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Key findings:
This study found that COVID-19 patients exhibited significantly lower vitamin D and calcium levels, along with higher BMI, particularly in severe cases. The results indicate that vitamin D insufficiency may be a shared mechanism underlying the adverse impacts of hypocalcemia and obesity on the severity of COVID-19 disease.
What is known and what is new?
The known aspect in this abstract is the reported high incidence of vitamin D deficiency in COVID-19 patients and its potential exacerbating effects on the immune and inflammatory systems. The new contribution lies in the investigation of vitamin D levels in COVID-19 patients, highlighting significant associations with calcium, BMI, and disease severity, shedding light on potential shared pathophysiological mechanisms impacting disease severity.
What is the implication, and what should change now?
The implication of this study is that vitamin D insufficiency may be a key factor in the severity of COVID-19, particularly in relation to hypocalcemia and obesity. Changes needed include considering vitamin D supplementation as a potential therapeutic approach to mitigate the adverse effects of these conditions on COVID-19 severity, especially in high-risk patient populations
Coronavirus Disease 2019 is caused by SARS-CoV-2. The disease began in Wuhan, Hubei Province's capital, and spread globally on 11 March 2020. Due to its rapid proliferation inside and beyond the neighborhood, prevention and control techniques failed. When asymptomatic and infectious, a virus incubates for 2–2 weeks. The severity of the illness by the time symptoms appear might vary from moderate to severe, depending on metabolic conditions such as obesity, diabetes, hypertension, and COPD [1-3]. Immunocompetence concerning both adaptive and innate immunity is influenced by vitamin D. It is generally acknowledged that there is a clear and severe correlation between low vitamin D levels and excess body fat and diabetes mellitus [4]. Several processes, including reduced vitamin D intake via food, decreased physical activity outdoors with less skin exposure to sunshine, and impaired hydroxylation process in adipose tissue, have been proposed to explain these correlations.
Consequently, several studies have shown a significant frequency of vitamin D insufficiency in COVID-19 patients, potentially impacting viral disease and infection symptoms [5]. Obesity has long been associated with a poor outcome for viral infections. Obese people had higher mortality rates and a longer time, more serious clinical course in the 1957-1960 "Asian" and 1968 "Hong Kong" influences; nonetheless, obesity was a risk factor for worse clinical outcomes and death in the 2009 H1N1 pandemic. More recent investigations have demonstrated that obesity is highly related to worse clinical outcomes in COVID-19 disease, regardless of whether no other comorbidities are present [6]. The present study aimed to assess vitamin D levels in COVID-19 patients and their connection to the variables evaluated, which included calcium, body mass index (BMI), and disease severity
Population study 2.1:
Patients admitted to the emergency Tikrit Hospital for COVID-19 were enrolled in this study from 21 June 2021 to 1 December 2021. This study included 60 patients in Tikrit Governorate with COVID-19 virus of both sexes (32 men and 28 females), ranging in age from 20 to 70 years. Patients were separated into two groups based on the ailment's severity. The first group consisted of 20 patients with mild instances of both sexes (13 men and 7 females), ranging in age from 35 to 55. The second group included 40 people with severe diseases affecting both sexes (18 men and 12 females), aged 45 to 70. At the same time, twenty healthy people of both sexes (12 males and 8 females) were chosen as a control group for comparison with the patients. The ethics committee authorized the current research; the study participants were Tikrit Health Department-licensed outpatient medical clinics and those seeking specialized treatments from the clinics.
2.2. Samples Collection:
Serum samples were collected by withdrawing 5 ml of venous blood, transferring it to a gel tube, and incubating it at 37 ° C for 10 minutes. After centrifugation, the serum was removed from the gel tube and frozen at -20 ° C for further analysis.
VaVariables Assay 2.3:
2.3.1 Estimation of Vitamin D Level:
The vitamin D level was determined by Roch Elecsys, offered by Roch Diagnostics. Indianapolis was made in Germany and carried out referring to manufacture instructions followed.
2.3.2 Estimate calcium level:
Calcium has been estimated using the spectrophotometric method using the Bay Labo factory kit.
2.3.3 Assay of Body mass index (BMI) :
It was estimated by dividing the weight (Kg) by the height (m2 ).
2.3.3 Statistical analysis :
Results were analyzed by the SPSS program, version 25. Results studies were expressed as mean ± SD (standard deviation). T-test independent student was used. Also, one one-way ANOVA test was applied to analysis between three groups. The results were considered statistically significant when the value was equal to or less than p 0.05. The correlation between the variables was created using the Pearson relationship [7].
In this prospective trial, sixty participants of both sexes participated. Their ages ranged from 20 to 70 years.
3.2 Vitamin D, calcium, and BMI levels in patients with COVID-19.
As shown in Table 1, patients with COVID-19 had significantly decreased (p≤ 0.0001) levels of vitamin D and calcium when compared to controls (healthy people). These results agree with [8-10].
Furthermore, patients with COVID-19 had increased significantly (p≤ 0.0001) level of BMI when compared to controls. These results agree with [11-13].
Table 1. Compression of the variables studies between patients with COVID-19 and control persons | ||
variables | Cases, Mean± Std. Deviation (SD) | |
Control, (Healthy persons), N = 20 | Patients (COVID-19), N =60 | |
Age (y) | 45±11.56856 | 49.7± 12.7 |
Vitamin D (U/L) | 39.7± 6.4 | ***24.3± 5.2 |
Calcium (mg/ml) | 9.1050± 0.9 | ***7.5± 0.8 |
BMI (Kg/m2) | 26.8± 4.7 | ***32.8±5.7 |
*** refer to significance at the p-value level (p≤ 0.0001).
3. 2 Level of vitamin D in the serum of patients according to disease severity.
As shown in Table 2, the result revealed that the patients with COVID-19 have decreased significantly (p≤ 0.05) the level of vitamin D severe cases when compared with mild cases. While patients with COVID-19 have increased significantly (p≤ 0.0001) BMI in severe cases compared to mild cases. These results agree with [14, 15].
Table 2. C Table 2- Compression of the variables studies between patients with COVID-19 according to the severity of the disease | ||||
variables | Severity of disease | N | Mean | SD |
Age | Mild | 20 | 38.95 | 1.8 |
Sever | 40 | ***55.07 | 1.5 | |
Vitamin D (U/L) | Mild | 20 | 30.01 | 1.09 |
Sever | 40 | ***21.6 | 0.46 | |
Calcium (mg/ml) | Mild | 20 | 10.01 | 2.24 |
Sever | 40 | 7.6191 | 1.12 | |
BMI(Kg/m2) | Mild | 20 | 29.05 | 1.2 |
Sever | 40 | *34.2 | 0.66 | |
*** refer to significantly at the p-value level (p≤ 0.0001); * refer to significantly at the p-value level (p≤ 0.05); SD: Std. Deviation
3.3 Level of vitamin D in the serum of patients according to gender factor.
Moreover, as shown in Table 3, the result revealed non-significant differences between male and female patients in the variable studies, except for the level of vitamin D and the age of patients. These results agree with [16].
Table 3. Compression of the variables studies between patients with COVID-19 according to the gender factor. | ||||
variables | Sex | N | Mean | SD |
Age | Male Patients | 28 | 45.9 | 13.5 |
Female Patients | 32 | *53 | 11 | |
Vitamin D (U/L) | Male Patients | 28 | 26 | 6.1 |
Female Patients | 32 | **22.7 | 3.6 | |
Calcium (mg/ml) | Male Patients | 28 | 7.5 | 0.9 |
Female Patients | 32 | 7.3 | 0.7 | |
BMI(Kg/m2) | Male Patients | 28 | 33.2 | 5.4 |
Female Patients | 32 | 32.4 | 4.1 | |
| ** refer to significantly at the p-value level (p≤ 0.001)* refer to significantly at the p-value level (p≤ 0.05); SD: Std. Deviation. | ||||
3.4 Level of vitamin D in the serum of patients according to age factor.Table 2 shows that the patients with COVID-19 have decreased vitamin D and calcium; these results agree with [17, 18]. While increased significantly in patients at age > 40 compared to patients at age <40. These results agree with [19, 20].
Table 4. Compression of the variables studies between patients with COVID-19 according to the age factor | |||||
variables | Age patients | N | Mean | SD | P-value |
Age | Age at (<40 years) | 13 | 32.5 | 5.4 | 0.0001 |
Age at (>40 years) | 47 | ***54.4 | 9.6 |
| |
Vitamin D (U/L) | Age at (<40 years) | 13 | 30.6 | 4.7 | 0.0001 |
Age at (>40 years) | 47 | ***22.5 | 3.8 | ||
Calcium (mg/ml) | Age at (<40 years) | 13 | 7.9 | 1.0 | 0.05 |
Age at (>40 years) | 47 | *7.3 | 0.7 | ||
BMI(Kg/m2) | Age at (<40 years) | 13 | 29.8 | 5.7 | 0.01 |
Age at (>40 years) | 47 | **33.6 | 4.1 | ||
3.4 Correlation of vitamin D with the variable studies.
Table 5 revealed the correlation of vitamin D with the variable studies.
3.4.1 Correlation of vitamin D with age of patients:
The result shows in Table 5 that there is a negative significant correlation between vitamin D and age for all patients. Moreover, a positive correlation appears between vitamin D and the age of patients in severe cases.
3.4.1 Correlation of Vitamin D activity with the level of calcium:
A positive correlation appears between vitamin D and calcium for all patients. Also, a positive correlation appears between vitamin D and calcium for patients in severe cases.
3.4.2 Correlation of Vitamin D with the BMI and severity:
A positive correlation between Vitamin D and the BMI and severity for all patients appears. While a non-significant positive correlation appears between Vitamin D with the BMI and severity for patients in the mild case, a positive significant correlation appears between Vitamin D with the BMI and severity for patients in the severe case.
| Table 5.Correlation of vitamin D with the variable studies | ||||
| Variables | Correlate of vitamin D with all patients | Correlate of vitamin D with mild patients | Correlate of vitamin D with with severe patients | |
Age | Pearson Correlation | -.600** | -.395 | -0.227 |
Sig. (2-tailed) | 0.000 | 0.085 | 0.160 | |
N | 60 | 20 | 40 | |
Calcium | Pearson Correlation | .339** | 0.24 | 0.428** |
Sig. (2-tailed) | .008 | 0.29 | 0.006 | |
N | 60 | 20 | 40 | |
Severity | Pearson Correlation | -.622-** | 0.34 | 0.68** |
Sig. (2-tailed) | .000 | 0.39 | 0.002 | |
N | 60 | 20 | 40 | |
BMI | Pearson Correlation | -.426-** | -0.17 | -0.59-** |
Sig. (2-tailed) | .001 | 0.46 | 0.000 | |
N | 60 | 20 | 40 | |
**Correlation is significant at the 0.01 level (2-tailed), and the p-value ≤ 0.0001 *Correlation is significant at the 0.01 level (2-tailed) and the p-value ≤ 0.05 | ||||
There is a definite link between vitamin D deficiency and obesity. Obesity has long been recognized as a risk factor for COVID-19 severity [4].A probable link has already been proposed between Vitamin D level, body fat, age, SARS-CoV-2 infection, and COVID-19 severity. Indeed, aging and fat buildup may reduce Vitamin D bioavailability and function.
Our cohort had a relatively high frequency of hypovitaminosis D. A negative connection between BMI and vitamin D levels in COVID-19 patients.[5]
Based on our findings, we may conclude that low levels of vitamin D in obese people are related to worsening COVID-19 and, as a result, impair the prognosis in such patients. In fact, vitamin D may have a preventive impact on obese people by lowering systemic inflammation. Furthermore, Vitamin D has been linked to fat distribution and activity changes. As a result, appropriate Vitamin D levels may also be important in protecting body composition during COVID-19 recovery.
6 Funding: No funding sources.
7. Conflict of interest: None declared.
8. Ethical approval: The study was approved by the Institutional Ethics Committee of University of Mosul.
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