This is the final piece in a three-part series focusing on the role vitamin and mineral supplements can play in supplementing essential vitamins and minerals Americans may not be getting from diet alone.
Part 1 of this series described the debate over the role vitamin and mineral supplements (VMS, both multiple and single-nutrient) may play in reducing the risks for various chronic diseases and how many health care professionals and consumers may have lost sight of the main function of vitamins and minerals as essential nutrients. Part 2 examined the basis for the Dietary Reference Intakes (DRIs), specific functions of the “gap” nutrients and the possible health consequences of insufficient intakes. Here, in the third, and final, Part of this series we examine the micronutrient gap in more detail, the prevalence of clinical deficiencies and how VMS can help.
Published reports based on 2001-2010 data from the National Health and Nutrition Examination Survey (NHANES) – a nationally representative survey of noninstitutionalized, U.S. civilian residents – consistently show many Americans obtain less than the Estimated Average Requirements (EARs)* for a number of vitamins and minerals, and that VMS use increases vitamin and mineral intake. [1,2,3,4,5]
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One such report, based on NHANES data (2007-2010) from more than 16,444 individuals four or more years of age, shows that virtually all Americans consume less than the EAR for one or more vitamins and minerals (see Table). [1] The Table also shows that fewer individuals who reported taking a multivitamin and mineral supplement (MVMS, 51% of those in the analysis) consume less than the EARs for most vitamins and minerals. For the analysis, a MVMS was defined as a supplement that included at least 100% of the recommended dietary allowance (RDA) or adequate intake (AI) for nine vitamins and minerals with defined dietary reference intake (DRI) values. The differences between supplement users and non-users might be less than expected because users were broadly defined as those who had taken a MVMS as infrequently as just one time during the 30 days prior to data collection, and so included occasional/sporadic as well as daily users. [1] Additionally, many MVMS provide low or no amounts of some nutrients, such as calcium, magnesium, zinc, potassium and choline.
Table: MVMS Non-Users and Users With Vitamin and Mineral Intakes Below Estimated Average Requirements or Adequate Intakes [1] **
* By definition, the EAR reflects the nutritional needs of only half the population, and is lower than the recommended dietary allowance (RDA), which has an added “cushion” to meet the needs of 97% – 98% of the population. An Adequate Intake (AI), used when an RDA has not been determined, is the recommended average intake assumed to be adequate based on intake estimates among healthy people.
** Less than 10% of individuals were below the EARs for thiamin, riboflavin, niacin, folic acid, vitamin B6, vitamin B12, iron, copper, phosphorus and selenium (not shown in Table).
On January 6, 2016, the U.S. Departments of Health and Human Services and of Agriculture released the 2015-2020 Dietary Guidelines for Americans, the 8th edition since the first release in 1980. [6] Consistent with the above findings, the Guidelines identified potassium, dietary fiber, choline, magnesium, calcium, and vitamins A, D, E, and C as nutrients “consumed by many individuals in amounts below the Estimated Average Requirement or Adequate Intake levels.” And while the Guidelines state as a goal that people should “meet nutritional needs primarily through foods,” they also recognize that dietary supplements are “useful in providing one or more nutrients that otherwise may be consumed in less than recommended amounts or that are of particular concern for specific population groups.”
Low intakes of vitamins and minerals can lead to nutritional deficiencies. Deficiencies for a number of (but not all) vitamins and minerals are defined by cut points in biomarkers, usually some level of the nutrient or a related metabolite in the serum or urine. The relatively few reports of vitamin and mineral status of Americans based on biomarker data show significant portions of the population have or are at risk for deficiencies. They also show rates of deficiencies are lower for supplement users. For example:
- NHANES data (2001-2006) show 10% of U.S. individuals two or more years of age are deficient in vitamin D, based on the biomarker of serum levels of 25-OH-D (<30 nmol/L). The rate of deficiency is 14% among those who do not take supplements compared to 5% among those who do. [7]
- Based on one standard definition for vitamin B12 deficiency (serum B12 < 258 pmol/L or methylmalonic acid > 0.21 ?mol/L), NHANES data (1999-2002) show 38% of adults age 60 years or more are deficient, but the rate is less (30%) among those who took any B12-containing supplement. This definition of deficiency also was associated with significantly increased risks for peripheral neuropathy and disabilities. [8]
- NHANES data (2003-2004) show 7% of Americans aged 6 years or older are deficient in vitamin C, based on the standard serum concentration cut off of <11.4 ?mol/L. Lower rates of deficiency are found among adult men and women who used any vitamin C-containing supplement compared to those who did not: 2% (both genders) vs. 16% and 11%, respectively. [9]
- NHANES data (2003-2006) show that, while only 1% of Americans age 20 years or more have serum levels of vitamin E meeting the criterion for clinical deficiency (aplha-tocopherol < 12 ?mol/L), 81% of supplement non-users have vitamin E “inadequacy” compared to 46% of supplement users. In this analysis, vitamin E inadequacy was defined as a serum alpha-tocopherol level below that associated with consuming the EAR and with the lowest mortality rate in a major interventional trial (< 30 ?mol/L). [10,11]
Interestingly, supplement users also obtain more vitamins and minerals from foods compared to non-users, [3,4] so it does not appear that supplements are primarily used to compensate for poor dietary habits. [1] Supplement use also is associated with moderate alcohol use, more exercise, smoking abstinence and having health insurance. [12]
Beyond nutritional deficiencies, low intakes of vitamins and minerals may be associated with sub-optimal health. Indeed, as noted in Part 2 of this series, the concept of optimizing health and preventing disease is a major underpinning for the shift, in 1994, from the Recommended Dietary Allowances to the Dietary Reference Intakes (DRIs) for nutrients. [13] Further, the Center for Disease Control’s Second National Report on Biochemical Indicators of Diet and Nutrition [14] notes:
“…recent findings have determined that less than optimal biochemical concentrations (representing suboptimal status) have been associated with risks of adverse health effects. These health effects include cardiovascular disease, stroke, impaired cognitive function, cancer, eye diseases, poor bone health, and other conditions.”
Some studies have associated Americans’ use of dietary supplements (containing vitamins, minerals and/or herbs or other substances) with positive health indicators, for example: [15]
- Healthier serum levels of various lipids and homocysteine
- Reduced prevalence of elevated blood pressure
- Better self-assessed health status
- Reduced markers of inflammation, including C-reactive protein and interleukin-6 [16]
Further research is needed on the effects of VMS, especially long-term epidemiological research. Such research could help address some of the challenges identified in using chronic disease endpoints to set DRI values. [17] Nevertheless, the collective evidence described here and in Parts 1 and 2 of this series leaves no doubt that many Americans are obtaining less than the required amounts of a number of vitamins and minerals, and that these nutritional shortfalls are associated with biomarker-defined deficiencies and inadequacies that can have health consequences. The evidence also shows that supplement use is associated with improved intakes of the “gap” nutrients as well as lower rates of deficiencies and inadequacies and, in some studies, improved health status. Health professionals should bear this in mind when seeing their patients, and consider recommending ways to improve their diets, which can include taking VMS.
The Campaign for Essential Nutrients is comprised of Bayer HealthCare LLC, DSM Nutritional Products, PHARMAVITE LLC. and Pfizer Inc.
References
[1]Wallace TC, McBurney M, Fulgoni VL 3rd. Multivitamin/mineral supplement contribution to micronutrient intakes in the United States, 2007-2010. J Am Coll Nutr. 2014;33(2):94-102.
[2] Fulgoni VL 3rd, Keast DR, Bailey RL, Dwyer J. Foods, fortificants, and supplements: Where do Americans get their nutrients? J Nutr. 2011 Oct;141(10):1847-54.
[3] Bailey RL, Fulgoni VL 3rd, Keast DR, Dwyer JT. Examination of vitamin intakes among US adults by dietary supplement use. J Acad Nutr Diet. 2012 May;112(5):657-63.
[4] Bailey RL, Fulgoni VL 3rd, Keast DR, Dwyer JT. Dietary supplement use is associated with higher intakes of minerals from food sources. Am J Clin Nutr. 2011 Nov;94(5):1376-81.
[5] Agarwal S, Reider C, Brooks JR, Fulgoni VL 3rd. Comparison of prevalence of inadequate nutrient intake based on body weight status of adults in the United States: an analysis of NHANES 2001-2008. J Am Coll Nutr. 2015;34(2):126-34
[6] U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015 – 2020 Dietary Guidelines for Americans. 8th Edition. December 2015. Available at http://health.gov/dietaryguidelines/2015/guidelines/.
[7] Ganji V, Zhang X, Tangpricha V. Serum 25-hydroxyvitamin D concentrations and prevalence estimates of hypovitaminosis D in the U.S. population based on assay-adjusted data. J Nutr. 2012 Mar;142(3):498-507.
[8] Oberlin BS, Tangney CC, Gustashaw KA, Rasmussen HE. Vitamin B12 deficiency in relation to functional disabilities. Nutrients. 2013 Nov 12;5(11):4462-75.
[9] Schleicher RL, Carroll MD, Ford ES, Lacher DA. Serum vitamin C and the prevalence of vitamin C deficiency in the United States: 2003-2004 National Health and Nutrition Examination Survey (NHANES). Am J Clin Nutr. 2009 Nov; 90(5):1252-63.
[10] McBurney MI, Yu EA, Ciappio ED, Bird JK, Eggersdorfer M, Mehta S (2015) Suboptimal serum alpha-tocopherol concentrations observed among younger adults and those depending exclusively upon food sources, NHANES 2003-2006. PLoS ONE 10(8): e0135510. doi:10.1371/journal.
[11] Wright ME, Lawson KA, Weinstein SJ, et al. Higher baseline serum concentrations of vitamin E are associated with lower total and cause-specific mortality in the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study. Am J Clin Nutr. 2006; 84:1200–7.
[12] Bailey RL, Gahche JJ, Miller PE, Thomas PR, Dwyer JT. Why US adults use dietary supplements. JAMA Intern Med. 2013 Mar 11;173(5):355-61.
[13] Otten JJ, Hellwig JP, Meyers LD, eds. Dietary Reference Intakes: The Essential Guide to Nutrient Requirements. Washington, DC: The National Academies Press; 2006. Available at http://www.nal.usda.gov/fnic/DRI/Essential_Guide/DRIEssentialGuideNutReq.pdf. Accessed December 22, 2015.
[14] Centers for Disease Control. Second National Report on Biochemical Indicators of Diet and Nutrition in the U.S. Population (2012). Available at http://www.cdc.gov/nutritionreport/pdf/4Page_%202nd%20Nutrition%20Report_508_032912.pdf. Accessed November 30, 2015.
[15] Block G, Jensen CD, Norkus EP, Dalvi TB, Wong LG, McManus JF, Hudes ML. Usage patterns, health, and nutritional status of long-term multiple dietary supplement users: a cross-sectional study. Nutr J. 2007 Oct 24;6:30.
[16] Colbert LH, Visser M, Simonsick EM, et al. Physical activity, exercise, and inflammatory markers in older adults: findings from the Health, Aging and Body Composition Study. J Am Geriatr Soc. 2004 Jul;52(7):1098-104.
[17] Office of Disease Prevention and Health Promotion. U.S. and Canadian Dietary Reference Intakes (DRI) Committees. Workshop: Options for Consideration of Chronic Disease Endpoints for Dietary Reference Intakes. Available at: http://health.gov/dietaryguidelines/dri/. Accessed December 23, 2015.
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Part 1: The American Nutrient Gap: What the Data Says We’re Missing
