Vitamin A in dietary supplements and fortified foods: Too much of a good thing?

doi:10.1016/S0002-8223(03)00978-7

Journal of the American Dietetic Association

Volume 103, Issue 9, September 2003, Pages 1185-1187

https://doi.org/10.1016/S0002-8223(03)00978-7 Get rights and content

Abstract

Vitamin A consumption by many Americans is quite high, in part because of the consumption of fortified foods and the use of vitamin supplements. Most multivitamin supplements provide two or more times the recommended dietary allowance (RDA) for vitamin A because the daily value (DV) is based on 1968 and not current RDAs. Consumption of just one multivitamin often provides excessive vitamin A, the majority of it as preformed vitamin A esters. Given recent epidemiologic evidence that suggests a link between chronic intakes of vitamin A that exceed the RDA and hip fractures, it may be time to reexamine food and supplement fortification policies and to discontinue the clinical practice of prescribing two multivitamins to the elderly and other patients whose needs for certain micronutrients are high.

Section snippets

Recommendations and intake

In lowering the RDAs for vitamin A in 2001 (4), the Institute of Medicine moved the US recommendations closer to those of other nations. Table 1 provides the current vitamin A RDAs and tolerable upper intake levels (ULs) by life stage group. There is a disconnect, however, between the RDA and the DV as shown on food labels. Consumers and health practitioners alike may be confused by what, in actuality, are conflicting recommendations. The consumer who measures his or her daily intake of vitamin

Supplements

Most supplements, such as multivitamins, specify the type and amount of vitamin A contained in the product. Most provide preformed vitamin A as either retinyl acetate or palmitate. Some may include beta-carotene as part of the source, but others do not. Some vitamin D supplements include preformed vitamin A. Consumers seeking a vitamin D supplement may not examine the labels of these supplements closely and may unwittingly choose one that also contains vitamin A. Fish liver oil and fish liver

Food fortification

Food manufacturers are increasingly fortifying foods with preformed vitamin A, presumably to enhance marketability in specific sections of the population. Some foods have long been vitamin A-fortified; these include milk, some margarine, instant oats, and ready-to-consume breakfast cereals. Recently, however, other foods have been fortified with relatively high amounts of vitamin A, as well as with other vitamins. These include cereal bars, energy bars, and candy. The decision regarding which

Summary

Recent epidemiologic evidence suggests a link between chronic intakes of vitamin A that exceed the RDA and hip fractures 1, 2, 3. Recent biochemical research suggests an interaction between vitamins A and D at the receptor level, potentially resulting in decreased calcium absorption and disruption of normal bone metabolism 13, 14. Research suggests that the elderly may require less vitamin A than younger adults because of higher circulating levels 15, 16. Although vitamin A deficiency is a

K. L. Penniston is a clinical nutritionist, University of Wisconsin Hospital and Clinics, and research assistant, Department of Nutritional Sciences, University of Wisconsin-Madison

References (19)

L.H. Allen et al.
Estimating the potential for vitamin A toxicity in women and young children
J Nutr
(2002)
T.O. Carpenter et al.
Severe hypervitaminosis A in siblingsEvidence of variable tolerance to retinol intake
J Pediatr
(1987)
C.M. Rohde et al.
Vitamin A antagonizes the action of vitamin D in rats
J Nutr
(1999)
D. Hollander et al.
Influence of aging on vitamin A transport into the lymphatic circulation
Exp Gerontol
(1990)
R.M. Russell
New views on the RDAs for older adults
J Am Diet Assoc
(1997)
P.K. Duitsman et al.
The vitamin A statuses of pregnant women from disadvantaged socioeconomic backgrounds in urban Iowa
Nutr Res
(1995)
J.R. Hunt
Tailoring advice on dietary supplementsAn opportunity for dietetics professionals
J Am Diet Assoc
(2002)
H. Melhus et al.
Excessive dietary intake of vitamin A is associated with reduced bone mineral density and increased risk for hip fracture
Ann Intern Med
(1998)
D. Feskanich et al.
Vitamin A intake and hip fractures among postmenopausal women
JAMA
(2002)

There are more references available in the full text version of this article.

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2017, American Journal of Clinical Nutrition
Background: Circulating concentrations of biomarkers that are related to vitamin status vary by factors such as diet, fortification, and supplement use. Published biomarker concentrations have also been influenced by the variation across laboratories, which complicates a comparison of results from different studies.
Objective: We robustly and comprehensively assessed differences in biomarkers that are related to vitamin status across geographic regions.
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Results: Circulating concentrations of riboflavin, pyridoxal 5′-phosphate, folate, vitamin B-12, all-trans retinol, 25-hydroxyvitamin D, and α-tocopherol as well as combined vitamin scores that were based on these nutrients showed that the general B-vitamin concentration was highest in the United States and that the B vitamins and lipid soluble vitamins were low in Asians. Conversely, circulating concentrations of metabolites that are inversely related to B vitamins involved in the one-carbon and kynurenine pathways were high in Asians. The high B-vitamin concentration in the United States appears to be driven mainly by multivitamin-supplement users.
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The method was validated using standard reference material (SRM 968c, NIST). Standard errors were 1.4%, 2.1% and 1.8% for 25OHD₃, vitamin A and vitamin E, respectively.
The ranges thus assessed were as follows: 17.1 ± 8.0 nmol/L, for 24,25(OH)₂D₃, 40.3 ± 34.6 nmol/L for 25OHD₃, 2.57 ± 0.7 μmol/L for retinol and 22.13 ± 8.30 μmol/L for α-tocopherol. Females showed lower serum levels of retinol (p < 0.01), α-tocopherol (p < 0.01) and 25OHD₃ (p = 0.028).
A total of 10.4% subjects showed vitamin E deficiency, 85.4% had normal levels and 4.2% had high levels of vitamin E. 65.6% of the target subjects showed normal levels of retinol, and 1.6% had moderate or severe vitamin A deficiency. High levels of vitamin A were found in 32.8% of the subjects.
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The reported data of high prevalence of lipid-soluble vitamin values outside the physiological range have important repercussions on public health. These data also uphold the need for simultaneous measurement of fat-soluble vitamins as a valuable tool in clinical practice as well as in epidemiological studies for awareness and correction.
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K. L. Penniston is a clinical nutritionist, University of Wisconsin Hospital and Clinics, and research assistant, Department of Nutritional Sciences, University of Wisconsin-Madison

S. A. Tanumihardjo is an assistant professor, Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI.

^☆: Supported by Hatch-Wisconsin Agricultural Experiment station number WIS04389, the University of Wisconsin Graduate School, and National Institutes of Health grant DK61973-01.

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Research and professional briefsVitamin A in dietary supplements and fortified foods: Too much of a good thing?☆

Abstract

Section snippets

Recommendations and intake

Supplements

Food fortification

Summary

J Nutr

J Pediatr

J Nutr

Exp Gerontol

J Am Diet Assoc

Nutr Res

J Am Diet Assoc

Excessive dietary intake of vitamin A is associated with reduced bone mineral density and increased risk for hip fracture

Ann Intern Med

Vitamin A intake and hip fractures among postmenopausal women

JAMA

Research and professional briefs
Vitamin A in dietary supplements and fortified foods: Too much of a good thing?☆