The Extent of the Use of Multivitamins and Multimineral Supplements Without Clinically Measurable Benefits Among Adults in Ha'il, Saudi Arabia: A Cross-Sectional Study

Introduction Multivitamins and multiminerals (MVMM) are nutritional supplements that contain a wide range of important nutrients. The use of vitamins and minerals has been showing a tremendous increase over the past few years due to the high demand for supplements to replenish nutritional deficiencies. Purpose This study aimed to assess MVMM usage, the reasons why people chose to use MVMM, and the factors related to this usage. Methodology A cross-sectional study was conducted on adults living in Ha'il, Saudi Arabia. Data were collected between October 31 and December 14, 2022, a self-administered online questionnaire was used, and data were analyzed using SPSS version 25.0 (IBM Corp, Armonk, NY). Results A total of 310 participants enrolled in the study, of which 240 (77.42%) were females and 70 (22.58%) were males. The extent of the use of MVMM supplements without clinically measurable benefits was more than half of the present study participants (58.71%). There was a significant difference between MVMM use and gender or employment status. MVMM usage on a regular basis was found to be associated with satisfaction with the outcomes. The majority of participants used MVMM to promote health. Calcium and vitamin D were found to be the most common types of dietary supplements used. Conclusion The use of MVMM supplements without clinically measurable benefits was more prevalent among females. It is important to promote public health awareness programs about the benefits and risks of overdose.


Introduction
Multivitamins and multiminerals (MVMM) are described as dietary supplements, which are different from ordinary food and are meant to enhance or complement the diet. Even if a product is labeled as a dietary supplement, it is still regarded as a drug, to the extent that it is meant to treat, diagnose, cure, or prevent diseases [1]. Capsules, tablets, soft gels, gummies, and liquid supplements are just some of the many various forms that supplements can be ingested. Such examples of these supplements are vitamins that can be multiple or single such as vitamin D and biotin. Also, minerals are supplements such as calcium and iron. Herbs also can be considered supplements such as ginger and echinacea [1,2]. An overwhelming amount of physiological data demonstrates the essential role of vitamins and minerals in energy metabolism, primarily, the B complex vitamins, which are required for mitochondrial function, thus, a deficiency of any one of these vitamins can jeopardize an entire chain of biochemical events required for converting food into physiological energy [3].
Despite a well-balanced and generally healthy diet, vitamin deficiencies can occur occasionally, which can have an impact on the individual's health [4]. Specific individual requirements vary depending on health, lifestyle, genetics, and other variables, hindering these needs challenging to quantify [3]. Nonetheless, using 1, 2 3 3 3 MVMM supplements has been found to minimize food intake gaps and enhance nutritional status without exceeding the dietary reference intake (DRI) [5].
Recently, with the COVID-19 pandemic, the use of MVMM such as vitamin D and vitamin C has been prevalent with evidence of improving the outcome of various respiratory infections [6]; regardless, a huge gap is present in the literature regarding the benefits of MVMM in COVID-19 patients. However, it is important to note that MVMM do not have a positive impact on all diseases, many randomized clinical studies have failed to support the idea that multivitamins can prevent chronic diseases specifically cardiovascular diseases such as stroke or myocardial infarction [7][8][9]. Even so, several studies show that using MVMM in levels more than the recommended daily intake (RDA), for example, large dosages of folic acid, beta carotene, vitamin E, and selenium may be detrimental, increasing mortality and leading to cancer in some patients [4,8].
The use of MVMM is often associated with adopting many healthy lifestyle habits [2,10,11]; however, understanding the health influences of consuming such preparations is crucial, especially in the absence of clinical research carried out by dietary supplement manufacturers prior to their products being introduced to the market.
Dietary supplements are not indicated for general health support and illness prevention, but rather for people who have a chronic nutritional shortage in their diet or a previously confirmed deficiency in their body [4]. As a result, greater focus should be placed on dietary adjustments, such as the advantages of eating more fruits and vegetables, where vitamins and minerals occur naturally in conjunction with other elements that cannot be mimicked by food supplements [12]. Yet, people continue to use the dietary supplements on their own without consultation which might increase the risk of toxicities, drug overdose, and consequent health problems [5,10]. Our study aimed to estimate the extent of MVMM users in Ha'il City, Saudi Arabia. And assess the pattern of the usage, its association with their sociodemographic data, and their general health status. Moreover, to investigate the factors, which justify using MVMM without actual clinical significance.

Materials And Methods
This cross-sectional study was carried out in Ha'il City, Saudi Arabia. For our inclusion criteria, participants were required to be 18 years or older, living in Ha'il City, and willing to participate in the study. We excluded incomplete submissions. Participants were reached through multiple social media platforms, such as Twitter, WhatsApp, etc., and were asked to fill out an electronic Google Form questionnaire (Appendices). Participation was voluntary and withdrawal was available at any time. A pilot questionnaire was conducted previously to measure comprehension and clarity. We received 310 responses, which demonstrated a complete understanding of the questions.
Data were collected between October 31 to December 14, 2022. The first section of the questionnaire covered the sociodemographics of the participants, including age, gender, nationality, residence, educational level, physical activity, family income, and relationship status. The second section included items addressing the use, frequency, and supply of MVMM. As well as checking participants' current use of MVMM, what specific types of MVMM are used, and participants' satisfaction after using these MVMM. The third section covered information regarding why participants used MVMM, who prescribed these MVMM, and participants spending budget on MVMM. Lastly, participants were asked to rate their overall health using a four-point Likert scale (excellent/very good, good, fair, poor), state if they have any chronic conditions -and how many if answered yes, and whether they are smoking or not.

Sample size
The sample size ideal for conducting this cross-sectional study was 273, which was calculated using the following formula: SS = [Z2p (1 − p)]/ C2. Where Z is 1.96, C is 5%, SS is the population of the Ha'il region, and p is 77% according to a recent study regarding prevalence of MVMM use in Saudi Arabia [13]. In total, 310 participants were included in the study.

Results
Data in this study were analyzed using SPSS version 25.0 for Windows (IBM Corp., Armonk, NY). Internal consistency was used to test the validation of the scale. The frequencies were conducted to describe the items. The chi-square test was used to test the cross relationships between the variables. A p-value of more than 0.05 was considered statistically significant.
As shown in Table 1, 310 people participated in the study, including 77.42% females and 22.58% males, most of them were in the young age group (18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29). The majority were Saudis, lived in Hail City, were university educated, 42.9% had a family monthly income of more than 10.000 SAR, and 57.42% were single. Only 20% were health professionals and 58.71% of the study participants used a MVMM.   Prompting health was the most reason for using these products with 38.71%, followed by a supplement diet. Forty-one point two one (41.21%) used to take MVMM daily, followed by weekly usage. Physicians were the source of information with 50.55%, followed by media and the Internet. Also, most of the participants reported that the usage of MVMM should be used with a medical prescription while 14.84% argued that they should be used on believing that diet covers all the nutrients needed. Sixty-nine point two three percent (69.23%) spent less than 200 Saudi Arabian Riyals (SAR) on supplements. Seventy-six point nine two percent (76.92%) addressed their satisfaction with the outcomes of using supplements. Thirty-four point seven eight percent (34.78%) of the present study participants preferred to take calcium and vitamin D, followed by iron then MVMM. Vitamin B complex was the most used vitamin with 20.65%, followed by others ( Figure 1).

FIGURE 1: Frequency of Vitamins and Minerals Taken
As shown in Table 3, there were no significant relationships between MVMM usage on a regular basis and sociodemographic factors (p>0.05).

MVMM: multivitamins and multiminerals
Two interesting relationships were found across the results as shown in Table 4. There was a significant relationship between MVMM usage on a regular basis and satisfaction with the outcomes of using supplements (p>0.05; =0.02). Eighty-six point six seven (86.67%) of participants using MVMM on a regular basis were satisfied with the outcomes of using supplements compared to those who did not use it regularly, at 70.75%. Also, 32.86% who had excellent/very good health were satisfied as compared to 14.29% who were not satisfied. In addition, 50% who had good health were satisfied as compared to 35.71% who were not satisfied (p>001).

Factor
Do you use a multivitamin and/or multimineral currently?   [17,18]. One cross-sectional study conducted in the United States of America (USA) demonstrated a higher MVMM prevalence in females as well [19]. In another study in Japan with 1,776 participants, females were far more likely to report supplement use than males [20]. Again, our current study agrees that MVMM use is higher among females than males (82.4% vs 17.6%). Additionally, MVMM use had been reported with higher use among females than males in several local studies [21][22][23].
Our study also showed a positive association between MVMM use with unemployed. However, a study performed by  reported that occupation was not associated with the frequency of using dietary supplements during pregnancy in Saudi women [24]. The relationship between MVMM use and employment status needs further focused investigation on its related factors to better understand it. Contrary to our expectations, our study did not suggest a significant difference between MVMM use with age, nationality, residency, family income relative, education, and relationship status.
A similar previous study showed the differences in health status and health outcomes between MVMM users and non-users; despite no clinically measured changes in health, MVMM users self-report 30% greater overall health than non-users [19]. A significant association between participants who self-reported excellent or very good health and satisfaction with outcomes as opposed to those who did not was also noted in our study. Furthermore, most of the participants who use MVMM regularly were satisfied with the outcomes of using it, unlike others who did not use it regularly and were not as satisfied. One study explored reasons behind the belief of perceived better health after using MVMM, results pointed to the concept of not getting ill and adopting a healthier lifestyle [25], which can explain why participants might feel that MVMM is the main reason for improved health outcomes.
Many studies reported that the most common reason for using MVMM was to promote health, the majority of individuals utilized MVMM as diet supplements, followed by health promotion [26]. Vitamin D insufficiency is extremely common in Saudi Arabia among all demographic groups and all different regions; it is linked to a number of extra-skeletal, and chronic diseases such as insulin resistance and its associated comorbidities [14]. That explains why most of our study findings indicate that participants preferred to take calcium and vitamin D rather than any other specific supplement.
Finally, several important limitations need to be considered. First, this was a single-center study, which might have led to bias. Second, some participants might have incorrectly reported their information. Third, the study did not evaluate the reasons why some of the participants did not take the MVMM currently. In addition, a larger and more widespread study is required to be conducted on dietary supplement usage to determine the specific factors related to MVMM usage.
Our study has raised multiple issues that need to be investigated further. An area of future research is to look into the widespread use of MVMM supplements for the purpose of COVID-19 prevention, evaluate the long-term effects of MVMM use in overdosing and toxicity, and identify certain associations between vitamin deficiencies and certain diseases.

Conclusions
Our study found a significant association between MVMM usage and sociodemographic factors -gender and employment status. Furthermore, the use of MVMM on a regular basis was found to be associated with satisfaction-of-MVMM-use outcomes, as well as high self-reported health outcomes. These findings spotlight the extent of the use of MVMM supplements without clinically measurable benefits. As a result, it was vital to throw light on the importance of public health awareness regarding the advantages of MVMM as well as warnings about overdoses and side effects. Hopefully, this will lead to improvements in the population's lifestyle.

Informed consent
A research team from the Faculty of Medicine -University of Hail aims to know the extent of the use of multivitamins and multimineral supplements without clinically measurable benefits among adults in Hail, Saudi Arabia: Cross sectional study. Please read the following information carefully, all information you provide will be treated confidentially and the identity of any participant will not be disclosed.

Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Research Ethics Commitee (REC) at the University of Ha'il issued approval H-2022-359. The study has been reviewed and approved by the research ethics committee (REC) at the University of Ha'il and is also approved by the university president. The research project is numbered H-2022-359 and dated October 31, 2022. Participants in the study were informed that their participation was voluntary and that their contribution was of great value. No personal identifiers were collected. All authors declare that informed consent was obtained from the participants for the publication of this original article. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.