Tendencies and attitudes towards dietary supplements use among undergraduate female students in Bangladesh.

BACKGROUND: Dietary supplements (DS) are products that improve the overall health and well-being of individuals and reduce the risk of disease. Evidence indicates a rising prevalence of the use of these products worldwide especially among the age group 18-23 years. AIM: The study investigates the tendencies and attitudes of Bangladeshi undergraduate female students towards dietary supplements (DS).
METHODS: A three-month (March 2018-May 2018) cross-sectional face-to-face survey was conducted in undergraduate female students in Chittagong, Bangladesh using a pre-validated dietary supplement questionnaire. The study was carried among the four private and three public university students of different disciplines in Chittagong to record their prevalent opinions and attitudes toward using DS. The results were documented and analyzed by SPSS version 22.0.
RESULTS: Ninety two percent (N = 925, 92.0%) of the respondents answered the survey questions. The prevalence of DS use was high in undergraduate female students. The respondents cited general health and well-being (n = 102, 11.0%) and physician recommendation (n = 101, 10.9%) as a reason for DS use. Majority of the students (n = 817, 88.3%) used DS cost monthly between USD 0.12 and USD 5.90. Most of the students (n = 749, 81.0%) agreed on the beneficial effect of DS and a significant portion (n = 493, 53.3%) recommended for a regular use of DS. Highly prevalent use of dietary supplements appeared in Chittagonian undergraduate female students. They were tremendously positive in using DS. The results demonstrate an increasing trend of using DS by the undergraduate females for both nutritional improvement and amelioration from diseases.
CONCLUSION: Dietary supplements prevalence was so much higher in students of private universities as compared to students of public universities. Likewise, maximal prevalence is indicated in pharmacy department compared to other departments. Students preferred brand products, had positive opinions and attitudes towards dietary supplements.

Introduction

Dietary supplement (DS) is a manufactured product containing one or more than one dietary elements such as vitamins, minerals, herbs or botanicals products, fatty acids, proteins purposive to supplement the diet [1]. DS provides nutrients either extracting from food or synthetic sources administered through the mouth as a tablet, capsule, or pill. It also contains other constituents that may not be therapeutically effective or essential for life, such as polyphenols or plant pigments. In many countries, DS’s are deliberated as a subset of foods and controlled consequently [2]. DS’s are commonly used by adults to progress or maintain health as well as disease recovery [3, 4]. The use of DS is gradually increasing over time over the world [4]. Around 68% of US adults are reported to use DS in different forms. During 2007–2010 in the United States (US), it was assessed that 23% of the supplements was suggested by the health care professional [5]. Another US investigation through NHANES (1999–2012) reported that nearly 52% of responders from the US had an uninterrupted DS consumption which is found as diverse testaments in US and Europe for extensive consumption [6]. Bangladesh is located in South Asia, where the use of DS among individuals is very common. During 2018, an assessment showed that approximately 41.3% of participants used the DS at least once in the previous year. The number of female users was 45%, which was higher than that of male users. Additionally, 33% of the users started taking supplements without any prescription or consultation healthcare professionals such as pharmacists consisting vast knowledge on the safer and effective uses of DS. DS’s using rate is less in good health people than in poor health people. The aims, perception and opinions of using DS varies in different age and professional groups while kids are given DS’s with the suspicion of nutritional insufficiency [6].

The college and undergraduate students feel they need extra nutrients from DS to compensate their energy deficit for extracurricular activities, study, or part-time jobs. Researchers reported 66% of the five US university students consume DS [7]. 63% of female participants from 16 US medical colleges use DS while male DS consumers were lesser than female [8]. Another study showed that 76.6% of Saudi female students love to use DS [9]. An insignificant difference between male and female DS uses in Japan and 56% of Australian DS using students in 2015 are reported in literature [10]. The micronutrient depletion situation in Bangladesh is growing day by day. In Bangladesh, one-fourth of the population aged 15 to <49 years had chronic energy deficiency or thinness (BMI<18.5) and in Bangladesh, about 25% of the adult population was undernourished or lean (BMI<18.5) aged 46-<60 years [11]. Moreover, females are more prone to suffer from nutritional deficiencies than men due to various factors such as female reproductive biology, low social status, poverty and lack of education [11]. Socio-cultural practices and inequalities in domestic job habits may also increase the possibility of malnutrition for females [12].

In Bangladesh, a group of researches revealed the dietary supplement especially calcium, zinc and iron supplement consumption pattern on pregnant and non-pregnant women [13]. Another research from southern parts of Bangladesh demonstrated that, male and females participants aged between 15–65 years consumed DS without prescriptions [14]. Unfortunately, no such study has been conducted for Bangladeshi female undergraduate students. This research was conducted to determine the prevalence, user opinions and attitudes towards DS among undergraduate female students in Chittagong city of Bangladesh.

Materials and methods

Participant consent and ethical consideration

Protocol used in this study for the research work entitled on (Dietary supplement use among undergraduate female students in public and private universities located in Chittagong, Bangladesh: prevalence, opinions, and attitudes) was approved by the institutional ethical review committee (P&D Committee) of International Islamic University Chittagong, Chittagong, Bangladesh-4318 (ref: P&D-147/13-19). Participants were known to purposes, protocol, and importance of the survey. The participation was deliberate except any influence. Before supplying the questionnaire, an informed written consent was searched from students (S1 File).

Study design and duration

A cross-sectional study was planned and conducted in undergraduate female students for an epoch of three months. All the participants of this study were undergraduate females who had been selected between March 2018—May 2018. The inclusion criteria were: willingness to participate in the study, age >18 years, ability to understand English or Bengali, and participants with previous experience using dietary supplements. Participants who did not match the above criteria were excluded from the study. Finally, incompletely or incorrectly filled questionnaires were also not included.

Study site

The study was carried out in public and private universities located in Chittagong, Bangladesh. Chittagong division is geographically the largest of the eight administrative divisions of Bangladesh including seven public and six private universities.

Sample size calculation

Sample size was calculated by using Raosoft, Inc. (USA) [15]. Present survey involved 925 respondents who were undergraduate female students from listed four private and three public universities.

Study population

This cross-sectional study participants chosen from the Departments of Pharmacy, Bachelor of Business Administration, Economics and Banking, Law, Computer Science and Engineering, Electronics and Electrical Engineering, Quranic Science, Dawa and Islamic Studies, Hadith, English Language and Literature from different universities.

Purposes of the study

The primary purpose of our survey was to explore the dynamics of using dietary supplements by the undergraduate females, involving the respondent’s choice, age, discipline, nature of the institution. The survey was directed among several age ranges of 18–23, 24–26, and 27–30 years. The cause of the ordination is the education period. The inclusion of undergraduate students usually occurs in 18 years, and the duration varies from 4–5 years in different disciplines. The second principal objective was to inquire about DS’s differences with the variation of demography, particular opinion, attitudes, disciplines, and ages. Expense regarding dietary supplement usage was recorded and indicated by the BDT (Bangladeshi Taka).

Research instrument development

The authors prepared a questionnaire with the title of “the dietary supplement questionnaire (DSQ)”. It consists of several multiple-choice questions. The DSQ was further polished by a group of specialists led by two assistant professors. A pilot study (100 students) was performed to confirm the questionnaire’s reliability and validity using different approaches. We distributed the questionnaire amongst students to get their feedback regarding the understanding and clarity of all questions. The questionnaire was then reviewed by experts in related fields and other expert colleagues within the university. We also asked external reviewers to provide their feedback and opinion in developing/improving the questionnaire to ensure the reliability of the test and compared the results of our pilot study with the results of similar work done previously. We introduced all necessary expert feedback and suggestions accordingly until we had a final questionnaire (S2 File) used in the present study.

The DSQ was subdivided into two parts: Part A contains questions in respect of demographic information like age, study year, ethnic region, current marital status, residence, siblings, use of dietary supplement in the last month, name of the departments, and university type. Part B included the questions where respondents were asked on their major illness, reasons for using DS, types of DS they used, their affordability (cost/month in BDT), adverse reactions experienced from DS, opinions, and attitudes. Furthermore, they were asked about their compliance regarding DS’s role in health and if they would personally recommend using DS to others. They were also inquired whether they know about DS they had used or currently using.

Pilot study and accessibility of the DSQ

A pilot study of the DSQ was performed by distributing the questionnaire among 100 undergraduate female students belonging to different universities’ disciplines. A 93% of response rate proved that there were no troubles in understanding the questionnaire. At this point, the DSQ was considered suitable to use.

Data analysis

The data were analyzed by statistical software Statistical Package for Social Science (SPSS, version 22.0, IBM Corporation, NY). Frequency counts (N) and percentages (%) were introduced to represent the demographic information, opinions, and attitudes. The chi-square (χ2) test, cross tabulation, and p values were used to measure associations between demographic variables and opinions/attitudes. Multinomial logistic regression was conducted to determine different relationships between DS use and demographic characteristics of students.

Results

The reflection of the respondents on the use of DS has been summarized as follows:

Demographic information of the respondents

The demographic information of the 925 participants is shown in Table 1. The majority (n = 823, 89.0%), out of 925 respondents, in our study participated from private universities. More than three and a half quarter of the students belonged to the age group 18–23 years (n = 859, 92.9%). The majority of students were in 4th year (n = 343, 37.1%), followed by 3rd year (n = 215, 23.2%), during the study years. Almost all of the respondents of the study were found to be unmarried (n = 885, 95.7%). Majority of the students were living with family (n = 757, 81.8%) and were between 1 and 2 siblings (n = 422, 45.6%). These data were contributed by the department of Pharmacy (25.3%), Bachelor of Business Administration (11%), Economics and Banking (14.4%), Law (14.7%), Computer Science and Engineering (12.8%), Electrical and Electronics Engineering (7.5%), Quranic Science (3.4%), Dawa (1.7%), Hadith (1.3%), English Language and Literature (8%) of different universities shown in Fig 1.

Table 1

Demographic information of the respondents.

Items	Subgroups	Sample (N)	Percentage (%)
Age	18–23 years	859	92.9
	24–26 years	66	7.1
	27-30years	-	-
Study year	1st year	173	18.7
	2nd year	194	21.0
	3rd year	215	23.2
	4th year	343	37.1
Ethnic origin	Bangladeshi	925	100.0
	Tribal	-	-
	Non-Tribal Bengali	-	-
Current marital status	Married	40	4.3
	Unmarried	885	95.7
	Divorced	-	-
Residence	Living with family	757	81.8
	Living alone (University accommodation)	148	16.0
	Living alone (Self accommodation)	20	2.2
Siblings	Between 1&2 siblings	422	45.6
	Between 3&5 siblings	355	38.4
	Between 6&8 siblings	74	8.0
	More than 8 siblings	37	4.0
	No siblings	37	4.0
University type	Private	823	89.0
	Public	102	11.0

Fig 1

Percentage of participations from various departmental students.

Here, BBA: Bachelor of Business Administration, EB: Economics and Banking, CSE: Computer Science and Engineering, EEE: Electrical and Electronics Engineering, ELL: English Language and Literature.

Suffering of the respondents from major illness

The detailed information for suffering of the respondents from major illness (if there is) is summarized in Table 2. Collectively, most of the students suffer from depression (n = 134, 14.5%) leading to hypertension (n = 96, 10.4%). Besides, less than two-quarters of the students did not have any major illness (n = 399, 43.1%).

Table 2

Suffering of the respondents from illness (if any).

Items	Subgroups	Sample (N)	Percentage (%)
Any major illness	Do not suffer from any illness	399	43.1
Suffer from a major illness	Depression	134	14.5
	Hypertension	96	10.4
	Diabetes mellitus	38	4.1
	Sickle cell anaemia	54	5.8
	Thalassemia	54	5.8
	Asthma	72	7.8
	Rheumatoid arthritis	36	3.9
	Psoriasis	-	-
	Ulcer	-	-
	Irregular ministration	-	-
	Migraine	21	2.3
	Obesity	-	-
	Epilepsy	-	-
	Others	21	2.3

Etiologies of using dietary supplements

The detail of the reasons for consuming DS’s is presented in Table 3. The greater portion of the respondents took DS to improve their general health and well-being (n = 102, 11.0%) while others consumed with physician’s recommendation (n = 101, 10.9%). There was no rationale (n = 124, 13.4%) for the use of DS amongst those who disagreed most strongly.

Table 3

Reasons for use of dietary supplements.

Statements	SD, N %	MD, N %	SLD, N %	NA/NOD, N %	SLA, N %	MA, N %	SA, N %
Physician recommendations	123	160	160	180	116	85	101
	13.3	17.3	17.3	19.5	12.5	9.2	10.9
General health and well being	119	163	162	180	112	87	102
	12.9	17.6	17.5	19.5	12.1	9.4	11.0
For weight gaining	114	166	166	184	109	88	98
	12.3	17.9	17.9	19.9	11.8	9.5	10.6
For energy source	122	161	163	181	115	89	94
	13.2	17.4	17.6	19.6	12.4	9.6	10.2
Immune booster	119	166	159	178	119	87	97
	12.9	17.9	17.2	19.2	12.9	9.4	10.5
Increase performance/sports	121	157	162	178	120	88	99
	13.1	17.0	17.5	19.2	13.0	9.5	10.7
To control hair fall and skin care	123	156	168	175	116	90	97
	13.3	16.9	18.2	18.9	12.5	9.7	10.5
Increase endurance/body building	121	160	159	180	119	87	99
	13.1	17.3	17.2	19.5	12.9	9.3	10.7
Memory enhancer	118	162	163	183	113	90	96
	12.8	17.5	17.6	19.8	12.2	9.7	10.4
Other reasons(pregnancy-induced anaemia & fatigue)	120	159	169	180	113	88	96
	13.0	17.2	18.3	19.5	12.2	9.5	10.4
No reason mentioned	124	158	163	182	112	87	99
	13.4	17.1	17.6	19.7	12.1	9.4	10.7

(SD = strongly Disagree, MD = Moderately disagree, SLD = Slightly disagree, NA/NOD = Neither agree Nor disagree, SLA = Slightly agree, MA = Moderately Agree, SA = strongly agree).

Types of dietary supplement used

A mixed-response was received on the type of dietary supplement the respondents sought out. Strongly agreed participants (10.4–10.9%) choose DS to be fortified with whey protein (n = 101, 10.9%), followed by omega 3 fatty acid. Strongly disagreed respondents ranging from 13.0–13.7% who sought DS to receive calcium (n = 127, 13.7%). In contrast, less than two-quarters of the participants disagreed to use no supplement. The details of the types of DS’s uses are presented in Table 4.

Table 4

Types of dietary supplement used.

Statements	SD, N %	MD, N %	SLD, N %	NA/NOD, N %	SLA, N %	MA, N %	SA, N %	Total, N %
Multivitamins alone or in combination with others	123	158	164	180	118	86	96	925
	13.3	17.1	17.7	19.5	12.8	9.3	10.4	100
Ginseng and Gingko biloba	120	158	168	180	115	86	98	925
	13.0	17.1	18.2	19.5	12.4	9.3	10.6	100
Omega 3 fatty acid	124	162	163	180	113	86	97	925
	13.4	17.5	17.6	19.5	12.2	9.3	10.5	100
Whey protein	120	158	166	181	114	85	101	925
	13.0	17.1	17.9	19.6	12.3	9.2	10.9	100
Calcium	127	161	161	177	113	89	97	925
	13.7	17.4	17.4	19.1	12.2	9.6	10.5	100
Other supplements (prescription and natural products)	125	159	168	179	110	86	98	925
	13.5	17.2	18.2	19.4	11.9	9.3	10.6	100
No supplements used	362	130	121	121	71	55	65	925
	39.1	14.1	13.1	13.1	7.7	5.9	7.0	100

(SD = strongly Disagree, MD = Moderately disagree, SLD = Slightly disagree, NA/NOD = Neither agree Nor disagree, SLA = Slightly agree, MA = Moderately Agree, SA = strongly agree).

Expenditure for dietary supplements per month

A brief summary on monthly cost of DS’s is presented in Table 5. The monthly cost of DS’s significantly differed among the participants. More than three and a half (n = 817, 88.3%), with DS spent monthly between BDT 10 (USD 0.12) and USD 500 (USD 5.90) participants. BDT 5000 (USD 58.99) and BDT 10 (USD 0.12) were the gross and minimum expenses involved in a month.

Table 5

Cost of dietary supplements per month in Taka.

Cost/Month	Sample (N)	Percentage (%)
BDT 10–500	817	88.3
BDT 501–1000	74	8.0
BDT 1001–5000	34	3.7
BDT 5001–10000	-	-

Adverse reactions experienced from dietary supplements

The details of an adverse reaction are presented in Table 6. The participants were asked if any adverse reactions to the use of DS had occurred. More than 59.0% of the respondents (n = 546) experienced no adverse reactions over DS sue. Nausea, vomiting and diarrhea (n = 75, 8.1%) were the common adverse reactions for those who experienced unwanted effects. Confusion, headaches, and vertigo were encountered by a very insignificant number of respondents (n = 09, 1.0%).

Table 6

Adverse reactions experienced from dietary supplement.

Adverse reactions experienced from dietary supplement	Variables	Sample (N)	Percentage (%)
Did you experience any adverse reactions?	Yes	295	31.9
	No	546	59.0
If yes, what were they?	Nausea, vomiting & diarrhoea	75	8.1
	Confusion, headaches & vertigo	9	1.0
	Hair fall	-	-
	Rapid weight gain	-	-
	Others	-	-

Pharmacy student’s opinions and attitudes regarding dietary supplement use

Detailed information on the views and attitudes of pharmacy students about DS usage is provided in Table 7. The data on the responses of pharmacy students using DS were close to each other. More than 14.1% (n = 130) of the respondents strongly disagreed to use DS in all ages while 11.5% (n = 108) strongly agreed on the same regardless of ages Mentionable number of participants agreed to use DS for cancer prevention (n = 106, 11.5%).

Table 7

Opinions and attitudes of pharmacy students regarding dietary supplement use.

Statements	SD, N %	MD, N %	SLD, N %	NA/NOD, N %	SLA, N %	MA, N %	SA, N %	TotalN %
It prevent chronic illness if used regularly	105	174	167	186	101	89	103	925
	11.4	18.8	18.1	20.1	10.9	9.6	11.1	100
Safe with minimal risk of adverse effects	109	166	160	184	111	90	105	925
	11.8	17.9	17.3	19.9	12.0	9.7	11.4	100
Essential for everyone regardless of age	102	173	166	185	101	90	108	925
	11.0	18.7	17.9	20	10.9	9.7	11.7	100
Prevents cancer	109	166	160	183	109	92	106	925
	11.8	17.9	17.3	19.8	11.8	9.9	11.5	100
Important for health and general well-being	103	168	177	187	97	89	104	925
	11.1	18.2	19.1	20.2	10.5	9.6	11.2	100
Use only as per physician recommendation/ harmful if not used properly	111	166	160	183	113	90	102	925
	12.0	17.9	17.3	19.8	12.2	9.7	11.0	100
Necessary for all ages	130	204	153	179	92	82	85	925
	14.1	22.1	16.5	19.4	9.9	8.9	9.2	100

(SD = strongly Disagree, MD = Moderately disagree, SLD = Slightly disagree, NA/NOD = Neither agree Nor disagree, SLA = Slightly agree, MA = Moderately Agree, SA = strongly agree).

Dietary supplements are good for health

The health specifics of DS use are shown in Table 8. More than three quarters and a half of students accepted that the use of DS is good for health (n = 749, 81.0%). Additionally, less than a quarter of students did not know whether its use is good for health or not (n = 139, 15.0%).

Table 8

Dietary supplements are good for health.

Items	Sample(N)	Percentage (%)
Agree	749	81.0
Disagree	37	4.0
Do not know	139	15.0

Personal advice to others when using dietary supplements

Details of personal recommendations relating to the use of DSs by others are given in Table 9. The students were asked about their thoughts concerning DS’s use. Almost half of the students (n = 493, 53.3%) recommended the daily use of DS while 37% of doctors did the same.

Table 9

Do you personally recommend use of dietary supplements to others.

Items	Sample (N)	Percentage (%)
Yes, I always recommend	493	53.3
Yes, only when doctors recommend	342	37.0
Not at all	90	9.7

Dietary supplement product information

The respondents were asked whether they were aware of DS product information. Very significant part of the students (n = 312, 33.7%) recognized the brand name of DS while a smaller fraction sensed either brand or generic name of the product (n = 127, 13.7%). The DS product attributes are shown in Table 10.

Table 10

Dietary supplement product information.

Items	Sample (N)	Percentage (%)
Brand name	312	33.7
Generic name	243	26.3
Both	243	26.3
Do not know	127	13.7

Association of demographic variables with opinions and attitudes

The association of demographic variables with opinions and attitudes are attributed in Table 11. The dependable variable (DV) of student opinion towards DS’s use good for health was associated with: age (p-value = 0.927), study year (p-value = 0.677), current marital status (p-value = 0.064), residence (p-value = 0.382), siblings (p-value = 0.832), university type (p-value = 0.735). Moreover, the DV of student opinion towards encouraging the use of DS was associated with: age (p-value = 0.507), study year (p-value = 0.510), current marital status (p-value = 0.490), residence (p-value = 0.097), siblings (p-value = 0.094), university type (p-value = 0.928).

Table 11

Association of demographic variables with opinions and attitudes.

Sample (N) observed (expected)
Dietary supplements are good for health
Statements	Agree	Disagree	Do not know	χ2	p vale
1. Age (years)				0.151	0.927
18–23	695 (695.6)	34 (34.4)	130 (129.1)
24–26	54 (53.4)	3 (2.6)	9 (9.9)
2. Study year				4.001	0.677
1st year	136 (140.1)	8 (6.9)	29 (26)
2nd year	157 (157.1)	8 (7.8)	29 (29.2)
3rd year	182 (174.1)	9 (8.6)	24 (32.3)
4th year	274 (277.7)	12 (13.7)	57 (51.5)
3. Ethnic origin	749 (749)	37 (37)	139 (139)	-	-
4. Current marital status				5.485	0.064
Married	38 (32.4)	0 (1.6)	2 (6)
Unmarried	711 (716.6)	37 (35.4)	137 (133)
5. Residence				4.185	0.382
Living with family	617 (613)	28 (30.3)	112 (113.8)
Living alone (University accommodation)	119 (119.8)	7 (5.9)	22 (22.2)
Living alone (Self accommodation)	13 (16.2)	2 (0.8)	5 (3.0)
6. Siblings				4.273	0.832
Between 1&2 siblings	341 (341.7)	16 (16.9)	65 (63.4)
Between 3&5 siblings	285 (287.5)	13 (14.2)	57 (53.3)
Between 6&8 siblings	61 (59.9)	4 (3.0)	9 (11.1)
More than 8 siblings	31 (30.0)	1 (1.5)	5 (5.6)
No siblings	31 (30.0)	3 (1.5)	3 (5.6)
7. University type				0.617	0.735
Private	669 (666.4)	33 (32.9)	121 (123.7)
Public	80 (82.6)	4 (4.1)	18 (15.3)
Do you encourage the use of dietary supplements?
	Yes, always	Yes, only when doctor recommend	Not at all
1. Age (years)				1.359	0.507
18–23	454 (457.8)	322 (317.6)	83 (83.6)
24–26	39 (35.2)	20 (24.4)	7 (6.4)
2. Study year				5.268	0.510
1st year	89 (92.2)	69 (20.2)	15 (16.8)
2nd year	96 (103.4)	82 (24)	16 (18.9)
3rd year	117 (114.6)	76 (79.5)	22 (20.9)
4th year	191 (182.8)	115 (126.8)	37 (33.4)
3. Ethnic origin	493 (493.0)	342 (342.0)	90 (90.0)	-	-
4. Current marital status				1.428	0.490
Married	25 (21.3)	12 (14.8)	3 (3.9)
Unmarried	468 (471.7)	330 (327.2)	87 (86.1)
5. Residence				7.844	0.097
Living with family	411 (403.5)	267 (279.9)	79 (73.7)
Living alone (University accommodation)	70 (78.9)	67 (54.7)	11 (14.4)
Living alone (Self accommodation)	12 (10.7)	8 (7.4)	0 (1.9)
6. Siblings				13.575	0.094
Between 1&2 siblings	227 (224.9)	160 (156.0)	35 (41.1)
Between 3&5 siblings	183 (189.2)	135 (131.3)	37 (34.5)
Between 6&8 siblings	41 (39.4)	29 (27.4)	4 (7.2)
More than 8 siblings	21 (19.7)	10 (13.7)	6 (3.6)
No siblings	21 (19.7)	8 (13.7)	8 (3.6)
7. University type				0.149	0.928
Private	439 (438.6)	305 (304.3)	79 (80.1)
Public	54 (54.4)	37 (37.7)	11 (9.9)

Multinomial regression analysis

Multinomial regression analysis on detail results is presented in Table 12. Multinomial logistic regression (MLR) was used to interpret the odds ratio for dependent variable (DV) of, “recommending dietary supplement use”. And the “age” was considered as an independent variable (IV) where “age variation” was fixed as a categorical IV. Student’s attitudes towards recommending DS use were taken as DV. The parameter of IV, i.e. “age: 24–26 years”, was redundant and therefore set to zero (0). The regression analysis stated that the odds of, “always recommending DS use” increases with every year-wise increase in age (OR’ 0.982). And also Students of “Age: 18-23years” were more likely to “recommend DS use” as compared to students of “Age: 24-26years” (OR’ 0.982).

Table 12

Multinomial logistic regression analysis.

Do you personally recommend use of dietary supplements to others?		Coefficient	Odds ratio (OR)	95% confidence interval
				Lower bound	Upper bound
Yes, I always recommend	Age	1.718
	18–23 years	−0.018	0.982	0.425	2.269
	24–26 years	0b	-	-	-
Yes, only when doctors recommend	Age	1.050
	18–23 years	0.306	1.358	0.555	3.319
	24–26 years	0b	-	-	-

Discussion

The use of dietary supplements is increasingly growing because they are readily available, cost-effective and consumer-compliant. The current survey was conducted to determine the prevalence, opinions and attitudes towards the use of dietary supplements of undergraduate female students at public and private universities in Chittagong, Bangladesh. The study was prevailed with the Bangladeshi unmarried undergraduate female student ages between 18–23 years. The study showed that DS use has increased in recent years. Several previous studies demonstrated the relationship between higher educational level and DS use. A significant straight relation between higher education level and dietary supplement usage among the full-aged population of France was displayed by Pouchieu and colleagues [16]. Likewise, a survey accomplished by Mileva-Peceva et al. indicated that highly educated females consume an extremely significant amount of vitamins and /or mineral food supplements [17]. In another study conducted in 16 medical colleges in the United States, female students used DS’s more than male students [8]. In Africa, a study carried among medical students of a Nigerian university reported DS usage by 50% of the students [18]. Therefore, our outcomes are consistent with the above findings.

The majority of the female students, living with families, suffer from major illnesses, i.e., depression, hypertension, diabetes mellitus, sickle cell anemia, thalassemia, asthma, rheumatoid arthritis, migraine, and others. Our results displayed that DS usage is higher in females with high education, which is also coherent with former studies [14]. The National Health and Nutrition Examination Survey (NHANES) 2003–2006 displayed, 61% of DS users passed high-school while only 37% of those were not able to do so [19]. NHANES 1999–2000 reported 62% of DS users with more than high-school education, 48% of those with high-school education and just 35% of those with less than high-school education [20]. Our sample’s highest prevalence was in the 18–23 age groups and the minimum in the 24–26 age range. More frequent use of DS’s has been observed among female students of private universities. Naqvi and colleagues have also been reported similar observations among female pharmacy undergraduate students from private-sector universities [1]. The socioeconomic condition and facilities may be the reasons behind this. These students typically belong to a relatively loftier socioeconomic condition and are aligned with support programs for students, healthcare facilities, and ease of consultation on physical activity, social and individual problems, and perceived dietary supplements. Whereas most of the students enrolled in the public universities belong to low-socioeconomic status, and these universities have low tuition fees [21]. Hence, the prevalence of DS use in public universities is lower than in private universities.

The female students were asked about the reasons behind the use of the DS. Students mentioned various reasons, such as recommendations from physicians, general health and well-being, weight gain, energy source, immune booster, performance or sports increase, hair fall and skincare control, endurance or bodybuilding increase, memory enhancer, other reasons involve pregnancy-induced anemia and fatigue while few others mentioned no reason. In our study, all the mentioned reasons for the usage of DS’s were so close to each other. Various DS types include multivitamins alone or in conjunction with Ginseng and Gingko Biloba, omega 3 fatty acid, whey protein, calcium, other supplements (prescription and natural products) non-supplements used by the participants. Previous studies showed that protein supplementation is verily common among students as it improves physical performance [22, 23], whereas omega 3 fatty acid may increase sleeping attributes and decrease depression and anxiety [24]. Abbas et al. have reported that anxiety and depression due to academic studies may prevail in undergraduate students [25-27]. Our study indicates that a small portion of the students suffered from adverse reactions by using DS. In most cases, they struggled with nausea, vomiting and diarrhea, which are mostly related to the previous studies reported in the literature [1, 28, 29]. The monthly expense of DS’s differed notably among the female students. Most of them (88.3%) indicated a monthly expense between Taka 10–500. A previous study also reported that students spent less than 1 to 3 USD per month [1]. The monetary value of dietary supplements in 2014 amounted to the United States dollar (USD) 165.62 billion and was rising with a compound annual growth rate (CAGR) of 7.3%. The projected market worth is expected to touch USD 278.96 billion by 2021. Asia Pacific region has emerged as the second-largest market for dietary supplements after the US and Canada [30]. Saudi Arabia is the biggest market for dietary supplements in the Middle East region as DS accounts for 4% of total pharmaceuticals sold in the country with an estimated worth of USD 2 billion [1, 31]. Female students preferred brand products rather than generics. Personal preferences are probably the reason behind this. Studies displayed that brand products are trusted to possess preferable quality; therefore, brands may be preferred by the individual [22, 32]. Dwyer and colleagues have reported that poor dietary supplements have resulted in adverse drug events (ADEs) and mortality [33]. Moreover, the quality of pharmaceutical packaging may also affect consumers’ preferences. Sabah and colleagues mentioned un-attractive packaging as a reason for the low preference of generic products in Pakistan [34]. Studies report that brands are generally expensive than generics [35]. This study observed pharmacy student’s opinions and attitudes regarding DS use. They give various statements from which the most considerable portion of students strongly disagreed with the statement that they only used DS as per the physician’s recommendation. Moreover, the largest portion of students strongly agreed that they used DS as essential for everyone regardless of age. All the values of given statements for pharmacy students’ opinions and attitudes regarding DS use were very close.

In previous study most of the students also agreed to use DS as per the physician’s recommendation [1]. But in another study in Lebanon most of the participants believed that they should use DS’s recommendation of friends, peers, and relatives [36]. However, there is an increasing evidence that suggests that dietary supplements can be dangerous if not taken in the prescribed dose [37]. In some cases, over usage of multivitamins may exceed the permissible limits of certain vitamins such as cholecalciferol that may result in adverse effects [33, 38, 39].

This study searched the opinions and attitudes of undergraduate female students about DS. The demographic variables of the age, study year, ethnic origin, current marital status, residence, siblings, and university type were associated. Most of the female students trusted that DS’s are good for health. An insignificant number of them disagreed with this, and the remaining students opined that they do not know regarding this. Several studies documented DS users having some positive attitude along with their health [40]. They were more likely to be prosperous, health sensible, less likely to smoke, and probably consume more hygienic food [41]. Various studies about the demographic features of DS’s consumers also revealed that they were chiefly high educated females with young age (20–39 years) [40, 42]. These consequences were compatible with our study outcomes.

Conclusions

To sum up, the survey provides details about the highly prevalent usage of dietary supplements among undergraduate female students in Chittagong, Bangladesh. The most noteworthy finding of the study was that the prevalence was higher in private universities than students of public universities. The study also found variation in prevalence and attitudes concerning dietary supplement use. The maximal prevalence is shown in health-related departments such as pharmacy compared to other non-health-related departments.

The limitation of our study was the non-inclusion of male students. To understand dietary supplement usage and how opinions change in identical populations according to gender would have determined by including male students. Therefore, it is recommended to lead the study in the male population with a larger sample size to view the impact of participants’ demographics such as economic status and other relevant factors such as dietary patterns and lifestyle on dietary supplement consumption.

Written consent of the respondent.

(DOCX)

Click here for additional data file.

Final questionnaire.

(DOCX)

Click here for additional data file.

Final version of the data sheet with all respondents (925).

(XLS)

Click here for additional data file.

4 Jan 2021

PONE-D-20-39326

Tendencies and attitudes of young students towards dietary supplements in Bangladesh: female students are more inclined

PLOS ONE

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Reviewer #2: No

Reviewer #3: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

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Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: No

**********

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Reviewer #3: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Reviewer comments:

Thank you for giving the opportunity to review this article.

The title of the article should be more understandable and self-explanatory.

Please edit the entire manuscript for English grammar and syntax for readability.

Abstract:

1. Background is not clear.

2. Methods: Include the study duration.

3. Avoid abbreviations in the conclusion.

Introduction

1. The introduction part is too short and didn’t mention about important key points.

2. The research question is not discussed and formulated with suitable references.

3. How come this study is differed from reference 7 -9?

4. Mention the aim or objective of the study.

5. Define the clinical significance of this study in related to researchers, clinicians and patients.

Methods

6. Why the search is limited with female students?

7. The duration of search?

8. The selection criteria should be more specific (inclusion and exclusion).

9. How the sample size was calculated - explain clearly?

10. Mention the procedure, reliability and validity of DSQ.

11. Software used for statistical analysis.

Discussion

12. Refine the conclusion according to the objective of your study.

Reviewer #2: Comments are found in the attached file, using side comments/track changes

Major comments:

The title is not representing the content. While all the recruited participants were females, the authors titled the study with "female students are more inclined", more than whom? The authors concluded that health-related departments were more prevalent with DS use, while nothing mentioned in the 12 tables about the academic departments. The study objectives and specific aims are not clearly mentioned. The 12 tables are dissecting different aspects from the mentioned aim of the study. The conclusions are not supported by the presented data. The authors dismissed any article related to DS use in Bangladesh in their discussion.

Reviewer #3: Paper titled (Tendencies and attitudes of young students towards dietary supplements in Bangladesh: female students are more inclined) by Rahman et al., studied the gender difference towards the dietary supplements in a national area in Bangaldish.

I appreciate such simple and hubmble trial, the study is interestingly written with correct statistical analysis. I recommend publication after a minor revision:

If the authors can discuss and metnion the specific type of supplements that are commonly used in this study in reation to the age ranges.

**********

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: Sawsan A Zaitone

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Submitted filename: Main Manuscript Final_Plos One 27122020.docx

Click here for additional data file.

28 Feb 2021

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When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

Response: The manuscript has been formatted according to Plos One style.

2. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

Response: The questionnaire has been incorporated as supporting file.

3. Thank you for including your ethics statement:

"The survey was permitted to the institutional review committee of International Islamic University Chittagong (ref: P&D-147/13-19).".

Please amend your current ethics statement to confirm that your named institutional review board or ethics committee specifically approved this study.

Once you have amended this/these statement(s) in the Methods section of the manuscript, please add the same text to the “Ethics Statement” field of the submission form (via “Edit Submission”).

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Response: The statement has been revised and incorporated in the main text (highlighted in yellow colour).

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Response: All data are available within the revised manuscript.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

Response: There are no ethical and legal restrictions regarding sharing our data. In our data there is no such information that is sensitive to any particular community. However, no data is left to be shared rather we incorporated all the data produced. The contact information of ethical review committee is Chairman, Ethical Review Committee and Department of Pharmacy, International Islamic University Chittagong, Chittagong, Bangladesh-4318.

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Response: The revised figure has been uploaded.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sounds, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: No

________________________________________

4. Is the manuscript presented in an intelligible fashion and written in Standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

________________________________________

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1:

Thank you for giving the opportunity to review this article.

The title of the article should be more understandable and self-explanatory.

Please edit the entire manuscript for English grammar and syntax for readability.

Abstract:

1. Background is not clear.

Response: Authors would like to thank the reviewer for his valuable comment. We have revised the abstract (highlighted in yellow color).

2. Methods: Include the study duration.

Response: Appreciable query indeed. The duration of the study was three months (March 2018-May 2018), which have been included (highlighted in yellow color).

3. Avoid abbreviations in the conclusion.

Response: Avoided accordingly (highlighted in yellow color).

Introduction

1. The introduction part is too short and didn’t mention about important key points.

Response:We have revised the introduction part. As per reviewer suggestions we also incorporated important key points (highlighted in yellow colour).

2. The research question is not discussed and formulated with suitable references.

Response: The authors specially developed the research question. It consists of several multiple-choice questions. The questionnaire was further polished by a group of specialists led by two assistant professors. We have explained the question formulation method is written in the revised version of the manuscript according to the reviewer's comments (highlighted in yellow colour).

A pilot study (100 students) was performed to confirm the questionnaire's reliability and validity by using different approaches. We distributed the questionnaire amongst students to get their feedback regarding the understanding and clarity of all questions. The questionnaire was then reviewed by experts in related fields and other expert colleagues within the university. We also asked external reviewers to provide their feedback and opinion in developing/improving the questionnaire to ensure the reliability of the test and compared the results of our pilot study with the results of similar work done previously. We introduced all necessary expert feedback and suggestions accordingly until we had a final questionnaire used in the present study.

3. How come this study is differed from reference 7 -9?

Response: Authors are thankful to the reviewer for such a novelty-creating question. By the way, the differences of our research with the cited references are given below:

In reference 7, Lieberman, Harris R., et al. showed dietary supplement use patterns among four United States college students. They considered both male and female respondents. All the respondents received a $10 incentive to complete the survey, and students at Cal State and LSU received a class-based extra credit incentive.

In reference 8 (Spencer, Elsa H et al), the author's main objective was to provide data on medical students' multivitamin and calcium supplement use during medical school. They mostly focused on non-underweight and non-exercising students may be essential targets for messages regarding appropriate and adequate vitamin/mineral use.

In references 9 (Alfawaz et al.), the authors aim to investigate the prevalence of dietary supplement use and its association with sociodemographic/lifestyle characteristics among Saudi female students. Among the participant, 25.5% were married and 74.5% single. Moreover, participants are from undergraduate and graduate level.

In our investigation, the primary focus is to investigate the tendencies and attitudes of Bangladeshi undergraduate female students (age group between 18-23 years) towards dietary supplements.

4. Mention the aim or objective of the study.

Response: The main aim and objective of this study are appended in the abstract section. Also, it has been quoted here.

Dietary supplements are products that improve individuals' overall health and well-being and reduce the risk of disease. Evidence indicates a rising prevalence of these products worldwide, especially among the age group 18-23 years. The study investigates the tendencies and attitudes of Bangladeshi undergraduate female students towards dietary supplements.

5. Define the clinical significance of this study in related to researchers, clinicians and patients.

Response: The micronutrient depletion situation in Bangladesh is growing day by day. In Bangladesh, one-fourth of the population is suffering from chronic energy deficiency. Among them, females are more prone to suffer from nutritional deficiencies than men due to various factors such as female reproductive biology, low social status, poverty, and lack of education. This research will provide comprehensive information related to prevalence, user opinions, and attitudes towards DS among undergraduate female students in Chittagong city of Bangladesh. This will lead the researcher to find out how demographic and lifestyle factors, such as monthly cost, educational status, and lifestyle status, correlate positively with dietary supplements consumption. After all, the clinicians will be able to perceive the research-reflection and they can suggest the said group of females in relevant cases.

Methods

6. Why the search is limited with female students?

Response: Females, particularly in Bangladesh, are more predisposed to suffer from nutritional deficiencies than men due to various factors such as female reproductive biology, low social status, poverty, and lack of education. Socio-cultural practices and inequalities in domestic job habits may also increase the possibility of malnutrition for females. Another reason is also is; no such study has been conducted for Bangladeshi female undergraduate students. Our future goal is to lead similar types of study amidst the male population.

7. The duration of search?

Response: The duration was: March 2018 to May 2018.

8. The selection criteria should be more specific (inclusion and exclusion).

Response: The selection criteria are included in the study design and duration section.

9. How the sample size was calculated - explain clearly?

Response: From seven private and public universities, ten departments were selected by using a lottery. A sample size of 664 was calculated by using Raosoft, Inc. However, by hypothesizing of getting a low number of participants with dietary supplements' previous experience and considering the number of drops out, a total of 1000 undergraduate female students with even ID number was selected randomly from odd and even students ID. Though only 75 female students did not match the study's inclusion criteria, and finally, 925 female students were interviewed and included in the study.

10. Mention the procedure, reliability and validity of DSQ.

Response: We have added the procedure, reliability, and validity of DSQ in the revised manuscript under the Research instrument development section (highlighted in yellow color).

A pilot study (100 students) was performed to confirm the questionnaire's reliability and validity by using different approaches. We distributed the questionnaire amongst students to get their feedback regarding the understanding and clarity of all questions. The questionnaire was then reviewed by experts in related fields and other expert colleagues within the university. We also asked external reviewers to provide their feedback and opinion in developing/improving the questionnaire to ensure the reliability of the test and compared the results of our pilot study with the results of similar work done previously. We introduced all necessary expert feedback and suggestions accordingly until we had a final questionnaire used in the present study.

11. Software used for statistical analysis.

Response: The data were analyzed by statistical software Statistical Package for Social Science (SPSS, version 22.0, IBM Corporation, NY).

Discussion

12. Refine the conclusion according to the objective of your study.

Response: According to reviewer’s remarks, we have revised the entire conclusion section matched with the objective of our study (highlighted in yellow color).

Reviewer #2:

Comments are found in the attached file, using side comments/track changes

Response: Comments found in track change are revised as per your suggestions. For further information please check the revised manuscript.

Major comments:

The title is not representing the content. While all the recruited participants were females, the authors titled the study with "female students are more inclined", more than whom?

Response: Title has been revised.

The authors concluded that health-related departments were more prevalent with DS use, while nothing mentioned in the 12 tables about the academic departments.

Response: In Table 7, we have summarized the opinions and attitudes of pharmacy students regarding dietary supplement use (highlighted in yellow color).

The study objectives and specific aims are not clearly mentioned. The 12 tables are dissecting different aspects from the mentioned aim of the study.

Response: According to the reviewers suggestion we have added the objectives and specific aims in the abstract and materials and methods section (highlighted in yellow color).

Aim

The study investigates the tendencies and attitudes of Bangladeshi undergraduate female students towards dietary supplements (DS).

Purposes of the study

The primary purpose of our survey was to explore the dynamics of using dietary supplements by the undergraduate females, involving the respondent's choice, age, discipline, nature of the institution. The survey was directed among several age ranges of 18-23, 24-26, and 27-30 years. The cause of the ordination is the education period. The inclusion of undergraduate students usually occurs in 18 years, and the duration varies from 4-5 years in different disciplines. The second principal objective was to inquire about DS's differences with the variation of demography, particular opinion, attitudes, disciplines, and ages. Expense regarding dietary supplement usage was recorded and indicated by the BDT (Bangladeshi Taka).

The conclusions are not supported by the presented data. The authors dismissed any article related to DS use in Bangladesh in their discussion.

Response: According to reviewers remarked we have revised the entire conclusion section matched with the objective of our study (highlighted in yellow color).

Reviewer #3:

Paper titled (Tendencies and attitudes of young students towards dietary supplements in Bangladesh: female students are more inclined) by Rahman et al., studied the gender difference towards the dietary supplements in a national area in Bangladesh.

I appreciate such simple and humble trial, the study is interestingly written with correct statistical analysis. I recommend publication after a minor revision:

If the authors can discuss and mention the specific type of supplements that are commonly used in this study in relation to the age ranges.

Response: Thank you very much for your valuable remarks. The present study investigates the tendencies and attitudes of Bangladeshi undergraduate female students towards dietary supplements. Several classes (Ginseng and Gingko biloba, Omega 3 fatty acid, Whey protein, Calcium, Natural products) supplements have been analysed in this study. The specific type of supplements commonly used in this study has been mentioned in table 4.

________________________________________

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: Sawsan A Zaitone

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While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: Response to Reviewers R1.docx

Click here for additional data file.

8 Mar 2021

PONE-D-20-39326R1

Trends and attitudes towards the use of dietary supplements by female university-students in Bangladesh

PLOS ONE

Dear Dr. Rahman,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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We look forward to receiving your revised manuscript.

Kind regards,

Walid Kamal Abdelbasset, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: No

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #3: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: No

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Reviewer comments:

Thank you for giving the opportunity to review this article.

Abstract:

1. Mention clearly in the conclusion, what prevalence? DS

Methods

2. Include the selection criteria of participants in detail.

3. Include the reliability and validity of outcome measures with references.

4. Mention who has extracted the data and their experience and qualifications.

Discussion

5. The discussion part should discuss the relation between the DS and its effects with latest references.

6. Add the clinical significance of this article over the participants and researchers.

Reviewer #3: Paper titled (Trends and attitudes towards the use of dietary supplements by female universitystudents in Bangladesh)

Spearman’s rank correlation was employed.Regression analysis was conducted to determine different relationships between DS use and demographic characteristics of students:

This reviewer cannot find the figure in which a regression analysis was done, kindly add to the paper

STat analysis in tables, I find it mandatory to stat analyze the percentages to explore the real differences between groups and conclude better on the results.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: Yes: GOPAL NAMBI

Reviewer #3: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

25 Mar 2021

Response to editorial and reviewer’s comments

Dear Editor

Thank you so much for your tremendous effort for having the manuscript reviewed. We have found both the editorial and reviewers comments highly impactful for improving the manuscript. We have addressed all the issues raised by reviewers and editorial office. Please scroll down to see the reviewer’s response below:

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Author’s Response: Authors would like to thank the editor for such concern over retracted articles. We, indeed, have not cited any retracted article in our manuscript. Additionally, the manuscript has been formatted according to Plos One style.

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #3: All comments have been addressed

2. Is the manuscript technically sound and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #3: Yes

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: No

Author’s Response: Authors have rechecked the probable inadequacy of statistical analysis and addressed in a right manner.

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #3: No

Author’s Response: In response to the reviewer 3, authors would like to show the gratitude to the reviewer for his keen observation. By the way, authors have ensured to make all the data available in the main manuscript and supporting files of the revised manuscript.

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: No

Author’s Response: Authors are happy to denounce that the manuscript has been crosschecked by all the authors for any grammatical or linguistic error. However, authors will appreciate very particular suggestion or recommendation for any mistake/change.

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Reviewer comments:

Thank you for giving the opportunity to review this article.

Abstract:

1. Mention clearly in the conclusion, what prevalence? DS

Author’s Response: The sentence has been rephrased accordingly.

Methods

2. Include the selection criteria of participants in detail.

Author’s Response: Authors wish to thank the reviewer for insightful suggestion. The inclusion criteria for participants were:

i. Undergraduate female students;

ii. Willingness to participate in the study,

iii. Age >18 years;

iv. Ability to understand English or Bengali, and

v. Previous experiences for dietary supplements.

3. Include the reliability and validity of outcome measures with references.

Author’s Response: Very appreciating comments indeed from the reviewer. We have included the reliability and validity of outcome measures in the revised manuscript under the Research instrument development section (highlighted in yellow color). We have supplemented the final questionnaire for your kind consideration.

A pilot study (100 students) was performed to confirm the questionnaire's reliability and validity using different approaches. We distributed the questionnaire amongst students to get their feedback regarding the understanding and clarity of all questions. The questionnaire was then reviewed by experts in related fields and other expert colleagues within the university. We also asked external reviewers to provide their feedback and opinion in developing/improving the questionnaire to ensure the reliability of the test and compared the results of our pilot study with the results of similar work done previously. We introduced all necessary expert feedback and suggestions accordingly until we had a final questionnaire used in the present study.

4. Mention who has extracted the data and their experience and qualifications.

Author’s Response: Data were extracted by the well-trained final year B. Pharm/M.Pharm research fellows under the direct supervision of a Professor of Biochemistry, working since 16 years (PD from Japan), who has a long expertise on the functional food and alternative medicine filed. Before data collection, they have attended seven days of hands-on training on the dietary supplement questionnaire (DSQ). The whole research work was assisted by two Assistant Professors (having eight to ten years research experience) of the department of pharmacy, International Islamic University Chittagong, Bangladesh.

Discussion

5. The discussion part should discuss the relation between the DS and its effects with latest references.

Author’s Response: Very thoughtful suggestion, thank you so much dear reviewer. Discussion part has been revised very carefully in accord with the suggestion of the reviewer. The relation between DS and its effects has been well-discussed and changes of the revised manuscript in this regard have been have been highlighted using a yellow text-highlighter (…..).

6. Add the clinical significance of this article over the participants and researchers.

Author’s Response: We appreciate such a reader-demanded suggestion from the reviewer. Indeed, the status of micronutrient depletion in Bangladesh is growing over the days. In Bangladesh, one-fourth of the population has been suffering from chronic energy deficiency. Among them, females are more prone to suffer from nutritional deficiencies than male because of various factors such as lack of awareness among females, their abnormalities in reproductive biology, lack of adequate knowledge, social and economic discrimination in prioritization for females. This research will create an extensive observation and perception on the prevalence of dietary supplements, necessity and trending of supplements by the educated females, their opinions over experiences and overall attitudes towards the use of DS among undergraduate female students in Chittagong, Bangladesh. This will lead the researcher to determine how demographic and lifestyle issues such as monthly cost, educational status and life-status expenditure are correlated with dietary supplement consumption.

Reviewer #3: Paper titled (Trends and attitudes towards the use of dietary supplements by female university students in Bangladesh)

Spearman’s rank correlation was employed. Regression analysis was conducted to determine different relationships between DS use and demographic characteristics of students:

This reviewer cannot find the figure in which a regression analysis was done, kindly add to the paper

Stat analysis in tables, I find it mandatory to stat analyze the percentages to explore the real differences between groups and conclude better on the results.

� Spearman’s rank correlation was employed.

Author’s Response: Thank you for your worthy remarks. We are confirming through several discussions with our senior statistician that chi-square test is the best befitting analytical tool for our study and we accomplished that to interpret the associations between demographic information and opinions/attitudes our study. We are truly sorry and apologizing for misdirecting the analytical approach on stating Spearman's rank correlation which was not included indeed. We hope the reviewers will accept the author’s clarification. We are again thanking the reviewer for keen observation.

� Regression analysis was conducted to determine different relationships between DS use and demographic characteristics of students. This reviewer cannot find the figure in which a regression analysis was done, kindly add to the paper.

Author’s Response: Many thanks for this comment to improve the quality of our manuscript. In our study, we actually performed the multinomial logistic regression, which is relevant for this study. The findings of the multinomial logistic regression analysis are presented in Table 12. Addition/changes in the revised manuscript according to the reviewer's comments have been highlighted in the text using a yellow color highlighter (…..).

� Stat analysis in tables, I find it mandatory to stat analyze the percentages to explore the real differences between groups and conclude better on the results.

Author’s Response: Thank you for your comments. In our study's statistical analysis, the percentages to explore the real differences between groups were performed and presented in Tables 1 to 10. Addition/changes in the revised manuscript according to the reviewer's comments have been highlighted in the text using a yellow color highlighter (…..).

Submitted filename: Response to Reviewer R2_Final.docx

Click here for additional data file.

29 Mar 2021

Trends and attitudes towards the use of dietary supplements by female university-students in Bangladesh

PONE-D-20-39326R2

Dear Dr. Rahman,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Walid Kamal Abdelbasset, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #3: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have satsfactorily justified the comments raised by me and the article can be published in the present format.

The authors have satsfactorily justified the comments raised by me and the article can be published in the present format.

Reviewer #3: The revised form of paper titled (Trends and attitudes towards the use of dietary supplements by female university students in Bangladesh) by Md. Atiar Rahman et al. is improved compared to the original one

Thanks for the authors for addressing the reviewer's comments.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Gopal Nambi

Reviewer #3: Yes: Sawsan A. Zaitone

1 Apr 2021

PONE-D-20-39326R2

Tendencies and attitudes towards dietary supplements use among undergraduate female students in Bangladesh

Dear Dr. Rahman:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Walid Kamal Abdelbasset

Academic Editor

PLOS ONE