Ethiopia’s Sunshine Paradox Unmasking Vitamin D Deficiency

Though bathed in year-round sunshine, Ethiopia faces a surprising yet critical health issue: vitamin D deficiency. This essential nutrient, crucial for bone health and immune function, is lacking in many Ethiopians, both children and adults. The paradox lies in several factors. Limited access to vitamin D-rich foods like fish and eggs, coupled with cultural practices and clothing that minimize sun exposure, contribute to the deficiency. Additionally, darker skin tones naturally synthesize vitamin D less effectively.

The consequences of this deficiency are far-reaching, increasing the risk of bone diseases like rickets and osteoporosis, weakening the immune system, and hindering muscle development.

Addressing this challenge necessitates a multifaceted approach. Promoting a balanced diet rich in vitamin D sources, along with public awareness campaigns highlighting the importance of sun exposure and vitamin D supplementation, are crucial steps. Additionally, government initiatives like fortifying staple foods and promoting outdoor activities can play a significant role.

Overcoming this public health concern requires collaboration between the government, healthcare providers, and communities. Only through concerted efforts can Ethiopia harness the power of sunshine and ensure the health and well-being of its citizens. EBR’s Dr. Brook Genene takes a closer look at the matter.

While Bethel Zeleke, a 23-year-old final-year medical student at Addis Ababa University, was studying for her final exams, she started experiencing new symptoms. Exam time is always stressful and anxious, but what she felt this time was something different. She started feeling tired while sitting and had numbness in her hands and legs. She also experienced bone pain. She did not feel energetic even after eight hours of sleep. She had mood changes, often feeling depressed because of minor reasons. She spent most of her time in the library when these symptoms occurred. She then decided to see a Doctor and was told that her Vitamin D level was low.

Vitamin D deficiency is one of the most prominent nutritional deficiencies worldwide, even though most people affected are elderly or hospitalized, including young and healthy adults.

Vitamin D deficiency can come from several factors. One reason is inadequate exposure to sunlight, which causes a deficiency in synthesized vitamin D made by the skin. Excessive use of sunscreen and inadequate sunlight, especially from 10 am to 3 pm, are also additional causes of Vitamin D deficiency.

The other reason is malabsorption syndrome- a disorder in the digestive system characterized by the inability to absorb nutrients from food. Most Ethiopian staple foods also lack vitamin D. Some drugs like Dilantin, phenobarbital (both medications for seizure), and rifampin (antibiotic) are associated with Vitamin D deficiency. Patients with known liver and kidney diseases will have problems producing active Vitamin D forms.

Ethiopia is lauded as a country with 13 months of sunshine, but ironically, Vitamin D deficiency is a severe problem in the health system. According to a study conducted by Tolossa Wakayo, Tefera Belachew, Hassan Vatanparast, and Susan J. Whiting in Central Ethiopia, there is a 42Pct prevalence of vitamin D deficiency among children aged 11-18 years old. Factors like place of residence (urban/rural area), socioeconomic status, and duration of sun exposure were significant determinants of vitamin D status.

“As a practicing physician in one of the largest hospitals in Ethiopia, I get to see patients from all corners of the country and from all socioeconomic backgrounds. The usual complaint of my patients is nonspecific back pain, fatigue, and lack of energy, and most of them will be found to have vitamin D deficiency,” explains Dr Bereket Abrha, a senior resident physician specializing in Internal Medicine at Tikur Anbessa Specialized Hospital.

The lifestyle in large cities like Addis Ababa also contributes to the problem. Many people spend most of their day indoors. Condominiums and apartments are increasingly becoming the main places of residence, which is another reason why people only need a little exposure to sunlight. A 2015 study around Adama, in central Oromia, has shown that more people in urban areas (61.8Pct) are affected by Vitamin D deficiencies than those in rural areas (21.8Pct).

Dr Brook Alemayheu, an internist at Lancet General Hospital in Addis Ababa and a volunteer at Yetena Weg- a network of health professionals that provides evidence-based health information in Ethiopia, states that the condition is prevalent, and he has seen many patients with Vitamin D deficiency.

“Most patients do not have symptoms and the condition is found incidentally on routine lab tests. However I have seen kids with Rickettes in the rural areas a few years back. More commonly I have also seen people with symptoms of hypocalcemia (low calcium levels) and osteoporosis with fragility fractures especially elderly individuals (more common in post-menopausal women in my experience).”

Vitamin D deficiency manifests in different forms across age groups. In children, it can cause developmental delay and causes rickets. Because children have not yet finished their development, they are prone to bone deformity. Breast milk’s regular vitamin D content is usually insufficient to provide the baby with daily requirements. Sunlight exposure, 30 minutes per week with only a diaper and at least two hours per week when fully clothed, is also sufficient for babies after six months.

Adults most commonly experience fatigue, not sleeping well, bone pain or achiness, depression or feelings of sadness, hair loss, muscle weakness, loss of appetite, and getting sick more easily. It could also lead to Osteomalacia, also known as “soft bones”, a metabolic bone disorder characterized by inadequate mineralization of bone tissue. Because of this, bones may not have enough calcium and other minerals, making them soft and weak. Bone pain or tenderness, muscle weakness, fracture, and difficulty walking are typical consequences for people suffering from the condition.

Beyond the symptoms above, deficiency of Vitamin D has been related to many health conditions, including diabetes, rheumatoid arthritis, and cancer.

Bethel says that, like many of her friends, she does not actively seek exposure to sunlight. With technological advancements, outdoor activities in large cities have become minimal, and experts believe that can be one of the reasons for the increased number of people affected by Vitamin D deficiency.

Medical doctors rarely ask for laboratory tests regarding Vitamin D deficiency. Doctors often order these tests for people they think are at risk. These people include older adults in nursing homes who spend most of their time indoors, people who sustain bone fractures, and children who have not been exposed to adequate sunlight. Doctors recommend milk, orange juice, Fish like salmon and Yoghurt and supplements to improve Vitamin D levels.

The two commonly available vitamin D supplements are ergocalciferol (D2) and cholecalciferol (D3). Various doses of these vitamin D forms can be given till normalization of the serum level of vitamin D. This should be followed by supplemental doses of Vitamin D containing 600-800 international units of vitamin D per day to maintain an average vitamin D level. Even at this intake level, older people confined indoors may have vitamin D deficiency and require higher doses (~1200IU per day).

Educating the public and encouraging them to be more involved in outdoor activities is helpful to prevent vitamin D deficiency. This condition should have been acceptable in a country like ours, where sunlight is abundant.

Indeed, Vitamin D deficiency is a preventable condition. Shockingly, the problem is prevalent in Ethiopia, a country known for abundant sunshine. Public education and awareness campaigns on improved dietary culture and promoting outdoor activities are crucial in addressing this issue. EBR

12th Year • December 16 2023 – January 15 2024 • No. 124

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