|Ahead of print publication
Evaluation of Vitamin-D, calcium, and phosphorus levels among diabetes mellitus type 2 in malwa belt of Punjab
Sohan Lal Nigah1, Gagandeep Jagota2, Saranpal Singh3, Gitanjali Goyal4
1 Centre for Interdisciplinary Biomedical Research, Adesh University, Bathinda, Punjab, India
2 Centre for Interdisciplinary Biomedical Research, Adesh Institute of Medical Sciences and Research, Adesh University, Bathinda, Punjab, India
3 Department of Biochemistry, Adesh Institute of Medical Sciences and Research, Adesh University, Bathinda, Punjab, India
4 Department of Biochemistry, Guru Gobind Singh Medical College, BFUHS, Faridkot, Punjab, India
|Date of Submission||21-May-2020|
|Date of Decision||19-Jun-2020|
|Date of Acceptance||03-Jul-2020|
Department of Biochemistry, Adesh Institute of Medical Sciences and Research, Adesh University, Bathinda, Punjab
Source of Support: None, Conflict of Interest: None
Background: Type-2 diabetes mellitus (T2DM) or noninsulin-dependent diabetes is an endocrinological disease of impaired metabolism of carbohydrates. T2DM is increasing both nationally and worldwide at an alarming rate. In intermediary metabolism, including enzyme activities, electrical gradients and cellular function Vitamin D, calcium and phosphorus play an important role. Disturbances in the levels of Vitamin D, calcium, and phosphorus were found to be associated with T2DM. The present study is aimed to evaluate the levels of Vitamin D, calcium, and phosphorus levels in 300 patients, of which 150 were nondiabetic healthy individuals (control) and 150 were T2DM patients. Materials and Methods: A volume of 5 ml of the blood sample was taken after 12 h of overnight fasting by complete aseptic means from the antecubital vein with the sterilized disposable syringe for fasting plasma glucose (FPG), postprandial plasma glucose (PPPG), glycated hemoglobin, serum 25 hydroxy (OH) Vitamin D (25[OH]D), calcium, and phosphorus. Results: Of 150 type-2 diabetic and 150 nondiabetic group, there was a significant statistical difference between the diabetic and nondiabetic group for FPG (P < 0.001), PPPG (P < 0.001), 25(OH) D (P < 0.001), calcium (P < 0.001), and phosphorus (P < 0.001). 25(OH) D, calcium, and phosphorus levels were decreased in T2DM patients as compared to the control group. Conclusion: This study revealed that there is a significant decrease in the levels of Vitamin D, calcium, and phosphorus in Type-2 diabetic patients, which may be an important factor in the early onset of the disease in susceptible individuals.
Keywords: 25 hydroxy Vitamin D, calcium and phosphorus, Type-2 diabetes mellitus
|How to cite this URL:|
Nigah SL, Jagota G, Singh S, Goyal G. Evaluation of Vitamin-D, calcium, and phosphorus levels among diabetes mellitus type 2 in malwa belt of Punjab. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 Dec 6]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=321338
| Introduction|| |
The incidence of diabetes mellitus Type 2 (T2DM) is increasing at an alarming rate; the significant increase in the number of people with diabetes will be in India. Most of the expected population growth between 2000 and 2030 will be concentrated in the urban areas of the world. The total number of people with diabetes is projected to rise from 171 million in 2000 to 366 million in 2030. In developing countries, the majority of people with diabetes are in the age group of 45–64 years, in contrast: the majority of people with diabetes in developed countries are >64 years of age. By 2030, it is estimated that the number of people with diabetes >64 years of age will be >82 million in developing countries and >48 million in developed countries.
Diabetes mellitus 2 is the endocrine disease characterized by hyperglycemia due to progressive failure of pancreatic cells in a setting of chronic insulin resistance. In experimental studies, calcium and Vitamin D have been shown to improve pancreatic beta-cell function and peripheral insulin sensitivity, whereas low Vitamin D status is associated with markers of impaired glucose metabolism, and insulin resistance. In recent decades, insulin resistance and secretion have been shown to depend on calcium and Vitamin D homeostasis. Insulin secretion is a calcium-dependent process requiring the influx of calcium to the beta-cell.,
The phosphate lowering action of insulin was recognized immediately after insulin preparations became available. There is a close correlation between the plasma concentration of phosphorus and the degree of metabolic control of diabetes. Various studies have shown great interest in low phosphorus diet on glucose homeostases such as insulin resistance and glucose tolerance. The main question is whether diabetes state had an impact on Vitamin D, calcium, and phosphorus. Therefore, the main aim of this study is to assess, is there any differences of serum Vitamin D, serum calcium and serum phosphorus value of diabetics versus nondiabetic persons and to find out the correlation of serum Vitamin D, serum calcium, and serum phosphorus with some biochemical parameters in two groups.
| Materials and Methods|| |
Study group (inclusion criteria)
The present study was a comparative case–control study conducted at a tertiary care hospital from March 2018 to March 2019 in the Department of Biochemistry, Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences Faridkot, Punjab in collaboration with Department of Medicine, Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences Faridkot, Punjab. The minimum sample size for each group has been calculated using the formula: N = (1 + 1/k) [σ(Z1−α/2 + Z1−β) 2/(ua − ub)]. Assuming equal group sizes to achieve a power of 80% and a (two sided) confidence level of 90%, the study requires a sample size of 99 for each group. Therefore, 150 diagnosed cases of T2DM of age group 30–60 years and 150 age- and sex-matched healthy individuals were recruited as a control group in the study. This study was conducted after taking the institutional approval by the ethical committee of Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences Faridkot, Punjab (Ref. no. GGS/IEC/18/82, dated February 15, 2018) and after obtaining written consent from all the patients.
Patients of T2DM with other complications such as chronic liver disease, chronic kidney disease, or patient taking drugs affecting Vitamin D metabolisms such as rifampicin, isoniazid, ketoconazole, and phenytoin or patients taking Vitamin D therapy were excluded from the study. Pregnant women, type-1 diabetes mellitus, and hypertension patients were also excluded from the study.
A sample of 5 ml venous blood was collected in both fasting and postprandial state under aseptic precautions out of it 3 ml of blood was poured in plan sterilized vial and allowed it to clot at room temperature for half an hour. Serum was separated by centrifugation process at 3000 revolutions per minute for 10 min, and it was utilized for the estimation of serum 25-hydroxy Vitamin D (25[OH] D), serum calcium, and serum phosphorus.
For the investigation of fasting plasma glucose (FPG), 2 ml of blood was poured in sugar vial containing an anticoagulant (sodium fluoride and potassium oxalate). In addition, postprandial plasma glucose (PPPG) was measured, 2 h after meals (75 g of glucose in a glass of water) by using standard kits. Serum 25(OH) D was estimated with the ELISA method. Estimation of serum calcium was done with Arsenazo 111 method/cresalphthalein complexions method. Estimation of serum phosphorus with Molybdate U. V. method. FPG and 2-h PPPG were measured using enzymatic methods (GOD-POD). Weight and height were measured, and body mass index (BMI) was calculated by dividing weight (kg) by the square of height (m). The study was conducted after the institutional approval by the ethical committee of Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences Faridkot, Punjab (Ref. No. GGS/IEC/18/82 dated February 15, 2018) after obtaining written consent from all the patients.
Data were expressed in terms of mean ± standard deviation (SD). The independent t-test was used to determine the significance of any baseline differences between groups and Pearson correlation was calculated using the expression. The data were analyzed with excel software version 12. Values of P < 0.05 were assumed to be significant (P < 0.05).
| Results|| |
This was a case–control study conducted on 150 cases of T2DM (n = 150) and 150 age- and sex-matched healthy controls (n = 100) [Table 1] provides a summary of the demographic characteristics of the study population (n = 300). The majority of the study population were female (56.0%) and belonged in the age group of 51–60 years. Results showed no significant difference in sex, age, area, and BMI between nondiabetic healthy individuals and T2DM patients. The results were expressed as mean ± SD. There was a statistically highly significant difference (P < 0.001) in age, BMI, FPG, PPPG, glycated hemoglobin (HbA1c), serum Vitamin D, calcium, and phosphorus levels [Table 2]. Results showed statistically significant difference (P < 0.05) in BMI, and nonsignificant difference (P > 0.05) in age, FPG, PPPG, HbA1c, serum Vitamin D, calcium and phosphorus levels between Type-2 diabetic male and Type-2 diabetic female [Table 3]. The levels of serum Vitamin D, serum calcium, and serum phosphorus were nonsignificantly lower, and levels of age, BMI, FPG, PPPG, and HbA1c were nonsignificantly higher in Type-2 diabetic female than in Type-2 diabetic male [Table 3].
|Table 1: Demographic Information of nondiabetic healthy individuals (control) and Type-2 diabetic mellitus patients (cases)|
Click here to view
|Table 2: Comparison of age, fasting plasma glucose, postprandial plasma glucose, serum Vitamin D, serum calcium and serum phosphorus in nondiabetic healthy individuals and Type-2 diabetic mellitus patients|
Click here to view
|Table 3: Comparison of age, fasting plasma glucose, postprandial plasma glucose, serum Vitamin D, serum calcium, and serum phosphorus in Type 2 diabetic individuals|
Click here to view
There was a positive correlation between age, BMI, FPG, PPPG, and HbA1c, and age, BMI, FPG, PPPG, HbA1c was negatively correlated with serum Vitamin D, calcium and phosphorus levels [Table 4]. Results of the present study showed an increased deficiency of serum levels of Vitamin D, calcium, and phosphorus in Type-2 diabetic females than in Type-2 diabetic males, but the difference was statistically nonsignificant (P < 0.05) [Table 5]. The study also showed an increased deficiency of serum levels of Vitamin D, calcium and phosphorus in normal healthy females than in normal healthy males, but the difference was statistically nonsignificant (P < 0.05) [Table 6].
|Table 4: Correlation of fasting plasma glucose, postprandial plasma glucose, serum Vitamin D, serum calcium, and serum phosphorus in Type-2 diabetic individuals and normal healthy individuals|
Click here to view
|Table 5: Variation in serum Vitamin D, serum calcium, serum phosphorus levels among Type-2 diabetic individuals|
Click here to view
|Table 6: Variation in serum Vitamin D, serum calcium, serum phosphorus levels among normal healthy individuals|
Click here to view
Comparison of FPG, PPPG, HbA1c, S. VIT D, S. CAL, S. PHOS levels of diabetic individuals distributed according to BMI was carried out, and there was a significant difference in FPG, PPPG, HbA1c, S. PHOS levels and nonsignificant difference in S. VIT D, S. CAL levels [Table 7]. The present study showed the comparison of FPG, PPPG, HbA1c, S. CAL, S. PHOS levels of male and female diabetic individuals distributed according to S. VIT D levels and there was a significant difference in FPG, PPPG, HbA1c, S. VIT D, S. CAL levels and nonsignificant difference in S. PHOS levels [Table 8] and [Table 9].
|Table 7: Comparison of fasting plasma glucose, postprandial plasma glucose, glycated hemoglobin, serum Vitamin D, serum calcium, serum phosphorus levels of diabetic individuals distributed according to body mass index|
Click here to view
|Table 8: Comparison of fasting plasma glucose, postprandial plasma glucose, glycated hemoglobin, serum calcium, serum phosphorus levels of female diabetic individuals distributed according to serum Vitamin D levels|
Click here to view
|Table 9: Comparison of fasting plasma glucose, postprandial plasma glucose, glycated hemoglobin, serum calcium, serum phosphorus levels of male diabetic individuals distributed according to serum Vitamin D levels|
Click here to view
| Discussion|| |
The present study showed that the prevalence of T2DM was more frequent in females 56.0% than males 44.0%; this finding agreed with a previous study done by Marwa et al. in which prevalence of T2DM in females was 63% than males, i.e., 37%. Furthermore, the present study showed that obesity was more common in T2DM females 28.6% than in T2DM males 25.7% this result agreed with a previous study done by McCord et al. and Marwa et al. who stated that the obesity effect women more than men., The present study showed that Vitamin D deficiency was more frequent in T2DM females 79.7% than males 71.2% this finding confirmed by Arif et al. 2017 who reported that T2DM female were four times more prone for Vitamin D deficiency than males 151 (79%) and 40 (21%), respectively. Vitamin D levels of patients were found to be in the range of 2.25–55.13 while that of controls were in the range of 1.51–71.0 ng/ml which slightly varies from a study conducted by Bayani et al., in which mean concentration of Vitamin D in the case group was 18.7 ± 10.2 and in the control group was 24.6 ± 13.5 ng/dl. The results showed that Vitamin D concentration was significantly lower in Type-2 diabetic patients than the healthy individuals, which was supported by several workers in the previous studies by Pittas et al. 2010, Anderson et al. 2010, and Knekt et al. 2008.,,
Another important finding was the significant negative association of Vitamin D level with age in diabetic patients (r = −0.145, P = 0.001), which was consistent with the study by Hagenau et al. 2009. Hagenau et al. 2009 showed, serum 25(OH) D levels varied with age. Serum calcium levels in patients were found to be in the range of 7.20–11.40 mg/dl, while the range of serum calcium concentration in the healthy individuals under study was 7.0–10.80 mg/dl. Thus, serum calcium concentration was significantly lower in patients as compared to controls. In this study, there was a significant difference in serum Vitamin D, calcium, and phosphorus levels between Type-2 diabetic and nondiabetic individuals.
Serum phosphorus levels in patients were found to be in the range of 2.8–6.0 mg/dl, whereas the range of serum phosphorus concentration in the healthy individuals understudy was 2.4–10.80 mg/dl. Thus, serum phosphorus concentration was also comparatively lower in patients as compared to controls with P value 0.001 at (P < 0.05). Serum phosphorus levels were higher in both male diabetic patients as well as in normal male healthy controls under study (P < 001) with higher serum Vitamin D levels but no difference in the case of female patients. Our results were the same as studies of Raab et al., Al-Shoumer et al., and Bierschenk et al., which revealed T2DM patients as compared to nondiabetic individuals have lower serum Vitamin D concentrations.,, In this study, the mean of Vitamin D in the individual with and without diabetes showed the presence of Vitamin D deficiency in both groups. However, differences in results as compared to other studies may be related partly to the high prevalence of Vitamin D deficiency in both groups. Several factors potentially influence on Vitamin D status, such as adiposity, genetic factors, and issues that have an effect on the cutaneous synthesis of Vitamin D such as season, skin pigmentation, melanin concentration, age, clothes, and consumption sunscreens Gaafar and Badr 2013. It seems that these results are due to imperfect exposure to sunlight, and little seafood ingestion possibly influenced Vitamin D status in these groups. The change in Vitamin D status with age probably might be the result of a lack of sunlight exposure related to social factors, supplementation intake, and physical inactivity.
The study concluded that there was a significant difference in serum 25(OH) D, calcium, and phosphorus levels between Type-2 diabetic patients and the control group. There appears to be a relationship between Vitamin D, phosphorus, and calcium status in T2DM. This study suggests that deficiency of Vitamin D influences postprandial glycemia and insulin response, as Vitamin D is needed for the release of insulin from the beta cells of islet of Langerhans of the pancreas it may be playing a role in the development of diabetes.
| Conclusion|| |
The decreasing levels of serum Vitamin D, calcium, and phosphorus may influence glycemia. The assessment of serum Vitamin D, calcium, and phosphorus levels are important to monitor the prognosis of T2DM. As Vitamin D, calcium and phosphorus levels were inversely associated with the development of T2DM and maybe with combined nutrients, glucose metabolism can be beneficial.
The help provided by the Chairperson, Dr. Ram Gopal Saini, Centre for Interdisciplinary Biomedical Research, Adesh University, is gratefully acknowledged.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Tabish SA. Is diabetes becoming the biggest epidemic of the twenty-first century? Int J Health Sci 2007;1:V.
Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030. Diabetes Care 2004;27:1047-53.
Gan D. Diabetes Atlas. Belgium: International Diabetes Federation; 2003.
American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2014;37 Suppl 1:S81-90.
Association AD. 1. Improving care and promoting health in populations: Standards of medical care in diabetes-2020. Diabetes Care 2020;43:S7-13.
Kirii K, Mizoue T, Iso H, Takahashi Y, Kato M, Inoue M, et al
. Japan public health center-based prospective study Group. Calcium, Vitamin D and dairy intake in relation to type 2 diabetes risk in a Japanese cohort. Diabetologia 2009;52:2542-50.
Kositsawat J, Freeman VL, Gerber BS, Geraci S. Association of A1C levels with Vitamin D status in U.S. adults: Data from the National Health and Nutrition Examination Survey. Diabetes Care 2010;33:1236-8.
Forouhi NG, Luan J, Cooper A, Boucher BJ, Wareham NJ. Baseline serum 25-hydroxy Vitamin D is predictive of future glycemic status and insulin resistance: The Medical Research Council Ely Prospective Study 1990-2000. Diabetes 2008;57:2619-25.
Teegarden D, Donkin SS. Vitamin D: Emerging new roles in insulin sensitivity. Nutr Res Rev 2009;22:82-92.
Pittas AG, Lau J, Hu FB, Dawson-Hughes B. The role of Vitamin D and calcium in type 2 diabetes. A systematic review and meta-analysis. J Clin Endocrinol Metab 2007;92:2017-29.
Ko SH, Lee GS, Vo TT, Jung EM, Choi KC, Cheung KW, et al
. Dietary calcium and 1,25-dihydroxyvitamin D3 regulate transcription of calcium transporter genes in calbindin-D9k knockout mice. J Reprod Dev 2009;55:137-42.
Bayani MA, Akbari R, Banasaz B, Saeedi F. Status of Vitamin-D in diabetic patients. Caspian J Intern Med 2014;5:40-2.
Al-Timimi DJ, Ali AF. Serum 25(OH) D in diabetes mellitus type 2: Relation to glycaemic control. J Clin Diagn Res 2013;7:2686-8.
Janssen JW, Helbing AR. Arsenazo III: An improvement of the routine calcium determination in serum. Eur J Clin Chem Clin Biochem 1991;29:197-201.
Berti G, Fossati P, Melzi d'Eril GV, Tarenghi G, Musitelli C. Enzymatic colorimetric assay of inorganic phosphate. Clin Chem 1987;33:312.
Hollis BW. Assessment of circulating 25(OH) D and 1,25(OH) 2D: Emergence as clinically important diagnostic tools. Nutr Rev 2007;65:S87-90.
Marwa AT, Amar M. Evaluation of calcium, phosphorus and magnesium level among Vitamin D deficient diabetes mellitus patients in Khartoum state. Sch. Bull 2015;1:235-41.
McCord J, Mundy BJ, Hudson MP, Maisel AS, Hollander JE, Abraham WT, et al
. Relationship between obesity and B-type natriuretic peptide levels. Arch Intern Med 2004;164:2247-52.
Arif MJ, Gupta SK, Al Khalifah F. Prevalence of Vitamin D deficiency and its associated disorders at a tertiary care hospital of the Al qassim region of Saudi Arabia. Natl J Community Med 2017;11:654-7.
Pittas AG, Sun Q, Manson JE, Dawson-Hughes B, Hu FB. Plasma 25-hydroxyvitamin D concentration and risk of incident type 2 diabetes in women. Diabetes Care 2010;33:2021-3.
Anderson JL, May HT, Horne BD, Bair TL, Hall NL, Carlquist JF, et al
. Relation of Vitamin D deficiency to cardiovascular risk factors, disease status, and incident events in a general healthcare population. Am J Cardiol 2010;106:963-8.
Knekt P, Laaksonen M, Mattila C, Härkänen T, Marniemi J, Heliövaara M, et al
. Serum Vitamin D and subsequent occurrence of type 2 diabetes. Epidemiology 2008;19:666-71.
Hagenau T, Vest R, Gissel TN, Poulsen CS, Erlandsen M, Mosekilde L, et al
. Global Vitamin D levels in relation to age, gender, skin pigmentation and latitude: An ecologic meta-regression analysis. Osteoporos Int 2009;20:133-40.
Raab J, Giannopoulou EZ, Schneider S, Warncke K, Krasmann M, Winkler C, et al
. Prevalence of Vitamin D deficiency in pre-type 1 diabetes and its association with disease progression. Diabetologia 2014;57:902-8.
Al-Shoumer KA, Al-Asoosi AA, Ali AH, Nair VS. Does insulin resistance in type 2 diabetes alter Vitamin D status? Prim Care Diabetes 2013;7:283-7.
Bierschenk L, Alexander J, Wasserfall C, Haller M, Schatz D, Atkinson M. Vitamin D levels in subjects with and without type 1 diabetes residing in a solar rich environment. Diabetes Care 2009;32:1977-9.
Gaafar M, Badr S. An alarming high prevalence of Vitamin D deficiency among healthy adults. Life Sci J 2013;10:3292-8.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]