1. 1 Profiling Dietary Supplement Use: Current Data and Challenges Office of Dietary Supplements Conference Bioavailability of Nutrients and Other Bioactive Components of Dietary Supplements: Defining the Research Agenda January 5, 2000 James T. Heimbach, Ph.D., F.A.C.N. Mary M. Murphy, M.S., R.D. Judith S. Douglass, M.S., R.D. ENVIRON International Corporation

2. 2 2 Recent Private Surveys

3. 3 “The Growing Self-Care Movement” Telephone survey of 1000 food shoppers Interviewing February-March, 1999 Sponsored by Prevention Magazine and the Food Marketing Institute (FMI)

4. 4 “The Growing Self-Care Movement” (Prevention/FMI Survey) Products used to maintain health 1998 1999 OTC medications 85% 76% Vitamins & minerals 67% 72% Fortified foods NA 66% Herbal remedies 28% 36% Homeopathic remedies 15% 17%

5. 5 “The Growing Self-Care Movement” (Prevention/FMI Survey) Use toUse to preventtreatcolds Vitamins & minerals 60% 50% Herbal remedies 32% 34%

6. 6 “Consumer Perceptions and Use of Vitamins & Herbal Products” Telephone survey of 2,000 individuals age 18+ Interviewing winter, 1998-99 Sponsored by Leiner Health Care Products (used by permission)

7. 7 “Consumer Perceptions and Use of Vitamins & Herbal Products” (Leiner Health Care Products) Take a vitamin supplement daily55% –Multivitamin45% –Vitamin C24% –Vitamin E22% –Vitamin A 3% –Zinc 5% –Iron 3% Take an herbal product daily14% –Ginkgo 6% –Ginseng 5%

8. 8 “Consumer Perceptions and Use of Vitamins & Herbal Products” (Leiner Health Care Products) Vitamin/Herbal Why take productMineralProduct –General health 40% 41% –Prevent illness 30% 20% –Compensate for poor diet 26% -- –Improve energy -- 10% –Improve memory -- 10%

9. 9 National Nutrition Monitoring and Related Research Program (NNMRRP) Established by the National Nutrition Monitoring and Related Research Act of 1990 (Public Law 101-445) Encompasses “the set of activities necessary to provide timely information about the role and status of factors that bear on the contribution that nutrition makes to the health of the people of the United States.”

10. 10 National Nutrition Monitoring and Related Research Program: Five Components dietary, nutritional, and health status measurements food consumption measurements food composition measurements and nutrient data banks dietary knowledge and attitude measurements food supply and demand determinations

11. 11 National Nutrition Monitoring and Related Research Program: Keystone Surveys National Health and Nutrition Examination Surveys (DHHS/CDC/NCHS) NHANES III, 1988-1994 Nationwide Food Consumption Surveys (USDA/ARS) Continuing Surveys of Food Intakes by Individuals (CSFII 1994-96)

12. 12 National Nutrition Monitoring and Related Research Program: Other Major Surveys National Health Interview Surveys (DHHS/CDC/NCHS) Annual NHIS (since 1957) Split-sample design with variable modules Various surveillance surveys (DHHS/CDC) Health and Diet Survey (DHHS/FDA) Special surveys

13. 13 Third National Health and Nutrition Examination Survey (NHANES III) Period covered: –Fall 1988 to Fall 1994 Number of respondents: –33,994 interviewed –31,311 examined Data obtained: –food consumption measurements (1 day) –dietary, nutritional, and health status measurements

14. 14 Third National Health and Nutrition Examination Survey (NHANES III) Key indicators: –food & nutrient intakes –body measurements –hematological tests –biochemical analyses of whole blood & serum –blood pressures –EKGs –urine tests –bone densiometry –dental exams –gallbladder ultrasonography –cognitive & physical functioning

15. 15 1994-96 Continuing Surveys of Food Intakes by Individuals (1994-96 CSFII) Period covered: –January 1994 to December 1996 Number of respondents: –16,103 provided Day-1 data –15,303 provided 2 days of data Data obtained: –food consumption measurements on two nonconsecutive days

16. 16 Current Activities NHANES IV –similar to NHANES III –in field now –will become continuous 1998 CSFII Children’s Survey –January 1998 to December 1998 –methodology similar to 1994-96 CSFII –interviewed 5,300 children birth to 9 years –summary data released December 1999 –CD-ROMs available March 2000

17. 17 Future Plan: Unified NHANES/CSFII Scheduled to begin January 2001 Continuous survey 10,000 respondents per year –oversample African-American, Mexican-American, and low-income populations –5,000 CATIs providing 2 days of data –5,000 CAPIs in the MECs providing 1 day of data; 10% sub-sample providing 2 days CD-ROMs to be released approximately 15 months after completion of each year

18. 18 “… provide timely information …” Time between surveys-- NHANES I: 1971-74 NHANES II: 1976-80 NHANES III: 1988-94 NHANES IV: 1999- ? NFCS:1977-78 CSFII:1985-86 NFCS:1987-88 CSFII:1989-91 CSFII:1994-96 CSFII:2001- ?

19. 19 “… provide timely information …” Time from completion of survey fieldwork to release of data-- Old standard:2-? years New standard:14-15 months

20. 20 Nutrient Bioavailability Not a priority...

21. 21 Example: Iron Bioavailability “Non-heme iron absorption from a meal containing meat, fish, or chicken is about 4 times greater than from equivalent portions of milk, cheese, or eggs.” Rossander et al., 1979

22. 22 Enhancers and Inhibitors of Iron Absorption + Ascorbic acid + Heme iron + Other meat factors - Phytic acid - Oxylates - Polyphenols - Calcium phosphate

23. 23 Proposed Research Paradigm Link data on enhancers and inhibitors in foods with USDA food codes Determine, for each eating occasion, the amount of non-heme iron as well as enhancers and inhibitors Employ iron absorption model to estimate the amount of bioavailable iron

24. 24 “… factors that bear on the contribution that nutrition makes…” National data regarding consumer use of dietary supplements-- in CSFII in NHANES in NHIS

25. 25 Dietary Supplements in CSFII “How often, if at all, do you take any vitamin supplement in pill or liquid form? Would you say-- –Every day or almost every day, –Every so often, or –Not at all?”

26. 26 Dietary Supplements in CSFII “Which of these types of supplements do you usually take?” –multivitamin –multivitamin with iron or other minerals –vitamin C and iron –single vitamins or minerals (list) “Do you take a fish oil supplement?” “Do you take a fiber supplement?”

27. 27 Dietary Supplements in NHANES “Have you taken any vitamins or minerals in the past month?” “How many vitamin or mineral products do you take?” [list all supplements reported, ask to see container, record product name and manufacturer or distributor]

28. 28 Dietary Supplements in NHANES “How often did you take [PRODUCT] in the past month?” “How much [PRODUCT] did you take each time you took it?” “For how long have you been taking this type of product?”

29. 29 Dietary Supplements in NHIS Questions on use of vitamin and mineral supplements were included in 1987 and in 1992 –“Have you taken any vitamin or mineral supplement in the past year?” –Information was obtained on frequency of use of multivitamins and a variety of specific vitamin or mineral supplements

30. 30 Challenge little change BIG EFFECT

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33. 33 Challenge Product Identification –Brand A formulation? –Brand B formulation? –Brand X ????????????

34. 34 Challenge Product Characterization Product Consistency

35. 35 Challenge Survey Respondent Burden Necessary Nice to know Can’t put EVERYTHING into NHANES/CSFII!

36. 36 Recommendation Examine critically the data needs for dietary supplement ingredients-- –Detailed linkage with food/nutrient intake –General linkage with food/nutrient intake –No needed linkage with food/nutrient intake

37. 37 Some thoughts on taxonomy... Vitamins, minerals Other substances found primarily in foods Substances found in foods at low levels Substances not found in foods, but with known/suspected food/nutrient interactions Substances not found in foods and with no suspected food/nutrient interactions

38. 38 Estimated Usual Intake of Iron Diet Alone v. Diet + Supplements (Source: NHANES III)

39. 39 Estimated Usual Intake of Iron Diet Alone v. Diet + Supplements (Source: NHANES III)

40. 40 Intake of Vitamin C From Foods Females Age 9+ (Source: NHANES III)

41. 41 Use of Vitamin C Supplements Females Age 9+ (Source: NHANES III)

42. 42 Use of Vitamin C Supplements by Dietary Vitamin C Intake

43. 43 Thank You!