Use of Herbal/Natural Supplements According to Racial/Ethnic Group

THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINEVolume 12, Number 6, 2006, pp. 555–561© Mary Ann Liebert, Inc.

Use of Herbal/Natural Supplements According to Racial/Ethnic Group

JUDITH PARSELLS KELLY, M.S., DAVID W. KAUFMAN, Sc.D., KATHERINE KELLEY, B.S.Pharm.,LYNN ROSENBERG, Sc.D., and ALLEN A. MITCHELL, M.D.

ABSTRACT

Objectives: The aim of this paper was to determine similarities and differences in the use of herbal/naturalsupplements among various racial/ethnic groups.

Design: A random-digit dial (RDD) telephone survey of medication use during the week before the inter-view was used.

Settings/Location: Households in the 48 contiguous United States comprised our study.Subjects: One (1) subject was selected by a random procedure from each contacted household, including in-

terviews conducted from 1998 through September 2004. There were 13,436 subjects at least 18 years of age,including 10,372 non-Hispanic whites, 1174 African Americans, 1109 Hispanics, 335 Asian/Pacific Islanders,and 446 others.

Outcome Measures: Use of any herbal/natural product during the prior week served as outcome measures.Prevalence of use was weighted according to household size; for comparisons among the three largest groups,estimates were also adjusted for age, gender, and education.

Results: The overall prevalence was lowest in African Americans (9.5%; 95% confidence interval [CI],7.8%–11%), intermediate in Hispanics (12%; 10%–14%), and highest in non-Hispanic whites (19%; 18%–20%).Use was higher among women and generally higher for subjects 45–64 years of age, regardless of race/ethnicity;use increased with increasing years of education. The most commonly taken individual herbal/natural substanceswere similar among the groups. Hispanics used the largest number of products. Distribution of product type dif-fered somewhat, with Hispanics taking more monopreparations and herbal mixtures than the other groups, andherbal mixture use particularly uncommon among African Americans. Use between 1998 and 2004 increased slightlyfor non-Hispanic whites, increased then declined for African Americans, and did not change for Hispanics.

Conclusions: Based on nationally representative U.S. data, these results provide a comparative picture ofcontemporary use of herbal/natural supplements in the largest racial/ethnic groups in the United States. Theprevalence of use was lowest among African Americans, with a possible decline in recent years, whereas His-panics take the greatest number of products.

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INTRODUCTION

Herbal and other natural products are taken by approxi-mately 1 in 5 U.S. adults,1 but use may vary within

population groups owing to cultural and socioeconomic dif-ferences. To learn more about use of these products amongracial/ethnic groups, we analyzed data from a U.S. popula-tion-based telephone survey ongoing since 1998.

MATERIALS AND METHODS

The Slone Survey collects detailed information on the useof all medications, including prescription and over-the-counter drugs, vitamins, and herbal and other natural sup-plements. The methods have been described in detail.2

Briefly, residents of households with telephones in the 48contiguous United States and District of Columbia are en-

Slone Epidemiology Center, Boston University School of Public Health, Boston, MA.

rolled using a list-assisted random-digit dialing (RDD) pro-cedure. One (1) individual in each identified household isselected for interview by a computer-generated, random-number procedure. Specially trained interviewers employedby the Slone Epidemiology Center administer the survey.

The subject is asked to report all prescription and over-the-counter medications and dietary supplements taken dur-ing the preceding 7 days, gathering the relevant containerswhenever possible. The product and brand names of thesemedications are recorded. In addition, to stimulate recall ofother drugs, a list of reasons for medication use (e.g., arthri-tis/joint pain) is read. A specific question focuses on use of“vitamins/iron/herbal preparations.”

Demographic information is also obtained. Ethnicity andrace are assessed using the 1997 Office of Management andBudget categories,3 asking first whether the subject is Span-ish/Hispanic/Latino, and then asking the person’s race (morethan one response is permitted). The survey has been ap-proved by the Institutional Review Board of Boston Uni-versity Medical Campus (Boston, MA).

Herbal/natural supplements

Medication names are coded for analysis using a dictio-nary developed and maintained by the Slone EpidemiologyCenter. The dictionary is a computerized linkage systemcomposed of individual agents and multicomponent prod-ucts, including herbal/natural supplements. The componentsof herbal/natural supplements are identified by a researchpharmacist using multiple sources, including, but not lim-ited to, the Natural Medicines Comprehensive Database,4

German Commission E Monographs,5 Botanical SafetyHandbook,6 PDR of Herbal Medicines,7 Herbs of Com-merce,8 product manufacturers, the internet, and texts onhomeopathic medications, Chinese herbals, and ayurvedicproducts. For this present study, herbal refers to plant or al-gae substances or their extracts, and natural refers to sub-stances derived from nonplant natural sources (e.g., animalorgans and marine exoskeletons) and includes amino acidsand enzymes.

Subjects

A recent comparison of Slone Survey data with U.S. Cen-sus data from 20002 revealed no major differences. Minor dif-ferences were observed for gender and annual household in-come, with the study population having a somewhat greaterproportion of female subjects (54% vs. 51%) and a smallerproportion with incomes less than $10,000 (6% versus 10%).The largest difference was observed for education level, withthe survey including fewer subjects who had not graduatedhigh school (11% versus 20% in Census 2000).

Subjects included in the analysis were adults interviewedfrom February 1998 through September 2004; there were13,436 subjects at least 18 years of age, and the overall re-sponse rate (AAPOR RR3)9 was 68%.

Data analysis

The information for ethnicity and race was combined tocreate the following mutually exclusive categories: Hispanic(any race), non-Hispanic white, African American, Asian/Pacific Islander, Native American, and other. Some recod-ing of the raw data was necessary because over 1000 sub-jects responded “something else” to the question and spec-ified another race/ethnicity. This text field was examined forresponses that could be assigned to one of the race codes(e.g., Cambodian, recoded as Asian/Pacific Islander). Somesubjects were not included in any racial/ethnic category: 225whose responses could not be assigned to a racial or ethniccode (e.g., people who were biracial, American, Jewish, etc.)and 59 who refused to provide the information.

Overall prevalence of use, number of products, type ofproduct, use over time, and use of individual herbal/naturalsupplements was examined according to racial/ethnic group.In order to provide valid and comparable results that couldbe extrapolated to the U.S. population, it was necessary toadjust the prevalence estimates. Although the Slone Surveyis a simple random sample of all households in the conti-nental U.S., only 1 individual is interviewed from eachhousehold. Because the probability of selection of individ-uals is inversely related to the number in the household, eachobservation was multiplied by a weight equal to the house-hold size. Estimates were also standardized to the overalldistribution of the study population, according to age, gen-der, and education level; the three factors can influence theuse of herbal/natural substances, and their distribution dif-fered according to racial/ethnic group. Ninety-five percent(95%) confidence intervals (CI) were calculated for theprevalence estimates.

RESULTS

Overall use of herbal/natural supplements during theweek before the interview is shown according to racial/eth-nic group in Table 1. The prevalence was lowest in AfricanAmericans (9.5%; 95% CI, 7.8%–11%), intermediate in His-panics (12%; 10%–14%), and highest in non-Hispanicwhites (19%: 18%–20%); the prevalence in Asian/PacificIslanders and Native Americans was 14% and 16%, re-spectively, with wide confidence intervals. Adjusting forage, gender, and education increased the estimates forAfrican Americans and Hispanics and decreased the esti-mate for non-Hispanic whites. Adjustment of the estimatesfor Asian/Pacific Islanders and Native Americans was notpossible owing to sparse data. Further consideration wasconfined to non-Hispanic whites, African Americans, andHispanics.

Overall use of herbal/natural supplements among thethree racial/ethnic groups is shown in Table 2, stratified bydemographic factors. The prevalence of use was generally

KELLY ET AL.556

lowest among subjects younger than 45 years of age andhighest among those ages 45–64, except for African Amer-icans, for whom the prevalence was lowest in the oldest agegroup (9.1%). The prevalence was higher among femalesthan males within each racial/ethnic group and increasedwith increasing level of education. In all categories, use waslower in African Americans than among Hispanics and non-Hispanic whites. Within each of the racial/ethnic groups,there was only minor variation in prevalence across fourU.S. regions (data not shown).

Table 3 shows the prevalence of the most commonly usedindividual herbal/natural substances within each racial/eth-

nic group. Lutein, almost exclusively ingested as a compo-nent of a multivitamin product, was the most commonly usedsubstance in each group; the prevalence ranged from 2.4%in African Americans to 5.2% in non-Hispanic whites. Ly-copene, another natural component of multivitamin prod-ucts, was also commonly used within each group. The threegroups largely took the same supplements, although theprevalence of use varied across the groups, and AfricanAmericans had the lowest estimates for each of the indi-vidual substances.

Among users of herbal/natural supplements, the numberof individual substances taken in the week before the inter-

HERBAL SUPPLEMENT USE IN RACIAL/ETHNIC GROUPS 557

TABLE 1. HERBAL/NATURAL SUPPLEMENT USE DURING THE WEEK BEFORE THE

INTERVIEW AMONG U.S. ADULTS ACCORDING TO RACIAL/ETHNIC GROUP

Percent Percent(95% confidence (95% confidence

Number of users Totala interval)b interval)c

White, non-Hispanic 2130 10,372 19 (18–20) 18 (17–19)African American 133 1174 9.5 (7.8–11) 11 (9–13)Hispanic 153 1109 12 (10–14) 15 (13–17)Asian/Pacific Islander 47 335 14 (10–18) —e

Native American 19 111 16 (9–23) —e

Otherd 51 335 17 (13–21) 20 (16–26)Total 2533 13,436 17 —

aNumber with known values for all stratification variables.bWeighted according to household size.cWeighted according to household size and adjusted for age, gender, and education.dIncludes “something else,” refused, unknown.eNot calculated owing to empty cells.

TABLE 2. HERBAL/NATURAL SUPPLEMENT USE DURING THE WEEK BEFORE THE INTERVIEW AMONG

U.S. ADULTS ACCORDING TO RACIAL/ETHNIC GROUP AND DEMOGRAPHIC FACTORS

White, non-Hispanic African American Hispanic(n � 10,372) (n � 1174) (n � 1109)

Percent Percent PercentNumber (95% confidence Number (95% confidence Number (95% confidence

Factor of users interval) of users interval) of users interval)

Total 2130 18 (17–19) 133 11 (9–13) 153 15 (13–17)Age (years)a

18–44 541 12 (11–13) 59 9.6 (7.2–12) 65 11 (9–13)45–64 943 24 (23–25) 52 13 (10–16) 64 19 (15–23)65� 646 24 (22–26) 22 9.1 (5.1–13) 24 17 (11–23)

Genderb

Male 768 15 (14–16) 43 9.4 (6.8–12) 52 13 (10–16)Female 1362 20 (19–21) 90 12 (10–14) 101 17 (14–20)

Educationc

�12 years 135 13 (11–15) 11 5.0 (1.8–8.2) 22 8.3 (5.2–11)High school graduate 602 15 (14–16) 34 7.2 (4.7–9.7) 39 14 (10–18)Some college 572 18 (17–19) 40 11 (8–14) 51 16 (12–20)College graduate 821 22 (21–23) 48 16 (12–20) 42 17 (12–22)

aWeighted according to household size and adjusted for gender and education.bWeighted according to household size and adjusted for age and education.cWeighted according to household size and adjusted for age and gender.

view ranged from 1 to 22. Among the racial/ethnic groups,as shown in Table 4, Hispanic users tended to take moreproducts: 21% took three or more, compared with 13%–14%among African Americans and non-Hispanic whites.

Subjects used herbal/natural supplements in several dif-ferent forms. Products reported by study subjects were clas-sified in the following categories: monopreparations; sim-ple combination products containing any combination ofone or two herbals, alone or with one or two vitamins (e.g.,garlic [Allium sativum]/bioflavonoid compound/ascorbicacid; glucosamine/chondroitin); and herbal mixtures (i.e.,products containing three or more herbals and not consid-ered a multivitamin, e.g., Shaklee Menopause BalanceComplex, Shaklee Corporation, Pleasanton, CA). In recentyears, herbal/natural supplements have been added to mul-tivitamin products. Thus, two additional categories of prod-uct type were considered: multivitamins that contained ei-ther one or two herbal/natural substances (e.g., Centrumwith lutein) and multivitamins containing at least three

herbal/natural substances (e.g., General Nutrition Corp.[GNC], Pittsburgh, PA, Mega Men Multivitamin). The dis-tribution of product type among users, according toracial/ethnic group, is shown in Table 5 (subjects who usedmore than one type are counted in multiple categories).Monopreparations were the most frequently taken producttype within each group, ranging from 40% in African Amer-icans to 44% in non-Hispanic whites to 53% in Hispanics.Multivitamin products containing one or two herbal/naturalsubstances were the second most common for each group.The largest proportional differences among the groups wereseen for use of herbal mixtures, with Hispanics having thehighest prevalence (23%) and African Americans the low-est (11%).

Table 6 displays the prevalence of herbal/natural supple-ment use in the three racial/ethnic groups for three time pe-riods. In order to exclude mainstream multivitamin use fromthe comparison, lutein and lycopene were not included inthe exposure definition for this table. For non-Hispanic

KELLY ET AL.558

TABLE 3. MOST COMMONLY TAKEN INDIVIDUAL HERBAL/NATURAL SUPPLEMENTS DURING THE WEEK

BEFORE THE INTERVIEW AMONG U.S. ADULTS ACCORDING TO RACIAL/ETHNIC GROUP

White,non-Hispanic African American Hispanic(n � 10,372) (n � 1174) (n � 1109)

Supplement Number Percenta Supplement Number Percenta Supplement Number Percenta

Total 2130 (18) Total 133 (11) Total 153 (15)Lutein 678 (5.2) Lutein 29 (2.4) Lutein 43 (5.1)Glucosamine 491 (3.5) Panax ginseng 19 (1.7) Garlic (Allium sativa) 23 (2.4)Lycopene 322 (2.6) Garlic 22 (1.5) Lycopene 19 (2.4)Ginseng (Panax ginseng) 266 (2.4) Lycopene 15 (1.0) Ginkgo (Ginkgo biloba) 26 (2.4)Chondroitin 318 (2.3) Echinacea 14 (1.0) Glucosamine 23 (2.3)Garlic 252 (2.1) Glucosamine 11 (1.0) Panax ginseng 22 (1.9)Ginkgo biloba 244 (2.1) Ginkgo biloba 10 (1.0) Saw palmetto (Serenoarepens) 11 (1.6)Lecithin 149 (1.4) Chondroitin 9 (0.9) Lecithin 15 (1.4)Echinacea 126 (1.3) Coenzyme Q-10 7 (0.7) Coenzyme Q-10 12 (1.3)Coenzyme Q-10 159 (1.3) Chondroitin 14 (1.3)

Ginger 12 (1.3)

aWeighted according to household size and adjusted for age, gender, and education.

TABLE 4. NUMBER OF HERBAL/NATURAL SUPPLEMENT PRODUCTS USED BY U.S. ADULTS WHO TOOK AT

LEAST ONE DURING THE WEEK BEFORE THE INTERVIEW ACCORDING TO RACIAL/ETHNIC GROUP

White, non-Hispanic African American Hispanic(n � 2130) (n � 133) (n � 153)

Number of Number Number Numberproducts of users Percenta of users Percentb of users Percenta

One 1399 (68) 98 (75) 100 (52)Two 423 (19) 18 (12) 30 (26)Three 154 (6.8) 8 (7.0) 12 (9.4)At least four 154 (6.7) 9 (5.9) 11 (12)

aWeighted according to household size and adjusted for age, gender, and education.bWeighted according to household size and adjusted for sex and education.

whites, the prevalence increased somewhat over time, from13% in 1998–2000 to 16% in 2003–2004. In contrast, amongAfrican Americans, the prevalence was lowest in the mostrecent time period (6.0%). Use over time did not vary forHispanics (11%–12% in each of the time periods).

DISCUSSION

Although several studies have reported on the use of com-plementary and alternative medicine (including chiroprac-tic, acupuncture, and other modes),10–12 there is little pub-lished information on herbal/supplement use specificallyamong racial or ethnic subgroups. Some previous studieshave been based on selected populations and do not providea national perspective on use of these supplements accord-ing to race/ethnicity.13–17 Others have reported prevalenceestimates for herbal/natural supplements combined with vi-tamins and minerals.18,19

Our exploration of nationally representative data fromthe Slone Survey reveals that the overall prevalence of useof herbal/natural supplements in the previous week islower among African Americans than in Hispanics andnon-Hispanic whites. However, there are several similar-ities in how herbal/natural products are used among thethree racial/ethnic groups. Use is greater among women

and among the middle-aged, and use increases with in-creasing years of education. Eight of the most commonlyused individual substances are shared by the three groups,including lutein, lycopene, panax ginseng, garlic, glu-cosamine, chondroitin, ginkgo (Ginkgo biloba), and coen-zyme Q-10. Thus, the low prevalence of herbal/naturalsupplement use in African Americans is not explained bythe absence of individual substances that subjects in othergroups are using, but rather by less common use of mostof the same substances.

Other noteworthy findings include the observation thatwhereas the prevalence of herbal use among Hispanics issomewhat lower than among non-Hispanic whites, use ofmultiple products is considerably more common. The preva-lence of individual substances differs somewhat accordingto racial/ethnic group. There is also variability in the typeof product taken, with monopreparations and herbal mix-tures more common in Hispanics and herbal mixtures lesscommon among African Americans. When lutein and ly-copene, herbal substances taken almost exclusively as com-ponents in mainstream multivitamins, are not considered,use between 1998 and 2004 increased slightly for non-His-panic whites, decreased for African Americans, and re-mained the same for Hispanics. The modest increase for non-Hispanic whites since 1998 contrasts with the steep increasesover time reported for the early 1990s.10


TABLE 5. TYPE OF HERBAL/NATURAL SUPPLEMENT PRODUCT USED BY U.S. ADULTS DURING

THE WEEK BEFORE THE INTERVIEW ACCORDING TO RACIAL/ETHNIC GROUP

White, non-Hispanic African American Hispanic(n � 2130) (n � 133) (n � 153)

Type of Number Number Numberproduct of users Percenta of users Percenta of users Percenta

Monopreparation 967 (44) 61 (40) 73 (53)Simple combination 439 (18) 22 (16) 28 (16)Herbal mixture 329 (16) 15 (11) 28 (23)1–2 herbal ingredients 723 (32) 36 (34) 45 (37)

(taken as a multivitamin)�3 herbal ingredients 294 (16) 26 (13) 24 (13)

(taken as a multivitamin)


TABLE 6. HERBAL/NATURAL SUPPLEMENT USE DURING THE WEEK BEFORE THE INTERVIEW

AMONG U.S. ADULTS ACCORDING TO RACIAL/ETHNIC GROUP AND YEAR OF INTERVIEW

White, non-Hispanic African American Hispanic

Year of interview Number Percenta Number Percentb Number Percenta

1998–2000 522 (13) 41 (9.4) 42 (11)2001–2002 463 (15) 38 (12) 42 (12)2003–2004 706 (16) 32 (6.0) 37 (11)


To place our findings in the context of other publishedinformation, we examined the results of other large, nation-ally representative surveys. The U.S. National Health Inter-view Survey20 for the year 2000 obtained information onherbal supplement use in the previous 12 months: The preva-lence was 10.7% in non-Hispanic blacks compared to 16.9%in non-Hispanic whites. Differences in both the exposuredefinition and interval make direct comparisons with SloneSurvey data difficult. However, the data are consistent withour finding of lower use among African Americans. The2002 U.S. National Health Interview Survey11 obtained dataon use of nonvitamin, nonmineral, natural products but hasnot reported findings according to race.

Another large, cross-sectional study that is representativeof the U.S. population is the National Health and NutritionExamination Survey (NHANES). NHANES III, with datafrom 1988 to 1994, obtained information on vitamin andmineral supplement use during the month before the inter-view. Some respondents volunteered information on use ofherbal/natural supplements, although they were not inquiredabout directly; thus, the estimates are likely to underestimatethe true prevalence. Use was highest for whites, intermedi-ate for Hispanics, and lowest for blacks.31 In contrast, theNHANES survey of 1999–2000 asked participants whetherthey had taken any vitamins, minerals, or other dietary sup-plements in the last month,19 but the data have not been re-ported specifically for herbal/natural supplement use ac-cording to race.

It is important to consider how methodological featurescould have influenced our findings. Although the Slone Sur-vey participation rate of 68% is high for a telephone survey,it leaves room for selection to have influenced the results.The data are reasonably representative of the U.S. popula-tion with regard to race and ethnicity, but the decision toparticipate in the survey could have been influenced by fac-tors associated with use of herbal/natural supplements, suchas education. Because the interview was conducted in onlytwo languages, individuals whose primary language is otherthan English or Spanish were not included. This may haveresulted in a nonrepresentative sample within someracial/ethnic categories (e.g., the exclusion of Asian/PacificIslanders who do not speak English, but it should not haveaffected African Americans, Hispanics, or non-Hispanicwhites).

We believe that the numerous prompts employed to ob-tain herbal/natural product use and the recency of the ex-posure interval (the previous 7 days) maximizes completereporting. Nonetheless, underreporting is possible forherbals ingested in certain forms, for example, herbalsbrewed as tea. Last, measuring race and ethnicity is inex-act, and classification systems are open to interpretation. Weassumed that we were measuring participants’ racial/ethnicidentity in the Slone Survey rather than ethnic origin, be-cause the relevant interview questions are of the form: “Doyou consider yourself . . . ”22 The survey does not include

measures of acculturation. Whereas it has been shown thatethnic background can be associated with the definition of,and attitudes toward, herbal medicines,23 it is unclearwhether racial/ethnic identity or origin is a stronger influ-ence on use of herbal/natural products.

CONCLUSIONS

Because the survey data are reasonably representative ofthe U.S. population, the present results provide a compara-tive picture of contemporary use of herbal/natural supple-ments in the largest racial/ethnic subgroups in the UnitedStates. Whereas race/ethnicity is only one of many poten-tial influences on the use of herbal/natural products, and thegroups, as defined in this paper, are probably somewhat het-erogeneous, a number of differences are apparent: Moststriking among these are the relatively low prevalence of useamong African Americans that appears to have declined inrecent years, as well as the tendency of Hispanics to takemultiple products.

ACKNOWLEDGMENTS

The authors greatly appreciate the contributions ofTheresa Anderson, study coordinator; Marie Berarducci andMarilyn Wasti, study supervisors; Gene Sun, informationsystems; and the interviewing staff. Funding for data col-lection was provided by the Slone Epidemiology Center.Data analysis was supported by National Institutes of Health[NIH] grant #R21 AT02239.

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Address reprint requests to:Judith Parsells Kelly, M.S.Slone Epidemiology Center

Boston University School of Public Health1010 Commonwealth Avenue

Boston, MA 02215

E-mail: [email protected]


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Use of Herbal/Natural Supplements According to Racial/Ethnic Group