Public Health Nutrition: 20(15), 2694–2705 doi:10.

1017/S1368980017001707

Exploring beliefs about dietary supplement use: focus group

discussions with Dutch adults
Emília Margit Pajor*, Anke Oenema, Sander Matthijs Eggers and Hein de Vries
Department of Health Promotion, School of Public Health and Primary Care, Maastricht University, PO Box 616,
6200 MD Maastricht, The Netherlands

Submitted 23 September 2016: Final revision received 22 May 2017: Accepted 16 June 2017: First published online 3 August 2017

Abstract
Objective: Although dietary supplement use is increasing in Europe and the USA,
little research involving adults’ beliefs regarding dietary supplements has been
conducted. Therefore, the present study aimed to explore and compare users’ and
non-users’ beliefs towards dietary supplements.
Design: Thirteen focus group discussions were conducted of which seven groups
were dietary supplement users and six groups were non-users. Based on the
socio-cognitive factors of the Integrated Change Model, a semi-structured topic
guide was set up. The discussions were audio-recorded and subjected to
qualitative content analysis, applying the framework approach.
Setting: Data were collected in Maastricht, the Netherlands, in 2014 and 2015.
Subjects: In total fifty-six individuals participated in the study, of whom twenty-eight
were dietary supplement users and twenty-eight non-users. The average age of
participants was 42·9 years.
Results: Dietary supplement users’ attitude beliefs were mainly related to mental
and physical health enhancement, illness prevention and curative health benefits.
Users were critical of the nutritional knowledge of health professionals and of the
quality of food products. Non-users were convinced that the human body does not
need any support and that regular food is enough to cover one’s nutritional needs.
Users and non-users held comparable beliefs regarding the definition and risks of
dietary supplements, and perceived social influences. Keywords
Conclusions: In their decision about dietary supplement use, both groups were Dietary supplement use
guided by their own convictions to a great extent. Both groups would benefit from Beliefs
improved understanding of the health effects of dietary supplements to improve Focus group discussion
informed decision making. The Netherlands

Dietary supplement use is increasing and widespread in was to gather in-depth knowledge on individuals’ beliefs
many European countries and the USA(1,2). As an example, concerning dietary supplements. In addition, users’ and
51·9 % of the US adult population and 40 % of the Dutch non-users’ most salient beliefs would be compared.
adult population takes dietary supplements regularly(3,4). Dietary supplement use has been shown to be associated
Yet evidence-based recommendations are established only with a healthy lifestyle: sufficient fruit and vegetable intake,
for certain population subgroups(4–6), such as vitamin D adequate level of physical activity, low alcohol consumption
and calcium supplementation among the elderly, which and being less likely to smoke(9–11). Additionally, women
lowers their risk of fractures(5). There is no scientific with a higher education level, higher income and belonging
consensus regarding the benefits of dietary supplement use to higher age groups are more likely to take dietary
at the general population level(7). Therefore, it can be supplements(11–13).
assumed that an individual’s decision to take dietary Certain motivational factors are also associated with diet-
supplements may be mainly a result of factors other than ary supplement use. Women who have stronger intentions to
physiological necessity. Yet knowledge on individuals’ take dietary supplements, attach more value to their health
motives for taking dietary supplements is fragmented and and are more convinced that dietary supplements make
inconclusive. Furthermore, no research has yet addressed them less susceptible to illnesses, are significantly more
the question of why certain consumers consciously choose inclined to take dietary supplements(14). Regarding one’s
not to take them(8). Therefore, the aim of the present study reasons for and beliefs towards dietary supplement use,

*Corresponding author: Email e.pajor@maastrichtuniversity.nl © The Authors 2017

Beliefs about dietary supplement use 2695
individuals are convinced that dietary supplements are alcohol use among pregnant women, binge drinking among
essential to health and can preserve or improve their overall young people, and genetics and cancer(21–23).
health condition(1,8,13,15–17). When comparing dietary In sum, the present study aimed to answer the following
supplement users with non-users, the following attitude research questions: (i) What are the most salient beliefs
beliefs differ significantly: dietary supplements ‘help me to be derived from the socio-cognitive determinants of the
healthy’; ‘stop me getting ill’; ‘are the best I can do for myself’; ICM regarding dietary supplements among users and
and ‘don’t do any harm’(18). The studies mentioned above non-users? (ii) What are the differences between users’
provided relevant but limited evidence since data were and non-users’ beliefs?
collected within the framework of larger projects, such as the
National Health and Nutrition Examination Survey(1), or the
study used a selective sample(14,18). Methods
Qualitative research on beliefs regarding dietary
supplement use is limited to a couple of studies that To gather in-depth information on Dutch individuals’
did not use a specific theoretical framework. In-depth beliefs towards dietary supplements, semi-structured
interviews with ten dietary supplement users revealed that focus group discussions were conducted. Focus group
curing an ailment, preventing chronic diseases, gaining discussion is a widely used method in health sciences,
‘peace of mind’, supplementing a poor diet, saving money since it can provide information about a range of ideas
on medical care and achieving cosmetic benefits are and feelings individuals have about a certain topic of
the most salient motives(8). Taking an anthropological interest(24,25). Furthermore, focus group discussions can
approach, Nichter and Thompson(17) identified the shed light on the differences in perspectives between
following five main categories of reasons for dietary groups of individuals(25). The in-depth information
supplement use: health management/enhancement (e.g. generated was also meant as a preparation for a quanti-
postponing ageing); harm reduction (e.g. counterbalance tative study on dietary supplement use. Systematic inter-
unhealthy behaviours); resisting illness (e.g. boost pretative content analysis was used as the methodological
immune system); illness management (e.g. slow progress approach of analysing the data(26).
of disease); and ideology (e.g. adoption of ‘natural health’
philosophy). Four focus group discussions held in Recruitment and participants
Germany revealed the following motives among users: The aim was to include both current dietary supplement
being afraid of having micronutrient deficiencies; relieving users and non-users in the study sample. To make a
one’s mind (unhealthy eating habits); preventive reasons distinction between users and non-users, inclusion and
(boost immune system); curative reasons (reduce health exclusion criteria were set up. Individuals were regarded
complaints); and restoring subjective well-being (e.g. as dietary supplement users if they took at least one pill
sufficient energy level)(19). Studies have also shown that per week of one or more types of dietary supplements
most dietary supplement users have multiple reasons at prior to the recruitment period of the study. Individuals
the same time(8,17). who consumed dietary supplements exclusively for
The studies mentioned above explored users’ overall sports-related purposes were excluded. Athletes’ needs,
motives for taking dietary supplements, but no attention has reasons and experiences regarding dietary supplement
been paid to why certain individuals do not use dietary use may be mostly related to enhancing their sporting
supplements. To explore specific beliefs and to be able to achievements, which may not be representative of
compare users and non-users, a socio-cognitive model was the general population of dietary supplement users(19).
used as the theoretical framework in the present study. The only inclusion criterion applied for non-users was not
One of the socio-cognitive theories that explains (health) having taken any type of dietary supplements for three
behaviours is the Integrated Change Model (ICM)(20). The months prior to the recruitment period.
ICM distinguishes between distal, pre-motivational and Online and offline platforms were utilized for recruit-
motivational factors that may influence behaviour. Distal ment. Digital advertisements were posted on social media
factors, such as behavioural, psychological and biological and Internet search engines, such as Google AdWords.
factors, have an indirect effect on behaviour that is mediated Hard copies of brochures and posters were placed on the
by pre-motivational and motivational factors. Knowledge, noticeboards of grocery shops, drugstores, community
risk perception, awareness and cues to action belong to pre- centres and general practices in Maastricht. Researchers
motivational factors. These socio-cognitive determinants recruited also through the handing out of flyers at local
further influence motivational factors: attitude (pros and events, such as the Maastricht book fair.
cons), social influence (social norm, social modelling, social Individuals who were interested in the study could contact
support) and self-efficacy. Intentions and factors of the the research team by telephone or email to receive more
motivational phase together influence individuals’ health information about it. When potential participants applied,
behaviour. The ICM has been applied previously in different they were asked to fill in a brief screening questionnaire to
qualitative studies on health-related behaviours, such as assess eligibility. Based on the answers, participants were
2696 EM Pajor et al.
allocated either to the dietary supplement user group or to During the focus group discussions, the first author
the non-user group. Focus group appointments were made (E.M.P.) functioned as moderator and a research assistant
according to respondents’ availability. took notes. The sessions took place in one of the buildings
Convenience sampling was used for recruiting participants of Maastricht University and lasted 70 to 80 min on
until theoretical saturation (e.g. little or no new information average. At the end of the sessions participants received
was discovered) was reached(27). As suggested by Krueger vouchers to the value of 15€ and a travel reimbursement.
and Casey(28), an initial analysis sample was set to at least four The focus group audio materials were transcribed
to five focus groups in order to adequately address the verbatim. In total thirteen focus group interviews were
research objective (i.e. to explore the most prevalent conducted; seven with dietary supplement users (twenty-
beliefs)(29). Additionally, after each session the research team eight individuals) and six with non-users (twenty-eight
discussed the main points participants made and to what individuals). The focus group size varied between three
extent those points differed from opinions expressed in and six participants.
previous sessions. Recruitment took place as long as potential
participants kept replying to the call for participation.
Ethics approval
Ethics approval from an accredited Regional Medical
Focus group interview guide
Ethics Committee in the Netherlands was not needed,
Based on the ICM(23), a semi-structured interview guide with
since the study does not fall within the scope of the
open-ended questions was developed. The questions aimed
Medical Research Involving Human Subjects Act (WMO):
to elicit data on participants’ definition of what a dietary
the present research is not of medical-scientific nature and
supplement is, risk perception, attitudes (pros and cons),
participants were not subjected to procedures or required
social environment (i.e. opinion of friends and family),
to follow certain rules of behaviour (http://www.ccmo.nl/
self-efficacy of taking dietary supplements and response
en/your-research-does-it-fall-under-the-wmo). Prior to the
efficacy. Each topic was introduced by a central question,
focus group discussions, all participants received our
followed by additional prompt questions to stimulate
brochure and invitation letter with important details about
the group discussion (see online supplementary material,
the study. This information was repeated verbally in the
Supplemental Tables 1 and 2). The semi-structured interview
presence of participants before the actual group discus-
guide also gave individuals the opportunity to talk about
sion took place. Verbal informed consent was obtained
additional relevant topics, such as (healthy) food.
from all participants before each session.
The interview questions were pilot-tested both in an
individual and a group setting. With the help of pilot-testing,
researchers can develop and test the adequacy of research Data analysis
instruments(30). Questions used for focus groups of users Descriptive statistics (i.e. percentages, frequencies) were
and non-users were as similar as possible, with slight used to analyse the data of the screening questionnaire
changes made where needed (e.g. advantages of dietary with the statistical software package IBM SPSS Statistics
supplements, users: ‘What are your most important reasons version 20. Transcripts of the focus group discussions
for taking dietary supplements?’; non-users: ‘Can you think were analysed by applying systematic interpretative
of reasons why you would take dietary supplements?’). content analysis(26), using the qualitative data analysis
software QSR NVivo version 9. The analysis process
Data collection and procedure followed the stages of the framework approach involving
A standardized study protocol was established to keep the familiarization, identifying a thematic framework, index-
procedures of each session consistent. According to the ing, charting, mapping and interpretation(31,32).
protocol, after welcoming participants and providing coffee, In the first stages, inductive coding was applied to the
tea and cake, a short introduction (research team, reason and data independently by two coders. This step involved
aims of the study) was given. As stated in the invitation letter obtaining insight into participants’ salient beliefs belonging
beforehand, it was emphasized that taking part in the dis- to the socio-cognitive constructs included in the topic
cussion was confidential and voluntary and that withdrawal guide (main themes). Coding was then compared and
from participation was possible at any time. Participants were discussed to determine the final coding categories for
asked to write down their first name on a name badge to users’ and non-users’ transcripts separately. Also, decision
enable them to address each other by name. At the same rules were made to standardize the coding process in the
time, individuals received a numerical identifier that was subsequent stages.
used in the notes and the transcripts. In this manner, it was In the last stages, through deductive coding, the definite
impossible to trace back participants’ real identity based on version of the thematic framework was applied to the data
the data. Before the actual discussion started, participants by two coders, using NVivo version 9 (2010). This step
had the opportunity to ask questions. The focus group involved regrouping participants’ statements according to
discussions were audio-recorded after participants gave the index reference and, if needed, new coding categories
permission to do so. were established(31).
Beliefs about dietary supplement use 2697
Sub-dimensions Sub-themes Main themes
Lowest level of abstraction Highest level of abstraction

Reduce health complaints

Attitude towards product’ s

Prevention
health effects

Enhance mental performance

Positive attitiude beliefs
Enjoying use
Attitude towards product
properties
Enjoying taste

Fig. 1 An example of the abstraction process (positive attitude beliefs, users)

In the interpretation phase data were reduced to present Table 1 Demographic characteristics of participants (n 56) in focus
results at a reasonable level of abstraction. Through grouping group discussions on dietary supplement use, Maastricht, the
Netherlands, 2014–2015
data, the number of (coding) categories was reduced by
collapsing those that were closely related into broader Users Non-users
categories(33). In this manner, the most concrete and specific (n 28) (n 28)
beliefs were at the lowest level of abstraction, and were then Characteristic n % n %
brought under integrative categories (sub-themes). At the
Gender
highest level of abstraction are socio-cognitive constructs Male 7 25·0 11 39·0
which are regarded as the main themes and consist of Female 21 75·0 17 61·0
several sub-themes (Fig. 1). During data interpretation, users’ Age (years)
18–29 13 46·4 10 35·7
and non-users’ complete thematic frameworks were put 30–39 3 10·7 0 0·0
against one another and were searched for differences and 40–49 3 10·7 4 14·3
similarities at the sub-dimension level. 50–59 3 10·7 9 32·1
≥ 60 7 25·0 5 17·9
Mean age (years) 41·6 44·2
Past experience of dietary supplements
Results Former user NA NA 16 57·1
No experience at all NA NA 12 42·9
Participants NA, not applicable.
In total, fifty-six individuals participated in the study. The
majority were female (75 % of users; 61 % of non-users). A priori themes
Users were slightly younger (mean age 41·6 years, range Pre-motivational factors
20–78 years) than non-users (mean age 44·2 years, range Definition of dietary supplements. Users and non-users
19–68 years). More than the half of non-users (57·1 %) held very similar opinions about what a dietary supple-
had past experience with using dietary supplements ment is and what its main functions are (Table 2, row
(see Table 1). A–B). Dietary supplements were described along several
product property dimensions, such as their aggregate
A priori and emergent themes from the (e.g. liquid), form (e.g. powders, pills, drops), and
qualitative data type and nature of ingredients (e.g. vitamins, minerals,
The following themes were a priori included in the topic synthetic, natural).
guide: (i) definition of what is a dietary supplement; Regarding functions that dietary supplements could
(ii) positive attitude beliefs towards dietary supplements fulfil, both users and non-users agreed that dietary
(advantages, reasons for use); (iii) negative attitude beliefs supplements are by no means a replacement for food,
towards dietary supplements (disadvantages, reasons and they should not be used out of pure laziness. The way
against use); (iv) risk perception (chance and severity of dietary supplements may help to maintain health and
adverse effects); (v) social environment; (vi) self-efficacy treat micronutrient deficiencies in one’s body was also
regarding taking dietary supplements; and (vii) response extensively discussed across several groups of users and
efficacy (noticing product efficacy). Emerging themes from non-users.
the focus group discussions were: (viii) attitude towards Risk perception. When speaking about commonly used
health professional and/or dietitian; and (ix) quality/safety products (e.g. multivitamins) risks were regarded as
of food, practices of food industry. In Tables 2, 3 and 4 negligible by both groups (Table 2, row C–D) and
direct quotations are given for illustrating each of these participants gave a few examples of possible side-effects
topics. Results are presented according to the overarching (Table 2, row E). Users and non-users were convinced that
topics outlined above. most dietary supplements may only cause adverse effects
Table 2 Qualitative results from focus group discussions regarding pre-motivational factors among users and non-users of dietary supplements, Maastricht, the Netherlands, 2014–2015

Main theme Sub-theme Quotes from dietary supplement users Quotes from non-users of dietary supplements
DEFINITION OF DIETARY SUPPLEMENTS
A Characteristics of the ‘It [dietary supplement] is something that you can find in food, but its ‘[Dietary supplements are] everything you may need in a pill format or
product [dietary supplement] concentration is higher.’ other formats like drops (…), or capsules (…), and they are often
produced in a synthetic manner.’
B Functions of the product/ Supplementary function towards food: ‘A dietary supplement Supplementary function towards food: ‘The word [dietary
purposes of use alone is never enough. (…) It [dietary supplements] must have an supplement] itself already tells you: it is supplementary. So, what
additional value [to the diet].’ you perhaps or definitely don’t get enough of [from food], you could
supplement with dietary supplements.’
Function towards body: ‘(…) it [dietary supplement] is something Function towards body: ‘Possibly in periods when you suffer from
that makes good a [possible] shortage in your body.’ shortcomings. When you have a lack of energy. You may need it
owing to doing sports (…) or after being ill for a while.’
Ease: ‘I do not eat fruit and it is also very expensive. I live on my own Ease and certainty: ‘(…) people who are aware of their bad dietary
and when I buy bananas, it takes a while until I finish them. Then I pattern might say: “well, with the use of multivitamins I cover my
think to myself: “perhaps I should take such a pill”.’ needs, so I know for sure that I’m getting enough [of (micro)
nutrients]”.’
Alternative for medicine: ‘Sometimes you have to take medicines, Alternative for medicine: ‘I would not immediately take a pill
but you do not want to. Then you do a search in natural medicine: prescribed by the doctor, I would first try a different pill that I can
what could replace it [medicine]? Very often you end up [the buy myself, you know.’
search] at dietary supplements.’
RISK PERCEPTION
C Chance and severity Low risk: ‘Most of the things I have been using have become very Low risk: ‘Most of the vitamins cannot do any harm, even if you took
well established, like multivitamins. So you already know it does too many of them because they will leave your body in your urine.’
not hurt to try.’
High risk: ‘(…) when you are using St. John’s Wort with High risk: ‘Vitamin B6 is a type of vitamin that might become toxic
antidepressants simultaneously, you may die of it.’ and may attack your nerves.’
D Deteriorating factors Excessive use: ‘(…) Sometimes people take not only one, but two or Excessive use: ‘Vitamin A may have [adverse effects]. You should
three [pills] of [dietary supplement]. (…) It is equal to 600 oranges. not take that much of it. It is not good for your liver. It may be stored
(…) It is actually hypervitaminosis.’ excessively. And then you are getting a high dose.’
Malfunctioning/sensitivity of the body: ‘It depends on your own Malfunctioning/sensitivity of the body: ‘It [risks] depends on your
sensitivity. Everybody has strong and weak points, right?’ own body. (…) If you already have poor health then I think you may
notice the consequences of an overdose sooner.’
Characteristics of the product: ‘You have to pay attention to what Characteristics of the product: ‘When I was using dietary
you take, because there are so many chemicals in it [dietary supplements, it was stated on the label that you get 600 % of the
supplements]. (…) Everybody takes the cheapest [dietary RDA [with the use of that dietary supplement]. Then I was just
supplement], (…) but they never look at what is in it.’ wondering: “600 % (…) is it necessary?” You may get an overdose.’
E Possible side-effects ‘Iron pills, they may colour your defecation black. You may have ‘I know with iron pills that you may get a lot of troubles with them. You
problems with your bowel.’ might get stomach-ache or diarrhoea from them. And your stools
may be a different colour.’
F Safety check/protection ‘I do not think they [possible side-effects] are serious. The dose is ‘No, you do not get side-effects easily when you take a low dose [of
stated [on the packaging] with small letters. If it was really harmful, dietary supplements], otherwise you should get it [prescribed] from
it would not be sold unrestricted, or it [dose] would be stated with a general practitioner.’
bigger letters.’
‘I do not think about it. It must be good. Otherwise it would be
prohibited to sell them. They [government] are already strict.’

Words in capitals are the main themes of the group discussions. A–F are sub-themes of the main themes. Words in bold font are dimensions of the sub-themes.
Table 3 Qualitative results from focus group discussions regarding motivational factors among users and non-users of dietary supplements, Maastricht, the Netherlands, 2014–2015

Main themes Sub-theme Quotes from dietary supplement users Quotes from non-users of dietary supplements

POSITIVE ATTITUDE BELIEFS

A Attitude towards Reduce health complaints: ‘I suffer from pain in my shoulders. (…) Reduce health complaints: ‘People, who are more sickly or weak, or
product’s effects on I hope that it [dietary supplement] will make the situation better (…). unsure. Those people (…) take dietary supplements very quickly.’
one’s body and mind It seems I have arthrosis.’
Prevention: ‘I think you get a stronger immune system with the use of Prevention: ‘Well, I think that for example people usually start using it for
vitamin C and echinacea.’ preventing illnesses.’
Enhance mental performance: ‘Most products I use are meant for Being at risk of deficiency: ‘(…) people who suffer from anaemia need
mental well-being, an example is ginseng. It is meant for enhancing vitamin B12 injections every month. Otherwise you have a deficiency of
my study performance.’ red blood cells.’
B Attitude towards the use Enjoying use: ‘I like to use this product. It is royal jelly. It is very delightful Effectiveness is evidence-based: ‘The reason why I would actually use
of the product or the when I am weak and I don’t feel well.’ it [dietary supplement] is that its effectiveness has been confirmed.’
product itself Enjoying taste: ‘(…) my mother had a very big jar of vitamin C tablets. Control with pills on health: ‘It is a typical sign of an affluent society.
I was eating it all the time because they tasted so good.’ I mean the idea that people are able to influence their health with pills
or dietary supplements.’
C Influence of commercials NA ‘In my opinion, it is more the commercial that wants to convince you to take
something than that you are in such a need of it [dietary supplements].’
D Ease NA ‘Sometimes the idea occurs to me that people just find it easier because
they are not fond of something and so they take a pill.’
NEGATIVE ATTITUDE BELIEFS
E Product properties and ‘Lately I bought a jar of “Guarana 800 mg” – it is quite a high dosage, ‘In my opinion, it is a kind of synthetic version of it [vitamin C], because it
sales-related so I may get hyper[active] from it.’ cannot be literally the same thing as what is in an orange.’
disadvantages Commercialization: ‘There are some brands and it is like a “hype” with lots Commercialization: ‘There is actually a whole industry by which enormous
of advertisements, commercials and marketing.’ amounts of money can be earned.’
F Consumers’ health, Hinder healthy eating: ‘I may easily assume that I eat healthily when I take Hinder healthy eating: ‘When you are using dietary supplements, I think
functioning and multivitamins. So it may be an excuse for eating less vegetables and fruits.’ you are more inclined to leave fruits and vegetables.’
lifestyle-related Not natural: ‘I am using them [dietary supplements]. But you feel like you are Normal way of functioning: ‘I consider it important that my body nourishes
disadvantages doing something unnatural. So you don’t let things stand at: “a varied diet is itself, I do not want my body to get habituated [to dietary supplements].’
enough”.’
G (No) necessity Conscious use: ‘You should only take something when you need it. It is Need: ‘In my opinion you should only use a dietary supplement – which is
beneficial to investigate critically and experience [the product]. You may meant for deficiency – when it is needed.’
leave it [dietary supplements] for a while or try out something new, when it Healthy diet is enough: ‘I think you should eat healthily and varied, this is
is necessary.’ the best [for yourself] I think. Things like this [dietary supplements] are
only needed in exceptional cases.’
H Safety check/ ‘Some possible side-effects have not been properly investigated yet and may ‘(…) it is very often claimed that it [dietary supplement] may not be harmful.
investigation become clearer only in the future.’ But it still has not been fully investigated.’
I Lack of (evidence-based) ‘Maybe the [beneficial] effect is not evidence-based.’ ‘Does it [dietary supplement] contain what it should contain? And does it
effects ‘Look, some people do not digest vitamin B12. So you can take whatever you work when you take it? You never know.’
want but it won’t have an effect.’
SOCIAL ENVIRONMENT
J Positive opinion ‘(...) my mother says that you can always use something on the side [besides ‘When I arrived at home and I told I was tired, my parents gave me an iron
food]. Therefore I take vitamin C (…), but I have never really had any pill. “Try this, it may help you”.”
[physical] complaints.’
Using dietary supplements: ‘Well, I think my girlfriend, my parents and my Using dietary supplements: ‘Yes, friends of mine (…) who feel weak and
sister are taking dietary supplements. And some fanatical friends of mine have to get out of their bed, then they take vitamin pills or energy
from the gym [are also taking dietary supplements].’ boosters.’
K Dietary supplements are ‘It [taking dietary supplements] does not hurt to try.’ ‘It [taking dietary supplements] does not hurt to try – they say.’
harmless
L Negative opinion ‘At the college where I study “dietary supplement” is almost a nasty word. ‘When you do not have any symptoms (…) most people think then: “What is
They are really against it [dietary supplements]’ the benefit of it [dietary supplements]?”’
M (Healthy) food is enough ‘(…) my friends are saying all the time: if you simply eat healthily, then they ‘I have got four sisters and none of them takes them [dietary supplements].
[(micro)nutrients] are all included in it [food]. Then you do not need to take One says: “I wouldn’t even start using them [dietary supplements]
something additionally.’ because I eat healthily”.’
 2700
Table 3 Continued

Main themes Sub-theme Quotes from dietary supplement users Quotes from non-users of dietary supplements

N No idea ‘My environment does not say anything about it [dietary supplements].’ ‘I have to admit, it is not a topic that is frequently discussed. I have never
talked about it.’
SELF-EFFICACY
O Difficult situations (to Medical reason: ‘For me, it [taking dietary supplements] is for medical Medical reason: ‘(…) indeed, if you have a certain disorder or Crohn’s
quitting dietary reasons because my body does not digest everything. So I have to play disease. Or your body is not able to digest nutrients from your intestine.
supplement use) around with those dietary supplements all the time because otherwise I do When people have chemotherapy treatment, and do not eat properly.
not get anything [(micro)nutrients].’ Also you do not feel well so in that case you could use something extra.’
Risk of deficiency: ‘When you know or feel that your body is not functioning Risk of deficiency: ‘I am a vegetarian. So you can easily sustain deficiency
as it should or your body has a deficiency. Then not to take [dietary of iron or vitamin B12. (…) I can imagine that people think “it is weird not
supplements] would feel like (…) you are wronging yourself or your body.’ to eat meat” and they are afraid that they do not get enough vitamins. So I
can imagine that they would take particular vitamins as a
supplementation.’
P Difficult situations (to External barrier: ‘Yes, exactly, being on holiday. (…) It is difficult when you External barrier: ‘I am not really good at swallowing pills. I had to swallow
taking dietary are somewhere else and you don’t take them with you, then you cannot the [vitamin] pills whole and those were for really big pills. They also
supplements) take them.’ tasted very bad, so it did not make it easy to get them down.’
Internal barrier: ‘You should not forget to take them [dietary supplements]. I notice
immediately when I have forgotten to take them. So my tactic is to put them
somewhere so I do not forget them [dietary supplements].’
RESPONSE EFFICACY
Q Effect of product is ‘(…) when I was diagnosed with arthrosis I was not able to do certain things. NA
present/noticeable For example, when I got on my bike and had to give the first push, it hurt
me. (…) After using this substance for three months, it [pain] has gone
away.’
W Effect of product is ‘My [vitamin] B12 level was considerably lower than the lower boundary of NA
absent/unnoticeable [vitamin] B12. (…) I took vitamin B12, I took a vitamin B complex product. I
have been checked several times for vitamin B12. But taking the pill
[vitamin B complex] had no effect or result.’
Z Doubt/uncertainty about Placebo effect: ‘But even if it is a placebo effect, it doesn’t matter. Of course it’s NA
effectiveness or not worth the money. But when it [dietary supplement] has a placebo effect and
noticing effects I am able to walk again from here, then I am fine with it.’
Effect is difficult to determine/measure: ‘I have tried a lot of things to get
rid of my energy shortage. I also did something with aloe vera so I cannot
indicate it [what helped] precisely because I did not use them consecutively
but simultaneously.’
Prevention: ‘If you use them [dietary supplements] for preventive purposes
then you do not know. You do not know whether you otherwise had noticed
something [symptoms] or got an illness. (…) You may prevent something,
but you don’t know.’

NA, not applicable.

Words in capitals are the main themes of the group discussions. A–Z are sub-themes of the main themes. Words in bold font are dimensions of the sub-themes.

EM Pajor et al.
 Beliefs about dietary supplement use
Table 4 Qualitative results from focus group discussions’ newly identified themes among users and non-users of dietary supplements, Maastricht, the Netherlands, 2014–2015

Main themes Sub-theme Quotes from dietary supplement users Quotes from non-users of dietary supplements
ATTITUDE TOWARDS HEALTH PROFESSIONAL AND/OR DIETITIAN
A Positive attitude, trust ‘I trust my general practitioner and also the dietitian, but I am a very ‘When I do not feel well I am more inclined to go to a [health]
critical person.’ professional like “I do not feel well (…) how come?” And then
you can decide to take something against it [illness].’
B ‘Very often it [advice on diet] is done at a general level (…). The
Negative attitude, NA
distrust person [dietitian] keeps giving the same advice while perhaps
someone is sitting in front of you who perhaps needs something
totally different. (…) I know more about it [diet] than the person on
the opposite side of the table. And that person suggests things,
which [food pyramid] are old old-fashioned.’
‘I never consult with a dietitian. I would have an argument with them
immediately. Simply because, generally speaking, I do not agree
with their recommendations.’
QUALITY/SAFETY OF FOOD, PRACTICES OF FOOD INDUSTRY
C Positive attitude NA Better supply: ‘Nowadays, if you look around you see how many
cherry tomatoes or mini-cucumbers or salads people eat in the
afternoon. In my opinion, you have more opportunities to eat
healthily than about 50 years ago when the supply was more
restricted. Then you had only vegetables of the actual season.’
‘I think that the supply of food, including industrial food, is quite good
and it is rich enough in minerals, and is very low in harmful
substances on the surface.’
Quality of food is good enough: ‘I think too that in certain cases it
could be that it is less [micronutrients in food], but you have to ask
yourself: is the amount that much less (…) that I get nothing or not
enough [of micronutrients from food]?’
D Negative attitude Poor quality of food: ‘It is awful what they sell in supermarkets. For NA
example, spinach is full of some kind of substance to let it grow
better. I do not eat spinach anymore because it is such a mess.’
‘If you make a comparison between now and 100 years ago … for
example in our spinach – there are less nutrients than 100 years ago.’
Poor practices of food industry: ‘I think the ground can become
depleted. If the ground is depleted, then you get fewer minerals
from it [ground].’

NA, not applicable.

Words in capitals are the main themes of the group discussions. A–D are sub-themes of the main themes. Words in bold font are dimensions of the sub-themes.

2701
2702 EM Pajor et al.
when they are excessively used, when the consumer’s body environment who consider regular food as a sufficient
is not functioning properly, or when someone is using source of nutrients and therefore taking dietary supple-
inappropriate products (Table 2, row D). Users and non-users ments is not necessary (Table 3, row M). Furthermore,
also believed that dietary supplements undergo rigorous users and non-users often heard from others that dietary
safety checks before being sold, otherwise – they argued – supplements are harmless (Table 3, row K).
it would not be permitted to sell those products Both users and non-users indicated that their decision
(Table 2, row F). regarding dietary supplement use did not depend on
others’ opinions. At the same time, both groups admitted
Motivational factors that ‘dietary supplement use’ is not a commonly talked
Positive attitude beliefs. Regarding reasons for dietary about topic.
supplement use, reducing health complaints and pre- Self-efficacy. Users and non-users mentioned situations
venting illnesses were frequently mentioned aspects both in which dietary supplement use would be difficult
by users and non-users (Table 3, row A). Users also (Table 3, row P). Some of the situations mentioned by
reported how dietary supplements help them enhance both groups were: having a different (daily) routine than
their mental performance. Also, users indicated enjoying usual (e.g. being on holiday) or not liking the taste of the
the taste and use of dietary supplements (Table 3, row B). product. Users also frequently mentioned forgetfulness as
Only non-users discussed micronutrient deficiency and a barrier to taking dietary supplements.
evidence-based effectiveness of the products as important Additionally, users and non-users mentioned a few
reasons for considering taking dietary supplements (Table 3, situations in which they would never stop using
row B). In addition, only non-users indicated that, in dietary supplements: when suffering from micronutrient
general, the persuasiveness of commercials or individuals’ deficiencies and in the case of medical prescription
laziness could also lead to dietary supplement use (Table 3, (Table 3, row O).
row C–D). Response efficacy. Only users were asked whether
Negative attitude beliefs. Both users and non-users they actually experience the beneficial health effects that
regarded the commercial nature of the dietary supplement dietary supplements are intended for (Table 3, row Q–Z).
industry as a disadvantage (Table 3, row E). Also, in Users agreed that taking dietary supplements can help
both groups concerns were expressed towards product people improve their health. Yet users’ opinions differed
properties, such as high-dosage pills, uncertainty about regarding their ability to experience directly those
ingredients and lack of sufficient evidence of safety beneficial health effects. Only some of them could
(Table 3, row E–I). Regarding eating habits, users and precisely indicate whether and how they notice the
non-users agreed that individuals’ nutritional intake may advantageous effects, and a large number of participants
decline as a consequence of using dietary supplements gave a detailed explanation as to why they have doubts
(Table 3, row F). about an immediate experience (Table 3, row W–Z).
While users raised the issue that getting micronutrients Users’ doubts were related to the preventive use of the
from dietary supplements is not natural, non-users went products and the difficulty in determining effectiveness.
further and regarded dietary supplements as an intervention Furthermore, users were aware of possible placebo effects
in the normal functioning of the body (Table 3, row F). through which dietary supplements may seem to be
Concerning necessity (Table 3, row G), users emphasized effective.
the need to think thoroughly about the aims one
Emergent themes
will achieve with dietary supplements and then decide
whether to (continue) to take them. Non-users approached Attitude towards health professional and/or dietitian
necessity differently: supplementation is only necessary One of the unprompted discussion topics raised both by
when suffering from deficiencies and there is no need for users and non-users was their experience with and opi-
dietary supplements if individuals already eat healthily nion towards physicians (Table 4, row A–B). Several users
(Table 3, row G). had had unfavourable experiences with their physician,
In several groups of users an extensively discussed such as not being able to diagnose a health problem. Users
topic was whether micronutrients from dietary supple- also did not confide in dietitians and labelled their
ments are properly absorbed through the digestive system recommendations as ‘old-fashioned’ or ‘inappropriate’.
(Table 3, row I). However, several users consulted regularly with so-called
Social environment. Both users and non-users reported anthroposophical general practitioners (adherents of a
being exposed to different social influences at the same spiritual philosophy aiming to optimize physical and
time. Individuals in their social environment held different mental health, and well-being) who gave them advice
opinions about dietary supplement use, ranging from about lifestyle and diet, including recommendations for
being positive and encouraging to being negative and dietary supplements. In contrast, the majority of non-users
discouraging (Table 3, row J–N). Besides approvers and held a positive attitude towards their physician (Table 4,
disapprovers, there were also people in participants’ social row A).
Beliefs about dietary supplement use 2703
Quality/safety of food, practices of food industry In contrast, non-users put emphasis on investigating the
An additional frequently discussed topic by users and non- necessity of use first when discussing reasons for taking
users was food quality (Table 4, row C–D). Very often, dietary supplements. As they argued, nutritional defi-
a comparison was made between food nowadays and ciencies can be detected, for example with the help of a
50–100 years ago regarding quality, supply and food blood test. Non-users indicated that a healthy, balanced
industry practices. The majority of users were convinced and varied diet would be of sufficient quality for most
that the quality of food products has gone downhill people to cover their nutritional needs. Additionally, most
recently and food contains considerably lower amounts of non-users were convinced that the human body is able to
vitamins and minerals (Table 4, row D). As users further regulate all the different biological processes properly on
argued, quality deterioration is a result of poor practices its own. Therefore, they considered supporting the normal
by the food industry. functioning of the body with dietary supplements as
Non-users acknowledged that the quality of food pro- unnecessary. Hence, non-users did not feel the need to
ducts may have declined a little recently. Yet food pro- improve their health as much as users did.
ducts still may contain sufficient amounts of vitamins, Most dietary supplement users were critical of general
minerals and other important nutrients. Moreover, com- practitioners’ and dietitians’ knowledge on nutrition,
pared with 100 years ago, there is more opportunity to eat whereas the majority of non-users did not have such a
healthily as a result of the enriched variety of supply of critical view of their physician. Research has shown that
fruits and vegetables (Table 4, row C). 44 % of frequent dietary supplement users believed that
their own physician knows little to nothing about nutri-
tion(13). The distrust towards health-care providers was
Discussion also revealed by previous research showing that dietary
supplement users often took control of their own health
The present study sought to explore and compare users’ by seeking alternative forms of medicine, including dietary
and non-users’ salient beliefs related to dietary supple- supplements(10).
ment use, applying the ICM as its theoretical background. Users’ and non-users’ beliefs regarding food quality and
Users’ and non-users’ beliefs were comparable regarding safety also differed considerably. Whereas users estimated
the risks of dietary supplements, how they define dietary food quality as poor, non-users still considered food products
supplements, and their decision regarding whether or not as a sufficient source of nutrients. Evidence suggests that
to take dietary supplements being independent from their dietary supplement users tend to have a healthy lifestyle and
social environment. Users’ and non-users’ beliefs differed sufficient nutritional intake(11,12,35). The fact that dietary
substantially regarding their attitude beliefs towards supplement users feel the need to supplement their nutritious
dietary supplements, trust in health professionals and diet might be explained by their distrust in food quality.
judgement on the quality of food products. It is important to note that many users were uncertain
The majority of users and non-users defined dietary whether they actually experienced any of the advanta-
supplements as products that are intended to supplement geous health effects of dietary supplements. Despite these
the normal diet. Both groups considered the risks of doubts, users still believed that dietary supplements help
dietary supplements as low and assigned the occurrence improve their health. High levels of response efficacy may
of possible adverse effects more to the consumer explain a contradictory result of a previous study: about
(e.g. excessive use, being ill) than to the product. How 70 % of dietary supplement users would still take dietary
dietary supplements are judged by significant others (e.g. supplements, even if the government or the Food and
family, friends) did not seem to influence participants’ Drug Administration announced that dietary supplements
own decision about whether to use dietary supplements are ineffective(13).
or not. The findings mentioned above may imply that both
Users considered dietary supplements as a potential tool to users and non-users base their decision regarding dietary
improve their health. Users’ most frequently mentioned supplement use mainly on their beliefs. To facilitate
reasons for taking dietary supplements can be grouped into consumers’ informed decision-making regarding dietary
three overarching categories: preventive reasons (e.g. to avert supplement use, users’ and non-users’ understanding of
getting the flu); mental and physical health enhancement dietary supplements’ health effects should be improved.
(e.g. to enhance mental performance); and curative benefits
(e.g. to reduce health complaints). Users’ motivations were Limitations
most commonly related to certain (health) complaints that As with many qualitative studies, the present sample may
they suffered from. This finding is in line with previous be biased since convenience sampling was used to recruit
research that suggests that health problems such as joint participants. Therefore, future research should assess indivi-
pain, muscle cramp, osteoporosis or arthritis are frequently duals’ motives towards dietary supplement use quantitatively,
mentioned motives for taking dietary supplements, especially using a representative sample. The semi-structured topic
among the elderly(1,34). guide made it possible to standardize the study procedure
2704 EM Pajor et al.
and topics discussed. But due to the predefined nature of the use, and the research assistants who performed different
discussions, participants had limited opportunities to discuss tasks. Financial support: This study was funded by the
relevant topics that were not included in the topic guide. With Netherlands Food and Consumer Safety Authority. The
regard to theoretical saturation, the research team evaluated Netherlands Food and Consumer Safety Authority had no role
each session in terms of differences and similarities in beliefs in the design, analysis or writing of this article. Conflict of
compared with previous sessions, but some aspects of dietary interest: The authors have no conflict of interest to declare.
supplement use may be still undiscovered. As an example, in Authorship: Each author of this article contributed
contrast to previous studies, compensation for unhealthy significantly to the study. All authors read and approved the
eating habits was not raised as a reason for taking dietary final manuscript. Ethics of human subject participation:
supplements by users(17,19). Ethics approval from an accredited Regional Medical Ethics
Committee in the Netherlands was not needed, since the
Implications for future research study does not fall within the scope of the Medical Research
Data were collected among a selective sample of Dutch Involving Human Subjects Act (WMO): the present research
individuals in the region of Maastricht. Therefore, the study is not of medical-scientific nature and participants were not
should be extended to more areas in the Netherlands as well subjected to procedures or required to follow certain rules
as to other countries. of behaviour (http://www.ccmo.nl/en/your-research-does-it-
Several salient beliefs regarding dietary supplements, food fall-under-the-wmo). Prior to the focus group discussions, all
and health have been discovered in the present study. participants received our brochure and invitation letter with
However, it is impossible to investigate the predictive value of important details about the study. This information was
those beliefs regarding dietary supplement use based on repeated verbally in the presence of participants before the
qualitative research. Therefore, future quantitative longi- actual group discussion took place. Verbal informed consent
tudinal studies should assess to what extent socio-cognitive was obtained from all participants.
factors determine dietary supplement use and non-use, and
address the question of, for example, whether decreased trust Supplementary material
in physicians and negative judgement on food quality may
indeed lead to dietary supplement use. To view supplementary material for this article, please visit
Some salient beliefs identified by the current study can https://doi.org/10.1017/S1368980017001707
be related to existing theoretical constructs, such as mental
and physical health enhancement and illness prevention,
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