It started with nausea and loss of appetite.
Robert Grafton of Turnersville, New Jersey, tried to make sure he was just going to do something on a weekend in mid-March. Then came the itching and dark urine. Grafton, a former interventional radiology technician whose wife is a nurse, has recognized the characteristics of liver failure.
The otherwise healthy 54-year-old had a gut feeling that his herbs and dietary supplements were the perpetrators.
“I stopped taking everything, thank you for the goodness,” Grafton said. “If I hadn't known, if I wasn't in the medical field, I might have been thinking, 'Yes, I think I'm sick. I need to bring more of these supplements to make me feel better.' ”
When his symptoms worsened by the middle of the week, Grafton visited his primary care physician. He said doctors are suspected of hepatitis A, a liver infection that can be caused by consuming hepatitis A or drink contaminated with hepatitis A virus. Grafton clinical laboratory results showed that this was not the case.
“My liver enzymes were very high and my bilirubin was really high. All signs of liver failure,” Grafton said. “My wife also broke down. At that point I thought it was liver cancer, pancreatic cancer, etc.”
That Friday, less than a week after his symptoms began, Grafton was admitted to Thomas Jefferson University Hospital in Philadelphia, where he was diagnosed.
“We found out there's something called drug-induced liver damage that comes from supplements.”
Increased liver damage rate
The liver is responsible for more than 500 functions in the human body, including filtering harmful substances from the blood. The liver of some people will metabolize toxins more slowly than others, but if there are too many certain drugs, even the healthiest liver will be overwhelmed.
For example, if consumed in excess, acetaminophen is the active ingredient in Tylenol and is one of the most common causes of drug-induced liver damage, also known as toxic hepatitis. Medicines are not simply the cause. Herbs and dietary supplements are causing liver damage.
From 1995 to 2020, a 2022 study of Journal Liver Transplants showed an eight-fold increase in supplement-related liver failure requiring US patients to be placed on waiting lists for transplants. Furthermore, a 2017 review in the Journal Hepatology found that 20% of liver toxic cases nationwide are linked to herbs and dietary supplements. The authors said that it is difficult to identify which components are responsible, as “multi-liation dietary supplements” have caused the majority of these cases.
While dietary supplements usually contain nutrients such as vitamins, minerals and amino acids from various sources such as fish oil, herbal supplements are a subset of dietary supplements made up of plant-based ingredients.
Liver damage linked to supplements is rare. It's unknown what's rare.
What is known is why the number of cases is on the rise. More Americans are taking supplements. A 2024 survey by the Responsible Nutrition Council, an industry association representing the dietary supplement and functional food industry, employs as many as three adults in four people aged 18 and older. Four in five users said they prefer supplements over prescription or over-the-counter medications.
In comparison, a 2017-2018 National Health and Nutrition Survey survey showed that 58% of adults aged 20 and older had used dietary supplements in the past 30 days.
“I think people think these are safe,” said Dr. Dina Hallegor de Marzio, Jefferson's health liver specialist who treated Grafton. “I don't think we realize that one reason people taking these are seen for their health or to supplement their health is that they are real risks here.”
Grafton was one such consumer. The fathers of five became health-sensitive when they attacked 50, and went to the gym to launch supplement regimens containing fenugreek, DHEA, ashwagandha, L-carnitine and nitric oxide. He continued his cocktail for years, for years. About a month before he got sick, Grafton added turmeric pills to the mix, with the goal of reducing inflammation.
Grafton then said he saw social media promotions and helped him drive the health crisis.
Ironically, he purchased some of the turmeric-based liquid supplements that were promoted to support long-term liver health. Similar products are widely available.
“The overall push with that is that you're getting a very high concentrated dose of turmeric and dandelion root and milk thistle that you've always known from my medical past,” Grafton said. “It all sounded good… I thought I'd dig enough.”
He got sick within a week of adding liquid supplements to his routine.
Grafton stopped turmeric pills the day he started using turmeric drinks, but Hallego Ademarzio said turmeric overload is likely to cause liver damage. It wasn't just the drink was super concentrated. The tablets contained 2,250 mg of curcumin. This is a substance that comes from the roots of turmeric plants. The tablets also contain black pepper extract, and Hallegor de Marzio warned that the increase in absorption would be doubled.
“When cooked with turmeric, it might be really safe. But some of the supplements are now 2,000 mg plus and are very high doses of turmeric,” she said. Coupled with the black pepper, “The liver needs to break down that supplement, but it can really get sick.”
The supplement spectrum includes everything from powders that claim to promote muscle growth to gummies that promise to reduce stress. When it comes to herbal supplements, nature isn't necessarily better or safer, said Harlegoua de Marzio.
“That's what I've always heard from patients: 'Oh, I want something natural' – the fear that prescription drugs are not safe,” she says, adding that they had undergone rigorous clinical trials while the prescription was at their own risk.
Supplements are not subject to the same pre-indoor test.
According to a study published last year in JAMA Network Open, turmeric is the most commonly consumed in the United States of all herbal ingredients linked to toxic hepatitis. It is followed by green tea extracts, ashwagandha, garcinia Cambodia, red yeast rice and black cohosh.
The study states that around 15.6 million Americans have taken supplements that contain at least one of these six plants. Most people reported doing so themselves, not under the advice of a doctor.
Prescription drugs are strictly regulated, making them more easily quantified. It is difficult to determine how many people consume supplements that ingredients can cause liver damage. The goal of Jama Network Open Research was to capture this size, co-author Dr. Robert Fontana, a professor of internal medicine at the University of Michigan School of Medicine.
“It's important for other doctors to know, and it's important for the public to know,” Fontana said. “The denominator of usage has risen.”
Fontana and Halegoua-de Marzio are part of the Drug-Induced Liver Injury Network, a research group supported by the National Diabetes and Gastrointestinal Diseases and Kidney Diseases, which is part of the National Institutes of Health. Since the program's inception in 2004, more than 1,800 patients have been enrolled, with 19% of cases linked to supplements.
Previous studies estimate that the US sees 44,000 liver damages related to medications and supplements each year, including 2,700 deaths. Fontana said the actual incidence is likely to be high. Symptoms of liver failure may be ambiguous, so some people may not be aware of the condition. People who seek natural treatment in the form of supplements may be wary of seeing a doctor. Others may be embarrassed about accidentally hurting themselves, Fontana said. The plant users of his 2024 study were older than the non-users, wealthy and educated.
“When you're a patient, you're like, 'Why did this happen to me?”,” Fontana said. “What do you mean, is this not safe?”
FDA does not monitor the safety of supplements prior to sales
For Joan Slavin, a registered dietitian and professor at the University of Minnesota's Faculty of Food Science and Nutrition, consumer education on supplement risk and reward is important.
“We only know human data if something goes wrong,” she said.
The Food and Drug Administration maintains a searchable database of recalls, market drawers and safety alerts, but it is not possible to consider supplements for safety or efficacy before reaching store shelves. Once they come to the market, agents have the authority to punish “adulterior or misbranded” products. This is thanks to the 1994 Nutrition Supplement Health and Education Act, which limited the scope of the FDA. The number of supplements on sale today is almost 20 times more than 30 years ago.
Consuming supplements are risky, the FDA warns.
“Dutch supplements may contain ingredients that have a strong effect on the body, whether natural or plant-based,” the agency said in a statement from NBC News. “Adverse events are more likely to occur when consumers take supplements at high doses, take multiple supplements, or take supplements in place of or in place of medication.”
According to the Responsible Nutrition Council (CRN), dietary supplements cannot make claims regarding the prevention, diagnosis, mitigation or treatment of disease.
“Dietary supplements can't cure your cold. They can't say they can prevent your Alzheimer's disease or cancer,” said Steve Mster, CRN's president and CEO. “If (such) products are there, it's blatantly illegal.”
Nutritional supplements have their locations
In short, he said the supplements are aimed at healthy people who are trying to stay healthy.
Everyone should ideally get all the nutrients through a balanced diet, but Slabin said he is aware that dietary supplements have their own place. For example, those who don't eat lean meat may need to look for alternative sources of iron.
“The supplements are certainly fine,” she said. “But it's not a global public health standard, it's a separate basis.”
According to Slabin, it's easy to monitor how many vitamins or mineral supplements are taken every day.
The Federal Bureau of Nutrition Supplements has established daily limits for nutrients, from vitamin A to zinc, which vary depending on age and gender. For example, calcium has a limit of 2,000 mg per day for adults over the age of 51.
Herbal supplements do not have such boundaries and are not well studied.
“Everything can be toxic in a certain amount,” said Andrea Wong, senior vice president of CRN science and regulatory affairs. “It's up to the manufacturer and researcher to look at these ingredients to determine the useful amounts. Also, look at the amounts that begin to look at the amounts of evidence of toxicity.”
She said it's important to let your doctor know about supplements you're taking or starting. Some supplements may be unsafe for people who interfere with prescription medications and each other or have certain medical conditions. For example, the FDA advises taking any combination of aspirin, vitamin E, or ginkgo biloba, a formulated warfarin or herbal supplement. All of these are blood thinners and can increase the risk of stroke or internal bleeding.
According to Fontana, some people are susceptible to supplemental-induced liver damage and genetically susceptible.
“That means there's a biological basis for why they're one in 1,000 people and one in 10,000 people got into trouble by taking this,” Fontana said of the supplements. “The same applies to prescription drugs. We are finding genetic connections.”
The Federal Livertox database is a free tool that highlights medications and supplements related to liver damage.
The liver is usually a tolerant organ, Fontana said.
Grafton was. His hospitalization was short and he said his blood tests returned to normal within weeks of stopping supplements. Additional tests revealed that there was no permanent damage to his liver.
He says he has a new lease in his life and resumes his health kick with one notable exception.
“I don't take any supplements at all.”
