How We Choose Supplements

If you have ever handed me a bottle and asked whether it's any good, you already know the answer usually starts with a few questions back. Supplements are one of the least honest corners of health, and most of what crosses my desk gets a quiet no. That isn't cynicism, it's the shape of the work, since a good recommendation is mostly the long list of products we ruled out before we got to it. We run three gates, always in the same order, and the order does most of the work.

Gate 1: Safety comes first, always

Nobody checks the bottle before it ships. The FDA (Food and Drug Administration) can pull a supplement once it is on the market and people are already swallowing it, but there is no pre-approval the way there is for a prescription, so the burden of proof falls on whoever is paying attention. I would rather that be me than you.

Two things have to be true before a product goes any further. I have to trust the manufacturer and the source, and I'll get to sourcing in a minute. And I want genuine third-party testing behind it, meaning an outside lab, USP or NSF or a credible equivalent, has opened the bottle and confirmed that the label is telling the truth: the ingredient is in there, at the amount it claims, without the contaminants you never agreed to swallow.

That last part is not a hypothetical worry. Independent groups keep looking and keep finding things: unapproved drugs spiked into the powder, herbs that turned out to be a different plant or barely any plant at all, contamination nobody disclosed. Our guide to supplement safety and independent testing goes deep on how to read those seals yourself, since the logos on the front of a bottle are not all equal.

When I can't verify a product, it stops right here and never reaches the second gate. A bottle that might be contaminated, or might hold a fraction of the dose it advertises, is a bad deal at any price.

Gate 2: Effectiveness, matched to you

Only after something clears safety do we get to the question you probably walked in with, which is whether it works. The more useful version is whether it works for you, at a dose that does something.

This is where it stops being a product decision and becomes a clinical one. What I choose depends on your labs, what you are trying to change, the medications you already take, and how much room there is to move the number we care about. Two people can ask me about the same supplement in the same week and leave with different forms, different doses, or different products, and one of them may leave with my blessing to skip it and keep the money. We are picking for the result, and the front of the box is marketing copy. A heavily advertised product at a token dose is doing nothing for you, however good the packaging looks.

Gate 3: Cost comes last, never first

Price comes up once the first two gates are settled, and what we want then is value, which is a different animal from cheap. Value here means the lowest price on the best product, from a source we trust, usually the manufacturer directly or a professional supplement service.

The math cuts both ways with supplements. The most expensive bottle on the shelf is often charging you for a label rather than a better molecule, and I have talked plenty of people out of those. But the cheap bottle is usually cheap for a reason, whether that is a dose too small to matter, a form your gut absorbs poorly, or a supply chain I can't stand behind. There is an old line about being too poor to buy cheap things, and supplements are where it earns its keep. A discount bottle that does nothing is the most expensive thing in your cabinet, because you paid for it and got nothing back. So cost breaks ties among options that already made it through the first two gates. It doesn't get to open the conversation.

Where we source from, and how we keep it honest

Most of what we recommend comes through a professional-grade supplement service, and when the direct route is better we point you to the manufacturer or an authorized seller. A professional channel is a short line from the factory to your kitchen counter, with no anonymous middle layer where fakes, diverted product, and expired stock creep in. Pricing follows the same rule as everything else here: whatever discount we negotiate on professional-grade supplements goes straight to you, with no markup added on our end.

And then the money question, which most practices would rather you never asked. Some of our links earn Fishtown Medicine a commission, and some do not. You deserve to hear that from us plainly. What it does not do is change a recommendation. Safety decides what is even eligible, effectiveness decides what I suggest for you, cost breaks the tie between what is left, and whether a link happens to pay us is not one of those three gates. When the best product for you is one we earn nothing on, that is still the one you will hear about.

How to vet a seller yourself

Buying on your own doesn't change the source rule, and the checks a careful reviewer runs on any retailer work just as well on a supplement seller:

• Buy direct or from an authorized seller. When authenticity matters, and with anything you swallow it does, go to the manufacturer's own site or a seller they list as authorized. Plenty of brands won't honor a warranty or a recall on a unit that came from somewhere else.
• Be wary of third-party sellers on big marketplaces. One product page can put the manufacturer and a crowd of anonymous sellers behind the same button, and the listing that wins on price is too often the counterfeit. Look at who the item is sold by and who ships it before you order.
• Read reviews skeptically. Fake glowing reviews are their own industry. The signal is in the specific complaints that repeat, like wrong item, broken seal, or nothing happened, rather than in the star average.
• Check the return and refund policy before you buy, and pay with something that carries buyer protection, so a bad order is a hassle instead of a loss.
• Trust your eyes when the box shows up on your porch. A seal that is torn or doesn't match, printing that looks a bit off, fonts that are not quite right, an expiration date coming up fast, any of those is a reason to stop and send it back.

For the fuller picture on how fakes get into cosmetics and supplements, and why they can be dangerous, see our guide to counterfeit skincare and supplements.

Guidance from the Clinic

"The order is everything. I would rather you take nothing than take something I cant verify, so safety is the first gate and it is not negotiable. Then we make it work for you, which usually means a meaningful dose rather than a sprinkle. Cost comes last, and I will happily point you to the cheaper bottle when the cheaper bottle is just as good. What I wont do is pretend the price tag, or a commission, decides anything. It doesnt."

Dr. Ash

Related reading

For the bigger picture on why the supplement industry produces so many products that pass the marketing test but fail the evidence test, see our Digital Health Literacy series:

• Why Most Supplements Don't Work (And Why You Still Feel Better) - the summary
• The Placebo Effect, Social Media, and Why Supplements Feel Like They Work - the mechanism deep-dive
• Quality and Contamination: What's in Your Supplement - FDA tainted-supplements data and how to vet a product

Scientific References

1. Tucker J, Fischer T, Upjohn L, Mazzera D, Kumar M. "Unapproved Pharmaceutical Ingredients Included in Dietary Supplements Associated With US Food and Drug Administration Warnings." JAMA Network Open. 2018;1(6):e183337.
2. Newmaster SG, Grguric M, Shanmughanandhan D, Ramalingam S, Ragupathy S. "DNA barcoding detects contamination and substitution in North American herbal products." BMC Medicine. 2013;11:222.
3. U.S. Government Accountability Office. "Intellectual Property: Agencies Can Improve Efforts to Address Risks Posed by Changing Counterfeits Market." GAO-18-216. 2018.
4. Organisation for Economic Co-operation and Development and EU Intellectual Property Office. "Trends in Trade in Counterfeit and Pirated Goods." 2019.
5. U.S. Food and Drug Administration. "Tainted Products Marketed as Dietary Supplements." FDA Health Fraud Database.