dietary supplement use and its micronutrient …
TRANSCRIPT
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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
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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
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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
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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
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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
Jun S, Gahche JJ, Potischman N, Dwyer JT, Guenther PM, Sauder KA, et al. 2020, Obstetrics & Gynecology. doi: 10.1097/AOG.0000000000003657
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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)
*
*
Jun S, Gahche JJ, Potischman N, Dwyer JT, Guenther PM, Sauder KA, et al. 2020, Obstetrics & Gynecology. doi: 10.1097/AOG.0000000000003657
* Significant linear trend across PIR categories (p<.001).
Family Income-to-poverty Ratio (PIR)
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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)
Jun S, Gahche JJ, Potischman N, Dwyer JT, Guenther PM, Sauder KA, et al. 2020, Obstetrics & Gynecology. doi: 10.1097/AOG.0000000000003657
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
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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
Jun S, Gahche JJ, Potischman N, Dwyer JT, Guenther PM, Sauder KA, et al. 2020, Obstetrics & Gynecology. doi: 10.1097/AOG.0000000000003657
a
b
*Estimates with different letter superscripts are significantly different at P<0.0167
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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
Jun S, Gahche JJ, Potischman N, Dwyer JT, Guenther PM, Sauder KA, et al. 2020, Obstetrics & Gynecology. doi: 10.1097/AOG.0000000000003657
a
ba,b
a
ba,b
a
bb
*Estimates with different alphabets are significantly different at P<0.0167
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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
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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
Jun S, Gahche JJ, Potischman N, Dwyer JT, Guenther PM, Sauder KA, et al. 2020, Obstetrics & Gynecology. doi: 10.1097/AOG.0000000000003657
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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
Jun S, Gahche JJ, Potischman N, Dwyer JT, Guenther PM, Sauder KA, et al. 2020, Obstetrics & Gynecology. doi: 10.1097/AOG.0000000000003657
*Estimates with different alphabets are significantly different at P<0.0167
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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
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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
(%)Jun S, Gahche JJ, Potischman N, Dwyer JT, Guenther PM, Sauder KA, et al. 2020, Obstetrics & Gynecology. doi: 10.1097/AOG.0000000000003657
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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
(%)Jun S, Gahche JJ, Potischman N, Dwyer JT, Guenther PM, Sauder KA, et al. 2020, Obstetrics & Gynecology. doi: 10.1097/AOG.0000000000003657
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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
(%)
Jun S, Gahche JJ, Potischman N, Dwyer JT, Guenther PM, Sauder KA, et al. 2020, Obstetrics & Gynecology. doi: 10.1097/AOG.0000000000003657
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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)
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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.
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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.
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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.
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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
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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.
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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