Position Statements on Oral Micronutrient Supplementation in Nutrition and Appetite Support Across

the Continuum of Care

Karin Estepa-Garcia, M.D.a; Joy Arabelle Fontanilla, M.D.b; Maria Antonia Ocampo-Yamamoto, M.D.b; Pia Angela
Receno, M.D.b; Joel Marquez Santiaguel, M.D.a; Marianna Ramona Sy-Quia-Sioson, M.D.c
a
University of the Philippines-Philippine General Hospital, bAsian Hospital and Medical Center, cThe Medical City,
Ortigas

Abstract

Nutrition plays a fundamental role in maintaining optimal health and well-being. While a well-balanced diet should
ideally provide all essential nutrients, certain circumstances like poor appetite due to infection, chronic diseases,
and aging, may hinder individuals from meeting their nutritional needs adequately. Oral micronutrient
supplementation or multivitamins have the potential to help bridge these gaps by providing a comprehensive
blend of essential nutrients in convenient daily doses. However, the absence of guidelines for multivitamin
supplementation is a concerning issue for public health as they gain popularity. Recognizing the significance of this
matter, a multispecialty expert panel actively engaged in clinical practice and research has been formed. The
primary objective of this group is to address the importance of nutrition and the role of multivitamins across the
continuum of care. This collective effort to address the knowledge gaps surrounding multivitamin supplementation
aims to facilitate the shaping of evidence-based recommendations for multivitamin supplementation use to aid in
appetite and nutrition across the continuum of care.

Introduction

A technical working group composed of health professionals and multispecialty healthcare experts, have come
together to emphasize the crucial role of nutrition in promoting overall health and well-being. Nutrition serves as
the cornerstone of optimal physical and mental functioning, and they firmly believe that a well-balanced diet
should be the primary source of essential nutrients for individuals of all ages.1-4 However, they acknowledge the
existence of prevalent gaps in nutrition and the potential benefits of oral micronutrient supplementation
particularly those that contain iron and appetite stimulants in addressing these gaps across the entire disease
spectrum.5

Proper nutrition is vital for maintaining optimal health. A well-balanced diet, consisting of a variety of nutrient-
dense foods, provides essential vitamins, minerals, macronutrients, and phytochemicals necessary for growth,
development, and the prevention of chronic diseases. Adequate nutrition supports immune function, cognitive
abilities, physical performance, and overall well-being.1,2,4

Challenges in Nutrition and Appetite

Despite the importance of nutrition, various factors like appetite loss due to medications and illnesses contribute
to gaps in dietary intake. Modern dietary patterns, often characterized by highly processed foods, excessive added
sugars, unhealthy fats, and insufficient intake of fruits, vegetables, whole grains, and lean proteins, can result in
nutrient deficiencies. Additionally, socio-economic factors, cultural practices, limited access to nutritious food
options, and individual dietary restrictions may further contribute to these gaps.5,6 Moreover, individuals who have
poor appetite and nutrient intakes with certain conditions, or those who avoid certain foods (such as strict
vegetarians and vegans) might benefit from taking supplementation.

Multivitamin supplementation can play a supportive role in addressing nutritional gaps. These supplements, when
used appropriately and as part of a balanced diet, can provide a convenient and reliable source of essential
vitamins and minerals. Multivitamins are particularly useful in situations where dietary intake alone may not meet

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individual nutrient requirements due to limitations or specific health conditions. They offer an accessible option to
help bridge the nutritional gaps and ensure adequate nutrient intake.7
Table 1. Glossary of Key Terms and Definitions.
Multivitamin supplement A product with widely varying composition of vitamins and minerals, and sometimes other
ingredients that is intended to supplement the diet.7
Recommended Energy/ Level of intake of energy or nutrient which is considered adequate for the maintenance of health
Nutrient Intake (REI/RNI) and well-being of healthy persons in the population.8
Active Disease Chronic, active medical conditions for which the patient received treatment or regular follow-up.
Patients with active disease may be further classified to outpatient and inpatient.
Outpatient Patients with controlled active diseases who consult at the primary care setting.
Inpatient/Hospitalized Patients with active diseases who are hospitalized.
Patients
Critical Care Encompasses the diagnosis and treatment of a wide variety of clinical problems representing the
extreme of human disease. Critically ill patients require intensive care by a coordinated team.9
Palliative Care Palliative care is specialized medical care for people living with a serious illness.9
Hospice Care Hospice care focuses on the care, comfort, and quality of life of a person with a serious illness who
is approaching the end of life.10
Anemia Anemia is defined as Hb <13 g/dL in men and Hb <12 g/dL in women, according to WHO criteria.11
Iron deficiency anemia Laboratory-confirmed evidence of anemia, as well as evidence of low iron stores.12

Table 2. Current Recommended Nutrient Intakes per day for B vitamins, vitamin C, and calcium for ages 19 and above13
Male Female Pregnant Lactating
Vitamin B1 (mg) 1.2 1.1 +0.3 +0.2
Vitamin B2 (mg) 1.3 1.1 +0.7 +0.6
Vitamin B3 (mgNE)a 16 14 +4 +3
Vitamin B6 (mg) 1.3-1.7 1.3-1.6 +0.6 +0.7
Vitamin B12 (µg) 2.4 2.4 +0.2 +0.5
Vitamin B9 (µgDFE)b 400 400 +200 +150
Vitamin C (mg) 70 60 +10 +35
Calcium (mg)c 750-800 750-800 +50 +0
aAs niacin equivalent (NE); b1 dietary folate equivalent (DFE) = 1 µg food folate = 0.6 µg folic acid from fortified foods or as supplement = 0.5 µg

taken on an empty stomach; cThe calcium recommendation for pregnant women is for 3rd trimester only.
Adapted from: Philippine Dietary Reference Intakes 2015: Summary Tables. Revised September 2018.

Table 3. Current Recommended Nutrient Intakes per day Table 4. Diagnostic criteria for iron deficiency anaemia14
for iron (mg) for ages 19 and above13 Serum Markers Diagnosis for IDA
Age Male Female Haemoglobin <130g/L males
<120g/L females
19-29 12 (28)
<110g/L in pregnancy
30-49 12 (28) Ferritin* <30ug/L if no
inflammation <100ug/L
50-59 12 10
if inflammation
60-69 12 10 Transferrin† Raised
>=70 12 10 Total iron binding capacity Raised
Iron Reduced
Pregnant (+10) Transferrin saturations <20%
Lactating +2 Mean corpuscular volume Low
*Is a positive acute phase protein and can be raised in
( ) Requirements cannot be met by usual diet alone. Intake of
iron-rich and iron-fortified foods and the use of supplements are
inflammatory conditions; †Is a negative acute phase
recommended, if necessary. Adapted from: Philippine Dietary
protein and can be normal or reduced in inflammatory
Reference Intakes 2015: Summary Tables. Revised September conditions. IDA, iron deficiency anemia
2018.

Methodology

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In April 2023, a group of multispecialty experts, including specialists from family and occupational medicine,
palliative care, pulmonology, hematology, and endocrinology, formed a technical working group composed of six
members (Estepa-Garcia K, Fontanilla JA, Ocampo-Yamamoto MA, Receno PA, Santiaguel JM, and Sy-Quia-Sioson
MR). The primary objective was to develop recommendations for multivitamin supplementation use for appetite
and nutrition support across the continuum of care. The secondary objective was to establish a standard dosing
recommendation for an iron-containing multivitamin supplement based on patient profiles and nutritional
requirements.

This assembly of experts acknowledged that the existing guidelines and recommendations for multivitamin
supplementation are currently insufficient and inconsistent. While scientific research has extensively explored the
benefits and risks of various nutrients, there is a lack of consensus on optimal dosage, formulation, duration, and
specific population groups that may benefit most from supplementation. Additionally, studies highlighting
potential interactions, adverse effects, and long-term implications call for the development of comprehensive
guidelines to ensure safe and effective use.7,15,16 By addressing guide clinical questions, the experts have reached a
consensus on the recommended utilization of multivitamin supplements across the continuum of care.

Experts’ opinions on the role of multivitamin supplementation in nutrition across the continuum of care.

Statement 1: The decision on prescribing multivitamins and minerals should be aligned to the patient profile,
clinical requirements, and personal preferences.

Summary of evidence linked to the position statement.

The most cited reason for using multivitamin supplements is for overall health and wellness and to fill nutrient
gaps in the diet.8 In a study, it was demonstrated that intakes of many nutrients were markedly inadequate among
Filipino adults, particularly iron (97–99%), vitamin C (96–98%), calcium (95–98%), riboflavin (86–91%), folate (89–
90%), thiamine (73–89%), energy (67–70%), total fat (55–67%), and vitamin A (54–56%).6 This “hidden hunger” is
largely due to eating patterns dominated by energy-dense, but nutrient-poor, foods that are often relatively
inexpensive.17 While the use of supplements is not routinely recommended18, people who use supplements tend
to have a better overall diet quality than those who don’t use them, and their nutrient intake from foods mostly
meets recommended intake levels.19,20 Recommendations for supplementation in specific populations will be
discussed in the succeeding statements.

Statement 2: A multivitamin supplement may have different roles on nutrition and appetite across the
continuum of care.

2.1 Healthy. In general, healthy individuals who can achieve recommended daily intakes through nutrition do not
require multivitamin supplementation. For people who follow a healthy and balanced diet – one that includes
all the main food groups in sufficient amounts – multivitamins are unlikely to have any positive health
effects.21
2.2 Active disease
2.2.1. Outpatient. For patients with controlled chronic medical conditions who consult at the primary care
setting, an oral multivitamin supplement may be given to help achieve the recommended daily
intakes. Some patients with active disease may benefit from multivitamin supplementation to get
enough of the recommended dietary allowances. For example, patients with inflammatory bowel
disease (IBD) who may need a bit of extra help preventing a nutritional deficiency may get the
necessary vitamins and minerals from eating a well-balanced, nutrient-rich diet, but flares, severe
symptoms, surgeries, and other complications may make it difficult for some patients with Crohn’s
disease or ulcerative colitis to get enough nutrients from food alone. Patients with IBD may also be
prescribed sulfasalazine and methotrexate, which may interfere with the absorption of folic acid.22
This goes the same for patients with rheumatoid arthritis who are being treated with methotrexate.
Appetite loss and ensuing weight loss are key features of severe illnesses, contributing significantly

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 to undernutrition and subsequently, the adverse outcome of these conditions.23 For these patient
groups, vitamin B supplementation may be instrumental in filling in nutritional gaps and preventing
deficiency.24

2.2.2. Inpatient/Hospitalized. For hospitalized patients who can eat, an oral multivitamin supplement may be
incorporated into the nutrition plans to help achieve the recommended daily intakes. Some
hospitalized patients such as those with heart failure25, alcohol use disorder26, or COVID-1927 may be
at risk for vitamin deficiencies. Dietary intake of micronutrients or supplementation has well-
established beneficial effects on the regulation and integrity of the immune system27 and improves
mood and reduces psychological distress in acutely hospitalized patients.28

For patients in critical care, it is necessary to have a comprehensive and detailed provision of
nutrition.29 Although about 40% of critically ill patients can eat during their ICU stay, according to the
few studies published so far, critically ill patients who were fed orally had very low intakes in terms
of both energy and proteins, compared to predicted requirements and recommendations, regardless
of the underlying cause.

Certain medical conditions, such as gastrointestinal disorders or malabsorption issues, may hinder
the body's ability to absorb or utilize B vitamins effectively.17 Vitamin B6 (pyridoxine)
supplementation during isoniazid (INH) therapy in patients with tuberculosis is necessary to prevent
the development of peripheral neuropathy.30 Admission to hospital has been linked with an
additional risk of malnutrition—feeding below 1500 kcal/day was frequent and has been associated
with a structural additional risk of insufficient micronutrient intake to cover basal needs. The
micronutrients at the highest risk are iron, zinc, thiamine, vitamin B12 and vitamin C.

Proton pump inhibitors have been associated with an increased risk of vitamin and mineral
deficiencies impacting vitamin B12, vitamin C, calcium, iron, and magnesium metabolism.31 Vitamin
deficiencies are also observed in patients undergoing chemotherapy. For example, in patients
undergoing intensive chemotherapy for acute myeloid leukemia, vitamin C and D supplementation
were found to be feasible, safe, and helpful in optimizing supportive care.32 Patients with diabetes
taking metformin at ≥1500 mg/day could experience vitamin B12 deficiency, but concurrent
supplementation of multivitamins may potentially protect against the deficiency.33 In such cases,
supplementation may be prescribed to address specific deficiencies and support overall health.34

In patients with trauma or burn, or in the case of wound healing disorders, tailored nutritional
measures or supplementation with micronutrients could be beneficial. Supplementation or repletion
of some micronutrients can be administered orally, separately, or as commercial preparations of
multivitamins and minerals. Unfortunately, the oral route can be associated with reduced
bioavailability or competition between trace elements (such as zinc and copper).35

Poor appetite may persist among patients 12 months after being discharged from the ICU. This may
lead to sarcopenia and a high mortality rate. Additionally, poor appetite is associated with high
severity of depression.36

It is reasonable to consider a dose of 2 ordinary multivitamins daily in the elderly, specifically

because of the high prevalence of suboptimal vitamin B12 and D intake. However, it might be safer
to supplement 1 multivitamin with additional vitamins B12 and D, taken separately, given the
possibility that increased vitamin A intake might increase the risk of hip fracture and that the iron in
most multivitamins may increase the risk of hemochromatosis in some people.37

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2.3 Palliative and hospice. For patients in palliative and hospice care, decisions concerning whether to use oral
multivitamin supplements must be made on the perceived benefits, harms, risks, and burdens of nutrition
support in individual patient circumstances.

As the primary goal of treatment in palliative and hospice care is the comfort of the patient, decisions
concerning whether to use oral multivitamin supplements must be made on the perceived benefits, harms,
risks, and burdens of artificial nutrition support in individual patient circumstances.38

The primary objective of nutritional therapy in palliative care is to preserve oral nutrition by minimizing food-
related discomfort and maximizing food enjoyment.39 Nutrition and hydration are more about the provision
of food and fluids that are in keeping with the individual and family/caregiver preferences, to achieve comfort
and the best quality of life that is possible. At this time, there are often a number of problems that may be
contributing to poor oral intake, including reduced appetite, nausea and vomiting, sore mouth and throat,
difficulty swallowing, dry mouth, loss of taste/smell, altered taste/smell, and pain.40 These problems lead to
nutrition deficiencies like vitamin D (86%), vitamin b12 (32%) and folic acid (63%), as shown in one study on
geriatric palliative care patients.41

2.4 Special populations. Special populations may benefit from multivitamin supplementation.

While routine supplementation is not advised for healthy individuals, certain circumstances may warrant
multivitamin supplementation. These are populations with high index of suspicion for certain types of
micronutrient deficiency in the primary care setting:

Older adults: Appetite loss, changes in taste and smell, and dysphagia are common in older adults.31 Many are
unable to absorb vitamin B12 from food sources. Additionally, older adults who consume little to no animal
products are at an increased risk for deficiency.42 It is also recommended that vitamin B supplements be
considered as preventive medication for patients with mild cognitive impairment or elderly adults without
cognitive impairment.43

Women of reproductive age: The Centers for Disease Control and Prevention urge every woman who could
become pregnant and who are pregnant to get 400 micrograms (400 mcg) of folic acid every day. Folic acid helps
prevent birth defects.44

Special diets: Individuals following strict plant-based diets (vegetarian or vegan diets), which may limit the intake
of certain B vitamins, such as vitamin B12, found predominantly in animal-based products, might benefit from
targeted supplementation or careful dietary planning to ensure adequate B vitamin levels.41

Highly restrictive diets: Randomized controlled trials suggest that the weight loss associated with intermittent
fasting is due to a reduced energy intake due to time restriction.45 Ketogenic diet is a high fat, low carbohydrate,
and adequate protein diet. Ketogenic diet does not contain all vitamins and minerals that are available in the
balanced diet. The patients should be advised to take vitamin and mineral supplements while on ketogenic diet.46
Because of restricted diets that provide limited vitamin intake from food, many patients with renal disease can
benefit from a tablet that adds an amount equal to one recommended daily allowance of water-soluble vitamins,
but larger amounts are not appropriate or beneficial.47

Fitness enthusiasts: Regular physical activity can accelerate the usage of vitamins and minerals in the body.
Calcium, iron, zinc, magnesium, B vitamins, vitamin D, and antioxidants are essential for individuals engaged in
fitness activities to perform at higher levels of intensity.48 High-protein diets are not recommended because they
restrict healthful foods that provide essential nutrients and do not provide the variety of foods needed to
adequately meet nutritional needs. Individuals who follow these diets are therefore at risk for compromised
vitamin and mineral intake, as well as potential cardiac, renal, bone, and liver abnormalities overall.49

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Patients with eating disorders: Disordered eating, such as anorexia nervosa and bulimia nervosa, is a challenging
health concern. The Academy of Nutrition and Dietetics noted in their Revised 2020 Standards of Practice for the
Professional Practice of the Registered Dietitian that dietary supplements, ranging from multivitamins, botanicals,
protein supplements, calorie-protein supplements, and more are standards of care for those being treated for an
eating disorder.50 For some patients with a long history of anorexia nervosa, the best option may be to maintain a
weight safe enough to allow some quality of life and prevent hospital admission. Particular attention should be
given to energy, protein, calcium, iron, zinc, vitamin B12 and vitamin D. 51

Patients trying to manage weight: Patients with cardiometabolic disease who are trying to lose weight as part of
their management, like patients with cardiometabolic conditions, may be at risk for nutrient and electrolyte
deficiency if they are not consuming adequate water or nutrient-dense foods. They may benefit from targeted
supplementation or careful dietary planning to ensure adequate vitamin levels.42 Vitamin B supplementation has
also shown some improvement in metabolic control in patients living with diabetes.52

Harmful or dependent alcohol drinkers: Thiamine is recommended by the National Institute for Health and Care
Excellence (NICE) guidelines for alcohol-use disorders (harmful drinking and alcohol dependence) in adults and
young people aged 10 to 17 years. However, vitamin B complex is not routinely recommended for this
population.53

People leading busy lives: People with hectic lifestyles frequently depend on “eating on the run” and are
associated with poor dietary intake, including a higher intake of fast foods and soft drinks and a lower intake of
vegetables. Inconsistent meal patterns, particularly skipping breakfast, are associated with poorer diet quality and
contribute to barriers to good nutrition.54 These patients who are not able to maintain a well-balanced diet may
also benefit from supplementation, as multivitamins help fill nutritional gaps and protect against the risks of
chronic diseases.55,56

Long-haulers: Long-haulers like security guards, call-center agents, and drivers often experience fatigue. Fatigue
that is due to iron-deficiency anemia usually improves after iron supplementation. Iron deficiency in the absence
of anemia can also cause fatigue because iron plays a role in various biochemical processes involved in energy
production.57

Depressed: The most common nutritional deficiencies seen in patients with mental disorders are omega–3 fatty
acids, B vitamins, minerals, and amino acids that are precursors to neurotransmitters. Randomized, controlled
trials that involve folate and vitamin B12 suggest that patients treated with 0.8 mg of folic acid/day or 0.4 mg of
vitamin B12/day will exhibit decreased depression symptoms. According to a study, supplementation of vitamins
including vitamin B2 and B6 for 1-year improved mood in both men and women.58

People living in certain geographic locations. Dietary intake can be influenced by geographic location. For
example, widespread vitamin D deficiency and insufficiency has been reported in many different areas of Asian
countries. Considering limited food sources for vitamin D such as fatty fish, solar exposure can be one of the major
factors contributing to vitamin D status in these populations.59 Environmental factors can also affect vitamin C
intake and status; these include geographic region, season, and climate, as well as pollution. Therefore, taking
supplements in addition to dietary intake can help to maintain optimal vitamin C status.60

Patients who are immunocompromised. Supplementation with vitamins, omega 3 fatty acids and zinc appears to
be a safe and low-cost way to support optimal function of the immune system, with the potential to reduce the
risk and consequences of infection, including viral respiratory infections.61

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Experts’ opinions for screening strategies and other validated tools to assess nutrition and appetite in adults.

Statement 3: Patients who are discharged from the hospital, especially post-ICU, should be screened for
malnutrition and appetite loss using validated tools.

3.1 Screening tools for malnutrition

3.1.1. MUST (Malnutrition Universal Screening Tool): MUST is a five-step screening tool to identify adults
who are malnourished, at risk of malnutrition, undernutrition), or obesity. It can be used in hospitals,
communities, and other care settings, and by all healthcare workers. It involves measurement of
height and weight to get the BMI, computation of unplanned weight loss, establishing the acute
disease effect score, calculation of the overall risk of malnutrition, and management guidelines to
help in the development of a care plan.62
3.2.2. Mini Nutritional Assessment (MNA®) Tool: The MNA® is a validated screening tool designed to help
identify older persons who are malnourished or at risk of malnutrition. It is the gold standard for
screening for the risk of malnutrition in the ambulatory elderly and those living in long-term care
facilities. The tool includes items for functionality and body composition and considers domains not
directly linked to food intake, but crucial when dealing with frail older people such as mobility,
depression, and dementia. It provides a nutritional assessment as well as prognostic information.63

3.2 Screening tools for appetite loss

3.2.1. Council on Nutrition Appetite Questionnaire (CNAQ): The CNAQ is a validated nutritional screening
tool also adapted from the AHSP. It is an 8-item questionnaire that has been found to be valid in
predicting clinically significant weight loss in older adults, both in community dwelling older adults
and in long term care residents. Each item is scored on a 5-point scale, with a possible total score
ranging from 8 (worst) to 40 (best). A score of ≤28 indicates significant risk of at least 5% weight loss
within 6 months, and such participants were classified as at risk of malnutrition.64
3.2.2. Simplified Nutritional Appetite Questionnaire (SNAQ): The Simplified Nutritional Appetite
Questionnaire (SNAQ) for anorexia is a validated nutritional screening tool. It is a self-administered
questionnaire adapted from the Appetite, Hunger and Sensory Perception questionnaire (AHSP), an
appetite assessment tool validated among community-dwelling older adults in the Netherlands. It is
a shorter four-item questionnaire comprising items 1, 2, 4 and 6 of the CNAQ and was shown to have
good reliability, sensitivity, and specificity to predict malnutrition in both specialized and
nonspecialized older adult populations.64

Experts’ opinions for iron and vitamin B supplementation.

Statement 4: Iron supplementation is recommended for adults with iron deficiency anemia.

Symptoms that may warrant suspicion and screening for iron-deficiency anemia are related to decreased oxygen
delivery to the entire body. These include paleness, unexplained fatigue or lack of energy, shortness of breath or
chest pain, especially with activity, unexplained generalized weakness, and headache.65

4.1. Identification of type of iron deficiency anemia. It is important to define absolute and functional IDA. In an
absolute iron deficiency state, total body iron stores are reduced. Functional iron deficiency, on the other hand, is
a state of imbalance between iron demand and serum iron availability, and it may occur despite adequate body
iron stores.66

4.2. Dosing. A dose of 60-120mg of elemental iron daily is recommended for patients with iron deficiency
anemia.67 Alternate day, low dose schedules provide higher fractional absorption compared to daily schedules. As
side effects are likely dose dependent, such schedules may result in higher compliance and efficacy.68,69

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4.3. Duration. Iron supplementation may be given 3-6 months or more for repletion of iron stores and
normalization of serum ferritin.66 The World Health Organization recommends 3 months of supplementation
followed by 3 months of no supplementation after which the provision of supplements should restart if
supplements are given once weekly. For those given a once-daily supplement of 30-60mg elemental iron,
supplements should be given for three consecutive months in a year. Iron supplements should be continued for 4-
6 months after anemia has been corrected to replenish iron stores and normalization of serum ferritin.70

4.4. Monitoring. When giving iron-containing supplements to patients with deficiency, it is best to monitor serum
ferritin and hemoglobin. A serum ferritin level should be obtained in patients with anemia and a mean corpuscular
volume less than 95 μm3. Ferritin is the most accurate test to diagnose iron deficiency anemia, as it reflects iron
stores. Although levels below 15 ng per mL (33.70 pmol/L) are consistent with a diagnosis of iron deficiency
anemia, using a cutoff of 30 ng per mL (67.41 pmol/L) improves sensitivity from 25 to 92 percent, and specificity
remains high at 98 percent. In patients with chronic inflammation, iron deficiency anemia is likely when the ferritin
level is less than 50 ng per mL (112.35 pmol/L). If the ferritin level is indeterminate in patients not in inflammatory
states, further tests can be performed to ascertain iron status. Values consistent with iron deficiency include a low
serum iron level, low transferrin saturation, and a high total iron-binding capacity.12 The usual benchmark for
successful iron supplementation is a 2-g/dL increase in the hemoglobin level in 3 weeks. However, a meta-analysis
of five randomized controlled trials concluded that in patients receiving oral iron supplementation, hemoglobin
measurement after 2 weeks showing an increase of 1.0 g/dL or more over baseline is an accurate predictor of
longer-term and sustained response to continued oral therapy and may help determine whether and when to
transition patients from oral to IV iron.71

4.5. Adverse reactions and toxicities. While iron absorption is more effective when iron supplements are taken
without food, it can lead to the development of nausea and epigastric pain due to the higher doses typically
administered (usually above 60 mg of iron per day). In case these adverse effects occur, it is advisable to try lower
doses between meals or take iron supplements with meals, even though the presence of food reduces the
absorption of medicinal iron by approximately two-thirds.13

Statement 5: Daily vitamin B supplementation is not routinely recommended to healthy individuals unless there
is suspicion of deficiency or underlying disease.

Summary of evidence linked to the position statement.

Vitamin B plays a crucial role in maintaining overall health and well-being. The B-complex vitamins, including B1
(thiamine), B2 (riboflavin), B3 (niacin), B5 (pantothenic acid), B6 (pyridoxine), B7 (biotin), B9 (folate), and B12
(cobalamin), are essential for the proper functioning of the body. They play vital roles in metabolism, brain
function, DNA synthesis, and nerve health.72,73 While a deficiency in vitamin B can have detrimental effects, daily
vitamin B supplementation is not routinely recommended for healthy individuals without any suspicion of
deficiency or underlying disease.

Most individuals can obtain enough B vitamins through a balanced diet that includes sources such as high intakes
of vegetables, fruit, low-fiber breakfast cereal, and low intake of processed meat, white bread, sugar, and
preserves. For those following a well-rounded diet, additional supplementation is typically unnecessary and may
even lead to excess vitamin levels in the body.74

One study has shown that supplementation with vitamin B (either alone or with a multivitamin) may particularly
benefit populations who are at risk due to poor nutrient status or poor mood status. Particularly, the meta-analysis
showed that providing a supplement containing B vitamins provided improvement in overall mood through a
reduction in stress.75

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Statement 6: Appetite stimulants may increase appetite and improve the nutritional status of patients with poor
nutrition.

Summary of evidence linked to the position statement.

Appetite stimulants are medications prescribed to increase appetite and improve the nutritional status of patients
experiencing severe weight loss associated with poor nutrition and certain chronic illnesses. An example is
buclizine, an agent with antihistaminic activity, which was shown to be effective in producing appetite stimulation
and increasing body weight in children and adults in older studies76-78 and possesses anti-emetic properties.79
Studies regarding the efficacy of buclizine as an appetite stimulant are limited80, but buclizine has not been shown
to cause birth defects or other problems in humans.81

Conclusion

Health professionals and experts must stress the importance of prioritizing nutrition as the primary source of
essential nutrients. However, the presence of nutritional gaps that may necessitate the use of multivitamin
supplementation should also be recognized. Even when a diet is well planned, it can be challenging for most
people to consistently consume foods that provide the recommended quantities of all essential micronutrients.
Chronic deficiencies in even small amounts of these nutrients can lead to health issues. While multivitamins can
offer support in meeting nutrient needs, it is crucial to approach supplementation with caution and consult
healthcare professionals.

Further research and the establishment of evidence-based guidelines to guide individuals in making informed
decisions regarding multivitamin supplementation should also be made as these will empower individuals with
accurate information to enable them to optimize their nutrition and enhance their overall health and well-being.
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World Health Organization. Healthy Diet. Available at https://www.who.int/news-room/fact-sheets/detail/healthy-diet. Accessed 18 May
2023. 3. Branca F, et al. Lancet 2020;395(10217):8–10. 4. Food and Agriculture Organization. Human nutrition: key to health and development.
Available at https://www.fao.org/3/U8480E/U8480E04.htm. Accessed 18 May 2023. 5. GBD 2017 Diet Collaborators. Lancet
2019;393(10184):1958–1972. 6. Angeles-Agdeppa I, Sun Y, Denney L, et al. Nutr J 2019;18:59. 7. National Institute of Health.
Multivitamin/mineral Supplements. Available at https://ods.od.nih.gov/factsheets/MVMS-HealthProfessional. Accessed 18 May 2023. 8. FNRI.
Philippine Dietary Reference Intakes (PDRI). Available at https://www.fnri.dost.gov.ph/index.php/tools-and-standard/philippine-dietary-
reference-intakes-pdri. Accessed 19 June 2023. 9. American College of Physicians. Critical Care Medicine. Available at
https://www.acponline.org/about-acp/about-internal-medicine/subspecialties-of-internal-medicine/critical-care-medicine. Accessed 18 June
2023. 10. National Institute on aging. What Are Palliative Care and Hospice Care? Available at https://www.nia.nih.gov/health/what-are-
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