Addressing contemporary health issues in the frame of the European Union and the Eastern Partnership countries

Written by Christos Tsagkaris and Anastasiia Hoian

In order to create effective strategies of solving global healthcare problems, medical researchers and practitioners from different countries have to cooperate by sharing information, using common research methodologies and tools, and addressing health issues in a multinational context, if applicable. Working on global healthcare problems is one of the aims of the European Union and its collaboration with neighboring countries including Ukraine, which belongs to the Eastern Partnership countries.

Among many global health problems, one of the most important is Vitamin D deficiency, which has recently been acknowledged as a pandemic by several researchers (Cashman et al 2017, European Commission, 2015). The Institute of Medicine and the Endocrine Practice Guidelines Committee (IMEPGC) have concluded that serum levels of 25(OH)D3 below 25 ng/ml (<50 nmol/l) are considered to be Vitamin D deficient and below 30 ng/ml (<75 nmol/l) to be Vitamin D insufficient. A level of 25(OH)D3 in serum between 30 ng/ml and 150 ng/ml is considered normal (Povoroznyuk et al, 2018, Hoian et al, 2019). Research around the world has revealed widespread Vitamin D deficiency, including in areas with a high level of exposure to sunlight (insolation), which suggests that the lack of ultraviolet radiation is not the only cause of low Vitamin D levels (European Commission, 2015).

Insufficient levels of Vitamin D may cause many pathological processes in the human body. At the cellular level, Vitamin D is considered as one of the key components of normal cell functioning in the whole organism – as a nutrient, hormone and regulator of functions of the endocrine, cardiovascular, nervous, immune and other systems and organs (Sassi et al, 2018). According to recent research, Vitamin D deficiency is also associated with diabetes mellitus, hypertonic disease, atherosclerosis, obesity, autoimmune thyroiditis and other autoimmune diseases (Sassi et al, 2018, Caccamo et al, 2018). There may also be a connection between Vitamin D deficiency and neurological diseases, such as multiple sclerosis, Parkinson’s disease, and Alzheimer’s disease (Caccamo et al, 2018).

Despite the potential consequences of Vitamin D deficiency, there is still considerable controversy in many countries. Although the IMEPGC definitions of deficiency and insufficiency are widely accepted, many studies adopt different Vitamin D levels as normal on the grounds of potential clinical outcomes, study population and design. Hence, a grey zone appears and people who are supposed to have normal Vitamin D levels in one study appear deficient in another.

Ukraine and Greece share potential causative factors or points of fruitful comparison in this frame. The following comparative approach is encouraged by the framework of the recent directive of the European Food Safety Authority (EFSA) on Vitamin D deficiency (European Food Safety Authority, 2016). It will present evidence from Ukraine and Greece and discuss whether common etiologic (causative) factors, disease prevalence or solutions can arise from such a comparative approach.

This article is set up as a literature review. International and national databases (Pubmed, Scopus) were searched with keywords (Vitamin D, deficiency, epidemiology). Furthermore, peer-reviewed studies that were closely related to the topic were included and studies which were conducted under a conflict of financial or another interest status were excluded.

Vitamin D deficiency in Ukraine

In Ukraine the levels of Vitamin D varied in different parts of the country according to 2013 and this trend seems to be stable. In the East and the West the average was close to 32 nmol/l. It was higher in the North and in the central part of the country with an average of 34 nmol/l whereas the highest levels of Vitamin D were measured in South Ukraine (Povoroznyuk et al, 2012). The average value for the whole country is 34,69±0,56 nmol/l, which is much lower than the normal level (50 nmol/l) (Balatska et al, 2013). The worst average was discovered in the Subcarpathian region, where the serum level of Vitamin D was almost 22 nmol/l. Vitamin D deficiency was established in 89,9% of the population (Hoian et al, 2019).

Old age, obesity, low BMI, female sex and living in the highlands or Northern regions of the country are assumed to be risk factors for Vitamin D deficiency (Balatska et al, 2013, Hoian et al, 2019). Unfortunately, these conclusions have not been proven in all research. Hence the full list of reasons for Vitamin D deficiency is incomplete.

Information regarding illnesses and pathological processes caused by Vitamin D deficiency is poor. A reliable link between Vitamin D levels and bone fracture risk, osteoporosis, osteopenia, and hyperparathyroidism was established in myriad studies (Balatska et al, 2013). The correlation between diabetes mellitus, anemia, autoimmune thyroiditis and cardiovascular problems has not been proved yet.

Vitamin D deficiency in Greece

Vitamin D deficiency in Greece seems to be highly prevalent among a wide range of age groups, from adolescents and pregnant women to elderly people. The prevalence of Vitamin D deficiency varies from study to study and the definition of the deficiency is also ambiguous. Several studies define deficiency of Vitamin D as a serum concentration of less than 50 nmol/L whereas other researchers focus on populations that exhibit Vitamin D serum levels below 22 nmol/L. This opposes the aforementioned definition of the IMEPGC that considered Vitamin D levels lower than 25nmol/L as a deficiency. This is a factor of significant invariability between the existing studies. The same population may exhibit a higher or lower prevalence towards Vitamin D deficiency in two different studies. Future studies, which will avoid these methodological pitfalls, may clarify the current misunderstandings (Papapetrou et al, 2007, Manios et al, 2017).

Several factors have been considered to cause Vitamin D deficiency. Restricted exposure to sunlight due to the use of sunscreen or heavy clothing during the winter months, and the low nutritional intake of Vitamin D, among others, have been greatly discussed (Manios et al, 2017).

As a result, Greece also appears to exemplify the so-called Mediterranean paradox, (Papapetrou et al, 2007) whereby populations suffer from Vitamin D deficiency, despite enjoying a high level of exposure to sunlight throughout the year. Considering the exposure of the Greek population to sunlight, most people are expected to have normal or high levels of serum Vitamin D on the grounds of such environmental features (Manios et al, 2017, Lapatsanis et al, 2005).

In Greece, rickets and osteoporosis appear to be the most common conditions detected in people who are presented with Vitamin D deficiency. A correlation between low Vitamin D levels (hypovitaminosis) and stunted growth retardation, hypercalcemia, sickle cell anemia, polyneuropathy, mental retardation and Multiple Sclerosis (MS) has also been suggested by various studies (Papapetrou et al, 2007, Manios et al, 2017). Vitamin D supplements are prescribed in many cases, including rheumatologic and degenerative diseases such as osteoarthritis. However, many individuals with low Vitamin D serum levels are healthy suggesting that hypovitaminosis is a factor which contributes to the development (pathogenesis) of the aforementioned conditions (Papapetrou et al, 2007, Lapatsanis et al, 2005, Cashman et al, 2016).

Greek and Ukrainian Vitamin D Deficiencies in the EU context

To conclude, Vitamin D deficiency has been acknowledged as a pan-European issue (Cashman et al, 2016), also afflicting Greece and Ukraine. In Greece, the prevalence of Vitamin D deficiency is equal or even higher than the prevalence in other European countries where sunlight exposure is considerably lower and nutritional factors are also not as favorable of an adequate Vitamin D intake (Manios et al, 2017, Cashman et al, 2015, Cashman et al, 2016). In Ukraine, the situation varies between different regions of the country, although a considerable portion of the population has low levels of Vitamin D (Balatska et al, 2013, Povoroznyuk et al, 2012). Tackling the situation in Ukraine and Greece requires a set of effective measures, from screening and monitoring to preventing and treating.

Addressing the problem in the context of this short comparative study it seems that nutritional, as well as cultural factors form a common etiological background. The Western diet has become popular in more countries, restricting the amount of Vitamin D in everyday nutritional intake (Naeem et al, 2010). Population awareness has also been low in recent years (Cashman et al, 2016).

In this context, a solution that would apply to both countries would be related to awareness campaigns, with a particular focus on nutritional factors. Both Ukraine and Greece, as well as any other EU state, can raise awareness on traditional and national diets that ensure a satisfactory intake of Vitamin D throughout the year.

Clear guidelines regarding the administration of Vitamin D supplements should also be addressed in both countries both to avoid excessive use and biased prescription, resulting from the lack of a consistent framework. This is important in correlation to the European commitment to transparency and qualitative healthcare for all member states and states in the European Partnership framework.

So far the EU Commission funded ODIN study, involving research groups from various EU countries has produced a large amount of data from the involved countries. A collaborative culture in research can provide researchers with valuable feedback, decipher unknown aspects of Vitamin D deficiency and hopefully cultivate genuine approaches and solutions (European Commission, 2015).

Christos Tsagkaris is studying Medicine in Greece. He has served in the editorial board of EuroMeds, the magazine of the European Medical Students Association and he has been involved either as a participant or as an organizing committee member in Model European Union simulations. His contributions focus on the intersection of the biomedical field and European affairs, Public Health, Sustainable Development, and Medical Humanities.

Anastasiia Hoian is a medical student from Chernivtsi, Ukraine. Despite the level of science and medicine in Ukraine isn’t so high, she believes in bright future for her country and for her. However, Science is not her only interest. Anastasiia is also the Head of Student Scientific Society and the President of Bukovinian International Medical Congress (BIMCO), which is the biggest scientific conference in Ukraine and Eastern Europe. She furthermore is a poet and considers this as a source of inspiration for writing articles in an evidence-based scientific context.


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