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Vitamins and Minerals

Vitamins and minerals are micronutrients required by the body to carry out a range of normal functions. However, these micronutrients are not produced in our bodies and must be derived from the food we eat.

Vitamins are organic substances that are generally classified as either fat soluble or water soluble. Fat-soluble vitamins ( vitamin A , vitamin D , vitamin E , and vitamin K ) dissolve in fat and tend to accumulate in the body. Water-soluble vitamins ( vitamin C and the B-complex vitamins , such as vitamin B6 , vitamin B12 , and folate ) must dissolve in water before they can be absorbed by the body, and therefore cannot be stored. Any water-soluble vitamins unused by the body is primarily lost through urine.

Minerals are inorganic elements present in soil and water, which are absorbed by plants or consumed by animals. While you’re likely familiar with calcium , sodium , and potassium , there is a range of other minerals, including trace minerals (e.g. copper , iodine , and zinc ) needed in very small amounts.

In the U.S., the National Academy of Medicine (formerly the Institute of Medicine) develops nutrient reference values called the Dietary Reference Intakes (DRIs) for vitamins and minerals. [1] These are intended as a guide for good nutrition and as a scientific basis for the development of food guidelines in both the U.S. and Canada. The DRIs are specific to age, gender, and life stages, and cover more than 40 nutrient substances. The guidelines are based on available reports of deficiency and toxicity of each nutrient. Learn more about vitamins and minerals and their recommended intakes in the table below.

What about multivitamins?

A diet that includes plenty of fruits, vegetables , whole grains , good protein packages , and healthful fats should provide most of the nutrients needed for good health. But not everyone manages to eat a healthful diet. Multivitamins can play an important role when nutritional requirements are not met through diet alone. Learn more about vitamin supplementation .

Did you know? 

Vitamins and their precise requirements have been controversial since their discovery in the late 1800s and early 1900s. It was the combined efforts of epidemiologists, physicians, chemists, and physiologists that led to our modern day understanding of vitamins and minerals. After years of observation, experiments, and trial and error, they were able to distinguish that some diseases were not caused by infections or toxins—a common belief at the time—but by vitamin deficiencies. [2] Chemists worked to identify a vitamin’s chemical structure so it could be replicated. Soon after, researchers determined specific amounts of vitamins needed to avoid diseases of deficiency.

In 1912, biochemist Casimir Funk was the first to coin the term “vitamin” in a research publication that was accepted by the medical community, derived from “vita” meaning life, and “amine” referring to a nitrogenous substance essential for life. [3] Funk is considered the father of vitamin therapy, as he identified nutritional components that were missing in diseases of deficiency like scurvy (too little vitamin C ), beri-beri (too little vitamin B1 ), pellagra (too little vitamin B3 ), and rickets (too little vitamin D ). The discovery of all vitamins occurred by 1948.

Vitamins were obtained only from food until the 1930s when commercially made supplements of certain vitamins became available. The U.S government also began fortifying foods with specific nutrients to prevent deficiencies common at the time, such as adding iodine to salt to prevent goiter, and adding folic acid to grain products to reduce birth defects during pregnancy. In the 1950s, most vitamins and multivitamins were available for sale to the general public to prevent deficiencies, some receiving a good amount of marketing in popular magazines such as promoting cod liver oil containing vitamin D as bottled sunshine.

• Dietary Reference Intakes for Calcium, Phosphorous, Magnesium, Vitamin D, and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline (1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000); Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc (2001); and Dietary Reference Intakes for Calcium and Vitamin D (2011) . These reports may be accessed via www.nap.edu .
• Semba RD. The discovery of the vitamins. Int J Vitam Nutr Res . 2012 Oct 1;82(5):310-5.
• Piro A, Tagarelli G, Lagonia P, Tagarelli A, Quattrone A. Casimir Funk: his discovery of the vitamins and their deficiency disorders. Ann Nutr Metab . 2010;57(2):85-8.

Last reviewed March 2023

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Micronutrient Facts

Micronutrients, often referred to as vitamins and minerals, are vital to healthy development, disease prevention, and wellbeing. With the exception of vitamin D, micronutrients are not produced in the body and must be derived from the diet 1 .

Though people only need small amounts of micronutrients, consuming the recommended amount is important. Micronutrient deficiencies can have devastating consequences. At least half of children worldwide younger than 5 years of age suffer from vitamin and mineral deficiencies 2 . The World Health Organization recommends multiple types of interventions to address nutrition deficiencies external icon 3 .

The role of six essential micronutrients is outlined below.

• Iron is critical for motor and cognitive development. Children and pregnant women are especially vulnerable to the consequences of iron deficiency 3 .
• Iron deficiency is a leading cause of anemia which is defined as low hemoglobin concentration. Anemia affects 40% of children younger than 5 years of age and 30% of pregnant women globally 4 .
• Anemia during pregnancy increases the risk of death for the mother and low birth weight for the infant. Worldwide, maternal and neonatal deaths total between 2.5 million and 3.4 million each year 5 .
• Babies fed only breast milk, only formula, or a mix of breast milk and formula have different needs  when it comes to iron.

Iron Fact Sheet external icon | Hierro Hoja Informativa external icon

Preventing iron deficiency helps improve children's learning ability and cognitive development.

• Vitamin A supports healthy eyesight and immune system functions. Children with vitamin A deficiency face an increased risk of blindness and death from infections such as measles and diarrhea 6 .
• Globally, vitamin A deficiency affects an estimated 190 million preschool-age children 6 .
• Providing vitamin A supplements to children ages 6-59 months is highly effective in reducing deaths from all causes where vitamin A deficiency is a public health concern 6 .

Vitamin A Fact Sheet external icon | Vitamina A Hoja Informativa external icon

• Vitamin D builds strong bones by helping the body absorb calcium 7 . This helps protect older adults from osteoporosis.
• Vitamin D deficiency causes bone diseases, including rickets in children and osteomalacia in adults 7 .
• Vitamin D helps the immune system resist bacteria and virsues 7 .
• Vitamin D is required for muscle and nerve functions 7 .
• Available data suggest that vitamin D deficiency may be widespread globally 8 .
• Bodies make vitamin D from sunlight, but this varies based on geography, skin color, air pollution, and other factors. Also, sunlight exposure needs to be limited to avoid risk of skin cancer .
• All children need vitamin D  beginning shortly after birth.

Vitamin D Fact Sheet external icon | Vitamina D Hoja Informativa external icon

• Iodine is required during pregnancy and infancy for the infant’s healthy growth and cognitive development 9 .
• Globally an estimated 1.8 billion people have insufficient iodine intake.
• Iodine content in most foods and beverages is low.
• Fortifying salt with iodine is a successful intervention – about 86% of households worldwide consume iodized salt 10 . The amount of iodine added to salt can be adjusted so that people maintain adequate iodine intake even if they consume less salt 11 .
• The American Thyroid Association and the American Academy of Pediatrics recommend that pregnant or breastfeeding women take a supplement every day containing 150 micrograms of iodine. The American Thyroid Association recommends women who are planning a pregnancy consume a daily iodine supplement starting at least 3 months in advance of pregnancy.

Iodine Fact Sheet external icon | Yodo Hoja Informativa external icon

Fortifying salt with iodine successfully increases intake of iodine.

• Everyone needs folate (vitamin B9) to make new cells  every day.
• Folate is essential in the earliest days of fetal growth for healthy development of the brain and spine 12 . Folic acid is another form of vitamin B9. Women of reproductive age need 400 micrograms of folic acid every day 12 .
• Ensuring sufficient levels of folate in women prior to conception can reduce neural tube defects such as spina bifida and anencephaly 12 .
• Providing folic acid supplements to women 15-49 years and fortifying foods such as wheat flour with folic acid reduces the incidence of neural tube defects and neonatal deaths 13 .

Folate Fact Sheet external icon | Folato Hoja Informativa external icon

Folate is especially important before and during pregnancy.

• Zinc promotes immune functions and helps people resist infectious diseases including diarrhea, pneumonia and malaria 14,15,16 . Zinc is also needed for healthy pregnancies 14 .
• Globally, 17.3% of the population is at risk for zinc deficiency due to dietary inadequacy; up to 30% of people are at risk in some regions of the world 17 .
• Providing zinc supplements reduces the incidence of premature birth, decreases childhood diarrhea and respiratory infections, lowers the number of deaths from all causes, and increases growth and weight gain among infants and young children 17 .
• Providing zinc supplementation to children younger than 5 years appears to be a highly cost-effective intervention in low- and middle-income countries 18,19 .
• When children are about 6 months old, it is important to start giving them foods with zinc .

Zinc Fact Sheet external icon | Zinc Hoja Informativa external icon

• Kraemer K, , Badham J, Christian P, Hyun Rah J, eds. Micronutrients; macro impact, the story of vitamins and a hungry world external icon . Sight and Life Press; 2015.
• The state of the world’s children 2019; children, food and nutrition: growing well in a changing world external icon . UNICEF; 2019.
• World Health Organization. e-Library of evidence for nutrition actions external icon . Accessed June 18, 2021.
• World Health Organization. WHO global anaemia estimates, 2021 edition external icon . Accessed June 3, 2021.
• Stevens GA, Finucane MM, De-Regil LM, et al. Global, regional, and national trends in haemoglobin concentration and prevalence of total and severe anaemia in children and pregnant and non-pregnant women for 1995-2011: a systematic analysis of population-representative data external icon .  Lancet Glob Health . 2013;1(1).
• World Health Organization. Guideline: vitamin A supplementation in infants and children 6-59 months of age; 2011 external icon . Accessed June 18, 2021.
• National Institutes of Health Office of Dietary Supplements. What is vitamin D and what does it do? external icon  Accessed June 18, 2021.
• Roth DE, Abrams SA, Aloia J, et al. Global prevalence and disease burden of vitamin d deficiency: a roadmap for action in low- and middle-income countries external icon .  Ann N Y Acad Sci . 2018;1430(1).
• Andersson M, Karumbunathan V, Zimmermann MB. Global iodine status in 2011 and trends over the past decade. external icon   J Nutr . 2012;142(4):744-750.
• Iodine Global Network. What is being done internationally about iodine deficiency? external icon Accessed June 18, 2021.
• World Health Organization. Iodization of salt for the prevention and control of iodine deficiency disorders external icon . Accessed June 18, 2021.
• Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities. Folic acid helps prevent some birth defects . Accessed June 18, 2021.
• Blencowe H, Cousens S, Modell B, Lawn J. Folic acid to reduce neonatal mortality from neural tube disorders external icon .  Int J Epidemiol . 2010;39 Suppl 1(Suppl 1):i110-i121.
• Ackland ML, Michalczyk AA. Zinc and infant nutrition external icon .  Arch Biochem Biophys . 2016;611:51-57.
• Lassi ZS, Moin A, Bhutta ZA. Zinc supplementation for the prevention of pneumonia in children aged 2 months to 59 months. external icon Cochrane Database of Systematic Reviews 2016, Issue 12. Art. No.: CD005978.
• Liu E, Pimpin L, Shulkin M, et al. Effect of zinc supplementation on growth outcomes in children under 5 years of age. external icon   Nutrients . 2018;10(3):377.
• Wessells KR, Brown KH. Estimating the global prevalence of zinc deficiency: results based on zinc availability in national food supplies and the prevalence of stunting external icon .  PLoS One . 2012;7(11):e50568.
• Fink G, Heitner J. Evaluating the cost-effectiveness of preventive zinc supplementation external icon .  BMC Public Health . 2014;14:852.
• Brown KH, Hess SY, Vosti SA, Baker SK. Comparison of the estimated cost-effectiveness of preventive and therapeutic zinc supplementation strategies for reducing child morbidity and mortality in sub-Saharan Africa. external icon   Food Nutr Bull . 2013;34(2):199-214.

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Are you getting the vitamins and minerals you need?

Essential nutrients for your body, micronutrients with a big role in the body, a closer look at water-soluble vitamins, a closer look at fat-soluble vitamins, a closer look at major minerals, a closer look at trace minerals, a closer look at antioxidants, vitamins and minerals.

There so many different vitamins and mineral supplements available, it can feel overwhelming trying to decide what you should take. Here’s how to ensure you’re getting the right amounts of everything you need.

Adapted with permission from Making Sense of Vitamins and Minerals , a special health report published by Harvard Health Publishing.

Vitamins and minerals are essential nutrients because they perform hundreds of roles in the body. There is a fine line between getting enough of these nutrients (which is healthy) and getting too much (which can end up harming you). Eating a healthy diet remains the best way to get sufficient amounts of the vitamins and minerals you need.

Every day, your body produces skin, muscle, and bone. It churns out rich red blood that carries nutrients and oxygen to remote outposts, and it sends nerve signals skipping along thousands of miles of brain and body pathways. It also formulates chemical messengers that shuttle from one organ to another, issuing the instructions that help sustain your life.

But to do all this, your body requires some raw materials. These include at least 30 vitamins, minerals, and dietary components that your body needs but cannot manufacture on its own in sufficient amounts.

Vitamins and minerals are considered essential nutrients—because acting in concert, they perform hundreds of roles in the body. They help shore up bones, heal wounds, and bolster your immune system. They also convert food into energy, and repair cellular damage.

But trying to keep track of what all these vitamins and minerals do can be confusing. Read enough articles on the topic, and your eyes may swim with the alphabet-soup references to these nutrients, which are known mainly be their initials (such as vitamins A, B, C, D, E, and K—to name just a few).

In this article, you’ll gain a better understanding of what these vitamins and minerals actually do in the body and why you want to make sure you’re getting enough of them.

Vitamins and minerals are often called micronutrients because your body needs only tiny amounts of them. Yet failing to get even those small quantities virtually guarantees disease. Here are a few examples of diseases that can result from vitamin deficiencies:

• Scurvy. Old-time sailors learned that living for months without fresh fruits or vegetables—the main sources of vitamin C—causes the bleeding gums and listlessness of scurvy.
• Blindness. In some developing countries, people still become blind from vitamin A deficiency.
• Rickets. A deficiency in vitamin D can cause rickets, a condition marked by soft, weak bones that can lead to skeletal deformities such as bowed legs. Partly to combat rickets, the U.S. has fortified milk with vitamin D since the 1930s.

Just as a lack of key micronutrients can cause substantial harm to your body, getting sufficient quantities can provide a substantial benefit. Some examples of these benefits:

• Strong bones. A combination of calcium, vitamin D, vitamin K, magnesium, and phosphorus protects your bones against fractures.
• Prevents birth defects. Taking folic acid supplements early in pregnancy helps prevent brain and spinal birth defects in offspring.
• Healthy teeth. The mineral fluoride not only helps bone formation but also keeps dental cavities from starting or worsening.

The difference between vitamins and minerals

Although they are all considered micronutrients, vitamins and minerals differ in basic ways. Vitamins are organic and can be broken down by heat, air, or acid. Minerals are inorganic and hold on to their chemical structure.

So why does this matter? It means the minerals in soil and water easily find their way into your body through the plants, fish, animals, and fluids you consume. But it’s tougher to shuttle vitamins from food and other sources into your body because cooking, storage, and simple exposure to air can inactivate these more fragile compounds.

Interacting—in good ways and bad

Many micronutrients interact. Vitamin D enables your body to pluck calcium from food sources passing through your digestive tract rather than harvesting it from your bones. Vitamin C helps you absorb iron.

The interplay of micronutrients isn’t always cooperative, however. For example, vitamin C blocks your body’s ability to assimilate the essential mineral copper. And even a minor overload of the mineral manganese can worsen iron deficiency.

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Water-soluble vitamins are packed into the watery portions of the foods you eat. They are absorbed directly into the bloodstream as food is broken down during digestion or as a supplement dissolves.

Because much of your body consists of water, many of the water-soluble vitamins circulate easily in your body. Your kidneys continuously regulate levels of water-soluble vitamins, shunting excesses out of the body in your urine.

Water-soluble vitamins

B vitamins:

• Biotin (vitamin B7)
• Folic acid (folate, vitamin B9)
• Niacin (vitamin B3)
• Pantothenic acid (vitamin B5
• Riboflavin (vitamin B2)
• Thiamin (vitamin B1)
• Vitamin B12

What they do

Although water-soluble vitamins have many tasks in the body, one of the most important is helping to free the energy found in the food you eat. Others help keep tissues healthy. Here are some examples of how different vitamins help you maintain health:

• Release energy. Several B vitamins are key components of certain coenzymes (molecules that aid enzymes) that help release energy from food.
• Produce energy. Thiamin, riboflavin, niacin, pantothenic acid, and biotin engage in energy production.
• Build proteins and cells. Vitamins B6, B12, and folic acid metabolize amino acids (the building blocks of proteins) and help cells multiply.
• Make collagen. One of many roles played by vitamin C is to help make collagen, which knits together wounds, supports blood vessel walls, and forms a base for teeth and bones.

Words to the wise

Contrary to popular belief, some water-soluble vitamins can stay in the body for long periods of time. You probably have several years’ supply of vitamin B12 in your liver. And even folic acid and vitamin C stores can last more than a couple of days.

Generally, though, water-soluble vitamins should be replenished every few days.

Just be aware that there is a small risk that consuming large amounts of some of these micronutrients through supplements may be quite harmful. For example, very high doses of B6—many times the recommended amount of 1.3 milligrams (mg) per day for adults—can damage nerves, causing numbness and muscle weakness.

Rather than slipping easily into the bloodstream like most water-soluble vitamins, fat-soluble vitamins gain entry to the blood via lymph channels in the intestinal wall (see illustration). Many fat-soluble vitamins travel through the body only under escort by proteins that act as carriers.

Absorption of fat-soluble vitamins

• Food containing fat-soluble vitamins is ingested.
• The food is digested by stomach acid and then travels to the small intestine, where it is digested further. Bile is needed for the absorption of fat-soluble vitamins. This substance, which is produced in the liver, flows into the small intestine, where it breaks down fats. Nutrients are then absorbed through the wall of the small intestine.
• Upon absorption, the fat-soluble vitamins enter the lymph vessels before making their way into the bloodstream. In most cases, fat-soluble vitamins must be coupled with a protein in order to travel through the body.
• These vitamins are used throughout the body, but excesses are stored in the liver and fat tissues.
• As additional amounts of these vitamins are needed, your body taps into the reserves, releasing them into the bloodstream from the liver.

Fatty foods and oils are reservoirs for the four fat-soluble vitamins. Within your body, fat tissues and the liver act as the main holding pens for these vitamins and release them as needed.

To some extent, you can think of these vitamins as time-release micronutrients. It’s possible to consume them every now and again, perhaps in doses weeks or months apart rather than daily, and still get your fill. Your body squirrels away the excess and doles it out gradually to meet your needs.

Fat-soluble vitamins

Together this vitamin quartet helps keep your eyes, skin, lungs, gastrointestinal tract, and nervous system in good repair. Here are some of the other essential roles these vitamins play:

• Build bones. Bone formation would be impossible without vitamins A, D, and K.
• Protect vision. Vitamin A also helps keep cells healthy and protects your vision.
• Interact favorably. Without vitamin E, your body would have difficulty absorbing and storing vitamin A.
• Protect the body. Vitamin E also acts as an antioxidant (a compound that helps protect the body against damage from unstable molecules).

Because fat-soluble vitamins are stored in your body for long periods, toxic levels can build up. This is most likely to happen if you take supplements. It’s very rare to get too much of a vitamin just from food.

The body needs, and stores, fairly large amounts of the major minerals. These minerals are no more important to your health than the trace minerals; they’re just present in your body in greater amounts.

Major minerals travel through the body in various ways. Potassium, for example, is quickly absorbed into the bloodstream, where it circulates freely and is excreted by the kidneys, much like a water-soluble vitamin. Calcium is more like a fat-soluble vitamin because it requires a carrier for absorption and transport.

Major minerals

One of the key tasks of major minerals is to maintain the proper balance of water in the body. Sodium, chloride, and potassium take the lead in doing this. Three other major minerals—calcium, phosphorus, and magnesium—are important for healthy bones. Sulfur helps stabilize protein structures, including some of those that make up hair, skin, and nails.

Having too much of one major mineral can result in a deficiency of another. These sorts of imbalances are usually caused by overloads from supplements, not food sources. Here are two examples:

• Salt overload. Calcium binds with excess sodium in the body and is excreted when the body senses that sodium levels must be lowered. That means that if you ingest too much sodium through table salt or processed foods, you could end up losing needed calcium as your body rids itself of the surplus sodium.
• Excess phosphorus. Likewise, too much phosphorus can hamper your ability to absorb magnesium.

A thimble could easily contain the distillation of all the trace minerals normally found in your body. Yet their contributions are just as essential as those of major minerals such as calcium and phosphorus, which each account for more than a pound of your body weight.

Trace minerals

Trace minerals carry out a diverse set of tasks. Here are a few examples:

• Iron is best known for ferrying oxygen throughout the body.
• Fluoride strengthens bones and wards off tooth decay.
• Zinc helps blood clot, is essential for taste and smell, and bolsters the immune response.
• Copper helps form several enzymes, one of which assists with iron metabolism and the creation of hemoglobin, which carries oxygen in the blood.

The other trace minerals perform equally vital jobs, such as helping to block damage to body cells and forming parts of key enzymes or enhancing their activity.

Trace minerals interact with one another, sometimes in ways that can trigger imbalances. Too much of one can cause or contribute to a deficiency of another. Here are some examples:

• A minor overload of manganese can exacerbate iron deficiency. Having too little can also cause problems.
• When the body has too little iodine, thyroid hormone production slows, causing sluggishness and weight gain as well as other health concerns. The problem worsens if the body also has too little selenium.

The difference between “just enough” and “too much” of the trace minerals is often tiny. Generally, food is a safe source of trace minerals, but if you take supplements, it’s important to make sure you’re not exceeding safe levels.

Antioxidant is a catchall term for any compound that can counteract unstable molecules such as free radicals that damage DNA, cell membranes, and other parts of cells.

Your body cells naturally produce plenty of antioxidants to put on patrol. The foods you eat—and, perhaps, some of the supplements you take—are another source of antioxidant compounds. Carotenoids (such as lycopene in tomatoes and lutein in kale) and flavonoids (such as anthocyanins in blueberries, quercetin in apples and onions, and catechins in green tea) are antioxidants. The vitamins C and E and the mineral selenium also have antioxidant properties.

Why free radicals may be harmful

Free radicals are a natural byproduct of energy metabolism and are also generated by ultraviolet rays, tobacco smoke, and air pollution. They lack a full complement of electrons, which makes them unstable, so they steal electrons from other molecules, damaging those molecules in the process.

Free radicals have a well-deserved reputation for causing cellular damage. But they can be helpful, too. When immune system cells muster to fight intruders, the oxygen they use spins off an army of free radicals that destroys viruses, bacteria, and damaged body cells in an oxidative burst. Vitamin C can then disarm the free radicals.

How antioxidants may help

Antioxidants are able to neutralize marauders such as free radicals by giving up some of their own electrons. When a vitamin C or E molecule makes this sacrifice, it may allow a crucial protein, gene, or cell membrane to escape damage. This helps break a chain reaction that can affect many other cells.

It is important to recognize that the term “antioxidant” reflects a chemical property rather than a specific nutritional property. Each of the nutrients that has antioxidant properties also has numerous other aspects and should be considered individually. The context is also important—in some settings, for example, vitamin C is an antioxidant, and in others it can be a pro-oxidant.

Articles and advertisements have touted antioxidants as a way to help slow aging, fend off heart disease, improve flagging vision, and curb cancer. And laboratory studies and many large-scale observational trials (the type that query people about their eating habits and supplement use and then track their disease patterns) have noted benefits from diets rich in certain antioxidants and, in some cases, from antioxidant supplements.

But results from randomized controlled trials (in which people are assigned to take specific nutrients or a placebo) have failed to back up many of these claims. One study that pooled results from 68 randomized trials with over 230,000 participants found that people who were given vitamin E, beta carotene, and vitamin A had a higher risk of death than those who took a placebo. There appeared to be no effect from vitamin C pills and a small reduction in mortality from selenium, but further research on these nutrients is needed.

These findings suggest little overall benefit of the antioxidants in pill form. On the other hand, many studies show that people who consume higher levels of these antioxidants in food have a lower risk of many diseases.

The bottom line? Eating a healthy diet is the best way to get your antioxidants.

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Micronutrient inadequacies in the us population: an overview, us national dietary surveys, nutritional biomarkers.

• Micronutrient Deficiencies and Inadequacies

Authors and Reviewers

The information in this article is also presented as an online course: " Meeting Micronutrient Needs ."

Overall adherence to the US Dietary Guidelines is low: the majority of Americans do not follow a healthy eating pattern. Together with physical inactivity, eating an energy-rich, nutrient-poor diet predisposes one to many chronic diseases , including type 2 diabetes mellitus , cardiovascular disease , cancer , and osteoporosis . Approximately one-half of American adults have at least one preventable chronic disease (1) , and additionally, obesity is a major public health problem in the US, with more than one-third of adults (2) and 17% of children and adolescents (3) classified as obese. Decades of public health messages to eat a balanced diet have not resulted in behavior change — energy-rich, nutrient-poor foods comprise an estimated 27% of daily caloric intake in the American diet, and alcohol constitutes an additional 4% of daily caloric intake (4) . Many Americans are exceeding energy (caloric) needs but not meeting micronutrient ( vitamin and nutritionally essential mineral ) requirements. One analysis of US national survey data (National Health and Nutrition Examination Survey 2003-2006) found that children and adults with high intakes of added sugars (>25% of energy intake; the upper limit recommended by the National Academy of Medicine) had lower dietary intakes of several micronutrients, especially vitamins A, C, and E, as well as magnesium (5) . An estimated 13% of the US population have added sugar intakes above this cutoff level for added sugars (5) and may be at risk for micronutrient inadequacies. In fact, National Health and Nutrition Examination Surveys (NHANES) that assess the nutritional and health status of a nationally representative sample of the civilian, non-institutionalized US population have reported a high prevalence of select micronutrient inadequacies in the US population (see Tables 1-3 ).

Assessing Nutrient Intake

Nutritional assessments in populations are typically done by measuring nutrient intake through dietary surveys and comparing mean intake with the age- and gender-specific nutrient requirements. Although more difficult and costly to do in entire populations, nutritional biomarkers  — biochemical indicators that give more objective and reliable measures of dietary exposure and nutrient body status  — are sometimes also employed (6, 7) .

“What We Eat in America” (WWEIA), the dietary assessment component of NHANES, is a joint effort of the US Department of Health and Human Services and the US Department of Agriculture. Nutrition data are collected during both in-depth household interviews and medical examinations; food intake is assessed by completing two 24-hour dietary recalls, the first being conducted at a mobile examination center and the second being a telephone interview 3 to 10 days later (8) . Details on the information collected during the interviews can be found on the USDA website . Intake of 65 nutrients and food components is derived from dietary assessment information using the USDA's Food and Nutrient Database for Dietary Studies (FNDDS). FNDDS and WWEIA datasets are released every two years. NHANES also assesses dietary supplement use in the US population, so total nutrient intake from dietary and supplemental sources can be determined.

To assess nutrient intake and derive an estimate of the prevalence of nutrient inadequacy in the US population, the mean intake of an age- or gender-specific group is compared to the corresponding Estimated Average Requirement ( EAR ) for a particular nutrient. Like the other Dietary Reference Intakes ( DRIs ), the EARs are determined by expert panels appointed by the Food and Nutrition Board of the National Academy of Medicine (formerly the Institute of Medicine). The DRIs are nutrient-based reference values for the US and Canadian populations; in addition to the EAR, the DRIs include the Adequate Intake ( AI ), which is used to estimate prevalence of inadequacy in a population when a requirement has not been set; the Recommended Dietary Allowance ( RDA ; see HIGHLIGHT ); and the Tolerable Upper Intake Level ( UL ; see HIGHLIGHT ). The EAR is the DRI that should be used to assess nutrient intake of an individual or of a group. Using the RDA to assess nutrient intake is not appropriate; the RDA should instead be used in the planning of diets for individuals (9) .

Estimated Average Requirement (EAR) - a nutrient intake value that is estimated to meet the requirement of half the healthy individuals in a particular life stage and gender group.

Recommended Dietary Allowance (RDA) - the dietary intake level that is sufficient to meet the nutrient requirement of nearly all (97 to 98 percent) healthy individuals in a particular life stage and gender group.

Adequate Intake (AI) - a recommended intake value based on observed or experimentally determined approximations or estimates of nutrient intake by a group (or groups) of healthy people that are assumed to be adequate — used when an RDA cannot be determined.

Tolerable Upper Intake Level (UL) - the highest level of nutrient intake that is likely to pose no risk of adverse health effects for almost all individuals in the general population.

Like all studies that assess dietary exposure using self-reported data, the NHANES analyses are subject to  bias and have some limitations. For example, the 24-hour dietary recall method relies on a person’s memory of food eaten and estimated portion size (10) . A type of measurement error called recall bias can occur if the recollections of study participants are inaccurate. Also, a single-day assessment of food intake may not reflect usual dietary intake of participants (10) . In a study that examined the validity of energy (caloric) intake data from NHANES 1971-2010 (28,993 men and 34,369 women), underreporting of caloric intake was found in 58.7% of men and 67.3% of women; underreporting of calories was even higher among obese individuals (11) . Misreporting of dietary intake, including underreporting of intake, appears to also be common among children and, particularly, among adolescents (12) . Thus, it is important to keep in mind that NHANES data of usual daily intakes of micronutrients may also be incorrectly estimated; the accuracy of micronutrient intake data of NHANES also depends on that of the FNDDS. In addition to collection of dietary data, some NHANES data include biochemical assessments that function as objective indicators of dietary intake and inform on participants’ nutritional status. Lastly, all the NHANES data are cross-sectional in nature and thus cannot provide any information about the causality of diet-health relationships.

To avoid the bias associated with self-reporting of dietary intake, nutritional biomarkers can be used to evaluate dietary exposure and nutrient intake. Nutritional biomarkers are considered objective biochemical indicators of past dietary exposure and help inform nutrient body status (7 , 13) . To measure nutrient exposure and estimate body status, plasma or serum concentrations of certain nutrients (e.g., folate, vitamin B 6 , vitamin B 12 , vitamin C, vitamin D, vitamin E, copper, selenium, zinc) are measured in NHANES analyses. Concentration of folate in red blood cells — a better biomarker of long-term intake and body stores compared to blood levels (14)  — has also been employed, and urinary iodine has been used as an indicator of recent iodine intake in NHANES participants (4 years and older). Moreover, no single biomarker captures body iron status, and NHANES analyses rely on the use and interpretation of several different measures, including serum iron, serum ferritin (the iron-storage protein), saturation of transferrin (the main carrier of iron in blood), transferrin receptor, and total iron-binding capacity.

It is important, however, to recognize the limitations of the biomarker used. For example, circulating levels are poor indicators of nutrient body status when the blood concentration of a nutrient is homeostatically regulated (e.g., vitamin A, calcium, zinc). Biomarkers are not available for every nutrient, and some are affected by disease states, including inflammation and infection, and also by kidney function or age (15) .

Thus, dietary surveys and nutritional biomarkers are two methods used to assess dietary exposure of a population. Each has its advantages and limitations but can be used in combination to better estimate dietary intake and inform on nutritional status.

Micronutrient Deficiencies and Inadequacies 

Very low dietary intake of a vitamin or nutritionally essential mineral can result in deficiency disease, termed micronutrient deficiency. Micronutrient deficiencies, especially iron, vitamin A, zinc, iodine, and folate, are prevalent in the developing world, affecting an estimated 2 billion people worldwide. They are a major contributor to infections and associated with severe illness and death (16) . Subpopulations most at risk for micronutrient deficiencies include pregnant women and children five years and younger (15) . Primarily affecting the developing world, micronutrient deficiencies are rare, but not absent, in populations residing in industrialized nations.

However, micronutrient inadequacies — defined as nutrient intake less than the EAR  — are common in the United States and other developed countries. Such inadequacies may occur when micronutrient intake is above the level associated with deficiency but below dietary intake recommendations (17) . In contrast to micronutrient deficiencies that result in clinically overt symptoms, micronutrient inadequacies may cause covert symptoms only that are difficult to detect clinically. For example, micronutrient inadequacies could elicit symptoms of general fatigue (18) , reduced ability to fight infections (19) , or impaired cognitive function (i.e., attention [concentration and focus], memory, and mood) (19) . Micronutrient inadequacies may also have important implications for long-term health and increase one’s risk for chronic diseases like cancer (17, 20) , cardiovascular disease (20) , type 2 diabetes mellitus (21) , osteoporosis (20, 22) , and age-related eye disease (23) .

Many Americans are not reaching micronutrient intake requirements from food alone (24, 25) , presumably due to eating an energy-rich, nutrient-poor diet. About 75% of the US population (ages ≥1 year) do not consume the recommended intake of fruit, and more than 80% do not consume the recommended intake of vegetables (1) . Intakes of whole grains are also well below current recommendations for all age groups, and dairy intake is below recommendations for those ages 4 years and older (1) . The 2015-2020 Dietary Guidelines for Americans highlighted the nutrients that are underconsumed in the US population, i.e., "shortfall nutrients," labeling a few as "nutrients of public health concern" because low intake may lead to adverse health effects: Vitamin D (adverse health effect: osteoporosis), calcium (osteoporosis), potassium ( hypertension and cardiovascular disease), dietary fiber (poor colonic health), and iron ( anemia in young children, women of childbearing age, and pregnant women) were such labeled (1) . Other nutrients, including vitamins A, C, and E; choline, and magnesium, were identified as also being underconsumed by the US population (1) .

A US national survey, NHANES 2007-2010, which surveyed 16,444 individuals four years and older, reported a high prevalence of inadequacies for multiple micronutrients (see Table 1 ). Specifically, 94.3% of the US population do not meet the daily requirement for vitamin D, 88.5% for vitamin E, 52.2% for magnesium, 44.1% for calcium, 43.0% for vitamin A, and 38.9% for vitamin C. For the nutrients in which a requirement has not been set, 100% of the population had intakes lower than the AI for potassium, 91.7% for choline, and 66.9% for vitamin K. The prevalence of inadequacies was low for all of the B vitamins and several minerals, including copper, iron, phosphorus, selenium, sodium, and zinc (see Table 1 ). Moreover, more than 97% of the population had excessive intakes of sodium, defined as daily intakes greater than the age-specific UL (26) .

It is important to note that the abovementioned data include micronutrient intake from enriched and fortified food and thus represent micronutrient intakes from all food sources. Enrichment is the addition of nutrients to replace losses that may occur in food processing, and fortification is the addition of nutrients to food to prevent or correct a nutritional deficiency. Fortified and enriched food help Americans — both children and adults — meet dietary requirements of many micronutrients, especially for folate, niacin, riboflavin, thiamin, vitamin A, vitamin D, and iron (see Table 2 and Table 3 below and the separate article on Micronutrient Inadequacies: the Remedy ) (24) .

Shortfall Micronutrients

Calcium is designated a nutrient of public health concern in the 2015-2020 Dietary Guidelines for Americans because it is underconsumed by certain subpopulations and because of its importance in bone health (see the article on Bone Health ) (1) . Calcium status must be assessed through dietary intake surveys because blood concentrations of calcium are tightly regulated at 2.5 mM (27) . Dietary surveys show that many Americans are not meeting the dietary requirements for calcium, especially older children, adolescents, and women (including pregnant women), and some older adults. Overall, more than 40% of the US population do not meet the calcium requirement from diet alone (28) . When accounting for intake from all sources, including calcium or multi-nutrient supplements (calcium-containing supplements are taken by 26% of the population), total usual calcium intakes for female adolescents (ages 12-19 years) and older women (ages ≥60 years) were still below the age-specific EAR (NHANES 2009-2010) (29) . Compiling intake data from all age groups (2 years and older), males had higher daily intakes, but when adjusting for total caloric intake, females had a higher calcium "density" than the males (29) . Dairy products, which represent rich and absorbable sources of calcium, comprised at least 37% of total calcium intake in this analysis (29) .

The Dietary Guidelines for Americans 2015-2020 highlights iron as a nutrient of public health concern for certain subgroups of the population, including young children, women who may become pregnant, and pregnant women.

Dietary surveys have estimated usual iron intake and the prevalence of iron inadequacy among young children in the US. A report from NHANES 2009-2012 found that 10% of infants ages 6 to 11 months (n=381) had dietary iron intakes less than the EAR (30) , and the prevalence of iron inadequacy for toddlers ages 12 to 23 months (n=516) was estimated to be only 1% (30) . Similar results were found in a study that examined intake of 3,022 US infants and toddlers: 7.5% of infants (7-11 months) and less than 1% of toddlers (12-24 months) had intakes below the EAR (31) . Additionally, compiling data from NHANES releases from 2003-2012, less than 1% of toddlers (n=1122) ages 12-23 months had intakes below the EAR for iron (32) .

Because iron content of breast milk is low, the American Academy of Pediatrics recommends that breast-fed infants be given 1 mg/kg/day of supplemental iron beginning at 4 months of age until complementary foods, including iron- fortified cereal, are introduced  (33) . Fortified and enriched food are significant sources of dietary iron for older children and adolescents (34) .

Adolescents have increased requirements for iron due to rapid growth. In particular, adolescent girls are at a heightened risk of iron deficiency due to inadequate intake of dietary iron, especially heme iron; increased demands of growth; and iron loss that occurs with menstruation . NHANES 2001-2002 found that 16% of US adolescent girls had iron intakes below the EAR, whereas fewer than 5% of adolescent boys were considered to have inadequate iron intake (35) .

Multiple biomarkers , including serum iron, red blood cell hemoglobin , serum ferritin, transferrin saturation, soluble transferrin receptor (sTfR), and total iron-binding capacity, have been used to assess iron status at the population level. However, these are often used to assess iron deficiency rather than dietary iron inadequacy. The CDC’s Second National Report on Biochemical Indicators of Diet and Nutrition in the US Population reported data from NHANES 2003-2006 using biochemical cutoffs for iron inadequacy in children, adolescents, and adults (36) . In particular, the prevalence of iron inadequacy assessed by serum ferritin (cutoffs of <12 ng/mL for children and <15 ng/mL for adolescents and adults) was 8.9% in US children ages 1-5 years, 15.2% in adolescent females ages 12-19 years, and 13.2% in nonpregnant women of childbearing age (ages 20-49 years) (36) . Additionally, 16.9% of adolescent females and 19.4% of nonpregnant women of childbearing age were found to have high serum sTfR concentrations (>4.4 mg/L), another biomarker of iron inadequacy (36) . In an analysis of NHANES 1999-2006 data that used various markers of iron deficiency, 9.8% of nonpregnant women (ages 18-49 years) and 25.4% of pregnant women were considered to be iron deficient, i.e., with values below at least two of the three iron deficiency cutoffs: hemoglobin concentration <12 g/dL, ferritin concentration <12 ng/mL, and transferrin saturation <16% (37) . Another analysis of these NHANES data, examining prevalence of iron deficiency among 1,171 pregnant women, found that 17.4% were deficient by sTfR concentrations and 18.0% by total body iron, a value that is calculated using serum ferritin and sTfR concentrations (38) . Not surprisingly, the prevalence of iron deficiency in the second, and especially, the third trimester of pregnancy was greater than in the first trimester (38) ; intake requirements for dietary iron increase starting in the second trimester despite an increase in intestinal iron absorption (39) .

For more information on life stage-specific needs for iron, see the article on Iron .

The 2015-2020 Dietary Guidelines state that magnesium is underconsumed in the US (1) ; however, it was not labeled as a "nutrient of public health concern" despite low intake of magnesium being associated with increased risks of several chronic diseases , including cardiovascular disease , type 2 diabetes , and potentially, osteoporosis (40, 41) . According to dietary surveys, more than one-half of the US population (ages ≥4 years) has intakes below the EAR for magnesium (see Table 1 ) (26)  — NHANES 2003-2006 found that about 36% of children and adolescents and 61% of adults had intakes lower than the EAR for magnesium (24) . Reliable biomarkers of magnesium intake are not available (40) , and data assessing magnesium status in the US population are lacking. Blood concentrations of magnesium are tightly regulated and cannot be used to assess magnesium nutritional status (41) .

Good sources of magnesium include green leafy vegetables, whole grains , beans, and nuts ; consumption of whole grains, dark-green vegetables, and beans among Americans is well below intake recommendations (1) .

The US Dietary Guidelines 2015-2020 highlights potassium as a nutrient of public health concern because it is underconsumed by Americans (1) . US national surveys indicate that the vast majority of the US population do not meet intake recommendations for potassium. Among US adults (ages ≥20 years) surveyed in NHANES 2011-2012 (n=4,730), fewer than 3% had potassium intakes greater than the adequate intake of 4,700 mg/day (42) . According to NHANES 2009-2010, average potassium intakes are well below the AI for all age groups assessed (2 years and older), with the potassium density of the diet being higher in females versus males (43) . Fruit and vegetables were the main dietary source of the mineral, comprising 20% of total potassium intake, about half of which came from white potatoes. Additionally, another NHANES analysis (2003-2010) found that almost all (97%) infants ages 7 to 11 months reached the AI for potassium, presumably because breast milk and infant formula provide sufficient amounts of potassium (44, 45) and because younger children have higher fruit intakes (1) . However, only ~5% of children ages 1 to 3 years and less than 1% of children ages 4 to 5 years met the age-specific AI (46) .

The richest sources of potassium are fruit and vegetables; approximately three-quarters of the US population do not meet intake recommendations for fruit and vegetables (1) .

NOTE: In 2019, the National Academy of Medicine established a new AI for potassium (see the article on Potassium ).

Dietary surveys indicate that many US adults are not meeting dietary requirements for vitamin A : Even when accounting for vitamin A from fortified food, which is significant, 51% of adults fall short of the EAR (24) . In contrast, more than 94% of children and adolescents (ages 2-18 years) have vitamin A intakes equivalent to the requirement or higher (24) . Fortified, ready-to-eat cereal and fortified milk are important sources of vitamin A for children and adolescents (34) . NHANES has also reported serum retinol concentrations: less than 1% of the US population is deficient in vitamin A (36) . Serum retinol concentrations can be used to assess deficiency in a population (47) , but this assay cannot assess vitamin A inadequacy because retinol concentrations decline only once liver reserves are depleted (48) . Moreover, serum retinol concentrations are decreased by inflammation and infection (47-49) .

Dietary intake surveys have found a higher prevalence of vitamin C inadequacy among adults (43%) compared to children and adolescents (19% for ages 2-18 years) (24) . Biomarker data confirm that adults are at an increased risk for vitamin C deficiency. Serum ascorbic acid concentrations are often used to assess vitamin C status ; concentrations between 11.4 and 23 μmol/L may be considered low, and concentrations lower than 11.4 μmol/L are generally considered deficient (36) . Based on data from NHANES 2003-2006, 6% of the US population (≥6 years) were severely deficient in vitamin C. The prevalence of vitamin C deficiency and low vitamin C concentrations was lower among children ages 6 to 11 years compared to adolescents and adults; greater than 6% of adults ages 20 to 59 years were considered vitamin C deficient and greater than 10% had low serum vitamin C concentrations (36) . Females had higher concentrations than males (36) .

Previous NHANES analyses have reported a higher prevalence of severe vitamin C deficiency in the US population (50) , suggesting that vitamin C status has improved in the US population over the past two decades.

Dietary intake surveys indicate a high prevalence of vitamin D inadequacy in the US population, with 81% of children and adolescents (age 2-18 years) and 95% of adults not meeting the EAR (24) . Fortified food substantially contribute to total vitamin D intake from the diet, especially among children and adolescents where intake from fortified food is 2.5 times that from natural sources ( Table 2) (24) .

However, surveys of dietary intake are not very informative because sunlight is the primary source of vitamin D (see the article on Vitamin D ). Measuring total serum 25-hydroxyvitamin D concentration (1 ng/mL corresponds to 2.5 nmol/L) is considered the best indicator to evaluate vitamin D status. Yet, high-quality evidence is still needed to ensure that the current cutoff values are optimal to define states of insufficiency and deficiency (51) . According to the National Academy of Medicine (NAM) (formerly the Institute of Medicine), dietary intake at a level equivalent to the EAR corresponds to a 25-hydroxyvitamin D concentration of 16 ng/mL (40 nmol/L) (52) ; thus, concentrations below that cutoff are considered inadequate. The NAM cutoff for vitamin D deficiency is 12 ng/mL or 30 nmol/L; 25-hydroxyvitamin D concentrations greater than 20 ng/mL (50 nmol/L) are considered adequate for bone health by the NAM (52) . Using these cutoffs, NHANES 2003-2006 found 17.2% and 8.1% of the US population (ages ≥1 year) to be inadequate or deficient in vitamin D, respectively (36) . Sharp differences were found when the data were examined by ethnicity, with vitamin D inadequacy and deficiency being quite prevalent among Non-Hispanic blacks (see Table 4 ) (36) . Additionally, obesity ( body mass index [BMI] ≥30 kg/m 2 ) — affecting more than one-third of US adults (53)   — is known to increase one’s risk for vitamin D deficiency (54) .

An analysis of NHANES 2003-2006 data examining vitamin D status among US children and adolescents (ages 6-18 years), found that 10.3% were inadequate and 4.6% were deficient according to the NAM cutoffs (55) . Stratifying the data by age group showed a lower prevalence of vitamin D insufficiency in younger children compared to older children and adolescents (see Table 5 ). Among children and adolescents considered obese (>95% BMI percentile), 17.8% had inadequate vitamin D status and 8.2% had vitamin D deficiency (55) .

Overall, the prevalence of vitamin D inadequacy measured by biomarker data is much lower than the prevalence assessed by dietary intake surveys for all age groups. As stated above, dietary surveys poorly assess vitamin D body status. Sun exposure, skin color, and BMI have variable, substantial impact on vitamin D status; thus, examining circulating 25-hydroxyvitamin D concentrations is the most reliable way to assess vitamin D status in a population.

The above-discussed biomarker data use the NAM cutoffs for inadequacy and deficiency. Others have used higher cutoffs to evaluate vitamin D status in a population. For example, the US Endocrine Society has suggested that vitamin D deficiency and insufficiency should be defined as serum 25-hydroxyvitamin D values of ≤20 ng/mL (≤50 nmol/L) and <30 ng/mL (75 nmol/L), respectively (51) . The Linus Pauling Institute recommends that individuals aim for serum 25-hydroxyvitamin D concentrations of at least 30 ng/mL (75 nmol/L). Using such cutoffs would result in higher estimates of the prevalence of vitamin D deficiency and inadequacy in a population.

Severe vitamin E deficiency rarely occurs in humans but has been observed as a result of malnutrition, from genetic defects affecting the transport of α-tocopherol (i.e., defects of the α-tocopherol transfer protein [α-TTP] or of apolipoprotein B), and in fat malabsorption syndromes (56) . Circulating levels of α-tocopherol are often used to assess vitamin E status , although concentrations should be adjusted for plasma lipid concentrations when elevated (57) . According to the US National Academy of Medicine, plasma α-tocopherol concentrations less than 12 μmol/L (516 μg/dL) in adults are indicative of vitamin E inadequacy (58) . Using this cutoff, data from NHANES 2005-2006 based on plasma concentrations show that the prevalence of vitamin E inadequacy among US adults (≥20 years), excluding pregnant and lactating women, is extremely low (<1% of the population) (36) . Past NHANES analyses have found a similar low prevalence of vitamin E inadequacy among US adults (36) . This contrasts with the data from dietary surveys that suggest vitamin E inadequacy in the US is widespread. Discrepancies may be due to a number of factors, including underreporting of fat and fat-soluble vitamin intake, inaccuracies in the food composition database that lists nutrient values of foods, and/or lack of correction of circulating vitamin E concentrations to lipid concentrations (36) . Some have questioned whether the nutritional requirement of vitamin E needs to be reevaluated (57) .

Micronutrient Excess

According to dietary surveys, almost all Americans meet the AI for sodium (1.2-1.5 g/day for ages ≥4 years). In fact, sodium is overconsumed by the US population: 90% of US adults surveyed in NHANES 2011-2012 had daily sodium intakes in excess of the UL of 2.3 g/day (42) . Several surveys have found that more than 99% of US adults have intakes in excess of the AI for all age and gender groups examined (26 , 59) . Combined data from NHANES 2007-2008 and 2009-2010 indicated that average dietary sodium intakes were 3.1 g/day in children (ages, 3-18 years), 3.8 g/day in adults ages 19-50 years, and 3.3 g/day in older adults (>50 years) (60) . All of these intakes are well above the UL — only about 22% of children, 8% of adults, and 15% of older adults consume less than the life stage-specific UL for sodium (60) . A more recent assessment from NHANES 2011-2012 examined sodium intakes of children by age group, finding average intakes of 3.1 g/day in children (ages, 6-10 years), 3.1 g/day in preadolescents (ages, 11-13 years), and 3.6 g/day in adolescents (ages, 14-18 years) — intakes all above the UL (61) . Overconsumption of sodium is apparent among younger children as well: A compilation of data from NHANES 2003-2010 found that 79% of children ages 1 to 3 years and 87% of children ages 4 to 5 years had sodium intakes in excess of the UL (46) . A UL has not been established for infants, but average sodium intake in infants ages 7 to 11 months was 500 mg/day (AI, 370 mg/day) (46) .

While dietary recall methods like those employed in NHANES are not the best measure of sodium intake due to day-to-day variations (24-hour urinary excretion is the gold standard), they likely underestimate intake in populations because of underreporting of food (62) . Thus, overconsumption of sodium, which is linked to adverse health outcomes ( hypertension , cardiovascular disease ), is a major public health concern in the US (see the article on Sodium ).

NOTE: In this article, average intakes in the US are compared to the Dietary Reference Intakes ( DRIs ) that were set in 2005. In 2019, the National Academy of Medicine (NAM) established new DRIs: an AI for sodium (see the article on Sodium ) and a Chronic Disease Risk Reduction Intake for sodium (see the article on Sodium ). The NAM did not set a UL (for details, see the article on Sodium ).

Written in November 2017 by: Victoria J. Drake, Ph.D. Linus Pauling Institute Oregon State University

Reviewed in March 2018 by: Balz Frei, Ph.D. Former Director, Linus Pauling Institute Distinguished Professor Emeritus, Dept. of Biochemistry and Biophysics Oregon State University

The writing of this article was supported by a grant from Pfizer Inc.

Copyright 2018-2024  Linus Pauling Institute

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39.  Food and Nutrition Board, Institute of Medicine. Iron. Dietary Reference Intakes for Vitamin A, Vitamin K, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. Washington, D.C.: National Academy Press; 2001:290-393.  (National Academy Press)

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Impact of Frequency of Multi-Vitamin/Multi-Mineral Supplement Intake on Nutritional Adequacy and Nutrient Deficiencies in U.S. Adults

Jeffrey b. blumberg.

1 Antioxidants Research Laboratory, Jean Mayer USDA Human Nutrition Research Center on Aging and Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA 02111, USA

Balz B. Frei

2 Linus Pauling Institute and Department of Biochemistry & Biophysics, Oregon State University, Corvallis, OR 97331, USA; [email protected]

Victor L. Fulgoni, III

3 Nutrition Impact, LLC, Battle Creek, MI 49014, USA; moc.loa@DR3CIV

Connie M. Weaver

4 Department of Nutrition Science, Purdue University, West Lafayette, IN 47907, USA; ude.eudrup@mcrevaew

Steven H. Zeisel

5 Nutrition Research Institute, Department of Nutrition, University of North Carolina, Kannapolis, NC 28081, USA; ude.cnu@lesiez_nevets

Although >50% of U.S. adults use dietary supplements, little information is available on the impact of supplement use frequency on nutrient intakes and deficiencies. Based on nationally representative data in 10,698 adults from the National Health and Nutrition Examination Surveys (NHANES) 2009 to 2012, assessments were made of intakes from food alone versus food plus multi-vitamin/multi-mineral supplements (MVMS) of 17 nutrients with an Estimated Average Requirement (EAR) and a Tolerable Upper Intake Level (UL), and of the status of five nutrients with recognized biomarkers of deficiency. Compared to food alone, MVMS use at any frequency was associated with a lower prevalence of inadequacy ( p < 0.01) for 15/17 nutrients examined and an increased prevalence of intakes >UL for 7 nutrients, but the latter was ≤4% for any nutrient. Except for calcium, magnesium, and vitamin D, most frequent MVMS use (≥21 days/30 days) virtually eliminated inadequacies of the nutrients examined, and was associated with significantly lower odds ratios of deficiency for the examined nutrient biomarkers except for iron. In conclusion, among U.S. adults, MVMS use is associated with decreased micronutrient inadequacies, intakes slightly exceeding the UL for a few nutrients, and a lower risk of nutrient deficiencies.

1. Introduction

Adequate intake of micronutrients (vitamins and nutritionally-essential minerals) is required for nearly all metabolic, developmental, and growth processes, and for good health across the lifespan. Despite repeated recommendations from the Dietary Guidelines Advisory Committee [ 1 ], many Americans have inadequate intakes of several essential nutrients. The recent 2015–2020 Dietary Guidelines for Americans (DGA) [ 2 ] identified vitamins A, D, E, and C, and choline, calcium, magnesium, iron (for certain age/gender groups), potassium, and fiber as “underconsumed nutrients”; of these, vitamin D, calcium, iron, potassium, and fiber are under-consumed to the extent that may lead to adverse health outcomes and, as such, were designated as “nutrients of public health concern”. The DGA [ 2 ] recommend consuming nutrient-dense foods as part of a healthy eating pattern and, in some cases, fortified foods and dietary supplements, especially for certain population groups.

Dietary supplement consumption has increased over time in the United States [ 3 ] and currently appears to have stabilized to about 50% of adults, of whom more than two-thirds use multi-vitamin/multi-mineral supplements (MVMS) [ 4 , 5 , 6 ]. A recent study [ 6 ] reported use of MVMS (defined as ≥10 vitamins and/or minerals at any level) has declined from 37 to 31% from 1999 to 2012 in U.S. adults 20 years and older. In addition to MVMS, single nutrient supplements, especially of vitamins C and E, and calcium and iron, are also commonly used by Americans [ 7 , 8 ]. Supplements are mostly perceived as a favorable health and lifestyle choice, and the key motivators for consumers are maintenance or improvement in overall health as well as specific health benefits rather than filling nutritional gaps [ 9 , 10 ]. Interestingly, there is no standardized definition of MVMS and a wide range of definitions encompassing a wide range of products of different compositions and characteristics are available in the marketplace [ 6 , 11 ]. This heterogeneity poses a significant challenge to studying the effects of MVMS, especially in a nonclinical setting.

The consumption of dietary supplements has been shown to increase overall nutrient intake and decrease the prevalence of nutrient inadequacies [ 12 ]. Based on a definition of MVMS as providing at least 100% of the recommended dietary allowance (RDA) or adequate intake (AI) for at least 9 vitamins and minerals, and using data from the National Health and Nutrition Examination Survey (NHANES) 2007–2010, MVMS were reported to contribute to a greater number of individuals meeting their recommended intakes of almost all micronutrients [ 5 ]. MVMS users in that study were defined as those who reported using MVMS any time during the last 30-day period. However, there is a great deal of diversity in the frequency of MVMS usage. A recent survey from Korea reported that only 60% of supplement users consume them every day [ 13 ]. To date, no studies have been reported examining the impact of frequency of supplement use on nutrient intakes in the U.S. population.

The U.S. Centers for Disease Control and Prevention (CDC) Second National Report on Biochemical Indicators of Diet and Nutrition in the U.S. Population reported that in 2003–2006 less than 10% of individuals had nutritional deficiencies based on measured nutrient biomarkers but, for most nutrition indicators, deficiencies varied by age, gender, or race/ethnicity and were as high as nearly one third of certain population groups [ 14 ]. Few studies have reported results of MVMS consumption on biomarkers of nutrient status. The primary objective of this cross-sectional study was to investigate the effect of frequency of MVMS consumption on nutrient intake, prevalence of inadequacies, and prevalence of deficiencies using a large, nationally representative NHANES data set.

2. Materials and Methods

2.1. study population.

This study analyzed data from NHANES, a yearly assessment by the National Center for Health Statistics (NCHS) of the health and nutrition status of a nationally-representative sample of noninstitutionalized U.S. civilians. The data from NHANES 2009–2010 and 2011–2012 surveys were combined for all analyses except where noted. The combined sample included 10,698 adults (5349 males and 5349 females) age 19 years and older, excluding pregnant and/or lactating females and those with incomplete or unreliable data as judged by the USDA Food Surveys Research Group staff. All participants or proxies provided written informed consent and the Research Ethics Review Board at the NCHS approved the survey protocol [ 15 ].

2.2. Micronutrient Intake from Food

Dietary intake data from two reliable 24-h recall dietary interviews using United States Department of Agriculture’s (USDA) automated multiple-pass method (AMPM) were used [ 15 ]. The Food and Nutrient Database for Dietary Studies (FNDDS) 2009–2010 and 2011–2012 [ 16 , 17 ] were used in conjunction with USDA National Nutrient Database for Standard Reference (SR) releases 24 and 26 [ 18 ], respectively, to determine the nutrient content of food consumed by subjects who participated in NHANES 2009–2010 and 2011–2012.

2.3. Definition of MVMS and Micronutrient Intake from MVMS

MVMS were defined as dietary supplements providing at least 100% of the RDA or AI for at least 9 vitamins and minerals with defined dietary reference intake (DRI) values for which NHANES 2009–2010 and 2011–2012 collected intake data. Specific EAR and AI values [ 19 , 20 ] for each adult age/gender group were used. In NHANES, a dietary supplement questionnaire assessing the usage of vitamins, minerals, botanicals, and other dietary supplements over the past 30 days was administered as part of the NHANES household interview [ 21 ]. The consumption frequency (i.e., number of days the product was taken in the past 30 days), the duration (i.e., how long the product was taken), and the amount usually consumed on days the supplement was taken in the past 30 days were recorded for each supplement. The complete product information from the dietary supplement container was also recorded so that every reported dietary supplement could be matched or entered into a dietary supplements database. The NCHS maintains a dietary supplements database that contains product label information obtained from manufacturers of dietary supplements reported in NHANES; these data include the labeled dosage or serving size, ingredients, and the amounts of ingredients per serving. The average daily intake of nutrients from MVMS was calculated for individuals using the supplement consumption frequency and dosage. Nutrients from other dietary supplements not meeting the definition of MVMS were not included (e.g., single nutrient supplements, other multi-vitamin/multi-mineral dietary supplements with fewer than 9 nutrients). Supplement consumers were defined as those taking any amount of MVMS at any frequency. The frequency of MVMS usage was defined based on reported consumption during the past 30 days of: (1) 0 days (non-consumers of MVMS); (2) 1–10 days; (3) 11–20 days; and (4) ≥21 days.

2.4. Biomarkers of Nutrient Deficiencies

As part of the NHANES in-person health examination in the Mobile Examination Center, participants provided a blood specimen for laboratory analyses. Values for serum levels of pyridoxal-5′-phosphate, cobalamin, ascorbic acid (vitamin C), 25-hydroxyvitamin D, transferrin receptor, and ferritin were obtained from laboratory files [ 22 ]. Body iron (mg/kg body weight) in females only was calculated as –[(log10((soluble transferrin receptor × 1000)/ferritin) − 2.8229)]/0.1207 where soluble transferrin receptor is in (mg/L) and ferritin is in (ng/mL) [ 23 ]. Because not all nutrient biomarkers were measured in each NHANES cycle, multiple cycles were combined to obtain an adequate sample size (for pyridoxal-5′-phosphate and body iron data from NHANES 2003–2010 were used; for serum cobalamin data from NHANES 2001–2012 were used; for ascorbic acid data from NHANES 2003–2006 were used; and for 25-hydroxyvitamin D data from NHANES 2001–2010 were used). The nutrient cut-off levels used to identify nutrient deficiency were: pyridoxal-5′-phosphate levels < 20 nmol/L for vitamin B 6 ; serum cobalamin < 200 pg/mL for vitamin B 12 ; serum ascorbic acid < 11.4 μmol/L for vitamin C; serum 25-hydroxyvitamin D < 30 nmol/L for vitamin D; and body iron < 0 mg/kg for iron deficiency [ 14 ].

2.5. Statistics

All statistical analyses were performed with SAS (version 9.2; SAS Institute Inc., Cary, NC, USA) and SUDAAN (version 11; Research Triangle Institute; Raleigh, NC, USA). NHANES survey weights, strata, and primary sampling units were used to calculate nationally representative estimates. Usual nutrient intakes (long-term intakes) from food only were estimated using two days of dietary intake in NHANES with the National Cancer Institute method [ 24 ] and with age groups, day of recall, weekday/weekend intake flag, and dietary supplement use (yes/no) flag as covariates. Nutrients provided by MVMS only were added to usual intake of food to obtain intakes from food and MVMS. The percentage of the population below the Estimated Average Requirement (EAR) using the cut-point method (except for iron where the probability method was used) for 17 micronutrients (calcium, copper, iron, magnesium, phosphorus, selenium, zinc, vitamin A, thiamin, riboflavin, niacin, folate, vitamin B 6 , vitamin B 12 , vitamin C, vitamin D, and vitamin E) and the percentage above the Tolerable Upper Intake Level (UL) for 12 micronutrients (calcium, copper, iron, phosphorus, selenium, zinc, vitamin A as retinol, folate as folic acid, vitamin B 6 , vitamin C, vitamin D, and vitamin E as added alpha-tocopherol) were assessed. A Z-statistic was used to test whether mean intakes and proportions of the population below the EAR or above the UL were similar between groups. Main comparisons were: (1) intakes from food alone and from food plus MVMS for MVMS consumers; and (2) intakes in non-consumers and the three groups of MVMS consumers, based on frequency of consumption. Logistic regression analyses were used to assess the association of MVMS usage on odds ratio of being below defined deficiency levels for certain nutrients in adults after adjustment for various covariates (age, gender, race/ethnicity, poverty income ratio, physical activity, and alcohol intake). To focus these analyses on MVMS, only subjects who consumed MVMS with no other dietary supplements were included in the logistic regression analyses. p- value < 0.01 was deemed statistically significant.

3.1. MVMS Usage

About 28% of adults ( n = 2623) reported taking a MVMS, including 3.6% ( n = 349) for 1–10/30 days, 4.1% ( n = 404) for 11–20/30 days, and 20.0% ( n = 1870) for ≥21/30 days.

3.2. Impact of MVMS Use and Frequency of Use

Among adults who reported taking a MVMS (at any frequency), usual intake from food and MVMS combined was significantly higher ( p < 0.01) for all micronutrients examined (except phosphorus) than from food only ( Table 1 ). The prevalence of inadequacy (intakes < EAR) was significantly lower ( p < 0.01) for seven of the DGA “underconsumed nutrients” and, except for calcium, magnesium, and vitamins D and E, was <5% for all 17 nutrients examined ( Table 1 and Figure 1 ). MVMS consumers also had a higher ( p < 0.01) prevalence of intakes above the UL for calcium, iron, selenium, zinc, vitamins A, B 6 , and folate (as folic acid) from food and MVMS compared to food only, however, all were ≤4% ( Table 1 ). Similar results were obtained when the data were analyzed for male and female adults separately except that there was a slightly smaller difference in prevalence of inadequacy among male adults than among female adults ( Figure 2 ).

Prevalence of inadequacy (% of population below EAR) for “underconsumed nutrients” identified in 2015–2020 Dietary Guidelines for Americans from food only and food + MVMS among adults age 19 years and older reporting taking a MVMS. NHANES 2009–2012. * Significantly different from Food only at p < 0.01. EAR: estimated average requirement; MVMS: multi-vitamin/multi-mineral supplements; NHANES: National Health and Nutrition Examination Survey.

Prevalence of inadequacy (% of population below EAR) of intakes of other micronutrients from food only and food + MVMS among females and males age 19 years and older reporting taking a MVMS. NHANES 2009–2012. ( A ) Females; ( B ) Males. * Significantly different from Food only at p < 0.01. EAR: estimated average requirement; MVMS: multi-vitamin/multi-mineral supplements; NHANES: National Health and Nutrition Examination Survey.

Usual intake, prevalence of inadequacy (% of population below EAR) and % of population exceeding the UL of 17 micronutrients from food only and food + MVMS among adults age 19 years and older reporting taking a MVMS. NHANES 2009–2012.

* Significantly different from Food Only column at p < 0.01; ND: Not determined as niacin and magnesium UL are based on a particular form/sources, which are not quantified in NHANES. a UL based on retinol; b UL based on folic acid; c UL based on added alpha-tocopherol. EAR: estimated average requirement; mg: milligram; MVMS: multi-vitamin/multi-mineral supplements; NHANES: National Health and Nutrition Examination Survey; RAE: retinol activity equivalents; DFE: dietary folate equivalents µg: microgram; UL: tolerable upper intake level.

3.3. Impact of Frequency of MVMS Usage

The usual intakes for most micronutrients significantly increased ( p < 0.01) with increased frequency of MVMS intake compared to not taking a MVMS ( Table 2 ). Any frequency of MVMS usage was associated with significant reductions in inadequate intakes for all DGA “underconsumed nutrients” except for calcium with the lowest MVMS frequency ( Figure 3 ). Prevalence of inadequacy for magnesium and vitamins A, C, D, and E also decreased significantly ( p < 0.01) with increased frequency of MVMS intake. The prevalence of inadequacy for vitamins A, C, D, and E dropped to ≤4% of adults with MVMS intake at the highest frequency (≥21 days per 30 days). The percentage of the population above the UL, while extremely low for those not taking a MVMS, increased significantly for calcium, iron, selenium, zinc, vitamin A, vitamin B 6 , and folate for the highest frequency of MVMS usage, however, it was never more than ~4% of the population for any of the nutrients ( Table 2 ). Again, similar results were observed when the data were analyzed for male and female adults separately. Reductions in inadequate intakes for all DGA “underconsumed nutrients” ( Figure 3 ) and for percentages <EAR/>UL were similar except that there was a slightly larger impact among female adults for percentages <EAR than among male adults. Additionally, male adults had slightly higher percentages >UL than females ( Figure 4 ). For many but not all nutrients, different MVMS usage frequencies were significantly different from one another in nutrient intakes and <EAR/>UL prevalence percentages ( Table 2 , Figure 3 and Figure 4 ).

Prevalence of inadequacy (% of population below EAR) of “underconsumed nutrients” identified in 2015–2020 Dietary Guidelines for Americans for food + MVMS by frequency of MVMS intake among all adults ( A ); females ( B ); and males ( C ) age 19 years and older. NHANES 2009–2012. * Significantly different from 0 days per month at p < 0.01. a,b,c Values by frequency of MVMS with different superscripts are significantly different at p < 0.01. EAR: estimated average requirement; MVMS: multi-vitamin/multi-mineral supplements; NHANES: National Health and Nutrition Examination Survey.

Prevalence of inadequacy (% of population below the EAR) and % population above the UL of other micronutrient intakes from food + MVMS by frequency of MVMS intake among adult females and males age 19 years and older. NHANES 2009–2012. ( A ) Females below EAR; ( B ) Males below EAR; ( C ) Females above UL; ( D ) Males above UL. * Significantly different from 0 days per month at p < 0.01. a,b,c Values by frequency of MVMS with different superscripts are significantly different at p < 0.01. EAR: estimated average requirement; MVMS: multi-vitamin/multi-mineral supplements; NHANES: National Health and Nutrition Examination Survey; UL: upper tolerable intake level.

Usual intake, prevalence of inadequacy (% population below EAR), and % population exceeding tolerable upper intake level (UL) of 17 micronutrients from food + MVMS by frequency of MVMS intake among all adults age 19 years and older. NHANES 2009–2012.

* Significantly different from 0 days column at p < 0.01; MVMS: multi-vitamin/multi-mineral supplements; a,b,c Values by frequency of MVMS with different superscripts are significantly different at p < 0.01. ND: Not determined as niacin and magnesium UL are based on a particular form/sources, which are not quantified in NHANES. a UL based on retinol; b UL based on folic acid; c UL based on added alpha-tocopherol. EAR: estimated average requirement; mg: milligram; MVMS: multi-vitamin/multi-mineral supplements; NHANES: National Health and Nutrition Examination Survey; µg: microgram; UL: tolerable upper intake level.

3.4. Impact of Frequency of MVMS Usage on Biomarkers of Nutrient Deficiencies

Those not taking a MVMS (0 days) had the following percentages of the population (SE) with biomarker-defined deficiency levels: 17.5 (0.7) for vitamin B 6 ; 2.7 (0.2) for vitamin B 12 ; 10.5 (1.1) for vitamin C; 8.5 (0.6) for vitamin D; and 7.3 (0.6) for total body iron (women only). The use of a MVMS at any frequency was associated with a significantly reduced risk ( p < 0.01) of being at or below deficiency levels for the vitamins examined, but not body iron ( Table 3 ). Compared to not using a MVMS, the most frequent MVMS usage (≥21 days per 30 days) was associated with a 58–76% reduced risk of being at or below deficiency levels for the vitamins examined (MVMS at any frequency was associated with a 58–69% lowered risk of nutrient deficiencies for vitamins B 6 , B 12 , C, and D). MVMS consumption was not associated with risk of low body iron stores (women only) ( Table 3 ). Less frequent MVMS usage (11–20 days per 30 days) was also associated with significantly lower OR of being deficient for vitamin B 6 and vitamin D compared to those not reporting use of MVMS.

Impact of MVMS intake frequency on odds ratios of risk of being below defined deficiency level for certain nutrients in adults.

* Significantly different from 0 Days at p < 0.01. a,b,c Values by frequency of MVMS with different superscripts are significantly different at p < 0.01. Those not taking an MVMS (0 days) had the following percentages of the population (SE) with deficiency levels of vitamin B 6 (<20 nmol/L), vitamin B 12 (<200 pg/mL) , vitamin C (<11.4 μmol/L), vitamin D (<30 nmol/L), and body iron (<0 mg/kg; women only):, 17.5 (0.7), 2.7 (0.2), 10.5 (1.1), 8.5 (0.6) and 7.3 (0.6)%, respectively. a NHANES 2003–2010; b NHANES 2001–2012; c NHANES 2003–2006; d NHANES 2001–2010. CI: confidence interval; kg: kilogram; L: liter; mg: milligrams; mL: milliliter; mmol: millimoles; MVMS: multi-vitamin/multi-mineral supplements; NHANES: National Health and Nutrition Examination Survey; nmol: nanomoles; pg: picograms; µmol: micromoles.

4. Discussion

This report evaluated the impact of frequency of MVMS use on the prevalence of micronutrient inadequacies (defined as nutrient intakes below the EAR) and deficiencies (defined as having low levels of biomarkers of nutrient status) in the U.S. adult population. Similar to earlier reports [ 4 , 5 , 6 ], in the present analysis using NHANES data from 2009–2012, about 28% reported taking MVMS as defined in this study. Most MVMS consumers reported taking MVMS every day, with a smaller number of occasional or sporadic users. Use of a MVMS at any frequency significantly increased nutrient intakes and decreased the percent of the population with inadequate intakes for most micronutrients, especially “underconsumed nutrients”, as compared to food alone. More frequent MVMS use was associated with significantly higher nutrient intakes and lower prevalence of nutrient inadequacies, with these effects being more pronounced among regular users compared to sporadic users.

Micronutrient inadequacies are associated with adverse health effects such as neural tube defects, poor bone health (osteoporosis), impaired immune function, and impaired cognitive function, as well as chronic diseases, such as certain cancers, age-related eye diseases, hypertension, and possibly coronary heart disease and stroke [ 14 , 25 , 26 ]. Low intakes of calcium, potassium, iron (adolescent and adult females), dietary fiber, and vitamin D have been linked in the scientific literature to adverse health outcomes and hence are considered nutrients of public health concern [ 2 ]. The CDC’s Second National Report on Biochemical Indicators of Diet and Nutrition in the U.S. Population [ 14 ] reported that about 10% of the U.S. population had nutritional deficiencies (based on nutrient status markers), which could be as high as nearly one third for certain subpopulations. Micronutrient deficiencies are known to cause deficiency disease, such as rickets (vitamin D), scurvy (vitamin C), megaloblastic anemia (folate or vitamin B 12 ), or iron-deficiency anemia. Our data indicate that use of MVMS at any frequency was associated with a 58–69% lowered risk of nutrient deficiencies for vitamins B 6 , B 12 , C, and D, and most frequent use of MVMS (≥21 days per 30 days) was associated with a 58–76% lowered risk.

As expected, more frequent MVMS intake shifted the population to higher nutrient intakes and thus lowered the prevalence of nutrient inadequacies, but also increased the prevalence of intakes above the UL for several nutrients. However, even with the most frequent usage of MVMS, the prevalence of overconsumption was ≤4%. Further, about 45% or more of those exceeding the UL were within 10% of the UL (data not shown). However, this study only examined the nutrient contribution of MVMS and not other dietary supplements simultaneously consumed; 33.1 ± 1.3% of MVMS consumers were also taking a single-nutrient supplement (defined as a dietary supplement with one and only one nutrient at any level), and their use increased in MVMS consumers as frequency of MVMS consumption increased (20.8 ± 1.3%, 29.2 ± 2.5%, and 36.3 ± 1.5% in the 1–10, 11–21, and ≥21 days per 30 days groups, respectively). Concomitant consumption of MVMS and single supplements (and other non-MVMS supplements) needs to be more thoroughly evaluated as intakes may increase the percentage of the population exceeding the UL.

A major strength of our study was the use of a large, nationally representative, population-based sample of adults examining frequency of consumption of one common type of dietary supplement, MVMS. A limitation of our study was that the estimates relied on self-reported intakes, which require memory and are subject to bias, especially in those who are overweight or obese [ 27 ]. Additionally, self-reported dietary supplement intake was assumed to accurately reflect long-term MVMS intake patterns. Although the dietary supplement data were self-reported, about 80% of the time, NHANES interviewers saw the dietary supplement bottles/labels and verified the self-reporting accuracy. Furthermore, estimates of vitamins and minerals contributed by MVMS relied on the label declarations rather than analytic values. Only the impact of MVMS was evaluated, and not other types of dietary supplements concomitantly consumed, which would further increase intake. The results of this study should be interpreted with these limitations in mind.

5. Conclusions

Frequent use of MVMS is effective in increasing micronutrient intakes, decreasing prevalence of most nutrient inadequacies, and decreasing risk of deficiencies of vitamins B 6 , B 12 , C, and D in the U.S. adult population. Intake of MVMS also slightly increased the prevalence of consumption above the UL for calcium, iron, zinc, and folic acid, but was ≤4% for any nutrient.

Acknowledgments

This research was supported by Bayer Consumer Healthcare, DSM and Pharmavite, which are members of the Campaign for Essential Nutrients (CFEN).

Author Contributions

All authors jointly conceived and designed the analyses. VLF performed the analyses and wrote the first draft of this article, to which all other authors provided input.

Conflicts of Interest

In addition to consulting work for the Campaign for Essential Nutrients (CFEN), the authors receive research support from USDA ARS grant 58-1950-014 (J.B.B.), NIH grant AT008754 (C.M.W.) and Nestle Nutrition (S.H.Z.). The authors serve on scientific advisory boards for AdvoCare (J.B.B.), Pfizer Consumer Healthcare (B.B.F., J.B.B.), Pharmavite (C.M.W., J.B.B.) and Metabolon (S.H.Z.). S.H.Z. is a founder of Nutrigene Sciences, LLC, a company in which he owns stock equity. V.L.F., as Senior Vice President of Nutrition Impact LLC, performs consulting and database analyses for various food and beverage companies and related entities. Neither CFEN nor its individual company members had any role in the design of this study; collection, analyses or interpretation of the data; or writing of the manuscript. The authors made the final decision to publish these findings.

Here’s how you know

• U.S. Department of Health and Human Services
• National Institutes of Health

Using Dietary Supplements Wisely

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How much do we know about dietary supplements.

The amount of scientific evidence we have on dietary supplements varies widely—we have a lot of information on some and very little on others.

What do we know about the effectiveness of dietary supplements?

• Studies have found that some dietary supplements may have some benefit, such as melatonin for jet lag, and others may have little or no benefit, such as ginkgo for dementia.
• Supplements you buy from stores or online may differ in important ways from products tested in studies.
• Most research shows that taking multivitamins doesn’t result in living longer, slowing cognitive decline, or lowering the chance of getting cancer, heart disease, or diabetes.

What do we know about the safety of dietary supplements?

• Taking a multivitamin is unlikely to pose any health risks.
• Dietary supplements may interact with your medications or pose risks if you have certain medical problems or are going to have surgery.
• Many dietary supplements haven’t been tested in pregnant women, nursing mothers, or children.
• Some products marketed as dietary supplements—promoted mainly for weight loss, sexual enhancement, and bodybuilding—may contain prescription drugs not allowed in dietary supplements or other ingredients not listed on the label. Some of these ingredients may be unsafe.

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Federal law defines dietary supplements as products that:

• You take by mouth (such as a tablet, capsule, powder, or liquid)
• Are made to supplement the diet
• Have one or more dietary ingredients, including vitamins, minerals, herbs or other botanicals , amino acids, enzymes, tissues from organs or glands, or extracts of these
• Are labeled as being dietary supplements.

What Are Herbal Supplements?

Herbal supplements are a type of dietary supplement containing one or more herbs. They are:

• Sometimes called botanicals
• Made from plants, algae, fungi, or a combination of these
• Sold as teas, extracts, tablets, capsules, powders, or in other forms.

Dietary Supplement Use in the United States

According to the 2012 National Health Interview Survey, which included questions on Americans’ use of natural products (dietary supplements other than vitamins and minerals), almost 18 percent of adults and about 5 percent of children used these products in 2012.

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• The National Health and Nutrition Examination Survey collected data from 2011 to 2012 on the use of all types of dietary supplements. It found that 52 percent of American adults took at least one dietary supplement. Multivitamin or multimineral supplements—a product having 10 or more vitamins or minerals—were one of the most common, and 31 percent of all adults took them. This was a decrease from 1999 to 2000, when 37 percent of American adults reported using multivitamin or multimineral supplements. Women were more likely than men to take dietary supplements.
• For more information on dietary supplement use in the United States, including among children, see the National Center for Complementary and Integrative Health (NCCIH) webpage with statistics about complementary and integrative health approaches .

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American adults often use dietary supplements for wellness. According to the 2012 National Health Interview Survey, 89 percent of American adults who took dietary supplements other than vitamins and minerals gave wellness-related reasons for using them, including:

• General wellness or disease prevention (83 percent)
• Improve immune function (42 percent)
• Improve energy (31 percent)
• Focuses on the whole person—mind, body, and spirit (27 percent)
• Improve memory or concentration (22 percent).

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• Federal regulations state that companies are responsible for having evidence that their dietary supplements are safe and for ensuring that product labels are truthful and not misleading. Manufacturers are required to produce dietary supplements in a quality manner, ensure that they don’t contain contaminants or impurities, and label them accurately.
• The U.S. Food and Drug Administration (FDA), which regulates dietary supplements, requires that companies submit safety data about any new ingredient not sold in the United States in a dietary supplement before 1994. In all other cases, the FDA is not authorized to review dietary supplements for safety and effectiveness before they are marketed.
• The FDA can take action against adulterated or misbranded dietary supplements only after the product is on the market. In contrast, companies must show the FDA evidence that their prescription and over-the-counter drugs are safe and effective before the drugs are marketed.
• Once a dietary supplement is on the market, the FDA tracks side effects reported by consumers, supplement companies, and others. You can report any safety concerns you may have about a dietary supplement through the U.S. Health and Human Services Safety Reporting Portal .
• If the FDA finds a product to be unsafe, it can take legal action against the manufacturer or distributor, and may issue a warning or require that the product be removed from the marketplace. However, the FDA says it can’t test all products marketed as dietary supplements that may have potentially harmful hidden ingredients. In 2023, the FDA launched the Dietary Supplement Ingredient Directory , a webpage where the public can look up ingredients used in products marketed as dietary supplements and find what the FDA has said about that ingredient, as well as whether the agency has taken any action with regard to the ingredient.
• For more information on contaminants in dietary supplements, see the FDA’s Dietary Supplement Products & Ingredients webpage.

Health and Structure/Function Claims

• Health claims describe a relationship between a substance in the supplement and reduced risk of a disease or condition. They must be based on scientific evidence. For example, if a supplement label says “Calcium may reduce the risk of the bone disease osteoporosis,” that’s a health claim.
• Structure/function claims describe the effect of a substance on maintaining the body’s normal structure or function. For example, if a supplement label says “Calcium builds strong bones,” that’s a structure/function claim. Structure/function claims on dietary supplement labels must be accompanied by this disclaimer: “This statement has not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, mitigate, or prevent any disease.”
• Advertising The U.S. Federal Trade Commission (FTC), which regulates advertising, requires that advertising be truthful and not misleading.

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• Some dietary supplements can be good for your health, while others haven’t been proven to work. For information on the effectiveness of different supplements, see the NCCIH webpage about dietary supplements .
• Studies of some supplements haven’t supported claims made about them. For example, in several studies, echinacea didn’t help cure colds and Ginkgo biloba wasn’t useful for dementia. Many times the research on a dietary supplement is conflicting, such as whether the supplements glucosamine and chondroitin improve symptoms of osteoarthritis.
• Strong evidence to back up claims made for dietary supplements is often lacking. For example, a 2022 review identified 27 ingredients frequently included in supplements with claims related to immune function, such as “supports healthy immune system” or “natural immune booster.” The reviewers searched the scientific literature for rigorous studies in people on the effectiveness of each ingredient, and they found evidence of this type for only eight of them. Some of the studies suggested possible benefits, but the evidence wasn’t strong enough to allow definite conclusions to be reached. Additional research is needed so consumers will know whether a dietary supplement promoted for immune health can help protect them from getting sick.

.header_greentext{color:green!important;font-size:24px!important;font-weight:500!important;}.header_bluetext{color:blue!important;font-size:18px!important;font-weight:500!important;}.header_redtext{color:red!important;font-size:28px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;font-size:28px!important;font-weight:500!important;}.header_purpletext{color:purple!important;font-size:31px!important;font-weight:500!important;}.header_yellowtext{color:yellow!important;font-size:20px!important;font-weight:500!important;}.header_blacktext{color:black!important;font-size:22px!important;font-weight:500!important;}.header_whitetext{color:white!important;font-size:22px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;}.Green_Header{color:green!important;font-size:24px!important;font-weight:500!important;}.Blue_Header{color:blue!important;font-size:18px!important;font-weight:500!important;}.Red_Header{color:red!important;font-size:28px!important;font-weight:500!important;}.Purple_Header{color:purple!important;font-size:31px!important;font-weight:500!important;}.Yellow_Header{color:yellow!important;font-size:20px!important;font-weight:500!important;}.Black_Header{color:black!important;font-size:22px!important;font-weight:500!important;}.White_Header{color:white!important;font-size:22px!important;font-weight:500!important;} What the Science Says About the Safety and Side Effects of Dietary Supplements

• What’s on the label may not be what’s in the product. For example, the FDA has found prescription drugs, including anticoagulants (e.g., warfarin), anticonvulsants (e.g., phenytoin), and others, in products being sold as dietary supplements. You can see a list of some of those products on the FDA’s Health Fraud Product Database webpage.
• A 2012 Government study of 127 dietary supplements marketed for weight loss or to support the immune system found that 20 percent made illegal claims.
• Some dietary supplements may harm you if you have a particular medical condition or risk factor or are taking certain prescription or over-the-counter medications. For example, the herbal supplement St. John’s wort makes many medications less effective.
• Dietary supplements result in an estimated 23,000 emergency room visits every year in the United States, according to a 2015 study. Many of the patients are young adults having heart problems from weight-loss or energy products and older adults having swallowing problems from taking large vitamin pills.
• Although it’s still rare, more cases are being reported of acute (sudden) liver damage in people taking dietary supplements in the United States and elsewhere. The liver injury can be severe, can require an emergency liver transplant, and is sometimes fatal.
• Many dietary supplements (and some prescription drugs) come from natural sources, but “natural” does not always mean “safe.” For example, the kava plant is a member of the pepper family but taking kava supplements can cause liver disease.
• A manufacturer’s use of the term “standardized” (or “verified” or “certified”) does not necessarily guarantee product quality or consistency .

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• If you’re going to have surgery, be aware that certain dietary supplements may increase the risk of bleeding or affect your response to anesthesia . Talk to your health care providers as far in advance of the operation as possible and tell them about all dietary supplements that you're taking.
• If you’re pregnant, nursing a baby, trying to get pregnant, or considering giving a child a dietary supplement, consider that many dietary supplements have not been tested in pregnant women, nursing mothers, or children .
• If you’re taking a dietary supplement, follow the instructions on the label . If you have side effects, stop taking the supplement and contact your health care provider. You may also want to contact the supplement manufacturer.

Take charge of your health—talk with your health care providers about any complementary health approaches you use. Together, you can make shared, well-informed decisions.

Research Funded by the National Center for Complementary and Integrative Health (NCCIH) and the National Institutes of Health (NIH)

NCCIH supports dozens of research projects on dietary supplements and how they might affect the body.

NCCIH cosponsors the Centers for Advancing Research on Botanical and Other Natural Products (CARBON) Program. Scientists at the centers conduct laboratory research concerning the safety, effectiveness, and mechanisms of action of botanical dietary supplements that have a high potential to benefit human health.

For More Information

Nccih clearinghouse.

The NCCIH Clearinghouse provides information on NCCIH and complementary and integrative health approaches, including publications and searches of Federal databases of scientific and medical literature. The Clearinghouse does not provide medical advice, treatment recommendations, or referrals to practitioners.

Toll-free in the U.S.: 1-888-644-6226

Telecommunications relay service (TRS): 7-1-1

Website: https://www.nccih.nih.gov

Email: [email protected] (link sends email)

A service of the National Library of Medicine, PubMed® contains publication information and (in most cases) brief summaries of articles from scientific and medical journals. For guidance from NCCIH on using PubMed, see How To Find Information About Complementary Health Approaches on PubMed .

Website: https://pubmed.ncbi.nlm.nih.gov/

Office of Dietary Supplements (ODS), National Institutes of Health (NIH)

ODS seeks to strengthen knowledge and understanding of dietary supplements by evaluating scientific information, supporting research, sharing research results, and educating the public. Its resources include publications (such as Dietary Supplements: What You Need To Know ) and fact sheets on a variety of specific supplement ingredients and products (such as vitamin D and multivitamin/mineral supplements).

Website: https://ods.od.nih.gov

Email: [email protected] (link sends email)

U.S. Food and Drug Administration (FDA)

The FDA oversees the safety of many products, such as foods, medicines, dietary supplements, medical devices, and cosmetics. See its webpage on Dietary Supplements .

Toll-free in the U.S.: 1-888-463-6332

Website: https://www.fda.gov/

Center for Food Safety and Applied Nutrition (CFSAN)

Part of the FDA, CFSAN oversees the safety and labeling of supplements, foods, and cosmetics. It provides information on dietary supplements. Online resources for consumers include Tips for Dietary Supplement Users: Making Informed Decisions and Evaluating Information.

Toll-free in the U.S.: 1-888-723-3366

Website: https://www.fda.gov/about-fda/fda-organization/center-food-safety-and-applied-nutrition-cfsan

Federal Trade Commission (FTC)

The FTC is the Federal agency charged with protecting the public against unfair and deceptive business practices. A key area of its work is the regulation of advertising (except for prescription drugs and medical devices).

Toll-free in the U.S.: 1-877-382-4357

Website: https://www.ftc.gov

MedlinePlus

To provide resources that help answer health questions, MedlinePlus (a service of the National Library of Medicine) brings together authoritative information from the National Institutes of Health as well as other Government agencies and health-related organizations.

Website: https://www.medlineplus.gov

Dietary Supplement Label Database

The Dietary Supplement Label Database—a project of the National Institutes of Health—has all the information found on labels of many brands of dietary supplements marketed in the United States. Users can compare the amount of a nutrient listed on a label with the Government’s recommended amounts.

Website: https://dsld.od.nih.gov

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• Cohen PA, Maller G, DeSouza R, et al. Presence of banned drugs in dietary supplements following FDA recalls . JAMA . 2014;312(16):1691-1693.
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• Dietary supplements. Office of Dietary Supplements website. Accessed at ods.od.nih.gov/factsheets/DietarySupplements-HealthProfessional on July 30, 2018.
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• Geller AI, Shehab N, Weidle NJ, et al. Emergency department visits for adverse events related to dietary supplements . New England Journal of Medicine . 2015;373(16):1531-1540.
• Gurley BJ, Fifer EK, Gardner Z. Pharmacokinetic herb-drug interactions (part 2): drug interactions involving popular botanical dietary supplements and their clinical relevance . Planta Medica . 2012;78(13):1490-1514.
• Hoofnagle JH, Navarro VJ. Drug-induced liver injury: Icelandic lessons . Gastroenterology . 2013;144(7):1335-1336.
• Information for consumers on using dietary supplements. U.S. Food and Drug Administration website. Accessed at www.fda.gov/food/dietarysupplements/usingdietarysupplements on July 30, 2018.
• Kantor ED, Rehm CD, Du M, et al. Trends in dietary supplement use among US adults from 1999-2012 . JAMA . 2016;316(14):1464-1474.
• Navarro VJ, Barnhart H, Bonkovsky HL, et al. Liver injury from herbals and dietary supplements in the U.S. Drug-Induced Liver Injury Network . Hepatology . 2014;60(4):1399-1408.
• Questions and answers on dietary supplements. U.S. Food and Drug Administration website. Accessed at www.fda.gov/Food/DietarySupplements/UsingDietarySupplements/ucm480069.htm on July 30, 2018.
• Stussman BJ, Black LI, Barnes PM, Clarke TC, Nahin RL. Wellness-related use of common complementary health approaches among adults: United States, 2012 . National health statistics reports; no 85. Hyattsville, MD: National Center for Health Statistics. 2015.

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• Crawford C, Brown LL, Costello RB, et al. Immune supplements under the magnifying glass: an expert panel develops priorities and evidence-based recommendations for future research regarding dietary supplements. Journal of Integrative and Complementary Medicine . March 1, 2023. [Epub ahead of print].
• DeKosky ST, Williamson JD, Fitzpatrick AL, et al. Ginkgo biloba for prevention of dementia: a randomized controlled trial. JAMA . 2008;300(19):2253-2262.
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• Fortman SP, Burda BU, Senger CA, et al. Vitamin and mineral supplements in the primary prevention of cardiovascular disease and cancer: an updated systematic evidence review for the U.S. Preventive Services Task Force. Annals of Internal Medicine . 2013;159(12):824-834.
• Fransen M, Agaliotis M, Nairn L, et al. Glucosamine and chondroitin for knee osteoarthritis: a double-blind randomised placebo-controlled clinical trial evaluating single and combination regimens. Annals of the Rheumatic Diseases . 2015;74(5):851-858.
• Galasko DR, Peskind E, Clark CM, et al. Antioxidants for Alzheimer disease: a randomized clinical trial with cerebrospinal fluid biomarker measures. Archives of Neurology . 2012;69(7);836-841.
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• Guidance for industry: questions and answers regarding adverse event reporting and recordkeeping for dietary supplements as required by the Dietary Supplement and Nonprescription Drug Consumer Protection Act. U.S. Food and Drug Administration website. Accessed at www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/ DietarySupplements/ucm171383.htm on July 30, 2018.
• Grodstein F, O’Brien J, Kang JH, et al. A randomized trial of long-term multivitamin supplementation and cognitive function in men: The Physicians’ Health Study II. Annals of Internal Medicine . 2013;159(12):806-814.
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• Herxheimer A, Petrie KJ. Melatonin for the prevention and treatment of jet lag. Cochrane Database of Systematic Reviews . 2002;(2):CD001520. Accessed at https://www.cochranelibrary.com on July 27, 2018.
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• Is it really ‘FDA approved?’ U.S. Food and Drug Administration website. Accessed at www.fda.gov/ForConsumers/ConsumerUpdates/ucm047470.htm on July 30, 2018.
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Acknowledgments

NCCIH thanks D. Craig Hopp, Ph.D., and David Shurtleff, Ph.D., NCCIH, for their review of the 2019 update of this publication.

This publication is not copyrighted and is in the public domain. Duplication is encouraged.

NCCIH has provided this material for your information. It is not intended to substitute for the medical expertise and advice of your health care provider(s). We encourage you to discuss any decisions about treatment or care with your health care provider. The mention of any product, service, or therapy is not an endorsement by NCCIH.

Related Fact Sheets

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Liquid Death is just one of many VC-backed beverage startups ready to disrupt Coke and Pepsi

Venture-backed beverage startups continue to pop.

On March 11, a fizzy startup announced that it had raised $67 million at a $1.4 billion valuation and reached $263 million in sales in 2023. Did you guess that this startup is Liquid Death, a canned water company?

Liquid Death has now raised more than $267 million in venture funding despite sitting in a category that doesn’t interest many investors. Beverage is a tough industry for VCs because it’s capital intensive; requires a knack for picking companies that will sell well on retail shelves or other direct-to-consumer methods; and inspire repeat customers as opposed to just one time.

Science Ventures’ managing director, Michael Jones, told TechCrunch that his firm wasn’t interested in getting active in the beverage sector but backed Liquid Death because of its potential to disrupt legacy players like Pepsi and Coke.

“We were in the market for culturally relevant companies with better-for-you products that redefined a tired and old category,” Jones said. His investing team considered Liquid Death to be “a super disruptive brand.”

Cutting through the fizz

Some of the new venture-backed beverage startups are hoping to upend the industry by creating new drink categories. This is akin to what technology companies often do, said Dan Buckstaff, chief marketing officer for retailer data company SPINS.

“You may think you can’t squeeze another category in here, but instead you approach it differently,” Buckstaff said. “You take inspiration from others or maybe there’s a new technology that allows you to do it, or data. That does lead to companies that can create hundreds of millions in ARR.”

He said Liquid Death drew from beer’s marketing and shelf placement to find success not only on grocery store shelves, but at events, bars and restaurants — even at conferences. (Liquid Death declined to comment.) In fact, while at the consumer packaged goods conference Expo West recently, Buckstaff hosted a Liquid Death party, and his room ended up looking like “we had a real binge.”

Poppi raises a can to fresh capital to support its functional beverage growth

He took an informal poll from people who attended asking how often they ordered beer or wine just to be thought of as social. Half of them said they did. That made him realize the enormous possible market for companies like Liquid Death that have alcohol-inspired brand names and packaging but are healthier alternatives.

“For those people, these non-alcoholic brands are well-positioned for that, and there is a massive potential,” Buckstaff said. “And not just at a social event, but just at home — people kicking back and having a beer. Instead, there’s a lot of alternatives now with mood setters or relaxers.”

Not Beer is one of those taking a nod from these early companies. Founder Dillion Dandurand is bootstrapping the new company, which is making a premium sparkling water brand launching April 9. He said his brand was created for consumers opting to drink less alcohol.

“Gen Z drinks less than any of the generations before them,” he said. “These people still want to have fun, but they are realizing they don’t need to drink alcohol to have fun or they don’t need to drink as much alcohol to have fun. In fact, getting a nice buzz but not getting wasted is probably more fun.”

Getting in front of the noise can be tough, though. There are two attributes that consumers care about, which presents an opportunity to set a brand apart from the competition, according to Dandurand: taste and the brand.

With so many options out there, brands have to sell on why their drink is better than a similar one in the category, and also sell why the drink is better than another category.

“That is a tough battle,” Dandurand said.

Functional beverage startup Odyssey grabs $6M to accelerate energy drink growth

Who else is popping?

Water isn’t the only category attracting startups and VC cash, often from celebrity angel investors. Drinks that feature vitamins, minerals, supplements and botanicals are also a burgeoning area.

For example, companies like Odyssey, which raised $6 million in venture capital in February from an investor group that includes Richard Laver from Rocket Beverage Group. The company is infusing lion’s mane and cordyceps mushrooms into its drinks, known for their cognitive clarity and increased energy effects.

Other beverage startups attracting VC dollars include better-for-you soda startups like Olipop, backed by Finn Capital Partners, Melitas Ventures, and celebrity angels like Camila Cabello ; and Poppi, backed by Electric Feel Ventures, Rocana Ventures partners and angels. Each raised more than $50 million in venture funding. Healthy lemonade alternative Lemon Perfect has raised more than $70 million cash from a long list of VC firms, athletes and celebrities like Beyoncé.

Poppi, which has CAVU Consumer Partners and a bevy of celebrity investors — like Russell Westbrook of the Chainsmokers, Olivia Munn and Nicole Scherzinger — has grabbed about 19% of the beverage market share since launching about four years ago. Forbes reports that is 1.5x higher than Coke. It also rose to be the 11th fastest-growing beverage brand in the last month, besting brands like Monster Energy, Gatorade and Liquid Death.

The brand is seeing success from “strategic marketing to become a part of culture, with an active and loyal following” and “filling a gap in the industry by providing a delicious better-for-you option,” Poppi CEO Chris Hall told TechCrunch via email.

VCs are chasing some of this category’s blockbuster returns. Coca-Cola bought celebrity sponsored coconut vitamin water BodyArmor for $5.6 billion in 2021. BodyArmor had raised $36 million in venture capital. Back in 2016 Bai, maker of drinks infused with antioxidants, sold to Dr Pepper Snapple Group for $1.7 billion after raising a little more than $10 million in venture capital. Smaller deals happen, too. In April, 2023, NextFoods bought tart cherry beverage Cheribundi for an undisclosed sum after a $15 million investment round in 2020 led by Emil Capital Partners, Food Dive reported.

While these startups make great acquisition targets because legacy companies often prefer to buy versus developing new products of their own, some may do well on the public market, Alex Malamatinas, founder and managing partner at food and beverage-focused Melitas Ventures, said.

“Obviously what is happening in tech and AI is amazing, [but] at the end of the day, everybody needs to eat and drink every day, they are very large markets with significant TAM,” Malamantinas said. “Despite everything that has been going on, the best performing stock is Monster beverage, not a tech stock.”

That’s a bit of hyperbole. Monster is up about 16% over the last 12 months at a respectable $63 billion in market cap, while the most valuable companies in the world are Microsoft, Apple and Nvidia, each worth multiple trillion. But the point that its market cap is higher than many tech companies is valid. For instance, only 7 out 100 companies on Bessemer’s Cloud Index are more valuable.

Camila Cabello, Mindy Kaling, Gwyneth Paltrow pour capital into Olipop’s mission to change soda

New innovation cycle for beverages

Buckstaff also noticed the food industry’s largest trade show, Expo West, booming with more new exhibitors. “It leads me to believe that maybe we’ve entered a new innovation cycle,” he said.

Jeff Klineman, editor in chief of food and beverage-oriented media company BevNET, certainly thinks so. Beverage startups remaining resilient despite a tougher fundraising market is a story of “haves and have nots,” Klineman told TechCrunch via email.

“In the past couple of years funds have had more trouble raising, strategics have cooled off their acquisition plans and lending has been tighter,” Klineman said. “CPG funds have been deploying more slowly while there’s more competition for brands that are actually growing and doing well.”

Though, beverage startups are having their difficulties fund raising in the touch VC environment as well. Those that haven’t hit “the sweet spot” of consumers making repeat purchases, aren’t seeing channel expansion, or showing a path to profitability, the market is challenging, Klineman said.

For investors, figuring out which brands will last and which ones just play into a fad is hard, Malamantinas said. He cited the trend of CBD beverages a few years ago that temporarily blew up but has been much quieter since. The firm avoided them he said, probably thankfully so, as the research on whether or not low-dose CBD beverages work is mixed .

“There are going to be several big outcomes in the years to come,” Malamatinas said. “I think the main reason people shy away from the space is it requires a certain level of expertise. We have experienced operators. There is a certain level of know how and skills for these businesses to scale.”

For investors willing to put in the work and the time to find those long-lasting brands, the category looks likely to produce strong returns. It worked with Bai. Olipop and Liquid Death seem well on their way. Now let’s see who’s next.

Poppin’ bottles: VCs continue to pour millions into independent beverage startups