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Prevalence of vitamin D deficiency and its predictors in the Portuguese population: a nationwide population-based study

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A Correction to this article was published on 02 April 2020

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Abstract

Summary

Vitamin D deficiency is prevalent worldwide, but its prevalence is unknown in adult Portuguese population. In Portugal, 66% of adults present Vitamin D insufficiency/deficiency. Winter, living in Azores, older age, and obesity were the most important risk factors. It highlights the need of strategies to prevent vitamin D deficiency in Portugal.

Objective

To estimate the prevalence and risk factors of vitamin D deficiency in the adult Portuguese population.

Methods

Adults (≥ 18 years old) from the EpiReumaPt Study (2011–2013) were included. Standardized questionnaires on socio-demographic and lifestyle features were obtained. Serum 25-hydroxyvitamin D [25(OH)D] concentrations were evaluated using ADVIA Centaur VitD competitive immunoassay (Siemens Healthineers) in 2015–2017 as 25 (OH)D Level 0: ≤ 10 ng/mL; Level 1: 11–19 ng/mL; Level 2: 20–29 ng/mL, and Level 3: ≥ 30 ng/mL. Weighted multinomial regression analysis was conducted to evaluate the association between socio-demographic and lifestyle variables and vitamin D status.

Results

Based on weighted analysis, the estimated prevalence of levels of 25(OH)D ≤ 10, < 20, and < 30 ng/mL was 21.2, 66.6, and 96.4%, respectively. The strongest independent predictors of serum 25 (OH)D ≤ 10 ng/mL were living in the Azores archipelagos (OR 9.39; 95%CI 1.27–69.6) and having the blood sample collection in winter (OR 18.53; 95%CI 7.83–43.87) or spring (11.55; 95%CI 5.18–25.74). Other significant predictors included older age (OR 5.65, 95%CI 2.08–15.35), obesity (OR 2.61; 95%CI 1.35–5.08), current smoking (OR 2.33; 95%CI 1.23–4.43), and female gender (OR 1.9, 95%CI 1.1–3.28). Conversely, physical exercise (OR 0.48, 95%CI 0.28–0.81) and occasional alcohol intake (OR 0.48, 95%CI 0.29–0.81) were associated with a lower risk of 25(OH)D ≤ 10 ng/mL.

Conclusion

Vitamin D deficiency/insufficiency [25(OH)D < 20 ng/ml] is highly prevalent in Portugal, affecting > 60% of all Portuguese adults, with strong geographical and seasonal variation. This study highlights the need to critically assess the relevance of vitamin D deficiency as a public health problem and the urgent need for a wide and scientifically robust debate about the most appropriate interventions at the individual and societal levels.

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Change history

  • 02 April 2020

    The original version of this article, published on 02 March 2020, unfortunately contained an error on “Fig. 3 Prevalence of Vitamin D Levels by NUTSII.”

References

  1. Holick MF (2017) The vitamin D deficiency pandemic: approaches for diagnosis, treatment and prevention. Rev Endocr Metab Disord 18(2):153–165

    CAS  PubMed  Google Scholar 

  2. Cesareo R et al (2018) Italian Association of Clinical Endocrinologists (AME) and Italian Chapter of the American Association of Clinical Endocrinologists (AACE) Position Statement: Clinical Management of Vitamin D Deficiency in Adults. Nutrients 10(5)

  3. Holick MF et al (2011) Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 96(7):1911–1930

    CAS  PubMed  Google Scholar 

  4. Adams JS, Hewison M (2008) Unexpected actions of vitamin D: new perspectives on the regulation of innate and adaptive immunity. Nat Clin Pract Endocrinol Metab 4(2):80–90

    CAS  PubMed  PubMed Central  Google Scholar 

  5. Thacher TD, Clarke BL (2011) Vitamin D insufficiency. Mayo Clin Proc 86(1):50–60

    CAS  PubMed  PubMed Central  Google Scholar 

  6. Chowdhury R et al (2014) Vitamin D and risk of cause specific death: systematic review and meta-analysis of observational cohort and randomised intervention studies. BMJ 348:g1903

    PubMed  PubMed Central  Google Scholar 

  7. Garland CF, Kim JJ, Mohr SB, Gorham ED, Grant WB, Giovannucci EL, Baggerly L, Hofflich H, Ramsdell JW, Zeng K, Heaney RP (2014) Meta-analysis of all-cause mortality according to serum 25-hydroxyvitamin D. Am J Public Health 104(8):e43–e50

    PubMed  PubMed Central  Google Scholar 

  8. Mithal A, Wahl DA, Bonjour JP, Burckhardt P, Dawson-Hughes B, Eisman JA, el-Hajj Fuleihan G, Josse RG, Lips P, Morales-Torres J, IOF Committee of Scientific Advisors (CSA) Nutrition Working Group (2009) Global vitamin D status and determinants of hypovitaminosis D. Osteoporos Int 20(11):1807–1820

    CAS  PubMed  Google Scholar 

  9. Dawson-Hughes B, Heaney RP, Holick MF, Lips P, Meunier PJ, Vieth R (2005) Estimates of optimal vitamin D status. Osteoporos Int 16(7):713–716

    CAS  PubMed  Google Scholar 

  10. Bouillon R (2017) Comparative analysis of nutritional guidelines for vitamin D. Nat Rev Endocrinol 13(8):466–479

    CAS  PubMed  Google Scholar 

  11. Lips P et al (2019) MANAGEMENT OF ENDOCRINE DISEASE: current vitamin D status in European and Middle East countries and strategies to prevent vitamin D deficiency; a position statement of the European Calcified Tissue Society. Eur J Endocrinol

  12. Ross AC et al (2011) The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. J Clin Endocrinol Metab 96(1):53–58

    CAS  PubMed  Google Scholar 

  13. Ginde AA, Liu MC, Camargo CA Jr (2009) Demographic differences and trends of vitamin D insufficiency in the US population, 1988-2004. Arch Intern Med 169(6):626–632

    CAS  PubMed  PubMed Central  Google Scholar 

  14. Looker AC, Dawson-Hughes B, Calvo MS, Gunter EW, Sahyoun NR (2002) Serum 25-hydroxyvitamin D status of adolescents and adults in two seasonal subpopulations from NHANES III. Bone 30(5):771–777

    CAS  PubMed  Google Scholar 

  15. Liu X, Baylin A, Levy PD (2018) Vitamin D deficiency and insufficiency among US adults: prevalence, predictors and clinical implications. Br J Nutr 119(8):928–936

    CAS  PubMed  Google Scholar 

  16. Greene-Finestone LS, Berger C, de Groh M, Hanley DA, Hidiroglou N, Sarafin K, Poliquin S, Krieger J, Richards JB, Goltzman D, CaMos Research Group (2011) 25-Hydroxyvitamin D in Canadian adults: biological, environmental, and behavioral correlates. Osteoporos Int 22(5):1389–1399

    CAS  PubMed  Google Scholar 

  17. Rockell JE, Skeaff CM, Williams SM, Green TJ (2006) Serum 25-hydroxyvitamin D concentrations of New Zealanders aged 15 years and older. Osteoporos Int 17(9):1382–1389

    CAS  PubMed  Google Scholar 

  18. Hirani V, Cumming RG, Blyth FM, Naganathan V, le Couteur DG, Handelsman DJ, Waite LM, Seibel MJ (2013) Vitamin D status among older community dwelling men living in a sunny country and associations with lifestyle factors: the Concord Health and Ageing in Men Project, Sydney, Australia. J Nutr Health Aging 17(7):587–593

    CAS  PubMed  Google Scholar 

  19. Daly RM, Gagnon C, Lu ZX, Magliano DJ, Dunstan DW, Sikaris KA, Zimmet PZ, Ebeling PR, Shaw JE (2012) Prevalence of vitamin D deficiency and its determinants in Australian adults aged 25 years and older: a national, population-based study. Clin Endocrinol 77(1):26–35

    Google Scholar 

  20. Cashman KD, Dowling KG, Škrabáková Z, Gonzalez-Gross M, Valtueña J, de Henauw S, Moreno L, Damsgaard CT, Michaelsen KF, Mølgaard C, Jorde R, Grimnes G, Moschonis G, Mavrogianni C, Manios Y, Thamm M, Mensink GB, Rabenberg M, Busch MA, Cox L, Meadows S, Goldberg G, Prentice A, Dekker JM, Nijpels G, Pilz S, Swart KM, van Schoor N, Lips P, Eiriksdottir G, Gudnason V, Cotch MF, Koskinen S, Lamberg-Allardt C, Durazo-Arvizu RA, Sempos CT, Kiely M (2016) Vitamin D deficiency in Europe: pandemic? Am J Clin Nutr 103(4):1033–1044

    CAS  PubMed  PubMed Central  Google Scholar 

  21. Santos MJ, Fernandes V, Garcia FM (2015) Vitamin D insufficiency in a hospital population: a photograph from the laboratory perspective. Acta Medica Port 28(6):726–734

    Google Scholar 

  22. Bettencourt A, Boleixa D, Reis J, Oliveira JC, Mendonça D, Costa PP, Silva BMD, Marinho A, Silva AMD (2018) Serum 25-hydroxyvitamin D levels in a healthy population from the north of Portugal. J Steroid Biochem Mol Biol 175:97–101

    CAS  PubMed  Google Scholar 

  23. Santos A, Amaral TF, Guerra RS, Sousa AS, Álvares L, Moreira P, Padrão P, Afonso C, Borges N (2017) Vitamin D status and associated factors among Portuguese older adults: results from the nutrition UP 65 cross-sectional study. BMJ Open 7(6):e016123

    PubMed  PubMed Central  Google Scholar 

  24. Raposo L, Martins S, Ferreira D, Guimarães JT, Santos AC (2017) Vitamin D, parathyroid hormone and metabolic syndrome - the PORMETS study. BMC Endocr Disord 17(1):71

    PubMed  PubMed Central  Google Scholar 

  25. Rodrigues AM, Gouveia N, da Costa LP, Eusébio M, Ramiro S, Machado P, Mourão AF, Silva I, Laires P, Sepriano A, Araújo F, Coelho PS, Gonçalves S, Zhao A, Fonseca JE, de Almeida JM, Tavares V, da Silva JA, Barros H, Cerol J, Mendes J, Carmona L, Canhão H, Branco JC (2015) EpiReumaPt- the study of rheumatic and musculoskeletal diseases in Portugal: a detailed view of the methodology. Acta Reumatol Port 40(2):110–124

    PubMed  Google Scholar 

  26. Branco JC, Rodrigues AM, Gouveia N, Eusébio M, Ramiro S, Machado PM, da Costa LP, Mourão AF, Silva I, Laires P, Sepriano A, Araújo F, Gonçalves S, Coelho PS, Tavares V, Cerol J, Mendes JM, Carmona L, Canhão H, EpiReumaPt study group (2016) Prevalence of rheumatic and musculoskeletal diseases and their impact on health-related quality of life, physical function and mental health in Portugal: results from EpiReumaPt- a national health survey. RMD Open 2(1):e000166

    PubMed  PubMed Central  Google Scholar 

  27. Gouveia N, Rodrigues AM, Ramiro S, Machado P, da Costa LP, Mourão AF, Silva I, Rego T, Laires P, André R, Mauricio L, Romeu JC, Tavares V, Cerol J, Canhão H, Branco JC (2015) EpiReumaPt: how to perform a national population based study - a practical guide. Acta Reumatol Port 40(2):128–136

    PubMed  Google Scholar 

  28. Diário da República Portuguesa (5 Novembro 2002). Decreto-Lei n.° 244/2002. 2002: Portugal

  29. World Health Organization Obesity (2000) Preventing and managing the global epidemic. World Health Organ Tech Rep Ser 894(i-xii):1–253

    Google Scholar 

  30. VDSCP: list of certified participants. 2018 September 2018 [cited 2018 12 October 2018]; Available from: https://www.cdc.gov/labstandards/vdscp_participants.html

  31. Freeman J et al (2015) Performance evaluation of four 25-hydroxyvitamin D assays to measure 25-hydroxyvitamin D2. Clin Biochem 48(16–17):1097–1104

    CAS  PubMed  Google Scholar 

  32. World Medical Association Declaration of Helsinki (2013) Ethical principles for medical research involving human subjects. Jama 310(20):2191–2194

    Google Scholar 

  33. Estatistica, I.N.d., Relatório: Resultados definitivos dos CEnsus 2011, Portugal. Secondary Relatório: Resultados definitivos dos CEnsus 2011. 2012: Portugal

  34. Ramiro S, Canhao H, Branco JC (2010) EpiReumaPt protocol - Portuguese epidemiologic study of the rheumatic diseases. Acta Reumatol Port 35(3):384–390

    PubMed  Google Scholar 

  35. Manios Y et al (2017) A systematic review of vitamin D status in southern European countries. Eur J Nutr 57(6):2001–2036

  36. Mogire RM, Mutua A, Kimita W, Kamau A, Bejon P, Pettifor JM, Adeyemo A, Williams TN, Atkinson SH (2020) Prevalence of vitamin D deficiency in Africa: a systematic review and meta-analysis. Lancet Glob Health 8(1):e134–e142

    PubMed  Google Scholar 

  37. MacLaughlin J, Holick MF (1985) Aging decreases the capacity of human skin to produce vitamin D3. J Clin Invest 76(4):1536–1538

    CAS  PubMed  PubMed Central  Google Scholar 

  38. Holick MF (2007) Vitamin D deficiency. N Engl J Med 357(3):266–281

    CAS  Google Scholar 

  39. ter Borg S, Verlaan S, Hemsworth J, Mijnarends DM, Schols JM, Luiking YC, de Groot LC (2015) Micronutrient intakes and potential inadequacies of community-dwelling older adults: a systematic review. Br J Nutr 113(8):1195–1206

    PubMed  PubMed Central  Google Scholar 

  40. Wortsman J, Matsuoka LY, Chen TC, Lu Z, Holick MF (2000) Decreased bioavailability of vitamin D in obesity. Am J Clin Nutr 72(3):690–693

    CAS  PubMed  Google Scholar 

  41. Kassi EN et al (2015) Smoking is a significant determinant of low serum vitamin D in young and middle-aged healthy males. Hormones (Athens) 14(2):245–250

    Google Scholar 

  42. Manavi KR et al (2015) Effect of serum cotinine on vitamin D serum concentrations among american females with different ethnic backgrounds. Anticancer Res 35(2):1211–1218

    CAS  PubMed  Google Scholar 

  43. Skaaby T et al (2016) Longitudinal associations between lifestyle and vitamin D: a general population study with repeated vitamin D measurements. Endocrine 51(2):342–350

    CAS  PubMed  Google Scholar 

  44. Cheng L (2018) The convergence of two epidemics: vitamin D deficiency in obese school-aged children. J Pediatr Nurs 38:20–26

    PubMed  Google Scholar 

  45. Bouillon R, Bikle D (2019) Vitamin D metabolism revised: fall of dogmas. J Bone Miner Res 34(11):1985–1992

    PubMed  Google Scholar 

  46. Holmes EW, Garbincius J, McKenna KM (2013) Analytical variability among methods for the measurement of 25-hydroxyvitamin D: still adding to the noise. Am J Clin Pathol 140(4):550–560

    CAS  PubMed  Google Scholar 

  47. Farrell CJ et al (2012) State-of-the-art vitamin D assays: a comparison of automated immunoassays with liquid chromatography-tandem mass spectrometry methods. Clin Chem 58(3):531–542

    CAS  PubMed  Google Scholar 

  48. Wyness SP, Straseski JA (2015) Performance characteristics of six automated 25-hydroxyvitamin D assays: mind your 3s and 2s. Clin Biochem 48(16–17):1089–1096

    CAS  PubMed  Google Scholar 

  49. Janssen MJ, Wielders JP, Bekker CC, Boesten LS, Buijs MM, Heijboer AC, van der Horst F, Loupatty FJ, van den Ouweland J (2012) Multicenter comparison study of current methods to measure 25-hydroxyvitamin D in serum. Steroids 77(13):1366–1372

    CAS  PubMed  Google Scholar 

  50. Colak A et al (2013) Effect of sample type, centrifugation and storage conditions on vitamin D concentration. Biochem Med (Zagreb) 23(3):321–325

    CAS  Google Scholar 

  51. Tanner M, Kent N, Smith B, Fletcher S, Lewer M (2008) Stability of common biochemical analytes in serum gel tubes subjected to various storage temperatures and times pre-centrifugation. Ann Clin Biochem 45(Pt 4):375–379

    CAS  PubMed  Google Scholar 

  52. Mena-Bravo A, Calderón-Santiago M, Luque de Castro MD, Priego-Capote F (2019) Evaluation of short-term storage prior to analysis of vitamin D3 and metabolites in human serum by liquid chromatography coupled to tandem mass spectrometry. Talanta 198:344–349

    CAS  PubMed  Google Scholar 

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Acknowledgments

We acknowledge the support from the EpiReuma Study Group and the invaluable input from Loreto Carmona, Phd, on the initial development of the study protocol.

Funding

This study received financial support from Portuguese Society of Rheumatology, Siemens Portugal, Jaba-Recordati and Tecnimed. There was no influence whatsoever of the sponsors on the design and performance of the study or analysis and report of its results.

Author information

Authors and Affiliations

  1. Department of Rheumatology, Centro Hospitalar e Universitário de Coimbra, Praceita Prof. Mota Pinto, 3000-075, Coimbra, Portugal

    Catia Duarte, Helena Carvalheiro, Andréa Marques, Tânia Santiago & José António Pereira da Silva

  2. Coimbra Institute for Clinical and Biomedical Research (iCBR) - Faculty of Medicine, University of Coimbra, Azinhaga Santa Comba, Celas, 3000-548, Coimbra, Portugal

    Catia Duarte, Tânia Santiago & José António Pereira da Silva

  3. Center for Neuroscience and Cell Biology, Faculdade de Medicina, University of Coimbra, Rua Larga, Pólo I,1°, 3004-504, Coimbra, Portugal

    Helena Carvalheiro

  4. EpiDoC Unit, CEDOC, NOVA Medical School, Universidade Nova de Lisboa (NMS-UNL), Rua Câmara Pestana, n°6, 6-A Edificio CEDOC II, 1150-082, Lisbon, Portugal

    Ana M. Rodrigues, Sara S. Dias, Helena Canhão & Jaime Cunha Branco

  5. Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028, Lisbon, Portugal

    Ana M. Rodrigues

  6. Center for Innovative Care and Health Technology (ciTechCare), Escola Superior de Saúde de Leiria (ESSLei), Instituto Politécnico de Leiria (IPLeiria), Campus 2- Morro do Lena- Alto do Vieiro, Apartado 4137, 2411-901, Leiria, Portugal

    Sara S. Dias

  7. Health Sciences Research Unit: Nursing Coimbra, Coimbra Nursing School, ESEnfc, Avenida Bissaya Barreto, Apartado 700, 3046-851, Coimbra, Portugal

    Andréa Marques

  8. National School of Public Health, Universidade Nova de Lisboa, Avenida Padre Cruz, 1600-560, Lisbon, Portugal

    Helena Canhão

  9. CHLC – Hospital Curry Cabral, Rua da Beneficência n.° 8, 1069-166, Lisbon, Portugal

    Helena Canhão

  10. Rheumatology Department, Centro Hospitalar de Lisboa Ocidental | Egas Moniz Hospital, Rua da Junqueira, 126, 1349-019, Lisbon, Portugal

    Jaime Cunha Branco

Authors
  1. Catia Duarte
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  2. Helena Carvalheiro
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  3. Ana M. Rodrigues
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  6. Tânia Santiago
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  7. Helena Canhão
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  8. Jaime Cunha Branco
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  9. José António Pereira da Silva
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Contributions

CD wrote the article. All the authors were involved in revising the manuscript critically and approved the final version to be submitted for publication. CD had full access to all of the data in the study and takes responsibility for its integrity and for the accuracy of the data analysis.

Study conception and design: CD, AM, JAPS.

Acquisition of data: AR, HC, JB, CD, HC.

Analysis and interpretation of data: CD, AR, SD, JAPS.

Final report writing: CD and JAPS.

Report revision and approval: all authors.

Corresponding author

Correspondence to Catia Duarte.

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Competing interests

Da Silva has received honoraria as speaker on Vitamina D from Tecnimed, Jaba-Recordati, Azevedos, Merck S.A, Laboratórios Vitoria and Siemens. da Silva has received as Scientific Director of Forum D (http://forumd.org/forumd/), which receive unrestricted financial support of pharmaceutical companies. Duarte has received Scientific Redactor of Forum D (http://forumd.org/forumd/) which received unrestricted financial support of pharmaceutical companies.

Ethics approval and consent to participate

This study was conducted respecting the Declaration of Helsinki and was approved by Coimbra Medical School Ethics Committee and EpiReumaPt Scientific Board.

EpiReumaPt was performed according to the principles established by the Declaration of Helsinki, revised in Fortaleza [32]. EpiReumaPt was approved by the National Committee for Data Protection (Comissão Nacional de Proteção de Dados) and by the NOVA Medical School Ethics Committee. Written informed consent was obtained in all phases for all participants, including a separated informed consent for biobank. Further details of ethical issues of EpiReumaPt have been described elsewhere [27].

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Duarte, C., Carvalheiro, H., Rodrigues, A.M. et al. Prevalence of vitamin D deficiency and its predictors in the Portuguese population: a nationwide population-based study. Arch Osteoporos 15, 36 (2020). https://doi.org/10.1007/s11657-020-0695-x

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