|Year : 2014 | Volume
| Issue : 1 | Page : 21-25
Vitamin D deficiency among Syrian elderly living in nursing homes
Department of Nutrition, Faculty of Health Sciences, University of Kalamoon, Deir attyah, Damascus, Syria
|Date of Web Publication||24-Dec-2013|
P. O. Box 30440, Damascus
Source of Support: None, Conflict of Interest: None
Background: There have been several studies in many parts of the world with regard to the prevalence of vitamin D deficiency. These studies showed high prevalence of vitamin D deficiency in vulnerable groups such as elderly and maybe associated with many adverse health outcomes. There are no data on the prevalence of vitamin D deficiency and its influencing factors in elderly population in Damascus. Therefore, the purpose of this study was to estimate the prevalence of vitamin D deficiency among Syrian elderly living in nursing homes.
Materials and Methods: Two hundred and ten elderly (110 males and 100 females) participated in this study; their ages ranged from 65-92 years and were randomly selected from two nursing homes in Damascus. 25-hydroxy vitamin D serum levels were measured; fat percentage and BMI were identified in addition to their dietary habits such as their calcium intake, vegetables intake, and dairy products intake. The durations of their exposure to sun and their physical status were also indentified.
Results: 169 elderly residents (80.5%) were vitamin D deficient. Their serum 25(OH) D level was: S15 ng/mL [: S37.5 nmol/L]. Using a cut-off level of 25(OH) D of: S20 ng/ml [: S50 nmol/l] 29 participants or (13.8%) were vitamin D insufficient. Overall 198 (94.3%) of study participants were either vitamin D deficient or/and insufficient. The prevalence of vitamin D deficiency varied between men (75.6%) and women (86%). It has been found that serum 25 hydroxy vitamin D concentrations were lower in females than in males but body mass index (BMI) did not correlate with vitamin D values contrary to fat percentage. Consumption of dairy products, vegetables, calcium and supplements increased serum levels in addition to sun exposure and physical status as well.
Conclusion: Vitamin D deficiency and insufficiency were highly prevalent in elderly, and more common in women.
Keywords: Body mass index, calcium intake, Damascus, elderly, fat percentage, vitamin D deficiency, 25(OH) D
|How to cite this article:|
Labban L. Vitamin D deficiency among Syrian elderly living in nursing homes. J Med Nutr Nutraceut 2014;3:21-5
| Introduction|| |
Vitamin D is a fat-soluble vitamin that is found in cod liver oil; two major biologically inert precursors of vitamin D are vitamin D3 (cholecalciferol) and vitamin D2 (ergocalciferol). 
Vitamin D3 is formed when 7-dehydrocholesterol in the skin is exposed to solar ultraviolet B (UVB, 290-320 nm), and is then converted to previtamin D3. In a heat-dependent process, previtamin D3 is immediately converted to vitamin D. Vitamin D2 is plant derived, produced exogenously by irradiation of ergosterol, and enters the circulation; vitamin D deficiency occurs when people do not have an appropriate dietary intake or exposure to UVB rays. It is universally accepted that the circulating level of 25-hydroxyvitamin D should be used as an indicator of vitamin D status due to its ease of measurement, long half-life in circulation (approximately 2 or 3 weeks), and the correlation of its level with clinical disease states. 
There is no consensus that on an optimal level of 25-hydroxyvitamin D has been reached; vitamin D deficiency is defined by most experts as a level of less than 20 ng/ml (50 nmol/l). ,
A level of 25-hydroxyvitamin D of 21 to 29 ng/ml (52 to 72 nmol/l) is considered as an insufficiency of vitamin D, and sufficient vitamin D should reach a level of 30 ng/ml or greater. 
Inadequate exposure to sunlight and low nutritional intake of vitamin D result in low serum concentrations of circulating 25(OH) D, a condition known as hypovitaminosis D.  Severe vitamin D deficiency in children leads to nutritional rickets and is associated with type 2 diabetes  and cardiovascular disease (CVD) risk factors such as hypertension, hyperglycemia, and metabolic syndrome. ,,,,,,,
Vitamin D deficiency in women in Arab countries has been attributed not only for inadequate dietary intake but also due to inadequate exposure of skin to sunlight due to a very conservative style of dress (e.g., hijab) that covers most of the body when they are outside. ,
The purpose of this study was to find out the prevalence of vitamin D deficiency in elderly living in nursing homes in Damascus.
| Materials and Methods|| |
The study was conducted during March to June of 2012 on 210 elderly participants (110 males and 100 females) living in two nursing homes in Damascus, Syria, aged 65 to 92 years. Study participants were randomly selected and then participants who used any medications regularly or had any chronic medical conditions that might affect their health status, body composition, dietary intake, or physical status were excluded from this study. The participants consented to fast for at least 8 h, and to take blood specimens to measure Serum 25(OH) D concentrations.
Before starting data collection procedure, each participant was given a personal identification number to maintain anonymity. The identification number was used to link participants to his/her respective clinical measurements. A questionnaire was designed in order to obtain relevant information related to age, gender, dietary habits, sun exposure durations, and physical status. The questionnaire was in Arabic language and validated by a pilot test using 10 volunteers. In the dietary habit section of the questionnaire, milk, milk products, and vegetables consumption frequencies data were categorized (per serving) as: Less than once per day, once per day, and more than once per day. Information about the ability of movement to assess the physical activity status in the study participants as follows: Independent, moving with assistance, and bedridden was included in the questionnaire. Also, participants taking calcium and multivitamin supplements was identified.
All measurements were performed at the same time of the day (between 8 and 11 am) for all participants. Height was measured in centimeters (cm) using a Stadiometer (MEDLINE) with the participant standing in an upright position without wearing shoes. For participants who were unable to stand, a regular measuring tape was used to get their length (heights). Body weight was measured to the nearest 0.2 kg using a Tanita scales with the participant standing in an upright position without shoes and in light clothing. The height and weight were taken three times and the average was calculated to be the participant's final measurement. With regard to fat percentage, a skinfold caliper (MEDLINE) was used and measurements were taken from four different areas: Triceps, biceps, abdomen, and shoulder. A trained nurse helped in measurement reading for women because of cultural limitations.
Five milliliter venous blood sample was obtained from the subjects by qualified nurses using standardized tubes. Prior to blood sampling, all participants had been instructed to fast for at least 8 h. Blood samples were underwent standardized (quality controlled) analyses. Serum 25 (OH) D concentrations were measured by radioimmunoassay (DiaSorin, Stillwater, MN).
Body mass index (BMI) was calculated as body weight in kilograms divided by height in meters squared. BMI was used to classify participants as either underweight (BMI < 18.5), normal weight (BMI 18.5-11 24.9), overweight (BMI 25-29.9) or obese (BMI > 30) according to WHO classification. 
The 25 (OH) D levels are the most commonly measured indicator of vitamin D status. It has been defined vitamin D deficient as having serum 25(OH) D level: S15 ng/mL [:S37.5 nmol/L] and vitamin D insufficient as 25(OH) D level: S20 ng/mL [:S50 nmol/L], respectively. 
These findings must be interpreted in light of the acknowledged limitations. We were not able to measure the parathyroid hormone, a measure of bone health closely associated with vitamin D status. ,
Descriptive statistics (means and standard deviations) were used to estimate serum 25(OH) D concentrations by gender. The statistical analysis was conducted using SPSS (v. 19). ANOVA and student t-test were used to analyze the association between serum 25(OH) D concentrations and potentially associated variables. Statistical significance was defined as P < 0.05.
| Results|| |
The age of the study participants (n = 210) ranged from 65 to 92 years and 47.6% were females (n = 100) and 52.4% (n = 110) were males. The mean age was 76.4 ± 6.34 years and 75.8 ± 6.12 years for females and males, respectively.
Mean serum 25 (OH) D concentrations was 14.46 ± 2.11 ng/mL in females as compared with males 14.86 ± 2.88 ng/mL. The difference was not statistically significant at P < 0.05.
Out of 210 participants, 169 (80.5%) were vitamin D deficient as their serum 25(OH) D concentrations were: S15 ng/mL [: S37.5 nmol/L]. Using a cutoff of 25(OH) D concentrations: S 20 ng/mL [: S50 nmol/L], 29 participants (13.8%) were vitamin D insufficient and 198 males and females (94.3%) were either deficient or insufficient. Nine males (8.1%) and three females (3%) had normal concentrations of 25(OH) D which is 2:20 ng/mL [2:50 nmol/L].
A higher proportion of females (86%) were vitamin D deficient compared to their male counterparts (75.5%); 91.9% of the males were vitamin D deficient and/or insufficient whereas 97% of the females were deficient and/or insufficient. The difference between males and females with regard to vitamin D deficiency and/or insufficiency was significant (P < 0.05). Mean fat percentage for females was 21.18 ± 3.39 % compared to their males' counterparts 12.18 ± 1.50% and the difference was statistically significant at P < 0.05 as shown in [Table 1].
|Table 1: Mean vitamin D levels, BMI and fat percentage in males and females|
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[Table 1] has also shown mean 25 (OH) D concentrations change with different BMI categories. The mean BMI value of vitamin D deficient group was 18.4 ± 17.4 for males and 18.1 ± 16.2 for females and the difference was not statistically significant. In the insufficient group, BMI values increased to be 19.9± 15.6 and 18.9 ± 14.8 for males and females, respectively, and also there was no significant difference between males and females (P < 0.05). Males with normal concentrations of 25(OH) D 2:20 ng/mL had BMI 22.6 ± 15.9 whereas females with normal concentrations of 25(OH) D their BMI value was 19.6 ± 14.7 and the difference was statistically significant (P < 0.05).
25(OH) D concentrations also increased with higher fat percentage in males and females. Deficient males and females had the lowest fat percentage than normal. 25(OH) D concentrations improved when fat percentage increased in both males and females. There difference was highly significant between males and females in the normal concentrations of 25(OH) D.
Also, this study examined the relationship between serum 25(OH) D levels in elderly and their physical status. Mean 25 (OH) D concentrations were the highest in those who were independent (n = 55 or 26.2%) in doing their daily activities to be 16.4 ng/mL (14.9-17.9 ng/mL). Concentrations of 25(OH) D declines in the elderly who lost their ability to do their daily activities as they needed help to move or were bedridden. Their mean 25(OH) D concentration was 12.1 ng/mL (11.7-12.5 ng/mL) (P < 0.005).
The duration of exposure to sun was an important factor in improving serum 25(OH) D concentrations in elderly. The concentration increased from 12.4 ng/mL when residents were exposed to less than 30 min/day to 16.7 and 19.4 ng/mL when they were exposed to 30-60 min/day and more than 60 min/day, respectively, as shown in [Table 2] and [Figure 1].
|Figure 1: The relationship between 25(OH) Vitamin D levels and exposure to sun|
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|Table 2: The relationship between Vitamin D level, physical status, and sun exposure durations and supplement intake|
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With regard to calcium intake and serum 25(OH) D concentrations, the later improved with an increased intake of calcium. 55.2% of the elderly consumed 572.2 mg/day of calcium (44% of their RDA) and their serum 25(OH) D level was 13.1 ng/mL. When calcium intake increases to 588.7 and 684.9 mg/day, serum 25(OH) D concentrations increased to 14.9 and 15.8 ng/mL, respectively. There was a significant difference only in the highest calcium intake comparing with other groups (P < 0.05).
The number of servings of milk and milk products had an impact on the status of vitamin D. 154 elderly (73.4%) consumed less than one serving/day of milk and its products. Their serum 25(OH) D concentration was 12.9 ng/mL whereas 39 elderly (18.6%) had one serving/day and only eight elderly (17%) consumed more than one serving/day. Their serum 25(OH) D concentrations became 13.7 and 16.8 ng/mL, respectively, and the difference was statistically significant (P < 0.05).
Serum 25(OH) D concentrations increased by increasing the number of servings of vegetables. They are increased with the increase of frequency of consuming vegetables. They were 12.2, 13.6, and 14.8 ng/mL when 61% of the elderly consumed less than one serving, 59% consumed one serving and 23% consumed more than one serving/day, respectively.
Taking supplements in the form of multivitamins also increased serum 25(OH) D concentrations. 38 elderly (18%) were taking supplements, their serum 25(OH) D levels was 19.9 ng/mL as compared to 172 elderly (82%) who did not take any supplements; therefore, their serum 25(OH) D concentrations decreased to 14.4 ng/mL and there was a significant difference (P < 0.05) as shown in [Table 3] and [Figure 2].
|Figure 2: The relationship between 25(OH) Vitamin D concentration and consumption of milk, milk products and vegetables|
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|Table 3: The relationship between serum 25(OH) D level (ng/mL) with Ca intake (mg/d), dairy intake vegetables intake (serving/day) and supplement intake|
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| Discussion|| |
Inadequate nutritional intake of vitamin D from dietary sources and supplements and inadequate exposure to sun due to traditional clothing or inability to move may further contribute to low serum vitamin D concentrations. Hashemipour et al. investigated the problem of vitamin D deficiency in population in Tehran and found that prevalence of severe, moderate, and mild vitamin D deficiency was 9.5%, 57.6%, and 14.2%, respectively. The results obtained from this study are very consistent with previously mentioned data. 
However, the data from this study have shown an inverse association between 25(OH) D concentrations and BMI values that are consistent with results from other studies. ,
Consumption of Milk and dairy products is also associated with an improvement in serum concentrations of 25(OH) D as presented in this study which is in total agreement with findings of. 
| Conclusion|| |
Vitamin D deficiency and insufficiency were highly prevalent in elderly living in nursing homes in Damascus due to their inadequate intake of milk, milk products, supplements, and their physical status and more common in females than males. Since vitamin D is a critical factor in public health in general and elderly health in particular, there is an urgent need for determination of the prevalence vitamin D deficiency and adjusting the status of vitamin D deficiency in the general population and mainly in elderly by following health measures such as daily sunlight exposure that has been shown to be effective in other Arab population  and educating them about consuming rich sources of vitamin D and taking dietary supplements.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]