Patient Awareness and Knowledge about Bleeding Risks Associated with Common Dietary Supplements

Patient Awareness and Knowledge about Bleeding Risks Associated with Common Dietary Supplements | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Patient Awareness and Knowledge about Bleeding Risks Associated with Common Dietary Supplements Eleanor Tung-Hahn, Ellie Black, Nathan Quint, Lauren Moy, Ronald Moy, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6909674/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Post-operative complications such as bleeding, hematoma formation and abnormal healing may be mitigated by withholding selected over-the-counter products including dietary supplements. Little is known about patients’ knowledge on this subject. Objective To assess participants’ baseline knowledge about common over-the-counter supplements, vitamins, herbal/botanical products as well as other substances (e.g., alcohol) that can be associated, if ingested, with an increased risk of bleeding during outpatient surgical procedures. Methods A survey administered to a willing consecutive sample of adults regarding their: baseline knowledge about possible bleeding risks associated with commonly taken dietary supplements and products; personal use of supplements and alcohol; history of post-procedural bleeding or healing issues; and personal demographic characteristics. Results One hundred and two participants completed the survey (93% response rate). Overall knowledge of risks was low (average score = 8/56 = 14%). Gender, supplement usage or non-usage, and use of prescription anticoagulants did not significantly impact score. Increasing age was negatively correlated with score. 69% of participants reported routinely taking supplements of any kind. 88% thought receiving information on this topic before surgical procedures about supplements that could affect procedure-related bleeding would be helpful. Conclusion Most participants were unaware of the potential bleeding risks of common dietary supplements but wanted education on the topic. Pre-operative education that encourages patients to hold selected supplements and other ingested substances may reduce peri-operative bleeding risk associated with cutaneous surgery. Blood thinner dietary supplement vitamin bleeding risk anticoagulant Introduction Patient knowledge about the bleeding risk potential associated with consumption of selected over-the-counter vitamins, supplements, herbal/botanical products and with alcohol intake is not well-studied. Patients’ understanding of the possible risks could encourage them to be proactive about pausing these products in the perioperative and postoperative periods. This, in turn, may minimize intra-operative and post-operative bleeding, hematoma formation, and related wound healing complications. Based on prior reports, various dietary supplements, vitamins, herbal and botanical products, cannabis, and alcohol have been documented to increase the risk of perioperative bleeding, either on their own or by interaction with other medications. Bleeding may be actuated directly, by a biochemical effect of the product, or by affecting the coagulation pathway or platelet aggregation. (1-58) Patients may not be the only group who are unaware of the bleeding risks associated with dietary supplements. In one study, even surgeons were unaware of the side-effect profiles for 90% of the medicinal supplements that were assessed. (40, 41) Notably, to avoid more serious health risks associated with discontinuation, for outpatient cutaneous procedures such as excision, patients are often advised to continue their prescribed or physician directed anticoagulant and antiplatelet therapies unless there are compelling risks. (2, 3) However, instructions regarding cessation or continuation of over-the-counter supplements are less clear-cut. To assess the extent of participants’ knowledge regarding the bleeding risk association with common dietary supplements and other non-prescription products that may be routinely ingested, a survey was administered to participants. Methods A multicenter in-person survey study of consenting consecutive adult patients was conducted in two dermatology clinics to assess their knowledge regarding the increased risk of bleeding associated with specific common over-the-counter vitamins, supplements, herbal/botanical products, and alcohol. The first part of the survey consisted of 56 questions that ascertained baseline knowledge about bleeding risk associated with specific products, which were selected based on a literature search. Google and PubMed were searched (Google, accessed January 2024). The supplements and products included in the survey were chosen based on Google and PubMed searches using the following key words: [(supplement, vitamin, alcohol, OR cannabis) AND (thrombosis, platelet aggregation, bleeding risk, complication, interaction with blood thinners, OR bleeding episodes)] and [(supplement, vitamin, alcohol, OR cannabis) AND (perioperative complication)]. Review articles, case reports and single-arm studies were included due to the paucity of controlled studies. The second part of the survey consisted of 5 questions about their personal use of supplements and alcohol, and whether they have had any issues with peri-procedural bleeding or delayed post-operative healing in the past. The third part of the survey consisted of 3 questions eliciting basic demographic information. Upon completion of the survey, each participant was given an answer key and information sheet. [Supplemental figures 1(survey), 2 (answer key),3 (information sheet)]. This survey study was deemed exempt by the Institutional Review Board of the Lake Erie College of Osteopathic Medicine (IRB exemption no. 31-108). Statistical Analysis: Descriptive statistics were obtained. Kruskal Wallis tests were performed to assess the association of specific participant characteristics (age, gender, supplement usage, prescribed or directed anticoagulant usage, alcohol intake, history of biopsy or surgery, history of post-procedural bleeding or wound healing complications) to overall score. Additionally, we assessed the correlation between the quantity of weekly alcohol intake to patient knowledge that alcohol can impair blood clotting and increase risk of bleeding. Total score was plotted against age of participants, and linear regression was used to develop a line of best fit. All statistical analyses were conducted using the program R running in RStudio version 2023.12.1. Results Of the 110 patients invited to participate, 102 provided informed consent and completed the survey (93% response rate). Forty-seven participants identified as female, 54 as male and 1 did not specify. Age ranged from 23 to 91 years (mean, 68). Racial/ethnic self-identification included: White/Caucasian (95), Hispanic/Latino (2), Black/African American (3), Asian/Pacific Islander (1) and preferred not to specify (1). Sixty-nine percent of participants reported regularly taking vitamins, dietary supplements or herbal or botanical supplements, while 30% stated they did not take any and 1% did not specify. Of those who routinely took vitamins and supplements, the most frequently reported types were vitamin D (44%), multiple vitamin (36%), fish oil (11%), turmeric (10%), zinc (7%) and vitamin E (4%), and 63% regularly took two or more varieties. Forty-one percent of participants were on a prescription blood thinning medication or were taking prescribed or physician-directed non-steroidal anti-inflammatory (NSAID) medications (e.g., ibuprofen, naproxen, meloxicam, celecoxib or other), 57% were not and 2% did not specify. Twenty-six percent of patients took NSAIDs on a daily basis. Fifty percent of participants took aspirin, either alone or in combination with another anticoagulant, 29% of participants took direct factor Xa inhibitors (e.g., rivaroxaban, edoxaban, and apixaban), and 7% were on clopidogrel. In this cohort, 49% drank alcoholic beverages weekly, 50% did not drink, and 1% did not specify. Of the participants who did drink, 70% had 1-3 standard drinks per week, 22% 4-7, and 8% 8 or more. A standard alcoholic drink was defined as any beverage containing 0.6 fluid ounces or 14 grams of pure alcohol-- roughly equivalent to 1 can (12 ounces) of beer, 5 ounces of wine, or a 1.5 ounce shot of 80 proof distilled spirits (e.g., gin, rum, tequila, vodka, whiskey). (59) Regarding the history of cutaneous procedures in our cohort, 90% had a history of skin biopsy or surgery and 10% did not. In terms of post-procedural complications after skin biopsy or cutaneous surgery, 83% of participants did not have any issues while 17% endorsed a history of minor post-procedural issues. Among the 17 participants who stated that they had experienced complications, post-operative events included lengthy or delayed healing (53%), postoperative bleeding (29%), excessive bruising (12%) and scarring (6%). Participants’ overall knowledge about the bleeding potential of dietary supplements, vitamins, and herbal/botanical products was low (average score = 8/56 =14 %). There was no single question that most participants answered correctly. Even patients who took aspirin were not fully aware that it was associated with bleeding risk. Factors which didnot significantly impact score included gender, supplement usage, use of prescription anticoagulation, alcohol drinking status, history of skin biopsy or surgery, and history of complication after cutaneous procedure or surgery. Based on linear regression, increasing participant age had a significant negative correlation (correlation coefficient -0.6764; p=8.465e-05) with overall score. While alcohol drinking status did not influence overall score positively or negatively, participants who drank more than 4 standard alcoholic beverages a week were nominally but not significantly more likely to know that drinking alcohol can impair blood clotting and increase the risk of bleeding. Regarding how participants liked to receive health education (multiple formats could be chosen), participant responses were as follows: written only (32%), email/text only (28%), written and email/text (11%), written, video and email/text (8%), written and video (5%), video only (4%) and unspecified (12%). Regarding participants’ opinions about whether receiving information about the bleeding risk potential of over-the-counter supplements before procedures would be helpful, 88% answered yes, 8% said no, and 4% did not specify. Discussion Little has been published about patient knowledge regarding the increased bleeding risks associated with specific over-the-counter vitamins, supplements, herbal/botanical products, and alcohol intake. Supplement use has become extremely popular to the extent that $55 billion was spent in 2020 in the US on vitamins and supplements. (60) According to the National Health and Nutrition Examination Survey (NHANES), 52% of all adult Americans take dietary supplements. (61) More specifically, older adults (71+ years) were identified as the highest consumers of dietary supplements. (61) Given these facts, providing enhanced patient education about the bleeding potential of common dietary supplements, vitamins, herbal/botanical products, and alcohol could reduce post-operative complications such as bleeding, hematoma formation, and abnormal wound healing. In the modern quest to improve health and practice self-care, people have looked to supplements and vitamins for a variety of reasons including improving overall health, refining blood sugar management, reducing joint pain and inflammation, improving immunity, and augmenting dermatologic, cardiovascular, urinary, digestive and mental health. As daily life has gotten busier and everyday responsibilities have multiplied, individuals have less time to cook and eat balanced meals, and they cannot be sure that they are getting everything they need from their diet. Past survey research in postmenopausal females by Albertazzi et al examined the reason why people take food supplements as well as the perceived efficacy and risks of these supplements. (62) A significant proportion of participants (66%) thought that food supplements helped to maintain good health. Among supplement users, 43% percent felt the products were very effective and over 49% of them noted an improvement of symptoms. While the majority (51%) did endorse that supplements may have side effects, over 66% would not attribute adverse effects to the food supplement. (62) In our study, participants similarly did not associate potential side effects (impaired blood clotting and increased risk of excess bleeding) with the supplements, vitamins, herbal/botanical products, and alcohol that actually can impede blood clotting and increase the chance of bleeding. (1-58) Healthy aging may be a contemporary societal goal. This notion of seeking good health at all points in the aging continuum may have prompted researchers to conceptualize the idea of “healthspan,” a term defined as health-adjusted life expectancy by which years of life are weighted by health status. (63, 64) Health-adjusted life expectancy approximates healthy longevity offering, an indicator of health and quality of life. (64-66) In a recent study, Terzic et al found that gains in life expectancy have not been matched by a corresponding increase in health-adjusted life expectancy. While this discrepancy was represented globally, the healthspan-lifespan gap was most pronounced in the United States. Of note, women worldwide had a larger healthspan-lifespan gap than men. (64) Perhaps, an attempt to bridge this health longevity-life expectancy gap is why people often turn to supplements as they age. Our study reveals a significant deficiency in what participants know about the potential bleeding risks of specific common supplements, vitamins, herbal/botanical products, and alcohol, as evidenced by the average survey score being only 8/56 =14 % correct. Participants were similarly unaware that certain supplements, vitamins and products mentioned in the survey such as vitamin K, homocysteine, collagen, probiotics, chromium, iron, calcium, and psyllium do not increase the risk of bleeding. (1-58) Within the context of the survey, distractor products and repetition of selected supplements were also utilized in questions to gain better insight into what participants did or did not know. This knowledge gap was not unexpected given that earlier findings from the National Assessment of Adult Literacy (NAAL) identified that only 12% of Americans have proficient health literacy skills. (67) The majority (69%) of participants in our study affirmed that they took dietary supplements and vitamins. This is consistent with earlier research, which also found that more than half of all US adults take supplements. (60) Even for this cohort’s the most commonly reported medically directed drug, aspirin, which 50% of our study participants took, only 61% of all participants surveyed were aware of its potential bleeding risk. This lack of knowledge about the adverse risks of aspirin is concerning especially in patients who may be undergoing surgical procedures. In a recent systematic meta-analysis review, Romain et al found that in 26,860 procedures reviewed, a statistically significant increase in odds of bleeding of any severity (16,748 procedures included) OR 1.39 (1.02-1.90) and for bleeding of severe severity (12,311 procedures included) OR 2.46 (1.53-3.95) was identified in patients taking aspirin. Their analysis identified a statistically significant increase in postoperative bleeding risk for patients taking aspirin and undergoing cutaneous surgery. (39) In our survey, we found that older participants were less likely to have extensive knowledge about supplements and over-the-counter products being associated with bleeding risks. In fact, increasing participant age had a significant negative correlation with overall score (correlation coefficient -0.6764; p=8.465e-05). Overall, knowledge on the subject was limited across all age groups. Therefore, educating all people who will be undergoing cutaneous surgery should be a central priority. Another consumable product that can affect bleeding risk is alcohol. Gallup, Inc reported in 2021 that 65% of US adults aged 21 years old or more drink alcohol. (68, 69) According to the CDC, Americans spent around $253 billion in alcohol in 2018 with average households spending $583 per year.(69, 70) Notably, nearly half (49%) of our participants drank alcohol regularly (on a weekly basis). While this percentage is consistent with the drinking habits of the general population, alcohol intake can have unintended bleeding effects for patients undergoing surgery. Previous research has demonstrated multiple alterations in platelet function and prolonged bleeding time, inhibition of platelet adhesion to fibrinogen, impairment of fibrinolysis, slower rates of fibrin formation and fibrin cross-linking, and reduced fibrinogen and fibrin functionality. (1) Similarly, another recreational and/or medicinal product, marijuana (cannabis and its derivatives), through various mechanisms, has also been shown to cause interactions with blood thinners such as warfarin, direct oral anticoagulants, and clopidogrel which can result in bleeding events and complications. (37) On its own, cannabis is also known to have independent anticoagulant effects through inhibition of thrombin-induced clot formation and adrenaline- and adenosine diphosphate–induced platelet aggregation in a dose dependent manner. (37, 38) Mamas et al suggests that given the potential effects on the coagulation cascade, platelet biology, and drug metabolism, physicians should try to ask and record patients’ history of marijuana use and advise them of potential bleeding risks, particularly in the context of treatment with antithrombotic regimens. (37) The lack of patient knowledge in this survey is an impetus for the refinement and distribution of understandable patient education resources on this topic. Participants’ responses as to their preferred methods of receiving health information were not uniform. While many favored only written pamphlets, email or text reminders, others desired purely video education or being able to receive information in multiple formats. In this survey, a possible rationale for participants’ preference for written or email/text reminders regarding the bleeding risks associated with specific supplements is that participants may want to be able to review and compare a ‘list’ versus supplements they take at home before an upcoming surgery. While a video format can provide an effective and accessible means of broad education on health topics (71, 72), the granular details on which supplements that have associated bleeding risks may be more easily perused in the paper or electronic written format. Each patient is unique, and preferences for the method of receiving education may change over time or depending on circumstances. Since patients may be making important decisions on which supplements or products might be proactively stopped in the perioperative period to minimize bleeding risks after cutaneous surgery, information should be available in their preferred format. Limitations of this study include that it had a small participant pool, recruited participants were dermatology patients, and it was performed at only 2 sites, so results may not be generalizable. Additionally, we only surveyed participants’ baseline knowledge as opposed to testing them again after reading the answer key/information sheet. Extended demographic information such as zip code, years of education, occupation and income level were not collected due to scheduling time constraints. Conclusion Overall, most participants were largely unaware of the potential bleeding risks of specific common supplements, vitamins, herbal/botanical products and alcohol as reflected by their low overall scores on this survey. Older participants were less likely to have pre-existing knowledge about bleeding risks. Educating all patients who are undergoing cutaneous surgery about specific supplement-related bleeding risks should be a priority. Most participants thought pre-procedural education on the topic would be beneficial and were open to receiving health information. Since supplement use is widespread in our society, pre-operative education may help reduce post-operative bleeding risks and abnormal healing. Educating patients who will be undergoing cutaneous surgery provides them the opportunity to take physician-guided proactive steps. Armed with further education, patients could opt to pause certain supplements and products during the pre-, peri- and/or postoperative phases to sidestep potentially avoidable adverse outcomes. For the broadest reach and maximal impact, health education on this topic should ideally use plain language, be easily distributed by health care team members and be available in multiple formats. Declarations Author Contribution ETH- Conception and design, writing and editing of manuscript, data analysis and interpretationEB - Writing and editing of manuscript, participant recruitment, data collection, data analysis andinterpretationNQ- data analysis and interpretation, writing and editing of manuscriptLM- writing and editing of manuscriptRM- writing and editing of manuscriptMS- writing and editing of manuscriptKC- editing of manuscriptOB- editing of manuscriptEK- editing of manuscriptID- editing of manuscriptAC- editing of manuscriptCM- editing of manuscriptGDC- participant recruitment, data collection, editing of manuscriptPS- conception and design, editing of manuscriptJML- conception and design, writing and editing of manuscript Data Availability The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request. 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Construction and evaluation of a practical model for measuring health-adjusted life expectancy (HALE) in China. BMC Public Health. 2024;24(1):1667. Services USDoHaH. America’s Health Literacy: Why We Need Accessible Health Information.2008 6/4/2025:[8 p.]. What Percentage of Americans Drink Alcohol?2022 6/4/2025. Available from: https://news.gallup.com/poll/467507/percentage-americans-drink-alcohol.aspx. Thiel K PG. Consumer expenditures in 20222023 6/4/2025. Available from: https://www.bls.gov/opub/reports/consumer-expenditures/2022/#:~:text=Average%20annual%20expenditures%20grew%20by,(15.7%20percent)%20from%202019. U.S. Beverage Alcohol Spending Hits $253.8 Billion in 2018, +5.1% versus 20172019 6/4/2025. Available from: https://www.bw166.com/2019/01/13/u-s-beverage-alcohol-spending-hits-253-8-billion-in-2018-5-1-versus-2017/. Lenczowski E, Tung-Hahn E, Higareda J, McCormick C, Markoff T, Arffa M, et al. Video education to improve recognition of common benign and malignant cutaneous lesions and skin cancer prevention in the public. Int J Womens Dermatol. 2018;4(2):80-2. Carnemolla AR, Tung-Hahn E, Solorzano G, Farid M, Quint N, Campbell C, et al. Improving Knowledge and Awareness of Diabetes-associated Skin Manifestations in a Resource Limited Setting: A Video Education Pilot Study. J Clin Aesthet Dermatol. 2025;18(3-4 Suppl 1):S34-S7. Additional Declarations No competing interests reported. Supplementary Files supplementalfigure1survey.pdf supplementalfigure2answerkey.pdf supplementalfigure3informationsheet.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 19 Jun, 2025 Reviewers agreed at journal 19 Jun, 2025 Reviews received at journal 19 Jun, 2025 Reviewers agreed at journal 19 Jun, 2025 Reviewers invited by journal 18 Jun, 2025 Editor assigned by journal 18 Jun, 2025 Submission checks completed at journal 18 Jun, 2025 First submitted to journal 16 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6909674","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":473746439,"identity":"0f1aaf81-705d-411d-8f20-fb9d1fa8ef63","order_by":0,"name":"Eleanor 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15:22:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":429738,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6909674/v1/f15b9abb-7ed8-48d5-b711-790e283c8e43.pdf"},{"id":85067573,"identity":"f0dd5293-8c01-4bc9-aae1-6739be53452c","added_by":"auto","created_at":"2025-06-20 15:14:36","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":544876,"visible":true,"origin":"","legend":"","description":"","filename":"supplementalfigure1survey.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6909674/v1/787e3b93f6b110f342e4d0bd.pdf"},{"id":85067574,"identity":"bc21ed89-ae8c-49a5-aa59-05a0c0b1fc93","added_by":"auto","created_at":"2025-06-20 15:14:36","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":88316,"visible":true,"origin":"","legend":"","description":"","filename":"supplementalfigure2answerkey.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6909674/v1/59c8b1fc543478ffe8c40e87.pdf"},{"id":85067580,"identity":"171137a9-b722-4771-926a-871ded838813","added_by":"auto","created_at":"2025-06-20 15:14:36","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":233017,"visible":true,"origin":"","legend":"","description":"","filename":"supplementalfigure3informationsheet.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6909674/v1/c98011b10d9d9b481d40e59f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Patient Awareness and Knowledge about Bleeding Risks Associated with Common Dietary Supplements","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePatient knowledge about the bleeding risk potential associated with consumption of selected over-the-counter vitamins, supplements, herbal/botanical products and with alcohol intake is not well-studied. Patients’ understanding of the possible risks could encourage them to be proactive about pausing these products in the perioperative and postoperative periods. \u0026nbsp;This, in turn, may minimize intra-operative and post-operative bleeding, hematoma formation, and related wound healing complications. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBased on prior reports, various dietary supplements, vitamins, herbal and botanical products, cannabis, and alcohol have been documented to increase the risk of perioperative bleeding, either on their own or by interaction with other medications. \u0026nbsp; Bleeding may be actuated directly, by a biochemical effect of the product, or by affecting the coagulation pathway or platelet aggregation.\u0026nbsp;(1-58)\u003c/p\u003e\n\u003cp\u003ePatients may not be the only group who are unaware of the bleeding risks associated with dietary supplements. In one study, even surgeons were unaware of the side-effect profiles for 90% of the medicinal supplements that were assessed. (40, 41) Notably, to avoid more serious health risks associated with discontinuation, for outpatient cutaneous procedures such as excision, patients are often advised to continue their prescribed or physician directed anticoagulant and antiplatelet therapies unless there are compelling risks. (2, 3) However, instructions regarding cessation or continuation of over-the-counter supplements are less clear-cut. To assess the extent of participants’ knowledge regarding the bleeding risk association with common dietary supplements and other non-prescription products that may be routinely ingested, a survey was administered to participants.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA multicenter in-person survey study of consenting consecutive\u0026nbsp;adult patients was conducted in two dermatology clinics to assess their knowledge regarding the increased risk of bleeding associated with specific common over-the-counter vitamins, supplements, herbal/botanical products, and alcohol. The first part of the survey consisted of 56 questions that ascertained baseline knowledge about bleeding risk associated with specific products, which were selected based on a literature search. \u0026nbsp;Google and PubMed were searched (Google, accessed January 2024). The supplements and products included in the survey were chosen based on Google and PubMed searches using the following key words: [(supplement, vitamin, alcohol, OR cannabis) AND (thrombosis, platelet aggregation, bleeding risk, complication, interaction with blood thinners, OR bleeding episodes)] and [(supplement, vitamin, alcohol, OR cannabis) AND (perioperative complication)]. Review articles, case reports and single-arm studies were included due to the paucity of controlled studies. The second part of the survey consisted of 5 questions about their personal use of supplements and alcohol, and whether they have had any issues with peri-procedural bleeding or delayed post-operative healing in the past. The third part of the survey consisted of 3 questions eliciting basic demographic information. Upon completion of the survey, each participant was given an answer key and information sheet. [Supplemental figures 1(survey), 2 (answer key),3 (information sheet)]. This survey study was deemed exempt by the Institutional Review Board of the Lake Erie College of Osteopathic Medicine (IRB exemption no. 31-108).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis:\u003c/strong\u003e Descriptive statistics were obtained. \u0026nbsp; Kruskal Wallis tests were performed to assess the association of specific participant characteristics (age, gender, supplement usage, prescribed or directed anticoagulant usage, alcohol intake, history of biopsy or surgery, history of post-procedural bleeding or wound healing complications) to overall score. Additionally, we assessed the correlation between the quantity of weekly alcohol intake to patient knowledge that alcohol can impair blood clotting and increase risk of bleeding. \u0026nbsp;Total score was plotted against age of participants, and linear regression was used to develop a line of best fit. All statistical analyses were conducted using the program R running in RStudio version 2023.12.1.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 110 patients invited to participate, 102 provided informed consent and completed the survey (93% response rate). \u0026nbsp;Forty-seven participants identified as female, 54 as male and 1 did not specify. Age ranged from 23 to 91 years (mean, 68). \u0026nbsp;Racial/ethnic self-identification included: White/Caucasian (95), Hispanic/Latino (2), Black/African American (3), Asian/Pacific Islander (1) and preferred not to specify (1). Sixty-nine percent of participants reported regularly taking vitamins, dietary supplements or herbal or botanical supplements, while 30% stated they did not take any and 1% did not specify. Of those who routinely took vitamins and supplements, the most frequently reported types were vitamin D (44%), multiple vitamin (36%), fish oil (11%), turmeric (10%), zinc (7%) and vitamin E (4%), and 63% regularly took two or more varieties.\u003c/p\u003e\n\u003cp\u003eForty-one percent of participants were on a prescription blood thinning medication or were taking prescribed or physician-directed non-steroidal anti-inflammatory (NSAID) medications (e.g., ibuprofen, naproxen, meloxicam, celecoxib or other), 57% were not and 2% did not specify. Twenty-six percent of patients took NSAIDs on a daily basis. Fifty percent of participants took aspirin, either alone or in combination with another anticoagulant, 29% of participants took direct factor Xa inhibitors (e.g., rivaroxaban, edoxaban, and apixaban), and 7% were on clopidogrel.\u003c/p\u003e\n\u003cp\u003eIn this cohort, 49% drank alcoholic beverages weekly, 50% did not drink, and 1% did not specify. \u0026nbsp; Of the participants who did drink, 70% had 1-3 standard drinks per week, 22% 4-7, and 8% 8 or more. \u0026nbsp;A standard alcoholic drink was defined as any beverage containing 0.6 fluid ounces or 14 grams of pure alcohol-- roughly equivalent to 1 can (12 ounces) of beer, 5 ounces of wine, or a 1.5 ounce shot of 80 proof distilled spirits (e.g., gin, rum, tequila, vodka, whiskey). (59)\u003c/p\u003e\n\u003cp\u003eRegarding the history of cutaneous procedures in our cohort, 90% had a history of skin biopsy or surgery and 10% did not. In terms of post-procedural complications after skin biopsy or cutaneous surgery, 83% of participants did not have any issues while 17% endorsed a history of minor post-procedural issues. Among the 17 participants who stated that they had experienced complications, post-operative events included lengthy or delayed healing (53%), postoperative bleeding (29%), excessive bruising (12%) and scarring (6%).\u003c/p\u003e\n\u003cp\u003eParticipants’ overall knowledge about the bleeding potential of dietary supplements, vitamins, and herbal/botanical products was low (average score = 8/56 =14 %). There was no single question that most participants answered correctly. Even patients who took aspirin were not fully aware that it was associated with bleeding risk. Factors which didnot significantly impact score included\u0026nbsp;gender, supplement usage, use of prescription anticoagulation, alcohol drinking status, history of skin biopsy or surgery, and history of complication after cutaneous procedure or surgery. \u0026nbsp;Based on linear regression, increasing participant age had a significant negative correlation (correlation coefficient -0.6764; p=8.465e-05) with overall score.\u003c/p\u003e\n\u003cp\u003eWhile alcohol drinking status did not influence overall score positively or negatively, participants who drank more than 4 standard alcoholic beverages a week were nominally but not significantly more likely to know that drinking alcohol can impair blood clotting and increase the risk of bleeding. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding how participants liked to receive health education (multiple formats could be chosen), participant responses were as follows: written only (32%), email/text only (28%), written and email/text (11%), written, video and email/text (8%), written and video (5%), video only (4%) and unspecified (12%).\u003c/p\u003e\n\u003cp\u003eRegarding participants’ opinions about whether receiving information about the bleeding risk potential of over-the-counter supplements before procedures would be helpful, 88% answered yes, 8% said no, and 4% did not specify.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eLittle has been published about\u0026nbsp;patient knowledge regarding the increased bleeding risks associated with specific over-the-counter vitamins, supplements, herbal/botanical products, and alcohol intake. Supplement use has become extremely popular to the extent that $55 billion was spent in 2020 in the US on vitamins and supplements. (60)\u0026nbsp; According to the National Health and Nutrition Examination Survey (NHANES), 52% of all adult Americans take dietary supplements. (61) More specifically,\u0026nbsp;older adults (71+ years) were identified as the highest consumers of dietary supplements.\u0026nbsp;(61)\u003c/p\u003e\n\u003cp\u003eGiven these facts, providing enhanced patient education about the bleeding potential of common dietary supplements, vitamins, herbal/botanical products, and alcohol\u0026nbsp;could reduce post-operative complications such as bleeding, hematoma formation, and abnormal wound healing.\u003c/p\u003e\n\u003cp\u003eIn the modern quest to improve health and practice self-care, people have looked to supplements and vitamins for a variety of reasons including improving overall health, refining blood sugar management, reducing joint pain and inflammation, improving immunity, and augmenting dermatologic, cardiovascular, urinary, digestive and mental health. \u0026nbsp;As daily life has gotten busier and everyday responsibilities have multiplied, individuals have less time to cook and eat balanced meals, and they cannot be sure that they are getting everything they need from their diet. Past survey research in postmenopausal females by Albertazzi et al examined the reason why people take food supplements as well as the perceived efficacy and risks of these supplements. (62) A significant proportion of participants (66%) thought that food supplements helped to maintain good health. Among supplement users, 43% percent felt the products were very effective and over 49% of them noted an improvement of symptoms. While the majority (51%) did endorse that supplements may have side effects, over 66% would not attribute adverse effects to the food supplement. (62)\u0026nbsp; In our study, participants similarly did not associate potential side effects (impaired blood clotting and increased risk of excess bleeding) with the supplements, vitamins, herbal/botanical products, and alcohol that actually can impede blood clotting and increase the chance of bleeding. \u0026nbsp;(1-58)\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHealthy aging may be a contemporary societal goal. This notion of seeking good health at all points in the aging continuum may have prompted researchers to conceptualize the idea of\u0026nbsp;“healthspan,” a term defined as health-adjusted life expectancy by which years of life are weighted by health status. (63, 64)\u0026nbsp; Health-adjusted life expectancy approximates healthy longevity offering, an indicator of health and quality of life. (64-66) In a recent study, Terzic et al found that gains in life expectancy have not been matched by a corresponding increase in health-adjusted life expectancy. While this discrepancy was represented globally, the healthspan-lifespan gap was most pronounced in the United States. Of note, women worldwide had a larger healthspan-lifespan gap than men. (64) Perhaps, an attempt to bridge this health longevity-life expectancy gap is why people often turn to supplements as they age.\u003c/p\u003e\n\u003cp\u003eOur study reveals a significant deficiency in what participants know about the potential bleeding risks of specific common supplements, vitamins, herbal/botanical products, and alcohol, as evidenced by the average survey score being only 8/56 =14 % correct. \u0026nbsp;Participants were similarly unaware that certain supplements, vitamins and products mentioned in the survey such as vitamin K, homocysteine, collagen, probiotics, chromium, iron, calcium, and psyllium do not increase the risk of bleeding.\u0026nbsp;(1-58)\u0026nbsp; Within the context of the survey, distractor products and repetition of selected supplements were also utilized in questions to gain better insight into what participants did or did not know.\u003c/p\u003e\n\u003cp\u003eThis knowledge gap was not unexpected given that earlier findings from the National Assessment of Adult Literacy (NAAL) identified that only 12% of Americans have proficient health literacy skills. (67) The majority (69%) of participants in our study affirmed that they took dietary supplements and vitamins. This is consistent with earlier research, which also found that more than half of all US adults take supplements. (60)\u003c/p\u003e\n\u003cp\u003eEven for this cohort’s the most commonly reported medically directed drug, aspirin, which 50% of our study participants took, only 61% of all participants surveyed were aware of its potential bleeding risk. This lack of knowledge about the adverse risks of aspirin is concerning especially in patients who may be undergoing surgical procedures. In a recent systematic meta-analysis review, Romain et al found that in 26,860 procedures reviewed, a statistically significant increase in odds of bleeding of any severity (16,748 procedures included) OR 1.39 (1.02-1.90) and for bleeding of severe severity (12,311 procedures included) OR 2.46 (1.53-3.95) was identified in patients taking aspirin.\u0026nbsp;Their analysis identified a statistically significant increase in postoperative bleeding risk for patients taking aspirin and undergoing cutaneous surgery.\u0026nbsp;(39)\u003c/p\u003e\n\u003cp\u003eIn our survey, we found that older participants were less likely to have extensive knowledge about supplements and over-the-counter products being associated with bleeding risks. In fact, increasing participant age had a significant negative correlation with overall score (correlation coefficient -0.6764; p=8.465e-05). Overall, knowledge on the subject was limited across all age groups.\u0026nbsp;Therefore, educating all people who will be undergoing cutaneous surgery should be a central priority.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother consumable product that can affect bleeding risk is alcohol. Gallup, Inc reported in 2021 that 65% of US adults aged 21 years old or more drink alcohol. (68, 69) According to the CDC, Americans spent around $253 billion in alcohol in 2018 with average households spending $583 per year.(69, 70) \u0026nbsp;Notably, nearly half (49%) of our participants drank alcohol regularly (on a weekly basis). While this percentage is consistent with the drinking habits of the general population, alcohol intake can have unintended bleeding effects for patients undergoing surgery. \u0026nbsp;Previous research has demonstrated multiple alterations in platelet function and prolonged bleeding time, inhibition of platelet adhesion to fibrinogen, impairment of fibrinolysis, slower rates of fibrin formation and fibrin cross-linking, and reduced fibrinogen and fibrin functionality. (1)\u003c/p\u003e\n\u003cp\u003eSimilarly, another recreational and/or medicinal product, marijuana (cannabis and its derivatives), through various mechanisms, has also been shown to cause interactions with blood thinners such as warfarin, direct oral anticoagulants, and clopidogrel which can result in bleeding events and complications. (37) On its own, cannabis is also known to have independent anticoagulant effects through inhibition of thrombin-induced clot formation and adrenaline- and adenosine diphosphate–induced platelet aggregation in a dose dependent manner. (37, 38) Mamas et al suggests that given the potential effects on the coagulation cascade, platelet biology, and drug metabolism, physicians should try to ask and record patients’ history of marijuana use and advise them of potential bleeding risks, particularly in the context of treatment with antithrombotic regimens. (37)\u003c/p\u003e\n\u003cp\u003eThe lack of patient knowledge in this survey is an impetus for the refinement and distribution of understandable patient education resources on this topic. Participants’ responses as to their preferred methods of receiving health information were not uniform. While many favored only written pamphlets, email or text reminders, others desired purely video education or being able to receive information in multiple formats. In this survey, a possible rationale for participants’ preference for written or email/text reminders regarding the bleeding risks associated with specific supplements is that participants may want to be able to review and compare a ‘list’ versus supplements they take at home before an upcoming surgery. While a video format can provide an effective and accessible means of broad education on health topics (71, 72), the granular details on which supplements that have associated bleeding risks may be more easily perused in the paper or electronic written format. Each patient is unique, and preferences for the method of receiving education may change over time or depending on circumstances. Since patients may be making important decisions on which supplements or products might be proactively stopped in the perioperative period to minimize bleeding risks after cutaneous surgery, information should be available in their preferred format. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLimitations of this study include that it had a small participant pool, recruited participants were dermatology patients, and it was performed at only 2 sites, so results may not be generalizable. Additionally, we only surveyed participants’ baseline knowledge as opposed to testing them again after reading the answer key/information sheet. Extended demographic information such as zip code, years of education, occupation and income level were not collected due to scheduling time constraints.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOverall, most participants were largely unaware of the potential bleeding risks of specific common supplements, vitamins, herbal/botanical products and alcohol as reflected by their low overall scores on this survey. \u0026nbsp;Older participants were less likely to have pre-existing knowledge about bleeding risks. Educating all patients who are undergoing cutaneous surgery about specific supplement-related bleeding risks should be a priority. \u0026nbsp; Most participants thought pre-procedural education on the topic would be beneficial and were open to receiving health information. Since supplement use is widespread in our society, pre-operative education may help reduce post-operative bleeding risks and abnormal healing. Educating patients who will be undergoing cutaneous surgery provides them the opportunity to take physician-guided proactive steps. Armed with further education, patients could opt to pause certain supplements and products during the pre-, peri- and/or postoperative phases to sidestep potentially avoidable adverse outcomes. For the broadest reach and maximal impact, health education on this topic should ideally use plain language, be easily distributed by health care team members and be available in multiple formats.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eETH- Conception and design, writing and editing of manuscript, data analysis and interpretationEB - Writing and editing of manuscript, participant recruitment, data collection, data analysis andinterpretationNQ- data analysis and interpretation, writing and editing of manuscriptLM- writing and editing of manuscriptRM- writing and editing of manuscriptMS- writing and editing of manuscriptKC- editing of manuscriptOB- editing of manuscriptEK- editing of manuscriptID- editing of manuscriptAC- editing of manuscriptCM- editing of manuscriptGDC- participant recruitment, data collection, editing of manuscriptPS- conception and design, editing of manuscriptJML- conception and design, writing and editing of manuscript\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eEismann H, Sieg L, Ahmed H, Teske J, Behrendt P, Friedrich L, et al. 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J Clin Aesthet Dermatol. 2025;18(3-4 Suppl 1):S34-S7.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-dermatological-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Archives of Dermatological Research](https://www.springer.com/journal/403)","snPcode":"403","submissionUrl":"https://submission.nature.com/new-submission/403/3","title":"Archives of Dermatological Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Blood thinner, dietary supplement, vitamin, bleeding risk, anticoagulant","lastPublishedDoi":"10.21203/rs.3.rs-6909674/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6909674/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePost-operative complications such as bleeding, hematoma formation and abnormal healing may be mitigated by withholding selected over-the-counter products including dietary supplements. Little is known about patients\u0026rsquo; knowledge on this subject.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo assess participants\u0026rsquo; baseline knowledge about common over-the-counter supplements, vitamins, herbal/botanical products as well as other substances (e.g., alcohol) that can be associated, if ingested, with an increased risk of bleeding during outpatient surgical procedures.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA survey administered to a willing consecutive sample of adults regarding their: baseline knowledge about possible bleeding risks associated with commonly taken dietary supplements and products; personal use of supplements and alcohol; history of post-procedural bleeding or healing issues; and personal demographic characteristics.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOne hundred and two participants completed the survey (93% response rate). Overall knowledge of risks was low (average score\u0026thinsp;=\u0026thinsp;8/56\u0026thinsp;=\u0026thinsp;14%). Gender, supplement usage or non-usage, and use of prescription anticoagulants did not significantly impact score. Increasing age was negatively correlated with score. 69% of participants reported routinely taking supplements of any kind. 88% thought receiving information on this topic before surgical procedures about supplements that could affect procedure-related bleeding would be helpful.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eMost participants were unaware of the potential bleeding risks of common dietary supplements but wanted education on the topic. Pre-operative education that encourages patients to hold selected supplements and other ingested substances may reduce peri-operative bleeding risk associated with cutaneous surgery.\u003c/p\u003e","manuscriptTitle":"Patient Awareness and Knowledge about Bleeding Risks Associated with Common Dietary Supplements","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-20 15:14:31","doi":"10.21203/rs.3.rs-6909674/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-06-19T17:18:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"10750195008659924251422579504820906992","date":"2025-06-19T17:12:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-19T15:05:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"256890830735013218185257519770956751050","date":"2025-06-19T15:03:31+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-18T15:27:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-18T09:34:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-18T09:33:31+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Dermatological Research","date":"2025-06-17T02:48:10+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-dermatological-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Archives of Dermatological Research](https://www.springer.com/journal/403)","snPcode":"403","submissionUrl":"https://submission.nature.com/new-submission/403/3","title":"Archives of Dermatological Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"e80d3f18-6c55-4bfd-a77f-22fbc9cd4a53","owner":[],"postedDate":"June 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-06-20T15:14:31+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-20 15:14:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6909674","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6909674","identity":"rs-6909674","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}