An Update on Vitamin D Deficiency Status in Malaysia

Zaleha Md Isa, Nor Rumaizah Mohd Nordin, Muhammad Hilmi Mahmud, Syahirah Hashim, Zaleha Md Isa, Nor Rumaizah Mohd Nordin, Muhammad Hilmi Mahmud, Syahirah Hashim

Abstract

Vitamin D is essential for maintaining serum calcium levels, ensuring sufficient bone mineralization, immunomodulatory properties, and a protective effect on the cardiovascular system, renal disease, cancer, as well as in pregnancy. Vitamin D deficiency is prevalent worldwide, and it is not related to a country's development index. However, the data on vitamin D deficiencies are primarily taken from out-of-date, small-scale studies on target age groups or specific diseases, rather than from large-scale, population-based surveys. In Malaysia, for the past 16 years, studies were conducted involving adult men and women, pregnant women, postmenopausal women, adolescent, and children especially with specific diseases such as spina bifida, epilepsy, chronic liver disease, and atopic dermatitis. Only a few large surveys were conducted involving children and adolescents. Across the specific target population studied, vitamin D deficiency and insufficiency were seen particularly among females, Indians, and those of Malay ethnicity. This is related to widely known causes of vitamin D deficiency such as skin type (melanin) and sun avoidant lifestyles that include covering clothes, largely practiced by Malay Muslims in Malaysia. Other related causes or the high-risk groups are breastfed infants, the elderly, the obese, those on medications, and those characterized by fat malabsorption and geophysical factors. Vitamin D deficiency can be managed with pharmacological or non-pharmacological approaches, depending on the severity. The objective is to raise serum vitamin D to a normal level, hence, relieving the symptoms and reducing the adverse health outcomes. Despite no clear guidelines in treating vitamin D deficiency in Malaysia, this condition can be prevented with taking adequate vitamin D in food resources, sun exposure, or supplementation. Special attention should be given to high-risk groups including infants, obese patients, and the elderly.

Keywords: Malaysia; prevalence; vitamin D deficiency.

Conflict of interest statement

The authors declare no conflict of interest.

References

    1. Ministry of Health Malaysia Recommended Nutrient Intakes for Malaysia. A Report of the Technical Working Group on Nutritional Guidelines (National Coordinating Committee on Food and Nutrition (NCCFN) [(accessed on 15 December 2021)];2017 Available online: .
    1. Morris H.A., Anderson P.H. Autocrine and Paracrine Actions of Vitamin D. Clin. Biochem. Rev. 2010;31:129–138.
    1. Al-Ishaq R.K., Kubatka P., Brozmanova M., Gazdikova K., Caprnda M., Büsselberg D. Health implication of vitamin D on the cardiovascular and the renal system. Arch. Physiol. Biochem. 2019;127:195–209. doi: 10.1080/13813455.2019.1628064.
    1. Keane J.T., Elangovan H., Stokes R.A., Gunton J.E. Vitamin D and the liver—Correlation or cause? Nutrients. 2018;10:496. doi: 10.3390/nu10040496.
    1. National Institutes of Health Vitamin D—Health Professional Fact Sheet. [(accessed on 25 December 2021)];2021 Available online:
    1. de la Puente Yagüe M., Yurrita L.C., Cabanas M.J.C., Cenzual M.A.C. Role of vitamin D in athletes and their performance: Current concepts and new trends. Nutrients. 2020;12:579. doi: 10.3390/nu12020579.
    1. Al-Sadat N., Majid H.A., Sim P.Y., Su T.T., Dahlui M., Abu Bakar M.F., Dzaki N., Norbaya S., Murray L., Cantwell M.M., et al. Vitamin D deficiency in Malaysian adolescents aged 13 years: Findings from the Malaysian Health and Adolescents Longitudinal Research Team study (MyHeARTs) BMJ Open. 2016;6:e010689. doi: 10.1136/bmjopen-2015-010689.
    1. Chin K.Y., Ima-Nirwana S., Ibrahim S., Mohamed I.N., Ngah W.Z.W. Vitamin D Status in Malaysian Men and Its Associated Factors. Nutrients. 2014;6:5419–5433. doi: 10.3390/nu6125419.
    1. Roth D.E., Abrams S.A., Aloia J., Bergeron G., Bourassa M.W., Brown K.H., Calvo M.S., Cashman K.D., Combs G., De-Regil L.M. Global prevalence and disease burden of vitamin D deficiency: A roadmap for action in low- and middle-income countries. Ann. N. Y. Acad. Sci. 2018;1430:44–79. doi: 10.1111/nyas.13968.
    1. Palacios C., De-Regil L.M., Lombardo L.K., Peña-Rosas J.P. Vitamin D supplementation during pregnancy: Updated meta-analysis on maternal outcomes. J. Steroid Biochem. Mol. Biol. 2016;164:148–155. doi: 10.1016/j.jsbmb.2016.02.008.
    1. Green T.J., Skeaff C.M., Rockell J.E.P., Venn B.J., Lambert A., Todd J., Khor G.L., Loh S.P., Muslimatun S., Agustina R., et al. Vitamin D status and its association with parathyroid hormone concentrations in women of child-bearing age living in Jakarta and Kuala Lumpur. Eur. J. Clin. Nutr. 2007;62:373–378. doi: 10.1038/sj.ejcn.1602696.
    1. Moy F.M. Vitamin D status and its associated factors of free living Malay adults in a tropical country, Malaysia. J. Photochem. Photobiol. B Biol. 2011;104:444–448. doi: 10.1016/j.jphotobiol.2011.05.002.
    1. Moy F.M., Hoe V.C., Hairi N.N., Vethakkan S.R., Bulgiba A. Vitamin D deficiency and depression among women from an urban community in a tropical country. Public Health Nutr. 2016;20:1844–1850. doi: 10.1017/S1368980016000811.
    1. Moy F.-M., Bulgiba A. High prevalence of vitamin D insufficiency and its association with obesity and metabolic syndrome among Malay adults in Kuala Lumpur, Malaysia. BMC Public Health. 2011;11:735. doi: 10.1186/1471-2458-11-735.
    1. Nurbazlin M., Chee W.S.S., Rokiah P., Tan A.T.B., Chew Y.Y., Siti Nusaibah A.R., Chan S.P. Effects of sun exposure on 25(OH) vitamin D concentration in urban and rural women in Malaysia. Asia Pac. J. Clin. Nutr. 2013;22:391–399.
    1. Shafinaz I.S., Moy F.M. Vitamin D level and its association with adiposity among multi-ethnic adults in Kuala Lumpur, Malaysia: A cross sectional study. BMC Public Health. 2016;16:232. doi: 10.1186/s12889-016-2924-1.
    1. Bukhary N.B.I., Isa Z.M., Shamsuddin K., Lin K.G., Mahdy Z.A., Hassan H., Yeop N.S.H. Risk factors for ante-natal hypovitaminosis D in an urban district in Malaysia. BMC Pregnancy Childbirth. 2016;16:156. doi: 10.1186/s12884-016-0939-3.
    1. Lee S.-S., Ling K.-H., Tusimin M., Subramaniam R., Rahim K.F., Loh S.-P. Influence of vitamin D binding protein polymorphism, demographics and lifestyle factors on vitamin D status of healthy Malaysian pregnant women. BMC Pregnancy Childbirth. 2020;20:714. doi: 10.1186/s12884-020-03397-7.
    1. Woon F.C., Chin Y.S., Ismail I.H., Batterham M., Abdul Latiff A.H., Gan W.Y., Appannah G., Hussien S.H.M., Edi M., Tan M.L., et al. Vitamin D deficiency during pregnancy and its associated factors among third trimester Malaysian pregnant women. PLoS ONE. 2019;14:e0216439. doi: 10.1371/journal.pone.0216439.
    1. Leiu K.H., Chin Y.S., Shariff Z.M., Arumugam M., Chan Y.M. High body fat percentage and low consumption of dairy products were associated with vitamin D inadequacy among older women in Malaysia. PLoS ONE. 2020;15:e0228803. doi: 10.1371/journal.pone.0228803.
    1. Rahman S.A., Chee W., Yassin Z., Chan S.P. Vitamin D status among postmenopausal Malaysian women. Asia Pac. J. Clin. Nutr. 2004;13:255–260.
    1. Quah S.W., Majid H.A., Al-Sadat N., Yahya A., Su T.T., Jalaludin M.Y. Risk factors of vitamin D deficiency among 15-year-old adolescents participating in the Malaysian Health and Adolescents Longitudinal Research Team Study (MyHeARTs) PLoS ONE. 2018;13:e0200736. doi: 10.1371/journal.pone.0200736.
    1. Khor G.L., Chee W.S.S., Shariff Z.M., Poh B.K., Arumugam M., Ab Rahman J., E Theobald H. High prevalence of vitamin D insufficiency and its association with BMI-for-age among primary school children in Kuala Lumpur, Malaysia. BMC Public Health. 2011;11:95. doi: 10.1186/1471-2458-11-95.
    1. Poh B.K., Ng B.K., Haslinda M.D.S., Shanita S.N., Wong J.E., Budin S.B., Ruzita A.T., Ng L.O., Khouw I., Norimah A.K. Nutritional status and dietary intakes of children aged 6 months to 12 years: Findings of the Nutrition Survey of Malaysian Children (SEANUTS Malaysia) Br. J. Nutr. 2013;110:S21–S35. doi: 10.1017/S0007114513002092.
    1. Fong C.Y., Ong F.N., Ong L.C., Khoo T.B., Lee M.L. Vitamin D deficiency and insufficiency in Malaysian children with spina bifida. Spinal Cord. 2020;58:1030–1036. doi: 10.1038/s41393-020-0441-7.
    1. Fong C.Y., Kong A.N., Poh B.K., Mohamed A.R., Khoo T.B., Ng R.L., Noordin M., Nadarajaw T., Ong L.C. Vitamin D deficiency and its risk factors in Malaysian children with epilepsy. Epilepsia. 2016;57:1271–1279. doi: 10.1111/epi.13443.
    1. Kong A.N., Fong C.Y., Ng C.C., Mohamed A.R., Khoo T.B., Ng R.L., Jalaludin M.Y., Nadarajaw T. Association of common genetic variants with vitamin D status in Malaysian children with epilepsy. Seizure. 2020;79:103–111. doi: 10.1016/j.seizure.2020.05.009.
    1. Lee W.S., Jalaludin M.Y., Wong S.Y., Ong S.Y., Foo H.W., Ng R.T. Vitamin D non-sufficiency is prevalent in children with chronic liver disease in a tropical country. Pediatr. Neonatol. 2019;60:12–18. doi: 10.1016/j.pedneo.2018.03.011.
    1. Lee Y.W., Choon S.E., Izham S. Serum 25-Hydroxyvitamin D deficiency in Malaysian children with severe atopic dermatitis. Med. J. Malays. 2019;74:259–265.
    1. Ross A.C., Taylor C.L., Yaktine A.L., Del Valle H.B. Institute of Medicine (US) Committee to Review Dietary Reference Intakes for Vitamin D and Calcium. The National Academies Press; Washington, DC, USA: 2011.
    1. US Endocrine Society Clinical Practice Guidelines Bone Health and Osteoporosis: Evaluation, Treatment and Prevention of Vitamin D Deficiency. 2011. [(accessed on 15 December 2021)]. Available online: .
    1. Pludowski P., Holick M.F., Grant W.B., Konstantynowicz J., Mascarenhas M.R., Haq A., Povoroznyuk V., Balatska N., Barbosa A.P., Karonova T., et al. Vitamin D supplementation guidelines. J Steroid Biochem Mol Biol. 2018;175:125–135. doi: 10.1016/j.jsbmb.2017.01.021.
    1. Misra M., Pacaud D., Petryk A., Collett-Solberg P.F., Kappy M. Vitamin D deficiency in children and its management: Review of current knowledge and recommendations. Pediatrics. 2008;122:398–417. doi: 10.1542/peds.2007-1894.
    1. Braegger C., Campoy C., Colomb V., Decsi T., Domellof M., Fewtrell M., Hjosak I., Mihatsh W., Molgaard C., Shamir R., et al. Vitamin D in the healthy European paediatric population. J. Pediatr. Gastroenterol. Nutr. 2013;56:692–701. doi: 10.1097/MPG.0b013e31828f3c05.
    1. Holick M.F. Vitamin D deficiency. N. Engl. J. Med. 2007;357:266–281. doi: 10.1056/NEJMra070553.
    1. Palacios C., Gonzalez L. Is vitamin D deficiency a major global public health problem? J. Steroid Biochem. Mol. Biol. 2014;144:138–145. doi: 10.1016/j.jsbmb.2013.11.003.
    1. Munns C.F., Simm P.J., Rodda C.P., Garnett S.P., Zacharin M.R., Ward L.M., Geddes J., Cherian S., Zurynski Y., Cowell C.T. Incidence of vitamin D deficiency rickets among Australian children: An Australian Paediatric Surveillance Unit study. Med. J. Aust. 2012;196:466–468. doi: 10.5694/mja11.10662.
    1. Holick M.F. Deficiency of sunlight and vitamin D. BMJ. 2008;336:1318. doi: 10.1136/bmj.39581.411424.80.
    1. Holick M.F., Chen T.C. Vitamin D deficiency: A worldwide problem with health consequences. Am. J. Clin. Nutr. 2008;87:1080S–1086S. doi: 10.1093/ajcn/87.4.1080S.
    1. Chen T., Chimeh F., Lu Z., Mathieu J., Person K.S., Zhang A., Kohn N., Martinello S., Berkowitz R., Holick M.F. Factors that influence the cutaneous synthesis and dietary sources of vitamin D. Arch. Biochem. Biophys. 2007;460:213–217. doi: 10.1016/j.abb.2006.12.017.
    1. Holick M.F. Vitamin D: A millenium perspective. J. Cell. Biochem. 2003;88:296–307. doi: 10.1002/jcb.10338.
    1. Clemens T.L., Henderson S.L., Adams J.S., Holick M.F. Increased Skin Pigment Reduces the Capacity of Skin to Synthesise Vitamin D3. Lancet. 1982;319:74–76. doi: 10.1016/S0140-6736(82)90214-8.
    1. Isa Z.M., Shamsuddin K., Bukhary N.B.I., Lin K.G., Mahdy Z.A., Hassan H., Yeop N.S.H., Ghazi H.F. The reliability of Fitzpatrick skin type chart comparing to mexameter (MX 18) in measuring skin color among first trimester pregnant mothers in Petaling district, Malaysia. Malays. J. Public Health Med. 2016;3:59–65.
    1. Matsuoka L.Y., Ide L., Wortsman J., MacLaughlin J.A., Holick M.F. Sunscreens suppress cutaneous vitamin D3 synthesis. J. Clin. Endocrinol. Metab. 1987;64:1165–1168. doi: 10.1210/jcem-64-6-1165.
    1. Fuleihan G.E.H., Nabulsi M., Choucair M., Salamoun M., Shahine C.H., Kizirian A., Tannous R. Hypovitaminosis D in healthy schoolchildren. Pediatrics. 2001;107:e53. doi: 10.1542/peds.107.4.e53.
    1. Sedrani S.H. Low 25-Hydroxyvitamin D and Normal Serum Calcium Concentrations in Saudi Arabia: Riyadh Region. Ann. Nutr. Metab. 1984;28:181–185. doi: 10.1159/000176801.
    1. Wacker M., Holick M.F. Sunlight and vitamin D: A global perspective for health. Derm.-Endocrinol. 2013;5:51–108. doi: 10.4161/derm.24494.
    1. Nair R., Maseeh A. Vitamin D: The “sunshine” vitamin. J. Pharmacol. Pharmacother. 2012;3:118.
    1. Wagner C.L., Greer F.R. The Section on Breastfeeding and Committee on Nutrition. Prevention of Rickets and Vitamin D Deficiency in Infants, Children, and Adolescents. Pediatrics. 2008;122:1142–1152. doi: 10.1542/peds.2008-1862.
    1. Holick M.F., Matsuoka L.Y., Wortsman J. Age, vitamin D, and solar ultraviolet. Lancet. 1989;2:1104–1105. doi: 10.1016/S0140-6736(89)91124-0.
    1. Compher C.W., Badellino K.O., Boullata J.I. Vitamin D and the Bariatric Surgical Patient: A Review. Obes. Surg. 2008;18:220–224. doi: 10.1007/s11695-007-9289-6.
    1. Malone M. Recommended Nutritional Supplements for Bariatric Surgery Patients. Ann. Pharmacother. 2008;42:1851–1858. doi: 10.1345/aph.1L321.
    1. Lo C.W., Paris P.W., Clemens T.L., Nolan J., Holick M.F. Vitamin D absorption in healthy subjects and in patients with intestinal malabsorption syndromes. Am. J. Clin. Nutr. 1985;42:644–649. doi: 10.1093/ajcn/42.4.644.
    1. Webb A.R., Kline L., Holick M.F. Influence of season and latitude on the cutaneous synthesis of vitamin D3: Exposure to winter sunlight in Boston and Edmonton will not promote vitamin D3 synthesis in human skin. J. Clin. Endocrinol. Metab. 1988;67:373–378. doi: 10.1210/jcem-67-2-373.
    1. Kimlin M.G., Olds W.J., Moore M.R. Location and vitamin D synthesis: Is the hypothesis validated by geophysical data? J. Photochem. Photobiol. B Biol. 2007;86:234–239. doi: 10.1016/j.jphotobiol.2006.10.004.
    1. Parisi A.V., Turnbull D.J., Downs N.J. Influence of high levels of cloud cover on vitamin D effective and erythemal solar UV irradiances. Photochem. Photobiol. Sci. 2012;11:1855–1859. doi: 10.1039/c2pp25160d.
    1. Pettifor J.M. Calcium and Vitamin D Metabolism in Children in Developing Countries. Ann. Nutr. Metab. 2014;64:15–22. doi: 10.1159/000365124.
    1. Creo A.L., Thacher T.D., Pettifor J.M., Strand M.A., Fischer P.R. Nutritional rickets around the world: An update. Paediatr. Int. Child Health. 2017;37:84–98. doi: 10.1080/20469047.2016.1248170.
    1. Elbossaty W.F. Mineralization of Bones in Osteoporosis and Osteomalacia. Ann. Clin. Lab. Res. 2017;5:201. doi: 10.21767/2386-5180.1000201.
    1. Elidrissy A.T.H. The return of congenital rickets, are we missing occult cases? Calcif. Tissue Int. 2016;99:227–236. doi: 10.1007/s00223-016-0146-2.
    1. Paterson C.R., Ayoub D. Congenital rickets due to vitamin D deficiency in the mothers. Clin. Nutr. 2015;34:793–798. doi: 10.1016/j.clnu.2014.12.006.
    1. Roth D.E., Leung M., Mesfin E., Qamar H., Watterworth J., Papp E. Vitamin D supplementation during pregnancy: State of the evidence from a systematic review of randomised trials. BMJ. 2017;359:j5237. doi: 10.1136/bmj.j5237.
    1. Brehm J.M., Acosta-Perez E., Klei L., Roeder K., Barmada M.M., Boutaoui N., Forno E., Kelly R., Paul K., Sylvia J., et al. Vitamin D Insufficiency and Severe Asthma Exacerbations in Puerto Rican Children. Am. J. Respir. Crit. Care Med. 2012;186:140–146. doi: 10.1164/rccm.201203-0431OC.
    1. Jolliffe D.A., Greenberg L., Hooper R.L., Griffiths C.J., Camargo C.A., Jr., Kerley C.P., Jensen M.E., Mauger D., Stelmach I., Urashima M., et al. Vitamin D supplementation to prevent asthma exacerbations: A systematic review and meta-analysis of individual participant data. Lancet Respir. Med. 2017;5:881–890. doi: 10.1016/S2213-2600(17)30306-5.
    1. Martineau A.R. Old wine in new bottles: Vitamin D in the treatment and prevention of tuberculosis. Proc. Nutr. Soc. 2011;71:84–89. doi: 10.1017/S0029665111003326.
    1. Rook G.A. The role of vitamin D in tuberculosis. Am. Rev. Respir. Dis. 1988;138:768–770. doi: 10.1164/ajrccm/138.4.768.
    1. Martineau A.R., Wilkinson K.A., Newton S.M., Floto R.A., Norman A.W., Skolimowska K., Davidson R.N., Sorenson O.E., Kampmann B., Griffiths C.J., et al. IFN-γ-and TNF-independent vitamin D-inducible human suppression of mycobacteria: The role of cathelicidin LL-37. J. Immunol. 2007;178:7190–7198. doi: 10.4049/jimmunol.178.11.7190.
    1. Ralph A.P., Kelly P.M., Anstey N.M. L-arginine and vitamin D: Novel adjunctive immunotherapies in tuberculosis. Trends Microbiol. 2008;16:336–344. doi: 10.1016/j.tim.2008.04.003.
    1. Martineau A., Cates C., Urashima M., Jensen M., Griffiths A., Nurmatov U., Sheikh A., Griffiths C. S5 Vitamin d for the management of asthma: Cochrane systematic review and meta-analysis. Thorax. 2016;71:A6. doi: 10.1136/thoraxjnl-2016-209333.11.
    1. Bordelon P., Ghetu M.V., Langan R.C. Recognition and management of vitamin D deficiency. Am. Fam. Physician. 2009;80:841–846.
    1. The Royal Children’s Hospital Melbourne Clinical Practice Guidelines: Vitamin D Deficiency. 2018. [(accessed on 15 December 2021)]. Available online:
    1. Jamil N.A., Yew M.H., Hafizah Y.N., Gray S.R., Poh B.K., Macdonald H.M. Estimated vitamin D synthesis and dietary vitamin D intake among Asians in two distinct geographical locations (Kuala Lumpur, 3° N v. Aberdeen, 57° N) and climates. Public Health Nutr. 2018;21:3118–3124. doi: 10.1017/S1368980018002057.
    1. Aris N., Mitra A.K., Wan Mohamed W.M.I., Wan Muda W.A.M., Jan Mohamed H.J. Effects of occupational sunlight exposure and monsoon season on vitamin D concentration among outdoor and indoor workers in Malaysia. Malays. J. Nutr. 2020;26:425–439. doi: 10.31246/mjn-2020-0038.
    1. MIMS Paediatrics Vitamin D Deficiency. [(accessed on 20 December 2021)]. Available online: .
    1. Malaysia Food Act 1983 and Malaysia Food Regulations 1985 . Warta Kerajaan Malaysia. Vol. 29 International Law Book Services (ILBS); Kuala Lumpur, Malaysia: 2021.
    1. USDA USDA Food Composition Database. [(accessed on 15 December 2021)];2016 Available online: .
    1. Kruger M.C., Chan Y.M., Lau C., Lau L.T., Chin Y.S., Kuhn-Sherlock B., Schollum L.M., Todd J.M. Fortified Milk Supplementation Improves Vitamin D Status, Grip Strength, and Maintains Bone Density in Chinese Premenopausal Women Living in Malaysia. BioResearch Open Access. 2019;8:16–24. doi: 10.1089/biores.2018.0027.
    1. MOH . Guide to Nutrition Labeling and Claims. Ministry of Health Malaysia; Putrajaya, Malaysia: 2010.
    1. Mohamed H.J.J., Rowan A., Fong B., Loy S.-L. Maternal Serum and Breast Milk Vitamin D Levels: Findings from the Universiti Sains Malaysia Pregnancy Cohort Study. PLoS ONE. 2014;9:e100705. doi: 10.1371/journal.pone.0100705.

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