|Year : 2021 | Volume
| Issue : 2 | Page : 190-196
Effect of COVID-19 on awareness and consumption of dietary supplements in Saudi Arabia
Sulaiman Abdullah Alshammari, Leena Sami Alwakeel, Jumana Abdullah Alghtani, Laila Mahmoud Alsabbagh
Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
|Date of Submission||02-Dec-2020|
|Date of Decision||23-Jan-2021|
|Date of Acceptance||01-Feb-2021|
|Date of Web Publication||13-Apr-2021|
Sulaiman Abdullah Alshammari
Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh 11461
Source of Support: None, Conflict of Interest: None
Objectives: We aimed to determine the role of the COVID 19 pandemic on dietary supplements' awareness, beliefs and consumption. Methods: A cross-sectional online-based survey distributed through social media was done on 575 participants aged 18 and above and living in Saudi Arabia. The Questionnaire contains sociodemographic, prevalence, type, pattern, and habit of D. S. usage and the effect of COVID-19 on consumption. Data were analyzed using SPSS version 24. Results: The users of D. S. 145 (25.5%), aged between 18 and 25 years old, with higher education levels and higher income. 58% used D. S. before the march, and 66% of D. S. users declared that COVID-19 did not affect their consumption decision. Most D. S. used was vitamins/multivitamins among males and females and were not influenced by anyone to enhance overall health and wellness. D. S. users have used the designated dosage based on the information on the product (43%) and took it randomly without specific time (38%). Our participants agreed on D. S. being harmless, useful, and have an impact on sports performance. They also disagreed on the necessity of D. S. for all ages. Respondents believe Vitamin D is essential for immunity and Vitamin C has a role in cold/flu prevention. Conclusion: Most of our respondents get their information from nonmedical sources even though they displayed the right level of awareness and were mindful of D. S.'s limited role in health during the pandemic.
Keywords: Beliefs, COVID-19, dietary supplements, multivitamins, Saudi Arabia
|How to cite this article:|
Alshammari SA, Alwakeel LS, Alghtani JA, Alsabbagh LM. Effect of COVID-19 on awareness and consumption of dietary supplements in Saudi Arabia. J Nat Sci Med 2021;4:190-6
|How to cite this URL:|
Alshammari SA, Alwakeel LS, Alghtani JA, Alsabbagh LM. Effect of COVID-19 on awareness and consumption of dietary supplements in Saudi Arabia. J Nat Sci Med [serial online] 2021 [cited 2021 May 16];4:190-6. Available from: https://www.jnsmonline.org/text.asp?2021/4/2/190/313647
| Introduction|| |
One of the fundamental elements that a human requires in life to live and function is nutrition. The Federal Food, Drug, and Cosmetic Act defines dietary supplement (D. S.) as “substance intake by individuals to supplement the diet by increasing the total dietary consumption, concentrate, metabolite, constituent, extract, or combination of the preceding substances.” The D. S. includes vitamins, minerals, herbs, amino acids, and enzymes. It can be found in multiple forms such as capsules, tablets, powder, or liquid. A meta-analysis study concluded that no significant adverse effects of D. S. were found except overuse. When comparing natural vegetable and fruit consumption with D. S., the benefit of natural food outweighs the supplement. However, in low-dietary consumption or Malnutrition, supplements are advantageous.
The number of nutrients a body needs varies depending on multiple factors such as; gender, body weight, and energy expenditure. Most importantly, the amount of energy intake (calories) should balance the amount of energy expenditure. As nutrition is vital to our health, some literature found that it also helps prevent some diseases, such as cardiac problems and obesity. Meanwhile, the WHO defines Malnutrition as “deficiencies or excesses in nutrient intake, imbalance of essential nutrients, or impaired nutrient utilization.” Malnutrition's burden starts to increase; 462 million adults are underweight and deaths have reached 45% among children.
In the U. S., according to the National Health and Nutrition Examination Survey NHANES III during (1988–1994), 40% of adults used one or more D. S., about half of them aged between 20 and 69. Based on 2007–2011, prevalence increased to 69%. In Saudi Arabia, a recent study found a similar result, around 63.2% of the general public were consuming D. S., while lower prevalence has been reported in some Asian countries.,
Recently due to the COVID-19 pandemic, D. S. sales dramatically increased up to 415% in the U. S. since the beginning of March 2020. An article pointed out that it could be due to their accessibility and a false sense of security. As a result, they might become more incentivized to use D. S.
Different studies around the world have shown that the most common reason for D. S. consumption is maintaining general health,,,,,,,, and filling nutritional gaps.,
A closer look into the gender differences found that males tend to focus on muscle gaining goals while females look for general well-being and overall health. Looking at specific patterns of D. S. consumption, we found that, in general, women are more conscious about their health and well-being. Many studies show that women from different age groups consume more supplements.,,,, A study also suggested that chronic illnesses play a significant role in D. S.'s consumption. It is observed that D. S. users tend to adhere to a daily intake regimen for an extended time and seem to incorporate more healthy habits such as avoiding obesity, exercise, and pay more attention to their diet.
A study done on the general public of Saudi Arabia showed that most participants have a positive attitude toward D. S. They believed that D. S. has more of a supportive role in a healthy diet and should be prescribed by a health professional. Even though the public is generally well informed, there are still misconceptions regarding the benefits of D. S. worldwide, such as effect on the health of skin and hair,, the prevention of diseases,, and the correlation of certain vitamins with specific indications such as correlating Vitamin A with blindness. However, the evidence is lacking in exploring these misconceptions locally.
Up to our knowledge, there are no studies on the Saudi general public exploring the beliefs and habits and the effect of the COVID-19 pandemic on D. S.'s consumption, so that is what we are aiming to address in this research.
| Methods|| |
The investigators conducted this observational, cross-sectional study on 575 participants aged 18 and above and living in Saudi Arabia. Those who consumed D. S. for medical purposes were excluded. The survey was distributed from July to September 2020 on social media as a web-based survey designed by Google forms. The participants received the link to the survey and filled it anonymously. All participants had consented to participate in the study by agreeing on a consent form on the survey's first page.
The questionnaire was designed in English and modified to suit the Saudi culture, and was translated into Arabic using the world health organization methodology.
The questionnaire contains 29 questions taken from an open-access study, domains that were included are sociodemographic characteristics (age, gender, body mass index [BMI], education, employment, marital and financial status), prevalence, and the type of D. S. usage, pattern, and habits of D. S. consumption with influencers, circumstances, dosage, and side effects. We also addressed D. S.'s beliefs regarding the purpose, effectiveness, safety, and effect of COVID-19 on consumption. Almost all the questions were in multiple-choice form, and the Likert scale was used to assess D. S.'s beliefs.
The Institutional Review Board of the College of Medicine, King Saud University approved this project (Research Project No. E-20-5171). All participants signed written informed consent.
Statistical analysis was performed using Statistical Package for the IBM SPSS Statistics, Version 24.0 (IBM Corp., Armonk, NY, USA).
We presented all variables as categorical variables (frequency and percentage) in the tables while BMI as a continuous variable (the mean ± standard deviation). Student's t-test compared D. S. users and D. S. nonusers concerning BMI.
Bivariate relationships or differences of each categorical variable with D. S. use were examined by the Chi-square test (χ2), while multivariate relationships between the D. S. use and various variables were determined by binary logistic regression. The D. S. used was the dependent variable and other variables as independent variables. The probability of D. S. use over the probability of no D. S. use was presented in the form of an odds ratio (OR) at a 95% confidence interval (CI). The P < 0.05 denoted a significant difference.
| Results|| |
The total number of the current study participants was 575. Out of them, 145 (25.5%) were D. S. users, and the remaining (74.5%) were non-DS users. Out of DS-users, 58% (84) used D. S. before the march, and 66% (95) declared that COVID-19 did not affect their consumption decision. The two age groups showed statistically significant differences (P < 0.04), and the highest percentage of individuals were in the age group of 18–25 years at 258 (44.9%). The two groups differed significantly by educational level and financial status as all P values were <0.05. There were, however, no differences between women and men (P = 0.74), and the highest percentage of the respondents were females at 328 (57%). Similar results were obtained for BMI, employment, and marital status, where there were no significant differences (all P > 0.05) between the two groups. The mean BMI was slightly higher in the non-DS users' group at 26.38 (6.8) versus 25.77 (5.1) in the other group, the largest proportion (310, 53.9%) of the participants were single, and students (235, 40.9%) [Table 1].
|Table 1: Association between sociodemographic characteristics, COVID-19 timing, and influence on dietary supplement consumption among the general public of Saudi Arabia from July to September 2020 (n=575)|
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The current study respondents' beliefs regarding D. S. are shown in [Table 2]. When the participants were asked about their opinion in the point that D. S. is essential for all ages, the highest percentage (37.7%) were “disagree/strongly disagree,” while 33% “agree/strongly agree,” and the remaining were neutral, with a significant P = 0.04. Highly statistically significant (P < 0.001) differences were obtained regarding participants' opinion in D. S. general effectiveness, effectiveness in sports performance, chronic diseases prevention, as well as its harm and if they might harm the kidney. Where it was found that the highest percentage strongly agree/agree that it is harmless at 41%, have a neutral effect in chronic diseases prevention at 38.3%, strongly agree/agree that it might harm the kidney at 44.5%, strongly agree/agree that they are effective at 62.6%, and useful on sports performance at 62.4%.
|Table 2: Beliefs regarding dietary supplement among the general public of Saudi Arabia from July to September 2020 (n=575)|
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A statistically significant higher percentage of the non-DS users thought that D. S. is used to enhance sports performance, to gain weight, to lose weight, replace a skipped meal, required during pregnancy and lactation at 33%, 15.1%, 9.3%, 20.9%, and 21.2% versus 13.1%, 6.9%, 2.8%. 12.4%, and 7.6%, respectively, with P < 0.05. On the other hand, significantly higher percentages of D. S. users believe that they are used to enhance overall health and wellness, enhance mental and cognitive performance at 78.6% and 20% compared to 58.1% and 8.6% of the non-DS users, with P < 0.05. Data are shown in [Table 3].
|Table 3: Main reasons for dietary supplement usage among the general public of Saudi Arabia from July to September 2020 (n=575)|
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[Table 4] demonstrates the binary logistic regression for the D. S. users versus age, level of education, and income. Only the income (OR = 2.339; 95% CI = 1.350–4.053) showed a statistically significant association. The higher the income, the consumption of D. S. increased. Other variables, such as age and level of education, failed to predict the D. S. use.
|Table 4: Binary logistic regression: Influence of the sociodemographic characteristics on supplement dietary supplement consumption among the general public of Saudi Arabia from July to September 2020 (n=575)|
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Vitamins, multivitamins, and minerals were the most commonly used types of D. S. in the current study, and the D. S. type distribution by gender is shown in [Figure 1]. It was found that D. S. is mostly self-medicated since the highest percentage (39.3%) of those who use D. S. reported that it is prescribed by “no one.” The family followed this as the secondary influencer of D. S. use at (24.1%), then friend or colleague at (17.2%), and unexpectedly, physicians, and pharmacists came after that [Figure 2]. The highest percentages (38%, 43%) of the respondents who use D. S. reported taking it randomly without a specific time and taking the dose based on the product's information, as shown in [Figure 3].
|Figure 1: Type of dietary supplement used by the respondents among the general public of Saudi Arabia from July to September 2020 (N = 145)|
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|Figure 2: Source of influence on the respondents' decision to use dietary supplement among the general public of Saudi Arabia from July to September 2020 (N = 145)|
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|Figure 3: A source of dosage information and Pattern of Dietary Supplement consumption among the general public of Saudi Arabia from July to September 2020 (N = 145)|
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When participants were asked about the essential vitamins for immunity, the highest percentage of respondents scored Vitamin D as the one, followed by Vitamin C, while when they were asked about which ones prevent common cold/flu, Vitamin C scored the highest, followed by Vitamin D, [Figure 4]a and [Figure 4]b.
|Figure 4: Distribution of beliefs about which vitamins are essential for immunity and which vitamins prevent common cold/flu among the general public of Saudi Arabia from July to September 2020 (N = 575) (a) Vitamins that are essential for immunity (b) vitamins that prevents common cold/flu|
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| Discussion|| |
We set out this cross-sectional survey study to assess the effect of COVID-19 on the consumption of D. S, and the results showed that COVID 19 does not affect the rate of D. S consumption. So far, we did not come across studies examining the rate of D. S intake during the COVID-19 pandemic, making it difficult to compare our findings. As per the literature, there is no link between D. S use and COVID-19 prevention. Although supplementation with Vitamins C, D, and trace elements, including zinc and selenium, was recommended for persons with, or at risk of, respiratory viral infections. A review study also showed that Vitamins (A and D) have a potential benefit, particularly in deficient populations, and trace elements (selenium and zinc) have also shown favorable immune-modulatory effects in viral respiratory infections. Following a previously published review, the current study showed that vitamin or mineral supplements are the most popular used D. S. Such finding was also reported from the USA college students, and the study conducted in United Arab Emirates (UAE) among Dubai population.
In our study, almost 40% of the respondents believe that D. S's are harmless, and this is almost the same percentage reported by Emirati students. Another study from Italy showed that 30.5% of the respondents strongly agree/agree that D. S. use is essentially harmless. For D. S.'s safety, the high evidence-based physicians' health study among males showed that minerals and multivitamins have no effects on the gastrointestinal tract, fatigue, drowsiness, or skin discoloration. This study showed that only minor skin rashes and an increase in epistaxis were reported with no severe or long-lasting side effects with its long time interval of minerals and multivitamins supplementation. Overall, multivitamins and minerals supplements were found to reduce dietary intake gaps and improve nutritional status measures without exceeding the dietary reference intake or tolerable upper intake level.
Most Italian participants in see that D. S. is unnecessary for all ages at 69.9% compared to 37.7% of our study participants. On the other hand, a higher percentage of the current study respondents strongly agreed/agree that D. S. prevents chronic disease compared to the Italian study at 25.7% versus 14.7%, respectively.
In line with a previously published study, the current study showed that educational and income levels are correlated with D. S use. Similarly, the D. S and multivitamin-mineral consumption were significantly higher among high household income and highly educated adults in the NHANES 2011–2014. D. S. use did not differ significantly by gender in the current study. It is higher among males, a finding which is in contrast to the recently published local study. They showed a significantly higher prevalence of D. S. use among females. Sicińska et al. in 2019 found that D. S. use is associated with normal BMI in children and adolescents. This finding is almost in line with ours, where the D. S. users have a mean Body mass index (BMI) of 25.8 (±5.10). Data concerning the association between D. S. use and social status is inconsistent. There was no association in the current study, which agrees with Al-Johani et al. However, other studies showed its association with unmarried and married.
The estimated prevalence of D. S. use (25%) among adults in Saudi Arabia in the current study is slightly lower than a recently published study in 2020 at 26.2% of Saudi adolescents, and it is also lower than a recent study in 2019 at 63.2% of the general public while considering that it did not exclude the consumption for medical purposes. Furthermore, this estimated prevalence is about half of what was reported from the U. S. at 52% in 2000 and 2018, and 52%–58% in 2020. It is also lower than the estimated use prevalence among college students in the UAE at 35.6%. On the other hand, Kobayashi et al. reported a lower prevalence from Japan at 16.8%.
Previous studies, showed that the common source of information about D. S. is healthcare providers followed by social media and family members, friends, while in our case, self-medication was the prominent, followed by friends then physicians. Vitamin and mineral supplement use was independently associated with age and gender in previous studies.,,
D. S.'s perceived effectiveness may impact an individual's reason for use., This study found that only around 8% of participants were uncertain or did not perceive the D. S's they used to be effective. The current study extended on previous literature to reveal that enhancing overall health and wellness is the most common justification of D. S. use. Also, improving or maintaining overall health, supporting bone health, as well as filling nutrient gaps rank at the top in all the Council for Responsible Nutrition surveys,,, and this is considered consistent with our results.
Due to the quarantine circumstances, the survey was primarily distributed on social media. It could not reach a broader population of Saudis, and no sampling frame estimate the response rate, subjecting it to convenience and under-coverage biases in addition to the low sample size may contribute further to these biases.
| Conclusion|| |
Most of our respondents get their information from nonmedical sources even though they displayed an adequate level of awareness and were mindful of D. S.'s limited role in health during the pandemic. We recommend repeating the survey after social distancing guidelines are seized to reach a broader population in various public places using different data collection methods, such as interviewing and paper-based surveys.
The authors are grateful to the participants in this study. They are thankful to the Deanship of Scientific Research at King Saud University for supporting this study through the Vice Deanship of Scientific Research Chairs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]