#534: Supplements in Primary Care

Summary

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The Curbsiders Internal Medicine Podcast

Episode #534: Supplements in Primary Care

Release Date: July 27, 2026
Hosts: Dr. Matthew Frank Watto, Dr. Paul Nelson Williams, Dr. Paul Wertz

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Episode Overview

This episode takes a deep dive into the ever-growing world of supplements in the context of primary care. With no external guest and hosted almost like a roundtable among primary care clinicians, the trio addresses practical issues clinicians and patients face: from how to systematically approach patient supplement lists, to the current evidence (and hype) behind common supplements like multivitamins, fish oil, creatine, magnesium, and more. The episode is underpinned by a framework for approaching supplement discussions, emphasizing nonjudgmental, evidence-informed, and individualized care—dispelling myths while acknowledging patient interest, marketing trends, and the clinical uncertainty that surrounds much of supplement use.

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Key Discussion Points & Insights

1. Why This Episode, and Approach to Supplements

• Hard to Find Unbiased Experts: Most "experts" are industry-conflicted (03:03).
• Primary Care Perspective: PCPs uniquely positioned to offer unbiased, pragmatic guidance.
• Framework Over Product Review: Focus on how to approach supplement discussions, not just reviewing individual products.

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2. The Supplement Conversation: How to Start and Structure It

Timestamps:

• [5:09] – [11:09]

• Normalize the Topic: Directly ask all patients about supplements, vitamins, herbals, and probe with specifics if initial answers are vague.

  • “I’m a no judgement kind of guy when it comes to supplements. I try to just make it as a what supplements do you take? No judgment.” – Dr. Watto [05:09]

• Patient Types:

  • Patients proud to be med-free may actually be heavy supplement users [05:35].

• Hidden Supplements: “If you just say supplements, they sort of just say no. But if you ask more specific, sometimes you’ll actually hit on something.” – Dr. Watto [06:02]

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3. A Framework for Approaching Supplements

Timestamps:

• [06:58], [09:03], [10:32], [11:09]

1. Why is the patient taking it?

   • Targeted symptom/goal? Or just “generally good for you”?

2. Is there evidence it works for the intended reason?

   • “If there’s no target…it’s very hard to measure, is it actually benefitting them?” – Dr. Watto [07:14]

3. Is there a plausible biology/mechanism?

4. Is there a way to track if it’s actually working?

   • Biomarker or clinical endpoint?

5. What are the risks?

   • Interactions, cost, health risks.

• Framework not for judgment, but for shared decision-making.
  • “In the moment, a lot of the times...I’m just saying I need to look this up and get back to you. But here’s how I would go about doing that.” – Dr. Watto [10:32]

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4. Supplements Industry Caveats

Timestamps:

• [11:52], [12:00] onward

• Beware of Blanket Dismissal: Taking supplements often signals health engagement.

• Supplements = Big Business, Too: Lack of FDA oversight; “the supplement industry does not deserve our blind good faith.” – Dr. Watto [12:00]

• Third-party Testing: Look for USP, NSF, Consumer Lab certifications for assurance of purity/content [17:11].

  • “USP...is a third party testing company...does what you’re making have in it what it says?” – Dr. Watto [17:11]

• Wild West of Proprietary Blends:

  • These mixtures often lack efficacy studies.
  • “It’s just like anyone's guess if it’s gonna work.” – Dr. Watto [16:47]
  • Some have been found to contain undisclosed or dangerous ingredients [16:47–17:11].

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5. Case-Based Supplement Review: Evidence & Counseling for Popular Supplements

A. Multivitamins & AG1

Timestamps:

• [19:24] – [26:53]

• AG1: “An expensive multivitamin and probiotic combination...it costs $100 a month.” [19:45]

  • Only small, non-outcomes-based trials support it.
  • “The clinical data on this product is so toothless and the hype is so high.” – Dr. Watto [21:57]

• Multivitamin Evidence:

  • No clear benefit for cancer, heart disease, or longevity.
    • “If you’re eating a balanced diet, there’s no need for a multivitamin in most cases.” – Dr. Williams [23:27]
  • CONFLICTING COGNITION DATA:
    • Cosmos Mind study showed small cognitive benefit but not compelling [23:53–26:28].
    • Previous larger trial (Physician’s Health Study) found no effect.
  • Potential Risks:
    • Overlapping supplements risk toxicity (e.g., vitamin A, B6 neuropathy) [28:00].
    • Cost.
  • “I don’t think this evidence is so strong…that you have to have people taking a multivitamin.” – Dr. Watto [25:53]

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B. Fish Oil (Omega-3s) & Cod Liver Oil

Timestamps:

• [29:29] – [46:23]

• Heart Health:

  • Over-the-counter fish oil has NOT convincingly reduced CV events (VITAL, ASCEND, OMEMI).
    • “They did NOT see a reduction in major adverse cardiac events.” – Dr. Watto [32:29]
  • Prescription icosapent ethyl for HIGH-RISK secondary prevention is evidence-based.
  • Risks: Modest increased risk for atrial fibrillation at higher doses (>2g/day) [34:15]
  • “As people get older, that [afib] is a real thing.” – Dr. Watto [45:51]

• Brain Health:

  • Observational data suggest possible benefit, but RCT evidence is lacking; healthy user bias possible.
  • “There’s some interesting research...but my confidence level is not super high.” [44:52]

• Omega-3 Index:

  • “Interesting but not fully validated surrogate marker.” [37:33]

• Practical Tips:

  • “Try to eat fatty fish two or three times a week. That would be my first choice.” [45:16]
  • OTC dosing of 1,000mg EPA/DHA is reasonable if supplementing, but benefit ambiguous.

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C. Magnesium (Including Glycinate, L-Threonate)

Timestamps:

• [47:42] – [55:17]

• Deficiency Myths:

  • “Half the U.S. is deficient” is a misinterpretation. Many don’t meet intake recommendations, but true deficiency is rare outside specific populations (diuretic users, alcohol use disorder) [48:31].

• Evidence-Based Uses:

  • Replacement when deficient
  • Constipation (chronic idiopathic): Definitely effective
  • Migraine prophylaxis: Probably effective

• Glycinate hype: Lack of evidence for better absorption or for sleep.

  • “It’s kind of magical thinking...leaping to a conclusion.” [48:31]
  • “The sleep foundation...should take magnesium glycinate based on GI tolerability...basically didn’t cite anything for...why they made that statement.” – Dr. Watto [52:41]

• L-Threonate: Animal studies show plausible mechanism for cognitive benefit; human data underwhelming [53:44]

• Risks: Generally low, mainly GI upset at high doses.

• Bottom Line: No reason for universal magnesium supplementation, especially for sleep.

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D. Vitamin D (with K2)

Timestamps:

• [56:03] – [64:34]

• Who Should Get Supplemented Empirically?

  • Adults 75+ years: Empiric supplementation (Endocrine Society 2024) [59:58]
  • Prediabetes: Those with 2/3 abnormal glycemic markers (fasting glucose, A1C, GTT)
  • Pregnant people, possibly children

• Levels:

  • Native populations: 40–50 ng/ml; >30 ng/ml sufficient for most. <20 is low.
  • “Been very hard to prove that vitamin D prevents bone fractures in healthy people.” – Dr. Watto [58:21]

• Dosing: 1,000–2,000 IU/day for maintenance. Avoid mega-dosing; higher bolus may increase fall risk [61:48–63:13].

• Vitamin K2 with D3:

  • “Theoretical benefit for bone/vascular health; evidence is weak but it’s safe and not expensive.” [63:39]

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E. Creatine

Timestamps:

• [64:34] – [71:05]

• Who Benefits?

  • Athletes needing short bursts of power (e.g., sprinters, CrossFit)
  • Modest benefit for lean mass (mostly water)
  • Not anabolic/steroid-level
  • Not beneficial for endurance athletes

• Brain Health:

  • Mechanism plausible (increases brain creatine/ATP); very early/limited human data for cognition and dementia.
  • “I would follow this under interesting, plausible and probably there’s something there. But right now we don’t know what dose to take and which population is most going to benefit.” – Dr. Watto [71:05]

• Renal Safety:

  • Benign in healthy and CKD, but may raise creatinine artifactually [71:08].

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F. Curcumin/Turmeric

Timestamps:

• [71:45] – [76:38]

• Efficacy:

  • Meta-analyses: “Comparable to NSAIDs for knee osteoarthritis” [71:55].
  • Case series: Effective for some pain and inflammatory symptoms.

• Risks:

  • Rare but serious liver toxicity, especially with highly bioavailable or black pepper (piperine) extracted forms.
  • “Curcumin...does seem like it’s comparable to NSAIDS for knee pain and seems to be safe for the most part. There are some caveats.” – Dr. Watto [71:55]

• Practical Advice:

  • Limit to short-term (≤1 month) use.
  • Avoid highly bioavailable/liposomal forms or those with piperine [75:17].

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6. Principles for Counseling and Resources

Timestamps: [78:50], [80:26], [81:14]

• Steer Patients towards:

  • Food first, lifestyle first (sleep, exercise, dietary improvement)
    • “Food first, lifestyle first...really have wide ranging effects.” [81:42]
  • Third-party certified supplements (USP, NSF)
  • Objective online resources for supplement info:
    • NIH Office of Dietary Supplements
    • Memorial Sloan Kettering Integrative Medicine Database
    • ConsumerLab.com (subscription)
    • Examine.com (pricier, more advanced)

• Role of PCP:

  • Nonjudgmental guidance; promote shared decision-making
  • “Some people just want to take the supplements...and they’re going to take it and that’s okay too.” – Dr. Watto [78:50]

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Notable Quotes

• “The patients who are very proud to not be on any prescribed medications tend to be the ones that are on the most supplements.” – Dr. Williams [05:35]

• “Supplements are an investment in health. I think it’s great that someone is interested in maintaining their health...but we don’t want to be dismissive.” – Dr. Williams [11:09]

• “The supplement industry does not deserve our blind good faith...It doesn’t make sense to just mistrust pharmaceutical companies...and then just blindly trust supplement companies.” – Dr. Watto [12:00]

• “Most proprietary blends have not been studied ever...you just can’t vet that. It’s almost like, don’t waste your time.” – Dr. Watto [16:47]

• “AG1...costs $100 a month...the clinical data on this product is so toothless and the hype is so high.” – Dr. Watto [19:45]

• “If you’re eating a balanced diet, there’s no need for a multivitamin in most cases...there’s not evidence that they actually help prevent or promote anything.” – Dr. Williams [23:27]

• “With prescription drugs in the U.S. we have trials, we have endpoints...with supplements, not so much.” – Dr. Watto [12:00]

• “I repeatedly hear people say that half of the U.S. population is magnesium deficient. Actually, they’re misspeaking in a way that’s actually important.” – Dr. Watto [48:31]

• “Food first, lifestyle first...is too hard to just say just supplementing something in isolation.” – Dr. Watto [36:05], [81:42]

• “There’s some interesting research about fish oil and cognition, but my confidence level is not super high...” – Dr. Watto [44:52]

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Timestamps of Important Segments

| Time | Topic | | ---------- | ------------------------------------------------------------------ | | 05:09–11:09| Approaching supplement discussions; normalizing conversation | | 06:58–11:09| The supplement framework: how to evaluate any supplement | | 16:47–19:24| Proprietary blends and quality/safety standards (USP, NSF, etc.) | | 19:24–26:53| AG1 & Multivitamin evidence | | 29:29–46:23| Fish oil (heart, brain health, risks, dosing, Omega 3 Index) | | 47:42–55:17| Magnesium: deficiency, forms, evidence for sleep, constipation, etc.| | 56:03–64:34| Vitamin D (empiric supplementation, levels, K2, dosing rationale) | | 64:34–71:05| Creatine (athletics, brain health, evidence, kidney safety) | | 71:45–76:38| Curcumin/Turmeric (knee OA evidence, risks, dosing) | | 78:50+ | Resources, patient education, “when do YOU recommend supplements?” | | 81:42+ | Food first/lifestyle first approach; closing thoughts |

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Practical Resources Mentioned

• For Physicians/Clinicians:
  • ConsumerLab.com ($)
  • Examine.com ($)
  • NIH Office of Dietary Supplements (free)
  • Memorial Sloan Kettering Integrative Medicine Database (free)
• For Patients:
  • NIH ODS Fact Sheets
  • Look for USP or NSF labels on products

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Final Takeaways

• Most supplements have little high-quality evidence in primary prevention or for general health in well-nourished individuals.
• A systematic (framework-driven), open, and patient-centered approach is key: normalize, inquire curiously, frame as shared exploration.
• Prioritize food and lifestyle changes over supplements.
• If supplementing, look for certifications (USP/NSF/etc.), avoid proprietary blends, and watch for unsafe combinations or ingredients.
• Be honest with patients about evidence gaps but respectful of their motivations.

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Host Sign-Off:
“You can kind of lay that foundation [healthy habits] and then maybe introduce the supplement conversation as a little icing on the cake.” – Dr. Wertz [81:14]

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End of Summary

Transcript

[A]

Hey, before we get to the show, I wanted to remind you to check out our [e-mail] curbsiders. If you haven't signed up yet, sign up now to get ad free episodes, twice monthly, bonus episodes, and a whole bunch of other cool [e-mail] curbsiders Paul, what's the hardest tea to swallow?

[B]

Is it the actor ice T meter?

[A]

That's probably pretty hard. No, Paul, it's reality.

[B]

Uh oh. I was a thinker. The Curbsiders podcast is for entertainment, education and information purposes only. And the topics discussed should not be used solely to diagnose, treat, cure or prevent any diseases or conditions. Furthermore, the views and statements expressed on this podcast are solely those of those and should not be interpreted to reflect official policy or position of any entity aside from possibly cash, like more hospital and affiliate outreach programs, if indeed there are any. In fact, there are none. Pretty much. We aren't responsible if you screw up. You should always do your own homework and let us know when we're wrong.

[A]

Welcome back to the curbsiders. I'm Dr. Matthew Frank Watto, here with my great friend and America's primary care physician and supplement enthusiast, Dr. Paul Nelson Williams. Hey, Paul.

[B]

Can't get enough of him. Hey Matt, how are you?

[A]

I'm doing well. What the audience can't see now on your wide angle camera is you just have like a giant, giant container of creatine on one side.

[B]

What else do you choking down Pre workout in between sentences?

[A]

Pre workout before every podcast. That's how Paul rolls, right, Paul?

[B]

Yep, that's why I'm so. What are the kids saying? Swole. I guess we'll call me Swole.

[A]

Yeah, absolutely. So Paul, let's introduce what is it that we do on Curbsiders and then you can introduce our co host.

[B]

Sure, Matt. As a reminder to our listeners, we are the internal medicine podcast. We use expert interviews to bring you clinical pearls and practice changing knowledge. This is a little bit of a different episode because the expert is you, which, I mean, you're always an expert, Matt, but in this case, this is really right in your wheelhouse. And we are joined, as you allude to, by the great Dr. Paul Wertz, who's also, I think, I don't want to call him a supplement enthusiast, but also has some expertise in this stuff too. So I'm excited to hear from you too, how to counsel and talk to our patients about the various supplements they may be asking about or taking.

[A]

Wirtz, how you been doing?

[C]

Fantastic. Happy to be here.

[A]

Just to remind the audience, Wirtz has been just like cranking out episodes during residency. I could barely function during residency, so it's always very impressive.

[C]

I just started my chief resident year, so luckily working more traditional hours. So very much looking forward to that, but it's been a lot of fun.

[A]

Paul Williams that's not an easier year though, is it?

[B]

It starts out, this may not be comparable across institutions, but the first month you're like, this is great. I'm living my best possible life. No one expects anything from me. And then it becomes insane right around recruitment time. So it will ramp up. But right now, Paul, live, live, damn you. This is the best time of your life.

[C]

I'm having a great time.

[A]

Summer of Paul okay, well the reason we wanted to do this episode and the reason we didn't have a guest is because we were trying to think about, number one, anybody that's an expert on supplements or calls themselves an expert on supplements. It's hard to find someone that's not insanely conflicted or selling own supplements. Paul williams that was part of our issue.

[B]

Yep.

[A]

And number two, who better to talk about supplements than a bunch of primary care people? Because, and looking around there really wasn't. You know how there's always like an article like high blood pressure for primary care, rheumatoid arthritis for primary. I could not find one that just did like a general review of supplements for primary care. So hopefully this will serve for that.

[B]

I mean this could be an authorship waiting for you to take over. Matt, you could write this.

[A]

Well, you can find a lot of single supplement reviews, but not how do you approach this topic? So that's what we tried to put together for this and that's what we're going to do this evening. So Paul Wertz, would you start us off with a case?

[C]

Absolutely. We've got a 52 year old man who comes in for his annual primary care visit. He has hypertension, dyslipidemia, mild KN osteoarthritis, intermittent constipation and difficulty sleeping. He recently started lifting weights three times per week. He takes Losartan for hypertension and Rosuvastatin for hyperlipidemia. His triglycerides are 190, his kidney and liver function are normal. When you ask about supplements, he pulls up a list on his phone. He shows you a once daily multivitamin, an over the counter fish oil. He also takes cod liver oil on days when he remembers magnesium glycinate for sleep and constipation vitamin D3 with vitamin K2, creatine monohydrate, and then finally curcumin with black pepper extract for knee pain. So just in general, when someone shows you a list like this, how do you bring up supplements? First of all, how do you even bring up supplements in a visit? And then what does that portion of the visit look like after they show you all the things that they've been taking?

[A]

I'm a no judgment kind of guy when it comes to supplements. I try to just make it as a what supplements do you take? No judgment. Can I see your list? I, I almost assume most people are taking a supplement. Paul Williams, you find that people are just, you have some people that just, they pride themselves on taking nothing and then there's the person that loves to take supplements and then there's some people kind of spot take it. But what's your experience?

[B]

That has been my experience as well. The patients who are very proud to not be on any prescribed medications tend to be the ones that are on the most supplements. I have found and I'm like you, I actually make it. When I do, my initial intake is part of my history. Like when I ask about medications, I'll ask about non prescribed medications and I will specifically ask any supplements or herbal supplements that you take as well. I try to bring it up first to normalize it and start the conversation because otherwise it may not be volunteered necessarily.

[A]

And for people who tell me they're weightlifters, a lot of the times I'll ask about supplements and be like, I don't take anything and I'm like creatine, protein, they're like, oh yeah, I take those. And then pre workout. Oh yeah, I take a pre workout. So I think sometimes you have to ask a couple follow up questions and sometimes if you just say supplement. So you might say supplements or herbals or any vitamins, minerals. Because sometimes people, if you just say supplements, they sort of just say no. But if you ask more specific, sometimes you'll actually hit on something. So the framework for this is something that I didn't have until the past probably two years or so. But it's something I've been developing because I, I just got tired of just saying like throwing my arms up, being like, yeah sure, go ahead, take it, who cares? Wirtz, Are they teaching a supplement framework in residency these days? I don't know, honestly, not really.

[C]

And I feel like since the age of AI you have patients that just bring in these giant AI generated list of supplements and they're like, should I be taking these? And it's just like ChatGPT organized supplements. And you're just like, where do I even begin?

[A]

Well, we can go through, we'll go through the framework and there are some questions that you want to ask yourself. I think the first question is always, why are you taking the supplement? Sometimes people don't know. Sometimes they're just like, I generally heard this is good for you, so I'm taking it. But they're not targeting anything. And if there's no target, I think it's very hard to measure, like, is it actually benefiting them and is it worth them taking? So I think it's really helpful to say like, we're targeting something. It could be a symptom, could be a level, could be some kind of medical condition. So that, that would be the first step. And then if, if you identify a reason they might take it, then you might say, okay, is there evidence that it actually works for this? So let's say they're taking vitamin D. Is there evidence that vitamin D is going to prevent bone fractures? That's something that's a specific question that we can now look up and try to apply to the problem they're taking, they're trying to use it for. But Paul Williams, a lot of the time when you ask people about supplements, are you getting a very specific targeted answer that can lead to a pico question kind of thing?

[B]

Sometimes, and then sometimes not. And we treat a little bit of a different patient population. I will say that sometimes the supplements that I see that are targeted are the ones that I find the hardest to investigate because they are these brain health things that have a list of ingredients or this is for men's health kind of stuff. So it's like a bunch of herbal things kind of smushed together into one thing that is hard to sort of evaluate there at the point of care. So when someone does have something targeted, it tends to be the hardest thing for me to at least evaluate in the moment because there's just so much stuff to kind of go through. But yeah, on the other hand, the things like, yeah, I take this for joint health, or I take this because someone told me it was healthy, tend to actually be the simpler things that they are taking. Things like the conjoitins or the vitamin Ds of the world or even magnesium I think is just, it has a good rep for whatever reason these days.

[A]

I want to come back to the proprietary blends in a second. So number one, why are they taking it? Number Two, is there evidence that it works for the reason they're taking it? Number three, is there a plausible biology underlying this? What's the mechanism of how this might actually do what they think it does or what they want it to do? And then is there a way we can track if it's actually working? I think that's a good question to ask. So vitamin D has a couple different things you can follow a biomarker there. So that's a target that we can at least hang our hat on a little bit. But the clinical outcomes, those are a little bit harder. But at least we have studies that have long term studies that have been done with vitamin D to look at certain clinical outcomes. So that's another important part of this. And then the final part of the framework is just like, what are the risks to the patient of taking this? Do they outweigh the benefits? And that could be interactions with drugs or other medical conditions they have. It could be cost to the person. And that's kind of how I think about it. So that's the framework.

[B]

And this framework, Matt, this is something you're doing with patients, right? Because you're not having the expectation they have a, an understanding of biological plausibility or the evidence behind it. Like that feels like a big hurdle to kind of get through at the visit. But this is something you guys are thinking about together to make sure that you're on the same health page, Is that exactly?

[A]

Yes, exactly. And in the moment, a lot of the times in the moment, I'm just saying I may, if it's a supplement that's not common, that I've never seen before, I'm gonna have to say I need to look this up and get back to you. But here's how I would go about doing that. So it's, why are you taking it? Is there evidence that it works for what you think? Is there a mechanism that we know, like, do we understand how this works or why it works? And then is there something we can track to prove that it's working, that it's worth your while? And then kind of what's like the risks to you, Is it just cost or is there actual health risks to you with this supplement?

[B]

Yeah, that's terrific. And I love, and I do the same thing where I'm like, I'm going to have to look this up and get back to you. But I think it's really important to bear in mind that people taking these supplements, this is an investment in their health, right? Like, this is someone who's interested in feeling better, interested in maintaining health. And I think it's potentially easy to be dismissive or feel sort of judgmental about these things. And I at least personally tried to be very cautious to not treat this like it's a silly thing to do or be dismissive and like, treat everything very seriously. Because I think it's great that someone is actually invested in maintaining their brain health or their joint health or whatever kind of health options they're looking for. So I think sometimes physicians can be a little bit sort of blanketly dismissive of supplements, which I think is probably dangerous and also not fair or kind to patients.

[A]

Yeah. And this episode is not meant to be us hating on supplements. It's just meant for us to just have a way to discuss with patients in like a non judgmental way. Because there is a lot of uncertainty around supplements. So people that are skeptical of the pharmaceutical industry, I get that there's been some bad faith things that have been done over time, but at least with prescription drugs in the U.S. we have big trials that were done usually targeting clinical endpoints, sometimes surrogate endpoints. But at least we have some things we can dig into and draw conclusions from that are much cleaner than when you try to look at the supplement industry. And I just try to remind patients that the supplement industry does not deserve our blind good faith, like they are out there to make money as well. So it doesn't make sense to just like mistrust pharmaceutical companies, which at least have a lot of oversight and then just blindly trust supplement companies. Because both sides of that equation, they both want to make money. So we need to protect you as you're navigating that system. And part of that is your health, but also your pocketbook, et cetera. This episode is brought to you by figs. And you know, I'm a huge fan of figs. I have five pairs of FIG scrubs, and when I wear scrubs to work, I just wear figs because they're so comfortable, they're versatile, they look good and they feel good. Remember, the traditional scrubs were all stiff, itchy, boxy, and they didn't fit right on anybody. But then about five years ago, I got my hands on a set of FIG scrubs and I remember thinking, wait, scrubs can actually look good. Figs are made for all of us in healthcare. They're lightweight, breathable, antimicrobial, and they have tons of pockets for your stethoscope, your pager, your electrolyte drink mix, your protein bar, whatever you can fit it all in there. I know you're going to love Figs Scrubs. And we've teamed up with Figs and now Curbsiders listeners can get 15% off. Just go to wherefigs.com and use the code figs rx. That's wherefigs.com and Use the code figs rx for 15% off.

[B]

Foreign.

[A]

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[B]

But even still, I think this is a hotcakes episode. And if it wasn't, we must have talked about at some point. But there was a great article that looked at what was actually in the compounds of men's health supplements specifically. And it was like none of it actually matched up half the time sildenafil was in there. It was just like what was on the label was not was actually in the bottle the majority of the time. And there were potentially dangerous medications in there depending on what the patient's backgr. So that makes a lot of sense to me.

[A]

And you're leading into the next point which is there's actually seals of approval that are at least some quality marker that we can look to. So there's USP is like US Pharmacopoeia. They would at least it's a third party testing company that would give its seal of approval. They're going to look to say like, does what you're making have in it what it says and is there a lack of certain amount of impurities? But no supplements. The FDA is not evaluating supplements to like for proven efficacy the way that like before you put a supplement on the market, you don't have to prove efficacy, you just have to prove that the ingredient that you're using is. Well, you don't even have to prove the ingredient is safe. If it's an ingredient that is generally regarded as safe, you can just put it in a supplement and say that you have 400 milligrams of whatever in there. And the FDA is probably not going to come knocking on your door to like spot check the batches of what you're making. So that's why a lot of people can can get away with having no melatonin in a melatonin pill. But if you have USP or NSF certified or NSF certified for sport, there's a couple other ones. Consumer lab certifies certain products, then these are third party companies that have tested things that you can at least be certain that it is what it says it is and there shouldn't be any really dangerous impurities in it. So that's kind of the best you can do there. But it's a wild west, Paul. And with these proprietary Blends. I mean, it's really the wild west because you can just. It's like, you know, in the cough and cold section. Paul it kind of reminds me of that where it's just like you have a mix of generally guarded as safe things and you just put them together in all different combinations and just brand it cough and cold, cold and flu, 24 hour this and that. And then people will buy it.

[B]

And they're expensive too. A lot of the times when I go to look it up and try to look at the actual ingredients list and I find out what my patients have actually paid for these things, that's almost my bigger point. I'm like, we don't have great evidence for most of the stuff in here. And also, I just don't want you to waste your money on something that's not going to help you. And I don't know if that resonates or not, but they can be really, really pricey for not having any demonstrable benefit.

[A]

Should we do AG1? I feel like that's a perfect transition to AG1. Wirtz, is that now an okay time?

[C]

No, 100%. So I feel like you can tie in the AG1 into the multivitamin conversation because our patient takes a multivitamin and I feel like some people will take the greens in place of that. So I guess, yeah, you can use that as a springboard.

[A]

So I won't bury the lead here. I think AG1 is like an expensive multivitamin and probiotic combination and it costs $100 a month. Paul Williams. $100 a month. And people are like subscribing to this and it has all these celebrity endorsements. Huberman, Tim Ferriss, I think Gwyneth Paltrow. Sorry to her if she hasn't endorsed it. But Rogan, of course, don't sue us.

[B]

Gwyneth.

[A]

Paul, where this came from. This guy, his name is Chris Ashenden, he's from New Zealand. He was a police officer there. And then he wanted to be in real estate. So he started this rent to buy scheme. A bunch of people that were his clients, I guess lost lots of money. There was warrants out for his arrest. So he flees New Zealand, he comes to the US somehow, he starts AG1. And in 2024 he stepped down as like the. I think he's still on their board, but he stepped down as like the public facing CEO. Because this powder keg podcast in New Zealand just like was like, this guy's like a grifter. Like he ripped all these People off in New Zealand and fled to the U.S. now he's like a supplement billionaire. It's like a billion dollar supplement. It's crazy. So AG1, if you look, they have a research page on their website, but I could only find two human clinical trials on AG1. One was from 2024 and one was from 2026. And one study had 10 men and 10 women. The other study had 15 men and 15 women. It was like a crossover trial for the most part, where they would like, you know, they would take AG1 for a couple weeks, have a washout, and then take place placebo or vice versa. And basically what they proved in these two studies is that AG1 was safe, which, I mean, it's a multivitamin and probiotic powder. They proved that certain bacteria in the gut that are favorable increased. Okay. And they proved that digestive quality of life questionnaire. On a digestive quality of life questionnaire that it was no worse. They didn't even go for it was better. They just said it was not worse,

[B]

not inferior to placebo.

[A]

It didn't change stool consistency. So essentially the one study was like, people did meet more of their estimated average requirements for 16 vitamins that we looked at. It's like, okay, if you take a multivitamin, of course you're scattershot. You're gonna hit more multivitamins than people who were on placebo. So basically, the clinical data on this product is so toothless and the hype is so high, and it's a $100 a month ball, and it's just like a proprietary blend. Like if you look at a multivitamin and AG1 side by side, they're very similar. And it's just there's some probiotics in there too.

[B]

It's the host of one of our favorite podcasts, I think, is a big proponent of it. So that's a real bummer.

[A]

Yeah. I mean, look, and for any of this, because I admitted at the outset that I am a non expert in supplementation, I'm just kind of reading through, reporting what I could find. If someone has a really great study of AG1 proving that it works, I would love to see that. And we'll correct our show here, but

[B]

mea culpa at the ready.

[A]

Yeah, I mean, look, and maybe if they keep studying it, maybe they will get some outcomes data. But right now we have like nothing that I would hang my hat on that's worth $100 a month. And that was clinically meaningful to my patients. So, you know, Multivitamins. Paul, what do you think about multivitamins? Just your gestalt as a primary care doctor.

[B]

I mean, the evidence is not good for them. So in general, my counseling, I think echoes, I think uspstf, I might be making that up. But if you're eating a balanced diet, there is no need for a multivitamin in most cases. And there's not evidence that they actually helps prevent or promote anything. I think there was one small study that maybe suggested potentially preventing dementia or reducing risk of dementia, but not enough to be really super compelling. But maybe something earth shattering has happened since I last checked.

[A]

No, there hasn't been. So the USPSTF, you did that episode, Paul, in 2022. They said, we have insufficient evidence to say that taking a multivitamin daily prevents cancer, prevents heart disease. Two of the big things that kill people in this country. Other studies looking at, do multivitamins, taking one a day help you live longer? We haven't been able to conclusively prove that either. The Cosmos Mind study is the one that you're talking about, Paul. That was a trial of cognition. This was by Baker in 2023. It was a randomized trial, two by two design. And actually they were looking at cocoa extract, placebo and, and a multivitamin. And so you could have either gotten like cocoa extract and multivitamin, or cocoa extract placebo, multivitamin placebo, or double placebo. And they followed these people and after three years, they did like a baseline and then annual cognitive testing. Everybody in both groups, placebo or not, got better at years two, but only the multivitamin group, not the cocoa. If someone was getting a multivitamin, they seem to have a little bit better cognition at year three. And the authors tried to math this out and they said, this is quote, by this albeit imprecise yardstick, three years of multivitamin supplementation appear to have slowed aging by 1.8 years or 60%. But they suggest more work is needed to be done. So These patients were 73 years old on average. So if you have someone in their 70s that wants to take a multivitamin and they're really worried about dementia, which is almost Everybody in their 70s, I think it's fine. I don't think this evidence is so strong. This is just one trial that you have to have people taking a multivitamin. Especially because 10 years prior to this, there was an even bigger trial the Physicians Health Study had educated. This was male physicians over 65 years old. And there was no effect of multivitamins on Global Cognition, this composite score that they looked at. So basically a conflicting trial, a bigger trial. They only tested them at the start of the study, and then at the end of the study, they didn't like, do the annual testing. But I don't think this is strong enough that I'm recommending it to everybody.

[B]

I'm with you. I don't recommend it. But I also don't fight it. Most of the time. If someone is on a multivitamin and they like it, I don't fight, especially if they're an older patient because they're probably on a couple of medications that actually predispose them to deficiency in the first place. Who knows if they're on a chronic PPI or if they're on metformin or they have some morbidity that may cause decreased absorption. I don't see significant harm. So it's not something I recommend against. But I'm with you that I don't advocate for them very aggressively.

[A]

And as for the risks of multi. I mean, multivitamins cost, you know, you should be able to get a cheap multivitamin. Like, I don't think you need to buy a really expensive multivitamin. And I haven't mentioned it yet. Or maybe I mentioned in passing. There's. There's a website that I really like that I subscribe to. It's. It's. I think it's like $70 a year. It's called consumerlab.com and it seems to be a good actor in the sense that, like, Paul, this, I think it was, the vitamin D review that they did had 345 citations. Like this guy, Todd Cooperman, who seems to do most of their review articles. He will go through, like, every study, every possible indication someone studied a supplement for. And he'll like, just kind of give like, almost like an abstract version of all the articles through. And then they also look at the formulations of different supplements in whatever review you're looking at, and they'll say, like, this one was good, this one was good. Don't get this one. Here's the breakdown per milligram cost. It's a very useful site.

[B]

Yeah. For six bucks a month. Not bad.

[A]

Yeah, I would highly recommend it to people, especially if you're ever thinking of putting together a talk like this. It's a really useful site. Four multivitamins. Just some things to look out for. Doubling up on things because, like, someone's taking a vitamin A supplement and a multivitamin, they might get too much vitamin A. Same with calcium Vitamin D and some of the B vitamins. Like, Paul, have you ever heard that vitamin B6 can cause a neuropathy if people are taking, like, mega doses of it?

[B]

I feel like I did hear that, but I may have heard it from you, so I'm not.

[A]

And that's one of the ones I just tell people. You know, I would prefer that they're not taking, like, overlapping supplements. That's the other issue with proprietary blends. Like, if you're taking, like, I had one guy that was taking, like, AG1 and a multivitamin, and I'm like, that doesn't make sense to take both. Just, you know, take the multivitamin. Take the multivitamin. It's cheaper. Save yourself the hundred dollars a month. So that's kind of my thoughts on multivitamins. I think there's lots of other things you could say about them, but I think that kind of squares us on that. So, Wirtz, what do you want to talk about next?

[C]

Yeah, so our patient's on rosuvastatin, but he also takes two different types of fish oil. He takes an over the counter and a cod liver oil. So how do you counsel patients on fish oil? Should they be taking it at all? Should they be taking two separate types in addition to their statin?

[A]

Okay, so code cod liver oil. It says liver, right? So cod liver, there's vitamin A in that, there's vitamin D in that, and there's fish omega 3. I would not recommend taking that just because of this. Doubling up on vitamin A, Paul, seeing

[B]

this often, this feels very Dickensian. I feel like this is like a chimney sweep shows up and then you give them cod liver oil. Is the vibes that I'm getting from this? I don't know that I've had a patient taking that that I've seen recently. Is this something you're running into?

[A]

Not. I haven't seen it a ton, but I imagine. Wirtz, is this ripped from the headlines, at least of your hospital?

[C]

I've seen a couple people on cod liver oil, more people on fish oil, though. I feel like a lot of people are on fish oil nowadays. It's kind of having its moment. So that's the one I really want to talk about.

[A]

But I thought that was a good thing to just bring up, just to highlight that it has. Cod liver oil is not just Omega 3. And if you're. I would rather someone just take, like, a fish oil and then they supplement vitamin D or vitamin A separately if they need that. I don't know why this person would need vitamin A. So I would tell them to stop taking the cod liver oil, in this case, fish oil. Wow. There's so much research on fish oil, Paul. There's just so much. But the things that we know about fish oil, like if people are taking it for heart health, I actually think it's not as straightforward as you would think because it has such a reputation for having cardiovascular benefit. And it's in the guidelines, Paul, on hypertriglyceridemia, because we know that there's a branded version, it's 4 grams a day. I think you take 2 grams twice a day that can actually lower your triglycerides, raise your HDL a little. But as far as linking that to cardiovascular outcomes, that version of it, to my knowledge, has not been linked to improved cardiovascular outcomes. It's the icosapent ethyl, which is this very specific branded version that was the Reduce it trial where in People for Secondary Prevention they gave that eicosapent ethyl to these people and they saw a reduction in major adverse cardiac events. So that. But that's probably the strongest evidence that one trial, and we've covered before that maybe the placebo was inflaming people and making the icosapent ethyl look better. But anyway, it's approved and that's one reason you could give it. But as far as over the counter fish oil, it is hard to prove that that actually does reduce cardiovascular events or stroke. Does that surprise you, Williams? It.

[B]

No, it doesn't. Is the short answer to that. Yeah. And it's. Yeah, same thing. I do see a ton of this and I always have to sort of ask what are we hoping to get out of here, out of this? And I don't. And I've looked this up a couple times, keep expecting to get my mind changed. And it still has not yet. It just seems not very compelling with the over the counter formulations.

[A]

The three big trials that I found in that the hypertriglyceridemia guidelines from the accident call out are the vital trial that was the one was like fish oil and vitamin D, they were trying to look at preventing cardiovascular disease and cancer. That was a negative trial for both supplements and they were giving 1,000 milligrams of fish oil. And fish oil it comes in, you'll often see EPA and DHA reported and those are just two types of omega 3 fatty acids that are found in fatty fish or oily fish. So 1000mg is a good dose. If you eat fatty fish Twice a week. I was trying to look this up to quantify it for people. Let's say you eat two meals of fatty fish twice a week. You're getting probably around 250mg per day of fish oil epadha from that. This is a big dose. It's like this would be, I guess maybe the equivalent of eating like fatty fish every day, something like that. And they followed these people for 5.3 years. They did not see a reduction in major adverse cardiac events. And then another trial, the Ascend trial, had over 15,000 patients. This is another primary prevention trial, also using 1,000 milligrams of fish oil, EPA and DHA. And they followed for seven, almost seven and a half years. And they also did not see a reduction in major adverse cardiac events. And then the secondary prevention trial that I found was this Omemi trial. They were giving 1.8 grams of fish oil. They did not find reduction in Mace, Paul, but they did find increased incidence of atrial fibrillation. So that's good.

[B]

It seems bad. That seems like the opposite of what you're shooting for.

[A]

Yeah, I mean, trying to quantify the increased risk of atrial fibrillation, it seemed like it was dose dependent. So doses of more than 2,000 milligrams or 2 grams per day. And it seemed like a small absolute increase. So the placebo group would have like a 4% risk versus a 5% risk in the group that's being supplemented with fish oil. And this was reproduced in not just like one trial, this is like multiple trials. If you look, there's several trials have reported this. It seems to be a real thing that happens. So it's a small increase and that I think as long as people are keeping it under that really mega dose, I think they're okay. And icosapent ethyl, they did see it with that as well because that's 2 grams twice a day. So it's a high dose.

[B]

I wonder what the mechanism is for that. It's very interesting.

[A]

Yeah, they said it was a little hand wavy, but it was possibly something to do with how it's changing electrical conduction in the heart. But I didn't. Sure, I didn't have atrial fibrillation so deeply into that, but it seemed like someone thought it was plausible. And it's been seen so many times in randomized trials that I think it's probably not just like just by chance.

[B]

I think it's even flagged in the acc. Aha. Lipid guidelines.

[C]

I think the thing with these Trials too. You wonder is, is five years enough time? Like are they trying to surrogate for a lifetime of someone e seafood based diet? Because you're looking at those blue zones and those people that eat seafood, are they trying to cram that into a five year period with this mega dose and if you space it out longer, would you see a difference? It's fascinating.

[A]

I think you're making a good point and this is why I should have said this earlier, but I think a food first approach for almost everything, food first approach, lifestyle first approach, you just end up hitting so many more bases and also you're just. There's all these intangibles, like little other nutrients that are coming along with the food and fiber and water and things that I think it's just, it's too hard to just say just supplementing something in isolation. I think a lot of these. Paul, remember we talked to Greg Katz, he mentioned like don't fall in love with mechanisms. I think that's what happens is like people fall in love with this biologic mechanism that seems plausible. And then when you maybe observational studies suggest something's going to be there, but you really have to try it in a human trial to see if it actually works. And a lot of the times because there's redundancies in the body, the body's so complicated. Even when it seemed biologically plausible, an observational study suggested something, there was some confounder and when you actually study it, you just don't get a positive result.

[B]

I forget the name of the trial every time, but I think about it all the time. It's the one that looked at combining aces and arbs, which mechanistically should be slam dunk home run. Like you're going to protect the kidneys all over the place. So the fact that actually caused harm.

[A]

Everyone's dying of hyperkalemia, right?

[B]

Yeah. But it seems like something that should be helpful. It seems so intuitive, the mechanism makes perfect sense and yet it does not work in practice. So that's something I think about often.

[A]

So one cool thing that I just wanted to mention about fish oil and just Omega 3s in general, there's this guy Harris who in 2004, that was the earliest I could find, started publishing about this omega 3 index, which is basically a branded test that he sells. And it has been inversely associated with like cardiac mortality. Essentially what they're doing is they're looking at like red cell membranes and the EPA DHA content and calculating like what percentage is omega, you know, what percentage of the red cell membrane is fatty acids are omega 3s. And they found that like an omega 3 index of 8% or higher is associated with improved cardiovascular health survival and less than 4% is associated with a poorer cardiovascular health and survival. And they're saying, okay, because it's red cells. This is like a three month index of are you getting enough omega 3 and you're not getting too much omega 6s? I think a lot of the times they'll give you, when you get any of these omega 3 indexes, they'll give you omega 6 in there as well. You know, this test, I would say it's validated by like observational studies, but not by randomized controlled trials that like you put people in a study, you give them fish oil, you make sure you get everybody above 8% and then you find outcomes to meet. That's what it would take to convince me that this is something that we really need for everybody. But I think that it's out there. Sometimes patients will ask me about it. And I know functional medicine targets the Omega 3 index a lot. The LabCorp and Quest have something called Omega Check, which is like their version, but it tests whole blood. So it's not that three month average that you get from the omega 3 index which is looking at red blood cell omega 3s. This is a little bit fraught, but it's out there. And I'm mentioning it because part of my framework was like, can we track, is this supplement doing something for you so you could get a baseline just to say like, okay, you're eating fatty fish. Let's see what your baseline omega 3 index is. And if it's above 8%, you probably don't even need to take fish oil. Or if they are supplementing, are they taking enough to even move the needle in that direction? So that's something. But that's like, like I said, that is more speculative and it should be studied more before because it, because it, there is a cost to the patient. So most people don't take me up on it. Hey, curbsiders, have you ever chosen a CME conference because of the destination, but then you were disappointed by the education once you got there? Well, that's where continuing education company really stands out because they host conferences in places that you want to visit like Maui, the Big island of Hawaii, several locations in Florida, including the Florida Keys, Nashville and Austin, Texas. Plus they pair those destinations with education that actually delivers. And this fall, CEC is offering a hospitalist conference in Nashville and an urgent care and emergency Med conference in Austin. The Austin conferences focus on practical acute care topics that clinicians encounter every day, whether they practice in primary care, urgent care, hospital medicine, or the emergency department. Their meetings are structured as half day morning sessions. That way you get focused practical learning without feeling overwhelmed and then you have the rest of the day to just enjoy the destination. It is a great way to get the best of both worlds and if on demand learning works better for your schedule. CEC also offers a large library of online CME courses and for Curbsiders listeners, there's a special offer. Use promo code CURB30 for 30% off all online courses and webcasts. That's promo code CURB30for 30% off all online courses and webcasts. See for yourself why Continuing Education Company is considered a leading source for medical education. Visit cmemeeting.org curbsiders to learn more. That's cmemeeting.org curBSiders. The other one is brain health, and this is one of those ideas that I think it's just going to be hard to I think brain health studies are hard to study. It's hard for me to wrap my head around, Paul, because we don't look at the neurology literature that much and when they're talking about the endpoints they're looking at, it's hard for me to quantify what's significantly benefit. You know, is this clinical significance or is this just like a statistical game they're playing?

[B]

Yes. I have nothing intelligent to add to that sentence, but that's exactly right. Yeah, I think it's a very hard thing to measure because it's also hard to even sort of assess what baseline is. I don't even really know what we're looking for other than what patients would experience as subjective symptoms. So yeah, it's sticky stuff for sure.

[A]

Yeah. Paul, for brain health, I struggled with this a little bit because I'm just not used to interpreting the neurology literature. But this is something that's interesting. And some of the supplements will say, like omega 3 for brain health, fish oil for brain health. So I think it's worth putting it in. In here and in observational studies, it does seem like cognitive function is better when people are taking omega 3 fatty acids and when people are, and the risk of dementia is lower in meta analyses, they haven't always borne that out. I found two meta analyses, one from 2025, one from 2024, both showing that like certain markers of cognitive function were improved in patients that were taking omega 3s, and then I found one study, this was by way in 2023. It was a longitudinal cohort in the Alzheimer's disease neuroimaging initiative. There was a little over 1100 patients in six year follow up and they were monitoring blood biomarkers and omega 3 intake and they found a reduction in Alzheimer's disease risk. And they tried to do a meta analysis with a bunch of other longitudinal cohorts with over 100,000 patients and they estimated a 20% reduction in cognitive decline in all cause dementia. And they specifically said like APOE 4 carriers seem to have more benefit from this. So I would file this under interesting, but not convincing me that I need to go out there and start taking fish oil every day. But I think like with supplements and with like omega 3s and vitamin D and some of these other ones, there's so many studies that I think anybody can find an answer that they want if they look at the literature and like draw the conclusion that they want. So my head was spinning a little bit trying to go through all these.

[B]

So this is one to stall is what I'm hearing.

[A]

I would say, yeah, but I mean if someone wants to take it, I think it's like there is something to this. You know, there's. It's not like, it's not like every trial has just, no, this doesn't work. Wirtz, what were you going to say?

[C]

I think you already answered. I was just going to say, so if somebody brings it to you, are you encouraging, discouraging or just sort of a shared decision making approach?

[A]

I guess we can kind of get to my bottom line on this. In general, I would say if people want to take fish oil to improve their Omega 3 status, I would say I'm not confident that this is going to reduce your risk of heart disease or cancer. You know, we have pretty good information on that. I think that there's some interesting research that suggests it might help with cognitive function. It's hard to know if this is just like a healthy user bias a little bit. These cognitive studies. That's what I would. I mean these are longitudinal cohorts, the Alzheimer's one that I mentioned. So I just wonder how much of that is like kind of the healthy user bias type thing or some confounder that we're not measuring that's kind of leading to that positive outcome in that one. So my confidence level is not super high that it's going to support brain health. I would tell them try to eat fatty fish two or three times a week. That would be my first choice for them before they take a supplement. But if they are going to take a supplement, I would say 1,000 milligrams a day of a supplement that has EPA and DHA and higher doses than that. I would start to worry about risk of afib, which as people get older is a real thing. So that's where I'm at with that. But it's hard to go through the literature on this one, like I said, because there's just so much out there and you really could find whatever answer you're looking for. Like if you're biased one way or another, you could draw the conclusion you want from this data.

[C]

Yeah, and the other thing is they take, you know, the studies, a lot of these are like 2 grams, 4 grams. But those over the counter fish oils might have, I don't know, 2, 300 milligrams. So are you telling them to take five pills, ten pills? Probably not, but I don't really know what to do with that information because that's lower than the doses that were studied. So just, it's ait's a complicated discussion. I feel like there'll be more that evolves as more studies come out.

[A]

Yeah, and I would look oni mean consumerlab.com would be a great place to look for that one because you could look up the supplements, they would tell you how much EPA and DHA is in each one and you could find a quality product that you could recommend to your people. But maybe, maybe we can put a couple different brands in the show notes. I guess that that probably would be okay with our CME overlords, Paul, since we're not like showing favoritism towards one or another. But I don't know.

[C]

Yeah, and there's like some extra strength ones and things too. So it's just there's. They're not all created equal.

[A]

That is. Yes, that is a good, that is a good point. So you want to try to get something 1000mg of EPA and DHA is, you know, that would be considered like a reasonable dose to take. But like I said, try to eat fish a couple times a week.

[B]

So we're about halfway through our theoretical patient supplement list. I do want to spend a little bit of time. So according to your framework, Matt, the magnesium glycinate that he takes for sleep and constipation. I'll remind our listeners. So now we actually have a clear goal or expectation of what the patient is taking the substance for. Mechanistically, I guess I will. With your mountains of research that you've done. Why would this be helpful? I guess maybe I can start with sleep. I'm not sure if you look into that or not, but I guess maybe more broadly a better way to ask is when someone is taking magnesium, sort of, how do you think about it? How do you counsel it? What data are out there that suggest that it's even helpful? Because I feel like this is Rogan podcasts and things. I feel magnesium is certainly out there as a thing that's great for brain health and sleep and, and heart health and all this kind of stuff. But what did the data tell us and what are you telling your patients?

[A]

I repeatedly hear people say that half of the US population is magnesium deficient. And that's just like actually they're misspeaking in a way that's actually important. There's an estimate out there that like half of the US population is not getting the, like the requirement or the estimated average requirement that we think people should be taking in through their diet. It doesn't mean that they're truly deficient. And the problem with magnesium is only about 1% of magnesium in the body is in the blood because it's in the bones, it's in other organs. So you can't really measure total body stores. You can just measure what's in the blood. So it's very hard to know if someone's total body magnesium deficient or not. And people that you can suspect are magnesium deficient. There are certain groups. This would be like people taking diuretics or people who are people with alcohol use disorder. Those would be two groups right off the bat that you might think of that might be magnesium deficient. And I just think that just making that leap that half the people are not eating enough magnesium to that half the population is automatically deficient and should be taking supplementation is just. It's one of those like, it's kind of magical thinking or it's like leaping to a conclusion that they shouldn't be. And magnesium, because it's a co factor in so many different reactions. People just assume that supplementing with it is just going to help the body with so many different processes. So you can go down such a rabbit hole on magnesium, which I did, but I want to just keep it to. Let's just say what we know it works for. If someone is magnesium deficient, like you measure their blood levels and their blood levels are low, then you can supplement there. And we do that in the hospital all the time. Someone has hypokalemia and it's not repleting. You check their magnesium. We learn that as interns in internal medicine for chronic idiopathic constipation. There's actually evidence there and it's in the AGA guidelines that you can give magnesium oxide 500 milligrams one to three times a day should do the trick. You can obviously give other forms of magnesium as well, the milk of magnesium and things like that for migraine prophylaxis. It is in the ANA guidelines as enlisted as like, probably effective. And 300 milligrams twice daily is like one of the common doses of magnesium that you would give for migraine prophylaxis. So those are the three things that I'm like, most confident in for magnesium. Leg cramps. Paul Williams. No, not, not leg cramps. I would not, I would not recommend it for leg cramps. There's a Cochrane review from 2020. It just doesn't seem to work. I really tried to find out where this magnesium glycinate thing comes from. The most I could find. Paul, you'll love this. In 1994, Chute et al had a crossover study of 12 patients. They found that 4 out of the 12 patients had better absorption and less side effects with magnesium diglycinate. I really could not find a study that was showing that this had better absorption in humans. That was the only thing I could find. And then there were some other studies basically just looking at it for like, bone turnover, glycemic control, blood pressure reduction. I don't know where they made this conclusion that it's so well tolerated, so well absorbed and that it should be used for sleep because, like the Sleep foundation lists on their website that magnesium is reasonable to take for sleep and that you should take magnesium glycinate based on GI tolerability. And I dug through their resources, like they basically didn't cite anything for, like, why they made that statement.

[B]

Just like an article of faith at this point.

[A]

Yeah. And the vadod guidelines from 2025 on sleep said there's insufficient evidence to recommend magnesium for treatment of chronic insomnia. So, you know, I think the mechanism is okay, it has some GABAergic effects and it maybe dampens, like excitatory effects in the brain. So that's why it's going to be good for sleep and anxiety. But when you actually look for studies that put the rubber to the road and prove that it does that clinically, it was hard to find. So I'm not recommending it for those indications. And I don't Think everybody out there is just needing to take magnesium. But it's one of those supplements that I, I do think is generally safe. I mean, we give mega doses to pregnant women and people with asthma, and, you know, most of the time they're just going to get like, diarrhea, GI upset if you give them too much. So what do you think?

[B]

No, you sold me on not recommending it.

[A]

The other popular one is this magnesium L Threonate. And there was a study by this guy Slutsky et Al, in 2010, they gave it to rats. They proved that rats had higher CSF levels compared to some of the other formulations of magnesium that are common. And then they tested the rats like memory and cognitive function, and it seemed to be better. So from there the legend just kind of grew that like, okay, plausible mechanism, it raises CSF levels better than other forms of magnesium. And these rats got smarter. Seemingly when they took it, their memory was better. Humans, it must do the same thing. But it's hard to find evidence, convincing evidence. Like the one study I looked at was Lopresti in 2026, and they saw a 2.6 point increase on a cognitive scale that was out of 130 points. So it kind of reminds me of the dementia drugs, Paul, where you look at like this, it's like this gigantic scale and they're like, we found a significant effect, but it's like, like a couple points on a 100 plus point scale.

[B]

Yeah.

[A]

So I would save your money on the magnesium L Threonate and the magnesium glycinate. I guess if you have the money and you don't care and you want to buy into the hype, you can again, this is what I could find. If listeners have, like, really good sources for this, we can put them in our show notes and we can, you know, update, make corrections.

[C]

Well, the mind is a powerful thing too. And I feel like a lot of this just gets thrown a lot of these complaints that are notoriously hard to treat. I'm not saying that that's a good thing, but sometimes it's just like, have you tried magnesium? And then people feel like it helps and then it's low risk to cause harm. And so I feel like that's kind of how it just gets thrown at everything, for better or worse.

[A]

Yeah. But I just, I love, in medicine, I mean, I wish it wasn't the case, but when you find something that people are just kind of putting out there as fact over and over and over again, and then you kind of find out where it came from. And you're like, that's what we've been basing this on, like this whole time.

[C]

There's so many things in medicine, so

[A]

many things, so it's tough. What do we want to talk about next?

[C]

Vitamin D. I feel like vitamin D is one of the most commonly checked labs and prescribed supplements. So our patient is on it despite not having a low level. He says that it supports his bones, his immune system, his mood, his testosterone, and his cardiovascular health. So where do we even begin with all of those multitude of possible effects?

[A]

I think one of the good things about vitamin D is there's actual smart people from the endocrine society and from ACE who have looked at this, and there's some guidance out there specifically for bone health that we can look to and even for some other things too, which we'll talk about the vitamin D levels. I get asked about this a lot in native populations, and there's still some out there. It seems like the level is somewhere between 40 and 50 nanograms. Is it nanograms per milliliter? Yes, nanograms per milliliter. For maybe some of our European listeners. Like 20 nanograms per milliliter is 50 nanomoles per liter, if that's what you're used to hearing. But in native populations, they have about 40 nanograms per milliliter to 50 nanograms per milliliter. And that's just natural. These are people that are. They get morning and early day sun and they kind of skip that hottest part of the day sun. And then they get the sun in the evenings when it's kind of cooling off a little bit. And that's the natural level. So, Paul, I'm taking that as a God given level. 40 to 50.

[B]

Sure.

[A]

And I think that's got to be safe if it's naturally occurring in people that are living outdoors. We know vitamin D is made by our bodies when we get sun exposure. So I think that that is a. And there are differences between, like, latitudes and things. But the guidelines are Saying levels above 30 should be good for most people, and levels below 20 are probably low. So between 20 and 30, it's like a little bit of a gray area. It's been very hard to prove that vitamin D prevents bone fractures in healthy people. Does that surprise you?

[B]

I mean, this has been since we were residents, Matt, which is like a million years ago now at this point where it's, it's. I feel like. Like we've been looking for vitamin D to save us now for Decades. And like, unfortunately the studies have not been super compelling. We've not found any data to kind of support most of that stuff. Like obviously we need it and you need it to be at certain levels. But like there's, I feel like we've been looking for vitamin D supplementation as a way to fix everything for years and years and years. And I don't know if the evidence is super compelling for most stuff.

[A]

Yeah. So for empiric supplementation, you know, I think a lot of people just want to take vitamin D without checking their levels or they want to check their levels over and over. The guidelines are recommending just like don't check the levels unless you have a reason, which would be osteoporosis or disorders of calcium. So like hypo or hypercalcemia, those would be the strongest reasons to check a vitamin D level. And for people with osteoporosis, it just calcium and vitamin D just get like a. Make sure you get this level. It's reasonable to supplement as an adjunct to some of the prescribed medical therapy. So let's put that one aside, that's a little easier. The Endocrine Society guidelines say that people 75 and older, you can actually empirically supplement them with vitamin D, which I don't know that I remembered that, Paul. Like it's not. I don't know that I'm putting all my 75 year olds on vitamin D. Are you doing that?

[B]

I'm trying to do a better job of it. But I also think that those guidelines are relatively recent, if memory serves, like this is within the past year or so. So this is not a swing and a miss for my medical career. But I'm trying to be more mindful about the empiric supplementation piece because it does make sense to me.

[A]

So let's stick with these guidelines because they're fairly Recent, updated in 2024. They're from a big society and presumably people smarter than me that put these together. So 75 and up, they recommend empiric supplementation, but not for people younger than that. And the dosing range that they gave for these older adults, they in studies it was like 400 to 3,333 international units. They had these very random ranges they gave in the guidelines, but they said on average it was around 900 international units. So let's call it 1000. So I think 1000 units a day would be a reasonable empiric supplementation based on these Endocrine Society guidelines for people 75 and up. The other group that they recommend empiric supplementation. I had no recollection of this. Paul Williams. I think you had. And this was based on a systematic review that they did. There were 24 studies on glycemia and vitamin D and they're actually recommending for prediabetes people that have at least two of the three. So elevated fasting glucose, elevated A1C and abnormal two hour glucose tolerance test that you give them empiric vitamin D supplementation. And again, and the dose can be similar to what I just quoted for people 75 and up 1000, maybe even 2000 units a day for that. But this is not something that I had heard of, Paul.

[B]

Yeah, this was the one that resonated with me just because it felt so weird like I had not heard of it. So when these guidelines first came out, that was one that stuck in my brain.

[A]

Yeah.

[B]

And then the other group that is probably germane to our listeners is pregnant persons. And maybe we assume that OB GYN will throw them on the supplement, but that is also a group for whom empiric recommendation or empiric supplementation is recommended. And I think kids too. But I don't care about kids. So less important and relevant.

[A]

Yeah. So I mean, just agreed with that. Look, I have kids, I care about them. I care about them a little bit, but you know, whatever. So that's vitamin D. I would say that things to watch out for. Some people I have noticed are taking mega doses in General, what the ACE guidelines from 2020 recommend Paul for supplementation. Because I was trying to find a specific number and I remember the 50,000 units weekly dosing was one that was out there for a while. But the 2020 ACE guidelines say give 5,000 units daily for eight to 12 weeks and then a maintenance dose of 1,000 to 2,000 units per day. And part of the reason we're getting away from these bigger bolus doses, they noticed that there's like an. When you give these big bolus doses, some of the vitamin D gets turned into this inactive form. And then also there was a couple trials of like the monthly or annual or this or the. These mega doses where there was an increased fall risk found. So those are the. That's what's kind of scared me away from giving these big mega doses. And outside of maybe some patients with like bariatric surgery who just don't seem to absorb vitamin D, I'm mostly just sticking with these smaller doses. Usually 5,000 units daily is the biggest pill that I'll give for a short Period of time. And that's where I'm at right now with this.

[B]

A pro tip I got from endocrinologist I work with is when you're trying to replete and you just can't seem to get the numbers where they should make sense. She's like, that's when I actually checked for celiac, which is not a connection I would have made initially, but I thought that was really smart. So there's your clinical pro for you.

[A]

Thank you. What's next? Let's see if we can rapid fire through some of the others.

[C]

Any benefit for adding K2 to the vitamin D3?

[A]

I think theoretical benefit, because vitamin D and K2 are. Vitamin D and K2 are linked together. And there's theories that, okay, it can better support bone health and cardiovascular or vascular health if you give both of them together. Vitamin D has some role in the liver making vitamin K Factors, and so K2 can help support that. So that's where that's from. I didn't look super deep into the. Into how much better it is. I think there's some evidence that maybe it increases bone density better when you give the two together than just vitamin D alone. But a lot of vitamin D formulations now have vitamin D and K2 together. And it's so cheap that I think it doesn't matter. I think it's safe to do so. I don't get too wumped up about K2 with my vitamin D. All right,

[B]

let me ask you about the patient's creatine, which is something I will admit to our listeners I have texted you personally about because I just didn't know the evidence and it just seems reasonably safe. But I think people take it. Historically, it's sort of associated with muscle health. But I think more recently there's been some buzz about brain health. Again, sort of back to those vague terms. But what are we telling patients about creatine these days?

[A]

Yeah, you know, I actually changed my own mind on this a little bit in the past year. I have taken creatine before myself just as an experiment because I had so many patients taking it. And what I can say about creatine, it supports cellular energy production. It basically helping us make ATP. And really the most evidence for creatine is during short bursts of like, kind of strength, power output. So someone's sprinting, someone. Like CrossFit workouts are like a perfect example of like when you would need it. Like. Cause CrossFit workouts have these short daily workouts where you're lifting heavy Things moving really fast and using a lot of energy at one time. And in those situations, people are able to perform more work and perform better with creatine. So that has been pretty consistent. And creatine has been studied for so long for endurance work, it does not seem to work because you're just using a different energy system. And creatine's not really supporting that. I would not recommend it for endurance athletes. If you're just someone who's just jogging, then you really don't need it. People think creatine's like almost a steroid where you're gonna get jacked when you take it. When you look at how much weight people gain, they're only gaining like 1-3 kg of lean mass. And most of it's probably water weight. So it's not really making people, like, huge, but it has that reputation and they definitely market it that way. I think part of what you have to factor in is if someone's taking creatine and they're working out really hard in these CrossFit workouts or in the gym lifting weights, they're going to get big because they're lifting weights and they're probably hitting, getting enough protein each day as well. And that makes big muscles. But creatine alone is not this massive anabolic agent that I think I always thought it had the reputation of that. In high school, I remember people taking creatine and they knew even back then in high school that it gained some water weight because people would say, oh, yeah, creatine makes you big, but you're kind of puffy. So that's what it is. So I would say if you are an athlete, definitely, if you're like a. An athlete who has, like, kind of doing a lot of sprinting or you're doing a lot of, like, intense physical, like weightlifting or CrossFit, that sort of thing, I think can be helpful. If you're doing it just because you want to get, like, huge, maybe it's going to give you, like, a little bit of extra lean mass. But it's not. It's not huge. It's not a huge amount. And if you're an endurance athlete, you can probably leave this one by. Have you heard about this for brain health, Paul?

[B]

Yeah, I think that was the more interesting thing to me, because I know it's because I feel like that has been the more recent buzz and actually why I'm seeing more patients take it now, even more so than to bulk up or to help with their exercise regimens. But I Don't know much about the data that support them.

[A]

Right? Yeah. And Rhonda Patrick is a. She's like a biomedical scientist of one and a podcaster and she talks about this a ton. She talks about a lot of supplements. And creatine is one of the ones she's been talking about lately. 10 milligrams or more or 10 grams or more per day, hypothesizing that it's going to help with the brain because they've looked at this for people in a sleep deprived state to say, do they perform better with creatine? Looking at people with dementia to say, can this prevent dementia or can this help people with dementia just kind of perform better cognitively? And that's where this has really taken off because dementia is that big bad thing that everyone's afraid of. There's been lots of study about this, but it's still mixed and I think it's still early days, I'll say for Alzheimer's. First, there was a pilot study in humans that was like 20 patients with Alzheimer's disease by Smith et al in 2025. And this was more just to say, is it feasible to give people with Alzheimer's disease creatine and are they going to take it or is it going to upset their stomach? They found that it increased brain creatine by 11%. They were giving them a big dose like 20 grams a day for eight weeks. A normal dose is 3 to 5 grams a day for a person as just a chronic dose. And they found some statistical improvements in cognitive and global and fluid composite scores. So there's some interesting early research in humans with creatine. And then as far as cognition goes, Paul, I've linked to at least five or six studies here on cognition and memory, and most of these were small studies. The biggest one had something like 120, some patients or so most of them were smaller. And they tried to put some of these together in a meta analysis and, and it seemed like in the meta analysis that older adults seem to have more of a benefit than younger adults as far as creatine. And they're looking at a lot of like surrogate. They're doing cognitive testing and then they're looking at all these different domains of cognitive testing. And sometimes the trials just had a lot of conflicting results. So it was hard to go through. So I would say it still shows promise. There's a plausible mechanism that when you take enough creatine, your brain creatine goes up, so your brain has more energy, so your brain can Perform better when you're doing cognitive tasks or when you're sleep deprived. That's why people are really interested in this. So as of right now, I'm not going to be taking it for cognitive enhancement. I'm not convinced enough that I need it. But I think this is an area where lots of people are studying it and I think they should. We know creatine's safe and I would say that you're going to hear more on this and maybe this is something we'll have to update over time. So I would follow this under interesting, plausible and probably there's something there. But right now we don't know what dose to take and which population is most going to benefit.

[B]

So it's and relatively low harm in as much as we know. Right?

[A]

Low harm even for the kidneys. Paul? Oh, pro tip. If you have somebody that's taking creatine, just check a cystat and see it's not going to be affected because creatine gets broken down, then you can theoretically raise the creatinine levels and it's going to interfere with kidney function. So you find all this stuff saying don't take creatine if you have kidney problems, but really it's just for that artifactual thing that happens. It's not that it actually becomes toxic to you. If you have chronic kidney disease, what's next? Do we have any more supplements for this guy?

[C]

I think the last one we've got is this turmeric or the curcumin with black pepper extract for his knee osteoarthritis. So what do you tell people about that in general?

[A]

Okay. And I should have put this up front but I wanted to just shout out that there's a couple sources that I use when I'm going through supplements and this is a place you can look for a quick question like this for like curcumin. So Memorial Sloan Kettering Cancer center has like a database of herbals and supplements. The NIH Office of Dietary Supplements has a really nice website as well. Both those are free. And then there's some paid things, consumerlab.com, which I mentioned. And then there's another one called examiner, which examine.com has all sorts of supplement reviews, evidence based reviews and has some cool features, but it's pretty pricey. I did not use that to prepare for this, but I just wanted to mention that. So for the review on curcumin I looked a lot. I used a lot of the NIH Consumer Lab and the Memorial Sloan Kettering Cancer Center. So curcumin for knee pain. Actually there was multiple meta analyses out there and it does seem like it's comparable to NSAIDS for knee pain and seems to be safe for the most part to be taking it. There are some caveats there, which I'll talk about, but I think it's interesting. The initial evidence right now suggests that there's probably something there. And this has been used in not so much Western countries for a long time, but more in the east. A lot of the research seems to come out of Iran for this one and the evidence seems to be pretty favorable. The studies did have moderate risk of bias. They were smaller studies, as you'd expect because we're talking about a supplement here. But for the most part it does seem like for knee osteoarthritis that it is effective at least comparable to NSAIDs. So my main concern with turmeric is that there have been a number of cases of liver like acute liver injury or liver like real serious liver failure from curcumin. And this was basically this highly bioavailable form of it. Specifically if it's taken with like piperine which is found in black pepper, or they have, if any of the formulation says like liposomal curcumin or highly bioavailable forms like that seems to be the ones that that has done it. It's a rare complication, but that's something to look out for with that. Which kind of scares me off of prescribing curcumin for people because a rare complication but a really bad one is not something that you want. And it's been seen in at least like 10 cases. The Memorial Sloan Kettering site and the NIH site both mention it and there's lots of case reports of this, so does the consumer lab. So I would be careful for this one. But you know, and also short term dosing because the longer term, like people that were on this, the longer term, that's when they started to see it. So a month or less. So you know, if someone has some acute knee pain and you're using curcumin, I think it's okay to do that. But, but just being careful about that because like curiously there are some studies in fatty liver disease showing that it can lower like the AST alt they didn't really find hit any hard outcomes with it. So they're like, in one sense it could be healthy for the liver in some things, but definitely there's cases out there of people that are getting really sick from taking high doses of this. So I would be careful about that. Most trials people are taking 500-2,000mg of curcuminoids. So Paul, turmeric is like the, the plant, right? And then turmeric plant has curcuminoids in it. And the one that's been studied for its health benefits is curcumin. And that's, you know, that's why you'll kind of see people talk about them interchangeably. But that's, that's what it is. All right, guys. So I would tell this guy, if he's taking it for knee pain, I would tell him to limit it to a month and I would make sure he's not taking a highly bioavailable form and give it a month trial. Does he think it's actually working for him or not? And if it's not, then he can stop it. What other questions you have before we wrap up here?

[B]

So let's recap our patient and actually talk about your framework one more time. Just I want to go through the steps just to make sure that I actually have them down. And then I had just a couple cleanup questions. But again, when you're talking to patients, Matt, you're assessing why they're taking the supplement and what, what they are actually hoping to address with it. Specifically, when you're talking together, you're trying to figure out the mechanism of action. Is there some sort of biological plausibility? Is there evidence that it works? Is there a way to track that it's actually working, that actually proves benefit and then is there a balance of risk to reward? So for instance, with the curcumin does seem to potentially be helpful. But then also there's this specter of acute liver injury which is, is sort of slightly scary. So for our guy just going through the multivitamin, it sounds like not super compelling evidence for. But you wouldn't necessarily stop it. Same for over the counter fish oil. That'll sort of be the theme for all of these things where it's the evidence for the over the counter formulations is not terrifically strong, but probably not going to cause any harm. And there may be some benefits uncovered later on in life. Cod liver oil, I think we'll just gloss fast. The magnesium glycinate. There are conditions that actually for which magnesium supplementation is beneficial. But the sleep and constipation, the constipation, perhaps the sleep, not so much strong evidence for. And then also migraine, prophylaxis and then preeclampsia that kind of stuff. And then magnesium deficiency, certainly vitamin D3. We're leaning towards the Endocrine Society guidelines about just empiric supplementation of higher risk groups. So older patients, pregnant persons, patients with high risk prediabetes, creatine maybe not bad for people who are doing sort of bursts of high performance, but for like endurance stuff and long term stuff, not necessarily that helpful. And then the brain stuff is kind of a tbd, but not, not an active recommendation right now. Is that a fair recap?

[A]

Fantastic recap, Paul. You should start doing recaps now.

[B]

Nope. Yeah, I would. I could not take the crown from you, my friend. I guess the question I wanted to follow up, Matt, is do, do patients ever ask you where they can look to find useful information? Like I think you shared some things with like that might be of use to clinicians. Are you pointing patients towards those same, Is there a different way that you're having them investigate these things? We've talked about this before. I like when patients do their own homework, but you want to make sure they're using sort of reliable sources for it. So how do you navigate that as someone to explore on their own?

[A]

Right. If it's someone who takes a ton of supplements, then I would just tell them, look for those USP NSF certified labels on there if they have access. ConsumerLab.com, look at, you know, make sure it's one of the formulations that was studied on there to look to see like, is it a good supplier? Do they have in the product what they have in the product? And then I ask them to, you know, they can look on, they can look on some of these websites like the NIH or Memorial Sloan Kettering to see like, does the product do what they say it does? And I try to steer them away from proprietary supplements and, and a lot of the times I'm helping them vet things. But I do try to give them this similar framework to what I'm giving to clinicians and then go from there. Some people just want to take the supplements and they just want me to just tell them that it's safe for them to take and they don't care what it costs them and they're going to take it and that's okay too because I can't prove that. In some cases you can tell them, I'm pretty sure this doesn't work for what you're taking it for, but in many cases you can't tell them that. You're just like, I don't know if it works for that. It hasn't been studied.

[B]

And I guess my last question, I want to hear what questions Paul has the better. Paul. But are there any supplements that you find yourself consistently recommending because the framework they're providing someone brings the supplements to you. But is there ever a point in time where there are certain cases where you're like, I think that you would benefit from this supplement and this might be a loaded question, but answer is as comfortably as you're able to.

[A]

Not really. I mean, once in a while I'll suggest to somebody, not really. You know, certain times, there are certain times I think it makes sense to have like a protein supplement around. Like if you, you know, if it's a day where you just didn't get enough meals and you're trying, it's someone that's struggling with weight loss or if it's someone that's wanting to build muscle and they're like skipping an important meal, I might tell them to take, you know, okay, you're, you eat breakfast and dinner, you're trying toyou're telling me you wanna gain muscle, you probably should have a protein bar, protein shake in the middle of the day and eat something else with it just so you're not having no calories then or no protein then. But there's not many times I'm telling somebody to take a supplement.

[B]

That was kind of my guess. Okay, great.

[A]

Yeah, yeah.

[C]

And sometimes I'll use this conversation to springboard into it kind of opens the door into here are some things that may work, but what really does work is sleeping well, working, eating a healthy diet. And so clearly if they're bringing this stuff up, they care about that sort of thing. And so you can kind of lay that foundation and then maybe introduce some of this conversation as a little icing on the cake. But that's kind of how I find this conversation often in clinic setting.

[A]

Yeah, the food first lifestyle first. I should have said that a million times on the episode. I think I only send it once or twice. But yeah, food first lifestyle first. That's going to really have wide ranging effects and make it so you don't need to take so many supplements to feel like you're having good health.

[B]

That's. Yeah. Probably the unspoken part that I. And not true all the time, but some of the times these are taken just because the dietary changes and the exercise, it's so hard to do consistently. So how much better would be if you could just take a supplement that would actually fill that gap? But unfortunately not. Unfortunately. But the diet and exercise are the best things that we have. Yeah, those are great points, Bob.

[C]

I feel like sometimes that's what the patients want is for you to tell them that, oh, they can just take a supplement, everything's going to be okay. And then you're like, all right, let's back up, let's lay the foundation and the things that actually do help. So that's kind of how I use this conversation.

[A]

Paul, should we get to an outro?

[B]

Let's. So this was great. Thank you for that, Matthew. And to our listeners, this has been another episode of the Curb Ciders bringing you a little knowledge food for your brain hole.

[C]

Yummy.

[B]

Thank you all. Still hungry for more? Join our Patreon get all our episodes ad free twice monthly bonus [e-mail] curbsiders. You can find our show [e-mail] and sign up for emailing us to get our weekly show notes in your inbox. This includes our Curbsider's Digest which recapsulates price changing articles, guidelines and news in internal medicine.

[A]

And we're committed to high value practice changing knowledge and we want your feedback. So email [e-mail] reminder that this and most episodes are available for CME for all health professionals through VCU healtherbsiders.vcuhealth.org a special thanks to our writer and producer for this episode, Dr. Paul Wertz, and to our whole Curbsiders team. Our technical production is done by Podpaste. Elizabeth Proto does our social media. Jen Wattle runs our Patreon. Chris the Chew Manchu moderates our discord. Stuart Brigham composed our theme music and with all that, until next time, I've been Dr. Matthew Frank Wadda.

[B]

I've been Dr. Paul Wertz and I almost made it through the entire episode without referring you to as a wunderkind. So wunderkind, Dr. Paul Wirtz and as always our main doctor Paul Nelson Williams. Thank you and goodbye.