jada nutrsupplem

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from the associationPosition of the American Dietetic Association: Nutrien

SupplementationABSTRACTIt is the position of the American Di-etetic Association that the best nutri-tion-based strategy for promoting op-timal health and reducing the risk of chronic disease is to wisely choose awide variety of nutrient-rich foods. Additional nutrients from supple-ments can help some people meettheir nutrition needs as specied byscience-based nutrition standardssuch as the Dietary Reference In-takes. The use of dietary supplementsin general, and nutrient supplementsin particular, is prevalent and grow-ing in the United States, with aboutone third of adults using a multivita-min and mineral supplement regu-larly. Consumers may not be well in-formed about the safety and efcacyof supplements and some may havedifculty interpreting product labels.The expertise of dietetics practitio-

ners is needed to help educate con-sumers on the safe and appropriateselection and use of nutrient supple-ments to optimize health. Dieteticspractitioners should position them-selves as the rst source of informa-tion on nutrient supplementation. Toaccomplish this, they must keep up todate on the efcacy and safety of nu-trient supplements and the regula-tory issues that affect the use of theseproducts. This position paper aims toincrease awareness of the current is-sues relevant to nutrient supple-ments and the resources available toassist dietetics practitioners in evalu-ating the potential benets and adverse outcomes regarding their use. J Am Diet Assoc. 2009;109: 2073-2085.

POSITION STATEMENT It is the position of the American Die-tetic Association that the best nutri-tion-based strategy for promoting op-timal health and reducing the risk of chronic disease is to wisely choose awide variety of foods. Additional nu-trients from supplements can helpsome people meet their nutrition needsas specied by science-based nutrition

standards such as the Dietary Refer- ence Intakes.

The focus of this American Die-tetic Association (ADA) positionpaper is the use of nutrient sup-plements, particularly vitamin andmineral supplements, in assisting people in meeting their nutrientneeds. Fortied food, a topic previ-ously included within this ADA posi-tion paper, is discussed in ADA’s po-sition paper on functional foods ( 1).Other nut ri ents such as fatty acids ( 2)

and ber ( 3) are also discussed in sep-arate ADA position papers. Supple-mentation of non-nutrient ingredi-ents is covered in ADA’s pr a cticepaper on dietary supplements ( 4).

The use of dietary supplements ingeneral and nutrient supplements

in particular is prevalent and growing in the United States. Based on the 1999-2000 National Health and NutritionExamination Survey, 52% of adultsreported taking a dietary supplementin the past month and 35% said theytook a multivitamin/mineral supple-ment (MVM) ( 5). Adults who usedMVM supplements most often in-cluded women, older adults, non-His-

panic whites, people with more thana high-school education, people whorate their health as excellent/verygood, and under- and normal-weightpeople ( 5). Supplements of vitamin E, vitamin C, calcium, and B-complex vi-tamins were used by at least 5% of adults. In the 1999-2004 NationalHealth and Nutrition ExaminationSurvey, 34% of children and adoles-cents reported supplementing theirdiets with some type of vitamin andmineral supplement ( 6). Factors asso-ciated with greater use among chil-

dren included younger age, morehealthful diets, greater food security,greater physical activ it y, and betteraccess to health care ( 6).

In 2007, dietary supplement salesgrew to $23.7 billion ( 7). Sales of mul-tivitamins, the most commonly pur-

This American Dietetic Association (ADA) position paper includes theauthors’ independent review of the literature in addition to systematicreview conducted using ADA’s Evidence Analysis Process and informationfrom ADA’s Evidence Analysis Library (EAL). Topics from the EAL areclearly delineated. The use of an evidence-based approach provides impor-tant added benets to earlier review methods. The major advantage of theapproach is the more rigorous standardization of review criteria, whichminimizes the likelihood of reviewer bias and increases the ease with whichdisparate articles may be compared. For a detai led description of the methodsused in the Evidence Analysis Process, go to http://adaeal.com/eaprocess/ .Evidenc e-based information for this a nd other topics can be found on theEAL at www.adae videncelibrary.com and subscriptions f or nonmembersare purchasable at www.adaevidencelibrary.com/store.cfm .).

Conclusion statements are assigned a grade by an expert work groupbased on the systematic analysis and evaluation of the supporting researchevidence. Grade I Good; Grade II Fair; Grade III Limited; GradeIV Expert Opinion Only; and Grade V Not Assignable (because there isno evidence to support or refute the conclusion).

0002-8223/09/10912-0013$36.00/0doi: 10.1016/j.jada.2009.10.020

© 2009 by the American Dietetic Association Journal of the AMERICAN DIETETIC ASSOCIATION 2073

http://adaeal.com/eaprocess/http://adaeal.com/eaprocess/http://adaeal.com/eaprocess/http://www.adaevidencelibrary.com/http://www.adaevidencelibrary.com/http://www.adaevidencelibrary.com/store.cfmhttp://www.adaevidencelibrary.com/store.cfmhttp://www.adaevidencelibrary.com/store.cfmhttp://www.adaevidencelibrary.com/store.cfmhttp://www.adaevidencelibrary.com/store.cfmhttp://www.adaevidencelibrary.com/http://adaeal.com/eaprocess/


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chased of supplements, grew 3.9% in2007 to $4.5 billion in sales for theyear. Sales of single-nutrient supple-ments, including calcium, B vitamins, vitamin C, vitamin A/beta carotene,magnesium, and iron also grew dur-ing this period, whereas vitamin E

supplement sales declined slightly(7). Contributing to this industry’sgrowth are the aging of the popula-tion and consumer desire to maintaingood health and prevent disease.

Although many Americans use di-etary supplements, a 2009 reportfrom the US Government Account-ability Ofce stated that “according toexperts, consumers are not well-in-formed about the safety and efcacyof dietary supplements and have dif-culty inte rp reting labels on theseproducts” ( 8). The Government Ac-

countability Ofce expressed concernthat the uninformed use of dietarysupplements ma y expose consumersto health risks ( 8). The expertise of dietetics practitioners is needed tohelp educate consumers on safe andappropriate selection and use of di-etary supplements, including nutri-ent supplements. The primary objec-tive of this paper is to increaseawareness of the current issues relevant to nutrient supplements and theresources available to assist dieteticspractitioners in evaluating the poten-tial benets and adverse outcomes re-garding their use.

DEFINITION AND REGULATORYFRAMEWORK Nutrient supplements, like other di-etary supplements, are regulated as asubcategory of food by the Food andDrug Administration’s (FDA’s) Cen-ter for Food Safety and Applied Nu-trition. The Dietary SupplementHealth and Education Act of 1994(DSHEA) ( 9), which amended the

Federal Food, Drug, and Cosmetic Act of 1938, denes and sets safetyand labeling requirements for dietarysupplements. The DSHEA denes adietary supplement, in part, as aproduct intended to supplement thediet that contains any of the following dietary ingredients: a vitamin; a min-eral; an herb or other botanical; anamino acid; a dietary substance foruse by humans to supplement the dietby increasing the total dietary intake;or a concentrate, metabolite, a con-

stituent, extract, or combination of any ingredient mentioned above ( 9).Dietary supplements are intended tobe taken by mouth and can be inmany forms, including pills, capsules,tablets, liquids, powders, or otherforms as long as they are not repre-sented for use as a conventional foodor as a sole item of a meal or diet ( 9).They must also be identied on thelabel as a dietary supplement ( 9).

Label ClaimsDietary supplement labels can bearhealth claims (authorized and quali-ed), nutrient content claims, andstructure/function claims ( 10). Healthclaims can be used to characterize therelationship between a dietary ingre-dient and reducing the risk of a dis-ease or health-related condition ( 10).Nutrient content claims can be usedto chara cterize the amount of a nutri-ent ( 10). Both health claims and nu-trient content claims must be pre-approved by the FDA. Structure/ function claims are the most com-monly used claims on dietary sup-plement labels ( 4). They can be usedto describe the following: the effect adietary ingredient has on the struc-ture or function of the body; the way adietary ingredient acts to maintain astructure or function; general well-be-ing from consumption of a dietaryingredient; or a benet related to anutrient deciency disease if theprevalence of the disease in th eUnited States is also indicated ( 10).Structure/function claims are not pre-approved by the FDA. The manufac-turer is responsible for ensuring theclaims they make are truthful and notmisleading and must provide theFDA with the text of structure/func-tions claims no later than 30 daysafter marketing the supplement ( 10).Labels that contain structure/func-tion claims must also carry the dis-claimer that explains to the consumerthat the FDA has not evaluated thelabel claim and that the product is notintended to “diagnose, treat, cure, orprevent any disease” ( 10). Althoughthe FDA has the primary responsibil-ity of claims on product labeling, theFederal Trade Commission has theresponsibility of regulating claimsmade in the advertising of dietarysupplements ( 11 ).

SafetyManufacturers are responsible for en-suring their products are safe beforethey put them on the market ( 12). Vitamins and minerals were sold asingredients in dietary supplementsbefore DSHEA was implemented andare, therefore, presumed to be safebased on their history of use. They donot require an FDA premarket reviewof safety or efcacy ( 12). For any newdietary ingredient (sold after DSHEA was passed) and not recognized as afood substance present in the foodsupply, the manufacturer (and dis-tributor) must provide notication tothe FDA of their intention to mar-ket the product and provide themwith the information they used to con-clude the ingredient was generallysafe to consume ( 12-14 ). Once mar-keted, the FDA has the authority toremove a product if they prove it tobe unsafe ( 12 ). The FDA monitorssafety, in large part, by collecting re-ports on adverse events from consum-ers, health professionals, and manu-facturers through their MedWatchprogram—The FDA Safety Informa-tion and Adverse Event Reporting Program ( 15 ). Reporting adverseevents associated with a dietary sup-plement was voluntary for manufac-turers until new legislation, the Di-etary Supplement and Nonprescrip tion

Drug Consumer Protection Act ( 16),went into effect December 22, 2007.The new regulation requires the re-sponsible party (ie, the manufacturer,packer, or distributor whose name ap-pears on the label) to submit Serious Adverse Event Reports to the FDA within 15 business days of receiving areport and to maintain records of alladverse event reports for 6 years ( 17).Reporting of events not consideredserious remains voluntary. Adverseevents are considered serious if theyresult in death, a life-threatening ex-

perience, inpatient hospitalization, apersistent or signicant disability orincapacity, or a congenital anomaly orbirth defect; or require, based on rea-sonable medical judgment, a medicalor surgical intervention to prevent anoutcome listed above ( 18). The sub-mission of an adverse event report isnot an admission by the company thatthe product involved caused or con-tributed to the adverse event ( 17).

According to a 2009 Government Accountability Ofce report, the num-

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ber of all adverse event reports re-ceived increased threefold after man-datory reporting went into effectcompared to the previous year, butunderreporting remains a concern ( 8).From December 2007 through Octo-ber 2008, the FDA received 596 man-

da tory serious adverse event reports(8). Of these reports, 66% were asso-ciated with combination products andproducts that did not fall under any of the available categories, 40% with vi-tamins, and 19% with minerals ( 8).The percentages total more than100% because reports that involvedmore than one product were countedin more than one category. No causalrelationships between adverse eventsand the associated products could bemade, in part, because of the variabil-ity in the quality and detail of t he

information provided in the reports ( 8).

QualityIn June 2007, the FDA, with author-ity granted under DSHEA, publisheda nal rule establishing current GoodManufacturing Practices for dietarysupplements ( 19). This rule estab-lishes regulations that require theconsistent manufacturing of productswith regard to iden tity , purity, strength,and composition ( 20). Companies areresponsible for ensuring their prod-ucts meet quality standards, includ-ing being accurately labeled (eg, prod-ucts contain the ingredients in theamounts stated on their labels) andfree from contaminants (eg, bacteria,pesticides, glass, lead, and otherhea vy metals) and foreign materials(19). The requirements are being phased-in over a 3-year period de-pending on the company size. All com-panies are expected to be in compli-ance by June 2010 ( 19).

Independent org anizations such asConsumerLab.com (a for-prot com-pany), NSF International, and US

Pharmacopoeia offer program s tha tevaluate supplement quality ( 21-23 ).Each organization has, at a mini-mum, a program that allows manu-facturers, if they choose, to pay a feeto have their products tested; thosethat conform to the organization’squality specications can bear thatorganization’s seal of approval ontheir label. The absence of a seal doesnot in and of itself indicate inferiorquality. High costs to analyze for eachingredient may be one factor that lim-

its some companies, particularlysmaller companies, from having theirproducts tested.

OPTIMAL INTAKESNutrient-Based Recommendations

Optimal nutrient intakes are thosethat promote health and reduce riskfor chronic disease while minimizing risk of excess. The Institute of Medi-cine’s (IOM’s) Dietary Reference In-takes (DRIs) are the best availableevidence-based nutrient standardsfor estimating optimal intakes. Theyinclude the Recommended Dietary Allowances (RDAs), Adequate In-takes (AIs), Estimated Average Re-quirements (EARs), and TolerableUpper Intake Levels (ULs) ( 24).

The RDAs and AIs (when data was

not sufcient to determine an EARand thus an RDA) serve as intakegoals for healthy individuals. Theselevels may not be adequate to repleteindi viduals who are malnourished(24). In addition, levels higher, orlower, than recommended levels maybe necessary to meet the needs of peo-ple with specic health conditions orwho take medications that a lter theirrequirement for a nutrient (24). Therecommended intakes can be used asgoals for nutrients not affected by thecondition or medication; estimates of other nutrients should be based onbest evidence for the circumstancesuch as provided in hospital diet man-uals a nd from professional organiza-tions ( 24). The recommended intake values and the endpoints on whichthe values were established havebeen summarized in the IOM’s Di- etary Reference Intakes: The Essen tia lGuide to Nutrient Requirements (25).

The UL is the “maximum level of daily nutrient intake that is lik ely topose no risk of adverse effects” ( 26). Itwas determined there was a need forULs because of increased intakes of

nutrients from forti ed foods and di-etary supplements ( 25). The ULs for vitamin E, niacin, and folate applyonly to synthetic forms of the nutri-ents as is foun d in supplements andfortied foods ( 26). The UL for mag-nesium applies to intake s from phar-macological agents only ( 26). The ULfor vitamin A is from pre formed vita-min A or retinol only ( 26). For allother nutrients, ULs apply to totalintake from food, water, and supple-ments. For nutrients for which data

were insufcient to determine a UL(ie, biotin, carotenoids, pantothenicacid, riboavin, thiamin, vitaminB-12, vitamin K) the IOM warns thatcaution may be warranted in consum-ing levels above the RDAs and AIs(26). See the Figure for IOM Websites that provide the UL values andthe adverse effects of excess consump-tion associated with each nutrient.DRI Updates. Experts have suggestedthe DRIs for vitamin D be updatedbased on evidence accumulated sincethe 1997 release. Although consensushas not been reached, some expertsindicate that the recommended in-take should be increased to 1,000 IU/ day for all adults ( 27) and the UL beincr eased from 2,000 IU to 10,000 IU(28). The desirable blood concentra-tion for optimal vitamin D status hasalso been debated. According to someexperts, advantages begin at a 25-hy-droxyvitamin D (25[OH]D) concentra-tion of 75 nmol/L (30 ng/mL), whereasbetween 90 and 100 nmol/L (36 to 40ng/mL) is ideal for a variety of end-points ( 27). An IOM committee is cur-rently assessing the relevant data toupdate the DRIs for vitamin D andcalcium as they nd appropriate ( 29).The report is scheduled to be releasedby May 2010.

The American Academy of Pediat-rics (AAP) released updated vitamin

D recommendations in 2008. Recom-mendations for healthy infants andchildren were increased from a mini-mum of 200 IU per day beginning inthe rst 2 months after birth to aminimum of 400 IU per day beginning soon after birth to prevent rickets and vitamin D deciency ( 30). The AAPrecommends serum 25(OH)D concen-trations of 50 nmol/L (20 ng/mL) ininfants and children ( 30). These rec-ommendations as they pertain to sup-plementation are further discussed inthe “Nutrient Supplements in Prac-

tice” section.Using DRIs to Assess Total Nutrient In-takes. The DRIs are used to assessadequate and excess nutrient intakesand plan diets for groups and individ-uals. Dietary assessment informationcan be used to help dietetics practitio-ners determine if an individual islikely to benet from or is at risk forexcess intakes from taking dietarysupplements and in appropriate prod-uct selection.

When an individual’s usual intake

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Web Sites

Organization URL Contents

Agency for Healthcare Researchand Quality (AHRQ)

www.ahrq.gov/clinic/epcindex.htm#dietsup ● AHRQ produced evidence-based reviews on nutrient supplements

American Dietetic Association www.eatright.org ● Position papers● Practice paper on dietary supplements● Evidence Analysis Library● Other documents: Guidelines Regarding the Recommendation

and Sale of Dietary Supplements, Code of Ethics for theProfession of Dietetics

Cochrane Collaboration www.cochrane.org/reviews/ ● Free access to abstracts and links to full reviews of evidence-based health care topics including vitamins and minerals usedfor disease prevention and treatment

Food and Drug Administration www.fda.gov/Food/DietarySupplements/ default.htm

● Dietary supplement alerts and safety information● Adverse event reporting● Guidance, compliance, and regulatory information● Other documents: Tips for the Savvy Supplement User: Making

Informed Decisions and Evaluating Information, Tips for the OlderDietary Supplement Users

Institute of Medicine Elements: www.iom.edu/Object.File/Master/7/

294/0.pdfElectrolytes and water: www.iom.edu/Object.File/Master/20/

004/0.pdfVitamins:

www.iom.edu/Object.File/Master/7/296/ webtablevitamins.pdf

● Tables that include Dietary Reference Intake values and adverseeffects of excessive consumption

Micronutrient Information Center,Linus Pauling Institute, OregonState University

lpi.orst.edu/infocenter ● Evidence-based monographs on vitamins, minerals, othernutrients, and dietary phytochemicals that include information onnutrient function, deciency symptoms, interactions,recommended intakes, supplements, and safety

National Agricultural Library www.nal.usda.gov/fnic/pubs/bibs/gen/ dietarysupplementsprofessionals08.pdf

● Dietary Supplements: Resources for Professionals (January 2008)● Listing of resources (bibliographies/databases, books/book chapters,

newsletters, Web resources, agencies and organizations)providing technical and professional-level information on dietarysupplements including nutrition information

National Library of Medicine dietarysupplements.nlm.nih.gov/dietary ● The Dietary Supplements Labels Database (DSID)—Informationabout label ingredients in 3,000 selected brands of dietarysupplements

www.nlm.nih.gov/medlineplus/ vitaminandmineralsupplements.html

● MedlinePlus for Vitamin and Mineral Supplements

Ofce of Dietary Supplements,National Institutes of Health(NIH)

ods.od.nih.gov ● International Bibliographic Information on Dietary Supplements(IBIDS) Database—Published, scientic literature on dietarysupplements including vitamins, minerals, and botanicals

● Expert reviewed Facts Sheets on vitamins, minerals andbotanicals that include information on medication interactionsand signs and symptoms of deciency and toxicity

● Computer Access to Research on Dietary Supplements(CARDS)—Database of federally-funded research projectspertaining to dietary supplements.

Therapeutic Research Center www.naturaldatabase.com ● Natural Medicines Comprehensive Database (subscriptionrequired)—Includes evidence-based monographs that contain

information on ingredient safety, effectiveness, adverse reactionsand interactions

US Department of Agriculture, Agricultural Research Service,Ofce of Dietary Supplements,NIH, and other federal agencies

dietarysupplementdatabase.usda.nih.gov/ ● Dietary Supplement Ingredient Databases (DSID)—Estimateslevels of ingredients in dietary supplement products

Books

Coates PM, Blackman MR, Cragg GM, Levine M, Moss J, White JD. Encyclopedia of Dietary Supplements, New York, NY: Marcel Dekker; 2005.Fragakis AS, Thomson CA. The Health Professional’s Guide to Popular Dietary Supplements. 3rd ed. Chicago, IL: American Dietetic Association; 2006.Hendler S, Rorvik D, eds. PDR for Nutritional Supplements . 2nd ed. Montvale, NJ: Thomson Reuters; 2008.Institute of Medicine. Dietary Reference Intakes: The Essential Guide to Nutrient Requirements . Washington, DC: National Academies Press; 2006.

Figure. Resources for information related to dietary supplements.



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meets or exceeds recommended lev-els, it is likely that their intake isadequate; that is, they are likely to beconsuming an amount of a nutrientneeded to maintain the specic ade-quacy endpoint for which the valuewas derived. This is because RDAs

meet or exceed the estimated require-ment of all but 2% to 3% of the popu-lation, and AIs represent intakeslikely to exceed the actual require-men ts of almost all healthy people(24). For the same reason, usual in-takes that fall below recommendedlevels shoul d not be interpreted asinadequate ( 24). Clinical status andbiochemical indexes should be among the factors included with intake datato assess an individual’s diet ary ade-quacy and nutritional status ( 24). Thetotality of information should be used

to determine if a person is likely tobenet from nutrient supplementa-tion. The UL is an important tool thatdietetics practitioners can use to as-sist consumers in the safe use of di-etary supplements. As average dailyintakes exceed the UL, the risk of adverse health effects increases ( 24).

It is important to note that whencomparing a person’s intake to DRIsto assess adequacy, one is actuallyassessing apparent adequacy becausean individual’s true requirement andtrue in tak e of a nutrient are notknown ( 24). Day-to-day variability inintakes and limitations in methods of collecting intake data and nutrientdatabases all affect intake estimates,and various factors including geneticsaffect true nutrient requirements.The IOM published Dietary Reference Intakes: A pplications in Dietary As-sessment (24) to provide guidance onusing the DRIs to assess intakes.

Food-Based RecommendationsWise selection of nutrient-rich foodsis generally the best strategy for

meeting nutrient needs. Foods, par-ticularly plant foods such as fruits, vegetables, whole grains, beans, nuts,seeds, and teas, provide an array of other health-promoting substancesbeyond vitamins and minerals, in-cluding carotenoids and polyphenolssuch as avonoids. Data suggest thatpositive health outcomes are relatedmore to dietary patterns, the typesand amounts of foods consumed , th anto intakes of individual nutrients ( 31).

The US Department of Health and

Human Services and the US Depart-ment of Agriculture’s 2005 DietaryGuidelines for Americans (DGA) provide guidance on diet and physicalactivity to promote health and de-crease the risk of chronic disease ( 32).The DGA will be revised in 2010. My-

Pyramid provides recommended foodintake patterns for 12 energy levelsthat ran ge from 1,000 to 3,200 kcalper day ( 33). These food-based recom-mendations incorporate advice fromthe DGA and use DRIs as nutrientintake goals. One alternative to theMyPyramid plan for meeting nutrientneeds is the National Heart, Lung,and Blood Institute’s Dietary Ap-proaches to Stop Hypertension Eat-ing Plan ( 32).

DIETARY GAPSMany Americans do not consume theamount and types of foods necessaryto meet recommended micronutrientintakes. Adherence to the DGA is low;only about 3% to 4% of Americansfollow all of the DGA ( 34). As a resultof low intakes of nutrient-rich foodsand sedentary lifestyles, many Amer-icans may be meeting or exceeding their energy requirements while fall-ing short of vitamin and mineral rec-ommendations. In assessing the dietsof population groups, the proportionwith intakes less than the EAR (notthe RDA) are interpreted as esti-mat es of the prevalence of inadequacy(24). The DGA identify calcium, po-tassium, magnesium, vitamin E, andber in adults and children, and vita-mins A and C in adults only, as nu-trients of concern (ie, nutrients forwhich the prevalence of inadequateintakes were high—in this case

40%—or for which low intakes wereassocia ted with public health prob-lems) ( 35). Also identied as nutri-ents of concern were vitamin B-12 inolder adults; vitamin D in older

adults, people with dark skin, andpeople with inadequate exposure tosunlight; iron in adolescent femalesand women of childbearing age whomay become pregnant; and folic acidin women of chi ldb earing age andpregnant women ( 32).

An analysis of intake data fromWhat We Eat in America , NationalHealth and Nutrition ExaminationSurvey 2001-2002 indicated potentialfor problems for vitamins A, E, and Cand magnesium for most age/sex

groups; vitamins B-6 for older adultfemales; zinc for all older adults andteenaged females; and phospho rus forpreteen and teenaged females ( 36). Inaddition, the following nutrients mayalso be of concern because a low per-centage of intakes were above AI lev-

els (adequacy cannot be determinedbecause the EARs needed for assess-ing adequacy have not been estab-lished for these nutrients): vitamin K,calc ium, potassium, and dietary ber(36). This analysis included intakesfrom food sources only.

According to national survey data,inadequate intakes from food sourcesare most prevalent for vitamin E andmagnesium. Overt symptoms of vita-min E deciency are uncommon inthe United States ( 37). According tothe IOM, actual vitamin E intakes

may be higher than reported in na-tional surveys for several reasons,including respondents underreportenergy and fat intakes (source of vitamin E), inaccurately estimateamounts of fats and oils they add dur-ing food preparation and uncertaintyabout the types fats or oils consumed(37). Authors of a balance study sug-gested that the EAR for magnesium isset too high and that it should be low-ered from 330 to 350 mg/day for menand 255 to 265 mg/day for women to165 mg/day for healthy persons re-gardless of age or sex ( 38).

NUTRIENT SUPPLEMENTATIONEffect on Total Nutrient IntakesNutrient supplements can have asubstantial impact on a person’s totalnutrient intake (39). Supplementshave the potential to ll dietary gapsbut, at the same time, may increaseintakes above ULs. Thus, intake fromsupplements must be included along with intakes from conventional andfortied foods and beverages when as-sessing nutritional adequacies and

excesses of individuals and popula-tion groups. With regard to supple-ments, The DGA state that:

Supplements may be useful whenthey ll a specic identied nutri-ent gap that cannot or is not other-wise being met by the individual’sintake of food. Nutrient supple-ments cannot replace a healthfuldiet. Individuals who are alreadyconsuming the recommended amo-unt of a nutrient in food will notachieve any additional health bene-t if they also take the nutrient as a



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supplement. In fact, in some cases,supplements and fortied foodsmay cause intakes to exceed thesafe levels of nutrients ( 32).

National survey data suggests thatsupplements may be taken by thosewho have healthful diets and life-styles more often than those at agreater risk for vitamin and mineralinadequacies.Filling Dietary Gaps. When taken regu-larly, MVMs can be an effective wayto increase nutrient intakes to meetrecommended levels of multiple nu-trients. The extent to which a MVMcan improve nutrient adequacy is im-pacted by the nutrient prole of thesupplement taken. Of the nutrientspreviously identied as being lowenough in diets to be of concern, MVMsupplements have been shown to de-crease the prevalence of nutrient in-adequacy most notably for vitamin E, vitamin A, zinc, and vitamin B-6 ( 39).MVMs are less likely to substantiallyincrease intakes of key nutrients suchas calcium, magnesium, and pota-ssium. Increasing consumption of foods rich in these nutrients will stillbe necessary to meet recommendedamounts. In some cases such as withcalcium, an additional supplementmay be considered to help meet rec-ommended intakes, particularly in at-risk groups (eg, older adults) where

supplementation has been shown tohave positive outcomes.Based on 1994-1996 Continuing

Survey of Food Intakes by Individualsdata, when intake from supplementswere added to food intakes of users,the percentage of older adults withinadequate intakes was reduced by atleast three quarters for vitamin B-6,folate, vitamin C, and zinc in bothmen and women and vitamins A andE in men only ( 40). In addition, theprevalence of inadequate magnesiumintakes was reduced from 71% to 41%

in men aged

71 years and 64% to29% in women ( 40). The prevalencerates for inadequacy in these womenwere also reduced from 18% to 6% for vitamin A and 93% to 17% for vitaminE. Most already met the EAR for ironand vitamin B-12 from food intakes,thus supplementation did not have agreat inuence on the proportion of subjects with adequate intakes. Forcalcium, the use of supplements in-creased the percentage with intakesabove the AI from 3% to 14% in

women aged 71 years and from 10%to 24% in men of the same age groupwhen intakes of supplements wereadded to their intakes from food ( 40).Exceeding ULs. There is potential forsupplement users to exceed the ULsof some nutrients when they takehigh dose supplements or multipleproducts with the same ingredients,and even when MVMs are takenalong with a diet rich in fortiedfoods. As daily intakes exceed the UL,risk of adverse health effects in-crease. In the Hawaii Los AngelesMultiethnic Cohort 1999-2001, thenutrients identied as those mostlikely to exceed the ULs were: iron,zinc, vitamin A, and niacin ( 39). Thepercentage of supplement users withintakes above the UL for folate wasnot estimated because intake from

supplements only was not available.Based on 1994-1996 Continuing Sur- vey of Food Intakes by Individualsdata, the percentages of groups of older adult supplement users that ex-ceeded the ULs ranged between 8%and 17% for iron, 4% and 15% forzinc, and 4% and 9% for vitamin A (40). Excess folate and niacin was notassessed. The percentages above ULlevels for vitamin B-6, vitamin C, andcalcium were 3%. In the 2002 Feed-ing Infants and Toddlers Study, in-takes of toddlers between 12 and 24months old using supplements ex-ceeded the ULs for vitamin A, zinc,and folate more often than nonusers(41). The percentage of intakes ex-ceeding the ULs for toddlers among nonusers compared to users were 15%and 97% for vitamin A, 38% and 68%for zinc, and 1% and 18% for folate,respectively ( 41).

Effect of Supplementation on ChronicDisease Prevention Although MVM supplementation canbe effective in helping meet recom-

mended levels of some nutrients, evi-dence has not proven them to be ef-fective in preventing chronic disease. A study published in 2009 from theWomen’s Health Initiative found noassociation between MVM supple-mentation and cancer or cardiovascu-lar disease risk or total mortality inpostmenopausal women ( 42). In 2006,a National Institutes of Health State-of-the-Science Panel reviewed evi-dence, including an evidence-basedreview of literature that was limited

to randomized controlled studies, onthe health benets and risks of MVMsupplements (dened as “any supple-ment containing three or more vi-tamins and minerals but no herbs,hormones, or drugs, with each compo-nent at a dose less than the Tolerable

Upper Intake Level”) ( 43). The panelconcluded that evidence, at the time,was insufcient to determine whetheror not taking MVM supplements wasbenecial in preventing chronic dis-ease in generally healthy people ( 43).

The evidence on supplemental cal-cium and vitamin D in relation to bonehealth has been favorable, particularlyin older women. The National Insitutesof Health State-of-the-Science Panel onMVM supplements concluded thatwhen used in combination, calcium and vitamin D supplements increase bonemineral density and decrease risk of hip and nonvertebral fracture in post-menopausal women ( 43). An evidence-based analysis of the literature on vita-min D and bone health outcomes foundthat vitamin D-3 (700 to 800 IU daily)with calcium (500 to 1,200 mg) resultedin small increases in bone mineral den-sity and reduced fall risk in olderadults and reduced risk of fractures inelderly women living in nursing homes(44).

NUTRIENT SUPPLEMENTS IN PRACTICE

When to Consider SupplementationNutrient supplements can be used tohelp meet a nutrient requirement orto treat a diagnosed deciency dis-ease. A person’s micronutrient intakemay be inadequate when they are re-stricting energy intake for weightloss/control, not consuming an ade-quate amount of food to meet energyrequirements as a result of poor ap-petite or illness, eliminating one ormore food groups from their diet on aregular basis, or consuming a diet lowin nutrient-rich foods despite ade-

quate or excessive energy intakes. Among the groups most vulnerable toinadequacy of one or more nutrientsare older adults; pregnant women;people who are food insecure (ie, theyare , “ at times, uncertain of having, orunable to acquire, enough food for allhousehold members because they hadinsufcient money and other re-sources for food”) ( 45); alcohol-depen-dent individuals; strict vegetariansand vegans; and those with increasedneeds due to a health condition or the



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chronic use of a medication that de-creases nutrient absorption or in-creases metabolism or excretion.

Some government and professionalorganizations and expert workgroupsprovide recommendations for nutri-ent supplementation. ADA position

papers that focus on particular seg-ments of the population, nutrients, orconditions often include recommenda-tions on nutrient supplementation.The following are examples of thesenutrient supplement recommenda-tions.

● Infants and children, including adolescents The AAP recom-mends the following groups of healthy infants and children re-ceive 400 IU daily of supplemental vitamin D: all infants who are ex-

clusively or partly breastfed (begin-ning the rst few days of life andcontinued unless infant is weanedto at least 1 qt/day vitamin D–for-tied formula or, if older than 12months, whole milk or low-fat milkwhen appropriate); all non-breast-fed infants and older children whoconsume less than 1qt/day vitaminD–fortied formula or milk; and ad-olescents with dietary intakes 400IU/day ( 30). Children at an in-creased risk for vitamin D de-ciency, such as those with fat mal-absorption and those taking seizuremedications, may need higheramounts to achieve normal vitaminD sta tus as determined by lab re-sults ( 30).

● Women of childbearing age whomay become pregnant The DGA and IOM recommend that womenwho can become pregnant consume400 g/day of folic acid from forti-ed foods and/or supplements daily,in addition to folate obtained fromeating a varied diet, to reduce therisk of neural tube defects (eg,spina bida and anencephaly)

(35,46 ).● Pregnant women The DGA rec-

ommend pregnant women consume600 g/day of folic acid from forti-ed foods or supplem en ts in addi-tion to dietary folate ( 32). The RDA of dietary folate equivalents forpregnant women is 600 g/day ( 46).The ADA position paper, “Nutritionand Lifestyle for a Healthy Preg-nancy Outcome” ( 47), recommendsMVM supplementation for preg-nant women who have iron de-

ciency anemia or poor-quality diets,consume no or small amounts of an-imal sources, are carrying two ormore fetuses and smoke or abusealcohol or drugs. The ADA positionpaper also recommends supplemen-tation with 27 mg iron daily (60 mg

daily if she has anemia) and with vitamin B-12 in som e vegans orlacto-ovo vegetarians ( 47).

● Older adults The DGA and IOMrecommend that people over age 50get 2.4 g/day vitamin B-12 mainlyfrom the crystalline form found inf ortie d foods and supplements(32,46 ). Age is associated with con-ditions like atrophic gastritis thatmay reduce a person’s ability t o di-gest food-bound vitamin B-12 ( 46).The DGA recommend older adultsconsume extra vitamin D from vita-

min D–f ort ied foods and/or supple-ments ( 32). This is because olderadults are at risk for low serum25(OH)D concentrations becausethey have a decreased ability of theskin to synthesize vitamin D fromsunlight (ultraviolet B radiati on)compared to younger adults ( 48)and some may have limited ex-posure to sunlight. The ModiedMyPyramid for Older Adults devel-oped by researchers at Tufts Uni- versity, includes a ag on top of thepyramid to alert people older thanage 70 years of the potential need tosupplement the diet with vitaminsB-12 and D and calcium ( 49). Cal-cium was included in the ag be-cause the diets of many older adultsare below recommended levels.

● People at risk for suboptimal vi-tamin D status The DGA recom-mend that in addition to olderadults, people with dark skin (be-cause they have a decreased abilityto synthesize vitamin D from sun-light), and those exposed to insuf-cient sunlight, consume extra vita-min D from vitamin D –for tied

foods and/or supplements ( 35).

ADA EALThis portion of the position paper in-cludes the results of a systematic review of literature conducted using ADA’s Evidence Analysis Process andinformation from ADA’s EAL. In thisprocess, an expert work group identi-ed dietetic practice related ques-tions, performed a systematic reviewof the literature and made and rated

a conclusion statement for each ques-tion. The workgroup used ADA’s pro-cess to answer a total of seven qu-estions related specically to thesupplementation of vitamins B-12and D in older adults.

To identify and select articles for

review, the National Library of Med-icine’s PubMed database was sear-ched using the term older adults andthe name of the respective vitamin(eg, vitamin D or cholecalciferol and vitamin B-12 or cobalamin or cyano-cobalamin). All study designs, exceptcase studies, were included in thesearch. Articles published from Janu-ary 2006 to January 2008 with sam-ple size 20 individuals per studygroup and with less than a 20% drop-out rate were searched. Studies werealso identied by screening the refer-

ence lists of the selected papers. Iden-tied papers were then excluded if they did not provide an answer di-rectly related to the question. In ad-dition, for questions related to vita-min D, a decision was made after theinitial search to exclude papers pub-lished before January 2006 due to theinclusion of a 2007 Agency for Health-care Research and Quality evidence-based review that incorporated re-search before this date .

The detailed search plan and re-sults and information on the processand how the conclusions of the Forti-cation and Supplements Evidence Analysis Project were reached ar eavailable at the EAL Web site ( 50).The conclusion statements and gradefor the strength of the evidence foreach question are provided below.

In addition to the Fortication andSupplements Evidence Analysisproject, several other ADA evidenceanalysis projects have included ques-tions related to the use of vitaminsand minerals as they pertain to die-tetics practice. To date, most ques-tions on the EAL on micronutrient

supplementation relate to cardiovas-cular disease and oncology.

Vitamin B-12What is the evidence regarding the effect of oral vitamin B-12 supplemen-tation and/or fortication on serumcobalamin levels in decient olderadults?

Conclusion statement Thirteenstudies (eight randomized control tri-als [RTCs], one non-RTC, three cohort



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studies, one cross-sectional study)found a dose–response effect in theadministration of oral cobalamin tocobalamin-decient older adults. Twoof these studies used multivitaminmineral supplements containing 6 g vitamin B-12 and the remaining stud-

ies used oral cobalamin ranging from2.5 g to 2,000 g per day. Researchendpoints were measured using se-rum cobalamin or serum methylma-lonic acid levels. Four studies com-pared oral B-12 supplementation tointramuscular injection and con-cluded that oral supplementation wasas effective as intramuscular supple-mentation. All of the studies useddoses of vitamin B-12 greater thanthe current RDA of 2.4 g per day forolder adults. Further research isneeded to dene serum cobalamin de-

ciency and to determine appropriatelevels of oral cobalamin supplementa-tion in decient older adults. GradeII Fair.

Are serum cobalamin concentra-tions associated with cognitive func-tion in older adults?

Conclusion statement Researchis inconclusive regarding specic se-rum cobalamin levels associated withcognitive function in older adults.Five studies (one RCT, one non-RCT,two cross-sectional studies, and oneprospective cohort study) found an as-sociation between low serum cobal-amin levels and impaired cognitivefunction in older adults. Four studies(one cross-sectional, three RCTs)found no signicant difference in cog-nitive function in individuals withnormal and decient cobalamin lev-els. One additional study (an RCT)found a decline in cognitive functionwith supplementation in cobalamindecient adults compared to placeboand another study (cross-sectional)found deteriorating cognitive functionin cobalamin- and folate-decient in-dividuals.

Current research is limited by lackof a standardized denition of vita-min B-12 deciency and lack of stan-dardized measures of cognitive func-tion. Further research is needed toestablish the role of vitamin B-12 incognitive function in older adults.Grade III Limited.

Vitamin DWhat is the evidence regarding the effect of supplemental vitamin D

on bone density in postmenopausalwomen and older adult men?

Conclusion statement One meta-analysis (a systematic review of 19studies), ve RCTs, and two cross-sec-tional studies found an associationbetween supplemental vitamin D and

bone mineral density in postmeno-pausal women and older adult men. Vitamin D dosage ranged from 400 IUto 1,400 IU (10 g to 35 g) per day;however, it is difcult to determinethe optimal dosage and the effect of vitamin D alone, since varying combi-nations of nutrients were used includ-ing calcium and vitamin K. One ad-ditional RCT with a supplementcontaining 200 IU (5 g) vitamin Dand other nutrients found an im-provement in bone turnover markers,but no effect in bone mineral density.

Further research is needed to deter-mine the independent association be-tween supplemental vitamin D andbone mineral density in postmeno-pausal women and older adult men.Grade II Fair.

What is the evidence regarding the effect of supplemental vitamin D on fractures in postmenopausal womenand older adult men?

Conclusion statement One meta-analysis/systematic review, combin-ing the results of 13 RCTs, suggeststhat supplementation with vitaminD-3 (400 IU to 800 IU) plus calcium(500 mg to 1,200 mg) may be bene-cial in reducing the incidence of fractures in institutionalized olderadults. The reduction of fracturesmight be accounted for by highermean serum levels of 25(OH)D (atleast 74 nmol/L), due to good volun-teer compliance. One RCT concludedthat supplementation with 100,000IU vitamin D-2 every 4 months doesnot signicantly reduce fractures ininstitutionalized older adults. Fur-ther research is needed to determinethe role of vitamin D-3 and D-2 sup-

plementation alone in reducing theincidence of fractures. Grade IIFair.

What is the evidence regarding the effect of supplemental vitamin D on falls in postmenopausal women andolder adult men?

Conclusion statement One meta-analysis/systematic review, one RCT,and one prospective cohort studyfound that evidence is inconsistent re-garding the effect of supplemental vi-tamin D-2 or D-3 on the reduction of

falls in older adult men and women.Further research is needed to deter-mine the role of vitamin D-2 or D-3alone in preventing falls in olderadults. Grade III Limited.

Are specic circulating concentra-tions of 25(OH)D associated with bone

health outcomes in postmenopausalwomen and older adult men?Conclusion statement Two RCTs

and one meta-analysis (a systematicreview of 42 papers) found that evi-dence is inconclusive regarding theassociation of specic circulating con-centrations of 25(OH)D and bonehealth outcomes in postmenopausalwomen and older adult men. In thosestudies reporting a positive associa-tion in the meta-analysis, specic25(OH)D concentrations ranging from 40 to 80 nmol/L were shown to

have declines in bone health out-comes (fractures, falls, and bone loss).Further research is needed to deter-mine the association of specic cir-culating concentrations of 25(OH)Dwith bone health outcomes. GradeIII Limited.

What is the effect of vitamin D supplementation on circulating 25(OH)Din postmenopausal women and olderadult men?

Conclusion statement Two RCTsand one meta-analysis (systematic review of 44 RCTs) found a direct effectof oral vitamin D-3 supplementationon circulating levels of 25(OH)D inpostmenopausal women and olderadult men. In studies reporting atreatment effect, specic doses rang-ing from 5 g to 50 g (200 to 2,000IU) vitamin D-3 were utilized. Meta-regression results suggested that 100IU (2.5 g) vitamin D-3 will increasethe serum 25(OH)D concentrations by1 to 2 nmol/L suggesting doses of 400to 800 IU (10 to 20 g) daily may beinadequate to prevent vitamin D de-ciency in at-risk individuals. It isdifcult to determine adequate intake

since there is a lack of agreement re-garding optimal levels of serum25(OH)D. Additional research isneeded to determine the vitamin Ddosage necessary to reach optimal se-rum 25(OH)D levels in postmeno-pausal women and older adult men.Grade II-Fair.

Assessing Need for Nutrient SupplementsTo support an optimal nutritional sta-tus, nutrient consumption should ad-



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equately meet requirements includ-ing any metabolic demands such asthose that may be a result of genetics,age, stress, and infection and diseasestates. The strategies of nutrition as-sessment, the rst of the four steps of the Nutrition Care Process, enable a

dietetics practitioner to gauge theneed for nutrient supplementation(51,52 ). The assessment processshould include a comprehensive eval-uation of medical, social, and food andnutrition-related history, anthropo-metric measurements, biochemicaldata, medical tests and proceduresand nutrition-focused physical exam-ination ( 53).

Issues to Consider

Total Nutrient Intakes. Intake assess-ments must include all nutrientsources including natural and forti-ed foods and dietary supplements;both nutrient adequacy and excesscould be underestimated if only conventional food sources are considered.One way to do this is to include open-ended questions about the consump-tion of nutrient supplements whencollecting nutrition data. Questionspertaining to dietary supplement usemay include the name and manufac-turer of the product, the frequency,the dose, and the duration of use ( 54).Clients using multiple supplementscan be asked to bring in the contain-ers of supplements used, particularlyif products with multiple ingredientsare used.

Food and nutrition-related histo-ries, food records, 24-hour recalls, andfood frequency questionnaires aremethods often used to assess dietaryintakes. New methods to analyze to-tal nutrient intakes are being usedwith varying degrees of success. Onemethod, a Web-based automated 24-hour recall, is available from the Na-

tional Cancer Institute (55). Food fre-quency questionnaires that includeinformation on nutrient content of fortied foods and nutrient supple-ments, such as the validated self-administered Short Calcium Ques-tionnaire, are available to quicklyestimate calcium intake ( 56 ).Laboratory Analyses. Laboratory analy-ses can be performed for vitamins A,C, D, E, K, thiamin, riboavin, niacin, vitamins B-6 and B-12, and folic acidand the minerals iron, copper, iodine,

zinc, manganese, and selenium ( 57). Additional laboratory tests can behelpful in assessing nutrient statusfor some nutrients. For example, se-rum ferritin is a sensitive indicator of body iron status except in situationsof inammation, infections, or neo-plastic disorders ( 53). Serum iron andtransferrin saturation are also usefulin evaluating iron status. In the prac-tical setting, however, laboratoryanalyses of most vitamins and miner-als are not generally available. Costand lack of cut-off points for dening suboptimal nutritional status forsome nutrients limit their use in prac-tice. Nutrition-focused physical nd-ings can also be useful when assess-ing nutritional status for somenutrients including vitamins A, C, D,riboavin, niacin, and vitamins B-6

and B-12 ( 57).Genetics/Genomics. The evolving sci-ence of nutrigenomics examines theinteraction between specic genesand nutrients ( 58). This emerging sci-ence may provide insight into how nu-trition inuences metabolic pathwaysand homeostatic control, and how di-etary intervention strategies can beused to promote health and preventdisease in individuals with differentgenotypes ( 58). Micronutrients suchas calcium, zinc, selenium, folate, and vitamins C and E are known to mod-

ify disease-related processes such ascarcinogen metabolism, hormonalbalance, cell signaling and cycle con-trol, apoptosis, and angiogenesis ( 59).For example, the reduced incidence of a variety of cancer types linked tosupplementation with selenium is in-uenced by genetic variability tha tgoverns individual responses ( 59).Methylation of DNA, inuenced by in-take of micronutrients such as sele-nium; vitamin A, B-6, and B-12; cho-line; zinc; methionine; and others, caninuence epigenetic processes which

affect gene expression or activationwithout changing DNA sequence ( 59).This has been looked at in relation tothe role of maternal diet on the sus-ceptibility of the offspring to diseasesand nutrition-related conditions suchas diabetes and cancer ( 59). Identi-cation of single nucleotide polymor-phisms in individuals may enhanceour understanding of why someonewith a genetic variant could reactnegatively or favorably to supplemen-tation. This is particularly relevant to

the potential benets of supplementalfolate with respect to homocysteinemetabolism and reduction of cardiovascular disease risk where a gene variant decreases the activity of methylenetetrahydrofolate reductase, afolate-metabolizing enzyme ( 60). As aresult, homocysteine accumulates un-less fol ate supplements are pre-scribed ( 53). In the future, use of DNA microarrays ( 61) to identify individ-ual genetic variation may be among the assessment tools used to adviseclients of their nutrient and supple-ment needs and to measure the ef-cacy of nutrition prescriptions ( 61).Ultimately, by taking into accountthe known genetic variability in pa-tients and clients, nutrient supple-mentation can be better tailored tothe individual with the goal of disease

prevention.Contraindications. Dietetics practition-ers must be aware of possible situa-tions in which individuals may needto temporarily or permanently limitor avoid specic nutrient supple-ments due to the potential for adverseeffects. For example, healthy post-menopausal women and adult mengenerally should not take iron supple-ments. The prevalence of inadequateiron intakes among older adults is low(40). Thus, concern of excess iron in-takes may be greater than inade-

quate intakes. Avoiding iron supple-mentation is particularly importantfor individuals homozygous for hemo-chromatosis and those with blooddisorders requiring frequent bloodtransfusions ( 62,63 ). To be cautious,smokers should avoid supplementa-tion with beta carotene because in-creased risk of lung cancer andincreased mortality have been associ-ated with high-dose beta carotenesupplements in this group ( 64). Post-menopausal women who take supple-ments containing vitamin A should

consider a product that contains amajority of the vitamin A from betacarotene sources rather than retinol.Intakes of more than 1,500 g/day vi-tamin A from retinol, but not betacarotene, compared to intakes of 500

g/day, have been associated with in-creased risk of hip fracture and re-duced bone mineral density in post-menopausal women ( 65). In addition,some dietary supplements are contra-indicated during surgery. For exam-ple, it has been recommended that



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because vitamin E acts as a bloodthinner, supplements of the vitaminshould be avoided at least 1 week be-fore surgery ( 53).Nutrient Excess. Certain vitamins havebeen associated with adverse effectsat high doses. For example, excess fo-lic acid may mask or exacerbatesympto ms of a vitamin B-12 de-ciency (66). Excessively high supple-mental intakes of vitamin B-6 havebeen reported to result in sensoryneuropathy ( 46). Gastrointestinal dis-turbances, kidney stones, and excessiron absorption, particularly for individuals with excessive iron absorp-tion due to hereditary hemochromato-sis, is cited as the possible adverseeffects of excessive consumption of vi-tamin C ( 37).Nutrient Interactions. Dietetics practi-tioners should also be aware of anddocument the potential nutrient/nu-trient and drug/nutrient interactionsthat can occur with the chronic use of nutrient supplements ( 67). An imbal-ance of nutrients, such that theamount of one nutrient interferes oralters absorption and/or utilization of another nutrient, can result from theconsumption of high-dose nutrientsupplements. For example, high-doseiron supplements can decrease zincabsorption and high amounts of zinccan inhibit copper absorption ( 68).The absorption of supplemental mag-nesium in the form of magnesiumsalts is inhibited by iron supple-ments, whereas the absorption of both heme- and non-iron is inhibitedby calcium supplements ( 62); thus, in-dividual supplements of minerals, if indicated, should be taken separately.

Drugs can increase the require-ment for certain nutrients and com-promise nutritional status. For exam-ple, anticonvulsant medications canincrease the need for folate ( 69). Cor-ticosteroids can deplete calcium ( 48)

and impair vitamin D metabolism(70). Certain diuretics, antibiotics,and antineoplastic medication cancause a magnesium deciency ( 71).Chronic alcohol consumption can in-crease the requirement for B vitaminsand magnesium due to decreased ab-sorption, increased diuresis, and in-creased metabolism of these nutri-ents ( 69,71-73 ). Multiple medicationsmanaging multiple diseases (polyp-harmacy), particularly among olderadults, can increase the likelihood of

drug/nutrient interactions and inu-ence the need for certain nutrients.

Nutrient supplements can inu-ence the dosage and/or bioactivity of medications. For example, vitamin K supplementation can decrease the ef-fectiveness of anticoagulant medica-tions like warfarin. Supplements con-taining vitamin K should be avoidedor used with caution and under themedical care of a physician by thosetaking such medications as a consis-tent intake of the vitamin is critical. Vitamin E, which can inhibit plateletaggregation and antagonize the ac-tions of vitamin K, may also interactwith anticoagulant and antiplateletmedications ( 74). High-dose vitaminE supplements may increase the riskof bleeding in individuals taking these medications (74). Resources

that provide information on precau-tions, contraindications, and poten-tial interactions with drugs, food orother supplements include the Ofceof Dietary Supplements’ fact sheets(75) and the PDR for Nutritional Sup- plements (76). A ddition al sources areprovided in the Figure .Supplement Forms and Dosages. Certainforms of nutrients are more likelythan others to contribute to nutrientadequacy based on their molecularstructure and chemical formula. Forexample, folic acid from supplements

and fortied foods is more bioavail-able than folate from foods due to theease of absorption of the unconju-gated form ( 46). Other issues of sup-plement selection, such as the chem-ical form, can affect both adverseeffects and efcacy. For example, thepharmacological use of niacin (nico-tinic acid), may be effective as a lipid-lowering agent, but may also causeside effects such as ushing and itch-ing (77). Strategies such as slowly in-creasing doses and taking aspirinmay help prevent or minimiz e th e dis-

comforts of niacin therapy ( 78). Theeffects of the two forms of supplemen-tal vitamin D (D-2 or ergocalciferolmade from yeast and D-3 or cholecal-ciferol from animal sources) on serumlevels of 25(OH)D have been com-pared. Some studies report a signi-cantly greater effect of vitamin D-3 onincreasing the levels of serum25(OH)D ( 44,79 ) while a more recentstudy found that the two forms of the vitamin were equally effective ( 80).These discrepancies in the literature

speak to the pressing need for up-dated guidelines for the treatment of vitamin D insufciency in healthyadults ( 81).

The effectiveness of mineral sup-plements is affected by the amount of the elemental mineral present in themineral salt. Due to the bulk of cal-cium salt, it is impossible for calciumat recommended amounts to be in-cluded in a reasonably sized MVMsupplement ( 82). Calcium carbonatehas the highest concentration of cal-cium among calcium salts but re-quires an acid medium for optimalabsorption. Thus it is recommendedthat it be consumed with meals ( 83).Calcium citrate can be taken with orwithout foods and can be used bythose with achlorhydria ( 84). Calciumlactate and gluconate are less usefuldue to the minimal content of calciumin these supplements. Maximum ab-sorption is obtained with doses 500mg, so splitting a 1,000 mg dose intotwo doses is advisable ( 85). Magne-sium chloride and magnesium lactateare more bioavailable than magne-sium oxide ( 71). In addition, entericcoating on supplements can block theabsorption and bioavailability of mag-nesium supplements ( 71).

Reporting Adverse EffectsDietetics practitioners are urged tocounsel clients to report adverse reac-tions to nutrient supplements to themanufacturer and to the FDA. Healthcare professionals are also encour-aged to report adverse effects experi-enced by their clients from the use of dietary supplements using the FDA’sMedWatch program. The Health In-surance Portability and Accountabil-ity Act Privacy Rule permits coveredentities to “report adverse events andother information related to the qual-ity, effectiveness, and safety of FDA-regulated products both to the manu-facturers and directly to the FDA”(86). Reports can be made by tele-phone by calling 800-FDA-1088 or on-line at www.fda.gov/Safety/MedWatch/ HowToReport/ucm085568.htm (87).

PROFESSIONAL RESOURCESThe Ofce of Dietary Supplements atthe National Institutes of Health,which was created in part to promote


http://www.fda.gov/Safety/MedWatch/HowToReport/ucm085568.htmhttp://www.fda.gov/Safety/MedWatch/HowToReport/ucm085568.htmhttp://www.fda.gov/Safety/MedWatch/HowToReport/ucm085568.htmhttp://www.fda.gov/Safety/MedWatch/HowToReport/ucm085568.htm


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research aimed at determining thehealth benets and risks of dietarysupplements, provides several toolsdietetics practitioners can use to in-crease their knowledge of dietary sup-plements. These include a 1-weekpracticum on dietary supplement is-

sues for nutrition and health-rel ate dfaculty and graduate students ( 88);the International Bibliographic Infor-mation on Dietary Supplements data-base, which contains citations and ab-stracts from the scienti c literatureon dietary supplements (89); and ex-pert-reviewed fact sheets on dietarysupplement ingredients ( 75). Theseand other re sources such as thoselisted in the Figure can be used bydietetics practitioners to stay in-formed on issues related to dietarysupplements.

ROLES AND RESPONSIBILITIES OFDIETETICS PRACTITIONERSGiven the prevalent use of nutrientsupplements by the public, dieteticspractitioners need to keep up-to-dateon the safety and efcacy of theseproducts to assist consumers in thesafe and appropriate use of supple-ments. The roles and responsibilitiesof dietetics practitioners include:

● assessing nutritional status of cli-ents to determine likelihood of in-adequate or excessive intake of vi-tamins and minerals;

● evaluating the potential benet orharm of nutrient supplementationgiven a client’s nutritional andhealth status;

● evaluating the safety of a nutrientsupplement given the form, dose,its potential for interaction withfood, other dietary supplementsand over-the-counter and prescri-bed medications;

● educating clients as to the potent-ial benet of receiving nutrients

through conventional and fortiedfoods;● recommending nutrient supple-

mentation when food intake is in-adequate;

● evaluating research regarding nu-trient supplementation; and

● being aware of regulatory, legal,and ethical issues of recommend-ing and selling of nutrient supple-ments.

These are clearly challenging yet

critical roles and responsibilities fordietetics practitioners. Continuing education and inclusion of dietarysupplements in didactic curricula areessential to ensuring dietetics practi-tioners have the skills necessary toperform these functions.

CONCLUSIONSConsumption of a wide variety of nu-tritious foods is the best way to main-tain health and prevent chronic dis-ease. The dietary intakes of many Americans do not meet recommendednutrient intake levels. It is among theroles and responsibilities of dieteticspractitioners to help educate the pub-lic on healthful dietary patterns andon the safe and appropriate selectionand use of nutrient supplements tomeet their nutrient needs and opti-

mize health. To this end, dieteticspractitioners must keep abreast of re-search ndings on potential benetsand safety of nutrient supplementsand on the regulations that governthese products.

To obtain references used for the evi-dence analysis sections of this posi-tion, go to www.eatright.org/cps/rde/ xchg/ada/hs.xsl/advocacy_15986_ENU_HTML.htm .

References

1. American Dietetic Association. Position of the American Dietetic Association: Func-tional foods. J Am Diet Assoc . 2009;109:735-746.

2. American Dietetic Association. Position of the American Dietetic Association and Die-titians of Canada: Dietary fatty acids. J Am Diet Assoc. 2007;107:1599-1611.

3. American Dietetic Association. Position of the American Dietetic Association: Healthimplications of dietary ber. J Am Diet As-soc. 2008;108:1716-1731.

4. American Dietetic Association. Practice pa-per of the American Dietetic Association: Di-etary supplements. J Am Diet Assoc . 2005;105:460-470.

5. Radimer K, Bindewald B, Hughes J, Rad-imer K, Bindewald B, Hughes J, Ervin B,

Swanson C, Picciano MF. Dietary supple-ment use by US adults: Data from the Na-tional Health and Nutrition ExaminationSurvey, 1999-2000. Am J Epidemiol . 2004;160:339-349.

6. Shaikh U, Byrd RS, Auinger P. Vitamin andmineral supplement use by children and ad-olescents in the 1999-2004 National Healthand Nutrition Examination Survey: Rela-tionship with nutrition, food security, phys-ical activity, and health care access. Arch Pediatr Adolesc Med . 2009;163:150-157.

7. Nutrition Business Journal. 2008 Supple-ment Business Report . San Diego, CA: NewHope Natural Media, Penton Media Inc;2008.

8. Dietary supplements: FDA should take fur-ther actions to improve oversight and con-sumer understanding. US Gover nment Ac-countability Ofce Web site. http://www.gao.gov/new.items/d09250.pdf. PublishedNovember 2009. Accessed June 1, 2009.

9. Dietary Supplement Health and Education Act of 1994. Public L No. 103-417 (codied at42 USC 287C-11).

10. Claims that can be made for conventionalfoods and dietary supplements. US Food andDrug Administration Web site. http://www.fda.gov/Food/LabelingNutrition/LabelClaims/ ucm111447.htm. Accessed June 1, 2009.

11. Dietary supplements: An advertising guidefor industr y. Federal Trade CommissionWeb site. http://www.ftc.gov/bcp/edu/pubs/ business/adv/bus09.shtm. Accessed June 26,2009.

12. Overview of dietary supplements. US Foodand Drug Administration Web site. http:// www.fda.gov/Food/DietarySupplements/ ConsumerInformation/ucm110417.htm . Ac-cessed June, 1, 2009.

13. Dietary supplements: Background infor-mation. O fce of Dietary SupplementsWeb site. http://ods.od.nih.gov/factsheets/ DietarySupplements_pf.asp. Accessed June1, 2009.

14. New dietary ingredients in dietary supple-ments—Background for industry. US Foodand Drug Administration Web site. http:// www.fda.gov/Food/DietarySupplements/ ucm109764.htm. Accessed June 1, 2009.

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