Background: Within the last years, excessive utilization of food supplements for prevention and prophylaxis in different chronic diseases is observed. In order to extend the control on the arrangement of the market, utilization, and safety of food supplements, the European Commission took genuine regulatory steps to harmonize the criteria for FS and to guarantee that they are not giving deceiving information. However, excessive use, uncontrolled patients consumption, exposure to higher than recommended intakes, and even interaction with specific medicines can cause toxicity risks and pose serious health concerns. The aim of this study is to examine the tendency of pharmacists to correctly recommend food supplements to chronically ill patients in order to extend the pharmaceutical care and prevent side effects.

Materials and methods: The used method is an anonymous survey that was conducted by using the direct questionnaire method among master pharmacists and assistant pharmacists working in community pharmacies in Bulgaria.

Results: The results show that the majority of the pharmacists are willing to recommend food supplements and that they could participate in the monitoring of chronically ill patients with food supplements intake. On the other side, the survey shows that most of the patients are seeking for food supplements and do ask for advice.

Conclusion: In conclusion, pharmacists as the most accessible health care professionals can provide more detailed information concerning food supplements in order to avoid negative effects on the safety of chronically ill patients, especially with additional training in the field.

pharmacists, food supplements, interactions, knowledge, risk

Food supplements (FS) placed on the market in a European Union (EU) Member State must comply with all relevant aspects of EU Food Law, ISO certification, and any specific national legislation of EU Member States with regard to their composition, manufacture, and control (Petkova et al. 2019; GMP 2021).

In the recent years an excessive use of food supplements as prevention and prophylaxis in different chronic diseases is observed. In order to increase the control on the placement on the market, utilization, and safety of food supplements, the European Commission took serious regulatory steps to harmonize the criteria for FS and to ensure that they are not provided with misleading information. A harmonized list of vitamins and minerals that may be added for nutritional purposed in FS and their doses was introduced with Directive 2002/46/EC and Directive 2006/37/EC/. Regulation (EC) No 1924/2006 established the rules for clear, accurate, and scientific evidence-based health claims of FS (EC 2006).

However, excessive use, uncontrolled consumption, or exposure to higher than recommended intakes and even interaction with specific medicines can cause toxicity risk and pose serious health concerns (Korfali et al. 2013).

Аs the most accessible health care professionals, pharmacists routinely encounter patients seeking advice on various food supplements in their daily practice (Bukic et al. 2021). Pharmacists can be a valuable source of reliable and independent information on the effects and safety of food supplement use for a variety of health conditions, but a sufficient number of surveys shows that additional training is required (Marupuru et al. 2019; Mazzilis et al. 2021).

Studies also show that pharmacists would like to receive more detailed information on the quality of food supplements, interactions with medicines, and adverse effects related to their intake. Pharmacists also need more training and knowledge related to food supplements, especially regarding more specific pharmaceutical information, but a national policy in this area needs to be developed not only on a national but on a regional level, as well (Stoimenova et al. 2010).

This prompted our interest to examine the pharmacists‘ attitudes working in community pharmacies in Bulgaria to dispensing and controlling food supplements to chronically ill patients.

A national anonymous survey was conducted using the direct questionnaire method among master pharmacists and assistant pharmacists working in community pharmacies in Bulgaria to assess their attitudes towards the dispensing and monitoring of food supplements in patients with chronic diseases. The questionnaire was prepared by the PhD student under the supervision and review of Maria Dimitrova. Pharmacists from 13 major cities were surveyed between June 2020 and June 2021. The point was to collect different answers from different parts of the country in order to analyze the behavior of the pharmacists in the community pharmacies in Bulgaria. In the beginning, the questionnaire was directly provided by the PhD candidate to the working pharmacists (in the pharmacies) and later on when the COVID-19 pandemic was seriously on-going the questionnaire was provided online via google forms. The asked pharmacists and assistant pharmacists were selected from chain pharmacies and small pharmacies in order to have a full overview. The questionnaire consisted of 8closed-ended and 2 opened-ended questions and aimed to collect data on the demographic characteristics of pharmacists (age, sex, location of workplace), as well as their attitudes regarding the role they might have and the knowledge they need to advise patients on food supplements, the risks associated with their use and the reporting of adverse effects by patients.

Data was proceeded through descriptive statistics on XLSTAT and Chi-Square test and cross tables for correlation.

In recent years an excessive use of food supplements for prevention, prophylaxis, and treatment of different chronic diseases is observed. In order to increase the control on the placement on the market, utilization, and safety of food supplements, the European Commission took serious regulatory steps to harmonize the criteria for food supplements and to ensure that they are not provided with misleading information. A harmonized list of vitamins and minerals that may be added for nutritional purposes in food supplements and their doses was introduced with Directive 2002/46/EC and Directive 2006/37/EC/. Regulation (EC) No 1924/2006 established the rules for clear, accurate, and scientific evidence-based health claims of food supplements (EC 2019).

Recent analyses of the Bulgarian pharmaceutical market show an increasing trend in the number of food supplements available on the pharmaceutical market in Bulgaria which almost reach the market of the over-the-counter medicines (Balkanska et al. 2019).

Our results are in line with other published articles. Pharmacists need more training and knowledge related to food supplements, as well as patients which are unable to distinguish OTC medication and food supplements. A national policy in this area needs to be developed on national and regional level. (Stoimenova et al. 2010).

In 2021 Bukic et al. performed a cross-sectional study in Croatia to explore the community pharmacists` perception and knowledge on dietary supplements. The results showed that they needed further education about the practice of evidence-based pharmacy, especially on safety.

Similar studies have been performed in multiple countries worldwide – Australia, Ethiopia, Germany, Malaysia, New Zealand, Saudi Arabia, United Arab Emirates, and the USA, focusing on the need to identify different barriers to pharmacists to adapt their professional responsibilities in terms of supporting the appropriate and safe use of food supplements. Most of the researchers find a substantial gap between public awareness of the safe and effective use of food supplements and the role of the pharmacists as trusted consulters. They also call for more detailed implementation of the professional competencies of pharmacists as accessible health care professionals but also find the need to encourage further specialization on the effective and safe use of food supplements (Fahmi et al. 2010; AI-Jazairi and Alharbi 2017; Tan and Hatah 2017; Welz and al. 2018; Emiru et al. 2019; Ung et al. 2019; Barnes and Butler 2020; Clayton et al. 2020).

Rigorous monitoring and risk assessment of food supplements-drug interactions in patients with chronic diseases is needed, as well as prior implementation of additional education and training and pharmaceutical care in the community pharmacies. The pharmacists, as the most accessible health care professionals, are willing to participate and be implemented in the pharmaceutical care related to the food supplements intake. In combination with different medications, food supplements can cause many side effects, which can be prevented with a carefully provided consultation.

It would also be advisable to introduce a tightened mechanism of registration and regulation of food supplements in Bulgaria in order to minimize drug interactions and adverse events in their future use.