Vitamin D status in Saudi school children based on knowledge

Nutraceutically-enhanced oral delivery of vitamin D3 via Bio-SNEDDS: Demonstrating in vivo superiority over pediatric formulations

BACKGROUND

Vitamin D3 (VD3) deficiency among children in Saudi Arabia remains a pressing concern due to its poor bioavailability and the limitations of current pediatric formulations. To address this challenge, we developed a groundbreaking pediatric self-nanoemulsifying drug delivery system (Bio-SNEDDS) for VD3, fortified with black seed oil and moringa seed oil for dual therapeutic benefits. Through meticulous formulation optimization using ternary phase diagrams and comprehensive testing, our Bio-SNEDDS demonstrated exceptional performance.

METHODS

Bio-SNEDDS were manufactured by incorporating Black seed oil and moringa seed oil as bioactive nutraceutical excipients along with various cosurfactant and surfactants. Bio-SNEDDS were systematically optimized through ternary phase diagrams, visual tests, droplet size analysis, drug solubilization studies, dispersion assessments, and pharmacokinetic testing in rats compared to Vi-De 3®.

RESULTS

Pseudoternary phase diagrams identified oil blends producing large nanoemulsion regions optimal for SNEDDS formation. The optimized F1 Bio-SNEDDS showed a mean droplet diameter of 33.7 nm, solubilized 154.46 mg/g VD3 with no metabolite formation, and maintained >88% VD3 in solution during 24 h dispersion testing. Notably, in vivo pharmacokinetic evaluation at a high VD3 dose demonstrated an approximately two-fold greater relative bioavailability over Vi-De 3®, validating the superb oral delivery performance of Bio-SNEDDS even under challenging high-dose conditions.

CONCLUSIONS

The Bio-SNEDDS provides an effective VD3 delivery strategy with established in vivo superiority over marketed products, along with offering additional health benefits from the natural oils.

Seasonal Variations in 25-Hydroxyvitamin D Levels among Pediatric Patients Attending the Healthcare Centre

Vitamin D plays an essential role in maintaining bone density, building the immune system, and regulating cell growth alongside other key biological functions. Limited data are available about the seasonal variation in vitamin D levels in the pediatric population in Saudi Arabia. This study aimed to investigate the seasonal influence on the pediatric circulating levels of 25(OH)D. A total of 1790 pediatric outpatients who visited the University healthcare centre were included in this study. Overall, there was a noticeably high prevalence (69%) of both combined 25(OH)D deficiency and insufficiency. The highest mean serum concentration of 25(OH)D was recorded in summer (29 ng/mL) and autumn (27 ng/mL). The deficient and insufficient categories were predominant, accounting for 33% and 36%, respectively. Comparable patterns were recorded during autumn, winter, and spring. Interestingly, the 25(OH)D level was significantly associated with the four seasons (p = 0.001), with females having a higher prevalence of 25(OH)D deficiency in the spring and summer than males. Furthermore, only in autumn and winter, we found a significant association between gender and 25(OH)D status (p < 0.001 for both). Another association between nationality and the circulating levels 25(OH)D was found during autumn and winter (p < 0.001 and p = 0.01), respectively. In all seasons, age had a negative impact on serum (OH)D levels. However, this relationship was statistically significant (p < 0.05) only in summer, autumn, and winter. Gender was a significant predictor, with 25(OH)D levels in autumn and winter and an odds ratio of 1.67 in autumn and 2 in winter, indicating that being men had a positive influence on circulating 25(OH)D levels. There were highly significant differences in 25(OH)D concentrations among different age categories. The Saudi population experiences low levels of vitamin D, particularly in autumn and winter periods. This study showed that seasonality, age category, nationality, and gender influence vitamin D status, suggesting the need for tailored intervention and monitoring of 25(OH)D status to reach adequate levels of vitamin D. Healthcare practitioners and policymakers may consider the interplay between age, nationality, gender, and seasonal variations when addressing vitamin D status and a targeted supplementation approach for high-risk groups that may develop health issues.

Nutritional Rickets Among Children: A Retrospective Study from Saudi Arabia

Background

Nutritional rickets remains a significant concern in certain countries, with increasing prevalence attributed to factors such as limited sunlight exposure and undernourishment. This study aimed to identify the factors associated with rickets due to nutritional deficiency in children from Jazan Province, southwestern Saudi Arabia.

Methods

A retrospective cross-sectional study was conducted using descriptive data from medical records at a tertiary hospital in Jazan Province. Records of patients diagnosed with rickets between January 2010 and December 2020 were analyzed. Symptomatic rickets cases from pediatric clinics were included, and diagnoses were based on biochemical and clinical tests. Risk factors were assessed using patient medical records. Data were analyzed using percentages, mean, and standard deviation.

Results

The study included 84 patients with rickets (53 females and 31 males), primarily between 11-18 years old. The mean body mass index (BMI) of the participants was 21.21. The most common risk factor was nutritional deficiencies, including vitamin D deficiency or calcium deficiency, with 75 patients reporting a family history of vitamin D deficiency. The children had limited sunlight exposure and low levels of calcium and vitamin D. Malnutrition was identified as the highest risk factor for rickets in the study population.

Conclusion

Nutritional rickets appears to be prevalent in the Jazan Province, emphasizing the need for government organizations to address this preventable disease. Adequate sun exposure and recommended dietary vitamin D intake are crucial to prevent rickets, as this study detected inadequate levels of calcium and vitamin D in children. National studies are required to further identify risk factors and develop appropriate strategies.

Vitamin D Knowledge, Awareness, and Attitudes of Adolescents and Adults: A Systematic Review

INTRODUCTION

The aims of this systematic review were 2-fold: (1) evaluate the effect of vitamin D educational interventions on serum 25-hydroxyvitamin D (25-OHD) concentration in adolescents (aged 10-19 years) and adults, and (2) assess the association between serum 25-OHD concentration and vitamin D knowledge, awareness of vitamin D deficiency risk, and attitudes toward behaviors associated with acquiring vitamin D.

METHODS

Medline, CINAHL, Embase, and SPORTDiscus were systematically searched for studies reporting associations between serum 25-OHD concentration and vitamin D knowledge, awareness, and attitudes. Results were summarized narratively. Effect sizes were calculated when data were available.

RESULTS

Eight studies reported experimental effects (2 randomized controlled trials, 1 cluster randomized trial, 4 quasi-experiments, 1 clinical audit), and 14 reported cross-sectional associations. Seven of 8 interventions reported no effect of educational interventions on serum 25-OHD concentration. A slight majority (53%; κ = 19) of studies reported statistically significant associations between serum 25-OHD concentration and vitamin D knowledge and attitudes.

IMPLICATIONS FOR RESEARCH AND PRACTICE

The few educational interventions employed to increase serum 25-OHD concentration lack effectiveness. Future studies may use randomized controlled trial designs, enroll those at risk for vitamin D insufficiency and underrepresented in the literature, increase the salience of the information to the target population, and include safe sun exposure recommendations.

Vitamin D and iron deficiencies among Saudi children and adolescents: A persistent problem in the 21st century

BACKGROUND

Although several studies have reported on the prevalence of micronutrients in Saudi Arabia, most frequently vitamin D and iron, they are either old or hospital- or primary health care center-based. The objectives of our study were to provide more updated data on the prevalence rate of micronutrients deficiency among the Saudi general pediatric population and to determine if there is an association between micronutrients deficiency and undernutrition.

METHODS

The present study is part of a cross-sectional mass screening study, "Exploring the Iceberg of Celiacs in Saudi Arabia" conducted among school-aged children (6-16 years) in 2014-2015. A sample of 7,931 children aged 6-16 years was randomly selected. We identified thin children [body mass index (BMI) z-score <-2 SD, for age and gender], using the WHO reference 2007. A case-control study was performed, where the sera of 182 thin children (cases) and 393 normal BMI children (controls) were tested for levels of iron, ferritin, vitamin D, zinc, selenium, and copper.

RESULTS

The prevalence of thinness was 3.5%. The two most common micronutrients deficient among Saudi children with normal BMI were iron (20%) and vitamin D (78%). Vitamin D levels were significantly higher among boys as compared to girls (39.6 nmol/L vs. 31.15 nmol/L; P < 0.001). Deficiency of copper, zinc, and selenium occurred in 0.25%, 1%, and 7.4% of the children with normal BMI. Comparisons between the cases and controls did not show statistically significant differences.

CONCLUSION

Vitamin D and iron deficiencies are still common forms of malnutrition in the Saudi community, that have remained unchanged over the past 20-30 years, while the intake of trace elements (zinc, copper, and selenium) is adequate as evident by normal serum levels in the vast majority of the investigated children. We could not observe a correlation between undernutrition and micronutrient deficiencies.

Evaluation of the knowledge regarding vitamin D, and sunscreen use of female adolescents in Iran

BACKGROUND

Vitamin D (Vit D) deficiency/insufficiency is an important risk factor for several chronic conditions. We aimed to evaluate the knowledge and behavior of female adolescents with respect to the association between sunlight exposure, sunscreen use, and Vit D status.

METHODS

This cross-sectional survey was performed in northeastern Iran, among 940 female adolescents in January 2015. Each subject completed a questionnaire containing items about demographic characteristics, knowledge about Vit D and their use of sunscreen. Serum Vit D levels were measured using an electrochemiluminescence method and dietary intake of Vit D was assessed using a Food Frequency Questionnaire. Statistical analyses were conducted using SPSS software. A P value < 0.05 was considered statistically significant.

RESULTS

Few of the participants were aware of the biological functions of Vit D (8.8%), the causes of Vit D deficiency (16.7%), and the sources of Vit D (9.3%). Less than half of the participants used sunscreen during the day. The serum levels of Vit D in subjects who used sunscreen were significantly lower than those who did not (p = 0.004). However, there was no significant association between their knowledge about Vit D and serum Vit D, or dietary intake of Vit D.

CONCLUSION

There appears to be a lack of coherence between lifestyle, behavior and knowledge that may affect the Vit D status of adolescent girls in northeastern Iran. This information provides a basis for developing public health planning (workshops or training at the college level) for the prevention of Vit D deficiency especially in adolescent girls.

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.

Study of low vitamin D among children with anorexia in Sulaymaniyah, Kurdistan region, Iraq during summer months

Objectives:

To determine the impact of vitamin D deficiency and insufficiency on the development of anorexia in children with mild malnutrition without an obvious cause.

Methods:

This cross-sectional study was conducted in Faruk Medical City, Sulaymaniyah, Kurdistan Region, Iraq, between May and September 2018. It included 39 mildly malnourished children with a poor appetite for over 3 months and 156 children who were healthy except for minor illnesses as the control group. All the children were regular attendees at the outpatient clinic and were tested for serum levels of 25-hydroxy vitamin D. We used binary logistic regression statistical analysis to measure the significance of the association between vitamin D deficiency/insufficiency and anorexia with mild malnutrition in young children.

Results:

Of the 39 children in the anorexia group, 20 had vitamin D deficiency, and the remaining 6 had vitamin D insufficiency. On the other hand, 16 of the remaining children with normal appetites, showed a vitamin D deficiency, and 38 of them displayed insufficiency. Statistically significant association between vitamin D deficiency and anorexia with malnutrition was noted (odd ratio: 9.808; 95% confidence interval: 4.089 - 23.523; p=0.0001), while it was insignificant with vitamin D insufficiency.

Conclusion:

This study displayed a noteworthy relationship between vitamin D deficiency and anorexia with mild malnutrition in young children.

An Investigation of Vitamin Levels Status in the Serum of Children in China

This study was to investigate the vitamin levels in the serum of children in the Northeast of China and some factors associated with the vitamin levels. The sera were obtained from 2096 normal children aged 1 month to 12 years in the Northeast of China. Vitamins A and E were detected using their sera by HPLC, and the level of vitamin D was detected by LC-MS. The 20 overweight children were chosen from the 7-8 age range and took additional vitamins studies for extra 3 months. The data were analyzed by IBM SPSS Statistics 21. The average levels of vitamins A, D, and E in sera samples from the 2096 children were 0.2715mg/L (95%CI, 0.2715-0.2791mg/L), 26.2848μg/L (95%CI, 25.7900-26.7786μg/L), and 8.6137mg/L (95% CI, 8.5077-8.7198mg/L), respectively. The percentages of vitamins A, D, and E deficiency were 19.61%, 47.47%, and 0.62%, respectively. For 20 children from the VDD or VAD groups, after giving them more VA and VD for 3 months, the levels of VA and VD in the sera were increased significantly; however, the average BMI has barely changed. According to our finding, vitamin D deficiency was severe, vitamin A deficiency was common, and vitamin E was insufficient in the sera of children in the Northeast of China. The levels of vitamins A, D, and E were correlated with age and overweight.

Efficacy of different modes of vitamin D supplementation strategies in Saudi adolescents

Vitamin D deficiency is rampant in the Middle East, even in children and adolescents. This study was designed to investigate the effects of different vitamin D repletion strategies commonly used on serum vitamin D levels of Saudi adolescents.

STUDY DESIGN

A 6-month multi-center, controlled, clinical study, involving 34 schools in the central region of Riyadh, Saudi Arabia. Different strategies of vitamin D supplementation were tested (200 ml fortified milk of different brands or vitamin D tablet (1,000IU). Anthropometrics were taken and fasting blood samples withdrawn at baseline and after intervention for the quantification of serum glucose, lipid profile and 25(OH) vitamin D. A significant increase in 25(OH)D level was observed in subjects supplemented with vitamin D tablet, milk brand 2 and milk brand 4, whereas subjects supplied with fortified milk brands 1 and 3 respectively, exhibited a significant decrease in 25(OH)D levels. Analysis of covariance showed that after adjusting for baseline 25(OH)D, age, gender and BMI, the mean 25(OH)D levels of children who were taking vitamin D tablet (9.1 ± 0.8 nmol/l) and milk brand 4 were significantly higher (7.3 ± 1.1 nmol/l) than children taking milk brand 2 (1.6 ± 1.0 nmol/l). Subjects supplied with milk brands 1 and 2 exhibited a significant increase in total cholesterol level, while it dropped significantly in subjects taking milk brand 3, while no changes were observed in other groups. Different strategies in vitamin D supplementation used in this clinical study elicited varying degrees of improvement in serum 25(OH)D level. The observed outcomes were dependent on the strategy and gender in the Saudi adolescent population, with oral tablet supplementation being favored in boys.

Factors associated with dietary supplement use in Saudi pregnant women

Background

The aim was to investigate the prevalence of dietary supplement use among pregnant Saudi women and its associations between various demographics.

Methods

In this cross-sectional study, a total of 137 pregnant women attending prenatal care from King Salman Hospital completed a self-administered questionnaire including socio-demographic characteristics, general awareness, attitude and behavior towards use of dietary supplements during pregnancy.

Results

Dietary supplement use among Saudi women in pregnancy was high (71.5%) and was significantly associated with level of education (p = 0.005), family income (p = 0.039) and number of children (p = 0.007). No significant association was observed between neonatal health outcomes and dietary supplement use during pregnancy. In all participants, 81.6% believed that supplement use is important for nutritional status and more favorable neonatal outcomes. For the majority of participants, the primary source of information for dietary supplement use was a doctor’s advice. The majority of the participants [65.7% (n = 90)] responded that dietary supplement use is safe. Folic acid was found to be the most common type of dietary supplement used (95.9%; n = 94); however, 53.1% (n = 52) did not take folic acid supplements 3 months prior to pregnancy. Other common supplements used were iron, calcium and vitamin D (88.8, 81.6, and 41%, respectively).

Conclusions

This study provided new information on dietary supplement use and its correlates in Saudi pregnant women. The prevalence of dietary supplement use was high in this group and was associated with socio-demographic and lifestyle characteristics.

Psychometric Properties of a Developed Questionnaire to Assess Knowledge, Attitude and Practice Regarding Vitamin D (D-KAP-38)

The aim of this study was to develop a valid and reliable questionnaire to assess vitamin D-related knowledge, attitude and practices in Tehranian adults, who may be at increased risk of vitamin D deficiency. This study was conducted on 572 individuals, aged ≥20 years from public health care centers in Tehran, Iran. Based on results of a literature review and in-depth interviews, the 38-item vitamin D-related KAP questionnaire (D-KAP-38) with four subscales was developed: (1) general knowledge; (2) nutritional knowledge; (3) attitudes; (4) behaviors. Validity of the D-KAP-38 questionnaire was assessed, utilizing face, content, and construct validity methods. Internal consistency was calculated to assess reliability of the current developed questionnaire. A total of 572 (54.1% female) adults, aged 30.2 ± 7.9 years, participated in the study. All items were perceived as relevant and comprehendible by participants. Content validity was confirmed by a panel of experts. The internal consistency, as measured by Cronbach's alpha coefficients, exceeded the minimum reliability standard of 0.60 for four subscales. Exploratory factor analysis suggested a four-factor construct and the results of the confirmatory factor analysis indicated acceptable fit indices for the proposed model. No ceiling effects were observed except for general knowledge (1.2%). Floor effects detected were 0%, 1.1%, 2.4%, and 8.7% for practice, attitude, general knowledge, and nutrition knowledge, respectively. General knowledge had the highest score (79.59 ± 14.52) and nutrition knowledge had the lowest (42.58 ± 20.40), among the four sub-scales. Results confirm the initial validity and reliability of D-KAP-38 questionnaire. Further investigations in different populations are recommended.

Impact of fortified biscuits on micronutrient deficiencies among primary school children in Bangladesh

BACKGROUND

Micronutrient deficiencies can compromise the development potential of school-aged children, and their later health and productivity as adults. School feeding and school-based fortification approaches have been utilized globally to redress nutritional deficiencies in this age group.

OBJECTIVE

We explored the acceptability and micronutrient impact of a Bangladesh Government supported school-based micronutrient fortification program for children attending rural primary schools in 10 disadvantaged sub-districts.

METHODS

We applied a mixed methods approach. The quantitative component assessed the impact of micronutrient fortification on 351 children aged 6-11 years using a cohort pre-post research design with a control group. The qualitative component explored the acceptability of the intervention using focus group discussions, body mapping and semi-structured interviews with teachers, school-going children and school authorities.

RESULTS

Daily consumption of fortified biscuits by primary school children had a significant positive impact on mean levels of iron, folic acid, vitamin B12, retinol and vitamin D controlling for sex, baseline deficiency status, CRP, and H. pylori. Levels of anemia and vitamin D deficiency were also significantly reduced. Qualitative findings indicated the widespread acceptability of the daily biscuit. Teachers perceived students to be more attentive in class, less tired, and some attributed better school performance to biscuit consumption. Children reported similar improvements in concentration and energy levels.

CONCLUSIONS

This study is among the first in Bangladesh to comprehensively assess a school-based fortification program in terms of its acceptability and impact on micronutrient status of children aged 6-11 years of age. While results strongly support this modality of school feeding, research on the cognitive impacts of micronutrient fortified biscuits will help clarify the case for scaled-up investments in school- based feeding program in Bangladesh and other low and middle income countries.

Celiac disease-related osteopathy among Saudi celiac patients: Are we adherent to recommendations?

BACKGROUND/AIMS

There are no reports from Saudi Arabia documenting the picture of osteopathy in celiac disease (CD) and the adherence of physicians to the guidelines and recommendations to screen for bone disease. We conducted this study to document the prevalence of CD-related osteopathy and the Saudi physicians' adherence to the screening recommendations.

PATIENTS AND METHODS

We identified the biopsy proven CD cases diagnosed between 2003 and 2012. In addition to demographic data, we collected laboratory (serum calcium, phosphate, alkaline phosphatase, 25-dihydroxy vitamin D, and parathyroid hormone levels) and imaging [Dual-energy X-ray absorptiometry (DEXA)] data. Vitamin D levels of <50 nmol/L and 50-<75 nmol/L defined deficiency and insufficiency, respectively. T score (of lumbar spine and femoral neck) of ≤-2.5 defined osteoporosis and a score of ≤-1 and >-2.5 defined osteopenia.

RESULTS

We identified 80 children and 128 adults with CD. Only 42% of children and 67% of adults had their serum vitamin D level measured. DEXA was ordered in 7% of children and 36% of adults. Vitamin D deficiency was widely prevalent and significantly higher in adults (95.3%) than children (76.3%). Low bone mass density (BMD) in adults was 86.9% (45.6% with osteopenia and 41.3% with osteoporosis).

CONCLUSIONS

We document low adherence of physicians to recommended guidelines to recommendations to screen for osteopathy in CD. Vitamin D deficiency and low BMD are highly prevalent among Saudi CD patients. This may be a reflection of the low vitamin D stores in the Saudi general population.

Assessment of vitamin D levels, awareness among Lebanese pharmacy students, and impact of pharmacist counseling

Vitamin D inadequacy, frequently underdiagnosed, affects people of all age groups worldwide. This prospective study aims at determining the percentage of inadequate vitamin D levels among students and evaluating the impact of pharmacist counseling on raising the awareness of the importance of sun exposure and adequate vitamin D intake. A total of 160 university students were recruited. Blood samples were taken to check the vitamin D, calcium, and phosphorous levels. Vitamin D levels ⩽30 ng/mL were defined as inadequate. Scores were given to the questions and aimed at gathering patient knowledge about vitamin D before and after pharmacist counseling. A total of 115 (71.87%) patients had vitamin D levels <30 ng/mL, with a mean vitamin D serum level of 16.80 ± 5.85 ng/mL. The mean level of calcium was 9.51 ± 1.23 mg/dL and, of phosphorus 3.62 ± 0.95 mg/dL. The mean difference in the knowledge score of the recommended daily amount of vitamin D before and after pharmacist counseling was 2.81 versus 5.88 (p < 0.001). Concerning patient education for diseases and drugs that affect vitamin D levels, pharmacist counseling was effective in raising the awareness (p < 0.001). Given that vitamin D inadequacy is linked to many disease progressions, it is important that health professionals provide interventional strategies and education measures to correct inadequate levels in patients of all age groups.