Attitude And Practices Regarding The Use Of Multivitamins For Hair Fall Among Students Of Majmaah University, Saudi Arabia

Introduction

One of the most frequent reasons to visit a dermatology clinic is for hair loss, or alopecia. It is a condition affecting men, women, and kids. Over half of men and one-third of women will, at some point in their lives, experience hair loss. 1,2 Scarring and nonscarring types of hair fall can be distinguished. The three types of non-scarring alopecia are alopecia areata (AA), telogen effluvium (TE), and androgenetic alopecia (AGA), with androgenic alopecia being the most prevalent in both men and women. 3,4

AGA is an androgen-related disorder that affects genetically predisposed individuals. It presents differently in men and women; in women, it typically only affects the crown, sparing the frontal hairline, whereas in men, the frontal hairline and the crown are the typical locations for hair thinning. 1,2 An immune-triggered condition called alopecia areata (AA) can result in temporary or permanent hair loss. The scalp is primarily affected by well-defined circular spots. 5,6 A form of non-scarring alopecia known as telogen effluvium (TE) can be recognized by scattered, frequently abrupt hair loss. Hormonal fluctuations, drugs, or metabolic stress may cause it. Acute febrile illness, severe infection, major surgery, severe trauma, postpartum hormone shifts, hypothyroidism, stopping estrogen-containing medicine, crash dieting, low protein intake, heavy metal absorption, and iron insufficiency are additional events that may cause TE.⁷

There are multiple reasons to believe that micronutrients may play a part in non-scarring alopecia. Micronutrients are important components of the healthy hair follicle cycle because they contribute to cellular turnover, which happens often in the matrix cells of the rapidly dividing follicle bulb. 8

Studies on non-scarring alopecia (hair loss) have explored the potential benefits of multivitamins in promoting hair health. Vitamins and minerals such as vitamin A, vitamin B, vitamin C, vitamin D, vitamin E, iron, selenium, and zinc have been studied for their role in supporting healthy hair growth and preventing hair loss. [8] Various therapies are employed to address the various forms of hair loss. Vitamins and supplements are the most often used, prescribed, and well-known remedies. A 2012 study carried out in Saudi Arabia evaluated dermatologists' attitudes and practices with reference to providing minerals and vitamins to patients who have hair loss. Sixty-four dermatologists advised treating at least one form of hair loss with vitamins and minerals. The supplements that are taken are biotin, zinc, iron, and vitamin D. Sixty-two percent of prescriptions were for acute telogen efflux.⁹ Given the frequency of hair loss and its substantial influence on patients' quality of life, alopecia management is a crucial component of clinical dermatology. One active and expanding field of study is how diet and nutrition affect hair loss. 8

It is important to understand the beliefs and behaviors of Majmaah University students regarding the use of multivitamins to treat hair loss. Therefore, we conducted this study.

Methodology:

This cross-sectional study conducted at AlMajmaah University in Saudi Arabia from November 2023 to April 2024 assessed the attitudes and behaviors related to the use of multivitamins for hair loss among students. Participants were enrolled students aged 18 and above, of any gender and nationality, residing in Saudi Arabia. Exclusion criteria included non-enrollment, being under 18, and non-residency. Recruitment was conducted through an online poll sent on WhatsApp and Twitter, with electronic informed consent to guarantee secrecy. The Majmmah University ethics Commission granted approval for the study, which targeted a sample size of 379. An attitude questionnaire consisting of two items and a 5-point Likert scale was used to evaluate attitudes towards multivitamins for hair loss, with results reflecting different levels of attitude. SPSS version 20 was used for data analysis, utilizing non-parametric tests including the Mann-Whitney Z-test and Kruskal-Wallis H-test because the attitude ratings did not follow a normal distribution. Statistical collinearity was evaluated using the Shapiro-Wilk and Kolmogorov-Smirnov tests. Univariate and multivariate analyses determined the factors that affect the use of multivitamins for hair loss, with statistical significance defined as a p-value below 0.05.

Results

Figure 1: Socio-demographic characteristics of the students

This cross-sectional study recruited 745 students. Figure 1 describes the socio-demographic characteristics of the students. The most common age group was between 18 and 20 years old (58.4%), with females being dominant (75.8%). Most of the students were earning less than 5,000 SAR per month. The prevalence of students who suffered from hair loss was 82.8%.

In Table 1, the prevalence of students who use multivitamins to treat hair loss was 41.1%. Regarding the attitude toward multivitamins for the treatment of hair fall, 46.6% agreed, and 14.6% strongly agreed that multivitamins could treat hair fall. Also, 36.9% agreed, and 15.2% strongly agreed that they would recommend multivitamins to their friends and families. Based on the above statements, the total mean attitude score was 715 (SD 1.67), with negative, neutral, and positive attitudes consisting of 13.2%, 70.7%, and 16.1%, respectively.

Table 1: Multivitamins use and attitude toward hair loss (n=745)
Statement	N (%)
Did you use multivitamins to treat it?
Yes	306 (41.1%)
No	311 (41.7%)
Did not suffer from hair loss	128 (17.2%)
Attitude toward multivitamins for hair fall
Do you believe that multivitamins treat hair fall?
Strongly disagree	16 (02.1%)
Disagree	53 (07.1%)
Neutral	220 (29.5%)
Agree	347 (46.6%)
Strongly agree	109 (14.6%)
Would you recommend your friends and family to use multivitamins for hair fall?
Strongly disagree	32 (04.3%)
Disagree	64 (08.6%)
Neutral	261 (35.0%)
Agree	275 (36.9%)
Strongly agree	113 (15.2%)
Total attitude score (mean ± SD)	7.15 ± 1.67
Level of attitude
Negative	98 (13.2%)
Neutral	527 (70.7%)
Positive	120 (16.1%)

In Table 2, among those who use multivitamins for the treatment of hair fall (n=306), 88.2% spent at least less than 1,000 SAR for multivitamin use. The proportion of students who measured vitamin blood level before taking multivitamins was 48%. Nearly half (49.7%) were taking multivitamins between 1 to 3 months. Only 16% measured blood levels after the treatment course, while 20.3% tried increasing the dose to get better results. Improvement from treatment was seen by 30.7% of students. The most common action to be taken for the incidence of side effects was to stop taking multivitamins without consulting a physician (28.8%).

Table 2: Characteristics of the students who use multivitamins for hair fall (n=306)
Statement	N (%)
How much did multivitamins cost per month?
<1000 SAR	270 (88.2%)
1000 – 2000 SAR	31 (10.1%)
>2000 SAR	05 (01.6%)
Did you measure your vitamin blood level before taking the multivitamins?
Yes	147 (48.0%)
No	159 (52.0%)
How long have you used multivitamins?
<1 month	82 (26.8%)
1 – 3 months	152 (49.7%)
4 – 6 months	34 (11.1%)
>6 months	38 (12.4%)
Did you check your blood level after finishing the course?
Yes	49 (16.0%)
No	257 (84.0%)
Have you tried increasing the dose for better results?
Yes	62 (20.3%)
No	244 (79.7%)
If you used them, did you notice an improvement regarding hair fall?
Yes	94 (30.7%)
No	212 (69.3%)
When you had the side effects, what did you do?
No side effect	109 (35.6%)
I went to see the Doctor	29 (09.5%)
I continued without consulting a physician	75 (24.5%)
I stopped without consulting a physician	88 (28.8%)
Others	05 (01.6%)

Figure 2: Sources of information regarding multivitamins for the treatment of hair fall

Of the students who were taking multivitamins, the most common source of multivitamin information was the doctor (39.5%), followed by friends (20.9%) and social media (15.4%).

We also assessed the side effects during treatment, and our results revealed that among those taking multivitamins (n=306), the most common side effect was stomach pain, experienced by 25.2% of participants. This was followed by diarrhea or constipation, also at 25.2%.

We performed univariate and multivariate analyses to identify the demographic factors that influence the use of multivitamins for hair fall. Based on the results, it was observed that compared to the younger age group (18-20 years), students who were between 21 and 23 years were 2.25 times more likely to use multivitamins for hair fall (AOR=2.252; 95% CI=1.385 – 3.660; p=0.001), while the odds of multivitamin use among students aged between 24 and 26 years was 1.86-fold higher (AOR=1.861; 95% CI=1.099 – 3.152; p=0.021). Also, compared to male students, female students were 2.6 times more likely to use multivitamins for the treatment of hair fall (AOR=2.603; 95% CI=1.640 – 4.130; p<0.001). No significant difference in the use of multivitamins for the treatment of hair falls in terms of monthly income after adjustment to a regression model (p=0.551).

§ P-value has been calculated using Mann Whitney Z-test.

‡ P-value has been calculated using Kruskal Wallis H-test.

When measuring the differences in the score of attitude in relation to the socio-demographic characteristics of the students (Table 3), it was revealed that all socio-demographic variables and the use of multivitamins for hair fall did not show significant differences when compared to the overall attitude score (p>0.05).

Table 3: Differences in the score of attitude in relation to the socio-demographic characteristics and the use of multivitamins for hair fall (n=745)
Factor	AttitudeScore (10)Mean ± SD	Z-test	P-value §
Age group
18 – 20 years	7.14 ± 1.58	0.276	0.871 ‡
21 – 23 years	7.18 ± 1.76
24 – 26 years	7.11 ± 1.87
Gender
Male	7.16 ± 1.77	0.321	0.748
Female	7.14 ± 1.64
Monthly income (SAR)
<5,000	7.18 ± 1.66	0.914	0.361
≥5,000	7.06 ± 1.70
Suffered from hair loss
Yes	7.18 ± 1.68	1.026	0.305
No	6.99 ± 1.62
Use of multivitamin for hair fall
Yes	7.23 ± 1.75	0.708	0.479
No	7.13 ± 1.62

Discussion

This study evaluates the attitudes and practices of university students regarding multivitamins for the treatment of hair fall. The results suggest that there was a high prevalence of multivitamin use for treating hair falls among students. Approximately 41.1% reported using multivitamins for hair loss disorders. This is almost consistent with the study conducted by Alghamdi et al. (2014) 10 . According to reports, the use of multivitamins for hair fall has been reported by 44%. However, only 37.4% indicated using it under medical supervision. This is corroborated by the study of Mubki et al. (2022). 12 Most of the Saudi adults use multivitamins for hair growth. However, 66% tried using different shampoo to prevent hair loss. Also, a minority (9.8%) noticed significant hair loss after desisting the product. The findings underscore the need for more clinical trials to prove the effectiveness of multivitamins and other supplements that are known to treat hair fall. Interestingly, in a literature review done by Patel et al.(2017) 13 , it has been documented that all patients who received biotin supplementation showed evidence of clinical improvement. However, the efficacy of biotin is not conclusive due to insufficient evidence to prove its worth.

Female gender and increasing age were identified as the significant predictors of multivitamins used. This is comparable to the results done in Kuwait 11. Research indicated that the use of natural health products (NHPs) was significantly associated with female gender (p<0.05). Likewise, in Jazan 14, the use of supplements for the treatment of hair loss was significantly higher in older participants (>45 years).

Various papers documented an association between hair loss and vitamin D deficiency 14,15,16,17. On the contrary, Mubki (2014) detected no association between participants' job titles and the different indications of vitamin D (p>0.05). They further noted that the relationship between the use of biotin for hair loss disorder in terms of specialists or consultants did not yield statistical significance (p>0.05). Other papers also found no significant link between iron deficiency and hair loss 18,19,20. However, in a paper by Kim et al.(2018) 21, patients with severe hair loss who had a perception and accurate information about hair disorders showed a higher tendency to receive treatment in the future.

Reinforcing the higher prevalence of multivitamins used, students' attitudes about it were also optimistic. Based on the given criteria, 70.7% were considered to have neutral attitudes, 16.1% were positive, and only 13.2% were considered to have negative attitude levels. This was mirrored by the study of Awad & Al-Shaye (2014) 11, which indicated that respondents' attitudes toward NHPs were generally positive. Interestingly, Mubki et al. (2022) 12 reported that the attitude of some Saudi adults regarding the products used to treat hair fall was negative, as approximately 36.8% did not use any of the anti-hair loss therapies.

The side effects associated with the use of multivitamins are one of the main reasons for not using the product. In our study, the most frequently reported side effect was stomach pain, followed by diarrhea or constipation. Other reported side effects, including allergies, nausea, and vomiting, were not prevalent. Furthermore, the most common action to be taken for any adverse events was stopping the multivitamins without a doctor's consultation (28.8%). Opposing this action, 24.5% would still continue taking multivitamins despite their side effects. These conflicting opinions likely depend on the severity of the side effects. Students may likely discontinue taking the supplements if they experience severe adverse effects, whereas they would continue taking them if the effects were mild. Despite this scenario, some students believed multivitamins are beneficial, as 20.3% noticed hair fall improvement after the process. These findings have coincided with the study done in Riyadh 10. Multivitamins' most common side effects were abdominal pain, diarrhea, and constipation. In addition, the effectiveness of the treatment method has been reported by 63.5%, and a similar proportion (61.4%) believed that the side effects could be due to other factors.

An appropriate understanding of this type of supplement is crucial. Having accurate information could lead to a better outcome. In our study, the most common sources of multivitamin information were doctors (39.5%), friends (20.9%), and social media (15.4%). Other sources were self-information (11.4%) and pharmacist (11.1%), while information given by the family was the least preferred (1.6%). This is almost consistent with the study of Assiri et al.(2023) 14.

Conclusion

There was a high prevalence and optimistic attitude of multivitamins used for the treatment of hair fall. Female students were seen to use multivitamins more frequently than male students. Further, increasing age was associated with increasing use of multivitamins. This study concurred that the use of multivitamins for treating hair fall is common among medical students. However, given the lack of evidence supporting the efficacy of multivitamins, more clinical studies are imperative to determine the effectiveness of multivitamins for the treatment of hair fall. In addition, an appropriate understanding of the misuse of multivitamins is necessary to alleviate any side effects of this type of supplement.

References

1. Mubki T, Shamsaldeen O, McElwee K, Shapiro J(2013): An update on diagnosis and treatment of female pattern hair loss. Expert Review of Dermatology,8(4):427-436.

1. Otberg N, Finner A, Shapiro J(2007): Androgenetic alopecia. Endocrinology and Metabolism Clinics of North America,36(2):379-398.

1. Shapiro J (2007): Hair Loss in Women.The New England Journal of Medicine, 357:1620-1630

1. Trüeb R(2010): Systematic approach to hair loss in women. JDDG: Journal derDeutschen Dermatologischen Gesellschaft,8(4):284-297.

1. Alkhalifah A (2013): Alopecia Areata Update. Dermatologic Clinics,31(1):93- 108. 7.

1. Roest Y, van Middendorp H, Evers A, van de Kerkhof P, Pasch M(2017): Nail Involvement in Alopecia Areata: A Questionnaire-Based Survey of Impact on Quality of Life and Review of the Literature. Acta Dermato Venereologica, 98(2):212-217.

1. Hughes EC, Taneja A(2017): Telogen Effluvium. [Updated 2017 Mar 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;

1. Almohanna HM, Ahmed AA, Tsatalis JP, Tosti A. The Role of Vitamins and Minerals in Hair Loss: A Review. Dermatol Ther (Heidelb). 2019 Mar;9(1):51-70. doi: 10.1007/s13555-018-0278-6. Epub 2018 Dec 13. PMID: 30547302; PMCID: PMC6380979.

1. Mubki T(2014): Use of Vitamins and Minerals in the Treatment of Hair Loss: A Cross-Sectional Survey among Dermatologists in Saudi Arabia. Journal of Cutaneous Medicine and Surgery,18(6):405-412.

1. Shahad D.Alghamdy, Bushra A. Algarni, Faten Albukhari (2018): Attitude and practice regarding the use of multivitamins for hair fall: Cross sectional study in Saudi Arabia. The Egyptian Journal of Hospital Medicine Vol 73, Issue 6, page 6838-6843

1. Awad, A.; Al-Shaye, D. Public awareness, patterns of use and attitudes toward natural health products in Kuwait: A cross-sectional survey. BMC Complement. Altern. Med. 2014, 14, 105. [CrossRef] [PubMed]

1. Mubki T, Alotaibi AN, aAlosaimi MS. THIS AWARENESS OF MULTIVITAMIN HAIR GROWTH USES AND BENEFIT OF SHAMPOO AND HAIR AMPULE IN SAUDI ADULTS Int. J. of Adv. Res. 10 (Jan) 2022. 534-551] (ISSN 2320-5407).

1. Patel DP, Swink SM, Castelo-Soccio L. A review of the use of biotin for hair loss. Skin appendage disorders. 2017 Aug 8;3(3):166-9.

1. Assiri A, Rajhi A, Sudi A, Akoor A, Juraybi S, Mahzara NK, Abutalib Y, Kariri AM, Altubayqi T, Madkhali AA, Akoor AA. Knowledge, Attitude, and Practices Related to Vitamin D, Zinc, and Ferritin Deficiencies and the Associated Risk of Hair Loss in Jazan, Saudi Arabia. Cureus. 2023 Nov 13;15(11).

1. Rasheed H, Mahgoub D, Hegazy R, El-Komy M, Abdel Hay R, Hamid MA, Hamdy E. Serum ferritin and vitamin d in female hair loss: do they play a role?. Skin pharmacology and physiology. 2013 Feb 20;26(2):101-7.

1. Alotaibi AA, Alsalhi WA, Almutiri AN, Alzahrani AJ, Alsaab AS, Alhassan MA, Alotaibi KA, Aleliwi YS. Knowledge and practice of vitamin D deficiency and risk of hair loss among adult population in Majmaah city, Saudi Arabia. International Journal of Medicine in developing countries. 2019 Mar 18;3(2):001-6.

1. Hailat R, Mughal H, Malik T, Sagheer A, Javed A, Memon Q. Possible Association of Female-Pattern Hair Loss with Alteration in Serum 25-Hydroxyvitamin D Levels. Pakistan Journal of Medical & Health Sciences. 2023 Apr 8;17(02):623-.

1. Sinclair R: There is no clear association between low serum ferritin and chronic diffuse telogen hair loss. Br J Dermatol 2002; 147: 982–984.

1. Rushton DH: Decreased serum ferritin and alopecia in women. J Invest Dermatol 2003; 121:xvii–xviii.

1. Olsen EA, Reed KB, Cacchio PB, Caudill L: Iron deficiency in female pattern hair loss, chronic telogen effluvium, and control groups. J Am Acad Dermatol 2010; 63: 991–999.

1. Kim BK, Lee S, Jun M, Chung HC, Oh SS, Lee WS. Perception of hair loss and education increases the treatment willingness in patients with androgenetic alopecica: a population-based study. Annals of dermatology. 2018 Aug 1;30(4):402-8.