Use of dietary supplements by pregnant and lactating women in North America

Major Gaps in Understanding Dietary Supplement Use in Health and Disease

Precise dietary assessment is critical for accurate exposure classification in nutritional research, typically aimed at understanding how diet relates to health. Dietary supplement (DS) use is widespread and represents a considerable source of nutrients. However, few studies have compared the best methods to measure DSs. Our literature review on the relative validity and reproducibility of DS instruments in the United States [e.g., product inventories, questionnaires, and 24-h dietary recalls (24HR)] identified five studies that examined validity (n = 5) and/or reproducibility (n = 4). No gold standard reference method exists for validating DS use; thus, each study's investigators chose the reference instrument used to measure validity. Self-administered questionnaires agreed well with 24HR and inventory methods when comparing the prevalence of commonly used DSs. The inventory method captured nutrient amounts more accurately than the other methods. Reproducibility (over 3 months to 2.4 years) of prevalence of use estimates on the questionnaires was acceptable for common DSs. Given the limited body of research on measurement error in DS assessment, only tentative conclusions on these DS instruments can be drawn at present. Further research is critical to advancing knowledge in DS assessment for research and monitoring purposes.

Pregnancy thiamine and riboflavin intake and the risk of gestational diabetes mellitus: A prospective cohort study

BACKGROUND

Thiamine and riboflavin deficiencies exist to varying degrees worldwide, especially in developing countries. Evidence regarding the association between thiamine and riboflavin intake and gestational diabetes mellitus (GDM) is scarce.

OBJECTIVES

We aimed to evaluate the association of thiamine and riboflavin intake during pregnancy, including dietary source and supplementation, with GDM risk in a prospective cohort study.

METHODS

We included 3036 pregnant women (923 in the first trimester and 2113 in the second trimester) from the Tongji Birth Cohort. A validated semi-quantitative food frequency questionnaire and a lifestyle questionnaire were used to assess thiamine and riboflavin intake from dietary source and supplementation, respectively. GDM was diagnosed using the 75 g 2-h oral glucose tolerance test at 24-28 weeks of gestation. A modified Poisson regression or logistic regression model was used to evaluate the association between thiamine and riboflavin intake and GDM risk.

RESULTS

Dietary intake of thiamine and riboflavin was at low levels during pregnancy. In the fully adjusted model, compared with participants in quartile 1 (Q1), those who had more total thiamine and riboflavin intake had a lower risk of GDM during the first trimester [thiamine: Q2: RR: 0.58 (95% CI: 0.34, 0.98); Q3: RR: 0.45 (95% CI: 0.24, 0.84); Q4: RR: 0.35 (95% CI: 0.17, 0.72), P for trend = 0.002; riboflavin: Q2: RR: 0.63 (95% CI: 0.37, 1.09); Q3: RR: 0.45 (95% CI: 0.24, 0.87); Q4: RR: 0.39 (95% CI: 0.19, 0.79), P for trend = 0.006]. This association was also observed during the second trimester. Similar results were observed for the association between thiamine and riboflavin supplement use but not dietary intake and GDM risk.

CONCLUSIONS

Higher intake of thiamine and riboflavin during pregnancy is associated with a lower incidence of GDM. This trial was registered at http://www.chictr.org.cn as ChiCTR1800016908.

Prevalence, patterns, and attitude regarding dietary supplement use in Saudi Arabia: Data from 2019

Dietary supplements are products containing dietary elements including vitamins, minerals, amino acids, herbs, or botanicals. They can aid consumers with low dietary intake and quality, as well as those with high demands, by boosting nutritious value. A cross-sectional study was conducted among adults living in Saudi Arabia aged between 18–60 years old using online self-administered questionnaire. Information regarding sociodemographic characteristics, use and type of dietary supplements, and attitude toward and patterns of dietary supplement use was collected. The chi-square test, Pearson correlations, and the independent t-test were used. In total, 531 participants (115 men and 416 women) were included. Approximately half of the participants (51.8%, n = 275) used dietary supplements. Participants who were using dietary supplements were significantly younger (29.16 ± 9.32 years), more highly educated (85.5%, n = 235), and worked in the health sector (63.7%, n = 100). Herbal supplement use was associated with older age and female sex. Single mineral supplements were used more frequently by married, female, pregnant, or breastfeeding participants and those not working in the health sector. Fatty supplements were used more frequently by participants with a higher level of education. Regarding the attitude toward dietary supplement use, women, single participants, and health care workers showed a significant positive attitude. In-depth investigation into the amount of and reasons for dietary supplement use in the health sector is required. Additionally, educating pregnant and breastfeeding women on the importance of dietary supplements is necessary.

Maternal food-avoidance diets and dietary supplements during breastfeeding

AIMS

To identify maternal food-avoidance diets and dietary supplement use during breastfeeding, and to explore factors associated with food avoidance diets.

DESIGN

A prospective mother-child birth cohort study.

METHODS

Electronic questionnaires were answered by 1,462 breastfeeding mothers 6 months postpartum in the Preventing Atopic Dermatitis and Allergies in Children (PreventADALL) study from 2014-2016. Demographic and antenatal factors were analysed for associations with food avoidance diets in 1,368 women by multiple logistic regression.

RESULTS

Overall, 289 breastfeeding women (19.8%) avoided at least one food item in their diet, most commonly cow's milk in 99 women (6.8%). Foods were most often avoided due to conditions in the child, maternal factors or lifestyle choice. The odds for food avoidance diets were 2.1 (95% CI: 1.3, 3.4) for food allergy (presumed or diagnosed) and 19.4 (5.4, 70.1) for celiac disease in the mother. Dietary supplements were reported by nearly 80%, most commonly cod liver oil.

Sex Differences Across the Life Course: A Focus On Unique Nutritional and Health Considerations among Women

In the United States, women, while having a longer life expectancy than men, experience a differential risk for chronic diseases and have unique nutritional needs based on physiological and hormonal changes across the life span. However, much of what is known about health is based on research conducted in men. Additional complexity in assessing nutritional needs within gender include the variations in genetics, body compositions, hormonal milieus, underlying chronic diseases, and medication usage, with this list expanding as we consider these variables across the life course. It is clear women experience nutrient shortfalls during key periods of their lives, which may differentially impact their health. Consequently, as we move into the era of precision nutrition, understanding these sex- and gender-based differences may help optimize recommendations and interventions chosen to support health and weight management. Recently, a scientific conference was convened with content experts to explore these topics from a life-course perspective at biological, physiological, and behavioral levels. This publication summarizes the presentations and discussions from the workshop and provides an overview of important nutrition and related lifestyle considerations across the life course. The landscape of addressing female-specific nutritional needs continues to grow; now more than ever, it is essential to increase our understanding of the physiological differences between men and women, and determine how these physiological considerations may aid in optimizing nutritional strategies to support certain personal goals related to health, quality of life, sleep, and exercise performance among women.

Rational Use of vitamins during pregnancy and The pregnancy multivitamin products' available in Turkey

Background: Despite the imperative role of sufficient vitamin intake during pregnancy, not all women are capable of following a balanced diet during these times. As an attempt to resolve the issue of micronutrient deficiencies, many women resort to the use of multivitamins; ones often made for pregnant women. Aim: The review aims to compare the Daily Recommended Dietary Allowance of each vitamin, micronutrient, and macronutrient with the doses available in a sample of products found in the Turkish markets, whether imported or manufactured in Turkey. Methods: The Daily Recommended Dietary Allowance doses were collected from the CDC, WHO, and IOM databases. The doses present in each product were gathered using the database offered by the Turkish pharmacist association "Tebrp" as well as RxMediaPharma. Elevit® and decavit® were selected as they've been approved by the Turkish Ministry of Health, while the other products were randomly chosen using a computer program. Results: Several formulations available in Turkey display higher or lower daily contents of vitamins and minerals than is normally ideal for pregnant women as specified by the Recommended Dietary Allowance (RDA). Formulations that exceed the recommended RDA while remaining underneath the tolerable Upper Intake Level (UL) range for specific vitamins includes Pregnacare®, Decavit®, and Elevit®. Conclusion: All of these variances in multivitamin content must be considered by physicians and clinical pharmacists when selecting the appropriate multivitamin for pregnant women, taking into account all of the hazards and benefits that vitamin supplements may bring to fetus health and development.

Ingestion of supplements and fortified food with iodine on the breast milk iodine concentration in deficiency areas: a systematic review

Introduction

The level of iodine in breast milk may be inadequate and compromise the health of this, both due to excess and lack, some population groups remain deficient because of the low consumption of iodate salt, because there is an increase in consumption of other sources of iodine, such as supplements and fortified foods.

Objective

To evaluate the effect of the consumption of fortified foods and nutritional supplements with iodine on maternal milk levels.

Methodology

Systematic review based on the Prism method, using the descriptors provided by DeCS. The reading, selection and analysis of the methodological quality of the articles was done by two researchers independently.

Results

From 346 abstracts, 6 were eligible. The median iodination range between the studies ranged from 75 to 600 µg in supplements and 150 and 225 µg in fortified foods with effect on increased iodine concentration of breastmilk (BMIC), achieving the adequacy of the median BMIC in 4 of the 6 studies.

Conclusion

Iodine ingestion through supplements or fortified foods results in improved iodine levels in breast milk.

Arsenic, Cadmium, Lead, and Mercury in Lactation Foods and Prenatal Vitamins: Potentially Avoidable Exposure for Breastfeeding Mothers and Infants

Background: Human milk is a biofluid that can contain heavy metals such as arsenic, cadmium, lead, and mercury. These toxins can adversely affect endocrine, respiratory, immune, and nervous systems. Infants may have higher dietary arsenic exposure than adults due to their more restricted diets and greater intake per unit body mass. We identified commonly purchased vitamins, lactation bars, and supplements, to measure the concentration of heavy metals. The goal of the study was to measure and determine if vitamins and lactation foods could be a source of exposure. Methods: We tested 9 popular vitamins and 16 lactation bars and supplements all marketed toward breastfeeding mothers to determine the presence of heavy metals. All vitamins, bars, and supplements were analyzed using inductively coupled plasma mass spectrometry, for the total concentration of arsenic, mercury, cadmium, and lead, with the lowest detection limit of 0.001 μg/L. Results: The majority of the samples had total arsenic levels below detectable quantities (detection limit of 1 part per trillion [0.001 μg/L]), one sample of syrup had a concentration of 0.112 ± 0.005, 0.132 ± 0.009, and 0.108 ± 0.010 μg of arsenic/g. We also tested nine popular prenatal vitamins for the amount of arsenic in one serving of vitamins per day and showed exposure to arsenic in one vitamin of 7.108 μg of arsenic/day. All lactation foods and vitamins tested had undetectable amounts of cadmium, mercury, and lead. Conclusion: Most of the vitamins and bars that were tested had below the detectable limit of arsenic, cadmium, lead, and mercury; we did find one vitamin and one rice syrup that had significantly higher levels. Our data suggest that it is highly feasible to manufacture vitamins and lactation foods and supplements with significantly lower concentrations of heavy metals.

Qualitative exploration of the factors influencing the use of dietary supplements in Iranian women: introduction to areas of focus for developing interventions

BACKGROUND

Literature shows that the consumption of Dietary Supplements (DS) is more common in Iran. This study aimed to explore the experiences of a sample of Iranian women regarding the factors influencing the use of DS.

METHODS

This qualitative content analysis study was conducted in Qods city, Tehran province, Iran from January to March 2020. Forty-two semi-structured in-depth interviews were performed with women. The participants were asked about their experiences about the determinants of the consumption of DS. After the first round of the interviews was done, we performed content analysis of the data and continued up to data saturation.

RESULTS

Two main themes including personal factors (with 5 subthemes including sociodemographic characteristics, perceived benefits of DS, history of illness, physiological conditions, and lifestyle factors) and socio-economic factors (with 3 subthemes including subjective norms, the price of food and commercial considerations of the sectors involved in the production and sale of DS) emerged as the experiences of the participants as to the intake of DS.

CONCLUSIONS

These variables may suggest areas which need to be focused on for performing more effective interventions to affect appropriate consumption of DS in Iran.

The impact of micronutrient deficiency on pregnancy complications and development origin of health and disease

Due to the spread of the western style diet, which is characterized by high intake of processed food, micronutrients (vitamins and minerals) deficiency is increasing in the Japanese population of all ages and genders. During pregnancy, the elevated demand for micronutrients put pregnant women at even higher risk of micronutrients deficiency. Some micronutrients are relatively famous such that women with reproductive age are recommended to take folic acid supplementation for the prevention of neural tube defect. However, it is not generally known that folate is also important for fetal growth throughout the pregnancy course and for prevention of pregnancy complications, and that pregnant women should continue to take supplementation during pregnancy and lactation. The types of micronutrients and the duration of supplementation are both important factors to maintain normal pregnancies. This review focused on four micronutrients that are commonly deficient in Japanese pregnant women, folate, vitamin B12, vitamin D, calcium, and magnesium. The detrimental effects of homocysteine accumulation associated with the above micronutrient defects and its link to catechol-o-methyltransferase insufficiency are described. We also discussed possible molecular mechanisms of pregnancy complications and the development origin of health and disease (DOHaD) regarding micronutrient deficiencies from the point of view of one carbon metabolism.

Is iodized salt efficient to overcome iodine deficiency in pregnants?

Objective:

Iodine is a trace element that synthesizes thyroid hormones necessary for optimal human growth and development. The relationship between dietary iodine intake and spot urinary iodine excretion in pregnant women has not been previously evaluated in Trabzon city, which is an endemic area of iodine deficiency in the Black Sea region of Turkey. This study aimed to evaluate the relationship between dietary iodine intake and urine iodine excretion in pregnant women.

Materials and Methods:

This study enrolled 150 pregnant women aged between 19 and 45 years who applied to Clinic of Gynecology and Obstetrics in Trabzon. Spot urine specimens were taken, and dietary iodine intake data were collected using a food frequency questionnaire (FFQ) and 24-hours dietary recall (24-h DR) method.

Results:

The median urinary iodine concentration (UIC) in the general specimen was 100.6 μg/L. Of the pregnant women, 80.0% had insufficient and 20.0% had sufficient iodine levels, according to UIC. Although total iodine-rich food intake determined by FFQ was sufficient in 20.7% (n=31) of participants, 24-h DR iodine intake was sufficient only 10.7% (n=16). A significant association between urinary iodine excretion and iodine intake was observed in both 24-h DR and FFQ intake estimates (p<0.05). The iodine intake values obtained in both 24-h DR and FFQ and the iodized salt effect were correlated with UIC in all models (p<0.05). Even though 96.0% of pregnant women used iodized salt, its effect on UIC was 15.2%.

Conclusion:

Both methods indicate that the iodine intake of pregnant women might be insufficient in Trabzon area. Also, although iodized salt use is high in pregnant women in Trabzon, it is not enough to prevent iodine deficiency.

Adaptive Fat Oxidation Is Coupled with Increased Lipid Storage in Adipose Tissue of Female Mice Fed High Dietary Fat and Sucrose

Western diets high in fat and sucrose are associated with metabolic syndrome (MetS). Although the prevalence of MetS in women is comparable to that in men, metabolic adaptations in females to Western diet have not been reported in preclinical studies. This study investigates the effects of Western diet on risk factors for MetS in female mice. Based on our earlier studies in male mice, we hypothesized that dietary supplementation with extracts of Artemisia dracunculus L. (PMI5011) and Momordica charantia (bitter melon) could affect MetS risk factors in females. Eight-week-old female mice were fed a 10% kcal fat, 17% kcal sucrose diet (LFD); high-fat, high-sucrose diet (HFS; 45% kcal fat, 30% kcal sucrose); or HFS diet with PMI5011 or bitter melon for three months. Body weight and adiposity in all HFS groups were greater than the LFD. Total cholesterol level was elevated with the HFS diets along with LDL cholesterol, but triglycerides and free fatty acids were unchanged from the LFD. Over the three month period, female mice responded to the HFS diet by adaptive increases in fat oxidation energy in muscle and liver. This was coupled with increased fat storage in white and brown adipose tissue depots. These responses were enhanced with botanical supplementation and confer protection from ectopic lipid accumulation associated with MetS in female mice fed an HFS diet.

Association of DHA Concentration in Human Breast Milk with Maternal Diet and Use of Supplements: A Cross-Sectional Analysis of Data from the Japanese Human Milk Study Cohort

BACKGROUND

DHA (22:6n-3) is essential for neurodevelopment in children, and its concentration in human breast milk is historically high in Japan. Dietary patterns in Japan might affect the fatty acid (FA) composition among lactating mothers.

OBJECTIVES

This study aimed to characterize the composition of milk FAs and to identify any dietary and sociodemographic factors associated with the variability of DHA concentration in breast milk in the Japanese population.

METHODS

This cross-sectional study was performed as part of the Japanese Human Milk Study. Milk FAs were analyzed by GC at 1-6 mo postpartum, and maternal diet was estimated using an FFQ, including 11 types and cooking methods of seafoods, and the use of DHA supplements. The association of milk DHA with maternal diet and sociodemographic factors was investigated.

RESULTS

Milk FA concentrations were measured in 78 mothers, including 24 who routinely used DHA supplements. The DHA concentration in milk (overall median: 0.62%; IQR: 0.47%-0.78%) was higher in women who took DHA supplements than in women who had never used DHA supplements (0.74%compared with 0.55%; P = 0.011). A linear regression model showed the association of milk DHA concentration with maternal dietary intake of grilled fish (β ± SE: 0.006 ± 0.003; standardized β: 0.234; r 2 = 0.232, P = 0.036) after adjustment for DHA supplementation status, maternal and infant age, maternal BMI, and infant birth weight. Other FA concentrations were consistent, whereas caproic acid (6:0), undecylic acid (11:0), pentadecylic acid (15:0), palmitoleic acid (16:1n-7), and vaccenic acid (18:1n-7) varied by DHA supplementation status.

CONCLUSIONS

The DHA concentration in human milk may be influenced by maternal grilled fish consumption and frequent DHA supplementation in lactating Japanese women. Milk DHA concentrations may reflect a dietary habit in Japanese mothers.This trial was registered at www.umin.ac.jp/ctr as UMIN000015494.

Vitamin D Supplementation during Pregnancy: An Evidence Analysis Center Systematic Review and Meta-Analysis

BACKGROUND

Given the high rates of vitamin D deficiency among pregnant women and possible effects on offspring health, a systematic review on this topic was conducted to help inform future practice guidelines.

OBJECTIVE

To evaluate associations between maternal vitamin D supplementation, maternal 25-hydroxyvitamin D (25(OH)D) concentrations, and health outcomes.

METHODS

A PubMed literature search was conducted to identify studies that examined the health effects of vitamin D supplementation during pregnancy on maternal and infant health outcomes published from 2000 to 2016. Among 976 identified publications, 20 randomized clinical trials met the inclusion criteria. The initial search was extended to include five studies published between July 2016 and September 2018.

MAIN OUTCOME MEASURES

Maternal and infant 25(OH)D concentrations, gestational diabetes, preeclampsia or gestational hypertension, cesarean section, maternal parathyroid hormone and calcium concentrations, and infant gestational age, birth weight, and birth length.

STATISTICAL ANALYSES

Mean differences, odds ratios, and 95% CIs were calculated, only for the initial search, using separate random-effects meta-analyses for each outcome.

RESULTS

Evidence was good or strong that maternal vitamin D supplementation significantly increased maternal (13 studies, n=18, mean difference, 14.1 ng/mL [35.2 nmol/L]; 95% CI=9.6-18.6 ng/mL [24.0-46.4 nmol/L]) and infant (nine studies, n=12; 9.7, 5.2, 14.2 ng/mL [24.2, 12.9, 35.5 nmol/L]) 25(OH)D concentrations, although heterogeneity was significant (I²=95.9% and I²=97.4, respectively, P<0.001). Evidence was fair that vitamin D supplementation significantly decreases maternal homeostatic model assessment-insulin resistance (five studies, n=7; -1.1, -1.5, -0.7) and increases infant birth weight (nine studies, n=11, 114.2, 63.4, 165.1 g), both had insignificant heterogeneity. A null effect of maternal supplementation on other maternal (preeclampsia, cesarean section) and infant (gestational age, birth length) outcomes was found.

CONCLUSIONS

Results show vitamin D supplementation during pregnancy improves maternal and infant 25(OH)D concentrations and may play a role in maternal insulin resistance and fetal growth. To further inform practice and policies on the amount of vitamin D, which supports a healthy pregnancy, high quality dose-response randomized clinical trials, which assess pregnancy-specific 25(OH)D thresholds, and appropriately powered clinical outcomes are needed.

NIH workshop on human milk composition: summary and visions

Nationally representative data from mother-child dyads that capture human milk composition (HMC) and associated health outcomes are important for advancing the evidence to inform federal nutrition and related health programs, policies, and consumer information across the governments in the United States and Canada as well as in nongovernment sectors. In response to identified gaps in knowledge, the National Institute of Diabetes and Digestive and Kidney Diseases of the NIH sponsored the "Workshop on Human Milk Composition-Biological, Environmental, Nutritional, and Methodological Considerations" held 16-17 November 2017 in Bethesda, Maryland. Through presentations and discussions, the workshop aimed to 1) share knowledge on the scientific need for data on HMC; 2) explore the current understanding of factors affecting HMC; 3) identify methodological challenges in human milk (HM) collection, storage, and analysis; and 4) develop a vision for a research program to develop an HMC data repository and database. The 4 workshop sessions included 1) perspectives from both federal agencies and nonfederal academic experts, articulating scientific needs for data on HMC that could lead to new research findings and programmatic advances to support public health; 2) information about the factors that influence lactation and/or HMC; 3) considerations for data quality, including addressing sampling strategies and the complexities in standardizing collection, storage, and analyses of HM; and 4) insights on how existing research programs and databases can inform potential visions for HMC initiatives. The general consensus from the workshop is that the limited scope of HM research initiatives has led to a lack of robust estimates of the composition and volume of HM consumed and, consequently, missed opportunities to improve maternal and infant health.

The effect of maternal vitamin C intake on fetal telomere length

BACKGROUND

A telomere is a nucleoprotein structure that is located at the end of a chromosome. Reduced telomere length manifests as physical ailments such as the increased risk of age-related illnesses. These age-related illnesses include heart disease and failure. Telomere length has been studied extensively in adults; however, limited information exists regarding maternal dietary influences on fetal telomere length.

OBJECTIVES

The objective of this study is to investigate the relationship between maternal vitamin C intake and fetal telomere length.

METHODS

Data for this analysis were collected as part of a prospective cohort study that recruited pregnant women upon admission into labor and delivery. Umbilical cord serum was collected for 96 maternal-fetal dyads, and DNA analysis was performed using a quantitative polymerase chain reaction. The telomere to single copy gene ratio method was used to determine telomere length, and maternal vitamin C intake was measured using the Dietary History Questionnaire (DHQ). Statistical analysis was conducted using generalized linear modeling-based analyses.

RESULTS

The linear model indicates that maternal vitamin C intake (OR = 1.0032, 95%CI: 1.0014-1.0052, p ≤ .05) was positively associated with fetal telomere length. BMI (OR = 1.1096, 95%CI: 1.0619-1.1660, p ≤ .05) had a significant positive association with fetal telomere length while sodium intake was negatively associated with this outcome (OR = 0.9997, 95%CI: 0.9995-0.9998, p ≤ .05). Black ethnicity had a significant negative association with fetal telomere length (OR = 0.0186, 95%CI: 0.0031-0.0824, p ≤ .05).

CONCLUSIONS

Our study shows a positive association between maternal vitamin C intake and fetal telomere length. These findings may provide a method of understanding and preventing adult-onset disease and mortality through intrauterine reprograming.

Estimation of Total Usual Dietary Intakes of Pregnant Women in the United States

IMPORTANCE

Nutrition during pregnancy is a critical dimension not only for women's health but also for the lifelong health of the offspring. Very limited national data exist on the usual dietary intakes of pregnant women.

OBJECTIVE

To estimate total usual nutrient intakes (from foods and dietary supplements) and the population prevalence of meeting or exceeding the National Academies of Sciences, Engineering, and Medicine Dietary Reference Intake recommendations among pregnant US women.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional analysis was performed of a nationally representative sample of 1003 pregnant US women aged 20 to 40 years from the 2001-2014 National Health and Nutrition Examination Survey.

EXPOSURE

Usual dietary intakes assessed by two 24-hour dietary recalls (including dietary supplements) adjusted for within-person variation using the National Cancer Institute method.

MAIN OUTCOMES AND MEASURES

The proportion of women at risk of inadequate dietary intake as determined by the Estimated Average Requirement, the proportion of women assumed to have adequate dietary intake as determined by the Adequate Intake, and the proportion of women at risk of excess dietary intake as determined by the Tolerable Upper Intake Level. Demographic differences between pregnant and nonpregnant women were compared with t tests.

RESULTS

As representative of the US population, this sample of 1003 pregnant women had a mean (SE) age of 28.0 (0.3) years, was predominantly non-Hispanic white (mean [SE], 54.5% [3.1%]), and was at above 185% of the income to poverty ratio (mean [SE], 56.8% [3.0%]). Most pregnant women used a dietary supplement (mean [SE], 69.8% [2.3%]). A total of 10% or more of pregnant women had a total usual intake that is less than the Estimated Average Requirement for magnesium (mean [SE], 47.5% [2.8%]), vitamin D (mean [SE], 46.4% [2.7%]), vitamin E (mean [SE], 43.3% [2.7%]), iron (mean [SE], 36.2% [2.8%]), vitamin A (mean [SE], 15.5% [2.1%]), folate (mean [SE], 16.4% [1.6%]), calcium (mean [SE], 12.9% [2.4%]), vitamin C (mean [SE], 11.5% [1.9%]), vitamin B6 (mean [SE], 11.5% [1.5%]), and zinc (mean [SE], 10.9% [1.9%]). Some pregnant women exceeded the Adequate Intake for potassium (mean [SE], 41.7% [2.9%]), choline (mean [SE], 7.9% [3.2%]), and vitamin K (mean [SE], 47.9% [4.3%]). Most women exceeded the Tolerable Upper Intake Level for sodium (mean [SE], 95.0% [2.2%]), and some women exceeded the Tolerable Upper Intake Level of folic acid (mean [SE], 33.4% [2.8%]), iron (mean [SE], 27.9% [2.8%]), calcium (mean [SE], 3.0% [0.8%]), and zinc (mean [SE], 7.1% [1.6%]). For iron, the prevalence of an at-risk intake from foods alone was lower among women who used supplements (mean [SE], 80.3% [4.3%]) than those who did not use supplements (mean [SE], 95.3% [7.3%]); however, supplement use increased the risk of excessive iron and folic acid intakes given the amounts that are being consumed from supplemental products.

CONCLUSIONS AND RELEVANCE

This study suggests that a significant number of pregnant women are not meeting recommendations for vitamins D, C, A, B6, K, and E, as well as folate, choline, iron, calcium, potassium, magnesium, and zinc even with the use of dietary supplements. Almost all pregnant women in this study were at risk of excessive consumption of sodium, and many were at risk of excessive consumption of folic acid and iron. Improved dietary guidance to help pregnant women meet but not exceed dietary recommendations is warranted.

A Tiered Approach for the Evaluation of the Safety of Botanicals Used as Dietary Supplements: An Industry Strategy

Exposure to botanicals in dietary supplements is increasing across many geographies; with increased expectations from consumers, regulators, and industry stewards centered on quality and safety of these products. We present a tiered approach to assess the safety of botanicals, and an in silico decision tree to address toxicity data gaps. Tier 1 describes a Threshold of Toxicologic Concern (TTC) approach that can be used to assess the safety of conceptual levels of botanicals. Tier 2 is an approach to document a history of safe human use for botanical exposures higher than the TTC. An assessment of botanical-drug interaction (BDI) may also be necessary at this stage. Tier 3 involves botanical chemical constituent identification and safety assessment and the in silico approach as needed. Our novel approaches to identify potential hazards and establish safe human use levels for botanicals is cost and time efficient and minimizes reliance on animal testing.

Human Milk Nutrient Composition in the United States: Current Knowledge, Challenges, and Research Needs

Human milk is considered to be the ideal food for infants. Accurate, representative, and up-to-date nutrient composition data of human milk are crucial for the management of infant feeding, assessment of infant and maternal nutritional needs, and as a guide for developing infant formula. Currently in the United States, the nutrient profiles of human milk can be found in the USDA National Nutrient Database for Standard Reference, and in books or review articles. Nonetheless, these resources all suffer major drawbacks, such as being outdated, incomplete profiles, limited sources of data, and uncertain data quality. Furthermore, no nutrient profile was developed specifically for the US population. The purposes of this review were to summarize the current knowledge of human milk nutrient composition from studies conducted in the United States and Canada, and to identify the knowledge gaps and research needs. The literature review was conducted to cover the years 1980-2017, and 28 research papers were found containing original data on macronutrients and micronutrients. Most of these 28 studies were published before 1990 and mainly examined samples from small groups of generally healthy lactating women. The experimental designs, including sampling, storage, and analytic methods, varied substantially between the different studies. Data of several components from these 28 studies showed some consistency for 1-6 mo postpartum, especially for protein, fat, lactose, energy, and certain minerals (e.g., calcium). The data for 7-12 mo postpartum and for other nutrients are very scarce. Comprehensive studies are required to provide current and complete nutrient information on human milk in the United States.

Dietary supplement intake during pregnancy; better safe than sorry?

Consumption of dietary supplements and specifically niche products such as supplements targeting pregnant women is increasing. The advantages of dietary supplementation during pregnancy with folic acid have been established, but health effects of many other supplements have not been confirmed. EU and US legislation on dietary supplements requires the product to be safe for the direct consumer, the mother. Long-term health effects for the fetus due to fetal programming (in utero adaptation of the fetal epigenome due to environmental stimuli such as supplementation) are not taken into account. Such epigenetic alterations can, however, influence the response to health challenges in adulthood. We therefore call for both conducting research in birth cohorts and animal studies to identify potential health effects in progeny of supplement consuming mothers as well as the establishment of a nutrivigilance scheme to identify favorable and adverse effects post-marketing. The acquired knowledge can be used to create more effective legislation on dietary supplement intake during pregnancy for safety of the child. Increasing knowledge on the effects of consuming supplements will create a safer environment for future mothers and their offspring to optimize their health before, during and after pregnancy.

Prenatal Developmental Toxicity Study of Glycosides-based Standardized Fenugreek Seed Extract in Rats

Context:

Glycoside-based standardized fenugreek seed extract (SFSE-G) demonstrated promising efficacy in animal models of immune-inflammatory conditions.

Aim:

The present study was aimed at embryo-fetal development toxicity evaluation of SFSE-G in Wistar rats as per guideline No. 414 of the Organization for Economic Co-operation and Development (OECD).

Material and Methods:

Mated female rats were randomized into four groups of 30 each and received oral doses of either SFSE-G at 250, 500, and 1000 mg/kg or vehicle (water) during the period of gestation (postconception) from gestational day 5 (GD5, an implantation day) until 1 day before cesarean sections (GD19). Maternal food consumption, body weights, and clinical signs were monitored throughout gestation. Cesarean sections were performed on GD20 and fetal observations (gravid uterine weight, implantation sites, early and late resorptions, live and dead fetuses) were recorded. Live fetuses were weighed and examined for external, visceral, and skeletal variations and malformations.

Results:

None of the SFSE-G-treated groups showed maternal and embryo–fetal toxicity. Occasional and incidental skeletal and visceral malformations were observed and found to be spontaneous and unrelated to the treatment.

Conclusion:

Oral exposure of SFSE-G during the prenatal period did not show significant maternal and embryo-fetal toxicity up to a dose of 1000 mg/kg in rats. Therefore, the no-observed-adverse-effect level for SFSE-G for prenatal oral exposure was considered to be 1000 mg/kg.

SUMMARY

Prenatal toxicity of glycoside-based standardized fenugreek seed extract (SFSE-G) was evaluated.

SFSE-G was orally gavaged to rats on gestational days 5-19 with a limit dose of 1000 mg/kg.

SFSE-G did not show maternal or developmental toxicity.

SFSE-G showed NOAEL of 1000 mg/kg for prenatal exposure in female rats.

Abbreviations used: CPCSEA: Committee for the Purpose of Control and Supervision of Experiments on Animals; GD: Gestational day; GRAS: Generally recognized as safe; HED: Human equivalent dose; NOAEL: No-observed adverse effect levels; OECD: Organization for Economic Co-operation and Development; SFSE-G: glycoside-based standardized fenugreek seed extract.

Dehydroepiandrosterone (DHEA) Feeding Protects Liver Steatosis in Obese Breast Cancer Rat Model

Obesity is a major health problem in the US and globally. Obesity is associated with the risk of cardiovascular disease, type 2 diabetes, cancers, hyperlipidemia, and liver steatosis development. Dehydroepiandrosterone (DHEA) is a dietary supplement used as an anti-obesity supplement. Previously, we reported that DHEA feeding protects 7,12-dimethylbenz(a)anthracene (DMBA)-induced mammary tumors. The objectives of this study were to investigate the effects of obesity and DHEA feeding on liver steatosis, body weight gain, and serum DHEA, DHEA sulfate (DHEA-S), insulin-like growth factor-1 (IGF-1), and insulin-like growth factor binding protein-3 (IGFBP-3) levels. Female Zucker rats were randomly assigned to either a control diet or a control diet with DHEA supplementation for 155 days. Livers were collected for histological examination. Serum was collected to measure DHEA, DHEA-S, IGF-1, and IGFBP-3. Our results show that DHEA-fed rats had significantly less liver steatosis (p < 0.001) than control-fed rats and gained less weight (p < 0.001). DHEA feeding caused significant decreases (p < 0.001) in the serum levels of IGF-1 and IGFBP-3 and significantly increased (p < 0.001) serum levels of DHEA and DHEA-S. Our results suggest that DHEA feeding can protect against liver steatosis by reducing body weight gain and modulating serum IGF-1 and IGFBP-3 levels in an obese breast cancer rat model.

Consumption of dietary supplements by Chinese women during pregnancy and postpartum: A prospective cohort study

The objectives of this study were to investigate usage patterns and factors associated with maternal dietary supplementation by Chinese women. A prospective cohort study of 695 mothers, who gave birth to a singleton baby, was conducted in Jiangyou, Sichuan Province of China. Information on dietary supplement use was collected from participants by personal interview at hospital discharge and followed up by telephone at 1, 3, and 6 months postpartum. Logistic regression analysis and generalised linear-mixed modelling were performed to determine factors affecting dietary supplementation during pregnancy and the first 6 months postpartum, respectively. A total of 81.8 and 32.1% of women consumed dietary supplements during pregnancy and postpartum, respectively. Calcium was the most popular supplement (pregnancy 63.9%; postpartum 28.1%), whereas folic acid was only taken during pregnancy (62.3%) with an average usage duration of 2.5 (standard deviation 1.3) months among users. High school and above education, adjusted odds ratio (OR) = 2.67, 95% confidence interval (CI) [1.63, 4.38], and attendance at prenatal classes (adjusted OR = 1.99, 95% CI [1.05, 3.76]) were associated with dietary supplementation during pregnancy. Mothers with a higher level of education (adjusted OR = 3.10, 95% CI [1.81, 5.30]) were also more likely to use dietary supplements in the postpartum period. Although dietary supplementation appeared to be common among Chinese mothers, maternal intake of folic acid was well below the guidelines. There is a need for further nutrition education on maternal use of micronutrient supplements, especially targeting mothers who are less educated.

The Role of Avocados in Maternal Diets during the Periconceptional Period, Pregnancy, and Lactation

Maternal nutrition plays a crucial role in influencing fertility, fetal development, birth outcomes, and breast milk composition. During the critical window of time from conception through the initiation of complementary feeding, the nutrition of the mother is the nutrition of the offspring—and a mother’s dietary choices can affect both the early health status and lifelong disease risk of the offspring. Most health expert recommendations and government-sponsored dietary guidelines agree that a healthy diet for children and adults (including those who are pregnant and/or lactating) should include an abundance of nutrient-rich foods such as fruits and vegetables. These foods should contain a variety of essential nutrients as well as other compounds that are associated with lower disease risk such as fiber and bioactives. However, the number and amounts of nutrients varies considerably among fruits and vegetables, and not all fruit and vegetable options are considered “nutrient-rich”. Avocados are unique among fruits and vegetables in that, by weight, they contain much higher amounts of the key nutrients folate and potassium, which are normally under-consumed in maternal diets. Avocados also contain higher amounts of several non-essential compounds, such as fiber, monounsaturated fats, and lipid-soluble antioxidants, which have all been linked to improvements in maternal health, birth outcomes and/or breast milk quality. The objective of this report is to review the evidence that avocados may be a unique nutrition source for pregnant and lactating women and, thus, should be considered for inclusion in future dietary recommendations for expecting and new mothers.

Evidence from a Randomized Trial That Exposure to Supplemental Folic Acid at Recommended Levels during Pregnancy Does Not Lead to Increased Unmetabolized Folic Acid Concentrations in Maternal or Cord Blood

BACKGROUND

Exposure to higher intakes of folic acid (FA) from fortified foods and supplements, although largely considered beneficial, is associated with unmetabolized FA in the circulation, which has raised some health concerns.

OBJECTIVE

The effect of supplemental FA at a dose of 400 μg/d during pregnancy on unmetabolized FA concentrations in maternal plasma and newborn cord blood plasma was investigated.

METHODS

A new analysis was performed of blood samples from participants in a randomized trial in pregnancy. Women aged 18-35 y, who had taken 400 μg FA/d as recommended in the first trimester, were recruited at the start of trimester 2 and randomly allocated to receive either 400 μg FA/d (n = 59) or a placebo (n = 67) throughout the second and third trimesters until delivery. Unmetabolized FA concentrations in maternal and cord blood samples were measured by LC-tandem MS analysis.

RESULTS

In response to the intervention from gestational week 14 through delivery, a higher proportion of women in the FA compared with the placebo group had detectable FA (≥0.27 nmol/L) in plasma, but the difference in concentrations was not statistically significant (mean ± SD: 0.44 ± 0.80 compared with 0.13 ± 0.49 nmol/L, P = 0.38). FA treatment throughout pregnancy resulted in higher cord blood plasma total folate (50.6 ± 20.1 compared with 34.5 ± 14.4 nmol/L; P = 0.004) and 5-methyltetrahydrofolate (50.4 ± 20.3 compared with 34.5 ± 14.4 nmol/L; P = 0.005) concentrations, but FA was detected only in 8 of 53 available cord blood samples, and the proportion of samples with detectable FA concentrations was similar in FA-treated and placebo groups.

CONCLUSIONS

Plasma concentrations of unmetabolized FA arising from supplemental FA at a dose of 400 μg/d, in addition to FA from fortified foods, were low or undetectable in mothers and newborns. The benefits for mothers and offspring of continuing FA supplementation beyond the first trimester of pregnancy can be achieved without posing any risk of increasing unmetabolized circulating FA, even in those already exposed to FA from fortified foods.

Validation of a Food Frequency Questionnaire for Estimating Micronutrient Intakes in an Urban US Sample of Multi-Ethnic Pregnant Women

OBJECTIVE(S)

To validate the Block98 food frequency questionnaire (FFQ) for estimating antioxidant, methyl-nutrient and polyunsaturated fatty acids (PUFA) intakes in a pregnant sample of ethnic/racial minority women in the United States (US).

METHODS

Participants (n = 42) were from the Programming of Intergenerational Stress Mechanisms study. Total micronutrient intakes from food and supplements was ascertained using the modified Block98 FFQ and two 24-h dietary recalls collected at random on nonconsecutive days subsequent to completion of the FFQ in mid-pregnancy. Correlation coefficients (r) corrected for attenuation from within-person variation in the recalls were calculated for antioxidants (n = 7), methyl-nutrients (n = 8), and PUFAs (n = 2).

RESULT(S)

The sample was largely ethnic minorities (38 % Black, 33 % Hispanic) with 21 % being foreign born and 41 % having less than or equal to a high school degree. Significant and adequate deattenuated correlations (r ≥ 0.40) for total dietary intakes of antioxidants were observed for vitamin C, vitamin E, magnesium, and zinc. Reasonable deattenuated correlations were also observed for methyl-nutrient intakes of vitamin B6, betaine, iron, and n:6 PUFAs; however, they did not reach significance. Most women were classified into the same or adjacent quartiles (≥70 %) for total (dietary + supplements) estimates of antioxidants (5 out of 7) and methyl-nutrients (4 out of 5).

CONCLUSIONS

The Block98 FFQ is an appropriate dietary method for evaluating antioxidants in pregnant ethnic/minorities in the US; it may be less efficient in measuring methyl-nutrient and PUFA intakes.

Greek pregnant women demonstrate inadequate micronutrient intake despite supplement use

BACKGROUND/AIM

Maternal diet is important in the outcome of pregnancy and the health of the children. The present cross-sectional study aimed to assess the use of dietary supplements during pregnancy and define the maternal characteristics associated with supplement use.

METHODS

The diet of 100 childbearing women was recorded for three consecutive days and micronutrient supplementation was added to the dietary intake and the median values were used in the analyses.

RESULTS

The majority of the participants (92%) consumed at least one supplement. Supplementation of folic acid (FA) was significantly lower during the third trimester compared to the second (p ≤ .007). Higher intake of Ca and Fe supplements was observed in the second trimester (p ≤ .001). The use of supplements contributed to an attenuated consumption of all reported micronutrients (Mg, Ca, FA, and Fe, p ≤ .001). The principal components analysis revealed that the most important factor contributing to supplementation was primiparity.

CONCLUSIONS

Overall, a high prevalence of micronutrient supplementation during pregnancy was observed without ensuring adequacy in the micronutrient intake. The increased rates of supplement users might be the result of an act for balancing diet in unplanned pregnancies.

Effect of traditional food supplements on nutritional status of lactating mothers and growth of their infants

OBJECTIVES

During lactation, traditional food supplements (TFS) are commonly consumed in India to increase lactation performance and health of mothers. TFS are rich in fats, nuts, dry fruits, and sugars and indulging in such supplements for 3 to 6 mo postpartum may put the mother at risk for obesity. The aim of this study was to assess the nutrient quality of TFS and its effect on nutritional status of lactating mothers and infant's weight gain in first 6 mo after delivery.

METHODS

A random sample of 125 Indian urban lactating mothers (28.9 ± 3.2 y) was assessed within 6 mo postpartum for anthropometry, diet by 24-h recall on 3 random days, along with socioeconomic factors, lactation history, and infant's birth weight and current weight.

RESULTS

Among 18 different TFS, 50% TFS were rich in calcium, 33% rich in iron, 38% in zinc, and only 13% were good sources of vitamins. Mothers consuming TFS (n = 75) had significantly higher fat intakes than mothers consuming no TFS Supplements (NTS; n = 50). A higher weight gain was seen in TFS mothers (10.5%) than NTS mothers (8.8%) after adjusting for number of days after delivery, parity, mother's age, and breast-feeding practices (P < 0.05). Percent weight gain in infants of TFS mothers (120.7% ± 7.3%) was higher than in infants of NTS mothers (96.2% ± 7.8%; P = 0.024) after adjusting for infant's age and mother's breast-feeding practices.

CONCLUSION

TFS may be modified to increase its micronutrient quality and to reduce fat contents with the goal of reducing the risk for obesity in mothers, while still benefiting infant growth.

You are what you eat, and so are your children: the impact of micronutrients on the epigenetic programming of offspring

The research field of fetal programming has developed tremendously over the years and increasing knowledge suggests that both maternal and paternal unbalanced diet can have long-lasting effects on the health of offspring. Studies implicate that macronutrients play an important role in fetal programming, although the importance of micronutrients is also becoming increasingly apparent. Folic acid and vitamins B2, B6 and B12 are essential for one-carbon metabolism and are involved in DNA methylation. They can therefore influence the programming of the offspring's epigenome. Also, other micronutrients such as vitamins A and C, iron, chromium, zinc and flavonoids play a role in fetal programming. Since it is estimated that approximately 78 % of pregnant women in the US take vitamin supplements during pregnancy, more attention should be given to the long-term effects of these supplements on offspring. In this review we address several different studies which illustrate that an unbalanced diet prior and during pregnancy, regarding the intake of micronutrients of both mother and father, can have long-lasting effects on the health of adult offspring.

Socioeconomic, lifestyle and dietary factors associated with dietary supplement use during pregnancy

Background

Information on dietary supplement (DS) use during pregnancy is largely lacking. Besides, little is known about the share of DS use as self-medication versus such use following a physician's advice/prescription. Our aim was to evaluate DS use and its socioeconomic, lifestyle and dietary correlates among pregnant women participating in the French NutriNet-Santé cohort study.

Method

Data were collected by self-administered web-based questionnaires. Food intake was assessed by repeated 24 h dietary records. 903 pregnant women provided data on their DS use (both “regular” DS and medication containing mainly vitamins/minerals). Supplement users were compared to non-users by unconditional logistic regression.

Results

DS use—in general and as regards folic acid in particular—was positively correlated with age, being primiparous, having higher income and belonging to a higher socioprofessional category. DS users had significantly higher dietary intakes of most vitamins and minerals. The proportion of DS users (e.g., those reporting use at least three days a week) increased significantly with the trimester of pregnancy (58.0%, 62.2% and 74.5%, respectively). 50.2% of women in their 1st trimester used folic acid. The proportion of iron users tripled from the 1st to the 3rd trimester (18.5 to 63.9%). DS use was prescribed or recommended by a physician in 86.7% of the cases.

Conclusion

This study provided new and detailed information on DS use and its correlates during pregnancy. Even in this relatively well-educated population, folic acid supplementation at the beginning of pregnancy was inadequate and was associated with socioeconomic and demographic disparities.

Use of dietary supplements in pregnant women in relation to sociodemographic factors - a report from The Environmental Determinants of Diabetes in the Young (TEDDY) study

OBJECTIVES

The aim of the present study was to examine the prevalence and associated factors of dietary supplement use, particularly supplements containing vitamin D and fatty acids, in pregnant women enrolled in a multi-national study.

DESIGN

The Environmental Determinants of Diabetes in the Young (TEDDY) study is a prospective longitudinal cohort study. Maternal dietary supplement use was self-reported through questionnaires at month 3 to 4 postpartum.

SETTING

Six clinical research centres; three in the USA (Colorado, Georgia/Florida and Washington) and three in Europe (Sweden, Finland and Germany).

SUBJECTS

Mothers (n 7326) to infants screened for high-risk HLA-DQ genotypes of type 1 diabetes.

RESULTS

Ninety-two per cent of the 7326 women used one or more types of supplement during pregnancy. Vitamin D supplements were taken by 65% of the women, with the highest proportion of users in the USA (80.5 %). Overall, 16% of the women reported taking fatty acid supplements and a growing trend was seen in all countries between 2004 and 2010 (P,0.0001). The use was more common in Germany (32 %) and the USA (24 %) compared with Finland (8.5%) and Sweden (7.0 %). Being pregnant with the first child was a strong predictor for any supplement use in all countries. Low maternal age (<25 years), higher education, BMI<=25.0 kg/m2 and smoking during pregnancy were factors associated with supplement use in some but not all countries.

CONCLUSIONS

The majority of the women used dietary supplements during pregnancy. The use was associated with sociodemographic and behavioural factors, such as parity, maternal age, education, BMI and maternal smoking.

Comparison of dietary food and nutrient intakes by supplement use in pregnant and lactating women in Seoul

This study was performed to compare the dietary food and nutrient intakes according to supplement use in pregnant and lactating women in Seoul. The subjects were composed of 201 pregnant and 104 lactating women, and their dietary food intake was assessed using the 24-h recall method. General information on demographic and socioeconomic factors, as well as health-related behaviors, including the use of dietary supplements, were collected. About 88% and 60% of the pregnant and lactating women took dietary supplements, respectively. The proportion of dietary supplements used was higher in pregnant women with a higher level of education. After adjusting for potential confounders, among the pregnant women, supplement users were found to consume 45% more vegetables, and those among the lactating women were found to consume 96% more beans and 58% more vegetables. The intakes of dietary fiber and β-carotene among supplement users were higher than those of non-users, by 23% and 39%, respectively. Among pregnant women, the proportion of women with an intake of vitamin C (from diet alone) below the estimated average requirements (EAR) was lower among supplement users [users (44%) vs. non-users (68%)], and the proportion of lactating women with intakes of iron (from diet alone) below the EAR was lower among supplement users [usesr (17%) vs. non-users (38%)]. These results suggest that among pregnant and lactating women, those who do not use dietary supplements tend to have a lower intake of healthy foods, such as beans and vegetables, as well as a lower intake of dietary fiber and β-carotene, which are abundant in these foods, and non-users are more likely than users to have inadequate intake of micro-nutrient such as vitamin C and iron.

Sociodemographic, lifestyle and dietary correlates of dietary supplement use in a large sample of French adults: results from the NutriNet-Santé cohort study

Information on the determinants of dietary supplement (DS) use in France is largely lacking, especially in population subgroups such as smokers. Also, little is known about the role of health professionals in DS purchases. The aim of the present study was to describe DS use along with its sociodemographic, lifestyle and dietary correlates in a large sample of French adults (age 18+years) participating in the NutriNet-Santé cohort study. Data were collected by self-administered Internet questionnaires. Food intakes were assessed by 24 h dietary records. Data on DS use were available for 79 786 participants. Supplement users were compared with non-users by logistic regression. Current DS use at least three times/week was reported by 14·6 % of men and 28·1 % of women. Mg, and vitamins B6 and C were the most frequently consumed nutrients. DS were prescribed or recommended by a physician in 54·9 % of the cases. DS use was positively associated with knowledge of nutritional recommendations and organic product consumption, following a healthier diet and lifestyle (non-smoker, moderate leisure-time physical activity). Current smokers used less DS than did non-smokers, but their DS consumption was substantial (19·0 %) and they were more likely to self-medicate. The present study provides updated and detailed information on DS use determinants in a large French cohort, including a focus on smokers, for whom the long-term effects of DS use are poorly documented and could represent a risk. These findings pave the way for future aetiological studies.

Cytochrome P450 regulation by α-tocopherol in Pxr-null and PXR-humanized mice

The pregnane X receptor (PXR) has been postulated to play a role in the metabolism of α-tocopherol owing to the up-regulation of hepatic cytochrome P450 (P450) 3A in human cell lines and murine models after α-tocopherol treatment. However, in vivo studies confirming the role of PXR in α-tocopherol metabolism in humans presents significant difficulties and has not been performed. PXR-humanized (hPXR), wild-type, and Pxr-null mouse models were used to determine whether α-tocopherol metabolism is influenced by species-specific differences in PXR function in vivo. No significant difference in the concentration of the major α-tocopherol metabolites was observed among the hPXR, wild-type, and Pxr-null mice through mass spectrometry-based metabolomics. Gene expression analysis revealed significantly increased expression of Cyp3a11 as well as several other P450s only in wild-type mice, suggesting species-specificity for α-tocopherol activation of PXR. Luciferase reporter assay confirmed activation of mouse PXR by α-tocopherol. Analysis of the Cyp2c family of genes revealed increased expression of Cyp2c29, Cyp2c37, and Cyp2c55 in wild-type, hPXR, and Pxr-null mice, which suggests PXR-independent induction of Cyp2c gene expression. This study revealed that α-tocopherol is a partial agonist of PXR and that PXR is necessary for Cyp3a induction by α-tocopherol. The implications of a novel role for α-tocopherol in Cyp2c gene regulation are also discussed.

Knowledge, Attitude and Practice of Vitamin Supplementation among Patients visiting Out-Patient Physicians in a Teaching Hospital in Karachi

OBJECTIVE

To determine the knowledge, attitude and practices regarding the use of vitamin supplements among patients visiting Out-Patient clinics of a teaching hospital.

METHODS

Four hundred patients were interviewed during the period of July to September 2008, at the Out-patient clinics, Aga Khan University hospital, Karachi. A pre-tested and structured questionnaire was used to collect information. It consisted of questions regarding demographics, awareness of vitamin supplements and its consumption, reasons for usage and its effects. The purpose of the study was explained and assurance of confidentiality was given. After obtaining written consent, eligible individuals were interviewed. Statistical Package for the Social Sciences version 19.0 was used to analyze the data.

RESULTS

The results revealed that 98% of the respondents were aware of vitamin supplements. The most known vitamin was found to be Vitamin C (16.9%) with Vitamin K being the least well-known (0.4%); while 51.8% of the respondents were unaware of the harmful effects of vitamin supplements. The results also showed that 84.8% of the study population had taken vitamin supplements, and 79% of the participants considered that vitamin supplements to be helpful. Taking vitamin supplements as a compensation for the deficiencies in the body was the most frequently chosen answer (17.7%) as the reason for use of vitamin supplements. On the other hand, a majority of the population was unaware of the indications for use of vitamin supplements.

CONCLUSION

This study highlights a very significant yet ignored issue of vitamin supplementation in Pakistan. A need exists to inform the general population about the use of vitamin supplementation. The media and the medical community are required to play their role in this regard. Short/ refresher training courses are needed for doctors to update and disseminate adequate knowledge of vitamin supplementation to their patients.

Folate-status response to a controlled folate intake in nonpregnant, pregnant, and lactating women

BACKGROUND

Folate dose-response studies in women of childbearing age who consumed a folic acid (FA)-containing multivitamin in the era of FA fortification are lacking.

OBJECTIVE

We sought to investigate folate-status response to a known folate dose comprising an FA-containing prenatal supplement (750 μg/d) plus natural food folate (400 μg/d) in third-trimester pregnant women, lactating women 5-15 wk postpartum, and nonpregnant women.

DESIGN

Pregnant (n = 26), lactating (n = 28), and nonpregnant (n = 21) women consumed the study folate dose under controlled intake conditions for 10-12 wk. Blood, urine, and breast milk were collected at baseline, study midpoint, and study end.

RESULTS

Study-end serum total folate concentrations averaged ~30 ng/mL and did not differ by physiologic group (P = 0.876). Study-end urinary folate excretion represented ~9-43% of total folate intake and ranged from 100 to 500 μg/d. Third-trimester pregnant women excreted less urinary folate than did lactating (P = 0.075) and nonpregnant (P < 0.001) women. Lactating women excreted less (P < 0.001) urinary FA than did nonpregnant women. Breast-milk total folate concentrations remained constant (P = 0.244; 61.8 ng/mL at study end), whereas breast-milk FA concentrations increased (P = 0.003) to 24.1 ng/mL at study end.

CONCLUSIONS

The consumption of the study folate dose yielded a supranutritional folate status regardless of the physiologic state. Based on urinary folate excretion, folate use was greatest to least: pregnant > lactating > nonpregnant women. Breast-milk folate species were responsive to maternal folate intake, and FA made up ~40% of breast-milk total folate at study end. These findings warrant revisiting prenatal supplement FA formulation in populations exposed to FA-fortification programs.

Dietitians use and recommend dietary supplements: report of a survey

BACKGROUND

Dietary supplement use is common in the United States, with more than half of the population using such products. Nutrition authorities consistently advocate a "food first" approach to achieving nutritional adequacy but some, including the Academy of Nutrition and Dietetics (formerly the American Dietetic Association), also recognize that dietary supplements have a role to play in improving nutrient intake to support health and wellness. Surveys show that many health professionals use dietary supplements themselves and also recommend dietary supplements to their patients or clients.

METHODS

As one component of a series of surveys of healthcare professionals (the "Life...supplemented" HCP Impact Studies), 300 registered dietitians were surveyed in 2009 regarding their personal use of dietary supplements and whether they recommend dietary supplements to their clients. Respondents were registered dietitians whose business involved seeing clients in a private practice or at a clinic.

RESULTS

Seventy-four percent of the dietitians surveyed said they were regular users of dietary supplements, while 22% said they used dietary supplements occasionally or seasonally. The primary reasons for using dietary supplements were for bone health (58%), overall health and wellness (53%), and to fill nutrient gaps (42%). When asked if they "ever recommend dietary supplements to clients," 97% of the respondents said they did. The primary reasons were for bone health (70%), to fill nutrient gaps (67%), and overall health and wellness (49%). Eighty-seven percent of the dietitians agreed with the statement, "There are gaps in clients' diets that could effectively be addressed with dietary supplements." The dietitians surveyed said they followed healthy habits including eating a balanced diet (96%), managing stress (92%), visiting their own healthcare professional regularly (86%), exercising regularly (83%), maintaining a healthy weight (80%), and getting a good night's sleep (72%). Nearly all respondents (95%) expressed an interest in continuing education about dietary supplements on a variety of topics.

CONCLUSIONS

Many dietitians, like other health professionals, use dietary supplements regularly as part of their own approach to a healthy diet and lifestyle. They also recommend dietary supplements to their clients or patients, to promote health.

Breastfeeding and the use of human milk

Breastfeeding and human milk are the normative standards for infant feeding and nutrition. Given the documented short- and long-term medical and neurodevelopmental advantages of breastfeeding, infant nutrition should be considered a public health issue and not only a lifestyle choice. The American Academy of Pediatrics reaffirms its recommendation of exclusive breastfeeding for about 6 months, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant. Medical contraindications to breastfeeding are rare. Infant growth should be monitored with the World Health Organization (WHO) Growth Curve Standards to avoid mislabeling infants as underweight or failing to thrive. Hospital routines to encourage and support the initiation and sustaining of exclusive breastfeeding should be based on the American Academy of Pediatrics-endorsed WHO/UNICEF "Ten Steps to Successful Breastfeeding." National strategies supported by the US Surgeon General's Call to Action, the Centers for Disease Control and Prevention, and The Joint Commission are involved to facilitate breastfeeding practices in US hospitals and communities. Pediatricians play a critical role in their practices and communities as advocates of breastfeeding and thus should be knowledgeable about the health risks of not breastfeeding, the economic benefits to society of breastfeeding, and the techniques for managing and supporting the breastfeeding dyad. The "Business Case for Breastfeeding" details how mothers can maintain lactation in the workplace and the benefits to employers who facilitate this practice.

Towards prevention of vitamin D deficiency and beyond: knowledge gaps and research needs in vitamin D nutrition and public health

The North American Institute of Medicine (IOM) recently published their report on dietary reference intakes (DRI) for Ca and vitamin D. The DRI committee's deliberations underpinning this most comprehensive report on vitamin D nutrition to date benefited hugely from a much expanded knowledge base in vitamin D over the last decade or more. However, since their release, the vitamin D DRI have been the subject of intense controversy, which is largely due to the persistence of fundamental knowledge gaps in vitamin D. These can be identified at the levels of exposure, metabolism, storage, status, dose-response, function and beneficial or adverse health effects, as well as safe and effective application of intake recommendations at the population level through sustainable food-based approaches. The present review provides a brief overview of the approach used by the IOM committee to revise the DRI for vitamin D and to collate from a number of authoritative sources key knowledge gaps in vitamin D nutrition from the public health perspective. A number of research topics are outlined and data requirements within these are identified and mapped to the risk assessment framework used by the DRI committee. While not intended as an exhaustive list, it provides a basis for organising and prioritising research efforts in the area of vitamin D, which may offer a perspective on the major areas in need of attention. It is intended to be of use to researchers, national policy makers, the public health community, industry groups and other relevant stakeholders including funding institutions.

Effect of multiple micronutrient supplementation during pregnancy on maternal and birth outcomes

Objectives/background

Given the widespread prevalence of micronutrient deficiencies in developing countries, supplementation with multiple micronutrients rather than iron-folate alone, could be of potential benefit to the mother and the fetus. These benefits could relate to prevention of maternal complications and reduction in other adverse pregnancy outcomes such as small-for-gestational age (SGA) births, low birth weight, stillbirths, perinatal and neonatal mortality. This review evaluates the evidence of the impact of multiple micronutrient supplements during pregnancy, in comparison with standard iron-folate supplements, on specific maternal and pregnancy outcomes of relevance to the Lives Saved Tool (LiST).

Data sources/review methods

A systematic review of randomized controlled trials was conducted. Search engines used were PubMed, the Cochrane Library, the WHO regional databases and hand search of bibliographies. A standardized data abstraction and Child Health Epidemiology Reference (CHERG) adaptation of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) technique were used for data abstraction and overall quality of evidence. Meta-analyses were performed to calculate summary estimates of utility to the LiST model for the specified outcome of incidence of SGA births. We also evaluated the potential impact of multiple micronutrients on neonatal mortality according to the proportion of deliveries occurring in facilities (using a threshold of 60% to indicate functionality of health systems for skilled births).

Results

We included 17 studies for detailed data abstraction. There was no significant benefit of multiple micronutrients as compared to iron folate on maternal anemia in third trimester [Relative risk (RR) = 1.03; 95% confidence interval (CI): 0.87 – 1.22 (random model)]. Our analysis, however, showed a significant reduction in SGA by 9% [RR = 0.91; 95% CI: 0.86 – 0.96 (fixed model)]. In the fixed model, the SGA outcome remained significant only in women with mean body mass index (BMI) ≥ 22 kg/m². There was an increased risk of neonatal mortality in studies with majority of births at home [RR = 1.47, 95% CI: 1.13-1.92]; such an effect was not evident where ≥ 60% of births occurred in facility settings [RR = 0.94, 95% CI: 0.81-1.09]. Overall there was no increase in the risk of neonatal mortality [RR = 1.05, 95% CI: 0.92 – 1.19 (fixed model)].

Conclusion

This review provides evidence of a significant benefit of MMN supplementation during pregnancy on reducing SGA births as compared to iron-folate, with no significant increase in the risk of neonatal mortality in populations where skilled birth care is available and majority of births take place in facilities. Given comparability of impacts on maternal anemia, the decision to replace iron-folate with multiple micronutrients during pregnancy may be taken in the context of available services in health systems and birth outcomes monitored.

Associations among dietary supplement use and dietary and activity behaviors by sex and race/ethnicity in a representative multiethnic sample of 11th-grade students in Texas

BACKGROUND AND OBJECTIVE

The purpose of this study was to examine associations among dietary supplement use and dietary/activity patterns in a representative sample of adolescents by sex and race/ethnicity, a research area where extant data is limited.

DESIGN/PARTICIPANTS

Cross-sectional, multistage, probability-based sample of 11th graders in Texas during 2004-2005 (n=6,422; 48.8% white/other, 37% Hispanic, and 14.2% African American; 50.6% boys; mean age 16.7 years).

SETTING

Classrooms. MAIN VARIABLES ASSESSED: Dietary supplement use, dietary/activity patterns, and anthropometrics.

STATISTICAL ANALYSES PERFORMED

Multiple logistic regression models (odds ratios [ORs] and 95% confidence intervals [CIs]).

RESULTS

Dietary supplement users reported healthy dietary and physical activity behaviors overall, yet sex- and race/ethnicity-specific differences were seen in associations among specific diet/activity behaviors and supplement use. In whites/others and Hispanics, but not African Americans, supplement use was associated with higher diet quality scores (OR 2.93, 95% CI 1.74 to 4.95 for whites/others; OR 3.93, 95% CI 2.26 to 6.83 for Hispanics), and regular consumption of breakfast (OR 2.27, 95% CI 1.40 to 3.66 for whites/others; OR 1.96, 95% CI 1.11 to 3.46 for Hispanics) and low-fat foods (OR 3.02, 95% CI 1.53 to 5.98 for whites/others; OR 3.59, 95% CI 1.11 to 11.6 for Hispanics). Supplement use was not associated with body mass index or with sedentary behaviors overall, but was associated with less television viewing only in whites/others (OR 0.53, 95% CI 0.33 to 0.84). For physical activity, boys and whites/others showed positive associations between supplement use and all indicators examined, but girls, Hispanics and African Americans showed mixed patterns of associations. Supplement use was associated with higher weight preference only in boys (OR 2.47, 95% CI 1.24 to 4.90), and vegetarian diets only in girls (OR 2.96, 95% CI 1.35 to 6.47).

CONCLUSIONS

Dietary and activity patterns associated with dietary supplement use may vary by sex- and racial/ethnic subpopulation, especially amongst African American youth. These findings together with further research on psychosocial and attitudinal characteristics associated with adolescent supplement use can enhance the development of targeted and tailored health communications about supplement use in adolescent subpopulations.

Maternal multiple micronutrient supplementation and pregnancy outcomes in developing countries: meta-analysis and meta-regression

OBJECTIVE

To systematically review randomized controlled trials comparing the effect of supplementation with multiple micronutrients versus iron and folic acid on pregnancy outcomes in developing countries.

METHODS

MEDLINE and EMBASE were searched. Outcomes of interest were birth weight, low birth weight, small size for gestational age, perinatal mortality and neonatal mortality. Pooled relative risks (RRs) were estimated by random effects models. Sources of heterogeneity were explored through subgroup meta-analyses and meta-regression.

FINDINGS

Multiple micronutrient supplementation was more effective than iron and folic acid supplementation at reducing the risk of low birth weight (RR: 0.86, 95% confidence interval, CI: 0.79-0.93) and of small size for gestational age (RR: 0.85; 95% CI: 0.78-0.93). Micronutrient supplementation had no overall effect on perinatal mortality (RR: 1.05; 95% CI: 0.90-1.22), although substantial heterogeneity was evident (I(2) = 58%; P for heterogeneity = 0.008). Subgroup and meta-regression analyses suggested that micronutrient supplementation was associated with a lower risk of perinatal mortality in trials in which > 50% of mothers had formal education (RR: 0.93; 95% CI: 0.82-1.06) or in which supplementation was initiated after a mean of 20 weeks of gestation (RR: 0.88; 95% CI: 0.80-0.97).

CONCLUSION

Maternal education or gestational age at initiation of supplementation may have contributed to the observed heterogeneous effects on perinatal mortality. The safety, efficacy and effective delivery of maternal micronutrient supplementation require further research.