Correlation between anthropometric and biological parameters of the offspring and parental plasma 25-hydroxyvitamin D levels: a cross-sectional study conducted at Oran, Algeria.

Correlation between anthropometric and biological parameters of the offspring and parental plasma 25-hydroxyvitamin D levels: a cross-sectional study conducted at Oran, Algeria. | 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 Correlation between anthropometric and biological parameters of the offspring and parental plasma 25-hydroxyvitamin D levels: a cross-sectional study conducted at Oran, Algeria. Sara Mama Abadi, Habib Hammou, Lidia Saidi, Soumia Fenni, Tawfik Addi, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5930305/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 22 May, 2025 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted 8 You are reading this latest preprint version Abstract Background Vitamin D is critical in overall health, particularly during pregnancy, as it supports a healthy pregnancy and promotes proper fetal development. This study examined the link between parental 25-hydroxyvitamin D (25(OH)D) deficiency and their offspring's anthropometric and biological parameters. Methods A cross-sectional study was conducted involving 50 Algerian families, which included 50 pregnant women in their third trimester, 50 fathers, and 50 newborns. Blood samples were collected from both parents and the umbilical cord of the newborns. Serum 25(OH)D concentrations were measured, and demographic and health-related information was gathered from the participants. The anthropometric parameters of the newborns were recorded at birth. Results In our study, 16% of women were insufficient in 25(OH)D, 54% were deficient, and the remaining 30% exhibited severe deficiency, with mean 25(OH)D levels of 24.53 ng/ml, 14.23 ng/ml, and 7.69 ng/ml, respectively. Among males, 40% were insufficient, 42% were deficient, and 18% had severe deficiency, with mean 25(OH)D levels of 25 ng/ml, 15.78 ng/ml, and 8.53 ng/ml, respectively. Furthermore, 24% of newborns were insufficient, 52% were deficient, and 24% had severe deficiency, with mean 25(OH)D levels of 23.53 ng/ml, 13.46 ng/ml, and 7.53 ng/ml, respectively. Maternal 25(OH)D levels were positively correlated with the anthropometric parameters of newborns (height, femur length, weight, and Apgar scores at 1 and 5 minutes after birth). Conversely, paternal deficiency showed no correlation with these parameters. Conclusion 25(OH)D deficiency significantly impacts newborns and represents a significant risk to their development, whereas paternal deficiency has no impact on the measured anthropometric parameters of newborns. 25-Hydroxyvitamin D pregnant women deficiency parents offspring anthropometric parameters Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Vitamin D is a prohormone ( 1 ) primarily recognized for regulating calcium homeostasis and bone metabolism ( 2 ) . The circulating 25(OH)D concentration is widely accepted as the individual vitamin D status marker. Many agencies use it to establish dietary requirements for vitamin D and monitor the population for deficiency or insufficiency ( 3 ) . Hypovitaminosis D poses a significant public health issue among the general population ( 4 ) . In Africa, data from 119 studies, including meta-analyses, estimated prevalence rates of 18.5% for serum 25(OH)D levels below 30 nmol/L and 34.2% for levels below 50 nmol/L. The analysis also indicated that most studies reporting low 25(OH)D concentrations originated from North and South African countries, compared to Sub-Saharan Africa. In Africa, urban populations exhibited lower 25(OH)D levels than rural areas. A guest commentary on the systematic review highlighted that, despite the long-held belief that Africa was spared mainly from severe vitamin D deficiency issues due to abundant sunlight across much of the continent, the findings of the systematic survey suggest a potentially higher prevalence of 25(OH)D levels below 30 ng/L compared to Europe (18.5% vs. 13%, respectively) ( 5 ) . Numerous studies underscore the role of vitamin D in the development of pathologies during pregnancy ( 6 ) . Although several studies have emphasized the beneficial effects of vitamin D supplementation on maternal and neonatal health during pregnancy and recommend daily supplementation during this critical period ( 7 ) , adherence to these recommendations remains low. Maternal vitamin D levels are influenced by maternal age, sample collection season, pre-pregnancy body mass index (BMI), ethnicity, and study site latitude ( 8 ) . Since the fetus's vitamin D supply is also ensured by transfer from the maternal placenta ( 9 ) , researchers have hypothesized that these factors above have long been involved in lasting changes in the offspring's body composition, physiology, and metabolism. Maternal vitamin D deficiency during pregnancy has several adverse effects on neonatal and maternal health ( 10 ) . Recently, vitamin D nuclear receptors (VDR) have been identified in various tissues, including organs involved in reproduction and infant growth, such as ovarian cells ( 11 ) , where calcitriol plays a significant role in placental physiology. It stimulates endometrial decidualization, estradiol, and progesterone synthesis, and regulates the expression of human chorionic gonadotropin (hCG) and human placental lactogen (hPL) ( 12 ) . This receptor is also expressed in testicular cells, where vitamin D influences male fertility, particularly sperm motility ( 13 ) . Therefore, vitamin D deficiency in both parents may impact the health of the offspring ( 14 ) , as demonstrated in a previous study that vitamin D deficiency in parents is linked to epigenetic alterations and higher blood pressure levels in their offspring ( 15 ) . In Algeria, the impact of maternal status on 25(OH)D on newborns' health is poorly studied. No studies have been conducted on the impact of parental 25(OH)D deficiency on newborns' phenotypes. Therefore, our study aims to determine whether the level of parental 25(OH)D deficiency affects the offspring's phenotype. Materials and methods Study Sample This study was a cross-sectional examination of Algerian families aimed at investigating the correlation between parental 25(OH)D levels during pregnancy and the anthropometric and biological parameters of newborns. Conducted over two years at the Department of Gynecology and Obstetrics at Oran University Hospital, the research involved 50 Algerian families, including 50 pregnant women in their third trimester, 50 males, and 50 newborns. The study received approval from the Medical Ethics Committee of Oran University Hospital under N°83/2021/DAPM. Inclusion criteria The participants included parents and their newborns with 25(OH)D levels below 30 ng/ml, aged between 20 and 45 for women and 25 to 45 for men, with the newborns being full-term singleton infants. According to the WHO, the parents had a normal BMI ranging from 18.5 to 24.9 kg/m². The sample selection was purposive, meaning participants were chosen to fulfill the study's objectives best. Exclusion criteria Participants with chronic diseases that directly or indirectly affect vitamin D metabolism, such as thyroid and parathyroid disorders, chronic liver diseases, renal impairment, and chronic inflammatory bowel diseases, as well as individuals taking vitamin D supplements or anticonvulsants, and those with a family history of rickets, were excluded from the study. Women with conditions such as preeclampsia, autoimmune diseases, antiphospholipid antibody syndrome, lupus, and abnormal placental locations (including placenta previa and accreta) were also excluded, along with newborns who had conditions like arteriovenous malformation, a single umbilical artery (due to velamentous insertion of the umbilical cord), fetal distress (from umbilical cord torsion), hemorrhages (such as feto-maternal transfusion), retroplacental hematoma, and prematurity. Data Collection After obtaining signed consent, a recruitment questionnaire (Supplemental data) was administered through face-to-face interviews with the couples, which included the following anthropometric data: participant serial number, age of parents, parity, mode of delivery, parental illness, vitamin intake during pregnancy, and the presence of a family history of vitamin D deficiency. Weight was measured while height and waist circumference were measured using a graduated tape measure in centimeters. Body Mass Index (BMI) was then calculated by dividing weight (kg) by the square of height (m²). The questionnaire also included information on occupation, educational level, and habitat type. Regarding the newborn, their gender, birth weight, height, and femur length were extracted from the maternal delivery records. The midwife assigned the Apgar score 1 and 5 minutes after birth. If respiratory support or other assistance was required, a pediatrician was immediately summoned to the delivery room to assign the score. This score was based on five objective criteria: appearance, pulse, grimace, activity, and respiration, each scored from 0 to 2. Apgar scores above 7 were considered "reassuring," those between 4 and 6 were regarded as "below normal," and those between 1 and 3 were classified as "critical," typically requiring urgent clinical intervention. The neonatal 25(OH)D level and any congenital abnormalities or signs of umbilical cord infection were recorded. All newborns were examined for these parameters after resuscitation ( 16 ) . Blood Sample Collection 25(OH)D concentrations were measured from fasting blood samples taken from parents and the umbilical cord of newborns at birth in heparin-lithium tubes. The blood was then centrifuged at 3000 rpm for 15 minutes at 4°C. Immediately afterward, the serum samples were stored in aliquots at -80°C until analysis. The samples were analyzed in the Duval El-Biar clinic laboratory in Algiers using the Atellica® system (Siemens Healthcare Diagnostics Inc., Tarrytown, NY, USA), which integrates modules for clinical biochemistry analysis and flexible immunoassays. The thresholds for determining 25(OH)D status are < 20 ng/ml for deficiency and 20 to 29.9 ng/ml for insufficiency, following guidelines from the Endocrine Society. Statistical Analysis The first part of the analysis used GraphPad Prism software, while the second part used IBM SPSS Statistics Version 26. To assess the normality of our data, we performed the Kolmogorov-Smirnov test for each group (mothers, fathers, newborns). The results showed that all p-values were greater than 0.05, indicating that the data from each group followed a normal distribution. Therefore, we could employ parametric tests for the subsequent statistical analyses. Continuous quantitative data were reported as means ± standard deviations, while qualitative data were shown as percentages. Comparisons were conducted using the Student’s t-test for qualitative variables with two categories and one-way ANOVA for those with three or more categories, followed by Tukey’s post hoc test when significant differences were detected. We employed Pearson’s correlation to analyze the relationships between two quantitative variables. A multiple linear regression was performed to examine the simultaneous effect of several independent variables on a single continuous quantitative dependent variable. After multiple comparisons, the Bonferroni adjustment was applied to correct the significance threshold, maintaining strict control over the overall Type I error rate. ROC analysis was performed to evaluate the predictive ability of parental 25(OH)D levels for a lower Apgar score in newborns of mothers with suboptimal vitamin D status. The area under the curve (AUC) was calculated to assess the overall accuracy of the prediction. Differences were considered significant if p < 0.05. Results Sociodemographic characteristics of the parents The present study included fifty Algerian families residing in Oran, comprising 50 males and 50 pregnant women who gave birth to 50 newborns. Parental characteristics are detailed in Table 1 . The median age of the women was 30 years, and most were stay-at-home mothers, with 18% having only a primary education, the majority (60%) possessing an intermediate level of education, and the remaining 11% having attained higher education. Sixty percent of the blood samples were collected during the winter season. A significant majority of the women (90%) gave birth vaginally. It was noted that 26% of the women had a history of COVID-19. Additionally, 60% of the women had dark skin, and 84% experienced insufficient sun exposure (less than 30 minutes per day). Concerning anemia, it was present in all the pregnant women, but its severity varied, with 62% of the women exhibiting severe anemia. Table 1 Sociodemographic characteristics in parents and their impact on 25(OH)D Levels Maternal description N Mean(SD) p -value Paternal description N Mean(SD) p -value 1 Age Age 20 years − 26 years 18 14.92 (6.486) 0.180 20 years − 26 years 1 26,41 (/) 0.310 27 years − 35 years 22 14.57 (5.846) 27 years − 35 years 23 18.37 (6.142) 36 years − 45 years 10 10.90 (3.814) 36 years − 45 years 27 17.97 (7.308) Blood sample Collection Season Blood sample Collection Season Winter 30 14.95 (6.298) 0.344 Winter 30 18.70 (6.933) 0.556 Spring 8 12.79 (5.944) Spring 8 15.780 (5.847) Autumn 12 12.27 (4.369) Autumn 12 18.34 (6.954) Education level Education level Never attendedschool / / 0.459 Never attendedschool 1 25.64 (/) 0.015* Primaryeducation 9 12.63 (4.505) Primaryeducation 11 16.30 (5.458) Middle schooleducation 30 14.82 (6.665) Middle schooleducation 32 17.17 (6.751) Highereducation 11 12.72 (4.202) Highereducation 6 25.49 (3.516) Occupation type Occupation type Low income 10 9.79 (3.67) 0.073 Low income 10 14.30 (5.717) 0.052 Moderateincome 39 14.74 (5.69) Moderateincome 39 18.89 (6.617) High income 1 25.52 (0) High income 1 27.76 (/) Housing occupation status Housing occupation status Housingprovided for free. 33 13,17(5,35) 0.276 Housingprovided for free. 33 16.15 (6.255) 0.006** Own a detached house. 13 15,29(6,61) Own a detached house. 13 21.14 (6.593) Renting an empty residence 4 16,24(7,61) Renting an empty rresidence 4 24.92 (2.234) COVID-19 COVID-19 Yes 13 7.47 (1.024) 0.000*** Yes / / / No 37 16.24 (5.083) No 50 18,21(6,785) Skin color Skin color Light 20 16.69 (6.78) 0.006** Light 25 22.12 (5.42) < 0.0001*** Dark 30 12.15 (4.40) Dark 25 14.18 (5.51) Sun exposure Sun exposure Insufficient < 30 min/day 42 12.64 (4.96) < 0.0001*** Insufficient < 30 min/day 40 44 (6.34) 0.0002*** Sufficient ≥ 30 min/day 8 20.95 (5.47) Sufficient ≥ 30 min/day 10 24.79 (2.79) Smoking Smoking Yes / / / Yes 34 17.50 (6.85) 0.324 No 50 13,96(5,800) No 16 19.53 (6.46) Anemia Low 19 19.66 (4.68) < 0.0001*** High 31 10.48 (3.15) Type of delivery Vaginal 45 14.22 (6.024) 0.322 Cesarean 5 11.47 (3.569) Significant differences between groups (Student’ test or ANOVA tests; * p < 0.05; ** p < 0.01; *** p < 0.001) The median age of the males participating in the study was 36 years, with most having a moderate level of education (64%) and 22% having completed primary education. In terms of occupational income, 78% reported moderate income. Among these families, 64% lived in free housing, while 26% were homeowners. Half of the males had dark skin, but the difference lay in the duration of sun exposure, as 40 out of 50 males had insufficient exposure to sunlight. Additionally, 68% of them were smokers. Among women, specific characteristics significantly increase the risk of developing 25(OH)D insufficiency, particularly a history of COVID-19, dark skin, anemia, and insufficient sun exposure (Table 1 ). In contrast, among men, two factors appeared to significantly affect this deficiency: skin color and insufficient sun exposure (Table 1 ). Other characteristics were examined, but they did not significantly influence the deficiency observed in the parents (Table 1 ). A multiple linear regression was conducted to examine the relationship between parental 25(OH)D status and sociodemographic characteristics. No significant relationship was observed between maternal 25(OH)D level and age (-0.82, CI 95% -0.56 to -0.60; p -value = 0.413), education level (-0.46, CI 95% -0.26 to -0.03; p -value = 0.646), occupation type ( -0.25, CI 95% -0.25 to -0.02; p -value = 0.804), housing occupation status (-0.41, CI 95% -0.30 to -0.03; p -value = 0.681), type of delivery (-0.17, CI 95% -0.28 to -0.01; p -value = 0.859) or skin color (1.18, CI 95% 1.25 to 0.10; p -value = 0.243). However, a significant relationship and weak association were noted between maternal 25(OH)D levels and blood sample collection season (-2.02, CI 95% -1.23 to -0.16; p -value = 0.049). A highly significant relationship and a moderate association with anemia (-2.76, CI 95% -9.26 to -0.22; p -value = 0.009) and strong association with very highly significant relationship was noted with COVID-19 (-5.68, CI 95% -6.34 to -0.48; p -value = 0.000) and sun exposure (5.71, CI 95% 0.80 to 0.49; p -value = 0.000). (Fig. 1 A). After applying the Bonferroni correction for multiple comparisons (adjusted significance threshold: p -value < 0.005), only two associations -those with COVID-19 status and sun exposure- remained statistically significant, suggesting a robust and reliable relationship. In contrast, the associations with anemia and the season of blood sample collection no longer reached statistical significance. The relationship was highly significant for males, showing a strong association between 25(OH)D levels and skin color (3.66, CI 95%, 6.61 to 0.49; p -value = 0.001). A significant, moderate association was observed with housing occupation status (2.08, CI 95% 2.92 to 0.27; p -value = 0.043). There was no statistically significant difference found among the remaining sociodemographic characteristics (age, blood sample collection season, education level, occupation type, sun exposure, smoking) (-0.01, CI 95% -0.03 to -0.002; p -value = 0.985), (-0.96, CI 95% -0.99 to -0.11; p -value = 0.341),(1.26, CI 95% 1.47 to 0.16; p -value = 0.215), (-0.44, CI 95% -0.76 to -0.05; p -value = 0.658), (1.12, CI 95% 0.04 to 0.13; p -value = 0.269), (1.63, CI 95% 2.98 to 0.20; p -value = 0.109) respectively (Fig. 1 B). Only skin color remained statistically significant after applying Bonferroni correction for multiple testing (adjusted significance threshold: p -value < 0.0062). Biological characteristics of parents After measuring 25(OH)D levels in parents, it was observed that the majority of parents were deficient in 25(OH)D, with 54% of women having an average of 14.23 ng/ml and 42% of men averaging 15.78 ng/ml. Sixteen percent of pregnant women studied were insufficient (with levels between 20 and 29.9 ng/ml), averaging 24.53 ng/ml, and 40% of men fall into this category. A severe deficiency was present in 30% of women, with an average of 7.69 ng/ml, and in 18% of men, with an average of 8.53 ng/ml. The averages also seem to be significantly lower in women compared to males overall (13.96 ng/ml vs 18.15 ng/ml, respectively), as well as in each category (insufficient and deficient). Biological and anthropometric parameters of newborns Newborns with parents exhibiting insufficiency (25(OH)D levels between 20 and 29.9 ng/ml) or deficiency (25(OH)D levels < 20 ng/ml) showed suboptimal 25(OH)D concentrations. Among these newborns, 52% of girls and 28% of boys were deficient, yielding average levels of 14.16 ng/ml and 12.77 ng/ml, respectively. Additionally, 25(OH)D insufficiency was noted in 24% of girls and 20% of boys, with average levels of 24.27 ng/ml and 22.79 ng/ml, respectively. Furthermore, 24% of girls and 52% of boys exhibited severe deficiency, with average levels of 7.26 ng/ml and 7.81 ng/ml, accordingly. However, no significant association was identified between 25(OH)D status and the newborn's sex ( p -value = 0.13). Various anthropometric parameters were studied in newborns, including height, femur length, weight, and Apgar scores at one minute (Apgar1) and at five minutes (Apgar5) after birth. All newborns with suboptimal 25(OH)D levels exhibited anthropometric parameters that measured below the norm (Table 2 ), showing a strong and highly significant correlation (p-value = 0.0001 for all anthropometric parameters). The normal values for these parameters were as follows: height > 47cm, weight > 2500g, femur length = 69-73cm, Apgar score at 1st minute ≥ 7/10, and Apgar score at 5th minute ≥ 7/10. No differences were observed between boys and girls for any of the physiological characteristics studied ( p -value > 0.05) (Table 2 ). Table 2 Normal and recorded values of anthropometric parameters in newborns Anthropometric parameters Normal Values Recorded Values p -value Total (n = 50) Mean(SD) Girls (n = 25) Mean(SD) Boys (n = 25 Mean(SD) Height(cm) > 47 45.80 (2.86) 46.28 (2.85) 45.32 (2.85) 0.24 Weight(g) > 2500 2420 (0.28) 2470 (0.32) 2370 (0.23) 0.17 Femur length(cm) 69–73 68.16 (2.37) 68.60 (2.57) 67.72 (2.11) 0.19 Apgar score at 1st min ≥ 7/10 6.7 (1.6) 7 (1.6) 6.3 (1.7) 0.14 Apgar score at 5th min ≥ 7/10 8.2 (1.4) 8.4 (1.3) 8 (1.5) 0.24 Significant differences between groups (ANOVA tests) Correlation between parental 25(OH)D levels and anthropometric parameters of newborns Maternal 25(OH)D levels were positively correlated with newborn parameters: height, femur length, weight, and Apgar score at 1 and 5 minutes, demonstrating a strong correlation ( p -value = 0.0009, 0.004, 0.023, 0.0007, 0.0042, respectively) (Fig. 2 A, B, C, D, E). No significant correlation was observed between paternal 25(OH)D levels and the anthropometric parameters of the offspring, including height, femur length, weight, and Apgar scores at 1 and 5 minutes for the newborns ( p -value = 0.19, 0.37, 0.45, 0.53, and 0.58, respectively) (Fig. 3 A, B, C, D, E). Two distinct ROC analyses were performed to assess the performance of maternal 25(OH)D concentration in predicting an Apgar score < 7 at the 1st and 5th minutes of life. For the score at the 1st minute, the area under the curve (AUC) was 0.785 (95% CI: 0.652–0.918), indicating good discriminative ability. The optimal cut-off identified using the Youden index was 12.58 ng/mL, with a sensitivity of 75% and specificity of 76%. (Fig. 4 .A). For the score at the 5th minute, the obtained AUC was 0.652 (95% CI: 0.444–0.871), reflecting moderate discriminative ability. The optimal cut-off determined was 12.49 ng/mL, with a sensitivity of 75% and specificity of 64%. (Fig. 4 .B) This indicates that Maternal 25(OH)D levels below 12.58 ng/mL and 12.49 ng/mL were associated with a higher risk of an Apgar score < 7 at the 1st and 5th minutes, respectively. Correlation between parental and umbilical cord serum 25(OH) D Levels A positive and moderate correlation was observed between the 25(OH)D levels in newborns and those in their mothers. In other words, the 25(OH)D levels of newborns were significantly correlated with those of their mothers (r = 0.419; p -value = 0.002) (Fig. 5 A). In contrast, no correlation was found between paternal 25(OH)D levels and those of their newborns ( p -value = 0.34) (Fig. 5 B). Discussion According to the Endocrine Society's guidelines, the thresholds for determining 25(OH)D status are < 20 ng/ml for deficiency and 20 to 29.9 ng/ml for insufficiency ( 17 ) . We observed a marked deficiency of 25(OH)D in pregnant women toward the end of their pregnancies, which was significantly correlated with insufficient sun exposure duration. In our sample, 42 out of 50 women did not receive adequate sun exposure (< 30 min/day) ( p -value < 0.0001). This result is supported by multivariate analysis, which identified sun exposure as the most impactful factor on maternal 25(OH)D status (p-value = 0.000). Some studies indicate that girls are more likely to experience vitamin D insufficiency due to less time outdoors and wearing clothing that reduces sunlight exposure ( 18 ) . It is widely accepted in the literature that when sun exposure falls below 30 minutes per day, even with substantial skin area exposed, the risk of vitamin D deficiency becomes significant ( 19 ) . Although the study region enjoys abundant sunlight, hypovitaminosis D remains prevalent in several countries with similar climates, such as Morocco ( 20 ) and Tunisia ( 21 ) . Additionally, darker skin color appears to predict this deficiency, significantly associated with varying 25(OH)D levels among pregnant women and males ( p -value = 0.006 and p -value < 0.0001, respectively). In the multivariate analysis, skin color lost its influence on maternal 25(OH)D status in the presence of other sociodemographic factors ( p -value = 0.24), while paternal 25(OH)D deficiency is more influenced by skin color ( p -value = 0.001). In line with the literature ( 22 ) , we observed a consistent positive relationship between low socioeconomic status- including educational level and housing occupation status- and various levels of decreased 25(OH)D ( p -values = 0.015 and 0.006, respectively). When accounting for other confounding factors, housing occupation status significantly impacts paternal 25(OH)D ( p -value = 0.004). This finding may relate to poor nutrition in many households or the substantial amounts spent on rent, which ultimately reduce purchasing power. This multivariate analysis also allowed us to determine the impact of blood sampling season on maternal 25(OH)D status. In the univariate analysis, this relationship was negative ( p -value = 0.34), but it became significantly positive ( p -value = 0.02) in the presence of several other confounding factors. This result is inconsistent with the findings of an Algerian study conducted in the Tlemcen region, which indicated a positive relationship between these two variables ( 23 ) . Our results also showed the negative effect of smoking on 25(OH)D levels in males, a finding that has already been reported in a study investigating the prevalence and factors associated with vitamin D deficiency in Hashimoto's thyroiditis ( 24 ) . Furthermore, pregnant women who are deficient in 25(OH)D are more likely to contract COVID-19 ( p -value = 0.000), and all of them exhibited anemia of varying severity. In pregnant women, anemia is defined as having a hemoglobin level below 110 g/L, with severe anemia characterized by levels below 70 g/L ( 25 ) . Eighty percent of the women had severe anemia, and this severity was positively correlated with decreased 25(OH)D levels in both univariate and multivariate studies ( p -value < 0.0001 and 0.009, respectively) compared to males. Our observation that 25(OH)D insufficiency during the third trimester of pregnancy was associated with a lower rate of gestational anemia aligns with several previous studies, suggesting that maternal vitamin D deficiency during pregnancy may contribute to gestational anemia. Several mechanisms explain the relationship between vitamin D deficiency and anemia. According to Young et al., vitamin D deficiency may positively regulate hepcidin, a peptide hormone that controls iron metabolism, which decreases hemoglobin concentrations and could therefore contribute to anemia ( 25 ) . A more recent study by Stallhofer et al. confirmed this association between vitamin D and anemia, demonstrating that vitamin D can improve iron deficiency, potentially by downregulating hepcidin and upregulating ceruloplasmin, thus enhancing intestinal iron absorption ( 26 ) . The Bonferroni adjustment resulted in the loss of statistical significance for certain sociodemographic variables. While this correction enhances statistical rigor by limiting false positives, it may also lead to type II errors. Therefore, some of these variables may still hold biological or social relevance despite the lack of statistically significant correction. In the present study, a significant difference in 25(OH)D levels was observed between pregnant women and men ( p -value = 0.001). Maternal 25(OH)D deficiency was identified in 27 out of 50 women, with an average level of 14.23 ng/ml, while severe deficiency was noted in 15 women, who had an average level of 7.69 ng/ml. These findings align with previous studies demonstrating the prevalence of 25(OH)D deficiency during pregnancy, with rates ranging from 8–70%, depending on skin pigmentation; darker skin is associated with a higher risk of vitamin D deficiency and longer duration of sun exposure. Additionally, it is crucial to consider other factors that affect vitamin D levels, such as poor nutrition stemming from low socioeconomic status, as diet contributes only a small amount of vitamin D. Furthermore, these women did not receive vitamin D supplementation. Similarly, these factors also influenced the 25(OH)D levels in men, with 21 out of 50 being deficient, 20 classified as insufficient, and the remaining 9 exhibiting severe deficiency. No significant difference was observed between the 25(OH)D levels of boys and girls ( p -value = 0.13). However, 40% of the newborns were deficient, 22% were insufficient, and 38% had severe deficiency. Additionally, our results indicate that 25(OH)D levels in offspring, regardless of gender, were positively correlated with their mothers' levels. These findings support a meta-analysis that provides evidence of an association between maternal blood 25(OH)D concentrations during pregnancy and umbilical cord blood 25(OH)D concentrations at birth. Overall, maternal 25(OH)D concentrations throughout all trimesters of pregnancy, especially during the third trimester, significantly influence umbilical cord blood 25(OH)D concentrations ( 29 ) . During pregnancy, 25(OH)D crosses the placenta from the mother to the fetus, and the level measured in umbilical cord blood at birth depends on maternal status, which is, on average, 80% of the woman's blood value. Therefore, if the mother is deficient, the fetus will likely experience the same deficiency ( 30 ) . In contrast, no significant difference was found between males and their newborns, and no studies have investigated this relationship, paving the way for potential future research. Examining the parent-offspring relationship further, a question arises: Is there a link between parental 25(OH)D levels and the anthropometric parameters of newborns? The results revealed a positive correlation between maternal 25(OH)D deficiency and reduced birth size, shorter femur length, and lower birth weight ( p -values = 0.0009, 0.023, 0.004, respectively). In this context, maternal vitamin D directly impacts neonatal anthropometric parameters, and deficiency in the last trimester of pregnancy poses a significant risk for both mothers and newborns. Several previous studies support this, linking maternal vitamin D deficiency to various health issues in both pregnant women and newborns, including bone problems for women, infertility, endometriosis, polycystic ovary syndrome, and adverse pregnancy outcomes such as miscarriages, gestational diabetes, bacterial infections, infectious diseases, premature birth, bacterial vaginosis, and preeclampsia ( 31 ) . Additionally, problems such as neonatal hypocalcemia, prematurity, growth disorders, and low birth weight in newborns have also been noted ( 32 ) . Zhang et al. explained in a study that placental VDR plays a crucial role in pregnancy, and maternal VDR gene polymorphism may affect birth weight. Maternal vitamin D status during pregnancy may also significantly determine offspring telomere length, which is positively correlated with birth weight ( 33 ) . In our study, we also noted a highly significant relationship between maternal deficiency in 25(OH)D and the Apgar score at the first and fifth minutes after birth ( p -values = 0.0007, 0.0042, respectively). The Apgar score is the most commonly used measure for assessing the health status of newborns, and non-malformed term infants with lower Apgar scores within the normal range face an increased risk of adverse long-term outcomes, such as epilepsy, cerebral palsy, and the need for additional care ( 34 ) . To further explore the relationship between maternal deficiency in 25(OH)D and the Apgar score, we conducted a ROC curve analysis, which revealed that maternal 25(OH)D concentration has a meaningful predictive value for neonatal vitality, particularly in the immediate minutes following birth. At the 1st minute, the area under the curve (AUC) reached 0.785 (95% CI: 0.652–0.918), indicating a good discriminative capacity. The optimal cut-off point determined by the Youden index was 12.58 ng/mL, with a sensitivity of 75% and a specificity of 76%. This suggests that maternal vitamin D status plays a significant role in the newborn’s initial adaptation to extrauterine life, and that a 25(OH)D concentration below this threshold is associated with an increased risk of compromised neonatal condition, as reflected by an Apgar score < 7. At the 5th minute, although the discriminative power decreased (AUC = 0.652, 95% CI: 0.444–0.871), the analysis still indicated a moderate predictive ability. The optimal cut-off was 12.49 ng/mL, with the same sensitivity of 75%, but a slightly lower specificity of 64%. This relative decline in specificity may reflect the growing influence of postnatal interventions or other perinatal factors on the Apgar score as time progresses. Nevertheless, the persistence of high sensitivity supports the idea that maternal 25(OH)D deficiency continues to exert an influence on neonatal adaptation even several minutes after birth. The relationship between vitamin D and the Apgar score has been confirmed by several studies, which found that women with vitamin D deficiency had a significantly higher proportion of infants born with a low Apgar score ( 35 – 37 ) .Augustin et al. suggested that poor vitamin D status disrupts myometrial function through several mechanisms, including impaired regulation of intracellular calcium concentration, diminished binding to the vitamin D receptor in the uterine endometrium and myometrium, and increased levels of inflammation-induced cytokines and factors associated with contraction in myometrial smooth muscle cells ( 38 ) . Conversely, our results did not show any significant relationship between various paternal 25(OH)D levels and neonatal anthropometric parameters (height, femur length, weight, Apgar scores at the 1st and 5th minutes, with p -values of 0.19, 0.37, 0.45, 0.53, and 0.58, respectively). These findings indicate that neonatal anthropometric parameters are positively associated with maternal 25(OH)D levels rather than paternal levels. Similarly, maternal 25(OH)D deficiency directly affects neonatal 25(OH)D levels, while paternal 25(OH)D levels do not influence those of the newborns. However, this study has limitations, such as the relatively small sample size due to limited available resources. This constraint may have affected the statistical power of certain comparisons, increasing the risk of Type II error, meaning the possibility of missing weak but clinically relevant associations between vitamin D levels and the studied parameters. Moreover, although the sample is representative of the local population (Oran, Algeria), the generalizability of the results to other geographic or demographic contexts remains limited. Future studies involving larger and more diverse samples will be necessary to confirm our findings and assess their external validity. Furthermore, the presence of a non-deficient couple group will be necessary for such a study, allowing for comparison with the deficient group. Additionally, the lack of a couple group where mothers are non-deficient and fathers are deficient has limited our ability to conclude the paternal-neonatal relationship. To conclude, this study revealed that 25(OH)D deficiency and insufficiency are highly prevalent among both Algerian women and men. Decreased 25(OH)D levels in late pregnancy significantly correlate with a higher risk of neonatal 25(OH)D deficiency, growth delays, and, most importantly, an Apgar score below 7 at the first and fifth minutes after birth. Paternal deficiency did not impact offspring outcomes. Individualized vitamin D supplementation at the end of pregnancy should be considered to minimize this risk. Administering vitamin D throughout pregnancy is essential to protect infants from adverse effects on neonatal health. Furthermore, fortifying food with vitamin D could be an effective preventive measure, especially in countries like Algeria, where specific groups (pregnant women, infants, and the elderly) are at a heightened risk of deficiency. Enhancing commonly consumed foods such as dairy products, flour, and other staples could help improve vitamin D coverage. Numerous studies conducted in other countries have demonstrated that this approach can reduce vitamin D deficiencies at the population level and enhance the health of at-risk groups. Therefore, we recommend that further studies be conducted to explore these fortification strategies in Algeria, particularly aimed at the most vulnerable groups, to mitigate the risks associated with vitamin D deficiency and improve public health in the country. Declarations Ethics approval and consent to participate This study was approved by the Medical Ethics Committee of Oran University Hospital N°83/2021/DAPM. The study was conducted according to the guidelines laid down in the Declaration of Helsinki of 1975 as revised in 1983 and to the guidelines for Good Clinical Practice of ICH. All persons gave their informed consent before their inclusion in the study. Consent for publication Not applicable Availability of data and materials The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no conflicts of interest. Funding The research presented in this publication was partially supported by the Laboratory of Physiology of Nutrition and Food Safety (LPNSA), Oran 1 University, as well as by the National Institute of Health and Medical Research (INSERM), the National Research Institute for Agriculture, Food, and Environment (INRAE), and Aix-Marseille University (AMU). Author contributions Sara Mama Abadi, Habib Hammou, Lidia Saidi, Fenni Soumia, and Tawfik Addi conducted the research and analyzed the data. Ilies Megueni provided essential tools for the study. Seyf El Islem Negadi assisted in the recruitment. Sahra Meziane, Farid Boubred contributed critical interpretation, revision, and input to the article. Sara Mama Abadi and Jean-Francois Landrier designed the experiment, interpreted the results, and wrote the paper. Acknowledgments We would like to acknowledge the head of the Obstetrics and Gynecology Department at Oran University Hospital, as well as to the coordinating physician, for ensuring the smooth implementation of this research protocol. We also extend our thanks to the medical and paramedical teams for their valuable advice and support throughout this doctoral project. Our sincere appreciation also goes to the medical analysis laboratory of the DU VAL Clinic Group in El-Biar, Algiers, Algeria, for their invaluable assistance. Finally, we extend our sincere gratitude to Mrs. Mokadem Zohra for her indispensable support in facilitating administrative procedures. References Al-Smadi K, Ali M, Alavi SE, Jin X, Imran M, Leite-Silva VR, et al. Using a Topical Formulation of Vitamin D for the Treatment of Vitiligo: A Systematic Review. Cells janv. 2023;12(19):2387. Kim DH, Meza CA, Clarke H, Kim JS, Hickner RC. Vitamin D and Endothelial Function. Nutrients. 22 févr. 2020;12(2):575. Giustina A, Bouillon R, Binkley N, Sempos C, Adler RA, Bollerslev J et al. Controversies in Vitamin D: A Statement From the Third International Conference. JBMR Plus. déc. 2020;4(12):e10417. Marek K, Cichoń N, Saluk-Bijak J, Bijak M, Miller E. The Role of Vitamin D in Stroke Prevention and the Effects of Its Supplementation for Post-Stroke Rehabilitation: A Narrative Review. Nutrients 4 juill. 2022;14(13):2761. Cashman KD, 100, YEARS OF VITAMIN D. Global differences in vitamin D status and dietary intake: a review of the data. Endocr Connect 3 déc. 2021;11(1):e210282. Dragomir RE, Toader DO, Gheoca Mutu DE, Dogaru IA, Răducu L, Tomescu LC, et al. Consequences of Maternal Vitamin D Deficiency on Newborn Health. Life juin. 2024;14(6):714. Varthaliti A, Rodolaki K, Lygizos V, Vlachos DE, Thomakos N, Sioutis D, et al. Neurodevelopmental Outcomes in the Offspring of Women with Vitamin D Deficiency and Women Who Received Vitamin D Supplementation During Pregnancy. Nutrients janv. 2025;17(6):978. Filgueiras MDS, Suhett LG, Silva MA, Rocha NP, de Novaes JF. Lower vitamin D intake is associated with low HDL cholesterol and vitamin D insufficiency/deficiency in Brazilian children. Public Health Nutr août. 2018;21(11):2004–12. Ashley B, Simner C, Manousopoulou A, Jenkinson C, Hey F, Frost JM, Placental uptake and metabolism of 25(OH)vitamin D determine its activity within the fetoplacental unit., Shoback D, Zaidi M, Hollis B et al. éditeurs. eLife. 8 mars 2022;11:e71094. Karras SN, Anagnostis P, Annweiler C, Naughton DP, Petroczi A, Bili E, et al. Maternal vitamin D status during pregnancy: the Mediterranean reality. Eur J Clin Nutr août. 2014;68(8):864–9. Shahmoradi A, Aghaei A, Ghaderi K, Jafar Rezaei M, Azarnezhad A. A meta-analysis of the association of ApaI, BsmI, FokI, and TaqI polymorphisms in the vitamin D receptor gene with the risk of polycystic ovary syndrome in the Eastern Mediterranean Regional Office population. Int J Reprod Biomed. 6 juill. 2022;20(6):433–46. Agarwal S, Kovilam O, Agrawal DK. Vitamin D and its impact on maternal-fetal outcomes in pregnancy: A critical review. Critical Reviews in Food Science and Nutrition. 24 mars. 2018;58(5):755–69. Törzsök P, Van Goubergen J, Pichler M, Pichler R, Santer FR. Isochromosome 12p Formation Regulates Vitamin D Metabolism in Testicular Cancer. Nutrients janv. 2023;15(10):2384. Wang X, Jiao X, Tian Y, Zhang J, Zhang Y, Li J, et al. Associations between maternal vitamin D status during three trimesters and cord blood 25(OH)D concentrations in newborns: a prospective Shanghai birth cohort study. Eur J Nutr sept. 2021;60(6):3473–83. Meems LMG, Mahmud H, Buikema H, Tost J, Michel S, Takens J, et al. Parental vitamin D deficiency during pregnancy is associated with increased blood pressure in offspring via Panx1 hypermethylation. Am J Physiol Heart Circ Physiol 1 déc. 2016;311(6):H1459–69. Chao M, Menon C, Elgendi M. Validity of Apgar Score as an Indicator of Neonatal SARS-CoV-2 Infection: A Scoping Review. Front Med (Lausanne). 2021;8:782376. Cheng Y, Chen J, Li T, Pei J, Fan Y, He M, et al. Maternal vitamin D status in early pregnancy and its association with gestational diabetes mellitus in Shanghai: a retrospective cohort study. BMC Pregnancy Childbirth 5 nov. 2022;22(1):819. Chebet M, Piloya T, Ameda F, Mukunya D, Kiguli S. Vitamin D deficiency in low-birth-weight infants in Uganda; a cross sectional study. PLoS One 11 nov. 2022;17(11):e0276182. Djerdjar L, Ramdane S, Oussadou L. Epidemiology of hypovitaminosis D among apparently healthy young adults in Algeria. Rev Med Brux. 2022;43(1):12–9. Khasmi ME, Farh M, Iddar A, Tahri E. La vitamine D: activités biologiques, dosage, résultats et état des lieux au Maroc. Biol médicale. 2021;1. Naifar M, Jerbi A, Turki M, Fourati S, Sawsan F, Bel Hsan K et al. Valeurs de référence de la vitamine D chez la Femme du Sud Tunisien. Nutrition Clinique et Métabolisme. mai 2020 ;34(2):169–76. Léger-Guist’hau J, Domingues-Faria C, Miolanne M, Peyrol F, Gerbaud L, Perreira B, et al. Low socio-economic status is a newly identified independent risk factor for poor vitamin D status in severely obese adults. J Hum Nutr Dietetics. 2017;30(2):203–15. Meghelli SM. Corrélation entre le statut de la vitamine d et le titre d’anticorps antithyroïdiens dans la thyroïdite d’Hashimoto chez les patients de la Wilaya de Tlemcen. Ann d’Endocrinologie 1 févr. 2023;84(1):108. Mouelhi Y, Yazidi M, Chaker F, Khessairi N, Grira W, Oueslati I, et al. Prévalence et facteurs associés à la carence en vitamine D au cours de la thyroïdite de Hashimoto. Ann d’Endocrinologie 1 oct. 2021;82(5):398–9. Young MF, Oaks BM, Tandon S, Martorell R, Dewey KG, Wendt AS. Maternal hemoglobin concentrations across pregnancy and maternal and child health: a systematic review and meta-analysis. Ann N Y Acad Sci. 2019;1450(1):47–68. Stallhofer J, Veith L, Diegelmann J, Probst P, Brand S, Schnitzler F, et al. Iron Deficiency in Inflammatory Bowel Disease Is Associated With Low Levels of Vitamin D Modulating Serum Hepcidin and Intestinal Ceruloplasmin Expression. Clin Transl Gastroenterol 13 janv. 2022;13(1):e00450. Bhowmik B, Siddiquee T, Mdala I, Quamrun Nesa L, Jahan Shelly S, Hassan Z, et al. Vitamin D3 and B12 supplementation in pregnancy. Diabetes Res Clin Pract avr. 2021;174:108728. Hu KL, Zhang CX, Chen P, Zhang D, Hunt S. Vitamin D Levels in Early and Middle Pregnancy and Preeclampsia, a Systematic Review and Meta-Analysis. Nutrients janv. 2022;14(5):999. Wong RS, Tung KTS, Mak RTW, Leung WC, Yam JC, Chua GT, et al. Vitamin D concentrations during pregnancy and in cord blood: a systematic review and meta-analysis. Nutr Rev. nov 2022;7(12):2225–36. Mansur JL, Oliveri B, Giacoia E, Fusaro D, Costanzo PR. Vitamin D: Before, during and after Pregnancy: Effect on Neonates and Children. Nutrients. 1 mai. 2022;14(9):1900. Tamblyn JA, Pilarski NSP, Markland AD, Marson EJ, Devall A, Hewison M, et al. Vitamin D and miscarriage: a systematic review and meta-analysis. Fertility Steril juill. 2022;118(1):111–22. Lhilali I, Zouine N, Menouni A, Godderis L, Kestemont MP, El Midaoui A, et al. Sun Exposure Score and Vitamin D Levels in Moroccan Women of Childbearing Age. Nutrients 29 janv. 2023;15(3):688. Zhang Y, Jukic AMZ, Song H, Zhang L, Yang F, Wu S et al. Serum Vitamin D Concentrations, Time to Pregnancy, and Pregnancy Outcomes among Preconception Couples: A Cohort Study in Shanghai, China. Nutrients. 26 juill. 2022;14(15):3058. Razaz N, Cnattingius S, Joseph KS. Association between Apgar scores of 7 to 9 and neonatal mortality and morbidity: population based cohort study of term infants in Sweden. BMJ. 7 mai. 2019;365:l1656. Lindqvist PG, Silva AT, Gustafsson SA, Gidlöf S. Maternal vitamin D deficiency and fetal distress/birth asphyxia: a population-based nested case–control study. BMJ Open sept. 2016;6(9):e009733. Liu W, Xu P. The association of serum vitamin D level and neonatal respiratory distress syndrome. Ital J Pediatr. 30 janv. 2023;49(1):16. Saboute M, Yavar R, Kashaki M, Khaledi FK, Khalesi N, Rohani F. Investigation of association between maternal 25-OH vitamin D serum levels and neonatal early onset sepsis in newborns by evaluating key factors. Lipids Health Dis 13 juill. 2019;18:153. Augustin H, Mulcahy S, Schoenmakers I, Bullarbo M, Glantz A, Winkvist A, et al. Late Pregnancy Vitamin D Deficiency is Associated with Doubled Odds of Birth Asphyxia and Emergency Caesarean Section: A Prospective Cohort Study. Matern Child Health J nov. 2020;24(11):1412–8. Additional Declarations No competing interests reported. Supplementary Files Supplementaryfiles.docx Cite Share Download PDF Status: Published Journal Publication published 22 May, 2025 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Editorial decision: Accepted 05 May, 2025 Reviews received at journal 03 May, 2025 Reviews received at journal 30 Apr, 2025 Reviewers agreed at journal 30 Apr, 2025 Reviewers agreed at journal 28 Apr, 2025 Reviewers invited by journal 26 Apr, 2025 Submission checks completed at journal 24 Apr, 2025 First submitted to journal 16 Apr, 2025 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. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5930305","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":448920204,"identity":"83cb6279-acd6-496a-ade0-99574ac1aebe","order_by":0,"name":"Sara Mama Abadi","email":"","orcid":"","institution":"Aix-Marseille University, INRAE, INSERM","correspondingAuthor":false,"prefix":"","firstName":"Sara","middleName":"Mama","lastName":"Abadi","suffix":""},{"id":448920206,"identity":"77c32bf3-1038-4a98-aa77-7977ecc8747f","order_by":1,"name":"Habib Hammou","email":"","orcid":"","institution":"Oran 1 University","correspondingAuthor":false,"prefix":"","firstName":"Habib","middleName":"","lastName":"Hammou","suffix":""},{"id":448920208,"identity":"606c5592-fb35-493a-99e0-12795f98ab15","order_by":2,"name":"Lidia Saidi","email":"","orcid":"","institution":"Aix-Marseille University, INRAE, INSERM","correspondingAuthor":false,"prefix":"","firstName":"Lidia","middleName":"","lastName":"Saidi","suffix":""},{"id":448920209,"identity":"deace1bd-c49a-4824-b9b7-fd2c9765ab2f","order_by":3,"name":"Soumia Fenni","email":"","orcid":"","institution":"Oran 1 University","correspondingAuthor":false,"prefix":"","firstName":"Soumia","middleName":"","lastName":"Fenni","suffix":""},{"id":448920210,"identity":"6f414275-a170-4f6f-9182-38ce95eb38c7","order_by":4,"name":"Tawfik Addi","email":"","orcid":"","institution":"Oran 1 University","correspondingAuthor":false,"prefix":"","firstName":"Tawfik","middleName":"","lastName":"Addi","suffix":""},{"id":448920211,"identity":"3d1f2a5e-3a4f-4143-8348-ec947860b5ff","order_by":5,"name":"Ilyes Meguenni","email":"","orcid":"","institution":"Oran 1 University","correspondingAuthor":false,"prefix":"","firstName":"Ilyes","middleName":"","lastName":"Meguenni","suffix":""},{"id":448920212,"identity":"e9d50551-c3fe-487e-8bbc-e1648d3054c4","order_by":6,"name":"Seyf El Islem Negadi","email":"","orcid":"","institution":"Oran 1 University","correspondingAuthor":false,"prefix":"","firstName":"Seyf","middleName":"El Islem","lastName":"Negadi","suffix":""},{"id":448920213,"identity":"af8e3085-fdc3-4560-8a4e-a9597af531ab","order_by":7,"name":"Sahra Meziane","email":"","orcid":"","institution":"Hospital University La Conception","correspondingAuthor":false,"prefix":"","firstName":"Sahra","middleName":"","lastName":"Meziane","suffix":""},{"id":448920214,"identity":"c0e8170c-0b30-424e-9f97-d355f790f032","order_by":8,"name":"Farid Boubred","email":"","orcid":"","institution":"Hospital University La Conception","correspondingAuthor":false,"prefix":"","firstName":"Farid","middleName":"","lastName":"Boubred","suffix":""},{"id":448920215,"identity":"0a95a3be-40a4-4e79-be08-cf48216bb375","order_by":9,"name":"Jean-François Landrier","email":"data:image/png;base64,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","orcid":"","institution":"Aix-Marseille University, INRAE, INSERM","correspondingAuthor":true,"prefix":"","firstName":"Jean-François","middleName":"","lastName":"Landrier","suffix":""}],"badges":[],"createdAt":"2025-01-30 12:38:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5930305/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5930305/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12884-025-07686-x","type":"published","date":"2025-05-22T15:58:27+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":81657160,"identity":"64b7a8f5-7949-4b29-b963-941cd4d61665","added_by":"auto","created_at":"2025-04-29 18:51:18","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":22882,"visible":true,"origin":"","legend":"\u003cp\u003eMultiple linear regression analysis of the relationship between sociodemographic characteristics and parental 25-hydroxyvitamin D (25(OH)D) levels. The thresholds used to determine 25(OH)D status are \u0026lt;20 ng/ml for insufficiency and 20 to 29.9 ng/ml for deficiency, according to the guidelines from the Endocrine Society. A. Relationship with maternal 25(OH)D levels. B. The relationship between sociodemographic characteristics and paternal 25(OH)D levels.\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5930305/v1/baf13d501ae4d3bcc8973c1a.jpg"},{"id":81657362,"identity":"3d04fe63-6faf-4977-94e2-44752935f6c0","added_by":"auto","created_at":"2025-04-29 18:59:18","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":155846,"visible":true,"origin":"","legend":"\u003cp\u003eCorrelation between maternal 25(OH)D levels and the anthropometric parameters of newborns. A. Correlation between maternal 25(OH)D levels and newborn height. B. Correlation between maternal 25(OH)D levels and newborn femur length. C. Correlation between maternal 25(OH)D levels and newborn weight. D. Correlation between maternal 25(OH)D levels and the Apgar score of newborns at the 1st minute. E. Correlation between maternal 25(OH)D levels and the Apgar score of newborns at the 5th minute.\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5930305/v1/6fdca7f21f39ca89aad24528.jpg"},{"id":81657163,"identity":"4374c4be-ef9c-4988-83d5-96cfb4169e00","added_by":"auto","created_at":"2025-04-29 18:51:18","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":148013,"visible":true,"origin":"","legend":"\u003cp\u003eCorrelation between paternal 25(OH)D levels and the anthropometric parameters of newborns. A. Correlation between paternal 25(OH)D levels and newborn height. B. Correlation between paternal 25(OH)D levels and newborn femur length. C. Correlation between paternal 25(OH)D levels and newborn weight. D. Correlation between paternal 25(OH)D levels and the Apgar score of newborns at 1 minute. E. Correlation between paternal 25(OH)D levels and the Apgar score of newborns at 5 minutes.\u003c/p\u003e","description":"","filename":"Picture3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5930305/v1/b4a5f33025a3d0b04788eb15.jpg"},{"id":81657161,"identity":"9d7940ff-abd5-46c2-9ca9-4f2c38e5630c","added_by":"auto","created_at":"2025-04-29 18:51:18","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":24680,"visible":true,"origin":"","legend":"\u003cp\u003eReceiver Operating Characteristic (ROC) curves illustrating the predictive performance of maternal 25(OH)D concentration for neonatal Apgar scores. A. ROC curve for predicting an Apgar score \u0026lt;7 at the 1st minute of life. B. ROC curve for predicting an Apgar score \u0026lt;7 at the 5th minute of life\u003c/p\u003e","description":"","filename":"Picture4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5930305/v1/bf57931456bbf6d3eea73272.jpg"},{"id":81657363,"identity":"e51e0710-53d8-456c-ae97-fc31c9d1154c","added_by":"auto","created_at":"2025-04-29 18:59:18","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":75655,"visible":true,"origin":"","legend":"\u003cp\u003eCorrelation between parental and newborn 25(OH) D levels. A. Correlation between maternal and newborn 25(OH) D levels and in the second graph. B. Correlation is between paternal and newborn 25(OH) D levels.\u003c/p\u003e","description":"","filename":"Picture5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5930305/v1/5a0ff72f58d99d5529569d70.jpg"},{"id":83460105,"identity":"73b8cc43-0060-4341-9ba7-f7905727df78","added_by":"auto","created_at":"2025-05-26 16:10:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1537716,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5930305/v1/6ea1f4a9-42e3-4bcf-b6ee-8fa4c2efb6c3.pdf"},{"id":81657168,"identity":"4152aaec-b18a-429d-a2f6-f053c90cef74","added_by":"auto","created_at":"2025-04-29 18:51:18","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":86039,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfiles.docx","url":"https://assets-eu.researchsquare.com/files/rs-5930305/v1/8d2d6754689401b3f4366ad7.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Correlation between anthropometric and biological parameters of the offspring and parental plasma 25-hydroxyvitamin D levels: a cross-sectional study conducted at Oran, Algeria.","fulltext":[{"header":"Introduction","content":"\u003cp\u003eVitamin D is a prohormone \u003csup\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/sup\u003e primarily recognized for regulating calcium homeostasis and bone metabolism \u003csup\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/sup\u003e. The circulating 25(OH)D concentration is widely accepted as the individual vitamin D status marker. Many agencies use it to establish dietary requirements for vitamin D and monitor the population for deficiency or insufficiency \u003csup\u003e(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/sup\u003e. Hypovitaminosis D poses a significant public health issue among the general population \u003csup\u003e(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/sup\u003e. In Africa, data from 119 studies, including meta-analyses, estimated prevalence rates of 18.5% for serum 25(OH)D levels below 30 nmol/L and 34.2% for levels below 50 nmol/L. The analysis also indicated that most studies reporting low 25(OH)D concentrations originated from North and South African countries, compared to Sub-Saharan Africa. In Africa, urban populations exhibited lower 25(OH)D levels than rural areas. A guest commentary on the systematic review highlighted that, despite the long-held belief that Africa was spared mainly from severe vitamin D deficiency issues due to abundant sunlight across much of the continent, the findings of the systematic survey suggest a potentially higher prevalence of 25(OH)D levels below 30 ng/L compared to Europe (18.5% vs. 13%, respectively) \u003csup\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/sup\u003e. Numerous studies underscore the role of vitamin D in the development of pathologies during pregnancy \u003csup\u003e(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/sup\u003e. Although several studies have emphasized the beneficial effects of vitamin D supplementation on maternal and neonatal health during pregnancy and recommend daily supplementation during this critical period \u003csup\u003e(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/sup\u003e, adherence to these recommendations remains low.\u003c/p\u003e \u003cp\u003eMaternal vitamin D levels are influenced by maternal age, sample collection season, pre-pregnancy body mass index (BMI), ethnicity, and study site latitude \u003csup\u003e(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/sup\u003e. Since the fetus's vitamin D supply is also ensured by transfer from the maternal placenta \u003csup\u003e(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/sup\u003e, researchers have hypothesized that these factors above have long been involved in lasting changes in the offspring's body composition, physiology, and metabolism. Maternal vitamin D deficiency during pregnancy has several adverse effects on neonatal and maternal health \u003csup\u003e(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/sup\u003e. Recently, vitamin D nuclear receptors (VDR) have been identified in various tissues, including organs involved in reproduction and infant growth, such as ovarian cells \u003csup\u003e(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/sup\u003e, where calcitriol plays a significant role in placental physiology. It stimulates endometrial decidualization, estradiol, and progesterone synthesis, and regulates the expression of human chorionic gonadotropin (hCG) and human placental lactogen (hPL) \u003csup\u003e(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/sup\u003e. This receptor is also expressed in testicular cells, where vitamin D influences male fertility, particularly sperm motility \u003csup\u003e(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/sup\u003e. Therefore, vitamin D deficiency in both parents may impact the health of the offspring \u003csup\u003e(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/sup\u003e, as demonstrated in a previous study that vitamin D deficiency in parents is linked to epigenetic alterations and higher blood pressure levels in their offspring \u003csup\u003e(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/sup\u003e. In Algeria, the impact of maternal status on 25(OH)D on newborns' health is poorly studied.\u003c/p\u003e \u003cp\u003eNo studies have been conducted on the impact of parental 25(OH)D deficiency on newborns' phenotypes. Therefore, our study aims to determine whether the level of parental 25(OH)D deficiency affects the offspring's phenotype.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Sample\u003c/h2\u003e \u003cp\u003eThis study was a cross-sectional examination of Algerian families aimed at investigating the correlation between parental 25(OH)D levels during pregnancy and the anthropometric and biological parameters of newborns. Conducted over two years at the Department of Gynecology and Obstetrics at Oran University Hospital, the research involved 50 Algerian families, including 50 pregnant women in their third trimester, 50 males, and 50 newborns. The study received approval from the Medical Ethics Committee of Oran University Hospital under N\u0026deg;83/2021/DAPM.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInclusion criteria\u003c/h3\u003e\n\u003cp\u003eThe participants included parents and their newborns with 25(OH)D levels below 30 ng/ml, aged between 20 and 45 for women and 25 to 45 for men, with the newborns being full-term singleton infants. According to the WHO, the parents had a normal BMI ranging from 18.5 to 24.9 kg/m\u0026sup2;. The sample selection was purposive, meaning participants were chosen to fulfill the study's objectives best.\u003c/p\u003e\n\u003ch3\u003eExclusion criteria\u003c/h3\u003e\n\u003cp\u003eParticipants with chronic diseases that directly or indirectly affect vitamin D metabolism, such as thyroid and parathyroid disorders, chronic liver diseases, renal impairment, and chronic inflammatory bowel diseases, as well as individuals taking vitamin D supplements or anticonvulsants, and those with a family history of rickets, were excluded from the study. Women with conditions such as preeclampsia, autoimmune diseases, antiphospholipid antibody syndrome, lupus, and abnormal placental locations (including placenta previa and accreta) were also excluded, along with newborns who had conditions like arteriovenous malformation, a single umbilical artery (due to velamentous insertion of the umbilical cord), fetal distress (from umbilical cord torsion), hemorrhages (such as feto-maternal transfusion), retroplacental hematoma, and prematurity.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eAfter obtaining signed consent, a recruitment questionnaire (Supplemental data) was administered through face-to-face interviews with the couples, which included the following anthropometric data: participant serial number, age of parents, parity, mode of delivery, parental illness, vitamin intake during pregnancy, and the presence of a family history of vitamin D deficiency. Weight was measured while height and waist circumference were measured using a graduated tape measure in centimeters. Body Mass Index (BMI) was then calculated by dividing weight (kg) by the square of height (m\u0026sup2;). The questionnaire also included information on occupation, educational level, and habitat type. Regarding the newborn, their gender, birth weight, height, and femur length were extracted from the maternal delivery records. The midwife assigned the Apgar score 1 and 5 minutes after birth. If respiratory support or other assistance was required, a pediatrician was immediately summoned to the delivery room to assign the score. This score was based on five objective criteria: appearance, pulse, grimace, activity, and respiration, each scored from 0 to 2. Apgar scores above 7 were considered \"reassuring,\" those between 4 and 6 were regarded as \"below normal,\" and those between 1 and 3 were classified as \"critical,\" typically requiring urgent clinical intervention. The neonatal 25(OH)D level and any congenital abnormalities or signs of umbilical cord infection were recorded. All newborns were examined for these parameters after resuscitation \u003csup\u003e(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e\n\u003ch3\u003eBlood Sample Collection\u003c/h3\u003e\n\u003cp\u003e25(OH)D concentrations were measured from fasting blood samples taken from parents and the umbilical cord of newborns at birth in heparin-lithium tubes. The blood was then centrifuged at 3000 rpm for 15 minutes at 4\u0026deg;C. Immediately afterward, the serum samples were stored in aliquots at -80\u0026deg;C until analysis. The samples were analyzed in the Duval El-Biar clinic laboratory in Algiers using the Atellica\u0026reg; system (Siemens Healthcare Diagnostics Inc., Tarrytown, NY, USA), which integrates modules for clinical biochemistry analysis and flexible immunoassays. The thresholds for determining 25(OH)D status are \u0026lt;\u0026thinsp;20 ng/ml for deficiency and 20 to 29.9 ng/ml for insufficiency, following guidelines from the Endocrine Society.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThe first part of the analysis used GraphPad Prism software, while the second part used IBM SPSS Statistics Version 26.\u003c/p\u003e \u003cp\u003eTo assess the normality of our data, we performed the Kolmogorov-Smirnov test for each group (mothers, fathers, newborns). The results showed that all p-values were greater than 0.05, indicating that the data from each group followed a normal distribution. Therefore, we could employ parametric tests for the subsequent statistical analyses.\u003c/p\u003e \u003cp\u003eContinuous quantitative data were reported as means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations, while qualitative data were shown as percentages. Comparisons were conducted using the Student\u0026rsquo;s t-test for qualitative variables with two categories and one-way ANOVA for those with three or more categories, followed by Tukey\u0026rsquo;s post hoc test when significant differences were detected. We employed Pearson\u0026rsquo;s correlation to analyze the relationships between two quantitative variables.\u003c/p\u003e \u003cp\u003eA multiple linear regression was performed to examine the simultaneous effect of several independent variables on a single continuous quantitative dependent variable.\u003c/p\u003e \u003cp\u003eAfter multiple comparisons, the Bonferroni adjustment was applied to correct the significance threshold, maintaining strict control over the overall Type I error rate.\u003c/p\u003e \u003cp\u003eROC analysis was performed to evaluate the predictive ability of parental 25(OH)D levels for a lower Apgar score in newborns of mothers with suboptimal vitamin D status. The area under the curve (AUC) was calculated to assess the overall accuracy of the prediction. Differences were considered significant if \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003eSociodemographic characteristics of the parents\u003c/h2\u003e\n \u003cp\u003eThe present study included fifty Algerian families residing in Oran, comprising 50 males and 50 pregnant women who gave birth to 50 newborns. Parental characteristics are detailed in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. The median age of the women was 30 years, and most were stay-at-home mothers, with 18% having only a primary education, the majority (60%) possessing an intermediate level of education, and the remaining 11% having attained higher education. Sixty percent of the blood samples were collected during the winter season. A significant majority of the women (90%) gave birth vaginally. It was noted that 26% of the women had a history of COVID-19. Additionally, 60% of the women had dark skin, and 84% experienced insufficient sun exposure (less than 30 minutes per day). Concerning anemia, it was present in all the pregnant women, but its severity varied, with 62% of the women exhibiting severe anemia.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSociodemographic characteristics in parents and their impact on 25(OH)D Levels\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"8\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMaternal description\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean(SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePaternal description\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean(SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003csup\u003e1\u003c/sup\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\u003eAge\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\n \u003cp\u003eAge\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 \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 years \u0026minus;\u0026thinsp;26 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.92 (6.486)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 years \u0026minus;\u0026thinsp;26 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26,41 (/)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.310\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 years \u0026minus;\u0026thinsp;35 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.57 (5.846)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 years \u0026minus;\u0026thinsp;35 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.37 (6.142)\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\u003e36 years \u0026minus;\u0026thinsp;45 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.90 (3.814)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36 years \u0026minus;\u0026thinsp;45 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.97 (7.308)\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\u003eBlood sample Collection Season\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\n \u003cp\u003eBlood sample Collection Season\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 \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWinter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.95 (6.298)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.344\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWinter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.70 (6.933)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.556\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSpring\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.79 (5.944)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSpring\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.780 (5.847)\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\u003eAutumn\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.27 (4.369)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAutumn\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.34 (6.954)\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\u003eEducation level\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\n \u003cp\u003eEducation level\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 \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNever attendedschool\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.459\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNever attendedschool\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.64 (/)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.015*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimaryeducation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.63 (4.505)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimaryeducation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.30 (5.458)\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\u003eMiddle schooleducation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.82 (6.665)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMiddle schooleducation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.17 (6.751)\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\u003eHighereducation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.72 (4.202)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHighereducation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.49 (3.516)\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\u003eOccupation type\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\n \u003cp\u003eOccupation type\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 \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.79 (3.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.073\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.30 (5.717)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.052\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eModerateincome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.74 (5.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eModerateincome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.89 (6.617)\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\u003eHigh income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.52 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.76 (/)\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\u003eHousing occupation status\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\n \u003cp\u003eHousing occupation status\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 \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHousingprovided for free.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13,17(5,35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.276\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHousingprovided for free.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.15 (6.255)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.006**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOwn a detached house.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15,29(6,61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOwn a detached house.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.14 (6.593)\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\u003eRenting an empty residence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16,24(7,61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRenting an empty rresidence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.92 (2.234)\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\u003eCOVID-19\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\n \u003cp\u003eCOVID-19\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 \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.47 (1.024)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.24 (5.083)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18,21(6,785)\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\u003eSkin color\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\n \u003cp\u003eSkin color\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 \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.69 (6.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.006**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.12 (5.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDark\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.15 (4.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDark\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.18 (5.51)\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\u003eSun 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 align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSun 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 align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInsufficient\u0026thinsp;\u0026lt;\u0026thinsp;30 min/day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.64 (4.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInsufficient\u0026thinsp;\u0026lt;\u0026thinsp;30 min/day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44 (6.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0002***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSufficient\u0026thinsp;\u0026ge;\u0026thinsp;30 min/day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.95 (5.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSufficient\u0026thinsp;\u0026ge;\u0026thinsp;30 min/day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.79 (2.79)\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\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 \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.50 (6.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.324\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13,96(5,800)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.53 (6.46)\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\u003eAnemia\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 \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\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.66 (4.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001***\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 \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.48 (3.15)\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\u003eType of delivery\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 \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\u003eVaginal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.22 (6.024)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.322\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 \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCesarean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.47 (3.569)\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 \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\"\u003eSignificant differences between groups (Student\u0026rsquo; test or ANOVA tests; \u003csup\u003e*\u003c/sup\u003e\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.05;\u003c/em\u003e \u003csup\u003e**\u003c/sup\u003e\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.01;\u003c/em\u003e \u003csup\u003e***\u003c/sup\u003e\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eThe median age of the males participating in the study was 36 years, with most having a moderate level of education (64%) and 22% having completed primary education. In terms of occupational income, 78% reported moderate income. Among these families, 64% lived in free housing, while 26% were homeowners. Half of the males had dark skin, but the difference lay in the duration of sun exposure, as 40 out of 50 males had insufficient exposure to sunlight. Additionally, 68% of them were smokers.\u003c/p\u003e\n \u003cp\u003eAmong women, specific characteristics significantly increase the risk of developing 25(OH)D insufficiency, particularly a history of COVID-19, dark skin, anemia, and insufficient sun exposure (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). In contrast, among men, two factors appeared to significantly affect this deficiency: skin color and insufficient sun exposure (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Other characteristics were examined, but they did not significantly influence the deficiency observed in the parents (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eA multiple linear regression was conducted to examine the relationship between parental 25(OH)D status and sociodemographic characteristics. No significant relationship was observed between maternal 25(OH)D level and age (-0.82, CI 95% -0.56 to -0.60; \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.413), education level (-0.46, CI 95% -0.26 to -0.03; \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.646), occupation type ( -0.25, CI 95% -0.25 to -0.02; \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.804), housing occupation status (-0.41, CI 95% -0.30 to -0.03; \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.681), type of delivery (-0.17, CI 95% -0.28 to -0.01; \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.859) or skin color (1.18, CI 95% 1.25 to 0.10; \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.243). However, a significant relationship and weak association were noted between maternal 25(OH)D levels and blood sample collection season (-2.02, CI 95% -1.23 to -0.16; \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.049). A highly significant relationship and a moderate association with anemia (-2.76, CI 95% -9.26 to -0.22; \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.009) and strong association with very highly significant relationship was noted with COVID-19 (-5.68, CI 95% -6.34 to -0.48; \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.000) and sun exposure (5.71, CI 95% 0.80 to 0.49; \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.000). (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eA). After applying the Bonferroni correction for multiple comparisons (adjusted significance threshold: \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.005), only two associations -those with COVID-19 status and sun exposure- remained statistically significant, suggesting a robust and reliable relationship. In contrast, the associations with anemia and the season of blood sample collection no longer reached statistical significance.\u003c/p\u003e\n \u003cp\u003eThe relationship was highly significant for males, showing a strong association between 25(OH)D levels and skin color (3.66, CI 95%, 6.61 to 0.49; \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.001). A significant, moderate association was observed with housing occupation status (2.08, CI 95% 2.92 to 0.27; \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.043). There was no statistically significant difference found among the remaining sociodemographic characteristics (age, blood sample collection season, education level, occupation type, sun exposure, smoking) (-0.01, CI 95% -0.03 to -0.002; \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.985), (-0.96, CI 95% -0.99 to -0.11; \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.341),(1.26, CI 95% 1.47 to 0.16; \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.215), (-0.44, CI 95% -0.76 to -0.05; \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.658), (1.12, CI 95% 0.04 to 0.13; \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.269), (1.63, CI 95% 2.98 to 0.20; \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.109) respectively (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eB).\u003c/p\u003e\n \u003cp\u003eOnly skin color remained statistically significant after applying Bonferroni correction for multiple testing (adjusted significance threshold: \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.0062).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eBiological characteristics of parents\u003c/h2\u003e\n \u003cp\u003eAfter measuring 25(OH)D levels in parents, it was observed that the majority of parents were deficient in 25(OH)D, with 54% of women having an average of 14.23 ng/ml and 42% of men averaging 15.78 ng/ml. Sixteen percent of pregnant women studied were insufficient (with levels between 20 and 29.9 ng/ml), averaging 24.53 ng/ml, and 40% of men fall into this category. A severe deficiency was present in 30% of women, with an average of 7.69 ng/ml, and in 18% of men, with an average of 8.53 ng/ml.\u003c/p\u003e\n \u003cp\u003eThe averages also seem to be significantly lower in women compared to males overall (13.96 ng/ml vs 18.15 ng/ml, respectively), as well as in each category (insufficient and deficient).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eBiological and anthropometric parameters of newborns\u003c/h2\u003e\n \u003cp\u003eNewborns with parents exhibiting insufficiency (25(OH)D levels between 20 and 29.9 ng/ml) or deficiency (25(OH)D levels\u0026thinsp;\u0026lt;\u0026thinsp;20 ng/ml) showed suboptimal 25(OH)D concentrations. Among these newborns, 52% of girls and 28% of boys were deficient, yielding average levels of 14.16 ng/ml and 12.77 ng/ml, respectively. Additionally, 25(OH)D insufficiency was noted in 24% of girls and 20% of boys, with average levels of 24.27 ng/ml and 22.79 ng/ml, respectively. Furthermore, 24% of girls and 52% of boys exhibited severe deficiency, with average levels of 7.26 ng/ml and 7.81 ng/ml, accordingly. However, no significant association was identified between 25(OH)D status and the newborn\u0026apos;s sex (\u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.13).\u003c/p\u003e\n \u003cp\u003eVarious anthropometric parameters were studied in newborns, including height, femur length, weight, and Apgar scores at one minute (Apgar1) and at five minutes (Apgar5) after birth. All newborns with suboptimal 25(OH)D levels exhibited anthropometric parameters that measured below the norm (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e), showing a strong and highly significant correlation (p-value\u0026thinsp;=\u0026thinsp;0.0001 for all anthropometric parameters). The normal values for these parameters were as follows: height\u0026thinsp;\u0026gt;\u0026thinsp;47cm, weight\u0026thinsp;\u0026gt;\u0026thinsp;2500g, femur length\u0026thinsp;=\u0026thinsp;69-73cm, Apgar score at 1st minute\u0026thinsp;\u0026ge;\u0026thinsp;7/10, and Apgar score at 5th minute\u0026thinsp;\u0026ge;\u0026thinsp;7/10. No differences were observed between boys and girls for any of the physiological characteristics studied (\u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eNormal and recorded values of anthropometric parameters in newborns\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eAnthropometric parameters\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eNormal Values\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eRecorded Values\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;50) Mean(SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGirls (n\u0026thinsp;=\u0026thinsp;25) Mean(SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBoys (n\u0026thinsp;=\u0026thinsp;25 Mean(SD)\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\u003eHeight(cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e45.80 (2.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e46.28 (2.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e45.32 (2.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWeight(g)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;2500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2420 (0.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2470 (0.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2370 (0.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemur length(cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69\u0026ndash;73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e68.16 (2.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e68.60 (2.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e67.72 (2.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eApgar score at 1st min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;7/10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.7 (1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7 (1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.3 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eApgar score at 5th min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;7/10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.2 (1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.4 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003eSignificant differences between groups (ANOVA tests)\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eCorrelation between parental 25(OH)D levels and anthropometric parameters of newborns\u003c/h2\u003e\n \u003cp\u003eMaternal 25(OH)D levels were positively correlated with newborn parameters: height, femur length, weight, and Apgar score at 1 and 5 minutes, demonstrating a strong correlation (\u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.0009, 0.004, 0.023, 0.0007, 0.0042, respectively) (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eA, B, C, D, E).\u003c/p\u003e\n \u003cp\u003eNo significant correlation was observed between paternal 25(OH)D levels and the anthropometric parameters of the offspring, including height, femur length, weight, and Apgar scores at 1 and 5 minutes for the newborns (\u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.19, 0.37, 0.45, 0.53, and 0.58, respectively) (Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003eA, B, C, D, E).\u003c/p\u003e\n \u003cp\u003eTwo distinct ROC analyses were performed to assess the performance of maternal 25(OH)D concentration in predicting an Apgar score\u0026thinsp;\u0026lt;\u0026thinsp;7 at the 1st and 5th minutes of life. For the score at the 1st minute, the area under the curve (AUC) was 0.785 (95% CI: 0.652\u0026ndash;0.918), indicating good discriminative ability. The optimal cut-off identified using the Youden index was 12.58 ng/mL, with a sensitivity of 75% and specificity of 76%. (Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e.A). For the score at the 5th minute, the obtained AUC was 0.652 (95% CI: 0.444\u0026ndash;0.871), reflecting moderate discriminative ability. The optimal cut-off determined was 12.49 ng/mL, with a sensitivity of 75% and specificity of 64%. (Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e.B)\u003c/p\u003e\n \u003cp\u003eThis indicates that Maternal 25(OH)D levels below 12.58 ng/mL and 12.49 ng/mL were associated with a higher risk of an Apgar score\u0026thinsp;\u0026lt;\u0026thinsp;7 at the 1st and 5th minutes, respectively.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eCorrelation between parental and umbilical cord serum 25(OH) D Levels\u003c/h2\u003e\n \u003cp\u003eA positive and moderate correlation was observed between the 25(OH)D levels in newborns and those in their mothers. In other words, the 25(OH)D levels of newborns were significantly correlated with those of their mothers (r\u0026thinsp;=\u0026thinsp;0.419; \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.002) (Fig. \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003eA). In contrast, no correlation was found between paternal 25(OH)D levels and those of their newborns (\u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.34) (Fig. \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003eB).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eAccording to the Endocrine Society's guidelines, the thresholds for determining 25(OH)D status are \u0026lt;\u0026thinsp;20 ng/ml for deficiency and 20 to 29.9 ng/ml for insufficiency \u003csup\u003e(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/sup\u003e. We observed a marked deficiency of 25(OH)D in pregnant women toward the end of their pregnancies, which was significantly correlated with insufficient sun exposure duration. In our sample, 42 out of 50 women did not receive adequate sun exposure (\u0026lt;\u0026thinsp;30 min/day) (\u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). This result is supported by multivariate analysis, which identified sun exposure as the most impactful factor on maternal 25(OH)D status (p-value\u0026thinsp;=\u0026thinsp;0.000). Some studies indicate that girls are more likely to experience vitamin D insufficiency due to less time outdoors and wearing clothing that reduces sunlight exposure \u003csup\u003e(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/sup\u003e. It is widely accepted in the literature that when sun exposure falls below 30 minutes per day, even with substantial skin area exposed, the risk of vitamin D deficiency becomes significant \u003csup\u003e(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/sup\u003e. Although the study region enjoys abundant sunlight, hypovitaminosis D remains prevalent in several countries with similar climates, such as Morocco \u003csup\u003e(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/sup\u003e and Tunisia \u003csup\u003e(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/sup\u003e. Additionally, darker skin color appears to predict this deficiency, significantly associated with varying 25(OH)D levels among pregnant women and males (\u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.006 and \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.0001, respectively). In the multivariate analysis, skin color lost its influence on maternal 25(OH)D status in the presence of other sociodemographic factors (\u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.24), while paternal 25(OH)D deficiency is more influenced by skin color (\u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eIn line with the literature \u003csup\u003e(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/sup\u003e, we observed a consistent positive relationship between low socioeconomic status- including educational level and housing occupation status- and various levels of decreased 25(OH)D (\u003cem\u003ep\u003c/em\u003e-values\u0026thinsp;=\u0026thinsp;0.015 and 0.006, respectively). When accounting for other confounding factors, housing occupation status significantly impacts paternal 25(OH)D (\u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.004). This finding may relate to poor nutrition in many households or the substantial amounts spent on rent, which ultimately reduce purchasing power.\u003c/p\u003e \u003cp\u003eThis multivariate analysis also allowed us to determine the impact of blood sampling season on maternal 25(OH)D status. In the univariate analysis, this relationship was negative (\u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.34), but it became significantly positive (\u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.02) in the presence of several other confounding factors. This result is inconsistent with the findings of an Algerian study conducted in the Tlemcen region, which indicated a positive relationship between these two variables \u003csup\u003e(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/sup\u003e. Our results also showed the negative effect of smoking on 25(OH)D levels in males, a finding that has already been reported in a study investigating the prevalence and factors associated with vitamin D deficiency in Hashimoto's thyroiditis \u003csup\u003e(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFurthermore, pregnant women who are deficient in 25(OH)D are more likely to contract COVID-19 (\u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.000), and all of them exhibited anemia of varying severity. In pregnant women, anemia is defined as having a hemoglobin level below 110 g/L, with severe anemia characterized by levels below 70 g/L \u003csup\u003e(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/sup\u003e. Eighty percent of the women had severe anemia, and this severity was positively correlated with decreased 25(OH)D levels in both univariate and multivariate studies (\u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.0001 and 0.009, respectively) compared to males. Our observation that 25(OH)D insufficiency during the third trimester of pregnancy was associated with a lower rate of gestational anemia aligns with several previous studies, suggesting that maternal vitamin D deficiency during pregnancy may contribute to gestational anemia. Several mechanisms explain the relationship between vitamin D deficiency and anemia. According to Young et al., vitamin D deficiency may positively regulate hepcidin, a peptide hormone that controls iron metabolism, which decreases hemoglobin concentrations and could therefore contribute to anemia \u003csup\u003e(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/sup\u003e. A more recent study by Stallhofer et al. confirmed this association between vitamin D and anemia, demonstrating that vitamin D can improve iron deficiency, potentially by downregulating hepcidin and upregulating ceruloplasmin, thus enhancing intestinal iron absorption \u003csup\u003e(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/sup\u003e. The Bonferroni adjustment resulted in the loss of statistical significance for certain sociodemographic variables. While this correction enhances statistical rigor by limiting false positives, it may also lead to type II errors. Therefore, some of these variables may still hold biological or social relevance despite the lack of statistically significant correction.\u003c/p\u003e \u003cp\u003eIn the present study, a significant difference in 25(OH)D levels was observed between pregnant women and men (\u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.001). Maternal 25(OH)D deficiency was identified in 27 out of 50 women, with an average level of 14.23 ng/ml, while severe deficiency was noted in 15 women, who had an average level of 7.69 ng/ml. These findings align with previous studies demonstrating the prevalence of 25(OH)D deficiency during pregnancy, with rates ranging from 8\u0026ndash;70%, depending on skin pigmentation; darker skin is associated with a higher risk of vitamin D deficiency and longer duration of sun exposure. Additionally, it is crucial to consider other factors that affect vitamin D levels, such as poor nutrition stemming from low socioeconomic status, as diet contributes only a small amount of vitamin D. Furthermore, these women did not receive vitamin D supplementation. Similarly, these factors also influenced the 25(OH)D levels in men, with 21 out of 50 being deficient, 20 classified as insufficient, and the remaining 9 exhibiting severe deficiency.\u003c/p\u003e \u003cp\u003eNo significant difference was observed between the 25(OH)D levels of boys and girls (\u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;=\u0026thinsp;0.13). However, 40% of the newborns were deficient, 22% were insufficient, and 38% had severe deficiency. Additionally, our results indicate that 25(OH)D levels in offspring, regardless of gender, were positively correlated with their mothers' levels. These findings support a meta-analysis that provides evidence of an association between maternal blood 25(OH)D concentrations during pregnancy and umbilical cord blood 25(OH)D concentrations at birth. Overall, maternal 25(OH)D concentrations throughout all trimesters of pregnancy, especially during the third trimester, significantly influence umbilical cord blood 25(OH)D concentrations \u003csup\u003e(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e)\u003c/sup\u003e. During pregnancy, 25(OH)D crosses the placenta from the mother to the fetus, and the level measured in umbilical cord blood at birth depends on maternal status, which is, on average, 80% of the woman's blood value. Therefore, if the mother is deficient, the fetus will likely experience the same deficiency \u003csup\u003e(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/sup\u003e. In contrast, no significant difference was found between males and their newborns, and no studies have investigated this relationship, paving the way for potential future research.\u003c/p\u003e \u003cp\u003eExamining the parent-offspring relationship further, a question arises: Is there a link between parental 25(OH)D levels and the anthropometric parameters of newborns? The results revealed a positive correlation between maternal 25(OH)D deficiency and reduced birth size, shorter femur length, and lower birth weight (\u003cem\u003ep\u003c/em\u003e-values\u0026thinsp;=\u0026thinsp;0.0009, 0.023, 0.004, respectively). In this context, maternal vitamin D directly impacts neonatal anthropometric parameters, and deficiency in the last trimester of pregnancy poses a significant risk for both mothers and newborns. Several previous studies support this, linking maternal vitamin D deficiency to various health issues in both pregnant women and newborns, including bone problems for women, infertility, endometriosis, polycystic ovary syndrome, and adverse pregnancy outcomes such as miscarriages, gestational diabetes, bacterial infections, infectious diseases, premature birth, bacterial vaginosis, and preeclampsia \u003csup\u003e(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e)\u003c/sup\u003e. Additionally, problems such as neonatal hypocalcemia, prematurity, growth disorders, and low birth weight in newborns have also been noted \u003csup\u003e(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/sup\u003e. Zhang et al. explained in a study that placental VDR plays a crucial role in pregnancy, and maternal VDR gene polymorphism may affect birth weight. Maternal vitamin D status during pregnancy may also significantly determine offspring telomere length, which is positively correlated with birth weight \u003csup\u003e(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn our study, we also noted a highly significant relationship between maternal deficiency in 25(OH)D and the Apgar score at the first and fifth minutes after birth (\u003cem\u003ep\u003c/em\u003e-values\u0026thinsp;=\u0026thinsp;0.0007, 0.0042, respectively). The Apgar score is the most commonly used measure for assessing the health status of newborns, and non-malformed term infants with lower Apgar scores within the normal range face an increased risk of adverse long-term outcomes, such as epilepsy, cerebral palsy, and the need for additional care \u003csup\u003e(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e)\u003c/sup\u003e. To further explore the relationship between maternal deficiency in 25(OH)D and the Apgar score, we conducted a ROC curve analysis, which revealed that maternal 25(OH)D concentration has a meaningful predictive value for neonatal vitality, particularly in the immediate minutes following birth. At the 1st minute, the area under the curve (AUC) reached 0.785 (95% CI: 0.652\u0026ndash;0.918), indicating a good discriminative capacity. The optimal cut-off point determined by the Youden index was 12.58 ng/mL, with a sensitivity of 75% and a specificity of 76%. This suggests that maternal vitamin D status plays a significant role in the newborn\u0026rsquo;s initial adaptation to extrauterine life, and that a 25(OH)D concentration below this threshold is associated with an increased risk of compromised neonatal condition, as reflected by an Apgar score\u0026thinsp;\u0026lt;\u0026thinsp;7. At the 5th minute, although the discriminative power decreased (AUC\u0026thinsp;=\u0026thinsp;0.652, 95% CI: 0.444\u0026ndash;0.871), the analysis still indicated a moderate predictive ability. The optimal cut-off was 12.49 ng/mL, with the same sensitivity of 75%, but a slightly lower specificity of 64%. This relative decline in specificity may reflect the growing influence of postnatal interventions or other perinatal factors on the Apgar score as time progresses. Nevertheless, the persistence of high sensitivity supports the idea that maternal 25(OH)D deficiency continues to exert an influence on neonatal adaptation even several minutes after birth.\u003c/p\u003e \u003cp\u003eThe relationship between vitamin D and the Apgar score has been confirmed by several studies, which found that women with vitamin D deficiency had a significantly higher proportion of infants born with a low Apgar score \u003csup\u003e(\u003cspan additionalcitationids=\"CR36\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e)\u003c/sup\u003e.Augustin et al. suggested that poor vitamin D status disrupts myometrial function through several mechanisms, including impaired regulation of intracellular calcium concentration, diminished binding to the vitamin D receptor in the uterine endometrium and myometrium, and increased levels of inflammation-induced cytokines and factors associated with contraction in myometrial smooth muscle cells \u003csup\u003e(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eConversely, our results did not show any significant relationship between various paternal 25(OH)D levels and neonatal anthropometric parameters (height, femur length, weight, Apgar scores at the 1st and 5th minutes, with \u003cem\u003ep\u003c/em\u003e-values of 0.19, 0.37, 0.45, 0.53, and 0.58, respectively). These findings indicate that neonatal anthropometric parameters are positively associated with maternal 25(OH)D levels rather than paternal levels. Similarly, maternal 25(OH)D deficiency directly affects neonatal 25(OH)D levels, while paternal 25(OH)D levels do not influence those of the newborns.\u003c/p\u003e \u003cp\u003eHowever, this study has limitations, such as the relatively small sample size due to limited available resources. This constraint may have affected the statistical power of certain comparisons, increasing the risk of Type II error, meaning the possibility of missing weak but clinically relevant associations between vitamin D levels and the studied parameters. Moreover, although the sample is representative of the local population (Oran, Algeria), the generalizability of the results to other geographic or demographic contexts remains limited. Future studies involving larger and more diverse samples will be necessary to confirm our findings and assess their external validity.\u003c/p\u003e \u003cp\u003eFurthermore, the presence of a non-deficient couple group will be necessary for such a study, allowing for comparison with the deficient group. Additionally, the lack of a couple group where mothers are non-deficient and fathers are deficient has limited our ability to conclude the paternal-neonatal relationship.\u003c/p\u003e \u003cp\u003eTo conclude, this study revealed that 25(OH)D deficiency and insufficiency are highly prevalent among both Algerian women and men. Decreased 25(OH)D levels in late pregnancy significantly correlate with a higher risk of neonatal 25(OH)D deficiency, growth delays, and, most importantly, an Apgar score below 7 at the first and fifth minutes after birth. Paternal deficiency did not impact offspring outcomes. Individualized vitamin D supplementation at the end of pregnancy should be considered to minimize this risk. Administering vitamin D throughout pregnancy is essential to protect infants from adverse effects on neonatal health. Furthermore, fortifying food with vitamin D could be an effective preventive measure, especially in countries like Algeria, where specific groups (pregnant women, infants, and the elderly) are at a heightened risk of deficiency. Enhancing commonly consumed foods such as dairy products, flour, and other staples could help improve vitamin D coverage. Numerous studies conducted in other countries have demonstrated that this approach can reduce vitamin D deficiencies at the population level and enhance the health of at-risk groups. Therefore, we recommend that further studies be conducted to explore these fortification strategies in Algeria, particularly aimed at the most vulnerable groups, to mitigate the risks associated with vitamin D deficiency and improve public health in the country.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Medical Ethics Committee of Oran University Hospital N°83/2021/DAPM. The study was conducted according to the guidelines laid down in the Declaration of Helsinki of 1975 as revised in 1983 and to the guidelines for Good Clinical Practice of ICH. All persons gave their informed consent before their inclusion in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research presented in this publication was partially supported by the Laboratory of Physiology of Nutrition and Food Safety (LPNSA), Oran 1 University, as well as by the National Institute of Health and Medical Research (INSERM), the National Research Institute for Agriculture, Food, and Environment (INRAE), and Aix-Marseille University (AMU).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSara Mama Abadi, Habib Hammou, Lidia Saidi, Fenni Soumia, and Tawfik Addi conducted the research and analyzed the data. Ilies Megueni provided essential tools for the study. Seyf El Islem Negadi assisted in the recruitment. Sahra Meziane, Farid Boubred contributed critical interpretation, revision, and input to the article. Sara Mama Abadi and Jean-Francois Landrier designed the experiment, interpreted the results, and wrote the paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge the head of the Obstetrics and Gynecology Department at Oran University Hospital, as well as to the coordinating physician, for ensuring the smooth implementation of this research protocol. We also extend our thanks to the medical and paramedical teams for their valuable advice and support throughout this doctoral project. Our sincere appreciation also goes to the medical analysis laboratory of the DU VAL Clinic Group in El-Biar, Algiers, Algeria, for their invaluable assistance. Finally, we extend our sincere gratitude to Mrs. Mokadem Zohra for her indispensable support in facilitating administrative procedures.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAl-Smadi K, Ali M, Alavi SE, Jin X, Imran M, Leite-Silva VR, et al. Using a Topical Formulation of Vitamin D for the Treatment of Vitiligo: A Systematic Review. Cells janv. 2023;12(19):2387.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim DH, Meza CA, Clarke H, Kim JS, Hickner RC. Vitamin D and Endothelial Function. Nutrients. 22 f\u0026eacute;vr. 2020;12(2):575.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGiustina A, Bouillon R, Binkley N, Sempos C, Adler RA, Bollerslev J et al. Controversies in Vitamin D: A Statement From the Third International Conference. JBMR Plus. d\u0026eacute;c. 2020;4(12):e10417.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarek K, Cichoń N, Saluk-Bijak J, Bijak M, Miller E. The Role of Vitamin D in Stroke Prevention and the Effects of Its Supplementation for Post-Stroke Rehabilitation: A Narrative Review. Nutrients 4 juill. 2022;14(13):2761.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCashman KD, 100, YEARS OF VITAMIN D. Global differences in vitamin D status and dietary intake: a review of the data. Endocr Connect 3 d\u0026eacute;c. 2021;11(1):e210282.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDragomir RE, Toader DO, Gheoca Mutu DE, Dogaru IA, Răducu L, Tomescu LC, et al. Consequences of Maternal Vitamin D Deficiency on Newborn Health. Life juin. 2024;14(6):714.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVarthaliti A, Rodolaki K, Lygizos V, Vlachos DE, Thomakos N, Sioutis D, et al. Neurodevelopmental Outcomes in the Offspring of Women with Vitamin D Deficiency and Women Who Received Vitamin D Supplementation During Pregnancy. Nutrients janv. 2025;17(6):978.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFilgueiras MDS, Suhett LG, Silva MA, Rocha NP, de Novaes JF. Lower vitamin D intake is associated with low HDL cholesterol and vitamin D insufficiency/deficiency in Brazilian children. Public Health Nutr ao\u0026ucirc;t. 2018;21(11):2004\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAshley B, Simner C, Manousopoulou A, Jenkinson C, Hey F, Frost JM, Placental uptake and metabolism of 25(OH)vitamin D determine its activity within the fetoplacental unit., Shoback D, Zaidi M, Hollis B et al. \u0026eacute;diteurs. eLife. 8 mars 2022;11:e71094.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarras SN, Anagnostis P, Annweiler C, Naughton DP, Petroczi A, Bili E, et al. Maternal vitamin D status during pregnancy: the Mediterranean reality. Eur J Clin Nutr ao\u0026ucirc;t. 2014;68(8):864\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShahmoradi A, Aghaei A, Ghaderi K, Jafar Rezaei M, Azarnezhad A. A meta-analysis of the association of ApaI, BsmI, FokI, and TaqI polymorphisms in the vitamin D receptor gene with the risk of polycystic ovary syndrome in the Eastern Mediterranean Regional Office population. Int J Reprod Biomed. 6 juill. 2022;20(6):433\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgarwal S, Kovilam O, Agrawal DK. Vitamin D and its impact on maternal-fetal outcomes in pregnancy: A critical review. Critical Reviews in Food Science and Nutrition. 24 mars. 2018;58(5):755\u0026ndash;69.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eT\u0026ouml;rzs\u0026ouml;k P, Van Goubergen J, Pichler M, Pichler R, Santer FR. Isochromosome 12p Formation Regulates Vitamin D Metabolism in Testicular Cancer. Nutrients janv. 2023;15(10):2384.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang X, Jiao X, Tian Y, Zhang J, Zhang Y, Li J, et al. Associations between maternal vitamin D status during three trimesters and cord blood 25(OH)D concentrations in newborns: a prospective Shanghai birth cohort study. Eur J Nutr sept. 2021;60(6):3473\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeems LMG, Mahmud H, Buikema H, Tost J, Michel S, Takens J, et al. Parental vitamin D deficiency during pregnancy is associated with increased blood pressure in offspring via Panx1 hypermethylation. Am J Physiol Heart Circ Physiol 1 d\u0026eacute;c. 2016;311(6):H1459\u0026ndash;69.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChao M, Menon C, Elgendi M. Validity of Apgar Score as an Indicator of Neonatal SARS-CoV-2 Infection: A Scoping Review. Front Med (Lausanne). 2021;8:782376.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheng Y, Chen J, Li T, Pei J, Fan Y, He M, et al. Maternal vitamin D status in early pregnancy and its association with gestational diabetes mellitus in Shanghai: a retrospective cohort study. BMC Pregnancy Childbirth 5 nov. 2022;22(1):819.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChebet M, Piloya T, Ameda F, Mukunya D, Kiguli S. Vitamin D deficiency in low-birth-weight infants in Uganda; a cross sectional study. PLoS One 11 nov. 2022;17(11):e0276182.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDjerdjar L, Ramdane S, Oussadou L. Epidemiology of hypovitaminosis D among apparently healthy young adults in Algeria. Rev Med Brux. 2022;43(1):12\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhasmi ME, Farh M, Iddar A, Tahri E. La vitamine D: activit\u0026eacute;s biologiques, dosage, r\u0026eacute;sultats et \u0026eacute;tat des lieux au Maroc. Biol m\u0026eacute;dicale. 2021;1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNaifar M, Jerbi A, Turki M, Fourati S, Sawsan F, Bel Hsan K et al. Valeurs de r\u0026eacute;f\u0026eacute;rence de la vitamine D chez la Femme du Sud Tunisien. Nutrition Clinique et M\u0026eacute;tabolisme. mai 2020 ;34(2):169\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eL\u0026eacute;ger-Guist\u0026rsquo;hau J, Domingues-Faria C, Miolanne M, Peyrol F, Gerbaud L, Perreira B, et al. Low socio-economic status is a newly identified independent risk factor for poor vitamin D status in severely obese adults. J Hum Nutr Dietetics. 2017;30(2):203\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeghelli SM. Corr\u0026eacute;lation entre le statut de la vitamine d et le titre d\u0026rsquo;anticorps antithyro\u0026iuml;diens dans la thyro\u0026iuml;dite d\u0026rsquo;Hashimoto chez les patients de la Wilaya de Tlemcen. Ann d\u0026rsquo;Endocrinologie 1 f\u0026eacute;vr. 2023;84(1):108.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMouelhi Y, Yazidi M, Chaker F, Khessairi N, Grira W, Oueslati I, et al. Pr\u0026eacute;valence et facteurs associ\u0026eacute;s \u0026agrave; la carence en vitamine D au cours de la thyro\u0026iuml;dite de Hashimoto. Ann d\u0026rsquo;Endocrinologie 1 oct. 2021;82(5):398\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoung MF, Oaks BM, Tandon S, Martorell R, Dewey KG, Wendt AS. Maternal hemoglobin concentrations across pregnancy and maternal and child health: a systematic review and meta-analysis. Ann N Y Acad Sci. 2019;1450(1):47\u0026ndash;68.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStallhofer J, Veith L, Diegelmann J, Probst P, Brand S, Schnitzler F, et al. Iron Deficiency in Inflammatory Bowel Disease Is Associated With Low Levels of Vitamin D Modulating Serum Hepcidin and Intestinal Ceruloplasmin Expression. Clin Transl Gastroenterol 13 janv. 2022;13(1):e00450.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhowmik B, Siddiquee T, Mdala I, Quamrun Nesa L, Jahan Shelly S, Hassan Z, et al. Vitamin D3 and B12 supplementation in pregnancy. Diabetes Res Clin Pract avr. 2021;174:108728.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHu KL, Zhang CX, Chen P, Zhang D, Hunt S. Vitamin D Levels in Early and Middle Pregnancy and Preeclampsia, a Systematic Review and Meta-Analysis. Nutrients janv. 2022;14(5):999.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWong RS, Tung KTS, Mak RTW, Leung WC, Yam JC, Chua GT, et al. Vitamin D concentrations during pregnancy and in cord blood: a systematic review and meta-analysis. Nutr Rev. nov 2022;7(12):2225\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMansur JL, Oliveri B, Giacoia E, Fusaro D, Costanzo PR. Vitamin D: Before, during and after Pregnancy: Effect on Neonates and Children. Nutrients. 1 mai. 2022;14(9):1900.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTamblyn JA, Pilarski NSP, Markland AD, Marson EJ, Devall A, Hewison M, et al. Vitamin D and miscarriage: a systematic review and meta-analysis. Fertility Steril juill. 2022;118(1):111\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLhilali I, Zouine N, Menouni A, Godderis L, Kestemont MP, El Midaoui A, et al. Sun Exposure Score and Vitamin D Levels in Moroccan Women of Childbearing Age. Nutrients 29 janv. 2023;15(3):688.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang Y, Jukic AMZ, Song H, Zhang L, Yang F, Wu S et al. Serum Vitamin D Concentrations, Time to Pregnancy, and Pregnancy Outcomes among Preconception Couples: A Cohort Study in Shanghai, China. Nutrients. 26 juill. 2022;14(15):3058.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRazaz N, Cnattingius S, Joseph KS. Association between Apgar scores of 7 to 9 and neonatal mortality and morbidity: population based cohort study of term infants in Sweden. BMJ. 7 mai. 2019;365:l1656.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLindqvist PG, Silva AT, Gustafsson SA, Gidl\u0026ouml;f S. Maternal vitamin D deficiency and fetal distress/birth asphyxia: a population-based nested case\u0026ndash;control study. BMJ Open sept. 2016;6(9):e009733.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu W, Xu P. The association of serum vitamin D level and neonatal respiratory distress syndrome. Ital J Pediatr. 30 janv. 2023;49(1):16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaboute M, Yavar R, Kashaki M, Khaledi FK, Khalesi N, Rohani F. Investigation of association between maternal 25-OH vitamin D serum levels and neonatal early onset sepsis in newborns by evaluating key factors. Lipids Health Dis 13 juill. 2019;18:153.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAugustin H, Mulcahy S, Schoenmakers I, Bullarbo M, Glantz A, Winkvist A, et al. Late Pregnancy Vitamin D Deficiency is Associated with Doubled Odds of Birth Asphyxia and Emergency Caesarean Section: A Prospective Cohort Study. Matern Child Health J nov. 2020;24(11):1412\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"25-Hydroxyvitamin D, pregnant women, deficiency, parents, offspring, anthropometric parameters","lastPublishedDoi":"10.21203/rs.3.rs-5930305/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5930305/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eVitamin D is critical in overall health, particularly during pregnancy, as it supports a healthy pregnancy and promotes proper fetal development. This study examined the link between parental 25-hydroxyvitamin D (25(OH)D) deficiency and their offspring's anthropometric and biological parameters.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional study was conducted involving 50 Algerian families, which included 50 pregnant women in their third trimester, 50 fathers, and 50 newborns. Blood samples were collected from both parents and the umbilical cord of the newborns. Serum 25(OH)D concentrations were measured, and demographic and health-related information was gathered from the participants. The anthropometric parameters of the newborns were recorded at birth.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn our study, 16% of women were insufficient in 25(OH)D, 54% were deficient, and the remaining 30% exhibited severe deficiency, with mean 25(OH)D levels of 24.53 ng/ml, 14.23 ng/ml, and 7.69 ng/ml, respectively. Among males, 40% were insufficient, 42% were deficient, and 18% had severe deficiency, with mean 25(OH)D levels of 25 ng/ml, 15.78 ng/ml, and 8.53 ng/ml, respectively. Furthermore, 24% of newborns were insufficient, 52% were deficient, and 24% had severe deficiency, with mean 25(OH)D levels of 23.53 ng/ml, 13.46 ng/ml, and 7.53 ng/ml, respectively. Maternal 25(OH)D levels were positively correlated with the anthropometric parameters of newborns (height, femur length, weight, and Apgar scores at 1 and 5 minutes after birth). Conversely, paternal deficiency showed no correlation with these parameters.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003e25(OH)D deficiency significantly impacts newborns and represents a significant risk to their development, whereas paternal deficiency has no impact on the measured anthropometric parameters of newborns.\u003c/p\u003e","manuscriptTitle":"Correlation between anthropometric and biological parameters of the offspring and parental plasma 25-hydroxyvitamin D levels: a cross-sectional study conducted at Oran, Algeria.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-29 18:51:13","doi":"10.21203/rs.3.rs-5930305/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accepted","date":"2025-05-05T05:08:54+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-03T09:53:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-30T18:26:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"210846591722244669384775674238966430601","date":"2025-04-30T18:16:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"119071485903704118890389714338050415335","date":"2025-04-28T07:41:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-26T06:42:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-24T23:50:06+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-04-16T13:23:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c1f4ad50-b2db-4c9b-9798-6dd9385d0bf4","owner":[],"postedDate":"April 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-26T16:04:19+00:00","versionOfRecord":{"articleIdentity":"rs-5930305","link":"https://doi.org/10.1186/s12884-025-07686-x","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2025-05-22 15:58:27","publishedOnDateReadable":"May 22nd, 2025"},"versionCreatedAt":"2025-04-29 18:51:13","video":"","vorDoi":"10.1186/s12884-025-07686-x","vorDoiUrl":"https://doi.org/10.1186/s12884-025-07686-x","workflowStages":[]},"version":"v1","identity":"rs-5930305","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5930305","identity":"rs-5930305","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}