الفهرس 
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Abstract
Calcium and vitamin D work together to protect bones. Calcium helps build and maintain bones, while vitamin D helps the body to absorb calcium efficiently. Without enough vitamin D and calcium, bones may not form properly and can lose mass, become fragile, and break easily. Vitamin D insufficiency and inadequate calcium intakes are a global issue and tend to be inversely related to wide variety of diseases.
It was valuable to conduct this study to assess intake adequacy of vitamin D and calcium among adults, to assess knowledge of studied sample about dietary sources, importance and deficiency of vitamin D and calcium, to measure serum vitamin D and calcium level of adults, and to assess the risk factors of vitamin D and calcium deficiency.
This is a cross sectional study that was conducted in nutrition clinic in a private hospital in Alexandria. Three hundred and thirty-four apparently healthy adults (20 years and above) of both sexes willing to participate in the study were included. The study excluded pregnant females, those taking dietary supplements, with any bone or systemic diseases, taking medications or any other condition interfere with calcium or vitamin D metabolism.
Data were collected using the following study techniques and tools:
1- A pre-designed interviewing questionnaire to collect the sociodemographic data, such as age, sex, marital state, education, profession, and income. Also, the questionnaire included questions about smoking, clothing style, sun exposure and sunscreen use, physical activity, and fast food and soft drinks intake. Additionally, participants were asked about dietary sources, importance and deficiency of both calcium and vitamin D.
Food frequency list and the 24 hours recall method were used to assess the dietary intake of each participant. The nutritional content of the daily diet (macronutrients, calcium, and vitamin D) was analyzed and percent adequacy was calculated relative to the recommended intakes.
2- Body weight and height were measured for each participant and Body Mass Index (BMI) was calculated.
3- Serum calcium (mg/dl) and vitamin D (ng/ml) were obtained from hospital lab for each participant.
Data were collected from December 2019 till March 2020. The researcher sought the approval of the Ethics Committee of the High Institute of Public Health for conducting the research. A verbal consent was taken from all study participants after explanation of the purpose and benefits of the research. Data were fed to the computer and analyzed using IBM SPSS software package version 20.0, analyzed and tabulated. Results of the present study can be summarized as follows:
Female gender comprised 59.5% of the sample. The study population age ranged between 21 and 60 years, with mean of 36.98 ± 11.25 years. No significant differences were noted between both genders as regards the age, educational level, or the income, while significant differences were noted in the marital status and profession (p=0.012, p=0.001, respectively).
The highest percentage of the total participants were overweight (39.3%) followed by obese (32.5%). However, no significant difference was noted between both genders in the BMI. Few percentage of the participants were having knowledge about vitamin D and calcium sources, importance, the daily requirements and deficiency effect. No statistically significant differences were noted between males and females in either of the described knowledge data.
Less than half of the participants (43.6%) had good knowlrdge about vitamin D and calcium, with females showing higher knowledge percentage (44.8%, compared to 41.7% in males). The difference is clinicaly insignificant (p= 0.728). The study particpants showed a mean score of 5.67 ± 3.50, and mean score percentage of 48.13 ± 29.92 %. These values were slightly higher in females (5.85 ± 3.66; 48.71 ± 30.48%) than males (5.67 ± 3.50; 47.29 ± 29.17). No statistically significant difference was noted (p = 0.643).
There were no significant differences noted between both genders in the serum levels of both the calcium and vitamin D. The majority of the study participants (94.5%) were having normal calcium levels, while only 14.4% of the study participants had sufficient vitamin D levels. No significant differences were noted between both genders in the frequency intake of different foods per week apart from fat full yogurt (higher in males) and nuts (higher in females) with p values of 0.013 and 0.01 respectively. The median values for daily intake of vitamin D and calcium were 11.85 µg/d and 1145.2mg/day respectively, with no significant difference between both genders. Males showed significantly higher energy (Kcal/day), protein (g/day), carbohydrates (g/day) and fat (g/day) intakes, with median values of 1410.10, 79.40, 163.81 and 44.34, respectively.
Vitamin D, energy (Kcal/day), carbohydrates and fat intakes by both genders failed to meet the recommended reference intakes with adequacy percentage of 78.97%, 44.39% and 50.18%, respectively, with lower %adequacy in males than females as regards energy (Kcal/day), carbohydrates and fat, that was statistically significant (p=0.001, 0.005, 0.023, respectively). Calcium and protein intakes were higher than the recommended references, with adequacy percentage of 124.36% and 103.61%, respectively.
Vitamin D deficiency was more prevalent among those aged >50 years old with statistically significant difference (p=0.004). Females had vitamin D deficiency (62.4%) higher than males (54.5%), but with no statistically significant difference. As regards the educational level, vitamin D deficiency was higher in those with technical and primary school graded (66.7%) than university graduates (57.2%), with no statistically significant difference. participants whose income was not enough had vitamin D deficiency higher than those who had enough income (66.7%, 56.5%, respectively). No statistical significance was noted. Vitamin D deficient participants were obese (65.1%) higher than other BMI categories, vitamin D deficiency was higher among sunscreens users than nonusers, female participants wearing Niqab had higher percentages of vitamin D deficiency (73.7%) as compared to those who wear Hijab (60.0%), with no statistically significant difference. the least percentage of vitamin D deficiency was noted in those who expose to sun at noon (50%), with statistically significant difference (p=0.006).
Calcium deficiency was was higher among those aged 31-40 and 41-50 years old than other age groups with no statistically significant difference (p=0.764). Females had calcium deficiency (7.2%) higher than males (3.0%), but with no statistically significant difference (p= 0.335). As regards the educational level, calcium deficiency was not different from technical and primary school graded and university graduates (5.8% and 5.4%, respectively).
Participants whose income was not enough had calcium deficiency more than those who had enough income (6.9% and 5.0%, respectively), but the difference was not statistically significant (p = 0.584). Calcium deficiency was more in those who didn’t exercise (6.2%) compared to those who had exercise (4.3%) with no statistically significant difference (p= 0.493). As regard drinking soft drinks regularly, calcium deficiency was higher among participants who were regularly drinking soft drinks (7.8%) than those who weren’t drinking (0.9%) and the difference was statistically significant (p= 0.011). Concerning dietary intake and % adequacy, serum calcium level was low among those who had low calcium and vitamin D intakes and low vitamin D adequacy with statistically significant difference (p=0.05, 0.021 and 0.02, respectively).
Protein intake was lower while % adequacy was higher among those with low serum calcium level than those with normal serum calcium, however the difference wasn’t statistically significant (p=0.795 and 0.705, respectively). Calcium deficiency was higher in those who never eat eggs as compared to those who eating it more than 3 times a week (p = 0.07). The same findings were detected in whole milk, the fresh tuna, fresh salmon, fresh sardines, canned fish, salted fish (sardines) with statistically non-significant difference.
No significant association was noted between all the tested variables and vitamin D levels (vitamin D intake (µg/d) sunscreens usage /times per day or food frequency intake/week). Association was found only between drinking soft drinks regularly and the calcium levels (p= 0.036). Otherwise, all the other tested variables did not show significant association with calcium levels (educational level, income, or food frequency /week).
from data of the current study, the following conclusions have been reached:
• Vitamin D deficiency is prevalent (59.2% of this study sample had deficiency, 26.4% had insufficiency and 14.4% were of normal levels) among apparently healthy adults, especially among women and in older age groups.
• The older age group showed the higher levels of vitamin D deficiency, which warrants signs of proper assessment and management.
• Bad awareness has been shown concerning calcium and vitamin D (as regards importance, aily requirements, sources and complications of calcium and vitamin D deficiency).
• Although the studied sample showed optimum mean of sun exposure hours per day of 1.25 ± 1.07, vitamin D deficiency was high probably due to that more than half (59.5% %) of the sample were females ,58.8% of them were wearing hijab or niqab, seasonal variation as the study was conducted in winter timing of sun exposure; as small percentage were exposing to the sun at the noon time (35.6% of males and 26.5% of females) and 71.1% of the sample had variable degrees of obesity.
• Obesity, which was prevalent among this study sample, has been shown to be significantly linked to vitamin D deficiency.
• Calcium levels were normal (≥8.8 mg/dl) in most of this study sample (94.5%), although, vitamin D deficiency was prevalent among the study sample.
• In calcium deficient participants, soft drinks were found to be involved, elucidating its harmful effect on bone and general body health.
• Considering the findings of the present study, the following recommendations are proposed:Periodic screeninig of vitamin D
• To enhance the comprehensive education and awareness campaigns to increase the knowledge of the population about this widespread epidemic.
• To assess the contribution of different modifiable and non-modifiable factors (such as genetic and skin pigmentation differences) to the problem.
• Healthcare professionals must be aware of the growing prevalence of vitamin D deficiency not only among patients with established risk factors, such as obesity, or diabetes.
• As a general practitioner and family physician, when there is suspicion of vitamin D deficiency and blood samples have been collected to validate the diagnosis, they should begin vitamin D supplementation.
• Population individuals, especially women with high percentage of covering, such as Niqab should have regular times of sun exposure, this could be assumed in open regions with optimum privacy and to focus on the best time of exposure (noon time).
• To assess the vitamin D status of others with overt chronic diseases such as HIV, cancers, and tuberculosis to identify risk groups for vitamin D deficiency for better intervention in healthcare.