Dietary supplement use among U.S. adults has increased since NHANES III (1988–1994)

CDC's NCHS, Division of Health and Nutrition Examination Surveys , Hyattsville, Maryland 20782, USA.
NCHS data brief 04/2011; 61(61):1-8.
Source: PubMed
ABSTRACT
Key findings:
Use of dietary supplements is common among the U.S. adult population. Over 40% used supplements in 1988-1994, and over one-half in 2003-2006. Multivitamins/multiminerals are the most commonly used dietary supplements, with approximately 40% of men and women reporting use during 2003-2006. Use of supplemental calcium increased from 28% during 1988-1994 to 61% during 2003-2006 among women aged 60 and over. Use of supplements containing folic acid among women aged 20-39 did not increase since 1988-1994. In 2003-2006, 34% of women aged 20-39 used a dietary supplement containing folic acid. Use of dietary supplements containing vitamin D increased from 1988-1994 through 1999-2002 for men and women in most age groups. Dietary supplements can contain nutrients in amounts as high as or higher than the Institute of Medicine's Recommended Dietary Reference Intakes, therefore contributing substantially to total nutrient intake. Dietary supplements are widely available to U.S. consumers, and monitoring their use over time is an important component of the National Nutrition Monitoring System. Failure to include these nutrients when assessing the adequacy of diets and nutrition in the U.S. population may lead to inaccurate and misleading results. This report provides estimates of dietary supplement use for specific population groups over time. In addition to overall use of dietary supplements, this report focuses on estimates for specific nutrients consumed through dietary supplement use.

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Available from: Regan L Bailey, Mar 18, 2014
NCHS Data Brief
No. 61
April 2011
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Disease Control and Prevention
National Center for Health Statistics
Dietary Supplement Use Among U.S. Adults Has Increased
Since NHANES III (1988–1994)
Jaime Gahche, M.P.H.; Regan Bailey, Ph.D., R.D.; Vicki Burt, Sc.M., R.N.; Jeffery Hughes, M.P.H.;
Elizabeth Yetley, Ph.D.; Johanna Dwyer, D.Sc., R.D.; Mary Frances Picciano, Ph.D.;
Margaret McDowell, Ph.D., R.D.; and Christopher Sempos, Ph.D.
Key ndings
Use of dietary supplements
is common among the U.S.
adult population. Over
40% used supplements in
1988–1994, and over one-half
in 2003–2006.
Multivitamins/multiminerals
are the most commonly used
dietary supplements, with
approximately 40% of men
and women reporting use
during 2003–2006.
Use of supplemental
calcium increased from 28%
during 1988–1994 to 61%
during 2003–2006 among
women aged 60 and over.
Use of supplements
containing folic acid among
women aged 20–39 did not
increase since 1988–1994. In
2003–2006, 34% of women
aged 20–39 used a dietary
supplement containing
folic acid.
Use of dietary supplements
containing vitamin D increased
from 1988–1994 through
1999–2002 for men and
women in most age groups.
Dietary supplements can contain nutrients in amounts as high as or higher
than the Institute of Medicine’s Recommended Dietary Reference Intakes,
therefore contributing substantially to total nutrient intake. Dietary
supplements are widely available to U.S. consumers, and monitoring their use
over time is an important component of the National Nutrition Monitoring
System (1). Failure to include these nutrients when assessing the adequacy
of diets and nutrition in the U.S. population may lead to inaccurate and
misleading results. This report provides estimates of dietary supplement use
for specic population groups over time. In addition to overall use of dietary
supplements, this report focuses on estimates for specic nutrients consumed
through dietary supplement use.
Keywords: vitamin D • folic acid • calcium • trends
Dietary supplement use in the United States has increased
since the National Health and Nutrition Examination Survey
(NHANES) III (1988–1994).
Percent
Figure 1. Trends in the percentage of persons using dietary supplements, by gender for adults
aged 20 and over: United States, 1988–2006
NOTES: Significant linear trend from 1988–1994 through 2003–2006. Statistically significant difference for men compared with
women for all time periods, p < 0.05 for comparison between genders within survey periods. Age adjusted by direct method to the
year 2000 projected U.S. population.
SOURCE: CDC/NCHS, National Health and Nutrition Examination Surveys.
0
10
20
30
40
50
60
70
1988–1994 1999–2002 2003–2006
Total
Men
Women
Years
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■  2 
Dietary supplement use is widespread among U.S. adults aged 20 and over. The percentage
of the U.S. population who used at least one dietary supplement increased from 42% in
1988–1994 to 53% in 2003–2006 (Figure 1).
Women were most likely to use one or more dietary supplements than men for all three time
periods.
The prevalence of multivitamin/multimineral use has increased since
NHANES III (1988–1994).
Multivitamins/multiminerals are dened as dietary supplements that contain at least three
vitamins and may or may not contain minerals (2). Multivitamins/multiminerals were the
most frequently reported dietary supplement across all NHANES survey years.
Patterns of use of multivitamins/multiminerals among adults aged 20 and over paralleled the
pattern noted for all dietary supplement use (Figure 2).
The percentage of the U.S. population who used at least one multivitamin/multimineral
product increased from 30% in 1988–1994 to 39% in 2003–2006, with use more common
among women than men.
Figure 2. Trends in the percentage of persons using multivitamins/multiminerals, by gender for adults aged 20 and over:
United States, 1988–2006
Percent
NOTES: Significant linear trend from 1988–1994 through 2003–2006. Statistically significant difference for men compared with women for all time periods, p < 0.05
for comparison between genders within survey periods. Age adjusted by direct method to the year 2000 projected U.S. population.
SOURCE: CDC/NCHS, National Health and Nutrition Examination Surveys.
0
10
20
30
40
50
60
70
1988–1994 1999–2002 2003–2006
Total
Men
Women
Years
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■  3 
The prevalence of supplemental calcium use has increased since NHANES
III (1988–1994) for women aged 60 and over, but varies by racial and ethnic
group.
Use of dietary supplements and antacids containing calcium increased from 1988–1994
through 1999–2002 among women aged 60 and over and in all racial and ethnic groups
(Figure 3).
Rates of supplemental calcium use continued to increase throughout 2003–2006 for women
aged 60 and over and for non-Hispanic white women (58.9% in 1999–2002 to 65.7% in
2003–2006) and Mexican-American women (39.5% to 52.3%), but the observed increase
for non-Hispanic black women was not signicant.
Non-Hispanic white women aged 60 and over were more likely to use at least one dietary
supplement that contained calcium compared with non-Hispanic black and Mexican-
American women for all survey periods.
Mexican-American women aged 60 and over were more likely to use at least one dietary
supplement that contained calcium than non-Hispanic black women for all survey periods.
Figure 3. Prevalence of supplemental calcium use in women aged 60 and over, by racial and ethnic group: United States,
1988–2006
Percent
1
Significantly different from non-Hispanic black and Mexican-American women.
2
Significantly different from non-Hispanic black women.
NOTE: 1988–1994 rates significantly different from those of the 1999–2002 and 2003–2006 survey periods.
SOURCE: CDC/NCHS, National Health and Nutrition Examination Surveys.
0
10
20
30
40
50
60
70
1988–1994 1999–2002 2003–2006
Years
28.2
53.8
61.0
1
29.9
1
58.9
1
65.7
12.4
29.5
33.8
2
23.2
2
39.5
2
52.3
Total Non-Hispanic white Non-Hispanic black Mexican American
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Use of dietary supplements containing folic acid differs by race and
ethnicity among women aged 20–39.
Rates of use of dietary supplements containing folic acid for all racial and ethnic groups
remained stable from 1988–1994 through 2003–2006 for women aged 20–39 (Figure 4).
Non-Hispanic white women were more likely to take one or more dietary supplements
containing folic acid compared with both non-Hispanic black and Mexican-American
women. The rates for non-Hispanic white women are approximately double that of the other
two racial and ethnic groups.
Figure 4. Prevalence of folic acid dietary supplement use in women aged 20–39, by survey and by racial and ethnic group:
United States, 1988–2006
Percent
1
Statistically different from non-Hispanic black and Mexican-American women aged 20–39.
SOURCE: CDC/NCHS, National Health and Nutrition Examination Surveys.
0
10
20
30
40
50
1988–1994 1999–2002 2003–2006
Years
32.6
34.2
34.4
1
37.7
1
41.5 1
40.7
22.3
21.8
23.7
19.1
18.7
18.8
Total Non-Hispanic white Non-Hispanic black Mexican American
Use of dietary supplements containing vitamin D has increased since
NHANES III (1988–1994).
All age groups had similar rates of supplemental vitamin D use in 1988–1994 for both men
(approximately 24%) and women (approximately 30%) (Figure 5). Rates for persons aged
20–39 remained stable for both men and women through 2003–2006, whereas for men and
women aged 40–59, rates increased from 1988–1994 through 1999–2002 and remained
stable in 2003–2006.
The observed increase of supplemental vitamin D use for men aged 60 and over was not
signicant between the years 1999–2002 and 2003–2006 (38.1% in 1999–2002 to 44.0%
in 2003–2006). For women aged 60 and over, the rates continued to increase through
2003–2006 (49.7% in 1999–2002 to 56.3% in 2003–2006).
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■  5 
Figure 5. Prevalence of supplemental vitamin D use in adults aged 20 and over, by age group: United States, 1988–2006
1
Statistically different from persons aged 40–59 and persons aged 60 and over.
2
Statistically different from persons aged 60 and over.
NOTE: 1988–1994 rates significantly different from those of the 1999–2002 and 2003–2006 survey periods for all age groups except persons aged 20–39.
SOURCE: CDC/NCHS, National Health and Nutrition Examination Surveys.
Percent
22.2
1
26.4
1
26.5
30.3
1
32.3
1
33.8
26.0
34.7
2
38.0
31.1
45.1
2
45.0
23.7
38.1
44.0
29.7
49.7
56.3
0 10 20 30 40 50 60
1988–1994
1999–2002
2003–2006
1988–1994
1999–2002
2003–2006
60 years and over
4059 years
20–39 years
Women
Men
Summary
This report indicates high use of dietary supplements in the U.S. adult population during the past
20 years, with over 40% of adults using one or more dietary supplements during 1988–1994,
and over one-half of adults using supplements during 2003–2006. This is an increase from the
1970s when NHANES began monitoring use of dietary supplements. In NHANES I (1971–1975),
age-adjusted supplement use prevalence was 28% among men and 38% among women aged 20
and over; in NHANES II (1976–1980), supplement use prevalence rates were 32% among men
and 43% among women aged 20 and over (3). Because a high proportion of the U.S. population
uses dietary supplements, it is essential for surveys and studies that assess nutrient intake to
collect information on these important contributors. Of particular importance is vitamin D,
which is found naturally in very few foods. Estimates of the population intake may be greatly
underestimated if dietary supplements are not taken into account. In 2003–2006, 60% of women
aged 60 and over took a dietary supplement containing calcium. The role of calcium in nutrient-
disease or nutrient-health associations would be difcult to measure if dietary supplement use
was not captured in studies. Folic acid intake is critical for women of childbearing age to prevent
neural tube defects. Folate is widely available in foods such as green leafy vegetables, beans, and
legumes. Additionally, the U.S. food supply is fortied with folic acid. Monitoring use of dietary
supplements containing folic acid is important in evaluating the proportion of the population
that has intake levels above recommendations. Therefore, it is critical to monitor intake from all
sources to reach a more accurate intake estimate.
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Denitions
Dietary supplement: As dened by the U.S. Congress in the Dietary Supplement Health and
Education Act, which became law in 1994, a dietary supplement is a product (other than tobacco)
that is intended to supplement the diet; contains one or more dietary ingredients (including
vitamins, minerals, herbs or other botanicals, amino acids, and other substances) or their
constituents; is intended to be taken by mouth as a pill, capsule, tablet, or liquid; and is labeled on
the front panel as being a dietary supplement (4).
Adequacy of nutrient intake: Intake of a nutrient that meets the individual’s requirement for that
nutrient.
Inadequacy of nutrient intake: Intake of a nutrient that fails to meet the individual’s requirement
for that nutrient.
Calcium: The most abundant mineral in the body; found in some foods, added to others, available
as a dietary supplement, and present in some medicines (such as antacids).
Vitamin D: A fat-soluble vitamin that occurs in many forms, is naturally found in very few
foods, and is synthesized in the skin. The two dietary forms are D
2
(ergocalciferol) and D
3
(cholecalciferol).
Folate: A water-soluble B vitamin that is found in many foods.
Folic acid: The synthetic form of folate that is found in dietary supplements and added to enriched
our and grain products such as breads, pasta, rice, and cereals.
Neural tube defect: A group of birth defects caused by incomplete development of the brain,
spinal cord, or their protective coverings. Spina bida is one of the most common defects.
Data source and methods
NHANES data were used for all of the analyses presented in this report, and all data are publicly
available on the NHANES website. NHANES is conducted by the Centers for Disease Control
and Prevention’s (CDC) National Center for Health Statistics (NCHS) to monitor the health
and nutritional status of the U.S. population. NHANES is a nationally representative sample of
the U.S. civilian noninstitutionalized population. This population-based survey uses a complex,
stratied, multistage probability cluster sampling design and oversamples in order to increase
precision in estimates for certain groups. NHANES III was one in a series of periodic surveys
conducted in two cycles during 1988–1994. In 1999, NHANES became a continuous survey,
with data collected annually and released to the public in 2-year cycles. Across all NHANES
waves, respondents were asked to participate in an interview at their home and in an examination
conducted in a specially equipped mobile examination center.
NHANES includes information on participants’ demographic characteristics and health status,
including dietary supplement use, as part of a personal interview conducted in the participant’s
home. Dietary supplement data were collected using a similar methodology in both NHANES
III and in 1999–2006. NHANES participants showed their prescription and nonprescription
dietary supplement and nonprescription antacid containers to interviewers. In all survey periods,
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NCHS Data Brief
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April 2011
■  7 
interviewers recorded the supplement name, manufacturer, and address, and collected information
on duration of use, frequency of use in the past month or past 30 days, and the amount taken
when used. Product label information was obtained by NCHS nutritionists and is also publicly
released with the dietary supplement-use data.
NHANES data for adults aged 20 and over were used to calculate the prevalence of dietary
supplement intake for three time periods (1988–1994, 1999–2002, and 2003–2006) by
demographic characteristics for ve supplement categories: 1) any supplement, 2) multivitamin/
multimineral (contains at least three vitamins and may or may not contain minerals), 3)
supplement with folic acid, 4) supplement with vitamin D, and 5) supplement with calcium,
including antacids containing calcium. Demographic variables used in the analyses were age,
gender, and race and ethnicity. Race and ethnicity were self-reported and categorized as Mexican
American, non-Hispanic black, non-Hispanic white, and other. People in the “other” racial and
ethnic category were included in analyses of the total sample, but results for this group are not
shown separately. Pregnant women were excluded from the analytic sample. The analytic sample
size was 37,596: 18,504 in NHANES 1988–1994; 9,660 in NHANES 1999–2002; and 9,432 in
NHANES 2003–2006. Response rates were 81% in NHANES 1988–1994, 77% in NHANES
1999–2002, and 73% in NHANES 2003–2006.
All analyses used the interview sample weights, which account for unequal probabilities of
selection, person-level nonresponse, and a poststratication adjustment to the estimated U.S.
population. Taylor series linearization was used to calculate standard errors. All estimates that
were not age-specic were age-adjusted to the 2000 U.S. standard population using three age
groups: 20–39, 40–59, and 60 and over (5). Trends were tested to evaluate changes in estimates
across survey periods. Differences among groups were assessed using a univariate t statistic.
To account for multiple comparisons, statistical signicance was set as a P value less than
0.0175, using the Bonferroni method to adjust for the three comparisons. Statistical analyses
were conducted using SAS version 9.2 (SAS Institute, Cary, N.C.) and SUDAAN version 10.90
(Research Triangle Institute, Research Triangle Park, N.C.).
About the authors
Jaime Gahche, Vicki Burt, and Jeffery Hughes are with the CDC’s NCHS, Division of Health and
Nutrition Examination Surveys. Regan Bailey, Elizabeth Yetley, Johanna Dwyer, Mary Frances
Picciano (deceased, August 2010), and Christopher Sempos are with the National Institutes of
Health’s (NIH) Ofce of Dietary Supplements. Margaret McDowell is with NIH’s National
Institute of Diabetes and Digestive and Kidney Diseases.
References
1. Heimbach JT. Using the national nutrition monitoring system to prole dietary supplement
use. J Nutr 131(4 Suppl):1335S–8S. 2001.
2. Radimer K, Bindewald B, Hughes J, Ervin B, Swanson C, Picciano MF. Dietary supplement
use by US adults: Data from the National Health and Nutrition Examination Survey, 1999–2000.
Am J Epidemiol 160(4):339–49. 2004.
3. Briefel RR, Johnson CL. Secular trends in dietary intake in the United States. Annu Rev Nutr
24:401–31. 2004.
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NCHS Data Brief
No. 61
April 2011
4. Dietary Supplement Health and Education Act of 1994, Pub. L. No.
103–417, 103rd Congress (Oct. 25, 1994).
5. Klein RJ, Schoenborn CA. Age adjustment using the 2000 projected U.S.
population. Healthy People 2010 Stat Notes (20):1–10. 2001.
Suggested citation
Gahche J, Bailey R, Burt V, et al. Dietary
supplement use among U.S. adults has
increased since NHANES III (1988–1994).
NCHS data brief, no 61. Hyattsville, MD:
National Center for Health Statistics. 2011.
Copyright information
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the public domain and may be reproduced
or copied without permission; citation as to
source, however, is appreciated.
National Center for Health
Statistics
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Jennifer H. Madans, Ph.D., Associate
Director for Science
Division of Health and Nutrition
Examination Surveys
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U.S. DEPARTMENT OF
HEALTH & HUMAN SERVICES
Centers for Disease Control and Prevention
National Center for Health Statistics
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    • "Between the 1988–1994 (NHANES III) and the 2003–2006 survey cycles, the age-adjusted prevalence of dietary supplement usage in US adult residents in the past 30 days rose from 42% to 53% [30]. In the 2003–2006 survey, supplement use was higher in females than in the males [30]. Moreover, demographic stratification revealed that the highest concentration of overall supplement use was among older non-Hispanic whites, in particular those with more than a high school education. "
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    • "A low vitamin E concentration is more prevalent among African Americans and Mexican-Americans than in non-Hispanic Whites. This may be at least partly due to lower use of dietary supplements overall in ethnic minorities [30]. While overt deficiency was rare in this nationally representative population, the prevalence of not meeting the criterion of vitamin E adequacy was significantly higher among those reporting exclusive dependence upon food sources. "
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