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FROM THE ACADEMY
Position Paper

Position of the Academy of Nutrition and


Dietetics: Micronutrient Supplementation
ABSTRACT POSITION STATEMENT
It is the position of the Academy of Nutrition and Dietetics that micronutrient supple- It is the position of the Academy of Nutrition
ments are warranted when requirements are not being met through the diet alone. and Dietetics that micronutrient supple-
ments are warranted when requirements are
Those with increased requirements secondary to growth, chronic disease, medication not being met through the diet alone. Those
use, malabsorption, pregnancy and lactation, and aging may be at particular risk for with increased requirements secondary to
inadequate dietary intakes. However, the routine and indiscriminate use of micro- growth, chronic disease, medication use,
nutrient supplements for the prevention of chronic disease is not recommended, given malabsorption, pregnancy and lactation, and
aging may be at particular risk for inade-
the lack of available scientific evidence. A few specific age and disease states that may quate dietary intakes. However, the routine
benefit from micronutrient supplementation are discussed. The most common dietary and indiscriminate use of micronutrient
supplements used by both children and adults in the United States contain micro- supplements for the prevention of chronic
nutrients. Consumers may not be well informed about the safety and use of these disease is not recommended, given the lack
of available scientific evidence.
products, and some may have difficulty interpreting product labels. Thus, the expertise
of registered dietitian nutritionists and nutrition and dietetic technicians, registered, is
needed to guide the safe and appropriate selection and use of micronutrient supple-
ments. To accomplish this, registered dietitian nutritionists and nutrition and dietetic
technicians, registered, must keep up to date on efficacy, safety, and the regulatory
issues influencing the use of these products. This position paper aims to increase
awareness of current issues relevant to micronutrient supplementation and of the re-
sources available to assist registered dietitian nutritionists and nutrition and dietetic
technicians, registered, in evaluating their potential benefits and adverse outcomes.
J Acad Nutr Diet. 2018;118(11):2162-2173.

T
HE FOCUS OF THIS ACADEMY previously by the manufacturer or by micronutrient supplements. To accom-
of Nutrition and Dietetics po- researchers, but heterogeneity of the plish this, RDNs and NDTRs must keep
sition paper is on the safe and MVM definition exists. However, to be up-to-date on efficacy, safety, and the
appropriate use of vitamin and consistent with the literature, MVM regulatory issues influencing the use of
mineral containing dietary supple- may be used in this position paper to these products. This position paper
ments to help individuals meet their reflect the term used by investigators aims to increase awareness of current
micronutrient requirements when di- and other sources. This position paper issues relevant to micronutrient sup-
etary intake is insufficient. Micro- does not address other dietary supple- plementation, and of the resources
nutrients are essential vitamins and ments such as amino acids, fatty acids, available to assist RDNs and NDTRs in
minerals required in small amounts enzymes, herbs, or other botanicals. evaluating the potential benefits and
from the diet to sustain virtually all MVMs continue to be the most adverse outcomes of their use as part
normal cellular and molecular func- commonly used dietary supplement in of the Nutrition Care Process.
tions.1 For the purposes of this position the United States. According to one
paper, the term micronutrient supple- authoritative estimate, total supple-
ments is used to indicate a category of ment sales in 2016 were $41.2 billion, DEFINITION AND REGULATORY
dietary supplements that contain sin- with the majority being composed of FRAMEWORK
gle or multiple vitamins and minerals. micronutrient supplements.2 Despite Dietary supplements, and therefore
The most common dietary supplement the widespread use, consumers may micronutrient supplements, are regu-
used in the United States is the multivi- not be well informed about the safety lated by the Food and Drug Adminis-
tamin mineral (MVM); however, there and use of micronutrient supplements tration (FDA) Center for Food Safety
is no legal or regulatory definition of and some may have difficulty inter- and Applied Nutrition as a subcategory
MVM. MVMs have been defined preting product labels. Thus, the of food. The Dietary Supplement Health
expertise of registered dietitian nutri- and Education Act of 1994 (DSHEA),
tionists (RDNs) and nutrition and di- which amended the Federal Food,
2212-2672/Copyright ª 2018 by the
etetic technicians, registered (NDTRs), Drug, and Cosmetic Act of 1938, defines
Academy of Nutrition and Dietetics.
is needed to guide the safe and and sets safety and labeling re-
https://doi.org/10.1016/j.jand.2018.07.022
appropriate selection and use of quirements for dietary supplements.3

2162 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS ª 2018 by the Academy of Nutrition and Dietetics.
FROM THE ACADEMY

DSHEA defines a dietary supplement as claims are not pre-approved by the event reports they receive for 6 years.10
a product intended to supplement the FDA.4 However, the manufacturer must As defined by the FDA, adverse events
diet that contains any of the following: provide the FDA with the text of are considered serious if “they result in
“a vitamin; a mineral; an herb or other structure/function claims no later than death, a life-threatening experience,
botanical; an amino acid; a dietary 30 days after marketing the supple- inpatient hospitalization, a persistent
substance for use by man to supple- ment and ensure that the claims are or significant disability or incapacity, or
ment the diet by increasing the total truthful and not misleading.4 Labels a congenital anomaly or birth defect, or
dietary intake; or a concentrate, with structure/function claims must requires, based on reasonable medical
metabolite, a constituent, extract, or carry this disclaimer: “These state- judgment, a medical or surgical inter-
combination of any ingredient ments have not been evaluated by the vention to prevent an outcome” listed
mentioned above.”3 However, there is Food and Drug Administration. This above.11
not a legal or regulatory definition of product is not intended to diagnose, The FDA received 6,307 mandatory
the term micronutrient supplement or treat, cure, or prevent any disease.”6 serious AERs for dietary supplements
MVM. Dietary supplements are avail- Although the FDA is responsible for from 2008 through 2011.12 Six of the 10
able as pills, capsules, tablets, liquids, product label claims, the Federal Trade dietary supplements receiving the
powders, or other forms taken orally, Commission regulates dietary supple- most mandatory AERs were MVM
as long as they are not represented for ments advertising claims.7 All claims supplements. However, an AER alone
use as a conventional food or as a sole must be truthful, not misleading, and does not indicate a causal relationships
item of a meal or diet.3 They must also substantiated by credible scientific ev- between adverse events and the asso-
be identified as a dietary supplement idence.7 Health professionals can con- ciated product, because other products
on the label.3 tact the Federal Trade Commission to consumed at the same time and pre-
report products they believed are existing health conditions could each
falsely advertised or labeled. contribute to the reported adverse
Label Claims event.12
Like food labels, dietary supplement
labels can bear authorized and quali- Safety Quality
fied health claims, nutrient content Manufacturers and/or distributors are
claims, and structure/function claims.4 Under DSHEA, the FDA established
responsible for ensuring product safety good manufacturing practices for di-
Health claims characterize the rela- before placing them on the market.6
tionship between a supplement ingre- etary supplements to ensure proper
Because micronutrients were refer- identity, purity, strength, and compo-
dient and reducing the risk of a disease enced and sold as dietary supplements
or health-related condition.4 Nutrient sition.13 Companies are responsible for
before DSHEA was implemented, they ensuring their products meet good
content claims characterize the are presumed to be safe based on their
amount of a nutrient in a dietary sup- manufacturing practices, including ac-
history of use; thus, they do not require curate labeling (eg, products contain
plement.5 For example, “high potency an FDA premarket review of safety or
multivitamin, multimineral dietary the ingredients in the amounts stated
efficacy. For any new dietary ingredient on their labels) and are free from con-
supplement tablets” can be used on a sold after DSHEA’s implementation and
product label in the case that it con- taminants (eg, bacteria, pesticide, glass,
not recognized as a food substance lead, and other heavy metals).13 In
tains 100% or more of the Reference present in the food supply, the manu-
Daily Intakes for at least two-thirds of addition to the FDA, independent or-
facturer and distributor must notify ganizations such as ConsumerLab.
the vitamins and minerals with Refer- the FDA of the intention to market the
ence Daily Intakes in the product.5 Both com,14 NSF International,15 and US
product and provide the FDA with the Pharmacopeial Convention16 offer pro-
health claims and nutrient content information used to conclude that
claims must be preapproved by the grams that evaluate supplement qual-
the ingredient was generally regarded ity. At a minimum, each organization
FDA.4 Structure/function claims are the as safe to consume.6 Once marketed,
most commonly used claims on sup- has a program that allows manufac-
the FDA has the authority to remove a turers to pay a fee to have its products
plement labels. There are three types of product in the case that they prove it to
structure/function claims,5 those that tested. Supplements conforming to the
be unsafe.6 The FDA monitors safety respective organization’s quality spec-
describe: largely by collecting adverse event re- ifications can bear that organization’s
 the nutrient’s role on normal ports from consumers, health pro- seal of approval on their label.17 The
structure or function of the body fessionals, and manufacturers through absence of a seal, does not indicate
or means by which it works to MedWatch, the FDA Safety Information inferior quality because the high costs
maintain a structure or function and Adverse Event Reporting Pro- of analyzing each ingredient may pre-
(eg, antioxidants maintain cell gram.8 The Dietary Supplement and vent some manufacturers from having
integrity); Nonprescription Drug Consumer Pro- its products tested.
 tection Act9 requires the responsible
general well-being from intake
party (ie, the manufacturers, packers,
of a nutrient; or
or distributors whose name appears on
USAGE IN THE UNITED STATES
 a benefit related to a nutrient
the label) to submit serious adverse Prevalence of Use
deficiency.
event reports (AERs) to the FDA within The prevalence estimates presented in
Labels cannot make statements that 15 business days of receiving a report, this position paper focus on large, na-
are disease claims. Structure/function and to maintain records of all adverse tional survey data to make population

November 2018 Volume 118 Number 11 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 2163
FROM THE ACADEMY

level generalizations, and characterize screen times (eg, television or com- the most common organ-specific rea-
use of both dietary supplements in puter), and are more physically sons for supplement use.22 Similarly,
general and specific micronutrient active.24,25 Only 16% of the dietary among older adults, the most common
supplements, including MVM. Such supplements used by children are motivations for supplement use
generalizations do not characterize based on the advice of a health care include to “improve overall health,”
special groups like elite athletes18 and professional.24 Health care providers “maintain health,” and “bone
individuals in the military,19 who are were most likely to recommend dietary health.”22,26
more likely to use dietary supplements supplements to children aged <2 years
than the general population, and are compared with children of any other Micronutrient Supplements. The
more likely to stack products (ie, use age group.24 most common motivation for MVM use
multiple products simultaneously). in children was to “improve overall
Micronutrient Supplements. Of health” (44%). This same motivation
Dietary Supplements. The National those using dietary supplements, MVM was reported for the use of multivi-
Health and Nutrition Examination products are by far the most commonly tamin supplements (ie, a combination
Survey (NHANES) is a continuous, used dietary supplement in children24 vitamin product without minerals)
federally supported monitoring proto- and adults.21,23 However, the defini- (35%).24 Vitamin C supplements,
col coordinated by the National Center tion of MVM is not consistent across although low in overall use (2% over-
for Health Statistics at the Centers for research studies.20,21,23 MVM and all), were reported by about half of
Disease Control and Prevention. micronutrient products are used by those users (47%) to “boost immune
NHANES has continuously monitored w90% of child dietary supplement system and prevent colds.” MVMs were
dietary supplement use for more than users, representing 24% of US children primarily used by adults to “improve
50 years. Based on the NHANES find- aged 19 years.24 Depending on the overall health” (48%). The majority of
ings across time, just more than half of definition, about one-third of US adults adults who use calcium supplements
adults (aged 20 years among use a MVM product.21-23 Among older (4% of men and 19% of women) do so
nonpregnant, nonlactating adults) adults (aged 60 years), MVM is the “for bone health” (75%). Similar to
report using a dietary supplement in most frequently used supplement children, whereas the proportion of
general.20-22 (40%), followed by supplements con- adults using vitamin C was low overall
In adult populations, dietary supple- taining vitamin D (26%), calcium (9%) (7%), many did so to “boost immune
ment use is more common in women or a vitamin D and calcium combina- system and prevent colds” (45%).
than men, and by non-Hispanic whites tion (13%), vitamin B-12 (8%) and B
when compared with by non-Hispanic complex (5%), and vitamin C (11%).26
blacks and Hispanic and Mexican About 75% of all pregnant women
NUTRIENT AND FOOD
Americans.22,23 Dietary supplements report using a MVM in NHANES 1999-
RECOMMENDATIONS
are used more often by nonsmokers, 2006.27 Folic acid or iron containing Optimal nutrient intakes are those that
people who exercise regularly, those supplements are most frequently promote health and reduce risk for
with higher education and incomes, consumed during pregnancy, but very chronic disease, while minimizing risk
and those who report better overall little is known about supplement use of excess. The Food and Nutrition Board
health.20,21 Use of dietary supplements in lactation.27 (FNB) of the National Academies of
in adults does not vary significantly by Sciences, Engineering, and Medicine,
weight status.21 In adults, supplement Health, and Medicine Division provides
use is noted to be more of a personal Motivations for Use the best available evidence-based
preference rather than a health care Dietary Supplements. Among chil- standards for estimating optimal
professional’s recommendation.22 Most dren, 41% use supplements to “improve nutrient intakes. Dietary Reference In-
adults (53%) use one dietary supple- overall health,” 37% to “maintain takes (DRIs) is an umbrella term used
ment product,21 but 8% to 10% of adults health,” 23% for “supplementing the to represent four factors relevant to
use more than four supplements diet,” 20% to “prevent health prob- nutrients: the Recommended Dietary
regularly.23 lems,” and 14% to “boost immunity.”24 Allowances (RDAs), Adequate Intakes
Consistently, about one-third of US In children aged <2 years, the most (AIs), Estimated Average Requirements
children take a dietary supplement; common reason for using supplements (EARs), and Tolerable Upper Intake
but, these are almost exclusively (95%) is for tooth health and cavity preven- Levels (ULs).28 The DRIs are used to
confined to micronutrient supple- tion (14%), whereas children aged 16 to assess adequate and excess nutrient
ments. Among children aged <2 years 19 years, “to get more energy” (10%) is intakes and plan diets for groups and
(NHANES 2007-2010), 17% reported use the most common reason cited for individuals.
of any dietary supplement, 45% in supplement use.24 For both men and The DRIs are recommendations for
children ages 2 to 5 years, 35% in chil- women, “improve overall health,” healthy individuals. As such, higher
dren ages 6 to 11 years, and w23% for “maintain health,” “supplement the requirements likely exist for in-
those aged 12 to 19 years.24 Similar to diet,” and “prevent health problems” dividuals who are malnourished or
trends observed in adults, dietary sup- are the most common motivations for have altered requirements due to a
plement use in children is more prev- general dietary supplement use.22 health condition or use of a medica-
alent in non-Hispanic whites, families Among men and women, “heart tion. Clinical status and biochemical
with private health insurance, higher health, lower cholesterol” (18%) and indexes should be combined with di-
incomes, and those less likely to have “bone health” (36%), respectively, were etary intake data to assess an

2164 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS November 2018 Volume 118 Number 11
FROM THE ACADEMY

individual’s dietary adequacy and relative to DRI exists across the popu- were much less likely than nonusers of
nutritional status28 and need for lation and that underconsumption has micronutrient supplements to have
micronutrient supplementation.29 A been linked to adverse health out- inadequate intakes of most minerals:
comprehensive nutrition assessment comes in the scientific literature. Iron is magnesium (21% vs 66%), calcium (20%
can inform RDNs and NDTRs when a of concern for adolescent and pre- vs 51%), (copper <0.5% vs 20%), zinc
micronutrient supplement is likely to menopausal women, including preg- (<0.5% vs 13%), and iron (<0.5% vs 8%)
be of benefit or if its consumption nant women. Many Americans do not and vitamins: folate (1% vs 14%),
places a client at risk of excess. consume the amount and types of vitamin C (3% vs 48%), vitamin A (4% vs
The EAR is the basis of micronutrient foods necessary to meet these recom- 58%), vitamin D (25% vs 96%), and
recommendations at the group level mended nutrient intakes. Adherence to vitamin E (5% vs 96%).37
(eg, meeting the needs of 50%), the DGAs is low; only about 3% to 4% of Unlike adults, micronutrient ade-
whereas the RDA is for use at the in- Americans follow all of the DGAs.32 As quacy from foods sources did not vary
dividual level (eg, meeting the needs of a result of low intakes of nutrient-rich among children who consumed vs who
97.5%). The RDA is determined as two foods and sedentary lifestyles, many did not consume dietary supplements
standard deviations above the EAR. An Americans may be meeting or (ie, classified by any dietary supple-
AI is set when there is not enough in- exceeding their energy requirements ment use).38 Children aged 2 to 8 years
formation available to estimate an RDA. while falling short of meeting nutrient who use dietary supplements are more
AIs represent intakes likely to exceed recommendations. Fortified foods and likely than older children to meet the
the actual requirements of almost all micronutrient supplements may be micronutrient recommendations from
healthy people. For the same reason, useful in bridging the gap of shortfall foods alone.38 Dietary supplement use
usual intakes that fall below the AI nutrients as examined in detail is lowest among adolescents, which is
recommendations should not be inter- below.33 paradoxical because nutrient intakes
preted as inadequate. Rather, when an from food sources among this age
individual’s usual intake meets or ex- NUTRIENT SUPPLEMENTATION group tend to be inadequate for many
ceeds recommended levels, it is likely micronutrients.38
that their intake is adequate.
Effect on Total Nutrient Intakes
The UL is used both at the individual Micronutrient supplements can have a
and at the group level to estimate risk substantial influence on a person’s to- Exceeding the ULs
of excessive micronutrient intakes. The tal intakes.34,35 The extent to which a Micronutrient supplements have the
UL is an important tool that RDNs and supplement can improve micro- potential to fill gaps in the diet but
NDTRs can use to educate consumers nutrient adequacy is influenced by the could potentially increase intakes
in the safe use of nutrient supplements. nutritional profile of the supplement above ULs. Intake from all supplements
As average daily intakes exceed the UL, taken. For example, although MVMs and foods and beverages must be
the risk of adverse health effects in- provide substantial amounts of some included when assessing usual nutrient
creases. The ULs for vitamin E, niacin, micronutrients (ie, folic acid and intake of individuals and groups. The
and folic acid apply only to synthetic vitamin C), they often lack key minerals prevalence of the population that ex-
forms of the nutrients found in sup- such as potassium, calcium, and ceeds the UL is low for most micro-
plements and fortified foods.30 The UL magnesium. nutrients (5% for folate; calcium;
for magnesium applies only to intakes iron; vitamins A, D, C, and E; and zinc)
from supplements or pharmacologic Filling Dietary Gaps when users and non-users of supple-
agents.30 The UL for vitamin A is from National survey data have provided ments are combined as a group.33,35
preformed vitamin A (ie, retinol insights on total usual micronutrient US adults typically do not have usual
only).30 For all other nutrients, ULs exposures from all sources (ie, intrinsic intakes of micronutrients that exceed
apply to total intake from food, bever- nutrients, fortified nutrients, and the UL from foods alone. However,
ages, and supplements. For nutrients micronutrient supplements). NHANES micronutrient supplement users do
for which data were insufficient to data reveal a high proportion of have an increased likelihood of intakes
determine a UL (ie, biotin, carotenoids, Americans that have at risk intakes above the UL for iron (9%), zinc (9%),
pantothenic acid, riboflavin, thiamin, (>25% with intakes <EAR) for vitamins folic acid (7%), calcium (6%), magne-
vitamin B-12, and vitamin K) the FNB A, C, D, and E; calcium; and magnesium sium (6%), vitamin B-6 (3.5%), vitamin
cautions about consuming large without the use of micronutrient sup- A (3%), and vitamin C (1.6%).36,37
amounts.30 plements.33,36,37 Overall, smaller pro- Among children, use of dietary sup-
The 2015 Dietary Guidelines for portions of the population had total plements in general (as previously
Americans (DGA) recommends that usual intakes below the EAR for B vi- mentioned is almost exclusively
nutrition needs should be met primar- tamins, zinc, folate, iron, phosphorus, micronutrient supplements) increases
ily from foods. However, the DGA also copper, and selenium (<1%).35-37 the prevalence of usual nutrient in-
highlights several nutrients that are a When adult users and nonusers of takes above the UL for iron, zinc, cop-
shortfall nutrient or a nutrient for micronutrient supplements are exam- per, selenium, folate, and vitamins A
public health concern (eg, vitamins A, ined separately, users tend to have a and C.38 Of most concern are 2- to 8-
C, D, E; folate; calcium; magnesium; lower prevalence of inadequate intakes year-old micronutrient supplement
and potassium) in Americans aged 2 (ie, <EAR) from diet alone.36,37 users who exceed the UL for zinc (84%),
years and older.31 This indicates that a Considering total intake (diet and folic acid (71%), and vitamin A (72%).38
high prevalence of inadequate intakes micronutrient supplements), users It should be noted that some children

November 2018 Volume 118 Number 11 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 2165
FROM THE ACADEMY

exceed the UL for folic acid and zinc prescribed amount of calcium was Infants and Young Children. The
from food sources alone.38 1,000 to 1,200 mg. In 2012, the USPSTF American Academy of Pediatrics rec-
recommended vitamin D supplemen- ommends 1 mg/kg daily iron supple-
Effect of Nutrient tation (based on median dose of 800 mentation for exclusively breastfed
Supplementation on Chronic IU) to help prevent falls in community- full-term infants from age 4 months
Disease Prevention dwelling adults 65 years of age or older until infants begin eating iron-
who are at increased fall risk.43 How- containing complementary foods, such
Although supplementation can be
ever, in 2018 the USPSTF recommended as iron-fortified cereals.46 They also
effective in meeting recommended
against daily supplementation of 400 recommend 1 mg/kg/day supplemental
intake of some micronutrients, it has
IU or less of vitamin D and 1,000 mg or iron beginning at age 4 months for in-
not been proven effective in preventing
less of calcium for the primary pre- fants who receive more than one-half
chronic disease. In 2006, a National
vention of fractures in postmenopausal of their daily feedings as human milk
Institutes of Health State-of-the-
women. They also concluded that evi- and who are not receiving iron-
Science Panel, after reviewing evi-
dence was insufficient to assess bene- containing complementary foods.46
dence on the health benefits and risks
fits or harm of higher amounts in
of MVM supplements, concluded that
postmenopausal women and at any Infants and Children, Including
there was insufficient evidence to
dose for fracture prevention among Adolescents. The American Academy
determine whether taking MVM sup-
community-dwelling men and pre- of Pediatrics recommends all infants
plements was beneficial for preventing
menopausal women.44 who are exclusively or partly breastfed
chronic disease in generally healthy
people.39 receive 400 IU of supplemental vitamin
The Agency for Healthcare Research D daily beginning the first few days of
MICRONUTRIENT SUPPLEMENTS life, and continued unless infant is
and Quality conducted a systematic
IN PRACTICE weaned to at least 1 qt/day vitamin D-
review on the use of multivitamins or
single and functionally related pairs of When to Consider fortified formula or, if older than age 12
nutrients (including MVM) for cardio- Supplementation months, whole milk or low-fat milk
vascular disease and cancer prevention Micronutrient supplements can be when appropriate; all nonbreastfed
to inform US Preventive Services Task used to help individuals meet a infants and older children who
Force (USPSTF) recommendations. nutrient requirement or to treat a consume <1 qt/day vitamin D-fortified
Based on this review, the USPSTF diagnosed deficiency. A person’s formula or milk and adolescents with
concluded in 2014 that the current micronutrient intake may be inade- dietary intakes <400 IU/day.47 If a baby
evidence is insufficient to assess the quate when they are restricting energy is drinking at least 32 oz formula,
balance of benefits and harms of the intake for weight loss/control, not vitamin D supplementation is not
use of multivitamins or single- or consuming an adequate amount of needed. Children at an increased risk
paired-micronutrient supplements food to meet energy requirements for vitamin D deficiency, such as those
(including MVM) and recommended resulting from poor appetite or illness, with fat malabsorption and those tak-
against the use of beta carotene or eliminating one or more food groups ing seizure medications, may need
vitamin E supplements for the pre- from their diet on a regular basis, or higher amounts to achieve normal
vention of cardiovascular disease or consuming a diet low in micronutrient- serum vitamin D levels.47
cancer.40 rich foods despite adequate or exces-
In 2011, the FNB updated the DRIs for sive energy intakes. Groups most Women of Childbearing Age Who
calcium and vitamin D.41 The FNB re- vulnerable to micronutrient in- May Become Pregnant. The FNB
ported that although data indicated a adequacy are older adults, pregnant recommends that women who can
key role for calcium and vitamin D in women, alcohol-dependent in- become pregnant consume 400 mg/day
skeletal health and provided a sound dividuals, strict vegetarians and folic acid from fortified foods and/or
basis for determining DRIs, it did not vegans, and those with increased re- supplements daily, in addition to folate
provide convincing evidence of other quirements secondary to health con- obtained from eating a varied diet to
health outcomes beyond bone or that ditions or the chronic use of a reduce the risk of neural tube defects
intakes greater than the DRIs have medication that alter nutrient absorp- (eg, spina bifida and anencephaly).48
health benefits. In fact, emerging evi- tion, metabolism, or excretion.45 The USPSTF recommends women
dence indicated that too much of these Academy of Nutrition and Dietetics planning or capable of pregnancy take
nutrients may result in harmful position papers that focus on partic- a daily supplement of 400 to 800 mg
outcomes.41 ular segments of the population or folic acid (grade A).49 Folic acid is the
The American Geriatrics Society ad- conditions often include recommen- form of the vitamin found in supple-
vises clinicians to recommend vitamin dations on micronutrient supplemen- ments and fortified foods, and folate is
D supplementation of at least 1,000 IU/ tation. In addition, some government the form found naturally occurring in
day and calcium supplementation to and professional organizations and foods.
community-dwelling adults aged 65 expert workgroups provide recom-
years or older to reduce risk of frac- mendations for micronutrient sup- Older Adults. The FNB recommend
tures and falls.42 The workgroup plementation. The following are that people older than age 50 years get
recommendation was based on specific examples of micronutrient 2.4 mg/day vitamin B-12 mainly from
studies in which the most commonly supplement recommendations. the crystalline form found in fortified

2166 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS November 2018 Volume 118 Number 11
FROM THE ACADEMY

foods and supplements.48 Age is asso- Calcium carbonate has the highest and/or utilization of another nutrient,
ciated with conditions like atrophic concentration of calcium among cal- can result from the consumption of
gastritis that may reduce a person’s cium salts, but requires an acidic me- high-dose or simultaneous consump-
ability to digest food-bound vitamin B- dium for optimal absorption. Thus, it is tion of nutrient supplements. For
12.48 recommended that it be consumed example, high-dose iron supplements
with meals.56 Calcium citrate can be can decrease zinc absorption and high
People with Intermediate or taken with or without foods and can be amounts of zinc can inhibit copper
Advanced Age-Related Macular used by those with achlorhydria.57 absorption.62 The absorption of both
Degeneration. The American Acad- Maximum absorption is obtained with heme- and nonheme iron is inhibited
emy of Ophthalmology recommends doses 500 mg, so splitting a 1,000-mg by calcium supplements, but the clin-
ophthalmologists consider antioxidant dose in two is advisable.41 ical significance of iron status is
vitamin and mineral supplementation unclear.63
as per the Age-Related Eye Disease Contraindications of Nutrient
Study (AREDS) and AREDS2 trials for Supplement Use Medication Interactions. Medications
patients with intermediate or can interfere with absorption or meta-
RDNs and NDTRs must be aware of
advanced age-related macular degen- bolism of certain nutrients, altering the
possible situations in which individual
eration to slow progression of the dis- nutrients requirements and compro-
clients must temporarily or perma-
ease.50 AREDS formulation contains mising nutritional status. Medication
nently limit or avoid specific micro-
vitamin C, vitamin E, beta carotene, interactions for most micronutrients
nutrient supplements due to the
zinc, and copper, and the AREDS2
potential for adverse effects. For can be found in the monographs on the
formulation substitutes lutein/zeax-
example, people who smoke should ODS website. For example, proton pump
anthin for beta carotene,51 because
avoid supplementation with beta inhibitors used to treat gastroesopha-
beta carotene was associated with
carotene due to an increased risk of geal reflux disease slow the release of
increased risk of lung cancer in
lung cancer.52,53 Health risks from gastric acid into the stomach have the
smokers.51-53
excessive nutrient intake and potential potential to interfere with vitamin B-12
nutrient/nutrient and nutrient/medi- absorption from food, potentially
Genetic Polymorphisms and Dis- cation interactions are provided for affecting serum vitamin B-12 levels.64
orders. Individuals that have a genetic individual vitamins and minerals in the Corticosteroids (eg, prednisone) may
predisposition that impairs digestion, Office of Dietary Supplements (ODS) deplete calcium64 and impair vitamin D
absorption, or metabolism may benefit Fact Sheets for Health Professionals. metabolism.65 Certain diuretics, antibi-
from micronutrient supplements under Some examples are listed below. otics, and proton pump inhibitors can
the care and direction of a health care
affect magnesium status.66 Poly-
practitioner. However, it is the position
Nutrient Excess. Healthy post- pharmacy, particularly among older
of the Academy of Nutrition and Di-
menopausal women and adult men adults, can increase the likelihood of
etetics that nutritional genomics is still
and individuals homozygous for he- drugenutrient interactions and influ-
emerging and its practice, including
mochromatosis generally should avoid ence the need for certain micro-
the use of commercial or consumer-
iron supplements.58 In post- nutrients. Individuals taking
based nutrigenetic testing, to provide
menopausal women, intakes >1,500 medications on a regular basis should
dietary advice is premature.54
mg/day retinol (below the UL), but not discuss their micronutrient supple-
beta carotene, have been associated ments with their health care providers.
Special Considerations for with reduced bone mineral density and Micronutrient supplements can in-
Micronutrient Supplements increased risk of hip fracture.59,60 Thus, fluence the dosage and bioactivity of
Certain forms of micronutrients have women who take supplements con- medications. For example, high doses
differential bioavailability based on taining vitamin A should consider a of vitamin E supplements (likely in
their molecular structure and chemical product that contains a majority of the doses >400 IU) can inhibit platelet
formula. For example, folic acid from vitamin A from the beta carotene form aggregation and therefore interfere
supplements and fortified foods is rather than retinol. Excessively high with anticoagulant blood thinning
more bioavailable than folate from supplemental intakes of vitamin B-6 medications such as coumadin.55
foods due to the ease of absorption of have been reported to result in sensory Vitamin K supplementation can also
the unconjugated form.48 For vitamin neuropathy.48 interact with the blood-thinning med-
E, consumption of about 50% more ications; thus, supplementation should
units of synthetic alpha tocopherol Micronutrient Interactions. RDNs be avoided or used with caution and
from dietary supplements and fortified and NDTRs must be aware of and under the care of a health care provider
foods are needed to obtain the same document the potential because a consistent intake of the
amount of the vitamin as from the nutrientenutrient and drugenutrient vitamin is critical. Additional resources
natural form (dl-alpha tocopherol).55 interactions that can occur with the that provide information on pre-
Furthermore, the effectiveness of min- chronic use of micronutrient supple- cautions, contraindications, and po-
eral supplements is influenced by their ments.61 An imbalance of micro- tential interactions with drugs, food, or
form and the amount of the elemental nutrients, such that the amount of one other supplements are provided in the
mineral present in the mineral salt. nutrient interferes or alters absorption Figure.

November 2018 Volume 118 Number 11 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 2167
FROM THE ACADEMY

Organization Website Contents


Academy of Nutrition and Dietetics www.eatrightpro.org  Position papers
 Evidence Analysis Library
 Other documents: Guidelines Regarding
the Recommendation and Sale of
Dietary Supplements, Code of Ethics for
the Profession of Dietetics
AHRQa Department of Health and https://archive.ahrq.gov/clinic/  AHRQ-produced evidence-based reviews
Human Services tp/multivittp.htm on nutrient supplements
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
used for disease prevention and
treatment
Epocrates www.epocrates.com/index.html  Private company with proprietary in-
formation on medications and dietary
supplements, available free and for
purchase for mobile devices and
online
Federal Trade Commission www.ftc.gov  Site to file a complaint when adver-
tising for a dietary supplement is
misleading or false
Food and Drug Administration www.fda.gov/Food/  Dietary supplement alerts and safety
DietarySupplements/default. information
htm  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 Older Dietary Supplement
User
 Warnings and safety information
 Consumer educational materials
 Industry information and guidance
 Labeling regulations and claims
National Academy of Medicine www.nam.edu  Tables that include Dietary Reference
Intake values and adverse effects of
excessive consumption
MedWatch www.fda.gov/Safety/  The Food and Drug Administration
MedWatch/ Safety Information and Adverse Event
Reporting Program. Health pro-
fessionals and consumers can report
adverse events from dietary
supplements.

(continued on next page)


Figure. Select evidence-based resources for information related to dietary supplements.

2168 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS November 2018 Volume 118 Number 11
FROM THE ACADEMY

Organization Website Contents


Micronutrient Information Center, Linus lpi.orst.edu/infocenter  Scientific information on the role of
Pauling Institute, Oregon State University vitamins, minerals, and phytochemicals
in preventing disease and promoting
health
National Agricultural Library www.nutrition.gov/dietary-  Listing of resources (bibliographies/
supplements databases, books/book chapters,
newsletters, web resources, and
agencies and organizations) providing
technical and professional-level
information on dietary supplements,
including nutrition information
National Library of Medicine www.nlm.nih.gov/medlineplus/  MedlinePlus for Vitamin and Mineral
vitaminandmineralsupplements. Supplements
html
Office of Dietary Supplements, National ods.od.nih.gov  Expert reviewed facts sheets on vita-
Institutes of Health https://ods.od.nih.gov/ mins, minerals, and product types (eg,
Research/PubMed_Dietary_ multivitamins and sports supplements)
Supplement_Subset.aspx that include information on medica-
https://ods.od.nih.gov/ tion interactions, signs, and symptoms
Research/CARDS_Database.aspx of deficiency and toxicity
 Subset of PubMed specific to infor-
mation on dietary supplements, Office
of Dietary Supplements and National
Library of Medicine
 Computer Access to Research on Di-
etary Supplements database of feder-
ally funded research projects
pertaining to dietary supplements
Operation Supplement Safety http://hprc-online.org/dietary-  Provides interactive tools to assess
supplements/opss potential adverse effects for some
types of dietary supplements
Office of Dietary Supplements, National https://  Dietary Supplement Ingredient Data-
Institutes of Health, and Department of dietarysupplementdatabase. base estimates levels of ingredients in
Agriculture, and other federal agencies usda.nih.gov dietary supplement products
https://dsld.nlm.nih.gov/dsld/  Dietary Supplement Label Database
offers label information for >70,000
different product types
Therapeutic Research Center www.naturaldatabase.com  Natural Medicines Comprehensive
Database (subscription required) in-
cludes evidence-based monographs
that contain information on ingredient
safety, effectiveness, adverse reactions,
and interactions

(continued on next page)


Figure. (continued) Select evidence-based resources for information related to dietary supplements.

November 2018 Volume 118 Number 11 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 2169
FROM THE ACADEMY

Organization Website Contents


Books
Coates PM, Betz JM, Blackman MR, Cragg GM, et al. Encyclopedia of Dietary Supplements. 2nd ed. New York, NY: Marcel
Dekker; 2010.
Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes: The Essential Guide to Nutrient Requirements.
Washington, DC: National Academies Press; 2006.
a
AHRQ¼Agency for Healthcare Research and Quality.
Figure. (continued) Select evidence-based resources for information related to dietary supplements.

Reporting Adverse Effects PRACTICE POINTERS  evaluating the potential benefit


RDNs and NDTRs are urged to counsel or harm of micronutrient sup-
Total Micronutrient Intakes
clients to report adverse reactions of plementation given the client’s
Intake assessment must include all nutritional and health status;
micronutrient supplements to the micronutrient sources, including those
manufacturer and to the FDA. Health  evaluating the safety of the
naturally occurring and fortified in micronutrient supplement given
care professionals are also encouraged foods and beverages and dietary sup-
to report adverse effects experienced the form, dose, its potential for
plements. Both micronutrient ade- interaction with food, other di-
by their clients from the use of any quacy and excess could be biased in the
dietary supplements using the FDA’s etary supplements, and over-
case that only conventional and forti- the-counter and prescribed
MedWatch program.8 The Health In- fied food sources are considered. To
surance Portability and Accountability medications;
accomplish this, practitioners should  educating clients as to the po-
Act Privacy Rule permits health care routinely collect use of micronutrient
professionals to report adverse events tential benefit of receiving
supplements as part of any dietary micronutrients through conven-
and other information related to assessment, including the frequency of
the quality, effectiveness, and safety tional and fortified foods;
use, typical dose, and the duration of  recommending micronutrient
of FDA-regulated products both to use. Given the potential for in-
the manufacturers and directly to supplementation when the
teractions, collecting information on all client does not consume the
FDA.67 dietary supplements used is of utility. amount of types of foods neces-
sary to obtain recommended
PROFESSIONAL RESOURCES Stacking and Similar Practices micronutrient intakes;
AND TRAINING OPPORTUNITIES Clients using multiple supplements can  evaluating research regarding
The ODS, which was created in part to be asked to bring in the containers of micronutrient supplementation;
promote research aimed at deter- supplements used, particularly when and
products with multiple ingredients are  being aware of regulatory, legal,
mining the health benefits and risks of
dietary supplements, provides several used. Using multiple supplements that and ethical issues of recom-
tools that researchers, RDNs, and have common ingredients could result mending and selling of micro-
NDTRs can use to increase their in levels that exceed the UL. nutrient supplements.
knowledge of dietary supplements, Continuing education and inclusion
including micronutrient supplements. How to Discuss Use of of dietary supplements and specifically
These include the Dietary Supplement micronutrient supplements in didactic
Supplements with Clients and
Research Practicum on dietary supple- curricula are essential to ensuring
Patients
ment issues for academic faculty and RDNs and NDTRs have the skills
students68; the PubMed Dietary Sup- Given the high use of micronutrient
supplements by the public, RDNs and necessary to perform these functions.
plement Subset,69 which allows a
literature search limited to dietary NDTRs need to keep up to date on the
supplements, a Dietary Supplement safety and efficacy of these products to CONCLUSIONS
Labels Database (https://www.dsld. assist consumers in the safe and The dietary intakes of many Americans
nlm.nih.gov/dsld-mobile/index.jsp) appropriate use of these supplements. are inadequate in some micronutrients.
and expert-reviewed fact sheets on The roles and responsibilities of the It is among the roles and re-
dietary supplement ingredients and NDTRs under the supervision of the sponsibilities of RDNs and NDTRs un-
specific product classes, like the RDN and RDNs within their individual der the supervision of an RDN to help
MVM.45 These and other resources scope of practice may include: educate the public on healthful dietary
such as those listed in the Figure can be  assessing nutritional status of patterns and on the safe and appro-
used by RDNs and NDTRs to stay clients to determine likelihood priate selection and use of micro-
informed on issues related to dietary of inadequate or excessive intake nutrient supplements to meet their
and micronutrient supplements. of vitamins and minerals; micronutrient needs and optimize

2170 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS November 2018 Volume 118 Number 11
FROM THE ACADEMY

health. To this end, RDNs and NDTRs 12. US Government Accountability Office. 27. Branum AM, Bailey R, Singer BJ. Dietary
Dietary supplements: FDA may have op- supplement use and folate status during
must keep abreast of research findings
portunities to expand its use of reported pregnancy in the United States. J Nutr.
on potential benefits and safety of health problems to oversee products. 2013;143(4):486-492.
micronutrient supplements, and on the http://www.gao.gov/products/ 28. Institute of Medicine Subcommittee on
regulatory issues that influence the use GAO-13-244. Published March 18, 2013. Interpretation and Uses of Dietary Refer-
Accessed August 27, 2017. ence Intakes, Institute of Medicine
of these products.
13. US Food and Drug Administration. Standing Committee on the Scientific
Manufacturing - facts about the current Evaluation of Dietary Reference Intakes.
References good manufacturing practices (CGMPs). DRI Dietary Reference Intakes: Applications
1. West KP, Stewart CP, Caballero B, http://www.fda.gov/Drugs/Development in Dietary Assessment. Washington, DC:
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2172 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS November 2018 Volume 118 Number 11
FROM THE ACADEMY

AUTHOR INFORMATION
This Academy of Nutrition and Dietetics position was adopted by the House of Delegates Leadership Team on October 29, 1995, and reaffirmed
on September 28, 1998; June 19, 2003; May 17, 2007; and January 2012. This position is in effect until December 31, 2022. Position papers should
not be used to indicate endorsement of products or services. All requests to use portions of the position or republish in its entirety must be
directed to the Academy at journal@eatright.org.
Authors: Melissa Ventura Marra, PhD, RDN, West Virginia University, Morgantown, WV; Regan L. Bailey, PhD, MPH, RD, Purdue University, West
Lafayette, IN.
STATEMENT OF POTENTIAL CONFLICT OF INTEREST
R. L. Bailey has received funding from the National Institutes of Health/National Cancer Institute (grant no. U01CA215834) and serves as a
scientific consultant to the National Institutes of Health, Office of Dietary Supplements; she has received a travel support from the Council of
Responsible Nutrition to present her research.
FUNDING/SUPPORT
There is no funding to report.
Reviewers: Mary Beth Arensberg, PhD, RDN, LDN, FAND (Abbott Nutrition, Division of Abbott, Columbus, OH); Feon Cheng, PhD, MPH, RDN
(Academy Research, International and Scientific Affairs, Chicago, IL); Emily K. Farina, PhD, RD (Henry Jackson Foundation/US Army Research
Institute of Environmental Medicine, Natick, MA); Sharon Denny, MS, RD (Libertyville, IL); Sarah Picklo Halabu, RDN, LDN (Academy Publications
and Resources, Chicago, IL); Lisa Moloney, MS, RD (Academy Research, International, and Scientific Affairs, Chicago, IL); Dietitians in Integrative
and Functional Medicine Dietetic Practice Group (Kelly Morrow, MS, RDN, Bastyr University, Kenmore, WA); Tracy L. Oliver, PhD, RDN, LDN
(Villanova University, Villanova, PA); and Medical Nutrition Therapy Dietetic Practice Group (Colene Stoernell, MS, RD, Scripps Health, La Jolla, CA).
Academy Positions Committee Workgroup: Valaree Williams, MS, RD, FAND (University of Colorado Cancer Center, Aurora, CO) (chair); Ainsley
Malone, MS, RD, LD, FAND, FASPEN (Mt. Carmel West Hospital, Columbus, OH); Mary Marian, DCN, RDN, FAND (University of Arizona, Tucson, AZ);
Mridul Datta, PhD, MS, RD, (Purdue University, West Lafayette, IN) (content advisor).
ACKNOWLEDGEMENTS
The authors thank the reviewers for their many constructive comments and suggestions. The reviewers were not asked to endorse this position
or the supporting paper.

November 2018 Volume 118 Number 11 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 2173
Published by/ D.T Mahmoud sultan

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