ORIGINAL CONTRIBUTION
Herbal Products and Dietary Supplements: A Survey of Use, Attitudes, and
Knowledge Among Older Adults
Jacqueline S. Marinac, PharmD; Colleen L. Buchinger, MD; Lincoln A. Godfrey, DO;
James M. Wooten, PharmD; Chao Sun, MD, MPH; and Sandra K. Willsie, DO
Context: Tens of millions of Americans use herbal products
and/or dietary supplements, yet scant data are available
regarding the purity, safety, or efficacy of these substances. A
better understanding of usage trends and patient attitudes
toward self-initiated supplementation is vital to obtaining
accurate and complete medical history data.
Objective: To survey Americans aged approximately 60 years
and older regarding their use of herbal products and dietary
supplements and their attitudes and knowledge regarding
the safety of these popular substances.
Methods: A face-to-face, 35-item survey was administered to
267 men and women residing in the Kansas City,
Mo–metropolitan area. Researchers documented usage pat-
terns for, attitudes about, and knowledge of herbal products
and dietary supplements in this population.
Results: Fifty-six (21%) respondents were currently taking at
least one herbal product or dietary supplement, and potential
for adverse drug reactions was apparent in 12 (19%). Glu-
cosamine, garlic, Echinacea, and Gingko biloba were the most fre-
quently cited substances used by survey participants. White
women with at least some college education were most likely
to report taking these products. However, preservation of
health was by far the most predictive indicator for use of
herbal products and dietary supplements. Subjects were found
to be receptive to patient education efforts for these products.
Conclusion: Although substantial misconceptions about
herbal products and dietary supplements exist among older
Americans, most individuals in this population are interested
in receiving additional information about these products.
Excellent opportunities exist for expanded patient educa-
tion—and improved patient care.
J Am Osteopath Assoc. 2007;107:13-23
From the Kansas City University of Medicine and Biosciences (Drs Marinac, Sun,
Willsie) in Mo, and the Department of Medicine (Drs Buchinger, Godfrey,
Wooten) at the University of Missouri–Kansas City School of Medicine.
Dr Marinac is currently a clinical education consultant for Pfizer, Inc, in
Shawnee, Kan.
Address correspondence to Jacqueline S. Marinac, PharmD, 14615 W
50th St, Shawnee Mission, KS 66216-5116.
Submitted November 13, 2003; revision received September 29, 2005; accepted
October 14, 2005.
Marinac et al • Original Contribution
R ecent statistics indicate that Americans are increasingly
replacing prescription medications with vitamin and
mineral supplements as well as medicinal herbs. Consumers
spend more than $19 billion a year on these substances—an
amount that has grown steadily since the early 1990s.1 In 2005,
a secondary analysis of the complementary and alternative
medicine (CAM) supplement to the 2002 National Health
Interview Survey (NHIS)2,3 estimated that more than 38 mil-
lion Americans use herbs and dietary supplements. More
recent estimates have placed this number as high as 60 mil-
lion.4 Despite the widespread use of these products, primary
care physicians are generally unaware of the nonprescribed
therapies their patients are taking. Most patients are reluctant
to share this information with their healthcare providers,5-8
even if they experience adverse events that might be related
to use of medicinal herbs or dietary supplements.9
Herbal remedies and dietary supplements are not classi-
fied as drugs by the US Food and Drug Administration (FDA).
Therefore, although the 1994 Dietary Supplement Health and
Education Act allows manufacturers to make claims intended
to influence public opinion regarding the benefits of these
products,10 herbs and supplements are exempt from the rig-
orous federal regulations and testing required for products
classified as prescription drugs. Only recently has the FDA
developed good manufacturing process guidelines for herbal
products and dietary supplements. On November 4, 2004, the
FDA released a strategy for dietary supplements that would
focus on monitoring and evaluating product and ingredient
safety, ensuring product quality, and monitoring and evalu-
ating product labeling.11,12 The focus of these measures is to
protect consumers against dietary supplements that are unsafe,
as well as those making unauthorized, false, or misleading
claims. However, no policy has been adopted to date. As a con-
sequence, research on herbs and supplements within the con-
text of randomized controlled trials has seldom been per-
formed, and many questions regarding the efficacy, safety,
and purity of these substances remain.13-18
Anecdotally, it is thought that herbal products and dietary
supplements are popular as a result of a widespread belief
that the preparations are natural and, therefore, safe. However,
in conjunction with this increasing popularity, the number of
adverse events, drug interactions, and deaths involving these
products has been on the rise.13,15,17,19,20 The World Health
Organization reported in 1995 that it had received thousands
JAOA • Vol 107 • No 1 • January 2007 • 13
ORIGINAL CONTRIBUTION
of reports of suspected adverse reactions to herbal products.21
From 1994 to 1998, the FDA received more than
800 reports of adverse events associated with dietary products
containing ephedrine alkaloids, specifically Ephedra or
ma huang.22 In 2004, after a meta-analysis commissioned by the
National Institutes of Health reported more than 16,000 adverse
events associated with Ephedra,23,24 the FDA banned dietary
supplements containing this plant-based alkaloid.25 Adverse
events associated with Ephedra sinica include cardiac arrest,
heart palpitation, insomnia, stroke, and tremor.23-25 Drug inter-
actions involving a number of other herbal products are also
becoming increasingly well documented.15,18-20
The popularity of unconventional and alternative medical
therapies in the United States is readily apparent. Unfortu-
nately, the extent and patterns of use for these therapies are
more difficult to ascertain. Commonly cited statistics come
from a landmark study by Eisenberg and colleagues6 of trends
in alternative medicine. In a 1991 telephone survey of
1539 American adults, about 34% of respondents reported
use of an “unconventional therapy” (eg, energy healing, herbs,
homeopathy, massage, megavitamins, self-help groups) during
the previous year.6 Three percent of these participants reported
using herbal products during that time.6 When the survey
was repeated in 1997 with 2055 participants, about 12% of
respondents reported that they were using herbal products.
In 2002, Kaufman and colleagues26 published the results
of a telephone survey analyzing medication use among
2590 adults in the United States. They reported that herbal
products and dietary supplements were used by 14% of par-
ticipants surveyed in 1998 and 1999.26 By contrast, another
study published that same year with the participation of more
than 31,000 subjects found that 19% of American adults use nat-
ural products (eg, herbs, other botanicals, enzymes).27
Limited data are available regarding the prevalence of
herbal product and dietary supplement use in “special” pop-
ulations (eg, low-income individuals, patients with cancer,
racial minorities).8,28-33 Information regarding the use of these
products in the elderly population is almost nonexistent.33,34 In
one of the few studies looking at usage patterns in this popu-
lation, a 1996 survey of 3939 elderly subjects in North Car-
olina documented that 26% of participants reported using
vitamin or mineral supplements.34
In September 2001, Howard Beales, director of the Bureau
of Consumer Protection of the Federal Trade Commission
(FTC), delivered a prepared statement before the US Senate
Special Committee on Aging titled, “Health Fraud and the
Elderly: A Continuing Health Epidemic.”35 The statement
concluded that health fraud poses a direct and immediate
threat of both economic and physical injury to individuals
already suffering from serious health conditions. Elderly Amer-
icans, noted Beales, are particularly vulnerable because of the
high incidence of age-related health problems.35 The FTC com-
bats fraudulent and deceptive advertising claims about the
health benefits and safety of dietary supplements.36 The Com-
14 • JAOA • Vol 107 • No 1 • January 2007
mission’s authority in this area derives from the Federal Trade
Commission Act, which prohibits “unfair or deceptive acts
or practices in or affecting commerce” and which prohibits
the false advertisement of food, drugs, devices, services, or
cosmetics.37,38
Dietary supplement labeling may include claims about the
supplement’s effect on the structure or function of the human
body. However, the law requires that claims related to struc-
ture or function have substantiation and be truthful and not
misleading. The FTC coordinates those efforts closely with
the FDA and frequently calls on the expertise of other gov-
ernment authorities, including the Office of Dietary Supple-
ments of the National Institutes of Health. The FTC has filed
over a dozen actions in the past year and more than 100 actions
over the past decade challenging allegedly false or unsub-
stantiated efficacy or safety claims for dietary supplements.37
With thousands of marketers promoting worthless or
unproven remedies to older people, and with limited federal
enforcement resources, Beales pointed out that there is much
cause for concern. Among the products for which marketers
have made unsubstantiated health claims are colloidal silver,
comfrey, a dehydroepiandrosterone hormonal supplement,
St John’s wort, several multiherbal supplements, and a variety
of electrical therapy devices.35 In his September 2001 statement
before the Senate committee, Beales noted that the FTC had filed
27 cases against companies between 1997 and 2001 for using
false or deceptive claims to market unproven products.35 These
fraudulent claims included cures for arthritis, cancer, circula-
tory diseases, impotence, osteoporosis, and sleep apnea. On
October 22, 2004, the FDA sent warning letters to 8 distributors
making unsubstantiated Internet claims for dietary supple-
ment weight loss products.12 Earlier that year, the FDA sent
warning letters to 16 dietary supplement distributors making
false and misleading claims for similar products.39 The FTC
has also sent warning letters to more than 90 Internet advertisers
who were selling alleged human growth hormone enhancers,
and monitoring those operations to ensure that the sites mod-
ified or dropped unfounded marketing claims.40
The purpose of the present survey-based study was to ana-
lyze patterns of use for herbal products and nutritional sup-
plements among individuals aged approximately 60 years
and older. The study also sought to clarify this population’s atti-
tudes and basic knowledge regarding the safety of herbs and
supplements.
Methods
Participants
The potential pool of study participants consisted of adults
aged approximately 60 years or older residing in the Kansas
City, Mo, metropolitan area. Participants were identified at
area clinics, retirement communities, assisted-living centers, and
community centers. Individuals were excluded for the fol-
lowing reasons: unwillingness to participate in the survey,
inability to speak or understand English (unless a translator was
Marinac et al • Original Contribution

available), and residence in a long-term care facility. The Uni-
versity of Missouri–Kansas City Social Sciences Institutional
Review Board approved study protocols. Each face-to-face
survey was administered within 20 minutes by one of four
interviewers—two physicians (C.L.B., L.A.G.) and two doctors
of pharmacy (J.S.M., J.M.W.).
Survey Instrument
The AIDS (acquired immune deficiency syndrome) Knowledge
and Attitudes Supplement to the 1992 NHIS,41 as well as the
instrument used by Eisenberg and colleagues,5 were used as
models for the creation of the present 35-item survey. The
instrument was designed to measure usage patterns for, atti-
tudes about, and knowledge of herbal products and nutri-
tional supplements. Both models5,41 have functioned as pro-
totypes for phraseology and format to assist in gathering
demographic data.
To assess interobserver reliability and to evaluate the
clarity of the survey queries, a pretest was conducted using
25 volunteers and 2 interviewers (J.S.M., S.K.W.).42 The inves-
tigator read the questions and statements on the survey form,
most of which required a “true/false/don’t know” or
“yes/no/don’t know” answer from the participant. The ques-
tions and statements used to solicit this information are pro-
vided in the Appendix.
Statistical Analysis
Data were prospectively stratified by sex, race, annual house-
hold income, and education level. Each demographic inquiry
and assessment question was tabulated and then recorded as
the percentage of the total survey. All statistical analyses were
performed using Statistical Analysis Software (Version 8.0;
SAS Institute, Cary, NC). We used descriptive statistics to
assess basic knowledge, as well as perceptions—especially
with regard to safety and usage.
Multiple logistic regression analysis was used to identify
the independent contribution of sociodemographic factors,
health status, and attitudes toward the probability of use of
herbal products and dietary supplements. The use of herbs and
supplements was the dependent variable. Sociodemographic
factors, current health status, and participants’ attitudes toward
use were the independent predictors. Adjusted odds ratio
(OR) and 95% confidence intervals (CI) for the probability of
using herbs and supplements were calculated for each predictor
to explain the strength of the association after controlling for
age, sex, race, health insurance status, annual income, and
education level.
Results
Demographic Data and Health Status
Two hundred sixty-seven surveys were successfully completed
over a 3-month period in late 1999 and early 2000. The sociode-
mographic characteristics and health status of the survey par-
ticipants are summarized in Table 1. The mean age of survey
Marinac et al • Original Contribution
ORIGINAL CONTRIBUTION
respondents was 74.5 years (range, 57-93 years). Of these respon-
dents, 186 (70%) were women and 81 (30%) were men. By race,
respondents were almost evenly split between white (134 [50%])
and black (130 [49%]), with 3 (1%) respondents self-classified as
“other.” The vast majority of survey respondents (232 [87%])
reported being currently under a physician’s care. A review of
body systems revealed that 251 (94%) participants reported at
least one current medical condition.
Information regarding interactions with nonphysician
healthcare practitioners was also solicited from participants. Of
the 67 (25%) participants who had seen CAM practitioners in
the past year, 45 reported seeing a chiropractor; 7, an acupunc-
turist; 4, a faith healer; 2, an herbalist; and 1, a massage ther-
apist. Four participants reported seeing both an acupuncturist
and a chiropractor, while 1 participant reported seeing a chi-
ropractor and an herbalist. Approximately 17% of patients
presented to multiple CAM practitioners. The most common
reason given for visiting these practitioners was for therapy
related to either a musculoskeletal condition or musculoskeletal
pain, which was mentioned by 13 (29%) of the 45 participants.
Use of Herbal Products and Dietary Supplements
Information regarding participant use of herbal products and
dietary supplements is summarized in Table 1. Fifty-six (21%)
survey respondents reported taking at least one of these prod-
ucts, with 19 individuals taking two or more products con-
currently.
A total of 90 different herbs or supplements were used by
participants. Glucosamine and garlic were the most frequently
used products, followed closely by Echinacea and Gingko biloba.
Thirty other products not listed in Table 1 were each used by
no more than 2 survey participants.
The most common reasons stated by survey respondents
for taking an herbal product or dietary supplement were to
improve general wellness, to help manage arthritis, to help
prevent or manage colds, or to improve memory.
More than half of the 56 individuals who reported taking
these products obtained them through health food stores,
though 23% purchased them at grocery stores, and 12%
received them via mail order or from a healthcare provider.
Survey participants were asked to estimate their monthly
expenditure for these products. Of the 56 participants, 48%
reported paying less than $5 per month; 27%, between $5 and
$10; 16%, between $10 and $20; and 1%, more than $100.
The results of our analysis of sociodemographic factors,
participant attitudes, and health status issues that might influ-
ence the use of herbal products and dietary supplements are
presented in Table 2. In terms of demographic factors, white
women who had at least some college education were more
than twice as likely as other survey participants to use an
herbal product or dietary supplement. With regard to health
status, those participants who reported having three or more
current medical problems were about twice as likely as other
respondents to use herbs or supplements.
JAOA • Vol 107 • No 1 • January 2007 • 15
ORIGINAL CONTRIBUTION

Table 1 Table 1 (continued)

Herbal Product/Dietary Supplement Survey: Herbal Product/Dietary Supplement Survey:
Baseline Sociodemographic Characteristics Baseline Sociodemographic Characteristics
and Health Status of Participants (N=267) and Health Status of Participants (N=267)

Characteristic No. (%) Characteristic No. (%)

䡲 Age, y 䡲 Medical History (continued)
▫ 57-64 50 (19) ▫ Current medication use*
▫ 65-74 90 (34) – Yes 249 (93)
▫ ⭓75 127 (48) – No 18 (7)
䡲 Sex ▫ Current client of CAM practitioner(s)†
▫ Men 81 (30) – Yes 67 (25)
▫ Women 186 (70) – No 200 (75)
䡲 Race ▫ Current use of herbal product(s) or
▫ Black 130 (49) dietary supplement(s)
▫ White 134 (50) – Yes 56 (21)
▫ Other 3 (1) – No 211 (79)
䡲 Employment Status ▫ Herbal product(s) and dietary
▫ Employed 24 (9) supplements used‡
▫ Retired 243 (91) – Glucosamine or glucosamine/chondrotin 14 (25)
䡲 Health Insurance Status – Garlic 9 (16)
▫ Insured 240 (90) – Echinacea 8 (14)
▫ Uninsured 27 (10) – Gingko biloba 8 (14)
䡲 Annual Income – Herbal tea 5 (9)
▫ ⬍$20,000 225 (84) – Cod liver oil 4 (7)
▫ ⭓$20,000 42 (16) – St John’s wort 4 (7)
䡲 Education – Ginseng 3 (5)
▫ Some high school 70 (2) – Saw palmetto 2 (4)
▫ High school graduate 98 (3) – Other 21 (38)
▫ Some college 56 (21) ▫ Concurrent use, No. of herbal products
▫ College graduate 42 (16) and dietary supplements used ‡
䡲 Medical History – 1 37 (66)
▫ Current medical condition(s) – 2 10 (18)
– Coronary artery disease/hypertension 119 (45) – 3 8 (14)
– Endocrine problem 55 (21) – 4 1 (2)
– Rheumatism 54 (20) ▫ Duration of herbal product(s)/
– Respiratory problem 22 (8) dietary supplement(s) use ‡
– Gastrointestinal problem 16 (6) – Weeks 2 (4)
– Central nervous system problem 14 (5) – Months 16 (29)
– Cancer 12 (5) – Years 38 (68)
– Eye problem 12 (5)
– Renal problem 8 (3) * Survey participants were queried as to current use of prescription or
over-the-counter medications.
(continued) † Survey participants were queried as to recent (ie,聿1 year) treatment
history with any of the following complementary or alternative
medicine (CAM) providers: acupuncturist, chiropractor, faith healer,
herbalist, or homeopath.
Other factors that appeared to be highly predictive of ‡ n= 56
herb or supplement use were (1) an attitude that these prod-
ucts are taken if the person thinks they will help, and (2) a
history of receiving healthcare from CAM practitioners. Par- were 16 times more likely than other participants to consume
ticipants who indicated that they do not take prescription or herbal products or dietary supplements. These findings sug-
over-the-counter medications were unlikely to take herbal gest that the preservation of health—regardless of an indi-
products or dietary supplements. vidual’s assessment of his or her own health status, medical his-
The strongest predictor of herb/supplement use was not tory, or concomitant medications—was by far the most
based on subject demographic variables or attitudes toward predictive indicator for use of herbal products and dietary
these products, however. Instead, individuals citing “general supplements.
health reasons” as an explanation for herb/supplement use Approximately 3 out of 4 survey participants reported

16 • JAOA • Vol 107 • No 1 • January 2007 Marinac et al • Original Contribution

 ORIGINAL CONTRIBUTION

reality (Table 3). Of 267 participants, the majority

Table 2 (176 [66%]) believed that these products “pose no
Herbal Product/Dietary Supplement Survey:
risk to the general population.” In addition, a large
Predictors of Patient Use (N=267)
number of participants (160 [60%]) were under
the misimpression that the FDA “regulates herbal
95% Confidence
Factors Odds Ratio* Interval products,” and an overwhelming majority (187
[70%]) incorrectly believed that the FDA routinely
䡲 Sociodemographic Factors tests these products. Although few participants
▫ Age, ⬎70 y 1.33 0.62-2.83 (72 [27%]) knew that the purity of these products
▫ Sex, woman 1.13 0.55-2.29 is questionable, nearly half (120 [45%]) knew that
▫ Race, white 2.87 1.45-5.68 product contents were not standardized among
▫ Insured (health) 0.61 0.22-1.71
manufacturers.
▫ Annual income, 肁$20,000 0.59 0.25-1.44
Participants’ responses to queries concerning
▫ Education, some college 2.10 1.11-3.99
䡲 Attitude Toward Supplementation
their attitudes toward herbal products and dietary
▫ Yes supplements also demonstrate a disparity between
– “if I think it will help me” 3.30 1.36-8.01 perceptions and reality. The vast majority of survey
– “only if my doctor tells me to” 0.42 0.39-0.90 respondents (243 [91%]) expressed their belief that
▫ No (does not take them) 0.37 0.04-3.47 older Americans are often the targets of “medical
䡲 Medical History quackery.” Yet, most participants (208 [78%]) also
▫ Currently under physician care 1.41 0.55-3.62 indicated that they believe herbal products and
▫ Medical condition(s) not present dietary supplements have health benefits, and
– Cancer 0.18 0.02-1.66 about half (137 [51%]) believe that Medicare, Medi-
– Central nervous system problem 0.27 0.05-1.51
caid, or private insurance should pay for these
– Coronary artery disease/hypertension
(cardiovascular problem) 0.45 0.16-1.27
therapies. A minority of participants (55 [21%])
– Endocrine problem 0.36 0.11-1.20 incorrectly believe that “dietary supplements pro-
– Eye problem 0.39 0.06-2.43 vide all the nutritional benefits of real food.” Nearly
– Gastrointestinal problem 1.56 0.42-5.97 half (121 [45%]) of respondents said they would
– Respiratory problem 0.65 0.18-2.41 take an herb or supplement “if my doctor tells me
– Rheumatism (musculoskeletal problem) 0.70 0.27-1.81 to,” whereas only 75 (28%) said they would take it
▫ Three or more concurrent medical on their own “if I think it will help me.”
conditions 1.99 1.06-3.73 A number of drug or disease interactions
▫ Current medication use† 0.92 0.27-3.11
involving herbal products and dietary supplements
▫ Current client of CAM practitioner(s)‡ 3.78 1.94-7.35
have been documented in the literature.15,18-20
▫ Current use of herbal product(s)
and/or dietary supplement(s) Potential interactions were apparent in 12 indi-
– For general health purposes 16.63 6.91-40.02 viduals participating in the present survey. For
– As a result of physician example, though garlic has been cited as an aggra-
recommendation or prescription 2.19 0.79-6.10 vating factor for gastroesophageal reflux disease
(GERD),43 1 participant with GERD was taking
* Adjusted odds ratio after controlling for sociodemographic factors. concomitant garlic and cimetidine. In addition,
† Survey participants were queried as to current use of prescription or over-the-counter
medications. though there may be an increased risk of bleeding
‡ For survey participants currently under care of complementary and alternative medicine when taking garlic with aspirin,44-47 we found that
(CAM) practitioners for pain, the odds ratio for herbal product and/or dietary supplement
use was 3.75 (95% CI, 1.89-7.46). 2 survey respondents were taking both substances
concurrently. One survey participant reported
taking estrogren in addition to ginseng, which
having received some information about herbal products and has been touted to have estrogen-like effects.48-50 Similarly,
dietary supplements in the previous month. Television was the patients have been advised against combining oral diabetic
most commonly reported source of this information (73%) for agents and ginseng, as ginseng may reduce blood glucose
these participants, followed by magazines and radio (both levels,51 but 1 respondent reported taking both agents simul-
30%), newspapers (13%), friends (8%), and store displays (5%). taneously. Five participants receiving aspirin or other nons-
teroidal anti-inflammatory drugs were also taking Gingko
Product Safety biloba, which has known antiplatelet and anticoagulant prop-
Participant responses to survey questions related to the safety erties.18,20 One participant with an anxiety disorder was taking
and government regulation of herbal products and dietary ginseng, which has been reported to exacerbate this condi-
supplements indicated a wide gap between perception and tion.18,20 Participants taking St John’s wort also reported taking

Marinac et al • Original Contribution JAOA • Vol 107 • No 1 • January 2007 • 17

ORIGINAL CONTRIBUTION
Table 3
Herbal Product/Dietary Supplement Survey:
Baseline Measures of Participant Perceptions
and Knowledge (N=267)
Participants No. (%)
䡲 Accurate Beliefs/Knowledge
▫ Herbal product purity is questionable 72 (27)
▫ Familiar with FDA-required labeling
for these products 168 (63)
▫ Herbs can be dangerous when combined
with prescription medications 224 (84)
▫ Herbal product contents are not standardized
among manufacturers 120 (45)
䡲 Inaccurate Beliefs/Knowledge
▫ Herbal products pose no widespread risk 176 (66)
▫ The FDA regulates herbal products 160 (60)
▫ The FDA tests herbal products 187 (70)
▫ Herbal products must fulfill labeling claims 187 (70)
Abbreviation: FDA, US Food and Drug Administration.
paroxetine hydrochloride, digoxin, or estrogen—all of which
have been shown to potentially interact with the herbal antide-
pressant.18,20
Comment
The present study is not intended as a commentary on the
benefits or risks of herbal products and dietary supplements—
or on the potential role of these substances in patient care.
Rather, the purpose of the study was to document and analyze
real use among older Americans and to determine this popu-
lation’s understanding of potential risks. It is our hope that the
information gained from the present study will assist health-
care providers in developing appropriate educational inter-
ventions for this patient population.
In our surveyed group of 267 older adults residing in a
large Midwestern metropolitan area, 21% of participants indi-
cated that they were currently taking at least one herbal product
or dietary supplement. This prevalence rate is similar to that
reported in various special populations.30-33 Most (86%) par-
ticipants in the survey were under the care of a physician, yet
less than 12% of the herbal or dietary products being used in
this study group were prescribed or recommended by physi-
cians.
Although no definite conclusions can be drawn regarding
the type of individual who uses herbal products or dietary
supplements, a few basic patterns are apparent. The results of
our survey indicate that the most likely individual to use an
herbal product or dietary supplement is a relatively well-edu-
cated white woman. These findings are consistent with other
surveys that were not limited by age.2,6,26,52 It should be noted,
however, that some investigators have found no correlation
between use of these products and demographic factors.8,53
18 • JAOA • Vol 107 • No 1 • January 2007
A variety of hypotheses have been proposed to explain the
increased use of CAM therapies, including herbal remedies, in
the United States.52 These explanations range from a dissatis-
faction with conventional treatments to a desire for more
autonomy over decisions involving one’s own health.52 In
support of the latter theory, the most significant predictor we
identified for patient use of herbs or supplements was an
interest in the “general health purposes” of these substances
(OR, 16.63; 95% CI, 6.91-40.02). Being aware of this and other
predictors can help physicians maximize their interactions
with patients. It is important for physicians to understand
which patients may be predisposed to use alternative forms of
therapy, as well as why those individuals might choose that
treatment course.
American consumers take for granted the high quality
inherent in the manufacture of prescription and over-the-
counter medications, usually accepting without question the
consistency, purity, and potency of these items. The results
of our survey suggest that many consumers have mistakenly
transferred this trust to unregulated herbal products and
dietary supplements. Two thirds of the survey respondents
mistakenly believe that herbal products and dietary supple-
ments are safe and pose no risk to the general public, 70%
incorrectly believe that the FDA tests these products, and 60%
falsely believe that the FDA regulates them.
These misperceptions may be the reason that 22% of
respondents in our survey incorrectly believe that it is unim-
portant to disclose herbal/supplement use to their primary care
physicians. Unfortunately, 19% of these patients were at risk
for adverse events or drug interactions as a result of their
failure to share this information with their physicians—and
possibly their physicians’ failure to consider asking more
pointed questions in patient encounters.
There are certain limitations of the present study. The
usage and attitude patterns of mature adult residents of
metropolitan Kansas City may not reflect the patterns of usage
and attitudes found in other areas of the country. In addition,
our data included mainly white and black patients and, there-
fore, cannot be extrapolated to other racial or cultural groups.
Finally, we focused our efforts on mature adults in an inde-
pendent-living setting; data derived from institutionalized
individuals would likely differ significantly.
The general trend toward increased acceptance of herbal
remedies and dietary supplements by American consumers is
undeniable.1-3,5,6,26 Prevalence data from our survey, as well as
others,27 indicate that herbal products and dietary supple-
ments are important components in the growing search for gen-
eral well-being by many Americans. Primary care physicians
need to appreciate how important these products appear to be
to patients’ self-care regimens. However, the communication
gap between patients and physicians regarding the role of
herbs and supplements as components of treatment is glaring.
Physicians must be cognizant of the potential adverse
effects and interactions of herbs and supplements with various
Marinac et al • Original Contribution

prescribed substances. Inquiries about herb/supplement use
should become a routine component of each patient’s medical
history interview.
Osteopathic physicians have a unique opportunity to take
a lead in this process. Patient education materials should rou-
tinely carry warnings and information about concomitant use
of herbal products and dietary supplements with conven-
tional prescription and over-the-counter products. Educa-
tional opportunities should be made readily available for
osteopathic physicians and trainees to increase their knowledge
of CAM.
The present survey found that the most common reason
for visiting a CAM practitioner was therapy for a muscu-
loskeletal condition or pain. This information should be seen
as yet another opportunity for osteopathic physicians. Given
the osteopathic medical profession’s emphasis on “whole
patient” care and its emphasis on musculoskeletal conditions,
osteopathic physicians have an excellent opportunity to transfer
their knowledge and training to the treatment of older adults
with painful chronic conditions.
Consumers need more information from their physicians
and other healthcare professionals about CAM approaches
to healthcare using herbal products and dietary supplements.
Conclusion
Tens of millions of Americans use herbal products and dietary
supplements, including about 20% of the participants in our
survey of older Americans. We found misperceptions among
these individuals regarding the safety and testing of these
products. Two thirds of all respondents falsely believe that
herbal products and dietary supplements pose no risk to the
general population. The majority of participants incorrectly
thought that the FDA tests these products and routinely reg-
ulates the herb and supplement industry. These findings indi-
cate a wide gap between perception and reality.
An encouraging finding of the present study was that
most respondents expressed interest in learning more about
herbal products and dietary supplements. Thus, an excellent
opportunity is available for expanded patient education and
improved patient-physician interactions.
Acknowledgment
The authors thank Nicola Dahl, PharmD, for her invaluable input and
editorial expertise.
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Appendix
University of Missouri–Kansas City School of Medicine herbal product and aged approximately 60 years or older. Survey has been altered for
dietary supplement survey. During the 3-month study, this survey instru- graphic enhancement only.
ment was used to solicit responses from 267 Kansas City–area residents

Marinac et al • Original Contribution JAOA • Vol 107 • No 1 • January 2007 • 21

ORIGINAL CONTRIBUTION

Appendix (continued)
University of Missouri–Kansas City School of Medicine herbal product and aged approximately 60 years or older. Survey has been altered for
dietary supplement survey. During the 3-month study, this survey instru- graphic enhancement only.
ment was used to solicit responses from 267 Kansas City–area residents

22 • JAOA • Vol 107 • No 1 • January 2007 Marinac et al • Original Contribution

 ORIGINAL CONTRIBUTION

Appendix (continued)