|Year : 2022 | Volume
| Issue : 4 | Page : 210-214
Low incidence of vitamin D levels deficiency in anesthesiology residents: A cross-sectional, retrospective study
Aida Rosita Tantri1, Ratna Farida Soenarto1, Riyadh Firdaus1, Sandy Theresia2, Vircha Anakotta2
1 Department of Anesthesiology and Intensive Care, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
2 Simulation Based Medical Education and Research, Indonesian Medical Education and Research Institute, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
|Date of Submission||12-Jun-2022|
|Date of Decision||04-Aug-2022|
|Date of Acceptance||16-Aug-2022|
|Date of Web Publication||31-Oct-2022|
Ratna Farida Soenarto
Department of Anesthesiology and Intensive Care, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo National General Hospital, Diponegoro Street No. 71, Medical Staff Wing, A Building, 6th Floor, Jakarta
Source of Support: None, Conflict of Interest: None
Background: Vitamin D deficiency is now a major global health problem. The prevalence of vitamin D deficiency in Indonesia is 60–90% in various studies. Age, race, sunscreen use, medication, and malabsorption diseases are all factors that affect vitamin D levels. Recent studies also show the relation between COVID-19 and vitamin D deficiency in severity and disease mortality. Vitamin D deficiency causes skeletal and extra-skeletal consequences. With limited studies on vitamin D levels of anesthesiology residents in Indonesia, we aim to determine the average vitamin D level and the affecting factors in this population. Materials and Methods: Sixty-nine anesthesiology residents working in a tertiary care hospital were enrolled in this study. The participants were asked to complete the questionnaire, and blood samples were drawn to measure serum 25(OH)D. The factors that influence vitamin D levels were recorded for analysis. Statistical analysis was performed using SPSS version 20. Results: The mean vitamin D level in anesthesiology residents was 39.99 ng/mL. There were no significant relationships between vitamin D levels among anesthesiology residents with vitamin D consumption, high-calcium foods, frequency of exercise, history of COVID-19 infection, comorbidities, and duration of exposure to sunlight. Conclusion: Prevalence of vitamin D deficiency/insufficiency was low among anesthesiology residents. Vitamin D levels were optimal in professionals who are taking vitamin D supplements.
Keywords: Anesthesiology, global health, sunlight, vitamin D deficiency
|How to cite this article:|
Tantri AR, Soenarto RF, Firdaus R, Theresia S, Anakotta V. Low incidence of vitamin D levels deficiency in anesthesiology residents: A cross-sectional, retrospective study. Bali J Anaesthesiol 2022;6:210-4
|How to cite this URL:|
Tantri AR, Soenarto RF, Firdaus R, Theresia S, Anakotta V. Low incidence of vitamin D levels deficiency in anesthesiology residents: A cross-sectional, retrospective study. Bali J Anaesthesiol [serial online] 2022 [cited 2022 Nov 26];6:210-4. Available from: https://www.bjoaonline.com/text.asp?2022/6/4/210/359927
| Introduction|| |
Vitamin D (calciferol) is a prehormone substance generated primarily on the skin and obtained in modest amounts from the diet. Vitamin D deficiency is now a major global health issue in medical students., Age, race, sunscreen use, medication, and malabsorption diseases are all factors that affect vitamin D levels. Vitamin D insufficiency causes skeletal problems such as osteopenia, osteoporosis, and muscle weakness. Cardiovascular disease, diabetes mellitus, autoimmune illness, schizophrenia, and depression, as well as unfavorable obstetric and infant outcomes, are all extra skeletal consequences.,
Vitamin D deficiency is caused by a lack of exposure to sunlight (especially UVB), a lack of outdoor activity, a sun-averse lifestyle, the use of sunscreen, a low intake of vitamin D-rich foods, and a tendency to reduce high-fat foods, which results in low vitamin D absorption. Even in tropical countries with abundant sunlight, vitamin D insufficiency is widespread. Due to limited exposure to UVB rays, several studies reveal a 30 percent incidence of vitamin D insufficiency in the Vietnamese female population. Furthermore, a Malaysian and Indonesian collaborative study conducted in Kuala Lumpur and Jakarta discovered that the average blood concentration of 25(OH)D was 48 nmol/L, with 63 percent of Indonesians deficient in this vitamin. Kelly et al. discovered that subjects in South Africa have low vitamin D levels.
Anesthesiologists’ workdays typically begin early and end late at night. These work environments are primarily restricted to indoors. The ultraviolet B light cannot pass through the glass in operating rooms and intensive care units. Daytime sleepiness is caused by sleep loss, resulting in insufficient sun exposure even after night duty. This study aimed to determine the average vitamin D level and the factors affecting anesthesiology residents.
| Materials and Methods|| |
This analytic, cross-sectional, retrospective study was conducted at a tertiary teaching hospital in Indonesia. Approval of the institutional ethical committee was obtained from the health research ethics committee at the Universitas of Indonesia and Cipto Mangunkusumo National General Hospital (KET-1071/UN2.F1/ETIK/PPM.00.02/2021) on 2 February 2021. We enrolled 69 subjects from June-September 2021 and written informed consent was taken. Inclusion criteria in this study were active residents of the Anesthesiology and Intensive Care Residency Program at the Faculty of Medicine Universitas Indonesia and are willing to be research respondents. The exclusion criteria were participants who did not provide complete data.
The data collected were factors contributing to vitamin D deficiency, including age, gender, weight, vitamin D levels, vitamin D consumption, eating high-calcium foods (i.e., dairy foods, milk, cheese, beans), frequency of exercise, history of COVID-19 infection, comorbidities, and exposure to sunlight. In this study, we divided vitamin D values into two groups. Normal vitamin D values are 30–100 ng/mL, less if <30 ng/mL. All collected data were taken from subjects’ medical examinations and laboratory results.
Continuous data were written either in the form of its mean and standard deviation or median and interquartile range. Measures of Kolmogorov–Smirnov checked the normality of quantitative data. For normally-distributed data, a t-test was applied, and for skewed data, a nonparametric Mann–Whitney U-test was used for statistical analysis. The Pearson Chi-square test or Fisher’s exact test compared for categorical data as appropriate. All the statistical tests were performed at a significance level of α <0.05. Analysis was conducted using IBM Statistical Package for the Social Sciences (SPSS) version 20 (IBM Corp. Released 2020. IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp).
| Results|| |
The study’s primary aim was to study vitamin D levels in anesthesiology residents. In this study, 69 residents were screened. Respondents who participated in this study had a mean age of 30.03 ± 3.09 years and were dominated by males. The demographic characteristics are shown in [Table 1]. The subjects’ mean±SD vitamin D level was 39.99 ± 11.91 ng/mL.
The characteristics of the number of respondents based on vitamin D levels can be seen in [Table 2]. From the descriptive data, it was found that only a few respondents had low levels of vitamin D. Most of the respondents did not take vitamin D before, rarely exercised, and had no comorbidities. However, many eat foods high in calcium and are mostly exposed to sunlight. Other variables such as a history of being infected with Covid-19 were also included, and it was found that most had normal vitamin D levels. No statistical significance was found between vitamin D levels and vitamin D consumption, high calcium intake, frequency of exercise, history of positive for COVID-19, comorbidities, or sunlight exposure [Table 3].
| Discussion|| |
Vitamin D’s importance in maintaining homeostasis extends far beyond calcium and bone health. Inadequate sun exposure appears to be frequently neglected or under-investigated. Working inside is known to increase the risk of vitamin D deficiency. Doctors are also at risk of deficiency because of their long working hours, particularly anesthetists who work thoroughly indoors for long periods and thus have less sun exposure.
The primary findings of this observational study were that vitamin D levels in anesthesiology residents are generally good, with a 25(OH) D concentration of 30 ng ml/L on average. Most anesthesiologist residents in this study were exposed to sunshine for more than 10 hours per week. Studies worldwide have found a high frequency of vitamin D insufficiency in medical residents to variable degrees., According to Haney et al., sun exposure, multivitamin use, and dietary vitamin D intake were all significant predictors of vitamin D levels. Limited sun exposure during periods of high intensity, increased body mass index, and limited body area exposed to the sun were all positively connected with lower 25(OH) D levels, but the relationship was weak. To keep the study population consistent, we only enrolled people who had worked in anesthesia for at least six months. Also, Indonesia is a country that gets sunlight throughout the year. This can affect the value of vitamin D, which is within the normal range for most residents. Compared to countries that have four seasons, the vitamin levels of residents in Indonesia have a good average. However, we found that there was no statistically significant relationship between sun exposure and vitamin D levels in our research
Calcium and vitamin D supplementation in the diet also influences vitamin D levels. Dietary vitamin D did not significantly correlate with vitamin D levels in our study. Our study differs from the previous one, which found a link between dietary intake and vitamin D levels. In addition, high vitamin D levels among residents can also be influenced by healthy lifestyle factors before residents enter residency.
A previous study stated that Indoor and outdoor exercise increases plasma vitamin D levels. Physical activity reduces serum vitamin D by promoting vitamin D, increasing bone mass, decreasing calcium excretion, increasing absorption, and increasing blood calcium levels. Previous research on the pediatric population found that vitamin D levels in the blood increase with increasing physical activity, even when the sunlight has been controlled. Although the statistical test results did not show a significant relationship between vitamin D levels and exercise, we suspect that anesthesia residents have good Vitamin D levels because our residents spend more time outdoors. On weekends, many residents spend time together exercising, walking, and doing other community activities.
The pandemic of COVID-19 created awareness among researchers regarding the role of vitamin D. Vitamin D deficiency can lead to hyper-inflammatory disease and a cytokines storm, increasing the severity and mortality of COVID-19. Data show significantly higher levels of biomarkers of inflammation and coagulation, including CRP, D-dimer, interleukin-6, tumor necrosis factor-α, fibrinogen, and ferritin,,, in patients with vitamin-deficient COVID-19 D. In addition, vitamin D is involved in the negative regulation of the renin-angiotensin system. Entry into SARS-CoV-2 cells depends on the binding of the angiotensin-2 converting enzyme (ACE2) as a receptor., D’Avolio et al. reported that 25-hydroxyvitamin D concentrations were lower in PCR-positive patients for SARS-CoV-2 than in PCR-negative patients. According to Melzer et al. vitamin D deficiency is associated with an increased risk of COVID-19 in the Chicago population. Two meta-analyzes show a positive association between vitamin D deficiency and the severity of COVID-19 and the increased risk of COVID-19 infection. Also contradicting our results, Luo et al. found a significant association between vitamin D deficiency and COVID-19 severity in the Chinese population. Radujkovic et al. demonstrated an association between vitamin D deficiency and the severity and mortality of COVID-19 in the German population. In our study, our residents were young and most had no comorbidities, which makes this research less suitable for comparison.
Although the current value of vitamin D levels is quite good, it is possible that in the long-term residents’ work in the room (especially in the operating room and ICU) will cause vitamin D levels in the body to decrease and will lead to Vitamin D deficiency. Unfortunately, we have not investigated so far. Therefore, further research is needed to determine the effect of long working hours as a resident and anesthesiologist on vitamin D levels. Another limitation that needs to be improved in this research is that we did not have a control group because the goal was to find vitamin D levels in anesthesiology residents and compare them to existing literature. More multicentric trials in a broader sample must be developed to evaluate vitamin D levels among anesthesiologists.
| Conclusion|| |
The prevalence of vitamin D insufficiency was low among anesthesiology residents. Further studies are needed to analyze contributing factors in Vitamin D insufficiency among anesthesiology residents.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Palacios C, Gonzalez L. Is vitamin D deficiency a major global public health problem? J Steroid Biochem Mol Biol 2014;144 Pt A:138-45.
Sowah D, Fan X, Dennett L, Hagtvedt R, Straube S. Vitamin D levels and deficiency with different occupations: A systematic review. BMC Public Health 2017;17:519.
G R, Gupta A. Vitamin D deficiency in india: Prevalence, causalities and interventions. Nutrients 2014;6:729-75.
Carrelli AL, Walker MD, Lowe H, McMahon DJ, Rundek T, Sacco RL, et al
. Vitamin D deficiency is associated with subclinical carotid atherosclerosis: The northern manhattan study. Stroke 2011;42:2240-5.
Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, et al
; Endocrine Society. Evaluation, treatment, and prevention of vitamin D deficiency: An endocrine society clinical practice guideline. J Clin Endocrinol Metab 2011;96:1911-30.
Nimitphong H, Holick MF. Vitamin D status and sun exposure in southeast asia. Dermatoendocrinol 2013;5:34-7.
Nguyen HT, von Schoultz B, Nguyen TV, Dzung DN, Duc PT, Thuy VT, et al
. Vitamin D deficiency in northern vietnam: Prevalence, risk factors and associations with bone mineral density. Bone 2012;51:1029-34.
Setiati S. Vitamin D status among indonesian elderly women living in institutionalized care units. Acta Med Indones 2008;40:78-83.
Kelly E, Perrie H, Scribante J, Chetty S. Vitamin D levels of anesthetists from ‘Sunny’ South Africa: An occupational exposure study. Middle East J Anesthesiol 2020;27:197-203.
Ahuja V, Sharma M, Chander A, Thapa D, Abhishek K. Cervical lymphadenectomy in a high-risk patient under superficial cervical plexus block as an alternative to general anesthesia. J Anaesthesiol Clin Pharmacol 2021;37:488-9. [Full text]
Ramírez-Vick M, Hernández-Dávila L, Rodríguez-Rivera N, López-Valentín M, Haddock L, Rodríguez-Martínez R, et al
. Prevalence of vitamin D insufficiency and deficiency among young physicians at University District Hospital in San Juan, Puerto Rico. P R Health Sci J 2015;34:83-8.
Mendoza V, Villanueva MT, Vargas G, González B, Halabe J, Simón J, et al
. Vitamin D deficiency among medical residents and its relationship with metabolic indices. Endocr Pract 2013;19:59-63.
Haney EM, Stadler D, Bliziotes MM. Vitamin D insufficiency in internal medicine residents. Calcif Tissue Int 2005;76:11-6.
Wiciński M, Adamkiewicz D, Adamkiewicz M, Śniegocki M, Podhorecka M, Szychta P, et al
. Impact of Vitamin D on Physical Efficiency and Exercise Performance-A Review. Nutrients 2019;11:2826.
Infante M, Buoso A, Pieri M, Lupisella S, Nuccetelli M, Bernardin S, et al
. Low vitamin d status at admission as a risk factor for poor survival in hospitalized patients with COVID-19: An Italian retrospective study. J Am Coll Nutr.2022;41:250-65.
Jain A, Chaurasia R, Sengar NS, Singh M, Mahor S, Narain S. Analysis of vitamin D level among asymptomatic and critically ill Covid-19 patients and its correlation with inflammatory markers. Sci Rep 2020;10:20191.
Pinheiro MM, Fabbri A, Infante M. Cytokine storm modulation in Covid-19: A proposed role for vitamin D and Dpp-4 inhibitor combination therapy (Vidpp-4i). Immunotherapy 2021;13:753-65.
Malek Mahdavi A. A brief review of interplay between vitamin D and angiotensin-converting enzyme 2: Implications for a potential treatment for COVID-19. Rev Med Virol 2020;30:e2119.
D’Avolio A, Avataneo V, Manca A, Cusato J, De Nicolò A, Lucchini R, et al
. 25-Hydroxyvitamin D concentrations are lower in patients with positive PCR for SARS-CoV-2. Nutrients 2020;12:1359.
Meltzer DO, Best TJ, Zhang H, Vokes T, Arora V, Solway J. Association of vitamin D status and other clinical characteristics with Covid-19 test results. Jama Netw Open 2020;3:e2019722.
Pereira M, Dantas Damascena A, Galvão Azevedo LM, de Almeida Oliveira T, da Mota Santana J. Vitamin D deficiency aggravates Covid-19: Systematic review and meta-analysis. Crit Rev Food Sci Nutr 2022;62:1308-16.
Liu N, Sun J, Wang X, Zhang T, Zhao M, Li H. Low vitamin D status is associated with coronavirus disease 2019 outcomes: A systematic review and meta-analysis. Int J Infect Dis 2021;104:58-64.
Luo X, Liao Q, Shen Y, Li H, Cheng L. Vitamin D deficiency is associated with Covid-19 incidence and disease severity in chinese people [corrected]. J Nutr 2021;151:98-103.
Radujkovic A, Hippchen T, Tiwari-Heckler S, Dreher S, Boxberger M, Merle U. Vitamin D deficiency and outcome of COVID-19 patients. Nutrients 2020;12:2757.
[Table 1], [Table 2], [Table 3]