FEZZAN UNIVERSITY SCIENTIFIC JOURNAL VOL.3 NO. 1 2024 ‫مجلة جامعة فزان العلمية‬ Fezzan University scientific Journal Journal homepage: wwwhttps://fezzanu.edu.ly/ Prevalence of vitamin D and calcium deficiency among population of southern region, Libya *Salha M. khames1 Medical Laboratory Technology, faculty of Nursing -Fezzan University Abstract Background: Despite the abundance of sunny weather in Libya, vitamin D deficiency becoming one of the most common health problems there. The consequences of low vitamin D levels include an increased risk of some cancers, cardiovascular diseases, and diabetes, which makes it a crucial public health concern. Objective: Our study aimed to study the prevalence of Vitamin D (D) deficiency in the southern region of Libya (Traghen City) and determine the relationship between the prevalence of vitamin D deficiency and calcium levels. Methods: A Cross-sectional study was carried out among 144 patients from private clinic laboratories in Traghen City, between April and July 2023. Vitamin D and calcium levels have been measured. Variables such as age and sex were recorded. Statistical analysis was carried out by using SPSS. Results: A total of 144 patients were included in the study. Female participants were more than male participants in the present study (66.0 %, 34.0 %) respectively. The prevalence of vitamin D deficiency/ insufficient was found to be 54.2% and 27.1% respectively. Our findings indicated that the level of Vitamin D was significantly lower among female (69.5%) patients in comparison to male (24.5%). Low serum calcium levels were observed among the study population (71.5%). A positive correlation was found between low vitamin D levels and calcium deficiency (P= 0.0001). Conclusion: In our study, the prevalence of vitamin D deficiency was found to be 54.2 %. VDD is prevalent in the southern part of Libya, especially among females and this could lead to serious health consequences if the issue is not urgently addressed. Keywords: prevalence, Vitamin D, calcium, vitamin D deficiency. ‫ ليبيا‬،‫انتشار نقص فيتامين د والكالسيوم بين سكان المنطقة الجنوبية‬ ‫*صالحة خميس محمد علي‬ 1 ‫كلية التمريض – جامعة فزان‬1 ً‫ أصبح نقص فيتامين (د) أحد أكثر المشاكل الصحية شيوعا‬،‫ على الرغم من وفرة الطقس المشمس في ليبيا‬:‫الخلفية‬ ‫ وتشمل عواقب انخفاض مستويات فيتامين د زيادة خطر اإلصابة ببعض أنواع السرطان وأمراض القلب‬, .‫هناك‬ .‫ مما يجعلها مصدر قلق بالغ األهمية للصحة العامة‬،‫واألوعية الدموية والسكري‬ 136 * Corresponding author: E-mail Sal.mohamedali@fezzanu.edu.ly . Received 25 October 2023 - Received in revised form 23 December 2023 Accepted 10 jaguar 2024 FEZZAN UNIVERSITY SCIENTIFIC JOURNAL VOL.3 NO. 1 2024 ‫مجلة جامعة فزان العلمية‬ Fezzan University scientific Journal Journal homepage: wwwhttps://fezzanu.edu.ly/ )‫ هدفت دراستنا إلى دراسة مدى انتشار نقص فيتامين د (د) في المنطقة الجنوبية من ليبيا (مدينة تراغن‬: ‫الهدف‬ .‫وتحديد العالقة بين مدى انتشار نقص فيتامين د ومستويات الكالسيوم‬ ‫ بين أبريل‬،‫يضا من مختبرات العيادات الخاصة في مدينة تراغن‬ ً ‫ مر‬144 ‫ تم إجراء دراسة مقطعية على‬:‫الطرق‬ ‫ وتم إجراء‬.‫ تم تسجيل المتغيرات مثل العمر والجنس‬.‫ وتم قياس مستويات فيتامين د والكالسيوم‬. 2023 ‫ويوليو‬ .SPSS ‫التحليل اإلحصائي باستخدام برنامج‬ ‫ وكانت المشاركات اإلناث أكثر من المشاركين الذكور‬.‫ مريضا في الدراسة‬144 ‫ تم تضمين مجموعه من‬:‫النتائج‬ %54.2 ‫نقص فيتامين د هو‬/‫ وجد أن معدل انتشار نقص‬.‫) على التوالي‬٪ 34.0 ،٪66.0( ‫في هذه الدراسة‬ ‫ حيث أشارت النتائج التي توصلنا إليها إلى أن مستوى فيتامين د كان أقل بشكل ملحوظ‬.‫ على التوالي‬%27.1‫و‬ ‫ ولوحظ انخفاض مستويات الكالسيوم في الدم بين‬.)%24.5( ‫) مقارنة بالذكور‬%69.5( ‫بين المرضى اإلناث‬ ‫ تم العثور على عالقة إيجابية بين انخفاض مستويات فيتامين د ونقص الكالسيوم‬.)٪71.5( ‫مجتمع الدراسة بنسبة‬ .)P = 0.0001( ‫ في الجزء‬VDD ‫ ينتشر مرض‬.%54.2 ‫ في هده الدراسة وجد أن معدل انتشار نقص فيتامين د يبلغ‬:‫االستنتاج‬ ‫ وقد يؤدي ذلك إلى عواقب صحية خطيرة إذا لم تتم معالجة المشكلة بشكل‬،‫ خاصة بين اإلناث‬،‫الجنوبي من ليبيا‬ .‫عاجل‬ ‫ نقص فيتامين د‬،‫ الكالسيوم‬،‫ فيتامين د‬،‫ انتشار‬:‫الكلمات المفتاحية‬ Introduction Vitamin D deficiency is a common health problem around the world, including in various regions of Africa. Several studies have determined vitamin D levels in various populations, to provide information on the prevalence and associated factors of deficiency [4], [10]. Vitamin D is a fat-soluble prohormone, the primary function activity of vitamin is to regulate the physiological processes [2], [24]. The two primary types of vitamin D are vitamin D3 or cholecalciferol, which is produced in the skin after exposure to sunshine or ultraviolet light, and vitamin D2 or ergocalciferol, which is derived from plants and foods including mushrooms, fish, and egg yolk [23]. Vitamin D is important for the maintenance of calcium homeostasis and crucial for skeletal health. Vitamin D deficiency is responsible for the development of rickets and osteomalacia in both children and adults, respectively [19], [23]. About 90% of the body's total need for vitamin D is produced by our skin with the aid of sunlight. Vitamin D is indispensable for serum calcium and phosphate levels in the body. As a result, it indirectly enhances how effectively the body performs as a whole. Additionally, it is crucial for immunity, cell growth, and cell differentiation. So, vitamin D is an essential component that the human body needs [2]. Furthermore, vitamin D plays an important role in enhancing physiological processes in both skeletal and extra-skeletal tissues [1], [9]. vitamin D insufficiency (VDI) and vitamin D deficiency (VDD) are associated with various acute and chronic diseases including problems of calcium (Ca) metabolism, autoimmune disorders, cardiovascular disease, some cancers, type 2 and type 1 diabetes 137 Volume 3 - Issue One - 2024 FEZZAN UNIVERSITY SCIENTIFIC JOURNAL VOL.3 NO. 1 2024 ‫مجلة جامعة فزان العلمية‬ Fezzan University scientific Journal Journal homepage: wwwhttps://fezzanu.edu.ly/ mellitus, and other conditions [9]. Around a billion individuals are thought to be suffering from a vitamin D deficiency or insufficiency on a global scale [24]. The prevalence of VDD in the area has been the subject of studies in neighboring nations. According to a recent study in Qatar, 83% to 91% of people lack enough vitamin D [14]. VDD prevalence in Tunisia was estimated to be 47.6% [14]. These results imply that VDD is a significant public health concern in the area. According to estimates, the Middle East has a higher rate of vitamin D deficiency than Western nations. A significant meta-analysis revealed that 20–80% of healthy individuals in Middle Easterners are really vitamin D deficient [18]. In Libya, previous studies have indicated that the population is at risk of VDD. One of the studies conducted in Misurata found that 75% of women had vitamin D levels below 50 nmol/L [10]. In addition, a very recent study conducted to study the incident of vitamin D deficiency in Derna city, in the Eastern part of Libya demonstrated that 61% of population suffering from Vit D deficiency [9]. However, there is a lack of specific data on the prevalence of vitamin D deficiency in the region of Traghen south of Libya. With this background, the present study was conducted to study the prevalence of vitamin D deficiency among patients attending private clinics and laboratories in Traghen City of Libya. Method 1. Study participants A descriptive cross-sectional study was conducted in Traghen City, a southern area of Libya in the period between April and July 2023 for persons of different age groups and either gender attending private medical laboratories who requested for vitamin D analysis or medical checkups to examine vitamin D and calcium status levels in Libyan population. Data were collected from 144 individuals from 3 to 78 years old willing to participate included in this study, patients on therapeutic doses of Vitamins were excluded previously. 2. Data collection A random sampling collection was performed and 10 ml venous fasting blood samples were collected from individuals participated in this study who filled the criteria. Variables such as age and sex were recorded. Samples were collected in tubes with a clot activator and then centrifuged to be analyzed. The analysis for serum 25 (OH)D was done by using Fluorescence immunoassay (IFA) techniques using I Chroma, or LanSionbio LS 1100 analyzers. Vitamin D level was estimated and defined according to cut-off values; deficient (25(OH)D level < 20 ng/ml, insufficient (25(OH)D level between 20 and < 30 ng/ml), sufficient (25(OH)D level 30-100 ng/ml). Calcium status was tested by a semi-automated single-beam Riele 4040 spectrophotometer, date of calcium status was analyzed according to cut-off values hypocalcemia (< 8.8 mg/dl ), normal or optimal ( 8.8-10.6 mg/dl) and hypercalcemia ( > 10.6 mg/dl). All technicians are trained, either by qualified trainers or by expert colleagues 3. Statistical Analysis Description and analysis of data were carried using SPSS version 21. All results were coded prior entering into a computer. Chi-square test was performed to test the 138 Volume 3 - Issue One - 2024 FEZZAN UNIVERSITY SCIENTIFIC JOURNAL VOL.3 NO. 1 2024 ‫مجلة جامعة فزان العلمية‬ Fezzan University scientific Journal Journal homepage: wwwhttps://fezzanu.edu.ly/ association of serum vitamin D with variables and used to determine the statistically significant differences at p<0.05. Results In the current study, the number of subjects who had undergone concurrent measurements of vitamin D and calcium levels between April and July 2023 was determined to be 144 respondents. Table 1: Demographic data of the study group AGE Age Valid <18 YEARS 18-40 YEARS > 40 YEARS Gender Valid Frequency Percent % 13 9.0 % 64 67 GENDER 44.4 % 46.5 % Frequency Percent % FEMALE 95 66.0 % MALE 49 34.0 % Female participants were more than male participants in the present study, out of 144 subjects; (34.0%) were male and 95 (66.0%) were female. The age range was from 3 to 78 years. Among them, 13 (9%) were below the age of 18 years, 64 (44.4%) were from 18-40 years old and 67 (46.5%) were older than 40 years. The demographic details are given in table (1). Figure (a): Gender of the study group 139 Volume 3 - Issue One - 2024 FEZZAN UNIVERSITY SCIENTIFIC JOURNAL VOL.3 NO. 1 2024 ‫مجلة جامعة فزان العلمية‬ Fezzan University scientific Journal Journal homepage: wwwhttps://fezzanu.edu.ly/ Figure (b): Age of the study group Table 3. Serum 25(OH)D values Vitamin D Frequency Valid Percent % Valid Deficient insufficient Sufficient 78 39 27 54.2% 27.1% 18.8% Overall, the estimated prevalence of vitamin D deficiency were as follows: 78(54.2%) were Vitamin D deficient (less than 20 ng/ml), while 39 (27%) of patients were Vitamin D insufficient (20-30 ng/ml), 27 (18.8%) were within the normal value of Vitamin D (sufficient) between 30 ng/ml and 100 ng/ml Table (3). Table 4: Prevalence of vitamin D deficiency according to gender GENDER * Vitamin D Crosstabulation Vitamin D Deficiency insufficient Sufficient Total FEMAL E Count % within GENDER 66 69.5% 17 17.9% 12 12.6% 95 100.0% MALE Count % within GENDER 12 24.5% 22 44.9% 15 30.6% 49 100.0% GENDER P value at (0.05) considered significant * -P value <(0.05) considered highly significant ** 140 Volume 3 - Issue One - 2024 P value .001** FEZZAN UNIVERSITY SCIENTIFIC JOURNAL VOL.3 NO. 1 2024 ‫مجلة جامعة فزان العلمية‬ Fezzan University scientific Journal Journal homepage: wwwhttps://fezzanu.edu.ly/ Significantly, the prevalence of vitamin D deficiency was higher among female 69.5%, had inadequate vitamin D status level compared with men 24.5%, which was analyzed by chi-square test (p-value = 0.001) statistically significant difference was found between men and women Table (4). Participants between 18-40 years showed the highest prevalence of deficiency /insufficiency of Vitamin D (serum 25(OH)D concentrations < 30 ng/ml) at 57.8%. Table 5. Serum calcium values CALCIUM VLAUES Frequency Valid Hypocalcemia Normal Hypercalcemia 103 34 7 Percent Valid Percent 71.5 23.6 4.9 71.5% 23.6% 4.9% Based on calcium levels, subjects were divided into hypocalcemia, normal, and hypercalcemia groups;103 (71.5 %) participants had hypocalcemia, 34 (23.6%) participants had normal calcium levels, and 7 (4.9%) had hypercalcemia (Table 5). Table 6: Correlation between gender and calcium statute GENDER * Calcium Crosstabulation HYPO GENDER FEMAL E MALE 72 75.8% 31 63.3% CAL NORMA L 21 22.1% 13 26.5% Total p- value HYPER 2 2.1% 5 10.2% 95 100.0% 49 100.0% 0.060 NS NS=Not significant The normal range of calcium in our laboratory was 8.8-10.6 mg/dl whereas the mean + (SD) of calcium in this study was 7.98±1.33 mg/dl. When calcium levels were compared based on gender, no significant difference was observed between the level of calcium of men and women (P value = 0.06) as showed in Table (5). 141 Volume 3 - Issue One - 2024 FEZZAN UNIVERSITY SCIENTIFIC JOURNAL VOL.3 NO. 1 2024 ‫مجلة جامعة فزان العلمية‬ Fezzan University scientific Journal Journal homepage: wwwhttps://fezzanu.edu.ly/ Table 7. The correlation analysis for vitamin D and calcium CALCIUM * Vitamin D Crosstabulation Vitamin D Calcium P value Hypocalcemia <8.8 mg/dl deficient 74 71.8% insufficient 27 26.2% sufficient 2 1.9% Normal 8.8-10.6 mg/dl 4 11.8% 12 35.3% 18 52.9% Hypercalcemia >10.6 mg/dl 0 0.0% 0 0.0% 7 100.0% .0001** P value at (0.05) considered significant * - P value < (0.05) considered highly significant ** In addition, our results show that 71.8% of study subjects suffering from calcium deficiency with Vitamin D deficiency. There is a highly significant relationship between vitamin D deficiency and calcium (P = 0.0001) as shown in Table (7). Discussion Vitamin D as well as calcium insufficiencies are risk factors for various chronic diseases. Recent studies from Europe, North Africa, Southeast Asia, and the South Pacific region clearly show that low vitamin D levels and inadequate calcium nutrition are significantly prevalent in the general population, and affect both males and females [20]. The results of this cross-sectional study showed the prevalence of Vitamin D deficiency as 54.2%, of insufficiency as 27.1%, and sufficient Vitamin D in 18.8% population. Our finding in this study in the line with local studies conducted in Libya. On study carried out Benwailed city by Nasef, et al [17], relieved that patients with vitamin D deficiency represent 70.68 % and patients with insufficiency represent 29.32 %. Another study conducted in Benghazi, reported vitamin D deficiency was 76.1%, insufficiency was 15.2% and Vitamin D sufficiency was 8.7% [19]. In Tunis, the finding estimated the prevalence of hypovitaminosis D and vitamin D deficiency were respectively 92.3% and 47.6% [5]. In the United Arab Emirates, 85.4% were vitamin D deficient, 12.5% showed insufficient serum vitamin D level, and only 2.1% had an appropriate level [26]. As a result, Vitamin D deficiency is considered to be a public health problem worldwide. A remarkable gender difference in vitamin D levels was observed in this study, as the prevalence of vitamin D deficiency was significantly higher in females participants (69.5%) than males (24.5%) who had Vitamin D levels below 20 ng/dl. This significant difference in gender is consistent with other publications. Atia & Arhoma found that 79.4% % of the females to be vitamin D deficient compared to 52%of male participants who had Vitamin D levels below 20 ng/ml [5]. Another finding released by Rumano et al. reported a higher level of vitamin D in males compared to females. The prevalence was higher among females 62% [21]. In contrast, Yammine and Al Adham studied the vitamin D status among adults in United Arab Emirates, 142 Volume 3 - Issue One - 2024 FEZZAN UNIVERSITY SCIENTIFIC JOURNAL VOL.3 NO. 1 2024 ‫مجلة جامعة فزان العلمية‬ Fezzan University scientific Journal Journal homepage: wwwhttps://fezzanu.edu.ly/ reported that there is a significant difference between males and females: males had lower serum vitamin D levels than females [26]. The higher vitamin D levels in men seen in this study might be related to the fact that men spend more time outside, whereas women wear protective clothing and avoid sun exposure. on the other hand, Men work outside more than women do, and they are more likely to be exposed to the sun. As noted in several studies, sunlight exposure and solar radiation serve as our body's main source of vitamin D production through a series of processes that start in the skin. Omar et al. [18] demonstrated that exposure and those exhibiting negative attitudes toward sunlight and identified factors included duration of sun exposure, type of work, preference for fair skin, use of sunblock, and dress code. These factors resulted in excessive sun avoidance among participants and they could be major contributing factors to the observed high prevalence of VDD in this study. Another study conducted in Qassim, Saudi Arabia showed that study subjects who were exposed to sunlight for a longer duration of time had adequate levels of vitamin D which is statistically significant [16]. In the current study, we observed that 71.5 % % of our study population had low levels of calcium. The calcium level in 103 of the study population was of less than normal range, which may be due to vitamin D deficiency. When calcium levels were compared based on gender, it was found to be no significant difference in the proportion of women (75.8%) compared to men (63.3%) who had hypocalcemia. We found that vitamin D levels were positively correlated with calcium. There is a relationship between vitamin D deficiency and low calcium levels (P= 0.0001). In the current study, we observed that 71.5 % % of our study population had low levels of calcium. The calcium level in 103 of the study population was of less than normal range, which may be due to vitamin D deficiency. When calcium levels were compared based on gender, it was found to be no significant difference in the proportion of women (75.8%) compared to men (63.3%) who had hypocalcemia. We found that vitamin D levels were positively correlated with calcium. There is a relationship between vitamin D deficiency and low calcium levels (P= 0.0001). This finding concurs with other studies. In a recent study carried out by the College of Medical Technology, Derna, Libya, there was a direct proportion between vitamin D deficiency and serum calcium deficiency. The study reported that A low admission of calcium and restricted exposure to sun-based bright (UV) light were related to Vitamin D deficiency [9]. Another study conducted in Jeddah, Saudi Arabia reported a positive relationship between low serum calcium and vitamin D deficiency, it also found a direct correlation between vitamin D deficiency and achy bones [11]. Al-Shaikh et al. [4] also assessed the prevalence of vitamin D deficiency and calcium homeostasis in Saudi children and found that vitamin D levels correlated significantly with Calcium level (p<0.001) [4]. Despite all these studies, a study conducted in Pakistan demonstrated there was no significant difference in serum calcium levels when compared with the vitamin D deficiency (p = 0.636) [25]. Supporting our findings, evidence reported that the active form, 1,25-dihydroxy vitamin D [1,25-(OH)2D3] markedly increases the efficiency of intestinal Calcium and 143 Volume 3 - Issue One - 2024 FEZZAN UNIVERSITY SCIENTIFIC JOURNAL VOL.3 NO. 1 2024 ‫مجلة جامعة فزان العلمية‬ Fezzan University scientific Journal Journal homepage: wwwhttps://fezzanu.edu.ly/ phosphorus absorption. Serum levels of 25(OH) vitamin D below 50 nmol/L are associated with a significant decrease in intestinal Calcium absorption [3]. Vitamin D increases the absorption of calcium and phosphorus in the intestine. About 10 to 15% of dietary calcium and 60% of phosphorus are absorbed without vitamin D. This proportion of absorption rises to 30% to 40% for calcium and 80% for phosphorus in the presence of vitamin D [8]. As a result, Vitamin D enhances calcium absorption in the intestine to maintain adequate serum calcium concentrations and is essential for bone growth. Conclusion Vitamin D deficiency is very prevalent among patients in south Libya. Our study showed that the prevalence of vitamin D deficiency is high in the Libyan population in the southern region despite the southern areas of Libya are being sunny. In addition, our findings showed that Vitamin D deficiency was more prevalent among females than in males. The study population generally had low calcium levels. there is also a positive correlation between Vitamin D deficiency and S. Calcium deficiency. Recommendation It is recommended that awareness about the importance of sparing time for sun exposure must be performed. Furthermore, Health education should be provided regarding the consumption of a diet rich in vitamin D to overcome such low levels of vitamin D in Libya. This suggests conducting investigations about contribution factors in the prevalence of vitamin D deficiency. Acknowledgments The author thanks all participants who participated in this study for their time and cooperation. Financial support and sponsorship: None. 1. 2. 3. 4. Conflicts of interest: There are no conflicts of interest. References Adnan, F., Memon, N. Q., Sami, A., Meraj, M., Shaikh, R., & Ali, S. Z. (2021). Prevalence of Vit-D Deficiency in Medical Students. Medical Journal Of South Punjab, 2(1). Ahmed, P., Babaniyi, I., Yusuf, K., Dodd, C., Langdon, G., Steinhoff, M., … & Dawodu, A. (2014). Vitamin d status and hospitalisation for childhood acute lower respiratory tract infections in nigeria. Paediatrics and International Child Health, 35(2), 151-156. Aljazzaf, B., Alghazeer, R., Swehli, A. I., Erhuma, M., Elgmati, E., Muammer, M. S., ... & Al-Griw, M. A. (2023). Association between Vitamin D Status and Health Status of Adults in Western Libya. Processes, 11(3), 930. Al Shaikh, A. M., Abaalkhail, B., Soliman, A., Kaddam, I., Aseri, K., Al Saleh, Y., ... & Mukhtar, A. M. (2016). Prevalence of vitamin D deficiency and calcium homeostasis in Saudi children. Journal of clinical research in pediatric endocrinology, 8(4), 461. 144 Volume 3 - Issue One - 2024 FEZZAN UNIVERSITY SCIENTIFIC JOURNAL VOL.3 NO. 1 2024 ‫مجلة جامعة فزان العلمية‬ Fezzan University scientific Journal Journal homepage: wwwhttps://fezzanu.edu.ly/ 5. Atia, A., & Arhoma, S. (2022). Epidemiological study of Vitamin D deficiency among Libyan patients. MRIMS Journal of Health Sciences, 10(1), 14. 6. Bahlous, A., Krir, A., Mrad, M., Bouksila, M., Kalai, S., Kilani, O., ... & Laadhari, N. (2022). Vitamin D in healthy Tunisian population: preliminary results. Journal of Medical Biochemistry, 41(2), 168. 7. Botros, R., Sayed, R., Samy, M., & Yassin, M. (2015). Study of vitamin D levels in adult males in Dakahlia governorate in Egypt. Int J Adv Res, 3, 80-95. 8. Çaykara, B., Öztürk, G., Mutlu, H. H., & Arslan, E. (2020). Relationship Between Vitamin D, Calcium, and Phosphorus Levels. Journal of Academic Research in Medicine, 10(3). 9. Eljamay, S. M., Alghazali, M. A. A., & Eldalal, H. H. A. (2022). Incident of Vitamin D Deficiency in Derna City\Libya. J Endo Metabol Res, 3(1), 1-15. 10. Faid, F., Nikolic, M., Milesevic, J., Zekovic, M., Kadvan, A., Gurinovic, M., & Glibetic, M. (2018). Assessment of vitamin D intake among Libyan women–adaptation and validation of specific food frequency questionnaire. Libyan Journal of Medicine, 13(1). 11. Gamal, M., Matyori, A., Alkaibari, M., Alzahrani, T., Al-Sanea, M. M., Iqubal, S. S., & Khan, A. A. (2018). Prevalence of Vitamin D Deficiency in Jeddah’s Children, Kingdom of Saudi Arabia. Journal of Pure and Applied Microbiology, 12(4), 17371741. 12. Golbahar, J., Al-Saffar, N., Diab, D. A., Al-Othman, S., & Darwish, A. (2013). Vitamin D status in adults: a cross sectional study. Bahrain Medical Bulletin, 35(1), 111. 13. Hovsepian, S., Amini, M., Aminorroaya, A., Amini, P., & Iraj, B. (2011). Prevalence of vitamin D deficiency among adult population of Isfahan City, Iran. Journal of health, population, and nutrition, 29(2), 149. 14. Malik, M., Nouh, F., Hussain, A., Kumar, S., & Kaler, J. (2020). Response of parathyroid hormone to vitamin d deficiency in otherwise healthy individuals. Cureus. 15. Murad, G., Hanan, E., Abdulghani, M., Abdulla, B., Mohammed, S., & Khaled, S. (2019). Prevalence of Vitamin D Deficiency in Pregnant Diabetic Patients in Western Libya. Archives of Internal Medicine Research, 2(1), 4-13. 16. Naeem, Z., AlMohaimeed, A., Sharaf, F. K., Ismail, H., Shaukat, F., & Inam, S. B. (2011). Vitamin D status among population of Qassim region, Saudi Arabia. International journal of health sciences, 5(2), 116. 17. Nasef, A , Hassan, M, Taguri, A & Nagi, A. (2020). PREVALENCE OF VITAMIN D DEFICIENCY IN CENTRAL REGION OF LIBYA. International Journal of Advanced Research. 8. 988-994. 10.21474/IJAR01/11009. 18. Omar, M., Nouh, F., Younis, M., Younis, M., Nabil, N., Saad, M., & Ali, M. (2018). Culture, sun exposure and Vitamin D deficiency in Benghazi Libya. Journal of Advances in Medicine and Medical Research, 25(5), 1-13. 19. Omar, M., Nouh, F., Younis, M., Younis, M., Nabil, N., Saad, M., & Ali, M. (2017). Vitamin D status and contributing factors in patients attending three polyclinics in Benghazi Libya. Journal of Advances in Medicine and medical Research, 24(5), 1-13. 145 Volume 3 - Issue One - 2024 FEZZAN UNIVERSITY SCIENTIFIC JOURNAL VOL.3 NO. 1 2024 ‫مجلة جامعة فزان العلمية‬ Fezzan University scientific Journal Journal homepage: wwwhttps://fezzanu.edu.ly/ 20. Peterlik, M., Boonen, S., Cross, H. S., & Lamberg-Allardt, C. (2009). Vitamin D and calcium insufficiency-related chronic diseases: an emerging world-wide public health problem. International journal of environmental research and public health, 6(10), 2585-2607. 21. Rumano, M., Bida, L. K., & Rumano, E. (2021). Vitamin D Status and Its Relationship with Age, Gender and Parathyroid Hormone. The Eurasia Proceedings of Health, Environment and Life Sciences, 1-9. 22. Sadat-Ali, M., AlElq, A., Al-Turki, H., Al-Mulhim, F., & Al-Ali, A. (2009). Vitamin D levels in healthy men in eastern Saudi Arabia. Annals of Saudi medicine, 29(5), 378382. 23. Sadat-Ali, M., AlElq, A., Al-Turki, H., Al-Mulhim, F., & Al-Ali, A. (2009). Vitamin D levels in healthy men in eastern Saudi Arabia. Annals of Saudi medicine, 29(5), 378– 382 24. Sadiya S, Masud R, Mashud P, Mahmuda M & Afsana H, S. (2021). Profile of Vitamin D in Patients Attending at Tertiary Care Hospital, Bangladesh, American Journal of Internal Medicine. Volume 9, Issue 2, pp. 83-86. 25. Sheikh, A., Saeed, Z., Jafri, S. A. D., Yazdani, I., & Hussain, S. A. (2012). Vitamin D levels in asymptomatic adults-a population survey in Karachi, Pakistan. PloS one, 7(3), e33452. 26. Yammine, K., & Al Adham, H. (2016). The status of serum vitamin D in the population of the United Arab Emirates. EMHJ-Eastern Mediterranean Health Journal, 22(9), 682-686. 146 Volume 3 - Issue One - 2024