It’s a good news—bad news story.

The good news is that ephedra is out. The Food and Drug Administration’s ban on ephedra finally took effect in April.

A powerful natural stimulant, ephedra had been implicated in numerous deaths and illnesses from circulatory problems, including heart attacks and stroke.

But when ephedra was sold as a dietary supplement for weight loss or energy enhancement or other purposes, the burden of proof was on the government and consumers to show that ephedra’s dangers outweighed its benefits. It took several years to do it, during which more people died, many others became sick or suffered permanent injury. But it’s done.l

Now for the bad news: there are plenty of other products pouring into the vacuum left by ephedra’s withdrawal, and while we’ve learned a lot about ephedra, the new products hitting the market put consumers up against a whole new array of dangerous unknowns.

And the worst news is that most of us aren’t even aware of that. A 2002 Harris poll showed that 59 percent of adults believe dietary supplements are approved by a government agency before being sold (they aren’t); 55 percent said they thought manufacturers need to have scientific evidence supporting their safety claims (they don’t); and 68 percent believe the government requires warning labels about supplements’ potential side effects (it doesn’t).

So supplement buyer beware, now more than ever. The devil you know is better than the devil you don’t know, and some of the most likely suspects are also most likely to be complete strangers to the average consumer. Here are some chief offenders to watch for:

The “Also-Banned”

Aristolochia herbs have been included in weight-loss formulas, but they have also frequently been associated with serious kidney damage, often because more toxic species of plants containing aristolochic acid were used in place of other, usually benign varieties.

Researchers find this kind of formula adulteration – whether deliberate or inadvertent – among the most troublesome in the unregulated world of dietary supplements. There simply is no production oversight, so you just don’t know what you’re getting.

To help limit the dangers, the FDA banned imports of aristolochic botanicals in 2001, but many products remain available online that contain aristolochic acid. Watch for mu tong and fang ji, but also beware of products containing clematis and stephania.

Just this March, the FDA sent 23 U.S. manufacturers of androstenedione (andro) a letter warning them to cease manufacture of the muscle-building supplement. But andro also is readily available online, with some sellers actually hyping the ban as a promotional tool – “Buy Andro and prohormones before they are banned!”

Of course, those sites won’t tell you about the risks, including heart and liver damage, and some gender-specific problems: testicular atrophy, impotence and breast development in men, and facial hair, menstrual problems and greater risks of breast and uterine cancer for women.

The “Also Rans”

With ephedra out of the way, formerly second-tier products in the weight-loss supplement races have been promoted to first position, hawked as the safe and sane alternatives to their risky forebear. But there’s nothing to say these are any safer. They’re simply as unproven and untested as ephedra initially was, and so far, they haven’t proven lethal.

Bitter Orange, an orange peel extract, is the pet ingredient of the moment. Also referred to as zhi shi or citrus aurantium, it contains synephrine, a stimulant chemically similar to ephedrine.

Synephrine can increase blood pressure and constrict blood vessels, as ephedrine does. If it’s mixed with caffeine – as it usually is in supplements – that effect can be enhanced.

Bitter orange also contains furanocoumarin, a known inhibitor of one of the body's drug-metabolism routes, so researchers are also concerned about how bitter orange might interact with other substances, particularly prescription drugs. This should be of particular interest for older consumers because furanocoumarin can cause some medicines – including cough syrup and blood pressure medicines – to build up to toxic levels in the blood.

Country mallow, heart leaf and chikana are other botanicals that contain the stimulant ephedrine. But because the ephedrine content of these plants is not as concentrated as in ephedra, you have to take more to get the same effect, and then – as with bitter orange – the question arises about what other chemical components you might be ingesting.

Most familiar to Americans as the kick in their coffee or cola, caffeine can be a mild appetite suppressant and pick-me-up. But in concentrated doses, it can cause nausea, tremor and circulatory problems. Guarana, kola nut, yerba maté, paulinia cupana, and tea extracts are common sources.

What’s a concentrated dose? Who knows? Just look at the instructions on one new ephedra-free product: “Standard Serving: To maintain energy and burn fat for up to 8 hours, take two tablets daily. Super Serving: To increase energy and fat-burning for up to 8 hours, take three tablets daily. Ultra Serving: For maximum energy and fat- burning for up to 8 hours, take four tablets daily.”

This kind of more-is-better labeling encourages increased consumption without addressing any potential complications.

Remember that manufacturers of ephedra-based products were not forthcoming about the complaints they were getting from consumers and that kept the lid on the problems with ephedra for a long time. If you’re taking dietary supplements for weight loss, keep in mind that the first negative reaction you hear about could be your own.

THROUGH THICK & THIN:

“Ephedra-free!” doesn’t mean worry-free. What are you getting instead? What are the new risks to watch for? The symptoms of overdosing or negative reaction? It’s buyer beware, more than ever now. Resist being lulled by marketing that promises “natural” weight loss. Remember that many toxic poisons are completely natural. That doesn’t make them good for you.

Caroline J. Cederquist, M.D. is a board certified Bariatric Physicians, the medical specialty of weight management, and a board certified Family Physician. She specializes in lifetime weight management at the Cederquist Medical Wellness Center, her Naples, FL private practice.

Dr. Cederquist is a contributing medical editor for NBC-2 News, a trustee of the American Society Of Bariatric Physicians and the author of " Helping Your Overweight Child - A Family Guide", www.Amazon.Com or by Calling Toll-Free 1-800-431-1579.

If you are interested in a delicious, doctor-designed, foolproof plan for fast and healthy weight loss please visit Dr. Cederquist's Diet-To-Your-Door program by clicking here.

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