• Users Online: 119
  • Print this page
  • Email this page


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 5  |  Issue : 2  |  Page : 135-138

Assessment of serum Vitamin D level in patient of mild to moderate asthma


1 Associate professor, Dept. of Physiology, IGIMS, Patna, Bihar, India
2 Additional professor & HOD, Dept. of Biochemistry, IGIMS, Patna, Bihar, India
3 Professor & HOD, Dept. of Physiology, IGIMS, Patna, Bihar, India
4 Additional Professor, Dept. of TB & chest, IGIMS, Patna, Bihar, India

Date of Submission26-Jun-2019
Date of Acceptance20-Jul-2019
Date of Web Publication20-Nov-2020

Correspondence Address:
Rekha Kumari
Additional professor & HOD, Dept. of Biochemistry, IGIMS, Patna, Bihar
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


Rights and PermissionsRights and Permissions
  Abstract 


Background: Asthma is one of the most common chronic disease affecting millions of population worldwide. It is a chronic respiratory disease characterized by increased airway inflammation and hyper-responsiveness. Several studies shows that deficiency of Vitamin D (25-OH) is related to occurrence of pulmonary diseases as well as reduced lung function and increased airway inflammation leading to poor results in asthmatic patients. In context to India, there were fewer studies which have evaluated the relationship between vitamin D (25- OH) and pulmonary function and its role in asthma. Thus, the present study was undertaken to study the role of vitamin D deficiency or insufficiency in mild to moderate asthmatic patients.
Aims: To assess the serum vitamin D(25-OH) level in mild to moderate asthmatic patients.
Material & Methods: The present study included 100 subjects of either sex with age group of 15 - 40 years. They were divided into two groups. Group A (control) include 40 healthy individual, and Group B include 60 asthmatic patients based upon GINA guidelines. Pulmonary function test and Vitamin D analysis were performed in both the groups.
Results: The study showed that serum vitamin D level was significantly decreased in asthmatic patients when compared with the control group (p<0.01).
Conclusion: Vitamin D deficiency is relatively frequent in asthmatic patients and there is a significant inverse relationship between serum vitamin D and severity of asthma symptoms. Therefore, measuring serum levels of vitamin D should be considered in the routine assessment of asthmatic patients. It may serve as a marker of asthma severity.

Keywords: Asthma, vitamin D deficiency


How to cite this article:
Sunita, Kumari R, Sharan A, Shankar M. Assessment of serum Vitamin D level in patient of mild to moderate asthma. J Indira Gandhi Inst Med Sci 2019;5:135-8

How to cite this URL:
Sunita, Kumari R, Sharan A, Shankar M. Assessment of serum Vitamin D level in patient of mild to moderate asthma. J Indira Gandhi Inst Med Sci [serial online] 2019 [cited 2021 Oct 26];5:135-8. Available from: http://www.jigims.co.in/text.asp?2019/5/2/135/301097




  Introduction: Top


Asthma is one of the most common and major public health problem affecting millions of population worldwide. It is a complex heterogeneous disorder with respect to immunopathology, clinical phenotypes and response to therapies[1]. It is characterized by chronic airway abnormalities such as airway hyper-responsiveness, airway remodelling and infiltration of eosinophils and T-helper type2(Th2) cells in the airway sub-mucosa, which leads to inflammation and edema in the bronchial mucosa and hyper-secretion of mucus[2].

Although the role of Vitamin D in bone health is well established but recently the effects of vitamin D on asthma have gained much attention due to its anti -inflammatory and immunomodulatory effects. Findings from many studies have indicated that vitamin D may act on structural cells of the airways regulating cell proliferation and differentiation as well as both innate and adaptive immune systems of the cells. Therefore its deficiency promotes inflammation. [3],[4],[5]

Prolonged breastfeeding without vitamin D supplementation, maternal vitamin D deficiency, poor diet and limited sunshine exposure have been suggested as major contributors to vitamin D deficiency.[6],[7]

Several studies shows that vitamin D deficiency (< 20 ng/mL) and its insufficiency (< 30ng/ml) is related to occurrence of pulmonary diseases including bacterial and viral infections as well as reduced lung function and increased airway inflammation leading to poor results in asthmatic patients[6],[7],[8],[9]. But results obtained from clinical trials are also not conclusive and do not provide supportive information about positive role of Vitamin D on asthma.

In context to India, there were fewer studies which have evaluated the relationship between vitamin D and pulmonary function and its role in asthma. Thus, the present study was undertaken to study the role of vitamin D deficiency or insufficiency in mild , moderate and severe Asthma.

The aim of this study was to examine whether there were any differences in serum vitamin D levels between asthmatic and non-asthmatic healthy subjects and to test for any associations between vitamin D deficiency and severity of asthma .


  Objective : Top


To assess the serum 25(OH) D level in mild, moderate and severe asthmatic patients.


  Methods: Top


This is a cross-sectional observational study carried out at IGIMS, PATNA after being approved by institutional ethical committee.

The present study included 100 subjects, of either sex with age group of 15 - 40 years. They were divided into two groups.

Group A (control) include 40 healthy individual, age and sex matched with the study group.

Group B include 60 asthmatic patients. They were further divided into three subgroups (A,B,C) depending upon FEV1% and severity of symptoms (according to the global initiative for asthma GINA guidelines)10

Subgroup A: Mild asthma. (FEV1 > 80%).

Subgroup B: Moderate asthma. (FEV1 = 60 - 80 %)

Subgroup C: Severe Asthma ( FEV1= < 60 %)

Subjects with past history of pulmonary illness, cardiovascular disease, any systemic pathology affecting the respiratory system, significant neuromuscular disorder, any history of recent abdominal and thoracic surgery, smokers and those receiving medications having potential effect on serum 25(OH)D level were excluded from the study.

Study Design: Cross sectional study

Study participant: Patients attending Pulmonary Medicine OPD and PFTlab in the Department of Physiology, IGIMS, Patna.

A written informed consent was taken from all the participants of the study prior to their inclusion. All the patients participating in the study were subjected to clinical history taking including medications. They underwent complete systemic examination.

Pulmonary Function Test:

PFT were performed in both the groups using computerized spirometer, Spiro Excel of Medicaid system Pvt. Ltd. in the Department of Physiology, IGIMS, Patna. Subject from both the group was asked to visit the department between 9AM to 10AM to mitigate the effect of diurnal variation[13]. For this study parameters included was FVC, FEV1, FEV1/FVC and MVV. The subjects were instructed to inhale and exhale forcefully and maximally and then after taking a forced inspiration they were asked to expire forcibly into the nozzle of the machine. This test was repeated 2 to 3 times and the best value was recorded. For MVV, the subjects were asked to inhale and exhale as deep and fast as possible over a period of 12 seconds during which recordings was done.

Vitamin D analysis: vitamin D was analysed by chemiluminescence immunoassay (Access 2 , Make - Beckman Coulter ) in the Department of Biochemistry, IGIMS, Patna.

Serum Calcium and Magnesium were measured spectrophotometrically using AU400 fully automated analyser and reagents from Diasys and Kopran companies respectively.

Serum ALP was measured by IFCC method with a Beckman AU 400 fully automated chemistry analyser.


  Results: Top


There was no significant difference in the demographic profile (age, sex and BMI) between asthmatic and control group.

[Table 1] shows serum Vit D levels in mild, moderate and severe asthmatic group i.e., 32.6±5.1 ng/ml, 22.32±7.6 ng/ml and 18.78±6.9ng/ml respectively. The difference of means was significant (p<0.01).
Table 1: Comparison of S. 25(OH)D, Ca2+, ALP & Mg2+ in different asthmatic groups

Click here to view


[Figure 1] clearly shows that serum levels of 25(OH)D decreases with the increase in disease severity as their levels are highest in mild form of asthma while lowest in severe asthma.
Figure 1: Comparison between Serum Vit D level among mild, moderate, severe asthamatics

Click here to view


There was no significant difference in serum calcium levels between asthmatic patients (9.42 ± 0.09 mg/dL) and controls (9.52 ± 0.08 mg/dL). They remain unaffected by decrease in vitamin D levels and hence they do not affect the severity of asthma (P = 0.61).

[Table 1] shows the serum levels of Alkaline phosphatase in different grades of Asthma. It was highest in severe asthmatics group 248±16.9mg /dl and was lowest in mild asthmatics group 80.26±7.2 mg /dl. This difference was statistically significant (p=0.01)

The mean serum Mg level (mg/dl) was 1.82 ±0.09, 1.68 ± 0.1, and 1.51 ± 0.07 in mild, moderate and severe asthmatic groups, respectively. (p<0.001)

Statistical study

All data were expressed as mean ± standard deviation (SD). To compare between variables of three or more groups ANOVA test was used. The analysis was performed using SPSS 17.


  Discussion: Top


Being a tropical country, Vitamin D deficiency is supposed to be uncommon in India[11]. However from the data available in published literature vitamin D deficiency is very common in India in all the age groups and both the sexes across the country[12][13][14].

The reasons for widespread vitamin D deficiencies in various populations are not completely understood. However, Webb et al reported that the major determinants contributing in vitamin D deficiency include less exposure to sun and time spent outdoors, less dietary intake, season, age, skin colour and skin coverage, resulting in a predisposition to the development of allergic diseases including asthma[15]. It is known that cutaneous synthesis of vitamin D is dramatically reduced amongst individuals who spend time in- doors and those who use protective clothing and sunscreen against ultraviolet radiation (sunlight).

For this reason, vitamin D deficiency has been documented in many populations around the world regardless of the degree of sun exposure 16 and is more common in India too. Till date, very few Indian studies have directly evaluated the role of vitamin D in asthma.

In our study, the mean levels of serum vitamin D in asthmatic patients are; mild Asthma:32.6±11.05ng/ml, moderate Asthma: 22.32 ±7.60ng/ml and severe asthma: 18.48±6.9ng/ml; p value of < 0.01 which is statistically significant. This means that higher the level of serum vitamin D, the lesser the degree of bronchial asthma severity. Our finding is also in accordance with the work conducted by Litonjua et al.[17], who proved that low vitamin D levels were associated with worse bronchial asthma symptoms and poorer lung function measures. Thus our study demonstrated a significant positive association between serum vitamin D levels and the severity of asthma.

A similar cross sectional study conducted by Somashekar et al on 44 asthmatic children in Bangalore, India shows concordant results[18]. They concluded that 68.18% of the asthmatic children had deficient serum vitamin D levels (<15ng/mL) and 31.28% of them had insufficient serum vitamin D levels (>15ng/mL to <20ng/mL) that is 100% of asthma children have deficient serum vitamin D level.. Similarly Bener et al.[19] and Columbo et al[20] reported the prevalence of vitamin D deficiency in asthmatic patient and concluded that vitamin D is strong predictor of asthma and its deficiency and insufficiency are extremely common in elderly patients with asthma and respiratory disease. Another study by Ginde et al.[21] have presented evidence to show that low vitamin D levels are associated with higher frequency of respiratory tract infections in asthmatic patients and with increased asthma severity. Brehm et al.[22] in their analysis found similar correlation. They found higher prevalence of allergic rhinitis and asthma with vitamin D deficiency.

The possible explanation of the involvement of vitamin D deficiency in the pathogenesis of Asthma could be through several mechanisms. It could be because Vitamin D inhibits the synthesis and releases cytokines which are Th1- associated and some other molecules, like IL17, which lead to decreased inflammation and proliferation of smooth muscle cell[23],[24]. Recent studies have shown that vitamin D deficiency is linked with increased expression of the pro-inflammatory cytokine TNF-a, enhancing a proinflammatory effect in patients with asthma[23],[25]. This vitamin promotes regulatory T cells and also increases synthesis of IL-10, which lead to an inhibition of Th2 responses as well as airway inflammation and airway hyperresponsiveness[23].

Our study also shows the elevated serum levels of Alkaline phosphatase (ALP). It was highest in severe asthmatics group 248±16.9 mg /dl and was lowest in mild asthmatics group 80.26±7.2 mg /dl. This difference is statistically significant [p=0.01]. This could be explained as, vitamin D deficiency causes secondary hyperparathyroidism leading to increase turnover of osteoid tissue and elevated serum levels of alkaline phosphatase.[26]

In the current study asthmatic patients had decreased serum levels of magnesium than controls. Causes of magnesium deficiency in asthma may be multifactorial. It may be genetically determined or may be due to low magnesium intake in asthmatic or increased urinary loss of magnesium as a side-effect of therapy with ß2-agonist, corticosteroid, and theophylline.[25],[26]


  Conclusion: Top


The present study suggests that vitamin D deficiency is relatively frequent in asthmatic patients and there is a significant inverse relationship between serum vitamin D, Magnesium level and severity of asthma symptoms. Therefore, measuring serum levels of vitamin D and magnesium should be considered in the routine assessment of asthmatic patients. It may serve as a markers of asthma severity.

A closed attention to vitamin D levels should be given to allergic patients so that it can be used as an adjuvant therapy for the treatment of asthma.


  Limitation: Top


  1. The sample size was relatively small (n =100).


  2. (A larger sample size would have increased our statistical power to detect associations.)

  3. Design was cross-sectional,


  4. (This limits our ability to establish a causal link between vitamin-D and asthma severity.)

  5. Even though there is a strong relation of lung function and 25(OH) D level, we could not establish a direct mechanistic link between vitamin D deficiency and asthma .
  6. We cannot exclude many confounding factors including atopy, outdoor activities, asthma medication, seasonal variation, dietary intake that can affect vitamin-D levels or asthma severity.


Long-term follow-up studies focusing on changes in vitamin-D status and asthma parameters will be needed to elucidate the effect of vitamin-D status on asthma.



 
  References Top

1.
Holgate ST. Pathogenesis of Asthma. Clin Exp Allergy. 2008;38(6):872-97.  Back to cited text no. 1
    
2.
National Asthma Education and Prevention Program TEP on the D and M of A. Expert panel report 3: Guidelines for the diagnosis and management of asthma [Internet]. U.S. department of Health and Human Services; 2007 Aug. Available from: http://www.ncbi.nlm.nih.gov/books/NBK7223/.  Back to cited text no. 2
    
3.
Kerley CP, Elnazir B, Faul J, et al. Vitamin D as an adjunctive therapy in asthma. Part 2: A review of human studies. Pulm Pharmacol Ther. 2015; 32: 75-92, doi: 10.1016/j. pupt.2015.02.010, indexed in Pubmed: 25749414  Back to cited text no. 3
    
4.
Hall SC, Fischer KD, Agrawal DK. The impact of vitaminD on asthmatic human airway smooth muscle. Expert Rev Respir Med. 2016; 10(2): 127-135, doi: 10.1586/17476348.2016.1128326, indexed in Pubmed: 26634624.  Back to cited text no. 4
    
5.
Yawn J, Lawrence LA, Carroll WW, et al. Vitamin D for the treatment of respiratory diseases: is it the end or just the beginning? J Steroid Biochem Mol Biol. 2015; 148: 326-337, doi: 10.1016/j. jsbmb.2015.01.017, indexed in Pubmed: 25625665.  Back to cited text no. 5
    
6.
Thacher TD, Clarke BL. Vitamin D insufficiency. Mayo ClinProc. 2011; 86(1): 50-60, doi: 10.4065/mcp.2010.0567, indexed in Pubmed: 21193656.  Back to cited text no. 6
    
7.
Bozzetto S, Carraro S, Giordano G, et al. Asthma, allergy and respiratory infections: the vitamin D hypothesis. Allergy. 2012; 67(1): 10-17, doi:10.1111/j.1398-9995.2011.02711.x, indexe in Pubmed: 21933195.  Back to cited text no. 7
    
8.
Gupta A, Bush A, Hawrylowicz C, et al. Vitamin D and asthmain children. Paediatr Respir Rev. 2012; 13(4): 236-43; quiz243, doi: 10.1016/j.prrv. 2011.07.003, indexed in Pubmed: 23069123.  Back to cited text no. 8
    
9.
Gomez AC, Naves DM, Rodriguez GM, Fernandez Martin JL, Cannata Andia JB. [Review of the concept of vitamin D “sufficiency and insufficiency”].Nefrologia %2003 ;23Suppl 2:73 -7 2003  Back to cited text no. 9
    
10.
Global Initiative for Asthma (GINA): Global Strategy for Asthma Management and Prevention; available from: http:// www.ginasthma.org. 2014.  Back to cited text no. 10
    
11.
Hodgkin P, Hine PM, Kay GH, Lumb GA, Stanbury SW. Vitamin-D deficiency in Asians at home and in Britain. Lancet 1973; 92: 167-171.  Back to cited text no. 11
    
12.
revalence of Vitamin D Deficiency among Healthy School Children in Jaipur District, Rajasthan, India. Int J Pediatr, Vol.3, N.4-2, Serial No.20, Aug 2015.  Back to cited text no. 12
    
13.
Khadilkar AV. Vitamin D deficiency in Indian Adolescents. Indian Paediatr 2010; 47:756-757.  Back to cited text no. 13
    
14.
Harinarayan CV, Joshi SR. Vitamin-D status in India: Its implications and remedial measures. J Assoc Physicians India 2009;57:40-48.  Back to cited text no. 14
    
15.
Webb AR. Who, what ,where and when - influences on cutaneous Vitamin D synthesis. Prog Biophys Mol Bio.2006;92:17-25.  Back to cited text no. 15
    
16.
Nesby-O’Dell S, Scanlon KS, Cogswell ME, Gillespie C, Hollis BW, Look AC, et al: Hypovitaminosis D prevalence and determinants among African-American and white women of reproductive age: third National Health and Nutrition Examination Survey, 1988-1994. Am J Clin Nutr 2002; 76: 187-192.  Back to cited text no. 16
    
17.
Litonjua AA, Weiss ST: Is vitamin D deficiency to blame for the asthma epidemic? J Allergy Clin Immunol 2007; 120: 1031-1035.  Back to cited text no. 17
    
18.
A. R. Somashekar,1 Ashwini B Prithvi,2 and M. N. VanithaGowda. Vitamin D Levels In Children with Bronchial Asthma. ClinDiagn Res. 2014 Oct; 8(10): PC04-PC07.  Back to cited text no. 18
    
19.
A. Bener, M. S. Ehlayel, M. K. Tulic, and Q. Hamid, “Vitamin D deficiency as a strong predictor of asthma in children,”International Archives of Allergy and Immunology, vol. 157, no.2, pp. 168-175, 2012.  Back to cited text no. 19
    
20.
M. Columbo, R. A. Panetferi, and A. S. Rohr, “Asthma in the elderly: a study of the role of vitamin D,” Allergy, Asthma and Clinical Immunology, vol. 10, no. 1, article 48, 2014.  Back to cited text no. 20
    
21.
A. A. Ginde, J. M. Mansbach, and C. A. Camargo Jr., “Association between Serum 25-hydroxyvitamin D level and upper respiratory tract infection in the Third National Health and Nutrition Examination Survey,” Archives of Internal Medicine, vol. 169, no. 4, pp. 384-390, 2009.  Back to cited text no. 21
    
22.
J. M. Brehm, J. C. Celed’on, M. E. Soto-Quiros et al., “Serum vitamin D levels and markers of severity of childhood asthma inCosta Rica,”AmericanJournal of Respiratory and Critical Care Medicine, vol. 179, no. 9, pp. 765-771, 2009.  Back to cited text no. 22
    
23.
Sandhu MS, Casale TB. The role of vitamin D in asthma. Ann Allergy Asthma Immunol. 2010; 105:191-199. https://doi.org/10.1016/ j.anai.2010.01.013 PMid:20800785  Back to cited text no. 23
    
24.
Felicia Montero-Arias,Giovanni Sedó-Mejía, Allan Ramos-Esquivel. Vitamin D Insufficiency and Asthma Severity in Adults From Costa Rica. Allergy Asthma Immunol Res. 2013;5(5):283-288. https://doi.org/10.4168/aair.2013.5.5.283 PMid:24003384 PMCid: PMC3756174  Back to cited text no. 24
    
25.
Sutherland ER, Goleva E, Jackson LP, Stevens AD, Leung DY. Vitamin D levels, lung function, and steroid response in adult asthma. Am J Respir Crit Care Med. 2010;181:699-704.  Back to cited text no. 25
    
26.
Mahmoud T. Abd El-Menem, Manal M. Abd Al-Aziz, et al. The frequency of vitamin D deficiency among asthmatic Egyptian children. Egypt J Pediatr Allergy Immunol 2013;11(2):69-73.  Back to cited text no. 26
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction:
Objective :
Methods:
Results:
Discussion:
Conclusion:
Limitation:
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed990    
    Printed22    
    Emailed0    
    PDF Downloaded44    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]