Chapter 1 Literature Review
During the past decades Vitamin D deficiency had become a major health concern among many Asian countries. Even countries where the sun shines all year round Vitamin D deficiency is still prevalent. This problem is attributed to the dietary factors, inadequate exposure to sunlight and skin pigmentation among Asian people. In terms of skin pigmentation, the majority of Asian inhabitants have highly pigmented skin. Although high skin pigmentation it is generally beneficial because pigmentation reduces the penetration of ultra-violet rays it can also reduces the production of building blocks required to produce Vitamin D. In Saudi Arabia, the cultural dominance encompasses a tradition incorporated to lifestyle and clothing preferences that covers the entire body particularly among women.
The fact that Saudi Arabia is geographically situated in the hottest regions in the planet, sunlight should not be a problem so is Vitamin D deficiency because the source for its adequate production is virtually unlimited. However recent studies suggests that Saudi Arabian inhabitants particularly women are becoming shown to have experiencing Vitamin D deficiency problems. In addition, since most women in the country are mostly covering themselves in dark veils, there is a speculation that such practices also contribute to the problem. Furthermore, recent urban developments in the country paved way for the construction of high-rise buildings and apartments in which air conditioning, thick concrete and glass walls obstructs the entry of sunlight. Therefore, these factors are to be considered when embarking on a study to determine the cause of Vitamin D deficiency among the Saudi Arabia population.
The exploration of the problem starts with the review of related literatures where the main subject of the study relates to determination of the causes of Vitamin D deficiency among the Saudi Arabian population. Fonseca et al. (1984) studied the causes of Vitamin D deficiency among children and women in Saudi Arabia. Part of the study is to establish the link between women’s cultural practices of wearing dark veils to the occurrences of Vitamin D deficiency. Fonseca et al. (1984) employed the use of mixed method approach in which the participants are interviewed first by a dietitian to determine the participants’ food intake. In addition, participants were also screened for those that have metabolic bone diseases. The reason for such is to exclude participants that are already suffering health conditions that result from Vitamin D deficiency such as bone disease. The statistical analysis entailed from the gathered data showed the median plasma 25-OH vitamin D in the majority of the subjects is about 6 ng/ml. In addition, only three of the participants were found to have higher Vitamin D range (Fonseca et al., 1984). The subjects were also divided according to the type of residence they live in such as those with air conditioning units and those that do not have one at home.
The important findings derived from the study is that the people residing in homes with air conditioning units as well as those that are using veil to cover themselves from direct sunlight are shown to have lower levels of 25-OH vitamin D. On the other hand, the subjects living in villas where sunlight penetrates well in their home appeared to have better Vitamin D readings. Fonseca et al, (1984) concluded that the aetiology of Vitamin D deficiency among women in Saudi Arabia could be caused by multi factors. Factors such as diet, non-exposure to direct sunlight and skin pigmentation are largely attributed to Vitamin D deficiency. However, among the factors identified in the study, cultural and social customs paired with urbanization greatly contributes to the problem. This study encompasses the theory that Vitamin D deficiency is not only caused by health related factors, but also social and cultural factors also insinuate the same results.
A similar study by Al-Othman et al. (2012) was conducted to determine the effects of physical activities and exposure to sunlight to Vitamin D status of children in Saudi Arabia. It is apparent from the study that Vitamin D deficiency is prevalent among children and adult particularly in Saudi Arabia. Statistically, there are about 30 to 50% of the children in Saudi Arabia and its neighboring countries are suffering in Vitamin D deficiency during the past couple of decades. Accumulated evidence from Al-Othman et al. (2012) study also suggests that the Middle East population is becoming more and more prone to the consequences of Vitamin D deficiency due to the absence of relative factors that include physical activities and direct exposure to sunlight. The method used in Al-Othman et al. (2012) is a cross sectional study wherein observational and survey approach was employed to determine if physical activities would render alleviate the problems of Vitamin D deficiency. The gathered data from the survey questionnaire were analyzed by means of Anthropometry and serum calcium. The study listed significant variables attributed to Vitamin D deficiency such as skin pigmentation, lack of adequate exposure to ultraviolet radiation (UVB) along with mutation in vitamin D receptor, polymorphism and low daily calcium intake (Al-Othman et al., 2012).
The research also specified the geographical appropriateness of the Kingdom of Saudi Arabia in terms of harnessing the potential benefits of having conditions suitable for adequate production of vitamin D. However, despite having the right environmental conditions for the vitamin D production it is apparent that a large number of the Saudi Arabian population is still suffering from the vitamin D deficiency. Having said that, behavioral factors such as physical activities are perceived to be necessary alleviating the problems of vitamin D deficiency among the Saudi Arabian children and adults. The objective of the study is address vitamin D deficiency problem from a different approach in which physical awareness and activities are involved to ensure that the Saudi Arabian population is getting enough exposure to sunlight. Al-Othman et al. (2012) approach through cross-sectional study comprised of 330 Saudi Arabian boys and girls between six to 17 years old. The statistical analysis carried out for the study encompasses findings revealing that 11.4% of the subjects having severe vitamin D deficiency while the rest of the subjects appeared to mild to moderate vitamin D deficiency. After a series of physical activities arranged to expose the subjects to direct sunlight encompasses results that shows improvement to vitamin D levels among the subjects up to 21%. The significance of this research is to show the importance being regularly exposed to direct sunlight at certain amount of time from March to December in order to allow the body to naturally produce its needed vitamin D.
The problem with vitamin D deficiency is also linked to other health problems such as chronic back pain according to Faraj and Mutairi (2003). In this study, a total of 360 patients composed of 90% women and 10% men that are attending spinal and internal medicine treatment for the last six years. The importance of the study is to establish the link between the occurrences of chronic back pain with vitamin D deficiency. It is apparent that the lack of vitamin D in the body affects bone health and it was speculated that chronic back pain caused by weak spinal column is related to vitamin D deficiency (Faraj and Mutairi 2003). Furthermore, the investigation on the relationship of lower back pain and vitamin deficiency, which is significant in terms of sensitive test screening for patients with idiopathic chronic back pain. The findings of this study reveal that 93% of the patients suffer in vitamin D deficiency and after systematic administration of vitamin D supplement, the subjects showed significant improvement both in vitamin D level and chronic back pain syndrome.
Statement of the Problem
In areas of Saudi Arabia where food and sunlight is abundant, there is still a high prevalence of vitamin D deficiency among its population. It is notion that people inhabiting sunny places are always exposed to the sunlight, thus eliminating the occurrences of vitamin D deficiency. It is apparent that several factors play the role in vitamin D deficiency such as social and cultural, food preferences, lifestyle and skin pigmentation. Therefore, given all the aforementioned factors, a number of Saudi Arabians are suffering vitamin D deficiency, which manifests in other chronic health condition and syndromes.
The purpose of this study is to evaluate the vitamin D status of a cohort of Saudi Arabians in which the relationship between chronic health conditions, vitamin D deficiency and other causal factors will be established. The findings will be a significant addition to the number or research contributing to the improvement of vitamin D deficiency among the population of Saudi Arabia and introduce practices that will promote the increase of vitamin D intake.
- How skin pigmentation affects the production of vitamin D in the body
- What are the symptoms that relates to vitamin D deficiency
- What are the practical approaches that can be attributed to significantly improve vitamin D deficiency among the Saudi Arabian population?
Definition of Terms
25-hydroxy-vitamin D — A form of vitamin D being measured to be able to determine level of deficiency.
Cholesterol — A fat-soluble steroid alcohol (sterol) naturally found oils, animal fats and other animal products such as egg yolks. The body with the help of cholesterol can produce Vitamin D.
Fat-soluble vitamin — The type of vitamin that easily dissolves in oil or fat, but not in water, which includes vitamin D.
International unit (IU) — A measurement of biological activity in which one IU is equal to one mg (milligram).
Osteomalacia — Osteomalacia is a type of bone disease that affects adults, which is caused by long periods of vitamin D deficiency.
Rickets — Rickets is a type of bone disease that emerge in growing children and infants also caused by long period of suffering from vitamin D deficiency.
Significance of the Study
The significance of the study evolves around the importance of maintaining adequate amount of vitamin D in the body, which will help to alleviate other problems resulting to prolonged period of vitamin D deficiency. In addition the correlation of causal factors will be determined in order to avoid create practices that will alleviate vitamin D deficiency.
The studies conducted in relation to the prevalence of vitamin D deficiency provides an insight to the often unforeseen circumstances that relative factors causes to the large number of Saudi Arabians. Vitamin D deficiency is a health problem attributed to factors that can be avoided if there is enough information that will tell the people in the Middle Eastern regions that the lack of vitamin D will cause other health related problems. The studies conducted by Fonseca et al. (1984), Faraj and Mutiari (2003) and Al-Othman (2012) are similar in nature and encompasses similar findings leading to the conclusion that inadequate exposure to sunlight in which the Kingdom of Saudi Arabia is very much abundant causes serious problems that can actually easily prevented by means of simple practices other than medication.
Al-Othman, A., Al-Musharaf, S., Al-Daghri, N. M., Krishnaswamy, S., Yusuf, D. S., Alkharfy, K. M., Al-Saleh, Y., Al-Attas, O. S., Alokail, M. S., Moharram, O., Sabico, S., & Chrousos, G. P. (2012). Effect of physical activity and sun exposure on vitamin D status of Saudi children and adolescents. Al-Othman et al. BMC Pediatrics, 12(92), 1-6.
Faraj, S. A., & Mutairi, K. A. (2003). Vitamin D Deﬁciency and Chronic Low Back Pain in Saudi Arabia. SPINE - Lippincott Williams & Wilkins, Inc, 28(2), 177–179.
Fonseca, V., El-Hamzi, M., Tongia, R., & Abu-Aisha, H. (1984). Exposure to sunlight and vitamin D deficiency in Saudi Arabian women. Postgraduate Medical Journal, 60, 589-591 .