Does Social Media Promote Health Misinformation? The Malaysian Scenario

Abstract

In Malaysia, social media such as MySpace, Twitter, LinkedIn, Flickr, Tumblr, Wikipedia, YouTube, Google Plus, and Facebook are the cheapest and easiest media platforms for consumers to access health information. In social media, the audiences will be presented with information on how to make self-diagnosis and select health products to treat their undesirable medical conditions. However, studies demonstrated the potential of social media to mislead audiences into believing that health products are safe and cost-effective. In contrast, the consumers might potentially encounter unwanted adverse drug events. It is even worse when the consumers experience emotional disturbance, financial loss, and physical damage. Therefore, this article will highlight the negative effect of social media on the healthcare system by pointing out an example of Nigella sativa. Hopefully, this article will alert the authorities to monitor social media for misleading health information.

1. Introduction

Social media such as MySpace, Twitter, LinkedIn, Pinterest, Flickr, Tumblr, Wikipedia, YouTube, Google Plus, and Facebook are most accessible platforms for seeking information about health products [1]. Social media is rapidly emerging as a powerful tool to establish strong trustworthiness and connection between marketers and audiences. It allows marketers to educate their audiences about health information as well as promote products [2]. Most of the time, marketers succeed in attaining their audiences’ reliability, truth, or ability to accept the truth about their speech or writing [3]. Unfortunately, social media might not have a precise unit or division to enforce legal action toward marketers’ misbehaviors [4]. It is crucial to form a legal advocacy organization to guarantee that marketers comply with domestic laws regarding medicine and cosmetic advertisements. Alternatively, the marketers may present or claim untrustworthy information that might potentially lead to health misinformation [1].

Marketers usually include individuals, entrepreneurs, or healthcare practitioners. Each marketer has distinct characteristics, knowledge, and skills. For example, individuals and entrepreneurs are not trained to act, behave, or conduct themselves according to medical practice. They do not attend any formal long-term course that can prepare them with knowledge and skills for advocating, educating, or responding to a particular medical disease. Therefore, they always assign someone to express ideas or feelings about health products on social media. The assignee shall reveal his or her experience of being healthier after consuming the product [5, 6, 7]. For that reason, he or she recommends that audiences buy and consume a similar product. Most of the time, the assignee shall not reveal undesirable experiences after consuming the product.

Therefore, the majority of them consistently provide proof of the safe usage and performance of their goods by emphasizing testimonials from customers who are familiar with the items. Entrepreneurs may designate someone to arrange a personal interview with an individual who may inform audiences about their experience and satisfaction with the items. Prior to being shared on social media, the entire interview session must be accurately documented. Typically, the interview process does not uncover negative events. The lack of training among entrepreneurs in assessing, analyzing, and reporting side effects or adverse pharmacological responses experienced by their clients is the reason for this.

Physicians or pharmacists are well-trained to act, behave, or conduct themselves in response to a specific medical condition and medication use. Their knowledge and skills had been evaluated appropriately during their long-term university course. Therefore, they can advocate for their audiences about medical conditions and medication selections. Nonetheless, it is essential to monitor potential unethical marketing conduct among physicians and pharmacists [8]. They have the ability to quickly earn the trust of the audience, who rely on them to use their words and writing responsibly [9]. Consequently, they may inadvertently deceive the audience into believing that their items for sale are the most superior or sought-after or quality in demand [10]. Such unethical actions will harm the reputation of the healthcare profession [11].

In Malaysia, there are a few articles that point out some health misinformation issues, particularly related to breast cancer prevention and treatment [12], vaccines [13, 14], smoking [15], and medicine [16]. However, the author could not find any article that highlights misinformation about health products on social media. The previous study showed that Twitter had a higher prevalence of health misinformation compared to other social media platforms [10]. Generally, the previous articles on social media have identified health misinformation pertaining to smoking goods [17, 18, 19], vaccines [20, 21, 22], diseases [23, 24, 25], and treatments [26, 27]. In the realm of social media, the dissemination of health misinformation, disinformation, or false news is more prevalent and widespread than the dissemination of scientific facts and data [28, 29]. Presenting such information in simple language is to facilitate audience comprehension. In addition, individuals with varying educational backgrounds may not possess knowledge of scientific and technical vocabulary, including words, concepts, formulae, and symbols that are widely comprehended by scientists [28, 29]. Consequently, viewers are more inclined to evaluate unscientific social media platforms for information. A number of studies in Malaysia highlight health misinformation concerns, namely breast cancer prevention and treatment [12], vaccines [13, 14], smoking [15], and medication [16]. Unfortunately, the author was unable to locate any articles that specifically address the dissemination of false or misleading information on health items on social media platforms.

In Malaysia, health products are registered under natural or traditional products or health supplements [30]. The National Pharmaceutical Regulatory Agency (NPRA) is a legal authority that organizes and approves product registrations [31]. During the application process, the applicants need to submit to NPRA a list of documents, such as a good manufacturing practice certificate, as well as quality, safety, and efficacy documents, respectively [32, 33]. Based on the documentation, NPRA shall analyze it in detail before assigning a unique, valid registration number for the product. Such registration numbers shall begin with “MAL,” followed by 8-digit numbers and end with an alphabet to indicate their registration category, which is “T” for natural or traditional products and “N” for health supplements [31]. The main reason for the registration number is to ease NPRA in monitoring the distribution of the products in the domestic market. Nonetheless, during the registration process, NPRA might not discover or identify the presence or existence of undesirable effects of the product unless the consumers report their experience about such adverse drug events to physicians or pharmacists. Therefore, NPRA has established a form to be filled out by the physician or pharmacist if they find potential or actual adverse drug reactions [34]. It reflects that the health care system requires physicians and pharmacists to identify, prevent, and monitor undesirable effects of health products. For that reason, physicians and pharmacists must know about each product and be alert of unwanted effects their patients might encounter after consuming it.

Nigella sativa (Habbatus Sauda), known as black seed, is commonly consumed by the Malay people in Malaysia. In general, people consume black seed as a daily basic supplement because they believe it can help them be healthier [35]. Social media highlights the black seed’s advantages to emphasize their possible negative pharmacological reactions. Hence, this chapter will specifically examine the black seed to ascertain any possible dissemination of inaccurate health information and its impact on the liver. This article aims to raise awareness among authorities regarding the dissemination of disinformation concerning black seed on social media.

2. Materials and methods

Searching for some information about black seed and its advertisements was performed by assessing Google and YouTube, respectively. Such activities paid particular attention to articles and advertisements published from January 1, 2014, till December 31, 2023. The keywords used to search were Nigella sativa, black seed, contents, active ingredients, liver disorders, advertisement, benefits, harmful, unwanted effects, side effects, adverse drug events, undesirable effects, pharmacological, toxicological properties, oral consumption, and cautions. In addition, the author highlights a few cases that were noted in actual practice regarding the potential undesirable effects of black seed on the liver.

3. Results

3.1 Nigella sativa

Nigella sativa, or black seed, originates from the Ranunculacea family [36]. Nigella sativa contains thymoquinone (TQ), alkaloids (nigellicines and nigelledine), saponins (alpha-hederin), flavonoids, proteins, fatty acids, and many others [37, 38]. Nonetheless, TQ is the black seed’s most abundant constituent or predominant active lipophilic component. Therefore, the black seed has some therapeutic effects, such as antiproliferation, apoptosis induction, cell cycle arrest, reactive oxygen species generation, and antimetastasis [39]. However, its effectiveness and oral bioavailability are limited by its lipophilicity and poor solubility in water [40, 41]. As a result, the black seed might potentially induce unwanted adverse effects. For example, a previous finding noted that the consumption of black seed in the form of oil and crushed seed demonstrated significant increases in the readings of liver markers, which are alanine transaminase (ALT) [42], alkaline phosphatase (ALP) [43], gamma-glutamyltransferase (GGT) [42], and aspartate transaminase (AST) [42, 43]. Another study found that nasal drops containing black seed oil increased significantly in AST and ALT [44].

Most previous studies assessed ALT, ALP, AST, and GGT among the participants who consumed black seed for less than 3 months [45, 46, 47, 48]. It is noted that the outcomes of the studies demonstrated desirable effects on liver function. Nonetheless, it is believed that prolonged exposure to TQ might result in toxicity to the biological body system [49, 50]. TQ might also have an undesirable drug interaction with other medications [51, 52]. TQ in black seed oil is well tolerated at a dose from 75 to 2600 mg/day or less than 2% with no toxicity to observe [53]. TQ is metabolized in the liver into thymohydroquinone [54]. In a previous study, following oral administration of TQ in animal models, the half-life (T1/2) was about 276.61 ± 8.48 minutes [55]. The estimated percentage of TQ-protein binding in human plasma is about 98.99% [56]. For that reason, it is believed that long-term consumption of Nigella sativa will lead consumers to undesirable medical conditions. A case study report of acute renal failure had been associated with 2–2.5 grams of Nigella sativa capsules daily for 6 days in a diabetic patient [57].

In actual practice, the author reported the occurrence of liver diseases resulting from the possible consumption of black seed.

3.2 Advertisements on YouTube

The data indicated that marketers on social media have been informing the audiences about the advantages of black seed. Black seed has been hailed as a miraculous natural remedy for treating several medical conditions, including diabetes [58, 59, 60, 61, 62], liver [59, 60], kidney [60], alopecia [61], cancer [60, 61, 62, 63, 64, 65], cardiovascular disease [58, 59, 60, 61, 62], central nervous system [59, 62], hyperlipidemia [59, 60, 61], man infertility [60, 61], libido [60], liver [60], menstrual pain [60], seizure [58], stomach [58, 59, 60, 64], asthma [59, 60, 65, 66], fibroid [66], immune system [58, 61, 62, 64, 65], parasites [60], fungal [58], human immunodeficiency virus [61], staphylococcus [61], tuberculosis [61], influenza [61], gonorrhea [61], candida [61], malaria [61], obesity [58, 61], and arthritis [62, 64, 65]. Several marketers contended that including black seed in one’s diet is a suitable means of achieving proper nutritional intake. However, the data also indicated that there were marketers who advised their audiences to visit their physicians for an appropriate dosage regimen prior to taking the black seed [62, 67]. Apart from that, some marketers were found to be educating their audiences about the safe use of black seed [59, 60, 61, 63].

4. Discussion

In Malaysia, black seed is controlled by the Food Safety and Quality Division, Ministry of Health. Food and drink supplement products are not allowed to make any medicinal claim. Such claims include, for example, that black seed is able to enhance men’s sexual drive, can induce weight loss, and treats kidney, cancer, seizure, venereal and cardiovascular diseases. Without such a claim, marketers are free to promote, market, and distribute black seed on social media. However, the potential for health misinformation about black seeds on social media still exists [68]. For example, black seed was described as a potential supplement to treat asthmatic patients even though the promotion content was inconsistent with the Global Initiative for Asthma 2019 guidelines [68]. For that reason, it is essential to control advertising activities on social media [1]. In Malaysia, any individual who advertises a product without permission from the legal authority can be fined up to a maximum of RM3,000 or a jail sentence not exceeding 1 year or both for the first offense and for a subsequent offense, a fine up to a maximum of RM5,000 or a jail sentence not exceeding 2 years or both [69]. The Medicines (Advertisement and Sale) Act of 1956 regulates individuals’ actions to prevent them from misleading their audiences [70].

Medicines (Advertisement and Sale) Act 1956 highlights that individuals cannot mislead people into believing and consuming a specific product to treat a specific medical disease [70]. Marketers are prohibited from advertising their products as effective in preventing or treating ailments, such as kidney failure, heart disease, diabetes, epilepsy or fits, paralysis, tuberculosis, asthma, leprosy, cancer, deafness, drug addiction, hernia or rupture, diseases of the eye, hypertension, mental disorder, infertility, frigidity, impairment of sexual function or impotence venereal disease, and nervous debility, or other complaint or infirmity, arising from or relating to sexual intercourse [70]. However, marketers from other countries are not bound by Malaysian law. For that reason, they continue to promote their products on social media to attract audiences’ attention [71, 72, 73]. It is even worse when Malaysian marketers promote their products on social media managed by other countries [74, 75, 76]. Consequently, the Malaysian government may face several obstacles in pursuing legal action against the marketers.

Most studies focused on the benefits of black seed instead of its unwanted effects. They were designed to investigate the positive impact of black seed toward health within 3 months. In addition, participants must adhere to the inclusion and exclusion criteria prior to the studies. A control group of health participants involved in such studies might not represent the actual scenario in practice. Therefore, most of the studies might not capture the incidence of unwanted effects. However, physicians and pharmacists in their line of work have the opportunity to inform patients about the adverse consequences of black seed. For instance, the author can identify such adverse consequences due to patients ingesting the black seed in an unregulated environment (see Tables 1–5).

A female patient, who is 56 years old, complained of unresolved vertigo. She did not consume any medication but the black seed for the past 1 year to treat the vertigo. She was not able to tell the exact strength of the black seed. An earlier laboratory test demonstrated the following abnormal readings, which were erythrocyte sedimentation rate (ESR) = 67.0 mm/hr., hemoglobin (Hb) = 12.8 g/dL, mean corpuscular hemoglobin concentration (MCHC) = 31 g/dL, neutrophil = 76%, fasting blood sugar (FBS) = 6.5 mmol/L, total cholesterol = 6.2 mmol/L, low-density lipoprotein (LDL) = 3.8 mmol/L, ALP = 125 U/L, AST = 73 U/L, ALT = 100 U/L, and lactate dehydrogenase (LDH) = 246 U/L. The author noted that the black seed could be the risk factor for the incidence of liver disorders. Therefore, the patient was advised to stop consuming the black seed. After 6 months, a post-laboratory test demonstrated the following readings, which were ESR = 37.0 mm/hr., hemoglobin = 11.0 g/dL, PCV = 35%, MCHC = 32 g/dL, neutrophil = 45.9%, fasting blood sugar = 5.2 mmol/L, total cholesterol = 5.1 mmol/L, LDL = 3.1 mmol/L, ALP = 144 U/L, AST = 14 U/L, ALT = 13 U/L, and LDH = 222 U/L.

Table 1.

Case # 1.

A male patient, 56 years old, complained of uncontrolled blood glucose. The patient had been diagnosed with diabetes mellitus type 2 for the past 7 years, but he refused to consume the prescribed medication to control his blood glucose. Instead, he constantly consumed the black seed for the past 3 years to eliminate the disease. A pre-laboratory test showed the following abnormal readings which were ESR = 13 mm/hr., platelet count = 146 x 10^9/L, eosinophil = 10.7, FBS = 23.8 mmol/L, glycosylated hemoglobin (HbA1C) = 13.3% (122 mmol/mol), LDL = 2.8 mmol/l, AST = 92 u/L, ALT = 205 u/L, GGT = 98 iu/L, thyroid stimulating hormone (TSH) = 0.32. Such results indicated that the black seed might cause a potential risk of liver disorders. Therefore, the patient was advised to stop the consumption of black seed. However, the patient failed to attend the follow-up monitoring session after 6 months. As a result, the latest laboratory test is lacking.

Table 2.

Case # 2

A male patient, 66 years old, complained of unresolved gouty arthritis. He had been diagnosed with gouty arthritis for the past 2 months. In addition, he was also diagnosed with obsessive-compulsive drugs and prescribed clonazepam 0.5 mg and fluvoxamine Maleate 50 mg. He also constantly consumed black seed for the past 2 months to eliminate gouty arthritis. Pre-laboratory test demonstrated the following abnormal readings which were Hb = 19 g/dL, red cell distribution width (RDW) = 14.5%, packed cell volume (PCV) = 58, ESR = 41 mm/hr., uric acid (UA) = 0.59 mmol/L, phosphate = 0.79 mmol/L, GGT = 83 U/L, total cholesterol = 5.6 mmol/L, high-density lipoprotein (HDL) = 0.9 mmol/L, LDL = 3.4 mmol/L, triglycerides = 2.8 mmol/L, and HbA1C = 6.5% (48 mmol/mol). Results from the test demonstrated that he potentially has a mild liver disorder due to the consumption of black seed. Therefore, the patient was advised to stop the consumption of the black seed, and he was advised to consume milk thistle 200 mg twice daily for 6 months. A post-laboratory test demonstrated the following readings which were Hb = 17.1 g/dL, RDW = 14.0%, PCV = 52, ESR = 43 mm/hr., UA = 0.45 mmol/L, GGT = 40 U/L, total cholesterol = 3.4 mmol/L, HDL = 0.9 mmol/L, LDL = 1.9 mmol/L, triglycerides = 1.3 mmol/L, and HbA1C = 6.5% (48 mmol/mol).

Table 3.

Case # 3.

A male patient, 38 years old, complained of being unhealthy. The patient had been diagnosed with liver disorders and cardiovascular disease for the past 1 year. Due to that reason, he constantly consumed the following medications which were perindopril 4 mg, trimetazidine 35 mg, and glyceryl trinitrate 0.5 mg. In addition, he also consumed black seed, Annona muricata, omega 3, vitamin B complex (B1, B2, B3, B5, B6, B7, B9, and B12), and olive oil daily for 1 year. Laboratory tests performed before the consultation session showed the following abnormal readings, which were ESR =12, mean corpuscular hemoglobin (MCH) = 26, MCHC = 31, HbA1C = 6.1% (43 mmol/mol), total cholesterol = 6.1, LDL = 4.1 mmol/L, triglyceride = 2.1 mmol/L, AST = 44 U/L, ALT = 90 U/L, hs-C reactive protein (CRP) = 7.3 mg/L, LDH = 232, and rheumatoid factor (RF) = 15. The laboratory test showed that he might have liver disorders due to the consumption of black seed. For that reason, he was advised to discontinue the consumption of the black seed. It was recommended that he consume 200 mg of milk thistle twice daily for 6 months. Nonetheless, the post-laboratory test was not performed because the patient did not finish the milk thistle within the recommended time frame.

Table 4.

Case # 4

A 61-year-old male complained of chronic kidney disease. He was also diagnosed with diabetes mellitus Type 1 and cardiovascular disease. The patient had been prescribed the following medications: vildagliptin 50 mg, amlodipine 5 mg, bisoprolol 5 mg, calcium carbonate 500 mg, calcium polystyrene sulfonate powder, atorvastatin 40 mg, frusemide 40 mg, aspirin 100 mg, sodium bicarbonate powder, pantoprazole 40 mg and insulin Mixtard 30. In addition, he consumed black seed, olive oil, and kratom leaves for the past 3 years to eliminate signs and symptoms of hyperglycemia and cardiovascular disease. Laboratory tests obtained during the consultation session demonstrated the following abnormal readings: ESR = 75 mm/hr., red blood cell (RBC) = 3.3 X 10^12, Hb = 8.5 g/dL, PCV = 27, MCH = 26, RDW = 15.6, lymphocyte = 19%, FBS = 15 mmol/L, HbA1C = 7.9% (63 mmol/mol), urea = 21.3 mmol/L, creatinine = 401 umol/L, estimated glomerular filtration rate = 13 ml/min/1.73m^3, UA = 0.50 mmol/L, HDL = 0.91 mmol/L, CRP = 89.7 mg/L, ALP = 437 U/L, GGT = 176 iu/L, LDH = 321 U/L, protein urine trace = 2+, and glucose urine trace = 1+, positive blood in the urine. The results reflected that the patient potentially has liver disorders due to the black seed. For that reason, the patient was advised to consume 200 mg of milk thistle twice daily for 6 months and stop the consumption of black seed. The patient shall perform the following laboratory test after 6 months.

Table 5.

Case # 5.

It is believed that the consumption of black seed can cause potential liver disorders. High readings of AST, ALP, ALP, and GGT reflect potential liver disorders, as depicted in Tables 1–5. A cross-reference to investigate the incidence of liver disorders also showed that black seed can cause medical conditions, as shown in previous reported studies [42, 43, 44]. Therefore, it is essential to determine if the customers are suitable candidates to consume black seed. It is because black seed is also not suitable for an individual who has specific medical conditions such as hypoglycemia [77], bleeding [78], and hypotension [79]. In addition, black seed might also potentially cause soft-tissue damage [80] due to the increased number of LDH (see Tables 1, 4, and 5) and CRP (see Tables 4 and 5). Nonetheless, these findings require further studies. Currently, physicians and chemists need to thoroughly evaluate their clients’ medical and prescription histories to determine if they are appropriate candidates for consuming black seed. The reason is that each client has a unique pathophysiology. These variances necessitate a distinct approach to therapy. For instance, a client with profuse and uncontrollable bleeding from an open cut may not be suited to ingest black seed. Alternatively, the consumption of the black seed might exacerbate bleeding and could result in fatality. Consequently, the consumer may require hospitalization to receive additional medical care.

The majority of social media platforms consistently emphasize favorable testimonials from customers [81, 82]. Engaging in such a course of action will deceive the audience into believing that the product is both safe and cost-effective. Disseminating deceptive health information can inspire audiences to make erroneous decisions, resulting in detrimental health consequences such as false optimism, emotional turmoil, financial loss, and both internal and exterior physical injury [83]. The efficacy and safety of the product should be evaluated based on clinical data acquired from medical labs and medical assessments. Physicians should assume the responsibility of conducting the medical evaluation and determining if customers are free from medical conditions. Otherwise, the entrepreneurs would persist in disseminating health disinformation to the audiences, which would have detrimental effects on the healthcare system [84]. Furthermore, it is advisable for pharmacists to employ the STARZ-DRP technique to assess the drug-related requirements of consumers and detect any existing or possible drug-related issues among those who eat black seed [85, 86, 87, 88, 89]. Prior research has confirmed the effectiveness of this method in ensuring that pharmacists are able to carry out their responsibilities in a suitable way [90]. Pharmacists, acting as primary healthcare providers, can effectively avoid adverse consequences resulting from prolonged ingestion of black seed.

In short, doctors and pharmacists should resume the role of assessing, monitoring, and evaluating the consumption of health products. Physicians and pharmacists should have the knowledge and skills to report to the legal authorities about the findings of unwanted effects of black seed. Health misinformation poses a potential danger of exposing consumers to undesirable consequences. Consequently, it is imperative for the legal authorities to implement a regulation to prevent marketers from deceiving the public with false health information. Legal authorities have the authority to notify and prevent domestic marketers from promoting false or misleading health information on social media platforms.

5. Conclusion

Dissemination of inaccurate health information on social media has detrimental consequences for the healthcare system. Consumers may mistakenly see black seed as a safer and more cost-effective alternative to receiving professional treatment in a medical setting. They may believe that black seed has the potential to eradicate a diverse array of both minor and significant medical ailments. However, pursuing this line of action might potentially result in encountering additional detrimental consequences, ultimately leading to unnecessary hospital admissions and necessitating more comprehensive medical treatment. Consequently, this will lead customers to expend additional funds on a preventable medical condition. Hence, it is imperative for the legal authorities to oversee social media platforms in order to prevent the dissemination of health disinformation. Legal authorities should promote and advocate for consumers to obtain appropriate medical guidance prior to ingesting black seeds.

Conflict of interest

The author declares no conflict of interest.

Background of practice

The author utilizes an approach known as STARZ-DRP to assess, evaluate, and monitor patients’ drug-related needs and drug-related problems.

Appreciation to my teammates who assisted in the completion of this article

1. Nur Aliah Binti Nazri, medical student at Kursk State of Medical University, Russian.

2. Nur Iman Binti Nazri, medical student at Kursk State of Medical University, Russian.