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Nutrients. 2017 Mar; 9(3): 260.
Prevalence of Vitamin D Deficiency and Its Associations with Skin Colour in Pregnant Women in the Starting time Trimester in a Sample from Switzerland
Katharina C. Quack Lötscher
twoClinic of Obstetrics, University Hospital Zurich, Frauenklinikstrasse x, CH-8091 Zurich, Switzerland
Received 2017 Jan 29; Accustomed 2017 Mar 6.
Abstract
Vitamin D deficiency in pregnancy has negative clinical consequences, such as associations with glucose intolerance, and has been shown to exist distributed differently in certain indigenous groups. In some countries, a difference in the charge per unit of vitamin D deficiency was detected in pregnant women depending on their peel color. We examined the prevalence of vitamin D deficiency (<xx ng/mL) in women in early pregnancy in Switzerland and evaluated the association of skin color with vitamin D deficiency. In a single-eye cohort study, the validated Fitzpatrick scale and objective melanin index were used to determine skin color. Of the 204 pregnant women included, 63% were vitamin D deficient. The mean serum 25-hydroxyvitamin D concentration was 26.one ng/mL (95% conviction interval (CI) 24.eight–27.iv) in vitamin D–sufficient women and 10.v ng/mL (95% CI 9.vii–11.5) in women with deficiency. In the most parsimonious model, women with dark peel colour were statistically significantly more often vitamin D deficient compared to women with low-cal skin color (OR two.60; 95% CI 1.08–half-dozen.22; adjusted for age, season, vitamin D supplement apply, body mass index, smoking, parity). This calls for more than intense counseling as one policy choice to better vitamin D status during pregnancy, i.due east., use of vitamin D supplements during pregnancy, in particular for women with darker skin color.
Keywords: vitamin D, pregnancy, skin color, vitamin D deficiency, Switzerland
one. Introduction
During the final century, vitamin D fortification programs have largely eradicated the wellness risks of vitamin D deficiency such every bit rickets and osteomalacia from western populations. Withal, vitamin D deficiency (<20 ng/mL) is reemerging and suboptimal vitamin D blood levels are widespread in industrialized nations, specifically in women with darker skin color [1,2,three,four,5,six,7]. A suboptimal vitamin D level is thought to exist associated with a range of diseases such as cardiovascular disease and diabetes [eight] equally well as with the gamble of several types of cancer or depression [ix,10]. Cholecalciferol (vitamin D3) is synthesized in the skin by sunlight (UVB) from seven-dehydrocholesterol, followed by transformation to the agile form 25-hydroxyvitamin D ((25(OH)D) in the liver. In a further step, 25(OH)D is metabolized into the physiologically agile 1,25-dihydroxyvitamin D (1,25(OH)2d) in the kidney. Every bit 25(OH)D has a half-life of 15 days, which is longer than that of 1,25(OH)2d, it is considered to be the better indicator of vitamin D status. Individuals living in countries with less sunday exposure might be at higher risk for vitamin D deficiency [xi]. Additionally, during winter and spring, sun exposure is low in northern countries. Also geographic and weather circumstances, several studies showed that personal characteristics affect vitamin D synthesis. Circulating vitamin D concentrations differ by pare color: Individuals with darker skin produce less vitamin D with the same corporeality of sunlight exposure than individuals with lighter peel color [x,12]. In Europe, estimated vitamin D levels showed a large variation due to adventure factors such as clearing from countries with higher sunday exposure, low consumption of foods rich in vitamin D or depression vitamin D supplementation [thirteen].
In pregnancy, increased calcium and adequate vitamin D levels are required and, thus, pregnant women are, in general, at college risk of vitamin D deficiency [6]. Vitamin D deficiency in pregnancy has been shown to be associated with a variety of clinical consequences [14,15,16,17] that range from a negative influence on glucose tolerance to an clan with preeclampsia. Vitamin D supplementation tin amend birth weight in certain ethnic groups [18].
Currently, the vitamin D condition of pregnant women living in Switzerland is unknown [xix] and, hence, the aim of our study was to evaluate vitamin D levels in pregnant women and to decide the prevalence of vitamin D deficiency. Furthermore, nosotros aimed to address the question of whether the prevalence of vitamin D deficiency differs between women with calorie-free or dark skin color, i.e., betwixt specific subgroups of the population living in Switzerland.
2. Materials and Methods
2.i. Study Population
Between September 2014 and December 2015, 80% of the women visiting the Clinic of Obstetric at the Academy Hospital Zurich for their first pregnancy visit in the first trimester were recruited for participation in this vitamin D study. The written report was approved by the ethics commission of the canton of Zurich, Switzerland (KEK-ZH-Nr. 2013-0213). Exclusion criteria were twin pregnancy, HIV, history of parathyroid, renal or liver affliction, chronic malabsorption syndromes or granuloma-forming disorders, age below 18 years or known or suspected drug or alcohol abuse, because they may modify vitamin D metabolism. We nerveless data of 205 women. Due to one missing information on vitamin D condition, our final sample consisted of 204 women.
2.2. Vitamin D Claret Samples
Afterward giving informed consent, a blood sample of 10 mL was collected during the routine blood drove of the pregnancy examination. Blood samples were centrifuged and serum was extracted in the Institute of Clinical Chemistry at the Academy Hospital Zurich within hours later on claret sampling. Total 25-hydroxyvitamin D was analyzed on the same twenty-four hour period using the vitamin D total-assay Roche Cobas® electrochemiluminescence immunoassay (Roche Diagnostics, Basel, Switzerland). The method has a detection range of 3.0–seventy.0 ng/mL for 25(OH) vitamin D and a variation coefficient of 2.ii%–half-dozen.8%.
Vitamin D deficiency was divers every bit 25(OH)D concentrations <20 ng/mL vs. sufficiency as ≥20 ng/mL as recommended by the Endocrine Lodge [xx]. The conversion factor to the SI units (nmol/L) is 2.496.
2.iii. Skin Colour
The doctor together with the participant filled out a questionnaire. The skin color of the women was assessed according to the classification by Fitzpatrick [21]. This scale allows for differentiating between pare phototypes based on skin reaction to sun exposure. The origin scale consists of six peel types (I to Half-dozen). Nosotros used an adapted scale, which converged type V (dark brown) and Half dozen (black) into blazon Five due to small numbers in these groups. The classification of skin type was assessed first past showing the participant a picture of the different skin color types (I–IV) and 2d, by request on what happens to the untanned skin if it is exposed in the early summer at noon for 45 to threescore min to the sunday. Answers varied from (I) "painful sunburn afterward 24 h and not tanned after one calendar week"; (II) "painful sunburn later on 24 h and minimally tanned later on one week"; (Three) "minimal sunburn after 24 h and uniformly tanned after one week"; (IV) "no sunburn after 24 h and tanned after one week" to (V) "Peel is deeply pigmented brown/black, no sunburn and tanned afterwards ane week". Based on the pictures and questions the women estimated their own peel phototype. Additionally, the interviewer evaluated the peel blazon. When the classification of meaning adult female and the interviewer disagreed, the rounded arithmetics hateful of was used to determine the skin colour type. Pare color blazon was dichotomized into Fitzpatrick scale I to 3 vs. IV and V.
Furthermore, the skin blazon was measured with a DSM 2 ColorMeter (Cortex Technology, Hadsund, Denmark) resulting in a melanin alphabetize [22]. The device is a narrow band spectroscopy musical instrument with a light-green diode centered on 568 nm and red diode centered on 655 nm. The device was calibrated every week with white residual. Melanin index was measured 3 times on the inner underarm and the arithmetic mean was calculated to categorize melanin in quartiles. Spearman correlation coefficient between melanin alphabetize and the Fitzpatrick index was 0.65.
ii.iv. Covariates
Based on the World Bank Map, country of a woman's origin (place of birth) was grouped into five categories; (ane) Switzerland and Germany; (two) Northern America, Northern Europe, Caucasus, Central Asia and New Zealand; (iii) Southern Europe, Australia, Latin America and the Caribbean; (four) South- and East Asia and Pacific; and (five) Africa and Middle East. For further analyses these countries were dichotomized into groups 1 and ii vs. groups three–5. Further covariates were age, week of pregnancy, parity, gravidity, body mass index (BMI) earlier pregnancy, actual BMI, educational level of the pregnant woman and her partner (less than compulsory didactics vs. low (compulsory teaching) vs. middle (secondary teaching) vs. high (tertiary education)), smoking status (never vs. old vs. current), season of blood collection (winter vs. spring vs. summertime vs. fall), number of days per week spent at least 1 hour outdoors in the past half year, dominicus protection (never vs. sometimes vs. always), fish consumption (simply salmon, tuna, mackerels and herring; at least in one case per week vs. less), vitamin D supplements intake every bit recommended 500 IE daily (yeah vs. no).
In addition, maternal age, parity, week of pregnancy, body mass index (BMI) before pregnancy and weight gain till the first visit were collected from medical records.
2.5. Statistical Analyses
All statistical analyses were conducted using STATA software version xiii.1 (College Station, TX, United states of america). Geometric means and corresponding 95% confidence intervals (CI) were used to illustrate the differences in vitamin D concentrations between light- and dark-skinned individuals.
Logistic regression analyses were used to determine associations of skin colour with vitamin D deficiency. The Akaike Data Criteria (AIC) was used for selecting the final model solution for multivariable aligning. As a result of the AIC and of dropping variables because of collinearity, nosotros presented the 4 near parsimonious models; (1) adjusted for age; (2) adapted for age and season, (3) adjusted for age, flavour, vitamin D supplement intake, BMI and smoking status; and (4) adapted for historic period, season, vitamin D supplement intake, BMI, smoking status and parity. Sensitivity-analyses were performed using the dichotomized countries of origin and the dichotomized melanin index (by median) instead of the Fitzpatrick scale. Differences between groups were examined using Anova and t-examination (p < 0.05, 2-sided).
3. Results
Descriptive characteristics of the 204 women are provided in Table 1 for women with and without vitamin D deficiency. A description by skin type can be found in Supplementary Table S1.
Table 1
Full general characteristics of pregnant women by vitamin D status.
| Variables of Interest | Vitamin D Sufficiency i | Vitamin D Deficiency 2 | p-Value v |
|---|---|---|---|
| northward (%) | 75 (37) | 129 (63) | |
| 25(OH)D ng/mL, geometric mean (95% CI) | 26.1 (24.eight–27.iv) | 10.five (ix.7–11.5) | <0.001 |
| Light skin color 3, % | 88 | 67 | <0.05 |
| Melanin levels, median (Q1, Q3) | 32.9 (30.8, 37.2) | 34.3 (30.eight, 41.8) | 0.07 |
| Age, mean (SD) | 31.ane (4.8) | 29.4 (4.8) | <0.05 |
| Week of pregnancy, median (Q1, Q3) | 9 (8, 10) | 9 (viii, x) | 0.39 |
| Parity, % nulliparous | 55 | 52 | 0.32 |
| Gravidity, % first pregnancy | 43 | 40 | 0.11 |
| BMI (kg/10002) before pregnancy, median (Q1, Q3) | 20.7 (19.7, 23.1) | 22.5 (twenty.4, 25.3) | <0.05 |
| BMI (kg/thouii) current, median (Q1, Q3) | 21.five (20.i, 23.ix) | 22.8 (20.7, 26.two) | <0.05 |
| State of origin, % | |||
| Switzerland and Deutschland | 35 | 14 | |
| North America, North Europe, Caucasus, Cardinal Asia and New Zealand (without Switzerland and Germany) | 28 | xv | |
| Southward Europe, Commonwealth of australia, Latin America and the Caribbean | 28 | 29 | |
| South-, East Asia and Pacific | 5 | 22 | |
| Africa and Middle East | iv | 22 | <0.001 |
| Educational level accomplished 4, % | |||
| less than compulsory education | 3 | 8 | |
| low education | 4 | 16 | |
| middle education | 35 | 33 | |
| high education | 59 | 44 | <0.05 |
| Educational level achieved of the partner 4, % | |||
| less than compulsory pedagogy | iv | eight | |
| low education | iii | xiv | |
| middle education | 33 | 43 | |
| high education | threescore | 35 | 0.001 |
| Smoking status, % | |||
| Never smoker | 47 | 67 | |
| Ever smoker | 45 | 22 | |
| Electric current smoker | 8 | 12 | <0.05 |
| Season | |||
| Wintertime | 24 | 25 | |
| Jump | nineteen | 23 | |
| Summer | 20 | nineteen | |
| Fall | 37 | 33 | 0.90 |
| Days per calendar week spent at least one h outdoor in the past half year, median (Q1, Q3) | 2 (2, 5) | three (ii, seven) | 0.44 |
| Using sunday protection in summer, % | |||
| Never | 13 | 31 | |
| Sometimes | 51 | 31 | |
| Always | 36 | 38 | <0.05 |
| Fish consumption at least once per week, % | 51 | 45 | 0.41 |
| Vitamin D supplement intake, % | 9 | 9 | 0.97 |
Nearly two-thirds of the women were vitamin D deficient. The mean serum vitamin D concentration was 26.1 ng/mL in vitamin D–sufficient women and x.v ng/mL in women with deficiency. Calorie-free skin color was reported by 88% of the women with sufficient vitamin D levels and past 66.half dozen% with vitamin D deficiency.
The mean historic period at blood collection was 31.one and 29.4 years in vitamin D–sufficient and –deficient women, respectively. Well-nigh one-third of the women with sufficient vitamin D levels and 14% of vitamin D–deficient women were of German or Swiss origin. One-half of the women with a sufficient vitamin D concentration sometimes used sun protection, xiii% never used information technology and 36% always used lord's day protection. In women with vitamin D deficiency, lord's day protection was used "never", "sometimes" or "ever" by one-third of women each. Fish consumption was reported past 51% of the women without and by 45% of the women with vitamin D deficiency, and vitamin D supplements intake was reported by ix% of the women without and with vitamin D deficiency, respectively.
The associations of dark skin color with vitamin D deficiency were assessed past logistic regression using different aligning models (Tabular array ii).
Table 2
Associations between pare colour and vitamin D deficiency in 204 pregnant women (reference: vitamin D level ≥ xx ng/mL).
| Dark Skin Color | OR | 95% CI | AIC |
|---|---|---|---|
| age adjusted model | 3.25 | (1.46, vii.24) | 259 |
| age and season adjusted | 3.29 | (one.47, 7.36) | 264 |
| multivariable adjusted model 1 | 2.56 | (1.08, 6.11) | 266 |
| multivariable adapted model 2 | ii.60 | (1.08, 6.22) | 268 |
The AIC fit best for the age-adjusted model with an OR of 3.25 (95% CI 1.46–vii.24) for the associations of skin colour with vitamin D deficiency. The next model with a expert AIC fit included age and season (OR three.29; 95% CI ane.4–7.36). In the multivariable adjusted model including age, season, vitamin D supplement intake, BMI, smoking status and parity, the OR was 2.60 (95% CI 1.08–6.22). In the sensitivity analysis using dichotomized countries of origin instead of the Fitzpatrick scale, the all-time AIC fit and the results remained similar (Supplementary Table S2). However, in the sensitivity analysis with the dichotomized melanin index as a proxy for skin color, the AIC fit all-time for the same model equally in our main analysis, but the associations of dark skin color with vitamin D deficiency were adulterate and the results for models 3 and 4 did not remain statistically significant (Supplementary Tabular array S3).
According to the results of the AIC, age and flavor explained the model best. Figure 1 depicts the geometric mean vitamin D levels by light and night peel color type (according to the Fitzpatrick scale) stratified past season.
Vitamin D levels stratified by calorie-free and dark peel color and season according to the Fitzpatrick calibration (I, 2, III vs. Four, V) and flavour (winter = December–February, spring = March–May, summer = June–August, autumn = September–Nov).
Women with light skin colour had the highest vitamin D levels in summer and the everyman in winter (18.4 ng/mL (95% CI 15.0–22.7) and 14.6 ng/mL (95% CI 12.3–17.four), respectively). For women with night skin color, these levels in summer and winter were lower (12.9 ng/mL (95% CI 8.v–19.half-dozen) and 7.half dozen ng/mL (95% CI 4.6–12.5), respectively). However, differences between seasons were not statistically significant either in light-skinned or in dark-skinned women.
Younger women had lower vitamin D levels compared to older women with light and with dark skin colour (Effigy 2).
Vitamin D levels stratified by light and nighttime peel color according to the Fitzpatrick calibration and the four age groups.
Vitamin D levels in women younger than 25 years were 11.8 ng/mL (95% CI 8.9–fifteen.6) and 8.six ng/mL (95% CI vi.0–12.three) in calorie-free and night skin color, respectively. Women anile 35 or higher up had a mean vitamin D level of 17.half-dozen ng/mL (95% CI 14.eight–20.8) (light skin colour) and 14.2 ng/mL (95% CI ix.5–21.9) (dark peel color). In dark-skinned women, differences were non statistically meaning; in light-skinned women, the p-value was 0.06 (Anova).
4. Discussion
In our study, almost two-thirds of the pregnant women were vitamin D deficient and nighttime skin color was associated with a college prevalence of vitamin D deficiency. This prevalence is almost twice as high as in the normal population (38%) [23].
To our noesis, the prevalence of vitamin D deficiency in women in the kickoff trimester of pregnancy has non nonetheless been evaluated in Switzerland. A recent systematic review looking at vitamin D deficiency in pregnant women in the Mediterranean region observed a prevalence of vitamin D deficiency (divers as ≤20 ng/mL) in meaning women ranging from 22.7% to 90.3% [24]. Merely 4 out of 15 studies included in the systematic review were conducted during the first trimester of pregnancy, with a vitamin D deficiency prevalence ranging from 22.7% to 59% [25,26,27,28]. Studies conducted in northern European countries or the Usa also reported heterogeneous rates of vitamin D deficiency, such every bit 10% in Us in women in early on pregnancy or 65% in pregnant women in Sweden (levels <fifty nmol/L, which corresponds to ≤twenty ng/mL). In Belgium, 47% of pregnant women in the get-go trimester were vitamin D deficient [29], in holland 8%–62% in the 12th calendar week of pregnancy were scarce (deficiency divers equally <25 nmol/Fifty) [30], and in Norway 77.four% of pregnant women in the offset trimester had a vitamin D deficiency [31]. Thus, our outcome lies inside the range of vitamin D deficiency observed in early pregnancy.
Apropos pare color, our results concord with previous data [thirty,32,33,34] showing that vitamin D deficiency varies by lite and nighttime pare phototypes, i.e., nighttime skin color was significantly associated with vitamin D deficiency. Furthermore, studies consistently testify that vitamin D levels among pregnant women in northern Europe and the US are lower in ethnic minority groups, which generally have darker skin. Dark-skinned individuals produce less 25(OH)D than individuals with light pare with the same sunlight exposure (UVB) [thirty,35,36,37].
Endogenous pare synthesis through UVB radiation and nutrition (or vitamin D supplement intake, respectively) are the two principal sources of vitamin D. In our study, adjusting for flavor showed the best model fit, expressed every bit AIC (including also age every bit a covariate), which serves as a proxy for sunlight. Looking in more detail into vitamin D levels stratified by pare color and seasons, women in our study had higher vitamin D levels in summertime compared to winter, and vitamin D levels were lower in women with dark than with light skin color, but differences between seasons were not statistically significant. Previous studies described lower vitamin D levels in winter for the full general population [35], and for pregnant women most studies institute higher vitamin D levels in summer than in winter, but not all tested for statistical significance [6,38,39,40].
In our study only a minor percentage of women took vitamin D supplements and only one-half of the women ate fish at least once per week. As vitamin D supplement intake was a adept AIC model fit, vitamin D levels stratified by intake and skin color were examined but differences were not statistically significant (Supplementary Figure S1). A recent meta-assay and a systematic review observed that supplementing pregnant women with vitamin D leads to college levels of vitamin D at term [41,42]. We hypothesize that in our report, it might be likewise early in pregnancy to see an effect. From a public health perspective, fortification of nutrient could improve vitamin D levels in all significant women. To date, vitamin D fortification of food is more than common in northern Europe (due east.g., Norway, Denmark and Sweden) than in other countries of Europe, such as Switzerland [43].
Nosotros observed that historic period was an of import covariate and that vitamin D levels were college in older compared to younger meaning women, although differences were not meaning. Results of other studies looking at the relationship between age and vitamin D are contradictory and no association, not-linear association [44], or similar results equally in our study [45] were observed. A possible explanation for an association with age may be that older individuals are more health conscious than younger meaning women.
In our analysis, we used three different variables to categorize past skin type, namely the Fitzpatrick calibration, melanin index and state of origin, and we observed that either variable was a predictor of vitamin D deficiency. However, the association of the (dichotomized) melanin alphabetize and vitamin D deficiency was strongly attenuated after adjusting for vitamin D supplement intake, BMI, and smoking status in add-on to age and season. Information technology might be that, despite the potent correlation between the melanin index and Fitzpatrick scale, the dichotomizing melanin alphabetize is less able to capture the extremes of skin color than the dichotomizing Fitzpatrick scale.
Women included in the study came from a great variety of countries of origin, which immune different pare pigmentation colors to be represented. A farther strength was the inclusion of a variety of confounders in our written report, but due to collinearity, such every bit from country of origin, and the melanin index with light and night peel colour according to the Fitzpatrick scale, we could not include these variables in our final multivariable adjusted models. Nevertheless, we performed sensitivity analyses with these variables, which generally confirmed our results with the Fitzpatrick scale. A further limitation was that women with night skin (Fitzpatrick calibration Five) were limited in number and that other factors that bear upon vitamin D levels were not assessed, such as veiling of the women or concrete activity. Hence, the ascertainment of non-statistically significant differences in our population might exist due to minor numbers. Finally, we included but one hospital in our analysis, which limits the generalizability of our results. Withal, women attending our clinical pregnancy controls came from the full general population. As well, residual confounding cannot be ruled out.
5. Conclusions
The prevalence of vitamin D deficiency is common in women in early pregnancy. Almost 2-thirds of all women in our study population had a vitamin D deficiency. To our cognition, this is the first study that assessed prevalence rates for meaning women in the Zurich area of Switzerland. We institute a difference in 25(OH) vitamin D levels and prevalence depending on maternal skin type, emphasizing a consequent screening and supplementation programme for meaning women, in particular for women with a darker peel type.
Acknowledgments
We thank the Swiss National Scientific discipline Foundation for their back up of this project (NRP69 grant 4069-145194). We thank Nina Pupikofer for data entry and all women who participated in this study.
Supplementary Materials
The following are available online at http://www.mdpi.com/2072-6643/ix/3/260/s1, Figure S1: Vitamin D levels past light and night skin color and vitamin D supplementation status, Table S1: General characteristics of pregnant women with light and night skin color, Table S2: Association between dichotomized country of origin and vitamin D deficiency in 204 significant women, Table S3: Association between dichotomized melanin index and vitamin D deficiency in 204 pregnant women.
Author Contributions
Katharina C. Quack Lötscher, Sabine Rohrmann and Aline Richard designed the study and planned the analyses. Katharina C. Quack Lötscher supervised the recruiting of participants. Aline Richard performed the analyses and prepared the commencement draft of the manuscript. All authors contributed to the interpretation of the data and edited the manuscript. Sabine Rohrmann supervised the written report. All authors have approved the final manuscript.
Conflicts of Interest
The authors declare no disharmonize of interest.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5372923/
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