Natl. J. Physiol. Pharm. Pharmacol. (2025), Vol. 15(2): 167–174

Original Research

10.5455/NJPPP.2025.v15.i2.9

---

A questionnaire-based assessment of role of antioxidants in clinical practices: A knowledge attitude practice based study at tertiary care hospital

Anjali Suryakant Bhure¹, Abhijeet D. Joshi^1*, Bhagyashree Bhure², Mayur Nagargoje³, Rajat Khanavkar¹ and Aditi Agashe¹

¹Department of Pharmacology, GGMC, Mumbai, India

²Department of Community Medicine, GMC, Baramati, India

³Bhatia Hospital, Mumbai, India

*Corresponding Author: Abhijeet D. Joshi, Department of Pharmacology, GGMC, Mumbai, India. Email: bindhast.abhijeet123 [at] gmail.com

Submitted: 19/08/2024 Accepted: 01/01/2025 Published: 28/02/2025

---

Abstract

Background: Antioxidants are defined as “any substance that is, when present at low concentrations compared with that of an oxidizable substrate, significantly delays, or inhibits oxidation of that substrate.” There is an increase in the frequency of antioxidants’ prescription by many healthcare professionals. Antioxidants available over the counter (OTC) are highly commercialized, but scientific evidence and clinical trials supporting their use are not yet conclusive. Relatively easy access and wide availability are important factors signifying the cost-effectiveness of antioxidant therapy. Antioxidant excess can be harmful by disturbing redox equilibrium; thus, proper guidelines are of utmost importance.

Objective: 1) To determine the knowledge, attitude, and practice of antioxidants by healthcare professionals in a tertiary care center.

2) To create social awareness about antioxidants among healthcare professionals.

Methods: Descriptive, cross sectional, data collected through predesigned, and semistructured questionnaires in Google Forms.

Results: 69.3% of participants correctly answered the definition of free radicals (FR). 58.7% of participants correctly answered what are antioxidants. 81.3% of participants correctly answered oxidative stress is when oxidants are produced in excess compared to antioxidants. 94.7% of participants think that there is a need of guidelines for antioxidants’ prescription. 49.4% of participants think that OTC use of antioxidants should be banned.

Conclusion: Three hundred healthcare professionals who participated in the study have sufficient knowledge about FR, antioxidants, and oxidative stress, but there is a need of further awareness. Attitude and practices of the study participants about antioxidant use were reassuring and participants feel that there should be standard guidelines for their prescription and use.

Keywords: Oxidative stress, Antioxidant, Free radical, Knowledge, Attitude, Practice.

---

Introduction

Free radicals (FRs) are highly reactive and unstable atoms or molecules with unpaired electrons. They can be created by the addition of a single electron to a neutral atom or molecule or by the loss of one electron from a neutral atom or molecule. FRs can exist in various forms, including negatively charged, positively charged, and electrically neutral states. In the human body, FR production occurs during many oxidation reactions (Tvrdá and Benko, 2020).

Endogenously FRs are produced as a response to inflammation, mental stress, and immune cell activation production of FRs occurred in mitochondria, peroxisomes, and endoplasmic reticulum. Exogenous factors, such as toxic environmental pollutants, ionizing radiations, and heavy metal poisoning, are responsible for the production of FRs. FRs are mainly classified into two groups: reactive oxygen species and reactive nitrogen species (Weidinger and Kozlov, 2015; NCI Dictionary of Cancer Terms National Cancer Institute; Stunda-Zujeva et al., 2023). The FRsare beneficial in the generation of adenosine triphosphate (ATP), detoxification of xenobiotics, and apoptosis of defective cells. Damage caused by FRs includes lipid peroxidation, oxidative destruction of polyunsaturated fatty acid (PUFA), attacks on proteins causing enzyme inactivation, and damage to nucleic acid causing breaks in DNA strands (Martinez and Andriantsitohaina, 2009).

Oxidative stress is a state in which the pro-oxidative processes overwhelm cellular antioxidant defense (Stone et al., 2002; Ji and Yeo, 2021). Oxidative stress is one of the important factors in the development of various pathological conditions such as Parkinson’s disease, Alzheimer’s disease, atherosclerosis, hypertension, and cancer (Bhardwaj and He, 2020). Antioxidants are defined as “any substance that is, when present at low concentrations compared with that of an oxidizable substrate, significantly delays, or inhibits oxidation of that substrate” (Vona et al., 2021). Antioxidants scavenge FRs that block the generation of toxic FRs, block chain reaction set by FRs, and enhance antioxidant capacity.

In recent decades, it has been seen that there is an increase in awareness about health and healthy lifestyles among people. Apart from adopting a healthy diet, many physical activities are taking nutritional supplements, which include the use of antioxidants. Also, it has been seen that there is an increase in the frequency of antioxidants’ prescription by many healthcare professionals. The most commonly prescribed antioxidants include vitamin C, vitamin E, beta carotene, and minerals such as selenium and manganese (Antioxidants, 2021). Globally, the nutrition and supplements market stood at over USD 90 billion. Antioxidants contribute USD 4.41 billion (Hassan et al., 2020).

Antioxidants available over the counter (OTC) are highly commercialized, but scientific evidence and clinical trials supporting their use are not yet conclusive (Kaisar and Cucullo, 2015). Relatively easy access and wide availability are important factors signifying the cost-effectiveness of antioxidant therapy. Antioxidant excess can be harmful by disturbing redox equilibrium; thus, proper guidelines are of utmost importance (Ghosh et al., 2022).

Noncommunicable diseases (NCDs) kill 41 million people each year, equivalent to 74% of all deaths globally. Of all NCD deaths, 77% are in low- and middle-income countries. Cardiovascular diseases (CVD) account for most NCD deaths or 17.9 million people annually (World Health Organisation, 2023). Higher adherence to healthy and equilibrated dietary patterns has been shown to be implicated in the prevention of NCDs. Many studies showed that high consumption of antioxidants and antioxidant-rich foods is associated with decreased risk of overall and CVD-related mortality and certain cancers (Grosso, 2018).

---

Aim

To study the level of knowledge, attitude, and practices (KAP) related to antioxidants among healthcare professionals at a tertiary care center.

---

Objective

1) To determine the KAP of antioxidants by healthcare professionals in a tertiary care center.

2) To create social awareness about antioxidants among healthcare professionals.

---

Methodology

Study design—It is descriptive, cross-sectional, and questionnaire-based study.

Study site—This study will be conducted in a tertiary care center.

Study duration—3 months.

Study population—Healthcare professionals at a tertiary care center.

Study material—Data collected through predesigned, semi-structured questionnaire in Google Forms.

---

Study procedure

The questionnaire is distributed in the Google Form format. Before answering the questionnaires, the subjects will be informed about the purpose and the course of study and only after obtaining informed consent; the subjects will be recruited as per eligibility criteria. The subjects thus enrolled will be offered the questionnaire, a total number of questions 20, of which 8 questions are in knowledge section, 7 questions in attitude section, and 5 questions in practice section. Participants requested to return a completely filled questionnaire within 24 hours. The same questionnaire will be provided through Google Forms.

---

Results

In our study entitled “A questionnaire-based assessment of role of antioxidants in clinical practices: a KAP study at tertiary care hospital,” we enrolled 300 participants. Awareness regarding antioxidants prescribed in clinical practices was tested in three domains of KAP by distributing a questionnaire (Google Forms) to participants containing 20 questions, after obtaining permission from the Institutional Ethics Committee. In this study, we got the following results.

---

Assessment of knowledge of participants about antioxidants

When knowledge of sample population regarding definition of FR was assessed by question no. 1 in knowledge section, (Table 1 and Fig. 1) it was found that 208 participants (69.3%) found to be correct, which is all of the above options containing atoms or molecules with unpaired electron, negatively charged or positively charged or electrically neutral, and highly reactive atoms or molecules.

In question no. 2 of knowledge section, it was found that 176 (58.7%) participants correctly answered antioxidants are nutraceuticals as well as drugs. When asked about the usefulness of FR, 65.3% of participants think that they are useful to the human body (Q3), and 81.3% of participants correctly answered that oxidative stress is when oxidants are produced in excess compared to antioxidants (Q4).

Table 2 and Figure 2 when asked about the most commonly used antioxidants in clinical practice (question no. 5), the maximum number of participants, i.e., 82.7% correctly answered it as vitamins, minerals, and polyphenols; 74.7% of participants have read articles and media reports about the impact of antioxidants on health (Q6). 90.7% of participants correctly answered that antioxidants are useful in the management of acute as well as chronic conditions, while 9.3% of participants think that antioxidants are not useful for the management of chronic health conditions (Q7), and 62.7% of participants felt that daily consumption of vitamin C can prolong human life, which is not true (Q8). Vitamin C acts as a potent antioxidant under normal physiological conditions and pro-oxidant under pathological conditions. Vitamin C can also exhibit bimodal activity as a pro-oxidant at a higher concentration (Chakraborthy et al., 2014).

---

Table 1. Assessment of knowledge about antioxidants in the sample population (n=300).

Fig. 1. Knowledge-% participants with appropriate response.

---

Assessment of attitude of participants about antioxidants

Table 3 and Figure 3 74.7% of participants have a positive attitude that FRs are useful as well as harmful (Q1). 97.3% of participants have a positive attitude that antioxidants are useful in clinical practice (Q2). 61.4% of the participants think that a healthy diet can substitute antioxidants in clinical practice (Q3). When asked about the use of antioxidants can delay the progression of diseases, 89.3% of participants have a positive attitude, 5.3% of them have a neutral attitude, and similarly, 5.3% of participants have a negative attitude (Q4).

Table 4 and Figure 4 49.4% of participants have a positive attitude that OTC use of antioxidants should be banned, and 32% of participants think that OTC use of antioxidants should not be banned (Q5). When asked about need of antioxidant knowledge in clinical practice, 97% of participants have a positive attitude, i.e., they agree with it (Q6). 94.7% of participants have a positive attitude that there is a need of guidelines for the prescription of antioxidants; 4% of participants have a neutral attitude, while 1.3% of participants have a negative attitude, and they think that there is no need of guidelines (Q7).

---

Assessment of practices of participants about antioxidants

Table 5 and Figure 5 when asked about the prescription of antioxidants without absolute indication, 56% of participants gave a positive response, i.e., they prescribe antioxidants without absolute indication, whereas 44% of participants do not prescribe them without absolute indication (Q1). 74.7% of participants observe that there is rampant or irrational use of antioxidants in private clinical practice (Q2); 80% of participants have attended seminar or workshop on antioxidants, while 20% of participants did not attend any seminar or workshop on antioxidant uses in clinical practice (Q3). Eighty-eight percent of participants think that the majority of antioxidants prescribed in private practices are expensive, while 12% do not think the same (Q4). Irrational prescription of antioxidants is one factor responsible for an increase in out-of-pocket expenditure of the patients, and 94.7% of participants think that it is true, while 5.3% of participants think that it is not true (Q5).

Table 2. Assessment of knowledge about antioxidants in the sample population (n=300).

Fig. 2. Knowledge-% participants with appropriate response.

---

Discussion

The present study may be among the few studies conducted to find out the level of awareness role of antioxidants in clinical practices among healthcare providers. Our study aimed at studying the awareness about the role of antioxidants in clinical practice among healthcare professionals for which questionnaires were distributed among 300 participants. The majority of participants in this study are well aware of the FRs, oxidative stress, and antioxidants’ role in clinical practice. FRs are atoms or molecules with unpaired electrons. FRs help in the generation of ATP, detoxification of xenobiotics, apoptosis of defective cells, and phagocytosis of micro-organisms. NO is important for nonspecific host defense and for killing intracellular pathogens and tumors (Pham-Huy et al., 2008).

FRs when present in excess cause damage to the body by oxidative destruction of PUFA, lipid peroxidation, attacks on proteins that cause enzyme inactivation, and damage to nucleic acid which causes breaks in DNA strands, e.g., lipid peroxidation. Oxidative damage to DNA leads to the formation of different oxidative DNA lesions, which can cause mutations (Halliwell, 2007; Pham-Huy et al., 2008).

Increased oxidative stress is one of the potentially common aetiologies for CVD. Oxidative stress and inflammation are the main drivers of endothelial dysfunction (Senoner and Dichtl, 2019). Cancer development is a complex process, with both cellular and molecular alterations mediated by endogenous and/or exogenous triggers. Oxidative DNA damage is one of those stimuli, which is responsible for cancer development (Valko et al., 2004).

Neurodegenerative disorders, Alzheimer’s disease, Parkinson’s disease, and amyotrophic lateral sclerosis, have common features that there is extensive evidence of oxidative stress. Extensive oxidative stress is responsible for the death of neuronal cells that contribute to disease pathogenesis.

Table 3. Assessment of attitude about antioxidants in sample population (n=300).

Fig. 3. Assessment of attitude of participants about antioxidants.

In many studies, it has been found that antioxidants are useful for the management of acute as well as chronic conditions. However, the results are mixed as most did not find the hoped-for benefits. In a trial carried out by Kryscio et al. (2017) with objective to determine if antioxidant supplements (vitamin E or selenium) used alone or in combination can prevent dementia in asymptomatic older men. It was found that neither supplement prevented dementia (Kryscio et al., 2017).

In a trial on the effect of vitamin C on oxidative stress indices and skin regimentation of vitiligo patients, it was found that vitamin C supplementation is effective in controlling oxidative stress in vitiligo patients (Fallah et al., 2023).

Some studies that have assessed antioxidant overuse and the associated adverse effects found that large doses of dietary antioxidant supplements have varying therapeutic effects. FRs damage cells and this phenomenon is known as “antioxidant paradox.” Overuse of antioxidants, such as vitamin C, vitamin E, and N-acetyl cysteine, may lead to oxidative stress, is dangerous to cells as oxidative stress, and can be the cause of diseases such as cancer or cardiomyopathy (Henkel et al., 2019).

There is a need of proper guidelines for the prescription of antioxidants, as many times antioxidants interact with other medications, which leads to the development of adverse drug reaction and oxidative stress. Antioxidant supplements block the response of high-density lipoproteins (HDL) to simvastatin–niacin therapy in patients with coronary artery disease and low HDL (Cheung et al., 2001).

In India, out-of-pocket health expenditure (OOP) is about 62.6% of total health expenditure one of the highest in the world. High OOP health expenditures are one factor responsible for poverty (Sriram and Albadrani, 2022). Factors responsible for an increase in out-of-pocket expenditure are unnecessary prescribing drugs, including prescribing many different drugs; prescribing drugs without indication; prescribing lower or more than the drug’s dose; and prescribing expensive drugs, vitamins, and antibiotics (Soroush et al., 2018).

---

Limitation

The limitation of this study relies on self-reported data, which could introduce response bias. Additionally, as a cross-sectional study, it only provides a snapshot of the KAP toward antioxidants at a specific point in time, limiting the ability to establish causality or assess changes over time. Moreover, conducting the study at a single tertiary care center may restrict the generalizability of the findings to other healthcare settings or regions.

---

Suggestion

Need of increasing awareness about role of antioxidants in clinical practice among healthcare professionals.

---

Summary and Conclusion

Antioxidants are helpful in protecting cells from the damage caused by FRs. Antioxidants available OTC are highly commercialized, but scientific evidence and clinical trials supporting their use are not yet conclusive. Relatively easy access and wide availability are important factors signifying the cost-effectiveness of antioxidant therapy. Antioxidant excess can be harmful by disturbing redox equilibrium.

This study provides us insight into KAP, which are prevalent among healthcare professionals about antioxidants. Three hundred healthcare professionals who participated in the study have sufficient knowledge about FRs, antioxidants, oxidative stress, and various types of antioxidants, but there is a need of further awareness. In many clinical studies, it was found that not all antioxidants are useful in the management of acute and chronic health conditions. The role of antioxidants is still under question, as they are a dual-edged sword.

Attitude and practices of the study participants about antioxidant use were reassuring where participants feel that there should be standard guidelines for their prescription and use among society in relation to their OTC use, cost, and irrational prescribing trends. For that, workshops and seminars should be arranged for healthcare professionals to increase their awareness about recent developments in antioxidants. There is a need of guidelines for the prescription of antioxidants because prescribing antioxidants without sufficient evidence of their beneficial effect in the management of disease condition causes an increase in out-of-pocket expenditure. We recommend to include topics on rational use of antioxidants in MBBS undergraduate textbook as well as every postgraduate medical curriculum.

Table 5. Assessment of practices about antioxidants in the sample population (n=300).

Fig. 5. Assessment of practices about antioxidants.

---

Reference

Antioxidants (2021). The nutrition source. Available via https://www.hsph.harvard.edu/nutritionsource/antioxidants/#:~:text=The%20most%20familiar%20ones%20are,%2C%20phytoestrogens%2C%20and%20many%20more (Accessed 19 March 2024).

Bhardwaj, V. and He, J. 2020. Reactive oxygen species, metabolic plasticity, and drug resistance in cancer. Int. J. Mol. Sci. 21, 3412.

Chakraborthy, A., Ramani, P., Sherlin, H.J., Premkumar, P. and Natesan, A. 2014. Antioxidant and pro-oxidant activity of Vitamin C in oral environment. Indian J. Dent. Res. 25(4), 499–504.

Cheung, M.C., Zhao, X.Q., Chait, A., Albers, J.J. and Brown, B.G. 2001. Antioxidant supplements block the response of HDL to simvastatin-niacin therapy in patients with coronary artery disease and low HDL. Arterioscler. Thromb. Vasc. Biol. 21(8), 1320–1326.

Fallah, M., Abedini, R., Mahiabadi, S.A., Montazeri, S., Hosseinzadeh-Attar, M.J. and Ebrahimpour-Koujan, S. 2023. The effect of vitamin C on oxidative stress indices and skin regimentation of vitiligo patients. Arch. Dermatol. Res. 315(9), 2655–2660.

Ghosh, N., Chatterjee, S. and Sil, P.C. 2022. Evolution of antioxidants over times (including current global market and trend). In Antioxidants effects in health. Eds., Nabavi, S.M. and Silva, A.S. Elsevier, pp: 3–32.

Grosso, G. 2018. Dietary antioxidants and prevention of non-communicable diseases. Antioxidants (Basel) 7(7), 94.

Halliwell, B. 2007. Biochemistry of oxidative stress. Biochem. Soc. Trans. 35(5), 1147–1150.

Hassan, S., Egbuna, C., Tijjani, H., Ifemeje, J.C., Olisah, M.C., Patrick-Iwuanyanwu, K.C., Onyeike, P.C. and Ephraim-Emmanuel, B.C. 2020. Dietary supplements: types, health benefits, industry and regulation. In Functional foods and nutraceuticals. Eds., Egbuna, C. and Dable Tupas, G. Cham, Switzerland: Springer, pp: 23–38.

Henkel, R., Sandhu, I.S. and Agarwal, A. 2019. The excessive use of antioxidant therapy: a possible cause of male infertility? Andrologia 51(1), e13162.

Ji, L.L. and Yeo, D. 2021. Oxidative stress: an evolving definition. Fac. Rev. 10, 13.

Kaisar, M.A. and Cucullo, L. 2015. OTC antioxidant products for the treatment of cardiovascular and other disorders: popular myth or fact?. J. Pharmacovigil. 3(2), e136.

Kryscio, R.J., Abner, E.L., Caban-Holt, A., Lovell, M., Goodman, P., Darke, A.K., Yee, M., Crowley, J. and Schmitt, F.A. 2017. Association of antioxidant supplement use and dementia in the prevention of Alzheimer’s disease by vitamin E and selenium trial (PREADViSE). JAMA Neurol. 74(5), 567–573.

Martinez, M.C. and Andriantsitohaina, R. 2009. Reactive nitrogen species: molecular mechanisms and potential significance in health and disease. Antioxid. Redox. Signal. 11(3), 669–702.

NCI Dictionary of Cancer terms (no date b) National Cancer Institute. Available via https://www.cancer.gov/publications/dictionaries/cancer-terms/def/reactive-oxygen-species (Accessed 15 May 2023).

Pham-Huy, L.A., He, H. and Pham-Huy, C. 2008. Free radicals, antioxidants in disease and health. Int. J. Biomed. Sci. 4(2), 89–96.

Senoner, T. and Dichtl, W. 2019. Oxidative stress in cardiovascular diseases: still a therapeutic target? Nutrients 11(9), 2090.

Soroush, A., Mohseni, M., Nakhaee, M. and Moradi, F. 2018. Rational drug prescribing a way to reduce patients out of pocket payment. Iran. J. Public Health. 47(3), 453–454.

Sriram, S. and Albadrani, M. 2022. Impoverishing effects of out-of-pocket healthcare expenditures in India. J. Fam. Med. Prim. Care. 11(11), 7120–7128.

Stone, W.L., Mukherjee, S., Smith, M. and Das, S.K. 2002. Therapeutic uses of antioxidant liposomes. Methods Mol. Biol. 199, 145–161.

Stunda-Zujeva, A., Berele, M., Lece, A. and Šķesters, A. 2023. Comparison of antioxidant activity in various Spirulina containing products and factors affecting it. Sci. Rep. 13(1), 4529.

Tvrdá, E. and Benko, F. 2020. Free radicals: what they are and what they do. Pathology 3–13.

Valko, M., Izakovic, M., Mazur, M., Rhodes, C.J. and Telser, J. 2004. Role of oxygen radicals in DNA damage and cancer incidence. Mol. Cell. Biochem. 266(1-2), 37–56.

Vona, R., Pallotta, L., Cappelletti, M., Severi, C. and Matarrese, P. 2021. The impact of oxidative stress in human pathology: focus on gastrointestinal disorders. Antioxidants [Internet] 10(2), 201.

Weidinger, A. and Kozlov, A.V. 2015. Biological activities of reactive oxygen and nitrogen species: oxidative stress versus signal transduction. Biomolecules 5(2), 472–484.

World Health Organisation. 2023. Non communicable diseases [Internet]. Geneva, Switzerland: World Health Organisation. Available via https://www.who.int/news-room/fact-sheets/detail/noncommunicablediseases#:~:text=Noncommunicable%20diseases%20(NCDs)%20kill%2041 (Accessed 26 March 2024)