VITAMEN D DEFICIENCY IN SAUDI ARABIA THE SILENT EPIDEMIC MONA A FOUDA NEEL,MBBS, MRCP(UK),FRCPE MONA A FOUDA NEEL,MBBS, MRCP(UK),FRCPE ASSOCIATE PROFESSOR

VITAMEN D VITAMEN D DEFICIENCY IN SAUDI DEFICIENCY IN SAUDI ARABIAARABIATHE SILENT EPIDEMICTHE SILENT EPIDEMIC

• MONA A FOUDA NEEL ,MBBS, MRCP(UK),FRCPEMONA A FOUDA NEEL ,MBBS, MRCP(UK),FRCPE• ASSOCIATE PROFESSOR OF MEDICINEASSOCIATE PROFESSOR OF MEDICINE• CONSULTANT ENDOCRINOLOGISTCONSULTANT ENDOCRINOLOGIST• COLLEGE OF MEDICINECOLLEGE OF MEDICINE• KING SAUD UNIVERSITYKING SAUD UNIVERSITY

• The population under study is classified into 3 The population under study is classified into 3 categories according to vit D nutritional categories according to vit D nutritional status: deficient (status: deficient ( 5 ng/ml), low (5-10 ng/ml) 5 ng/ml), low (5-10 ng/ml) and adequate (and adequate ( 10 ng/ml). 10 ng/ml).

• The frequency of low 25-OHD concentration (5-The frequency of low 25-OHD concentration (5-10 ng/ml) is high (22% in total children and 10 ng/ml) is high (22% in total children and 20% in total adults) in the Saudi population, 20% in total adults) in the Saudi population, while the frequency of vit D deficiency (25-while the frequency of vit D deficiency (25-OHD level OHD level 5 ng/ml) is 3.4% in total children 5 ng/ml) is 3.4% in total children and 5.5% in total adults. This is true whether and 5.5% in total adults. This is true whether the population is urban or rural.the population is urban or rural.

• 26% of female children of female adults have 26% of female children of female adults have low vit D status in comparison with 19% and low vit D status in comparison with 19% and 17% for male children and male adults, 17% for male children and male adults, respectively.respectively.

STUDY OF VITAMIN D STATUS AND FACTORS LEADING TO ITS DEFICIIENCY IN SAUDI ARABIA

SALEH SEDRANI ET AL4078 subjects

• Bone mineral density of the spine and Bone mineral density of the spine and femur in healhy saudi females femur in healhy saudi females : relation to vitamin D status, : relation to vitamin D status, pregnancy, and lactationpregnancy, and lactation

• N N GHANNAM ETAL calcif Tissue int 1999 N N GHANNAM ETAL calcif Tissue int 1999

• 321 females 321 females

• 25 vit D 24.5+17.2 nmol/l 25 vit D 24.5+17.2 nmol/l

• Severe hypovitaminosis D (25 OHD less Severe hypovitaminosis D (25 OHD less than 20 nmol/l )= 52% than 20 nmol/l )= 52% Osteoporosis and osteopenia in subjects Osteoporosis and osteopenia in subjects more than 31=18-41 %, 0-7%more than 31=18-41 %, 0-7%

Lumbar BMD of 830 postmenopausal Saudis according to Lumbar BMD of 830 postmenopausal Saudis according to ageage

CategoryCategoryNumberNumber (%) (%)

BMD BMD ++ SD SD

T-T-ScoreScore

Age 50-59 yrs.Age 50-59 yrs. NormalNormal OsteopeniaOsteopenia OsteoporosisOsteoporosisLow BMDLow BMD

216 216 171 171 124 124

295295

42 42 33 33 2424

5757

1.098 1.098 ++ 0.11 0.11 0.893 0.893 ++ 0.13 0.130.795 0.795 ++ 0.15 0.15

- 0.61 - 0.61 - 2.36 - 2.36

- 3.21- 3.21


28 28 69 69 157 157

226 226

11 11 27 27

6262

8989

1.092 1.092 ++ 0.12 0.12 0.986 0.986 ++ 0.13 0.13

0.774 0.774 ++ 0.1410.141

- 0.71 - 0.71 - 2.41 - 2.41

- 3.4- 3.4


3 3

1414 48 48

6262

4.6 4.6 21.4 21.4

74 7495.495.4

1.102 1.102 ++ 0.13 0.13 0.981 0.981 ++ 0.12 0.12 0.732 0.732 ++ 0.12 0.12

- 0.78 - 0.78 - 2.43 - 2.43

- 3.5- 3.5

El Desouki. Saudi Med J 2003;Vol. 24 (9)

Study by El Desouki 2003

CategoryCategoryNumbNumberer(%)(%)BMDBMD SD SDT-T-

ScoreScoreAge 51-60Age 51-60

NormalNormal22422437371.130 (0.05)1.130 (0.05)-0.55-0.55OsteopeniaOsteopenia21821836360.978 (0.05)0.978 (0.05)-1.84-1.84OsteoporosOsteoporos

isis16416427270.793 (0.07)0.793 (0.07)-3.40-3.40

TotalTotal6066061001000.952 (0.15)0.952 (0.15)-2.06-2.06

Low BMDLow BMD3823826363

Age 61-70Age 61-70

NormalNormal1818 771.100 (0.03)1.100 (0.03)-0.84-0.84OsteopeniaOsteopenia808032320.970 (0.05)0.970 (0.05)-1.93-1.93OsteoporosOsteoporos

isis15215261610.774 0.774 (0.07)(0.07)-3.56-3.56

TotalTotal2502501001000.704 (0.11)0.704 (0.11)-2.27-2.27


Age 71-80Age 71-80NormalNormal 33 441.149 (0.07)1.149 (0.07)-0.40-0.40OsteopeniaOsteopenia161622220.962 (0.05)0.962 (0.05)-2.00-2.00OsteoporosOsteoporos

isis353574740.771 (0.02)0.771 (0.02)-3.50-3.50

TotalTotal54541001000.821 (0.12)0.821 (0.12)-1.57-1.57


BMD – Bone Mineral DensityBMD – Bone Mineral DensitySD-Standard DeviationSD-Standard Deviation

Spine BMD In Postmenopausal Saudis by Spine BMD In Postmenopausal Saudis by AgeAge

CategoryCategoryNo:No:(%)(%)BMDBMD SD SDT-ScoreT-ScoreAge 51-60Age 51-60

NormalNormal262262 43430.915 (0.07)0.915 (0.07)-0.50-0.50OsteopeniaOsteopenia247247 41410.755 (0.04)0.755 (0.04)-1.87-1.87OsteoporosOsteoporosisis 9797 16160.606 (0.5)0.606 (0.5)-3.10-3.10

TotalTotal6066061001000.800 (0.12)0.800 (0.12)-1.48-1.48

Low BMDLow BMD344344 5757

Age 61-70Age 61-70

NormalNormal 383815150.905 (0.04)0.905 (0.04)-0.60-0.60OsteopeniaOsteopenia12112148480.740 (0.04)0.740 (0.04)-1.99-1.99OsteoporosOsteoporosisis 919136360.587 (0.06)0.587 (0.06)-3.27-3.27

TotalTotal25025099990.704 (0.11)0.704 (0.11)-2.27-2.27


Age 71-80Age 71-80NormalNormal 33 4 4 0.848 (0.01)0.848 (0.01)-0.90-0.90OsteopeniaOsteopenia 303041410.743 (0.04)0.743 (0.04)-1.97-1.97OsteoporosOsteoporosisis 393954540.596 (0.06)0.596 (0.06)-3.19-3.19

TotalTotal 727299990.668 (0.10)0.668 (0.10)-2.59-2.59

Low BMDLow BMD 69699595


Femur BMD In Postmenopausal Saudis by Femur BMD In Postmenopausal Saudis by AgeAge

CategoryCategoryNumbeNumberr

(%(%))

BMD BMD SDSD

T-T-ScoreScore

NormalNormal24324326261.12 1.12 (0.05)(0.05)-0.62-0.62

OsteopeniaOsteopenia28428431310.962 0.962 (0.04)(0.04)-1.99-1.99

OsteoporosiOsteoporosiss40140143430.782 0.782

(0.07)(0.07)-3.480-3.480

TotalTotal928928101000

0.912 0.912 (0.15)(0.15)-2.40-2.40



Spine BMD In All Patients (50-Spine BMD In All Patients (50-80 Yrs)80 Yrs)

CategoryCategoryNumberNumber(%)(%)BMDBMD SD SDT-ScoreT-Score

NormalNormal30330332.732.70.908 (0.08)0.908 (0.08)-0.54-0.54

OsteopeniaOsteopenia39739742.842.80.750 (0.04)0.750 (0.04)-1.91-1.91

OsteoporosOsteoporosisis

22822824.524.50.597 (0.06)0.597 (0.06)-3.19-3.19

TotalTotal9289281001000.764 (0.13)0.764 (0.13)-1.78-1.78

Low BMDLow BMD62562567.367.3


Femur BMD In All Patients (50-80 Femur BMD In All Patients (50-80 Yrs)Yrs)

Prevalence of osteopenia and osteoporosis in Saudis (50 years), using US/European and Saudi reference data. Data are presented as percentages with osteopenia (> -2.5 SD to < -1 SD below young adult BMD) and osteoporosis (< -2.5 SD below young adult BMD), for spine (L2-L4) and femur (total).

(Ardawi MSM, et al. Osteoporosis Int 2005; 16: 43-55)

1980 PTS20-79 AGEM 915

F 1065

The proportion of Saudis aged 50 years with lower than -2.5 SD,

stratified by body weight quartiles and sex.

(Ardawi MSM, et al. Osteoporosis Int 2005; 16: 43-55)

•VITAMIN D LEVELS VITAMIN D LEVELS BELOW 20 NMOL/L BELOW 20 NMOL/L EXCLUDEDEXCLUDED !!

•Optimal vitamin D status Optimal vitamin D status for the prevention and for the prevention and treatment of osteoporosistreatment of osteoporosis

• Holick MF Drugs Aging 2007Holick MF Drugs Aging 2007

• Vitamin D deficiency is defined as Vitamin D deficiency is defined as serum 25 OH D level <50 nmol/l or serum 25 OH D level <50 nmol/l or 20 ng/ml20 ng/ml

optimal 25 hydroxyvitamin

D values45-50 nglml or

115-128 nmol/l

Normal

25-hydroxyvitamin D values20-56 ng/ml or

50-140 nmol/l

Table: Threshold values for vitamin D insufficiency based on different outcomes and study types. A common threshold value of 50 nmol/l has been proposed for vitamin D insufficiency, whereas vitamin D deficiency is characterized by values < 25 nmol/l.

Higher 25OHD levels Higher 25OHD levels prevent prevent

Threshold Threshold values values

for 25-OHD for 25-OHD (nmol/l)(nmol/l)

Study type Study type ReferencesReferences

SecondarySecondary

hyperparathyroidismhyperparathyroidism

Decrease in BMDDecrease in BMDIncrease in bone turnoverIncrease in bone turnover

Seasonal variation in PTHSeasonal variation in PTH

Suppresible P-PTHSuppresible P-PTH

30-8030-80

Increases with Increases with ageage

3030

6060

9090

50 50

Cross-Cross-sectionalsectional



Crpss-Crpss-sectionalsectional

interventionintervention

Dawson-Hughes Dawson-Hughes et al.et al. 19911991

Ooms 1994Ooms 1994

Ooms Ooms et al.et al. 1995 1995

Chapuy Chapuy et al.et al. 1997 1997

Guillemant Guillemant et al.et al. 1999 1999

Jesudason Jesudason et al.et al. 2002 2002

Vieth Vieth et al.et al. 2003 2003

Ooms Ooms et al.et al. 1995 1995

Jesudason Jesudason et al.et al. 2002 2002

Krall Krall et al.et al. 1989 1989

Malabanan Malabanan et al.et al. 1998 1998

Lips 2001Lips 2001

(Mosekilde L. Clin Endocrinol 2005; 62: 265-281)

(Sadat-Ali M & AlElq AM. Ann Saudi Med 2006; 26: 450-454)

(Sadat-Ali M & AlElq AM. Ann Saudi Med 2006; 26: 450-454)

(El-Desouki MI & Sulimani RA. Saudi Med J 2007; 28: 774-777)

(El-Desouki MI & Sulimani RA. Saudi Med J 2007; 28: 774-777)

•Resurrection of vitamin D Resurrection of vitamin D deficiency and ricketsdeficiency and rickets

• M F HOLICK J. Clin.Inves 2006M F HOLICK J. Clin.Inves 2006• Upward of 35-80 % OF Children in Saudi Upward of 35-80 % OF Children in Saudi

Arabia and other sunny countries are Arabia and other sunny countries are vitamin D deficient !vitamin D deficient !

• Subclinical vitamin D deficiency in Subclinical vitamin D deficiency in neonates (10 – 20 ng/ml) is associated with neonates (10 – 20 ng/ml) is associated with normal serum calcium and elvated PTH.normal serum calcium and elvated PTH.

In conclusionIn conclusion

• Vitamin D deficiency is pandemic Vitamin D deficiency is pandemic worldwide worldwide

• Saudi Arabia and many other Saudi Arabia and many other sunnysunny countriescountries are no exception

• THE IMPACT OF THIS PROBLEM ON SKELETAL HEALTH AND MANY OTHER DISEASES SO PREVALENT ALREADY IN SAUDI ARABIA HAS TO BE ADRESSED URGENTLY

Documents

VITAMEN D DEFICIENCY IN SAUDI ARABIA THE SILENT EPIDEMIC MONA A FOUDA NEEL,MBBS, MRCP(UK),FRCPE MONA A FOUDA NEEL,MBBS, MRCP(UK),FRCPE ASSOCIATE PROFESSOR