crawford_2024_oi_240338_1713544689.0795

Original Investigation | Public Health
Label Accuracy of Weight Loss Dietary Supplements Marketed Online

With Military Discounts
Cindy Crawford, BA; Bharathi Avula, PhD; Andrea T. Lindsey, MS; Kumar Katragunta, PhD; Ikhlas A. Khan, PhD; Patricia A. Deuster, PhD
Abstract Key Points

Question Are select dietary
IMPORTANCE Dietary supplements for weight loss, among the most popular supplement products
supplements marketed for weight loss
on the market, are promoted not only for losing weight and shedding fat, but also for added benefits
that offer military discounts accurately
of energy and performance, all packed into 1 capsule with multiple combinations of ingredients.
labeled according to the Supplement
Fraudulent marketing of weight loss supplements, some with exaggerated claims, some that are
Facts listed ingredients on
potentially dangerous, and some that contain illegal ingredients, is ever present, especially through
product labels?
online sources, where multiple manufacturers target service members by offering military discounts.
Findings This case series study
OBJECTIVES To examine whether select dietary supplements marketed online for weight loss from analyzed 30 dietary supplement
companies advertising military discounts are accurately labeled according to the Supplement Facts products purchased from online
listed ingredients, whether they contain any ingredients prohibited for use in the military, and to companies advertising military
qualitatively describe the products’ label claims. discounts for products with claims about
weight loss. Twenty-five had inaccurate
DESIGN, SETTING, AND PARTICIPANTS In this case series, 30 dietary supplement products labels, 24 were misbranded, 7 had
marketed for weight loss were selected and purchased in June 2023 from 12 online companies hidden components detected, and 10
advertising military discounts. Data were analyzed from July to August 2023. contained substances prohibited for
military use.
MAIN OUTCOMES AND MEASURES Liquid chromatography-mass spectrometry was used to verify
Meaning These findings suggest that
whether products were accurately labeled according to the Supplement Facts listed ingredients and
predatory marketing and low quality of
whether they contained any substances on the DoD Prohibited Dietary Supplement Ingredients List.
weight loss supplements pose a threat
A separate analysis was conducted to describe product label claims by using the Operation
to military members and the public.
Supplement Safety (OPSS) Risk Assessment Scorecard.
RESULTS Of the 30 products tested, analysis showed that 25 had inaccurate labels. Of these, 24 had + Supplemental content
ingredients listed on the label that were not detected (misbranded); 7 had hidden components not Author affiliations and article information are
present on the label, some of which would be considered adulterated; and 10 had substances on the listed at the end of this article.
DoD Prohibited Dietary Supplement Ingredients List either on or hidden from the label. All products
were rated as risky when applying the OPSS Scorecard.
CONCLUSIONS AND RELEVANCE In this case series study, the majority of products had inaccurate
labels. Some were misbranded, others would be considered adulterated with ingredients not allowed
in dietary supplements, and some contained ingredients prohibited for use in the military.
JAMA Network Open. 2024;7(5):e249131. doi:10.1001/jamanetworkopen.2024.9131
Introduction
The global market for weight loss dietary supplements is estimated at US $43.9 billion in 2022 and
projected to rise to US $135.7 billion by 2030.1 Losing body weight is one of the top reasons for
dietary supplement use.2,3 The demand for these supplements is ever-present as people attempt to
take control of their own health and pursue healthy lifestyles, now more than ever.4,5 The growing
Open Access. This is an open access article distributed under the terms of the CC-BY License.
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JAMA Network Open | Public Health Label Accuracy of Weight Loss Dietary Supplements Marketed Online With Military Discounts
obesity concern is one factor associated with the demand for these products. However, the
advertising market has also shifted toward more holistic solutions offered by weight loss products,
with the added benefit of not only losing weight and shedding fat, but also building lean muscle and
enhancing energy and performance. Many different ingredients are packed into one pill with various
combinations to include vitamins, minerals, herbal extracts, and purportedly natural stimulants. This
strategy is likely to rapidly expand the growth opportunities for the market6; with service members
a prime target for the industry. In fact, surveys have shown that service members use more dietary
supplements than civilians and that their use of these combination products has increased in
recent years.7-9
Misinformation surrounding dietary supplements is common as individuals often obtain
information through social media channels, peer-to-peer communication, and other online sources,
which are not necessarily evidence-based or trustworthy for making informed decisions.10,11
According to a Council for Responsible Nutrition report, most Americans believe the dietary
supplement industry is trustworthy (77% of all US adults and 84% of supplement users) and 85% are
confident in the safety and quality of supplements overall.12-14 People tend to mistakenly believe that
dietary supplements have been declared safe and effective by the Food and Drug Administration
(FDA) if they are available for purchase in stores and online, despite a body of research showing that
weight loss products are often misbranded, contaminated, or even adulterated with illegal
ingredients.15-20 These dietary supplement products have been associated with adverse events such
as stroke, hepatoxicity, and even death.20-27 The most recent statistics from 2004 to 2013 showed
that dietary supplements were associated with an estimated 23 000 emergency department visits
each year and many were due to products marketed as weight loss.28 It is unknown what these
statistics are today. In addition, the FDA hosts a Weight Loss Tainted Products database, and has
identified over 100 weight loss dietary supplements containing hidden ingredients, such as blood
pressure medications, seizure medications, and/or drugs not approved in the US.29 Unfortunately,
the FDA cannot test all weight loss products that enter the market, so the products identified by the
FDA likely constitute only a small fraction of the potentially dangerous products available to
consumers.
Service members may face serious consequences beyond exposure to a potential serious
adverse health effect or a resulting performance decrement, such as the risk of positive drug tests,
which could jeopardize their military careers if they mistakenly take a product that contains a drug
(prescription or unapproved) or other substance prohibited for use.26,30 Yet, fraudulent marketing of
weight loss products—some with exaggerated claims, some that are potentially dangerous, and some
containing illegal ingredients—continues, especially through online sources. Some sources even
target service members through offering military discounts. Service members need to know that the
weight loss products they access through online sources are of high quality.
The purpose of this case series study was to analyze and qualitatively describe select weight loss
dietary supplement products being marketed online from companies specifically advertising military
discounts. Funding allowed for the selection of 30 products in total. Products were tested to assess
quality and verify whether they were accurately labeled according to the Supplement Facts listed
ingredients and identify any prohibited ingredients contained in products according to the DoD
Prohibited Dietary Supplement Ingredients List (DoD Prohibited List).31 The Operation Supplement
Safety (OPSS) Risk Assessment Scorecard criteria32,33 was used as a screening tool to assess a
product’s relative safety potential and to mitigate risk based solely upon the product label claims.
Methods
Thirty dietary supplement products were selected and purchased over the internet for this case
series with claims about weight loss from various online shops that advertise military discounts for
dietary supplements in June, 2023. First, the primary author (C.C.) signed out of Google and cleared
cache, cookies, and browser history. From the Chrome browser, “weight loss supplements military

discount” was entered into Google search engine. Next, hyperlinks that appeared on the results page,
contained the text of “military discount,” and led directly to a company website selling dietary
supplement products were recorded in the order of first appearance. The author selected up to 5
weight loss products from each company’s website (going down the list of results), until a total of 30
products were identified for purchase from 12 distinct companies. If a specific company had more
than 5 weight loss products available for purchase, the author filtered the products advertised as
best sellers, highest ratings, or narrowed the search to a goal within weight loss (fat burning) if
available. The author did not examine the claims or Supplement Facts labels as part of the selection
of products. In accordance with the Common Rule, the authors did not seek institutional review
board approval since this case series evaluated products, not patients. The reporting guideline for
case series and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)
reporting guideline were followed, as applicable to case series.34
One sample of each selected product was purchased over the internet and sent to the
University of Mississippi’s National Center for Natural Products Research for product analysis. Liquid
chromatography-mass spectrometry was used to determine the quality of the 30 dietary
supplement products.19,35,36 All ingredients listed on the label and any hidden compounds were
analyzed except for lipids and minerals. The list of ingredients detected through analysis for each
product was compared with the ingredients on the product’s Supplement Facts label to determine
whether the product’s label was accurate. Full methods are detailed in the eMethods in
Supplement 1.
Data Analysis
A separate qualitative analysis was conducted by the authors not affiliated with University of
Mississippi by using the set of questions from the OPSS Scorecard33 in parallel with the testing (see
eMethods in Supplement 1). This scorecard was developed as an educational tool to help consumers
learn about a product by carefully reading the label and quickly assessing whether it might be risky
based solely upon the label claims.32,36 Authors read the labels of the products and answered 7
questions about topics such as third-party certification and proprietary blends. A score of 4 or more
is “likely okay/less risky;” less than 4 is considered a “no-go/risky.” If a product contained any
ingredients on the DoD Prohibited List,31 it was also a “no-go.” All analyses were conducted in Excel
2019 (Microsoft) in duplicate by 2 authors (A.T.L. and C.C.). Any discrepancies were resolved through
discussion and consensus. Data were analyzed from July to August 2023.
Results
Product Analysis
Twenty-five of the 30 products (83%) had inaccurate labels confirmed through product testing.
Twenty-four (80%) had ingredients listed on the label that were not detected through analysis, such
that their labels were misbranded. Ingredients not detected from products ranged from 1 (5%) to 4
(44%) missing from any single product. Not detected ingredients included plant extracts such as
bitter orange whole plant, hoodia Chinese extract, Huperzia serrata extract, kola nut, raspberry
ketones, Rauwolfia, and white willow bark extract. Seven products (23%) contained additional
hidden components detected that were not present on the label. Hidden compounds consisted of 1,4
DMAA, butyrylcarnitine, epigallocatechin gallate (EGCG), methylsynephrine (oxilofrine), N-methyl-
β-phenylethylamine, N-phenethyl dimethyl amine (N, N-DMPEA), and yohimbine. One product
claimed saffron but Carthamus tinctorius flower was detected instead, a less expensive substitute for
saffron. Six products (20%) were both mislabeled and had hidden components detected as not
present on the label (Table).
Ten of the 30 products (30%) contained ingredients listed on the DoD Prohibited List31 either
on or hidden from the label. Prohibited ingredients confirmed through product testing ranged from 1
to 7 from any single product and consisted of the following: 2-aminoisoheptane HCl (DMHA), 1,4

DMAA, Acacia rigidula, ephedra extract listed on labels but detected as ephedrine, methylephedrine
and pseudoephedrine, higenamine, hordenine, isopropylnorsynephrine, methylsynephrine,
octopamine, and vinpocetine. An unapproved drug, 7-[2-hydroxy-3-(2-hydroxyethyl-methylamino)
Table. Product Analysis of 30 Weight Loss Dietary Supplements Tested

No. of Ingredients on
ingredients Product label label analyzable Additional or hidden
presented on verification but not detected, components detected
Product No. product label accuracy No. (%)a not present on the label DoD prohibited ingredients detected WADA S6 stimulants detected
1 14 Accurate None None None None
2 14 Not accurate 1 (8) None None None
4 15 Not accurate 3 (21) None Hordenine Hydrochloride;b None
Vinpocetine;b Higenamine
Hydrochloride;b 2-Aminoisoheptane
Hydrochloride (DMHA)b
5 10 Not accurate 1 (10) None Octopamine Hydrochloride;b 1,4 N-Phenethyl dimethyl amine
DMAAb (N,N-DMPEA); β-Phenylethylamine
Hydrochloride (β-PEA)
6 12 Accurate None None Isopropylnorsynephrineb None
8 14 Not accurate None Butyrylcarnitine Hordenine Hydrochlorideb None
9 12 Not accurate 3 (25) Yohimbine None None
11 11 Accurate None None Higenamine Hydrochloride;b N-Phenethyl dimethyl amine
Hordenine Hydrochloride;b (N,N-DMPEA)
N-Isopropylnorsynephrineb
13 19 Not accurate 2 (11) None Higenamine Hydrochloride;b β-phenylethylamine (β-PEA)
Isopropylnorsynephrineb
16 14 Not accurate 1 (9) None None N-Phenethyl dimethyl amine
(N,N-DMPEA)
19 10 Not accurate 1 (11) Carthamus tinctorius flower None None
22 15 Not accurate 1 (7) 1,4 DMAA Ephedrine, methylephedrine and Phenylethylamine (β-PEA);
pseudoephedrine;b N-phenethyl dimethylamine
Methylsynephrine;b (N,N-DMPEA); N-methyl-β-
2-Aminoisoheptane Hydrochloride phenylethlamine
(DMHA);b 1,4 DMAAc
23 9 Not accurate 2 (22) EGCG 7-[2-hydroxy-3-(2- hydroxyethyl- 2-Phenylethan-1-amine
methylamino)propyl]-
1,3-dimethylpurine-2,6- dioneb
24 11 Not accurate 1 (9) 1,4 DMAA 2-Aminoisoheptane Hydrochloride Phenylethylamine (β-PEA);
(DMHA);b ephedrine, methylephedrine N-phenethyl dimethylamine
and pseudoephedrine;b (N,N-DMPEA); N-methyl-β-
Methylsynephrine;b Higenamine phenylethlamine
Hydrochloride;b 1,4 DMAAc
26 14 Not accurate 3 (21) N -methyl-β- Ephedrine and pseudoephedrine, N-methyl-β-phenylethylamine;
phenylethylamine methylephedrine;b Acacia rigidula;b N-Phenethyl dimethyl amine
Methylsynephrine (Oxilofrine) Methylsynephrine (Oxilofrine)c (N, N-DMPEA)
N-Phenethyl dimethyl amine
(N, N-DMPEA)
29 10 Not accurate 4 (44) None None Phenylethylamine Hydrochloride
a
The number of analyzable ingredients differs from the number of ingredients presented on the product label due to the instrumentation limits for analysis. Elements including zinc,
selenium, calcium, chromium, manganese, magnesium, potassium, sodium, and so forth are not able to be analyzed as well as fat soluble vitamins, including Vitamin D3.
b
Ingredient appeared on label.
c
Ingredient did not appear on label.

propyl]-1,3-dimethylpurine-2,6-dione, known as Xanthinol, was listed on a label and detected in

1 product.37
Nine products contained stimulants of phenethylamine and its derivatives, prohibited in sport
according to the World Anti-Doping Agency38 (WADA) including: β-phenylethylamine HCl (β-PEA),
N-phenethyl dimethyl amine (N, N-DMPEA, N, N -dimethylphenylethylamine), and N-methyl-β-
phenethylamine. Seven products had ingredients on both the DoD Prohibited List and the WADA List
(S6 stimulants), with 2 to 10 of these ingredients in any one of the 7 products.
Product Descriptions
The 12 online stores offered military discounts for up to 20% off dietary supplement products, with
language such as, “we’re proud to offer…to salute military personnel,” “we offer discounts as a way to
say thanks,” and “to thank you for your service.” The 30 weight loss products not only had claims
about “crushing” weight loss and shedding fat, but additional claims for enhanced energy, mood, and
mental clarity all in one pill. Examples of claims made on product bottles were: “shed fat while
building lean muscle,” “also gives you energy, heightened mood,” “combat mental fatigue,” “destroy
body fat,” “without the jitters,” and “fat incinerating best friend.” Nineteen of the products also had
additional scientific-sounding claims such as, “clinically effective,” “clinically proven,” “scientifically
formulated,” “super-dosed, potent combination,” “maximum strength,” and “scientifically researched
and proven ingredients.” One product was advertised as made specifically for the “elite athlete.” The
cost of these products ranged from $19.99 to $59.99 with a median (IQR) cost of $39.99 ($14.10) for a
30-day supply.
No product had an independent, third-party certification seal on the label to show that it had
been tested by an independent laboratory for quality and/or contaminants, such as BSCG Certified
Drug Free, NSF Certified Sport, LGC’s Informed Sport, or USP (United States Pharmacopeia).
Fourteen of the products had a Good Manufacturing Practice (GMP) seal or GMP text on their
product label. GMP is an FDA requirement, but such seals should not be mistaken as indications of
safety, quality, or federal approval. Still other products had seals stating “tested for purity” or “lab
tested,” but not associated with any known independent, third-party organization.
The number of ingredients present on the Supplement Facts labels ranged from 8 to 29 (mean
[SD], 14.03 [5.18]) on any single product. Fourteen products consisted of proprietary blends,
matrices, or complexes, where the consumer is not privy to the amount of each ingredient(s)
contained in the proprietary blend, thus the actual content of the entire product was unclear.
Twenty-one of the 30 products listed caffeine on Supplement Facts labels as either: (a) contained in
a proprietary blend (where it was not possible to know the amount) or (b) in amounts over 200 mg
per serving. Besides caffeine, which was contained in all products, other common ingredients listed
on labels included green tea extract (17 products), yohimbe/yohimbine (15 products), black pepper
(13 products), L-tyrosine (12 products), grains of paradise (6-paradol) (12 products), acetyl-L-carnitine
(10 products), huperzine A (10 products), Citrus aurantium [standardized for p-synephrine] or
synephrine (10 products), Rauwolfia/rauwolscine (8 products), and raspberry ketones (7 products).
In addition, all products were rated as “no-go/risky” according to the OPSS Scorecard.
Discussion
In this study, we analyzed 30 weight loss dietary supplement products advertised with military
discounts online. Our analyses revealed that 25 of the 30 products tested for quality had inaccurate
labels: 24 had ingredients listed on the label but not detected in the product (misbranded), 7 had
hidden components not present on the label, and 10 contained ingredients on the DoD Prohibited
List, either on the label or hidden from the label. All products were rated as risky according to the
OPSS Scorecard. In addition, no product was third-party certified to show that the product had been
tested and verified for its quality to mitigate risk.39

The predatory marketing to service members and low quality of dietary supplements promoted
for weight loss pose a threat to military members and the public. Phrases such as, “We’re proud to
offer …,” “… to salute our Service Members,” “to help you take your fitness to the next level,” and “to
empower and support our military,” are of concern because these products might actually threaten
the health, readiness, performance, and careers of those who volunteer to defend our country.
Beyond the dangers to one’s health and career, the cost of these products may create financial
burdens on individuals, often without a positive return on investment, and may contribute to a
financial readiness issue for military families. Overall, the findings from this study are problematic and
require solutions. As of now, the only way to know the actual ingredients in a product is to ensure it
has been tested by an independent third-party organization.
Of concern was the fact that most of the products contained multiple ingredients, and multiple
combinations with stimulant effects. It is unknown how these stimulant and other ingredients
interact with each other, not to mention current use of over-the-counter and/or prescription
medications or additional dietary supplement products. Also, some products listed herbal/botanical
extracts containing compounds such as methylsynephrine, N-methyl-β-phenylethylamine,
N,N-dimethylphenylethylamine, where the plant authenticity could not be verified. In fact,
adulteration of botanicals to boost profits has occurred with unintentional or intentional substitution
or dilution with undisclosed lower-cost ingredients.40,41 These issues present clear health risks for all
consumers.
Of note, the DoD has taken a number of actions to protect personnel from problematic
ingredients that appear in marketed supplements.42 For example, in 2002, the DoD banned the sale
of products containing ephedrine alkaloids from military commissaries worldwide. The FDA banned
ephedra in April 2004. In 2011, after many adverse events and several deaths were linked with the
use of products containing a synthetic ingredient, DMAA, the DoD restricted its sale on bases.
Although the FDA banned the ingredient in April 2013, our analyses reveal products still contain both
DMAA and ephedra alkaloids, with the ingredients sometimes still listed right on the labels.
In January 2012, the Assistant Secretary for Health Affairs requested a DoD-wide educational
campaign on dietary supplements, OPSS, to increase awareness within the DoD community about
potential health risks and how to choose safe dietary supplements.43 Due to the frequency of dietary
supplement use by service members, an overall DoD policy was developed as guidance to ensure
safe dietary supplement use and minimize risks to the force. In 2022, the DoD issued Instruction
6130.06, Use of Dietary Supplements in the DoD, in which the DoD establishes OPSS as the go-to
program for dietary supplements.44 It states that OPSS will maintain the official DoD Prohibited List,
and provide educational training on the topic of dietary supplements for all service members and
those who provide health-related services to the military. OPSS provides the tools and resources to
help users make informed decisions about dietary supplements and actively educates on this topic
with health care providers, allied health professionals, and all service members. More education as
well as other solutions are needed to address this public health issue. It’s imperative that our service
members remain healthy and ready to serve, and not be put in harm’s way with predatory marketing.
Limitations
This analysis has limitations worth noting. First, these 30 products are not meant to be
representative of all weight loss dietary supplement products found online, nor do they represent all
product advertisements targeted toward service members with military discounts. Second, fat
soluble vitamins including Vitamin A/D/E/K, lipids (oils), and elements cannot be detected and/or
have low sensitivity using liquid chromatography-mass spectrometry, and thus those ingredients
listed on product labels were not analyzable. In addition, the analysis was qualitative in nature in that
the amount of each ingredient detected was outside the scope of the project and thus the authors
cannot comment on whether the amount detected of any ingredient matches the labeled amount for
any one ingredient.

Conclusions
In summary, our analysis does suggest that predatory marketing and access to low-quality dietary
supplements is present through online sources. The majority of products analyzed had inaccurate
labels, some were misbranded, some would be considered adulterated with ingredients not allowed
in dietary supplements, and some contained ingredients prohibited for use in the military.
ARTICLE INFORMATION
Accepted for Publication: March 1, 2024.
Published: May 1, 2024. doi:10.1001/jamanetworkopen.2024.9131
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2024 Crawford C
et al. JAMA Network Open.
Corresponding Author: Patricia A. Deuster, PhD, MPH, FACSM, Consortium for Health and Military Performance,
Department of Military & Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services
University, 4301 Jones Bridge Rd, Bethesda, MD 20814 (patricia.deuster@usuhs.edu).
Author Affiliations: Consortium for Health and Military Performance, Department of Military and Emergency
Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, Maryland (Crawford,
Lindsey, Deuster); Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda,
Maryland (Crawford, Lindsey); National Center for Natural Products Research, School of Pharmacy, University of
Mississippi, University, Mississippi (Avula, Katragunta, Khan).
Author Contributions: Ms Crawford and Dr Avula had full access to all of the data in the study and take
responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Crawford, Avula, Lindsey, Khan, Deuster.
Acquisition, analysis, or interpretation of data: Crawford, Avula, Lindsey, Katragunta.
Drafting of the manuscript: Crawford, Avula, Lindsey, Katragunta, Deuster.
Critical review of the manuscript for important intellectual content: Avula, Lindsey, Khan, Deuster.
Statistical analysis: Crawford, Katragunta.
Obtained funding: Khan, Deuster.
Administrative, technical, or material support: Crawford, Lindsey.
Supervision: Deuster.
Conflict of Interest Disclosures: None reported.
Funding/Support: Funding for this work was provided by the Consortium for Health and Military Performance and
Operation Supplement Safety award number HU0001-23-2-0048.
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection,
management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and
decision to submit the manuscript for publication.
Disclaimer: The opinions and assertions expressed herein are those of the authors and do not reflect the official
policy or position of the Uniformed Services University or the Department of Defense. The contents of this
publication are the sole responsibility of the authors and do not necessarily reflect the views, opinions or policies
of The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc.
Data Sharing Statement: See Supplement 2.
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SUPPLEMENT 1.
eMethods.
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SUPPLEMENT 2.
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Original Investigation | Public Health

Label Accuracy of Weight Loss Dietary Supplements Marketed Online

Abstract Key Points

JAMA Network Open. 2024;7(5):e249131. doi:10.1001/jamanetworkopen.2024.9131

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Table. Product Analysis of 30 Weight Loss Dietary Supplements Tested

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propyl]-1,3-dimethylpurine-2,6-dione, known as Xanthinol, was listed on a label and detected in

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