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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 37  |  Issue : 3  |  Page : 119-124

Vitamin D status among patients with chronic low back pain attending a tertiary care hospital: A cross-sectional study


1 Andaman and Nicobar Islands Institute of Medical Sciences, Port Blair, India
2 Atal Bihari Vajpayee Institute of Medical Science and Dr RML Hospital, New Delhi, India

Date of Submission14-Sep-2022
Date of Acceptance25-Oct-2022
Date of Web Publication15-Dec-2022

Correspondence Address:
Mohit Singh
Atal Bihari Vajpayee Institute of Medical Science and Dr RML Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jbjd.jbjd_24_22

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  Abstract 

Introduction: Low lower back pain (LBP) is one of the maximum commonplace health troubles related to economic losses in the society. Chronic LBP (CLBP, pain for more than 3 months) is not an unusual cause of disability and absence from work from obligation. Etiologically, decreased lower back ache is a multifactorial disease with numerous possible symptoms and causes. Vitamin D plays a critical role in the immune system and bone healing. Despite the fact that Indians receive ample sunshine throughout the year, hypovitaminosis D continues to be a developing problem. Aims and Objectives: The aim of this study is to describe the association between vitamin D deficiency and chronic low backache attending OPD of a tertiary care hospital in Andaman and Nicobar Island and to compare the data with that of Mainland India. Materials and Methods: A prospective cross-sectional study was conducted during the period from 1 January 2019 to 31 December 2020. The primary inclusion criterion for CLBP is defined as self-reported pain in the low back area for more than half of the time in the past 3 months, following the standardized criteria proposed by Dionne et al. Serum 25-hydroxyvitamin D is considered as a marker for the recent status of vitamin D levels in the blood. Results: In our study, we took 664 patients with the mean age of 40.45 ± 15.2 years. We also found that 174 patients were vitamin D-deficient (26.20%). Vitamin D insufficiency was seen in 310 patients (46.69%), and 180 patients were vitamin D-sufficient (27.11%). The mean vitamin D level in females was 28.46 ± 17.12 and that in males was 29.02 ± 13.54. Conclusion: To conclude, the majority of the patients with chronic low backache have vitamin D deficiency or insufficiency, and supplementation of vitamin D should be considered.

Keywords: Andaman and Nicobar Island, low backache, vitamin D level


How to cite this article:
Saha S P, Deb S, Singh M, Joshy VM, Pandey SK, Khare R, Yadav AK, Kumar D. Vitamin D status among patients with chronic low back pain attending a tertiary care hospital: A cross-sectional study. J Bone Joint Dis 2022;37:119-24

How to cite this URL:
Saha S P, Deb S, Singh M, Joshy VM, Pandey SK, Khare R, Yadav AK, Kumar D. Vitamin D status among patients with chronic low back pain attending a tertiary care hospital: A cross-sectional study. J Bone Joint Dis [serial online] 2022 [cited 2023 Feb 6];37:119-24. Available from: http://www.jbjd.in/text.asp?2022/37/3/119/363847




  Highlights Top


  1. Low lower back pain (LBP) is one of the maximum commonplace health troubles related to economic losses in the society. Chronic LBP (CLBP, pain for more than 3 months) is not an unusual cause of disability and absence from work from obligation.


  2. Etiologically, decreased lower back ache is a multifactorial disease with numerous possible symptoms and causes. Vitamin D plays a critical role in the immune system and bone healing. Despite the fact that Indians receive ample sunshine throughout the year, hypovitaminosis D continues to be a developing problem.


  3. CLBP is defined as self-reported pain in the low back area for more than half of the time in the past 3 months, following the standardized criteria proposed by Dionne et al. Serum 25-hydroxyvitamin D is considered as a marker for the recent status of vitamin D levels in the blood.


  4. In our study, we found that 174 patients were vitamin D-deficient (26.20%). Vitamin D insufficiency was seen in 310 patients (46.69%) and 180 patients were vitamin D-sufficient (27.11%). The mean vitamin D level in females was 28.46 ± 17.12 and in males was 29.02 ± 13.54.


  5. To conclude, the majority of the patients with chronic low backache have vitamin D deficiency or insufficiency, and supplementation of vitamin D should be considered.



  Introduction Top


Andaman and Nicobar Islands is located 140 km east of Mainland India. Latitude and longitude coordinates of Andaman and Nicobar Islands are 11.623377° N, 92.726486° E. This island is spread over 600 km in vertical chain from north to south in the tropical area, 150 km west and parallel to the Indonesian island of Bali, southeast Asia. Due to proximity to Indonesia, which has 105 active volcanoes, the troposphere over Andaman and Nicobar Islands remains covered with volcanic ash in the form of smog almost throughout the year impending ultraviolet rays. This study was done to know the vitamin D level in symptomatic chronic low backache patients in this Indian Island and to compare data with those of Mainland India and South East Asia. Low lower back pain (LBP) is one of the maximum commonplace health troubles related to economic losses in the society. Chronic LBP (CLBP, pain for more than 3 months) is a common cause of disability and absence from duty.[1],[2] The optimal management of patients with chronic low back pain remains a challenge for healthcare services. Probably in elderly populations, back pain is the most prevalent source of musculoskeletal soreness worldwide.[3] It was suggested that more than 58% of the elderly suffer from chronic back pain, generalized body ache with different clinical presentations. In women, higher rates of lower back pain were reported when compared with men.[4],[5] The increase in the scores of back pains among women might be due to an increase in bone loss and poor bone mineral density (BMD), either because of post-menopausal or dietary deficiency. That is why females are more prone to osteoporosis and vertebral fracture.[6],[7] Etiologically, lower back pain is a multifactorial disease with several possible symptoms and causes.[8],[9] A variety of factors were shown to be associated with lower back pain, particularly increased age, female sex, high body mass index, smoking, strenuous physical activity, chronic co-morbidities, poor levels of physical activities, vascular pathology, depression, and psychological disturbances.[10],[11] However, a previous history of on and off LBP appears to be the only strong and consistent risk factor for developing severe LBP. There are three diagnostic categories of LBP. These are radiculopathy, specific LBP, and non-specific LBP. Non-specific LBP is defined as symptoms without a clear specific cause, for example, infection, malignancy, spondylolisthesis, spondyloarthritis, spinal stenosis, and fracture. More than 90% of the patients complaining of LBP have non-specific LBP.[12],[13] Vitamin D plays an important role in the immune system and bone healing.[14],[15] Regulation of inflammatory cytokines by vitamin D may be correlated with chronic pain conditions. Furthermore, the effect of vitamin D administration on the improvement of chronic pain has been demonstrated in some studies.[16],[17] Several studies have been conducted for association between vitamin D deficiency and the presence of chronic painful conditions. But there is a disparity in the effect of treatment with vitamin D between randomized and double-blind clinical trials in comparison to studies of other designs.[18],[19] Some studies show a positive association between vitamin D deficiency and LBP[16],[17] and between vitamin D levels and pain intensity,[18],[19] whereas others have failed to find an association[20] or have only found a significant association in women.[21] Numerous mechanisms provide a rationale for the link between vitamin D and the risk of LBP, including the regulation of anti- and proinflammatory cytokines that control pain and inflammation[22] and the modulation of pain through sensory neuron excitability.[23],[24] Furthermore, there appears to be an inverse relationship between inflammatory markers and serum concentrations of 25-hydroxyvitamin D [25(OH)D] (a common measure of vitamin D levels,[25] with research showing reductions in inflammatory markers following vitamin D supplementation).[26],[27] Therefore, given the increasing interests in vitamin D supplementation for the management of LBP,[28],[29] a better understanding of the relationship between vitamin D levels and LBP is needed. Even though Indian people receive enough sunshine, hypovitaminosis D is still considered a significant problem. A high prevalence (50–90%) of vitamin D deficiency along with low dietary intake of calcium has been documented in the Indian population. There is no such study to date conducted in Andaman and Nicobar Islands to look for the vitamin D level among patients of musculoskeletal soreness.


  Materials and Methods Top


Study population and recruitment of participants

A cross-sectional study was conducted at the GB Pant Hospital attached to Andaman and Nicobar Islands of Medical Sciences, Port Blair, a tertiary care hospital during the period from 1 January 2019 to 31 December 2020. All the patients were informed about the study, and written informed consent was obtained. The ethical approval was received from the Institutional Review Committee of ANIIMS Medical College and GB Pant Teaching Hospital. Sampling was done through non-probability consecutive sampling.

Inclusion criteria and exclusion criteria

Inclusion criteria

Patients of age group of 15–85 years attending Orthopedic OPD of GB Pant Hospital having self-reported backache were included. The primary inclusion criterion for CLBP was defined as self-reported pain in the low back area for more than half of the time in the past 3 months. Patients having lower back pain required analgesic often. All the cases with backache attending the OPD of orthopedics were screened for this criterion.

Exclusion criteria

Patients suffering from any liver or kidney pathology, the refusal for consent, suffering from any parathyroid diseases, rheumatoid arthritis, diabetes mellitus, or on vitamin D supplements were excluded. Patients taking treatment for epilepsy, psychiatric disease, or taking corticosteroids and bisphosphonates were also excluded.

Vitamin D levels

Overnight fasting venous blood was drawn from the patients. Serum 25-hydroxyvitamin D was considered as a marker for the recent status of vitamin D levels in the blood. The samples obtained were centrifuged immediately and processed and estimated by the enzyme-linked immunoassay (ELISA), which is designed by Calbiotech. The following consensus was provided by Dawson-Hughes et al.,[30] Grant and Hollick,[31] and Hollis[32]: vitamin D-deficient: <20 ng/mL, vitamin D-insufficient: 20–30 ng/mL, and vitamin D-sufficient: >30 ng/mL.

Statistical analysis

A descriptive method such as mean, median, and proportion was used to describe the result. Appropriate statistical tests were applied. categorical variables were presented in number and percentage (%), and continuous variables were presented as mean ± SD and median. Quantitative variables were analyzed using the Mann–Whitney U-test and Kruskal–Wallis test across follow-up. A P-value of less than 0.05 was considered statistically significant. The data were entered in MS EXCEL spreadsheet, and analysis was done using Statistical Package for Social Sciences (SPSS) version 21.0.


  Results Top


We included 664 patients attending our OPD of GB Pant Hospital attached to Andaman and Nicobar Islands Institute of Medical Sciences, Port Blair, a tertiary care hospital during the period from 1 January 2019 to 31 December 2020 with low backache complaints. The mean age in our study was 40.45 ± 15.28 years, with a range of 15–85 [Table 1]. Maximum patients were in the 31–40-year age group constituting about 24.8%, followed by the 41–50-year age group (19.3%). The lowest patient was in the 81–85 age group (0.8%) of our study [Table 2] and [Graph 1]. Out of 664 patients, there were 460 female patients (69.3%) and 204 male patients (30.7%) [Table 3]. The mean vitamin D level in our study was 28.63 ± 16.10. In our study, we found 174 patients were vitamin D-deficient (26.20%), vitamin D insufficiency was seen in 310 patients (46.69%), and 180 patients were vitamin D-sufficient (27.11%). All the younger age group below 60 years were found to be vitamin D-deficient in our study. There was no co-relation between age and mean vitamin D level as per Spearman’s correlation coefficient (r), which was 0.060 and P-value 0.121 and was not significant at all [Table 4] and [Table 5]. Among males and females, females were more deficient in vitamin D than males. The mean vitamin D in females was 28.46 ± 17.12 and males was 29.02 ± 13.54. There was no significant relationship between sex and mean vitamin D level [Table 6][Table 7][Table 8] and [Graph 2].
Table 1: Mean age of low backache patients

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Table 2: Frequency of low backache in different age groups

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Graph 1: Frequency of low backache in different age groups

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Table 3: Frequency of different gender with chronic Low backache

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Table 4: Mean Vitamin D level

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Table 5: Spearman's rank correlation between age and Vitamin D

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Table 6: Co relation between sex and Vitamin D level

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Table 7: Different age groups with mean Vitamin D level

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{Table 8}
Graph 2: Vitamin D levels with different age groups

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  Discussion Top


The deficiency of vitamin D has emerged as an important area of research in the Indian context. A widespread deficiency of vitamin D has been noticed in recent times in different age groups of people irrespective of age/group/gender/geographical variation and it has been reflected in recent studies. Vitamin D though it is a fat-soluble vitamin, it also functions as a hormone as it is also involved in the skeletal system integrity by regulation of parathyroid hormone, calcium, and phosphate metabolism. It also plays an important role necessary in calcium homeostasis and musculoskeletal health. Out of various types of vitamin D, 25-hydroxy Vitamin D is considered the most reliable index for assessing an individual Vitamin D status. There is a controversy regarding the correlation of hypovitaminosis D with chronic LBP and the role of vitamin D in the improvement of LBP. Both hypovitaminosis D and LBP are emerging public health problems in developing countries. Deficient levels of vitamin D raise the chances of inflammatory activity at the vertebral endplates, causing the diminished pain threshold and thus resulting in generalized pain in the muscle and bone leading to weakness.[33] In India, located between 8°N-38°N, there’s lots of sunshine all 12 months round and accordingly human beings in India ought to now not have an insufficient vitamin D fame. At the contrary, epidemiologic studies from one-of-a-kind parts of India reported a better than 70% occurrence of diet D deficiency [25(OH) D <50 nmol/L] in all age groups, including toddlers, school children, pregnant women, and their neonates and adult males.5 for example, a take a look at in school girls (n = 404, forty eight% lower socioeconomic area of Delhi, located at 28.38° N, pronounced 91% had been nutrition D deficient.[34],[35]Among these Southeast Asia countries, Thailand had the least prevalence of vitamin D deficiency, possibly related to its geographical location close to the equator.[36] Singapore had a slightly higher prevalence of vitamin D deficiency than in Thailand, partly due to being a more industrialized country even though Singapore is located closer to the equator. Overall, the common predictors of having low vitamin D status in this Southeast Asia were younger age, being female, living in an urban area, and being less physically active[37]Vitamin D also has anti-inflammatory properties. Multiple factors affect the serum levels of vitamin D like geographical location, sunlight exposure, malnutrition, and ethnicity. It is possible that the threshold for the development of clinical symptoms differs across different ethnic groups. As vitamin D deficiency is highly prevalent among the sub-tropical Asian population, the low levels have been attributed as one of the main causes of higher prevalence of non-specific back pain in that population.[36],[38],[39] Our study showed that 90% of the patients with low back pain had low vitamin D levels. The findings were similar to those of Siddique and Malik.[40] However, for intensity or duration of back pain, no association was found with vitamin D levels in a study conducted by Lotfi et al..[41] The prevalence of low vitamin D levels in low back pain patients was similar in both genders. As hormonal factors are involved in the metabolism of vitamin D and calcium, lower values of vitamin D were expected in post-menopausal women but our study showed similar serum values in pre-and post-menopausal age groups. This was in contrast to the study by Lips et al..[42]

In general, the synthesis of vitamin D inside the skin under sunlight declines with age. aging is related to decreases the 7-Dehydrocholesterol concentration inside the skin, resulting in reduction by means of more than 4-fold diet D3 synthesis in a 70-year-old compared with a 20-year-old person. Further, the elderly man or woman generally stays indoors for longer intervals due to comorbidities and limited physical activity, inflicting less solar exposure. interestingly, the elderly in Southeast Asia including Thailand[38] and Korea[36] have a higher diet D status while compare with younger people. The feasible rationalization is these elderlies have more free time and spend time doing outside activities. The rapid economic development over the past decade in many countries of Southeast Asia has led to teenagers having indoor jobs, even as elderly adults tend to have outside job.[43]

In this study female patients outnumbered the male patients who attended our OPD for backache-related problems may be because women are more involved in household activities thus less exposure to sunlight moreover more clothing in comparison to male patients hinder sunlight exposure even though this Island gets sufficient sunlight exposure. As in western international locations, there may be proof that women in Asian nations have lower 25(OH)D ranges than males. Gender differences occur especially because of clothing and solar protection behaviour in ladies due to cosmetic worries. countries near the equator receive greater sunlight all 12 months round compare with the ones far from the equator.[44] But use of solar sunshine is unusual in those populations because the weather is often too hot. for this reason, sun-protecting behaviours; along with wearing a hat, applying sunscreen, the use of an umbrella, wearing long sleeves, or staying within the shade, affect diet D reputation in this sunshine place.


  Conclusion Top


In conclusion, vitamin D deficiency is common in South Asia and Southeast Asia, affecting all age groups. latitude of the nations as well as attitudes and behaviour toward daylight exposure are the foremost determinants of vitamin D status in a population in which sunshine is considerable. consequently, reduced levels of serum vitamin D need to be considered as a contributing issue for the improvement of chronic low lower back pain. To conclude, the majority of the patients with chronic low backache have nutrition D deficiency or insufficiency, and supplementation of nutrition D must be taken into consideration. How ever the limitation of the study was the only that it done on only out patient department.

Financial support and sponsorship

Nil.

Conflicts of interest

No potential conflicts of interest relevant to this article were reported.

Authors’ contribution

SD collects all information, investigation, records and done work related to conceptualization. MS review and done draft making. He also gathers information and analyze all the study. SPS was the supervisor of the study. VMJ completed work-related to statics and artwork.



 
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 6], [Table 7], [Table 5], [Table 5]



 

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