Nishitha Sharma felt a wave of exhaustion wash over her. Gripping the armrests of her office chair, she tried to stand up but felt faint. The 30-year-old struggled to keep her eyes open, then slowly felt herself crumpling down. ‘That was the last thing I could remember,’ says the Indian expat who worked for a computer accessories company in Dubai. Luckily for Nishitha, a couple of colleagues who were close by saw her collapse and rushed her to hospital.
‘I came to quickly,’ she says. ‘In fact before I even reached hospital.’
There she was asked to take a battery of tests – including ones for thyroid and hypertension. ‘All of them turned out negative,’ she says.
‘However, I’d been putting on weight despite being careful about my diet so since I was in hospital I decided to consult a nutritionist to find out if there was a reason behind my weight gain.’
In hindsight, that was a good thing. The nutritionist suggested she take a blood test to check her vitamin D levels.
‘I did, and was shocked when the results arrived,’ she says.
While the required level of vitamin D is around 30ng/ml, Nishitha’s was an abysmal 5ng/ml. A reading of 20ng/ml or below is considered deficient and cause for concern.
Nishitha was immediately directed to a doctor who prescribed vitamin D tablets for her. ‘I was also told to spend more time out in the sun.’ Now, two months later, she says she feels a lot better. ‘I don’t feel as tired and drowsy like I used to earlier. I also feel a lot more positive.
‘I didn’t know much about vitamin D deficiency at the time and never for a moment thought I could have it.’
Nishitha is not alone. According to the International Osteoporosis Foundation, despite ample sunshine, Hypovitaminosis D – vitamin D deficiency – is very common in the Middle East and Africa. According to one report, more than 90 per cent of people in the UAE suffer from vitamin D deficiency. The Foundation’s study also found that close to 70 per cent of pregnant women in the region are vitamin D deficient – a condition some experts believe could lead to children having autism, although this has not been confirmed conclusively.
‘Vitamin D deficiency is often clinically silent,’ says Dr Zeeshan Khan, internal medicines specialist at Medeor 24x7 Hospital in Dubai. ‘This is a reason it often goes undetected or is detected late.’
The human body obtains vitamin D from exposure to sunlight or through supplements. Insufficient exposure to direct sunlight can contribute to deficiency.
‘In the short term, vitamin D deficiency can lead to weight gain, fatigue, joint pain especially in the back and knees, low calcium levels, reduced immunity, weak muscles and blood sugar discrepancies.’
In the long term, the deficiency can contribute to severe health issues.
‘It can lead to rickets in children and osteomalacia – or soft bone disease – where the bones easily bend or break in adults,’ says the doctor. ‘If left untreated vitamin D deficiency in the long run can contribute to the onset of osteoporosis.’
The initial symptoms of vitamin D deficiency are non-specific and as Dr Khan says, clinically silent.
‘In children, the warning signs are when their walking is delayed or if they prefer to sit down for prolonged periods of time. In adults it causes chronic muscle aches and pain, and fatigue.’
Some people may have bone pain, muscle aches and weakness, low mood or depression.
So, is a lack of adequate exposure to sunlight the only cause of vitamin D deficiency?
‘Not really,’ says Dr Khan. ‘There are several reasons that can cause low vitamin D and place you in the ‘at risk’ category.’
He lists lifestyle as a major reason. ‘People who spend less time outdoors, or who cover up when they are outdoors get less sun exposure. Ergo, their body makes less vitamin D,’ he says. ‘Other causative factors include sunscreen use, skin tone and age – the skin’s ability to make vitamin D drops as we age. Certain health conditions such as osteoporosis and chronic kidney diseases too could result in poor vitamin D absorption by the body.’
Abu Dhabi-based Dr Melissa Li-Ng lists a few more at-risk categories. ‘People who are overweight, who follow a vegan diet (because most natural sources of the vitamin are animal-based and found in liver, fish, eggs and milk) and those who live in the very southern and northern latitudes – could be at risk,’ says the staff physician at the Medical Subspecialties Institute in Abu Dhabi’s Cleveland Clinic.
Skin tone, it appears, is a crucial factor when it comes to the body’s ability to produce vitamin D.
According to experts, people who have a darker skin tone have more melanin in their skin. This pigment is a ‘natural sunscreen’ that slows down production of vitamin D. This means those with fair complexions need to spend less time in the sun to get their daily requirement of vitamin D compared to those with darker skin tones.
‘If you were to ask demographics, I’d say people from Asian and African backgrounds are more at risk,’ says Dr Khan.
Dubai-based Bandana Peters matched that profile. She never used to shy away from the sun while in her hometown of New Delhi. ‘But that changed when I arrived here,’ says Bandana who moved to the UAE four years ago. A hectic job meant she had little time to be outdoors during much of the day. Then two years ago, she began experiencing severe pain in the joints of her legs. ‘I also used to feel drowsy and weak all day,’ she says.
Initially she put it down to being on her feet for a large part of her working day. ‘But when the symptoms began to get really severe, I decided to undergo a complete check-up,’ she says.
‘The doctor at Medeor did a series of tests including to check vitamin D.’ That last test revealed the cause of her problems – vitamin D deficiency.
In Bandana’s case it was an alarming 10 ng/ml. Like Nishitha, she too, never expected to be suffering from the condition.
So what could be the reason for the high rate of vitamin D deficiency in the UAE?
Dr Li-Ng attributes it to the fact that although this region enjoys a lot of sunshine, ‘most people who live here seem to avoid the sun. So there is limited sun exposure.
‘And when they do go out, they are usually well covered.’ To make matters worse as far as vitamin D production is concerned, those who do step outdoors use a lot of sunblock.
‘While correctly-applied sunscreen blocks the harmful ultraviolet B rays that cause skin cancer, it also blocks most of the skin’s production of vitamin D,’ says Dr Khan.
Dr Li-Ng agrees. ‘Any type of sunscreen – because it blocks UVA and UVB rays – is going to be blocking vitamin D activation. So if the reason to be out in the sun is to boost your vitamin D then you should be out without sunscreen,’ she says. ‘But you should take care to maintain a balance. If the sun exposure on the skin is for a long time there is the risk of developing skin cancer.’
So how much sun is enough?
‘Ten minutes of full-body exposure is enough. But because most of us are clothed and pretty much covered up, being out in the sun with your face, arms and legs exposed for about 15 or 20 minutes would be good,’ says Dr Li-Ng.
She also says it’s important to have direct sun exposure. ‘Going out at 6am or 7am is not good enough because at that time there is not enough UV light to activate the production of vitamin D.’
Can vitamin D be ‘banked’ – can we stay out more on weekends and less on weekdays to get our required amounts of vitamin from the sun? ‘Yes,’ says Dr Khan. A single 15-20 minutes exposure of direct sunlight would be enough for more than a week.
He also suggests eating food that contains vitamin D. ‘Very few foods have vitamin D, and that too, in small quantities. Salmon, mackerel, tuna and egg yolks do have vitamin D. It’s also in fortified foods for babies.
‘Vegetarians can include mushrooms, cheese and soya milk in their diets,’ he says.
(Research published in Dermato-Endocrinology has shown mushrooms can give as much vitamin D as a health supplement, but they need to be exposed to sunlight for 30-60 minutes before eating. This is because they can transform UV light into vitamin B, just like the human body does.)
Dr Khan admits there’ve been reports suggesting pregnant women with vitamin D deficiency at 20 weeks are more prone to have autistic babies. ‘But that’s still being debated,’ he says. ‘Vitamin D insufficiency data is expanding to include evidence on its role in asthma, allergic disorders, and atopic dermatitis.’
According to Dr Meis Moukayed, vitamin D has been found to act synergistically with chemotherapy agents to combat cancer cells and potentiate the effect of chemotherapy drugs. ‘Several lines of evidence have supported a strong role for Vitamin D in cancer prevention,’ says the Harvard-trained scientist who has years of experience in health and science sectors. She wants more research done in this field.
While going out in the sun is important to get enough vitamin D experts make it clear too much sun too, could cause harm. What’s needed is a common-sense approach.