The Effect of Clothing on Vitamin D Status, Bone Turnover Markers, and Bone Mineral Density in Young Kuwaiti Females

Structural diversification of vitamin D using microbial biotransformations

Vitamin D deficiencies are linked to multiple human diseases. Optimizing its synthesis, physicochemical properties, and delivery systems while minimizing side effects is of clinical relevance and is of great medical and industrial interest. Biotechnological techniques may render new modified forms of vitamin D that may exhibit improved absorption, stability, or targeted physiological effects. Novel modified vitamin D derivatives hold promise for developing future therapeutic approaches and addressing specific health concerns related to vitamin D deficiency or impaired metabolism, such as avoiding hypercalcemic effects. Identifying and engineering key enzymes and biosynthetic pathways involved, as well as developing efficient cultures, are therefore of outmost importance and subject of intense research. Moreover, we elaborate on the critical role that microbial bioconversions might play in the a la carte design, synthesis, and production of novel, more efficient, and safer forms of vitamin D and its analogs. In summary, the novelty of this work resides in the detailed description of the physiological, medical, biochemical, and epidemiological aspects of vitamin D supplementation and the steps towards the enhanced and simplified industrial production of this family of bioactives relying on microbial enzymes. KEY POINTS: • Liver or kidney pathologies may hamper vitamin D biosynthesis • Actinomycetes are able to carry out 1α- or 25-hydroxylation on vitamin D precursors.

The effects of exposure to solar radiation on human health

This assessment by the Environmental Effects Assessment Panel (EEAP) of the Montreal Protocol under the United Nations Environment Programme (UNEP) evaluates the effects of ultraviolet (UV) radiation on human health within the context of the Montreal Protocol and its Amendments. We assess work published since our last comprehensive assessment in 2018. Over the last four years gains have been made in knowledge of the links between sun exposure and health outcomes, mechanisms, and estimates of disease burden, including economic impacts. Of particular note, there is new information about the way in which exposure to UV radiation modulates the immune system, causing both harms and benefits for health. The burden of skin cancer remains high, with many lives lost to melanoma and many more people treated for keratinocyte cancer, but it has been estimated that the Montreal Protocol will prevent 11 million cases of melanoma and 432 million cases of keratinocyte cancer that would otherwise have occurred in the United States in people born between 1890 and 2100. While the incidence of skin cancer continues to rise, rates have stabilised in younger populations in some countries. Mortality has also plateaued, partly due to the use of systemic therapies for advanced disease. However, these therapies are very expensive, contributing to the extremely high economic burden of skin cancer, and emphasising the importance and comparative cost-effectiveness of prevention. Photodermatoses, inflammatory skin conditions induced by exposure to UV radiation, can have a marked detrimental impact on the quality of life of sufferers. More information is emerging about their potential link with commonly used drugs, particularly anti-hypertensives. The eyes are also harmed by over-exposure to UV radiation. The incidence of cataract and pterygium is continuing to rise, and there is now evidence of a link between intraocular melanoma and sun exposure. It has been estimated that the Montreal Protocol will prevent 63 million cases of cataract that would otherwise have occurred in the United States in people born between 1890 and 2100. Despite the clearly established harms, exposure to UV radiation also has benefits for human health. While the best recognised benefit is production of vitamin D, beneficial effects mediated by factors other than vitamin D are emerging. For both sun exposure and vitamin D, there is increasingly convincing evidence of a positive role in diseases related to immune function, including both autoimmune diseases and infection. With its influence on the intensity of UV radiation and global warming, the Montreal Protocol has, and will have, both direct and indirect effects on human health, potentially changing the balance of the risks and benefits of spending time outdoors.

Assessment of the vitamin D status and its determinants in young healthy students from Palestine

The global prevalence of vitamin D deficiency is high. Poor vitamin D status, especially in women, has been reported in several countries in the Middle East despite adequate year-round sunlight for vitamin D synthesis. However, data on vitamin D status in Palestine are scarce. The aim of this cross-sectional study was to evaluate vitamin D status based on serum concentrations of 25-hydroxycholecalciferol [25-(OH)D] among young healthy Palestinian students (18-27 years) and to assess associations between 25-(OH)D concentrations and several predictors. The mean 25-(OH)D concentration of women (n 151) was 27⋅2 ± 14⋅5 nmol/l, with the majority having insufficient (31⋅1 %) or deficient (<60 %) 25-(OH)D status. Only 7 % of women achieved sufficient or optimal 25-(OH)D status. In contrast, men (n 52) had a mean 25-(OH)D concentration of 58⋅3 ± 14⋅5 nmol/l, with none classified as deficient, and most obtaining sufficient (55⋅8 %) or even optimal 25-(OH)D status (11⋅5 %). Among women, 98 % wore a hijab and 74 % regularly used sunscreen. Daily dietary vitamin D intake (3-d 24-h recalls) was 45⋅1 ± 36⋅1 IU in the total group (no sex differences). After adjustment, multiple linear regression models showed significant associations between 25-(OH)D concentrations and the use of supplements (B = 0⋅069; P = 0⋅020) and dietary vitamin D (B = 0⋅001; P = 0⋅028). In gender-stratified analysis, the association between supplement use and 25-(OH)D concentrations was significant in women (B = 0⋅076; P = 0⋅040). The vitamin D status of women in the present cohort is critical and appears to be mainly due to wearing a hijab, regular use of sunscreen and low dietary vitamin D intake. The vitamin D status of the women should be improved by taking vitamin D containing supplements or fortified foods.

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.

Bone mass in Saudi women aged 20-40 years: the association with obesity and vitamin D deficiency

This study describes that low bone density is prevalent in premenopausal Saudi women, especially women of normal weight and vitamin D deficiency. Although BMD is higher in obese young women, this may not be beneficial later in life in conjunction with persistent vitamin D deficiency.

INTRODUCTION

Not attaining peak bone mass is one crucial factor contributing to the risk of developing osteoporosis and suffering fractures in later life. The objectives of this study were to describe the normal range of bone mineral density (BMD) and bone mineral content (BMC) in premenopausal Saudi women in relation to obesity and vitamin D insufficiency.

METHODS

A cross-sectional study involving 312 healthy Saudi women aged 20-40. All women were clinically examined. BMD (g/cm²) and BMC (g) assessed at total body (TB), femoral neck (FN) and lumbar spine (LS) were performed using dual-energy X-ray absorptiometry (DXA). Obesity was defined as BMI ≥ 30 kg/m² and vitamin D deficiency defined as 25(OH)D < 50 nmol/L.

RESULTS

Almost half of the studied women were obese, and the majority (86.2%) were deficient in vitamin D. Mean BMD in TB 1.060 ± 0.091, FN 0.918 ± 0.153 and LS 1.118 ± 0.123 g/cm², while TB-BMC 2077 ± 272 g. When classified by BMI, the proportion with low bone density was 2-3 times higher among the normal weight compared to the obese women, p < 0.001. In the cohort overall, ~ 19% of these young premenopausal women had osteopenia or osteoporosis at the femoral neck, but 26% in normal weight, vitamin D deficient women.

CONCLUSION

This study shows low bone density in premenopausal Saudi women, particularly those with normal weight. While obesity appears to confer some protection against vitamin D deficiency at this age, this is assumed to change in later life.

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.

Vitamin D Deficiency and Associated Risk Factors in Muslim Housewives of Quetta, Pakistan: A Cross-Sectional Study

Background Vitamin D (Vit-D) plays a central role in calcium homeostasis and maintains skeletal integrity. Housewives in Quetta, Pakistan are at increased risk of vitamin D deficiency (VDD). They spend a greater part of their day in cleaning, washing, cooking, managing daily groceries, and other household chores. Thus, little time is left for self-care and outdoor activities. They wear hijab and have very little exposure to sunlight. In addition, their diet is deficient in Vit-D-rich food items, rendering them at high risk of VDD. Fear of getting tanned, melasma, and preference for a fair complexion further limit their sun exposure. This study evaluates the prevalence of VDD in housewives and determines its various risk factors to recommend screening guidelines for VDD. Methods A cross-sectional study was performed between November 2020 and April 2021 and recruited housewives aged >18 from the outpatient department of a tertiary care hospital in Quetta. Informed consent was obtained from all participants. VDD was defined as a serum 25(OH)-D level <20 ng/mL (50 nmol/L). Sociodemographic variables and information about the dietary habits, perception, attitudes towards sunlight, and daily duration of sunlight exposure were collected. Mean and standard deviation (SD) were calculated for continuous variables and counts, and proportions were calculated for categorical variables like education, age. Univariate and multivariate logistic regression analyses were performed to determine the risk factors and associations of VDD. Data were analyzed by SAS/STAT software (version 9.4). Results Among 151 housewives, 58.9% of housewives had VDD. VDD group had a higher proportion of females aged 18-30 years and a lower proportion of graduates. The reported use of Vit-D supplements was much lower in the VDD group compared with the non-deficient group, 38.2% versus 71.0 %, P-value <0.001. History of fragility fractures was reported by 10.1% of housewives in the VDD group compared to 4.8% in the non-deficient group, P-value: 0.03. Around 77.5% of housewives in the VDD group spent 15 minutes or less outdoors versus 51.6% in the non-deficient group; 55.1% of housewives in the VDD group reported that they never consumed milk versus 17.7 % in the non-deficient group, P-value <0.00001. In the univariate logistic regression model, housewives with an 11-12th grade of education had 4.80-fold higher odds of VDD compared to those who had undergraduate or graduate degrees (OR: 4.80, 95 % CI: 1.07-21.45). Housewives who never consumed milk had 9.72-fold (95 % CI: 3.69-25.58) higher odds of VDD compared to those who consumed milk on daily basis. Odds of VDD were 3.61-fold (95% CI: 1.06-12.31) higher in those who never consumed fish as compared to those who ate fish at least 1-2 days/week. In multivariate logistic regression, age group 18-30 (OR: 17.07, 95% CI: 1.18-246.86), and never consuming milk (OR: 7.33, 95 % CI: 1.99-26.89) were independently associated with VDD. Conclusion VDD is highly prevalent (58.9%) in housewives of Quetta. It is the need of time to increase awareness regarding the health benefits, sources, and deficiency symptoms of Vit-D. Our study revealed VDD in housewives irrespective of education and income. Dietary supplementations were greater predictors of VDD. Daily sun exposure should be encouraged, and food items should be fortified with Vit-D. Recommendations for Vitamin D screening would be a good step, especially in Muslim housewives.

Biochemical characteristics and calcium and PTH levels of patients with high normal and elevated serum 25(OH)D levels in Turkey: DeVIT-TOX survey

Vitamin D intake over the recommended dose is usually associated with high serum 25(OH)D levels and generally not associated with symptoms of hypercalcemia. High doses of cholecalciferol need to be avoided to protect against vitamin D toxicity and related complications. Strict adherence to the clinical guidelines for treating vitamin D deficiency can ensure safe and effective treatment.

PURPOSE

We observed a tendency to use high doses of cholecalciferol for vitamin D deficiency treatment or vitamin D supplementation. We aimed to determine the biochemical characteristics of patients with high normal and elevated serum 25(OH)D levels.

METHODS

An online invitation was sent to all tertiary endocrinology clinics in Turkey to complete an online retrospective survey (DeVIT-TOX Survey) for patients diagnosed with high serum 25(OH)D levels (> 88 ng/mL) between January 2019 and December 2019. The patients were evaluated according to the presence of signs and symptoms of hypercalcemia and doses of vitamin D intake, evaluated into the following three groups according to their 25(OH)D levels: group 1, > 150 ng/mL; group 2, 149-100 ng/mL; and group 3, 99-88 ng/mL.

RESULTS

A total of 253 patients were included in the final analysis (female/male: 215/38; mean age, 51.5 ± 15.6 years). The average serum 25(OH)D level was 119.9 ± 33 (range, 88-455) ng/mL, and the average serum calcium level was 9.8 ± 0.7 (range, 8.1-13.1) mg/dL. Most (n = 201; 75.4%) patients were asymptomatic despite having high serum 25(OH)D and calcium levels. The serum 25(OH)D level was significantly higher in the symptomatic groups than in the asymptomatic groups (138.6 ± 64 ng/mL vs. 117.7 ± 31 ng/mL, p < 0.05). The most common cause (73.5%) associated with high serum 25(OH)D levels was the inappropriate prescription of a high dose of oral vitamin D (600.000-1.500.000 IU) for treating vitamin D deficiency/insufficiency in a short time (1-3 months). The cut-off value of 25 (OH) D level in patients with hypercalcemia was found to be 89 ng/mL [median 116.5 (89-216)].

CONCLUSIONS

High dose of vitamin D intake is associated with a high serum 25 OH D level, without symptoms of hypercalcemia. Inappropriate prescription of vitamin D is the primary cause for elevated 25(OH) D levels and related hypercalcemia. Hypercalcemia may not be observed in every patient at very high 25(OH) D levels. Adherence to the recommendation of guidelines is essential to ensure safe and effective treatment of vitamin D deficiency.

Development of chemiluminescence method based on serum type I collagen hydroxyl terminal peptide β special sequence (β-CTX)

The objective of this work is to develop and verify the analytical performance of a chemiluminescence immunoassay for the specific sequence β-carboxy-terminal cross-linking telopeptide of type I collagen (β-CTX) in human serum. Two specific monoclonal antibodies (mAb-8A03 and mAb-3D12) with high affinity for β-CTX were selected, and, under optimized conditions, a chemiluminescence immunoassay method (CLIA) for β-CTX was established. The CLIA of β-CTX detected β-CTX in a wide range of 2.0-6000 ng/L. The recovery rate in serum is 95-105%, the specificity is high, and the cross-reaction rate with common easily interfering substances is low (not more than 0.01%). The CLIA correlates well with Roche electrochemiluminescence immunoassay (ECLIA), with a correlation coefficient of 0.9551, which fully meets the requirements of clinical analysis. The developed β-CTX CLIA kit has high sensitivity and good stability. It has the same performance as the commercial Roche ECLIA kit and can be applied clinically.

Vitamin D Metabolic Profiles in Premenopausal Women Wearing Niqab and Hijab in Sunny Basrah

Background Conservative clothing like niqab and hijab may affect the wearer's vitamin D metabolic parameters even in predominantly sunny areas of the world (i.e., areas with adequate sunlight exposure throughout the year). Our objective was to evaluate the effect of wearing the niqab or hijab on different vitamin D3 metabolic parameters in a sample of premenopausal women from Basrah. Methodology This was a cross-sectional observational study on premenopausal women who wore a niqab (n = 64), with a comparable age-matched group of women who wore the hijab (n = 60). Biochemical evaluation of the vitamin D3 metabolic profile involved 25-hydroxycholecalciferol (25-OH)-vitamin D, corrected serum calcium, parathyroid hormone (PTH), phosphorus, and alkaline phosphatase estimation. Statistical comparison of these parameters was made using the independent sample t-test and Mann-Whitney-U test. Results The two groups of women were age- and weight-matched, with a median age of 39 and median body mass index (BMI) of 31.8 kg/m2. Overall, age, marital status, and BMI of women in both groups had no significant relationship with the vitamin D3 metabolic parameters (low 25-OH-vitamin D, low corrected calcium, and high PTH). The subgroup analysis for women wearing the niqab showed the same results. Conclusions Wearing niqab or hijab in premenopausal women was not associated with any significant statistical relationship or difference in vitamin D3 metabolic parameters. Conservative dress styles like niqab and hijab are practical barriers to sun exposure and contribute to suboptimal vitamin D levels, affecting subsequent metabolic pathways. Healthcare professionals should advise women who wear niqab or hijab to increase their vitamin D3 levels through culturally appropriate alternative mechanisms.

Physical Determinants of Vitamin D Photosynthesis: A Review

Vitamin D synthesis by exposure of skin to solar ultraviolet radiation (UVR) provides the majority of this hormone that is essential for bone development and maintenance but may be important for many other health outcomes. This process, which is the only well-established benefit of solar UVR exposure, depends on many factors including genetics, age, health, and behavior. However, the most important factor is the quantity and quality of UVR reaching the skin. Vitamin D synthesis specifically requires ultraviolet B (UVB) radiation that is the minority component (<5%) of solar UVR. This waveband is also the most important for the adverse effects of solar exposure. The most obvious of which is sunburn (erythema), but UVB is also the main cause of DNA damage to the skin that is a prerequisite for most skin cancers. UVB at the Earth's surface depends on many physical and temporal factors such as latitude, altitude, season, and weather. Personal, cultural, and behavioral factors are also important. These include skin melanin, clothing, body surface area exposed, holiday habits, and sunscreen use. There is considerable disagreement in the literature about the role of some of these factors, possibly because some studies have been done by researchers with little understanding of photobiology. It can be argued that vitamin D supplementation obviates the need for solar exposure, but many studies have shown little benefit from this approach for a wide range of health outcomes. There is also increasing evidence that such exposure offers health benefits independently of vitamin D: the most important of which is blood-pressure reduction. In any case, public health advice must optimize risk versus benefit for solar exposure. It is fortunate that the individual UVB doses necessary for maintaining optimal vitamin D status are lower than those for sunburn, irrespective of skin melanin. © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC. on behalf of American Society for Bone and Mineral Research.

Risk factors of multiple sclerosis in Aseer region, Kingdom of Saudi Arabia A case-control study

OBJECTIVES

To investigate socio-demographic and environmental risk factors of multiple sclerosis (MS) in Aseer region, Kingdom of Saudi Arabia (KSA).

METHODS

This was a retrospective, record, and interview based matched case control study completed in the neurology clinics at tertiary hospitals in Aseer, KSA. It included 82 MS cases and 82 controls. The study used a structured questionnaire to collect information on key socio-demographic and environmental exposures. The main outcome measure was a statistically significant relationship of key socio-demographic and environmental risk factors with MS.

RESULTS

A total of 82 registered patients, 50 were females, resulting in a female to male ratio of 1.56:1. Various risk factors were found to have a statistically significant association with MS which included female (OR=3.01, 95% CI [1.59:5.69]; p<0.001), family history of MS (OR=2.1, 95%CI [2.4:1.7] p=0.04), low exposure to sunlight (OR=2.02, 95%CI [2.53: 9.9] p<0.001), only fed breast milk in childhood (OR=0.46, 95%CI [0.55:0.39]; p<0.001), parental consanguinity (OR=2.17 95%CI [4.11:1.14] p=0.017), history of chickenpox (OR=15.59 95% CI [68.7:3.55]; p<0.01). On using multiple logistic regression, chicken pox infection (AOR=0.045, 95%CI [0.015-0.135]; p=0.001)and low sun-exposure (AOR=.271, 95%CI [.121-.609]; p<0.05) were deduced as the predictors of MS in this region.

CONCLUSION

This study offers unique insights into the risk factors of MS. Low sun exposure and childhood chickenpox are significantly related to the development of MS in the Aseer region.

Poor dietary consumption and limited sun exposure are risk factors for vitamin D deficiency in premenopausal Kuwaiti women: A cross-sectional study

Background: Low serum vitamin D levels are reported constantly among females living in the Arabian Gulf countries, presumably due to their lifestyle, which limits direct sun exposure. Because Vitamin D deficiency has been implicated in a wide range of ailments, healthy females with the deficiency might be at risk for developing many health problems. Thus, the aim was to assess lifestyle risk factors for vitamin D deficiency in healthy women in Kuwait. Methods: A total of 104, disease-free, premenopausal women were recruited for assessment of their serum 25OHD and intact PTH levels. Physical examination, blood withdrawal and interviewer-administered questionnaires were used to collect the relevant data. Associations were detected statistically using nonparametric tests and logistic regression was used to identify risk factors for vitamin D deficiency. Results: Vitamin D deficiency ( < 25 nmol/L) occurred in 84.6%, and hyperparathyroidism ( ≥ 6.9 pmol/L) occurred in 25% of women, among which all were vitamin D deficient. Significant risk factors of vitamin D deficiency were nondaily milk intake (OR:25, CI%:4.2-147), no fish intake (OR:5, CI%:1-22.8), and no weekend sun exposure (OR:8.2, CI%:1.28-52.6). Having PTH ≥ 6 pmol/L was also associated with a higher likelihood of having vitamin D deficiency. Conclusion: Vitamin D deficiency is very common in disease-free, premenopausal Kuwaiti women and can be avoided by improving food consumption and obtaining more sun exposure.