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Prevalence, Adverse Events, and Factors Associated with Dietary Supplement and Nutritional Supplement Use by US Navy and Marine Corps Personnel

Open AccessPublished:April 12, 2016DOI:https://doi.org/10.1016/j.jand.2016.02.015

      Abstract

      Background

      About 50% of Americans and 60% to 70% of US military personnel use dietary supplements, some of which have been associated with adverse events (AEs). Nutritional supplements like sport drinks and sport bars/gels are also commonly used by athletes and service members. Previous dietary supplement and nutritional supplement surveys were conducted on Army, Air Force, and Coast Guard personnel.

      Objective

      The aim of this cross-sectional study was to investigate dietary and nutritional supplement use in Navy and Marine Corps personnel, including the prevalence, types, factors associated with use, and AEs.

      Design

      A random sample of 10,000 Navy and Marine Corps personnel were contacted. Service members were asked to complete a detailed questionnaire describing their personal characteristics, supplement use, and AEs experienced.

      Results

      In total, 1,708 service members completed the questionnaire during August through December 2014, with 1,683 used for analysis. Overall, 73% reported using dietary supplements one or more times per week. The most commonly used dietary supplements (used one or more times per week) were multivitamins/multiminerals (48%), protein/amino acids (34%), combination products (33%), and individual vitamins and minerals (29%). About 31% of service members reported using five or more dietary supplements. Sport drinks and sport bars/gels were used by 45% and 23% of service members, respectively. Monthly expenditures on dietary supplements averaged $39; 31% of service members spent ≥$50/mo. Multivariate logistic regression modeling indicated that female sex (women/men; odds ratio [OR]=1.76, 95% CI 1.32 to 2.36), higher educational level (college degree/no college degree; OR=2.23, 95% CI 1.62 to 3.30), higher body mass index (calculated as kg/m2) (≥30/<25; OR=1.67, 95% CI 1.06 to 2.63), and a greater amount of resistance training (≥271/0 to 45 min/week; OR=2.85, 95% CI 1.94 to 4.17) were associated with dietary supplement use. Twenty-two percent of dietary supplement users and 6% of nutritional supplement users reported one or more AEs. For combination products alone, 29% of users reported one or more AEs.

      Conclusions

      The prevalence of dietary supplement use in Navy and Marine Corps personnel was considerably higher than reported in civilian investigations for almost all types of dietary supplements, although similar to most other military services. Factors associated with dietary supplement use were similar to those reported in previous military and civilian investigations. Prevalence of self-reported AEs was very high, especially for combination products.

      Keywords

      Dietary supplements are commercially available products consumed as an addition to the usual diet and include vitamins, minerals, herbs (botanicals), amino acids, and a variety of other products.

      Strengthening knowledge and understanding of dietary supplements. https://ods.od.nih.gov/About/dshea_Wording.aspx. Accessed December 2, 2015.

      Marketing claims for some dietary supplements include improvements in overall health status, enhancement of cognitive or physical performance, increases in energy, loss of excess weight, attenuation of pain, and other favorable effects. It is estimated that about 50% of Americans and 60% to 70% of US military personnel use dietary supplements.
      • Knapik J.J.
      • Steelman R.
      • Hoedebecke S.
      • et al.
      A systematic review and meta-analysis on the prevalence of dietary supplement use by military personnel.
      • Radimer K.
      • Bindewald B.
      • Hughes J.
      • et al.
      Dietary supplement use by US adults: Data from the National Health and Nutrition Examination Survey, 1999-2000.
      • Kennedy E.T.
      • Luo H.
      • Houser R.F.
      Dietary supplement use pattern of US adult population in the 2007-2008 National Health and Nutrition Survey (NHANES).
      The Dietary Supplement Health and Education Act of 1994

      Strengthening knowledge and understanding of dietary supplements. https://ods.od.nih.gov/About/dshea_Wording.aspx. Accessed December 2, 2015.

      established the regulatory framework for dietary supplements in the United States. Since the Dietary Supplement Health and Education Act became law, US sales of dietary supplements have increased from $4 billion in 1994 to $37 billion in 2014,
      • Saldanha L.G.
      The dietary supplement marketplace. Constantly evolving.

      Supplement Business Report 2015. Market Research Reports. Nutr Bus J. http://newhope360.com/site-files/newhope360.com/files/uploads/2015/05/2015_SupplementReport_TOC.pdf. Published June 29, 2015. Accessed March 27, 2016.

      a more than ninefold increase over 20 years.
      Reports of adverse events (AEs) associated with dietary supplements have been published regularly,
      • Brasfield K.
      Dietary supplement intake in the active duty enlisted population.
      • Corum S.
      Findings of recent surveys on dietary supplements use by military personnel and the general population (Appendix C).
      • Timbo B.B.
      • Ross M.P.
      • McCarthy P.V.
      • et al.
      Dietary supplements in a national survey: Prevalence of use and reports of adverse events.
      • Bunchorntavakul C.
      • Reddy K.R.
      Review article: Herbal and dietary supplement hepatotoxicity.
      and a recent study of a nationally representative sample estimated that 23,005 emergency department visits and 2,154 hospitalizations per year could be attributed to AEs from dietary supplements.
      • Geller A.I.
      • Shehab N.
      • Weidle N.J.
      • et al.
      Emergency room visits for adverse events related to dietary supplements.
      The US Food and Drug Administration (FDA) has banned or warned consumers about specific products,

      FDA issues regulation prohibiting sale of dietary supplements containing ephedrine alkaloids and reiterates its advice that consumers stop using these products. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2004/ucm108242.htm. Accessed December 2, 2015.

      FDA warns consumers to stop using Hydroxycut products. Dietary supplement linked to one death; pose risk of liver injury. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm149575.htm. Accessed December 2, 2015.

      but under the Dietary Supplement Health and Education Act, the FDA has only limited ability to regulate dietary supplements that might pose safety risks. Manufacturers must notify the FDA 75 days before marketing a new dietary supplement, and although the FDA can review marketing claims, FDA approval is not required for retailing the product. The FDA has the burden of demonstrating that a specific product is unsafe either in the pre- or post-marketing phases before taking action, although since 2007, manufacturers are required to notify the FDA about serious AEs.
      • Morrow J.D.
      Why the United States still needs improved dietary supplement regulation and oversight.
      Besides dietary supplements, both athletes and military personnel commonly use nutritional supplements like sport drinks, sport bars, sport gels, and meal-replacement beverages. It is estimated that about 25% to 35% of athletes
      • Knapik J.J.
      • Steelman R.A.
      • Hoedebecke S.S.
      • et al.
      Prevalence of dietary supplement use by athletes: Systematic review and meta-analysis.
      and at least 25% of military personnel
      • Lieberman H.R.
      • Stavinoha T.B.
      • McGraw S.M.
      • et al.
      Use of dietary supplements among active-duty US Army soldiers.

      Austin KG, Price LL, McGraw SM, et al. Demographic, lifestyle factors and reasons for use of dietary supplements by Air Force personnel. Aerosp Med Hum Perf. In press.

      • Austin K.G.
      • Price L.L.
      • McGraw S.M.
      • et al.
      Predictors of dietary supplement use by US Coast Guard personnel.
      use nutritional supplements of these types. Sport drinks and sport bars/gels are typically used before, during, or after exercise to provide hydration or nutrients. Sport drinks are generally carbohydrate-electrolyte solutions, while sport bars/gels are generally composed of carbohydrate and protein complexes. Meal-replacement beverages are consumed as a substitute for solid food and are usually used for weight control. These products are classified as nutritional supplements because they are labeled as foods (as opposed to dietary supplements that are labeled as supplements) and are subject to FDA regulation as foods.

      FDA Food Safety Modernization Act (FSMA). http://www.fda.gov/Food/GuidanceRegulation/FSMA/default.htm. Accessed December 3, 2015.

      An Institute of Medicine report titled “Use of Dietary Supplements by Military Personnel” recognized that a clear picture of use of dietary supplements in the military (eg, prevalence, patterns of use, and AEs) did not exist and recommended conducting surveys to provide detailed information on dietary supplement use by service members.
      Institute of Medicine
      Use of Dietary Supplements by Military Personnel.
      To this end, previous studies were conducted in Army,
      • Lieberman H.R.
      • Stavinoha T.B.
      • McGraw S.M.
      • et al.
      Use of dietary supplements among active-duty US Army soldiers.
      Air Force,

      Austin KG, Price LL, McGraw SM, et al. Demographic, lifestyle factors and reasons for use of dietary supplements by Air Force personnel. Aerosp Med Hum Perf. In press.

      and Coast Guard
      • Austin K.G.
      • Price L.L.
      • McGraw S.M.
      • et al.
      Predictors of dietary supplement use by US Coast Guard personnel.
      personnel. The present study was conducted to complete the survey of military services by assessing the types and number of supplements used, factors associated with supplement use, and the incidence of AEs associated with supplement use in active-duty Navy and Marine Corps personnel.

      Materials and Methods

      This investigation was a cross-sectional survey study conducted among US active-duty Navy and Marine Corps personnel and approved by Naval Health Research Center’s Institutional Review Board. Investigators requested information from the Defense Manpower Data Center (DMDC) on a random sample of 4,000 Navy personnel (3,000 men and 1,000 women) and 6,000 Marine Corps personnel (4,500 men and 1,500 women) currently on active-duty and with at least 6 months of service as of February 2014 (10,000 personnel in total). Data obtained from DMDC included the service member’s name, branch of service, pay grade (rank), postal address, e-mail address, sex, age, marital status, education level, and occupation. The National Change of Address records provided by the US Postal Service were referenced to ensure the most up to date postal address was used.
      The random sample request to DMDC was based on previous experience with similar Naval Health Research Center’s questionnaire investigations indicating an approximate 20% response rate from Navy and Marine Corps personnel
      • Smith T.C.
      The US Department of Defense Millennium Cohort Study: Career span and beyond longitudinal follow-up.
      and statistical power considerations. Minimum sample size was determined with the α-error level set at ≤.05, β-error at <.20 (power≥.80), using the prevalence of Army supplement use of 53%,
      • Lieberman H.R.
      • Stavinoha T.B.
      • McGraw S.M.
      • et al.
      Use of dietary supplements among active-duty US Army soldiers.
      and the prevalence of exposure of 0.10. If stratified analyses were conducted on the combined Navy and Marine Corps study population, the minimum sample size required to detect a difference equivalent to an odds ratio (OR) of 2.0 was 784.

      Recruitment Procedures

      Recruitment of participants in the random sample involved a maximum of six sequential contacts. The prospective participant was first sent an introductory postal letter including information about the purpose of the study, the investigators and their command affiliations, the sponsors, and the reason for conducting the study. The introductory letter provided the service member with a pre-incentive $10 gift card to nationally available businesses to encourage participation. The letter also included a description of the survey, a link to a secure website, and a subject identification number that could be used to access the survey and electronically sign the consent form. A follow-up e-mail message after 10 days and postcard after 3 weeks were sent as a reminder to those who did not initially complete the survey. If no response was received after sending the postcard, up to three additional e-mail reminders were sent over 3 months, after which contact with the service member ended. Those who responded were sent “thank you” e-mail messages. All postal and online contacts stated that at any time the service member could decline participation and be removed from the contact list. Recruitment began in August 2014 and no further recruitment was conducted or surveys accepted after December 2014.

      Survey (Questionnaire) Description

      The first section of the questionnaire was designed to characterize participants. Questions included items on demographics (ie, sex, age, height, weight, marital status, and education level), military characteristics (ie, service, rank, occupation assignment, and special operations status), and physical activity (ie, frequency and duration of aerobic and resistance training). This descriptive section was followed by questions about specific dietary supplements, which included 70 generic dietary supplements and nutritional supplements (eg, multivitamins/multiminerals [MVM], individual vitamins and minerals, amino acids [AA], proteins, sport drinks, sport bars) and 111 brand-name products. The brand-name products were similar to those used in previous studies of Army,
      • Lieberman H.R.
      • Stavinoha T.B.
      • McGraw S.M.
      • et al.
      Use of dietary supplements among active-duty US Army soldiers.
      Air Force,

      Austin KG, Price LL, McGraw SM, et al. Demographic, lifestyle factors and reasons for use of dietary supplements by Air Force personnel. Aerosp Med Hum Perf. In press.

      and Coast Guard
      • Austin K.G.
      • Price L.L.
      • McGraw S.M.
      • et al.
      Predictors of dietary supplement use by US Coast Guard personnel.
      personnel, but were updated based on a survey of dietary supplement and nutritional supplement inventories in the Navy and Marine Corps Exchange System and General Nutrition Center stores on or near Navy and Marine Corps installations. Dietary supplement and nutritional supplement category definitions are provided in the Figure. Service members were asked to estimate how frequently each supplement was used during the past 6 months (“never,” “once a month,” “once a week,” “2 to 6 times/week,” or “daily”) and to describe any AEs. AEs on the questionnaire were called “side effects” and a list of AEs was located alongside each dietary supplement and nutritional supplement. The AE list included symptoms related to cardiovascular, gastrointestinal, muscular, sleep disturbance, and neurologic symptoms. Specific symptoms listed on the questionnaire included “palpitations, racing heart,” “abdominal pain,” “nausea/vomiting,” “diarrhea,” “muscle cramps/pain/weakness,” “sleep disturbances/insomnia,” “dizziness/confusion/lightheadedness,” “tingling/numb in extremities,” “seizures/convulsions/tremors,” and “other.” If “other” was selected by the service member, a space was provided at the bottom of the page to explain the experienced AE.
      FigureDietary and nutritional supplement categories as defined in study of US Navy and Marine Corps Personnel.
      ClassificationCategoryDefinition
      Dietary supplementDietary supplementAny substance defined by the Dietary Supplement Health and Education Act.
      Multivitamin/multimineralDietary supplement containing two or more vitamins and/or two or more minerals with no additional supplement ingredients.
      Protein or amino acidAmino acid mixtures, protein powders, and similar products where the intent is to provide a single or complex protein source.
      Individual vitamin or mineralDietary supplement that is a single vitamin or mineral supplement, such as calcium or vitamin D.
      Herbal supplementDietary supplement that includes one or more herbal ingredients with no nutrient or other supplement ingredient. Also includes plant-derived ingredients.
      Purported prohormoneSteroidal hormone or herbal substitute for hormones that were marketed as a dietary supplement and included the Supplement Facts panel on the label.
      Combination productDietary supplement with mixtures of ingredients from any of the above categories including two or more categories and multiple ingredients.
      Joint health productSubstance that purports to improve the functioning of body joints, such as glucosamine (with or without chondroitin) or methylsulfonylmethane.
      Other dietary supplementOther dietary supplement that does not fit into the categories above.
      Nutritional supplementSport drinkLiquids designed for use before, during, or after physical activity often containing carbohydrates and electrolytes, such as Gatorade
      The Gatorade Company, Inc. PepsiCo.
      and Powerade
      The Coca-Cola Company.
      .
      Sport bar or gelSubstances designed to provide nutrients before, during, or after physical activity, such as PowerBar
      PowerBar Inc. Nestlé.
      , Tiger’s Milk
      Schiff Nutrition International (Reckitt Benckiser Group plc).
      (sport bar), PowerBar Gel
      PowerBar Inc. Nestlé.
      , and Sport Beans
      Jelly Belly Candy Company.
      .
      Meal-replacement beverageA drink intended as a substitute for a solid food meal, usually with controlled quantities of calories and nutrients, such as meal-replacement shakes.
      a The Gatorade Company, Inc. PepsiCo.
      b The Coca-Cola Company.
      c PowerBar Inc. Nestlé.
      d Schiff Nutrition International (Reckitt Benckiser Group plc).
      e Jelly Belly Candy Company.

      Data Analysis

      All statistical analysis was conducted using the Statistical Package for the Social Sciences (version 19.0.0, 2010, IBM Corp). Body mass index (BMI) was calculated from the questionnaire responses as weight/height2 (kg/m2). Weekly duration of aerobic and resistance training was calculated by multiplying weekly exercise frequency (sessions/week) by the duration of training (minutes/session). Prevalences (as a percent) were calculated with their standard error for each dietary supplement, nutritional supplement, and AE. χ2 Statistics were used to examine differences across various strata of demographics (sex, age, BMI, marital status); military characteristics (service, rank, occupation assignment, special operations status); and physical activity (weekly frequency of aerobic and resistance training). The amount of money spent on dietary supplements per month in the past 6 months was analyzed using a one-way analysis of variance across strata of demographic characteristics, military characteristics, and physical activity. Multivariate logistic regression examined associations between independent variables involving demographic characteristics, military characteristics, and physical activity and dependent variables that included any dietary supplement, any nutritional supplement, MVM, protein/AA, herbals, more than five dietary supplements, and spending >$50/mo on dietary supplements. Because some participants did not complete all questions, the number of subjects is shown for each variable.
      To address response bias, analyses were performed on the characteristics of service members who did (responders) and did not (nonresponders) complete the survey in the de-identified random-sample data obtained from DMDC. χ2 Analyses compared responders and nonresponders in terms of sex, rank, marital status, education level, occupational group, and military service; t tests were used to assess age differences.

      Results

      Of the random sample of 10,000 active-duty service members requested from DMDC, 328 were not contacted because they were enrolled in other Naval Health Research Center’s military survey studies.
      • Smith T.C.
      The US Department of Defense Millennium Cohort Study: Career span and beyond longitudinal follow-up.
      • Ryan M.A.
      • Smith T.C.
      • Smith B.
      • et al.
      Millennium cohort: Enrollment begins a 21-year contribution to understanding the impact of military service.
      Therefore, 9,672 (5,810 Marines and 3,862 Navy personnel) were initially contacted, 9,598 by postal letter, and 74 without valid postal addresses who were contacted by e-mail. Of the invited service members, 999 Marine Corps (17.2%) and 709 Navy (18.4%) completed the questionnaire (17.7% total response rate). Sixteen Marines and 9 Navy personnel reported service in the reserves and were not considered further. This resulted in a final sample of 983 Marine Corps and 700 Navy active-duty personnel who were included in the analyses.

      Dietary and Nutritional Supplement Use

      Table 1 provides prevalence and number of dietary supplements taken during the past 6 months for the Marine Corps and Navy personnel surveyed. Seventy-three percent reported using one or more dietary supplements one or more times per week. A larger proportion of women reported taking MVMs, individual vitamins and minerals, and other dietary supplements; a greater proportion of men reported taking protein/AA supplements, supplements purportedly containing prohormones, and joint health products. A smaller proportion of the youngest service members reported taking dietary supplements, especially MVMs and joint health products; the 25- to 29-year-olds reported the highest prevalence of proteins/AAs, while the 30- to 39-year-olds reported the greatest use of combination products. Although younger service members reported taking fewer dietary supplements overall, those who did use dietary supplements reported taking a great number of supplements (five or more dietary supplements one or more times per week). A higher proportion of service members with some college reported using dietary supplements of any type, including combination products, and herbal substances; those with college degrees were more likely to report use of MVMs, individual vitamins and minerals, joint heath products, and other dietary supplements. A greater number of concurrent dietary supplements were used by a greater proportion of those with some college or an associate’s degree. Compared with married service members, a larger proportion of single service members reported concurrently taking multiple supplements and consuming individual vitamins or minerals. Compared with those of other ranks, a smaller proportion of junior enlisted personnel (E1 to E4) reported using dietary supplements, especially MVMs and joint health products. Compared with officers, a greater proportion of enlisted service members and warrant officers reported using a greater number of supplements (more than five) and using more combination products. Senior enlisted and senior officers were more likely to use joint health products than junior enlisted and junior officers. There was no difference in reported prevalence of dietary supplement use by occupational assignment group. Compared with those with BMI <25, a larger proportion of those with BMI ≥25 reported concurrently consuming a greater number of dietary supplements, especially protein/AAs, combination products, herbals, and purported prohormones. Individuals performing more weekly aerobic exercise reported consuming a greater number of dietary supplements and were more likely to use proteins/AAs and other dietary supplements. For resistance training, there was a positive association (ie, more resistance training, higher use prevalence) with many dietary supplements; service members reporting more weekly resistance training consumed a greater number of dietary supplements and used more dietary supplements overall, especially MVMs, proteins/AAs, combination products, purported prohormones, and other dietary supplements. Special Operations personnel were generally greater users of dietary supplements than all other service members; however, this could not be supported statistically, likely due to the small sample size of Special Operations personnel (2.5% of the study population). Compared with Navy personnel, a greater proportion of Marine Corps personnel reported use of protein/AA supplements, combination products, and purported prohormones. Compared with Navy personnel, Marines reported more (mean±standard deviation) aerobic (265±280 min/wk vs 224±261 min/wk; P<0.01) and resistance training (249±296 min/wk vs 187±285 min/wk; P<0.01) activity.
      Table 1Prevalence of reported dietary supplements by demographic and lifestyle characteristics of Navy and Marine Corps personnel
      VariableStrataDietary Supplements Taken 1 or More Times per Week
      Any dietary supplementNo. of Dietary SupplementsDietary Supplement
      1 to 23 to 4≥5MVM
      MVM=multivitamin/multimineral.
      Individual vitamin or mineralProtein or AA
      AA=amino acid.
      Combination productHerbalPurported prohormoneJoint health productOther
      %±standard error
      GroupAll (n=1,683)72.7±1.127.7±1.113.9±0.831.1±1.148.0±1.229.0±1.133.6±1.233.0±1.115.3±0.93.8±0.58.0±0.727.2±1.1
      SexMale (n=1,198)71.5±1.327.5±1.313.4±1.030.6±1.345.3±1.424.1±1.237.4±1.434.2±1.414.4±1.04.8±0.68.9±0.825.8±1.3
      Female (n=485)75.9±2.028.5±1.315.3±1.032.2±1.454.6±2.241.0±2.224.3±1.929.9±2.117.3±1.71.2±0.55.8±1.130.5±2.1
      P value
      From χ2 analysis.
      0.070.29<0.01<0.01<0.010.090.14<0.010.030.05
      %±standard error
      Age18 to 24 y (n=443)66.8±2.221.9±2.010.8±1.534.1±2.341.1±2.328.2±2.136.8±2.333.6±2.214.7±1.73.8±0.93.6±0.923.7±2.0
      25 to 29 y (n=407)74.7±2.229.0±2.214.7±1.831.0±2.348.6±2.526.8±2.239.1±2.432.9±2.315.0±1.72.7±0.87.1±1.327.3±2.2
      30 to 39 y (n=552)75.9±1.830.3±2.315.0±1.830.6±2.352.7±2.128.4±1.932.1±2.036.4±2.014.5±1.53.8±0.89.2±1.229.2±1.9
      ≥40 y (n=280)73.2±2.630.4±2.715.4±2.227.5±2.748.9±3.034.6±2.823.9±2.525.4±2.618.2±2.35.4±1.413.9±2.128.6±2.7
      P value
      From χ2 analysis.
      0.01<0.01<0.010.14<0.010.020.520.36<0.010.25
      %±standard error
      EducationSome HS
      HS=high school.
      /HS graduate (n=393)
      61.1±2.520.4±2.012.5±1.728.2±2.337.9±2.423.7±2.133.6±2.431.8±2.313.0±1.73.8±1.05.1±1.121.9±2.1
      Some college/associates degree (n=729)77.4±1.528.1±1.714.0±1.335.3±1.850.5±1.929.8±1.735.0±1.837.6±1.817.8±1.44.3±0.88.4±1.027.3±1.7
      Bachelors/graduate degree (n=561)74.9±1.932.4±2.014.8±1.527.6±1.951.9±2.131.7±2.031.9±2.027.8±1.913.5±1.43.2±0.79.6±1.230.7±1.9
      P value
      From χ2 analysis.
      <0.01<0.01<0.010.020.51<0.010.040.620.040.01
      %±standard error
      Marital statusSingle (n=570)70.4±1.922.1±1.714.7±1.533.5±2.047.9±2.132.8±2.036.7±2.034.9±2.014.7±1.52.8±0.76.5±1.026.7±1.9
      Married (n=1,113)73.9±1.330.6±1.413.5±1.029.8±1.448.1±1.527.0±1.332.1±1.432.0±1.415.5±1.14.3±0.68.8±0.827.4±1.3
      P value
      From χ2 analysis.
      0.12<0.010.950.010.060.230.660.130.100.75
      %±standard error
      RankJunior Enlisted (n=442)66.5±2.224.2±2.010.4±1.531.9±2.241.2±2.329.9±2.235.3±2.332.1±2.212.7±1.63.8±0.93.4±0.923.1±2.0
      Senior enlisted (n=786)75.6±1.528.0±1.614.8±1.332.8±1.749.0±1.827.4±1.634.5±1.737.7±1.717.7±1.44.8±0.89.9±1.127.2±1.6
      Warrant Officer (n=38)73.7±7.123.7±6.97.9±4.442.1±8.063.2±7.839.5±7.928.9±7.444.7±8.110.5±5.02.6±2.67.9±4.426.3±7.1
      Junior Officer (n=235)75.3±2.833.2±3.115.7±2.426.4±2.952.8±3.326.8±2.934.0±3.127.2±2.912.8±2.21.3±0.76.8±1.630.6±3.0
      Senior Officer (n=182)72.0±3.329.1±3.417.6±2.825.3±3.251.1±3.734.6±3.526.4±3.319.8±3.015.4±2.72.7±1.212.6±2.532.4±3.5
      P value
      From χ2 analysis.
      0.01<0.01<0.010.160.24<0.010.110.13<0.010.10
      %±standard error
      Occupational assignment groupCombat arms (n=483)72.7±2.026.7±2.014.3±1.631.7±2.148.2±2.327.5±2.035.6±2.233.5±2.114.1±1.63.5±0.89.7±1.329.8±2.1
      Combat support (n=479)74.1±2.027.6±2.015.7±1.730.9±2.146.1±2.329.4±2.135.5±2.234.0±2.218.0±1.83.5±0.87.7±1.226.9±2.0
      Combat service support (n=656)71.5±1.827.9±1.812.2±1.331.4±1.848.3±2.030.3±1.831.1±1.832.3±1.814.5±1.44.4±0.87.0±1.025.0±1.7
      P value
      From χ2 analysis.
      0.620.760.730.590.180.820.180.660.240.31
      %±standard error
      Body mass index
      Calculated as kg/m2.
      <25 (n=659)70.0±1.829.1±1.814.1±1.426.7±1.746.3±1.929.7±1.828.7±1.826.4±1.712.9±1.31.1±0.46.2±0.925.6±1.7
      25 to 29.9 (n=844)73.9±1.527.5±1.514.1±1.232.3±1.648.1±1.728.0±1.537.2±1.736.6±1.715.2±1.25.7±0.89.5±1.027.3±1.5
      ≥30.0 (n=163)77.3±3.324.5±3.412.9±2.639.9±3.854.0±3.930.1±3.633.7±3.741.7±3.924.5±3.44.9±1.78.0±2.131.3±3.6
      P value
      From χ2 analysis.
      0.090.040.210.71<0.01<0.01<0.01<0.010.070.34
      %±standard error
      Aerobic exercise duration0 to 100 min/wk (n=414)71.0±2.227.5±2.215.2±1.828.3±2.247.8±2.529.5±2.230.4±2.332.1±2.313.3±1.72.9±0.86.5±1.224.4±2.1
      101 to 180 min/wk (n=384)70.8±2.329.9±2.315.1±1.825.8±2.246.4±2.527.1±2.327.1±2.328.9±2.313.5±1.73.6±1.07.6±1.423.4±2.2
      181 to 290 min/wk (n=462)74.9±2.029.4±2.112.6±1.532.9±2.247.6±2.328.1±2.136.4±2.234.0±2.216.7±1.74.3±0.98.0±1.330.7±2.1
      ≥291 min/wk (n=409)74.6±2.223.5±2.113.4±1.737.7±2.450.6±2.532.3±2.340.3±2.437.4±2.417.4±1.94.4±1.010.3±1.530.1±2.3
      P value
      From χ2 analysis.
      0.38<0.010.670.40<0.010.080.240.640.250.03
      %±standard error
      Resistance training duration0 to 45 min/wk (n=402)65.4±2.436.6±2.411.9±1.616.9±1.941.5±2.525.4±2.212.9±1.719.7±2.013.9±1.71.2±0.56.2±1.220.9±2.0
      46 to 135 min/wk (n=470)70.4±2.129.8±2.114.7±1.626.0±2.047.7±2.330.2±2.123.8±2.026.8±2.015.7±1.71.3±0.57.2±1.226.2±2.0
      136 to 270 min/wk (n=395)79.2±2.024.8±2.217.0±1.937.5±2.452.7±2.533.2±2.444.1±2.539.7±2.518.0±1.95.8±1.210.4±1.530.6±2.3
      ≥271 min/wk (n=389)78.7±2.119.0±2.012.9±1.746.8±2.551.4±2.528.8±2.357.3±2.549.1±2.513.9±1.87.7±1.49.0+1.532.1±1.4
      P value
      From χ2 analysis.
      <0.01<0.01<0.010.11<0.01<0.010.33<0.010.14<0.01
      %±standard error
      Special OperationsNo (n=1,632)72.7±1.127.8±1.113.9±0.930.9±1.147.7±1.229.0±1.133.5±1.233.1±1.215.1±0.93.8±0.57.8±0.726.5±1.1
      Yes (n=41)80.5±6.229.3±7.112.2±5.139.0±7.658.5±7.734.1±7.446.3±7.831.7±7.317.1±5.94.9±3.414.6±5.548.8±7.8
      P value
      From χ2 analysis.
      0.270.600.170.470.090.850.730.720.11<0.01
      %±standard error
      ServiceNavy (n=700)70.7±1.728.6±1.713.3±1.328.9±1.748.6±1.929.6±1.730.3±1.729.9±1.715.4±1.42.7±0.68.3±1.028.6±1.7
      Marine Corps (n=983)74.2±1.427.2±1.414.3±1.132.7±1.547.6±1.628.6±1.436.0±1.535.2±1.515.2±1.14.6±0.77.8±0.926.1±1.4
      P value
      From χ2 analysis.
      0.120.230.700.660.010.020.880.050.740.27
      a MVM=multivitamin/multimineral.
      b AA=amino acid.
      c From χ2 analysis.
      d HS=high school.
      e Calculated as kg/m2.
      Table 2 provides the prevalence of nutritional supplements consumed during the past 6 months by Navy and Marine Corps personnel. Fifty-three percent reported using one or more nutritional supplements one or more times per week. Compared with women, a larger proportion of men used nutritional supplements, especially sport drinks; a larger proportion of women reported using meal-replacement beverages. A larger proportion of younger service members consumed sport drinks. A larger proportion of those with higher educational levels were likely to consume sport bars/gels, but less likely to use sport drinks. Marital status had little association with dietary supplement use. Compared with officers, a greater proportion of enlisted personnel and warrant officers used sport drinks, but were generally less likely to use sport bars/gels. A greater proportion of combat arms personnel used nutritional supplements, especially sport drinks and sport bars/gels, and sport bars/gels consumption was similar among the combat arms and combat support personnel. BMI had little association with nutritional supplement use. Higher levels of weekly aerobic or resistance training were generally associated with increasing sport drinks and sport bars/gels consumption. A greater proportion of Special Operations personnel and Marines reported using nutritional supplements. More Special Operations personnel reported using sport bars/gels and a greater proportion of Marine Corps personnel reporting consuming sport drinks.
      Table 2Prevalence of reported nutritional supplements and dollars spent on dietary supplements by demographic and lifestyle characteristics of Navy and Marine Corps personnel
      VariableStrataNutritional Supplements Taken 1 or More Times per WeekMoney spent on DS
      DS=dietary supplement.
      in last 6 months, $±SD
      SD=standard deviation.
      ≥$50 Spent on DSs in last 6 months, %±SE
      SE=standard error.
      Any NS
      NS=nutritional supplement.
      Any sport drinkAny sport bar or gelAny meal-replacement

      beverage
      %±SE
      GroupAll (n=1,683)53.1±1.244.5±1.222.8±1.06.8±0.639±230.8±1.1
      SexMale (n=1,198)55.8±1.447.8±1.423.9±1.25.8±0.742±232.8±1.4
      Female (n=485)46.4±2.336.3±2.220.0±1.89.3±1.332±325.5±2.0
      P value
      From χ2 analyses.
      <0.01<0.010.090.010.010.01
      %±SE
      Age18 to 24 y (n=443)57.1±2.451.5±2.419.2±1.95.2±1.142±334.7±2.3
      25 to 29 y (n=407)51.8±2.543.7±2.522.9±2.16.6±1.237±330.7±2.3
      30 to 39 y (n=552)52.7±2.142.6±2.124.5±1.87.6±1.142±330.8±2.0
      ≥40 y (n=280)49.6±3.038.9±2.925.0±2.68.2±1.632±325.1±2.6
      P value
      From χ2 analyses.
      0.21<0.010.180.350.150.17
      %±SE
      EducationSome HS
      HS=high school.
      /HS graduate (n=393)
      54.7±2.549.6±2.515.8±1.84.6±1.149±436.3±2.4
      Some college/associates degree (n=729)53.2±1.845.3±1.820.4±1.58.0±1.040±233.1±1.7
      Bachelors/graduate degree(n=561)51.9±2.139.9±2.130.7±1.97.0±1.131±224.5±1.8
      P value
      From χ2 analyses.
      0.690.01<0.010.10<0.01<0.01
      %±SE
      Marital StatusSingle (n=570)53.2±2.145.6±2.123.9±1.87.2±1.142±333.9±2.0
      Married (n=1,113)52.9±1.543.9±1.522.2±1.26.6±0.738±229.2±1.4
      P value
      From χ2 analyses.
      0.820.510.440.680.260.10
      %±SE
      RankJunior Enlisted (n=442)55.2±2.449.5±2.417.6±1.85.4±1.141±333.6±2.2
      Senior Enlisted (n=786)52.7±1.844.5±1.820.9±1.57.5±0.944±334.3±1.7
      Warrant Officer (n=38)55.3±8.144.7±8.128.9±7.47.9±4.432±827.6±7.3
      Junior Officer (n=235)50.6±3.339.6±3.232.8±3.15.1±1.426±321.6±2.7
      Senior Officer (n=182)52.7±3.738.5±3.629.1±3.49.3±2.232±423.0±3.1
      P value
      From χ2 analyses.
      0.830.05<0.010.30<0.01<0.01
      %±SE
      Occupational

      assignment group
      Combat arms (n=483)59.4±2.252.6±2.325.9±2.07.5±1.238±331.6±2.1
      Combat support (n=479)53.0±2.342.2±2.324.6±2.06.7±1.139±329.6±2.1
      Combat service support (n=656)50.0±2.041.9±1.920.0±1.66.7±1.040±330.9±1.8
      P value
      From χ2 analyses.
      <0.01<0.010.040.860.770.86
      %±SE
      Body mass index
      Calculated as kg/m2.
      <25 (n=659)51.1±1.944.2±1.921.4±1.65.2±0.928±224.7±1.7
      25 to 29.9 (n=844)54.3±1.744.9±1.724.3±1.57.7±0.945±333.9±1.6
      ≥30.0 (n=163)55.2±3.945.4±3.920.2±3.18.6±2.248±537.4±3.8
      P value
      From χ2 analyses.
      0.410.940.300.10<0.01<0.01
      %±SE
      Aerobic exercise duration0 to 100 min/wk (n=414)47.8±2.541.1±2.416.7±1.87.0±1.336±425.5±2.1
      101 to 180 min/wk (n=384)50.3±2.640.9±2.520.3±2.14.9±1.132±325.4±2.2
      181 to 290 min/wk (n=462)56.5±2.347.6±2.327.7±2.17.6±1.240±332.6±2.2
      ≥291 min/wk (n=409)58.4±2.448.9±2.526.2±2.27.8±1.347±338.9±2.4
      P value
      From χ2 analyses.
      <0.010.03<0.010.370.01<0.01
      %±SE
      Resistance training duration0 to 45 min/wk (n=402)45.0±2.536.3±2.416.4±1.86.7±1.220±212.1. ±1.6
      46 to 135 min/wk (n=470)54.3±2.346.4±2.323.8±2.06.0±1.129±223.7±2.0
      136 to 270 min/wk (n=395)56.2±2.546.8±2.527.6±2.28.9±1.444±338.7±2.5
      ≥271 min/wk (n=389)59.1±2.550.1±2.524.2±2.26.4±1.266±551.0±2.5
      P value
      From χ2 analyses.
      <0.01<0.01<0.010.37<0.01<0.01
      %±SE
      Special OperationsNo (n=1,632)52.5±1.244.2±1.222.4±1.06.8±0.639±230.3±1.1
      Yes (n=41)75.6±5.756.1±7.843.9±7.87.3±4.154±1050.0±7.8
      P value
      From χ2 analyses.
      <0.010.13<0.010.900.130.02
      %±SE
      ServiceNavy (n=700)47.7±1.936.1±1.823.3±1.67.4±1.035±227.2±1.7
      Marine Corps (n=983)57.0±1.650.5±1.622.4±1.36.4±0.842±233.3±1.5
      P value
      <0.01<0.010.660.410.040.03
      a NS=nutritional supplement.
      b DS=dietary supplement.
      c SD=standard deviation.
      d SE=standard error.
      e From χ2 analyses.
      f HS=high school.
      g Calculated as kg/m2.
      Table 2 also reports the total dollars spent on dietary supplements during the past 6 months, and the proportion of the population spending ≥$50 on dietary supplements each month by demographic, military, and physical activity characteristics. Those spending more dollars on dietary supplements each month included men, those of lower education level, enlisted service members (compared with officers), those with higher BMI, those performing more aerobic or resistance exercise, and Marines. These same groups had a greater proportion of individuals spending >$50/mo; Special Operations personnel were also more likely to spend >$50/mo.
      Table 3 shows the results of the multivariate logistic regression examining factors associated with dietary supplement use. Factors independently associated with use of any dietary supplement, use of five or more dietary supplements, and MVMs included female sex, higher educational level, higher BMI, and longer weekly duration of resistance training. Protein/AA use was independently associated with male sex, higher educational level, BMI of 25.0 to 29.9, and longer weekly resistance training. Combination product use was independently associated with higher BMI and more weekly resistance training. Herbal supplement use was independently associated with female sex and higher BMI. Factors independently associated with spending ≥$50/mo on dietary supplements included higher BMI and more weekly resistance training. Nutritional supplement use was associated with male sex, longer weekly duration of aerobic and resistance training and Marine Corps affiliation.
      Table 3Factors associated with dietary and nutritional supplement use among Navy and Marine Corps personnel
      Multivariate logistic regression.
      VariableStrataDietary Supplements Taken 1 or More Times per WeekAny NS
      NS=nutritional supplement.
      taken 1 or more times per week
      Any DS
      DS=dietary supplement.
      Use of ≥5 DSsMVM
      MVM=multivitamin/multimineral.
      Protein or AA
      AA=amino acid.
      Combination productsHerbal≥$50 Spent on DSs per month
      odds ratio (95% CI)
      SexMale1.001.001.001.001.001.001.001.00
      Female1.76 (1.32-2.36)1.37 (1.04-1.81)1.85 (1.44-2.39)0.62 (0.46-0.83)1.12 (0.85-1.48)1.56 (1.11-2.18)0.91 (0.64-1.30)0.68 (0.53-0.87)
      Age18 to 24 y1.001.001.001.001.001.001.001.00
      25 to 29 y1.18 (0.84-1.67)0.83 (0.59-1.15)1.25 (0.92-1.70)0.93 (0.66-1.30)0.97 (0.69-1.34)0.99 (0.66-1.51)1.00 (0.67-1.51)0.74 (0.54-1.00)
      30 to 39 y1.36 (0.95-1.96)0.95 (0.68-1.34)1.58 (1.15-2.17)0.86 (0.60-1.22)1.45 (1.03-2.04)0.91 (0.59-1.40)1.28 (0.83-1.96)0.78 (0.57-1.07)
      ≥40 y1.30 (0.84-2.02)0.89 (0.58-1.37)1.43 (0.97-2.12)0.56 (0.35-0.87)0.89 (0.58-1.38)1.28 (0.77-2.14)1.08 (0.63-1.85)0.67 (0.54-1.00)
      EducationSome HS
      HS=high school.
      /HS graduate
      1.001.001.001.001.001.001.001.00
      Some college2.27 (1.68-3.06)1.81 (1.33-2.45)1.59 (1.21-2.10)1.44 (1.06-1.97)1.48 (1.10-1.99)1.47 (1.00-2.17)1.10 (0.76-1.59)1.16 (0.88-1.53)
      College degree2.23 (1.62-3.30)1.49 (1.03-2.14)1.77 (1.28-2.45)1.66 (1.16-2.40)1.10 (0.77-1.57)1.11 (0.70-1.76)0.84 (0.54-1.31)1.16 (0.84-1.61)
      Marital statusSingle1.001.001.001.001.001.001.001.00
      Married1.14 (0.87-1.49)0.94 (0.73-1.22)0.98 (0.77-1.25)0.90 (0.69-1.17)0.83 (0.64-1.07)1.09 (0.78-1.51)0.73 (0.53-1.00)0.95 (0.75-1.21)
      Occupational assignment groupCombat arms1.001.001.001.001.001.001.001.00
      Combat support1.11 (0.81-1.51)0.87 (0.65-1.17)0.90 (0.69-1.18)0.98 (0.73-1.33)0.97 (0.72-1.30)1.26 (0.87-1.81)0.86 (0.60-1.23)0.76 (0.58-1.00)
      Combat service support0.90 (0.68-1.19)0.92 (0.70-1.21)0.92 (0.77-1.18)0.87 (0.65-1.15)0.93 (0.70-1.22)0.99 (0.69-1.41)0.96 (0.69-1.35)0.70 (0.54-0.90)
      Body mass index
      Calculated as kg/m2.
      <25.01.001.001.001.001.001.001.001.00
      25.0 to 29.91.26 (0.98-1.63)1.48 (1.15-1.91)1.19 (0.95-1.49)1.46 (1.13-1.89)1.70 (1.32-2.19)1.32 (0.96-1.82)1.67 (1.21-2.31)1.08 (0.86-1.36)
      ≥30.01.67 (1.06-2.63)2.27 (1.50-3.45)1.52 (1.03-2.25)1.37 (0.88-2.13)2.44 (1.61-3.69)2.24 (1.37-3.67)2.17 (1.31-3.59)1.21 (0.82-1.79)
      Aerobic exercise duration0 to 100 min/wk1.001.001.001.001.001.001.001.00
      101 to 180 min/wk0.83 (0.60-1.16)0.78 (0.55-1.10)0.80 (0.59-1.08)0.74 (0.52-1.06)0.80 (0.57-1.11)0.95 (0.62-1.45)0.86 (0.56-1.31)1.12 (0.83-1.51)
      181 to 290 min/wk0.98 (0.70-1.37)0.92 (0.67-1.28)0.81 (0.60-1.09)0.93 (0.66-1.30)0.80 (0.58-1.10)1.08 (0.71-1.62)1.03 (0.69-1.55)1.35 (1.01-1.82)
      ≥291 min/wk0.83 (0.58-1.19)0.89 (0.63-1.25)0.87 (0.64-1.19)0.75 (0.53-1.06)0.72 (0.51-1.01)1.30 (0.85-1.99)1.02 (0.67-1.55)1.45 (1.06-1.98)
      Resistance training duration0 to 45 min/wk1.001.001.001.001.001.001.001.00
      46 to 135 min/wk1.27 (0.94-1.74)1.78 (1.25-2.53)1.34 (1.00-1.79)2.16 (1.48-3.16)1.63 (1.16-2.29)1.18 (0.79-1.76)2.25 (1.42-3.56)1.38 (1.04-1.83)
      136 to 270 min/wk2.37 (1.65-3.40)3.17 (2.19-4.59)1.92 (1.40-2.65)5.16 (3.49-7.62)3.20 (2.23-4.59)1.49 (0.97-2.28)4.30 (2.68-6.91)1.35 (0.99-1.86)
      ≥271 min/wk2.85 (1.94-4.17)4.90 (3.35-7.17)2.12 (1.51-2.96)9.15 (6.10-13.73)4.74 (3.26-6.88)0.92 (0.57-1.48)6.63 (4.08-10.77)1.42 (1.02-1.98)
      ServiceMarine Corps1.001.001.001.001.001.001.001.00
      Navy0.78 (0.61-1.00)0.95 (0.75-1.21)0.97 (0.78-1.20)0.93 (0.72-1.19)0.85 (0.67-1.08)0.96 (0.71-1.30)0.85 (0.63-1.15)0.71 (0.57-0.88)
      a Multivariate logistic regression.
      b DS=dietary supplement.
      c MVM=multivitamin/multimineral.
      d AA=amino acid.
      e NS=nutritional supplement.
      f HS=high school.
      g Calculated as kg/m2.

      Adverse Events

      Table 4 shows the prevalence of AEs reported by service members. The prevalence in Table 4 is the proportion of the population consuming the listed product who reported experiencing the AE. The proportion of service members reporting one or more AEs (%±standard error) was 22.1%±1.2% for dietary supplements and 5.6%±0.8% for nutritional supplements (data not shown in Table 4). In rank order, the supplement types eliciting the most to least percentage of AEs were combination products, purported prohormones, herbals, meal-replacement drinks, and MVMs. If combination products were excluded, 13.0%±1.0% of the users of other dietary supplements reported one or more AEs. The proportion of service members reporting AEs with specific combination products was 64% (AE n=16/user n=25) for OxyElite Pro (USP Labs), 43% (AE n=6/user n=14) for Roxylean (BPI Sports), 42% (AE n=18/user n=43) for NO-Xplode (Bioengineered Supplements), 40% (AE n=22/user n=55) for Hydroxycut Hardcore (Inovate Health Science International), 40% (AE=8/user n=20) for Hydroxycut Advanced (Inovate Health Science International), 38% (AE n=3/user n=8) for D4 Thermal (Cellucor), and 35% (AE=45/user n=128) for C4 Extreme (Cellucor). There was little difference between Marine Corps and Navy personnel in the incidence of overall AEs for dietary supplements (P=0.36) or nutritional supplements (P=0.69).
      Table 4Prevalence of adverse events reported by Navy and Marine Corps personnel
      CategoryAdverse EventsIndividuals reporting 1 or more adverse events
      PalpitationsAbdominal painNausea, vomitingDiarrheaMuscle cramps pain or weaknessSleep problems, insomniaDizzy, confused, lightheadedTingling, numbnessSeizure, convulsion, tremorOther
      Dietary supplement%±standard error (n)
      MVM
      MVM=multivitamin/multimineral.
      (n=808)
      0.7±0.3 (6)1.0±0.4 (8)3.2±0.6 (26)1.5±0.4 (12)0.5±0.2 (4)0.6±0.3 (5)0.5±0.2 (4)0.4±0.2 (3)0.0±0.0 (0)3.2±0.6 (26)8.4±1.0 (68)
      Individual vitamin/mineral (n=488)0.8±0.4 (4)0.6±0.3 (3)1.2±0.5 (6)0.6±0.3 (3)0.0±0.0 (0)0.4±0.3 (2)0.4±0.3 (2)0.6±0.3 (3)0.2±0.2 (1)2.5±0.7 (12)5.3±1.0 (26)
      Protein or amino acid (n=566)0.7±0.4 (4)0.9±0.4 (5)0.9±0.4 (5)1.8±0.6 (10)0.2±0.2 (1)0.5±0.3 (3)0.2±0.2 (1)0.2±0.2 (1)0.2±0.2 (1)3.2±0.7 (18)7.4±1.1 (42)
      Combination products (n=555)15.9±1.6 (88)3.2±0.7 (18)2.9±0.7 (16)4.5±0.9 (25)2.2±0.6 (12)5.8±1.0 (32)4.7±0.9 (26)9.9±1.3 (55)0.9±0.4 (5)5.8±1.0 (32)28.8±1.9 (160)
      Herbal (n=257)2.3±0.9 (6)2.3±0.6 (6)0.8±0.4 (2)0.4±0.3 (1)0.8±0.4 (2)1.2±0.5 (3)1.2±0.5 (3)0.8±0.4 (2)0.4±0.3 (1)5.1±0.9 (13)8.9±1.9 (23)
      Purported prohormone (n=64)1.6±1.6 (1)0.0±00 (0)0.0±0.0 (0)1.6±1.6 (1)1.6±1.6 (1)1.6±1.6 (1)1.6±1.6 (1)3.1±2.2 (2)0.0±0.0 (0)6.3±3.0 (4)9.4±3.6 (6)
      Joint health product (n=135)0.0±0.0 (0)1.5±1.0 (2)0.7±0.7 (1)0.7±0.7 (1)0.7±0.7 (1)0.7±0.7 (1)0.0±0.0 (0)0.0±0.0 (0)0.0±0.0 (0)2.2±1.3 (3)5.9±2.0 (8)
      Other (n=457)0.0±0.0 (0)0.7±0.4 (3)0.4±0.3 (2)0.7±0.4 (3)0.2±0.2 (1)0.9±0.4 (4)0.2±0.2 (1)0.0±0.0 (0)0.0±0.0 (0)1.8±0.6 (8)4.6±1.0 (21)
      Nutritional supplement
      Sport drink (n=749)0.4±0.2 (3)0.4±0.2 (3)0.4±0.2 (3)0.7±0.3 (5)0.4±0.2 (3)0.4±0.2 (3)0.3±0.2 (2)0.1±0.1 (1)0.0±0.0 (0)1.9±0.5 (14)3.7±0.7 (28)
      Sport bar/gel (n=383)0.0±0.0 (0)0.8±0.5 (3)0.3±0.3 (1)1.0±0.5 (4)0.3±0.3 (1)0.0±0.0 (0)0.3±0.3 (1)0.0±0.0 (0)0.0±0.0 (0)1.6±0.6 (6)3.1±0.9 (12)
      Meal-replacement drinks (n=115)0.0±0.0 (0)0.9±0.9 (1)2.6±1.5 (3)1.7±1.2 (2)1.7±1.2 (2)0.9±0.9 (1)0.0±0.0 (0)0.0±0.0 (0)0.0±0.0 (0)4.3±1.9 (5)8.7±2.6 (10)
      a MVM=multivitamin/multimineral.

      Survey Responders and Nonresponders

      Survey responders were older (31±8 vs 27±7 years; P<0.01), and more likely to be women (21% vs 17%; P<0.01), married (22% vs 13%; P<0.01), and had some college or higher education (28% vs 15%; P<0.01). Officers and warrant officers were more likely to complete the survey than enlisted personnel (31% vs 15%; P<0.01), although senior enlisted were more likely than junior enlisted to respond (20% vs 11%; P<0.01). Of 10 occupational groups, those more likely to respond were medical/health care (27%), support and administration (21%), electrical repair (21%), and infantry (20%). There was little difference in the proportion of responders between Navy and Marine Corps personnel (18% vs 17%; P=0.16).

      Discussion

      The prevalence of dietary supplement use in Marine Corps and Navy personnel was high, with 73% using at least one dietary supplement one or more times per week and 31% using five or more dietary supplements one or more times per week. Factors independently associated with use of any dietary supplement and use of five or more dietary supplements per week included female sex, higher educational level, higher BMI, and greater weekly duration of resistance training. When individual types of supplements were examined, men were more likely than women to use protein/AAs and nutritional supplements, and women were more likely to use MVM and herbal products. MVM and protein/AA use was greater among those with higher educational level, higher BMI, and greater weekly duration of resistance training. At least one AE was reported in association with dietary supplement use in 22% of the service members, with the largest number reported by combination product users. Only 6% of nutritional supplement users reported AEs.

      Prevalence and Types of Dietary Supplement Use

      Dietary supplement use by the service members in this investigation demonstrated a different pattern of use compared with that of the general US population, as reported in the National Health and Nutrition Surveys (NHANES). In making comparisons, it is important to keep in mind that the NHANES sample was older and the reporting timeframe differed: the NHANES survey asked participants about any use in the last month, and the current study examined use one or more times per week in the past 6 months. In the NHANES data, overall dietary supplement use prevalences of 23%, 24%, 34%, 49%, and 48% were reported in the surveys conducted in 1987, 1992, 2000, 2003 to 2006, and 2007 to 2008, respectively.
      • Kennedy E.T.
      • Luo H.
      • Houser R.F.
      Dietary supplement use pattern of US adult population in the 2007-2008 National Health and Nutrition Survey (NHANES).
      • Millen A.E.
      • Dodd K.W.
      • Subar A.F.
      Use of vitamin, mineral nonvitamin and nonmineral supplements in the United States: The 1987, 1992 and 2000 National Health Interview Survey results.
      • Bailey R.L.
      • Gahche J.J.
      • Lentino C.V.
      • et al.
      Dietary supplement use in the United States, 2003-2006.
      For MVMs, prevalences during similar periods were 17%, 19%, 28%, 33%, and 32%, respectively.
      • Millen A.E.
      • Dodd K.W.
      • Subar A.F.
      Use of vitamin, mineral nonvitamin and nonmineral supplements in the United States: The 1987, 1992 and 2000 National Health Interview Survey results.
      • Bailey R.L.
      • Gahche J.J.
      • Lentino C.V.
      • et al.
      Dietary supplement use in the United States, 2003-2006.
      • Nicastro H.L.
      • Bailey R.L.
      • Dodd K.W.
      Using two assessment methods may better describe dietary supplement use in the United States.
      Even the most recent NHANES prevalences were considerably lower than those found in the current study, which were 73% for any dietary supplement and 48% for MVMs. The 2003 to 2006 NHANES data also indicated that only 4% of the general population used AA supplements and 14% used herbals in the last month
      • Bailey R.L.
      • Gahche J.J.
      • Lentino C.V.
      • et al.
      Dietary supplement use in the United States, 2003-2006.
      compared with 34% and 15% of service members, respectively, who reported using them in the current study. Thus, compared with national samples, service members in the present study had a much higher use of dietary supplements, especially MVMs and proteins/AAs, but similar use of herbal substances.
      The current study found similarities and differences with data collected from other military services. A systematic review and meta-analysis of dietary supplement use in the military showed that the Army personnel had the lowest overall use of dietary supplements with 55% of men and 65% of women reporting use, and other military services had higher use of about 60% for men and 73% for women.
      • Knapik J.J.
      • Steelman R.
      • Hoedebecke S.
      • et al.
      A systematic review and meta-analysis on the prevalence of dietary supplement use by military personnel.
      Much of these data were collected more than 10 years ago. More recently, overall use rates of any dietary supplement in the Air Force

      Austin KG, Price LL, McGraw SM, et al. Demographic, lifestyle factors and reasons for use of dietary supplements by Air Force personnel. Aerosp Med Hum Perf. In press.

      and Coast Guard
      • Austin K.G.
      • Price L.L.
      • McGraw S.M.
      • et al.
      Predictors of dietary supplement use by US Coast Guard personnel.
      were shown to be 68% and 70%, which is slightly lower but similar to the 73% reported here. In comparing other categories of dietary supplements, the Air Force and Coast Guard data are very similar for the use prevalence of MVMs (approximately 47%), proteins/AAs (approximately 33%), and other dietary supplements (approximately 25%), but the service members in the current study used more individual vitamins/minerals (29% vs 22%), herbal substances (15% vs 8%), and purported prohormones (4% vs 1%).
      The only previous study of Navy and Marine Corps personnel was conducted in 2005 as part of the Department of Defense Survey of Health Related Behaviors,
      • Bray R.M.
      • Hourani L.L.
      • Olmsted K.L.R.
      • et al.
      2005 Department of Defense Survey of Health Related Behaviors among Active Duty Military Personnel. A Component of the Defense Lifestyle Assessment Program (DLAP).
      which, like the current study, employed a random sample of service members. Table 5 shows a comparison of this Department of Defense study
      • Bray R.M.
      • Hourani L.L.
      • Olmsted K.L.R.
      • et al.
      2005 Department of Defense Survey of Health Related Behaviors among Active Duty Military Personnel. A Component of the Defense Lifestyle Assessment Program (DLAP).
      with that of the current investigation. Caution must be exercised in interpretation because of differences in questionnaire structures, definition of DS categories, and the fact that the Department of Defense study reported weighted prevalence rates while the current study does not involve a weighted sample. The prevalence of any dietary supplement use was ≥10% higher in the current study compared with that of Bray and colleagues,
      • Bray R.M.
      • Hourani L.L.
      • Olmsted K.L.R.
      • et al.
      2005 Department of Defense Survey of Health Related Behaviors among Active Duty Military Personnel. A Component of the Defense Lifestyle Assessment Program (DLAP).
      and dietary supplement use was higher in all comparable categories, with the exception of joint health products. Temporal trends indicating increasing use of dietary supplements over time have been observed in civilian studies, as noted here.
      • Radimer K.
      • Bindewald B.
      • Hughes J.
      • et al.
      Dietary supplement use by US adults: Data from the National Health and Nutrition Examination Survey, 1999-2000.
      • Millen A.E.
      • Dodd K.W.
      • Subar A.F.
      Use of vitamin, mineral nonvitamin and nonmineral supplements in the United States: The 1987, 1992 and 2000 National Health Interview Survey results.
      • Bailey R.L.
      • Gahche J.J.
      • Lentino C.V.
      • et al.
      Dietary supplement use in the United States, 2003-2006.
      Cassler and colleagues
      • Cassler N.M.
      • Sams R.
      • Cripe P.A.
      • et al.
      Patterns and perceptions of supplement use by US Marines deployed to Afghanistan.
      collected data in 2011 among a convenience sample of deployed Marines and found that 72% of men (n=310) and 42% of women (n=19) reported using dietary supplements in the last 30 days.
      Table 5Comparison of dietary supplement prevalence in Navy and Marine Corps personnel in current study with that of Department of Defense study of health-related behaviors
      The Bray27 study differed from the current study in questionnaire structure and reported weighted prevalence rates.
      Military serviceAny DS
      DS=dietary supplement.
      MVM
      MVM=multivitamin/multimineral.
      Any Individual Vitamin/MineralHerbalsJoint Health Products
      Bray, 2006
      • Bray R.M.
      • Hourani L.L.
      • Olmsted K.L.R.
      • et al.
      2005 Department of Defense Survey of Health Related Behaviors among Active Duty Military Personnel. A Component of the Defense Lifestyle Assessment Program (DLAP).
      Current studyBray, 2006
      • Bray R.M.
      • Hourani L.L.
      • Olmsted K.L.R.
      • et al.
      2005 Department of Defense Survey of Health Related Behaviors among Active Duty Military Personnel. A Component of the Defense Lifestyle Assessment Program (DLAP).
      Current studyBray, 2006
      • Bray R.M.
      • Hourani L.L.
      • Olmsted K.L.R.
      • et al.
      2005 Department of Defense Survey of Health Related Behaviors among Active Duty Military Personnel. A Component of the Defense Lifestyle Assessment Program (DLAP).
      Current studyBray, 2006
      • Bray R.M.
      • Hourani L.L.
      • Olmsted K.L.R.
      • et al.
      2005 Department of Defense Survey of Health Related Behaviors among Active Duty Military Personnel. A Component of the Defense Lifestyle Assessment Program (DLAP).
      Current studyBray, 2006
      • Bray R.M.
      • Hourani L.L.
      • Olmsted K.L.R.
      • et al.
      2005 Department of Defense Survey of Health Related Behaviors among Active Duty Military Personnel. A Component of the Defense Lifestyle Assessment Program (DLAP).
      Current study
      %±standard error
      Marines61±1.274±1.442±1.248±1.625±1.229±1.412±0.715±1.18±0.68±0.9
      Navy61±1.171±1.748±1.149±1.928±1.730±1.713±0.915±1.410±0.58±1.0
      a The Bray
      • Bray R.M.
      • Hourani L.L.
      • Olmsted K.L.R.
      • et al.
      2005 Department of Defense Survey of Health Related Behaviors among Active Duty Military Personnel. A Component of the Defense Lifestyle Assessment Program (DLAP).
      study differed from the current study in questionnaire structure and reported weighted prevalence rates.
      b DS=dietary supplement.
      c MVM=multivitamin/multimineral.

      Factors Associated with Dietary Supplement and Nutritional Supplement Use

      Both civilian
      • Radimer K.
      • Bindewald B.
      • Hughes J.
      • et al.
      Dietary supplement use by US adults: Data from the National Health and Nutrition Examination Survey, 1999-2000.
      • Kennedy E.T.
      • Luo H.
      • Houser R.F.
      Dietary supplement use pattern of US adult population in the 2007-2008 National Health and Nutrition Survey (NHANES).
      • Timbo B.B.
      • Ross M.P.
      • McCarthy P.V.
      • et al.
      Dietary supplements in a national survey: Prevalence of use and reports of adverse events.
      • Millen A.E.
      • Dodd K.W.
      • Subar A.F.
      Use of vitamin, mineral nonvitamin and nonmineral supplements in the United States: The 1987, 1992 and 2000 National Health Interview Survey results.
      • Bailey R.L.
      • Gahche J.J.
      • Lentino C.V.
      • et al.
      Dietary supplement use in the United States, 2003-2006.
      • Balluz L.S.
      • Kieszak S.M.
      • Philen R.M.
      • et al.
      Vitamin and mineral supplement use in the United States.
      • Balluz L.S.
      • Okoro C.A.
      • Bowman B.A.
      • et al.
      Vitamin or supplement use among adults, Behavioral Risk Factor Surveillance System, 13 states, 2001.
      • Bailey R.L.
      • Gahche J.J.
      • Miller P.E.
      • et al.
      Why US adults use dietary supplements.
      and military
      • Knapik J.J.
      • Steelman R.
      • Hoedebecke S.
      • et al.
      A systematic review and meta-analysis on the prevalence of dietary supplement use by military personnel.
      • Lieberman H.R.
      • Stavinoha T.B.
      • McGraw S.M.
      • et al.
      Use of dietary supplements among active-duty US Army soldiers.

      Austin KG, Price LL, McGraw SM, et al. Demographic, lifestyle factors and reasons for use of dietary supplements by Air Force personnel. Aerosp Med Hum Perf. In press.

      • Austin K.G.
      • Price L.L.
      • McGraw S.M.
      • et al.
      Predictors of dietary supplement use by US Coast Guard personnel.
      investigations have generally found that women and those with of higher educational levels are more likely to use dietary supplements. In our study, the sex effect was marginal in the univariate analysis, but in the multivariate analysis female sex was strongly associated with dietary supplement use, especially for MVMs and herbal supplements; educational level was associated with dietary supplement use in both univariate and multivariate analyses, especially for MVMs and vitamins/minerals. Sex differences may be associated with psychosocial factors relating to greater health awareness in women: numerous studies have shown that, compared with men, women are more active consumers of medical care
      • Owens G.M.
      Gender differences in health care expenditures, resource utilization, and quality of care.
      • Muller C.
      Review of twenty years of research on medical care utilization.
      • Ladwig K.H.
      • Marten-Mittag B.
      • Formanek B.
      • et al.
      Gender differences in symptom reporting and medical care utilization in the German population.
      and are generally more likely to make lifestyle changes in an effort to improve their health.
      • Patterson R.E.
      • Neuhouser M.L.
      • Hedderson M.M.
      • et al.
      Changes in diet, physical activity, and supplement use among adults diagnosed with cancer.
      • Assaf A.R.
      • Parker D.
      • Lapane K.L.
      • et al.
      Does the Y chromosome make a difference? Cardiovascular disease risk factors.
      However, diverging from the general trend, men in our study used proteins/AAs to a greater extent than women. This may be related to the fact that active men are more interested in the development of strength and muscle mass
      • Kristiansen M.
      • Levy-Milne R.
      • Barr S.
      • et al.
      Dietary supplement use by varsity athletes at a Canadian university.
      • Erdman K.A.
      • Fung T.S.
      • Doyle-Baker P.K.
      • et al.
      Dietary supplementation of high-performance Canadian athletes by age and gender.
      • Kim J.
      • Chun Y.S.
      • Kang S.K.
      • et al.
      The use of herbal/traditional products supplementation and doping tests in elite athletes.
      and studies have shown that appropriate physical training in conjunction with judicious protein/AA supplementation will result in improved muscle mass and strength.
      • Cermak N.M.
      • Res P.T.
      • deGroot L.C.
      • et al.
      Protein supplementation augments the adaptive response of skeletal muscle to resistance-type exercise training: A meta-analysis.
      With regard to the association between dietary supplements and education, individuals who have achieved higher educational levels are generally more health conscious, more prone to engage in health-promoting behaviors, and more likely to explore multiple channels of information related to their health
      • Harper S.
      • Lynch J.
      Trends in socioeconomic inequalities in adult health behaviors among U.S. States, 1990-2004.
      • Iversen A.C.
      • Kraft P.
      Does socioeconomic status and health consciousness influence how women respond to health related messages in media?.
      • Pal-deBruin K.M.V.P.
      • deWalle H.E.K.
      • deRover C.M.
      • et al.
      Influence of education on determinates of folic acid use.
      • Kim K.H.
      • Shin H.R.
      • Nakama H.
      Health consciousness in relation to education in Korea—Focusing on seven preventable risk factors.
      that can lead to higher use of supplements.
      In contrast to sex and education level, studies on BMI and dietary supplement use have been conflicting.
      • Radimer K.
      • Bindewald B.
      • Hughes J.
      • et al.
      Dietary supplement use by US adults: Data from the National Health and Nutrition Examination Survey, 1999-2000.
      • Lieberman H.R.
      • Stavinoha T.B.
      • McGraw S.M.
      • et al.
      Use of dietary supplements among active-duty US Army soldiers.

      Austin KG, Price LL, McGraw SM, et al. Demographic, lifestyle factors and reasons for use of dietary supplements by Air Force personnel. Aerosp Med Hum Perf. In press.

      • Bailey R.L.
      • Gahche J.J.
      • Miller P.E.
      • et al.
      Why US adults use dietary supplements.
      In general agreement with Army data,
      • Lieberman H.R.
      • Stavinoha T.B.
      • McGraw S.M.
      • et al.
      Use of dietary supplements among active-duty US Army soldiers.
      the multivariate analysis in the present investigation found a linear response effect, such that the higher the BMI, the greater the overall use of dietary supplements, and especially for MVMs, combination products, and herbal substances. Service members with high BMI were also more likely to use five or more dietary supplements and spend >$50/mo. There are strict weight-for-height and body fat requirements for continued service in the Army, Marine Corps, and Navy that are described in service regulations.

      Marine Corps body composition and military appearance program. Marine Corps Order 6110.3. Washington, DC: Department of the Navy; 2008. http://www.marines.mil/Portals/59/Publications/MCO%206110.3%20W%20CH%201.pdf. Accessed March 27, 2016.

      Physical Readiness Program. OPNAV Instruction 6110.1J. Washington, DC: Department of the Navy; 2011. http://www.colorado.edu/nrotc/sites/default/files/attached-files/6110.1j_-_physical_readiness_program.pdf. Accessed March 27, 2016.

      The Army Body Composition Program. Army Regulation 600-9. Washington, DC: Department of the Army; 2013.

      Individuals who do not meet these standards receive adverse performance reports and can be discharged from service for repeated failures to achieve the standard. This might prompt some individuals who are marginal with regard to meeting these height/weight and body fat standards to use dietary supplements promoted to assist with weight or body fat control.
      In many prior investigations, those who were more physically active were more likely to use dietary supplements.
      • Radimer K.
      • Bindewald B.
      • Hughes J.
      • et al.
      Dietary supplement use by US adults: Data from the National Health and Nutrition Examination Survey, 1999-2000.
      • Lieberman H.R.
      • Stavinoha T.B.
      • McGraw S.M.
      • et al.
      Use of dietary supplements among active-duty US Army soldiers.

      Austin KG, Price LL, McGraw SM, et al. Demographic, lifestyle factors and reasons for use of dietary supplements by Air Force personnel. Aerosp Med Hum Perf. In press.

      • Austin K.G.
      • Price L.L.
      • McGraw S.M.
      • et al.
      Predictors of dietary supplement use by US Coast Guard personnel.
      • Balluz L.S.
      • Okoro C.A.
      • Bowman B.A.
      • et al.
      Vitamin or supplement use among adults, Behavioral Risk Factor Surveillance System, 13 states, 2001.
      • Kao T.C.
      • Deuster P.A.
      • Burnett D.
      • et al.
      Health behaviors associated with use of body building, weight loss, and performance enhancing supplements.
      The current study found a strong relationship between dietary supplement use and resistance training but few relationships with aerobic training. The discrepancies in the literature can possibly be explained by different definitions of physical activity and the fact that some past studies
      • Radimer K.
      • Bindewald B.
      • Hughes J.
      • et al.
      Dietary supplement use by US adults: Data from the National Health and Nutrition Examination Survey, 1999-2000.
      • Balluz L.S.
      • Okoro C.A.
      • Bowman B.A.
      • et al.
      Vitamin or supplement use among adults, Behavioral Risk Factor Surveillance System, 13 states, 2001.
      • Kao T.C.
      • Deuster P.A.
      • Burnett D.
      • et al.
      Health behaviors associated with use of body building, weight loss, and performance enhancing supplements.
      did not adequately distinguish between different modes of physical training (eg, aerobic vs resistance) that might influence which types of dietary supplements are used. In the present study, service members were specifically asked to report separately on their aerobic and strength/resistance training frequency and duration and the weekly training duration of both exercise modes were calculated. Previous studies in the Army, Air Force, and Coast Guard personnel have shown that, when considered on a dichotomous basis, those performing resistance training were more likely to use dietary supplements than those not performing this type of training.
      • Lieberman H.R.
      • Stavinoha T.B.
      • McGraw S.M.
      • et al.
      Use of dietary supplements among active-duty US Army soldiers.

      Austin KG, Price LL, McGraw SM, et al. Demographic, lifestyle factors and reasons for use of dietary supplements by Air Force personnel. Aerosp Med Hum Perf. In press.

      • Austin K.G.
      • Price L.L.
      • McGraw S.M.
      • et al.
      Predictors of dietary supplement use by US Coast Guard personnel.
      In the present study, four levels of resistance training duration were examined and a very strong dose−response relationship was found between resistance training duration and use of any dietary supplement/nutritional supplement, protein/AAs, combination products, purported prohormones, sport drinks, sport bars/gels, and money spent on dietary supplements. These relationships were present even after controlling for a number of other factors in a multivariate analysis (multivariate data for some categories are not shown).
      Nutritional supplements were used to a larger extent by those performing more aerobic and resistance training. This was because there was greater use of sport drinks and sport bars/gels in the more active service members, in consonance with data reported in other military services.
      • Lieberman H.R.
      • Stavinoha T.B.
      • McGraw S.M.
      • et al.
      Use of dietary supplements among active-duty US Army soldiers.

      Austin KG, Price LL, McGraw SM, et al. Demographic, lifestyle factors and reasons for use of dietary supplements by Air Force personnel. Aerosp Med Hum Perf. In press.

      • Austin K.G.
      • Price L.L.
      • McGraw S.M.
      • et al.
      Predictors of dietary supplement use by US Coast Guard personnel.
      Sport drinks containing up to about 8% carbohydrate and consumed at a rate of about 1 L/h have been shown to maintain blood glucose levels (a major factor in long-term fatigue) and delay fatigue when exercise is performed for >1 hour.
      • Coyle E.F.
      • Montain S.J.
      Carbohydrate and fluid ingestion during exercise: Are there trade-offs?.
      Sport drink consumption during shorter-term exercise is probably not necessary, but can benefit hydration, albeit in a manner similar to water.
      • Hill R.J.
      • Bluck L.J.C.
      • Davies P.S.W.
      The hydration ability of three commercially available sports drinks and water.
      • Kalpana K.
      • Lal P.R.
      • Khanna G.L.
      The effects of ingestion of sugarcane juice and commercial sports drinks on cycling performance of athletes in comparison to plain water.
      Consumption in the post-exercise period is advantageous for both rehydration and optimal repletion of muscle and liver glucose.
      • Bowtell J.L.
      • Gelly K.
      • Jackman M.L.
      • et al.
      Effect of different carbohydrate drinks on whole body carbohydrate storage after exercise.
      • Decombaz J.
      • Jentjens R.
      • Ith M.
      • et al.
      Fructose and galactose enhance postexercise human liver glycogen synthesis.
      • Evans G.H.
      • Shirreffs P.M.
      • Maughan R.J.
      Postexercise rehydration in man: The effect of osmolality and carbohydrate content of ingested drinks.
      Carbohydrate gels consumed before or during physical activity have been shown to improve some aspects of performance.

      Harper LD, Briggs MA, McNamee G, et al. Physiological and performance effects of carbohydrate gels consumed prior to the extra-time period of prolonged simulated soccer match-play. J Sci Med Sport. In press.

      • Phillips S.M.
      • Turner A.P.
      • Sanderson M.F.
      • et al.
      Carbohydrate gel ingestion significantly improves the intermittent endurance capacity, but not sprint performance, of adolescent team game players during a simulated team games protocol.
      Like sport drinks, post-exercise consumption (within about 1 hour) of bars or gels will lead to greater repletion of muscle glycogen because post-exercise glucose transport and the activity of glycogen synthase (the rate-limiting enzyme for glycogen resynthesis) are considerably augmented.
      • Jentjens R.
      • Jeukendrup A.
      Determinates of post-exercise glycogen synthesis during short-term exercise recovery.
      • Jensen T.E.
      • Richter E.A.
      Regulation of glucose and glycogen metabolism during and after exercise.

      Adverse Events

      Timbo and colleagues
      • Timbo B.B.
      • Ross M.P.
      • McCarthy P.V.
      • et al.
      Dietary supplements in a national survey: Prevalence of use and reports of adverse events.
      examined AEs reported in the 2002 Health and Diet Survey, a telephone interview of a nationally representative sample. They asked about vitamins, minerals, proteins, and herbal substances in the last 12 months and only 4% of the sample reported AEs. In the present study, if only MVMs, single vitamins/minerals, proteins/AAs, and herbals were included, 9% of service members reported AEs. Previous studies of military personnel found AE prevalences ranging from 8% in Air Force personnel to 20% in deployed British service members.
      • Brasfield K.
      Dietary supplement intake in the active duty enlisted population.
      • Corum S.
      Findings of recent surveys on dietary supplements use by military personnel and the general population (Appendix C).
      • Timbo B.B.
      • Ross M.P.
      • McCarthy P.V.
      • et al.
      Dietary supplements in a national survey: Prevalence of use and reports of adverse events.
      • Cassler N.M.
      • Sams R.
      • Cripe P.A.
      • et al.
      Patterns and perceptions of supplement use by US Marines deployed to Afghanistan.
      • Thomasos C.J.
      Findings of recent surveys on dietary supplements use by military personnel and the general population (Appendix C).
      • Boos C.J.
      • Wheble G.A.C.
      • Campbell M.J.
      • et al.
      Self-administration of exercise and dietary supplements in deployed British military personnel during operation TELIC 13.

      Austin KG, Farina EK, Lieberman HR. Self-reported adverse effects associated with the use of dietary supplements in an Armed Forces population [published online ahead of print November 2, 2015]. Drug Test Anal. 2015. http://onlinelibrary.wiley.com/doi/10.1002/dta.1905/abstract. Accessed March 29, 2015.

      Both Brasfield
      • Brasfield K.
      Dietary supplement intake in the active duty enlisted population.
      and Corum
      • Corum S.
      Findings of recent surveys on dietary supplements use by military personnel and the general population (Appendix C).
      found that 18% reported AEs in separate broad surveys of Army personnel. The 22% of service members reporting AEs is higher than previous studies. This might be because of questionnaire design and the broader range of dietary supplements addressed in the present study. Our questionnaire listed very specific dietary supplements and then service members were asked to recall whether they had an AE to that particular dietary supplement. Many questionnaires appear to ask for AEs without linking them to specific dietary supplements,
      • Brasfield K.
      Dietary supplement intake in the active duty enlisted population.
      • Cassler N.M.
      • Sams R.
      • Cripe P.A.
      • et al.
      Patterns and perceptions of supplement use by US Marines deployed to Afghanistan.
      • Boos C.J.
      • Wheble G.A.C.
      • Campbell M.J.
      • et al.
      Self-administration of exercise and dietary supplements in deployed British military personnel during operation TELIC 13.

      Austin KG, Farina EK, Lieberman HR. Self-reported adverse effects associated with the use of dietary supplements in an Armed Forces population [published online ahead of print November 2, 2015]. Drug Test Anal. 2015. http://onlinelibrary.wiley.com/doi/10.1002/dta.1905/abstract. Accessed March 29, 2015.

      although the questionnaire design was not clear in some investigations.
      • Corum S.
      Findings of recent surveys on dietary supplements use by military personnel and the general population (Appendix C).
      • Thomasos C.J.
      Findings of recent surveys on dietary supplements use by military personnel and the general population (Appendix C).
      The dietary supplement category with the largest proportion of AEs was combination products, and the high AE prevalence for this category was also reported in a previous study of service members.

      Austin KG, Farina EK, Lieberman HR. Self-reported adverse effects associated with the use of dietary supplements in an Armed Forces population [published online ahead of print November 2, 2015]. Drug Test Anal. 2015. http://onlinelibrary.wiley.com/doi/10.1002/dta.1905/abstract. Accessed March 29, 2015.

      Combination products were those that included a number of different substances that were generally (but not exclusively) purported to assist in weight loss and/or muscle building. Combination products typically have a number of constituents that may potentiate physiological effects (eg, caffeine and guaraná) or may interact with other medications service members are ingesting. It is difficult to assume direct causality of AEs to supplements in the current study because the AEs were self-reported and can have alternative explanations.
      • Teschke R.
      • Schulze J.
      • Schwarzenboech A.
      • et al.
      Herbal heptotoxicity: Suspected cases assessed for alternative causes.
      Nonetheless, the proportion of service members reporting AEs was high and of concern.
      The presumed weight-loss and muscle-building combination product OxyElite Pro had the highest proportion of users reporting AEs, although the number of users was relatively small (n=25). OxyElite Pro was recalled by the FDA in 2013 after reports of 29 cases of acute hepatitis and liver failure associated with this supplement in Hawaii.
      • Park S.Y.
      • Varay M.
      • Johnson D.
      Notes from the field: Acute hepatitis and liver failure following use of a dietary supplement intended for weight loss or muscle building—May-October 2013.
      • Kuehn B.M.
      Dietary supplement linked to cases of acute hepatitis.
      OxyElite Pro contained 1,3 dimethylamylamine, which was also associated with cardiovascular events, including deaths.
      • Eliason M.J.
      • Eichner A.
      • Cancio A.
      • et al.
      Case reports: Death of active duty soldiers following ingestion of dietary supplements containing 1,3-dimethylamyamine.
      • Armstrong M.
      Atrial fibrillation with rapid ventricular response following use of dietary supplement containing 1,3 dimethylamylamine and caffeine.
      • Gee P.
      • Tallon C.
      • Long N.
      • et al.
      Use of recreational drug 1,3 dimethylethylamine (DMAA) associated with cerebral hemorrhage.
      One concern with FDA recalls is that they target specific dietary supplements and manufacturers can reformulate compounds, rename the new reformulation, and sell these reformulated supplements, despite the fact that they may contain substances similar to the banned dietary supplement. After OxyElite Pro was reformulated as “Super Thermogenic,” case series involving liver damage from the use of this dietary supplement emerged.
      • Foley S.
      • Butlin E.
      • Shields W.
      • et al.
      Experience with OxyELITE Pro and acute liver injury in active duty service members.
      • Roytman M.M.
      • Porzgen P.
      • Lee C.L.
      • et al.
      Outbreak of severe hepatitis linked weight-loss supplement OxyELITE Pro.
      In 2015, the FDA advised consumers not to use this reformulated dietary supplement because it contained a nondisclosed drug, the selective serotonin reuptake inhibitor fluoxetine.

      Public notification: OxyELITE Pro Super Thermogenic contains hidden drug ingredient. http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/MedicationHealthFraud/ucm436017.htm. Accessed December 2, 2015.

      Other dietary supplements for which a number of AEs were reported included Roxylean, NO- Xplode, Hydroxycut Hardcore, and Hydroxycut Advanced, although the number of users for most of these dietary supplements was relatively small. No case reports of specific AEs in association with the use of Roxylean were found. The original formula of this dietary supplement (Roxylean ECA) contained 1,3 dimethylamylamine, but the manufacturer was not contacted by the FDA in its ban of 1,3 dimethylamylamine. Examination of the nutrition supplement labels of the currently available product showed that it contained no 1,3 dimethylamylamine.

      Roxylean Dietary supplement label. http://www.dsld.nlm.nih.gov/dsld/prdDSF.jsp?id=30828. Accessed December 2, 2015.

      Case reports of hepatotoxicity, ischemic colitis, and renal failure have been reported in association with the use of NO-Xplode.
      • Martin D.J.
      • Partridge B.J.
      • Shield W.
      Hepatotoxicity associated with dietary supplement NO-Xplode.
      • Magee C.D.
      • Moawad F.J.
      • Moses F.
      NO-Xplode: A case of supplement-associated ischemic colitis.
      • Siano K.A.
      Renal failure in a soldier taking NO-Xplode.
      Hydroxycut products have a long history of associations with AEs. Early formulations of Hydroxycut contained ephedra.

      Review of original Hydroxycut with ephedra. http://ephedrasinica.org/origional-hydroxycut-ephedra/. Accessed December 2, 2015.

      Ephedra alkaloids were banned by the FDA in 2004

      FDA issues regulation prohibiting sale of dietary supplements containing ephedrine alkaloids and reiterates its advice that consumers stop using these products. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2004/ucm108242.htm. Accessed December 2, 2015.

      after many AEs were reported and a comprehensive literature review suggested significant “risk of psychiatric, autonomic, or gastrointestinal symptoms, and heart palpitations.”
      • Shekelle P.G.
      • Hardy M.L.
      • Morton S.C.
      • et al.
      Efficacy and safety of ephedra and ephedrine for weight loss and athletic performance.
      Despite court challenges, the ban was upheld in 2006.

      FDA statement on Tenth Circuit's ruling to uphold FDA decision banning dietary supplements containing ephedrine alkaloids. http://www.fda.gov/newsevents/newsroom/pressannouncements/2006/ucm108715.htm. Accessed December 2, 2015.

      Seizure activity and severe hepatotoxicity were reported in association with the Hydroxycut ephedra formulation.
      • Kockler D.R.
      • McCarthy M.W.
      • Lawson C.L.
      Seizure activity and unresponsiveness after Hydroxycut ingestion.
      • Neff G.W.
      • Durazo F.A.
      • Marrero R.
      Severe hepatotoxicity associated with the use of weight loss diet supplements containing ma huang or usnic acid.
      Hydroxycut was reformulated without ephedra, but cases of hepatotoxicity
      • Stevens T.
      • Qadri A.
      • Zein N.N.
      Two patients with acute liver injury associated with the use of the herbal weight-loss supplement hydroxycut.
      • Jones F.J.
      • Andrews A.H.
      Acute liver injury associated with the herbal supplement hydroxycut in a soldier deployed to Iraq.
      • Dara L.
      • Hewett J.
      • Lim J.K.
      Hydroxycut heptatoxicity: A case series and review of liver toxicity from herbal weight loss supplement.
      • Laczek J.
      • Duncan M.
      Three cases of acute hepatitis in patients taking hydroxycut bodybuilding supplement.
      and rhabdomyolysis
      • Dehoney S.
      • Wellein M.
      Rhabdomyolysis associated with the nutritional supplement hydroxycut.
      • Carol M.L.
      Hydroxycut weight loss dietary supplements: A contributing factor in the development of exertional rhabdomyolysis in three US Army soldiers.
      were associated with this new formulation. In 2009, the FDA warned consumers to stop using specific Hydroxycut products

      FDA warns consumers to stop using Hydroxycut products. Dietary supplement linked to one death; pose risk of liver injury. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm149575.htm. Accessed December 2, 2015.

      and the manufacturer voluntarily recalled some Hydroxycut-labeled products.

      Iovate Health Science USA, Inc. voluntarily recalls Hydroxycut-branded products. www.fda.gov/Safety/recalls/ucm145164.htm. Accessed December 2, 2015.

      Possible hepatotoxic substances in the pre-2009 Hydroxycut formulation included Garcinia Cambogia, chromium, and Camellia Senensis.
      • Dara L.
      • Hewett J.
      • Lim J.K.
      Hydroxycut heptatoxicity: A case series and review of liver toxicity from herbal weight loss supplement.
      Hydroxycut was again reformulated without these substances, but the older formulations still appear to be available.
      • Karth A.
      • Holoshitz N.
      • Kavinsky C.J.
      • et al.
      A case report of atrial fibrillation potentially induced by hydroxycut: A multicomponent dietary weight loss supplement devoid of sympathomimetric amines.
      • Kaswala D.H.
      • Shah S.
      • Patel N.
      • et al.
      Hydroxycut liver toxicity.
      Some cases of AEs continue to appear even with the newer formulation.
      • Araujo J.L.
      • Worman H.J.
      Acute liver injury associated with a newer formulation of the herbal weight loss supplement Hydroxycut.
      • Sherid M.
      • Samo S.
      • Sulaiman S.
      • et al.
      Ischemic colitis induced by the newly reformulated multicomponent weight-loss supplement Hydroxycut.

      Limitations

      This study has limitations. All data were self-reported and suffer from the usual limitations associated with this method, including recall bias, social desirability, errors in self-observation, and inadequate recall.
      • Podsakoff P.M.
      • MacKenzie S.B.
      • Lee J.Y.
      • et al.
      Common method biases in behavioral research: A critical review of the literature and recommended remedies.
      • Furnham A.
      Response bias, social desirability and dissimulation.
      Our analysis of responders and nonresponders indicated that there was some response bias. It was somewhat more likely to obtain data from women, older service members, married personnel, those of higher educational level, officers and senior enlisted personnel, and certain occupational groups. Nonetheless, individuals from all these demographic groups were well represented in the analyses.

      Conclusions

      Among Navy and Marine Corps personnel, 73% reported the use of dietary supplements one or more times per week. The most commonly used dietary supplements and nutritional supplements (one or more times per week) were multivitamins/multiminerals (48%), sport drinks (45%), protein/AAs (34%), combination products (33%), individual vitamins and minerals (29%), and sport bars/gels (23%). Multivariate logistic regression modeling indicated that female sex, higher educational level, higher BMI, and a greater amount of resistance training were associated with dietary supplement use. Twenty-two percent of dietary supplement users and 6% of nutritional supplement users reported one or more AEs. For combination products alone, 29% of users reported one or more AEs. The prevalence of dietary supplement use in Navy and Marine Corps personnel was considerably higher than reported in civilian investigations for almost all types of dietary supplements, although similar to most other military services. Future studies should be designed to identify dietary supplements associated with AEs documented in medical records.

      Acknowledgements

      The authors thank Susan McGraw for assistance with questionnaire design and structure.

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      Biography

      J. J. Knapik is a research physiologist, Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, MA, US Army Public Health Center, Aberdeen Proving Ground, MD, and Oak Ridge Institute for Science and Education, Belcamp, MD.
      D. W. Trone is an epidemiologist, Naval Health Research Center, San Diego, CA.
      K. G. Austin is a senior physical fitness scientist, Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, MA, and Oak Ridge Institute for Science and Education, Belcamp, MD.
      R. A. Steelman is an epidemiologist, US Army Public Health Center, Aberdeen Proving Ground, MD.
      E. K. Farina is an epidemiologist, Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, MA, and Oak Ridge Institute for Science and Education, Belcamp, MD.
      H. R. Lieberman is a research psychologist, Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, MA.