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CHP6 Results *UPGRADED VERSION*. By Data Sub-group. Pilot Study. Uneligible 1. Fully completed 28. Participated 30. Doors answered 96. Partially completed 2. Rejected 49. Total doors knocked 184. Uncontactable 16. Uncontactable 88. Fieldwork. Uneligible 119.

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pilot study
Pilot Study

Uneligible

1

Fully completed

28

Participated

30

Doors answered

96

Partially completed

2

Rejected

49

Total doors knocked

184

Uncontactable

16

Uncontactable

88

fieldwork
Fieldwork

Uneligible

119

Fully completed

682

Participated

687

Doors answered

1559

Partially completed

5

Rejected

668

Total doors knocked

2046

Uncontactable

85

Uncontactable

487

demographics of study sample
Demographics of study sample

Is our sample representative of the population?

prevalence of the usage of dietary supplements in singaporean adults
Prevalence of the usage of dietary supplements in Singaporean adults

(“use” and “dietary supplements” as defined by Lit Review)

no of different supplements used
No. of different supplements used
  • n: 382
  • Median: 2
  • Inter-quartile range: 1 – 4
average length of use
Average length of use
  • n: 380
  • Median:3 yrs
  • Inter-quartile range:1 yr 3 mnths – 6 yrs 3 mnths
longest length of use
Longest length of use
  • n: 380
  • Median:4 yrs 6 mnths
  • Inter-quartile range: 2 yrs – 10 yrs
spending on supplements per year
Spending on supplements per year
  • n: 348
  • Median:$200
  • Inter-quartile range:$100 – $600
what lit review tells us
What Lit Review tells us
  • Factors established to have positive association with the use of dietary supplements
    • Female gender
    • High education level
    • High socio-economic status
    • Alcohol drinking
    • High physical activity
    • Non-obese / low BMI
    • Concern with healthy diet, vegetarians
    • Stressful lifestyle
    • Presence of a medical condition, medication use
    • Positive view of the potential health benefits of using supplements
what lit review tells us1
What Lit Review tells us
  • Factors with contradictory reports on association with the use of dietary supplements
    • Age
    • Smoking
    • Self-perceived health status
statistical tests used
Statistical tests used
  • To evaluate relationship between 2 qualitative variables
    • Chi-square test
      • Pearson chi-square & Fisher’s exact test for p values
      • Linear-by-linear association for trend
  • To evaluate relationship between a quantitative and a qualitative variable
    • Independent samples t-test & One-way analysis of variance (ANOVA)
      • For t-test, equal variances assumed or unassumed is used depending on p value from Levene’s test
    • Log transformation using ln (is done first if continuous variable is not normally distributed)
      • Results presented after re-conversion back to geometric mean & relative mean difference
ethnic group
Ethnic group
  • Ethnic group is not a significant factor affecting the use of dietary supplements in general
  • It becomes significant only when we stratify by specific supplement use
confounding
Confounding
  • We suspect gender to be a confounder for smoking status

Smoking status

Gender

Use of supplement

confounding2
Confounding
  • After stratification by gender, using the Mantel-Haenszel ratio calculation, the adjusted PRR for smoking is 0.860, which is 12.3% different from the crude ratio of 0.766.
  • Since this difference is >10%, it could be significant.
  • Thus, gender is a potential confounder for smoking with regards to its effects on the use of supplements.
  • It could be investigated further by using multi-variate analysis.
overview of characteristics relation to use of supplement
Overview of characteristics & relation to use of supplement
  • Significantly related & shown in this ppt
    • Gender
    • Ethnic group
    • Education level
    • Household income
    • Smoking status
    • Physical activity
    • View that diet is sufficient
    • Presence of chronic disease
    • Diagnosed with Arthritis & Osteoporosis
    • View that supplements are effective
    • View that supplements have scientific evidence
    • View that supplements can have harmful side effects

Green – shown by Lit Review to be positively related

Yellow – inconclusive evidence from Lit Review

overview of characteristics relation to use of supplement1
Overview of characteristics & relation to use of supplement
  • Not significantly related, but still shown in this ppt
    • Age
    • Body mass index
    • Healthy diet (fruits / vegetables) **to be confirmed again

Green – shown by Lit Review to be positively related

Yellow – inconclusive evidence from Lit Review

overview of characteristics relation to use of supplement2
Overview of characteristics & relation to use of supplement
  • Not significantly related & not shown in this ppt at all
    • Marital status
    • Occupational status
    • Alcohol intake
    • Pack-years of smoking
    • Months since quit smoking
    • Dietary restriction
    • Diagnosed with other specific chronic disease
    • Pregnancy
    • Self-perceived health status
    • Stress in lifestyle
    • Adequacy of sleep

Green – shown by Lit Review to be positively related

Yellow – inconclusive evidence from Lit Review

profile of a typical supplement user
Profile of a typical supplement user
  • Female
  • Has up to secondary or tertiary level education
  • Has high household income per year
  • Is a non-smoker
  • Exercises at least once a week
  • Views that diet does not provide sufficient nutrients
  • Is diagnosed with chronic disease(s), particularly Arthritis and Osteoporosis
  • Views that supplements are effective in improving health and that there is scientific evidence for their use
a look at calcium in detail
A look at Calcium in detail

The top of the list supplement

what lit review tells us2
What Lit Review tells us
  • The motivations for taking supplements can be varied and include ensuring nutritional adequacy, reducing one’s risk for certain diseases and age-related changes, and enhancing physical performance.
  • Women are more likely to be using supplements to promote weight loss, burn-up fat, prevent colds, improve memory, and relieve stress; whereas men are more likely to use supplements to enhance athletic performance, retard the onset of aging, build muscle, and improve sexual function.
reason s stratified by age group
Reason(s) stratified by age group

p = 0.255

p = 0.136

p = 0.000

p = 0.011

p = 0.137

p = 0.000

p = 0.018

p = 0.389

p = 0.086

n = 846

slide61

Is there an association between particular supplements and special reasons for taking them?

  • (Reasons stratified by supplement)
for cosmetic purpose
For cosmetic purpose

p = 0.002

p = 0.000

p = 0.013

p = 0.117

to compensate for deficiencies in diet
To compensate for deficiencies in diet

p = 0.049

p = 0.075

p = 0.049

p = 0.000

what lit review tells us3
What Lit Review tells us
  • The relative ease with which individuals can access information on an extensive number of topics (eg. via the Internet) has increased interest in the use of dietary supplements.
source s of information stratified by age group
Source(s) of information stratified by age group

p = 0.289

p = 0.671

p = 0.011

p = 0.019

p = 0.002

p = 0.210

n = 648

stratified by supplement traditional medicine practitioner
Stratified by supplement – Traditional Medicine practitioner

p = 0.011

p = 0.007

p = 0.002

p = 0.003

p = 0.290

questionable sources of information
Questionable sources of information?
  • Among all users who strongly agree or agree that supplements can have harmful side effects (163),
    • 46.6% (76) obtain information about supplements from friends & family and/or advertisements only (and no other sources)
  • Among all users who strongly agree or agree that supplements have scientific evidence for use (251),
    • 45.8% (115) obtain information about supplements from friends & family and/or advertisements only (and no other sources)
what lit review tells us4
What Lit Review tells us
  • Women and those with higher education are more likely to use supplements based on evidence-based indications.
drug supplement interactions
Drug-supplement interactions
  • Among those with at least 1 chronic disease diagnosed (310),
    • 26.1% (81) are on medication(s) only
    • 18.1% (56) are on supplement(s) only
    • 41.6% (129) are on both medication(s) and supplement(s)
    • 14.2% (44) are on neither

presence of chronic disease

supplement

medication

56

129

81

44

n = 310

drug supplement interactions1
Drug-supplement interactions
  • 32.5% of all supplement users are on regular medication(s) for chronic disease(s)
    • 88.6% of all those on regular medication(s) for chronic disease(s) use at least 1 supplement
  • Among supplement users on medication(s) for chronic disease(s),
    • 23.0% know about the possible drug-supplement interaction(s)
    • 49.6% have discussed the usage of supplement(s) with their doctor
    • 23.4% have discussed the usage of supplement(s) with their doctor AND none of the supplements used were prescribed by a doctor
example
Example
  • Aspirin-Gingko increases risk of bleeding (as cited in the article by Dima M. Qato et al.)
  • From our study,
    • 9.5% of those on regular medications for Heart disease (likely to be on Aspirin) are also using Gingko extracts
      • 10.0% of those using Gingko extracts are on regular medications for Heart disease
    • Among all Gingko users on medication(s) for chronic disease(s),
      • 16.7% are aware of the possible drug-supplement interactions
      • 50.0% have discussed the usage of supplement with their doctor
summary of important findings
Summary of important findings
  • 55.6% of the Singaporean adult population use dietary supplements.
  • Calcium is the most widely used dietary supplement.
  • 14.2% of all supplement uses are prescribed by a Western doctor.
  • Half of the population spend between $100 – $600 on dietary supplements per year.
  • The most common reasons for taking dietary supplements are to improve general health and to prevent disease.
  • Reasons for use change depending on age, gender and supplement used.
summary of important findings1
Summary of important findings
  • People mostly get their information about dietary supplements from family & friends and advertisements.
  • The most important reasons keeping people from using dietary supplements are that they are unnecessary and too expensive.
  • Knowledge of the scientific evidence of dietary supplements increases their perceived effectiveness.
  • There exists drug-supplement interactions which people are largely not aware of.
  • About half of those on regular medication(s) and also using supplements have not discussed the issue of supplement usage with their doctors.
summary of important findings2
Summary of important findings
  • The use of dietary supplements is associated with female gender, high education level, high socioeconomic status, non-smoker, physical activity, presence of a chronic medical condition (especially Arthritis or Osteoporosis), positive opinion of supplements and the view that one’s diet is insufficient.
  • Chinese are more likely to use Bird’s Nest, Cordyceps, Echinacea and Berry extracts.
  • Knowledge of the harmful side effects of dietary supplements do not seem to matter.
  • Use of dietary supplements is unrelated to age, alcohol drinking, obesity, self-perceived health status or stress levels.
thank you

Thank you

Questions? Suggestions?

prepared answers
“Prepared answers”
  • Q.In the questionnaire, people taking Combined vitamins & minerals or Multi-minerals could have also responded yes to taking Calcium, causing the prevalence to be falsely high?
  • A. Out of 112 who responded yes to taking (single) Calcium, only 18 (16.1%) also responded yes to taking Combined vitamins & minerals and/or Multi-minerals.
    • The remaining 94 (83.9%) form the majority who responded yes to taking (single) Calcium only
prepared answers1
“Prepared answers”
  • Q. Since response rate is only 50.7%, what about refusal bias?
  • A.Out of 668 units which rejected us, we managed to capture simple demographic data (gender, ethnicity & age) for 127 units (19.0%)
  • See next 2 slides for comparison graphs.
gender ethnic group
Gender & Ethnic group

p = 0.165

p = 0.061

estimated age
Estimated age

p = 0.002

prepared answers2
“Prepared answers”
  • Q. Can you give other examples of significant drug-supplement interactions besides Aspirin-Gingko?
  • A. (Summary of Lit Review team’s research) In clinical practice, polypharmacy is common, and to the mixture physicians prescribe, patients add various over-the-counter medications, vitamins, herbs, and foods.
  • For example, Warfarin is known to interact with Garlic, Gingko, Glucosamine, Omega fatty acids / Fish oil & Vitamin E. The consequence is prolonged INR and increased risk of bleeding. Intracerebral haemorrhage, subdural haematoma and spontaneous hyphema are possible.
  • As a precaution, patients on Warfarin should have INR measured within a week of starting any supplement.
  • Patients may not be forthcoming about the use of supplements, even if it causes severe adverse effects, because they fear censure.