Very poor knowledge, even after being diagnosed as vitamin D deficient.

Apparently many had gotten weekly injection of 50,000 IU of vitamin D (probably vitamin D2)

Results summary

• 28% of participants were aware about their condition,
• 53% related pain to vitamin D deficiency,
• 33% knew the presence of relation between vitamin D deficiency and joint pain.
• 33% received the loading dose of vitamin D (50,000 IU weekly)
• 17% had the maintenance dose (1,000 IU D2? daily for 8 weeks)
• 21% believed that they feel better regarding musculoskeletal symptoms after taking treatment doses
• 12% of the participants knew that the level of vitamin D dropped again after stopping medication.
• 29% knew the relation between vitamin D and other diseases.
• 85 agreed about the importance of sunshine as a source of vitamin D
• 60% thought that they can get vitamin D from the nutrients.

Source of their knowledge of vitamin D

• 40% of patients got knowledge from doctors,
• 12% from the media,
• 29% from relatives and friends
• 8% from background information
• 9% from journals and magazines.

PDF is at bottom of this page; Text is extracted for ease of translation to other languages

Overview Vitamin D3 not D2 has the following graphs

AlexandriaJournal of Medicine

Available online 17 March 2012

Knowledge, attitude and practice of patientsattending primary care centers toward vitamin D in Kuwait

• Bassam A. Al Bathi^a, ,

• Khaled E. Al Zayed^a, ,

• Mohammad Al Qenai^b, ,

• Gamal Makboul^{c, d,} ,

• Medhat K. El-Shazly^{d, e, ,}

• ^a AlSalam Clinic, Primary Health Care, Ministry of Health, Kuwait

• ^b AlKhaldyia Clinic, Primary Health Care, Ministry of Health, Kuwait

• ^c Department of Community Medicine, Faculty of Medicine, Alexandria University, Egypt

• ^d Department of Health Information and Medical records, Ministry of Health, Kuwait

• ^e Department of Medical Statistics, Medical Research Institute, Alexandria University, Egypt

• Received 4 January 2012. Accepted 15 February 2012. Available online 17 March 2012.

• http://dx.doi.org/10.1016/j.ajme.2012.02.003, How to Cite or Link Using DOI

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Abstract

Background

Extracellular calcium is vital for the functioning of manymetabolic processes and neuromuscular activities. Awareness andpractice of patients with vitamin D deficiency are very important.

Objective

To explore knowledge, attitude and practice of patients receivingvitamin D supplement and attending primary health care (PHC) inKuwait.

Subjects and methods

The study design is a simple descriptive cross-sectional one thatwas carried out in two PHC centers. Two hundred patients wereselected randomly from a list of all registered patients in theselected centers. Criteria for inclusion included adult age~18 years, diagnosis with hypovitaminosis D within ayear, and under vitamin D supplement.

Results

Only 28.5% of participants were aware about their condition, 53.5%related pain to vitamin D deficiency, 33.5% knew the presence ofrelation between vitamin D deficiency and joint pain. One third ofthe participants received the loading dose of vitamin D, and, 17.5%had the maintenance dose. Only 21.0% believed that they feel betterregarding musculoskeletal symptoms after taking treatment doses and12.5% of the participants knew that the level of vitamin D droppedagain after stopping medication. Only 29.5% knew the relation betweenvitamin D and other diseases. The majority of patients (85.5%) agreedabout the importance of sunshine as a source of vitamin D and 60.0%thought that they can get vitamin D from the nutrients. Regarding themain sources of knowledge about vitamin D, 40.5 % of patients gotknowledge from doctors, 12.5% from the media, 29.0% from relativesand friends, 8.5% from background information and 9.5% from journalsand magazines.

Conclusions

The majority of the study participants had limited knowledge, poorpractices, and negative attitude toward vitamin D problems. Planninghealth education interventions for this group of patients areessential.

1. Introduction

Vitamin D plays a primary physiological role in maintainingextracellular calcium ion levels in the human body. Extracellularcalcium is vital for the functioning of many metabolic processes andneuromuscular activities. Vitamin D influences calcium levelsprimarily by controlling the absorption of calcium from theintestine, through the direct effects on bone and also through itseffects on parathyroid hormone secretion.¹Furthermore, vitamin D deficiency, resulting in decreased bonemineralization, secondary hyperparathyroidism, and increased corticalbone loss, has been linked to the pathogenesis of osteoporosis andhip fractures.^{[2] and [3]}Vitamin D is acquired both through nutritional means (10–20%)and by the cutaneous synthesis under the action of sunlight(80–90%).⁴Vitamin D may play a role in muscle strength, pathogenesis ofpsoriasis, certain cancers, multiple sclerosis, diabetes, and bloodpressure, among other physiological and pathophysiologicalprocesses.^{[5],[6] and [7]}

Determining vitamin D status of a population can be a challengingtask.⁸Earlier observational studies have measured serum 25(OH)D levels inhealthy population cohorts to determine reference values forsufficient levels of vitamin D. However, these are known to beinfluenced by lifestyle and environmental characteristics and,therefore, may not be applied clinically and worldwide.^{[1] and [2]}

Clinical hypovitaminosis D is associated with rickets in infancy andosteomalacia in adults, which causes muscle weakness and contributesto falls and bone fractures.⁵Defining categories of vitamin D insufficiency and deficiency willaffect the prevention strategies employed in a clinical setting.These are oral vitamin D supplementation, increased exposure to UVlight (especially sunlight), and a better dietary intake.^{[2],[3] and [9]}

Studies from Saudi Arabia, Kuwait, United Arab Emirates, and Iranreveal that 10–60%of mothers and 40–80% of their neonateshad undetectable low vitamin D levels (0–25 nmol/L) atdelivery. Higher socioeconomic status, antenatal care, and vitamin Dintake were associated with higher vitamin D levels.^{[10],[11] and [12]}

Propercompliance to medicines and life style modification strategiesinvolving mainly diet and activity are important tools of secondaryprevention. It has been shown that knowledge about disease in apatient improves his treatment compliance and decreases manycomplications associated with a disease.¹³

The aim of the present study was to exploreknowledge, attitude and practice of patients attending primary healthcare (PHC) centers for vitamin D supplement.

2. Methods

2.1. Setting and design

The study design is a descriptivecross-sectional one that was carried out in two PHC centers. Kuwaitwas divided into five health regions, and each individual in thepopulation was linked to one of the PHC units that are available inall residential areas in Kuwait. Two health regions were selectedrandomly for conducting the study, Capital and Hawalli. From each onePHC center was chosen randomly (AlSalam health center in Hawalliregion and AlKhaldiya health center in the Capital region). Withineach selected center a list of all patients >18 years old,newly diagnosed and receiving vitamin D therapy was prepared. Thisstudy was conducted during the period from August to December 2010.

2.2. Subjects

The study population was Kuwaiti andnon-Kuwaiti patients who attend the PHC centers for treatment byvitamin D supplement. Upon reviewing the computerized database of theselected centers, all registered subjects aged ~18 yearswithin the enrollment period were identified (1050 registeredpatients were in AlSalam center and 795 were in Khaldiya), and arandom sample of 200 patients were proportionally and electronicallyselected. Selected subjects were recalled for interview and theirrecords were reviewed manually for extraction of the requiredinformation.

Subjects were eligible for the study if theywere ~18 years old, newly diagnosed with vitamin Ddeficiency, under vitamin D treatment and registered in the selectedcenters within the enrollment period. Subjects were excluded from thestudy, if they presented with acute disease during the last two weekspreceding the study or diagnosed earlier than a year.

2.3. Data collection

The necessary data were collected with astructured questionnaire and via the interviews between the trainedinterviewers and the eligible subject. Also, patients’ recordswere reviewed for abstracting data regarding the intake of loadingand maintenance dose of vitamin D. Loading dose was defined asmonthly injection of weekly capsules of 50,000 IU andmaintenance dose as 1000 IU/day for 8 weeks. The collecteddata included information related to patient’s knowledge aboutthe signs and symptoms of vitamin D deficiency as bone pain, musclepain and joint pain, attitude toward vitamin D treatment, right orwrong beliefs about the relation between vitamin D and some chronicdiseases, practice regarding intake of loading and maintenance dosesas well as exposure to health sun rays. The sources of patients’knowledge about vitamin D test was also inquired.

All the necessary approvals for carrying outthe research were obtained. The Ethical Committee of the KuwaitiMinistry of Health approved the research. A written format explainingthe purpose of the research was prepared and signed by theparticipant.

3. Statistical analysis

Data were collected and coded then enteredinto an IBM compatible computer, using the SPSS version 12 forWindows. Simple descriptive statistics were used. Qualitativevariables were expressed as number and percentage while quantitativevariables were expressed as mean and standard deviation.

4. Results

Thegeneral characteristics of the participants were illustrated in table1.The age of the participants ranged from 18 to 62 yearswith a mean = 41.3 ± 14.3 years. Twothirds of them were females and 33.5% were males, about one fifth ofthe sample were non-Kuwaiti, while the majority were Kuwaiti patients(81.0%).A one third of the participants were highly educated, only 7%positioned in professional jobs, the majority were married (81.5%),two thirds had monthly family income >1000 KD. The meanvitamin D level ranged from 4 to 76 nmol/L (mean = 23.5 + 6.2).

Table2 illustrates the awareness of participants about their vitamin Dhypovitaminosis, their knowledge and attitude regarding vitamin D.When the patients were asked about their complaining from vitamin Ddeficiency symptoms, 33.0% answered negatively, 38.5% mentioned thatthey did not know and only 28.5% answered positively. When askedabout the relation between vitamin D deficiency and pain, about halfof the patients (53.5%) answered correctly regarding bone pain, 20.5%refuse this relation and 26.0% have no knowledge about this issue.Similarly, 33.5% of the participants answered correctly about thepresence of relation between vitamin D deficiency and joint pain,while 40.0% refuse this relation and 26.5% have no knowledge.Slightly more than one half (53.0%) of the participants did notrelated muscle pain to vitamin D deficiency and 26.0% have noknowledge about the topic, while only 21.0% knew the relation.

About one fifth of the participants (21.0%)believed that they feel better regarding musculoskeletal symptomsafter taking treatment, while 20% did not believe that and themajority 59% did not know. When participants asked if they noticedthat the level of vitamin D dropped again after stopping medication,87.5% did not know or answered negatively, whereas 12.5% believedthis issue. However, 73.0% of the participants thought that vitamin Ddeficiency related to some musculoskeletal diseases. When patientswere asked about the relation between vitamin D and other diseaseslike cardiovascular, diabetes mellitus, depression,hypercholestermia, cancer and multiple sclerosis, only 29.5% believedpositively, 21.5% negatively and 49% reported that they did not know.The majority of the patients (85.5%) agreed about the importance ofsunshine as a source of vitamin D, 60.0% thought that they can getvitamin D from nutrients, milk products and oily fish.

Concerningthe intake of the loading dose of vitamin D as monthly injection orweekly capsules, only about one third of the participants (30.5%),mentioned that they got the dose. Moreover, only 17.5% reported thatthey had the maintenance dose. More than a half of the participants(56%) reported that they spend less than three times per week underthe sunshine for 20 min between the time 9 am–3 pm,while 25.5% practiced that 3–4 times and less than a fifth ofcases practiced that from 5 to 7 times as shown in table. Table3.

Table4 illustrates participants’ main sources of informationregarding vitamin D deficiency, treatment and test. Less than half ofparticipants (40.5%) depended on the physician to get information,12.5% from the media, 29.0% from relatives and friends, 8.5% fromtheir background information and 9.5% from journals and magazines.

5. Discussion

Individuals with vitamin D deficiency have proximal muscle atrophyand loss of type II muscle fibers. They usually recover within6–12 months of vitamin D supplementation. These effectsmay be a direct consequence of the action of vitamin D on specificreceptors on skeletal muscle or mediated by the effects of vitamin Don serum calcium and phosphate.⁵The results of the current study revealed the lack of knowledge amongthe participants of the study regarding the effect of vitamin Ddeficiency. The low level of knowledge found in this study is inkeeping with the reports of other studies that revealed that vitaminD deficiency has been associated with impaired muscle strength⁶and that inadequate vitamin D is associated with increased bodysway.⁷In a similar study on hypertensive patients, it was shown that poorperception of good health and irregular visits to physician are someof the most important factors for unawareness, untreated anduncontrolled hypertension.¹⁴Also, the relatively lower levels of education of a considerableproportion of participants in this study could contribute to the lackof knowledge and awareness. Patient education plays a critical rolein facilitating patients’ acceptance of their diagnosis andunderstanding behavioral changes required for the participation intreatment.¹⁵

Vitamin D may play a role in muscle strength, pathogenesis of certaincancers, some skin and other chronic diseases. When patients wereasked about the relation between vitamin D and other diseases likecardiovascular, diabetes mellitus, depression, hypercholestermia,cancer and multiple sclerosis, only 29.5% believed positively.^{[5],[6] and [7]}

Although the best-characterized sequel of vitamin D deficiencyinvolves the musculoskeletal system, a growing body of evidencesuggests that low levels of vitamin D may adversely affect thecardiovascular system.¹⁶Clinical studies have reported cross-sectional associations betweenlower vitamin D levels and blood pressure, coronary arterycalcification, and prevalent cardiovascular disease.^{[16],[17] and [18]}Despite these clinical observations, prospective data are neededbecause vitamin D deficiency could be a consequence of cardiovasculardisease rather than a cause. Thus, patients knowledge regarding thisissue could not be taken as an indicator for their awarenessregarding the results of vitamin D deficiency.

Vitamin D is acquired both through nutritional means (10–20%)and by the cutaneous synthesis under the action of sunlight(80–90%).⁴Participants in our study had the right attitude toward sunshine,where 85.5% agreed about the importance of sunshine as a source ofvitamin D, 60.0% thought that they can get vitamin D from nutrientsas milk products and oily fish. It is indicated that patients withvitamin D deficiency had adequate general knowledge and awarenessabout the importance of sun rays as a source of vitamin D, but theydid not practice enough exposure to sun as they have no comprehensiveunderstanding of their condition.

Several factors have significant effects on serum vitamin D levels,including season, sunlight exposure, age, race and diet.^{[19],[20],[21] and [22]}About one third of the participants mentioned that they got theloading dose of vitamin D and only 17.5% reported that they had themaintenance dose. These figures should be taken cautiously as manypatients received the prescribed treatment without discussing itsnature with their physicians due to the overload of work of them.Also, patients could have the impression that the treatment is forrelieving their musculoskeletal symptoms. More than a half of theparticipants reported that they either not exposed or spend less thanthree times per week under the sunshine for 20 min between thetime 9 am–3 pm, while 25.5% practiced that 3–4times and less than one fifth of cases practiced that from 5 to 7times. Other studies revealed that vitamin D is predominantly derivedfrom exposure of the skin to solar ultraviolet Bradiation.^{[19] and [20]}Natural dietary sources of vitamin D are limited, unlessfortification or supplementation practices are adopted.²¹Knowledge of vitamin D testing is confused between the participants.The lack of knowledge and beliefs may be related to the effects ofdifferent dress styles in working, where exposure to sunlight issupposed to be adequate in summer time and negligible in winter inGulf countries. For religious and cultural reasons, women’sdress styles range from those that totally cover the whole body,including the hands and face, to western-type dress styles. Womenwearing these continue doing so during their working hours, butusually free themselves from these dresses inside their homes andthis could expose them to deficiency.⁴Therefore, health education programs should be targeted at womenthrough various media including leaflets, television, and radio.

We apologize certain limitations of thisstudy. One of this limitation is non inclusion of many categories ofpatients who may have better knowledge, attitude and practice thanthose participated in the study. Another limitation is conducting thestudy in two centers only. However, the general characteristics ofthe practice and the study population shared many of the features ofall health structures available in Kuwait.

6. Conclusion

Our results indicated that the majority of thestudy participants had limited knowledge, poor practices, andnegative attitude toward vitamin D problems and have to improve.Health care workers may play an important role in communicatinghealth behaviors to the general public and planning health educationinterventions for this group of patients.