|Ahead of print publication
Vitamin D status and its determinants among young unmarried adult females in Northeast India: A cross-sectional study
N Nagaraja1, Barun Kumar Chakrabarty2, Y Singh3, M Jayalakshmi4
1 Department of Gynaecology, 151 Base Hospital, Guwahati, Assam, India
2 Department of Pathology, 151 Base Hospital, Guwahati, Assam, India
3 Department of Gynaecology, Command Hospital, (SC) Pune, Maharasthra, India
4 Professor Cum Principal, Army Institute of Nursing, Guwahati, Assam, India
|Date of Submission||21-Jan-2020|
|Date of Decision||10-Aug-2020|
|Date of Acceptance||27-Nov-2020|
|Date of Web Publication||01-Apr-2021|
Barun Kumar Chakrabarty,
Department of Cytogenetics, Tata Medical Centre, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
Context: Undiagnosed Vitamin D deficiency is a widely prevalent problem in the Indian subcontinent. The prevalence and severity of Vitamin D deficiency are more commonly revealed among Indian females compared to males. Subjects and Methods: The study subjects comprised 198 female students of a nursing college located in Northeast India who were attending the gynecology outpatient department of a tertiary care center. Study participants were invited to respond to online queries related to Vitamin D deficiency and associated sociocultural practices. Among them, 126 students who had volunteered, 25 OH Vitamin D total levels were estimated by enzyme-linked fluorescent assay method along with linked blood parameters. Results: In this cross-sectional study, among the 198 study subjects attending outpatient services, 75.3% reported less than an hour daily exposure to the sun though 93.4% had awareness that sunlight exposure is the best natural resource of Vitamin D. All eight participants who did not have the proper knowledge of Vitamin D source were detected to be deficient. Our study showed that out of studied 126 students, half of them had severe Vitamin D deficiency (<8.1 ng/ml) and 45.2% demonstrated Vitamin D level <20 ng/ml (deficient). About 3.2%, i.e., four females, divulged Vitamin D level of 20–29 ng/ml (insufficient). Conclusions: Our study revealed relevant knowledge, belief, and sociocultural practices related to Vitamin D deficiency among young adult females of Northeast India. Contrary to previous studies, the findings also highlighted the alarmingly high prevalence of Vitamin D deficiency in the studied population.
Keywords: Northeast India, Vitamin D, young adult female
|How to cite this URL:|
Nagaraja N, Chakrabarty BK, Singh Y, Jayalakshmi M. Vitamin D status and its determinants among young unmarried adult females in Northeast India: A cross-sectional study. J Mar Med Soc [Epub ahead of print] [cited 2021 Apr 23]. Available from: https://www.marinemedicalsociety.in/preprintarticle.asp?id=312892
| Introduction|| |
Vitamin D deficiency is a well-known pandemic but is largely ignored globally. In addition to skeletal problems, Vitamin D deficiency may play a role as a causative factor for autoimmune disorders, thyroid disorders, cardiovascular diseases, diabetes, adverse reproductive outcomes, and even cancer. At present, India has the largest youth population in the world. It is generally believed that young adults enjoy better health compared to aged groups, but several studies challenged the prevailing concept. The widespread prevalence of this deficiency is being observed in both rural and urban India.,,,
Vitamin D is relatively easy to access from inexpensive natural resources like sun exposure and several food/cheap supplement sources. Although Indian subcontinent assumed to get adequate sunshine to meet individual requirements for Vitamin D, major possible causes of widespread deficiency are due to various limiting factors such as lack of knowledge and awareness, pollution, clothing pattern, urban indoor lifestyles, food habits, skin tone, and cultural and social taboos. Previous research showed that Indian females tend to have more and severe Vitamin D deficiency compared to their male counterparts, and lower socioeconomic female group suffered the most.
Previous studies showed that female university students had high chances of Vitamin D deficiency. In addition to impacting the formation of lifelong behaviors and quality of their individual lives for many years, young adult females also influence the health behavior of their family members and the next generations., Selection of young nursing students in this study provides a twofold prospect of targeting a prime section of the population that would also be future first-line health-care providers of the community. It has been proposed that community-level awareness campaigns about Vitamin D targeting both general and high-risk people might help prevent health consequences.
Nutritional deficiencies, allergic disorders, diabetes, and thyroid-related disorders are demonstrated to be strongly associated with Vitamin D deficiency condition. Vitamin D level also suggested to highlight a number of sex-specific health and lifestyle factors. There is limited and conflicting information available about health-related issues associated with Vitamin D insuffiency in young adult Indian females. The reported associations between anemia, diabetes mellitus, serum immunoglobulin (IgE) abnormalities, and thyroid abnormalities with Vitamin D insufficiency/deficiency warrant further examination to assess the potential nature of causal relationship between these clinical conditions in young adult Indian females.,,
This study was conducted to find the prevalence of Vitamin D deficiency/insufficiency among young adult female nursing students of northeast India and to find its association with determinants of Vitamin D, the potential predisposing factors for the deficiency or insufficiency including sociodemographics, dietary and lifestyle-related factors, and health disorders.
| Subjects and Methods|| |
This cross-sectional, single-center study was organized in a 699-bedded hospital of Northeast India, for 3-month period from February 2019 to April 2019. Ethical approval for the research study was obtained from the ethical committee of the institution. The sample size was determined by software Epi Info Version 7 (CDC, Atlanta, Georgia, US), using a prevalence rate of Vitamin D deficiency and insufficiency of 44% among adult northeastern healthy females, determining study confidence interval of 95% and power of study as 80%. The study requirement of minimum sample size was calculated as 95. During the period of the study, all unmarried adult female nursing students of a single nursing institute aged between 18 and 24 years who visited gynecology department health awareness clinic were enrolled in the study. During the initial visit, the study plan and prospects were explained to suitable candidates. Enrolled study participants accepted written informed consent before participation in the study. The online survey based on free Google Form was forwarded to the participants' mobile. The married candidates, nursing students from other institutes, and those who did not consent or respond to the online survey sent to their mobile phones were excluded from the study. The sample questionnaire was pilot tested for usability and adequate explanation was provided to the study subjects.
A total of 198 nursing students participated in a voluntary online survey related to general health and Vitamin D-related sociocultural practices. All the participants who responded to the initial survey were requested to attend the clinic after 7 days. The participants were living in ladies' hostel within the city area with adequate open space for outdoor physical activity. All the study participants had access to balanced healthy diet services and free basic health-care services. A total of 126 participants reported back for the next part of the study. In the next visit, they were interviewed for general health conditions and examined by the competent gynecologist. The height, weight, pulse, and blood pressure were noted. Body mass index was derived for every participant. During this phase of the study, fasting blood samples were obtained from each participant for evaluation of complete blood count, fasting blood sugar, (FBS) serum thyroid-stimulating hormone (TSH), serum IgE, and serum 25 OH Vitamin D total. Based on the common accessible facilities, the authors presumed that the study population had adequate facilities for exposure to natural sources of Vitamin D [Figure 1]. Serum TSH, total IgE, and 25 OH Vitamin D total levels were estimated by enzyme-linked fluorescent assay technique. In this study, the World Health Organization definition of anemia, i.e., blood hemoglobin concentration <12 g/dl, was followed as defining criteria for anemia for young adult females. 2018 American Diabetes Association criteria were followed for FBS level interpretation. We have utilized kit literature reference range for analysis of immnoanalyser assays. Serum TSH and serum total IgE reference range were taken as 0.25–5 μIU/ml and <150 KIU/l, respectively. Serum Vitamin D level <20 ng/ml was conveyed as “Deficient,” range of 20–29 ng/ml was taken as “Insufficient,” and 30–100 ng/ml marked as “Sufficient.” Estimated values lower than the detectable lower limit of the method range were reported as <8.1 ng/mL and reported as “Severely Deficient.”
All data were initially tabulated into MS Excel with Windows 10 Operating System and subsequently analyzed by means of Statistical Package for the Social Sciences(SPSS) version 22 (IBM Corp., Armonk, NY, USA). Study descriptive characteristics were analyzed and multiple comparison analysis was performed. Online survey data were illustrated in the frequencies and percentages format. Chi-square test and analysis of variance test was used to assess significant statistical associations between the study groups based on Vitamin D level and different studied variables. Pearson's correlation analysis was performed to test the status of correlation between studied parameters. P < 0.05 was recorded as statistically significant.
| Results|| |
A total of 198 nursing students participated in the initial survey. Our participants were mostly nonvegetarian (71.7%). Approximately 93.4% of participants had the correct understanding that exposure to sunlight is the best natural source of Vitamin D, but most of them exposed them to sunlight <1 h duration per day. A significant percentage of them regularly used sunscreen (24.7%) and most of them had a habit of using sunscreen bearing sun protection factor (SPF) >15 (19.2%). About 68.2% of our study participants declared themselves free of illnesses. Nearly 32.8% of them were regularly playing outdoor sports. Only 5.6% of them were taking supplementary medicines [Table 1].
A total of 126 participants reported back for the next part of the evaluation. Our final participants were also predominantly nonvegetarian (70.6%). Most of them (93.7%) had the correct knowledge of the best source of Vitamin D, but 77% of them exposed them to sunlight <1 h duration per day. 23% of the study participants responded that they were using sunscreen and most of them(16.7%) reported that they were using sunscreen bearing SPF>15. About 65.9% of our final study group was declared free of illnesses. Nearly 25.4% of them are regularly playing outdoor sports. Only 4.8% of them were taking supplementary medicines [Table 1].
The mean age of the final study population who volunteered for clinical and aboratory examination (n = 126) was 20.8 ± 1.3 years with a range of 18–24 years. All our participants were found to be normotensive. In our study, we found that Vitamin D deficiency prevalence rate among the participated nursing students was 95.2%, while that of Vitamin D insufficiency was 3.2% [Table 2]. The two Vitamin D-sufficient cases were nonvegetarian, spend less than an hour per day under the sun, not playing outdoor games, and not using any supplements. One of them used sunscreen with >15 SPF with mildly high IgE level and both the sufficient cases were detected with anemia. They had proper knowledge of the source of Vitamin D and were free from any health complaints. Among our study groups those who were free from any health complaints, none of the studied parameters were found significantly altered (n = 82). Anemia, impaired fasting glucose, and high serum IgE level were seen in 60%, 30%, and 43% Vitamin D-deficient participants, respectively [Table 3]. Serum IgE level exhibited a negative correlation trend (Pearson correlation: −0.96) with Vitamin D level, although it was found statistically nonsignificant.
| Discussion|| |
Our study showed that the prevalence of Vitamin D deficiency and insufficiency among the studied young adult female nursing students of Northeast India was 98.4%. In India, various studies reported a higher rate of prevalence for deficiency of Vitamin D among females. Studies also showed that poor and village living Indian women were particularly vulnerable. It is generally believed that urban educated young adult university students have better nutritional status than rest of the population. The study conducted in part of the year when there were chances of maximum exposure to the sun due to weather conditions. Although the students were from various parts of India, during the study, they were independently staying in a hostel in a female-dominated progressive society in Northeast urban India. The cultural norms and sociocultural tradition pressures of the veiling system followed for young unmarried females thought to be minimal for our study population. The study population was unmarried, apparently healthier, normotensive, and had access to better lodging facilities, health-care facilities, and balanced diet. Therefore, the data generated represent the best-case scenario for the age group. The authors believe that further studies among the age group with random sampling across all seasons should yield an even scary scenario for Vitamin D insufficiency. Previous studies on northeastern ladies showed a significantly lower rate of prevalence for Vitamin D deficiency. The higher deficiency prevalence similar to other parts of India emanating from this study may be due to their own sociocultural and food habit effects imbibed in the studied population.
Our study highlighted that the occurrence of Vitamin D deficiency was very high in unmarried females, and even when they were educated and had adequate knowledge of sources of Vitamin D. It is generally observed in Indian society with the improvement of socioeconomic condition, Indian females tend to adopt less outdoor exposure. Unmarried Indian females generally restrict their food habits to look slimmer and try achieving a fairer complexion by avoiding the sun adopting various fashionable ways and means., The availability of Vitamin D in cooked food deteriorated due to traditional cooking practices followed in India due to thermal degradation. Another important aspect of Vitamin D deficiency is that it is apparently asymptomatic. Probably due to the prevailing conditions, even after adequate access to free health care and sun exposure facilities, our studied population did not take on preventive lifestyle changes.
Decreased 25(OH) Vitamin D level was demonstrated to be linked with nutritional deficiencies and increased risk of diabetes and thyroid-related disorders, andcardiovascular diseases, especially hypertension.,,, Among the studied Vitamin D-deficient/insufficient population, 37 (29.4%) were having impaired fasting glucose level and 2 deficient ladies were found to have blood glucose level at a diabetic range. Subclinical hypothyroidism level increase in TSH was seen in 2 Vitamin D-deficient/insufficient females. In our study, we found that a significant number of Vitamin D-deficient participants (n = 72) were anemic [Table 3].
Previous experimental studies related to Vitamin D hypothesized that VDR gene polymorphism and other Vitamin D-related genes which control host response and utilization of Vitamin D may also have an influence on serum IgE level. Therefore, several studies correlated with high serum IgE level with the intensity of Vitamin D deficiency. Our study also depicted an inverse relationship between obtained serum IgE and Vitamin D level.
The primary strength of our study is that it is the first study of its kind conducted among young adult female nursing students in NE India. The study has a limitation of small sample size. The sample size was calculated with a 10% deviation, and hence, the statistically calculated required sample size is less, which is a limitation of the study. There are controversies going on regarding the normal range of Vitamin D in Indian females. We could not study various known parameters which can influence the Vitamin D level due to resource constraints. However, the study was designed in such a manner that important determinants of Vitamin D insufficiency have been well described so that the key aim of the study was contented.
| Conclusions|| |
India has a demographic advantage due to the presence of the largest young adult population in the world. Focusing on the health and well-being of the female counterpart of this cohort is especially important because of advantageous economic and social reform to work. In Indian society, unmarried young females face substantial hurdles in terms of sociocultural and gender standards. At the same time, they are found to be strongly responsive to education and training to create and contribute a healthy societal future. The selection of future health-care professionals in our study has cascading effects in the society. Contrary to the popular belief, our study demonstrated that there is a worryingly high-level prevalence of Vitamin D deficiency and insufficiency among the unmarried young adult Indian females residing in the northeastern part of urban India. It revealed the belief and practices related to Vitamin D determinants. It also highlighted the urgent need for intervention in form of national programme targeting the young adult population for preventive measures in form of health awareness, regular screening, social reforms, and fortification of locally available staple foods with Vitamin D. Further large scale studies are recommended in the targeted population to formulate a plan to eliminate this preventable nutritional deficiency disorder.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Arabi A, El Rassi R, El-Hajj Fuleihan G. Hypovitaminosis D in developing countries-prevalence, risk factors and outcomes. Nat Rev Endocrinol 2010;6:550-61.
G R, Gupta A. Vitamin D deficiency in India: Prevalence, causalities and interventions. Nutrients 2014;6:729-75.
Tandon N, Marwaha RK, Kalra S, Gupta N, Dudha A, Kochupillai N. Bone mineral parameters in healthy young Indian adults with optimal vitamin D availability. Natl Med J India 2003;16:298-302.
Wacker M, Holick MF. Vitamin D-effects on skeletal and extraskeletal health and the need for supplementation. Nutrients 2013;5:111-48.
Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, et al
. Evaluation, treatment, and prevention of vitamin D deficiency: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2011;96:1911-30.
Misra P, Srivastava R, Misra A, Kant S, Kardam P, Vikram NK. Vitamin D status of adult females residing in Ballabgarh health and demographic surveillance system: A community-based study. Indian J Public Health 2017;61:194-8.
] [Full text]
Beloyartseva M, Mithal A, Kaur P, Kalra S, Baruah MP, Mukhopadhyay S, et al
. Widespread vitamin D deficiency among Indian health care professionals. Arch Osteoporos 2012;7:187-92.
Hattapornsawan Y, Pangsuwan S, Ongphiphadhanakul B, Udomsubpayakun U. Prevalence of vitamin D deficiency in nurses at the Royal Irrigation Hospital. J Med Assoc Thai 2012;95:1569-74.
Von Ah D, Ebert S, Ngamvitroj A, Park N, Kang DH. Predictors of health behaviours in college students. J Adv Nurs 2004;48:463-74.
Bouillon R, Marcocci C, Carmeliet G, Bikle D, White JH, Dawson-Hughes B, et al.
Skeletal and extraskeletal actions of vitamin D: Current evidence and outstanding questions. Endocr Rev 2019;40:1109-51.
Giustina A, Adler RA, Binkley N, Bouillon R, Ebeling PR, Lazaretti-Castro M, et al
. Controversies in Vitamin D: Summary statement from an international conference. J Clin Endocrinol Metab 2019;104:234-40.
Bouillon R. Comparative analysis of nutritional guidelines for vitamin D. Nat Rev Endocrinol 2017;13:466-79.
Dasgupta A, Saikia U, Sarma D. Status of 25(OH) D levels in pregnancy: A study from the North Eastern part of India. Indian J Endocrinol Metab 2012;16:S405-7.
Kamboj P, Dwivedi S, Toteja GS. Prevalence of hypovitaminosis D in India & way forward. Indian J Med Res 2018;148:548-56.
] [Full text]
Selvarajan S, Gunaseelan V, Anandabaskar N, Xavier AS, Srinivasamurthy S, Kamalanathan SK, et al
. Systematic Review on Vitamin D Level in Apparently Healthy Indian Population and Analysis of Its Associated Factors. Indian J Endocrinol Metab 2017;21:765-75.
Ganguly N, Roy S, Mukhopadhyay S. Association of socio-culture factors with disordered eating behavior: An empirical study on urban young girls of West Bengal, India. Anthropol Rev 2018;81:364-78.
Ke L, Mason RS, Kariuki M, Mpofu E, Brock KE. Vitamin D status and hypertension: A review. Integr Blood Press Control 2015;8:13-35.
Alkhatatbeh MJ, Abdul-Razzak KK, Khasawneh LQ, Saadeh NA. High Prevalence of vitamin d deficiency and correlation of serum vitamin d with cardiovascular risk in patients with metabolic syndrome. Metab Syndr Relat Disord 2017;15:213-9.
Ke L, Mason RS, Mpofu E, Vingren JL, Li Y, Graubard BI, et al
. Hypertension and other cardiovascular risk factors are associated with vitamin D deficiency in an urban Chinese population: A short report. J Steroid Biochem Mol Biol 2017;173:286-91.
Ismail MF, Elnady HG, Fouda EM. Genetic variants in vitamin D pathway in Egyptian asthmatic children: A pilot study. Hum Immunol 2013;74:1659-64.
Ross AC, Manson JE, Abrams SA, Aloia JF, Brannon PM, Clinton SK, et al.
The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: What clinicians need to know. J Clin Endocrinol Metab 2011;96:53-8.
[Table 1], [Table 2], [Table 3]