ArticlePDF Available

Multivitamin/Mineral Supplement Contribution to Micronutrient Intakes in the United States, 2007–2010

Authors:

Abstract and Figures

Objective: Multivitamin/mineral (MVMM) supplements are the most common dietary supplements consumed in the United States; however, intake data specific to how MVMM use contributes to micronutrient intakes among Americans are absent from the current scientific literature. Methods: This analysis aimed to assess contributions of micronutrients to usual intakes derived from MVMM supplements and to compare those intakes to the dietary reference intakes for US residents aged ≥ 4 years according to the National Health and Nutrition Examination Survey (NHANES) 2007-2010 (n = 16,444). We used the National Cancer Institute method to assess usual intakes of 21 micronutrients. Results: Our results showed that 51% of Americans consumed MVMM supplements containing ≥ 9 micronutrients. Large portions of the population had total usual intakes (food and MVMM supplement use) below the estimated average requirement for vitamins A (35%), C (31%), D (74%), and E (67%) as well as calcium (39%) and magnesium (46%). Only 0%, 8%, and 33% of the population had total usual intakes of potassium, choline, and vitamin K above the adequate intake when food and MVMM use was considered. The percentage of the population with total intakes greater than the tolerable upper intake level (UL) was very low for all nutrients; excess intakes of zinc were the highest (3.5%) across the population of all of the nutrients assessed in NHANES. Conclusions: In large proportions of the population, micronutrient sufficiency is currently not being achieved through food solutions for several essential vitamins and minerals. Use of age- and gender-specific MVMM supplements may serve as a practical means to increase the micronutrient status in subpopulations of Americans while not increasing intakes above the UL.
Content may be subject to copyright.
Original Research
Multivitamin/Mineral Supplement Contribution to
Micronutrient Intakes in the United States, 2007–2010
Taylor C. Wallace, PhD, FACN, Michael McBurney, PhD, FACN, Victor L. Fulgoni III, PhD
Department of Scientific & Regulatory Affairs, Council for Responsible Nutrition, Washington, DC (T.C.W.); DSM Nutritional
Products North America, Parsippany, New Jersey (M.M.); Nutrition Impact, Battle Creek, Michigan (V.L.F.)
Key words: multivitamin/mineral, micronutrient, NHANES
Objective: Multivitamin/mineral (MVMM) supplements are the most common dietary supplements consumed
in the United States; however, intake data specific to how MVMM use contributes to micronutrient intakes among
Americans are absent from the current scientific literature.
Methods: This analysis aimed to assess contributions of micronutrients to usual intakes derived from MVMM
supplements and to compare those intakes to the dietary reference intakes for US residents aged 4 years
according to the National Health and Nutrition Examination Survey (NHANES) 2007–2010 (n=16,444).
We used the National Cancer Institute method to assess usual intakes of 21 micronutrients.
Results: Our results showed that 51% of Americans consumed MVMM supplements containing 9mi-
cronutrients. Large portions of the population had total usual intakes (food and MVMM supplement use) below
the estimated average requirement for vitamins A (35%), C (31%), D (74%), and E (67%) as well as calcium
(39%) and magnesium (46%). Only 0%, 8%, and 33% of the population had total usual intakes of potassium,
choline, and vitamin K above the adequate intake when food and MVMM use was considered. The percentage
of the population with total intakes greater than the tolerable upper intake level (UL) was very low for all nu-
trients; excess intakes of zinc were the highest (3.5%) across the population of all of the nutrients assessed in
NHANES.
Conclusions: In large proportions of the population, micronutrient sufficiency is currently not being achieved
through food solutions for several essential vitamins and minerals. Use of age- and gender-specific MVMM
supplements may serve as a practical means to increase the micronutrient status in subpopulations of Americans
while not increasing intakes above the UL.
INTRODUCTION
Multivitamin/mineral (MVMM) supplements have been pre-
viously reported to be the most common dietary supplement, reg-
ularly taken by roughly 40% of adults in the National Health and
Nutrition Examination Survey (NHANES) and 31% of children
in the National Health Interview Survey [1–3]. Approximately
71% of dietary supplement users reported taking an MVMM
supplement in a recent series of nationally representative surveys
of adults from 2007 to 2011 [4]. Many adult users of MVMM
products (48%) report their motivation for use of these dietary
supplements as being “to improve overall health.” Accordingly,
Address correspondence to: Taylor C. Wallace, PhD, 1828 L Street, NW, Suite 510, Washington, DC 20008. E-mail: taylor.wallace@me.com
T.C.W. is currently employed by the Council for Responsible Nutrition. M.M. is currently employed by DSM Nutritional Products North America. V.L.F. has no conflicts to
disclose.
Abbreviations: AI =adequate intake, DRI =dietary reference intake, EAR =estimated average requirement, IOM FNB =Institute of Medicine Food and Nutrition Board,
MVMM =multivitamin/mineral, NCHS =National Center for Health Statistics, NCI =National Cancer Institute, NHANES =National Health and Nutrition Examination
Survey, RDA =recommended dietary allowance, UL =tolerable upper intake level.
dietary supplement use has been previously reported to be higher
among those who report excellent or very good health [5]. The
long-term benefits of MVMM use have not been widely stud-
ied, and current disease prevention trials of MVMM supplement
use show mixed results. Results from the Physicians’ Health
Study II, the largest randomized controlled trial of 14,641 male
physicians who were given a daily MVMM supplement, showed
a significant modest reduction in total cancer but no effect on
cardiovascular outcomes over an average median follow-up of
11.2 years [6,7]. A meta-analysis of randomized controlled trials
found no statistically significant benefit or harm of MVMM sup-
plements on the risk of mortality from cardiovascular disease,
Journal of the American College of Nutrition, Vol. 33, No. 2, 94–102 (2014) C
American College of Nutrition
Published by Taylor & Francis Group, LLC
94
Downloaded by [Taylor C. Wallace] at 07:03 14 April 2014
Multivitamin/Mineral Intakes
cancer, or all causes [8]. Similarly, a systematic review of
epidemiological and clinical trials, including the Physicians’
Health Study II data, reported that MVMM use does not ap-
pear to increase all-cause mortality, cancer incidence or mor-
tality, or cardiovascular disease incidence or mortality and may
provide a modest protective benefit among healthy populations
[9]. Another recent systematic review and meta-analysis of ran-
domized controlled trials found that MVMM supplements en-
hanced immediate free recall memory but no other cognitive
domains [10]. Because secondary analyses (e.g., Age Related
Eye Disease Study II [AREDS2]) have identified significant
supplementation-specific benefits in the more poorly nourished
subpopulation, it is important to assess both food and MVMM
usage.
The definition of an MVMM supplement is fluid, and no
standard of identity currently exists because many specialized,
innovative, and unique formulations are present on the market
for subpopulations including but not limited to children, older
men, pregnant women, and those with a family history of age-
related eye disease. The lack of standard terminology and com-
position among products makes it difficult to study the effects
of MVMM supplements in a nonclinical setting (e.g., inferences
from epidemiological studies). In many analyses, including the
2006 “NIH State-of-the-Science Conference Statement on Mul-
tivitamin/Mineral Supplements in Chronic Disease Prevention,
MVMM supplements have been defined as being “three or more
vitamins and minerals in combination” [11]. In 2006, Congress
defined MVMM as a dietary supplement that “is in compliance
with all applicable government quality standards and provides
at least 2/3 of the essential vitamins and minerals at 100 percent
of the daily value as determined by the Commissioner of Food
and Drugs” as reflected in the Older Americans Act [12].
The contribution of dietary supplements to the total nutrient
intakes of Americans has been previously reported [13]. Briefly,
dietary supplements have been shown to decrease the percentage
of the US population consuming less than the estimated average
requirement (EAR) for all nutrients. Excess intakes above the
tolerable upper intake level (UL) for most nutrients are low, ex-
cept in the case of niacin and zinc, for which 10.3% and 8.4%
of the general population have intakes above the UL when in-
takes from food and dietary supplements are considered [12].
However, intake data specific to mainstream MVMM use are
absent from the current scientific literature. A bioavailability
study of an MVMM supplement found positive postprandial
changes in plasma or serum concentrations, further indicating
that these common dietary supplements may serve as a vehicle to
decrease the prevalence of multiple micronutrient insufficiencies
and deficiencies in healthy adults. Tablet disintegration charac-
teristics (i.e., whole or crushed) did not limit absorption of the
micronutrients [14]. Consistent results were also reported in an
8-week study of 80 free-living older adults aged 50–87 years
who were already consuming a fortified diet and also under-
went daily supplementation with an MVMM supplement. The
authors concluded that an MVMM supplement formulated with
100% of the daily value was effective in decreasing the pres-
ence of suboptimal vitamin status in older adults and improving
their micronutrient status to levels associated with reduced risk
for several chronic diseases [15]. Because these studies suggest
that MVMM supplements are beneficial among healthy individ-
uals, and that dietary supplements in general are associated with
higher nutrient intakes among Americans, our study sought to
determine the contribution of these popular dietary supplement
products to micronutrient intakes of Americans.
MATERIALS AND METHODS
Study Population
The National Center for Health Statistics (NCHS) of the US
Centers for Disease Control and Prevention administers and col-
lects the NHANES, a nationally representative, cross-sectional
survey of noninstitutionalized, civilian US residents [16]. The
NHANES survey protocol was approved by the Research
Ethics Review Board of the NCHS. Written informed consent
was obtained for all survey participants. Data from NHANES
2007–2008 and 2009–2010 were combined for these analyses.
The combined sample included 16,444 participants who had
completed and provided 24-hour dietary intake data.
Micronutrient Intake from Food
Subjects aged <4 years and pregnant and/or lactating women
were excluded from these analyses. NHANES participants were
asked to complete 2 dietary recall interviews, with the first col-
lected in person by trained interviewers. Proxy respondents pro-
vided dietary information for young children and proxy-assisted
interviews were used for children aged 6–11 years. The sec-
ond dietary recall interview was completed by telephone 3–
10 days after the health examination. The US Department of
Agriculture (USDA) automated multiple-pass method was uti-
lized for both dietary recall interviews [17,18]. Questionnaires,
data sets, and related documentation from each NHANES anal-
ysis can be found on the NCHS NHANES website [19]. Vari-
ous USDA food composition databases were utilized to deter-
mine the micronutrient contribution of specific foods consumed
by NHANES participants. The USDA estimated the calcium
and vitamin D contents of NHANES foods in recipes by link-
ing the ingredients in survey food recipes to food composi-
tion data provided by the USDA National Nutrient Database
for Standard Reference [20]. Calcium intake calculated from re-
ported consumption of water in the NHANES analyses was also
included.
MVMM Supplements
Information on the use of MVMM supplements over the
30 days prior to the dietary recall interview was collected as
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION 95
Downloaded by [Taylor C. Wallace] at 07:03 14 April 2014
Multivitamin/Mineral Intakes
part of the dietary supplement questionnaire [4]. Detailed in-
formation was obtained for each reported MVMM supplement,
including frequency of consumption (i.e., number of days the
product was taken in the past 30 days), duration of use (i.e., how
many days, weeks, months, or years the product was taken), and
amount normally taken per day on days it was taken over the
30-day period. The interviewer also examined each MVMM sup-
plement container and recorded complete product information
so that each product could be matched or entered into a database.
Average daily intakes obtained from MVMM supplements were
calculated using the number of days use was reported, the re-
ported amount taken daily, and the serving size unit from the
Supplement Facts Panel.
Definitions
To be included in the study, any given dietary supplement had
to include at least 100% of the recommended dietary allowance
or adequate intake (AI) for 9 vitamins and minerals with de-
fined dietary reference intake (DRI) values for which NHANES
2007–2008 and 2009–2010 collected intake data. This cutoff en-
abled us to eliminate dietary supplements that contain multiple
vitamins but do not provide a broad spectrum of essential vita-
mins and minerals (e.g., B-complex and single nutrient dietary
supplements) from the data set and allowed us to make sole in-
ference on the effect of MVMM supplements. The cutoff also
enabled us to look at both children and adult MVMM supple-
ments (i.e., children’s MVMM supplements often contain fewer
nutrients) without interference of dietary supplements with only
multiple vitamins. Users of MVMM supplements were defined
as those who reported taking an MVMM supplement as defined
above during the 30-day period. Nonusers were defined as those
individuals who did not report taking any dietary supplements
(including MVMM supplements) during the 30-day period; thus,
dietary intakes for nonusers were based on intakes from foods
alone. DRI age groups (4–8, 9–13, 14–18, 19–30, 31–50, 51–70,
and 71 years) were used to compare estimates of micronutrient
intakes. Children and adults were defined as those individuals
who were aged between 4 and 18 years and 19 years, unless
otherwise specified.
Comparison to DRI Values
The DRI are a family of nutrient reference values, defined
by the Institute of Medicine Food and Nutrition Board (IOM
FNB), intended to serve as a guide for good nutrition and to
provide the basis for the development of nutrient guidelines in
both the United States and Canada. The values differ for in-
dividuals based on age and gender (there are also values for
lactating and/or pregnant women; these populations as well as
those aged <4 years were not included in this study). The EAR
is used for planning and assessing diets of populations and, by
definition, is the average daily nutrient intake level estimated
to meet the requirements of half of the healthy individuals in a
group. The EAR serves as the basis for calculating the recom-
mended dietary allowance, defined as the average daily nutrient
intake level estimated to meet the requirements of 97%–98%
of the healthy individuals in a group [21,22]. Therefore, the
prevalence of inadequate dietary intakes was determined using
the EAR cut-point method (except for iron, which was assessed
using the probability method) as described previously [23] for
micronutrients and was reported as the percentage of the popula-
tion with usual intakes below the EAR. The prevalence (reported
as a percentage of the population) of dietary intakes above the
UL was also determined.
Statistical Analysis
The National Cancer Institute (NCI) method as previously
described [24] was used to determine estimates of usual intakes
from the diet for nonusers and users of MVMM supplements.
The covariates used in the NCI model were as follows: (1) se-
quence of 24-hour recall, (2) day of the week the 24-hour recall
was collected, and (3) MVMM supplement use. All statistical
analyses were performed with SAS software (version 9; SAS
Institute Inc., Cary, NC). SAS macros necessary to fit this model
and to perform the estimation of usual intake distributions as well
as additional details and resources regarding the NCI method are
available on the NCI website [25]. Sample weights were used to
account for differential response and noncoverage and to adjust
for planned overlapping of some groups. Survey weights were
also used to generate a nationally representative sample. Mean
dietary intakes between users and nonusers of MVMM supple-
ments, as well as the portion of the population that failed to meet
the EAR and exceeded the UL, were compared by computing a
z-statistic. Significance was set at <0.01.
RESULTS
Fifty-one percent of consumers in the NHANES 2007–2008
and 2009–2010 data sets took an MVMM supplement as pre-
viously defined. Table 1 illustrates lifestyle demographics for
child (4–18 years) MVMM users vs nonusers. Children who
used MVMM were more likely to be younger in age. Children
who used MVMM were also more likely to be non-Hispanic
white and have a higher poverty income ratio. Vigorous phys-
ical activity did not differ among children; however, those
who were users of MVMM were less likely to have sedentary
physical activity and more likely to exhibit moderate physical
activity.
Table 2 illustrates lifestyle demographics for adult
(19 years) MVMM users vs nonusers. Adult users of MVMM
supplements were more likely to be older in age, female, non-
Hispanic white, have attended college, and have a higher poverty
income ratio. These individuals were less likely to smoke and be
96 VOL. 33, NO. 2
Downloaded by [Taylor C. Wallace] at 07:03 14 April 2014
Multivitamin/Mineral Intakes
Table 1. Lifestyle Demographics of Children (4–18 years) Mul-
tivitamin/Mineral Supplement Nonusers and Users1
Variable Nonusers (n=4489) Users (n=658)
Age (y)211.3 ±0.1 10.2 ±0.3
Female sex (%) 49.8 ±1.1 51.5 ±3.0
Race (%)
Mexican
American/Hispanic2
22.0 ±2.5 11.7 ±1.8
Non-Hispanic white256.7 ±2.8 74.0 ±2.4
Non-Hispanic black314.7 ±1.2 10.0 ±1.5
Poverty income ratio22.4 ±0.1 3.0 ±0.2
Current smoker (%) 7.2 ±0.6 5.7 ±1.3
Physical activity (%)
Sedentary310.6 ±0.7 7.5 ±1.0
Moderate423.4 ±1.0 20.8 ±2.8
Vigorous 66.04 ±1.1 71.7 ±3.0
Education (%)
High school graduate,
no college
3.0 ±0.4 2.6 ±0.9
Attended college 1.2 ±0.3 1.5 ±1.0
Alcohol consumer (%) 3.1 ±0.5 3.1 ±1.3
Alcohol (g/d) 0.5 ±0.2 0.5 ±0.3
1Data are presented as the value ±SE.
2p<0.001.
3p<0.01.
4p<0.05.
sedentary. Adult users of MVMM supplements were also more
likely to refrain from sedentary physical activity and to engage
in vigorous physical activity (Table 2). Smoking, alcohol use,
and education were low among both users and nonusers and not
significantly different.
Fifty-one percent of consumers in the NHANES 2007–2008
and 2009–2010 data sets took an MVMM supplement as previ-
ously defined. Table 1 illustrates lifestyle demographics for adult
(19 years) MVMM users vs nonusers. Adult users of MVMM
supplements were more likely to be older in age, female, non-
Hispanic white, have attended college, and have a higher poverty
income ratio. These individuals were less likely to smoke and be
sedentary. Adult users of MVMM supplements were also more
likely to refrain from sedentary physical activity and to engage in
vigorous physical activity (Table 1). Table 2 illustrates lifestyle
demographics for child (4–18 years) MVMM users vs nonusers.
Unlike adults, children who used MVMM were more likely
to be younger in age. Children who used MVMM were also
more likely to be non-Hispanic white and have a higher poverty
income ratio. Smoking, alcohol use, and education were low
among both users and nonusers and not significantly different.
Vigorous physical activity did not differ among children; how-
ever, those who were users of MVMM were less likely to have
sedentary physical activity and more likely to exhibit moderate
physical activity.
The percentage of individuals aged 4 years with total nutri-
ent intakes, including that from foods and MVMM supplements,
falling below the EAR was considerable for vitamin D (74%),
Table 2. Lifestyle Demographics of Adult (19 years) Multivi-
tamin/Mineral Supplement Nonusers and Users1
Variable Nonusers (n=8282) Users (n=3015)
Age (y)244.8 ±0.3 50.6 ±0.6
Female sex (%)249.8 ±0.6 55.3 ±1.2
Race (%)
Mexican
American/Hispanic2
15.8 ±2.0 7.9 ±1.1
Non-Hispanic white264.9 ±2.9 79.7 ±1.6
Non-Hispanic black213.1 ±1.3 7.8 ±0.9
Poverty income ratio22.8 ±0.1 3.4 ±0.1
Current smoker (%)226.6 ±1.0 12.9 ±1.1
Physical activity (%)
Sedentary324.1 ±0.9 19.7 ±1.2
Moderate 38.4 ±0.7 39.2 ±1.3
Vigorous437.5 ±1.0 41.2 ±1.7
Education (%)
High school graduate,
no college2
26.0 ±0.9 20. ±1.1
Attended college250.9 ±1.4 68.8 ±1.7
Alcohol consumer
(%)4
26.2 ±1.2 29.1 ±1.6
Alcohol (g/d) 10.8 ±0.6 10.6 ±0.8
1Data are presented as the value ±SE.
2p<0.001.
3p<0.01.
4p<0.05.
vitamin E (67%), magnesium (46%), calcium (39%), vitamin A
(35%), and vitamin C (31%). Approximately 8% and 33% of the
US population had total usual intakes that exceeded the AI for
total choline and vitamin K (Table 3); virtually no one exceeded
the AI for potassium. In contrast, smaller proportions of the
population had total usual intakes below the EAR (in decreas-
ing prevalence) for zinc, folic acid, vitamin B6, iron, copper,
thiamin, vitamin B12, riboflavin, phosphorus, niacin, and sele-
nium. Use of MVMM supplements decreased the percentage of
the population that fell below the EAR or AI for most of the nu-
trients measured in NHANES. Sodium, potassium, choline, and
phosphorus intakes were unaffected by MVMM consumption.
These effects of MVMM toward meeting EAR targets were more
pronounced in adults aged 19 years than in children 4–19 years
(Figs. 1–3). The percentages of children aged 4–18 years with
total nutrient intakes, including that from foods and MVMM
supplements, falling below the EAR were higher vs the general
population for vitamin D (80%), vitamin E (70%), and calcium
(49%). Significant portions of children aged 4–18 years also fell
below the EAR for magnesium (38%), vitamin A (26%), and
vitamin C (22%). Approximately 62%, 82%, and 100% of chil-
dren aged 4–18 years had total usual intakes falling below the AI
for vitamin K, total choline, and potassium (food and MVMM
use combined; data not shown).
The percentage of the population that exceeded the UL was
<1% for all nutrients except sodium and zinc. There were no
significant differences in the percentage of the population that
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION 97
Downloaded by [Taylor C. Wallace] at 07:03 14 April 2014
Multivitamin/Mineral Intakes
Table 3. Usual Intakes from NHANES 2007–2010 Compared to DRI from Food Only and MVMM Use in Individuals Aged 4 years1
Percentiles
Nutrient Usual Intake 10 25 50 75 90 <EAR >UL
Mean ±SEM % ±SEM % ±SEM
Vitamin D (μg/d)2
Food 4.9 ±0.1 2.0 2.9 4.3 6.3 8.6 94.3 ±0.5 0.0 ±0.0
Food +MVMM 7.6 ±0.1 2.1 3.3 5.4 10.2 16.3 74.6 ±0.6 0.0 ±0.0
Calcium (mg/d)2
Food 987 ±9 567.1 721.4 932.2 1192.8 1478.0 44.1 ±0.9 0.3 ±0.1
Food +MVMM 1040 ±10 583.6 751.1 981.2 1263.5 1568.6 39.5 ±0.9 0.8 ±0.1
Vitamin A (μRAE/d)
Food 621 ±9 304.8 417.3 575.5 775.9 995.9 43.0 ±1.2
Food +MVMM 865 ±16 319.5 449.0 663.6 1108.9 1684.9 35.0 ±1.1
Retinol (μg/d)
Food 446 ±6 206.5 290.3 410.4 562.9 731.6 69.6 ±1.1 0.5 ±0.1
Food +MVMM 605 ±7 217.1 314.6 476.3 775.4 1161.9 55.3 ±0.8 1.7 ±0.1
Vitamin C (mg/d)
Food 84.0 ±1.2 30.8 47.3 73.0 108.5 151.2 38.9 ±1.2 0.0 ±0.0
Food +MVMM 109 ±3 33.2 53.0 87.4 137.8 197.9 31.2 ±1.2 0.0 ±0.0
Vitamin E (mg AT/d)
Food 7.4 ±0.1 4.1 5.3 7.0 9.1 11.4 88.5 ±0.7
Food +MVMM 14.8 ±0.5 4.2 5.7 8.0 15.0 34.2 67.1 ±0.9
Added α-tocopherol (mg/d)
Food 0.6 ±0.0 0.0 0.0 0.1 0.4 1.4 0.0 ±0.0
Food +MVMM 8.0 ±0.4 0.0 0.0 0.2 6.9 26.7 0.0 ±0.0
Thiamin (mg/d)
Food 1.6 ±0.0 1.0 1.2 1.5 1.9 2.3 4.7 ±0.6
Food +MVMM 2.9 ±0.1 1.1 1.3 1.8 2.5 3.4 3.8 ±0.5
Riboflavin (mg/d)
Food 2.2 ±0.0 1.3 1.6 2.0 2.6 3.2 2.1 ±0.2
Food +MVMM 3.5 ±0.1 1.3 1.7 2.3 3.3 4.4 1.8 ±0.2
Niacin (mg/d)
Food 24.7 ±0.2 15.0 18.5 23.4 29.6 36.3 1.1 ±0.3
Food +MVMM 29.7 ±0.3 15.7 19.8 26.5 36.3 46.6 1.0 ±0.3
Vitamin B6 (mg/d)
Food 2.0 ±0.0 1.1 1.4 1.9 2.4 3.0 9.5 ±0.8 0.0 ±0.0
Food +MVMM 3.5 ±0.1 1.2 1.5 2.1 3.3 5.0 7.4 ±0.7 0.1 ±0.0
Vitamin B12 (μg/d)
Food 5.3 ±0.1 2.7 3.6 4.9 6.5 8.4 2.5 ±0.3
Food +MVMM 11.1 ±0.5 2.9 4.0 5.8 9.3 20.1 2.1 ±0.3
Folate (μg DFE/d)
Food 542 ±6 314.4 398.5 513.4 654.6 807.5 9.5 ±0.6
Food +MVMM 709 ±9 330.5 430.1 590.6 902.9 1268.6 7.6 ±0.6
Folic acid (μg/d)
Food 200 ±3 91.3 128.7 183.1 252.8 330.3 0.4 ±0.1
Food +MVMM 298 ±5 101.6 148.0 226.9 393.8 605.0 2.5 ±0.2
Phosphorus (mg/d)
Food 1350 ±8 1082.8 1149.9 1259.2 1567.9 1710.1 1.0 ±2.9 0.0 ±0.0
Food +MVMM 1361 ±8 1079.4 1149.8 1286.6 1573.4 1725.7 1.0 ±2.1 0.0 ±0.0
Magnesium (mg/d)
Food 286 ±3 172.4 215.2 272.7 342.7 417.8 52.2 ±1.2
Food +MVMM 303 ±3 176.7 222.5 286.0 364.6 448.5 46.6 ±1.3
Mg from MVMM 16.5 ±0.7 0.0 0.0 0.0 1.7 50.0 0.2 ±0.1
Iron (mg/d)
Food 15.1 ±0.1 9.1 11.3 14.3 18.0 22.0 7.4 ±0.4 0.0 ±0.0
Food +MVMM 17.3 ±0.2 9.4 11.8 15.4 20.6 28.8 6.2 ±0.4 0.7 ±0.1
Zinc (mg/d)
Food 11.7 ±0.1 7.0 8.7 11.0 14.0 17.2 11.7 ±1.0 1.6 ±0.1
Food +MVMM 14.7 ±0.2 7.3 9.3 12.5 18.3 25.5 9.6 ±0.8 3.4 ±0.1
Copper (μg/d)
Food 1.3 ±0.0 0.8 0.9 1.2 1.5 1.9 4.2 ±0.6 0.0 ±0.0
Food +MVMM 1.6 ±0.0 0.8 1.0 1.3 1.9 2.9 3.8 ±0.5 0.4 ±0.1
(Continued on next page)
98 VOL. 33, NO. 2
Downloaded by [Taylor C. Wallace] at 07:03 14 April 2014
Multivitamin/Mineral Intakes
Table 3. Usual Intakes from NHANES 2007–2010 Compared to DRI from Food Only and MVMM Use in Individuals Aged 4 years1
(Continued)
Percentiles
Nutrient Usual Intake 10 25 50 75 90 <EAR >UL
Selenium (mg/d)
Food 108 ±1 68.7 82.8 102.2 128.0 156.0 0.3 ±0.2 0.1 ±0.0
Food +MVMM 120 ±1 70.7 86.3 109.4 141.9 179.0 0.2 ±0.1 0.1 ±0.0
Nutrients with an AI
Potassium (mg/d2)
Food 2595 ±20 2052.8 2262.3 2491.9 3012.0 3222.9 100 ±0
Food +MVMM 2606 ±20 2044.6 2242.0 2498.1 3005.9 3238.4 100 ±1
Sodium (mg/d)
Food 3433 ±23 2572.8 2819.9 3066.8 3855.3 4920.3 0.1 ±0.3 97.5 ±8.3
Food +MVMM 3433 ±20 2575.7 2821.2 3067.3 3856.5 4915.2 0.1 ±0.3 97.6 ±7.4
Vitamin K (μg/d)
Food 85.2 ±2.1 37.9 52.8 75.5 106.7 144.3 66.9 ±1.8
Food +MVMM 90.4 ±2.2 38.3 54.3 79.4 114.4 156.0 62.8 ±1.9
Choline (mg/d)
Food 315 ±2.4 188.2 232.5 294.9 377.9 469.7 91.7 ±0.6 0.0 ±0.0
Food +MVMM 316 ±2.1 190.9 234.1 295.1 377.6 470.9 91.6 ±0.6 0.0 ±0.0
NHANES =National Health and Nutrition Examination Survey, DRI =dietary reference intake, MVMM =multivitamin/multimineral, EAR =estimated average
requirement, UL =tolerable upper intake level, SEM =standard error of the mean, RAE =retinol activity equivalents, AT =alpha-tocopherol, DFE =dietary folate
equivalents, AI =adequate intake.
1n=16,444.
2Nutrient identified by the 2010 Dietary Guidelines Advisory Committee as being a nutrient of public health concern.
Fig. 1. Percentage of US adults aged 19 years with vitamin (top)
and mineral (bottom) intakes below the EAR. The asterisk represents
nutrients with an adequate intake. n=11,297. (Color figure available
online.)
Fig. 2. Percentage of US children aged 4–18 years with vitamin (top)
and mineral (bottom) intakes below the EAR. The asterisk represents
nutrients with an adequate intake. n=2659. (Color figure available
online.)
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION 99
Downloaded by [Taylor C. Wallace] at 07:03 14 April 2014
Multivitamin/Mineral Intakes
Fig. 3. Prevalence of children aged 4–8 years with micronutrient intakes
exceeding the UL from food only and MVMM use. n=1895. (Color
figure available online.)
exceeded the UL for sodium among users and nonusers of
MVMM supplements. The percentage of the population that ex-
ceeded the UL for zinc, including that from foods and MVMM
supplements, was <1% for all age groups except in children
aged 4–8 years (32%) and 9–13 years (4%; Fig. 3). Food alone
contributed to 22% of children aged 4–8 years exceeding the
UL for zinc; use of MVMM supplements increased this value to
32%.
DISCUSSION
It has previously been reported that dietary supplement use
has been on the rise over the past 30 +years [1–3]. To our knowl-
edge, this is the first report from NHANES showing that over
half the population uses MVMM. Previous data from NHANES
2003–2006 analyses defining an MVMM supplement as “a prod-
uct containing 3 or more vitamins and 1 or more minerals per
supplement” showed usage to be about 33% of the entire popu-
lation 1 year [1]. Comparison of these data might suggest an
increase in the use of MVMM. However, it is important to note
that the Dietary Supplement Questionnaire was introduced for
the first time during NHANES 2007–2008 [19], allowing more
accurate estimates of nutrient intakes from dietary supplements
in general but making data on dietary supplement usage from
previous NHANES data sets harder to fully compare. Our find-
ings on MVMM usage do more closely mimic those reported in
the multiethnic cohort [26].
Our findings on the lifestyle demographics of MVMM adult
users complement other studies of participants enrolled in the
Multiethnic Cohort Study [25], as well as in previous NHANES
analyses [1,2,5]. Similar observations on the lifestyle demo-
graphics of children have also recently been published. In par-
ticular, a study looking at the prevalence and predictors of chil-
dren’s supplement usage in the National Health InterviewSurvey
showed that children who used MVMM were more likely to be
non-Hispanic white and to be from families with higher parental
education and/or income status. Children who were reported
to have good, very good, or excellent health status were more
likely to use MVMM than were children with poor or fair health
[3]. Our study showed significant differences in children with
sedentary and moderate physical activity; however, it should be
noted that the variance between users and nonusers of MVMM
was not drastic, and the majority of children (67%) enrolled in
NHANES 2008–2010 reported vigorous physical activity.
MVMM usage significantly decreased the percentage of the
population who did not meet the EAR for most vitamins and
minerals measured in NHANES, although the reduction was not
extremely dramatic. Users were defined as those who had taken
an MVMM product during the 30 days prior to data collection.
This includes those who are daily and occasional/sporadic users.
Though the use of MVMM shifts intakes up (measured by usual
intake percentile), the shift is not great until the top 2 percentiles
(75% and 90%). These top 2 percentiles more than likely reflect
regular/daily users of MVMM products, whereas the lower per-
centiles more than likely reflect occasional/sporadic users. The
data emphasize the safety of MVMM because they contribute
nutritional (vs pharmacological) levels of nutrients. These data
also complement previous reports [2,4,5] that the best-nourished
people are making repeated good choices, in terms of both foods
and supplements, and it does not appear that individuals with
more adequate nutrient intakes use MVMM to compensate for
poor dietary habits.
MVMM usage did not contribute to excessive intakes above
the UL across the population as a whole, except in the case
of zinc, which was driven by excessive intakes among children
4–8 years. The UL for children are generally extrapolated down
using safety data from clinical studies of healthy adults. At the
time the IOM FNB released the DRI for zinc, there was only
one case report of a zinc-induced copper deficiency anemia in
a young child [27]. There were no published studies of adverse
effects of zinc on copper status in children or adolescents at the
time [27]. Thus, our data would call for more research on the ad-
verse health effects, if any, from intake levels exceeding the UL
for zinc. It might also suggest that the IOM FNB consider revis-
iting the DRI for zinc [28]. Similarly, MVMM supplementation
contributed to excess copper intakes of <5% in children age
4–8 years (Fig. 3); however, this was not large enough to affect
the entire population.
A limitation of this article is that the estimates relied on self-
reported dietary data for both nutrient intakes from foods and
MVMM. The models that we applied also relied on assumptions
that reported nutrient intakes from food sources on the 24-hour
recalls were unbiased, and the self-reported dietary supplement
intake reflected the true long-term MVMM intake patterns. Al-
though the dietary supplement data are self-reported, 85% of the
time, NHANES interviewers saw the dietary supplement bottles
and labels that participants reported using to verify accuracy.
Furthermore, estimates of vitamins and minerals contributed by
100 VOL. 33, NO. 2
Downloaded by [Taylor C. Wallace] at 07:03 14 April 2014
Multivitamin/Mineral Intakes
dietary supplements depended on the label declarations rather
than analytic values. The oversampling of Mexican American
population in the NHANES 2007–2010 data sets [16] could
have affected the outcomes of this study, given that non-Hispanic
white individuals have consistently shown higher rates of dietary
supplement and MVMM use compared to other racial groups in
this study and others [1,2,26]. We did not present data for preg-
nant and/or lactating females and this information is virtually
unknown because of the small sample size of this population
among NHANES participants. The data presented in this article
should be interpreted with these limitations in mind.
CONCLUSION
Micronutrient sufficiency is not currently being achieved
through food solutions in large portions of the population.
Nutrient-dense foods such as fruits, vegetables, legumes, whole
grains, low- or nonfat dairy products, and lean meats are the pre-
ferred means of obtaining recommended intakes of micronutri-
ents. Nevertheless, MVMM supplements contribute to a greater
number of individuals meeting their recommended intakes of
almost all micronutrients measured by NHANES. Use of age-
and gender-specific MVMM supplements may be advantageous
in generally healthy populations when the diet is not sufficient
because they rarely led to excessive intakes when consumed
as directed. Ideally, formulations and amounts of vitamins and
minerals in MVMM should be used to help meet, but not ex-
ceed, DRI recommendations to best fit the nutrient needs of the
population.
Author’s Contributions
T.C.W., M.M., and V.L.F. designed research, analyzed data,
and wrote the article. V.L.F. conducted the research. All authors
read and approved the final article.
Funding
Source of financial support: Council for Responsible Nutri-
tion.
REFERENCES
1. Bailey RL, Gahche JJ, Lentino CV, Dwyer JT, Engel JS, Thomas
PR, Betz JM, Sempos CT, Picciano MF: Dietary supplement use in
the United States, 2003–2006. J Nutr 141:261–266, 2011.
2. Gahche J, Bailey R, Burt V, Hughes J, Yetley E, Dwyer J, Picciano
MF, McDowell M, Sempos C: Dietary supplement use among US
adults has increased since NHANES III (1988–1994). NCHS Data
Brief 61:1–8, 2011.
3. Dwyer J, Nahin RL, Rogers GT, Barnes PM, Jacques PM, Sempos
CT, Bailey R: Prevalence and predictors of children’s dietary sup-
plement use: the 2007 National Health Interview Survey. Am J Clin
Nutr 97:1331–1337, 2013.
4. Dickenson A, Blatman J, El-Dash N, Franco JC: Consumer usage
and reasons for using dietary supplements: report of a series of
surveys. J Am Coll Nutr 33:178–184, 2013.
5. Bailey RL, Gahche JJ, Miller PE, Thomas PR, Dwyer JT: Why US
adults use dietary supplements. JAMA Intern Med 173:355–361,
2013.
6. Gaziano JM, Sesso HD, Christen WG, Bubes V, Smith JP, Mac-
Fadyen J, Schvartz M, Manson JE, Glynn RJ, Buring JE: Multivi-
tamins in the prevention of cancer in men: the Physicians’ Health
Study II randomized controlled trial. JAMA 308:1871–1880, 2012.
7. Sesso HD, Christen WG, Bubes V, Smith JP, MacFadyen J, Schvartz
M, Manson JE, Glynn RJ, Buring JE, Gaziano JM: Multivitamins
in the prevention of cardiovascular disease in men: the Physicians’
Health Study II randomized controlled trial. JAMA 308:1751–1760,
2012.
8. Macpherson H, Pipingas A, Pase MP: Multivitamin–multimineral
supplementation and mortality: a meta-analysis of randomized con-
trolled trials. Am J Clin Nutr 97:437–444, 2013.
9. Alexander D, Weed DL, Chang ET, Miller PE, Mohamed MA,
Elkayam L: A systematic review of multivitamin–multimineral use
and cardiovascular disease and cancer incidence and total mortality.
J Am Coll Nutr 32:339–354, 2013.
10. Grima NA, Pase MP, Macpherson H, Pipingas A: The effects of
multivitamins on cognitive performance: a systematic review and
meta-analysis. J Alzheimers Dis 29:561–569, 2012.
11. National Institutes of Health: NIH State-of-the-Science Conference
Statement on Multivitamin/Mineral Supplements in Chronic Dis-
ease Prevention. NIH Consens State Sci Statements 23:1–30, 2006.
12. Older Americans Act, Pub L No. 109–365.
13. Fulgoni VL III, Keast DR, Bailey RL, Dwyer J: Foods, fortificants
and supplements: where do Americans get their nutrients? J Nutr
141:1847–1854, 2011.
14. Navarro M, Wood RJ: Plasma changes in micronutrients following
a multivitamin and mineral supplement in healthy adults. J Am Coll
Nutr 22:124–132, 2003.
15. McKay DL, Perrone G, Rasmussen H, Dallal G, Hartman W,
Cao G, Prior RL, Roubenoff R, Blumberg JB: The effects
of a multivitamin/mineral supplement on micronutrient status,
antioxidant capacity and cytokine production in healthy older
adults consuming a fortified diet. J Am Coll Nutr 19:613–621,
2000.
16. National Center for Health Statistics: About the National
Health and Nutrition Examination Survey. Accessed at:
http://www.cdc.gov/nchs/nhanes/about nhanes.htm.
17. Blanton CA, Moshfegh AJ, Baer DJ, Kretsch MJ: The USDA auto-
mated multiple-pass method accurately estimates group total energy
and nutrient intake. J Nutr 136:2594–2599, 2006.
18. Moshfegh AJ, Rhodes DG, Baer DJ, Murayi T, Clemens JC,
Rumpler WV, Paul DR, Sebastian RS, Kuczynski KJ, Ingw-
ersen LA, Staples RC, Cleveland LE: The US Department of
Agriculture automated multiple-pass method reduces bias in the
collection of energy intakes. Am J Clin Nutr 288:324–332,
2008.
19. US Centers for Disease Control and Prevention: National Health
and Nutrition Examination Survey SP Questionnaire Component:
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION 101
Downloaded by [Taylor C. Wallace] at 07:03 14 April 2014
Multivitamin/Mineral Intakes
Dietary Supplements Questionnaire Data. Accessed at:
http://www.cdc.gov/nchs/nhanes/nhanes questionnaires.htm.
20. US Department of Agriculture National Agriculture Library: Na-
tional Nutrient Database for Standard Reference. Accessed at:
http://ndb.nal.usda.gov/.
21. Institute of Medicine Food and Nutrition Board: “Reference Intakes:
Applications in Dietary Assessment.” Washington, DC: National
Academy Press, 2000.
22. Institute of Medicine Food and Nutrition Board: “Dietary Refer-
ence Intakes: Applications in Dietary Planning.” Washington, DC:
National Academy Press, 2003.
23. Bailey RL, Dodd KW, Goldman JA, Gahche JJ, Dwyer JT, Mosh-
fegh AJ, Sempos CT, Picciano MF: Estimation of total usual calcium
and vitamin D intakes in the United States. J Nutr 140:817–822,
2010.
24. Tooze JA, Midthune D, Dodd KW, Freedman LS, Krebs-Smith
SM, Subar AF, Guenther PM, Carroll RJ, Kipnis V: A new sta-
tistical method for estimating the usual intake of episodically con-
sumed foods with application to their distribution. J Am Diet Assoc
106:1575–1587, 2006.
25. National Cancer Institute: Usual Dietary Intakes: The NCI
Method. Accessed at: http://riskfactor.cancer.gov/diet/usualintakes/
method.html.
26. Park SY, Murphy SP, Wilkens LR, Henderson BE, Kolonel LN:
Multivitamin use and the risk of mortality and cancer incidence.
Am J Epidemiol 173:906–914, 2011.
27. Botash AS, Nasca J, Dubowy R, et al. Oliphant M. Zinc-induced
copper deficiency in an infant. Am J Dis Child 146:709–711,
1992.
28. Food and Nutrition Board, Institute of Medicine: Dietary Refer-
ence Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium,
Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon,
Vanadium, and Zinc. Washington, DC: National Academy Press,
2001.
Received July 19, 2013; revision accepted September 17, 2013.
102 VOL. 33, NO. 2
Downloaded by [Taylor C. Wallace] at 07:03 14 April 2014
... Although choline is essential for healthy brain development [8,9], its intake is often limiting during the high-demand periods of pregnancy and lactation [10,11]. Supplemental choline significantly improves offspring cognition and memory [8,9,12], prompting parallel investigations for FASD. ...
... These findings highlight that genetic variance in nutrient transporters may be an important influence on tissue-level nutrient status. Because choline insufficiency is common during pregnancy, lactation, and early childhood [9][10][11]46], these data support the importance of choline adequacy for healthy brain development through dietary and/or supplement approaches. The interaction between PAE status and genotype was associated with reduced cognitive performance in normotypic carriers to levels that did not differ from those with PAE under either genotype. ...
... Multivitamin and multi mineral supplements are intended for the maintenance of health and studies have shown that they are effective in bridging dietary gaps [49]. A US study found that 51 percent of the population who took a multivitamin and multi mineral supplement which provided more than nine nutrients, effectively bridged the dietary gaps created by shortages of several nutrients in the diet [50]. ...
Article
Full-text available
Vitamins, minerals and essential fatty acids are vital to health. In the UK, the National Diet and Nutrition survey rolling programme estimates the intake of a range of these essential nutrients and foods that contain them. Since this programme began in 2008/2009 nutrient intakes have not improved. The aim of this paper is to evaluate vitamin and mineral intakes in the latest iteration of the National Diet and Nutrition Survey and compare these intakes with those in 2008/2009 and where possible with similar data from UK surveys going back to 1997. This paper also analysed findings from a survey of reviewing people’s knowledge, habits and opinions on nutrition, vitamin and mineral intakes and supplementation to contribute to the interpretation of findings from the NDNS. Consumption of the majority of the micronutrients measured in the NDNS fell from 2008/2009 to 2018/2019. These decreases were greater in women than men and particularly worrying in younger women especially for vitamin A, riboflavin, folate, calcium, magnesium, iron, zinc, iodine and selenium. Reductions of the same micronutrients in young men were also evident and only zinc intakes have improved in older men. Poor dietary intakes are due to confusion and lack of knowledge as to what constitutes a healthy diet, lack of time and the cost of healthy eating which has increased during recent years. Nutrients can be provided from a healthy diet, but this is not being achieved. Hence a multivitamin and multi mineral food supplement is the best policy to bridge these dietary gaps.
... Complementary and alternative medicine has huge positive aspect as compared to the conventional treatment strategy [46]. Another report suggested that multivitamin/mineral (MVMM) supplements are the most common dietary supplements consumed about 51% in the United States [47]. Overall data suggest that the novel formulation could be immunomodulatory, antioxidant, and anti-inflammatory effect and might produce as a better immunomodulatory medicine in the near future. ...
Article
Full-text available
The aim of the present study was to investigate the antioxidant activity of Consciousness Energy Healing (The Trivedi Effect®) based novel proprietary formulation in male Sprague Dawley (SD) rats. The formulation was divided into two parts. One part received the Biofield Energy Healing Treatment by renowned Biofield Energy Healer, Mahendra Kumar Trivedi, defined as the Biofield Energy Treated sample. Another part did not receive any treatment and referred as a control. Additionally, three groups of animals were also received Biofield Energy Healing Treatment at day -15 per se. The tissue lipid peroxidation data exhibited that the level of malondialdehyde (MDA) was reduced by 22.75% and 19.57% in the Biofield Energy Treated test formulation (G5) and Biofield Energy Treatment per se plus Biofield Energy Treated test formulation from the day -15 (G8), respectively compared to the disease control group (G2). Antioxidant enzyme like superoxide dismutase (SOD) was significantly increased by 35.35% and 37.53% in the G7 and G8 groups, respectively as compared to the G2 group. Additionally, the level of catalase was significantly (p≤0.05) increased by 85.29%, 78.84%, 135.87%, 130.08%, 102.15%, and 66.45% in the G4, G5, G6, G7, G8, G9 groups, respectively compared to the G2 group. Further, hematology data showed that the platelet count was significantly increased by 17.09% and 9.42% in the G6 and G8 groups, respectively as compared to the G2 group. Biochemical results showed that the level of blood urea was reduced by 26.26%, 28.51%, 26.88%, 17.19%, and 18.05% in the G3, G4, G6, G7, and G9, groups respectively compared to the G2 group. The level of uric acid level was significantly reduced by 31.25% in the G6 group, while phosphorus was significantly increased by 20.57% and 33.03% in the G7 and G8 groups, respectively compared to the G2 group. Further, the change in body weight and feed consumption did not suggest any statistical difference, which depicts that the Biofield Energy Treated test formulation was found to be safe. Thus, the Biofield Treated test formulation has shown sigificant antioxidant activity and can be used for autoimmune and inflammatory diseases, stress management and prevention, and act as anti-aging therapy for the improvement of overall health.
Book
\"Egzersiz ve Beslenme\" adlı kitap, Dr. Akan Bayrakdar ve Prof. Dr. Erdal Zorba tarafından kaleme alınmıştır. Kitap, doğru beslenmenin vücut ağırlığı yönetimi ve fonksiyonlarının sürdürülmesi için önemini vurgulamaktadır. Besinlerle yeterli enerji almanın aktiflik ve kas kütlesi koruması sağladığı belirtilmektedir. Sporcu beslenmesi ise sporcuların antrenman ve müsabaka performanslarını geliştirmek için hazırlanan özel bir beslenme programıdır. Kitap, besin ögelerinin sağlık ve sporcu performansı üzerindeki etkilerinin yanı sıra kan gruplarına göre beslenme, alkali beslenme ve yeme bozuklukları gibi konuları ele almaktadır. Kitap, 300'den fazla kaynaktan yararlanılarak hazırlanmış olup, üniversitelerin Spor Bilimleri fakülteleri ve Beden Eğitimi ve Spor Yüksekokulları'nda kullanılabilecek düzeydedir. Kan gruplarına göre beslenme konusu, Mehmet Ali Bulut ve Peter J. D'Adamo'nun kitaplarından alıntılarla işlenmiştir. Alkali beslenme konusu ise Dr. Ayşegül Çoruhlu'nun kitaplarından faydalanılarak ele alınmıştır. Kitap ayrıca anoreksiya nevroza, bulimia nevroza ve ortoreksiya nevroza gibi yeme bozukluklarına da değinmektedir. The book titled \"Exercise and Nutrition\" is written by Dr. Akan Bayrakdar and Prof. Dr. Erdal Zorba. The book emphasizes the importance of proper nutrition for managing body weight and maintaining bodily functions. It states that consuming sufficient energy through food provides benefits such as maintaining activity levels and preserving muscle mass. Sports nutrition, on the other hand, is a specialized nutrition program designed to improve athletes' training and competition performance. The book covers topics such as the effects of nutrients on health and athletic performance, as well as subjects like nutrition based on blood types, alkaline nutrition, and eating disorders. The book is based on over 300 sources and is suitable for use in universities' faculties of Sports Sciences and Physical Education and Sports Schools. The topic of nutrition based on blood types is discussed with excerpts from the books of Mehmet Ali Bulut and Peter J. D'Adamo. The topic of alkaline nutrition is approached by benefiting from the books of Dr. Ayşegül Çoruhlu. The book also addresses eating disorders such as anorexia nervosa, bulimia nervosa, and orthorexia nervosa.
Article
Full-text available
Objective:to simulate the impact on calcium intake- effectiveness and safety- of fortifying wheat flour with 200, 400 and 500 mg of calcium per 100 g of flour. Design:secondary analysis of cross-sectional data collected through repeated 24-hour dietary recalls using IOWA the Intake Modelling, Assessment and Planning Program. Setting:urban cities in the National Health and Nutrition Survey of Argentina (ENNyS 2018 – 2019). Participants:21358 participants, including children, adolescents, and adults. Results:Most individuals in all age groups reported consuming wheat flour. The prevalence of low calcium intake was above 80% in individuals older than 9 years. Simulating the fortification of 500 mg of calcium per 100 g of wheat flour showed that the prevalence of low calcium intake could be reduced by more than 40 percentage points in girls and women aged 19 to less than 51 and boys and men aged 4 to less than 71, while it remained above 65% in older ages. The percentages above the upper intake level remained below 1.5% in all age groups. Conclusions:Calcium flour fortification could be further explored to improve calcium intake. Subnational simulations could be performed to identify groups that might not be reached by this strategy that could be explored in Argentina. This analysis could be used to advocate for a strategy to fortify wheat flour.
Article
Nutrition labels on packaged foods or on shelf tags are used to help the general population make informed food choices to prevent or reduce diet-related chronic diseases and meet nutritional needs. However, inaccurate nutrition labeling can mislead consumers by providing unsuitable nutritional assessments, which can increase the risk of certain chronic diseases and cause huge medical costs. So, inaccurate nutrition labeling should be avoided. A study of 8,596 foods from the USDA National Nutrient Database revealed that only 0.2% of foods are customarily consumed 100 g or 100 mL per eating occasion. Thus, it is not reasonable to provide nutrient information based on 100 g or 100 mL on nutrition labels. Despite the fact that providing nutrient information based on 100 g or 100 mL on nutrition labels is an incorrect approach, unfortunately, most of the nutrient regulations in the world are based on 100 g or 100 mL. The Nutrition Facts label regulated by the U.S. Food and Drug Administration (FDA): (1) cannot make a significant contribution to the prevention or reduction of obesity and overweight; (2) makes food choices difficult and time-consuming; (3) helps consumers choose some foods containing excessive energy; (4) helps consumers choose some foods high in negative nutrients (including energy/calories, saturated fat, trans fat, sodium, cholesterol, fat, and sugars); (5) discourages consumers from choosing some foods low in negative nutrients; (6) helps consumers choose foods high in saturated fat or trans fat and low in cholesterol; (7) helps consumers choose some small serving foods high in negative nutrients; (8) discourages consumers from choosing some nutritious foods; (9) eliminates the ability of consumers to monitor their intake of many positive nutrients and to identify and compare foods in terms of many positive nutrients; (10) encourages unsuitable or excessive uses of fortification; and (11) promotes fortified foods and degrades unfortified foods. The proposed Nutrition Facts label helps individuals who want to comply with public health guidance or dietary recommendations from health care providers. The proposed Nutrition Facts label is an accurate, convenient, and quick information tool for making informed food choices to prevent or reduce diet-related chronic diseases and to meet nutritional needs in the context of daily energy needs.
Article
Background & Aims Micronutrient deficiency (MND) (ie, lack of vitamins and minerals) during pregnancy is a major public health concern. Historically, studies have considered micronutrients in isolation; however, MNDs rarely occur alone. The impact of co-occurring MNDs on public health, mainly in shaping mucosal colonization by pathobionts from the Enterobacteriaceae family, remains undetermined due to lack of relevant animal models. Methods To establish a maternal murine model of multiple MND (MMND), we customized a diet deficient in vitamins (A, B12, and B9) and minerals (iron and zinc) that most commonly affect children and women of reproductive age. Thereafter, mucosal adherence by Enterobacteriaceae, the associated inflammatory markers, and proteomic profile of intestines were determined in the offspring of MMND mothers (hereafter, low micronutrient [LM] pups) via bacterial plating, flow cytometry, and mass spectrometry, respectively. For human validation, Enterobacteriaceae abundance, assessed via 16s sequencing of 3-month-old infant fecal samples (n = 100), was correlated with micronutrient metabolites using Spearman’s correlation in meconium of children from the CHILD birth cohort. Results We developed an MMND model and reported an increase in colonic abundance of Enterobacteriaceae in LM pups at weaning. Findings from CHILD cohort confirmed a negative correlation between Enterobacteriaceae and micronutrient availability. Furthermore, pro-inflammatory cytokines and increased infiltration of lymphocyte antigen 6 complex high monocytes and M1-like macrophages were evident in the colons of LM pups. Mechanistically, mitochondrial dysfunction marked by reduced expression of nicotinamide adenine dinucleotide (NAD)H dehydrogenase and increased expression of NAD phosphate oxidase (Nox) 1 contributed to the Enterobacteriaceae bloom. Conclusion This study establishes an early life MMND link to intestinal pathobiont colonization and mucosal inflammation via damaged mitochondria in the offspring.
Article
Zinc acts as an important cofactor in the body and is essential for normal functions. Several zinc interventions have been implemented worldwide to improve the public's zinc status, but limited studies have assessed their cost‐effectiveness. To help inform decision‐making on zinc interventions to maximize benefits within a fixed budget, we took China as an example and evaluated the cost‐effectiveness of three interventions, that is, supplementation, food fortification, and biofortification. As an essential group at high risk of zinc deficiency, children aged 5–14 years, who account for 10% of the Chinese population, were selected as the target group in this study. We constructed a decision‐analytic Markov model to determine the cost‐effectiveness of interventions in China under different scenarios. In our model, biofortification through conventional breeding was shown to be the most cost‐effective approach in most scenarios. Compared with other interventions, zinc supplementation gained fewer quality‐adjusted life years at a higher net cost, suggesting that this common approach may not be optimal for large‐scale, long‐term implementation at the national level. While the robustness of the results was further confirmed by the sensitivity analysis, more research is needed to assess the cost‐effectiveness of addressing zinc deficiency with other interventions. Further clinical trials are also expected to evaluate the effectiveness of zinc interventions in reducing pneumonia cases [EconLit Citations: I18, Q16, Q18].
Article
Full-text available
Background: Little is known about the characteristics of US children who are dietary supplement users. Objective: We described the prevalence and predictors of and reasons for giving children dietary supplements. Design: The study included children <18 y of age who participated in the Complementary and Alternative Medicine supplement of the National Health Interview Survey of 2007 whose proxies provided complete information on child dietary supplement use. Results: A total of 37% of subjects used dietary supplements, 31% of subjects used multivitamin mineral (MVM) products exclusively, 4% of subjects used single vitamins or minerals solely or in combination with MVMs, and 2% of subjects used nonvitamin, nonmineral products either solely or in combination with other supplements. Users were more likely than nonusers to be Asian, white, or non-Hispanic; belong to families with higher parental education and income levels; reside in areas other than the South; be in good, very good, or excellent health; have private health insurance; and have a usual place at which they received conventional medical care. Children (3%) with the most disease burden and health care were more likely to use supplements than were healthier children. Supplements were given for the prevention or treatment of many illnesses and conditions. Neither the caregiver's reasons nor specific supplements used were consistently associated with particular conditions. Conclusions: The 37% of US children who used any type of dietary supplements differed from nonusers in family socioeconomic status and many other health-related characteristics. Users were given supplements to prevent or treat many illnesses and conditions for which there is only limited evidence of their efficacy.
Article
Full-text available
Background: Dietary supplements are used by more than half of adults, although to our knowledge, the reasons motivating use have not been previously examined in US adults using nationally representative data. The purpose of this analysis was to examine motivations for dietary supplement use, characterize the types of products used for the most commonly reported motivations, and to examine the role of physicians and health care practitioners in guiding choices about dietary supplements. Methods: Data from adults (≥20 years; n = 11 956) were examined in the 2007-2010 National Health and Nutrition Examination Survey, a nationally representative, cross-sectional, population-based survey. Results: The most commonly reported reasons for using supplements were to "improve" (45%) or "maintain" (33%) overall health. Women used calcium products for "bone health" (36%), whereas men were more likely to report supplement use for "heart health or to lower cholesterol" (18%). Older adults (≥60 years) were more likely than younger individuals to report motivations related to site-specific reasons like heart, bone and joint, and eye health. Only 23% of products were used based on recommendations of a health care provider. Multivitamin-mineral products were the most frequently reported type of supplement taken, followed by calcium and ω-3 or fish oil supplements. Supplement users are more likely to report very good or excellent health, have health insurance, use alcohol moderately, eschew cigarette smoking, and exercise more frequently than nonusers. Conclusions: Supplement users reported motivations related to overall health more commonly than for supplementing nutrients from food intakes. Use of supplements was related to more favorable health and lifestyle choices. Less than a quarter of supplements used by adults were recommended by a physician or health care provider.
Article
Full-text available
Complementary medicine use is becoming increasingly popular with multivitamins being the most commonly used vitamin supplement. Although adequate vitamin and nutrient concentrations are necessary for optimal health and cognitive functioning, there is no scientific consensus as to whether multivitamin use prevents cognitive decline or improves mental functioning. The aim of the present study was to determine if multivitamins can be used efficaciously to improve cognitive abilities. A systematic review of randomized controlled trials was performed. Meta-analysis was performed on those cognitive tests used across the largest number of studies. Multiple electronic databases were searched until July 2011 by two authors. Randomized, placebo-controlled trials were considered appropriate if they reported on the chronic effects (≥1 month) of oral multivitamin supplementation on any valid cognitive outcomes. Ten trials were included in review (n = 3,200). Meta-analysis indicated that multivitamins were effective in improving immediate free recall memory (SMD = 0.32; 95% CI: 0.09-0.56, p < 0.01) but not delayed free recall memory (SMD = -0.14; 95% CI: -0.43-0.14, p = 0.33) or verbal fluency (SMD = 0.06; 95% CI: -0.05-0.18, p = 0.26). There was no evidence of publication bias or heterogeneity. Other cognitive abilities sensitive to AD pathology, such as executive and visuospatial functions, were found to be under researched. In conclusion, multivitamins were found to enhance immediate free recall memory but no other cognitive domains.
Article
Background Dietary supplements are used by more than half of adults, although to our knowledge, the reasons motivating use have not been previously examined in US adults using nationally representative data. The purpose of this analysis was to examine motivations for dietary supplement use, characterize the types of products used for the most commonly reported motivations, and to examine the role of physicians and health care practitioners in guiding choices about dietary supplements. Methods Data from adults (≥20 years; n = 11 956) were examined in the 2007-2010 National Health and Nutrition Examination Survey, a nationally representative, cross-sectional, population-based survey. Results The most commonly reported reasons for using supplements were to “improve” (45%) or “maintain” (33%) overall health. Women used calcium products for “bone health” (36%), whereas men were more likely to report supplement use for “heart health or to lower cholesterol” (18%). Older adults (≥60 years) were more likely than younger individuals to report motivations related to site-specific reasons like heart, bone and joint, and eye health. Only 23% of products were used based on recommendations of a health care provider. Multivitamin-mineral products were the most frequently reported type of supplement taken, followed by calcium and ω-3 or fish oil supplements. Supplement users are more likely to report very good or excellent health, have health insurance, use alcohol moderately, eschew cigarette smoking, and exercise more frequently than nonusers. Conclusions Supplement users reported motivations related to overall health more commonly than for supplementing nutrients from food intakes. Use of supplements was related to more favorable health and lifestyle choices. Less than a quarter of supplements used by adults were recommended by a physician or health care provider.
Article
National Institutes of Health (NIH) consensus and state-of-the-science statements are prepared by independent panels of health professionals and public representatives on the basis of 1) the results of a systematic literature review prepared under contract with the Agency for Healthcare Research and Quality (AHRQ), 2) presentations by investigators working in areas relevant to the conference questions during a 2-day public session, 3) questions and statements from conference attendees during open discussion periods that are part of the public session, and 4) closed deliberations by the panel during the remainder of the second day and the morning of the third. This statement is an independent report of the panel and is not a policy statement of the NIH or the federal government. The statement reflects the panel's assessment of medical knowledge available at the time the statement was written. Thus, it provides a "snapshot in time" of the state of knowledge on the conference topic. When reading the statement, keep in mind that new knowledge is inevitably accumulating through medical research.
Article
Multivitamin-multimineral (MVM) supplements are the most frequently used dietary supplements in the United States, with one third or more of the population using at least one daily. However, the health-related implications of MVM use are unclear. Thus, we systematically reviewed and summarized the prospective studies of MVM supplementation and all-cause and cause-specific mortality, as well as cardiovascular disease (CVD) and cancer incidence, to critically evaluate the current evidence on this topic. We included studies of generally healthy adult populations that evaluated multivitamin (the most commonly used dietary supplement) and/or multimineral supplement use or simultaneous use of 3 or more vitamins and minerals. We did not evaluate individual supplements. A total of 12 cohort studies and 3 primary prevention randomized controlled trials met our inclusion criteria. The majority of the studies were conducted in the United States (n = 11), and the remaining were conducted in European countries (n = 3) and Japan (n = 1). Although between-study methodological variation was present, most relative risks hovered closely around or slightly below the null value. No clear patterns of associations by study country, gender, smoking status, or frequency of use were observed. Based upon the available scientific evidence to date, supplementation with MVMs does not appear to increase all-cause mortality, cancer incidence or mortality, or CVD incidence or mortality and may provide a modest protective benefit.
Article
Background: Multivitamins are the most commonly used supplement in the developed world. Recent epidemiologic findings suggest that multivitamin use increases the risk of mortality. Objective: We aimed to determine whether multivitamin-multimineral treatment, used for primary or secondary prevention, increases the risk of mortality in independently living adults. Design: We performed a meta-analysis of randomized controlled trials. Multiple electronic databases were systematically searched from March to October 2012. Randomized controlled primary or secondary prevention trials were considered for inclusion. Eligible trials investigated daily multivitamin-multimineral supplementation for ≥1 y. Cohorts described as institutionalized or as having terminal illness (tertiary prevention) were excluded. The number of deaths and the sample size of each study arm were extracted independently by 2 researchers. Twenty-one articles were included in the analysis, which generated a total pooled sample of 91,074 people and 8794 deaths. These trials were pooled in a meta-analysis, and the outcomes were expressed as RRs and 95% CIs. Results: The average age of the pooled sample was 62 y, and the average duration of supplementation was 43 mo. Across all studies, no effect of multivitamin-multimineral treatment on all-cause mortality (RR: 0.98; 95% CI: 0.94, 1.02) was observed. There was a trend for a reduced risk of all-cause mortality across primary prevention trials (RR: 0.94; 95% CI: 0.89, 1.00). Multivitamin-multimineral treatment had no effect on mortality due to vascular causes (RR: 1.01; 95% CI: 0.93, 1.09) or cancer (RR: 0.96; 95% CI: 0.88, 1.04). No statistical evidence of heterogeneity or publication bias was observed. Conclusion: Multivitamin-multimineral treatment has no effect on mortality risk.
Article
Multivitamin preparations are the most common dietary supplement, taken by at least one-third of all US adults. Observational studies have not provided evidence regarding associations of multivitamin use with total and site-specific cancer incidence or mortality. To determine whether long-term multivitamin supplementation decreases the risk of total and site-specific cancer events among men. A large-scale, randomized, double-blind, placebo controlled trial (Physicians" Health Study II) of 14 641 male US physicians initially aged 50 years or older (mean [SD] age, 64.3 [9.2] years), including 1312 men with a history of cancer at randomization, enrolled in a common multivitamin study that began in 1997 with treatment and follow-up through June 1, 2011. Daily multivitamin or placebo. Total cancer (excluding nonmelanoma skin cancer), with prostate, colorectal, and other site-specific cancers among the secondary end points. During a median (interquartile range) follow-up of 11.2 (10.7-13.3) years, there were 2669 men with confirmed cancer, including 1373 cases of prostate cancer and 210 cases of colorectal cancer. Compared with placebo, men taking a daily multivitamin had a statistically significant reduction in the incidence of total cancer (multivitamin and placebo groups, 17.0 and 18.3 events, respectively, per 1000 person-years; hazard ratio [HR], 0.92; 95% CI, 0.86-0.998; P=.04). There was no significant effect of a daily multivitamin on prostate cancer (multivitamin and placebo groups, 9.1 and 9.2 events, respectively, per 1000 person-years; HR, 0.98; 95% CI, 0.88-1.09; P=.76), colorectal cancer (multivitamin and placebo groups, 1.2 and 1.4 events, respectively, per 1000 person-years; HR, 0.89; 95% CI, 0.68-1.17; P=.39), or other site-specific cancers. There was no significant difference in the risk of cancer mortality (multivitamin and placebo groups, 4.9 and 5.6 events, respectively, per 1000 person-years; HR, 0.88; 95% CI, 0.77-1.01; P=.07). Daily multivitamin use was associated with a reduction in total cancer among 1312 men with a baseline history of cancer (HR, 0.73; 95% CI, 0.56-0.96; P=.02), but this did not differ significantly from that among 13 329 men initially without cancer (HR, 0.94; 95% CI, 0.87-1.02; P=.15; P for interaction=.07). Conclusion In this large prevention trial of male physicians, daily multivitamin supplementation modestly but significantly reduced the risk of total cancer. clinicaltrials.gov Identifier: NCT00270647.
Article
Context: Although multivitamins are used to prevent vitamin and mineral deficiency, there is a perception that multivitamins may prevent cardiovascular disease (CVD). Observational studies have shown inconsistent associations between regular multivitamin use and CVD, with no long-term clinical trials of multivitamin use. Objective: To determine whether long-term multivitamin supplementation decreases the risk of major cardiovascular events among men. Design, setting, and participants: The Physicians' Health Study II, a randomized, double-blind, placebo-controlled trial of a common daily multivitamin, began in 1997 with continued treatment and follow-up through June 1, 2011. A total of 14,641 male US physicians initially aged 50 years or older (mean, 64.3 [SD, 9.2] years), including 754 men with a history of CVD at randomization, were enrolled. Intervention: Daily multivitamin or placebo. Main outcome measures: Composite end point of major cardiovascular events, including nonfatal myocardial infarction (MI), nonfatal stroke, and CVD mortality. Secondary outcomes included MI and stroke individually. Results: During a median follow-up of 11.2 (interquartile range, 10.7-13.3) years, there were 1732 confirmed major cardiovascular events. Compared with placebo, there was no significant effect of a daily multivitamin on major cardiovascular events (11.0 and 10.8 events per 1000 person-years for multivitamin vs placebo, respectively; hazard ratio [HR], 1.01; 95% CI, 0.91-1.10; P = .91). Further, a daily multivitamin had no effect on total MI (3.9 and 4.2 events per 1000 person-years; HR, 0.93; 95% CI, 0.80-1.09; P = .39), total stroke (4.1 and 3.9 events per 1000 person-years; HR, 1.06; 95% CI, 0.91-1.23; P = .48), or CVD mortality (5.0 and 5.1 events per 1000 person-years; HR, 0.95; 95% CI, 0.83-1.09; P = .47). A daily multivitamin was also not significantly associated with total mortality (HR, 0.94; 95% CI, 0.88-1.02; P = .13). The effect of a daily multivitamin on major cardiovascular events did not differ between men with or without a baseline history of CVD (P = .62 for interaction). Conclusion: Among this population of US male physicians, taking a daily multivitamin did not reduce major cardiovascular events, MI, stroke, and CVD mortality after more than a decade of treatment and follow-up. Trial registration: clinicaltrials.gov Identifier: NCT00270647.