31 (2) 2016 - Bosbd

Original ArticleEvaluation of Vitamin D Status amongDoctors of a Specialized Hospital inBangladeshSyed Shahidul Islam1, Md. Abdul Gani Mollah2, Mohammad Mahfuzur Rahman3, Md. Alimur Reza4,Monaim Hossen5, Md. Wahidur Rahman5, Md. Jahangir Alam5, Susmita Islam6ABSTRACTVitamin D deficiency is now recognized as a widespread phenomenon, even in a sunny country likeBangladesh.Physicians may be vulnerable to low vitamin D levels due to long work hours and lack of sun exposure.This studysought to determine the prevalence of vitamin D deficiency and its relationship with sociodemographiccharacteristics among doctors of a specialized hospital in Bangladesh. This cross-sectional study involved 157doctors who were present in the hospital at the day of examination and were willing to take part in the study.Levels of 25-hydroxyvitamin D [25(OH) D] were measured and other sociodemographic characteristics wererecorded according to detailed study criteria. Vitamin D deficiency was defined as serum 25(OH) D levels below20 ng/mL.The prevalence of vitamin D deficiency was present in 89.8% of the entire study population. The prevalenceof vitamin D deficiency was significantly lower in those aged more than 45 years than those aged less than 30years (77.3% & 94.3% respectively; p-value 0.003). Participants who had history of vitamin D supplementation hadsignificantly lower percentage of vitamin D deficiency than those who had no such history (80% and 95.1%respectively; p-value 0.005). Vitamin D deficiency is prevalent among the doctors of tertiary care hospital and islargely attributed to obesity, female sex, smoking, hypertension and CHD. History of Vitamin D supplementation isa strong protective factor for vitamin D Deficiency.Considering that vitamin D deficiency is very common in all agegroups and that only few foods contain vitamin D, supplementation might be considered at suggested daily intakeand tolerable upper limit levels, depending on age and clinical circumstances.Keywords: Vit-D Status, Doctors, Specialized HospitalINTRODUCTIONVitamin D deficiency is pandemic, yet it is the most underdiagnosed and under-treated nutritional deficiency in theworld 1–3. It is widespread in individuals irrespective oftheir age, gender, race and geography. It has been estimatedthat 20% to 80% of US, Canadian, and European men andwomen are vitamin D deficient.4,5In a study on the vitaminD status of Australian adults, vitamin D deficiency(25[OH]D 20 ng/mL) was 31% (22% in men and 39% inwomen); 73% had 25(OH)D levels less than 30 ng/mL.6 Inthe Middle East and Asia, vitamin D deficiency in childrenand adults is highly prevalent.7 In South Asia, 80% of theapparently healthy population is deficient in vitamin D( 20 ng/mL) and up to 40% of the population is severelydeficient ( 9 ng/mL)8. In Bangladesh, a prevalence studywas done on women and found that hypovitaminosis D iscommon in women regardless of age, lifestyle andclothing9.The classical functions of vitamin D include the regulationof mineral ion homeostasis and bone metabolism.Therefore, vitamin D has been associated primarily withbone health, and it is well known that vitamin D can reducebone resorption and subsequent bone loss. Recently,nonclassical functions of vitamin D have been recognized,e.g. control of cell growth and differentiation; regulationof immune function and endocrine effects, such as insulinresistance; inflammation, renal and muscle function10.Vitamin D receptor (VDR), which triggers most of vitamin1. Professor of Ortho Surgery & Academic Director, NITOR2. Professor of Ortho Surgery & Director of NITOR3. Medical Officer, Department of Ortho Surgery, BSMMU, Dhaka4. Deputy Manager, DMA, Beximco Pharmaceuticals Limited5. Associate Professor, Ortho Surgery, NITOR, Dhaka.6. Lecturer, Physical Medicine, NITOR, DhakaCorrespondence: Dr. Syed Shahidul Islam, Professor of Ortho Surgery & Academic Director, NITOR, DhakaVOL. 31, NO. 2, JULY 201680

81Syed Shahidul Islam, Md. Abdul Gani Mollah, Md. Alimur Reza, Monaim Hossen, Md. Wahidur Rahman, Md. Jahangir Alam et alD actions, is widely distributed across almost all the majorhuman organs including heart, brain, livers, bone, kidney,and urinary system, as well as a number of tissues such asimmune cells, pancreatic ² cells, cardiomyocytes,endothelial cells, and vascular smooth cells. Through thewidely distributed VDR, vitamin D controls vital genesrelated to bone metabolism, oxidative damage,inflammation, and chronic diseases11. Therefore, vitaminD deficiency has been linked to a wide spectrum of diseasesincluding osteoporosis, cancer, diabetes, cardiovascularand immune disorders11.Physicians may be vulnerable tolow vitamin D levels due to long work hours and lack ofsun exposure. This study sought to determine theprevalence of vitamin D deficiency and its relationshipwith sociodemographic characteristics among doctors ofa specialized hospital in Bangladesh.MATERIALSAND METHODS:This study was conducted using a cross-sectional studydesign which was carried out at National Institute ofTraumatology and Orthopedic Rehabilitation which is aspecialized hospital in Dhaka, Bangladesh. A total of 168doctors (153 men and 4 women) of NITOR hospital tookpart in the study who were available at the day of datacollection. To be eligible, participants were required to bethe doctor of NITOR, healthy males and females agedbetween 18 to 65 years. Participants were excluded if theywere pregnant or diagnosed with any hepatic or renaldisease, metabolic bone disease, malabsorption, type 1diabetes, hypercortisolism, malignancy etc and who wereimmobile for more than one week. Subjects usingmedications affecting either vitamin D absorption or bonehealth were also excluded. This study was conductedaccording to the guidelines laid down in the Declarationof Helsinki.Data collectionwas conducted in examination centers atNITOR by trained staff according to a standard protocol.All subjects were medically examined and interviewedusing a standardized questionnaire to collect informationonage, gender, physicalactivity level during leisure time, useof vitamins and medications,sunlight exposure time, coffeedrinking (yes/no), smoking, self-reported diabetes, selfreported coronary heart disease(CHD), and self-reportedstroke. The smoking habit was classified as never, current(smoking regularly in the past 6 months), or ever(cessationof smoking for more than 6 months),Subjectswere divided into four groups based on teaconsumption:group I, 0 to 4 cups of tea weekly; group II,5–8 cups of tea weekly;group III, 9–12 cups of tea weekly;and group IV, N12 cups of teaweekly. Daily sunlightexposure was quantified based on the interviewquestionson frequency and length of outdoor activities,sunscreenuse, and usual outdoor attire. Body weightandheight were measured according to a standard protocol.Blood pressure was measured in the non-dominant armwhile the participants were in a seated position after 5 minof rest using asphygmomanometer device.A blood sample was collected from the subjects bydisposable syringe through venepuncture and protectedfrom sunlight. After clotting, serum was separated bycomplete centrifuge of blood sample. The serum wascollected in tubes and preserved at -200C. Finally, the serumsample was transported to the laboratory on dry ice in aspecial type of container and preserved in the freezingroom of the International Centre for Diarrhoeal DiseaseResearch, Bangladesh for further analysis. Serum 25-OHDwas used to evaluate the vitamin D status. According toUS Endocrine society guideline12 Vitamin D deficiencywas defined as a serum circulating 25-hydroxyvitamin D[25(OH)D] level below 20 ng/ml (50 nmol/liter), and vitaminD insufficiency as a 25(OH)D of 21–29 ng/ml (52.5–72.5nmol/liter).Descriptive analysis was carried out on the study variablesand the frequency table of determinants and sociodemographic characteristics was created. Data was shownas mean SD and prevalence rates was reported aspercentages and 95% confidence intervals. The differenceswas considered significant at p values of less than 0.05.With respect to the participants’ vitamin D statuses andcharacteristics, t-test for independent samples and oneway ANOVA were used for continuous data, and the Chisquare test was used to compare frequencies.All analyseswere performed using SPSS for Windows, version 24.0(SPSS Inc., Chicago, IL, USA).OBSERVATION AND RESULTSAmong the 157 subjects 97.4% (153 Subjects) were maleand 2.6% (4 subjects) were female. Mean age of theparticipants were 39.18 9.447. Among all the participants13.6% were obese and 47.8% were overweight; around30% were current or ever (cessation of smoking for morethan 6 months) smoker and 14% had a history ofdyslipidemia, 7.6% had Diabetes and 3.8% had otherdiseases mainly hypertension. The overall mean ( SD)serum 25(OH)D level was 13.71 5.364 ng/mL. Theprevalence of vitamin D deficiency was 89.8% among theThe Journal of Bangladesh Orthopaedic Society

Ortho-Make (January 2016 Vol 31 No. 1)82Evaluation of Vitamin D Status among Doctors of a Specialized Hospital in Bangladeshdoctors of National Institute of Traumatology andOrthopedic Rehabilitation (Figure-1). The vitamin D statusof all participants according to different characteristics issummarized in Table-1. The studiedpopulation aged morethan 45 years exhibited a mean serum 25(OH)D levelthatwas higher than the studied population who wereaged 3045 years and less than 30 years of age. Indeed, there wasa significant differencein the prevalence of vitamin Ddeficiency among the total populationof different agegroups: the prevalence of vitamin D deficiency wassignificantly lower in those aged more than 45 years (P 0.003).82Fig.-1: Vitamin D Status of the participants (n 157)Table-IVitamin D status of all participants according to different characteristics(n 157).VariablesAge (Years) 30 years31-45 years 45 kingNeverCurrentEverTea/Coffee Drinking0-4 Cups/Week5-8 Cups/Week9-12 Cups/Week 12 Cups/WeekDaily sunlight exposureSufficientNot SufficientMedical HistoryHyperlipidemiaDiabetesChronic Heart DiseaseOthersVOL. 31, NO. 2, JULY 2016FrequencySerum D3 concentration (ng/dl)Vitamion D DefficiencyN(%)Mean SDP-value%P-value35(22.3%)78(49.7%)44(28.0%)12.17 3.8613.77 4.1814.84 7.62.08794.3%94.9%77.3%0.03153(97.4%)4(2.6%)13.80 5.3910.15 )13.86 5.8313.74 4.8513.15 7.6%)14.84 6.8513.39 5.0213.50 (15.3%)50(31.8%)14.27 5.3313.94 6.7413.73 4.7712.20 %)13.27 4.4814.17 3.8%)13.62 4.6015.39 10.1010.90 5.0910.03 2.34-90.90%83.30%100%100%-

Ortho-Make (January 2016 Vol 31 No. 1)8383Syed Shahidul Islam, Md. Abdul Gani Mollah, Md. Alimur Reza, Monaim Hossen, Md. Wahidur Rahman, Md. Jahangir Alam et alMoreover, men exhibited significantly higher serum25(OH)D levels compared with women (13.80 5.39 vs.10.15 2.90 ng/mL, respectively). Vitamin D deficiency wasmore prevalent in women (100%) than in men (89.5%).Mean serum concentration of 25(OH) D was lower in thegroup of obese participants than normat weightparticipants. Subjects with increased tea consumption weremore likely to have higher 25(OH)D concentrations andlower percentages of vitamin D deficiency. Participantswith history of chronic heart disease and hypertensionhad lower mean 25(OH)D concentrations, and 100% hadvitamin D deficiency.Table-IIVitamin D Defficiency status of the participants inrespect to H/O Vitamin D SupplementationH/O Vitamin DVitamin D StatusP-Supplementation Deficiency Insufficiency Sufficiency valueLast 3 months33.30%66.70%0.00%3-6 months100.00%0.00%0.00% 6 Pearson Chi-Square-35.885Mean serum concentration of 25(OH) D was significantlyhigherin the group of individuals who had a history ofvitamin D supplementation than those who had no suchhistory. Similarly, participants who had history of vitaminD supplementation had significantly lower percentage ofvitamin D deficiency (Table-2). All the participants (100%)had vitamin D deficiency who were current smoker whereas86.5% had vitamin D deficiency who have never smoked.DISCUSSIONThe results of the study inNational Institute ofTraumatology and Orthopedic Rehabilitation which is aspecialized hospital in Dhaka, Bangladesh, confirmsthehigh prevalence of vitamin D deficiency (89.8%)andinsufficiency (8.3%) among the adult populationand aneven higher prevalence amongwomen.Although Dhaka isasunny city, direct exposure to sun is, however,limited.Traditionally, all women are requiredto wear traditionalclothes. On the other hand, most men wear longsleeveshirts, especially as all our participants work ingovernmentaladministrations. Indeed, poor vitamin Dstatus has also been reported previously in Bangladeshthat were conducted with premenopausal Bangladeshiwomen9. The prevalence of vitamin D deficiency in thisstudy was higher than the findings in North-WesternChina13 (89.8% vs. 75.2%), US4, Canada5 and Europe6.Conversely,the prevalence was almost similar than whathas been reported for SaudiArabianmen (where 87.8%ofmiddle-aged and elderly men had vitaminD levels lowerthan 20 ng/mL)14, Iran15 and Pakistan16.The present study demonstrated that obesity, smoking,hypertension and CHDwere independent predictors ofvitamin D deficiency. Previous study have demonstratedthat obesity17is associatedwith lower serum25(OH)Dlevels. The inverse relationshipbetween 25(OH)D levelsand obesity may be because of a largerbody pool of vitaminD and 25(OH)D, or to a slower saturation andmobilizationofthesemetabolites fromadipose tissues, or both. Thus,obeseindividuals have lower vitamin D bioavailabilityfromcutaneous and dietarysources because of a tendencyfor vitamin D to deposit in adipose tissue18. Furthermore,in diseases thatcause disability such as CHD, reducedoutdoor activity mightinduce low vitamin D levels, whichhas been linked to calcium malabsorptionand may causesecondary hyperparathyroidism. In this study as therewas misperception about the level of sun exposure, hencefound conflicting result between sun exposure and vitaminD level. According to clinical practice guideline of Americanendocrine society12 a variety of factors reduce the skin’sproduction of vitamin D3, including increased skinpigmentation, aging, and the topical application of asunscreen, change in latitude, season of the year, or timeof day etc. For sufficient vitamin D we need 15 to 20 minutesof daily sun exposure without sunscreen in lowerMidwestern and southern latitudes between 10:00 amand 3:00 pm in bare chest & back is usually sufficient toensure adequate synthesis of vitamin-D metabolites. So,It will be very difficult to achieve the necessary amount ofvitamin D by safe sun exposure.Furthermore,the presentstudy demonstrated that tea intake and H/O vitaminDsupplementation were protective factors againstvitaminD deficiency. Such an observation suggests thatsubjectswith theserisk factors will particularly benefit fromvitamin D supplementationand/or food fortification andincreased sunshine exposure andtea consumption.CONCLUSIONVitamin D deficiency is very common (89.8% with 25(OH)D 20 ng/ml) among doctors of tertiary care institute andhospital in Bangladesh and and is largely attributed toobesity, female sex, smoking, hypertension and CHD.It isvery difficult to achieve the necessary amount of vitaminD by safe sun exposure and fortified food. History ofThe Journal of Bangladesh Orthopaedic Society

Ortho-Make (January 2016 Vol 31 No. 1)Evaluation of Vitamin D Status among Doctors of a Specialized Hospital in BangladeshVitamin D supplementation has a statistically significantassociation with vitamin D Deficiency. Considering thatvitamin D deficiency is very common in all age groups andthat few foods contain vitamin D, supplementation mightbe considered at suggested daily intake and tolerableupper limit levels, depending on age and clinicalcircumstances.Van Schoor, N.M.; Lips, P. Worldwide Vitamin D Status.Best Pract. Res. Clin. Endocrinol. Metab. 2011, 25, 671–680.2.Mithal, A.; Wahl, D.A.; Bonjour, J.P.; Burckhardt, P.;Dawson-Hughes, B.; Eisman, J.A.; El-Hajj Fuleihan, G.;Josse, R.G.; Lips, P.; Morales-Torres, J.; et al. Globalvitamin D status and determinants of hypovitaminosis D.Osteoporos Int. 2009, 20, 1807–1820.3.Van der Meer, I.M.; Middelkoop, B.J.; Boeke, A.J.; Lips,P. Prevalence of vitamin D deficiency among Turkish,Moroccan, Indian and sub-Sahara African populations inEurope and their countries of origin: An overview.Osteoporos. Int. 2011, 22, 1009–1021.4.Ganji V, Zhang X, Tangpricha V. Serum 25-hydroxyvitaminD concentrations and prevalence estimates ofhypovitaminosis D in the U.S. population based on assayadjusted data. J Nutr. 2012; 142(3):498–507. [PubMed:22323766]5.Greene-Finestone LS, Berger C, de Groh M, et al. 25Hydroxyvitamin D in Canadian adults: biological,environmental, and behavioral correlates. Osteoporos Int.2011; 22(5):1389–1399. [PubMed: 20730415]6.van Schoor NM, Lips P. Worldwide vitamin D status.Best Pract Res Clin Endocrinol Metab. 2011; 25(4):671–680. [PubMed: 21872807]7.Singh RJ, Taylor RL, Reddy GS, Grebe SK. C-3 epimerscan account for a significant proportion of total circulating25-hydroxyvitamin D in infants, complicating accuratemeasurement and interpretation of vitamin D status. JClin Endocrinol Metab. 2006; 91(8):3055–3061. [PubMed:16720650]8.Arya V, Bhambri R, Godbole MM, Mithal A.Vitamin Dstatus and its relationship with bone mineral density inhealthy Asian Indians. Osteoporsis Int 2004; 15(1): 56—61.VOL. 31, NO. 2, JULY 2016849.Islam MZ, Lamberg-Allardt C, Karkkainen M, et al.(2002) Vitamin D deficiency: a concern in premenopausalBangladeshi women of two socio-economic groups in ruraland urban region. Eur J Clin Nutr 56:51-56.10.Haussler MR, Haussler CA, Bartik L, Whitfield GK, HsiehJC, Slater S, et al. (2008) Vitamin D receptor: molecularsignaling and actions of nutritional ligands in diseaseprevention. Nutr Rev 66:S98–S112. doi: 10.1111/j.17534887.2008.00093.x PMID: 1884485211.Davis CD, Dwyer JT (2007) The “sunshine vitamin”;benefits beyond bone? J Natl Cancer Inst 99:1563–5.PMID: 1797152312.Holick MF, Binkley NC, Bischoff-Ferrari HA, GordonCM, Hanley DA, Heaney RP, et al. Evaluation, treatment,and prevention of vitamin D deficiency: an EndocrineSociety clinical practice guideline. J Clin EndocrinolMetab. 2011;96(7):1911–30.13.Zhen D,Liu L, Guan C, Zhao N, & Tang X. High prevalenceof vitamin D deficiency among middle-aged and elderlyindividuals in northwestern China: its relations hip toosteoporosis and lifestyle factors. Bone.2015;71:1 528415714.Ardawi MS, Sibiany AM, Bakhsh TM, Qari MH,Maimani AA. High prevalence of vitamin D deficiencyamong healthy Saudi Arabian men: relationship to bonemineral density, parathyroid hormone, bone turnovermarkers, and lifestyle factors. Osteoporos Int2012;23:675–86.15.Hovsepian, S.; Amini, M.; Aminorroaya, A.; Amini, P.;Iraj, B. Prevalence of vitamin D deficiency among adultpopulation of Isfahan City, Iran. J. Health Popul. Nutr.2011,29, 49–155.16.Mehboobali N, Iqbal SP, Iqbal MP. High prevalence ofvitamin D deficiency and insufficiency in a low incomeperi-urban community in Karachi. JPMA. 2015;65: 946.17.Holick MF. Vitamin D, status: measurement,interpretation, and clinical application. Ann Epidemiol2009;19:73–8.18.Need AG, Morris HA, Horowitz M, Nordin C. Effects ofskin thickness, age, body fat,and sunlight on serum 25hydroxyvitamin D. Am J Clin Nutr 1993;58:882–5.REFERENCES1.84

Ortho-Make (January 2016 Vol 31 No. 1)85Original ArticleEvaluation of Closed Reduction ofShoulder Dislocation with or withoutAvulsion Fracture of Greater Tuberosityof Humerus in AdultMd. Nazrul Islam1, MAK Shamsuddin2, Md. Rezaul Alom3, Nazmul Huda4ABSTR

Nasir Uddin Ahmed, Suhel Ahmed, Nuzhat Nadia, Golam Sarwar, Abdus Salam, M A Gani Mollah Evaluation of the Treatment of Closed Tibial Diaphyseal Fracture by SIGN Interlocking 134 Intramedullary Nail in Adults Md. Ferdous Rayhan, Manjurul Haque Akanda Chowdhury, Md. Abdus Sabur,