Abstract
Background
Dietary supplement use is prevalent in the general US population, but little is known regarding the driving reasons for their use among those with atherosclerotic cardiovascular disease (ASCVD).
Methods and Results
Data from the National Health and Nutrition Examination Survey (NHANES) from 2017 to March 2020 were used to identify adults with ASCVD. Supplement use was assessed by interviewers using label review, and surveys captured self‐reported reasons for use. Demographic, clinical, medication, and laboratory characteristics were compared between supplement users and nonusers. Among individuals with ASCVD in the National Health and Nutrition Examination Survey (n=965; mean age, 65 years; 56.1% men; 73.7% White individuals), 73.1% reported taking ≥1 dietary supplements, most commonly multivitamins (35.4%), vitamin D (30.8%), and fish oil (19.8%). Of those taking supplements, 47.3% report taking them under the advisement of a health professional. Nearly one fifth (17.9%) reported taking at least 1 supplement for “heart health,” most commonly fish oil (11.1%), followed by CoQ10 (4.2%) and resveratrol (1.5%). Supplement users were older (68 versus 62 years; P=0.003), included more women (45.8% versus 37.7%; P=0.17), were less likely to smoke (11.0% versus 36.4%; P<0.001), had higher levels of education (P=0.005) and income (P<0.001), and higher use of statins (69.4% versus 55.8%; P=0.046).
Conclusions
Supplement use is common in people with ASCVD. Among the top 3 supplements, a substantial minority were being taken under the direction of health professionals. Supplement users often report taking supplements “for heart health,” despite a lack of randomized trial evidence for benefit in ASCVD, indicating a need for more patient and clinician education regarding health benefits of dietary supplements in ASCVD.
Keywords: atherosclerotic cardiovascular disease, dietary supplements, fish oils, vitamins
Subject Categories: Diet and Nutrition, Cardiovascular Disease
Nonstandard Abbreviations and Acronyms
- GISSI‐HF
Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico ‐ Heart failure
- NHANES
National Health and Nutrition Examination Survey
- OMEMI
Omega‐3 Fatty Acids in Elderly With Myocardial Infarction
- Q‐SYMBIO
Coenzyme Q10 as Adjunctive Treatment of Chronic Heart Failure: A Randomised, Double‐Blind, Multicentre Trial with Focus on Symptoms, Biomarker Status, and Long‐Term Outcomes
- REDUCE‐IT
Reduction of Cardiovascular Events With Icosapent Ethyl–Intervention Trial
- STRENGTH
Long‐Term Outcomes Study to Assess Statin Residual Risk With Epanova in High Cardiovascular Risk Patients With Hypertriglyceridemia
Clinical Perspective.
What Is New?
Between 2017 and 2020, 7 in 10 people with atherosclerotic cardiovascular disease reported taking a dietary supplement, most commonly multivitamins, vitamin D, and fish oil, and nearly 1 in 5 took a supplement “for heart health.”
Almost half of individuals reported taking dietary supplements under the advisement of a health professional.
What Are the Clinical Implications?
Clinicians caring for patients with atherosclerotic cardiovascular disease should educate patients regarding lack of known benefit in atherosclerotic cardiovascular disease.
Nutritional supplements contribute to polypharmacy in patients with atherosclerotic cardiovascular disease.
Future randomized clinical trials are necessary to determine the safety and efficacy of dietary supplements.
The use of dietary supplements is increasing nationally in the United States. Among all US adults, dietary supplement use increased from 48.4% to 56.1% from 2007 to 2008 through 2017 to 2018. 1 The most common supplements used in the United States are multivitamins, vitamin D, and fish oil/omega‐3 fatty acids. 1 , 2 While supplement users most often take supplements to “improve/maintain overall health,” “heart health” is a leading reason for supplement use. 3
Despite widespread use of supplements for “heart health,” the evidence supporting dietary supplements for preventing atherosclerotic cardiovascular disease (ASCVD) or improving cardiovascular outcomes in established ASCVD is quite limited. Large randomized clinical trials of multivitamins, vitamin D, and fish oil supplements have all failed to show benefits to prevent ASCVD. 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 Reflecting this lack of evidence, guidelines for management of patients with ASCVD including chronic coronary heart disease or prior stroke do not include any recommendations for dietary supplements. 12 , 13
To date, relatively little is known about contemporary patterns of supplement use in people with ASCVD or reasons for their use. To address this, we used data from the National Health and Nutrition Examination Survey (NHANES) to (1) describe contemporary overall use of dietary supplements in patients with ASCVD, (2) compare characteristics of supplement users and nonusers, and (3) assess the individuals' reasons for their use of supplements.
Methods
Database Description and Data Collection
Data for this study were obtained from NHANES, a multiyear, nationally representative cross‐sectional survey that uses multistage, stratified probability sampling to gather demographic, dietary, examination, laboratory, and questionnaire data to generate nationally representative estimates of adults in the United States; all NHANES data used for this analysis are publicly available and can be accessed at https://wwwn.cdc.gov/nchs/nhanes/default.aspx. 14 Given the interruption of surveying during the COVID‐19 pandemic, the 2017 to 2018 cycle was combined with partial data from the 2019 to 2020 cycle to make a robust, nationally representative sample including data from 2017 through March 2020.
NHANES participants provide informed consent to participate, and the cross‐sectional survey design is approved by the National Center for Health Statistics Ethics Review Board. This study used publicly available anonymous data from NHANES; further institutional review board review was not required.
Surveys were used to obtain self‐reported information regarding age, sex, race or ethnicity, education level, income, health insurance status, subjective general health status, smoking status, and medical comorbidities. NHANES race and ethnicity data are collected using a single question that combines race and ethnicity into mutually exclusive self‐reported categories. Income level is captured by the ratio of family income to poverty by calculating the total annual family income by the poverty guidelines specific to the survey year.
People with ASCVD were identified on the basis of a self‐reported history of coronary heart disease, myocardial infarction, or ischemic stroke on the basis of survey responses to the question: “Has a doctor or other health professional ever told you/selected person(s) (SP) that you had …” to any of the three conditions.
Survey questions were obtained on all participants, while a subset underwent further testing at the mobile examination center, half of which were fasting. Data from mobile examination center participants included body mass index; blood pressure; glycated hemoglobin; fasting glucose; and lipid testing, including low‐density lipoprotein cholesterol, high‐density lipoprotein cholesterol, triglycerides, and total cholesterol.
Medication and Supplement Data
To assess prescription medication use, individuals were asked if any prescription medication was taken in the past 30 days. If so, the medication name, the duration of medication use, and the main reason for the medication were collected. Interviewers manually viewed the medication label when possible and used the Lexicon Plus database for data collection. For this study, medications were classified by ingredient into the following categories: antihyperlipidemic drugs, statins, antidiabetic drugs, anticoagulants, antiplatelet medications, and antihypertensive medications (see Table S1).
For dietary supplements, individuals were also asked if they indicated they had taken any dietary supplement in the past 30 days and asked by the interviewer to see the supplement if available. Supplement users were asked if they took the product on their own or under the advisement of their physician. If they indicated they took the product on their own, the following question was asked: “For what reason or reasons do you take (PRODUCT NAME)?” If they indicated they took the product under doctor advisement, the following question was asked: “For what reason or reasons did the doctor or other health professional tell you to take (PRODUCT)?” Reasons for use varied from general health reasons to specific organ‐related health reasons (see Table S2). Participants could report >1 health reason for use.
We reviewed all dietary supplements in the NHANES data set manually and grouped them by name into ≥1 of 58 categories (see Table S3). Multivitamins were categorized as “multivitamin,” while other multi‐ingredient supplements were included in all relevant categories: for example, a calcium–vitamin D supplement was classified as both calcium and vitamin D.
Statistical Analysis
The percentage of people with ASCVD taking any supplement and taking each supplement for any reason and under the advisement of a doctor or other healthcare provider (HCP) was described. Then, we evaluated the percentage of adults with ASCVD taking a supplement “for heart health” overall and under the advisement of a doctor or other HCP. We also describe which reasons were cited for using multivitamins, vitamin D, and fish oil supplements, the top 3 most commonly used supplements in the data set.
Characteristics of people with ASCVD who reported taking any supplement were compared with those who did not, as well as among those who did and did not report using fish oil. T tests were used to test for differences in continuous variables and Pearson's χ2 test for categorical variables. For all analyses, NHANES analytic guidelines were followed to generate national estimates. 15 We used NHANES‐provided sample weights, which account for the complex, multistage probability‐sampling design of NHANES, including sample weights for the overall population who participated (“wtintprp”), the subsample who were seen at mobile examination centers with laboratory data (“wtmecprp”), and the fasting mobile examination center subsample (“wtsafprp”) as appropriate. 15 Data processing was performed in Excel (Microsoft, Redmond, WA), analysis was performed in STATA/SE 17.0 (StataCorp, College Station, TX), and Prism 9 (GraphPad Software, La Jolla, CA) was used to create figures.
Results
Supplement Use and Reasons for Use
Among the overall population in NHANES 2017 to March 2020, 8.6% (n=965 [95% CI, 7.4%–9.9%]) had ASCVD. Of these, 6.3% (n=60) were missing supplement use information and were excluded from subsequent analyses. Table 1 shows characteristics of the overall population of adults with ASCVD in the United States. The average age of those with ASCVD was 65 years; 43.9% were women; and 73.7% were White individuals, 10.4% Black individuals, 4.9% Other Hispanic individuals, and 3.2% Mexican American individuals.
Table 1.
Characteristics of Patients With ASCVD in NHANES Overall and Stratified by Supplement Use
| Overall ASCVD population, n=965 (8.57%) % (95% CI) | Supplement use, n=627 (73.1%) % (95% CI) | No supplement use, n=277 (26.9%) % (95% CI) | P value* | |
|---|---|---|---|---|
| Age, y | ||||
| Mean (95% CI) | 65 (63–66) | 67 (66–68) | 60 (57–64) | 0.003 |
| Age group, y | ||||
| 20–39 | 5.3 (3.3–8.2) | 3.0 (1.5–6.3) | 11.5 (5.5–22.6) | 0.003 |
| 40–59 | 24.2 (19.7–29.5) | 20.2 (15.5–25.8) | 32.0 (22.5–43.3) | |
| 60–79 | 54.7 (50.1–59.3) | 58.2 (52.9–63.4) | 46.2 (35.6–57.2) | |
| 80+ | 15.8 (13.1–18.9) | 18.5 (15.1–22.4) | 10.3 (6.5–15.9) | |
| Sex | ||||
| Male | 56.1 (49.4–62.6) | 54.2 (46.6–61.6) | 62.3 (52.4–71.2) | 0.172 |
| Race or ethnicity | ||||
| Black | 10.4 (7.3–14.6) | 8.4 (5.7–12.2) | 15.6 (9.9–23.7) | 0.021 |
| Mexican American | 3.2 (2.1–4.9) | 2.8 (1.5–5.0) | 4.5 (2.5–7.8) | |
| Multiracial | 4.9 (3.0–8.1) | 4.5 (2.4–8.2) | 5.5 (2.5–11.4) | |
| Multiracial/Other | 2.8 (1.7–4.4) | 2.9 (1.8–4.7) | 2.6 (1.1–6.0) | |
| Other Hispanic/Latinx | 4.9 (3.3–7.4) | 4.1 (2.5–6.8) | 7.0 (3.9–12.0) | |
| White | 73.7 (66.8–79.7) | 77.3 (70.1–83.2) | 64.9 (53.4–74.9) | |
| Education | ||||
| <9th grade | 5.5 (4.0–7.5) | 3.9 (2.8–5.6) | 10.1 (6.4–15.4) | 0.005 |
| 9th–11th grade | 10.9 (8.5–13.9) | 9.1 (6.4–12.8) | 16.4 (11.6–22.7) | |
| High school or equivalent | 32.7 (29.3–36.2) | 30.3 (25.1–36.0) | 39.5 (30.1–49.7) | |
| Some college or associate's degree | 30.3 (26.4–34.6) | 31.9 (27.3–36.9) | 21.1 (14.1–30.3) | |
| College graduate or above | 20.7 (15.5–27.0) | 24.8 (18.1–33.0) | 13.0 (6.8–23.6) | |
| Income | ||||
| <133% | 19.3 (15.6–23.7) | 15.5 (11.8–20.1) | 30.1 (20.7–41.5) | <0.001 |
| 133%–300% | 29.7 (25.0–35.0) | 28.4 (23.0–34.5) | 34.9 (27.3–43.3) | |
| 300%+ | 50.9 (44.3–57.5) | 56.1 (49.1–62.9) | 35.1 (24.7–47.0) | |
| Health insurance | ||||
| Private | 5.3 (3.2–8.6) | 3.9 (1.9–7.9) | 10.1 (6.5–15.5) | 0.001 |
| Medicare/Medigap | 49.9 (44.3–55.4) | 55.9 (49.2–62.3) | 36.4 (24.3–50.5) | |
| Medicaid/CHIP | 32.0 (27.1–37.3) | 28.1 (23.9–32.7) | 39.1 (28.3–51.1) | |
| Other government | 6.8 (4.3–10.4) | 4.6 (3.2–6.5) | 11.6 (5.3–23.4) | |
| None | 6.1 (4.3–8.6) | 7.6 (5.2–11.0) | 2.8 (1.2–6.4) | |
| General health status | ||||
| Excellent | 3.7 (2.4–5.5) | 4.1 (2.6–6.3) | 3.4 (1.5–7.5) | 0.287 |
| Very good | 19.8 (14.7–26.1) | 22.6 (17.3–29.0) | 15.0 (7.1–28.7) | |
| Good | 37.7 (30.9–44.9) | 37.8 (28.6–47.8) | 36.9 (26.3–49.0) | |
| Fair | 30.2 (25.1–35.8) | 28.8 (22.3–36.3) | 31.9 (23.2–41.9) | |
| Poor | 8.6 (5.7–12.8) | 6.8 (4.5–10.2) | 12.9 (6.9–22.9) | |
| Comorbidities | ||||
| Diabetes | 38.4 (32.7–40.0) | 40.3 (34.6–47.9) | 34.6 (25.8–45.5) | 0.444 |
| Hypertension | 72.1 (68.0–75.9) | 71.5 (65.6–76.8) | 71.7 (61.0–80.5) | 0.971 |
| Coronary artery disease | 49.7 (42.4–57.1) | 49.9 (41.9–57.8) | 49.6 (38.8–60.4) | 0.955 |
| Prior myocardial infarction | 43.9 (39.1–48.8) | 38.4 (32.6–44.6) | 52.1 (37.1–66.7) | 0.109 |
| Prior stroke | 44.5 (36.4–52.9) | 44.2 (35.4–53.5) | 46.2 (33.3–59.7) | 0.745 |
| Smoking | ||||
| Current | 18.8 (14.9–23.6) | 11.0 (7.7–15.5) | 36.4 (24.3–50.4) | < 0.001 |
| Former | 40.3 (33.5–47.4) | 43.1 (35.5–51.0) | 32.8 (22.4–45.3) | |
| Never | 40.9 (35.5–46.6) | 45.9 (37.3–54.8) | 30.8 (22.8–40.1) | |
| Medication use | ||||
| Any prescription drug use | 92.5 (90.3–94.3) | 95.8 (93.6–97.3) | 83.7 (77.8–88.2) | < 0.001 |
| Aspirin use | 67.8 (61.0–70.3) | 69.1 (63.1–75.3) | 59.6 (47.8–72.0) | 0.150 |
| Statin use | 64.6 (59.6–69.4) | 69.4 (62.6–75.4) | 55.8 (46.0–65.2) | 0.046 |
| Antihyperlipidemic therapy | 68.6 (63.9–73.0) | 74.8 (69.9–79.2) | 56.8 (47.0–66.1) | 0.002 |
| Antihypertension therapy | 74.8 (71.1–78.2) | 76.6 (71.8–80.9) | 72.0 (64.0–78.9) | 0.288 |
| Antidiabetic therapy | 30.7 (27.9–33.6) | 33.6 (29.4–37.9) | 24.8 (17.0–34.8) | 0.145 |
| Anticoagulation therapy | 11.1 (8.1–15.0) | 14.0 (10.0–19.2) | 5.7 (2.5–12.6) | 0.031 |
| Antiplatelet therapy | 22.6 (19.4–26.3) | 23.5 (19.9–27.6) | 22.0 (15.0–31.1) | 0.730 |
| Mobile examination center population | ||||
| N=876 (99.9%) | N=572 (74.8%) | N=247 (25.2%) | ||
| Body mass index, kg/m2 | 30.7 (30.2–31.2) | 30.6 (29.8–31.4) | 30.7 (28.7–32.8) | 0.917 |
| Blood pressure | ||||
| Systolic blood pressure, mm Hg | 131.0 (128.7–133.2) | 131.3 (128.8–133.7) | 130.8 (125.9–135.6) | 0.861 |
| Diastolic blood pressure, mm Hg | 73.7 (72.0–75.4) | 73.4 (71.7–75.0) | 74.7 (71.6–77.7) | 0.392 |
|
Glycated hemoglobin, % |
6.2 (6.1–6.3) | 6.1 (6.0–6.2) | 6.4 (6.1–6.7) | 0.059 |
| High‐density lipoprotein, mg/dL | 50.9 (48.5–53.3) | 52.1 (49.7–54.4) | 47.7 (43.7–51.8) | 0.011 |
| Total cholesterol, mg/dL | 172.3 (166.4–178.2) | 170.7 (162.1–179.3) | 173.4 (162.6–184.2) | 0.734 |
| Fasting mobile examination center population | ||||
| N=422 (45.4%) | N=267 (74.0%) | N=123 (26.0%) | ||
| Fasting glucose, mg/dL | 125.9 (117.1–134.7) | 121.6 (113.0–130.3) | 138.5 (117.9–159.2) | 0.112 |
| Low‐density lipoprotein, mg/dL | 97.2 (90.7–103.8) | 93.5 (83.7–103.3) | 103.9 (83.0–124.9) | 0.437 |
| Triglycerides, mg/dL | 124.1 (107.5–140.8) | 120.9 (103.9–137.9) | 127.0 (99.8–154.1) | 0.580 |
ASCVD indicates atherosclerotic cardiovascular disease; CHIP, Children's Health Insurance Program; and NHANES, National Health and Nutrition Examination Survey.
The P value represents the comparison between the supplement users and those not using supplements.
Of those with supplement information available, 73.1% (95% CI, 69.0%–76.8%) of people with ASCVD reported taking at least 1 supplement. Figure 1 shows the top 10 most common supplements taken by people with ASCVD for any reason and the percentage of adults with ASCVD taking each of those supplements as advised by their doctor or other HCP. The most common supplement taken overall was a multivitamin (35.4% of those with ASCVD [95% CI, 29.2%–42.2%]), followed by vitamin D (30.8% [95% CI, 25.1%–37.2%]), and fish oil (19.8% [95% CI, 15.6%–24.8%]). The most common supplement taken as advised by a doctor was vitamin D (25.6% of those with ASCVD [95% CI, 21.0%–30.9%]), followed by a multivitamin (21.7% [95% CI, 16.7%–27.6%]) and fish oil (9.4% [95% CI, 6.6%–13.4%]).
Figure 1. Supplements used among individuals with ASCVD.
This figure shows the top 10 most commonly used dietary supplements taken by people with ASCVD, the percentage of individuals with ASCVD taking each supplement, and the percentage of individuals taking each supplement on the advice of their doctor or other health care provider (HCP). “Calcium +” refers to supplements primarily containing only calcium and calcium with other minerals (ie, vitamin D, magnesium, etc). “Magnesium +” refers to supplements primarily containing magnesium and/or other minerals (ie, vitamin D, calcium, etc). ASCVD indicates atherosclerotic cardiovascular disease; and CoQ10, coenzyme Q10.
Figures S1 through S3 show the self‐reported reasons people cited for taking multivitamins, vitamin D, and fish oil, respectively. Among those taking multivitamins, the top 3 reasons cited were to improve overall health (82.3%), to supplement their diet (32.5%), and for bone health (26.9%). The top 3 reasons cited for vitamin D use were overall health (59.6%), bone health (40.0%), and supplementing diet (32.7%). For fish oil, the top 3 reasons for use were heart health (56.1%), overall health (32.3%), and eye health (5.6%).
Among those with ASCVD, 17.9% (95% CI, 14.6%–21.7%) were taking at least 1 supplement “for heart health.” Figure 2A shows the top 10 supplements taken by people with ASCVD reporting taking a supplement “for heart health.” The most commonly used supplement “for heart health” was fish oil (taken by 11.1% of those with ASCVD “for heart health” [95% CI, 8.1%–15.0%]), coenzyme Q10 (4.2% [95% CI, 2.3%–7.5%]), and resveratrol (1.5% [95% CI, 0.3%–6.9%]). Figure 2B shows the percentage of individuals taking each supplement both for heart health and because they were recommended to do so by a doctor or HCP. The majority of supplement users taking a supplement for heart health were not doing so on the advice of their physician/HCP but rather were self‐directed. Only 2.1% of people with ASCVD reported taking fish oil for heart health and under advisement by a health professional.
Figure 2. Supplements taken by people with ASCVD “for heart health” overall and as advised by health care provider.
(A) Percentage of people with ASCVD taking any supplement “for heart health,” the top 9 supplements used for this reason, and the percentage of people with ASCVD taking each supplement “for heart health.” (B) Percentage of people with ASCVD taking the top 9 supplements “for heart health” under the advisement of their physician or other health care provider. ASCVD indicates atherosclerotic cardiovascular disease and CoQ10, coenzyme Q10.
Characteristics of Supplement Users
Table 1 shows characteristics of those with ASCVD who did versus did not report supplement use. People who used supplements were typically older (mean age, 67 versus 60 years; P=0.003). Significant differences were also noted in race and ethnicity (P=0.021), with more White and fewer Hispanic and Black individuals using dietary supplements. Supplement users reported higher levels of attained education (P=0.005) and higher income (P<0.001) and were less likely to smoke (P<0.001). Overall prescription drug use was higher in supplement users (95.8% versus 83.7%; P<0.001), including statistically significantly higher use of statins (P=0.046), antihyperlipidemic agents (P=0.002), and anticoagulation agents (P=0.031) among supplement users, but no statistically significant differences in the prevalence of aspirin use, antihypertension agents, antidiabetic agents, and antiplatelet agents. No differences were seen between dietary supplement users and nonusers in body mass index, blood pressure, fasting glucose, glycated hemoglobin, low‐density lipoprotein, high‐density lipoprotein, total cholesterol, and triglyceride level. However, supplement users had higher high‐density lipoprotein cholesterol levels (52.1 versus 47.7 mg/dL; P=0.011) than those not taking any dietary supplements.
Fish oil was the most common supplement taken “for heart health.” Characteristics of people with ASCVD taking fish oil versus those not taking fish oil are presented in Table 2. Generally, similar trends were seen for fish oil users compared with nonusers as were seen for supplements overall. Those taking fish oil were older (P=0.001), included more White individuals (P=0.006), had higher education (P=0.018) and income (P<0.001) levels, and were less likely to smoke (P=0.001). Fish oil users were also more likely to take any form of prescription medication (97.6% versus 91.3%; P=0.017), including statins (P=0.014) and antihyperlipidemic therapy. No difference was seen in blood pressure, glycated hemoglobin, fasting glucose, high‐density lipoprotein cholesterol, triglycerides, or total cholesterol levels in fish oil users versus nonusers. However, fish oil users had lower low‐density lipoprotein cholesterol levels (85.1 versus 99.7 mg/dL; P=0.020) than those not taking any fish oil supplements.
Table 2.
Characteristics of Patients With ASCVD in NHANES Overall and Stratified by Fish Oil Use
| Fish oil users, N=142 (19.8%) % (95% CI) | Fish oil nonusers, N=762 (80.2%) % (95% CI) | P value | |
|---|---|---|---|
| Age continuous | |||
| Mean (95% CI) | 69 (67–71) | 64 (63–66) | 0.001 |
| Age, y | |||
| 20–39 | 1.4 (0.2–7.7) | 6.3 (3.7–10.6) | 0.087 |
| 40–59 | 15.5 (7.7–28.7) | 25.3 (19.9–31.6) | |
| 60–79 | 64.9 (55.3–73.5) | 52.5 (47.5–57.5) | |
| 80+ | 18.2 (12.4–26.0) | 15.8 (12.5–19.9) | |
| Sex | |||
| Male | 56.4 (43.2–68.8) | 56.4 (50.0–62.6) | 0.999 |
| Race | |||
| Black | 4.0 (1.9–8.3) | 11.9 (8.3–16.8) | 0.006 |
| Mexican American | 1.8 (0.6–5.0) | 3.6 (2.3–5.6) | |
| Multiracial | 3.2 (1.0–9.5) | 5.1 (3.0–8.5) | |
| Multiracial/Other | 4.1 (2.5–6.6) | 2.5 (1.4–4.4) | |
| Other Hispanic/Latinx | 3.5 (1.6–7.8) | 5.2 (3.3–8.2) | |
| White | 83.4 (75.1–89.3) | 71.7 (63.9–78.3) | |
| Education | |||
| <9th grade | 3.0 (1.8–5.0) | 6.2 (4.4–8.7) | 0.018 |
| 9th–11th grade | 6.1 (2.3–15.0) | 12.3 (9.5–15.8) | |
| High school or equivalent | 23.6 (11.5–42.3) | 35.0 (29.4–41.0) | |
| Some college or associate's degree | 28.3 (19.5–39.1) | 29.2 (24.8–34.0) | |
| College graduate or above | 39.1 (25.0–55.2) | 17.3 (12.6–23.4) | |
| Income | |||
| <133% | 7.5 (3.5–15.3) | 22.3 (17.7–27.8) | <0.001 |
| 133%–300% | 27.2 (20.8–34.6) | 30.9 (25.4–36.9) | |
| 300%+ | 65.3 (54.9–74.5) | 46.8 (39.5–54.3) | |
| Health insurance | |||
| Private | 1.9 (0.4–7.8) | 6.5 (3.8–10.8) | 0.215 |
| Medicare/Medigap | 62.8 (51.5–72.9) | 47.7 (41.7–53.7) | |
| Medicaid/CHIP | 26.4 (13.5–45.2) | 32.2 (27.2–37.6) | |
| Other government | 2.0 (0.6–6.5) | 7.5 (4.7–11.9) | |
| None | 6.9 (1.7–23.5) | 6.2 (4.1–9.0) | |
| General health status | |||
| Excellent | 4.2 (1.5–11.1) | 3.8 (2.1–6.9) | 0.033 |
| Very good | 31.4 (23.1–41.0) | 17.9 (12.2–25.4) | |
| Good | 27.7 (17.4–41.0) | 40.0 (32.1–48.4) | |
| Fair | 33.6 (23.3–45.7) | 28.6 (22.9–35.0) | |
| Poor | 3.2 (1.6–6.2) | 9.7 (6.2–15.1) | |
| Comorbidities | |||
| Diabetes | 34.6 (26.8–46.5) | 39.9 (33.7–47.3) | 0.394 |
| Hypertension | 65.4 (54.5–74.9) | 73.1 (68.5–77.2) | 0.128 |
| Coronary disease | 46.0 (35.3–57.0) | 50.7 (41.1–60.3) | 0.509 |
| Prior myocardial infarction | 30.3 (21.4–41.0) | 45.1 (39.0–51.2) | 0.011 |
| Prior stroke | 48.9 (41.0–56.9) | 43.8 (34.2–53.8) | 0.246 |
| Smoking | |||
| Current | 3.7 (0.9–13.5) | 21.3 (16.1–27.7) | 0.001 |
| Former | 34.5 (25.0–45.5) | 41.8 (33.3–50.7) | |
| Never | 61.8 (48.4–73.6) | 36.9 (31.4–42.9) | |
| Medication use | |||
| Any prescription drug use | 97.6 (93.2–99.2) | 91.3 (88.1–93.7) | 0.017 |
| Aspirin use | 67.9 (52.6–80.1) | 65.0 (58.2–71.2) | 0.775 |
| Statin use | 77.4 (67.2–85.2) | 62.8 (57.9–67.6) | 0.014 |
| Antihyperlipidemic therapy | 80.8 (71.7–87.5) | 67.3 (62.3–71.9) | 0.013 |
| Antihypertension therapy | 75.2 (65.7–82.8) | 75.5 (71.1–79.4) | 0.959 |
| Antidiabetic therapy | 31.4 (24.4–39.4) | 31.2 (27.1–35.6) | 0.961 |
| Anticoagulation therapy | 17.0 (8.7–30.6) | 10.4 (7.4–14.5) | 0.175 |
| Antiplatelet therapy | 21.0 (15.2–28.3) | 23.7 (19.1–28.9) | 0.585 |
| Mobile examination center data | |||
| N=134 (21.6%) | N=685 (78.4%) | ||
| Body mass index, kg/m2 | 31.0 (29.6–32.4) | 30.5 (29.9–31.2) | 0.553 |
| Blood pressure | |||
| Systolic blood pressure, mm Hg | 131.8 (127.4–136.3) | 130.9 (128.2–133.7) | 0.746 |
| Diastolic blood pressure, mm Hg | 72.2 (69.0–75.3) | 74.2 (72.4–75.9) | 0.247 |
| Glycated hemoglobin, % | 6.1 (5.9–6.2) | 6.2 (6.1–6.4) | 0.091 |
| High‐density lipoprotein, mg/dL | 54.5 (47.9–61.0) | 50.1 (48.1–52.0) | 0.132 |
| Total cholesterol, mg/dL | 171.2 (161.7–180.7) | 171.4 (164.9–177.9) | 0.975 |
| Fasting mobile exam center population | |||
| N=69 (23.3%) | N=321 (76.7%) | ||
| Fasting glucose, mg/dL | 130.1 (112.1–148.1) | 124.8 (114.1–135.4) | 0.588 |
| Low‐density lipoprotein, mg/dL | 85.1 (74.8–95.2) | 99.7 (92.2–107.2) | 0.020 |
| Triglycerides, mg/dL | 114.2 (79.3–149.2) | 125.0 (105.4–144.6) | 0.575 |
ASCVD indicates atherosclerotic cardiovascular disease; CHIP, Children's Health Insurance Program; and NHANES, National Health and Nutrition Examination Survey.
Discussion
Supplement use is more common in adults with ASCVD than has previously been reported in the general population. 2 , 3 While 56% of people overall use supplements, our study found that 73% of those with ASCVD used at least 1 dietary supplement. 1 Nearly half of those on a supplement (47.3%) reported taking one under the advisement of a physician or health professional. While reasons for supplement use vary by type of supplement, nearly 1 in 5 individuals with ASCVD takes at least 1 supplement for the reported purpose of “heart health,” most often fish oil followed by coenzyme Q10 and resveratrol, none of which have been shown to prevent cardiovascular events in persons with ASCVD. 10 , 11
Despite widespread belief of a “heart health” benefit, no large randomized trial has shown that supplement doses of fish oil lower cardiovascular events in patients with established ASCVD, and large trials of fish oil in primary prevention have shown no benefit. 8 , 9 , 11 Some mainstream beliefs regarding fish oil and possible heart health benefit may stem from recent clinical trials on prescription‐level doses of omega‐3 fatty acids, but these also have mixed results. REDUCE‐IT (Reduction of Cardiovascular Events With Icosapent Ethyl–Intervention Trial) compared high‐dose eicosapentaenoic acid with mineral oil and found a significant reduction in cardiovascular events in the eicosapentaenoic acid group. 16 In contrast, the STRENGTH (Long‐Term Outcomes Study to Assess Statin Residual Risk With Epanova in High Cardiovascular Risk Patients With Hypertriglyceridemia) trial found no benefit to high‐dose eicosapentaenoic acid and docosahexaenoic acid when compared with a corn oil placebo. 17 Importantly, the dose of eicosapentaenoic acid tested in REDUCE‐IT, 4 g/d, is significantly higher than what is available for the majority of over‐the‐counter fish oil supplements. 18 There is a guideline recommendation for fish oil supplements for people with symptomatic heart failure and reduced ejection fraction based on the GISSI‐HF (Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico ‐ Heart failure) trial from 2008, but this is not applicable for the majority of the US population. 19 , 20 Nevertheless, many patients with ASCVD taking fish oil supplements do so “for heart health.” 18
Two other supplements commonly cited “for heart health” included resveratrol and coenzyme Q10. Resveratrol is a compound found in grapes and has been largely marketed for its antioxidant properties. No large randomized trials have been conducted on resveratrol and cardiovascular outcomes, though a meta‐analysis found no significant impact of resveratrol on cardiovascular risk factors such as blood pressure and low‐density lipoprotein. 21 Coenzyme Q10, also known as ubiquinol or ubiquinone, is involved in mitochondrial energy production, and is often used to treat individuals with statin‐induced myalgias. 22 However, a large randomized controlled trial and a meta‐analysis of small trials has shown no benefit of coenzyme Q10 to alleviate statin‐induced myalgias. 23 , 24 One small randomized trial, Q‐SYMBIO (Coenzyme Q10 as Adjunctive Treatment of Chronic Heart Failure: A Randomised, Double‐Blind, Multicentre Trial with Focus on Symptoms, Biomarker Atatus, and Long‐Term Outcomes), showed benefit in individuals with moderate to severe heart failure, but larger studies have not been conducted. 25 There are no randomized outcome trial data for coenzyme Q10 in patients with ASCVD.
Not all supplement use was self‐directed. In fact, over a third of those on a multivitamin or vitamin D, and one fifth of those on fish oil, reported doing so under the advice of their doctor or health care professional. The proportion of patients taking 1 of these supplements due to a medically indicated reason (ie, vitamin D for osteopenia) is unknown. Most patients taking a supplement for heart health did not report doing so as recommended by a health care provider. However, given a broad lack of outcome data for nutritional supplements, the high reported prevalence of doctor‐advised supplement use suggests a possible knowledge gap at the clinician level.
High usage of nutritional supplements may pose a safety risk to patients. Unlike for prescription medications, large, randomized safety and efficacy studies are not required for dietary supplements. To date, though clinical trials have generally shown multivitamins and vitamin D do not reduce cardiovascular disease, they have been shown to be safe. 4 , 5 , 6 , 7 , 26 , 27 In contrast, higher doses of omega‐3 fatty acids have shown to increase the risk of atrial fibrillation in the REDUCE‐IT, STRENGTH, and OMEMI (Omega‐3 Fatty Acids in Elderly With Myocardial Infarction) trials with a recent meta‐analysis noting increased risk starting at >1 g/d. 10 , 16 , 17 Additional clinical concerns regarding dietary supplement use in patients with ASCVD include the risks of financial toxicity, since supplements are typically not covered by insurance, and risks of polypharmacy.
We found multiple differences in the clinical and demographic characteristics of supplement users versus nonusers. Individuals on a supplement were older, more likely to be non‐Hispanic White individuals, and reported a higher education level and income. Supplement users may also have increased health‐seeking behaviors overall. Smoking prevalence was lower and prescription drug use higher in supplement users versus nonusers. This finding has important implications for observational epidemiology of nutritional supplements as the potential for healthy user bias and unmeasured confounding is extremely high and reinforces the need for randomized trials to test the effects of nutritional supplements on health outcomes.
Limitations of this study include the following: First, health conditions are assessed via self‐report, which may not be fully accurate. Next, the small sample size limits statistical power in certain subgroups. Similarly, a small number of respondents did not provide information relating to their dietary supplement information. Furthermore, reasons for supplement use were captured using a structured questionnaire rather than free text and therefore may not have fully captured patient reasons for use.
Dietary supplement use is common among patients with ASCVD and continues to increase. Among individuals with ASCVD, roughly 70% report taking ≥1 dietary supplements and many indicating “for heart health” reasons, despite a lack of randomized trial data for benefit in ASCVD. Given the prevalence of supplement use in individuals with ASCVD, prospective, randomized controlled trials are needed to assess their safety and efficacy in this population. Almost half of individuals are taking dietary supplements under the advisement of a physician or health professional. Both patients and clinicians may need increased education regarding the lack of data for the benefit of dietary supplements in patients with ASCVD.
Sources of Funding
This study was internally funded by University of Texas Southwestern Medical Center.
Disclosures
Dr Navar reports receiving grants from BMS, Esperion, Amgen, and Janssen; and personal fees from AstraZeneca, Boehringer Ingelheim, Bayer, Janssen, Lilly, Merck, Silence Therapeutics, Novo Nordisk, Novartis, New Amsterdam, and Pfizer outside the submitted work. She serves as Deputy Editor for Equity, Diversity, and Inclusion at JAMA Cardiology. Dr Peterson reports receiving grants from BMS, Esperion, Amgen, and Janssen; and personal fees from Boehringer Ingelheim and Janssen, outside the submitted work. He serves on the oversight board at JAMA. The remaining authors have no disclosures to report.
Supporting information
Data S1
This manuscript was sent to Mahasin S. Mujahid, PhD, MS, FAHA, Associate Editor, for review by expert referees, editorial decision, and final disposition.
Supplemental Material is available at https://www.ahajournals.org/doi/suppl/10.1161/JAHA.123.033748
For Sources of Funding and Disclosures, see page 10.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data S1