Dietary Supplement Use in a Large, Representative Sample of the US Armed Forces

Open AccessPublished:June 19, 2018DOI:https://doi.org/10.1016/j.jand.2018.03.024

      Abstract

      Background

      Dietary supplement (DS) use is prevalent among the US Armed Forces personnel, but representative cross-service comparisons and characteristics of personnel using DSs are limited.

      Objective

      Examine DS use and characteristics associated with use in a representative sample of US Armed Forces personnel (Army, Navy, Air Force, Marine Corps, and Coast Guard) using data from the 2011 Department of Defense Survey of Health-Related Behaviors.

      Design and participants

      A stratified random sample of service members (SMs) was contacted and asked to complete a questionnaire assessing personal characteristics and DS use.

      Results

      Overall, 69% of the 39,877 SMs reported using DSs ≥1 time per week. The most commonly used DSs were multivitamin or multiminerals (50%), antioxidants (34%), individual vitamins or minerals (33%), bodybuilding supplements (27%), fish oils (26%), herbals (16%), and weight-loss supplements (16%). Multiple logistic regression indicated overall DS use was higher among women, those with higher educational levels, Marine Corps SMs, officers, those with higher body mass index, those engaged in greater physical activity and weight training, and people in weight control programs. DS use was lower when peer groups or leadership discouraged substance abuse.

      Conclusions

      DS use was considerably higher in the US Armed Forces compared with civilian populations, although many demographic and lifestyle factors associated with use were similar. Some categories of DSs extensively used by SMs such as bodybuilding supplements have been associated with adverse events. Discouraging substance abuse through peer groups and leadership actions may reduce use of unnecessary or dangerous DSs.

      Keywords

      The Continuing Professional Education (CPE) quiz for this article is available for free to Academy members through the MyCDRGo app (available for iOS and Android devices) and through www.jandonline.org (click on “CPE” in the menu and then “Academy Journal CPE Articles”). Log in with your Academy of Nutrition and Dietetics or Commission on Dietetic Registration username and password, click “Journal Article Quiz” on the next page, then click the “Additional Journal CPE quizzes” button to view a list of available quizzes. Non-members may take CPE quizzes by sending a request to [email protected] . There is a fee of $45 per quiz (includes quiz and copy of article) for non-member Journal CPE. CPE quizzes are valid for 1 year after the issue date in which the articles are published.
      Research Question: What is the prevalence of dietary supplement (DS) use in the Armed Forces and what demographic and lifestyle factors are associated with DS use?
      Key Findings: In this cross-sectional survey of 39,877 Armed Forces personnel, 69% reported using DSs ≥1 time per week. The most commonly used DSs were multivitamin or multiminerals (50%), antioxidants (34%), individual vitamins or minerals (33%), bodybuilding supplements (27%), fish oils (26%), herbals (16%), and weight-loss supplements (16%). Factors associated with greater use included female sex, higher educational levels, Marine and officer status, higher body mass index, greater physical activity, and participation in weight control programs.
      Dietary supplements (DSs) 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.

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

      The Dietary Supplement Health and Education Act of 1994

      US Department of Health and Human Services. 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 DSs in the United States. Since the Dietary Supplement Health and Education Act became law, US sales of DSs 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.
      a greater than ninefold increase over 21 years. The National Health and Nutrition Examination Surveys (NHANES), which continuously assess a large representative sample of the civilian population, found that about 50% of Americans use DSs,
      • 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).
      • Kantor E.D.
      • Rehm C.D.
      • Du M.
      • et al.
      Trends in dietary supplement use among US adults from 1999-2012.
      but surveys of US service members (SMs) suggest use is considerably higher in this population, with about 60% to 70% reporting DS use.
      • Lieberman H.R.
      • Stavinoha T.B.
      • McGraw S.M.
      • et al.
      Use of dietary supplements among active-duty US Army soldiers.
      • 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.
      • Austin K.G.
      • Price L.L.
      • McGraw S.M.
      • et al.
      Predictors of dietary supplement use by US Coast Guard personnel.
      • Austin K.G.
      • Price L.L.
      • Mcgraw S.M.
      • et al.
      Demographic, lifestyle factors and reasons for use of dietary supplements by Air Force personnel.
      • Knapik J.J.
      • Trone D.W.
      • Austin K.G.
      • et al.
      Prevalence, adverse effects, and factors associated with dietary supplement and nutritional supplement use by United States Navy and Marine Corps personnel.
      Both civilian
      • Bailey R.L.
      • Gahche J.J.
      • Miller P.E.
      • et al.
      Why US adults use dietary supplements.
      and military
      • Lieberman H.R.
      • Stavinoha T.B.
      • McGraw S.M.
      • et al.
      Use of dietary supplements among active-duty US Army soldiers.
      • Austin K.G.
      • Price L.L.
      • McGraw S.M.
      • et al.
      Predictors of dietary supplement use by US Coast Guard personnel.
      • Austin K.G.
      • Price L.L.
      • Mcgraw S.M.
      • et al.
      Demographic, lifestyle factors and reasons for use of dietary supplements by Air Force personnel.
      surveys indicate the major reason people report using DS is to improve their health, but SMs cite improved physical performance as the second most common reason, a rationale seldom reported in civilian studies,
      • Bailey R.L.
      • Gahche J.J.
      • Miller P.E.
      • et al.
      Why US adults use dietary supplements.
      but often found in surveys of athletes.
      • Krumbach C.J.
      • Ellis D.R.
      • Driskell J.A.
      A report on vitamin and mineral supplement use among university athletes in a division I institution.
      • Froiland K.
      • Koszewski W.
      • Hingst J.
      • et al.
      Nutritional supplement use among college athletes and their sources of information.
      • Lun V.
      • Erdman K.A.
      • Fung T.S.
      • et al.
      Dietary supplementation practices in Canadian high-performance athletes.
      The types of DSs used by SMs are considerably different from those used by civilian populations because SMs are much more likely to use purported strength and bodybuilding supplements such as protein or amino acids, creatine, and various combination products marketed as physical performance enhancers.
      • Lieberman H.R.
      • Stavinoha T.B.
      • McGraw S.M.
      • et al.
      Use of dietary supplements among active-duty US Army soldiers.
      • 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.
      • Austin K.G.
      • Price L.L.
      • McGraw S.M.
      • et al.
      Predictors of dietary supplement use by US Coast Guard personnel.
      • Austin K.G.
      • Price L.L.
      • Mcgraw S.M.
      • et al.
      Demographic, lifestyle factors and reasons for use of dietary supplements by Air Force personnel.
      • Knapik J.J.
      • Trone D.W.
      • Austin K.G.
      • et al.
      Prevalence, adverse effects, and factors associated with dietary supplement and nutritional supplement use by United States Navy and Marine Corps personnel.
      The Department of Defense (DoD) Survey of Health-Related Behaviors regularly collects anonymous behavioral health data to examine the well-being of the US Armed Forces. The survey is administered to a large, stratified random sample of SMs from all the Armed Forces, which include the Army, Navy, Air Force, Marine Corps, and Coast Guard. The survey includes questions on DS use as well as demographic, military, and lifestyle characteristics. An analysis of the 2005 DoD Survey of Health-Related Behaviors examined some types of DS use and how they were related to demographic and lifestyle factors.
      • 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 present investigation examines data from the 2011 DoD survey and, compared with the 2005 investigation,
      • Kao T.C.
      • Deuster P.A.
      • Burnett D.
      • et al.
      Health behaviors associated with use of body building, weight loss, and performance enhancing supplements.
      considerably expands on the number of DS categories examined, and provides an opportunity to examine longitudinal trends in DS use by SMs. It also permits direct comparison of DS use among the individual uniformed services based on an identical survey conducted simultaneously. Many other studies of DS use in the US Armed Forces have only examined services individually.
      • Lieberman H.R.
      • Stavinoha T.B.
      • McGraw S.M.
      • et al.
      Use of dietary supplements among active-duty US Army soldiers.
      • Austin K.G.
      • Price L.L.
      • McGraw S.M.
      • et al.
      Predictors of dietary supplement use by US Coast Guard personnel.
      • Austin K.G.
      • Price L.L.
      • Mcgraw S.M.
      • et al.
      Demographic, lifestyle factors and reasons for use of dietary supplements by Air Force personnel.
      • Knapik J.J.
      • Trone D.W.
      • Austin K.G.
      • et al.
      Prevalence, adverse effects, and factors associated with dietary supplement and nutritional supplement use by United States Navy and Marine Corps personnel.
      • Austin K.G.
      • Price L.L.
      • McGraw S.M.
      • et al.
      Longitudinal trends in use of dietary supplements by US Army personnel differ from those of civilians.
      The overall objective of this study was to describe the prevalence of DS use in a stratified random sample of the US Armed Forces and to examine characteristics associated with their use.

      Methods

      The 2011 DoD Survey of Health-Related Behaviors was conducted by Inner City Fund International, Inc, under the supervision of the Office of Assistant Secretary of Defense for Health Affairs and Tricare Management Activity. This was the 11th iteration of the survey and the first time it was administered electronically. Survey content was developed by a group of subject matter experts from the DoD, US Coast Guard, and professionals in the fields of health and fitness. The present study was a secondary analysis of selected cross-sectional data from this survey. Details regarding sampling and administration of the survey are contained in the original report.

      Barlas FM, Higgins WB, Pflieger JC, et al. 2011 Health related behaviors survey of active duty military personnel. https://www.documentcloud.org/documents/694942-2011-final-department-of-defense-survey-of.html. Accessed March 5, 2018.

      Briefly, the research objective of the survey was to assess the state of the behavioral and mental health of the active duty military population. The target population included all members of the Army, Navy, Marine Corps, Air Force, and Coast Guard who were nondeployed and on active duty. For survey administration, senior officers from each service served as liaisons to work with their respective service’s information technology departments to whitelist the survey’s Uniform Resource Locator on their respective computer systems, to obtain a letter of support from a ranking officer within their command hierarchy to encourage participation in the survey and provide authenticity for the Web-based survey, and to act as their service’s primary point of contact for respondents regarding issues and questions. The survey was pretested with a group of junior enlisted personnel at five locations (n=22). They provided numerous comments about specific survey items including suggestions for improving question and response option clarity, the addition of response options, the addition of clarification instructions, improvements to question format, and improvements to question flow and order. Survey administration was approved by the Inter City Fund International Institutional Review Board. The Human Use Review Committee of the US Army Research Institute of Environmental Medicine approved the secondary data analyses presented here.

      Sampling and Recruitment

      The Figure shows the number of SMs involved in each stage of the sampling and recruitment from the initial sample frame to the final respondents. To establish the sampling frame for the DoD sample (Army, Navy, Marine Corps, Air Force), the Defense Manpower Data Center’s Active Duty Master Edit File was obtained. The sample frame for the Coast Guard was established from a census file of all Coast Guard active duty members. Both files were current up to June 2011. The final sample frame included all active duty members of the Army, Navy, Marine Corps, Air Force, and Coast Guard. Those who were deployed at the time of the sample selection were excluded. The specified definition of the population resulted in a sample frame with 1,262,251 eligible SMs.
      Figure thumbnail gr1
      FigureSampling frame, stratification, solicitation, and responses. The number of service members involved at each stage of the process are shown in parentheses. DoD=Department of Defense.
      For the DoD sample, the four services were considered primary strata for sampling. After finalizing the sampling frame, an initial stratified random sample of 281,872 members was selected using a computerized random sampling technique. There were 12 substrata in this sample, defined as the six pay grade levels within sex. This initial sample file was randomly divided into three groups, a primary group (n=118,971) and two holdback groups (n=83,121 and n=79,780). The holdback groups were created in case response rate was lower than anticipated. After an assessment of survey completion rates by strata subsequent to the initial fielding of the primary sample, an additional 36,797 sample members from first holdback group were randomly selected disproportionately from strata and sent invitations to participate in the survey. This resulted in a total of 155,768 DoD members who were invited to participate in the survey. No members from the second holdback group were invited to participate.
      Sampling for the Coast Guard differed from the DoD. After stratification based on sex and pay grade, the Coast Guard population was subdivided into two separate groups, one for a site-centered, clustered sample and one for a distributed, unclustered sample. The first group (site centered) involved a random selection of 10 installations with a probability of selection proportional to the size of installations. The second population (other locations) consisted of all other Coast Guard members who were not part of the 10 chosen installations.
      Electronic invitations for survey participation were sent by e-mail to potential respondents between August 2011 and January 2012. Potential respondents who did not have an e-mail address on file were mailed paper invitations. Reminder e-mails and postcards (to those without e-mail addresses) were sent on a staggered schedule. Participation by potential respondents was voluntary and anonymous. The initial batch of Web-survey invitations to the DoD sample was sent in August 2011. The initial invitation emails to USCG personnel were sent in October 2011. The last reminder e-mail was sent on December 29, 2011.

      Survey Questions

      The survey consisted of 166 primary questions and included questions on categories and frequency of DS use. The DS use question asked, “In the PAST 12 MONTHS, how often did you take any of the following supplements? Please select one response per row.” Below this, 7 DS categories were listed in rows as follows: “multiple vitamins and minerals (such as Centrum [Pfizer], One-A-Day [Bayer])”; “individual vitamins or minerals (such as calcium, iron, selenium, vitamin D)”; “antioxidants (such as combinations of beta-carotene, vitamin E, vitamin C)”; “bodybuilding products that are legal (such as amino acids, protein powders, creatine, ‘andro,’ nitric acid boosters)”; “herbal supplements (such as ginkgo biloba, echinacea, ginseng)”; “weight-loss products (such as Ripped Fuel [TWINLAB], caffeine, Dexatrim [NVE Pharmaceuticals], Lipo6 [Nutrex Research], Metabolife [Metabolife International, Inc], QuickTrim [QuickTrim LLC], Xenadrine [Iovate Health Sciences International Inc])”; and “fish oil.” Frequencies of use were listed after each category and included “never, 1 time per month, 1 time per week, every other day, daily, two or more times per day.”
      In addition to the DS categories, the survey collected information on demographic, military, physical and lifestyle factors, and whether or not SMs perceived that their peer group and leadership discouraged substance abuse. Demographics included sex, age, education, and marital status. Military characteristics were service branch, rank, and occupational category. Occupational categories included combat (eg, Infantry, Armor, Field Artillery, Air Defense, Special Forces, Aviation), combat support (eg, Engineer, Chemical, Military Intelligence, Military Police, Signal, Civil Affairs), and combat service support (eg, Ordnance, Quartermaster, Transportation, Adjutant, Medical, Finance, Judge Advocate General). Physical characteristics included height and weight. Lifestyle characteristics encompassed the frequency and duration of moderate and vigorous physical activity, weekly frequency of strength training, sleep, alcohol intake, smoking habits, and participation in weight control programs. Moderate physical activity was described to the SM as “exertion that raises heart rate and breathing, but you should be able to carry on a conversation comfortably during the activity.” Vigorous physical activity was described to the SM as “exertion that is high enough that you would find it difficult to carry on a conversation during the activity.”

      Data Analysis

      A data set for analysis with a codebook was obtained from the Defense Health Cost Assessment and Program Evaluation Center under a data sharing agreement. Data were provided in an SPSS file format (version 20.0; SPSS Inc) and converted to an SAS (version 9.2; SAS Institute) data file for statistical analyses. The various strata were weighted to reflect the active duty population of each sample, but calculations differed for the DoD vs the Coast Guard samples. For the DoD sample, a base weight was created accounting for disproportionate stratification, unequal selection probabilities, and differential nonresponse using substrata from the active duty population. Within each military service, the substrata were defined by sex and rank group. For a case i in substratum j of service k, the design weight was computed as w1ijk=Njk/njk where Njk are the population counts and njk are the number of sampled active duty SMs in the substratum j of service k. A second weight adjusting for differential nonresponse was further computed. Within each service, the substrata were again defined by sex and rank group. For a case i in stratum j of service k, the weight that adjusted for nonresponse was computed as w2ijk=njk/rjk, where njk were the number of sampled active duty members and rjk were the number of completed cases in stratum j of service k. The full weight adjusted for both unequal selection probabilities and differential nonresponses and was calculated by the following: w3ijk=Njk/rjk.
      Because there were two populations for Coast Guard (site centered and other locations), two separate weighting procedures were developed. For the site-centered sample, data were weighted to the proportions of the census of the 10 sites within the strata of work setting (air, afloat, ashore), sex, and pay grade using a poststratification weight only. For the other locations sample, drawn from the population that excluded the 10 sites, a base weight was first computed using the proportions within strata of the distributed population, followed by a poststratification weight to adjust for nonresponse. The weights, computed for each population separately, were used in combination to adjust the sample to be representative of the total Coast Guard population (from both populations). The combined sample size (including both the site-centered and other locations samples) was used to compute sample weights as a proportion of the population.
      Body mass index (BMI) was calculated from the self-reported height and weight as weight/height2 (kg/m2). For vigorous and moderate physical activity, the reported weekly frequency (days per week) and duration (minutes per day) were multiplied to get the weekly duration (minutes per week).
      Frequencies for each response category of each DS category were calculated. Any DS use was defined as responding in ≥1 DS categories. Prevalence of use (% using a DS ≥1 time per week) for any DS and each of the 7 DS categories was determined and standard errors were estimated using a Taylor series linearization method.

      SAS. The SURVEYREG Procedure, Taylor Series Linearization. https://support.sas.com/documentation/cdl/en/statug/63962/HTML/default/viewer.htm#statug_surveyreg_a0000000274.htm. Accessed December 27, 2017.

      Differences in DS use were determined using Wald χ2 tests to compare levels of categorized demographic, military, lifestyle, and substance abuse attitude variables. Eight logistic regression models (any DS use and seven DS categories) were constructed to examine relationships between DS use (≥1 time per week) and the various characteristics. Results of logistic regressions were presented as odds ratios with their 95% confidence intervals.

      Results

      As shown in the Figure, the survey was completed by 41,752 Armed Forces personnel for an overall response rate of 25%. However, a small portion of SMs (n=1,875) were not included in the analyses, either because they were no longer on active duty or did not complete critical demographic question (service, sex, pay grade, and active duty status). This resulted in a final sample of 39,877. Table 1 shows the stratification variables with the initial sample solicited, and those who were eligible for the survey (ie, those on active duty and who completed critical demographic questions). The mean±standard deviation for self-reported age, height, weight, and BMI of men were 32±9 years, 178±7 cm, 84±12 kg, and 26.4±3.2, respectively; for women these values were 30±8 years, 165±8 cm, 66±10 kg and 24.4±3.3, respectively.
      Table 1Sample sizes by stratification variables including service, sex, and rank and (for Coast Guard) work setting for study of dietary supplement use in the US Armed Forces
      ServiceWork settingPay grade (rank)SexSample (n)Eligible sample (n)Usable respondents (n)Usable responses (%)
      ArmyNA
      NA=not applicable to this service.
      E1-E4
      E1-E9=enlisted grades 1 to 9.
      Male19,83319,3179975.0
      E5-E6Male5,9775,8221,14119.6
      E7-E9Male2,1292,07470934.2
      WO1-WO5
      WO1-WO5=warrant officer grades 1 to 5.
      Male2,1112,05653125.8
      O1-O3
      O1-O4 and above=officer grades 1 to 9.
      Male2,1092,05440419.7
      O4 and aboveMale1,4471,40975253.4
      E1-E4Female8,0097,80188211.3
      E5-E6Female2,4292,36655123.3
      E7-E9Female85783527833.3
      WO1-WO5Female51350016733.4
      O1-O3Female81479325632.3
      O4 and aboveFemale62260626443.6
      Total46,85045,6326,93215.2
      NavyNAE1-E4Male11,97211,9128527.2
      E5-E6Male6,0856,0551,47724.4
      E7-E9Male2,1412,13099646.8
      WO1-WO5Male58658329350.3
      O1-O3Male2,7832,76963723.0
      O4 and aboveMale1,0331,02848647.3
      E1-E4Female4,7944,77076116.0
      E5-E6Female2,3462,33487237.4
      E7-E9Female82081650461.8
      WO1-WO5Female27272281.5
      O1-O3Female1,1211,11541837.5
      O4 and aboveFemale44244025357.5
      Total34,15033,9797,57122.3
      Marine CorpsNAE1-E4Male20,00319,8551,7428.8
      E5-E6Male5,9325,8881,62227.5
      E7-E9Male2,0962,0801,04750.3
      WO1-WO5Male77576940152.1
      O1-O3Male2,0612,04658428.5
      O4 and aboveMale1,3981,38856740.9
      E1-E4Female4,7314,6961,31728.0
      E5-E6Female1,7321,71968740.0
      E7-E9Female30530316454.1
      WO1-WO5Female35351440.0
      O1-O3Female35435113839.3
      O4 and aboveFemale78775672.7
      Total39,50039,2088,33921.3
      Air ForceNAE1-E4Male12,02612,0002,68022.3
      E5-E6Male5,9735,9602,22637.3
      E7-E9Male2,5402,5341,26349.8
      O1-O3Male3,3953,38887925.9
      O4 and aboveMale1,3261,32353040.1
      E1-E4Female4,7784,7671,64334.5
      E5-E6Female2,3392,3341,01743.6
      E7-E9Female1,0251,02355254.0
      O1-O3Female1,3321,32949937.5
      O4 and aboveFemale53453328553.5
      Total35,26835,19011,57432.9
      Coast GuardAshoreE1-E4Male2,3412,32277933.5
      E5-E6Male2,4492,4291,14647.2
      E7-E9Male70569946266.1
      WO1-WO5Male30430219464.2
      O1-O3Male55655227349.5
      O4 and aboveMale64263734854.6
      E1-E4Female50550121743.3
      E5-E6Female32332021767.8
      E7-E9Female75745168.9
      WO1-WO5Female29292172.4
      O1-O3Female1631628250.6
      O4 and aboveFemale1041036361.2
      AfloatE1-E4Male2,8302,80736513.0
      E5-E6Male1,0381,03036535.5
      E7-E9Male19819611357.5
      WO1-WO5Male43432865.6
      O1-O3Male1871867238.8
      O4 and aboveMale64632336.2
      E1-E4Female2702686423.9
      E5-E9Female1431425035.3
      OfficersFemale68672537.1
      AirE1-E4Male63462913321.1
      E5-E6Male54654217632.5
      E7-E9Male1031024342.2
      WO1-WO5Male1616637.5
      O1-O3Male1931917036.6
      O4 and aboveMale45453475.6
      E1-E4Female1031022120.6
      E5-E9Female82811417.3
      OfficersFemale1212650.0
      Total14,77114,6535,46137.3
      a NA=not applicable to this service.
      b E1-E9=enlisted grades 1 to 9.
      c WO1-WO5=warrant officer grades 1 to 5.
      d O1-O4 and above=officer grades 1 to 9.

      DS Use Prevalence and Univariate Analysis of Characteristics Associated with Use

      Table 2 provides the prevalence of use in each response category. The most commonly used DSs (any use) were multivitamin or multiminerals (MVMs), followed (in order of use) by antioxidants, individual vitamins or minerals (VMs), bodybuilding supplements, fish oils, herbals, and weight-loss supplements.
      Table 2Frequency of DS
      DS=dietary supplement.
      use by US Armed Forces personnel in each DS category
      Frequency of useMultivitamins or multimineralsIndividual vitamins or mineralsAntioxidantsBodybuildingHerbalsWeight lossFish oil
      % (n)
      Two or more per day3.2 (1,269)3.2 (1,267)2.7 (1,077)3.7 (1,467)1.5 (593)3.6 (1,427)3.6 (1,424)
      Once a day33.4 (13,250)19.5 (7,720)18.2 (7,258)12.3 (4,878)7.3 (2,888)6.8 (2,694)14.4 (5,697)
      Every other day6.8 (2,698)5.0 (1,979)5.7 (2,273)7.1 (2,816)2.6 (1,029)2.5 (991)3.5 (1,385)
      Once a week5.8 (2,301)5.1 (2,020)7.0 (2,791)4.1 (1,626)4.7 (1,859)3.1 (1.229)4.3 (1,701)
      Once a month7.2 (2,856)8.6 (3,405)8.0 (3,190)5.3 (2,102)6.9 (2,730)4.5 (1,783)5.8 (2,295)
      Never in past year42.9 (17,019)57.6 (22,803)57.3 (22,850)66.6 (26,412)75.7 (29,948)78.5 (31,110)67.2 (26,585)
      Missing0.9 (357)1.1 (435)1.1 (439)0.9 (357)1.2 (475)0.9 (357)1.2 (475)
      a DS=dietary supplement.
      Table 3 provides prevalence (≥1 time per week) and the number of supplement categories in which participants responded by their demographic, military, physical, lifestyle, and attitudes regarding substance abuse. Sixty-nine percent of military personnel surveyed reported using a DS at least ≥1 time per week in the 12 months prior to the survey. Compared with men, women reported higher prevalence of use of any DS, MVMs, individual VMs, and weight-loss supplements; men were more likely to report using supplements in ≥5 categories and more use of bodybuilding, herbal, and fish oil supplements. Younger people were more likely to report using ≥5 DS categories and using antioxidants, bodybuilding, herbal, and weight-loss supplements, and the oldest people (≥40 years) had the highest use prevalence for MVMs and fish oils. As education increased, so did the prevalence of use of any DSs, MVMs, and fish oils; as education decreased, there was greater reported use of DSs in ≥5 categories and bodybuilding supplements. Married SMs reported greater use of MVMs and fish oils; single SMs were more likely to report use of ≥5 DS categories and more use of individual VMs, antioxidants, bodybuilding supplements, and herbals.
      Table 3Prevalence (%±SE
      SE=standard error.
      ) of reported use of number and type DS
      DS=dietary supplement
      categories reported ≥1 time/wk over the 12 months prior to the survey by demographic, military, lifestyle, and attitudes regarding substance abuse among active duty military personnel, DoD
      DoD=Department of Defense.
      Survey of Health-Related Behaviors, 2011, with statistical significance noted above each variable
      CharacteristicNo. of DS Categories Reported ≥1 Time/wkDS Categories Reported ≥1 Time/wk
      Any DS1-23-45 or moreMultivitamin or multimineralIndividual vitamins or mineralsAntioxidantsBodybuildingHerbalWeight lossFish oils
      %±SE
      Total (N=39,877)69.1±0.3448.3±0.4331.1±0.4020.7±0.3649.5±0.3633.1±0.3433.9±0.3427.2±0.3316.3±0.2716.2±0.2726.0±0.32
      Sex
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.05.
      P<0.05.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      Male (n=27,446)67.9±0.3947.5±0.5030.6±0.4721.8±0.4248.0±0.4231.1±0.3933.8±0.3929.9±0.3816.6±0.3115.8±0.3126.6±0.36
      Female (n=12,431)75.4±0.4651.9±0.6233.3±0.5814.8±0.4458.2±0.5343.8±0.5333.8±1.5112.0±0.3514.8±0.3919.0±0.4322.4±0.44
      Age (y)
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.05.
      P<0.05.
      P<0.05.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.05.
      <18 (n=4,256)70.2±1.0344.0±1.3132.1±1.2523.9±1.1550.8±1.1235.9±1.0738.0±1.0829.6±1.0419.2±0.9018.0±0.8927.0±0.99
      18-24 (n=8,605)67.6±0.7345.7±0.9330.3±0.8624.0±0.8145.4±0.7734.2±0.7334.1±0.7334.8±0.7517.9±0.5918.2±0.6023.1±0.65
      25-29 (n=8,003)69.9±0.7548.6±0.9529.6±0.8721.7±0.8049.5±0.8032.1±0.7433.0±0.7630.4±0.7517.0±0.6118.1±0.6424.8±0.69
      30-39 (n=11,987)69.2±0.6150.2±0.7831.5±0.7318.3±0.6151.3±0.6631.2±0.6132.9±0.6123.4±0.5614.6±0.4715.5±0.4726.1±0.57
      ≥40 (n=7026)69.3±0.7951.5±0.9933.2±0.9215.3±0.7652.5±0.8434.1±0.7832.7±0.7814.1±0.6213.7±0.599.8±0.4932.2±0.79
      Education
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.05.
      P<0.05.
      P<0.05.
      P<0.01.
      Some HS
      HS=high school.
      or HS graduate (n=20,046)
      64.3±0.7646.5±0.9929.1±0.9224.4±0.8642.2±0.7932.2±0.7432.9±0.7530.7±0.7417.4±0.6018.6±0.6322.4±11.6
      Some Cllg
      Cllg=college.
      or Cllg degree (n=12,368)
      70.3±0.4347.8±0.5431.4±0.5120.9±0.4550.9±0.4633.6±0.4334.5±0.4427.9±0.4216.8±0.3517.1±0.3526.2±0.66
      Graduate degree (n=7,426)72.1±0.7153.0±0.9432.9±0.8814.0±0.7156.7±0.7932.4±0.7431.9±0.7517.8±0.6612.4±0.5318.3±0.4531.3±0.75
      Marital status
      P<0.01.
      P<0.01.
      P<0.05.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.05.
      Married (n=25,508)68.9±0.4245.8±0.7231.6±0.5018.8±0.4350.1±0.4531.9±0.4232.7±0.4224.3±0.4015.1±0.3315.2±0.3326.0±0.39
      Not married (n=14,369)69.4±0.5749.7±0.5430.3±0.6623.9±0.6347.5±0.6035.1±0.5835.5±0.5832.2±0.5818.4±0.4918.0±0.4725.9±0.53
      Service branch
      P<0.05.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.05.
      P<0.05.
      P<0.05.
      P<0.01.
      P<0.05.
      P<0.01.
      P<0.05.
      Army (n=6,932)68.0±0.7349.0±0.9231.5±0.8619.5±0.7548.3±0.7732.7±0.7232.1±0.7224.5±0.6915.5±0.5816.8±0.5825.2±0.66
      Navy (n=7,571)70.0±0.6846.5±0.8832.0±0.8221.5±0.7751.3±0.7435.0±0.7136.4±0.7126.2±0.6917.7±0.5616.1±0.5527.4±0.66
      Marine Corps (n=8,339)70.3±0.6743.8±0.8628.9±0.7927.4±0.8047.2±0.7334.9±0.7036.5±0.7037.2±0.7219.8±0.6022.3±0.6127.3±0.65
      Air Force (n=11,574)69.2±0.4651.3±0.6030.8±0.5517.9±0.4750.8±0.5030.9±0.4632.0±0.4726.7±0.4514.8±0.3612.9±0.3324.9±0.43
      Coast Guard (n=5461)68.0±0.6949.4±0.9031.8±0.8318.9±0.7151.6±0.7432.1±0.6935.4±0.7124.5±0.6414.0±0.5110.3±0.4427.2±0.65
      Rank
      P<0.05.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.05.
      P<0.05.
      P<0.01.
      P<0.05.
      Junior enlisted (E1-E4
      E1-E9=enlisted grades 1 to 9.
      ) (n=12,462)
      67.2±0.6345.4±0.7930.6±0.7424.0±0.6845.5±0.6634.2±0.6234.3±0.6231.8±0.6118.3±0.5018.4±0.5124.1±0.56
      Senior enlisted (E5-E9) (n=17,733)69.9±0.4548.6±0.5831.1±0.5420.3±0.4851.2±0.4932.9±0.4634.3±0.4624.9±0.4316.1±0.3617.5±0.3726.7±0.43
      Warrant officer (n=1,678)69.5±1.4146.4±1.8436.1±1.7717.5±1.4354.8±1.5332.5±1.4434.4±1.4619.0±1.2215.4±1.1311.3±0.9632.1±1.44
      Officer (n=8,004)72.1±0.6154.9±0.8131.9±0.7513.2±0.5756.0±0.6830.2±0.6230.9±0.6420.8±0.5811.6±0.457.6±0.3728.8±0.63
      Occupational category
      P<0.05.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.05.
      P<0.05.
      P<0.01.
      P<0.05.
      Combat (n=9,025)71.1±0.7145.9±0.9131.3±0.8522.9±0.7750.2±0.7834.2±0.7336.0±0.7432.2±0.7417.5±0.5918.1±0.6126.9±0.68
      Combat service (n=10,921)67.4±0.6850.9±0.8430.4±0.7618.7±0.6947.8±0.7031.9±0.6631.7±0.6123.1±0.6114.4±0.5114.6±0.5125.4±0.60
      Combat service support (n=19,930)68.8±0.4748.3±0.5931.3±0.5520.3±0.4950.0±0.5033.0±0.4633.5±0.4526.4±0.4516.7±0.3816.0±0.3725.7±0.43
      Body mass index (kg/m2)
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.05.
      P<0.05.
      P<0.05.
      P<0.01.
      P<0.01.
      ≤24.9 (n=11,750)66.4±0.6651.3±0.8331.2±0.7717.5±0.6647.5±0.6832.2±0.6332.6±0.6525.8±0.6215.3±0.518.0±0.3621.6±0.56
      25.0-29.9 (n=20,905)69.6±0.4647.7±0.5931.1±0.5521.3±0.4950.5±0.5033.0±0.4633.7±0.4728.3±0.4616.4±0.3716.7±0.3827.1±0.44
      ≥30 (n=6,363)71.1±0.8045.8±1.0331.0±0.9523.2±0.8949.8±0.8834.0±0.8335.3±0.8426.1±0.7817.4±0.6626.3±0.7928.8±0.79
      Vigorous physical activity (min/wk)
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.05.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      <75 (n=18,969)64.6±0.5152.4±0.6531.1±0.6016.6±0.5146.5±0.5329.7±0.4829.5±0.4819.3±0.4413.9±0.3813.9±0.3722.8±0.44
      75-150 (n=4,215)69.6±1.0150.4±1.2831.0±1.2118.6±0.9749.0±1.0830.8±0.9832.4±1.0029.1±0.9915.1±0.7714.7±0.7625.0±0.92
      >150 (n=15,430)73.4±0.5243.9±0.6631.2±0.6224.9±0.5953.1±0.5837.1±0.5638.5±0.5635.3±0.5619.3±0.4619.1±0.4629.6±0.52
      Moderate physical activity (min/wk)
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      < 150 (n=15,129)64.4±0.5754.3±0.7230.1±0.6615.6±0.5345.6±0.5828.3±0.5228.5±0.5220.5±0.4813.5±0.4013.8±0.4222.1±0.48
      150-300 (n=14,610)69.4±0.5647.7±0.7031.6±0.6520.6±0.5949.9±0.5933.7±0.5634.3±0.5626.2±0.5316.2±0.4516.7±0.4526.7±0.53
      >300 (n=8,499)74.2±0.7142.1±0.9031.6±0.8426.3±0.8056.3±0.7938.4±0.7639.7±0.7736.6±0.7720.1±0.6318.5±0.6129.5±0.71
      Strength training (day/wk)
      P<0.01.
      P<0.01.
      P<0.05.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      <1 (n=11,327)57.7±0.6858.9±0.8829.2±0.8111.9±0.6140.6±0.6725.0±0.5824.3±0.5910.2±0.4410.6±0.4311.3±0.4418.5±0.53
      1-2 (n=10,877)66.7±0.6753.2±0.8431.3±0.7815.60.6348.3±0.6930.3±0.6331.2±0.6418.7±0.5714.1±0.4914.4±0.5022.3±0.57
      ≥3 (n=16,149)77.7±0.4840.7±0.6232.0±0.5927.3±0.5756.3±0.5639.7±0.5541.2±0.5543.2±0.5621.3±0.4620.3±0.4632.9±0.52
      Sleep (h/day)
      P<0.05.
      P<0.01.
      P<0.01.
      P<0.05.
      ≤4 (n=979)69.7±2.1749.5±2.7228.1±2.4027.4±2.1648.1±2.3032.6±2.0833.5±2.1227.0±2.0617.8±1.6923.3±1.8823.8±1.87
      5-6 (n=4,435)68.1±1.0349.6±1.3030.9±1.2019.5±1.0448.3±1.0830.7±1.0032.5±1.0025.2±0.9516.4±0.8116.0±0.8126.0±0.94
      7-8 (n=4,552)69.0±1.0050.4±1.2831.3±1.2018.2±1.0351.0±1.0630.6±0.9931.7±0.9926.6±0.9812.8±0.6912.6±0.7428.4±0.99
      ≥9 (n=456)62.6±3.3252.8±4.2424.3±3.3322.9±3.9343.3±3.3629.4±3.0828.9±3.0524.7±3.0515.3±2.5118.6±2.8222.5±2.77
      Alcoholic beverages
      P<0.05.
      P<0.05.
      Never (4,231)70.8±1.4547.1±1.7828.3±1.5924.5±1.5952.4±1.5436.6±1.4534.1±1.4329.6±1.4619.1±1.2119.9±1.2928.9±1.40
      <1 time/mo (n=6,903)67.7±0.8049.1±1.0031.7±0.9319.2±0.7949.4±0.8432.2±0.7732.9±0.7823.6±0.7315.6±0.6216.3±0.6425.1±0.71
      1 time/mo (n=892)70.1±0.6348.3±0.8030.8±0.7321.0±0.6751.2±0.6833.2±0.6334.6±0.6427.3±0.6116.3±0.5116.1±0.5026.1±0.59
      1-3 times/wk (n=18,491)71.7±0.6547.5±0.8531.9±0.8020.6±0.7050.6±0.7233.0±0.6834.8±0.6931.0±0.6816.6±0.5417.6±0.5726.7±0.63
      ≥4 times/wk (n=9,360)68.0±1.5148.5±1.8832.0±1.7619.4±1.6147.0±1.5729.3±1.4431.6±1.4627.6±1.4617.0±1.2414.5±1.1826.7±1.40
      Cigarette smoking
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      Not at all (n=21,975)72.1±0.8347.6±1.0331.6±0.9520.9±0.8854.0±0.9033.4±0.8435.8±0.8527.9±0.8216.4±0.6715.3±0.6528.9±0.81
      Some days (n=2,431)71.6±1.3544.6±1.7132.0±1.6023.4±1.4848.7±1.4735.5±1.4137.0±1.4230.8±1.3720.0±1.2121.3±1.2328.1±1.33
      Every day (n=4,511)61.3±1.0449.6±1.3430.7±1.2519.7±1.0741.1±1.0427.7±0.9428.5±0.9324.1±0.9216.3±0.7817.8±0.8218.5±0.82
      Participation in a weight control program
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      No (n=38,686)68.8±0.3548.4±0.4431.1±0.4120.5±0.3649.5±0.3732.9±0.3433.7±0.3427.3±0.3416.3±0.2815.5±0.2725.9±0.32
      Yes (n=1,111)76.2±1.9145.0±2.6530.4±2.3724.6±2.3050.9±2.2837.8±2.1937.2±2.2122.9±1.9318.4±1.7237.1±2.2228.4±2.06
      Peer group deterrence of substance use
      P<0.01.
      P<0.01.
      P<0.05.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      No (n=23,225)70.2±0.6944.2±0.8931.1±0.8424.7±0.7850.9±0.7536.8±0.7336.9±0.7330.0±0.7119.4±0.6118.4±0.5928.2±0.68
      Yes (n=10,563)68.7±0.3949.6±0.4931.1±0.4519.3±0.4049.1±0.4131.9±0.3832.7±0.3926.3±0.3715.4±0.3015.5±0.3125.3±0.36
      Leadership deterrence of substance use
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      P<0.01.
      No (n=30,245)71.4±0.7143.0±0.9331.0±0.8826.1±0.8451.4±0.7938.1±0.7838.1±0.7732.2±0.7520.3±0.6519.8±0.6529.1±0.72
      Yes (n=2,963)68.4±0.3949.8±0.4931.1±0.4519.0±0.3949.0±0.4131.6±0.3831.6±0.3825.7±0.3715.2±0.3015.2±0.3025.1±0.35
      a SE=standard error.
      b DS=dietary supplement
      c DoD=Department of Defense.
      d HS=high school.
      e Cllg=college.
      f E1-E9=enlisted grades 1 to 9.
      P<0.05.
      ∗∗ P<0.01.
      Table 3 shows that Marine Corps personnel had the highest overall prevalence of DS use, were most likely to report use of ≥5 categories, and reported the highest prevalence of use of antioxidants, bodybuilding, herbal, and weight-loss supplements. Navy personnel reported the highest use of individual VMs and fish oils. Officers reported higher use of any DS, and as military rank increased, so did the use of MVMs. As rank decreased, there was greater reported use of supplements in ≥5 categories and a greater use of individual VMs, herbals, and weight-loss supplements. Enlisted personnel (ranks other than officers) were more likely to use bodybuilding supplements. SMs in combat-related occupations reported the highest use of any DSs, supplements in ≥5 categories, MVMs, antioxidants, bodybuilding supplements, herbals, weight-loss supplements, and fish oils.
      Table 3 shows that as BMI increased, SMs were more likely to report use of ≥5 categories and higher use of any DS, individual VMs, herbals, weight-loss supplements, and fish oils; those in the 25.0 to 29.9 BMI category had a higher use of MVMs and bodybuilding supplements. As duration of vigorous and moderate physical activity and frequency of strength training increased, so did the reported use of ≥5 DS categories, use of any DS, and use of all 7 DS categories. Those reporting the most (≥9 hours) and least (≤4 hours) sleep were more likely to report using DS in ≥5 categories; those reporting the most sleep were least likely to use MVMs; those reporting the least sleep reported the highest use of herbal and weight-loss supplements. Those reporting the highest consumption of alcoholic beverages had the lowest use of antioxidants, and those reporting never drinking had the highest use of fish oils. As the frequency of smoking increased, the use of any DS, MVMs, and fish oils decreased; people who smoked every day reported the lowest use of individual VMs, antioxidants, and bodybuilding supplements. Those reporting participation in a weight control program reported higher use of any DS, use of ≥5 DS categories, and weight-loss supplements. Those reporting peer group or leadership deterrence of substance abuse reported lower use of all 7 DS categories and were less likely to report use of ≥5 DS categories.

      Characteristics Independently Associated with DS Use

      Table 4 presents the results of eight logistic regression models examining factors associated with any DS use and the seven individual DS categories. Factors independently associated with higher use of any DSs included female sex, higher educational level, service in the Marine Corps, senior enlisted and officers, combat service occupations, higher BMI, higher weekly duration of vigorous or moderate physical activity, greater frequency of strength training, and participation in a weight control program. Lower use of any DS was associated with cigarette smoking on some days and peer group or leadership deterrence of substance abuse.
      Table 4Logistic regression examining the association of any DS
      DS=dietary supplement.
      use and categories of DSs used ≥1 time/wk over the past 12 months and selected demographic, military, lifestyle, and attitudes regarding substance abuse predictors among Armed Forces personnel, DoD
      DoD=Department of Defense.
      Survey of Health-Related Behaviors, 2011
      CharacteristicDS Categories Reported ≥1 Time/wk
      Any DSMultivitamin or multimineralIndividual vitamins or mineralsAntioxidantsBodybuildingHerbalWeight lossFish oils
      OR
      OR=odds ratio.
      (95 CI)
      Sex
      Male1.01.01.01.01.01.01.01.0
      Female1.44
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.36, 1.53)
      1.53
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.45, 1.61)
      1.74
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.64, 1.83)
      1.02 (0.96, 1.08)0.30
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.28, 0.32)
      0.87 (0.82, 1.02)1.25
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.17, 1.35)
      0.81
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.76, 0.86)
      Age (y)
      <181.01.01.01.01.01.01.01.0
      18-240.94 (0.83, 1.07)0.87
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (0.78, 0.98)
      0.89 (0.79, 1.00)0.84
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (0.75, 0.95)
      1.29 (1.14, 1.47)0.87 (0.75, 1.01)0.98 (0.84, 1.14)0.83
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (0.73, 0.95)
      25-290.97 (0.86, 1.09)0.94 (0.84, 1.04)0.84
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (0.75, 0.95)
      0.81
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.72, 0.90)
      1.06 (0.94, 1.20)0.88 (0.76, 1.01)1.02 (0.89, 1.19)0.89 (0.79, 1.01)
      30-390.90 (0.81, 1.02)0.95 (0.86, 1.06)0.84
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.75, 0.94)
      0.81
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.72, 0.90)
      0.73
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.64, 0.82)
      0.76
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.66, 0.87)
      0.89 (0.77, 1.02)0.93 (0.83, 1.05)
      ≥400.88 (0.78, 1.00)0.95 (0.84, 1.06)1.00 (0.89, 1.13)0.83
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (0.74, 0.93)
      0.39
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.34, 0.46)
      0.75
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.64, 0.88)
      0.60
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.51, 0.70)
      1.22 (1.08, 1.39)
      Education
      Some HS
      HS=high school.
      or HS graduate
      1.01.01.01.01.01.01.01.0
      Some college or college degree1.28
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.18, 1.39)
      1.31
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (1.22, 1.42)
      1.07 (0.99, 1.17)1.11 (1.02, 1.20)1.13
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (1.04, 1.24)
      1.06 (0.96, 1.18)0.97 (0.87, 1.07)1.21
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.10, 1.32)
      Graduate degree1.38
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.20, 1.58)
      1.52
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (1.34, 1.73)
      1.16 (1.01, 1.34)1.13 (0.98, 1.29)0.89 (0.75, 1.05)1.01 (0.84, 1.20)0.75
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.62, 0.90)
      1.53
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.32, 1.77)
      Marital status
      Not married1.01.01.01.01.01.01.01.0
      Married0.97 (0.90, 1.04)1.06 (0.99, 1.13)0.92
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (0.86, 0.98)
      0.88
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.82, 0.94)
      0.76
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.70, 0.82)
      0.83
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.76, 0.91)
      0.92 (0.84, 1.00)0.89
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (0.82, 0.96)
      Service branch
      Army1.01.01.01.01.01.01.01.0
      Navy1.08 (0.98, 1.18)1.12
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (1.03, 1.22)
      1.11 (1.02, 1.22)1.22
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.12, 1.33)
      1.05 (0.95, 1.17)1.18
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (1.05, 1.33)
      0.91 (0.81, 1.02)1.16 (1.05, 1.27)
      Marine Corps1.17
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (1.06, 1.28)
      1.05 (0.96, 1.15)1.16
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (1.05, 1.27)
      1.22
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.11, 1.33)
      1.40
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.27, 1.55)
      1.27
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.13, 1.43)
      1.31
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.17, 1.47)
      1.20
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (1.09, 1.33)
      Air Force1.02 (0.94, 1.10)1.07 (0.99, 1.15)0.91
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (0.84, 0.98)
      1.00 (0.93, 1.08)1.09 (1.00, 1.20)0.96 (0.87, 1.07)0.70
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.63, 0.78)
      1.02 (0.94, 1.11)
      Coast Guard0.98 (0.90, 1.07)1.12
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (1.03, 1.21)
      0.99 (0.91, 1.08)1.16
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (1.06, 1.26)
      0.96 (0.87, 1.06)0.89 (0.80, 1.01)0.54
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.48, 0.62)
      1.12 (1.02, 1.23)
      Rank
      Junior enlisted (E1-E4
      E1-E9=enlisted grades 1 to 9.
      )
      1.01.01.01.01.01.01.01.0
      Senior enlisted (E5-E9)1.17
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (1.07, 1.28)
      1.22
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.12, 1.33)
      0.95 (0.87, 1.04)1.01 (0.92, 1.10)0.98 (0.89, 1.08)0.91 (0.82, 1.02)1.05 (0.94, 1.17)1.04 (0.95, 1.15)
      Warrant officer1.20
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (1.02, 1.41)
      1.43
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.23, 1.66)
      0.92 (0.79, 1.08)1.03 (0.88, 1.21)0.88 (0.73, 1.06)0.90 (0.73, 1.10)0.75
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (0.60, 0.93)
      1.21 (1.03, 1.42)
      Officer1.30
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.18, 1.44)
      1.46
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.33, 1.61)
      0.81
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.73, 0.89)
      0.87
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (0.79, 0.96)
      0.87
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (0.78, 0.97)
      0.64
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.56, 0.73)
      0.42
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.37, 0.48)
      1.13 (1.01, 1.26)
      Occupational category
      Combat service support1.01.01.01.01.01.01.01.0
      Combat service1.14
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (1.05, 1.24)
      1.04 (0.97, 1.12)1.09 (1.01, 1.18)1.12
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (1.04, 1.21)
      1.24
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.14, 1.34)
      1.04 (0.95, 1.15)1.16
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (1.06, 1.28)
      1.06 (0.98, 1.16)
      Combat0.91
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (0.85, 0.99)
      0.87
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.81, 0.93)
      0.96 (0.89, 1.03)0.94 (0.87, 1.01)0.91
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (0.84, 0.99)
      0.89
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.81, 0.98)
      1.02 (0.92, 1.12)0.94 (0.87, 1.02)
      Body mass index (calculated as kg/m2)
      ≤24.91.01.01.01.01.01.01.01.0
      25.0-29.91.23
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.14, 1.33)
      1.16
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.09, 1.25)
      1.15
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (1.07, 1.24)
      1.07 (0.99, 1.15)1.15
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (1.06, 1.26)
      1.12
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (1.02, 1.24)
      2.81
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (2.51, 3.15)
      1.27
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.17, 1.38)
      ≥301.36
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.22, 1.50)
      1.13 (1.03, 1.24)1.23
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.11, 1.36)
      1.15 (1.04, 1.26)1.10 (0.98, 1.23)1.22
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (1.07, 1.38)
      5.44
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (4.75, 6.23)
      1.35
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.21, 1.50)
      Vigorous physical activity (min/wk)
      <751.01.01.01.01.01.01.01.0
      75-1501.27
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.14, 1.41)
      1.13 (1.02, 1.24)1.09 (0.99, 1.21)1.15
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (1.04, 1.28)
      1.62
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.45, 1.82)
      1.10 (0.96, 1.25)1.09 (0.95, 1.24)1.14 (1.02, 1.27)
      >1501.58
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.48, 1.69)
      1.35
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.27, 1.44)
      1.45
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.35, 1.54)
      1.50
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.41, 1.60)
      2.16
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (2.01, 2.33)
      1.46
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.34, 1.59)
      1.48
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.36, 1.62)
      1.44
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.34, 1.54)
      Moderate physical activity (min/wk)
      <1501.01.01.01.01.01.01.01.0
      150-3001.26
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.18, 1.36)
      1.20
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.13, 1.28)
      1.29
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.20, 1.38)
      1.31
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.22, 1.40)
      1.39
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.28, 1.51)
      1.23
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.12, 1.35)
      1.24
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.13, 1.37)
      1.29
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.19, 1.39)
      >3001.66
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.52, 1.81)
      1.48
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.37, 1.60)
      1.61
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.49, 1.75)
      1.65
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.52, 1.79)
      2.11
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.92, 2.30)
      1.56
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.40, 1.72)
      1.37
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.23, 1.52)
      1.52
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.39, 1.65)
      Strength training (d/wk)
      <11.01.01.01.01.01.01.01.0
      1-21.49
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.37, 1.61)
      1.39
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.29, 1.51)
      1.33
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.22, 1.45)
      1.42
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.30, 1.55)
      2.00
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.77, 2.26)
      1.37
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.22, 1.55)
      1.34
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.19, 1.50)
      1.27
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.15, 1.39)
      ≥32.71
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (2.50, 2.93)
      2.04
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.90, 2.19)
      2.10
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.94, 2.27)
      2.19
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (2.03, 2.37)
      6.27
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (5.60, 7.00)
      2.21
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.99, 2.45)
      1.97
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.77, 2.18)
      2.23
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (2.05, 2.42)
      Sleep (h/day)
      ≤41.01.01.01.01.01.01.01.0
      5-60.90 (0.72, 1.13)0.97 (0.79, 1.18)0.95 (0.77, 1.18)0.97 (0.79, 1.20)0.96 (0.76, 1.22)0.94 (0.73, 1.22)0.69
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (0.55, 0.59)
      1.09 (0.87, 1.37)
      7-80.93 (0.75, 1.17)1.07 (0.87, 1.31)0.95 (0.77, 1.18)0.95 (0.77, 1.18)1.05 (0.83, 1.34)0.72
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.55, 0.94)
      0.55
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.43, 0.71)
      1.25 (0.99, 1.57)
      ≥90.71 (0.50, 1.00)0.81 (0.58, 1.12)0.79 (0.56, 1.12)0.81 (0.57, 1.15)0.94 (0.64, 1.40)0.86 (0.55, 1.35)0.74 (0.48, 1.13)1.00 (0.69, 1.46)
      Alcoholic beverages
      Never1.01.01.01.01.01.01.01.0
      <1 time/mo0.87 (0.74, 1.02)0.88 (0.76, 1.01)0.85 (0.74, 1.04)0.95 (0.83, 1.10)0.74
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.63, 0.88)
      0.80 (0.67, 0.99)0.82
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.68, 0.98)
      0.80
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (0.69, 0.94)
      1 time/mo0.99 (0.85, 1.15)0.96 (0.84, 1.10)0.91 (0.80, 1.05)1.04 (0.90, 1.19)0.85
      P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      (0.73, 0.99)
      0.85 (0.71, 1.01)0.83 (0.69, 0.99)0.85 (0.73, 0.98)
      1-3 times/wk1.07 (0.92, 1.25)0.94 (0.82, 1.07)0.95 (0.82, 1.09)1.06 (0.92, 1.22)1.00 (0.85, 1.16)0.89 (0.75, 1.06)1.00 (0.83, 1.20)0.85 (0.73, 0.99)
      ≥4 times/wk0.91 (0.75, 1.10)0.82 (0.68, 0.97)0.81 (0.67, 0.98)0.92 (0.77, 1.11)0.86 (0.70, 1.06)0.93 (0.74, 1.18)0.83 (0.65, 1.07)0.83 (0.68, 1.01)
      Cigarette smoking
      Not at all1.01.01.01.01.01.01.01.0
      Some days0.64
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.57, 0.72)
      0.64
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.57, 0.72)
      0.74
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.66, 0.84)
      0.70
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.62, 0.79)
      0.69
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.60, 0.79)
      0.90 (0.78, 1.05)1.06 (0.91, 1.24)0.59
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.52, 0.68)
      Every day1.01 (0.86, 1.18)0.87 (0.76, 1.00)1.07 (0.92, 1.24)1.01 (0.88, 1.17)0.90 (0.77, 1.06)1.12 (0.94, 1.35)1.30 (1.08, 1.55)1.01 (0.87, 1.18)
      Participation in a weight control program
      No1.01.01.01.01.01.01.01.0
      Yes1.46
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (1.19, 1.81)
      1.08 (0.90, 1.30)1.18 (0.98, 1.42)1.15 (0.95, 1.39)0.78 (0.62, 0.98)1.10 (0.88, 1.39)2.94
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (2.42, 3.57)
      1.18 (0.97, 1.45)
      Peer group deterrence of substance use
      No1.01.01.01.01.01.01.01.0
      Yes0.91
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.85, 0.98)
      0.91
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.85, 0.97)
      0.81
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.75, 0.87)
      0.84
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.78, 0.90)
      0.86
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.79, 0.93)
      0.77
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.71, 0.85)
      0.85
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.77, 0.93)
      0.85
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.79, 0.92)
      Leadership deterrence of substance use
      No1.01.01.01.01.01.01.01.0
      Yes0.85
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.78, 0.91)
      0.87
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.81, 0.94)
      0.75
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.70, 0.81)
      0.79
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.73, 0.85)
      0.77
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.71, 0.84)
      0.73
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.66, 0.80)
      0.76
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.69, 0.83)
      0.80
      P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      (0.74, 0.86)
      a DS=dietary supplement.
      b DoD=Department of Defense.
      c OR=odds ratio.
      d HS=high school.
      e E1-E9=enlisted grades 1 to 9.
      ∗∗ P≤0.01 (difference between the stratum with the asterisk and the baseline stratum).
      ∗∗∗ P≤0.001 (difference between the stratum with the asterisk and the baseline stratum).
      Factors independently associated with higher use of MVMs included female sex, higher educational level, service in the Navy or Coast Guard, higher rank, BMI of 25 to 29.9, higher weekly duration of vigorous or moderate physical activity, and greater frequency of strength training. Lower use of MVMs was associated with people in the 18- to 24-year age group, service in combat-related occupations, cigarette smoking on some days, and peer group or leadership deterrence of substance abuse.
      For individual VMs, factors independently associated with higher use included female sex, Marine Corps service, higher BMI, higher weekly duration of vigorous or moderate physical activity, and greater frequency of strength training. Lower use of individual VMs was associated with ages 25 to 39 years, being married, service in the Air Force, officer status, smoking on some days, and peer group or leadership deterrence of substance abuse.
      For antioxidants, factors independently associated with higher use included service in the Navy, Marine Corps, or Coast Guard; combat service occupations; higher weekly duration of vigorous or moderate physical activity; and greater frequency of strength training. Lower use of antioxidants was associated with older age, being married, officer status, smoking on some days, and peer group or leadership deterrence of substance abuse.
      For bodybuilding supplements, factors independently associated with higher use included male sex, some college or a college degree, service in the Marine Corps, combat service occupations, BMI of 25.0 to 29.9, higher weekly duration of vigorous or moderate physical activity, and greater frequency of strength training. Lower use of bodybuilding supplements was associated with female sex, older age, being married, officer status, combat-related occupations, less frequent alcohol consumption, cigarette smoking on some days, and peer group or leadership deterrence of substance abuse.
      For herbal supplements, factors independently associated with higher use included service in the Navy or Marine Corps, higher BMI, higher weekly duration of vigorous or moderate physical activity, and greater frequency of strength training. Lower use of herbal supplements was associated with older age, being married, officer status, combat-related occupations, 7 to 8 hours of sleep per night, and peer group or leadership deterrence of substance abuse.
      For weight-loss supplements, factors independently associated with higher use included female sex, service in the Marine Corps, combat service occupations, higher BMI, higher weekly duration of vigorous or moderate physical activity, greater frequency of strength training, and participation in a weight control program. Lower use of weight-loss supplements was associated with older age, a graduate degree, service in the Air Force or Coast Guard, warrant officer or officer status, 5 to 8 hours of sleep each night, alcohol consumption <1 time per month, and peer group or leadership deterrence of substance abuse.
      For fish oils, factors independently associated with higher use included male sex, higher educational level, service in the Marine Corps, higher BMI, higher weekly duration of vigorous or moderate physical activity, and greater frequency of strength training. Lower use of fish oils was associated with female sex, people in the 18- to 24-year age group, being married, some alcohol consumption, cigarette smoking on some days, and peer group or leadership deterrence of substance abuse.

      Discussion

      The present study is the first to examine broad and comprehensive categories of DS use in all the military services using a single identical survey and a representative sample of the population of interest. Previous investigations
      • Lieberman H.R.
      • Stavinoha T.B.
      • McGraw S.M.
      • et al.
      Use of dietary supplements among active-duty US Army soldiers.
      • Austin K.G.
      • Price L.L.
      • McGraw S.M.
      • et al.
      Predictors of dietary supplement use by US Coast Guard personnel.
      • Austin K.G.
      • Price L.L.
      • Mcgraw S.M.
      • et al.
      Demographic, lifestyle factors and reasons for use of dietary supplements by Air Force personnel.
      • Knapik J.J.
      • Trone D.W.
      • Austin K.G.
      • et al.
      Prevalence, adverse effects, and factors associated with dietary supplement and nutritional supplement use by United States Navy and Marine Corps personnel.
      • Austin K.G.
      • Price L.L.
      • McGraw S.M.
      • et al.
      Longitudinal trends in use of dietary supplements by US Army personnel differ from those of civilians.
      examined each service separately, and as a consequence, cross-service comparisons were limited due to differences in sampling techniques, passage of time between the conduct of surveys, and revision of questionnaires over time to include new DSs.
      • Knapik J.J.
      • Trone D.W.
      • Austin K.G.
      • et al.
      Prevalence, adverse effects, and factors associated with dietary supplement and nutritional supplement use by United States Navy and Marine Corps personnel.
      Analysis of the 2005 DoD survey
      • Kao T.C.
      • Deuster P.A.
      • Burnett D.
      • et al.
      Health behaviors associated with use of body building, weight loss, and performance enhancing supplements.
      was limited because only three categories of DSs, bodybuilding, weight loss, and performance-enhancing, were assessed. Another large representative study of the DoD also only assessed intake of a limited number of supplements: bodybuilding supplements, energy supplements, and weight-loss supplements.
      • Jacobson I.G.
      • Horton J.L.
      • Smith B.
      • et al.
      Bodybuilding, energy, and weight loss supplements are associated with deployment and physical activity in U.S. military personnel.
      The current study used data collected from a stratified random sample of all the Armed Forces and found 69% of SMs reported using DSs from at least one of seven categories and 21% reported use of ≥5 categories per week. Overall prevalence of use was 50% for MVMs, 34% for antioxidants, 33% for individual VMs, 27% for bodybuilding supplements, 26% for fish oils, and 16% for herbals and weight-loss supplements. Factors independently associated with higher use of any DS included female sex, higher educational level, service in the Marines Corps, officer or senior enlisted status, combat service occupations, higher BMI, longer duration of vigorous or moderate physical activity, greater frequency of weight training, and participation in a weight control program. Peer group or leadership deterrence of substance abuse was associated with lower DS use and this is likely the first time such an association has been noted.

      Prevalence

      Table 5 presents DS prevalences in this and previous military studies across directly comparable DS categories. The table indicates overall DS and MVM use observed in the current study were largely similar to those observed in previous studies. For individual VMs, prevalence in the current study was generally higher than past studies,
      • Lieberman H.R.
      • Stavinoha T.B.
      • McGraw S.M.
      • et al.
      Use of dietary supplements among active-duty US Army soldiers.
      • Austin K.G.
      • Price L.L.
      • McGraw S.M.
      • et al.
      Predictors of dietary supplement use by US Coast Guard personnel.
      • Austin K.G.
      • Price L.L.
      • Mcgraw S.M.
      • et al.
      Demographic, lifestyle factors and reasons for use of dietary supplements by Air Force personnel.
      • Knapik J.J.
      • Trone D.W.
      • Austin K.G.
      • et al.
      Prevalence, adverse effects, and factors associated with dietary supplement and nutritional supplement use by United States Navy and Marine Corps personnel.
      • Austin K.G.
      • Price L.L.
      • McGraw S.M.
      • et al.
      Longitudinal trends in use of dietary supplements by US Army personnel differ from those of civilians.
      and this may be due to differences in the questionnaires used. When comparing similar categories in the 2005 DoD survey
      • Kao T.C.
      • Deuster P.A.
      • Burnett D.
      • et al.
      Health behaviors associated with use of body building, weight loss, and performance enhancing supplements.
      to the 2011 survey, the use of bodybuilding substances appear to have increased 1.4-fold, while those for weight-loss supplements changed little. Bodybuilding supplements and weight-loss supplements are among the most dangerous DSs because they are frequently associated with adverse effects
      • Knapik J.J.
      • Trone D.W.
      • Austin K.G.
      • et al.
      Prevalence, adverse effects, and factors associated with dietary supplement and nutritional supplement use by United States Navy and Marine Corps personnel.
      and a number have been recalled by the Federal Drug Administration.

      US Food and Drug Administration. FDA acts to remove Ephedra-containing dietary supplements from market. ScienceDaily. November 25, 2004. www.sciencedaily.com/releases/2004/11/041124160436.htm. Accessed May 22, 2018.

      Young S. Stop using Hydroxycut products, FDA says. http://www.cnn.com/2009/HEALTH/05/01/hydroxycut.fda.recall/index.html. May 1, 2009. Accessed May 23, 2018.

      US Food and Drug Administration. 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.

      Table 5Comparison of DS
      DS=dietary supplement
      use prevalence (≥1 time/wk) in present and former Armed Forces studies (values are % using DS±SE
      SE=standard error.
      )
      Military ServiceAny DSMultivitamin or MultimineralsIndividual Vitamins or MineralsBodybuilding SupplementsWeight-Loss Supplements
      Present study (2011 DoD
      DoD=Department of Defense
      Survey)
      Past studies
      From references 9-11,17.
      Present study (2011 DoD Survey)Past studies
      From references 9-11,17.
      Present study (2011 DoD Survey)Past studies
      From references 9-11,17.
      Present study (2011 DoD Survey)Past study
      From reference 16.
      (2005 DoD Survey)
      Present study (2011 DoD Survey)Past study
      From reference 16.
      (2005 DoD Survey)
      Army68.0±0.763.9±1.748.3±0.839.2±1.732.7±0.720.4±1.424.5±0.720.9±1.516.8±0.618.0±0.8
      Navy70.0±0.770.7±1.751.3±0.748.6±1.935.0±0.729.6±1.726.2±0.719.1±1.516.1±0.618.8±1.0
      Marine Corps70.3±0.774.2±1.447.2±0.747.6±1.634.9±0.728.6±1.437.2±0.728.4±1.322.3±0.621.1±1.1
      Air Force69.2±0.568.0±1.150.8±0.545.4±1.230.9±0.523.5±1.026.7±0.517.8±1.112.9±0.315.9±1.0
      Coast Guard68.0±0.769.9±1.551.6±0.747.7±1.732.1±0.722.3±1.424.5±0.6ND
      ND=no data (not reported or available in respective studies).
      10.3±0.4ND
      DoD surveys (all services)69.1±0.3ND49.5±0.4ND33.9±0.3ND27.2±0.321.5±0.816.2±0.317.4±0.7
      a DS=dietary supplement
      b SE=standard error.
      c DoD=Department of Defense
      d From references
      • Austin K.G.
      • Price L.L.
      • McGraw S.M.
      • et al.
      Predictors of dietary supplement use by US Coast Guard personnel.
      ,
      • Austin K.G.
      • Price L.L.
      • Mcgraw S.M.
      • et al.
      Demographic, lifestyle factors and reasons for use of dietary supplements by Air Force personnel.
      ,
      • Knapik J.J.
      • Trone D.W.
      • Austin K.G.
      • et al.
      Prevalence, adverse effects, and factors associated with dietary supplement and nutritional supplement use by United States Navy and Marine Corps personnel.
      ,
      • Austin K.G.
      • Price L.L.
      • McGraw S.M.
      • et al.
      Longitudinal trends in use of dietary supplements by US Army personnel differ from those of civilians.
      .
      e From reference 
      • Kao T.C.
      • Deuster P.A.
      • Burnett D.
      • et al.
      Health behaviors associated with use of body building, weight loss, and performance enhancing supplements.
      .
      f ND=no data (not reported or available in respective studies).
      When data from the present study are compared with population-based data from the civilian NHANES, it is apparent SMs are more likely to use DSs, use different DSs, and use multiple DSs simultaneously (stacking) compared with civilians. Overall, DS prevalences of use in the NHANES data were 23% in 1987, 24% in 1992, 34% in 2000, 49% in 2003 to 2006, and 48% in 2007 to 2008.
      • 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 over 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.
      A recent analyses of seven cycles of NHANES data collected from 1999 through 2012 reported use of any supplement was relatively stable with 52% reporting any DS use; however, there was a decline in MVM use, from 37% in 1999 to 2000 to 31% in 2011 to 2012.
      • Kantor E.D.
      • Rehm C.D.
      • Du M.
      • et al.
      Trends in dietary supplement use among US adults from 1999-2012.
      Civilian use of any DS as determined by NHANES was considerably lower than the 69% for any DS and 50% MVMs reported here. The 2003 to 2006 NHANES data indicated 14% of the sample used herbal supplements in the last month,
      • Bailey R.L.
      • Gahche J.J.
      • Lentino C.V.
      • et al.
      Dietary supplement use in the United States, 2003-2006.
      and 2011 to 2012 data indicated 12% used fish oils
      • Kantor E.D.
      • Rehm C.D.
      • Du M.
      • et al.
      Trends in dietary supplement use among US adults from 1999-2012.
      ; this compares with 16% and 26%, respectively, in the present study. A category of “bodybuilding” supplements was not included in any analysis of NHANES data but 2003 to 2006 NHANES data indicate only 4% of participants use amino acids, which are often used for bodybuilding,
      • Bailey R.L.
      • Gahche J.J.
      • Lentino C.V.
      • et al.
      Dietary supplement use in the United States, 2003-2006.
      compared with 27% who reported using legal bodybuilding supplements in the present study. Thus, compared with national samples, SMs in the present study had a much higher use of any DSs, MVMs, and fish oils, but similar use of herbal substances. It should be noted the NHANES samples include people whose average age was older than the military population and the reporting time frame differed: in NHANES the reporting time frame was the last 30 days, and the present study examined use ≥1 time per week in the past year.

      Characteristics Associated with DS Use

      Many 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).
      • Kantor E.D.
      • Rehm C.D.
      • Du M.
      • et al.
      Trends in dietary supplement use among US adults from 1999-2012.
      • Bailey R.L.
      • Gahche J.J.
      • Miller P.E.
      • et al.
      Why US adults use dietary supplements.
      • 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. Results from the third National Health and Nutrition Examination Survey.
      • 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.
      • 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.
      and military
      • Lieberman H.R.
      • Stavinoha T.B.
      • McGraw S.M.
      • et al.
      Use of dietary supplements among active-duty US Army soldiers.
      • 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.
      • Austin K.G.
      • Price L.L.
      • McGraw S.M.
      • et al.
      Predictors of dietary supplement use by US Coast Guard personnel.
      • Austin K.G.
      • Price L.L.
      • Mcgraw S.M.
      • et al.
      Demographic, lifestyle factors and reasons for use of dietary supplements by Air Force personnel.
      • Knapik J.J.
      • Trone D.W.
      • Austin K.G.
      • et al.
      Prevalence, adverse effects, and factors associated with dietary supplement and nutritional supplement use by United States Navy and Marine Corps personnel.
      investigations have found women were more likely to use DS overall, especially MVMs and individual VMs. Such sex differences may be associated with 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 more likely to make lifestyle changes 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, men in the DoD reported they were much more likely to use bodybuilding supplements, as found in the 2005 DoD survey and numerous other studies.
      • Kao T.C.
      • Deuster P.A.
      • Burnett D.
      • et al.
      Health behaviors associated with use of body building, weight loss, and performance enhancing supplements.
      This may be related to the fact 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.
      As also noted in the 2005 DoD Survey of Health Related Behaviors, service women, SMs with higher BMI, and SMs who previously participated in weight control programs were both more likely to use weight-loss supplements.
      • Kao T.C.
      • Deuster P.A.
      • Burnett D.
      • et al.
      Health behaviors associated with use of body building, weight loss, and performance enhancing supplements.
      There are strict weight-for-height and body fat requirements in the Armed Forces.

      Department of Defense. DoD Physical Fitness and Body Fat Programs Procedures. Department of Defense Instruction 1308.3. November 5, 2002.

      US Department of Homeland Security. United States Coast Guard. Coast Guard Weight and Body Fat Standards. COMDTINST M1020.8H. September 2015.

      Those who cannot meet the standards in specified time frames are subject to disciplinary action and may be discharged from service. Therefore, SMs who have difficulty meeting the body weight or body fat requirements may be more likely to use weight-loss supplements.
      Previous military
      • Lieberman H.R.
      • Stavinoha T.B.
      • McGraw S.M.
      • et al.
      Use of dietary supplements among active-duty US Army soldiers.
      • Austin K.G.
      • Price L.L.
      • Mcgraw S.M.
      • et al.
      Demographic, lifestyle factors and reasons for use of dietary supplements by Air Force personnel.
      • Knapik J.J.
      • Trone D.W.
      • Austin K.G.
      • et al.
      Prevalence, adverse effects, and factors associated with dietary supplement and nutritional supplement use by United States Navy and Marine Corps personnel.
      • Austin K.G.
      • Price L.L.
      • McGraw S.M.
      • et al.
      Longitudinal trends in use of dietary supplements by US Army personnel differ from those of civilians.
      and civilian investigations
      • 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).
      • Kantor E.D.
      • Rehm C.D.
      • Du M.
      • et al.
      Trends in dietary supplement use among US adults from 1999-2012.
      • 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.
      • 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.
      • Koplan J.P.
      • Annest J.L.
      • Layde P.M.
      • et al.
      Nutrient intake and supplementation in the United States (NHANES II).
       have generally found higher educational levels are associated with higher DS use. The current investigation also observed this association with the strongest relationships among users of MVMs and fish oils. People 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 level on determinants 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.
      which may lead to higher use of some type of DSs.
      • Khorsan R.
      • Crawford C.
      • J.A I
      • et al.
      The effect of omega-3 fatty acids on biomarkers of inflammation: A rapid evidence assessment of the literature.
      • DiNicolantonio J.J.
      • Niazi A.K.
      • McCarty M.F.
      • et al.
      Omega-3s and cardiovascular health.
      • Hibbeln C.R.
      • Gow R.V.
      The potential for military diets to reduce depression, suicide, and impulsive aggression: A review of current evidence for omega-3 and omega-6 fatty acids.
      Across all military services, total DS use was similar, but Marines were distinctive for their higher use of weight-loss and bodybuilding supplements, as also noted in the 2005 DoD survey of Health-Related Behaviors.
      • Kao T.C.
      • Deuster P.A.
      • Burnett D.
      • et al.
      Health behaviors associated with use of body building, weight loss, and performance enhancing supplements.
      Greater use of weight-loss supplements by Marines may be related to the emphasis this service places on body fat and military appearance. As noted previously, military services have strict weight-for-height and body fat standards,
      US Marine Corps
      Marine Corps Body Composition and Military Appearance Program. Marine Corps Order 6110.3.
      US Airforce
      Fitness Program. Air Force Instruction 36-2905.
      US Army
      The Army Body Composition Program. Army Regulation 600-9.
      • US Navy
      Physical Readiness Program, OPNAV Instruction 6110.1J.
      and the weight-for-height standards of the Marine Corps are similar to the other services. Body fat assessment is only conducted if an SM does not meet the weight-for-height standard, and the Marine Corps standards permits less body fat than most of the other services. Also, the Marine Corps is the only service that permits commanders to evaluate a person’s “military appearance,” a subjective assessment of “improper distribution/excessive accumulation of body fat.”
      US Marine Corps
      Marine Corps Body Composition and Military Appearance Program. Marine Corps Order 6110.3.
      The greater emphasis on body fat and appearance may at least partly account for the higher use of some supplements among Marines.
      In both univariate and multiple regression analyses, measures of moderate physical activity, vigorous physical activity, and strength training were all associated in a dose-dependent manner with higher overall use of DSs and each of the 7 DS categories. Most military investigations examining this relationship have reported similar results
      • Austin K.G.
      • Price L.L.
      • McGraw S.M.
      • et al.
      Predictors of dietary supplement use by US Coast Guard personnel.
      • Austin K.G.
      • Price L.L.
      • Mcgraw S.M.
      • et al.
      Demographic, lifestyle factors and reasons for use of dietary supplements by Air Force personnel.
      • Kao T.C.
      • Deuster P.A.
      • Burnett D.
      • et al.
      Health behaviors associated with use of body building, weight loss, and performance enhancing supplements.
      • Austin K.G.
      • Price L.L.
      • McGraw S.M.
      • et al.
      Longitudinal trends in use of dietary supplements by US Army personnel differ from those of civilians.
      or showed trends in this direction,
      • Lieberman H.R.
      • Stavinoha T.B.
      • McGraw S.M.
      • et al.
      Use of dietary supplements among active-duty US Army soldiers.
      • Knapik J.J.
      • Trone D.W.
      • Austin K.G.
      • et al.
      Prevalence, adverse effects, and factors associated with dietary supplement and nutritional supplement use by United States Navy and Marine Corps personnel.
      as have most
      • 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.
      • Bailey R.L.
      • Gahche J.J.
      • Miller P.E.
      • et al.
      Why US adults use dietary supplements.
      • 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.
      but not all
      • Block G.
      • Cox C.
      • Madans J.
      • et al.
      Vitamin supplement use, by demographic characteristics.
      civilian investigations. People who have higher levels of physical activity tend to have other favorable health habits,
      • Pate R.R.
      • Trost S.G.
      • Levin S.
      • et al.
      Sports participation and health-related behaviors among US youth.
      • Steptoe A.
      • Wardle J.
      • Fuller R.
      • et al.
      Leisure-time physical exercise: prevalence, attitudinal correlates and behavioral correlates among young Europeans from 21 countries.
      • Pate R.R.
      • Heath G.W.
      • Dowda M.
      • et al.
      Associations between physical activity and other health behaviors in a representative sample of US adolescents.
      and more active people may perceive certain DSs to be an additional way to improve their health and performance.
      Personnel who reported peer group or leadership deterrence of substance use reported significantly less DS use in each of the seven DS categories. Peer groups are known to influence health-related behaviors through peer modeling, imitation, and social learning.
      • Bandura A.
      Social Leaning Theory.
      • Brechwald W.A.
      • Prinstein M.J.
      Beyond homophily: A decade of advances in understanding peer influence processes.
      Leaders influence SMs through a number of mechanisms such as the issues they emphasize, measure, and control; how they allocate resources; role modeling; mentoring; rewards; and promotion.
      • Schneider B.
      • Ehrhart M.G.
      • Macey W.H.
      Organizational climate and culture.
      Lower use of DSs by those reporting leadership deterrence of substance abuse suggests leaders can provide an important deterrent to unnecessary and dangerous DS use.

      Conclusions

      This secondary analysis was a comprehensive evaluation of self-reported DS use conducted simultaneously in all services of the Armed Forces using a single survey instrument. Use of DSs was very common in all services of the Armed Forces with 69% of personnel reporting use compared with about 50% in civilian populations. Patterns of use observed in SMs differed from representative civilian populations with SMs more likely to use (≥1 time per week) MVMs (50%), individual VMs (33%), bodybuilding supplements (27%), fish oils (26%), and weight-loss supplements (16%). The extensive use of bodybuilding supplements is of concern because of the number of adverse events associated with them.
      • Knapik J.J.
      • Trone D.W.
      • Austin K.G.
      • et al.
      Prevalence, adverse effects, and factors associated with dietary supplement and nutritional supplement use by United States Navy and Marine Corps personnel.
      • Deuster P.A.
      • Lieberman H.R.
      Protecting military personnel from high risk dietary supplements.
      Demographic and lifestyle factors associated with DS use were similar to those found in other military and civilian investigations. An important finding of this study was lower use of DS when substance abuse was discouraged by the peer group or leadership. DoD and civilian education policy should strongly encourage this, and future investigations should be conducted to determine the effectiveness of such a strategy.

      Acknowledgements

      Thanks to the US Armed Forces personnel who participated in this study and the Inner City Fund International for data collection. Kimberley Aiyelawo, PhD (Dr Marshall) assisted with technical aspects of the manuscript.
      The opinions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Army or the Department of Defense. Citations of commercial organizations and trade names in this report do not constitute an official Department of the Army endorsement or approval of the products or services of these organizations. Approved for public release; distribution is unlimited.

      Author Contributions

      H. R. Lieberman and K. G. Austin designed the study; J. J. Knapik, K. G. Austin, E. K. Farina, and H. R. Lieberman analyzed data and wrote and edited the paper.

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      Biography

      J. J. Knapik is a senior epidemiologist and research physiologist, Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, MA, and at the Henry M. Jackson Foundation, Bethesda, MD.
      K. G. Austin is a research physiologist, Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, MA, and at the Oak Ridge Institute for Science and Education, Belcamp, MD.
      E. K. Farina is a nutritional epidemiologist, Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, MA, and at the Henry M. Jackson Foundation, Bethesda, MD.
      H. R. Lieberman is a research psychologist, Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, MA.