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Precise dietary assessment is critical for accurate exposure classification in nutritional research, typically aimed at understanding how diet relates to health. Dietary supplement (DS) use is widespread and represents a considerable source of nutrients. However, few studies have compared the best methods to measure DSs. Our literature review on the relative validity and reproducibility of DS instruments in the United States [e.g., product inventories, questionnaires, and 24-h dietary recalls (24HR)] identified five studies that examined validity ( n = 5) and/or reproducibility ( n = 4). No gold standard reference method exists for validating DS use; thus, each study's investigators chose the reference instrument used to measure validity. Self-administered questionnaires agreed well with 24HR and inventory methods when comparing the prevalence of commonly used DSs. The inventory method captured nutrient amounts more accurately than the other methods. Reproducibility (over 3 months to 2.4 years) of prevalence of use estimates on the questionnaires was acceptable for common DSs. Given the limited body of research on measurement error in DS assessment, only tentative conclusions on these DS instruments can be drawn at present. Further research is critical to advancing knowledge in DS assessment for research and monitoring purposes. Expected final online publication date for the Annual Review of Nutrition, Volume 43 is August 2023. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Background Nearly a third of young US children take multivitamin/mineral (MVM) dietary supplements, yet it is unclear how formulations compare with requirements. Objective Describe the number and amounts of micronutrients contained in MVMs for young children and compare suggested amounts on product labels to micronutrient requirements. Design Cross-sectional. Setting All 288 MVMs on the market in the United States in the National Institutes of Health’s Dietary Supplement Label Database in 2018 labeled for children 1 to Main outcome measures Number of MVM products and amounts per day of micronutrients in each product suggested on labels compared with requirements represented by age-appropriate Daily Values (DV). Micronutrients of public health concern identified by the Dietary Guidelines for Americans (DGA) 2015-2020 (DGA 2015) and DGA 2020-2025 (DGA 2020) or those of concern for exceeding the upper tolerable intake levels. Statistical analyses Number of products and percent DV per day provided by each micronutrient in each product. Results The 288 MVMs contained a mean of 10.1 ± 2.27 vitamins and 4.59 ± 2.27 minerals. The most common were, in rank order, vitamins C, A, D, E, B6, B12; zinc, biotin, pantothenic acid, iodine, and folic acid. For micronutrients denoted by the DGA 2015 and DGA 2020 of public health concern, 56% of the 281 products containing vitamin D, 4% of the 144 with calcium, and none of the 60 containing potassium provided at least half of the DV. The upper tolerable intake level was exceeded by 49% of 197 products with folic acid, 17% of 283 with vitamin A, and 14% of 264 with zinc. Most MVMs contained many of 16 other vitamins and minerals identified in national surveys as already abundant in children’s diets. Conclusions A reexamination of the amounts and types of micronutrients in MVMs might consider formulations that better fill critical gaps in intakes and avoid excess.

Background Food insecurity is associated with poorer nutrient intakes from food sources and lower dietary supplement use. However, its association with total usual nutrient intakes, inclusive of dietary supplements, and biomarkers of nutritional status among US children remains unknown. Objective The objective was to assess total usual nutrient intakes, Healthy Eating Index-2015 (HEI-2015) scores, and nutritional biomarkers by food security status, sex, and age among US children. Methods Cross-sectional data from 9147 children aged 1-18 y from the 2011-2016 NHANES were analyzed. Usual energy and total nutrient intakes and HEI-2015 scores were estimated using the National Cancer Institute method from 24-h dietary recalls. Results Overall diet quality was poor, and intakes of sodium, added sugars, and saturated fat were higher than recommended limits, regardless of food security status. Food-insecure girls and boys were at higher risk of inadequate intakes for vitamin D and magnesium, and girls also had higher risk for inadequate calcium intakes compared with their food-secure counterparts, when total intakes were examined. Choline intakes of food-insecure children were less likely to meet the adequate intake than those of their food-secure peers. No differences by food security status were noted for folate, vitamin C, iron, zinc, potassium, and sodium intakes. Food-insecure adolescent girls aged 14-18 y were at higher risk of micronutrient inadequacies than any other subgroup, with 92.8% (SE: 3.6%) at risk of inadequate intakes for vitamin D. No differences in biomarkers for vitamin D, folate, iron, and zinc were observed by food security status. The prevalence of iron deficiency was 12.7% in food-secure and 12.0% in food-insecure adolescent girls. Conclusions Food insecurity was associated with compromised intake of some micronutrients, especially among adolescent girls. These results highlight a need for targeted interventions to improve children's overall diet quality, including the reduction of specific nutrient inadequacies, especially among food-insecure children. This study was registered at clinicaltrials.gov as NCT03400436.

BACKGROUND: Data from the 2007–2010 NHANES suggested that vitamin D supplements contributed to increased serum concentrations of 25-hydroxyvitamin D [25(OH)D] in the US population. OBJECTIVES: We sought to determine whether 25(OH)D continued to increase during NHANES 2011–2014 and whether associations of 25(OH)D with preselected covariates differed across time periods. METHODS: For this study, 25(OH)D was measured in adults (≥20 y) using LC-MS/MS. Descriptive and regression analyses were stratified by survey period to investigate the effects of age, race–Hispanic origin, sex, season, BMI, dietary vitamin D, and vitamin D–containing supplements. A multiple linear regression model was used to assess 25(OH)D changes between two 4-y survey periods, namely 2007–2010 and 2011–2014. RESULTS: We observed several significant concomitant increases between 2007–2010 and 2011–2014: unadjusted mean 25(OH)D increased by 2.7 nmol/L (95% CI: 0, 5.4 nmol/L; P = 0.048), the percentage of persons taking any vitamin D–containing supplements increased 2.9% (95% CI: 0.03, 5.5%; P = 0.0314), and the percentage of persons taking high-dose (≥1000 IU/d) vitamin D–containing supplements increased 8.6% (95% CI: 6.9, 9.9%; P

Dietary supplement (DS) use is widespread in the U.S. and contributes large amounts of micronutrients to users. Most studies have relied on data from one assessment method to characterize the prevalence of DS use. Combining multiple methods enhances the ability to capture nutrient exposures from DS and examine trends over time.The objective of this study was to characterize DS use and examine trends in any DS as well as micronutrient-containing (MN) DS use among a nationally representative sample of the U.S. population (≥1y) from the 2007-2018 NHANES using a combined approach (i.e., DSMQ and/or ≥1 24HR).NHANES obtains an in-home inventory with a frequency-based DS and Prescription Medicine Questionnaire (DSMQ), and two 24-hr recalls (24HR). The objective of this study was to characterize DS use and examine trends in any and micronutrient-containing (MN) DS use among a nationally representative sample of the U.S. population (≥1y) from the 2007-2018 NHANES, using a combined approach (i.e., DSMQ and/or ≥1 24HR). Trends in the prevalence of use and selected types of products used were estimated for the population and by sex, age, race/Hispanic origin, family income (poverty-to-income ratio (PIR)), and household food security (food-secure vs. food-insecure). Linear trends were tested using orthogonal polynomials (significance set at p0.05).DS use increased from 50% in 2007 to 56% in 2018 (p = 0.001); use of MN products increased from 46% to 49% (p = 0.03), and single-nutrient DS (e.g., magnesium, vitamins B12 and D) use also increased (all p0.001). In contrast, multivitamin-mineral use decreased (70% to 56%; p0.001). Among adults (≥19y), any (54% to 61%) and MN (49% to 54%) DS use increased, especially among men, non-Hispanic Blacks and Hispanics, and low-income adults (PIR≤130%). Among children (1-18y), any DS use remained stable (∼38%), as did MN use, except for food-insecure children, whose use increased from 24% to 31% over the decade (p = 0.03).The prevalence of any and MN DS use increased over time in the U.S. This may be partially attributed to increased use of single-nutrient products. Population subgroups differed in their DS use.

BackgroundPotential safety concerns relative to impaired cognitive function may exist when high folic acid exposures are combined with low vitamin B-12 status.ObjectivesWe aimed to examine the relation of the coexistence of high folate and low vitamin B-12 status with cognitive function, utilizing various definitions of "high" folate status.MethodsCross-sectional data from older adults (≥60 y; n=2420) from the 2011-2014 NHANES were analyzed. High folate status was defined as unmetabolized serum folic acid (UMFA)>1 nmol/L or serum total folate>74.1 nmol/L, and low vitamin B-12 status as methylmalonic acid>271 nmol/L or serum vitamin B-12&nbsp

Objective:To evaluate total usual intakes and biomarkers of micronutrients, overall dietary quality and related health characteristics of US older adults who were overweight or obese compared with a healthy weight.Design:Cross-sectional study.Setting:Two 24-h dietary recalls, nutritional biomarkers and objective and subjective health characteristic data were analysed from the National Health and Nutrition Examination Survey 2011–2014. We used the National Cancer Institute method to estimate distributions of total usual intakes from foods and dietary supplements for eleven micronutrients of potential concern and the Healthy Eating Index (HEI)-2015 score.Participants:Older adults aged ≥60 years (n 2969) were categorised by sex and body weight status, using standard BMI categories. Underweight individuals (n 47) were excluded due to small sample size.Results:A greater percentage of obese older adults compared with their healthy-weight counterparts was at risk of inadequate Mg (both sexes), Ca, vitamin B6 and vitamin D (women only) intakes. The proportion of those with serum 25-hydroxyvitamin D < 40 nmol/l was higher in obese (12 %) than in healthy-weight older women (6 %). Mean overall HEI-2015 scores were 8·6 (men) and 7·1 (women) points lower in obese than in healthy-weight older adults. In addition, compared with healthy-weight counterparts, obese older adults were more likely to self-report fair/poor health, use ≥ 5 medications and have limitations in activities of daily living and cardio-metabolic risk factors; and obese older women were more likely to be food-insecure and have depression.Conclusions:Our findings suggest that obesity may coexist with micronutrient inadequacy in older adults, especially among women.

BACKGROUND: Accurate and reliable methods to assess prevalence of use of and nutrient intakes from dietary supplements (DSs) are critical for research, clinical practice, and public health monitoring. NHANES has been the primary source of DS usage patterns using an in-home inventory with a frequency-based DS and Prescription Medicine Questionnaire (DSMQ), but little is known regarding DS information obtained from 24-h dietary recalls (24HRs). METHODS: The objectives of this analysis were to compare results from 4 different methods for measuring DS use constructed from two data collection instruments (i.e., DSMQ and 24HR) and to determine the most comprehensive method for measuring the prevalence of use and estimating nutrient intakes from DS for selected nutrients. NHANES 2011–2014 data from US adults (aged ≥19 y; n = 11,451) were used to examine the 4 combinations of methods constructed for measuring the prevalence of use of and amount of selected nutrients from DSs (i.e., riboflavin, vitamin D, folate, magnesium, calcium): 1) DSMQ, 2) 24HR day 1, 3) two 24HRs (i.e., mean), and 4) DSMQ or at least one 24HR. RESULTS: Half of US adults reported DS use on the DSMQ (52%) and on two 24HRs (mean of 49%), as compared with a lower prevalence of DS use when using a single 24HR (43%) and a higher (57%) prevalence when combining the DSMQ with at least one 24HR. Mean nutrient intake estimates were highest using 24HR day 1. Mean supplemental calcium from the DSMQ or at least one 24HR was 372 mg/d, but 464 mg/d on the 24HR only. For vitamin D, the estimated intakes per consumption day were higher on the DSMQ (46 μg) and the DSMQ or at least one 24HR (44 μg) than those on the 24HR day 1 (32 μg) or the mean 24HR (31 μg). Fewer products were also classed as a default or reasonable match on the DSMQ than on the 24HR. CONCLUSIONS: A higher prevalence of use of DSs is obtained using frequency-based methods, whereas higher amounts of nutrients are reported from a 24HR. The home inventory results in greater accuracy for products reported. Collectively, these findings suggest that combining the DSMQ with at least one 24HR (i.e., DSMQ or at least one 24HR) is the most comprehensive method for assessing the prevalence of and estimating usual intake from DSs in US adults. This trial was registered at clinicaltrials.gov as NCT03400436.

Background to meet the challenges of an aging population and improve public health it is imperative to reduce factors that decrease independence and increase morbidity. Malnutrition (particularly protein-energy undernutrition), sarcopenia, frailty, and obesity all result in disability but are potentially changeable. The purpose of this study was to determine whether state/territorial plans on aging for Older Americans Act (OAA) programs include nutrition-related conditions/interventions that could impact healthy aging. Methods OAA aging plans available on the ADvancing States website in February 2021 (n=52) were searched for number of mentions of defined nutrition terms including malnutrition, sarcopenia, frailty, obesity, and if terms were included in plans’ goals/objectives, strategies/actions or solely in the narrative. Results 33% of plans mentioned malnutrition; 8% (goals/objectives), 15% (strategies/actions). 62% mentioned frailty; 6% (goals/objectives), 15% (strategies/actions). None mentioned sarcopenia. In contrast 21% mentioned obesity; 2% (goals/objectives), 2% (strategies/actions). Nutrition intervention mentions were nearly nil. There were no significant differences in frequency of term mentions by region or by states with higher % older adults or obese adults. Malnutrition, sarcopenia, frailty, and obesity adversely affect healthy aging and contribute to disability/poorer health outcomes but are mentioned infrequently in state/territorial plans on aging. Conclusions the incorporation of OAA nutrition programming to include addressing malnutrition in 2022 plans can best be realized by clearly specifying definitions of malnutrition-related conditions and incorporating them among the measurable goals/objectives, defined strategies/actions, and outcomes.

BACKGROUND: Most dietary indices reflect foods and beverages and do not include exposures from dietary supplements (DS) that provide substantial amounts of micronutrients. A nutrient-based approach that captures total intake inclusive of DS can strengthen exposure assessment. OBJECTIVE: To examine the construct and criterion validity of the Total Nutrient Index (TNI) among U.S. adults (≥19y; non-pregnant or lactating). METHODS: The TNI includes eight under-consumed micronutrients identified by the Dietary Guidelines for Americans: calcium; magnesium; potassium; choline; and vitamins A, C, D, and E. The TNI is expressed as a percentage of the Recommended Dietary Allowance or Adequate Intake to compute micronutrient component scores; the mean of the component scores yields the TNI score, ranging from 0-100. Data from exemplary menus and the 2003-2006 (≥19y; n = 8,861) and 2011-2014 NHANES (≥19y; n = 9,954) were employed. Exemplary menus were used to determine if the TNI yielded high scores from dietary sources (women 31-50y; men ≥70y). TNI scores were correlated with Healthy Eating Index (HEI)-2015 overall and component scores for dairy, fruits, and vegetables; TNI component scores for vitamins A, C, D, and E were correlated with respective biomarker data. TNI scores were compared between groups with known differences in nutrient intake based on the literature. RESULTS: The TNI yielded high scores on exemplary menus (84.8-93.3/100) and was moderately correlated (r = 0.48) with the HEI-2015. Mean TNI scores were significantly different for DS users (83.5) vs. non-users (67.1), non-smokers (76.8) vs. smokers (70.3), and those living with food security (76.6) vs. food insecurity (69.1). Correlations of TNI vitamin component scores with available biomarkers ranged from r = 0.12 (α-tocopherol) to r = 0.36 (serum 25(OH)D), and were significantly higher than correlations obtained from the diet alone. CONCLUSION: The evaluation of validity supports that the TNI is a useful construct to assess total micronutrient exposures of under-consumed micronutrients among U.S. adults.

BACKGROUND: Enriched cereal-grain products have been fortified in the United States for >20 y to improve folate status in women of reproductive age and reduce the risk of folic acid–responsive neural tube birth defects (NTDs). OBJECTIVES: Our objectives were to assess postfortification changes in folate status in the overall US population and in women aged 12–49 y and to characterize recent folate status by demographic group and use of folic acid–containing supplements. METHODS: We examined cross-sectional serum and RBC folate data from the NHANES 1999–2016. RESULTS: Serum folate geometric means increased from 2007–2010 to 2011–2016 in persons aged ≥1 y (38.7 compared with 40.6 nmol/L) and in women (35.3 compared with 37.0 nmol/L), whereas RBC folate showed no significant change. Younger age groups, men, and Hispanic persons showed increased serum and RBC folate concentrations, whereas non-Hispanic black persons and supplement nonusers showed increased serum folate concentrations. The folate insufficiency prevalence (RBC folate

BACKGROUND: Sarcopenia, a progressive loss of skeletal muscle mass and strength, can begin in the 4th decade of life. Protein intake predicts skeletal muscle mass and strength among older adults, but knowledge of similar associations among middle-aged adults is lacking. OBJECTIVES: We aimed to assess associations between protein intake and skeletal muscle mass, characterized by appendicular lean mass adjusted for BMI [in kg/m(2) (ALM(BMI))], and muscle strength, represented by handgrip strength adjusted for BMI (GSMAX(BMI)), among middle-aged adults. METHODS: We analyzed cross-sectional data from 1209 men and 1208 women aged 40–59 y in the 2011–2014 NHANES. Protein intake per kilogram actual body weight (BW), assessed by two 24-h recalls, was examined as continuous and categorical parameters [low (

BACKGROUND: Dietary supplements are commonly taken by adults in the United States and can contribute substantially to daily nutrient intakes. Short supplement-use questionnaires are often used in dietary surveys, but their accuracy has not been well studied. OBJECTIVES: The primary objective was to evaluate the accuracy of a short, self-administered supplement frequency questionnaire (SFQ) relative to a comprehensive 1-y inventory of supplement use. A secondary objective was to compare SFQ responses for participants in the intensive measurement study to those from a control group to investigate a possible research participation effect. METHODS: The Supplement Reporting study enrolled 1029 older adults in 2005–2006, with a mean age of 67.8 y, who participated in the Multiethnic Cohort and reported regular use of dietary supplements. Of these, 375 were interviewed quarterly to collect detailed information on types and amounts of dietary supplements used, while 654 served as the control group. All participants completed 2 SFQs, 1 y apart. RESULTS: Agreement between the 2 instruments in use at least weekly ranged from 88% to 97% for 15 of 16 supplement types, with a lower agreement of 74% for vitamin D. The correlations of nutrient intakes from supplements between the 2 instruments were high, ranging from 0.48 to 0.75, except for iron (r = 0.29). However, mean nutrient intakes as reported on the SFQ were higher than intakes from the inventory for most nutrients, sometimes twice as high. Nutrient intakes based on the SFQ were similar for the inventory and control groups, at both baseline and the end of the study. CONCLUSIONS: A self-administered short SFQ can be used in large surveys to identify participants who use 16 categories of dietary supplements at least once a week and can correctly rank participant intakes of nutrients. However, the SFQ does not accurately estimate absolute levels of nutrient intakes from supplements.

OBJECTIVES: Data on the iodine content of foods are needed to assess intake and plan dietary guidance. Iodine is central for thyroid function in human growth, reproduction, neurologic development and energy metabolism, and inadequate or excessive intakes can cause thyroid dysfunction and/or disease. Overall, U.S. iodine intake is sufficient, but some women of reproductive age and pregnant women may be at risk for deficiency, as well as people whose dietary patterns do not include iodine-rich foods. METHODS: A Special Interest Database (SID) was developed through the collaboration of the Methods and Application of Food Composition Laboratory (USDA), the Food and Drug Administration (FDA), and the Office of Dietary Supplements (NIH). Data for foods and beverages were derived from samples analyzed by USDA and the FDA Total Diet Study; foods included seaweed, fish and other seafood, dairy, iodized salt, eggs, and commercial foods; metadata were captured as varying iodine levels may arise from feed supplementation, iodophor use, and iodine-containing ingredients in processed foods. Samples were analyzed for iodine using inductively coupled plasma mass spectrometry (ICP-MS). Quality control included certified reference materials and secondary in-house controls. RESULTS: The Special Interest Database on Iodine (https://www.ars.usda.gov/northeast-area/beltsville-md-bhnrc/beltsville-human-nutrition-research-center/methods-and-application-of-food-composition-laboratory/mafcl-site-pages/iodine/) was released in 2020 and includes food descriptions, means, standard deviations, value ranges, sample sizes, and supporting information for 430 foods. Foods continue to be analyzed for iodine and added to the database. In addition, iodine intakes of the U.S. population are being calculated by mapping the iodine content of foods to food consumption data from the 2014 U.S. National Health and Nutrition Examination Survey (NHANES) and eventually more recent NHANES dietary data. CONCLUSIONS: The SID on Iodine and the mapped NHANES data provide needed information to monitor iodine status and develop dietary guidance for the general U.S. population and vulnerable subgroups. Furthermore, the database can provide a valuable tool for other research programs and clinical applications in iodine nutrition. FUNDING SOURCES: NIH Office of Dietary Supplements.

Both undernutrition and frailty adversely affect the health and functional outcomes of the older adult population. Timely and accurate national data are necessary to assess those at risk of these debilitating but often preventable conditions, to correct them and support healthy aging. The objective was to identify relevant measures in undernutrition and frailty screening tools and determine if these measures are collected in recent protocols for US national surveys sampling older adults and which measures could be added to be able to better assess risk of undernutrition and frailty. Commonly used undernutrition and frailty screening tools were evaluated to identify measures that were unique or common to both. US national surveys were examined to determine whether they included older adults in their survey sample, collected health measures from participants, in what form, and whether they were functional indexes or survey questions. A comparative analysis of survey protocols was performed to determine which surveys collected data related to the measures of undernutrition and frailty. Of the 8 national surveys, only 3 provided ≥1 physical measurement (i.e., height/weight, grip strength, balance). Most surveys included self-reported data on height/weight, physical functioning/mobility, disability, and psychological components. Whereas 6 included questions on food security/food program participation, only 1 collected data on dietary intake. Currently national surveys include only limited health measures that can be used to identify undernutrition and frailty risk in older adults. Adding a few simple screening measures already included in popular screening tools, such as grip strength, unintentional weight loss, and loss of appetite, to national surveys which monitor older Americans would facilitate estimation of the prevalence of undernutrition and frailty risk, better estimate those at risk, provide an opportunity to set national goals to reduce their risk, and help implement strategies for improved health outcomes.

Dietary supplement use is common in the United States (1). The additional nutrients provided by dietary supplements can help meet recommended nutrient targets but can also potentially lead to excess intakes (2,3). This report describes recent prevalence estimates for dietary supplement use among U.S. adults, the distribution of the number of dietary supplements used, and the most common types of dietary supplements used. Trends in dietary supplement use from 2007-2008 through 2017-2018 are also reported.

Dietary supplement use is common in the United States (1). The additional nutrients provided by dietary supplements can help meet recommended nutrient targets but can also potentially lead to excess intakes (2,3). This report describes recent prevalence estimates for dietary supplement use among U.S. adults, the distribution of the number of dietary supplements used, and the most common types of dietary supplements used. Trends in dietary supplement use from 2007-2008 through 2017-2018 are also reported.

A priori dietary indices provide a standardized, reproducible way to evaluate adherence to dietary recommendations across different populations. Existing nutrient-based indices were developed to reflect food/beverage intake; however, given the high prevalence of dietary supplement (DS) use and its potentially large contribution to nutrient intakes for those that use them, exposure classification without accounting for DS is incomplete. The purpose of this article is to review existing nutrient-based indices and describe the development of the Total Nutrient Index (TNI), an index developed to capture usual intakes from all sources of under-consumed micronutrients among the U.S. population. The TNI assesses U.S. adults' total nutrient intakes relative to recommended nutrient standards for eight under-consumed micronutrients identified by the Dietary Guidelines for Americans: calcium, magnesium, potassium, choline, and vitamins A, C, D, E. The TNI is scored from 0 to 100 (truncated at 100). The mean TNI score of U.S. adults (≥19 y; n = 9,954) based on dietary data from NHANES 2011-2014, was 75.4; the mean score for the index ignoring DS contributions was only 69.0 (t-test; p < 0.001). The TNI extends existing measures of diet quality by including nutrient intakes from all sources and was developed for research, monitoring, and policy purposes.

Background & Aims Public interest in pre-, pro-, and synbiotic products is increasing because of interactions between gut microbiota and human health. Our aim was to describe nonfood (from dietary supplements or medication) pre-, pro-, and synbiotic use by US adults and children and reported reasons. Methods Using data from the National Health and Nutrition Examination Survey (NHANES), we text-mined dietary supplement and prescription medication labels and ingredients to identify pre-, pro-, and synbiotic products used in the past 30 days. We describe trends in use from 1999 to 2018 (n = 101,199) and prevalence in 2015–2016 and 2017–2018 (n = 19,215) by age groups, sex, ethnicity/race, education, income, self-reported diet and health quality, and prescription gastrointestinal medication use stratified by children ( Results Nonfood pre-, pro-, and synbiotic use increased up to 3-fold in recent cycles. Prevalence of use for all ages for prebiotics was 2.4% (95% confidence interval [CI], 2.0–2.9), for probiotics was 4.5% (95% CI, 3.5–5.6), and for synbiotics was 1.1% (95% CI, 0.8–1.5). Use was highest among older adults (8.8% [95% CI, 5.4–13.3] among those aged 60–69 years for probiotics), non-Hispanic Whites, those with higher educational attainment and income, those with more favorable self-reported diet or health quality, and those with concurrent prescription gastrointestinal medication use. The top reasons for use were for digestive health and to promote/maintain general health. Less than 30% reported using these products based on a health care provider's recommendation. Conclusions One in 20 US adults or children use nonfood pre-, pro-, or synbiotic products, and use has sharply increased in recent years. Most individuals voluntarily take these products for general digestive or overall health reasons.

© 2019 American Society for Nutrition. All rights reserved. The use of dietary supplements (DS) is pervasive and can provide substantial amounts of micronutrients to those who use them. Therefore when characterizing dietary intakes, describing the prevalence of inadequacy or excess, or assessing relations between nutrients and health outcomes, it is critical to incorporate DS intakes to improve exposure estimates. Unfortunately, little is known about the best methods to assess DS, and the structure of measurement error in DS reporting. Several characteristics of nutrients from DS are salient to understand when comparing to those in foods. First, DS can be consumed daily or episodically, in bolus form and can deliver discrete and often very high doses of nutrients that are not limited by energy intakes. These characteristics contribute to bimodal distributions and distributions severely skewed to the right. Labels on DS often provide nutrient forms that differ from those found in conventional foods, and underestimate analytically derived values. Finally, the bioavailability of many nutrient-containing DS is not known and it may not be the same as the nutrients in a food matrix. Current methods to estimate usual intakes are not designed specifically to handle DS. Two temporal procedures are described to refer to the order that nutrient intakes are combined relative to usual intake procedures, referred to as a shrinking the distribution to remove random error. The shrink then add approach is preferable to the add then shrink approach when users and nonusers are combined for most research questions. Stratifying by DS before usual intake methods is another defensible option. This review describes how to incorporate nutrient intakes from DS to usual intakes from foods, and describes the available methods and fit-for-purpose of different analytical strategies to address research questions where total usual intakes are of interest at the group level for use in nutrition research and to inform policy decisions. Clinical Trial Registry: NCT03400436. J Nutr 2019;149:181-197.

Data on the iodine content of foods and dietary supplements are needed to develop general population intake estimates and identify major contributors to intake. Samples of seafood, dairy products, eggs, baked products, salts, tap water, other foods and beverages, and dietary supplements were collected according to established sampling plans of the U.S. Department of Agriculture (USDA) and the U.S. Food and Drug Administration (FDA). Samples were assayed for iodine content using inductively coupled plasma mass spectrometry with rigorous quality control measures. The food data were released through a collaboration of USDA, FDA, and the Office of Dietary Supplements-National Institutes of Health (ODS-NIH) as the USDA, FDA, and ODS-NIH Database for the Iodine Content of Common Foods at www.ars.usda.gov/mafcl. Iodine data for dietary supplements are available in the ODS-USDA Dietary Supplement Ingredient Database and the ODS Dietary Supplement Label Database. Data from the iodine databases linked to national dietary survey data can provide needed information to monitor iodine status and develop dietary guidance for the general U.S. population and vulnerable subgroups. This iodine information is critical for dietary guidance development, especially for those at risk for iodine deficiency (i.e., women of reproductive age and young children). National Institutes of Health's Office of Dietary Supplements Published version This work was funded by the National Institutes of Health's Office of Dietary Supplements and in-kind contributions from the USDA and FDA. Public domain – authored by a U.S. government employee

Objective To describe the history, key features, recent enhancements, and common applications of the Dietary Supplement Label Database (DSLD). Background and history Although many Americans use dietary supplements, databases of dietary supplements sold in the United States have not been widely available. The DSLD, an easily accessible public-use database was created in 2008 to provide information on dietary supplement composition for use by researchers and consumers. Rationale Accessing current information easily and quickly is crucial for documenting exposures to dietary supplements because they contain nutrients and other bioactive ingredients that may have beneficial or adverse effects on human health. This manuscript details recent developments with the DSLD to achieve this goal and provides examples of how the DSLD has been used. Recent developments With periodic updates to track changes in product composition and capture new products entering the market, the DSLD currently contains more than 71,000 dietary supplement labels. Following usability testing with consumer and researcher user groups completed in 2016, improvements to the DSLD interface were made. As of 2017, both a desktop and mobile device version are now available. Since its inception in 2008, the use of the DSLD has included research, exposure monitoring, and other purposes by users in the public and private sectors. Future directions Further refinement of the user interface and search features to facilitate ease of use for stakeholders is planned. Conclusions The DSLD can be used to track changes in product composition and capture new products entering the market. With over 71,000 DS labels it is a unique resource that policymakers, researchers, clinicians, and consumers may find valuable for multiple applications.

Objective This review summarizes the current and previous data on dietary supplement (DS) use collected from participants in the National Health and Nutrition Examination Survey (NHANES), describes the NHANES dietary supplement database used to compute nutrient intakes from DSs, discussed recent developments and future direction, and describes many examples to demonstrate the utility of these data in informing nutrition research and policy. Background and history Since 1971, NHANES, has been collecting information on the use of DSs from participants. These data are critical to national nutrition surveillance and have been used to characterize usage patterns, examine trends over time, assess the percentage of the population meeting or exceeding nutrient recommendations, and to help elucidate the sources contributing nutrients to the diet of the US population. Rationale Over half of adults and about one-third of children in the United States use at least one dietary supplement in the past 30 days. Dietary supplements contribute to the dietary intake of nutrients and bioactive compounds in the US and therefore need to be assessed when monitoring nutritional status of the population and when studying diet-health associations. Recent developments With the recent development and availability of the Dietary Supplement Label Database (DSLD), a comprehensive DS database that will eventually contain labels for all products marketed in the US, NHANES DS data will be more easily linked to product information to estimate nutrient intake from DS. Future directions Over time, NHANES has both expanded and improved collection methods. The continued understanding of sources of error in collection methods will continue to be explored and is critical to improved accuracy. Conclusions NHANES provides a rich source of nationally representative data on the usage of dietary supplements in the US.

Background: Dietary supplements (DSs) have the potential to be both beneficial and harmful to health, especially in adults aged ≥60 y, and therefore it is important to monitor the patterns of their use.Objective: This study evaluated DS use by adults aged ≥60 y to characterize the use of DSs, determine the motivations for use, and examine the associations between the use of DSs and selected demographic, lifestyle, and health characteristics.Methods: Data from 3469 older adults aged ≥60 y from the 2011-2014 NHANES were analyzed. DSs used in the past 30 d were ascertained via an interviewer-administered questionnaire in participants' homes. The prevalence of overall DS use and specific types of DSs were estimated. The number of DSs reported and the frequency, duration, and motivation(s) for use were assessed. Logistic regression models were constructed to examine the association between DS use and selected characteristics.Results: Seventy percent of older adults in the United States reported using ≥1 DS in the past 30 d; 54% of users took 1 or 2 products, and 29% reported taking ≥4 products. The most frequently reported products were multivitamin or mineral (MVM) (39%), vitamin D only (26%), and omega-3 fatty acids (22%). Women used DSs almost twice as often as men [adjusted OR (aOR), 1.8; 95% CI: 1.5, 2.3). Those not reporting prescription medications were less likely to take a DS than those reporting ≥3 prescription medications (aOR, 0.4; 95% CI: 0.3, 0.6). The most frequently reported motivation for DS use was to improve overall health (41%).Conclusions: Use of DSs among older adults continues to be high in the United States, with 29% of users regularly taking ≥4 DSs, and there is a high concurrent usage of them with prescription medications.

Background:Nationally representative normative values for cardiorespiratory fitness (CRF) have not been described for US children since the mid 1980s.Objective:To provide sex- and age-specific normative values for CRF of US children aged 6–11 years.Methods:Data from 624 children aged 6–11 years who participated in the CRF testing as part of the 2012 National Health and Nutrition Examination Survey National Youth Fitness Survey, a cross-sectional survey, were analyzed. Participants were assigned to one of three age-specific protocols and asked to exercise to volitional fatigue. The difficulty of the protocols increased with successive age groups. CRF was assessed as maximal endurance time (min:sec). Data analysis was conducted in 2016.Results:For 6–7, 8–9, 10–11 year olds, corresponding with the age-specific protocols, mean endurance time was 12:10 min:sec (95% CI: 11:49–12:31), 11:16 min:sec (95% CI: 11:00–11:31), and 10:01 min:sec (95% CI: 9:37–10:25), respectively. Youth in the lowest 20th percentile for endurance time were more likely to be obese, to report less favorable health, and to report greater than two hours of screen time per day.Conclusions:These data may serve as baseline estimates to monitor trends over time in CRF among US children aged 6–11 years.

Background: Iodine is an essential nutrient required for normal thyroid function in all age groups as well as healthy fetal, infant, and child development and growth. Because iodine levels in most foods are low, iodine usually must be provided through dietary supplements or fortified foods (such as salt). In recent NHANES cycles, sub-optimal iodine status has been observed in some U.S. populations, most notably pregnant women. Recent health campaigns have emphasized consuming less sodium and have focused on the primary source of the excess sodium in the U.S. diet: commercially prepared foods, most of which are made with non-iodized salt. Also, recent secular trends towards less home cooking and more use of non-iodized table salts may be contributing to relatively low usage of iodized salt, which was estimated in 2014 to comprise only half of retail salt sales. Therefore, for individuals who also limit their home use of salt in food preparation or at the table, an unintended consequence may be a decline in iodine intake. Population-level data thus are needed on the relative contributions of various foods to iodine intake in relation to iodine status markers, to characterize population groups at risk and develop guidance on appropriate dietary and supplementation strategies. Objective: Describe new measures of iodine intake and iodine status added into NHANES 2019-20, which is a nationally representative survey of the U.S. population. Methods: Iodine intake is being assessed through a questionnaire about household salt types (such as iodized salt or sea salt) and measured iodine content of household iodized salt, as well as individual 24-hour dietary recalls and use of iodine containing dietary supplements. This will be the first time NHANES will estimate dietary iodine intake using a newly developed USDA Special Interest Database on Iodine Content of Foods. Biomarkers include a thyroid panel (including thyroglobulin), inhibitors of iodine uptake in the thyroid (e.g., perchlorates), and urinary iodine concentration. Conclusions: The upcoming NHANES cycle will yield novel data on U.S. population coverage of household iodized salt, as well as individual thyroid and iodine status in relation to dietary iodine intake. Groups at risk from increased physiologic need or dietary preferences that limit iodine sources will be identified. A key tool in undertaking this work will be a new food composition database on the iodine content of U.S. foods. Clarification of key sources of iodine in the U.S. diet will be important in developing dietary guidance.

OBJECTIVE: To estimate the prevalence of use and the micronutrient contribution of dietary supplements among pregnant, lactating, and non-pregnant and non-lactating women in the United States. METHODS: Cross-sectional data from 1,314 pregnant, 297 lactating, and 8,096 non-pregnant and non-lactating women (aged 20-44 years) in the 1999-2014 National Health and Nutrition Examination Surveys were combined to produce statistically reliable, nationally representative estimates. Information about dietary supplements used in the past 30 days was collected through an interviewer-administered questionnaire and in-home inventory. The prevalence of nutrient-specific supplement use, mean daily nutrient intakes from supplements among users, and motivations for supplement use were assessed. Differences by age, income, and trimester within pregnant women were also tested. RESULTS: Seventy-seven percent of pregnant and 70% of lactating women used one or more dietary supplements, whereas 45% of non-pregnant and non-lactating women used supplements. In particular, 64% of pregnant and 54% of lactating women used prenatal supplements. Mean intakes of thiamin, riboflavin, niacin, folic acid, vitamins B6, B12, and C, iron, and zinc from supplements alone were at or above their respective Recommended Dietary Allowances among pregnant and lactating supplement users. About half of pregnant and 40% of lactating women took supplements based on the recommendation of a health care provider. Among pregnant women, those in their first trimester, aged 20-34 years, or in a lower-income family were less likely to use supplements compared to their counterparts. CONCLUSION: The majority of pregnant and lactating women used dietary supplements, which contributed many nutrients in doses above the Recommended Dietary Allowances. While inadequate intakes of folate and iron are of concern among pregnant women not using supplements, supplement users often consumed high doses, suggesting a potential need of health care providers to discuss dietary supplement use and the recommended doses of nutrients during pregnancy and lactation.

This study examined total usual micronutrient intakes from foods, beverages, and dietary supplements (DS) compared to the Dietary Reference Intakes among U.S. adults (&ge, 19 years) by sex and food security status using NHANES 2011&ndash, 2014 data (n = 9954). DS data were collected via an in-home interview, the NCI method was used to estimate distributions of total usual intakes from two 24 h recalls for food and beverages, after which DS were added. Food security status was categorized using the USDA Household Food Security Survey Module. Adults living in food insecure households had a higher prevalence of risk of inadequacy among both men and women for magnesium, potassium, vitamins A, B6, B12, C, D, E, and K, similar findings were apparent for phosphorous, selenium, and zinc in men alone. Meanwhile, no differences in the prevalence of risk for inadequacy were observed for calcium, iron (examined in men only), choline, or folate by food security status. Some DS users, especially food secure adults, had total usual intakes that exceeded the Tolerable Upper Intake Level (UL) for folic acid, vitamin D, calcium, and iron. In conclusion, while DS can be helpful in meeting nutrient requirements for adults for some micronutrients, potential excess may also be of concern for certain micronutrients among supplement users. In general, food insecure adults have higher risk for micronutrient inadequacy than food secure adults.

Protein-energy malnutrition (PEM)/undernutrition and frailty are prevalent, overlapping conditions impacting on functional and health outcomes of older adults, but are frequently unidentified and untreated in community settings in the United States. Using the World Health Organization criteria for effective screening programs, we reviewed validity, reliability, and feasibility of data-driven screening tools for identifying PEM and frailty risk among community-dwelling older adults. The SCREEN II is recommended for PEM screening and the FRAIL scale is recommended as the most promising frailty screening tool, based on test characteristics, cost, and ease of use, but more research on both tools is needed, particularly on predictive validity of favorable outcomes after nutritional/physical activity interventions. The Malnutrition Screening Tool (MST) has been recommended by one expert group as a screening tool for all adults, regardless of age/care setting. However, it has not been tested in US community settings, likely yields large numbers of false positives (particularly in community settings), and its predictive validity of favorable outcomes after nutritional interventions is unknown. Community subgroups at highest priority for screening are those at increased risk due to prior illness, certain demographics and/or domiciliary characteristics, and those with BMI 2 or 70 years or recent unintentional weight loss > 10% (who are likely already malnourished). Community-based health professionals can better support healthy aging by increasing their awareness/use of PEM and frailty screening tools, prioritizing high-risk populations for systematic screening, following screening with more definitive diagnoses and appropriate interventions, and re-evaluating and revising screening protocols and measures as more data become available.

BACKGROUND: Vitamin D is important for bone health; in 2014 it was the fifth most commonly ordered laboratory test among Medicare Part B payments. OBJECTIVES: The aim of this study was to describe vitamin D status in the US population in 2011–2014 and trends from 2003 to 2014. METHODS: We used serum 25-hydroxyvitamin D data from NHANES 2011–2014 (n = 16,180), and estimated the prevalence at risk of deficiency (

OBJECTIVES: To estimate total mean usual micronutrient intakes (inclusive of dietary supplements (DS)), Dietary Reference Intakes (DRI) adherence, and the % contribution of DS to total usual micronutrient intakes for U.S. adults (≥19y) using data from the 2011–2014 National Health and Nutrition Examination Survey (NHANES, n = 9474), by sex, age, and race and Hispanic origin groupings. METHODS: Dietary data were collected using two 24-hour recalls; DS data was collected via an in-home 30-day questionnaire that ascertained participants’ usage in the past 30 days. The National Cancer Institute Method was used to estimate mean total usual micronutrient intakes and the proportion of the population complying with DRI by population subgroups: sex, age, and race and Hispanic origin. RESULTS: DS contributed substantially to meeting the DRI recommendations for several key nutrients, including calcium, magnesium, folate, zinc, and vitamins C, D, B6, and K in both men and women. However, approximately half of U.S. adults still failed to meet the estimated average requirement (EAR) for magnesium (45%), and vitamins C (35%), K (45%), and D (63%), even with the inclusion of DS. The proportion of total usual intakes

OBJECTIVES: Little is known whether the prevalence of dietary supplement (DS) use among children varies by assessment method as it does among adults. We assessed the prevalence of use of different DS product types among U.S. children using four different combinations of assessment methods constructed from two instruments (i.e., frequency-based questionnaire and 24-hour dietary recall (24HR)). METHODS: DS use information is collected in the National Health and Nutrition Examination Survey (NHANES) via a 30-day frequency questionnaire in conjunction with an in-home inventory (Dietary Supplement and Prescription Medicine, DSMQ) and during up to two 24HR. NHANES 2013–2016 data were used to estimate the prevalence of use of any DS and selected types of DS products among 8369 children (≤18y) using four methods constructed from DSMQ and 24HR: 1) DSMQ; 2) 24HR day 1; 3) 24HR day 1 and day 2; and 4) DSMQ and ≥1 24HR. RESULTS: About one-third (34.4%) of children took at least one DS in the previous 30 days according to the DSMQ. This decreased to 21.0% when data from only the 24HR day 1 were used, increased to 26.2% when data from both the 24HR day 1 and day 2 were used, and increased further to 37.3% when data from the DSMQ and ≥1 24HR were combined. Similar patterns were found when stratified by age (

OBJECTIVES: Turmeric root (Curcuma longa) and its constituents, the curcuminoids, are widely reported to have anti-inflammatory effects. A recent meta-analysis found that 8 studies that met the review criteria “provide scientific evidence that supports the efficacy of turmeric extract…in the treatment of arthritis” but notes the small number of trials and “the methodological quality of the studies were not sufficient to draw definitive conclusions.” The objective of this project was to apply p-curve analysis to these trials, to assess the likelihood of biased data reporting or p-hacking, a common source of false positive reports. METHODS: PubMed was searched for English language reports of randomized, placebo-controlled clinical trials of turmeric- or curcuminoid-containing products for osteoarthritis or rheumatoid arthritis (henceforth arthritis) pain or other inflammatory conditions in arthritis patients. Trials in which curcumin was combined with other supplements or drugs were included. Data for primary outcomes from the retrieved papers were used to generate a p-curve. Where multiple primary outcomes were reported, or no primary outcome was specified, results for a well-validated arthritis scale were used for the analysis. RESULTS: Twelve randomized, double-blind, placebo-controlled clinical trials of curcumin for arthritis were identified and analyzed. Dates of publication ranged from 1991 to 2019, group sizes ranged from 12 to 80, doses, where specified, ranged from 180 to 1500 mg curcuminoids or turmeric extract per day, and treatment duration ranged from 6 to 36 weeks. The p-curve analysis did not reveal a left-skewed curve which would be diagnostic of p-hacking (more p-values concentrated around .04 and fewer low values) and thus does not suggest that p-hacking is present. CONCLUSIONS: Inspection of the distribution of p values for placebo-controlled clinical trials of curcumin-containing products for osteo- and rheumatoid arthritis in the PubMed database do not show evidence of extensive p-hacking. FUNDING SOURCES: NIH Office of Dietary Supplements.

OBJECTIVES: To estimate distributions of total usual vitamin D intakes from foods and supplements among U.S. adults, using four different methods of assessment. Usual intake is defined as long-term average daily intake. METHODS: Distributions of total usual vitamin D intakes were estimated from data provided by 9954 adults (≥19 y) from the 2011–2014 NHANES. Dietary and dietary supplement (DS) data were collected using two 24-hour recalls (24HR), and DS data were also collected via an in-home inventory that ascertained participants’ DS use in the past 30 days. The four methods used included: combined “add then shrink” (Method 1); combined “shrink then add” (Method 2); stratified “shrink then add” (Method 3); three-part (Method 4). Briefly, Method 1 analyzes DS users and nonusers together and includes DS use as a covariate in the model. Nutrient intake from foods and DS are “added” prior to applying usual intake procedures to “shrink” the total intake distribution. Method 2 combines DS users and nonusers identically, but “shrinks” the nutrient intake distribution from foods prior to incorporating nutrient intake from DS to produce total usual intakes. Method 3 also follows the “shrink then add” framework but stratifies DS users and nonusers separately in the model. Method 4 also stratifies DS users and nonusers but computes total usual intakes in three parts: 1) usual intake from foods for DS nonusers; 2) usual intake from foods for DS users; and 3) usual intake from DS for DS users. RESULTS: All methods following the “shrink then add” framework (i.e., methods 2- 4) resulted in similar estimated distributions of total usual vitamin D intakes; but Method 1, the “add then shrink” method, resulted in distributions that were wider as a result of inflated within-person variation. Among the “shrink then add” methods, the main differences existed between methods 2 and 3 vs. method 4, partly due to differences in modeling of DS intake information reported on 24HRs vs. the in-home inventory. CONCLUSIONS: Currently, no consensus exists on the best method for incorporating DS nutrients into usual intake models designed to estimate intake from foods and beverages. These findings support the notion that the “shrink then add” methods are more amenable to modeling when compared to “add then shrink.” FUNDING SOURCES: This work was supported by a grant from the National Institutes of Health.

This analysis characterizes use of dietary supplements (DS) and motivations for DS use among U.S. children (&le, 18 years) by family income level, food security status, and federal nutrition assistance program participation using the 2011&ndash, 2014 National Health and Nutrition Examination Survey data. About one-third (32%) of children used DS, mostly multivitamin-minerals (MVM, 24%). DS and MVM use were associated with higher family income and higher household food security level. DS use was lowest among children in households participating in the Supplemental Nutrition Assistance Program (SNAP, 20%) and those participating in the Special Supplemental Nutrition Assistance Program for Women, Infants, and Children (WIC, 26%) compared to both income-eligible and income-ineligible nonparticipants. Most children who used DS took only one (83%) or two (12%) products, although children in low-income families took fewer products than those in higher income families. The most common motivations for DS and MVM use were to &ldquo, improve (42% or 46%)&rdquo, or &ldquo, maintain (34 or 38%)&rdquo, health, followed by &ldquo, to supplement the diet (23 or 24%)&rdquo, for DS or MVM, respectively. High-income children were more likely to use DS and MVM &ldquo, to supplement the diet&rdquo, than middle- or low-income children. Only 18% of child DS users took DS based on a health practitioner&rsquo, s recommendation. In conclusion, DS use was lower among children who were in low-income or food-insecure families, or families participating in nutrition assistance programs.

BACKGROUND: Limited nationally representative data are available on dietary supplement (DS) use and resulting nutrient exposures among infants and toddlers. OBJECTIVE: This study evaluated DS use among US infants and toddlers to characterize DS use, estimate nutrient intake from DSs, and assess trends in DS use over time. METHODS: Using nationally representative data from NHANES (2007–2014) and trends over time (1999–2014), we estimated prevalence of DS use and types of products used for US infants and toddlers aged

The objective of this study was to estimate the prevalence of use and types of dietary supplements (DS) used by U.S. adults (&ge, 19 years) by sociodemographic characteristics: family income-to-poverty ratio (PIR), food security status, and Supplemental Nutrition Assistance Program (SNAP) participation using NHANES 2011&ndash, 2014 data (n = 11,024). DS use was ascertained via a home inventory and a retrospective 30-day questionnaire. Demographic and socioeconomic differences related to DS use were evaluated using a univariate t statistic. Half of U.S. adults (52%) took at least one DS during a 30-day period, multivitamin-mineral (MVM) products were the most commonly used (31%). DS and MVM use was significantly higher among those with a household income of &ge, 350% of the poverty level, those who were food secure, and SNAP income-ineligible nonparticipants across all sex, age, and race/ethnic groups. Among women, prevalence of use significantly differed between SNAP participants (39%) and SNAP income-eligible nonparticipants (54%). Older adults (71+ years) remained the highest consumers of DS, specifically among the highest income group (82%), while younger adults (19&ndash, 30 years), predominantly in the lowest income group (28%), were the lowest consumers. Among U.S. adults, DS use and the types of products consumed varied with income, food security, and SNAP participation.

Background: Previous data suggest that elevated serum total homocysteine (tHcy) may be a risk factor for bone fracture and osteoporosis. Nutritional causes of elevated tHcy are suboptimal B-vitamin status. To our knowledge, this is the first nationally representative report on the relation of B vitamins and bone health from a population with folic acid fortification. Objective: The purpose of this analysis was to examine the relation between B-vitamin status biomarkers and bone mineral density (BMD), risk of osteoporosis, and biomarkers of bone turnover. Design: We examined the relation of tHcy, methylmalonic acid (MMA), and serum/red blood cell folate and total-body and lumbar spine BMD in women aged ≥50 y participating in the NHANES 1999–2004 (n = 2806), a nationally representative cross-sectional survey. These are the only years with concurrent measurement of tHcy and whole-body dual-energy X-ray absorptiometry. We also examined B-vitamin biomarkers relative to bone turnover markers, bone alkaline phosphatase, and urinary N-terminal cross-linked telopeptide of type I collagen in a 1999–2002 subset with available data (n = 1813). Results: In comparison with optimal concentrations, women with elevated tHcy were older with lower serum vitamin B-12, red blood cell folate, and dietary micronutrient intakes and had significantly higher mean ± SE markers of bone turnover (bone alkaline phosphatase: 15.8 ± 0.59 compared with 14.0 ± 0.25 μg/L; urinary N-terminal cross-linked telopeptide of type I collagen: 48.2 ± 2.9 compared with 38.9 ± 0.90 nmol bone collagen equivalents per mmol creatinine/L). Elevated MMA (OR: 1.88; 95% CI: 1.10, 3.18) and tHcy (OR: 2.17; 95% CI: 1.14, 4.15) were related to increased risk of lumbar osteoporosis. When examined as a continuous variable, tHcy was negatively associated, serum folates were positively associated, and MMA and vitamin B-12 were not significantly associated with lumbar and total-body BMD. Conclusion: In this nationally representative population of older US women with high exposure to B vitamins through food fortification and dietary supplements, only elevated tHcy and MMA were independently associated with risk of lumbar spine osteoporosis.

Background: Multivitamin-mineral (MVM) products are the most commonly used supplements in the United States, followed by multivitamin (MV) products. Two randomized clinical trials (RCTs) did not show an effect of MVMs or MVs on cardiovascular disease (CVD) mortality; however, no clinical trial data are available for women with MVM supplement use and CVD mortality. Objective: The objective of this research was to examine the association between MVM and MV use and CVD-specific mortality among US adults without CVD. Methods: Anationallyrepresentativesample of adults fromthe restricted dataNHANESIII(1988‐1994;n= 8678; age$40y) were matched with mortality data reported by the National Death Index through 2011 to examine associations between MVM and MV use and CVD mortality by using Cox proportional hazards models, adjusting for multiple potential confounders. Results: We observed no significant association between CVD mortality and users of MVMs or MVs compared with nonusers; however, when users were classified by the reported length of time products were used, a significant association was found with MVM use of >3 y compared with nonusers (HR: 0.65; 95% CI: 0.49, 0.85). This finding was largely driven by the significant association among women (HR: 0.56; 95% CI: 0.37, 0.85) but not men (HR: 0.79; 95% CI: 0.44, 1.42). No significant association was observed for MV products and CVD mortality in fully adjusted models. Conclusions: In this nationally representative data set with detailed information on supplement use and CVD mortality data ;20 y later, we found an association between MVM use of >3 y and reduced CVD mortality risk for women when models controlled for age, race, education, body mass index, alcohol, aspirin use, serum lipids, blood pressure, and blood glucose/glycated hemoglobin. Our results are consistent with the 1 available RCT in men, indicating no relation with MVM use and CVD mortality. J Nutr doi: 10.3945/jn.114.204743.

The Academy of Nutrition and Dietetics recognizes the importance of including dietary supplements in assessing and planning dietary intakes.1 Dietary supplement (DS) use in the United States has increased markedly during the last 30 years and is now widespread across all segments of society.2,3,4,5,6 Today, over half of adults and a third of US children have used one or more DS within the past 30 days, with multi-vitamin, multi-mineral (MVMM) products especially common.7, 8 Since supplements are now major sources of several nutrients such as calcium and vitamin D in American diets, it is important for registered dietitians and nutritionists (RDNs) to include their contributions when assessing intakes or planning diets.9,10,11 Likewise, for national nutrition surveillance the contributions to nutrient intakes from supplements must be considered in order to identify groups at dietary risk because their intakes fall below the estimated average requirement (EAR) or above the upper tolerable intake level (UL).12 For example, when supplements are included in assessments, the proportion of the United States population that is below the EAR is much less for several vitamins11 and fewer women are “at risk” (defined as below the EAR) for folate intake than when they are not.13,14 For some nutrients, like folic acid, the UL is established based solely for the form that comes from fortificants in foods and in dietary supplements. RDNs, epidemiologists, and public health officials also need accurate dietary supplement databases in order to evaluate possible associations between nutrient intake and disease outcomes. The National Health and Nutrition Examination Survey (NHANES) dietary supplement label database contains label-derived information from supplement products that is updated every two years. Information contained in the database is driven by what is reported by survey participants. The currently available database contains supplement label information for products reported from 1999–2010. While the NHANES DS database provides useful information, it is not comprehensive and is more likely to contain commonly used supplements and less likely to contain infrequently used supplements.15 In fact, MVMM products account for only about half of all supplements used.3 Additionally, not all information from the label is recorded and released in the database. For example, the NHANES database does not contain information such as health claims, other ingredients and warning statements that may have been on the label.

No consistent definition exists for energy products in the United States. These products have been marketed and sold as beverages (conventional foods), energy shots (dietary supplements), and in pill or tablet form. Recently, the number of available products has surged, and formulations have changed to include caffeine. To help characterize the use of caffeine-containing energy products in the United States, three sources of data were analyzed: sales data, data from federal sources, and reports from the Drug Abuse Warning Network. These data indicate that sales of caffeine-containing energy products and emergency room visits involving their consumption appear to be increasing over time. Data from the National Health and Nutrition Examination Survey (NHANES) 2007–2010 indicate that 2.7% [standard error (SE) 0.2%] of the US population ≥1 year of age used a caffeine-containing energy product, providing approximately 150–200 mg/day of caffeine per day in addition to caffeine from traditional sources like coffee, tea, and colas. The highest usage of these products was among males between the ages of 19 and 30 years (7.6%, SE 1.0). Although the prevalence of caffeine-containing energy product use remains low overall in the US population, certain subgroups appear to be using these products in larger amounts. Several challenges remain in determining the level of caffeine exposure from and accurate usage patterns of caffeine-containing energy products.

OBJECTIVES: The purpose was to evaluate nutritional status, food security, and related health factors of older adults who were overweight or obese compared to those with a healthy weight. METHODS: Data from 2969 adults aged ≥60 years from NHANES 2011–2014 were analyzed. Participants were categorized by sex and body weight status as healthy weight (body mass index (BMI, kg/m(2)) 18.5–24.9), overweight (BMI 25–29.9), or obese (BMI ≥ 30); underweight individuals were excluded. Healthy Eating Index (HEI)-2015 scores and total usual micronutrient intakes from foods and dietary supplements were estimated using two 24-hour dietary recalls and the National Cancer Institute method. Nutritional biomarkers, including serum vitamin D, vitamin B-12, and methylmalonic acid, and cardiometabolic risk factors were also assessed. RESULTS: A substantial proportion of older adults (>30%) had intakes below Estimated Average Requirements (EAR) for calcium, magnesium, and vitamins C and D even with dietary supplements. Men and women with obesity had a higher prevalence of usual magnesium intakes

Background: Dietary supplements are used by one-third of children. We examined motivations for supplement use in children, the types of products used by motivations, and the role of physicians and health care practitioners in guiding choices about supplements. Methods: We examined motivations for dietary supplement use reported for children (from birth to 19 y of age; n = 8,245) using the National Health and Nutrition Examination Survey 2007–2010. Results: Dietary supplements were used by 31% of children; many different reasons were given as follows: to “improve overall health” (41%), to “maintain health” (37%), for “supplementing the diet” (23%), to “prevent health problems” (20%), and to “boost immunity” (14%). Most children (~90%) who use dietary supplements use a multivitamin–mineral or multivitamin product. Supplement users tend to be non-Hispanic white, have higher family incomes, report more physical activity, and have health insurance. Only a small group of supplements used by children (15%) were based on the recommendation of a physician or other health care provider. Conclusion: Most supplements used by children are not under the recommendation of a health care provider. The most common reasons for use of supplements in children are for health promotion, yet little scientific data support this notion in nutrient-replete children.

A reverse J-shaped association between serum 25-hydroxyvitamin D (25[OH]D) concentration and all-cause mortality was suggested in a 9-year follow-up (1991-2000) analysis of the Third National Health and Nutrition Examination Survey (NHANES III, 1988-1994).Our objective was to repeat the analyses with 6 years additional follow-up to evaluate whether the association persists through 15 years of follow-up.The study included 15 099 participants aged ≥ 20 years with 3784 deaths.Relative risk (RR) of death from all causes was adjusted for age, sex, race/ethnicity, and season using 2 Poisson regression approaches: traditional categorical and cubic splines. Results were given for 9 25(OH)D levels:20, 20 to 29, 30 to 39, 40 to 49, 50 to 59, 60 to 74, 75 to 99 (reference), 100 to 119, and ≥ 120 nmol/L.The reverse J-shaped association became stronger with longer follow-up and was not affected by excluding deaths within the first 3 years of follow-up. Similar results were found from both statistical approaches for levels20 through 119 nmol/L. Adjusted RR (95% confidence interval [CI]) estimates for all levels60 nmol/L were significantly1 compared with the reference group. The nadir of risk was 81 nmol/L (95% CI, 73-90 nmol/L). For 25(OH)D ≥ 120 nmol/L, results (RR, 95% CI) were slightly different using traditional categorical (1.5, 1.02-2.3) and cubic splines approaches (1.2, 0.9-1.4). The association appeared in men, women, adults ages 20 to 64 years, and non-Hispanic whites but was weaker in older adults. The study was too small to evaluate the association in non-Hispanic black and Mexican-American adults.A reverse J-shaped association between serum 25(OH)D and all-cause mortality appears to be real. It is uncertain whether the association is causal.

Food composition databases are critical to assess and plan dietary intakes. Dietary supplement databases are also needed because dietary supplements make significant contributions to total nutrient intakes. However, no uniform system exists for classifying dietary supplement products and indexing their ingredients in such databases. Differing approaches to classifying these products make it difficult to retrieve or link information effectively. A consistent approach to classifying information within food composition databases led to the development of LanguaL™, a structured vocabulary. LanguaL™ is being adapted as an interface tool for classifying and retrieving product information in dietary supplement databases. This paper outlines proposed changes to the LanguaL™ thesaurus for indexing dietary supplement products and ingredients in databases. The choice of 12 of the original 14 LanguaL™ facets pertinent to dietary supplements, modifications to their scopes, and applications are described. The 12 chosen facets are: Product Type; Source; Part of Source; Physical State, Shape or Form; Ingredients; Preservation Method, Packing Medium, Container or Wrapping; Contact Surface; Consumer Group/Dietary Use/Label Claim; Geographic Places and Regions; and Adjunct Characteristics of food.

Dietary supplement use has steadily increased over time since the 1970s; however, no current data exist for the U.S. population. Therefore, the purpose of this analysis was to estimate dietary supplement use using the NHANES 2003–2006, a nationally representative, cross-sectional survey. Dietary supplement use was analyzed for the U.S. population (≥1 y of age) by the DRI age groupings. Supplement use was measured through a questionnaire and was reported by 49% of the U.S. population (44% of males, 53% of females). Multivitamin-multimineral use was the most frequently reported dietary supplement (33%). The majority of people reported taking only 1 dietary supplement and did so on a daily basis. Dietary supplement use was lowest in obese adults and highest among non-Hispanic whites, older adults, and those with more than a high-school education. Between 28 and 30% reported using dietary supplements containing vitamins B-6, B-12, C, A, and E; 18–19% reported using iron, selenium, and chromium; and 26–27% reported using zinc- and magnesium-containing supplements. Botanical supplement use was more common in older than in younger age groups and was lowest in those aged 1–13 y but was reported by ~20% of adults. About one-half of the U.S. population and 70% of adults ≥ 71 y use dietary supplements; one-third use multivitamin-multimineral dietary supplements. Given the widespread use of supplements, data should be included with nutrient intakes from foods to correctly determine total nutrient exposure.