Running head: VITAMIN D DEFICIENCY

Vitamin D Deficiencies In Middle Eastern Women

Nutritional Science 417B Section 1
Winter Quarter 2015
California State University, Los Angeles
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Jenna Battaglia Kristoff
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TABLE OF CONTENTS

Subject

Page Number

Abstract....3
Introduction..4-6
Literature Review.7-9
Population of Interest...10-11
Summary...11
Reference List...12-13
Appendices....14-17

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I.

Abstract

Vitamin D deficiency is a widespread issue with the highest concentration existing in the Middle
East. High rates of deficiency among women, men and children were astonishing as this is
known to be a sunny region. Our goal is to determine factors contributing to the significantly
high number of vitamin D deficiencies in this region. Research shows correlation between
melanin content of the skin, socioeconomic status, cultural dress, sedentary lifestyles and large
families as predictors of Serum 25(OH)D deficiencies and related diseases. Despite having
access to adequate sunlight, the Middle Eastern culture implements sun restriction due to their
religious practices that limits the amount of skin exposure for women. This was the underlying
factor in a majority of the studies which found a higher prevalence of deficiencies in women than
in men. The stigma surrounding women exposing skin is thus relevant to the rampant deficiency.
By providing education on the importance of vitamin D, women will feel empowered to achieve
well-being for themselves and their families. This paper examines ten studies to propose that
vitamin D deficiencies should be further analyzed in Middle Eastern women (Palacios &
Gonzalez, 2013).

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II.

Introduction

A. Vitamin D, also referred to as 25(OH)D, is an indispensable fat-soluble vitamin essential for

bone health; however, according to Floor (2011), It is currently estimated that one billion people
suffer from vitamin D deficiency worldwide. Vitamin D has both genomic and nongenomic
functions and is associated with the prevention of autoimmune disorders, serum calcium
homeostasis, and regulation of blood pressure (Gropper, Smith, & Groff, 2009). Consequently,
vitamin D deficiencies are linked with myopathy, autoimmune disorders such as Crohns disease
and type I diabetes, rickets in children and osteomalacia in adults (Gropper, Smith, & Groff,
2009). According to Gropper et al., it is stated that the majority of the worlds population can
maintain sufficient vitamin D levels with natural exposure to sunlight. Although, vitamin D
deficiency is prevalent within various groups, including Middle Eastern women (Palacios &
Gonzalez, 2013).
B.

Aims
i. To alleviate vitamin D deficiencies in women of the Middle East through education and
fortification.
ii. To implement a community program alongside Medical Doctors, Community and
religious leaders, in order to educate the people of the community to alleviate and prevent
deficiency.
iii. Previous studies such as, Kelishadi et al. (2013), noted that vitamin D deficiencies
may be related to factors such as clothing, lifestyle choices and dietary habits. The best
way to impact the field attentively would be to implement increased vitamin D
consumption through food fortification. As mentioned in Jani (2014), we need to remain
culturally sensitive when educating the Middle Eastern population. The plan of action is

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to fortify wheat, which is a staple food consumed across all socioeconomic levels, to
reduce regional deficiency issues.
iv. Objectives
1. Fortification of local foods.
With minimal sun exposure, Middle Eastern women need alternative ways to
increase their vitamin D levels. Increasing consumption of foods naturally rich in vitamin
D as well as fortifying staple foods, such as wheat, will help alleviate vitamin D
deficiencies.
2. Womens Education
Our intent is to empower women to prevent and alleviate their vitamin D
deficiencies. We would reach this goal by educating women to cook with foods high in
vitamin D, both fortified foods and natural sources. Recipes compliant with religious and
regional standards would be incorporated.
The next step in our education program would be to discuss discreet sun exposure
(i.e. placement of hands or feet in sunlight). Our goal would be to work within the
religious and regional standards that permit sun exposure.
3. Community Program
A conference will be held with community leaders of every region regarding vitamin D
deficiency. Topics discussed will include changes that families can implement to meet adequate
serum 25(OH)D levels and steps for program continuation in order to prevent vitamin D
deficiencies in future generations.

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C.

Search criteria
Inclusion criteria:

Reputable journals that have researched vitamin D

Studies conducted in the Middle East
The development of vitamin D deficiencies
Screening tools for identifying vitamin D deficiencies
Nutritional screening tools that assess vitamin D deficiencies
Exclusion criteria:

Non-English language
Countries outside of the Middle East
Studies with inconclusive results
Search for relevant studies
The studies in this project were accessed through electronic databases and standard
searching of applicable articles listed in the reference list. The electronic databases MEDLINE,
PUBMED, Science Direct, and the CSULA Library were searched using the following
keywords: vitamin D deficiency, malnutrition, Middle East, sun exposure, middle eastern
women, fortification of vitamin D. Search was from January to March 2015. If the abstracts
emphasized or included the keywords and search criteria, the entire text was retained.
Critical appraisal plan
The applicability of the articles retained were assessed initially by analysis of each
abstract and then the entire article. The final criteria was then implemented for adult women in
Middle Eastern countries. Added analysis and correlation between findings are described
subsequently.

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III. Literature Review

In a study conducted by Van Schoor and Lips (2011), results showed there is a strong
relationship between vitamin D levels and attire among Jordanian and Turkish women. The link
between womens clothing has also demonstrated that women with less covering, and more sun
exposure, have higher serum 25(OH)D levels than women wearing hijabs and niqab (p. 673). AlMohaimeed (2012) found comparable findings among Middle Eastern women, suggesting their
lifestyle, with limited exposure to the sun, may be putting them at risk for vitamin D
deficiencies.
Vitamin D deficiency is associated with an array of health ramifications including rickets
in children and osteomalacia in adults (Gropper, Smith, & Groff, 2009). Rickets and
osteomalacia are both disorders in which softening of the bones occurs (Starkebaum, 2014).
Transient receptor potential vanilloid 6 (TRPV6), calbindin D9k and Ca-ATPase pump, are all
vitamin D-dependent proteins necessary for the absorption of calcium into enterocytes. With a
lack of these essential proteins, calcium absorption is obstructed causing hypocalcemia to ensue.
As low serum calcium levels are detected by the body, parathyroid hormone (PTH) is released by
the parathyroid gland. An increase in PTH stimulates the release of calcium and phosphorus from
the bone matrix (Gropper, Smith, & Groff, 2009). The absence of vitamin D therefore affects
bone calcium, which in turn softens and weakens bones (Kaneshiro, 2014).
Other possible contributing factors to vitamin D deficiencies include: gender, skin color
and obesity. Our research demonstrates a strong indication that gender alone is not an
independent predictor of vitamin D status. Although the majority of vitamin D studies were
conducted on Middle Eastern males who are not required to wear head coverings, significant
indications of vitamin D deficiencies for this group were present. In a study conducted by

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Hamilton et al. (2010), 84 out of 93 Middle Eastern male athletes were vitamin D deficient, with
58% severely deficient and 32% only moderately deficient. An additional study of 1095 students
indicated that 40% of the students were deficient and 39% had insufficient serum 25(OH)D
levels. However, there was no significant difference between genders (Kelishadi et al., 2013).
Thus, this demonstrates vitamin D deficiencies are not gender specific to women.
In addition to gender, it has been recognized that skin colour is another contributing
factor to insufficient vitamin D levels. Palacios and Gonzales indicate a darker complexion
correlates with higher melanin content of the skin (2013). Jani et al. further analyzed that, those
with higher melanin content, may need 3-5 times the sunlight to gain the same amount of vitamin
D, as their caucasian counterparts (2014). On the contrary, a study conducted by Hamilton et al.
utilized an informal questionnaire which classified 93 athletes into dark, olive, or fair skin. When
comparing the levels of deficiency, there were no significant differences found among the skin
colour classifications. Although this contradicts the previous studies mentioned, more evidence
stipulates that skin colour is a contributing factor to UVB absorption and the metabolism of
serum 25(OH)D. Due to inconsistent findings across all studies, skin colour should be further
analyzed.
Lastly, obesity is a contributing factor that has been linked to vitamin D status as
evidenced by a study conducted by Al-Daghri et al. (2014). The basis of this study was to
analyze the factors influenced by a healthy lifestyle intervention. It was noted that after six
months there was a significant increase in circulating vitamin D levels for those who were obese.
Van Schoor and Lips conducted further research and discovered that obese children were more
likely to be vitamin D deficient than nonobese children (2011). Nonetheless, further research still
needs to be conducted to evaluate the relationship between obesity and vitamin D deficiencies.

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Vitamin D deficiency is also a concern for newborns who have mothers with low serum
25(OH)D. Regardless of socioeconomic status, infants with vitamin D deficient mothers develop
rickets (Jani, 2014). In order to better serve this population and alleviate vitamin D deficiencies,
a vitamin D level requirement needs to be properly defined. Amidst the research recommended
intakes were conflicting (Fuleihan, 2009). In addition, there is lacking representative data from
other countries of this region, which precludes the ability to accurately assess vitamin D status
from these countries (Palacios & Gonzales, 2013). Kelishadi et al. agrees that, it is essential that
normal values be determined according to each populations characteristics, risk factors, and
environmental conditions (2013).
Although there is an abundance of research on vitamin D deficiencies in Middle Eastern
women, there is lacking research on successful work being done to improve the situation at hand.
Previous work in this field has focused solely on the fortification of foods and yet data shows,
vitamin D deficiency is prevalent even in industrialized countries where vitamin D fortification
has been implemented now for years (Palacios & Gonzales, 2013). Our proposal not only
focuses on the fortification of local foods, but emphasizes educating women why vitamin D is
essential and creating a community program that will have lasting effects within communities.
Efforts to teach and empower women will allow women to confront the problem head on and
will give them the opportunity to create lasting change, preventing deficiencies in the future.

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IV. Population of interest

The Middle East is known for its warm climate and the availability of sun all year
around; however, vitamin D deficiencies remain prevalent among its inhabitants. Middle eastern
women in particular, have higher rates of deficiencies. This population of women have been
known for their traditional dress which is thought to be a key factor in their vitamin D levels and
why this population is of interest. As stated in a study conducted by Hamilton et al. (2010),
despite high sunlight hours, vitamin D deficiency is well described in women in the Middle
East, primarily as a result of cultural norms of keeping skin covered.
According to Arabs in America (2012), there are many different kinds of head coverings.
The hijab, which covers of the head and neck leaving the face exposed, might be the most well
known. The khimar, on the other hand, covers the head, neck and shoulders still leaving the face
exposed while the scarf hangs in the middle of the back. Chador covers the entire body, even the
womans feet, but still leaves the face uncovered. Niqab covers the entire face only leaving small
openings for the eyes. This covering is similar to khimar and other forms of coverings, which
also cover the entire body. Lastly, burqa covers the entire face and body leaving only a small
netting face screen for the woman to see through. Throughout the Middle East women wear a
variety of these head covering for religious as well as other reasons.
Some Middle Eastern woman declare their decision to wear a hijab after puberty. It is
believed that God instructed women to wear it as means of fulfilling his commandment for
modesty and to be witnesses of their faith (Arabs in America, 2012). Others, however, wear a
hijab to identify with their culture and to represent their countrys political and social ways and
to challenge the western prejudice of Arabic-speaking countries (Hamilton et al. 2010). Due to
the heat in the Middle East, following an indoor lifestyle has been identified as a factor for the

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lack of sun exposure. Another influential factor assumed is cultural tradition, whereby Muslim
communities avoid body exposure (Floor, 2012). Therefore, the rationale for choosing women of
the Middle East and the corresponding high risk of vitamin D deficiency due to lifestyle
behaviors.

V. Summary
As stated by Kelishadi et al. (2013), there are several ways to compensate for the
increasing prevalence of vitamin D deficiencies. The importance of our proposed project is to
empower women through education so that the community can counteract the lack of vitamin D.
Women of the Middle East will have the opportunity to attend cooking classes that will promote
increased consumption of vitamin D rich foods for the entire family. It is also important to
demonstrate the unique ability to acquire Vitamin D with just a few minutes of sun exposure a
day, all while doing so in a discreet manner. But most importantly, the improvement in health
status for the Middle East calls for food fortification of staple foods for the entire region. Our
proposed plan of action to educate women and fortify staple foods will alleviate high rates of
vitamin D deficiency and its corresponding repercussions.

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References
Al-Daghri, N., & Alfawaz, H. (2014). A 6-month self-monitoring lifestyle modification with
increased sunlight exposure modestly improves vitamin D status, lipid profile and
glycemic status in overweight and obese Saudi adults with varying glycemic levels.
Lipids in Health and Disease, 13(87), 7-7.
Al-Saffar N, Diab N.A., Al-Othman S., Darwish A. and Al-Kafaji G, Golbahar J, (2014).
Predictors of vitamin D deficiency and insufficiency in adult Bahrainis: a cross-sectional
study . Public Health Nutrition, 17, pp 732-738. doi:10.1017/S136898001300030X.
Arabs in America (2012). Retrieved February 19, 2015, from
http://arabsinamerica.unc.edu/identity/veiling/hijab/
Elshafie, D., Al-Khashan, H., & Mishriky, A. (2012). Comparison of vitamin D deficiency in
Saudi married couples. European Journal of Clinical Nutrition, 742-745.
Fuleihan, G. E. (2009). Vitamin D Deficiency in the Middle East and its Health Consequences
for Children and Adults. Clinical Reviews in Bone and Mineral Metabolism, 7, 77-93.
doi:10.1007/s12018-009-9027-9
Hamilton, B., Grantham, J., Racinais, S., & Chalabi, H. (2010). Vitamin D deficiency is endemic
in Middle Eastern sportsmen. Public Health Nutrition, 1528-1534.
Jani, R., Palekar, S., & Munipally, T. (2014). Widespread 25-Hydroxyvitamin D Deficiency in
Affluent and Nonaffluent Pregnant Indian Women. Department of Food Science and
Technology, 2014, 1-8.
Kaneshiro, N. (2014). Rickets: MedlinePlus Medical Encyclopedia. Retrieved February 15,
2015, from http://www.nlm.nih.gov/medlineplus/ency/article/000344.htm

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Kelishadi, R., Ardalan, G., Motlagh, M., Shariatinejad, K., Heshmat, R., Poursafa, P., ... Taslimi,
M. (2013). National report on the association of serum vitamin D with cardiometabolic
risk factors in the pediatric population of the Middle East and North Africa (MENA): The
CASPIAN-III Study. Nutrition, 33-38.
Palacios, C., & Gonzalez, L. (2013). Is vitamin D deficiency a major global public health
problem? The Journal of Steroid Biochemistry and Molecular Biology, 144, 138-145.
Retrieved January 26, 2015, from ScienceDirect.
Starkebaum, G. (2014). Osteomalacia: MedlinePlus Medical Encyclopedia. Retrieved February
15, 2015, from http://www.nlm.nih.gov/medlineplus/ency/article/000376.htm
Van Schoor, N. M., & Lips, P. (2011). Worldwide vitamin D status. Best Practice & Research
Clinical Endocrinology & Metabolism, 25, 671-680. Retrieved January 26, 2015, from
ScienceDirect.

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Appendices
Middle East Community Leaders Conference Program
I.

II.

III.

Introduction
A. Board of the program
B. Introduction of all the regional community leaders
State the problem
A. Previous vitamin D deficiency research
B. Address any current research
Intermission (10 minutes)

IV. Breakout session

A. Discuss preventative ways to help their regional populations
B. Community leaders with present to the rest of the program about their discussions
V. Present our proposal and goals
A. Show the plan
B. Contract signing to work as a preventative team
VI.

Closing
A. Thank you
B. Discuss information on the next conference in 6 months

Images to show at the conference:

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Here is the image that provide information regarding the dress code throughout the middle east
and the northern african region.

Here is the image of the percentage of the women that wear the different kinds of head coverings
throughout the Middle East countries.
Al-Amira head covering has the highest percentage of women that wear it throughout the
countries.
While Burka has the least percentage of head coverings.

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The following Countries of the Middle East will be visited and taught educational courses on
vitamin D.

1. Bahrain
5. Jordan

2. Iraq

3. Iran
6. Kuwait

9. Palestine 10. Qatar

13. United Arab Emirates

4. Israel
7. Lebanon

8. Oman

11. Saudi Arabia 12. Syria

14. Yemen

Cooking and Educational courses will consist of:

Vitamin D super foods that may be found in this region:
Salmon (especially wild-caught)
Mackerel (especially wild-caught; eat up to 12 ounces a week of a variety of fish and shellfish
that are low in mercury)
Mushrooms exposed to ultraviolet light to increase vitamin D
As well as other food sources of vitamin D include:

Cod liver oil (warning of possible toxicity)

Tuna (canned is also an option)
Sardines (canned is also an option)
Milk or yogurt (fortified with vitamin D)
Beef or calf liver

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Egg yolks
Cheese/ dairy products

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