VITAMEN D DEFICIENCY IN SAUDI ARABIA THE SILENT EPIDEMIC MONA A FOUDA NEEL ,MBBS, MRCP(UK),FRCPE ASSOCIATE PROFESSOR OF MEDICINE CONSULTANT ENDOCRINOLOGIST COLLEGE OF MEDICINE KING SAUD UNIVERSITY

STUDY OF VITAMIN D STATUS AND FACTORS LEADING TO ITS DEFICIIENCY IN SAUDI ARABIA SALEH SEDRANI ET AL 4078 subjects The population under study is classified into 3 categories according to vit D nutritional status: deficient ( 5 ng/ml), low (5-10 ng/ml) and adequate ( 10 ng/ml). The frequency of low 25-OHD concentration (5-10 ng/ml) is high (22% in total children and 20% in total adults) in the Saudi population, while the frequency of vit D deficiency (25-OHD level  5 ng/ml) is 3.4% in total children and 5.5% in total adults. This is true whether the population is urban or rural. 26% of female children of female adults have low vit D status in comparison with 19% and 17% for male children and male adults, respectively.

Bone mineral density of the spine and femur in healhy saudi females : relation to vitamin D status, pregnancy, and lactation N N GHANNAM ETAL calcif Tissue int 1999 321 females 25 vit D 24.5+17.2 nmol/l Severe hypovitaminosis D (25 OHD less than 20 nmol/l )= 52% Osteoporosis and osteopenia in subjects more than 31=18-41 %, 0-7%

Study by El Desouki 2003 Lumbar BMD of 830 postmenopausal Saudis according to age Category Number (%) BMD + SD T-Score Age 50-59 yrs. Normal Osteopenia Osteoporosis Low BMD 216 171 124 295 42 33 24 57 1.098 + 0.11 0.893 + 0.13 0.795 + 0.15 - 0.61 - 2.36 - 3.21 Age 60-69 yrs. 28 69 157 226 11 27 62 89 1.092 + 0.12 0.986 + 0.13 0.774 + 0.141 - 0.71 - 2.41 - 3.4 Age 70-80 yrs. 3 14 48 4.6 21.4 74 95.4 1.102 + 0.13 0.981 + 0.12 0.732 + 0.12 - 0.78 - 2.43 - 3.5 El Desouki. Saudi Med J 2003;Vol. 24 (9)

Spine BMD In Postmenopausal Saudis by Age Category Number (%) BMD SD T-Score Age 51-60 Normal 224 37 1.130 (0.05) -0.55 Osteopenia 218 36 0.978 (0.05) -1.84 Osteoporosis 164 27 0.793 (0.07) -3.40 Total 606 100 0.952 (0.15) -2.06 Low BMD 382 63 Age 61-70 18 7 1.100 (0.03) -0.84 80 32 0.970 (0.05) -1.93 152 61 0.774 (0.07) -3.56 250 0.704 (0.11) -2.27 232 93 Age 71-80 3 4 1.149 (0.07) -0.40 16 22 0.962 (0.05) -2.00 35 74 0.771 (0.02) -3.50 54 0.821 (0.12) -1.57 51 96 BMD – Bone Mineral Density SD-Standard Deviation

Femur BMD In Postmenopausal Saudis by Age Category No: (%) BMD SD T-Score Age 51-60 Normal 262 43 0.915 (0.07) -0.50 Osteopenia 247 41 0.755 (0.04) -1.87 Osteoporosis 97 16 0.606 (0.5) -3.10 Total 606 100 0.800 (0.12) -1.48 Low BMD 344 57 Age 61-70 38 15 0.905 (0.04) -0.60 121 48 0.740 (0.04) -1.99 91 36 0.587 (0.06) -3.27 250 99 0.704 (0.11) -2.27 212 84 Age 71-80 3 4 0.848 (0.01) -0.90 30 0.743 (0.04) -1.97 39 54 0.596 (0.06) -3.19 72 0.668 (0.10) -2.59 69 95 BMD – Bone Mineral Density SD-Standard Deviation

Spine BMD In All Patients (50-80 Yrs) Category Number (%) BMD  SD T-Score Normal 243 26 1.12 (0.05) -0.62 Osteopenia 284 31 0.962 (0.04) -1.99 Osteoporosis 401 43 0.782 (0.07) -3.480 Total 928 100 0.912 (0.15) -2.40 Low BMD 685 74 BMD – Bone Mineral Density SD-Standard Deviation Femur BMD In All Patients (50-80 Yrs) Category Number (%) BMD SD T-Score Normal 303 32.7 0.908 (0.08) -0.54 Osteopenia 397 42.8 0.750 (0.04) -1.91 Osteoporosis 228 24.5 0.597 (0.06) -3.19 Total 928 100 0.764 (0.13) -1.78 Low BMD 625 67.3 BMD – Bone Mineral Density SD-Standard Deviation

Prevalence of osteopenia and osteoporosis in Saudis (50 years), using US/European and Saudi reference data. Data are presented as percentages with osteopenia (> -2.5 SD to < -1 SD below young adult BMD) and osteoporosis (< -2.5 SD below young adult BMD), for spine (L2-L4) and femur (total). (Ardawi MSM, et al. Osteoporosis Int 2005; 16: 43-55) 1980 PTS 20-79 AGE M 915 F 1065

The proportion of Saudis aged 50 years with lower than -2 The proportion of Saudis aged 50 years with lower than -2.5 SD, stratified by body weight quartiles and sex. (Ardawi MSM, et al. Osteoporosis Int 2005; 16: 43-55)

VITAMIN D LEVELS BELOW 20 NMOL/L EXCLUDED !

Optimal vitamin D status for the prevention and treatment of osteoporosis Holick MF Drugs Aging 2007 Vitamin D deficiency is defined as serum 25 OH D level <50 nmol/l or 20 ng/ml

optimal 25 hydroxyvitamin D values Normal 25-hydroxyvitamin D values 20-56 ng/ml or 50-140 nmol/l optimal 25 hydroxyvitamin D values 45-50 nglml or 115-128 nmol/l

Higher 25OHD levels prevent Table: Threshold values for vitamin D insufficiency based on different outcomes and study types. A common threshold value of 50 nmol/l has been proposed for vitamin D insufficiency, whereas vitamin D deficiency is characterized by values < 25 nmol/l. References Study type Threshold values for 25-OHD (nmol/l) Higher 25OHD levels prevent Dawson-Hughes et al. 1991 Ooms 1994 Ooms et al. 1995 Chapuy et al. 1997 Guillemant et al. 1999 Jesudason et al. 2002 Vieth et al. 2003 Krall et al. 1989 Malabanan et al. 1998 Lips 2001 Cross-sectional Crpss-sectional intervention 30-80 Increases with age 30 60 90 50 Secondary hyperparathyroidism Decrease in BMD Increase in bone turnover Seasonal variation in PTH Suppresible P-PTH (Mosekilde L. Clin Endocrinol 2005; 62: 265-281)

(Sadat-Ali M & AlElq AM. Ann Saudi Med 2006; 26: 450-454)

(Sadat-Ali M & AlElq AM. Ann Saudi Med 2006; 26: 450-454)

(El-Desouki MI & Sulimani RA. Saudi Med J 2007; 28: 774-777)

(El-Desouki MI & Sulimani RA. Saudi Med J 2007; 28: 774-777)

Resurrection of vitamin D deficiency and rickets M F HOLICK J. Clin.Inves 2006 Upward of 35-80 % OF Children in Saudi Arabia and other sunny countries are vitamin D deficient ! Subclinical vitamin D deficiency in neonates (10 – 20 ng/ml) is associated with normal serum calcium and elvated PTH.

In conclusion Vitamin D deficiency is pandemic worldwide Saudi Arabia and many other sunny countries are no exception THE IMPACT OF THIS PROBLEM ON SKELETAL HEALTH AND MANY OTHER DISEASES SO PREVALENT ALREADY IN SAUDI ARABIA HAS TO BE ADRESSED URGENTLY