A Questionnaire-based Study for Weight Loss by Using Herbal Drugs in Dammam (Eastern Region), Kingdom of Saudi Arabia.

BACKGROUND: Obesity is a common health problem and it is increasing around the world. Herbal drugs are the most commonly used alternative treatment for weight reduction. The aim of this study was to identify the most commonly used plants for the treatment of obesity or to reduce the weight of patients with obesity and to determine the usage rate of herbal drugs in Dammam, Kingdom of Saudi Arabia.
MATERIALS AND METHODS: This cross-sectional study was performed on people who were overweight and obese in Dammam (Eastern Region), Kingdom of Saudi Arabia, by using pretested questionnaire. Participants were randomly selected for this questionnaire study. P value was calculated by using chi-square test.
RESULTS: A total of 500 participants were selected, of which 355 participants completed the questionnaire-based study and the remaining 145 were excluded from the study. The majority (n = 190, 53.52%, P > 0.05) used herbal drugs to reduce weight. The most commonly used herbal drugs included green tea (53.52%, P > 0.05), ginger (31.54%, P < 0.01), and flax seed (17.46%, P < 0.01). However, nearly 35% of participants stated that they had unwanted effects; therefore, majority of the participants stated they would use herbal drugs in future to reduce weight.
CONCLUSION: This investigation showed that the treatment to reduce weight of those who were overweight or obese by herbal drugs and the usage rate of herbal drugs/fruits/vegetables were high in Dammam. Further investigations are required to prove the efficacy of herbal drugs and their side effects for the treatment of obesity. A community awareness program is essential to explain the positive and adverse effects of herbal drugs.

Introduction

Overweight and obesity are defined as abnormal or excessive fat accumulation that may impair health. Body mass index (BMI) is a generally used method to categorize overweight and obesity in adults. It is defined as a person’s weight in kilograms divided by the square of the height in meters (kg/m2). According to the World Health Organization (WHO), BMI more than or equal to 25kg/m2 is considered as overweight and BMI more than or equal to 30kg/m2 is considered as obese.[1] The prevalence rate of obesity almost triplicated in between 1975 and 2016 worldwide (WHO Guidelines). The WHO estimated globally that more than 1.9 billion adults and older people were overweight and of these over 650 million adults were obese.[2] Obesity is a major risk factor for many noncommunicable diseases, including cardiovascular diseases (especially heart disease and stroke), type 2 diabetes, musculoskeletal disorders (especially osteoarthritis—a highly disabling degenerative disease of the joints), and some cancers (including endometrial, breast, ovarian, prostate, liver, gallbladder, kidney, and colon).[3] The risk increases when the level of obesity increases (BMI). Obesity and overweight are also allied with mental health and eating disorders.[4]

Obesity and overweight have become the most prevalent nutritional problems in the world, putting an increased burden on the health-care system. Approximately one-third of the global population (2.1 billion people) were affected from these problems and 5% of all deaths worldwide.[456] If the current scenario continues then these problems may affect almost half of the world’s adult population by 2030.[7] Treatment methods used for obesity and overweight are conservative therapy, pharmacological therapy, and bariatric surgery. All of the treatment plans have varying degree of effectiveness due to cost, unwanted side effects, and compliance issues. Conservative therapy, such as lifestyle and diet control, includes exercise, avoid fatty intakes, reduced caloric intakes, and increased energy expenditure. Pharmacological therapies were recommended for short period because of adverse effects. In addition to the pharmacological intervention for obesity, consumers are continually seeking a more natural alternative treatment to achieve the same weight loss goal. Currently, herbal products that claimed to give weight loss are popular.[8]

Herbal drugs have been used as medicines to cure various diseases since ancient times. Medicinal plants played an important part in world health. In spite of the great developments observed in modern medicine in the present period, plants still make an important contribution to health care.[9] Natural products have been our primary source of medicines.[10] There are at least 120 different chemical constituents isolated from the plants and widely used in modern medicine around the world, whereas several other drugs are simple synthetic alterations of the natural products.[11] Many studies have been investigated for the efficacy and safety of the herbal drugs to treat patients who are overweight and obese. A clinical trial conducted in China on traditional Chinese medicine on 140 patients who were obese for 24 weeks using herbals, namely rhubarb, Coptis, Cassiae semen, and Citrus aurantium, were found to be very effective in reducing the weight with no serious adverse effect.[12] Another Chinese study reported that long-term consumption of oolong tea prevents obesity.[13] According to the observational studies, ginger extract is among the top 10 ingredients in weight loss products.[14]

Obesity and overweight are the most common health problems, affecting male and female of all ages in the Kingdom of Saudi Arabia (KSA). Approximately, 60% of the total population were affected from overweight and obesity as per the report of the Ministry of Health, Obesity Control Program, 2016, in KSA (Saudi guidelines on the prevention and management of obesity, first edition, 2016). The rate of obesity prevalence between males and females was 24.1% and 33.5%, respectively, whereas 33.4% males and 28.0% females were overweight.[15] The aim of this investigation was to show the importance of herbal drugs for the treatment of obesity and weight loss and also to determine the usage rate of the herbal drugs, but it is not intended to compare their effects with the synthetic drugs traditionally used for this purpose.

Materials and Methods

A cross-sectional, questionnaire-based study was conducted in Dammam community, KSA, for 4 months from February 2018 to May 2018. A total of 500 questionnaires were distributed to the participants, of which only 355 participants answered the questionnaire, which was designed to know the demographic details and the number of participants using herbal drugs to reduce weight. To conduct this study, ethical approval was obtained from the scientific research unit of Mohammed Al Mana College for Medical Sciences (MACHS) (letter no. SR/RP/04) Dammam, KSA.

Study Tool

The questionnaire contained 15 validated questions.[16] It contained two parts. First part contained the participants’ demographic details such as age, gender, nationality, and education level, and the participants’ history of obesity. The second part contained usage rate of herbal medicines for participants with obesity/obese; its name, method of use, frequency, whether the plant was prescribed by a doctor, and the patient’s experience with herbal medicines.

Data collection was carried out by a B.Sc. final-year pharmacy student who visited different areas of Dammam, including health-care centers, housing areas, malls, and shopping centers; questionnaires were distributed to different participants of the study after explaining the objectives of the study. A written consent form was obtained from each participant who enrolled in the study. The participants were informed that their involvement was voluntary in the study and the data would be confidential and would be used for research purposes.

Data were analyzed using Statistical Package for the Social Sciences (version 21) (SPSS, Chicago, Illinois). The descriptive analysis was carried out using mean values and SD for continuous variables and percentage for qualitative variables. The chi-square test was used to calculate P values for categorical variables. P values of less than 0.05 were considered significant.

Results

The questionnaires survey were distributed to 500 participants, of which only 355 (17.23% male and 81.9% female) completed the survey. More than one-fourth of the participants, 98 (27%), were in the age group of 15–20 years, whereas one-third of the participants belonged to age group of 20–30 years. Majority of the participants were Saudi nationals (n = 321, 90.4%) and very few were expats (n = 34, 9.5%). Female participants (n = 291, 81.9%) were more as compared to male participants (n = 61, 17.2%). A majority of participants (n = 325, 91.5%) were urban residents, whereas some of them were rural residents (n = 30, 8.4%). More than two-third of the participants (n = 251, 71%) were university educated and nearly one-fourth of the participants (n = 80, 24%) were secondary school educated [Table 1].

Table 1

Demographic characteristics of participants (n = 355)

Characteristics	Response (n)	Percentage (%)	P value (χ2 test)
Gender			<0.01
Male	61	17.2%
Female	291	81.9%
Age (years)			<0.01
15–20	98	27%
20–30	127	34%
30–40	90	25%
>50	26	8%
Nationality			<0.01
Saudi	321	90.7%
Non-Saudi	34	9.3%
Residence			<0.01
Rural	30	8.4%
Urban	325	91.5%
Education			<0.01
University	251	71%
Secondary	80	24%
Less than secondary illiterate	24	6%

P < 0.05 considered as significant P value

The data presented in Table 2 showed that 43% of the participants (n = 152) were overweight or obese before the age of 20 years, whereas 27% (n = 96) and 18% (n = 65) became overweight or obese at the age of 20–30 and 30–40 years, respectively. Exactly one-third of the participants (n = 119, 33.5%) had obesity due to genetic causes; duration of obesity or overweight in the participants (n = 137, 38.6%) was less than 5 years. Approximately 80% of the participants did not consult with the doctors to treat their overweight or obesity.

Table 2

Obesity/overweight history among participants (n = 355)

Characteristics	Response (n)	Percentage (%)	P value (χ2 test)
Age at obesity diagnosis (years)			<0.01
<20	152	43%
20–30	96	27%
30–40	65	18%
40–50	24	7%
>50	18	5%
Cause of obesity			<0.01
Genetic	119	33.5%
Others	236	66.4%
Duration of obesity (years)			<0.01
<5	137	38.6%
5–9	70	19.7%
10–14	49	13.8%
15–19	33	9.2%
20–24	19	5.3%
≥25	15	4.2%
Follow-up with doctor			<0.01
Yes every 1 year	41	11.5%
Yes every 6 months	32	32%
No	282	79.6%

P < 0.05 considered as significant P value

Figure 1 shows that slightly more than half of the participants (n = 190, 53.52%) were using herbal drugs to reduce their weight. In Table 3, the data showed that more than half of the participants (n = 190, 53.52%) used green tea to reduce their weight. An attempt has been made by the participants to reduce their weight by using herbal drugs, namely ginger (n = 112, 31.5%), fruits (n = 94, 26.4%), vegetables (n = 87, 24.5%), flaxseed (n = 62, 17.4%), and bran (n = 45, 12.6%).

Figure 1

Rate of herbal drugs used by participants

Table 3

Participants who were overweight or obese reducing weight by using herbal drugs (n = 355)

Characteristics	Response (n)	Percentage (%)	P value (χ2 test)
Using herbal medicines with drugs			<0.01
Yes	77	21.6%
No	278	78.3%
Using herbal medicines (if yes)
Green tea (Camellia sinensis)			>0.05
Yes	190	53.5%
No	165	46.4%
Bran (Triticum sativum)			<0.01
Yes	45	12.6%
No	310	87.3%
Plantain (Musa paradisiaca)			<0.01
Yes	6	1.6%
No	349	98.3%
Senna (Cassia angustifolia)			<0.01
Yes	13	3.6%
No	342	96.3%
Capsicum (Capsicum annum)			<0.01
Yes	14	3.9%
No	341	96.0%
Ginger (Zingiber officinale)			<0.05
Yes	112	31.5%
No	243	68.4%
Turmeric (Curcuma longa)			<0.01
Yes	38	10.7%
No	317	89.3%
Fenugreek (Trigonella foenum-graecum)			<0.01
Yes	22	6.1%
No	333	93.8%
Flaxseed (Linum usitatissimum)			<0.01
Yes	62	17.4%
No	293	82.5%
Fennel (Foeniculum vulgare)			<0.01
Yes	26	7.3%
No	329	92.6%
Fruits			<0.01
Yes	94	26.4%
No	261	73.4%
Vegetable			<0.01
Yes	87	24.5%
No	268	74.4%

P < 0.05 considered as significant P value

According to the data in Table 4, friends (n = 75, 39.4%) and doctors (n = 40, 21%) were the most common prescriber of the herbal drugs, whereas 34 and 9 participants reported that their herbal drugs advisors were herbalists and pharmacists, respectively. Majority of the participants (n = 154, 81%) stated that they prepared and used the herbal formulation by mixing them with boiling water.

Table 4

Herbal drugs instruction (n = 190)

Characteristics	Response (n)	Percentage (%)	P value (χ2 test)
Who recommended herbal medicines?			<0.01
Doctors	40	21.0%
Pharmacists	9	4.7%
Herbalists	34	17.8%
Friends	75	39.4%
Patients with obesity	32	16.8%
Formulation used			<0.01
Boiling with water	154	81%
Powder	36	10.1%
Frequency of herbal use			<0.01
Once daily	75	39.4%
Twice daily	29	15.2%
Three times/day	30	15.7%
Once weekly	16	8.4%
Whenever needed	40	21.0%
Positive results of herbal drugs			>0.05
Yes	100	52.6%
No	90	47.3%

P < 0.05 considered as significant P value

Approximately one-third of the participants (n = 66, 34.7%) reported side effects of herbal drugs, of which the maximum participants had diarrhea herbal drugs (Table 5) (n = 37, 56%) as compared to those who had headache (n = 16, 24.2%) and abdominal pain (n = 9, 13.6%). Although majority of the participants (n = 47, 71.2%) had not informed the doctor about side effects, more than half of the participants informed positive effects of herbal drugs. Figure 2 showed that majority of the participants (n = 149, 78.4%) reported that they would use herbal drugs again in future to reduce their weight.

Table 5

Participants involvement with herbal drugs

Characteristics	Response (n)	Percentage (%)	P value (χ2 test)
Having side effects (n = 190)			<0.01
Yes	66	34.7%
No	124	65.2%
Specification of side effects (n = 66)			<0.01
Headache	16	24.2%
Diarrhea	37	56.0%
Vomiting	1	1.5%
Abdominal pain	9	13.6%
Dizziness	3	4.5%
Informing doctor about side effects (n = 66)			<0.01
Yes	19	28.7%
No	47	71.2%
Doctor’s opinion regarding side effects (n = 66)			<0.01
Agree to use	45	68.1%
Disagree to use	12	18.1%
Do not care	9	13.6%

P < 0.05 considered as significant P value

Figure 2

Participants attitude toward repeating herbal drugs

Discussion

Obesity has become an increasingly important medical problem, which is one of the most prevalent nutritional disorders rising in the developed countries and progressively increasing in the developing world, affecting particularly teenagers and adults, especially females. In this investigation, more than half of the participants (52.7%) reported reducing weight after using herbal drugs. Mohamed et al.[17] reported that 33% of the patients who were obese in the US used herbal medicine for the treatment of obesity, of which majority of them were female. This investigation showed high usage rate of herbal drugs in Dammam, KSA. Herbal products are among a comprehensive assortment of treatments referred to as complementary and alternative medicine.

This investigation showed high usage rate of green tea and ginger to reduce weight. Various studies carried out to examine the effectiveness of green tea and ginger confirmed its beneficiary effect on obesity and various other diseases, such as type 2 diabetes mellitus and cardiovascular diseases. Wang et al.[18] reported that regular drinking of green tea for over 90 days leads to significant reduction in body weight in moderately overweight Chinese men and women. Auvichayapat et al.[19] reported that green tea can reduce body weight in Thais who were obese by increasing energy expenditure and fat oxidation. Azushima et al.[20] reported that herbal medicines have positive effects on obesity-related hypertension compared with conventional pharmaceutical treatments.

Majority of the participants had not discussed with their doctors before starting herbal drugs for weight reduction. They were advised by friends, relatives, patients who were obese, and herbalists. Most commonly used medications in Iran for obesity were herbal drugs, approximately 60% of women with obesity stated that their friends and relatives, followed by social media were the main source of receiving information for herbal drugs to reduce weight or treat obesity. The trend of self-treatment and self-diet management in younger women in Tehran (Iran) is of concern because of increasing self-medication for obtaining satisfaction regarding their physical appearance.[21]

Jacqueline et al.[22] reported that the Americans are progressively substituting prescription medications with herbal medicines. A study based in Jordan reported that 82% of university students use herbal drugs over the conventional medicine for weight loss.[23] Zaidi et al. and Ahmad et al. reported that a traditional Unani polyherbo-mineral formulation namely Safoof-e-Pathar Phori was very effective as noninvasive remedy for the Urolithaitic patients.[24-25]

Eldalo et al.[16] reported that green tea was the most commonly used herbal medicine for the treatment of obesity and the usage rate of herbal drugs was high in Taif, KSA.

Many people choose herbal drugs over conventional medications for weight loss because of the availability of herbs; they can be obtained without a prescription and are generally less expensive and have less side effects. A wide range of herbal drugs as well as their extracts or isolated active constituents from plants can be used for weight loss and for prevention of weight gain. Initial analyses suggest that herbal drugs may be a cost-effective intervention in the management of obesity.

The use of herbal supplements among the US residents has been increasing over the years. It is unclear whether this increase is due to the effectiveness and safety of herbal medicines or due to other components, such as extensive marketing. More research is needed to confirm the already concluded reasons such as improving health and well-being, alleviate symptoms accompanying chronic diseases, relief of unpleasant side effects associated with conventional treatments, and holistic beliefs or disclose new rationale explaining people’s choice to use herbal supplements. Mail-order pharmacy, over the counter products users, and those having chronic diseases associated positively with the use of herbal supplements. Further studies are needed to assess attitudes, perceptions, beliefs, perceived outcome, and overall effectiveness of herbal medicine use.[22]

Conclusion

This investigation showed that green tea, ginger, and flaxseed were the most commonly and frequently used herbal drugs and their usage rates were high in Dammam for the treatment of patients with obesity. Apart from the herbal drugs commonly used, fruits and vegetables also played a very good role in reducing the weight (to treat obesity in Dammam). Further investigations are required for the standardization and quality control of herbal drugs/fruits/vegetables to find out the active principle components that are responsible to reduce the weight and their side effects.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.