Identifying and assessing views among physically-active adult gym members in Israel on dietary supplements

Prevalence of sports dietary supplement use

The prevalence of using sports dietary supplements (SDS) has increased over the last 30 years among adults in the United States. Approximately half of the adult population in the United States reports using one or more dietary supplement [1]. The prevalence of using sports dietary supplements among gymnasium users in Riyadh, Saudi Arabia in 2015 was 37.8% [2] and in gyms in Lebanon the intake of dietary supplements was observed in 38% of the study participants [3].

In Israel, according to data which were published in the Israeli National Health and Nutrition Survey for the years 1999–2001, 21.5% of the people who were sampled reported taking nutrition supplements [4]. Previous studies on SDS and their effectiveness indicate that some may have side effects and others do for certain. Therefore, they must be used with caution [5]. Nevertheless, the use of SDS among gym members is on the increase.

Reasons for increased use of SDS among gym members

Many gym goers, who are eager to add muscle bulk, use SDS to maintain a low-fat, thin figure for athletic and esthetic purposes. This is called “body capital” and can have extreme ramifications [6]. A preoccupation with physical appearance is a factor that increases the likelihood of using these products [7, 8]. Other reasons for taking SDS include a combination of social and psychological factors, knowledge and financial conditions [1, 913] as well as media influence. The theory of planned behavior assumes that an individual would tend to take SDS if their action involves a combination of social norms with a belief that the action is controlled and made by choice [10]. According to the literature, the consumers of supplements want to maintain health and prevent nutritional deficits, increase their energy level, speed up recovery after physical activity, and boost their immune systems [12]. People tend to overestimate their physiological needs [14], and even when they know that supplements are unnecessary, they may consume them [15], even if they are ineffective [16].

The risk of taking sports nutrition supplements

Studies indicate that some supplements have been found to contain additional substances that might have side effects, such as caffeine, which might cause anxiety, sleeping disorders, and such cardiovascular problems as high blood pressure and physiological symptoms of emotional turmoil [17]. There is growing evidence about a poor quality of sports nutrition supplements based on their manufacturing and packing processes [18]. The most common problem is the presence of allergens in a product, which are not reported by the manufacturer. Additionally, there is concern about microbiological infection or infection caused by stimulating substances, estrogenic ingredients, variables, and anabolic substances [19, 20]. The presence of estrogenic substances might cause significant health problems when they go beyond the recommended dosage, and this is often the case in sports nutrition supplements [21]. DMAA is an additional substance that is added to nutrition supplements and is known for its ability to lead to weight loss, body contouring, and increased heart rate. It might cause heart problems (particularly sudden heart death), severe liver damage, and liver failure [19]; and melamine, which is added to 47% of the researched nutrition supplements, is a source of nitrogen from a non-protein source and might cause kidney stones [22].

Loopholes in the regulation

The FDA regulates dietary supplements in the United States, including both the final product and its ingredients. The FDA acts under the Dietary Supplement Health and Education Act of 1994 (DSHEA). Companies are responsible for labeling their products and assessing their safety before marketing them, ensuring that they meet DSHEA and FDA regulations [23].

The loophole in the control process is that although manufacturers are required to register their supplements through the FDA, they are not required to receive approval before producing or selling the product. Manufacturers are not required to test the ingredients or new supplements in clinical trials. DSHEA allows the FDA to stop a company from manufacturing a particular dietary supplement only when the FDA proves that it causes damage. There is no need for a prescription for dietary supplements, so there is no controlled system through which one can report negative reactions and side effects.

In Israel, dietary supplements are regulated according to regulations that apply to food, which require labeling to be “true and not misleading.” The Health Ministry can stop the marketing of a supplement that claims to have “healing qualities” only if it is hazardous to public health [24]. Due to the current regulation on dietary supplements, many products that have never been tested are sold over the counter [25].

SDS have been sold OTC in gyms too. Some studies have shown that SDS users take them without consulting anyone [26]. With regard to competitive professional sports, studies have shown that men consult with the salespeople who work at stores selling SDS. Women tend to consult with family members. Neither men nor women tend to consult with professionals [27, 28]. There are two issues not addressed by previous studies that this study addresses. First, studies have not addressed the views of professionals (dietitians and trainers) on SDS consumption. Second, they have also not addressed how gym members view different types of professionals in the context of their views on SDS consumption.

The present study seeks to fill this gap and ascertain risk perceptions of different target audiences, in order to examine whether there is a gap between perceptions among nutrition specialists and the risk perception among the community of trainees and trainers.

Communicating SDS risk

SDS involve uncertainty, and therefore there is a need to communicate risks to the public and convey a message that every active substance might have benefits but can also have adverse effects on health [29]. The public’s risk perception is influenced by personal, psychological, environmental and social factors [30, 31]. In order to communicate the risk, there is a need to take the risk communication approach to create an interactive process of exchanging information and opinions among individuals, groups and institutes. The public responds and becomes influenced not only by information about the risk, but also by how the risk is communicated. The public’s assessment of risk is based on criteria not necessarily obvious to experts [32]. This insight encourages the dialogue approach in risk communication, which sees the public as an active part of the process and not a passive one [33].

According to Sandman’s risk communication model [34], risk perception is comprised of the hazard level (risk estimation) and outrage level (the emotions the risk stimulates). If the hazard level and outrage level are similar among the experts and the target audience, the risk may be communicated very effectively, but if they are different, this can lead to controversy. According to Sandman, people associate low risk with issues towards which they have positive attitudes, and vice versa, regardless of the proved risk. In order to communicate the risk successfully, one should consider the public’s feelings about the risk and make efforts to minimize the gap between the estimation of the risk among the experts and the public’s risk perception.

Sports organizations such as ACSM, IOC and ISSN tend to communicate the risk by providing information about the supplements and classifying them into four categories: 1. Apparently effective, 2. Possibly effective, 3. Uncertainty regarding effectiveness, 4. Supplements that seem ineffective and possibly dangerous [20]. According to the Academy of Nutrition and Dietetics (formerly the American Dietetic Association), supplements should be used with caution, and only after careful evaluation of the product for safety, efficacy, potency, and whether or not it is a banned or illegal substance [35]. However, sports organizations do not consider public risk perception. Research indicates that risk perception among the population is low because SDS are perceived as dietary products, and as such, as healthy [36].

The present study seeks to fill this gap and ascertain risk perceptions of different audiences, in order to examine whether there is a gap between perceptions of SDS among nutrition specialists and among the community of gym goers and trainers. This study seeks to understand the perspectives of adults who regularly work out in gyms in Israel versus the approaches and perspectives of professionals regarding SDS consumption, and the risk communication by those considered authorities by gym goers.