Rozga et al.

BMC Complementary and Alternative Medicine 2013, 13:200

http://www.biomedcentral.com/1472-6882/13/200

RESEARCH ARTICLE

Open Access

Dietary supplement users vary in attitudes and

sources of dietary supplement information in East
and West geographic regions: a cross-sectional
study
Mary R Rozga1,4*, Judith S Stern2, Kimber Stanhope3, Peter J Havel3 and Alexandra G Kazaks1

Abstract
Background: Over 50% of adults currently use dietary supplements (DS) but manufacturers do not have to prove
the safety or efficacy of a DS before it is marketed. Therefore, consumers may be exposed to inaccurate DS
information, may lack confidence in choosing appropriate DS and may seek advice for usage. The objective of this
study was to examine trends in usage, attitudes, and sources of information regarding DS according to geographic
location, demographic group, and lifestyle choices.
Methods: Eligible individuals completed a 10-item researcher-developed survey tool to determine DS use, sources
of DS information, and DS-related knowledge and attitudes over the previous year. Healthy participants (637
individuals aged 2175 years) from two population-based cohorts that had been recruited for lipoprotein
assessment studies at Tufts University in Boston, Massachusetts and University of California at Davis. Outcome
measures included participants use, beliefs regarding essentiality of DS, confidence in choosing appropriate DS, and
sources of information on DS. Univariate and multivariate logistic regression were utilized to examine differences in
survey responses between groups.
Results: Of the total population 72.7% reported taking dietary supplements in the previous year. Those living on
the West Coast (80.3%) had greater use than those living on the East Coast (60.7%). Those on the East Coast were
more likely to believe DS were essential to health (48.7%) and to feel confident in choosing DS that were
appropriate for them (51.0%). Overall, physicians were the most frequent source of DS information for more than
50% of participants on both coasts.
Conclusion: Because DS usage is widespread, health care providers and nutrition educators must encourage
patients to discuss their DS use and be equipped to provide information conducive to safe, efficacious
consumption. Tailoring interventions for healthcare providers, media sources, industry, and the public may allow for
dissemination of up-to-date information regarding DS.
Keywords: Dietary supplements/utilization, Dietary supplement knowledge, Attitudes, Practices

* Correspondence: rozgamar@msu.edu
1
Department of Nutrition and Exercise Science, Bastyr University, 14500
Juanita Dr. NE, Kenmore, WA 98028, USA
4
Present address: Department of Food Science and Human Nutrition,
Michigan State University, 2125 Anthony Hall, East Lansing, MI 48825, USA
Full list of author information is available at the end of the article
2013 Rozga et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.

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Background
Rates of dietary supplement (DS) usage have increased
over the past decades and the National Center for Health
Statistics reports over 50% of adults used DS from 2003
2006 [1]. In the present study, DS encompass vitamins,
minerals and herbs as well as other products such as coenzyme Q10, fish oil, and alpha lipoic acid. Adults may
use DS to self-manage specific ailments or for general
health reasons, as was found in three surveys of older
adults, cancer survivors, and adults over age 18 using
supplements [2-4]. Though DS are regulated by the FDA,
manufacturers do not have to prove the safety or efficacy
of a DS before it is produced, sold, or marketed [5].
Consequently, there are many untested products in the
marketplace. It is crucial that consumers are adequately
informed about DS from reputable sources and to understand how these products may interact with other DS,
food, or medications [6].
It is uncertain whether DS usage is rising due to an increased need for self-treatment due to rising medical costs
[7], or if manufacturers are marketing their products more
effectively. Few studies have investigated consumer motivations at the root of supplement usage. In a 2001 report,
researchers found that many women believed supplement
use would serve as insurance against illness [8]. While
this finding implies that consumers may believe supplementation to be essential to health, the current study
asked healthy consumers this question directly. More importantly, since there are no regulations for dispensing
evidence-based supplement information, consumers may
not feel confident in choosing DS that are appropriate. In
this study, the authors examined whether study participants believed DS were essential for health and how
confident subjects felt in choosing DS.
An additional concern is the variety of resources of DS
information available to consumers that may or may not
be accurate. A 2007 survey of Americans 60 years and
older revealed that 73% of participants reported television as the most common source of information,
followed distantly by magazines and radio, newspapers,
friends and store displays [2]. This study was in agreement with a study of women from an urban health clinic
in which the authors concluded the most common
sources of DS information to be radio and television,
followed by family, newspapers and magazines, and
friends. The least common sources cited were physicians, the internet, health food stores and registered
nurses [9]. Likewise, a study of adults 18 years and older
revealed that family, friends, and written materials were
the leading sources of information, and health care
professionals were the least frequently cited source of information [4]. Finally, a study of consumers in an urban
health food store found that 41% of subjects relied on retail
staff for DS information, followed by the media, alternative

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medicine care providers and doctors, nurses and pharmacists [10]. Though many studies have attempted to describe
sources of DS information, they are often limited to very
specific or disease-related populations, and information is
lacking for the general, healthy population.
This objective of this study was to examine two separate geographic regions of the United States to test for
overall trends and congruence in the percentage of
participants who use DS and to examine the perceived
essentiality of DS use to health, the reported confidence
in choosing appropriate DS, and sources that inform
supplement usage. The data may be used to develop
accurate, appropriate information for dissemination to
target groups through the most effective media.

Methods
Participant recruitment

This was a cross-sectional study in which data was collected from two population-based cohorts recruited for
lipoprotein assessment studies at Tufts University in
Boston, Massachusetts and University of California at
Davis (UCD) between June 2008 and August 2009.
Study protocols had institutional review board approval
from both institutions and informed consent was
obtained from each participant. Participants were recruited by advertisements, press releases, and notices.
The study sample included 653 healthy volunteers aged
2175 (49.5% males), that were matched for age and
sex by geographic location. Inclusion criteria included
HDL-C levels 40 mg/dL, LDL-C <160 mg/dL, TG
levels < 200 mg/dL, and fasting glucose < 126 mg/dL.
Exclusion criteria included use of drugs affecting
lipoprotein metabolism, use of drugs for diabetes treatment, use of illegal drugs, hormone replacement therapy, current/recent CHD/CVD, current/recent diabetes,
current/recent hepatic diseases, current/recent renal
diseases, current/recent cancer, and current/recent hospitalizations (excluding infectious diseases and external
injuries). To ensure eligibility, a medical history, blood
pressure, heart rate, anthropometric data and blood
samples from participants were collected and evaluated.
DS assessment

Eligible individuals completed a researcher-developed

survey tool to determine dietary supplement use,
knowledge and attitudes over the past year. Full label
information about each supplement was requested.
Other questionnaire items focused on whether DS are
essential for health, whether specific supplements had
been recommended by a doctor, confidence in understanding which supplements were right for the individual, and where the individual got information about
the DS (Additional file 1).

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Participant variables
Geographic location

Categorization by geographic location refers to the study

location; the Tufts University subjects were considered
East Coast and the UCD subjects were considered West
Coast.

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independent variable, geographic location. Stata 12.0 was

used to conduct statistical analyses. An alpha level of 0.05
was set to denote statistical significance.

Results
East vs. West Coast participants

Subjects were divided into three age groups: 2139, 40

59, and 6075. If the subjects did not answer this question, they were excluded from analyses regarding age.

Of the participants in this study, 72.7% used DS in

the past year. Those on the West Coast were more
likely to be supplement users than those on the East
Coast (p < 0.001), and those living on the East Coast
had a significantly higher BMI (p < 0.001), were less
likely to engage in physical activity (p = 0.046), were
less likely to consume alcohol (p < 0.001), and were
more likely to consume tobacco (p < 0.001) compared
with those living on the West Coast. The populations
did not significantly vary by age, or sex (Table 1).

BMI

Supplement usage

Body Mass Index (BMI) was calculated from self-reported

height and weight and presented in units of kg/m2. A BMI
between 18.5 and 24.9 indicates a normal weight status, a
BMI between 25.0 and 29.9 was classified as overweight,
and a BMI over 30.0 was defined as obese. Only 15 participants (2.3%) had a BMI <18.5, and these participants were
eliminated from analysis. Participants over three standard
deviations above the mean were considered outliers and
eliminated from analysis regarding BMI (n = 10).

Multivariate logistic regression revealed that even after

adjustment for demographic and lifestyle factors, those
on the West Coast were still significantly more likely to
consume DS (adjusted OR: 1.88 (1.20, 2.93); p = 0.005).
The oldest age group (6075 years) had the highest

Sex

Subjects were placed into a male or female category. If

subjects did not answer this question, they were excluded
from analyses regarding sex.
Age

Table 1 Demographics and supplement use for all

participants and divided into East Coast and West Coast
groups
Total

Physical activity, alcohol use, and tobacco use

Participants self-reported whether they engaged in regular

weekly physical activity, alcohol consumption, and tobacco
consumption.

Supplement use
(n = 637)b

Statistical analysis

Age (n = 631)bc

Yes
No

A chi-squared test for independence was used to detect

relationships between group inclusion and geographic
location and to compare sources of information; results
for categorical variables are presented as n(%). Students
t-tests were used to compare continuous variables
between geographic locations and results are presented
as Mean SD. Univariate and multivariate logistic regression was conducted to determine the odds of using
supplements, believing supplements were essential to
health, and feeling confident choosing appropriate supplements by demographic group and lifestyle factors.
Odds ratios for believing supplements were essential to
health compare those who responded Yes, Essential to
those who responded either No, Not Essential or
Dont Know. Odds ratios for feeling confident choosing
appropriate supplements compare those who responded
Agree to those who responded either Neutral, Disagree, or Dont Know. Multivariate logistic regression
controlled for participant age, sex, BMI, physical activity,
tobacco and alcohol use in addition to the primary

East coast West coast p-valuea

463 (72.7)

150 (60.7)

174 (27.3)

97 (39.3)

313 (80.3)

<0.001*

77 (19.7)

47.2 14.8 47.5 12.8

47.0 15.9

0.69

Male

310 (49.3)

123 (51.5)

187 (48.0)

0.39

Female

319 (50.7)

116 (48.5)

203 (52.1)

BMI (kg/m2) (n = 606)b

26.5 4.8

28.2 5.1

25.5 4.3

<0.001*

Yes

502 (81.0)

180 (76.9)

322 (83.4)

0.046*

No

118 (19.0)

54 (23.1)

64 (16.6)

bd

Sex (n = 629)

Physical activity
(n = 620)b

Alcohol use (n = 632)b

Yes

411 (65.0)

121 (49.8)

290 (74.6)

No

221 (35.0)

122 (50.2)

99 (25.5)

Yes

80 (12.7)

67 (27.7)

13 (3.3)

No

551 (87.3)

175 (72.3)

376 (96.7)

<0.001*

Tobacco use (n = 631)b

Compares East Coast to West Coast Participants.

b
n may vary between variables due to missing or incomplete data.
c
Continuous variables expressed in Mean SD.
d
Categorical variables expressed as n (%).
*Denotes statistical significance p < 0.05.

<0.001*

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proportion of participants who used any supplement

(84.1%) compared with 4059 year and 2139 year
groups and were significantly more likely to consume
DS compared to the youngest age group (adjusted OR:
2.04 (1.12, 3.70); p = 0.02). Compared to males, females
were significantly more likely to consume any DS
(63.8% vs. 82.8% respectively) (adjusted OR: 2.48 (1.64,
3.74); p < 0.001) (Table 2).
Those in the normal weight category were more
likely to consume any DS, compared with those in the
overweight and obese BMI groups (adjusted OR:
0.48 (0.30, 0.76); p = 0.002 and 0.58 (0.35, 0.97); p = 0.04
respectively). Those who engaged in regular physical
activity were more likely to consume a supplement
compared with those who did not engage in physical
activity (adjusted OR: 1.87 (1.18, 2.99); p = 0.008) and
those who were tobacco users were less likely to use DS
(adjusted OR: 0.48 (0.28, 0.84); p = 0.01) (Table 2).

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Attitudes about DS supplementation

In this study, 41.7% of all participants believed DS to be

essential to health, however only 44.4% felt confident in
choosing appropriate DS for themselves (data not shown).
Responses to the question Do you consider taking vitamins or other supplements such as minerals and herbs
to be essential for health? were significantly different between participants according to geographic location (adjusted OR for believing DS to be essential: 0.45 (0.29, 0.72)
for West compared to East Coast participants; p = 0.001).
Results varied for other demographic and lifestyle groups,
but were attenuated after adjustment, and only supplement use remained a positive predictor of belief in essentiality (adjusted OR for believing DS to be essential: 11.37
(6.35, 20.39); p < 0.001) (Table 3).
Those living in the West were less likely to agree that
they were confidant in understanding which vitamins,
minerals, botanicals and other supplements were right

Table 2 Supplement use by participant characteristics

Any supplement use

None

Odds ratio,
raw (95% CI)

Odds ratio,
adjusted (95% CI)a

East Coast

150 (60.7)

97 (39.3)

Ref

Ref

West Coast

313 (80.3)

77 (19.7)

2.62 (1.83, 3.75)***

1.88 (1.20, 2.93)**

125 (66.1)

64 (33.9)

Ref

Ref

Location (n = 637)bc

Age (n = 628)
2139
4059

216 (71.8)

85 (28.2)

1.30 (0.9, 1.9)

1.37 (0.87, 2.16)

60-75

116 (84.1)

22 (15.9)

2.70 (1.56, 4.66)***

2.04 (1.12,3.70)*

Male

198 (63.9)

112 (36.1)

Ref

Ref

Female

264 (82.8)

55 (17.2)

2.72 (1.87, 3.94)***

2.48 (1.64, 3.74)***

Sex (n = 629)

BMI (n = 637)
Normal weight

218 (82.0)

48 (18.1)

Ref

Ref

Overweight

134 (65.4)

71 (34.6)

0.42 (0.27, 0.64)***

0.48 (0.30, 0.76)**

Obese

111 (66.9)

55 (33.1)

0.44 (0.28, 0.70)***

0.58 (0.35, 0.97)*

Yes

380 (75.7)

122 (24.3)

2.00 (1.30, 3.04)**

1.87 (1.18, 2.99)**

No

72 (61.0)

46 (39.0)

Ref

Ref

Yes

314 (76.4)

97 (23.6)

1.60 (1.11, 2.29)*

1.31 (0.85, 2.00)

No

148 (67.0)

73 (33.0)

Ref

Ref

Physical activity (n = 620)

Alcohol use (n = 632)

Tobacco use (n = 631)

Yes

43 (53.8)

37 (46.3)

0.37 (0.23, 0.60)***

0.48 (0.28, 0.84)*

No

418 (75.9)

133 (24.1)

Ref

Ref

Adjusted odds ratios controlled for all independent variables.

b
Data expressed as n(%).
c
n may vary between variables due to missing or incomplete data.
*p < 0.05; **p < 0.01; ***p < 0.001.

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Table 3 Participant responses to belief that supplements are essential for health by demographic groups
Yes, essential

No, not essential

Dont know

Odds ratio,
raw (95% CI)a

Odds ratio,
adjusted (95% CI)b

Geographic location (n = 618)cd

East

113 (48.7)

78 (33.6)

41 (17.7)

Ref

Ref

West

15 (30.7)

187 (48.5)

42 (10.9)

0.72 (0.52, 1.00)

0.45 (0.29, 0.72)**

Male

111 (36.8)

149 (49.3)

42 (13.9)

Ref

Ref

Female

158 (51.3)

112 (36.4)

38 (12.3)

1.81 (1.31, 2.50)***

1.31 (0.89, 1.91)

2139

63 (34.2)

102 (55.4)

19 (10.3)

Ref

Ref

4059

130 (45.0)

113 (39.1)

46 (15.9)

1.57 (1.07, 2.30)*

1.18 (0.76, 1.84)

60-75

73 (53.6)

47 (34.6)

16 (11.8)

2.22 (1.41, 3.51)**

1.65 (0.98, 2.77)

Normal weight

119 (46.0)

111 (42.9)

29 (11.2)

Ref

Ref

Overweight

73 (36.7)

95 (47.7)

31 (15.6)

0.68 (0.47, 0.99)*

0.82 (0.52, 1.28)

Obese

78 (48.8)

59 (36.9)

23 (14.4)

1.11 (0.75, 1.66)

1.27 (0.79, 2.05)

No

20 (12.1)

107 (64.5)

39 (23.5)

Ref

Ref

Yes

250 (55.3)

158 (35.0)

44 (9.7)

9.03 (5.46, 14.9)*

11.37 (6.35, 20.39)***

Yes

225 (46.0)

200 (40.9)

64 (13.1)

1.70 (1.11, 2.61)*

1.55 (0.94, 2.55)

No

38 (33.3)

60 (52.6)

16 (14.0)

Ref

Ref

Yes

162 (40.8)

185 (46.6)

50 (12.6)

0.70 (0.50, 0.98)*

0.70 (0.47, 1.05)

No

107 (49.5)

77 (35.7)

32 (14.8)

Ref

Ref

Yes

34 (44.7)

26 (34.2)

16 (21.1)

1.03 (0.64, 1.68)

1.30 (0.68, 2.49)

No

235 (43.8)

235 (43.8)

66 (12.3)

Ref

Ref

Sex (n = 610)

Age group (n = 609)d

BMI (n = 618)

Supplement use (n = 618)

Physical activity (n = 603)

Alcohol use (n = 613)

Tobacco use (n = 612)

Odds Ratio is the odds of believing supplements are essential compared to other responses.
b
Adjusted odds ratios are controlled for all independent variables.
c
n may vary between variables due to missing or incomplete data.
d
Data expressed as n(%).
*p < 0.05; **p < 0.01; ***p < 0.001.

for them compared with those in the West (adjusted OR

for feeling confident: 0.60 (0.40,0.89); p = 0.01. No significant differences in participant reports of confidence were
noted according to sex, age, BMI, supplement usage, physical activity, or alcohol or tobacco use (Table 4).
Sources of DS information

The most common source of information subjects referred to for DS information was physicians followed by
books, magazines/journals/the news, the internet, DS labels, family, friends, and health food retailers.
There were marked differences in sources of DS information between geographic locations. Considered
together, both groups considered physicians to be the
primary sources of information (52.4%), and there was
no significant difference between East and West Coast

respondents (p = 0.645) (Figure 1). Among all participants, 30.4% described that their doctors recommended
specific DS, though there were no significant differences in the proportions of participants recommended
DS according to geographic location, BMI, physical activity, or tobacco or alcohol use. Participants were more
likely to have received a doctor recommendation for
DS if they were female (44.4% vs. 17.0% for males; p <
0.001) or in the oldest age group (45.7% for 6075 years
compared with 31.8% for 4059 years and 17.6% for
2139 years; p < 0.001) (data not shown). Apart from
physicians and books, other sources of information varied between groups: Those on the East Coast relied
more heavily on DS labels, while those on the West
Coast relied more heavily on magazines/journals/news
and the internet (Figure 1).

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Table 4 Participant responses to confidence in choosing appropriate supplementation by demographic groups

Agree

Neutral

Disagree

Dont know

Odds ratio,
raw (95% CI)a

Odds ratio,
adjusted (95% CI)b

Geographic location (n = 631)cd

East

123 (51.0)

58 (24.1)

17 (7.1)

43 (17.8)

Ref

Ref

West

165 (42.3)

112 (28.7)

70 (18.0)

43 (11.0)

0.70 (0.51, 0.97)*

0.60 (0.40, 0.89)*

Male

136 (44.4)

87 (28.4)

42 (13.7)

41 (13.4)

Ref

Ref

Female

149 (47.0)

81 (25.6)

45 (14.2)

42 (13.3)

1.10 (0.81, 1.52)

0.98 (0.69, 1.38)

2139

84 (44.9)

64 (34.2)

20 (10.7)

19 (10.2)

Ref

Ref

4059

131 (44.1)

73 (24.6)

45 (15.2)

48 (16.2)

0.97 (0.67, 1.40)

0.86 (0.58, 1.27)

60-75

70 (50.7)

28 (20.3)

22 (15.9)

18 (13.0)

1.26 (0.81, 1.96)

1.17 (0.73, 1.86)

Sex (n = 623)

Age group (n = 593)

BMI (n = 600)
Normal weight

123 (46.6)

78 (29.6)

28 (10.6)

35 (13.3)

Ref

Ref

Overweight

85 (41.9)

58 (28.6)

32 (15.8)

28 (13.8)

0.83 (0.57, 1.19)

0.78 (0.53, 1.16)

Obese

80 (48.8)

34 (20.7)

27 (16.5)

23 (14.0)

1.09 (0.74, 1.61)

0.97 (0.63, 1.48)

Supplement use (n = 631)

No

68 (48.00)

47 (27.7)

19 (11.2)

36 (21.2)

Ref

Ref

Yes

220 (47.7)

123 (26.7)

68 (14.8)

50 (10.9)

0.84 (0.72, 0.98)*

1.32 (0.88, 1.98)

Yes

232 (46.7)

135 (27.2)

68 (13.7)

62 (12.5)

1.30 (0.87, 1.96)

1.23 (0.80, 1.89)

No

47 (40.2)

33 (28.2)

16 (13.7)

21 (18.0)

Ref

Ref

Yes

181 (44.3)

114 (27.9)

65 (15.9)

49 (12.0)

0.86 (0.62, 1.19)

0.95 (0.66, 1.36)

No

104 (47.9)

54 (24.9)

22 (10.1)

37 (17.1)

Ref

Ref

Yes

34 (43.6

21 (26.9)

147 (26.9)

17 (21.8)

0.91 (0.56, 1.47)

0.77 (0.45, 1.33)

No

251 (45.9)

147 (26.9)

80 (14.6)

69 (12.6)

Ref

Ref

Physical activity (n = 625)

Alcohol use (n = 638)

Tobacco use (n = 637)

Odds Ratio is the odds of feeling confident choosing appropriate supplementation compared to other responses.
b
Adjusted odds ratios are controlled for all independent variables.
c
n may vary between variables due to missing or incomplete data.
d
Data expressed as n(%).
*p < 0.05; **p < 0.01; ***p < 0.001.

Discussion
DS usage

A majority of subjects in this study were supplement

users, in agreement with the National Center for Health
Statistics [1], but in contrast to NHANES data in which
only 49% of the population were DS users and the 2007
National Health Interview Survey (NHIS) in which the
authors describe only 17.9% of healthy adults in the
United States consumed DS [11]. These differences may
be attributed both to the volunteer nature of the participants and the geographic locations in which the participants reside in this study. Females and older participants
were more likely to be DS users compared with males and
younger participants, which is consistent with 20032006
NHANES data [12] and 2007 NHIS data [11], though the
current data was collected more recently from 2008

2009. To our knowledge, there are no prior studies

reporting DS use in healthy individuals by geographic
location. In this analysis, participants living on the West
Coast had a higher likelihood of DS use compared with
those living on the East Coast. Interestingly, despite higher
usage, West Coast participants were less likely than East
Coast participants to believe that DS were essential for
health and were less likely to feel confident choosing
appropriate DS, though the later results were not significant after adjustment for demographic and lifestyle
factors. Thus, future studies are needed to examine
reasons for varying usage between these populations.
Similarly to NHANES data [12], this study demonstrates
that participants classified as obese had lower DS use
compared with those with a normal weight status. However, in the current data those in the overweight group

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Figure 1 Sources for East and West Coast participant dietary supplement information. aSubjects were able to choose as many sources as
applied. Cumulative values may exceed 100%. * p < 0.05 for differences between East Coast and West Coast participants.

had usage patterns more similar to the obese group while

in the NHANES data, they were more similar to those in
the normal weight group.
Attitudes regarding DS supplementation

As medical costs and information about personal

healthcare increase, people are turning to alternative
therapies and self-treatment, and supplement usage has
become mainstream [1]. The prevalence of perceived
essentiality of DS and the lack of confidence in choosing
DS highlight the opportunity for this topic to be addressed in the traditional medical care setting. Previous
research has suggested that patients may be hesitant to
initiate conversations about DS with their physicians,
creating the possibility for inappropriate dosing and drug
interactions [6,13]. This hesitancy to discuss DS use with
health care providers is demonstrated in the 2007 NHIS,
in which the authors found that only 43.5% of the study
population of healthy adults in the United States
disclosed DS use to their medical doctors [11], and in a
2008 study conducted by Mehta, et al. which revealed
that only about one third of DS users reported use to
their conventional health care providers [14]. The need
for individualized DS education is demonstrated by the
fact that less than 50% of participants were confident in
choosing a correct supplement for themselves, despite
over 70% of subjects being DS users. To meet the needs
of individuals who use DS health care providers and nutrition educators must be prepared to address trends in
DS usage and stay current on information about specific
DS for diverse patient groups.

Sources of DS information

This study found that physicians were the most common

source for DS information among male and female
subjects ages 2175 at two geographic locations. This
finding is similar to those found in a cohort of cancer
survivors [3], but are in disagreement with other studies
examining healthy participants: A 2004 study of women
participants describes health care providers as among
the least common sources of information [9], and over
half of a population of randomly selected adults from a
military family practice did not share their alternative
health care practices with their physicians [15]. Archer
et al. found that the most common source of information was health food retailers, which was the least common source in this study, and physicians were one of the
lowest sources [10], though the population in this study
was drawn from a natural food store. Physicians were
also among the lowest sources in a study of subjects
from Minneapolis/St. Paul and in a study of WIC adult
participants from Kansas and Wisconsin [4,16]. A possible reason for this discrepancy may be that the questionnaire in this study did not include TV and radio,
which have been noted as primary sources of DS information, as a discrete category and instead included the
news with journal articles and magazines. Still, this
difference in classification does not account for the
physicians becoming a primary source of information
from being one of the least referred to sources, and this
finding may be reflective of the geographic locations
studied or of secular changes in the population in general. Though the results of this study do not agree with

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many other studies, they are encouraging, as physicians

may be more reputable sources of scientific information
compared with the media or family and friends. The findings of this study support a need for training in DS among
health care providers, as patients expect physicians to have
the best information on DS to optimize health. In a 2003
study, authors tested knowledge of clinically relevant DS
and found that, on average, physicians correctly answered
only 46% of the twenty questions asked [17]. A later revised
survey (2006) revealed that DS knowledge among 374 physicians and physician assistants (PAs) had increased to
70.3%. In this same study, an additional survey was
conducted to understand how confident physicians felt in
providing DS information and authors discovered physicians and PAs were 55.5% confident in this task [18]. In a
recent study of DS knowledge among military physicians,
65% of physicians did not feel they had a reliable source of
DS information [19]. The results of the current study suggest that provider conversations about patient-directed DS
use are increasing. Improved access to DS knowledge and
effective provider-patient communication may lead to more
efficacious usage and fewer possible adverse interactions
with other supplements, diet, and medications.
Strengths and limitations

To our knowledge, this is one of the first studies to examine

attitudes concerning DS use in a healthy population and
the first study to examine attitudes and sources of information regarding DS by geographic location in sex-and
age-matched populations. A limitation of this study was the
volunteer nature of the study population; individuals agreeing to participate may not be representative of the general
population in terms DS attitudes and usage, and findings
may not be generalizable to the population of healthy adults
in the United States. The data presented here demonstrates
that those living on the East and West Coasts may have
higher rates of DS usage compared with the general population of healthy adults living in the United States; thus, results from this study should be applied to individuals living
in these locations only.
This is a cross-sectional study and, therefore, gives only a
snapshot of participants attitudes and sources of DS information at the time of the survey. Since that time the internet has become a significant and substantial source of
health information. It is possible that current assessments
would indicate that online information has a more important role. Also, participants generally did not list any additional information sources such as billboards, television
commercials, or radio, missing: that were not included in
the main questionnaire items.

Conclusion
Nearly 73% of this population of healthy subjects reported
using DS in the prior year, with females, older participants,

Page 8 of 9

and those living on the West Coast tending toward higher

supplementation use. Over 40% of participants believed DS
to be essential to health, however only 44.4% felt confident
in choosing appropriate DS for themselves. There were
differences in these attitudes according to geographic location, sex, age, physical activity, and alcohol use. The most
common source of DS information was physicians; who
may be perceived as providers of more accurate information than other sources. Health care providers and nutrition educators must encourage patients to discuss their DS
use and be equipped to provide information conducive to
safe, effective, and practical consumption.

Additional file
Additional file 1: Dietary Supplement Questionnaire. Questionnaire
used to assess participant attitudes about DS as well as sources of DS
information.
Abbreviations
DS: Dietary supplements; NHANES: National health and nutrition examination
survey; PA: Physicians assistant; BMI: Body mass index; NHIS: National health
interview survey.
Competing interests
The authors declare that they have no competing interests.
Authors contributions
MR participated in the design of the current study, performed the statistical
analysis, and drafted the manuscript. JS and AK participated in the study
design for collection of supplement data as part of the lipoprotein study, in
the design of the current study, and in drafting and editing the manuscript.
PH was the Principle Investigator of the original study, and KS was the Study
Supervisor. All authors read and approved the final manuscript.
Acknowledgements
We appreciate the excellent organizational and research assistance of
Marinelle Nunez at University of California at Davis and gratefully
acknowledge the contribution of participants on both coasts.
Author details
Department of Nutrition and Exercise Science, Bastyr University, 14500
Juanita Dr. NE, Kenmore, WA 98028, USA. 2Department of Nutrition,
Department of Internal Medicine, University of California, Davis, 1 Shields
Avenue, Davis, CA 95616, USA. 3Department of Molecular Biosciences: SVM,
Department of Nutrition, University of California, Davis, 1 Shields Avenue,
Davis, CA 95616, USA. 4Present address: Department of Food Science and
Human Nutrition, Michigan State University, 2125 Anthony Hall, East Lansing,
MI 48825, USA.

Received: 23 October 2012 Accepted: 25 July 2013

Published: 30 July 2013
References
1. Gahche J, Burt V, Hughes J, Yetley E, Dwyer J, Picciano MF, McDowell M,
Sempos C: Dietary supplement use among U.S. adults has increased
since NHANES III (19881994). NCHS Data Brief 2011, 61:18.
2. Marinac JS, Buchinger CL, Godfrey LA, Wooten JM, Sun C, Willsie SK: Herbal
products and dietary supplements: a survey of use, attitudes, and
knowledge among older adults. J Am Osteopath Assoc 2007, 107:1322.
3. Ferrucci LM, McCorkle R, Smith T, Stein KD, Cartmel B: Factors related to
the use of dietary supplements by cancer survivors. J Altern Complement
Med 2009, 15:673680.
4. Harnack LJ, Pydell SA, Stang J: Prevalence of use of herbal products by
adults in the Minneapolis/St Paul, Minn, Metropolitan area. Mayo Clin
Proc 2001, 76:688694.

Rozga et al. BMC Complementary and Alternative Medicine 2013, 13:200

http://www.biomedcentral.com/1472-6882/13/200

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.
16.

17.

18.

19.

Page 9 of 9

US Food and Drug Association: Dietary Supplements. Silver Springs, MD: US

Food and Drug Administration; 2012. http://www.fda.gov/Food/
DietarySupplements/default.htm
National Center for Complementary and Alternative Medicine: Get the facts:
using dietary supplements wisely. Bethesda, MD: National Center for
Complementary and Alternative Medicine; 2012. http://nccam.nih.gov/
health/supplements/wiseuse.htm
Dickinson A: Nutritional supplements for health promotion and disease
prevention: a policy perspective, From the benefits of nutritional supplements
Council for Responsible Nutrition 2002. Washington DC: Council for
Responsible Nutrition; 2012. http://www.crnusa.org/benpdfs/
CRN001benefits_policy.pdf
Conner M, Kirk SFL, Cade JE, Barrett JH: Why do women use dietary
supplements? The use of the theory of planned behaviour to explore
beliefs about their use. Soc Sci Med 2001, 53:621633.
Pettigrew AC, OBrien King M, McGee K, Rudolph C: Complementary
therapy use by womens health clinic clients. Altern Ther Health Med 2004,
10:5055.
Archer EL, Boyle DK: Herb and supplement use among the retail
population of an independent, urban herb store. J Holist Nurs 2008,
26:2735.
Wu CH, Wang CC, Kennedy J: Changes in herb and dietary supplement
use in the U.S. adult population: a comparison of the 2002 and 2007
National Health Interview Surveys. Clin Ther 2011, 33(11):17491758.
Bailey RL, Gahche JJ, Lentino CV, Lentino CV, Dwyer JT, Engel JS, Thomas
PR, Betz JM, Sempos CT, Picciano MF: Dietary supplement use in the
United States, 20032006. J Nutr 2011, 141:261266.
Shelley BM, Sussman AL, Williams RL, Segal AR, Crabtree BF: They dont ask
me so I dont tell them: patient-clinician communication about
traditional, complementary, and alternative medicine. Ann Fam Med
2009, 7(2):139147.
Mehta DH, Gardiner PM, Phillips PR, McCarthy EP: Herbal and dietary
supplement disclosure to health care providers by individuals with
chronic conditions. J Altern Complement Med 2008, 14(10):12631269.
Drivdahl CE, Miser WF: The use of alternative health care by a family
practice population. J Am Board Fam Pract 1998, 11:193199.
Lohse B, Stotts JL, Priebe JR: Survey of herbal use by Kansas and
Wisconsin WIC participants reveals moderate, appropriate use and
identifies herbal education needs. J Am Diet Assoc 2006, 106:227237.
Kemper KJ, Amata-Kynvi A, Dvorkin L, Whelan JS, Woolf A, Samuels RC,
Hibberd P: Herbs and other dietary supplements: healthcare
professionals knowledge, attitudes, and practices. Altern Ther Health Med
2003, 9:4249.
Kemper KJ, Gardiner P, Gobble J, Woods C: Expertise about herbs and
dietary supplements among diverse health professionals.
BMC Complement Altern Med 2006, 6:15.
Cellini M, Attipoe S, Seales P, Gray R, Ward A, Stephens M, Deuster PA:
Dietary supplements: physician knowledge and adverse event reporting.
Med Sci Sports Exerc 2012, 45(1):2328.

doi:10.1186/1472-6882-13-200
Cite this article as: Rozga et al.: Dietary supplement users vary in
attitudes and sources of dietary supplement information in East and
West geographic regions: a cross-sectional study. BMC Complementary
and Alternative Medicine 2013 13:200.

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