Let us start by apologizing to the Bard and my 8th grade English teacher for the headline. It’s a good way to ask the question of how closely nutritional supplement companies can connect with the fast-moving world of social media. Should you Tweet about a new ingredient? What happens when an unidentified person posts that your product cured his illness? What if a customer posts online — with photos — evidence of an adverse reaction to your product?

The FDA will address these questions at a hearing Nov. 12-13 in Washington. The agency is soliciting comments in the Federal Register “to help guide FDA in making policy decisions on the promotion of human and animal prescription drugs and biologics and medical devices using the Internet and social media tools.”

Good luck, regulators. The techies who created Twitter, Facebook and their ilk cannot keep pace with technological and user-driven changes. That’s what happens when you put control in the hands of the people.

There is no crowdsourcing at the FDA, but the agency uses Twitter to release news on drugs and medical devices, and to announce recalls. Clearly, someone inside the FDA has a teenage son or daughter.

The FDA now recognizes that it is playing catch-up and writes in the Federal Registry that “special characteristics of Web 2.0 and other emerging technologies may require the agency to provide additional guidance to the industry on how the regulations should be applied.”

May require additional guidance? The agency must know that social media are spreading from computers to cell phones. The FDA’s alternative to writing rules is to dole them out through warning letters and the like. Guidelines would benefit everyone. The Federal Register is so last century, though. How about a Fan Page for suggestions?

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This is a tale of two types of weight-loss products and how the Food and Drug Administration had different responses to similar problems with them. The separate, but not equivalent treatment raises questions about how the FDA operates.

On Aug. 24, the FDA issued a statement about an ongoing safety review of orlistat based on reports of liver injury in people taking the weight-loss drug. It is marketed as the prescription drug Xenical and the over-the-counter medication Alli.

The FDA said it had received 32 reports of serious liver injury in patients taking orlistat between 1999 and 2008.  Of those cases, 27 required hospitalization and six resulted in liver failure.

Sound familiar? It should. On May 1, the FDA issued a warning about the danger of Hydroxycut based on 23 reported liver problems over seven years, including 16 hospitalizations. One person died in February 2007 after taking that weight-loss product.

That is where the stories diverge. For orlistat, the FDA is conducting a review because, “no definite association between liver injury and orlistat has been established at this time,” according to the release. “Consumers taking Xenical should continue to take it as prescribed, and those using over-the-counter Alli should continue to use the product as directed.”

In contrast, the FDA told consumers to stop immediately using Hydroxycut even though the agency acknowledged in a health hazard evaluation board report that “The Board does not know what ingredient(s) of Hydroxycut are responsible for producing liver toxicity. In addition, there is insufficient information to determine whether there is a dose-response effect between Hydroxycut ingestion and liver disease or whether its effects are cumulative over time.”

Despite a lack of direct evidence, the board concluded “that the ingestion of the dietary supplement, Hydroxycut, presents a severe potentially life-threatening hazard to some users.” The makers of Hydroxycut immediately ordered a recall.

What might the same health board members think about orlistat? It has caused liver injuries for a longer time period and has put more people in the hospital with similar ailments — jaundice and liver failure.

Does the FDA give greater weight to the patient death? If so, it seems to us that the product would have been recalled in 2007.

Is the difference the way the products are regulated? The FDA approved Xenical in 1999 and Alli in 2007. None of the ingredients in Hydroxycut were identified in the report as needing FDA review.

If the distinctions are not clear from a review of the facts, then what are we to expect the next time a weight-loss product is associated with health problems?

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Outside the industry, the viewpoints were more pragmatic. Scot Long, an exercise physiologist and professor from Mississippi, weighed in, writing: “Bottom line, do I think that Hydroxycut is an evil product? No. I think many people abused this product (taking too much) and some may have even had pre-existing medical conditions. Do I recommend it to my students, clients and friends? Of course not. I do think, however, that Iovate Health Sciences could have made a safer product. But it shouldn’t shoulder all the blame.”

Marion Nestle, author of “Food Politics,”  wrote in her San Francisco Chronicle column, “I freely concede that most supplement companies make reliable products, but without federal oversight how is anyone – even a store clerk – supposed to know which ones they are. Some clerks may know their business, but in my experience few think critically about the products they are selling and most appear to take the manufacturers’ words at face value.”

After a Hydroxycut recall article was posted on FitSugar.com, a commenter who goes by the name Mondaymoos offered this first-person experience : “I never took diet pills for the purpose of losing weight. Me, and a lot of other people in the military, used them as a tool to work 12 hour shifts and still go out and have a life afterwards without racking up massive calories in energy drinks and soda. Was it a healthy decision, probably not. Did it work? Definitely yes.”

Consumers seem to know that there are no magic diet pills and that abusing a product is probably harmful. Thus, rhetoric that casts the FDA — or a manufacturer — as hero or villain does not sway consumers. They would rather know the benefits and risks of a product, and make an informed choice based on that.

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When it comes to dietary supplements, it’s like the Wild West, and the bad guys know they don’t have to take the sheriff seriously.

Industry and consumer voices are split in their interpretations of a GAO report on how the FDA should regulate dietary supplements. All sides agree that the FDA needs more resources, but they are divided on how best to ensure public safety. The Booster Shots blog run by the Los Angeles Times highlighted these conclusions from the report:

• Some companies that make herbal products are not required to identify themselves as dietary supplement companies.
• Manufacturers are required to report only serious adverse events.
• The FDA has few resources for oversight.
• The FDA lacks the power to remove a product from the market.

The Council for Responsible Nutrition, which represents dietary supplement manufacturers and ingredient suppliers, agreed with parts of the report, saying in a press release that the FDA needs additional resources.  But the trade group said, “We strongly believe, however, that these resources — including agency staff time and funding — should be focused on enforcing the current laws and regulations.”

The Natural Products Association disagreed with the GAO report on several counts. Association CEO David Seckman said in a press release that the FDA:

• Has a great deal of information about individual dietary supplement products and their manufacturers.
• Has sufficient power to remove products from the marketplace.
• Should receive reports only on serious adverse events, not all events.

On the other side, the Center for Science in the Public Interest, interpreted the report as showing the FDA could not effectively monitor the industry. Here’s what CSPI legal affairs director Bruce Silverglade said, “When it comes to dietary supplements, it’s like the Wild West, and the bad guys know they don’t have to take the sheriff seriously. … The supplement industry operates in a gray area where the loopholes loom larger than the law. Congress should close those loopholes by requiring that ingredients be reviewed for safety and effectiveness and that cautionary information appear on product labels.”

There are broad divides on several issues:

• The GAO report calls for reporting all adverse events, but the CRN and NPA want the current rules on reporting just serious events.
• The CSPI wants tighter limits on labeling and claims. The industry groups say that rules are sufficient.

The NPA and CSPI do agree on having the FDA clarify when it thinks products such as teas and energy drinks should be marketed as conventional foods and when they should be listed as dietary supplements.

What’s next? In the CSPI release, Rep. Henry A. Waxman, D-Calif., who was one of the House members who commissioned the report, lamented the lack of resources at the FDA. But he didn’t call for boosting the agency’s budget. And that leaves industry and the federal regulator where they were before.

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Although Section 403(y) of the Federal Food, Drug, and Cosmetic Act (FFD&C Act) (21 U.S.C. 343(y), does not require a dietary supplement label to include anything other than a domestic address or phone number for the responsible person, the FDA recommends that the label also bear a clear, prominent statement informing consumers that the domestic address or phone number is for reporting serious adverse events associated with use of the product.

Under section 3(d)(2) of the Dietary Supplement and Nonprescription Drug Consumer Protection Act, the labeling requirements of section 403(y) ofthe FFD&C Act apply to all dietary supplements labeled on or after December 22, 2007. Therefore, these labeling requirements are already in effect. However, FDA intends to exercise enforcement discretion for the new labeling requirements until January 1, 2010.

FDA would have no objection to a firm’s combining the recommended statement with language informing consumers that the domestic address or phone number on the label may also be used for other purposes, as long as the information provided is not false or misleading. For example, a dual-purpose label statement might be “To report a serious adverse event or obtain product information, contact. .. ” or other similar language.

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