THE TOXIN HUNTER
Meet the maverick doctor fighting to put a cap on dangerous fitness supps
Both hiding in plain sight and in the recesses of the dark web, retailers are pushing pills and powders that purport to enhance your health – yet cause more pain than gain. To combat the trend, a rebel doctor in the US state of Massachusetts is taking on rogue manufacturers, one false claim at a time. His findings call into question how much we really know about the supplements we’re taking
FIRST, IT WAS INSOMNIA. THE PATIENTS STREAMING INTO THE OFFICE OF DR PIETER COHEN ALL COMPLAINED OF SLEEPLESS NIGHTS.
One woman had headaches, chest pain and nausea. Another was depressed, sweating and trembling. Then a truck driver came to him with another concern: he couldn’t figure out why he had just tested positive for amphetamines.
It was 2006, and Cohen, who was working at a community health clinic in Somerville, Massachusetts, realised that something was amiss. Many of his patients were Brazilian immigrants, so Cohen, who speaks some Portuguese, began to ask them questions. There was little that was surprising about their diet or exercise habits, but the results of their lab tests shocked him. A number of the patients had amphetamines in their systems, though none believed they had taken any. Some also showed traces of known tranquilisers, hypnotics and antidepressants.
Eventually, staff members at the clinic suggested a possible culprit: Brazilian-made diet pills, sold in generic packaging in the local area. Cohen asked his patients about the pills and they all admitted to taking them.
“Because people were having such significant symptoms, it just gave me the sense that something powerful was in the pills that was mysterious or interesting,” Cohen recalls.
He acquired samples and found a lab that could analyse them. The tests showed that the pills contained dangerous amounts of fenproporex, an amphetamine linked to anxiety and addiction. The supplement had been spiked, a practice in which manufacturers cut corners by covertly including harmful ingredients. Cohen alerted his regional Food and Drug Administration (FDA) office, hoping that it would take the pills off the market. But nothing happened. No warnings were issued. After several months, the pills were still on the shelves.
Undeterred, Cohen produced warning pamphlets and shared them in the community. He talked to local radio stations and newspapers. Eventually, the pills started disappearing.
Cohen never imagined that this experience might lead him to investigate another toxic supplement, then another, until his self-appointed role of policing the inadequately regulated world of supplements turned into an obsessive quest. He now analyses dozens of pills and powders every year, pursuing any hunch that a dangerous ingredient might be lurking behind a too-good-to-be-true marketing claim.
LAW AND DISORDER
In the US, adverse events related to dietary supplements cause an estimated 23,000 emergency room visits a year. But it’s not a problem confined to the US. In June this year, the UK’s Medicines and Healthcare Products Regulatory Agency (MHRA) seized £9m worth of fake or unlicensed online drugs, including numerous diet pills. Meanwhile, researchers at Harvard University recently found that dietary supplements that claim to build muscle, sustain energy or help with weight loss were linked to nearly three times as many severe medical events in people aged 25 and under as vitamins alone.
In one of Cohen’s published studies, an experimental stimulant called 1,3-dimethylbutylamine (DMBA), unstudied in humans, was detected in a pre-workout product sold by an online UK retailer. In a 2014 letter to the
BMJ, British researchers described finding the breast cancer drug tamoxifen in bodybuilding supplements. Since 2015, the UK’s National Food Crime Unit has removed more than 350 online listings as part of an effort to target the sale of DNP, a potentially lethal and illegal fat-burner. Since January 2020, the UK Food Standards
COHEN ON AIR, LEADING THE CRUSADE AGAINST UNSAFE DIETARY SUPPLEMENTS
“I THINK SOME PEOPLE WERE PROBABLY, LIKE, ‘PIETER’S CRAZY’”
Agency has investigated 201 incidents related to food supplements.
“Shops importing supplements into the UK are legally responsible for all aspects of those products, including composition, safety and labelling,” says sports scientist Professor Greg Whyte. “Contamination – inadvertent or deliberate – is possible.” What’s more, our purchases are no longer confined to those from domestic retailers. “Internet access to supplements from countries outside of the UK and EU is big business,” Whyte adds. Ergogenic aids (athletic performance enhancers) are a particular issue.
Cohen has stepped in where he sees the American regulatory system failing, bent on pulling unsafe and mislabelled products off the shelves. But being a solo sleuth taking on the multibillion-dollar supplement industry is not without its risks. “I think some people were probably, like, ‘Pieter’s crazy,’” says Cohen.
“But to me, it’s fundamental to the work. It’s an extension of caring for the patients.”
Tall, bald and fit, Cohen is 51 years old and wears well-worn trainers with his medical scrubs. When he is talking about supplements, he becomes loud and animated. When he is with his patients, however, he is calmer and carefully inquisitive. When Men’s Health visited him at work, he made use of an unusual piece of equipment to enhance his bedside manner: instead of a face mask, he sported an air-purifying respirator with a clear face shield, so his patients could read his lips and see his facial expressions.
Cohen grew up in an affluent suburb of Boston, the son of a lawyer and state superior-court judge (his mother) and a professor of experimental psychology (his father). He enrolled in medical school with the objective of helping underserved communities. “I had all this privilege,” he says, “and I wanted to make sure I gave back.” The Somerville clinic where Cohen works today is part of the Harvard Medical School-affiliated community health network, Cambridge Health Alliance. One day, his phone rang, and on the other end was a lawyer at the FDA’s office, who told Cohen that what he was seeing in Somerville was what they were seeing nationally: supplements were being spiked with drugs all over the country. And it wasn’t just diet pills. It was potentially everything from brain boosters to protein powders to vitamins.
Since many different manufacturers make these products, issuing a recall or seizing them directly from companies can feel like playing whack-a-mixture. “A lot of people would be, like, ‘That’s not my lane – let the lawyers or the public-health experts figure that out,’” says Cohen. Instead, the doctor started studying chemical structures, read about the history of the FDA and came to recognise some serious problems in the regulatory protocols for supplements.
This framework wasn’t outlined until the 1990s, when bodybuilding and diet supplements started gaining popularity. The industry objected with a well-financed campaign, including a TV commercial showing an armed squad seizing vitamin C from Mel Gibson.
The American FDA has no power to approve most supplements before they hit the market and little recourse to stop distribution afterwards. As a result, while some products purchased online contain exactly what is listed on the label, it cannot be guaranteed.
ON SHAKY GROUND
When the first US law specifically governing the sale of supplements passed, there were about 4,000 products on the market. Now, there are between 50,000 and north of 80,000. In 2020, the global supplement market grew to almost £100bn, and is expected to keep expanding fast.
Slow responses can have dire consequences. Consider the amphetamine derivative DMAA, which is associated with heart attacks, seizures and neurological problems. In 2011, two soldiers died while exercising. After it emerged that they had taken workout supplements spiked with the substance, the US Department of Defence banned the sale of products containing this ingredient from its on-base stores. It also released a warning about the dangers linked
to DMAA-containing products. By
April 2013, the FDA had received 86 reports of people harmed by them. Soon afterwards, it stopped the manufacturer from distributing some of the products. Until then, it had only sent warning letters. (DMAA has also been found in a significant number of products on sale in the UK.)
Cohen’s goal is to speed up that process, to spur either the FDA or some other governmental agency to act at the first sign of trouble. To do so, he has developed his own network of doctors, academics and doping experts who share tips about what emerging product ingredients might be harmful. Over the past decade, this small pharma rebel alliance has turned up an almost endless array of pills, powders and botanical products containing banned stimulants, alternative versions of dangerous stimulants and ingredients with adverse effects at high doses.
MISSION ACCOMPLISHED
In 2013, a source tipped Cohen off that athletes using a popular workout powder called Craze were testing positive for an unknown amphetamine. The previous year, the product had been named the “New Supplement of the Year” by bodybuilding.com, and it was being sold through online retailers. When Cohen bought and tested it, he identified a chemical called DEPEA, which is similar to meth.
Craze was manufactured by a US-based company called Driven Sports, whose owner had previously been sentenced for mail fraud and shipping misbranded drugs. Cohen published his findings and shared the story with news outlets. That same week, Craze’s manufacturer announced it had ceased production due to safety concerns.
In recent years, Cohen has had similar success at identifying both an amphetamine variant called BMPEA in several weight-loss supplements and a neurologic drug called picamilon in supposedly memory-boosting products. After the release of Cohen’s reports on the two chemicals, the state of Oregon’s attorney general sued supplement giants GNC and pushed through a deal banning nutritional supplement chain Vitamin Shoppe from selling products containing the ingredients. The retailer paid a $545,000 fine, pulled the relevant products and suspended sales of anything with an FDA warning or advisory. Then Nebraska picked up the baton: the Vitamin Shoppe agreed with its attorney general to no longer sell BMPEA products.
In 2015, GNC announced that it had stopped selling picamilon and BMPEA products, too, though it publicly stated that the FDA had not, at that point, raised safety concerns about those ingredients. GNC now claims that all of the products it sells must meet specific standards for purity and strength. A spokesperson for the Vitamin Shoppe says that vendors must assure the retailer that their products “comply with all applicable laws”, and all products are reviewed by its scientific and regulatory affairs team before being sold.
Even Amazon, an emerging force in the retail-supplement world, says that it has “proactive measures in place to prevent suspicious, non-compliant or prohibited products from being listed”. Amazon requires companies to share a certificate of analysis – testing that confirms the make-up of a product.
Cohen says that even though some stores and chains are taking steps to ensure the safety of supplements amid serious shortcomings in the laws, smaller shops and internet sites will continue to fuel the problem. He would like the FDA to issue rulings more quickly. “They’re simply not doing their job,” he says.
The FDA has a more diplomatic stance. “We appreciate stakeholder interaction like this for raising awareness and bringing needed attention to these matters,” says a spokesperson. “We look forward to collaborating… to help ensure that products marketed as dietary supplements are safe, well manufactured and accurately labelled while preserving the original commitment to consumer access.”
Cohen has criticised the FDA’s lack of effectiveness for years – but he never expected that he would have to defend his tactics in court. In 2014, he read a study written by FDA scientists about supplements that purported to contain acacia rigidula, a shrub that had become popular on weight-loss products’ labels.
FDA scientists tested 21 products listing the acacia ingredient and found that nine of them instead contained BMPEA. However, the agency did not specify which supplements had the dangerous ingredient. So Cohen ran similar research, finding BMPEA in several products for weight loss, sports or cognitive function.
He published the names of the products and their manufacturers.
COURTING TROUBLE
That April, one of the companies Cohen cited, Hi-Tech Pharmaceuticals, sued him for $50m in compensatory damages, as well as $150m for slander and libel. The issue wasn’t whether some of its products included BMPEA; Hi-Tech admitted that they did.
Rather, Hi-Tech fought his statements that BMPEA was dangerous, hadn’t been rigorously tested in humans and wasn’t derived from acacia rigidula.
Harvard defended Cohen, covering the costs of the lawyers. But the litigation process was all-consuming. Cohen had to dig through his emails to find anything related to this study and hand it over to Hi-Tech. Then he had to analyse all of those communications in case he was asked about them in his deposition or at trial. “I spent every free moment I had [on it],” he says. After a six-day trial, the jury found in his favour.
Hi-Tech’s CEO and lawyers did not respond to requests for comment, and while some of its brand names that Cohen analysed are still available, it is unclear whether the company has altered the supplements’ make-up.
The trial did have one upside: it proved that Cohen’s work was having an effect. “I didn’t want to have research that is just sitting there and never read,” he says. “I want to have a positive impact on health.”
In spite of the continuing threat of lawsuits, he has not slowed down. He has now published more than 50 academic papers skewering major manufacturers for being less than forthright about their products and promises. He paused his investigations when the global pandemic hit, as he put all his energy into sharing anything that might be helpful for doctors trying to diagnose and treat COVID-19. But this March, Cohen published a new study looking at 17 sports and weight-loss supplements with labels that listed the ingredient deterenol, a stimulant that can cause sweating, nausea and cardiac arrest. Four of the supplements he tested didn’t contain the substance at all, despite the claim that they did; all of the others contained it or had cocktails of deterenol with other stimulants.
“It’s dizzying how complicated all these products are,” he says.
In the meantime, hyperbolic online reviews of some of these products suggest how strong they might be. Of one pre-workout, a reviewer wrote: “This stuff is just a few levels below cocaine… I can smell colours.” Of another, a reviewer said, “As I like to call it, edge of a heart attack.”
Personally, Cohen doesn’t even use multivitamins. “My take is just: it’s best to go with exercise and healthy food, and you have to have pretty strong evidence to convince me that something is better than that,” he says. But he did make a small concession at home: when his 19-year-old son got interested in supplements and his 15-year-old son started watching TikToks on pre-workout regimens, he let one of them try protein powders. Now, though, they stick to healthy diets – not sports supplements.
He understands the pressure that comes with comparing yourself with others, and how anyone who wants to stay a step ahead might go searching for an edge. So Cohen continues to research and write and pitch and advocate, trying to get a single message to consumers of supplements: buyer beware.
“IT’S DIZZYING HOW COMPLICATED ALL OF THESE PRODUCTS ARE”