Vitamin D Deficiency and Calcium Metabolism

Abstract

Vitamin D is an essential vitamin for the growth and development of all human beings. The most important function of vitamin D is to accelerate calcium absorption in the body. It regulates the body immune system and prevents diseases. This life giving vital vitamin is endogenously produced by exposure to the solar rays that emit UVB radiation. Lack of enough exposure to sunlight causes reduced Vitamin D production in the body.

Deficiency of this vitamin can lead to several diseases such as rickets, osteomalacia, obesity, hypertension etc in people. In the Arabian Gulf about 53% of the people including children and women are suffering from vitamin D deficiency and insufficiency. This is an alarming situation in the region as the extreme sunny climate does not allow the people to have enough exposure to sunlight. Moreover, the religious and cultural aspects in this region restrict the ethnic people from exposure to sunlight due to their dressing code innate with the religion. Due to this the people of the Middle East countries including the Arabian Gulf are inflicted with several diseases associated with vitamin D deficiency and also insufficiency.

To combat the situation, governmental machineries in these regions and the other public health organizations world over are undertaking population based studies and researches to make people aware of the need to be fit in body and mind, and towards this, they introduce enough health care and dietary supplementation, for the young children as well as pregnant and lactating women. Since young children are those would be great citizens of the world it is the duty of the general public to keep their children healthy in body and spirit and thus to make them ready to face the future. To achieve this aim, situations that lessen the endogenous production of vitamin D should be curtailed and necessary dietary intake with vitamin D supplementation should be adhered. Moderate lifestyle and prudent dietary intake and physical activities will improve the situation of vitamin D deficiency.

Introduction

Around 60000 years ago some deep pigmented humans born in the Great Lakes region of East-Central Africa migrated northward, and moving farther and farther it happened that they received only less and less ultraviolet B radiation from the sun. They got adapted to it gradually from generation to generation, yet their skin became depigmented more and more. This change in the body turned out to be very advantageous for them to survive over the deep pigmented humans who were experiencing adverse mobility conditions and reproduction problems due to vitamin D deficiency (1-2).

However, the Eskimos dwelled in the far north were less affected as they consumed vitamin D enriched fat and fish as daily food. Jablonski and Chaplin (1) conducted a research recently on this aspect of those indigenous people and established that the skin colour is the main and proper way to define the human races as variations seen in skin colour are very much adaptive and interlinked with the quantum of ultraviolet radiation (UVR) penetrated through the skin, which is the natural outer covering of the human body.

By using certain remotely sensed data on the different levels of ultraviolet radiations and the distribution of colours on the skin of indigenous people, they explained and quantitatively proved that the vitamin D impact syndrome is the direct as well as indirect consequences on the fitness of the body due to the ultraviolet radiation penetration (1).

Vitamin D is endogenously produced when sunlight falls on the skin. It acts like a steroid hormone that responds to vitamin D receptors (3) and controls the calcium metabolism in the body and affects on growth of brain and its functions. It also influences cell proliferation, apoptosis, insulin secretion and blood pressure along with differentiation of cells and its immune responses (4). Deficiency of this vital vitamin will lead to several body malfunctions and diseases including multiple sclerosis, cancers, soft bones, lung diseases, obesity, hypertension and depression.

Source and metabolism of Vitamin D

The primary and basic formation of vitamin D known as calciol or vitamin D3 is available from exposure of skin to UVB radiation in the sun and food intake. The UVB 290-315 nm range, after the photolyses of 7-dehydrocholesterol contained in the skin, will transform into D3 isomerized to cholecalciferol (calciol). Though cholecalciferol is also found in fortified foods such as milk, cereals, orange, cheese, dark fish and vitamin supplements, they are relatively very poor sources when compared to sun exposure, because they deliver only a small quantity amounting 40-400 IU/food serving, whereas UVB radiation exposure on the whole body for about 20 minutes will build 10000 IU, provided the person is light skinned and the environmental factors are not negative.

But, the strength of UVB will be poor if the skin is deep pigmented or there are environmental variations like winter, atmospheric pollution, cloudy sky and low ozone level. In such conditions the production of the skin cholecalciferol will be reduced necessitating the requirement of diet sources of the vitamin. Colecalciferol and ergocalciferol are the two types of vitamin D. They are transformed to 25-hydroxy vitamin D, initially in the liver, and then undergo hydroxylation and become 1, 25-dihydroxyvitamin D called calcitriol (4).

To ascertain the nutritional status of a person the measure of 25-hydroxyvitamin D is used, as it is regulated loosely and has a long half life ranging from 20 to 60 days. Though it is accepted that 50 nmol/L and above of concentrations of 25-hydroxyvitamin D is enough to tackle the vitamin D deficiency problem, generally it requires 75 nmol/L and above of 25-hydroxyvitamin D to bring out a better health result. It is found that majority of the population has low production of vitamin D from UVB radiation exposure, and so it is advised that an individual should have a minimum sunlight exposure to yield at least a little over 75 nmol/L 25-hydroxyvitamin D to overcome the problem of vitamin D deficiency in a person (4).

Vitamin D Deficiency Syndrome

The adaptation to the changing environment through generations has developed longstanding biological changes in the form of skin colour variation in people which is reflected in the behavioural patterns like clothing, religious rites and rituals, and food intake. In the modern times there are rapid shifts in the matter of location and environment, generating advantages like time management and better living standard and also disadvantages like mental stress and strained social relationships wanting space and time for adaptation. These changes in the life style and the choices in multitudes deeply affect the levels of Vitamin D in the body. Aging, lack of exercise, obesity, and short in sun exposure etc. contribute much to the vitamin D syndrome (2).

Impact of vitamin D deficiency

Vitamin D deficiency is more widespread in cold climates and where people wear full body cover clothes. It is also seen in gulf countries where women, according to the religious custom, are fully covered. A woman who is pregnant and has vitamin D deficiency will develop osteomalacia. The new born of such women receives only less sunlight and it will become prone to rickets as the breast milk of its mother may not have enough vitamin D content (5). According to Abdulrahman Obaid Musaiger (6), though the gulf countries have achieved considerable improvement in the field of economics and health, nutritional problems vitamin D deficiency are still rampant. This causes anaemia and obesity in women, weight loss and dental caries in children (Musaiger (6).

A recent study conducted by Wael Latif Jabur (7) of Dubai New Medical Center Specialty Hospital has established that Osteomalacia which is caused by vitamin D deficiency is largely found in Arabic women who work outdoors in hot climate. They will develop black skin and also be affected by renal osteodystrophy. The deficiency of this vitamin is also responsible in developing mental health problems, especially schizophrenia, depression and seasonal behaviour disorders that are persistent among women.

But yet, no studies have focused on the psychological consequences of the deficiency of vitamin D and the inherent issue of seasonal variations and symptom severity in women (8). It is interesting to notice that too much exposure to sunlight increases the risk of non melanoma skin cancer, but its frequency of occurrence is more seen in the least sunny areas (9).

Multiple sclerosis

It is known that genetic and environmental conditions are some of the causes for the development of multiple sclerosis. Smoking, vitamin D deficiency and diet are directly involved in the acceleration of this disease (10). The impact of vitamin D deficiency is very severe and it ranges from the metabolism of bone to various illnesses like multiple sclerosis, Alzheimer, rheumatism, diabetes, mycobacterium tuberculosis, cardiovascular disorders, body pain etc.

It is estimated that 65% females and 60% of males in Abudhabi suffer from Vitamin D deficiency (11). The environmental conditions that determine multiple sclerosis in young adults include Epstein-Barr virus (EBV) infection, low level serum concentration of vitamin D (4). Genes can also affect the essential vitamin D metabolism which in turn will influence 25-hydroxyvitamin D concentrations.

The genetic alterations in VDR will control the impacts of vitamin D on the immune system of the body, thereby causing multiple sclerosis directly or indirectly by regulating the vitamin D effects (4). The risk connected with multiple sclerosis in young children is due to the presence of HLA-DRB1 15 alleles, Epstein-Barr virus and 25-hydroxyvitamin D low level serum concentrations. Children having standard MRI are prone to monophasic illness (12).

Calcium metabolism

Calcium is linked with the development and metabolism of bone. More than 99 percent of the calcium is stored in bones and teeth as calcium hydroxyapatite (Ca10[PO4]6[OH]2) which provides strength and rigidity in tissues. The calcium that exists in the blood circulatory system, muscle and other tissues is responsible for vascular contraction and vasodilatation. It controls the function of the muscles, intra cellular signaling, and nerve transmission. The tissue of the bone is a reservoir of calcium to cover the metabolic functions relating to bone remodeling. The parathyroid hormone vitamin D endocrine in the form of homeostatic feedback loops regulates the calcium metabolism in the body.

To keep adequate ionized calcium in the serum rapid liberation of mineral from bone tissues is necessary. If there is vitamin D deficiency, it will affect the bone metabolism due to the decrease in calcium absorption leading to a higher rate of PTH secretion as the sensing receptor of calcium inherent in the parathyroid gland changes ionic calcium circulation which in turn induces the activities of enzymes in the kidneys where vitamin D is converted to calcitriol that stimulates calcium absorption for the alimentary canal. This variation in the functions between calcium and vitamin D makes it impossible to determine the relative calcium requirements, intensity of deficiency and the excess intake (13).

Obesity and excess weight

The following statistics relating to the occurrence of excess weight, obesity and nutrition based non-communicable diseases in the Gulf countries such as Saudi Arabia, UAE, Bahrain, Qatar and Oman throws enough light on the health hazards the gulf region face in connection with vitamin D and calcium deficiency. According to the statistics, obesity is very common among Arab women while a higher percentage of their men show overweight in Saudi Arabia, Qatar and Kuwait. 70 to 85 % of men and 75 to 88 % of women belonging to 30-60 year old group exhibit obesity. The rate of increase in obesity is significantly high in the states of Saudi Arabia and Kuwait.

8 to 9 percent of the pre schoolers and 40 to 46% of adolescents of these two countries are also experiencing obesity. Kuwait has the highest percentage of adolescent obesity in the world. Hypertension and diabetes are also on the increase and it corresponds to the age factors. UAE marks the highest rate in this regard during the period from the year 1995 to 2000. The intensity of presence of calcium metabolic syndrome and cancers are yet to be determined. National level representative surveys from individual to communities are required to ascertain the factors that decide these problematic trends (14).

Aims and Objectives

Vitamin D deficiency is widespread and has become a major health problem in the world, nowadays. The impact of deficiency of Vitamin D is that much alarming that most of the countries are focusing on alleviating its intensity and occurrences. Arabian Gulf countries especially Saudi Arabia is highly concerned about it as most of the Arab children and pregnant and lactating mothers as well as adolescents and adult males are prone to the critical situation of vitamin D and Calcium deficiencies paving the way for different diseases like Alzheimers, Parkinson’s, Neurological disorder, Multiple sclerosis, Rheumatism, Diabetes, Mycobacterium tuberculosis, Cardiovascular problems, Obesity, body pain and several other diseases (11).

Therefore, the present research is focused on the various factors relating to the vitamin D deficiency syndrome and calcium metabolism and the direct effects of it on the health condition of the people, especially the young generation inhabiting the region. The researcher aims to find answers to the following research questions:

1. What is the effect of Vitamin D Deficiency/insufficiency syndrome and Calcium Metabolism in Arabian Gulf Children Aged 6 to 18 Years?
2. What is the impact of Nutritional Status and Lifestyle Factors on Peak Bone Mass Attainment?

The answers to these questions will give an insight to the status of vitamin D deficiency and calcium metabolism and the intensity of the various diseases contributed due to the deficiency syndrome on the young people between 6-18 years and lactating and pregnant women in the Gulf region, especially the Kingdom of Saudi Arabia. Moreover, it will help to find out new measures that are needed to overcome these deficiencies and will throw light on the necessity to change the dietary pattern to ward off mal nutrition and the inherent diseases.

The main objectives of this study are:

1. To assess the nutritional influences on PBM attainment: Ca, vitamin D, protein, minerals, trace elements, food groups, supplementation (during pregnancy and lactation) – influences on bone
2. To assess non nutritional influences on PBM attainment: Lifestyle, physical activity, sunshine exposure; smoking, Parity, extent of bone pain, education, economic status, fracture history, extent of veiling
3. To assess the state of bone health – DXA, BUA, bone turnover markers
4. To assess the characteristics of vitamin D – methodologies, strengths & weaknesses of each method
5. To assess the dietary intake of key foods and food groups in males and females and examine if there are any nutritional associations with 25OHD status and indices of bone health.
6. To assess the association between body weight and 25OHD statuses to see if a higher BMI is associated with a lower 25OHD level in adolescents, and determine the extent of obesity prevalence in both males and females
7. To assess the effectiveness of Bone formation markers – osteocalcin (OC) and alkaline phosphatase (AP)
8. To assess the effectiveness of Bone resorption markers – C-Telopeptide [CTx]; de-oxpyridinoline [DPD]
9. To assess Nutritional supplementation of the mother – impact on child/adolescence BMD
10. To assess Impact of veiling and type of dress on bone health indices
11. To assess the different methods used to measure vitamin D strengths and the weakness of each method.
12. To compare between Western Children and Adolescents using the NDNS National Diet and Nutrition Survey 6-18 years

To find out reasonable answers to the above research questions and objectives the study is discussed under the following different chapters.

1. Introduction: It gives a brief account of background, problems and leads to the research approach.
2. Literature Review: The entire data collected is reviewed here.
3. Methodology: The data collection methods and analysis are done under this head
4. Results (Analysis): Findings derived out of the study are elaborated in this chapter.
5. Discussion: The findings are analysed and discussed here.
6. Conclusion & Recommendation: The outcome of the research and recommendation for furtherance of the study are given under this chapter.

Methodology

Introduction to Methodology

Research in generic means searches for knowledge. Therefore, research methodology can be identified as a systematic approach adopted for solving a research problem scientifically, wherein the various steps are applied and analysed through logical means. The research methods are classified into 4 groups viz., (i) Descriptive vs. Analytical, (ii) Applied vs. Fundamental, (iii) Conceptual vs. Empirical and (iv) Quantitative vs. Qualitative. Here, in this research, quantitative research is applied with respect to the quantity of the data (15).

According to Habermas, every research made shall be in accordance with motivation which is guided by interests and values. The social, scientific and personal notions of the researcher will naturally find a place in such researches. Therefore, the value problems that may come up while the researcher traverses forward to fulfill the task will naturally become the guiding principles for the study (16).

This research paper, as such, attempts to find out the extent of vitamin D deficiency/insufficiency and Calcium Metabolism affecting the Arabian Gulf children & adolescents between 6 years and 18 years. It also strives to assess the impact of nutritional status and lifestyle factors on peak bone mass attainment. To complete the task the researcher has investigated the available literature and learning procedures which put insights to formulate ideas to achieve the objectives. Quantitative analysis and cross studies were incorporated to streamline the research.

The useable literature on vitamin D deficiency and Calcium metabolism was re-examined to gather applicable data for this research. Further, to find the required answer to the research questions, a sampling population was selected in a purposeful way and quantitatively examined. There were some useful sources over the Internet about research methods which were put to study (17).

Yin (18) states

Every type of empirical research has implicit, if not explicit, research design. In the most elementary sense, the design is a logical sequence that connects empirical data to a study’s initial research questions and ultimately, to its conclusions. In a sense the research design is a blueprint of research, dealing with at least four problems: what questions to study, what data are relevant, what data to collect and how to analyze the results (18).

Selection of research technique

There are many elements to be considered before selecting a method as there are benefits as well as drawbacks with every method chosen, and the researchers have to discover the most appropriate for them. It is more effective to separate research into approaches rather than methods. In addition, the research techniques utilized in the theory-testing approach are field studies and reviews on clinical studies. The features of such a study are the hypothesis, form or structure which is gathered from literature, formulated or polished to conform to that specific study. The main purpose of this study is to find out answers to the following research questions:

1. What is the effect of Vitamin D deficiency/insufficiency syndrome and Calcium Metabolism in Arabian Gulf Children Aged 6 to 18 Years?
2. What is the impact of Nutritional Status and Lifestyle Factors on Peak Bone Mass Attainment?

The main objectives are:

1. To assess the nutritional influences on PBM attainment: Ca, vitamin D, protein, minerals, trace elements, food groups, supplementation (during pregnancy and lactation) – influences on bone
2. To assess non nutritional influences on PBM attainment: Lifestyle, physical activity, sunshine exposure; smoking, Parity, extent of bone pain, education, economic status, fracture history, extent of veiling
3. To assess the state of bone health – DXA, BUA, bone turnover markers
4. To assess the characteristics of vitamin D – methodologies, strengths & weaknesses of each method
5. To assess the dietary intake of key foods and food groups in males and females and examine if there are any nutritional associations with 25OHD status and indices of bone health.
6. To assess the association between body weight and 25OHD statuses to see if a higher BMI is associated with a lower 25OHD level in adolescents, and determine the extent of obesity prevalence in both males and females
7. To assess the effectiveness of Bone formation markers – osteocalcin (OC) and alkaline phosphatase (AP)
8. To assess the effectiveness of Bone resorption markers – C-Telopeptide [CTx]; de-oxpyridinoline [DPD]
9. To assess Nutritional supplementation of the mother – impact on child/adolescence BMD
10. To assess Impact of veiling and type of dress on bone health indices
11. To assess the different methods used to measure vitamin D strengths and the weakness of each method.
12. To compare between Western Children and Adolescents using the NDNS National Diet and Nutrition Survey 6-18 years

When an investigator wants to construe an incident, the study is expected to serve an understandable purpose. Firstly, the awareness should support the researcher to augment the knowledge of the studied incident. Secondly, it should build up new thoughts and theoretical views, and eventually the purpose permits disclosing of on hand problems inside the phenomenon. The present research is fulfilled by examining the conclusions of professionals on the Vitamin D deficiency/insufficiency syndrome and Calcium Metabolism in Arabian Gulf Children Aged 6 to 18 Years?

The results were analysed to ascertain the feasibility and adaptability of their studies to know how far the outcome of such studies, suggestions and applications on vitamin D deficiency syndrome are acceptable. Additionally, it will provide the status of understanding of the grave situation. The data towards this were collected systematically. While gathering data from the samples maximum effort was put in to avoid any embarrassment to the subjects or the respondents.

In addition to the surveys a set of nine predetermined questions was drafted for interviewing 32 professionals engaged in the treatment of patients having vitamin D deficiency and calcium metabolic syndrome. The interviews were short and objective, and were limited to duration of 15 minutes. The time of the interview was limited to 15 minutes to maintain the focusing on the questions and to avoid any further implication. Such a limitation enabled the respondents to maintain more interest in answering the questions with enthusiasm. Moreover, it helped the researcher to save the much valued time.

Population and Sample

The researcher decides and describes the population based data that are collected with reference to time, territory and other appropriate component such as individuals and age. Furthermore, the region of the population has to be defined, and according to Miller, the territory is government limits e.g. a city or a region. Non-probability sample distribution is undertaken when the investigator has some control over the chosen sample.

The investigator can select the sample established on judgment or repute, expediency, share, and/or offers (19). The questionnaire was given to the medical professionals after obtaining permission from them. Care has been taken to get the answers very authentic and free from prejudices. The researcher was under the impression that the professionals would interact with each other and the patients to share their thoughts about vitamin D deficiency syndrome and calcium metabolism.

Data collection

The primary data collection was based on literature, interviews, survey and questionnaire. The details provided by the professionals were considered as supplementary data and therefore, the statistics and opinions given by them were included in the study. Electronic archival research was comprised of information from the webs and hard and soft copies of journals and other related sources.

Literature Review

Since people are becoming urbanized, the life style also changes bringing consequences like reduced exposure to sunlight. Because of this, it becomes difficult for the skin to synthesize vitamin D in the body. The extreme environmental changes also cause reduced exposure to sunlight as people stay indoors in such conditions. It is more prevalent in colder climates, and other places where sun shines long, forcing people to cover their body in full to escape from the scorching heat (5).

If the time of exposure to sunlight is increased it will need them to wear sunscreens to protect the body from the strong UVB rays due to the decreasing atmospheric ozone layers, thereby lowering the exposure required for the vitamin production in the body. The outcome of these demand a search for an alternative exogenous source of vitamin D as at present there are not enough natural sources other than the fatty fish, fruits and cereals (2).

Vitamin D deficiency is widespread and has become a major health problem in the world. The impact of deficiency of Vitamin D is so much alarming that most of the countries are focusing on alleviating its intensity and occurrences.

Arabian Gulf countries, especially Saudi Arabia, is highly concerned about it as most of the Arab children and pregnant, as well as lactating mothers are becoming preys to the overpowering vitamin D and Calcium deficiencies leading to the onslaught of several diseases like Multiple sclerosis, osteoporosis, Alzheimers, Parkinson’s, Neurological disorders, Rheumatism, Diabetes, Mycobacterium tuberculosis, Cardiovascular problems, Obesity, body pain and many other diseases (11). As such, it is necessary to have enough vitamin D from exposure to the sun, if not, that deficiency should be made well through the intake of supplements (20). But the extent to what quantity it should be taken is yet to be determined because the intake must be regulated according to the age factor, gender, structure, ethnicity and location of each individual.

Situation is this, and considering the health hazards facing the Arab young populace and the women as a whole in the gulf region the government machineries of the Gulf States are striving hard to overcome the crisis. But the life style habits and dietary pattern of the people together with the extreme environmental conditions are accelerating the issues. To make things worse there is no authentic data available on the rate of consumption of these nutrients by the Arabs in the Gulf region to tackle the consequences of vitamin D deficiencies (21).

Qatar University’s Department of Health Sciences has revealed that 53.5% of females of young age are still affected by vitamin D deficiency and that the children aged between 11 and 16 are developing skeletal as well as muscle development problems due to the decrease in production of Vitamin D in the months of summer when it becomes difficult to go outdoors (22).

As per the report of the Natural News, the deficiency of this health-promoting vitamin is highly connected to breast cancer, weak and soft bones, hives, obesity etc. It also affects healthy breathing. The American Journal of Respiratory and Critical Care Medicine has evidence that vitamin D deficiency can strongly affect the lung growth and lessen the performance of the lungs. It can also alter the structure and function of the lungs. Some of their studies conducted earlier had proved that vitamin D deficiency could lead to severe asthma and continual obstructive pulmonary disease (20).

Impact of vitamin D deficiency in the Arabian Gulf

The Middle East region includes Arabian Gulf consisting of western Asia and a part of North Africa. It covers Bahrain, Saudi Arabia, Qatar, United Arab Emirates, Yemen, and the Sinai province of Egypt, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman and Palestine. These regions have arid climate and a latitude from 12_to 42_N, which provides vitamin D synthesis due to UVB rays throughout the year.

Yet, these regions have the highest rate of rickets, though the western developed countries have almost eradicated the disease. This is because of the restricted sun exposure, religious customs and cultural practices. Added to these are the problems of dark skin and the reduced calcium intake. Hypovitaminosis D, the lack of which is the root cause of osteoporosis, creates the major health issue in these regions (23). It is a fact that anything that restricts the transmission of UVB radiation from the solar rays and its penetration into the skin will thwart the cutaneous synthesis of vitamin D3.

Though the Arab Gulf countries have acquired significant advancement in the fields of economic, social and health status, the nutritional disorders are still rampant among the people. Anaemia, obesity, low birth weight, vitamin D deficiency, dental caries are very common among women and children (24). There are not enough population oriented studies to examine the link between vitamin D and T1 diabetes mellitus and, style of living and diet pattern of the young children in Arabian Gulf (21). Though Al-Madinah city recorded incidences of childhood T1DM, it has not reached an alarming situation yet (25) and that soothes the situation a little bit.

Nutritional influences on peak bone mass attainment: Supplementation (during pregnancy and lactation)

Nutrition is an important factor in the advancement and preservation of bone mass as well as in the treatment of osteoporosis. Around 80% to 90% of the bone mineral mass consists of calcium and phosphorus. Along with these, the dietary components like protein, zinc, magnesium, copper, fluoride, iron, vitamins D, A, C, and K are also necessary for the normal metabolism of bone. The other nutrients such as caffeine, alcohol and phytoestrogens are also decisive in maintaining the bone health. Most of them are co-dependent and interactive with the genetic components. This aspect makes them complex and unstable in extending to bone health (26).

.The vitamin D deficiency in a pregnant woman will lead to osteomalacia (soft bones) and her new born may become prone to rickets. As breast milk lacks enough amount of vitamin D, the infant, if not exposed to sun sufficiently and supplemented with nutrition, will develop rickets. The vitamin D test will be a help in such situations to ascertain the nutritional status so that enough remedial measures can be taken.

According to researcher, Dr. Grunton, Vitamin D insufficiency will impact upon the density of bones, calcium metabolism, neonatal vitamin D and rickets regardless of soft or weak bones in childhood (Peterson n.pag). Osteomalacia is a familial disease characterised by low serum content of 25(OH) D2 < 10 nmol/L (normal range 75-200) & low 1, 25(OH) D3 23 pmol/L (normal range 43-140). The high percentage of parathyroid hormone holds the calcium serum within the bone matrix and this establishes the role of vitamin D in phosphorus and calcium homeostasis. Jabur WL (7) writes:

Being familial is an unusual feature for osteomalacia secondary to vitamin D deficiency. The drastically low 25(OH) D (severe vitamin D deficiency defined as serum 25(OH) D below 20 nmol/L) and the severity of the disease are unexpectedly out of proportion to the currently reported tempo of the disease in general. Whether the patients are having unique inherent predisposition to develop myopathy or it’s a presentation of vitamin D deficiency, needs further clarification. Pure vegetarian diet was the only risk factor; nevertheless such diet causing an advanced osteomalacia is difficult to explain solely (7).

The children between 4 to 8 or 9 years experience rapid growth and they must get enough nutrients to capacitate the growth. The milestone for the development of puberty in the females is from 9 years to 13 years whereas for males it is only from 14 to 18 years. The female growth starts before the breast growth and the rate of bone mass development in these years becomes the determining factor to the risk of osteoporosis at a later stage, even at the time of pregnancy.

Therefore, it is necessary to ingest enough nutrition at a time when the bone grows very rapidly (27). Throughout the transition from childhood to adolescence, the calcium deposition into bone is continual and reaches its maximal level of 37% of what she had achieved during the pubertal stages, at the rate of 300-400 mg per day. In adolescence the skeleton continues to grow and the pregnancy lowers peak bone mass and increases the risk of osteoporosis (28).

During pregnancy and lactation there are quick and significant changes in the physical condition of a female, and therefore, she needs more nutrition in her diet to cope with the situation of growth of the fetus and production of milk, and to make good the loss of nutrients after the changes in the physiological mechanism ( 28). The nutrition ingested provides the building blocks and activates the mechanical force for the development of bone. The mean intake of calcium by girls is less than that of the boys, thereby making a difference of _200 mg (27).

The dietary intake of pregnant women shall consist of proper and balanced food that contains vitamin enriched constituents including orange juice, green vegetables, berries, asparagus, peas, beans and fortified items enriched in folic acid like cereals, bread, rice or pasta in moderately large quantity. Otherwise, they should see that they take enough supplements to make good of the shortage. Additionally, women aged 19 and more must have a gradual increase of supplements having calcium content of 800mg/day to 1,000 mg/day irrespective of whether they are pregnant or lactating.

To achieve this end they need to take 3-4 servings of nutritious diet including milk, cheese, yogurt etc. so that it provides calcium intake of 1300 mg/day (29). Attention is also required regarding calcium intake in females as it is crucial in maintaining the peak bone mass attainment, for they are the target population of osteoporosis prophylaxis, much time later. However, excessive intake of other nutrients such as phosphorus, protein, caffeine etc., if added to the other risk factors, will make a deleterious effect in attaining peak bone mass in them (30).

Impact on child/adolescence bone mineral density (BMD)

Childhood and adolescence are crucial stages in the matter of bone mass accrual and it reaches the maximum from 10.4 years to 14.6 years in females. Calcium being the main structural component, adequate quantity of calcium is essential throughout the childhood and adolescence which is the most important factor in the determinant of bone mineral density in later on. The progress in the development of bone in children and adolescence is directly proportional to the level of intake of calcium during this period and any deficiency in its intake will lead to impaired bone condition. It is seen that most of the girls in this age group lack adequate calcium intake. To activate calcium absorption in the body sufficient quantity of vitamin D intake is necessary.

Adequate vitamin D input maintains normal levels of calcium and phosphate components in the blood which is responsible for the mineralization of bone to a large extent. The level of serum 25(OH)D, otherwise called calcidiol, marks the nutritional status relating to vitamin D (31).

In European countries where sun does not shine throughout in winter mere exposure to sunlight may not bring in enough vitamin D synthesis in skin. In such situations the children and adolescents require additional intake of vitamin D throughout for maintaining normal bone mineralization. Insufficiency in its intake reduces bone mineral accrual in them.

The association of serum 25(OH)D in acting as an indicator to the nutritional level of vitamin D and mineral density of bone or its mineral content in these young people has been confirmed by the previous human observational and intervention studies. 25(OF)D also indicates the outcome or impact on bone mass density and bone mass mineral content due to the combined supplementation of regular diet having calcium and vitamin D. That was why the Panel on the Human Observational Intervention Studies put forward the scientific evidence: “calcium and vitamin D are needed for normal growth and development of bone in children” (31).

The above Panel stipulated that the calcium and vitamin D content in food should be according to the requirements provided in Annex to Regulation 1924/2006, which is considered as the balanced diet for the target population up to the age of 18 years, without limiting the intake of calcium to Tolerable Upper Intake Levels, though for adults the UL fixed is 2500 mg/day. But in the case of vitamin D intake of children and adolescents, the UL established is 25μg/day, till the age of 10 years and, 50μg/day for the age up to 11 years (31). These stipulations indicate the severity of the impact of the nutritional elements on the bone mineral density of children and adolescents.

The skeleton of the human body is remodelled constantly by a well coordinated cellular function that eliminates, revives and restores damaged bones. It is estimated that during the life span, an adult skeleton is remodelled to around 10% every year. Certain stimulated specialized cells reabsorb a specific quantity of the damaged portion just before subjecting the ruined part to the programmed cell death. This repairing process continues till the formation of new bone.

Required quantity of nutrition intake is essential and has utmost importance in this natural ageing process. Lack of nutrition will put any person; irrespective whether he or she is young, adolescent or adult is at risk of osteoporosis. Low level of calcium ingestion in childhood can increase the possibilities of running osteoporosis in later life, and therefore, children and adolescents must intake more calcium so that such intakes will improve their BMD. If not done, the structure of the bone is altered to become fragile and fractured. Peak bone mass is accrued in the very early childhood and the mineral density does not improve thereafter (32). Therefore, lack of nutrition in the childhood and adolescence is decisive in maintaining BMD.

Calcium is the foundational and structural component that facilitates the normal mineralization of the bone as well as the cartilage matrix. If calcium intake is adequate to prevent the diseases like rickets which originates in the form of disordered organization of cartilage matrix, and osteomalacia that results in the defective mineralization of bone, the input of the very additional calcium increases the bone density by impacting upon the bone turnover as well as the size of remodeling space. Vitamin D deficiency is much associated to fracture and in the development of low bone mass (33), and it has an important part to play in the metabolism of bone. Explicit vitamin D deficiency in children will affect the bone mineralization gravely (34).

Non nutritional influences on peak bone mass attainment

Adolescence is a crucial period during which bone mass is attained in the body, especially in the case of females. Although a major portion of the peak bone mass is settled based on genetic factor, certain environmental components can also affect the bone accumulation. In healthy individuals, such decisive elements are calcium and vitamin intakes, gender, estrogen, smoking, ethnicity, sun exposure, physical activity, life style etc. Physical activity augments accrual of bone mass in children and adolescents, and it surpasses all other environmental factors that relate to peak bone mass attainment (35). The lifestyle factors like smoking, alcohol consumption etc. contribute much to the bone health of the young people (36).

The extreme temperatures in countries like Kuwait, force the people, especially the women, to get away from sun exposure by veiling, thereby they practically discard the chances of getting enough vitamin D from the sunlight. This non exposure to sunlight and the lifestyle put the adolescents at risk of vitamin D deficiency which in turn affect the peak bone mass attainment (37). Bone strength is associated with the quality of bone and its structure, mass and mineral density. The decisive factors of bone density are those elements that influence the peak attainment throughout the growth consolidation and bone loss.

There is genetic attachment to the peak bone density that can be achieved in the first two and a half decades of life and it is regulated by mechanical factors and hormonal status along with nutrition. The main components for bone loss are estrogen deficiency that exists in women, low index of body mass, smoking, consumption of alcohol, apparently reduced calcium intake, physical non activity, drug addiction, and rheumatic complaints (38).

Low bone mass causes osteoporosis, which is characterized by reduced bone strength which places children susceptible to multiple fractures. There is clear cut evidence that osteoporosis has geriatric outcomes, but it is a pediatric stage as the major portion of the bone mass is attained during adolescence. As such, adolescents should utilize the opportunities to acquire maximal bone mass through calcium intake propped by regular and continued physical activity and appropriate life styles (39). The peak bone mass of young females is less than their counterparts in lieu of their large bone size, but the two BMDs remain identical. However, body weight, physical exercise and endocrine factors affect the development of bone in adolescents. If the mother is osteoporotic the children will also suffer the same.

Recent epidemiological studies throw light that smoking has significant impact on bone mass. Smokers are often thin and have a reduced production and increased rate of metabolic estrogen clearance. Added to these is the osteoblast function. Existing or previous alcoholic status of the individual also contributes to the decline in bone mass and the inebriation or intoxication increase the tendencies to fall resulting in fractures.

Alcohol causes osteoblast proliferation, thwarts synthesis of matrix protein, and affects other cells of the body. The skeleton of the body requires steady and continued physical stimulation to maintain health bone mass, and any deviation from the normal life will affect it adversely (40).

Osteoblast function is very sensitive to mechanical stresses and it increases bone formation, while immobilization results in bone loss. Physically active females have more bone mineral content than those who are inactive. Anti gravity activities like dancing and running are most productive in bone building than the exercises like swimming. However, prolonged and severe exercise may create negative effects on bone mass attainment because increased physical activities may develop hypothalamic amenorrhea that causes estrogen deficiency. The racial differences also influence the peak bone mass density. Africans have more bone mass and minimum fractures than the whites (40).

Impact of veiling and dress code on bone health indices

Vitamin D is essential for several metabolic processes in an individual. For the production of melatonin hormone sunlight must fall on the eyes. Muslim women who according to their religious custom wear burkha and it deprive them from availing this health giving hormone. It is known that melatonin hormone is essential for getting good sleep and mental health. Moreover, the lack of vitamin D due to the veiling affects the development of bone, thereby paving way for risk of osteomalacia (41).

The young Saudi females aged 13 and above have now a different life style and tend to create Nocturnal Society Syndrome by going outdoors only after sun set and in the night when which results in Vitamin D3 deficiency. They don’t have any activity during the day devoid of sun exposure extending their selves to the possibility of becoming prostrate to osteomalacia (42).

The Arab-American woman who wears hijab veils the head and body and that prevents her from getting the much wanted vitamin D from the sun, placing her in a perilous condition of vitamin D deficiency and she has to compromise it with the intake of vitamin enriched food. But even if it is done there may not be any variation in the rate of health hazards connected with vitamin D deficiency, like bone pain or fractures, for though they wear hijab, they take vitamin D and calcium supplements along with their food. The deficiency of vitamin D was earlier considered to cause only rickets or soft bones, but now it is found that it has associations with multiple sclerosis and other related diseases.

The physicians argue that their intention is not meant to link veiling to vitamin D deficiency that affects a billion people, and that their earlier study which was published in Pediatrics 2000 had proved that the Orthodox Jewish children located in Brooklyn who were veiled in long sleeves throughout also suffered from vitamin D deficiency. Other studies conducted in the tropical climatic areas of Kingdom of Saudi Arabia, United Arab Emirates, Australia, India, Lebanon etc, where people veil their body as a part of their religious customs or for other reasons, revealed that 30 to 50 percent of them were suffering from vitamin D deficiency and related diseases.

If the vitamin is supplemented through food one has to consume at least 80 eggs or drink 20 glasses of milk, but 10 or 20 minutes sunshine will give 20000 units, which is tenfold that the supplement. It is truly a steroid hormone than a vitamin having pleiotropic associations with phosphorus and calcium metabolism (43, 69).

The style of clothing the body is a major determinant in the matter of vitamin D production in the body, and that translates into the bone mineral density. Concealment of the outer body pars increases the risk of osteoporosis. Even if there are factors such as pregnancy, smoking or peripheral fractures osteoporosis risk is there in these people. The recent study conducted by Allali and Achaoui et al. indicate this aspect.

Two reports relating to Saudi Arabia and Kuwait have also established that vitamin D deficiency is rampant among the people of these areas due to the veiling. But the deficiency seen in Iran has association with BMD in the spine and it has got no connection with femoral BMD. Moreover, wearing a veil is an independent factor for the risk of hypovitaminosis. Veiling can cause drop of vitamin D status and risk of fractures linked to osteoporosis (44).

Nutritional factor associations with 25OHD status & bone health

Vitamin D is generally seen as a vitamin soluble in fat, and that it is only found in fish, cod liver oil and fortified milk, bread and cereals. It is also considered as the vitamin that prevents rickets and that it is associated with exposure to sun. But according to the Nutrition and Bone Health Working Group of American Society for Bone and Mineral Research, vitamin D is more than that its deficiency has lifelong impact and even in fetal stage.

It influences the deposition of bone minerals in childhood as well as adolescence. It has links with heredity, sex, food, physical activities and many other factors. Moreover, vitamin D deficiency in the mother regulates the mineral accumulation in intrauterine life and has connections with the size of the infant and that it determines the risk of fractures in later life. A mother, with low vitamin D level, when gives birth, the child born to her continues to have less mineral content in bone at the age of 9 years (9).

Serum 25(OH)D status during adolescence is affected by various elements like ethnicity, puberty, hormone level, dietary intake etc. and therefore, there exists no agreement in the concentration of serum 25(OH)D in the bone mass of adolescents. Vitamin D deficiency originates in adolescents when the level of 25(OH)D comes below 10ng/mL. If this is treated as the marker for measuring vitamin D deficiency, such deficiency in the adolescents may range from 0 to 32% subject to climatic and geographical conditions. And if the cut points are increased for 25(OH)D, the rate of prevalence will also go upward reaching 75%. The vitamin D requirement of the adolescents is an activity of dietary intake and growth.

The calcium intake of children from 821 to 1110 mg/day, will not make any notable correlation in the serum 25(OH)D levels and the fractional absorption of calcium. This means that 25(OH)D is more effectively metabolized to 1,25-dihydroxycholecalciferol during the puberty growth spurt, which accelerates the ability to absorb calcium in the intestine even when vitamin D is not maximal (9).

The 25(OH)D level is linked to the health of bone during puberty. Young females having 25(OH)D concentrations higher than 40 nmol/L (16 ng/mL) have more radial and ulna BMD. In addition, there is progressive rise in cortical BMD with increasing serum 25(OH)D. However, there are no remarkable differences in the total BMD when it is related to 25(OH)D levels. Vitamin D deficiency has great impact in the maintenance of skeleton.

It restricts the accrual of maximum calcium in it. When peak bone mass has reached the individuals who experience vitamin D deficiency loses 0.25 to 0.5% of their bone mass each year provided they have no required calcium and vitamin D. Due to vitamin D deficiency, secondary hyperparathyroidism will develop thereby increasing the production of osteoclasts, which dissolves bone and releases calcium direct into the blood stream. This can cause osteopenia that develops into osteoporosis (9).

Additionally, vitamin D deficiency activates defective mineralization of collagen matrix and that leads the person to the risk of osteomalacia, which causes severe bone pain. Vitamin D has a key role in the prevention of many diseases like cancers, multiple sclerosis, diabetes etc. Most of the young people acquire vitamin D from exposure to sunlight. The lack of exposure to sunlight can be supplied with 1000 IU of cholecalciferol/per day as it will suffice the body’s requirement to restore 25(OH)D above 30 nag/mol.

Body weight & 25OHD statuses-higher BMI association with lower 25OHD level-adolescents

Body weight is associated with the metabolic changes in the vitamin D endocrine system. Low serum 25-hydroxyvitamin D (25-OHD) can alter the distribution of tissues due to the high adipose mass. Therefore, such individuals need somewhat higher percentage of vitamin D supplementation. But it is not yet known whether the body fat percentage should be counted for the determination of vitamin D supplementation. Obesity related to vitamin D insufficiency is the outcome of low bioavailability of vitamin D3 (45).

Excess body weight results in somatic and psychological disorders. Overweight and obesity are highly associated with low vitamin D status. In other words it is the high body mass index linked to the low 25OHD status. During the recent years the incidence of childhood and adolescent obesity regardless of whether male or female has increased to an alarming level. Vitamin D deficiency and insufficiency is seen more in the overweight adolescents than in the overweight children. The reason for this is contributed to the relative low outdoor activities and vitamin D intakes (46).

Overweight and obesity cause low 25(OH)D status. Vitamin D deficiency is more seen among individuals with BMI ≥40. This generally ranges from 32% in females to 46% in males. The 25(OH)D3 level and its corresponding variation together with the vitamin D deficiency depend upon the BMI and age factor. It is estimated that the ratio of overweight people having vitamin D deficiency is 1 in 3 in the female population and 1in2 in the male population having status of BMI ≥40 (46).

Extent of obesity prevalence in both males and females

As obesity rates continue to rise, scientists are trying their best to identify the risks involved with the increasing body weight in adolescents. It was revealed recently that an inverse relationship exists between adiposity and status of vitamin D and that the lower level of the vitamin in the obese adolescents and children is the result of decrease in vitamin D that is available in the body, because of the withdrawal of the vitamin towards the fat cells. This association is denser in whites than the blacks (Stein).

It is alarming to find that the prevalence of obesity in children and the adolescents has increased many folds in the last two decades. The scientists and health care professionals are striving to find out a way as to how the problem could be solved. Studies on this department of biological science have revealed only mixed results about obesity and increasing rate of vitamin D deficiency status (Stein). In 2002 in nation-wise average there were 22% of young girls and 18% of boys who had bone mass index which is above 25 while it was only ten in the year 1982. And again nearly one third of girls aged 10 amounting to 30% and one fifth of boys aged 10 amounting to 21% had BMI above 25 in the year 2002, whereas it was only 14% of girls and 8% boys respectively in 1982. This shows the extent of obesity prevailing in both males and females (47)

Bone formation markers

Bone formation markers are used by physicians to find out the details of the products of bone remodeling. If the percentage of bone resorption in the body is high, the blood and urine tests will enable the physician to find it out easily. It also helps to see whether there is an abnormal increase in bone formation as well. This indicates that there is a potential bone disorder. Bone markers are used to determine the quantum or intensity of bone fracture in an individual and it helps the doctors in determining and monitoring a suitable drug therapy for the patients who are suffering from bone disorders.

Osteocalcin happens to be a small protein and is combined with osteoblasts, hypertrophic chondrocytes and mature odontoplasts. The serum osteocalcin is a marker that helps in osteoblast function. This is due to the fact that osteocalcin levels tend to correspond with the rate of bone formation. Gradually, the peptide degrades in the serum rapidly. As a result there originate intact but fragmented segments in the serum that coexists.

Due to the heterogeneity nature of osteocalcin fragments that are found in the serum makes it a marker that has limited use. A circadian rhythm is also observed in the osteocalcin levels. There is a decline in the morning, around noon the level is low followed by an increase after midnight. There are several advantages of using osteocalcin to measure bone turnover as it is a clinical index. Osteocalcin is known for tissue specificity, availability and turnover rate.

The expected changes in bone formation that occur after a surgical intervention are indicated by the serum levels. Alkaline phosphatase is another bone formation marker which has been use for several years. The serum alkaline phosphatise contains dimeric isoforms that are formed from different tissues. The tissues where serum is formed are the liver, intestine, placenta, bone, spleen and also the kidney. In adults around 50% of this serum is produced in the liver itself and the rest is the contribution of the bone (48).

Osteoblastic activity takes place with the help of serum osteocalcin. This protein is found in high concentration in the human bone. It has been found that the bone specific alkaline phosphatase is highly sensitive and more specific than the other serum such as alkaline phosphatise. The particular enzyme is formed by active osteoblasts. (49).

Bone markers are tests that indicate bone remodeling and the doctors can find out about bone resorption and bone formation with the help of bone formation markers and suggest a line of treatment for the patient. If there is a bone disorder then it can be detected early. Bone has a 10% turnover rate annually and is a growing tissue in the body. The bone is formed of type-I collagen. It is a protein network and the bone derives its framework and strength from it. Another mineralized complex such as the calcium phosphate strengthens the human skeletal framework. The combination of calcium and collagen makes the bone strong and hard (50).

Bone resorption markers – C-Telopeptide [CTx]

Bone resorption markers are generally determined in the patient’s blood and/or urine specimens. A lot of research is on to find out new biomarkers. With the help of these bone resorption markers doctors can predict bone loss in patients who are suffering from different diseases. Extreme care should be taken in translating the results in these markers as there can be variation in physical exercise, food intake and time when the sample is collected from the patients. Bone resorption includes blood and urine tests. The following are the bone resorption markers:

C-telopeptide is a commonly used bone resorption marker. It is also known in medical terms as the C-terminal telopeptide of type 1 collagen (CTx)). It is a fragment of peptide that comes from the carboxy terminal end of protein matrix. This bone resorption marker helps in antiresorptive monitoring therapies. It is useful in hormone replacement therapy; Ctx is effective in women who are in postmenopausal stage and people that have low bone mass.

Deoxypyridinoline (DPD) is another effective bone resorption marker. It happens to be a breakdown product of collagen that has a distinct ring structure. There are a few other bone resorption markers such as: Bone resorption marker called the Pyridinium Crosslinks., The bone resorption marker tartrate-resistant acid phosphatise and N-telopeptide or the N-terminal telopeptide of type 1 collagen (50).

Bone turnover markers

During the past few years there were considerable progress in the field of bone turnover markers. The biochemical monitoring and overseeing of the metabolism of bone depends solely upon the results of the measurement of enzymes and proteins that are released at the time of formation of the bone mass and its degradation during bone resorption. Several biochemical markers are accessible now so that a particular assessment of bone formation rate and resorption rate of the skeleton as a whole can be made conveniently. But these markers are not yet recommended in diagnoses related to osteoporosis. Nevertheless, they seem to be very useful and convenient for monitoring osteoporotic patients individually with antiresorptive agents (51).

Most of the available markers can be applied in selected cases to enhance the determination of the fracture risk of the individual when the measurement of the density of bone mineral provides only a vague result. In such cases the combined application of the BMD measurement will improve the assessment and finalisation of the risk of fractures. The diagnosis of osteoporosis is not at all solely based on the evaluation of bone markers. The normal mineral density of the bone (BMD) analysis and its assessment is still the criterion for evaluating the fracture and its diagnosis (52).

Reference range of bone health – DXA, BUA

Scanning of the density of bone is called Dual energy X-ray Absorptiometry (DXA or DEXA) or otherwise called Bone Densitometry. It is the most widely applied method for the measurement of bone mineral density. This is the sole method available to confirm the diagnosis of osteoporosis to monitor the response of the patient to the medical treatment. It is an advanced type of the X-ray technology itself, and it needs no injections or drugs for sedation. It also requires no special diet or any other planned preparations. The test can be executed by the physician or the technician within 30 minutes.

DEXA is generally applied on the lower spine or hips. There are portable DEXA devices that use ultrasound waves instead of X-rays, and that can measure the wrist or fingers. They are also viable for screening purpose. But there are controversies regarding selection of bones to make the best use of it for measuring bone density (53).

Broadband Ultrasonic Attenuation (BUA) technique was introduced in 1984 by Chril Langton, and now it is the foundation of QUS bone assessment, though its empirical method is far from satisfactory. This technique measures the amount of insertion loss, enumerated by comparing the spectrum of certain ultrasonic pulses that pass through the bone using a reference medium such as water (54).

Osteocalcin (OC) and alkaline phosphatase (ALP)

Bone histology is the standard for diagnosing renal osteodystrophy. It being costly several new other biochemical bone turnover markers are in use recently. Yet, there is no test which gives 100% result in monitoring bone turnover in ESRD patients. The type of modality of dialysis determines the different levels of the biochemical markers in metabolic bone disease. Some investigators report that iPTH, total ALP and bone specific ALP do not identify low-turnover bone diseases, mild osteitis fibrosa and normal bone diseases. They allege that the serum measurement of Calcium and Potassium is beyond any help in distinguishing high and low bone turnover levels. In the case of Hypermagnesemia which is very common among the dialysis patients, compresses PTH synthesis and its release (55).

De-oxpyridinoline [DPD] in children (6-18) years

The cross linking compound of collagen namely, deoxypyridinoline (DPD) is a proven bone marker for resorption as well as skeletal growth in young children. But the previous peptide-bound method of determination is still in demand technically. However the recent simple enzyme-linked immunosorbent assay is more convenient for the quantification of immunogenic DPD (iDPD) in samples of urine.

This immunoassay gives specific measurement of Rat deoxypyridinoline concentrations of DPD in cell culture supernates, plasma and serum. Deoxypyridinoline (Dpd) originates in Type I bone collagen. After the formation of this collagen matrix, lysyl oxidase acts on two hydroxylysine resulting in a lysine residue to make a Dpd cross link within the collagen’s two triple helical strands. During bone gradation, the Dpd enters blood which is purified by the kidneys. That’s why Dpd is considered as a biochemical indicator for resorption of bone (56).

The Dpd test is used to determine the rates of resorption of bone in healthy individuals as well as in the patients who are with the risk of metabolic bone disease. High levels of Dpd can be found in children and postmenopausal women because of estrogen deficiency. It is also found in patients having increased bone turnover rates. Dpd is applicable to monitor antiresorptive therapies in osteoporotic patients as well as postmenopausal women (56).

Methods to measure vitamin D strength, and the weakness of each method

Vitamin D is soluble in fat and is produced endogenously in sunlight. It is very essential for the human body to activate absorption of calcium, growth of bone and protect from different forms of cancer and other diseases (Vitamin D characteristics and function). There are two types of this vitamin measurable in the blood, the first one being 25-hydroxyvitamin D [25(OH)D] and the second 1,25-dihydroxyvitamin D [1,25(OH)(2)D], of which 25-hydroxyvitamin D is considered as the inactive initiator to active hormone1,25-dihydroxyvitamin D.

Due to its long half life and higher level of concentration, 25-hydroxyvitamin D is the usual measure to determine and monitor vitamin D status in a person. Some tests for 25-hydroxyvitamin D fail to identify its D₂ and D₃ forms and report only the total 25-hydroxyvitamin D. But the recent methods report all levels of 25-hydroxy i.e., D₂ and D₃ and then give the total 25-hydroxyvitamin D concentration level, which is used to assess the status of vitamin D.

25-hydroxyvitamin D

When calcium is at a low level or the patient exhibits vitamin D deficiency symptoms of rickets, bone weakness and bone softness, 25-hydroxyvitamin D is used to identify the of vitamin D.

1,25-dihydroxyvitamin D

If calcium is at high level or the patient suffers from a disease that produces more vitamin D as in the case of sarcoidosis, 1,25-dihydroxyvitamin D is used. This testing may be necessary in case there is suspected 1-alphahydroxylase (57).

There are different methods of testing, of which the gold standard is DiaSorin. Their method of radioimmunoassay (RIA) for measuring the levels of vitamin D cannot be accepted as accurate but most of the studies on vitamin D are performed on their recommended blood levels. Therefore, to get relevant clinical results, the test values shall be corresponding to the DiaSorin RIA results. Generally, there are three methods for measuring vitamin D3. They are:

1. LC-MS/MS: This test measures 25-hydroxyvitamin D2 and D3 individually.
2. RIA (DiaSorin): This measures total 25-hydroxyvitamin D accurately but do not separate D2 and D3)
3. Liaison (DiaSorin): This is the recent method developed by DiaSorin replacingRIA.

The LC-MS/MS method is the most wanted. Several labs use this method including Quest Labs, Mayo Clinic, Esoterix and ZRT, whereas Liaison is preferred by labs like LabCorp. The result of Quest Labs gives 40 percent higher than that of DiaSorin assay, which means the test results lack credibility. Quest Labs has not aligned their test values with DiaSorin so far. There are reports that many of the split samples sent to them return duly with inconsistent results. The LC-MS/MS is the accurate test but it needs highly qualified hands to operate and it needs calibration on par with RIA (58).

Liaison is DiaSorin’s recently developed test and it gives clinically accurate results. It is meant for high volume tests, and needs no expertise of lab technicians. LabCorp adopts this method as it invites less complaints. Moreover, the charge for the Lab Corp test is very less than the Quest test, and that makes Lab Corp affordable and reliable (58).

Compare between Western Children and Adolescents-NDNS-6-18 years

For human beings it is important to have calcium, vitamin D, protein, minerals etc for strong bones. Calcium is regarded as an important nutrient and is found in the body fluids and tissues. Its deposition in bone indicates the rate of growth and the children who have adequate intake of calcium will have strong bone mass. Calcium is important for attainment of peak bone mass in children and adolescents. If the diets have insufficient amounts of calcium, it means that the children will have only low bone mineral density leading to poor bone health in the future. Western children as compared to the Arabian children have stronger bones (74).

The health of children and adolescents are associated with their health related behavioural pattern, eating habits and physical activities. Evidence from various studies on their eating habits brings alarm about the future implications on their health condition as they are the least bothered about the long term results of their lifestyle and health practices. Cultural as well as socioeconomic factors and education contribute much to their lifestyles and dietary practices. Adolescents, to conform to the current fashions and body image put themselves under heavy pressure. The material developments in the western culture and dietary practices have direct impact upon them. The psychological variables like body image and modulation of self made dietary practices lead to obesity (60).

The information gathered from the national surveys extends necessary information about the quantity of food intake and the nutritional status an adolescent should adhere to (61). The diet of the teenager should lead to growth and good health. While they grow many physiological changes happen that affect the nutritional requirement of the adolescents towards rapid growth. During this period they show independent tendencies marked by making decisions about what they should eat and what should not. They choose food just for the peer pleasure or in a challenging mood against the parents.

The National Diet and Nutrition Survey of Young People Aged 4-18 Years give enough information about the nutritional intake as well as physical activities and proposes such activities. It is revealed that most of the children and the adolescents in UK consume large quantity of saturated fat, sugar and salt, but at the same time the consumption of starchy carbohydrates and fibre is found to be very low. The survey also revealed that one among ten teen agers have low intake of nutrition including vitamins, magnesium etc. Calcium and iron intake was significantly below the national level and at the same time obesity is in the high (59).

During the last three decades there has been considerable increase in the percentage of obesity and overweight among the children and adolescents of America. It reveals that the young people of USA have higher intake of food and less engagement in physical activities (62). Moreover they seem to be in the grip of some sort of alienation and social isolation. They are estranged and do not have the spirit to move in the social mainstream. However they think that they have more responsibilities but lack the ability in making decisions. These paradoxical notions have the outlets in the form of over emphasized emotional responses, medication, distress and aggression (63).

Results (Analysis)

The collected data were detailed and explicit, and therefore, it was important to make them more manageable. The questionnaire was used to collect parts of the data and to analyse the results quantitatively. The results were examined and then a meaningful conclusion was drawn out of it. The analysis of the data collected through the questionnaire was done by means of inductive approach, wherein inductive analysis denotes the origination of information inherent in the data itself (64). To fulfill the aims and objectives of this research the brief contents are analysed by means of survey results and clinical studies.

Survey-1 Sickle Cell Disease

Sickle cell disease (SCD) is categorized as prototypical molecular disorder that affects the red cells of the blood. Such blood cells of the children who are affected with SCD will be hard and pointed. SCD and Glucose 6-phosphate dehydrogenase is considered as the major health hazards in Saudi Arabia (65).

This survey analysis was conducted for studying the impact of vitamin D deficiency and mineral metabolism in children inflicted with sickle cell disease (SCD) in Jeddah, Saudi Arabia. It was done by measuring the serum 25(OH) Vitamin D and mineral concentrations in children aged up to 12 years. The number of subjects involved is 51, consisting of 28 males and 23 females up to 12 years old. 70 healthy controls were admitted to the sickle cell department of Jeddah Maternity and Children Hospital. After collecting fasting blood samples the serum was taken out and placed at minus 30 degree centigrade till analysis. Serum 25 (OH) Vitamin D was assessed by means of VDBP. Gc globulin. Calcium and the other two minerals namely, magnesium and phosphorus were measured through the application of clinical auto analyser.

The 51 patients were made into groups: A & B. The group A had 21 patients from new born to 6 years, while group B had 30 patients from 7 to 12 years.

The results arrived showed that 25 (OH) Vitamin D serum concentrations of the two groups were very low when compared with the matching controls, P<0.01 and P<.001. The group A exhibited no variations of serum concentrations of the minerals, namely calcium, magnesium and phosphorus, but group B showed less CA+2 serum concentrations than the controls P<0.05. There was no notable variation in P in the two groups (P<0.05) and it was very high in the serum concentration of magnesium related to group B (P<.05). This result established the relationship between Vitamin D deficiency and the children who were inflicted with sickle cell disease.

Survey-2 Vitamin D deficiency and Diabetes

The epidemiological researches indicate that there is a strong connection with vitamin D deficiency during the young stage and the type 1 diabetes that develop in the later stage. The study aimed to ascertain the link between vitamin D and T1DM. The population or subjects selected for conducting this study was 170 numbers of T1DM Qatari male and female children who are under the physical age of18 years registered at the endocrinology outpatient clinics working under the patronage of Hamad General Hospital.

The study was based on age, sex and ethnicity. The issues considered for the study were non-dietary covariates, dietary intake including vitamin D supplement, feeding pattern and the related clinical investigations. The status of their health was conceived by interacting with their families and also based on their clinical history. It was found that 90% of the T1DM children had vitamin D deficiency while it was only 85.3% in the non diabetic children exhibiting a mean difference of P<0.47. The deficiency was about 35.3% in the T1DM children whereas it was only 22.9% in the non-diabetic children. It was observed that there was only 37.4% of vitamin D supplement supported by milk in the case of diabetic children.

But in the non-diabetic children it was 47.7%. The multivariate logistic regression analysis indicated that the causes of the T1DM were directly proportional to the deficiency level of vitamin D, occupation of the parents and their family history, low level exposure to sunlight and reduced intake of breast milk. Thus it was concluded that vitamin D deficiency was higher in T1DM children, and that vitamin D deficiency was prevalent in almost all of the Qatari children. This risk could be prevented if vitamin D is supplemented in the infants (66).

Clinical study-1 Scoliosis and low bone mass? A comparative study between siblings of Saudi Arabia

Scoliosis is a malformation of the spine in which there is a curve of more than 10 degrees laterally. It is estimated that 2-4% of children aged between 10 and 16 years are affected by scoliosis. Out of this 27-38% of the girls are osteopenic.

Previous studies on the topic have indicated that vitamin D status among Saudi Arabians was very low but there were no significant studies since then. Therefore, the present study aims to determine the prevalence of low bone mass that is found among girls who are affected by Adolescent Idiopathic Scoliosis (AIS). The subjects selected for this study were Saudi girls affected by AIS whose bone mineral density relating to hip and spine were taken initially using DEXA scan. Thereafter their was mass was measured to commence the clinical examination to confirm that there were no other causes of scoliosis (67).

Patients having BMD of < −2.6 was noted as osteoporotic and those ranging from < −1 to −2.5 was placed as osteopenic for conducting the analysis. The BMD measurement of the controls was taken after determining their BMI and it was followed by the calculation of the mean BMI of those 32 girls. Their average age was: 18.42 ± 5.71 years and the mean BMI was: 17.7 ± 0.69 kg/M2. On analysis of the hip scans it was revealed that 62.5% of the subjects were osteoporotic having BMD of 0.837 (0.697–0.936) ± 0.04, T-score −3.8 ± 0.56 (−2.6 to −3.9) and Z-score. Nine (28.1%) of them were osteopenic having BMD of 0.768 ± 0.15 (0.638–0.878), mean T-score of −1.6 (−1.1 to 2.5) and Z-score −3.5 ± 0.63 (−2.9 to −3.9).

BMD of the spine revealed similar results. Patients having standard spine recorded a higher level of BMI and BMD marked as P < 0.001. The T- and Z-score was low in the case of scoliotic patients against the normal spine patients, and it was recorded as P < 0.001 (CI 95%). This study confirms that scoliosis is responsible for developing osteopenia and osteoporosis in girls (67).

Clinical study-2 Nutritional rickets in children

Nutritional rickets (NR) affect children and adolescents when they undergo rapid growth. It Fortified food, change in life styles and non exposure to sun are the main causes for affliction of this disease. As it is different from other form of rickets it can be treated if it is well detected. The statistical analysis was performed by utilizing SPSS 18.0, and for determining the differences in the mean values, the Student’s t-test was applied, and for evaluating the strength between the variables, the Pearson’s correlation coefficient was sought.

This study was conducted to explain the characteristics of nutritional rickets in the young children and the risk factors connected with it. A sample of 730 healthy children who visited the health clinics was selected for the study and out of the 570 gave consent. The diagnosis was done using clinical radiological and biochemical methods. Vitamin D therapy for 6 weeks was also carried out without break normalizing the level of alkaline phosphatase. The study indicated that 23.9% of the subjects had nutritional rickets and that the mean age of them was a little higher than those without rickets.

The family history related to vitamin D and diabetes mellitus were 44.2%; P-.oo1 and 53.5%; P=.002, respectively and the same was higher in rachitic children when compared to non rachitic children. The children having rickets received sun exposure only for a short duration while those without rickets were exposed to sun a bit longer. It was evident that a major section of the rachitic children was in the grip of vitamin D deficiency of 75.2% against 62%; P<.001 and secondary hypothyroidism of 100% against 7.5%P=.009. They experienced muscular weakness of 56.6% against 26.3%; P<.001. It was concluded that the main risk elements were reduced level of vitamin D and Calcium intakes, non exposure to sun and the breast feeding which lacked supplementation of vitamin D (68).

Questionnaire survey

To analyse the frequency and intensity of vitamin D deficiency and calcium metabolic syndrome and its impact on the overall health status of the people in Saudi Arabia, an interview was conducted among 32 professionals consisting of 16 males and 16 females within the age of 35 to 45 years, belonging to different ethnic groups including Saudis, Indians and Philippinos who were working in different hospitals in Dammam and Riyadh. These physicians were engaged in the treatment of patients for various diseases inflicted by vitamin D deficiency and calcium metabolic syndrome. They were also found to be participating in another research to evaluate the effects of betaine on cardiovascular risk factor.

Before the interview a set of 9 questions were served to them to gather the required data. The result of the interview and answers to the questionnaire revealed that 99% of them were aware that lack of vitamin D resulting from non exposure to sunlight and the life style added by ignorance were the main causes for the occurrence of several diseases.

Discussion

The present study deals with vitamin D deficiency/insufficiency and calcium metabolism in the Arabian Gulf children aged 6 to 18 years and analyses the impact of nutritional status and lifestyle factors on peak bone mass (PBM) attainment. The various studies on the nutritional influences on PBM attainment indicate that for developing and maintaining strong and hard bones in the body adequate amount of calcium, vitamin D, protein and minerals are necessary. The women during pregnancy need proper dietary supplements so that the offspring inherits strong bones from birth. It is apt to make a note here that the Arabian children have weaker bones when compared to the Western children (74).

Currently, an Arab-American woman who wears hijab or burqua, which is a religious custom oriented dress code for Muslims, has to veil her hair and the whole body, and it deprives her birth right to have the God given sunshine, and it incapacitates her to the extent that she is devoid of the natural endogenous production of vitamin D in her body. The deficiency can indeed be substituted by dietary supplements but to what extent and level?

There may still exist no variation in the rate of health hazards connected with vitamin D deficiency, like bone pain or fractures and hypertension. A few years ago it was thought that the deficiency would cause only rickets or soft bones, but now it is found that it has too many associations with multiple sclerosis and other related diseases (74). Who knows, as time goes by, further studies may invoke new and new findings revealing that vitamin D determines even the life spinning mechanism in the human body as well as the entire living beings on this earth.

The American physicians are all set to argue that their intention is not meant to link veiling to vitamin D deficiency that affects a billion people, and that their earlier study which was published in Pediatrics 2000 had proved that the Orthodox Jewish children located in Brooklyn who were veiled in long sleeves throughout also suffered from vitamin D deficiency. Other studies conducted in the tropical climatic areas of Asia and Australia where some people veil their body revealed that 30 to 50 percent of them were suffering from vitamin D deficiency and related diseases. If the vitamin is supposed to be intake through food, a person needs to eat at least 80 eggs or drink 20 glasses of milk, but 10 or 20 minutes sunshine will give that person 20000 units of vitamin D, which is tenfold than the supplement (69).

Vitamin D is essential for the effective absorption of calcium in the body to maintain the bone health in children and adolescents. Vitamin D deficiency is that much associated to fracture and in the development of low bone mass (Loud and Gordon). According to Zitterman 5, vitamin D is a substance endogenously produced in the skin of our body upon exposure to UVB rays by acting on 7-dehydrocholesterol and hydroxylation in the internal organs such as kidneys and liver. It acts like a steroid hormone that responds to vitamin D receptors (3).

The importance of serum 25(OH)D as an indicator to the nutritional level of vitamin D and mineral density of bone in the young generations has been confirmed and it indicates its impact on bone mass density and bone mass mineral content. In this context it is very relevant to note that the statement of the Panel on the Human Observational Intervention Studies which put forward the scientific legend: “calcium and vitamin D are needed for normal growth and development of bone in children” (31).

The stipulation of the Panel in the matter of calcium and vitamin D is that the food content shall contain all of the nutrients provided in the Annex to Regulation 1924/2006, which is the balanced diet for the target population up to the age of 18 years, without limiting the intake of calcium to Tolerable Upper Intake Levels, though for adults the UL fixed is 2500 mg/day. But in the case of vitamin D intake of children and adolescents, the UL established is 25μg/day, till the age of 10 years and, 50μg/day for the age up to 11 years (31). This is an eye opener to the rest of the world to see the consequences of vitamin D deficiency.

Lifestyle and physical activity play an important role in PBM attainment. These changes in the life style and the choices in multitudes deeply affect the levels of Vitamin D in the body. Aging, lack of exercise, obesity, and short in sun exposure etc. contribute much to the vitamin D syndrome (2). Musaiger states that though the gulf countries have achieved considerable improvement in the field of economics and health, nutritional problems vitamin D deficiency are still rampant. This causes anaemia and obesity in women, weight loss and dental caries in children (6).

Calcium is regarded as an important nutrient and is found in the body fluids and tissues and its deposition in bone indicates the rate of growth. If children have adequate intake of calcium, then they will attain the required bone mass. Calcium is important for attainment of peak bone mass in children and adolescents. If the diets have insufficient amounts of calcium then it means that the children will have only low bone mineral density. This will lead to poor bone health in the future. Western children as compared to the Arabian children have stronger bones.

The bone mineral density or BMD determines the risk of fracture. The mother’s diet should be such that the child inherits strong bones at its birth. A single measurement if taken shows the current BMD, but it does not tell about the bone loss in future.

If the mother does not get proper nutrition then her child will have no strong bones later. Thus, Calcium contributes to the formation and metabolism of bone. More than 99 percent of it exists in the bones and teeth of the body as calcium hydroxyapatite which is chemically represented as Ca10 [PO4]6[OH] 2. It provides strength and hard covering and regulates the functions of the circulatory system, muscles, vascular contraction and vasodilatation, nerve transmission, signaling, hormonal secretions etc. The tissue of bone acts as a reservoir of calcium and performs the metabolism through bone remodeling. When there is deficiency of vitamin D, the bone metabolism is affected resulting in reduced absorption of calcium (28).

Different bone formation markers are used by doctors to find out the products of bone remodelling. They are blood and urine tests that help to determine if there is increased rate of bone resorption in the body. It also helps to find out there is an abnormal increase in bone formation as well. This indicates that there may be a potential bone disorder. Bone markers determine the risk of bone fracture in a person and help doctors to monitor suitable drug therapy for such patients who are undergoing different treatment for bone disorders. However, vitamin D is essential for the effective absorption of calcium in the body and also for maintaining the bone health of children and adolescents. Vitamin D deficiency is much associated to fracture and in the development of low bone mass (33).

Bone markers are tests that indicate bone remodelling. Physicians can find out the details of bone resorption and bone formation with the help of bone formation markers and suggest a line of treatment for the patient. If there is a bone disorder then it can be detected sooner. Bone has a 10% turnover rate annually and is a growing tissue in the body. The bone is formed of type-I collagen and is a protein network deriving frame and strength from it. Another mineralized complex such as the calcium phosphate strengthens the human skeletal framework. The combination of calcium and collagen makes the bone strong and hard (50).

Another mineralized complex such as calcium phosphate strengthens the human skeletal framework. The combination of calcium and collagen makes the bone strong and hard with adequate calcium and Vitamin D when they are pregnant. These bone markers show good result in selected cases. It helps to assess individual fracture risk especially when bone mineral density measurement does not provide an answer. In such cases it has been found that the use of BMD measurement and bone markers together has been effective in assessing the risk of fractures in patients (48).

A report that appeared in the Emirates Medical Journal, quoted a statement of Associate Professor Dr. Hussein Saadi of UAE University. He stated that along with vitamin D intake, prolonged calcium intake was needed to maintain the bone and normal health. The food is the main source of calcium and as such every adult should take minimum 1000 mg of elemental calcium every day. The necessity of calcium would become crucial when one could not take enough dietary intakes (71).

Vitamin D deficiency is the root cause for the infliction of several diseases such as diabetes, rickets, cardiovascular malfunctions, and sclerosis, and osteoporosis, different types of cancers, calcium shortage, and mental disorders. A recent survey held by the Health Sciences department of the University of Qatar on the health status of the Qatari people proved that almost 53.5% of college going females are suffering from vitamin D deficiency and another 43% are affected by insufficiency of that particular vitamin. Qatari children aged 11 to 16 years suffer from vitamin D insufficiency and are prone to skeletal and muscle development (72).

According to Lagunova and Porojnicu (46), excess body weight causes somatic and psychological disorders. Overweight and obesity are highly associated with low vitamin D status. During recent years the incidence of childhood and adolescent obesity is increasing to an alarming level. Vitamin D deficiency and insufficiency is seen more in the overweight adolescents than in the overweight children. The reason for this is the relative low outdoor activities and vitamin D intakes (46).

The major portion of mineral contents of a skeleton is calcium and its low intake during childhood can bring havoc in his late life, for calcium is associated with osteoporosis. As a result of this deficiency of bone mass happens followed by a reduced bone density. The structure of the bone is altered and becomes fragile. Smoking, poor diet, alcohol etc. further the disease. Osteoporotic bones are susceptible to fractures and the bone becomes curved.

The height of the person may also decrease up to 3 inches. The structural alterations affect the normal breathing level. Therefore, to combat these situations adequate input of nutrition is necessary. Hollis and Wagner stipulate that a higher dose of vitamin D is essential for a large section of Americans to acquire the required concentrations of 25-hydroxyvitamin D between 15 and 80 ng/mL which is equivalent to those who live in sunny environments (73).

This situation is caused by restricted sun exposure, religious custom and cultural practices. Added to this are the dark skin of the people and their reduced calcium intake. Hypovitaminosis D, which is the root cause of osteoporosis, creates the major health issue in these regions. It is known that vitamin D deficiency is connected with autoimmune disorders, cancers, metabolic syndrome, diabetes etc. The inability of the dark skin to create vitamin D from UVB rays of the sun paves way for rickets and hypovitaminosis D (23). It is a fact that anything that restricts the transmission of UVB radiation from the solar rays and its penetration into the skin will thwart the cutaneous synthesis of vitamin D3.

Though the Arab Gulf countries have acquired significant advancement in the fields of economic and social status, the nutritional disorders are still rampant among the people. Anaemia, obesity, low birth weight, vitamin D deficiency, dental caries are very common among women and children (24).

Olarte (11) pointed out that the effects of vitamin D deficiency extend from bone metabolism to noncalcemic diseases like neurological disorder, multiple sclerosis, Alzheimer, rheumatic complaints, diabetes, mycobacterium tuberculosis, cardiovascular problems, body pain and several other diseases. It is estimated that 65% of females and 60% of males in Abudhabi suffer from Vitamin D deficiency (11).

Conclusion

Vitamin D is a vital nutrient for human health. Vitamin D deficiency is a worldwide problem as most of the people are in its grip. The deficiency and insufficiency of this vitamin can lead to several unending problems in the health condition of the people on this globe of ours. Vitamin D is endogenously produced by exposure to sunlight and is found in a few items like fatty fish, milk products and cereals. But the quantity content of vitamin D in these materials is too negligible, compared to the production of the vitamin in our body with sun exposure for a few minutes.

Dietary supplements about 2500 mg per day for an adult will not always give adequate vitamin D, and therefore exposure to sunlight is the best essential for that. The recent developments in the studies on vitamin D prove that it is what regulates a series of biological processes such as cell division, cell turnovers, differentiation and the like.

Osteoporosis is identified by the low bone mass and impaired micro-architectural bone structure that tends to fracture. The strength of the bone is influenced genetically to a large extent and that too in quality and quantity. But some other factors like nutrition, lifestyle, and environment are also responsible for it. Nutrition is an important factor in the development. Maintenance and restoration of bone mass. It also helps prevention and effective treatment of osteoporosis.

It is estimated that 80–90% of the mineral content of bone consists of calcium and phosphorus. For the normal metabolism of bone protein, zinc, magnesium, copper, fluoride, iron, and vitamins are required, whereas caffeine, alcohol and phytoestrogens impact upon bone health. Unraveling the interaction of these different factors such as nutritional, lifestyle, heredity and environment it is wise to conclude that vitamin D deficiency is very critical by its function in our body.

The documentary evidences prove that vitamin D deficiency is rampant among our populace and the very fact is attaining alarming proportions. The most affected people are the dark skinned ethnic groups in Asia and Africa. The sunny countries of Gulf region are also fallen prey to the deficiency and insufficiency of this life giving vitamin. The women of the Arab world are the most hit people of the world as they cover their bodies with veils keeping away from the sunlight.

The epidemiological researches have established unequivocally about the correlation between vitamin D deficiency and diseases in the bone and other organs of our body including brain, lungs and heart, and that it helps strengthen the immune system. Therefore enough exposure to sun is required, if not the deficiency or insufficiency shall be supplied through dietary supplements, failing which the people will face long standing consequences.

Recommendation

Since vitamin D deficiency affects the total immune system of the body and determines the health of an offspring throughout its journey of life from infant to adolescence and from adolescence to adulthood and old age, the government machineries of the world should interact with each other and take immediate steps on war foot basis to extend their help to each other of their counterparts in combating vitamin D deficiency and calcium metabolic syndrome thereby enabling the humanity to keep a very strong and healthy populace to mark the future of the world.

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