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Journal of Nutrition & Food Sciences DOI: 10.4172/2155-9600.1000304

ciences
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ISSN: 2155-9600

Research Article Open Access

A Survey of Dietary Supplement Knowledge, Attitudes, and Use in a Rural

Population
Christopher Owens*, Tiffanie Toone and Michelle Steed-Ivie
Idaho State University College of Pharmacy, Pocatello, Idaho, USA

Abstract
Dietary supplements, including vitamins and herbal products, are often used to treat self-diagnosed conditions
and/or to promote health. We conducted a community-based survey in a rural population to assess consumers’
knowledge, practices, and attitudes regarding the use of dietary supplements. A total of 526 adults (≥ 18 years)
completed the survey. Information collected included product(s) used, frequency and use in combination with
prescription or over-the-counter medications, and perceptions of efficacy and safety. Most respondents (71.5%)
indicated a preference for dietary supplements over conventional pharmaceuticals to maintain health. Most (71.1%)
reported daily or almost daily use of conventional pharmaceuticals use as well. Most respondents (>86%) indicated
they were comfortable discussing the use of supplements with their physician or pharmacist; there was weaker
agreement regarding perceived potential for drug-supplement interactions or adverse effects, indicating that these
issues may be under-recognized. These results indicate that dietary supplements are often used in combination with
pharmaceuticals and there is continuing need for clinicians to assess patients’ use of these products and to provide
direction for their appropriate place in therapy.

Keywords: Dietary supplement; Herbal dietary supplement; drugs increased by 20% and the use of five or more drugs increased
Over-the-counter medication; Prescription medication; Drug-herb by 70%. By 2007-2008, one-half of Americans were taking at least one
interactions; Attitudes; Survey; Rural population prescription drug and 1 out of 10 were taking five or more [9].

Introduction Given the increasing prevalence of dietary supplement and

prescription as well as OTC medication usage in the US population,
Dietary supplements, including vitamins, minerals, and herbal clinicians and health educators have expressed concerns regarding
products are used by millions of Americans to treat self-diagnosed the potential for drug-supplement interactions and other safety
conditions and/or to promote health. Their usage and popularity concerns [2,10,11]. The purpose of our survey was to assess typical
continues to grow in the twenty-first century [1-3]. Defined by the dietary supplement consumers’ knowledge, practices, and attitudes
Dietary Supplement Health and Education Act (DSHEA) of 1994, regarding the use of these products for health-related purposes, alone
dietary supplements include a wide array of non-food, non-drug and in combination with conventional pharmaceuticals. We sought to
substances intended to supplement the diet, but are not intended to determine which products were being used, individuals’ willingness to
treat diseases or disorders of the human body. According to DSHEA, discuss the use of dietary supplements with healthcare professionals,
these products may contain one or more dietary ingredients such as and preferred sources of information that were consulted when
a vitamin, mineral, herb or other botanical, amino acid, concentrate, choosing a product or for guidance on appropriate use.
metabolite, or combination of these ingredients. They may be purchased
without a prescription and federal regulation of these products differs Methods
significantly from that of food or drugs [4]. Standardization of active An 18-question survey was developed to assess consumer’s
ingredients, as well as quality assurance related to identity, purity, and knowledge, practices, and attitudes related to dietary supplements
bioavailability is largely left up to individual manufacturers, although (Appendix A). The survey instrument contained items adapted from
the United States Pharmacopeia (USP) and other independent testers, similar surveys conducted previously [12,13]. Individual survey items
such as Consumer Lab, may also provide certification [5]. were reviewed by a group of College of Pharmacy faculty members
and consensus was reached regarding clarity and importance of each
Data from the National Health and Nutrition Examination Survey
item. The survey was pretested and additional comment was utilized to
(NHANES) collected from 2003-2006 on the use of dietary supplements
further refine the instrument. The survey was distributed from February
reported that 54% of American adults reported use of at least one dietary
to April 2013 in two rural Southeast Idaho communities (Pocatello
supplement, the most common type being multivitamin/multi-mineral
products [1]. A 2002 National Health Interview Survey indicated
that nearly 1 in 5 adults report using an herb for treatment of health
*Corresponding author: Christopher Owens, Idaho State University
conditions and/or health promotion [6]. The 2007 National Health College of Pharmacy, Pocatello, Idaho, USA, Tel: (208) 282-4454; E-mail:
Interview Surveys revealed that the number of adults in the United ctowens@[Link]
States that ever used herbals or supplements grew from 50.6 million in Received July 14, 2014; Accepted August 21, 2014; Published August 23, 2014
2002 to 55.1 million in 2007 [7]. A 2012 report by Nutrition Business
Journal reported that the dietary supplement industry surpassed $30 Citation: Owens C, Toone T, Steed-Ivie M (2014) A Survey of Dietary Supplement
Knowledge, Attitudes, and Use in a Rural Population. J Nutr Food Sci 4: 304. doi:
billion in US sales for the year 2011 [8]. 10.4172/2155-9600.1000304

In addition to increases in dietary supplement use, Americans are Copyright: © 2014 Owens C, et al. This is an open-access article distributed under
also using more prescription and over-the-counter (OTC) medications the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and
than ever before. Over the last decade the use of multiple prescription source are credited.

J Nutr Food Sci, an open access journal

ISSN: 2155-9600 Volume 4 • Issue 5 • 1000304
Citation: Owens C, Toone T, Steed-Ivie M (2014) A Survey of Dietary Supplement Knowledge, Attitudes, and Use in a Rural Population. J Nutr Food
Sci 4: 304. doi: 10.4172/2155-9600.1000304

Page 2 of 5

and Chubbuck, combined population approximately 70,000). Surveys of respondent demographics is shown in Table 1. Approximately 60%
were distributed at community health-fair events, local supermarkets of respondents were female and nearly half were in the age range of
and pharmacies, and fitness centers. Participation was solicited at 18-30 years. Most respondents (>85%) indicated at least some college
the different sites where background information on the scope and education.
purpose of the survey was also provided. Participants were asked to
The majority of respondents (71.5%) reported a preference for
complete paper surveys privately on the spot within 5-10 minutes, but
herbal products over prescription and OTC medicines for treating
participants could take as much time as desired to fill out the survey.
medical conditions and/or to maintain health. Overall, respondents
Additional clarification was provided if needed. Surveys were briefly
agreed that dietary supplements are useful for treating medical
assessed by the survey team for completeness on location before being
conditions and/or promoting health and wellness (Likert scale mean =
filed for later analysis.
4.31). The mean agreement level for consumers’ comfort in discussing
Participants were required to be at least 18 years of age to complete use of herbal products and dietary supplements with healthcare
the questionnaire and only respondents who reported taking at least professionals was high, 4.39 for physicians and 4.32 pharmacists. The
one dietary supplement for a health-related reason within the past year lowest level of agreement was related to consumers’ perception of
were eligible to complete the survey. Respondents indicated which potential harmful side effects with dietary supplements and interactions
supplement(s) they had used from a list of common dietary supplements with other supplements or medications (Likert scale mean = 3.39 and
included on the survey. They also had the option to indicate “other” and 3.94, respectively) (Figure 1).
write in any other product used. Basic demographic information was
A list of dietary supplements reportedly used by respondents is
collected including respondent age, sex, occupation, and highest level
included in Table 2. Vitamins and minerals topped the list with 83.1%
of education.
of respondents reporting use. Other commonly used supplements
The frequency of dietary supplements use, as well as the frequency of included fish oil (53%), cranberry (19.6%), and melatonin (18.1%). The
prescription and non-prescription medication use in the past year was breakdown of frequency of use of dietary supplements was reported
assessed (as daily, weekly, monthly, or occasionally for each) to determine as: daily or almost daily (71.1%), occasionally (13.8%), weekly (11.1%),
possible concomitant use. Respondents were asked to indicate if they and monthly (4%). The majority of respondents (74.0%) also reported
had a preference for dietary supplements over conventional medicines taking prescription medication in the past year. The frequency of
for treating medical conditions or for health maintenance. Items prescription drug use was: daily or almost daily (64.6%), weekly (3.8%),
addressing knowledge, practices, and attitudes were answered using a monthly (2.2%), and occasionally (29.4%). Even more respondents
5-point Likert-type scale ranging from strongly disagree (1) to strongly reported OTC medication use in the past year (87.2%) with occasional
agree (5). Survey items in this area asked consumers perceptions of the use being most common; OTC frequency of use breakdown: daily
efficacy of dietary supplements for treating medical conditions and/or or almost daily use (19.6%), weekly (12.8%), monthly (12.3%), and
for promoting health and wellness, as well as their beliefs related to the occasionally (55.2%). There was near equal agreement in respondents’
potential for harmful side effects and interaction potential with other trust in the accuracy of label information for both OTC products and
supplements or medications. Respondents were also asked to rate their dietary supplements, most indicated that they “usually” trust the label of
level of comfort in discussing dietary supplements with health care non-prescription medications (58%) and dietary supplements (56.5%);
providers and pharmacists. Individuals were asked to indicate which approximately 10.4% of respondents indicated that they “always” trust
resources were consulted when choosing a dietary supplement or for
guidance on appropriate use. Possible answers included print resources Demographics Total No. (%)
(including books or magazines), television programs, friends or family, N 526
healthcare professionals, or the Internet. They also had the option to Gender  
indicate “other” and write in other resources used. Male 211 (40.2)
Female 314 (59.8)
Knowledge-related survey items asked respondents to indicate
Age  
their familiarity with the role of the FDA and the DSHEA legislation in
the regulation and definition of dietary supplements. Respondents were 18-30 210 (43.9)

also queried regarding the role of the United States Pharmacopeia (USP) 31-45 115 (23.0)
and Consumer Lab in verifying the accuracy of dietary supplement 46-64 130 (24.8)
label information related to purity, potency, and quality. The final two ≥ 65 31 (6.2)
survey items asked respondents to indicate their level of trust in the Occupation  
accuracy of the label information for dietary supplements as compared Healthcare 49 (9.4)
to non-prescription pharmaceuticals. Non-Healthcare 264 (50.8)
Student 132 (25.4)
The survey was conducted following approval from the Institutional
Retired 41 (7.9)
Review Board at Idaho State University. Local businesses that were
Unemployed 9 (1.7)
invited to host the study received an invitation to participate and also
provided their consent. Confidentiality was ensured throughout data Other/Unknown 25 (4.8)

collection and analysis. Mean values were calculated for Likert scale Highest Level of Education  
agreement questions, and overall percentages were reported for survey High School 74 (14.2)
responses. Data was analyzed using SPSS version 21.0, IBM Corp., Some College 182 (35.0)
Armonk, NY, 2012. Associates Degree 71 (13.7)
Bachelors Degree 128 (24.6)
Results Graduate Degree 65 (12.5)
A total of 526 surveys were collected and analyzed. A breakdown Table 1. Demographics of dietary supplement consumers.

J Nutr Food Sci, an open access journal

ISSN: 2155-9600 Volume 4 • Issue 5 • 1000304
Citation: Owens C, Toone T, Steed-Ivie M (2014) A Survey of Dietary Supplement Knowledge, Attitudes, and Use in a Rural Population. J Nutr Food
Sci 4: 304. doi: 10.4172/2155-9600.1000304

Page 3 of 5

the label of non-prescription medications, while 8.1% “always” trust supplement information, the Internet had the highest percentage of
dietary supplement labeling. reported use (58.6%), followed by family/friends (57.1%), books/
magazines (40.8%), physician/nurse (37.9%), pharmacist (21.5%), and
For the knowledge-based questions, the majority (61.1%) responded
TV programs (18.6%). Other reported sources of information consulted
correctly that dietary supplements are not currently regulated by the
included gym trainers, medical journals, and chiropractors.
FDA for purity, potency, safety and efficacy; however, approximately
66% reported that they have never heard of DSHEA legislation of 1994. Discussion
There was similar reporting of familiarity with USP-certified labeling
or the role of Consumer Lab in verifying purity and potency of herbals, While many surveys concerning dietary supplement use have been
vitamins, and other dietary supplements. Approximately 81% of conducted in recent years [12-16] our survey was unique in several
respondents indicated that they “had never heard of ” or had only heard important ways. To our knowledge, this was the largest survey to date in
“a little bit” about USP-certified labeling of dietary supplements or the a rural area that included a significant population of health-conscious
role of Consumer Lab in this regard. dietary supplement users (as evidenced by participation in health fairs
and fitness center attendance). Our survey also sought to better quantify
Of the sources identified by participants to access dietary frequency of concomitant use of supplements and pharmaceuticals, an
important area of ongoing clinical concern. We also assessed consumer
Herbal Products and Dietary Supplements Total No. (%) preference related to information sources consulted to help guide use
Vitamin/Mineral 437 (83.1) of supplements as well as consumers’ knowledge regarding dietary
Fish Oil 279 (53) supplement regulation, standardization, and how to determine quality
Cranberry 103 (19.6) products when making their decisions.
Melatonin 95 (18.1) Since the establishment of the National Center for Complementary
Glucosamine 95 (18.1) and Alternative Medicine (NCCAM) in 1998 there has been increased
Cinnamon 94 (17.9) information availability concerning the appropriate use and place
Echinacea 86 (16.3) in therapy of herbal products and dietary supplements; however, not
Garlic 86 (16.3) all information has been positive. Several large, controlled clinical
Probiotics 70 (13.3) trials have found that many supplements are inferior to conventional
Other 67 (12.7) pharmaceuticals or placebo and/or have important safety concerns
Ginseng 55 (10.5) [17-21]. Most of our respondents indicated a preference for dietary
Ginkgo 36 (6.8) supplements to conventional pharmaceuticals for treating medical
Milk Thistle 29 (5.5) conditions or to maintain health. Many also indicated a lower level
Protein 27 (5.1) of concern regarding potential adverse effects and drug-supplement
St. John’s Wort 23 (4.4)
interaction potential. These findings may reflect the ongoing public
Black Cohosh 16 (3.0)
erroneous perception that as natural products, dietary supplements
must be safer and more efficacious than conventional pharmaceuticals
Saw Palmetto 16 (3.0)
[2,10,22].
Kava 12 (2.3)
Green Tea 8 (1.5) The reported concomitant use of dietary supplements and
Table 2. List of dietary supplements used by respondents. pharmaceuticals indicated by our survey continues to demonstrate

5
Number Scale: Mean, 4.31 Mean, 4.39 Mean, 4.32
Mean, 3.94
5 = Strongly Agree 4
4 = Agree Mean, 3.39
3 = Neutral
2 = Disagre
3
1 = Strongly
Disagree
2

1
Q5 Q6 Q7 Q8 Q9

(Treatment) (Side Effects) (Interactions) (Physician) (Pharmicist)

Questionnaire:

Q5: Herbal products and dietary supplements can be useful for trating certain medical
conditions and /or promote health and wellness.
Q6: Herbal products and dietary supplements can have harmful side effects.
Q7: Herbal products and dietary supplements can interact with other supplements or
medications.
Q8: I feel comfortable discussing my use of herbal products and dietary supplements with
my doctor or health care provider.
Q9: I feel comfortable discussing my use of herbal products and dietary supplements with
my pharmacist.

Figure 1: Likert-Scale Agreement Level Herbal.

J Nutr Food Sci, an open access journal

ISSN: 2155-9600 Volume 4 • Issue 5 • 1000304
Citation: Owens C, Toone T, Steed-Ivie M (2014) A Survey of Dietary Supplement Knowledge, Attitudes, and Use in a Rural Population. J Nutr Food
Sci 4: 304. doi: 10.4172/2155-9600.1000304

Page 4 of 5

risks for drug-supplement interactions and adverse patient outcomes. Our survey had important limitations. First, because it was
According to the Natural Medicines Comprehensive Database all of completed by a convenience sample derived from a rural population,
the top 20 selling herbal dietary supplement products are associated our results may not necessarily reflect that of the general population.
with potential for drug interactions. Among these, major herb- In addition, of the different locations where the survey was distributed,
drug interactions have been noted with St. John’s wort, soy, garlic, the two largest demographic groups (totaling approximately 64% of
ginseng, green tea, evening primrose, valerian, and aloe vera [23]. respondents) were gym members and/or participants in local health
Our survey results indicated that many of these supplements may be fairs, which could likewise affect the generalizability of our findings.
potentially used in combination with pharmaceuticals. Over 60% Still, our survey responses do capture the perceptions of an important
of our respondents reported daily use of a dietary supplement and a group of health-conscious dietary supplement consumer that is an
prescription drug. Over 55% indicated at least occasional use of OTC important voice in the dialog that should exist between regular users
drugs. This represents a population that is at-risk for drug-supplement of these products and healthcare professionals. Another limitation of
interactions. our study was the self-reported nature of the information that detailed
a personal and even controversial practice –taking dietary supplements
Dietary supplements are regulated differently from drugs with
to promote health or treat medical conditions. Respondents may have
regard to labeling and quality assurance of products [5,10]. The
been hesitant to fully disclose their preferences, there may have been
standardization of active ingredients is regulated by individual
differing interpretations of what constitutes a certain level of agreement,
manufacturers and no regulatory process exists for these products
and there may well have been differing levels of health literacy in the
comparable to OTC and prescription medications [5,24]. Supplement
population surveyed. While worth considering, it is important to note
manufacturers are not required to have proof of efficacy, safety, or batch-
that these factors play a role in most surveys of this type. A reassurance
related standards of quality control. Furthermore, dietary supplement
of confidentiality and use of clear and understandable survey language
manufacturers may include information on labeling that may not be
based upon past validated survey items was likely helpful in mitigating
substantiated by evidence or include disease claims that the product
such concerns. A final limitation regards the caution with which certain
may prevent, treat, cure, mitigate, or diagnose diseases [3,10,25-27].
findings related to drug-supplement interactions must be interpreted.
Most of our respondents indicated that they were aware that the FDA
Although we were able to determine that a majority of dietary
does not regulate dietary supplements in the same way it regulates
supplement users also took one or more prescription or OTC products
drugs, but the details and implications of this may still not be well
in the past year, we were unable to determine the exact scope and
understood. The indication from our respondents that they “usually”
frequency of true concurrent use. Any conclusions as to the frequency
or “always” trust the labeling of dietary supplements as much as they
and severity of drug-supplement interactions in this regard must be
do OTC medications also raises concerns. Although each undergo
made cautiously.
significantly different approval processes for marketing and distribution,
supplements and pharmaceuticals may still be viewed similarly in the Implications for Research and Practice
public’s eye in this regard. This finding is also complicated by the fact
that most respondents were unaware of the role of USP or Consumer This survey in a rural population found that dietary supplements
Lab as quality assurance testers whose seal may be found on products are commonly taken on a daily basis and their use concomitantly with
that meet minimum standards of purity and potency. prescription and OTC medication is also frequent. Most consumers
of these products perceive a benefit to their use and often prefer them
Because these products may be purchased without a prescription to conventional pharmaceuticals for treating medical conditions or
in grocery and drug stores or via the Internet, patients often do not to maintain health. A promising finding of our survey is the reported
seek professional guidance prior to their purchase and use [14,28,29]. comfort of dietary supplement users in discussing usage of these
This finding was further substantiated by our survey results. While products with healthcare professionals. Physicians should make
information sources abound for these products, the validity of many consistent efforts to assess use of these products before prescribing
is questionable [25,26,29]. In our survey, the Internet was the most medications or recommending OTC treatments. There is a continuing
commonly reported resource that consumers consult to guide their use need for patient as well as provider education to better determine the
of dietary supplements. While the Internet does provide a convenient place in therapy and appropriate use of dietary supplements as well as to
tool for consumers to obtain a wide-range of health-related information, improve awareness of the potential for adverse effects and supplement-
reviews of Web site quality have found that many omit important safety drug interactions.
precautions, including potential adverse effects and drug-supplement
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J Nutr Food Sci, an open access journal

ISSN: 2155-9600 Volume 4 • Issue 5 • 1000304
Citation: Owens C, Toone T, Steed-Ivie M (2014) A Survey of Dietary Supplement Knowledge, Attitudes, and Use in a Rural Population. J Nutr Food
Sci 4: 304. doi: 10.4172/2155-9600.1000304

Page 5 of 5

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