dietary supplement use and its micronutrient …

Regan Bailey, Ph.D., M.P.H., R.D.Professor of Nutrition Science

Purdue University

DIETARY SUPPLEMENT USE AND ITS MICRONUTRIENT CONTRIBUTION DURING

PREGNANCY AND LACTATION IN THE UNITED STATES

Data from 2 Publications

NHANES 2001 - 2014• Usual total nutrient

intakes of pregnant women in the U.S.

NHANES 1999-2014• Dietary supplement use,

product type, doses, etc.o Pregnanto Lactatingo Not pregnant, not lactating

Bailey RL, Pac SG, Fulgoni VL, Reidy KC, Catalano PM.2019, JAMA Network Open 2(6): e195967.

Jun S, Gahche JJ, Potischman N, Dwyer JT, Guenther PM, Sauder KA, et al. 2020, Obstetrics & Gynecology. doi: 10.1097/AOG.0000000000003657

NHANES Methods

• Nationally-representative sample of U.S. residents

• In home interview oDemographic and questionnaire collectedoProduct inventory for dietary supplements

• Medical examination centero Clinical and24-hour dietary recall

• Follow up telephone callo 24-hour dietary recall

The majority of pregnant and lactating

women use dietary supplements

•77% of pregnant women •70% of lactating women•45% of non-pregnant, non-lactating women

Bailey et al. (2019), JAMA Network Open 2(6): e195967; Jun S, Gahche JJ, Potischman N, Dwyer JT, Guenther PM, Sauder KA, et al. 2020, Obstetrics & Gynecology. doi: 10.1097/AOG.0000000000003657

Prevalence (%) of dietary supplement use by younger (20-34y) and older (35-44y) pregnant women in the United States, NHANES 1999-2014

75.2

62.9

88.1

70.8

Any supplement Prenatal supplement

Diet

ary

supp

lem

ent u

se (%

)

20-34 years of age (n=1,159)

35-44 years of age (n=155)

a

*Estimates with different letters superscripts are significantly different at P<0.05.

b


Prevalence (%) of dietary supplement use by family income-to-poverty level among pregnant women (20-44y) in the United States, NHANES 1999-2014

58.449.7

79.5

61.4

89.1

78.4

0

10

20

30

40

50

60

70

80

90

100

Any dietary supplement Prenatal supplement

Diet

ary

supp

lem

ent u

se (%

) PIR≤130% (n=420)PIR 131-350% (n=419)

PIR>350% (n=379)

*

*


* Significant linear trend across PIR categories (p<.001).

Family Income-to-poverty Ratio (PIR)

89.1

74.2

53.444.1

67.6

55.1

Any dietary supplement Prenatal supplement

Diet

ary

supp

lem

ent u

se (%

)

Non-Hispanic white(n=578)Non-Hispanic black(n=207)Hispanic/MexicanAmerican (n=429)


Race/ethnicity

Prevalence (%) of dietary supplement use by Race/ethnicity among pregnant women in the United States, NHANES 1999-2014

a

b

ca

b

b

*Estimates with different letter superscripts are significantly different at P<0.0167

Dietary Supplement Use by women (20-44y) by pregnancy and lactation status in the United States, NHANES 1999-2014

77.472.9

11.1 10.9

64.470.3

64.4

10.1 12

54.2

44.8

31

157.8

3.40

10

20

30

40

50

60

70

80

90

Any supplement use MVM Single- or MV Single- or MM Prenatal supplementuse

Diet

ary

supp

lem

ent u

se (%

)

Pregnant womenLactating womenNon-pregnant and non-lactating womena

a

b

a

a

b

c


a

b

*Estimates with different letter superscripts are significantly different at P<0.0167

Prevalence of dietary supplement use by trimester of pregnancy among pregnant women (20-44y) in the United States, NHANES 1999-2012 (n=790)

72 69.9 70.666.1

22.8

52.4

86.382.2 84.3 81.9

19.8

80

90.887 87.5 89.3

22.8

80.4

0

10

20

30

40

50

60

70

80

90

100

Any supplementuse

MVM Folic acid-containing

Iron-containing Iodine-containing Prenatalsupplement use

Diet

ary

supp

lem

ent u

se (%

)

1st Trimester 2nd Trimester 3rd Trimester


a

ba,b

a

ba,b

a

bb

*Estimates with different alphabets are significantly different at P<0.0167

Prevalence of reasons for dietary supplement use among pregnant and lactating women (20-44y) in the US, NHANES 2007-2014 (n=330)

10.9 6.31.1

9.9 6.8

16.1 22.8 30.6 10.310

47.4 39.8

11.541.7

24.4

Pregnant (n=246) Lactating (n=84) NPNL (n=4,655) Pregnant (n=246) Lactating (n=84)

Diet

ary

supp

lem

ent u

se (%

)

Recommended by a healthcare providerTook on ownMotivation unknown

Any supplement Prenatal supplementJun S, Gahche JJ, Potischman N, Dwyer JT, Guenther PM, Sauder KA, et al. 2020, Obstetrics & Gynecology. doi: 10.1097/AOG.0000000000003657

Percentages of women (20-44y) using dietary supplements containing specified vitamins by pregnancy and lactation status in the United States, NHANES 1999-2014

Pregnant women(n=1,314)

Lactating women(n=297)

Non-pregnant andnon-lactating women

(n=8,096)Vitamin A 40.3 ± 2.2 a 41.6 ± 3.7 a 22.0 ± 0.6 b

Thiamin 69.4 ± 2.2 a 63.7 ± 3.4 a 30.4 ± 0.7 b

Riboflavin 69.4 ± 2.2 a 63.7 ± 3.4 a 30.4 ± 0.7 b

Niacin 69.6 ± 2.2 a 63.9 ± 3.4 a 31.2 ± 0.7 b

Vitamin B6 72.8 ± 2.1 a 65.1 ± 3.4 a 32.7 ± 0.7 b

Folic acid 73.3 ± 2.1 a 65.1 ± 3.4 a 32.9 ± 0.7 b

Vitamin B12 69.9 ± 2.1 a 63.9 ± 3.5 a 32.9 ± 0.7 b

Vitamin C 73.3 ± 2.0 a 64.6 ± 3.4 a 35.5 ± 0.8 b

Vitamin D 71.7 ± 2.0 a 66.8 ± 3.3 a 33.1 ± 0.7 b

Vitamin E 72.0 ± 2.0 a 64.0 ± 3.5 a 32.6 ± 0.7 b

Choline 4.9 ± 1.1 a 7.6 ± 2.1 a 5.2 ± 0.3 a


Percentages of women (20-44y) using dietary supplements containing specified minerals by pregnancy and lactation status in the United States, NHANES 1999-2014

Pregnant women(n=1,314)

Lactating women(n=297)

Non-pregnant andnon-lactating

women (n=8,096)Calcium 68.1 ± 2.2 a 62.3 ± 3.2 a 32.2 ± 0.7 b

Iodine 20.4 ± 1.7 a 17.5 ± 2.5 a 18.2 ± 0.6 a

Iron 72.3 ± 2.0 a 65.0 ± 3.3 a 28.3 ± 0.7 b

Magnesium 28.1 ± 2.1 a 26.2 ± 3.8 a 26.0 ± 0.6 a

Phosphorous 5.2 ± 1.0 a 6.2 ± 2.0 a 13.3 ± 0.5 b

Selenium 9.9 ± 1.2 a 11.7 ± 2.7 a 21.0 ± 0.6 b

Zinc 68.0 ± 2.2 a 60.6 ± 3.5 a 29.8 ± 0.7 b


*Estimates with different alphabets are significantly different at P<0.0167

Pregnant women- median intake from supplements, % of RDA and UL

65.3

64.1

33.3

19.7

14.3

13.2

2.2

9.8

12.8

5.0

7.9

2.5

13.4

0.3

0 10 20 30 40 50 60 70

Vitamin D

Iodine

Selenium

Calcium

Phosphorous

Magnesium

Choline*

UL RDA

(%)Jun S, Gahche JJ, Potischman N, Dwyer JT, Guenther PM, Sauder KA, et al. 2020, Obstetrics & Gynecology. doi: 10.1097/AOG.0000000000003657

296.2

218.3

189.1

136.8

128.6

121.4

116.7

110.0

101.9

78.6

52.0

2.6

5.0

56.6

61.1

0 50 100 150 200 250 300

Vitamin B12

Folic acid

Zinc

Vitamin B6

Thiamin

Riboflavin

Vitamin C

Niacin

Iron

UL RDA

Pregnant women- median intake from dietary supplements, % of RDA and UL


Lactating women- median intake from dietary supplements, % of RDA and UL

82.5

65.3

37.2

27.3

19.3

13.4

10.3

1.5

5

9.8

9.8

4.8

7.7

12

1.8

0.2

0 10 20 30 40 50 60 70 80 90

Vitamin C

Vitamin D

Iodine

Selenium

Calcium

Magnesium

Phosphorous

Choline*

UL RDA


Lactating women- median intake from dietary supplements, % of RDA and UL

298.9

278.6

260.7

193.3

130

128.6

114.7

106.3

59.8

78.2

58

2.6

55.7

0 50 100 150 200 250 300 350

Iron

Vitamin B12

Folic acid

Zinc

Vitamin B6

Thiamin

Niacin

Riboflavin

UL RDA

(%)


Pregnancy DataNHANES 2001-2014

• Two 24-hour dietary recalls

• National Cancer Institute (NCI) method was used to produce usual intakes and prevalence of meeting/exceeding the DRI

• Estimated Average Requirement (EAR, %<EAR)Adequate Intake (AI, %>AI)Tolerable Upper Intake Level

(UL, %>UL)

Total usual intakes (foods, beverages, supplements)

% < EAR• Magnesium (48%)• Vitamin D (46%)• Vitamin E (43%)• Iron (36%)• Vitamin A (16%)• Folate (16%)• Calcium (13%)• Vitamin C (12%)• Vitamin B6 (11%)• Zinc (11%)

% > Adequate Intake• Vitamin K (48%)• Potassium (42%)• Choline (8 %)

% > UL*• Sodium (95%)• Folic Acid (33%)• Iron (28 %)• Zinc (7%)• Calcium (3*)

* For all nutrients other than sodium UL estimates are for supplement users only

Bailey et al. (2019), JAMA Network Open 2(6): e195967.

35

95

0 0

80

0 05

14

4740

0102030405060708090

100

<EAR <EAR >UL >UL

Folate Iron Folic Acid Iron

% o

f pre

gnan

t wom

enFood: Non-UsersFood: UsersTotal: Users

Prevalence (SE) of usual nutrient intake distributions <EAR and >UL for folate/folic acid and iron stratified by dietary supplement use

Bailey et al. (2019), JAMA Network Open 2(6): e195967.

Limitations• Small sample sizes and self-reported dataoTotal intake data for lactating women is largely unknown

• Iodine contributions from foods are not available

oNHANES 1999-2006: mean urinary iodine content was 148 μg/L, lower than WHO cut off for “insufficiency” (<150 μg/L)

• Our team did not publish data on omega-3 fatty acid use or other product typeso 0.6% of childbearing-age women and 7.3% of pregnant women reported use of

DHA/EPA dietary supplements NHANES 2003-2014, no differences in DHA/EPA from diet alone

Gahche JJ, Bailey RL, Mirel LB, Dwyer JT. Journal of Nutrition, 2013; 143:872-877.

Thompson M, Nicholas H, [...], and Nordgren TM. Nutrients. 2019 Jan; 11(1): 177.

Summary and Conclusions

• Most pregnant and lactating women use dietary supplements

• Dietary supplement use varies by age, race/ethnicity, family income, and trimester of pregnancy

• The “doses” of micronutrients provided exhibit considerable variability

• Dietary supplements help consumers meet the recommended targets, but also contribute to potentially excessive intakes for certain nutrients

Summary and Conclusions• Many pregnant women do not consume enough of

key nutrients; specifically iron, potassium, calcium, magnesium, zinc, and vitamins A, C, D, E, K, B6, folate, and choline - even with the use of dietary supplement.

• Almost all pregnant women are at risk of excessive consumption of sodium, and many are at risk of excessive consumption of folic acid and iron, especially among dietary supplement users.

• Improved dietary guidance to help pregnant [and potentially lactating] women meet and not exceed dietary recommendations is warranted.

Thanks and Acknowledgements• Patrick Catalano• Johanna Dwyer• Victor Fulgoni• Jaime Gahche• Patricia Guenther• Shinyoung Jun• Kathleen Reidy• Susan Pac• Nancy Potischman• Kate Sauder

Shinyoung Jun Peishan ZouAlex CowanAnita Panjwani

dietary supplement use and its micronutrient …

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