Knowledge, attitudes, and practices regarding food-medicine dual-purpose substances among adults in China: a cross-sectional online survey

Abstract

Background

Food medicine homology originated in ancient China and has been officially named food-medicine dual-purpose substances (FMS). However, the relationship between residents’ knowledge, attitudes, practices (KAP) and FMS among adults in China remains unclear. This study evaluated the current situation of FMS-related knowledge, awareness and actual consumption behaviors and practices of Chinese residents to provide a basis for both perfect related regulations and scientific advice on FMS consumption.

Methods

A cross-sectional online survey on FMS perception and consumption was conducted through a convenience sampling strategy from August to December 2020. A total of 2,815 residents (96.3% were aged between 18 and 50 years old, 47.8% were male and 52.2% were female) from 31 provinces were recruited for this study. Descriptive analysis and multivariate logistic regression analysis was performed in the statistical analysis.

Results

The results showed that residents’ identification of FMS had an accurate response rate of 22.7% (640/2,815). Educational level was the factor associated with residents’ knowledge of FMS. A total of 62.0% (1,744/2,815) of the residents would take the initiative to learn more about FMS. 93.8% (2,639/2,815) of them thought that manufacturers should make clear food labels when they add FMS. Almost half of the residents bought FMS products frequently (more than 12 times per year), and 96.1% (1,880/2,747) of the residents bought FMS mainly used for healthcare. Among the FMS they had ever consumed, the two most frequently consumed FMS by residents were yam (35.3%) and wolfberry (15.9%). 40.6%(1,143/2,815) of residents hoped that the government could increase publicity and conduct more popular science activities.

Conclusion

The findings indicate that adult residents in China who have substantial knowledge of FMS are not optimistic; however, they express positive attitudes toward knowing and consuming FMS, and there is a high need for labeling and a high demand for consumption. It is imperative to enhance research and policy development regarding FMS, to actively promote FMS knowledge, and to guide residents towards a more scientific and rational consumption of FMS in the future.

Background

The concept of food medicine homology, or one root of food and medicine, an affinal drug and diet, a food and medicine continuum, among others, which has been officially named food-medicine dual-purpose substances (FMS), has existed in China for thousands of years. Hippocrates as well as the book named “Huangdi Neijing (Huangdi’s internal classic)” had stated that ‘let medicine be thy food and food be thy medicine’, the food and medicine continuum is a common phenomenon in the world. FMS that can be used as both food and medicine are also commonly referred to as Medicine Food Homology (MFH) in China because there is no obvious boundary between their ‘food’ and ‘medicine’ properties [1]. The concept of FMS originated in ancient China and has continued for centuries, and its application in modern functional foods has been described [1, 2]. In fact, many crude Traditional Chinese Medicine (TCMs) or Chinese herbal medicine (CHM), such as Barbary wolfberry fruit (Lycium barbarum L.), adhere to the principle of FMS [1]. To date, 106 kinds of substances were listed in the FMS catalog in 1987, 2002, 2019, 2023 and 2024 by the National Health Commission of the People’s Republic of China, and FMS management regulations were issued in November 2021 [3].

FMS contain many bioactive substances and secondary metabolites (such as flavonoids, polysaccharide, tannin) and are of considerable value for nutrition, health protection, and comprehensive utilization [1, 2]. People worldwide use or consume these types of food–medicines, for example, common yam rhizome (Rhizoma dioscoreae), Chinese date(Ziziphus), although there are some differences in the name of the FMS list, the parts to be consumed, the dietary patterns or habits, and all other aspects, resulting in different knowledge, attitudes and consumption behaviors [4,5,6,7,8]. With the ever-increasing burden of chronic diseases around the world, governments are making efforts to integrate food and nutrition into the prevention and treatment of diet-related diseases in healthcare, implying that food is a medicine and emphasizing the importance of nutritional security [9, 10]. Previous studies [11,12,13,14] have focused on the nutritional and pharmacological properties as well as the health mechanisms of FMS or similar concepts. Several studies have shown that the use of plants as food and medicine is common among local people [4,5,6], indicating that the sources of knowledge based on various approaches, such as books, the internet, friends, colleagues or neighbors [7], and the use and perceptions that influence the consumption of food-medicines depend on factors such as age, education, availability and taste [5, 8]. However, the relationship between knowledge, attitudes, practices (KAP) and FMS among adults in China remains unclear. Therefore, this study aims to achieve a better understanding of the knowledge, attitudes, and practices regarding FMS among adults in China, which will provide the basis for perfect relevant regulations and provide people with scientific advice on FMS consumption.

Methods

Participants

Chinese residents aged 18 years or older were eligible to participate in the survey. Inclusion criteria: age ≥ 18 years; local residence ≥ 6 months; able to independently complete the online e-questionnaire; IP address in China. Exclusion criteria: those who took less than 70 s to complete the questionnaire (the shortest time normally required to read the questionnaire in its entirety); those who answered the questionnaire incompletely; and those who answered the questionnaire repeatedly.

Procedures

Sampling method and survey design

This study adopted a convenience sampling method and surveyed permanent adult residents of China by publishing an online Wenjuanxing e-questionnaire platform (WJX). The content included the basic sociodemographic information of the residents (age, gender, area of residence, education level, and occupation) as well as knowledge, attitude and consumption behavior survey on FMS.

Sample size calculation

The sample size was calculated according to the sample size calculation formula for simple random sampling n = Z² × σ²/E², where Z statistical value: 1.96 at 95% confidence level, σ: the sample size is the largest when the overall standard deviation is 0.5, and E: the allowable sampling error is taken as ± 3%, which results in a minimum sample size of 1,067 people.

Questionnaire

The self-designed “FMS Special Research-Consumer KAP Questionnaire” was used to conduct an online questionnaire survey on the residents. The self-administered questionnaire was carried out through the WJX platform and placed on the WeChat APP through link sharing and forwarding, QR code image sharing and forwarding. Before the start of the online survey, residents were informed of the purpose of the questionnaire, and all of them gave their informed consent, and the survey process was filled out and submitted online by themselves.

Questionnaire content

The core content of the questionnaire is to understand the knowledge of the residents by setting questions on the FMS catalog list in China, the knowledge of substances and substance properties in the list, the source of information on FMS, the identification of FMS, as well as the five key questions related to FMS(Know that the FMS have a clear catalogue, Know the official number of FMS released to date, Know that the FMS have a clear prescribed dosage, Judge the FMS in the choices correctly, Judge the non-FMS in the choices correctly), to understand the attitudes of the residents towards FMS by setting questions on the willingness to purchase and consume and understand FMS, and the necessity of labeling and marking, and by setting questions on the frequency of purchasing and consuming FMS, Purpose, way, concern, actual consumer goods category and other questions to understand the survey residents’ consumption behavior towards FMS. The options of KAP multiple-choice questions in the questionnaire include: regular single-choice questions, multiple-choice questions, very good, good, average, or need, don’t need, don’t care, or often, occasionally, never, and other similar hierarchical descriptive questions.

Scoring system

The individual received one point for each correct answer, 0 points for an incorrect answer, or if they chose “I don’t know”, or assigning scores and ratings by choosing different scores from 0 to 10.

Quality control

The survey used an electronic questionnaire that was determined through expert discussion and pre-survey testing by the project team, with pre-filled instructions, built-in logical jumps and quality control questions to ensure the validity, accuracy and reliability of the data. The survey project team personnel were uniformly trained, and after the survey was completed, the data were directly exported through the online survey platform, and double-verified by the investigators to exclude duplicate residents based on IP address, microblogging name, and so on. Valid questionnaires that met the inclusion and exclusion criteria were collected and analyzed for the study.

Data analysis

Statistical analysis was performed using SPSS software (version 20.0, IBM Corporation, Armonk, NY, USA). The residents were divided into 7 groups according to their permanent residence status: northern China, eastern China, southern China, central China, northeastern China, northwestern China, and southwestern China. The frequencies and percentages of residents’ sociodemographic characteristics and KAP-related questions were calculated. A series of questions related to the level of knowledge and attitude towards the FMS were set on a scale of 0–10, with higher scores being chosen to indicate a higher level of understanding or trust. residents’ actual knowledge of FMS, as reflected in their scores on five core FMS knowledge questions, was divided into ‘good’ (≥ 3 points) and ‘poor’ (< 3 points) groups. Multivariate logistic regression analysis was performed to identify the factors associated with residents’ knowledge. Based on the open-ended questions, the types of FMS frequently consumed by the residents and their family members in their daily lives were counted, and the frequency of their frequently consumed FMS was analyzed by word frequency statistics and the composition ratio of the top 10 was analyzed. A P value < 0.05 was considered significant.

Results

Sociodemographic characteristics of the residents

A total of 3,000 questionnaires were collected, of which 2,815 were valid after manual verification and screening, for an effective rate of 93.8%. The residents consisted of residents from 31 regions nationwide aged between 18 and 80 years, including 1,345 men (47.8%) and 1,470 women (52.2%) (Table 1).

Table 1 Sociodemographic characteristics of the residents (n = 2,815)

The situation of the residents’ knowledge about FMS

Residents’ knowledge of five key questions related to FMS

A majority, 72.7% (2,045/2,815) of the residents were aware that there was a clear catalog of FMS specified by the state. However, only a small fraction, 18.4% (377/2,045) were cognizant of the precise count of FMS items in the official catalog. Furthermore, 78.3% (2,205/2,815) of the residents were under the impression the current FMS guidelines include specified serving sizes. The accuracy in identifying FMS among consumers is relatively low, with 22.7% (640/2,815) correctly recognizing FMS, and an even smaller percentage, 1.0% (28/2,815), accurately distinguishing non-FMS items (Fig. 1).

Fig. 1

Residents’ knowledge of five core questions related to FMS

Main sources of knowledge and information about FMS

Excluding those 47 residents who were completely unaware of the concept of FMS, a total of 2,768 residents were included in this analysis. The main ways in which residents obtained knowledge and information about FMS (the top four) were through TV and radio (69.1%), the internet, social platforms and software (67.8%), doctors, specialists, nutritionists (51.3%), while traditional media such as books, newspapers, and magazines accounted for 50.4%. The remaining means were relatives and friends (32.9%), community bulletin boards (leaflets) and lectures (29.4%), shopping mall promotions (23.4%), scientific literature (16.8%) and others (0.7%).

Factors associated with residents’ knowledge of FMS

Among the variables in the multi-variable logistic regression analysis, only educational level showed a significant association (Table 2). A level of education within the Bachelor’s, Master’s and Ph.D. degrees was more likely to result in a good knowledge score (score of ≥ 3).

Table 2 Multi-variable logistic regression predicting residents’ knowledge of FMS (n = 2,815)

The residents’ attitudes toward FMS

A total of 62.0% (1,744/2,815) of the residents would take the initiative to learn about FMS, 35.1% (988/2,815) of residents were willing to be passively informed, and the remaining 2.9%(83/2,815) indicated that they were less concerned or did not want to be informed. In terms of propensity to purchase, 62.4% (1,756/2,815) of residents were more likely to purchase a food product if it was labeled as using FMS on the packaging, even if its function was not stated. In total, 93.8% (2,639/2,815) of consumers thought that if manufacturers added FMS to food, it should be indicated on food labels. For the labeling of intake, 90.9% (2,719/2,815) of consumers thought that the intake of FMS should be regulated or stated. 90.1% (2,536/2,815) of residents thought that the government should take active measures to promote FMS-related information.

Residents’ ratings of a series of questions on the level of knowledge and attitudes toward FMS

In terms of the residents’ knowledge of FMS and other concepts as well as functions, all scores of 6 and above were above 70.0%, and less than 2% did not know at all. In terms of the residents’ attitudes, such as the confidence and the health-promoting effect of FMS, all scores ≥ 6 were approximately 80.00%, and those less than 0.3% had no confidence at all and thought that there was no health-promoting effect. The means and standard deviation of understanding degree of FMS concepts as well as the function were 6.72 ± 2.23, 6.49 ± 2.20. The means and standard deviation of assess the current level of trust in knowledge related to FMS, to what extent do you think that FMS can improve your health were 7.29 ± 1.95, 7.03 ± 2.00 (Table 3).

Table 3 The means and standard deviation of different degree scores for a series of degree-related problems regarding FMS knowledge and attitudes

Residents’ behaviors and practices in relation to the purchase and consumption of FMS

Factors influencing residents’ purchase of food containing FMS

Regarding the consumption behavior of purchasing FMS, nearly half of the residents often buy food containing FMS, and 42.8%(1,206/2,815) purchase it occasionally. Among them, 96.1% (1,880/2,747) of residents bought food mainly to improve their health condition and health care, and supermarkets, e-commerce platforms, and pharmacies were the main ways for residents to purchase FMS food, accounting for 34.3% (943/2,747), 31.9% (875/2,747) and 25.0%(686/2,747), respectively. When buying food containing FMS, 43.8% (1,202/2,747) of the residents were concerned with quality, 16.6% (457/2,747) with the presence of FMS, 15.1% (416/2,747) with the price, 12.3% (337/2,747) with the brand, 11.7% (320/2,747) with the health function, and 0.5% (15/2,747) with other purposes, such as taste.

FMS frequently consumed by residents

Out of 2,800 recorded food mentions, 73.7% corresponded to FMS not listed in the official catalog, with the rest being non-FMS items like bananas and ginseng. The most popular FMS were common yam rhizome (35.3%) and Barbary wolfberry fruit (15.9%) (Fig. 2).

Fig. 2

The frequent consumption of FMS by residents

Residents’ suggestions on FMS

Integrating the results of the residents’ suggestions about the current FMS, it was found that 40.6% of consumers hope that the government can increase publicity and conduct more popular science activities, and 18.3% of consumers hope that the government can strengthen the supervision of FMS. Other suggestions or concerns include safety (10.4%), quality control (9.8%) and standardizing the use of FMS (8.2%). A limited number of people focused on price reduction (3.6%), functional identification (2.1%) and other factors (7.0%), such as pesticide residues and food hygiene.

Discussion

FMS-related knowledge may differ among nations or regions due to biocultural differences; therefore, it is necessary to bridge FMS knowledge in Eastern and Western countries [13]. Currently, there are insufficient data from domestic and international studies on FMS, and the knowledge and consumption of FMS by residents are still not clear enough, although several studies have investigated the use of plants as food and medicine [8,9,10], the sources of knowledge [11], the use and perceptions that influence the consumption of food–medicines [9, 12] and so on. Hence, it is imperative to elucidate the present situation of FMS awareness, actual consumption status, and scientific popularization needs of Chinese residents. Furthermore, offering scientific recommendations can serve as a foundational reference for the subsequent formulation of pertinent policies and the implementation of targeted publicity and educational initiatives. This, in turn, will facilitate the ongoing enhancement of residents’ nutritional health and food safety literacy.

This study has investigated the knowledge, attitudes, and consumption of FMS among adults in China, and the main results regarding the current status of residents’ perceptions and consumption of FMS were obtained. The results indicate that the accuracy rates were 22.7% for consumers able to identify FMS, which means that they have a smattering of knowledge about FMS, sometimes they even rarely realize that they have consumed FMS. A level of education within the Bachelor’s, Master’s and Ph.D. degrees was more likely to result in a good knowledge score, which is consistent with the results of related studies [5, 8]. On consumer behaviors, the consumption rate of FMS among the Chinese population was higher than that of medicinal plants in European countries (42.8% vs. 20.1%), and most of them are willing to pay attention to FMS (food labels, potential health benefits) and consume them, which laid the foundation for promoting FMS. However, this study has limitations. Convenience sampling for online surveys limits sample representativeness, especially for the elderly due to device access and usability issues, causing sample bias and impacting result comprehensiveness. Data quality is also affected. Thus, it’s recommended to use multi-stage stratified random sampling for in-depth studies to fully understand intake frequency, usage methods, and factors affecting residents’ consumption of food and drug substances when conditions allow.

China’s diverse dietary habits lead to confusion over FMS among residents, often mistaking it for dietary supplements, herbs, or ordinary food. The concept of “health preservation with food” has gained popularity, especially during the COVID-19 pandemic. Hence, strengthening FMS research, regulatory mechanisms, and developing nutritional FMS food is crucial [15, 16]. This will also promote local economic development and globalize FMS/TCM. Specifically, because the FMS catalog has yet to be unified, it requires an expansion of listed substances and a substantial augmentation of pertinent information, which is currently limited or even scant. This includes an increase in the number of key Latin scientific names, detailed characteristic mappings, accurate processing methods, essential food precautions, and other data that reflect the typical characteristics of these substances. Regulatory bodies should bolster their oversight of major consumer purchase channels, including stores, supermarkets, e-commerce platforms, and pharmacies, to guarantee that consumers have access to safe and reliable FMS. Relevant organizations can augment consumers’ awareness by conducting both online and offline scientific educational activities. Through diverse methods and approaches, these activities will help consumers gain a proper understanding of FMS and use them responsibly, thereby making safe, nutritious, and healthy FMS foods accessible to a broader segment of the population.

Conclusions

As one of the few studies to examine the knowledge, attitudes, and behaviors of Chinese residents toward FMS in theory and practice, it is useful for future understanding of the FMS consumption status of Chinese residents, promoting the development of the FMS industry and consumption policies, and linking the knowledge of FMS and medicinal food (or similarly named substances) between the East and the West to enhance related research and cross-cultural exchanges of traditional health wisdom.

In detail, adults show interest in FMS and prefer clear product labeling. Despite limited knowledge, they have a positive outlook on FMS and a strong desire for increased scientific education on the topic. This study will provide the basis for perfect related regulations and provide people with scientific advice on FMS consumption. Subsequent research and policy on FMS application should be strengthened to scientifically guide residents to consume FMS in a scientific and reasonable way. It is suggest a follow-up survey and research on the consumption of processed foods containing FMS, method of use, and factors affecting residents’ consumption habits and patterns to understand the current situation of FMS in China in all aspects.