t need to submit products to the FDA for approval before putting them on the market.

This can lead to some misleading labels. Jen Messer, a registered dietitian and president elect of the New Hampshire Academy of Nutrition and Dietetics, pointed our reporter Daryl Austin to an analysis of 57 dietary supplements. It found that 84 percent didn’t contain the amount of ingredients claimed, 40 percent didn’t have any of the ingredients claimed—and 12 percent “contained undeclared ingredients, which is prohibited by the FDA,” she said in our November 2023 article.

It also means that companies don’t need to provide the FDA with evidence that their products actually do what their labels purport to do. “It’s the Wild West right now,” David Hibbett, a professor of biology at Clark University, told us in our January 2024 story about the booming market of mushroom supplements like chaga and lion’s mane. “The evidence is still very, very limited and, certainly in my mind, does not warrant the very strong marketing of these products as nutritional supplements.”

2) Not everyone should take them—even multivitamins.

I grew up thinking that taking a multivitamin a day was the epitome of health, but this isn’t true for everyone, we reported in June 2023—and you should consult a doctor before you start a daily multivitamin regimen.

There are a few reasons why. For one, multivitamins can interfere with certain drugs like antibiotics or blood thinners. Additionally, people with liver or kidney disease might not be able to efficiently clear the high levels of nutrients contained in a multivitamin. Finally, it’s possible for anyone to get too much of a good thing. (More on this in a bit.)

Ultimately, as with everything, it comes down to your individual needs.

3) The body doesn’t break all vitamins down the same way.

But it’s not just your own personal health factors to keep in mind. Some vitamins are also absorbed differently in the body—which can make a big difference in deciding whether to take them.

Experts warned in a story we published in November 2023 to be particularly careful with vitamins A and E because they are fat-soluble. This means that the body stores these nutrients in your liver and fatty tissues for future use rather than quickly breaking them down and metabolizing them as it does for other types of vitamins. Large doses of either one could actually harm you.

4) It’s possible to overdo it.

As I’ve been alluding to here, there is such a thing as vitamin toxicity—or consuming so much of these nutrients that they actually begin to harm rather than help you.

Take, vitamin A, for example: Exceeding the daily upper intake limit of 3,000 micrograms can ultimately cause issues like joint pain, liver damage, and birth defects. High doses of vitamin E can interfere with blood clotting, causing hemorrhages, among other issues. And an excess of vitamin D can cause nausea, muscle weakness, confusion, vomiting, and dehydration.

5) Food is the best way to get nutrients.

Many nutrients like collagen and vitamin C are already abundant in the foods that make up a typical diet—and eating whole, unprocessed foods, such as fiber-rich vegetables and fruit, is often a more efficient way to get the vitamins, minerals, and probiotics your body needs, Cleveland Clinic nutritionist Gail Cresci told us in March 2023. “Taking a probiotic or a probiotic supplement,” she said, “isn’t going to fix a bad diet.”

The benefits—and downsides—of taking ashwagandha

Ashwagandha is suddenly everywhere. A growing interest in natural healthcare—plus the enthusiastic endorsements of celebrities and influencers—has led to a surge in curiosity about the medicinal plant.

But there’s nothing new about ashwagandha; it’s been used in traditional Indian medicine, or Ayurveda, for thousands of years. Such staying power signals that many people really believe that the herb is good for you, and scientific studies do suggest that ashwagandha offers some benefits for stress, anxiety, sleep, and other aspects of overall health.

“The body of research around botanicals such as ashwagandha is increasing, providing scientific validation for their use,” says Melinda Ring, executive director of the Osher Center for Integrative Health at Northwestern University.

But ashwagandha is no cure-all. Scientists aren’t entirely sure which of the plant’s bioactive components help, or exactly how they work. And supplements like ashwagandha aren’t beneficial for everyone; in Ayurveda, these herbs are prescribed based on an individual’s symptoms, constitution, and medical background, explains Chiti Parikh, co-founder of Integrative Health at New York Presbyterian Hospital – Weill Cornell Medicine. Parikh also cautions that misuse of ashwagandha can produce adverse effects.

What is ashwagandha and how does it work?

Ashwagandha is an evergreen shrub (Withania somnifera) also called Indian ginseng or Indian winter cherry. “Ashwagandha has been used for centuries for various health concerns, Parikh says. “It is often called an adaptogen, meaning it helps the body adapt to stressors and restore balance. Its other benefits are reducing inflammation, increasing energy, alleviating anxiety, and improving sleep.”

It’s believed ashwagandha works by regulating the body’s stress response and reducing inflammation via active components that include alkaloids, lactones, and steroidal compounds.

“Different parts of the ashwagandha plant, such as the root, leaves, and berries, may have different concentrations of bioactive compounds,” Parikh explains. Notable among these are withanolides, naturally occurring steroid compounds which have been associated with beneficial antioxidant and anti-inflammatory effects on the body. “Research suggests that standardized extracts containing a high concentration of withanolides are the most effective,” Parikh says.

Ring notes that these bioactive components may impact signaling pathways, the chemical reactions that guide cell function. “However, the precise mechanisms through which ashwagandha exerts its varied effects remain an area of active research,” she says.

What are the benefits of ashwagandha?

Growing scientific research does suggest that, whatever the mechanisms, some people may benefit from consuming the plant product.

A number of small scientific studies suggest that ashwagandha can help relieve stress. A 2021 review compiled the results of seven separate studies involving 491 adults in India. Participants suffering from stress and anxiety took a placebo, or various extracts of ashwagandha root or leaves for six to eight weeks. Participants who took ashwagandha reported significantly reduced levels of stress and anxiety, as did those in several additional studies involving 250 adults in India and the United States.

Ring says these clinical studies “offer promising evidence” of ashwagandha’s ability to reduce anxiety but adds that “it should be approached as part of a comprehensive treatment plan that may include conventional therapies, lifestyle modifications, and other support measures.”

The species name somnifera comes from the Latin term for inducing sleep, suggesting the plant has long been esteemed for this property. Sleep studies confirming this effect are also small but promising. In a 2021 review of five separate research studies, all in India, 372 adults took either ashwagandha extract or a placebo. The authors report a “small but significant” impact on improving sleep duration and quality, particularly among those who suffered from insomnia.

Studies conducted in mice suggest that triethylene glycol, a compound that can be isolated from ashwagandha leaves, might somehow promote sleep, perhaps by impacting GABA receptors that trigger a calming effect in the brain by blocking nerve cell activity associated with stress or fear.

“Ashwagandha extract was also found to improve mental alertness on rising, and no serious side effects were reported,” Ring says.

Other studies, past and ongoing, have explored the herb’s possible benefits as an aid for arthritis, sexual health and male infertility, diabetes, and cognition, including attention span and memory. In most cases, more data is needed.

Is ashwagandha safe?

“Using ashwagandha for up to about three months appears to be safe for most people,” says Barbara C. Sorkin, director of the U.S. National Institutes of Health’s Botanical Research Centers Program. “However, ashwagandha might not be safe to use if you are pregnant, breastfeeding, or have prostate cancer. In addition, scientists don’t know whether ashwagandha is safe to use for longer than about three months.”

Generally, side effects tend to be mild and include upset stomach and nausea. “However, in some cases, ashwagandha has been reported to have serious side effects, including liver problems,” Sorkin says. “Ashwagandha might also affect how your thyroid gland works, and it might interact with thyroid hormone medications and other medications.”

In fact, Denmark has banned ashwagandha over the concerns that its use can cause liver problems or cause miscarriages because of its impact on hormone levels.

Furthermore, dietary supplements like ashwagandha aren’t regulated like drugs in the U.S., so it’s difficult to know for certain how much of the plant’s bioactive compounds are actually in a particular supplement—or whether they’re in it at all. Third-party testing platforms, like ConsumerLab, can help consumers identify brands that meet quality standards.

Parikh also advises anyone interested in using ashwagandha to see a doctor first to be sure the herb is the right choice for their own health conditions and medications—and then check in again after using it for a short amount of time.

“As an internal medicine doctor who is also trained in Ayurveda, I use this herb for people dealing with a lot of stress and when inflammation seems to be part of the symptomology,” she says. “Remember, when it comes to ashwagandha more isn’t always better.”

Resources

nationalgeographic.com, “Liver problems linked to supplement use are on the rise—here’s why.” By Ali Pattillo; nationalgeographic.com, “5 things you should know before trusting that supplement.” By Amy McKeever; nationalgeographic.com, “The benefits—and downsides—of taking ashwagandha.” By Brian Handwerk;