Why Vitamin D deficiency in Lebanon should not be ignored

Despite the abundant sunshine in Lebanon Vitamin D deficiency is surprisingly widespread. This phenomenon has become known as the sunshine paradox. Are we spending less time outdoors?  Do we absorb less Vitamin D than other populations? There appears to be a number of reasons for this deficiency which affects anywhere from 40-80% of the Lebanese population. Based on the collective findings of randomized studies done throughout Lebanon, women had the highest overall deficiency rates. 

Importance of Vitamin D 

Let’s first stress on the significance of this vitamin. Our bodies need Vitamin D, along with calcium to build bones and keep them healthy. But here is the catch: the body can absorb calcium only if it has vitamin D (with the help of Vitamin D the body produces proteins in the gut that transports calcium from the food we eat into the bloodstream). The average healthy person loses about 500 milligrams of calcium every day from bones and replaces it with the same amount of new calcium. When someone is vitamin D-deficient, calcium is not replaced adequately, which leads to weak and fragile bones, that could lead to the bone weakening conditions osteomalacia, osteoporosis and rickets in children.

Vitamin D is not only important for bones and calcium explains endocrinologist Dr. Carole Saba from the Saint Georges Hospital University Medical Center. “It is a misconception to think it’s only for bone density,” says Saba.

Vitamin D is equally important for the immune system function, cardiac function, muscle movement, nerve connections and our brains. It truly is a vital component in order to have a proper functioning body.

Worldwide studies are now also suggesting that low levels of vitamin D could contribute to cancer, multiple sclerosis (MS) and heart and circulatory disease. Research is showing that Vitamin D may play an important role in regulating mood and decreasing the risk of depression. Maybe you have heard of or experienced the “winter blues”? You know that kind of sad feeling for no particular reason which is often attributed to lack of sunlight. 

Lebanese at risk: Women in particular

Low Vitamin D levels affect the entire MENA region, and Lebanon is no exception. One reason is our skin color, specifically those with olive or darker complexion. The darker the skin, the more melanin which acts like a natural sunscreen protecting against UV rays. This ‘protection’ decreases the amount of ultra violet rays that reaches the skin cells responsible for Vitamin D production. This means people with darker skin need more time in the sun than people with lighter skin. In Lebanon multiple factors stack the odds against women. First, you have lower sun exposure due to cultural clothing norm, such as wearing the hijab. Secondly, women have higher BMI (body mass index) on average (vitamin D is fat-soluble and can be hidden in fat tissue) and women who are pregnant/lactating require more Vitamin D. For example, one community study in Lebanon reported that 83.5% of those in the deficient group were female, and severe deficiency (<25 nmol/L) affected ~55% of women vs ~37% of men. Older and specialty cohorts of postmenopausal Lebanese women also showed striking inadequacy rates (~85%). At the same time, newer large lab datasets from Greater Beirut (2013–2022) found men sometimes fared worse, reminding us that urban living, air pollution (pollution blocks UV light), spending more time indoors and other lifestyle shifts can blunt sun-derived vitamin D across both sexes. 

Furthermore, there is a genetic predisposition which maybe affecting Lebanese in particular. In 2023, a National Institute of Health (NIH) funded study on elderly Lebanese was able to link a genetic variant (found in the MGAM and PHF2 genes) that is directly associated with lower 25-hydroxyvitamin D (25(OH)D) levels. The authors of this study showed that polygenic scores derived in Europeans underperform in Lebanese, underscoring population-specific genetic architecture. In other words, some Lebanese individuals may have inherited an increased risk for lower Vitamin D levels. Besides a genetic tendency and lifestyle habits, Saba stresses there could be other more serious health reasons behind it. “The body’s inability to absorb vitamin D could be due to liver, gastrointestinal or bone diseases in some cases,” says Saba. “Always find out the cause of very low Vitamin D, as there may be underlying issues.” 

Prioritizing sun and eating right

Functional Dietician Alexandra Daccache, MSc, first and foremost recommends healthy eating and getting ample sunshine. “Nothing beats sun exposure,” she says. “However, we should make sure not to have vegetable oils in our system to minimize sun oxidation and to choose non peak hours for sunbathing.” As a general rule Vitamin D researchers and experts recommend approximately 5 to 30 minutes of sun exposure preferably daily, which could be done by taking a walk outside between 10:00 a.m. and 4 p.m. Of course, Vitamin D supplements is another option that your health practitioner can assess and safely prescribe for you. For supplementation, Daccache recommends anywhere up to 2,000 IU of Vitamin D per day taken with a main meal and before sunset. “The Vit D should be taken with Vitamin K2 which helps to  keep calcium in your bones and teeth and avoids calcification in other organ systems like your arteries. What’s more, make sure you have enough magnesium to be able to absorb that Vitamin D,” she advises. 

In addition to regular and responsible sun exposure, eating the right foods is equally important. The richest sources of  vitamin D are found in oily fish, such as salmon, sardines, herring, mackerel and canned tuna. Other good sources are cod liver oil, beef liver, egg yolk, and mushrooms (regular and those treated with ultraviolet light). There are food items that come fortified with Vitamin D, such as milk, cereals, yoghurt and orange juice (it is usually mentioned on the packaging), which in Lebanon would be found mostly in imported food products as fortified food is being currently explored in the local food industry but not yet practiced.