Bioavailability of Nutrients and Other Bioactive Components

from Dietary Supplements

Dietary Supplement Use: Consumer Characteristics and Interests1

J. L. Greger 2
Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI 53706

ABSTRACT Four major issues should be considered in a discussion of what consumers need to know about
supplements and herbal treatments. 1) Usage of supplements is changing as consumers are taking charge of their

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health and seeking alternative forms of medicine (Eisenberg et al. 1998, Gilbert 1999). 2) The characteristics of
supplement users have been profiled in numerous academic and industrial surveys. However, even the best
models based on consumers’ characteristics can predict ⬍ 30% of diet-related behavior (Baranowski et al. 1999).
3) Experts in traditional medicine and nutrition lack information on supplements and herbals. The Practice and
Policy Guidelines Panel of the National Institute of Health Office of Alternative Medicine (1997) stated that practices
used in complementary and alternative medicine were “unsuitable for the development of evidence-based practice
guidelines.” Well-designed basic and clinical research is needed on the efficacy, bioavailability and safety of
supplements and herbal medications. 4) It is debatable which agencies and professionals are the best gatekeepers
of information on supplements and herbals. Significant numbers of consumers do not seem to rely on their
physicians for information on alternative forms of medicine (Eisenberg 1997). Despite the obstacles, the traditional
medical community (including nutritionists) should focus more research efforts on diet supplements and herbal
treatments and increase training on these topics for students majoring in health care fields. Then health care
professionals can mount high quality, targeted education programs for consumers. J. Nutr. 131: 1339S–1343S,
2001.

KEY WORDS: ● supplements ● herbal treatments ● consumers ● education models ● bioavailability

What do consumers need to know about diet supplements
and herbals in terms of their efficacy, bioavailability and
toxicity? At least four major issues must be considered in this
discussion.
1. Usage of supplements is changing. Pollsters suggest that
one of the biggest trends in the health care industry is
that consumers are taking charge of their health and
seeking alternative forms of medicine (Eisenberg et al.
1998, Gilbert 1999). It is likely that the trends ob-
served in the use of nutrients supplements and herbals
reflect this larger trend.
2. The characteristics of supplement users have been pro-
filed in numerous academic and industrial surveys.
However, even the best models based on consumers’
characteristics can predict ⬍ 30% of diet-related be-
havior (Baranowski et al. 1999). Thus, consumer edu-
1
Presented at the conference “Bioavailability of Nutrients and Other Bioactive
Components from Dietary Supplements” held January 5– 6, 2000 in Bethesda,
Maryland. This conference was sponsored by the Office of Dietary Supplements,
National Institutes of Health and Life Sciences Research Office, American Society
for Nutritional Sciences. Conference proceedings are published as a supplement
to The Journal of Nutrition. Guest editors for the supplement publications were
Mary Frances Picciano, Pennsylvania State University, University Park, PA and
Daniel J. Raiten, National Institutes of Child Health and Human Development,
National Institutes of Health, Bethesda, MD.
2
To whom correspondence should be addressed.
E-mail: jlgreger@facstaff.wisc.edu
cation efforts, even when focused, are apt to have
limited success.
3. Experts in traditional medicine lack information on
supplements and herbals. The Practice and Policy
Guidelines Panel of the National Institutes of Health
Office of Alternative Medicine (1997) stated that prac-
tices used in complementary and alternative medicine
were “unsuitable for the development of evidence-
based practice guidelines.” More research is needed on
the efficacy, toxicity and bioavailability of supplements
and herbal medicines.
4. It is debatable which agencies and professionals are the
best gatekeepers of information on supplements and
herbals. Significant numbers of consumers do not seem
to rely on their physicians for information on alternative
forms of medicine (Eisenberg 1997). Experts also do not
agree on the best way to advertise dietary supplements
(Dickinson 1999, Mitka 1998, Nestle 1999).
Thus, the initial question in this manuscript splits into a
series of questions (Table 1). The answers to these questions
are still being developed by investigators in a broad range of
fields that includes nutrition, medicine, pharmacology, educa-
tion, sociology and marketing.
Are consumers taking charge of their health?
One way to assess the interest of Americans in taking
charge of their health is to examine their health care expen-

0022-3166/01 $3.00 © 2001 American Society for Nutritional Sciences.

1339S
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TABLE 1
Questions that must be addressed if health care professionals
are going to develop effective education and intervention
programs for consumers on diet supplements and herbal
treatments in terms of their efficacy, bioavailability and toxicity
■ Are consumers taking charge of their health?
■ Which Americans are most apt to consume supplements?
■ Can educators use consumer profiles to plan education and
intervention programs?
■ What should we teach about complementary and alternative
medicine?
■ Who should provide information on supplements and herbal
treatments to consumers?
ditures. In 1990 Eisenberg et al. (1993) estimated that Amer-
icans made $10.3 billion of out-of-pocket expenditures for
unconventional medicine, including diet supplements, herbals
and service by providers of unconventional therapy. These
expenditures were 44% as great as of the out-of-pocket expen-
ditures for physician services ($23.3 billion). In 1998 Eisen-
berg et al. (1998) called these procedures and services alter-
native medicine, not unconventional medicine. They
estimated that the out-of-pocket expenditures of U.S. consum-
ers for alternative medicine in 1997 had more than doubled
since 1990 and were between 27 and $34.4 billion. In contrast,
out-of-pocket expenditures of consumers for traditional physi-
cian services increased at a slower rate and were $29.3 billion
in 1997.
Not all categories of alternative medicine treatments grew
equally between 1990 and 1997. The U.S. Nutraceutical Re-
port 1997 indicated sales of functional foods and dietary sup-
plements increased 62 and 40%, respectively, between 1992
and 1996 (Anonymous 1998). Similar trends were observed in
Western Europe and Japan (Table 2).
Another index of the interest of Americans in taking
charge of their health is the increased number of Americans
taking herbal medications and supplements regularly. Eisen-
berg et al. (1998) reported that although only 2.5% of adults
in the United States reported using herbs in the past 12 mo in
1990, 12.1% did in 1997. The 1999 HealthFocus Trend Re-
port indicated that 35% of U.S. adults used herbals in 1998
(Gilbert 1999). On the basis of the 1986 National Health
Interview Survey, Moss et al. (1989) estimated that 36% of
U.S. adults consumed nonprescription vitamin and minerals.
The 1999 HealthFocus Trends Report indicated that 48 and
54% of American used vitamin/mineral supplements once a
week in 1990 and 1998, respectively (Gilbert 1999). Kim et al.
(1999) observed that the apparent increased use of supple-
ments reflected not just the “passage of time” but also the
changing demographics of those surveyed.
Other smaller surveys have indicated that 3–93% of the
groups studied used herbals, vitamins or diet supplements (Lyle
et al. 1998, Rock et al. 1998, Winslow and Kroll 1998). The
prevalence of supplement use varied with the populations, the
definition of supplements and the definition of what consti-
tuted regular supplement usage.
Which Americans are most apt to consume supplements?
The following demographic characteristics generally have
been associated with a higher usage of supplements (especially
multinutrient supplements): being female, education beyond
high school, higher income, being white and being older
SUPPLEMENT
(Bender et al. 1992, Koplan et al. 1986, Lyle et al. 1998,
Medeiros et al. 1989, Moss et al. 1989, Newman et al. 1998,
Slesinski et al. 1995, Stewart et al. 1985, Subar and Block 1990).
Although supplement users tend to be more educated, researchers
have demonstrated no correlation (Kim et al. 1999, Schutz et al.
1986) or a negative correlation (Barr 1986) between supplement
use and nutrition knowledge.
A few investigators have attempted to characterize the
attitudes toward nutrition and health of supplement users.
Patterson et al. (1998) reported that supplement users were
more apt to have a strong belief in diet-cancer connections
than were nonusers. However, surveyed individuals more often
cited health promotion or taking control of their health rather
than disease prevention (except for the prevention of colds) as
a reason for using supplements or herbs (Hensrud et al. 1999,
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Schutz et al. 1982). Consumers may perceive plant products to
be more natural than manufactured medicines (Winslow and
Kroll 1998).
Supplement use has also been related to various health-
related behavior patterns. Generally, positive lifestyle factors
were associated with increased supplement usage. For example,
nonsmokers were more apt to take supplements than were
current smokers (Lyle et al. 1998, Patterson et al. 1998, Slesin-
ski et al. 1995, Subar and Block 1990). Individuals who
consumed either no alcohol or moderate amounts of alcohol
(less than seven servings of alcohol/wk) were more apt to use
supplements than were those who consumed more alcohol
(Lyle et al. 1998, Newman et al. 1998, Subar and Block 1990).
Patterson et al. (1998) reported that individuals who used
various cancer-screening tests were more apt to ingest supple-
ments.
Individuals who exercised regularly (strenuously at least
three times/wk) were more apt to take supplements in some
(Lyle et al. 1998, Patterson et al. 1998) but not all studies
(Willett et al. 1981). Barr (1986) reported that 75% of the
marathon runners and 64% of the fitness class participants
who she studied used supplements and average intake was
more than two supplements daily.
Those individuals who seem to be more sensitive to dietary
messages (such as maintain optimal weight, consume adequate
levels of micronutrients and eat fruits and vegetables) may also
be more apt to consume supplements. For example, individuals
who were overweight or had high body mass indices were less
apt to take dietary supplements than were thinner individuals
in most (Lyle et al. 1998, Newman et al. 1998, Moss et al.
1989, Subar and Block 1990) but not all studies (Willett et al.
TABLE 2
Global market value of nutraceuticals1
1992 1996
($ U.S. billion)
Diet supplements
United States 5.6 7.9
United Kingdom, France and
West Germany 2.9 4.3
Japan 2.0 2.8
Functional foods
United States 5.4 8.9
United Kingdom, France and
West Germany 5.8 6.9
Japan 5.2 6.7
1 Data from anonymous (1998).
 CHARACTERISTICS AND INTERESTS OF SUPPLEMENT USERS
1981). Several groups have noted that supplement users
tended to consume more nutrient-dense diets (especially for
nutrients contained in the supplements) than did nonusers
(Koplan et al. 1986, Looker et al. 1988, Lyle et al. 1998, Rock
et al. 1997). Supplement users have been reported to consume
more fruits and/or vegetables (Joshipura et al. 1999, Looker et
al. 1988, Lyle et al. 1998, Patterson et al. 1998) and to
consume less dietary fat (Lyle et al. 1998, Patterson et al. 1998,
Rock et al. 1997) than nonsupplement users.
The relationship of health status to supplement usage is
complex. Individuals who reported their health to be excellent
or very good were more apt to use supplements than were those
who reported poor health (Bender et al. 1992, Moss et al.
1989). In contrast, Bender et al. (1992) also reported that that
supplement usage was more likely among individuals with one
or more health problems. However, Lyle et al. (1998) reported
that generally individuals with hypertension, cancer or heart
disease did not use more supplements than did individuals
without these conditions. These apparent inconsistencies may
reflect the importance of age, seriousness of conditions and
time since diagnosis. For example, men between 43 and 54 y
of age with a history of heart disease were more apt to use
multinutrient supplements and women older than 75 y with a
history of cancer were more apt to consume supplemental
vitamin E (Lyle et al. 1998). Newman et al. (1998) noted that
the use of nutrient supplements and herbals by women with
breast cancer declined with time after diagnosis. Patients with
more advanced stages of cancer were more apt to use nonnu-
tritional supplements, such as shark cartilage (Newman et al.
1998).
Can educators use consumer profiles to plan education and
intervention programs?
These surveys provide data that could be used to target
health education and behavior modification efforts in regard to
the use of supplements, herbals and nutraceuticals. Prochaska
et al. (1997) hypothesized that health intervention programs
should be matched to each individual’s stage of change in the
transtheoretical model (Table 3). However, Baranowski et al.
(1999) reported that assessing the stage of change of partici-
pants in dietary intervention programs was often difficult. For
example, is an individual who has used megavitamin supple-
ments or large doses of herbals with only minor and nonspe-
cific adverse effects in a precontemplation stage? Just creating
an awareness of potential adverse interactions among supple-
ments and herbals may be the most reasonable goal. Are
TABLE 3
The transtheoretical (stages of change) model predicts the
readiness of consumers to modify their
diet related behaviors1
■ Precontemplation stage
Consumer has no intention to act within the next 6 mo
■ Contemplation stage
Consumer intends to act within the next 6 mo
■ Preparation stage
Consumer intends to act within 30 days and has taken some
positive steps
■ Action stage
Consumer has changed overt behavior for ⬍6 mo
■ Maintenance stage
Consumer has changed overt behavior for ⬎6 mo
1 Descriptions from Prochaska et al. 1997.
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consumers at the preparation or action stage when they are
selecting herbals at a pharmacy? Would this be an effective
time to provide information on the bioavailability of various
products?
Nutritionists and physicians should use the techniques and
models used in effective marketing and health intervention
programs when they develop programs on supplements and
herbals for consumers. Obviously more research is needed
because even the best psychosocial models can only predict
30% of the variance in consumer health-related behavior
(Baranowski et al. 1999).
What should we teach about complementary and
alternative medicine?
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Ferguson (1998) noted that targeting the audience was the
first step in planning a health intervention program; the sec-
ond was deciding on the content of the educational message.
This is problematic because experts do not know what consti-
tutes optimal complementary and alternate medicine practices
(Angell and Kassirer 1998, Fontanarosa and Lundberg 1998).
Recently the Practice and Policy Guidelines Panel of the
National Institutes of Health Office of Alternative Medicine
(1997) stated that practices used in complementary and alter-
native medicine were “unsuitable for the development of ev-
idence-based practice guidelines, in part because of the lack of
relevant outcomes data from well-designed clinical trials.”
Experts in traditional medicine have recognized their lack
of information on herbal medications in a variety of ways in
recent years. The National Institutes of Health has created an
Office of Alternative Medicine and funded centers and clinical
trials of popular herbal medications (Marwick 1998). In 1998
several major medical journals published research evaluating
the efficacy and the potential toxicity of herbal medications
(DiPaola et al. 1998, Ernst 1998, Miller 1998, Wilt et al. 1998,
Winslow and Kroll 1998). Many investigators have reported
that a number of common plants (including mushrooms, soy-
beans and teas) may have disease-preventing properties (Blot
et al. 1997, Borchers et al. 1999, Messina et al. 1998). Unfor-
tunately, scientists have only begun to identify the active
components in these herbal medicines and foods and to stan-
dardize the amounts and bioavailability of active ingredients in
products. These research activities must be completed before
well-designed clinical trials can be conducted.
Our knowledge of the bioavailability and toxicity of micro-
nutrients also is incomplete. However, vitamin/mineral sup-
plementation trials, evaluations of food fortification programs
and clinical and animal studies of interactions among nutri-
ents and other substances in food provide considerable data on
the bioavailability and toxicity of micronutrients (Blot 1997,
Greger 1987, Mertz et al. 1994, Patterson et al. 1997, Pfeiffer
et al. 1997, Sandström 1998). These limited data were the
basis of standards, such as the Tolerable Upper Intake Levels
established by the Food and Nutrition Board (Yates et al.
1998) and the position article of the American Dietetics
Association on vitamin and mineral supplementation (Amer-
ican Dietetics Association 1996).
Moreover, investigators have documented excessive intake
of micronutrients through supplementation in several surveys.
In the National Health Interview Survey, supplement users at
the 95th percentile consumed daily from supplements ⬎2-fold
the Recommended Dietary Allowance (RDA)3 for vitamin A,
7-fold the RDA for riboflavin and 17-fold the RDA for vita-
3
Abbreviation: RDA, Recommended Dietary Allowance.
1342S SUPPLEMENT
min C (Subar and Block 1990). Stewart et al. (1985) found
that individuals (at the 95th percentile) who reported using
specific nutrient supplements in a national telephone survey
consumed ⬎5-fold the RDA for thiamin, riboflavin, vitamin
C, vitamin E, vitamin B-12, niacin, vitamin B-6 and iron.
Rock et al. (1998) noted that a few (⬍ 4.4%) women at risk
of breast cancer consumed potentially toxic levels daily of
vitamin A, vitamin B-6, iron and zinc.
Obviously some consumers need information on the poten-
tial toxicity of megasupplemnts and herbals. The educational
messages on diet supplements for consumers should be evi-
dence-based (Fontanarosa and Lundberg 1998), admit the
limitations of available data and emphasize what is important.
Goodwin and Tangum (1998) stated that the only important
issues to consumers using dietary supplements were efficacy,
toxicity and cost of treatments. Bioavailability is an aspect of
both efficacy and toxicity. Consumers should be alerted also to
the potential that excessive levels of some nutrients could be
ingested in a combination of fortified foods, nutraceuticals and
supplements.
Who should provide information on supplements and
herbal treatments to consumers?
Supplement users in several surveys reported that books,
magazines, health food stores and even fitness and/or nutrition
classes were more useful sources of nutrition information than
were physicians or dietitians/nutritionists (Barr 1986, Levy
and Schucker 1987, Schutz et al. 1986). Moreover, Levy and
Schucker (1987) reported that individuals who consumed
more than two supplements daily were less likely to rely on
physicians than were individuals who consumed less than two
supplements daily.
Not only do many consumers not consider physicians a
major source of nutrition information, they also do not appear
to report their usage of supplements to physicians. Hensrud et
al. (1999) found that 30.5% of patients reported use of sup-
plements on a standard medical questionnaire that was part of
a routine physical. During a more intensive survey conducted
for research purposes, 61% of the same patients reported use of
supplements, including herbals. Eisenberg et al. (1993) noted
that 72% of patients who used unconventional therapies did
not inform their physicians.
Consumers may not rely on traditional health care provid-
ers for information on dietary supplements for several reasons.
Most physicians receive limited training on clinical nutrition
(Halsted 1999) or on complementary and alternative medicine
(Wetzel et al. 1998). Similarly, few graduate nutrition pro-
grams offer a course on nonnutrient substances in food. Fur-
thermore, consumers may perceive that traditional health care
providers have negative attitudes toward alternative medical
therapies (Goodwin and Tangum 1998). Wetzel et al. (1998)
noted that instructors in elective course on complementary or
alternative medicine should encourage medical students to
communicate professionally with alternative health care cli-
nicians and should teach students to talk to patients about
alternative therapies. The same advice should be given to
nutrition professors.
Finally, the Dietary Supplement Health and Education Act
of 1994 changed the type of information available to consum-
ers on dietary supplements. The Dietary Supplement Health
and Education Act of 1994 allowed manufacturers (without
preauthorization by the Food and Drug Administration) to
describe on the label how a product affects the structure or
function of the body but not to make claims in regard to
disease prevention. Manufacturers, federal officials and medi-
cal and nutrition professionals have extensively debated the
impact of this act and the recently published Federal Trade
Commission guidelines for advertising (Angell and Kassirer
1998, Dickinson 1999, Mitka 1998, Nestle 1999). The debate
seems to have made consumers more interested in diet sup-
plements and to have encouraged them to change their be-
havior in regard to supplement usage.
Now is the time for the medical community (including
nutritionists) to focus more research efforts on herbal treat-
ments and diet supplements and to increase training on these
topics for students majoring in health care fields. Then health
care professionals can mount high quality, targeted education
and intervention programs for consumers.
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