Abstract
Osteoporosis results from low bone mass and microstructure and leads to fragility fractures. Nutritional supplements play a vital role in maintaining bone health. However, many people are unaware of the significance of this nutritional supplement, specifically magnesium, in reducing the risk of osteoporosis. Therefore, we aimed to explore the level of knowledge among adults towards osteoporosis and the role of magnesium, their attitudes, and practices towards magnesium supplementation. A cross-sectional study was conducted involving 755 participants aged ≥ 18 years from various regions of Jazan, Saudi Arabia. Data were collected via an online questionnaire using the KAP assessment tool, which consists of 35 questions in Arabic. The tool was validated in a pilot study involving 25 participants. The data were analyzed using the SPSS software. Of the 755 participants (31.8% male and 68.2% female), a moderate level of knowledge was found among participants (53.1%); there was no significant difference between the level of knowledge and sociodemographic characteristics (P-value > .05). Intriguingly, 66.4% of the participants had a positive attitude towards osteoporosis; age groups were statistically significant with overall attitude (P-value = .001). Regarding protective practices against osteoporosis, the findings revealed that 61.7% of participants had a poor practice; the consumption of magnesium, vitamin D, and calcium supplements was not significantly different between males and females (P-value = .710, .219, and .987, respectively). Furthermore, a higher level of awareness and positive attitude of participants were correlated with better practice, with a statistically significant P-value < .001. The results of this study showed that the participants’ level of knowledge was moderate, and a positive attitude towards managing osteoporosis was notable. However, they had poor practices for osteoporosis prevention and management.
Keywords: attitude, general practice, knowledge, magnesium, osteoporosis
1. Introduction
Osteoporosis, a common skeletal disorder linked to aging, is characterized by a reduction in bone mineral density, deterioration of bone microarchitecture, and elevated susceptibility to fragility fractures.[1] Osteoporosis and fractures are becoming major health concerns as more people age.[2,3] It is considered to be one of the most prevalent bone diseases and can affect individuals of all sexes and races. In particular, postmenopausal women and older persons are more likely to suffer from it, leading to serious secondary health issues or even death.[4] Worldwide, over 200 million people are believed to have osteoporosis, which results in more than 8.9 million fractures annually.[5] Globally, every 3 seconds, 1 in 3 women and 1 in 5 men experience a fragility fracture that necessitates a hospital visit.[6] According to a report, osteoporosis is prevalent among adults in Saudi Arabia aged 50 to 79 years, affecting approximately 34% of women and 30.7% of men.[7]
In Saudi Arabia, the most recent systematic review on osteoporosis outcomes found that in 2019, there were a total of 174,225 osteoporosis-related fractures, which resulted in an estimated economic burden exceeding 2.3 billion Saudi riyals.[8] Osteoporosis risk of osteoporosis significantly increases with age, particularly among elderly and postmenopausal women. This heightened risk often goes undetected as bone loss progresses silently and gradually, without overt signs or symptoms, until fractures manifest. Osteoporosis often remains undiagnosed until fragility fractures occur, owing to its asymptomatic nature. As such, the primary focus of osteoporosis prevention has shifted towards avoiding fragility fractures, leading to an increased interest in preventive measures, especially nutritional interventions, to reduce the incidence of osteoporosis.[4]
Nutritional factors play a pivotal role in bone health, extending beyond the traditional focus on calcium and vitamin D. Recent studies have emphasized the significance of magnesium in bone health, owing to its role as a critical cofactor in the enzymatic processes necessary for bone matrix formation, cell proliferation, and bone mineralization.[9] Furthermore, magnesium deficiency affects vitamin D and parathyroid hormone (PTH) levels, enhancing osteoclast activity, releasing inflammatory cytokines,[9] and reducing markers of bone formation, such as alkaline phosphatase and osteocalcin. This deficiency also disrupts the delicate balance between calcium-regulating hormones, which may lead to hypocalcemia.[4] In Saudi Arabia, demographic shifts indicate a significant rise in the elderly population, specifically individuals aged 60 to 79 years, from 1.96 million in 2018 to an estimated 4.63 million by mid-2030.[10] Moreover, a recent study highlighting the prevalence of vitamin and mineral deficiencies among adults in Saudi Arabia identified a trend of magnesium deficiency in the elderly population.[11]
Without timely preventive interventions such as implementing food-based recommendations and nutritional strategies, the burden of osteoporosis is projected to escalate significantly in Saudi Arabia by 2030. This trajectory not only poses significant health risks to individuals, but also places a substantial strain on the healthcare system.[7] Therefore, this cross-sectional study aimed to explore the level of knowledge, attitude, and practice towards the association between magnesium levels and osteoporosis in Saudi Arabia, aiming to raise awareness of the significance of magnesium in bone health and to advocate for dietary interventions and nutritional supplements to prevent osteoporosis and its associated complications.
2. Materials and methods
2.1. Study design
For this survey, a cross-sectional design was used because it is a descriptive epidemiological study designed to describe the knowledge, attitude, and practice towards osteoporosis and its association with magnesium intake among adults in Jazan, Saudi Arabia.
2.2. Study setting and participants
The study was conducted in the Jazan region, which lies in the southwest corner of Saudi Arabia, on the coast of the Red Sea, directly north of the border with Yemen. The data were collected between January and February 2024.
The targeted population for this survey included all adults older than 18 years from the entire Jazan region (almost exceeding 1 million according to the General Authority for Statistics), selected from the governments in the Jazan region using a convenient sampling technique.
2.3. Eligibility criteria
Participants were included if they were adult male or female individuals aged 18 years or above, able to communicate in Arabic, and willing to participate in the study. Individuals who were unable to provide informed consent or complete the study questionnaire and those not residing in the Jazan region were excluded. Participants were invited to participate in the study through a survey link, and online copies of the questionnaire were distributed through various social media platforms including WhatsApp, Telegram, Twitter, and other similar platforms.
2.4. Sample size
The sample size for this study was determined using the statistical formula n = [(z² × p × q)]/e². The parameters of the formula included n is the sample size, z is the standard normal distribution (1.96 to a confidence level of 95%), p is the anticipated population proportion, q is 1 − p, and e is the margin of error. The anticipated population proportion (p) of the sample is estimated to be 50% because this is the safest choice for (p) because the required sample size is largest when P = 50%. It was assumed that half of the population had relatively low knowledge of osteoporosis and magnesium as well as inadequate dietary magnesium intake. Hence, P = .5. With a 95% confidence level and 5% margin of error, the sample size required for this study was 385, without accounting for the non-response rate. Accounting for a 25% non-response rate, the required sample size was 482.
2.5. Data collection
Data were collected from the participants using a newly developed online questionnaire via a KAP assessment tool after extensive literature consultations. The online questionnaire consisted of 35 questions. The questionnaire was in Arabic and categorized into 5 sections. Section 1 explains the study and obtains the participants’ consent. Section 2 includes 6 questions to obtain sociodemographic information. Section 3 included 12 questions to obtain information about participants’ knowledge. Section 4 includes 6 questions to obtain information about the attitudes of the participants. Section 5 included 11 questions to obtain information about the practice of the participants.
The knowledge scale ranged from 0 to 12 points, attitude scale from 5 to 30 points, and practice scale from 0 to 18 points. The scores were further classified as poor knowledge (scores 0–4), moderate knowledge (scores 5–7), and high knowledge (scores 8–12). Attitude scores were dichotomized into positive scores >24 and negative attitudes <24. The practice scores were also dichotomized into good practice (score > 12) and poor practice (score 0–12).
2.6. Validation of the survey
The survey instrument underwent a robust validation process that was suitable for the context of our study. Initially, the KAP questionnaire was developed based on a thorough review of the relevant literature.
Content validity was established through a review by a panel of local experts (total 3) from the Jazan region, including 2 consultants and research methodologists, who reviewed the clarity, relevance, and cultural appropriateness of the items.
Facial validity was established through pilot testing with 25 adults from different regions in Jazan, who were not included in the final sample. The pilot test assessed comprehension, cultural appropriateness, and the time required for completion. Based on the pilot feedback, minor modifications were made to improve the clarity and cultural relevance of certain items. In the second round, another 25 participants were administered the questionnaire after making changes based on the findings of the pilot study.
The second pilot study yielded a calculated Cronbach alpha (α) value of 0.7, indicating that the internal consistency and reliability associated with the survey instrument were acceptable.
2.7. Statistical analysis
SPSS Statistics (version 26.0, IBM Corp., Armonk) was used to conduct a thorough statistical analysis and to generate descriptive data. Variables were categorized as either categorical or numerical (continuous) based on their nature. Categorical variables included age group, sex, marital status, educational level, residence (town or village), prior diagnosis of osteoporosis, knowledge level (poor, moderate, high), attitude (positive, negative), and practice level (poor, good). These were presented as frequencies and percentages. Numerical variables included the scores of knowledge, attitudes, and practice. No inferential analyses were conducted on the raw numerical scores; therefore, normality testing was not performed. The analysis included both descriptive and comparative statistics to examine the various study factors. In the analysis, significance tests were applied, including the chi-square test to determine the association between KAP towards osteoporosis, and magnesium intake. Statistical differences were considered significant if the P-value was <.05.
2.8. Ethical statement
Institutional Review Board Statement: The study was conducted in accordance with the Declaration of Helsinki and was approved by the Standing Committee for Scientific Research in Jazan University (Reference No. REC-45/05/866), with an approval date of December 04, 2023.
Informed consent statement: Participants consented to participate prior to completing the online survey.
3. Results
3.1. Sociodemographic characteristics
A total of 755 completed questionnaires were collected, surpassing the target sample size.
The results in Table 1 show that the majority of participants (301, 39.9%) were between 18 and 29 years of age, followed by those aged 30 to 39 years (205, 27.2%). Females constituted the largest sex group, accounting for 68.2% (515) of the sample. Most participants were married (n = 415, 55.0%), with single individuals accounting for 41.2% (311). In terms of education, a significant proportion held a university degree (417, 55.2%), while 24.4% (184) had completed secondary education. Regarding residence, the majority of participants (398, 52.7%) lived in towns, and 88 (11.7%) had been diagnosed with osteoporosis by a trained health professional.
Table 1.
Background characteristics of the study participants.
| Characteristic | N | % | |
|---|---|---|---|
| Age groups | 18–29 yr | 301 | 39.9 |
| 30–39 yr | 205 | 27.2 | |
| 40–49 yr | 134 | 17.7 | |
| 50–59 yr | 88 | 11.7 | |
| 60 and above | 27 | 3.6 | |
| Sex | Male | 515 | 68.2 |
| Female | 240 | 31.8 | |
| Marital status | Single | 311 | 41.2 |
| Married | 415 | 55.0 | |
| Divorced | 23 | 3.0 | |
| Widowed | 6 | 0.8 | |
| Educational level | Primary and below | 5 | 0.7 |
| Intermediate | 22 | 2.9 | |
| Secondary | 184 | 24.4 | |
| University | 417 | 55.2 | |
| Postgraduate | 36 | 4.8 | |
| Diploma or vocational training | 91 | 12.1 | |
| Residence | Town | 398 | 52.7 |
| Village | 357 | 47.3 | |
| Previous diagnosis with osteoporosis by a trained health professional | Yes | 88 | 11.7 |
| No | 53 | 7.0 | |
| I do not know | 614 | 81.3 | |
3.2. Knowledge
The information shown in Table 2 is related to knowledge of osteoporosis and its association with magnesium intake. Regarding the overall level of knowledge, almost half of the participants 401 (53.1%) had moderate knowledge and 216 (28.6%) had poor knowledge. In comparison, only 138 participants (18.3%) had a high level of knowledge (Fig. 1). While measuring the differences in the knowledge score with sociodemographic characteristics of participants (Table 2), it was found that the differences in the knowledge scores among the age group, sex, marital status, educational level, and residence did not reach statistical significance (P-value > .05).
Table 2.
Knowledge level of osteoporosis and its association with magnesium intake among adults in Jazan, Saudi Arabia (n = 755).
| Variables | Knowledge Level | P-value* | ||||||
|---|---|---|---|---|---|---|---|---|
| Poor | Moderate | High | ||||||
| N | % | N | % | N | % | |||
| Age | 18–29 yr | 92 | (30.6) | 147 | (48.8) | 62 | (20.6) | .143 |
| 30–39 yr | 49 | (23.9) | 115 | (56.1) | 41 | (20.0) | ||
| 40–49 yr | 47 | (35.1) | 71 | (53.0) | 16 | (11.9) | ||
| 50–59 yr | 22 | (25.0) | 50 | (56.8) | 16 | (18.2) | ||
| 60 and above | 6 | (22.2) | 18 | (66.7) | 3 | (11.1) | ||
| Sex | Male | 152 | (29.5) | 269 | (52.2) | 94 | (18.3) | .704 |
| Female | 64 | (26.7) | 132 | (55.0) | 44 | (18.3) | ||
| Marital status | Single | 93 | (29.9) | 155 | (49.8) | 63 | (20.3) | .158† |
| Married | 115 | (27.7) | 233 | (56.1) | 67 | (16.1) | ||
| Divorced | 5 | (21.7) | 10 | (43.5) | 8 | (34.8) | ||
| Widowed | 3 | (50.0) | 3 | (50.0) | 0 | (0.0) | ||
| Educational level | Primary and below | 2 | (40.0) | 3 | (60.0) | 0 | (.0) | .451 |
| Intermediate | 7 | (31.8) | 9 | (40.9) | 6 | (27.3) | ||
| Secondary | 58 | (31.5) | 88 | (47.8) | 38 | (20.7) | ||
| University | 113 | (27.1) | 233 | (55.9) | 71 | (17.0) | ||
| Postgraduate | 10 | (27.8) | 23 | (63.9) | 3 | (8.3) | ||
| Diploma or vocational training | 26 | (28.6) | 45 | (49.5) | 20 | (22.0) | ||
| Residence | Town | 123 | (30.9) | 205 | (51.5) | 70 | (17.6) | .337 |
| Village | 93 | (26.1) | 196 | (54.9) | 68 | (19.0) | ||
| Have you ever been diagnosed by a specialist doctor as having osteoporosis? | Yes | 24 | (27.3) | 41 | (46.6) | 23 | (26.1) | .369 |
| No | 16 | (30.2) | 28 | (52.8) | 9 | (17.0) | ||
| I do not know | 176 | (28.7) | 332 | (54.1) | 106 | (17.3) | ||
| Overall level of knowledge | 216 | (28.6) | 401 | (53.1) | 138 | (18.3) | ||
P-value is based on the chi-square test.
P-value is based on the Fisher–Freeman–Halton exact test.
Figure 1.
Percentage of knowledge regarding osteoporosis and its association with Mg intake.
3.3. Attitude
Participants’ attitudes towards the intake of essential nutrients for bone health, particularly magnesium, calcium, and vitamin D, were predominantly positive. A large proportion of the participants strongly agreed or agreed on the importance of consuming calcium-rich foods or supplements (83.9%), vitamin D (88.4%), and magnesium (87.8%) for bone health and osteoporosis prevention. Additionally, most participants expressed a willingness to modify their dietary habits to increase their intake of these nutrients. Specifically, 88.4% supported modifying their diet to increase magnesium intake, 88.8% to increase vitamin D intake, and 90.1% to increase calcium intake (Fig. 2).
Figure 2.
The proportions of participants’ responses regarding their attitudes towards nutrient supplementation for osteoporosis.
Table 3 shows that the majority of adults in Jazan, Saudi Arabia (60, 66.4%) had a positive attitude towards osteoporosis, while 29 participants (32.6%) had a negative attitude. Analysis of individual factors revealed a significant association between age group and attitude (P = .001), with younger adults exhibiting a more negative outlook. Sex, marital status, education level, residence, and prior osteoporosis diagnosis showed no significant association (P > .05) with attitudes towards the condition.
Table 3.
Attitude towards osteoporosis and its association with magnesium intake among adults in Jazan, Saudi Arabia (n = 755).
| Variables | Attitude | P-value* | ||||
|---|---|---|---|---|---|---|
| Negative | Positive | |||||
| N | % | N | % | |||
| Age | 18–29 yr | 89 | (29.6) | 212 | (70.4) | .001 |
| 30–39 yr | 60 | (29.3) | 145 | (70.7) | ||
| 40–49 yr | 57 | (42.5) | 77 | (57.5) | ||
| 50–59 yr | 42 | (47.7) | 46 | (52.3) | ||
| 60 and above | 6 | (22.2) | 21 | (77.8) | ||
| Sex | Male | 169 | (32.8) | 346 | (67.2) | .481 |
| Female | 85 | (35.4) | 155 | (64.6) | ||
| Marital status | Single | 101 | (32.5) | 210 | (67.5) | .636 |
| Married | 144 | (34.7) | 271 | (65.3) | ||
| Divorced | 6 | (26.1) | 17 | (73.9) | ||
| Widowed | 3 | (50.0) | 3 | (50.0) | ||
| Educational level | Primary and below | 3 | (60.0) | 2 | (40.0) | .811 |
| Intermediate | 10 | (45.5) | 12 | (54.5) | ||
| Secondary | 52 | (28.3) | 132 | (71.7) | ||
| University | 144 | (34.5) | 273 | (65.5) | ||
| Postgraduate | 16 | (44.4) | 20 | (55.6) | ||
| Diploma or vocational training | 29 | (31.9) | 62 | (68.1) | ||
| Residence | Town | 137 | (34.4) | 261 | (65.6) | .632 |
| Village | 117 | (32.8) | 240 | (67.2) | ||
| Have you ever been diagnosed by a specialist doctor as having osteoporosis? | Yes | 34 | (38.6) | 54 | (61.4) | .516 |
| No | 19 | (35.8) | 34 | (64.2) | ||
| I do not know | 201 | (32.7) | 413 | (67.3) | ||
| Overall attitude | 254 | (33.6) | 501 | (66.4) | ||
P-value is based on the chi-square test.
3.4. Practice
Regarding the information provided in (Table 4), the usage rate of magnesium supplements was reported by 18.8% (142) of all participants, with no significant difference between males (18.4%) (95) and females (19.6%) (47). A P-value of .710 indicates that sex did not have a statistically significant association with magnesium supplement usage. Regarding the frequency of consuming magnesium-rich foods, 24.6% (186) of participants reported that they never made an effort to consume such foods. While there was a slight difference between males and females, the P-value of .056 suggests that this difference was not statistically significant.
Table 4.
Practice towards osteoporosis and its association with magnesium intake among adults in Jazan, Saudi Arabia.
| Questions | All participants | Sex | P-value | |||||
|---|---|---|---|---|---|---|---|---|
| Male | Female | |||||||
| N | % | N | % | N | % | |||
| Do you currently use magnesium supplement? | Yes | 142 | (18.8) | 95 | (18.4) | 47 | (19.6) | .710 |
| No | 613 | (81.2) | 420 | (81.6) | 193 | (80.4) | ||
| Do you have a desire to use/continue magnesium supplements in the future? | Yes | 529 | (70.1) | 372 | (72.2) | 157 | (65.4) | .057 |
| No | 226 | (29.9) | 143 | (27.8) | 83 | (34.6) | ||
| Do you currently use vitamin D supplements? | Yes | 317 | (42.0) | 224 | (43.5) | 93 | (38.8) | .219 |
| No | 438 | (58.0) | 291 | (56.5) | 147 | (61.3) | ||
| Do you have a desire to use/continue vitamin D supplements in the future? | Yes | 573 | (75.9) | 401 | (77.9) | 172 | (71.7) | .064 |
| No | 182 | (24.1) | 114 | (22.1) | 68 | (28.3) | ||
| Do you currently use calcium supplements? | Yes | 167 | (22.1) | 114 | (22.1) | 53 | (22.1) | .987 |
| No | 588 | (77.9) | 401 | (77.9) | 187 | (77.9) | ||
| How often do you make sure to consume magnesium-rich foods during the week? | Never | 186 | (24.6) | 121 | (23.5) | 65 | (27.1) | .056 |
| Once | 210 | (27.8) | 159 | (30.9) | 51 | (21.3) | ||
| Twice | 191 | (25.3) | 125 | (24.3) | 66 | (27.5) | ||
| More than twice | 168 | (22.3) | 110 | (21.4) | 58 | (24.2) | ||
| Do you read food labels to identify the magnesium content in products? | No Never | 250 | (33.1) | 182 | (35.3) | 68 | (28.3) | .050 |
| Some times | 382 | (50.6) | 245 | (47.6) | 137 | (57.1) | ||
| Yes always | 123 | (16.3) | 88 | (17.1) | 35 | (14.6) | ||
| How often during the week do you make sure to consume food sources that contain vitamin D to meet your daily needs? | Never | 146 | (19.3) | 103 | (20.0) | 43 | (17.9) | .323 |
| Once | 237 | (31.4) | 170 | (33.0) | 67 | (27.9) | ||
| Twice | 163 | (21.6) | 105 | (20.4) | 58 | (24.2) | ||
| More than twice | 209 | (27.7) | 137 | (26.6) | 72 | (30.0) | ||
| Do you incorporate calcium-rich food such as broccoli, milk, and dairy products into your daily routine? | Never | 100 | (13.2) | 74 | (14.4) | 26 | (10.8) | .091 |
| Once | 261 | (34.6) | 187 | (36.3) | 74 | (30.8) | ||
| Twice | 137 | (18.1) | 84 | (16.3) | 53 | (22.1) | ||
| More than twice | 257 | (34.0) | 170 | (33.0) | 87 | (36.3) | ||
When it comes to reading food labels for magnesium content, 33.1% (250) of participants never did so, while 16.3% (123) always read food labels for magnesium content. Importantly, there was a significant difference based on sex (P = .050). The desire to use/continue magnesium supplements in the future was expressed by 70.1% of participants. While there were slight differences between males (72.2%, 529) and females (65.4%, 157), the P-value of .057 suggests that these differences were not statistically significant. For vitamin D consumption, 19.3% (146) participants reported never ensuring the consumption of food sources containing vitamin D. However, there was no significant difference in the frequency of consuming vitamin D-rich foods between males and females, with a P-value of .323.
Regarding the use of vitamin D supplements, 42.0% (317) of participants reported using them. There was no statistically significant difference between males and females based on a P-value of .219. The desire to use/continue vitamin D supplements in the future was expressed by 75.9% (n = 573) of the participants. Although there were slight differences between males (77.9%, 401) and females (71.7%, 172), the P-value of .064 indicated that these differences were not statistically significant.
In terms of incorporating calcium-rich foods into their daily diet, 13.2% (100) of the participants reported never doing so. The difference in frequency between males and females was not statistically significant, as indicated by a P-value of .091. Lastly, the use of calcium supplements was reported by 22.1% (167) of participants, with no significant difference between males and females (P = .987).
Regarding the information shown in Table 5 is, practices of Adults in Jazan regarding osteoporosis and its association with other factors, almost more than half of the participants (61.7%, 466) had poor practice. In comparison, only 38.3% (n = 289) had good practices. Participants were divided into different age groups. The association between age and practice was not statistically significant (P = .080). Among participants, there was no significant association between sex and practice (P = .889). The participants were categorized into different marital status groups. The association between marital status and practice was not significant (P = .194).
Table 5.
Practices of adults in Jazan regarding the osteoporosis and its association with other factors (n = 755).
| Variables | Practices | P-value* | ||||
|---|---|---|---|---|---|---|
| Poor | Good | |||||
| N | % | N | % | |||
| Age | 18–29 yr | 181 | (60.1) | 120 | (39.9) | .080 |
| 30–39 yr | 129 | (62.9) | 76 | (37.1) | ||
| 40–49 yr | 83 | (61.9) | 51 | (38.1) | ||
| 50–59 yr | 62 | (70.5) | 26 | (29.5) | ||
| 60 and above | 11 | (40.7) | 16 | (59.3) | ||
| Sex | Male | 317 | (61.6) | 198 | (38.4) | .889 |
| Female | 149 | (62.1) | 91 | (37.9) | ||
| Marital status | Single | 193 | (62.1) | 118 | (37.9) | .194 |
| Married | 250 | (60.2) | 165 | (39.8) | ||
| Divorced | 19 | (82.6) | 4 | (17.4) | ||
| Widowed | 4 | (66.7) | 2 | (33.3) | ||
| Educational level | Primary and below | 5 | (100.0) | 0 | (.0) | .628 |
| Intermediate | 14 | (63.6) | 8 | (36.4) | ||
| Secondary | 111 | (60.3) | 73 | (39.7) | ||
| University | 256 | (61.4) | 161 | (38.6) | ||
| Postgraduate | 22 | (61.1) | 14 | (38.9) | ||
| Diploma or vocational training | 58 | (63.7) | 33 | (36.3) | ||
| Residence | Town | 242 | (60.8) | 156 | (39.2) | .584 |
| Village | 224 | (62.7) | 133 | (37.3) | ||
| Have you ever been diagnosed by a specialist doctor as having osteoporosis? | Yes | 43 | (48.9) | 45 | (51.1) | .012 |
| No | 29 | (54.7) | 24 | (45.3) | ||
| I do not know | 394 | (64.2) | 220 | (35.8) | ||
| Knowledge level | Poor knowledge | 153 | (70.8) | 63 | (29.2) | <.001 |
| Moderate knowledge | 252 | (62.8) | 149 | (37.2) | ||
| High knowledge | 61 | (44.2) | 77 | (55.8) | ||
| Attitude | Negative attitude | 181 | (71.3) | 73 | (28.7) | <.001 |
| Positive attitude | 285 | (56.9) | 216 | (43.1) | ||
| Over all practice | 466 | (61.7) | 289 | (38.3) | ||
P-value is based on the chi-square test.
Participants had varying levels of education. There was no significant association between the educational level and practice (P = .628). The participants were recruited from different locations, including towns and villages. The association between residence and practice was not significant (P = .584).
Diagnosis of osteoporosis: When asked if they had ever been diagnosed with osteoporosis, 45 participants (51.1%) answered yes and practiced well. The association between osteoporosis diagnosis and practice was statistically significant (P = .012). Regarding the knowledge level of osteoporosis, its association with practice was statistically significant (P < .001). Participants with a moderate level (37.2%, 149) and a high knowledge level (55.8%, 77) showed significantly better practice compared to those with a poor knowledge level (29.2%, 63).
Moreover, participants with a positive attitude towards osteoporosis and its association with practice reported better practices (43.1%, 216) than those with negative attitudes (28.7%, 73). This association was statistically significant (P < .001).
4. Discussion
The current study was conducted to address the increasing concerns regarding osteoporosis and its correlation with magnesium intake, especially in Saudi Arabia. As the incidence of osteoporosis is increasing globally and nationally, the role of nutritional factors, such as magnesium intake, must be considered when developing effective preventive strategies. The current study revealed that while 53.1% of the participants had a moderate level of knowledge regarding osteoporosis and magnesium intake, only 18.3% demonstrated a high level of knowledge. Attitudes towards osteoporosis were generally positive, with 66.4% of the participants showing a favorable attitude. However, there was a notable gap between knowledge and practice, as 61.7% of the participants reported poor preventive practices, highlighting the need for targeted interventions to bridge this gap and promote better osteoporosis management.
4.1. Sociodemographic characteristics
While many who participated in the research fell into the cohort aged 20 to 29, comprising over a quarter of all those involved, others exhibited greater variability in age. More females than males contributed to their perspectives, representing over two-thirds of all the data collected; however, the statistical analysis of our study revealed no statistically significant differences between both sexes in knowledge, attitude, or practice. More than half the participants were married. A sizeable portion demonstrated higher educational attainment, with over half holding university degrees. The place of residence also demonstrated differences, with over half inhabiting towns, although other settings were also represented. However, none of these factors had a significant relationship with KAP.
4.2. Knowledge
Almost half of the participants (53.1%) had moderate knowledge. This figure, however, was lower than that of Lebanon, where 65.4% of people were said to have moderate knowledge.[12] The lower level of knowledge compared to the study carried out in Lebanon could be explained by different educational systems, access to health information, or cultural factors that affect health literacy. Furthermore, the number of people with a good level of knowledge (63.1%) in the Qassim region of Saudi Arabia was higher than that in the current study.[13] This discrepancy, although these 2 regions share a similar culture, may be explained by differences in their socioeconomic status, availability of health care infrastructure, and health promotion initiatives.
Remarkably, this research showed that those with mid-term education level, as well as those in the range of 18 to 29 years of age, showed more understanding regarding what osteoporosis is than the participants from other age groups. This reveals that among younger participants, those with higher-level classroom knowledge can more easily find information and have a better grasp of health-related issues. However, in villages, the knowledge of magnesium intake to avoid osteoporosis is likely to be greater. Their community cohesion may bring people traditional health that they would not receive in major cities, and sharing such knowledge is easier than anywhere else. However, this study revealed that participants’ sociodemographic characteristics showed no statistically significant difference in their level of knowledge of magnesium intake and osteoporosis. This may be due to various reasons, such as differences in background culture, survey methods, and sample size.
According to the results of the current study, the participants believed that osteoporosis could increase the risk of bone fractures (77.1%), which is consistent with another study that indicated that as many as 96.1% of participants thought that osteoporosis could increase the chance of fracture, while a total of 3% participants disagreed or were doubtful.[14] However, for 20.2% of the participants, prevention through calcium alone was possible, at least to some extent. This result was confirmed by another study conducted in the Jazan region.[14]
Magnesium affects bone formation. It also plays a vital role in osteoblast and osteoclast functions. Mg can affect PTH levels and the active form of vitamin D (28-hydroxyvitamin D).[15,16] These 2 hormones act as regulators of normal bone metabolism. In other words, this study was designed to determine whether a person is aware of the role of magnesium in the absorption and control of vitamin D. According to the questionnaire responses, a large percentage of participants (71%) understood magnesium, which helps sustain healthy bones and regulates or absorbs vitamin D in their bloodstream. It is also worth pointing out that 63.9% of participants knew how magnesium is related to osteoporosis.
4.3. Attitude
More than 66% of the participants in this study had a positive attitude towards osteoporosis. This percentage was significantly higher than the results of a study performed in Riyadh among female university students. Participants in the survey demonstrated a favorable outlook of <57%.[17] Likewise, another study conducted in Riyadh among young adults reported a gallant rate of 56.26%.[18] Another study conducted in the Jazan region among Jazan University students recorded a positive attitude of 60.2%.[14]
With a response rate of 77.8%, the 60 + years age group demonstrated the highest positive attitude percentage among all age groups discussed. Moreover, 71.7% of participants with a secondary educational level showed a high positive attitude rate. It is crucial to remember that attitudes towards osteoporosis did not significantly change based on sex, marital status, or place of residence.
According to the present study, only 50.5% of the participants (184/364) strongly believed that they must eat foods rich in calcium or take calcium supplements to keep their skeleton healthy. However, a survey carried out in Riyadh revealed a far greater proportion, as 90.5% of participants acknowledged the significance of calcium for bone health. It is well recognized that calcium supplements can help prevent osteoporosis.[17] According to results from another Singaporean survey, 74.7% of participants thought that calcium supplements could help prevent osteoporosis.[19] The findings from the present survey revealed that 53.2% of participants opined that consuming foods rich in vitamin D or taking supplements was necessary for maintaining strong bones. Additionally, only 42.1% of the individuals firmly believed that eating foods high in magnesium or taking magnesium supplements was necessary to retain healthy bones and prevent osteoporosis. Research in this area is limited and studies have primarily focused on the application and importance of these nutrients.
According to the study, 51% of the participants indicated a willingness to change their eating habits to increase their intake of vitamin D for healthy bones, while 51.4% expressed the same willingness for calcium. However, only 47.1% of the participants believed that modifying their dietary practices to consume more magnesium would benefit bone health. This lower percentage highlights the need for additional educational efforts, particularly regarding magnesium, to improve the public’s understanding of its advantages for bone health.
4.4. Practice
This study showed that most participants (61.7 %) had inadequate practices, while only 38.3% exhibited good practices. A strong relationship was observed between the knowledge level and practice (P < .001). Participants with higher knowledge levels (37.2% and 55.8%, respectively, n = 149 and 77) demonstrated significantly better practices than those with lower knowledge levels (29.2%, n = 63). This association between knowledge and practice emphasizes the significance of learning in promoting preventive behaviors. With a better understanding of osteoporosis, a greater number of individuals can realize that magnesium is essential for healthy bones. In this way, they would be more likely to adapt a better practice, for example, by adding a variety of magnesium-rich foods to their diets and taking quality magnesium supplements. The outcome of this study is consistent with that of similar Iranian studies.[20] Results’ congruence of the results of this study with the study conducted in Iran enhances the validity and applicability of the knowledge-practice relationship in the context of osteoporosis prevention. It also emphasizes how knowledge-based treatments may enhance health outcomes and behaviors related to osteoporosis in various populations.
When considering sex differences, both male and female participants demonstrated comparable levels of proficiency, as 38.4% of males and 37.9% of females exhibited strong practice, while 61.6% of males and 62.1% of females showed weak practice. This disparity may be attributed to the sampling methods and sample sizes employed. A study conducted in Riyadh showed that a greater proportion of the male population had better practices (52.5% vs 35% for females).[18] In terms of age groups, younger participants demonstrated a commendable level of satisfaction, while participants aged 60 years and above showed a slightly higher level of satisfaction. This could be attributed to the ongoing cultural changes and the increasing tendency of this age group to seek medical attention. These results are in contrast to those of the other age groups. A study found that participants in the 17 to 20 age group had the greatest practice level (45.6%), which was higher than those in the 21 to 25 and 26 to 30 age groups.[18]
Interestingly, there was no significant difference in practice between participants with a high level of education and those without a high level of education as well as the participants from different locations, including towns and villages. This could be related to the expansion and widespread availability of knowledge everywhere, including the Internet, which is consistent with the findings of a study conducted in Riyadh.[18] Most participants (81.2%) did not use magnesium supplements. However, a significant portion (70.1%) expressed willingness to use or continue taking magnesium supplements in the future. Additionally, approximately 50.6% of participants occasionally checked food labels to determine the magnesium content of various products. UL (700.0 mg) and RDI (330.0 mg) for magnesium were the upper and normal recommended dietary intake levels, respectively. According to this study, individuals with dietary magnesium intake below the RDI were more likely to develop osteoporosis. However, those with daily intake above the RDI or UL seemed to have the opposite outcome. This study emphasizes the vital role of Mg in maintaining bone health.[9]
While considering calcium consumption, most participants (77.9%) did not take calcium supplements. Only 34.6% ate calcium-rich foods once per week. In contrast, a study conducted in Taif City showed that 65.1% of participants drank milk every day and 45.9% took calcium supplements. Among osteoporotic patients in the same study, 52% drank milk every day, but none took calcium supplements.[21] Adequate calcium intake is essential for preserving bone health, and insufficient calcium intake can result in a higher risk of osteoporosis. In terms of vitamin D, the study found that most participants (75.9%) did not currently use vitamin D supplements, but were willing to consume or use them in the future. Approximately 31.4% of the participants ensured that they consumed products that served as sources of vitamin D at least once a week. When compared to another study conducted in Lebanon, which revealed that 42.31% of participants had moderate vitamin D-related practices,[22] several randomized placebo-controlled trials have consistently shown a substantial decrease in the incidence of fractures with the use of vitamin D and calcium supplements. Vitamin D supplementation has been found to positively affect bone health, as it can decrease bone turnover and increase bone mineral density, which are crucial factors in maintaining strong and healthy bones.[23] It is important to note that sufficient vitamin D intake is vital for calcium absorption, reducing the risk of osteoporosis and fractures, and maintaining strong bones.
Interestingly, despite the current study showed that more than half of the respondents showed moderate knowledge (53.1%) and approximately two-thirds of them had positive attitudes (66.4%) towards osteoporosis prevention, a considerable proportion of participants (61.7%) reported poor preventive practices. Such a gap between awareness and behavior is consistent with other findings in the literature. For example, a study carried out in Kuala Lumpur showed no significant relationship between participants’ knowledge or attitudes and preventive practices, indicating that other possible factors may play a role in translating awareness into action.[24] These factors might include social or environmental factors, such as access to resources, time constraints or lack of motivation. Similarly, a study in Thailand highlighted that young women had good knowledge and favorable attitudes; yet, however, the majority of women did not engage in adequate osteoporosis preventive behaviors.[25] These results suggest that targeted health education interventions should consider the social, environmental and psychological barriers of practice by adopting tailored behavioral support to promote actionable change.
Given the observed gap between participants knowledge and attitudes and their preventive actions, it is necessary to implement structured public health strategies that go beyond general awareness campaigns. One practical recommendation is to integrate the guidelines of magnesium, calcium and vitamin D intake into national osteoporosis prevention programs. As suggested recently, it is necessary to prioritize self-care and nutrition education in sustainable healthcare frameworks in order to improve long-term outcomes and healthcare sustainability.[26] The incorporation of dietary recommendations, food fortification policies, and supplementation programs which focus on magnesium intake would ultimately promote bone health and support preventive strategies, particularly in populations with limited dietary diversity and low awareness levels regarding magnesium.
5. Limitation and strength
One of the key strengths of the current study is its large sample size, which supports the generalizability of the results within the Jazan region. The diverse demographic backgrounds of the participants provided a broad perspective on the KAP for osteoporosis and magnesium intake. Furthermore, the use of a validated tool ensured the reliability of the collected data. Conducting a pilot analysis supported the strengths of the study by refining the items and enhancing the clarity of the questions. Moreover, the current analysis focused on an under-researched area of research, which has received less attention than vitamin D and calcium. This study adds valuable insights into osteoporosis, offering an acceptable foundation for future initiatives aimed at enhancing bone health through detailed nutritional interventions.
Despite these strengths, this study had some limitations. Applying a convenience sampling technique might have introduced a selection bias and limited the generalizability of the findings to the broader population of Saudi Arabia. Furthermore, the cross-sectional design limits the ability to draw causal inferences regarding the KAP of osteoporosis and magnesium intake. Another limitation is that the authors relied on self-reported records, which might have caused recall or social desirability bias. While the survey was validated via a pilot study, the methodological rigor could have benefited from more details about the content validity and cultural adaptation process. Finally, the analysis did not account for potential confounders, such as access to healthcare or employing specific dietary patterns, which might have influenced the participants’ knowledge and practices.
6. Conclusion and recommendations
In conclusion, the results indicated that, although adults understood osteoporosis and showed a positive attitude, their preventive actions revealed a significant discrepancy between knowledge and practice. Future studies should utilize more rigorous methodologies (e.g., randomized controlled trials) to definitively determine whether there is a gap between knowledge and practice related to magnesium intake and osteoporosis risk, once other confounding variables are considered. If a gap exists, the government must focus on creating and implementing educational interventions tailored to the needs of the population, such as advocating for changes in diet or dietary supplements, organizing screening programs based on community health standards, establishing partnerships with healthcare providers and involving them strategically in this holistic approach, and utilizing the media and technology. Additionally, dedicated public health strategies are required that include specific and targeted guidelines for the intake of calcium, magnesium and calcium within the national prevention framework of osteoporosis prevention. Tailored strategies that target improving long-term health outcomes may enhance prioritizing self-care and nutrition-focused education, along with policies such as food fortification and supplementation. The establishment of the above-mentioned consideration could be on the continuum of enhancing results and decreasing osteoporosis stress by improving bone health. To effectively prevent and manage osteoporosis in the population, a multidisciplinary intervention is required that includes education, diet, and supplement consumption, screening campaigns based on a health professional’s commitment, and targeting the general public exposed by social media.
Acknowledgments
The authors acknowledge the help and support of Dr Mohamed Salih Mahfouz in data analysis and Mostafa A. Abdelmoaty from StatisMed for article refinement and proofreading.
Author contributions
Conceptualization: Sarah Salih, Zenat Khired, Rimas Sumayli, Asrar Jabrah, Noran Henishi, Shaima Wadani, Atiaf Faqihi, Sarah Innab, Aisha Alameer.
Data curation: Rimas Sumayli, Asrar Jabrah, Noran Henishi, Shaima Wadani, Atiaf Faqihi, Sarah Innab, Aisha Alameer.
Formal analysis: Rimas Sumayli.
Funding acquisition: Sarah Salih.
Investigation: Rimas Sumayli, Asrar Jabrah, Noran Henishi, Shaima Wadani, Atiaf Faqihi, Sarah Innab.
Methodology: Sarah Salih, Rimas Sumayli Noran Henishi, Shaima Wadani, Atiaf Faqihi, Sarah Innab, Aisha Alameer.
Project administration: Rimas Sumayli, Asrar Jabrah, Noran Henishi, Shaima Wadani, Atiaf Faqihi, Sarah Innab.
Resources: Rimas Sumayli.
Supervision: Sarah Salih, Zenat Khired.
Visualization: Zenat Khired.
Writing – original draft: Rimas Sumayli, Asrar Jabrah, Noran Henishi, Shaima Wadani, Atiaf Faqihi, Sarah Innab, Aisha Alameer.
Writing – review & editing: Sarah Salih, Zenat Khired.
Supplementary Material
Abbreviations:
- BMD
- bone mineral density
- KAP
- knowledge, attitude, and practice
- PTH
- parathyroid hormone.
The authors have no conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
How to cite this article: Salih S, Khired Z, Sumayli R, Jabrah A, Henishi N, Wadani S, Faqihi A, Innab S, Alameer A. Knowledge, attitude, and practice towards osteoporosis and its association with magnesium intake in Jazan, Saudi Arabia: A cross-sectional study. Medicine 2025;104:28(e43288).
Contributor Information
Zenat Khired, Email: zkherd@jazanu.edu.sa.
Rimas Sumayli, Email: rimas9821@gmail.com.
Asrar Jabrah, Email: Asrarahmed1422@gmail.com.
Noran Henishi, Email: Noran.henishi@gmail.com.
Shaima Wadani, Email: Wadanishaima@gmail.com.
Atiaf Faqihi, Email: Atiaf.f111@gmail.com.
Sarah Innab, Email: Xsa1423x@gmail.com.
Aisha Alameer, Email: Alameer.ca13@gmail.com.
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