Knowledge, attitudes, and practices of Lebanese patients with type II diabetes towards the use and abuse of dietary supplements: A cross-sectional study

Background Dietary supplements (DS) use among Lebanese patients with type 2 diabetes mellitus (T2DM) increased widely due to the country’s economic and financial situation. This study was conducted (1) to estimate the prevalence of DS use among persons with T2DM amid the escalating economic crisis in Lebanon; (2) to explore the knowledge, attitude, and practice (KAP) of DS use; and (3) to determine any significant association between socio-economic and socio-demographic factors and the use of DS modality Methods A cross-sectional study was conducted during the worst episode of the economic crisis between October and April 2022 on 460 adult patients with T2DM of both sexes. Patients were interviewed using a pre-tested questionnaire. Results Almost 4 out of 10 patients with T2DM in our study were found to be using DS, where 27.6% take multivitamins frequently. One-third of the participants agreed that nutritional supplements are necessary to control diabetes symptoms and complications. Around 41.1% of the participants complained about hypoglycemia and used DS to control their blood sugar levels (56.4%), while the rest used it to improve their health (35.5%) and control their diet (2.2%). The predictors of DS usage were the patient’s level of education [OR=3.9, CI=1.5-10, p=0.003), self-monitoring of blood sugars (OR=4.9, CI=1.68-14.6; p=0.004) and reading the nutrition label [OR=59.3, CI=6.3-55.8, p=0.000]. Conclusion This study estimated the prevalence of DS use and abuse, among persons with diabetes type II and found three significant predictors of DS use among patients with T2DM. Public health experts should encourage healthy discussions and awareness with their patients to comprehend their views regarding DS use.


Introduction
Among the sustainable developmental goals (SDG), SDG 3.4 addresses Non-Communicable Diseases (NCDs) specifically, and world leaders committed to a one-third reduction in deaths between the ages 30 to 70 years from diabetes by the year 2030.Although the burden is worldwide, low-and middle-income countries (LMICs) are struggling with NCDs, especially Lebanon, with over three-quarters of all NCD deaths occurring in these countries. 14][5] This is due to the country's political and economic challenges. 6On the other hand, Lebanese patients with type 2 diabetes mellitus (T2DM) are experiencing medicine shortages 7 with rise in medication prices, which leads the patients to be incapable of buying their medical drugs.This deviation increased the health risk for these patients and increased the use and abuse of dietary supplements (DS).This increase may be due to several factors, including patients' perceptions that DS's natural products are safer, more effective, and cheaper than conventional medicines. 8In Lebanon, there are no studies that investigate the prevalence of DS use and abuse among persons with T2DM or their knowledge, attitudes, and practices toward DS use.Our research group had already investigated DS use among children under 5 and their mothers (DS use: 64%), 9 among adults before versus during the COVID-19 pandemic (DS use: 73% versus 70%, respectively), 10 and among athletes (DS use: 74%). 11On the other hand, in the United Sates, approximately 54% of individuals with diabetes used dietary supplements based on data from the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2014.Older adults over 65 years had the highest usage at 62%, followed by those aged 40 to 64 years at 51%.Individuals aged 20 to 39 years had the lowest usage at 30%.Factors associated with higher dietary supplement consumption among individuals with diabetes included older age, female gender, non-Hispanic white ethnicity, higher education level, longer duration of diabetes, and presence of comorbidities such as cancer, chronic kidney disease, cardiovascular disease, and chronic obstructive pulmonary disease. 12However, REVISED Amendments from Version 1 According to reviewer 1 and 2: -No change was made in the title and abstract of the manuscript.
-Changes are made in the "Introduction" where specific information about the rationale of the study, the global context of dietary use among patients with type 2 diabetes and the national use of dietary supplements were added.
-In addition, the objectives were reformulated to fit the rationale of the study.
-In the sampling paragraph: few changes were made by making reformulation of the sentence and addition of an exclusion criteria which was diabetes type 1.This was already available but reformulated clearly in this section.
-Figures 1 and 2 were amended to include explanations about X and Y. Also, the responses to "No" were also added to the figures.
-In paragraph 3.4, we made small typo edits and in Table 6, we made edits concerning decimals according to the reviewer 1 comments.
-In discussion: a paragraph was added concerning the valuable insights of the current study for healthcare professionals.
-In general, two references were added (13 and 14).
Any further responses from the reviewers can be found at the end of the article 6217 studies suggest limited clinical evidence supporting the use of dietary supplements for reducing or controlling diabetes. 13 national level, conducting an assessment of knowledge, attitudes, and practices of dietary supplements among patients with Type II diabetes during the current Lebanese economic crisis is crucial for several reasons: 1) access to healthcare services and resources may be limited, leading individuals to seek alternative methods for managing their health conditions.2) Understanding the knowledge, attitudes, and practices of dietary supplements among patients with Type II diabetes can help healthcare providers identify potential gaps in information and provide targeted education and support.3) Individuals may experience heightened stress levels, changes in routine, and disruptions to their usual healthcare management.This can impact their dietary habits, medications use and supplement use, potentially leading to suboptimal health outcomes.By assessing the knowledge, attitudes, and practices of dietary supplements among patients with Type II diabetes, healthcare providers can tailor interventions to address specific needs and promote safe and effective supplement use during challenging times.Thus, the aims of the current study are: (1) to estimate the prevalence of DS use among persons with T2DM amid the escalating economic crisis in Lebanon; (2) to explore the knowledge, attitude, and practice (KAP) of DS use; and (3) to determine any significant association between socio-economic and socio-demographic factors and the use of DS modality.

Study design
A cross-sectional study was conducted between August 1 and November 2022 across the 4 main governorates in Lebanon (Beirut, Mount Lebanon, Beqaa, and North Lebanon).This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki.After the approval of the ethical committee at al Zahraa University Medical Center (#157/May 7, 2022), we approached the medical files of patients with T2DM to retrieve their phone numbers from many hospitals, outpatient departments, and private clinics in Lebanon.Patients signed a written consent form before being enrolled in the study.

Sample
Convenience sampling was the method adopted to collect the information from the respondents.A total of 460 patients with T2DM were enrolled in this survey.The response rate was 100%.

Inclusion and exclusion criteria
The criteria for inclusion of patients in the current study were: participants with T2DM who are older than 18 years and have given their informed consent to take part in the study.The exclusion criteria were individuals under the age of 18 years because of the high probability of having type 1 diabetes mellitus at this age.Moreover, all older patients with diabetes type 1 were also excluded.In addition, pregnant women with gestational diabetes, elderly people, and people with intellectual disabilities were excluded from this study.

Questionnaire
Using a standardized questionnaire, a face-to-face interview between licensed dietitians and the patients was conducted.
To ensure the validity of the data collection tool, the questionnaire was adapted from relevant literature in English, then translated by experts into Arabic and back-translated into English to check the translation. 14The data was gathered using the administered questionnaire in Arabic.The questionnaire was made to find out the participants' KAP on DS use as well as to identify the prevalence and most popular DS modalities in Lebanon.It was divided into five sections: (1) demographics, (2) clinical data about T2DM, (3) knowledge, (4) attitude, and (5) practice of DS therapies.All information about the patient's demographics, including gender, age, marital status, level of education, and employment status, was recorded.Additionally, the time of the first time being diagnosed with T2DM, the type of T2DM therapy (insulin or oral medicines), the complications related to T2DM, and other co-morbid issues are clinical factors that were included in the study.In the knowledge section, we checked the knowledge of patients with T2DM with regard to DS efficacy and safety concerns.Moreover, in the attitude part, participants were asked about their attitudes toward the use of DS.Would they, for example, abide by their doctor's recommendations to avoid using DS.Would they consult their physicians before using DS or not.In the practice section, we asked patients with T2DM if they had ever used DS for diabetes specifically.Participants who replied "yes" were then questioned about the type of DS used, who prescribed it, whether they were informed by their physician about it, whether they combined it with their T2DM medications, and whether they had ever used DS for a condition other than T2DM.

Data management and analysis
The data was coded and checked for completeness and consistency.All responses from the questionnaire were entered into Microsoft Excel, and a quality check was performed; data cleaning.Then it was exported to SPSS.Statistical analysis was conducted using SPSS (IBM Corp, SPSS Statistics version 26) (https://www.ibm.com/support/pages/spss-statistics-260-fix-pack-1).SPSS was used for data entry, coding, data management, and analysis.The results were described as frequencies and percentages for variables.The associations between both the demographic factors and the clinical data about T2DM with DS were determined using Pearson's Chi-square test.A p value of ≤ 0.05 was considered significant.Odds ratio was considered as a measure of strength.Multivariate logistic regression was used to identify predictors of DS usage.

Sociodemographic Characteristics of the study population
Four hundred and sixty subjects participated in this study.The frequency distribution of their socio-demographic findings is presented in Table 1.Most of the participants were aged 41-60 years (51.3 %), males (51.3 %), from North Lebanon (49.1%), married (60.2%), had a university degree (39.8%), unemployed (41.3%), and had no monthly income (35.4%)

Participant's medical characteristics
The clinical data characteristics of the study participants with T2DM are shown in Table 2. Most of the patients conducted their laboratory tests three months prior to the data collection (37%), and around 34% were newly diagnosed with T2DM.Furthermore, approximately 32% of the study participants developed diabetic complications such as neuropathy (5.7%), nephropathy (5.7%), diabetic foot syndrome (7.2%), and retinal disease (13.5%), which was the most common.Most of the study participants had a family history of T2DM (88.7%), most of them inherited T2DM from their fathers (31.3%).
As for medical treatment, the vast majority of patients (72%) were on oral anti-diabetic medications, and most of them had other medical comorbidities such as coronary artery disease (21.3%), osteoporosis (9.3%), kidney disease (8.7%), and hypertension (23.7%).

Knowledge, attitudes, and practices concerning the dietary supplements use 3.3.1 Knowledge
Figure 1 shows the participants' knowledge towards the use of DS among persons with T2DM during the economic crisis.It appears that most of them (85.9%) had heard about DS, more than half of the sample (63%) knew that DS had efficacity, and 67% believed that DS are safe as shown in Figure 1.

Attitudes
The participants' attitudes regarding DS use are presented in Figure 2. It was shown that 81% of patients would first discuss DS use with their physician and that the majority (85.7%) would not use it if their physicians didn't recommend it.On the other hand, more than half of participants (57.6%) suggested the same DS to a family member as shown in Figure 2. Table 3 displays the results of the participants' attitudes based on a Likert scale scoring system consisting of responses of strongly agree, agree, neutral, disagree, and strongly disagree."Strongly agree" and "agree" responses were combined to show the total percentage of "good attitude," "neutral" for "not aware", while "disagree" and "strongly disagree" were also combined to show the total percentage for "poor attitude."One-third of the participants agreed that nutritional supplements can control the management of diabetes and prevent further complications such as retinal disease, foot disease, kidney disease, and nerve damage.On the contrary, only 34% of patients disagreed that nutritional supplements are a suitable substitute for a healthy and balanced diet in the treatment of diabetes.Furthermore, more than 44% disagreed that nutritional supplements are as effective as medication in modifying blood sugar levels in diabetic patients.

Practices
Among people with T2DM, the estimated prevalence of DS use during the escalating crisis was 41.1% as shown in Figure 3.It appears that more than half the participants used previously DS to prevent other medical complications and combine DS with their diabetes medications.This use was always controlled by their physicians rather than using it on their own as shown in Figure 4. Multivitamins (27.6%) and vitamin C (22.4%) were the most DS used daily (Table 4).Furthermore, per monthly and/or weekly use, vitamin D (11.3%), ginger supplements (14.3%) and green tea supplements (7.4%) were the most recorded DS (Table 4).According to Table 5, around 41.1% of the participants complain about hypoglycemia and used DS to control their blood sugar levels (56.4%), while the rest used it to improve their health (35.5%) and control their diet (2.2%).What's more, it has been demonstrated that 65% of the participants always read the DS label before ingesting it and 67.6% will use always continue using the DS (Table 5).

Determinants of DS use using binary logistic analysis among study participants
Based on the bivariate analysis, we attempted to determine the extent of the contribution of the variables of interest to the probability of dietary supplements use among patients with T2DM using the logistic regression analysis.Table 6 shows that the gender, age, residency, marital status, monthly income, being employed, being on diet, having other     comorbidities, length of diabetes disease, family history, knowledge about the efficacity and safety of DS and the source of information regarding DS were not considered as predictors for the use of DS among T2MD patients.On the other hand, the level of education can mediate the use of DS.For instance, those who are university graduates ranked first among DS consumers compared to those who are uneducated or above [OR=3.9,CI=1.5-10, p=0.003).In addition, patients with T2DM who monitor less their blood sugars have a 5 times higher odd to buy more DS compared to their counterparts (OR=4.3,CI=1.78-10.8;p=0.001).Furthermore, patients who never read the label were more prone to buy DS compared to patients who always read the label [OR=28.2,CI=3.5-225, p=0.002].

Discussion
To the best of our knowledge, this is the first study that investigates the prevalence, and correlates of DS use among patients with T2DM during the economic crisis and drug shortage time in Lebanon.Almost 4 out of 10 patients with T2DM in our study were found to be using and abusing DS.[22] The most common DS used daily in the current study were multivitamins (27.6%), vitamin C (22.4%), followed by vitamin D (21.5%), iron (18%), and calcium (17.4%).These findings came hand in hand with the data reported in a Canadian study 19   According to the literature, the use of DS for diabetes management has always been reviewed from a pharmacy standpoint and from that of complementary and alternative medicine. 23However, as supplement use continues to grow in Lebanon, [9][10][11] it is important for healthcare professionals to understand the evidence behind prescribing supplements and their potential role as part of medical care especially during the unstable conditions.8][29] As for B12 supplementation, many studies showed that individuals taking Metformin suffer from depleted serum B12 levels, and human studies on both B6 and biotin were extremely limited, with a lack of narrative reviews on both vitamins' impact on T2DM patients. 30On the other hand, a meta-analysis that assessed the niacin supplementation showed an increased risk of T2DM onset following supplementation. 31As for vitamin D, a review conducted by Li et al. showed that most studies in patients with T2DM used vitamin D at 2000 IU/day, which may improve glycemic control and a dose of 4000 IU/day may be elicited to provide positive effects on HbA1c, HOMA-IR, and the fasting plasma glucose. 32e DS used by our study population was prescribed mainly by their physicians (70.2%).However, in the Arabian Gulf states, patients with T2DM did not reveal, discuss, or even seek medical advice from a physician, which differed from our findings, where participants relied heavily on physicians for DS advice.For instance, out of six studies conducted in the Gulf Club Countries (GCC), most DS users did not tell their physicians about the use of DS. 16,[33][34][35][36][37] Similarly, in Nigeria and the USA where the majority of DS among patients with T2DM were not being taken based on a recommendation from a health provider. 15,38re than half of the participants in our study were satisfied with their DS use and intended to use it again (67.6%).Unlike Saudi Arabian participants with T2DM, where only 6.7% of respondents said they would use DS again, and 55.7% regretted its use. 14In our study, 85% of the participants had heard of DS, some of them (67.4%)believed DS were safe, and more than half (63%) knew that DS are effective where 33.9% agreed that DS are necessary to control diabetes and 31% strongly agreed that DS prevent diabetic complications.These findings align with the data reported in an updated literature review that showed that patients usually expressed the attitude that DS may not help much but will not hurt. 39dditionally, our participants' main reason for utilizing DS in this study was to lower their blood sugar level (56.1%), followed by improving overall health (35.5%).Thus, a responsible healthcare approach is much needed for the patients to receive evidence-based DS information about efficacy, effectiveness, adverse effects, and possible interactions.A slight majority (57.2%) of participants supported the use of DS in conjunction with their medical treatment for T2DM.This finding aligns with the result observed in a Saudi Arabian and Nigerian study where 90% and 67% of the patients with T2DM preferred combining DS with their conventional therapies, respectively. 16,38 a qualitative study in Pakistan, the principal motivator of DS use was the desire to cure T2DM, where 41% preferred combining DS and T2DM. 40 our study, the level of education, the frequency of monitoring blood sugars, and reading labels can mediate the use of DS.On contrary, the predictors of DS use in Saudi Arabia were age above 51 years, unemployment, and the participants' knowledge about the effectiveness of complementary and alternative medicine (CAM) products. 16Moreover, in Thailand, female gender, age 40-69 years, and diabetes duration of less than 10 years were significant correlators of DS use. 41A Chinese study found that DS use among people with T2DM was associated with a history of previous DS use for other conditions, a positive attitude towards DS, efficacy of DS, and a longer duration of diabetes. 42reover, a study from Malaysia found that females were 1.8 times more likely to use DS than males. 43Furthermore, a study from Bahrain showed that females DS users were more likely to be dominating, and those who have had diabetes for a longer time and have T2DM complications were the top users. 44Another study from Saudi Arabia showed that the most common users of DS practices were older females, housewives, and illiterates. 45

Clinical implications of the current study
The current study can provide valuable insights for healthcare professionals to optimize patient care and support informed decision-making regarding supplement use in several ways: 1. Improved patient education: Understanding the knowledge, attitudes, and practices of dietary supplement use among individuals with diabetes can help healthcare professionals tailor their patient education efforts.
They can provide more targeted information on the benefits and risks of specific supplements, as well as guidance on safe and effective supplement use.
2. Enhanced treatment planning: Healthcare professionals can use the findings from the study to inform their treatment planning for individuals with diabetes.They can incorporate evidence-based recommendations on dietary supplements that may complement conventional treatment approaches and support overall health outcomes.

Identification of gaps in care:
The study can help healthcare professionals identify any gaps in care related to dietary supplement use among individuals with diabetes.This information can guide the development of interventions or resources to address these gaps and improve patient outcomes.
4. Promotion of evidence-based practice: By understanding the knowledge, attitudes, and practices of dietary supplement use among individuals with diabetes, healthcare professionals can promote evidence-based practice and discourage the use of potentially harmful or ineffective supplements.This can lead to better health outcomes for individuals with diabetes.

Limits and strengths
This study presents some limitations.First, it lacks the impact of DS on T2DM compared to conventional therapy.Second, a self-reported questionnaire was used for most of the reported measures.Thus, bias may be present due to inaccurate self-reporting and memory in some questions.Third, this study was of cross-sectional survey; therefore, only associations can be determined and not causations.Notably, the strength of this study is that it is the first study that has been carried out in Lebanon which brought up the topic of knowledge, attitudes, and practices to DS use among patients with T2DM.

Conclusion
This study estimated the prevalence of DS use and abuse among patients with T2DM during the time of medicine shortage and economic crisis.Public health experts should encourage healthy discussions with their patients to comprehend their views regarding DS use.In addition, clinicians and researchers should collaborate to initiate safety and efficacy trials on common DS used for diabetes.Accordingly, relevant institutions whether governmental and non-governmental organizations, are strongly asked to design awareness programs that will be addressed to target groups and implemented by a specialized team in which social workers and health promoters play an important role by developing materials which fit all the perception of all categories that were shown by the study, and especially suitable to those who are illiterate, and who cannot read labels.The presence of evidence-based studies in the form of randomized controlled trials will help both patients and clinicians regarding the use of a DS product.
Introduction : • Introduction is too short and lack of the rational.If there is shortage in medicine in Lebanon.why the authors worry about DS? .may be need some information about % Dm in Lebanon or DS use ?-Introduction is too short and lack of the rational.If there is shortage in medicine in Lebanon.why the authors worry about DS?
Thank you for this comment.The introduction was amended based on your comments.We are worried about DS use because Lebanese patients with type 2 diabetes mellitus (T2DM) are experiencing medicine shortages with rise in medication prices, which leads the patients to be incapable of buying their medical drugs.This deviation increased the health risk for these patients and increased the use and abuse of dietary supplements (DS).This increase may be due to several factors, including patients' perceptions that DS's natural products are safer, more effective, and cheaper than conventional medicines.This was mentioned in lines 56-60.
-May be need some information about % Dm in Lebanon or DS use ?
There is no information concerning DS use among patients with diabetes type 2 in Lebanon but we already mentioned that we already assessed DS use among: children under 5 and their mothers, adults and athletes.This was added in lines 62-64.
-Does the objective to assess DS among all individuals with DM or only Type 2?
This is mentioned in rationale, objectives and methodology: patients with type 2 diabetes only.
-Methods : -Please correct "convenient sample size was collected from all governorates in Lebanon.A total of 460 patients with T2DM were enrolled in this survey to "convenient sample technique" The whole paragraph was amended.
Inclusion/ exclusion criteria, "The exclusion criteria were individuals under the age of 18 years because of the high probability of having type 1 diabetes mellitus at this age."Some individuals maybe older than 18 with type 1. Are those excluded?
Yes these patients were also excluded.This was amended in the same paragraph.
What about other diseases such as Celiac or food allergies.Are those excluded?
This was not mentioned as an exclusion criterion.However, none of our patients were having these diseases because we were collecting the medical history of the patients.All patients who were excluded were having abnormal levels of glycemia, confirmed having type 2 diabetes and not diabetes type 1.
Regarding the KSP.More information is needed about scoring.does the questions with one option.
As mentioned in the "Methodology" section, the questions were having multiple responses for instance the Table 3 displays the results of the participants' attitudes based on a Likert scale scoring system consisting of responses of strongly agree, agree, neutral, disagree, and strongly disagree.There was no single score, but we were showing the response of the patients.We are planning in future studies to validate this score.
Regarding the use of DS, I feel the questions/information are not clear.Do you mean they are currently use?Past use?If past use, how frequent?If a person has taken 1 pill in the last year.How you consider this?Need more clarifications.
We already mention in "Methodology" that we are assessing the current use of the DS by the patients.The answers of these questions are mentioned in Table 4 showing the frequency of the current use by the patients (per day, week, month…).The use of pills was most considered compared to the quantity.Based on that the frequency was our main objective.
Results : This was presented in Table 6 which shows that people who are educated had an 1.4-3.9higher odd of using DS compared to those who are illiterate.
• Duration of Disease newly diagnosis vs < 5 years.I would say 1-5 years are not newly diagnosis.Can you separate them as one subgroup?Newly diagnosed are those who were diagnosed in the same year.The other sub-groups are defined as 1-5 years.This was amended in the manuscript and the tables.

•
For me, it is still not clear, all sample with type 2 DM? Did you exclude type 1?
All patients with DT1 were excluded.And yes only patients with type 2 DM were included in the study.
• Figure 1, x axis refers to % but the sum does not = 100%, have you heard about DS is = 86 %? 86% of participants know and heard about DS and 14% don't know about it.We only highlighted the answer "Yes" and "Don't Know".However, we amended Figure 1.
Figure 1 there are 2 option yes and don't know what about no ?In addition, the knowledge items that have been asked are not knowledge questions, maybe awareness?Based on the study source of the questionnaire, these questions were related to knowledge questions.
• Be consistent with decimals This was amended in the manuscript.• How many participants have never used DS? 59% of the population in the current study.This is shown in Figure 3.
• Table 6 in education, I did not see the illiterate group in the Determinants.
It is available but said " uneducated".We will change it to be consistent.

Competing Interests:
No competing interests were disclosed.

Rabih Hallit
1 Holy Spirit University of Kaslik, Jounieh, Lebanon 2 Holy Spirit University of Kaslik, Jounieh, Lebanon Thank you for inviting me to review this paper.Dear authors, Thank you for this paper.I have some comments that you might want to take into account in order to improve its quality: -The introduction is too short and can be easily expanded.You did not introduce the idea of dietary supplements, the knowledge, attitude and practice about these supplements according to previous international studies.
-Rationale is missing: why is it important to conduct this study in patients with diabetes?The fact that the same study was conducted among patients with other diseases is not sufficient.
-Your first objective needs to be introduced.What is the relation of the economic crisis in Lebanon with your study and with the use of dietary supplements in patients with diabetes?-In section 2.3, how did you build the questionnaire?based on previous studies or you created your own scale?I suggest adding the questionnaire as an appendix with the right answers for the knowledge questions most importantly.
-The results lack the bivariate analyses.Please add them and then you enter in the multivariable model all variables that showed a p < 0.25 in the bivariate analysis only.
-The discussion is good but it needs adjustment maybe after implementing the changes to the results.
-Please add the clinical implications paragraph to the discussion: how would other healthcare professionals benefit from your study?Reviewer Expertise: Infectious disease and internal medicine I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Figure 1 .
Figure 1.Participants' responses to the knowledge questions concerning DS use.X axis refers to the percentage of patients responding the questions raised in Y axis.DS, Dietary supplements.

Figure 2 .
Figure 2. Participants' responses to the attitude questions concerning DS use.X axis refers to the percentage of patients responding to the questions raised in Y axis.Only "Yes" responses are shown in this Figure.DS, Dietary supplements.

Figure 3 .
Figure 3. Prevalence responses of DS use and practices among patients with T2DM.DS, Dietary supplements; T2DM, type 2 diabetes mellitus.

Figure 4 .
Figure 4. Sources of information on DS for patients with T2DM.DS, Dietary supplements; T2DM, type 2 diabetes mellitus.

• Figure 2
not clear.what does the bar stand for?I think you need to work on all your figure legends.explain what X and Y axis means, it refers to n number or %.X axis refers to the percentage of patients responding to the questions raised in Y axis.Only "Yes" responses are shown in this Figure.This sentence was added to the Figures in the manuscript to make it more clearer.

Reviewer Report 10
May 2024 https://doi.org/10.5256/f1000research.161131.r275466© 2024 Hallit R.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
the work clearly and accurately presented and does it cite the current literature?PartlyIs the study design appropriate and is the work technically sound?YesAre sufficient details of methods and analysis provided to allow replication by others?YesIf applicable, is the statistical analysis and its interpretation appropriate?PartlyAre all the source data underlying the results available to ensure full reproducibility?YesAre the conclusions drawn adequately supported by the results?YesCompeting Interests: No competing interests were disclosed.

Table 2 .
Medical characteristics of the study participants.

Table 3
. Frequency of responses to the attitudes-related questions that are based on a Likert scale scoring system.

Table 4 .
Frequency of consumption of dietary supplements by patients with T2DM.

Table 5 .
Answers to questions on using dietary supplements, symptoms, labels, and continuous use.

Table 6 .
Determinants of DS use among patients with T2DM.

Table 1 :
Past use?If past use, how frequent?If a person has taken 1 pill in the last year.How you consider this?Need more clarifications.You had 14 % illiterate.Do you think those are significantly different in KSP and DS

Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate?
I cannot comment.A qualified statistician is required.

all the source data underlying the results available to ensure full reproducibility? No source data required Are the conclusions drawn adequately supported by the results? Partly Competing Interests:
No competing interests were disclosed.

Table 1 :
You had 14 % illiterate.Do you think those are significantly different in KSP and DS use than others?