Emergency Department Visits for Adverse Events Related to Dietary Supplements

Dietary Supplements: Knowledge and Adverse Event Reporting Practices of Department of Defense Health Care Providers

INTRODUCTION

The purpose of the study was to assess the knowledge of dietary supplements (DS) and adverse event (AE) reporting practices of the Department of Defense health care providers. AEs related to use of DS are not uncommon. However, it is estimated that less than 2% of AEs are reported. This is problematic given the Food and Drug Administration relies on AE reports to identify and ultimately remove unsafe products from the market. Inadequate reporting of AE puts all DS users at risk.

MATERIALS AND METHODS

Cross-sectional design was used. Electronic surveys were sent to the Department of Defense health care professionals (HCPs) and Emergency Medicine (EM) physicians asking questions about practices regarding DS and AE knowledge and reporting behaviors. The surveys were open for 5 months. During this period of time, HCPs received three email reminders following the initial email to enhance participation. The computer package IBM SPSS version 25 software (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 21.0, Armonk, New York) was used for statistical analysis. Frequency distributions of the responses were analyzed.

RESULTS

Of the 1,700 surveyed, 270 HCPs and 68 EM physicians completed the surveys. At least 39% of HCPs reported never receiving formal DS training. Seventy-two percent of HCPs reported asking their patients about the use of DS. However, when asked if they knew where to report an AE, only 40% of HCPs knew where to report an AE and only 38% knew how to report an AE. Of the EM physicians, only 38% asked their patients about DS. However, a majority (78%) reported that they had encountered an AE. EM physicians also reported they lacked knowledge regarding where (87%) and how (87%) to report AE.

CONCLUSIONS

It is clear that physician and nonphysician HCPs would benefit from additional training about DS and how and where to report suspected AE. Providing regular training on risks, common AE, and how and where to report an AE would help fill the knowledge gap in the ever-changing DS industry. Addressing these issues and coming up with a solution to integrating AE reporting into clinical care could improve health care practices and increase AE reporting to the Food and Drug Administration, which would have a beneficial impact on patient care, public safety, and mission readiness.

Multi-factorial pharmacokinetic interactions: unraveling complexities in precision drug therapy

Introduction: Precision drug therapy requires accounting for pertinent factors in pharmacokinetic (PK) inter-individual variability (i.e., pharmacogenetics, diseases, polypharmacy, and natural product use) that can cause sub-therapeutic or adverse effects. Although each of these individual factors can alter victim drug PK, multi-factorial interactions can cause additive, synergistic, or opposing effects. Determining the magnitude and direction of these complex multi-factorial effects requires understanding the rate-limiting redundant and/or sequential PK processes for each drug.Areas covered: Perturbations in drug-metabolizing enzymes and/or transporters are integral to single- and multi-factorial PK interactions. Examples of single factor PK interactions presented include gene-drug (pharmacogenetic), disease-drug, drug-drug, and natural product-drug interactions. Examples of multi-factorial PK interactions presented include drug-gene-drug, natural product-gene-drug, gene-gene-drug, disease-natural product-drug, and disease-gene-drug interactions. Clear interpretation of multi-factorial interactions can be complicated by study design, complexity in victim drug PK, and incomplete mechanistic understanding of victim drug PK.Expert opinion: Incorporation of complex multi-factorial PK interactions into precision drug therapy requires advances in clinical decision tools, intentional PK study designs, drug-metabolizing enzyme and transporter fractional contribution determinations, systems and computational approaches (e.g., physiologically-based pharmacokinetic modeling), and PK phenotyping of progressive diseases.

Effect of respiratory muscle training on dysphagia in stroke patients-A retrospective pilot study

BACKGROUND

Dysphagia is prevalent with cerebrovascular accidents and contributes to the burden of disease and mortality. Strengthening dysfunctional swallow muscles through respiratory muscle training (RMT) has proven effective in improving swallow effectiveness and safety. However, approaches to strengthen only the expiratory muscle groups (EMST) dominate the clinical study literature, with variable outcomes. This study investigated the effect of simultaneous inspiratory-expiratory muscle strengthening to improve swallowing function in stroke patients.

METHODS

Recorded data of 20 patients receiving pro bono medical care for dysphagia following stroke were allocated to intervention (IG) or control group (CG) based upon whether they chose combined RMT (cRMT) or not while awaiting swallow therapy services. The intervention group was treated with three 5-minute sessions of resistive respiratory muscle training for 28 days, while the control group received no RMT or other exercise intervention. Respiratory and swallow outcomes were assessed pre- and post-intervention and included Mann Assessment of Swallowing Ability (MASA), fiberoptic endoscopic evaluation of swallowing (FEES) with penetration-aspiration scale (PAS), functional oral intake scale (FOIS), patient visual analogue scale (VAS), and peak expiratory flow (PEF).

RESULTS

After 28 days, the intervention group demonstrated greater improvements (P value < 0.05) in PEF (IG: 168.03% vs CG: 17.47%), VAS (IG: 103.85% vs CG: 27.54%), MASA (IG: 37.28% vs CG: 6.92%), PAS (IG: 69.84% vs CG: 12.12%), and FOIS (IG: 93.75% vs CG: 21.21%).

CONCLUSION

cRMT is a feasible and effective method to improve signs and symptoms of dysphagia while improving airway protection.

LEVEL OF EVIDENCE

3.

Therapeutic potential of nutraceuticals to protect brain after stroke

Stroke leads to significant neuronal death and long-term neurological disability due to synergistic pathogenic mechanisms. Stroke induces a change in eating habits and in many cases, leads to undernutrition that aggravates the post-stroke pathology. Proper nutritional regimen remains a major strategy to control the modifiable risk factors for cardiovascular and cerebrovascular diseases including stroke. Studies indicate that nutraceuticals (isolated and concentrated form of high-potency natural bioactive substances present in dietary nutritional components) can act as prophylactic as well as adjuvant therapeutic agents to prevent stroke risk, to promote ischemic tolerance and to reduce post-stroke consequences. Nutraceuticals are also thought to regulate blood pressure, delay neurodegeneration and improve overall vascular health. Nutraceuticals potentially mediate these effects by their powerful antioxidant and anti-inflammatory properties. This review discusses the studies that have highlighted the translational potential of nutraceuticals as stroke therapies.

Risks of Skin, Hair, and Nail Supplements

Skin, hair, and nail supplements, sometimes referred to as "beauty supplements" or "ingestible skin care," are a large and growing industry. These products may contain vitamins and minerals, sometimes in very high doses. They may also contain herbs, hormones, microbes, or animal derivatives such as fish oils and collagen powders. Dietary supplements are regulated as foods, not as drugs, by the US Food and Drug Administration (FDA). Therefore, manufacturers do not need to provide any proof of safety, efficacy, or quality prior to sale. This is of serious concern, as many adverse effects due to supplement components have been reported. The potential risks cover multiple categories. These include acute toxicities, such as choking, as well as chronic toxicities, such as increased risk of diabetes. Teratogenicity and interactions with drugs and laboratory testing have been documented in research studies. Other risks include potentially increased risk of cancer with long-term use, allergic reactions, and others. It is vital that physicians educate their patients on these risks. As no post-marketing surveillance programs are required for supplements, our understanding of supplement risks is incomplete. Physicians should be wary of these risks and encourage further research and regulation.

Self-reported health without clinically measurable benefits among adult users of multivitamin and multimineral supplements: a cross-sectional study

OBJECTIVE

Multiple clinical trials fail to identify clinically measurable health benefits of daily multivitamin and multimineral (MVM) consumption in the general adult population. Understanding the determinants of widespread use of MVMs may guide efforts to better educate the public about effective nutritional practices. The objective of this study was to compare self-reported and clinically measurable health outcomes among MVM users and non-users in a large, nationally representative adult civilian non-institutionalised population in the USA surveyed on the use of complementary health practices.

DESIGN

Cross-sectional analysis of the effect of MVM consumption on self-reported overall health and clinically measurable health outcomes.

PARTICIPANTS

Adult MVM users and non-users from the 2012 National Health Interview Survey (n=21 603).

PRIMARY AND SECONDARY OUTCOME MEASURES

Five psychological, physical, and functional health outcomes: (1) self-rated health status, (2) needing help with routine needs, (3) history of 10 chronic diseases, (4) presence of 19 health conditions in the past 12 months, and (5) Kessler 6-Item (K6) Psychological Distress Scale to measure non-specific psychological distress in the past month.

RESULTS

Among 4933 adult MVM users and 16 670 adult non-users, MVM users self-reported 30% better overall health than non-users (adjusted OR 1.31; 95% CI 1.17 to 1.46; false discovery rate adjusted p<0.001). There were no differences between MVM users and non-users in history of 10 chronic diseases, number of present health conditions, severity of current psychological distress on the K6 Scale and rates of needing help with daily activities. No effect modification was observed after stratification by sex, education, and race.

CONCLUSIONS

MVM users self-reported better overall health despite no apparent differences in clinically measurable health outcomes. These results suggest that widespread use of multivitamins in adults may be a result of individuals' positive expectation that multivitamin use leads to better health outcomes or a self-selection bias in which MVM users intrinsically harbour more positive views regarding their health.

Chronological Review and Rational and Future Prospects of Cannabis-Based Drug Development

Despite the surge in cannabis chemistry research and its biological and medical activity, only a few cannabis-based pharmaceutical-grade drugs have been developed and marketed to date. Not many of these drugs are Food and Drug Administration (FDA)-approved, and some are still going through regulation processes. Active compounds including cannabinergic compounds (i.e., molecules targeted to modulate the endocannabinoid system) or phytocannabinoid analogues (cannabinoids produced by the plant) may be developed into single-molecule drugs. However, since in many cases treatment with whole-plant extract (whether as a solvent extraction, galenic preparation, or crude oil) is preferred over treatment with a single purified molecule, some more recently developed cannabis-derived drugs contain several molecules. Different combinations of active plant ingredients (API) from cannabis with proven synergies may be identified and developed as drugs to treat different medical conditions. However, possible negative effects between cannabis compounds should also be considered, as well as the effect of the cannabis treatment on the endocannabinoid system. FDA registration of single, few, or multiple molecules as drugs is a challenging process, and certain considerations that should be reviewed in this process, including issues of drug–drug interactions, are also discussed here.

Expanding Student Knowledge and Confidence on Dietary Supplements Through Mock Patient Consultations

INTRODUCTION

As dietary supplements are widely used in the United States, student pharmacists should be prepared to assess their appropriateness for self-care. The purpose of this project was to assess the impact of mock patient consults regarding common dietary supplements on second-year (P2) Doctor of Pharmacy (PharmD) students.

METHODS

This activity was part of a required course, Self-Care I. Twenty-four groups of 4 to 5 students were created, with each assigned a unique patient vignette. Students had 10 minutes to speak on the phone with their "patient" to obtain needed information in order to make an appropriate recommendation in the form of a 2 to 3-minute recorded oral response. Anonymous, voluntary pre- and post-project surveys assessing perceived dietary supplement knowledge, patient counseling skills, and attitudes about the activity were conducted during class through Google Forms. The Wilcoxon Signed-Rank Test was used to determine differences in mean 10-point Likert scale score between pre- and post-test for each survey question, with significance if p < 0.05.

RESULTS

Significant differences were found between pre- and post-survey Likert scale means. Reported confidence in using the QuEST/SCHOLAR-MAC approaches to self-care counseling increased by 45% from baseline. Perceived student knowledge on dietary supplements increased by 44%. Self-rated counseling abilities of students increased by 87% for glucosamine/chondroitin, 28% for melatonin, 39% for red yeast rice, 38% for fish oil, and 42% for cranberry regarding their use in particular cases.

CONCLUSIONS

The activity provided students with realistic exposure to questions about dietary supplements that patients ask community pharmacists.

Lessons for Local Policy Initiatives to Address Dietary Supplement Use Among Adolescents: A Qualitative Study of Stakeholders' Perceptions

PURPOSE

Weight-loss and muscle-building dietary supplements can have adverse health consequences for youth. At a time, when the Food and Drug Administration is considering increasing oversight of dietary supplements, this study aimed to explore community stakeholders' perceptions about the use of and access to such supplements among adolescents and to identify challenges and opportunities to engage stakeholders with policy initiatives to curtail youth access to supplements at the local level.

METHOD

We conducted 32 key informant semistructured interviews in four municipalities in Massachusetts with purposefully selected participants representing three categories of community stakeholders who could contribute to policy agenda setting at the local level: policy professionals, youth service providers, and young adults aged 18-25 years who used weight-loss or muscle-building supplements as minors. Interviews were audio-recorded, transcribed, deidentified, and analyzed using thematic analysis approach, facilitated by Dedoose software.

RESULTS

Community stakeholders reported wide availability and easy access to dietary supplements. Most participants were unaware of health risks. Many stakeholders did not perceive the use of these products as an issue impacting youth in their communities. The challenges identified in engaging stakeholders were competing concerns on the policy agenda, limited capacity of stakeholders, and uncertainty about who is accountable for the problem.

CONCLUSION

This study indicates the need for complementary, multipronged approaches at the municipal level to address the problem of weak regulation and easy access to potentially dangerous weight-loss and muscle-building supplements for youth.

Healthy lifestyles among military active duty service members, and associations with body-building and weight-loss supplement use

PURPOSE

The purpose of this study was to characterize health behavior profiles among active duty service members and associate these profiles with body-building and weight-loss dietary supplement (DS) use.

METHODS

Based on U.S. active duty service members who completed the 2011 Health-Related Behavior Survey (n = 39,877), we used latent class analysis to place respondents into latent classes (using healthy/unhealthy food consumption, aerobic activity, strength training, and sleep) and examined associations between latent class and DS use.

RESULTS

We identified seven health behavior classes that could be classified by physical activity and diet. Three classes with high activity were further characterized by healthy diet (24%); few unhealthy foods (18%); and unrestricted diet (9%). Three classes with low activity were further characterized by restricted diet (15%), healthy diet (15%), and unhealthy diet (6%). The last class (13%) reported moderate levels of all behaviors. The classes did not vary by sleep. Participant characteristics across most classes were relatively homogenous along demographics and military branch. The active classes had relatively higher usage of body-building and weight-loss DSs.

CONCLUSIONS

Latent classes from health behavior indicators might be considered "market segments", which can be targeted with distinct messaging. Service members appear to consume DSs as part of an otherwise healthy lifestyle.

National Center for Complementary and Integrative Health Perspectives on Clinical Research Involving Natural Products

The sales of dietary supplements continue to increase year after year. Despite their use by a large percentage of Americans, there is little evidence for the vast majority of products regarding their safety or efficacy. National Center for Complementary and Integrative Health supports a broad range of research on dietary supplements, including clinical trials. Our experience with these trials has shaped our current policies and priorities for clinical research. This perspective outlines those policies and priorities that are shaping our investments going forward. SIGNIFICANCE STATEMENT: The sales of dietary supplements continue to increase year after year. Despite their use by a large percentage of Americans, there is little evidence for the vast majority of products regarding their safety or efficacy. National Center for Complementary and Integrative Health supports a broad range of research on dietary supplements, including clinical trials. Our experience with these trials has shaped our current policies and priorities for clinical research. This perspective outlines those policies and priorities that are shaping our investments going forward.

Safety issues and harmful pharmacological interactions of nutritional supplements in Duchenne muscular dystrophy: considerations for Standard of Care and emerging virus outbreaks

At the moment, little treatment options are available for Duchenne muscular dystrophy (DMD). The absence of the dystrophin protein leads to a complex cascade of pathogenic events in myofibres, including chronic inflammation and oxidative stress as well as altered metabolism. The attention towards dietary supplements in DMD is rapidly increasing, with the aim to counteract pathology-related alteration in nutrient intake, the consequences of catabolic distress or to enhance the immunological response of patients as nowadays for the COVID-19 pandemic emergency. By definition, supplements do not exert therapeutic actions, although a great confusion may arise in daily life by the improper distinction between supplements and therapeutic compounds. For most supplements, little research has been done and little evidence is available concerning their effects in DMD as well as their preventing actions against infections. Often these are not prescribed by clinicians and patients/caregivers do not discuss the use with their clinical team. Then, little is known about the real extent of supplement use in DMD patients. It is mistakenly assumed that, since compounds are of natural origin, if a supplement is not effective, it will also do no harm. However, supplements can have serious side effects and also have harmful interactions, in terms of reducing efficacy or leading to toxicity, with other therapies. It is therefore pivotal to shed light on this unclear scenario for the sake of patients. This review discusses the supplements mostly used by DMD patients, focusing on their potential toxicity, due to a variety of mechanisms including pharmacodynamic or pharmacokinetic interactions and contaminations, as well as on reports of adverse events. This overview underlines the need for caution in uncontrolled use of dietary supplements in fragile populations such as DMD patients. A culture of appropriate use has to be implemented between clinicians and patients' groups.

Dietary Supplement Use among Non-athlete Students at a Canadian University: A Pilot-Survey

Despite the emerging evidence of adverse consequences and interaction with doping substances, dietary supplements (DS) are commonly used by many Canadians. The purpose of this study was to evaluate the patterns and determinants of current DS use among non-athlete students at a Canadian university using a cross-sectional approach. Of the 475 participants who completed the online survey, 43.4% declared using DS in the past six months. Participants who were male, aged ≥20 years old, and had a parent/guardian with a bachelor’s degree were significantly more likely to use DS. The types of DS used and the sources of information regarding DS were significantly influenced by age and gender. The most commonly used DS were vitamin and mineral and protein supplements. Most participants referred to healthcare professionals for information on DS, but many continued to depend on unreliable sources including family and friends. Of DS users, 10.1% reported experiencing adverse events from using DS. Findings from this study indicate that supplementation is very common among Canadian non-athlete students and highlight the urgent need for the development of educational programs surrounding DS use.

Assessment of adverse reactions to α-lipoic acid containing dietary supplements through spontaneous reporting systems

BACKGROUND & AIMS

Alpha-lipoic acid (ALA)-containing dietary supplements are widely used in clinical practice, although their safety assessment is under-investigated. We characterize the safety profile of ALA-containing products by analysing spontaneous reports of suspected adverse reactions (ARs).

METHODS

Suspected ARs to ALA-containing products were extracted from the Italian Phytovigilance System (IPS), and scrutinized in terms of seriousness and causality (through WHO UMC system), with a specific focus on important (IMEs) and designated medical events (DMEs). To characterize the reporting profile from an international perspective, the WHO-VigiBase was also queried.

RESULTS

From March 2002 to February 2020, out of 2147 total reports, 116 reports concerning 212 ARs to ALA-containing products were collected. Women were involved in 68.1% of cases. Skin (44.9%) and gastrointestinal disorders (10.8%) were the most frequently represented ARs. Causality assessment resulted as definite (15), probable (35), possible (24), unlikely (5), and unclassifiable (37). In 70% of cases, events occurred within 30 days of ALA use. Forty-five reports were serious (38.8%), being insulin autoimmune syndrome the most frequently reported (N = 10). IMEs were recorded in 20 cases, including four DMEs (3 angioedema and one anaphylactic shock). Similar distribution emerged from the 5641 reports in the WHO-VigiBase.

CONCLUSIONS

The remarkable reporting of unpredictable skin, immune and hepatic ARs, coupled with seriousness, strong causality and early onset, calls for a) careful risk-benefit assessment of ALA-containing products by regulators; b) awareness and monitoring by clinicians and c) continuous vigilance of their safety profile through valuable spontaneous reporting systems such as IPS.

Signal Management in Pharmacovigilance: A Review of Activities and Case Studies

PURPOSE

After nearly 12 decades of pharmaceutical catastrophes and the associated groundbreaking regulatory innovations, pharmacovigilance has come down to us in the present day as 3 interlocking core disciplines: case management, signal management, and benefit-risk management. This review provides a state-of-the-art introduction to the great variety of sources of safety information, both dependent on and independent of the Individual Case Safety Report (ICSR), and explains how this content undergoes management-system processes with globally accepted definitions, standards, and structures that make possible the ongoing safe use of a pharmaceutical product throughout its lifecycle. This occurs in the context of: (1) new products coming to market with new risks for drug-drug interactions, and (2) new global threats to safe manufacturing and distribution.

METHODS

This narrative review, reflective of the author's experience, uses a large-frame system of signal management developed by the Council for International Organizations of Medical Sciences VIII Working Group and modified by the author to include governance. A key feature of the review is the regular inclusion of relevant case studies to provide a backdrop of the unexpected, with resulting tragic outcomes, to the ever-evolving regulatory landscape.

FINDINGS

Regarding content, beyond the commonly appreciated sources of safety information that find their way into ICSRs are non-ICSR-based sources, including preclinical data, manufacturing data, findings from subject-matter experts who participate on data-monitoring committees, outside expert panels, advocacy groups, and independent investigator studies. Regarding process, it is important to recognize that governance is crucial in the effective conduct of signal management, in that subject-matter experts are essential to the scientific and medical aspects of decision making, and business and policy executives are essential in determining the final courses of action, as these decisions have implications for the company.

IMPLICATIONS

Signal management is an integral part of pharmacovigilance practices that strive to obtain all of the information necessary for maintaining the safety profiles of a company's pharmaceutical and biological products, to support favorable benefit-risk balances, and to ensure safe use by health care providers and their patients.

Endorsers' presence in regulation and endorsements in dietary supplements' advertising on Spanish radio

Healthy lifestyles provide a market niche for products offering health benefits in a context where consumers have a misconception of the characteristics and functions of dietary supplements (DS). Due to an increase of endorsers' advertising persuasion, their presence is limited and, in some cases, forbidden. The main objective of this work is to analyse the presence of endorsers in DS advertising on Spanish radio in order to verify its compliance with current legislation and determine the endorsements' characteristics. Specifically, this paper analyses the quantity, frequency, placement and endorsement type of DS spots on full-service radio stations. Content analysis of the totality of radio spots broadcast throughout the year 2017 is conducted, deriving a corpus of 165 different radio spots belonging to the product category of dietary supplements, broadcast a total of 10,566 times. The results show that 40% of radio spots use endorsers not allowed by law, such as health care professionals, typical consumers and celebrities. The latter have an unusually high presence in DS radio advertising, with one out of four spots featuring celebrities or opinion leaders, including journalists and radio hosts as well as a frequent use of testimonial endorsements. Implications for health and public policy are made.

An educational intervention improved knowledge of dietary supplements in college students

BACKGROUND

We have previously reported on the prevalence of dietary supplements among college students; it was deduced that their intake of supplements increased according to their grade (i.e., 13.1% in the first grade to 20.5% in the sixth grade). We also reported that some students had experienced adverse events in Japan due to their intake of these supplements. However, awareness of dietary supplements among college students remains limited, even among pharmaceutical students. Being appropriately educated about them is important for pharmaceutical students, both for themselves as well as for their future careers as pharmacists.

METHODS

We conducted a lecture-based educational intervention about dietary supplements on 328 college students in Japan-184 from pharmaceutical science and 144 from environmental science or food and life science disciplines. The purpose of this study was to evaluate the effects of an educational intervention on college students' understanding of dietary supplements. The intervention involved a lecture that covered the quality of dietary supplements, how they differed from drugs, and a summary of their adverse events. The lecture was evaluated using a 14-question questionnaire. We then compared the pre- and post-intervention responses to the same questionnaire using a Wilcoxon signed-rank test. The questions were assessed using a Likert scale that ranged from "strongly agree" to "strongly disagree"; the latter being the preferred answer.

RESULTS

Before the intervention had taken place, the students' understanding of dietary supplements was shown to be deficient. Conversely, post-intervention, their knowledge levels had significantly improved, especially concerning agreement on whether "Dietary supplements are safe because they are just food items". Pre-intervention, 2.7% strongly agreed and 37.5% agreed; post-intervention, 1.2% strongly agreed and 15.6% agreed. On whether "Dietary supplements made from natural ingredients or herbs are safe", at the pre-intervention stage 2.8% strongly agreed and 44.0% agreed and post-intervention, 2.2% strongly agreed and 16.9% agreed. On whether "Dietary supplements made from food items are safe", 4.0% strongly agreed and 43.6% agreed pre-intervention and 0.9% strongly agreed and 16.6% agreed post-intervention. Despite there being a greater number of pharmaceutical students who had a correct understanding of dietary supplements before the intervention, these students still showed improvement after the lecture.

CONCLUSION

An intervention in the form of a single educational lecture has the capacity to improve college students' understanding of dietary supplements. It is important for pharmacists to be appropriately educated about dietary supplements when they consult with patients. We will evaluate the long-term effects of the intervention on the alumni (pharmacists) in a subsequent study.

Assessment of Knowledge, Attitudes, and Practice of Community Pharmacists Regarding Weight Reduction Agents and Supplements in Aseer Region, Saudi Arabia

Purpose

This study investigated the knowledge, attitudes, and practice of community pharmacists regarding weight reduction products in Aseer region, Saudi Arabia.

Materials and Methods

A questionnaire-based study of community pharmacists in Aseer region, Saudi Arabia, was conducted between March and May 2019.

Results

The most commonly prescribed weight reduction agent was green tea followed by oatmeal products and ginseng. The results revealed that almost 85% of the respondents did not know which weight reduction agents are approved as over-the-counter products by the US Food and Drug Administration. Community pharmacists had positive attitudes toward the safety and efficacy of weight reduction products, but 64.91% indicated that they would limit weight reduction agents to obese patients who could not reduce their weight through exercise and diet. More than 80% of the participants agreed that it is very important to counsel patients regarding weight reduction products, and more than 80% also agreed that pharmacists should regularly discuss weight reduction products with other healthcare professionals.

Conclusion

Community pharmacists showed positive attitudes and efficient practice towards prescribing weight reducing products. However, there was a deficit regarding the knowledge about which products approved by FDA to manage overweight. That requires to consolidate the role of community pharmacists in weight management in Saudi Arabia with more continuous education and regulation.

Quercetin Is a Flavonoid Breast Cancer Resistance Protein Inhibitor with an Impact on the Oral Pharmacokinetics of Sulfasalazine in Rats

The potential inhibitory effect of quercetin, a major plant flavonol, on breast cancer resistance protein (BCRP) activity was investigated in this study. The presence of quercetin significantly increased the cellular accumulation and associated cytotoxicity of the BCRP substrate mitoxantrone in human cervical cancer cells (HeLa cells) in a concentration-dependent manner. The transcellular efflux of prazosin, a stereotypical BCRP substrate, was also significantly reduced in the presence of quercetin in a bidirectional transport assay using human BCRP-overexpressing cells; further kinetic analysis revealed IC₅₀ and Ki values of 4.22 and 3.91 μM, respectively. Moreover, pretreatment with 10 mg/kg quercetin in rats led to a 1.8-fold and 1.5-fold increase in the AUC_8h (i.e., 44.5 ± 11.8 min∙μg/mL vs. 25.7 ± 9.98 min∙μg/mL, p < 0.05) and C_max (i.e., 179 ± 23.0 ng/mL vs. 122 ± 23.2 ng/mL, p < 0.05) of orally administered sulfasalazine, respectively. Collectively, these results provide evidence that quercetin acts as an in vivo as well as in vitro inhibitor of BCRP. Considering the high dietary intake of quercetin as well as its consumption as a dietary supplement, issuing a caution regarding its food-drug interactions should be considered.

The prevalence, perceptions and behaviors associated with traditional/complementary medicine use by breastfeeding women living in Macau: a cross-sectional survey study

BACKGROUND

There is a long history of traditional/complementary medicine (T/CM) use by women during lactation. While it is important to evaluate such use within a scientific paradigm to ensure efficacy and safety, knowledge about the prevalence and characteristics of T/CM use during lactation is limited. This study aimed to generate preliminary data on the prevalence, perceptions and behaviors related to T/CM use by women living in Macau during lactation.

METHODS

Between April to June 2018, women aged 18 years or above who had breastfed within the previous 12 months were invited to complete a questionnaire which asked about their perceptions and behaviors related to the use of T/CM while breastfeeding. Chi-square analysis and logistic regressions were used to conduct data analysis.

RESULTS

A total of 500 women completed the survey with 62.6% (95% CI 58.37-66.83) reporting use of at least 1 T/CM while breastfeeding. Of these 48.9% (95% CI 44.67 to 53.13) believed T/CM were safe to take during lactation and 55.6% (95% CI 51.37 to 59.83) suggested there were inadequate resources to assist making an informed decision. Working status, monthly family income and the presence of a breastfeeding-related health problems were associated with T/CM use (all p < 0.05). The most commonly used T/CM were Tetrapanax papyriferus, lecithin, Vaccaria segetalis, docosahexaenoic acid and Trigonella foenum-graecum commonly referred to as Fenugreek. The most common reasons for using T/CM were "to unblock milk ducts", "to increase milk supply" and "to improve baby development". Women were recommended to use T/CM from multiple sources; 15.0% from health personnel (HP) only, 40.0% received recommendations from non-HP only; and 42.2% from both.

CONCLUSIONS

The use of T/CM by women during lactation is common in Macau. The current support and resources available to women during the breastfeeding period to make informed decisions about T/CM use is not standardized nor integrated. The gaps identified in this study provide an opportunity to develop resources and a more defined role for HPs to ensure the appropriate and safe use of T/CM in this population.

Ashwagandha-induced liver injury: A case series from Iceland and the US Drug-Induced Liver Injury Network

BACKGROUND & AIMS

Ashwagandha (Withania somnifera) is widely used in Indian Ayurvedic medicine. Several dietary supplements containing ashwagandha are marketed in the US and Europe, but only one case of drug-induced liver injury (DILI) due to ashwagandha has been published. The aim of this case series was to describe the clinical phenotype of suspected ashwagandha-induced liver injury.

METHODS

Five cases of liver injury attributed to ashwagandha-containing supplements were identified; three were collected in Iceland during 2017-2018 and two from the Drug-Induced Liver Injury Network (DILIN) in 2016. Other causes for liver injury were excluded. Causality was assessed using the DILIN structured expert opinion causality approach.

RESULTS

Among the five patients, three were males; mean age was 43 years (range 21-62). All patients developed jaundice and symptoms such as nausea, lethargy, pruritus and abdominal discomfort after a latency of 2-12 weeks. Liver injury was cholestatic or mixed (R ratios 1.4-3.3). Pruritus and hyperbilirubinaemia were prolonged (5-20 weeks). No patient developed hepatic failure. Liver tests normalized within 1-5 months in four patients. One patient was lost to follow-up. One biopsy was performed, showing acute cholestatic hepatitis. Chemical analysis confirmed ashwagandha in available supplements; no other toxic compounds were identified. No patient was taking potentially hepatotoxic prescription medications, although four were consuming additional supplements, and in one case, rhodiola was a possible causative agent along with ashwagandha.

CONCLUSIONS

These cases illustrate the hepatotoxic potential of ashwagandha. Liver injury is typically cholestatic or mixed with severe jaundice and pruritus, but self-limited with liver tests normalizing in 1-5 months.

Analysis of Ingredients of Supplements in the National Institutes of Health Supplement Database Marketed as Containing a Novel Alternative to Anabolic Steroids

This case series analyzes whether supplements categorized as containing novel ingredients in the National Institutes of Health Dietary Supplement Label Database are accurately labeled.

Personality Traits and Occupational Demands Are Linked to Dietary Supplement Use in Soldiers: A Cross-sectional Study of Sensation Seeking Behaviors

INTRODUCTION

Military personnel use dietary supplements (DS) more frequently and in a higher quantity than the general population. Patterns of DS used and the motivation for use among the military population are different than those of the civilian population. Soldiers are much more likely to use potentially dangerous DS purported to enhance physical performance and/or promote weight loss in spite of limited evidence regarding the safety and efficacy of these products. Sensation seeking (SS) behaviors can be associated with risky lifestyle behaviors and may be associated with use of DS by Soldiers. This study assessed Soldiers' SS behaviors in relation to DS use and various demographic factors.

MATERIALS AND METHODS

Demographic and behavioral questionnaires were administered to 289 Soldiers (mean ± SD, 28 ± 6 years, 27 ± 3 kg/m2 BMI, 83% male) at three U.S. military installations. The Brief SS Scale (four 10-point subscales) and Arnett Inventory of SS (two 40-point subscales) were used to assess SS behaviors. Independent sample t-tests determined the significant differences between SS subscale scores of DS users and non-users for each type of DS (i.e., protein, multivitamin, etc.). One-way analysis of variances and Tukey's post hoc comparisons assessed differences in SS scores across demographic categories. Tukey's post hoc analyses assessed SS scores between users and non-users within the DS categories.

RESULTS

Overall, 75% of Soldiers used DS ≥1 time/week. The most frequently used DS were protein/amino acids (52%), multivitamins/multiminerals (47%), "other" supplements (43%), and combination products (35%). Overall, DS users scored higher in experience seeking (8.0 ± 1.7 vs 7.5 ± 2.0; p < 0.05) and novelty (28.4 ± 3.7 vs 26.8 ± 4.7; p < 0.05) than non-users. Protein/amino acid users scored higher than non-users for all six SS traits: experience seeking (p < 0.001), boredom susceptibility (p < 0.001), thrill seeking (p < 0.001), disinhibition (p < 0.01), novelty (p < 0.001), and intensity (p < 0.001). Users of bodybuilding DS scored higher than non-users in four of the six SS traits: boredom susceptibility (p < 0.05), thrill seeking (p < 0.001), disinhibition (p < 0.01), and intensity (p < 0.001).

CONCLUSIONS

Soldiers who use DS that are frequently associated with health risks scored higher for sensation-seeking characteristics which are predictors of risky behaviors. Protein/AA and combination product DS users scored higher in sensation-seeking traits and this may be due to underestimation of risk, anticipation of positive outcomes, and/or high levels of confidence in these types of DS by high sensation seekers. Additional investigation into the association of sensation-seeking behaviors as predictors of harmful DS use is warranted.

Prevalence of dietary supplement use by gym members in Portugal and associated factors

Background

Although there seems to be an increasing interest in the use of dietary supplements in those who exercise recreationally and want to improve body composition, there is little published data regarding gym users and dietary supplement use.

Methods

This cross-sectional study describes the prevalence and type of supplements used by gyms members, the reasons for using them and the information source using a self-administered online questionnaire.

Results

Of the 459 participants (301 females) who answered the survey, 43.8% reported using dietary supplements. Users were more likely men (62.7% vs. 33.9%, p < 0.05), younger (32 ± 9 vs. 34 ± 11 years, p < 0.05) and trained more hours per week (6 ± 3 vs 4 ± 3 h, p < 0.05) than non-users. The most consumed supplements were proteins (80.1%), multivitamins and/or minerals (38.3%), sport bars (37.3%), branched-chain amino acids (BCAA’s) (36.8%) and n-3 fatty acids (35.5%). Men consumed more arginine, BCAA’s, creatine, glutamine, β-hydroxy-β-methylbutyrate (HMB), proteins, β-alanine, taurine, multivitamin/minerals, and carbohydrate supplements (p < 0.05). The most commonly cited reasons for the use of supplements were gaining muscle (55.7%), accelerating recovery (52.7%) and improving performance (47.3%). Men have more often referred increase strength, increase resistance, gain muscle mass, accelerate recovery and improve performance as reasons to use supplements than women (p < 0.05). Those who mentioned muscle gain as a reason were younger than those who did not (30.4 years vs. 33.7 years, p < 0.05). The sources of information most mentioned were registered dietitians (23.1%), internet (22.2%) and him/herself (16.6%). The majority (> 70%) of participants declared being well or very well informed about supplements, while only a minority (4%) felt very poorly or poorly informed. Most individuals purchased dietary supplements from the internet (56.2%) and supplement/health food stores (43.4%).

Conclusion

This study concluded that gyms users are large consumers of dietary supplements, and are more likely to be men, young, use protein powders, aiming to increase muscle mass, obtain information from registered dietitians, consider themselves well informed and buy supplements online.

A Systematic Review of the Effect of Dietary Supplements on Cognitive Performance in Healthy Young Adults and Military Personnel

Intake of dietary supplements has increased, despite evidence that some of these have adverse side effects and uncertainty about their effectiveness. This systematic review examined the evidence for the cognitive benefits of a wide range of dietary supplements in healthy young adult samples; the aim was to identify if any might be useful for optimising cognitive performance during deployment in military personnel. Searches were conducted in 9 databases and 13 grey literature repositories for relevant studies published between January 2000 and June 2017. Eligible studies recruited healthy young adults (18-35 years), administered a legal dietary supplement, included a comparison control group, and assessed cognitive outcome(s). Thirty-seven of 394 identified studies met inclusion criteria and were included for synthesis. Most research was deemed of low quality (72.97%; SIGN50 guidelines), highlighting the need for sound empirical research in this area. Nonetheless, we suggest that tyrosine or caffeine could be used in healthy young adults in a military context to enhance cognitive performance when personnel are sleep-deprived. Caffeine also has the potential benefit of improving vigilance and attention during sustained operations offering little opportunity for sleep. Inconsistent findings and methodological limitations preclude firm recommendations about the use of other specific dietary supplements.

United States Pharmacopeia (USP) comprehensive review of the hepatotoxicity of green tea extracts

As part of the United States Pharmacopeia's ongoing review of dietary supplement safety data, a new comprehensive systematic review on green tea extracts (GTE) has been completed. GTEs may contain hepatotoxic solvent residues, pesticide residues, pyrrolizidine alkaloids and elemental impurities, but no evidence of their involvement in GTE-induced liver injury was found during this review. GTE catechin profiles vary significantly with manufacturing processes. Animal and human data indicate that repeated oral administration of bolus doses of GTE during fasting significantly increases bioavailability of catechins, specifically EGCG, possibly involving saturation of first-pass elimination mechanisms. Toxicological studies show a hepatocellular pattern of liver injury. Published adverse event case reports associate hepatotoxicity with EGCG intake amounts from 140 mg to ∼1000 mg/day and substantial inter-individual variability in susceptibility, possibly due to genetic factors. Based on these findings, USP included a cautionary labeling requirement in its Powdered Decaffeinated Green Tea Extract monograph that reads as follows: "Do not take on an empty stomach. Take with food. Do not use if you have a liver problem and discontinue use and consult a healthcare practitioner if you develop symptoms of liver trouble, such as abdominal pain, dark urine, or jaundice (yellowing of the skin or eyes)."

Towards appropriate polypharmacy in older cardiovascular patients: How many medications do I have to take?

BACKGROUND

Polypharmacy in older adults leads to increased risks of side effects and drug-drug interactions, affecting their health outcomes and quality of life. Deprescribing, the act of simplifying medication regimens, is challenging due to the lack of consensus guidelines.

HYPOTHESIS

To offer some guidance on managing medication regimens for older cardiovascular patients.

METHODS

We reviewed the most recent pertinent guidelines and literature.

RESULTS

This review provides practical considerations for appropriate prescribing in the older population with cardiovascular disease in order to strike a balance between unnecessary or harmful medications and therapies with proven long-term benefits.

CONCLUSION

On-going dialogue between healthcare providers and patients allows close monitoring of medication effectiveness and prevention of side effects. Medication regimens require individualization, as patients' goals of care change with advancing age.

Critical Differences Between Dietary Supplement and Prescription Omega-3 Fatty Acids: A Narrative Review

INTRODUCTION

Currently available omega-3 (OM-3) fatty acid products in the US are either nonprescription dietary supplements (e.g., fish oils) or prescription (Rx) medications. As such, we aimed to describe critical therapeutic differences among the OM-3 fatty acids, focusing on differences between fish oil supplements and Rx OM-3s.

METHODS

A narrative review of known papers salient to this topic was conducted.

RESULTS

Despite the multiple purported clinical benefits, the published evidence for OM-3 dietary supplements is generally insufficient, inconsistent, or negative. Rx OM-3 products are indicated as an adjunct to diet to reduce triglycerides (TG) in adults with severe hypertriglyceridemia (TG ≥ 500 mg/dl). Recently, the Rx eicosapentaenoic acid (EPA)-only OM-3, icosapent ethyl, demonstrated cardiovascular (CV) risk reduction among statin-treated patients at high risk of CV disease in a large CV outcomes trial (CVOT), and is now also indicated as an adjunct to maximally tolerated statin therapy to reduce the risk of myocardial infarction, stroke, coronary revascularization, and unstable angina requiring hospitalization in adult patients with elevated TG (≥ 150 mg/dL) and established CVD or diabetes mellitus and ≥ 2 additional risk factors for CVD. In contrast to the rigorous regulatory standards for safety, efficacy, and manufacturing of medications (whether Rx or over the counter), the Food and Drug Administration manages dietary supplements as food. Issues specific to OM-3 dietary supplements include variable content, labeling inconsistencies, and poor product quality/impurity. Given these issues, OM-3 dietary supplements should not be substituted for Rx OM-3 products. The efficacy of the EPA-only Rx OM-3 product in a large CVOT cannot be extrapolated to other OM-3 products.

CONCLUSION

Consumers and health care providers need to recognize critical differences between Rx and OM-3 dietary supplements to ensure appropriate use of each OM-3 product.

Hepatitis-associated aplastic anemia from workout supplement: Rare but potentially fatal entity

Hepatitis-associated aplastic anemia (HAAA) is a rare clinical syndrome characterized by bone marrow failure 1–3 months after development of hepatitis. Untreated, hepatitis-associated aplastic anemia has poor outcome and the mainstay of treatment remains either bone marrow transplant or immunosuppressive therapy. A previously healthy 21-year-old man presented with a 1-week history of right upper quadrant pain and jaundice. Admission labs revealed mixed hyperbilirubinemia and elevated transaminases ranging in 2000s IU/dl. Extensive workup for etiologies of acute hepatitis including viruses, autoimmune, toxins etc. were negative. He admitted to taking “Dust V2,” a workout supplement, for 4 months prior to the presentation. His liver function tests started to improve after conservative treatment. Two months after his discharge, he was found to have severe pancytopenia on routine labs. Bone marrow biopsy revealed hypocellular marrow consistent with aplastic anemia. Extensive workup for etiologies of aplastic anemia were negative. On literature review, none of the components of the supplement were found to cause aplastic anemia. A diagnosis of hepatitis-associated aplastic anemia was made as there was a lag time before development of anemia. His counts failed to improve despite treatment with filgrastim and he was referred for hematopoietic cell transplant.

Protecting consumers from fraudulent health claims: A taxonomy of psychological drivers, interventions, barriers, and treatments

OBJECTIVE

Fraudulent health claims-false or misleading claims used to promote health remedies that are untested, ineffective, and often harmful-cause extensive and persistent harm to consumers. To address this problem, novel interventions are needed that address the underlying cognitive mechanisms that render consumers susceptible to fraudulent health claims. However, there is currently no single framework of relevant psychological insights to design interventions for this purpose. The current review aims to address this gap.

METHOD

An integrative theoretical review was conducted across several relevant disciplines including criminology; behavioural economics; and cognitive, health, and social psychology.

RESULTS

The current review presents a novel taxonomy that aims to serve as an agenda for future research to systematically design and compare interventions based on empirical evidence. Specifically, this taxonomy identifies (i) the psychological drivers that make consumers susceptible to fraudulent health claims, (ii) the psychological barriers that may prevent successful application of interventions, and (iii) proposes evidence-informed treatments to overcome those barriers.

CONCLUSIONS

The resulting framework integrates behavioural insights from several hitherto distinct disciplines and structures promising interventions according to five underlying psychological drivers: Visceral influence, Affect, Nescience, Misinformation, and Norms (VANMaN). The taxonomy presents an integrative and accessible theoretical framework for designing evidence-informed interventions to protect consumers from fraudulent health claims. This review has broad implications for numerous topical issues including the design and evaluation of anti-fraud campaigns, efforts to address the growing problem of health-related misinformation, and for countering the polarisation of politically sensitive health issues.

Characteristics, Preferences and Health Care Utilization in Patients Using a Dietary Supplement for Improving Sleeping Disturbances: Results from an Explorative Online Survey

PURPOSE

Sleeping disturbances are highly prevalent in the general population, and pharmacological drug treatment harbours the risk of serious side effects. Many affected persons use dietary supplements for self-treating their symptoms, but little is known about the specific characteristics and preferences of these patients. Even less evidence exists about the consequences of a specific dietary supplement usage on health care utilization. The aim of this study was to explore characteristics, preferences and the impact on health care utilization in patients using a specific over-the-counter dietary supplement, which is promoted for improving sleeping disturbances.

PATIENTS AND METHODS

We conducted a structured survey and invited a sample of 297 customers of a specific dietary supplement to participate. The survey was open between June and September 2020. Participants were invited by email. All participants accepted an informed consent.

RESULTS

A total of 127 customers participated in the survey (participation rate: 42.8%). Of them, 87.7% were female and the mean age 50.5 years. Participants reported an overall good improvement of symptoms (7.66 on a ten-point Likert-scale) and showed a strong belief in the effectiveness of supplements in general; 67% of participants reported that the intake led to fever physician encounters, and 48.3% reported that they could stop the intake of other pharmaceutical sleeping drugs.

CONCLUSION

A significant proportion of participants reported a substantial reduction in pharmaceutical drug use and health care utilization. While these self-reports lack an adequate control, they are still real consumer experiences, and the large beneficial effects - whether placebo or not - explain the popularity of such supplements and their therapeutic potential in sleeping disorders.

Use of complementary and alternative medicine in patients with inborn errors of metabolism: A single-center study

Background and Objectives

There is a paucity of information on the use of complementary and alternative medicine (CAM) in patients with inborn errors of metabolism (IEM). This study's objective was to evaluate the self-reported use and perceived effectiveness of CAM in adults and children with IEM.

Methods

Patients aged 0-70 years and caregivers seen at the London Health Sciences Centre Metabolic Clinic (London, Ontario, Canada) between July 2017 and August 2017 were recruited to complete a questionnaire regarding CAM use to help their IEM diagnosis and perceived effectiveness of these therapies. Survey responses were analyzed using descriptive statistics; age, sex, and education level associations among CAM users were tested using the Pearson χ ² test.

Results

Of 50 potential participants, 44 (88%) completed the questionnaire, including 21 adults (6 by caregivers) and 23 children (22 by caregivers). The most common IEM category was Aminoacidopathies and Small Molecule Disorders (50%). Twenty-seven (61%) participants reported CAM use to help their IEM diagnosis. The most common CAM therapies used were chiropractic manipulation, omega-3 fatty acids, probiotics, and aromatherapy/essential oils. Most CAM users and caregivers (74%) perceived their CAM therapies as effective overall. Among CAM users, 40% had not discussed CAM use with a health care professional (HCP). CAM use was similar when comparing age, sex and education level.

Conclusions

CAM is commonly used among patients with IEM. The safety and efficacy of CAM therapies for IEM should be further investigated. HCPs and patients should openly discuss CAM use in order to evaluate safety.

An evaluation of randomized controlled trials on nutraceuticals containing traditional Chinese medicines for diabetes management: a systematic review

BACKGROUND

Nutraceuticals containing traditional Chinese medicine (TCM) are promoted for use in the management of diabetes. The evidence to support such use is largely unknown. This study aimed to summarise and evaluate the literature reporting the results of randomized controlled trials (RCTs) investigating the effects of nutraceuticals in people living with diabetes.

METHODS

Literature from four electronic databases (PubMed, Scopus, CINAHL and Web of Science) was searched following PRISMA guidelines to yield RCT publications on nutraceutical for diabetes management published since 2009. The quality of reporting was assessed using the CONSORT 2010 checklist statement. Risk-of-bias for each study was assessed using the Cochrane risk of bias tool.

RESULTS

Out of 1978 records identified in the initial search, 24 randomized, double/triple-blinded, controlled trials that investigated the effect of nutraceuticals covering 17 different TCM herbs for diabetes management were selected. Participants included people who were diabetic (n = 16), pre-diabetic (n = 3) or predisposed to diabetes (n = 5). Sample sizes ranged between 23 and 117 for 2 arms, or 99-165 for 3 arms. Comparisons were made against placebo (n = 22), conventional medicine (n = 1), or regular diet (n = 1) for a duration between 4 and 24 weeks. All but one study tested the effect on fasting blood glucose levels (n = 23) or glycated haemoglobin levels (n = 18), and/or postprandial 2-h blood glucose levels (n = 4) as the primary outcomes. Nineteen studies reported some statistically significant reductions in the respective measures while 5 studies showed no effect on primary or secondary outcomes. None of the included studies met all the criteria for the CONSORT guidelines. Incomplete reporting about randomization and blinding, and a lack of ancillary analyses to explore other influential factors and potential harms associated with the use were repeatedly noted. Based on the Cochrane risk-of-bias tool, 19 studies were deemed to have a high risk of bias mainly attributed to sponsor bias.

CONCLUSIONS

There is some evidence to suggest positive clinical outcomes in response to the administration of a range of nutraceuticals containing TCM in the management of diabetes. However, these results must be interpreted with caution due to the overall low quality of the trials.

Energy drinks and population health: consumption pattern and adverse effects among Saudi population

BACKGROUND

Caffeine containing energy drinks (EDs) are heavily consumed, particularly among young adults. The number of reports of caffeine intoxication from caffeinated EDs and problems related to caffeine dependence and withdrawal is increasing. The objective was to assess the knowledge and perceived beneficial effects of EDs consumers, to assess consumption patterns and determine the adverse effects experienced by different EDs consumer groups residing in Saudi Arabia.

METHODS

An observational cross-sectional study with data from a randomly selected Saudi population was conducted during the period of January 15th, 2015, to April 15th, 2015, using a pre-tested 43-item questionnaire. The data were obtained and collected using interview questionnaires. Sociodemographic characteristics and data on EDs consumption patterns, the level of awareness among study subjects, and the purported benefits and reported adverse effects of EDs were collected. Frequency, percentage, and arithmetic means were calculated using Chi-square and ANOVA tests, and data with p < 0.05 were considered significant.

RESULTS

Of the 816 individuals invited to participate in the study, 783 participants responded and completed interviews, response rate was 96%. Consumers attributed the popularity of EDs to massive advertising media (46.7%) and their stimulating and invigorating effects (37.5%). EDs are consumed by subjects for their effects on fatigue reduction (64.6%), increased alertness and focus (75.8%), and assistance during long driving trips (75.7%). Study subjects reported suffering from adverse effects, including mainly diuresis (53.7%), palpitations (50.7%), insomnia (50.7%). Importantly, an inverse association was identified between knowledge of EDs and consumption rate, and a proportional association was identified between experienced adverse effects and consumption frequency. Lower knowledge scores were identified in daily consumers than in 1-3 times monthly consumers; higher adverse events were experienced by daily consumers than by 1-3 times monthly consumers. The majority of consumers (84.6%) recommended that authorities should regulate EDs consumption.

CONCLUSIONS

Excessive EDs consumption is associated with an increased risk of experiencing several adverse events, which is commensurate with published studies. Increasing knowledge about EDs and their possible risks could decrease their consumption by the general public.