Usage of nutritional supplements and its side effects among gym goers in Pune

Bhavika Singhvi, Devaki Gokhale. Usage of nutritional supplements and its side effects among gym goers in pune. Cardi- ometry; Issue 20; November 2021; p. 151-159; DOI: 10.18137/ cardiometry.2021.20.151159; Available from:

The supplement market has become a big business all over the world. Its consumption has increased up to 51% in the US. The estimates for 2016 include $41.1 billion in sales with 6% growth. The focus on living a healthy lifestyle, being physically fit is growing with time. This can be achieved easily through supplements. The ease in availability of supplements indicates the unreasonable population being reliable on dietary supplements, especially protein-based products reported by Global sports Nutrition Supplement Industry[1]. The amount of population searching for protein-rich food items has increased from 2006 to 2014 by 14%.

According to Dietary Supplement Health and Education Act (DSHEA), a dietary supplement includes one or more of the following ingredients: vitamin, mineral, herb or botanical, amino acids, concentrate, metabolite, constituent, and/or extracts[2]. The American Dietetic Association states that only individuals with poor dietary intake who are on severe dietary regimes or eliminate few foods items from their diets may require supplementation. Despite these guidelines, the usage of supplements is high in both athletes and people who exercise daily[3].

Survey results have shown that dietary supplements have been taken for various advantages related to exercise, physical, mental strength, immunity, treating diseases, or health-related issues.) In short, they give “miraculous” or “magical” results, which attract con-sumers[4]. In addition to these advantages, there is also much influence by media and the role models for better physic. The users constantly contact advertisements in glossy magazines and on the internet, which has led to increased consumption of dietary supplements[5].

The reasons for consumption have been attributed earlier; however, the usage of supplements is not devoid of potential hazards. There are still various misconceptions regarding the use of dietary supplements among individuals[6]. The irrational use of nutritional supplements carries several health risks; hypertensive reaction, gastrointestinal disturbance, depression.

Nevertheless, consumption of supplements in gym-goers has been high irrespective of its side effects [7]. This can be attributed to the lack of knowledge about the requirements, the amounts to be consumed, and their actual use. The quality control ensuring the supplements to be safe, containing no adulterated or banned substances depends upon the manufacturers of the supplements[8]. There are no strict regulations for it, neither are they well documented.

Lately, India has also witnessed a surge in the number of people attending gyms and fitness centers for achieving a healthy and fit lifestyle[9]. There have been gyms at every corner, and more young adults are following such practices. In recent years, along with an increase in the global market, individual spending capacity has also increased[10]. Thus, people are spending more on supplements. Differences in supplement consumption exist depending upon age, gender, source of information, and aim of exercising. Unfortunately, there is a dearth of evidence suggesting usage and awareness about dietary supplements among the population. Thus, the study on nutritional supplement consumption among gym-goers will bring to light a great deal of information about a topic that has not been researched in this part of the country[11].

Material and Methods

The present study was a cross-sectional study conducted in the city of Pune. The study was approved by the Institute Research Committee (IRC) of Symbiosis School of Biological Sciences (SSBS), and approval by the Independent Ethical Committee (IEC) of Symbiosis International Deemed University was obtained.

Selection of samples

The participants taken from 10 different gyms were of both genders from age 18-40 years. The inclusion criteria were: the participants should come to the gym at least four times a week and consuming any of the supplements. Athletes, sports persons, trainers, and health professionals were excluded from the samples. A random sampling method was used to enroll the participants.

The gym-goers were approached, considering the inclusion and exclusion criteria in mind, and explained thoroughly about the study. A short introduction of the researcher was given in the beginning to each participant[12]. The study objective was explained through the subject information sheet and 152 | Cardiometry | Issue 20. November 2021

in–person. The subjects were then provided with informed consent, those who voluntarily agreed to participate in the study.

Selection of gyms

The participants were collected from the gyms situated in the different areas of Pune. A map of the city was taken and divided into five different geographic locations (North, East, South, West, and Central). The selection of gyms was random and as per the permissions given. Before the commencement of the study, official permissions were taken from different gyms. The managers or floor-in-charge were contacted for permission[13] [29]. Later on, senior authorities were approached for the permissions. Those who granted them permission to collect the data were included in the study.

Sample Size

The sample size was calculated considering 95% level of significance, 84% proportion of picking a choice, and 0.05 as the degree of precision. The estimated sample size was n = 246, but due to personal reasons, those who withdrew or could not complete the questionnaire; the data was then available for 121 participants[14].

Questionnaire

A structured self-designed questionnaire included domains regarding the demographics, physical activity, supplements use, and side effects. Questions concerning age, gender, educational qualifications, income came under the demographic characteristics of the participants. The type, frequency, and purpose of exercising, time since they started coming to the gym, and hours spent per day at the gym were also included[15]. Lastly, it included types, dosage, and frequency, source of information, access, and side effects of supplement consumption. A pilot study was conducted to check the efficacy of the questionnaire in 4 different gyms for 30 participants[16].

The limitations were corrected, and a final questionnaire consisting above domains was used for the main study. The data was collected via an interview method involving one-to-one interaction with the participants. The researcher was present while filling the questionnaire to provide help. At a time, two people were approached. Each participant required 10 – 15 minutes to fill the questionnaire. In the end, the questionnaire was checked by the researcher, and missing details were filled in to avoid inconsistencies [17] [20].

Statistical Analysis

Statistical analysis was done by SPSS software (version 20). The normality of data was tested using the Shapiro Wilk test, and Z scores for skewness and kurtosis within ± 2.58 with the p < 0.05 were checked[18]. The data was first entered into excel and then in SPSS to avoid errors. The variables were categorical and appropriate codes were assigned to them[30]. Descriptive statistics were used for identifying percentages, frequencies, and standard deviations of demographic characteristics, supplement usage, and side effects. A Chi-square test was used to identify associations for supplement usage across gender, age group, and physical activity. The significance level was considered at <0.05[19].

Results

Demographic characteristic

The socio-demographic characteristics of the participants are shown in Table 1. Of 121 samples, 96 % were men. The participants mostly consisted of young individuals, with 44.6% falling in the age group 1825 years. All the samples were literate. Most of them were graduates (55.4%), while some were having higher professional degrees (35%). Only 7.5% were at the high school level[21].

Substance abuse

As shown in Table 1, 49.6 % of the supplement users consumed alcohol. This was significantly associated. (p = 0.039). Out of which 38% reported that they drank only once a week that too on weekends. Most participants (68.6%) were non-smokers. Out of the ones who smoked, the majority (24%) smoked 1 – 2 cigarettes a day[22].

Physical Activity

The types of exercises performed by the participants are shown in Table 1. Also, the time since they were exercising in the gyms has been depicted[23]. Out of all the participants, 56.2% performed strength exercises, 9% performed balancing postures, and 33.1% performed a combination of strength, balancing, endurance, and flexibility exercises[24]. The time spent by the participants at the gym varied: 59% of individ-

Table 1

Demographics, types of physical activity, and supplement usage of the participants

Variables Percentage of participants (n) Gender Male Female 79.3(96) 20.7(25) Age 18-25 26-33 >33 44.6(54) 38(40) 17.4(27) Alcohol Yes No 49.6(60) 50.4(61) Smoking Yes No 31.4(38) 68.6(83) Qualifications Profession or honors Graduate Intermediate or diploma High school certificate Middle school certificate 28.9(35) 55.4(67) 8.3(10) 5.8(7) 1.7(2) Type Strength exercises Balance exercises Aerobic/Endurance exercises Flexibility exercises Combination 56.2(68) 7.4(9) 1.7(2) 1.7(2) 33.1(40) Time Period 1 – 3 months 3 – 6 months 6 – 12 months >1 year 17.4(21) 14.0(17) 16.5(20) 52.1(63) Aim Health and fitness Muscle growth Weight gain/Weight loss Improvement in performance Fitness and muscle growth 47.9(58) 33.1(40) 15.7(29) 8(1) 2.5(3) Continued Continuation Duration ( in hours) 1 2 3 4 48.8(59) 45.5(55) 5.0(6) 0.8(1) Dosage of supplements 20 – 40gms 40 – 60 gms 60 – 80 gms >80 gms 54.5(66) 33.9(41) 5.8(7) 5.8(7) Duration of consumption Quarterly Half-yearly Yearly More than one year 38.8(47) 16.5(20) 3.1(11) 35.5(43) Form of supplements Powder Capsules Pills, powder, and capsules Powders and pills Powders, pills, capsules, and drinks 81(98) 2.5(3) 7.4(9) 5.0(6) 4.1(5) uals spent 1 hour at the gym, and 55% spent 2 hours. The participants who were coming to the gym for more than one year comprised 52%[25]. They joined the gym for the following reasons: health and fitness (47.9%), muscle growth (33.1 %), and weight gain or weight loss (15.7%) which was significant. (Table 2)

Table 2

The reason for exercising in the participants consuming supplements by gender

Aim	Percentage of supplement users		Chisquare value (χ2)
	Male %(n)	Female %(n)
Health and fitness	42.7 %(41)	68%(17)	8.286*
Muscle growth	38.5%(37)	12%(3)
Weight gain/weight loss	14.6(14)	20%(5)
Health and Muscle growth	4.2% (4)	0%(0)

*p = <0.05

Use of Supplements

The participants in the study reported a total of 13 products that were used as supplements in one form or another [26]. The list of the type of supplements consumed is given in Table 3. The five most common types of supplements consumed were: Protein powders (97.5%), Branched-chain amino acids (43%), Multivitamins (32%), Antioxidants (27.3%), and B- complex (16.5%), as shown in Figure 1. Men consumed more amounts of supplements than women. The majority of the participants consumed 20-40 gms of supplements (54.5%). The powder form of supplements was majorly n = 98(81) used, as shown in Table 1. Others took a combination of powders, pills, capsules, and sports/ energy drinks. Multiple brand choices were found among the participants [27]. Almost half of the population spent 1 – 5 k on the supplements. Only a few were spending more than 20 k per month (data not shown). 39% of the individuals started consuming supplements in the initial three months of joining the gym [28]. Thus, Table 4 depicts that individuals who exercised in the gym for longer time periods tend to consume supplements and that too in higher dosages. (χ2= 58.621, p = 0.000; χ2 = 26.810, p = 0.002)

Supplement consumption on the basis of gender

Men took more supplements than women (Table 5). None of the women reported consuming glutamine 154 | Cardiometry | Issue 20. November 2021

Table 3

Different categories of supplements used by the participants

Antioxidants- Vitamin C,E	ZINC
Beta-Alanine	Coenzyme Q10
Chromium	Creatine
Tyrosine	Ephedra
Glutamine	L- Arginine
L- creatine	Melatonin
Multivitamin	Question
Anabolic Compounds	Sports drinks
Sports gels	Energy Drinks
B complex	Protein bars
BCAA	Protein powders

Figure 1. Different types of supplements were reported by the participants

(p = 0.023) since it is involved in muscle growth which is the aim of the male population. Similarly, BCAA was consumed mostly by men (52.1%). Only 8% of women reported consuming BCAA. (p = 0.000) Though there wasn’t a significant association found in the consumption of protein powders, multivitamins, and others, their consumption was higher in men than women.

Supplement consumption on the basis of age groups

The association of supplement usage amidst different age groups is shown in Table 5. For comparative reasons, the age group was divided into 18-25, 26-33, and >33 years old. It was found out that supplements were mostly consumed by the younger participants. (18 – 25 years). Among all the supplements, B- complex (p = 0.020), BCAA (p =0.042) was significantly associated with age group.

Table 4

The dosage and time period of consumption of the participants with their period of exercising in the gym

Time since started exercising (in months)	Time since they are consuming supplements ( in months)				ChiSquare ( χ2)	Dosage of supplements consumed (in gms)				ChiSquare ( χ2)
	<3	< 6	< 12	>12		20 – 40	40 – 60	60 – 80	>80
1 – 3 % (n)	34 (16)	15 (3)	9.1 (1)	2.3 (1)	58.621*	80.9 (38)	17 (8)	2.1 (1)	0 (0)	26.810*
3 – 6 % (n)	25.2 (12)	25 (5)	0 (0)	0 (0)		40 (8)	50 (10)	5 (1)	5 (1)
6 – 12 % (n)	21.3 (10)	20 (4)	36.4 (4)	4.7 (2)		36 (4)	54.5 (6)	0 (0)	9.1 (1)

*p = <0.05

Table 5

Сonsumption of different types of supplements with respect to gender and age*p = <0.05, **p = <0.01

Type of supplement	Gender		Chi-square value ( χ2)	Age group (in years)			Chi-square value ( χ2)
	Male	Female		18- 25	26 – 33	>33
Glutamine Yes No % (n)	17.7(17) 82.3(79)	0(0) 25(100)	5.151*	47.1(8) 44.2(46)	35.3(6) 38.5(40)	17.6(3) 17.3(18)	0.066
BCAA Yes No % (n)	52.1(50) 47.9(46)	8(2) 92(23)	15.729**	32.7(17) 53.6(37)	50(26) 29(20)	17.3(9) 17.4(12)	6.356*
Protein Powder Yes No % (n)	96.9(93) 3.1(3)	100(25) 0(0)	0.801	45.8(54) 0(0)	36.6(37) 3(100)	17.8(21) 0(0)	5.016
B- complex Yes No % (n)	16.7(16) 83.3(80)	16(4) 84(21)	0.006	20(4) 49.5(50)	45(9) 36.6(37)	35(7) 13.9(14)	7.862*
Multivitamin Yes No % (n)	35.4(34) 64.6(62)	20(5) 80(20)	2.158	25.9(14) 74.1(40)	42.5(17) 57.5(23)	29.6(8) 70.4(19)	2.998

Access to supplements

The access to supplements was majorly n = 68(57) through stores. The rest of them preferred either gyms (15.7%) or online (18.2%) or medical shops (3.3%). It is evident from Figure 2 that medical shops were the last chosen option to buy supplements.

Source of supplement information

Half of the population (51.2%) took advice from trainers before taking supplements (Figure 3). Unfortunately, only a small percentage (9.9%) took professional advice from dieticians. The participants also self-prescribed themselves (22.3%). Uncertain and convenient sources such as friends, family, or fellow

Figure 2. Access to supplements

Figure 3. Source of information among supplement users

mates (12.4%) were also the source of information for the participants.

Side effects

The side effects (Figure 4) associated with the use of supplements were reported by the participants. The side effects reported were abdominal pain, abdominal bloating, cramps (p=0.015), nausea ( p = 0.087), Vomiting, headache, dizziness, feeling of fullness, and few others. However, the majority of them did not experience any side effects or said that the use of supplements did not have any.

Figure 4. The percentage of participants experiencing any of the side effects

Discussions

The objective of the study is to find the intake of nutritional supplements among the people exercising in the gym. This is one of the first studies done in this area of the country. There is scanty information available on the patterns, usage, and consumption of the supplements, especially in India. There are studies published worldwide in this domain (Khoury, 2012; Morrison, 2004; Lacerda, 2015; Saleh, 2015; Alsham-mari, 2017; Goston, 2010; Attlee, 2018, Bianco, 2011, 2014). However, most of the studies on supplement usage focus on the athletic or sports individuals who form the major percentage of it (Knapik, 2016; Al-jaloud, 2013; Wilson, 2016; Rockwell, 2001; Huang, 2006). The requirement of the body is increased due to high-intensity physical activities done in various sports; thereafter, the metabolic requirements also increase. Hence, this constitutes the foremost category of supplement users. Another important category of supplement users is Gym goers. Few studies conducted in other parts of the country focus on a similar theme (Malik, 2010; Karthik, 2017).

In the present study, several gyms were approached from 5 zones of the city, and those who voluntarily agreed were enrolled in the study. Socio-demographic characteristics of the participants were calculated using the Kuppuswamy scale, which included details about their age, gender, educational qualifications, income, and substance abuse. The present study population consuming supplements was more with a degree of graduates or diploma. There are similar findings from a study done in Brazil wherein the participants at least held a high school certificate or were college graduates. Another study done in the same locale showed 69.9% of participants had completed their high school. Socioeconomic status is also a factor of supplement consumption among individuals. Population belonging to low socioeconomic status tends to compromise on the quality of supplements and food. On the other hand, high socioeconomic class people have a greater purchasing capacity to buy good quality products.

The BMI score (WHO, 2004) fell in the normal range for the majority of the participants. The probable reason for this can be health consciousness and the period since they are into exercising. The aim of females found in other studies included fitness, toning their body, general health benefits, while the males were more interested in leaner bodies, muscle growth, bodybuilding, and enhancement in performance. Similar results were found in this study wherein females (68%) were more diverted towards health and fitness, and males (37%) were interested in muscle growth and improvement in performance. The results were statistically significant. (χ2=8.286, p = 0.040)

Supplement consumption patterns differ by gender, age, purpose, and duration of exercise. It has been consistently shown that the male population tends to consume more supplements than the female population. The present study found the consumption of Glutamine, BCAA in male participants. Glutamine has a role in the oxidative metabolism of the body. Its supplementation leads to an increase in VO2 response time and an increase in muscle oxygen uptake. It also preserves phosphocreatine and glycogen in the fibers of the muscle, which depicts its role in aerobic exercises. These types of results reflect the use of these supplements in bodybuilding or muscle growth, hence more commonly consumed by males. Other supplements did not correlate with gender. On the contrary, studies prove the consumption of protein powders is higher in males while consumption of vitamins and minerals is higher in females. This is due to the effects they produce on the bodies. Many investigators have reported that protein is the most used ergogenic supplement. This is clear because of its role in muscle building and other metabolic mechanisms. The present study also found out that the consumption of protein powders by 97% of the participants but was not statistically significant, possibly due to the small sample size. It has been suggested that the requirements of protein increase either in special circumstances or for athletes. Individuals who exercise regularly can easily fulfill their requirements by consuming wholesome, nutritious meals or following a well-balanced diet. There is no requirement for supplementation in such populations.

The percentage of supplement consumption was found higher in younger age groups than older adults. There are similar findings in the present study as well. Other studies like one done in Belo Horizonte also showed higher percentages amidst the population younger than 30.

Anabolic steroids have been relatively used by athletes in sports. Studies reveal that they have an effect on protein synthesis in muscles and neural changes in the brain. The results are contradictory. In the current study, only two subjects reported consuming these. There can be under-reporting of this. Generally, people do not openly report regarding anabolic steroids or about their diets. This study did not find a significant association of consumption of antioxidants and multivitamins within respective age groups. This is contradictory to other studies which got a significant association of antioxidants, natural supplements, and protein powders to the age group of 20 – 30 years. In another study, it was proved that multivitamins and mineral supplements are consumed more in the older population than younger ones.

The participants who have been exercising for a longer duration tend to consume supplements in higher dosages (Table 4). This can be due to increased interest in a healthy body, sports activities, to be in that environment for a longer duration which has a greater impact on one’s mind. Moreover, the trainers, coaches, and fellows with good bodies influence them to consume supplements. This study highlights those findings wherein the participants (34%) are found to start consuming supplements immediately the time they join the gym.

As the period of exercising in the gym increases, the dosage of the supplement also increases (Table 4). This can probably be because of a plateau that is attained in the body. To break the plateau, individuals tend to consume more supplements to get the leaner cuts or increase the muscle mass in the body. The individuals opt for supplements since they feel they are experienced enough now and linger for better bodies which resort them to consume dietary supplements. Also, long durations of exercise lead to increased muscle hypertrophy, which cannot be attributed to supplement use by the population. Another study by Sao Paulo found a similar association with periods of exercising and increasing supplement use.

European Journal of sports mentions the scientific researches stating that people belonging to different locations, different backgrounds have varied opinions about supplements and proper dietary habits. This can also be due to underreporting or over-reporting by the individuals.

In spite of people being aware of the potential side effects caused by supplement consumption, people continue to consume them. The results from various studies reflect that a greater percentage of people were unaware of side effects caused by supplement consumption. Consumption of high doses of supplements can cause potential adverse outcomes. In spite of knowing such outcomes, people continue to consume supplements in the illusion of “magical” results they produce. The participants in the study reported various self-perceived side effects. Maximum numbers of individuals are not aware of the adverse side effects of excess consumption of supplements. They primarily report digestive issues and are not aware of long-term side effects.

The media have been quite influential in the supplement industry. The advertisements put upon such platforms have a major impact on the population. Internet and self-prescribed supplements accounted for a major percentage. Guston reported 55% of participants consumed supplements without any guidance from health professionals. Only 12.8% consulted dieticians before taking supplements. Other sources like magazines, posters, pamphlets, advertisements, friends, the family were considered as major sources. A study by Bianco in Italy in 2011 showed that fitness instructors were a major source (37%) of information for gym-goers. Individuals do not consult any health professional regarding the information of supplements. Either they self-prescribe or consult their trainers or coaches.

The present study shows half of the participants consulted their trainers. Only a small percentage consulted dieticians before consuming supplements. The reason for this could be the extra money they have to put in to consult a dietician. Apart from that, people also have to invest more time in such consultations. It takes a longer time to get those results which they get easily from supplements in a very short duration of time. It was found out that the participants had incomplete knowledge about nutrients found in foods. They researched on Google and start following it without any scientific evidence or guidance from health professionals.

Conclusion

In conclusion, Supplements have long been appealing to athletes. Also known to enhance workout performance, muscle strength, weight growth, or loss. The irrational usage of supplements has caused numerous adverse effects. There is a lack of research and understanding about dietary supplements. Cross-sectional research was performed with 121 randomly selected participants from 5 distinct metropolitan zones. A good number of people who exercise regularly at gyms consume dietary supplements without taking any professional expertise. Due to lack of data, the long-term side effects of over intake of supplements are not known. Supplementation must be given in cases of poor diets or diseased conditions, which is possi- 158 | Cardiometry | Issue 20. November 2021

bly not the case with gym-goers. Irrational use of supplements can lead to various health-related problems. Also, these over-the-counter drugs are easily available in the markets, which poses a serious concern in their regulation. Hence the study reflects upon the irrational use of supplements and recommends further researches in the same area to generate relevant data from the entire country to channelize the sale of supplements.

Statement on ethical issues

Research involving people and/or animals is in full compliance with current national and international ethical standards.

Conflict of interest

None declared.

Author contributions

The authors read the ICMJE criteria for authorship and approved the final manuscript.