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Current Medical Research and Opinion Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/icmo20

Vitamin D deficiency among the elderly: insights from Qatar a

a

Hanadi Khamis Alhamad , Navas Nadukkandiyil , Ayman El-Menyar a

bcd

a

, Luay Abdel Wahab ,

a

Anoop Sankaranarayanan & Essa Mubarak Al Sulaiti a

Al-Rumailah hospital, Hamad Medical Corporation DohaQatar

b

Weill Cornell Medical College DohaQatar

c

Hamad General Hospital DohaQatar

d

Ahmed Maher Teaching Hospital CairoEgypt Published online: 26 May 2015.

Click for updates To cite this article: Hanadi Khamis Alhamad, Navas Nadukkandiyil, Ayman El-Menyar, Luay Abdel Wahab, Anoop Sankaranarayanan & Essa Mubarak Al Sulaiti (2014) Vitamin D deficiency among the elderly: insights from Qatar, Current Medical Research and Opinion, 30:6, 1189-1196 To link to this article: http://dx.doi.org/10.1185/03007995.2014.900003

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Current Medical Research & Opinion 0300-7995 doi:10.1185/03007995.2014.900003

Vol. 30, No. 6, 2014, 1189–1196

Article FT-0074.R1/900003 All rights reserved: reproduction in whole or part not permitted

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Original article Vitamin D deficiency among the elderly: insights from Qatar

Hanadi Khamis Alhamad Navas Nadukkandiyil Al-Rumailah hospital, Hamad Medical Corporation, Doha, Qatar

Ayman El-Menyar Weill Cornell Medical College, Doha, Qatar Hamad General Hospital, Doha, Qatar Ahmed Maher Teaching Hospital, Cairo, Egypt

Luay Abdel Wahab Anoop Sankaranarayanan Essa Mubarak Al Sulaiti Al-Rumailah hospital, Hamad Medical Corporation, Doha, Qatar Address for correspondence: Hanadi Khamis Alhamad MD, Consultant, Geriatrics, Al-Rumailah hospital, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar. Tel.: +974 44394029; Fax: +974 44394031; [email protected]; [email protected] Keywords: Elderly – Geriatrics – Qatar – Vitamin D deficiency Accepted: 26 February 2014; published online: 13 March 2014 Citation: Curr Med Res Opin 2014; 30:1189–96

Abstract Objectives: Vitamin D (VitD) deficiency is associated with comorbidities in the elderly. The present study investigates the prevalence of VitD deficiency among the elderly in Qatar. Research design and methods: A retrospective study conducted between April 2010 and April 2012 that involved chart reviews. All elderly patients of age 65 years in geriatrics facilities including Rumailah hospital, skilled nursing facility and home healthcare services in Qatar were included in the study. Measurements: Patient characteristics and outcomes were analyzed and compared according to the severity of VitD deficiency. Correlation of VitD with comorbidities was analyzed. Mean follow-up period was 6 months. Results: A total of 889 patients were enrolled; the majority (66%) were females and the mean age was 75  8.7 years. Patient comorbidities included hypertension (76.5%), diabetes mellitus (63%), dyslipidemia, (47.5%), dementia (26%) coronary artery disease (24%) and cerebrovascular accident (24%). The mean baseline serum VitD level was 24.4  13.5 ng/ml; 72% of patients had VitD deficiency: mild (31%), moderate (30%) and severe (11%). Patients with severe VitD deficiency had significantly higher HbA1c levels compared with patients with optimal VitD (P ¼ 0.03). High density lipoprotein (HDL-C) levels were significantly lower in severe VitD deficiency patients compared with optimal VitD patients (P ¼ 0.04). There was a positive correlation between HDL-C and VitD level (r ¼ 0.17, P ¼ 0.001), whereas HbA1c levels showed negative correlation with VitD (r ¼ 0.15, P ¼ 0.009). Conclusions: A high prevalence of VitD deficiency (72%) was observed among the elderly in Qatar. Lower VitD was associated with higher HbA1c and lower HDL-C levels. Further studies are warranted to evaluate whether VitD supplementation controls diabetes mellitus (DM) and low HDL-C levels among the elderly.

Introduction Vitamin D (VitD) plays an important role in normal physiological function and is essential for bone mineralization1. Recently, VitD deficiency is under consideration due to the fact that it has been associated with cardiovascular disorders, malignancy, fractures and deaths2–4. VitD deficiency represents an important public health concern which is commonly observed worldwide5–7. VitD deficiency remains an under-recognized problem in the general population and is poorly defined in elderly patients. In a geriatric population, VitD deficiency has been associated with poor muscular, physical and cognitive physical performance as well as falls and fractures8. ! 2014 Informa UK Ltd www.cmrojournal.com

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VitD deficiency is significantly associated with older age and elderly patients who need hospitalization for a longer duration are more susceptible9,10. Advanced age and low exposure to sunlight are the major factors associated with VitD deficiency. Van der Wielen et al.11 found that regardless of geographical location, free-living elderly (470 years) living in 11 European countries are at substantial risk of inadequate VitD status during winter. Several studies have reported VitD deficiency among different populations from the Middle East12–15. A report from Kuwait showed subclinical VitD deficiency among veiled women16. Also, reports from Saudi Arabia demonstrated higher VitD deficiency in Saudi women. The authors found female gender, sedentary lifestyle and low milk consumption to be independently associated with lower VitD levels17. In a previous study from Qatar, El-Menyar et al. reported a high percentage (91%) of low VitD level (530 ng/ml) in adults (mean age: 49  12 years); they also found a strong association between low VitD and hypertension14. Several studies addressed the association between low VitD and high triglyceride (TG) levels, low levels of high density lipoprotein (HDL-C) and the quality of HDL18. Furthermore, the interference of ‘VitD’ in cholesterol synthesis and potential synergistic action with statins has been reported18. VitD also plays a role in insulin secretion and therefore is associated with type 2 DM (T2DM). Earlier studies suggested a significantly higher risk of T2DM in VitD deficient patients19,20. In contrast, Hidayat et al.21 observed no significant association between the incidence of T2DM and VitD deficiency in an older population. Patients with chronic kidney disease (CKD) have an exceptionally high rate of VitD deficiency that is further exacerbated by their reduced ability to convert 25-(OH) VitD into the active form: 1,25 dihydroxy-VitD22. There are no studies in the elderly population in the Gulf region. Therefore, the present study was designed to assess the prevalence of VitD deficiency and the associated risk factors among a geriatric population in Qatar.

Patients and methods Study setting This study was conducted between April 2010 and April 2012 and involved retrospectively collected data for elderly patients (65 years). All patients seen in geriatrics facilities including Rumailah hospital (out- and in-patients), skilled nursing facilities (SNF), and home healthcare services (HHS) were included, and their serum total 25-hydroxyvitamin D (25(OH)D) levels were measured. Patient who were not evaluated for VitD level or who had incomplete data were excluded. 1190

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Measures We developed a data-extraction tool that included information pertaining to demographics, body mass index (BMI was calculated based on the height and weight; kg/m2), blood investigations (complete blood count, serum albumin, calcium, phosphorus, parathyroid hormone and thyroid stimulating hormone (TSH), and 25(OH)D levels), comorbidities, medications, and outcome. For measurement of VitD, we used an immunoanalyser (Liaison, Diasorin Inc.). It is an automated direct competitive chemiluminescence immunoassay (CLIA) for quantitative determination of total 25-OH VitD in serum or plasma. The imprecision at 56 and 19 ng/ml as measured by coefficient of variation was 8.7 and 13.2%, respectively14. VitD deficiency was defined as 530 ng/ml which was further subdivided into mild (20–29 ng/ml), moderate (10–19 ng/ml) and severe insufficiency (510 ng/ml)14,21. Patient characteristics and outcomes were analyzed and compared according to the severity of VitD deficiency. Patients were followed up after 6 months for re-evaluation of VitD levels and all-cause mortality. The Medical Research Center at Hamad Medical Corporation, Qatar, approved the study (IRB# 12122).

Statistical analysis Data are presented as proportions, medians, or mean  SD as appropriate. The continuous variables were analyzed using Student’s t tests or one-way ANOVA wherever applicable. For skewed continuous data, a non-parametric Mann–Whitney test was used. Categorical variables between groups were compared using the chi-square test. We evaluated the associations between VitD deficiency and socio-demographic and clinical indicators. We also studied correlation between age, HbA1c, HDL-C and VitD levels using Pearson’s correlation method. A twotailed P50.05 was considered significant. All data analyses were carried out using the Statistical Package for Social Sciences version 18 (SPSS Inc., USA).

Results A total of 889 patients were enrolled in the study with a mean age of 74.9  8.7 years. A summary of the results is presented in Tables 1–3. The majority of patients were females (66%) and 77% were Qataris. Sixty percent of the patients were recruited from HHS followed by the out-patient (31.8%) and in-patient (7.2%) departments. Patients were mainly diagnosed with hypertension (76.5%), diabetes mellitus (63.2%), dyslipidemia, (47.5%), dementia (26.25%), coronary artery disease (23.65%) and cerebrovascular accident (24.4%) (Table 1). www.cmrojournal.com ! 2014 Informa UK Ltd

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Table 1. Demographics, clinical presentation and outcome in geriatric patients (n ¼ 889). Age (years)* Female Unit Home Care Out-Patient In-Patient Nationality Qatari Non-Qatari Marital Status Married Non-Married Diagnosis Hypertension Diabetes Mellitus (Type II) Dyslipidemia Cerebrovascular Accident Dementia Coronary Artery Disease Hypothyroidism Heart Failure Renal Dysfunction Fracture Traumatic Injury Aspiration Pneumonia Urinary Tract Infection

74.9  8.7 589 (66.3%) 421 (59.3%) 283 (31.8%) 64 (7.2%) 655 (76.6%) 200 (23.4%) 473 (60.1%) 314 (39.9%) 680 (76.5%) 562 (63.2%) 422 (47.5%) 217 (24.4%) 233 (26.2%) 210 (23.6%) 110 (12.4%) 37 (4.2%) 99 (11.1%) 32 (3.6%) 21 (2.4%) 24 (2.7%) 12 (1.3%)

Overall Vitamin D levels* Optimal Mild Deficiency Moderate Deficiency Severe Deficiency Medication Multi-Vitamin Proton Pump Inhibitors Vitamin D 50,000 IU (Orally) Calcium Supplement Combined Fosamax þ VitD Calcium þ VitD Baseline Vitamin-D (ng/ml)* Calcium (mmol/L)* Phosphorus (mmol/L)* Parathyroid hormone (pmol/L)** Follow-Up Vitamin D (ng/ml)* Calcium (mmol/L)* Phosphorus (mmol/L)* Parathyroid hormone (pmol/L)** Mortality

24.4  13.5 175 (28.2%) 195 (31.4%) 184 (29.6%) 67 (10.8%) 147 (16.5%) 304 (34.2%) 298 (33.5%) 79 (8.9%) 7 (0.8%) 2 (0.2%) 24.4  13.5 2.3  0.14 1.17  0.29 65 (4–625) 28.5  13.4 2.28  0.2 1.19  0.3 85 (4–848) 11 (1.2%)

*Mean  SD. **Median (range).

At baseline, the mean serum VitD level was 24.4  13.5 ng/ml. The majority of patients (72%) had VitD deficiency (mild [31.4%], moderate [29.6%], and severe [10.8%]) (Table 1). Oral VitD supplementation was prescribed for 33.5% of patients. Follow-up VitD level (after 6 months) was available in 325 cases; the serum VitD changed to 28.5  13.4 (P ¼ 0.001). Table 2 describes the frequency of association of sociodemographic and clinical variables according to VitD levels. VitD deficiency was more common in females (mild [70.3 vs. 29.7%], moderate [68.5 vs. 31.5%] and severe [70 vs. 30%]; P ¼ 0.91); however, this was not significant. Patients admitted to HHS had significantly more VitD deficiency (mild [54.2 vs. 45.8%], moderate [68.0 vs. 32%] and severe [87.5 vs. 15%]; P ¼ 0.001) than other admitting services. Married patients had significantly higher numbers of optimal VitD level. On admission, diagnoses were comparable according to VitD levels. Oral VitD supplementation (P ¼ 0.003) and proton pump inhibitors (P ¼ 0.038) were prescribed more in VitD deficient patients (Table 2). The mean age was comparable among different VitD deficiency groups (P ¼ 0.462) (Table 3). The mean blood glucose level was significantly higher in the severe VitD deficiency group compared with the optimal group (9.5  5 vs. 7.2  3.2 ng/ml; P ¼ 0.005). Similarly, more patients in the severe group had increased HbA1c level compared with patients with optimal VitD levels (8.0  1.9 vs. 7.0  1.5%; P ¼ 0.03). ! 2014 Informa UK Ltd www.cmrojournal.com

Patients with severe VitD deficiency also had lower mean HDL-C level than those with optimal VitD levels (1.1  0.4 vs. 1.4  0.9 mmol/l; P ¼ 0.04). The overall mortality was 1.2% and was comparable among all VitD deficiency groups (P ¼ 0.755). In patients with T2DM and an eGFR 30 ml/min/ 1.73 m2, the mean eGFR was 55.3  8.5 ml/min/1.73 m2. Of these, 55 (19.9%) had Kidney Disease Outcomes Quality Initiative CKD stage 1 disease (eGFR 90 ml/ min/1.73 m2), 142 (51.4%) had stage 2 disease (eGFR 60–89 ml/min/1.73 m2), and 79 (28.6%) had stage 3 disease (eGFR 30–59 ml/min/1.73 m2). There was no significant association between eGFR in DM and VitD levels (P ¼ 0.43). There was no correlation analysis done between VitD level and eGFR in non-diabetic patient as the study population was negligible. Figures 1 and 2 describe the correlation between VitD deficiency and HDL-C and HbA1c. There was a positive association between HDL-C and VitD levels (r ¼ 0.173, P ¼ 0.001), whereas HbA1c levels showed negative correlation with VitD levels (r ¼ 0.152, P ¼ 0.009).

Discussion A high prevalence of VitD deficiency has been reported among the young in Qatar, which could be related to lifestyle and socio-cultural practices23. However, the relationship between VitD deficiency and its impact on the The elderly and vitamin D in Qatar Alhamad et al.

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Table 2. Comparison of qualitative variables according to vitamin D levels (VDL).

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Optimal VDL (n ¼ 175)

Gender Female Male Unit HHS Out-Patient In-patient Nationality Qatari Non-Qatari Marital Status Married Non-Married Diagnosis (On Admission) Diabetes Mellitus (T2DM) Hypertension Dementia Coronary Artery Disease Heart Failure Dyslipidemia Renal Dysfunction Cerebrovascular Accident Hypothyroidism Fracture Traumatic Social Admission Aspiration Pneumonia Urinary Tract Infection Infected Bedsore Medication Multi-Vitamins Proton Pump Inhibitors Vitamin D 50,000 IU (Orally) Calcium Supplement Fosamax þ Vitamin D Calcium þ Vitamin D Mortality

Vitamin D Deficiency

P

Mild (n ¼ 195)

Moderate (n ¼ 184)

Severe (n ¼ 67)

126 (72.0%) 49 (28%)

137 (70.3%) 58 (29.7%)

126 (68.5%) 58 (31.5%)

47 (70%) 20 (30%)

0.912

66 (42.0%) 67 (42.7%) 24 (15.3%)

91 (54.2%) 55 (32.7%) 22 (13.1%)

102 (68.0%) 34 (22.7%) 14 (9.3%)

49 (87.5%) 5 (9.4%) 2 (3.6%)

0.001

135 (79.4%) 35 (20.6%)

146 (77.2%) 43 (22.8%)

133 (75.6%) 43 (24.4%)

49 (76.6%) 15 (23.4%)

0.354

104 (69.8%) 45 (30.2%)

88 (52.0%) 81 (48.0%)

89 (54.0%) 76 (46.0%)

28 (43.8%) 36 (56.2%)

0.008

107 (61.1%) 135 (77.1%) 43 (24.6%) 37 (21.1%) 7 (4.0%) 85 (48.6%) 24 (13.7%) 46 (26.3%) 26 (14.9%) 6 (1%) 2 (1.1%) 1 (0.6%) 5 (2.9%) 1 (0.6%) 1 (0.6%)

128 (65.6%) 159 (81.5%) 60 (30.8%) 36 (18.6%) 7 (3.6%) 97 (49.7%) 15 (2.4%) 50 (25.6%) 33 (16.98%) 5 (7.7%) 3 (1.5%) 2 (1.0%) 3 (1.5%) 4 (2.1%) 2 (1.0%)

124 (67.4%) 148 (80.4%) 44 (23.9%) 49 (26.6%) 11 (6.0%) 95 (51.6%) 31 (5%) 47 (25.5%) 25 (13.6%) 9 (16.8%) 9 (4.9%) 2 (1.1%) 4 (2.2%) 4 (2.2%) 2 (1.1%)

46 (68.7%) 47 (70.1%) 16 (23.9%) 22 (32.8%) 3 (4.5%) 31 (46.3%) 10 (1.6%) 18 (26.9%) 11 (16.4%) 5 (14.9%) 2 (3.0%) 3 (4.5%) 3 (4.5%) 0 (0.0%) 2 (3.0%)

0.566 0.217 0.388 0.055 0.703 0.879 0.055 0.996 0.824 0.302 0.100 0.101 0.565 0.376 0.461

34 (19.4%) 52 (29.7%) 65 (37.1%) 22 (12.6%) 1 (0.6%) 0 (0%) 2 (1.1%)

41 (21.0%) 79 (40.5%) 81(41.5%) 21 (10.8%) 1 (0.5%) 1 (0.5%) 1 (0.5%)

25 (13.6%) 76 (41.3%) 96 (52.2%) 19 (10.3%) 1 (0.5%) 0 (0%) 1 (0.5%)

15 (22.4%) 34 (50.7%) 39 (58.2%) 8 (11.9%) 0 (0%) 1 (1.5%) 0 (0%)

0.209 0.038 0.003 0.910 0.946 0.237 0.755

HHS: home healthcare services.

health of the elderly is still lacking. This is a unique study from our region that addresses the influence of age, diabetic status, and dyslipidemia on VitD among a geriatric population. The present study shows a high prevalence of VitD deficiency (71.8%) among the elderly in Qatar, which might be explained by limited sunlight exposure with increasing age, usually due to sedentary lifestyle, clothing, extreme summers and minimal outdoor activity. The incidence of VitD deficiency in our patients is in agreement with a study from Indonesia that reported 78.2% VitD deficiency among an elderly population21. Moreover, with increasing age the capacity of the skin to produce VitD on sunlight exposure also decreases3. In addition, advanced age reduces VitD (1,25(OH)2D) production by the kidneys24. Therefore, physiological changes and climate conditions together with advanced age influence VitD metabolism among the elderly25. In older age, VitD deficiency is associated with an increased risk of falls, 1192

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osteoporosis and fractures26. At present, investigation of plasma 25(OH)D is considered as a reliable marker for VitD level assessment27–28. In our study, significantly more patients from home HHS had VitD insufficiency as well as severe VitD deficiency compared with the in- and out-patient departments of Rumailah hospital (P ¼ 0.001). This is in keeping with previous reports from western literature that also showed a higher frequency of VitD insufficiency among communitydwelling elderly25. However, in the US, VitD insufficiency was incidentally lower in the elderly except in those patients who sustained hip fracture25. Lund et al.29 found VitD deficiency in 25% of hip fracture cases, of which 5% had severe VitD deficiency. However, the incidence of hip fractures in our study (14.9%) was relatively lower compared with earlier studies29. The present study observed severe VitD deficiency in 70% of elderly females; Hidayat et al.21 also reported higher incidence of VitD deficiency among elderly females www.cmrojournal.com ! 2014 Informa UK Ltd

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Table 3. Comparison of quantitative variables according to vitamin D levels (VDL).

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Baseline

Age (years) Body Mass Index Vitamin D (ng/ml) Calcium (mmol/L) Cholesterol (mmol/L) Triglycerides (mmol/L) TSH (mIU/L) ALP (IU/L) Glucose (mmol/L) HbA1c (%) LDL (mmol/L) eGFR (mL/min/1.73 m2) T4 (ng/L) Phosphorus (mmol/L) Parathormone (pmol/L) Hemoglobin (g/dl) HDL-C (mmol/L) Ejection Fraction (%) Albumin (mmol/L) Follow-up Vitamin D (2) ng/ml Parathyroid hormone (pmol/L) Calcium (mmol/L) Phosphorus (mmol/L)

Optimal VDL (n ¼ 175)

Vitamin D Deficiency

P

Mild (n ¼ 195)

Moderate (n ¼ 184)

Severe (n ¼ 67)

74  8.4 24.7  5.7 41.2  11.5 2.3  0.14 4.3  0.9 1.28  0.65 2.2  1.6 82.4  45.1 7.2  3.2 7.05  1.5 2.5  0.73 55.3  8.5 18  17.5 1.17  0.2 96.8  124.3 12.1  1.6 1.4  0.9 51.9  11.4 38.4  6.1

75.3  8.3 23.1  5.2 24.6  2.9 2.28  0.12 4.4  0.96 1.38  1.1 3.9  8.9 89.6  57.8 7.7  3.7 7.3  1.4 2.6  0.8 47.9  18.1 16  6.8 1.2  0.4 108.5  105.3 12  1.8 1.3  0.3 54.4  5.5 38.5  4.5

74.8  7.6 26.7  6.5 14.9  2.9 2.29  0.15 4.5  1.2 1.45  0.7 3.8  10.2 99.3  63.4 8.2  5.1 7.2  1.8 2.7  1 56.1  6.7 13.6  2 1.15  0.3 161  164 12.1  1.9 1.2  0.4 53.4  9.6 38.2  9.9

75.5  9.8 27.2  7.4 6.5  1.9 2.26  0.13 4.5  1 1.53  0.9 7.1  17.8 105  84 9.5  5 8  1.9 2.8  0.8 50  17.3 12.9  2.8 1.05  0.27 130.2  104.7 12.07  1.7 1.1  0.4 52.8  8.2 36.7  5.2

0.462 0.263 0.001 0.307 0.464 0.304 0.081 0.049 0.005 0.034 0.133 0.432 0.381 0.118 0.212 0.959 0.040 0.916 0.344

38.2  15.9 104  81.8 2.28  0.13 1.1  0.25

26.9  9.4 122.2  111.4 2.32  0.37 1.2  0.29

25.6  11.5 154.2  171.9 2.25  0.15 1.2  0.23

22.3  13.8 151.7  185.9 2.27  0.12 1.2  0.26

0.001 0.807 0.516 0.693

TSH: thyroid stimulating hormone; ALP: alkaline phosphatase; LDL-C: low density lipoprotein cholesterol; HDL-C: high density lipoprotein cholesterol; T4: thyroxine; eGFR: estimated glomerular filtration rate. All variables are expressed as mean  standard deviation.

in Indonesia compared with elderly males. This increased rate of VitD deficiency among women could be attributed to the socio-cultural practices (use of the veil) in our region. There is an increased association between T2DM and advanced age30. Moreover, several epidemiological studies have found a negative correlation between T2DM, obesity, and VitD deficiency31–33. Mathieu et al. advocated VitD supplementation for improving glucose tolerance in patients with VitD deficiency34. Further, Hidayat et al.21 reported that in obese elderly patients, higher BMI was significantly associated with increased VitD deficiency. Our findings confirm these earlier reports on the relationship between T2DM, BMI and VitD deficiency. In the present study, markers of T2DM (high fasting blood glucose levels and raised HbA1c) had a negative correlation with levels of circulating vitamin D3. It has been observed in our study that significantly higher levels of blood glucose (P ¼ 0.005) and HbA1c (P ¼ 0.03) were associated with severe VitD deficiency. The association of low VitD levels in CKD has also been well documented. Earlier studies showed that in majority of patients with advanced CKD (stage 2), the levels of VitD tend to be on the lower limit of the normal, whereas in patients with more advanced CKD (stage 3 and 4), VitD levels reached significantly lower ! 2014 Informa UK Ltd www.cmrojournal.com

values35,36. Also, elderly patients (465 years) had increased association of VitD deficiency and renal dysfunction with lower glomerular filtration rate (GFR)37. The present study showed that eGFR was not associated with VitD levels. Our findings are consistent with an earlier study showing no association between an impaired eGFR and VitD deficiency (P ¼ 0.432)38. Fraser et al.39 investigated the role of serum 25(OH)D, parathyroid hormone and calcium for the development of cardiovascular diseases. They found a positive association between HDL-C and 25(OH)D levels. In this study, significantly lower HDL-C levels were observed in patients with severe VitD deficiency which is consistent with the findings of Fraser et al.39. Thus, HDL-C level and VitD deficiency had a significant inverse relationship, as patients with lower levels of HDL-C had severe VitD deficiency. LDL-C and triglyceride were non-significantly higher in patients with severe VitD deficiency compared with those with optimal levels40. Several epidemiological studies highlighted the importance of VitD and calcium supplementation for community-dwelling, hospitalized and care home elderly. Considering the genetic and socio-cultural factors prevailing in the Middle East, management of VitD deficiency together with metabolic disorders should be an integral part of treatment for the elderly. Further, prevention of The elderly and vitamin D in Qatar Alhamad et al.

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3.0

High Density Lipoprotein-Cholesterol (mmol/l)

2.0

1.5

1.0

.5

.0 0

20

40

60

80

Vitamin D levels (ng/ml)

Figure 1. Correlation between HDL-C and vitamin D levels in geriatric patients (P ¼ 0.001).

15.0

12.5

HbA1c (%)

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2.5

10.0

7.5

5.0

0

20

40

60

Vitamin D levels (ng/ml)

Figure 2. Correlation between HbA1c and vitamin D levels in geriatric patients (P ¼ 0.009).

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VitD deficiency among the elderly could be useful for better management of high risk metabolic disorders such as T2DM and dyslipidemia which eventually improves care and outcome among this population. Important limitations of our study include the lack of the cause-specific mortality data as well as the details of VitD supplementation. Another limitation is that we have not taken into consideration the influence of seasons in our analyses. The retrospective nature of the study is another limitation. Despite these limitations, our study with a large sample size represents the geriatric population of our region. The present study gives an insight into the prevalence of VitD deficiency and its associated factors among the elderly in Qatar. In conclusion, a high incidence of VitD deficiency was observed in the elderly in Qatar. Lower serum VitD levels were inversely correlated with HbA1c and HDL-C levels. The follow-up showed a small but significant improvement in VitD level after VitD supplementation. Therefore, further intervention studies are warranted to evaluate whether VitD supplementation improves low HDL-C levels and/or glycemic control in T2DM.

Transparency Declaration of funding This study was not funded. Author contributions: H.K.A.: study design, data collection and manuscript drafting; N.N.: data collection and manuscript drafting; A.E.-M.: study design, data analysis and manuscript review; L.A.W.: data collection and manuscript drafting; A.S.: data collection and manuscript drafting; E.M.A.S.: study design and manuscript drafting. All the authors have read and approved the manuscript. Declaration of financial/other relationships H.K.A., N.N., A.E.-M., L.A.W., A.S., and E.M.A.S. have disclosed that they have no significant relationships with or financial interests in any commercial companies related to this study or article. CMRO peer reviewers may have received honoraria for their review work. The peer reviewers on this manuscript have disclosed that they have no relevant financial relationships. Acknowledgments The authors thank the nursing staff in the geriatric department for their care and cooperation. We are grateful to Dr Prem Chandra for his statistical analysis.

References 1. Mawer EB, Davies M. Vitamin D nutrition and bone disease in adults. Rev Endocr Metab Disord 2001;2:153-64 2. Dobnig H, Pilz S, Scharnagl H, et al. Independent association of low serum 25-hydroxyvitamin d and 1,25-dihydroxyvitamin D levels with all-cause and cardiovascular mortality. Arch Intern Med 2008;168:1340-9

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The elderly and vitamin D in Qatar Alhamad et al.

www.cmrojournal.com ! 2014 Informa UK Ltd

Vitamin D deficiency among the elderly: insights from Qatar.

Vitamin D (VitD) deficiency is associated with comorbidities in the elderly. The present study investigates the prevalence of VitD deficiency among th...
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