Exploring the Dietary Supplement Use During COVID-19: Insights from Community Pharmacists,Pharmacy Staff,Academics,and Industry Experts

Abstract

Introduction:

The increased use of dietary supplements is a consequence of the coronavirus disease 2019 (COVID-19) pandemic. Although their efficacy has not been consistently proven, they have been perceived as a preventive tool against COVID-19. Less strict regulations and debates on their definitions in a regulatory framework raise concerns about safety issues. Apart from dietary supplement use, information demand has increased, and pharmacists have played a key role as accessible health professionals. This study aimed to reveal the opinions of community pharmacists, pharmacy staff, sector representatives, and academicians regarding the sale and use of dietary supplements during the COVID-19 pandemic.

Methods:

A qualitative study approach was followed, using grounded theory. Data were collected between September 2021 and July 2022, analyzed using MAXQDA 2020 software, and reported according to the Consolidated Criteria for Reporting Qualitative Research.

Results:

After refining the open codes, two themes emerged: dietary supplements and the effects of the pandemic. It was found that increased dietary supplement use was rooted in COVID-19 fear, promotional activities, and social media influence. The interaction between consumers and the dietary supplement industry is bidirectional.

Conclusions:

Pharmacies, as access points for these products, played a crucial role in struggling with the effects of the pandemic. Although dietary supplements are considered safe, their potential for adverse reactions poses a public health risk. Flexible regulations, unregulated alternative advertising channels, and a lack of awareness of the safety of these products pose a challenge to public health. In this regard, all stakeholders should work to minimize the risks from undergraduate education to professional life.

Introduction

The coronavirus disease 2019 (COVID-19) pandemic has affected the world in various ways.^1,2 Health-related behaviors are one of the facets of these effects. Correspondingly, studies have shown that preventive health behaviors have increased with the pandemic.^3,4 The perpetual risk of COVID-19 has led to an increasing interest in alternative solutions such as dietary supplements.^5
–7 Dietary supplements are defined as products that can contain vitamins, minerals, and other nutritional compounds in different forms such as capsules, powders, and liquids at certain doses. These products are intended to support normal nutrition.⁸ In Türkiye, legislation complies with the European Directive and dietary supplements are not subject to prescription.⁹ Since prescription restrictions do not apply to these products, consumers can access them of their own will, and the industry is allowed to advertise dietary supplements. Thus, promotional activities targeting consumers and health professionals have been conducted in the dietary supplement industry.^10
–12

Despite the regulative definition of dietary supplements and their clinical effects have not been consistently proven, they were considered a preventive tool for COVID-19.^13,14 Accordingly, the sale of dietary supplements has increased in many countries during the pandemic.^13,15,16 In Türkiye, sales data are not available, but traces of market growth were determined via the official list of the authorities. According to the list of the Ministry of Food and Agriculture, from the declaration of the pandemic to the end of 2022, the total number of products has increased more than twice comparing before the pandemic. Remarkably, more than half of the total products were included in the list between 2020 and 2023.¹⁷ Next to dietary supplement use, the information needs regarding preventive measures for COVID-19 are also highlighted in the literature.^18,19 Social media and web-based tools have been demonstrated as major information sources next to health professionals.^20
–22 The roles of pharmacists as health care professionals have been emphasized in numerous studies in terms of patient counseling during the pandemic.^21,23

–26 Besides, community pharmacies served as an access point to the products as health institutions.²⁷ Along with the adverse reactions, flexible regulations on products, advertising, and social media interfere with the user’s access to information and their awareness of the safety of dietary supplements.²⁸

Numerous studies have examined different aspects of dietary supplement use, such as clinical outcomes, consumer preferences, determinants and patterns of use of these products, and the effects of the pandemic on pharmacy services.^{5,6,14
–16,29
–31} Although the use of dietary supplements during COVID-19 and its implications have been studied in the available literature, the evaluation of different stakeholders of this phenomenon remains limited. Thus, this study aimed to reveal the opinions of community pharmacists, pharmacy staff, sector representatives, and academics regarding the sale and use of dietary supplements during the COVID-19 pandemic. Ensuring the participants’ variety in terms of profession was intended to widen and disclose different angles on the research aim. Moreover, the current perspective on dietary supplements will be banded together in terms of public health.

Material and Methods

An exploratory qualitative research design was followed and reported regarding Consolidated Criteria for Reporting Qualitative Research (COREQ).³² The data have been systematically gathered throughout the study and analyzed as per the grounded theory approach.³³ The grounded theory (GT) was first introduced by Glaser and Strauss.³⁴ From the initial introduction, the GT approach was used not only for sociological studies but also for health-related research.^35

–38 The two-phased research protocol was followed: The initial phase was the document search and analysis. The second phase consisted of semi-structured interviews with community pharmacists, pharmacy staff, industrial representatives, and academics from the pharmacy schools. These stakeholders represent the core components of the dietary supplement industry by providing knowledge, products, and counseling services to consumers. Industry is the first component of manufacturing and supplying products to the market. Pharmacists and pharmacy staff are key allies in selling products and providing counseling services to consumers. Academics are knowledge sources for dietary supplements considering their health benefits.

Document analysis

All online accessible documents were included in the document search phase from Türkiye’s official online legislation database in November 2022.³⁹ Search terms were defined as “dietary supplement,” “promotion,” “advertising,” and “consumer.” The results were screened according to legislation names and scopes. All documents included search terms in the titles and scopes included in this study. Since all documents were legislative, the name and scope of the legislation reveal the scope of the document.

Semi-structured interviews

Semi-structured in-depth interviews were conducted. The open-ended interview questions were addressed to the participants. These questions were defined by the researchers through discussions based on a literature review. Different yet similar questions were directed to each group of participants according to their work field. Questions were developed to gather different perspectives on the same topic. A list of all the questions is provided in the Supplementary Data S1. Interviews were conducted between September and July 2022. The snowball sampling technique was followed in the invitation process.⁴⁰ Community pharmacists and their staff were invited by reaching through their pharmacy’s phone number. Industry representatives and academics were contacted via their official email addresses.

All interviews were conducted via Zoom with open cameras by one researcher (L.Y.) to ensure uniformity, and another researcher joined the interviews as an observer. Each interview was audiotaped as per the participants’ informed consent, and all participants were allowed to withdraw their consent at any time. Records were transcribed verbatim by one researcher. To avoid misspellings and other kinds of errors, one researcher (except the interviewer) controlled the transcriptions in synchrony with the audio records. The reviewed transcriptions were shared among all researchers, resulting in consensus-determined data saturation.

Analysis

The GT approach allows the structure of the theory to be derived directly from data. Thus, the coding process was inductive and open.⁴¹ The initial coding process was followed by an axial coding process. Two researchers (B.S.S. and L.Y.) independently conducted the coding to avoid bias. Constant comparison was applied through the coding and theory-forming process in addition to the memo-writing technique, as Charmaz defined.⁴² By comparing data to data, and data to codes, the focused codes emerged and refined. After finalizing the coding process, the member-checking process was conducted to ensure credibility, and the data were analyzed using MAXQDA2020 (VERBI Software GmbH, Berlin, Germany).

Ethical approval

Approval for the COVID-19 study was obtained from the Ministry of Health via email. Ethical approval was obtained from the Hacettepe University Ethical Commission (Permit no. 1449727) before conducting the study.

Results

Document analysis

A total of 122 documents were obtained during document analysis. Documents were screened based on their relevance to the research objective. The terms “dietary supplement,” “promotion,” “advertising,” and “consumer.” were used as the basis for the screening process. After reviewing their relevance regarding the legislation’s name and scope, 19 documents were included in the data analysis. Eleven of these were legislations from the Ministry of Health, six from the Ministry of Trade, and two from the Ministry of Food and Agriculture.¹⁷

A list of the included documents is provided in Table 1.

Table 1.

List of Included Documents

Document no	Date	Legislation name
D1	16.08.2013	Turkish Food Codex Dietary Supplement Declaration (Number: 2013/49)
D2	02.05.2013	Regulation on Import, Production, Processing and Distribution of Dietary Supplements
D3	03.07.2015	Regulation on Promotional Activities of Medicinal Products for Human Use
D4	15.05.2014	Medical Device Sales, Advertising and Promotion Regulation
D5	10.01.2015	Commercial Advertising and Unfair Competition Practices Regulation
D6	24.12.2014	Advertising Council Regulation
D7	03.07.2014	Advertisement Board Regulation
D8	26.08.2009	Türkiye Radio-Television Institution Advertisement Regulation
D9	28.11.2013	Consumer Protection Law
D10	20.04.2012	Declaration on Determining the Safety Risks Of Consumer Products
D11	18.10.1952	Regulations on the Special Characteristics of Foodstuffs, Goods and Equipment Concerning Public Health
D12	15.05.1987	Health Services Fundamental Law
D13	24.12.1953	Law on Pharmacists and Pharmacies
D14	26.05.1928	Pharmaceuticals and Medical Preparations Law
D15	06.10.2010	Traditional Herbal Medicinal Products Regulation
D16	03.07.2015	Regulation on Promotional Activities of Medicinal Products for Human Use
D17	16.06.2004	Regulation on Classification of Medicinal Products for Human Use
D18	07.06.2013	Regulation on Health Claims of Products Commercialized with Health Claims
D19	12.04.2014	Regulation of Pharmacists and Pharmacies

Semi-structured interviews

In the second phase, semi-structured interviews were conducted with the 20 participants. Information on the participants is presented in Table 2. The mean duration of the interviews was 29 min (min. 10, max. 45) min.

Table 2.

Participant Characteristics

Profession		Age (years) (mean, min–max)	Experience (years) (mean, min–max)
Pharmacist	P1, P2, P3, P4, P5	45.6 (28—62)	19.9 (4.5—28)
Pharmacy staff	P6, P7, P8, P9, P10	32.6 (24—49)	21.4 (4—24)
Industry representative	P11, P12, P13, P14, P18	48.4 (42—54)	16.4 (7.5—28)
Academics	P15, P16, P17, P19, P20	56.2 (42—70)	35 (22—53)

Data analysis

With the inductive coding approach, more than 300 open codes have emerged, including the definition of dietary supplements, use of supplements, pandemic precautions, suggestions, promotional activities, education, product sales, consumer behavior, falsified products, legislative situations, patient counseling, and social media. In the axial coding process, the open codes were refined and grouped into broader categories. Each category was reviewed for each code to ensure conceptual coherence. Consequently, the data were structured into a comprehensive set of themes and codes. Eventually, two themes and seven subcodes emerged. The list of themes and codes is given in Table 3. Selected quotations are provided in the Supplementary Data S1.

Table 3.

Themes, Subthemes, and Codes

Themes	Subthemes and codes	Participant/document no
Dietary supplement	Conceptual framework	D1, P11, P13, P14, P15, P16, D19, P19, P20
	Legislative framework	D1, D5, P5, P11, P13, P14, P15, P16, P17, D18, P19, P20
	Market overview	P4, P5, P11, P12, P13, P14, P18
	Future directions	P12, P14, P17, P20
	For public health	P5, P12, P13, P15, P17, P19, P20
	For industry development	P11, P12, P14, P17, P20
	For consumer behavior	P17, P20
Effects of pandemic	On the dietary supplement industry	P1, P6, P8, P11, P12, P13, P14, P17, P19, P20
	On pharmacy services	P4, P5, P12, P18, P19
	Patient counseling and product training	P1, P4, P5, P6, P13, P18
	Physical, and economic effects	P3, P4, P5, P13
	On consumer’s health-related behaviors	P2, P4, P6, P8, P9, P10, P11, P13, P17, P18, P20
	Fear-based behaviors	P1, P3, P4, P7, P12, P14, P15, P17, P18, P19, P20
	Advertisements related behaviors	P1, P2, P5, P6, P8, P9, P10, P12, P15, P16, P20
	Product training-related behaviors	P13, P14, P15, P16, P19, P20
	Social media influence	P1, P5, P13, P18

Dietary supplement

Dietary supplement is a comprehensive concept as expressed by the participants. Although dietary supplements have a narrow definition in legislative documents, participants related these products to their health benefits. Apart from definition, dietary supplements were also emphasized by their legislative status. Even though their health benefits are highlighted, their legislative definition and status are considered controversial. Market growth was mostly expressed with an increase in the number of products. Participants expressed the market growth, and they stated the reliability and quality of the products considering their controversial status. The dietary supplement theme is categorized into four subtheme categories: conceptual framework, legislative framework, market overview, and future directions in terms of dietary supplements.

Participants expressed that dietary supplements as self-medication tools to cure health conditions. Next to the supplemental use, they highlighted the health benefits of these products.

“Dietary supplement is more of a self-medication; this is the term I prefer. These products are meant to be used before illness with the [consumer’s] own will or by pharmacist consultation.” (P 13)

Participants emphasized the importance of legislative measures and their effects on the industry. They stated that considering legislative measures, the regulations in Türkiye were expressed as relatively new. They compared these products with human medicines, from a regulatory perspective.

“In 2013, the Ministry of Agriculture and Food declared a new regulation. This action regulated the market…. Before this regulation, there was no legislation for the sector.” (P 11)

“When we think from the industry side, I think their reliability should be prioritized.” (P 17)

The participants underlined the number of products and companies related to market growth. They expressed the market as complicated and they highlighted that internet sales have made the market more complicated.

There is a severe mess [in the market]. 538 companies [in total], what on earth! 160 new companies have entered the market in the first months of 2021. These are very huge numbers. We are on the market with 538 companies.” (P 13)

Considering the excess growth in the market, participants made suggestions for regulative measures to control the reliability and quality of the industry. Apart from regulative measures, they also emphasized that awareness of the use of dietary supplements is another critical issue. On this basis, participants highlighted the importance of collaboration between different health professionals, industry, and health authorities along with legislative measures.

“It is necessary to increase this awareness by working more together with the Provincial Health Directorates of the Ministry of Health. For example, the side effects, they are [consumers] not aware of it.” (P 20)

“Manufacturers could get together and do some such as… Perhaps a quality association can be formed. Because it is [dietary supplement industry] a low-quality industry.” (P 14)

Effects of pandemic

The pandemic has affected lives from different aspects as participants expressed. The effects of the pandemic theme were divided into three subthemes: effects on the dietary supplement industry, pharmacy services, and consumers’ health-related behavior. The effects on the dietary supplement industry are expressed by an increase in sales of the products. Participants also highlighted specific products such as Vitamin C, Vitamin D, and multivitamins.

“Suddenly, an incredible blast occurred in the market, prevailing for Türkiye too. [Companies] could not even sell the number of products in 3 years in that year [first year of pandemic], such an accretion out of nowhere” (P 14)

Next to the dietary supplement industry, the participants stated that pharmacy services and patient counseling shifted to a different phase considering the physical distance. The major effects on pharmacy services have been described in terms of patient counseling and physical-economical aspects. From the pharmacists’ perspective of the increase in consultation demand from patients, they served as the first consultants, and they expressed their professional satisfaction in this regard.

“Surely it affected. Because visual image is also important for people. When we think of this, the visual image is affected. In this case, of course, there was a slight decrease [in sales in pharmacy].” (P 5)

“So, everyone turned to self-medication. Here, the first consultant is the pharmacists.” (P 18)

Apart from industry and pharmacists, the effects on consumers were also highlighted. Consumer awareness of immune-boosting products has been emphasized as a consequence of the pandemic. Moreover, participants highlighted that even though consumers have no specific health issues, they tend to use dietary supplements. The participants associated the effects on consumers with fear, advertisements, product training, and social media.

Participants underlined that fear of COVID-19 affected consumers and increased demand. Fear is mostly expressed as the fear of dying from COVID-19. Next to this, participants also underlined the fear of unknown diseases have affected people’s actions.

“Why such a situation [increasing demand] occurred… Because people were afraid. It is something that they do not know since they acted with fear, they attacked and started to listen everyone.” (P 4)

Along with fear, participants expressed that the demand for the product increased with advertisements, and they highlighted the influential effects of the advertorials on television. In addition, the participants expressed that the effects of advertorials also increased product choice and sales.

“It can be noticed, it increases distinctly [with the advertisements]. There are people who take it very seriously. Such as it is convenient in the advertisement, it is suitable for me, I need to use this etc.” (P 10)

Product training has been linked to raising awareness of dietary supplement use and public recognition of these products. Participants expressed that the effects of training could not be specified but doing such training gave them a great opportunity to increase consumer commitment. Next to commitments, training has been seen as a tool for recognition from consumers’ perspective.

“At a certain point, if your product is well-known, it is sold. So, the education programs are very important.” (P 13)

Participants specified social media as “very influential” and expressed that social media has been used by consumers as a tool for information. Moreover, participants expressed that social media is a “word-of-mouth marketing” tool for our era.

“Social media is very influential in this matter. It increased [demand] somehow. Also, at least they know the thing. We need to strengthen our immune system and so on. There is such a perception. Even they do not hear anything (from us) they came (to pharmacy) with a certain product.” (P 1)

After integrating the data, two themes were defined as the core categories. The diagram was structured through an additional discussion and comparison. A data-driven theoretical diagram is provided in Figure 1 to visualize the interactions among consumer behaviors, the dietary supplement industry, and pharmacy services. The straight lines represent the subcodes clustered in a code and theme and the dashed lines represent the interactions between the codes and subcodes.

FIG. 1.

Data-driven theoretical diagram. Subcodes clustered in a code and theme. Interactions between the codes and subcodes.

The diagram illustrates the interactions between the different themes and codes. Considering the effects of the pandemic and dietary supplements, our data-driven diagram showed that these concepts are entangled in different aspects. The pandemic has affected both the dietary supplement industry and pharmacy services, apart from consumer behavior, advertisements, and training on products. Remarkably, alterations in consumers’ health-related behaviors also altered pharmacy services. Next to the effects on consumers, advertisement-related behaviors altered the pharmacy services. Alterations in consumers’ health-related behaviors, advertisement-related behaviors, and pharmacy services also lead to changes in the dietary supplement. These interactions were found to be bilateral. Thus, all the interactions can be expressed on the other side. The changes in product training also came out with the alterations in both pharmacy services and fear-based behaviors Along with the fear of COVID-19, a bidirectional interaction between the dietary supplement industry and consumers was found, as shown in the theoretical diagram.

Discussion

This study explored the opinions of community pharmacists, pharmacy staff, sector representatives, and academics on the sale and use of dietary supplements during the COVID-19 pandemic. The participants underlined that the pandemic affected consumers’ health-related behaviors considering fear of COVID-19, advertorials, social media influence, and product training. Apart from consumers, the pandemic has also led to alterations in pharmacy services and the dietary supplement industry. Notably, suggestions on dietary supplements for consumers, the industry, and the public were expressed from different angles. Besides, the market status was highlighted with regard to the increase in companies and the elevated use of dietary supplements. Next to the market, participants also stated dietary supplements as a concept considering the definition and legislative status.

The definition of dietary supplements switched to a broader perspective and the difference between dietary supplements and pharmaceutical products was stated as becoming slightly.⁴³ Alteration in health perceptions and health-related products such as dietary supplements placed beyond their defined intentions.⁴⁴ Even though dietary supplements are defined as a support for normal nutrition in the legislation, their functions are also linked with health benefits. Various studies have shown that consumers’ views on dietary supplement use are related to the curative and preventive benefits of these products.^45

–48 Accordingly, participants defined dietary supplements as self-medication.

Several studies have examined the clinical outcomes of supplements in COVID-19 patients. However, the potential effects of supplements in COVID-19 are still debatable.^13,29,30,49 Despite controversial studies on their effects, the demand for dietary supplements has risen during COVID-19. After the declaration of the pandemic in March 2020, dietary supplement sales increased exponentially worldwide, to 51.2% in the United States, and 63% in the United Kingdom.¹³ Correspondingly, our participants also highlighted the sales with a remarkable increase. Even though public sales data are not available in Türkiye, market growth could be followed in terms of the Ministry of Food and Agriculture’s approved dietary supplement list. At the end of 2023, 20,776 products were listed. After extraction by date, it is seen that in 2019, a total of 1760, in 2020 a total of 2935, in 2021 a total of 3019 products were included in the list. A gradual increase was found to remain in 2022 and 2023 with the addition of 3280 and 3947 products to the list, respectively. The trends in product approval were consistent with the participants’ observations. Nearly, half of all approved products were included in the list between 2021 and 2023.¹⁷

Relatively, participants pointed out that the increased use of dietary supplements in COVID-19 arose from fear, social media influences, advertising activities, and product training. Similarly, the impact of COVID-19 fear on consumer behavior has been reported in the existing literature. Studies have shown that fear of COVID-19 has led to a tendency to use dietary supplements.^3,31,50 In Türkiye, the number of products increased by more than two-fold after the declaration of COVID-19.¹⁷

Consumers’ increased demand has affected the dietary supplement industry, and advertising and other promotional activities (such as social media marketing and product training) have also affected consumer tendencies. Zhao and Besnyat emphasized the surge of health information seeking on social media during the pandemic.⁵¹ Correspondingly, participants underlined that social media served as a channel to spread information and influence individuals’ product choices^. Similarly, Mukkattash et al. and Alyami et al. revealed that recommendations from social media greatly affected the embracing of dietary supplements in COVID-19.^14,16 In addition, studies have shown that consumer interests and advertisement strategies have differed during the pandemic, and COVID-19 has increased consumer interest in messages about dietary supplements.⁵² Okuhara et al., reported an increase in dietary supplement advertisements in newspapers in Japan. Preventing infection appeared as a common claim next to claims about joint and digestive functions.⁵³ Respectively, participants expressed that the demand for the product increased with advertisements, and they highlighted the influential effects of the advertorials on television.

Together with advertising messages and online sources, recommendations from health professionals also shaped dietary supplement use.⁵⁴ Pharmacists served as accessible and affordable health care professionals during the pandemic.²⁷ Patient counseling remained the main duty of the pharmacist along with drug information.²¹ The increased demand for dietary supplements and the uncertainty of COVID-19 have resulted in an increase in the counseling needs of pharmacists. Notably, one participant noted that the shift to self-medication made pharmacists the first consultant. Similarly, Kharaba et al. showed that counseling on dietary supplements was one of the top areas for pharmacists during the pandemic.⁵⁵ Yet, social distancing and other physical protective measures affected patient-pharmacist interaction. Koster et al. showed that patient-pharmacist interactions are disrupted due to physical barriers, and patients tend to ask fewer questions.⁵⁶

Even though studies have shown that the main source of information on dietary supplements is health care professionals, the effects of other resources such as advertisements and the internet are substantial.^16,57
–59 In addition to active monitoring and regulative improvements, public awareness should be established to overcome the issues of dietary supplement use, such as misinformation, abuse, unsafe purchasing, efficacy, and safety of products. Likewise, Daher et al. emphasized that educational activities for different groups could raise public awareness of the use of dietary supplements.⁶⁰ Particularly, participants emphasized the educational activities considering public awareness of the risks of dietary supplement use.

The widespread use of dietary supplements raises a question about the regulatory framework around the world.^12,61

–64 Even these products’ definitions differ from country to country.¹² Starting from the definition, the global consensus is still not structured on the categories of these products. This gap in legislative systems brings a gray area to marketing actions.⁶¹ False or misleading information on dietary supplement advertisements has been reported in the existing literature.^65

–68 In contrast to pharmaceuticals, dietary supplement advertisements are not prohibited in Türkiye. However, comparative advertisements for dietary supplements are forbidden, and slight restrictions are effective for labeling, packaging, and advertisements. Regulation of dietary supplement advertising remains limited by health claims and comparisons.^69,70 Yet, false claims or misleading labels could pose a threat to public health. Crawford et al. showed that claims of dietary supplements for brain health have not been evidence-based.⁷¹ Therefore, effective and strict regulations should be enacted, and health claims should be subjected to stricter rules, such as pharmaceuticals.⁶⁷

Limitations

Although studies on dietary supplement use in Türkiye during the pandemic are diminished, this study had some limitations. First, the dietary supplement as a term is broad and its scope differs from country to country, we prefer the “dietary supplement” as a term to ensure uniformity in the study. In addition, document search was conducted using the official legislation database. Yet, the database search algorithm is not incisive, and the number of search results was high in numbers. In the second phase of the study, participants were recruited from a specific population based on their profession using snowball sampling. The focus on alterations during COVID-19, as a consequence of the aim of this study, may narrow the responses. This may limit the generalizability of the results. Moreover, the research design was not suitable for exploring the effects of population size on consumers. Therefore, quantitative studies should be conducted to integrate the results of all stakeholders. However, participants recruited from different professions with different backgrounds related to dietary supplement use facilitated an exploration of the situation from a broader perspective. Besides, the sales report of dietary supplements in Türkiye is not accessible. Hence, it was not possible to compare between years in terms of sales data.

Conclusions

This study showed elevated use of dietary supplements during the pandemic, accompanied by fear, uncertainty, and promotional activities, from the perspective of participants. The increasing use of these products has led to a surge in information needs during the pandemic. Information demand has resulted in a variety of sources such as social media and health care professionals. As health care professionals, pharmacists play a crucial role in counseling patients as an information source in counseling patients. However, the increased use of dietary supplements raises questions regarding the safety of these products, as they have the potential to lead to adverse reactions. Less stringent regulations, unregulated alternative advertising channels, and lack of awareness of dietary supplements pose a challenge to public health. In light of these, stakeholders, from undergraduate education to professional life, have to put effort into raising awareness of the rational and safe use of dietary supplements.

Footnotes

Acknowledgments

The authors thank all participants for their answers and contributions.

Authors’ Contributions

L.Y.: Conceptualization (equal), data curation (lead), methodology (lead), formal analysis and investigation (equal), writing—original draft preparation (lead), writing—review and editing. B.S.Ş.: Conceptualization (equal), data curation (equal), methodology (equal), formal analysis and investigation (equal), writing—review and editing (equal). İ.S.: Conceptualization (equal), funding acquisition (lead), supervision, writing—review and editing (equal). S.Y.: Conceptualization (lead), funding acquisition (lead), methodology (equal), supervision, writing—review and editing (lead).

Author Disclosure Statement

The authors declare no conflict of interest.

Funding Information

This study was supported by Hacettepe University Scientific Research Coordination Unit (Project Number: THD-193350).

Supplementary Material

Supplementary Data S1

References

Shrestha

, Shad

, Ulvi

, et al. The impact of COVID-19 on globalization. One Health, 2020; 11:100180; doi: 10.1016/j.onehlt.2020.100180

Meyer

, Prescott

, Sheng

. The impact of the COVID-19 pandemic on business expectations. Int J Forecast, 2022; 38(2):529–544; doi: 10.1016/j.ijforecast.2021.02.009

Addo

, Jiaming

, Kulbo

, et al. COVID-19: Fear appeal favoring purchase behavior towards personal protective equipment. Service Industries J, 2020; 40(7–8):471–490; doi: 10.1080/02642069.2020.1751823

Olapegba

, Chovwen

, Ayandele

, et al. Fear of COVID-19 and preventive health behavior: Mediating role of post-traumatic stress symptomology and psychological distress. Int J Ment Health Addict, 2022; 20(5):2922–2933; doi: 10.1007/s11469-021-00557-4

Radwan

, Hasan

, Jaafar

, et al. Diets and dietary supplements used during the COVID-19 pandemic in the United Arab Emirates: A cross-sectional survey. Saudi Pharm J, 2022; 30(4):421–432; doi: 10.1016/j.jsps.2022.01.019

Norton

, Politis

, Bimali

, et al. Analysis of COVID-19 Pandemic on supplement usage and its combination with self-medication within the state of Arkansas. J Diet Suppl, 2023; 20(2):171–198; doi: 10.1080/19390211.2022.2128500

Chiba

, Tanemura

. The prevalence of dietary supplement use for the purpose of COVID-19 Prevention in Japan. Nutrients, 2022; 14(15):3215; doi: 10.3390/nu14153215

European Parliament and of the Council. Directive 2002/46/EC. 2002. Available from: https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:32002L0046 [Last accessed October 1, 2023 ].

Ministry of Agriculture and Forestry. Türk gida kodeksi takviye edici gidalar tebliği [Turkish Food Codex Food Supplement Declaration]. Resmi Gazete [Official Gazette]; 2013. Available from: https://www.resmigazete.gov.tr/eskiler/2013/08/20130816-16.htm [Last accessed 0 5, 2022 ].

10.

Ayrancı

, Son

. Prevalence of nonvitamin, nonmineral supplement usage among students in a Turkish university. BMC Public Health, 2005; 5(1):47; doi: 10.1186/1471-2458-5-47

11.

Irmak

, Has

. Changing advertising discourses in the pandemic period: Case of supradyn energy focus. Mediarts Medya ve Sanat Çalışmaları Dergisi, 2023; 5:83–104; doi: 10.13140/RG.2.2.10966.52809

12.

Binns

, Lee

. Problems and prospects: Public health regulation of dietary supplements. Annu Rev Public Health, 2018; 39(1):403–420; doi: 10.1146/annurev-publhealth-040617-013638

13.

Lordan

. Dietary supplements and nutraceuticals market growth during the coronavirus pandemic—Implications for consumers and regulatory oversight. PharmaNutrition, 2021; 18:100282; doi: 10.1016/j.phanu.2021.100282

14.

Alyami

, Orabi

MAA

, Aldhabbah

, et al. Knowledge about COVID-19 and beliefs about and use of herbal products during the COVID-19 pandemic: A cross-sectional study in Saudi Arabia. Saudi Pharm J, 2020; 28(11):1326–1332; doi: 10.1016/j.jsps.2020.08.023

15.

Louca

, Murray

, Klaser

, et al. Modest effects of dietary supplements during the COVID-19 pandemic: Insights from 445 850 users of the COVID-19 symptom study app. BMJ Nutr Prev Health, 2021; 4(1):149–157; doi: 10.1136/bmjnph-2021-000250

16.

Mukattash

, Alkhalidy

, Alzu’bi

, et al. Dietary supplements intake during the second wave of COVID-19 pandemic: A Multinational Middle Eastern study. Eur J Integr Med, 2022; 49:102102; doi: 10.1016/j.eujim.2022.102102

17.

Ministry of Agriculture and Forestry. Onaylı takviye edici gidalar listesi [Approved Dietary Supplement List]. 2023. Available from: https://ggbs.tarim.gov.tr/cis/FSIS/ggbs.takviyeGidaSorgu.html [Last accessed: May 23, 2022].

18.

, Nguyen

, Beydoun

, et al. Demand for Health Information on COVID-19 among Vietnamese. Int J Environ Res Public Health, 2020; 17(12):4377; doi: 10.3390/ijerph17124377

19.

Sulistyawati

, Rokhmayanti

, Aji

, et al. Knowledge, Attitudes, Practices and information needs during the COVID-19 pandemic in Indonesia. Risk Manag Healthc Policy, 2021; 14:163–175; doi: 10.2147/RMHP.S288579

20.

, Zheng

. Online information seeking and disease prevention intent during COVID-19 outbreak. Journalism & Mass Communication Quarterly, 2022; 99(1):69–88; doi: 10.1177/1077699020961518

21.

Visacri

, Figueiredo

, Lima

TDM

. Role of pharmacist during the COVID-19 pandemic: A scoping review. Res Social Adm Pharm, 2021; 17(1):1799–1806; doi: 10.1016/j.sapharm.2020.07.003

22.

Tsao

S-F

, Chen

, Tisseverasinghe

, et al. What social media told us in the time of COVID-19: A scoping review. Lancet Digit Health, 2021; 3(3):e175–e194; doi: 10.1016/S2589-7500(20)30315-0

23.

Bou-Saba

, Kassak

, Salameh

. Public views of community pharmacy services during the COVID-19 pandemic: A national survey. J Pharm Policy Pract, 2022; 15(1):76; doi: 10.1186/s40545-022-00474-4

24.

Jovičić-Bata

, Pavlović

, Milošević

, et al. Coping with the burden of the COVID-19 pandemic: A cross-sectional study of community pharmacists from Serbia. BMC Health Serv Res, 2021; 21(1):304; doi: 10.1186/s12913-021-06327-1

25.

Hijazi

, Shatila

, Abu Qiyas

, et al. Complementary and alternative medicine use during the COVID-19 pandemic: Community pharmacists’ knowledge, attitudes, and practices. Res Social Adm Pharm, 2023; 19(3):502–509; doi: 10.1016/j.sapharm.2022.10.009

26.

Sridhar

, Rabbani

. Pharmaceutical care services provided by pharmacists during COVID-19 pandemic: Perspectives from around the World. Journal of Pharmaceutical Health Services Research, 2021; 12(3):463–468; doi: 10.1093/jphsr/rmab017

27.

Karout

, Khojah

HMJ

, Itani

, et al. Assessing the pharmaceutical care provision to suspected COVID-19 patients in community pharmacies: A simulated patient study. BMC Health Serv Res, 2022; 22(1):467; doi: 10.1186/s12913-022-07870-1

28.

Molin

TRD

, Leal

, Muratt

, et al. Regulatory framework for dietary supplements and the public health challenge. Rev Saude Publica, 2019; 53:90; doi: 10.11606/s1518-8787.2019053001263

29.

Singh

, Eshaghian

, Chuang

, et al. Do diet and dietary supplements mitigate clinical outcomes in COVID-19? Nutrients, 2022; 14(9):1909; doi: 10.3390/nu14091909

30.

Chavda

, Patel

, Vihol

, et al. Herbal remedies, nutraceuticals, and dietary supplements for COVID-19 management: An update. Clin Complement Med Pharmacol, 2022; 2(1):100021; doi: 10.1016/j.ccmp.2022.100021

31.

Liu

, Sun

, Chang

, et al. The impact of the fear of covid-19 on purchase behavior of dietary supplements: Integration of the theory of planned behavior and the protection motivation theory. Sustainability, 2021; 13(22):12900; doi: 10.3390/su132212900

32.

Tong

, Sainsbury

, Craig

. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. Int J Qual Health Care, 2007; 19(6):349–357; doi: 10.1093/intqhc/mzm042

33.

Strauss

, Corbin

. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. Sage Publications: London; 1998.

34.

Glaser

, Strauss

. The Discovery of Grounded Theory: Strategies for Qualitative Research. Aldine Transaction: Mill Walley CA; 1967.

35.

Foley

, Timonen

. Using grounded theory method to capture and analyze health care experiences. Health Serv Res, 2015; 50(4):1195–1210; doi: 10.1111/1475-6773.12275

36.

Harper

, Thompson

. Qualitative Research Methods in Mental Health and Psychotherapy: A Guide for Students and Practitioners. John Wiley & Sons: Malden, MA; 2012.

37.

Poteat

, German

, Kerrigan

. Managing uncertainty: A grounded theory of stigma in transgender health care encounters. Soc Sci Med, 2013; 84:22–29; doi: 10.1016/j.socscimed.2013.02.019

38.

Woods

, Gapp

, King

. Generating or developing grounded theory: Methods to understand health and illness. Int J Clin Pharm, 2016; 38(3):663–670; doi: 10.1007/s11096-016-0260-2

39.

Kanunu

. Cumhurbaşkanlığı idari işler başkanliği hukuk ve mevzuat genel müdürlüğü. Mevzuat Bilgi Sistemi. 2020. Available from: www.mevzuat.gov.tr [Last accessed: November 01, 2022].

40.

Johnson

. Snowball Sampling: Introduction. In Wiley StatsRef: Statistics Reference Online ( Balakrishnan

, Colton

, Everitt

, Piegorsch

, Ruggeri

and Teugels

J.L.

.eds) Wiley online library; 2014; doi: 10.1002/9781118445112.stat05720

41.

Creswell

. Qualitative Inquiry and Research Design Choosing Among Five Approaches. SAGE Publications: Inc, California; 2013.

42.

Charmaz

. Constructing Grounded Theory: A Practical Guide through Qualitative Analysis. Sage Publications: London; 2006.

43.

Kickbusch

, Payne

. Twenty-first century health promotion: The public health revolution meets the wellness revolution. Health Promot Int, 2003; 18(4):275–278; doi: 10.1093/heapro/dag418

44.

Wang

, Neilson

, Ji

. Why and how do consumers use dietary supplements? A systematic review and thematic analysis. Health Promot Int, 2023; 38(1):daac197; doi: 10.1093/heapro/daac197

45.

Sirico

, Miressi

, Castaldo

, et al. Habits and beliefs related to food supplements: Results of a survey among Italian students of different education fields and levels. PLoS One, 2018; 13(1):e0191424; doi: 10.1371/journal.pone.0191424

46.

Conner

, Kirk

SFL

, Cade

, et al. Why do women use dietary supplements? The use of the theory of planned behaviour to explore beliefs about their use. Soc Sci Med, 2001; 52(4):621–633; doi: 10.1016/S0277-9536(00)00165-9

47.

Syed

, Samarkandi

, Sadoun

, et al. Prevalence, Beliefs, and the practice of the use of herbal and dietary supplements among adults in Saudi Arabia: An Observational Study. Inquiry, 2022; 59:469580221102202; doi: 10.1177/00469580221102202

48.

Pajor

, Oenema

, Eggers

, et al. Exploring beliefs about dietary supplement use: Focus group discussions with Dutch adults. Public Health Nutr, 2017; 20(15):2694–2705; doi: 10.1017/S1368980017001707

49.

Naidu

, Pressman

, Clemens

. Coronavirus and Nutrition: What is the evidence for dietary supplements usage for COVID-19 control and management? Nutr Today, 2021; 56(1):19–25; doi: 10.1097/NT.0000000000000462

50.

Eger

, Komárková

, Egerová

, et al. The effect of COVID-19 on consumer shopping behaviour: Generational cohort perspective. Journal of Retailing and Consumer Services, 2021; 61:102542; doi: 10.1016/j.jretconser.2021.102542

51.

Zhao

, Basnyat

. Online information and support seeking during COVID-19 lockdown in Wuhan: Implications for health promotion. Health Promot Int, 2022; 37(3):daac057; doi: 10.1093/heapro/daac057

52.

Uysal

. The relationships among Fear of COVID-19, health consciousness, attitude toward supplements, and purchase intention using a moderated mediation analysis. Eskişehir Osmangazi Üniversitesi İktisadi ve İdari Bilimler Dergisi [2023; 18(1):145–161; doi: 10.17153/oguiibf.1233783Eskişehir Osmangazi University Journal of Economics and Administrative Sciences

53.

Okuhara

, Yokota

, Shirabe

, et al. Japanese newspaper advertisements for dietary supplements before and after COVID-19: A content analysis. BMJ Open, 2021; 11(11):e050898; doi: 10.1136/bmjopen-2021-050898

54.

Ayer

, Celep

AGS

. Assessment of dietary habits and use of nutritional supplements in COVID-19: A Cross-Sectional Study. PharmaNutrition, 2022; 22:100309; doi: 10.1016/j.phanu.2022.100309

55.

Kharaba

, Moutraji

, Al Khawaldeh

, et al. What has changed in the pharmaceutical care after COVID-19: Pharmacists’ perspective. Pharm Pract (Granada), 2022; 20(2):2656–2608; doi: 10.18549/PharmPract.2022.2.2656

56.

Koster

, Philbert

, Bouvy

. Impact of the COVID-19 epidemic on the provision of pharmaceutical care in community pharmacies. Res Social Adm Pharm, 2021; 17(1):2002–2004; doi: 10.1016/j.sapharm.2020.07.001

57.

Mohsen

, Yazbeck

, Al-Jawaldeh

, et al. Knowledge, Attitudes, and Practices related to dietary supplementation, before and during the COVID-19 pandemic: Findings from a Cross-sectional survey in the Lebanese population. Int J Environ Res Public Health, 2021; 18(16):8856; doi: 10.3390/ijerph18168856

58.

Mason

, Narcum

, Mason

. Social media marketing gains importance after Covid-19. Cogent Business & Management, 2021; 8(1):1870797; doi: 10.1080/23311975.2020.1870797

59.

Wahab

MSA

, Jalani

, Goh

, et al. Why did i consult my pharmacist about herbal and dietary supplements? An online survey amid the COVID-19 pandemic in Malaysia. Int J Environ Res Public Health, 2022; 19(17):10994; doi: 10.3390/ijerph191710994

60.

Daher

, El Khoury

, Dwyer

JJM

. Education interventions to improve knowledge, beliefs, intentions and practices with respect to dietary supplements and doping substances: A narrative review. Nutrients, 2021; 13(11):3935; doi: 10.3390/nu13113935

61.

Dwyer

, Coates

, Smith

. Dietary supplements: Regulatory challenges and research resources. Nutrients, 2018; 10(1):41; doi: 10.3390/nu10010041

62.

Starr

. Too little, Too late: Ineffective regulation of dietary supplements in the United States. Am J Public Health, 2015; 105(3):478–485; doi: 10.2105/AJPH.2014.302348

63.

Petroczi

, Taylor

, Naughton

. Mission impossible? Regulatory and enforcement issues to ensure safety of dietary supplements. Food Chem Toxicol, 2011; 49(2):393–402; doi: 10.1016/j.fct.2010.11.014

64.

Djaoudene

, Romano

, Bradai

, et al. Global overview of dietary supplements: Regulation, Market trends, Usage during the COVID-19 pandemic, and health effects. Nutrients, 2023; 15(15):3320; doi: 10.3390/nu15153320

65.

Muela-Molina

, Perelló-Oliver

, García-Arranz

. False and misleading health-related claims in food supplements on Spanish radio: An analysis from a european regulatory framework. Public Health Nutr, 2021; 24(15):5156–5165; doi: 10.1017/S1368980021002007

66.

Temple

, Wilson

, Jacobs

, (eds). Nutritional Health: Strategies for Disease Prevention. Humana Press: Totowa, NJ; 2012.

67.

Fontanarosa

, Rennie

, DeAngelis

. The need for regulation of dietary supplements—Lessons from Ephedra. The Journal of the American Medical Association, 2003; 289(12):1568–1570; doi: 10.1001/jama.289.12.1568

68.

Wierzejska

, Wiosetek-Reske

, Siuba-Strzelińska

, et al. Health-related content of tv and radio advertising of dietary supplements—analysis of legal aspects after introduction of self-regulation for advertising of these products in Poland. Int J Environ Res Public Health, 2022; 19(13):8037; doi: 10.3390/ijerph19138037

69.

Ministry of Health. Beşerî tibbi ürünlerin tanitim faaliyetleri hakkinda yönetmelik [Regulation on License Authorization of Medicinal Products for Humans]. Resmi Gazete [Official Gazette]; 2015. Available from: https://www.resmigazete.gov.tr/eskiler/2015/07/20150703-2.htm [Last accessed: November 6, 2022 ].

70.

Ministry of Health. Sağlık beyani ile satişa sunulan ürünlerin sağlik beyanlari hakkinda yönetmelik [Regulation on Health Claims of Products Offered for Sale with Health Declaration]. Resmi Gazete [Official Gazette]; 2013:. Available from: https://www.resmigazete.gov.tr/eskiler/2013/06/20130607-11.htm [Last accessed: November 6, 2022 ].

71.

Crawford

, Boyd

, Avula

, et al. A public health issue: Dietary supplements promoted for brain health and cognitive performance. J Altern Complement Med, 2020; 26(4):265–272; doi: 10.1089/acm.2019.0447

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