Nutrition Supplementation Practices of Recreational Gym Users in Uganda’s Capital City: A Cross Sectional Study

Background: This study focused on investigating the prevalence of nutritional supplement (NS) usage, establishing their source and the motivating factors for the usage of NS among Gym users in Kampala city, Uganda. Methods : The study employed a cross-sectional research design. Multistage random sampling techniques were used to select 45 gym users among the 5 divisions that constitute Kampala city. Data were collected using questionnaires and analyzed using SPSS Version 26, where means, SD, frequencies and percentages were obtained. Chi-square tests were used for categorical comparisons between variables. Results: The results showed that there were more male participants (62.2%) than female participants (37.8%). The majority (76.9%) of gym users obtained NS from retail stores such as pharmacies, (10.2%) from their sports coaches, (7.7%) nutritionists/dieticians, and (5.1%) from team mates. Non-professional gym users (62.3%) reported higher levels of energy drink consumption than professional gym users (26.7%). The consumption of vitamins, herbal products and proteins was also considerably high. We also identified coaches/trainers (30.8%) as the main source of information, followed by nutritionists/dieticians (23.1%) and online websites (20.5%). Most gym users strongly agreed that supplements increase endurance training, increase strength, and make one healthier. Conclusions: The prevalence of nutritional supplement usage among gym users was high, with energy drinks and herbal products being the most preferred supplements.


Introduction
Uganda, a landlocked country in the eastern region of Africa, has an estimated population of 45 million, with a population of approximately 4 million people flocking Kampala capital city during the day. 1 Although faced with the challenge of not having a sea port for easy exportation and importation, various medicinal products easily find their way to different marketing outlets in Kampala city through neighboring countries, especially Kenya and Tanzania. Among these are sports nutrition-related products that have flooded Kampala and have been linked to successful sports figures in Uganda. 2 A recent report indicated challenges in reporting, tracking and identifying poor-quality medical products in Uganda. 3 However, such products may include various types of nonlocally made NS.
It is important to understand that the consumption of foods in diets that do not necessarily meet the Recommended Dietary Allowance (RDA) is grounds for the legitimate consumption of additional foods that are widely referred to as nutritional supplements. 4 These nutritional supplements (NS) contain food components that might provide more than one or more food nutrients. 5 Furthermore, the recommendations for usage of NS are clear and suggest usage only among those individuals with restricted diets, those with severe weight loss and those that consume high quantities of one food group. 6 However, as an increasing number of people purchase NS, more of those products continue to flock the market due to the increasing interest among users. 2 Among recreational athletes in Greece, low levels of awareness and lack of information have been previously highlighted as a challenge. 7 A previous self-reported study on the usage of NS among professional athletes in Uganda found that although the level of usage was low, there was a need to further sensitize frequent users. 8 The literature on NS usage among gym users globally is still scant, with these few studies concentrated in developed countries. [9][10][11][12] There is an increased influx of recreation centers or gyms in Kampala city of Uganda, leading to the continued demand for NS. The misuse of these products is concerning, particularly arising from high dosage and mixed usage. 13 Therefore, the aim of this study was to assess the prevalence of nutrition supplement usage among gym users, sources of supplements and related information, and understand the perceptions and motivating factors for NS usage in an effort to design a community-based education awareness campaign for the public in Kampala city.

Design
The study used a cross-sectional design with a convenient sample involving gym users in selected gyms in the five divisions (Rubaga, Central, Nakawa, Makindye and Kawempe) of Kampala city in Uganda in 2019.

Population
A sample of 45 recreational gym users was enrolled in the study. We utilized a multistage sampling technique where gyms were eliminated based on their proximity to each other. In the first stage, gyms that were excluded were those that were in close proximity to each other. We instituted a fixed distance of approximately a 5-mile radius between the selected gyms as a way to increase the spread. A total of two gyms in each of the five divisions of Kampala were then randomly selected. In the second stage, adults in the selected gym (n = 45) were randomly approached and enrolled in the study. For one to be included in this study, they had to be > 18 years of age. All participants in this study consented to voluntary participation and were free to terminate participation at any time. The study was conducted according to the principles of the Helsinki Declaration and was approved by the Institutional Review Board of University of Missouri-St. Louis, the School of Biomedical Sciences in the College of Health Sciences at Makerere University in Kampala Uganda. This study was also registered and approved by the Uganda National Council for Science and Technology, IRB# SS 5026.

Instrument
This study utilized a modified questionnaire from the original questionnaire designed by the researchers. 8 This study's questionnaire consisted of various sections. The first section captured responses to questions relating to an individual's sociodemographic factors such as age, gender and level of education. The second section was designed to solicit the respondent's motivating factors for using supplements. The third section gathered information on the sources of the utilized supplements and sources of supplemental information.

Data Collection
Prior to conducting the data collection, the researchers conducted two trainings for three research assistants at Makerere University in Kampala. The first training reviewed human participant protocols and usage of data capture forms. The second training equipped them on how to review and interpret the survey in local language and how to securely protect the consent and survey forms. Research assistants distributed surveys and collected data at gyms and post respondent workout sessions. Nine respondents were conveniently selected at each of the five selected gyms in the five regions of Kampala city.

Statistical Analysis
Data were entered and analyzed using SPSS 26.0 software for Windows. Continuous variables were summarized using means and standard deviations after assessing the normality of the data.
We standardized our variables and tested the normality of our data using Lillieforts corrections and Kolmogorov_Smirnov tests. Categorical variables were summarized using frequencies and percentages. Chi-square tests were used to compare categorical variables between groups. A probability p value < 0.05 at a 95% confidence interval was considered significant.

Participant characteristics
A total of 45 recreation gym users (male; 62.2%, female; 37.8%) in five subdivisions of Kampala city in Uganda participated in this study. Participant characteristics are provided in table 1. In terms of age groups, the majority of the participants (26.6%) were within 20-25 years of age compared to the least number of participants from the 35 years and above age group (13.3%).
There was a significant difference (P =.004) in users' education levels, with the majority of participants (27.9%) having had some secondary school education and the least education level being nursery school (2.3%). It was evident from the participant responses that fewer gym users in Kampala were current students (4.4%), business managers (11.1%), unemployed (11.1%), skilled agriculturalists (15.6%), or professional workers (17.8%) compared to the majority who engaged in a variety of other professions (40%). These occupational group differences were, however, not significant (P = 0.126). The majority of recreation gym users were professional users (51.1%) compared to their nonprofessional counterparts (48.9%). These male and female participants also engaged in a number of sports: football/soccer (2.2%), netball (4.4%), athletics (6.7%), and weightlifting (40%). A significant number of participants (46.7%) did not indicate any sports participation (P = .017).

Source of nutrition supplement
When we asked the participants about the sources of their NS, the majority (76.9%) indicated retail stores such as pharmacies (figure 1). Other sources of NS were sports coaches (10.2%), nutritionists and dieticians (7.7%), and teammates (5.1%).

Figure 1: Source of NSs for recreation gym user participants in Kampala.
This figure illustrates a variety of sources that participants reported as reliable avenues on the various products they consume. Individuals regard these as both valid and reliable sources of supplement effectiveness and any potential effects. Some participants indicated relying on more than just one source.

Professional versus Non-Professional gym user consumption
As indicated in Table 3

Source of Supplements Information
Recreation gym users indicated obtaining what they considered to be relevant NS information from coaches or trainers, nutritionists or dieticians, teammates, online websites, physicians or doctors, magazines or books and other sources that were not specified. The majority of participants (30.8%) indicated coaches or trainers as a reliable source of information, followed by nutritionists/dieticians (23.1%) and online websites (20.5%). Physicians/doctors, teammates and magazines or books were indicated among other sources. (Figure 3).

Figure 3. Various sources of information on NSs reported by gym users in Kampala city
Uganda. This illustration includes sources of information that individual participants regard as both valid and reliable sources on supplement information and an avenue for information on product effectiveness and any potential side effects.  Table 4. In general, these responses showed variations in gym users' perceptions regarding NS. Most gym users strongly agreed that supplements increase endurance during training, increase strength, and make one healthier. In contrast, most gym users strongly disagreed on the statement that NS may contain doping agents (Table 4).

Discussion
Our study aimed to understand NS usage among regular recreation gym users in Kampala city of Uganda. Over half of gym users who used NS played either netball, soccer, athletics, or weightlifting. A significant number of gym users who utilized NSs reported not playing sports (46.7%, p = .017). Male and female gym users both reported that their primary source for NS products was either a retail store or pharmacy. Most supplements were consumed for endurance, increased training load, increased strength, health reasons and motivation to compete at higher levels. Overall, the study respondents, who were a representative sample of gym users in Kampala city, reported a high level of usage (86.7%) of NS. Such prevalence rates are higher than those described in previous studies in urban cities. 9,15 Selling NS in developing cities such as Kampala is a lucrative business for manufacturers of foreign products, which is a persuasive strategy to increase sales.
In developed countries, education, employment status and level of income are forms of socioeconomic status that are known determinants for the usage of NS, [16][17][18] whereas cultural factors play a significant role in NS usage in developing countries such as Malawi. 18 Higher levels of education have previously been associated with higher NS usage. [19][20][21] Although the majority of participants in this study reported having attained some form of secondary school education, it is possible that those with a higher education level greatly value the role of nutrition in their overall health. 22 In the neighboring country of Kenya, income and education have also been attributed to higher usage of dietary supplements, 23 although the levels of education among teachers in Kenyan secondary schools were not significantly related to supplement consumption. 24 In other African countries, such as Malawi, cultural factors may also play a significant role in NS usage. 18 Furthermore, the majority of participants in this study reported having received NS products from retail area sources in urban areas of Kampala. In Uganda, most of these retail areas include urban pharmacies, shops and small clinics. Although most pharmacies in Uganda have been largely approved by the National Drug Authority, 25  that the available evidence on falsified and substandard medical products in Uganda's pharmaceutical wholesalers might be misleading given that the evidence was not collected from the informal sector but rather from a wholesaler, rendering that evidence inadmissible. 26 However, there has been the implementation of strict policies and the enforcement of laws against the sale of counterfeit products in Uganda and neighboring Kenya, as cited by a recent study indicating a shift to online markets, which lack relevant legislation. 27 Energy drinks (26.7%), vitamins (26.7%) and protein supplements (22.2%) were the most consumed types of supplements among professional gym users in Kampala city, whereas energy drinks (62.2%) and herbal products (46.7%) were the most widely used NS types among nonprofessional gym users in Kampala city. The reported impact of energy drinks on cardiorespiratory fitness could have been the main motivating factor for the widespread use of energy drinks. 28 A large proportion of respondents in our study indicated weightlifting as a main professional sport played. Likewise, supplement usage among weightlifters in the current study was high, corroborating earlier findings. 8 Overall, the results of this study partially agree with those of previous studies on nutrition supplement usage in other cities. 9 Our study reveals the occurrence of multiple supplement consumption patterns of professional and nonprofessional gym users in Kampala city. Such patterns of multiple usages of NS have been similarly reported in the U.S., where vitamins/minerals, herbs, and other specific supplements were concurrently used daily. 29 However, multiple supplement usage might be detrimental for consumers in Uganda, especially given the lack of individual primary physicians for many of the people in Uganda, 30 compared to their counterparts in the U.S., thus putting consumers in Uganda at a risk for serious adverse effects arising from high intakes.
As was reported in an earlier study, 8

Conclusion
Our study is the first to evaluate the usage of NS among gym users in Kampala city in Uganda.
The results indicate that there is a very high prevalence of NS usage among gym users, most of whom indicated the role of trainers, coaches and retail stores or pharmacies in the acquisition and distribution of NS. Energy drinks and herbal supplements were among the most preferred types of supplements among professional and nonprofessional gym users. Perceptions and motivations for NS usage were related to performance enhancement aspects of endurance and strength rather than as a doping agent. Other motivations were related to the users' perception of acquiring health benefits with the use of supplements.

Perspectives
The findings of this current study are vital in guiding interventions and education programs that address community usage of NS in Kampala city. Furthermore, the heightened usage of NS underscores the immediate necessity for coaches and trainer certification and continuing education in nutrition and wellness. There is a need for strict enforcement by the National Drug Authority to ensure the sale of safe nutrition supplement products in the retail outlets of Kampala city. Although enforceable policies could act as a deterrent to the possible sale and eventual consumption of expired and counterfeit products, it is highly recommended that legislation on the sale of products via online markets be introduced.