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Supplement: Dietary Supplement Use in Women: Current Status and Future Directions

Dietary Supplement Use in the Context of Health Disparities: Cultural, Ethnic and Demographic Determinants of Use

Department of Nutrition, School of Public Health, University of North Carolina, Chapel Hill, NC and the Carolina Population Center, Chapel Hill, NC 27516-3997

²To whom correspondence should be addressed. E-mail: am_siegariz{at}unc.edu.

	ABSTRACT

TOP ABSTRACT Women in the United... Health disparities among... Health knowledge and attitudes... Ethnicity versus cultural... Cultural factors influence use... Gaps in research and... LITERATURE CITED

 
Women of African American, Hispanic, Asian, Pacific Islander, Native American and Alaskan descent constitute 29% of the female population in the United States but they experience health problems disproportionately. Compared with white women as a group, they are in poorer health and use fewer health services. We know from recent studies that the daily use of multivitamins has been associated with lower risk of coronary disease, colon cancer and breast cancer, particularly for alcohol drinkers. In addition, daily multivitamin and multimineral usage by the elderly can reduce the number of days of illness due to infections by 50%. However, supplement use among women tends to be more prevalent among the middle and older age categories; white, well-educated and higher income women; and those residing in the western part of the United States. This examination of the current health disparities and usage patterns indicates that the women who could benefit most from supplements are not typical users. Qualitative data collected on iron and folic acid supplementation programs in developing countries indicate that diverse cultural practices, attitudes and beliefs among vulnerable populations may influence supplement use. However, data in the U.S literature that describe these factors by culture or ethnicity are sparse. If we are to promote dietary supplements to women who are most vulnerable, more research is warranted in the area of health beliefs, attitudes and sociodemographic determinants of supplement use by culture and or ethnicity, particularly among underprivileged groups.

KEY WORDS: • dietary supplements • multivitamins • women • culture

There is convincing evidence of the beneficial effects of multivitamin supplement use on health status. Daily intake of multivitamin supplements has been shown to be associated with lower risk of congenital birth defects (1,2), coronary disease (3), colon cancer (4) and breast cancer, particularly in alcohol drinkers (5). It also reduced the number of days of illness due to infections in the elderly (6). In the context of health disparities and the evidence that daily use of multivitamin supplements is beneficial for health, understanding the ethnic and cultural determinants of supplement use among women has important programmatic relevance.

	Women in the United States: ethnic distribution and the changing demographics

TOP ABSTRACT Women in the United... Health disparities among... Health knowledge and attitudes... Ethnicity versus cultural... Cultural factors influence use... Gaps in research and... LITERATURE CITED

 
In the United States, minorities constitute 29% of the total female population of 143 million, including 13% African American, 11% Hispanic, 4% Asian American/Pacific Islander, and 1% Native American and Alaskan women (7). By 2050 it is estimated that 47% of the U.S female population will be minorities (8). Each minority group consists of several subgroups reflecting large linguistic and cultural diversity. For example, individuals of Chinese, Japanese, Vietnamese, Cambodian, Korean, Filipino and Native Hawaiian descent are all considered Asian American/Pacific Islander, and people of Latin American, Mexican, South American, Cuban and Puerto Rican descent are all considered Hispanic. Thus these heterogeneous ethnicity categories reflect the richness of cultural diversity among minorities as well as among whites.

	Health disparities among minority women

TOP ABSTRACT Women in the United... Health disparities among... Health knowledge and attitudes... Ethnicity versus cultural... Cultural factors influence use... Gaps in research and... LITERATURE CITED

 
It is well documented that minority groups experience health problems and consequences disproportionately (9–13). Women of minority groups are in poorer health and use fewer health services than do nonminority U.S women (9). Although white women have a higher incidence rate for breast cancer than do African American women (116 compared with 102 per 100,000), the latter group experiences a higher mortality rate (24 compared with 31 per 100,000) from breast cancer (14). The overall death rate from cardiovascular disease is higher in African American women than in whites (402 compared with 295 per 100,000) (15). Women constitute 25% of all people with AIDS in the United States and 77% are African American and Hispanics (16).

A recent report on trends in racial and ethnic-specific rates for the health status indicators in the United States showed changes in health disparities between 1990 and 1998 (17). An index of disparity was calculated for 17 health status indicators (HSI) that measure the degree of difference in race- and ethnic-specific rates. The index of disparity declined for 12 of 17 HSI from 1990 to 1998, although the declines were significant only for 6 HSI. Percentage of low birthweight infants (-19%), percentage of women with no prenatal care in the first trimester (-7%), stroke death rate (-11%) and lung cancer death rate (-9%) were among those with significant decline in the index of disparities. Infant mortality rate, heart disease death rate and female breast cancer rate were among the HSI where the declines were not significant. The index of disparity increased significantly for live birth rate for women aged 15–17 y (+3.5%). The analysis in this report highlights the poor health status among minorities and the large disparities in race- and ethnic-specific rates despite small declines for some of the HSIs in the past 10 y (17).

Current knowledge regarding benefits of vitamin and mineral supplements led to recommendations and guidelines for their use in some population subgroups, for example, iron and folic acid supplementation for pregnant women (18). In the United States supplement users are more likely to be older nonHispanic white women, having >12 y of education and higher income. They are also more likely to be physically active, nonsmokers, with lower body mass index and a higher intake of nutrients from food (19–21). This finding in the context of health disparities in minorities suggests that targeting efforts to encourage supplement use in groups that can benefit most may be a useful strategy. Understanding cultural factors in addition to the demographic determinants of supplement use is crucial for the success of these efforts in the vulnerable population groups.

	Health knowledge and attitudes of supplement users in the 1994–96 Continuing Survey of Food Intake by Individuals

TOP ABSTRACT Women in the United... Health disparities among... Health knowledge and attitudes... Ethnicity versus cultural... Cultural factors influence use... Gaps in research and... LITERATURE CITED

 
We examined data from the 1994–96 Continuing Survey of Food Intake by Individuals (CSFII96) for health knowledge and attitudes of female supplement users and explored ethnic variability. CSFII96 was a self-weighted, multistage, stratified area probability sample that covered all 50 states to express a representative sample of the noninstitutionalized U.S. population. Approximately 23,700 individuals participated in the survey and provided two 1-d dietary recalls (22). Survey data contain sociodemographics and other characteristics such as smoking and exercise. In addition, a subset of 7344 adults completed the Diet and Health Knowledge Survey questionnaire (DHK). Analysis of sociodemographic variables included only women aged 13 y and older (5457 women) and analysis with DHK variables included a subset of women aged 18 y and older (2868 women). Women were considered supplement users if they reported use of any single vitamin or mineral supplement or multivitamin and/or mineral supplements in pill or liquid form.

The prevalence of supplement use varied significantly among sociodemographic groups and by other health behaviors and followed the patterns reported by others (19–21), reemphasizing that vulnerable populations that might benefit most from use of supplements use them the least. In this sample, a significantly higher proportion of white women (57%, P < 0.01) reported the use of a supplement than did black women (40%), Hispanic women (45%) and women of other ethnicities (45%). This difference remained significant after control for age, education and household income. Our results from DHK data analysis shed light on other differences between supplement users and nonusers, such as those in health beliefs (Table 1). Supplement users were more likely to have been diagnosed with a disease (36% compared with 31%) and were more likely to be on some kind of a diet (20% compared with 14%) and yet more of them perceived their health status to be good (87% compared with 83%) compared with nonusers. More supplement users believed that what we eat affects our chance of disease. More nonusers agreed with the statements "some people are born to be fat and some thin, there is not much we can do to change this" and "eating a variety of foods each day probably gives all the vitamins and minerals you need." Supplement users read food labels more often than do nonusers. Differences seen in Table 1 indicate that supplement users are more likely to take additional measures to ensure good health. Table 2 shows differences in some of these same DHK variables among various ethnic groups, with women of minority groups being less likely to make a connection between diet and health and more likely to believe that there is not much we can do to change being fat or thin. However, after control for age, education and household income, only the "cannot change fat/thin" belief is significantly different among whites and minorities (data not shown).

	Ethnicity versus cultural factors

TOP ABSTRACT Women in the United... Health disparities among... Health knowledge and attitudes... Ethnicity versus cultural... Cultural factors influence use... Gaps in research and... LITERATURE CITED

The effect of culture on health outcomes and behaviors has been well documented (27,28). Popular examples of cultural constructs that are directly associated with health behaviors include the hot-cold food and medical theories that were extensively studied in East Asian, South Asian and Latin American populations (27) and the fatalismo (fatalistic outlook) reported among Latinos, which was identified as a barrier to use of cancer screening tests (28). However, the role of culture on health outcomes is usually taken for granted, and culture is infrequently conceptualized or measured as an independent variable that influences differential health outcomes (29). Culture is frequently reported as an explanatory variable to explain ethnic or population differences (30,31).

	Cultural factors influence use of supplements by women

TOP ABSTRACT Women in the United... Health disparities among... Health knowledge and attitudes... Ethnicity versus cultural... Cultural factors influence use... Gaps in research and... LITERATURE CITED

 
Findings from ethnographic studies of iron and folic acid supplementation by women of reproductive age in developing countries reveal that cultural factors potentially play a role in supplement use behaviors as well. Researchers in Malawi found that health care decisions are made by the family rather than the individual. For example, the husband, in-laws or both have to approve the buying of iron tablets by a woman (32). Beliefs held by communities regarding treatment of anemia and effects of supplements that may influence their use were reported. In Malawi, Coca-Cola® was believed to increase blood and was bought more often than iron tablets despite its higher price. There was also fear among women that "too much blood" would be caused by taking iron tablets when they did not actually lack blood and that it would activate dormant diseases in the body. All these beliefs were found to be barriers to the use of iron tablets in Malawi (32). Women in Indonesia expressed fear of iron tablets producing bigger babies (33), a belief also found in Honduran women (34). Honduran women were also worried about gaining too much weight and iron tablets causing deformities in babies. Because iron tablets were distributed at low cost, there was no status attached to their use and it was felt that they were not beneficial (34). Indian women considered tiredness, weakness and dizziness to be part of a normal pregnancy and not symptoms for anemia and, thus, women do not seek treatment (35). These studies suggest that culture can affect the way people perceive or respond to public health messages or interventions and can play an important role in their success or failure. Culture, therefore, does matter. One challenge is how to transform a cultural belief into a quantifiable variable and go beyond descriptive or ethnographic data.

	Gaps in research and recommendations for further research

TOP ABSTRACT Women in the United... Health disparities among... Health knowledge and attitudes... Ethnicity versus cultural... Cultural factors influence use... Gaps in research and... LITERATURE CITED

 
Traditionally, research with consideration of cultural factors in models of health behavior has been given low priority and has mainly been limited to qualitative studies (25). Quantitative measures of cultural variables are scarce, and although some studies acknowledge cultural differences, they are not addressed appropriately. However, in the past 10–15 y, anthropologists and epidemiologists have come closer in their efforts, and collaborative projects are leading to more detailed and accurate descriptions of human behavior and more appropriate and effective interventions (36). Applied social scientists have been developing tools and methods to design public health programs that are more sensitive to cultural issues (37,38). Compared with the early 1980s there is now a greater potential to combine qualitative and quantitative methods, leading to greater ability to link health and cultural data (25).

In general, research is limited on factors influencing supplement use. Focus has been placed more commonly on sociodemographic factors. Although health beliefs and attitudes are studied to some extent (39), the effects of these cultural factors in various ethnic subgroups in study populations need attention. If we are to promote dietary supplements to women who are most vulnerable, more in-depth understanding of these differences in cultural beliefs related to supplement use among various minority subgroups is necessary. Methodologically, we are now in a better place than ever to effect such investigations through combining both qualitative and quantitative approaches.

	FOOTNOTES

 
¹ From the National Institutes of Health (NIH) conference "Dietary Supplement Use in Women: Current Status and Future Directions" held on January 28–29, 2002, in Bethesda, MD. The conference was sponsored by the National Institute of Child Health and Human Development and the Office of Dietary Supplements, NIH, U.S. Department of Health and Human Services (DHHS) and was cosponsored by the Centers for Disease Control and Prevention, Food and Drug Administration Office of Women’s Health, NIH Office of Research on Women’s Health, National Institute of Diabetes and Digestive and Kidney Diseases Division of Nutrition Research Coordination, DHHS; National Center for Complementary Medicine, U.S. Department of Agriculture Agricultural Research Service; International Life Sciences Institute North America; March of Dimes; and Whitehall Robbins Healthcare. Conference proceedings were published in a supplement to The Journal of Nutrition. Guest editors for this workshop were Mary Frances Picciano, Office of Dietary Supplements, NIH, DHHS; Daniel J. Raiten, Office of Prevention Research and International Programs, National Institute of Child Health and Human Development, NIH, DHHS; and Paul M. Coates, Office of Dietary Supplements, NIH, DHHS.

³ Abbreviations used: CSFII96, 1994–96 Continuing Survey of Food Intake by Individuals; DHK, Diet and Health Knowledge Survey questionnaire; HSI, health status indicator.

	LITERATURE CITED

TOP ABSTRACT Women in the United... Health disparities among... Health knowledge and attitudes... Ethnicity versus cultural... Cultural factors influence use... Gaps in research and... LITERATURE CITED

 

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