RESEARCH
Current Research
Older Adults Who Use Vitamin/Mineral
Supplements Differ from Nonusers in Nutrient
Intake Adequacy and Dietary Attitudes
RHONDA S. SEBASTIAN, MA; LINDA E. CLEVELAND, MS, RD; JOSEPH D. GOLDMAN, MA; ALANNA J. MOSHFEGH, MS, RD
ABSTRACT
Objective To measure nutrient intake adequacy of vitamin/
mineral supplement users and nonusers aged 51 years
and older, determine the efficacy of supplement practices
in compensating for dietary deficits, and identify predic-
tors of supplement use.
Design Analyses of two 24-hour recalls, demographic vari-
ables, and attitude questions collected during the Con-
tinuing Survey of Food Intakes by Individuals and Diet
and Health Knowledge Survey in 1994 to 1996. Data were
weighted to be representative of older Americans.
Subjects Four thousand three hundred eighty-four adults
aged 51 years and older (1,777 daily supplement users,
428 infrequent users, and 2,179 nonusers) residing in
households in the United States.
Statistical analyses Usual nutrient intake distributions
were estimated using the Iowa State University method.
The Estimated Average Requirement (EAR) cutpoint
method was applied to determine the proportion of older
adults not meeting requirements before and after ac-
counting for nutrient intake from supplements. Student t
tests were used to assess differences between users and
nonusers. Logistic regression was used to determine so-
ciodemographic and attitudinal predictors of supplement
use.
Results For one or more of the sex-age groups studied, a
significantly smaller proportion of supplement users than
nonusers had intakes from food alone below the EAR for
vitamins A, B-6, and C; folate; zinc; and magnesium.
R. S. Sebastian is a nutritionist, J. D. Goldman is a
statistician, and A. J. Moshfegh is research leader, US
Department of Agriculture, Agricultural Research Ser-
vice, Food Surveys Research Group, Beltsville, MD.
L. E. Cleveland is retired; at the time of the study, she
was a supervisory nutritionist, US Department of Agri-
culture, Agricultural Research Service, Food Surveys
Research Group, Beltsville, MD.
Address correspondence to: Rhonda S. Sebastian, MA,
Nutritionist, US Department of Agriculture, Agricul-
tural Research Service, Food Surveys Research Group,
10300 Baltimore Ave, Bldg 005, Room 102, BARC-West,
Beltsville, MD 20705. E-mail: Rhonda.Sebastian@ars.
usda.gov
Published by Elsevier Company on behalf of the
American Dietetic Association.
0002-8223/07/10708-0002$0.00/0
doi: 10.1016/j.jada.2007.05.010
1322 Journal of the AMERICAN DIETETIC ASSOCIATION
Even so, less than 50% of both users and nonusers met
the EAR for folate, vitamin E, and magnesium from food
sources alone. Overall, supplements improved the nutri-
ent intake of older adults. After accounting for the con-
tribution of supplements, 80% or more of users met the
EAR for vitamins A, B-6, B-12, C, and E; folate; iron; and
zinc, but not magnesium. However, some supplement
users, particularly men, exceeded Tolerable Upper Intake
Levels for iron and zinc and a small percentage of women
exceeded the Tolerable Upper Intake Level for vitamin A.
Significant sociodemographic factors related to supple-
ment use for older men were age group, metropolitan
area, and educational status. Race, region, smoking sta-
tus, and vegetarian status were significant factors for
women. Attitude about the importance of following a
healthful diet was a consistent predictor of supplement
use for both men and women.
Conclusions A large proportion of older adults do not con-
sume sufficient amounts of many nutrients from foods
alone. Supplements compensate to some extent, but only
an estimated half of this population uses them daily.
These widespread inadequacies should be considered
when developing recommendations for supplement use
for clients in this age group. Modifying dietary attitudes
may result in a higher rate of supplement use in this
at-risk population.
J Am Diet Assoc. 2007;107:1322-1332.
A
nalyses of nationwide survey data have shown that
a large percentage of older adults do not receive
recommended amounts of many nutrients from food
alone (1-11). Other measures, such as the Healthy Eating
Index, also indicate that the diets of older adults need
improvement and may leave them susceptible to nutri-
tion-related problems (12,13). This is of particular con-
cern because conditions prevalent in this population, in-
cluding chronic diseases and absorption problems, can
compromise nutritional status (14-16). At the same time,
a growing proportion of older adults are using vitamin
and mineral supplements, which can substantially in-
crease nutrient intake and counter some of these short-
falls (17-19). Little is known about the effectiveness of
vitamin/mineral supplements in appropriately compen-
sating for dietary deficits.
With the introduction of the Dietary Reference Intakes
(DRIs), new standards are available for the assessment of
nutrient intakes. The establishment of Estimated Average
Requirements (EARs) makes it possible, for the first time, to
estimate the prevalence of nutritional inadequacy in popu-
lation groups. Additionally, the Tolerable Upper Intake
Levels (ULs) provide cutpoints for estimating the percent-
age of the population of interest that is at potential risk of
adverse effects due to overconsumption of a nutrient (20).
These two components of the DRIs provide new opportuni-
ties for assessing nutrient intake and evaluating the influ-
ence of supplement use on dietary status.
Although supplement use provides potential benefits in
increasing nutrient intakes, there are potential draw-
backs (21-25). The extensive use of supplements by older
adults increases the possibility for overconsumption of
nutrients. The American Dietetic Association’s position
paper on food fortification and dietary supplements (26)
notes that documented cases of toxicity are often caused
by supplementation. In fact, the ULs were developed
largely in response to the growing use of supplements and
fortified foods (20).
Considering the potential for both positive and nega-
tive effects on overall nutrient intake, an important ques-
tion to ask is what factors influence supplement use.
Characteristics associated with taking supplements are
well documented. Users generally consume more nutri-
ent-dense diets and vary significantly from nonusers in
many sociodemographic factors, including age, sex, race,
education status, and income level (17,27-45). Research is
more limited on the effect of more modifiable factors, such
as attitudes about diet and health, on supplement use.
The Diet and Health Knowledge Survey, a component of
the US Department of Agriculture’s Continuing Survey of
Food Intakes by Individuals (CSFII), was designed to
provide information about people’s attitudes and knowl-
edge on topics that could affect their dietary intake (46).
Currently, the Diet and Health Knowledge Survey offers
the only national survey data that links attitudes about
diet and health with dietary behavior, including supple-
ment use.
The purpose of this study was to examine the effects of
supplement use on nutrient intake and dietary adequacy
for adults aged 51 years and older, and to identify deter-
minants of supplement use. Objectives were to compare
the nutrient intake adequacy of older adults who con-
sumed vitamin/mineral supplements daily to those who
did not, to estimate the contribution of supplements to
total nutrient intake and the associated reduction in nu-
tritional inadequacy, to determine if supplement use cre-
ates nutrient intake excesses among older adults, and to
identify sociodemographic and attitudinal factors that
are predictive of supplement use.
METHODS
Data Source and Sample
Data for this study were drawn from US Department of
Agriculture’s 1994-96 CSFII and Diet and Health Knowl-
edge Survey. The CSFII- Diet and Health Knowledge
Survey is a nationally representative survey of noninsti-
tutionalized individuals in all 50 states and Washington,
DC. A complex multistage, area probability sample de-
sign was used to select persons within households. Indi-
viduals aged 51 years and older were oversampled. De-
tails of the sample design and methods have been
enumerated elsewhere (46). Dietary intake data were
collected using two in-person, interviewer-administered
24-hour recalls conducted 3 to 10 days apart. The Diet
and Health Knowledge Survey was administered by tele-
phone to one adult sample person in the household 3
weeks after the second intake interview.
Supplement information was collected through a series
of questions following the first 24-hour recall. Two hand-
cards were used to query respondents on the types of
vitamin/mineral supplements taken (ie, multivitamin,
multivitamin with iron, combination of vitamin C and
iron, and single vitamins and/or minerals); and if indi-
cated, what specific types of single vitamins/minerals
were consumed (eg, vitamin A, vitamin C, calcium, and
iron). The frequency of consumption (taken daily or less
often) was also obtained, but not the specific quantity.
The amount of each nutrient in the supplement (the
formulation) and the brand name were not collected.
Data from the CSFII sample were used to determine
nutrient intake adequacy of supplement users and non-
users. Data from the smaller Diet and Health Knowledge
Survey sample were used to identify attitudinal and so-
ciodemographic predictors of supplement use. A total of
4,384 respondents aged 51 and older provided two com-
plete 24-hour recalls in the CSFII. Supplement users
were defined as individuals who took any kind of vitamin
or mineral supplement every day. Almost 10% of the
sample (n⫽428) was classified as infrequent supplement
users and excluded from the analysis. These individuals
reported that they took vitamin or mineral supplements
“every so often.” The remaining sample of 3,956 supple-
ment users and nonusers was used in assessments of
nutrient intake adequacy. The infrequent users were
then added back to the sample, and information from the
2,571 respondents aged 51 years and older providing
complete responses to the Diet and Health Knowledge
Survey attitude questions were used in the analysis to
identify predictors of supplement use.
Calculating Nutrient Intake from Foods and Supplements
Foods. Some nutrients required conversion to standard-
ized measurement units before comparison of dietary in-
takes to the DRIs could be made. Vitamin A had to be
converted to retinol activity equivalents, vitamin E to
milligrams ␣-tocopherol, and folate to dietary folate
equivalents. For vitamins A and E, a special database
developed by the US Department of Agriculture, which
translated intake estimates of dietary vitamin A from
retinol equivalents into retinol activity equivalents and
dietary vitamin E from ␣-tocopherol equivalents into mil-
ligrams ␣-tocopherol was employed (47). For folate, the
food composition database did not distinguish between
the naturally occurring form and the synthetic form (folic
acid), so all contributions to folate intake by food were
assumed to be the less bioavailable folate form. One mi-
crogram converted directly to 1 ␮g dietary folate equiva-
lent. Because the dietary data for this study were from
1994 through 1996 and widespread fortification of en-
riched cereal-grain foods with folic acid was not com-
pleted until 1998, the underestimation of total folate in-
take is not as great as it would be if folate fortification had
been in place (48-51). Nonetheless, dietary inadequacy for
folate is overestimated to some immeasurable degree.
August 2007 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1323
Supplements. Because brand names and formulations of
supplements were not collected in CSFII, assignment of
nutritive values for both single nutrient and multivita-
min-mineral supplements was based on the nutrient pro-
file of the most frequently reported supplement of that
type in the 1999-2000 National Health and Nutrition
Examination Survey (NHANES). This is following the
procedure used in NHANES when brand and/or formula-
tion were not available (52). The source of the nutrient
values for the supplements was the NHANES Dietary
Supplement Database (52). Before conversions to stan-
dardized units could be made for vitamins A and E, and
folate, assumptions concerning the form of the nutrient in
the supplement were required. Vitamin A in multivita-
min-mineral supplements was assumed to be comprised
of 60% retinol and 40% beta-carotene, which was the
formulation most commonly seen in supplements re-
corded in the NHANES Dietary Supplement Database.
Dietary vitamin A measured in international units was
multiplied by 0.30 and beta-carotene by 0.15 to convert to
retinol activity equivalents (53). For vitamin E, the factor
of .45 for all-racemic ␣-tocopherols was used for all sup-
plemental sources to convert to milligram ␣-tocopherol
units (54). All supplemental folate was considered to be
folic acid, and intake in micrograms was multiplied by 1.7
to convert to dietary folate equivalents (55,56).
Method for Comparing Intakes to DRIs
To assess the nutrient intake adequacy of groups using
the DRIs, an estimate of the usual or long-term intake
distribution is needed (20). For this study, the Iowa State
University method, implemented with C-Side software
(version 1.02, 1997, Department of Statistics, Iowa State
University, Ames), was used to estimate the usual nutri-
ent intake distributions and apply the EAR cutpoint
method (57,58). Estimates were generated for percent-
ages of individuals below the EAR and above the UL. The
proportion of older adults considered to be inadequate for
each nutrient was estimated as the percentage whose
usual intake fell below the EAR for that nutrient (57).
To account for contributions to nutrient intake from all
sources, nutrient values assigned to each type of supple-
ment reported were added to the nutrient intake contrib-
uted by food. Because supplement users were defined as
those who took supplements every day, the contribution
from supplements was applied to both of the dietary
intake days.
The DRIs used in these analyses were taken from re-
ports of the National Academy of Sciences on vitamin A,
iron, and zinc (53); vitamin C and vitamin E (54); calcium
and magnesium (59); and vitamin B-6, folate, and vita-
min B-12 (55).
Identification of Factors Related to Supplement Use
Sociodemographic variables for this analysis included
variables shown in previous studies to be related to sup-
plement use, including sex, age, race, poverty status, and
education level (17,27-31,33-40,42,44). In addition, two
attitude scales, composed of 11 questions each, were de-
rived from Diet and Health Knowledge Survey data. The
first scale was developed from questions on perceived
1324 August 2007 Volume 107 Number 8
adequacy of the respondent’s own diet. Respondents in-
dicated if they believed their diets were too low, too high,
or about right in each of 11 nutrients. Higher scores
indicated a more favorable assessment of the healthful-
ness of one’s daily food intake. The second scale measured
the importance the respondent placed on following the
1990 Dietary Guidelines for Americans—the most recent
government recommendations at the time of CSFII- Diet
and Health Knowledge Survey data collection (60).
Higher scores indicated a greater importance placed on
incorporating the recommendations into one’s own diet.
Statistical Analyses
The SUDAAN program (version 9.0, 2005, Research Tri-
angle Institute, Research Triangle Park, NC) and SAS
(release 8.2, 2001, SAS Institute Inc, Cary, NC) were used
for all statistical calculations. Student t tests were con-
ducted to measure for significant differences between
supplement users and nonusers in proportions below the
EAR for each analyzed nutrient. Dietary intakes of non-
users were tested against the dietary (food only) intake of
supplement users; and the total intake of users, including
the supplement contribution. A P level of 0.001 was ap-
plied to account for the large number of comparisons
made.
␹2 analyses were conducted to determine if there were
differences in supplement use between men and women,
and between age groups.
Logistic regression was performed using the Diet and
Health Knowledge Survey sample to identify sociodemo-
graphic variables and attitudes associated with the deci-
sion to use supplements. Contrasts were done when a
variable was significant in the model and the variable
had more than two response choices.
RESULTS
Table 1 shows that supplement use was widespread
among older adults. In CSFII, 37% of men and 47% of
women consumed at least one type of supplement every
day. Significant differences were noted between men and
women, but not between age groups.
Overall, multivitamin-multimineral supplements were
the most frequently reported supplement type for both
men and women (Table 2) with 34% of all older men and
41% of all older women taking one. Among all supplement
users, 74% of men and 70% of women aged 51 years and
older took this type. Vitamin C and vitamin E were the
most commonly mentioned single vitamin or mineral sup-
plements with 19% to 34% of respondents reporting use.
Calcium supplements were popular among older women;
26% of users aged 51 to 70 years and 18% of users aged 71
years and older took them.
Comparison of Nutrient Adequacy from Food between Users and
Nonusers
Tables 3 and 4 present the mean usual daily nutrient
intake and intake at the 25th, 50th, and 75th percentiles
for supplement users and nonusers. For supplement us-
ers, estimates are presented for intake from food sources
only and for the combined intake from both food and
supplements. Also shown are percentages of the popula-
 Table 1. Supplement use by older adults, based on data from the Continuing Survey of Food Intakes by Individuals, 1994-1996
Percent using Infrequent
Characteristic n supplements Daily users usersa Nonusers
a
Total 4,384 43 1,777 428 2,179
Sex
Male 2,253 37* 806 201 1,246
Female 2,131 47* 971 227 933
Age
51-70 y 3,107 42 1,248 342 1,517
ⱖ71 y 1,277 43 529 86 662
a
Excluded when assessing intakes against the Dietary Reference Intakes (Tables 3-6) but included in the analysis of variables related to supplement use (Table 7).
*P⬍0.001.

Table 2. Frequency of use of selected supplements by adults aged 51 years and older, based on data from the Continuing Survey of Food
Intakes by Individuals, 1994-1996
Men Women
51-70 y (%) >71 y (%) 51-70 y (%) >71 y (%)
Supplement Supplement Supplement Supplement
Supplement All users All users All users All users

Multivitamin/mineral 34 75 33 72 43 70 37 70
Vitamin C 15 33 14 30 21 34 15 28
Vitamin E 13 29 13 28 16 27 10 19
Calcium 4 8 5 11 16 26 9 18
Vitamin B/B complex 6 12 7 16 9 14 6 11
Zinc 3 7 3 6 3 5 2 3
Iron 2 4 2 4 3 5 2 4
Vitamin A 2 5 2 5 4 6 2 4

tion with intakes below the EAR (ie, percentages with
inadequate intakes). Data are shown separately for men
(Table 3) and women (Table 4).
When considering nutrient intake from food sources
alone, generally smaller proportions of supplement users
than nonusers had inadequate intakes. Intakes of vita-
mins A and C were significantly higher for users than
nonusers in both age groups of men. Vitamin B-6 and
magnesium were significantly higher for users as com-
pared to nonusers in both age groups of women. More
than 50% of both supplement users and nonusers had
inadequate intakes of folate, vitamin E, and magnesium
from food. In addition, for most of the sex/age groups
studied, more than 25% had inadequate intakes of vita-
mins A, B-6, and C from food. Iron was the only nutrient
studied for which the prevalence of inadequate intakes
among older adults was consistently low; 3% or fewer
older adults had intakes below the EAR.
It was not possible to determine proportions of the
population with inadequate calcium intakes because the
DRI is expressed as an Adequate Intake and not as an
EAR. Although mean intakes from food alone were higher
among supplement users than nonusers (Table 5), the
only statistical difference between users and nonusers
was among men aged 51 to 70 years.
The nutrient intake from food alone was not sufficient
to exceed the ULs for any of the nutrients in this analysis.
This was true for men and women in both age groups,
regardless of supplement use.
Contribution of Supplements to Nutrient Intake
Regular supplement use, in effect, reduced the percent-
age of older adults with inadequate intakes by at least
three fourths for most nutrients (Table 3 and 4). Folate
and vitamin E intakes were particularly improved by
supplements. Food-only intakes of these nutrients were
inadequate for 57% to 96% of supplement users. After
accounting for supplements, only 6% to 17% were classi-
fied as inadequate.
When the nutrient contribution of supplements was
considered, significant differences were found between
users and nonusers in percentages with inadequate in-
takes for nearly all the nutrients studied. Mean intakes of
vitamin B-12 and iron were boosted by supplements, but
the percent of this population with inadequate intakes
was largely unaffected, because most older adults met the
EAR from food intake alone. An exception was that sig-
nificantly more nonuser women aged 71 years and older
had inadequate intakes of vitamin B-12 compared to the
total intake of supplement users in this sex/age group.
Although for the most part the percent meeting the EAR
was not significantly increased for vitamin B-12 and iron,

August 2007 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1325

 Table 3. Men’s usual nutrient intake (mean and selected percentiles) and percent below the Estimated Average Requirement (EAR), based on
data from the Continuing Survey of Food Intakes by Individuals, 1994-1996
51-70 y >71 y
Nutrient and 25th, 75th % Below 25th, 75th % Below
supplement status EAR MeanⴞSEa Median Quartiles EARⴞSE MeanⴞSE Median Quartiles EARⴞSE

Vitamin A (RAEb) 625

Nonusers: Food only 733⫾48c 601 428, 870 53⫾4.0cd 751⫾47c 598 400, 907 53⫾3.5cd
Users: Food only 864⫾61 769 578, 1,034 31⫾4.5d 892⫾51 808 606, 1,080 27⫾5.0d
Food and supplements 2,060⫾76c 1,867 1,451, 2,426 5⫾1.0c 1,963⫾73c 1,853 1,379, 2,381 4⫾1.3c
Vitamin B-6 (mg) 1.4
Nonusers: Food only 2.0⫾0.1c 1.9 1.5, 2.4 17⫾2.8c 1.8⫾0.1c 1.7 1.2, 2.2 34⫾3.4cd
Users: Food only 2.2⫾0.1 2.1 1.7, 2.7 14⫾2.0 2.1⫾0.1 2.0 1.6, 2.5 17⫾3.4d
Food and supplements 4.9⫾0.2c 4.1 3.2, 5.8 ⬍3c 5.0⫾0.2c 4.2 3.1, 6.0 3⫾1.0c
Vitamin B-12 (␮g) 2.0
Nonusers: Food only 6.4⫾0.5c 5.0 3.5, 7.5 4⫾1.3 5.7⫾0.7c 3.9 2.7, 5.8 10⫾2.4c
Users: Food only 7.8⫾1.2 6.0 4.2, 9.2 ⬍3 5.4⫾0.4 4.8 3.6, 6.5 ⬍3
Food and supplements 15.8⫾1.1c 11.7 8.7, 16.1 ⬍3 14.3⫾0.8c 11.6 8.4, 17.3 ⬍3c
Folate (DFEe) 320
Nonusers: Food only 277⫾9c 254 189, 342 70⫾2.9c 258⫾13c 235 168, 322 75⫾3.9c
Users: Food only 320⫾12 297 224, 391 57⫾3.4 298⫾16 281 215, 363 63⫾5.5
Food and supplements 955⫾27c 940 751, 1,136 6⫾3.3c 915⫾29c 924 737, 1,115 7⫾1.4c
Vitamin C (mg) 75
Nonusers: Food only 98⫾5cd 84 54, 127 43⫾3.1cd 94⫾6c 78 45, 126 48⫾3.3cd
Users: Food only 123⫾4d 111 73, 161 26⫾2.1d 119⫾6 109 72, 155 27⫾4.1d
Food and supplements 510⫾25c 317 156, 873 5⫾1.3c 469⫾32c 299 151, 758 5⫾1.5c
Vitamin E
(mg ␣-tocopherol) 12
Nonusers: Food only 7.4⫾0.3c 6.6 4.8, 9.1 90⫾2.4c 6.2⫾0.4c 5.2 3.8, 7.3 93⫾2.3c
Users: Food only 9.6⫾0.7 8.1 6.0, 11.3 78⫾3.8 8.1⫾0.7 6.8 4.8, 9.7 85⫾4.0
Food and supplements 76.1⫾4.8c 37.0 21.0, 126.0 10⫾4.8c 67.6⫾6.1c 35.0 17.0, 107.0 14⫾2.9c
Iron (mg) 6
Nonusers: Food only 16.6⫾0.5c 15.7 12.5, 19.7 ⬍3 14.8⫾0.7c 13.7 10.3, 18.1 3⫾0.8
Users: Food only 18.8⫾0.6 17.7 14.1, 22.2 ⬍3 17.5⫾0.8 16.6 13.0, 21.0 ⬍3
Food and supplements 34.5⫾0.7c 33.1 26.3, 40.8 ⬍3 32.4⫾1.1c 31.2 23.8, 38.8 ⬍3
Magnesium (mg) 350
Nonusers: Food only 294⫾5cd 284 232, 345 77⫾2.0cd 258⫾8cd 246 198, 304 87⫾2.4c
Users: Food only 346⫾9d 334 265, 415 56⫾3.2d 307⫾10d 297 241, 362 71⫾4.0
Food and supplements 424⫾10c 412 335, 499 30⫾3.1c 382⫾11c 372 307, 446 41⫾4.0c
Zinc (mg) 9.4
Nonusers: Food only 12.7⫾0.4c 11.7 9.3, 14.8 26⫾2.5c 10.7⫾0.8c 10.0 7.8, 12.7 43⫾7.0c
Users: Food only 13.1⫾0.4 12.5 10.4, 15.2 16⫾2.5 11.6⫾0.5 11.1 9.0, 13.6 29⫾5.4
Food and supplements 28.6⫾0.8c 26.1 20.3, 33.7 4⫾0.9c 25.7⫾1.3c 24.1 18.4, 30.2 5⫾1.5c
a
SE⫽standard error.
b
RAE⫽retinol activity equivalents.
c
Significant difference between nonusers and users (food and supplements) (P⬍0.001).
d
Significant difference between nonusers and users (food only) (P⬍0.001).
e
DFE⫽dietary folate equivalents.

supplements did affect intake. Mean intakes from food
and supplements for users were significantly different
from total intake of nonusers. Supplements more than
doubled vitamin B-12 intake for men and women, and
this may be of benefit because the absorption of naturally
occurring vitamin B-12 may be problematic in older
adults (55).
Older men and women who consumed supplements had
significantly higher total calcium intakes than nonusers
of these products (Table 5). The proportion reaching or
exceeding the Adequate Intake increased from 15% to
29% for men aged 51 to 70 years. Large improvements
were also found for older women and men aged 71 years
and older.
Supplements and Overconsumption of Nutrients
Fewer than 3% of men in both age groups had total
intakes that exceeded the UL for vitamins B-6, and C,
and calcium, indicating that risk of adverse effects from
excesses of these nutrients is low in this population group
(Table 6). Supplement use did, however, result in intakes
that exceeded the ULs for iron and zinc for 10% or more
of older men.
Women in both age groups exceeded the UL for iron
and zinc, but they did so in smaller proportions than the
men. Unique to the women was that a higher proportion
(5% to 9%) exceeded the UL for vitamin A than the
proportion of men (4%) who did so.

1326 August 2007 Volume 107 Number 8

 Table 4. Women’s usual nutrient intake (mean and selected percentiles) and percent below the Estimated Average Requirement (EAR), based
on data from the Continuing Survey of Food Intakes by Individuals, 1994-1996
51-70 y >71 y
Nutrient and 25th, 75th % Below 25th, 75th % Below
supplement status EAR MeanⴞSEa Median Quartiles EARⴞSE MeanⴞSE Median Quartiles EARⴞSE

Vitamin A (RAEb) 500

Nonusers: Food only 569⫾36c 496 353, 699 51⫾3.4c 614⫾33c 521 376, 738 47⫾3.8c
Users: Food only 629⫾34 566 419, 767 39⫾4.1 795⫾95 709 544, 951 18⫾8.4
Food and supplements 2,015⫾78c 1,618 1,211, 2,388 8⫾1.1c 1,934⫾98c 1,672 1,179, 2,333 6⫾1.3c
Vitamin B-6 (mg) 1.3
Nonusers: Food only 1.4⫾0.1cd 1.3 1.1, 1.6 48⫾3.1cd 1.4⫾0.1cd 1.3 1.0, 1.7 49⫾4.5cd
Users: Food only 1.6⫾0.1d 1.5 1.3, 1.9 28⫾3.3d 1.7⫾0.1d 1.6 1.3, 2.0 28⫾4.3d
Food and supplements 4.3⫾0.1c 3.5 2.6, 5.1 5⫾0.8c 4.0⫾0.2c 3.5 2.5, 4.8 7⫾1.6c
Vitamin B-12 (␮g) 2.0
Nonusers: Food only 3.7⫾0.2c 3.4 2.6, 4.5 10⫾2.3 3.7⫾0.2c 2.7 2.0, 3.9 25⫾5.4c
Users: Food only 4.2⫾0.3 3.5 2.6, 4.9 11⫾3.1 5.7⫾1.2 3.7 2.5, 6.0 14⫾3.7
Food and supplements 12.6⫾0.6c 9.9 6.9, 13.9 4⫾0.9 13.1⫾1.4c 9.6 6.6, 13.5 5⫾1.5c
Folate (DFEe) 320
Nonusers: Food only 200⫾5cd 188 147, 239 93⫾1.4cd 203⫾9cd 190 143, 249 91⫾2.2c
Users: Food only 238⫾7d 225 173, 288 83⫾2.4d 257⫾13d 243 188, 312 77⫾5.0
Food and supplements 851⫾20c 845 640, 1,029 11⫾1.4c 823⫾34c 846 616, 1,034 12⫾2.1c
Vitamin C (mg) 60
Nonusers: Food only 81⫾8c 72 46, 106 39⫾2.7cd 84⫾6c 74 48, 110 37⫾5.0c
Users: Food only 108⫾3 97 65, 139 21⫾2.4d 101⫾6 98 68, 129 19⫾4.5
Food and supplements 504⫾23c 312 152, 867 4⫾0.8c 428⫾41c 251 121, 611 5⫾1.8c
Vitamin E
(mg ␣-tocopherol) 12
Nonusers: Food only 5.1⫾0.2cd 4.8 3.8, 6.1 ⬎97c 4.5⫾0.2cd 4.1 3.1, 5.4 ⬎97c
Users: Food only 6.3⫾0.2d 5.7 4.4, 7.5 96⫾1.1 6.7⫾0.5d 5.8 4.4, 8.0 93⫾3.9
Food and supplements 66.7⫾4.1c 35.0 17.0, 103.0 14⫾1.8c 53.4⫾5.2c 28.4 14.2, 52.6 17⫾3.3c
Iron (mg) 5
Nonusers: Food only 11.7⫾0.3c 11.2 9.2, 13.7 ⬍3 11.3⫾0.4c 10.6 8.2, 13.6 ⬍3
Users: Food only 12.8⫾0.3 12.2 9.9, 15.0 ⬍3 13.4⫾0.5 12.8 10.3, 15.9 ⬍3
Food and supplements 29.2⫾0.6c 27.1 20.6, 35.0 ⬍3 28.4⫾1.0c 27.2 20.5, 33.8 ⬍3
Magnesium (mg) 265
Nonusers: Food only 218⫾4cd 212 176, 252 81⫾1.9cd 200⫾5cd 194 155, 238 85⫾3.3cd
Users: Food only 252⫾5d 245 203, 292 62⫾2.7d 246⫾6d 239 195, 289 64⫾3.6d
Food and supplements 326⫾5c 319 264, 380 26⫾1.8c 318⫾6c 312 255, 374 29⫾2.9c
Zinc (mg) 6.8
Nonusers: Food only 8.3⫾0.2c 8.0 6.8, 9.4 24.7⫾4.2c 7.4⫾0.2c 7.1 5.8, 8.7 44.8⫾4.4cd
Users: Food only 8.6⫾0.2 8.3 6.9, 10.0 23.3⫾3.2 8.9⫾0.4 8.7 7.1, 10.5 20.2⫾4.3d
Food and supplements 21.9⫾0.5c 21.0 15.7, 26.4 5.8⫾1.5c 21.2⫾0.8c 21.2 15.3, 25.5 5.2⫾2.1c
a
SE⫽standard error.
b
RAE⫽retinol activity equivalents.
c
Significant difference between nonusers and users (food and supplements) (P⬍0.001).
d
Significant difference between nonusers and users (food only) (P⬍0.001).
e
DFE⫽dietary folate equivalents.

Demographic and Attitudinal Predictors of Supplement Use
Predictors of supplement use were different for older
men than for older women (Table 7). Men aged 71 years
and older and those living in metropolitan areas were
significantly more likely to consume supplements com-
pared to men in the 51- to 70-year age group and those
in nonmetropolitan areas, respectively. Education sta-
tus was also a predictor of supplement use for men.
Contrasts showed that significant differences were
found between the least educated men (less than high
school completion attained) and those with either a
high school education or formal education beyond high
school. No differences were noted between the two
higher education categories. For the women, race, re-
gion, smoking status, and vegetarian status were sig-
nificant predictors of supplement use. White women
were more likely to take supplements than all other
racial groups combined, and were twice as likely to
take supplements as Hispanic women. Residence in the
western region of the United States indicated greater
prevalence of supplement use than in all other regions
together; those in the northeast and midwest were
about half as likely to be users. Women who were
nonsmokers were more likely to consume supplements
than women who smoked, and the small percentage of
older women who were vegetarians (4%) were twice as
likely to be supplement users as their nonvegetarian
counterparts.
Of the two attitude variables included in the logistic
regression model, the personal importance of consuming

August 2007 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1327

 Table 5. Calcium intake from food and supplements for men and women aged 51 years and older, based on data from the Continuing Survey
of Food Intakes by Individuals, 1994-1996
% Above the
Sex, age, and supplement status MeanⴞSEa Median (mg) 25th, 75th Quartiles (mg) Adequate IntakeⴞSEb

Males 51-70 y
Nonusers: Food only 726⫾20cd 681 513, 889 7⫾1.2
Users: Food only 871⫾24c 827 638, 1,056 15⫾2.1
Food and supplement 1,038⫾25d 989 768, 1,256 29⫾2.5
Males >71 y
Nonusers: Food only 677⫾24d 636 475, 834 5⫾1.1
Users: Food only 810⫾34 773 598, 983 10⫾2.1
Food and supplement 981⫾32d 941 731, 1,187 24⫾3.0
Females 51-70 y
Nonusers: Food only 573⫾16d 544 416, 699 ⬍3
Users: Food only 630⫾16 599 459, 767 ⬍3
Food and supplement 892⫾19d 849 629, 1,109 19⫾1.4
Females >71 y
Nonusers: Food only 540⫾21d 513 388, 662 ⬍3
Users: Food only 645⫾29 611 473, 779 ⬍3
Food and supplement 856⫾36d 808 617, 1,042 14⫾3.1
a
SE⫽standard error.
b
The Adequate Intake for men and women aged 51 y and older is 1,200 mg.
c
Significant difference between nonusers and users (food only) (P⬍0.001).
d
Significant difference between nonusers and users (food and supplements) (P⬍0.001).

Table 6. Percent of supplement users⫾standard error aged 51 years and older exceeding the Tolerable Upper Limit (UL), based on data from
the Continuing Survey of Food Intakes by Individuals, 1994-1996a
% Supplement Users Above the UL
Men Women
b c
Nutrient UL 51-70 y >71 y 51-70 y >71 y

Vitamin Ad 3,000 ␮g 4⫾1.0 4⫾0.9 9⫾1.3 5⫾2.8

Vitamin B-6 100 mg ⬍3 ⬍3 ⬍3 ⬍3
Vitamin C 2,000 mg ⬍3 ⬍3 ⬍3 ⬍3
Irone 45 mg 17⫾2.0 14⫾2.4 9⫾1.3 8⫾2.1
Zincf 40 mg 15⫾2.0 10⫾2.6 5⫾1.1 4⫾1.6
Calcium 2,500 mg ⬍3 ⬍3 ⬍3 ⬍3
a
Food-only intakes of older adults did not exceed the UL for any nutrient studied.
b
It was not possible to determine the percent exceeding the UL for vitamins B-12, E, folate, and magnesium. Vitamin B-12 has no established UL. The ULs for vitamin E and folate apply
to synthetic forms obtained from supplements, fortified foods, or a combination of the two, and intake from these sources cannot be separated from natural sources in these data. The
UL for magnesium represents intake from pharmacological agents only (not from food and water), information not collected in the Continuing Survey of Food Intakes by Individuals.
c
Levels listed are applicable to men and women aged 51 y of age and older.
d
95th and 99th percentiles of retinol intake were as follows: men 51-70 y—2,847 ␮g, 5,001 ␮g; men 71⫹ y—2,719 ␮g, 4,001 ␮g; women 51-70 y— 4,386 ␮g, 8,607 ␮g; and women
71⫹ y—3,114 ␮g, 8,868 ␮g.
e
95th and 99th percentiles of iron intake were as follows: men 51-70 y—59 mg, 75 mg; men ⱕ71 y—57 mg, 77 mg; women 51-70 y—58 mg, 88 mg; and women ⱕ71—51 mg,
76 mg.
f
95th and 99th percentiles of zinc intake were as follows: men 51-70 y—57 mg, 76 mg; men ⱕ71 y— 49 mg, 72 mg; women 51-70 y— 41 mg, 62 mg; and women ⱕ71 y—37
mg, 52 mg.

a diet consistent with Dietary Guidelines recommenda- DISCUSSION

tions was a significant predictor of supplement use. In-
terestingly, it was also the only factor that was significant
for both men and women. Attitudes related to the percep-
tion of the adequacy of one’s own diet were not related to
supplement use.
This study provides estimates of the prevalence of nutri-
ent inadequacies and excesses among older adults, and
compares intakes of supplement users and nonusers. The
estimates cover total nutrient intake from both foods and

1328 August 2007 Volume 107 Number 8

 Table 7. Attitudinal and sociodemographic variables related to supplement use, based on data from the Diet and Health Knowledge Survey,
1994-1996
Men Women
Variable Odds ratio 95% CIa Significance Odds ratio 95% CI Significance

Attitudinal variables
Perceived adequacy of dietb 0.74 (0.45-1.23) 0.95 (0.70-1.29)
Importance of healthy dietc 1.65 (1.25-2.17) *** 1.62 (1.10-2.38) *
Sociodemographic variablesd
Age group (51-70 y, ⱕ71 y) 0.68 (0.49-0.94) * 1.22 (0.88-1.69)
Race (Non-Hispanic whiteⴝ1.00) **
Hispanic 1.20 (0.49-2.91) 0.45 (0.24-0.82)
Non-Hispanic Black 0.65 (0.33-1.28) 0.63 (0.35-1.11)
Non-Hispanic other race 0.53 (0.14-2.04) 0.33 (0.09-1.18)
Region (Westⴝ1.00) **
Northeast 0.70 (0.40-1.22) 0.46 (0.30-0.69)
Midwest 0.93 (0.51-1.71) 0.59 (0.40-0.87)
South 0.96 (0.57-1.62) 0.66 (0.43-1.02)
Metropolitan area (yes/no) 1.65 (1.09-2.49) * 1.26 (0.94-1.69)
Poverty statuse (350% and over⫽1.00)
⬍130% 0.83 (0.52-1.32) 0.65 (0.40-1.08)
131%-350% 0.86 (0.60-1.24) 0.83 (0.58-1.18)
Educational status (education
beyond high schoolⴝ1.00) **
⬍High school completed 0.50 (0.33-0.76) 0.72 (0.46-1.15)
High school completed 0.76 (0.51-1.13) 0.75 (0.52-1.08)
Current smoker (yes/no) 0.92 (0.62-1.37) 0.67 (0.46-0.97) *
Weight status (overweight/not
overweight) 0.73 (0.52-1.03) 0.82 (0.60-1.13)
Exercise (ⱕ1 time/wk, ⱖ2
times/week) 0.96 (0.69-1.33) 0.78 (0.57-1.07)
Television watching (ⱕ1 h/d, 1⫹ h/d) 0.78 (0.53-1.16) 0.79 (0.58-1.06)
Follows special diet (yes/no) 1.36 (0.93-1.99) 1.28 (0.95-1.72)
Vegetarian (yes/no) 1.14 (0.44-2.92) 2.03 (1.18-3.49) **
a
CI⫽confidence interval.
b
11 item scale querying respondent if their diet was too high, too low, or about right in (nutrient).
c
11 item scale asking respondent if it was very important, somewhat important, not too important, or not at all important to follow (1990 Dietary Guidelines [60]).
d
For dichotomous variables, latter choice was base for comparison.
e
Poverty categories expressed as percent of the Federal poverty level.
*P⬍0.05.
**P⬍0.01.
***P⬍0.001.

supplements. To our knowledge, this is the first study to
use DRIs in combination with estimates of usual total
nutrient intake to evaluate intakes in this population.
The results are consistent with those from previous
studies (27,32,38,40,41,43-45) in showing that, generally,
supplement users consume more nutritious diets than
nonusers. We found that supplement users were more
likely to have adequate nutrient intakes from food alone
than nonusers for many of the nutrients studied. How-
ever, both supplement users and nonusers had large
shortfalls in intake from food alone for several nutrients,
most notably folate, vitamin E, and magnesium. Supple-
mentation was most beneficial in improving intakes for
these nutrients. Nutrients for which little benefit from
supplementation was observed were vitamin B-12 (as-
suming adequate absorption) and iron because most older
adults met the EARs from foods alone. Among users, 80%
or more met EARs with their total intake for all nutrients
studied except magnesium.
The folate estimates here underestimate current in-
takes because the US Food and Drug Administration did
not mandate fortification of grain products until 1998,
after data for this study were collected; however, they
provide a benchmark for comparison to post-fortification
levels. Fortification was expected to add 70 to 130 ␮g to
the daily diet, but subsequent studies have shown that
intakes have been increased by 200 ␮g or more
(48,49,61,62). Based on our study, most older adults
would meet adequacy standards if diets provided a net
increase of 200 ␮g/day. Nevertheless, recent analyses
using NHANES 2001-2002 data and the accompanying
US Department of Agriculture’s Food and Nutrient Da-
tabase for Dietary Studies 1.0, which accounts for current
fortification levels found that depending on the sex/age

August 2007 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1329

category, 7% to 21% of older adults still had inadequate
intakes from food alone (63). Further study is needed to
determine if folate taken as a dietary supplement should
be recommended for this population to improve intake
and achieve dietary adequacy.
Most older adults appear to obtain adequate amounts
of vitamin B-12 from dietary sources. However, the Insti-
tute of Medicine has advised that individuals aged 50
years and older obtain vitamin B-12 from supplemental
sources because 10% to 30% of older adults may not be
able to absorb the naturally occurring form found in foods
(55). With databases available for these analyses, it was
not possible to differentiate between the naturally occur-
ring form and the synthetic form added to fortified foods
for estimating intake. In the future, with such a data-
base, research can determine if supplemental vitamin
B-12 is needed to meet EARs in addition to the vitamin
B-12 typically provided by the food supply.
Supplements boosted total intakes of iron and zinc so
that a considerable proportion of older adults, particu-
larly men, exceeded the UL. Due to the adverse effects
associated with iron overload and the possibility of its
association with coronary heart disease, the Institute of
Medicine has recommended that men and postmeno-
pausal women avoid iron supplements and highly forti-
fied foods (53). Data from this study support those rec-
ommendations. In contrast, zinc intake inadequacy
before supplementation affected 20% or more of the pop-
ulation. This finding is consistent with other research
that has found that older adults, particularly those aged
71 years and older, are the population at greatest risk of
zinc intake inadequacy (4,6,7,11,64,65). At the same time,
data from this study indicate that approximately 15% of
men aged 51 to 70 years and 10% of men aged 71 years
and older who are supplement users are exceeding the
UL for zinc. Excess consumption of zinc is associated with
a risk of reduced copper status, impaired immune re-
sponse, and lowered plasma high-density lipoprotein cho-
lesterol levels (53). Supplementation of zinc appears to be
needed by a sizable proportion of older men and women,
but should be undertaken prudently.
The UL for vitamin A was exceeded by 9% of women
aged 51 to 70 years and by 5% of women aged 71 years
and older who took supplements. This finding is of con-
cern because long-term vitamin A intake ⱖ3,000 ␮g per
day has been associated with hip fractures in postmeno-
pausal women (66-68). Most of the supplemental vitamin
A was consumed in a multivitamin/multimineral supple-
ment. An imputed retinol:beta-carotene ratio was used
for estimating intake based on the most commonly re-
ported supplement of that type in NHANES 1999-2000.
The percentage of women actually consuming vitamin A
in levels above the UL, and therefore at risk of adverse
effects, may be higher or lower if the particular brands of
supplements consumed have a different ratio. Further
investigation with more precise data is needed to identify
if excess vitamin A intake by supplementation is an issue
affecting large numbers of older women.
A secondary objective of the study was to identify char-
acteristics associated with supplement use with particu-
lar emphasis on more modifiable factors like attitudes.
Whereas sociodemographic factors related to supplement
use varied by sex, attitudes about the importance of fol-
1330 August 2007 Volume 107 Number 8
lowing a healthful diet consistent with expert recommen-
dations was a significant predictor for both men and
women. Those respondents most concerned about their
diets and dietary recommendations were more likely to
take supplements. These findings suggest that encourag-
ing positive attitudes about a healthful diet in combina-
tion with nutrition guidance and appropriate supplement
information may result in promoting advantageous use of
supplements by this at-risk population.
The fact that the CSFII 1994-1996 is more than 10
years old raises questions as to the applicability of
these findings to current dietary adequacy of older
adults. However, nutrient intakes from food in this
study are comparable to those reported in assessments
using the NHANES 2001-2002 data, suggesting that
there has been little change in nutrient intake from
food during this time period (63). Using approximate t
tests, we investigated changes from 1994 to 1996 to
2001 to 2002 in the percent of the older adult popula-
tion meeting the EAR for the nutrients included in this
study. Except for folate and calcium, no differences
were found. Folate intake dramatically increased by
more than 200 ␮g in all of the age/sex groups due to
changes in fortification regulations implemented after
the data for this study were collected. The mean cal-
cium intake from food increased significantly for men
aged 51 to 70 years (611 mg⫾12 to 874 mg⫾30) and
women aged 51 to 70 years (589 mg⫾17 to 701 mg⫾19).
Results concerning the other eight nutrients we ana-
lyzed should apply now as they do to a decade ago.
Methodologic limitations demand caution be taken in
interpreting results from this research. Supplement use
was not tied to a specific day of intake, and the validity of
applying quantitative intake assessment to frequency
data has been questioned (69). If the supplement infor-
mation had been collected to match the days of the 24-
hour food recalls, it would be better suited to the statis-
tical requirements for intake assessment (69). Another
methodologic limitation is the need for assumptions due
to the lack of specificity of the available supplement data.
Because brand name information was not collected, esti-
mates were derived using formularies reflecting the com-
position of the most commonly reported supplement of
that type in NHANES 1999-2000. If a respondent did not
take the most frequently used product of that type, this
imputation may not accurately reflect what nutrients
were actually consumed. Moreover, formulations of sup-
plements are changed frequently, and a specific supple-
ment manufactured in 1994 through 1996 may not be
identical to the 1999 through 2000 product. In addition,
whereas frequency information on supplement use was
collected (ie, every day/infrequently/not at all), the quan-
tity of supplements taken was not obtained. Last, supple-
ment use is subject to misreporting. Respondents may not
remember any or all the supplements they take or how
often they take them. Because of these limitations, the
proportions of supplement users meeting EARs and ex-
ceeding ULs may be higher or lower than reported in this
study. Also absent from these intake data is information
on supplements such as antacids and medicinal products
that may have been taken and would contribute nutri-
ents. Older adults are heavy consumers of these products
(17,19,27,28,33,70). Calcium intake in particular may be
underestimated due to lack of data on intake of antacids,
which are promoted as calcium supplements and popular
among the older population (71).
CONCLUSIONS
Supplements had a positive influence on nutrient ade-
quacy for men and women aged 51 years and older.
Whereas dietary modifications to improve intake are par-
amount, the use of supplements by older adults appears
beneficial to attain nutrient adequacy. To avoid exceeding
the UL, this population should avoid the routine supple-
mental intake of certain nutrients including vitamin A in
the form of retinol and iron.
The link between dietary attitudes and subsequent
behavior, including supplement use, needs further re-
search. Currently there is no attitude data collected in
conjunction with dietary information on a nationwide
scale (72,73). Comprehensive attitude data related to di-
etary issues needs to be obtained to investigate possible
avenues for intervention to encourage healthful behavior.
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