Choking Hazard: Another Reason to Skip Supplements

Ricki Lewis, PhD

August 19, 2019

Large, hard multivitamin and calcium supplements are a frequent cause of choking in seniors, according to results of a study published online August 19 in Annals of Internal Medicine.

People in the United States shell out $30 billion a year on vitamins and other supplements, but questions of efficacy and safety have arisen. A recent "umbrella review" of randomized trials of vitamins and supplements showed that using the products has no effect on overall mortality, according to a report published online July 9 in Medscape. Observational studies that tend to have positive findings may over-represent more healthy individuals, those researchers stated.

Results of the new investigation suggest that choking on supplement pills is a preventable hazard.

The US Food and Drug Administration (FDA) provides voluntary guidance concerning tablet and capsule size of generic drug formulations, restricting them to 17 mm or less in a single dimension, or not to exceed the size of the corresponding branded pharmaceutical. No generic or branded product can exceed 22 mm. But dietary supplements are not subject to such scrutiny.

Cecile Punzalan, MD, MPH, from the FDA, and colleagues investigated swallowing problems associated with use of dietary supplements, considering factors such as pill size. They consulted a decade of data from adverse event reports submitted to the FDA Center for Food Safety and Applied Nutrition Adverse Event Reporting System (CAERS) from January 1, 2006, through December 31, 2015.

The researchers measured pill dimensions, categorized products according to ingredients or common reasons for use, and noted sex and age of people experiencing difficulty swallowing. They excluded reports of multiple supplements and powders and liquids.

During the decade the study covered, CAERS received reports of 20,791 adverse events for dietary supplements, and 3962 (19.1%) were for swallowing problems. The study group was disproportionately female, accounting for (85.6%) of the adverse event reports involving supplement swallowing, and difficulty swallowing accounted for 25.4% of all CAERS reports among females.

Age was also a risk factor for difficulty swallowing supplements. Of the 64.5% of swallowing problem reports that included patient age, 76.8% were from adults aged 65 years or older.

The most often cited swallowing difficulty was choking (86.0%), and 14.3% of those reports described serious adverse events, including three deaths resulting from airway obstruction or aspiration linked to attempting to swallow a large, hard, supplement pill.

The second most reported swallowing difficulty was foreign body trauma, at 7.8%.

The investigation pinpointed the products most likely to lodge in the throats of seniors. Multivitamins were the most dangerous, accounting for 72.9% (2889) of the reports, with calcium supplements and "bone health" products coming in second at 17.3% (687).

Next were supplements for pain or arthritis relief at 2.3% (93), cardiovascular health at 1.7% (67), "specified other" at 1.7% (67), immunity or infection/cold at 1.3% (50), single-ingredient vitamins or minerals (not calcium) at 1.2% (48), and unspecified other at 1.5% (61).

The researchers also evaluated the top 10 supplements indicated in the adverse event reports for swallowing problems, which account for 76.4% (3026) of them. Average pill length, width, and height of these products were 19.3 mm, 9.8 mm, and 7.8 mm, respectively. "The 10 products most commonly identified in reports of swallowing complications all exceed 17 mm in length," the researchers conclude.

Seven of the top 10 products were multivitamins marketed to older adults or calcium supplements. One multivitamin that targets older women was implicated in 40.6% of the swallowing problem reports.

The researchers point out that up to 35% of older adults take multivitamins and up to 24% take calcium supplements, and that the older population has higher rates of dysphagia and other eating limitations compared with younger people. They offer suggestions to lower the risks from taking these supplements.

Manufacturers can offer smaller dosage forms or add coatings that ease the journey down a throat, and patients can ask providers and pharmacists for strategies to avoid choking on hard supplements, such as switching to gummy versions.

Limitations of the study include lack of information on the frequency of taking products, accounting for patients who did not report swallowing problems, and applicability to other populations. "Nevertheless, these data identify a specific harm — choking — that may be preventable, particularly in older adults who regularly consume dietary supplements," the researchers conclude.

The investigators have disclosed no relevant financial relationships.

Ann Intern Med. Published online August 19, 2019. Abstract

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