Hypovitaminosis D in the Middle East and North Africa

Figures & data

Table 1. Overview of Studies on 25(OH) D Values in Adults in Middle East and North Africa

Country	Author/Yr	Sampling Method City (Latitude)	N Gender/ Age		Exclusion criteria specified		Assay type/ Manufacturer	Season Yr	Predictors for low 25(OH)D		25(OH)D Level Mean ng/ml % below cut-off
Middle East
Iran	Baradaran et al. 2012^39	Hospital based Iran (32°N)		259 ♀♂ 20–64 y		Yes	EIA/IDS	NA 2010	High adiposity, high BMI	12 ± 6 Median: 10
	Kashi et al. 2011^40	Telephone population based Sari (37°N)		232 ♀,118♂ 11–69 y		Yes	ELISA/DRG	End of summer and winter NA	High humidity climate, winter	Summer: 13.4 ± 13 Winter: 11.7 ± 11
	Hovsepian et al. 2011^41	Outpatient clinic Isfahan (32°N)		243 ♂, 868 ♀ 20–80 y		Yes	RIA/ Biosource	Autumn/ Winter-Spring/ Summer NA	Young age, women	Median Spring: 21 (2–300) Median Summer: 18 (3–208) Median Autumn: 19 (1.5–425) Median Winter: 17 (2–281) 27% < 10, 24% 10–20, 20% 20–30
	Kaykhaei et al. 2010^42	Population based Zahedan (30°N)		431 ♂, 562♀ 20–88 y		No	CIA/ DiaSorin	June -Aug 2008	Younger age	13.8 95% < 30 85% < 20 10% 20–30 5% 30–150
	Hosseinpanah et al. 2010^43	Clustered sampling Tehran (35° N), Ghazvin (36°N)		200♀ 20- 55 y		Yes	EIA/DRG	Sept 2007	Air pollution	Ghazvinian: ♀ 18 ± 11 Tehranian: ♀ 13 ± 7 Tehranian: 36% < 10 54% 10–20 Ghazvinian: 31% < 10 32% 10–20
	Maddah et al. 2009^44	Clustered sampling Guilan (37°N)		427 ♀ Urban 219 ♀ Rural 51–92 y		No	Commercial kit/ BioSource	Oct 2004-Feb 2005	Low education, urban living	♀ Urban: 18.5 ± 13.5 ♀ Rural: 22.9 ± 13.8
	Masoompour et al. 2008^45	Clustered sampling Shiraz (30°N)		520 ♂ 20–74 y		Yes	IRMA/IDS	Jan-Mar 2001	NA	14 ± 6.8 34% ≤ 10
	Hosseinpanah et al. 2008^46	Population based study Tehran (35°N)		245 p.m.♀ 40–80 y		Yes	RIA/IDS	NA	NA	5% < 10 38% 10–20 43% < 20 25% > 32
	Hashemipour et al. 2006^47	Clustered sampling Tehran (35°N)		1210 ♂♀ 20–69 y		Yes	RIA/IDS	NA	NA	12.9 ± 16.5 9% ≤ 5 56% 5–10
	Rassouli et al. 2001^48	Densitometry center Tehran (35°N)		73 p.m.♀ 49–63 y		Yes	HPLC	Feb-June 2000	NA	Winter: 13.3 ± 5.0 Spring: 18.3 ± 12 36% < 12
Occupied Palestine/Israel	Saliba et al. 2012^49	Population Based CHF covers > 50% of Israeli population (31°N)		198,834♀♂ Median 60 y		Yes	CIA/ Diasorin	Jan-Dec 2009	Female gender, winter, adults, Arabs > Jews	Summer-Autumn: 22.52 ± 9.8 Winter-Spring: 18.72 ± 9.4 14% < 10 31% < 15 50% < 20 16% > 30
	Saliba et al. 2012^50	Population Based		2571♂, 6310♀ 56.1 ± 17.6 y (1st test) 57.6 ± 17.7 y (Last test)		Yes	CIA / Diasorin	Jan 2008-Sep 2011	Female gender	First test: 20.68 ± 9.6 50% < 20 Last test: 22.68 ± 9.88 41% < 20 *First and last test done in the same month
Middle East
	Saliba et al. 2012^51	Population Based		182, 152 ♀♂ VitD ≤ 13: 59.4 ± 17.4yrs VitD13–20: 61 ± 16.1 y VitD20–26: 61.1 ± 16 y VitD > 26: 59.9 ± 17.1yrs		No	CIA/ Diasorin	Jan 2008 - Dec 2009	History of diabetes History of Cardiovascular disease	25% ≤ 13ng/ml, mean 9.3 ± 2.7 25% 13–20 ng/ml, mean 16.8 ± 1.8 25% 20–26ng/ml, mean 22.8 ± 1.8 25% > 26ng/ml, mean 32.6 ± 6.4
	Tsur et al. 2011^52	Institution based Jerusalem (31.7°N)		74♂ students (A) Ultra-orthodox Indoors 20.1 ± 0.6yrs (B) Ultra-Orthodox Outdoors 33.0 ± 4.2yrs (C) Religious 19 ± 2.0yrs		Yes	RIA /DLS	Mar-Apr NA	Low sun exposure, traditional clothing		(A) 8.9 ± 3.6 100% < 20 65% < 10 (B) 10.2 ± 5.7 91% < 20 65% < 10 (C) 21.7 ± 10.4 51% < 20 12% < 10
	Saliba et al. 2011 ^53	Population Based (31°N)		19,172 ♂♀ 63.7 ± 15.5 y Normal:19,172 Renal failure:5449		No	CIA/ Diasorin	Jan-Dec 2009	Renal Failure		Renal Failure: 22.8 ± 11 Normal Function: 25.32 ± 10.64
	Steinvil et al. 2011^54	Retrospective Population based (31°N)		26,699♀ 55 ± 15 y 8175♂ 55 ± 17 y		No	RIA /Diasorin	Jan-Dec 2001–2008	Low sun exposure		♂ 23.22 ± 10.1 79% < 30 ♀ 22.7 ± 9.9 78% < 30
	Oren et al. 2010^55	NA (31°N)		100♀, 95♂ < 5yrs - > 50yrs		No	CIA/ Diasorin	Feb-Jan NA	Older Age, Ashkenazi > Sephardic > Arab		22.9 ± 10.1 78% < 30
Jordan	Nichols et al. 2012^56	National micronutrient survey Jordan (31°N)		2032 ♂ 15–49 y		No	LC-MS/MS	Mar-Apr 2010	Urban living, veiling		Median: 11 96% < 20 60% < 12 No cover n = 98 40% < 12 Scarf/hijab n = 1842 62% < 12 Niqab (full) n = 73 68% < 12
	Batieha et al. 2011^57	National population based Jordan (31°N)		1128 ♂, 3462 ♀ > 18 y		No	RIA/ Biosource	July–Oct-Nov 2009	Older age, middle and south region, winter season, low altitude, sunscreen use, indoor work, urban, veiling		♂ 73.3 ± 29.3 94% ≥ 30 4% 20–29.9 2% < 20 ♀ 39.8 ± 20.7 63% ≥ 30 23% 20–29.9 14% < 20
	Mallah et al. 2011^58	NA Jordan (31°N)		201 ♀, 99 ♂ 29–32 y		No	ELISA/IDS	November 2010	Veiling		♂18 ± 4 ♀ 12 ± 5 Western Style: 16 ± 3 Hijab: 12.5 ± 2.5 Niqab: 11.4 ± 1.52
	Mishal 2001^59	Hospital based Jordan (31°N)		131 ♀, 23 ♂ 18- 45 y		Yes	RIA/Diasorin	Summer: July–Sep Winter: Jan–Mar NA	Winter, veiling		3% < 5 60% 5–12 Both seasons: 62% < 12 Summer: 50% < 12 Winter: 73% < 12
Middle East
Lebanon	Gannaje-Yared et al. 2009^60	Hospital based Lebanon (33°N)		151 Christians, 100 Muslims ♀ 50–87 y		Yes	CIA/Nichols	July –Aug 2004 Feb-Mar 2005	Dress code covering the arms, high BMI, low education		19·5 ± 9·8
	Arabi et al. 2006^61-2010^62	Population based Beirut (34°N)		286♀,157 ♂ 65–85 y Mean 73 y		Yes	RIA/ IDS	Nov 2002-Mar2003	Female gender		11.4 ± 4.9 ♀ 55% < 10 ♂ 37% < 10
	Gannaje-Yared et al. 2000^63	Community centers Bekaa, Beirut (34°N)		99 ♂, 217 Prem♀ 30–50 y		Yes	RIA/ Incstar		Veiling, ♀ rural living, ♂urban living, low vit D intake		9.7 ± 7.1 31% (42% ♀, 7% ♂) < 5 73% (84%♀, 49% ♂) < 12 80% (89% ♀, 51% ♂) < 15
Saudi Arabia	Ardawi et al. 2012^64	Population based Health Care Centers Jeddah (22°N)		834 ♂ 20–74yrs 42.1 ± 13.9 y		Yes	CIA/ Liaison	Jun 2008-Jun 2009	Heavy weight, summer, smoking, no education, sedentary lifestyle, low Vit D supplementation, low sun exposure		Total: 11.6 ± 6.45 < 50 y: 12.5 ± 7.01 ≥ 50yrs: 10.7 ± 5.992 88% < 20 10% ≥ 20–30
	El Shafie et al. 2012^65	Healthcare Center Riyadh (25°N)		50 married couples ♂40.1 ± 7.4 y ♀30.6 ± 6.8yrs		Yes	ECLIA/Roche	Dec 2010 - Jan 2011	Male gender, high physical activity, milk intake		♀ 8.5 ± 3.9 70% < 10 98% < 20 ♂ 12.2 ± 5.5 40% < 10 92% < 20
	Kanan et al. 2012^66	Retrospective out-patient clinics Riyadh (25°N)		1556 ♀ Summer 44.4 ± 16.1 y Winter 46.1 ± 15.9 y		Yes	HPLC	Jan- Dec 2009	Low latitude, veiling, sun avoidance		13.3 ± 0.7 Prem Summer 80% < 20 11.4 ± 0.5 Prem Winter 85% < 20 17.7 ± 0.9 p.m. Summer 68% < 20 14.5 ± 0.6 p.m. Winter 76% < 20
	Ardawi et al. 2011^67	Population based Health Care centers Jeddah (22°N)		1,172 healthy ♀ 50.9 ± 12.6 y		Yes	CIA/ Liaison	Jun 2008-Jun 2009	Older age, high BMI, low sun exposure, poor dietary, low vit D supplementation, high WHR		17.18 ± 12.19 (Prem) 13.32 ± 9.94 (PM) 11% (6% Prem 14% PM) < 5 46% (38% Prem 51% PM) < 10 34% (34% Prem 34% PM) 10–20 9% (11% Prem 7% PM) 20–30 12% (16% Prem 8% PM) ≥ 30
	Alissa et al. 2011^68	Hospital based Jeddah (22°N)		122 p.m.♀ 46–70 y		Yes	RIA/ Diasorin	NA	High SES, heavy weight, low activity		9.6 ± 0.47 (Controls) 100% < 20 12.7 ± 1.06 (Osteopenic) 97% < 20
Middle East
	Sadat-Ali et al. 2011^69	Hospital based Al-Khobar (26°N)		400 Peak Bone Mass age group and ≥ 50yrs		Yes	RIA / Wallac	Feb -May 2008	Older age		PBM age group 11% ♀ 10% ♂ < 20 19% ♀ 19% ♂ 20–30 70% ♀ 71% ♂ > 30 ≥ 50 y 19% ♀ 12% ♂ < 20 36% ♀ 25% ♂ 20–30 45% ♀ 63% ♂ > 30
	El Sammak et al. 2011^70	Hospital based Al-Khobar (26°N)		87 ♂, 52 ♀ blood donors		Yes	CIA/ Liaison	Dec 2008- Mar2009	Veiling		♂ 10.1 ± 4.5 ♀ 9.9 ± 4.5
	El Sammak et al. 2010^71	Hospital based Al-Khobar (26°N)		87 ♂ 30.0 ± 8.5yrs 52 ♀ 31.0 ± 7.2yrs		Yes	CIA/Liaison	Dec 2008-Mar 2009	NA		♂ 10.1 ± 4.7 ♀ 9.9 ± 4.5
	Al-Elq et al. 2009^72	Hospital based Al-Khobar (26°N)		200 ♂ 46.5 ± 14.6yrs 200 ♀ 42.6 ± 15.9yrs		Yes	RIA/Wallac	Feb-May 2008	Older age, life Style, higher BMI ♂, lower BMI♀		♂ 31.1 ± 10.7 ♀ 28.9 ± 10.7
	Sadat-Ali et al. 2009^73	Hospital based Al-Khobar (26°N)		100 ♂ 28.2 ± 4.5yrs 100 ♂ 59.4 ± 15.6yrs		Yes	RIA/ Wallac	Feb-May 2008	Low sun exposure		Younger: Mean 16.6 ± 3.4 in those ≤ 20 Mean 25.4 ± 2.7 in those > 20- < 30 Older: Mean 16.7 ± 3.4 in those ≤ 20 Mean 25.3 ± 3.3 in those > 20–30
	Al-Turki et al. 2008^74	Hospital based Al-Khobar (26°N)		200 ♀ 25–35 y (Group 1) ≥ 50 y (Group 2)		Yes	RIA/ Wallac	Feb -May 2008	Low sun exposure, low vit D diet		Group 1: 11% < 20 19% 21–29 70% > 30 Group 2: 19% < 20 36% 21–29 45% > 30
UAE	Al Anouti et al. 2011^75	University based Al-Ain (24° N)		208 ♀ 20.8 ± 4.0 y 70 ♂ 21.0 ± 4.6 y		No	HPLC	Oct 2009 138♀70 ♂ Apr 2010 70 ♀	Low sun exposure, female gender		Summer ♀ 8.3 ± 5.9 ♂10.9 ± 6.2 Winter ♀ 12.5 ± 4.9
	Dawodu et al. 2011^76	Pilot Study Al-Ain (24° N)		8 Healthy Arab ♀ 20–30 y.		Yes	HPLC	Sep –Nov 2001	Decreased surface area of the skin exposed, sun exposure low vit D intake		Expose face, arms and hands 15 min/ d twice a week for 4 weeks pre-intervention 7.04 post intervention 9.2
	Saadi et al. 2006^77	Local clubs, primary care clinics, local hospitals Al-Ain (24° N)		175Prem 84PM♀ Prem: 37.5 ± 9.5 y PM: 58.3 ± 8.9 y		Yes	RIA/Diasorin	Jan 2003-Jun 2005	Younger age, low vit D intake, summer		10.1 ± 4.3 Prem: 9.7 ± 4.2 PM: 10.9 ± 4.5 All ♀ vit D < 32 Apr 11.6 ± 5.2 Aug 7.2 ± 2.3
North Africa
Morocco
	El Maghraoui et al. 2012^78	Hospital based Rabat (34°N)	178 p.m. ♀ ≥ 50 y		Yes		ECLIA/Roche	Summer 2010	NA	15.8 ± 11.6 85% < 30 66% < 20 52% < 10
	Allali et al. 2009^79	Hospital based Rabat (34°N)	415 ♀ 24–77 y		Yes		CIA/Diasorin	Summer NA	Older age, lack of sun exposure, veiling, Ca intake < 700 mg	91% < 30 43% < 15 4% < 5
Tunisia	Bahlous et al. 2009^80	NA Manouba (37°N)	134 p.m. ♀ with osteoporosis		Yes		HPLC	March–April 2004	Osteoporosis	Fracture pts: 27.5 ± 15.1 51% < 20 Non fracture pts: 21.3 ± 13 25% < 20
	Meddeb et al. 2005^81	NA Ariana (37°N)	261♀ 128♂ 20–60 y		Yes		RIA/Incstar	Jan-March 2002	Older age, veiling, high parity, postmenopausal	47% < 15, 16% 5–10 36% 20–28 y 60% 50–59 y

Abbreviations in table listed here in alphabetical order: BMI: Body Mass Index; Ca: Calcium; CIA: Chemiluminescent Assay; EIA: Enzyme immunoassay; ELISA: Enzyme-linked immunosorbent Assay; ECLIA: Electrochemiluminescent Immunoassay; HPLC: High-performance liquid chromatography; IDS: Immunodiagnostic Systems; IRMA: Immunoradiometric Assay; LC-MS: Liquid Chromatography–Mass Spectrometry; NA: Not Available; PM: Post-Menopausal; Prem: Pre-Menopausal; PBM: Peak Bone Mass; RIA: Radioimmunoassay; SES: Socio-Economic Status; Vit: Vitamin ; WHR: Waist Hip Ratio ; Yrs: Years

Table 2. Overview of studies on 25(OH) D values in Children in Middle East

Country	Author/Yr	Sampling Method City (Latitude)	N Gender/ Age	Exclusion criteria specified	Assay type/ Manufacturer	Season Yr	Predictors for low 25(OH)D	25(OH)D Level Mean ng/ml % below cut-off
Iran	Ghergherechi et al. 2012^93	Children hospital Tabriz (38°N)	52 Obese children 4–16 y 57 Control	Yes	CIA/ Nichols	NA 2009–2011	Obesity, high BMI	Case: 32.7 ± 29.6 Control: 44.2 ± 11.2
	Neysestani et al. 2012^86	Random systematic districts schools Tehran (35°N)	573 Boys, 538 Girls 9–12 y	Yes	Competitive protein-binding assay/ IDS	Fall-winter 2007–2008	Female gender	Boys: 11 Girls: 8
	Olang et al. 2011^87	Vaccination heath centers Tehran (35°N)	7112 infants 15– 23 mo	Yes	HPLC	May– June2001	Female gender	24.5 3% < 10 33% < 20 44% 20–30 20% > 30
	Ardestani et al. 2010^91	School random sampling Isfahan (32°N)	271 Boys, 242 Girls 6–7 y	Yes	RIA/ Incstar	Summer 2006	Low intake of vitamin D, low sun exposure, dress style	46 ± 17 3% < 20
	Razzaghy Azar 2010^89	Clinic university hospital Tehran (35°N)	192 Girls, 121 Boys 8–18 y	Yes	EIA/ IDS	Apr 2006-Apr 2007	High BMI, puberty stage, female gender	25% (Boys 8% Girls 92%) < 5 27% (Boys 34% Girls 66%) 5–10 26% (Boys 58% Girls 42%) 10–20
	Dahifar et al. 2007^30	One middle school Tehran (35°N)	414 Girls 11–15 y	Yes	Gamma counter/ Genesys	Dec 2002- Mar 2003	NA	30 ± 15.8
	Moussavi et al. 2005^84	High school Sampling Isfahan (32°N)	153 Boys, 165 Girls 14–18 y	Yes	RIA/ Biosource	NA 2004	Female gender	Total: 46.2% < 20 Boys: 37.3 ± 18.8 18% < 20 1% < 8 Girls: 16.8 ± 8.4 72% < 20 14% < 8
Jordan	Abdul Razzak et al. 2011^88	Hospital based Amman (32°N)	136 Infants, 139 Toddlers 6–36 mo	Yes	EIA/ IDS	Oct 2008- Jan 2009	Sun exposure < 30 min, female gender, exclusive breast feeding	17% < 15 11% < 20 28% < 30 44% > 30
	Jazar et al. 2011^97	Pediatrics Clinic Jordan (31°N)	100 Boys 1–3 y 100 Girls 3–6 y	Yes	ECLIA/ Roche	May – June 2009	Older age, high BMI, low outdoor activity indoor physical activity, nutrition	Toddler: 26.2 ± 1.2 Preschool children: 21.5 ± 1.2 17% ≤ 15 16% 15- 20
	Gharaibeh et al. 2009^98	Local community center Jordan (31°N)	93 Mothers 30yrs Children 60.7 mo	Yes	ELISA/IDS	June -July 2007	Low milk intake, high income > 212$/month	Mother: 10.2 2% < 5 49% < 10 98% < 20 Children: 22.3 82% < 20 15% > 30
Lebanon	El Hajj-Fuleihan et al. 2007^99	School based Beirut (33.5°N)	180 Boys13.1 ± 2 y	Yes	RIA/ Diasorin	Winter- Spring 2001–2002	NA	17 ± 7
	El Hajj-Fuleihan et al. 2006^100	School based Beirut (33.5°N)	179 Girls 13.1 ± 2 y	Yes	RIA/ Diasorin	Winter- Spring 2001–2002	NA	14 ± 8
	El Hajj-Fuleihan et al. 2001^83	School based Beirut (33.5°N)	Spring: 81 Boys, 88 Girls 13.3 ± 1.6yrs Fall: 83 Boys, 94 Girls 13.3 ± 1.7yrs	Yes	RIA/ Diasorin	Spring- Fall 1999	Spring season, female gender, age, Tanner staging, low sun exposure, calcium intake, vitamin D intake, BMI	Spring: Total:17 ± 8 21% < 10 44% 10–20 Boys:19 ± 7 9% < 10 46% 10–20 Girls:15 ± 8 32% < 10 42% 10–20 Fall: Total: 22 ± 7 4% < 10 36% 10–20 Boys: 24 ± 6.2 25% 10–20 Girls: 19 ± 7 7% < 10 46% 10–20
Qatar	Bener et al. 2009^103	Primary Health Care Centers Doha (25.3°N)	458 Mean 10.9 ± 3.54 y in those < 20 ng/ml Mean 9.54 ± 3.98 y in those 20–80 ng/ml	No	RIA/ Diasorin	Aug 2007-Mar 2008.	Older Age, non White low sunlight expos, low physical activity, low dietary vit D, family history of vit D deficiency	69% < 20 ng/ml, mean 13.4 ± 8.9 31% < 20 ng/ml, mean 27.5 ± 8.3
Saudi Arabia	Al-Ghamdi et al. 2012^85	School-based Jeddah (22°N)	150 ♂ 7–16 y 150 ♀ 6–18 y	Yes	ECLIA/ Roche	May NA	Female gender	16.5 ± 3.7 (6–9 y ♀) 24.5 ± 5.2 (6–9 y ♂) 22 ± 4.5 (10–12 y ♂) 12.6 ± 3.7 (10–12 y ♀) 19.6 ± 5.2 (13–14 y ♂) 11.6 ± 3.6 (13–14 y ♀) 8.8 ± 3.8 (15–18 y ♀) 15.7 ± 5.6 (15–18 y ♂)
	Al Othman et al. 2012^82	Primary Health Care Centers Riyadh (25°N)	331 (153♂178 ♀) Physically inactive: 13.4 ± 3.2 y Moderate Activity: 12.6 ± 3.3 y Active: 12.1 ± 3.6 y	Yes	ELISA /IDS	Mar- Dec 2010	Low physical activity, low sun exposure	7.1 ± 0.6 (Physically In Active) 8.5 ± 0.6 (Moderate Activity) 9.1 ± 0.6 (Active) 11% < 5 72% 5–10 17% 10–20
	Kensarah et al. 2012^102	School-based Makkah (21°N)	87 ♂ 61♀ ♂10.4yrs,♀9.6yrs	Yes	ECLIA /Roche	NA	Female gender	97% ♀ < 20 78% ♂ < 20
UAE	Rajah et al. 2012^101	Pediatric outpatient clinics Abu Dhabi(24°N)	183 (52% ♂) 5.32 ± 3.76 y	Yes	RIA /Diasorin	All year 2005–2008	Sedentary lifestyle, veiling, Ca deficient diet.	Total:21.4 18% > 10 27.5 (0–0.9yrs) 31 (1–2yrs) 21.2 (2–8yrs) 14.1(8–12yrs)
	Dawodu et al. 2003^90	Maternal and child health clinics Al-Ain (24° N)	90 unsupp breast feeding Infants and Mothers	Yes	HPLC	Apr- Oct 1999	Low dietary vit D intake, low sun exposure	Mothers 8.6 (61% < 10) Infants 4.6 (82% < 10)
	Dawodu et al. 2001^104	Hospital based Al-Ain (24° N)	51 15.4 mo UAE nationals (26) non-Gulf Arabs(25)	Yes	HPLC	Feb- Sep NA	Low Vit D supplementation	Infants 22% < 10 25 ± 11.9 (dietary Vit D supp) 15.4 ± 10.9 (unsupp) Mothers 50% < 10 11.36 ± 5.6

Abbreviations in table listed here in alphabetical order. BMI: Body Mass Index; CIA: Chemiluminescent Assay; EIA: Enzyme immunoassay; ELISA: Enzyme-linked immunosorbent Assay; ECLIA: Electrochemiluminescent Immunoassay; HPLC: High-performance liquid chromatography; IDS: Immunodiagnostic Systems; NA: Not Available; RIA: Radioimmunoassay; Supp: Supplemented; Unsupp: Unsupplemented; Vit: Vitamin; Yrs: Years

Table 3. Overview of Studies on 25(OH) D Values in Pregnant Women/Neonates in Middle East

Country	Authors/Yr	Sampling Method City (Latitude)	N/ Age	Exclusion criteria specified	Assay type/ Manufacturer	Season /Yr	Predictors for low 25(OH)D	25(OH)D Level Mean ng/ml % below cut-off
Iran	Asemi et al. 2010^109	Maternity clinic Kashan (34°N)	147 pregnant ♀ 18–35 y	Yes	HPLC	NA/ 2008–2009	NA	15 ± 8
	Kazemi et al. 2009^108	Maternity clinics general hospital Zanjan (37°N)	67 full-term pregnant mothers 28.5 ± 5 y and 61 neonates	Yes	ELISA	Mar- Sep 2005	Winter for maternal and cord blood	Mother 8 ± 1.5 Summer 13 Winter 3 Cord 7 ± 1 Summer 8.7 Winter 5
	Bassir et al. 2001^110	Maternity Hospital Shohalda Tehran (25–35°N)	50 mothers 16–40 y and their neonates	Yes	Radioligand assay	Jan- Sep 1997	NA	Mother 5 ± 2 80% < 10 Cord 2
Israel	Mukamel et al. 2001^111		156 Orthodox and 185 non- Orthodox Jewish mothers at delivery	Yes	Competitive Protein Binding Assay	All year 1998–1999	Sect	Orthodox 13.5 ± 7.5 5% < 5 32% < 10 Non-Orthodox 18.6 ± 9.6 3% < 5 13% < 10
Kuwait	Molla et al. 2005^112	Hospital based n = 2 Kuwait city (29 °N)	214 pregnant mothers 27.7yrs and their neonates	Yes	RIA/ Incstar	All year 1999–2000	NA	Mothers 13–17 Neonates 8 40% mothers, 60% neonates < 15
UAE	Narchi et al. 2010^92	Maternal and Child Health Al Ain (24°N)	75 pregnant from early pregnancy to 6 mo postpartum 18–40 y	Yes	RIA/IDS	Sep-Nov 2007	Dietary habits, voluntary avoidance of sun exposure, veiling	First antenatal visit 17.3 ± 10.5 After delivery 14.4 ± 9.8 At 6 mo 11.9 ± 11.2

Abbreviations listed in alphabetical order: ELISA: Enzyme-linked immunosorbent Assay; HPLC: High-performance liquid chromatography; IDS: Immunodiagnostic Systems; NA: Not Available; RIA: Radioimmunoassay; Yrs: Years

Figure 1. Serum 25(OH)D Levels in Adults (A) and Children (B) Based on Color Codes. The color codes are: green > 30 ng/ml, yellow 20–29 ng/ml, orange 10–19 ng/ml, and red < 10 ng/ml. To convert from ng/ml to nmol multiply by 2.5. The color codes were selected based on mean or median results from population based studies available or as obtained from most representative studies for each country. For countries with varying results, the color code was chosen as valid for ≥ 50% of reported values; or more than one color code was used (for, e.g., children in Iran).

Table 4. Overview on Association Studies Between 25(OH) D Levels and Health Outcomes in the Middle East and North Africa

Country	Author/Yr		Sampling Method City Cases/ Controls N Gender/ Age	Assay type /Manufacturer	Exclusion criteria specified	Disease condition /Health Outcomes	25(OH)D Level Mean ng/ml	Association between 25(OH)D and outcome (Correlation)
Egypt		Olama et al. 2012^123	Clinic based Cases: 50 ♀ 32.3 ± 9.4 y Controls: 50 healthy ♀ 33.1 ± 9.7 y	ELISA/IDS	Yes	Fibromyalgia	Cases: 15.1 ± 6.1 Controls: 18.8 ± 5.4	Lumbar spine: r = -0.352 VAS of pain: r = -0.338 Beck score for depression: r = -0.328
		El Husseiny et al. 2012^124	Clinic based Cairo Cases: 36♂, 14 ♀ 30–65 y Controls:: 25 age- and gender-matched healthy subjects	RIA/Incstar	Yes	HCV infection	Cases: 15 ± 5.2 Controls: 39.7 ± 10.8	Cases: Viral load: r = -0.84 IL-23: r = -0.776 IL-17: r = -0.665 MCP-1: r = -0.94
		Schaalan et al. 2012^125	Clinic based Cairo Cases: 36♂, 14 ♀ Controls:: 25 age- and gender matched healthy subjects	RIA/Incstar	Yes	HCV infection	Cases: ♂10.30 ± 2.12 ♀10.00 ± 2.60 Controls: 39.70 ± 10.80	Cases: 25(OH)D and IL-17: r = -0.679 1.25(OH)D and IL-17: r = -0.679 1.25(OH)D and IL-23: r = -0.801
		Hamza et al. 2011^126	Clinic, Hospital and university based Cairo Cases: 52 ♀ and 8 ♂/ 6–19 y Controls: 50 ♀, 10 ♂/ 7.2–18.5 y	ELISA/ VDBP	Yes	SLE	Cases: 26.33 ± 12.05 13% < 10 60% < 30 27% > 30 Controls: 42.66 ± 9.20	SLEDAI: r = -0.91
		Al Sayed 2007^127	Clinic based Cairo Cases:93♂♀ 45.2 ± 2.6 y Controls:70 healthy 47.1 ± 3.1 y	RIA/IDS	Yes	Metabolic syndrome	Cases: 16.2 ± 4.52 Control: 25 ± 4.48	Cases: BMI: r = -0.684 HOMA: r = -0.395 HDL: r = 0.277 PTH: r = -0.235 S. Insulin:r = -0.396
Iran		Khalili et al. 2012^128	Hospital based Tehran 139 ♀ > 55 y, ♂ > 45 y	RIA/ Abcam pic	Yes	Acute Myocardial infarction	10.92 ± 7.2	Hypertension: OR = 2.92 Use of cardiovascular drugs: OR = 2.36 Survival: OR = 0.216
		Hosseinpanah et al. 2011^129	Population based Tehran Cases: 251♂♀ 56.0 ± 10.6 y Controls: 251 healthy subjects 56.7 ± 11.7 y	EIA/ DRG	Yes	Cardiovascular	Median Cases: 12.5 (8.4–24.4) Controls: 18.1 (11–31)	Vit D < 10 had an almost 3-fold higher risk of developing cardiovascular outcomes r^a = 2.90 than those between 10–15ng/ml r = 1.46
		Bonakdar et al. 2011^130	Clinic based Isfahan 40 ♀ 25.46 ± 4.16 y	RIA/ DIAsource	Yes	SLE	9.68 ± 0.84	BILAG: r = -0.486 BILAG after Adjustment: r^b = - 0.292 Low vit D higher titers of anti-dsDNA
		Heidari et al. 2010^131	Clinic based Babol Cases: 276 ♂♀ 44.3 ± 15 y Controls: 202♂♀ 46.4 ± 14.2 y	ELISA/DRG	Yes	Musculoskeletal pain	Cases: 33.1 ± 28.4 Controls: 23.8 ± 29.1	Vit D < 20 vs. ≥ 20 with: Musculoskeletal pain: OR^c = 2.95 Leg pain: OR^c = 7.4 Widespread pain: OR^c = 2.8 Arthralgia: OR^c = 3.9
		Garakyaraghi et al. 2010^132	Hospital based Isfahan 28 ♀, 67 ♂ 62 ± 11 y	CIA/Diasorin	Yes	Heart failure	56.78 ± 51.33	Diastolic volume: r = −0.24 Adjusted for age, Creatinine: r = −0.261
		Bonakkdaran et al. 2009^133	Hospital based Mashhad 119 ♂♀ 55.3 ± 11.2 y	RIA/Biosource	Yes	T2DM	32.4 ± 21.6	Age: r = -0.21, BMI: r = -0.25, CRP: r = -0.06
		Omrani et al. 2006^134	Cluster sampling Shiraz 676 healthy women aged 20–74 y	IRMA/ IDS	Yes	Mineral Metabolism	28.9 ± 23.0	PTH r = –0.10 Independent of age
Occupied Palestine/ Israel		Saliba et al. 2012^135	Population Based Clalit Health Services Cases: 1180 ♂♀ 65.30 ± 13.52 y Controls:184,479 ♂♀ 57.67 ± 18.25 y	CIA/DiaSorin	Yes	Primary Hyperparathyroidism	Cases: 19 ± 9 Controls: 20.8 ± 9.8	Cases: PTH: r = −0.238 ALKPhos: r = −0.180 Calcium: r = −0.054
		Amital et al. 2010^136	278 with systemic lupus erythematosus activity (SLEDAI) 100 with European Lupus activity measurement (ECLAM) 40.2 ± 14.2 y	CIA/Diasorin	No	SLE	SLEDAI: 23.9 ± 14.0 ECLAM: 27.6 ± 13.9	Standardized values z-scores r = -0.12 The more active the disease, the lower the vitamin D concentration
Lebanon		Arabi et al. 2012^94	Population based Beirut 65 ♂and 130 ♀ 72.5 ± 5.1 y	RIA/ IDS	Yes	BMD Mineral Metabolism	♂ 14.7 ± 4.0 ♀ 14.6 ± 7.4	Overall: % Change Trochanter BMD: r^d = 0.19 ♂:% Change Total hip BMD: r^d = 0.31 % Change F. Neck BMD: r^d = 0.36 % Change Trochanter BMD r^d = 0.26
		Arabi et al. 2006^61	Population based Beirut 286♀ 73.4 ± 5.2 y 157♂ 74.1 ± 5.08 y	RIA/ IDS	Yes	BMD Mineral Metabolism		♀BMD Total hip, FN, Troch: r^e = 0.10–0.18 ♂ BMD Total hip,spine, FN, Troch:r^e = 0.16 -0.27
Qatar		Bener et al. 2009^137	Clinics /Face to face Interviews Doha Cases: 170 ♂♀ 10.5 ± 3.8 y Controls: 170 ♂♀ 9.9 ± 4.2. yrs	RIA/DiaSorin	No	T1DM	Cases: 15.8 ± 9.2 Controls:18.5 ± 9.6	NA
Saudi Arabia		Bin –Abbas et al. 2011^138	Pediatric and Endo Clinics Riyadh Cases:59 ♀ 41 ♂ Controls: 52♀ 48 ♂	HPLC	Yes	T1DM	Cases: 14.7 ± 5.7 Controls:17.9 ± 5.6	No Correlation between glycemic control and 25 OHD level.
		Al Daghri et al. 2010^139	Primary Health Care Centers Riyadh Cases: 76 ♀, 88 ♂ 50.6 ± 10.1 y Controls: 106 ♀, 71 ♂non-diabetic 37.5 ± 15.3 y	ELISA/ IDS	Yes	T2DM	Cases: 10.8 ± 4.7 Controls: 7.2 ± 2.9	Cases: TC: r = -0.20 LDL-C: r = -0.17 TG: r = -0.17 BMI: r = -0.22 Controls: SBP: r = 0.22 WHR: r = 0.16 Non-Adjusted values
Yemen		Salem et al. 2009^140	Hospital based Sana’a 152 children with VSP 2–59 mo	ELISA/ IDS	yes	Very severe pneumonia, some with rickets	Deficient n = 50:37.2 ± 17.3 Sufficient n = 9: 47.3 ± 17.6	Failure to respond to antibiotic therapy in rachitic compared with non rachitic OR = 1.38

* Only significantly different 25(OH)D levels between cases and controls, and correlations .Details on studies that presented adjusted correlations are as follows: Hosseinpahanh et al. 2011, r^a adjusted for BMI, FPG, SBP, DBP,CT,TG,HDL-C, Smoking Status, degree of physical activity, premature CVD familial history . Bonakdar et al. 2011, r^b adjusted for age, BMI, sun exposure, use of sunscreen, physical activity. Heidari et al. 2011, OR^c adjusted for sex. Arabi et al. 2012, r^c adjusted for age, calcium intake, serum Creatinine and PTH in multivariate models, mean 25OHD was no more a predictor of bone loss. Arabi et al. 2006, r^d adjusted for age, height, lean mass and PTH levels, 25OHD level did not have residual significant contribution to BMD at any skeletal site except the trochanter in men. Abbreviations in table listed here in alphabetical order: ALKPhos:Alkaline Phosphatase; BILAG: British Isles Lupus Assessment Group; BMD: Bone Mineral Density; BMI: Body Mass Index; CIA: Chemiluminescent Assay; CRP: C- Reactive Protein; DsDNA: Double Stranded DNA; EIA: Enzyme immunoassay; ELISA: Enzyme-linked immunosorbent Assay; ECLAM: European Consensus Lupus Activity Measurement; FN: Femoral Neck; HCV: Hepatitis C virus; HDL: High Density Lipoprotein; HOMA: Homeostasis Model Assessment ; HPLC: High-performance liquid chromatography; IDS: Immunodiagnostic Systems; IL-17: Interleukin-17; IL-23: Interleukin-23; IRMA: Immunoradiometric Assay; LDL-C: Low Density Lipoprotein- Cholesterol; MCP-1: Macrophage chemoattractant protein-1; NA: Not Available; OR: Odds Ratio; r: Correlation; RIA: Radioimmunoassay; SBP: Systolic Blood Pressure; SLE: Systemic Lupus Erythematosus; SLEDAI: Systemic Lupus Erythematosus Disease Activity Index; TC: Total Cholesterol; TG: Triglycerides ; Troch: Trochanter; T1DM: Type 1 Diabetes Mellitus; T2DM: Type 2 Diabetes Mellitus; Vit: Vitamin; VAS: Visual Analogue Scale; VSP: Very Severe Pneumonia; VDBP: Vitamin Tracer, for the Binding Pocket of Vitamin D Protein; WHR: Waist Hip Ratio; Yrs: Years

Table 5. Overview on Interventional Studies between 25(OH)D Levels and Health Outcomes in the Middle East

Country	Author Yr	Sampling Method City (Latitude) N Gender/ Age	Protocol Design	Intervention Type/Dose/Duration	Assay type/ Manufacturer	Exclusion criteria specified	25(OH)D Level Mean ng/ml	Effect on Health Outcome
Iran	Shakinba et al. 2011^141	School Based Yazd (32°N) 120 girls 12–15 y Group 1: 28 with Vit D Deficiency Group 2: 23 with Vit D Deficiency Group 3: 30 Group 4: 30	RCT	Group 1: 300,000 IU D3 once, randomized to 50,000IU D3/month Group 2: 300,000 IU D3 once, randomized to 100,000 IU D3/ 3 mo Group 3: 50,000 IU D3/3 mo Group 4: 100,000 IU D3/3 mo	CIA/DiaSorin	No	Baseline One year Group 1 29.7 ± 4.6 47% 20–30 53% 30–100 Group 2 30 ± 5.6 57% 20–30 43% 30–100 Group 3 15.2 ± 6 13% < 10 73% 10–20 11% 20–30 3% 30–100 Group 4 23 ± 6.8 45% 10–20 35% 20–30 19% 30–100	NA
	Ghazi et al. 2010^142	School Based Tehran (35.7°N) 105 ♂, 105 ♀14–20 y 16 ± 1.5 y Group A:35♂,35♀ Group B:34♂,35♀ Group C:34♂,35♀	Double-blinded RCT	Group A:50,000 IU D3/monthly Group B: 50,000 IU D3/2 mo+ placebo every alternative month Group C:Placebo	ELISA/IDS		Baseline 6 mo Group A: 12.8 ± 8.8 ♀19.2 ± 9.4 ♂29 ± 10.5 Group B: 11.3 ± 5.8 ♀13.5 ± 9.2 ♂23.1 ± 7.6 Group C: 11.6 ± 7.2 ♀8 ± 5.6 ♂15.6 ± 6.4	NA
Israel	Gotsman et al. 2012^143	Population based Clalit Health Services A- 3009 ♂♀ with Heart Failure 75.9 ± 10.7 y 46,825♀♂ controls 64.7 ± 11.3 y B- 791 ♂♀with Heart Failure 458 ♂♀ with supplementation 333 ♀♂without supplementation	A-Case-Control B-Interventional	B. 800 IU/d and 1000 IU/d for median follow up of 518 d.	RIA/DiaSorin	No	A- Cases Median:14.8 Controls Median:16.3 B- Survival Rate HF patients < 10 ng/ml with supplementation:85.6 ± 1.7% HF patients < 10 ng/ml without supplementation:81.6 ± 1.7%	Reduced Mortality in Heart Failure patients HR = 1.52 and controls HR = 1.91
Lebanon	El-Hajj Fuleihan et al 2006^100	School Based Beirut (33°N) 179 ♀ Group A: 13 ± 2.1 y Group B: 13.1 ± 2.2 y Group C: 13.6 ± 2.1 y	Double-blinded RCT	Group A:Placebo Group B: Low dose 200 IU D3/d Group C: High dose 2000 IU D3/d	RIA/DiaSorin	Yes	Baseline One year Group A: 14 ± 7 16 ± 8 Group B: 14 ± 9 17 ± 6 Group C: 14 ± 8 38 ± 31	Low dose and High dose: increase in BMD, Lean Mass High dose:increase in Total BMD, Bone Area Premenarcheal girls had the highest increment
Country	Author Yr	Sampling Method City (Latitude) N Gender/ Age	Protocol Design	Intervention Type/Dose/Duration	Assay type/ Manufacturer	Exclusion criteria specified	25(OH)D Level Mean ng/ml	Effect on Health Outcome
Qatar	Soliman et al. 2011^144	General Practitioner Clinic Doha(25.3°N) 40 Adolescents with Vit D Deficiency	Prospective Open-Label Non-Randomized	600,000 IU D3 every 2–3 mo	RIA	No	Pre-Interv Post Interv 9.3 ± 4.6 27.7 ± 9.2	Healing of Rickets in all patients at one year.
Saudi Arabia	Al-Daghri et al. 2012^145	Primary Health Care Centers Riyadh (24.6°N) 31♂28♀ 18–65 y 38 ± 14.1 y	Interventional	Advice for 5–30 min sun exposure twice/ week and vitamin-D rich foods	ELISA/IDS	Yes	Baseline 6 mo 12 mo 7.6 ± 0.6 10.7 ± 0.6 11.4 ± 0.6	Decrease of Metabolic Syndrome from 25% to 13%
UAE	Rajah et al. 2010^146	Hospital Based Abu Dhabi (24°N) 10 Children with Rickets: Group 1: 7 children Group 2: 3 children 21.2 ± 8.4 mo	Retrospective Audit	Group 1:2000 IU D2/d for 3 mo +400 IU D2/d subsequently+ Ca 40 mg/Kg/d for 3 mo Group 2: stosstherapy 600,000IU D2 single dose + Ca 40 mg/Kg/d for 3 mo	HPLC	Yes	Baseline 3 mo 15.1 ± 10.3 NA Median: 11.6 Median: 57.4	NA
	Saadi et al. 2009^147	Maternal-Child Health Clinic Al-Ain(24°N) Group 1: 22 mothers 28.1 ± 4.7 y Group 2: 22 mothers 27.6 ± 6.5 y Group 1: 22 infants 19.1 ± 25.4 d Group 2: 24 infants 20.6 ± 22.9 d	RCT	Mothers: Group 1:2000 IU D2/d for 3 mo Group 2:60,000 IU D2/m for 3months Infants:400 IU D2/d for 3 mo	RIA /DiaSorin	No	Mothers Pre-Interv Post Interv Group 1: 11 ± 4 16.9 ± 5.6 Group 2: 8.9 ± 4 15 ± 4 Infants 30% < 20 ng/ml at 3 mo Group 1: 5.6 ± 3.4 19.8 ± 7.4 Group 2: 5.5 ± 4.8 17.8 ± 6	NA
	Rajah et al. 2008^148	Hospital Based Abu Dhabi (24°N) 31 Children with Rickets: 8 Vit D deficient 14.8 ± 3.2 mo 8 Ca deficient 19.8 ± 2.3 mo	Quasi-Experimental Non-Randomized	2000–5000 IU D2/d for 3 mo + 400 IU D2/d for a variable period	CIA/Nichols	No	Baseline: 8 Vit D deficient: 6.9 ± 1.3 8 Ca deficient: 17.7 ± 7.1	Height z-score Entry: -1.74 Termination:-0.88
	Saadi et al. 2007^149	Maternal-Child Health Clinic Al-Ain(24°N) Group 1:45 lactating♀29.2 ± 5.5yrs Group 2:45 lactating♀29.9 ± 6.7yrs Group1:43nulliparous♀23 ± 5.2yrs Group2:45nulliparous♀24.6 ± 5.1yrs	Open-Label RCT	Group 1:2000 IU D2/d for 3 mo Group 2:60,000 IU D2/m for 3months	RIA /DiaSorin	Yes	Lactating Pre-Interv Post-Interv Group 1: 10.9 ± 4.2 17 ± 5.6 Group 2: 9.3 ± 4.3 15 ± 4.2 Nulliparous Group 1: 7.8 ± 5 16.7 ± 10.6 Group 2: 7.6 ± 4.9 15.7 ± 8.6	1/3 ♀achieved 25(0H)D ≥ 20ng/ml

Abbreviations in table listed here in alphabetical order: BMD: Bone Mineral Density; Ca: Calcium; CIA: Chemiluminescent Assay; ELISA: Enzyme-linked immunosorbent Assay; HPLC: High-performance liquid chromatography; HR: Hazard Ratio; IDS: Immunodiagnostic Systems; NA: Not Available; RIA: Radioimmunoassay.

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