Evidence of Use of Dietary Supplements by the Elderly: Current

Usage Patterns: Who and What?

Katherine L. Tucker Jean Mayer USDA Human Nutrition Research

Center on Aging at Tufts University

Supplement Use in the Elderly

• What do we know?– How many elders are using supplements?– Is supplement use increasing among the

elderly?– Are they taking multivitamin preparations or

single nutrients?– What are the characteristics of users vs. non-

users?– What about herbal/other supplements?

NHANES III, 1988-94 (60+ y)

41.3

55.2

30.2

42.235.6

44.6

0

10

20

30

40

50

60

Male Female

%

Non Hispanic whiteNon Hispanic BlackMexican American

From: Ervin, RB et al. Vital and Health Statistics Series 11, No. 244, June 1999.N: Male, NHW=1826, NHB=596, MA=609; Female, NHW=2135, NHB=659, MA=568

NHANES III, 1988-94 (all ages)

32

43

33

43

32

4044

52

0

10

20

30

40

50

60

Male Female

%

NorthwestMidwestSouthWest

From: Ervin, RB et al. Vital and Health Statistics Series 11, No. 244, June 1999.

Multi-nutrient Supplement Use (%) by Older Adults in Beaver Dam, WI (1988-90, 65-86 y)

27

3331

28

0

5

10

15

20

25

30

35

Men Women

%

65-74 y75+ y

• Supplement users (43-86 y) were more likely than non-users to:– have higher education– be physically active– drink < 91 g alcohol/wk– be never smokers– have lower BMI– have better nutrient

intakes from diet

From: Lyle BJ et al. J Nutr 1998;128:2355-2362. N: Men = 366, Women = 513

Supplement Use (%) by Rural Elders in North Carolina (70 + y)

64

25

51

0

10

20

30

40

50

60

70

%

Non-Hispanic white n=44Non-Hispanic Blackn=47Native American n=39

• Supplement users were more likely than non-users to:– have better

diets – be female– be married

From: Vitolins MZ et al. J Gerontol 2000;55A:M613-M617.

Massachusetts Hispanic Elders Study (1992-96, 60 + y)

39

27

0

5

10

15

2025

30

35

40

45

%

Non-Hispanic whiten=164Puerto Rican orDominican n=492

NHANES III, 1988-94 (40 + y)# Supplements Used (% of Users)

55.9

22.1 22

0

10

20

30

40

50

60

%

1 supplement2 supplements3 or more supplements

From: Ervin, RB et al. Vital and Health Statistics Series 11, No. 244, June 1999.

Supplement Use (%) by Older Adults in the Slone Survey (1998-99, 65+ y)

47

59

31 33

1419

12 147

23

2 327

0

10

20

30

40

50

60

70

Men Women

%

anymultivitaminVitamin EVitamin CCalciumVitamin B12Vitamin D

From: Kaufman DW et al. JAMA 2002;287:337-344. N: Men=243; women=351

Baltimore Longitudinal Study of Aging 1993-1999 (60 + y)

38

53.6

22

36

19

30

21

31

11

37

2 4

0

10

20

30

40

50

60

Men Women

%

Any (%)MultivitaminsVitamin CVitamin ECalcium Vitamin B12

Calcium from Supplements NHANES III, 1988-94 (60 +y)

42

56

3228

4651

0

10

20

30

40

50

60

Male Female

%

Non-Hispanic whiteNon-Hispanic blackMexican American

% below 924 mg/d*supplement

• Males no yes– NHW 73 58– NHB 87 80– MA 77 64

• Females– NHW 86 64– NHB 91 86– MA 88 75

From: Ervin, RB and Kennedy-Stephenson J. J Nutr 2002;132:3422-3427. * Healthy People 2010 calcium objective

Calcium Supplement Use in a NE US Medicare HMO, (65 +y)

25

67

0

10

20

30

40

50

60

70

80

%

MalesFemales

Factors associated with calcium use:

-history of fracture-been told they have

osteoporosis-using bone

medication-higher dairy intake

From: Dawson-Hughes B et al. Osteoporosis Int 2002;13:657-662. N=2408

Calcium and vitamin D Supplement Use (%) by Rural Elders in North Carolina

(70 + y)

52

2823

9

2922

0

10

20

30

40

50

60

Calcium Vitamin D

%

Non-Hispanic whiten=81non-Hispanic blackn=79Native American n=80

Dietary Intake by supplement use:

Calcium:Users 572 mgNon-users 498 *Vitamin DUsers 603 mgNon-users 506 *

*p<0.05

From: Bell et al. J Am Diet Assoc 2002;102:844-847.

Supplement Use in the Normative Aging Study: Men, (60 + y)

31

64

0

10

20

30

40

50

60

70

%

1987-89 n=630 1990-99 n=913

Supplement Use in the Framingham Studies, Men, 60 + y

25.5

32.7

42.7

8 1015

712

15

05

1015202530354045

Cohort 1988-89 Offspring 1991-95 Offspring 1995-99

Any

Multivitamins

Multivitamins +Minerals

Supplement Use in the Framingham Studies, Women, 60 + y

33.1

44.6

59.2

13 1117

7

1622

0

10

20

30

40

50

60

70

Cohort 1988-89 Offspring 1991-95 Offspring 1995-99

Any

Multivitamins

Multivitamins +Minerals

Individual Vitamin/Mineral Use in the Framingham Studies

Men, 60 + y

1315

20

11 11

30

58

13

3 36

2 2 3

0

5

10

15

20

25

30

35

Cohort 1988-89 Offspring 1991-95 Offspring 1995-99

Vitamin CVitamin ECalcium Vitamin B12Vitamin D

Individual Vitamin/Mineral Use in the Framingham Studies

Women, 60 + y

13

19

26

1116

41

16

24

39

25

10

2 3 5

05

1015202530354045

Cohort 1988-89 Offspring 1991-95 Offspring 1995-99

Vitamin CVitamin ECalcium Vitamin B12Vitamin D

Characteristics Associated with Supplement Use, Framingham

Offspring 1995-99Women Men

– BMI <= 25 64%>25 56%

– Alcohol users 64% 46%non-users 52% 35%

– Smoking past 65%never 55%

current 47%

Trend in Supplement Use

0

10

20

30

40

50

60

70

88-89MA

88-90WI

88-94US

91-95MA

93-99MD

95-99MA

98-99US

%

MenWomenLinear (Women)Linear (Men)

Herbal/Other Supplement Products Reported in NHANES III

(3.6% Reported Any Use)

Aloe veraPsylliumBee pollenGinsengAlfalfaFish/other oilsAmino AcidsGarlicLecithinProduct

182323364452102117127N

111214131516171818N

GoldensealBrewers yeastWheat branAcidophilusCholine/inositolCo-enzyme Q10KelpAnabolic mixturesFiberProduct

Radimer et al. J Am Diet Assoc 2000;100:447-454

Characteristics Associated With Herbal/ Other Supplement Use in NHANES III

• Female• 45-75 y• “Other” ethnicity (than

white, black or Hispanic)

• West region• Education > 12 y• Higher income• Divorced

• Greater alcohol use• Former smoker• > 5 Fruit and

vegetable servings/d• Exercise reported• Overweight/obese• Good/excellent self

reported health

Radimer et al. J Am Diet Assoc 2000;100:447-454

Herbal/other Supplement Use (%) by Older Adults in the Slone Survey (1998-99, 65+ Y)

11

14

1

54

34 44

01

2

0

2

4

6

8

10

12

14

16

Men Women

AnyGingko GarlicGlucosamineSaw palmettoGinseng

From: Kaufman DW et al. JAMA 2002;287:337-344. Nationwide telephone survey. N: Men=243; women=351 aged 65+

Use of Herbal Products by Adults in Minneapolis (1999, N=376)

• 61.2% reported some use in past 12 m

• Users were more likely to:– Be female– Use vitamin

supplements– Have higher education

• Products used – Ginseng 31%– Echinacea 28– Garlic 25– Ginkgo 21– St John’s wort 18– Ginger 17– Ephedra 12– Goldenseal 10– Kava 6– Saw palmetto 4

Harnack LJ et al. Mayo Clin Proc 2001;76:688-694. Mail survey, 65% response

Summary• Supplement use

– Increasing rapidly– Currently more than 40% men and 50% women

• More users– Are women – Are non-Hispanic white– Have higher SES– Have better diets– Participate in other positive health behaviors

• Herbal/other supplement use– Poorly defined– Growing rapidly

Conclusions

• Those most in need of supplements are not using them as frequently as those already practicing good health behaviors

• African Americans and some Hispanic groups may benefit from greater supplement use

• Among specifically recommended supplements for elders, calcium use is widespread but use of vitamin D and vitamin B12 remain low

• We know very little about the possible effects of rapidly increasing use of herbal/other supplements

Research Needs• Prevalence and patterns of use of herbal/other

supplements• Continued monitoring of vitamin/mineral supplement

use– Improved data on dose and length of use

• Better understanding of implications for dietary assessment and research on diet and health– Effects of individual vs. multiple nutrients and of interactions– Confounding with dietary intake

• Methods to improve communication – appropriate supplement use for elders most likely to benefit– potential risks, particularly for new, untested supplements