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Original Research
Multivitamin/Mineral Supplement Contribution to
Micronutrient Intakes in the United States, 2007–2010
Taylor C. Wallace, PhD, FACN, Michael McBurney, PhD, FACN, Victor L. Fulgoni III, PhD
Department of Scientific & Regulatory Affairs, Council for Responsible Nutrition, Washington, DC (T.C.W.); DSM Nutritional
Products North America, Parsippany, New Jersey (M.M.); Nutrition Impact, Battle Creek, Michigan (V.L.F.)
Key words: multivitamin/mineral, micronutrient, NHANES
Objective: Multivitamin/mineral (MVMM) supplements are the most common dietary supplements consumed
in the United States; however, intake data specific to how MVMM use contributes to micronutrient intakes among
Americans are absent from the current scientific literature.
Methods: This analysis aimed to assess contributions of micronutrients to usual intakes derived from MVMM
supplements and to compare those intakes to the dietary reference intakes for US residents aged ≥4 years
according to the National Health and Nutrition Examination Survey (NHANES) 2007–2010 (n=16,444).
We used the National Cancer Institute method to assess usual intakes of 21 micronutrients.
Results: Our results showed that 51% of Americans consumed MVMM supplements containing ≥9mi-
cronutrients. Large portions of the population had total usual intakes (food and MVMM supplement use) below
the estimated average requirement for vitamins A (35%), C (31%), D (74%), and E (67%) as well as calcium
(39%) and magnesium (46%). Only 0%, 8%, and 33% of the population had total usual intakes of potassium,
choline, and vitamin K above the adequate intake when food and MVMM use was considered. The percentage
of the population with total intakes greater than the tolerable upper intake level (UL) was very low for all nu-
trients; excess intakes of zinc were the highest (3.5%) across the population of all of the nutrients assessed in
NHANES.
Conclusions: In large proportions of the population, micronutrient sufficiency is currently not being achieved
through food solutions for several essential vitamins and minerals. Use of age- and gender-specific MVMM
supplements may serve as a practical means to increase the micronutrient status in subpopulations of Americans
while not increasing intakes above the UL.
INTRODUCTION
Multivitamin/mineral (MVMM) supplements have been pre-
viously reported to be the most common dietary supplement, reg-
ularly taken by roughly 40% of adults in the National Health and
Nutrition Examination Survey (NHANES) and 31% of children
in the National Health Interview Survey [1–3]. Approximately
71% of dietary supplement users reported taking an MVMM
supplement in a recent series of nationally representative surveys
of adults from 2007 to 2011 [4]. Many adult users of MVMM
products (48%) report their motivation for use of these dietary
supplements as being “to improve overall health.” Accordingly,
Address correspondence to: Taylor C. Wallace, PhD, 1828 L Street, NW, Suite 510, Washington, DC 20008. E-mail: taylor.wallace@me.com
T.C.W. is currently employed by the Council for Responsible Nutrition. M.M. is currently employed by DSM Nutritional Products North America. V.L.F. has no conflicts to
disclose.
Abbreviations: AI =adequate intake, DRI =dietary reference intake, EAR =estimated average requirement, IOM FNB =Institute of Medicine Food and Nutrition Board,
MVMM =multivitamin/mineral, NCHS =National Center for Health Statistics, NCI =National Cancer Institute, NHANES =National Health and Nutrition Examination
Survey, RDA =recommended dietary allowance, UL =tolerable upper intake level.
dietary supplement use has been previously reported to be higher
among those who report excellent or very good health [5]. The
long-term benefits of MVMM use have not been widely stud-
ied, and current disease prevention trials of MVMM supplement
use show mixed results. Results from the Physicians’ Health
Study II, the largest randomized controlled trial of 14,641 male
physicians who were given a daily MVMM supplement, showed
a significant modest reduction in total cancer but no effect on
cardiovascular outcomes over an average median follow-up of
11.2 years [6,7]. A meta-analysis of randomized controlled trials
found no statistically significant benefit or harm of MVMM sup-
plements on the risk of mortality from cardiovascular disease,
Journal of the American College of Nutrition, Vol. 33, No. 2, 94–102 (2014) C
American College of Nutrition
Published by Taylor & Francis Group, LLC
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Multivitamin/Mineral Intakes
cancer, or all causes [8]. Similarly, a systematic review of
epidemiological and clinical trials, including the Physicians’
Health Study II data, reported that MVMM use does not ap-
pear to increase all-cause mortality, cancer incidence or mor-
tality, or cardiovascular disease incidence or mortality and may
provide a modest protective benefit among healthy populations
[9]. Another recent systematic review and meta-analysis of ran-
domized controlled trials found that MVMM supplements en-
hanced immediate free recall memory but no other cognitive
domains [10]. Because secondary analyses (e.g., Age Related
Eye Disease Study II [AREDS2]) have identified significant
supplementation-specific benefits in the more poorly nourished
subpopulation, it is important to assess both food and MVMM
usage.
The definition of an MVMM supplement is fluid, and no
standard of identity currently exists because many specialized,
innovative, and unique formulations are present on the market
for subpopulations including but not limited to children, older
men, pregnant women, and those with a family history of age-
related eye disease. The lack of standard terminology and com-
position among products makes it difficult to study the effects
of MVMM supplements in a nonclinical setting (e.g., inferences
from epidemiological studies). In many analyses, including the
2006 “NIH State-of-the-Science Conference Statement on Mul-
tivitamin/Mineral Supplements in Chronic Disease Prevention,”
MVMM supplements have been defined as being “three or more
vitamins and minerals in combination” [11]. In 2006, Congress
defined MVMM as a dietary supplement that “is in compliance
with all applicable government quality standards and provides
at least 2/3 of the essential vitamins and minerals at 100 percent
of the daily value as determined by the Commissioner of Food
and Drugs” as reflected in the Older Americans Act [12].
The contribution of dietary supplements to the total nutrient
intakes of Americans has been previously reported [13]. Briefly,
dietary supplements have been shown to decrease the percentage
of the US population consuming less than the estimated average
requirement (EAR) for all nutrients. Excess intakes above the
tolerable upper intake level (UL) for most nutrients are low, ex-
cept in the case of niacin and zinc, for which 10.3% and 8.4%
of the general population have intakes above the UL when in-
takes from food and dietary supplements are considered [12].
However, intake data specific to mainstream MVMM use are
absent from the current scientific literature. A bioavailability
study of an MVMM supplement found positive postprandial
changes in plasma or serum concentrations, further indicating
that these common dietary supplements may serve as a vehicle to
decrease the prevalence of multiple micronutrient insufficiencies
and deficiencies in healthy adults. Tablet disintegration charac-
teristics (i.e., whole or crushed) did not limit absorption of the
micronutrients [14]. Consistent results were also reported in an
8-week study of 80 free-living older adults aged 50–87 years
who were already consuming a fortified diet and also under-
went daily supplementation with an MVMM supplement. The
authors concluded that an MVMM supplement formulated with
100% of the daily value was effective in decreasing the pres-
ence of suboptimal vitamin status in older adults and improving
their micronutrient status to levels associated with reduced risk
for several chronic diseases [15]. Because these studies suggest
that MVMM supplements are beneficial among healthy individ-
uals, and that dietary supplements in general are associated with
higher nutrient intakes among Americans, our study sought to
determine the contribution of these popular dietary supplement
products to micronutrient intakes of Americans.
MATERIALS AND METHODS
Study Population
The National Center for Health Statistics (NCHS) of the US
Centers for Disease Control and Prevention administers and col-
lects the NHANES, a nationally representative, cross-sectional
survey of noninstitutionalized, civilian US residents [16]. The
NHANES survey protocol was approved by the Research
Ethics Review Board of the NCHS. Written informed consent
was obtained for all survey participants. Data from NHANES
2007–2008 and 2009–2010 were combined for these analyses.
The combined sample included 16,444 participants who had
completed and provided 24-hour dietary intake data.
Micronutrient Intake from Food
Subjects aged <4 years and pregnant and/or lactating women
were excluded from these analyses. NHANES participants were
asked to complete 2 dietary recall interviews, with the first col-
lected in person by trained interviewers. Proxy respondents pro-
vided dietary information for young children and proxy-assisted
interviews were used for children aged 6–11 years. The sec-
ond dietary recall interview was completed by telephone 3–
10 days after the health examination. The US Department of
Agriculture (USDA) automated multiple-pass method was uti-
lized for both dietary recall interviews [17,18]. Questionnaires,
data sets, and related documentation from each NHANES anal-
ysis can be found on the NCHS NHANES website [19]. Vari-
ous USDA food composition databases were utilized to deter-
mine the micronutrient contribution of specific foods consumed
by NHANES participants. The USDA estimated the calcium
and vitamin D contents of NHANES foods in recipes by link-
ing the ingredients in survey food recipes to food composi-
tion data provided by the USDA National Nutrient Database
for Standard Reference [20]. Calcium intake calculated from re-
ported consumption of water in the NHANES analyses was also
included.
MVMM Supplements
Information on the use of MVMM supplements over the
30 days prior to the dietary recall interview was collected as
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Multivitamin/Mineral Intakes
part of the dietary supplement questionnaire [4]. Detailed in-
formation was obtained for each reported MVMM supplement,
including frequency of consumption (i.e., number of days the
product was taken in the past 30 days), duration of use (i.e., how
many days, weeks, months, or years the product was taken), and
amount normally taken per day on days it was taken over the
30-day period. The interviewer also examined each MVMM sup-
plement container and recorded complete product information
so that each product could be matched or entered into a database.
Average daily intakes obtained from MVMM supplements were
calculated using the number of days use was reported, the re-
ported amount taken daily, and the serving size unit from the
Supplement Facts Panel.
Definitions
To be included in the study, any given dietary supplement had
to include at least 100% of the recommended dietary allowance
or adequate intake (AI) for 9 vitamins and minerals with de-
fined dietary reference intake (DRI) values for which NHANES
2007–2008 and 2009–2010 collected intake data. This cutoff en-
abled us to eliminate dietary supplements that contain multiple
vitamins but do not provide a broad spectrum of essential vita-
mins and minerals (e.g., B-complex and single nutrient dietary
supplements) from the data set and allowed us to make sole in-
ference on the effect of MVMM supplements. The cutoff also
enabled us to look at both children and adult MVMM supple-
ments (i.e., children’s MVMM supplements often contain fewer
nutrients) without interference of dietary supplements with only
multiple vitamins. Users of MVMM supplements were defined
as those who reported taking an MVMM supplement as defined
above during the 30-day period. Nonusers were defined as those
individuals who did not report taking any dietary supplements
(including MVMM supplements) during the 30-day period; thus,
dietary intakes for nonusers were based on intakes from foods
alone. DRI age groups (4–8, 9–13, 14–18, 19–30, 31–50, 51–70,
and ≥71 years) were used to compare estimates of micronutrient
intakes. Children and adults were defined as those individuals
who were aged between 4 and 18 years and ≥19 years, unless
otherwise specified.
Comparison to DRI Values
The DRI are a family of nutrient reference values, defined
by the Institute of Medicine Food and Nutrition Board (IOM
FNB), intended to serve as a guide for good nutrition and to
provide the basis for the development of nutrient guidelines in
both the United States and Canada. The values differ for in-
dividuals based on age and gender (there are also values for
lactating and/or pregnant women; these populations as well as
those aged <4 years were not included in this study). The EAR
is used for planning and assessing diets of populations and, by
definition, is the average daily nutrient intake level estimated
to meet the requirements of half of the healthy individuals in a
group. The EAR serves as the basis for calculating the recom-
mended dietary allowance, defined as the average daily nutrient
intake level estimated to meet the requirements of 97%–98%
of the healthy individuals in a group [21,22]. Therefore, the
prevalence of inadequate dietary intakes was determined using
the EAR cut-point method (except for iron, which was assessed
using the probability method) as described previously [23] for
micronutrients and was reported as the percentage of the popula-
tion with usual intakes below the EAR. The prevalence (reported
as a percentage of the population) of dietary intakes above the
UL was also determined.
Statistical Analysis
The National Cancer Institute (NCI) method as previously
described [24] was used to determine estimates of usual intakes
from the diet for nonusers and users of MVMM supplements.
The covariates used in the NCI model were as follows: (1) se-
quence of 24-hour recall, (2) day of the week the 24-hour recall
was collected, and (3) MVMM supplement use. All statistical
analyses were performed with SAS software (version 9; SAS
Institute Inc., Cary, NC). SAS macros necessary to fit this model
and to perform the estimation of usual intake distributions as well
as additional details and resources regarding the NCI method are
available on the NCI website [25]. Sample weights were used to
account for differential response and noncoverage and to adjust
for planned overlapping of some groups. Survey weights were
also used to generate a nationally representative sample. Mean
dietary intakes between users and nonusers of MVMM supple-
ments, as well as the portion of the population that failed to meet
the EAR and exceeded the UL, were compared by computing a
z-statistic. Significance was set at <0.01.
RESULTS
Fifty-one percent of consumers in the NHANES 2007–2008
and 2009–2010 data sets took an MVMM supplement as pre-
viously defined. Table 1 illustrates lifestyle demographics for
child (4–18 years) MVMM users vs nonusers. Children who
used MVMM were more likely to be younger in age. Children
who used MVMM were also more likely to be non-Hispanic
white and have a higher poverty income ratio. Vigorous phys-
ical activity did not differ among children; however, those
who were users of MVMM were less likely to have sedentary
physical activity and more likely to exhibit moderate physical
activity.
Table 2 illustrates lifestyle demographics for adult
(≥19 years) MVMM users vs nonusers. Adult users of MVMM
supplements were more likely to be older in age, female, non-
Hispanic white, have attended college, and have a higher poverty
income ratio. These individuals were less likely to smoke and be
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Table 1. Lifestyle Demographics of Children (4–18 years) Mul-
tivitamin/Mineral Supplement Nonusers and Users1
Variable Nonusers (n=4489) Users (n=658)
Age (y)211.3 ±0.1 10.2 ±0.3
Female sex (%) 49.8 ±1.1 51.5 ±3.0
Race (%)
Mexican
American/Hispanic2
22.0 ±2.5 11.7 ±1.8
Non-Hispanic white256.7 ±2.8 74.0 ±2.4
Non-Hispanic black314.7 ±1.2 10.0 ±1.5
Poverty income ratio22.4 ±0.1 3.0 ±0.2
Current smoker (%) 7.2 ±0.6 5.7 ±1.3
Physical activity (%)
Sedentary310.6 ±0.7 7.5 ±1.0
Moderate423.4 ±1.0 20.8 ±2.8
Vigorous 66.04 ±1.1 71.7 ±3.0
Education (%)
High school graduate,
no college
3.0 ±0.4 2.6 ±0.9
Attended college 1.2 ±0.3 1.5 ±1.0
Alcohol consumer (%) 3.1 ±0.5 3.1 ±1.3
Alcohol (g/d) 0.5 ±0.2 0.5 ±0.3
1Data are presented as the value ±SE.
2p<0.001.
3p<0.01.
4p<0.05.
sedentary. Adult users of MVMM supplements were also more
likely to refrain from sedentary physical activity and to engage
in vigorous physical activity (Table 2). Smoking, alcohol use,
and education were low among both users and nonusers and not
significantly different.
Fifty-one percent of consumers in the NHANES 2007–2008
and 2009–2010 data sets took an MVMM supplement as previ-
ously defined. Table 1 illustrates lifestyle demographics for adult
(≥19 years) MVMM users vs nonusers. Adult users of MVMM
supplements were more likely to be older in age, female, non-
Hispanic white, have attended college, and have a higher poverty
income ratio. These individuals were less likely to smoke and be
sedentary. Adult users of MVMM supplements were also more
likely to refrain from sedentary physical activity and to engage in
vigorous physical activity (Table 1). Table 2 illustrates lifestyle
demographics for child (4–18 years) MVMM users vs nonusers.
Unlike adults, children who used MVMM were more likely
to be younger in age. Children who used MVMM were also
more likely to be non-Hispanic white and have a higher poverty
income ratio. Smoking, alcohol use, and education were low
among both users and nonusers and not significantly different.
Vigorous physical activity did not differ among children; how-
ever, those who were users of MVMM were less likely to have
sedentary physical activity and more likely to exhibit moderate
physical activity.
The percentage of individuals aged ≥4 years with total nutri-
ent intakes, including that from foods and MVMM supplements,
falling below the EAR was considerable for vitamin D (74%),
Table 2. Lifestyle Demographics of Adult (≥19 years) Multivi-
tamin/Mineral Supplement Nonusers and Users1
Variable Nonusers (n=8282) Users (n=3015)
Age (y)244.8 ±0.3 50.6 ±0.6
Female sex (%)249.8 ±0.6 55.3 ±1.2
Race (%)
Mexican
American/Hispanic2
15.8 ±2.0 7.9 ±1.1
Non-Hispanic white264.9 ±2.9 79.7 ±1.6
Non-Hispanic black213.1 ±1.3 7.8 ±0.9
Poverty income ratio22.8 ±0.1 3.4 ±0.1
Current smoker (%)226.6 ±1.0 12.9 ±1.1
Physical activity (%)
Sedentary324.1 ±0.9 19.7 ±1.2
Moderate 38.4 ±0.7 39.2 ±1.3
Vigorous437.5 ±1.0 41.2 ±1.7
Education (%)
High school graduate,
no college2
26.0 ±0.9 20. ±1.1
Attended college250.9 ±1.4 68.8 ±1.7
Alcohol consumer
(%)4
26.2 ±1.2 29.1 ±1.6
Alcohol (g/d) 10.8 ±0.6 10.6 ±0.8
1Data are presented as the value ±SE.
2p<0.001.
3p<0.01.
4p<0.05.
vitamin E (67%), magnesium (46%), calcium (39%), vitamin A
(35%), and vitamin C (31%). Approximately 8% and 33% of the
US population had total usual intakes that exceeded the AI for
total choline and vitamin K (Table 3); virtually no one exceeded
the AI for potassium. In contrast, smaller proportions of the
population had total usual intakes below the EAR (in decreas-
ing prevalence) for zinc, folic acid, vitamin B6, iron, copper,
thiamin, vitamin B12, riboflavin, phosphorus, niacin, and sele-
nium. Use of MVMM supplements decreased the percentage of
the population that fell below the EAR or AI for most of the nu-
trients measured in NHANES. Sodium, potassium, choline, and
phosphorus intakes were unaffected by MVMM consumption.
These effects of MVMM toward meeting EAR targets were more
pronounced in adults aged ≥19 years than in children 4–19 years
(Figs. 1–3). The percentages of children aged 4–18 years with
total nutrient intakes, including that from foods and MVMM
supplements, falling below the EAR were higher vs the general
population for vitamin D (80%), vitamin E (70%), and calcium
(49%). Significant portions of children aged 4–18 years also fell
below the EAR for magnesium (38%), vitamin A (26%), and
vitamin C (22%). Approximately 62%, 82%, and 100% of chil-
dren aged 4–18 years had total usual intakes falling below the AI
for vitamin K, total choline, and potassium (food and MVMM
use combined; data not shown).
The percentage of the population that exceeded the UL was
<1% for all nutrients except sodium and zinc. There were no
significant differences in the percentage of the population that
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Multivitamin/Mineral Intakes
Table 3. Usual Intakes from NHANES 2007–2010 Compared to DRI from Food Only and MVMM Use in Individuals Aged ≥4 years1
Percentiles
Nutrient Usual Intake 10 25 50 75 90 <EAR >UL
Mean ±SEM % ±SEM % ±SEM
Vitamin D (μg/d)2
Food 4.9 ±0.1 2.0 2.9 4.3 6.3 8.6 94.3 ±0.5 0.0 ±0.0
Food +MVMM 7.6 ±0.1 2.1 3.3 5.4 10.2 16.3 74.6 ±0.6 0.0 ±0.0
Calcium (mg/d)2
Food 987 ±9 567.1 721.4 932.2 1192.8 1478.0 44.1 ±0.9 0.3 ±0.1
Food +MVMM 1040 ±10 583.6 751.1 981.2 1263.5 1568.6 39.5 ±0.9 0.8 ±0.1
Vitamin A (μRAE/d)
Food 621 ±9 304.8 417.3 575.5 775.9 995.9 43.0 ±1.2
Food +MVMM 865 ±16 319.5 449.0 663.6 1108.9 1684.9 35.0 ±1.1
Retinol (μg/d)
Food 446 ±6 206.5 290.3 410.4 562.9 731.6 69.6 ±1.1 0.5 ±0.1
Food +MVMM 605 ±7 217.1 314.6 476.3 775.4 1161.9 55.3 ±0.8 1.7 ±0.1
Vitamin C (mg/d)
Food 84.0 ±1.2 30.8 47.3 73.0 108.5 151.2 38.9 ±1.2 0.0 ±0.0
Food +MVMM 109 ±3 33.2 53.0 87.4 137.8 197.9 31.2 ±1.2 0.0 ±0.0
Vitamin E (mg AT/d)
Food 7.4 ±0.1 4.1 5.3 7.0 9.1 11.4 88.5 ±0.7
Food +MVMM 14.8 ±0.5 4.2 5.7 8.0 15.0 34.2 67.1 ±0.9
Added α-tocopherol (mg/d)
Food 0.6 ±0.0 0.0 0.0 0.1 0.4 1.4 0.0 ±0.0
Food +MVMM 8.0 ±0.4 0.0 0.0 0.2 6.9 26.7 0.0 ±0.0
Thiamin (mg/d)
Food 1.6 ±0.0 1.0 1.2 1.5 1.9 2.3 4.7 ±0.6
Food +MVMM 2.9 ±0.1 1.1 1.3 1.8 2.5 3.4 3.8 ±0.5
Riboflavin (mg/d)
Food 2.2 ±0.0 1.3 1.6 2.0 2.6 3.2 2.1 ±0.2
Food +MVMM 3.5 ±0.1 1.3 1.7 2.3 3.3 4.4 1.8 ±0.2
Niacin (mg/d)
Food 24.7 ±0.2 15.0 18.5 23.4 29.6 36.3 1.1 ±0.3
Food +MVMM 29.7 ±0.3 15.7 19.8 26.5 36.3 46.6 1.0 ±0.3
Vitamin B6 (mg/d)
Food 2.0 ±0.0 1.1 1.4 1.9 2.4 3.0 9.5 ±0.8 0.0 ±0.0
Food +MVMM 3.5 ±0.1 1.2 1.5 2.1 3.3 5.0 7.4 ±0.7 0.1 ±0.0
Vitamin B12 (μg/d)
Food 5.3 ±0.1 2.7 3.6 4.9 6.5 8.4 2.5 ±0.3
Food +MVMM 11.1 ±0.5 2.9 4.0 5.8 9.3 20.1 2.1 ±0.3
Folate (μg DFE/d)
Food 542 ±6 314.4 398.5 513.4 654.6 807.5 9.5 ±0.6
Food +MVMM 709 ±9 330.5 430.1 590.6 902.9 1268.6 7.6 ±0.6
Folic acid (μg/d)
Food 200 ±3 91.3 128.7 183.1 252.8 330.3 0.4 ±0.1
Food +MVMM 298 ±5 101.6 148.0 226.9 393.8 605.0 2.5 ±0.2
Phosphorus (mg/d)
Food 1350 ±8 1082.8 1149.9 1259.2 1567.9 1710.1 1.0 ±2.9 0.0 ±0.0
Food +MVMM 1361 ±8 1079.4 1149.8 1286.6 1573.4 1725.7 1.0 ±2.1 0.0 ±0.0
Magnesium (mg/d)
Food 286 ±3 172.4 215.2 272.7 342.7 417.8 52.2 ±1.2
Food +MVMM 303 ±3 176.7 222.5 286.0 364.6 448.5 46.6 ±1.3
Mg from MVMM 16.5 ±0.7 0.0 0.0 0.0 1.7 50.0 0.2 ±0.1
Iron (mg/d)
Food 15.1 ±0.1 9.1 11.3 14.3 18.0 22.0 7.4 ±0.4 0.0 ±0.0
Food +MVMM 17.3 ±0.2 9.4 11.8 15.4 20.6 28.8 6.2 ±0.4 0.7 ±0.1
Zinc (mg/d)
Food 11.7 ±0.1 7.0 8.7 11.0 14.0 17.2 11.7 ±1.0 1.6 ±0.1
Food +MVMM 14.7 ±0.2 7.3 9.3 12.5 18.3 25.5 9.6 ±0.8 3.4 ±0.1
Copper (μg/d)
Food 1.3 ±0.0 0.8 0.9 1.2 1.5 1.9 4.2 ±0.6 0.0 ±0.0
Food +MVMM 1.6 ±0.0 0.8 1.0 1.3 1.9 2.9 3.8 ±0.5 0.4 ±0.1
(Continued on next page)
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Multivitamin/Mineral Intakes
Table 3. Usual Intakes from NHANES 2007–2010 Compared to DRI from Food Only and MVMM Use in Individuals Aged ≥4 years1
(Continued)
Percentiles
Nutrient Usual Intake 10 25 50 75 90 <EAR >UL
Selenium (mg/d)
Food 108 ±1 68.7 82.8 102.2 128.0 156.0 0.3 ±0.2 0.1 ±0.0
Food +MVMM 120 ±1 70.7 86.3 109.4 141.9 179.0 0.2 ±0.1 0.1 ±0.0
Nutrients with an AI
Potassium (mg/d2)
Food 2595 ±20 2052.8 2262.3 2491.9 3012.0 3222.9 100 ±0
Food +MVMM 2606 ±20 2044.6 2242.0 2498.1 3005.9 3238.4 100 ±1
Sodium (mg/d)
Food 3433 ±23 2572.8 2819.9 3066.8 3855.3 4920.3 0.1 ±0.3 97.5 ±8.3
Food +MVMM 3433 ±20 2575.7 2821.2 3067.3 3856.5 4915.2 0.1 ±0.3 97.6 ±7.4
Vitamin K (μg/d)
Food 85.2 ±2.1 37.9 52.8 75.5 106.7 144.3 66.9 ±1.8
Food +MVMM 90.4 ±2.2 38.3 54.3 79.4 114.4 156.0 62.8 ±1.9
Choline (mg/d)
Food 315 ±2.4 188.2 232.5 294.9 377.9 469.7 91.7 ±0.6 0.0 ±0.0
Food +MVMM 316 ±2.1 190.9 234.1 295.1 377.6 470.9 91.6 ±0.6 0.0 ±0.0
NHANES =National Health and Nutrition Examination Survey, DRI =dietary reference intake, MVMM =multivitamin/multimineral, EAR =estimated average
requirement, UL =tolerable upper intake level, SEM =standard error of the mean, RAE =retinol activity equivalents, AT =alpha-tocopherol, DFE =dietary folate
equivalents, AI =adequate intake.
1n=16,444.
2Nutrient identified by the 2010 Dietary Guidelines Advisory Committee as being a nutrient of public health concern.
Fig. 1. Percentage of US adults aged ≥19 years with vitamin (top)
and mineral (bottom) intakes below the EAR. The asterisk represents
nutrients with an adequate intake. n=11,297. (Color figure available
online.)
Fig. 2. Percentage of US children aged 4–18 years with vitamin (top)
and mineral (bottom) intakes below the EAR. The asterisk represents
nutrients with an adequate intake. n=2659. (Color figure available
online.)
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Fig. 3. Prevalence of children aged 4–8 years with micronutrient intakes
exceeding the UL from food only and MVMM use. n=1895. (Color
figure available online.)
exceeded the UL for sodium among users and nonusers of
MVMM supplements. The percentage of the population that ex-
ceeded the UL for zinc, including that from foods and MVMM
supplements, was <1% for all age groups except in children
aged 4–8 years (32%) and 9–13 years (4%; Fig. 3). Food alone
contributed to 22% of children aged 4–8 years exceeding the
UL for zinc; use of MVMM supplements increased this value to
32%.
DISCUSSION
It has previously been reported that dietary supplement use
has been on the rise over the past 30 +years [1–3]. To our knowl-
edge, this is the first report from NHANES showing that over
half the population uses MVMM. Previous data from NHANES
2003–2006 analyses defining an MVMM supplement as “a prod-
uct containing 3 or more vitamins and 1 or more minerals per
supplement” showed usage to be about 33% of the entire popu-
lation ≥1 year [1]. Comparison of these data might suggest an
increase in the use of MVMM. However, it is important to note
that the Dietary Supplement Questionnaire was introduced for
the first time during NHANES 2007–2008 [19], allowing more
accurate estimates of nutrient intakes from dietary supplements
in general but making data on dietary supplement usage from
previous NHANES data sets harder to fully compare. Our find-
ings on MVMM usage do more closely mimic those reported in
the multiethnic cohort [26].
Our findings on the lifestyle demographics of MVMM adult
users complement other studies of participants enrolled in the
Multiethnic Cohort Study [25], as well as in previous NHANES
analyses [1,2,5]. Similar observations on the lifestyle demo-
graphics of children have also recently been published. In par-
ticular, a study looking at the prevalence and predictors of chil-
dren’s supplement usage in the National Health InterviewSurvey
showed that children who used MVMM were more likely to be
non-Hispanic white and to be from families with higher parental
education and/or income status. Children who were reported
to have good, very good, or excellent health status were more
likely to use MVMM than were children with poor or fair health
[3]. Our study showed significant differences in children with
sedentary and moderate physical activity; however, it should be
noted that the variance between users and nonusers of MVMM
was not drastic, and the majority of children (67%) enrolled in
NHANES 2008–2010 reported vigorous physical activity.
MVMM usage significantly decreased the percentage of the
population who did not meet the EAR for most vitamins and
minerals measured in NHANES, although the reduction was not
extremely dramatic. Users were defined as those who had taken
an MVMM product during the 30 days prior to data collection.
This includes those who are daily and occasional/sporadic users.
Though the use of MVMM shifts intakes up (measured by usual
intake percentile), the shift is not great until the top 2 percentiles
(75% and 90%). These top 2 percentiles more than likely reflect
regular/daily users of MVMM products, whereas the lower per-
centiles more than likely reflect occasional/sporadic users. The
data emphasize the safety of MVMM because they contribute
nutritional (vs pharmacological) levels of nutrients. These data
also complement previous reports [2,4,5] that the best-nourished
people are making repeated good choices, in terms of both foods
and supplements, and it does not appear that individuals with
more adequate nutrient intakes use MVMM to compensate for
poor dietary habits.
MVMM usage did not contribute to excessive intakes above
the UL across the population as a whole, except in the case
of zinc, which was driven by excessive intakes among children
4–8 years. The UL for children are generally extrapolated down
using safety data from clinical studies of healthy adults. At the
time the IOM FNB released the DRI for zinc, there was only
one case report of a zinc-induced copper deficiency anemia in
a young child [27]. There were no published studies of adverse
effects of zinc on copper status in children or adolescents at the
time [27]. Thus, our data would call for more research on the ad-
verse health effects, if any, from intake levels exceeding the UL
for zinc. It might also suggest that the IOM FNB consider revis-
iting the DRI for zinc [28]. Similarly, MVMM supplementation
contributed to excess copper intakes of <5% in children age
4–8 years (Fig. 3); however, this was not large enough to affect
the entire population.
A limitation of this article is that the estimates relied on self-
reported dietary data for both nutrient intakes from foods and
MVMM. The models that we applied also relied on assumptions
that reported nutrient intakes from food sources on the 24-hour
recalls were unbiased, and the self-reported dietary supplement
intake reflected the true long-term MVMM intake patterns. Al-
though the dietary supplement data are self-reported, 85% of the
time, NHANES interviewers saw the dietary supplement bottles
and labels that participants reported using to verify accuracy.
Furthermore, estimates of vitamins and minerals contributed by
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Multivitamin/Mineral Intakes
dietary supplements depended on the label declarations rather
than analytic values. The oversampling of Mexican American
population in the NHANES 2007–2010 data sets [16] could
have affected the outcomes of this study, given that non-Hispanic
white individuals have consistently shown higher rates of dietary
supplement and MVMM use compared to other racial groups in
this study and others [1,2,26]. We did not present data for preg-
nant and/or lactating females and this information is virtually
unknown because of the small sample size of this population
among NHANES participants. The data presented in this article
should be interpreted with these limitations in mind.
CONCLUSION
Micronutrient sufficiency is not currently being achieved
through food solutions in large portions of the population.
Nutrient-dense foods such as fruits, vegetables, legumes, whole
grains, low- or nonfat dairy products, and lean meats are the pre-
ferred means of obtaining recommended intakes of micronutri-
ents. Nevertheless, MVMM supplements contribute to a greater
number of individuals meeting their recommended intakes of
almost all micronutrients measured by NHANES. Use of age-
and gender-specific MVMM supplements may be advantageous
in generally healthy populations when the diet is not sufficient
because they rarely led to excessive intakes when consumed
as directed. Ideally, formulations and amounts of vitamins and
minerals in MVMM should be used to help meet, but not ex-
ceed, DRI recommendations to best fit the nutrient needs of the
population.
Author’s Contributions
T.C.W., M.M., and V.L.F. designed research, analyzed data,
and wrote the article. V.L.F. conducted the research. All authors
read and approved the final article.
Funding
Source of financial support: Council for Responsible Nutri-
tion.
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Received July 19, 2013; revision accepted September 17, 2013.
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