Juice Plus

Juice Plus+ is a branded line of dietary supplements containing concentrated fruit and vegetable juice extracts fortified with added vitamins and nutrients. It is produced by Natural Alternatives International of San Marcos, California, for National Safety Associates (NSA; Collierville, Tennessee). Introduced in 1993, the supplements are distributed by NSA via multi-level marketing.

Studies of Juice Plus' effects have generated conflicting and controversial results. Although Juice Plus claims its products' efficacy is backed by research, critics have argued that there is no scientific proof that Juice Plus offers significant health benefits and that deceptive claims are used in the product's marketing information. Some marketing claims made about Juice Plus products have been disputed by consumer watchdog organizations and governmental agencies as misleading and according to Quackwatch it is "a colossal waste of money".

History
Juice Plus was NSA's first nutritional product. Previously, since its foundation in 1970, NSA had been known for other products such as water filters, air filters, fire-protection equipment and educational games for pre-schoolers, which were also distributed by multi-level marketing.

The primary products in the Juice Plus line are "Orchard Blend" (a fruit juice powder-based supplement) and "Garden Blend" (vegetable juice powder-based) capsules, which are sold together in a four-month pack at a cost of approximately $167 USD (2009). Other supplement products available in the Juice Plus line are (in 2011) Vineyard Blend (grape/berry juice powder-based) capsules, Juice Plus Complete (meal replacement powder), Juice Plus Chewables (Orchard and Garden Blends), and Juice Plus Chewables (Vineyard Blend). Discontinued products include Juice Plus Gummies, Juice Plus Thins (wafers), chewable tablets, and a vitamin formulation for dogs and cats.

Manufacturing
The main ingredients in Juice Plus Orchard Blend and Garden Blend capsules (vegetable and fruit juices, fibers, plant enzymes, and food actives) are reduced to powder through a proprietary process by an unrelated supplier, and then blended and encapsulated by NAI, who produce the finished product. Juice Plus capsules are “enriched with pure β-carotene, ascorbic acid, vitamin E, and folic acid”. According to the manufacturer these are added to restore the levels of micronutrients lost during processing and to ensure uniformity.” Two NAI-sponsored studies mention that the fruit and vegetable powders in Juice Plus include standardized levels of natural β-carotene derived from Dunaliella salina and soy-derived d-α-tocopherol (vitamin E), which are supplied by the Henkel Corporation (now doing business as Cognis Corporation),  and ascorbic acid derived from acerola cherry, which is supplied by Schweizerhall Pharma.

Reception
Juice Plus+ Garden Blend was tested by ConsumerLab.com in their Multivitamin and Multimineral Supplements Review of 38 of the leading multivitamin/multimineral products sold in the U.S. and Canada. Testing included amounts of selected index elements, their ability to disintegrate in solution per United States Pharmacopeia guidelines, lead contamination threshold set in California Proposition 65, and meeting U.S. Food and Drug Administration (FDA) labeling requirements.

Garden Blend failed ConsumerLab's test as it contained only 76.4% of its claimed calcium, which was noted was low to start (labeled as just 4% of the Daily Value per serving.) On 23 June 2011, ConsumerLab was informed of misinformation circulated by a Juice Plus distributor incorrectly stating the variation was due to the analytical method used. ConsumerLab responded that their analytic method used was ICP-MS (Inductively Coupled Plasma Mass Spectrometry), a "highly precise and sensitive method of testing calcium". ConsumerLab also noted that the calcium deficiency in Juice Plus was confirmed with this method in two independent laboratories prior to publication of their Review.

Sales
Juice Plus products are marketed by individual distributors who receive sales commissions ranging from 6% (for enrolling five customers in 30 days) to 14% (for enrolling twenty customers in 30 days). Detailed sales figures for Juice Plus are not publicly available, but NSA representatives claimed that Juice Plus achieved monthly sales of $6 million USD in 1993 and that it was the company’s most successful new product. According to NSA vice-president John Blair, sales of Juice Plus in 2008 were "approaching 300 million but have leveled off due to economic factors."

Product research
National Safety Associates, the owner of Juice Plus, claim that it is “the next best thing to eating fruits and vegetables”, containing the “nutritional essence of 17 different fruits, vegetables, and grains” with key phytonutrients and that the product is absorbed by the body, reduces oxidative stress, promotes cardiovascular wellness, supports a healthy immune system, and helps protect DNA. Multiple studies have produced conflicting results as to the truth of these claims. Doubts have been raised about the advertised benefits of Juice Plus by Memorial Sloan-Kettering Cancer Center, University of California Berkeley, Center for Science in the Public Interest, and other sources. The product has been criticized on the basis that: its marketing is unsupported by research data, it contains too little fruit and vegetable powder to offer significant clinical benefits, its effects can be attributed to the inclusion of added exogenous vitamins and micronutrients, and it is excessively priced relative to its potential benefits. Memorial Sloan-Kettering Cancer Clinic referred to Juice Plus as a “pricey supplement” that is “distributed through a multi-tiered marketing scheme with exaggerated value and cost."

Of the published peer-reviewed studies on Juice Plus products, the majority were funded and/or authored by the manufacturer, Natural Alternatives International (NAI);     or the main distributor, NSA.;      two were funded by individual Juice Plus distributors;  and one was conducted independently.

Nutrients and phytochemicals
Concerns have been raised that these nutrients in Juice Plus+ capsules may not be bioavailable, not effectively absorbed by the human body, and that some of the nutrients claimed to be in the products may not be present in significant amounts. Studies on nutrient absorption showed that subjects taking Juice Plus had elevated blood levels of folate and β-carotene,  but the effects on blood levels of vitamin E and vitamin C were inconsistent. Some studies have shown significant increases in vitamin E  and C levels,    while other studies have shown much weaker effects on vitamin E  and C levels, and that the levels of vitamin E are not significantly increased. and vitamin C  Juice Plus was found to increase blood lycopene levels in several studies,   while other studies have indicated that Juice Plus does not raise blood levels of lycopene  or other phytochemicals in fresh fruits and vegetables such as lutein,   zeaxanthin,     and β-cryptoxanthin.

Concerns have also been raised about the accuracy of product labeling. Three studies which included chemical analyses of Juice Plus have indicated nutrient amounts that differ from the amounts listed on the product labels.

According to Consumer Reports, in 2005, National Safety Associates used advertising featuring Dr. William Sears (a distributor of Juice Plus products), which implied that Juice Plus Gummies were low in sugar and a nutritional alternative to fruits and vegetables. This claim resulted in consumer complaints to the Better Business Bureau's National Advertising Division (NAD). The BBB issued a complaint that NSA's claims were misleading, and as a result, NSA promised to modify its ads and stop calling Gummies “the next best thing to fruits and vegetables”. The Juice Plus homepage continues to advertise Juice Plus as “the next best thing to fruits and vegetables”; the Gummies product has since been discontinued; the product "Chewables" has been introduced.

In December 2007, the Center for Science in the Public Interest (CSPI) filed a complaint with the U.S. Food and Drug Administration (FDA) to “halt the marketing of NSA's Juice Plus Orchard Blend and Garden Blend capsules because the products appear to be adulterated and misbranded”. CSPI said it was “concerned that the products' claim, ‘the next best thing to fruits and vegetables,’ may lead consumers to believe the pills are closer to real fruits and vegetables than is likely to be the case." According to CSPI, the labels say the capsules contain high levels of vitamins A and C and folate naturally, but “do not disclose that these vitamins and minerals are added to the capsules during processing and are nutrients only characteristic of the original fruit and vegetable sources.”

Registered dietician Fudeko T. Maruyama and nutritional education specialist Mary P. Clarke of Kansas State University commented that “the promotional literature for Juice Plus, billed as a whole food concentrate, is a carefully worded blend of incorrect information, misleading health claims, and nonscientific jargon” and concluded that “Juice Plus probably won't harm you, but can hurt your pocketbook." Others have provided similar skeptical assessments of Juice Plus+.

In November 2007, the Complaints Resolution Panel for the Therapeutic Goods Administration Advertising Code Council ruled that statements on NSA’s Juice Plus website were in breach of Australia’s Therapeutic Goods Advertising Code. According to the panel, the “clear message” in the ads was that Juice Plus tablets/capsules are “equivalent to fruits and vegetables” and that “consuming Juice Plus tablets would help Australians to consume the ‘recommended 5–7 servings’ of fruits and vegetables”. NSA was sanctioned by the Council to withdraw any representations that the products “are equivalent to fruits and vegetables or that their consumption can aid in meeting dietary recommendations relating to fruits and vegetables.”

Antioxidant activity
NSA claims that Juice Plus is an effective antioxidant, and quotes a study that showed a 75% reduction in lipid peroxidation (an oxidative stress marker) in subjects that took Juice Plus for 7 to 28 days. This report was criticized as “a particularly poor study” by nutritionist Rosemary Stanton in the Australian journal, The Skeptic. Other studies have also reported reductions in lipid peroxidation and DNA oxidation. These three studies were not blinded or placebo-controlled, included few participants (in one case no more than 15), and did not include monitoring or control of the participants' food intake. Other studies conducted under more rigorous conditions (randomized, double-blind, placebo-controlled, longer in duration and with more subjects), found no significant reductions in lipid peroxidation,  DNA oxidation,    or other markers of oxidative stress.

One study, which measured in vitro antioxidant activity, found that 1 g of Juice Plus Orchard Blend/Garden Blend powder (500 mg of each combined) had the corresponding antioxidant capacity to approximately 10 g (fresh weight) of fruit or vegetable, amounting to 30 g (roughly one-third of a serving) per four capsules. Tests of antioxidant activity of polyphenols (such as those in Juice Plus capsules) in vitro likely show higher results than the negligible antioxidant activity in vivo following oral ingestion and digestion.

One placebo-controlled study conducted in 2002 found that Juice Plus Gummie candies did not significantly improve the antioxidant status of children, as indicated by negative results from 6 different antioxidant tests. The authors explained this by saying it was possible that the supplement did not contain enough of the proper antioxidants to make a significant difference or that the antioxidants extracted in the fruit/vegetable extract were not bioavailable. The study was originally sponsored by NSA, but because the results were disappointing, NSA officials elected to remove the company’s name from the published article.

Jim Sears, a pediatrician and Juice Plus distributor/spokesperson who co-hosts the syndicated daytime television talk show The Doctors, claimed on a February 27, 2009 episode of the program that Juice Plus "helps fight cancer". In October 2009, Dr. Barrie R. Cassileth, Chair and Chief of Integrative Medicine at Memorial Sloan-Kettering Cancer Center, cautioned that while Juice Plus is being "aggressively promoted to cancer patients based on claims of antioxidant effects", the supplement should not be taken by patients because it can interfere with chemotherapy, nor should it be considered a substitute for fruits and vegetables.

Cardiovascular system
Several studies have examined the effects of Juice Plus capsules on biochemical parameters associated with cardiovascular function, again with conflicting results. In October 2009, Dr. Barrie R. Cassileth, Chair and Chief of Integrative Medicine at Memorial Sloan-Kettering Cancer Center, noted that the results of Juice Plus studies on plasma homocysteine levels were not reproducible, and that studies on cardiovascular effects, such as blood pressure and cholesterol, were inconclusive.

The effects of Juice Plus on blood levels of homocysteine have been reported in the following five studies all conducted in subjects with normal homocysteine levels (15 μmol/L). An initial study, which was not double blinded or placebo controlled, reported a 37% decrease in homocysteine levels in subjects taking Juice Plus. More rigorous studies, including three that were randomized, double-blind, placebo-controlled trials, found that homocysteine levels were not reduced or were reduced to a much lesser extent than originally reported.

Two randomized, double-blind placebo controlled studies have examined the effect of Juice Plus on serum cholesterol and LDL levels. One study found that Juice Plus had no significant effects; the other found slight decreases in cholesterol (6%) and LDL (9%) in subjects that took Orchard/Garden Blend, but no reductions among subjects who took Juice Plus Vineyard blend in addition.

A study reported that a combined regimen of Juice Plus Orchard Blend and Garden Blend significantly decreased the impairment of brachial artery vasoactivity caused by a high-fat meal in healthy subjects. The addition of the Vineyard Blend product to this regimen had no additional effect on brachial artery vasoactivity and led to an increase in total lipoprotein and LDL as compared with Orchard Blend/Garden Blend alone. This study also found that Juice Plus had no effect on blood pressure.

In a randomized placebo-controlled, crossover study in overweight insulin-resistant adults, 8-week supplementation with Juice Plus had no significant effect on vascular endothelial function, serum insulin, blood glucose, body weight, total cholesterol, or LDL cholesterol.

Immune system
A non-randomized, non-blinded, non-controlled study in elderly cigarette smokers and non-smokers examined the effects of Juice Plus Orchard Blend and Garden Blend on 9 immunologic parameters, including stimulated T-cell cytokine production (IL-2, IL-6, TNF-α and IFN-γ) and the activity of various immune cells (peripheral blood monocytes, natural killer [NK] cells, T-helper cells, and cytotoxic T cells). Juice Plus significantly increased peripheral blood monocyte proliferation and NK cell cytotoxicity in non-smokers but not in smokers, and increased in vitro IL-2 production by stimulated monocytes in both smokers and non-smokers. Juice Plus had no significant effect on cell counts (NK cells, T-helper cells, or cytotoxic T cells) or on the levels of IL-6, TNF-α, or IFN-γ in either smokers or non-smokers. Memorial Sloan-Kettering Cancer Center noted several faults with this study including that it lacked placebo controls and was not blinded, that the results do not necessarily correlate with an overall increase in immunity, and that it would have been more informative had clinical parameters been measured, such as whether fewer patients became sick.

A double-blind, randomized, placebo-controlled study examined the effect of Juice Plus Orchard Blend and Garden Blend on T cell counts, lymphocyte cytokine production, Epstein-Barr virus (EBV) antibody titers, and the incidence of illness in healthy subjects. The percentage of circulating γδ-CD3+ T cells and αβ-CD3+ T cells did not change significantly in subjects who took Juice Plus; however, at the end of the supplementation period, subjects taking the supplement had a significantly higher percentage of γδ-CD3+ T cells (7.2%) as compared with placebo (5.4%). IFN-γ produced by stimulated lymphocytes in vitro was reduced in the Juice Plus (68%) and placebo groups (41%), but the reduction was statistically significant only in the Juice Plus group. The levels of other cytokines (IL-4, IL-6, TGF-β) were unchanged and Juice Plus had no significant effect on the incidence and symptoms of illness or on EBV antibody titers.

A double-blind, randomized, placebo-controlled 28-week study examined the effect of Juice Plus (two capsules each of Orchard Blend, Garden Blend, and Vineyard blend per day) on cytokine (i.e., IL-6 and TNF-α) levels, and on the incidence of illness. Subjects who took Juice Plus had lower TNF-α levels than the placebo group at later time points in the study (week 16 and 28) but overall the effect was not statistically significant. Juice Plus was found to have no significant effect on IL-6 levels or on the incidence of illness during the course of the study.

Adverse effects
Adverse effects of Juice Plus have been mentioned in three studies, No monitoring of adverse effects was reported in other published Juice Plus studies. The first of these studies (in 2000) reported adverse effects (upper-respiratory tract, urinary, and musculoskeletal) in roughly a third of the participants who took the products for 7 days; these events resolved spontaneously and were deemed unlikely to have derived from use of Juice Plus. Memorial Sloan-Kettering Cancer Center noted that in the second of these studies, some subjects who took Orchard Blend and Garden Blend developed a hive-like rash. In the third study, from 2007, some subjects withdrew due to gastrointestinal distress, possibly caused by the Juice Plus regimen (a combination of Orchard Blend, Garden Blend, and Vineyard Blend). In addition a medical case report was published in which Juice Plus was identified as the probable cause of liver toxicity (hepatic inflammation) in a 51-year old female patient with endometrial cancer. The liver injury was reversed upon discontinuation of Juice Plus.

Conflicts of interest in studies
In a critique of Juice Plus, consumer health advocate and alternative medicine critic Stephen Barrett of MLM Watch remarked upon the previous association between two authors of a 1996 Juice Plus research study and United Sciences of America, Inc. (USAI), a multilevel marketing company that sold vitamin supplements with illegal claims that they could prevent many diseases. In 1986, lead author John A. Wise, who later co-authored several other Juice Plus research studies,    was USAI's Executive Vice-President of Research and Development; and second author Robert J. Morin was a scientific advisor who helped design the products. State and federal enforcement actions     drove USAI out of business in 1987. Wise became a consultant to Natural Alternatives International (NAI) in 1987 and a company executive (Vice-President of Research and Development) in 1992. Barrett noted that Wise was also an NAI shareholder and that production of Juice Plus for National Safety Associates (NSA) was responsible for 16% of NAIs sales in 1999.

NSAs Juice Plus website cites various research articles in support of the company's marketing claims about the biological effects of Juice Plus, maintaining that these “studies were conducted by independent researchers” at various universities. Several of the studies were co-authored by Wise    and Morin.

O.J. Simpson
University of California Berkeley Wellness Letter and MLMWatch also commented on the unreliability of Juice Plus testimonials provided by former professional athlete O.J. Simpson. Simpson, known commonly as "O.J." and "The Juice", signed a multi-year six-figure contract with NSA in January 1994 and became an official celebrity endorser of Juice Plus. In March 1994, Simpson was videotaped telling 4,000 Juice Plus distributors at a sales meeting that the product had cured his arthritis, improved his golf game, and freed him from using anti-arthritic drugs. However, regarding the murder of his ex-wife Nicole Brown Simpson and her friend, Ronald Goldman, for which Simpson was tried and acquitted, Simpson claimed in his defence that he was too incapacitated by arthritis to have committed the murders and had continued to take the anti-inflammatory drug sulfasalazine. As a result of the controversy surrounding Simpson, NSA cancelled his endorsement contract and stopped using the Simpson videotape to promote Juice Plus.

Juice Plus Children's Research Foundation
The Juice Plus Children's Research Foundation (JPCRF), founded in 1997, is a non-profit medical research organization (NTEE code H99) whose stated goal is to initiate and/or support programs that advance the principle that improved nutrition leads to healthier lifestyle and overall better health in children. The foundation is chaired by executives of National Safety Associates and operates from the company's head office in Collierville, Tennessee. In fiscal year 2007, the majority of funds donated to the foundation were disbursed to Volunteers of America (a faith-based social welfare organization) and to the Boys and Girls Clubs of Memphis.

The Foundation's website shows results of an ongoing customer survey (The Juice Plus Children's Health Study) which suggests a link between Juice Plus consumption and a general improvement in diet and lifestyle habits. The University of California Berkeley Wellness Letter and Stephen Barrett of MLM Watch questioned the survey's scientific value, and claimed that the Foundation is being used mainly as a marketing gimmick to get families to buy Juice Plus products. Barrett's organization Quackwatch includes the JPCRF among its list of "Questionable 'Research' Entities".