Determinants and Prevalence of Depression Among Dietary Supplement Users in Saudi Arabia: A Cross-Sectional Study

Background: Dietary supplements (DSs) are used by a large number of people globally. It is widely believed that DSs can improve health, prevent diseases, and replenish vitamin and micronutrient deficiencies. We aimed to determine the prevalence of and factors associated with DS use among the Saudi population and the association between DS consumption and depressive symptoms. Research methodology: This observational cross-sectional study was conducted in 2022. The questionnaire was distributed through an online mode among adult Saudis (18 years or older) living in the Kingdom of Saudi Arabia. The survey included four parts: socio-demographic characteristics, participants’ health, lifestyle, and activity, vitamin and mineral supplement use, and a patient health questionnaire (PHQ-9) as a valid and reliable diagnostic tool for depression. Result: Of the 1309 respondents, 1173 were enrolled. The mean age of the participants was 26.3 ± 8.8 (range, 18-24) years, and approximately 14.7% exhibited psychological anxiety while 8.4% experienced psychological depression. The prevalence of DS use among Saudis was found to be relatively high (52.2%). The most commonly used DS was vitamin D (43%). DSs improved depressive symptoms in 49.4% of the participants. Conclusion: The prevalence of DS use is high among the Saudi population, and vitamin D is the most common DS. The use of multivitamins and minerals, especially iron, is associated with improved depressive symptoms; however, further studies are needed to understand the relationship between DS use and depressive symptoms.


Introduction
Billions of people worldwide take dietary supplements (DSs), such as multivitamin-multimineral (MVMM) preparations to improve their health, prevent diseases, and replenish vitamin and mineral deficiencies [1].A DS must contain one or more of the following: vitamins, minerals, amino acids, herbs, food components, metabolites, and extracts that can provide nutritional or physiological benefits to the body [2].MVMM consumption is common in Saudi Arabia, and people consider that these preparations can help them stay healthy [3].A previous study showed that 47% of the general Saudi population consumes MVMM supplements [4].
Depression is a leading cause of disability worldwide and the fourth leading cause of early death [5].It has been suggested that a poor diet is associated with poor mental health, including depression [6].Although there are several effective therapies for depression, researching alternate therapies or preventative measures is necessary [7].Dietary therapies and vitamin supplementation, particularly vitamin B supplementation, are among the most popular complementary and alternative medical interventions for depression [8].Clinical studies have shown that patients with a low folate status have a higher risk of developing depression and worsening depressive symptoms and exhibit a lower response to antidepressants [9].Besides depression, several other factors are also associated with DS consumption.A cross-sectional study showed that 71% of individuals who consume DS are females, older adults, and highly educated [10].Regular exercising is shown to be associated with DS consumption [11] and DS usage is more prevalent among athletes than nonathletes.Moreover, the use of DSs is higher among non-smokers than in smokers [12].
A previous study showed a link between depressive symptoms and vitamin inadequacies in Japanese individuals [13].A study conducted in Saudi Arabia during the coronavirus disease 2019 (COVID- 19) pandemic showed that more than 25% of the participants had depression, and the majority of them were not using any DS [14].Another study from Saudi Arabia showed that MVMM use is significantly correlated with the sex, marital status, educational levels, regular exercise, smoking status special diet consumption, and fruit and vegetable consumption [4].We aimed to investigate the correlation between DS intake and relevant factors, including depressive symptoms.Our study provides an understanding of DS use among adult Saudis and the factors influencing the use of these supplements.

Materials And Methods
This observational cross-sectional study was conducted from July 21, 2022, to September 2, 2022, using an online survey.Out of 1309, a total of 1173 of the participants were included in the current study.The study participants were adult Saudis aged ≥18 years living in the Kingdom of Saudi Arabia (KSA).The study was conducted in accordance with the guidelines of the Declaration of Helsinki and approved by the Regional Ethics Committee of the Qassim Region, KSA (21-18-11).A self-administered structured survey instrument was developed by our research team based on published work in this field.The survey included four parts: socio-demographic characteristics (age, sex, residence, marital status, level of education, occupation), and we also collected data on participants' self-reported height and weight to determine their body mass index (BMI) following the WHO classification for adults.The healthy adult BMI range is 18.5-24.9kg/m 2 , with those below the range being considered underweight.Those whose BMI is between 25.0 and 29.9 kg/m 2 are overweight, and those whose BMI is above 30 kg/m 2 are obese.Participants' health, lifestyle, and activity status (health status, diet, eating healthy food, exercise, and chronic conditions), vitamin and mineral supplement use (type of DS, frequency of use, source of these products, and reason for using DSs), and a patient health questionnaire (PHQ-9) were used as a valid and reliable diagnostic tool for depression.
In the first three sections, we used a modified questionnaire adapted from the study by Alwalan et al. [4].The validity of the survey instrument was ensured through a pilot study on ten randomly selected Saudis.The questionnaire was then translated into Arabic.Data were collected after obtaining ethical approval from the research ethics committee.The questionnaire was distributed online among participants selected using the snowball sampling method.Participation was voluntary, and electronic informed consent was obtained before data collection.Once consent was provided, they completed the online questionnaire.The participants were assured confidentiality and were free to withdraw from the study at any time.The data were collected, organized, tabulated, and analyzed using IBM SPSS Statistics for Windows, Version 23 (Released 2015; IBM Corp., Armonk, New York, United States).Categorical data were expressed as numbers and percentages.The chi-squared (χ2) test was used to assess the relationship between two or more qualitative variables.Quantitative variables were analyzed using the Mann-Whitney test.Quantitative data were expressed as a p-value < 0.05, indicating statistical significance.

Prevalence of DS use among the Saudi population
The prevalence of DS use among the Saudi population was found to be relatively high, as 612 (52.2%) participants used DSs regularly for more than one month (Figure 3).Among the study population, 393 (64.2%) used DSs on a daily basis, 177 (28.9%) used DSs every week, 35 (5.7%) used them every month, and 7 (1.1%) were not sure.Moreover, 297 (48.5%) participants obtained these products from hospitals with a prescription, 124 (20.3%) obtained them from a pharmacy without a prescription, 141 (23%) ordered these products online, 21 (3.4%) got these products from complementary health stores, 9 (1.5%) from trainers in the gym, 8 (1.3) from social media and friends, and 4 (0.7%) from other sources.Interestingly, 532 (45.4%) participants believed that these products might help in maintaining good health, 464 (39.6%) believed that these supplements helped a lot, 109 (9.3%) did not think these mattered, and 68 (5.8%) believed that these did not do any harm.The general effects of using one of these products were improving and maintaining the general form of health as reported by 750 (63.9%) participants, preventing the occurrence of diseases related to the heart and blood vessels as mentioned by 43 (3.7%) participants, and preventing the occurrence of some cancers as reported by 17 (1.4%)participants, and 363 (30.9%) participants were not sure.Finally, 580 (49.4%) participants believed that DSs improved the symptoms of depression, and 228 (17.4%) did not think that DSs improved depressive symptoms, whereas 365 (31.1%) were not sure (Table 3).

FIGURE 5: Purpose of using dietary supplements.
Sex was found to be significantly associated with DS use among the Saudi Arabian population (p < 0.001), with females tending to use these products more than males.BMI was found to be significantly associated with the use of DSs (p = 0.002), with underweight and healthy participants using supplements more frequently than others.Marital status and the use of DSs were found to be significantly associated (p = 0.024), as divorced and widowed participants tended to use DSs more frequently.The educational level and the use of DSs were found to be significantly associated (p = 0.045) with the postgraduate group using DSs more frequently than others.Health status was also found to be significantly associated with DS use (p = 0.009), as participants who thought that their health was bad tended to use DSs more frequently.Special diet consumption and using DSs were found to be significantly associated (p < 0.001).Participants following special diets tended to use vitamin supplements more frequently than others.A statistically significant association was found between smoking status and the use of DSs (p = 0.017), as non-smokers tended to use DSs more frequently.Employment status, monthly income, and regular exercising were not significantly associated with DS use (p = 0.380, 0.138, and 0.162, respectively) (Table 4).

Association between DS consumption and depressive symptoms
A significant correlation was observed between multivitamin use and PHQ-9 scores (p = 0.024).Participants using multivitamins had a lower PHQ-9 score and fewer depressive symptoms than others.Vitamin C use was correlated with PHQ-9 scores (p ˂ 0.001), as participants who were not taking vitamin C tended to have lower PHQ-9 scores and lesser depressive symptoms than did those who were taking it.The use of vitamin B12, vitamin A, vitamin D, and zinc was found to be significantly associated with the PHQ-9 score (p = 0.002, 0.040, 0.013, and 0.028, respectively).Participants who did not use these supplements tended to have fewer depressive symptoms than did those who did.The intake of vitamins and minerals and iron supplements was significantly associated with the PHQ-9 score (p = 0.001 and 0.025, respectively); participants taking these products tended to have fewer depressive symptoms than others.Vitamin E, folic acid, calcium, omega-3 supplement, and collagen use showed no significant association with PHQ-9 scores (p = 0.169, 0.710, 0.299, 0.130, and 0.089, respectively) (Table 5).

Discussion
A balanced intake of various types of nutrients is key to a healthy life.Importantly, body requirements of proteins, carbohydrates, and fats should be fulfilled.Vitamins and minerals are essential micronutrients required by the body.
We aimed to determine the prevalence of DS use, associated factors, types of DSs used, and depressive symptoms among the Saudi population.MVMM consumption is common in Saudi Arabia and people consider that these preparations might help them to stay healthy.In our study, the prevalence of DS use was found to be 52.2%, and these participants used DSs regularly.Similar to our study, a previous cross-sectional study conducted in Riyadh, KSA, showed that nearly half of the general population consumes MVMM supplements [3], whereas the prevalence of nutritional supplement use among the Chinese population was 0.71% [15].Thus, there is a considerable difference in DS use between Chinese and Saudi populations.In the United States, the use of DSs has consistently increased over the past 40 years, with 49% of the general population and 70% of individuals over the age of 70 years reportedly consuming DSs [16].Several factors could affect the use of DSs.We observed that DS consumption was significantly higher in females than in males.Similar findings have been reported in previous studies [3,4,17].In general, women are more health conscious than men.Women use DSs during pregnancy and for purely cosmetic purposes to maintain their hair and skin health.Furthermore, women frequently use supplemental calcium, vitamin D, and iron for maintaining bone health, preventing the onset of osteoporosis during aging, and reducing the risk of developing anemia [18,19].We found that DS intake was higher in individuals with a high level of education than others, which is similar to the results of the study by Alhashem et al. showing that approximately 85.5% of individuals with higher education prefer consuming DSs [17].The National Health and Nutrition

FIGURE 1 :
FIGURE 1: Special diets consumed by the study participants.

FIGURE 2 :
FIGURE 2: The prevalence of chronic diseases among study participants.

FIGURE 3 :
FIGURE 3: Dietary supplement use among the Saudi population.

FIGURE 4 :
FIGURE 4: Types of dietary supplements used by the study participants.

FIGURE 6 :
FIGURE 6: Depression severity among the study participants.

TABLE 5 : Association between dietary supplement consumption and depressive symptoms.
*p-values were calculated using the Mann-Whitney test.