Jordanian Population Knowledge, Attitude and Practices on the Uses of Antidiabetics for Weight Loss Purposes: A Cross Sectional Study

doi:10.21203/rs.3.rs-3325697/v1

Download PDF

Research Article

Jordanian Population Knowledge, Attitude and Practices on the Uses of Antidiabetics for Weight Loss Purposes: A Cross Sectional Study

https://doi.org/10.21203/rs.3.rs-3325697/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Background

Obesity became a recent pandemic, especially, during the Corona Virus Pandemic of 2019 (COVID-19) lockdown. Therefore, people started to adopt effortless methods to lose weight such as certain antidiabetic medications.

Objectives

To evaluate Jordanian population knowledge, attitude and practices towards the use of antidiabetic medications such as (Ozempic®), (Saxenda®), (Mounjaro®) and (Glucophage®) for weight loss.

Method

A self-administered validated online questionnaire was developed and disseminated to public. Data were extracted to examine descriptive statistics. Linear regression was performed to evaluate predictors of knowledge and attitude. A P-value ≤ 0.05 was chosen to indicate statistical significance.

Results

Total of 389 responses were analyzed, 65.6% females, 54.2% married, 78.1% living in the center of Jordan, 35.5% overweight and 26.5% have > 1000 Jordanian Dinars (JOD) monthly income. 57% think that antidiabetics could be used for weight loss. 47.27%, 44.55%, 68.18% recognized (Ozempic®), (Saxenda®), (Mounjaro®) and (Glucophage®) use for weight loss, respectively and 12.3% of participants used medications to lose weight. Neutral attitude was observed. Gender and body mass index (BMI) were significant predictors of knowledge (P < 0.001, P = 0.002, respectively).

Conclusion

Use of (Ozempic®), (Saxenda®) and other antidiabetics to lose weight become a common practice. The results of this study suggests supervising prescription and dispensing to avoid misuse, especially, in people who are contraindicated to use them.

Ozempic®

Saxenda®

Mounjaro®

weight loss

off-label use

According to the World Health Organization (WHO), obesity is defined as having a body mass index (BMI) greater than 30 kg/m² [1]. However, this definition differs from one nation to another based on the fat distribution which is considered a major factor for predicting comorbidities [2]. Obesity is recognized as a risk factor for many chronic diseases such as hypertension, diabetes mellitus type II and other coronary heart disease [3, 4]. Consequently, managing body weight within a BMI value of 18–25 kg/m² as well as avoiding fat accumulation in the viscera beyond 15% and 25% in males and females, respectively is a health necessity [5]. The United nations Global Health Targets report for 2025 stated that Jordan has one of the highest percentages of obesity in both genders and the chances to meet obesity targets by 2025 are considered poor ≤ 1% [6].

In 2017, Ajlouni et al conducted a national survey in Jordan to investigate the rate of obesity among both males and females and the risk of developing comorbidities [7]. The results showed that odd ratios (OR) of obesity are high 1.98 (n = 1193) and 1.96 (n = 2863) in males and females, respectively, which are twice that during 2009 assessment [7]. Additionally, risk of type II diabetes, hypertension and high triglycerides level has increased [7]. The results of this study were adopted by the WHO and documented a percentage prevalence of obesity of 60.4 and 75.6 in men and women, respectively [8]

Recently, people started to consider convenient tools and/or methodologies for weight reduction or management such as bariatric surgeries, weight loss medications and more recently are injectable hypoglycemic agents [9, 10]. For instance, the glucagon-like peptide-1 (GLP-1) receptor agonists; (Ozempic®, Semaglutide), (Saxenda®, Liraglutide) and (Mounjaro®, Tirzepatide) [11–13]. In developing countries access to these medications without medical prescription is possible and increased with the possibility of buying them over the internet [14, 15]. However, the fact that users of these injectable medications rely on peers experience or reviews from other users on social media platforms impose more health risks, especially, adverse events and long-term effects that are not well-understood yet.

(Ozempic®), (Mounjaro®) and (Glucophage®) (metformin) are hypoglycemic agents recommended in treating patients with type II diabetes [16–18]. Efficacy of these agents in producing weight loss is considered an off-label use, yet Food and Drug Administration (FDA) unapproved for this indication [11, 17, 18]. On the contrary, a higher dose of Semaglutide that is licensed under the name (Wegovy®) as well as (Saxenda®, Liraglutide ) are FDA-approved for weight loss [19, 20]. Previous studies have reported that these agents might lead to the development of gastrointestinal adverse events, kidney disease, pancreatitis, gallbladder problems and most importantly, thyroid tumors and cancer [21–23].

Social media platforms (i.e. Facebook®, Instagram®, Twitter®, Whatsapp®) have changed the buying behaviors of their users, relying mostly on other users’ experience rather than healthcare providers’ recommendations [24]. One of these buying and using behaviors are (Ozempic®) and (Saxenda®) use for weight loss [11, 25]. This would result in improper use, especially, in people with risk factors for developing cancer, kidney disease or low blood glucose levels. Furthermore, the massive demand on buying these preparations has led to deficiency in their market availability which led to buying them from unauthorized suppliers [26]. As a result, this lead to increase in counterfeited preparations and sometimes to replace the abovementioned active ingredients with Insulin [27]. This was expected due to the inability of regulatory agencies to oversee and quality-check smuggled counterfeited preparations [28]. Consequently, this study aims primarily to assess the Jordanian population knowledge, attitudes and practices and buying behaviors of (Ozempic®), (Saxenda®) and (Mounjaro®) for the purposes of weight loss.

Ethical approvals

This study was granted the ethical approval after protocol review by the institutional review board (IRB) committee at Applied Sciences University with an approval number (2023-PHA-29) on 10th of July 2023. Confidentiality and anonymity of data are reassured and this was identified to participants prior to responses collection in the provided informed consent before taking part in the study. Respondents were informed that they can withdraw participation at any time during questionnaire filling out and the data they share will only be used for research purposes.

Questionnaire content development and validation

A self-administered survey was developed using Google® forms after reviewing the literature [29]. The questionnaire consists of four main sections. The first one addresses participants demographics such as age, gender, marital status, weight, height, education, family monthly income, place of residence, being health insured and having chronic diseases or not. The second section evaluated participants’ knowledge of antidiabetic medications in five main questions. Participants were asked about the possibility of using certain antidiabetic medications for weight loss (e.g. (Ozempic®), (Saxenda®) and (Mounjaro®), (Glucophage®), Insulin, (Amaryl®) and (Jardiance®)) and approval by regulatory agencies for this indication. Additionally, participants were asked about possible side effects for using antidiabetic agents to lose weight and the source of information about the aforementioned medications in weight loss purposes (e.g. health care provider, nutritionist, social media, scientific articles, family and friends and others). The third section assessed participants’ society's awareness of the uses of antidiabetic medications for weight loss purposes. Based on a five degree likert scale ranging from strongly agree to strongly disagree, participants were requested to provide their opinion about level of regulatory authorities supervision on dispensing of antidiabetic medication for weight loss, as well as using these medications under medical supervision. Additionally, being the first option in the methods used to lose weight, the ability of these medications in improving the lifestyle, being safe without any complications or adverse events, guarantee of effectiveness and sustainability of efficacy after discontinuation were all evaluated using the same scale. The last section evaluated the practices of Jordanian population in using injectable antidiabetic agents for weight loss i.e. GLP-1 receptor agonists in addition to (Glucophage®). Only participants who used antidiabetic agents for weight loss proceeded to this section. Participants were requested to declare which antidiabetic agent they have used from the following medications (Ozempic®), (Saxenda®) and (Mounjaro®) and (Glucophage®). Other common practices to lose weight such as diet, herbal preparations, exercises and diet were also evaluated. Data regarding checking the source of antidiabetic medications, difficulty in obtaining them, the lost weight (if applicable), method of verifying the medication sources, doctors’ consultation, weight gain after medication cessation, adverse events development and reading medical information prior to use were collected in this section. Participants were also offered the option if they would like to share more information about their experience in using antidiabetic agents for weight loss. Pictures of the brand names of study medications were provided within the questionnaire to help people identify them.

Content validity was assured after piloting the questionnaire to 12 subjects (5 academics and 7 from the public). Their feedback considering any scientific jargon or unclear questions were taken into account and the questionnaire was updated accordingly where applicable. The questionnaire was first designed in Arabic; the national language of Jordan and was translated to English by two academics who are fluent in both languages. Responses were collected in Arabic which is the national and spoken language in Jordan.

The questionnaire was disseminated using different social media platforms such as Facebook®, Instagram®, Twitter®, Whatsapp® to collect individual responses of the target group over the period 4th to 25th of August 2023.. An estimated sample size of 385 was calculated with a margin of error of 0.05 and 95% confidence interval and according to the total number of Jordanian population [30]. Attitude score was assessed using Likert scale with a maximum of 5 to a minimum of 1. Scores were categorized using Bloom's cut-off points: < 3 (< 59%) were considered negative attitude, 3-3.9 (60.0–79.0%) as neutral and 4–5 (80.0-100.0%) as a positive attitude toward weight reduction medication. [31].

Statistical analysis

Data were exported from Google® Forms into an Excel® spreadsheet, entered into the Statistical Package for Social Sciences version 24.0 (SPSS® Inc., Chicago, IL, USA), and statistically analyzed. The mean and standard deviation (SD) for continuous variables were employed in descriptive statistical analysis to analyze the sociodemographic data. Examples of categorical variables were frequencies and percentages. To evaluate the normalcy, the Shapiro-Wilk test was applied. Cronbach's alpha was used to assess the questionnaire's reliability (= 0.81), i.e., that the scales built were appropriate for the task at hand. Values below 0.7 indicate good internal consistency.

Using univariate linear regression analysis, independent factors that might influence participants' knowledge and attitude regarding weight reduction medications were looked at. Then, variables that had been determined to be significant on a single predictor level (P < 0.25 in each case) were added to multiple linear regression models. After confirming their independence, variables were chosen; tolerance values > 0.1 and Variance Inflation Factor (VIF) values < 10 were tested to show that multicollinearity between the independent variables in regression analysis was not present. No included variable had multicollinearity; as a result, none was deleted. P-value ≤ 0.05 was used to determine statistical significance.

Sociodemographic characteristics

A total of 395 responses were received by the participants; six responses were excluded due to reluctance to consent. Three hundred eighty-nine responses were included in the final analysis. More than half of the respondents were female (255, 65.6%), married (211, 54.2%), living in the central area of Jordan (304, 78.1%), and holding a bachelor's degree (219, 56.3%). Most of the participants worked in the medical field (190, 48.8%) and had medical insurance (255, 65.5%). The BMI was normal for 152, 39.1% of participants, Table 1.

Table 1

Sociodemographic characteristics of the participants (n = 389).
Variable	n	%
Gender
• Male	134	34.4
• Female	255	65.6
Marital status
• Single	170	43.7
• Married	211	54.2
• Others	8	2.1
Residencial area
• North governorates (Irbid, Jerash, Ajloun, Mafraq)	62	15.9
• Central governorates (Amman, Zarqa, Balqa, Madaba)	304	78.1
• Southern governorates (Karak, Tafila, Ma'an, Aqaba)	23	5.9
Monthly income of the family (Jordanian Dinars)
• Less than 300	70	18.0
• 300–700	145	37.3
• 701–1000	71	18.3
• More than 1000	103	26.5
The highest degree or level of education you have completed
• High School	36	9.3
• Vocational education	1	0.3
• Diploma	40	10.3
• Bachelor's degree	219	56.3
• Postgraduate degree (Master's, Ph.D.)	93	23.9
Occupation (profession)
• Medical occupations (medicine, pharmacy, nursing, laboratories...etc.)	190	48.8
• Non-medical occupations (engineering, information technology, arts, Craft occupations, etc.)	155	39.8
• Not applicable	44	11.3
Health insurance status
• Insured	255	65.6
• Uninsured	134	34.4
Presence of chronic diseases
Do you suffer from chronic diseases?
• Yes	85	21.9
• No	304	78.1
If yes, what are these diseases?*
• Diabetes	26	6.7
• Hypertension	30	7.7
• Cardiovascular disease	14	3.6
• Thyroid diseases	14	3.6
• Hyperlipidemia	31	8.0
• Obesity	35	9.0
• Others	29	7.5
BMI Categories^$
• Severely Underweight (< 16.0)	0	0.0
• Underweight (16.0–18.4)	16	4.1
• Normal (18.5–24.9)	152	39.1
• Overweight (25.0–29.9)	138	35.5
• Moderately Obese (30.0–34.9)	53	13.6
• Severely Obese (35.0–39.9)	23	5.9
• Morbidly Obese (> 40.0)	7	1.8
	Mean	SD
Height (cm)	166.46	9.2
Weight (kg)	73.64	18.0
Age (in years)	35.79	13.2
*More than one option was allowed, $ according to the WHO categorization of BMI

Participants' knowledge about antidiabetic medications uses for weight reduction

Upon asking participants about the possible use of some antidiabetic medications for weight reduction, more than half of them agreed with their use (220, 57%), while 99 participants were unsure, Fig. 1.

In general, the knowledge score about this medication showed that study participants were fairly unconfident, as the mean and SD were 6.2 ± 3.03 (out of 27), Table 2. Among the participants who agreed with their use (n = 220), almost one-third of the participants chose (Glucophage®), as a possible medication used for weight loss (150, 68.2%). At the same time, 47.3% and 44.5% of the respondents reported (Ozempic®) and (Saxenda®). Most of participants declared that (Ozempic®) and (Saxenda®) are not approved (143, 65% and 189, 85.91%, respectively). Regarding the knowledge about side effects of the injectable weight reduction medications, more than half stated nausea/vomiting (128, 58.2%), Fatigue (120, 54.6%), diarrhea (115, 52.3%) and headache (111, 50.5%), Table 2.

Furthermore, study participants declared that the main sources of information about these medications were healthcare providers (129, 58.6%), social media (113, 51.4%), scientific articles (113, 51.4%) and family/friends (112, 50.9%), Fig. 2.

Table 2

Participants' knowledge about weight reduction medications (n = 220). More than one option was allowed.
Questions	Correct answer
Questions	n	%
To the best of your knowledge, which of the following medications can be used to lose weight?
• (Ozempic^®)	104	47.27
• (Saxenda^®)	98	44.55
• (Mounjaro^®)	47	21.36
• (Glucophage^®)	150	68.18
• Insulin	93	42.27
• (Amaryl^®)	88	40.00
• (Jardiance^®)	64	29.09
Which of the following medications is approved to be used for weight loss by regulatory authorities such as the Food and Drug Administration?
• (Ozempic^®)	143	65.00
• (Saxenda^®)	76	34.55
• (Mounjaro^®)	189	85.91
• (Glucophage^®)	85	38.64
• Insulin	82	37.27
• (Amaryl^®)	74	33.64
• (Jardiance^®)	66	30.00
To the best of your knowledge, what are the side effects of the injectable medications used for weight loss?
• Nausea and vomiting	128	58.18
• Diarrhea	115	52.27
• Abdominal pain	111	50.45
• Headache	105	47.73
• Fatigue	120	54.55
• Weight gain	108	49.09
• Skin swelling or irritation where the needle was inserted	72	32.73
• Dark patches of skin	49	22.27
• Unwanted sexual responses (sexual dysfunction or arousal)	34	15.45
• Depression	63	28.64
• Pancreatitis	53	24.09
• Tumors such as thyroid tumors	47	21.36
• Urinary tract infection	49	22.27
Total knowledge score (out of 27)*	Mean	SD
Total knowledge score (out of 27)*	6.2	3.03
*Knowledge was assessed by giving 1 to the correct Answer and 0 to the Wrong Answer. The scale measured knowledge from a maximum of 27 to a minimum of Zero. The score < 5.4 were considered very unconfident, 5.4–10.8 as fairly unconfident, 10.9–16.2 as neutral, 16.3–21.6 as fairly confident, 21.7–27 as very confident knowledge about weight reduction medication

Participants attitudes toward antidiabetic medications uses for weight reduction

Generally, the study participants demonstrated a neutral attitude toward antidiabetic medication use for weight reduction; the mean score was 3.35 ± 0.45. As shown in Table 3. The majority of them agreed and strongly agreed that using these medications for weight loss should be under medical supervision (220, 56.7%). While most of the respondents strongly disagreed and disagreed with the rest of the attitude items in Table 3, including the presence of sufficient supervision in Jordan over these medication use (191, 49.1%).

Table 3

Participants' attitude toward antidiabetic medications uses for weight reduction (n = 389).
Statements	n (%)
Statements	Strongly agree	Agree	Neutral	Disagree	Strongly disagree
• There is sufficient supervision in Jordan by the concerned authorities on the dispensing of antidiabetic medications used for weight loss purposes	17(4.37)	60(15.42)	121(31.11)	160(41.13)	31(7.97)
• These medications can be used for weight loss, but under medical supervision	70(17.99)	150(38.56)	124(31.88)	33(8.48)	12(3.08)
• The use of these medications is the first and best option for weight loss	10(2.57)	42(10.80)	112(28.79)	155(39.85)	70(17.99)
• These medications help you make the lifestyle changes you need to lose weight and improve your health	32(8.23)	95(24.42)	139(35.73)	94(24.16)	29(7.46)
• These medications are considered safe and can be used without complications	13(3.34)	52(13.37)	137(35.22)	138(35.48)	49(12.60)
• The effectiveness of these medications for weight loss is guaranteed	18(4.63)	73(18.77)	172(44.22)	86(22.11)	40(10.28)
• The efficacy of these medications is long-lasting	10(2.57)	41(10.54)	173(44.47)	125(32.13)	40(10.28)
Attitude score*	Mean	SD
Attitude score*	3.35	0.45

* Attitude Score (mean ± SD) = 3.35 ± 0.45. Attitude score was assessed using Likert scale with a maximum of 5 to a minimum of 1. Scores were categorized using Bloom's cut-off points: < 3 (< 59.%) were considered negative attitude, 3-3.9 (60.0–79.0%) as neutral and 4–5 (80.0-100.0%) as a positive attitude toward weight reduction medication.

Participants practices toward antidiabetic medications uses for weight reduction

Among the study participants, only 48 (12.3%) of them have used medication for weight loss purposes in the last 12 months, Table 4. As most of them reported the use of (Glucophage®) (26, 54.2%) and (Ozempic®) (15, 31.3%). In addition, they declared the use of other methods for weight loss such as a healthy diet (42, 87.5%), exercising (40, 83.3%), use of other prescription medication (21, 43.8%) and use of herbals (20, 41.7%). More than three-quarters of these users utilized these medications from pharmacies (38, 79.2%) but reported difficulty obtaining them (36, 75.0%). The mean (± SD) of body weight lost after the use of antidiabetic medication was 6.22 (± 3.3) kg; however, 64.6% (n = 31) reported gaining weight after stopping these medications. Furthermore, 72.9% (n = 35) of the users experienced side effects from these medications, even 41.7% (n = 20) consulted a doctor before using medications.

Table 4

Participants' practice toward antidiabetic medications uses for weight reduction.
Questions	n	%
Have you used any medication for weight loss purposes in the last 12 months? *
No	341	87.7
Yes	48	12.3
Which of the following antidiabetic medications have you used for weight loss purposes? ^$
• (Ozempic^®)	15	31.3
• (Saxenda^®)	9	18.8
• (Mounjaro^®)	3	6.3
• (Glucophage^®)	26	54.2
What other ways do you usually follow to lose weight in addition to using antidiabetic medications? ^$
• Diet	42	87.5
• Other prescription medications	21	43.8
• Herbal products	20	41.7
• Exercising	40	83.3
• Others	9	18.8
What is the source of these medications? ^$
• Pharmacy	38	79.2
• private clinics/ medical centers	14	29.2
• Hospitals	13	27.1
• Facebook Pages	14	29.2
• Family and friends abroad	9	18.8
• Other sources	7	14.6
Have you had difficulty obtaining these medications recently? ^$
• Yes	36	75.0
• No	12	25.0
If you have ever used these medications, how much weight (kg) did you lose? ( Mean ± SD)	6.22 ± 3.3 kg
Do you check the source of these medications when purchasing them? ^$
• Yes	16	33.3
• No	32	66.7
Did you consult a doctor before using these medications? ^$
• Yes	20	41.7
• No	28	58.3
Did you gain any weight back after you stopped using these medications? ^$
• Yes	31	64.6
• No	17	35.4
Have you experienced any side effects when using these medicines? ^$
• Yes	35	72.9
• No	13	27.1
Do you read medical information about the products you use to lose weight? ^$
• Yes	41	85.4
• No	7	14.6

^*Percentage was calculated based on total sample size (n = 389). ^$Percentages were calculated based on the number of participants who have experience with weight reduction medications.

Factors associated with knowledge and attitude toward antidiabetic medications uses for weight reduction

Table 5 demonstrates that many factors affected the participants' knowledge and attitude scores significantly. Both scores were positively affected by female gender, high monthly income (> 1000 JOD), medical profession and use of medication for weight loss in the last 12 months. In addition, the knowledge score was affected significantly by the presence of chronic diseases and increased BMI. In parallel, attitude score was affected positively by living in the center of Jordan and having medical insurance.

Table 5

Multiple linear regression for predictors affecting the knowledge and attitude scores among participants.
Predictors	Knowledge score		Attitude score
Predictors	Beta	P-vlaue	Beta	P-vlaue
• Gender (Ref = female)	0.191	< 0.001	0.304	< 0.001
• Marital status (Ref = single)	….............	….........	-0.07	0.279
• Place of residence (Ref = center)	0.038	0.421	0.104	0.042
• The monthly income of the family (Ref = > 1000JD)	0.176	0.001	0.171	0.005
• Level of education (Ref = high school)	….............	….........	-0.042	0.476
• Profession (Ref = non-medical)	-0.367	< 0.001	-0.139	0.023
• Health insurance (Ref = Insured)	0.013	0.793	0.097	0.066
• Chronic diseases (Ref = No)	-0.113	0.025	….............	….........
• Use of any medication for weight loss in the last 12 months (Ref = Yes)	0.157	0.001	0.114	0.03
• Height (cm)	0.063	0.342	0.074	0.303
• Weight (kg)	0.124	0.032	0.057	0.366
• BMI (Ref = Underweight)	0.223	0.002	0.145	0.071
• Age (in years)	-0.142	0.051	….............	….........
• Attitude score	-0.064	0.171	….............	….............
• Knowledge score	…...............	…...............	-0.063	0.2

*Significance measure at P-value < 0.05 is presented in bold.

The impact of COVID-19 pandemic and accompanying lockdown on weight management cannot be disregarded. A recent systematic review reported an increase in the BMI by 11.1–72.4% in individuals > 16 years following COVID-19 lockdown during the period March to May 2020 [32]. Furthermore, both (Ozempic®) and (Saxenda®) have a rising popularity in weight loss practices that was marketed over different online platforms.[11] Consequently, this study aimed to evaluate Jordanian population knowledge, awareness and practices towards using antidiabetic agents in weight loss.

Up to the authors’ knowledge, this is the first study performed in Jordan and recording the use of antidiabetic agents for weight loss. The medications to be investigated for their use were selected following observations of social media users mentioning them as potential weight loss agents.

In this study, 18.8% of our study participants used (Saxenda®) and most probably without medical advice. This could be attributed to the possibility of self-medication that is not uncommon in Jordan [33]. Changes in body weight were also comparable 8.6 ± 6.7kg compared to 6.22 ± 3.3kg [34]. On the contrary, a previous study that compared the prescription of anti-obesity medication before and after COVID-19 pandemic reported a 28.2% prescribing of Liraglutide (i.e. (Saxenda®) [34].

Metformin that is licensed under the name (Glucophage®) demonstrated a profound effect in weight loss, yet, not FDA approved for this purpose [35]. Massive literature is available about the beneficial impact of metformin in weight reduction, especially, in people with insulin resistance[18, 36]. Added to the fact that metformin is the first line to treat type 2 diabetes and Jordanian population has one of the highest percentages of diabetic patients [7, 37]. This could be a justification for the superior knowledge about metformin efficacy in weight loss as people might have encountered this in reality. For instance, a mean loss of 5.8 ± 7.0 kg was observed when metformin was administered to non-diabetic patients with a BMI ≥ 27 kg/m² [36]. This decrease is comparable to the mean ± SD weight loss in this study 6.22 (± 3.3) kg. However, the overall knowledge score was considered poor (6.6 ± 3.03) which might be due to people relying on different sources for medical information other than healthcare providers such as social media (51.4%) [38].

In contrast to a previous findings, respondents generally demonstrated good knowledge about FDA approvals for the selected antidiabetic agents commonly used for weight loss. The highest was for (Mounjaro®) with a knowledge score of 85.91% [39]. However, both studies reported participants’ opinion about regulatory agencies supervision as insufficient [39]. On the other hand, the participants of this study demonstrated fairly superior knowledge about the use of (Ozempic®) and (Saxenda®) in weight loss (47.27%, 44.55%, respectively) compared to another study conducted on Saudi population (33%, 31.8%, respectively) [40]. Overall, humble knowledge was demonstrated in both studies regardless of the high prevalence of obesity.

Albeit pharmacies are the main source for obtaining weight loss medications, a 29.2% of study participants who used antidiabetics for weight loss declared that they purchase these medications over Facebook® pages and 14.6% from other unrecognized sources. Similarly, a recent content analysis of TikTok® users search about (Ozempic®) for the purpose of weight loss showed that it was viewed hundreds of millions times [41]. This confirms peoples’ main source of information being the social media platforms [38]. However, this might impose certain degree of health risk due to the absence of regulatory authorities’ supervision for the items being sold over these platforms [42].

Female gender was one of the predictors of knowledge and attitude scores (P < 0.001). These results supports previous research findings by Tsai et. al that reported poor weight loss perception OR = 0.36) and attempted weight loss (OR = 0.39) by men [43]. Additionally, 3.1% of women have reported willingness to use prescription pills to lose weight compared to 0.5% in men [43]. Whereas in this study, (n = 38/48), 79.16% of antidiabetic medication users for weight loss are female. In agreement with Almubarak et. al findings, men showed poor attitude compared to women when it comes to weight loss strategies [44]. Dieting (87.5%) and exercising (83.3%) were the most common practices to lose weight in conjunction to medications which is comparable to a report published about Saudi female attitudes and practices in weight management [45].

Unsurprisingly, having a chronic disease was a significant predictor of knowledge concerning anti-diabetic drugs used for weight loss (P = 0.025). This was anticipated due to the patients’ experience who might have used these antidiabetics in the past to treat diabetes, and they might have encountered weight loss as a form of side effect [46]. Furthermore, using antidiabetic agent in the last 12 months to lose weight was a significant predictor of both knowledge and attitude (P = 0.001, P = 0.03, respectively). This also could be justified by encountering both weight loss and browsing online databases for medical information. However, 58.3% declared that they do not consult their doctors before utilizing these medications to lose weight. This practice is alarming due to the possibility of being administered these medications in presence of precautions and/or contraindications to use.

Respondents were stratified according to their BMI, and the knowledge and attitude predictors were assessed accordingly. We found that BMI significantly predicts the knowledge about antidiabetic medications in weight loss practices (P = 0.002). This could be justified by that people with BMI indicating overweight or obesity is trying to utilize different methods to lose weight which led to be more educated about the off-label uses [47, 48].

In general, participants’ attitude both who used or did not use these medications was neutral. This could be explained by the limited use of these medications, especially, that only 12.3% of the study participants use it. It was surprising that despite the rigorous supervision by regulatory authorities in Jordan, respondents had a negative attitude towards the level of supervision about these medications (191, 49.1%). This could be ascribed to the advertisement that blew the social media platforms about using these medications for weight loss, especially, by celebrities and bloggers [41]. The percentages of respondents who got these medications from sources other than legalized suppliers i.e. pharmacies, supports this interpretation besides difficulty obtaining them by (36, 75.0%). This combination of findings provides some support for the conceptual premise that dispensing medications for off-label use needs to be controlled to guarantee maintaining safe and sufficient national drug supply. Especially, there are worldwide press reports about shortages in GLP-1 receptor agonists.

Both (Mounjaro®) and Wegovy® are not licensed yet in Jordan. As a result and due to the social media propaganda, people started to either smuggle these products from other countries or to fake others such as (Ozempic®) and (Saxenda®) due to shortages by adding insulin instead [27]. This is rather difficult to supervise by regulatory authorities, especially, if the quantity being smuggled is small. Thus, educating the public about the harm of receiving these medications without regulatory supervision might place them at risk of developing severe adverse effects. However, more research on this topic needs to be undertaken before the association between medications smuggling and its influence on consumers’ health. Moreover, there is abundant room for further studies to investigate the influence of social media on consumers’ behavior in purchasing medications in general. Then, a special focus on weight loss medications.

Limitations to this study is that most of respondents were from central of Jordan who might have better access to the internet compared to other areas as the questionnaire was distributed online.

The purpose of the current study was to assess knowledge, attitude and practices of Jordanian population towards using anti-diabetic agents for the purposes of weight loss. The most obvious finding that gender, BMI, health profession, monthly income and chronic diseases and the use of these medications are predictors of Jordanian population knowledge of antidiabetics for weight loss. Also, the percentage of (Ozempic®) and (Glucophage®) users for weight loss purposes is too high besides a substantial percentage obtaining these medications from social media retailers or other undeclared sources. Taken together, these results warrant regulatory authorities’ supervision of the off-label use of these medications, especially, for people with chronic illnesses to avoid long-term adverse event.

Body Mass Index	BMI
Food and Drug Administration	FDA
Glucagon-like peptide-1	GLP-1
Institutional Review Board	IRB
Jordanian Dinars	JOD
Odd Ratio	OR
Standard Deviation	SD
Statistical Package for Social Sciences version	SPSS^®
Variance Inflation Factor	VIF
World Health Organization	WHO

Ethics approval and consent to participate

Ethical approval to conduct this research was obtained from the institutional review board (IRB) committee at Applied Sciences University with an approval number (2023-PHA-29). Participants’ were asked to sign an informed consent before taking part in the study.

Consent for publication

Not applicable

Availability of data and materials

All data generated in this study are available within the article.

Competing interests

The authors declare no competing interest.

Funding

This research was funded by the Deanship of Scientific Research at Zarqa University

Authors' contributions

Rana Abutaima, principal investigator of the study, conceptualization, interpretation, questionnaire and manuscript development. Muna Barakat, conceptualization, data analysis, manuscript and questionnaire development. Hana abu Sawan, Shatha Alomari and Nizar Mhaidat, conceptualization, manuscript development.

Acknowledgements

The authors would like to acknowledge the funding body for this study the Deanship of Scientific Research at Zarqa University.

Organization, W.H. Nutrition » Malnutrition. 2023 [cited 2023 14 May]; Available from: https://www.emro.who.int/nutrition/double-burden-of-nutrition/index.html.
Purnell, J.Q., Definitions, classification, and epidemiology of obesity. Endotext [Internet], 2018.
De Schutter, A., C.J. Lavie, and R.V. Milani, The Impact of Obesity on Risk Factors and Prevalence and Prognosis of Coronary Heart Disease—The Obesity Paradox. Progress in Cardiovascular Diseases, 2014. 56(4): p. 401-408.
Seravalle, G. and G. Grassi, Obesity and hypertension. Pharmacological Research, 2017. 122: p. 1-7.
Ji, W., et al., Thresholds of visceral fat area and percent of body fat to define sarcopenic obesity and its clinical consequences in Chinese cancer patients. Clinical Nutrition, 2022. 41(3): p. 737-745.
Federation, W.O., Obesity: missing the 2025 global targets. 2020.
Ajlouni, K., et al., An alarmingly high and increasing prevalence of obesity in Jordan. Epidemiology and Health, 2020. 42.
Al Hadidi, A., Prevalence of Obesity Among Adults in Jordan: National Survey. Iproceedings, 2022. 8(1): p. e36398.
Hendricks, E.J., Off-label drugs for weight management. Diabetes, metabolic syndrome and obesity: targets and therapy, 2017: p. 223-234.
Rabkin, S. and H. Campbell, Comparison of reducing epicardial fat by exercise, diet or bariatric surgery weight loss strategies: a systematic review and meta‐analysis. Obesity reviews, 2015. 16(5): p. 406-415.
Han, S.H., et al., Public Interest in the Off-Label Use of Glucagon-Like Peptide 1 Agonists (Ozempic) for Cosmetic Weight Loss: A Google Trends Analysis. Aesthetic Surgery Journal, 2023: p. sjad211.
Park, J.S., et al., Clinical effectiveness of liraglutide on weight loss in South Koreans: First real-world retrospective data on Saxenda in Asia. Medicine, 2021. 100(2).
Chavda, V.P., et al., Tirzepatide, a new era of dual-targeted treatment for diabetes and obesity: a mini-review. Molecules, 2022. 27(13): p. 4315.
Fincham, J.E., Negative consequences of the widespread and inappropriate easy access to purchasing prescription medications on the internet. American Health & Drug Benefits, 2021. 14(1): p. 22.
Shankar, P., P. Partha, and N. Shenoy, Self-medication and non-doctor prescription practices in Pokhara valley, Western Nepal: a questionnaire-based study. BMC family practice, 2002. 3: p. 1-7.
Chamberlin, S. and W. Dabbs, Semaglutide (ozempic) for type 2 diabetes mellitus. American Family Physician, 2019. 100(2): p. 116-117.
Chowdhury, Z., Mounjaro (Tirzepatide): Dual-Targeted Treatment for Type 2 Diabetes.
Yerevanian, A. and A.A. Soukas, Metformin: mechanisms in human obesity and weight loss. Current obesity reports, 2019. 8: p. 156-164.
Singh, G., M. Krauthamer, and M. Bjalme-Evans, Wegovy (semaglutide): a new weight loss drug for chronic weight management. Journal of Investigative Medicine, 2022. 70(1): p. 5-13.
Whitten, J.S., Liraglutide (Saxenda) for weight loss. American family physician, 2016. 94(2): p. 161-166.
Garvey, W.T., et al., Two-year effects of semaglutide in adults with overweight or obesity: the STEP 5 trial. Nature medicine, 2022. 28(10): p. 2083-2091.
Shu, Y., et al., Gastrointestinal adverse events associated with semaglutide: A pharmacovigilance study based on FDA adverse event reporting system. Frontiers in Public Health, 2022. 10: p. 996179.
Smits, M.M. and D.H. Van Raalte, Safety of semaglutide. Frontiers in endocrinology, 2021. 12: p. 645563.
Moureaud, C., et al., Purchase of prescription medicines via social media: A survey-based study of prevalence, risk perceptions, and motivations. Health Policy, 2021. 125(11): p. 1421-1429.
Fromage, G., How the COVID-19 pandemic has affected obesity levels and how liraglutide may play a role in its control. Journal of Aesthetic Nursing, 2022. 11(3): p. 118-126.
Liang, B.A. and T.K. Mackey, Online availability and safety of drugs in shortage: a descriptive study of internet vendor characteristics. Journal of Medical Internet Research, 2012. 14(1): p. e1999.
Gallagher, A., FDA, Novo Nordisk Warn of Counterfeit Semaglutide Injection Pens. 2023.
OECD., Trade in Counterfeit Pharmaceutical Products. 2020: OECD Publishing.
Yoong, S.L., et al., A cross-sectional study assessing the self-reported weight loss strategies used by adult Australian general practice patients. BMC Family Practice, 2012. 13(1): p. 1-7.
Raosoft. Sample Size Calculator. 2004 [cited 2022; Available from: http://www.raosoft.com/samplesize.html.
Fang, Y., P. Liu, and Q. Gao, Assessment of knowledge, attitude, and practice toward COVID-19 in China: an online cross-sectional survey. The American journal of tropical medicine and hygiene, 2021. 104(4): p. 1461.
Bakaloudi, D.R., et al., Impact of the first COVID-19 lockdown on body weight: A combined systematic review and a meta-analysis. Clinical Nutrition, 2022. 41(12): p. 3046-3054.
Gogazeh, E., Dispensing errors and self-medication practice observed by community pharmacists in Jordan. Saudi Pharmaceutical Journal, 2020. 28(3): p. 233-237.
De la Rosa, A., et al., A comparison between weight loss outcomes with anti-obesity medications before and during Covid-19 pandemic at a tertiary weight management center. Obesity Pillars, 2022. 4: p. 100046.
Haddad, F., et al., A Comprehensive Review on Weight Loss Associated with Anti-Diabetic Medications. Life, 2023. 13(4): p. 1012.
Seifarth, C., B. Schehler, and H. Schneider, Effectiveness of metformin on weight loss in non-diabetic individuals with obesity. Experimental and clinical endocrinology & diabetes, 2012: p. 27-31.
Baker, C., et al., Should metformin remain the first-line therapy for treatment of type 2 diabetes? Therapeutic Advances in Endocrinology and Metabolism, 2021. 12: p. 2042018820980225.
Chen, J. and Y. Wang, Social media use for health purposes: systematic review. Journal of medical Internet research, 2021. 23(5): p. e17917.
Sullivan, H.W., et al., Consumer understanding of the scope of FDA's prescription drug regulatory oversight: A nationally representative survey. Pharmacoepidemiology and drug safety, 2020. 29(2): p. 134-140.
Algarni, M.A., et al., Knowledge and Attitude of the General Population in Saudi Arabia Toward Weight Management Medications (WMMs): A Cross-Sectional Study. Cureus, 2023. 15(8).
Lennon, J., Can you stomach it? A content analysis of TikTok videos and comments about weight loss with Ozempic. 2023.
Kanchan, S. and A. Gaidhane, Social Media Role and Its Impact on Public Health: A Narrative Review. Cureus, 2023. 15(1).
Tsai, S.A., et al., Gender differences in weight-related attitudes and behaviors among overweight and obese adults in the United States. American journal of men's health, 2016. 10(5): p. 389-398.
Almubark, R.A., et al., Gender differences in the attitudes and management of people with obesity in Saudi Arabia: data from the ACTION-IO study. Risk Management and Healthcare Policy, 2022: p. 1179-1188.
Hasan, T. and K. Ganesh, Weight lowering medications to alter morphological indices: a cross-sectional study among Saudi females. J Biol Today's World, 2020. 9: p. 1-8.
Lazzaroni, E., et al., Anti-diabetic drugs and weight loss in patients with type 2 diabetes. Pharmacological Research, 2021. 171: p. 105782.
Saperstein, S., N. Atkinson, and R. Gold, The impact of Internet use for weight loss. Obesity reviews, 2007. 8(5): p. 459-465.
Jahangiry, L. and M.A. Farhangi, Obesity paradigm and web-based weight loss programs: an updated systematic review and meta-analysis of randomized controlled trials. Journal of Health, Population and Nutrition, 2021. 40(1): p. 1-8.

No competing interests reported.

Download PDF

Version 1

posted

You are reading this latest preprint version

Jordanian Population Knowledge, Attitude and Practices on the Uses of Antidiabetics for Weight Loss Purposes: A Cross Sectional Study

Status:

Version 1

Abstract

Figures

Introduction

Methodology

Ethical approvals

Questionnaire content development and validation

Statistical analysis

Results

Sociodemographic characteristics

Participants' knowledge about antidiabetic medications uses for weight reduction

Participants attitudes toward antidiabetic medications uses for weight reduction

Participants practices toward antidiabetic medications uses for weight reduction

Factors associated with knowledge and attitude toward antidiabetic medications uses for weight reduction

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1