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Dietary Supplements: and Fact Sheet No. 9.338 and Series| by L. Bellows, R. Moore, A. Gross* The current food environment can (CAM). It is important to remember that Quick Facts be complicated, given the multitude of supplements are not required to go through choices and purchasing options available the same stringent testing as over the counter • Most individuals can for consumers. Many individuals are left (OTC) and prescribed medicine, and are not obtain all the vitamins and questioning the best way to obtain vitamins regulated as closely by the Food and minerals needed to meet and minerals, as a variety of options Administration (FDA). the recommended dietary are available- including whole , allowances and adequate and multiminerals, as well Choose Food First, intakes by a variety of as individual dietary supplements. The foods. incredible variety of dietary supplements Supplements Second available in today’s market comprises a wide and supplements are • Dietary supplements, range of brand names, supplement forms the most common used including multivitamins (pill, powder), and amounts (10 to 100 times by approximately 40% of adults and 30% of and multiminerals, do not the daily recommended intake value), which children in the . Despite the guarantee protection against can make purchasing supplements very popularity of supplements, many individuals disease. confusing. The following information defines are capable of obtaining all of the required dietary supplements and helps to explain the vitamins and minerals through a healthy • Large doses of either single value of food in comparison to vitamin and alone. In fact, those who consume a supplements or mineral supplements. General guidelines are or multimineral on a daily high potency vitamin and also provided to help individuals choose an basis may be at risk for excessive intake, or mineral combinations may be appropriate supplement to fit their needs, toxicity of certain . Additionally, harmful. as well as recommendations for obtaining supplements can be very expensive—as important nutrients from diet alone. For evidenced by the $30 billion that Americans • Although more information on herbal supplements, see spend annually on all forms, a number is rare, it may occur when fact sheet Dietary Supplements: Herbals and that continues to grow every year. In some nutrients are limited in one’s Botanicals. circumstances a daily supplement may not diet, or as a result of a be necessary, and for many, consuming a secondary deficiency caused What are Dietary multivitamin or multimineral once every by tobacco, alcohol use, or 2 to 3 days may be a cost-effective choice. disease. Supplements? Since the body has limited storage for many Dietary supplements include vitamins, of these nutrients, most of the time they are • Consult a medical minerals, herbs, amino acids, enzymes, and simply excreted. Essentially, the most cost- professional before taking any other substances that may be “supplemented,” effective way to promote good health is eat a self-prescribed single nutrient or added to a diet, in order to complete wide selection of foods and regularly. supplements. dietary needs or to make up for a nutrition For a better understanding of how to choose deficiency—they are not intended to replace foods that provide the daily requirements a . Dietary supplements may for nutrients see the USDA websites: be found in many forms, including pills, Choose MyPlate or The Dietary Guidelines capsules, powders, , or energy bars. for Americans. See Table 1 for common Supplement use can also be considered a type myths associated with vitamin and mineral of complementary or supplements. © Colorado State University Extension. 12/98. Revised 9/13. www.ext.colostate.edu *L. Bellows, Colorado State University Extension food and nutrition specialist and assistant professor; R. Moore, graduate student; A. Gross, undergraduate student. 9/2013 Who Should Consider a nutrient. Those who do not consume Multivitamin, Multimineral, How Are Dietary these food items and do not receive or Individual Nutrient Supplements exposure to regular should Regulated? consider a supplement. Supplements? • is mostly found in dairy National food consumption data and In 1994 Congress passed the Dietary products, therefore vegans and dietary surveys show that the majority of Supplement Health and vegetarians who do not consume dairy Americans consume all of the nutrients Act (DSHEA), which clearly defines may not receive enough calcium in needed, through a balanced and varied supplements as food, not . their diet. diet that includes healthy food choices. Unlike drugs, supplements do not • is found in two different forms— Some nutrients, like calcium and iron, may need FDA approval before being heme iron (from products) require careful food selection, but can be marketed and sold to the public. is more available for absorption, and obtained from adequate consumption of a The supplement manufacturer is nonheme iron (from foods) variety of foods. Certain individuals may responsible for the safe consumption is less available for absorption. have dietary restrictions (such as those with Vegetarians and vegans may receive of supplements and providing celiac disease or intolerance), or enough iron from their diet, although evidence to support health claims. belong to a particular stage (pregnant, if it is strictly from plant foods , or older adult) and may However, evidence does not have to (nonheme sources), twice as much benefit from taking specific supplements. be provided before the supplement dietary iron each day may be needed. Consult a medical professional before is marketed, and the FDA will take • is primarily found in animal deciding to take a dietary supplement. See action against any unsafe dietary , therefore vegetarians Table 2 for recommendations for the type supplements after they reach the and vegans may require 50% more and amount of supplement that may be market. In 2007 the FDA implemented zinc in the diet than is generally best, and Table 3 for a description of how to the Current Good recommended. Additionally, beans obtain important nutrients through food. Practices (CGMPs), which act to and grains have compounds that Pregnant women or women who may insure the consistency, identity, purity, may keep zinc from being absorbed become pregnant: This population is strength, and composition, of dietary as readily. For more information regarding dietary recommendations strongly advised to consume supplements supplements. for folic acid (), iron, or a prenatal for vegetarians and vegans, see fact vitamin that contains these nutrients. Before consuming any type of sheet Vegetarian Diets. • Folic Acid helps to prevent birth supplement, consult a medical Women with heavy menstrual bleeding: defects of the brain and spine, and may professional and research the This population should consume extra iron, be obtained through fortified foods supplement thoroughly. which acts to replace that which is lost due (such as enriched breads and cereals), to loss. vitamin supplements, or a combination The following website resources Those with a restrictive diet (1,600 of both. are provided to help one make calories per day or less): For most • Iron helps to increase the amount an educated decision and identify adults, a diet that includes less than 1,600 of blood in the body and helps keep inaccurate information when choosing calories per day will not supply all of the blood healthy. Too iron little may a dietary supplement: necessary vitamins and nutrients to meet to . National Library of Medicine the body’s needs—and these individuals • A prenatal vitamin may contain both should consume a multivitamin and/ folic acid and iron, as well as other (NLM)–Dietary Supplements or multimineral supplement. Consult a important vitamins and minerals both Labels Database medical professional regarding type and mother and baby need for proper CSU Extension fact sheet, recommended amount of supplement. nutrition (for example, vitamin Nutrition Misinformation: How to B12 is important if the mother is a Older adults (50+), menopausal, Identify Fraud and Misleading vegetarian). Some nutrients, however, and postmenopausal women: These Claims may be harmful to babies (such as individuals should consume , , where too much can calcium, and a vitamin D supplement. cause birth defects), and a prenatal Vitamin B12, calcium, and vitamin D, work supplement ensures that both mother together to maintain healthy bones and Vegans and strict vegetarians that do reduce the risk for fractures. and child are receiving healthy doses of not consume eggs or dairy products all nutrients. • Vitamin B12 is absorbed less readily should consider taking a vitamin B12 from foods as one ages. These Vegetarians and vegans: This population supplement. individuals should receive vitamin should adequate intake of vitamin • Vitamin D is found in very few food B12 from fortified foods such as B12, vitamin D, calcium, iron, and zinc. items, although dairy products, breakfast cereals, or through a dietary • Vitamin B12 (cobalamin) is only alternatives (soy or milk), supplement. found naturally in foods of animal juice, breakfast cereals, and • Calcium may not be absorbed as well origin such as eggs and dairy products. eggs, may be fortified with this in older adults and this population may experience bone loss. A Misinformation: How to Identify Fraud and combination of calcium intake from Misleading Claims. Additional Resources both food sources and supplemental The termnatural on a supplement For more information on mineral form is important. is not synonymous with safe. Several recommendations for age and life • Vitamin D is not produced as natural products may cause negative stage, see the National Institutes efficiently in older adults upon drug interactions, worsen certain health exposure to sunlight. Additionally, the conditions, and may be harmful at higher of Health (NIH) Office of Dietary ability of the kidney to convert vitamin doses. Do not take a supplement prior Supplements website–Vitamin and D to a form that the body can use is to taking prescription , Mineral fact sheet. also dampened with age. or receiving advice from a medical For more information on how to spot professional. Before choosing to take a Breastfed and partially breastfed infants: a false , see the Federal dietary supplement, consider whether Since human milk is a poor source of Trade Commission (FTC) website. vitamin D, infants who are solely breastfed the supplement is necessary, and possible or less than 1 quart per day of dietary modifications that might be a better For information on recent supplement vitamin D-fortified formula or milk should option (Table 3). alerts and safety information, see the receive a supplemental form of vitamin D. Food and Drug Administration (FDA) Limited milk intake and sunlight Do Vitamin and Mineral website. exposure: Dairy products and sunlight Supplements Pose a exposure are two primary means of Health Risk? obtaining vitamin D, therefore if either Large doses of either single-nutrient research shows that vitamin B-6 is limited, a supplemental form may be can cause nerve damage at the high necessary. supplements or high potency vitamin- mineral combinations may be harmful. doses prescribed for pre-menstrual Health conditions that may limit nutrient These megavitamins may contain 10 to syndrome (PMS). High intakes of folic use and absorption: Those with health over 100 times the acid can mask or worsen the symptoms conditions that may affect digestion, (DRI) for a vitamin or mineral and can act associated with a vitamin B-12 appetite, and limit nutrient absorption, like drugs with potentially serious results. deficiency. Large amounts of may not be receiving adequate nutrients Very high doses of many supplements, can cause and nausea. from diet alone (examples include those especially vitamins A, D, C, and B6, can • Many factors influence toxicity. with food , physical trauma, and cause serious health problems if taken Supplement potency, dose (number gluten intolerance).These populations regularly. Excess of one nutrient may cause and frequency), body size, and how should consider a multivitamin and/ nutritional imbalances or increase the need long the supplement is taken, all or multimineral supplement. Consult a for other nutrients. Severe side effects such influence whether a supplement can medical professional regarding the type and as kidney stones, or nerve damage, be toxic. recommended amount of supplement. birth defects, and even death can occur For more information, see fact sheet from 10 to over 100 times of the DRI. -Soluble Vitamins: B-Complex and • Taken in high amounts, some Vitamin C, and -Soluble Vitamins: A, D, How to Choose a E, and K. Supplement supplements may produce undesirable effects such as fatigue, diarrhea and It is important for healthy individuals hair loss. Summary who take vitamin or mineral supplements • Others may cause more severe side to limit the potency to 100% or less of effects such as kidney stones, liver or With the increased availability and wide the Dietary Reference Intake (DRI) for nerve damage, birth defects, or even variety of food accessible to consumers their age, gender, and life stage (Table 2). death. At high levels, single-nutrient in the United States, most individuals can Consuming a supplement that contains supplements function as a drug in the receive all of the vitamins and minerals no more than 100% of the Daily Value body and not as a nutrient. needed from food alone—this unique (DV) is usually considered safe. High • Fat-soluble vitamins such as vitamins balance cannot be duplicated by taking potency supplements that contain more A and D are harmful in high doses. For any combination of supplements. Certain than 100% of the DV are not suggested. non-smokers, supplements of vitamin individuals that have dietary restrictions, Avoid supplements that provide mega A should contain the majority of the are pregnant or breastfeeding, older than doses of any vitamins or minerals, or have vitamin in the beta-carotene rather 50, or with special dietary requirements, added botanicals whose properties are than the form. may may need to supplement their diet with unknown. Information about vitamin act as a blood thinner and should not a multivitamin and/or multimineral, or and mineral content can be found on the be taken for at least one week prior to individual nutrient supplements. Consult a label of all dietary supplements. Be aware surgery. medical professional for recommendations of misleading claims that promise the • Water-soluble vitamins are commonly regarding the type and amount of product is a “cure all” or can treat a disease. thought of as harmless, however, supplement best for one’s individual needs. For more information on how to identify nutrition fraud, see fact sheet Nutrition Table 1. Common myths and facts regarding dietary supplements. Myth Fact Healthy Suggestion “Vitamin and mineral Supplements supply only a fraction of the Food contains important components such as phytonutrients, supplements can make up for nutrients needed daily, and are not a quick fix , fiber, and dietary fat, which cannot be found an unhealthy diet.” for suboptimal food choices. in supplements. Consuming whole foods will provide these components naturally, in much higher levels. “Consuming large quantities The body will only use the vitamins and Consult a doctor or before consuming any of supplements will lead to minerals that it needs. Any extra will be supplement, and avoid consuming large quantities of optimal health.” excreted or may pose a risk for toxicity. supplements. Consuming more nutrients than the body requires does not give added energy, increased brain power, or greater protection against disease. “Supplements with added The body makes its’ own digestive enzymes Added enzymes are unnecessary; however, consuming enzymes are easier to digest.” to breakdown and absorb supplements. lactase enzymes may be beneficial for those who are lactose intolerant.

“Timed-release supplements Timed-release supplements are costly and Supplements should be consumed when they do not aid in absorption throughout are not absorbed throughout the day. compete for absorption with other foods. Consult a the day.” medical professional regarding the type and combination of supplements to consume at certain times of the day. “More expensive vitamin and The cost of the vitamin does not necessarily Consider purchasing your vitamins from well-known retailers mineral supplements are worth translate to quality. Generic vitamins are that restock frequently. the extra cost.” often as good as brand names. Vitamins and minerals are commodity items, and every manufacturer has access to the same ingredients. For that reason, paying more for a brand name won’t necessarily buy you better vitamins. Also, vitamins lose their potency over time and must be stored at, or below, room temperature. If bottles are sitting on a shelf in warm room or in direct sunlight, they may degrade even before their expiration date. “Taking supplements that supplements do not offer Consuming foods rich in antioxidants, such as green contain antioxidants such as protection against cancer or disease, vegetables, citrus , deep-orange colored produce, and vitamin A, E, and C will prevent and may even do some harm. Heart other fruits and vegetables have many cancer and disease cancer and heart disease.” disease, cancer, diabetes and high blood fighting properties. pressure are affected by many factors, one of which is eating patterns. If a variety of foods are consumed in adequate and moderate amounts, supplements are unnecessary and will not provide added protection. “Osteoporosis can be Many factors such as calcium, estrogen While calcium consumption from foods such as milk and prevented by consuming levels, exercise, gender, body size, yogurt is the best way to meet daily needs, a daily calcium calcium supplements.” smoking, race, and , contribute to supplement with vitamin D may be beneficial if calcium intake the development of osteoporosis. The most is below recommended levels. effective treatment in postmenopausal women may be a combination of additional calcium, vitamin D, exercise, and estrogen. “Those who are sick or Emotional stress does not increase nutrient Individuals who are sick or stressed should aim for a healthful stressed will benefit from needs. Physiological stress such as burns, balanced diet with adequate intake of all recommended vitamins.” trauma, and surgery, do increase nutrient vitamins and nutrients. Additionally, research shows that 30 needs, and a supplement may be prescribed. minutes of exercise for 5 days out of the week is an important part of a healthy lifestyle, and acts to combat the effects of stress on the body. “Those who smoke or consume Smoking will increase the body's need for Individuals who smoke or drink alcohol in excess should speak alcohol in excess should take vitamin C, and alcohol can interfere with to a medical professional who will provide resources to help one vitamins to protect their body the body's ability to utilize several nutrients. discontinue these harmful behaviors. from the harmful effects of However, taking additional vitamins and smoking and drinking.” minerals will not protect people from the harmful effects of smoking or alcohol abuse. Table 2. How to choose a vitamin or mineral supplement. The following list includes the recommended daily instakes of important vitamins and minerals for certain populations at greatest risk for deficiency. Supplement Which Form? Daily Recommended Intake (Dietary Reference Intakes—DRI) Calcium: Important for women who Calcium is best absorbed in several Life Stage Group Milligrams/Day (mg/d) are pregnant, may become pregnant, smaller doses, rather than all at vegetarians, vegans, adults over 50, once. is the most Infants 0-6 months 200** menopausal, and postmenopausal popular , and 7-12 mo 260** women contains more calcium per tablet than , calcium gluconate or 1-3 years 700* calcium citrate, though all will provide 4-8 years 1,000* adequate calcium. Consume calcium carbonate with - stomach acids 9-18 years 1,300* will aid in calcium absorption. Avoid 19-50 years 1,000* tablets containing bone or dolomite, which may be contaminated Men 51-70 years 1,000* with lead. Women 51- 70 years 1,200* Adults 71+ 1,200* Pregnancy and Lactation 19+ 1,000* Vitamin D: An important and widely Vitamin D is found in 2 forms: Life Stage Group Micrograms/Day (ug/d) under consumed nutrient, especially D2 () and D3 in vegetarians, vegans, infants, those (). Both forms are Infants 0-12 months 10 (400 IU) with dark , those who may not effective and will increase vitamin D 1-70 years 15* (600 IU) receive enough sunlight, and those concentrations in the blood. over the age of 50. 71+ years 20 * (800 IU) For infants, the fortification of formula with vitamin D has been mandated, and contains between 40-100 IU / 100 kcal. Iron: Important for women with heavy The most common iron supplements Life Stage Group Milligrams/Day (mg/d) menstrual bleeding, vegetarians, and include ferrous fumarate, ferrous vegans. , and ferrous gluconate, all 7-12 months 11* of which are absorbed well. Since 1-3 years 7* the amount of iron that is absorbed decreases with an increasing dose, 4-8 years 10* it is best to take an 9-13 years 8* in 2 to 3 equally spaced doses throughout the day. Iron supplements Males 14-18 years 11* should be consumed with water Females 14-18 years 15* on an empty stomach (meals may reduce absorption by 30%). Males 19-50 years 8* Taking iron with vitamin C will aid in Females 19-50 years 18* absorption. Adults 51+ 8* Pregnancy 27* Vitamin B12: This nutrient is Supplements contain vitamin B12 Life Stage Group Micrograms/Day (ug/d) important, especially for vegetarians as , which the body and vegans (including those who can readily convert to an active form Infants 0-6 mo 0.4** are pregnant or breastfeeding), and for use. Research suggests little Infants 6-12 mo 0.5** those over the age of 50. difference among forms (oral or injection) regarding the body’s ability 1-3 years 0.9* to absorb vitamin B12. However, the 4-8 years 1.2* body absorbs vitamin B12 through an intrinsic factor in the stomach, 9-13 years 1.8* which can only absorb 0.02% of a 14-70 years 2.4* typical supplement. Pregnancy 2.6* Lactation 2.8* Table 2. How to choose a vitamin or mineral supplement continued. The following list includes the recommended daily instakes of important vitamins and minerals for certain populations at greatest risk for deficiency. Supplement Which Form? Daily Recommended Intake (Dietary Reference Intakes—DRI) Zinc: This important mineral may be Supplements may contain zinc Life Stage Group Milligrams/Day (mg/d) lacking especially in a vegetarian or gluconate, zinc sulfate, or zinc vegan diet, as well as zinc deficient acetate, each with varying levels of Infants 0-6 months 2** women who are pregnant or elemental zinc. There is still some 6-12 months 3* breastfeeding. debate as to which form of zinc is most effective regarding absorption, 1-3 years 3* bioavailability, or tolerability. Zinc 4-8 years 5* may also be present in cold lozenges and over the counter medications for 9-13 years 8* the treatment of colds. Males 14-70+ 11* Females 14-18 years 9* Females 19-70+ 8* Pregnancy 19+ 11* Lactation 19+ 12* Folate (Folic Acid): Important for Folic acid is available in Life Stage Group Micrograms/Day (ug/d) women who are of childbearing age, multivitamins, prenatal vitamins, women who are pregnant, or women and supplements that contain Pregnancy 600* who may become pregnant. other B-complex vitamins. The Lactation 500* bioavailability of folic acid decreases when taken with food, from 100% to 85%.

*RDA (Recommended Dietary Allowance): The average daily dietary intake level that is sufficient to meet the nutrient requirements of 97%-98% of health individuals in a population **AI (Adequate Intake): For healthy infants, AI is the average intake. For other individuals, the AI is believed to cover the needs of all healthy individuals in a population, but lack of available data prevent specificity of a particular percentage of individuals covered by this intake.

Table 3. Food first.Acquiring important nutritients from food sources. Nutrient Food Sources Strategies Calcium Low-fat dairy products, dark green leafy vegetables like Calcium is best absorbed from food rather than supplements. broccoli and kale, , most grains, and fortified food Consume foods rich in calcium along with vitamin D for maximal products such as milk alternatives (soy or almond milk), absorption. orange juice, and breakfast cereals. Vitamin D Fatty fish such as salmon, tuna, and mackerel, and fortified Expose skin to brief amounts of sunlight (5-30 minutes between foods like milk, milk alternatives, breakfast cereals, and 10am and 3pm, twice a week to face, arms, legs, or back without yogurt. sunscreen), in addition to consuming food sources rich in vitamin D. Iron Animal sources include red , fish, oysters, and poultry. It is important to select iron sources from both animal and plant Plant sources include beans, spinach, fortified cereal and sources. Vitamin C will also aid in iron absorption from plant sources. oatmeal, beans, and tofu. cereals, , spinach, soy beans, butter, Consuming the recommended daily amount (RDA) is important. Only bananas, potatoes, and yogurt. one-third to one-half of dietary magnesium is actually absorbed into the body. Vitamin B12 Animal products such as fish, , poultry, eggs, milk, When selecting animal products with vitamin B12, choose those that and other dairy products. It can also be found in fortified are low in fat. Fortified breakfast cereals are a good source of readily breakfast cereals and nutritional products. absorbed vitamin B12 for vegetarians and vegans. Zinc Animal products such as red meat, poultry, seafood, and Phytates that are present in breads, cereals, and legumes bind zinc dairy products. Plant based sources include beans, nuts, and inhibit its absorption. It is important for strict vegetarians and whole grains, and fortified breakfast cereals. vegans to soak beans, grains, and before cooking, to increase the bioavailability of zinc. Leavened products such as bread, break down more phytate than unleavened products like crackers, resulting in more zinc absorption. Folate Dark leafy vegetables such as spinach, peas, fortified Some women have a difficult time obtaining adequate amounts of (Folic Acid) breakfast cereals, , asparagus, brussel sprouts, romaine folate, therefore a combination of food and dietary supplements is lettuce, avocado, broccoli, dairy products, and . recommended for women of childbearing age. References Office of Dietary Supplements. National American Dietetic Association: Position Institutes of Health. What Dietary of the American Dietetic Association: Supplements Are You Taking? http:// Nutrient Supplementation. J Am Diet ods.od.nih.gov/pubs/partnersbrochure. Assoc. 2009; 109:2973-85. asp accessed April 25, 2013. Bailey RL, Fulgoni III VL, Keast DR, and Office of Dietary Supplements. JT Dwyer. Dietary supplement use National Institutes of Health. is associated with higher intakes of Dietary Supplements: What you minerals from food sources. Am J Clin need to know. Available at http:// Nutr 2011; 94:1376-1381. ods.od.nih.gov/HealthInformation/ CDC Publications and Information DS_WhatYouNeedToKnow.aspx last Products. Dietary Supplement Use accessed April 25, 2013. Among U.S. Adults Has Increased Since Office of Dietary Supplements. National NHANES III (1988-1994). Available Institutes of Health. Dietary Supplement at http://www.cdc.gov/nchs/data/ Fact Sheets (Calcium, Vitamin B12, databriefs/db61.htm last accessed April Iron, Vitamin D, Folate, and Zinc). 25, 2013 Available at http://ods.od.nih.gov/ Federal Trade Commission: Dietary factsheets/list-all/ last accessed April 25, Supplements. Available at http://www. 2013. consumer.ftc.gov/articles/0261-dietary- Sesso HD. Buring Je. Christen WG. Kurth supplements last accessed April 25, T. Belanger C. MacFadyen J. Bubes V. 2013. Manson JE. Glynn RJ. Gaziano JM. Food and Drug Administration: Vitamins E and C in the prevention Overview of Dietary Supplements, of in men: the Available at http://www.fda.gov/Food/ Physicians’ Health Study II randomized DietarySupplements/default.htm last controlled trial JAMA. 300(18): 2123- accessed April 25, 2013. 33, 2008 Nov 12.

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