The use of the nutritional supplements during the covid-19 outbreak in Saudi Arabia: A cross-sectional study

Abstract

Background

COVID-19 causes moderate to severe illness and is spreading globally. During a pandemic, vitamins and minerals are vital to health. Therefore, the prevalence and epidemiology of supplement use in Saudi Arabia during the COVID-19 pandemic must be known.

Methods

This cross-sectional study was conducted in Saudi Arabia using an online survey. The study was conducted from June to March 2022 on both adults and children. The link to the survey was shared on social media platforms. The survey included questions on participants' demographics, vaccination status, supplements they used, and side effects of supplements. Participation in this study was optional, and there was no obligation to participate. There was a declaration about the aim of the study and different objectives before starting the survey.

Results

The present study reported that most of the participants reported that they used vitamin C (64.6 %), zinc (51.9 %), multivitamins (46.1 %), black seeds (26.7 %), garlic (Allium sativum) (15.4 %), omega-3 (22.1 %), vitamin D (22.2 %), echinacea (10.1 %), manuka honey (26.0 %), curcumin (13.6 %), ginger (22.5 %), royal jelly (12.9 %), and propolis (7.5 %) before and during the COVID-19 pandemic period. These supplements were used more frequently by subjects during the pandemic than before.

Discussion and conclusion

The respondents' risk of these supplements’ use may partially reflect the public's behavioral response during a pandemic. Future studies can document the health beliefs and motivations of nutritional supplement users.

1. Introduction

Coronavirus disease 2019 (COVID-19) is a novel human disease. COVID-19 shares feature with the coronavirus family and it is classified as having beta-coronavirus-2b ancestry[. In late December 2019, a novel COV was identified in Wuhan, China, and caused the outbreak of COVID-19. On March 11, 2020, the World Health Organization declared it a global pandemic[2], [3], [4].

The virus has affected more than 205 countries, with over 655 million confirmed cases, and resulted in more than 6.7 million deaths since December 31, 2019^[5]. The rapid spread of COVID-19 has led to increased morbidity and mortality^[1].

The Saudi Ministry of Health declared four new cases infected with COVID-19 on March 9, 2020, ^[6] and on June 10, 2020, there were 3717 confirmed COVID-19 cases^[7]. Due to the high rate of viral transmission, Saudi Arabia implemented a partial lockdown, followed by a 24-hour lockdown, to limit the virus's spread; by November 18, 2020, there were over 350,000 confirmed cases of COVID-19 and over 5000 deaths[8], [9].

Dietary supplements are products used to supplement one's diet that contain one or more dietary ingredients^[10]. During the last few decades, nutritional supplements have been used globally, with consumption based on gender, illness prevention, age, and nutritional deficiency^[11].

Individuals consume nutritional supplements for many reasons, such as protection against diseases, increasing energy, improving physical performance, and solving health problems such as neural tube defects in infants, osteoporosis, and tooth decay [12], [13], [14], [15].

The use of herbal extracts, natural products, and nutritional supplements has been implemented to increase immunity and reduce the risk of contracting COVID-19 [16], [17], [18]. Because of its immune regulation, vitamin D may be a potential immune modulator in COVID-19 infection [19], [20]. In Saudi Arabia, almost 60 % of the population suffers from vitamin D deficiency; therefore, they can benefit from vitamin D supplementation, especially during the COVID-19 pandemic^[21]. Vitamin C has several physiological characteristics that make it beneficial for preventing viral infections. Zinc is a trace mineral that is hypothesized to inhibit viral replication and attachment to the nasopharyngeal mucous; the common cold can be managed through this mechanism^[22]. Since the COVID-19 pandemic began, well-known medical entertainment figures have promoted the use of particular dietary supplements in treating acute infection of COVID-19 and prevention on social media and television.

COVID-19 is a disease caused by a novel coronavirus that causes a disease ranging in severity from mild cold symptoms to more severe symptoms that may lead to mortality. Increasing the immunity of an individual is necessary to fight the COVID-19 infection. Individuals have used nutritional supplements worldwide to promote their health for a long time. After the emergence of the COVID-19 pandemic, nutritional supplementation was recommended via social media to families, friends, and some physicians. However, using such supplementation for treatment or protection against COVID-19 is controversial. This study was conducted to assess the prevalence and epidemiology of nutritional supplement use in Saudi Arabia during the COVID-19 pandemic.

2. Materials and methods

2.1. Study design

This study is a cross-sectional study with convenience sampling conducted in Saudi Arabia using an online survey. The study was conducted from June to March 2022 on both adults and children. The survey's link was shared through social media platforms such as Instagram, Twitter, and WhatsApp. The retrieved surveys with incomplete data were excluded, and only surveys with complete data were included in the study analysis. Participation in the study was optional, and there was no obligation to participate. Before starting the survey, there was a declaration about the aim of the study and different objectives. The survey included questions on participants' demographics, vaccination status, supplements they used, and side effects of supplements.

2.2. Population and study samples

The study included both pediatric and adult populations ranging in age from 12 to 80 years. Convenient sample size was used.

The sample size was calculated using the following formula

$$=\frac{{\mathrm{Z}}^2*\mathrm{P}(1-\mathrm{P})}{{\mathrm{d}}^2}=385$$

Where n = sample sizeZ = level of confidence (2-sided 95 % confidence interval, Z = 1.96 for 95 % CI)P = expected true proportion (0.5)$\mathrm{d}$ =desired precision (5 %)(Taking into account the 40 % non-response rate).

2.3. Collection of data

The data was collected via an online questionnaire; the link to the questionnaire was shared through social media platforms such as Instagram, Twitter, and WhatsApp. The retrieved questionnaires with incomplete data were excluded, and only surveys with complete data were included in the study's analysis. The information was extracted and collected from the retrieved questionnaires before being analyzed.

2.4. Exposure assessment

A cross-sectional study was conducted on COVID-19 patients in Saudi Arabia who received nutritional supplements. The researcher was in charge of all data.

2.5. Statistical analysis

Data were simultaneously entered and updated into a form. It was entered into Microsoft Excel (MS Office 2010). The data were analyzed using SPSS software version 26.0. Descriptive analysis included the computation of frequencies and percentages. The number was used to represent categorical variables, whereas quantitative variables were represented using the mean SD. Chi-squared tests were used to differentiate between qualitative variables. McNemar tests were used to differentiate between dietary supplements used before and during the COVID-19 infection. ANOVA tests were used to differentiate between doses of dietary supplements used before and during the COVID-19 infection. A P-value of 0.05 is considered significant.

3. Results and data analysis

3.1. Results

3.1.1. Socio-demographic characteristics of the respondents

A total of 751 valid responses were enrolled in this study. The summary of socio-demographic characteristics is shown in Table 1. Most of the participants were female (n = 516, 68.7 %). Most of the participants, 645 (84.9 %), were from Saudi Arabia.

Table 1.

Demographic Characteristics of dietary supplements users before and during COVID-19.

the number of total respondents	N = 751 (100 %)
	N (%)
Gender Male Female	235 (31.3 %) 516 (68.7 %)
Nationality Saudi Non-Saudi	645 (85.9 %) 106 (14.1 %)
Age Less than 18 years 18–25 years 26–35 years 36–45 years 46–55 years More than 55	35 (4.7 %) 199 (26.5 %) 235 (31.3 %) 152 (20.2 %) 83 (11.1 %) 47 (6.3 %)
Education level diploma Secondary school Bachelor Postgraduate	85 (11.3 %) 115 (15.3 %) 461 (61.4 %) 90 (12.0 %)
Employment status Employed Unemployed Student Retired	405 (53.9 %) 105 (14.0 %) 195 (26.0 %) 46 (6.1 %)
Family income (Saudi Riyal) Less than 2000 2000–4000 5000–7000 8000–10000 More than 10000	38 (5.1 %) 120 (16.0 %) 146 (19.4 %) 187 (24.9 %) 260 (34.6 %)
Smoking Smoker Non-smoker	346 (46.1 %) 405 (53.9 %)
Chronic illnesses Yes •Hypertension •Diabetes •Cardiovascular •Asthma •Others No	185 (24.6 %) •96 (9.2 %) •43 (5.7 %) •14 (1.9 %) •40 (5.3 %) •25 (3.3 %) 566 (75.4 %)
Chronic medication Yes No	185 (24.6 %) 566 (75.4 %)
Vaccination Yes No	728 (96.9 %) 23 (3.1 %)
COVID-19 vaccine doses One dose Two doses Three doses	12 (1.6 %) 133 (17.7 %) 606 (80.7 %)
Respondents' COVID status COVID-negative Not tested but suspect to have been infected Not tested and not suspected to have been infected COVID-positive and have recovered COVID-positive and currently on treatment	397 (52.9 %) 17 (2.3 %) 211(28.1 %) 106 (14.1 %) 20 (2.7 %)
Family members' COVID status COVID-positive and currently on treatment COVID-positive and have recovered COVID-negative Not tested but suspect to have been infected Not tested and not suspected to have been infected Not known	17 (2.3 %) 219 (29.2 %) 296 (39.4 %) 44 (5.9 %) 125 (16.6 %) 50 (6.7 %)

Dietary supplements, Traditional, Complementary and Integrative Medicine.

The largest proportion of participants, 235 (31.3 %), were 26–35 years old; 199 (26.5 %) were 18–25 years old; 152 (20.2 %) were 36–45 years old; 83 (11.1 %) were 46–55 years old; and 47 (6.3 %) were more than 55 years old.

Level of education was reported as over half of participants in bachelor level 461 (61.4 %) and 405 (53.9 %) were employed, 195 (26.0 %) participants were a student. There were 346 (46.1 %) smokers, and 185 (24.6 %) had comorbidity; the significant comorbid disease was hypertension 96 (9.2 %). Diabetes was 43 (5.7 %), Asthma was reported in 40 (5.3 %), cardiovascular diseases were reported in 14 (1.9 %), and other diseases were reported in 25 (3.3 %).

Most respondents had either received COVID-19 vaccination (n = 728, 96.9 %). Six hundred and six (80.7 %) participants had three doses of vaccine, and one hundred and thirty-three (17.7 %) participants had two doses of vaccine. While only 12 (1.6 %) participants had one dose of the vaccine.

Over half of the respondents had either received a negative COVID-19 test result (n = 397, 52.9 %) or had not been tested and were not suspected of having been infected (n = 17, 2.3 %). In addition, 211 (28.1 %) participants had not been tested and were suspected of being infected. In the contest, 106 (14.1 %) participants had received a positive COVID-19 test result and have recovered, and twenty respondents had a positive COVID-19 test result and are currently on treatment.

Two hundred and ninety-six (39.4 %) family respondents had either received a negative COVID-19 test result or had not been tested and were not suspected of being infected (n = 44, 5.9 %). In addition, 125 (16.6 %) of family respondents had not been tested and were suspected of being infected. In the contest, 219 (29.2 %) of family respondents had received a positive COVID-19 test result and have recovered, and 17 (2.3 %) of family respondents had a positive COVID-19 test result and were currently on treatment.

3.2. The pattern of dietary supplement use before and during COVID-19

The pattern of dietary supplement use before and during COVID-19 was summarized in Table 2. Among the 751 respondents, 64.6 % (n = 485) reported using vitamin C in treatment. a significant increase in vitamin C in respondents during infection than before COVID-19 (76.4 vs. 47.2 %, p 0.001). Also, 51.9 % (n = 390) reported using zinc in treatment. Respondents used zinc at a higher rate during infection than before COVID-19 (60.4% vs. 34.1 %, p 0.001). 263 (46.1 %) reported the use of multivitamins in treatment. Respondents used multivitamins more frequently during infection than before COVID-19 (39.0 % vs. 29.2 %, p = 0.025). 167 (22.2 %) respondents used vitamin D in treatment. Respondents used vitamin D at a non-significantly higher rate during infection than before COVID-19 (39.4 % vs. 30.1 %, p = 0.776). Non-significant increases in using Echinacea, Manuka, curcumin, and ginger were observed in respondents during infection compared with before COVID-19 (Table 2). However, non-significant decreases in the use of royal jelly, probiotics, and propolis were reported in respondents before and after COVID-19 infection (Table 2).

Table 2.

Pattern of dietary supplements use before and during COVID-19 (N = 751).

	Before COVID-19 pandemic (%)	During COVID-19 pandemic (%)	P-value
Vitamin C	144 (47.2 %)	341 (76.4 %)	0.000
Zinc	104 (34.1 %)	286 (60.4 %)	0.000
Omega 3	61 (20.0 %)	105 (23.5 %)	0.337
Vitamin D	92 (30.1 %)	176 (39.4 %)	0.776
Echinacea	23 (7.5 %)	53 (11.9 %)	0.058
Royal Jelly	41 (13.4 %)	56 (12.6 %)	0.487
Manuka	60 (19.7 %)	138 (30.9 %)	0.204
Propolis	19 (6.2 %)	24 (5.4 %)	0.609
Multivitamins	89 (29.2 %)	174 (39.0 %)	0.025
Probiotic	74 (24.2 %)	22 (5.0 %)	0.001
Black seeds	71 (23.3 %)	130 (29.1 %)	0.047
Curcumin	32 (10.5 %)	70 (15.7 %)	0.060
Ginger	30 (9.8 %)	139 (31.1 %)	0.450
Garlic	13 (4.2 %)	103 (23.1 %)	0.000

McNemar test

3.3. Regarding risk perception

The respondents think that nutritional supplements relieve the symptoms of COVID-19 infection (mean score = 7.5, standard deviation [SD] = 1.9). The respondents are convinced that nutritional supplements help protect your family members from infection with COVID-19 (mean score = 7.1, SD = 2.2). The respondents are convinced that using nutritional supplements is an alternative to not adhering to the preventive measures (mean score = 3.5, SD = 2.5). The respondents are convinced that nutritional supplements reduce the spread of the virus (mean score = 4.3, SD = 2.6). They are satisfied with the benefits of using nutritional supplements (mean score = 7.7, SD = 2.1). The risk perception score is summarized in Table 3.

Table 3.

Risk perception score from low (1) to high risk (10).

	Mean ± SD	P-value
To what extent do you think that nutritional supplements relieve the symptoms of COVID-19 infection	7.5 ± 1.9	0.001
How convinced are you that nutritional supplements help protect your family members from infection with COVID-19?	7.1 ± 2.2	0.001
How convinced are you that the use of nutritional supplements is an alternative to not adhering to preventive measures?	3.5 ± 2.5	0.001
How convinced are you that nutritional supplements reduce the spread of the virus?	4.3 ± 2.6	0.001
How satisfied are you with the benefits of using nutritional supplements?	7.7 ± 2.1	0.001

Chi-square test

3.4. The side effects of dietary supplements on patients before and during infection with COVID-19

The adverse effects of dietary supplements before and during infection with COVID-19 were reported as nausea (0.7 % and 1.1 %, respectively), diarrhea (0.0 % and 0.2 %, respectively), vomiting (0.3 % and 0.2 %, respectively), headache (0.7 % and 0.0 %, respectively), low blood sugar level (0.7 % and 0.2 %, respectively), high blood sugar level (0.0 % and 0.2 %, respectively), reflux (0.0 % and 0.7 %, respectively), more than one side effect (2.3 % and 6.3 %, respectively), and other side effects (1.0 % and 0.7 %; respectively). A summary of the side effects of the dietary supplements on patients before and during their infection with COVID-19 is shown in Table 4.

Table 4.

Side effects of dietary supplements on patients before and during infection with COVID-19.

	Before COVID-19 pandemic (%)	During COVID-19 pandemic (%)
Nausea	2 (0.7 %)	5 (1.1 %)
Diarrhea	0 (0.0 %)	1 (0.2 %)
Vomiting	1 (0.3 %)	1 (0.2 %)
Headache	2 (0.7 %)	0 (0.0 %)
Low blood sugar level	2 (0.7 %)	1 (0.2 %)
High blood sugar level	0 (0.0 %)	1 (0.2 %)
Reflux	0 (0.0 %)	3 (0.7 %)
More than one	7 (2.3 %)	28 (6.3 %)
Other	3 (1.0 %)	3 (0.7 %)

3.5. doses of dietary supplements per day before and during the COVID-19 infection

A summary of doses of dietary supplements per day before and during the COVID-19 infection is shown in Table 5.

Table 5.

doses of dietary supplements per day before and during COVID-19 (N = 751).

	Before COVID-19 pandemic (%)				During COVID-19 pandemic (%)				P-value
	One time/day	2-times/day	3-times/day	4-time/day	One time/day	2-times/day	3-times/day	4-time/day
Vitamin C	123 (40.2 %)	13 (4.2 %)	4 (1.3 %)	4 (1.3 %)	218 (24.5 %)	109 (24.5 %)	12 (2.7 %)	2 (0.4 %)	0.745
Zinc	81 (26.5 %)	20 (6.5 %)	2 (0.7 %)	1 (0.3 %)	138 (31.0 %)	138 (31.0 %)	8 (1.8 %)	2 (0.4 %)	0.056
Omega 3	44 (14.4 %)	11 (3.6 %)	4 (1.3 %)	2 (0.7 %)	60 (13.5 %)	19 (4.3 %)	26 (5.8 %)	0 (0.0 %)	0.731
Vitamin D	83 (27.1 %)	7 (2.3 %)	1 (0.3 %)	1 (0.3 %)	168 (37.8 %)	7 (1.6 %)	1 (0.2 %)	0 (0.0 %)	0.268
Echinacea	16 (5.2 %)	4 (1.3 %)	1 (0.3 %)	2 (0.7 %)	22 (4.9 %)	8 (1.8 %)	23 (5.2 %)	0 (0.0 %)	0.655
Royal Jelly	35 (11.4 %)	4 (1.3 %)	0 (0.0 %)	2 (0.7 %)	41 (9.2 %)	15 (3.4 %)	0 (0.0 %)	0 (0.0 %)	0.616
Propolis	15 (4.9 %)	3 (1.0 %)	0 (0.0 %)	1 (0.3 %)	18 (4.0 %)	5 (1.1 %)	1 (0.2 %)	0 (0.0 %)	0.454
Manuka	46 (15.0 %)	11 (3.6 %)	0 (0.0 %)	3 (1.0 %)	53 (11.9 %)	65 (14.6 %)	16 (3.6 %)	4 (0.9 %)	0.820
Multivitamins	65 (21.2 %)	17 (5.6 %)	3 (1.0 %)	1 (0.3 %)	118 (26.5 %)	54 (12.1 %)	2 (0.4 %)	0 (0.0 %)	0.848
Probiotic	20 (6.5 %)	5 (1.6 %)	1 (0.3 %)	1 (0.3 %)	16 (3.6 %)	5 (1.1 %)	1 (0.2 %)	0 (0.0 %)	0.796
Black seeds	52 (17.0 %)	16 (5.2 %)	2 (0.7 %)	1 (0.3 %)	55 (12.9 %)	60 (13.5 %)	13 (2.9 %)	2 (0.4 %)	0.676
Curcumin	21 (6.9 %)	5 (1.6 %)	5 (1.6 %)	1 (0.3 %)	38 (8.5 %)	26 (5.8 %)	5 (1.1 %)	1 (0.2 %)	0.251
Ginger	36 (11.8 %)	15 (4.9 %)	9 (2.9 %)	0 (0.0 %)	52 (18.4 %)	43 (9.7 %)	13 (2.9 %)	1 (0.2 %)	0.102
Garlic	25 (8.2 %)	10 (3.3 %)	2 (0.7 %)	1 (0.3 %)	44 (9.9 %)	45 (10.1 %)	13 (2.9 %)	2 (0.4 %)	0.527

ANOVA test

3.5.1. Vitamin C

The doses of vitamin C in respondents before infection with COVID-19 were documented as a single dose (n = 123, 40.2 %), two doses (n = 13, 4.2 %), three doses (n = 4, 1.3 %), and four doses (n = 4, 1.3 %) per day. while doses of vitamin C in respondents during infection with COVID-19 were documented as a single dose (n = 218, 24.5 %), two doses (n = 109, 24.5 %), three doses (n = 12, 2.7 %), and four doses (n = 2, 0.4 %) per day.

3.5.2. Zinc

The doses of zinc in respondents before infection with COVID-19 were documented as a single dose (n = 81, 26.5 %), two doses (n = 20, 6.5 %), three doses (n = 2, 0.7 %), and four doses (n = 1, 0.3 %) per day. while doses of zinc in respondents during infection with COVID-19 were documented as a single dose (n = 138, 31.0 %), two doses (n = 138, 31.0 %), three doses (n = 8, 1.8 %), and four doses (n = 2, 0.4 %) per day.

3.5.3. Vitamin D

The doses of vitamin D in respondents before infection with COVID-19 were reported as a single dose (n = 83, 27.1 %), two doses (n = 7, 2.3 %), three doses (n = 1, 0.3 %), and four doses (n = 1, 0.3 %) per day. while doses of vitamin D in respondents during infection with COVID-19 were reported as a single dose (n = 168, 37.8 %), two doses (n = 7, 1.6 %), three doses (n = 1, 0.2 %), and four doses (n = 0, 0.0 %) per day.

Respondents' intake of all dietary supplements (except probiotics) increased by at least one dose per day during the COVID-19 infection compared to before.

4. Discussion

This cross-sectional study aimed to describe the prevalence, dosage, and perceived utility and side effects of dietary supplements among a convenience sample of Saudi adults and children before and during the COVID-19 pandemic.

The findings of our study reported that the intake of nutritional supplements during the COVID-19 pandemic period was higher than before the COVID-19 pandemic period. Also, the frequency of consumer nutritional supplements during the COVID-19 pandemic was higher than before the COVID-19 pandemic period. These observations agree with the recent study, which documented that around 22.1 % of the respondents reported that they had used nutritional supplements during the COVID-19 pandemic period to decrease the risk of contracting the disease^[23].

This study reported a significant increase in vitamin C (76.4 vs. 47.2 %, p < 0.001), zinc (60.4 vs. 34.1 %, p < 0.001), and multivitamins (39.5 vs. 29.2 %, p = 0.025) in respondents during infection than before COVID-19. Non-significant increases in using Vitamin D, Echinacea, Manuka, curcumin, and ginger and non-significant decreases in using royal jelly, probiotics, and propolis were reported in respondents before and during the COVID-19 infection. Consistent with our findings, the Saudi population in Riyadh used nutritional supplements and herbal products at much higher rates during the COVID-19 pandemic period compared to the pre-pandemic period. During the COVID-19 pandemic, the majority of people used zinc (72.9%), vitamin C (56.0%), garlic (Allium sativum) (53.80%), and cinnamon (52.0 %)^[24].

There is no specific antiviral recommended for the treatment of COVID-19, and the currently available vaccine is a few numbers. Only supportive care and personal protection are available[25], [26]. With the increased number of users of herbal products and dietary supplements, many studies have documented that they are safer than prescription medications and are of good quality to prevent most chronic diseases or increase health[27], [28], [29].

The clinical studies documented herb and food combinations of traditional Chinese herbs to prevent the influenza virus and COVID-19[30], [31], [32].

The present study reported that most of the participants reported that they used vitamin C (64.6 %), zinc (51.9 %), multivitamins (46.1 %), black seeds (26.7 %), garlic (Allium sativum) (15.4 %), omega-3 (22.1 %), vitamin D (22.2 %), echinacea (10.1 %), manuka honey (26.0 %), curcumin (13.6 %), ginger (22.5 %), royal jelly (12.9 %), and propolis (7.5 %) before and during the COVID-19 pandemic period.

Those results agreed with Zhang and Liu, who suggested that dietary supplementation with vitamins (e.g., A, B, C, and D) be used as a treatment for COVID-19 patients and as preventive therapy against lung infection^[33]. Several dietary supplements have been shown to have antiviral benefits in studies. These include black seeds, garlic, ginger, cranberries, oranges, omega-3, and − 6 polyunsaturated fatty acids, vitamins (e.g., A, B vitamins, C, D, and E), and minerals (e.g., Cu, Fe, Mg, Mn, Na, Se, and Zn). SARS-coronaviruses and other respiratory viruses are common targets for many of them. Therefore, antiviral drugs can be used in combination with dietary supplements, including vitamins, minerals, probiotics, and even just traditional eating habits, to control COVID-19 disease^[34].

The most common vitamin used across different populations is vitamin C because it has a crucial role in acquired (specific) and innate (nonspecific) immunity^[35]. In addition, vitamin C protects against infections caused by COVID-19 and supports immune functions^[36].

Omega-3 fatty acids have also been shown to protect against COVID-19 infection. Zinc supplementation has an essential role in the maintenance and growth of innate and adaptive immune cells^[37]. Because of its antioxidant and anti-inflammatory properties, low zinc levels may be a risk factor for pneumonia in the elderly. It can regulate tight junction proteins such as Zonula occludens-1 and Claudin-1^[38].

Garlic is commonly used among the general population. Garlic extracts have been reported to have a role in antiviral activity against different viruses by inhibiting viral RNA polymerase, reverse transcriptase, DNA synthesis, blocking viral entry into host cells, and immediate-early gene 1 (IEG1) transcription^[39].

Furthermore, compounds derived from garlic have been shown to reduce the expression of pro-inflammatory cytokines as well as the hormone leptin; this results in an inhibition of the pro-inflammatory nature and helps relieve some symptoms observed during COVID-19 infection^[40].

Natural honey has been documented as antimicrobial and approved by the Food and Drug Administration (FDA) for wound treatment in 2007^[41]. The natural honey supplement has a role as an antimicrobial in many research investigations and is reported as an excellent antiviral drug for the treatment of some viral infections^[42]. A clinical trial reported that natural honey caused a reduction in the symptoms of COVID-19 patients^[43]. A similar study also reported that black seeds and natural honey significantly improved viral clearance and symptoms in patients of both sexes^[44].

Many extracts and chemicals from medicinal plants have been found to have antiviral properties against various viruses in laboratory and animal studies. It is therefore not surprising that many researchers have concentrated on natural product activity, especially TCM, since the COVID-19, SARS, and MERS outbreaks for the prevention and treatment of novel CoV infections. Additionally, many natural products are known to promote immune function, act as anti-inflammatory and antioxidant agents, and simultaneously contribute to a balanced healthy status, among other impacts, in addition to their antiviral actions^[45].

Several limitations are noted in this study, including Due to the limited sample size and cross-sectional survey design, no causal correlations can be inferred between the research variables. Since there is so little population-based research on the efficacy of dietary supplements and herbal products in the prevention and treatment of COVID-19 infection, we were unable to reliably compare our results to those from other countries, including Saudi Arabia. The use of an online survey to gather information also raises the possibility of data misreporting and the exclusion of some at-risk groups. Participants were entirely from Makkah, hence, the regional distribution of the study was limited. The predictive value of these results has to be determined by conducting large-scale prospective investigations.

5. Conclusion

Our results were cross-sectional; dietary supplements were common among the public in Saudi Arabia during the COVID-19 pandemic. The respondents' risk of dietary supplement use may partially reflect the public's behavioral response during a pandemic. Our study's findings demonstrated that the intake of nutritional supplements increased among the general population in Saudi Arabia before and during the COVID-19 pandemic period to protect them from the disease. In addition, the intake of nutritional supplements should be evidence-based to ensure patient safety. Future studies can document the health beliefs and motivations of dietary supplement users. At the same time, we acknowledge that social distancing, vaccination, and basic hygiene remain the mainstays of controlling the pandemic.

Conflicts of Interest

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

Appendix A. Supplementary material

Supplementary material.

.