Knowledge, awareness and practices regarding dietary supplements in Jordan

Purpose: To investigative the knowledge, attitudes and beliefs pertaining to dietary supplements (DS) use in Jordan. Methods: Participants were enrolled from four main cities in Jordan, viz, Amman, Zarqa, Irbid, and Mafraq, to fill a self-administered questionnaire which explored the objectives of the study. Results: Most participants (80 %) knew what DS are. The prevalence of DS use was high (62.1 %) and significantly higher among females (p = 0.004). The most commonly consumed DS among users were in the form of multivitamins (93.0 %), vitamin D (65.8 %) and vitamin C (57.6 %). About half of the participants (46.2 %) believed that DS have no side effects. The most frequent source of information for participants about DS was from non-reliable references, such as social media. Self-prescription was the most common approach by DS users for supplement intake. Finally, the common hypothesis of associating healthy habits with DS use was not found to be true among Jordanians. Conclusion: These results highlight the need to implement appropriate awareness programs for the public regarding DS benefits and hazards, and especially to advise the public not to initiate DS use without first consulting an appropriate healthcare professional.


INTRODUCTION
The use of DS to treat health conditions is well established, with the use of vitamin C to treat scurvy disease and vitamin D in preventing and treating rickets as primary examples [1].
In addition, the role of DS in non-communicable diseases including cancer and cardiovascular complications has shown to be conflicting. It has been reported by many studies that DS can reduce the risk of developing the aforementioned health issues [1]. In contrast, some researchers have presented that the unnecessary use of DS showed neither positive nor negative outcomes, likewise, others have observed overwhelming side effects. In the Park et al study, an association between the use of multivitamins and the increase or decrease of cancer or cardiovascular deaths could not be found during the eleven years follow up study with 182,099 participants [2].
In recent years, there has been a substantial increase in the use of DS worldwide due to media advertising supplements as health products free of any potential risks. Accordingly, many studies have been conducted in different countries including Italy, Korea, and USA, to assess the population's knowledge about DS and to assure that they are used safely and effectively [3][4][5]. In Jordan, to our best knowledge, there is only one study that has examined the attitudes of DS users. However, it was only conducted among university students at University of Jordan; in which 27.4 % of participants reported the use of DS mostly in the form of multivitamins [6].
Furthermore, there is an increasing evidence of an association between healthy habits such as regular physical activity, avoiding smoking products and maintaining healthy body weight with DS intake [7].
Limited evidence is available regarding the user's knowledge and attitudes among the Jordanian population, in respect to DS consumption in different demographic backgrounds. This study aims to investigate the awareness and knowledge about DS among the Jordanian population as well as their habits and beliefs regarding the use of supplements. The findings of the current study shed light on knowledge about DS use, factors influencing DS use, and the attitudes and characteristics of the typical user in Jordan.

Study design
A cross sectional study was conducted in four main cities in Jordan including; Amman, Zarqa, Irbid, and Mafraq. Participants above 18 years old were randomly recruited during weekdays from individuals attending universities and workplaces over a period of six weeks from Nov 2019, on a voluntary basis. The minimum required sample size (385) was calculated at (95 %) confidence level and (5 %) margin of error with (50 %) response [8]. The same research assistant handed all the self-administered questionnaires and a script containing information about the questionnaire and privacy rights was read to all participants beforehand. Persons who had no interest in the survey refused to participate and only the persons who agreed to the terms of participation were included. The informed written consent forms were obtained from all participants and all questionnaires were filled anonymously. The study protocol was conducted in accordance to the good clinical practices and principles as stated in the Declaration of Helsinki document [9]. The study was approved by the ethical committee review board at Zarqa University in Jordan (no: 3/1/2019-2020).

Study tools
The questionnaire was adapted after comprehensive literature search based on other relevant published questionnaires [3,10]. It was developed into closed/open ended questions and reviewed internally at the faculty of pharmacy at Zarqa University. Then, a pilot study of 60 participants was carried out to evaluate the clarity of the survey items as well as the analysis of preliminary data before performing the full launch. Data obtained during the internal piloting study was included in the main study analysis. The survey was designed in Arabic language and consisted of three main sections; the first section aimed to collect demographic characteristics; which included nationality, gender, age, educational level and discipline, social status, occupation, weight, height, smoking status and physical activity (frequency and intensity). The second part aimed to assess the participant's knowledge and awareness about DS. Participants were explicitly asked about the knowledge indicated by being able to give one example of DS, source of information, beliefs in term of benefits and risks regarding DS use. If the participants assumed a beneficial role of DS in the course of any disease, they were requested to indicate if DS have a role in terms of treatment and/or prevention of diseases and to specify the supplement involved in this role. Finally, the participants were asked in the third section to answer questions regarding their use of DS, reasons for intake, most consumed DS, prescription method, as well as their attitudes toward use of DS including adherence. Participants were allowed to choose more than one answer when appropriate. Participants were considered non-users of DS if they indicated that they had never used DS until the time of study.

Data analysis
Data were coded and inputted into IBM Statistical Package for Social Sciences (SPSS © ) Statistics for Windows, Version 22, (IBM Corp., Armonk, N.Y., USA), for statistical analysis. Descriptive statistics with corresponding 95 % confidence intervals were constructed. Differences between various groups were evaluated using Pearson chi-Square correlation test χ² and Fisher exact tests for categorical variables. P < 0.05 were considered statistically significant. To measure the association between variables, the Cramer's V coefficient test was used. Results of Cramer's V coefficient test was interpreted as > 0.25 = very strong, > 0.15 = Strong, > 0.10 = moderate, > 0.05 = weak and > 0 = no or very weak following "User's guide to correlation coefficients" by Akoglu [11].

Study sample and demographic characteristics
Questionnaires were handed out to the public to participate in the survey entitled "Knowledge, awareness and practices about dietary supplements in Jordan". The final sample size was 509 participants. The participants were included in the study if they completed the questionnaire and gave written informed consent for participation.
The majority of participants were female (52.7 %), in the age group 18 -25 years (45.0 %), Jordanian (91.8 %), non-smokers (66 %), with abnormal weight as indicated by BMI (57.6 %) and physically inactive (54.6 %). In addition, most of the participants were bachelor degree holders (63.3 %) and have no association with the medical field (65.4 %) ( Table 1 and 2).   Table 3 shows results in regard to knowledge and awareness about DS, most participants (80 %) knew what DS are and most of the information was obtained from the internet and social media web pages (45 %). A significant difference was observed between genders (Table 4).

Knowledge and awareness about DS
Females had more knowledge about DS (p = 0.003) compared to males. Furthermore, the knowledge about DS was significantly higher among the medical field participants (p = 0.016) ( Table 4).
Regarding possible side effects of DS, 46.8 % of participants believed that DS have side effects (Table 3), and this was strongly associated with medical field specialty (Cramer's V = 0.184) (p = 0.005) (Table 4). Furthermore, participants who were physically active strongly believed that DS have side effects (Cramer's V = 0.184) (p = 0.001, Table 4). In respect to the role of DS in disease prevention or treatment, the majority of participants answered that DS use could neither prevent (64.6 %) nor treat (73.3 %) chronic diseases (Table 3). This was found to be statistically significant, mainly among participants who are related to the medical field (Cramer's V = 0.178, 0.131) (p ≤ 0.005, 0.013), respectively for prevention and treatment (Table 3).
Concerning gender difference, there was a strong association between gender and belief of DS role in disease course. Females believed significantly more in the role of DS in disease prevention and treatment (Cramer's V = 0.157, 0.158) (p = 0.002, 0.002), respectively (Table 4). Unexpectedly, most of the participants, even the ones who agreed that DS could prevent or treat diseases, were not sure about which diseases are treatable or preventable (Table 5).

Attitudes, habits and use of dietary supplements
Most of the survey participants (62.1 %) have used DS, with the majority of DS users being females (p = 0.004) and from the age group 31-40 years (p = 0.025). Furthermore, the belief about DS benefits was statistically significant among females (p = 0.013), medical field participants (p = 0.001) ( Table 6).
In respect of association of DS intake and healthy habits, no association was found between DS use and BMI (Cramer's V = 0.072), physical activity (Cramer's V = 0.025), and smoking status (Cramer's V = 0.012) ( Table 7).
The most commonly used DS by participants were in the form of multivitamins (93.0 %) followed by vitamin D (65.8 %) and vitamin C (57.6 %) ( Table 8). Of note, a very strong association was only found between the intake of body building supplements, such as proteins and creatine, with gender (Cramer's V = 0.286), and physical activity (Cramer's V = 0.252) (p ≤ 0.005).
Furthermore, smoking status (Cramer's V = 0.223) and young age 18 -25 years (Cramer's V = 0.226) were also strongly associated with body building supplements intake (Table 9). Other demographic data showed low or no association with body building supplements intake.
The study's results showed a very significant association between knowledge and use (Cramer's V = 0.408) (p ≤ 0.005) (        Indeed, more than half of the participants have used DS and these users were mostly females from the age group 30-41 years old. In this regard, our results were in agreement with previous studies, in which the users where mostly females and from older age groups [13].

s V test showed no association between DS intake and indicators of healthy habits (BMI, Physical activity and being a non-smoker). Carmer's V values < 0.05. DS = Dietary Supplements
Many studies worldwide have shown that nonsmokers and physically active participants consumed DS at a higher rate [14]. On the contrary, this study results showed no association between using DS and positive habits such as regular exercise and nonsmoking. The difference between these reported results and others could be attributed to the high proportion of smokers and social acceptance of smoking in Jordan [15], with 33.5 % of DS users in the current report being smokers. Furthermore, our results showed that exercise is not a regular habit by users as 54.4 % were physically inactive and 53.8 % of the users were with BMI indicating overweight or obesity. In fact, obesity and overweight are concerning issues in Jordan [16]. Altogether, the belief that DS users are more interested in improving overall health by maintaining healthy habits was shown to be untrue by our results and another Korean study [4].
Based on findings from this study and others [3], the reason(s) for the intake of DS were mainly to overcome a deficiency or to improve health and wellbeing. The most DS used were in the form of multivitamins followed by vitamin D and/or vitamin C. The benefits of DS use are well documented in case of nutrients deficiencies [1].
The use of DS by the participants to prevent or treat diseases was low. However, these results were expected since the majority of them did not believe in the role of DS in reducing the risk of diseases or treating them. Furthermore, they were mostly uneducated about which DS are involved in disease prevention and/or treatment. Few studies have shown that DS can reduce the risk of chronic diseases [17]. Nonetheless, others have reported that the use of DS to treat or prevent diseases in healthy individuals without nutrients deficiencies is questionable and might be a health concern [18]. For instance, the use of vitamin E increased the risk of prostate cancer as shown in a follow-up study conducted on 35,533 men from the USA, Canada, and Puerto Rico for 4 years [19].
In regard to source of influence for DS intake, most of the participants of this study consumed DS by self-prescription, which might put them at risk of developing potential side effects. This selfprescription could be related to the fact that DS are advertised to be generally safe. Lam et al have reported similar results to our study, in which 84.4 % users were using self-prescribed DS [20]. DS users in present survey either did not seek information on supplements or if they did it was mostly from non-reliable sources such as social media and friends rather than healthcare providers. Consistent with these results, Alfawaz et al have shown that social media was the most common source of information about DS [21].
Our results showed that about half of our DS users were not aware of potential side effects; this awareness was significantly higher among medical participants and physically active participants. Jovanov et al have shown in their international study that the majority of young athletes (72.1 %) who were using DS to enhance body image were aware of health risks associated with body building supplements use, nonetheless this did not stop them of using the supplements [22]. In reference to the usage of body building supplements, such as creatine and chained amino acids, our results showed higher intake among physically active participants and males. Therefore, advising physically active people about natural resource alternatives to enhance sports performance and body image is recommended to reduce the possible risks associated with the use of body building supplements. It is well documented that exceeding the normal required level of nutrients has its own risks. Many studies have shown that using DS in excess can result in a different range of side effects; as simple as diarrhea to a more serious risk of liver injury and cancer [5].
Based on current evidence of DS use with reference to its possible side effects, the public should always be encouraged to seek medical advice from trustworthy and reliable resources. Therefore, supplement intake should not be initiated before health care providers' recommendations; based on results from biochemical laboratory assays. This is highly valuable to avoid any harmful effects that might result from exceeding the normal levels of vitamins and minerals.

Limitations of the study
The present study has some limitations that should be considered. Our findings were from participants from 4 major cities in Jordan and therefore to have better generalization of the results, further studies including other parts of Jordan should be included.

CONCLUSION
DS users are more likely to take supplements on their own instead of consulting healthcare providers. Consequently, when this selfrecommended use of DS is linked with their personal belief that DS are free from any side effects and can treat or prevent a disease, the risks of DS use might outweigh the benefits, leading to negative health consequences. Therefore, it is recommended that the public should be educated about the advantages and disadvantages of DS, by implementing educational programs mainly through healthcare providers as they are the most accessible professionals to the public and have more opportunities to make a significant impact in these settings.

Open Access
This is an Open Access article that uses a funding model which does not charge readers or their institutions for access and distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/ 4.0) and the Budapest Open Access Initiative (http://www.budapestopenaccessinitiative.org/rea d), which permit unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited.