Regan Bailey, Ph.D., M.P.H., R.D.Professor of Nutrition Science
Purdue University
DIETARY SUPPLEMENT USE AND ITS MICRONUTRIENT CONTRIBUTION DURING
PREGNANCY AND LACTATION IN THE UNITED STATES
Data from 2 Publications
NHANES 2001 - 2014• Usual total nutrient
intakes of pregnant women in the U.S.
NHANES 1999-2014• Dietary supplement use,
product type, doses, etc.o Pregnanto Lactatingo Not pregnant, not lactating
Bailey RL, Pac SG, Fulgoni VL, Reidy KC, Catalano PM.2019, JAMA Network Open 2(6): e195967.
Jun S, Gahche JJ, Potischman N, Dwyer JT, Guenther PM, Sauder KA, et al. 2020, Obstetrics & Gynecology. doi: 10.1097/AOG.0000000000003657
NHANES Methods
• Nationally-representative sample of U.S. residents
• In home interview oDemographic and questionnaire collectedoProduct inventory for dietary supplements
• Medical examination centero Clinical and24-hour dietary recall
• Follow up telephone callo 24-hour dietary recall
The majority of pregnant and lactating
women use dietary supplements
•77% of pregnant women •70% of lactating women•45% of non-pregnant, non-lactating women
Bailey et al. (2019), JAMA Network Open 2(6): e195967; Jun S, Gahche JJ, Potischman N, Dwyer JT, Guenther PM, Sauder KA, et al. 2020, Obstetrics & Gynecology. doi: 10.1097/AOG.0000000000003657
Prevalence (%) of dietary supplement use by younger (20-34y) and older (35-44y) pregnant women in the United States, NHANES 1999-2014
75.2
62.9
88.1
70.8
Any supplement Prenatal supplement
Diet
ary
supp
lem
ent u
se (%
)
20-34 years of age (n=1,159)
35-44 years of age (n=155)
a
*Estimates with different letters superscripts are significantly different at P<0.05.
b
Jun S, Gahche JJ, Potischman N, Dwyer JT, Guenther PM, Sauder KA, et al. 2020, Obstetrics & Gynecology. doi: 10.1097/AOG.0000000000003657
Prevalence (%) of dietary supplement use by 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)
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
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
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
Prevalence of reasons for dietary supplement use among pregnant and lactating women (20-44y) in the US, NHANES 2007-2014 (n=330)
10.9 6.31.1
9.9 6.8
16.1 22.8 30.6 10.310
47.4 39.8
11.541.7
24.4
Pregnant (n=246) Lactating (n=84) NPNL (n=4,655) Pregnant (n=246) Lactating (n=84)
Diet
ary
supp
lem
ent u
se (%
)
Recommended by a healthcare providerTook on ownMotivation unknown
Any supplement Prenatal supplementJun S, Gahche JJ, Potischman N, Dwyer JT, Guenther PM, Sauder KA, et al. 2020, Obstetrics & Gynecology. doi: 10.1097/AOG.0000000000003657
Percentages of women (20-44y) using dietary supplements containing specified vitamins by pregnancy and lactation status in the United States, NHANES 1999-2014
Pregnant women(n=1,314)
Lactating women(n=297)
Non-pregnant andnon-lactating women
(n=8,096)Vitamin A 40.3 ± 2.2 a 41.6 ± 3.7 a 22.0 ± 0.6 b
Thiamin 69.4 ± 2.2 a 63.7 ± 3.4 a 30.4 ± 0.7 b
Riboflavin 69.4 ± 2.2 a 63.7 ± 3.4 a 30.4 ± 0.7 b
Niacin 69.6 ± 2.2 a 63.9 ± 3.4 a 31.2 ± 0.7 b
Vitamin B6 72.8 ± 2.1 a 65.1 ± 3.4 a 32.7 ± 0.7 b
Folic acid 73.3 ± 2.1 a 65.1 ± 3.4 a 32.9 ± 0.7 b
Vitamin B12 69.9 ± 2.1 a 63.9 ± 3.5 a 32.9 ± 0.7 b
Vitamin C 73.3 ± 2.0 a 64.6 ± 3.4 a 35.5 ± 0.8 b
Vitamin D 71.7 ± 2.0 a 66.8 ± 3.3 a 33.1 ± 0.7 b
Vitamin E 72.0 ± 2.0 a 64.0 ± 3.5 a 32.6 ± 0.7 b
Choline 4.9 ± 1.1 a 7.6 ± 2.1 a 5.2 ± 0.3 a
Jun S, Gahche JJ, Potischman N, Dwyer JT, Guenther PM, Sauder KA, et al. 2020, Obstetrics & Gynecology. doi: 10.1097/AOG.0000000000003657
Percentages of women (20-44y) using dietary supplements containing specified 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
Pregnant women- median intake from supplements, % of RDA and UL
65.3
64.1
33.3
19.7
14.3
13.2
2.2
9.8
12.8
5.0
7.9
2.5
13.4
0.3
0 10 20 30 40 50 60 70
Vitamin D
Iodine
Selenium
Calcium
Phosphorous
Magnesium
Choline*
UL RDA
(%)Jun S, Gahche JJ, Potischman N, Dwyer JT, Guenther PM, Sauder KA, et al. 2020, Obstetrics & Gynecology. doi: 10.1097/AOG.0000000000003657
296.2
218.3
189.1
136.8
128.6
121.4
116.7
110.0
101.9
78.6
52.0
2.6
5.0
56.6
61.1
0 50 100 150 200 250 300
Vitamin B12
Folic acid
Zinc
Vitamin B6
Thiamin
Riboflavin
Vitamin C
Niacin
Iron
UL RDA
Pregnant women- median intake from dietary supplements, % of RDA and UL
(%)Jun S, Gahche JJ, Potischman N, Dwyer JT, Guenther PM, Sauder KA, et al. 2020, Obstetrics & Gynecology. doi: 10.1097/AOG.0000000000003657
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
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
Pregnancy DataNHANES 2001-2014
• Two 24-hour dietary recalls
• National Cancer Institute (NCI) method was used to produce usual intakes and prevalence of meeting/exceeding the DRI
• Estimated Average Requirement (EAR, %<EAR)Adequate Intake (AI, %>AI)Tolerable Upper Intake Level
(UL, %>UL)
Total usual intakes (foods, beverages, supplements)
% < EAR• Magnesium (48%)• Vitamin D (46%)• Vitamin E (43%)• Iron (36%)• Vitamin A (16%)• Folate (16%)• Calcium (13%)• Vitamin C (12%)• Vitamin B6 (11%)• Zinc (11%)
% > Adequate Intake• Vitamin K (48%)• Potassium (42%)• Choline (8 %)
% > UL*• Sodium (95%)• Folic Acid (33%)• Iron (28 %)• Zinc (7%)• Calcium (3*)
* For all nutrients other than sodium UL estimates are for supplement users only
Bailey et al. (2019), JAMA Network Open 2(6): e195967.
35
95
0 0
80
0 05
14
4740
0102030405060708090
100
<EAR <EAR >UL >UL
Folate Iron Folic Acid Iron
% o
f pre
gnan
t wom
enFood: Non-UsersFood: UsersTotal: Users
Prevalence (SE) of usual nutrient intake distributions <EAR and >UL for folate/folic acid and iron stratified by dietary supplement use
Bailey et al. (2019), JAMA Network Open 2(6): e195967.
Limitations• Small sample sizes and self-reported dataoTotal intake data for lactating women is largely unknown
• Iodine contributions from foods are not available
oNHANES 1999-2006: mean urinary iodine content was 148 μg/L, lower than WHO cut off for “insufficiency” (<150 μg/L)
• Our team did not publish data on omega-3 fatty acid use or other product typeso 0.6% of childbearing-age women and 7.3% of pregnant women reported use of
DHA/EPA dietary supplements NHANES 2003-2014, no differences in DHA/EPA from diet alone
Gahche JJ, Bailey RL, Mirel LB, Dwyer JT. Journal of Nutrition, 2013; 143:872-877.
Thompson M, Nicholas H, [...], and Nordgren TM. Nutrients. 2019 Jan; 11(1): 177.
Summary and Conclusions
• Most pregnant and lactating women use dietary supplements
• Dietary supplement use varies by age, race/ethnicity, family income, and trimester of pregnancy
• The “doses” of micronutrients provided exhibit considerable variability
• Dietary supplements help consumers meet the recommended targets, but also contribute to potentially excessive intakes for certain nutrients
Summary and Conclusions• Many pregnant women do not consume enough of
key nutrients; specifically iron, potassium, calcium, magnesium, zinc, and vitamins A, C, D, E, K, B6, folate, and choline - even with the use of dietary supplement.
• Almost all pregnant women are at risk of excessive consumption of sodium, and many are at risk of excessive consumption of folic acid and iron, especially among dietary supplement users.
• Improved dietary guidance to help pregnant [and potentially lactating] women meet and not exceed dietary recommendations is warranted.
Thanks and Acknowledgements• Patrick Catalano• Johanna Dwyer• Victor Fulgoni• Jaime Gahche• Patricia Guenther• Shinyoung Jun• Kathleen Reidy• Susan Pac• Nancy Potischman• Kate Sauder
Shinyoung Jun Peishan ZouAlex CowanAnita Panjwani
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