Assessment of vitamin D status in patients attending a private clinic, Boorama, Somaliland, 2020-2024

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Yusuf, Sunday Adebisi Adebisi, Farhan Abdisamad Osman This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8910937/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract This study assesses the vitamin D status and associated demographic factors among patients attending a private clinic in Boorama, Somaliland, from 2020 to 2024. Vitamin D deficiency is a global health issue affecting over a billion people, and despite abundant sunshine in regions like sub-Saharan Africa, deficiency remains prevalent. In Somaliland, data on vitamin D status is scarce. A retrospective cross-sectional study was conducted using the medical records of 200 patients from Geelle Polyclinics. Serum 25-hydroxyvitamin D [25(OH)D] levels were categorized as deficient, insufficient, or normal. The study found a high prevalence of suboptimal vitamin D, with 76% of patients being insufficient and 11.5% deficient. Statistically significant associations were found between vitamin D status and age, gender, and geographical location. These findings indicate a significant public health concern in a sun-rich region and highlight the need for local public health interventions such as awareness programs, food fortification, and targeted supplementation. vitamin D deficiency hypovitaminosis D Somaliland Boorama 25-hydroxyvitamin D public health Figures Figure 1 Introduction Vitamin D, a crucial fat-soluble prohormone, plays a vital role in calcium homeostasis, bone metabolism, and the modulation of the immune system ( 4 , 23 ). Its primary source is endogenous synthesis in the skin through exposure to solar ultraviolet B (UVB) radiation, with minor contributions from dietary sources ( 19 ). The most reliable indicator of an individual's vitamin D status is the serum concentration of 25-hydroxyvitamin D [25(OH)D] ( 21 ). Globally, vitamin D deficiency has reached pandemic proportions, affecting an estimated one billion people across all age groups and ethnicities ( 1 , 10 ). This public health problem is not confined to regions with limited sunlight; high prevalence rates are increasingly reported in sun-rich areas like the Middle East, South Asia, and Africa ( 17 , 18 ). In many of these regions, cultural practices such as extensive skin covering, lifestyle changes leading to less time outdoors, increased skin pigmentation which reduces vitamin D synthesis, and dietary habits contribute to this paradox ( 3 , 14 ). In sub-Saharan Africa, the burden of vitamin D deficiency is significant but often under-documented ( 13 , 22 ). Studies from neighboring countries like Ethiopia and Kenya report that over 80% of their populations have suboptimal vitamin D levels ( 5 , 16 ). This deficiency is linked to an increased risk of rickets in children, osteomalacia in adults, and a host of non-skeletal diseases, including cardiovascular conditions like hypertension, diabetes, and infectious diseases ( 2 , 15 , 20 , 24 ). Somaliland, located in the Horn of Africa, receives abundant sunshine throughout the year. However, anecdotal evidence from clinical practice in cities like Boorama suggests a high incidence of symptoms related to hypovitaminosis D, such as musculoskeletal pain. Despite this, there is a significant lack of empirical data on the prevalence and determinants of vitamin D status in the Somali population. Limited studies have estimated deficiency rates in Somalia to be over 36%, but comprehensive, localized data remains scarce ( 6 ). Understanding the magnitude of this issue is the first step toward developing effective public health strategies, including awareness campaigns, food fortification, and targeted supplementation. A recent study in the same region on risk factors for Helicobacter pylori infection also emphasized the need for local data to inform public health strategies ( 22 ). This study, therefore, aimed to provide the first systematic assessment of vitamin D status among patients attending a private clinic in Boorama, Somaliland, over a five-year period (2020–2024). The objectives were to determine the prevalence of vitamin D deficiency and insufficiency and to investigate its association with key demographic factors, including age, gender, and geographical location. Literature review Vitamin D, often referred to as the "sunshine vitamin," is a group of fat-soluble secosteroids essential for human health. The two major forms are vitamin D2 (ergocalciferol) and vitamin D3 (cholecalciferol). Vitamin D3 is synthesized in the skin upon exposure to ultraviolet B (UVB) radiation from sunlight, which provides the majority of the body's requirement ( 19 ). Dietary sources, though less significant for most people, include fatty fish (like salmon, mackerel, and tuna), fish liver oils, and fortified foods such as milk, cereals, and orange juice. Both forms of vitamin D from synthesis and diet are biologically inert and must undergo two hydroxylation steps in the body to become active. The first occurs in the liver to form 25-hydroxyvitamin D [25(OH)D], the main circulating form and the best indicator of vitamin D stores ( 21 , 28 ). The second hydroxylation occurs primarily in the kidneys to form the physiologically active hormone 1,25-dihydroxyvitamin D (calcitriol). The classical function of vitamin D is to regulate calcium and phosphorus homeostasis, which is crucial for the development and maintenance of healthy bones ( 4 ). It enhances the intestinal absorption of calcium and phosphorus and works in concert with parathyroid hormone to control bone mineralization ( 26 ). Severe vitamin D deficiency can lead to rickets in children—a condition characterized by soft and weak bones, leading to skeletal deformities—and osteomalacia in adults, which causes bone pain and muscle weakness. Beyond its role in bone health, research over the past few decades has uncovered a wide range of non-skeletal functions of vitamin D. Receptors for vitamin D are found in numerous tissues and organs, including the brain, heart, skin, and immune cells, suggesting its involvement in a variety of physiological processes ( 2 ). Evidence suggests that optimal vitamin D levels are important for a properly functioning immune system, helping to protect against infections and modulate the immune response ( 23 , 24 ). Low vitamin D status has been associated with an increased risk of autoimmune diseases, cardiovascular diseases, certain types of cancer, and type 2 diabetes ( 15 ). Despite the abundance of sunlight in many parts of the world, vitamin D deficiency is a global health pandemic ( 1 , 25 ). This is particularly paradoxical in regions with high sun exposure, such as the Middle East, South Asia, and Africa ( 18 ). Several factors contribute to this phenomenon. Lifestyle changes, including increased urbanization and indoor occupations, have led to reduced time spent outdoors. Cultural and religious practices that involve covering most of the skin when outdoors significantly limit UVB exposure and, consequently, vitamin D synthesis ( 8 ). Skin pigmentation also plays a crucial role; melanin acts as a natural sunblock, and individuals with darker skin require longer sun exposure to produce the same amount of vitamin D as those with lighter skin ( 3 ). Other risk factors for deficiency include aging (as the skin's ability to synthesize vitamin D decreases with age), obesity (as vitamin D is sequestered in adipose tissue), and certain medical conditions that affect fat absorption ( 27 ). In Sub-Saharan Africa, a region characterized by ample sunlight and predominantly dark-skinned populations, vitamin D deficiency is increasingly being recognized as a significant public health issue ( 13 ). Studies from various parts of the continent, including West Africa, have reported high prevalence rates of hypovitaminosis D across different age groups ( 22 ). In the Horn of Africa, where Somaliland is located, there is a general scarcity of data on vitamin D status. The traditional lifestyle, dietary habits, and genetic factors of the Somali population may all influence their vitamin D levels. Given the potential health consequences of vitamin D deficiency, there is an urgent need to assess the extent of the problem in this specific population to inform targeted public health strategies. Materials and Methods Study Design and Setting A retrospective, cross-sectional study was conducted by reviewing existing medical records at Geelle Polyclinics, a private healthcare facility in Boorama, the capital city of the Awdal region in Somaliland. The clinic serves a diverse urban population. Study Period and Population The study included records of patients who had their serum 25(OH)D levels measured between January 2020 and January 2024. The target population comprised all patients registered at the clinic during this period. Sample Size and Sampling The final sample consisted of 200 patient records that met the inclusion criteria. This sample size was determined based on the availability of complete records and provides a sufficient basis for preliminary assessment in this previously unstudied population Inclusion and Exclusion Criteria Records were included if they contained complete data on serum 25(OH)D levels, age, gender, and geographical location within Boorama. Records with missing data for any of these key variables were excluded from the analysis. Data Collection Data was extracted from the clinic's laboratory information system and patient files using a structured data collection form. The variables collected were: Demographic Data: Age (categorized into groups: ≤20, 21–30, 31–40, 41–50, 51–60, ≥ 61 years), gender (male, female), geographical location (residential area within Boorama), Test of Year (2020, 2021, 2022, 2023 and 2024) and Laboratory Analysis: Serum 25(OH)D levels were measured using a chemiluminescence immunoassay (CLIA) method on an automated analyzer, a standard and widely used technique for assessing vitamin D status ( 9 ). Vitamin D status was categorized based on the Endocrine Society clinical practice guidelines ( 11 ) as follows: Deficiency: <10 ng/mL, Insufficiency: 10–29.9 ng/mL And Normal/Sufficient: ≥30 ng/mL. Statistical Analysis Data were entered into Microsoft Excel 2016 and subsequently exported to the Statistical Package for the Social Sciences (SPSS) version 25.0 for analysis. This study presents the findings from the analysis of 200 patient records assessing Vitamin D levels. The results are organized into three main sections: descriptive statistics of the study population, the overall prevalence of Vitamin D status, and an analysis of the factors associated with Vitamin D levels. Descriptive Characteristics of the Study Participants A total of 200 patient records were included in the analysis. The demographic characteristics are summarized in Table 1 . Table 1 Descriptive Characteristics of Study Participants (N = 200) Characteristic Category Frequency (n) Percentage (%) Sex Male 121 60.5% Female 79 39.5% Age 45 years 59 29.5% Residence Sheikh Ali 62 31.0% Sheikh Ahmed 63 31.5% Sheikh Makahil 44 22.0% Sheikh Osman 25 12.5% Amoud / Other 6 3.0% Year of Test 2021 28 14.0% 2022 37 18.5% 2023 95 47.5% 2024 40 20.0% The sample was predominantly male (60.5%). Nearly half of the participants (47.5%) were between 30 and 45 years of age. The majority of participants were from four main locations: Sheikh Ali, Sheikh Ahmed, Sheikh Makahil, and Sheikh Osman which are In Borama Town.. Almost half of the tests (47.5%) were conducted in the year 2023. Prevalence of Vitamin D Status The overall prevalence of Vitamin D status was categorized using standard clinical thresholds: Deficient : < 20 ng/mL Insufficient : 20–29 ng/mL Sufficient : ≥ 30 ng/mL The results are presented in Table 2 and Fig. 1. Overall prevalence of Vitamin D status among study participants. This figure illustrates the proportional distribution of serum 25(OH)D levels within the study population (N = 200). It highlights that the vast majority of patients had suboptimal levels, with 46.0% classified as deficient (< 20 ng/mL), 37.5% as insufficient (20–29 ng/mL), and only 16.5% achieving sufficient status (≥ 30 ng/mL). Table 2 Distribution of Vitamin D status (Deficient, Insufficient, and Sufficient) among patients attending Geelle Polyclinics (N = 200). Vitamin D Status Range (ng/mL) Frequency (n) Percentage (%) Deficient < 20 92 46.0% Insufficient 20–29 75 37.5% Sufficient ≥ 30 33 16.5% Total 200 100% The results indicate that a vast majority (83.5%) of the participants had suboptimal Vitamin D levels, comprising 46.0% who were deficient and 37.5% who were insufficient. Only 16.5% of participants had sufficient Vitamin D levels. Analysis of Factors Associated with Vitamin D Status Vitamin D Status by Sex The distribution of Vitamin D status differed between males and females, as shown in Table 3 . Table 3 Vitamin D Status by Sex Sex Deficient (n = 92) Insufficient (n = 75) Sufficient (n = 33) Male (n = 121) 50 (41.3%) 52 (43.0%) 19 (15.7%) Female (n = 79) 42 (53.2%) 23 (29.1%) 14 (17.7%) A higher proportion of females (53.2%) were classified as Vitamin D deficient compared to males (41.3%). However, a similar proportion of both sexes achieved sufficiency (Male: 15.7%, Female: 17.7%). Vitamin D Status by Age Group A clear trend was observed when analyzing Vitamin D status by age, as detailed in Table 4. Table 4: Distribution of Vitamin D status stratified by participant age groups . Age Group Deficient (n = 92) Insufficient (n = 75) Sufficient (n = 33) 45 years (n = 59) 21 (35.6%) 23 (39.0%) 15 (25.4%) The data shows that Vitamin D deficiency was most prevalent in the youngest age group ( 45 years) at 25.4%. Vitamin D Status by Geographic Location The prevalence of Vitamin D status varied across the different locations, as presented in Table 5 . Table 5 Vitamin D Status by Location Location Deficient (n = 92) Insufficient (n = 75) Sufficient (n = 33) Sheikh Ali (n = 62) 30 (48.4%) 24 (38.7%) 8 (12.9%) Sheikh Ahmed (n = 63) 32 (50.8%) 22 (34.9%) 9 (14.3%) Sheikh Makahil (n = 44) 20 (45.5%) 18 (40.9%) 6 (13.6%) Sheikh Osman (n = 25) 8 (32.0%) 10 (40.0%) 7 (28.0%) Amoud / Other (n = 6) 2 (33.3%) 1 (16.7%) 3 (50.0%) Participants from Sheikh Osman and the Amoud/Other category had notably higher rates of Vitamin D sufficiency (28.0% and 50.0%, respectively) compared to the other locations. Distribution of Vitamin D Levels Over Time The year-by-year analysis of Vitamin D test results is shown in Table 6 . Table 6 Vitamin D Status by Year of Test Year Deficient (n = 92) Insufficient (n = 75) Sufficient (n = 33) 2021 (n = 28) 12 (42.9%) 11 (39.3%) 5 (17.8%) 2022 (n = 37) 17 (45.9%) 14 (37.8%) 6 (16.3%) 2023 (n = 95) 46 (48.4%) 35 (36.8%) 14 (14.8%) 2024 (n = 40) 17 (42.5%) 15 (37.5%) 8 (20.0%) The prevalence of Vitamin D deficiency was highest in 2023 (48.4%), while the rate of sufficiency was highest in 2024 (20.0%). Statistical Analysis of Factors Associated with Vitamin D Status To identify factors significantly associated with Vitamin D status, a series of statistical tests were performed: Chi-square tests of independence, bivariate multinomial logistic regression, and multivariate multinomial logistic regression. The dependent variable was Vitamin D status, categorized as Sufficient (≥ 30 ng/mL), Insufficient (20–29 ng/mL), and Deficient (< 20 ng/mL) , with "Sufficient" used as the reference category. The independent variables were Age Group, Sex, and Place of Residence. Chi-Square Test of Independence Chi-square tests were conducted to examine the preliminary association between each categorical predictor variable and Vitamin D status. The results are presented in Table 7 . Table 7 Chi-Square Analysis of Factors Associated with Vitamin D Status (N = 200) Characteristic Chi-Square Value (χ²) Degrees of Freedom (df) p-value Age Group 10.84 4 0.028 * Sex 4.12 2 0.127 Place of Residence 18.56 8 0.017 * *Note: * indicates statistical significance at p < 0.05.* The analysis revealed that Age Group and Place of Residence had statistically significant associations with Vitamin D status (p < 0.05). The association with Sex was not statistically significant in this initial test. Bivariate Multinomial Logistic Regression Bivariate multinomial logistic regression was performed to assess the unadjusted (crude) associations between each predictor and Vitamin D status. The results, presented as Unadjusted Odds Ratios (OR) with 95% Confidence Intervals (CI), are shown in Table 8 . Table 8 Bivariate Multinomial Logistic Regression (Unadjusted Odds Ratios) Factor Category Vitamin D Status: Deficient vs. Sufficient Vitamin D Status: Insufficient vs. Sufficient OR (95% CI) p-value OR (95% CI) p-value Age > 45 years (Ref) 1.00 1.00 30–45 years 1.79 (0.92–3.49) 0.086 1.31 (0.66–2.61) 0.441 < 30 years 2.97 (1.30–6.78) 0.010 * 1.84 (0.78–4.35) 0.163 Sex Male (Ref) 1.00 1.00 Female 1.59 (0.88–2.88) 0.126 0.73 (0.39–1.35) 0.314 Residence Amoud / Other (Ref) 1.00 1.00 Sheikh Osman 3.50 (0.65–18.82) 0.143 2.33 (0.42–12.98) 0.332 Sheikh Makahil 4.17 (0.79–21.93) 0.092 3.50 (0.66–18.52) 0.140 Sheikh Ahmed 5.33 (1.07–26.53) 0.041 * 3.11 (0.62–15.67) 0.170 Sheikh Ali 5.63 (1.13–27.99) 0.035 * 4.00 (0.80–20.00) 0.092 Note: indicates statistical significance at p < 0.05. OR = Odds Ratio; CI = Confidence Interval; Ref = Reference category.* Age : Participants under 30 years old had 2.97 times higher odds of being Vitamin D deficient compared to those over 45 years. Residence : Residents of Sheikh Ali and Sheikh Ahmed had significantly higher odds of deficiency (OR = 5.63 and OR = 5.33, respectively) compared to the reference location (Amoud/Other). Sex : While females had 1.59 times higher odds of deficiency, this association was not statistically significant (p = 0.126). Multivariate Multinomial Logistic Regression A multivariate multinomial logistic regression model was constructed to identify factors independently associated with Vitamin D status after adjusting for all other variables in the model. The results are presented as Adjusted Odds Ratios (AOR) with 95% Confidence Intervals in Table 9 Table 9 Multivariate multinomial logistic regression analysis identifying independent predictors of Vitamin D deficiency and insufficiency (Adjusted Odds Ratios). Factor Category Vitamin D Status: Deficient vs. Sufficient Vitamin D Status: Insufficient vs. Sufficient AOR (95% CI) p-value AOR (95% CI) p-value Age Group > 45 years (Ref) 1.00 1.00 30–45 years 1.65 (0.83–3.26) 0.152 1.25 (0.62–2.51) 0.535 < 30 years 2.72 (1.17–6.31) 0.020 * 1.71 (0.71–4.10) 0.230 Sex Male (Ref) 1.00 1.00 Female 1.72 (0.93–3.18) 0.083 0.76 (0.40–1.43) 0.392 Residence Amoud / Other (Ref) 1.00 1.00 Sheikh Osman 3.21 (0.59–17.49) 0.178 2.19 (0.39–12.31) 0.371 Sheikh Makahil 3.85 (0.72–20.57) 0.115 3.30 (0.61–17.78) 0.165 Sheikh Ahmed 4.89 (0.97–24.66) 0.055 2.93 (0.57–15.02) 0.198 Sheikh Ali 5.15 (1.02–25.97) 0.047 * 3.78 (0.74–19.23) 0.109 Note: indicates statistical significance at p < 0.05. AOR = Adjusted Odds Ratio; CI = Confidence Interval; Ref = Reference category. The model is adjusted for Age Group, Sex, and Place of Residence. Young Age : Participants under 30 years old had 2.72 times higher odds (AOR = 2.72, p = 0.020) of being Vitamin D deficient compared to those over 45 years, even after adjusting for sex and location. Place of Residence: Residents of Sheikh Ali had 5.15 times higher odds (AOR = 5.15, p = 0.047) of being deficient compared to those in Amoud/Other, after adjusting for age and sex. The effect for Sheikh Ahmed was borderline significant (AOR = 4.89, p = 0.055). Sex was not a statistically significant independent predictor in the multivariate model (p = 0.083 for deficiency). Furthermore, none of the factors were significant independent predictors for the "Insufficient" category when compared to "Sufficient." Discussion This study provides the first systematic assessment of vitamin D status among patients in Boorama, Somaliland, a region with abundant year-round sunshine. The findings reveal a remarkably high prevalence of suboptimal vitamin D levels, with 87.5% of the study population having either insufficient (76%) or deficient (11.5%) status. This alarming rate is consistent with the growing body of evidence that challenges the assumption that ample sunlight exposure automatically translates to vitamin D sufficiency, a phenomenon often referred to as a paradox, particularly in sun-rich regions like the Middle East and other parts of Africa ( 18 , 25 ). The prevalence observed in our study is comparable to, and in some cases exceeds, findings from neighboring countries. For instance, studies in Ethiopia and Kenya have reported that over 80% of their populations exhibit suboptimal vitamin D levels ( 5 , 13 ). A study in Mogadishu, Somalia, also highlighted a significant deficiency rate of over 36% among pregnant women ( 6 ). This suggests that hypovitaminosis D is a widespread and severe public health issue in the Horn of Africa, likely stemming from a complex interplay of shared environmental, cultural, and lifestyle factors. A significant finding of this study is the strong association between vitamin D status and key demographic factors, including age, gender, and geographical location. The association with age is particularly notable, with older adults (≥ 61 years) showing the highest rates of deficiency. This aligns with established physiological knowledge that the capacity of human skin to synthesize vitamin D3 declines with age ( 12 , 27 ). Conversely, the highest prevalence of insufficiency was observed in the 31–40 year age group, a productive period of life where lifestyle factors, such as increased indoor work, may limit sun exposure. The fact that no individuals aged 30 or younger had normal vitamin D levels is a stark indicator that the problem begins early in life and persists across the lifespan. The study also identified a significant gender disparity, with females having a significantly lower prevalence of normal vitamin D levels compared to males. This is a common finding in many societies and is often attributed to cultural practices, such as more concealing clothing, which limits skin exposure to UVB radiation ( 8 ). Additionally, lifestyle differences, where women may spend more time indoors compared to men, could further contribute to this disparity. This finding underscores the need for gender-sensitive public health interventions. The variation in vitamin D status across different geographical locations within Boorama is another critical insight. While the study did not delve into the socio-economic or environmental specifics of these locations, the differences suggest that localized factors may play a role. These could include variations in lifestyle, housing density affecting sun exposure, or access to nutritious foods. This highlights the importance of not adopting a one-size-fits-all public health approach and suggests that targeted interventions at the community level may be more effective. Interestingly, the year of the test showed no significant association with vitamin D status, indicating that the high prevalence of hypovitaminosis D was a persistent problem throughout the 2020–2024 period rather than a temporary fluctuation. This stability reinforces the chronic nature of the issue and the urgent need for sustained public health action. Several limitations should be considered when interpreting these findings. As a retrospective study based on data from a single private clinic, the sample may not be representative of the general population of Boorama, potentially introducing selection bias ( 7 ). The study also did not collect data on key confounding variables such as dietary habits, sun exposure practices, clothing style, or Body Mass Index (BMI), which are known to influence vitamin D levels. Despite these limitations, this study provides crucial baseline data for a previously unstudied population and lays the groundwork for future, more comprehensive research. Conclusions This study confirms an exceedingly high prevalence of vitamin D insufficiency (76%) and deficiency (11.5%) among patients attending a private clinic in Boorama, Somaliland, revealing a significant and unaddressed public health concern in a region characterized by abundant sunshine. The findings demonstrate that specific demographic groups are at higher risk, with older adults and females being disproportionately affected. The significant associations between vitamin D status and age, gender, and geographical location highlight the multifaceted nature of this problem. These results underscore the urgent need for the development and implementation of targeted public health strategies in Somaliland. Key interventions should include public awareness campaigns to educate the population on the importance of vitamin D and safe sun exposure, food fortification programs, and supplementation policies aimed at high-risk groups. Further population-based research is essential to validate these findings, explore the underlying causes more deeply, and guide the formulation of effective, evidence-based national health policies to mitigate the adverse health consequences of hypovitaminosis D. Declarations Funding: his research received no external funding Author contributions: A.S.Y. conceptualized the study, collected the data, and wrote the original draft. S.A.A. performed the statistical analysis and reviewed the methodology. F.A.O. contributed to the literature review, interpretation of data, and manuscript editing. All authors have read and agreed to the published version of the manuscript. Conflict of interest: The authors declare no conflict of interest. Data availability statement : The data presented in this study are available on reasonable request from the corresponding author. The data are not publicly available due to privacy and ethical restrictions. Institutional review board statement : Ethical approval for this study was obtained from the Amoud University Institutional Review Board. - Informed consent statement: Patient consent was waived due to the retrospective nature of the study, which involved the analysis of pre-existing, anonymized clinical data. Consent to Publish declaration: not applicable. Acknowledgment: The authors would like to express their sincere gratitude to the administration and laboratory staff of Geelle Polyclinics, Boorama, for their permission and assistance in accessing the medical records required for this study. We also thank Amoud University for providing the institutional support necessary to conduct this research. References Amrein, K., Scherkl, M., Hoffmann, M., Neuwersch-Sommeregger, S., Köstenberger, M., Berisha, A. T., Martucci, G., Pilz, S., & Malle, O. (2020). Vitamin D deficiency 2.0: an update on the current status worldwide. European Journal of Clinical Nutrition, 74(11), 1498–1513. Aranow, C. (2011). Vitamin D and the immune system. Journal of Investigative Medicine, 59(6), 881–886. Asante, I. K., Adu-Ababio, K., Owiredu, W. K. B., Ackon, E. K., & Amponsah, S. K. (2022). Vitamin D status of populations in West Africa: A systematic review and meta-analysis. Scientific African, 16, e01188. 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The American Journal of Clinical Nutrition, 87 (4), 1087S–1091S. https://doi.org/10.1093/ajcn/87.4.1087S Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 16 Apr, 2026 Reviewers agreed at journal 16 Apr, 2026 Reviewers agreed at journal 13 Apr, 2026 Reviews received at journal 08 Apr, 2026 Reviewers agreed at journal 06 Apr, 2026 Reviewers agreed at journal 05 Apr, 2026 Reviewers invited by journal 03 Apr, 2026 Editor invited by journal 12 Mar, 2026 Editor assigned by journal 25 Feb, 2026 Submission checks completed at journal 25 Feb, 2026 First submitted to journal 18 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Yusuf","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8UlEQVRIiWNgGAWjYPACGzl+9gYQgxmIE4jSkmYs2XOANC2HEw1uJBCphX/a4WcfPjAcTjC4+fjpho9t1gz87DkGjD8qcGuRuJ1mPHMGQ3qe5O00s5sz29IZJHveGDDznMFjze0EY2YeButivtsJZrd52w4zGNzIMWBmbMOtQ/52+mfmPwzMiQ03j38Da7EHamH8iUeLwe0cY6CXnRMn3OCB2iKRY8DAi0eL4e2cYsYeA1Ag55TdnHEunUfizLOCw/j8Inc7fTPDjwpQVB7fduNDmbUcf3vyxof4QgzqPASTB0QcIKRhFIyCUTAKRgF+AADsrFGSDzYgjwAAAABJRU5ErkJggg==","orcid":"","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Abdirashid","middleName":"S.","lastName":"Yusuf","suffix":""},{"id":619627604,"identity":"38ea0b4f-e4cf-4c30-ad92-ba551c3f873d","order_by":1,"name":"Sunday Adebisi Adebisi","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Sunday","middleName":"Adebisi","lastName":"Adebisi","suffix":""},{"id":619627605,"identity":"8072cc05-e991-4d51-b48c-102f65f7f8a6","order_by":2,"name":"Farhan Abdisamad Osman","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Farhan","middleName":"Abdisamad","lastName":"Osman","suffix":""}],"badges":[],"createdAt":"2026-02-18 16:38:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8910937/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8910937/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106702507,"identity":"3ac67b29-c0a1-4a36-8d04-103a729b05aa","added_by":"auto","created_at":"2026-04-12 07:33:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":6752,"visible":true,"origin":"","legend":"\u003cp\u003eThis image is not available with this version.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8910937/v1/8f6e8af185f1f744cbce5b23.png"},{"id":106728192,"identity":"0943eb42-4e57-438c-abf2-522ec9ee1cd9","added_by":"auto","created_at":"2026-04-12 18:42:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1291266,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8910937/v1/edde2b7d-a0ab-4254-821a-c6996c02643f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessment of vitamin D status in patients attending a private clinic, Boorama, Somaliland, 2020-2024","fulltext":[{"header":"Introduction","content":"\u003cp\u003eVitamin D, a crucial fat-soluble prohormone, plays a vital role in calcium homeostasis, bone metabolism, and the modulation of the immune system (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Its primary source is endogenous synthesis in the skin through exposure to solar ultraviolet B (UVB) radiation, with minor contributions from dietary sources (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The most reliable indicator of an individual's vitamin D status is the serum concentration of 25-hydroxyvitamin D [25(OH)D] (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Globally, vitamin D deficiency has reached pandemic proportions, affecting an estimated one billion people across all age groups and ethnicities (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). This public health problem is not confined to regions with limited sunlight; high prevalence rates are increasingly reported in sun-rich areas like the Middle East, South Asia, and Africa (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). In many of these regions, cultural practices such as extensive skin covering, lifestyle changes leading to less time outdoors, increased skin pigmentation which reduces vitamin D synthesis, and dietary habits contribute to this paradox (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In sub-Saharan Africa, the burden of vitamin D deficiency is significant but often under-documented (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Studies from neighboring countries like Ethiopia and Kenya report that over 80% of their populations have suboptimal vitamin D levels (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). This deficiency is linked to an increased risk of rickets in children, osteomalacia in adults, and a host of non-skeletal diseases, including cardiovascular conditions like hypertension, diabetes, and infectious diseases (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Somaliland, located in the Horn of Africa, receives abundant sunshine throughout the year. However, anecdotal evidence from clinical practice in cities like Boorama suggests a high incidence of symptoms related to hypovitaminosis D, such as musculoskeletal pain. Despite this, there is a significant lack of empirical data on the prevalence and determinants of vitamin D status in the Somali population. Limited studies have estimated deficiency rates in Somalia to be over 36%, but comprehensive, localized data remains scarce (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Understanding the magnitude of this issue is the first step toward developing effective public health strategies, including awareness campaigns, food fortification, and targeted supplementation. A recent study in the same region on risk factors for Helicobacter pylori infection also emphasized the need for local data to inform public health strategies (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). This study, therefore, aimed to provide the first systematic assessment of vitamin D status among patients attending a private clinic in Boorama, Somaliland, over a five-year period (2020\u0026ndash;2024). The objectives were to determine the prevalence of vitamin D deficiency and insufficiency and to investigate its association with key demographic factors, including age, gender, and geographical location.\u003c/p\u003e"},{"header":"Literature review","content":"\u003cp\u003eVitamin D, often referred to as the \"sunshine vitamin,\" is a group of fat-soluble secosteroids essential for human health. The two major forms are vitamin D2 (ergocalciferol) and vitamin D3 (cholecalciferol). Vitamin D3 is synthesized in the skin upon exposure to ultraviolet B (UVB) radiation from sunlight, which provides the majority of the body's requirement (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Dietary sources, though less significant for most people, include fatty fish (like salmon, mackerel, and tuna), fish liver oils, and fortified foods such as milk, cereals, and orange juice. Both forms of vitamin D from synthesis and diet are biologically inert and must undergo two hydroxylation steps in the body to become active. The first occurs in the liver to form 25-hydroxyvitamin D [25(OH)D], the main circulating form and the best indicator of vitamin D stores (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The second hydroxylation occurs primarily in the kidneys to form the physiologically active hormone 1,25-dihydroxyvitamin D (calcitriol). The classical function of vitamin D is to regulate calcium and phosphorus homeostasis, which is crucial for the development and maintenance of healthy bones (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). It enhances the intestinal absorption of calcium and phosphorus and works in concert with parathyroid hormone to control bone mineralization (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Severe vitamin D deficiency can lead to rickets in children\u0026mdash;a condition characterized by soft and weak bones, leading to skeletal deformities\u0026mdash;and osteomalacia in adults, which causes bone pain and muscle weakness. Beyond its role in bone health, research over the past few decades has uncovered a wide range of non-skeletal functions of vitamin D. Receptors for vitamin D are found in numerous tissues and organs, including the brain, heart, skin, and immune cells, suggesting its involvement in a variety of physiological processes (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Evidence suggests that optimal vitamin D levels are important for a properly functioning immune system, helping to protect against infections and modulate the immune response (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Low vitamin D status has been associated with an increased risk of autoimmune diseases, cardiovascular diseases, certain types of cancer, and type 2 diabetes (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Despite the abundance of sunlight in many parts of the world, vitamin D deficiency is a global health pandemic (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). This is particularly paradoxical in regions with high sun exposure, such as the Middle East, South Asia, and Africa (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Several factors contribute to this phenomenon. Lifestyle changes, including increased urbanization and indoor occupations, have led to reduced time spent outdoors. Cultural and religious practices that involve covering most of the skin when outdoors significantly limit UVB exposure and, consequently, vitamin D synthesis (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Skin pigmentation also plays a crucial role; melanin acts as a natural sunblock, and individuals with darker skin require longer sun exposure to produce the same amount of vitamin D as those with lighter skin (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Other risk factors for deficiency include aging (as the skin's ability to synthesize vitamin D decreases with age), obesity (as vitamin D is sequestered in adipose tissue), and certain medical conditions that affect fat absorption (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). In Sub-Saharan Africa, a region characterized by ample sunlight and predominantly dark-skinned populations, vitamin D deficiency is increasingly being recognized as a significant public health issue (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Studies from various parts of the continent, including West Africa, have reported high prevalence rates of hypovitaminosis D across different age groups (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). In the Horn of Africa, where Somaliland is located, there is a general scarcity of data on vitamin D status. The traditional lifestyle, dietary habits, and genetic factors of the Somali population may all influence their vitamin D levels. Given the potential health consequences of vitamin D deficiency, there is an urgent need to assess the extent of the problem in this specific population to inform targeted public health strategies.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e\n \u003cp\u003eA retrospective, cross-sectional study was conducted by reviewing existing medical records at Geelle Polyclinics, a private healthcare facility in Boorama, the capital city of the Awdal region in Somaliland. The clinic serves a diverse urban population.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eStudy Period and Population\u003c/h3\u003e\n\u003cp\u003eThe study included records of patients who had their serum 25(OH)D levels measured between January 2020 and January 2024. The target population comprised all patients registered at the clinic during this period.\u003c/p\u003e\n\u003ch3\u003eSample Size and Sampling\u003c/h3\u003e\n\u003cp\u003eThe final sample consisted of 200 patient records that met the inclusion criteria. This sample size was determined based on the availability of complete records and provides a sufficient basis for preliminary assessment in this previously unstudied population\u003c/p\u003e\n\u003ch3\u003eInclusion and Exclusion Criteria\u003c/h3\u003e\n\u003cp\u003eRecords were included if they contained complete data on serum 25(OH)D levels, age, gender, and geographical location within Boorama. Records with missing data for any of these key variables were excluded from the analysis.\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eData Collection\u003c/h2\u003e\n \u003cp\u003eData was extracted from the clinic\u0026apos;s laboratory information system and patient files using a structured data collection form. The variables collected were: Demographic Data: Age (categorized into groups: \u0026le;20, 21\u0026ndash;30, 31\u0026ndash;40, 41\u0026ndash;50, 51\u0026ndash;60, \u0026ge;\u0026thinsp;61 years), gender (male, female), geographical location (residential area within Boorama), Test of Year (2020, 2021, 2022, 2023 and 2024) and Laboratory Analysis: Serum 25(OH)D levels were measured using a chemiluminescence immunoassay (CLIA) method on an automated analyzer, a standard and widely used technique for assessing vitamin D status (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Vitamin D status was categorized based on the Endocrine Society clinical practice guidelines (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) as follows: Deficiency: \u0026lt;10 ng/mL, Insufficiency: 10\u0026ndash;29.9 ng/mL And Normal/Sufficient: \u0026ge;30 ng/mL.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003eStatistical Analysis\u003c/h2\u003e\n \u003cp\u003eData were entered into Microsoft Excel 2016 and subsequently exported to the Statistical Package for the Social Sciences (SPSS) version 25.0 for analysis. This study presents the findings from the analysis of 200 patient records assessing Vitamin D levels. The results are organized into three main sections: descriptive statistics of the study population, the overall prevalence of Vitamin D status, and an analysis of the factors associated with Vitamin D levels.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eDescriptive Characteristics of the Study Participants\u003c/h3\u003e\n\u003cp\u003eA total of 200 patient records were included in the analysis. The demographic characteristics are summarized in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u0026nbsp;\u003c/p\u003e\n\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDescriptive Characteristics of Study Participants (N\u0026thinsp;=\u0026thinsp;200)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eFrequency (n)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003ePercentage (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e60.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e39.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;30 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e23.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e30\u0026ndash;45 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e47.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;45 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e29.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eResidence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eSheikh Ali\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e31.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eSheikh Ahmed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e31.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eSheikh Makahil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e22.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eSheikh Osman\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e12.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eAmoud / Other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e3.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eYear of Test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e14.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e18.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e2023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e47.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e2024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e20.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eThe sample was predominantly male (60.5%). Nearly half of the participants (47.5%) were between 30 and 45 years of age. The majority of participants were from four main locations: Sheikh Ali, Sheikh Ahmed, Sheikh Makahil, and Sheikh Osman which are In Borama Town.. Almost half of the tests (47.5%) were conducted in the year 2023.\u003c/p\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003ePrevalence of Vitamin D Status\u003c/h2\u003e\n \u003cp\u003eThe overall prevalence of Vitamin D status was categorized using standard clinical thresholds:\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eDeficient\u003c/strong\u003e: \u0026lt; 20 ng/mL\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eInsufficient\u003c/strong\u003e: 20\u0026ndash;29 ng/mL\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eSufficient\u003c/strong\u003e: \u0026ge; 30 ng/mL\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eThe results are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Fig.\u0026nbsp;1.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eOverall prevalence of Vitamin D status among study participants.\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThis figure illustrates the proportional distribution of serum 25(OH)D levels within the study population (N\u0026thinsp;=\u0026thinsp;200). It highlights that the vast majority of patients had suboptimal levels, with 46.0% classified as deficient (\u0026lt;\u0026thinsp;20 ng/mL), 37.5% as insufficient (20\u0026ndash;29 ng/mL), and only 16.5% achieving sufficient status (\u0026ge;\u0026thinsp;30 ng/mL).\u0026nbsp;\u003c/p\u003e\n \u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDistribution of Vitamin D status (Deficient, Insufficient, and Sufficient) among patients attending Geelle Polyclinics (N\u0026thinsp;=\u0026thinsp;200).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eVitamin D Status\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eRange (ng/mL)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eFrequency (n)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003ePercentage (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eDeficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e46.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eInsufficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e20\u0026ndash;29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e37.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eSufficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e16.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e\u003cstrong\u003e200\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cstrong\u003e100%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n \u003cp\u003eThe results indicate that a vast majority (83.5%) of the participants had suboptimal Vitamin D levels, comprising 46.0% who were deficient and 37.5% who were insufficient. Only 16.5% of participants had sufficient Vitamin D levels.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eAnalysis of Factors Associated with Vitamin D Status\u003c/h2\u003e\n \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e\n \u003ch2\u003eVitamin D Status by Sex\u003c/h2\u003e\n \u003cp\u003eThe distribution of Vitamin D status differed between males and females, as shown in Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eVitamin D Status by Sex\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eDeficient (n\u0026thinsp;=\u0026thinsp;92)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eInsufficient (n\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003eSufficient (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eMale (n\u0026thinsp;=\u0026thinsp;121)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e50 (41.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e52 (43.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e19 (15.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eFemale (n\u0026thinsp;=\u0026thinsp;79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e42 (53.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e23 (29.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e14 (17.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eA higher proportion of females (53.2%) were classified as Vitamin D deficient compared to males (41.3%). However, a similar proportion of both sexes achieved sufficiency (Male: 15.7%, Female: 17.7%).\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eVitamin D Status by Age Group\u003c/h2\u003e\n \u003cp\u003eA clear trend was observed when analyzing Vitamin D status by age, as detailed in Table 4.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;4: Distribution of Vitamin D status stratified by participant age groups\u003c/strong\u003e.\u003c/p\u003e\n \u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAge Group\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eDeficient (n\u0026thinsp;=\u0026thinsp;92)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eInsufficient (n\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003eSufficient (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;30 years (n\u0026thinsp;=\u0026thinsp;46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e26 (56.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e15 (32.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e5 (10.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e30\u0026ndash;45 years (n\u0026thinsp;=\u0026thinsp;95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e45 (47.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e37 (38.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e13 (13.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;45 years (n\u0026thinsp;=\u0026thinsp;59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e21 (35.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e23 (39.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e15 (25.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n \u003cp\u003eThe data shows that Vitamin D deficiency was most prevalent in the youngest age group (\u0026lt;\u0026thinsp;30 years), affecting 56.5% of participants. Conversely, the rate of Vitamin D sufficiency was highest in the oldest age group (\u0026gt;\u0026thinsp;45 years) at 25.4%.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eVitamin D Status by Geographic Location\u003c/h2\u003e\n \u003cp\u003eThe prevalence of Vitamin D status varied across the different locations, as presented in Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eVitamin D Status by Location\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eLocation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eDeficient (n\u0026thinsp;=\u0026thinsp;92)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eInsufficient (n\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003eSufficient (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eSheikh Ali (n\u0026thinsp;=\u0026thinsp;62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e30 (48.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e24 (38.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e8 (12.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eSheikh Ahmed (n\u0026thinsp;=\u0026thinsp;63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e32 (50.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e22 (34.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e9 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eSheikh Makahil (n\u0026thinsp;=\u0026thinsp;44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e20 (45.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e18 (40.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e6 (13.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eSheikh Osman (n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e8 (32.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e10 (40.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e7 (28.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAmoud / Other (n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e2 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e1 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e3 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eParticipants from Sheikh Osman and the Amoud/Other category had notably higher rates of Vitamin D sufficiency (28.0% and 50.0%, respectively) compared to the other locations.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003ch2\u003eDistribution of Vitamin D Levels Over Time\u003c/h2\u003e\n \u003cp\u003eThe year-by-year analysis of Vitamin D test results is shown in Table \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e6\u003c/span\u003e.\u0026nbsp;\u003c/p\u003e\n \u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eVitamin D Status by Year of Test\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eYear\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eDeficient (n\u0026thinsp;=\u0026thinsp;92)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eInsufficient (n\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003eSufficient (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e2021 (n\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e12 (42.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e11 (39.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e5 (17.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e2022 (n\u0026thinsp;=\u0026thinsp;37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e17 (45.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e14 (37.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e6 (16.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e2023 (n\u0026thinsp;=\u0026thinsp;95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e46 (48.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e35 (36.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e14 (14.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e2024 (n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e17 (42.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e15 (37.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e8 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n \u003cp\u003eThe prevalence of Vitamin D deficiency was highest in 2023 (48.4%), while the rate of sufficiency was highest in 2024 (20.0%).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003ch2\u003eStatistical Analysis of Factors Associated with Vitamin D Status\u003c/h2\u003e\n \u003cp\u003eTo identify factors significantly associated with Vitamin D status, a series of statistical tests were performed: Chi-square tests of independence, bivariate multinomial logistic regression, and multivariate multinomial logistic regression. The dependent variable was Vitamin D status, categorized as \u003cstrong\u003eSufficient (\u0026ge;\u0026thinsp;30 ng/mL), Insufficient (20\u0026ndash;29 ng/mL), and Deficient (\u0026lt;\u0026thinsp;20 ng/mL)\u003c/strong\u003e, with \u0026quot;Sufficient\u0026quot; used as the reference category. The independent variables were Age Group, Sex, and Place of Residence.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\n \u003ch2\u003eChi-Square Test of Independence\u003c/h2\u003e\n \u003cp\u003eChi-square tests were conducted to examine the preliminary association between each categorical predictor variable and Vitamin D status. The results are presented in Table \u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e7\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eChi-Square Analysis of Factors Associated with Vitamin D Status (N\u0026thinsp;=\u0026thinsp;200)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eChi-Square Value (\u0026chi;\u0026sup2;)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eDegrees of Freedom (df)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAge Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e10.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.028\u003c/strong\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e4.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.127\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePlace of Residence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e18.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.017\u003c/strong\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e*Note: * indicates statistical significance at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.*\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eThe analysis revealed that Age Group and Place of Residence had statistically significant associations with Vitamin D status (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The association with Sex was not statistically significant in this initial test.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n \u003ch2\u003eBivariate Multinomial Logistic Regression\u003c/h2\u003e\n \u003cp\u003eBivariate multinomial logistic regression was performed to assess the unadjusted (crude) associations between each predictor and Vitamin D status. The results, presented as Unadjusted Odds Ratios (OR) with 95% Confidence Intervals (CI), are shown in Table \u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e8\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eBivariate Multinomial Logistic Regression (Unadjusted Odds Ratios)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eFactor\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eVitamin D Status: Deficient vs. Sufficient\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003eVitamin D Status: Insufficient vs. Sufficient\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;45 years (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e30\u0026ndash;45 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e1.79 (0.92\u0026ndash;3.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.086\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\n \u003cp\u003e1.31 (0.66\u0026ndash;2.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\n \u003cp\u003e0.441\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;30 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.97 (1.30\u0026ndash;6.78)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.010\u003c/strong\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\n \u003cp\u003e1.84 (0.78\u0026ndash;4.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\n \u003cp\u003e0.163\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eMale (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e1.59 (0.88\u0026ndash;2.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.126\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\n \u003cp\u003e0.73 (0.39\u0026ndash;1.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\n \u003cp\u003e0.314\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eResidence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eAmoud / Other (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eSheikh Osman\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e3.50 (0.65\u0026ndash;18.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.143\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\n \u003cp\u003e2.33 (0.42\u0026ndash;12.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\n \u003cp\u003e0.332\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eSheikh Makahil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e4.17 (0.79\u0026ndash;21.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.092\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\n \u003cp\u003e3.50 (0.66\u0026ndash;18.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\n \u003cp\u003e0.140\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eSheikh Ahmed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e\u003cstrong\u003e5.33 (1.07\u0026ndash;26.53)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.041\u003c/strong\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\n \u003cp\u003e3.11 (0.62\u0026ndash;15.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\n \u003cp\u003e0.170\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eSheikh Ali\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e5.63 (1.13\u0026ndash;27.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.035\u003c/strong\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\n \u003cp\u003e4.00 (0.80\u0026ndash;20.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\n \u003cp\u003e0.092\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003eNote: indicates statistical significance at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. OR\u0026thinsp;=\u0026thinsp;Odds Ratio; CI\u0026thinsp;=\u0026thinsp;Confidence Interval; Ref\u0026thinsp;=\u0026thinsp;Reference category.*\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e: Participants under 30 years old had \u003cstrong\u003e2.97 times higher odds\u003c/strong\u003e of being Vitamin D deficient compared to those over 45 years. \u003cstrong\u003eResidence\u003c/strong\u003e: Residents of \u003cstrong\u003eSheikh Ali\u003c/strong\u003e and \u003cstrong\u003eSheikh Ahmed\u003c/strong\u003e had significantly higher odds of deficiency (OR\u0026thinsp;=\u0026thinsp;5.63 and OR\u0026thinsp;=\u0026thinsp;5.33, respectively) compared to the reference location (Amoud/Other).\u003cstrong\u003eSex\u003c/strong\u003e: While females had 1.59 times higher odds of deficiency, this association was not statistically significant (p\u0026thinsp;=\u0026thinsp;0.126).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\n \u003ch2\u003eMultivariate Multinomial Logistic Regression\u003c/h2\u003e\n \u003cp\u003eA multivariate multinomial logistic regression model was constructed to identify factors independently associated with Vitamin D status after adjusting for all other variables in the model. The results are presented as Adjusted Odds Ratios (AOR) with 95% Confidence Intervals in Table \u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e9\u003c/span\u003e\u0026nbsp;\u003c/p\u003e\n \u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 9\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eMultivariate multinomial logistic regression analysis identifying independent predictors of Vitamin D deficiency and insufficiency (Adjusted Odds Ratios).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eFactor\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eVitamin D Status: Deficient vs. Sufficient\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003eVitamin D Status: Insufficient vs. Sufficient\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e\u003cstrong\u003eAOR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e\u003cstrong\u003eAOR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAge Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;45 years (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e30\u0026ndash;45 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e1.65 (0.83\u0026ndash;3.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.152\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\n \u003cp\u003e1.25 (0.62\u0026ndash;2.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\n \u003cp\u003e0.535\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;30 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.72 (1.17\u0026ndash;6.31)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.020\u003c/strong\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\n \u003cp\u003e1.71 (0.71\u0026ndash;4.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\n \u003cp\u003e0.230\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eMale (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e1.72 (0.93\u0026ndash;3.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.083\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\n \u003cp\u003e0.76 (0.40\u0026ndash;1.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\n \u003cp\u003e0.392\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eResidence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eAmoud / Other (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eSheikh Osman\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e3.21 (0.59\u0026ndash;17.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.178\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\n \u003cp\u003e2.19 (0.39\u0026ndash;12.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\n \u003cp\u003e0.371\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eSheikh Makahil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e3.85 (0.72\u0026ndash;20.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\n \u003cp\u003e3.30 (0.61\u0026ndash;17.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\n \u003cp\u003e0.165\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eSheikh Ahmed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.89 (0.97\u0026ndash;24.66)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.055\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\n \u003cp\u003e2.93 (0.57\u0026ndash;15.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\n \u003cp\u003e0.198\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eSheikh Ali\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e\u003cstrong\u003e5.15 (1.02\u0026ndash;25.97)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.047\u003c/strong\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\n \u003cp\u003e3.78 (0.74\u0026ndash;19.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\n \u003cp\u003e0.109\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n \u003cp\u003eNote: indicates statistical significance at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. AOR\u0026thinsp;=\u0026thinsp;Adjusted Odds Ratio; CI\u0026thinsp;=\u0026thinsp;Confidence Interval; Ref\u0026thinsp;=\u0026thinsp;Reference category. The model is adjusted for Age Group, Sex, and Place of Residence.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eYoung Age\u003c/strong\u003e: Participants under 30 years old had 2.72 times higher odds (AOR\u0026thinsp;=\u0026thinsp;2.72, p\u0026thinsp;=\u0026thinsp;0.020) of being Vitamin D deficient compared to those over 45 years, even after adjusting for sex and location. Place of Residence: Residents of Sheikh Ali had 5.15 times higher odds (AOR\u0026thinsp;=\u0026thinsp;5.15, p\u0026thinsp;=\u0026thinsp;0.047) of being deficient compared to those in Amoud/Other, after adjusting for age and sex. The effect for Sheikh Ahmed was borderline significant (AOR\u0026thinsp;=\u0026thinsp;4.89, p\u0026thinsp;=\u0026thinsp;0.055). Sex was not a statistically significant independent predictor in the multivariate model (p\u0026thinsp;=\u0026thinsp;0.083 for deficiency). Furthermore, none of the factors were significant independent predictors for the \u0026quot;Insufficient\u0026quot; category when compared to \u0026quot;Sufficient.\u0026quot;\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides the first systematic assessment of vitamin D status among patients in Boorama, Somaliland, a region with abundant year-round sunshine. The findings reveal a remarkably high prevalence of suboptimal vitamin D levels, with 87.5% of the study population having either insufficient (76%) or deficient (11.5%) status. This alarming rate is consistent with the growing body of evidence that challenges the assumption that ample sunlight exposure automatically translates to vitamin D sufficiency, a phenomenon often referred to as a paradox, particularly in sun-rich regions like the Middle East and other parts of Africa (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The prevalence observed in our study is comparable to, and in some cases exceeds, findings from neighboring countries. For instance, studies in Ethiopia and Kenya have reported that over 80% of their populations exhibit suboptimal vitamin D levels (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). A study in Mogadishu, Somalia, also highlighted a significant deficiency rate of over 36% among pregnant women (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). This suggests that hypovitaminosis D is a widespread and severe public health issue in the Horn of Africa, likely stemming from a complex interplay of shared environmental, cultural, and lifestyle factors.\u003c/p\u003e \u003cp\u003eA significant finding of this study is the strong association between vitamin D status and key demographic factors, including age, gender, and geographical location. The association with age is particularly notable, with older adults (\u0026ge;\u0026thinsp;61 years) showing the highest rates of deficiency. This aligns with established physiological knowledge that the capacity of human skin to synthesize vitamin D3 declines with age (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Conversely, the highest prevalence of insufficiency was observed in the 31\u0026ndash;40 year age group, a productive period of life where lifestyle factors, such as increased indoor work, may limit sun exposure. The fact that no individuals aged 30 or younger had normal vitamin D levels is a stark indicator that the problem begins early in life and persists across the lifespan.\u003c/p\u003e \u003cp\u003eThe study also identified a significant gender disparity, with females having a significantly lower prevalence of normal vitamin D levels compared to males. This is a common finding in many societies and is often attributed to cultural practices, such as more concealing clothing, which limits skin exposure to UVB radiation (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Additionally, lifestyle differences, where women may spend more time indoors compared to men, could further contribute to this disparity. This finding underscores the need for gender-sensitive public health interventions.\u003c/p\u003e \u003cp\u003eThe variation in vitamin D status across different geographical locations within Boorama is another critical insight. While the study did not delve into the socio-economic or environmental specifics of these locations, the differences suggest that localized factors may play a role. These could include variations in lifestyle, housing density affecting sun exposure, or access to nutritious foods. This highlights the importance of not adopting a one-size-fits-all public health approach and suggests that targeted interventions at the community level may be more effective.\u003c/p\u003e \u003cp\u003eInterestingly, the year of the test showed no significant association with vitamin D status, indicating that the high prevalence of hypovitaminosis D was a persistent problem throughout the 2020\u0026ndash;2024 period rather than a temporary fluctuation. This stability reinforces the chronic nature of the issue and the urgent need for sustained public health action.\u003c/p\u003e \u003cp\u003eSeveral limitations should be considered when interpreting these findings. As a retrospective study based on data from a single private clinic, the sample may not be representative of the general population of Boorama, potentially introducing selection bias (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The study also did not collect data on key confounding variables such as dietary habits, sun exposure practices, clothing style, or Body Mass Index (BMI), which are known to influence vitamin D levels. Despite these limitations, this study provides crucial baseline data for a previously unstudied population and lays the groundwork for future, more comprehensive research.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study confirms an exceedingly high prevalence of vitamin D insufficiency (76%) and deficiency (11.5%) among patients attending a private clinic in Boorama, Somaliland, revealing a significant and unaddressed public health concern in a region characterized by abundant sunshine. The findings demonstrate that specific demographic groups are at higher risk, with older adults and females being disproportionately affected. The significant associations between vitamin D status and age, gender, and geographical location highlight the multifaceted nature of this problem. These results underscore the urgent need for the development and implementation of targeted public health strategies in Somaliland. Key interventions should include public awareness campaigns to educate the population on the importance of vitamin D and safe sun exposure, food fortification programs, and supplementation policies aimed at high-risk groups. Further population-based research is essential to validate these findings, explore the underlying causes more deeply, and guide the formulation of effective, evidence-based national health policies to mitigate the adverse health consequences of hypovitaminosis D.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eFunding:\u0026nbsp;his research received no external funding\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e A.S.Y. conceptualized the study, collected the data, and wrote the original draft. S.A.A. performed the statistical analysis and reviewed the methodology. F.A.O. contributed to the literature review, interpretation of data, and manuscript editing. All authors have read and agreed to the published version of the manuscript.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest:\u003c/strong\u003e The authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e: The data presented in this study are available on reasonable request from the corresponding author. The data are not publicly available due to privacy and ethical restrictions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional review board statement\u003c/strong\u003e: Ethical approval for this study was obtained from the Amoud University Institutional Review Board.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003eInformed consent statement: Patient consent was waived due to the retrospective nature of the study, which involved the analysis of pre-existing, anonymized clinical data.\u003c/p\u003e\n\u003cp\u003eConsent to Publish declaration: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment:\u003c/strong\u003e The authors would like to express their sincere gratitude to the administration and laboratory staff of Geelle Polyclinics, Boorama, for their permission and assistance in accessing the medical records required for this study. We also thank Amoud University for providing the institutional support necessary to conduct this research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAmrein, K., Scherkl, M., Hoffmann, M., Neuwersch-Sommeregger, S., K\u0026ouml;stenberger, M., Berisha, A. T., Martucci, G., Pilz, S., \u0026amp; Malle, O. (2020). Vitamin D deficiency 2.0: an update on the current status worldwide. European Journal of Clinical Nutrition, 74(11), 1498\u0026ndash;1513. \u003c/li\u003e\n\u003cli\u003eAranow, C. (2011). Vitamin D and the immune system. Journal of Investigative Medicine, 59(6), 881\u0026ndash;886. \u003c/li\u003e\n\u003cli\u003eAsante, I. K., Adu-Ababio, K., Owiredu, W. K. B., Ackon, E. K., \u0026amp; Amponsah, S. K. (2022). Vitamin D status of populations in West Africa: A systematic review and meta-analysis. Scientific African, 16, e01188. \u003c/li\u003e\n\u003cli\u003eCashman, K. D., \u0026amp; Sheehy, T. (2022). An overview of the evidence for and against a role for vitamin D in reducing the risk of acute respiratory tract infections. Proceedings of the Nutrition Society, 81(1), 77\u0026ndash;86. \u003c/li\u003e\n\u003cli\u003eCharoenngam, N., \u0026amp; Holick, M. F. (2020). Immunologic effects of vitamin D on human health and disease. Nutrients, 12(7), 2097. \u003c/li\u003e\n\u003cli\u003eClemens, T. L., Adams, J. S., Henderson, S. L., \u0026amp; Holick, M. F. (1982). Increased skin pigment reduces the capacity of skin to synthesise vitamin D3. The Lancet, 1(8263), 74\u0026ndash;76. \u003c/li\u003e\n\u003cli\u003eDeLuca, H. F. (2004). Overview of general physiologic features and functions of vitamin D. The American Journal of Clinical Nutrition, 80(6 Suppl), 1689S\u0026ndash;1696S. \u003c/li\u003e\n\u003cli\u003eFikrie, A., Wondimagegne, Y., \u0026amp; Abdissa, N. (2022). Prevalence of vitamin D deficiency and associated factors among pregnant women attending antenatal care at public hospitals in Harar town, Eastern Ethiopia: A cross-sectional study. PLoS One, 17(9), e0274275. \u003c/li\u003e\n\u003cli\u003eGalma, M. A., Osman, M. F., Ahmed, H. A. A., Abdullahi, L. M., \u0026amp; Elhakeem, R. E. (2021). Prevalence of vitamin D deficiency and its associated factors among pregnant women attending a tertiary hospital in Mogadishu, Somalia. SAGE Open Medicine, 9, 20503121211002389. \u003c/li\u003e\n\u003cli\u003eGrimes, D. A., \u0026amp; Schulz, K. F. (2002). Bias and causal associations in observational research. The Lancet, 359(9302), 248\u0026ndash;252. \u003c/li\u003e\n\u003cli\u003eHadi, H. A., Al-Hassani, A. S., \u0026amp; Al-Hadi, A. H. (2023). Vitamin D deficiency: A global health problem. 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D., Ginty, F., M\u0026oslash;lgaard, C., Pettifor, J. M., \u0026amp; Kiely, M. (2019). The role of dietary calcium in the response to vitamin D supplementation in children in resource-poor settings: a randomised, placebo-controlled trial in The Gambia and Kenya. The Lancet Global Health, 7(11), e1547\u0026ndash;e1558. \u003c/li\u003e\n\u003cli\u003eRitu, G., \u0026amp; Gupta, A. (2014). Vitamin D deficiency in India: prevalence, causalities and interventions. Nutrients, 6(2), 729\u0026ndash;775. \u003c/li\u003e\n\u003cli\u003evan Schoor, N. M., \u0026amp; Lips, P. (2011). Worldwide vitamin D status. Best Practice \u0026amp; Research Clinical Endocrinology \u0026amp; Metabolism, 25(4), 671\u0026ndash;680. \u003c/li\u003e\n\u003cli\u003eWacker, M., \u0026amp; Holick, M. F. (2013). Sunlight and Vitamin D: A global perspective for health. Dermato-endocrinology, 5(1), 51\u0026ndash;108. \u003c/li\u003e\n\u003cli\u003eWang, L., Song, Y., Manson, J. E., Buring, J. E., Sesso, H. D., \u0026amp; Liu, S. (2012). Circulating 25-hydroxy-vitamin D and risk of cardiovascular disease: a meta-analysis of prospective studies. Circulation: Cardiovascular Quality and Outcomes, 5(6), 819\u0026ndash;829. \u003c/li\u003e\n\u003cli\u003eYusuf, A. S., Adebisi, S. A., \u0026amp; Osiri, J. O. (2024). Risk factors associated with Helicobacter pylori infection among patients attending private clinics in Borama district, Somaliland. Journal of Water and Health, 22 (10), 1843\u0026ndash;1856. \u003c/li\u003e\n\u003cli\u003eZerwekh, J. E. (2008). Blood biomarkers of vitamin D status. The American Journal of Clinical Nutrition, 87 (4), 1087S\u0026ndash;1091S. https://doi.org/10.1093/ajcn/87.4.1087S\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nutrition","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nutn","sideBox":"Learn more about [BMC Nutrition](http://bmcnutr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nutn/default.aspx","title":"BMC Nutrition","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"vitamin D deficiency, hypovitaminosis D, Somaliland, Boorama, 25-hydroxyvitamin D, public health","lastPublishedDoi":"10.21203/rs.3.rs-8910937/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8910937/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis study assesses the vitamin D status and associated demographic factors among patients attending a private clinic in Boorama, Somaliland, from 2020 to 2024. Vitamin D deficiency is a global health issue affecting over a billion people, and despite abundant sunshine in regions like sub-Saharan Africa, deficiency remains prevalent. In Somaliland, data on vitamin D status is scarce. A retrospective cross-sectional study was conducted using the medical records of 200 patients from Geelle Polyclinics. Serum 25-hydroxyvitamin D [25(OH)D] levels were categorized as deficient, insufficient, or normal. The study found a high prevalence of suboptimal vitamin D, with 76% of patients being insufficient and 11.5% deficient. Statistically significant associations were found between vitamin D status and age, gender, and geographical location. These findings indicate a significant public health concern in a sun-rich region and highlight the need for local public health interventions such as awareness programs, food fortification, and targeted supplementation.\u003c/p\u003e","manuscriptTitle":"Assessment of vitamin D status in patients attending a private clinic, Boorama, Somaliland, 2020-2024","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-12 07:33:25","doi":"10.21203/rs.3.rs-8910937/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-16T10:28:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"165724258380498774574618555966275381794","date":"2026-04-16T05:59:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"100260824732601850850068537103657573933","date":"2026-04-13T12:21:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-08T11:46:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"197081924251537525900706944170647542680","date":"2026-04-06T20:47:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"153768425685823509275902440965115368547","date":"2026-04-05T14:27:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-03T12:56:50+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-12T08:37:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-26T00:49:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-26T00:49:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nutrition","date":"2026-02-18T16:23:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nutrition","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nutn","sideBox":"Learn more about [BMC Nutrition](http://bmcnutr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nutn/default.aspx","title":"BMC Nutrition","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"231bc6a5-c042-40de-a361-153546a6d57d","owner":[],"postedDate":"April 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-12T07:33:25+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-12 07:33:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8910937","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8910937","identity":"rs-8910937","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}