Skip to main content

Consumption of dietary supplements and their determinants among adults in six Arabic countries: a cross-sectional survey

Abstract

Background

Since the onset of the coronavirus (COVID-19) pandemic crisis, the supplement market has consistently grown. Therefore, we conducted this survey during the fourth wave of the COVID-19 pandemic to study the frequency and context of dietary supplement (DS) consumption (vitamins and mineral intake) and explore the consumer’s pharmaceutical buying behaviour; and (3) to study its determinants as regards the demographics, Fatigue Severity Scale (FSS), and healthy eating pyramids.

Methods

We conducted a cross-sectional web-based survey on 1333 Arabic adults aged 18 years or more residing in six Arabic-speaking countries in May 2022, using a validated self-administrated questionnaire. The survey-involved questions about sociodemographic characteristics, physical activity, FSS, healthy eating pyramid, DS consumption, and consumers’ pharmaceutical purchasing behaviour.

Results

Most participants were aged 20 to less than 35 years, and 64.6% used dietary supplements. There was a statistically significant difference between supplement users and nonusers as regards consumers’ pharmaceutical buying behaviour in terms of advertising quality, safety rules, pharmaceutical forms, and packet quality. Arabic adults consumed the following dietary supplements: 63.5% vitamin C, 60.1% vitamin D, 47.1% iron, and 44.4% zinc. Authorised products (76.0%), natural contents (75.0%), and safety rules (68%), were the most common factors influencing Arabic consumers’ pharmaceutical purchasing behavior. Multi-logistic regression analysis showed that being female, having a history of COVID-19, having a positive attitude about the benefits, and being recommended for supplement use were predictors of dietary supplement use.

Conclusion

The dietary consumption of supplements is prevalent, mainly including vitamin C, vitamin D, iron, zinc, vitamin B, and magnesium. In addition, Arabic adults are poorly adherent to healthy eating pyramids. Given the ongoing COVID-19 pandemic, Arabic health authorities should prioritize this issue to minimize the potential for misusing dietary supplements.

Introduction

The World Health Organization (WHO) has reported more than 608 million confirmed cases of COVID-19 and more than 6 million deaths as of May 2022 [1]. Even in those at low or high risk of developing a severe acute illness, COVID-19 infection can cause multi-organ damage [2, 3]. As there are limited treatments available for COVID-19, individuals increasingly rely on vitamins and supplements to enhance their immune systems and prevent disease progression [4].

The Dietary Supplement Health and Education Act, approved by Congress in 1994 and passed into law, defines a dietary supplement as any product (other than tobacco), i.e., a pill, capsule, tablet, or liquid, that is designed to be taken by mouth and is marked on the front label panel as a dietary supplement. It also contains one or more dietary elements (e.g., vitamins, minerals, herbs or other botanicals, amino acids, and other substances) or their constituents [5].

During the COVID-19 pandemic, consumer perceptions and opinions about nutraceuticals, as well as factors such as healthy eating behaviour, actual clinical benefit and safety, media coverage, and the behaviour of healthcare providers, can all influence the consumption of dietary supplements. However, these supplements' negative effects remain inadequately documented or tracked [6,7,8].

In many countries, promoting and advertising dietary supplements is legal. The Food and Drug Administration (FDA) does not require approval for the registration of nutraceutical companies, putting consumers at risk for false, exaggerated health claims that lack sufficient evidence of their efficacy; moreover, the law does not effectively defend and protect consumer rights [9, 10]. The (USA) FDA and Federal Trade Commission (FTC) have issued warnings to many companies selling products that fraudulently claim to prevent or treat COVID-19 [11]. Despite these warnings, the global market for supplements has expanded consistently over the past ten years. However, after the pandemic, sales of dietary supplements unexpectedly surged, for example, by 5% in the USA, 63% in the United Kingdom (UK) for vitamins, and between 40 and 60% in France in March 2020 compared to the same month last year. Customers' enthusiasm greatly increased sales of nutraceuticals in China, the USA, Canada, and France [12,13,14,15,16]. Unfortunately, little information is available on the current state of dietary supplement consumption in the Middle Eastern and Arabic regions.

We anticipate that the market for nutraceuticals and supplements will not sustain exceptional growth rates and will revert to its pre-pandemic levels. As the industry continues to expand, regulatory agencies must ensure customer safety by monitoring products for accuracy, deception, and harmful effects through evidence-based research. Therefore, we conducted this multinational study among adult Arabic populations from six different countries during the fourth wave of the COVID-19 pandemic in May 2022 for the following reasons: (1) to study the frequency, types, and context of dietary supplement consumption among Arabic populations; (2) to explore the consumer’s pharmaceutical purchasing behaviour; and (3) to study the determinants of dietary supplement consumption as regards the demographics, excess fatigability scale, and healthy eating pyramids associated with the usage of dietary supplements.

Methods

Study design and participants

We conducted a cross-sectional web-based survey of 1333 Arabic participants during the fourth wave of the COVID-19 pandemic in May 2022. The selection criteria were as follows: adult’s aged 18 years or more residing in one of six Arabic-speaking countries (Egypt, Saudi Arabia, Syria, Libya, Iraq, and Algeria). We excluded individuals who were illiterate, did not use the internet, did not own smartphones or computers, had complicated mental, chronic, or psychiatric comorbidities, or did not complete the questionnaire.

Sample size and sampling techniques

We use the following method to determine the sample size: n = Z2 P (1 − P)/d2, where n is the sample size, Z is the level of confidence equal to 1.96 for a confidence level of 95%, P is the expected prevalence equal to 0.0466, and d is precision equal to 0.05 (equivalent to effect size) [17].

The sample size was calculated to be 1400 participants, with a 95% confidence level; it was found that 46.6% of public participants from a multicenter study during the second wave of COVID-19 took dietary supplements [18].

We adopted a multistage sampling technique to select the six-targeted Arabic-speaking countries in the Middle East (Egypt, Saudi Arabia, Syria, Libya, Iraq, and Algeria). We determined the required number of samples from each area, ensuring they met all the selection criteria. We began by selecting three governorates at random from each of the six; we then selected one urban and one rural area from each of the three governorates; and finally, we used the official websites and social media platforms (Facebook, Twitter, official emails, and WhatsApp groups) in each of these areas.

The data collection tool

Questionnaire development and structure

Evidence from other studies was incorporated into the survey’s creation and adoption [5, 18,19,20,21,22,23]. It was initially written in English and then translated into Arabic. A bilingual group of two medical experts and one externally certified medical translator translated the questionnaire’s English version into Arabic.

Questionnaire validation

To confirm its comprehension and cultural acceptability, a pilot test was conducted with 60 volunteers from the general community in the six studied countries (15 volunteers completed the Arabic version from each nation). The participants were asked to rate the questionnaire’s structure, clarity, and length, as well as to provide a general opinion. Following that, certain questions were revised in light of their input. To check for reliability and reproducibility, the questionnaire was tested again on the same people one week later. The final data analysis did not include the data collected during the pilot test. We calculated a Cronbach’s alpha of 0.78 for the questionnaire.

The structure of the questionnaire

After giving their permission to take part in the study (informed consent), the participants filled out and sent in the questionnaire. The questionnaire was composed of the following sections:

(I) Sociodemographic and health-related factors: age, sex, residence, nationality, educational level, occupation, marital status, weight, height, and comorbidities.

(II) Physical fitness status was assessed using the following:

*Fatigue Severity Scale (FSS). The level of fatigue was assessed using the FSS questionnaire, which had a 0.88 internal consistency and a 0.84 test–retest reliability. In the FSS questionnaire, nine statements assess the severity of fatigue symptoms. It was assessed using a Likert scale. A low value (such as 1) indicates strong disagreement, while a high value (such as 7) indicates strong agreement. A total score of less than 36 indicates that you may not feel fatigued. A total score of 36 or higher indicates that additional medical testing may be necessary [19].

*The level of physical activity was measured based on the average step count (using smart watches or smart phones’ free applications, such as pedometers or accelerometers) or the subjective report over the last week: The level of physical activity was classified as sedentary if it was less than 5000 steps per day, low if it was between 5000 and 7000 steps per day, average if it was between 7000 and 1000 steps per day, and high if it was greater than 10000 steps [20].

(III) The Healthy Eating Pyramid includes vegetables, fruits, whole grains, healthy oils, and healthy proteins, like nuts, beans, fish, and chicken, in addition to addressing other healthy lifestyle aspects, like exercise and multivitamin supplements. The questionnaire illustrated the size of portions or amounts of each food element (e.g., protein) and the required amount of water, based on Harvard University's Healthy Eating Pyramid. It was available to download and use without authorization [21, 22].

(IV) The context of vitamin, mineral, and other commonly used products, including testosterone and growth hormones: the frequency of use, the forms and types used by participants, the source of information, and the causes and adverse effects of vitamin and mineral intake [23].

(V) Consumer’s pharmaceutical purchasing behaviour (e.g., cost, serving size, list of dietary ingredients, amount per serving size (by weight), percent of the daily value (%DV), if established). If the dietary ingredient is botanical, it uses the plant's scientific name, or the common or usual name [5].

The data collection method

Using a multistage sample technique, we chose three governorates at random from each of the six Arabic-speaking countries; we then chose one urban area and one rural area from each of the three governorates; and finally, we used the official websites for each governorate’s constituent regions to gather community-based samples.

The questionnaire was filled out and submitted by participants after they agreed to participate in the study (informed consent). The targeted nations in randomly chosen regions and locations were given the questionnaire, which asked about the most popular and official social media platforms in each of these areas (Facebook, Twitter, and WhatsApp groups). To improve the response rate, follow-up and reminder emails were adopted until the required sample was completed.

Following their consent to take part in the study, participants completed and submitted all questions that were obligatory, and they were allowed to fill out the survey once. Follow-up and reminder emails and messages were delivered to the administrators and the targeted demographics until the required sample was completed in order to increase the response rate.

Statistical analysis

The Software Package of Statistical Analysis (SPSS) program version 27 was used to analyze the data. Quantitative information, such as BMI, was presented as mean ± SD and frequencies and percentages for categorical variables. After analyzing the normally distributed quantitative data using the Kolmogorov-Smirnov test, then the mean, standard deviation (SD), and Student’s t-tests were performed to examine the quantitative data. A Chi-squared test (χ2) was used to determine if categorical variables were associated with qualitative data, such as age groups and sex, which were provided as frequency and percentages. To evaluate the independent relationships between each potential factor and the outcome of interest, we built an adjusted logistic regression model using a stepwise approach. We first included all the variables that the univariable analyses found to be significant (P<0.05) in the stepwise regression technique. We calculated the adjusted odds ratios (OR) and 95% confidence interval (CI) from the above-fitted final model and presented them.

Results

The demographic and clinical characteristics of the studied participants

Most of the participants (881, 66.1%) were aged between 20 and less than 35 years. Most of them were female (72.8%) and had a university level of education (77.8%). Nearly half of the participants worked in medical professions (51.3%), and more than one-fourth of the participants were from Egypt (26.1%) and Algeria (18.8%). Most participants were nonsmokers and had no history of chronic diseases (88.9% and 86.6%, respectively). There was a statistically significant relationship between dietary supplement use and sociodemographic criteria, in which supplement use was significantly higher among females, single or married, living in urban regions, and those from Saudi Arabia, Libya, and Egypt compared to their counterparts (P < 0.05). Participants reported a confirmed history of SARS-CoV-2 infection in about 35.8% of cases, while 22.7% showed suspicions (Table 1).

Table 1 Socio-demographic and clinical characteristics of the study participants

The frequency of DS consumption: nearly two-thirds of study participants used dietary supplements in the last 2 months preceding the study (64.6%). Dietary supplement use was significantly higher (71.7%) among those with a confirmed SARS-CoV-2 infection (Table 1).

The healthy eating pyramids and total fatigue severity scale

We found that nearly one-third of the participants took the daily-recommended requirements from protein (32%), vegetables (31.4%), and sun exposure (37%), respectively, and only 17.2% took the daily-recommended requirements from fruits and 23.6% from water. Interestingly, dietary supplement use was significantly higher among those who took daily requirements of protein and water as recommended or less than recommended compared to those who never took the recommended requirements (P < 0.05), but there was no difference in supplement use regarding other dietary preventive measures.

About half of the participants rarely or never practice physical activity at all (49.8%), with no differences between dietary supplement users and nonusers. About three-quarters of participants recommended the use of supplements, which was significantly more recommended by supplement users compared to nonusers (73.4% vs. 26.6%) (Table 2).

Table 2 The Healthy Eating Pyramid, the practice of preventive measures and their relationship to dietary supplements use

The total fatigue severity score was 30.03 ± 13.82. It was significantly higher among supplement users compared to nonusers (30.93 ± 13.88 vs. 28.39 ± 13.57). In addition, the scores of individual domains of fatigue severity were all significantly higher among dietary supplement users compared to nonusers (P < 0.05), except for the second and sixth domains. More than two-thirds of supplement users had suspected fatigue compared to nonusers (69.9% vs. 30.1%) (Table 3).

Table 3 Association between fatigue severity scale and the preventive measure practiced by participants according to dietary supplements use

The context of dietary or other supplement consumption

Figure 1 shows the main sources of information for participants regarding dietary supplements. Physicians and pharmacists (79.9%), specialized coaches (78.3%), scientific books and journals (74.4%), and the internet/specialized pages (74.4%) were the most common sources, while family and friends (66%) were the least common. Non-supplement users, on the other hand, had family and/or friends, TV and/or radio, and social media as the most common information sources, respectively. Figure 2 shows the main causes of using DS, in descending order: to promote general health (87.1%), improve immunity (66.7%), improve hair and nails (50.2%), and improve the shape of the body (41.5%).

Fig. 1
figure 1

The sources of information about dietary supplements among  adult participants

Fig. 2
figure 2

The main causes of using dietary supplements among the DS users

Table 4 shows that tablets were the most commonly used form of dietary supplements amongusers (90.6%), with 52.5% using them under medical supervision, while 42.7% used them without any supervision. The most used vitamins during COVID-19 pandemic were vitamins C and D [2 (2.40 ± 1.42) and 2 (2.10 ± 1.75), respectively]. Zinc and iron were the most used minerals [1 (2.01 ± 1.39) and 1 (2.05 ± 1.37), respectively] as well.

Table 4 The context of the used DS and other products among the Arabic adult DS users

Figures 3 and 4 show that among the 287, 21.5% of participants who reported a history of adverse effects (AEs) from the consumption of DS, the most common causes were the type of product used (50, 17.4%), using DS without a prescription (45, 15.7%), other causes (41, 14.3%), and health conditions (35, 12.3%). The most frequently reported AEs associated with the use of DS, in descending order, were stomachache (209, 72.9%), constipation (172, 58.9%), nausea and vomiting (102, 35.5%), tachycardia (75, 26.1%), and diarrhea (67, 23.3%).

Fig. 3
figure 3

The main adverse effects among participants who reported history of adverse effects (N = 287, 21.5%)

Fig. 4
figure 4

The main causes of adverse effects among participants who reported history adverse effects (N = 287, 21.5%)

Authorized and approved product 1024 (76.8%), safety rules 906 (67.9%), and natural products 864 (64.8%). There were statistically significant differences between DS users and nonusers, where advertising quality, safety rules, pharmaceutical forms, packet quality, and approved products significantly influenced supplement choice among users (P < 0.05). However, there were no statistically significant differences between groups regarding cost, manufacturing country, packet size, natural contents, or the presence of discount offers (Table 5).

Table 5 Consumer’s pharmaceutical purchasing behaviour and its relationship with the use of dietary supplements among Arabic adults

In terms of participants’ self-reported evaluation of the beneficialness of DS consumption, 47.7% of Arabic adults reported that it is beneficial, while 33.1% of them said that DS is harmful. We found a statistically significant association between participants self-reported evaluation of the beneficialness of DS consumption and the consumption of DS, as the majority of DS users reported that the DS consumption was very beneficial (81.1%) and beneficial (74.5%), while the majority of DS nonusers thought it was harmful (84.6%) and very harmful (80.0%), respectively (Table 5).

Multi-logistic regression analysis revealed that the main predictors linked to supplement use were being female (OR: 2.57; 95% CI 1.93–3.42), having a positive self-reported evaluation of the beneficialness of DS consumption, and recommending the use of DS (OR: 2.33; 95% CI 1.75–3.11 and OR: 2.49; 95% CI 1.79–3.44, respectively).However, one of the risks of DS use was associated with its nonuse (OR: 0.35; 95% CI 0.15–0.855–0.85), as shown in Table 6.

Table 6 Multi-logistic regression analysis for predictors of nutritional supplements use

Discussion

During the COVID-19 pandemic, the demand for nutritional supplements has increased dramatically. That is why individuals require additional preventive measures by taking nutritional supplements and pharmaceutical alternatives, including vitamins and minerals; these supplements were hoped to provide protection from COVID-19 by boosting the immune system, and they can help reduce disease severity for those who become infected with SARS-CoV-2 [23].

Dietary supplement consumption frequency

This multinational survey found that, during the fourth wave of the COVID-19 pandemic, 64.6% of adults from more than six nations consumed nutritional supplements. The frequency of DS consumption varied between different places and times; according to a Chinese survey, 31.2% of participants consumed DS to cope with the pandemic [24]. In a Lebanese study (2016), approximately 35% reported using at least 1 herbal product or dietary supplement [25]. In Saudi Arabia in 2017, it was 68.33% [26], while in Saudi Arabia in 2020, 22.1% suggested the use of DS to protect themselves from infection during the pandemic [27]; however, others showed no significant difference in consumption before and during the pandemic [28].

In terms of sex, using a multi-logistic regression analysis, we found that females took more dietary supplements in the previous two months [OR 2.57, 95% C.I. (1.93–3.42)] than men did (P = 0.01). Consistent with our findings, other studies conducted in Korea, the United Arab Emirates, and the US have found a higher frequency among women. Wirnitizer et al. [29] have shown a correlation between the high prevalence of mineral and vitamin consumption among females and the high prevalence of CHO and protein intake among males. A cohort-based study in Greece found that the prevalence of DS was 31.4% and 36.6% for females and 21.2% for men, respectively, with no significant difference; however, the COVID-19 pandemic observed a suggestive increase in the prevalence of consumption among men [30].

In terms of age group, in this study, middle-aged adults were more likely to use DS than other age groups, and this likelihood declined with age. In agreement with a study conducted in Switzerland [31] that revealed that the consumption of vitamins and DS decreases with age in women while increasing in men, the Netherlands reported inconsistent findings, indicating an increase in DS consumption with age, particularly among women between the ages of 51 and 70 [32].

In terms of the level of education, the proportion of postgraduate DS consumption and participants in previous research suggested that DS users were more likely to be aware of contemporary dietary recommendations [33], but this was not the case in this study.

In terms of nationality, the prevalence of dietary supplement users was higher among Saudi, Libyan, and Egyptian participants. Studies suggest that the high use of irrational prescriptions is a common practice in Arab countries, especially in Saudi Arabia [34, 35]. This is consistent with our study, as 42.7% of DS users take it without medical supervision.

Other studies indicated that dietary supplement users versus nonusers were more likely to live in urban areas [36] and less likely to be smokers [37], which is in accordance with our results, with the presence of chronic diseases (OR: 2.37, CI: 1.89–2.98).

Adults' perceptions that these supplements are beneficial in treating COVID-19 patients (45.4%) and have a borderline benefit (33.1%). Moreover, 46.6% of the adults considered DS useful for preventing COVID-19. Certain nutrients or dietary supplements are associated with a slight decrease in COVID-19 risk. Many things can affect the immune system and cytokine release. These include trace elements, vitamins (A, B6, B12, C, D, and E), amino acids, long-chain omega-3 fatty acids (docosahexaenoic and eicosapentaenoic), and bioactive substances that are not nutrients, such as polyphenols. Furthermore, arachidonic or linoleic acid administration partially inhibits SARS-CoV-1 and coronavirus 229E replication [38]. Furthermore, the Arabic adult consumer's confidence in adopting these items for both preventative and therapeutic immunological enhancement has increased due to the dietary supplements' affordability, accessibility, and acceptability.

The DS consumption during the pandemic revealed high consumption of minerals and multivitamins among women, particularly those aged 35 to 54, during the shutdown in Spain. Other studies have attributed the low consumption of DS among both men and women to a lack of knowledge regarding the benefits of these supplements and the fear that excessive use may result in serious side effects. The current study posits that the low consumption of DS in both genders can be attributed to a lack of knowledge. Rontogianni et al. [30] discovered that employed men were more likely to use DS than unemployed ones, indicating that they are more likely to have a better level of education and economic position.

The healthy eating pyramids

Sicinska et al. [39] used multivariate logistic analysis to find the factors that could predict DS. They found that physical activity had an OR of 1.79 and a 95% CI of 1.45–2.20. Researchers have registered and are currently conducting several clinical studies to evaluate the effectiveness of specific nutrients in COVID-19 patients [40]. We reported that, among Arabic adults, 32.1% consumed the daily-recommended requirements of protein, 31.4% of vegetables, 17.2% of fruits, and 23.6% of water. This is inconsistent with another cross-sectional study of university students in Poland and other cohort studies in France, which showed that DS users consumed a lot of vegetables, seeds, and fruits, which does not agree with this result [33, 39].

The COVID-19 pandemic may be associated with changes in dietary habits towards a healthier diet regarding health restrictions imposed on lockdown. Many foods, fruits, and vegetables that provide nutrients that have anti-inflammatory properties and boost immunity were recommended for managing and reducing the risk of COVID-19. Using a network analysis-based technique, 60 disease-diet interactions were predicted, yielding a considerable precision of 76.7% validated interactions between foods and diets, COVID-19, and 46 other disorders as relevant in either illness progression or risk prevention or mitigation. Therefore, diet-based approaches are challenging [41]. Therefore, adherence to nutritious eating guidelines could be a close-in expression of faraway social factors, such as malnutrition, that influence health and decrease the burden of some infectious diseases in the past [38].

The context of dietary consumption and the total fatigue severity scale

In terms of the prescription of the dietary supplements, we reported that the majority of users (444, 52.5%) were under medical prescription and (361, 42.7%) were self-prescribers, compared to a study conducted in SA in 2017, where higher frequencies were reported as (57, 69.5%) were under medical prescription and only (15, 18.2%) were self-prescribers [26]. Even though different approaches have been made to fight the pandemic and 70% of the world’s population will be protected against COVID-19 by the middle of 2022, the need for additional preventative measures and studies, including the use of vitamin and mineral supplements and pharmaceutical substitutes, is required. It is hoped that this supplement will protect against SARS-CoV-2 infection, boost the immune system, and make COVID-19 less severe [22].

During the fourth wave of the COVID-19 pandemic, Arabic adults consumed the following DS types: 63.5% vitamin C, 61.1% vitamin D, 47.1% iron, 44.4% zinc, 43.3% vitamin B, and 33.2% magnesium. Recent research has discovered that adequate doses of vitamins C, D, and E, as well as zinc and omega-3 fatty acids, may have clinical benefits in infectious diseases. Their plasma concentration deficiency is associated with immune system dysfunction, and their well-established immunomodulatory and antioxidant effects predispose them to certain infections. Furthermore, managing COVID-19 requires a crucial role that involves lowering the viral load, reducing the severity of the disease, and reducing the length of hospital stays [26, 41].

The most used vitamins during the COVID-19 pandemic were vitamins C and D [2 (2.40 ± 1.42) and 2 (2.10 ± 1.75), resp.]. We reported that vitamin C was the most commonly used DS at 63.5%, which was higher than the 34.4% of another study [41]. Vitamin C's multiple pharmacological characteristics, including its effectiveness as an antiviral and antioxidant and its ability to enhance immunity, make it a promising immune response for combating COVID-19 infection [42]; similarly, vitamin D's antiviral effect suggests its theoretical benefit as an enhancement in treating COVID-19 infections [43]. Furthermore, studies have linked vitamin D deficiency to various illnesses such as diabetes, high blood pressure, and obesity, all of which heighten the risk of COVID-19 [41].

The most used minerals during the COVID-19 pandemic. Zinc and iron were the most commonly used minerals [1 (2.01 ± 1.39) and 1 (2.05 ± 1.37), resp.] because they are inexpensive and widely available [42]. Clinical practice uses both zinc and iron as medicine, immune boosters, and food supplements [43]. Taking zinc supplements boosts the natural anti-infective abilities of different kinds of white blood cells, like neutrophils, basophils, and eosinophils. This makes the immune system work better and helps treat mild to moderate COVID-19 [44, 45].

Our study demonstrated that the main sources of information about dietary supplements were healthcare providers, with almost 80%, and specialized coaches, with 78.3%. In addition, about 28.8% had no sources. Sources of information on dietary supplements appear to vary greatly in a couple of previous studies in Saudi Arabia, which reported lower use of nutritional supplements. They were both very similar in the supplement’s adoption, with 37.5% and 39.4% relying on social media or websites [27, 46], while Yani et al. [47] reported that magazines, scientific books, and the internet were the three main sources of information.

Healthcare professionals and specialized coaches were the main information sources. This accounts for the evaluation of dietary supplements by Arabic adults, 47.7% of whom viewed them as beneficial and 33.1% as harmful. This may be due to their role in assisting patients by discussing their health situation with them; this could significantly reduce the number of poor outcomes associated with acquiring medication from unlicensed manufacturers [48, 49]. Zinc, for example, has many positive or negative effects depending on the customer's health condition; it is required for the growth of certain pathogenic fungi that cause fatal mucormycosis. High zinc levels in hepatitis patients can increase the virus load by inhibiting interferon production, causing T cells, B cells, and thymocytes to die, and preventing copper absorption, which can lead to anemia and leukopenia [44].

The FSS, which assesses the effects of fatigue on cognitive and psychosocial aspects, found that 488 (36.6%) of Arabic adults had suspected fatigue. Given that fatigue is a common post-COVID-19 symptom [50], it is likely that 477 (35.8%) of participants had a positive history of SARS-CoV-2 infection. DS was recommended for 1006 (75.5%) of the recruited Arabic adults, as it is well known that minerals and vitamins play important roles in improving chronic physical, mental, and general health conditions. Vitamin C, zinc, iron, and magnesium are all involved in energy metabolism and, when used in the right amounts, can stimulate physiological functions by enhancing the body's self-sufficiency, which has health benefits in terms of physical and mental fatigue [51]. Additionally, the DS could potentially decrease the reliance on commonly used drugs in these situations.

FSS was significantly higher among DS users (341, 39.6%) compared to non-users (147, 31.1%). In the current study, multi-logistic regression analysis showed that having COVID-19 is a good predictor of dietary supplement use (OR: 1.53, 95% CI: 1.14–2.06). This finding contradicts the reported decrease in FSS among supplement users [52,53,54].

Finally, based on our findings, we recommend:

1. To share the results regarding consumers' pharmaceutical purchasing behavior in terms of advertising quality, safety regulations, pharmaceutical forms, and packet quality with the pharmaceutical campaigns in the Arabic region.

2. Medical prescriptions and health education regarding the standard of consumption of DS to maximize the benefits of their use and minimize the potential risks.

3. Further cohort and laboratory studies should be conducted to better comprehend the effects of DS.

4. Mass media campaigns to increase the public's adherence to the recommended dietary eating pyramid and physical activity level.

Strength

This multicounty study aims to represent a large sample of Arabic adults from six different nationalities in Arabic countries. The study focuses on dietary supplement consumption and the demographic factors that influence it. Moreover, we used three internationally validated tools including Healthy eating pyramids, consumers’ pharmaceutical purchasing behavior and FSS determinants in Arabic adults during the fourth wave of the COVID-19 pandemic.

Limitations

The first limitation is that our study has all the biases and confounding factors that observational studies have. The second limitation is that the study used an online self-administered survey, which makes the data less reliable because of recall bias, as well as the fact that more than 80% of the sample were well-educated women (72.3%) who worked in the medical (51.3%), had access to, and knew how to use the internet. The data was also less reliable because it was self-administered and self-reported. We also disqualified participants who did not use the internet or could not read or write.

The third limitation is that a lack of knowledge regarding the negative effects of vitamin and mineral intake may have contributed to the failure to submit pertinent information at this time. It is impossible to distinguish between issues caused by COVID-19-related effects and problems that already existed. Despite the fact that these factors are not ideal, other international research has found support for our findings.

Finally, the sample sizes from different countries vary greatly for two main reasons: 1) The methodology estimated the sample size based on a variety of variables, such as the total population. For instance, Syria's population was approximately 17 million, Saudi Arabia's was approximately 34 million, and Egypt's was over 110 million. 2) The response rate from Syria was extremely low due to the use of an online questionnaire and political upheaval, which hinders people's ability to use the internet effectively and frequently in those countries.

Conclusion

This multinational cross-sectional study, conducted in six Arab countries, found that the dietary consumption of supplements is prevalent. Arabic adults are poorly adherent to the healthy eating pyramids, which indeed call for advice and support for a healthy dietary pattern. Being female and having a prior history of SARS-CoV-2 infection are independent predictors of supplement use.

Authorized and approved products, natural contents, safety rules, packet quality, cost, and manufacturing country were the most common factors influencing Arabic adults’ pharmaceutical purchasing behavior.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request (dr_samar11@yahoo.com).

Abbreviations

AEs:

Adverse effects

CI:

Confidence interval

DS:

Dietary Supplement

FSS:

Fatigue Severity Scale.

FDA:

Food and Drug Administration

OR:

Odds ratios

% DV:

Percent of the daily value

SD:

Standard Deviation

χ2 :

The chi-squared test

FTC:

The Federal Trade Commission

SA:

Saudi Arabia

UK:

The United Kingdom

USA:

United States of America

References

  1. World Health Organization. Weekly operational update on COVID-19—4 July 2021. Weekly operational update on COVID-19 - 5 July 2021 (who.int)

  2. Chen T, Wu D, Chen H et al (2020) Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. BMJ. 368:m1091. https://doi.org/10.1136/bmj.m1091 pmid: 32217556.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Del Rio C, Collins LF, Malani P (2020) Long-term health consequences of COVID-19. JAMA 324(17):1723–1724

    Article  PubMed  PubMed Central  Google Scholar 

  4. Adams YKK, Baker WL, Sobieraj DM (2020) Myth busters: dietary supplements and COVID-19 Ann. Pharmacother 54:820–826. https://doi.org/10.1177/1060028020928052

    Article  CAS  Google Scholar 

  5. Background Information: Dietary Supplements.National Institute of health. Updated: March 11, 2020 History of changes to this fact sheet. https://ods.od.nih.gov/factsheets/DietarySupplements-Consumer/ - :~:text= What is a dietary supplement%3F 1,panel as being a dietary supplement. More

  6. Lordan R, Rando HM, Greene CS (2021) Dietary supplements and nutraceuticals under investigation for COVID-19 prevention and treatment. MSystems. 6(3):e00122–21. https://doi.org/10.1128/mSystems.00122-21

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Infusino F, Marazzato M, Mancone M, Fedele F, Mastroianni CM, Severino P, Ceccarelli G, Santinelli L, Cavarretta E et al (2020) Diet supplementation, probiotics, and nutraceuticals in SARS-CoV-2 infection: a scoping review. Nutrients 12:1718

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Starr RR (2015) Too little, too late: ineffective regulation of dietary supplements in the United States. Am J Public Health 105:478–485. https://doi.org/10.2105/AJPH.2014.302348

    Article  PubMed  PubMed Central  Google Scholar 

  9. U.S. Food & Drug Administration, Dietary Supplements, (2020). https://www.fda.gov/food/dietary-supplements Accessed 24 Apr 2021.

  10. Bailey Rl (2020) Current regulatory guidelines and resources to support research of dietary supplements in the United States. Crit. Rev. Food Sci. Nutr 60(2):298–309. https://doi.org/10.1080/10408398.2018.1524364

    Article  PubMed  Google Scholar 

  11. U.S. Food and Drug AdminisrationAdministration, Coronavirus update: FDA and FTC Warn Seven Companies selling fraudulent products that claim to treat or prevent COVID-19, (2020). https://www.fda.gov/news-events/press-announcements/coronavirus-update-fda-and-ftc-warn-seven-companies-selling-fraudulent-products-claim-treat-or Accessed 25 Apr 2021.

  12. Grebrow J. 2021. Peak Dietary Supplement Sales Leveling Off During COVID-19 Pandemic, but Growth Still Remains Strong Over Last Year, Market Researchers Report During Webcast. Availabe online: https://www.nutritionaloutlook.com/view/peak-dietary-supplement-sales-leveling-during-covid-19-pandemic-growth-still-remains-strongAccessed 10 Nov 2020.

  13. Financial Times .Times. 2021. Rise in Vitamin Sales During Pandemic a Tonic for Consumer Goods Groups. Availabe online: https://www.ft.com/content/fbcfe8df-4ab9-47c3-974e-320e0d320d19Accessed 16 Jul 2021.

  14. European Field Marketing Partners .Partners. 2021. The Impact of COVID-19 on Consumers Purchasing in Europe. Availabe online: https://efmp.com/articles/the-impact-of-covid19-on-consumers-purchasing-in-europe/Accessed 16 Jul 2021.

  15. Hamulka J, Jeruszka-Bielak M, Górnicka M, Drywień ME, Zielinska-Pukos MA (2021) Dietary supplements during COVID-19 outbreak. Results of google trends analysis supported by PLifeCOVID-19 online studies. Nutrients 13(1):54

    Article  CAS  Google Scholar 

  16. Grebow J. 2021. Dietary Supplement Sales Success post-COVID: How Can Industry Keep the Momentum Going After the Pandemic? Availabe online: https://www.nutritionaloutlook.com/view/dietary-supplement-sales-success-post-covid-how-can-industry-keep-the-momentum-going-after-the-pandemicAccessed 16 Jul 2021.

  17. https://goodcalculators.com/sample-size-calculator//" © 2015–2023 goodcalculators.com

  18. Tareq L Mukattash, Alkhalidy Hana, Alzu’bi Buthaina, Rana Abu-Farha et al (2022) Dietary supplements intake during the second wave of COVID-19 pandemic: A multinational Middle Eastern study. Eur J Integr Med 49:102102. https://doi.org/10.1016/j.eujim.2022.102102 (https://www.sciencedirect.com/science/article/pii/S187638202200004X)

    Article  Google Scholar 

  19. Lerdal A, Wahl AK, Rustoen T, Hanestad BR, Moum T (2005) Fatigue in the general population: A translation and test of the psychometric properties of the Norwegian version of the fatigue severity scale. Scandinavian Journal of Public Health 33(2):123–130. https://doi.org/10.1080/14034940410028406

    Article  PubMed  Google Scholar 

  20. Tudor-Locke C, Craig CL, Thyfault JP, Spence JC (2013) A step-defined sedentary lifestyle index: <5000 steps/day. Applied Physiology, Nutrition, and Metabolism 38(2):100–14. https://doi.org/10.1139/apnm-2012-0235. PMID: 23438219.

    Article  PubMed  Google Scholar 

  21. Healthy Eating Pyramid | The Nutrition Source | Harvard T.H. Chan School of Public Health

  22. Sabur AM, Alsharief LA, Amer SA (2022) Determinants of Healthy Food Consumption and the Effect of Saudi Food Related Policies on the Adult Saudi Population, a National Descriptive Assessment 2019. Curr Res Nutr Food Sci 10(3):1058–76. https://doi.org/10.12944/CRNFSJ.10.3.21

    Article  Google Scholar 

  23. Alkharashi NA (2021) The consumption of nutritional supplements and herbal products for the prevention and treatment of COVID-19 infection among the Saudi population in riyadh. Clinical Nutrition Open Science 39:11–20

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Zhao A, Li Z, Ke Y, Huo S, Ma Y, Zhang Y, Ren Z (2020) Dietary diversity among Chinese residents during the COVID-19 outbreak and its associated factors. Nutrients 12(6):1699

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. El Khoury G, Ramadan W, Zeeni N (2016) Herbal products and dietary supplements: a cross-sectional survey of use, attitudes, and knowledge among the Lebanese population. J Community Health 41(3):566–573

    Article  PubMed  Google Scholar 

  26. Maggini S, Pierre A, Calder PC (2018) Immune function and micronutrient requirements change over the life course. Nutrients 10(10):1531

    Article  PubMed  PubMed Central  Google Scholar 

  27. Alyami HS, Orabi MA, Aldhabbah FM, Alturki HN, Aburas WI, Alfayez AI, Alsuhaibani NA (2020) Knowledge about COVID-19 and beliefs about and use of herbal products during the COVID-19 pandemic: A cross-sectional study in Saudi Arabia. Saudi Pharmaceutical Journal 28(11):1326–32

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Lam CS, Koon HK, Chung VCH, Cheung YT (2021) A public survey of traditional, complementary and integrative medicine use during the COVID-19 outbreak in Hong Kong. PloS one 16(7)

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Wirnitzer K, Motevalli M, Tanous DR, Gregori M, Wirnitzer G, Leitzmann C, Knechtle B (2021) Sex differences in supplement intake in recreational endurance runners—results from the NURMI Study (Step 2). Nutrients 13(8):2776

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Rontogianni MO, Kanellopoulou A, Markozannes G, Bouras E, Derdemezis C, Doumas MT, Tsilidis KK (2021) Prevalence and determinants of sex-specific dietary supplement use in a Greek cohort. Nutrients 13(8):2857

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Marques-Vidal P, Pecoud A, Hayoz D, Paccaud F, Mooser V, Waeber G, Vollenweider P (2009) Prevalence and characteristics of vitamin or dietary supplement users in Lausanne, Switzerland: the CoLaus study. Eur J Clin Nutr 63(2):273–281

    Article  CAS  PubMed  Google Scholar 

  32. Van Rossum, C. T. M., Buurma-Rethans, E. J. M., Dinnissen, C. S., Beukers, M. H., Brants, H. A. M., & Ocké, M. C (2020) The diet of the Dutch: Results of the Dutch National Food Consumption Survey 2012–2016

    Google Scholar 

  33. Pouchieu C, Andreeva VA, Péneau S, Kesse-Guyot E, Lassale C, Hercberg S, Touvier M (2013) Sociodemographic, lifestyle and dietary correlates of dietary supplement use in a large sample of French adults: results from the NutriNet-Sante cohort study. Br J Nutr 110(8):1480–1491

    Article  CAS  PubMed  Google Scholar 

  34. Wajid S, Al-Arifi M, Al Nomay H, Al Mousa YN, Babelghaith SD (2015) Knowledge and perception of community pharmacists’ towards generic medicines in Saudi Arabia. Biomed Res 26(4):800–806

    Google Scholar 

  35. Salunkhe SD, Pandit VA, Dawane JS, Sarda KD, More CS (2013) Study of over the counter sale of antimicrobials in pharmacy outlets in Pune, India: a cross sectional study. Int J Pharm Bio Sci 4(2):616–622

    Google Scholar 

  36. Keshavarz P, Shafiee M, Islam N, Whiting SJ, Vatanparast H (2021) Prevalence of vitamin-mineral supplement use and associated factors among Canadians: results from the 2015 Canadian Community Health Survey. Appl Physiol Nutr Metab 46(11):1370–1377

    Article  CAS  PubMed  Google Scholar 

  37. Mullie P, Clarys P, Hulens M, Vansant G (2011) Socioeconomic, health, and dietary determinants of multivitamin supplements use in Belgium. Int J Public Health 56(3):289–294

    Article  PubMed  Google Scholar 

  38. Merino J, Joshi AD, Nguyen LH, Leeming ER, Mazidi M, Drew DA, Gibson R, Graham MS, Lo CH, Capdevila J, Murray B, Hu C, Selvachandran S, Hammers A, Bhupathiraju SN, Sharma SV, Sudre C, Astley CM, Chavarro JE, Kwon S, Ma W, Menni C, Willett WC, Ourselin S, Steves CJ, Wolf J, Franks PW, Spector TD, Berry S, Chan AT (2021) Diet quality and risk and severity of COVID-19: a prospective cohort study. Gut. 70(11):2096–2104. https://doi.org/10.1136/gutjnl-2021-325353. (Epub 2021 Sep 6. PMID: 34489306; PMCID: PMC8500931.)

    Article  CAS  PubMed  Google Scholar 

  39. Sicinska E, Madej D, Szmidt MK, Januszko O, Kaluza J (2022) Dietary Supplement Use in Relation to Socio-Demographic and Lifestyle Factors, including Adherence to Mediterranean-Style Diet in University Students. Nutrients 14(13):2745

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Shakoor H, Feehan J, Al Dhaheri AS, Ali HI, Platat C, Ismail LC, Stojanovska L (2021) Immune-boosting role of vitamins D, C, E, zinc, selenium and omega-3 fatty acids: Could they help against COVID-19? Maturitas 143:1–9

    Article  CAS  PubMed  Google Scholar 

  41. Toor R, Chana I (2022) Exploring diet associations with Covid-19 and other diseases: a Network Analysis-based approach. Med Biol Eng Comput. 60(4):991–1013. https://doi.org/10.1007/s11517-022-02505-3. (Epub 2022 Feb 16. PMID: 35171411; PMCID: PMC8852958.)

    Article  PubMed  PubMed Central  Google Scholar 

  42. Grebow, J. (2020). Dietary supplement sales skyrocket during coronavirus pandemic. Nutr Outlook, 23(4).https://www.nutritionaloutlook.com/view/dietary-supplement-sales-skyrocket-during-coronavirus-pandemicAccessed Sep 2022.

  43. Malaguarnera L (2020) Vitamin D3 as potential treatment adjuncts for COVID-19. Nutrients 12(11):3512 (https://www.mdpi.com/2072-6643/12/11/3512/)

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  44. Imran M, Fatima W, Alzahrani AK, Suhail N, Alshammari MK, Alghitran AA, Alshammari FN, Ghoneim MM, Alshehri S, Shakeel F (2022) Development of Therapeutic and Prophylactic Zinc Compositions for Use against COVID-19: A Glimpse of the Trends, Inventions, and Patents. Nutrients 14:1227. https://doi.org/10.3390/nu14061227. (Academic Editors: Andrea P. Rossi and Marwan El Ghoch)

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  45. Singh M, Das RR (2013) Zinc for the common cold. Cochrane Database of Systematic Reviews 18(6):CD001364

    Google Scholar 

  46. Mukattash TL, Alkhalidy H, Alzu’bi B, Abu-Farha R, Itani R, Karout S, Jarab A (2022) Dietary supplements intake during the second wave of COVID-19 pandemic: a multinational middle eastern study. European Journal of Integrative Medicine 49

    Article  PubMed  PubMed Central  Google Scholar 

  47. Alsofyani MAA, Al-Essa MHA, Assiri MA, Alalwani BM, Abuzeefa AA, Qasim AT, Ali SI (2018) Prevalence of people that using multivitamins supplementation & experiencing a side effect in Saudi Arabia. The Egyptian Journal of Hospital Medicine 70(1):65–71

    Article  Google Scholar 

  48. Desai K, Chewning B, Mott D (2015) Health care use amongst online buyers of medications and vitamins. Res Social Adm Pharm 11(6):844–858

    Article  PubMed  Google Scholar 

  49. Fittler A, Lankó E, Brachmann B, Botz L (2012) Behaviour analysis of patients who purchase medicines on the internet: can hospital pharmacists facilitate online medication safety? Eur J Hosp Pharm 20(1):8–12

    Article  Google Scholar 

  50. Tleyjeh Imad M, Kashour Tarek, Riaz Muhammad, Amer Samar A, AlSwaidan Nourah, Almutairi Laila, Halwani Rabih, Assiri Abdullah (2022) Persistent COVID-19 symptoms at least one month after diagnosis: A national survey. Journal of Infection and Public Health. 15(5):578–585. ISSN 1876-0341 https://doi.org/10.1016/j.jiph.2022.04.006 (https://www.sciencedirect.com/science/article/pii/S1876034122000946)

    Article  PubMed  PubMed Central  Google Scholar 

  51. Tardy AL, Pouteau E, Marquez D, Yilmaz C, Scholey A (2020) Vitamins and minerals for energy, fatigue and cognition: a narrative review of the biochemical and clinical evidence. Nutrients 12(1):228

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  52. Ferorelli P, Antonelli F, Shevchenko A, Mischiati C, Doepp M, Lenzi S, Borromeo I, Feriotto G, Beninati S (2021) Reduction in Fatigue Symptoms Following the Administration of Nutritional Supplements in Patients with Multiple Sclerosis. Med Sci (Basel) 9(3):52. https://doi.org/10.3390/medsci9030052. PMID: 34287336; PMCID: PMC8293375.

    Article  CAS  PubMed  Google Scholar 

  53. Ahmad SR (2022) Vitamin C for COVID-19 Treatment: Have We Got Enough Evidence? Frontiers in Nutrition 9:892561. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9161352/

    Article  PubMed  PubMed Central  Google Scholar 

  54. Rani I, Goyal A, Bhatnagar M, Manhas S, Goel P, Pal A, Prasad R (2021) Potential molecular mechanisms of zinc- and copper-mediated antiviral activity on COVID-19. Nutr Res 92:109–112

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

I would like to express special thanks to all the recruited cases in this study. Special thanks to Professor Dr. Mohamed Liaquat Raza, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia, for his role in the complimentary editing of this manuscript

Funding

Financial support was not obtained from any individual, institutions, agencies, drug industries, or organizations, nor was it funded by any tobacco company.

Author information

Authors and Affiliations

Authors

Contributions

Conceptualization: Samar Amer (SA), Mohammed N. A. Abdel-hameid (MN), Shimaa Y. S. Elsheikh (SHE). Methodology: SA .Validation: SA, MN, SHE. Formal analysis: Mona Ibrahim (MI). Data curation: MN, SHE, Lina Douaouia(LD), Sara Nasser Abuhaimed (SHN), Ehab M. Ishteiwy(EMI), Lina Raad Abdullh (LR), Mohamed Muhanad Balid (MB), Youmna Amer(YA). Writing and preparation of the first draft: SA, Taher Shailabi (TS), Nahla Zaitoun(NAZ), Nermeen Zaitoun (NEZ). Writing, reviewing and editing: SA, YA,Sarya Swed (SS). Visualization: SS, MI. Supervision: SA, SS. Project administration: SA. All authors have read and agreed to the published version of the manuscript.

Corresponding author

Correspondence to Sarya Swed.

Ethics declarations

Ethics approval and consent to participate

All participants provided informed written consent after clarification of the goals, data confidentiality, voluntary participation, and withdrawal. The questionnaire contains no sensitive questions, and the data was collected anonymously. The Zagazig University Institutional Review Board approved this study ZU-IRP#9921/28-4-2022. Harvard University owns the Healthy Eating Pyramid. It was acceptable to download and use it without authorization.

Consent for publication

A written informed consent for publication was obtained from all authors

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Amer, S., Abdel-hameid, M., Elsheikh, S. et al. Consumption of dietary supplements and their determinants among adults in six Arabic countries: a cross-sectional survey. Egypt J Intern Med 36, 70 (2024). https://doi.org/10.1186/s43162-024-00323-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s43162-024-00323-7

Keywords