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Ewout Kieckens
Rest of Italy
eWOUT
KIECKENS
Italian mothers are rare artifacts now
New Italian film museum is true experience
ewout - 18 December 2019
The new Italian film museum couldn't find a better place than in Cinecittà in Rome, the mecca of Italian film. The musuem that opened...
Turbulent history of Italian Tyrol
ewout - 1 November 2019
The Italian author Marco Balzano wrote an interesting novel about the turbulent history of Italian Tyrol around the Second World War. The book is called...
In Italy, the birth rate is falling dramatically. In the event that an Italian woman has a child, it is at the average at the age of 32. Moreover, Italy is the European country with the largest number of childless women. The "demographic recession" is the worst in 100 years.
The traditional Italian mother with the role of the caretaker of a large family is no longer. Almost a quarter of Italian women no longer have a child at all. Women who want to become pregnant keep it at one child.
Thirty percent of babies are born outside of marriage. Here is another sign that the traditional Italian mother is now an artifact.
The fact that the Italian woman produces few children is not new. The average number of children per woman has been well below 2.0 for decades. To maintain a population, every woman must have 2.1 children statistically. The figure in 2017 was 1.32, a decade earlier 1.46. The fact that the population remained at the same level until a few years ago was only due to immigration.
However, large-scale immigration has come to an end. In addition, the Italian tendency to have few children has spread to women of foreign origin. In 2010 a foreign woman had an average of 2.43 children; seven years later that figure was already below 2.0. It does not help that the Italian woman is quite old when her child sees the light. With an average age of 32, the Italian mother is the oldest in Europe.
Risk for sustainability
Italy currently has 60.4 million inhabitants; four years ago that figure was closer to 61 million. The decline in population is still modest. On average, Italians, along with the Japanese, live to be the oldest in the world. In any case, 15,000 over-100s already live in Italy. The decline is still modest, but if the trend continues, the consequences for the future cannot be foreseen.
"In recent decades, the imbalance in the age structure of the population has increased. A demographic recession has been taking place in recent years. A low birth rate and an aging population has led to overrepresentation of the elderly compared to the young. This is a risk factor for the sustainability of our socio-economic system," says Giancarlo Bangiardo, head of the National Institute of Statistics. The expectation is that between 2030 and 2040, one million fewer children will attend primary school. The effect is of course also disastrous on the financing of pensions, among other things.
According to Bangiardo, we have to go back a hundred years in time to see a similar population decline. "The numerical decline that we are now experiencing is only comparable with the years 1917 and 1918." But the cause at that time was a high death rate. The First World War took 1.2 million Italian victims (3.5% of the population).
In the unlikely event that a birth wave suddenly occurs, the effects would only be evident in the very long term. There is another figure that is very worrying. The number of fertile women–between the ages of 15 and 49–is decreasing rapidly. In the last ten years, the number of fertile Italian women has decreased by 900,000.
Therefore, there are fewer and fewer potential mothers in Italy.
Italian mothers are maybe rare artifacts but that is not the case with regard to the Italian mother-in-law. Read more.
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Morgue life
ewout - 28 October 2019
MORGUE LIFE When my wife's father died in 2001, there was no place at the local cemetery. My mother-in-law then had to buy a grave...
ABOUT THIS SITE This site's goal is to inform you about Italy with our original content. We cover current affairs (news, reports, backgrounds) in a journalistic way....
Welcome to my portal on Italian experiences, with original content regarding Italian current affairs and lifestyle.
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The Searle & Taylor gift with purchase promotion commences from Monday 1stApril 2019 and ends on Tuesday 30th June 2019.
To qualify for the promotion, an order needs to be placed for a complete kitchen including kitchen furniture, appliances, worktops and accessories.
If an order is placed 'in part' e.g excluding worktops, appliances or accessories that are purchased separately, the promotion offer will no longer apply.
All products that comprise the entire kitchen order must be made via Searle & Taylor.
The retail sale value of the kitchen has to be £25,000 or more, and all of our kitchens come with separately itemised quotes. The £25,000 value includes cabinetry, worktops, accessories and appliances but does not include VAT. It does not include the cost of installation, which is separate.
The promotion includes a Quooker Flex Boiling water tap in chrome and a PRO3-VAQ tank with a combined value of £1,445. No other style is offered. There is no brand alternative, and no cash alternative.
Searle & Taylor will add the Quooker Flex Boiling Water Tap and tank to your overall kitchen order and will itemise it as Free of Charge.


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'DEBATE ME': Jewish Voices For Trump Co-Chair Challenges 'pro antisemitism' Biden Camp
In an exclusive interview for SaraACarter.com, Jewish Voices for Trump co-chair Boris Epshteyn challenged his counterpart at Joe Biden's presidential campaign to a debate, which he claims he refuses to accept.
This Biden Campaign didn't respond to this reporter's request for an interview with its Jewish Outreach Director, Aaron Keyak.
Current polling suggests President Trump is favored by nearly 30% of Jewish voters.
"That's 5% higher than what President Trump got four years ago in 2016 and Joe Biden's 67% support in that same poll is much lower than Hillary Clinton got in 2016 from Jewish Americans. And it would be, if that held on election day, would be the lowest Jewish American support for a Democrat sinceMichael Dukakis," says Epshteyn.
With Keyak and Doug Emhoff, who's headlined a number of Jewish voter outreach events for Biden and is married to his vice presidential pick Kamala Harris, Biden's team is "sad," Epshteyn said, adding "[Emhoff's] only qualification I guess is being Kamala Harris's husband."
But, it"s also the fact that Biden and his party have aligned themselves with a number of antisemitic figures and it's a cause for alarm, Epshteyn explained.
"In terms of where they stand, it's clear," Epshteyn said. "Joe Biden and Kamala Harris met with Jacob Blake Senior. He's an antisemite. He's a supporter of Louis Farrakhan who calls people like you and me termites."
Blake Senior's Facebook was found to be ripe with recent antisemitic posts lauding Nation of Islam leader Louis Farrakhan, who has called Jews 'termites' and the like. The antisemitism doesn't stop there.
"They had Linda Sarsour speaking at their Democrat National Convention. She's another pal of Louis Farrakhan's. He's not antisemite, he's anti-termite, which means he wants to terminate people like you and me," Epshteyn added.
"President Obama and Joe Biden treated Iran better than they treated Israel. We cannot go back to that. Jewish Americans cannot trust Joe Biden."
According to Biden's campaign site, however, he pledges to combat antisemitism, vows to support a strong U.S.-Israel relationship, and even says he'll fight the antisemitic Boycott, Divestment, and Sanctions (BDS) movement that seeks to economically strangle Israel.
"Jewish Americans cannot trust Joe Biden," Epshteyn said. "And, by the way, since when is not supporting BDS some sort of line in the sand? BDS is an antisemitic movement, so that shouldn't be something that Joe Biden even has to say, but he does and it's a lie because his people, the people who will be controlling him, the puppet masters behind Joe Biden do support BDS, they are antisemites, and Joe Biden is no friend to Jews or the State of Israel."
Biden recently compared Trump to Adolf Hitler's confidante and Nazi chief Joseph Goebbels, which Epshteyn says "was demeaning of the Holocaust," adding that Biden's Jewish Outreach Director recently liked and soon unliked a tweet comparing Trump to Hitler.
Epshteyn also gave an open offer to "anybody who's willing to moderate" the debate including me and Jewish Telegraph Agency's "leftist" Ron Kampeas. "Aaron Keyak better come out of hiding and debate me on the clear contrast between President Trump fighting against antisemitism and standing for the State of Israel and Joe Biden being pro antisemitism and pro-Iran," said Epshteyn.
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SXSW 2018: Midnighters Reveal Hereditary, Field Guide to Evil, an Untitled Blumhouse Film + More!
by Jonathan Barkan February 7, 2018, 11:00 am
Austin, Texas, is getting ready for the mass influx of tourism that comes with its annual South by Southwest (SXSW) festival. A gargantuan gala that celebrates film, technology, video games, music, art, and more, SXSW has become one of the premier events of the year. Just imagine Austin as a house and each area of the city is a different room. If you get bored in one part of the house, just walk to another room, and you'll find a wild amount of activities to keep you entertained.
For horror/film fans, one of the highlights of SXSW's film festival portion is the Midnighters showcase, which feature the more genre-centric titles. Today those titles have been revealed and include films such as Hereditary, which is being hailed as THE horror film of the year; Ajin: Demi-Human, a Japanese action/thriller based on Gamon Sakurai's manga; Field Guide to Evil, an anthology horror film with stories based on folklore from around the world; and more.
SXSW Senior Film Programmer Jarod Neece, whom we interviewed last year, states, "It is the highlight of my year to get to dive into the yearly pool of genre film submission and see what wild and devilish ideas these filmmakers have brought to life. This year's Midnighters, made both by veteran filmmakers and many first-timers, are sure to delight and terrify lucky SXSW audiences. And if they can survive the onslaught, they will be treated to the fantastical world of Wes Anderson's latest stop-motion masterpiece, SXSW Closing Night Film Isle of Dogs."
SXSW's Midnighters are "scary, funny, sexy, controversial – ten provocative after-dark features for night owls and the terminally curious."
Director: Katsuyuki Motohiro, Screenwriter: Kouji Seko
Endless battle between human being and immortal demi-human "Ajin". A stunning, strikingly original action masterpiece! Cast: Takeru Satoh, Go Ayano, Tetsuji Tamayama, Yu Shirota, Yudai Chiba, Rina Kawaei, Minami Hamabe (North American Premiere)
Director/Screenwriter: Owen Egerton
In Blood Fest, fans flock to a festival celebrating the most iconic horror movies, only to discover that the charismatic showman behind the event has a diabolical agenda. Cast: Robbie Kay, Jacob Batalon, Seychelle Gabriel, Tate Donovan, Barbara Dunkelman, Nick Rutherford, Zachary Levi (World Premiere)
Untitled Blumhouse-Bazelevs Film
Director/Screenwriter: Stephen Susco
A 20-something finds a cache of hidden files on his new laptop and is thrust into the deep waters of the dark web. From the makers of Unfriended, this thriller unravels in real-time, entirely on a computer screen. A warning for the digital age. Cast: Colin Woodell, Betty Gabriel, Rebecca Rittenhouse, Andrew Lees, Conor del Rio, Stephanie Nogueras, Savira Windyani (World Premiere)
Field Guide to Evil
(Austria, Germany, Greece, Hungary, India, Poland, Turkey, U.S.)
Directors: Veronika Franz and Severin Fiala, Peter Strickland, Agnieszka Smoczynska, Katrin Gebbe, Can Evrenol, Calvin Reeder, Ashim Ahluwalia, Yannis Veslemes
They are known as dark folklore. Created to give logic to mankind's darkest fears, these stories and others laid the foundation for what we now call the horror genre. (World Premiere)
Directors/Screenwriters: Jeremy Dyson, Andy Nyman
An arch skeptic debunker of the supernatural embarks upon a terror filled quest when he stumbles across a long lost file containing details of three cases of inexplicable 'hauntings'. Adapted from the Olivier Award Winning hit stage play. Cast: Martin Freeman, Alex Lawther, Jill Halfpenny, Andy Nyman, Paul Whitehouse (North American Premiere)
Director/Screenwriter: Ari Aster
When Ellen, the matriarch of the Graham family, passes away, her daughter's family begins to unravel cryptic and increasingly terrifying secrets about their ancestry. Cast: Toni Collette, Gabriel Byrne, Ann Dowd, Alex Wolff, Milly Shapiro
(United States, France)
Director: Jean-Stéphane Sauvaire, Screenwriters: Jonathan Hirschbein, Nick Saltrese
Based on the international best-seller, A Prayer Before Dawn is the true story of Billy Moore, a troubled young British boxer sent to one of Thailand's most notorious jails. Cast: Joe Cole, Vithaya Pansringar, Panya Yimmumphai, Nicolas Shake (North American Premiere)
Director: Jenn Wexler, Screenwriters: Jenn Wexler, Giaco Furino
Teen punks, on the run from the cops and hiding out in the woods, come up against the local authority—an unhinged park ranger with an axe to grind. Cast: Chloë Levine, Granit Lahu, Jeremy Pope, Bubba Weiler, Amanda Grace Benitez, Jeremy Holm, Larry Fessenden (World Premiere)
Director/Screenwriter: Leigh Whannell
In a utopian near-future when technology controls everything, a technophobe avenges his wife's murder and his own paralysis-causing injury with the help of an experimental computer chip implant – STEM – that turns out to have a mind of its own. Cast: Logan Marshall-Green, Betty Gabriel, Harrison Gilbertson, Benedict Hardie (World Premiere)
Director: Colin Minihan, Screenwriters: Colin Minihan, Brittany Allen
Majestic mountains, a still lake and venomous betrayals engulf a female married couple attempting to celebrate their one-year anniversary. Cast: Hannah Emily Anderson, Brittany Allen, Martha Macisaac, Joey Klein, Charlotte Lindsay Marron (World Premiere)
Badges for SXSW can be purchased here.
Previous article Venom Starring Tom Hardy Gets Official Teaser Poster; Trailer Tomorrow?
Next article Exclusive: Aaron Vehling Dives Into the Synth World of Videoman
Written by Jonathan Barkan
Lifelong horror fan with a love of music on the side.
Trailer: Rob Grant's Nightmarish Hospital Horror ALIVE Hits VOD Tomorrow
Exclusive (And Gruesome) Clip from Certified Fresh Shocker HARPOON
Venom Starring Tom Hardy Gets Official Teaser Poster; Trailer Tomorrow?
Exclusive: Aaron Vehling Dives Into the Synth World of Videoman


The watch and jewelry season has just ended, and we can now go on to enjoy the summer with grace and style. Criticized as often as it is praised, Saint-Tropez remains a small village in the South of France where the warbling of the crickets and the smell of lavender permeate your entire body with delectable pleasure.
Here are my five recommendations for those visiting Saint-Tropez, including three of the best-kept secrets in town.
A fashion store owned by a half-Italian half-Tropezian couple — it presents an eclectic selection of brands for the shrewd and discerning, ranging from Japanese denim designers to 1970s chopper-style clothes and accessories, topped up with Christian Louboutin and Helmut Lang pieces, all showcased in a gallery-like space. The selection of jewelry includes Ugo Cacciatori, Castro NYC and vintage Native American jewelry — perfect for the super-hipster in you.
She's from Lebanon, she's ultra-talented and nobody knows her (yet). The earrings of the Aura collection are light and comfortable and the 96 diamonds (totalling 1 carat) set around the marquise shaped turquoise or cornelian stone (mounted on white or red gold depending on what matches best your tan) are perfect to wear, whether swimming or partying!
Hypnotizing and just a bit unsettling, the Perrelet Turbine XS with diamonds is a direct appeal to a woman's aestheticism. The double rotor — signature of the brand — triggers fascination because of the constant movement of the dial-side rotor combined with the lower dial set with radiating lines of diamonds. A 41mm diameter steel case with an automatic movement makes this piece perfect for the summer, especially when mounted on a white rubber strap.
Established in the south of France and the French Alps, the family-run business retails watches and jewelry, including their eponymous line, since 1974. Aside from the usual, you can find a wide range of new talented designers such as Yvonne Léon, Stephen Webster or Ileana Makri, where you would want to get (in the following order): the dragonfly diamond and emerald paved single earring, the crystal haze pendant or the deco single flower ring.
For anything else, just call me!


Engage New Zealand's OpenText experts in the implementation of end-to-end Enterprise Content Management systems.
As a vendor representative for Enterprise Content Management as a Service (ECMS), OpenText shares a Premium Partner relationship with Techtonics. This is due to Techtonics' extensive consultative experience in OpenText products and solutions.
Engaging experts is important when contemplating the delivery of complex and multi-faceted solutions for agencies that seek document and record management solutions. These solutions will unlock the value of their information in the delivery of new services.
OpenText offers a distinct advantage to records management projects in that "bundles of software" are used to deliver seamless automated systems, completely removing the complexities of electronic records management, which become invisible to the end user.
This translates into transparent lifecycle management for all enterprise content and is in stark contrast to other market software solutions, which can rely on "bolted together" products.


Appearance: Clear. Copper/Amber color. Thick, full and creamy head. Lots of bubble streams.
Smell: Malty. Smells alright. Light hops.
Taste: Not bad…at first. I'd expected a little more. Very watered down.
Drinkability: It's drinkable. Light and easy. Not very flavorful though.
Serving Type: Bottle poured in glass.
Oh Bud…what happened here? I was so excited to drink this beer, and it started with so much potential! Nice color, good head, decent enough smell. But really, it all gets down to the taste. And this really fell short of par. Way too watery with little to no flavor at all. Those Europeans over at InBev were on to something – introducing a new beer in this market of drinkers looking for more full bodied, small batch beers. And yes – your business has taken a hit by the hard working "little man" breweries, and highly skilled craft brewers behind the true American Ales of the world. Maybe I bought a bad bottle - maybe not. But you are sorely mistaken if you think you can simply dump MILLIONS behind a new branding campaign, slap the word "American" on a rustic looking logo, charge a premium beer price with a "pry-off" cap – and assume you can pull the wool over the eyes and mouths of true beer drinkers! Oh no my friend. I may enjoy a nice cold Bud – but don't expect me to pass up a quality Boont Amber Ale for something like this.


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Previews// Forgotten Anne
Posted 20 Nov 2017 11:09 by Chris O'Regan
Games: Forgotten Anne (Xbox One)
Ever wondered what happened to that umbrella you left on the train? Or perhaps the scarf you dropped when running for a bus? You probably think it was taken by someone and passed onto a charity shop and thought nothing more of it. You forgot about it and moved on with your life.
Well, what if I told you that objects only exist if you remember them? If you forget them then they cease to be and become forgotten. When they do, they enter another realm, one that is inhabited by things that have been forgotten and they become Forgotlings. This is the world in which Forgotten Anne is set - a place that exists because we forgot about it. It's a tricky thing to get your head around and ThroughLine Games has attempted to explain this concept through a game that is both compelling and wondrous to look at.
This isn't the first time I had encountered Forgotten Anne but this is the first time I played it at Indie Mixer, a showcase of indie games that was also an opportunity to sample a few cocktails. I decided to forgo the drinks as I was keen to experience the games there in a fully conscious and sober state. I was thankful that I did as Forgotten Anne is a very odd game that no inebriated person should be anywhere near.
As explained above, Forgotten Anne takes place in a world formed from forgotten things and Anne, the main protagonist is living here for reasons that are far from obvious. Is she forgotten herself? If so why is she in this place? How can a sentient being forget who they are to the point of vanishing from our reality? All of these questions become muddled with the other more pressing query of why Anne acts so dismissively to the Forgotlings in this world. For yes, not only are these objects forgotten but they also gain sentience once they enter this realm. So that scarf you dropped while running for a bus is now a living thing that Anne interacts with.
At its heart, Forgotten Anne is a 2D puzzle platformer that requires the player to use the special powers Anne has (thanks to a bracelet that she operates) to gather energy that the Fogotlings rely upon to become animated. Without it, they return to their inanimate state that they once were in upon entering the forgotten realm.
This gives the player a choice as to whether or not to take the energy from these beings for Anne's own gain. Anne is not the only human in this world as she shares it with Bonku, a man she refers to as her 'master'. Both of them are committed to doing their utmost to return to our realm.
They are so determined to do so that they will do anything to get back to the lives they have lost, even at the expense of the Forgotlings. This has led to many of them rebelling against Anne and Bonku to the point where Forgotten Anne opens with a sabotage event happening within their residence.
As you'll notice I'm spending a lot of time on the story for Forgotten Anne in this preview. That's quite deliberate, as it is this more than anything that separates it from the myriad of other puzzle platforming games out there. It's the thing that drives you on as the more you explore the more questions are raised and that more than anything pushes the player along to complete it.
Forgotten Anne is presented using cartoon-like animations in a similar style to Studio Ghibli, only with a mite less anime influence thanks to its Western origins. The voice acting is really well done and that's important for such a story-laden title like this.
Forgotten Anne is due to arrive on PS4, Xbox One, Windows PC and Mac sometime in 2018.
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LONG AWAITED GOOD NEWS FROM VOCATIONAL SCHOOLS: THEY PRODUCED THE N95 STANDARD MASK MACHINE
As a result of the research and development studies carried out as part of the coronavirus measures, the Tekirdağ Çerkezköy Turkish Textile Foundation Vocational and Technical Anatolia High School has manufactured the N95 standard mask machine. Deputy Minister of National Education Mahmut Özer said, "We have produced the N95 standard mask machine, the last product we were keen to produce. I am very happy to produce all the products which we targeted."
Production capabilities of the Vocational and Technical Anatolian High Schools has been activated as part of the fight against new type of coronavirus (Covid-19) epidemic. Within this framework, vocational schools are making mass production of different kinds of products varying from cleaning and disinfection productions to masks, from disposal aprons and allovers to face shields.
At this stage, the Ministry focused on R&D activities for the design and production of surgical mask machines, ventilators and machines which will produce N95 face masks. Following the first good news that came about the manufacture of the automatic 3 layer ultrasonic surgical mask machine from İstanbul, reports about the production of ventilators came from Hatay and İstanbul.
Last week, Deputy Minister of National Education Mahmut Özer announced that schools are in the last phase of producing N95 standard mask machines. Tekirdağ Çerkezköy Turkish Textile Foundation Vocational and Technical Anatolia High School produced the N95 standard mask machine which is vital in the protection against the coronavirus.
"We have founded 4 R&D centers in vocational high schools in İstanbul, Tekirdağ, Bursa and Hatay"
Deputy Minister of National Education Mahmut Özer noted in a speech that the Ministry has activated the production capabilities of vocational schools during the epidemic and vocational schools are making mass production of different kinds of products varying from cleaning and disinfection products to masks, from disposal aprons and allovers to face shields.
Stating that vocational schools have produced 8 million surgical/medical masks, 5 million liters of hypochlorite disinfectant and 120 thousand liters of hand disinfectant and 3 thousand liters of cologne, 750 thousand face shields and 1 million disposal apron/overalls and sent these products to places they are needed under the coordination of governors' offices till now, Özer said, "We have founded 4 R&D centers in vocational highschools in İstanbul, Tekirdağ, Bursa and Hatayand focused on production of three products, namely the surgical mask machine, ventilators and the N95 mask machine. We produced the surgical mask machine and started mass production in İstanbul. Moreover, we produced ventilators in Hatay and İstanbul. Finally, we produced the last product we focused on, the N95 mask machine in Tekirdağ. I am very happy to produce all the products that we targetted as a part of our studies."
Stating that vocational school will be able to produce N95 standard masks with the mask machine produced in Tekirdağ Çerkezköy Turkish Textile Foundation Vocational and Technical Anatolia High School, Özer said, "Devoted work by our colleagues, administrators and teachers during this process is beyond all praise."
Deputy Minister Mahmut Özer thanked Provincial Director of National Education Tekirdağ Ersan Ulusan and his colleagues, District Director of National Education in Çerkezköy Hüseyin Gümüş, Principal of Tekirdağ Çerkezköy Turkish Textile Foundation Vocational and Technical Anatolia High School Murat Kıroğlu, Deputy Principal Tuncay Şanlı all teachers and students of the team who worked under the coordination of Hasan Kurtuluş and also General Director of Vocational and Technical Education Kemal Varın Numanoğlu and his colleagues for their devoted work.


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https://www.engineeringnews.co.za/article/regius-developing-coal-to-liquids-fertiliser-project-in-mozambique-2018-12-07
Regius developing coal-to-liquids, fertiliser project in Mozambique
7th December 2018 By: Tasneem Bulbulia - Creamer Media Reporter
UK-incorporated company Regius Synfuels is, through its Mozambican subsidiary Regius Synfuels Mozambique, developing an integrated 10 000 bbl/d clean diesel and gasoline and a 409 000 t/y fertiliser project, in the Tete province of Mozambique.
The project is registered with the Investment Promotion Centre, in Mozambique, and the Council of Ministers of the Government of Mozambique approved the project through a decree issued on May 7.
The recently completed prefeasibility study has confirmed exceptional project economics with a pre-tax internal rate of return of 53.62% and a pre-tax net present value of $4.93-billion.
Construction is expected to start in the third quarter of 2021, with commercial operations scheduled to start in 2023.
In June, Regius signed a memorandum of understanding with China Tianchen Engineering Corp – a Chinese engineering, procurement and construction company with extensive coal chemicals experience and fundraising abilities.
The company is currently in advanced discussions with various funding and development partners.
"This project is an absolute game changer for Mozambique as it looks to use some of the country's stranded thermal coal in a highly efficient process to produce fuels and fertilisers for Mozambican and regional markets," Regius Synfuels Mozambique chairperson Felicio Zacarias commented in a statement issued this week.
The project will produce 300 000 t (2.25-million barrels) of ultraclean-burning diesel, 112 000 t (946 000 bbl) of gasoline and 409 000 t of high-grade urea (fertiliser) a year, all highly sought after products in the local and regional markets.
The selected products serve to increase the efficiency of the overall plant, eliminate the carbon footprint and enhance the economics of the project.
The diesel and gasoline produced will be distributed in the local Mozambican and regional markets to replace existing expensive imports.
Mozambique uses about 1.5-million tonnes a year of diesel and gasoline, all of which is imported.
Diesel and gasoline demand in the surrounding region also collectively exceeds 2.1-million tonnes a year, all of which is imported via Mozambique.
Owing to increasing mining activities in Tete, the region is also considered a high-growth diesel market, which is estimated to consume more than 5 000 bbl/d of diesel.
A considerable and fast-growing regional market also exists for the urea fertiliser produced, as all fertiliser is currently imported resulting in significantly higher prices.
Since 2008, the demand for fertiliser in sub-Saharan Africa has grown by, on average, 8% a year.
LEVERAGING PROVEN TECHNOLOGY
The project technology is designed by South African chemical engineering firm Holland & Hausberger (H&H), licensing Clean Coal Technology South Africa's Fischer-Tropsch (FT) reactor technology.
The H&H coal-to-liquids and urea (CTLU) process, as the project technology is called, is predicated on the proven FT process.
The H&H CTLU process will be deployed at a modular scale of 10 000 bbl/d, requiring shorter project timelines and less capital, making it suitable for implementation in Mozambique.
The process incorporates key improvements that have been made to proven technology resulting in higher plant efficiency, zero carbon dioxide, less carbon feed required and lower water dependency.
These improvements in FT reactors and process design have been successfully demonstrated by way of an operational plant in China, where the reactors have been proven on a full commercial scale.
The H&H CTLU process has an inherent cogeneration capability, allowing multiple high-value product streams namely diesel, gasoline, liquefied petroleum gas, urea and electricity.


Dr.Sameer Karkhanis – Director & Chief Plastic Surgeon Thane, Maharashtra, India Summary Dr. Sameer Karkhanis, Chief Plastic Surgeon & Director of CCRS, is a Board certified plastic surgeon with an experience of over 13 years in the field of Plastic Surgery. He is also featured as a Top Doctor on Realself.com, the world's largest online community & resource for cosmetic surgery patients. He is an active member of several medical fraternities: International Society of Aesthetic Plastic Surgery (ISAPS), Indian Association of Aesthetic Plastic Surgeons (IAAPS), Association of Plastic Surgeons of India (APSI), Association of Medical Consultants, AMC Mumbai, & Indian Medical Association (IMA). Dr. Karkhanis keeps himself abreast with the newer nuances and techniques in the field of Aesthetic Surgery. He has a sub speciality interest & an almost exclusive practice consisting of cosmetic breast surgery, body contouring, hair restoration surgery & aesthetic surgery of the face. Dr. Karkhanis is also affiliated with Currae Hospital, Thane, as a Consultant Aesthetic Plastic Surgeon.
Centre for Cosmetic & Reconstructive Surgery Director & Chief Plastic Surgeon October 2006 – Present Thane The Centre for Cosmetic & Reconstructive Surgery (CCRS), especially caters to surgical specialists in Aesthetic Plastic and Reconstructive surgery.
Our dedicated facility is specifically designed to make every cosmetic surgery procedure more effective, more affordable and safer. Our team of surgeons, skilled nurses, and dedicated support staff are privileged to serve you in a unique, state-of-the-art operating complex.
At our specialized centre we perform only cosmetic and reconstructive surgery; both these fields of plastic surgery demand a very high level of ability, expertise, and super specialization.
Chembur Evolve Medspa Consultant Cosmetic Surgeon February 2009 – October 2010 (1 year 9 months) Evolve, India's first international Med Spa, a joint venture between the Yash Birla Group and Pacific Healthcare, Singapore, is a unique & revolutionary concept in the emerging & expanding field of cosmetic medicine with successful ventures in Singapore, Hong Kong, Bangkok, Shanghai & Shenzhen.


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Time's Not Up: Less Than 7% of World's Leaders are Women, UN Declares 'Serious Regression'
Woman Accidentally Hits Accelerator instead of Brakes; Plunges Car into River
Watch: Flight Making a Close Landing Few Feet away from Spectators Will Leave You in Jitters
Florida City is Playing 'Baby Shark' on Loop to Prevent Homeless People from Sleeping
News18 »	Buzz
Current women world leaders include New Zealand PM Jacinda Ardern, British PM Theresa May, German Chancellor Angela Merkel, and Bangladesh PM Sheikh Hasina, among others.
Updated:March 14, 2019, 12:02 PM IST
G20 leaders pose for a photo at the summit in Hamburg, Germany. (Photo: Reuters)
Even as individuals and organizations trumpet their committment to ending gender disparity and their solidarity with movements like Time's Up! and #MeToo, the cacaphony surrounding them, from street protests to viral social media threads, usually peters out after the months of October and January, the months of their inception.
In the corridors of power, from presidential palaces to parliament buildings, women are totally overshadowedc by men, and account for less than 7% of the world's leaders and only 24% of lawmakers, according to the latest statistics.
UN General Assembly President María Fernanda Espinosa told delegates at the Commission on the Status of Women that there has been a "serious regression" in the political power of women across the world.
The percentage of female elected heads of state dropped from 7.2% to 6.6 — 10 out of the 153 leaders considered — between 2017 to 2018. The percentage of female heads of government dropped from 5.7% to 5.2% — 10 out of 193 — in the same period.
In parliaments, things were marginally better, and the global share of women legislators increased by nearly one percentage point from 2017 to 2018, to 24.3%. Indicidentally, it took 25 years to get to that figure, up from 11% in 1995.
As India gears up for its 2019 Lok Sabha elections, Congress president Rahul Gandhi announced that if his party came to power, it would pass a bill reserving 33% of seats for women in Parliament as well as state legislatures. Gandhi also said that 33% central government posts will also be reserved for women.
Similarly, Trinamool Congress supremo and West Bengal CM Mamata Banerjee is fielding a remarkable 41 per cent women candidates on her party's nominee list. Odisha CM Naveen Patnaik had also announced a 33% reservation for women by his party, the Biju Janata Dal (BJD), in allocation of Lok Sabha seats.
(With AP inputs)
Sena Chief Uddhav Thackeray
Adam's Bridge
Hema Malini's birthday
Friday 12 July , 2019 Rishikesh's Iconic 'Lakshman Jhula' Closed Down After 90 Years, Deemed Unsafe and Beyond Repair
Hrithik Roshan, Anand Kumar Host Special Screening of Super 30 for Vice President Venkaiah Naidu


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Awards, Fellowships, and Grants
Awards for Excellence in Research
Copper Black Award for Creative Achievement
Dissertation Mini-Grant
Distinguished Teacher Award
Early Career Researcher Mini-Grant
Gifted Education Fellowship
Intellectual Benefits to Society Award
Laura Joyner Award
Mensa Foundation Prize
Foundation Prize winners
2019: Prof. Aron K. Barbey
2017: Dr. David Silver
Mensa Press Award
Professor Aron K. Barbey has significantly advanced the neuroscience of brain connectivity with his innovative research applying functional magnetic resonance imaging to the mapping of brain lesions and measuring their effects on raw intelligence.
The Foundation Trustees are proud to present the inaugural Prize to Dr. David Silver, who led Google's efforts to develop the first computer program to defeat the world's best Go players.


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« 2012: Liberal Versus Conservative Puritan
Not Just the New Yorker »
Louis Béroud: "The Delights of Flooding"
Art, Auction Sales, Louis Béroud
Louis Béroud, Les Joies De L'Inondation (Dans La Galerie Médicis) [The Delights of Flooding (in the Medici Gallery)], 1910
From Sotheby's catalogue of Sale 8783, 19th Century European Art, November 4, 2011, Lot 31:
After visiting the Louvre in the 1870s, an American traveller noted that "along the galleries are numerous temporary
stands, easels, etc., at which artists are constantly at work copying such paintings as they may have orders for, or
hope to find purchasers for"… Stumbling across a working artist and his accoutrements was not a rare
occurrence for the museum goer in the nineteenth and early twentieth centuries. Viewing and copying the museum's
masterpieces was a traditional part of an artist's education, and a practice Béroud both enjoyed and used as the
subject of at least twenty-six of his compositions. Indeed, the artist was such a frequent visitor to the Louvre that he is
credited with sounding the alarm upon discovering the Mona Lisa's theft in 1911.
The Louvre held the entirety of art history, and its crowded walls offered a bounty of choices for diverse study. In the
present work, Béroud places the dapper, mustachioed copyist among the paintings of the Marie de' Medici cycle, an
aggrandized biography of the ruler, visualized in twenty four works executed by Peter Paul Rubens in the 1620s for
the Luxembourg Palace, later reinstalled into a devoted gallery at the Louvre. The copyist sits before The
Disembarkation of Marie de' Medici at Marseilles, one of the most popular in the cycle. The painting depicts
Marie upon her marriage to Henry IV, as she walks down a gangplank into the open arms of an allegorical figure of
France, while a trumpeting angel of Fame flies above and Neptune and his naiads rise from the sea. The muscular,
fish tailed naiads proved particularly tempting subjects to copy. Eugène Delacroix had copied one of the sensual
mythological figures. …
Béroud's copyist makes a similar choice, his canvas focusing on the figure on the right in broad, expressive strokes
and dissonant colors of a fauvist style. … His careful study is interrupted as the trio of naiads literally flows from the canvas on swirling waves which threaten to soak the gallery and wash him away. The copyist tosses his brush aside as his body is thrown back in shock at the surreal experience. The humor of the composition is further suggested by its title Les joies de l'inondation (The Joys of the Flood) as the rushing waters promise to bring the robust beauties into the artist's lap. Such levity may also serve to counter a serious situation the artist and his fellow Parisians experienced: in January 1910, the year of the present work's execution, when the Seine overflowed its banks, bringing quick and catastrophic flooding to Paris. … Water inundated several of the Louvre's basements, threatening the stored artworks. It was only through the rapidly organized and heroic efforts of Parisians working to build sandbag barricades that further destruction to the museum was prevented — allowing Béroud, his fellow artists, and generations of visitors since to continue to enjoy its many treasures.
Alas, though estimated to bring $300,000-500,000, this amusingly surreal painting failed to make its reserve. The Recession, of course.
Hat tip to Marius Kaubrys.


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Original Article| Volume 36, P1-13, April 2021
Association of serum vitamin D status with development of type 2 diabetes: A retrospective cross-sectional study
Hannah Marcus
University of Alberta School of Public Health, Edmonton, Alberta, Canada
Muralidhar Varma
Department of Infectious Diseases, Kasturba Medical College and Hospital, Manipal Academy of Higher Education, Karnataka, India, 576104
Sonal Sekhar M
Corresponding author. Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India.
Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, India, 576104
Next ArticleHoney reverses disease progression, has anti-nociceptive and anti-inflammatory effects in a rat model of knee osteoarthritis induced by monosodium iodoacetate
Background and aims
Vitamin D deficiency (VDD) has become a growing global public health issue, which is placing increasing burdens on healthcare systems worldwide due to its multifactorial clinical manifestations. However, epidemiological findings pertaining to VDD's link with various disease pathologies, especially type 2 diabetes mellitus (T2DM), remain contradictory. Through a retrospective cross-sectional analysis, this study aimed to contribute towards the construction of a novel framework for understanding the relationship between VDD and T2DM to subsequently inform relevant public health policy.
A retrospective cross-sectional analysis of the prevalence of diabetes in both VDD and non-VDD groups was conducted. Data pertaining to various biochemical parameters was obtained from the Kasturba hospital database for 500 patients tested for both serum 25(OH)D and blood glucose levels [i.e. random, fasting, post-prandial, and/or hemoglobin A1c (HbA1C)] between 1st January and 30th April 2018.
Within the study sample, 117 (41.1%) of patients with VDD had T2DM, whereas 72 (33.5%) of patients without VDD had T2DM. This indicates no association between VDD and T2DM (χ2 = 2.98; p = 0.084). Still, an OR value of 1.4, despite statistical insignificance (95%CI:0.96–2.0, p = 0.084) indicates that there is an approximately 40% greater odds of developing T2DM in VDD patients relative to non-VDD patients. Moreover, the likelihood ratio (LR) is 2.99, which indicates an approximately 3-fold chance of having T2DM as a VDD patient, relative to a non-VDD patient.
Despite the lack of statistical significance, the findings of this study make important contributions to the existing literature and must be considered in light of their inherent limitations. Taking these into account, it becomes clear that these results should not be extrapolated nor assumed to entirely invalidate the hypothesized link between VDD and T2DM. Rather, such gaps warrant need for further research and more robust study designs to draw sufficiently significant conclusions to justify reforms in clinical practice.
Glycemic control
Serum 25(OH)D
VDD (vitamin D deficiency), T2DM (type 2 diabetes mellitus), HbA1C (hemoglobin A1C), CRP (C-reactive protein), PTH (parathyroid hormone), Ca (calcium), P (phosphorous)
Vitamin D deficiency (VDD) has become a growing global public health issue1. Although various researchers have considered different cut-off value for vitamin D status, the majority defined VDD as serum 25(OH)D level <20 ng/mL and insufficiency as serum 25(OH)D level 20–30 ng/mL, which affects almost 1 billion people worldwide, representing a staggering 15% of the global population [
Pfotenhauer K.M.
Shubrook J.H.
Vitamin D deficiency, its role in health and disease, and current supplementation recommendations.
J Am Osteopath Assoc. 2017; 117: 301-305https://doi.org/10.7556/jaoa.2017.055
]. Vitamin D plays a vital role in many central homeostatic processes such as bone metabolism, cellular growth, neuromuscular and immune function, and inflammation [
]. As a result, low serum vitamin D levels render an individual susceptible to a multiplicity of health complications, such as multiple sclerosis, autoimmune disorders, infectious, respiratory, and cardiometabolic diseases, and cancer, amongst others [
]. Therefore, the high prevalence of VDD places a large burden on healthcare systems worldwide, which must increasingly deal with its multifactorial clinical manifestations.
However, epidemiological findings pertaining to VDD's link with various disease pathologies, especially type 2 diabetes mellitus (T2DM), remain contradictory. Many observational longitudinal studies and its systematic review and metaanalysis support the hypothesis that VDD may increase risk of T2DM [
Rhee S.Y.
Hwang Y.C.
Chung H.Y.
Woo J.T.
Vitamin D and diabetes in Koreans: analyses based on the fourth Korea national health and nutrition examination survey (KNHANES), 2008-2009.
Diabet Med. 2012; 29: 1003-1010https://doi.org/10.1111/j.1464-5491.2012.03575.x
Park S.K.
Garland C.F.
Gorham E.D.
BuDoff L.
Plasma 25-hydroxyvitamin D concentration and risk of type 2 diabetes and pre-diabetes: 12-year cohort study.
PloS One. 2018; 13e0193070https://doi.org/10.1371/journal.pone.0193070
Rafiq S.
Jeppesen P.B.
Is hypovitaminosis D related to incidence of type 2 diabetes and high fasting glucose level in healthy subjects: a systematic review and meta-analysis of observational studies.
Nutrients. 2018; 10: 59https://doi.org/10.3390/nu10010059
Lucato P.
Solmi M.
Maggi S.
Bertocco A.
Bano G.
Trevisan C.
Low vitamin D levels increase the risk of type 2 diabetes in older adults: a systematic review and meta-analysis.
Maturitas. 2017; 100: 8-15https://doi.org/10.1016/j.maturitas.2017.02.016
] and related complications [
Luo B.A.
Gao F.
Qin L.L.
The association between vitamin D deficiency and diabetic retinopathy in type 2 diabetes: a meta-analysis of observational studies.
Nutrients. 2017; 9: 307https://doi.org/10.3390/nu9030307
]. Yet simultaneously, results of many, more robust, randomized controlled trials (RCTs) appear to suggest otherwise [
Angellotti E.
D'Alessio D.
Dawson-Hughes B.
Nelson J.
Cohen R.M.
Gastaldelli A.
Vitamin D supplementation in patients with type 2 diabetes: the vitamin D for established type 2 diabetes (DDM2) study.
J Endocr Soc. 2018; 2: 310-321https://doi.org/10.1210/js.2018-00015
Pittas A.G.
Sheehan P.
Ware J.H.
Knowler W.C.
Aroda V.R.
Vitamin D supplementation and prevention of type 2 diabetes.
N Engl J Med. 2019; 381: 520-530https://doi.org/10.1056/NEJMoa1900906
]. A meta-analysis reported no significant effect of vitamin D supplementation on the risk or incidence of T2DM, but found a probable dose-response effect of supplementation on improvement of glycaemia and insulin metabolism among non-T2DM adults, demonstrating a possible advantage of high-dose vitamin D supplementation for T2DM prevention [
Tang H.
Li D.
Song Y.
Effects of vitamin D supplementation on glucose and insulin homeostasis and incident diabetes among nondiabetic adults: a meta-analysis of randomized controlled trials.
Int J Endocrinol. 2018; 2018: 7908764https://doi.org/10.1155/2018/7908764
]. Similarly, a RCT found that in those with prediabetes as well as VDD, high-dose vitamin D supplementation improves insulin sensitivity and reduces risk of diabetes progression [
Niroomand M.
Fotouhi A.
Irannejad N.
Hosseinpanah F.
Does high-dose vitamin D supplementation impact insulin resistance and risk of development of diabetes in patients with pre-diabetes? A double-blind randomized clinical trial.
Diabetes Res Clin Pract. 2019; 148: 1-9https://doi.org/10.1016/j.diabres.2018.12.008
]. The discrepancy in the above findings, along with inherent limitations apparent in the design and conduct of the studies have prolonged the scholarly debate concerning the association between VDD and T2DM. Meanwhile, biomolecular evidence suggests that vitamin D may play a protective role against insulin resistance and many diabetes-associated epigenetic alterations, providing a strong biological basis for the hypothesized etiological relationship. However, epidemiological findings must be more conclusive if they are to invalidate or lend further merit to such molecular work. Due to the uncertainties that currently persist in the scientific literature, there is a need for further research to discern the relationship between VDD and T2DM. Through a cross-sectional analysis of the prevalence of T2DM in VDD and non-VDD groups, this study aims to address the need for more robust scientific literature pertaining to this growing yet controversial body of research. Should this study, alongside others, help strengthen support for this association, the clinical significance of VDD can be further established and new policies aimed at improving national vitamin D status implemented.
1.1 Vitamin D deficiency in India
In spite of India's tropical climate, which should theoretically enable high UV light exposure, the country bears a disproportionately high burden of the global VDD crisis. The estimated prevalence of VDD ranges from 70% to 100% in the Indian population [
Ritu G.
Gupta A.
Vitamin D deficiency in India: prevalence, causalities and interventions.
Nutrients. 2014; 6: 729-775https://doi.org/10.3390/nu6020729
]. Interestingly, relatively consistent and equally concerning trends regarding vitamin D status have been noted across the entire Indian subcontinent, with few urban-rural disparities despite varied social factors [
]. Individual rural and urban social determinants which simultaneously contribute to VDD may explain this nation-wide universality in vitamin D health indicators. In rural India, dietary factors including lack of animal product consumption and severe protein malnutrition due to financial constraints contribute to low vitamin D intake. Less access to healthcare for VDD screening and management may further exacerbate the issue [
]. Meanwhile, in urban areas, the uptake of non-laborious occupations and reduced sun exposure resulting from overcrowding and high atmospheric pollution may contribute to the VDD epidemic [
]. Other potential attributable factors are common to the entire Indian population. Overall high rates of vegetarianism further decrease dietary intake of animal sources from which vitamin D is primarily derived [
]. Although degradation of dietary vitamin D during heating depends on the type of food items as well as the heating process, it is proven that cooking may affect retention or lead to detrimental loss vitamin D [
Jakobsen J.
Knuthsen P.
Stability of vitamin D in foodstuffs during cooking.
Food Chem. 2014; 148: 170-175https://doi.org/10.1016/j.foodchem.2013.10.043
]. Therefore, high-temperature cooking practices due to ancient climactic adaptations coupled with a current lack of government regulation on the hygiene and microbial quality control of fresh produce, leads to degradation of vitamin D and further exacerbates the prevailing issue of low vitamin D content in the Indian diet [
]. Moreover, VDD in individuals with obesity is attributed to volumetric dilution in higher volumes of fat in these subjects [
Vranić L.
Mikolašević I.
Milić S.
Vitamin D deficiency: consequence or cause of obesity?.
Medicina (Kaunas). 2019; 55: 541https://doi.org/10.3390/medicina55090541
]. Phosphatase and tensin homolog deleted on chromosome 10 (PTEN), a primary thrifty gene, play a role in various cellular processes involved in energy metabolism, downstream insulin regulation, and mitochondrial function [
Venniyoor A.
PTEN: a thrifty gene that causes disease in times of plenty?.
Front Nutr. 2020; 7: 81https://doi.org/10.3389/fnut.2020.00081
]. PTEN underexpression promotes excess storage of fat and reduced ability to burn calories [
]. Remarkably, although Indian new born babies have lower weight on average, they have been found to possess higher mean fat storage which is correlated with a higher risk of metabolic syndromes in adulthood [
Wells J.C.
Sawaya A.L.
Wibaek R.
Mwangome M.
Poullas M.S.
Yajnik C.S.
The double burden of malnutrition: aetiological pathways and consequences for health.
Lancet. 2020; 395: 75-88https://doi.org/10.1016/S0140-6736(19)32472-9
Lubree H.G.
Rege S.S.
Naik S.S.
Deshpande J.A.
Deshpande S.S.
Adiposity and hyperinsulinemia in Indians are present at birth.
J Clin Endocrinol Metab. 2002; 87: 5575-5580https://doi.org/10.1210/jc.2002-020434
]. Researchers have found that vitamin B12 deficiency as well as one-carbon chain abnormalities might result in the thrifty gene phenotype implicated in the current diabetes epidemic in India [
Finer S.
Saravanan P.
Hitman G.
Yajnik C.
The role of the one-carbon cycle in the developmental origins of Type 2 diabetes and obesity.
Diabet Med. 2014; 31: 263-272https://doi.org/10.1111/dme.12390
]. Altogether, this evidence shows increased risk of VDD in Indian populations owing to thrifty-gene obesity. Finally, socio-cultural practices of modest dress code and efforts to attain a pale skin composition are not conducive to adequate sun exposure [
Despite the universality of concerning vitamin D status amongst the Indian subpopulation, there has been a lack of public recognition and consequential political will to implement robust public health policy to mitigate the issue [
]. This indicates a lack of epidemiological research pertaining to the national health impact of VDD. As India is currently the "diabetes capital of the world", with the number of cases expected to rise to 69.9 million by 2025 and an alarmingly high diabetes prevalence in the South Indian population in particular, there is a highly concentrated research effort to discern the causal factors of diabetes in India [
Mohan V.
Sandeep S.
Deepa R.
Shah B.
Varghese C.
Epidemiology of type 2 diabetes: Indian scenario.
Indian J Med Res. 2007; 125: 217-230
]. The high economic burden of the diabetes epidemic on the Indian healthcare system has further enhanced government interest in public health efforts to understand the roots of and subsequently address this crisis. To date, commonly proposed causes include genetic factors which give rise to an "Asian Indian phenotype" of increased diabetes susceptibility and urbanization-associated increases in sedentary lifestyles and fast food consumption resulting in an "epidemiological transition" towards a "first world disease profile" [
]. While these factors have been long recognized for their contribution to the national diabetes epidemic, resultant policy reform has been slow due to the multifaceted approach needed to address such large-scale social forces [
Kumar A.
Goel M.K.
Jain R.B.
Khanna P.
Chaudhary V.
India towards diabetes control: key issues.
Australas Med J. 2013; 6: 524-531https://doi.org/10.4066/AMJ.2013.1791
To encourage hastened implementation of new public health policy and political reform to address diabetes in India, there is a need for scholars to identify more direct causes of the epidemic for which sufficiently concrete targets can be designed. The identification of VDD as a risk factor for T2DM in India may precisely serve this need, for studies have shown that relatively simple public health reforms such as vitamin D fortification and supplementation programs are highly effective at improving population vitamin D status [
]. Therefore, the implications of this work are far-reaching; an understanding of the etiological role of VDD in T2DM development may help to inform important public health efforts to reduce diabetes prevalence whilst simultaneously increasing political will to address the VDD crisis, with its multidimensional health consequences.
1.2 VDD and T2DM-review of the literature
An in-depth analysis of the current literature reveals a wide array of evidence which suggests that VDD may be associated with an increased risk of diabetes. Such evidence comes from both epidemiological and biomolecular studies which have respectively identified clinical associations and potential biological mechanisms which may mediate them. Nonetheless, contradictions remain in the current literature, as there exist discrepancies in the findings across different study designs.
1.2.1 Epidemiological research
1.2.1.1 Observational longitudinal studies
In a systematic review, eight different longitudinal cohort studies were identified for having reported an association between vitamin D status and risk of developing T2DM [
Mitri J.
Muraru M.D.
Vitamin D and type 2 diabetes: a systematic review.
Eur J Clin Nutr. 2011; 65: 1005-1015https://doi.org/10.1038/ejcn.2011.118
]. In a Women's Health Study, an intake of >511 international units (IU)/day of vitamin D was associated with a 27% lower risk of developing T2DM compared with an intake of <159 IU/day [
Liu S.
Ford E.S.
Manson J.E.
Buring J.E.
Ridker P.M.
Dietary calcium, vitamin D, and the prevalence of metabolic syndrome in middle-aged and older U.S. women.
Diabetes Care. 2005; 28: 2926-2932https://doi.org/10.2337/diacare.28.12.2926
]. However, this analysis was limited by the lack of adjustment for potentially confounding risk factors for T2DM. In a Nurses' health study which adjusted for multiple covariates, women who reported consumption of >800 IU/day of vitamin D had a 23% lower risk of developing incident T2DM, by validated self-report, compared with women who reported consumption of <200 IU/day [
Li T.
Van Dam R.M.
Willett W.C.
Vitamin D and calcium intake in relation to type 2 diabetes in women.
Diabetes Care. 2006; 29: 650-656https://doi.org/10.2337/diacare.29.03.06.dc05-1961
]. This association, however, was later invalidated after further adjustment for dietary factors. Other nested case-control studies have compared measured blood 25(OH)D concentration with T2DM incidence. After multivariate adjustment in a nested case-control study which pulled data from two cohorts in Finland, participants who were in the highest quartile of serum 25(OH)D levels at baseline (mean 25[OH]D 27.6 ng/mL), compared with those in the lowest quartile (mean 25[OH]D 8.9 ng/mL), had a 40% lower risk of developing incident T2DM [
Knekt P.
Laaksonen M.
Mattila C.
Härkänen T.
Marniemi J.
Heliövaara M.
Rissanen H.
Montonen J.
Reunanen A.
Serum vitamin D and subsequent occurrence of type 2 diabetes.
Epidemiology. 2008; 19: 666-671https://doi.org/10.1097/EDE.0b013e318176b8ad
1.2.1.2 Randomized controlled trials
A systematic review identified 11 RCTs which reported the effects of vitamin D supplementation on measures of glycemia or incident diabetes by self-report [
]. There was no effect of vitamin D supplementation on measures of glycemia including fasting plasma glucose or hemoglobin A1c (HbA1C) and insulin resistance measured by homeostatic model assessment (HOMA) in participants with normal glucose tolerance at baseline in seven trials [
Nilas L.
Christiansen C.
Treatment with vitamin D or its analogues does not change body weight or blood glucose level in postmenopausal women.
Int J Obes. 1984; 8: 407-411
Hsia J.
Heiss G.
Ren H.
Dolan N.C.
Greenland P.
Calcium/vitamin D supplementation and cardiovascular events.
Circulation. 2007; 115: 846-854https://doi.org/10.1161/CIRCULATIONAHA.106.673491
Harris S.S.
Stark P.C.
The effects of calcium and vitamin D supplementation on blood glucose and markers of inflammation in nondiabetic adults.
Diabetes Care. 2007; 30: 980-986https://doi.org/10.2337/dc06-1994
de Boer I.H.
Tinker L.F.
Connelly S.
Curb J.D.
Howard B.V.
Kestenbaum B.
Calcium plus vitamin D supplementation and the risk of incident diabetes in the Women's Health Initiative.
Avenell A.
Cook J.A.
MacLennan G.S.
McPherson G.C.
RECORD trial group. Vitamin D supplementation and type 2 diabetes: a substudy of a randomised placebo-controlled trial in older people (RECORD trial, ISRCTN 51647438).
Age Ageing. 2009; 38: 606-609https://doi.org/10.1093/ageing/afp109
Zittermann A.
Frisch S.
Berthold H.K.
Götting C.
Kuhn J.
Kleesiek K.
Stehle P.
Koertke H.
Koerfer R.
Vitamin D supplementation enhances the beneficial effects of weight loss on cardiovascular disease risk markers.
Am J Clin Nutr. 2009; 89: 1321-1327https://doi.org/10.3945/ajcn.2008.27004
von Hurst P.R.
Stonehouse W.
Coad J.
Vitamin D supplementation reduces insulin resistance in South Asian women living in New Zealand who are insulin resistant and vitamin D deficient - a randomised, placebo-controlled trial.
Br J Nutr. 2010; 103: 549-555https://doi.org/10.1017/S0007114509992017
Jorde R.
Sneve M.
Torjesen P.
Figenschau Y.
No improvement in cardiovascular risk factors in overweight and obese subjects after supplementation with vitamin D3 for 1 year.
J Intern Med. 2010; 267: 462-472https://doi.org/10.1111/j.1365-2796.2009.02181.x
]. Similar results were obtained from three small underpowered RCTs in which participants with established T2DM were randomized to receive vitamin D supplementation [
Sugden J.A.
Davies J.I.
Witham M.D.
Morris A.D.
Struthers A.D.
Vitamin D improves endothelial function in patients with Type 2 diabetes mellitus and low vitamin D levels.
Diabet Med. 2008; 25: 320-325https://doi.org/10.1111/j.1464-5491.2007.02360.x
Supplementation with cholecalciferol does not improve glycaemic control in diabetic subjects with normal serum 25-hydroxyvitamin D levels.
Eur J Nutr. 2009; 48: 349-354https://doi.org/10.1007/s00394-009-0020-3
Dove F.J.
Dryburgh M.
The effect of different doses of vitamin D(3) on markers of vascular health in patients with type 2 diabetes: a randomised controlled trial.
Diabetologia. 2010; 53: 2112-2119https://doi.org/10.1007/s00125-010-1838-1
]. Of the 11 identified trials, only a select few published results of statistically significant improvements in insulin resistance in response to vitamin D supplementation. Furthermore, methodological and other flaws warrant need for further validation of the significance of the findings across most trials. For example, all trials with the exception of the Women's Health Initiative Trial lacked sufficient statistical power for analysis of glycemic outcomes. Additionally, adherence with supplementation was suboptimal in several trials, which may have further weakened any subsequent conclusions drawn. This suggests that RCTs assessing the effect of vitamin D supplementation on T2DM risk should rely on 25 (OH)D concentrations as the exposure variable rather than vitamin D supplementation dose, a conclusion supported by recent research [
Staten M.A.
Vickery E.M.
LeBlanc E.S.
Intratrial exposure to vitamin D and new-onset diabetes among adults with prediabetes: a secondary analysis from the vitamin D and type 2 diabetes (D2d) study.
Diabetes Care. 2020; 43: 2916-2922https://doi.org/10.2337/dc20-1765
1.2.2 Biomolecular research
Numerous cellular and molecular biological studies have elucidated potential etiological mechanisms to explain the association between VDD and T2DM [
Berridge M.J.
Vitamin D deficiency and diabetes.
Biochem J. 2017; 474: 1321-1332https://doi.org/10.1042/BCJ20170042
]. Such mechanisms are multifactorial and primarily center around vitamin D's apparent protective role against insulin resistance, diabetes-associated epigenetic alterations, mitochondrial dysfunction, and pancreatic β-cell apoptosis.
1.2.2.1 Insulin resistance
Evidence pertaining to several cellular pathways supports the notion that vitamin D may provide protection against insulin resistance. It is now understood that insulin resistance in obesity results largely from the high presence of serum fatty acids and associated metabolites which have been shown to reduce insulin signalling by phosphorylating the insulin receptor substrate [
Qatanani M.
Lazar M.A.
Mechanisms of obesity-associated insulin resistance: many choices on the menu.
Genes Dev. 2007; 21: 1443-1455https://doi.org/10.1101/gad.1550907
]. Vitamin D helps to mitigate this effect by helping to maintain the insulin signalling pathway through increasing cell-surface expression of the insulin receptor [
Maestro B.
Molero S.
Bajo S.
Dávila N.
Calle C.
Transcriptional activation of the human insulin receptor gene by 1,25-dihydroxyvitamin D(3).
Cell Biochem Funct. 2002; 20: 227-232https://doi.org/10.1002/cbf.951
]. Consequently, VDD would render decreased insulin receptor expression, contributing to insulin resistance. Another mechanism by which vitamin D might play a protective role against insulin resistance is by decreasing intracellular calcium concentrations, which in turn increases activity of the glucose transporter-4 (GLUT4) involved in cellular glucose uptake in response to insulin signalling [
Reusch J.E.
Begum N.
Sussman K.E.
Draznin B.
Regulation of GLUT-4 phosphorylation by intracellular calcium in adipocytes.
Endocrinology. 1991; 129: 3269-3273https://doi.org/10.1210/endo-129-6-3269
]. Furthermore, vitamin D plays an important role in regulating the secretion of various adipokines such as leptin, adiponectin, and resistin [
]. In doing so, it helps to maintain narrow homeostatic ranges of such hormones to prevent the development of insulin resistance which often occurs in the presence of high resistin and/or low leptin and adiponectin [
Kershaw E.E.
Flier J.S.
Adipose tissue as an endocrine organ.
J Clin Endocrinol Metab. 2004; 89: 2548-2556https://doi.org/10.1210/jc.2004-0395
]. There is also increasing evidence which suggests that Vitamin D acts to reduce the release of chemokines and cytokines that drive inflammation, a major factor implicated in the development of insulin resistance [
Marcotorchino J.
Gouranton E.
Romier B.
Tourniaire F.
Astier J.
Malezet C.
Vitamin D reduces the inflammatory response and restores glucose uptake in adipocytes.
Mol Nutr Food Res. 2012; 56: 1771-1782https://doi.org/10.1002/mnfr.201200383
]. Finally, by helping to increase the expression of many cellular antioxidants, vitamin D helps to control intracellular reactive oxygen species (ROS) levels [
Vitamin D cell signalling in health and disease.
Biochem Biophys Res Commun. 2015; 460: 53-71https://doi.org/10.1016/j.bbrc.2015.01.008
]. As increased ROS has been shown to reduce the activity of various components of the insulin signalling pathway, low ROS levels play an important preventative role against insulin resistance [
1.2.2.2 Epigenetic alterations
With regards to the epigenome, evidence suggests that vitamin D may play a role in increasing the expression of certain DNA demethylases [
Alam F.
Islam M.A.
Gan S.H.
Mohamed M.
Sasongko T.H.
DNA methylation: an epigenetic insight into type 2 diabetes mellitus.
Curr Pharmaceut Des. 2016; 22: 4398-4419https://doi.org/10.2174/1381612822666160527111152
]. Such factors, along with vitamin D-induced ROS level decrease, serve to prevent hypermethylation of promoter regions of many diabetes-associated genes which are otherwise inactivated through hypermethylation in the diabetic epigenome [
Consiglio M.
Viano M.
Casarin S.
Castagnoli C.
Pescarmona G.
Silvagno F.
Mitochondrial and lipogenic effects of vitamin D on differentiating and proliferating human keratinocytes.
Exp Dermatol. 2015; 24: 748-753https://doi.org/10.1111/exd.12761
1.2.2.3 Mitochondrial dysfunction
Mitochondrial function may be another factor mediating the link between T2DM and VDD. There is increasing evidence that vitamin D helps regulate mitochondrial function, reducing risk of mitochondrial dysfunction which plays a pathophysiological role in T2DM [
]. Vitamin D receptor signalling pathways serve to increase genomic expression of many of the components responsible for mitochondrial function [
]. Declines in mitochondrial respiration during VDD have been attributed to the resultant reduction in nuclear mRNA molecules and proteins involved in this process [
Scaini G.
Rezin G.T.
Carvalho A.F.
Streck E.L.
Berk M.
Quevedo J.
Mitochondrial dysfunction in bipolar disorder: evidence, pathophysiology and translational implications.
Neurosci Biobehav Rev. 2016; 68: 694-713https://doi.org/10.1016/j.neubiorev.2016.06.040
]. In response to mitochondrial dysfunction, electron transport chain activity declines and this results in increased formation of ROS that induce oxidative stress and consequently contribute to T2DM development [
Lowell B.B.
Shulman G.I.
Mitochondrial dysfunction and type 2 diabetes.
Science. 2005; 307: 384-387https://doi.org/10.1126/science.1104343
1.2.2.4 Pancreatic β-cell apoptosis
Evidence from numerous studies suggests that vitamin D plays an important role in many Ca2+ signalling pathways. This is significant in the context of T2DM because abnormal Ca2+ signalling is implicated in pancreatic β-Cell dysfunction which plays a role in the pathophysiology of T2DM [
Guerrero-Hernandez A.
Verkhratsky A.
Calcium signalling in diabetes.
Cell Calcium. 2014; 56: 297-301https://doi.org/10.1016/j.ceca.2014.08.009
]. Specifically, vitamin D helps to prevent excessive Ca2+ signalling by reducing the expression of L-type Ca2+ channels and increasing the expression of various components that act to maintain low resting levels of Ca2+, such as the buffers calbindin D-9k, calbindin D-28k and parvalbumin, Ca2+ pumps, the sodium/calcium exchanger (NCX) and the plasma membrane Ca2+-ATPase 1b [
Gezen-Ak D.
Dursun E.
Yilmazer S.
The effects of vitamin D receptor silencing on the expression of LVSCC-A1C and LVSCC-A1D and the release of NGF in cortical neurons.
PloS One. 2011; 6e17553https://doi.org/10.1371/journal.pone.0017553
Haussler M.R.
Whitfield G.K.
Kaneko I.
Haussler C.A.
Hsieh D.
Hsieh J.C.
Jurutka P.W.
Molecular mechanisms of vitamin D action.
Calcif Tissue Int. 2013; 92: 77-98https://doi.org/10.1007/s00223-012-9619-0
]. Excessive Ca2+ signalling in response to high glucose levels typically induces apoptosis and subsequent cell death of pancreatic β-cell in the normal pathophysiological progression of T2DM [
Efanova I.B.
Zaitsev S.V.
Zhivotovsky B.
Köhler M.
Efendić S.
Orrenius S.
Berggren P.O.
Glucose and tolbutamide induce apoptosis in pancreatic beta-cells. A process dependent on intracellular Ca2+ concentration.
J Biol Chem. 1998; 273: 33501-33507https://doi.org/10.1074/jbc.273.50.33501
]. Therefore, by regulating Ca2+ signalling pathways through the aforementioned mechanisms, vitamin D helps to preserve pancreatic β-cell function and hence maintain normal insulin secretion. Moreover, by reducing intracellular levels of ROS which have been linked to enhanced Ca2+ signalling, vitamin D further protects pancreatic β-cells from Ca2+ overstimulation [
Donoso P.
Sanchez G.
Bull R.
Hidalgo C.
Modulation of cardiac ryanodine receptor activity by ROS and RNS.
Front Biosci (Landmark Ed). 2011; 16: 553-567https://doi.org/10.2741/3705
2. Materials & methods
This study was conducted using a retrospective cross-sectional analysis of the prevalence of diabetes in both VDD and non-VDD groups. Retrospective data pertaining to various biochemical parameters was obtained from the hospital database of Kasturba Medical College and Hospital, Manipal, India.
2.2 Study population
The study population included 500 patients registered through the Kasturba hospital database who had both serum 25(OH)D and blood glucose levels (i.e. random, fasting, post-prandial, and/or HbA1C) tested between 1st January and 30th April 2018. All patients were obtained from the departments of medicine, orthopedics, and dermatology. Patients with incomplete medical records were excluded, as information pertaining to various covariates was required for adjustment in the statistical analysis. Additionally, patients with any conditions that could play a confounding role, such as hepatic or renal diseases or metabolic rickets, and/or those receiving current treatment for VDD (i.e. vitamin D supplementation) were excluded and/or adjusted for in the statistical analysis to ensure greater internal validity. Finally, those taking any medications known to interfere with vitamin D metabolism [i.e. Pregnane X Receptor (PXR) ligands, glucocorticoids, bisphosphates, anti-estrogens, cytostatic agents] were excluded to limit the effect of additional external factors on vitamin D status amongst study participants.
2.3 Study procedure
After identifying the vitamin D status of all study participants according to laboratory test results for serum 25(OH)D levels, participants were divided into two groups: VDD [serum 25(OH)D level < 20 ng/mL) and non-VDD (serum 25(OH)D level > 20 ng/mL] (Fig. 1). These criteria were based on the vitamin D status indicated in the hospital database, which categorizes serum 25(OH)D levels of <20 ng/mL, 20–30 ng/mL, and >30 ng/mL as deficient, insufficient, and normal, respectively. Patients who either had previous diagnoses of diabetes and/or blood glucose levels (i.e. random, fasting, post-prandial, or HbA1C) which fell into the medically accepted diabetic range were labelled as diabetic (with labels confirmed through reference to ICD-10 coding of T2DM (E11) given for case files in hospital data management system) and the proportion of diabetic individuals in both VDD and non-VDD groups was calculated. The relative prevalence of diabetes in VDD and non-VDD groups was then used to determine an odds ratio (OR) which was further analyzed for statistical significance.
Fig. 1Study flow chart.
2.4 Serum vitamin D test procedure
Laboratory measurements of serum 25(OH)D concentration was determined using the electrochemiluminescence binding assay (Cobas® immunoassay analyzers, Roche Diagnostics). The Cobas® Vitamin D total assay enabled determination of the total 25(OH)D [25(OH)D2 and 25(OH)D3]. The stability of 25(OH)D found with the Cobas® Vitamin D total assay is in line with earlier studies using a vitamin D binding protein assay and mass spectrometry. The functional sensitivity was determined to be 4.01 ng/mL (CV 18.5%). The functional sensitivity is the lowest analyte concentration that can be reproducibly measured with an intermediate precision CV of ≤20%.
2.5 Ethical considerations
The study was conducted after obtaining approval from the Institutional Ethics Committee (IEC) of Kasturba Medical College and Kasturba Hospital, Manipal (Ref. No. IEC 354/2018). The data were collected based on the rules of the Declaration of Helsinki of 1975, revised in 2013.
2.6 Statistical analysis
A standardized frequency analysis was conducted on all quantitative variables, namely serum levels of vitamin D, fasting, post prandial, and random blood glucose, HbA1C, C-reactive protein (CRP), parathyroid hormone (PTH), serum calcium (Ca), and phosphorus (P). For all such measures, respective mean and standard deviation (SD) were also calculated. Pearson Chi-square (χ2) tests were conducted to determine association of vitamin D status with various factors. Primary outcome measures included χ2 values for the calculated associations between vitamin D status and diabetes status; and mean serum levels of vitamin D and HbA1C. Furthermore, χ2 values were determined to analyze the correlations of both vitamin D and diabetes status with various covariates (i.e. CRP, PTH, Ca, and P serum levels).
3.1 Characteristics of study population
A total of 500 subjects were enrolled in the study, of which 220 (44%) were males and 280 (56%) were females. A total of 213 participants (42.6%) were administered on vitamin D supplementation as of their most recent visit to the hospital. For each of the following comorbidities (Fig. 2), listed in order of decreasing prevalence, the number of recorded participants and corresponding percentage of the study population is outlined as follows: hypertension (202, 40.4%), infection and/or infectious disease (65, 13%), pulmonary disorder (56, 11.2%), renal complication (44, 8.8%), hypothyroidism (34, 6.8%), cardiovascular disease (29, 5.8%), hepatic complication (16, 3.2%), cancer (11, 2.2%), hyperthyroidism (6, 1.2%). Whereas 211 participants (42.2%) had no significant comorbidities.
Fig. 2Major comorbidities among the study population.
3.2 Prevalence of VDD and T2DM
Only 95 participants (19%) had normal serum vitamin D levels (i.e. 25(OH)D conc. > 30 ng/mL), with the remaining 405 participants (81%) having sub-normal levels (Fig. 3). Of these, 285 (57%) could be categorized as deficient in vitamin D (i.e. 25(OH)D conc. < 20 ng/mL) and 120 (24%) as insufficient (i.e. 25(OH)D conc. of 20–30 ng/mL). Vitamin D serum levels amongst study participants exhibited a positively skewed distribution with a respective mean and SD of 20.4 and 11.9 ng/mL.
Fig. 3Vitamin D status among study population (N = 500).
With regards to diabetes status, a total of 189 participants (37.8%) could be diagnosed with diabetes according to the aforementioned diagnostic criteria used in the study (Fig. 4). An additional 80 participants (16%) could likewise be diagnosed with pre-diabetes, leaving 231 participants (46.2%) with normal blood glucose levels according to all four indicators used (i.e. fasting, post prandial, and random blood glucose, and HbA1C). The distribution of serum concentrations for HbA1C, the most clinically reliable indicator of diabetes status, was also slightly positively skewed, with a respective mean and standard deviation of 6.5 and 1.8%.
Fig. 4Diabetes status among study population (N = 500).
3.3 Association between VDD and T2DM
Within the study sample, 117 (41.1%) of patients with VDD had T2DM, whereas 72 (33.5%) of patients without VDD had T2DM (see Table 1). This indicates no association between VDD and T2DM (χ2 = 2.98; p = 0.084). Still, an OR value of 1.4, despite statistical insignificance (95%CI:0.96–2.0, p = 0.084) indicates that there is an approximately 40% greater odds of developing T2DM in VDD patients relative to non-VDD patients. Moreover, the likelihood ratio (LR) is 2.99, which indicates an approximately 3-fold chance of having T2DM as a VDD patient, relative to a non-VDD patient. However, there is no statistically significant association between vitamin D status and HbA1C (p = 0.07).
Table 1Association between VDD and T2DM.
VDD status
Diabetes status
Statistical test
∗
Pearson Chi-square (χ2); VDD: Vitamin D Deficiency.
Yes 117 (41.1%) 168 (58.9%) 285 (100%) χ2 = 2.98
p = 0.084
OR:1.4(CI:0.96–2.0)
No 72 (33.5%) 143 (66.5%) 215 (100%)
Total 189 (37.8%) 311 (62.2%) 500 (100%)
∗ Pearson Chi-square (χ2); VDD: Vitamin D Deficiency.
3.4 Associations involving other covariates
χ2 test were conducted to determine the degree of association of both vitamin D and T2DM status with other covariates, including serum levels of CRP, PTH, Ca, and P. However, a statistically significant association was only found between vitamin D status and serum Ca level (p = 0.01).
4.1 Main findings and significance
A few main findings pertaining to vitamin D status and its corresponding associations emerged from this study. Of most significance is the high prevalence of poor vitamin D status found in the study population, with 81% of patients exhibiting serum vitamin D levels below the optimal healthy range, and a positively skewed distribution with a mean almost 10 ng/mL below the minimum healthy vitamin D serum level. This finding is compatible with previous studies reporting a 70–100% prevalence of VDD in India [
], lending further merit to such claims. Yet interestingly, Karnataka, as other South Indian states, ranks on the lower end in terms of state-wide incidence (30–40%) of vegetarianism [
Natrajan B.
Jacob S.
Provincialising' vegetarianism putting Indian food habits in their place.
Econ Polit Wkly. 2018; 53: 54-64
], a contributor to low vitamin D dietary intake [
Crowe F.L.
Steur M.
Allen N.E.
Appleby P.N.
Travis R.C.
Key T.J.
Plasma concentrations of 25- hydroxyvitamin D in meat eaters, fish eaters, vegetarians and vegans: results from the EPIC-Oxford study.
Publ Health Nutr. 2011; 14: 340-346https://doi.org/10.1017/S1368980010002454
]. Similarly, the prevalence of consumption of beef, a high source of vitamin D [
Liu J.
Arcot J.
Cunningham J.
Greenfield H.
Hsu J.
Padula D.
New data for vitamin D in Australian foods of animal origin: impact on estimates of national adult vitamin D intakes in 1995 and 2011-13.
Asia Pac J Clin Nutr. 2015; 24: 464-471https://doi.org/10.6133/apjcn.2015.24.4.04
], is relatively high in Karnataka relative to the Indian average [
]. This raises concerns regarding the high prevalence of VDD observed in this Karnataka study population where risk factors such as vegetarianism may be relatively less present than in populations across other Indian states.
Similarly, the high proportion of patients with serum glucose levels in the diabetic and/or prediabetic range, precisely 53.8% or just over half of the study population, is indicative of the widely reported burden of diabetes in India and the growing public health threat that it poses. Although the proportion of patients with T2DM was higher amongst those with VDD (41.1%) than amongst those without VDD (33.5%), the association between VDD and T2DM was not statistically significant in this study. In contrary, the results from risk and LR estimation provide justification for further investigation of this association. As the LR denotes how likely a VDD patient is to have T2DM in relation to a non-VDD patient, a value of 2.99 suggests that a statistically insignificant p-value for the association may be insufficient evidence alone to reject the possibility that VDD plays a role in the etiology of T2DM. Furthermore, the statistically significant association of vitamin D status and serum Ca level observed in this study is consistent with the established literature concerning their physiological links in associated homeostatic pathways.
4.2 Analysis of results, strengths, and limitations
The high prevalence of VDD amongst study participants, while compatible with previous epidemiological findings, may be due in part to the higher tendency of those tested to be deficient in vitamin D. This limitation is attributable to the inherently biased selection of participants according to retrospective vitamin D testing. This may have amplified the detected prevalence and hence led to an overestimation of the epidemiological burden of VDD in the mainstream south Indian population. The effect on serum vitamin D of other comorbidities, which may have been present at higher than average rates in this study population due to their selection from a tertiary healthcare setting, can also not be ruled at as a potential contributor to an over- or under-estimated VDD prevalence.
Existing ambiguities in the mainstream literature regarding the epidemiological and clinical distinction between deficiency and insufficiency of vitamin D pose additional challenges to comparing findings concerning the categorical distribution of vitamin D status amongst study participants to that of the greater Indian population. Therefore, while the detected VDD prevalence of 81% is in line with the 70–100% prevalence rates reported across Indian subpopulations, few cross-study comparisons can be drawn regarding the epidemiological distinction between deficiency and insufficiency of vitamin D.
With regards to diabetes prevalence amongst study participants, there are limitations to extrapolating these findings to the Indian population as a whole due to the unique diagnostic criteria used for defining diabetes status in the specific context of this study. While previous studies have identified diabetes as a major public health threat in India, prior estimates of T2DM prevalence are much lower than those ascertained from this study [
]. This is likely due to the fact that clinical T2DM status is dependent on more stringent diagnostic criteria (i.e. consistently high blood glucose levels upon several consecutive measurements), while, for the purposes of our analysis, a single blood glucose test result in the diabetic range was sufficient to meet the requirements for diagnosis of T2DM. The high proportion of hypertensive study participants may also be implicated in the high diabetes prevalence observed due to the established correlation between these interrelated comorbidities. However, misclassification of T2DM status could have also occurred in the other direction wherein cases of T2DM were missed as a result of an abnormally low blood glucose level upon measurement, depending on the time of day at which the measurement was taken. While the inclusion of participants with a medically documented T2D diagnosis aimed to limit this form of misclassification, it may still have been unavoidable in some, very early stage, T2DM cases. The high proportion of participants exhibiting at least one blood glucose measure characteristic of the diabetic phenotype may indicate a high prevalence of individuals on the verge of becoming diabetic, an additional important measure of the potential diabetes burden in India. Furthermore, the convergent trends of high VDD and T2DM prevalence amongst study participants may lend further justification for continued investigation of their association.
The lack of statistical significance in findings pertaining to VDD's association with T2DM, while important to take into account when drawing conclusions, does not entirely invalidate the hypothesized link. Rather, this finding must be viewed in light of the existing literature and potential limitations in the study design and conduct. The effect of overestimating diabetes cases due to clinically inconsistent diagnostic criteria may have been greater in the smaller non-VDD group and hence decreased the measured difference in diabetes prevalence, weakening any observed correlation. Furthermore, the high VDD prevalence amongst study participants led to a significant discrepancy in the sample sizes of VDD and non-VDD groups, making it difficult to draw robust comparisons between them upon statistical analysis. Such limitations likely also played a mediating role in the relationships observed with other covariates. While retrospective data collection allowed efficient pooling of information pertaining to various parameters and covariates, it also rendered gaps in the data which may have been disproportionally distributed across study groups, introducing further information bias. Additionally, the inability to detect chronology from retrospective data records allowed us to only make cross-sectional measurements without regard to pathways of causality. Inconsistent temporality likely rendered a more heterogenous study population, making it more difficult to pool results and draw comparisons. Nonetheless, the stronger association observed between vitamin D and HbA1C serum levels is important to take into account, particularly due to the increased consistency and reliability of HbA1C as a clinical indicator of diabetes status. The fact that excluding other, less reliable, glucose parameters from the statistical analysis strengthened the measured association is perhaps indicative of the limitations imposed by their inclusion in the diagnostic criteria utilized for determining diabetes status. As HbA1C is a more robust metric, this result, of higher statistical significance, may therefore also hold greater internal validity.
5. Conclusions and future considerations
Although the findings from this study exhibit several limitations which may reduce the validity and overall generalizability, the findings contribute one further piece of evidence to a growing yet controversial body of research. While the results may not independently address many of the existing ambiguities in the corresponding literature, they lend important justification for the need for further research to investigate this association and address such gaps. Other researchers should view these findings in light of the strengths and weaknesses when drawing conclusions and designing future studies to further investigate the links between VDD and T2DM. Specifically, future research should focus on more robust studies such as prospective cohorts and RCTs to overcome some of the limitations imposed by the weaker retrospective cross-sectional study design. Should sufficient quantity and quality of research ultimately be obtained to address the existing literature gaps and contradictions, novel clinical modalities with profound public health consequences may be implemented for addressing VDD and T2DM, both in India and globally.
Statement of authorship
All persons who meet authorship criteria are listed as authors, and all authors certify that they have participated sufficiently in the work to take public responsibility for the content, including participation in the concept, design, analysis, writing, or revision of the manuscript. Both Ms. Hannah Marcus and Dr. Sonal Sekhar M were involved in the initial study designing and planning stages. Ms. Hannah Marcus was responsible for the data collection and writing components, and Dr. Sonal Sekhar M assisted with data synthesis, analysis, and editing of the final manuscript. Dr. Muralidhar Varma oversaw the research process and provided the necessary consultation and critically reviewed the final draft of the manuscript. All the authors approved the final draft of the manuscript.
Authors have no conflict of interest.
The authors express their gratitude to Manipal College of Pharmaceutical Sciences & Kasturba Medical College and Hospital, Manipal, Academy of Higher Education, Manipal, India for the research support and facilities. Finally, the first author thanks to AIESEC, a global exchange organization for youth, enabled this student-led research by facilitating the international internship and coordinating partnerships between Manipal and McMaster University.
Accepted: December 22, 2020
Received: July 19, 2019


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