DOI 10.

1515/jpem-2013-0198

J Pediatr Endocr Met 2014; 27(5-6): 431436

Shakeri Habibesadat, Khakshour Ali, Jalili Moghaddam Shabnam and Akaberi Arash*

Prevalence of vitamin D deficiency and its related

factors in children and adolescents living in North
Khorasan, Iran
Abstract
Introduction: Vitamin D deficiency is recognized as an
epidemic among children. The present study has analyzed
serum 25 hydroxyvitamin D [25(OH)D] levels of children
living in the city of Bojnurd, located in the North Khorasan
province of Iran.
Methods: In this cross-sectional study, 361 subjects (175
boys and 186 girls) aged 718 years participated; 25(OH)
D, parathyroid hormone (PTH), and anthropometric
measurements were obtained. Deficiency, insufficiency
and sufficiency of vitamin D was assessed based on
the relationship between 25(OH)D and PTH. Vitamin D
status was reported according to gender and age group of
participants.
Results: The prevalence of vitamin D deficiency was 16.1%
and its insufficiency was 25.2%. Girls had higher levels of
vitamin D deficiency (30.6%) and insufficiency (38.7%).
The mean level of serum 25(OH)D decreased in older age
groups. The age-adjusted odds of serum 25(OH)D <30 was
21.12 higher in girls compared to boys.
Conclusion: The prevalence of vitamin D deficiency and
insufficiency was high. The ratio in girls was higher than
in boys.
Keywords: adolescents; children; 25 hydroxyvitamin D;
parathyroid hormone; vitamin D deficiency.
*Corresponding author: Akaberi Arash, Faculty of Public Health,
School of Medicine, North Khorasan University of Medical Sciences,
Bojnurd, Iran, Phone: +98-5842211009,
E-mail: arashdata@yahoo.com; akaberi@nkums.ac.ir
Shakeri Habibesadat: Department of endocrinology, School of
Medicine, North Khorasan University of Medical Sciences, Bojnurd,
Iran
Khakshour Ali: Department of Pediatrics, School of Medicine,
Mashhad University of Medical Sciences, Mashhad, Iran
Jalili Moghaddam Shabnam: Faculty of Health and Environmental
Science, Auckland University of Technology, Auckland, New Zealand

Introduction
Vitamin D deficiency has grown to become a worldwide
medical problem (1). Although current studies have reported
that vitamin D deficiency among children is widespread (2),
little is known about the prevalence of vitamin D deficiency
in childhood (3). In the USA, Canada, Europe, Australia,
New Zealand, and Asia, the prevalence of vitamin D deficiency in both children and adults is 30%58.8% (19).
Vitamin D is known as the sunshine vitamin (10), and
its best indicator is the serum concentration of calcidiol or
25 hydroxyvitamin D [25(OH)D] (11). To maintain regular
bone metabolism, normal levels of serum 25(OH)D is necessary (5). Vitamin D also provides protection against some
diseases, such as autoimmune disease, cardiometabolic
disease, and cancer (2, 5, 10, 12). Identification, treatment,
and prevention of vitamin D deficiency in childhood may
have profound future health effects (13). Mild, moderate,
and severe vitamin D deficiencies were defined as 25(OH)
D ng/mL values of 2030, 1020, and <10, respectively (1).
Sunlight has a significant role in vitamin D synthesis, therefore, it is quite logical to have low prevalence
of vitamin D deficiency in tropical countries. However,
studies over two decades show a high prevalence of
vitamin D deficiency in tropical countries such as China,
Turkey, India, Iran, and Saudi Arabia (1, 2, 7, 8,14). The
role of various factors, such as different exposure to sunlight, low dietary intake of vitamin D, and low consumption of supplements has been confirmed as the main cause
of this deficiency in these countries. However, the majority of recent studies have reported that the prevalence of
vitamin D deficiency in different sex and age groups differs
in developing countries (15). In addition, the majority of
studies aimed at estimating the prevalence of vitamin D
were limited to a small sample size or recruited a specific
age group, especially the elderly(15).
In a Finnish study by Qutila et al. (16) (latitude 60N)
conducted during the winter on 14 to 16-year-old girls,
13.5% were reported to have vitamin D deficiency and
61.8% had vitamin D insufficiency. It was concluded that
the majority of girl adolescents had low vitamin D status

Habibesadat etal.: Prevalence of vitamin D deficiency in North Khorasan, Iran

during the winter in Finland, which seems to have negative effects on bone health.
The Optiford study of four Northern European countries (Denmark, Finland, Poland, and Ireland) concluded
that 30%50% of 199 children with a mean age of 12.5years
had serum 25(OH)D concentrations below 25 nmol/L, and
in over 90% of their counterparts this number was below
48 nmol/L (6).
The vitamin D status of Iranian children has rarely
been investigated. To our knowledge, this is the first study
to examine the prevalence of this problem in boys and girls,
especially in northern Iran during the end of summer when
the length of the days and sunlight is at its longest and the
synthesis of vitamin D is at its highest level. In the present
study, we analyzed serum 25(OH)D levels of 361 Iranian
children from 7 to 18years of age in the summer. This data
could be important in considering policies for the prevention of vitamin D deficiency and improving the vitamin D
status in the Khorasan province as well as all over Iran.

Methods
Subjects
This cross-sectional study was carried out during the last weeks of
summer (September 2011) in order to survey the mean serum 25(OH)
D among 361 Iranian subjects aged 718years old, living in the city
of Bojnurd, located in the North Khorasan Province, north-eastern
Iran (36 21N).
A sample size of 315 produced a 95% confidence interval equal
to the sample proportion 0.05 when the estimated proportion was
30%. Subjects were categorized into three age groups (710, 1114,
and 1418years old).
The method of sampling was random multi steps sampling
(stratified cluster sampling). The school grades under study and the
subjects gender were identified as strata, and schools that fell under
each subclass were identified as clusters. A number of schools and a
sufficient number of students were randomly selected in proportion
to the population in each stratum.
The studys protocol was approved by the Ethics Committee of
North Khorasan University of Medical Sciences. Written consent was
obtained from the parents of all participants and verbal consent was
taken from the participants. Exclusion criteria were students taking
vitamin D and calcium supplementation and students suffering from
any systemic diseases, such as current endocrine disorders, diabetes,
renal or liver dysfunction, hyper/hypothyroidism and respiratory disease, or calcium metabolism disorder.

were responsible for bringing it back to the researcher. However,

older counterparts completed the questionnaire by themselves.
The questionnaire included details of family size, parents education and occupation and type of housing (single-family housing or
apartment building), and received sunlight or not. In addition, the
students were asked about the duration of exposure to sunlight in the
previous summer, travelling to tropical areas, swimming in outdoor
pools, using sunscreen, and clothing (exposure of the face or more).
Sampling was performed at schools with the presence of a physician
and two nurses.

25-hydroxyvitamin D measurement
Calcium, phosphorus, 25(OH)D, parathyroid hormone (PTH), and
alkaline phosphatise were measured. Serum 25(OH)D was measured
using the EIA kit. The IDS 25-hydroxyvitamin D EIA kit is an enzyme
immunoassay for the quantization of 25(OH)D and other hydroxylated
metabolites in serum or plasma. The PTH level was measured using
the electrochemiluminescence immunoassay ECLIA. The normal
range for PTH was 1065 pg/mL. The normal ranges of calcium and
phosphorus were 8.510.1 mg/dL and 3.55 mg/dL, respectively.

Anthropometric measurements
All the anthropometric measurements were obtained early in the
morning after an overnight fast, with the children wearing lightweight clothing, either barefoot or with socks. Anthropometric
assessments were conducted in a private setting at school.
Height was taken using a stadiometer and rounded to the nearest 0.5 cm and weight was measured using a digital Seca (model
767-1321004) weighing balance, rounded to the nearest 0.1 kg.

Statistical analysis
In this study we assessed PTH in levels of 25(OH)D (Figure 1). Similar
to the HOLIK study (17), we defined vitamin D deficiency as having
100
80
PTH, pg/mL

432

PTH pg/mL=84.5334*25(OH)D ng/mL ^ -0.264758

60
40
20
0

Data collection
The parents of students 712years of age were asked to fill out a brief
socio-demographic self-report questionnaire in the Farsi language.
This questionnaire was sent to them through their children, who

10

20

30
40
50
25(OH)D, ng/mL

60

70

Figure 1Serum parathyroid hormone (PTH) by serum 25

hydroxyvitamin D [25(OH)D].
Serum PTH values began to increase with 25(OH)D <30 ng/mL.

80

Habibesadat etal.: Prevalence of vitamin D deficiency in North Khorasan, Iran

serum 25(OH)D level below 20 ng/mL, insufficiency as having serum
25(OH)D level of 2029 ng/mL, and sufficiency as having serum
25(OH)D level above 30 ng/mL.
In addition, in order to compute the odds ratio (OR) in this
study, the vitamin D status of subjects was categorized in two groups;
serum 25(OH)D levels of 30 ng/mL was defined as sufficiency
and <30 ng/mL was defined as not-sufficiency. Mean serum levels
of 25(OH)D were computed and compared between groups using the
2-tailed independent t-test where appropriate. Logistic regression
was used for sufficiency of vitamin D by gender and age. The regression model was used for assessing the effects of age and the length
of daily sun exposure in boys and girls. 2-test and Fishers exact
test were calculated for gender-based comparison of results. Statistical analyses were performed using the SPSS 15 software (SPSS Inc.,
Chicago, IL, USA). Differences were considered significant at p<0.05.

433

60
50
40

51

45.6

43.7

35.7

30

25.4

21.3

20
10
0

710

1114
Girls

15 18
Boys

Figure 2Mean of 25 hydroxyvitamin D in boy and girl subjects in

three age group.

Results
The study enrolled 361 healthy subjects (175 boys and 186
girls) with a mean age of 13.22.6 years. The mean body
mass index of subjects was 19.33.5 kg/m2. There was a
significant difference in the mean body mass index (BMI)
of boys and girls (p=0.024). The mean serum 25(OH)D
and PTH were 36.3615.55 ng/mL and 33.8416.45 ng/mL,
respectively. In addition, the mean serum 25(OH)D level
in adolescent girls was lower than that of boys (p<0.001)
(Table 1).
Figure 1 shows that the plasma levels of PTH in serum
25(OH) levels of lower than 30 ng/mL began to increase,
while in serum 25(OH)D levels higher than 30 ng/mL, we
witnessed lower levels of PTH.
There was a significant difference in mean serum
25(OH)D level in the three age groups of girls (p<0.001).
Based on post hoc Tukeys test, the mean serum 25(OH)D
level in the second and third age group of girls were significantly lower than of the first group (p<0.001) Also, the
third group had a lower mean serum 25(OH)D than the
second group (p=0.028). In boys as well, the mean level of
vitamin D was different among the age groups (p=0.002)

but there was a significant difference only in the second

and third age groups (p=0.001) (Figure 2).
It was found that 16.1% of the subjects had vitamin
D deficiency, 25.2% had vitamin D insufficiency, and only
58.7% had sufficient vitamin D levels. The rate of deficiency and insufficiency in each of the three age groups
of girls were significantly higher than for the boys. In
addition, the rate of deficiency and insufficiency in girls
showed an increase in the older ones. Vitamin D deficiency in 710, 1114, and 1518 year old girls was 2.9%,
29.9%, and 50%, respectively (Table 2).
Odds of girls with non-sufficient vitamin D was more
than that of boys. This ratio showed an increase in older
subjects (Table 3). The multiple logistic regression analysis adjusted for age showed that girls are more likely to be
non-sufficient than boys (ORadjusted for age=21.21, 95% confidence interval, 11.67, 38.57) (Table 4).
The mean of exposure to sunlight was 52.13 min in
boys and 31.01min in girls. Meanwhile, 20.6% of the boys
and 36.6% of the girls had no suitable exposure to sunlight
on any day of the week. To study the relationship of

Table 1Characteristics of the subjects.

Characteristic
Age, years
Weight, kg
Height, cm
BMI, kg/m2
Vitamin D; 25(OH)D, ng/mL
PTH, pg/mL

Girls
(n=186)

Boys
(n=175)

Total
(n=361)

p-Value

13.02.5
46.720.5
144.424.1
19.73.4
26.1810.50
36.3419.85

13.32.8
46.317.1
151.920.7
18.93.4
47.1912.44
31.1811.28

13.22.6
46.518.9
148.022.8
19.33.5
36.3615.55
33.8416.45

0.321
0.837
0.002
0.024
<0.001
0.003

BMI, body mass index; 25(OH)D, 25 hydroxyvitamin D; PTH, parathyroid hormone.

434

Habibesadat etal.: Prevalence of vitamin D deficiency in North Khorasan, Iran

Table 2Distribution levels of serum 25 hydroxyvitamin D [25(OH)D] by sex and age group.
Age stage

Gender

710 years

1114 years

1518 years

Total (718 years)

Girls
Boys
Total
Girls
Boys
Total
Girls
Boys
Total
Girls
Boys
Total

Vitamin D, ng/mL
Deficiency
25(OH)D <20

Insufficiency
2025(OH)D <30

Sufficiency
3025(OH)D

1 (2.9)a
0 (0)
1 (1.5)
29 (29.9)
1 (1.3)
30 (17.2)
27 (50.0)
0 (0)
27 (22.1)
57 (30.6)
1 (0.6)
58 (16.1)

10 (28.6)
2 (6.7)
12 (18.5)
42 (43.3)
13 (16.9)
55 (31.6)
20 (37.0)
4 (5.9)
24 (19.7)
72 (38.7)
19 (10.8)
91 (25.2)

24 (68.6)
28 (93.3)
52 (80.0)
26 (26.8)
63 (81.8)
89 (51.1)
7 (13.0)
64 (94.1)
71 (58.2)
57 (30.6)
155 (88.6)
212 (58.7)

p-Value

0.027f

<0.001

<0.001

<0.001

Number (percent); f, Fishers exact test.

vitamin D with age and exposure to sunlight in both

genders separately, based on linear regression, the sunlight
time variable was omitted and Vit. Dgirls=49.631.80 Age
model was reached. In boys, the age variable was moved
from the model and Vit. Dboys=37.17+0.062 Sunlighttime
was obtained.

Discussion
The present study is the first in its kind to investigate
vitamin D status among the pediatric population in
Bojnurd, located in 36 21N. Bojnurd is a city in the North
Khorasan Province, north-east of Iran, with a mean sunlight exposure of 8 h daily. It was found that the prevalence of vitamin D deficiency and insufficiency in girls
was 16.1% and 25.2%, respectively (41.3% <30 ng/mL). In
boy students, the results were 0.6% and 10.8%. Results
Table 3Comparison of non-sufficient vitamin D in boys and girls in
age group.
Age Stage

Gender

710 years

Girls
Boys
Girls
Boys
Girls
Boys

1114 years

1518 years

OR

95% confidence
interval for OR

p-Value

6.417
1 ref
12.288
1 ref
107.429
1 ref

(1.29, 31.85)

0.023

(5.90, 25.58)

<0.001

(29.72, 388.27)

<0.001

Non-sufficient, 25 hydroxyvitamin D <30; OR, odds ratio;

ref, reference category.

from this study show that girl students had higher levels
of vitamin D deficiency (30.6%) and insufficiency (38.7%).
The mean level of serum 25-hydroxyvitamin D among girl
adolescents decreased in older age groups, and the prevalence of vitamin D deficiency increased. The inverse association of vitamin D status with age during childhood and
adolescence has not been well described and because the
age ranges of prior studies were limited, it has not been
determined whether the vitamin D serum levels varied
with age (11).
Many studies on vitamin D status among children in
different countries have been carried out and most of them
have reported high prevalence of vitamin D insufficiency
and deficiency. In a study by Khor etal., it was mentioned
that 72.4% of 7 to 12-year-old children in Kuala Lumpur,
Malaysia, had vitamin D deficiency (7). In addition, Zhu
et al. in Hangzhou, China determined that the prevalence of this deficiency in 6 to 16-year-old subjects was
41.1% (2). Weng mentioned that 26% of the 9 to 21-year-old
North American population had vitamin D deficiency
(55% <30ng/mL) (11). In a study on 7 to 18-year-old subjects in Tehran, Iran, Rabani etal. reported that 34.9% were
Table 4Compare non-sufficient Vitamin D in boys and girls
adjusted for age with multiple logistic regression.

Sexa
Age

OR

95% confidence
interval for OR

p-Value

21.21
1.21

(11.67, 38.57)
(1.08, 1.34)

<0.001
0.001

Non-sufficient, 25 hydroxyvitamin D <30; OR, odds ratio.

a
reference category, boys.

Habibesadat etal.: Prevalence of vitamin D deficiency in North Khorasan, Iran

suffering from vitamin D deficiency (54.3% <32 ng/mL)

(18). Absoud et al. found that the prevalence of vitamin
D deficiency in 7 to 18-year-old English children was 35%
(19). The prevalence of vitamin D deficiency has also been
reported in tropical areas such as Jeddah, Saudi Arabia,
being 86.3% in 4 to 15-year-old children (8) and in Qatar
having 61.6% vitamin D deficient children between the
ages of 1116years (20).
No significant differences have been reported among
boy and girl counterparts in gender-specific comparisons of vitamin D status of subjects in studies by Absoud
etal. in England (19), Weng etal. in North America (11),
and Ahiwei in China. However, Khor etal. in Malaysia (7),
Mansour and Alhadidi in Saudi Arabia (8), Rabani etal.
(18), Neyestani etal. (children 1012years old) (21), and
Azizi et al. (children 1019 years old) (22) in Iran found
that the prevalence of vitamin D deficiency was significantly more in girls compared to boy subjects. Bener etal.
in Qatar also determined that girls were suffering more
from this deficiency than boys (20).
Regarding the significant role of sunlight in vitamin
D synthesis (17), the role of some factors, such as different exposure to sunlight, region, type of housing, low
dietary intake of vitamin D and low consumption of supplements, seasons, clothing and use of sunscreen has been
confirmed as the main cause of vitamin D deficiency (9).
In this study, clothing and regional status were the most
reasonable explanation for the poorer vitamin D status of
boy and girl subjects. In the study of Batieha etal. among
boy and girl subjects in Qatar, vitamin D deficiency among
girls was related to their type of clothing (23). In addition,
in a research by Ardestani etal. on 6 to 7-year-old children
in Isfahan, Iran, it was found out that the level of vitamin D
has no significant difference by gender because of the type
of clothing at this age. The mean level of serum 25(OH)D
was 46.7 ng/mL in boys and 46.4 ng/mL in girls (24).
In a study by Weng etal. the risk of having <30 ng/mL
serum 25(OH)D in girl subjects compared to boys had no
significant difference (11), however, this risk in Malaysian
girls was 1.76 (7) and was 2.29 in Iranian girls living in Tehran
(21), which was significant. Zhu etal. mentioned that the
prevalence of having vitamin D levels below 30 ng/mL
in 12 to 16-year-old girls is higher than 6 to 11-year-old girls
in comparison with boys (2). Bener etal. showed that the
risk of vitamin D deficiency in 11 to 16-year-old children
was 1.54 times more than 5 to 10-year-old children (20). In
this study, it has also been found that older subjects were
more vitamin D deficient and this was seen more in girl
counterparts.
In a study by Rahnavard etal. (5), it has been revealed
that in Iran, Mashhad has the lowest (21%) and Tehran

435

has the highest (33%) non-exposure to sunlight. In addition, 28.8% did not have sufficient exposure to sunlight
in any days of the week (21). This study showed the same
results as Neyestanis study that girls had a significantly
lower exposure to sunlight than boys. In this study, based
on the regression model, it had been concluded that the
level of vitamin D in girls had no significant relation with
the length of exposure to sunlight, while this was significant in boys. It is important to mention that the length of
exposure to sunlight in girls was less than boys, therefore,
it did not have an effective influence on their vitamin D
levels.
In addition, to levels of 25(OH)D serum, the level of
PTH, which is another important calciotropic hormone,
was also measured. Raising the synthesis and release of
PTH into blood circulation is a response of the parathyroid glands that are sensitive to the decrease of ionized
calcium. This relates to the decline of calcium absorption that is due to vitamin D deficiency (17). This study
showed that the level of PTH had a sharp increase when
the concentration of 25(OH)D was below 30 ng/mL, a state
defined as vitamin D insufficiency. We found that the relation between PTH and 25(OH)D was nonlinear, as reflected
in Holicks study (17).
The study was cross-sectional and subjects were
recruited from a single site, therefore, our results were
not necessarily generalizable to all populations and geographic regions of Iran. Only a longitudinal study will be
able to confirm that the identified correlates are definite
risk factors for vitamin D deficiency or insufficiency. We
did not obtain information regarding food intakes and
physical activity which are potential confounders influencing coetaneous synthesis of vitamin D.
In conclusion, the level of vitamin D was low in children under study living in Bojnurd, and this level was
significantly lower in girls than in boys. This deficiency
increased in older subjects. This research was carried
out in the summer when exposure of sunlight was at
its highest; therefore, it is assumed that the mean level
of serum 25(OH)D of the subjects will be lower than the
current results in the winter.
In this study, the results showed that vitamin D
deficiency is more prevalent in girls and mean serum of
25(OH)D was likely to decline in older ones compared to
boys. Educating girls in order to increase their awareness and advancing the approach to increase the level of
vitamin D with interventional programs, such as taking
calcium and vitamin D supplements, is suggested. We
hope that more research of this kind at studying vitamin
D level in children can be completed and the risk of osteoporosis among this age group can be assessed.

436

Habibesadat etal.: Prevalence of vitamin D deficiency in North Khorasan, Iran

Acknowledgments: This work was supported by funds

from the Research Council of North Khorasan University
of Medical sciences. The authors gratefully acknowledge
the contributions of the school administrators, teachers,
parents, and children who participated in this project.
Special thanks to Research Assistants Shahpasandi,

Rohani, HodaAlavinia, Maryam Soleymanpur and Dr.

Mehrdad Ghezelbash.

Received May 23, 2013; accepted December 2, 2013; previously

published online February 12, 2014

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