3.3 Supplements

Regulations and Recommendations for the Use of Supplements

Eating a diet with fresh and minimally processed foods is the best source of vitamins and minerals. However, even people with healthy eating habits sometimes need help to bridge occasional nutrient gaps, and supplements may help.

Deciding on the right vitamin-mineral supplement can be difficult, considering that hundreds of different types are available and no real guidance is provided at the point of sale (NIH, 2018). With almost 60% (Mishra et al., 2021) of the population taking multiple vitamin and mineral supplements, guidance is important. People who are more likely to need a supplement include those with the following characteristics (Weyh et al., 2022):

• With restricted diets
• Who are pregnant
• With loss of appetite due to sickness, injury, or surgery—note that vitamin/mineral supplements alone do not provide calories or protein needed for healing
• With severe food allergies resulting in a restricted diet
• With a depleted immune system

Broadly, vitamin-mineral supplements are divided into three main groups: basic, high-potency, and specialized (Table 3.6). Examples of when each group would apply include:

• Basic—Individuals needing to bridge occasional vitamin and mineral gaps.
• High-potency—Pregnant women have higher iron and folate needs and need a diet formulated for prenatal care.
• Specialized—Clients with age-related macular degeneration (AMD) may need to supplement with specific vitamins and minerals: vitamin C (500 mg), vitamin E (400 IU), beta-carotene (15 mg), zinc (80 mg), and copper (2 mg), which is effective in slowing AMD (NIH-National Center for Complementary and Integrative Health, 2018; NIH, 2023).

Vitamin-mineral supplements fall under the regulatory powers of the FDA. However, the weak regulation and the vast array of supplements can confuse the consumer. The Dietary Supplement Health and Education Act (DSHEA) of 1994 altered the FDA’s authority to regulate dietary supplements (NIH Office of Dietary Supplements, 1994). Under DSHEA, the FDA does not authorize or evaluate dietary supplements for safety or effectiveness before reaching store shelves; unfortunately, this makes a “buyer beware” situation. Vitamin manufacturers can lawfully introduce dietary supplements without even notifying the FDA. Since DSHEA was enacted, the dietary supplement market has exploded, with the number of products multiplying nearly 20 times since 1994 (FDA, 2022).

Supplements and Nutritional Plans

Nurses should take a food-first approach to vitamins and minerals as the most prudent advice for clients. Food has multiple advantages over a manufactured pill by providing complex carbohydrates, fiber, protein, unsaturated fats, and antioxidants.

Table 3.7 is an example of a food-first approach with a diet full of vitamins and minerals from dairy, legumes, lean meat, nuts, fish, fruits, and vegetables. A vitamin- and mineral-rich daily menu could be as simple as the following meals:

• Breakfast—cereal with 5 g or less of added sugar, low-fat animal or plant milk (fortified with calcium and Vitamin D), and a banana
• Lunch—carrot sticks, a tuna sandwich on whole wheat bread, and orange sections
• Snack—roasted almonds
• Dinner—broiled pork chop, collards, and lightly salted sweet potato fries (air-fried)

According to the National Institutes of Health (NIH-National Center for Complementary and Integrative Health, 2018), supplement manufacturers can make three health-related claims on their labels:

• Health—describes a relationship between a food, food component, or dietary supplement ingredient and reducing the risk of a specific disease or health-related condition
• Nutrient—describes the relative amount of a nutrient or dietary substance in a product
• Structure or function—describes how a product may affect the organs or systems of the body and cannot mention any specific disease

The dosage of specific vitamin and mineral supplements a client should consume will vary because the Recommended Dietary Allowance (RDA) differs based on age and sex. For example, note the differences in recommended daily iron intake for each of these groups:

• Adolescent (age 12 to 18 years) female: 15 mg
• Adolescent (age 12 to 18 years) male: 11 mg
• Adult (age 18 plus years) female: 18 mg
• Adult (age 18 plus years) male: 8 mg

Because of specific needs, vitamin-mineral supplements are customized and marketed to population segments based on activity and age. For example, vitamins for children sport bright and catchy labels, gummy textures, and fruity tastes. Prenatal vitamins often have labels with pastel colors. Supplements for older adults are packaged in silver labeled bottles. Vitamin-mineral supplements can also be found as liquid drinks, including water, milk, and coffee.

Clients may ask if they need a vitamin-mineral supplement. There is little scientific support for taking a vitamin-mineral supplement when no deficiency signs and symptom exist (Seres, 2023); foods provide many vitamins, minerals, and phytochemicals and are more bioavailable than those found in supplements (Harguth, 2022). In some situations, vitamin-mineral supplements are essential for good health, but promoting food as the first line of health defense is strongly supported by science and health professionals.

Recommended Dietary Allowance

The RDAs are published by the Food and National Academies of Sciences every 5–10 years. RDAs were developed during World War II for nutritional guidance in feeding soldiers and food relief in the U.S. and internationally. They were set at the minimum level for good health and not every nutrient has an RDA (Murphy et al., 2016). The nutrients listed in the RDA are used as a goal for healthy individuals at every age. They are preventative in nature and not meant to be treatment for disease.

Dietary Guidelines are updated every 5 years; they help interpret and apply the RDAs to dietary patterns. In 1985, the Dietary Guidelines scientific report supporting their recommendations totaled 19 pages. In the 2020 version, the total was over 800 pages, demonstrating the prolific research occurring over the past 40 years on vitamins and minerals, dietary patterns, and health. The 2020–2025 Dietary Guidelines’ call to action “Make Every Bite Count” includes four overarching values:

• Follow a healthy dietary pattern at every life stage.
• Customize and enjoy nutrient-dense food and beverage choices to reflect personal preferences, cultural traditions, and budgetary considerations.
• Focus on meeting food group needs with nutrient-dense foods and beverages and stay within calorie limits.
• Limit foods and beverages higher in added sugars, saturated fat, and sodium, and limit alcoholic beverages (U.S. Department of Agriculture and U.S. Department of Health and Human Services, 2020).

These Dietary Guidelines are reflected throughout this chapter as nutrient-dense foods are emphasized over supplements.