Osteoporosis as Perceived by Saudi Physicians: A Cross-Sectional Study of Quality of Practice and Current Barriers in Management

Background Osteoporosis (OP) is a state of abnormal bone quality and architecture that leads to fragility fractures, with lifetime costs reaching 16.27 billion Saudi Arabian Riyal (SAR). Methods An electronic survey was distributed to physicians from July 2020 to May 2021 to assess the quality of the practice of physicians toward OP and barriers in OP management in Saudi Arabia. Specialties included were endocrinology, general medicine, family medicine, primary care, orthopedic surgery, rheumatology, obstetrics and gynecology, and geriatrics. Results A total of 177 surveys were eligible (55.9% female and 44.1% male). The majority were family consultants (42.9%). In terms of knowledge, 18.1% of our sample recognized all risk factors, and 24.9% recognized all indications to assess bone density. A central dual-energy X-ray absorptiometry (DEXA) was accessible to only 49.4% of the sample. Over 80% of the sample performed comprehensive laboratory workup. Although 68.4% of participants were aware of fracture risk assessment (FRAX), 53.7% used it in their practice. The most cited barrier was a lack of physicians' awareness (80.2%), followed by a lack of patients' awareness (63.6%). The specialty was significantly associated with the awareness of the densitometry certificate (P-value < 0.0001) and the use of FRAX (P-value = 0.0001). Conclusion Our results revealed a below-satisfactory quality of practice among Saudi physicians toward OP. Additionally, our results identified many gaps in knowledge and many barriers to optimal care.

Real-world evidence: new opportunities for osteoporosis research. Recommendations from a Working Group from the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO)

This narrative review summarises the recommendations of a Working Group of the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) for the conduct and reporting of real-world evidence studies with a focus on osteoporosis research.

PURPOSE

Vast amounts of data are routinely generated at every healthcare contact and activity, and there is increasing recognition that these real-world data can be analysed to generate scientific evidence. Real-world evidence (RWE) is increasingly used to delineate the natural history of disease, assess real-life drug effectiveness, understand adverse events and in health economic analysis. The aim of this work was to understand the benefits and limitations of this type of data and outline approaches to ensure that transparent and high-quality evidence is generated.

METHODS

A ESCEO Working Group was convened in December 2022 to discuss the applicability of RWE to osteoporosis research and approaches to best practice.

RESULTS

This narrative review summarises the agreed recommendations for the conduct and reporting of RWE studies with a focus on osteoporosis research.

CONCLUSIONS

It is imperative that research using real-world data is conducted to the highest standards with close attention to limitations and biases of these data, and with transparency at all stages of study design, data acquisition and curation, analysis and reporting to increase the trustworthiness of RWE study findings.

Diagnosis and management of osteoporosis in Saudi Arabia: 2023 key updates from the Saudi Osteoporosis Society

The Saudi Osteoporosis Society (SOS) has updated its guidelines for the diagnosis and management of osteoporosis in Saudi Arabia (SA), with emphasis on postmenopausal women. This document is relevant to all healthcare professionals in SA involved in the care of patients with osteoporosis and osteoporosis-related fractures.

INTRODUCTION

The SOS launched the first national osteoporosis guidelines in 2015 and spearheaded the Gulf Cooperation Council Countries (GCC) osteoporosis consensus report in 2020 which was under the auspices of the European Society for Clinical and Economic Aspects of Osteoporosis (ESCEO). This paper highlights a major update of the guidelines in the SA setting.

METHODS

This guideline is an adaptation of the current guidelines derived from ESCEO, the American Association of Clinical Endocrinologists (AACE), and the GCC osteoporosis consensus report and studies on osteoporosis done in SA. Where accessible, the timeliest systematic review, meta-analysis, and randomized controlled trials were used as evidence.

RESULTS

The present update includes new recommendations for the assessment of osteoporosis taking into consideration the Saudi model of FRAX for fracture probabilities, appropriate doses for the maintenance of vitamin D status and calcium, the use of representative blood analytes for therapy monitoring, the use of romosozumab and sequential therapy in the pharmacological management strategies, and the establishment of fracture liaison services to prevent secondary fractures.

CONCLUSION

This updated guideline is for all healthcare professionals involved in osteoporosis and post-fracture care and management in SA and harmonized the most up-to-date changes in the field based on evidence-based medicine for use in the local setting.

Association of Vitamin D Knowledge, Behavior and Attitude with BMI Status among Arab Adults

This study aims to investigate the association of vitamin D (VD) knowledge, behavior, and attitude with BMI status among Saudi adults. This cross-sectional online survey included a total of 774 participants (M/F: 239/535). Knowledge about the overall sources of VD was highest in OB participants in correctly identifying sunlight (95.1%; p < 0.001) while significantly more OW participants answered food (83.1%; p = 0.04) and fortified food (66.5%; p = 0.02). However, 18.9% of OB participants also wrongly identified air as a VD source and this was significantly higher than in other groups (p = 0.03). OW participants were 50% less likely to identify salmon and fish oil (odds ratio, OR 0.5 (95% Confidence interval, CI 0.4-0.7); p < 0.01) and 40% more likely to identify chicken (OR 1.4 (1.0-1.9); p < 0.05) as dietary sources of VD than controls. On the other hand, OB participants were almost three times more likely to know that sunlight exposure is the main source of VD than controls (OR 2.65 (1.2-6.0); p < 0.05). In conclusion, while VD knowledge overall was apparently high in Saudi adults regardless of BMI status, the quality of knowledge among OB and OW individuals appear inconsistent, particularly in terms of identifying the right VD sources. Public health awareness campaigns should include the correction of VD misconceptions so that high-risk populations are able to make well-informed decisions in achieving optimal VD levels.

Primary hyperparathyroidism in Saudi Arabia revisited: a multi-centre observational study

PURPOSE

Primary hyperparathyroidism (PHPT) is a common cause of hypercalcemia and remains understudied within the Arabian population. The present study, the largest of its kind within the Gulf Cooperation Council (GCC) countries, aims to determine the demographics and clinical presentation of PHPT in Saudi Arabia.

METHODS

In this multi-center retrospective study involving three tertiary hospitals in different geographic locations of Saudi Arabia namely, Riyadh, Al Ahsa and Jeddah, a total of 205 out of 243 confirmed PHPT cases aged 16 to 93 years old were included (N = 96 from Riyadh; N = 59 from Al Ahsa and N = 50 from Jeddah). Demographics, clinical manifestations and surgical outcomes were recorded as well as laboratory and radiologic investigations including serum parathyroid hormone (PTH), 25(OH)D, adjusted calcium, estimated glomerular filtration rate (eGFR) and nuclear scan outcome.

RESULTS

PHPT cases appeared to increase over time when compared to other local studies published so far, with 12.8 cases per 100,000 hospital population. Females outnumber males (3:1) with 86% seen as out-patients. The average age was 59.8 ± 15.5 years. Abnormal PTH scan was seen in 171 patients (83.4%). Kidney stones was the most common renal manifestation (32 cases, 15.6%) and osteoporosis was the most common skeletal manifestation (67 cases, 32.7%). Al Ahsa had the highest prevalence of multiple comorbidities at 54% and the highest prevalence of obesity as a single comorbidity (17%) compared to other regions (p < 0.05). Jeddah recorded the highest prevalence of osteoporosis with bone and joint pains (30%) (p < 0.05).

CONCLUSION

Comparison of present data with previous local studies suggest an increasing trend in PHPT cases in Saudi Arabia. Regional variations in the clinical presentation of PHPT were observed and warrant further investigation.

The application of FRAX in Saudi Arabia

Assessment and treatment pathways based on age-specific intervention thresholds in Saudi Arabi can be used to identify patients at high risk of fracture and avoid unnecessary treatment in those at low fracture risk.

PURPOSE

Intervention thresholds for the treatment of osteoporosis have historically been based on the measurement of bone mineral density. The aim of the present study was to explore treatment paths and characteristics of women eligible for treatment in Saudi Arabia based on fracture probabilities derived from FRAX®.

METHODS

The approach to the setting of intervention and assessment thresholds used the methodology adopted by the National Osteoporosis Guideline Group for FRAX-based guidelines in the UK but based on the epidemiology of fracture and death in Saudi Arabia. The methodology was applied to women age 40 years or more drawn from a tertiary referral population for skeletal assessment. Missing data for the calculation of FRAX was simulated using data from the referral and FRAX derivation cohorts.

RESULTS

Intervention thresholds expressed as a 10-year probability of a major osteoporotic fracture ranged from 2.0% at the age of 50 years increasing to 7.6% at the age of 70 years. A total of 163 of 1365 women (11.9%) had a prior fragility fracture and would be eligible for treatment for this reason. An additional 5 women were eligible for treatment in that MOF probabilities lay above the upper assessment threshold. A BMD test would be recommended for 593 women (43.4%) so that FRAX could be recalculated with the inclusion of femoral neck BMD. Of these, 220 individuals would be eligible for treatment after a BMD test and 373 women categorised at low risk after a BMD test.

CONCLUSION

Probability-based assessment of fracture risk using age-specific intervention thresholds was developed for Saudi Arabia to help guide decisions about treatment.

Decreasing prevalence of vitamin D deficiency in the central region of Saudi Arabia (2008-2017)

OBJECTIVE

Widespread vitamin D deficiency (serum 25-hydroxyvitamin D < 50 nmol/L) in Saudi Arabia (SA) has been documented, yet a time trend is needed to establish where the prevalence is headed. This study aims to fill this gap.

STUDY DESIGN AND SETTING

This cross-sectional series (N = 7360) were conducted in the central region of SA from 2008 to 2017. Participants of all ages were taken from multiple cohorts that included the Biomarker Screening in Riyadh (2008-2010; N = 1460), the Osteoporosis Registry (2014-2017; N = 1225), Gestational Diabetes Mellitus cohort (2014-2017, N = 281), Vitamin D School Project (2011-2017; N = 3039) and Prediabetes cohort (2012-2017; N = 1355) master databases.

RESULTS

Vitamin D deficiency in SA has a 10-year prevalence of 73.2 %. Between 2008-2017, the prevalence of vitamin D deficiency decreased from 87.1% to 64.7% for participants aged 18-40 years (p-trend<0.001), and from 86.2% to 45.7% in participants aged > 40 years (p-trend<0.001). During this period, vitamin D deficiency in females decreased from 80.1% to 69.6% (p-trend<0.001), whereas in males, it decreased from 93.2% to 49.3% (p-trend<0.001). Serum 25(OH)D was observed to have an overall increase of 2.2 ± 0.1 nmol/l (p < 0.001) along with the seasonally adjusted annual increase of 1.3 ± 0.2 nmol/l from 2008 to 2017 (p < 0.001).

CONCLUSION

The decreasing trend in vitamin D deficiency in SA across all demographics suggests successful public health campaigns over time. It will be interesting to investigate further whether the general improvement in the vitamin D status at the community level also translated in lesser incidences of vitamin d-related diseases over time.

Sulfonylureas in the Current Practice of Type 2 Diabetes Management: Are They All the Same? Consensus from the Gulf Cooperation Council (GCC) Countries Advisory Board on Sulfonylureas

Since their inception in the commercial market in the mid-twentieth century, sulfonylureas (SUs) have remained a therapeutic option in the management of type 2 diabetes (T2D). Despite their established glucose-lowering effects, there is no consensus among global experts and modern guidelines regarding the priority of SUs in relation to other therapeutic options, given the lack of evidence that SUs are associated with a low risk of macrovascular events and excess mortality. However, findings from recent trials and real-time observations have resolved this contentious issue somewhat, albeit to varying degrees. The present consensus discusses the role of SUs in contemporary diabetes management in the Gulf Cooperation Council (GCC) countries. Regional experts from these countries gathered virtually to formulate a consensus following presentations of topics relevant to SU therapy with an emphasis on gliclazide, including long-term efficacy, cost, end-organ benefits, and side effects, based on up-to-date evidence. The present narrative review reflects the conclusions of this assembly and provides a platform upon which future guidelines for the use of SUs in the GCC can be tailored.

Novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2) and Other Coronaviruses: A Genome-wide Comparative Annotation and Analysis

Novel strain of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2) causes mild to severe respiratory illness. The early symptoms may be fever, dry cough, sour throat, and difficulty in breathing which may lead to death in severe cases. Compared to previous outbreaks like SARS-CoV and Middle East Respiratory Syndrome (MERS), SARS-CoV2 disease (COVID-19) outbreak has been much distressing due to its high rate of infection but low infection fatality rate (IFR) with 1.4% around the world. World Health Organization (WHO) has declared (COVID-19) a pandemic on March 11, 2020. In the month of January 2020, the whole genome of SARS-CoV2 was sequenced which made work easy for researchers to develop diagnostic kits and to carry out drug repurposing to effectively alleviate the pandemic situation in the world. Now, it is important to understand why this virus has high rate of infectivity or is there any factor involved at the genome level which actually facilitates this virus infection globally? In this study, we have extensively analyzed the whole genomes of different coronaviruses infecting humans and animals in different geographical locations around the world. The main aim of the study is to identify the similarity and the mutational adaptation of the coronaviruses from different host and geographical locations to the SARS-CoV2 and provide a better strategy to understand the mutational rate for specific target-based drug designing. This study is focused to every annotation in a comparative manner which includes SNPs, repeat analysis with the different categorization of the short-sequence repeats and long-sequence repeats, different UTR’s, transcriptional factors, and the predicted matured peptides with the specific length and positions on the genomes. The extensive analysis on SNPs revealed that Wuhan SARS-CoV2 and Indian SARS-CoV2 are having only eight SNPs. Collectively, phylogenetic analysis, repeat analysis, and the polymorphism revealed the genomic conserveness within the SARS-CoV2 and few other coronaviruses with very less mutational chances and the huge distance and mutations from the few other species.

Insulin Pump Therapy Issues Among Adults with Type 1 Diabetes Mellitus in Saudi Arabia: A Retrospective Study

INTRODUCTION

Type 1 diabetes mellitus (T1DM) is on the rise in Saudi Arabia. Management of T1DM is crucial in curbing the economic burden of this disease. Studies on insulin pump issues are scarce in the region. The present study aims to fill this gap.

METHODS

In this single-centre, retrospective study done in King Abdulaziz Medical City (KAMC) from March 2018 to March 2019, a total of 118 known Saudi T1DM adults (34 males and 84 females) were included. Data on demographics, glycated haemoglobin (HbA1c) and CSII use were collected.

RESULTS

The most common problem encountered by the patients on CSII was breaking down of the pump (30.0%), relocation of the cannula or tubing (22%) and air bubbles affecting delivery (16.1%). Eighty-one subjects (68.6%) claimed to have been admitted for DM management while on CSII. The use of CSII led to a significant reduction in HbA1c in all subjects (p < 0.001), but levels remain suboptimal. Only 53 subjects (44.9%) reported no significant problems in their CSII experience.

CONCLUSION

There is a high prevalence of T1DM adult patients experiencing device malfunctions and other issues while on CSII therapy. This may account for suboptimal improvement in the glycaemic control among T1DM Saudi patients. Issues on adherence and device malfunctions should be investigated further.

Diagnosis and management of osteoporosis in postmenopausal women in Gulf Cooperation Council (GCC) countries: consensus statement of the GCC countries' osteoporosis societies under the auspices of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO)

A consensus platform is provided by the experts of the Gulf Cooperation Council (GCC) countries' respective osteoporosis societies, on which specific guidelines can be developed further for regional use on the assessment and treatment of postmenopausal women at risk from fractures due to osteoporosis.

INTRODUCTION

Guidance is provided in a Gulf Cooperation Council (GCC) country setting on the assessment and treatment of postmenopausal women at risk from fractures due to osteoporosis, which is an adaptation of the European guidance by Kanis et al., jointly published by the International Osteoporosis Foundation and the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). The respective osteoporosis societies of the Gulf Cooperation Council (GCC) countries assembled for a unifying consensus on the diagnosis and management of osteoporosis in postmenopausal women for the region.

METHODS

The Chair for Biomarkers of Chronic Diseases (CBCD) in King Saud University (KSU), Riyadh, Kingdom of Saudi Arabia (KSA), in cooperation with the Saudi Osteoporosis Society (SOS), hosted regional experts and respective leaders from different GCC osteoporosis societies, together with an adviser from the ESCEO. An assembly of experts representing the different osteoporosis societies from Saudi Arabia, the UAE, Bahrain, Oman, and Kuwait gathered on February 15-16, 2019 in Riyadh, KSA for the formulation of a general osteoporosis consensus for the region.

RESULTS

The following areas were covered: diagnosis of osteoporosis and assessment of fracture risk; general and pharmacological management of osteoporosis; and hip fractures, vitamin D, recommendation on which FRAX tool to follow, and the importance of country-specific FRAX® and fracture liaison services for secondary fracture prevention.

CONCLUSIONS

A platform is provided on which specific guidelines can be developed for regional use in GCC.

Effects of different vitamin D supplementation strategies in reversing metabolic syndrome and its component risk factors in adolescents

There is little evidence on the efficacy of various vitamin D supplementation strategies in reversing metabolic syndrome (MetS) in adolescents. The present study aims to fill this gap. A total of 535 (243/292) out of 650 apparently healthy Saudi adolescents were randomly selected from the Vitamin D School Project database which has baseline and post-intervention information of more than 1000 Saudi adolescents 12-18 years old attending 34 schools in Riyadh, Saudi Arabia from Nov 2014-May 2015. Allocation of intervention was done in 3 groups using cluster randomization: vitamin D tablet, 1000IU/day (N = 180; 69 boys, 111 girls); vitamin D fortified milk consumption, 200 ml/day, 40IU/100 ml (N = 189; 93 boys, 96 girls) and control (educational awareness) (N = 166; 81 boys, 85 girls). All groups were given educational awareness on how to increase vitamin D levels. All groups were matched for BMI and analysis adjusted for age. Post-intervention and using intent-to-treat approach, within-group analysis revealed a statistically significant increase in 25(OH)D levels in all groups, and a clinically significant increase in favor of the tablet group (between-group) [10.7 nmol/l (34.7%) versus 6.3 nmol/l (19.8%) in milk and 2.1 nmol/l (7.0%) in control; p < 0.001], adjusted for age and BMI-matched. Between group analysis also revealed a clinically significant decrease in triglycerides (p = 0.05), glucose (p < 0.001) and systolic blood pressure (p = 0.005) as well as a clinically significant increase in HDL-cholesterol (p = 0.004) over time, all in favor of the tablet group. Within-group comparison showed a significant decrease in the incidence of MetS in the tablet group (9.4% versus 4.4%; p < 0.05) only. In conclusion, oral vitamin D supplementation is superior to vitamin D fortified milk in improving vitamin D status. Reduction in the incidence of MetS in the Arab adolescent population secondary to vitamin D correction may be dose-dependent.

Management of osteoporosis in the Middle East and North Africa: a survey of physicians' perceptions and practices

We surveyed 573 physicians in the Middle East regarding osteoporosis management. Sixty percent had access to, but were not in charge of, densitometry reporting. Screening for secondary causes was common; 62% were aware of FRAX®; less than half used it. Medications were accessible, and most participants had concerns regarding bisphosphonates. Barriers to care were identified.

INTRODUCTION

The 2011 IOF Middle East Osteoporosis Audit highlighted major care gaps in osteoporosis care in the Middle East and North Africa (MENA) region. We investigated osteoporosis management practice patterns in this region.

METHODS

We mailed an electronic survey to a convenience sample of physicians, explaining the study rationale and methods. It gathered information on physicians' profiles, availability and utilization of resources, risk assessment, and management.

RESULTS

Five hundred seventy-three responses were obtained from the United Arab Emirates (UAE, 36%), Saudi Arabia (KSA, 25%), Lebanon (14%), and others (25%). Endocrinology was the single most represented specialty. Sixty percent of participants had access to densitometers, but treating physicians were not in charge of densitometry reading. Screening for vitamin D deficiency and secondary contributors to osteoporosis was frequently implemented. Although two-thirds of professionals were aware of FRAX®, only 42% used it, either because of lack of know how or of a country specific calculator. Almost all (96.0%) had access to oral and 68.9% to intravenous bisphosphonates, and over half to teriparatide (46.4%) and denosumab (45.0%). Most participants (92%) were aware of concerns regarding side effects of bisphosphonates, and this changed the management in the majority (73%). Important barriers to osteoporosis care were lack of osteoporosis awareness among physicians, patients, and cost of treatment.

CONCLUSIONS

This first look at physicians' practice patterns on the diagnosis and treatment of osteoporosis in the MENA region underscores the pressing need for an official call for action, at all levels, to address this large care gap.

SAT-021 Efficacy of Vitamin D Supplementation According to Vitamin D Binding Protein Polymorphisms

The study aimed to determine the influence of DBP gene polymorphisms in vitamin D metabolites before and after vitamin D supplementation. Out of 234 participants (126 females and 108 males), 146 had vitamin D deficiency (25(OH)D <50nmol/l) and were given 2000IU daily dose of vitamin D for 12 months. Two common single nucleotide polymorphisms (SNPs), (rs4588 and rs7041) of the DBP gene were assessed. Post supplementation median 25(OH)D was significantly higher [61.2 (46.3-76.8) and 66.6 (53.2-83.7)] in participants with CC genotype of rs4588 and GG genotype of rs7041 than other genotypes (p<0.001). Participants with T allele are 2.9 (1.9-4.5) times more likely to be a non-responder (unable to achieve serum 25(OH)D post-supplementation) than those with G allele (p<0.001). Participants with A allele are 3.7 (2.1-6.6) times more likely to be a non-responder than those with C allele (p<0.001). Furthermore, participants with TT and TG are 6.2 and 4.2 times more likely to be a non-responder than those with the GG genotype (p-values <0.001) even after adjustments for age, gender, BMI, baseline 25(OH)D concentration and other alleles. Participants with AA and CA genotypes are 12.4 (1.4-110) and 4.1 (2.1-8.0) times more likely to be non-responders as compared to those with CC genotype but lost significance after adjustment. The SNPs, rs7041 and rs4588 variants of the DBP gene are associated with baseline 25(OH)D levels and modifies 25(OH)D response after vitamin D supplementation in Saudi adults.

Sex-specific correlation of IGFBP-2 and IGFBP-3 with vitamin D status in adults with obesity: a cross-sectional serum proteomics study

Objective

Subjects with low vitamin D levels are at risk of cardiometabolic disease. The aim of this study was to identify novel serological markers linking vitamin D status with cardiometabolic profile in non-diabetic adults with obesity.

Methods

For the discovery phase, we used quantitative serum proteomics in sex-matched, age-matched and BMI-matched subjects with obesity [BMI: 25–35 kg/m²] and low [25(OH)D < 50 nmol/L] vs. high vitamin D status [25(OH)D > 50 nmol/L] (n = 16). For the validation phase, we performed ELISA in a larger cohort with similar characteristics (n = 179).

Results

We identified 423 and 549 differentially expressed proteins in the high vs. low vitamin D groups of the male and female cohorts, respectively. The small molecule biochemistry protein networks and the glycolysis|gluconeogenesis pathway were significantly enriched in the DEPs of both sexes. As surrogate markers to these processes, the insulin-like growth factor binding protein -2  (IGFBP-2) was upregulated in males, whereas   IGFBP-3 was upregulated in females from the high Vitamin D status. This sex-specific trend  was confirmed using Luminex ELISA to an independent but clinically analogous cohort of males (n = 84, p = 0.002) and females (n = 95, p = 0.03).

Conclusions

The high Vitamin D status correlated with the serological upregulation of IGFBP-2 in males and IGFBP-3 in females with obesity and may constitute surrogate markers of risk reduction of cardiometabolic disease.

Sex-specific expression of apolipoprotein levels following replenishment of vitamin D

Numerous studies have been done to establish the relationship between vitamin D and lipids, yet a definitive causal link is not found. This interventional study aims to evaluate and compare levels of apolipoproteins among vitamin D deficient subjects at baseline and after they achieved full vitamin D status correction.120 Saudi adults with vitamin D deficiency [25(OH)D < 50nmol/l] were recruited and given 50,000IU cholecalciferol weekly for first 2 months, then twice a month for next 2 months, followed by daily 1000IU until month 6. Blood samples were taken at baseline and after 6 months. Serum 25(OH)D, lipid profile and apolipoproteins (A1, A2, B, C1, C2, C3, E and H) were analyzed using commercially available kits. Overall, serum 25(OH)D increased significantly(63.3 ± 16.5nmol/l at end of study vs. 32.5 ± 10.8 at baseline; p < 0.0001). In parallel, a significant increase in apolipoproteins C1, C2, C3 and E (all p-values < 0.01) and a significant decrease in apolipoprotein B (p = 0.02) was observed. Following, stratification according to sex, apolipoproteins C2 and C3 significantly increased only in males (p-values < 0.01) while apolipoprotein C1 significantly increased only in females (p < 0.01). In addition, apolipoprotein B significantly decreased only in females (p = 0.002). These results suggests role of vitamin D in modulation of circulating levels of lipoproteins. The sexual dimorphism observed in circulating levels of measured apolipoproteins following vitamin D correction may explain, in part, known sexual disparity in the events of cardiometabolic health.

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.

Efficacy of Vitamin D interventional strategies in saudi children and adults

Despite the amount of sunshine in Saudi Arabia, vitamin D (25(OH)D) deficiency is highly prevalent among Saudis. Several strategies are known to improve 25(OH)D status. The aim of this study was to evaluate the efficacy of different interventional strategies in improving 25(OH)D status in Saudi children and adults. This interventional study was undertaken among 593 out of 1152 Saudi subjects [530 students (aged 13-17 years) and 63 teachers (aged 26-46 years)] over a 6-month period from different secondary schools in Riyadh, Saudi Arabia. 25(OH)D status was taken at baseline and after 6 months post interventions. Subjects were divided into 3 groups and requested to implement different vitamin D correction schemes: sun-exposure, vitamin D-fortified milk consumption, and oral vitamin D supplementation (1000IU/day). Follow-up results revealed that all correction strategies used could decrease the deficiency of serum 25(OH)D with different potencies, with the highest positive percentage change observed in oral supplementation in both adults and children (11% men, 17% women, 16% boys and 8% girls). The oral vitamin D supplementation strategy also showed significant positive associations between delta (Δ) changes and HDL-cholesterol in both adults and children. In conclusion, oral vitamin D supplementation was the most effective strategy in improving vitamin D status in Saudi adults and children than sunlight exposure or consumption of vitamin D-fortified dairy products.

Effects of Different Dietary and Lifestyle Modification Therapies on Metabolic Syndrome in Prediabetic Arab Patients: A 12-Month Longitudinal Study

This three-arm, randomized, controlled study aimed to determine the differences in the effects of general advice (GA) on lifestyle change, intensive lifestyle modification programme (ILMP) and GA + metformin (GA + Met) in reducing the prevalence of full metabolic syndrome (MetS) in subjects with prediabetes; 294 Saudis with prediabetes (fasting glucose 5.6–6.9 mmol/L) were initially randomized, 263 completed 6 months and 237 completed 12 months. They were allocated into three groups: GA group which received a standard lifestyle change education; ILMP which followed a rigorous lifestyle modification support on diet and physical activity; and a GA + Met group. Anthropometric and biochemical estimations were measured. Full MetS (primary endpoint) and its components (secondary endpoint) were screened at baseline, 6 and 12 months. Full MetS in the ILMP group decreased by 26% (p < 0.001); in GA + Met group by 22.4% (p = 0.01) and in GA group by 8.2% (p = 0.28). The number of MetS components decreased significantly in the ILMP and GA + Met groups (mean change 0.81, p < 0.001 and 0.35, p = 0.05, respectively). Between-group comparison revealed a clinically significant decrease in MetS components in favor of the ILMP group (−0.58 (−0.88–0.28), p < 0.001). This study highlights the clinical potency of ILMP versus other diabetes prevention options in reducing MetS in Saudi adults with elevated fasting glucose.

Parathyroid hormone in relation to various vitamin D metabolites in adult females

Vitamin D binding protein (DBP) and albumin are the important determinants of circulatory 25(OH)D in adults. Physiological function of vitamin D is particularly regulated by DBPs. Serum parathyroid hormone (PTH) is considered as the biological activity reader of circulating 25(OH)D. We therefore examined the relationships between serum total, free, and bioavailable 25(OH)D versus PTH in apparently healthy Saudi female adults.A total of 350 apparently healthy Saudi female adults ([Mean ± standard deviation] age [years] 52.9 ± 9.2; body mass index [kg/m] 32.9 ± 5.4) were included in this observational study. Anthropometrics was measured as well as fasting glucose, lipid profile, calcium and phosphorous using routine methods. Serum 25(OH)D was measured using an electrochemiluminescence immunoassay. Serum DBP was determined by ELISA. Free and bioavailable 25(OH)D were calculated by comparing concentrations of total 25(OH)D, DBP, and albumin.Data revealed that circulating total 25(OH)D had weak but significant inverse association with DBP (R = -0.24; P < .01), and strong inverse associations with free 25(OH)D (R = -0.87; P < .001), albumin-bound 25(OH)D (R = -0.88; P < .001), and bioavailable 25(OH)D (R = -0.89; p < 0.001). None of the vitamin D metabolites, including 25(OH)D, correlated with serum PTH.Various metabolites of 25(OH)D are not correlated with serum PTH in Saudi adult females. Bioavailable, albumin-bound and free 25(OH)D cannot be surrogate measures for vitamin D status, at least in this population.

Vitamin D status correction in Saudi Arabia: an experts' consensus under the auspices of the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis, and Musculoskeletal Diseases (ESCEO)

BACKGROUND

Vitamin D deficiency is common in the Middle East and in Saudi Arabia, in particular. While several international recommendations on the management of vitamin D deficiency have been documented and practiced globally, these recommendations should be adapted to the conditions of the Middle Eastern region. To address this challenge, the Prince Mutaib Chair for Biomarkers of Osteoporosis (PMCO) in King Saud University (KSU), Riyadh, KSA, together with local experts and in cooperation with the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO), organized a panel that formulated unified recommendations in the diagnosis and treatment of vitamin D deficiency in the region.

METHODS

The selection of local and international experts commenced during the 2nd International Vitamin D Symposium conducted in Riyadh, Saudi Arabia, last January 20--21, 2016. Reviews of the most recent literature were done, and face-to-face meetings were conducted for revisions and final recommendations.

RESULTS

Vitamin D sufficiency is defined as circulating serum 25(OH)D ≥50 nmol (≥20 ng/ml) for the general population and vitamin D adequacy as serum 25(OH)D >75 nmol/L l (>30 ng/ml) for the frail and osteoporotic elderly. Despite overwhelming prevalence of vitamin D deficiency, universal screening is not recommended. Recommendations for the general population, children, pregnant/lactating women, post-menopausal women, the elderly, and those with subsequent metabolic diseases were provided.

RESULTS

Vitamin D sufficiency is defined as circulating serum 25(OH)D ≥50 nmol (≥20 ng/ml) for the general population and vitamin D adequacy as serum 25(OH)D >75 nmol/L l (>30 ng/ml) for the frail and osteoporotic elderly. Despite overwhelming prevalence of vitamin D deficiency, universal screening is not recommended. Recommendations for the general population, children, pregnant/lactating women, post-menopausal women, the elderly, and those with subsequent metabolic diseases were provided.

CONCLUSION

Vitamin D supplementation/correction is advised in all persons whose serum 25(OH)D falls below 50 nmol/l (20 ng/ml), and achieving a target of 75 nmol/l (30 ng/ml) is particularly suited for frail, osteoporotic, and older patients. Conducting well-designed clinical trials in the region that will address economic implications and investigations on the treatment persistence and compliance to vitamin D treatment in the region are encouraged.

Inflammation as a contributing factor among postmenopausal Saudi women with osteoporosis

Postmenopausal osteoporosis is an important metabolic bone disease characterized by rapid bone loss occurring in the postmenopausal period. Recently, the most prevalent form of clinically significant osteopenia and osteoporosis involves various inflammatory conditions. The aim of the study is to evaluate the association between proinflammatory markers (interleukin [IL]-1β, IL-6, TNF-α) with bone turnover markers (BTMs) in postmenopausal Saudi women with and without osteoporosis. A total of 200 postmenopausal Saudi women ≥50 years old, 100 with osteoporosis and 100 without osteoporosis (control) were recruited under the supervision of qualified physicians in King Salman Hospital and King Fahd Medical City, Riyadh, Saudi Arabia. Serum tumor necrosis factor alpha (TNF-α), IL-1, IL-4, IL-6, and parathyroid hormone (PTH) were determined using Luminex xMAP technology. N-telopeptides of collagen type I (NTx) was assessed using ELISA, 25(OH) vitamin D and osteocalcin were determined using electrochemiluminescence, serum calcium and inorganic phosphate (Pi) were measured by a chemical analyzer. Serum IL-1β, IL-6, NTx, and PTH levels in women with osteoporosis were significantly higher than controls. Although IL-4 and osteocalcin were significantly lower than controls. IL-1β and TNF-α were positively associated with NTx in osteoporosis women. TNF-α, IL-6, and TNF-α were positively correlated with IL-lβ in both groups. A significant negative correlation between osteocalcin and IL-1β in healthy women and women with osteoporosis were observed. Findings of the present study implicate a role for cytokine pattern-mediated inflammation in patients with osteoporosis.

Sex-specific vitamin D effects on blood coagulation among overweight adults

BACKGROUND

Overweight adults are at increased risk for cardiovascular disease and vitamin D deficiency, whereas an important feature to vitamin D physiology is its sex dependence. The aim of this study was to examine whether vitamin D status improvement exerts a sexually dimorphic effect on serum proteins associated with cardiovascular risk among overweight adults.

MATERIALS AND METHODS

Unprocessed serum from age- and BMI-matched men (n = 26) and premenopausal women (n = 24) with vitamin D deficiency and after they achieved sufficiency through a 12-month nutritional intervention was analysed using our previously published depletion-free quantitative proteomics method. Key findings were verified with ELISA. Differentially expressed proteins were subjected to in silico bioinformatics assessment using principal component analysis, hierarchical clustering and Metacore^™ pathway analysis. All mass spectrometry proteomic data are available via ProteomeXchange (identifier: PXD003663).

RESULTS

A total of 282 proteins were differentially expressed after the intervention between men and women (P-value ≤ 0·05), in which the blood coagulation pathway was significantly enriched. In agreement with the proteomics findings, ELISA measurements showed vitamin K-dependent protein C, von Willebrand factor, fibrinogen gamma chain and multimerin-1 proteins, of relevance to blood coagulation, to be differentially affected (P-value ≤ 0·05) between sexes after vitamin D status correction.

CONCLUSIONS

This study identified novel protein-level molecular indicators on the sexually dimorphic effect of vitamin D status correction associated with blood coagulation among overweight adults. These sex-mediated vitamin D effects should be factored in the design and interpretation of vitamin D observational and interventional studies testing cardiometabolic outcomes.

Sun exposure, skin color and vitamin D status in Arab children and adults

Accumulating evidence suggests an increased prevalence of vitamin D deficiency in the Middle East and North African countries. Sunlight has long been recognized as a major provider of vitamin D and lighter skin color has been associated with better vitamin D status. In this context, we aimed to determine whether 25-hydroxyvitamin D[25-(OH)D] concentrations are related to skin color, sun exposure and gender among healthy Saudi children and adults. A total of 808 Saudi children (age=14.6±0.04years) and 561 (age=31.4±0.3years) adults of both genders were included in this study. Levels of sun exposure and skin color were determined using a standard questionnaire. Anthropometry and plasma 25-(OH)D concentrations were analyzed. On the basis of duration of sun exposure (<20min vs. >20min), a significantly lower concentration of 25-(OH)D (40.9±1.2 vs. 35.5±1.8nmol/l; p<0.019) was demonstrated in dark-skinned boys with exposure time less than 20min than those exposed longer than 20min. We were unable to show an effect of sunlight exposure or skin color on vitamin D status of children or adults, except in dark-skinned boys who had lower 25(OH)D concentrations associated with limited sun exposure.

Comparisons in childhood obesity and cardiometabolic risk factors among urban Saudi Arab adolescents in 2008 and 2013

BACKGROUND

We aimed to compare the prevalence of childhood obesity and other cardiometabolic risk factors from two independent cohorts (2008 and 2013) in Riyadh, Saudi Arabia.

METHODS

A total of 4549 adolescents aged 12-18 years [2454 boys, 2095 girls], taken from two independent cohorts, 5 years apart (2008 and 2013), were included. Anthropometrics were measured, and fasting blood samples were taken to ascertain glucose and lipid profile.

RESULTS

The overall prevalence of obesity was significantly higher in 2013 [15.3 (95% confidence interval 13.7-16.9)] than 2008 [12.6 (11.3-13.9)] (P = 0.012). Stratified by sex, the prevalence of obesity among boys was significantly higher in 2013 than 2008 [2008 = 12.0 (10.3-13.7) versus 2013 = 17.4 (15.1-19.7); P < 0.001]. The age groups 13 and 15 years had a significantly higher mean triglycerides in 2013 than 2008 (P-values 0.003 and <0.001, respectively) and lower mean HDL-cholesterol also in the 13 years old age group (P < 0.001).

CONCLUSIONS

The prevalence of childhood obesity in Saudi Arabia has increased in particular age groups (13-15 years) during a 5-year span. Special attention is warranted in these vulnerable age groups, particularly in boys, as cardiometabolic risk factors appear to worsen.

Calculated adiposity and lipid indices in healthy Arab children as influenced by vitamin D status

BACKGROUND

Both childhood obesity and vitamin D deficiency are common in the Middle East. This study aims to determine whether the associations of vitamin D status to traditional anthropometric parameters hold true for nonconventional measures of adiposity, such as body adiposity index (BAI), a measure of body fat percentage, waist-to-hip ratio, waist-to-height ratio (WHtR), and lipid indices, in apparently healthy Arab children.

METHODS

A total of 4183 apparently healthy Saudi school students (1906 boys; 2277 girls) aged 12 to 17 years were recruited in this cross-sectional study. Anthropometrics were obtained. Fasting blood glucose and lipids were measured routinely. Serum 25(OH)D was measured using chemiluminescence.

RESULTS

In all subjects, age, BAI, waist-to-hip ratio, and high-density lipoprotein cholesterol (HDL-C) accounted for 4% of the variance in serum 25(OH)D (P < .001). All adiposity indices were inversely associated with 25(OH)D, with WHtR being the most inferior in terms of strength of association. Vitamin D deficiency significantly increased risk for low HDL-C in all subjects (odds ratio [95% confidence interval]: 1.70 [1.24-2.3]; P < .001).

CONCLUSION

BAI is significantly associated with 25(OH)D levels in Arab children. WHtR is inferior than other anthropometric measures of obesity regarding the strength of association with 25(OH)D. Risk for or low HDL-C is significantly increased with vitamin D deficiency. Interventional studies may determine the potential cardioprotective effects of vitamin D correction in this population.

Vitamin D Deficiency and Cardiometabolic Risks: A Juxtaposition of Arab Adolescents and Adults

The recent exponential surge in vitamin D research reflects the global epidemic of vitamin D deficiency and its potential impact on several chronic diseases in both children and adults. Several subpopulations, including Arab adolescent boys and girls, remain understudied. This study aims to fill this gap. A total of 2225 apparently healthy Saudi adolescents (1187 boys and 1038 girls, aged 13-17 years old) and 830 adults (368 men and 462 women, aged 18-50 years old) were respectively recruited from different public schools and medical practices within Riyadh, Saudi Arabia. Anthropometrics were taken and fasting blood samples withdrawn to examine serum glucose and lipid profile by routine analysis and 25-hydroxyvitamin D by ELISA. Almost half of the girls (47.0%) had vitamin D deficiency as compared to only 19.4% of the boys (p<0.001), 36.8% of the adult women and 17.7% of the adult men (p<0.001). Furthermore, in boys there were more significant inverse associations between serum 25(OH)vitamin D levels and cardiometabolic indices than girls, while in contrast women had more significant associations than men. Vitamin D deficiency was significantly associated with diabetes mellitus type 2 (DMT2) [OR 3.47 (CI1.26-5.55); p<0.05] and pre-DM [OR 2.47 (CI 1.48-4.12); p<0.01] in boys. Furthermore, vitamin D insufficiency was significantly associated with abdominal obesity in boys [OR 2.75 (CI 1.1-7.1); p<0.05]. These associations for DMT2 and abdominal obesity were not observed in adult males, girls and adult women. Vitamin D deficiency/insufficiency and hyperglycemia is high among Arab adolescents. Vitamin D deficiency is mostly associated with cardiometabolic risk factors in adolescent Arab boys. This indicates a sex- and age-related disadvantage for boys with low vitamin D status and challenges the extra-skeletal protection of vitamin D correction in adolescent females.

Vitamin D status in Saudi school children based on knowledge

BACKGROUND

The prevalence of vitamin D deficiency in the kingdom of Saudi Arabia is rising unexpectedly in every age group. Apart from several risk factors, the lack of awareness is posing a serious threat for low vitamin D levels in children as well. The aim of our study was to compare the knowledge and status of vitamin D in Saudi school children.

METHODS

Saudi students, 1188 boys (15.1 ± 2.2 years) and 1038 girls (15.1 ± 2.0 years), were recruited and a pre-designed questionnaire with regards to knowledge about vitamin D was administered. Blood samples were collected and serum 25hydroxyvitamin D (25(OH)D was measured.

RESULTS

A significantly higher percentage of boys answered correctly than girls regarding knowledge questions as sun exposure (p = 0.002, and 0.011), breastfeeding (p < 0.001) and diseases (p < 0.001). The percentage of girls was significantly higher who thought that fruits and vegetables are not rich sources of vitamin D (24.7% girls vs. 15.4% boys; p < 0.001and 29.6% girls vs. 20.9% boys p < 0.001), respectively. Boys had a higher prevalence and frequency of sun exposure than girls (p < 0.001 for both). Girls showed a significantly higher percentage of sunscreen use and full covering during sun exposure (p = 0.001 for both).Vitamin D deficiency was significantly higher in girls than boys (47.0% versus 19.4.0%; p < 0.001). Vitamin D status in boys was significantly higher than girls (p < 0.001). In girls, those who answered correctly about vitamin D related disease (p = 0.03) and sources (p = 0.015), demonstrated significantly higher vitamin D levels.

CONCLUSIONS

The awareness of vitamin D and sunlight in children needs to be improved by provision of trained physicians and school teachers. Creating more areas where girls can uncover freely during routine works and outdoor activities will help increase their vitamin D levels.

2015 Guidelines for Osteoporosis in Saudi Arabia: Recommendations from the Saudi Osteoporosis Society

BACKGROUND AND OBJECTIVES

To provide guidelines for medical professionals in Saudi Arabia regarding osteoporosis.

DESIGN AND SETTINGS

A panel of 14 local experts in osteoporosis assembled to provide consensus based on the strength of evidence and expert opinions on osteoporosis treatment.

PATIENTS AND METHODS

The Saudi Osteoporosis Society (SOS) formed a panel of experts who performed an extensive published studies search to formulate recommendations regarding prevention, diagnosis, and treatment of osteoporosis in Saudi Arabia. Both local and international published studies were utilized whenever available.

RESULTS

Dual x-ray absorptiometry (DXA) scanning is still the golden standard for assessing bone mineral density (BMD). In the absence of local, country-specific fracture risk assessment tool (FRAX), the SOS recommends using the USA (White) version of the FRAX tool. All women above 60 years of age should be evaluated for BMD. This is because the panel recognized that osteoporosis and osteoporotic fractures occur at a younger age in Saudi Arabia. Hormone replacement therapy (HRT) is not recommended for treating postmenopausal women with osteoporosis. BMD evaluation should be performed 1-2 years after initiating intervention, and the assessment of bone turnover biomarkers should be performed whenever available to determine the efficacy of intervention.

CONCLUSION

All Saudi women above the age of 60 years must undergo a BMD assessment using DXA. Therapy decisions should be formulated with the use of the USA (White) version of the FRAX tool.

Non-high-density lipoprotein cholesterol and other lipid indices vs elevated glucose risk in Arab adolescents

BACKGROUND

Non-high-density lipoprotein cholesterol (non-HDL-C) has been identified as a significant predictor of various cardiovascular events in adults. Limited studies have been conducted in the pediatric population with diverse results, depending on ethnic origin. None has been conducted in the Arabic adolescent population so far; this study aims to fill this gap.

METHODS

In this cross-sectional study, 1690 Saudi school adolescents (968 boys [mean age 14.8 ± 1.7] and 722 girls [mean age 14.6 ± 1.7]) were recruited. Anthropometrics were obtained. Fasting blood glucose and lipid profiles were quantified routinely. Non-HDL-C was calculated and screening was done for dyslipidemia using cutoffs obtained from the cohort and elevated fasting glucose.

RESULTS

Using the 90th percentile cutoff obtained, the overall prevalence of high non-HDL-C (≥4.26 mmol/L) was 10.1%. Prevalence was slightly higher in girls (10.5%) than boys (9.9%). Non-HDL-C was similar to other lipids in terms of significant associations with anthropometric measures and glucose in both boys and girls. Elevated triglycerides was most predictive of elevated glucose in both girls (odds ratio 2.41; confidence interval 1.43-4.08; P = .001) and boys (odds ratio 2.61; confidence interval 1.70-4.0); P < .001).

CONCLUSION

Non-HDL-C appears to be gender-specific and is cardiometabolically more associated with Saudi boys, despite higher levels in girls. It is inferior compared with triglycerides in assessing elevated glucose risk. Further investigations may provide a more definite value for non-HDL-C use as a biomarker in assessing cardiometabolic risk in the Arab adolescent population.

Inflammatory and bone turnover markers in relation to PTH and vitamin D status among saudi postmenopausal women with and without osteoporosis

Postmenopausal osteoporosis is characterized by rapid bone loss occurring in the post-menopausal period. The bone loss predominantly involves the trabecular bone and is brought about by an imbalance between the bone remodeling process which can be influenced by factors that could cause or contribute to osteoporosis. Pro-inflammatory cytokines (Il-1β, Il-6, IL-8 and TNF-α) have been implicated in the regulation of bone cells and play a critical role in bone remodeling. They act both directly and indirectly to increase bone resorption, and/or inhibit bone formation. The aim of the study is to determine whether pro-inflammatory cytokines correlate with bone turnover markers (BTM) in a cohort of Saudi post-menopausal women with or without osteoporosis and which BTMs will correlate with PTH and Vitamin D for use in osteoporosis diagnosis. The study is composed of 100 post-menopausal patients and 100 controls aged around 50 years. Serum concentrations of pro-inflammatory and BTMs as well as PTH and vitamin D were determined by ELISA, Luminex and electrochemiluminescence. Serum calcium, phosphorus, glucose, and lipid profile were measured by using a chemical analyzer. There was a significant increase in the levels of pro-inflammatory cytokines, PTH, CTx, and glucose. A significantly lower vitamin D and osteocalcin levels were observed in subjects with osteoporosis than those without. No significant differences were recorded in the circulating lipid profile between groups. The present study proved that the pro-inflammatory cytokines accelerate the bone loss in postmenopausal women.

Inflammatory and bone turnover markers in relation to PTH and vitamin D status among Saudi postmenopausal women with and without osteoporosis

Postmenopausal osteoporosis is characterized by rapid bone loss occurring in the post-menopausal period. The bone loss predominantly involves the trabecular bone and is brought about by an imbalance between the bone remodeling process which can be influenced by factors that could cause or contribute to osteoporosis. Pro-inflammatory cytokines (Il-1β, Il-6, IL-8 and TNF-α) have been implicated in the regulation of bone cells and play a critical role in bone remodeling. They act both directly and indirectly to increase bone resorption, and/or inhibit bone formation. The aim of the study is to determine whether pro-inflammatory cytokines correlate with bone turnover markers (BTM) in a cohort of Saudi post-menopausal women with or without osteoporosis and which BTMs will correlate with PTH and Vitamin D for use in osteoporosis diagnosis. The study is composed of 100 post-menopausal patients and 100 controls aged 50 years and above. Serum concentrations of pro-inflammatory and BTMs as well as PTH and vitamin D were determined by ELISA, Luminex and electrochemiluminescence. Serum calcium, phosphorus, glucose, and lipid profile were measured by using a chemical analyzer. There was a significant increase in the levels of pro-inflammatory cytokines, PTH, CTx, and glucose. A significantly lower vitamin D and osteocalcin levels were observed in subjects with osteoporosis than those without. No significant differences were recorded in the circulating lipid profile between groups. The present study proved that the pro-inflammatory cytokines accelerate the bone loss in postmenopausal women.

A 6-month "self-monitoring" lifestyle modification with increased sunlight exposure modestly improves vitamin D status, lipid profile and glycemic status in overweight and obese Saudi adults with varying glycemic levels

Background

The over-all age-adjusted prevalence of diabetes mellitus type 2 (DMT2) in Saudi Arabia is unprecedented at 31%. Aggressive measures should be done to curb down increasing incidence. In this prospective 6-month study we aim to determine whether a self-monitoring, life-style modification program that includes increased sunlight exposure confer improvement in vitamin D status and health benefits among adult Saudi overweight and obese patients with varying glycemic status.

Methods

A total of 150 overweight and obese Saudi adults with varying glycemic status aged 30–60 years were included in this study. They were divided into 3 groups (Non-DMT2, Pre-diabetes and DMT2). Baseline anthropometrics and blood glucose were taken at baseline and after 6 months. Fasting blood sugar, lipid profile, calcium, albumin and phosphate were measured routinely. Serum 25(OH) vitamin D was measured using standard assays. Within the time period they were instructed to reduce total intake of fat, increased fiber intake and increase sun exposure.

Results

In all groups there was a significant improvement in vitamin D levels as well as serum triglycerides, LDL- and total cholesterol. However, a significant increase in serum glucose levels was noted in the non-DMT2 group, and a significant decrease in HDL-cholesterol in both non-DMT2 and pre-diabetes group. In the pre-diabetes group, 53.2% were able to normalize their fasting blood levels after 6 months, with 8.5% reaching the DMT2 stage and 38.3% remaining pre-diabetic. In all groups there was a significant increase in the prevalence of hypertension.

Conclusion

Improving vitamin D status with modest lifestyle modifications over a short-period translates to improvement in lipid profile except HDL-cholesterol among overweight and obese Saudi adults, but not BMI and blood pressure. Findings of the present study merit further investigation as to whether full vitamin D status correction can delay or prevent onset of DMT2.

Effect of non-pharmacologic vitamin D status correction on circulating bone markers in healthy overweight and obese Saudis

While moderate to severe vitamin D deficiency is prevalent in Saudi Arabia, skeletal effects associated with this deficiency are not common in this population. In this interventional study we measured the effects of improving vitamin D status on bone biochemical markers in overweight and obese adult Saudis. A total of 47 volunteers (21 males, 26 females) out of the initial 95 subjects were given verbal advice to expose themselves to sunlight for 5–30 min twice weekly and were encouraged to increase their intake of vitamin D–rich foods. Serum 25(OH)D, osteocalcin, and type 1 collagen cross-linked C-telopeptide (CTx), were measured at baseline and after one year. A significant decrease in the prevalence of vitamin D deficiency was observed (44% to 27%) after one year follow-up (p = 0.025). Also, a parallel significant increase in osteocalcin and a decrease in CTX and osteoprotegerin were observed. The results suggest that a modest increase in vitamin D levels among overweight and obese subjects through the promotion of lifestyle changes for one year have marginal effects in bone turnover markers as well as obesity itself.

Vitamin D supplementation in patients with diabetes mellitus type 2 on different therapeutic regimens: a one-year prospective study

Background

Little or no research has determined the effect of vitamin D3 supplementation in conjunction with pharmacological and non-pharmacological approaches in the diabetes mellitus type 2 (DMT2) patients. The objective of this study was to determine the effect of vitamin D3 supplementation in a cohort of Saudi DMT2 population on diet, insulin and/or different oral hypoglycemic agents and compare them with a non-DMT2 control cohort.

Methods

A total of 499 randomly selected Saudi subjects divided into 8 groups [Non-DMT2 Control = 151; Rosiglitazone alone = 49; Diet = 15; Insulin alone = 55; Insulin + Orals = 12; Metformin alone = 121; Oral agents combination = 37; Sulphonylurea alone = 59] were included in this 12-month interventional study. All DMT2 patients were given 2000 IU vitamin D3 daily, while the control group received none but were advised to increase sun exposure. Anthropometrics, glucose, lipid profile and 25-hydroxyvitamin D (25-OHVitD) were measured at baseline, 6 and 12 months.

Results

Circulating 25-OHVitD concentrations improved in all patient groups. The metformin group showed the highest change in circulating vitamin D levels both at 6 months (62.6%) and 12 months (50.6%) as compared to baseline (p < 0.001). No significant changes were observed in the BMI and glucose in any of the DMT2 groups. In contrast, the insulin + oral agents group showed more significant improvements in the metabolic profile, which included triglycerides and total cholesterol, as well as systolic blood pressure and HDL-cholesterol in males. Also, significant decreases in triglycerides were observed in the rosiglitazone and insulin + oral hypoglycemic agent groups both at 6 and 12 months of supplementation (both p-values <0.001).

Conclusion

While in all DMT2 groups circulating levels of 25-OHVitD increased after supplementation, in DMT2 patients on insulin in combination with other drugs benefitted the most in improving cardiovascular risk. Metformin improves 25-hydroxyvitamin D levels but did not seem to confer other added cardiometabolic benefits.

Effects of probiotics in patients with diabetes mellitus type 2: study protocol for a randomized, double-blind, placebo-controlled trial

BACKGROUND

Low grade chronic inflammation is observed in patients with type 2 diabetes mellitus (T2DM). Endotoxin derived from gut bacteria may act as a potent inflammatory stimulant. Probiotics, which are believed to contain health promoting live microorganisms, may influence circulating endotoxin levels. Ingestion of live probiotic cultures may alter gut microbiota in a beneficial manner to reduce inflammation; no information is available whether or not they do so in patients with T2DM. Therefore, the aim of this study is to characterize the beneficial effects of probiotics on circulating endotoxin levels and other biomarkers related to systemic low-grade inflammation in patients with T2DM.

METHODS

One hundred and twenty consenting adult Saudi T2DM patients (naïve or newly diagnosed and without co-morbidities) will be enrolled in this clinical trial and randomized to receive daily placebo or probiotics (Ecologic®Barrier) for 26 weeks in a double-blind manner. Inflammatory and metabolic markers will be measured and fecal samples analyzed. Measurements/samples will be obtained at baseline and after 4, 8, 12/13 and 26 weeks of treatment.

DISCUSSION

It is expected that the probiotic product will induce beneficial changes in gut microbiota, reduce the systemic inflammatory state through altering systemic endotoxin levels and, as such, reduce the systemic inflammatory response observed in T2DM subjects.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01765517.

Effects of probiotics in patients with diabetes mellitus type 2: study protocol for a randomized, double-blind, placebo-controlled trial

Background

Low grade chronic inflammation is observed in patients with type 2 diabetes mellitus (T2DM). Endotoxin derived from gut bacteria may act as a potent inflammatory stimulant. Probiotics, which are believed to contain health promoting live microorganisms, may influence circulating endotoxin levels. Ingestion of live probiotic cultures may alter gut microbiota in a beneficial manner to reduce inflammation; no information is available whether or not they do so in patients with T2DM. Therefore, the aim of this study is to characterize the beneficial effects of probiotics on circulating endotoxin levels and other biomarkers related to systemic low-grade inflammation in patients with T2DM.

Methods

One hundred and twenty consenting adult Saudi T2DM patients (naïve or newly diagnosed and without co-morbidities) will be enrolled in this clinical trial and randomized to receive daily placebo or probiotics (Ecologic®Barrier) for 26 weeks in a double-blind manner. Inflammatory and metabolic markers will be measured and fecal samples analyzed. Measurements/samples will be obtained at baseline and after 4, 8, 12/13 and 26 weeks of treatment.

Discussion

It is expected that the probiotic product will induce beneficial changes in gut microbiota, reduce the systemic inflammatory state through altering systemic endotoxin levels and, as such, reduce the systemic inflammatory response observed in T2DM subjects.

Trial registration

ClinicalTrials.gov Identifier: NCT01765517

Normal circulating PTH in Saudi healthy individuals with hypovitaminosis D

Recent studies in the Middle East have shown an increased incidence of vitamin D deficiency across this region of year-round sunlight. There is scarcity of information, however, as to the levels of 1,25-dihydroxyvitamin D [1,25(OH)2D], the active form of vitamin D, and its associations with cardiometabolic parameters in an Arab cohort and this study aims to fill this gap. In a cross-sectional study, 33 male and 43 female (22 children and 54 adults, total 76) Saudis with previously established low levels of serum 25-hydroxyvitamin D [25(OH)D] (<50 ng/ml or 20 nmol/l) were recruited. Anthropometrics were obtained and fasting blood samples were taken for a routine measurement of glucose, lipid profile, calcium, and albumin, while serum 25(OH)D, 1,25-(OH)2D, and intact PTH were quantified using specific ELISAs. Serum calcium, intact PTH, and 1,25(OH)2D were all within the normal range in both children and adults in both genders. In all subjects, serum 1,25(OH)2D was not associated with intact PTH, while circulating 1,25(OH)D inversely correlated with systolic blood pressure (p=0.01) and waist circumference (p=0.04). Thus, vitamin D deficient Saudi children and adults with normal levels of 1,25-(OH)2D also had normal circulating calcium and PTH. This study suggests that local cutoffs should be set that will be of clinical significance in the identification of those at true risk for harder end-points, such as secondary hyperparathyroidism and bone-related diseases.

Hypovitaminosis D associations with adverse metabolic parameters are accentuated in patients with Type 2 diabetes mellitus: a body mass index-independent role of adiponectin?

BACKGROUND

Hypovitaminosis D has been associated with an increased prevalence of Type 2 diabetes mellitus (DMT2) and metabolic syndrome manifestations. The purpose of this study was to examine the association between 25-hydroxy-vitamin D (25-OH-VitD) levels and indices of insulin resistance (IR), including adipocytokines, in a Saudi population with or without DMT2.

SUBJECTS AND METHODS

A total of 266 subjects (153 DMT2 and 113 healthy controls) aged 26-80 yr were randomly selected from the existing Biomarkers Screening in Riyadh Program (RIYADH Cohort). Subjects were assessed clinically, anthropometry was performed, morning blood chemistries, including fasting glucose (FG), triglycerides, total cholesterol, LDL cholesterol (LDL-C), and HDL cholesterol were obtained. Homeostasis model assessment of IR (HOMA-IR) was calculated, and serum 25-OH-VitD, leptin, adiponectin, resistin, insulin, high sensitivity CRP (hsCRP), and tumor necrosis factor α concentrations were measured using specific assays.

RESULTS

In DMT2 subjects, negative correlations between 25-OH-vitD and body mass index (BMI), FG, insulin, HOMA-IR, cholesterol, LDL-C, and hsCRP were observed, while a positive correlation between 25-OH-VitD and adiponectin was detected. The later remained significant after controlling for BMI. Interestingly, only weak and nonsignificant associations between 25-OH-VitD and metabolic parameters were observed in the control group, whereas, when the entire population was examined, negative correlations were evident primarily between 25-OH-VitD and FG, HOMA-IR, total cholesterol, LDL-C. These associations remained significant after controlling for BMI.

CONCLUSIONS

These results suggest that hypovitaminosis D associations with metabolic disturbances are accentuated in DMT2. The BMIindependent positive correlation between 25-OH-VitD and adiponectin suggests a potential role for this adipocytokine as a link between 25-OH-VitD and IR in patients with DMT2.

Vitamin D supplementation as an adjuvant therapy for patients with T2DM: an 18-month prospective interventional study

Background

Vitamin D deficiency has been associated with impaired human insulin action, suggesting a role in the pathogenesis of diabetes mellitus type 2 (T2DM). In this prospective interventional study we investigated the effects of vitamin D3 supplementation on the metabolic profiles of Saudi T2DM subjects pre- and post-vitamin D supplementation over an 18-month period.

Methods

T2DM Saudi subjects (men, N = 34: Age: 56.6 ± 8.7 yr, BMI, 29.1 ± 3.3 kg/m²; women, N = 58: Age: 51.2 ± 10.6 yr, BMI 34.3 ± 4.9 kg/m²;) were recruited and given 2000 IU vitamin D3 daily for 18 months. Anthropometrics and fasting blood were collected (0, 6, 12, 18 months) to monitor serum 25-hydroxyvitamin D using specific ELISA, and to determine metabolic profiles by standard methods.

Results

In all subjects there was a significant increase in mean 25-hydroxyvitamin D levels from baseline (32.2 ± 1.5 nmol/L) to 18 months (54.7 ± 1.5 nmol/L; p  < 0.001), as well as serum calcium (baseline = 2.3 ± 0.23 mmol/L vs. 18 months = 2.6 ± 0.1 mmol/L; p = 0.003). A significant decrease in LDL- (baseline = 4.4 ± 0.8 mmol/L vs. 18 months = 3.6 ± 0.8 mmol/L, p  < 0.001] and total cholesterol (baseline = 5.4 ± 0.2 mmol/L vs. 18 months = 4.9 ± 0.3 mmol/L, p < 0.001) were noted, as well as a significant improvement in HOMA-β function ( p  = 0.002). Majority of the improvements elicited were more prominent in women than men.

Conclusion

In the Saudi T2DM population receiving oral Vitamin D3 supplementation (2000 IU/day), circulating 25-hydroxyvitamin D levels remained below normal 18 months after the onset of treatment. Yet, this “suboptimal” supplementation significantly improved lipid profile with a favorable change in HDL/LDL ratio, and HOMA-β function, which were more pronounced in T2DM females.

Effect of physical activity and sun exposure on vitamin D status of Saudi children and adolescents

Background

Accumulating evidence suggests an increased prevalence of vitamin D deficiency in the Middle East. In this context, we aimed to determine whether the prevalence of vitamin D deficiency is related to degree of physical activity and sun exposure among apparently healthy Saudi children and adolescents, a little studied population.

Methods

A total of 331 Saudi children aged 6–17 years (153 boys and 178 girls) were included in this cross sectional study. Levels of physical activity and sun exposure were determined using a standard questionnaire. Anthropometry, serum calcium and 25-(OH) vitamin D were analyzed.

Results

All subjects were vitamin D deficient, the majority being moderately deficient (71.6%). Age was the single most significant predictor affecting 25 (OH) Vitamin D levels, explaining 21% of the variance perceived (p = 1.68 x 10^-14). Age-matched comparisons revealed that for groups having the same amount of sun exposure, those with moderate or are physically active will have higher levels of vitamin D status, though levels in across groups remained deficient.

Conclusion

Vitamin D deficiency is common among Saudi children and adolescents, and is influenced by both sun exposure and physical activity. Promotion of an active outdoor lifestyle among Saudi children in both homes and schools may counteract the vitamin D deficiency epidemic in this vulnerable population. Vitamin D supplementation is suggested in all groups, including those with the highest sun exposure and physical activity.

Vitamin D deficiency and calcium intake in reference to increased body mass index in children and adolescents

Vitamin D deficiency has been linked to several chronic diseases in adults. Studies focusing on children and adolescents, however, are limited. In this randomized cross-sectional study, we aimed to determine the prevalence of vitamin D deficiency and its relationship with childhood obesity and dietary calcium intake among a population of healthy urban Saudi children and adolescents. To achieve this, 331 randomly selected Saudi children (53.8% females and 46.2% males) aged 6-17 years were included. Demographic, medical, and dietary information were collected; anthropometrics were measured. Levels of serum fasting glucose, lipid profile, 25(OH) D, and for albumin corrected calcium were analyzed. Vitamin D deficiency was noted in all subjects, with girls having significantly lower vitamin D levels than boys. Mean calcium intake was found to be 60% of the required dietary allowance (RDA), while the mean vitamin D intake was 23% of RDA. Vitamin D status and calcium intake were comparable in both normal and overweight/obese children and adolescents. Vitamin D status was highest among children who had calcium intake >800 mg/day. In adolescents there was insignificant but decreasing trend in BMI, which was observed to be highest among those whose calcium intake was <250 mg/day and lowest among those taking >800 mg/day.

CONCLUSION

results from this study suggest the importance of vitamin D fortification and increased dietary calcium in the Saudi diet to meet RDA requirements and avoid onset of vitamin D deficiency-related diseases in Saudi children and adolescents.

Modest reversal of metabolic syndrome manifestations with vitamin D status correction: a 12-month prospective study

Numerous cross-sectional studies have noted significant negative associations between circulating levels of 25-hydroxyvitamin D and cardiometabolic risk factors, highlighting potential extraskeletal functions of this sterol hormone. Prospective studies, however, have been limited; and hence, no cause-and-effect relations can be inferred. This study aims to determine whether vitamin D status correction can reverse already established manifestations of the metabolic syndrome (MetS). A total of 59 adult nondiabetic, overweight, and obese Saudis (31 male, 28 female) were prospectively enrolled in this 1-year interventional study. Anthropometry and biochemical evaluation were performed, including determination of serum 25-hydroxyvitamin D, calcium, and phosphorous concentrations, as well as fasting blood glucose and lipid profile. Subjects were advised to regularly expose themselves to sunlight and increase intake of vitamin D-rich foods. All measurements were repeated 6 and 12 months later. At the initial baseline visit, the prevalence of both low high-density lipoprotein cholesterol and hypertension was significantly increased among patients with 25-vitamin D deficiency (P < .05), even after adjusting for sex and body mass index. Overall prevalence of MetS patients by the modified National Health and Nutrition Examination Survey Adult Treatment Panel III definition decreased from 25.2% to 13.0%; and this was largely due to a parallel decrease in the prevalence of low high-density lipoprotein cholesterol, triglycerides, and hypertension. Optimization of vitamin D status through sun exposure and increased intake of a vitamin D-rich diet can lead to an improved cardiometabolic profile, offering a promising nonpharmacologic approach in the prevention of MetS manifestations.

Increased vitamin D supplementation recommended during summer season in the gulf region: a counterintuitive seasonal effect in vitamin D levels in adult, overweight and obese Middle Eastern residents

PURPOSE

  Seasonal variations in circulating vitamin D levels provide vital information as to the most appropriate time to either start or increase vitamin D supplementation to maintain optimal vitamin D levels. In this follow-up study, we determined seasonal differences in serum 25(OH)-vitamin D (25(OH)D) levels, as well as parallel changes in metabolic parameters, in a cohort of adult, overweight and obese Saudis.

METHODS

  A total of 121 adult, overweight, obese, and consenting Saudis aged 18-70 years were randomly recruited from four Primary Health Care Centers in Riyadh, Saudi Arabia. They were divided according to the season when baseline measurements were made [74 summer (April-October); 47 winter (November-March)]. Anthropometrics were obtained, and fasting blood samples were taken at baseline and every 3 months for 1 year. Fasting blood glucose, corrected calcium levels, and lipid profiles were measured routinely. Serum 25(OH)-vitamin D was quantified using a specific enzyme-linked immunosorbent assay (ELISA).

RESULTS

  Age- and BMI-matched mean 25(OH)-vitamin D levels from the winter group were significantly higher than those of the summer group (P < 0·001). In both groups, HDL-C levels improved significantly as 25(OH)-vitamin D levels increased with subsequent follow-ups, even after adjusting for age, gender and BMI (P < 0·001).

CONCLUSION

  Seasonal differences in serum 25(OH)-vitamin D levels in Saudi Arabia are counterintuitive, with circulating levels being higher during the winter than the summer season. Increased vitamin D supplementation is thus recommended to maintain optimal serum 25(OH)-vitamin D levels during the summer season.