Prescribing practices of healthcare professionals regarding multivitamins and mineral supplements in Pakistan: a cross-sectional study

Abstract

Background

Multivitamins and minerals (MVMs) are readily available dietary supplements that help prevent nutritional deficiencies and boost energy. This study examined the prescribing and consultation practices of healthcare professionals (HCPs) related to MVM supplements in Pakistan.

Methods

This cross-sectional study used a web-based structured questionnaire to collect data from HCPs from February 2021 to January 2022. The study link, which included a consent form and questionnaire, was circulated on social media platforms, and all individuals who provided consent and completed the forms were included in the study.

Results

A total of 524 HCPs participated in the study, with the majority being males, holding MBBS or Fellow of the College of Physicians and Surgeons qualifications, and working in urban settings. Findings revealed that HCPs prescribe MVMs for varied reasons. We assessed differences based on various factors like gender, education level, area of practice and specialty. Most of the differences observed were not statistically significant, except for a few related to area of practice and education level that were found significant. The primary conditions prompting MVM prescriptions included osteoporosis and bone pain (80% for vitamin D and calcium), fatigue and weakness (over 70% for iron) and numbness/tingling (more than half for folate and vitamin B₁₂). Regarding biospecimen analysis before prescribing MVMs, 46% of HCPs required laboratory investigations before prescribing vitamin D and calcium and 60% for iron prescriptions. Common formulations prescribed include cholecalciferol for vitamin D deficiency (62%) and ferrous sulfate for iron deficiency (76%).

Conclusion

Our study findings highlight that the prescribing practices of MVMs by HCPs are primarily in line with the known physiological roles of these supplements. However, a few identified gaps in practices highlight the need for standardised guidelines to ensure patients’ health and well-being.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• The large, diverse sample of healthcare professionals (HCPs) with varying education levels, specialties and from different healthcare organisations, along with extensive years of experience, captures a broad range of perspectives.

• Prescribing and consultation practices were analysed across multiple HCP characteristics including gender, area of practice, level of education, specialty and type of practice, allowing meaningful comparisons.

• The study relies on self-reported data, which may be subject to social desirability bias.

Introduction

According to WHO, around 2 billion people worldwide are affected by micronutrient deficiencies, including vitamins A and D, iron, folate, zinc and iodine.^{1 2} These nutritional deficiencies can adversely affect health, leading to impaired immunity, increased fatigue and cognitive deficits. In addition, severe or long-term deficiencies may cause chronic conditions like anaemia, osteoporosis and cancer.³ Multivitamins and minerals (MVMs) are readily available dietary supplements that help prevent nutritional deficiencies and boost energy.⁴

Globally, the use of MVMs has risen due to increased awareness of micronutrient deficiencies and their consequent health impacts. The use of MVMs is also growing in South Asian countries, where micronutrient deficiencies are prevalent, especially of vitamin A, D and iron.^{5 6} According to the National Nutrition Survey of Pakistan conducted in 2018, over half of the under-five children are anaemic (53.7%) and deficient in vitamins A (51.5%) and D (62.7%).⁷ Similarly, micronutrient deficiencies significantly affect women of reproductive age (WRA), with over 40% being anaemic, primarily iron deficient (47%), and around 80% being vitamin D deficient.⁷ These deficiencies are well-acknowledged by healthcare professionals (HCPs), for whom they often prescribe MVMs to their patients. For instance, a study in India revealed that 34.7% of doctors prescribed MVMs to every third patient.⁸ Another study conducted in secondary care settings in Nepal found that 40% of patients were prescribed a combination of MVM supplements.⁹ In Bangladesh, a study found that >40% (n=300) of people (aged 15–65 years) consumed MVMs to improve overall health, bone health, disease recovery or beautification.¹⁰ Similar prescribing trends are observed in Pakistan, where recent studies in Rawalpindi, Islamabad and Peshawar found that 37.3% to >40% of the patients are prescribed MVMs by their doctors,^{11 12} highlighting the regular prescription of MVMs by HCPs.

Despite widespread use, the need for MVM supplements remains debatable for several reasons. Some inherited metabolic disorders need high doses of vitamins and minerals to be treated, such as exogenous biotin in the case of biotinidase deficiency.¹³ Additionally, in some physiological conditions like pregnancy, there is an increased nutritional demand, and diet alone might not meet the daily requirement of micronutrients in such cases.¹⁴ However, there are also several risks associated with MVM prescription; for instance, the excessive and irrational use of MVM can result in toxicity, interactions with other medications and other adverse health effects like gastrointestinal issues, including diarrhoea, constipation, nausea and vomiting.^{15 16} Moreover, the vast array of multivitamin formulations on the market can be confusing, especially for the less educated, necessitating medical advice.¹⁷

HCPs across various fields, including physicians/doctors, dental practitioners, dietitians and nutritionists, frequently prescribe MVM supplements to their patients using some national and international guidelines.¹⁸,²⁰ These guidelines typically recommend that the HCPs only prescribe MVMs to their patients if there is an apparent deficiency of vitamins or minerals.²¹ However, various factors influence HCPs’ decision to prescribe these supplements. For instance, a recent review reported that factors like physicians’ personal characteristics, patient demand, patient knowledge, medicine cost and marketing and promotion strategies by pharmaceuticals often influence the decision to prescribe MVMs.²² With the growing use of MVMs, concerns about their safe use and potential health risks, and the dearth of data on the prescribing practices of HCPs, this cross-sectional study aimed to examine prescribing practices of HCPs related to MVM supplementation in Pakistan and to assess how they vary across different demographic and professional characteristics such as gender, area, education, specialty and practice.

Methodology

A cross-sectional survey was conducted through digital and social media from 18 February 2021 to 12 January 2022. We shared the survey link on social media platforms, including Facebook, LinkedIn as well as via email with various national societies, including the Pakistan Society of Chemical Pathologists, Pakistan Society of Internal Medicine, Pakistan Society of Family Physicians, Pakistan Nutrition and Dietetic Society, Female Physicians and Surgeons of Pakistan, College of Physician and Surgeon Pakistan-Resident Organisation and Aga Khan University’s physicians, surgeons and alumni. We also employed a snowball sampling technique and requested that the participants share the survey link with their colleagues. HCPs not involved in prescribing MVM, including medical students, nurses and allied HCPs in radiology and pathology, were excluded from the study.

A structured web-based proforma was created using Google Forms (see online supplemental file 1). The questionnaire was designed after an extensive and thorough search of relevant literature was conducted. The questionnaire was then revised by subject experts, who reviewed the questions for relevance and clarity. Feedback was incorporated to refine the tool, and pretesting was done before data collection began.

The questionnaire includes items on the demographic characteristics of the HCPs, such as age, sex, education level, area of practice, field of specialty, type of organisation, type of practice and years of experience. Information was collected on the prescribing practices of HCPs regarding MVM supplements based on MVM prescription and consultation practices, common conditions for which MVMs are prescribed, considerations for laboratory tests/ investigations and the most commonly prescribed MVM formulations.

We estimated the sample size assuming that about half of the prescriptions include MVM. According to the literature from the South Asian region, MVM prescription rates ranged from 34% to over 40%.⁸,¹² Given this variation, we used an estimate of 50% to maximise the sample size. With 80% power, a 0.05 significance level and a 5% margin of error, the calculated sample size was 384 participants. We increased this by 10% to account for non-response, resulting in a total sample size of 430.

Patient and public involvement

It was not appropriate or possible to involve patients or the public in the design, or conduct, reporting or dissemination of our research

Statistical analysis

Data were analysed using Microsoft 365 Excel V.2501 and Stata V.17. Frequencies and percentages were used to present the characteristics of HCPs, including age, sex, education level, area of practice, field of specialty, type of organisation, type of practice and years of experience. Frequencies and percentages were also reported for practices related to MVM prescription and consultation, along with p values calculated using χ² and Fisher’s exact tests. Common conditions for prescribing MVM to patients are presented graphically, that is, bar charts and in tabular form for considerations related to lab tests and commonly prescribed MVM formulations. Missing data were minimal, and analysis was performed using complete case analysis.

Results

Characteristics of HCPs

A total of 540 HCPs responded to the questionnaire. After data cleaning, 16 were excluded due to ineligibility, resulting in a final sample of 524 participants. The characteristics of participating HCPs are summarised in table 1. More than half of the respondents (53%) were between 40 and 59 years of age, with a higher proportion of respondents being male (64%). Education levels varied among respondents, with a higher proportion holding MBBS/MD (48%) or Fellow of the College of Physicians and Surgeons degrees (40%). Most HCPs (84%) practised in urban settings. About 82% of the HCPs were physicians, and >60% worked in private organisations. More than half of the HCPs (52.9%) had >5 years of work experience.

Table 1. Characteristics of healthcare professionals (n=524).

Variable	N	(%)
Age (years)
20–39	198	−37.8
40–59	280	−53.4
>60	41	−7.8
Gender
Male	335	−63.9
Female	187	−35.7
Level of education
BSc/MSc (food nutrition)	22	−4.2
MBBS/MD	250	−47.7
MCPS	38	−7.3
FCPS	212	−40.5
Area of practice
Urban	440	−84
Rural	84	−16
Field of specialty
Physician	430	−82.1
Surgeon	77	−14.7
Nutritionist	17	−3.2
Type of organisation
Private set up	333	−63.5
Government set up	122	−23.3
Semi-government set up	45	−8.59
NGO/Welfare hospital	24	−4.58
Type of practice
Primary care	256	−48.9
Secondary care	80	−15.3
Tertiary care	185	−35.3
Not disclosed	3	−0.57
Years of experience
<1	92	−17.6
1–5	155	−29.6
>5	277	−52.9

FCPS, Fellow of the College of Physicians and Surgeons; MCPS, Member of the College of Physicians and Surgeons; NGO, non-government organisation.

Prescribing practices of MVM by HCPs

Practices related to MVM prescription and consultation

Table 2 shows the prescribing practices of HCPs and the consultation provided on the use of MVM supplements across different characteristics. Significant differences were identified, mainly in the areas of practice and level of education.

Table 2. Prescribing and consultation practices of HCPs across different characteristics.

Practices of HCPs	Prescribing practices (%) Consultation practices (%)
	Discuss the side effects of MVM Discuss the RDA of MVM						Discuss dietary sources of MVM			Consider the dietary habits of patients			Prescribe on patient demand			Prescribe to malnourished patients
	Yes	No	P value	Yes	No	P value	Yes	No	P value	Yes	No	P value	Yes	No	P value	Yes	No	P value
Gender
Male	78	22	0.647	78	22	0.088	90	10	0.088	92	8	0.247	68	32	0.092	76	24	0.051
Female	77	23		84	16		95	5		95	5		60	40		68	32
Area
Rural	87	13	0.029*	90	10	0.008*	98	2	0.046*	95	5	0.488	65	35	0.933	68	23	0.661
Urban	76	24		78	22		91	9		93	8		65	35		73	28
Education
Basic	75	25	0.136	79	21	0.574	90	10	0.021*	91	9	0.036*	62	38	0.041*	73	27	0.8
Fellowship	81	19		81	19		95	5		96	4		70	30		74	26
Specialty
Physician	76	24	0.149	80	20	0.806	91	9	0.448	92	8	0.236	67	33	0.105	74	26	0.607
Specialist	83	17		79	21		94	6		95	5		59	41		71	29
Practice
Primary care	80	20	0.194	83	17	0.064	90	10	0.152	91	9	0.193	67	33	0.416	77	23	0.053
Secondary care and others	76	24		77	23		94	6		94	6		63	37		69	31

*P<0.05.

HCP, healthcare professional; MVM, multivitamins and minerals; RDA, Recommended Dietary Allowance.

In terms of gender, differences were observed across both genders; however, none of these differences were significant. HCPs working in rural areas were significantly more likely to discuss side effects, recommended dietary allowances (RDA) and dietary sources with their patients when prescribing the MVMs. Other differences were found to be non-significant. Level of education was another factor that influenced practices. HCPs holding fellowships were significantly more likely to discuss dietary sources of MVMs with their patients during the prescription and consultation; they were also more likely to consider patients’ dietary habits. An interesting finding was that fellowship holders were also significantly more likely to prescribe MVMs on patient demand. In terms of specialty and area of practice, the differences observed were not significant.

Common conditions for prescribing MVM to patients

HCPs prescribed MVMs for various health conditions (figure 1). About 80% of the HCPs (n=417) indicated that bone pain and osteoporosis were the major conditions for prescribing vitamin D and calcium (figure 1). For iron, over 70% of the HCPs (n=371) reported fatigue and weakness as the major reasons for prescription, followed by pallor and pale skin (n=115, 22%) (figure 1). While considering folate and vitamin B₁₂, more than half of the HCPs reported numbness/tingling and paraesthesia as the main conditions necessitating the prescription (n=269, 51%), while others reported glossitis and mouth ulcers (n=128, 25%) (figure 1). Lastly, a few HCPs prescribed vitamin A, considering various conditions, such as fatigue (n=98) and lower immunity (n=98), each accounting for 25%, followed by night blindness and loss of tears (n=89, 23%), dry cracked lips (n=58, 15%) and measles (n=51, 13%) (figure 1).

Figure 1. Common conditions for prescribing multivitamins and minerals to patients. (a–c) Responses from 524 participants. (d) Vitamin (Vit) A is based on 394 participants due to missing responses. *Vitamin A is based on 394 participants due to missing responses.

Considerations for lab tests and commonly prescribed MVM formulations

Table 3 outlines the considerations and commonly recommended laboratory tests by HCPs before prescribing various MVMs. For vitamin D and calcium, 46% of HCPs considered lab tests before prescribing MVMs, with >50% recommending 25 hydroxyvitamin D₃ along with other tests. Regarding iron supplements, >60% of the HCPs based their decision on lab results, with a complete blood count being the most recommended test alongside other tests. Lastly, more than half of the HCPs (51%) prescribed folate and vitamin A based on lab test results. Serum B₁₂ (26%) and red blood cell folate (19%) are frequently recommended, individually or in combination with other tests.

Table 3. Laboratory test prescription practices for vitamin D, iron and folate/B₁₂ (n=524).

Laboratory test prescription	Vitamin D and calcium Iron						Folate/B12
		N	%		N	%		N	%
Prescribe laboratory tests
Yes		243	46.4		359	68.5		265	50.6
No		85	16.2		27	5.2		101	19.3
Sometimes		196	37.4		138	26.3		158	30.2
Test name	25-Hydroxyvitamin D3 146	146	27.9	CBC	127	24.2	Serum B12	134	25.6
	25-Hydroxyvitamin D3 and others*	272	51.9	CBC and others†	363	69.3	RBC folate	102	19.5
							Others‡	174	33.2

^*Ionised calcium, parathyroid hormone, serum calcium, urinary calcium and others.

^†Serum ferritin, serum iron, Total Iron Binding Capacity (TIBC) and others.

^‡Folate, homocysteine, intrinsic factor antibody, serum folate levels and urine methylmalonic acid.

CBC, complete blood count; RBC, red blood cell.

While considering the commonly prescribed MVM formulations, HCPs reported cholecalciferol (62%) as the commonly prescribed formulation for vitamin D deficiency. Most HCPs prescribed calcium carbonate (64%) to correct calcium deficiency, ferrous sulfate (76%) to correct iron deficiency, folic acid (84%) to correct folate deficiency and methylcobalamin (75%) for vitamin B₁₂ deficiency.

Discussion

With current trends in MVM prescription, our study aimed to examine how HCPs in Pakistan prescribe and consult regarding MVM supplementation. We assessed differences based on various factors like gender, education level, area of practice and specialty. Most of the differences observed were not statistically significant, except for a few related to the area of practice and education level. Most HCPs prescribed MVMs only to malnourished patients across all characteristics, although these differences were not significant. Additionally, most HCPs considered patients’ dietary habits when prescribing MVMs. HCPs with a fellowship were significantly more likely to consider this factor compared with those with a basic MBBS. However, it is also concerning that they were significantly more likely to prescribe MVMs on patient demand.

Consuming MVM supplements helps people get the recommended number of vitamins and minerals if their daily dietary intake alone does not fulfil their requirements due to medical conditions like osteoporosis or anaemia, or those recovering from surgery or chronic illnesses, and people at certain life stages, such as pregnancy or older people.²³ The prescribing practices of MVM in our study reflected this, as the HCPs primarily prescribed MVMs only to patients presumed to be malnourished; however, differences across different characteristics were not significant. In line with the literature, a study by Güney et al reported that physicians prescribed MVMs to only patients diagnosed with vitamin and/or mineral deficiency.²⁴ In addition, we also found that the majority of HCPs considered patients’ dietary habits while prescribing MVMs, with fellowship holders significantly more likely to do so (p=0.036). This may reflect the impact of having advanced clinical training in delivering appropriate counselling.

MVMs are generally safe when prescribed by an HCP in a healthcare setting for the treatment of specific diseases or to prevent nutrient deficiencies.²⁵ However, our study revealed that the majority of HCPs prescribed MVMs based on patient demand, with fellowship holders significantly more likely to do so (p=0.036). This practice contrasts with existing literature, which suggests that physicians rarely prescribe MVMs solely based on patient preference, indicating a potential gap between evidence-based practice and patient-driven prescribing behaviour²⁵ in our setting. Hence, our study findings highlight the need to develop and adhere to specific guidelines when prescribing MVMs to patients. In addition, HCPs should engage in open discussions with patients about the benefits, risks and evidence supporting MVM use, educating them on when supplements are necessary and when they may be unnecessary or harmful. This can help bridge the gap between patient expectations and appropriate clinical practice.

Our study findings indicate that HCPs follow appropriate practices while prescribing MVMs to their patients, as the majority of the HCPs regularly discussed the dietary sources of MVMs and educated them on their natural sources. In terms of HCP characteristics, HCPs practising in rural areas (p=0.046) and HCPs holding a fellowship (p=0.021) were found to be significantly more likely to do so. In addition, the majority of them discussed the recommended allowance of MVMs with their patients with rural HCPs significantly more likely to do so (p=0.008). However, the literature suggests variability in these discussions, as most HCPs lack adequate training in prescribing MVMs.²⁶,²⁸ Patients also rely on their personal experiences, research and advice from family and friends to justify their supplement use.²⁹ HCPs need to be well-informed and educate their patients on dietary sources and RDA to discourage unnecessary use of MVMs.³⁰ Our study findings indicate that HCPs follow appropriate practices when prescribing MVMs to their patients, as most of them regularly discuss the dietary sources of MVMs and educate patients about their natural sources. Regarding HCP characteristics, those practising in rural areas (p=0.046) and those holding a fellowship (p=0.021) were significantly more likely to do so. Additionally, the majority of them discussed the recommended allowance of MVMs with their patients, with rural HCPs being significantly more likely to do so (p=0.008). However, the literature suggests variability in these discussions, as most HCPs lack adequate training in prescribing MVMs. Patients also rely on their personal experiences, research and advice from family and friends to justify their supplement use. HCPs need to be well-informed and educate their patients about dietary sources and RDA to discourage unnecessary use of MVMs.

Our study focused explicitly on the prescribing practices of vitamin D and calcium, iron, folate or vitamin B₁₂ and vitamin A. We found the most common conditions requiring MVM prescription to be bone pain and osteoporosis (80%) for calcium and vitamin D, fatigue and weakness (71%) for iron, numbness/tingling and paraesthesia (51%) for folate and vitamin B₁₂ and fatigue and lower immunity (each 25%) for vitamin A. The conditions considered by HCPs in our study for various MVM prescriptions are consistent with existing literature³¹ and align with the well-established relationship between these conditions and nutrient requirements.³²,³⁵ In addition, a significant proportion (46%–68%) of HCPs reported considering lab tests to assess nutrient levels before prescribing MVMs to their patients. However, over 30% of HCPs indicated that they only occasionally prescribe these tests, suggesting variability in clinical practices. This inconsistency could be due to differences in the levels of awareness among HCPs or limited resources available to patients. These findings highlight the need for standardised guidelines and education on the importance of nutrient testing in clinical practice.

Our study has certain strengths and limitations. To the best of our knowledge, this is the first study to assess HCPs’ prescribing practices regarding MVMs in Pakistan. In addition, our study provides valuable insights into understanding the rationale for prescribing MVMs for various health conditions. Furthermore, it identifies gaps in HCP practices to inform policies and contribute to developing standardised guidelines for using MVMs appropriately. We included a large sample of HCPs with varying levels of education, different specialties and from various types of healthcare organisations, along with wide years of experience. This diversity enhances the generalisability of our study findings, making them applicable to a broad spectrum of healthcare settings and professionals in similar contexts. The major limitation of the study is reliance on self-reported data, which may be subject to social desirability bias; however, we ensured that participants’ responses remained anonymous and confidential to help them feel comfortable and provide truthful information. Another limitation could be that some aspects were not included in the study, such as pharmaceutical marketing, economic and cultural factors and costs. These factors may influence HCP practices and recommendations regarding MVM prescriptions. Lastly, since the survey was conducted online using a non-probability sampling approach, urban HCPs were over-represented. This may have introduced selection bias and affected generalisability of the findings. Although HCPs from urban areas accounted for the majority of samples, 16% of the HCPs were from rural areas, providing some representation from non-urban settings.

Conclusion

Our study findings highlight the prescribing practices of MVMs by HCPs. We found that the prescribing practices of most HCPs are in line with the known physiological roles of these supplements. In addition, considering laboratory tests before prescribing MVMs ensures that HCPs make informed decisions based on the specific nutritional needs of their patients. However, the tendency of some HCPs to prescribe MVMs based on patient demand without confirming nutrient deficiencies through laboratory tests highlights significant gaps in practices. Addressing these gaps through targeted education and developing and implementing guidelines is essential to standardised practices and promoting patients’ health and well-being.

Data availability statement

Data are available on reasonable request.