Appendix C
Findings from Recent Surveys on Dietary Supplement Use by Military Personnel and the General Population



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Appendix C Findings from Recent Surveys on Dietary Supplement Use by Military Personnel and the General Population 

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 USE OF DIETARY SUPPLEMENTS BY MILITARY PERSONNEL TABLE C-1 Findings from Recent Surveys on Dietary Supplement Use by Military Personnel and the General Populationa Reference Demographics Group Questions MILITARY PERSONNEL Corum, 2007 2003–2005 Soldiers Health Promotion and Mean age: 25.4 years (ranks: E1–E9) Prevention Initiative, dietary (n=5,206) supplements questionnaire Response rate not “Estimate how often you use known each of the following individual vitamin and mineral supplements (pills, tablets, gel caps, etc). For each supplement listed below: Step 1: Select ONE bubble in the yellow section that best describes how frequently you use a supplement. Step 2: Select ONE or MORE check boxes in the blue section to select the reasons you use that supplement.”

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 APPENDIX C Authors’ Conclusions and Findings: Usage Other Findings Study Limitations Vitamins/minerals: Motivation Conclusions: Multivitamin: 33.8% Vitamins/minerals: • 16% listed dehydration as Vitamin C: 24.4% Health an adverse effect (concern) Calcium: 19.3% Prevent illness • Women and men tend to use Iron: 14.4% different dietary Potassium: 12.1% Ergogenic aids: supplements (DS) Vitamin A: 12.5% Performance enhancement • Many of the DS used were Vitamin B6: 11.5% Strength associated with palpitations or anxiety, which could be Ergogenic aids: Herbal supplements: due to caffeine Sports drinks: 42.8% Prevent fatigue • Perception that if something Sports bars: 17.3% is sold in the base, it means Sources of information: Protein: 13.7% it is safe Ephedra-free: 10.1% (n=2,241) Limitations: Friends: 36% Herbal supplements: Magazines: 31.7% • Surveys not designed to Caffeine: 17.5% Internet: 22.1% relate adverse effects or Ginseng: 6.7% Sales associates: 10.4% benefits to any particular Doctors: <10% Garlic: 5% DS Ginkgo: 3.9% TV/radio/newspaper: • Response rate not known <5% Echinacea: 3.6% • Results might be skewed because it was completed Supplement purchase: voluntarily (n=2,241) • They do not have dietary Commissary/PX: 35.6% pattern surveys of Nutrition/health food store respondents on post: 25.3% • Adverse effects are not Nutrition/health food store usually reported to health off post: 25.3% care providers Mail order/Internet: 13.2% Adverse effects: (n=951) Abdominal pain, breathing difficulty, chest pain, dehydration, diarrhea, dizziness, heart attack, heat stroke, loss of consciousness, muscle cramping, nausea/ vomiting, numbness in extremities, palpitations, tremors continued

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 USE OF DIETARY SUPPLEMENTS BY MILITARY PERSONNEL TABLE C-1 Continued Reference Demographics Group Questions French, 2007 2005 Nationally The Natural Marketing Men and women representative Institute ESP 18 y and older group of U.S. (E-screener panel) (n=376) adults “currently Questionnaire Index serving in the Response rate: 60% military, national Supplement use in past 3 mo guard, or reserve”

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 APPENDIX C Authors’ Conclusions and Findings: Usage Other Findings Study Limitations Supplement use: Supplement purchase (by Conclusions: Any: 69% age, military only): • Supplement use increases 18–29 years: Multivitamin only: 23% with age (over age 45 y Two or more supplements: GNC: 28% more likely), higher income, 46% Internet: 19% and higher education in Nutrition/health food store: military Categories: 8% • Military more likely to use Protein powders: 14% Natural food market: 6% multivitamins only, Weight loss: 9% Mail order/catalog: 4% significantly more sports- Herbal: 8% related supplement products 30–44 years: Sports nutrition: 8% • Study also gives information Fiber: 4% GNC: 19% on overall use by gender Children’s: 3% Internet: 17% • Study provides brand names Homeopathic: 2% Natural food market: 12% of sports nutrition and Condition specific: 2% Nutrition/health food store: muscle-building supplements 7% used Specific: Mail order/catalog: 5% Multivitamins: 57% 45 years and older: Calcium: 13% Vitamin E: 9% Internet: 23% Vitamin B: 8% GNC: 13% Glucosamine/Chondroitin: Nutrition/health food store: 7% 13% Creatine: 6% Mail order/catalog: 10% Fish oil: 5% Natural food market: 8% Omega-3: 4% Flaxseed oil: 4% Amino acids: 4% Vitamin D: 3% Conjugated linoleic acid (CLA): 3% Lycopene: 2% Arginine: 1% continued

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 USE OF DIETARY SUPPLEMENTS BY MILITARY PERSONNEL TABLE C-1 Continued Reference Demographics Group Questions French, 2007 2005 Nationally The Natural Marketing Men representative Institute ESP (E-screener and women 18 y and group of U.S. panel) Questionnaire Index older adults (nonmilitary) Supplement use in past 3 mo Response rate: 60%

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 APPENDIX C Authors’ Conclusions and Findings: Usage Other Findings Study Limitations Supplement use: Conclusions: Any: 73% • See above for general Multivitamin (only): 18% comments (French, 2007) 2 or more supplements: • Supplement use increases 55% with age • Nonmilitary significantly Categories: higher in DS use for specific Protein powders: 4% supplements except for Weight loss: 7% creatine, CLA, amino acids Herbal: 12% Sports nutrition: 2% Fiber: 8% Children’s: 3% Homeopathic: 4% Condition specific: 3% Specific: Multivitamins: 58% Calcium: 26% Vitamin E: 20% Vitamin B: 14% Glucosamine/chondroitin: 11% Creatine: 1% Fish oil: 9% Omega-3: 7% Flaxseed oil: 6% Amino acids: 2% Vitamin D: 8% CLA: 1% Lycopene: 2% Arginine: 1% continued

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0 USE OF DIETARY SUPPLEMENTS BY MILITARY PERSONNEL TABLE C-1 Continued Reference Demographics Group Questions GENERAL POPULATION Gardiner, 2002 National Health NHIS 2007 18–30 y Interview Survey (n=6,666) (NHIS) “Have you ever used a In-person multivitamin or vitamin?” Response rate: interviews 73.4% “During the past 12 months, did you use natural herbs for your own health or treatment?”

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 APPENDIX C Authors’ Conclusions and Findings: Usage Other Findings Study Limitations Supplement use Conclusions: Vitamin (ever): 63% • Nonvitamin and mineral Nonvitamin mineral: 17% supplement users were more likely to have high Of the 17%: education, high physical Echinacea: 47% activity, poor self-perceived Ginseng: 36% health status; and be Gingko: 23% prescription medication Garlic: 16% users St. John’s wort: 15% Limitations: Peppermint: 15% Ginger: 11% • DS use is underrepresented Chamomile: 9% because only those that Kava: 9% responded positively to the Glucosamine: 4% question: “have you ever Ephedra: 7% used a natural herb?” were further surveyed about use Prevalence of supplement of specific DS; “natural use by physical activity level herb” may be misleading (any/nonvitamin): • Only 35 herbs listed in Sedentary: 34%/9% survey; thousands are sold Moderate: 22%/19% • Herbs have unique common High: 43%/23% names based on region or cultural background Prescription medication users also taking nonvitamin/mineral supplement: 22% continued

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 USE OF DIETARY SUPPLEMENTS BY MILITARY PERSONNEL TABLE C-1 Continued Reference Demographics Group Questions Gardiner, 1999–2002 National Health NHANES 2007 18–30 y and Nutrition (n=3,231) Examination “Have you used or taken any Survey (NHANES) vitamins, minerals, or other Response rates: In-person dietary supplement in the past 1999–2000: 82%, interviews month?” 2001–2002: 84% If Yes, asked to provide dose, frequency, and duration of use and to show supplement container. If container was not available, asked for exact name.

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 APPENDIX C Authors’ Conclusions and Findings: Usage Other Findings Study Limitations Supplement use: Conclusion: Any DS: 37% Supplement users more likely Nonvitamin/mineral: 7% to be ages 23–30 y female, non-Hispanic white, have high self-perceived health status, Of the 37%: and have high physical activity Multivitamin (any): 23% level Vitamin C: 7% Limitations: Vitamin E: 2% Vitamin B: 1.4% • DS use likely Iron: 2.1% underrepresented because Calcium: 2.6% survey does not include teas, loose herbs, etc., or DS Of the 7%: without a bottle or label Sport: 2% • Did not record reason for Weight loss: 3% use or health condition Herbs: 4% associated with use • Did not ask about sports Prevalence of DS use by drinks, teas, or fortified physical activity level (any foods DS/nonvitamin): Sedentary: 30%/5% Moderate: 38%/5% High: 41%/9% Prevalence of DS use among prescription medication users (any DS/nonvitamin): 45%/7% continued

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0 APPENDIX C Findings: Motivation Other Findings Authors Conclusions and Study Limitations Use for: Conclusions: • Use is higher than in General health, general population • Military population is at risk for performance of young men (39% potential adverse effects of inadequate enhancement, use them use of DS, including abrupt cessation interest in preventing occasionally) when deployed in operations or entering infectious diseases, • Supplement use training physical associated with • Presence of DS on military bases and performance, and higher scores for discontent with food might result in wound healing Army physical higher use of DS fitness tests, daily Recommendations: exercise, weight lifting, and • Further studies of benefits and risks are nonsmokers necessary • Not associated with • Routine one-size-fits-all advice should age, ethnicity, BMI, not be given chewing tobacco, or • OK to treat deficiencies but questions alcohol use about performance effects • Military health care professionals should be well informed about risks and benefits General health: 63% • Supplement use Performance: 20% associated with frequency of strength training • Not associated with age or habitual exercise • Information on nutrition from: Magazines/ newspapers/ books: 76% Friends: 54% Radio/TV: 34% Physicians/nurses: 33% Internet: 30% continued

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0 USE OF DIETARY SUPPLEMENTS BY MILITARY PERSONNEL TABLE C-2 Continued Reference Demographics Group Questions Findings: Usage Supplement use: Bovill n=157 male U.S. Army et al., (119 Special Special Forces Current: 87% 2003 Forces, and support Specific use: 38 non-Special soldiers (non- Forces) Special Similar to above (Bovill Forces) et al., 2000) Response rate: 89%

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 APPENDIX C Findings: Motivation Other Findings Authors Conclusions and Study Limitations Conclusions: A majority (64%) of • Supplements used by soldiers incorrectly more Special Forces Possible trend in increased use of believed that protein (90%) than non- supplements in military is used for energy Special Forces for short-term (76%) athletic events, 58% • Supplement use believed that associated with vitamins provide more frequent energy exercise and greater nutrition knowledge • Not associated with age, weight, ethnicity • Information on nutrition similar to above (Bovill et al., 2000) continued

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 USE OF DIETARY SUPPLEMENTS BY MILITARY PERSONNEL TABLE C-2 Continued Reference Demographics Group Questions Findings: Usage Supplement use: 60.9% Brasfield, n=874 Enlisted U.S. Use of Frequency: 2004 750 men Army, active supplements 124 women duty and motivation Multivitamin: 56% Average age: Vitamin C: 28% 24.9 y Representative Creatine: 23% (17–49 y) sample of Ephedra: 21% soldiers Ginseng: 21% Response rate: Calcium: 20% 64% Vitamin E: 15% Vitamin A: 13% Iron: 13% Garlic: 12% DS users consumed: Three or more DS: 53% Two DS: 22% One DS: 25% Daily supplement use: Deuster n=38 U.S. Army Nutrient, et al., Average age: Rangers alcohol, DS 81.5% Most common: 2003 25 y (18–40 y) intake, and physical CHO/electrolyte fluids Response rate: activity level Protein powder: 24% 100% Creatine: 13% Ephedrine: 13% Also reported use of ginseng, glutamine, vitamins/minerals

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 APPENDIX C Findings: Motivation Other Findings Authors Conclusions and Study Limitations Source of information Conclusions: General health, performance (in order of High number of adverse effects that might enhancement, frequency): be attributed to DS use prevent illness Other (friends, family, Recommendations: etc.) Magazines • Use of some DS should be discontinued Store salesperson prior to undergoing surgery Internet • Health care screening Doctors • Routine assessment Books • Education TV • Further surveys recommended Limitations: More females than males consumed a DS; • Self-reporting might result in however, more men misunderstanding and misreporting consumed creatine, • Generalizations to general population are ginseng, and garlic not possible • Categorization of DS No association with aerobic exercise Stores on military bases specifically to sell frequency DS, in 2004, 92 stores worldwide on military installations Adverse events: 18% Palpitations: 46% Dizziness/confusion: 30% Tremors: 26% Abdominal pain: 24% Numbness/tingling extremities: 16% Loss of consciousness: 4% Conclusions: Use of supplements is not necessary based on the dietary intakes of protein by the Rangers continued

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 USE OF DIETARY SUPPLEMENTS BY MILITARY PERSONNEL TABLE C-2 Continued Reference Demographics Group Questions Findings: Usage Supplement use: 56% Johnson n=294 U.S. Army Use of et al., In Average age: Rangers supplements; Frequency: press 23 y potential (survey was factors Whole protein: 62% conducted in associated: age, Creatine: 46% 1999) participation in Thermogenics: 44% Anabolic steroids: <2% competitive or Response rate: recreational 40% athletics, weight training; sources of nutritional information Supplement use: McGraw n=367 U.S. Army Use of et al., Average age: Rangers supplements 36% 2000 22 y and associated Frequency: factors Response rate Creatine: 19% not known Multivitamin/ multimineral: 16% Protein/Amino acids: 14% Vitamin C: 7% Sport bars: 6% McPherson n=291 U.S. soldiers, Use of Massage and supplements and Average age: retirees, complementary were most commonly Schwenka, 39 y (18–83 y) spouses in and alternative used 2004 military medicine CAM use: Response rate: hospital (CAM) 73% Active duty: 72% Retiree: 85% Family: 89% Supplement use: Herbal supplements: 36% Nutritional food supplements: 36%

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 APPENDIX C Findings: Motivation Other Findings Authors Conclusions and Study Limitations Conclusions: • No difference in age of user compared to • Soldiers consume ergogenics at the same nonuser rate as other athletic populations • Supplement use • Supplement use is inversely correlated to associated with nutritional knowledge recreational Recommendation: activities, weight training Further education of unit surgeons • Source of Limitation: information: Other soldiers: 59% Self-exclusion of soldiers with higher usage Fitness magazines: might result in low response and 46% apparently lower supplement use level Internet: 18% Nutritionist: 8% Unit surgeon: 6% • Supplement use lower than general male population (42%), elite athletes (59%), or U.S. Army Special Operations candidates (64%) • Supplement use associated with frequency of strength training • Not associated with smoking or aerobic training. Conclusions: Pain, 81–98% thought the stress, treatment was effective • Health providers need to become anxiety, educated in CAM therapies depression, • Further studies needed weight loss Limitation: Geographical area might have biased the results, Western region (increased CAM, more providers) continued

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 USE OF DIETARY SUPPLEMENTS BY MILITARY PERSONNEL TABLE C-2 Continued Reference Demographics Group Questions Findings: Usage Supplement use: 78% Schneider n=91 Naval Sea, et al., Air, Land 1998 Response rate (SEAL) Using more than one not known personnel supplement concurrently: 4–9 DS: 32% 3 DS: 34% 2 DS: 18% 1 DS: 16% Creatine use: Sheppard n=229 U.S. civilian Use of creatine et al., (133 military) and military and other 12.2 g/d for 40 wk 2000 health clubs supplements Military supplement use: Response rate: 40% Vitamin: 65% Mineral: 47% Protein: 45% Creatine: 29% Herbal: 21% Androstenedione: 13% Hydroxy-β-methyl- butyrate (HMB): 10% Anabolic/androgenic steroids: 3% a Some of the findings from Bovill et al. (2000) and Bovill et al. (2003) are virtually the same and might come from the same study.

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 APPENDIX C Findings: Motivation Other Findings Authors Conclusions and Study Limitations Notes: Navy, concurrent supplements Increase muscle mass, strength, and power; provide energy; improve general health Conclusions: • Supplement use associated with • Concerns: creatine use with other resistance training anabolic supplements goal of strength • Popular magazines as main source of • Creatine use information associated with male • Education and access to information of gender, goal of users is critical strength training, • 45% of current creatine users reported lower frequency and adverse effects: gastrointestinal, muscle duration of aerobic cramping/spasms, dehydration training, use of protein, andro/ DHEA, and HMB • Information on creatine from: Popular media: 69% Physicians: 14% Dieticians: 10%

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 USE OF DIETARY SUPPLEMENTS BY MILITARY PERSONNEL REFERENCES Arsenault, J., and J. Kennedy. 1999. Dietary supplement use in U.S. Army Special Operations candidates. Mil Med 164(7):495-501. Bovill, M. E., S. M. McGraw, W. J. Tharion, and H. R. Lieberman. 2000. Supplement use and nutrition knowledge in a Special Forces unit. FASEB Journal 15(5):A999. Bovill, M. E., W. J. Tharion, and H. R. Lieberman. 2003. Nutrition knowledge and supple- ment use among elite U.S. army soldiers. Mil Med 168(12):997-1000. Brasfield, K. 2004. Dietary supplement intake in the active duty enlisted population. US Army Med Dept J (Oct-Dec):44-56. Corum, S. J. C. 2007. Dietary supplements questionnaire. Paper presented at the Institute of Medicine Workshop on Dietary Supplement Use by Military Personnel, Washington, DC, February 13. Institute of Medicine Committee on Dietary Supplement Use by Military Personnel. Deuster, P. A., A. Sridhar, W. J. Becker, R. Coll, K. K. O’Brien, and G. Bathalon. 2003. Health assessment of U.S. Army Rangers. Mil Med 168(1):57-62. French, S. 2007. Insights into dietary supplement usage by U.S. actie military personnel. Paper presented at the Institute of Medicine Workshop on Dietary Supplement Use by Military Personnel, Washington, DC, February 13. Institute of Medicine Committee on Dietary Supplement Use by Military Personnel. Gardiner, P. 2007. Prealence of dietary supplements in the U.S. young adult population. Paper presented at the Institute of Medicine Workshop on Dietary Supplement Use by Military Personnel, Washington, DC, February 13. Institute of Medicine Committee on Dietary Supplement Use by Military Personnel. Jaghab, D. 2007. Surey of Army health care proiders concerning dietary supplements. Paper presented at the Institute of Medicine Workshop on Dietary Supplement Use by Military Personnel, Washington, DC, February 13. Institute of Medicine Committee on Dietary Supplement Use by Military Personnel. Johnson, A. E., C. A. Haley, and J. A. Ward. In Press. Hazards of dietary supplement use. Kaufman, D. W. 2007. Design and conduct of sureys on dietary supplement use. Paper presented at the Institute of Medicine Workshop on Dietary Supplement Use by Military Personnel, Washington, DC, February 12. Institute of Medicine Committee on Dietary Supplement Use by Military Personnel. Lieberman, H. R., T. Stavinoha, S. McGraw, and L. Sigrist. 2007. Use of dietary supplements in U.S. Army populations. Paper presented at the Institute of Medicine Workshop on Dietary Supplement Use by Military Personnel, Washington, DC, February 13. Institute of Medicine Committee on Dietary Supplement Use by Military Personnel. Marriott, B. M. 2007. Dietary supplement use by actie duty military personnel: A world wide sample. Paper presented at the Institute of Medicine Workshop on Dietary Supplement Use by Military Personnel, Washington, DC, February 13. Institute of Medicine Com- mittee on Dietary Supplement Use by Military Personnel. McGraw, S. M., W. J. Tharion, and H. R. Lieberman. 2000. Use of nutritional supplements by U.S. Army Rangers. FASEB J 14(4):A742. McPherson, F., and M. A. Schwenka. 2004. Use of complementary and alternative therapies among active duty soldiers, military retirees, and family members at a military hospital. Mil Med 169(5):354-357. Schneider, K., L. Hervig, W. Y. Ensign, Jr., W. K. Prusaczyk, and H. W. Goforth, Jr. 1998. Use of supplements by U.S. Navy SEALS. Med Sci Sports Exerc 30:S60. Sheppard, H. L., S. M. Raichada, K. M. Kouri, L. Stenson Bar Maor, and J. D. Branch. 2000. Use of creatine and other supplements by members of civilian and military health clubs: A cross-sectional survey. Int J Sport Nutr Exerc Metab 10(3):245-259.

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 APPENDIX C Thomasos, C. 2007. Assessment of Air Force dietary supplement usage by major commands. Paper presented at the Institute of Medicine Workshop on Dietary Supplement Use by Military Personnel, Washington, DC, February 13. Institute of Medicine Committee on Dietary Supplement Use by Military Personnel.