Temporal and Spatial Distribution of vitamin D Deficiency worldwide as 2019- Systematic review

Temporal and Spatial Distribution of vitamin D Deficiency worldwide as 2019- Systematic review | 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 Systematic Review Temporal and Spatial Distribution of vitamin D Deficiency worldwide as 2019- Systematic review Ibtihal Elsayed This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8642238/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Vitamin D deficiency is a growing global public health concern with important skeletal and extra-skeletal health consequences. Although sunlight exposure is the primary source of vitamin D, deficiency remains prevalent even in regions with abundant sunshine. This systematic review aimed to describe the temporal and spatial distribution of vitamin D deficiency worldwide as at 2019 using epidemiological and geospatial approaches. Methods: A systematic review of studies published between 1995 and 2019 was conducted using PubMed. Eligible studies included healthy adults aged ≥ 18 years and reported the prevalence of vitamin D deficiency, defined as serum 25-hydroxyvitamin D levels < 30 ng/mL (75 nmol/L). Studies involving children, pregnant women, individuals with comorbidities, or vitamin D supplementation were excluded. Data were extracted on sample size, number of deficiency cases, and prevalence with confidence intervals. Statistical analysis was performed using SPSS, while geographic distribution and predictive risk mapping were generated using ArcGIS 10.3 employing kriging interpolation. Results: A total of 144 studies from 46 countries were included, encompassing 357,089 participants, of whom 218,174 were vitamin D deficient, resulting in an overall prevalence of 51.3% (95% CI: 48.4–58.6). The highest prevalence was observed in Africa (65%) and the Middle East (63.1%), followed by Europe (56.1%), South America (53.5%), Asia (52.1%), and Australia (46.2%). North America had the lowest prevalence (23%). Geospatial analysis identified a high-risk belt extending across Europe, North Africa, Western Asia, and parts of South America. Publication trends increased markedly after 2004. Conclusion: Vitamin D deficiency is highly prevalent worldwide, including in sun-rich regions. Geospatial mapping highlights critical high-risk areas, emphasizing the need for targeted screening, prevention strategies, and public health interventions globally Endocrinology & Metabolism vitaminD deficiency prevelenace worldwide geospatial analysis systematic review Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Vitamin D is a fat-soluble vitamin which is mostly synthesized under the skin by the influence of Ultra Violet (UV) sunlight. Its importance is well known in bone metabolism, calcium and phosphorus homeostasis. However, recent evidence demonstrates its roles as a transcription factor, immune modulator and gene regulator; which indicate its crucial clinical implications. Studies associated Vitamin D deficiency to various health consequences including bone diseases, diabetes mellitus, obesity, metabolic syndrome, cardiovascular morbidity, multiple sclerosis, rheumatoid arthritis, cognitive dysfunctions and various types of cancers [1–3]. Various studies related low vitamin D levels to adverse maternal and neonatal outcomes [4–5]. Moreover, low Vitamin D levels are associated with various mortality causes [6]. Vitamin D not only has a considerable role in modifying the immune system and regulating cell proliferation and cell differentiation [7, 8], but also has a role in reducing mortality. Vitamin D supplementation were found to reduce deaths due to Cancer [9]. Level of serum vitamin D is affected by many factors, some are well established and others are still under investigation. Sun exposure is the most vital influencer. Nevertheless, time of day, time of year and latitude determine the effectiveness of sun exposure; incident Ultra Violet radiation levels reach a maximum at mid-day in the summer. Below a latitude of approximately 35° North and its adequate for vitamin D3 synthesis all the year except in winter in some parts of the world [10]. A study included rural Chinese twins concluded that male gender, summer and physical activity increases level of vitamin D significantly [11]. An ecological study conducted in Calgary, Canada, found that there was a significant higher levels in the inner city neighborhood when compared to far north and north-east areas which had lower levels of vitamin D levels. Moreover, regarding age and gender, curiously they found that vitamin D levels reaches it is lowest point at age 35 years then it increased to reaches the maximum at age > 60 with females possess higher levels than males [12] ; children and elderly are defined as the age group at risk [13]. Generally, increased body mass index (BMI), low socioeconomic status and tobacco use were found inversely related to level of vitamin D (14, 15, 16) There is no universal definition of vitamin D deficiency; Institute of Medicine (IOM) has defined a serum 25(OH) D concentration of 30nmol/L as the threshold below which clinical vitamin D deficiency may occur [17,18]. Another definition is a serum 25-hydroxy vitamin D (25-OH D) concentration less than 20 ng/ml, while vitamin D insufficiency was defined as a 25-(OH)-D concentration less than 30 ng/ml[19]. Reports demonstrated that vitamin D insufficiency prevailed world-wide across populations. In the United States, using the data of National Health and Nutrition Examination Survey (NHANES), a study observed vitamin D insufficiency in 39.92% of the study population [20]. In Europe, a pooled estimate showed that 13% had serum vitamin D deficiency (< 30ng/ml) on average in the year [21]. In Asian countries, a prevalence of vitamin D deficiency of 84.3% was reported by a study in asymptomatic adult population [22]. In the Middle-East, in spite of the sunlight most of the year, vitamin D levels among the general population was still inadequate, particularly in young adult females. This is might be related to a decreased exposure to sun light in this group of population [23]. A systemic review claimed a prevalence of 30 and 90% in the Middle East [24]. Another review on > 40 observational studies in Middle East and North Africa revealed that the prevalence of low vitamin D in adults ranged from 44% to 96% with a mean vitamin D level 25(OH) D ranging between 11 and 20ng/ml [25]. In Africa, vitamin D deficiency is a threat as well; the pooled prevalence of low vitamin D status (less than 30 nmol/L) was 18·46% (95% CI 10·66–27·78) identified in a Meta-analysis [26]. Vitamin D deficiency is becoming a global health issue; lack of adequate data cripples the effort directed to tackle this problem. This systemic review aims to identify and analyse previous studies on prevalence of vitamin D deficiency among healthy adults world-wide. METHODS Study design A systematic review was implemented during the period from October 1st to December 15th, 2019. Data sources and searches: This systematic review was done using PubMed as search engine, restricted to studies between (1995–2019). A comprehensive assessment of the articles accessed on the electronic database was carried out using the keywords “vitamin D”, “deficiency”, “prevalence” and “adults” yielding 4663 articles. Unaccusable articles were downloaded using SCI-Hub web site. Study selection: In this review; Vitamin D levels below 75 nmol/l (30 ngm/ml) was classified as deficient. We included studies carried out among healthy adults ≥ 18 year-old and in which the prevalence and the sample size were obtainable. Any study with participants below 18 years, patients with co-morbidities, patients on vitamin D supplements and pregnant ladies was excluded. Data extraction: The 4663 selected articles were firstly distributed equally among the eight members of the research team. Then a total of 144 articles which fulfill the inclusion criteria were extracted using MS Excel tables. Those tables included the following data: The title, authors, year of publication, journal, sample size, number of cases, prevalence, upper and lower confidence intervals. After that these articles were redistributed according to their respected continent. Data synthesis and analysis: MS Excel was used to calculate the upper and lower confidence interval using the prevalence and sample size. Longitude and latitude of each study setting were identified using Google Earth Professional. The yielded data were then transferred to the statistical package for social sciences (SPSS, Ver.23) to generate frequency tables and trend graph. Data projection was done through Arc GIS 10.3 to generate epidemiological map and risk map using Kriging method which is a technique based on estimating the distance and degree of variation between known data points when estimating values in unknown areas. RESULTS Number of cases and estimated prevalence by countries : From 1995 to 2019, a total of 218,174 cases of vitamin D deficiency on a total sample of 357,089. Reported by 144 articles from 46 countries. This representing an average prevalence of 51.3% (95% [CI: (48.4 – 58.6)] of vitamin D deficiency worldwide (Tables 4.1 ). In Africa five countries were included with a total number of cases of vitamin D deficiency of 881 out of 1436 cases, with an average prevalence of 65% (95%[CI: 58.5–71.6]). Of the five countries Libya is having the highest prevalence of 77.9% (95% [CI: 73.7–82.0]) in contrast to Tunisia which having the lowest prevalence of 47.6% (95% [CI: 42.6–52.6]). Elsewhere in Africa the prevalence were 63% in Egypt, 66.7% in Nigeria and 70% in morocco. In Middle East eight countries were included with a total number of cases of vitamin D deficiency of 83657 out of 115394 cases, with an average prevalence of 63.1% (95% [CI: 57.2–69.1]). The highest prevalence was reported in Israel 92.5% (95% [CI: 72.5-112.6]). In contradiction to UAE which showed the lowest prevalence of 19.7% (95% [CI: 15.3–24.1]). In Europe studies conducted in sixteen countries with a total number of cases of vitamin D deficiency of 65947 out of 92240 study population with an average prevalence of 56.1% (95% [CI: 52.3–59.8]). Turkey reported the highest prevalence of vitamin D deficiency of 87.3% (95% [CI: 85.1–89.3]) followed by France and Belgium with prevalence of 86.4 (95% [CI: 83.2–89.5]) and 86.2% (95% [CI: 83.8–88.3]) respectively. However the lowest prevalence was in Austrian 6.9% (95% [CI: 3.5–10.3]) followed by Greece 10.7% (95% [CI: 7.8–13.7]) and Netherland 34% (95% [CI: 31.4–36.6]). In Asia a total of ten countries were included with a total number of cases of vitamin D deficiency 30992 out of 46932 study sample size with an average prevalence of 52.1% (95%[CI:46.9–57.3]). The highest prevalence was reported in Malaysia of 78.5% (95% [CI: 74.9–82.1]) followed by South Korea, Pakistan and China with prevalence of 77.9% (95% [CI: 75.5–80.3]), 61.1% (95% [CI: 57-66.5]) and 60% (95%[CI:]). (95% [CI: 57.4–62.7]) respectively. While the lowest prevalence was observed in Thailand 32% (95% [CI: 27.7–36.3]). In South America a total of six countries were included with a total number of cases of vitamin D deficiency 3322 out of 9588 total sample size with an average prevalence of 53.5% (95%[CI:48.4–58.6]). The highest prevalence was reported in Argentina of 87.8% (95% [CI: 81.3–94.2]) contemporary to Puerto Rico which showed the lowest prevalence of 7.1% (95% [CI: 3.6–10.6]). North America and Australia showed the lowest prevalence of vitamin D deficiency worldwide of 23% (95% [CI: 20.7–24.5]) and 46.2% (95% [CI: 42.3–50]). Table 4.1 Number of cases and estimated prevalence by countries: LOCATION COUNTRY SAMPLE CASE PREV 95% CI for prevalence LCI UCI Africa Nigeria 51 34 66.7 53.8 79.6 Egypt 354 223 63.0 58.0 68.0 Libya 388 302 77.9 73.7 82.0 Morocco 254 178 70.0 64.4 75.6 Tunisia 389 144 47.6 42.6 52.6 Total 1436 881 65.0 58.5 71.6 Asia Bangladesh 394 70 37.1 31.5 42.6 China 33755 24126 60.0 57.4 62.7 India 3105 1287 48.1 44.1 52.2 Indonesia 74 26 35.1 24.2 46.0 Japan 1863 939 46.5 39.8 53.1 Malaysia 1046 779 78.5 74.9 82.1 Pakistan 4953 2670 61.8 57.0 66.5 South Korea 1126 877 77.9 75.5 80.3 Taiwan 170 75 44.2 36.7 51.6 Thailand 446 143 32.0 27.7 36.3 Total 16932 30992 52.1 46.9 57.3 Australia Australia 14185 5143 52.8 48.0 57.6 New Zealand 2853 1339 39.5 36.6 42.4 Total 17038 6482 46.2 42.3 50.0 Europe Germany 9972 5416 41.1 35.6 46.7 Norway 1032 531 37.9 34.1 41.6 Spain 1811 1503 83.0 81.3 84.7 Austrian 215 15 6.9 3.5 10.3 Belgium 915 787 86.2 83.8 88.3 France 1091 900 86.4 83.2 89.5 Greece 1306 61 10.7 7.8 13.7 Ireland 7633 1707 37.8 33.7 41.8 Italy 427 351 82.2 78.6 85.8 Netherlands 3740 1162 34.0 31.4 36.6 Poland 7839 6039 67.6 63.5 71.7 Portugal 198 167 84.5 79.5 89.5 Slovenia 578 237 41.0 37.0 45.0 Spain 2769 743 49.5 42.4 56.5 Turkey 36058 34008 87.3 85.1 89.3 United Kingdom 16656 12320 62.2 57.0 65.6 Total 92240 65947 56.1 52.3 59.8 Middle East Qatar 102342 73072 71.4 71.1 71.7 Saudi Arabia 9140 7809 74.4 71.9 76.8 Iran 2635 2180 79.075 74.15 84 Bahrain 500 247 49.4 45 53.8 Israel 81 75 92.5 86.88 98.29 Jordan 381 212 55.6 50.6 60.6 UAE 315 62 19.7 15.3 24.1 Total 115394 83657 63.1 57.2 69.1 North America Canada 10191 856 8.4 7.9 8.9 USA 64270 26037 37.6 33.4 40.1 Total 74661 26893 23 20.7 24.5 South America Ecuador 2374 1610 67.8 65.9 69.6 Mexico 585 255 43.6 39.6 47.6 Puerto Rico 4188 24 7.1 3.6 10.6 Argentina 383 334 87.8 81.3 94.2 Brazil 1634 985 62.76 56.7 68.9 Tobago 424 114 26.8 22.6 31.0 Total 9588 3322 53.5 48.4 58.6 4.2. Trend of vitamin D deficiency cases over years. There were limited number of publications of vitamin D deficiency till 2004 in which the number of publications rose dramatically until it reached a peak in 2007. Thereafter it fluctuated until it rose steadily from 2017 (Fig. 4.1 ) 4.3. Geographical distribution of the study setting : One hundred forty four articles from forty six countries were used to develop the geographical distribution of study setting. Figure 4 − 2. Figure 4 − 2: Geographical distribution of the study setting with vitamin D deficiency prevalence data. 4.4. Epidemiological distribution of the prevalence (%) of vitamin D deficiency worldwide : The epidemiological map (Fig. 4.3.) of the prevalence of vitamin D deficiency worldwide delineate four levels of prevalence: the very high prevalence areas (70–100%) represented in red color, high prevalence (50-69.9%) in pink, intermediate prevalence (5-49.9%) in green and low prevalence (0.2–4.9%) in violet color. The highest prevalence was found in a belt extended from Japan, China, India, Middle East, Europe, and North Africa. There is also some foci in eastern part of Australia, South and North America. 4.5. Vitamin D deficiency risk map : The predictive risk map (Fig. 4 – 4 ) enables to delineate three levels of risk: high risk (prevalence > 72.9%) areas represented in plain orange and red color, an intermediate risk areas (prevalence 58– 72.9) delineated in yellow to orange, and a low risk areas (prevalence 0.2–57.9) delineated in blue to a mix yellow blow. The risk of vitamin D deficiency was predicted to be highest in a belt including Europe, North Africa, western Asia (KSA, Iraq, Yemen and Kazakhstan) and some foci in western part of North America and southern part of South America (Chile and Argentina). DISCUSSION Throughout the studies, we noticed there was a high degree of variability in the prevalence of vitamin D deficiency worldwide, considering the cutoff value to be a serum 25-hydroxy D (25-OH D) concentration of less than 30 ng/ml. This variation can be illustrated by the noticeably high prevalence of vitamin D deficiency in areas such as Africa and the Middle East in contradiction to areas with lower prevalence like North America. This was a particularly unexpected feature seeing as both Africa and the Middle East witness sun exposure most of the year around and the number of cases were expected to be much lower. North and South America: Southern America reported prevalence of 53,5% of vitamin D deficiency with comparative results of 49,36% from previous studies[ 31 ] ,in contrast to Northern America in which 23% of the study population suffered from its deficiency which is almost less than half the 39.92% yielded by the National Health and Nutrition Examination Survey (NHANES) [5]. In both studies, paediatrics were excluded from the target population. However, NHANES also excluded housebound candidates and those living in residential institutions while our study did not. Asia: In Asian countries, we found there was a prevalence of 52.1% of vitamin D deficiency which is considerably less than the 84.3% reported by a study in the asymptomatic adult population [12]. Africa and the Middle East: Africa and the Middle East yielded the highest level of vitamin D deficiency, despite sunlight most of the year with 65 and 63.1% respectively. In comparison to similar studies five from Iran, one from Egypt, one from occupied Palestine/Israel and one from Lebanon with prevalence ranging from 44 to96%. [28]. this is can be explained by Seasonal variations of vitamin D with low level in winter, working indoor and using sunblock due to sunny climate especially in gulf states and covering parts of the body (Hijab) is both a cultural and religious act among females in that areas. Moreover genetic factors, namely polymorphisms in key genes of the vitamin D pathway, modulate vitamin D status in western populations and possibly the Middle East [29]. Europe : Meanwhile, as expected, Europe revealed vitamin D deficiency prevalence of (56.5%) which can be attributed to the little amount of sunlight exposure throughout the year. Nevertheless better vitamin D level is reported in Nordic than in Mediterranean countries despite high altitude and less sunshine, which can be explained by high intake of cod, cod liver and cod liver oil in Norway and Sweden .[32] However the role of sun light is vital for vitamin D synthesis as well for general health as reflected by a study of Australian dermatologist in the summer revealed that their use of a sunscreen resulted in 87% of them being vitamin D deficient at the end of the summer [27] Prevalence of vitamin D deficiency varied even among countries within the same continent or that share similar conditions like sunlight exposure and diet ; this illustrated in the difference between Indonesia and Malaysia (35.1%,78.5% ) respectively .these variations shed light on the contribution of other factors such as genetic variation ; recent studies defined single nucleotide polymorphisms that affect level of vitamin D ; some of them were widely among young Canadian, white women Hispanics and African Americans, Dutch with chronic obstructive pulmonary disease, British, Han Chinese and Poles (35). The limitation of our study is the limited access for publication as we just used PubMed as a search engine and SCI HUB web-site to open some papers. It is important to note that, data on children and pregnant ladies were not included in this review. International : The results conclude that vitamin D deficiency is an international public health problem and the pre-made assumptions that sunny areas do not suffer from this are false and misleading. Moreover, v itamin D deficiency may present with full-blown symptoms or may be covert which means that the aforementioned populations with less risk factors shouldn’t be neglected in the screening and management plans since clinical presentation may be a very late feature of a long overdue diagnosis. References Beata Matyjaszek-Matuszek, Monika Lenart-Lipińska, Ewa Woźniakowska Prz Menopauzalny. Clinical implications of vitamin D deficiency. Menopause Review/Przegląd Menopauzalny 14(2) 2015 2015; 14(2): 75–81. 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18:04:57","extension":"html","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":83668,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8642238/v1/517baf0418790f9c6b3acffa.html"},{"id":100821877,"identity":"c033108a-4d79-47c8-bb8a-7d9d97fea964","added_by":"auto","created_at":"2026-01-21 18:04:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":18393,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 4.1: Trend of vitamin D deficiency cases published from 1995 to 2019 (n= 218174)\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8642238/v1/97088ea9d0658d443951ac49.png"},{"id":100821887,"identity":"ff760115-020f-4fdd-b522-4c5c65127923","added_by":"auto","created_at":"2026-01-21 18:04:57","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":247724,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 4-2: Geographical distribution of the study setting with vitamin D deficiency prevalence data.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8642238/v1/7091d4a8d7aedbd7edf0cf19.png"},{"id":100821886,"identity":"85ddd1ce-598c-4d96-9c58-fb7faf41a0ee","added_by":"auto","created_at":"2026-01-21 18:04:56","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":251776,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 4-3: Epidemiological distribution of the prevalence (%) of vitamin D deficiency worldwide.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8642238/v1/d9a792a6e5c3505111ee993e.png"},{"id":100821885,"identity":"e13e496a-92e7-4f71-b01d-4ec9b5717a81","added_by":"auto","created_at":"2026-01-21 18:04:56","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":226989,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 4-4: Vitamin D deficiency predictive risk map\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8642238/v1/378246b91522d0eedec78a32.png"},{"id":100949813,"identity":"7ac110c0-b80e-4e9b-a03c-edb960bace7a","added_by":"auto","created_at":"2026-01-23 07:05:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1489565,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8642238/v1/8ad5195d-9d30-4b39-933c-fbf33148e1ca.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eTemporal and Spatial Distribution of vitamin D Deficiency worldwide as 2019- Systematic review \u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eVitamin D is a fat-soluble vitamin which is mostly synthesized under the skin by the influence of Ultra Violet (UV) sunlight. Its importance is well known in bone metabolism, calcium and phosphorus homeostasis. However, recent evidence demonstrates its roles as a transcription factor, immune modulator and gene regulator; which indicate its crucial clinical implications. Studies associated Vitamin D deficiency to various health consequences including bone diseases, diabetes mellitus, obesity, metabolic syndrome, cardiovascular morbidity, multiple sclerosis, rheumatoid arthritis, cognitive dysfunctions and various types of cancers [1\u0026ndash;3]. Various studies related low vitamin D levels to adverse maternal and neonatal outcomes [4\u0026ndash;5]. Moreover, low Vitamin D levels are associated with various mortality causes [6]. Vitamin D not only has a considerable role in modifying the immune system and regulating cell proliferation and cell differentiation [7, 8], but also has a role in reducing mortality. Vitamin D supplementation were found to reduce deaths due to Cancer [9].\u003c/p\u003e \u003cp\u003eLevel of serum vitamin D is affected by many factors, some are well established and others are still under investigation. Sun exposure is the most vital influencer. Nevertheless, time of day, time of year and latitude determine the effectiveness of sun exposure; incident Ultra Violet radiation levels reach a maximum at mid-day in the summer. Below a latitude of approximately 35\u0026deg; North and its adequate for vitamin D3 synthesis all the year except in winter in some parts of the world [10]. A study included rural Chinese twins concluded that male gender, summer and physical activity increases level of vitamin D significantly [11]. An ecological study conducted in Calgary, Canada, found that there was a significant higher levels in the inner city neighborhood when compared to far north and north-east areas which had lower levels of vitamin D levels. Moreover, regarding age and gender, curiously they found that vitamin D levels reaches it is lowest point at age 35 years then it increased to reaches the maximum at age\u0026thinsp;\u0026gt;\u0026thinsp;60 with females possess higher levels than males [12] ; children and elderly are defined as the age group at risk [13]. Generally, increased body mass index (BMI), low socioeconomic status and tobacco use were found inversely related to level of vitamin D (14, 15, 16)\u003c/p\u003e \u003cp\u003eThere is no universal definition of vitamin D deficiency; Institute of Medicine (IOM) has defined a serum 25(OH) D concentration of 30nmol/L as the threshold below which clinical vitamin D deficiency may occur [17,18]. Another definition is a serum 25-hydroxy vitamin D (25-OH D) concentration less than 20 ng/ml, while vitamin D insufficiency was defined as a 25-(OH)-D concentration less than 30 ng/ml[19].\u003c/p\u003e \u003cp\u003eReports demonstrated that vitamin D insufficiency prevailed world-wide across populations. In the United States, using the data of National Health and Nutrition Examination Survey (NHANES), a study observed vitamin D insufficiency in 39.92% of the study population [20]. In Europe, a pooled estimate showed that 13% had serum vitamin D deficiency (\u0026lt;\u0026thinsp;30ng/ml) on average in the year [21]. In Asian countries, a prevalence of vitamin D deficiency of 84.3% was reported by a study in asymptomatic adult population [22]. In the Middle-East, in spite of the sunlight most of the year, vitamin D levels among the general population was still inadequate, particularly in young adult females. This is might be related to a decreased exposure to sun light in this group of population [23]. A systemic review claimed a prevalence of 30 and 90% in the Middle East [24]. Another review on \u0026gt;\u0026thinsp;40 observational studies in Middle East and North Africa revealed that the prevalence of low vitamin D in adults ranged from 44% to 96% with a mean vitamin D level 25(OH) D ranging between 11 and 20ng/ml [25]. In Africa, vitamin D deficiency is a threat as well; the pooled prevalence of low vitamin D status (less than 30 nmol/L) was 18\u0026middot;46% (95% CI 10\u0026middot;66\u0026ndash;27\u0026middot;78) identified in a Meta-analysis [26].\u003c/p\u003e \u003cp\u003eVitamin D deficiency is becoming a global health issue; lack of adequate data cripples the effort directed to tackle this problem. This systemic review aims to identify and analyse previous studies on prevalence of vitamin D deficiency among healthy adults world-wide.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eA systematic review was implemented during the period from October 1st to December 15th, 2019.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData sources and searches:\u003c/h3\u003e\n\u003cp\u003eThis systematic review was done using PubMed as search engine, restricted to studies between (1995\u0026ndash;2019). A comprehensive assessment of the articles accessed on the electronic database was carried out using the keywords \u0026ldquo;vitamin D\u0026rdquo;, \u0026ldquo;deficiency\u0026rdquo;, \u0026ldquo;prevalence\u0026rdquo; and \u0026ldquo;adults\u0026rdquo; yielding 4663 articles. Unaccusable articles were downloaded using SCI-Hub web site.\u003c/p\u003e\n\u003ch3\u003eStudy selection:\u003c/h3\u003e\n\u003cp\u003eIn this review; Vitamin D levels below 75 nmol/l (30 ngm/ml) was classified as deficient. We included studies carried out among healthy adults\u0026thinsp;\u0026ge;\u0026thinsp;18 year-old and in which the prevalence and the sample size were obtainable. Any study with participants below 18 years, patients with co-morbidities, patients on vitamin D supplements and pregnant ladies was excluded.\u003c/p\u003e\n\u003ch3\u003eData extraction:\u003c/h3\u003e\n\u003cp\u003eThe 4663 selected articles were firstly distributed equally among the eight members of the research team. Then a total of 144 articles which fulfill the inclusion criteria were extracted using MS Excel tables. Those tables included the following data: The title, authors, year of publication, journal, sample size, number of cases, prevalence, upper and lower confidence intervals. After that these articles were redistributed according to their respected continent.\u003c/p\u003e\n\u003ch3\u003eData synthesis and analysis:\u003c/h3\u003e\n\u003cp\u003eMS Excel was used to calculate the upper and lower confidence interval using the prevalence and sample size. Longitude and latitude of each study setting were identified using Google Earth Professional. The yielded data were then transferred to the statistical package for social sciences (SPSS, Ver.23) to generate frequency tables and trend graph. Data projection was done through Arc GIS 10.3 to generate epidemiological map and risk map using Kriging method which is a technique based on estimating the distance and degree of variation between known data points when estimating values in unknown areas.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eNumber of cases and estimated prevalence by countries\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003eFrom 1995 to 2019, a total of 218,174 cases of vitamin D deficiency on a total sample of 357,089. Reported by 144 articles from 46 countries. This representing an average prevalence of 51.3% (95% [CI: (48.4\u003cb\u003e\u0026ndash;\u003c/b\u003e58.6)] of vitamin D deficiency worldwide (Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e4.1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Africa five countries were included with a total number of cases of vitamin D deficiency of 881 out of 1436 cases, with an average prevalence of 65% (95%[CI: 58.5\u0026ndash;71.6]). Of the five countries Libya is having the highest prevalence of 77.9% (95% [CI: 73.7\u0026ndash;82.0]) in contrast to Tunisia which having the lowest prevalence of 47.6% (95% [CI: 42.6\u0026ndash;52.6]). Elsewhere in Africa the prevalence were 63% in Egypt, 66.7% in Nigeria and 70% in morocco.\u003c/p\u003e \u003cp\u003eIn Middle East eight countries were included with a total number of cases of vitamin D deficiency of 83657 out of 115394 cases, with an average prevalence of 63.1% (95% [CI: 57.2\u0026ndash;69.1]). The highest prevalence was reported in Israel 92.5% (95% [CI: 72.5-112.6]). In contradiction to UAE which showed the lowest prevalence of 19.7% (95% [CI: 15.3\u0026ndash;24.1]).\u003c/p\u003e \u003cp\u003eIn Europe studies conducted in sixteen countries with a total number of cases of vitamin D deficiency of 65947 out of 92240 study population with an average prevalence of 56.1% (95% [CI: 52.3\u0026ndash;59.8]). Turkey reported the highest prevalence of vitamin D deficiency of 87.3% (95% [CI: 85.1\u0026ndash;89.3]) followed by France and Belgium with prevalence of 86.4 (95% [CI: 83.2\u0026ndash;89.5]) and 86.2% (95% [CI: 83.8\u0026ndash;88.3]) respectively. However the lowest prevalence was in Austrian 6.9% (95% [CI: 3.5\u0026ndash;10.3]) followed by Greece 10.7% (95% [CI: 7.8\u0026ndash;13.7]) and Netherland 34% (95% [CI: 31.4\u0026ndash;36.6]).\u003c/p\u003e \u003cp\u003eIn Asia a total of ten countries were included with a total number of cases of vitamin D deficiency 30992 out of 46932 study sample size with an average prevalence of 52.1% (95%[CI:46.9\u0026ndash;57.3]). The highest prevalence was reported in Malaysia of 78.5% (95% [CI: 74.9\u0026ndash;82.1]) followed by South Korea, Pakistan and China with prevalence of 77.9% (95% [CI: 75.5\u0026ndash;80.3]), 61.1% (95% [CI: 57-66.5]) and 60% (95%[CI:]). (95% [CI: 57.4\u0026ndash;62.7]) respectively. While the lowest prevalence was observed in Thailand 32% (95% [CI: 27.7\u0026ndash;36.3]).\u003c/p\u003e \u003cp\u003eIn South America a total of six countries were included with a total number of cases of vitamin D deficiency 3322 out of 9588 total sample size with an average prevalence of 53.5% (95%[CI:48.4\u0026ndash;58.6]). The highest prevalence was reported in Argentina of 87.8% (95% [CI: 81.3\u0026ndash;94.2]) contemporary to Puerto Rico which showed the lowest prevalence of 7.1% (95% [CI: 3.6\u0026ndash;10.6]).\u003c/p\u003e \u003cp\u003eNorth America and Australia showed the lowest prevalence of vitamin D deficiency worldwide of 23% (95% [CI: 20.7\u0026ndash;24.5]) and 46.2% (95% [CI: 42.3\u0026ndash;50]).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4.1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNumber of cases and estimated prevalence by countries:\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLOCATION\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCOUNTRY\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSAMPLE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCASE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePREV\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e95% CI for prevalence\u003c/p\u003e \u003cp\u003eLCI UCI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eAfrica\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e66.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e53.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e79.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEgypt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e354\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e223\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e63.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e58.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e68.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLibya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e388\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e302\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e77.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e73.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e82.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMorocco\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e254\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e178\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e64.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e75.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTunisia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e389\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e52.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1436\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e881\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e65.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e58.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e71.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"9\" rowspan=\"10\"\u003e \u003cp\u003e\u003cb\u003eAsia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBangladesh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e394\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e42.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChina\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33755\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e57.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e62.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1287\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e44.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e52.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndonesia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e46.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJapan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1863\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e939\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e46.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e39.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e53.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMalaysia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1046\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e779\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e78.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e74.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e82.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePakistan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4953\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2670\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e61.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e57.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e66.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSouth Korea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e877\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e77.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e75.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e80.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTaiwan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e44.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e36.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e51.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThailand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e446\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e143\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e36.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16932\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30992\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e52.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e46.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e57.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eAustralia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAustralia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14185\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5143\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e52.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e48.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e57.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNew Zealand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2853\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1339\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e39.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e36.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e42.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17038\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6482\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e46.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"15\" rowspan=\"16\"\u003e \u003cp\u003e\u003cb\u003eEurope\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGermany\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9972\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5416\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e41.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e35.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e46.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorway\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1032\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e531\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e34.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e41.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1811\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1503\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e83.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e81.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e84.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAustrian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e215\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBelgium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e915\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e787\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e86.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e83.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e88.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1091\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e900\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e86.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e83.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e89.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGreece\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1306\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIreland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7633\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1707\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e33.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e41.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eItaly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e427\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e351\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e82.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e78.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e85.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNetherlands\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3740\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1162\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e36.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7839\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6039\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e67.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e63.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e71.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePortugal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e198\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e84.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e79.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e89.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSlovenia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e578\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e237\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e41.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e37.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e45.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2769\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e743\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e56.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTurkey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36058\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e34008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e87.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e85.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e89.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnited Kingdom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16656\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12320\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e62.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e57.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e65.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e92240\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e65947\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e56.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e52.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e59.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003e\u003cb\u003eMiddle East\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQatar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e102342\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e73072\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e71.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e71.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e71.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSaudi Arabia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7809\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e74.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e71.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e76.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIran\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2635\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e79.075\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e74.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBahrain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e247\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e53.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIsrael\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e92.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e86.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e98.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJordan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e381\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e212\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e55.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e50.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e60.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUAE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e315\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e24.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e115394\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e83657\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e63.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e57.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e69.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eNorth America\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e856\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64270\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26037\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e33.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e40.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e74661\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26893\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e24.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u003cb\u003eSouth America\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEcuador\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2374\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1610\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e67.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e65.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e69.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMexico\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e585\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e255\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e43.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e39.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e47.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePuerto Rico\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4188\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eArgentina\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e383\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e334\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e87.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e81.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e94.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBrazil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1634\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e985\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e62.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e56.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e68.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTobago\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e424\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e31.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9588\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3322\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e53.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e48.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e58.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003e4.2. Trend of vitamin D deficiency cases over years.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThere were limited number of publications of vitamin D deficiency till 2004 in which the number of publications rose dramatically until it reached a peak in 2007. Thereafter it fluctuated until it rose steadily from 2017 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e4.1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003e4.3. Geographical distribution of the study setting\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eOne hundred forty four articles from forty six countries were used to develop the geographical distribution of study setting. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u0026thinsp;\u0026minus;\u0026thinsp;2.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u0026thinsp;\u003cb\u003e\u0026minus;\u0026thinsp;2: Geographical distribution of the study setting with vitamin D deficiency prevalence data.\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003e4.4. Epidemiological distribution of the prevalence (%) of vitamin D deficiency worldwide\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eThe epidemiological map (Fig.\u0026nbsp;4.3.) of the prevalence of vitamin D deficiency worldwide delineate four levels of prevalence: the very high prevalence areas (70\u0026ndash;100%) represented in red color, high prevalence (50-69.9%) in pink, intermediate prevalence (5-49.9%) in green and low prevalence (0.2\u0026ndash;4.9%) in violet color. The highest prevalence was found in a belt extended from Japan, China, India, Middle East, Europe, and North Africa. There is also some foci in eastern part of Australia, South and North America.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003e4.5. Vitamin D deficiency risk map\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eThe predictive risk map (Fig.\u0026nbsp;\u0026lt;link rid=\"fig2\"\u0026gt;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e4\u0026lt;/link\u0026gt;\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e4\u003c/span\u003e ) enables to delineate three levels of risk: high risk (prevalence\u0026thinsp;\u0026gt;\u0026thinsp;72.9%) areas represented in plain orange and red color, an intermediate risk areas (prevalence 58\u0026ndash; 72.9) delineated in yellow to orange, and a low risk areas (prevalence 0.2\u0026ndash;57.9) delineated in blue to a mix yellow blow.\u003c/p\u003e \u003cp\u003eThe risk of vitamin D deficiency was predicted to be highest in a belt including Europe, North Africa, western Asia (KSA, Iraq, Yemen and Kazakhstan) and some foci in western part of North America and southern part of South America (Chile and Argentina).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThroughout the studies, we noticed there was a high degree of variability in the prevalence of vitamin D deficiency worldwide, considering the cutoff value to be a serum 25-hydroxy D (25-OH D) concentration of less than 30 ng/ml. This variation can be illustrated by the noticeably high prevalence of vitamin D deficiency in areas such as Africa and the Middle East in contradiction to areas with lower prevalence like North America. This was a particularly unexpected feature seeing as both Africa and the Middle East witness sun exposure most of the year around and the number of cases were expected to be much lower.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eNorth and South America:\u003c/h2\u003e \u003cp\u003eSouthern America reported prevalence of 53,5% of vitamin D deficiency with comparative results of 49,36% from previous studies[ 31 ] ,in contrast to Northern America in which 23% of the study population suffered from its deficiency which is almost less than half the 39.92% yielded by the National Health and Nutrition Examination Survey (NHANES) [5]. In both studies, paediatrics were excluded from the target population. However, NHANES also excluded housebound candidates and those living in residential institutions while our study did not.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eAsia:\u003c/h2\u003e \u003cp\u003eIn Asian countries, we found there was a prevalence of 52.1% of vitamin D deficiency which is considerably less than the 84.3% reported by a study in the asymptomatic adult population [12].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eAfrica and the Middle East:\u003c/h2\u003e \u003cp\u003eAfrica and the Middle East yielded the highest level of vitamin D deficiency, despite sunlight most of the year with 65 and 63.1% respectively. In comparison to similar studies five from Iran, one from Egypt, one from occupied Palestine/Israel and one from Lebanon with prevalence ranging from 44 to96%. [28]. this is can be explained by Seasonal variations of vitamin D with low level in winter, working indoor and using sunblock due to sunny climate especially in gulf states and covering parts of the body (Hijab) is both a cultural and religious act among females in that areas. Moreover genetic factors, namely polymorphisms in key genes of the vitamin D pathway, modulate vitamin D status in western populations and possibly the Middle East [29].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eEurope\u003c/span\u003e:\u003c/h2\u003e \u003cp\u003eMeanwhile, as expected, Europe revealed vitamin D deficiency prevalence of (56.5%) which can be attributed to the little amount of sunlight exposure throughout the year. Nevertheless better vitamin D level is reported in Nordic than in Mediterranean countries despite high altitude and less sunshine, which can be explained by high intake of cod, cod liver and cod liver oil in Norway and Sweden .[32]\u003c/p\u003e \u003cp\u003eHowever the role of sun light is vital for vitamin D synthesis as well for general health as reflected by a study of Australian dermatologist in the summer revealed that their use of a sunscreen resulted in 87% of them being vitamin D deficient at the end of the summer [27]\u003c/p\u003e \u003cp\u003ePrevalence of vitamin D deficiency varied even among countries within the same continent or that share similar conditions like sunlight exposure and diet ; this illustrated in the difference between Indonesia and Malaysia (35.1%,78.5% ) respectively .these variations shed light on the contribution of other factors such as genetic variation ; recent studies defined single nucleotide polymorphisms that affect level of vitamin D ; some of them were widely among young Canadian, white women Hispanics and African Americans, Dutch with chronic obstructive pulmonary disease, British, Han Chinese and Poles (35).\u003c/p\u003e \u003cp\u003eThe limitation of our study is the limited access for publication as we just used PubMed as a search engine and SCI HUB web-site to open some papers. It is important to note that, data on children and pregnant ladies were not included in this review.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eInternational\u003c/span\u003e:\u003c/h2\u003e \u003cp\u003eThe results conclude that vitamin D deficiency is an international public health problem and the pre-made assumptions that sunny areas do not suffer from this are false and misleading. Moreover, \u003cb\u003ev\u003c/b\u003eitamin D deficiency may present with full-blown symptoms or may be covert which means that the aforementioned populations with less risk factors shouldn\u0026rsquo;t be neglected in the screening and management plans since clinical presentation may be a very late feature of a long overdue diagnosis.\u003c/p\u003e \u003c/div\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eBeata Matyjaszek-Matuszek, Monika Lenart-Lipińska, Ewa Woźniakowska Prz Menopauzalny. Clinical implications of vitamin D deficiency. Menopause Review/Przegląd Menopauzalny 14(2) 2015 2015; 14(2): 75\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003e\u003cem\u003eMichael F Holick and Tai C Chen.\u003c/em\u003e Vitamin D deficiency: a worldwide problem with health consequences \u003cem\u003eAm J Clin Nutr\u003c/em\u003e 2008;87(suppl):1080S\u0026ndash;6S.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eParva N R, Tadepalli S, Singh P, et al. Prevalence of Vitamin D Deficiency and Associated Risk Factors in the US Population (2011\u0026ndash;2012). Cureus 2018 Jun 5; 10(6): e2741.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBaca KM, Simhan HN, Platt RW, Bodnar LM. Low maternal 25-hydroxyvitamin D concentration increases the risk of severe and mild preeclampsia.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMiliku K, Vinkhuyzen A, Blanken LM, McGrath JJ, Eyles DW, Burne TH, et al. Maternal vitamin D concentrations during pregnancy, fetal growth patterns, and risks of adverse birth outcomes. Am J Clin Nutr. 2016;103(6):1514\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003e25-Hydroxyvitamin D Levels and the Risk of Mortality in the General Population \u003cem\u003eMichal L. Melamed et al\u003c/em\u003e ARCH INTERN MED/ VOL 168 (NO. 15), AUG 11/25, 2008\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBellavia D, Costa V, De Luca A, Maglio M, Pagani S, Fini M, et al. Vitamin D Level Between Calcium-Phosphorus Homeostasis and Immune System: New Perspective in Osteoporosis. Curr Osteoporos Rep. 2016.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eCortes M, Chen MJ, Stachura DL, Liu SY, Kwan W, Wright F, et al. Developmental Vitamin D Availability Impacts Hematopoietic Stem Cell Production. Cell Rep. 2016;17(2):458\u0026ndash;468.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eZhang, Y., Fang, F., Tang, J., Jia, L., Feng, Y., Xu, P., \u0026amp; Faramand, A. (2019). \u003cem\u003eAssociation between vitamin D supplementation and mortality: systematic review and meta-analysis. BMJ, l4673.\u003c/em\u003edoi:10.1136/bmj.l4673\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eWebb AR, Engelsen O. Ultraviolet exposure scenarios: risks of erythema from recommendations on cutaneous vitamin D synthesis. Adv Exp Med Biol 2008; 624: 72\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eArguelles, L. M., Langman, C. B., Ariza, A. J., Ali, F. N., Dilley, K., Price, H., \u0026hellip; Wang, X. (2009). \u003cem\u003eHeritability and Environmental Factors Affecting Vitamin D Status in Rural Chinese Adolescent Twins. The Journal of Clinical Endocrinology \u0026amp; Metabolism, 94(9), 3273\u0026ndash;3281.\u003c/em\u003e doi:10.1210/jc.2008-1532\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eNaugler C, et al. Association of vitamin D status with socio-demographic factors in Calgary, Alberta: an ecological study using Census Canada data. BMC Public Health. 2013; 13:316.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSchleicher RL, Sternberg MR, Looker AC, Yetley EA, Lacher DA, Sempos CT, Taylor CL, et al. National estimates of serum total 25-Hydroxyvitamin D and metabolite concentrations measured by liquid chromatography\u0026ndash;tandem mass spectrometry in the US population during 2007\u0026ndash;2010 1\u0026ndash;4. J Nutr. 2016;146:1051\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eCheng S, Massaro JM, Fox CS, Larson MG, Keyes MJ, McCabe EL, Robins SJ, O\u0026apos;Donnell CJ, Hoffmann U, Jacques PF, et al. Adiposity, cardiometabolic risk, and vitamin D status: the Framingham Heart Study. Diabetes. 2010;59(1):242\u0026ndash;8\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eJaaskelainen T, Knekt P, Marniemi J, Sares-Jaske L, Mannisto S, Heliovaara M, Jarvinen R. Vitamin D status is associated with sociodemographic factors, lifestyle and metabolic health. Eur J Nutr. 2013;52(2):513\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKassi EN, Stavropoulos S, Kokkoris P, Galanos A, Moutsatsou P, Dimas C, Papatheodorou A, Zafeiris C, G L. Smoking is a significant determinant of low serum vitamin D in young and middle-aged healthy males. Hormones(Athens). 2014;14(2):245\u0026ndash;50\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eInstitute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. Washington DC: The National Academies Press, 2011.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003e\u0026minus;\u0026thinsp;4 Ross AC, Manson JE, Abrams SA, Aloia JF, Brannon PM, Clinton SK, Durazo-Arvizu RA, Gallagher JC, Gallo RL, Jones G et al. The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. Journal of Clinical Endocrinology and Metabolism 2011 96 53\u0026ndash;58. (https://doi.org/10.1210/jc.2010-2704)\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHolick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, et al.; Endocrine Society. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011; 96(7):1911\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eParva NR, Tadepalli S, Singh P, Qian A, Joshi R, Kandala H, Nookala VK, Cheriyath P. Prevalence of Vitamin D Deficiency and Associated Risk Factors in the US Population (2011\u0026ndash;2012). Cureus. 2018 Jun 5;10(6):e2741. doi: 10.7759/cureus.2741. PMID: 30087817; PMCID: PMC6075634.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eCashman KD, Dowling KG, Skrabakova Z, Gonzalez-Gross M, Valtuena J, De Henauw S, Moreno L, Damsgaard CT, Michaelsen KF, Molgaard C et al. Vitamin D deficiency in Europe: pandemic? American Journal of Clinical Nutrition 2016 103 1033\u0026ndash;1044. (https://doi.org/10.3945/ajcn.115.120873)\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003e12- Adil Sheikh, Zeb Saeed, Syed Ali Danial Jafri, Iffat Yazdani, Syed Ather Hussain2 Vitamin D Levels in Asymptomatic Adults-A Population. Survey in Karachi, Pakistan. Plos ONE March 2012 | Volume 7 | Issue 3 | e33452\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003e\u003cem\u003eAlsuwaida et al.\u003c/em\u003e Prevalence of vitamin D defciency in Saudi adults \u003cem\u003eSaudi Med J 2013; Vol. 34 (8): 814\u0026ndash;818\u003c/em\u003e .\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBassil D, Rahme M, Hoteit M \u0026amp; El-Hajj Fuleihan Gel-H. Hypovitaminosis D in the Middle East and North Africa: prevalence, risk factors and impact on outcomes. Dermato-Endocrinology 2013 5 274\u0026ndash;298. (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ehttps://doi.org/10.4161/derm.25111).\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMarlene Chakhtoura⁎, Maya Rahme, Nariman Chamoun, Ghada El-Hajj Fuleihan. 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Lancet 2010. 376(9736) 180\u0026ndash;188.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBrustad M, Sandanger T, Aksnes L, et al. Vitamin D status in arural population of northen Norway with high fish liver consumption .public health Nutr 2004;7(6)783-9.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eNatasja Van Schoor, Paul Lips. Global overview of vitamin D status, Endocrinol Metab Clin N Am 46 (2017) 845\u0026ndash;870.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHossein-nezhad A, Holick MF (2013) vitamin D for health: a global perspective. Mayo Clin Proc 88(7):720\u0026ndash;755.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eIOM (Institute of medicine) (2011) Dietary reference intakes for calcium and vitamin D. Committee to review dietary reference intakes for calcium and vitamin D. The National Academies Press Institute of Medicine, Washington, DC.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHolic MF et al, evaluation,treatment and prevention of vitamin D deficiency: an endocrine society clinical practice guidline. J Clin Endocrinol Metab (2011), 96(7):1911\u0026ndash;1930.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAbboud M, Rybchyn MS, Rizk R, Fraser DR, Mason RS, Sunlight exposure is just one of the factors which influence vitamin D status. Photochem Photobiol Sci. 2017 Mar 16;16(3):302\u0026ndash;313.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University of Medical Sciences and Technology","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"vitaminD deficiency, prevelenace worldwide, geospatial analysis, systematic review","lastPublishedDoi":"10.21203/rs.3.rs-8642238/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8642238/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eVitamin D deficiency is a growing global public health concern with important skeletal and extra-skeletal health consequences. Although sunlight exposure is the primary source of vitamin D, deficiency remains prevalent even in regions with abundant sunshine. This systematic review aimed to describe the temporal and spatial distribution of vitamin D deficiency worldwide as at 2019 using epidemiological and geospatial approaches.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eA systematic review of studies published between 1995 and 2019 was conducted using PubMed. Eligible studies included healthy adults aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years and reported the prevalence of vitamin D deficiency, defined as serum 25-hydroxyvitamin D levels\u0026thinsp;\u0026lt;\u0026thinsp;30 ng/mL (75 nmol/L). Studies involving children, pregnant women, individuals with comorbidities, or vitamin D supplementation were excluded. Data were extracted on sample size, number of deficiency cases, and prevalence with confidence intervals. Statistical analysis was performed using SPSS, while geographic distribution and predictive risk mapping were generated using ArcGIS 10.3 employing kriging interpolation.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eA total of 144 studies from 46 countries were included, encompassing 357,089 participants, of whom 218,174 were vitamin D deficient, resulting in an overall prevalence of 51.3% (95% CI: 48.4\u0026ndash;58.6). The highest prevalence was observed in Africa (65%) and the Middle East (63.1%), followed by Europe (56.1%), South America (53.5%), Asia (52.1%), and Australia (46.2%). North America had the lowest prevalence (23%). Geospatial analysis identified a high-risk belt extending across Europe, North Africa, Western Asia, and parts of South America. Publication trends increased markedly after 2004.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eVitamin D deficiency is highly prevalent worldwide, including in sun-rich regions. Geospatial mapping highlights critical high-risk areas, emphasizing the need for targeted screening, prevention strategies, and public health interventions globally\u003c/p\u003e","manuscriptTitle":"Temporal and Spatial Distribution of vitamin D Deficiency worldwide as 2019- Systematic review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-21 18:04:44","doi":"10.21203/rs.3.rs-8642238/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"56542617-a3cf-4cce-8f09-a2c12240e703","owner":[],"postedDate":"January 21st, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":61438339,"name":"Endocrinology \u0026 Metabolism"}],"tags":[],"updatedAt":"2026-01-21T18:04:45+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-21 18:04:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8642238","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8642238","identity":"rs-8642238","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}