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© 2005 The American Society for Nutritional Sciences J. Nutr. 135:1782-1789, July 2005

Nutritional Epidemiology

Supplement Use Is Associated with Health Status and Health-Related Behaviors in the 1946 British Birth Cohort1,2,3

Sarah A. McNaughton4, Gita D. Mishra, Alison A. Paul, Celia J. Prynne and Mike E. J. Wadsworth*

MRC Human Nutrition Research, Elsie Widdowson Laboratory, Cambridge CB1 9NL, UK and * MRC National Survey of Health and Development, University College and Royal Free Medical School, London WC1E 6BT, UK

4To whom correspondence should be addressed. E-mail: sarah.mcnaughton{at}mrc-hnr.cam.ac.uk.


   ABSTRACT
TOP
 ABSTRACT
SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 LITERATURE CITED
 
Use of dietary supplements may be one of a number of health-related behaviors that cluster together. The current study investigated the underlying diet, health-related characteristics, and behaviors of users and nonusers of dietary supplements in a longitudinal study of health. Participants (n = 1776) completed a 5-d food diary including information on dietary supplement use (vitamins, minerals, and nutraceuticals) at age 53 y. Sociodemographic information and data on smoking, alcohol, and physical activity were obtained along with anthropometric measurements, blood pressure, and a blood sample (nonfasting subjects). A significantly greater percentage of women reported supplement use compared with men (45.1 vs. 25.2%). Supplement use was associated with lower BMI, lower waist circumference, higher plasma folate and plasma vitamin B-12 concentrations, nonsmoking, participation in physical activity, and nonmanual social class in women and with plasma folate concentrations and participation in physical activity in men. Nonsupplement users tended to be nonconsumers of breakfast cereals, fruit, fruit juice, yogurt, oily fish, and olive oil and had lower dietary intakes of potassium, magnesium, phosphorus, iron, and vitamin C even after adjustment for sociodemographic and behavioral factors. Overall, supplement users tended to differ from nonsupplement users on a range of health-related behaviors and health status indicators, although there were fewer significant associations in men. Similarly, dietary supplements users tended to have underlying diets that, were healthier and those taking supplements may be the least likely to need them. These results support the notion of a clustering of healthy behaviors and cardiovascular risk factors, particularly for women.

KEY WORDS: • dietary supplements • dietary intake • life-style behaviors • health status • cardiovascular disease risk

Dietary supplement use has increased substantially in the past 2 decades in a number of countries; therefore, it is becoming of increasing importance from a public health nutrition perspective (1,2). Recent dietary surveys in the UK found that 40% of women and 29% of men aged 19–64 y reported taking supplements (3).

It has been suggested that use of dietary supplements may be associated with a range of healthy behaviors, and those taking supplements may be the least likely to need them (4). Supplement use was shown to be associated with healthier food choices including increased intake of fruits and vegetables and higher intakes of many micronutrients (4–6). A range of other lifestyle factors and behaviors were also shown to be associated with supplement use including lower BMI, higher levels of physical activity, lower alcohol intake, and nonsmoking (4,7).

There have been few studies of supplement use within the UK, and many of the worldwide studies of supplement use have focused on women only (4,6–10). The objective of this study was to investigate the underlying diet, health-related characteristics, and behaviors of users and nonusers of dietary supplements in a representative cohort of the British population, the Medical Research Council (MRC) National Survey of Health and Development. An understanding of the characteristics of people who use supplements is important in light of public health issues surrounding toxicity, cost-benefit considerations, inconsistent evidence of beneficial effect, and conflicting recommendations for the general public (11–17).


   SUBJECTS AND METHODS
TOP
 ABSTRACT
 SUBJECTS AND METHODS
RESULTS
 DISCUSSION
 LITERATURE CITED
 
The MRC National Survey of Health and Development (also known as the 1946 British Birth Cohort) is a longitudinal study of health based on a social class–stratified, random sample of 5362 singleton births in England, Scotland, or Wales during the first week of March, 1946 (18). Data reported here relate to information collected at an interview in 1999 when subjects were 53 y old. A total of 3035 participants were interviewed in 1999, with 1776 completing a food diary (18). The population interviewed at the age of 53 y continued to be representative in most respects of 53-y-olds in the native-born population (18).

Subjects were classified according to their social class and region of residence. Four regions of residence were defined: 1) Scotland; 2) The North (North, North-West, Yorkshire); 3) Central, South-West, and Wales (Midlands, North-Midlands, Eastern, Southern, South-West, Wales); 4) London and South-East. Categories of occupational social class in 1999 were defined as nonmanual (managerial, professional, skilled professional ancillaries, and service providers) and manual (skilled, unskilled, and agricultural workers) (19). Subjects provided information on behaviors such as alcohol consumption, physical activity, and smoking, during an interview with trained health nurses. Alcohol consumption was categorized as none, special occasions only, and more frequently. Physical activity was based on response to the question: Do you regularly participate in vigorous leisure activity (yes/no). Smoking status was categorized as nonsmokers, past smokers, and current smokers.

A physical examination was conducted including anthropometric and blood pressure measurements, and a blood sample was collected from nonfasting subjects (18,20,21). Waist circumference, height, and weight were measured with a standardized protocol and BMI was calculated (kg/m2). Blood pressure was measured twice, with the survey member seated and after 5 min of rest, with the Omron HEM-705 automated digital oscillometric sphygmomanometer (Omron); the second blood pressure reading was used for this analysis (22). Subjects were defined as at risk with respect to hypertension if their systolic blood pressure was >140 mm Hg and their diastolic blood pressure was >90 mm Hg, or if the subject was taking medication for hypertension (23). Plasma total cholesterol was analyzed by enzymatic CHOD-PAP using standardized procedures using a Bayer DAX-72 analyzer (20). Plasma folate, plasma ferritin, and plasma vitamin B-12 concentrations were measured by a standardized magnetically enhanced enzyme immunoassay (Abbott AxSYM system).

    Diet and supplement use. Participants were asked to complete a 5-d food diary in which they recorded information on their food and drink intake over 5 d including brand names of food products, food preparation methods, and recipes used (24). Participants were asked to record the amounts eaten in household measures, with black and white food photographs provided to aid in the estimation of portion size.

Food intake from the food diary was entered and coded using a specially designed data entry program (24). Mean daily nutrient intakes were calculated using an in-house computer analysis program based on McCance & Widdowson’s The Composition of Foods (25–27). All foods and beverages consumed were categorized into 1 of 63 food groups (see Supplemental Table 1). Food groups were devised based on their relevance for the development of chronic disease and to public health nutrition, with guidance from previously published work and existing advice on the development of food groups (3,28–30).

Subjects were also asked to record any dietary supplements (including vitamins, minerals, and nutraceuticals) that they consumed each day, including information on brand and the amount taken as the number of pills or teaspoons for liquids or powders. Use of dietary supplements and intake of nutrients from supplements was analyzed using a newly created supplement database containing >800 dietary supplements frequently consumed in the UK with nutrient data derived from product labels, websites, and information provided directly by the manufacturer (31). Supplement users were defined as those subjects who reported taking at least 1 supplement (including vitamins, minerals, and bioactive compounds) during the 5-d food diary.

    Statistical analysis. The distribution of consumption of the 63 food groups was highly skewed; therefore a binary variable for each food group was created and respondents were dichotomized as consumer or nonconsumer. Tertiles of nutrient intake were calculated and used as cut-points for grouping.

Logistic regression models were used to investigate the relations between 1) supplement use and sociodemographic factors and health behaviors; 2) supplement use and each of the health status indicators (BMI, waist circumference, blood pressure, plasma cholesterol, plasma folate, plasma ferritin, and plasma vitamin B-12 concentrations); 3) supplement use and consumption of the individual food groups, and 4) supplement use and tertiles of nutrient intake. The adjusted odds ratios (ORs) and 95% CIs for supplement use were calculated after inclusion of sociodemographic factors (social class and region of residence) and health behaviors (smoking, alcohol consumption, and physical activity) in the logistic regression models. All analyses were conducted using SAS program software (version 8.0; SAS Institute). Differences with P-values ≤ 0.05 were considered to be significant.


   RESULTS
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 RESULTS
DISCUSSION
 LITERATURE CITED
 
Overall, a greater percentage of women than men reported supplement use (45.1% vs. 25.2%, {chi}2 = 75.5, P < 0.001) (Table 1). A higher percentage of men consumed fish oil supplements, whereas more women consumed vitamin and mineral combinations, vitamin E, evening primrose and starflower (borage) oils, calcium, and vitamin B-6 (P < 0.05). Men and women did not differ in the number of different supplements taken. Of supplement users, 84% recorded taking at least 1 of their supplements on all 5 d of the food diary with no differences between men and women ({chi}2 = 0.37, P = 0.5).


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  		TABLE 1 Dietary supplement use among men and women aged 53 y1

 
Men participating in vigorous leisure activity were 50% more likely to be supplement users than men not participating in such activity, even after adjustment for all other variables (Table 2). No other factors were independently associated with supplement use in men. Women from the manual social classes were 30% less likely to be supplement users compared with those among the nonmanual social class. Among women, never smokers were 50% more likely, and past smokers were 10% more likely to be supplement users compared with current smokers. Women who participated in physical activity were 60% more likely to be supplement users than those who did not participate in physical activity. Region of residence and alcohol consumption were not associated with supplement use.


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  		TABLE 2 Crude and adjusted ORs and 95% CIs for supplement use for each sociodemographic factor and health behavior in British adults aged 53 y

 
In men, supplement use was associated with higher plasma folate concentrations (Table 3). In women, supplement use was significantly associated with lower BMI, lower waist circumference, and higher plasma folate and vitamin B-12 concentrations. These associations persisted after adjustment for social class, region of residence, smoking, alcohol, and exercise behavior.


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  		TABLE 3 Crude and adjusted ORs and 95% CIs for supplement use for each of the health status indicators in British adults aged 53 y

 
In women, nonconsumers of breakfast cereals, rice and rice dishes, yogurt (regular and low-fat or low-calorie), fresh and dried fruit, fruit juice, oily fish and fish dishes, olive oil, and nuts and seeds, were significantly more likely to be nonsupplement users than consumers of these foods (Table 4). Nonconsumers of red meat, cream, and animal fats were significantly more likely to be supplement users than consumers of these foods. For men, nonconsumers of breakfast cereals, yogurt, canned and cooked fruit, fruit juice, oily fish and fish dishes, fat spreads, olive oil, ice cream, puddings and desserts, and other alcoholic beverages were significantly more likely to be nonsupplement users than consumers, whereas nonconsumers of meat products were significantly more likely to be supplement users than consumers.


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  		TABLE 4 Adjusted ORs and 95% CIs for supplement use for each food group consumed by British adults aged 53 y1, 2, 3

 
Men in the lowest tertile of intake of potassium, magnesium, phosphorus, iron, thiamin, and vitamin C were more likely to be nonsupplement users than men in the highest tertile of intakes (Table 5). Women in the lowest tertile of potassium, magnesium, phosphorus, iron, vitamin B-6, folate, and vitamin C intakes were more likely to be nonsupplement users than those in the highest tertile.


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  		TABLE 5 Adjusted ORs and 95% CIs for supplement use for daily intake of each nutrient from diet only1, 2

 

   DISCUSSION
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
LITERATURE CITED
 
This study investigated the diet, health-related behaviors, and measurements of health status of users and nonusers of dietary supplements in a nationally representative cohort of British adults. The current study found that ~45% of women and 25% of men were using dietary supplements. This is lower than the findings of the 2000–2001 UK National Diet and Nutrition Survey, which found that in the relevant age group (50–64 y), 55% of women and 34% of men reported taking supplements (3). Similar to our results, the previously described study found that women were more likely to consume evening primrose oil–type supplements and men were more likely than women to consume cod liver oil and other fish oils (3). In both men and women in the current study, fish oils were the most commonly consumed type of supplement. This is in contrast to studies in other countries where multivitamins are the most commonly used supplement (32–34). This may reflect variations in the uptake of public health messages in different countries.

Another recent UK study reported higher supplement use than in the present study. Kirk et al. (35) investigated supplement use in the UK Women’s Cohort Study and found that 61% of women reported consuming supplements. However, this study was based on a population that was recruited via a mail-out from a World Cancer Research Fund register; therefore, participants were more likely to be health conscious and aware of the role of diet in health and disease. They represented a self-selected, highly educated population, and were not representative of the UK female population (4).

Other studies also showed differences in the level of uptake of dietary supplements by men and women. Radimer et al. (34) reported on data collected by interview from the U.S. National Health and Nutrition Examination Survey (1999–2000) and found that 46.9% of men and 56.7% of women reported supplement use. Smaller (but still significant) differences were found in a study from the north of England in which 32 and 38% of men and women, respectively, reported consuming supplements (7). These differences between men and women are consistent with studies elsewhere (32,33,36).

In the current study, supplement use was associated with a range of health-related behaviors and health status characteristics, although there were fewer significant associations in men. In women, supplement use was independently associated with lower BMI, lower waist circumference, and higher plasma folate and vitamin B-12 concentrations, whereas in men, significant independent associations were shown only for plasma folate. Similarly, with respect to behaviors, supplement use was significantly associated with smoking and physical activity in women, but only physical activity in men. Women also showed social class differences in supplement use with those from the manual social class less likely to be taking supplements. The differences between men and women in supplement use behavior are further reflected in the frequency of supplement use, the types of supplements taken, and the nutrient intakes achieved from the dietary supplements. Differences between supplement users and nonusers on a range of health-related behaviors, health status indicators, and sociodemographic characteristics such as education and socioeconomic status were shown in other populations in the UK, Europe, and the United States and in men and women (7,9,10,34,37,38).

Differences between supplement users and nonusers were also shown in terms of the types of foods consumed and the nutrient intakes from diet in both men and women. Overall, supplement users had more favorable diets than nonsupplement users, with nonsupplement users more likely to be nonconsumers of breakfast cereals, fruit, fruit juice, yogurt, oily fish, and olive oil and have lower intakes of a range of micronutrients including potassium, magnesium, phosphorus, iron, and vitamin C.

The dietary differences in the current study between supplement users and nonusers are consistent with those of previous studies. For example, Frank et al. (6) and Harrison et al. (7) found that supplement use was associated with higher consumption of fruit and vegetables. Kirk et al. (4) found that supplement users were consuming higher levels of all nutrients except total fat and vitamin B-12; however, the association between supplement use and nutrient intakes was not adjusted for other lifestyle or confounding factors. This is important considering that a range of lifestyle factors including lower BMI, higher levels of physical activity, lower alcohol intake, and nonsmoking were found to be associated with supplement use, and many of these are independently associated with dietary intake (39). The dietary intake differences in the current study persisted even after adjustment for a range of sociodemographic and behavioral factors. These results support the notion that those taking supplements may be the least likely to need them (4).

There are a number of methodological issues surrounding the assessment of dietary supplement use that make it difficult to compare surveys and may be responsible for differences among studies. Evidence of variations due to methodology is provided by Bates et al. (40). In free-living participants of the 1994–1995 UK National Diet and Nutrition Survey (people aged >65 y), participants’ responses to questions on supplement use in a health and lifestyle questionnaire were compared with details on supplement use recorded on a 4-d weighed food record. The pattern of dietary supplement usage differed according to the method of assessment with 28.7 and 22.2% reporting supplement use on the questionnaire and food record, respectively. Murphy et al. (41) compared a dietary questionnaire with three 24-h recalls and found that reported prevalence of supplement use was lower on the recalls than the questionnaire and that intake of infrequently used supplements showed the most variation in reported use across the 2 methods. Similarly, Kiely et al. (2) found that of those who reported supplement use in a health questionnaire, only 84% recorded any supplement use in the following week in a 7-d food diary.

It is important to recognize that food records and questionnaires generally have different time scales for measurement in that food records cover a particular number of days, whereas questionnaires generally refer to the previous 3–12 mo (42). Therefore, although food records can provide more detailed information than questionnaires, they are limited to providing a measure of current supplement use, which is then often assumed to reflect habitual or long-term use. Limited research exists on this issue with respect to supplements, but there is some indication that food records may not indicate long-term use. For example, the time of year when a survey is conducted may influence rates of supplement use (7). In addition, if questionnaires do not include a time frame in the questioning, it is possible that supplement use will be overestimated because participants who have used supplements in the past and may contemplate using them again may be inclined to indicate they are current supplement users (7)

It is also important to recognize that the definitions of supplement use may vary across studies. For example, the questionnaire used by Ishihara et al. (43) asked about supplements in 5 categories: multivitamins, ß-carotene, vitamin C and vitamin E, and other supplements; this last category included minerals, herbal supplements, and other vitamins not previously covered. Lyle et al. (38) asked participants about use of any vitamin or mineral supplement, but included only users of multivitamins, vitamin C, and vitamin E in their analysis, whereas Kiely et al. (2) investigated use of any vitamin, mineral, or food supplement. In addition, the definition of regular or irregular supplement may vary between surveys or may not be adequately defined at all. Ishihara et al. (44) defined users as subjects taking a supplement at least 1 time/wk, but short-term users defined as those using supplements for <1 y were excluded. In contrast, Neuhoser et al. (45) defined regular supplement use as consumption of the supplement at least 3 times/wk. Not surprisingly, differing definitions result in different estimates of the prevalence of supplement use (46). However, despite these methodological differences, similar results with respect to the clustering of healthy behaviors with supplement use were identified in a number of studies as described above.

Although this study found that there was a relation between supplement use and a number of cardiovascular disease risk factors, it is not possible to say whether this relation is causal. Consistent with our results, in a randomized controlled trial, Church et al. (47) found that daily multivitamin use significantly decreased C-reactive protein concentrations, which are a risk factor for cardiovascular disease. Greger et al. (11) suggested that the relation between supplement use and disease is complex and can depend on whether supplement use in generic terms is investigated or whether specific types of supplements are investigated. However, many studies will not have the capability to investigate specific supplements due to complexities in measurement and limitations related to sample size and power. The relation between supplement use and disease may also be affected by other factors. For example, in women diagnosed with breast cancer, supplement use varied according to the time since diagnosis (11).

An understanding of the relations between lifestyle behaviors and risk factors is also important from a public health policy perspective. Investigation into the clustering of these factors and potential gender differences can help to identify high-risk groups and help develop effective health promotion programs because the risk of disease associated with multiple risk factors may be higher than that associated with individual risk factors (48,49). For example, there was an interaction between smoking and alcohol consumption for cancers of the esophagus, mouth, and pharynx (50). In addition, supplement use may act as a confounder in investigations of exposure-disease relations, and interpretation of these relations will be improved by an enhanced understanding of the interrelations between these factors (48).

In the current study, supplement users tended to differ from nonsupplement users for a range of health-related behaviors and health-status characteristics, although there were fewer significant associations in men. Users of dietary supplements tend to have dietary intakes that are healthier. Those taking supplements appear to be the least likely to need them. These results support the notion of a clustering of healthy behaviors and risk factors, particularly for women, and may help to inform public health programs.


   ACKNOWLEDGMENTS
 
We are grateful to Donna Thomas for data entry, to Mick Tumilty for preparation and supervision of dietary coding frameworks, to Anna Gent for data entry and development of the dietary supplements database, and to Mark Conner and Warren Hilder at the MRC National Survey of Health and Development for data collation.


   FOOTNOTES
 
1 Presented in part at the UK Nutrition Society Summer Meeting "Obesity: Taking Theory into Practice," July 2004, Trinity College, Dublin, Ireland [Doherty, S. J., McNaughton, S. A., Paul, A. A. & Wadsworth, M.E.J. (2004) Health-related characteristics and behaviours of dietary supplement users at age 53 years in the 1946 British Birth Cohort. Proc. Nutr. Soc. 63: 123A]. Back

2 Supported by funding from the Medical Research Council (UK). Back

3 Supplemental Table 1 is available as Online Supporting Material with the online posting of this paper at www.nutrition.org. Back

Manuscript received 7 January 2005. Initial review completed 17 February 2005. Revision accepted 27 April 2005.


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 DISCUSSION
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