MD, PhD, MAE, FMedSci, FRSB, FRCP, FRCPEd.

vitamin

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Dietary supplements are touted for cognitive protection, but supporting evidence is mixed. COSMOS-Mind tested whether daily administration of cocoa extract (containing 500 mg/day flavanols) versus placebo and a commercial multivitamin-mineral (MVM) versus placebo improved cognition in older women and men.

COSMOS-Mind, a large randomized two-by-two factorial 3-year trial, assessed cognition by telephone at baseline and annually. The primary outcome was a global cognition composite formed from mean standardized (z) scores (relative to baseline) from individual tests, including the Telephone Interview of Cognitive Status, Word List and Story Recall, Oral Trail-Making, Verbal Fluency, Number Span, and Digit Ordering. Using intention-to-treat, the primary endpoint was change in this composite with 3 years of cocoa extract use. The pre-specified secondary endpoint was change in the composite with 3 years of MVM supplementation. Treatment effects were also examined for executive function and memory composite scores, and in pre-specified subgroups at higher risk for cognitive decline.

A total of 2262 participants were enrolled (mean age = 73y; 60% women; 89% non-Hispanic White), and 92% completed the baseline and at least one annual assessment. Cocoa extract had no effect on global cognition (mean z-score = 0.03, 95% CI: -0.02 to 0.08; P = .28). Daily MVM supplementation, relative to placebo, resulted in a statistically significant benefit on global cognition (mean z = 0.07, 95% CI 0.02 to 0.12; P = .007), and this effect was most pronounced in participants with a history of cardiovascular disease (no history: 0.06, 95% CI 0.01 to 0.11; history: 0.14, 95% CI -0.02 to 0.31; interaction, nominal P = .01). Multivitamin-mineral benefits were also observed for memory and executive function. The cocoa extract by MVM group interaction was not significant for any of the cognitive composites.

The authors concluded that the Cocoa extract did not benefit cognition. However, COSMOS-Mind provides the first evidence from a large, long-term, pragmatic trial to support the potential efficacy of a MVM to improve cognition in older adults. Additional work is needed to confirm these findings in a more diverse cohort and to identify mechanisms to account for MVM effects.

This trial certainly has a few stunning features. For instance, its sample size was impressive and its follow-up period long. But it also has a few weak points. The study was conducted remotely via mail or telephone which means that compliance was impossible to control. Moreover, the outcome measures were subjective, and blinding was not checked. In addition, I fail to see a plausible mechanism of action. Most importantly, the generalizability of the results to the population at large seems questionable. It might make sense that older individuals many of whom might have low vitamin levels can profit from MVM. Whether this is also true for younger people who are well-nourished might be a different matter.

Many older adults commonly take multivitamin-multimineral (MVM) supplements to promote health. Yet, evidence on the use of daily MVMs on invasive cancer is limited. 

The objective of this study was therefore to determine if a daily MVM decreases total invasive cancer among older adults. For this purpose,  a team of researchers performed a randomized, double-blind, placebo-controlled, 2-by-2 factorial trial of a daily MVM and cocoa extract for prevention of cancer and cardiovascular disease (CVD) among 21,442 US adults (12,666 women aged ≥65 y and 8776 men aged ≥60 y) free of major CVD and recently diagnosed cancer. The intervention phase was from June 2015 through December 2020. This article reports on the MVM intervention.

Participants were randomly assigned to daily MVM or placebo. The primary outcome was total invasive cancer, excluding nonmelanoma skin cancer. Secondary outcomes included major site-specific cancers, total CVD, all-cause mortality, and total cancer risk among those with a baseline history of cancer.

During a median follow-up of 3.6 y, invasive cancer occurred in 518 participants in the MVM group and 535 participants in the placebo group (HR: 0.97; 95% CI: 0.86, 1.09; P = 0.57). No significant effect was observed of a daily MVM on breast cancer (HR: 1.06; 95% CI: 0.79, 1.42) or colorectal cancer (HR: 1.30; 95% CI: 0.80, 2.12). The researchers observed a protective effect of a daily MVM on lung cancer (HR: 0.62; 95% CI: 0.42, 0.92). The composite CVD outcome occurred in 429 participants in the MVM group and 437 participants in the placebo group (HR: 0.98; 95% CI: 0.86, 1.12). MVM use did not significantly affect all-cause mortality (HR: 0.93; 95% CI: 0.81, 1.08). There were no safety concerns.

The authors concluded that a daily MVM supplement, compared with placebo, did not significantly reduce the incidence of total cancer among older men and women. Future studies are needed to determine the effects of MVMs on other aging-related outcomes among older adults.

This is an excellent and important study with clear findings. Nevertheless, the authors insist that several limitations should be considered. First, the COSMOS intervention was relatively short to detect a potential small-to-moderate effect on cancer outcomes given the long duration of time typically required for nutritional interventions to potentially reduce cancer risk. Second, the secondary and exploratory analyses should be interpreted with caution, especially given an overall lack of effect of an MVM on the primary outcome of total invasive cancer. Third, the authors successfully leveraged existing cohorts with mass mailings to expedite recruitment and randomization of 21,442 participants into COSMOS. However, generalizability may be limited, with modest diversity of 10% non-Whites and 2.6% Hispanics plus healthy volunteer bias for participants willing and eligible to enroll in a mail-based clinical trial.

Traditional, complementary, and alternative medicine (TCAM) – as most of my readers know, I prefer the abbreviation SCAM for so-called alternative medicine – refers to a broad range of health practices and products typically not part of the ‘conventional medicine’ system. Its use is substantial among the general population. TCAM products and therapies may be used in addition to, or instead of, conventional medicine approaches, and some have been associated with adverse reactions or other harms.

The aims of this systematic review were to identify and examine recently published national studies globally on the prevalence of TCAM use in the general population, to review the research methods used in these studies, and to propose best practices for future studies exploring the prevalence of use of TCAM.

MEDLINE, Embase, CINAHL, PsycINFO, and AMED were searched to identify relevant studies published since 2010. Reports describing the prevalence of TCAM use in a national study among the general population were included. The quality of included studies was assessed using a risk of bias tool developed by Hoy et al. Relevant data were extracted and summarised.

Forty studies from 14 countries, comprising 21 national surveys and one cross-national survey, were included. Studies explored the use of TCAM products (e.g. herbal medicines), TCAM practitioners/therapies, or both. Included studies used different TCAM definitions, prevalence time frames and data collection tools, methods and analyses, thereby limiting comparability across studies. The reported prevalence of use of TCAM (products and/or practitioners/therapies) over the previous 12 months was 24–71.3%.

The authors concluded that the reported prevalence of use of TCAM (products and/or practitioners/therapies) is high, but may underestimate use. Published prevalence data varied considerably, at least in part because studies utilise different data collection tools, methods and operational definitions, limiting cross-study comparisons and study reproducibility. For best practice, comprehensive, detailed data on TCAM exposures are needed, and studies should report an operational definition (including the context of TCAM use, products/practices/therapies included and excluded), publish survey questions and describe the data-coding criteria and analysis approach used.

[Trends in prevalence of TCAM use by country for countries with at least two data collection waves from a nationally representative study. For data collected over several years (e.g. 2007–2009), the prevalence data are plotted at the end of the data collection period (e.g. 2009). Solid and perforated lines between consecutive points are for illustrative purposes only and are not intended to represent linearity. NHANES National Health and Nutrition Examination Survey, NHIS National Health and Interview Survey, SLAN Survey of Lifestyle, Attitudes and Nutrition.]

The review discloses that the prevalence reported across countries ranges from 24 to 71%. This huge variability is not very surprising; some of the many reasons for this phenomenon include:

  • different TCAM definitions,
  • different prevalence time frames,
  • different data collection tools,
  • different methods of analyzing the data.

Despite these problems, the information summarized in the review is fascinating in several respects. For me, the most interesting message here is this: the plethora of claims that SCAM use is increasing are not supported by sound evidence.

The US Food and Drug Administration created the Tainted Dietary Supplement Database in 2007 to identify dietary supplements adulterated with active pharmaceutical ingredients (APIs). This article compared API adulterations in dietary supplements from the 10-year time period of 2007 through 2016 to the most recent 5-year period of 2017 through 2021. Its findings are alarming:

  • From 2007 through 2021, 1068 unique products were found to be adulterated with APIs.
  • Sexual enhancement and weight-loss dietary supplements are the most common products adulterated with APIs.
  • Phosphodiesterase-5 inhibitors are commonly included in sexual enhancement dietary supplements.
  • A single product can include up to 5 APIs.
  • Sibutramine, a drug removed from the market due to cardiovascular adverse events, is the most included adulterant API in weight loss products.
  • Sibutramine analogues, phenolphthalein (which was removed from the US market because of cancer risk), and fluoxetine were also included.
  • Muscle-building dietary supplements were commonly adulterated before 2016, but since 2017 no additional adulterated products have been identified.

The authors concluded that the lack of disclosure of APIs in dietary supplements, circumventing the normal procedure with clinician oversight of prescription drug use, and the use of APIs that are banned by the Food and Drug Administration or used in combinations that were never studied are important health risks for consumers.

The problem of adulterated supplements is by no means new. A similar review published 4 years ago already warned that “active pharmaceuticals continue to be identified in dietary supplements, especially those marketed for sexual enhancement or weight loss, even after FDA warnings. The drug ingredients in these dietary supplements have the potential to cause serious adverse health effects owing to accidental misuse, overuse, or interaction with other medications, underlying health conditions, or other pharmaceuticals within the supplement.”

These papers relate to the US where supplement use is highly prevalent. The harm done by adulterated products is thus huge. If we focus on Chinese or Ayurvedic supplements, the problem might even be more serious. In 2002, my own review concluded that adulteration of Chinese herbal medicines with synthetic drugs is a potentially serious problem which needs to be addressed by adequate regulatory measures. Twenty years later, we seem to be still waiting for effective regulations that protect the consumer.

Progress in medicine, they say, is made funeral by funeral!

 

Due to polypharmacy combined with the rising popularity of so-called alternative medicines (SCAM), oncology patients are at particular risk of drug-drug interactions (DDI) or herb-drug interactions (HDI). Caution is therefore indicated.

The aims of this study were to assess DDI and HDI in outpatients taking oral anticancer drugs.

All prescribed and non-prescribed medications, including SCAM, were prospectively collected by hospital pharmacists during a structured interview with the patient. DDI and HDI were analyzed using four interaction software programs: Thériaque®, Drugs.com®, Hédrine, and Memorial Sloan Kettering Cancer Center (MSKCC) database. All detected interactions were characterized by severity, risk, and action mechanism. The need for pharmaceutical intervention to modify drug use was determined on a case-by-case basis.

294 patients were included, with a mean age of 67 years. The median number of chronic drugs per patient was 8 [1-29] and 55% of patients used at least one SCAM. At least 0ne interaction was found for 267 patients (90.8%): 263 (89.4%) with DDI, 68 (23.1%) with HDI, and 64 (21.7%) with both DDI and HDI. Only 13% of the DDI were found in Thériaque® and Drugs.com® databases, and 125 (2.5%) were reported with a similar level of risk on both databases. 104 HDI were identified with only 9.5% of the interactions found in both databases. 103 pharmaceutical interventions were performed, involving 61 patients (20.7%).

The authors concluded that potentially clinically relevant drug interactions were frequently identified in this study, showing that several databases and structured screening are required to detect more interactions and optimize medication safety.

This figure of potential HDIs is high – much higher than in most previous studies. A possible explanation could be that the study was carried out in France where the use of herbal remedies is considerable. As some HDIs can cause serious problems for patients, my advice is to think twice about using herbal remedies while taking prescription drugs. I think this advice is sound regardless of whether someone is suffering from cancer or any other condition.

If you have been following my blog for a while, you probably know the answer to this question. A recent article published in JAMA re-emphasizes it in an exemplary fashion:

According to National Health and Nutrition Examination Survey data, 52% of surveyed US adults reported using at least 1 dietary supplement in the prior 30 days and 31% reported using a multivitamin-mineral supplement. The most commonly cited reason for using supplements is for overall health and wellness and to fill nutrient gaps in the diet. Cardiovascular disease and cancer are the 2 leading causes of death and combined account for approximately half of all deaths in the US annually. Inflammation and oxidative stress have been shown to have a role in both cardiovascular disease and cancer, and dietary supplements may have anti-inflammatory and antioxidative effects.

Objective  To update its 2014 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a review of the evidence on the efficacy of supplementation with single nutrients, functionally related nutrient pairs, or multivitamins for reducing the risk of cardiovascular disease, cancer, and mortality in the general adult population, as well as the harms of supplementation.

Population  Community-dwelling, nonpregnant adults.

Evidence Assessment  The USPSTF concludes with moderate certainty that the harms of beta carotene supplementation outweigh the benefits for the prevention of cardiovascular disease or cancer. The USPSTF also concludes with moderate certainty that there is no net benefit of supplementation with vitamin E for the prevention of cardiovascular disease or cancer. The USPSTF concludes that the evidence is insufficient to determine the balance of benefits and harms of supplementation with multivitamins for the prevention of cardiovascular disease or cancer. Evidence is lacking and the balance of benefits and harms cannot be determined. The USPSTF concludes that the evidence is insufficient to determine the balance of benefits and harms of supplementation with single or paired nutrients (other than beta carotene and vitamin E) for the prevention of cardiovascular disease or cancer. Evidence is lacking and the balance of benefits and harms cannot be determined.

Recommendation  The USPSTF recommends against the use of beta carotene or vitamin E supplements for the prevention of cardiovascular disease or cancer. (D recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the use of multivitamin supplements for the prevention of cardiovascular disease or cancer. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the use of single- or paired-nutrient supplements (other than beta carotene and vitamin E) for the prevention of cardiovascular disease or cancer. (I statement)

The report also elaborates on potential harms:

For many of the vitamins and nutrients reviewed, there was little evidence of serious harms. However, an important harm of increased lung cancer incidence was reported with the use of beta carotene by persons who smoke tobacco or have occupational exposure to asbestos.

Excessive doses of vitamin supplements can cause several known adverse effects; for example, moderate doses of vitamin A supplements may reduce bone mineral density, and high doses may be hepatotoxic or teratogenic. Vitamin D has potential harms, such as a risk of hypercalcemia and kidney stones, when given at high doses. The potential for harm from other supplements at high doses should be carefully considered.

There is nothing new here, of course. I (and others) have been trying to get these points across for many years. But it is nevertheless most gratifying to see the message repeated by a top journal such as JAMA. I hope JAMA is more successful than I was in changing the behavior of the often all too gullible public!

When I first saw this, I was expecting something like If Homeopathy Beats Science (Mitchell and Webb) – YouTube : videos (reddit.com). But no, “Acute Care Homeopathy for Medical Professionals” is not a masterpiece by gifted satirists. It is much better; it is for real! In fact, it is a collaboration between the “Academy of Homeopathy Education” (AHE) and the American Institute of Homeopathy (AIH). Together, they published the following announcement:

AHE and AIH are pleased to present a customized educational program designed for busy medical professionals interested in enhancing their practice and expanding the treatment tools available with Homeopathy. Grounded in the original theory and philosophy of Homeopathy, AHE’s quality curriculum empowers practitioners and the material’s inspirational delivery encourages further study towards the mastery of Homeopathy for chronic care.

This course is open to all licensed healthcare providers— medical, osteopathic, naturopathic, dentists, chiropractors, veterinarians, nurse practitioners, nurses, physician assistants, pharmacologists and pharmacists.

Acute-care homeopathy addresses the challenges of 21st-century medical practice.

Among many things, you’ll learn safe and effective ways to manage pain and mitigate antibiotic overuse with FDA-regulated and approved Homeopathic remedies. AHE delivers an integrated learning experience that combines online real-time classroom experiences culminating in a telehealth based clinical internship allowing participants to study from anywhere in the world.

AHE’s team of Homeopathy experts have taught thousands of students around the globe and are known for unparalleled academic rigor, comprehensive clinical training, and robust research initiatives. AHE ensures that every graduate develops the necessary critical thinking skills in homeopathy case taking, analysis, and prescribing to succeed in practice with confidence and competence.

  • Smart and savvy tech support team helps to on-board and train even the most reticent digital participants
  • Academic support professionals provide an educational safety-net
  • Stellar faculty to inspire confidence and encourage students to achieve their best work
  • “Fireside Chats,” forums, and social gatherings build community
  • Tried and true administrative systems keep things running smoothly so you can focus on learning Homeopathy.

All AHE students receive Radar Opus, the leading software package used by professional homeopaths worldwide.

Upon completion of the didactic program, practitioners begin an Acute Care Internship through AHE and the Homeopathy Help Network’s Acute Care Telehealth Clinic “Homeopathy Help Now” (HHN) which sees thousands of cases each year. Upon successful completion of the internship, practitioners will be invited to participate in ongoing supervised practice through HHN.

AHE is part of a larger vision to shape the future of Homeopathy: HOHM Foundation and the Homeopathy Help NetworkAll clinical services are delivered in an education and research-driven model. HOHM’s Office of Research has multiple peer-reviewed publications focused on education, practice, and clinical outcomes. HOHM is committed to funding Homeopathy study and research at every level.

The Academy of Homeopathy Education (AHE) operates in conjunction with HOHM Foundation, a 501c3 initiative committed to education, advocacy, and access. The Homeopathy Help Network is a telehealth clinic providing fee-for-service chronic care as well as donation-based acute care through Homeopathy Help Now.

____________________________

I suspect you simply cannot wait to enroll. To learn more about “Acute Care Homeopathy for Medical Professionals” please fill out the form.

… and don’t forget to pay the fee of US$ 5 500.

No, it’s not expensive, if you think about it. After all, acute-care homeopathy addresses the challenges of 21st-century medical practice.

Brite is an herbal energy drink that is currently being marketed aggressively. It is even for sale in one leading UK supermarket. It comes in various flavors the ingredients of which vary slightly.

The pineapple/mango drink, for instance, contains:

  • guarana extract,
  • green tea extract,
  • guayusa extract,
  • ashwagandha extract,
  • matcha tea,
  • ascorbic acid (vitamin C),
  • natural caffeine.

The website of the manufacturer tells us that Brite uses ingredients and dosages that are safe and effective, utilising the power of nootropic superfoods organic Matcha, Guarana and Guayusa to provide a long-lasting boost.

Brite is based on peer reviewed, double-blind, placebo-controlled clinical trials and studies that can be found here.

It does not tell us the dosages of the ingredients, and I am puzzled by the claim that the drink is safe. A quick search seems to cast considerable doubt on it.

_____________________________

Guarana (Paullinia cupana) is a plant from the Amazon region with a high content of bioactive compounds. It is by no means free of adverse effects. It is known to interact with:

And it can cause the following adverse effects:

Green tea is made from the leaves of the Camellia sinensis plant. It can cause the following adverse effects:

  • headache,
  • nervousness,
  • sleep problems,
  • vomiting,
  • diarrhea,
  • irritability,
  • irregular heartbeat,
  • tremor,
  • heartburn,
  • dizziness,
  • ringing in the ears,
  • convulsions,
  • confusion.

Guayusa is a plant native to the Amazon rainforest that contains plenty of caffeine. Its adverse effects include:

  • High Blood Pressure
  • Rapid Heartbeat
  • Anxiety
  • Jitters
  • Energy Crashes
  • Insomnia
  • Headaches
  • Upset Stomach

Ashwagandha is a plant from India; the root and berry are used in Ayurvedic medicine. Its adverse effects include:

  • stomach upset,
  • diarrhea,
  • vomiting.

Matcha tea also contains a high amount of caffeine. It is associated with the following adverse effects:

Caffeine is a chemical found in coffee, tea, cola, guarana, mate, and other products. Adverse effects include:

  • insomnia,
  • nervousness,
  • restlessness,
  • stomach irritation,
  • nausea and vomiting,
  • increased heart rate and respiration,
  • headache,
  • anxiety,
  • agitation,
  • chest pain,
  • ringing in the ears.

A case report documented a case of myocardial infarction in a 25-year-old man who presented to the emergency department with chest pain. The patient had been consuming massive quantities of caffeinated energy drinks daily for the past week. This case report and previously documented studies support a possible connection between caffeinated energy drinks and myocardial infarction.

________________________

Yes, the adverse effects are predominantly (but not exclusively) caused by high doses. Yet, the claim that Brite is safe should nevertheless be taken with a very large pinch of salt. If I like the taste of the drink and thus consume a few bottles per day, the dosages of the ingredients would surely be high!

And what about the claim that it is effective? Here the pinch of salt must be even larger, I am afraid. I could not find a single trial that confirmed the notion. For backing up their claims, the manufacturers offer a few references, but if you look them up, you will find that they were not done with the mixture of ingredients contained in Brite.

So, what is the conclusion?

Based on the evidence that I have seen, the herbal drink ‘Brite’ has not been shown to be an effective nootropic. In addition, there are legitimate concerns about the safety of the product. I for one will therefore not purchase the (rather expensive) drink.

Micronutrient supplements such as vitamin D, vitamin C, and zinc have been used in managing viral illnesses. However, the clinical significance of these individual micronutrients in patients with Coronavirus disease 2019 (COVID-19) remains unclear. A team of researchers conducted this meta-analysis to provide a quantitative assessment of the clinical significance of these individual micronutrients in COVID-19.

They performed a literature search using MEDLINE, Embase, and Cochrane databases through December 5th, 2021. All individual micronutrients reported by ≥ 3 studies and compared with standard-of-care (SOC) were included. The primary outcome was mortality. The secondary outcomes were intubation rate and length of hospital stay (LOS). Pooled risk ratios (RR) and mean difference (MD) with corresponding 95% confidence intervals (CI) were calculated using the random-effects model.

The authors identified 26 studies (10 randomized controlled trials and 16 observational studies) involving 5633 COVID-19 patients that compared three individual micronutrient supplements (vitamin C, vitamin D, and zinc) with SOC.

Vitamin C

Nine studies evaluated vitamin C in 1488 patients (605 in vitamin C and 883 in SOC). Vitamin C supplementation had no significant effect on mortality (RR 1.00, 95% CI 0.62–1.62, P = 1.00), intubation rate (RR 1.77, 95% CI 0.56–5.56, P = 0.33), or LOS (MD 0.64; 95% CI -1.70, 2.99; P = 0.59).

Vitamin D

Fourteen studies assessed the impact of vitamin D on mortality among 3497 patients (927 in vitamin D and 2570 in SOC). Vitamin D did not reduce mortality (RR 0.75, 95% CI 0.49–1.17, P = 0.21) but reduced intubation rate (RR 0.55, 95% CI 0.32–0.97, P = 0.04) and LOS (MD -1.26; 95% CI -2.27, −0.25; P = 0.01). Subgroup analysis showed that vitamin D supplementation was not associated with a mortality benefit in patients receiving vitamin D pre or post COVID-19 diagnosis.

Zinc

Five studies, including 738 patients, compared zinc intake with SOC (447 in zinc and 291 in SOC). Zinc supplementation was not associated with a significant reduction of mortality (RR 0.79, 95% CI 0.60–1.03, P = 0.08).

The authors concluded that individual micronutrient supplementations, including vitamin C, vitamin D, and zinc, were not associated with a mortality benefit in COVID-19. Vitamin D may be associated with lower intubation rate and shorter LOS, but vitamin C did not reduce intubation rate or LOS. Further research is needed to validate our findings.

Holland & Barrett (H&B), the UK’s largest store for supplements and wellbeing products, is under pressure over its links to oligarch Mikhail Fridman. The private equity firm ‘LetterOne’, founded by Fridman, holds a major stake in H&B. On Twitter, people thus urged us to buy our supplements elsewhere. One customer tweeted: ‘Please boycott Holland & Barrett as it is owned by a Russian oligarch with links to Putin.’

Fridman who owns Athlone House, a sprawling £65million mansion in Highgate, North London, was sanctioned by the European Union. His assets were frozen and he is banned from traveling. Consequently, he spoke out against the fighting in Ukraine but refused to denounce Putin. He has since stepped down from the board of LetterOne.

Holland & Barrett itself is unlikely to face sanctions as the oligarch owns less than half the shares in the parent company LetterOne. Fridman convened a press conference last week, which was broadcast on television. However, the move might have backfired, as it alerted H&B shoppers to his connection with the stores.

Fridman was born in Ukraine and has an Israelian passport. He made most of his £11billion fortune from oil, gas, banking, and telecoms. He founded Alfa Bank in January 1991, which grew to become one of the largest private banks in Russia. In 2013, he set up LetterOne in London using £11billion raised from the sale of his stake in TNKBP to Kremlin-backed oil giant Rosneft, whose petrol is currently fuelling Russian tanks. Fridman and Aven (another oligarch) own just under 50 percent of LetterOne. The rest of the company is split between board members German Khan, Alexey Kuzmichev and Andrei Kosogov – who all left the board recently.

A spokesman for LetterOne said: ‘Holland and Barrett is a fantastic business. The business employs thousands of people and we will do everything to protect them.’ Holland & Barrett’s made a gross profit of £445million for the year to the end of September 2020. Fridman and Aven said the EU sanctions are spurious and unfounded and vowed to contest them.

____________________

PS

Quite apart from the oligarch co-ownership, I did ask myself some time ago: is H&B a recommendable shop? It is advertised on Facebook as follows:

Book your online wellness consultation today and speak to one of our qualified health & wellbeing advisors.
We are able to advise on a range of health topics including gut health, immunity, anxiety & more.
Several times during the last months, I went to my local H&B and asked specific questions about supplements. The overall impression I got was far from positive.
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