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Use of Dietary Supplements by Military Personnel (2008)
Food and Nutrition Board (FNB)

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Use of Dietary Supplements by Military Personnel

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

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383

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Use of Dietary Supplements by Military Personnel 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 Mean age: 25.4 years (n=5,206) Soldiers (ranks: E1–E9) Health Promotion and Prevention Initiative, dietary supplements questionnaire   Response rate not known   “Estimate how often you use 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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Use of Dietary Supplements by Military Personnel Findings: Usage Other Findings Authors’ Conclusions and Study Limitations Vitamins/minerals: Multivitamin: 33.8% Vitamin C: 24.4% Calcium: 19.3% Iron: 14.4% Potassium: 12.1% Vitamin A: 12.5% Vitamin B6: 11.5% Motivation Vitamins/minerals: Health Prevent illness Conclusions: 16% listed dehydration as an adverse effect (concern) Women and men tend to use different dietary supplements (DS) Many of the DS used were associated with palpitations or anxiety, which could be due to caffeine Perception that if something is sold in the base, it means it is safe Ergogenic aids: Performance enhancement Strength Ergogenic aids: Sports drinks: 42.8% Sports bars: 17.3% Protein: 13.7% Ephedra-free: 10.1% Herbal supplements: Prevent fatigue Sources of information: (n=2,241) Friends: 36% Magazines: 31.7% Internet: 22.1% Sales associates: 10.4% Doctors: <10% TV/radio/newspaper: <5%   Herbal supplements: Caffeine: 17.5% Ginseng: 6.7% Garlic: 5% Ginkgo: 3.9% Echinacea: 3.6% Limitations: Surveys not designed to relate adverse effects or benefits to any particular DS Response rate not known Results might be skewed because it was completed voluntarily They do not have dietary pattern surveys of respondents Adverse effects are not usually reported to health care providers   Supplement purchase: (n=2,241) Commissary/PX: 35.6% Nutrition/health food store on post: 25.3% Nutrition/health food store off post: 25.3% 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

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Use of Dietary Supplements by Military Personnel Reference Demographics Group Questions French, 2007 2005 Men and women 18 y and older (n=376) Nationally representative group of U.S. adults “currently serving in the military, national guard, or reserve” The Natural Marketing Institute ESP (E-screener panel) Questionnaire Index   Response rate: 60% Supplement use in past 3 mo

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

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Use of Dietary Supplements by Military Personnel Reference Demographics Group Questions French, 2007 2005 Men and women 18 y and older Nationally representative group of U.S. adults (nonmilitary) The Natural Marketing Institute ESP (E-screener panel) Questionnaire Index       Supplement use in past 3 mo   Response rate: 60%    

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Use of Dietary Supplements by Military Personnel Findings: Usage Other Findings Authors’ Conclusions and Study Limitations Supplement use: Any: 73% Multivitamin (only): 18% 2 or more supplements: 55%   Conclusions: See above for general comments (French, 2007) Supplement use increases with age Nonmilitary significantly higher in DS use for specific supplements except for creatine, CLA, amino acids Categories: Protein powders: 4% Weight loss: 7% 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%  

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Use of Dietary Supplements by Military Personnel Reference Demographics Group Questions GENERAL POPULATION Gardiner, 2007 2002 18–30 y (n=6,666) National Health Interview Survey (NHIS) In-person interviews NHIS   “Have you ever used a multivitamin or vitamin?”   Response rate: 73.4%         “During the past 12 months, did you use natural herbs for your own health or treatment?”

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

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Use of Dietary Supplements by Military Personnel Reference Demographics Group Questions Gardiner, 2007 1999–2002 18–30 y (n=3,231) National Health and Nutrition Examination Survey (NHANES) In-person interviews NHANES   “Have you used or taken any vitamins, minerals, or other dietary supplement in the past month?” 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.   Response rates: 1999–2000: 82%, 2001–2002: 84%

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

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Use of Dietary Supplements by Military Personnel Findings: Motivation Other Findings Authors Conclusions and Study Limitations Use for: General health, performance enhancement, interest in preventing infectious diseases, physical performance, and wound healing Use is higher than in general population of young men (39% use them occasionally) Supplement use associated with higher scores for Army physical fitness tests, daily exercise, weight lifting, and nonsmokers Not associated with age, ethnicity, BMI, chewing tobacco, or alcohol use Conclusions: Military population is at risk for potential adverse effects of inadequate use of DS, including abrupt cessation when deployed in operations or entering training Presence of DS on military bases and discontent with food might result in higher use of DS   Recommendations: Further studies of benefits and risks are necessary Routine one-size-fits-all advice should not be given OK to treat deficiencies but questions about performance effects Military health care professionals should be well informed about risks and benefits General health: 63% Performance: 20% Supplement use 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%  

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Use of Dietary Supplements by Military Personnel Reference Demographics Group Questions Findings: Usage Bovill et al., 2003 n=157 male (119 Special Forces, 38 non-Special Forces) U.S. Army Special Forces and support soldiers (non-Special Forces)   Supplement use: Current: 87%     Specific use: Similar to above (Bovill et al., 2000)   Response rate: 89%      

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

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

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Use of Dietary Supplements by Military Personnel Findings: Motivation Other Findings Authors Conclusions and Study Limitations General health, performance enhancement, prevent illness Source of information (in order of frequency): Other (friends, family, etc.) Magazines Store salesperson Internet Doctors Books TV Conclusions: High number of adverse effects that might be attributed to DS use   Recommendations: Use of some DS should be discontinued prior to undergoing surgery Health care screening Routine assessment Education Further surveys recommended   More females than males consumed a DS; however, more men consumed creatine, ginseng, and garlic Limitations: Self-reporting might result in misunderstanding and misreporting Generalizations to general population are not possible Categorization of DS   No association with aerobic exercise frequency   Stores on military bases specifically to sell 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

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

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Use of Dietary Supplements by Military Personnel Findings: Motivation Other Findings Authors Conclusions and Study Limitations   No difference in age of user compared to nonuser Supplement use associated with recreational activities, weight training Source of information: Other soldiers: 59% Fitness magazines: 46% Internet: 18% Nutritionist: 8% Unit surgeon: 6% Conclusions: Soldiers consume ergogenics at the same rate as other athletic populations Supplement use is inversely correlated to nutritional knowledge   Recommendation: Further education of unit surgeons   Limitation: Self-exclusion of soldiers with higher usage might result in low response and apparently lower supplement use level 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. Pain, stress, anxiety, depression, weight loss 81–98% thought the treatment was effective Conclusions: Health providers need to become educated in CAM therapies Further studies needed     Limitation: Geographical area might have biased the results, Western region (increased CAM, more providers)

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Use of Dietary Supplements by Military Personnel Reference Demographics Group Questions Findings: Usage Schneider et al., 1998 n=91 Naval Sea, Air, Land (SEAL) personnel   Supplement use: 78%   Response rate not known   Using more than one supplement concurrently: 4–9 DS: 32% 3 DS: 34% 2 DS: 18% 1 DS: 16% Sheppard et al., 2000 n=229 (133 military) U.S. civilian and military health clubs Use of creatine and other supplements Creatine use: 12.2 g/d for 40 wk   Response rate: 40%     Military supplement use: Vitamin: 65% Mineral: 47% Protein: 45% Creatine: 29% Herbal: 21% Androstenedione: 13% Hydroxy-β-methyl-butyrate (HMB): 10% Anabolic/androgenic steroids: 3% aSome 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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Use of Dietary Supplements by Military Personnel Findings: Motivation Other Findings Authors Conclusions and Study Limitations Increase muscle mass, strength, and power; provide energy; improve general health   Notes: Navy, concurrent supplements   Supplement use associated with resistance training goal of strength Creatine use associated with male gender, goal of strength training, lower frequency and duration of aerobic training, use of protein, andro/DHEA, and HMB Information on creatine from: Popular media: 69% Physicians: 14% Dieticians: 10% Conclusions: Concerns: creatine use with other anabolic supplements Popular magazines as main source of information Education and access to information of users is critical 45% of current creatine users reported adverse effects: gastrointestinal, muscle cramping/spasms, dehydration

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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 supplement 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. active 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. Prevalence 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. Survey of Army health care providers 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 surveys 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 active 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 Committee 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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Use of Dietary Supplements by Military Personnel 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.