Vitamin D Intake among Premenopausal Women Living in Jeddah: Food Sources and Relationship to Demographic Factors and Bone Health

A comprehensive review on the impact of calcium and vitamin D insufficiency and allied metabolic disorders in females

Calcium is imperative in maintaining a quality life, particularly during later ages. Its deficiency results in a wide range of metabolic disorders such as dental changes, cataracts, alterations in brain function, and osteoporosis. These deficiencies are more pronounced in females due to increased calcium turnover throughout their life cycle, especially during pregnancy and lactation. Vitamin D perform a central role in the metabolism of calcium. Recent scientific interventions have linked calcium with an array of metabolic disorders in females including hypertension, obesity, premenstrual dysphoric disorder, polycystic ovary syndrome (PCOS), multiple sclerosis, and breast cancer. This review encompasses these female metabolic disorders with special reference to calcium and vitamin D deficiency. This review article aims to present and elaborate on available data regarding the worldwide occurrence of insufficient calcium consumption in females and allied health risks, to provide a basis for formulating strategies and population-level scientific studies to adequately boost calcium intake and position where required.

Prevalence and Associated Factors of Vitamin D Deficiency in High Altitude Region in Saudi Arabia: Three-Year Retrospective Study

Background

Vitamin D has many functions in the human body, and its deficiency is associated with skeletal and non-skeletal diseases. Vitamin D deficiency (blood level of 25 (OH) vitamin D < 20 ng/mL) has been reported worldwide, including Kingdom of Saudi Arabia (KSA). Its prevalence and associated factors vary according to KSA region. Therefore, this study aimed to explore the prevalence and risk factors of vitamin D deficiency in the Taif region of KSA.

Methods

This retrospective study included patients who attended outpatient clinics at the Alameen General Hospital from 2019 to 2021. Demographic, clinical, and laboratory data were collected using a hospital software system.

Results

The study included 2153 patients and vitamin D deficiency was diagnosed in 900 (41.8%) of whom were diagnosed with vitamin D deficiency. It was more common in males (P=0.021), younger age (<0.001), and in patients without comorbidities. There was a positive correlation between 25 (OH) vitamin D levels and blood cholesterol, high-density lipoprotein, calcium, and vitamin B12 levels. In the binary logistic regression analysis, age was the most significant predictor (P<0.001), followed by the absence of thyroid disease (P=0.012) and asthma (P=0.030).

Conclusion

Vitamin D deficiency is common in the Saudi population despite sunny weather in KSA. It is more prevalent among males, younger individuals, and those without comorbidities such as thyroid diseases and asthma.

Optimal Serum 25(OH)D Level and Vitamin D Intake in Young Korean Women

Vitamin D status is essential for preventing bone disease. Young Korean women have the highest vitamin D deficiency prevalence compared with other demographic groups. This study aimed to establish the optimal vitamin D intake level for maintaining an adequate serum 25-hydroxyvitamin D (25[OH]D) level by season in young Korean women (mean age: 23.1 years). Each participant (wintertime, n = 101; summertime, n = 117) completed a lifestyle survey, dietary record, bone mineral density, and biochemical tests. Seasonal factors impacting 25(OH)D were identified, vitamin D intake for sufficient 25(OH)D levels was calculated, and the relationship between 25(OH)D and intact parathyroid hormone (iPTH) was analyzed. During summertime, 25(OH)D levels were higher than in wintertime (17.9 vs. 15.0 ng/mL). A 1 µg/1000 kcal increase in vitamin D intake increased 25(OH)D levels by 0.170 ng/mL in wintertime and 0.149 ng/mL in summertime. iPTH levels reached a theoretical plateau corresponding to an 18.4 ng/mL 25(OH)D level. The vitamin D intake threshold for maintaining 25(OH)D levels at ≥20 and ≥18.4 ng/mL was ≥10.97 μg/day. For a sufficient level of 25(OH)D in young Korean women, increasing summertime UV irradiation time and increasing vitamin D supplements and vitamin D-containing foods throughout the year is beneficial.

Factors Associated with Low Vitamin D Status among Older Adults in Kuwait

Low vitamin D levels among older people represent a significant health problem worldwide. This study aimed to examine the factors associated with vitamin D deficiency in older people (aged ≥ 65) in the Kuwaiti population. A cross-sectional study was conducted in seven primary healthcare centers across Kuwait (November 2020 to June 2021). The participants (n = 237) had their serum vitamin D (25(OH)D) concentrations (analyzed using LC-MS) classified as sufficiency 75 nmol/L (30 ng/mL) or deficiency < 75 nmol/L (below 30 ng/mL). The data were collected using self-administered questionnaires and face-to-face interviews with participants in geriatric clinics. Binomial logistic regression analysis was applied to assess factors associated with vitamin D deficiency. Vitamin D deficiency was found to be present in two thirds of the participants (n = 150, 63%), with a higher prevalence of deficiency in participants who did not receive vitamin D supplements, compared to those who did (84% vs. 16%, p = 0.001). The results from the binary logistic regression showed that a low duration of sun exposure (OR = 0.24, 95% C.I. [0.08−0.7], p = 0.011), dark skin pigmentation (OR = 4.46, 95% [1.35−20.49], p = 0.026), and lower caloric intake (OR = 0.9, 95% C.I. [0.85−0.96], p = 0.001) were risk factors for vitamin D deficiency. Furthermore, a significant inverse relationship was found between vitamin D levels and parathyroid hormone (PTH) levels (OR = 1.16, 95% C.I. [1.04−1.31], p = 0.016). These findings support the recommendation that vitamin D supplementation and adequate sunlight exposure are necessary for raising low vitamin D levels in older people in Kuwait.

Lower Blood Vitamin D Levels Are Associated with Depressive Symptoms in a Population of Older Adults in Kuwait: A Cross-Sectional Study

Low serum vitamin D has been associated with an increased risk of neuropsychiatry disorders. This study aimed to examine the association between vitamin D deficiency and depression in adults aged 65 years and older. This cross-sectional study was conducted in seven primary healthcare centers across Kuwait (November 2020 to June 2021). The participants (n = 237) had their serum vitamin D 25-(OH)-D concentrations (analyzed by LC-MS) classified as sufficient, ≥75 nmol/L (30 ng/mL); insufficient, 50−75 nmol/L (20−30 ng/mL); or deficient, <50 nmol/L (20 ng/mL). Depressive symptoms were evaluated using the 15-Item Geriatric Depression Scale (15-item GDS). The mean serum 25-OH-D levels (nmol/L) in volunteers with normal, mild, moderate, and severe depression were 100.0 ± 31.7, 71.2 ± 38.6, 58.6 ± 30.1 and 49.0 ± 6.93, respectively (p < 0.001). The participants in the vitamin D sufficiency group were significantly less likely to exhibit depressive symptoms (88.2%) than patients with mild (36%) and moderate (21%) depression (p < 0.001). Ordinal logistic regression showed that vitamin D deficiency (OR = 19.7, 95% CI 5.60, 74.86, p < 0.001) and insufficiency (OR = 6.40, 95% CI 2.20, 19.91, p < 0.001) were associated with higher odds of having depressive symptoms. A low serum vitamin D level is a significant predictor of symptoms of depression among older individuals.

The Impact of Vitamin D Level on the Severity and Outcome of Hospitalized Patients with COVID-19 Disease

PURPOSE

The world is experiencing a life-altering and extraordinary situation in response to the COVID-19 pandemic. There are limited data and controversies regarding the relationship between vitamin D (Vit D) status and COVID-19 disease. Thus, this study was designed to investigate the association between Vit D levels and the severity or outcomes of COVID-19 disease.

METHODS

A cross-sectional observational study was conducted in the Eastern province of Saudi Arabia from January to August 2021. All the admitted patients who were diagnosed with COVID-19 infection were distributed into three groups depending on their Vit D levels: normal, insufficiency, and deficiency. For the three groups, demographic data, and laboratory investigations as well as data regarding the severity of COVID-19 were collected and analysed.

RESULTS

A total of 203 diagnosed cases of COVID-19 were included in this study. The Vit D level was normal (>30) in 31 (15.3%) cases, insufficient in 45 (22.2%) cases and deficient in 127 (62.6%) cases. Among the included cases, 58 (28.6%) were critical cases, 109 (53.7%) were severe and 36 (17.7%) had a mild-moderate COVID-19 infection. The most prevalent comorbidity of patients was diabetes mellitus 117 (57.6%), followed by hypertension 70 (34.5%), cardiac disease 24 (11.8%), chronic kidney disease 19 (9.4%) and chronic respiratory disease in 17 (8.4%) cases. Importantly, the current study did not detect any significant association between Vit D status and COVID-19 severity (p-value=0.371) or outcomes (hospital stay, intensive care units admission, ventilation, and mortality rate) (p-value > 0.05), even after adjusting the statistical model for the confounders.

CONCLUSION

In hospital settings, Vit D levels are not associated with the severity or outcomes of COVID-19 disease. Further, well-designed studies are required to determine whether Vit D status provides protective effects against worse COVID-19 outcomes.

Directly measured free and total 25-hydroxyvitamin D levels in relation to metabolic health in multi-ethnic postmenopausal females in Saudi Arabia

BACKGROUND

Measurement of free 25-hydroyvitamin D (25(OH)D) status has been suggested as a more representative marker of vitamin D status than that of total 25(OH)D. Previously, free 25(OH)D could only be calculated indirectly; however, a newly developed direct assay for the measurement of free 25(OH)D is now available. The aim of this study therefore was to investigate directly measured total and free vitamin D levels association with metabolic health in postmenopausal healthy women living in Saudi Arabia.

METHODS

A sample of 302 postmenopausal women aged ≥50 years (n = 302) living in Saudi Arabia were recruited in a cross-sectional study design. Blood samples were collected from subjects for measurement of serum levels of total 25(OH)D, directly measured free 25(OH)D, metabolic bone parameters, lipid profile, and other biochemical tests.

RESULTS

A positive correlation was found between directly measured free and total 25(OH)D (r = 0.64, P< 0.0001). Total but not free 25(OH)D showed significant association with serum intact parathyroid hormone (P = 0.004), whilst free 25(OH)D but not total 25(OH)D showed a significant association with total cholesterol and LDL-C (P = 0.032 and P = 0.045, respectively).

CONCLUSIONS

Free 25(OH)D and total 25(OH)D were found to be consistently correlated but with different associations to metabolic health parameters. Further research is needed to determine which marker of vitamin D status would be the most appropriate in population studies.

Knowledge and attitudes about vitamin D and sunlight exposure in premenopausal women living in Jeddah, and their relationship with serum vitamin D levels

BACKGROUND

Saudi women are at risk of vitamin D deficiency because they are fully covered by traditional clothing and because of their indoor lifestyle. The latest national study reported that vitamin D deficiency (serum 25(OH)D < 50 nmol/L) affects 72% of young Saudi women. Because little information is available regarding knowledge on vitamin D, attitudes toward sun exposure, and the vitamin D status of premenopausal women in Jeddah, more research is necessary in order to develop effective intervention programs. The purpose of this study is to explore how the relationship between knowledge of vitamin D and attitudes about sun exposure affect the serum 25(OH)D levels in premenopausal Saudi women.

METHODS

This cross-sectional study included 257 women aged 20-50 years attending the primary care clinic in Jeddah, Saudi Arabia. Participants completed questionnaires about socio-demographics, dietary vitamin D intake, attitudes toward sun exposure, and were tested on their knowledge of vitamin D. Serum 25(OH)D was evaluated using chemiluminescent microparticle immunoassay.

RESULTS

Although 99% of participants had heard of vitamin D and 91% knew that sunlight exposure is a primary source of vitamin D, they also expressed the feeling of having insufficient knowledge regarding vitamin D sources. Furthermore, the majority of participants had negative attitudes toward sun exposure. High fish consumption was associated with a higher level of knowledge regarding vitamin D. The binary logistic regression indicated that low levels of knowledge about vitamin D were associated with low education levels (odds ratio = 0.397, 95% CI = [0.206, 0.765], p = 0.019) and with being married (odds ratio = 0.522, 95% CI = [0.281, 0.971], p = 0.04). In addition, spending time outside in the sun was significantly associated with increased serum 25(OH)D levels (p = 0.006), and the wearing of colored abaya was significantly associated with increased serum 25(OH)D levels (p = 0.008).

CONCLUSION

Suboptimal vitamin D status and insufficient knowledge of vitamin D intake sources are common in premenopausal women in Jeddah. Based on this data, health professionals could provide medical intervention to the most vulnerable female patients, as well as offer clear guidelines and information to the general public.

Association between vitamin D and glycaemic parameters in a multi-ethnic cohort of postmenopausal women with type 2 diabetes in Saudi Arabia

BACKGROUND

The relationship between vitamin D (VitD) and insulin sensitivity and secretion in type 2 diabetes mellitus (T2D) has been shown to be different amongst different ethnic populations. In Saudi Arabia, where both T2D and VitD deficiency are highly prevalent health concerns, little is known about the relationship between VitD, insulin sensitivity, resistance and the relative importance of ethnicity. Our primary aim in this study was to investigate influence of ethnicity on VitD association with glycaemic profile and to measures of obesity as a secondary outcome, among multiethnic postmenopausal women with T2D in Saudi Arabia.

METHODS

A cross-sectional study was conducted at King Fahad Medical Research Center, King Abdulaziz University, Jeddah, Saudi Arabia. Postmenopausal females (n = 173, age ≥ 50 years) with T2D were randomly selected in this study. Anthropometric measures and fasting blood samples were obtained for all study participants. Several biochemical parameters were measured including 25-hydroxyvitamin D (25(OH)D), glycosylated hemoglobin (HbA1c), insulin, glucose and c-peptide. Surrogate markers for insulin resistance were calculated using Homeostasis Model Assessment 2 for insulin resistance and beta cell activity (HOMA2-IR, HOMA2-β).

RESULTS

Overall, 25(OH)D was inversely associated with fasting glucose (r=-0.165, P = 0.037), insulin (r=-0.184, P = 0.02), C-peptide (r=-0.19, P = 0.015) and HOMA2- IR C-peptide (r=-0.23, P = 0.004). Additionally, serum 25 (OH)D showed a negative correlation with body weight (r=-0.173 P = 0.028), waist and hip circumferences (r=-0.167, P = 0.033; r=-0.22, P = 0.004 respectively) but not with body mass index (BMI) or waist hip ratio (WHR). In the white ethnic group but not in black or Asian population groups, 25(OH)D level was also associated with only serum fasting C-peptide and HOMA2-IR C-peptide and BMI (P < 0.05).

CONCLUSIONS

Insulin resistance and obesity were associated with VitD status in T2D in this cohort. Our findings also suggest that these VitD associations in women from white ethnic background are different than in those from black/Asian ethnic backgrounds. Whether VitD supplements are able to improve either obesity and/or insulin sensitivity should be further investigated in different ethnic population groups.

Meta-Analysis and Systematic Review of Micro- and Macro-Nutrient Intakes and Trajectories of Macro-Nutrient Supply in the Eastern Mediterranean Region

The Eastern Mediterranean Region (EMR) is experiencing a nutrition transition, characterized by the emergence of overnutrition and micro-nutrient deficiencies. No previous study has comparatively examined nutrient intake in adults across countries in the EMR. This review examined the adequacy of nutrients in adults living in the EMR. Moreover, it analyzed the food balance sheets (FBS) for 1961–2018 to identify the trajectory of energy supply from macro-nutrients in the EMR. A systematic search was conducted from January 2012 to September 2020. Only observational studies were retained with a random sampling design. An assessment of the methodological quality was conducted. Levels of nutrient daily intake and their adequacy compared to the daily reference intake of the Institute of Medicine were reported across the region. No studies were identified for half of the region’s countries. Although nutrient energy intake was satisfactory overall, fat and carbohydrate intake were high. Intake of vitamin D, calcium, potassium, zinc, and magnesium were below that recommended. The analysis of the FBS data allowed for the identification of four linear patterns of trajectories, with countries in the EMR best fitting the ‘high-energy-supply from carbohydrate’ group. This systematic review warrants multi-sectorial commitment to optimize nutrient intake.

The significant role of dietary intake of vitamin D in non-menopausal women health

Optimal vitamin D status is very important for reflecting not only bone but overall woman's health. The aim of the study was to determine pharmacokinetic variability of 25-hydroxy vitamin D, to reveal and quantify the most significant factors that affect its variability in the population of healthy non-menopausal women using the population pharmacokinetic (PopPK) approach. The study population consisted of 74 healthy reproductive women aged from 35 to 50 years, without the use of any supplement. A population pharmacokinetics analysis was conducted using a nonlinear mixed-effects model software. A total of 35 factors were assessed: demographic, clinical, biochemical data and lifestyle factors. The average age and bodyweight of our participants were 40.11 ± 4.35 years 65.30 ± 6.80 kg, respectively. The observed mean serum concentration of 25-hydroxy vitamin D was 26.51 ± 13.49 ng/mL with a wide range of 6.97 to 59.89 ng/mL. Development final PopPK model of the clearance of 25-hydroxy vitamin D showed that only the average daily dose of vitamin D intake from food had a significant influence, with a magnitude of its effects of 0.00401. These results could help when individualizing vitamin D intake in the form of supplements, especially during the wintertime, in healthy reproductive women.

Vitamin D Levels and Bone Mineral Density in Premenopausal Women Compared to Postmenopausal Women: A Multi-Centre Study From Pakistan

Introduction Despite the sunny climate, women in Pakistan are prone to vitamin D deficiency and subsequent low bone mineral density. The current study explores the extent of this deficiency in both pre- and postmenopausal women in our setting.  Methodology A cross-sectional study was conducted at the outpatient departments of Lady Reading Hospital and Hayatabad Medical Complex Peshawar, Pakistan during the time period between March 2018 and June 2019. Hundred premenopausal women (control group) and 100 postmenopausal women (study group) were inducted in the study. Serum vitamin D levels were determined in patients with suspected vitamin D deficiency. Bone mineral density (BMD) was determined for each patient and the cost of each scan was afforded by our department. A dual-energy x-ray absorptiometry (DEXA) scan was used to perform the bone mineral density assessment. The data was analyzed using Statistical Package for Social Sciences (SPSS) version 26 (IBM, Chicago, IL). Results Serum 25OHD concentration in postmenopausal women was significantly lower compared to premenopausal women (p<0.001). In the study group, 36.0% of women had a severe deficiency of serum vitamin D levels, whereas, in the control group, only two women suffered from severe deficiency of vitamin D. Similarly, bone mineral density was also significantly correlated with the menopausal status of the women (p<0001). It was found that three-fifths of the postmenopausal women had a low bone density. Twenty-four percent of postmenopausal women had very low BMD. In comparison, only a single premenopausal woman was found to have a Z-score of below -2.0. Conclusion The current study highlights the impact of menopause on vitamin D levels and BMD. In our study, we found a significant difference between vitamin D levels and BMD in women of reproductive age compared to postmenopausal women.

Osteoporosis in Premenopausal Women: A Clinical Narrative Review by the ECTS and the IOF

CONTEXT

Consensus regarding diagnosis and management of osteoporosis in premenopausal women (PW) is still lacking due to few studies carried out in this population.

DESIGN

The European Calcified Tissue Society and the International Osteoporosis Foundation convened a working group to produce an updated review of literature published after 2017 on this topic.

RESULTS

Fragility fractures in PW are rare and mostly due to secondary osteoporosis (ie, in presence of an underlying disease such as hormonal, inflammatory, or digestive disorders). In absence of another disorder, low bone mineral density (BMD) together with fragility fractures qualifies as idiopathic osteoporosis. In contrast, low BMD alone does not necessarily represent osteoporosis in absence of bone microarchitectural abnormalities. BMD increases in PW with osteoporosis when the underlying disease is treated. For example, in celiac disease, an increase of 9% in radius trabecular volumetric density was achieved after 1 year of gluten-free diet, while anti-tumor necrosis factor alpha improved BMD in PW with inflammatory bowel diseases. In amenorrhea, including anorexia nervosa, appropriately delivered estrogen replacement therapy can also improve BMD. Alternatively, antiresorptive or anabolic therapy has been shown to improve BMD in a variety of conditions, the range of improvement (3%-16%) depending on skeletal site and the nature of the secondary cause. No studies were powered to demonstrate fracture reduction. The effects of bisphosphonates in childbearing women have been scantly studied and caution is needed.

CONCLUSION

The majority of PW with osteoporosis have an underlying disease. Specific therapy of these diseases, as well as antiresorptive and anabolic drugs, improve BMD, but without evidence of fracture reduction.

The Affect of Lifestyle on Bone Mineral Density and Bone Turnover in Young Women

INTRODUCTION

This research aimed to evaluate the effect of lifestyle factors such as nutrient intake and physical activity on bone mineral density (BMD) and bone turnover in young women.

MATERIALS AND METHODS

BMD was assessed using Quantitative Ultrasound; lifestyle-related factors such as dietary habits, and physical activity were examined using questionnaires in 194 female college students. The biochemical markers of bone turnover were measured in the Osteopenia (BMD below the Young Adult Mean [YAM] -1.0SD, 16 subjects) and Normal (above the YAM-1.0SD, 31 subjects) groups.

RESULTS

The percentage of osteopenia was 11.9%. Calcium and magnesium intake (p<0.05), and physical activity (p<0.1) were found to be factors influencing BMD. The level of osteocalcin and type 1 procollagen N-terminal propeptide (P1NP) were higher in the Osteopenia group than in the Normal group (p<0.05). There was tendency that showed relationship between the level of undercarboxylated osteocalcin (ucOC) and BMD (p<0.1). The level of bone-specific alkaline phosphatase was significantly higher in the 25OH vitamin D insufficiency group compared to sufficiency group (p<0.05). The levels of OC, tartrate-resistant acid phosphatase-5b and P1NP were lower in the ucOC <4.5 ng/ml group compared to ≥4.5 ng/ml group (p<0.01, p<0.05, p<0.1), respectively.

CONCLUSION

This study showed that BMD in young women is affected by calcium and magnesium intake, physical activity, and vitamin D and K levels. It was suggested that the insufficiency of vitamin D and K might be contributable to low BMD through the change of bone turnover.

Vitamin D Deficiency and Associated Risk Factors in Women from Riyadh, Saudi Arabia

Vitamin D deficiency is an epidemic public health problem worldwide. It is common in the Middle East and is more severe in women. This cross-sectional study was conducted to assess vitamin D deficiency and associated risk factors in women living in Riyadh, Saudi Arabia. Serum 25-hydroxyvitamin D (25(OH)D) was measured in 166 women aged 30-65 years. Socio-demographic, lifestyle and health status characteristics, as well as intake of selected dietary supplements, were collected. Weight and height were measured. Vitamin D deficiency (25(OH)D < 20 ng/mL) was reported in 60.2% of participants. Mean of serum 25(OH)D was 20.7 ng/mL. Older age and taking the supplements of vitamin D, multi-vitamins or calcium were identified as factors that associated with a lower risk of hypovitaminosis D. A national strategy is needed to control a hypovitaminosis D crisis in Saudi Arabia. This could be accomplished by raising public awareness regarding vitamin D, regulating and enhancing vitamin D fortification and supplementation and screening vitamin D status among women at high risk.

Pathophysiology of the Risk Factors Associated with Osteoporosis and their Correlation to the T-score Value in Patients with Osteopenia and Osteoporosis in the United Arab Emirates

Introduction:

Osteoporosis is a growing major health problem with medical, social, and economic burden. The pathogenesis of osteoporosis involves excessive bone resorption by osteoclasts and decreased new bone formation by osteoblasts. Early diagnosis is the key to minimize the impact of osteoporosis on patients. Dual-energy X-ray absorptiometry at the hip or spine is the main standard test for measuring bone mineral density, and according to the World Health Organization, the T-score value of –2.5 or less determines osteoporosis.

Aim:

In this work, we aimed to study the risk factors associated with osteoporosis among a population sample of osteoporotic and controls in the United Arab Emirates (UAE) and relate them to the T-score value.

Material and Methods:

Two hundred male and female participants were recruited in the study. A questionnaire was used and data were correlated with the T-score value of the participants.

Results:

Results showed a positive correlation between the T-score value of the patients with osteoporosis and their calcium intake, exercise duration, and the age at menopause of female patients, whereas a negative correlation was evident between the T-score value and both caffeine and nicotine consumption. Results also revealed that patients with osteoporosis have significantly low body mass index, low calcium intake, and shorter duration of exposure to the sun than the control group.

Conclusion:

In conclusion, more intervention should be directed toward changing the modifiable risk factors in patients with osteoporosis and more studies should be directed toward osteoporosis in the UAE.

Concurrent Bilateral Anterior Tibial Stress Fractures and Vitamin D Deficiency in an Adolescent Female Athlete: Treatment With Early Surgical Intervention

Case: A 16-year-old African American multi-sport female athlete presents with bilateral worsening activity-related leg pain for 5 months. Multiple bilateral anterior tibial diaphyseal stress fractures and significant vitamin D deficiency were identified. She was treated with a combination of vitamin D supplements and static intramedullary nailing of the bilateral tibias resulting in clinical and radiographic healing and return to sports. Discussion: Vitamin D deficiency and high level of activity in a young athlete may be the etiology to atypical multiple stress fractures. In athletes who may want to return to sport rapidly, early operative intervention and correction of vitamin D deficiency may be treatment options. Level of Evidence: Level V- case report.

The Possibility of Applying the Vitamin D Brief Food Frequency Questionnaire as a Tool for a Country with No Vitamin D Data in Food Composition Tables

Although the role of vitamin D is well known, the possibility of assessing its intake may be constricted in countries with no vitamin D data in food composition tables, as in the case of Croatia. The aim of the presented study was to adjust the VIDEO-FFQ (Vitamin D Estimation Only-Food Frequency Questionnaire), previously validated in Poland, to the Croatian population and to assess the validity and reproducibility of the adjusted Cro-VIDEO-FFQ (Croatian-VIDEO-FFQ). The study involved a group of Croatian women aged 20⁻30 and the Polish questionnaire was adjusted for a population due to similarities of the nutritional habits between countries. 106 individuals were recruited and 63 completed all the stages of the study. Participants conducted a 3-day dietary record and filled out the Cro-VIDEO-FFQ1 (first stage), as well as the same questionnaire (Cro-VIDEO-FFQ2) 6 weeks after (second stage). The following vitamin D intakes were observed in the studied group: 1.9 µg (0.2⁻8.0 µg) for 3-day dietary record, 3.3 µg (1.1⁻10.6 µg) for Cro-VIDEO-FFQ1, 3.6 µg (1.4⁻7.8 µg) for Cro-VIDEO-FFQ2. The Bland-Altman indexes in assessment of validity and reproducibility were 4.8% and 6.3%, respectively, with mean differences of 0.55 µg and 0.12 µg, as well as limits of agreement -0.91⁻2.01 µg and -0.44⁻0.69 µg. The kappa coefficient indicated a fair agreement for validity (0.21) and substantial for reproducibility (0.62), while correlations were significant (p = 0.0027, r = 0.37 for validity; p < 0.0001, r = 0.80 for reproducibility). It was observed that VIDEO-FFQ may be adjusted as a simple tool to assess vitamin D intake in a population with no vitamin D data in food composition tables, while Cro-VIDEO-FFQ may be a valid tool for nutritional assessment in Croatia.