CLINICAL PRACTICE | PATIENT EDUCATION & COUNSELING

June 2026 | NP Chronicles Clinical Education

Your Older Patients Are Taking More Supplements Than You Realize — And It's Getting More Complicated

By Valerie Watters-Burke, DNSc, MSN, MBA, FNP-BC, GNP-BC, PPCNP-BC

Based on: Lam CS et al. Emerging Patterns in Dietary Supplement Use Among US Adults, 1999–2023. JAMA Network Open. 2026;9(6):e2619291.

CLINICAL BOTTOM LINE

A landmark 25-year NHANES analysis published in JAMA Network Open (June 2026) reveals that supplement use among US adults climbed from 51% in 1999 to 60% in 2023 — with the most dramatic growth in adults aged 65 and older (62% to 78%). The supplement landscape has shifted away from multivitamins toward a complex, personalized mix of vitamins, minerals, and nonvitamin/nonmineral products. For NPs, this is not a benign background trend. It is a polypharmacy story in disguise — and your patients need you to ask about it.

Why This Study Matters to Your Practice

Think about the last patient you saw who was 70 or older. Did you ask them about supplements? If so, did you ask specifically — by name, with follow-up questions — or did you ask generally and accept 'I just take a multivitamin' at face value?

New data suggest that answer matters more than ever. A large, nationally representative study just analyzed 25 years of National Health and Nutrition Examination Survey (NHANES) data across 63,442 adults, tracking supplement use across 11 survey cycles from 1999 through August 2023. The findings paint a picture that should recalibrate how NPs approach medication reconciliation and patient counseling — especially with older adults.

The supplement market is now valued at nearly $200 billion globally and is projected to double by 2033. More than 100,000 distinct supplement products are available in the US alone. And critically: roughly 3 out of 4 supplement users are doing so without guidance from a healthcare professional. Your patients are making pharmacologically relevant decisions without you in the room.

What 25 Years of Data Actually Show Us

The Overall Trend: Supplement Use Is Growing and Accelerating

Overall supplement use rose from 51% to 60% over the study period — but the trajectory matters as much as the endpoint. Use was essentially flat from 1999 through 2009. After 2009, the curve bent sharply upward. The researchers used joinpoint analysis to identify this inflection, and it held across multiple supplement categories. What happened around 2009? Market expansion, digital health marketing, the rise of social media as a supplement promotion vehicle, and a broad cultural shift toward self-directed health management — all converging.

Use of 4 or more supplements simultaneously nearly doubled, rising from 8.8% to 15% of adults. That is a population taking multiple non-prescription, non-FDA-premarket-approved compounds concurrently — often without telling their provider.

The Older Adult Story: The Most Clinically Urgent Finding

Among adults 65 and older, supplement use rose from 62% to 78%. This is the group that:

• Has the highest medication burden and the greatest risk of drug-supplement interactions

• Is most likely to have renal and hepatic changes that alter supplement metabolism

• Is most likely to see multiple providers who may not coordinate supplement review

• Is most likely to be taking supplements for disease management — not just general wellness

⚠ Clinical alert: The study notes that NHANES excludes institutionalized adults (nursing homes, long-term care). This means the 78% figure almost certainly underestimates supplement use in your highest-acuity older patients. If anything, the true prevalence in complex older adults is higher.

The Multivitamin is Falling Out of Favor

One of the counterintuitive findings: multivitamin-multimineral (MVMM) use actually declined, from 35% to 31%. But this decline is not a sign of less supplement activity — it is a sign of more sophisticated (and potentially more risky) supplement behavior. Patients who used to take one multivitamin are now taking multiple targeted, single-ingredient or combination products instead.

This matters clinically because MVMMs typically contain lower doses of individual nutrients. When patients shift to single-ingredient supplements, they may be dosing individual vitamins or minerals at levels far exceeding what a multivitamin provides — and those doses can have real clinical consequences.

What Your Patients Are Actually Taking: The Rising Stars

Vitamin D: The Breakout Supplement of the Era

Vitamin D supplementation increased from 5.1% to 29% of adults — nearly a sixfold rise. This is the single largest increase among individual supplements in the study. The clinical community drove much of this growth, as vitamin D deficiency screening became widespread after the early 2000s, and evidence accumulated for roles in skeletal health, autoimmune disease, and multiple other outcomes.

For your practice: vitamin D levels matter and testing is appropriate in at-risk populations. But higher is not always better. Vitamin D toxicity (typically from supplement excess rather than sun exposure or food) causes hypercalcemia, nausea, vomiting, weakness, renal impairment, and — over time — nephrolithiasis and soft tissue calcification. Patients taking doses above 4,000 IU/day without monitoring need a conversation.

Zinc: From Obscurity to Mainstream — Then the Pandemic Supercharged It

Zinc use outside of multivitamins rose from 4.6% to 11% overall — but the pandemic-era analysis shows it nearly doubled between the pre-pandemic and post-pandemic periods (5.4% to 11%). Zinc for immune support became a ubiquitous pandemic recommendation, and consumers have not let go of it.

Clinical concern: zinc is not a benign supplement at high doses. Chronic excess zinc intake suppresses copper absorption and can cause copper deficiency — which manifests as anemia, neutropenia, and neurological symptoms that can be subtle and difficult to recognize. Long-term zinc supplementers taking 50 mg/day or more are genuinely at risk, and this is not well understood by consumers buying zinc lozenges or capsules.

Magnesium: The Quiet Surge

Magnesium supplementation doubled (from 4.7% to 9.8% outside of MVMMs). It is now being marketed for sleep, muscle cramps, migraine prevention, anxiety, and constipation — and there is at least some evidence base for several of these uses. For NPs, the key clinical questions are: what form is the patient taking, at what dose, and do they have any degree of renal impairment?

Magnesium is renally cleared. In CKD, supplemental magnesium can accumulate and cause hypermagnesemia — bradycardia, hypotension, respiratory depression, and cardiac arrest at extreme levels. This is not common but it is real, and it is more likely in older adults on high-dose supplements who have never had their renal function correlated with their supplement regimen.

Omega-3 / Fish Oil: From 2% to 14% in 25 Years

Fish oil is now one of the most commonly used supplements in the country, climbing from 2.1% to 13.6%. Evidence has evolved significantly on this one. While omega-3 supplementation has shown benefits in hypertriglyceridemia (prescription-strength icosapentaenoic acid, i.e., Vascepa, is guideline-supported), the evidence for standard fish oil in cardiovascular event reduction is much weaker than early studies suggested. The VITAL trial found neutral cardiovascular effects, though benefits were seen in specific subgroups and for autoimmune outcomes.

At high doses, omega-3 has antiplatelet effects. Patients on anticoagulation or antiplatelet therapy who are also taking high-dose fish oil need this flagged.

Turmeric/Curcumin: The Anti-Inflammatory Darling

Turmeric and curcumin use rose more than eightfold (from 0.6% to 5.2%). Marketed for joint pain, inflammation, and general anti-inflammatory support, curcumin is one of the most studied botanical compounds. The evidence is mixed — bioavailability is inherently poor (most formulations are not well absorbed without piperine or lipid-based delivery systems), and high-quality RCTs are limited.

Drug interaction alert: curcumin inhibits CYP3A4 and P-glycoprotein at higher doses, which can affect plasma levels of drugs including some statins, immunosuppressants, and anticoagulants. Patients on warfarin taking turmeric supplements deserve monitoring.

The Adaptogens and Gut Health Supplements: Ashwagandha, Probiotics, Prebiotics, Collagen

Several supplements that were essentially absent from NHANES data in 1999 now appear at measurable prevalence:

• Ashwagandha (an adaptogen marketed for stress, cortisol, and sleep): emerged in recent cycles, rose sharply in the pandemic period. Evidence is preliminary; case reports of hepatotoxicity have appeared in the literature and deserve monitoring.

• Probiotics: now used by 6.7% of adults, nearly nonexistent in 1999. Evidence supports specific indications (antibiotic-associated diarrhea, IBS symptom management), but strain specificity matters enormously and most consumer products lack clinical evidence for their specific formulations.

• Prebiotics: growing rapidly, especially post-pandemic. Generally safe but can cause significant GI disturbance (bloating, gas, cramping) at higher doses.

• Collagen and hyaluronic acid: emerging for skin and joint health. Some clinical trial evidence for each, though data quality varies. Generally well tolerated.

What Fell Out of Fashion — and Why It Matters

The study also identified dramatic declines in several supplements. Understanding why things fall is as clinically informative as understanding why they rise:

• Ephedra: banned by the FDA in 2004 after being linked to serious cardiovascular events and deaths. Its near-disappearance from NHANES data after 2005 is a textbook example of regulatory action working.

• Ginseng: declined from 6.0% to 0.72%. Drug interaction concerns (CYP enzyme interactions, antiplatelet effects) and inconsistent evidence for purported cognitive and energy benefits appear to have eroded consumer confidence.

• Ginkgo biloba: declined from 4.6% to 1.1%. The landmark Ginkgo Evaluation of Memory (GEM) trial failed to show any reduction in dementia incidence, deflating a primary marketing claim. Drug interactions (particularly anticoagulant potentiation) also dampened enthusiasm.

• Trace minerals (nickel, tin, silicon, vanadium): dramatic declines reflecting safety concerns and absence of clinical benefit evidence. Vanadium, for example, was once marketed for blood sugar control — evidence is insufficient and toxicity concerns are real.

The Pandemic Effect: Immune Supplements Surged — And Haven't Come Back Down

The study's analysis comparing pre/early pandemic (2017–March 2020) to later/post-pandemic (August 2021–August 2023) periods shows significant increases in:

• Zinc: doubled in the post-pandemic period

• Vitamin D: increased 30% above pre-pandemic use

• Vitamin K: more than doubled

• Elderberry: increased 50%

• Ashwagandha: nearly tripled

• Prebiotics and collagen: each increased substantially

What this tells us: pandemic-driven supplement behavior has not reverted to baseline. The immune health supplement category, which exploded during COVID, has become structurally embedded in consumer behavior. Whether evidence catches up to this demand is a separate question — but your patients are still buying these products, and they are doing so independently of provider guidance.

What This Means for Your Clinical Practice

1. Supplement Review Is Now a Required Component of Medication Reconciliation

The data make this clear: more than 60% of your patients — and nearly 80% of your patients over 65 — are using supplements. A medication reconciliation that misses supplements is incomplete. Build it into your intake workflow explicitly. Ask not just 'do you take any vitamins?' but:

"Tell me about everything you take for your health — including any vitamins, minerals, herbs, probiotics, or supplements you buy at a pharmacy, health food store, or online. Even things you take occasionally."

2. The Polypharmacy Calculation Must Include Supplements

When you are evaluating a patient on 7 medications and calculating their polypharmacy burden, the patient who is also taking fish oil, magnesium, vitamin D, zinc, turmeric, and ashwagandha is effectively on 13 compounds. The drug-supplement interaction database is incomplete compared to the drug-drug interaction database, but known interactions include:

• Warfarin + fish oil, vitamin E, ginkgo, garlic, turmeric → enhanced anticoagulation, bleeding risk

• Statins + red yeast rice (contains lovastatin) → unpredictable statin dosing and myopathy risk

• Thyroid medications + calcium, iron, magnesium → absorption interference if taken together

• Immunosuppressants + St. John's Wort → CYP3A4 induction reduces drug levels (St. John's Wort use has declined but is still present)

• Antidepressants + high-dose omega-3 → generally safe but additive serotonergic potential at very high doses

• Antihypertensives + high-dose magnesium → additive hypotensive effect, especially in renal impairment

3. Ask About Dosing, Not Just Product Name

'I take vitamin D' tells you very little. A patient taking 1,000 IU/day of vitamin D is in a fundamentally different clinical situation than one taking 10,000 IU/day. The same applies to zinc, magnesium, vitamin E, and most other micronutrients. When you identify high-volume supplement users, dose matters.

4. Sociodemographic Awareness in Supplement Counseling

The study found significant disparities in supplement use patterns. Non-Hispanic White adults and those with higher education and income have historically had the highest supplement use. However, the data show notable increases in Mexican American and non-Hispanic Black adults over the study period. This means:

• Assumptions about who does and doesn't use supplements can lead to missed conversations

• Supplement marketing is reaching more diverse populations — and provider counseling needs to keep pace

• Lower-income patients who use supplements may be spending significant out-of-pocket dollars on products with limited evidence

5. Be a Non-Judgmental, Evidence-Informed Guide

When you identify supplement use, resist the reflex to dismiss it or deliver a lecture. Patients who feel judged about their supplement choices will stop disclosing them. Your clinical goal is information — you cannot assess risk for something you don't know about.

A more effective approach: acknowledge what you hear, ask about the reason they are taking it, provide evidence-based information about what is known (including both potential benefits and harms), and flag any genuine interactions with their medications or conditions. For supplements with reasonable evidence and no significant risk in their clinical context, support informed patient autonomy.

For NP Students and AANP/ANCC Board Prep

Supplement interactions and patient counseling are fair game on board exams. The key testable concepts include:

1. Drug-supplement interactions — warfarin is the most tested. Know that vitamin K, fish oil, garlic, ginkgo, and vitamin E all affect coagulation.

2. St. John's Wort is the most tested botanical — a potent CYP3A4 inducer that can reduce levels of oral contraceptives, cyclosporine, antiretrovirals, and digoxin among others.

3. Calcium and iron are absorption competitors — timing relative to thyroid medication, fluoroquinolones, and bisphosphonates is clinically important.

4. Dietary supplement regulation: supplements are regulated under DSHEA (Dietary Supplement Health and Education Act of 1994) — manufacturers do not need FDA premarket approval for safety or efficacy. This is a foundational fact for counseling patients about the evidence landscape.

5. Older adults and supplement risk: the combination of polypharmacy, altered renal and hepatic function, and high supplement prevalence makes this population the highest-risk group for drug-supplement interactions.

A Practical Supplement Counseling Framework for Your Clinic

When a patient discloses supplement use:

• Ask: What are you taking, at what dose, how often, and why?

• Record: Add supplements to the medication list in the chart — not as a separate category that gets skipped during reconciliation.

• Evaluate: Check for interactions with current medications using a current drug interaction checker (Lexicomp, Micromedex, or Natural Medicines database, which is specifically designed for supplements).

• Educate: Share what is known — briefly and without judgment. Focus on safety over efficacy debates when time is limited.

• Follow up: For high-dose supplement users with complex medication regimens, build supplement review into your follow-up visits.

Clinical resource: The Natural Medicines database (naturalmedicines.therapeuticresearch.com) is the most comprehensive evidence-based reference for supplement-drug interactions, efficacy ratings, and safety profiles. If your practice does not have access, advocate for it — the supplement prevalence data make it clinically justifiable.

The Bottom Line

The JAMA Network Open analysis gives us 25 years of data confirming what many of us have observed at the bedside: supplement use is widespread, growing, diversifying, and skewing heavily toward your oldest and most clinically complex patients. The shift away from multivitamins toward multiple targeted products is not a safer trend — it is a more pharmacologically complicated one.

For NPs in any practice setting, this is a call to make supplement review a routine, explicit, non-judgmental, and evidence-informed part of every patient encounter — especially for patients over 65, those on multiple medications, and those managing chronic disease. You cannot counsel on what you don't ask about.

The supplement aisle has gotten a lot more crowded since 1999. Your clinical conversations need to keep up.

References

• Lam CS, O'Connell K, Monroy-Iglesias MJ, et al. Emerging Patterns in Dietary Supplement Use Among US Adults, 1999–2023. JAMA Netw Open. 2026;9(6):e2619291. doi:10.1001/jamanetworkopen.2026.19291

• Kantor ED, Rehm CD, Du M, White E, Giovannucci EL. Trends in dietary supplement use among US adults from 1999–2012. JAMA. 2016;316(14):1464–1474.

• Bailey RL, Gahche JJ, Miller PE, et al. Why US adults use dietary supplements. JAMA Intern Med. 2013;173(5):355–361.

• Mangione CM et al; US Preventive Services Task Force. Vitamin, mineral, and multivitamin supplementation to prevent cardiovascular disease and cancer: USPSTF recommendation statement. JAMA. 2022;327(23):2326–2333.

• Natural Medicines Database. naturalmedicines.therapeuticresearch.com

• NIH Office of Dietary Supplements. ods.od.nih.gov

This post is intended for educational purposes. Always consult current clinical guidelines and evidence-based references for patient care decisions.

Nurse Practitioner Chronicles