20. Rock CL. Nutritional factors in cancer prevention.Hematol Oncol Clin North Am. 1998;12:975-991.

21. Krebs-Smith SM, Heimendinger J, Subar AF, Patter-son BH, Pivonka E. Using food frequency question-naires to estimate fruit and vegetable intake: Associ-ation between the number of questions and totalintakes. J Nutr Educ. 1995;27:80-85.

22. Thompson FE, Moler ME, Freedman LS, Clifford CK,Stables GJ, Willett WC. Register of dietary assess-ment calibration-validation studies: A status report.Am J Clin Nutr. 1997;65(suppl):S1142-S1147.

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25. Newman V, Rock CL, Faerber S, Flatt SW, WrightFA, Pierce JP. Dietary supplement use by women atrisk for breast cancer recurrence. The Women’sHealthy Eating and Living Study Group. J Am DietAssoc. 1998;98:285-292.

26. Strecher VJ, Rosenstock IM. The health belief model.In: Glanz K, Lewis FM, Rimer BK, eds. Health Be-havior and Health Education: Theory, Research, andPractice. San Francisco, CA: Jossey-Bass; 1997.

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APPLICATIONS

Including Dietary Supplements in Nutrition Assessment

The study by Reedy and colleagues (1) offers promis-ing results and should encourage dietetic practitio-ners to expand their understanding and assessment

of the use of dietary supplements. The data support therationale for a more comprehensive approach when eval-uating the quality of individuals’ diets and reiterate theimportance of documenting complete nutrient intake, in-cluding dietary supplements, as a routine part of nutri-tion research studies. It also reaffirms the need for prac-

titioners and health officials to foster effective educationefforts that not only underscore the importance of vege-tables and fruits, but motivate increased intake of them.

The methodology described by Reedy and colleagues (1)does not permit analysis of actual participant nutrientintake, but the results offer important insights. The par-ticipants in this study who were regular multivitamin/multimineral users were not necessarily eating morehealthfully than nonusers. It is also likely that the mul-tivitamin/multimineral users better met micronutrientDietary Reference Intake recommendations than thosewho did not take supplements at all.

Another recently published study similarly affirmedthe need to include dietary supplement use in dietaryassessments. Archer and colleagues found that supple-ment use “sizably increases daily intakes of several mi-cronutrients” (2). Likewise, after examining data from

This article was written by Rick Hall, MS, RD,a lecturer in the Nutrition Department at Arizona StateUniversity, a doctoral student at Iowa State University,and the immediate past chair for the Nutrition in Com-plementary Care Dietetic Practice Group.

doi: 10.1016/j.jada.2005.09.025

1756 November 2005 Volume 105 Number 11

the National Health and Nutrition Examination Survey,Radimer and colleagues (3) emphasized the importance ofdocumenting dietary supplement use in epidemiologicalstudies because of their large contribution to nutrientintake. Further studies are needed to establish true mi-cronutrient consumption including contributions fromcomplete supplement use.

Dietetics professionals recognize the importance of eat-ing a healthful diet including a variety of vegetables andfruits. However, as identified in this study and others(2,3), lifestyle behaviors affecting health are multifacto-rial. Body mass index (1,2) and smoking (2,3) are in-versely associated with the use of supplements. In thisstudy, however, Reedy and colleagues did not find a sig-nificant difference in body mass index between multivi-tamin/multimineral users and nonusers of supplements.More research is needed to clarify these associations.

Savvy dietetics professionals understand that the one-size-fits-all approach to nutrition education ignores im-portant research that advocates a more holistic approach.It is only appropriate to prescribe a nutrition plan afterfirst assessing individual needs, and it is equally appro-priate to recommend a dietary supplement regimen onlyafter evaluating the physical activity level, medical andpsychosocial history, and dietary intake of the specificindividual. An individualized approach to nutrition coun-seling should be the goal of every client encounter.

Reedy and colleagues (1) have offered a potential par-adigm shift regarding previously documented evidence(4) that supplement users tended to eat more healthfullythan nonsupplement users. By assigning supplement us-ers to categories based on the type of food products con-sumed, notable differences are evident among the groups.These variations are not surprising, since similar differ-ences are evident by categorizing vegetable consumersinto those who eat high-quality, nutrient-dense varietiesvs those who primarily eat deep-fried potatoes. Addi-

tional research is needed to confirm these differences, andresearchers should be encouraged to incorporate morecomprehensive nutrient analyses when evaluating nutri-ent consumption of subjects.

Practitioners should be encouraged by this study andchallenged by its implications. Basic nutrition educationis still needed, even for consumers who take supplementsand appear knowledgeable about health. Dietary assess-ment is clearly more complex than calculating servings offood guide components. Dietetics professionals areuniquely positioned to be leaders in research and educa-tion in regard to the growing use of dietary supplementsand should be encouraged to take advantage of continu-ing education opportunities to expand their knowledgeand comfort level in this area.

References1. Reedy J, Haines PS, Campbell MK. Differences in fruit

and vegetable intake among categories of dietary sup-plement users. J Am Diet Assoc. 2005;105:1749-1756.

2. Archer SL, Stamler J, Moag-Stahlberg A, Van Horn L,Garside D, Chan Q, Buffington JJ, Dyer AR. Associa-tion of dietary supplement use with specific micronu-trient intakes among middle-aged American men andwomen: The INTERMAP Study. J Am Diet Assoc.2005;105:1106-1114.

3. Radimer K, Bindewalk B, Hughes J, Ervin B, SwansonC, Picciano MF. Dietary supplement use by US adults:Data from the National Health and Nutrition Exami-nation Survey, 1999-2000. Am J Epidemiol. 2004;160:339-349.

4. Lyle BJ, Mares-Perlman JA, Klein BEK, Klein R, Gre-ger JL. Supplement users differ from nonusers in de-mographic, lifestyle, dietary and health characteris-tics. J Nutr. 1998;128:2355-2362.

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