300 J Contemp Med Sci | Vol. 6, No. 6, November–December 2020: 300–305 Original ISSN 2413-0516 Introduction Dietary supplements are considered as food products that contain dietary ingredients intended to supplement nutri- tional value to a diet. It encompasses specific vitamins, mul- tivitamins, minerals, enzymes, amino acids, and herbs.1,2 As a balanced diet is essential for development and maintenance of the human body, dietary supplement usage has become commonplace to improve overall health and well-being, and to reduce the risk of certain diseases. Dietary supplements use has become very common in the US, Europe, and GCC countries.3 A previous study indicated that almost half of Saudi participants consumed dietary supplements.4 Another study reported 93.3% of Saudi athletes consumed supplements,5 while 76.6% of female Saudi college students reported con- sumption of dietary supplements.3 Furthermore, dietary supplements were reported to be used by ~36% and ~24% of students in Saudi health and non-health colleges, respectively, while 62.3% of Saudi adults were reported to be supplement users or had used supplements at least once before.4 Such widespread usage has been attributed to increased availability of dietary supplements, and the belief that dietary supplements are more natural and safer to use compared to prescription medication.6 This rise in supplement use, how- ever, is also associated with an increase in the adverse effects caused by supplement mis-/overuse, with studies reporting health complications (and fatalities in severe cases) due to overdose, drug–drug, and drug–disease interactions caused by supplement misuse.7, 8. For example, excessive use of chole- calciferol and vitamin D may adversely affect soft tissues and kidney functions,9 while the medical management of cardio- vascular diseases can be affected due to interactions between the supplement and various drugs used in the management of diseases.10 This study aimed to explore the use of dietary supple- ments among physically active adults and the general popula- tion in Saudi Arabia, and their awareness of positive/adverse effects of dietary supplements. Methods Study Design This is a cross-sectional study using an online self-adminis- tered questionnaire. Questions included covered sociodemo- graphic and lifestyle characteristics, perceived health status, dietary supplement use, and general awareness regarding adverse effects. Study Population Our target population was adults living in Saudi Arabia. Participants <18 and >65 years of age were excluded. Convenience sampling was utilized: assuming the estimated population of Saudi Arabia of 33.7 million, 95% confidence interval, we calculated a target sample size of 384. After excluding respondents under 18 and over 65 years of age, we analyzed a total of 574 responses. Frequency of dietary supplements usage in the Saudi Arabian public and gym users Muhammad Raihan Sajid1, Lama Nasser Quraiba2, Rahaf Iyad Khames2, Noara AlHusseini3, Haifa Alsheikh2, Nabel Rajab Basha2, Saad Mansoor4, Aamir Omair5 1Department of pathology, Alfaisal University, Riyadh, Saudi Arabia. 2Alfaisal University, Riyadh, Saudi Arabia. 3Alfaisal University, Riyadh, Saudi Arabia. 4Department of Medical education, Alfaisal University, Riyadh, Saudi Arabia. 5Research Unit, Department of Medical Education, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia. Corresponding Author: Noara Alhusseini (E-mail: nalhusseini@alfaisal.edu ) (Submitted: 25 August 2020 – Revised version received: 22 September 2020 – Accepted: 25 October 2020 – Published online: 26 December 2020) Abstract Objectives: The aim of the study is to explore the use of dietary supplements and to assess awareness of its positive/adverse effects among physically active adults and the general population in Saudi Arabia. Methods: We conducted a cross-sectional online survey-based study and received 574 responses showing frequencies and types of dietary supplements. Results: The results show that 44.6% of respondents use dietary supplements. The most used dietary supplements were Vitamin C and multivitamins, consumed by 44% of the respondents, Vitamin D (44%), Iron (41%), and Calcium (39%). Protein sports bars and powder were consumed mainly by gym members, particularly those practicing weight-training exercises. Approximately, 4% of respondents reported side-effects secondary to the usage of the dietary supplements. We conclude that the dietary supplement usage is widespread in Saudi Arabia among both gym members and the general public. Conclusion: It is highly recommended to increase awareness measures from official health entities by educating the general population and physically active adults about dietary supplement use and adverse effects to ensure safe practices. Keywords: 301 Original Frequency of dietary supplements usage in the Saudi Arabian public and gym users Muhammad Raihan Sajid J Contemp Med Sci | Vol. 6, No. 6, November–December 2020: 300–305 Survey Tool (Questionnaire) Questions included covered sociodemographic and lifestyle characteristics, perceived health status, dietary supplement use, and general awareness regarding adverse effects. We modified and designed our questionnaire from the previously used and validated surveys.11, 12 Content validity was performed by an expert in the field. The survey was also translated and made available in Arabic as well as English. Face validity was performed by an Arabic language translation expert. The survey included questions aimed at assessing the knowledge, experience, and awareness of participants regard- ing dietary supplements in addition to demographic factors (such as age, gender, nationality, and level of education). We also queried the use, purpose, reasons, and duration of taking dietary supplements, as well as short-/long-term side effects, exercising, frequency of going to the gym, and type of supple- ment used among participants. Ethical Considerations Ethical approval was obtained from Alfaisal University Institutional Review Board (approval number IRB20026). Researchers abided by the rules and regulations of the Saudi National Committee of Bioethics and the Research Policies & Procedures of Alfaisal University. No identifying data were collected to ensure anonymity and confidentiality. Access to the surveys’ responses was limited to the investigators. Data Collection and Analysis The questionnaire was shared via electronic-social media plat- forms (Instagram, Twitter, and WhatsApp and work/personal emails). Data were extracted and analyzed using the SPSS Statistics 21 data analysis package. The descriptive statistics of mean, standard deviation, percentages, and frequencies were calculated. The Chi-square test was employed on categorical variables to examine associations. The significance was deter- mined if the p-value was <0.05. Results A total of 636 respondents completed the questionnaire from different regions in Saudi Arabia, of which 574 respondents fit the inclusion criteria. The sociodemographic characteris- tics of the participants are summarized in Table 1 and their lifestyle choices are presented in Table 2. The majority of the respondents were females (67%), from the younger age group of 18–25 years (68%), most had a bachelor’s degree or higher (68%), and almost two-thirds were Saudi nationals (66%). The Body Mass Index (BMI) grouping showed that 6% were underweight, while almost half were in the normal weight category (49%); 28% overweight, and 15% obese among the respondents as shown in Table 1. Table 2 shows that 163 (28%) did not exercise, while most reported exercising 3–5 days per week (37%) and another 14% exercised 6–7 days per week. There were 199 (35%) who were using some specific diet, while 264 (46%) of the partici- pants used dietary supplements in the last month. There were 106 (18%) of the respondents who were members of a Gym (Table 3). Table 1. Sociodemographic characteristics of the study participants (n=574). Variable n % Gender Females 383 66.5 Males 191 33.2 Age (years) 18-25 392 68.1 26-45 156 27.1 >45 28 4.9 Educational level High School / Diploma / Intermediate 183 31.7 Bachelor’s Degree / Graduate 391 67.8 Nationality Saudi 381 66.1 Non-Saudi 195 33.8 BMI (kg/m2) <18.5 33 5.7 18.5-24.9 284 49.3 25-29.9 162 28.1 30+ 85 14.8 Missing 12 2.1 Table 2. Lifestyle choices of respondents (N=576). N % Exercise No exercise 163 28.3 1-2 days/week 122 21.2 3-5 days/week 212 36.8 6-7 days/week 79 13.7 Diet Any specific diet 199 34.7 No specific diet 375 65.3 Use of dietary supplements Yes 264 44.6 No 317 55 302 Original Frequency of dietary supplements usage in the Saudi Arabian public and gym users Muhammad Raihan Sajid J Contemp Med Sci | Vol. 6, No. 6, November–December 2020: 300–305 Length of usage of dietary supplements (N=264) <1 month 40 6.9 1-3 months 73 12.7 >3 months 151 26.2 Use of dietary supplements in the last month (N=264) Daily 157 27.3 Weekly 82 14.2 Once a month 25 4.3 Gym members Yes 106 18.4 No 470 81.3 There were 264 respondents who were using dietary sup- plements; the most common supplements were Vitamin C, Vitamin D, and multivitamins consumed by 44% of these 264 respondents. Other commonly used supplements included Iron (41%) and Calcium (39%). Protein sports bars and pow- der were consumed mainly by gym members, particularly those practicing weight-training exercises. A few respon- dents reported using other specific dietary supplements that included probiotics, Zinc, Magnesium, and Folic acid. There were 39% of the 264 respondents using dietary supplements who reported short- or long-term adverse effects directly resulting from supplement-use, while 4% reported side-effects secondary to the usage of the dietary supplements, including acne, constipation, bloating sensation, nausea, low appetite, change in urine color due to beta-carotene, dizziness, depen- dency, hair loss, erectile dysfunction, hypotension, changes in bowel movements, increased blood pressure, liver damage, anxiety, tremors, hypervitaminosis, and agitation. The major sources of information regarding dietary supple- ments were identified as the internet (31%), doctors/pharma- cists (18%), and friends/family (8%). The most common reason for supplement use was to complete dietary/nutrient needs (34%), while 16% of the participants used it for muscle build- ing; another (15%) reported use for medical recommendation/ prescription from a doctor. Other reported reasons included boosting immunity, enhancing performance (stamina), and improving memory. Of those who exercised, 60% reported exercising 1–2 h/session, while 38% reported exercising for <1 h. The most commonly reported type of workout was car- dio (37%) and weight training (34%) exercises.Table 3 shows the association between the demographic variables and use of dietary supplements. There was a significantly higher propor- tion of females (48.8%) than males (36.8%) who reported using dietary supplements (p=0004). Respondents aged more than 45 years of age were more likely (70.3%) to use dietary supple- ments (p=0.002) as compared to the younger respondents aged 18–25 years (41.1%) and 26–45 years (49.3%). Also, those with BMI greater than 30 kg/m2 (48.2%) and 25–29.9 kg/m2 (50.3%) were more likely to use dietary supplements as compared to those with BMI <18.5 (36.3%) and 18.5–24.9 kg/m2 (41.9%) (p=0.002). The use of dietary supplements was also higher in those who exercised (49.2%) as compared to those who did not (33.7%) (p=0.001). Educational level was not significantly related to the use of dietary supplements (p=0.12). There was also no significant difference (p=0.13) in the use between Saudis and Non-Saudis (Table 3). Table 3. Association of demographic variables with use of dietary supplements. n Use dietary supplement n (%) Do not use dietary supplement n (%) p-value Gender Females 383 187 (48.8%) 196 (51.1%) 0.004 Males 190 70 (36.8%) 120 (63.2%) Educational level Bachelor / graduate 391 168 (42.9%) 223 (57.1%) 0.12 High school / diploma 183 89 (48.6%) 94 (51.3%) Age groups (yrs) 18-25 391 161 (41.1%) 230 (58.9%) 0.002 26-45 156 77 (49.3%) 79 (50.7%) >45 27 19 (70.3%) 8 (29.7%) BMI groups (kg/m2) <18.5 33 12 (36.3%) 21 (63.7%) 0.002 18.5-24.9 284 119 (41.9%) 165 (58.1%) 25-29.9 161 81 (50.3%) 80 (49.7%) >30 85 41 (48.2%) 44 (51.8%) Nationality Saudi 382 178 (46.6%) 204 (53.4%) 0.13 Non-Saudi 192 79 (41.1%) 113 (58.9%) Exercise Yes 410 202 (49.2%) 208 (50.7%) 0.001 No 163 55 (33.7%) 108 (66.2%) 303 Original Frequency of dietary supplements usage in the Saudi Arabian public and gym users Muhammad Raihan Sajid J Contemp Med Sci | Vol. 6, No. 6, November–December 2020: 300–305 Table 4 presents the association between demographic variables with being on a specific diet. There was no dif- ference with regards to gender (p=0.09), educational level (p=0.40), age group (p=0.62), and nationality (p=0.07). It was found that respondents who were overweight or obese (BMI 25 kg/m2 and above) were more likely to be on a spe- cific diet (42%) as compared to those with BMI <18.5 kg/m2 (6%) and those with normal BMI of 18.5 to <25 kg/m2 (31%) (p<0.001). Table 5 also shows that there was no difference for exer- cising or not by gender (p=0.08), education level (p=0.32), and age group (p=0.69). Respondents who had BMI <18.5 kg/m2 (48.5%) or BMI >30 kg/m2 were less likely to exercise as com- pared to those with normal BMI (76%) or BMI between 25 and <30 kg/m2 (74%) (p=0.001). Also, Saudi nationals were more likely (76%) to exercise as compared to non-Saudis (63%) (p=0.001). Table 5 shows no difference by gender in those who exer- cised (p=0.08). Also, no statistically significant difference was seen in respondents who exercised based on their education levels (p=0.31). Respondents with a higher BMI (>30 kg/m2) were more likely to exercise as compared to those having a normal BMI (p=0.001). Saudis were more likely to exercise as compared to the non-Saudi respondents (p=0.001). Table 4. Association of demographic variables with being on a specific diet. n On specific diet n (%) No specific diet n (%) p-value Gender Females 383 142 (37.1%) 241 (62.9%) 0.09 Males 190 57 (30%) 133 (70%) Educational level Bachelor / graduate 391 140 (35.8%) 251 (64.2%) 0.40 High school / diploma 183 59 (32.2%) 124 (67.8%) Age groups (yrs) 18-25 391 126 (32.2%) 265 (67.8%) 0.62 26-45 156 70 (44.9%) 86 (55.1%) >45 27 3 (11.1%) 24 (88.9%) BMI groups (kg/m2) <18.5 33 2 (6.1%) 31 (93.9%) <0.001 18.5-24.9 284 87 (30.6%) 197 (69.4%) 25-29.9 161 68 (42.2%) 93 (57.8%) >30 85 36 (42.4%) 49 (57.6%) Nationality Saudi 382 141 (36.9%) 241 (63.1%) 0.07 Non-Saudi 192 58 (30.2%) 134 (69.8%) Table 5. Association of demographic variables with exercise. n Exercise n (%) Do not exercise n (%) p-value Gender Females 383 265 (69.2%) 118 (30.8%) 0.08 Males 189 144 (76.2%) 45 (23.8%) Educational level Bachelor / graduate 390 274 (70.3%) 116 (29.7%) 0.32 High school / diploma 183 136 (74.3%) 47 (25.7%) Age groups (yrs) 18-25 391 275 (70.3%) 116 (29.7%) 0.69 26-45 155 118 (76.1%) 37 (23.9%) >45 27 17 (63%) 10 (37%) BMI groups (kg/m2) <18.5 33 16 (48.5%) 17 (51.5%) 0.001 18.5-24.9 284 216 (76.1%) 68 (23.9%) 25-29.9 161 119 (73.9%) 42 (26.1%) >30 84 51 (60.7%) 33 (39.3%) Nationality Saudi 381 289 (75.9%) 92 (24.1%) 0.001 Non-Saudi 192 121 (63%) 71 (37%) 304 Original Frequency of dietary supplements usage in the Saudi Arabian public and gym users Muhammad Raihan Sajid J Contemp Med Sci | Vol. 6, No. 6, November–December 2020: 300–305 Discussion The findings of this study demonstrated a high prevalence of dietary supplement use in Saudi Arabia (45.8%) and showed an association with certain demographics and lifestyle fac- tors. Other studies have suggested that dietary supplement use has been very common on a global level.13 The prevalence of dietary supplement use varies globally, however, the findings indicate that it is relatively high in Saudi Arabia compared to other counties. A cross-sectional study used nationally representative data from the National Health and Nutrition Examination Survey in the United States indicated that over half of Americans used at least one type of dietary supple- ments during the previous month of the study.14 In addition, the prevalence of dietary supplement use among Pakistanis was 48.2%,15 and 35.6% among college students in the United Arab Emirates,16 which confirm the findings of the high prevalence of dietary supplements use in general. Another cross-sectional study among Saudi population revealed that more than half of its participants used dietary supplements, which is similar to our findings.17 Moreover, a local study at Princess Nourah Bint Abdulrahman University in Riyadh also highlighted the finding of the high prevalence of dietary sup- plement use in Saudi as all its participants have used it at some point in time and 32.3% were using it at the time of the study.18 Alowais et al have suggested that increased awareness levels about health promotion and disease prevention contributed to the increased use of dietary supplements in many countries,17 which may justify the high prevalence of dietary supplement use in Saudi Arabia. However, a Chinese study revealed that only 24.2% of its participants consumed dietary supplements during the past year.19 The frequency of dietary supplement use in Saudi Arabia seems to be higher than other countries. A comparison of educational levels (Bachelors and grad- uates vs high school and diploma holders) did not show a statistically significant difference regarding the use of dietary supplements. These findings match another study conducted in Saudi Arabia that found no association between dietary supplement use and the level of education.1 However, another study in Saudi Arabia found that dietary supplement use was more prevalent (84.5%) among those with high educational levels.17 Also, another study indicated higher dietary supple- ment use among Chinese medical students (58.9%) com- pared to non-medical students.19 The difference between these results and other studies can be due to the nature of this study, since the survey was distributed electronically and most par- ticipants (67.8%) had higher education. Since dietary supplements have been very common, sources of information about it vary. The major sources of information regarding dietary supplements identified by the participants were internet, doctors, or pharmacists, and friends, family, or relatives which is in concordance with findings of other studies.17 However, Rogza et al. found that physicians were the most frequent source of information for dietary supplement use, which is safer for consumers unlike unreliable sources like Internet.20 Though only 15% of the participants used dietary supplements due to a medical rec- ommendation/prescription from a doctor, it is recommended to increase awareness measures from official health entities by educating the general population and physically active adults about dietary supplement use and adverse effects to ensure safe practices. The findings show that the most used dietary supplements were Vitamin C and multivitamins or both, unlike another Saudi-based study among females that showed that cod liver oil, Omega 3, multivitamins, ginseng, and vitamin A to be most commonly used supplements. The difference could be a result of limiting the study to college females only as their reason for dietary supplement use was to maintain healthy hair, unlike this study that included both males and females up to 65 years old.3 Similarly, a study conducted among Saudi females suggested that the primary reason for using dietary supplements was for aesthetic reasons.18 Other commonly used supplements in this study were: Vitamin D, Iron, and Calcium. Protein sports bars and protein powder were consumed mainly by gym members, particularly those practicing weight-training exercises. A few participants reported using other specific dietary supplements that include probiotics, Zinc, Magnesium, and finally folic acid. However, Jawadi et al found that most commonly used supplements among active adults who go to the gym in Saudi were whey protein, amino acids, multivitamins, creatinine, and Omega 3 to improve body shape,21 which is slightly similar to the find- ings in this study as 16% of participants used it for muscle building. Other reported reasons included boosting immunity, enhancing performance (stamina), and improving memory. Athletes use dietary supplements for various reasons such as maintenance of good health and improving micronutrient deficiencies. Maintaining a balanced meal can be a challenge, therefore, dietary supplements replace inadequate energy and macronutrient intake.13 This study mirrors the findings as the most common reason for using dietary supplements reported by the participants was completing dietary/nutrient needs. The results indicate that almost 40% of the responses replied in affirmative regarding dietary supplements having short- or long-term adverse effects. Significantly just 4% of respondents reported side-effects secondary to the usage of the dietary supplements. Another study conducted among Saudis also revealed that dietary supplement consumers (75%) were aware of its adverse effects.4 In contrast, another study in India showed that only 16.9% of dietary supplement users felt that regular use results in side-effects.22 Some of the adverse effects reported included acne, con- stipation, bloating sensation, nausea, low appetite, change in urine color due to beta carotene, dizziness, dependency, hair loss, erectile dysfunction, hypotension, changes in bowel movements, increased blood pressure, liver damage, anxi- ety, tremors, hypervitaminosis, and agitation. Some of the adverse effects including diarrhea, constipation, stomachache, headache, nausea, and vomiting have been reported among Japanese adults from using dietary supplements. However, only just under 10% of them have reported the symptoms due to the inability to link the cause and effect relationship of these adverse effects.23 The results showed that respondents who exercised were more likely to use dietary supplements. A cross-sectional study among Saudi females mirrors our findings as it showed that more physical activity was significantly positively associated with dietary supplements use.3 While another study in Saudi Arabia showed that dietary supplement users believed that its use is most needed among pregnant women and during recov- ery from diseases.17 Since this study sample included physi- cally active participants, this difference can be justified by the type of dietary supplements and the purpose of its use. 305 Original Frequency of dietary supplements usage in the Saudi Arabian public and gym users Muhammad Raihan Sajid J Contemp Med Sci | Vol. 6, No. 6, November–December 2020: 300–305 Study limitations Since our study was conducted during coronavirus COVID-19 pandemic, all sports activities including gyms were closed due to social distancing and quarantine regulations, which might have impacted physical activity levels and dietary supplement use. Therefore, this factor can affect the generalizability of our study. In addition, due to the nature of the cross-sectional studies, causal inferences cannot be achieved. Moreover, recall bias in the type and frequency of supplement use may be pres- ent. Selection bias is another limitation given that only people with internet access were included in our study. Conclusion The dietary supplement usage is widespread in Saudi Arabia among both gym members and general public. The incidence of reported adverse effects is low as compared to other published studies. Since there are many dietary supplements available, future studies should be conducted to assess different types of dietary supplements and its adverse effects in Saudi Arabia. In addition, it is highly recommended to increase awareness measures from official health entities by educating the general population and physically active adults about dietary supple- ment use and adverse effects to ensure safe practices. 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Chiba T, Sato Y, Kobayashi E, Ide K, Yamada H, Umegaki K. Behaviors of consumers, physicians and pharmacists in response to adverse events associated with dietary supplement use. Nutr J. 2017. https://doi.org/10.22317/jcms.v6i6.891 This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License which allows users to read, copy, distribute and make derivative works for non-commercial purposes from the material, as long as the author of the original work is cited properly.