Ann Pediatr Endocrinol Metab.  2021 Jun;26(2):92-98. 10.6065/apem.2040132.066.

Vitamin D insufficiency and its contributing factors in primary school-aged children in Indonesia, a sun-rich country

• Pulungan A
• Soesanti F
• Tridjaja B
• Batubara J

• KMID: 2517586
• DOI: http://doi.org/10.6065/apem.2040132.066

Abstract

Purpose
The prevalence of rickets is increasing worldwide in association with an increase in vitamin D deficiency. This study aimed to investigate the vitamin D profile of healthy school-aged children in a sun-rich country and its contributing factors.
Methods
This cross-sectional study was conducted in 120 healthy children from 7–12 years of age who live in Jakarta, Indonesia. Their demographic status, sun exposure duration time, and lifestyle were recorded using a structured questionnaire. Serum calcium, phosphate, bone-alkaline phosphatase (B-ALP), and 25-hydroxy vitamin D (25(OH)₂D₃) levels were measured. The participants were categorized into vitamin D sufficient and non-vitamin D sufficient groups, and we analyzed variables that contributed to the 25(OH)₂D₃ level.
Results
Of the participants, 73 (60.8%) were vitamin D sufficient, 45 (37.5%) were vitamin D insufficient, and 2 (1.7%) were vitamin D deficient. Sex, age, body mass index, Fitzpatrick skin type, daily milk intake, and clothing type were not different between the vitamin D sufficient and non-vitamin D sufficient groups. There were no differences in serum calcium, phosphate, and B-ALP between the 2 groups. Sun exposure time was significantly longer in the vitamin D sufficient group compared with that in the non-vitamin D sufficient group (511.4 min/wk vs. 318.7 min/wk, P=0.004), and this effect remained consistent on multivariate analysis after adjustment for covariates (adjusted odds ratio, 1.002; 95% confidence interval, 1.000–1.003). More participants in the vitamin D sufficient group did not use sunscreen (59 vs. 27, P=0.02), but this finding was inconsistent with our multivariate analysis.
Conclusion
Despite year-round sun exposure, approximately 1 in 3 primary school-aged children had insufficient vitamin D level. Sun exposure duration was a major contributing factor.

Keyword

Vitamin D deficiency; 25-Hydroxy vitamin D; Rickets; Sun-rich country

Reference

References

1. Munns CF, Shaw N, Kiely M, Specker BL, Thacher TD, Ozono K, et al. Global consensus recommendations on prevention and management of nutritional rickets. Horm Res Paediatr. 2016; 85:83–106.

2. Voortman T, van den Hooven EH, Heijboer AC, Hofman A, Jaddoe VW, Franco OH. Vitamin D deficiency in school-age children is associated with sociodemographic and lifestyle factors. J Nutr. 2015; 145:791–8.

3. Saggese G, Vierucci F, Prodam F, Cardinale F, Cetin I, Chiappini E, et al. Vitamin D in pediatric age: consensus of the Italian Pediatric Society and the Italian Society of Preventive and Social Pediatrics, jointly with the Italian Federation of Pediatricians. Ital J Pediatr. 2018; 44:1–40.

4. Bener A, Al-Ali M, Hoffmann GF. Vitamin D deficiency in healthy children in a sunny country: associated factors. Int J Food Sci Nutr. 2009; 60(Suppl 5):60–70.

5. Roh YE, Kim BR, Choi WB, Kim YM, Cho MJ, Kim HY, et al. Vitamin D deficiency in children aged 6 to 12 years: Single center's experience in busan. Ann Pediatr Endocrinol Metab. 2016; 21:149–54.

6. Absoud M, Cummins C, Lim MJ, Wassmer E, Shaw N. Prevalence and predictors of vitamin D insufficiency in children: a great britain population based study. PLoS One. 2011; 6:6–11.

7. Khor GL, Chee WS, Zalilah MS, Poh BK, Arumugam M, Ab Rahman J, et al. Vitamin D insufficiency and its association with obesity among primary school children in Kuala Lumpur, Malaysia. Osteoporos Int. 2010; 21(Idd):S717–8.

8. Kumar J, Muntner P, Kaskel FJ, Hailpern SM, Melamed ML. Prevalence and associations of 25-hydroxyvitamin D deficiency in US children: NHANES 2001-2004. Pediatrics. 2009; 124:1–18.

9. Rovner AJ, O'Brien KO. Hypovitaminosis D among healthy children in the United States: a review of the current evidence. Arch Pediatr Adolesc Med. 2008; 162:513–9.

10. Poh BK, Rojroongwasinkul N, Nguyen BK, Ruzita AT, Yamborisut U, et al. 25-hydroxy-vitamin D demography and the risk of vitamin D insufficiency in the South East Asian Nutrition Surveys (SEANUTS). Asia Pac J Clin Nutr. 2016; 25:538–48.

11. Fitzpatrick TB. The validity and practicality of sun-reactive skin types I through VI. Arch Dermatol. 1988; 124:869–71.

12. Center for Disease Control and Prevention. Defining childhood obesity [Internet]. Atlanta (GA): Center for Disease Control and Prevention;2018. [cited 2020 Jul 27]. Available from: https://www.cdc.gov/obesity/childhood/defining.html.

13. Nimitphong H, Holick MF. Prevalence of vitamin D deficiency in Asia vitamin D status and sun exposure in Southeast Asia. Dermatoendocrinol. 2013; 5:34–7.

14. Moy FM. Vitamin D status and its associated factors of free living Malay adults in a tropical country, Malaysia. J Photochem Photobiol B Biol. 2011; 104:444–8.

15. Al-Othman A, Al-Musharaf S, Al-Daghri NM, Krishnaswamy S, Yusuf DS, Alkharfy KM, et al. Effect of physical activity and sun exposure on vitamin D status of Saudi children and adolescents. BMC Pediatr. 2012; 12:92.

16. Zakharova I, Klimov L, Kuryaninova V, Nikitina I, Malyavskaya S, Dolbnya S, et al. Vitamin D insufficiency in overweight and obese children and adolescents. Front Endocrinol (Lausanne). 2019; 10:103.

17. Kumaratne M, Early G, Cisneros J. Vitamin D deficiency and association with body mass index and lipid levels in hispanic American adolescents. Glob Pediatr Heal. 2017; 4:1–4.

18. Durá-Travé T, Gallinas-Victoriano F, Chueca-Guindulain MJ, Berrade-Zubiri S. Prevalence of hypovitaminosis D and associated factors in obese Spanish children. Nutr Diabetes. 2017; 7:1–5.

19. Laing EM, Lewis RD. New concepts in vitamin D requirements for children and adolescents: a controversy revisited. Front Horm Res. 2018; 50:42–65.

20. Sawicki CM, Van Rompay MI, Au LE, Gordon CM, Sacheck JM. Sun-exposed skin color is associated with changes in serum 25-hydroxyvitamin d in racially/ethnically diverse children. J Nutr. 2015; 146:751–7.

21. HUGO Pan-Asian SNP Consortium, Abdulla MA, Ahmed I, Assawamakin A, Bhak J, Brahmachari SK, et al. Mapping human genetic diversity in Asia. Science. 2009; 326:1541–5.

22. Tumonggor MK, Karafet TM, Hallmark B, Lansing JS, Sudoyo H, Hammer MF, et al. The Indonesian archipelago: an ancient genetic highway linking Asia and the Pacific. J Hum Genet. 2013; 58:165–73.

23. Cancer Council Australia. SunSmart position statement | Cancer Council [Internet]. Sydney (Australia): Cancer Council;[cited 2020 Jul 27]. Available from: https://www.cancer.org.au/about-us/policy-and-advocacy/position-statements/sunsmart.

24. Kanellis VG. Ultraviolet radiation sensors: a review. Biophys Rev. 2019; 11:895–9.

25. Tolppanen AM, Fraser A, Fraser WD, Lawlor DA. Risk factors for variation in 25-hydroxyvitamin D 3and D 2 concentrations and vitamin D deficiency in children. J Clin Endocrinol Metab. 2012; 97:1202–10.

26. Ikonen H, Palaniswamy S, Nordström T, Järvelin MR, Herzig KH, Jääskeläinen E, et al. Vitamin D status and correlates of low vitamin D in schizophrenia, other psychoses and non-psychotic depression – The Northern Finland Birth Cohort 1966 study. Psychiatry Res. 2019; 279:186–94.