Dietary supplementation by older adults in southern China: a hospital outpatient clinic study
© Liang et al; licensee BioMed Central Ltd. 2009
Received: 25 June 2009
Accepted: 20 October 2009
Published: 20 October 2009
There has been little knowledge about dietary supplementation by the Chinese elderly. The aim of this cross-sectional study was to investigate the usage of dietary supplements by older adults in southern China.
A total of 600 community-dwelling older adults were recruited from the outpatient clinics of three major hospitals in Foshan city between July 2007 and July 2008. Face-to-face interviews of participants were conducted to obtain information on demographics, lifestyle and dietary supplements use. Frequency and duration of usage were recorded for six categories of dietary supplements.
Among the 446 consented participants (241 men and 205 women) who were over 55 years of age, 19.1% consumed one or more types of dietary supplements. The prevalence of usage was significantly higher (p = 0.008) for females (24.4%) than for males (14.5%). Dietary supplements were more likely to be consumed by non-smokers (p = 0.021) and those with hyperlipidemia (p = 0.003). The most popular supplement among users was calcium (53%). The majority (71%) of the users consumed supplements on a regular basis at one or more times per day, with an average duration of 2.95 (SD 4.80) years.
The overall prevalence of dietary supplementation in this older Chinese population was considerably lower than those in other Asia-Pacific countries.
Dietary supplements, especially multivitamins and mineral supplements, have been widely consumed in many developed countries even though their effectiveness is unclear [1–3]. A randomized controlled trial suggested that regular intake of multivitamin and multi-mineral supplements may reduce infection among patients with diabetes . The protective effect of multivitamin supplements intake against the progression of HIV was also observed in a randomized controlled trial . However, a meta-analysis of five randomized control trials found no significant beneficial effect of multivitamin and multi-mineral supplements . In another study that investigated the pooled data from eight prospective studies, no association was evident between the lung cancer risk and the use of folate, vitamins A, C, E, and multivitamins . On the contrary, a meta-analysis of 19 trials concluded that high-dosage of vitamin E supplements could actually lead to an increased mortality . In spite of these and other contradictory evidence, use of dietary supplements remains popular in Western populations.
The Chinese economy has been growing rapidly over the past 20 years . Various types of dietary supplements are now readily available in the Chinese market. It is unclear whether the use of dietary supplements affects the health of the Chinese adults. There have been little details documenting their usage of dietary supplements in the literature. Therefore, the objective of the present study was to ascertain the prevalence and types of dietary supplements used by older adults in southern China. The focus was on the usage of tablet and capsule forms of dietary supplements, whereas traditional Chinese medicines, herbals and botanicals were not investigated.
The findings would be important for monitoring the consumption trends in relation to disease prevention and in comparison with other Asia-Pacific countries.
Study design and participants
A cross-sectional study was conducted between July 2007 and July 2008 in Foshan city located in the Guangdong Province of southern China. A total of 600 community-dwelling older adults were initially recruited from the outpatient clinics of three major hospitals, namely, the First People's Hospital of Shunde, First People's Hospital of Nanhai, and Second People's Hospital of Foshan. These three hospitals were similar in size and types of medical treatments provided. Subjects from the clinics of the Departments of Gastroenterology, Dermatology, Chinese Medicine, Urology and Otolaryngology were approached at random while they were waiting for medical service. To be eligible, subjects must be 55 years of age or over and have resided in Foshan for at least the past five years. Those subjects with a diagnosis of Alzheimer's disease or had been on long-term modification of diet for medical reasons were excluded. Long term dietary modification for medical reasons refers to people who stopped eating certain foods for reasons that include allergy, chemotherapy treatment of cancer, and surgery of the digestive system. Of the 512 subjects who signed the consent form and agreed to take part, 446 participants (241 men and 205 women) completed the interview and were available for analysis, representing a final response rate of 74.3%. No significant differences in mean age and gender distributions were found between participants and those who declined or subsequently withdrew from the study.
Interview and questionnaire
The study protocol was approved by the participating hospitals and the Human Research Ethics Committee of the researchers' institution. All participants were assured confidentiality and their right to withdraw without prejudice before obtaining their formal consent. Face-to-face interviews of participants were conducted by the first author at the outpatient clinics.
A structured questionnaire was administered to obtain demographic and lifestyle characteristics including age, gender, weight (kg), height (m), education level (primary school; secondary school or above), occupation before retirement (professional; others), smoking status (non-smoker; smoker), and alcohol drinking status (non-drinker; drinker). Self-reported height and weight measurements and health conditions such as the presence of hypertension, hyperlipidemia and diabetes were confirmed with medical records whenever available; see Additional File 1.
Participants were asked whether they had used dietary supplements over the last year. Information on the frequency and duration of usage was then recorded for six categories of common dietary supplements, namely, multivitamins and minerals, vitamin C, vitamin E, fish oil, calcium, and miscellaneous (such as vitamin A, garlic, ganoderma lucidum, propolis, cordyceps, ginseng and panax notoginseng).
Descriptive statistics and chi-square tests were performed to summarise and compare characteristics between dietary supplement users and non-users. The prevalence of dietary supplementation by gender was tabulated, as well as the frequency and duration of usage for each category of supplements among users. Logistic regression analysis was conducted to examine whether the reported chronic conditions would affect the usage of dietary supplements. All statistical analyses were undertaken using the SPSS for Windows package version 13.
Characteristics of participants by dietary supplementation status
Non-user (n = 361)
User (n = 85)
Body mass index (kg/m2)
Secondary school or above
Occupation before retirement
Smoking status *
Alcohol drinking status
Presence of hyperlipidemia *
Presence of hypertension
Presence of diabetes
Prevalence, frequency and duration of dietary supplements intake by users (n = 85)
(n = 35)
(n = 50)
(n = 85)
Prevalence of daily use
Mean duration (SD) in months
Multivitamins and minerals
Prevalence of dietary supplementation by older adults in the Asia-Pacific region
New Zealand 
Calcium was found to be the most popular supplement among our study participants. Dietary calcium intake by Chinese has been estimated to be lower than Western populations  at 430 mg/day, while the average consumption of milk is only 4 g/day . The low consumption of dairy products is partly due to their intolerance to lactose . The presence of hyperlipidemia was found to be associated with dietary supplement usage. The literature has suggested that insufficient calcium intake can increase the risk of cardiovascular diseases [20, 21]. Intake of calcium supplements could also improve bone health and reduce the risk of osteoporosis for Chinese elderly .
In this study, information on dietary supplementation was obtained from self report. As with other surveys of elderly subjects, the responses from our participants inevitably incurred some recall error. Therefore, face-to-face interviews were used to increase the response rate and to improve the accuracy of their answers. All interviews were conducted by the first author to eliminate inter-interviewer bias.
A limitation of our study was the lack of qualitative data on the perception and belief behind dietary supplement use due to time constraints. We recommend this to be the topic of a further study. Another limitation concerned the selection bias of our convenience sample. Subjects were approached at random while waiting for medical service. We recruited these voluntary participants from hospital outpatient departments rather than community health clinics because the majority of urban Chinese people seek medical service from major hospitals . Currently, there is no medical referral system in China and the quality of service provided by community clinics is low . It is not uncommon for a person to seek medical advice from a hospital specialist, such as a cardiologist for influenza or other minor symptoms. Consequently, the place of interview for each individual was not recorded. Moreover, community-based randomised sampling would be difficult to implement with high refusal rate expected in practice.
The prevalence of dietary supplements usage by older Chinese adults was considerably lower than those in other Asia-Pacific countries. Nevertheless, almost 20% took supplements within the past year and 71% of users did so on a regular basis. This study provided useful baseline data for comparison with future surveys to monitor the consumption trends in southern China.
- Rock CL: Multivitamin-multimineral supplements: who uses them?. Am J Clin Nutr. 2007, 85 (1): 277S-279S.PubMedGoogle Scholar
- Messerer M, Johansson SE, Wolk A: Sociodemographic and health behaviour factors among dietary supplement and natural remedy users. Eur J Clin Nutr. 2001, 55 (12): 1104-1110. 10.1038/sj.ejcn.1601272.View ArticlePubMedGoogle Scholar
- de Jong N, Ocke MC, Branderhorst HA, Friele R: Demographic and lifestyle characteristics of functional food consumers and dietary supplement users. Br J Nutr. 2003, 89 (2): 273-281. 10.1079/BJN2002772.View ArticlePubMedGoogle Scholar
- Barringer TA, Kirk JK, Santaniello AC, Foley KL, Michielutte R: Effect of a multivitamin and mineral supplement on infection and quality of life. A randomized, double-blind, placebo-controlled trial. Ann Intern Med. 2003, 138 (5): 365-371.View ArticlePubMedGoogle Scholar
- Fawzi WW, Msamanga GI, Spiegelman D, Wei R, Kapiga S, Villamor E, Mwakagile D, Mugusi F, Hertzmark E, Essex M: A randomized trial of multivitamin supplements and HIV disease progression and mortality. N Engl J Med. 2004, 351 (1): 23-32. 10.1056/NEJMoa040541.View ArticlePubMedGoogle Scholar
- Huang HY, Caballero B, Chang S, Alberg AJ, Semba RD, Schneyer CR, Wilson RF, Cheng TY, Vassy J, Prokopowicz G: The efficacy and safety of multivitamin and mineral supplement use to prevent cancer and chronic disease in adults: a systematic review for a National Institutes of Health state-of-the-science conference. Ann Intern Med. 2006, 145 (5): 372-385.View ArticlePubMedGoogle Scholar
- Cho E, Hunter DJ, Spiegelman D, Albanes D, Beeson WL, Brandt van den PA, Colditz GA, Feskanich D, Folsom AR, Fraser GE: Intakes of vitamins A, C and E and folate and multivitamins and lung cancer: a pooled analysis of 8 prospective studies. Int J Cancer. 2006, 118 (4): 970-978. 10.1002/ijc.21441.View ArticlePubMedGoogle Scholar
- Miller ER, Pastor-Barriuso R, Dalal D, Riemersma RA, Appel LJ, Guallar E: Meta-analysis: high-dosage vitamin E supplementation may increase all-cause mortality. Ann Intern Med. 2005, 142 (1): 37-46.View ArticlePubMedGoogle Scholar
- Chow GC, Li K-W: China's Economic Growth: 1952-2010. Economic Development and Cultural Change. 2002, 51 (1): 247-256. 10.1086/344158.View ArticleGoogle Scholar
- Chen SY, Lin JR, Kao MD, Hang CM: The usage of dietary supplements among the elderly individuals in Taiwan. Asia Pac J Clin Nutr. 2005, 14 (3): 230-237.PubMedGoogle Scholar
- Hirayama F, Lee AH, Binns CW, Watanabe F, Ogawa T: Dietary supplementation by older adults in Japan. Asia Pac J Clin Nutr. 2008, 17 (2): 280-284.PubMedGoogle Scholar
- Brownie S, Rolfe M: Health characteristics of older Australian dietary supplement users compared to non-supplement users. Asia Pac J Clin Nutr. 2004, 13 (4): 365-371.PubMedGoogle Scholar
- NZ Food: NZ People: Key results of the 1997 National Nutrition Survey. [http://www.moh.govt.nz/moh.nsf/0/8F1DBEB1E0E1C70C4C2567D80009B770]
- Andrade Juguan J, Lukito W, Schultink W: Thiamine deficiency is prevalent in a selected group of urban Indonesian elderly people. J Nutr. 1999, 129 (2): 366-371.PubMedGoogle Scholar
- Kim J, Lee M, Cheong S, Lee J, Kim H, Lee J: A study on supplements use in the middle-aged and elderly. Korean Journal of Community Nutrition. 2001, 6 (5): 798-808.Google Scholar
- Ghazali E, Mutum D, Lee LL: Dietary supplement users vs non-users In Malaysia: profile comparisons for marketing purposes. AGBA 3rd World Congress, Advances in Global Business Research: 2006; Kula Lumpur. 2006, 43-54.Google Scholar
- Woo J, Leung SS, Ho SC, Lam TH, Janus ED: Dietary intake and practices in the Hong Kong Chinese population. J Epidemiol Community Health. 1998, 52 (10): 631-637. 10.1136/jech.52.10.631.View ArticlePubMedPubMed CentralGoogle Scholar
- Zhai F, Wang H, Du S, He Y, Wang Z, Ge K, Popkin BM: Lifespan nutrition and changing socio-economic conditions in China. Asia Pac J Clin Nutr. 2007, 16 (S1): 374-382.PubMedGoogle Scholar
- Jackson KA, Savaiano DA: Lactose maldigestion, calcium intake and osteoporosis in African-, Asian-, and Hispanic-Americans. J Am Coll Nutr. 2001, 20 (2 Suppl): 198S-207S.View ArticlePubMedGoogle Scholar
- Jorde R, Sundsfjord J, Haug E, Bonaa KH: Relation between low calcium intake, parathyroid hormone, and blood pressure. Hypertension. 2000, 35 (5): 1154-1159.View ArticlePubMedGoogle Scholar
- Umesawa M, Iso H, Ishihara J, Saito I, Kokubo Y, Inoue M, Tsugane S: Dietary calcium intake and risks of stroke, its subtypes, and coronary heart disease in Japanese: The JPHC Study Cohort I. Stroke. 2008, 39 (9): 2449-2456. 10.1161/STROKEAHA.107.512236.View ArticlePubMedGoogle Scholar
- Eggleston K, Yip W: Hospital competition under regulated prices: application to urban health sector reforms in China. Int J Health Care Finance Econ. 2004, 4 (4): 343-368. 10.1023/B:IHFE.0000043762.33274.4f.View ArticlePubMedGoogle Scholar
- Liang W, Binns CW, Lee AH: Computerised clinical decision support in rural China. Lancet. 2009, 373 (9657): 30-10.1016/S0140-6736(08)61955-8.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6882/9/39/prepub
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.