How Vitamin D deficiency is wreaking havoc on people's lives and the healthcare system in Bangladesh

Infographic: TBS

Riza Ahmed (not his real name), a senior executive of a top-level company based in Dhaka, has long been suffering from pain in his feet whenever the weather gets a little damp. He used to think it was some sort of rheumatism, as his mother also used to suffer from such kind of pain. 

"Around seven years ago, I went to visit a cardiologist. Looking at my face, the doctor asked me to test my vitamin D level. But then he said I do not even have to do the test, and told me to start taking vitamin D. He was sure I had a vitamin D deficiency," said Riza Ahmed.  

According to the doctor, Riza Ahmed started taking vitamin D and he was relieved of his physical pain immediately afterwards.

Mohammad Zaman (not his real name) has been working in a private company for around four years. Last month, he started feeling anxious over two of his pending tasks. The tasks were not that complex. But he could not concentrate on his work and he continuously felt lethargic. 

Later, he talked to a psychological counsellor who prescribed him to test his vitamin D level. Accordingly, Zaman got tested and found that his vitamin D level was half of what it was supposed to be. 

Fahmida Khan (not her real name) works for a specialised agency of the United Nations. For the last three years,  she was suffering from elbow pain. When she visited an orthopaedic doctor recently, the doctor prescribed her to test his vitamin D level. The test found she has a mild vitamin D deficiency.  

Riaz, Zaman and Fahmida are not alone. Studies show that Bangladesh is experiencing a silent epidemic of vitamin D deficiency. 

People in Bangladesh often suffer from different types of health conditions as a result of vitamin D deficiency, without ever being aware of it. When they show up to doctors with different symptoms or conditions, doctors often find it difficult to directly connect it to the deficiency, and end up misdiagnosing or misprescribing diseases and treatments. 

Vitamin D helps our body absorb calcium. Calcium is one of the main building blocks of bone. Vitamin D also has a role in your nervous, muscle, and immune systems. We can get vitamin D in three ways: through our skin, from our diet, and from supplements. Our body forms vitamin D naturally after exposure to sunlight. 

Vitamin D deficiency is an important public health problem worldwide. The vitamin in question is essential for the maintenance of calcium homeostasis and bone mineralisation. A deficiency of vitamin D causes rickets in children and osteomalacia in adults, according to one study. 

Doctors say awareness about vitamins A, B and C has for long been created in Bangladesh, and as a result, people are conscious of these vitamins. However, people are not aware of this particular silent killer – the deficiency of vitamin D. Moreover, doctors tend not to prescribe vitamin D tests to their patients because of its expensive price tag, around Tk2,500-5,000 from any health facility. 

And now, as older people are suffering more and more from vitamin D deficiency-related health conditions, evidenced by test results and doctors' prognosis, people are now becoming aware of it.     

Vitamin D deficiency in Bangladesh

The Asia Pacific Journal of Clinical Nutrition published a review article (a survey of previously published research on a topic) in 2022. It examined the available published data from all peer-reviewed original research articles of community and hospital-based research carried out on Vitamin D status in different population groups in Bangladesh. 

The studies, in total eight, had been conducted between 2002 to 2022, spanning Cox's Bazar, Sylhet, Gazipur and Dhaka, and covering upper and lower socio-economic groups in both urban and rural settings. Across the eight studies, 3,047 people were surveyed. 

"Vitamin D deficiency is one of the major public health problems globally in all age groups of the population. Due to lack of diagnosis and treatment, vitamin D deficiency is still an epidemic in this era of medical advancement," according to the review article.  

The joint study titled "Vitamin D deficiency in Bangladesh: A review of the prevalence, causes and recommendations for mitigation" conducted by the Department of Food and Nutrition, Helsinki, Finland and the Institute of Nutrition and Food Science, University of Dhaka, found that the prevalence of Vitamin D deficiency in different groups of the population in Bangladesh was uniformly high, irrespective of age, sex, race, religion location and socio-economic status. 

The study found that the prevalence of vitamin D deficiency ranged from 27.2% to 100% in different population groups. The study also found that age and sex-specific comparisons indicate that prevalence is higher for the elderly and women. 

Hypovitaminosis D (Vitamin D deficiency) ranged from 21% to 75% for infants, children and adolescents. The rate is 38% to 100% for premenopausal women while the rate is 66% to 94.2% for pregnant women.

Vitamin D deficiency is 6% to 91.3% for adult men. The rate of vitamin D deficiency is found to be the highest between 82% and 95.8% for postmenopausal women. 

The study found that the key factors for the 'silent epidemic' of vitamin D deficiency include dark skin colour, lifestyles that are homebound and/or include sedentary jobs, insufficient sunlight exposure, atmospheric pollution, clothing style, obesity, use of sunscreen and lack of Vitamin D supplementation.     

"A compressive strategy to alleviate and control the health consequences of vitamin D deficiency is necessary. This would include the creation of public awareness, encouraging people to refrain from sunscreen usage, being exposed to sunlight, regular exercise, food fortification and supplementation with vitamin D, " the review article recommended.  

Mohammed Akhtaruzzaman, a professor at the Institute of Nutrition and Food Science, University of Dhaka, who was involved in conducting the study, said the overall scenario of vitamin D health status in the country is not good. 

"If a man crosses 60 years of age, he starts to suffer pain in his bones, but in developed countries, people who are much older do not suffer that [kind of] pain," said Professor Akhtaruzzaman. 

Professor Akhtaruzzaman recommended that people stay in sunlight to alleviate vitamin D deficiency. At the same time, people should drink milk or dairy products to make up for the deficiency on a regular basis. And people will have to be aware of a balanced diet.      

How vitamin D wreaks havoc on your body

The number of people suffering from vitamin D deficiency in Bangladesh is substantially high. 

To mitigate vitamin D deficiency, all people, irrespective of age and sex should get more sunlight exposure. 

"If we do not try to get sunlight, vitamin D deficiency will prevail, calcium absorption will be low and bones will be weak. Ultimately it will increase the possibility of bone fractures," said Dr Md Abdur Rob, professor (orthopaedic surgery) at the National Institute of Traumatology and Orthopaedic Rehabilitation.

He said that women are the worst victims of vitamin D deficiency. Normally, the level is supposed to be 30 nanomoles per litre (nmol/L), but in some instances, he found some severe cases with 4-5 nmol/L. 

"They suffer from severe pain in their hands, feet and bones. They feel weak. The bone pains are mainly because of the vitamin D deficiency," said Dr Rob. 

First of all, women suffer more from vitamin D deficiency because they are exposed to sunlight less than men, and wear more clothing. "As the main source of vitamin D is sunlight, those who are exposed to less sunlight suffer from vitamin D deficiency the most," said Dr Rob. 

In his professional experience, he has found people who are covered in terms of their attire, or more likely to be Vitamin D deficient. Women and children who mostly stay at home are more likely to suffer from vitamin D deficiency. When it comes to office-goers, those who spend most of their time at the office and only step out to commute between home and the office – are also more likely to suffer from this deficiency. 

Physicians usually prescribe oral vitamin D for mild deficiency. And when it comes to a severe deficiency, physicians prescribe injections. Vitamin D supplements can make up for deficiency for a certain interval, but is not deemed a long-term solution.  

"Irrespective of whether you provide someone with vitamin D supplementation, he or she must get sunlight exposure to bring down the vitamin D deficiency in the long run," said Dr Rob, adding, "At the same time, we need to have a balanced diet."

Dr Rob said prolonged suffering due to vitamin D deficiency can also lead people to depression. 

"If there is no physical fitness, there will be no mental fitness," said Dr Rob.

How the deficiency ails the mind 

Dr Mahjabeen Haque, a professor at the Department of Educational and Counselling Psychology, said that there is a link between vitamin D deficiency and mental health. "If there is a deficiency of vitamin D, one of the happy hormones called serotonin is not produced. Serotonin is related to helping keep our mood in good shape," said Dr Haque. 

She said that studies suggest that there is a link between the level of serotonin and impulsive behaviour. When the level of serotonin runs low, people exhibit impulsive behaviour. 

"When they exhibit impulsive behaviour, all of a sudden, they do something or other without thinking about the consequences of it," said Dr Haque. "The results of impulsive behaviour are almost always bad." 

She further explained that nowadays the tendency for impulsive behaviour is increasing among people in our society, office, as well as in our family. Some of them are even criminal acts.

"Now I think we should look into vitamin D status as well as the serotonin level of the person who is behaving impulsively," Dr Haque. 

An uptick in vitamin D demand

The vitamin D market, which is Tk103 crore in the country, is growing at 7.5%, said Syed S Kaiser Kabir, Managing Director of Renata Limited. The Vitamin D + Calcium market is worth Tk942 crore, while Vitamin D and others (Multivitamins) market is worth Tk315 crore. While the former market has grown 17.5%, the latter has grown at 4.3%.  

"This growth occurred over the last 12 months," he added. 

Dr Rob said that as people are becoming more and more conscious of the deficiency of  

Vitamin D, local pharmaceutical companies are making more and more vitamin D supplements to meet the demand in the country. 

"Even five years ago, there was no local production of vitamin D in the country, because the market size was small," said Dr Rob. "Now as people are becoming aware, the market of vitamin D is expanding." As a result, pharmaceutical companies have started to produce oral as well as injectable vitamin D supplements.