Vitamin D Deficiency and its Risk Factors among Adults in Sharg El-Nile Locality 2022-2023: A cross-sectional study at Primary Health care Centers

Vitamin D Deficiency and its Risk Factors among Adults in Sharg El-Nile Locality 2022-2023: A cross-sectional study at Primary Health care Centers | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Vitamin D Deficiency and its Risk Factors among Adults in Sharg El-Nile Locality 2022-2023: A cross-sectional study at Primary Health care Centers Ziryab Imad, Abeer Ahmad, Tarig Alhadi Madibbo, Arwa Nasr This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7547116/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Vitamin D significantly affects the musculoskeletal, endocrine, immunological, and cardiovascular systems. An estimated one billion persons globally present with hypovitaminosis D, according to current recorded data, indicating a global pandemic. In this study, we investigated vitamin D Deficiency and its Risk Factors among Adults at Primary Health care Centers in Sharg El-Nile Locality 2022–2023. Methods This is a cross-sectional facility-based study conducted during the period from December 2022 to May 2023, in nine Primary health care centers (PHC) in Sharg El-Nile locality, Bahri, Sudan. Participants were randomly selected from adults attending these nine healthcare centers during the study period. The following categories were excluded: known cases of vitamin D deficiency, Adults taking supplements because supplements contain up to 400 IU of vitamin D, Pregnant Females attending for ANC, adults with recent fractures, recent major surgery, and chronic kidney disease as they take vitamin D regularly. The calculated sample size was 242 patients. Direct interviewing questionnaire used then participants tested for Vitamin D level. Data were processed using the SPSS version 26. Results Out of 242 participants, the majority (48.8%) were in the age group of 40–59 years, with females constituting 62.4%. Vitamin D deficiency prevalence was 63.6%, while insufficiency reported in 31%, and sufficient vitamin D reported in only 5.4% of participants. Participants aging 40–59 years and females had significantly higher frequency of Vit-D deficiency compared to others (P values: 0.042 and 0.003, respectively). Vitamin D deficiency was significantly associated with less consumption of milk (P value = 0.039) and tuna (P = 0.041), as well as inadequate Sun exposure. BMI, education level, frequency of exercise and smoking behaviour were not found to be associated with vitamin D deficiency (P value > 0.05). Conclusions Vitamin D deficiency was critically high prevalent among respondents, and it was significantly higher among females, and people aged 40–59 years. The factors, which contributed significantly to deficiency, included low intake of milk and tuna and low sun exposure. Vitamin D deficiency Sudan Sun exposure Risk factors sufficient vitamin D Figures Figure 1 Figure 2 Background Vitamin D is an important element in our bodies that maintains serum calcium within its normal physiological range. The calcium homeostasis is crucial for various metabolic and neuromuscular activities ( 1 ). There is growing evidence that vitamin D has positive effects on our tissues and organs, and that the higher the concentration of vitamin D, the lower the incidence of cancer and its associated mortality ( 2 ). Vitamin D deficiency is defined as serum levels of less than 20 ng/ml; because at this level, parathyroid hormone starts to rise, and this cut point thought to be the physiologic definition for vitamin D deficiency ( 3 ). Serum vitamin D of 20–30 ng/ml is referred to as insufficiency ( 4 ). It’s a global health problem with approximately 1 billion people affected with vitamin D deficiency worldwide, and about 50% are suffering vitamin D insufficiency ( 5 ). Alongside the high prevalence, a wide variation of vitamin D status exists among different countries. For example, reports from Iran and Syria shows very low average level of vitamin D (14 ng/mL and 10 ng/mL, respectively) ( 6 , 7 ), compared to the adults in the European countries like Denmark and France (26 ng/mL and 24 ng/mL, respectively) ( 8 , 9 ). There is a strong correlation between low serum levels of the vitamin D and both communicable and non-communicable diseases ( 10 ). It has been linked to high blood pressure, type I diabetes, multiple sclerosis, rheumatoid arthritis, and other autoimmune diseases ( 11 ). Etiological factors implicated in vitamin D deficiency includes; low dietary intake and/or absorption, decreased sun exposure, decreased endogenous synthesis, and increased catabolism in the liver in response to enzyme inducers ( 12 – 14 ). Therefore, taking vitamin D supplements and adequate exposure to sunlight can help most people avoid vitamin D insufficiency. The Endocrine Society recommends 400–1000 International Units (IU) per day for infants under one year of age, 600–1000 IU for children and adolescents aged 1–18, and 1500–2000 IU for everyone ( 15 ). Optimum sun exposure can be achieved through exposing the arms and legs to direct sunshine for five to ten minutes between 10:00 AM and 3:00 PM in the spring, summer, and fall. Serum 25-hydroxyvitamin D is measured to assess vitamin D circulating levels in high-risk patients ( 16 ). The amount of vitamin D required to treat the deficiency depends largely on the degree of the deficiency and underlying risk factors. Vitamin D3 supplementation for eight weeks at a dose of 6,000 IU per day or 50,000 IU per week may be an option. After the serum 25-hydroxyvitamin D level rises beyond 30 ng/mL, 1,000–2,000 IU should be taken daily as a maintenance dose. These doses should be adjusted based on individual patient’s status; for instance, two to three times higher doses (6000 − 10,000 IU/d) are recommended for obese patients, patients with malabsorption and those taking enzyme-inducing medications. The recommended maintenance dose for this category is 3000–6000 IU/d ( 17 ). Vitamin D deficiency is an emerging public health problem in adults from different parts of the world, inclusive of grave implications on bone health, immune function, and general well-being. Despite abundant sunshine over many parts of the world, including Sudan, poor sun exposure added to the dietary insufficiency and lifestyle factors, contributes to the frequency of vitamin D deficiency. We lack the data and clear statistics describing vitamin D status in Sudan. Furthermore, there’re no local studies addressing the potential risk factors associated with vitamin D deficiency. This current study tries to delve into the state of vitamin D deficiency and highlights its risk factors among adults at Primary Health Centers in Sharg El-Nile locality. Methods This is a cross-sectional facility-based study conducted in Sharg El-Nile locality, Bahri, Sudan. We included the nine Primary health Care centers (PHC) in the locality. There’re family medicine specialists in the centers serving large areas with high patients’ frequency. The study duration was six months, from December 2022 to May 2023. All adults attended health center for any purpose during the study period, were included. The following categories were excluded: known cases of vitamin D deficiency, Adults taking supplements because supplements contain up to 400 IU of vitamin D, Pregnant Females attending for ANC, adults with recent fractures, recent major surgery, and chronic kidney disease as they take vitamin D regularly. Patients were randomly selected using patients’ lists of the nine healthcare centers. The calculated sample size was 242 patients; we contacted them directly and took the consent. The Primary Health Care center Number of participants (n = 242) Helat Koko 43 Al-Shaheda Nada 32 Um Dom 27 AlJerief East 26 Alwehda Altethady = 18 18 Alaylafoun 52 East Suba 15 Edd Babkie 13 Alwadi Alakhdar 16 Data were collected through a structured close-ended interviewer-administered questionnaire (Supplementary). During the interview, consents were obtained from patients for vitamin D measurement. Frequency of vitamin D deficiency was measured as the dependent variable, while age, gender, BMI, educational level, chronic diseases, daily milk products consumption, daily sun light exposure, and exercise were the independent variables. Data analysis was performed using the Statistical Package for the Social Sciences (SPSS) version 26. We obtained the ethical approval from the Ethics Review Committee of Sudan Medical Specialization Board (SMSB)- Council of Family Medicine, research unit (E.D.C), Sudan Ministry of health, Local Government office of Sharg El-Nile locality and the administration of the Health Centers. The study purpose and concepts were clearly stated to the participants and written informed consents were taken. We used serial numbers from patients and chaperone to ensure privacy and confidentiality, and all the data were used for research purposes only. The study has been conducted in accordance with the Declaration of Helsinki. Results A total of 242 patients participated in the study. The majority were 40–59 years old (48.8%) with general female predominance (62.4%) (Table 1 ). As part of the assessment, we measured the BMI of the participants and their values were grouped into four categories and reported in frequencies and percentages as shown in Table 1 . In terms of education, only 13.2% didn’t complete their high school education. The majority were high school graduates (45.9%) and a slightly fewer percentage (40.9%) had college education (Table 1 ). Table 1 Distribution of participants by Age, Gender, BMI and Educational Level Patients’ characteristics N (%) Age groups 22–39 40–59 51 ( 21 ) 118 (48.8) \(\:\ge\:60\) 73 (30.2) Gender Male 91 (37.6) Female BMI Underweight Normal Overweight Obese 151 (62.4) 3 (1.2) 102 (42.2) 94 (38.8) 43 (17.8) Educational level Did not finish high school Finished high school Had college education 32 (13.2) 111 (45.9) 99 (40.9) To assess the vitamin D sources, questions about eating habits and sun exposure were included in the interview. They revealed consumption of egg and milk by most of the participants (n = 196, 80.9% and n = 180, 74.4%; respectively) twice or often per week, while other dietary sources of vitamin D were less frequently consumed (Table 3 ). Interestingly, 22 (9.1%) of the participants stated that they do not consume any of the listed vitamin D- containing dietary products. Regarding sunlight exposure during the day, more than half (55.5%) demonstrated less than 15 minutes daily sun exposure. 24.3% showed longer daily exposure for more than 30 minutes, followed by 20.2% with 15–30 minutes of sunlight per day (Table 3 ). Table 4 shows the details about lifestyle and social habits, particularly, exercise and smoking, respectively. Interviewer asked the participants about how frequently they exercise, and nearly half of the answered that they rarely or not doing exercise. As for smoking, only the status was evaluated in the interview and no further details about the frequency have been addressed in the study. Two thirds of the participants (n = 164, 67.8%) stated that they have never smoked and only 14 (5.8%) were former smokers. Vitamin D deficiency reported in 154 (63.6%) of participants, insufficiency reported in 75 (31%), and sufficient vitamin D reported in only 13 (5.4%) of participants (Fig. 1 ). Regarding the co-existing medical conditions; Hypertension, diabetes mellitus, gout and cancer among others have reported frequencies of 98 (40.5%), 68 (28.1%), 27 (11.1%), and 4 (1.6%), respectively (Fig. 2 ). We studied the association of vitamin D deficiency with several modifiable and non-modifiable factors; age, gender, BMI, consumption of vitamin D- containing dietary products, sun exposure, exercise and smoking, and the presence of comorbidities. Participants within age group 40–59 years showed significantly higher frequency of Vit-D deficiency compared to other age groups (P value = 0.042) (Table 2 ). Female gender also had significantly more frequency of vitamin D deficiency (74.2%) compared to males (46.1%) (P value = 0.003) (Table 2 ). Conversely, BMI and education level showed no significant association with vitamin D deficiency (P value = 0.072 and 0.329, respectively) (Tables 2 ). Association with diet is variable; participants with less milk and tuna consumption were likely to have vitamin D deficiency (P values = 0.039 and 0.041, respectively), while no significant association found with consumption frequency of other listed products (fish, cheese and eggs) (P value > 0.05) (Table 3 ). Our analysis showed increased frequency of vitamin D deficiency with inadequate sun exposure. Less than 15 minutes had more frequency (83.1%) compared to 15–30 minutes and more than 30 minutes (59.6%, and 36.6%, respectively) with p value of 0.026 (Table 3 ). According to our data, there’s no significant association between vitamin D deficiency and frequency of exercise and smoking behaviour (P value > 0.05) (Table 4 ), as well as the presence of comorbidities (Table 5 ). Table 2 Association of vit - D level with Age group, Gender, BMI and Educational Level of study participants Patient’s characteristic Vitamin D level Total P value 0.042* Age group Deficient (30ng/ml) 22 – 39 33 (64.7%) 17 (33.3%) 1 (1.9%) 51 (21%) 40 – 59 97 (82.2%) 18 (15.2%) 3 (2.5%) 118 (48.8%) ≥60 24 (32.9%) 40 (54.8%) 9 (12.3%) 73 (30.2%) Gender 0.003* Male 42 (46.1%) 39 (42.8%) 10 (10.9%) 91 (100%) Female 112 (74.2%) 36 (23.8%) 3 (2.0%) 151 (100%) BMI Underweight 3 (100%) 0 (0.0%) 0 (0.0%) 3 (1.2%) Normal 83 (81.4%) 12 (11.7%) 7 (6.8%) 102 (42.2%) Overweight 57 (60.6%) 35 (37.2%) 2 (2.1%) 94 (38.8%) 0.072 Obese 11 (25.5%) 28 (65.1%) 4 (9.3%) 43 (17.8%) Educational level Did not finish high school 24 (75.0%) 7 (21.8%) 1 (3.1%) 32 (13.2%) Finished high school 57 (51.3%) 45 (47.7%) 9 (8.1%) 111 (45.9%) 0.329 had college education 73 (73.7%) 23 (23.2%) 3 (33.3%) 99 (40.9%) Total 154(63.6%) 75(31%) 13(5.4%) 242(100.0%) *Statistically significant association Table 3 Association of vit - D level with consumption of some vit - D resources and sun exposure among participants Products containing vitamin D Vitamin D level Total P value Deficient ( 30ng/ml) Milk 105 (58.3%) 64 (35.5%) 11 (6.1%) 180 (100%) 0.039* Fish 43 (76.8%) 10 (17.9%) 3 (5.3%) 56 (100%) 0.93 Tuna 66 (58.4%) 40 (35.4%) 7 (6.2%) 113 (100%) 0.041* Cheese 94 (58.1%) 59 (36.4%) 9 (5.5%) 162 (100%) 0.057 Eggs 122 (62.3%) 68 (34.7%) 6 (3.0%) 196 (100%) 0.780 Non 17 (77.3%) 3 (13.6%) 2 (9.1%) 22 (100%) 0.33 Average of sun exposure Less than 15 minutes per day 74 (83.1%) 14 (15.7%) 1 (1.1%) 89 (100.0%) 0.026* 15–30 minutes per day 62 (59.6%) 39 (37.5%) 3 (2.8%) 104 (100.0%) More 30 minutes per day 18 (36.7%) 22 (44.9%) 9 (18.3%) 49 (100.0%) Total 154 (63.6%) 75 (31%) 13 (5.4%) 242 (100.0%) *Statistically significant association Table 4 Association of vit - D level with frequency of doing exercise and smoking among participants Frequency of doing exercise Vitamin D level Total P value Deficient ( 30ng/ml) Daily or almost daily 25(46.3%) 25(46.3%) 4(7.4%) 54(100.0%) 0.198 Weekly 32(47.0%) 30(44.1%) 6(8.8%) 68(100.0%) Rarely or none 97(80.8%) 20(16.7%) 3(2.5%) 120(100.0%) Smoking Never smoked 109(66.4%) 49(29.9%) 6(3.7%) 164(100%) 0.972 Former smoker 12(85.7%) 2(14.3%) 0(0%) 14(100%) Current smoker. 33(51.5%) 24(37.5%) 7(10.4%) 64(100%) Total 154(63.6%) 75(31%) 13(5.4%) 242(100.0%) Table 5 Association of vitamin D level and having any comorbidity among participants Having any comorbidity Vitamin D level Total P value Deficient ( 30ng/ml) Hypertension 49(50%) 43(43.9%) 6(6.1%) 98(100%) 0.36 Diabetes 44(64.7%) 22(32.3%) 2(2.9%) 68(100%) 0.74 Cancer 3(75.0%) 1(25.0%) 0(0.0%) 4(100%) 0.99 Gout 15(55.0%) 9(33.3%) 3(11.1%) 27(100%) 0.82 Other 37(68.5%) 13(24.1%) 4(7.4%) 54(100%) 0.39 Discussion Vitamin D deficiency is still highly prevalent among community-dwelling Sudanese adults. In this study, vitamin D deficiency was reported in 154 participants (63.6%), insufficiency in 75 (31%), and sufficient vitamin D in only 13 participant (5.4%). High prevalence also reported in local study by Husain NE, et al. done among Sudanese women ( 18 ). They found that 157 out of 190 (82.6%) had vitamin D serum levels below 20 ng/ml (deficient). Similarly, among the adults in the UAE, 74% had vitamin D deficiency at serum levels ≤ 30 nmol/L (12 ng/ml) ( 19 ). In Iran, on the other hand, the prevalence was relatively lower: 28% were deficient, 50% had insufficient levels, and 22% had sufficient levels ( 20 ). However, the Iranian study has been done in a rural area and this could partially explain the lower percentages and it points to the possible influence of modernization on vitamin D status. Tangoh DA et al. studied vitamin D in the southwest region of Cameroon, they demonstrated that only 3.2% were deficient with overall 25.8% were having vitamin levels less than 30 ng/ml ( 21 ). Another study done among US Armed Forces showed a lower prevalence of 2.2% annual average ( 22 ). Due to the fact that there are different definitions for “deficiency” based on different cut points, Arabi A et al. described their findings on vit- D deficiency among Lebanese in relevance to the commonly used definitions. They found that 71.9% were deficient at 50 nmol/L (20 ng/ml) and 39.1% at 30 nmol/L (12 ng/ml) ( 23 ). These regional and global variations could be related to multiple environmental, dietary, social and cultural factors, along with the variable diagnosis standards. Participants within the age group of 40–59 years had significantly higher frequency of Vit-D deficiency compared to other age groups, with a P value of 0.042. This comes in consistency with the existing literature that describes the increased likelihood of vitamin D deficiency in older population. Kelly DC et al. found that the age groups 30–39 years and older than 40 years had significantly higher odds of vitamin D deficiency as compared to younger subjects, even after adjustment for covariates and occupation ( 22 ). Another study highlighted the significant inverse association (r = − 0.119, p = 0.02) of age with 25(OH)D level, indicating a tendency of vitamin D levels to fall with increasing age ( 21 ). This is further supported by a report showing that 96% of the participants aged 56 years or older were vitamin D deficient, followed by 73.53% aged between 40 and 55 years, and 57.35% aged between 23 and 39 years ( 19 ). These consistent findings across different studies underpin the increasing risk of vitamin D deficiency with advancing age. This observation has been attributed to several factors: reduced skin synthesis of the vitamin D, reduced dietary intake, and possible changes in lifestyle or health with aging. Various studies have investigated the relation between gender and vitamin D deficiency and they came up with conflicting results. We have found a significantly higher frequency of vitamin D deficiency among females (74.2%) compared to males (46.1%), with a P value of 0.003. While some studies support our findings ( 22 , 23 ), multiple researches stood on the other side demonstrating no gender-related differences in the rates of vitamin D deficiency ( 19 – 21 ). Religion and body covering traditions were thought to play a role in vitamin D level among females; where females who tend to wear hijab show higher odds of deficiency ( 18 , 24 ). Therefore, the dressing pattern may also be a contributor to the demonstrated gender disparities regarding vitamin D levels. The relationship between BMI, education level, and vitamin D deficiency is inconsistent in various studies. In the current study, no significant association was found between BMI or education level and vitamin D deficiency, with a P value of > 0.05. However, other studies have shown conflicting results. For instance, Bani-Issa W et al. reported a highly significant positive correlation between higher BMI (≥ 30) and the probability of vitamin D deficiency, as subjects with higher BMI were at more than a fivefold increased risk when compared to their peers with lower BMI (< 25) ( 19 ). Another evidence shows that men with vitamin D deficiency had higher BMI (P = 0.008), yet no similar association was observed among women (P = 0.7) and this suggests a gender-based variability in the correlation between BMI and vitamin D status ( 20 ). Moreover, Arabi A et al. found that correlations between BMI and body fat mass, as well as certain socioeconomic factors, such as income and education level, exist with vitamin D status; hence, such variables can affect vitamin D levels ( 23 ). These results indicate that the interaction of BMI and educational level may contribute to deficiency of vitamin D and can further be affected by factors related to gender and socio-economic background, in addition to regional and life style variations. When considering the relationship between dietary intake and vitamin D deficiency, it appears to be complex and varies across different studies. In our study, vitamin D deficiency was significantly associated with lower consumption of milk (P value = 0.039) and tuna (P value = 0.041), while no significant association was found with the consumption of fish, cheese, or eggs (P value > 0.05). This indicates that certain food items, such as milk and tuna, may play a more critical role in maintaining adequate vitamin D levels. Also, Arabi A et al. identified several dietary factors associated with vitamin D status, including alcohol consumption, dietary intake of fat and vitamin D resources ( 23 ). In contrast, Marzban M et al. found no significant difference between the frequency of consumption of food items and vitamin D status (P > 0.05), suggesting that diet alone may not be a strong predictor of vitamin D levels in their study population ( 20 ). This discrepancy could be due to differences in dietary habits, sunlight exposure, or other environmental factors across the studied populations and it highlights the multifactorial nature of vitamin D deficiency, where dietary intake is just one of many contributing factors. Our study demonstrates that the frequency of exercise, smoking behavior, and the presence of comorbidities are not significantly associated with vitamin D deficiency, with P values greater than 0.05. This indicates that these factors have no statistically significant impact on vitamin D levels among the study participants. The association of sun exposure with the deficiency of vitamin D is mentioned by various studies, including the current one, which shows significant associations. The majority of participants (55.5%) exposed themselves to sunlight for less than 15 minutes per day, leading to a higher frequency of vitamin D deficiency. The deficiency rate for those who had less than 15 minutes of sun exposure was 83.1%, for 15–30 minutes it was 59.6%, and above 30 minutes it was 36.6%. the existing evidence supports these findings, where a linear relationship has been demonstrated between sunlight exposure and serum vitamin D levels ( 25 ). Lifestyle changes towards urbanization and traditional dressing that covers most of the body parts may account for the lowest sun exposure even in rural areas. Husain NE et al. found a significant correlation with vitamin D levels when exposing some body parts to sunlight compared to complete covering ( 18 ). One study, conducted at Michigan Hospital, revealed a notably higher percentage of vitamin D deficiency and insufficiency in women who used hijab or Niqab compared to non-users ( 24 ). This further supports the claim that sun exposure, and therefore vitamin D status, may well be influenced largely by factors like culture and form of dress. These studies underline that adequate sun exposure is important for maintaining vitamin D levels and point out the need for public health strategies considering cultural and lifestyle factors. Our current study provides insights about vitamin D status among Sudanese patients across different age groups. We have studied multiple factors in terms of their potential influence on serum vitamin D levels. It serves as a local guide for future studies and public health interventions addressing this issue aiming to decrease vitamin D deficiency rates. However, it is limited by its cross-sectional design that hinders the establishment of any causal relationship between the vitamin D deficiency and its associated factors. Additionally, Geographical region, socio-economic status and cultural lifestyle may all impact vitamin D levels and our study population may not be representative of the wider demographic diversity. Due to the financial constrains and high cost of vitamin D measurement, the sample size was relatively small and this may affect the results generalizability. Also, some data, such as; sun exposure, diet and frequency of exercise were self-reported by the participants, and as such may contain bias in reporting; participants may overestimate or underestimate their actual behavior. Dietary assessment was restricted to a few food items, all containing vitamin D. A more comprehensive dietary assessment of the intake of fortified foods and the general nutrient intake could allow a better understanding of dietary influences on vitamin D status. Sun exposure was assessed as self-reported time in sunlight without considering factors that may influence the validity of the sun exposure assessment, such as clothing, sunscreen use, and actual ultraviolet-B radiation received. Other potential confounders that may influence an individual's vitamin D level were not studied, such as genetic predisposition, skin pigmentation, or supplemental intake of vitamin D. We recommend adequate sun exposure, from 15–30 minutes per day, 2–3 times a week, for better vitamin D synthesis. Also, increasing the intake of vitamin D- containing food and encouraging fortification of common foods with vitamin D. Supplementation and periodic testing should be considered in high-risk groups. In addition, it’s of a substantial value to train the health professionals on the identification of signs of vitamin D deficiency and the relevance of the problem as well as to educate the public on the importance of vitamin D, its deficiency, and how to maintain adequate levels. As mentioned, Sudanese studies revealed rates that cannot be ignored. More studies are needed to shed the light on the prevalence of vitamin D deficiency in Sudan and risk screening to understand the status of vitamin D among Sudanese population. Larger, longitudinal studies are recommended for more comprehensive conclusions. Conclusions Vitamin D deficiency isn’t of a single-factor etiology, rather it’s a multi-factorial disease with modifiable and non-modifiable risk factors. Two third of participants had vitamin D deficiency, with significantly higher frequency among participants aged 40–59 years and female participants. Lower consumption of milk and tuna was significantly associated with vitamin D deficiency. Fish, cheese, and eggs showed no significant association. As well, less sun exposure was significantly associated with higher rates of vitamin D deficiency. No significant association found between BMI, education level, frequency of exercise or smoking behavior and vitamin D deficiency. The inconsistent findings among different studies signifies the importance of considering a comprehensive approach to address vitamin D deficiency. Individualized treatment plans that take into account not only dietary intake, but also other factors such as age, lifestyle, socioeconomic status, and overall health are crucial for effectively managing and preventing vitamin D deficiency in different populations. Interventions may include the promotion of sun-safe practices while ensuring adequate UV exposure, dietary supplementation, and public education about the importance of vitamin D. Abbreviations BMI Body Mass Index D2 Ergocalciferol D3 cholecalciferol EMR Eastern Mediterranean Region IU International Unit PHC Primary health care centers SARS-CoV-2 Severe acute respiratory tract infections corona virus − 2 SD Stander Deviation SPSS Statistical Package for social science UAE United Arab Emirate Declarations Ethics approval and consent to participate The ethical approval was obtained from the Ethics Review Committee of Sudan Medical Specialization Board (SMSB)- Council of Family Medicine, research unit (E.D.C), Sudan Ministry of health, Local Government office of Sharg El-Nile locality and the administration of the Health Centers. Written informed consents were taken from the participants and all data were handled confidentially. Consent for publication Not applicable Competing interests The authors declare that they have no competing interests" in this section. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Author Contribution ZI contributed to the idea conceptualization, critical revision and approval of the final manuscript. AA contributed to the concept, design, data collection and drafting the manuscript. AA, TM and AN contributed to data interpretation, article drafting, revision and approval of the submitted manuscript Acknowledgments We would like to acknowledge Ziryab Research group for their guidance through this research. Data Availability The datasets used in the current study are available from the corresponding author on reasonable request. References on behalf of the IOF Committee of Scientific Advisors (CSA) Nutrition Working Group, Mithal A, Wahl DA, Bonjour JP, Burckhardt P, Dawson-Hughes B, et al. Global vitamin D status and determinants of hypovitaminosis D. Osteoporos Int. 2009;20(11):1807–20. Brenner H, Jansen L, Saum KU, Holleczek B, Schöttker B. Vitamin D Supplementation Trials Aimed at Reducing Mortality Have Much Higher Power When Focusing on People with Low Serum 25-Hydroxyvitamin D Concentrations. J Nutr. 2017 July;147(7):1325–33. Holick MF, Vitamin D, Deficiency. N Engl J Med. 2007. Kaykhaei MA, Hashemi M, Narouie B, Shikhzadeh A, Rashidi H, Moulaei N, et al. High Prevalence of Vitamin D Deficiency in Zahedan, Southeast Iran. Ann Nutr Metab. 2011;58(1):37–41. Kaur J, Khare S, Sizar O, Givler A. Vitamin D Deficiency. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 [cited 2025 July 17]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK532266/ Kaykhaei MA, Hashemi M, Narouie B, Shikhzadeh A, Rashidi H, Moulaei N, et al. High Prevalence of Vitamin D Deficiency in Zahedan, Southeast Iran. Ann Nutr Metab. 2011;58(1):37–41. Sayed-Hassan R, Abazid N, Alourfi Z. Relationship between 25-hydroxyvitamin D concentrations, serum calcium, and parathyroid hormone in apparently healthy Syrian people. Arch Osteoporos. 2014;9(1):176. Souberbielle JC, Massart C, Brailly-Tabard S, Cavalier E, Chanson P. Prevalence and determinants of vitamin D deficiency in healthy French adults: the VARIETE study. Endocrine. 2016;53(2):543–50. Cashman KD, Dowling KG, Škrabáková Z, Gonzalez-Gross M, Valtueña J, De Henauw S, et al. Vitamin D deficiency in Europe: pandemic?12. Am J Clin Nutr. 2016;103(4):1033–44. Autier P, Boniol M, Pizot C, Mullie P. Vitamin D status and ill health: a systematic review. Lancet Diabetes Endocrinol. 2014;2(1):76–89. Liu X, Baylin A, Levy PD. Vitamin D deficiency and insufficiency among US adults: prevalence, predictors and clinical implications. Br J Nutr. 2018;119(8):928–36. Han A, Park Y, Lee YK, Park SY, Park CY. Position Statement: Vitamin D Intake to Prevent Osteoporosis and Fracture in Adults. J Bone Metab. 2022;29(4):205–15. Ved R, Taylor P, Stewart P, Foulkes J, Fields-Jewell W, Davies S, et al. Vitamin D deficiency is endemic in neurosurgical patients and is associated with a longer length of inpatient stay. Endocrinol Diabetes Metab. 2019;3(1):e00097. Wakeman M. A Literature Review of the Potential Impact of Medication on Vitamin D Status. Risk Manag Healthc Policy. 2021;14:3357–81. Ostermeier T. Untersuchung des Zusammenhangs zwischen der 25-Hydroxy-Vitamin-D-Serumkonzentration und der Handkraft bei älteren Traumapatienten [Internet] [Text.PhDThesis]. Ludwig-Maximilians-Universität München; 2023 [cited 2025 July 17]. Available from: https://edoc.ub.uni-muenchen.de/32678/ Nair R, Maseeh A, Vitamin D. The sunshine vitamin. J Pharmacol Pharmacother. 2012;3(2):118–26. 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 July 1;96(7):1911–30. Husain NE, Badie Suliman AA, Abdelrahman I, Bedri SA, Musa RM, Osman HE, et al. Vitamin D level and its determinants among Sudanese Women: Does it matter in a sunshine African Country? J Fam Med Prim Care. 2019 July;8(7):2389–94. Bani-issa W, Eldeirawi K, Harfil S, Fakhry R. Vitamin D Deficiency and Its Determinants in Adults: A Sample from Community-Based Settings in the United Arab Emirates. Int J Endocrinol. 2017;2017:3906306. Marzban M, Kalantarhormozi M, Mahmudpour M, Ostovar A, Keshmiri S, Darabi AH, et al. Prevalence of vitamin D deficiency and its associated risk factors among rural population of the northern part of the Persian Gulf. BMC Endocr Disord. 2021;21:219. Tangoh DA, Apinjoh TO, Mahmood Y, Nyingchu RV, Tangunyi BA, Nji EN, et al. Vitamin D Status and Its Associated Risk Factors among Adults in the Southwest Region of Cameroon. J Nutr Metab. 2018;2018(1):4742574. Kelly DC, Fan M, Langton RS, Stahlman SL, Vitamin DD, Trends. Risk Factors, and Occupational Risk in Active Component Service Members of the U.S. Armed Forces, 2018–2022. Med Surveill Mon Rep. 2024;31(8):2. Arabi A, Chamoun N, Nasrallah MP, Tamim HM. Vitamin D Deficiency in Lebanese Adults: Prevalence and Predictors from a Cross-Sectional Community-Based Study. Int J Endocrinol. 2021;2021:3170129. Collins-Fulea C, Klima K, Wegienka GR. Prevalence of Low Vitamin D Levels in an Urban Midwestern Obstetric Practice. J Midwifery Womens Health. 2012 Sept;57(5):439–44. Häusler D, Weber MS. Vitamin D Supplementation in Central Nervous System Demyelinating Disease—Enough Is Enough. Int J Mol Sci. 2019;20(1):218. Additional Declarations No competing interests reported. Supplementary Files VitaminDdeficiencyquestionnaire.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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University","correspondingAuthor":false,"prefix":"","firstName":"Abeer","middleName":"","lastName":"Ahmad","suffix":""},{"id":541969467,"identity":"ea89e918-067f-4b53-ab15-754180a4cd72","order_by":2,"name":"Tarig Alhadi Madibbo","email":"","orcid":"","institution":"University of Bahri","correspondingAuthor":false,"prefix":"","firstName":"Tarig","middleName":"Alhadi","lastName":"Madibbo","suffix":""},{"id":541969468,"identity":"4aca5cb6-a64a-4325-ad3c-3b25e7d410ac","order_by":3,"name":"Arwa 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08:05:54","extension":"html","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":110540,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7547116/v1/22049f1c4ff1c326994c68ad.html"},{"id":95668515,"identity":"6f6bddc9-08f8-4a17-b9ba-07f61e95d1bb","added_by":"auto","created_at":"2025-11-11 17:06:24","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":53330,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eVit\u003c/strong\u003e-\u003cstrong\u003eD level among study participants at Primary Health Care Centers in Sharg El-Nile Locality 2022-2023\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7547116/v1/f7f3faabeded47867ef601dc.png"},{"id":95668517,"identity":"91fd7bfa-8aa3-4aa5-96a2-40947b966793","added_by":"auto","created_at":"2025-11-11 17:06:25","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":75978,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComorbidities among study participants at Primary Health Care Centers in Sharg El-Nile Locality 2022-2023\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7547116/v1/f8496418fbb2e8c99b4c7798.png"},{"id":109296564,"identity":"38f0ac4c-0062-4c8a-9eb8-da752ec3d0a3","added_by":"auto","created_at":"2026-05-15 08:48:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":429013,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7547116/v1/767befd7-26a1-4df3-9c34-60d004a807db.pdf"},{"id":95797273,"identity":"08e6fae2-2384-466c-a91d-bcb75fa8ed96","added_by":"auto","created_at":"2025-11-13 08:02:49","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":16244,"visible":true,"origin":"","legend":"","description":"","filename":"VitaminDdeficiencyquestionnaire.docx","url":"https://assets-eu.researchsquare.com/files/rs-7547116/v1/448c6753239b0737e5ffdf28.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Vitamin D Deficiency and its Risk Factors among Adults in Sharg El-Nile Locality 2022-2023: A cross-sectional study at Primary Health care Centers","fulltext":[{"header":"Background","content":"\u003cp\u003eVitamin D is an important element in our bodies that maintains serum calcium within its normal physiological range. The calcium homeostasis is crucial for various metabolic and neuromuscular activities (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). There is growing evidence that vitamin D has positive effects on our tissues and organs, and that the higher the concentration of vitamin D, the lower the incidence of cancer and its associated mortality (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Vitamin D deficiency is defined as serum levels of less than 20 ng/ml; because at this level, parathyroid hormone starts to rise, and this cut point thought to be the physiologic definition for vitamin D deficiency (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Serum vitamin D of 20\u0026ndash;30 ng/ml is referred to as insufficiency (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). It\u0026rsquo;s a global health problem with approximately 1\u0026nbsp;billion people affected with vitamin D deficiency worldwide, and about 50% are suffering vitamin D insufficiency (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Alongside the high prevalence, a wide variation of vitamin D status exists among different countries. For example, reports from Iran and Syria shows very low average level of vitamin D (14 ng/mL and 10 ng/mL, respectively) (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), compared to the adults in the European countries like Denmark and France (26 ng/mL and 24 ng/mL, respectively) (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThere is a strong correlation between low serum levels of the vitamin D and both communicable and non-communicable diseases (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). It has been linked to high blood pressure, type I diabetes, multiple sclerosis, rheumatoid arthritis, and other autoimmune diseases (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Etiological factors implicated in vitamin D deficiency includes; low dietary intake and/or absorption, decreased sun exposure, decreased endogenous synthesis, and increased catabolism in the liver in response to enzyme inducers (\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Therefore, taking vitamin D supplements and adequate exposure to sunlight can help most people avoid vitamin D insufficiency. The Endocrine Society recommends 400\u0026ndash;1000 International Units (IU) per day for infants under one year of age, 600\u0026ndash;1000 IU for children and adolescents aged 1\u0026ndash;18, and 1500\u0026ndash;2000 IU for everyone (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Optimum sun exposure can be achieved through exposing the arms and legs to direct sunshine for five to ten minutes between 10:00 AM and 3:00 PM in the spring, summer, and fall. Serum 25-hydroxyvitamin D is measured to assess vitamin D circulating levels in high-risk patients (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe amount of vitamin D required to treat the deficiency depends largely on the degree of the deficiency and underlying risk factors. Vitamin D3 supplementation for eight weeks at a dose of 6,000 IU per day or 50,000 IU per week may be an option. After the serum 25-hydroxyvitamin D level rises beyond 30 ng/mL, 1,000\u0026ndash;2,000 IU should be taken daily as a maintenance dose. These doses should be adjusted based on individual patient\u0026rsquo;s status; for instance, two to three times higher doses (6000 \u0026minus;\u0026thinsp;10,000 IU/d) are recommended for obese patients, patients with malabsorption and those taking enzyme-inducing medications. The recommended maintenance dose for this category is 3000\u0026ndash;6000 IU/d (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eVitamin D deficiency is an emerging public health problem in adults from different parts of the world, inclusive of grave implications on bone health, immune function, and general well-being. Despite abundant sunshine over many parts of the world, including Sudan, poor sun exposure added to the dietary insufficiency and lifestyle factors, contributes to the frequency of vitamin D deficiency. We lack the data and clear statistics describing vitamin D status in Sudan. Furthermore, there\u0026rsquo;re no local studies addressing the potential risk factors associated with vitamin D deficiency. This current study tries to delve into the state of vitamin D deficiency and highlights its risk factors among adults at Primary Health Centers in Sharg El-Nile locality.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis is a cross-sectional facility-based study conducted in Sharg El-Nile locality, Bahri, Sudan. We included the nine Primary health Care centers (PHC) in the locality. There\u0026rsquo;re family medicine specialists in the centers serving large areas with high patients\u0026rsquo; frequency. The study duration was six months, from December 2022 to May 2023. All adults attended health center for any purpose during the study period, were included. The following categories were excluded: known cases of vitamin D deficiency, Adults taking supplements because supplements contain up to 400 IU of vitamin D, Pregnant Females attending for ANC, adults with recent fractures, recent major surgery, and chronic kidney disease as they take vitamin D regularly. Patients were randomly selected using patients\u0026rsquo; lists of the nine healthcare centers. The calculated sample size was 242 patients; we contacted them directly and took the consent.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe Primary Health Care center\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber of participants (n\u0026thinsp;=\u0026thinsp;242)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHelat Koko\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e43\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAl-Shaheda Nada\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUm Dom\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlJerief East\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlwehda Altethady\u0026thinsp;=\u0026thinsp;18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlaylafoun\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEast Suba\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEdd Babkie\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlwadi Alakhdar\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eData were collected through a structured close-ended interviewer-administered questionnaire (Supplementary). During the interview, consents were obtained from patients for vitamin D measurement. Frequency of vitamin D deficiency was measured as the dependent variable, while age, gender, BMI, educational level, chronic diseases, daily milk products consumption, daily sun light exposure, and exercise were the independent variables. Data analysis was performed using the Statistical Package for the Social Sciences (SPSS) version 26.\u003c/p\u003e\u003cp\u003e We obtained the ethical approval from the Ethics Review Committee of Sudan Medical Specialization Board (SMSB)- Council of Family Medicine, research unit (E.D.C), Sudan Ministry of health, Local Government office of Sharg El-Nile locality and the administration of the Health Centers. The study purpose and concepts were clearly stated to the participants and written informed consents were taken. We used serial numbers from patients and chaperone to ensure privacy and confidentiality, and all the data were used for research purposes only. The study has been conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 242 patients participated in the study. The majority were 40\u0026ndash;59 years old (48.8%) with general female predominance (62.4%) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). As part of the assessment, we measured the BMI of the participants and their values were grouped into four categories and reported in frequencies and percentages as shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. In terms of education, only 13.2% didn\u0026rsquo;t complete their high school education. The majority were high school graduates (45.9%) and a slightly fewer percentage (40.9%) had college education (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eDistribution of participants by Age, Gender, BMI and Educational Level\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePatients\u0026rsquo; characteristics\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eN (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAge groups\u003c/p\u003e\n\u003cp\u003e22\u0026ndash;39\u003c/p\u003e\n\u003cp\u003e40\u0026ndash;59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e51 (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003e118 (48.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\ge\\:60\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\"\u003e\n\u003cp\u003e73 (30.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGender\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\"\u003e\n\u003cp\u003e91 (37.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003cp\u003eBMI\u003c/p\u003e\n\u003cp\u003eUnderweight\u003c/p\u003e\n\u003cp\u003eNormal\u003c/p\u003e\n\u003cp\u003eOverweight\u003c/p\u003e\n\u003cp\u003eObese\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e151 (62.4)\u003c/p\u003e\n\u003cp\u003e3 (1.2)\u003c/p\u003e\n\u003cp\u003e102 (42.2)\u003c/p\u003e\n\u003cp\u003e94 (38.8)\u003c/p\u003e\n\u003cp\u003e43 (17.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEducational level\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDid not finish high school\u003c/p\u003e\n\u003cp\u003eFinished high school\u003c/p\u003e\n\u003cp\u003eHad college education\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\"\u003e\n\u003cp\u003e32 (13.2)\u003c/p\u003e\n\u003cp\u003e111 (45.9)\u003c/p\u003e\n\u003cp\u003e99 (40.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003eTo assess the vitamin D sources, questions about eating habits and sun exposure were included in the interview. They revealed consumption of egg and milk by most of the participants (n\u0026thinsp;=\u0026thinsp;196, 80.9% and n\u0026thinsp;=\u0026thinsp;180, 74.4%; respectively) twice or often per week, while other dietary sources of vitamin D were less frequently consumed (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). Interestingly, 22 (9.1%) of the participants stated that they do not consume any of the listed vitamin D- containing dietary products. Regarding sunlight exposure during the day, more than half (55.5%) demonstrated less than 15 minutes daily sun exposure. 24.3% showed longer daily exposure for more than 30 minutes, followed by 20.2% with 15\u0026ndash;30 minutes of sunlight per day (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e shows the details about lifestyle and social habits, particularly, exercise and smoking, respectively. Interviewer asked the participants about how frequently they exercise, and nearly half of the answered that they rarely or not doing exercise. As for smoking, only the status was evaluated in the interview and no further details about the frequency have been addressed in the study. Two thirds of the participants (n\u0026thinsp;=\u0026thinsp;164, 67.8%) stated that they have never smoked and only 14 (5.8%) were former smokers.\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eVitamin D deficiency reported in 154 (63.6%) of participants, insufficiency reported in 75 (31%), and sufficient vitamin D reported in only 13 (5.4%) of participants (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Regarding the co-existing medical conditions; Hypertension, diabetes mellitus, gout and cancer among others have reported frequencies of 98 (40.5%), 68 (28.1%), 27 (11.1%), and 4 (1.6%), respectively (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eWe studied the association of vitamin D deficiency with several modifiable and non-modifiable factors; age, gender, BMI, consumption of vitamin D- containing dietary products, sun exposure, exercise and smoking, and the presence of comorbidities. Participants within age group 40\u0026ndash;59 years showed significantly higher frequency of Vit-D deficiency compared to other age groups (P value\u0026thinsp;=\u0026thinsp;0.042) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Female gender also had significantly more frequency of vitamin D deficiency (74.2%) compared to males (46.1%) (P value\u0026thinsp;=\u0026thinsp;0.003) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Conversely, BMI and education level showed no significant association with vitamin D deficiency (P value\u0026thinsp;=\u0026thinsp;0.072 and 0.329, respectively) (Tables\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Association with diet is variable; participants with less milk and tuna consumption were likely to have vitamin D deficiency (P values\u0026thinsp;=\u0026thinsp;0.039 and 0.041, respectively), while no significant association found with consumption frequency of other listed products (fish, cheese and eggs) (P value\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eOur analysis showed increased frequency of vitamin D deficiency with inadequate sun exposure. Less than 15 minutes had more frequency (83.1%) compared to 15\u0026ndash;30 minutes and more than 30 minutes (59.6%, and 36.6%, respectively) with p value of 0.026 (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). According to our data, there\u0026rsquo;s no significant association between vitamin D deficiency and frequency of exercise and smoking behaviour (P value\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e), as well as the presence of comorbidities (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" style=\"width: 742px;\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003e\u003cstrong\u003eAssociation of vit\u003c/strong\u003e-\u003cstrong\u003eD level with Age group, Gender, BMI and Educational Level of study participants\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003ePatient\u0026rsquo;s characteristic\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"4\" width=\"305\"\u003e\n\u003cp\u003e\u003cstrong\u003eVitamin D level\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" rowspan=\"2\" width=\"116\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"5\" width=\"82\"\u003e\n\u003cp\u003e\u003cstrong\u003eP value \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e0.042*\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003eAge group\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e\u003cstrong\u003eDeficient (\u0026lt;20ng/ml)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003e\u003cstrong\u003eInsufficient (20-30ng/ml)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"100\"\u003e\n\u003cp\u003e\u003cstrong\u003eSufficient (\u0026gt;30ng/ml)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e22 \u0026ndash; 39\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e33 (64.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003e17 (33.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"100\"\u003e\n\u003cp\u003e1 (1.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"116\"\u003e\n\u003cp\u003e51 (21%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e40 \u0026ndash; 59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e97 (82.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003e18 (15.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"100\"\u003e\n\u003cp\u003e3 (2.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"116\"\u003e\n\u003cp\u003e118 (48.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u0026ge;60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e24 (32.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003e40 (54.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"100\"\u003e\n\u003cp\u003e9 (12.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"116\"\u003e\n\u003cp\u003e73 (30.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"99\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"102\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"3\" width=\"82\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e0.003*\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e42 (46.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"99\"\u003e\n\u003cp\u003e39 (42.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"102\"\u003e\n\u003cp\u003e10 (10.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e91 (100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e112 (74.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"99\"\u003e\n\u003cp\u003e36 (23.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"102\"\u003e\n\u003cp\u003e3 (2.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e151 (100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003eBMI\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"99\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"102\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003ctable width=\"639\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eUnderweight\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; 3 (100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e\u0026nbsp; 0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"115\"\u003e\n\u003cp\u003e3 (1.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eNormal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e83 (81.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e12 (11.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e7 (6.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"115\"\u003e\n\u003cp\u003e102 (42.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eOverweight\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e57 (60.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e35 (37.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e2 (2.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"115\"\u003e\n\u003cp\u003e94 (38.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003e0.072\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eObese\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e11 (25.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e28 (65.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e4 (9.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"115\"\u003e\n\u003cp\u003e43 (17.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003e\u003cstrong\u003eEducational level\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"115\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eDid not finish high school\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e24 (75.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e7 (21.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e1 (3.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"115\"\u003e\n\u003cp\u003e32 (13.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eFinished high school\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e57 (51.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e45 (47.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e9 (8.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"115\"\u003e\n\u003cp\u003e111 (45.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003e0.329\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003ehad college education\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e73 (73.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e23 (23.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e3 (33.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"115\"\u003e\n\u003cp\u003e99 (40.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e154(63.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e75(31%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003e13(5.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"195\"\u003e\n\u003cp\u003e242(100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Statistically significant association\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003e\u003cstrong\u003eAssociation of vit\u003c/strong\u003e-\u003cstrong\u003eD level with consumption of some vit\u003c/strong\u003e-\u003cstrong\u003eD resources and sun exposure among participants\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eProducts containing vitamin D\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eVitamin D level\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTotal\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eP value\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDeficient (\u0026lt;\u0026thinsp;20ng/ml)\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eInsufficient (20-30ng/ml)\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSufficient (\u0026gt;\u0026thinsp;30ng/ml)\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMilk\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e105 (58.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e64 (35.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e11 (6.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e180 (100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e0.039*\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFish\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e43 (76.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10 (17.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e3 (5.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e56 (100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.93\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTuna\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e66 (58.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e40 (35.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e7 (6.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e113 (100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e0.041*\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCheese\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e94 (58.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e59 (36.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e9 (5.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e162 (100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.057\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEggs\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e122 (62.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e68 (34.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e6 (3.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e196 (100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.780\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNon\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17 (77.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (13.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e2 (9.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22 (100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.33\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAverage of sun exposure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLess than 15 minutes per day\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e74 (83.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14 (15.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e1 (1.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e89 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e0.026*\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15\u0026ndash;30 minutes per day\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e62 (59.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e39 (37.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e3 (2.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e104 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMore 30 minutes per day\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18 (36.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e22 (44.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 (18.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e49 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"1\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTotal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e154 (63.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e75 (31%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13 (5.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e242 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"1\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"7\"\u003e*Statistically significant association\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab4\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003e\u003cstrong\u003eAssociation of vit\u003c/strong\u003e-\u003cstrong\u003eD level with frequency of doing exercise and smoking among participants\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eFrequency of doing exercise\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eVitamin D level\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eTotal\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eP value\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDeficient (\u0026lt;\u0026thinsp;20ng/ml)\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eInsufficient (20-30ng/ml)\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSufficient (\u0026gt;\u0026thinsp;30ng/ml)\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDaily or almost daily\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25(46.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25(46.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4(7.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e54(100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e0.198\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWeekly\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e32(47.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30(44.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6(8.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e68(100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRarely or none\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e97(80.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20(16.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3(2.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e120(100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSmoking\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNever smoked\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e109(66.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e49(29.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6(3.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e164(100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e0.972\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFormer smoker\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12(85.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(14.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0(0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14(100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCurrent smoker.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e33(51.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24(37.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7(10.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e64(100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTotal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e154(63.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e75(31%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13(5.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e242(100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab5\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eAssociation of vitamin D level and having any comorbidity among participants\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eHaving any comorbidity\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eVitamin D level\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eTotal\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eP value\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDeficient (\u0026lt;\u0026thinsp;20ng/ml)\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eInsufficient (20-30ng/ml)\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSufficient (\u0026gt;\u0026thinsp;30ng/ml)\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHypertension\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e49(50%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e43(43.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6(6.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e98(100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.36\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiabetes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e44(64.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22(32.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(2.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e68(100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.74\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCancer\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3(75.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(25.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0(0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4(100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.99\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGout\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15(55.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9(33.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3(11.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27(100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.82\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOther\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e37(68.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13(24.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4(7.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e54(100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.39\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eVitamin D deficiency is still highly prevalent among community-dwelling Sudanese adults. In this study, vitamin D deficiency was reported in 154 participants (63.6%), insufficiency in 75 (31%), and sufficient vitamin D in only 13 participant (5.4%). High prevalence also reported in local study by Husain NE, et al. done among Sudanese women (\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e). They found that 157 out of 190 (82.6%) had vitamin D serum levels below 20 ng/ml (deficient). Similarly, among the adults in the UAE, 74% had vitamin D deficiency at serum levels\u0026thinsp;\u0026le;\u0026thinsp;30 nmol/L (12 ng/ml) (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e). In Iran, on the other hand, the prevalence was relatively lower: 28% were deficient, 50% had insufficient levels, and 22% had sufficient levels (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e). However, the Iranian study has been done in a rural area and this could partially explain the lower percentages and it points to the possible influence of modernization on vitamin D status. Tangoh DA et al. studied vitamin D in the southwest region of Cameroon, they demonstrated that only 3.2% were deficient with overall 25.8% were having vitamin levels less than 30 ng/ml (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e). Another study done among US Armed Forces showed a lower prevalence of 2.2% annual average (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e). Due to the fact that there are different definitions for \u0026ldquo;deficiency\u0026rdquo; based on different cut points, Arabi A et al. described their findings on vit- D deficiency among Lebanese in relevance to the commonly used definitions. They found that 71.9% were deficient at 50 nmol/L (20 ng/ml) and 39.1% at 30 nmol/L (12 ng/ml) (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e). These regional and global variations could be related to multiple environmental, dietary, social and cultural factors, along with the variable diagnosis standards.\u003c/p\u003e\n\u003cp\u003eParticipants within the age group of 40\u0026ndash;59 years had significantly higher frequency of Vit-D deficiency compared to other age groups, with a P value of 0.042. This comes in consistency with the existing literature that describes the increased likelihood of vitamin D deficiency in older population. Kelly DC et al. found that the age groups 30\u0026ndash;39 years and older than 40 years had significantly higher odds of vitamin D deficiency as compared to younger subjects, even after adjustment for covariates and occupation (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e). Another study highlighted the significant inverse association (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.119, p\u0026thinsp;=\u0026thinsp;0.02) of age with 25(OH)D level, indicating a tendency of vitamin D levels to fall with increasing age (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e). This is further supported by a report showing that 96% of the participants aged 56 years or older were vitamin D deficient, followed by 73.53% aged between 40 and 55 years, and 57.35% aged between 23 and 39 years (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e). These consistent findings across different studies underpin the increasing risk of vitamin D deficiency with advancing age. This observation has been attributed to several factors: reduced skin synthesis of the vitamin D, reduced dietary intake, and possible changes in lifestyle or health with aging.\u003c/p\u003e\n\u003cp\u003eVarious studies have investigated the relation between gender and vitamin D deficiency and they came up with conflicting results. We have found a significantly higher frequency of vitamin D deficiency among females (74.2%) compared to males (46.1%), with a P value of 0.003. While some studies support our findings (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e), multiple researches stood on the other side demonstrating no gender-related differences in the rates of vitamin D deficiency (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e). Religion and body covering traditions were thought to play a role in vitamin D level among females; where females who tend to wear hijab show higher odds of deficiency (\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e). Therefore, the dressing pattern may also be a contributor to the demonstrated gender disparities regarding vitamin D levels.\u003c/p\u003e\n\u003cp\u003eThe relationship between BMI, education level, and vitamin D deficiency is inconsistent in various studies. In the current study, no significant association was found between BMI or education level and vitamin D deficiency, with a P value of \u0026gt;\u0026thinsp;0.05. However, other studies have shown conflicting results. For instance, Bani-Issa W et al. reported a highly significant positive correlation between higher BMI (\u0026ge;\u0026thinsp;30) and the probability of vitamin D deficiency, as subjects with higher BMI were at more than a fivefold increased risk when compared to their peers with lower BMI (\u0026lt;\u0026thinsp;25) (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e). Another evidence shows that men with vitamin D deficiency had higher BMI (P\u0026thinsp;=\u0026thinsp;0.008), yet no similar association was observed among women (P\u0026thinsp;=\u0026thinsp;0.7) and this suggests a gender-based variability in the correlation between BMI and vitamin D status (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e). Moreover, Arabi A et al. found that correlations between BMI and body fat mass, as well as certain socioeconomic factors, such as income and education level, exist with vitamin D status; hence, such variables can affect vitamin D levels (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e). These results indicate that the interaction of BMI and educational level may contribute to deficiency of vitamin D and can further be affected by factors related to gender and socio-economic background, in addition to regional and life style variations.\u003c/p\u003e\n\u003cp\u003eWhen considering the relationship between dietary intake and vitamin D deficiency, it appears to be complex and varies across different studies. In our study, vitamin D deficiency was significantly associated with lower consumption of milk (P value\u0026thinsp;=\u0026thinsp;0.039) and tuna (P value\u0026thinsp;=\u0026thinsp;0.041), while no significant association was found with the consumption of fish, cheese, or eggs (P value\u0026thinsp;\u0026gt;\u0026thinsp;0.05). This indicates that certain food items, such as milk and tuna, may play a more critical role in maintaining adequate vitamin D levels. Also, Arabi A et al. identified several dietary factors associated with vitamin D status, including alcohol consumption, dietary intake of fat and vitamin D resources (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e). In contrast, Marzban M et al. found no significant difference between the frequency of consumption of food items and vitamin D status (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), suggesting that diet alone may not be a strong predictor of vitamin D levels in their study population (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e). This discrepancy could be due to differences in dietary habits, sunlight exposure, or other environmental factors across the studied populations and it highlights the multifactorial nature of vitamin D deficiency, where dietary intake is just one of many contributing factors.\u003c/p\u003e\n\u003cp\u003eOur study demonstrates that the frequency of exercise, smoking behavior, and the presence of comorbidities are not significantly associated with vitamin D deficiency, with P values greater than 0.05. This indicates that these factors have no statistically significant impact on vitamin D levels among the study participants. The association of sun exposure with the deficiency of vitamin D is mentioned by various studies, including the current one, which shows significant associations. The majority of participants (55.5%) exposed themselves to sunlight for less than 15 minutes per day, leading to a higher frequency of vitamin D deficiency. The deficiency rate for those who had less than 15 minutes of sun exposure was 83.1%, for 15\u0026ndash;30 minutes it was 59.6%, and above 30 minutes it was 36.6%. the existing evidence supports these findings, where a linear relationship has been demonstrated between sunlight exposure and serum vitamin D levels (\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLifestyle changes towards urbanization and traditional dressing that covers most of the body parts may account for the lowest sun exposure even in rural areas. Husain NE et al. found a significant correlation with vitamin D levels when exposing some body parts to sunlight compared to complete covering (\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e). One study, conducted at Michigan Hospital, revealed a notably higher percentage of vitamin D deficiency and insufficiency in women who used hijab or Niqab compared to non-users (\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e). This further supports the claim that sun exposure, and therefore vitamin D status, may well be influenced largely by factors like culture and form of dress. These studies underline that adequate sun exposure is important for maintaining vitamin D levels and point out the need for public health strategies considering cultural and lifestyle factors.\u003c/p\u003e\n\u003cp\u003eOur current study provides insights about vitamin D status among Sudanese patients across different age groups. We have studied multiple factors in terms of their potential influence on serum vitamin D levels. It serves as a local guide for future studies and public health interventions addressing this issue aiming to decrease vitamin D deficiency rates. However, it is limited by its cross-sectional design that hinders the establishment of any causal relationship between the vitamin D deficiency and its associated factors. Additionally, Geographical region, socio-economic status and cultural lifestyle may all impact vitamin D levels and our study population may not be representative of the wider demographic diversity. Due to the financial constrains and high cost of vitamin D measurement, the sample size was relatively small and this may affect the results generalizability. Also, some data, such as; sun exposure, diet and frequency of exercise were self-reported by the participants, and as such may contain bias in reporting; participants may overestimate or underestimate their actual behavior. Dietary assessment was restricted to a few food items, all containing vitamin D. A more comprehensive dietary assessment of the intake of fortified foods and the general nutrient intake could allow a better understanding of dietary influences on vitamin D status. Sun exposure was assessed as self-reported time in sunlight without considering factors that may influence the validity of the sun exposure assessment, such as clothing, sunscreen use, and actual ultraviolet-B radiation received. Other potential confounders that may influence an individual's vitamin D level were not studied, such as genetic predisposition, skin pigmentation, or supplemental intake of vitamin D.\u003c/p\u003e\n\u003cp\u003eWe recommend adequate sun exposure, from 15\u0026ndash;30 minutes per day, 2\u0026ndash;3 times a week, for better vitamin D synthesis. Also, increasing the intake of vitamin D- containing food and encouraging fortification of common foods with vitamin D. Supplementation and periodic testing should be considered in high-risk groups. In addition, it\u0026rsquo;s of a substantial value to train the health professionals on the identification of signs of vitamin D deficiency and the relevance of the problem as well as to educate the public on the importance of vitamin D, its deficiency, and how to maintain adequate levels. As mentioned, Sudanese studies revealed rates that cannot be ignored. More studies are needed to shed the light on the prevalence of vitamin D deficiency in Sudan and risk screening to understand the status of vitamin D among Sudanese population. Larger, longitudinal studies are recommended for more comprehensive conclusions.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eVitamin D deficiency isn\u0026rsquo;t of a single-factor etiology, rather it\u0026rsquo;s a multi-factorial disease with modifiable and non-modifiable risk factors. Two third of participants had vitamin D deficiency, with significantly higher frequency among participants aged 40\u0026ndash;59 years and female participants. Lower consumption of milk and tuna was significantly associated with vitamin D deficiency. Fish, cheese, and eggs showed no significant association. As well, less sun exposure was significantly associated with higher rates of vitamin D deficiency. No significant association found between BMI, education level, frequency of exercise or smoking behavior and vitamin D deficiency. The inconsistent findings among different studies signifies the importance of considering a comprehensive approach to address vitamin D deficiency. Individualized treatment plans that take into account not only dietary intake, but also other factors such as age, lifestyle, socioeconomic status, and overall health are crucial for effectively managing and preventing vitamin D deficiency in different populations. Interventions may include the promotion of sun-safe practices while ensuring adequate UV exposure, dietary supplementation, and public education about the importance of vitamin D.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBody Mass Index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eD2\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eErgocalciferol\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eD3\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003echolecalciferol\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEMR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEastern Mediterranean Region\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIU\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInternational Unit\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePHC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePrimary health care centers\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSARS-CoV-2\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSevere acute respiratory tract infections corona virus \u0026minus;\u0026thinsp;2\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStander Deviation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSPSS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStatistical Package for social science\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUAE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUnited Arab Emirate\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003e The ethical approval was obtained from the Ethics Review Committee of Sudan Medical Specialization Board (SMSB)- Council of Family Medicine, research unit (E.D.C), Sudan Ministry of health, Local Government office of Sharg El-Nile locality and the administration of the Health Centers. Written informed consents were taken from the participants and all data were handled confidentially.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no competing interests\" in this section.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eZI contributed to the idea conceptualization, critical revision and approval of the final manuscript. AA contributed to the concept, design, data collection and drafting the manuscript. AA, TM and AN contributed to data interpretation, article drafting, revision and approval of the submitted manuscript\u003c/p\u003e\u003ch2\u003eAcknowledgments\u003c/h2\u003e\u003cp\u003eWe would like to acknowledge Ziryab Research group for their guidance through this research.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used in the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eon behalf of the IOF Committee of Scientific Advisors (CSA) Nutrition Working Group, Mithal A, Wahl DA, Bonjour JP, Burckhardt P, Dawson-Hughes B, et al. Global vitamin D status and determinants of hypovitaminosis D. Osteoporos Int. 2009;20(11):1807\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrenner H, Jansen L, Saum KU, Holleczek B, Sch\u0026ouml;ttker B. Vitamin D Supplementation Trials Aimed at Reducing Mortality Have Much Higher Power When Focusing on People with Low Serum 25-Hydroxyvitamin D Concentrations. J Nutr. 2017 July;147(7):1325\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHolick MF, Vitamin D, Deficiency. N Engl J Med. 2007.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKaykhaei MA, Hashemi M, Narouie B, Shikhzadeh A, Rashidi H, Moulaei N, et al. High Prevalence of Vitamin D Deficiency in Zahedan, Southeast Iran. Ann Nutr Metab. 2011;58(1):37\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKaur J, Khare S, Sizar O, Givler A. Vitamin D Deficiency. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 [cited 2025 July 17]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.ncbi.nlm.nih.gov/books/NBK532266/\u003c/span\u003e\u003cspan address=\"http://www.ncbi.nlm.nih.gov/books/NBK532266/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKaykhaei MA, Hashemi M, Narouie B, Shikhzadeh A, Rashidi H, Moulaei N, et al. High Prevalence of Vitamin D Deficiency in Zahedan, Southeast Iran. Ann Nutr Metab. 2011;58(1):37\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSayed-Hassan R, Abazid N, Alourfi Z. Relationship between 25-hydroxyvitamin D concentrations, serum calcium, and parathyroid hormone in apparently healthy Syrian people. Arch Osteoporos. 2014;9(1):176.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSouberbielle JC, Massart C, Brailly-Tabard S, Cavalier E, Chanson P. Prevalence and determinants of vitamin D deficiency in healthy French adults: the VARIETE study. Endocrine. 2016;53(2):543\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCashman KD, Dowling KG, Škrab\u0026aacute;kov\u0026aacute; Z, Gonzalez-Gross M, Valtue\u0026ntilde;a J, De Henauw S, et al. Vitamin D deficiency in Europe: pandemic?12. Am J Clin Nutr. 2016;103(4):1033\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAutier P, Boniol M, Pizot C, Mullie P. Vitamin D status and ill health: a systematic review. Lancet Diabetes Endocrinol. 2014;2(1):76\u0026ndash;89.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiu X, Baylin A, Levy PD. Vitamin D deficiency and insufficiency among US adults: prevalence, predictors and clinical implications. Br J Nutr. 2018;119(8):928\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHan A, Park Y, Lee YK, Park SY, Park CY. Position Statement: Vitamin D Intake to Prevent Osteoporosis and Fracture in Adults. J Bone Metab. 2022;29(4):205\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVed R, Taylor P, Stewart P, Foulkes J, Fields-Jewell W, Davies S, et al. Vitamin D deficiency is endemic in neurosurgical patients and is associated with a longer length of inpatient stay. Endocrinol Diabetes Metab. 2019;3(1):e00097.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWakeman M. A Literature Review of the Potential Impact of Medication on Vitamin D Status. Risk Manag Healthc Policy. 2021;14:3357\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOstermeier T. Untersuchung des Zusammenhangs zwischen der 25-Hydroxy-Vitamin-D-Serumkonzentration und der Handkraft bei \u0026auml;lteren Traumapatienten [Internet] [Text.PhDThesis]. Ludwig-Maximilians-Universit\u0026auml;t M\u0026uuml;nchen; 2023 [cited 2025 July 17]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://edoc.ub.uni-muenchen.de/32678/\u003c/span\u003e\u003cspan address=\"https://edoc.ub.uni-muenchen.de/32678/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNair R, Maseeh A, Vitamin D. The sunshine vitamin. J Pharmacol Pharmacother. 2012;3(2):118\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHolick 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 July 1;96(7):1911\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHusain NE, Badie Suliman AA, Abdelrahman I, Bedri SA, Musa RM, Osman HE, et al. Vitamin D level and its determinants among Sudanese Women: Does it matter in a sunshine African Country? J Fam Med Prim Care. 2019 July;8(7):2389\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBani-issa W, Eldeirawi K, Harfil S, Fakhry R. Vitamin D Deficiency and Its Determinants in Adults: A Sample from Community-Based Settings in the United Arab Emirates. Int J Endocrinol. 2017;2017:3906306.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMarzban M, Kalantarhormozi M, Mahmudpour M, Ostovar A, Keshmiri S, Darabi AH, et al. Prevalence of vitamin D deficiency and its associated risk factors among rural population of the northern part of the Persian Gulf. BMC Endocr Disord. 2021;21:219.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTangoh DA, Apinjoh TO, Mahmood Y, Nyingchu RV, Tangunyi BA, Nji EN, et al. Vitamin D Status and Its Associated Risk Factors among Adults in the Southwest Region of Cameroon. J Nutr Metab. 2018;2018(1):4742574.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKelly DC, Fan M, Langton RS, Stahlman SL, Vitamin DD, Trends. Risk Factors, and Occupational Risk in Active Component Service Members of the U.S. Armed Forces, 2018\u0026ndash;2022. Med Surveill Mon Rep. 2024;31(8):2.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eArabi A, Chamoun N, Nasrallah MP, Tamim HM. Vitamin D Deficiency in Lebanese Adults: Prevalence and Predictors from a Cross-Sectional Community-Based Study. Int J Endocrinol. 2021;2021:3170129.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCollins-Fulea C, Klima K, Wegienka GR. Prevalence of Low Vitamin D Levels in an Urban Midwestern Obstetric Practice. J Midwifery Womens Health. 2012 Sept;57(5):439\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eH\u0026auml;usler D, Weber MS. Vitamin D Supplementation in Central Nervous System Demyelinating Disease\u0026mdash;Enough Is Enough. Int J Mol Sci. 2019;20(1):218.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Vitamin D deficiency, Sudan, Sun exposure, Risk factors, sufficient vitamin D","lastPublishedDoi":"10.21203/rs.3.rs-7547116/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7547116/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eVitamin D significantly affects the musculoskeletal, endocrine, immunological, and cardiovascular systems. An estimated one billion persons globally present with hypovitaminosis D, according to current recorded data, indicating a global pandemic. In this study, we investigated vitamin D Deficiency and its Risk Factors among Adults at Primary Health care Centers in Sharg El-Nile Locality 2022\u0026ndash;2023.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e This is a cross-sectional facility-based study conducted during the period from December 2022 to May 2023, in nine Primary health care centers (PHC) in Sharg El-Nile locality, Bahri, Sudan. Participants were randomly selected from adults attending these nine healthcare centers during the study period. The following categories were excluded: known cases of vitamin D deficiency, Adults taking supplements because supplements contain up to 400 IU of vitamin D, Pregnant Females attending for ANC, adults with recent fractures, recent major surgery, and chronic kidney disease as they take vitamin D regularly. The calculated sample size was 242 patients. Direct interviewing questionnaire used then participants tested for Vitamin D level. Data were processed using the SPSS version 26.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eOut of 242 participants, the majority (48.8%) were in the age group of 40\u0026ndash;59 years, with females constituting 62.4%. Vitamin D deficiency prevalence was 63.6%, while insufficiency reported in 31%, and sufficient vitamin D reported in only 5.4% of participants. Participants aging 40\u0026ndash;59 years and females had significantly higher frequency of Vit-D deficiency compared to others (P values: 0.042 and 0.003, respectively). Vitamin D deficiency was significantly associated with less consumption of milk (P value\u0026thinsp;=\u0026thinsp;0.039) and tuna (P\u0026thinsp;=\u0026thinsp;0.041), as well as inadequate Sun exposure. BMI, education level, frequency of exercise and smoking behaviour were not found to be associated with vitamin D deficiency (P value\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eVitamin D deficiency was critically high prevalent among respondents, and it was significantly higher among females, and people aged 40\u0026ndash;59 years. The factors, which contributed significantly to deficiency, included low intake of milk and tuna and low sun exposure.\u003c/p\u003e","manuscriptTitle":"Vitamin D Deficiency and its Risk Factors among Adults in Sharg El-Nile Locality 2022-2023: A cross-sectional study at Primary Health care Centers","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-11 17:06:19","doi":"10.21203/rs.3.rs-7547116/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a55cb23a-4079-4c0e-b79d-0e0d13e0f198","owner":[],"postedDate":"November 11th, 2025","published":true,"recentEditorialEvents":[{"type":"decision","content":"Withdrawn","date":"2026-05-15T06:07:21+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-15T06:23:43+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-11 17:06:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7547116","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7547116","identity":"rs-7547116","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}