Dietary Supplements Nursing CE Course

ents, and there is little scientific proof of necessity or outcome with their intake. On average, over $163.9 billion is spent on nutritional supplements globally; this is expected to increase to $327.4 billion by 2030. With this number of products in use, consistency, quality, and safety are of primary concern to most (Grand View Research, n.d.; NIH, 2023a).

 

Regulatory Process

Dietary supplement regulation began in 1906 with the passing of the Pure Food and Drug Act. This act was an effort by the federal government to emphasize the safety and accuracy of marketed products. This was in response to the growing prevalence of unsafe food and medication and the increase in fraud regarding the efficacy of remedies. During the 1900s to 1920s, more information was discovered regarding food elements responsible for various aspects of health and nutrition. The role of upholding the rules and punishing violators was given to the US Food and Drug Association (FDA). In 1938, in response to the sulfanilamide scandal that resulted in 107 deaths, the Federal Food, Drug, and Cosmetic Act was passed, making the 1906 regulations obsolete (Natural Products Association [NPA], n.d.).

In 1994, the US Congress unanimously passed the Dietary Supplement Health and Education Act (DSHEA), which defined the term dietary supplement as a product that supplements the diet under the category of food (rather than medication). The DSHEA also outlined the types of ingredients that could be used in dietary supplements and that they must contain one or more ingredients or their constituents (components, parts, or ingredients of a larger whole). This act also prohibited manufacturers and distributors from marketing adultered or misbranded products. According to the DSHEA, supplements are to be taken orally (by mouth) as a capsule, pill, tablet, or liquid and should be labeled on the front panel as a dietary supplement. Products can range from children's vitamins to sports nutrition or weight-loss products for adults (FDA, 2023; NPA, n.d.).

The DSHEA provides the FDA with the regulatory authority and ability to enforce processes that ensure consumer access to quality dietary supplements. However, the FDA regulations regarding dietary supplements are much less stringent than other food and drug products. Manufacturers do not have to prove that dietary supplements are safe and effective through testing or clinical trials before marketing as other drugs are required to do; instead, the FDA simply requires that a dietary supplement is proven safe. The DSHEA also gave the FDA the power to develop manufacturing guidelines for dietary supplements. In 2007, the FDA mandated that dietary supplements be produced in compliance with current Good Manufacturing Practices (GMPs) to help ensure their quality, purity, strength, and composition. As a result, the FDA can remove potentially unsafe products from the market (NIH, 2023a; NPA, n.d.).

When a manufacturer develops a new product, they only have to notify the FDA if it contains a new dietary ingredient (NDI) not on the market before October 15, 1994. There is no definitive list of dietary ingredients in dietary supplements before 1994, but manufacturers and distributors are expected to determine all ingredients in their supplements and ensure compliance. In the event of an NDI, the manufacturer must submit an NDI dossier to notify the FDA and provide a rationale as to why the manufacturer feels it is appropriate to add the ingredient, a description of the ingredient, and any identifying published materials that are available (NPA, n.d.).

Dietary supplements with false or misleading labeling are considered misbranded foods (FDA, 2023). Misbranding provisions are applied if the label does any of the following:

• fails to list each ingredient’s name and quantity
• fails to identify the product as a dietary supplement
• fails to state from which plant each ingredient is derived
• makes claims that the supplement is a cure for a particular disease
• fails to include a statement that health claims have not been evaluated by the FDA (FDA, 2023; NIH, 2023a)

Dietary supplements may have claims of health, nutrition, and function. Each type of claim has implications based on FDA expectations. For example, health claims may describe a relationship between a food or dietary supplement ingredient and a reduced disease or health-related condition risk. A nutrient content claim describes the amount of a nutrient or dietary substance in a product. A structure or function claim explains how the product may affect a body system or organ (i.e., the cardiovascular system or the liver). If a structure or function claim is made, the manufacturer must notify the FDA with the text of the claim and the results of at least two randomized controlled clinical trials at least 30 days before the product is put on the market for sale (NPA, n.d.). The manufacturer must also add a disclaimer to any health-related claim that it “has not been evaluated by the FDA” and “is not intended to diagnose, treat, cure, or prevent any disease" (NIH, 2023a, para. 17).

In 1985, The US Department of Health and Human Services (HHS) and the USDA jointly formed the Dietary Guidelines Advisory Committee (DGAC). This committee evaluates dietary guidelines, identifying common healthy diet characteristics, identifying new research, and developing food-based recommendations critical to good health every 5 years. The most recent report from the DGAC was released in 2020. This report found that over 70% of Americans were classified as overweight or obese. This number has been increasing over the past two decades, and the prevalence of children that are overweight or obese is of particular concern. The prevalence of obesity has contributed to several diet-related chronic conditions such as type 2 diabetes and CVD. It is estimated that 6 out of 10 Americans have one chronic illness, and 4 out of 10 have at least two chronic illnesses. The report also found that food insecurity is a contributing problem for 37 million individuals, including 6 million children in the US who live in food-insecure households (DGAC, 2020).

The report notes that positive changes to dietary habits can affect individual outcomes related to preventable disease progression. While this report primarily focuses on good nutrition through a healthy diet, the value and limitations of dietary supplements are also discussed. Nutritional supplements are typically utilized for wellness rather than disease management; however, there is recognized value to supplementation in some disease processes. Therefore, healthcare professionals (HCPs) are advised to discuss dietary supplements with their patients to determine the best supplemental regime for each individual. Approximately 61% of 18-34-year-olds, 74% of 35-54-year-olds, and 81% of individuals older than 55 take dietary supplements (DGAC, 2020; Mikulic, 2022).

Current Recommendations

The Food and Nutrition Board (FNB) was established in 1940 as a component of the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine (NASEM). The FNB is tasked with managing food safety and quality issues; establishing guidelines for adequate dietary intake by individuals; and giving authoritative judgments on the relationship between food intake, nutrition, and overall health maintenance and disease prevention (NASEM, n.d.).

Dietary reference intake (DRI) is a general term for a set of reference values used to plan and assess the nutrient intake of healthy individuals. DRIs can also be used to develop optimal diet plans and dietary supplement options (DGAC, 2020). The values often differ based on age, gender, and whether an individual is pregnant or lactating, but include:

• recommended daily allowance (RDA): the average daily intake deemed sufficient to meet the nutritional requirements of most healthy individuals
• adequate intake (AI): the quantity assumed to ensure adequate nutrition (this is used when the evidence is insufficient to determine an RDA)
• percent of the daily value (DV): similar to the RDA and AI for a particular nutrient; developed by the FDA to inform consumers how much of a specific nutrient is present in a serving of food or supplement in relation to the RDA or AI; included on labels as a percentage (%DV)
• tolerable upper intake level (UL): the maximum daily intake unlikely to cause harmful health effects (Johnson, 2022b; NIH, n.d.-b)

HCPS must remember that good nutrition is the foundation of good health, and nutritional assessments and education are vital to assisting patients in maintaining or achieving optimal health and wellness. Dietary supplements are widely marketed directly to the consumer and have a variety of ingredients intended to provide multiple benefits for health and wellness (NIH, n.d.-b).

 

Common Categories of Dietary Supplements

For this module, dietary supplements discussed are limited to those characterized by the NIH Office of Dietary Health, including a broad overview of vitamins, minerals, herbs/botanicals, amino acids, probiotics, and fish oil products. If additional details are sought, the NIH Office of Dietary Health offers in-depth individual educational resources and fact sheets on its website (NIH, n.d.-a).

 

Vitamins

As previously noted, there are 13 vitamins needed by the body for normal growth, health, and wellness. These vitamins are vitamin A, B vitamins (thiamine, niacin, riboflavin, biotin, pantothenic acid, vitamin B6, vitamin B12, and folate), vitamin C, vitamin D, vitamin E, and vitamin K. Most of these vitamins are obtained from dietary intake. Each vitamin has a unique function within the body, and low or high levels can lead to health problems (Johnson, 2022b). See Table 2 for the 13 essential vitamins, their potential benefits, and nursing implications; Table 3 contains these vitamins' RDAs (or AIs).

 

Table 2

Essential Vitamins

 

Table 3

Recommended Daily Allowances of Vitamins 

Vitamin	Males aged 18+	Females aged 18+	Pregnancy	Lactating
Vitamin A	900 mcg RAE	700 mcg RAE	770 mcg RAE	1300 mcg RAE
Thiamine (B1)	1.2 mg	1.1 mg	1.4 mg	1.4 mg
Riboflavin (B2)	1.3 mg	1.1 mg	1.4 mg	1.6 mg
Niacin (B3)	16 mg	14 mg	18 mg	17 mg
Pantothenic Acid (B5)	5 mg	5 mg	6 mg	7 mg
Pyridoxine (B6) - AI	1.3 mg	1.3 mg	1.9 mg	2.0 mg
Biotin (B7) - AI	30 mcg	30 mcg	30 mcg	35 mcg
Folate (B9)	400 mcg DFE	400 mcg DFE	600 mcg DFE	500 mcg DFE
Cyanocobalamin (B12)	2.4 mcg	2.4 mcg	2.6 mcg	2.8 mcg
Vitamin C	90 mg	75 mg	85 mg	120 mg
Vitamin D	600 IU Age > 71 800 IU	600 IU Age > 71 800 IU	600 IU	600 IU
Vitamin E	15 mg	15 mg	15 mg	19 mg
Vitamin K	120 mcg	90 mcg	90 mcg	90 mcg

(Johnson, 2022b; NIH, 2021c, 2022; USDA, 2020)

 

Minerals

Complete nutrition is dependent on both vitamins and minerals. The body uses minerals to maintain the functionality of the bones, muscles, brain, and heart. Minerals are also necessary for making hormones and enzymes. There are two types of minerals: macrominerals and trace minerals. Macrominerals are needed in larger quantities and include calcium, potassium, sodium, phosphorus, magnesium, chloride, and sulfur. Trace minerals, including iron, copper, iodine, manganese, zinc, fluoride, cobalt, and selenium, are only required in small amounts. Generally, minerals are obtained through dietary intake, but a mineral supplement may be recommended for those who lack a varied diet. Individuals with certain health conditions, such as chronic kidney disease, must limit their intake of certain minerals, such as potassium, due to adverse effects from decreased elimination (Johnson, 2020a). See Table 4 for minerals and their implications and Table 5 for their RDAs.

 

Table 4

Minerals

 

Table 5

Recommended Daily Allowances of Minerals

Mineral	Males aged 18+	Females aged 18+	Pregnancy	Lactation
Calcium	1,000 mg	1,000 mg	1,000 mg	1,000 mg
Chloride	n/a	n/a	n/a	n/a
Chromium	35 mcg	25 mcg	30 mcg	45 mcg
Copper	900 mcg	900 mcg	1000 mcg	1300 mcg
Fluoride	4 mg	3 mg	3 mg	3 mg
Iodine	150 mcg	150 mcg	220 mcg	290 mcg
Iron	8 mg	18 mg	27 mg	9 mg
Magnesium	400-420 mg	310-320 mg	350 mg	310 mg
Manganese	2.3 mg	1.8 mg	2.0 mg	2.6 mg
Molybdenum	45 mcg	45 mcg	50 mcg	50 mcg
Nickel	n/a	n/a	n/a	n/a
Phosphorus	700 mg	700 mg	700-1250 mg	700 mg
Potassium	3,400 mg	2,600 mg	2,900 mg	2,800 mg
Selenium	55 mcg	55 mcg	60 mcg	70 mcg
Sodium	2,300 mg	2,300 mg	2,300 mg	2,300 mg
Zinc	11 mg	8 mg	11 mg	12 mg

(Johnson, 2022a; USDA, 2020)

Botanicals/Herbs

A botanical is a plant or plant portion used for its therapeutic or medicinal properties, flavors, or scents. Herbs are a type of botanical. Products made from botanicals to maintain or improve health are called botanical products, herbal products, or phytomedicines. Botanicals may be sold as fresh or dried products, liquid or solid extracts, tablets, capsules, powders, or teas. Typically, dietary supplements are in tablet or capsule forms. Botanicals may have specific chemicals known as markers used to manufacture a consistent or standardized product; this should be the portion of the botanical that provides the therapeutic effect. It is difficult to determine the quality of a botanical dietary supplement from its label as the quality is related to the manufacturer, supplier, and production process. Many people take botanicals and herbs for various conditions because they are natural substances, but the validity of their usefulness is primarily unsubstantiated by research. Many of these dietary supplements can be harmful, causing severe adverse effects. Pregnant individuals and those who take anticoagulation therapy or have bleeding disorders are at the highest risk of experiencing adverse effects (NIH, 2020b). See Table 6 for common botanicals and herbs.

 

Table 6

Botanicals/Herbs

Dietary Supplement and Dosing Information	Potential Indications	Nursing Implications/Alerts
Black cohosh doses range from 6.5 to 160 mg/d median dose of 40 mg/d	Promoted for menopausal symptoms, sleep disturbances, irritability, or heart palpitations	limit use to 6 months or less due to the risk of liver damage with long-term use or high doses instruct patients to report abdominal pain, dark urine, or jaundice not advised for patients with estrogen-receptor-positive cancers (i.e., breast; NIH, 2020a)
Echinacea dosing ranges from 2400-4000 mg/d	May prevent or treat infections such as the common cold by boosting the human immune system or topically for skin wounds or conditions	short-term use is considered safe, but long-term safety is not proven common adverse effects include nausea, stomach pain, or allergic reaction no significant drug interactions (National Center for Complementary and Integrative Health [NCCIH], 2020a)
Garlic 1000-7200 mg/d for hyperlipidemia 300-1500 mg/d for hypertension 1 mg/kg/d for cancer prevention	May prevent the common cold and colon or stomach cancer; it may treat hypertension or hyperlipidemia	may interact with blood thinners such as warfarin (Coumadin) and antiviral drugs such as saquinavir (Invirase) and ritonavir (Norvir; NCCIH, 2020b)
Ginkgo biloba dosing ranges from 120-240 mg/d	Promoted for dementia, intermittent claudication, glaucoma, vertigo, or tinnitus	adverse effects include constipation, headaches, dizziness, and palpitations increased risk of bleeding with concurrent use of warfarin (Coumadin) and during pregnancy increased risk of liver and thyroid cancer avoid consumption of raw or roasted seeds of the plant due to toxicity (NCCIH, 2020c)
Saw palmetto doses range from 160-230 mg/d	Promoted for treatment of urinary symptoms associated with benign prostatic hyperplasia, chronic pelvic pain, migraines, hair loss, or decreased sex drive	use with caution during pregnancy and while breastfeeding no significant drug interactions may cause digestive symptoms or headaches (NCCIH, 2020d)
St. John’s wort dosing ranges from 750-900 mg/d	Promoted for depression, menopausal symptoms, attention-deficit hyperactivity disorder (ADHD), and obsessive-compulsive disorder (OCD)	interacts with numerous medications, including antiretroviral drugs, chemotherapeutics such as irinotecan HCL (Camptosar), antidepressants, cyclosporine (Neoral), digoxin (Lanoxin), oral contraceptives, and warfarin (Coumadin) monitor for suicidal ideations in patients taking St. John's wort for depression (NCCIH, 2020e)

 

Amino Acids

Amino acids are the building blocks of proteins. They naturally occur in foods but can also be taken as dietary supplements. Amino acids are categorized as either essential (or indispensable), nonessential, or conditionally essential. Although many amino acids are present in nature, only twenty specific amino acids are needed to produce all the proteins in the human body. Nine are essential (histidine, leucine, methionine, threonine, valine, L-tryptophan, isoleucine, lysine, and phenylalanine) because the body cannot produce them endogenously. Optimal sources for amino acids are animal proteins, including meat, eggs, and poultry. Proteins are broken down into amino acids for use by the body. Six remaining amino acids are considered conditionally essential (arginine, cysteine, proline, tyrosine, glutamine, and glycine). Conditionally essential amino acids become essential under particular circumstances such as stress or illness (i.e., cancer, wound healing, liver disease, premature infants). Nonessential amino acids include those produced endogenously by the body (alanine, asparagine, aspartic acid, glutamic acid, and serine; Blachier et al., 2021; Lopez & Mohiuddin, 2023). See Table 7 for a listing of amino acids and their nursing implications. A complete listing can be found in the US National Library of Medicine-Herbs and Supplements for further information on various amino acids in dietary supplements.

Table 7

Amino Acids

Essential Amino Acids
Physiologic Role	Typical Dosing	Nursing Implications/Alerts
Phenylalanine is required for the function of proteins and enzymes and is a precursor for neurotransmitters.	33 mg/kg/d	phenylalanine can act as a neurotoxin at high levels the genetic disorder phenylketonuria (PKU) impairs phenylalanine function
Valine stimulates muscle growth and regeneration and is involved in energy production.	24 mg/kg/d	may decrease the absorption of levodopa (Sinemet) may cause hypoglycemia if used with antidiabetic medications
Threonine is needed for protein, glycine, and acetyl-CoA synthesis.	20 mg/kg/d	used in disorders marked by muscle tightness and involuntary movements, such as MS or amyotrophic lateral sclerosis (ALS)
L-tryptophan is required for serotonin production, which regulates mood, behavior, and sleep.	5 mg/kg/d	may be effective with smoking cessation, teeth grinding, and myofascial pain syndrome associated with drowsiness
Methionine is involved in producing cysteine to build proteins and is required to synthesize biologically active sulfur.	19 mg/kg/d	can be used to treat patients with liver disease, viral infection, AUD, pancreatitis, depression, allergies, asthma, radiation side effects, schizophrenia, drug withdrawal, or symptoms of a urinary tract infection (UTI) can prevent liver damage when taken after an acetaminophen (Tylenol) overdose may reduce the risk of breast and colon cancer, neural tube defects, and hot flashes
Leucine is crucial for muscle repair and protein synthesis.	42 mg/kg/d	helps regulate blood glucose levels produces growth hormones stimulates wound healing
Isoleucine induces muscle protein synthesis.	19 mg/kg/d	increases glucose uptake during exercise used as a performance enhancer by athletes essential for immune function, energy regulation, and hemoglobin production
Lysine is involved in protein synthesis, hormone and enzyme production, collagen and elastin production, and calcium absorption.	38 mg/kg/d	enhances energy production and immune function
Histidine is a precursor for several hormones and critical metabolites affecting renal function, neurotransmission, gastric secretion, and immune function.	14 mg/kg/d	used for metabolic syndrome, diarrhea related to cholera infection, RA, gastric ulcers, anemia associated with renal failure, and allergic conditions
Nonessential and Conditionally Essential Amino Acids
Glutamine plays a critical role in the immune system and GI health.	35-50 mg/kg/d	can decrease the risk of infection, improve overall health, and shorten hospital stays in comparison to placebos used with burn patients and severe infections for improved outcomes bodybuilders use it to decrease fatigue and muscle soreness after exercise
Aspartate increases the absorption of minerals and may improve athletic performance.	No recommended dietary intakes listed	may be used with liver failure to slow brain damage often combined with minerals to enhance absorption, such as copper aspartate
L-arginine is involved in wound healing, maintaining immune and hormone function, and vasodilation.	2000-3000 mg/d	used in the treatment of hypertension, angina, peripheral artery disease, and erectile dysfunction may interact with medications such as captopril (Capoten), enalapril (Vasotec), diltiazem (Cardizem), nitroglycerin (Nitro-Bid, Nitro-Dur, (Nitrostat), isosorbide (Imdur, Isordil), or sildenafil (Viagra)
Ornithine is thought to increase arginine levels and may also elevate hormone levels associated with increasing muscle size.	2000 mg/d for 7 days, then 3000 mg before exercise; 1000 mg/d may be taken in combination with arginine routinely	primarily used for performance enhancement in athletes may be used for weight loss, improved sleep quality, or wound healing
Tyrosine is involved in protein production and is a precursor for adrenaline, noradrenaline, and dopamine.	500-2000 mg/d in most adults; up to 7600 mg/d to treat PKU	used to treat PKU since these individuals cannot consume foods high in phenylalanine, resulting in a tyrosine deficiency interacts with monoamine oxidase inhibitors (MAOIs), thyroid hormones, and levodopa (Sinemet)
Taurine is involved in brain and nerve growth and appears to calm the sympathetic nervous system.	1500-6000 mg/d	may interact with lithium (Lithobid), causing toxic levels used in patients with hepatitis, cystic fibrosis, diabetes, or chemotherapy-related nausea and vomiting may improve memory or cognitive functioning, athletic performance, and energy levels

(Blachier et al., 2021; Institute of Medicine [IOM], 2005; Kubala, 2023)

Branched-Chain Amino Acids (BCAAs)

Three essential amino acids, leucine, isoleucine, and valine, belong to the particular class of amino acids known as BCAAs. BCAAs are primarily found in eggs, meat, and dairy products. BCAAs provide five benefits: increased muscle growth, decreased muscle soreness, reduced exercise fatigue, prevention of muscle wasting, and improved liver diseases such as cirrhosis. BCAA supplementation of 200-240 mg/kg/day has also been shown to reduce blood glucose levels. However, BCCAs should be avoided during pregnancy and breastfeeding as insufficient information supports the use or implications. BCAAs are also contraindicated in patients with ALS due to an increased risk of respiratory failure and should not be used with branched-chain ketoaciduria, as seizures can result (Mann et al., 2021).

 

Probiotics

Probiotics are living microorganisms that have health benefits when consumed or applied to the human body. Sources include yogurt, dietary supplements, and beauty products. Most people consider bacteria or microorganisms potentially harmful, yet many bacteria benefit digestion, produce vitamins, or destroy disease-causing cells. The microorganisms in probiotic dietary supplements are like the microorganisms found in humans naturally. Probiotic supplements contain several microorganisms, but the most commonly used belong to Lactobacillus or Bifidobacterium groups. The yeast used as a probiotic is Saccharomyces boulardi (NCCIH, 2019).

Probiotics are the third most commonly used dietary supplement behind vitamins and minerals. Probiotics work by helping the body maintain a healthy community of cooperative microorganisms or return to a healthy condition after an illness or the use of certain medications such as antibiotics. They influence the body's immune response and support optimal GI health. While many studies related to probiotics are inconclusive, some areas of study have shown promise. Research has favored using probiotics to prevent antibiotic-associated diarrhea, necrotizing enterocolitis, sepsis in infants, and treating infant colic or periodontal disease. Other claims by manufacturers of probiotics are related to decreasing or preventing allergies, skin conditions such as acne, dental caries, UTIs, and upper respiratory infections. Probiotics appear to be safe, with few, if any, adverse effects in healthy individuals. The risk of side effects increases with immunocompromised patients or those with severe illnesses. Some probiotic supplements may contain additional microorganisms other than the ones listed on the label, and those contaminants could pose health risks (International Scientific Association for Probiotics and Prebiotics [ISAPP]; 2022; NCCIH, 2019). See Table 8 for information about probiotics.

 

Table 8

Probiotics

Dietary Supplement	Role	RDA	Nursing Implications/Alerts
Lactobacillus acidophilus	A bacterium found in the human intestines and an ingredient found in fermented foods such as yogurt, sauerkraut, miso, tempeh, or dietary supplements; it aids in digestion and produces lactic acid by breaking down lactose.	1-2 capsules per day; or 1-10 billion colony forming units (CFU) in 3-4 divided doses	Common side effects include bloating and flatulence (gas). Lactobacillus acidophilus is associated with reduced cholesterol and weight loss, decreased diarrhea among hospitalized children, improved IBS symptoms, and treatment or prevention of vaginal infections, particularly after antibiotic use.

(ISAPP, 2022; NCCIH, 2019)

Fish Oil

Fish oil is a dietary source of omega-3 fatty acids, which are polyunsaturated fatty acids needed for numerous body functions ranging from muscle activity to cellular growth. Specific functions include blood clotting, cell division and growth, and fertility. Fish oil supplements typically contain two omega-3 fatty acids: docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). DHA is needed for brain development and function. Omega-3 fatty acids are found in many foods. The primary dietary sources for DHA and EPA are cold-water fatty fish such as salmon, mackerel, trout, mussels, oysters, shellfish, and crabs. Other foods such as eggs, yogurt, infant formula, and milk may be fortified with DHA and other omega-3s. Nuts, seeds, and vegetable oils (including flaxseed, soybean, and canola) also contain a third omega-3 fatty acid, alpha-linolenic acid (ALA). ALA must be obtained from food sources since the body cannot make it. Similarly, EPA and DHA are mainly obtained from food sources as the body can only convert ALA into EPA and then DHA in minimal amounts (roughly 15%). In addition to dietary consumption, EPA and DHA can be supplemented via fish oil. Research supports using fish oil supplements to reduce the risk of CVD, hypertension, elevated triglycerides or cholesterol, preterm delivery, and RA (NIH, 2023b; Shane-McWhorter, 2023). See Table 9 for more information regarding fish oils.

 

Table 9

Fish Oil

Role	Typical Dosing	Nursing Implications/Alerts
Omega-3 fatty acids are needed for numerous body functions ranging from muscle activity to cellular growth, such as clotting of blood, cell division and growth, and fertility. uses include the prevention or treatment of CVD, RA, macular degeneration, depression, and cyclosporine nephrotoxicity	The AI of ALA is 0.5-1.2 g in infants/children and 1.1-1.6 in adolescents/adults. A 1 g fish oil supplement typically provides approximately 300 mg of combined EPA and DHA.	Side effects include fishy eructation, nausea or indigestion, loose stools, or rash Use with caution in those with allergies to shellfish Interacts with the following medications: anticoagulants such as warfarin (Coumadin) antihypertensive medications: results in severe hypotension contraceptive drugs: make the fish oil less effective in triglyceride reduction orlistat (Alli): may cause a decreased absorption of fatty acids; should be taken 2 hours apart may reduce vitamin E levels

(NIH, 2023b; Shane-McWhorter, 2023)

 

Conclusions

The NCCIH states that dietary supplements have many ingredients which may not appear on their labels. While there have been many studies on dietary supplements with evidence of value, many do not have solid clinical research that confirms their efficacy in treating or preventing various conditions. Safe use of supplements requires that the user read the label carefully and follow the directions for safe use. Also, the user should remember that natural sources do not always translate to safety, mainly where herbs or botanicals are concerned. Often unknown or multiple ingredients are in the products. There is always the possibility of food or drug interactions with dietary supplements, and some of the interactions pose a severe risk. While significant interactions have been shared in this module, other risks could exist. Most supplements are not approved for children or pregnant/breastfeeding women. Finally, while the FDA oversees dietary supplements, their regulation is much less rigorous or controlled than prescription or over-the-counter medications (NIH, 2023a).

References

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Blachier, F., Blais, A., Elango, R., Saito, K., Shimomura, Y., Kadowaki, M., & Matsumoto, H. (2021). Tolerable amounts of amino acids for human supplementation: Summary and lessons from published peer-reviewed studies. Amino Acids, 53, 1313-1328. https://doi.org/10.1007/s00726-021-03054-z

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International Scientific Association for Probiotics and Prebiotics. (2022). The ISAPP quick guide to probiotics for health professionals: History, efficacy, and safety. https://isappscience.org/for-clinicians/resources/probiotics

Johnson, L. E. (2022a). Overview of minerals. Merck Manual Professional Version. https://www.merckmanuals.com/professional/nutritional-disorders/mineral-deficiency-and-toxicity/overview-of-minerals

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Kantor, E. D., Rehm, C. D., Du, M., White, E., & Givannucci, E. L. (2016). Trends in dietary supplement use among US adults from 1999-2012. JAMA, 316(14) 1464-1474. https://doi.org/ 10.1001/jama.2016.14403.

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Mann, G., Mora, S., Madu, G., & Adegoke, O. A. J. (2021). Branched-chain amino acids: Catabolism in skeletal muscle and implications for muscle and whole-body metabolism. Frontiers in Physiology, 12. https://doi.org/10.3389/fphys.2021.702826

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National Center for Complimentary and Integrative Health. (2020a). Echinacea. https://www.nccih.nih.gov/health/echinacea

National Center for Complimentary and Integrative Health. (2020b). Garlic. https://www.nccih.nih.gov/health/garlic

National Center for Complimentary and Integrative Health. (2020c). Ginkgo. https://www.nccih.nih.gov/health/ginkgo

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