Diet and Nutrition in Oral Health
Third Edition
Chapter 10
Dietary Supplements
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Learning Objectives (1 of 2)
10.1 Discuss the different types of dietary supplements
available today.
10.2 Explain the reasons people use dietary supplements.
10.3 Understand the regulatory aspects of supplements.
10.4 Distinguish between appropriate and inappropriate
use of dietary supplements.
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Learning Objectives (2 of 2)
10.5 Discuss the potential benefits and risks of dietary
supplements.
10.6 Explain how supplements and drugs can interact.
10.7 Take a dietary history that includes information on
dietary supplement use.
10.8 Access reliable resources for more information.
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Introduction: The What, Who, and Why of
Dietary Supplements (1 of 4)
• Defined by the Dietary Supplement Health and Education
Act (DSHEA) of 1994
• A product containing a “dietary ingredient” that is taken by
mouth and intended to supplement the diet
• Found in many forms such as tablets, capsules, softgels,
gelcaps, liquids, powders, drinks, or bars
• Not for use as a conventional food or as the sole item of a
meal or diet
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Introduction: The What, Who, and Why of
Dietary Supplements (2 of 4)
• The “dietary ingredient” may include:
– Vitamin
– Mineral
– Herb or other botanical
– Enzyme
– Hormone
– Amino acid
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Introduction: The What, Who, and Why of
Dietary Supplements (3 of 4)
– Dietary substance used to supplement the diet by
increasing the total daily intake
– Concentrate, metabolite, constituent, extract
– Combinations of any of these ingredients
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Table 10-1 Top 10 Supplements in Sales and
Growth, 1999-2009
Multivitamins
Sports powders/formulas
B vitamins
Calcium
Fish/animal oils
Vitamin C
Homeopathics
Glucosamine/chondroitin
Probiotics
Vitamin D
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Introduction: The What, Who, and Why of
Dietary Supplements (4 of 4)
• Unproven reasons for taking dietary supplements
– Pep, energy, nutrition insurance against poor eating
habits, cold prevention, stress reduction, protection
from serious diseases, prolonging the aging process,
losing weight, gaining strength, improved fitness and
performance
• Supplements may be indicated and/or prescribed for
certain documented health conditions or life stages.
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Figure 10-1 Dietary Supplement Label
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Table 10-2 Regulation of Drugs versus
Dietary Supplements
FDA Approval Drugs Required Dietary Supplements
Not required
Evidence of Manufacturers must provide F DA with The manufacturer is responsible for
safety and evidence of product’s safety and determining the safety of the product
efficacy efficacy based on clinical trials. but does not have to provide
evidence of safety and efficacy to F D
A.
Risk disclosure Labels and inserts must list all Not required to have safety warnings
potential adverse effects and on labels.
interactions.
Product quality Must follow strict Good Manufacturing No current G MP regulations for
Practice (GMP) regulations to ensure supplements; must follow food G M
purity and accurate labeling. Ps, which do not ensure all aspects
of supplement quality.
Adverse event Drug companies required to report all Manufacturers not required to record
reporting adverse events to the F DA. or investigate adverse events.
Reporting of adverse events to the F
DA is voluntary.
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How Supplements Are Regulated (1 of 6)
• Dietary Supplement Health and Education Act (DSHEA),
1994 is the law that created a regulatory framework for
oversight and labeling of dietary supplements.
• Requires every supplement is labeled properly, no
standards DRIs unless the supplement has
vitamins/minerals
• FDA must determine if a dietary supplement presents “a
significant or unreasonable risk of illness or injury.”
• FDA is reactive, not proactive.
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How Supplements Are Regulated (2 of 6)
• DSHEA also regulates the types of claims allowed on
dietary supplement labels.
• Supplements may Not claim that their product will
diagnose, cure, mitigate, treat or prevent a disease.
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How Supplements Are Regulated (3 of 6)
• The label may contain one of three types of claims:
– Health claim
– Nutrient content claim
– Structure/function claim
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How Supplements Are Regulated (4 of 6)
• Health claims describe a relationship between a food,
food component, or dietary supplement ingredient as well
as reducing risk of a disease or health-related condition.
• Nutrient content claims describe the relative amount of a
nutrient or dietary substance in a product
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How Supplements Are Regulated (5 of 6)
• Structure/function claims are statements describing how
a product may affect the organs or systems of the body.
– Cannot mention any specific disease
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How Supplements Are Regulated (6 of 6)
• Regulating health claims
– The Federal Trade Commission (FTC) is responsible
for regulating health claims made in dietary supplement
advertising
– FTC has the power to:
▪ Require companies to show evidence to support
claims suspected of being false or misleading
▪ Remove products from the market if their
advertising is unsubstantiated
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Types of Supplements
• Nutrition-related
– Said to have nutritional roles that improve health
▪ Vitamins, minerals, amino acids, fatty acids,
complete liquid nutrition
• Herbal remedies
– Intended to be used as medicines
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Table 10-3 Populations Among Which
Dietary Supplementation May Be Indicated
Newborns Routinely Given a Dose of Needed for Proper Blood
Vitamin K at Birth Formation
Children Fluoride supplementation If insufficient fluoride is available in
water
Multivitamin/mineral complex If child is not eating sufficient quantity
Vitamin D or quality from food
Those at risk for eficiency
Pregnant or about Folate Reduced risk for NTD
to become Multivitamin/mineral complex
pregnant
Teenagers Calcium, vitamin D Energy-dense, but nutrient-deficient
dietary selections
Adults Calcium, vitamin D Bone health
Older adults Multivitamin/mineral supplement B12 Low intake, anemias
Calcium, vitamin D Suppressed immunity
Poor overall intake, bone health
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Table 10-3 (Conditions) Populations Among Which
Dietary Supplementation May Be Indicated
Specific conditions blank blank
Heavy alcohol users Multivitamin/mineral Inadequate diet, altered
supplement metabolism
Vegan Multivitamin/mineral May be low in nutrients present
Calcium/vitamins D, B12 in greatest quantities in animal
sources
Lactose intolerant Calcium/vitamin D May get little, if any, calcium from
food sources; vitamin D is found
in the same sources
Immune- Multivitamin/mineral Anorexia, pain, malaise can
compromised complex make eating difficult; medical
patients: HIV/AIDS, condition can increase
cancer, requirement
radiation/chemo
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Vitamin and Mineral Supplements (1 of 9)
• Misconception
– Consumers do not need to rely on a healthy diet to
provide nutrients if they take dietary supplements.
• Foods contain healthful substances other than vitamins
and minerals, including fiber and phytochemicals, which
may play important roles in health promotion and disease
prevention.
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Vitamin and Mineral Supplements (2 of 9)
• Supplements are used to treat clinically proven vitamin and
mineral deficiencies.
• Supplements may be appropriate for specific types of
individuals.
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Vitamin and Mineral Supplements (3 of 9)
• Potential benefits
– Multivitamin with minerals
▪ A supplement containing 100% of the Daily Value for
most vitamins and several minerals.
▪ Recommended daily for:
• Those who are over the age of 50
• Those on weight-loss diets and who consume
less than 1200 kilocalories per day
• Pregnant women, who should take a prenatal
vitamin
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Vitamin and Mineral Supplements (4 of 9)
– Folate
▪ Women of childbearing age should consume 400 μ
g/day.
– Vitamin B12
▪ Recommended for people over age 50 who do not
produce enough stomach acid, as well as vegans
– Vitamin D
▪ Lack of sun and age-related changes can benefit
from a supplement of 600 IU (800 IU over age 70)
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Vitamin and Mineral Supplements (5 of 9)
– Calcium
▪ People who are lactose intolerant, postmenopausal
and older women may benefit.
– Iron
▪ Routinely recommended for pregnant women
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Vitamin and Mineral Supplements (6 of 9)
• Potential risks
– Toxicity
▪ Upper Limit of Safety (UL) established in DRI
▪ Minerals have a narrower range of safety than do
vitamins.
▪ Toxicity of vitamin A, vitamin D, iron, selenium, and
chromium have been reported.
▪ Megadoses (very large doses or 10x the DRI or
more) should be undertaken only under the
supervision of a physician.
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Vitamin and Mineral Supplements (7 of 9)
– Contamination
▪ Look for supplements with the USP (United States
Pharmacopoeia) “Dietary Supplement Verified” logo
or NSF (National Sanitation Foundation) on the
label.
▪ The supplement has undergone voluntary testing
and meets standards for purity, potency, and quality.
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Vitamin and Mineral Supplements (8 of 9)
– Contraindications for certain populations
▪ Iron supplementation may be dangerous for
individuals (particularly men) with hemochromatosis
(excess iron storage).
▪ People with impaired kidney function are at
increased risk for toxicity from magnesium
supplements.
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Vitamin and Mineral Supplements (9 of 9)
– Drug interactions
▪ About 16% of people who take prescription drugs
also take herbal or dietary supplements of some
type.
▪ Men who took 400 IU of vitamin E had more
prostate cancers than those who took a placebo.
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Herbal or Botanical Supplements (1 of 5)
• An herb is a type of botanical, defined as “a plant or plant
part valued for its medicinal, savory, or aromatic
properties.”
– Plant parts include leaves, roots, stems, bark, seeds,
whole flowers, pollen, petals, pistils, stamen, and their
extracts.
– Herbs may be purchased fresh or dried, as extracts,
capsules, tablets, powders, or teas.
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Herbal or Botanical Supplements (2 of 5)
• Potential benefits
– There is not sufficient evidence to prove the efficacy of
the majority of herbal supplements, but some may
have potential benefits.
– Systematic reviews have found evidence that:
▪ Garlic may lower cholesterol.
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Herbal or Botanical Supplements (3 of 5)
▪ Saw palmetto may be beneficial for benign prostatic
hyperplasia.
▪ St. John’s Wort may alleviate mild to moderate
depression.
▪ Ginkgo biloba may improve Alzheimer’s, vascular
dementia and claudication.
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Herbal or Botanical Supplements (4 of 5)
• Potential risks
– Adverse effects
– Surgical complications
– Possibility of adulteration of products with potent
standard drugs (including prescription drugs), and other
potentially harmful substances
– Drug interactions
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Table 10-5 Herb-Drug Interactions with
Some Commonly Used Herbs (1 of 2)
Herb Drug Interaction
Garlic Warfarin Bleeding, increase in international normalized ratio
Chlorpropamide Hypoglycemia
Ginkgo biloba Warfarin Bleeding
Aspirin Bleeding
Thiazide diuretic Increase in blood pressure
Trazodone Increased sedation
Ginseng Warfarin Decrease in international normalized ratio
Phenelzine Insomnia, headache, tremulousness, mania
St. John’s wort Amitriptyline Reduced plasma concentrations
Cyclosporine Reduced plasma concentrations
Digoxin Reduced plasma concentrations
Indinavir Reduced plasma concentrations
Nefazodone Symptoms of central serotonin excess
Oral contraceptives Altered menstrual bleeding
Paroxetine Symptoms of central serotonin excess
Phenprocoumon Reduced plasma concentrations
Sertraline Symptoms of central serotonin excess
Theophylline Reduced plasma concentrations
Warfarin Decrease in international normalized ratio
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Table 10-5 Herb-Drug Interactions with
Some Commonly Used Herbs (2 of 2)
Herb Drug Interaction
Ginkgo biloba Warfarin Bleeding
Aspirin Bleeding
Thiazide diuretic Increase in blood pressure
Trazodone Increased sedation
Ginseng Warfarin Decrease in international normalized ratio
Phenelzine Insomnia, headache, tremulousness, mania
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Herbal or Botanical Supplements (5 of 5)
• Potential risks
– No standardization of product names
– No standardization of doses
– Failure to provide information for proper use by
consumers
– Failure to track product use for unanticipated adverse
effects
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Sports Nutrition and Ergogenic Aids (1 of 2)
• Include certain herbals as well as amino acids, whey
protein, carnitine, creatine, chromium picolinate, glutamine,
DHEA, and other products
• Athletic performance is determined largely by genetic
potential, training, and nutritional status.
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Sports Nutrition and Ergogenic Aids (2 of 2)
• Potential benefits
– Supplemental creatine may be beneficial for anaerobic
exercise involving high-intensity, repetitive activity.
• Potential risks
– Many products sold as ergogenic aids do not increase
performance and/or may have serious side effects.
– High-protein diets can cause abnormal strain on the
kidneys.
– Anabolic steroids are associated with dangerous
adverse effects and are banned by the Olympics.
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Table 10-6 Common Dietary Supplements
Used by Trained Athletes (1 of 3)
Performance Supplement
Effective for claim Caffeine
Carbohydrate loading
Creatine
Electrolyte sports drinks
Insufficient evidence for claim/more Alkalizing agents
research needed Aspartate salts
B-Alanine and leucine
B-hydroxy-b-methylbutyrate
Carnitine
Nitrate powders
Phosphate salts
Protein powders and supplements
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Table 10-6 Common Dietary Supplements
Used by Trained Athletes (2 of 3)
Performance Supplement
Ineffective for claim Anabolic steroids precursors: Androstenedione,
Dehydroepiandrosterone (D HEA), Yohimbine,
Tribulis
Terrestris, Chrysin, Indole-3-carbinol, Saw Palmetto
Gamma-Oryzanol, Smilax, Mummio
Branch-chain amino acids
Energy drinks
Lipid-related (conjugated linoleic acid and medium-
chain triglycerides)
Minerals supplements beyond needs: calcium and
iron
Phytochemicals: quercertin and E CGC
Pyruvate
Ribose
Vitamin megadoses: antioxidants, B-complex
vitamins, vitamins D, C, and E
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Table 10-6 Common Dietary Supplements
Used by Trained Athletes (3 of 3)
Performance Supplement
Banned, dangerous, or illegal Alcohol
supplements Steroid precurors: D HEA and
Androstenedione/androstenediol
Stimulants: caffeine (guarana) in excess of 15 μ/m l
in urine), bitter orange, ephedra (ma huang)
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Table 10-7 What’s in Energy Drinks?
blank Red Bull™ Rockstar™ Amp™ Monster™ 5-hour
Energy XXL Energy Shot
Serving 8.3 oz 8 oz 8 oz 8 oz 1.93 oz
size
Calories 110 130 110 100 4
Caffeine 80 mg 80 mg 71 mg 80 mg 207 mg
Sugars 27 g 30 g 27 g 25 g 1g
Vitamin B2 blank 200% DV blank 100% DV blank
Niacin 100% DV 100% DV 100% DV 100% DV 150% DV
Vitamin B6 250% DV 100% DV blank 100% DV 2000% DV
Vitamin 80% DV 100% DV blank 100% DV 8333% DV
B12
Herbals Glucuronlactone Guarana Guarana Guarana Taurine
Inositol Panax ginseng Ginseng Panax ginseng Glucuronic acid
Taurine Carnitine Taurine Carnitine
Inositol Glucuronlactone
Taurine
Ginkgo biloba
Milk Thistle
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Specialty Supplements (1 of 2)
• Supplements that do not fall into the other categories
– Glucosamine, melatonin, other hormones, amino acids,
lecithin, fish oils
• Omega-3 fatty acids may have beneficial effects on
cardiovascular disease.
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Specialty Supplements (2 of 2)
• Also pose same risks of potential adverse effects, possible
contamination, and contraindications for certain individuals
• L-Tryptophan was promoted as a sleep aid until it caused
harm and was taken off the market.
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Probiotics
• Helpful bacteria (lactobacilli) found naturally in the human
intestines and fermented products with “active cultures”
• Thought to be beneficial for conditions such as diarrhea,
irritable bowel syndrome, inflammatory bowel disease,
lactose intolerance, and infections affecting normal flora.
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Nutritionally Complete or Meal
Replacement Liquid Supplements (1 of 3)
• Originally developed for medically compromised hospital
patients
• All are typically lactose-free.
– High calorie
– High protein
– Fiber added
• Next marketed to healthy people “on the run”
– Instant nutritional drinks
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Nutritionally Complete or Meal
Replacement Liquid Supplements (2 of 3)
• Now marketed to healthy people to increase vitality,
energy, and well-being
• May be beneficial for:
– Dentally impaired
– Frail elderly
– Very sick patient (cancer, HIV/AIDS, anorexia nervosa)
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Nutritionally Complete or Meal
Replacement Liquid Supplements (3 of 3)
• “Something is better than nothing.”
– Alternative to not eating at all
• A way to improve nutrient intake in addition to meals.
• An alternative to sugary beverages and non-nutritious
foods for meals or snacks.
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Table 10-8 Liquid Nutrition Supplements: Comparison of
Nutrient Composition of Eight-Ounce Liquid Nutrition
Supplements
blank Calories Protein (g) Fat (g) CHO (g)
Ensure 250 9 6 40
Ensure Plus 360 13 11 50
Boost 240 10 4 41
Boost Plus 360 14 14 45
Instant Breakfast 280 13 8 39
with whole milk
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Sound Versus Unsound Claims
• Many studies on dietary supplements are not well
designed, executed, or analyzed.
• For example, the Federal Trade Commission found many
claims for weight-loss supplements were unsubstantiated.
• Patients may be at risk for harm if they rely on false
medical information.
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Reliable Resources on Dietary Supplements
• Office of Dietary Supplements (ODS) from the National
Institutes of Health (NIH)
• National Center for Complementary and Alternative
Medicine (NCCAM) from the National Institutes of Health
(NIH)
• The FDA
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Summary and Implications for Dentistry
(1 of 3)
• Ask patients what they are taking.
– Take a dietary supplement history.
• Know whether there may be a risk for interaction with
drugs used in dentistry.
• Look out for unfounded nutrition promotion of products.
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Table 10-9 Questions to Ask When Taking a
Dietary Supplement History
1. Do you take any over-the-counter or prescribed dietary
supplements?*
2. What kind of supplement(s) do you use (vitamin, mineral, herbal,
amino acid, fiber, liquid nutritional, etc.)?
3. What is the brand or manufacturer of the supplement(s)?
4. How long have you been taking the supplement(s) ?
5. How long do you plan to use the supplement(s)?
6. What are your primary reason(s) for taking the supplement(s)?
7. What amount or dose of the supplement(s) do you take?
8. How often do you take the supplement(s)?
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Summary and Implications for Dentistry
(2 of 3)
• Ask patients what they are taking.
– Take a dietary supplement history.
• Know whether there may be a risk for interaction with
drugs used in dentistry.
• Look out for unfounded nutrition promotion of products.
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Summary and Implications for Dentistry
(3 of 3)
• Be able to answer patients’ questions about dietary
supplements.
• Report any adverse events that may be related to dietary
supplement usage to the FDA MedWatch program.
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Copyright
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