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Vitamin D Deficiency and Risk of Hair Loss: Knowledge and Practice of Adult Female Population in Saudi Arabia, 2020

Background: Vitamin D deficiency is a global problem related to public health causing multiple disorders, for example rickets, osteoporosis (weak bones) and osteomalacia. Lack of information, education and perception about the normal requirements of vitamin D is leading to emergence of many diseases in Saudi population. We aimed to assess Knowledge and practice of vitamin D deficiency and risk of hair loss among adult female population in Saudi Arabia. Methods: We performed a cross sectional study in adult females older than 16 years who are residing in Saudi Arabia. We excluded female healthcare workers. Knowledge and practice of vitamin D deficiency and risk of hair loss were measured among included female. Data were analyzed using SPSS. Results: A total of 810 female were included. Most of participants were between 18-25 (41.6%) and 26-35 (39.5%) years old. 42.6% of total participant were single. 96% of them heard about vitamin D. The main source of information were Relatives & friends (55.8%) followed by health care professional (50.75%). 503 (62.1%) of the participating females correctly knew that there is a relationship between vitamin D deficiency and hair loss, 188 (23.2%) thought that there is no relationship while 119 (14.7%) did not know or did not have any opinion. Regarding practice, about 216 (26.7%) participants exposed themselves to sunlight, and 40% were taking Vitamin D Original Research Article Alotaibi et al.; JPRI, 33(60B): 2464-2475, 2021; Article no.JPRI.8216


BACKGROUND
Hair loss is a common problem that can be treated with vitamins and minerals. Vitamins and minerals are essential for growth of normal cell and performing their function and in case of its deficiency, it may contribute to hair loss. Although supplements are relatively affordable and easily accessible, it is important to have the knowledge about which vitamins and minerals are useful in treating hair loss [1].
Vitamin D is a fat-soluble vitamin that regulates the metabolism of calcium and phosphorous [2]. There are two types of vitamin D; cholecalciferol (vitamin D3) and ergocalciferol (vitamin D2) [3]. Sun exposure is the main source of vitamin D [4]. There are few sources of vitamin D, including fatty fish, such as sardines, tuna, mackerel, and salmon. cod liver oil; yolk; And mushrooms. It is rarely found in vegetables, grains, and fruits [5]. In human body, the major function of vitamin D is its contribution in detachment of phosphorus and calcium homoeostasis by enhancing the intestinal absorption of calcium and phosphorus from ingested food sources. The absorbed calcium and phosphorous are required for proper transduction signaling, skeletal mineralization, neuromuscular function, and metabolism processes. Numerous studies have reported sunlight to be the most important source of vitamin D production within human body [6,7]. Vitamin D deficiency is one of the commonest global health conditions as there are more than billion of people worldwide who are vitamin D deficient or insufficient despite the huge advance in the medical services [8]. This deficiency disorder has been reported as a global problem related to public health considering its primary involvement in pathogenesis of the most widespread medical conditions of the skeletal system [9,10].
Numerous research reports have revealed a consistent relationship between vitamin D deficiency and prognosis of several disorders including multiple types of cancers, coronary heart disease, diabetes [11][12][13][14], hypertension, Alzheimer and multiple sclerosis [15]. Although the synthesis of vitamin D in human body is significantly dependent on sunlight exposure, yet a number of global regions with best sunlight exposure have shown highest rates of vitamin D deficiency [16]. About 2-3 million cases of nonmelanoma skin cancer and 132,000 malignant skin cancers occur worldwide each year due to exposure to sunlight [17]. Alopecia areata (AA) is one of the main problems of vitamin D deficiency. AA is a common form of hair loss that is characterized with sharply demarcated, skincolored patches of non-scarring alopecia. Study results support immune nature AA, including presence of other autoimmune diseases, presence of hair follicle-specific autoantibodies, or improvement after immunotherapy [8].
Saudi Arabia is one of the brightest countries in the world, and vitamin D deficiency has been widely reported in Saudi Arabia [18]. Level of vitamin D should be sustained ≥30 ng/ml, the normal level is 40-60 ng/ml, the level of vitamin D is insufficient when it is 21-29 ng/ ml, and deficient when it is < 20 ng/ml [19].

Rationale of Study
Vitamin D performs a crucial role in sustaining the homeostasis of different biological systems in the human body. One of the main roles of vitamin D is its involvement in uptake and use of minerals such as calcium and phosphorus. Another key role played by vitamin D is its function in development of skin and adnexa. Other vitamin D functions are involved in epidermal differentiation and, especially, in protection of hair follicle integrity [20,21].
However, lack of information, education and perception about the normal requirements of vitamin D by human body, enriched intake and supplementation practice towards vitamin D is leading to emergence of many diseases in Saudi population. Only a few studies have been conducted on the awareness of the vitamin D deficiency [20].

Literature Review
The role of the vitamin D3 receptor (VDR) in AA pathogens has also been evaluated. Fawzi et al showed tissue and serum VDR in AA significantly lower levels compared to the control group. A significant negative correlation was observed between AA and tissue VDR volume. The results are based on lime and others. The authors found that VDR expression was significantly lower than in intact skin in hair follicles and in Alzheimer's disease [22][23][24]. Since most of the studies were in adult patients, Unal et al. He has a special interest. The authors demonstrated vitamin D deficiency in pediatric patients in the AA and follow-up group. However, they reported significant relapses between serum 25(OH)D levels, disease severity and duration, and obesity. The authors note that vitamin D deficiency can exacerbate the disease and lead to severe hair loss [22].
In another study, Al-Faris reported vitamin D deficiency being a global nature of health condition, prevailing in the Middle East with female population being more affected [25]. It was observed that old age females were taking the vitamin D supplements and multi-vitamins/calcium supplements were acknowledged as factors related to lower risk of hypovitaminosis D. Further, this study also elaborated that vitamin D deficiency risks factors in Saudi women can be managed by increasing the public awareness related to vitamin D, availability of more efficient vitamin D supplementation and widespread vitamin D screening protocols.
Likewise, Gerkowicz et al. investigated the problem of hair loss due to the deficiency of the vitamins D in the women [22]. They explained that hair loss without scar is a general dilemma equally affecting both the male and female members of population. Moreover, deficiency of vitamin D is described to be major cause of hair loss in men and women. Furthermore, Abdullah A. et al. [8] reported an increasing trend of vitamin D deficiency in the local population of Saudi Arabia, which can be controlled by increased knowledge, awareness and education about the disorders and causing factors. They observed that most of the study participants were aware about vitamin D though media as a major source of information. Approximately 17% believed that there is connection between hair loss and vitamin D deficiency.

Aims and Objectives of the Study
To assess Knowledge and practice of vitamin D deficiency and risk of hair loss among adult female population in Saudi Arabia as well as assessment of practices related to vitamin D deficiency among adult female population in Saudi Arabia.

Study Area/Setting
The sample was selected by contacting participants via social media platforms (WhatsApp, Facebook, Twitter, Telegram, etc.).

Study Subjects
The study was conducted on selected sample of adult females who are residing in Saudi Arabia at the time of study period. The study included both Saudi and non-Saudi national females with age criteria being set at greater than 16 years. The only exclusion criteria are healthcare worker females who assumed to have higher level of awareness because of their work.

Study Design
This is an observational, cross-sectional, descriptive, community based study.

Sample Size
The sample size was determined using Epi Info 7 software with following parameters being taken into consideration Confidence interval = 95% Acceptable margin of error = 5% Expected frequency (lack of awareness of the relationship between vitamin D deficiency and hair loss) = 83% (Based on Alotaibi AA study [8]).
Population size = Based on Saudi General Authority of Statistics in 2018, total Saudi / Non-Saudi female population who are > 15 years is 10,138,222.

Sample size = 384 subjects
The survey form was available online until the required sample size is achieved (Fig. 1).

Fig. 1. The questionnaire and scoring system used in this study
Knowledge and practice of vitamin D deficiency and risk of hair loss:

Sampling Technique
Non-random convenience sampling techniques was deployed to selected study participants.

Data Collection Methods, Instrument Used, Measurements
Data was collected utilizing an electronic, selfadministered, author designed, pre-tested, close-ended questionnaire to obtain information about demographic data, knowledge and practice of vitamin D deficiency and risk of hair loss.

Data Management and Analysis Plan
Data was coded, entered and analyzed using Statistical Package for Social sciences (SPSS) software version 24. Qualitative categorical variables were analyzed and presented as frequencies and percentages, while continuous data was reported as means and standard deviations (SD). In addition, one way ANOVA test and independent T test were used to explore differences between proportions of study groups while chi-test was used for analysis of correlation of qualitative variables. Knowledge score was devised and calculated such that for every positive response was awarded 1 point and every negative response was awarded 0 point.

RESULTS
The present study included 810 adult females.

Knowledge about Vitamin D Deficiency & Risk of Hair Loss
The vast majority of the participants (96%) have heard about vitamin D while only 32 (4%) did not know about it. The most common source of participants' information about vitamin D was relatives and friends representing 452 (55.8%), followed by health care professionals 411 (50.7%), then internet 377 (46.5%), media 270 (33.3%) and other different sources 117 (14.4%). did not know or did not have any opinion (Fig. 2). Details of the participants' knowledge are shown in Table 2.  Table 3.  The overall knowledge and practice scores are shown in Table 4. Regarding knowledge, the mean score of participants was 9.4 ± 2.80 out of 18, with a minimum score of 3 and a maximum score of 16. The mean practice score was found to be 6.7 ± 1.41 out of 12, with a minimum score of 3 and a maximum score of 10.

Factors Associated with Knowledge and Practices about Vitamin D Deficiency and Risk of Hair Loss
One way ANOVA test and independent samples T test were performed to identify differences between various groups (based on participants' demographics: age, nationality, residence, marital status) regarding knowledge and practices about vitamin D deficiency and risk of hair loss.
Regarding knowledge score, a statistically significant association (p < 0.05) was found with the following factors: age, nationality, residence and marital status. The comparison demonstrated that participants who aged 26 to 35 years had a significantly higher score (10.7 ± 2.22) while who aged 56 years or older had the lower score compared to other age groups (P=0.000). Also, Saudi Arabian nationals showed a higher score (9.4 ± 2.76) compared to non-Saudi (P=0.026). Participants who resident in northern region and married participants had a significantly higher score compared to other groups (P=0.000).
Regarding practice score, a statistically significant association (p < 0.05) was found with the following factors: age, nationality, residence and marital status. The comparison demonstrated that participants who aged 56 years older had a significantly higher practice score (8.4 ± 0.51) compared to other age groups (P=0.000). Also, non-Saudi Arabian nationals showed a higher score (7.1 ± 1.63) compared to Saudi (P=0.032). Participants who resident in eastern region or western and widowed participants had a significantly higher score compared to other groups (P=0.000). All comparisons are detailed in Table 5.

DISCUSSION
Vitamin D deficiency is a global problem related to public health causing multiple disorders, for example rickets, osteoporosis (weak bones) and osteomalacia. Lack of information, education and perception about the normal requirements of vitamin D is leading to emergence of many diseases in Saudi population. We aimed to assess Knowledge and practice of vitamin D deficiency and risk of hair loss among adult female population in Saudi Arabia.
This study among Saudi female in Saudi Arabia showed that female had an average knowledge score about vitamin D and low knowledge for older and younger participants. Also, we found good practice toward vitamin D among included female, and there is difference in knowledge score according to age, nationality, residence and marital status.
Vitamin D is considered an essential vitamin for prevention from several diseases that affecting bone. In this study, a 96% of total female heard about vitamin D which is considered a high percentage and good indicator that female was aware about the importance of vitamin D. A previous study in Saudi Arabia among adult people found 80% of total participants heard about vitamin D and knew it [8], and this considered a high percentage and closer to our results. Other study among population also reported similar results [26].
Regarding the sources of information for vitamin D, our study identified Relatives & friends followed by health workers as the most common source of information. But in other previous study among population in Saudi Arabia, media (35%) then heath care professionals (28%) were the most common source of information [8], and this give a valuable information that most of female liked to hear information about vitamin D from relatives.
For the knowledge of vitamin D in our study, the overall score was 9.4 ±2.80, and majority of participants answered sunlight followed by fish as the source for taking vitamin D, and 68.3% said that vitamin D would strengthen their bones. Also, they identified lack of sun exposure as main cause for vitamin D deficiency, and hair loss (70.2%) and osteoporosis (72.8%) were identified as the endpoint for vitamin D by most of participants. According to a study conducted in 2014 among students (n = 4,035) and staff (n = 2,104) in three regions of Saudi Arabia, the study found that 49% of students and 44% of employee are vitamin D deficient indicating that vitamin D deficiency is rising in Saudi Arabia [27]. There are many studies on vitamin D deficiency in Saudi Arabia, where a study conducted in Riyadh among pregnant women in the first half of 2010 showed that 50% of all samples (n = 160) were vitamin D deficient [28]. Another short-term study of medical students at King Fasil University in 2009 found that 96% of 95 students (95 males and 103 females) were deficient in vitamin D [29].
The overall practice of vitamin D was 6.7 ±1.41 in our study, and only 26.7% of total participants were exposing to sun, and half of them use sunscreen product usually and sometimes. Only 40% were taking vitamin D supplement. The etiology of vitamin D deficiency in Saudi women could be related to number of factors including residents of Saudi Arabia mostly practice indoor lifestyle due to very hot climate with scorching temperature. Moreover, direct exposure of sunlight to most body parts are restricted in Saudi population due to religious/cultural habits, as Muslims tend to keep their bodies covered in public. Additionally, in another study, almost 19% of Saudi girls were found to have no direct sun exposure, 67% were observed to have the direct sun exposure while 75% were reported to have an indirect exposure to sunlight [16]. Moreover, direct sun exposure to human body in Saudi female population was previously found to be limited because women tend to hide their entire bodies by wearing a special dress known as "abaya" that covers from head to toe [16,30]. In Saudi Arabia, 40.7 % of adult population were found exposing to sun, and more than 67.8% were not using any kind of skin product [8].
As we know, involving in educational program would make a good impact in improving the knowledge and practice of vitamin D. Among 271 participants, educational intervention programs were found effective in increasing dietary intake of vitamin D [31].
Our study assessed the knowledge and practice toward vitamin D and hair loss among Saudi female in Saudi Arabia. Getting Data about vitamin D is important to know the age distribution and places for low knowledge and practice among female which fasten the intervention by ministry of health and local authority to show the importance of vitamin D for prevention from diseases caused by vitamin D deficiency.
Regarding limitations, this study included only Saudi female to assess their knowledge and practice toward vitamin D without any response from male. Thus, we can't generalize the result and know the knowledge and practice for Saudi male. Also, the attitude toward vitamin D was not measured among the participants.

CONCLUSION
The results for this study showed an average knowledge about vitamin D among Saudi female, and good practice toward vitamin D. Also, a difference in knowledge score were found according to age, nationality, residence and marital status. About two third of the participants knew that there is a relationship between vitamin D deficiency and hair loss.
The knowledge of vitamin D should be enhanced to decrease the incidence of diseases caused by vitamin D deficiency. According to age distribution of included participants, younger and older age female of included were having low knowledge score; thus, we they need an attention to enhance their knowledge toward vitamin D. Further research should investigate effective strategies to improve vitamin D knowledge and include a larger sample with representation of all subgroups of the Saudi Arabia population to confirm these results.

CONSIDERATIONS AND CONSENT
Ethical approval was obtained from the ethical committee of King Abdullah International Medical Research Center. Informed consent was obtained from each participant after explaining the aims and benefits of the study.