High prevalence of vitamin D deficiency in Pakistan and its relation to uterine fibroids development and progression : IJS Global Health

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High prevalence of vitamin D deficiency in Pakistan and its relation to uterine fibroids development and progression

Arif, Aabiya MBBSa; Lal, Priyanka Mohan MBBSa; Shaikh, Omer Ahmed MBBSa,; Mohan, Anmol MBBSb

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International Journal of Surgery: Global Health 6(2):p e124, March 2023. | DOI: 10.1097/GH9.0000000000000124
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A class of steroid substances known as vitamin D has a variety of physiological impacts on people. Over a billion people worldwide suffer from vitamin D deficiency, a disorder that is progressively becoming more prevalent. In all, 53.5% of Pakistan’s population had vitamin D deficiency, according to Riaz et al, and another 31.2% had insufficient levels1. Lack of exposure to sunlight, insufficient dietary intake, and poor absorption into the body has been identified as the 3 main reasons for vitamin D deficiency2. According to reports, 63% of Pakistan’s female population is vitamin D deficient, and 47% have inadequate levels of vitamin D. Lack of vitamin D has been associated with osteoporosis development and osteoporotic fractures resulting from secondary hyperparathyroidism. It can also cause rickets and osteomalacia. Moreover, research has shown connections between vitamin D deficiency and diabetes, cancers/tumors, and autoimmune disorders like multiple sclerosis3. According to recent studies, uterine leiomyoma (UL) growth and progression may be influenced by vitamin D deficiency, a serious health issue with a number of consequences, including a higher risk of female reproductive malignancies4.

The cause of ULs is unknown. These benign tumors seem to be the result of myometrial alteration brought on by specific clinical and physiological conditions. The bulk of these monoclonal estrogen-dependent uterine neoformations affects women primarily in their reproductive years, with 80% of them experiencing them throughout their lives. The proliferation of leiomyomas has been linked to a number of growth factors, including VEGF, EGF, heparin-binding epidermal growth factor, PDGF, IGF, transforming growth factor (TGF), TGF-β, acidic fibroblast growth factor, and basic fibroblast growth factor, as well as their receptors5. According to a study conducted in Pakistan by Shahid and colleagues, 14.01% of hysterectomies performed on women of reproductive age in the sample were carried out because of leiomyoma. Leiomyoma (33.12%) was also the most typical finding in the population’s myometrium6.

ULs, despite being the most prevalent benign pelvic tumor, to this date, do not have a satisfactory long-term medical treatment. Multiple factors, such as the size and placement of the uterine fibroid (UF), as well as factors like age, symptoms, and wish for children, are all taken into account before deciding on the treatment plan. The most popular form of treatment for symptomatic UFs is still surgery, such as hysterectomy and myomectomy; however, these procedures raise the risk of an operation’s complications for patients and are very expensive for health care systems7. However, recent studies have shown that vitamin D inhibits UF, mostly via activating vitamin D receptors, which are found in both myometrial and endometrial layers, as well as in UL monoclonal tumor cells. Moreover, previous studies have shown that the active metabolite of vitamin D can reduce TGF-β, which is involved in the development and progression of UF8. Corachán et al9, in their study, showed that downregulation of the Wnt/β-catenin pathway and inducing cell growth arrest are 2 mechanisms by which vitamin D suppresses the proliferation of human primary UL cells. Moreover, a clinical trial was done by Aryeh and colleagues demonstrated in their study that supplementation of 50,000 IU of vitamin D for 3 months might inhibit the growth of ULs and hence could be a possible intervention for this disease. This reduces the need for conventional surgical or medical therapy10. The crux is that vitamin D deficiency is a prominent risk factor for the development and progression of UF, and vitamin D supplements can be used to prevent, treat or reduce the size of UF.

Pakistan is a low-income country, with the percentage of people in poverty in Pakistan being 31.3% (69 million) in 2018, which was expected to reach 40% by 2020 (69–87 million)11. Hence an important factor for vitamin D deficiency could be the unaffordability of foods that are naturally or artificially rich sources of vitamin D or supplements. Moreover, lack of awareness and knowledge of the importance of vitamin D, its sources, and the signs and symptoms of vitamin D deficiency plays a crucial role in the fact that more than half of the Pakistani population is deficient in vitamin D. In any case, there is an urgent need to address Pakistan’s present high levels of vitamin D insufficiency among the population.

A variety of strategies can be employed to counteract these issues. At first, raising awareness regarding the signs and manifestations of vitamin D deficiency in the public, such as hair fall, fatigue, bone pain, muscle weakness, etc. In addition, the masses need to be educated regarding the sources of vitamin D. Pakistan is among the world’s most sun-rich countries, and with cutaneous vitamin D synthesis feasible all year, boosting civilian exposure to sunshine is a very accomplishable method to decrease nationwide vitamin D deficiency. Vitamin D supplements should be encouraged, especially for women of reproductive age. Building on the 1965 Food Act, measures for education and vitamin D fortification programs should be implemented in full force. In addition, efforts need to be made to increase awareness regarding common signs and symptoms of UFs and to provide gynecological checkups for underprivileged women. This also warrants a need for further research in the arena of links between vitamin d deficiency and UFs, as well as the possibility of vitamin D supplementation as a management or treatment option for women with UFs.

As vitamin D deficiency is highly prevalent in Pakistan generally, and it predisposes individuals to many underlying diseases, one of which is UL. Symptomatic UL may require invasive or noninvasive treatment plans depending on the severity of symptoms. But consumption of vitamin D supplements can be beneficial as a preventive or interventional therapy for delaying surgery or completely removing the need for surgery. Hence there is a dire need to advocate for preventing vitamin D deficiency and fill in the vacuum of noninvasive treatments for UFs by further researching vitamin D supplements as a possible treatment option.

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Author contributions

A.A., P.M.L., O.A.S., and A.M.: manuscript was written. O.H.S. and P.M.L.: review editing, formatting, and referencing.

Conflict of interest disclosure

The authors declare that they have no financial conflict of interest with regard to the content of this report.

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Omer Ahmed Shaikh.


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