The US FDA recently updated the DVs to be in line with the current dietary intake recommendations i. However, supplement labels may not yet reflect these changes. Because micronutrient requirements differ by gender and life stage, several MVM products currently on the market are formulated for specific subpopulations, i.

MVMs marketed to young women generally contain iron, while many of those marketed to postmenopausal women and men typically do not.

Use of nutritional supplements is common in the United States, with MVMs being the most popular type of dietary supplement. Dietary supplement use is generally more prevalent among females, non-Hispanic whites, older adults, and individuals with greater formal education Supplement use is also more common among those with a lower body mass index BMI and higher levels of physical activity reviewed in 34 ; MVM users also more likely rate their health as excellent or very good 35, A few studies have found that supplement users in general 33 , 37, 38 or MVM users in particular 39, 40 are more likely to have healthier diets, including higher intakes of some micronutrients, suggesting that those who do not take MVMs may be the ones who would benefit the most from supplementation.

NHANES 11, survey respondents reported that Americans take MVMs mainly to "improve overall health" but also to "supplement the diet" Several studies have shown that MVM use is associated with increased micronutrient intake , suggesting that an MVM can help fill nutritional gaps and improve the prevalence of nutrient adequacy in a population.

Compared to intake from food alone, use of MVMs was associated with a lower prevalence of inadequacy for several 'shortfall' i.

Moreover, an analysis from NHANES that stratified the data by ethnicity found that taking dietary supplements , including MVMs, was associated with a lower prevalence of inadequacies for vitamins D and E across all ethnicities examined Non-Hispanic white, non-Hispanic black, Hispanic, and Non-Hispanic Asian Improvements of intakes of other nutrients i.

Biomarkers of nutrient intake e. It is important to note that data from NHANES are cross-sectional in nature and thus cannot show that MVM supplementation causes improvements in micronutrient status. For example, supplement users may have healthier diets than non-users. Moreover, average total intakes of vitamins folate; vitamins A, B 6 , B 12 , C, D, E, and K among supplement users — intake from food and supplemental sources — were significantly higher than average intakes from food alone in this group 37 , suggesting that dietary supplement use does indeed help to improve micronutrient status.

Further, several clinical trials have found that multivitamin supplementation improves status of various micronutrients, including folate , vitamins B 6 47 , 50 , B 12 , C 47 , D 47, 48 , and E While many MVMs on the market contain most micronutrients, some nutrients are not typically included in MVMs or included only at a small percentage of the recommended amount.

For example, no MVM contains the recommended amount of calcium, magnesium, potassium, or phosphorus since the resulting pill would be too bulky; vitamin K and choline may not be included in MVMs.

Many of these nutrients — calcium, magnesium, potassium, vitamin K, and choline — are underconsumed by the US population called 'shortfall nutrients' , and the Dietary Guidelines label calcium and potassium as 'nutrients of public health concern' because inadequate intakes are linked to specific health concerns in the population osteoporosis for calcium and hypertension and cardiovascular disease for potassium 1.

An overall healthy diet see Healthy Eating above that is abundant in fruit, vegetables , and whole grains and includes dairy or fortified sources of calcium is thus key to meeting requirements of these nutrients.

Additionally, vitamin D is of particular concern because the vitamin is found only in a few foods, mainly fatty fish, and may not be included at adequate amounts in MVMs. Sunlight is the primary source of vitamin D.

Some good sources of nutrients that are often not present in MVMs at recommended levels are listed in Table 4 see also LPI's " Micronutrients for Health " handout and the "Sources" section in articles on specific vitamins or minerals.

While taking a daily MVM can significantly improve micronutrient intake and help fill nutrient gaps, it is important to be cognizant of any remaining nutrient shortfalls.

Micronutrient inadequacies may increase susceptibility to illness and chronic disease. However, the majority of studies looking at MVM supplementation and chronic disease endpoints, including cardiovascular disease , cancer , and age-related eye diseases, have reported no significant effect or association reviewed in 51 ; see the Highlight for additional references.

Information on the safety of MVMs comes from randomized controlled trials of long-term supplementation. No effect was found for fatigue, drowsiness, migraine, skin discoloration, or gastrointestinal tract symptoms; a reduction in hematuria blood in the urine was noted with MVM supplementation Other smaller randomized controlled trials of shorter duration have not reported serious adverse effects of MVM supplementation reviewed in 52 , but adverse effects are not commonly addressed in such trials.

Moreover, MVM supplementation was not linked with an increase in all-cause mortality in a meta-analysis of 21 randomized controlled trials of MVM supplementation of at least one year in duration No effect of MVM supplementation on vascular-related mortality 10 trials or cancer -related mortality 9 trials was found in this meta-analysis Another meta-analysis that included prospective cohort studies , in addition to randomized controlled trials, reported similar results Thus, MVMs are generally considered as safe in healthy individuals because they contain amounts of micronutrients that approximate or equal the DVs.

For adults, the DV for most micronutrients is considerably lower than the tolerable upper intake level UL — "the highest level of daily intake of a specific nutrient likely to pose no risk of adverse health effects in almost all individuals of a specified age" Intake of any micronutrient from food, fortified food, and supplements should not chronically exceed its UL Some analyses of NHANES data have looked at the proportion of the US population with nutrient intakes in excess of the UL when accounting for intake from all sources — food, including fortified and enriched food, and dietary supplements.

Micronutrient intakes above the UL are more common among children. As stated above, some have expressed concern that the UL for children is set too low for certain nutrients i. More generally, some have pointed out that the dose-response curves needed for risk assessment of individuals in a specific gender and life stage group have not been done for most micronutrients, and for these nutrients, estimating an intake level that is associated with risk of adverse effects is not possible Thus, for some nutrients, one cannot label intakes greater than the UL as "excessive" The nutrient that is overconsumed by the US population, sodium, is not included in MVMs — sodium intake comes from dietary sources, mainly processed food 1.

Thus, it is important to look for an MVM that contains no more than recommended amounts of vitamins and minerals i. Although dosages of micronutrients included in most MVMs are generally safe, some supplements may provide excessive vitamin A or iron.

For this reason, the Linus Pauling Institute LPI recommends that adults take a MVM supplement that provides no more than 2, IU μg of preformed vitamin A usually labeled vitamin A acetate or vitamin A palmitate and no more than 2, IU of additional vitamin A as β-carotene. Additionally, because excess preformed vitamin A retinol during pregnancy is known to cause birth defects and because a number of foods in the US are fortified with retinol, LPI recommends that pregnant women avoid a MVM or prenatal supplements that contain more than 5, IU 1, μg of vitamin A in the form of retinol.

Moreover, children should not be given a MVM supplement that contains more retinol than the RDA for their age group see the Table 1 in the article on vitamin A. Men and postmenopausal women are not at risk for iron deficiency, and excess iron from the diet and supplements can have adverse effects.

Therefore, LPI recommends that men and postmenopausal women take a MVM supplement without iron. A number of MVMs formulated specifically for men or for those over 50 years of age do not contain iron.

Even though MVM supplements are safe for most people, individuals should discuss the use of all nutritional supplements with a competent healthcare professional. People taking pharmaceutical drugs to treat certain medical conditions need to be aware of any potential drug-nutrient interactions; some potential interactions are listed in the article on Subpopulations at Risk for Micronutrient Inadequacy or Deficiency: see the section on Those Taking Drugs Known to Interact with Nutrients.

Another safety issue concerns the quality of commercially available MVM supplements. In , the US Food and Drug Administration established standards of current good manufacturing practices CGMPs , which ensure dietary supplements meet quality standards with respect to identity, purity, strength, and composition All US and foreign companies were required to comply with the CGMPs by June In addition to these government regulations, at least three independent organizations evaluate the quality of dietary supplements on a fee basis: NSF International , US Pharmacopeia , and ConsumerLab.

Supplement labels of approved products can bear the certification mark, verification mark, or seal of approval of these organizations. However, many products that are in full compliance do not carry such certification marks on their labels, and absence of a seal does not mean lack of adherence to CGMP or other regulations.

Nutrition education campaigns have yet to convince people to make better food choices: The reality is that most Americans do not follow a healthy eating pattern and instead eat an energy-rich, nutrient-poor diet 1.

MVMs are a simple, inexpensive, and safe way to help fill nutritional gaps and improve micronutrient status.

While the specific consequences of chronic micronutrient inadequacies are difficult to document, it is prudent and affordable to ensure adequacy for health by taking a daily MVM supplement.

Other micronutrient supplements may be needed if intake recommendations are not being met by a combination of dietary sources and the MVM. As mentioned above, some micronutrients e. In addition to a daily MVM, the Linus Pauling Institute recommends a few additional micronutrient supplements:.

The Linus Pauling Institute recommends that generally healthy adults take 2, IU 50 μg of supplemental vitamin D daily. Most multivitamins contain IU 10 μg or IU 15 μg of vitamin D, and single-ingredient supplements are available for additional supplementation.

Sun exposure, diet, skin color, and body mass index BMI have variable, substantial impact on body vitamin D levels. The American Academy of Pediatrics currently suggests that all infants, children, and adolescents receive IU of supplemental vitamin D daily Consistent with the recommendations of the Endocrine Society 61 , the Linus Pauling Institute recommends daily intakes of to 1, IU 10 to 25 µg of vitamin D in infants and to 1, IU 15 to 25 µg of vitamin D in children and adolescents.

Given the average vitamin D content of breast milk, infant formula, and the diets of children and adolescents, supplementation may be necessary to meet these recommendations. More on vitamin D. Because of the high benefit-to-risk ratio of vitamin C supplementation, and to ensure tissue and body saturation of vitamin C in almost all healthy people, the Linus Pauling Institute recommends a vitamin C intake of at least mg daily for adult men and women.

Consuming at least five servings 2½ cups of fruit and vegetables daily provides about mg of vitamin C. More on vitamin C. A varied diet should provide enough vitamin B 12 to prevent deficiency in most individuals 50 years of age and younger. Strict vegetarians and women planning to become pregnant should take a daily multivitamin supplement or eat fortified cereal, which would ensure a daily intake of 6 to 30 µg of vitamin B 12 in a form that is easily absorbed.

Supplemental vitamin B 12 is also recommended for patients taking medications that interfere with its absorption see Drug interactions in the separate article on vitamin B More on vitamin B Consumption of an energy-rich, nutrient-poor diet — the current dietary pattern in the United States — results in suboptimal health and increases risk of chronic disease.

Despite decades of public health messages to eat a balanced diet, overall adherence to the Dietary Guidelines for Americans 1 is low. As a result, micronutrient inadequacies, especially vitamins A, C, D, and E; calcium; and magnesium, are quite prevalent in the population among various age groups and ethnicities 33 , Certain subgroups of the population are at a heightened risk of micronutrient deficiencies due to several factors, including life stage, disease status, pharmaceutical use, and various lifestyle choices.

While debate about the optimal diet for health continues 64 , there is ample evidence to support the benefits of following a healthy eating pattern like those discussed in the Dietary Guidelines for Americans — plant-based diets abundant in fruit, vegetables , legumes , whole grains , nuts , and seeds and limited in processed food.

Adhering to such an eating pattern is important to obtain the nutrients needed for optimal health and to help prevent chronic disease throughout the lifespan. Depending on diet and life stage, additional single-nutrient supplements like vitamins B 12 , C, and D may be needed to reach micronutrient intake recommendations.

Many studies have shown that use of dietary supplements results in improved micronutrient intake and thus decreased prevalence of micronutrient inadequacy in the population. However, supplements should not replace a healthful eating pattern; on the contrary, by definition "supplements" should be used to complement healthy eating to ensure nutrient adequacy for optimal health.

Written in January by: Victoria J. Drake, Ph. Linus Pauling Institute Oregon State University. Reviewed in March by: Balz Frei, Ph. Former Director, Linus Pauling Institute Distinguished Professor Emeritus, Dept.

of Biochemistry and Biophysics Oregon State University. The writing of this article was supported by a grant from Pfizer Inc. US Department of Health and Human Services and US Department of Agriculture. December Byrd-Bredbenner C, Ferruzzi MG, Fulgoni VL, 3 rd , Murray R, Pivonka E, Wallace TC.

J Food Sci. Scientific report of the Dietary Guidelines Advisory Committee: Advisory report to the Secretary of Health and Human Services and the Secretary of Agriculture; Papanikolaou Y, Fulgoni VL.

Grain foods are contributors of nutrient density for American adults and help close nutrient recommendation gaps: data from the National Health and Nutrition Examination Survey, Certain grain foods can be meaningful contributors to nutrient density in the diets of US children and adolescents: data from the National Health and Nutrition Examination Survey, Cifelli CJ, Houchins JA, Demmer E, Fulgoni VL.

Increasing plant based foods or dairy foods differentially affects nutrient intakes: dietary scenarios using NHANES Quann EE, Fulgoni VL, 3 rd , Auestad N. Consuming the daily recommended amounts of dairy products would reduce the prevalence of inadequate micronutrient intakes in the United States: diet modeling study based on NHANES Nutr J.

Bailey RL, Parker EA, Rhodes DG, et al. Estimating sodium and potassium intakes and their ratio in the American diet: data from the NHANES. J Nutr.

Lowering salt in your diet. de Lourdes Samaniego-Vaesken M, Alonso-Aperte E, Varela-Moreiras G. Vitamin food fortification today. Food Nutr Res. Sacco JE, Dodd KW, Kirkpatrick SI, Tarasuk V. Voluntary food fortification in the United States: potential for excessive intakes.

Eur J Clin Nutr. American Dietetic Association. Position of the American Dietetic Association: fortification and nutritional supplements. J Am Diet Assoc. Carriquiry AL, Camano-Garcia G.

Evaluation of dietary intake data using the tolerable upper intake levels. Uauy R, Hawkesworth S, Dangour AD.

Food-based dietary guidelines for healthier populations: international considerations. In: Ross AC, Caballero B, Cousins RJ, Tucker KL, Ziegler TR, eds. Modern Nutrition in Health and Disease.

Ganji V, Kafai MR. Trends in serum folate, RBC folate, and circulating total homocysteine concentrations in the United States: analysis of data from National Health and Nutrition Examination Surveys, , , and Fulgoni VL, 3 rd , Keast DR, Bailey RL, Dwyer J.

Foods, fortificants, and supplements: Where do Americans get their nutrients? Fulgoni VL, Buckley RB. The contribution of fortified ready-to-eat cereal to vitamin and mineral intake in the US population, NHANES Yeung LF, Cogswell ME, Carriquiry AL, Bailey LB, Pfeiffer CM, Berry RJ.

Contributions of enriched cereal-grain products, ready-to-eat cereals, and supplements to folic acid and vitamin B usual intake and folate and vitamin B status in US children: National Health and Nutrition Examination Survey NHANES , Am J Clin Nutr. Zlotkin S. A critical assessment of the upper intake levels for infants and children.

Ward E. Addressing nutritional gaps with multivitamin and mineral supplements. Ames BN. Low micronutrient intake may accelerate the degenerative diseases of aging through allocation of scarce micronutrients by triage.

Proc Natl Acad Sci U S A. Ames BN, Wakimoto P. Are vitamin and mineral deficiencies a major cancer risk? Nat Rev Cancer. Raisz LG. Pathogenesis of osteoporosis: concepts, conflicts, and prospects. J Clin Invest. Huskisson E, Maggini S, Ruf M. The role of vitamins and minerals in energy metabolism and well-being.

J Int Med Res. Bhaskaram P. Immunobiology of mild micronutrient deficiencies. Br J Nutr. Kennedy DO, Haskell CF.

Vitamins and cognition: what is the evidence? Policy - National Policy and Guidelines for Micronutrient Supplementation to Prevent and Control Deficiencies in Cambodia. Date: Published by: National Nutrition Programme.

Published year: Type of policy: Nutrition policy, strategy or plan focusing on specific nutrition areas. Tabs Goals Goals, objectives or targets related to nutrition:. Strategies and activities related to nutrition:.

Dietary diversity and modification 2. Food fortification 3. Helminth control 4. Malaria control 5. Reproductive and obstetric strategies 6. Public health measure for disease control 7. Improved infant and young child feeding 3.

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In this section About Clinical Practice Guidelines CPG index Nursing Guidelines Paediatric Improvement Collaborative Parent resources Retrieval services CPG Committee Calendar CPG information Other resources CPG feedback. Micronutrient deficiency.

Micronutrient deficiency See also Iron deficiency Vitamin D deficiency Key Points Consider micronutrient deficiencies in all children with diets which are highly restricted in variety and balanced nutritional content due to neurodevelopmental conditions eg ASD, cognitive impairment Normal growth parameters do not exclude possible micronutrient deficiency Micronutrient deficiencies can be associated with permanent physical disabilities eg blindness or death Clinical features of micronutrient deficiency may be subtle, consider in children with highly restricted diets presenting with non-specific symptoms Background Micronutrient deficiency may occur in children who have sufficient caloric intake for acceptable growth, but a diet significantly restricted in food variety.

Seek advice from dietician on choice and dosage of multivitamins meeting recommended vitamin and mineral daily intake for age, while considering tolerability of different formulations eg liquid, tablet, powder Occupational or speech therapy services can assist with administration strategies and addressing underlying food aversions.

Specialised feeding services or feeding therapists may be available in some regions or via telehealth from larger centres Children with identified micronutrient deficiency who have completed initial replacement should have management put in place to maintain sufficient nutrient intake maintenance dosing.

This should continue until such a time that the dietary risk factors have been addressed or resolved Consider consultation with local paediatric team when Child has symptomatic micronutrient deficiency Cause of micronutrient deficiency is not clear Oral supplementation not successful Consideration of feeding support through nasogastric tube or gastrostomy is required Consider transfer when Care required is beyond the capability of the local hospital Consider discharge when Micronutrient deficiency successfully treated, and risk factors have been addressed Parent information Healthy Eating for Children Nutrition — babies and toddlers Nutrition — school age to adolescence Iron Vitamin D Additional notes Australian Government Eat for Health Resources and Nutritional Guidelines Nutrient reference values for age RCH Food and Nutrition resources Nutrition Education Materials Online NEMO Queensland Health Last updated September Reference List Abrahms S.

Zinc deficiency. Up to date. Folic acid. Adelaide: Australian Medicines Handbook Pty Ltd; July. Vitamin B Developmental medicine and child neurology. DOI: Differences in food consumption and nutritional intake between children with autism spectrum disorders and typically developing children: A meta-analysis.

Nelson Textbok of Pediatrics 21st edition. Chapter Elsevier Inc. Overview of water soluble vitamins. Overview of vitamin A. Nutritional status of individuals with autism spectrum disorders: do we know enough?

Advances in Nutrition. Scurvy as a sequela of avoidant-restrictive food intake disorder in autism: a systematic review. Journal of Developmental and Behavioral Pediatrics. Nutritional Deficiency Disease Secondary to ARFID Symptoms Associated with Autism and the Broad Autism Phenotype: A Qualitative Systematic Review of Case Reports and Case Series.

Journal of the Academy of Nutrition and Dietetics. Clinical features of deficiency. Risks for deficiency. Vitamin A Retinol. Xerophthalmia: night blindness, dry conjunctiva, corneal ulceration, blindness Dry skin and pruritis Increased susceptibility to infection Poor growth.

Malabsorption eg exocrine pancreatic insufficiency, chronic liver disease, short bowel syndrome, inflammatory bowel disease Maternal deficiency Some refugee populations. Vitamin B1 Thiamine. Fatigue, irritability, apathy, nausea, abdominal discomfort Dry beriberi symmetric peripheral neuropathy Wet beriberi cardiac failure Wernicke encephalopathy: confusion, reduced consciousness, ataxia, ophthalmoplegia Korsakoff syndrome: confusion, amnesia.

White rice-based diets Malabsorption Some refugee populations. Vitamin B3 Niacin. Anorexia, vomiting, abdominal pain Glossitis, cheilitis Pellagra: triad of dermatitis, diarrhoea and confusion Late symptoms include apathy, weakness, headache, confusion, irritability, anxiety, tremor, depression.

Vitamin B9 Folate. Clinical signs of anaemia Macrocytic anaemia and hyper-segmented neutrophils on full blood count Glossitis, oral ulcers Fatigue, slow growth.

Lack of fresh food in diet Malabsorption, Medications eg phenytoin, phenobarbital, methotrexate, long-term NSAID use. Vitamin B12 Cobalamin.

Clinical skins of anaemia Macrocytic anaemia and hyper-segmented neutrophils on full blood count Irritability, developmental delay, developmental regression, involuntary movements, peripheral neuropathy Glossitis, oral ulcers Skin changes eg hyperpigmentation, vitiligo.

Vegan and vegetarian diet Some refugee populations Gastrointestinal disease Exclusively breastfed infants of mothers with Vitamin B12 deficiency. Vitamin C Ascorbic acid. Vitamin D Calciferol. Recent research has shown the importance of MNs in common pathologies, with significant deficiencies impacting the outcome.

Objective: This guideline aims to provide information for daily clinical nutrition practice regarding assessment of MN status, monitoring, and prescription. It proposes a consensus terminology, since many words are used imprecisely, resulting in confusion.

This is particularly true for the words "deficiency", "repletion", "complement", and "supplement". Methods: The expert group attempted to apply the standard operating procedures SOP for ESPEN which focuses on disease.

However, this approach could not be applied due to the multiple diseases requiring clinical nutrition resulting in one text for each MN, rather than for diseases.

An extensive search of the literature was conducted in the databases Medline, PubMed, Cochrane, Google Scholar, and CINAHL. For each MN, the main functions, optimal analytical methods, impact of inflammation, potential toxicity, and provision during enteral or parenteral nutrition were addressed.

The SOP wording was applied for strength of recommendations. Results: There was a limited number of interventional trials, preventing meta-analysis and leading to a low level of evidence. Altogether the guideline proposes sets of recommendations for 26 MNs, resulting in single recommendations.