The two most important findings of this study were that more students (52%) than the general population (25%) reported ever using at least one dietary supplement, and students considered their education on dietary supplements to be inadequate. The primary reasons that students used dietary supplements was to prevent disease, improve physical performance, improve immune function, or because family or friends had recommended the product. A few students (2%) attributed adverse effects to the dietary supplement they had used.
Although students considered dietary supplements not essential for health, student use of at least one dietary supplement was greater than that of the general public. This relates to the findings of previous studies that found high prevalence and widespread use of herbal supplements among pharmacists.[14,18] However, only two products--fiber/psyllium and fish oil/omega-3–were used by more than 20% of the respondents. Use of all other products was less than 20%. Although the college is located in a multicultural environment, the student cohort is not a representative sample. Therefore this greater use of supplements among students cannot be attributed to particular cultural influences. No student indicated that they used dietary supplements because prescription or over-the-counter medications were too expensive or ineffective. Variations in terminology and studies that include complementary and alternative medicine in addition to dietary supplements make it difficult to compare students' use of dietary supplements. An Australian study found that 93.7% of Australian student pharmacists in their sample had used "complementary medicines." In Minnesota, 20% of P4 students had used "herbal medicines" and 35% had used "nutritional supplements." Thus, the 52% of students who had used at least one dietary supplement at least once, seems consistent with the findings of other studies that a substantial portion of student pharmacists use at least some alternative or complementary therapies. However, this is higher than the general population use of 25% who had ever used a dietary or herbal supplement.
The second important finding relates to the education student pharmacists receive. Student pharmacists reported that having knowledge of dietary supplements was important, but considered their education on dietary supplements to be insufficient. Similar findings have been reported in other studies.[21–22] A study of pharmacists in Missouri found over half of them received questions from patients about natural products, but only 2.4% were able to answer them. Another study reported health care professionals had insufficient knowledge about adverse effects of dietary and herbal supplements, and did not routinely communicate with patients about dietary and herbal supplements. Since dietary and herbal supplements are taught in the spring semester of the second year, and the survey was administered in the fall, only P3 students would have been taught about dietary and herbal supplements when responding to the survey. Students have the opportunity to apply the knowledge they have learned in class during IPPEs; however, P1 or P2 students who have not received any formal instruction on dietary and herbal supplements may not have adequate knowledge to correctly identify interactions or provide advice and counseling to patients. This finding has important implications for pharmacy education, suggesting that there is a need to improve the education student pharmacists receive about dietary and herbal supplements so that they are better able to deal with pharmaceutical issues arising from dietary and herbal supplements when they enter service as a registered pharmacist.
Interactions between prescription medications and dietary supplements are a huge concern. Research using NHANES data found 34.3% of all adults in the US and 47.3% of patients with a diagnosed medical condition take both a prescription medication and dietary supplement together. Another nationally representative survey of older adults in the US found 52% took a dietary supplement with prescription medication. Furthermore, many supplements contain pharmaceutical contaminants. The FDA website warns that health fraud drug products can have serious or fatal consequences, and publishes an extensive list of public notifications describing contaminated supplements. For example, a dietary supplement for weight loss contaminated with a stimulant resulted in consumers being hospitalized with serious health conditions. These studies clearly highlight the need for pharmacists to have good knowledge of drug-supplement interactions, so that they are able to identify interactions and offer the best advice possible to patients.
There has long been a call to increase student pharmacists' education in dietary and herbal supplements.[14,24,28–29] Funding has been made available in the past to both medical and nursing schools to teach complementary and alternative medicines in the curriculum, which brought benefits such as greater collaboration among faculty and institutions, but challenges such as a lack of qualified faculty and a crowded and changing curricula remain. Such benefits and challenges may be similar in the pharmacy school environment. A white paper published by the American College of Clinical Pharmacy recommended that natural products, such as dietary and herbal supplements, should be included in the curriculum of pharmacy schools.
The Accreditation Council for Pharmacy Education (ACPE) has since included dietary supplements as a required element of the didactic pharmacy curriculum. Several pharmacy schools have attempted to improve dietary supplement teaching; dedicated classes using active learning exercises have been found to improve students' dietary supplement knowledge and emphasized the importance of pharmacists' dietary supplement knowledge in clinical practice.[33–34] Our institution provided the results of this study to the curriculum committee, with the intention that changes will be made in the forthcoming curriculum review. Given that student pharmacists' views of dietary and herbal supplements are dependent upon the education they receive, it is important to educate future pharmacists appropriately so that they can offer holistic advice to patients in the future. A survey of pharmacists at a national meeting found pharmacists typically self-educated themselves about dietary supplements, using online references, other practitioners, and word of mouth. Another study revealed that only 12.5% of pharmacists learned about natural products in pharmacy school, suggesting there may be a need for a continuing education program for pharmacists who received no or inadequate education about dietary supplements while in pharmacy school. An instrument has been developed and tested to assess pharmacists' and student pharmacists' ability to counsel patients on dietary and herbal supplements. The authors also suggest this instrument to assess student pharmacists' dietary supplement counseling could be used to examine student pharmacists' competencies for dietary and herbal supplements.
Since there appears to have been improvements in natural product teaching across the United States and a formal requirement for it to be taught at pharmacy schools, it would be interesting to survey pharmacists who have recently graduated to investigate whether or not they think they have an adequate knowledge of dietary supplements, since they should have received at least some education on the topic in pharmacy school. In addition, a survey such as the one administered in this study could be administered to student pharmacists at other US pharmacy schools to identify current perceptions of dietary and herbal supplements teaching. The findings of our study suggest that although student pharmacists receive education on dietary supplements, it is deemed insufficient. It would be useful to know if this is a nationwide or local perception. Therefore, it may also be interesting to investigate how information about dietary and herbal supplements was taught, to identify methods that appear to work and make recommendations to improving the pharmacy curriculum with respect to dietary supplement teaching.
A limitation of this study was that it included only the students who were present in class at the time when the questionnaire was administered. P4 students were taking advanced pharmacy practice rotations so were not included in the study. Their potentially enhanced knowledge and experience over students in the first three years may have impacted the results. Also, this study only examined student pharmacists from one college of pharmacy; thus, the results may not be generalizable to all student pharmacists across the US, or the general population.
Am J Pharm Educ. 2017;81(5):92 © 2017 American Association of Colleges of Pharmacy