25(OH)₂D]; 25-dihydroxyvitamin D [24; 25-hydroxyvitamin D [25(OH)D]; 4; Adolescents; Bone health; Saudi population; Vitamin D metabolite ratio (VMR); Endocrinology, Diabetes and Metabolism; Biochemistry; Molecular Medicine; Molecular Biology; Endocrinology; Clinical Biochemistry; Cell Biology
Abstract :
[en] Vitamin D deficiency is a widespread public health issue among Saudi adolescents, posing significant risks to bone health and long-term well-being. Traditional markers such as serum 25-hydroxyvitamin D [25(OH)D] may not fully capture functional vitamin D status, particularly during critical growth periods such as adolescence. This study aimed to evaluate vitamin D metabolite levels and their association with calcium intake and bone health markers in Saudi adolescents, with a focus on the vitamin D metabolite ratio (VMR) as a potential indicator of functional vitamin D sufficiency. A cross-sectional analysis was conducted involving 949 (54 % females) Saudi adolescents. Serum levels of vitamin D metabolites, including 25(OH)D; 24,25-dihydroxyvitamin D [24,25(OH)₂D], and 25(OH)D₂, were measured using liquid chromatography-tandem mass spectrometry (LC-MS/MS). VMR was calculated as the ratio of 24,25(OH)₂D to 25(OH)D. Dietary calcium intake was assessed via validated questionnaires. Parathyroid hormone (PTH) and serum calcium levels were analyzed in a subset of participants. Vitamin D deficiency was highly prevalent, with 86.5 % of participants showing insufficient 25(OH)D levels. Over 93 % had low 24,25(OH)₂D, 99.7 % had undetectable 25(OH)D₂, and 74.9 % exhibited low VMR. VMR was significantly associated with serum and dietary calcium intake among girls, but not boys, suggesting potential sex-specific metabolic differences. Additionally, only VMR showed a significant association with serum calcium. An inverse association between PTH and both total vitamin D (r = -0.28, p < 0.05) and serum calcium (r = -0.34, p < 0.01) was observed in the subset analysis. In conclusion, VMR may serve as a useful sex-specific biomarker of functional vitamin D status in adolescents. The findings highlight the importance of addressing both intake and metabolic processing of vitamin D to optimize bone health during adolescence.
Disciplines :
Laboratory medicine & medical technology
Author, co-author :
Al-Daghri, Nasser ; Université de Liège - ULiège > Département des sciences de la santé publique > Santé publique, Epidémiologie et Economie de la santé ; Chair for Biomarkers of Chronic Diseases, Department of Biochemistry, College of Science, King Saud University, Riyadh 11451, Saudi Arabia. Electronic address: ndaghri@ksu.edu.sa
Alenad, Amal M; Chair for Biomarkers of Chronic Diseases, Department of Biochemistry, College of Science, King Saud University, Riyadh 11451, Saudi Arabia, Department of Biochemistry, College of Science, King Saud University, Riyadh 11451, Saudi Arabia
Sabico, Shaun; Chair for Biomarkers of Chronic Diseases, Department of Biochemistry, College of Science, King Saud University, Riyadh 11451, Saudi Arabia
Wani, Kaiser; Chair for Biomarkers of Chronic Diseases, Department of Biochemistry, College of Science, King Saud University, Riyadh 11451, Saudi Arabia
Al-Saleh, Yousef; Department of Medicine, Healthoasis Hospital, Riyadh, Saudi Arabia
Khattak, Malak N K; Chair for Biomarkers of Chronic Diseases, Department of Biochemistry, College of Science, King Saud University, Riyadh 11451, Saudi Arabia
Alnaami, Abdullah M; Chair for Biomarkers of Chronic Diseases, Department of Biochemistry, College of Science, King Saud University, Riyadh 11451, Saudi Arabia
Fakhurji, Leena T; Department of Food Science & Nutrition, College of Food & Agriculture Science, King Saud University, PO Box 2460, Riyadh 11495, Saudi Arabia
Alokail, Majed S; Protein Research Chair, Department of Biochemistry, College of Science, King Saud University, Riyadh 11451, Saudi Arabia
Reginster, Jean-Yves ; Université de Liège - ULiège > Département des sciences de la santé publique ; Protein Research Chair, Department of Biochemistry, College of Science, King Saud University, Riyadh 11451, Saudi Arabia
Cavalier, Etienne ; Université de Liège - ULiège > Département de pharmacie > Chimie médicale
Language :
English
Title :
Vitamin D metabolite ratio as a marker of nutritional bone health in adolescents.
Publication date :
03 December 2025
Journal title :
Journal of Steroid Biochemistry and Molecular Biology
Aloia, J., Fazzari, M., Shieh, A., Dhaliwal, R., Mikhail, M., Hoofnagle, A.N., Ragolia, L., The vitamin D metabolite ratio (VMR) as a predictor of functional biomarkers of bone health. Clin. Endocrinol. 86 (2017), 674–679.
Herrmann, M., Farrell, C.-J.L., Pusceddu, I., Fabregat-Cabello, N., Cavalier, E., Assessment of vitamin D status–a changing landscape. Clin. Chem. Lab. Med. (CCLM) 55 (2017), 3–26.
Tang, J.C., Jackson, S., Walsh, N.P., Greeves, J., Fraser, W.D., The dynamic relationships between the active and catabolic vitamin D metabolites, their ratios, and associations with PTH. Sci. Rep., 9, 2019, 6974.
Ginsberg, C., Hoofnagle, A.N., Katz, R., Hughes-Austin, J., Miller, L.M., Becker, J.O., Kritchevsky, S.B., Shlipak, M.G., Sarnak, M.J., Ix, J.H., The vitamin D metabolite ratio is associated with changes in bone density and fracture risk in older adults. J. Bone Miner. Res. 36 (2020), 2343–2350.
Ginsberg, C., Blackwell, T., Cheng, J.H., Potok, O.A., Cauley, J.A., Ensrud, K.E., Hsu, S., Kado, D.M., Orwoll, E., Cawthon, P.M., The vitamin D metabolite ratio is associated with volumetric bone density in older men. J. Clin. Endocrinol. Metab. 109 (2024), e513–e521.
Darelid, A., Nilsson, M., Kindblom, J.M., Mellström, D., Ohlsson, C., Lorentzon, M., Bone turnover markers predict bone mass development in young adult men: a five-year longitudinal study. J. Clin. Endocrinol. Metab. 100 (2015), 1460–1468.
Song, K., Kwon, A., Chae, H.W., Suh, J., Choi, H.S., Choi, Y., Oh, J.S., Kim, H.-S., Vitamin D status is associated with bone mineral density in adolescents: findings from the Korea National Health and Nutrition Examination Survey. Nutr. Res. 87 (2021), 13–21.
Högström, M., Nordström, A., Nordstr, P., öm, Relationship between vitamin D metabolites and bone mineral density in young males: a cross-sectional and longitudinal study. Calcif. Tissue Int. 79 (2006), 95–101.
Kopiczko, A., Łopuszańska-Dawid, M., Gryko, K., Bone mineral density in young adults: the influence of vitamin D status, biochemical indicators, physical activity and body composition. Arch. Osteoporos., 15, 2020, 45.
Alonso, N., Zelzer, S., Eibinger, G., Herrmann, M., Vitamin D metabolites: analytical challenges and clinical relevance. Calcif. Tissue Int. 112 (2023), 158–177.
Jones, G., Kaufmann, M., Diagnostic aspects of vitamin D: clinical utility of vitamin D metabolite profiling. J. Bone Miner. Res., 5, 2021, e10581.
Ginsberg, C., Zelnick, L.R., Block, G.A., Chertow, G.M., Chonchol, M., Hoofnagle, A., Kestenbaum, B., de Boer, I.H., Differential effects of phosphate binders on vitamin D metabolism in chronic kidney disease. Nephrol. Dial. Transpl. 35 (2020), 616–623.
Lee, S., Chung, H.J., Jung, S., Jang, H.N., Chang, S.H., Kim, H.J., Cho, M.C., 24,25-dihydroxy vitamin D and vitamin D metabolite ratio as biomarkers of vitamin d in chronic kidney disease. Nutrients, 15, 2023.
Turner, M.E., Rowsell, T.S., Kaufmann, M., Norman, P.A., Neville, K., Sarabia, S., White, C.A., Petkovich, M., Jones, G., Adams, M.A., Holden, R.M., The 1,24,25(OH)(3)D(3) metabolite in clinical and experimental CKD: Impact of calcitriol treatment. J. Steroid Biochem Mol. Biol., 226, 2023, 106207.
Kaufmann, M., Gallagher, J.C., Peacock, M., Schlingmann, K.-P., Konrad, M., DeLuca, H.F., Sigueiro, R., Lopez, B., Mourino, A., Maestro, M., Clinical utility of simultaneous quantitation of 25-hydroxyvitamin D and 24, 25-dihydroxyvitamin D by LC-MS/MS involving derivatization with DMEQ-TAD. J. Clin. Endocrinol. Metab. 99 (2014), 2567–2574.
Zelzer, S., Meinitzer, A., Enko, D., Keppel, M.H., Herrmann, M., Theiler-Schwetz, V., Trummer, C., Schmitt, L., Tomaschitz, A., Sadoghi, P., Dierkes, J., Pludowski, P., Zittermann, A., März, W., Pilz, S., Classification of vitamin D status based on vitamin D metabolism: a randomized controlled trial in hypertensive patients. Nutrients, 16, 2024.
Francic, V., Ursem, S.R., Dirks, N.F., Keppel, M.H., Theiler-Schwetz, V., Trummer, C., Pandis, M., Borzan, V., Grübler, M.R., Verheyen, N.D., März, W., Tomaschitz, A., Pilz, S., Heijboer, A.C., Obermayer-Pietsch, B., The Effect of Vitamin D supplementation on its metabolism and the vitamin D metabolite ratio. Nutrients, 11, 2019.
Lombardi, G., Ziemann, E., Banfi, G., Corbetta, S., Physical activity-dependent regulation of parathyroid hormone and calcium-phosphorous metabolism. Int. J. Mol. Sci., 21, 2020, 5388.
Lewis, M.E., Exploring adolescence as a key life history stage in bioarchaeology. Am. J. Biol. Anthropol. 179 (2022), 519–534.
Chevalley, T., Rizzoli, R., Acquisition of peak bone mass. Best. Pract. Res. Clin. Endocrinol. Metab., 36, 2022, 101616.
Proia, P., Amato, A., Drid, P., Korovljev, D., Vasto, S., Baldassano, S., The impact of diet and physical activity on bone health in children and adolescents. Front. Endocrinol., 12, 2021, 704647.
Hargreaves, D., Mates, E., Menon, P., Alderman, H., Devakumar, D., Fawzi, W., Greenfield, G., Hammoudeh, W., He, S., Lahiri, A., Strategies and interventions for healthy adolescent growth, nutrition, and development. Lancet 399 (2022), 198–210.
Al-Daghri, N.M., Hussain, S.D., Ansari, M.G., Khattak, M.N., Aljohani, N., Al-Saleh, Y., Al-Harbi, M.Y., Sabico, S., Alokail, M.S., Decreasing prevalence of vitamin D deficiency in the central region of Saudi Arabia (2008-2017). J. Steroid Biochem. Mol. Biol., 212, 2021, 105920.
Alhamed, M.S., Alharbi, F., Al Joher, A., Dhahry, S., Fallatah, A.A., Alanazi, O.H., Almutiri, J.M., Albaradie, S.S., Al Enezi, B.A.A., Albishi, M.S., Vitamin D deficiency in children and adolescents in Saudi Arabia: a systematic review. Cureus, 16, 2024.
Al-Daghri, N.M., Vitamin D in Saudi Arabia: prevalence, distribution and disease associations. J. Steroid Biochem. Mol. Biol. 175 (2018), 102–107.
Daniel, J.B., de Farias Costa, P.R., Pereira, M., Oliveira, A.M., Vitamin D deficiency and cardiometabolic risk factors in adolescents: systematic review and meta-analysis. Rev. Endocr. Metab. Disord. 23 (2022), 995–1010.
Al-Daghri, N.M., Yakout, S., Sabico, S., Wani, K., Hussain, S.D., Aljohani, N., Uday, S., Högler, W., Establishing the prevalence of osteomalacia in Arab adolescents using biochemical markers of bone health. Nutrients, 14, 2022, 5354.
Al-Daghri, N.M., Sabico, S., Wani, K., Hussain, S.D., Yakout, S., Aljohani, N., Uday, S., Högler, W., Association of bone mineralization markers with dietary nutrient intake in adolescents with and without biochemical osteomalacia. Front. Nutr., 10, 2023, 1206711.
Ladang, A., Gendebien, A.-S., Kovacs, S., Demonceau, C., Beaudart, C., Peeters, S., Alokail, M.S., Al-Daghri, N.M., Le Goff, C., Reginster, J.-Y., Investigation of the Vitamin D Metabolite Ratio (VMR) as a Marker of Functional Vitamin D Deficiency: findings from the SarcoPhAge Cohort. Nutrients, 16, 2024, 3224.
LADANG, A., ROUSSELLE, O., Huyghebaert, L., BEKAERT, A.-C., KOVACS, S., GOFF, C.L.E., CAVALIER, E., 24, 25 (OH) 2D as a marker of vitamin d deficiency in children: a retrospective. Euromedlab, 2019, 2019.
Tang, J.C., Nicholls, H., Piec, I., Washbourne, C.J., Dutton, J.J., Jackson, S., Greeves, J., Fraser, W.D., Reference intervals for serum 24, 25-dihydroxyvitamin D and the ratio with 25-hydroxyvitamin D established using a newly developed LC–MS/MS method. J. Nutr. Biochem. 46 (2017), 21–29.
Booth, M., Sabacinski, K., Watkins, C., Butcho, E., Kramer, E., Meadows, L., Bramer, M.A., Vitamin D levels and bone mineral density: a prospective cross-sectional analysis of young orthopedic trauma patients at a rural United States trauma center. J. Trauma Inj., 37, 2024, 276.
Sioen, I., Lust, E., De Henauw, S., Moreno, L., Jiménez-Pavón, D., Associations between body composition and bone health in children and adolescents: a systematic review. Calcif. Tissue Int. 99 (2016), 557–577.
Giudici, K.V., Fisberg, R.M., Marchioni, D.M.L., Peters, B.S.E., Martini, L.A., Crosstalk between bone and fat tissue: associations between vitamin D, osteocalcin, adipokines, and markers of glucose metabolism among adolescents. J. Am. Coll. Nutr. 36 (2017), 273–280.
Li, C., Chen, P., Duan, X., Wang, J., Shu, B., Li, X., Ba, Q., Li, J., Wang, Y., Wang, H., Bioavailable 25 (OH) D but not total 25 (OH) D is an independent determinant for bone mineral density in Chinese postmenopausal women. EBioMedicine 15 (2017), 184–192.
Ouyang, S., Cao, D., Yin, Y., Ma, F., Ren, G., Sex differences in physical activity dose-response effects on site-specific bone mineral density during childhood and adolescence. Sci. Rep., 15, 2025, 17003.
Zhu, K., Oddy, W.H., Holt, P., Ping-Delfos, W.C.S., Mountain, J., Lye, S., Pennell, C., Hart, P.H., Walsh, J.P., Tracking of vitamin D status from childhood to early adulthood and its association with peak bone mass. Am. J. Clin. Nutr. 106 (2017), 276–283.
Segheto, K.J., Pereira, M., Silva, D.C.Gd, Carvalho, C.Jd, Massardi, F.R., Kakehasi, A.M., Juvanhol, L.L., Longo, G.Z., Vitamin D and bone health in adults: a systematic review and meta-analysis. Ciência SaúDe. Coletiva 26 (2021), 3221–3244.
Ahmed, L.H., Butler, A.E., Dargham, S.R., Latif, A., Chidiac, O.M., Atkin, S.L., Khalil, C.Abi, Vitamin D3 metabolite ratio as an indicator of vitamin D status and its association with diabetes complications. BMC Endocr. Disord., 20, 2020, 161.
Sabico, S., Al-Daghri, N., Alenad, A., Al-Saleh, Y., Khattak, M.N., Wani, K., Alnaami, A., Reginster, J.-Y., Alokail, M.S., Cavalier, E., Sexual Dimorphism in LC-MS/MS-Based Vitamin D Metabolite Profiling and Nutrition-Acquired Biochemical Osteomalacia among Adolescents. Front. Nutr., 12, 2025, 1696230.
Dugar, A., Hoofnagle, A.N., Sanchez, A.P., Ward, D.M., Corey-Bloom, J., Cheng, J.H., Ix, J.H., Ginsberg, C., The vitamin D metabolite ratio (VMR) is a biomarker of vitamin D status that is not affected by acute changes in vitamin D binding protein. Clin. Chem. 69 (2023), 718–723.
Kim, S.M., Lutsey, P.L., Michos, E.D., Vitamin D and cardiovascular disease: can novel measures of vitamin D status improve risk prediction and address the vitamin D racial paradox?. Curr. Cardiovasc. risk Rep., 11, 2017, 3.
Cipriani, C., Pepe, J., Colangelo, L., Minisola, S., Vitamin D and secondary hyperparathyroid states. Front Horm. Res 50 (2018), 138–148.
Lemoine, S., Figueres, L., Bacchetta, J., Frey, S., Dubourg, L., Calcium homeostasis and hyperparathyroidism: nephrologic and endocrinologic points of view. Annales d′Endocrinologie, 2022, Elsevier, 237–243.
Alfredsson, L., Armstrong, B.K., Butterfield, D.A., Chowdhury, R., de Gruijl, F.R., Feelisch, M., Garland, C.F., Hart, P.H., Hoel, D.G., Jacobsen, R., Insufficient sun exposure has become a real public health problem. Int. J. Environ. Res. Public Health, 17, 2020, 5014.
