876151

research-article2019
SMO0010.1177/2050312119876151SAGE Open MedicineEl-Khateeb et al.

SAGE Open Medicine

Original Article

SAGE Open Medicine

Vitamin D deficiency and associated Volume 7: 1­–6

© The Author(s) 2019
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DOI: 10.1177/2050312119876151
https://doi.org/10.1177/2050312119876151
journals.sagepub.com/home/smo

Mohammed El-Khateeb1, Yousef Khader2 , Anwer Batieha2 ,

Hashem Jaddou2, Dana Hyassat1, Nahla Khawaja1,
Mousa Abujbara1 and Kamel Ajlouni1

Abstract
Background: In Jordan, many studies reported various rates of vitamin D deficiency and insufficiency among different
groups. This study aimed to determine the prevalence of low vitamin D level among Jordanian adults and determine its
association with selected variables.
Methods: The vitamin D level was assessed in a national representative sample of 4056 subjects aged >17 years. The study
involved face-to-face interviews with the subjects and measurement of serum 25(OH)D. Low vitamin D level was defined
as 25(OH)D < 30 ng/mL. Deficiency was defined as 25(OH)D < 20 ng/mL, and insufficiency was defined as 25(OH)D level of
20–30 ng/mL.
Results: The overall prevalence of low vitamin D status (25(OH)D < 30 ng/mL) was 89.7%, with higher prevalence in males
(92.4%) than in females (88.6%). Vitamin D was sufficient in 7.6% of males, insufficient in 38.4% of males, and deficient in 54%
of males. Among females, vitamin D was insufficient in 10.1% and deficient in 78.5%. The prevalence of vitamin D deficiency
was much higher in females than in males (p = 0.001). The only variables that were significantly associated with low level of
vitamin D were gender, age, obesity, and employment.
Conclusion: The prevalence of low vitamin D level is extremely high in Jordan. Age, gender, obesity, and unemployment
were associated with low levels of vitamin D. Health authorities in Jordan need to increase the level of awareness about
vitamin D deficiency and its prevention, particularly among women.

Keywords
Vitamin D deficiency, prevalence, Jordan

Date received: 12 May 2019; accepted: 22 August 2019

Introduction nutritional sources such as codfish, mushrooms, milk, eggs,

and fortified food. Although vitamin D synthesis depends on
Vitamin D deficiency is currently recognized as a common UVB sunlight exposure, many other factors such as age, obe-
public health problem.1 The role of vitamin D in calcium and sity, skin color, dress style, and sunscreen-use might affect
phosphate homeostasis and skeletal and non-skeletal health is vitamin D level.8
well established. Vitamin D deficiency plays an important role In Arab countries, with sunlight throughout the year, vita-
among other factors in metabolic bone disorders leading to min D serum levels are expected to be adequate, yet studies
osteomalacia in adults and rickets in children.2 Vitamin D from different Arab countries showed high prevalence of
deficiency is associated with many chronic diseases including
cardiovascular diseases, hypertension, diabetes, metabolic
1TheNational Center (Institute) for Diabetes, Endocrinology and
syndrome, depression, autoimmune diseases, cancer, neuro-
Genetics (NCDEG), The University of Jordan, Amman, Jordan
cognitive function, and increased occurrence of infection.3–7 2Jordan University for Science and Technology, Irbid, Jordan
Almost 90% of the human endogenous vitamin D is syn-
Corresponding author:
thesized primarily in the skin by activation of 7-dehydrocho-
Kamel Ajlouni, The National Center (Institute) for Diabetes,
lesterol triggered by the exposure to ultraviolet (UVB) Endocrinology and Genetics (NCDEG), The University of Jordan, P.O.
sunlight, so limited exposure to the sunlight might lead to Box 13165, Amman 11942, Jordan.
vitamin D deficiency. The remaining 10% is acquired from Email: [email protected]

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2 SAGE Open Medicine

vitamin D deficiency and insufficiency.9–14 Globally, the measurement of 25(OH)D in human serum and plasma sam-
prevalence of vitamin D deficiency is very high and varies ples. Low vitamin D level was defined as 25(OH)D < 30 ng/
from 70% to 90% in different populations.15,16 mL. Deficiency was defined as 25(OH)D < 20 ng/mL and
In Jordan, studies reported various rates of vitamin D insufficiency was defined as 25(OH)D level of 20–30 ng/
deficiency and insufficiency among different groups. A 2009 mL.19 Body mass index (BMI) was calculated by dividing
national study showed that 37% of women were vitamin D the weight (kg) by the height (m2). Participants with BMI of
deficient.17 Another study reported a much higher prevalence 30 kg/m2 or more were considered obese.
rate of vitamin D deficiency (62.3%) among women.18 This The study was approved by the Ethical Committee at the
study aimed to determine the prevalence of low vitamin D National Center for Diabetes, Endocrinology, and Genetics,
level among Jordanian adults and determine its association Amman, Jordan. Written informed consent was obtained
with selected variables. from each participant. All participants were informed that
their information will be kept confidential.
Methods
Statistical analysis
Sampling and data collection
Data were described using mean values and percentages.
This national cross-sectional study was conducted among Differences between proportions were tested using Chi-
Jordanian adults over a period of 4 months between May and square test. Multivariable logistic regression analysis was
August 2017. A population-based household sample was performed to identify factors associated with low levels of
selected from 12 governorates covering the three regions of vitamin D. For this purpose, vitamin D level was dichoto-
the country; the north, middle, and south. A multistage sam- mized, using 30 ng/mL as cutoff point, and entered into the
pling technique was used to select the participants. A system- model as a dependent variable. All other relevant variables
atic sample of households from the catchment areas of 17 were treated as independent variables. Variables showing no
selected health centers was selected. A team of two members relationship to vitamin D status were excluded from the
(a male and a female) visited the selected households and model, and the process was repeated until the best model was
invited household members ⩾18 years of age to participate obtained. A p-value of less than 0.05 was considered statisti-
in the study and to report next morning to the health center cally significant.
after an overnight fast.

Results
Data collection and laboratory analysis
Trained persons interviewed the participants using a struc-
Participant characteristics
tured questionnaire. The questionnaire was developed by the This study included a total of 4056 subjects (1193 males and
research scholars to study various risk factors of cardiovas- 2863 females), aged between 18 and 90 years. Table 1 shows
cular diseases and nutritional status in Jordan including vita- the sociodemographic and relevant characteristics of the
min D deficiency. The same questionnaire was used in study participants. The mean age was 43.8 (SD = 14.3) years.
previous national surveys in 1994, 2004, and 2009. The The prevailing skin color of participants was wheatish (about
questionnaire included sociodemographic variables and 54.3%); 15.9% had dark skin, and the rest were whites or
information on diabetes and other cardiovascular disease blondes.
risk factors, morbidity, quality of life, and health services.
Height, weight, waist and hip circumferences, and blood
Prevalence of low vitamin D
pressure were carried out in a standard way by trained
research scholars. Three blood samples were drawn from a Table 2 shows the mean values of serum 25(OH)D according
cannula inserted into the antecubital vein and used for differ- to gender and age. The mean values were significantly higher
ent laboratory measurements. Samples were centrifuged in males than in females across all age groups. The overall
within 1 h at the survey site, and transferred by separate crude prevalence of low vitamin D status (25(OH)D < 30 ng/
labeled tubes in ice boxes to the central laboratory of the mL) was 89.7%, with higher prevalence in males (92.4%)
National Center of Diabetes, Endocrinology, and Genetics in than in females (88.6%). Vitamin D was sufficient in 7.6% of
Amman, Jordan. All biochemical measurements were car- males, insufficient in 38.4% of males, and deficient in 54%
ried out by the same team of laboratory technicians using the of males. Among females, vitamin D was insufficient in
same method throughout the study period. 25-Hydroxyvitamin 10.1% and deficient in 78.5%. The prevalence of vitamin D
D (25(OH)D) was measured using the ARCHITECT 25-OH deficiency was much higher in females than in males
Vitamin D assay (Abbott Laboratories, Abbott Park, IL, (p = 0.001). The prevalence rates of low vitamin D level dif-
USA). The assay is a delayed, one-step immunoassay with fered significantly according to age, years of education, mar-
6-point calibration. The method is used for the quantitative ital status, and occupation among females only. (Table 3).
El-Khateeb et al. 3

Table 1.  Distribution of the study population by associated with increased odds of low vitamin D level
sociodemographic characteristics. (OR = 1.52). Unemployed people had higher odds of low
Variable No. % vitamin D level (OR = 1.55) compared to employed people.

Age, years (mean = 43.7, SD = 14.2)

 18–39 1543 38.1 Discussion
 40–59 1922 47.5 The prevalence of vitamin D deficiency is alarming high
  60 and above 582 14.4 globally.20 Previous studies in Jordan revealed various rates
Gender of vitamin D deficiency.17,18,21 In this study, 89.7% of
 Male 1191 29.4
Jordanian adults had low vitamin D level (25(OH)D < 30 ng/
 Female 2856 70.6
mL). Nichols et al.21 reported that 60.3% of non-pregnant
Education, years of completed formal schooling
women of childbearing age were vitamin D deficient. This
 Illiterate 210 5.3
estimate was much higher than what had been reported by
 1–11 1205 30.5
 12 1112 28.2
Batieha et al.17 in a previous national study who reported a
  >12 1424 36.0 prevalence of 37.3% in females and 5.1% in males.
BMI, kg/m2 (mean = 29.8, SD = 8.3) It is well-known that many methods have been developed
Underweight 93 2.3 by several companies to measure 25(OH)D levels in serum
 Normal 810 20.2 or plasma. Numerous publications have shown the limita-
 Overweight 1293 32.2 tions of these methods, with notable variations in vitamin D
 Obese 1815 45.3 determination by using these different assays.22,23 The differ-
Marital status (n = 4038) ences in the measurements of 25(OH)D levels because of
 Single 604 15.0 using different assays might explain the variations in the
 Married 3100 76.8 prevalence rates. To investigate the differences in the find-
 Divorced 64 1.6 ings of this study and the findings of a previous national
 Widowed 254 6.2 study by Batieha et al.,17 we re-measured the level of vitamin
 Separated 16 0.4 D in 1000 stored samples from Batieha et al.17 study using
Occupational (n = 3952) Abbott reagents (Abbott Laboratories) instead of the previ-
 Unemployed 2094 53.0 ously used radioimmunoassay (RIA). We found that 91% of
 Retired 469 11.9 the study group had low vitamin D level.
  Indoor job 870 22.0 Moreover, high prevalence rates of low vitamin D were
  Outdoor job 519 13.1 reported in other countries of the region including Lebanon,
Smoking status (n = 4027) 44%;8 Syria, 90.1%;9 Saudi Arabia, 83.6%;10 Qatar, 90.4%;11
  Current smoker 584 14.5
Morocco, 91%;12 Tunisia, 47.6%;13 and Egypt, 60%.14
  Never smoked 3443 85.5
The main factors that were significantly associated with
Skin color (n = 3908)
low level of vitamin D in the multivariate analysis in our
  Blonde and white 1164 29.8
study were gender, age, obesity, and employment. Vitamin
  Light brown 2121 54.3
  Dark or black 623 15.9
D deficiency and insufficiency affected all age groups in
Clothing style (n = 2764) this study. Females were twice more likely than men to have
Niqab 259 9.4 low level of vitamin D. Although Jordan is a sunny country
 Scarf 2386 86.3 almost all of the year, the high rate among females might be
 Western 119 4.3 explained by that they are not receiving enough exposure to
sun because of their dressing style. In this study, 95% of
SD: standard deviation; BMI: body mass index. women were either veiled, wearing the niqab (which covers
the whole body including the face and hands), or wearing
Multivariate analysis of factors associated with the hijab (which covers the whole body but spares the face
and hands). The finding of a higher prevalence of low vita-
low vitamin D min D status in women wearing the niqab or hijab compared
The multivariate analysis of factors associated with low level to women wearing Western dress styles is consistent with
of vitamin D is shown in Table 4. The only variables that previous studies.17,18 The prevalence of hypovitaminosis
were significantly associated with low level of vitamin D reported by Mishal18 study was 31% in Western-dressed
were gender, age, obesity, and employment. The odds of low women, 55% in women wearing the hijab, and 83% in
vitamin D level among women was almost twice that odds women wearing the niqab.
for men (odds ratio (OR) = 2.11). People aged 40–59 years The findings of our study supported the association
had higher odds of low vitamin D level (OR = 2.56) com- between obesity and low vitamin D levels. Previous studies
pared to those who were younger than 40 years. Obesity was showed that obesity was associated with lower serum
4 SAGE Open Medicine

Table 2.  Vitamin D status by age and gender (Jordan, 2016).

Age, years n 25(OH)D (ng/mL), 25(OH)D level (ng/mL) p-value

mean ± SD
<20 20–29.9 ⩾30
Gender <0.001
 Male 1183 20.2 ± 7.4 639 (54.0) 454 (38.4) 90 (7.6)
 Female 2771 15.1 ± 11.7 2176 (78.5) 279 (10.1) 316 (11.4)
 Total 3954 16.6 ± 10.8 2815 (71.2) 733 (18.5) 406 (10.3)  
Male 0.048
 18–39 333 20.4 ± 6.4 170 (51.1) 140 (42.0) 23 (6.9)
 40–59 601 20.4 ± 7.4 317 (52.7) 239 (39.8) 45 (7.5)
  ⩾60 249 19.2 ± 8.6 152 (61.0) 75 (30.1) 22 (8.8)
 Total 1183 20.2 ± 7.4 639 (54) 454 (38.4) 90 (7.6)  
Female <0.001
 18–39 1174 12.9 ± 10.1 1002 (85.3) 79 (6.7) 93 (7.9)
 40–59 1269 16.4 ± 12.3 944 (74.4) 153 (12.1) 172 (13.6)
  ⩾60 328 17.8 ± 13.3 230 (70.1) 47 (14.3) 51 (15.5)
Total 2771 15.1 ± 11.7 2176 (78.5) 279 (10.1) 316 (11.4)  

SD: standard deviation.

Table 3.  Prevalence of low vitamin D (25(OH)D < 30 ng/mL) in the study population among males and females according to selected
variables.

Males Females

  n % p-value N % p-value
Age, years 0.684 <0.001
 18–39 309 93.1 1076 92.2  
 40–59 555 92.5 1091 86.4  
  ⩾60 227 91.2 276 84.4  
Marital status 0.813 0.002
  Ever married 958 92.3 2025 87.8  
 Single 130 92.9 413 92.8  
Occupation 0.412 <0.001
 Unemployed 132 93.6 1719 91.1  
 Retired 297 90.3 99 74.4  
  Office work 325 93.4 428 85.1  
  Field work 325 92.6 138 86.8  
Body mass index 0.131 0.095
 Normal 213 89.1 489 88.6  
 Overweight 445 93.7 695 86.7  
 Obese 414 93.0 1192 89.5  
 Underweight 19 86.4 67 94.4  
Years of education 0.508 0.001
 Illiterate 12 100.0 169 92.3  
 1–11 321 90.9 742 89.3  
 12 325 92.1 666 91.2  
  >12 406 93.1 816 85.7  
Smoking 0.346 0.346
 Yes 366 93.4 167 91.3  
 No 718 91.8 2266 88.4  
El-Khateeb et al. 5

Table 4.  Factors independently related to low vitamin D, using contributed to the conception and design of the study and assisted
multivariate logistic regression analysis. in analyzing the data. D.H. assisted in collecting data and helped
in developing the idea and setting the protocol. N.K. contributed
Variable OR (95% CI) p-value to the conception and design of the study. M.A. contributed to the
Gender conception and design of the study, the acquisition of data, and
 Male 1   the analysis and interpretation of data. K.A. was the originator of
 Female 2.11 <0.001 the manuscript subject and supervised the research and writing of
Age, years the paper.
 18–39 1  
 40–59 2.56 <0.001 Declaration of conflicting interests
  60 and above 1.31 0.085 The author(s) declared no potential conflicts of interest with respect
Body mass index, kg/m2 to the research, authorship, and/or publication of this article.
 Normal 1  
 Overweight 1.20 0.224 Ethical approval
 Obese 1.52 0.005
All procedures performed in this study that involved human partici-
Occupation pants were in accordance with the National Center for Diabetes,
 Employed 1   Endocrinology, and Genetics (NCDEG) Ethics Committee, which
 Unemployed 1.55 <0.001 is accredited by the National Ethics Committee (ID: 12/2017).

Funding
25(OH)D concentrations.24,25 However, the mechanism
The author(s) disclosed receipt of the following financial support
explaining this association is not fully described. One pos-
for the research, authorship, and/or publication of this article: This
sible explanation is that people with obesity are less likely research was funded by the Scientific Research Support Fund, The
to participate in outdoor activities and more likely to cover- Ministry of Higher Education.
up and wear more clothing than leaner individuals, thus
decreasing sun exposure and limiting endogenous produc- Informed consent
tion of cholecalciferol in the skin.
Written informed consent was obtained from all subjects before the
The link between vitamin D levels and occupation has
study.
previously been explored. Low levels of vitamin D have
been reported in occupational groups with low exposure to
ORCID iDs
sunlight26 and high levels were reported among outdoor
workers.27 In our study, unemployment was significantly Yousef Khader https://orcid.org/0000-0002-7830-6857
associated with low vitamin D level. Unemployed people in Anwer Batieha https://orcid.org/0000-0001-8639-2807
Jordan, especially women, spend less time outdoors and Kamel Ajlouni https://orcid.org/0000-0001-5569-6306
therefore they are less likely to be exposed to the sun.
The main limitation of this study is inherited in its cross- References
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