CLINICAL & BASIC RESEARCH

SQU Med J, February 2011, Vol. 11, Iss. 1, pp. 45-51, Epub. 12th Feb 11
Submitted 2nd Aug 10
Revision ReQ. 11th Oct 10, Revision recd. 17th Oct 10
Accepted 10th Nov 10

·^€ �¬<ª<ÁeÜ÷]<Ó◊¬<ÏÜ�Èä÷]
ÍeÜ√÷]<sÈ◊§]<ª<?ÁeÜ◊÷<̜Ȝ£]Ê<–È€√÷]<‹„À÷]@<ŸÁu<ÌÈflõÁ÷]<sÒ^jfl÷]<

<ÓfiÅ˘]<—Üé÷]Ê<


 “”
 
 2007 102
 “  2008
 201 %21
 %43 16
 %45 %57 
 
 %44 
 %47
 %5 %34.8 %32.6

 0.054

 

 

aBStract: Objectives: The Asthma Insights and Reality (AIR) study in the Gulf and Near East (one of a worldwide 
series of surveys conducted in adults and children to assess asthma control) was conducted in Oman to assess 
how closely asthma control meets international guidelines recommendations. Methods: From January 2007 to 
March 2008, asthmatics receiving treatment or currently suffering from asthma symptoms were interviewed 
among nationals randomly surveyed from the most populated urban areas in Oman (Muscat, Sohar and Nizwa). 
The standard AIR questionnaire was used to assess symptom severity, health care utilisation, limitation of activity 
and medication use. Results: From 201 asthmatic participants, 21% were under 16 years and 43% were female. 
Tobacco use was low in our asthmatics. Disparity in asthma perception was wide in Oman; while 57% of asthmatics 
perceived their asthma as well or completely controlled, actually 54% had poorly or not well controlled asthma. All 
recommendations for asthma control by the Global Initiative for Asthma were largely unmet, especially in child 
asthmatics, with 44% reporting night awakenings due to asthma during the previous 4 weeks and 47% exercise-
induced asthma in the previous 12 months. Overall, 32.6% of children and 34.8% of adults reported absence due to 
asthma from school/work during the previous year. Use of preventive inhaled corticosteroids was only 5.0%, one 
of the lowest even within the AIR Gulf and Near East study, producing an unacceptable ratio ICS/SABA (inhaled 
corticosteroid/short acting beta-agonist) of 0.054 in Omani asthmatics. Conclusion: Asthma control in Oman falls 
far below the goals of current international guidelines therefore corrective strategies are needed.

Keywords: Asthma; Oman; Health survey; Asthma Prevention & Control; Adult; Child

CLINICAL & BASIC RESEARCH

Asthma Control in Oman
National Results within the Asthma Insights and Reality in the Gulf 

and the Near East (AIRGNE) Study 
*Nasser Al-Busaidi1 and Joan B Soriano 2

CLINICAL & BASIC RESEARCH

1Department of Medicine, Royal Hospital, Muscat, Oman; 2Epidemiology and Clinical Research, Fundación Caubet-Cimera (Centro 
Internacional de Medicina Respiratoria Avanzada), Islas Baleares, Spain.
*Corresponding Author email: enhsa@hotmail.com 

ADVanceS in KnoWleDGe
1.  Current international asthma initiatives, both for children and adults, recommend to measure the asthma burden worldwide. However, 



Asthma Control in Oman 
National Results within the Asthma Insights and Reality in the Gulf and the Near East (AIRGNE) Study 

46 | SQU Medical Journal, February 2011, Volume 11, Issue 1

The Global Initiative for Asthma (GINA) guidelines, which were introduced in 1995,1 followed by many other local 
guidelines, all aimed at improving asthma patient 
care and ensuring better long-term control of the 
disease. Control was the cornerstone of the latest 
GINA update in 2006.2 Studies have shown that 
total asthma control is achievable in most patients.3 

There exists, however, a wide gap between the goals 
of treatment as set out in the guidelines and actual 
real-life clinical practice outcomes. Recently, several 
Asthma Insights and Reality (AIR) surveys were 
conducted in various countries around the world, 
including the USA, Canada, the Asia-Pacific region, 
Western and Central-Eastern Europe, Japan, Latin 
America, Saudi Arabia, and most recently in the 
Gulf and the Near East. They all aimed to determine 
variations in asthma severity and control, both from 
the patient perspective and objectively, compared 
to what is recommended by the guidelines. 
Consistently, these surveys demonstrated a poor 
level of asthma control in all the above mentioned 
countries and regions, with local variations specific 
to each country.

Oman is in the Middle East at the northern 
edge of the Gulf with a population of about 2.6 
million inhabitants. There is a paucity of statistics 
about asthma prevalence and asthma burden in 
Oman. By using the International Study of Asthma 
and Allergies in Childhood (ISAAC) methodology 
2003, Al-Riyami et al. reported prevalence rates of 
diagnosed asthma in Oman of 20.7% in 13–14 year-
olds, whereas in younger children (6–7 years) it was 
10.5%.4

The prevalence of severe asthma (sleep-
disturbing wheeze and speech-limiting wheeze) and 
frequent symptoms in Omani schoolchildren (age 
between 6–7 years), compared with other ISAAC 
participating countries in the East Mediterranean 
region, was higher than in any other country in the 
study. Similarly, the prevalence of sleep-disturbing 
wheeze among Omani children was nearly four 

times that of Iran and almost double that of Malta.4 
We also previously reported that more than 50% of 
our adult asthmatic patients felt that their asthma 
had a negative impact in their work, school or home 
duties.5 Nocturnal symptoms were common in our 
studied patients, only 44% reported having had no 
night-symptoms in the previous 4 weeks, while the 
rest felt their asthma often disturbed their sleep. 
This ranged from 4% reporting two to three wake-
ups per night to 28% reporting one to two wake-ups 
due to asthma in the last 4 weeks.5 

The GINA guidelines have been developed 
to promote standardised methods of diagnosis 
and treatment of asthma that now are generally 
accepted worldwide. Research published since the 
release of the GINA guidelines indicates that in 
many countries patients with asthma are unequally 
treated and that adherence to asthma treatment 
guidelines is poor.6,7

All AIR studies aimed to assess the discrepancy 
between perceived symptoms and subjective 
assessments versus objective control and the 
burden of asthma in order to determine the 
implementation status of the goals and management 
recommendations advocated by GINA. They 
also have helped to shed light on the perceptions, 
knowledge and attitudes related to asthma at the 
local level in order to assist in future national policy 
development. Oman was one of the Gulf and Near 
East countries included in the AIR Gulf and Near 
East (AIRGNE) study, together with Jordan, Kuwait, 
Lebanon, and the UAE. The summary results have 
been published elsewhere,8 but the specific Omani 
data results warrant a closer look and are presented 
in this paper.

Methods
The AIRGNE survey was conducted between 
January 2007 and March 2008. The most populated 
urban areas in Oman were surveyed in AIRGNE, 
namely the capital area, Muscat/Seeb/Mutrah, with 

to date there were few studies conducted in the Gulf and none in Oman focused on measuring asthma control and asthma severity.
2.  The current use of preventive medications in Omani asthmatic children and adults appear to be one of the lowest in the Gulf region, and 

even worldwide.

Application to Patient Care
1.  Doctors in Oman should be aware of the burden of asthma.
2.  Educational and corrective strategies should be implemented in Oman to improve individual and population asthma management.



Nasser Al-Busaidi and Joan B Soriano

Clinical and Basic Research | 47

60% of the sample; Sohar, a port city on the northern 
coast of Oman with 25%, and Nizwa, a city 120km 
south west of Muscat in the Dakhiliyah region with 
15%. The sampling was structured by gender and 
age within each city or urban area. 

Asthma patients were identified by 
systematically screening a sample of households 
for persons who had been diagnosed with asthma. 
A sampling plan was designed to provide a 
nationally representative sample of households 
that could be screened to identify a community 
sample of current asthma sufferers for Oman. A 
geographically stratified sample of households, 
proportionate to the population, was drawn within 
the three designated areas. The survey design 
required a sample of 200 asthma patients. In each 
household, an adult was asked whether a physician 
had ever diagnosed any member of the household 
as having asthma. If the answer was “yes”, the 
interviewer asked whether any of these individuals 
were currently taking medication for their asthma, 
or had suffered an asthma attack or experienced 
asthma symptoms in the past year. The number of 
persons in the household, as well as the number 
who had been diagnosed with asthma and met the 
survey criteria for current asthma, were collected 
to provide estimates of comparative prevalence. If 
more than one household member qualified as a 
current asthma patient, the interviewer randomly 
selected one as the designated respondent. Only 
one respondent was interviewed per household 
because multiple interviews in the same household 
would have created a bias. If the selected respondent 
was 16 years of age or older, the interview was 
conducted with the patient; if he/she was 15 years 
or younger, the interview was conducted with the 
parent or guardian most knowledgeable about the 
child’s asthma condition and treatment.

The study was approved by the Ethics 
Committee of the Ministry of Health, Oman. This 
study was non-interventional and anonymous, and 
no individual identifiers were obtained or stored. 
Following the advice of the coordinating team 
in Europe (JB Soriano) it was considered that the 
verbal authorisation from individual asthmatics (or 
his/her parent) would be sufficient consent. 

The core questionnaire was that used in 
previous AIR studies in Europe and elsewhere,8 
which was  based on the original ATS (American 
Thoracic Society) questionnaire.9 The questionnaire 

was translated into Arabic and then translated 
back again; any discrepancies or inconsistencies 
discovered by this process were solved by consensus. 
In addition, the following items were included: 
self-completion of the asthma control test (ACT) 
questionnaire,10 various questions modified to  
reflect the local conditions and characteristics of 
asthma in Oman and some additional questions 
to reflect the latest GINA guidelines. It was 
administered with an English-Arabic side-by-side 
layout,8 available online from the International 
Journal of Tuberculosis and Lung Disease (IJTLD) 
website.10 

As per standard quality control procedures, all 
materials were piloted. There was also a personal 
briefing of all interviewers in each region, and 
each interviewer conducted two pilot interviews 
and reviewed the completed questionnaires with 
a supervisor before starting fieldwork. Completed 
questionnaires were checked locally and again 
centrally, and a random double check of interviews 
in all regions was conducted by telephone. Finally, all 
data were included in a database after independent 
double typing.

The frequency and severity of daytime and night-
time symptoms, exercise-induced symptoms and 
severe episodes, and total symptom frequency, were 
used to develop a symptom severity index similar 
to the GINA asthma severity scale.11 In addition, 
events such as hospitalisations and emergency care 
utilisation were documented, as well as the impact 
of days of school/work lost due to asthma. Patient 
demographic and asthma severity characteristics 
were compared using chi-squared analysis to 
identify factors that might account for differences in 
asthma management across the country, or analysis 
of variance for quantitative variables whenever 
required. Statistical comparisons within the country 
versus the published international AIR estimates 
were explored. All statistical tests were two-sided 
and comparisons with <5% probability of error were 
considered statistically significant.

Results
A total of 201 valid interviews with Omani 
asthmatics in the three participating cities were 
completed, of whom 115 (57%) were male. The 
age distribution was very young, with 21% of 
the sample being 5–15 years old and 33% 16–29  



Asthma Control in Oman 
National Results within the Asthma Insights and Reality in the Gulf and the Near East (AIRGNE) Study 

48 | SQU Medical Journal, February 2011, Volume 11, Issue 1

years old. Most participants had only completed 
primary (38%) or secondary (30%) education. 
Reported income was lower than $1,000 per year 
in 75% of surveyed participants, while reported 
smoking in adults was minimal [Table 1].

A total of 90 (57%) of adult asthmatic responders 
(n = 158) perceived their asthma as "well" or 
"completely" controlled. The actual figures show,  
on the contrary,  that 54% of adult responders had 
"poorly" or "not well" controlled asthma. (P <0.05 ).

A total of 71% of participating Omani asthmatics 
reported day-symptoms during the previous 4 
weeks. Similarly, 44% reported night awakenings 
due to asthma during the previous 4 weeks and 47% 

exercise-induced asthma in the previous 12 months, 
both were particularly frequent in child asthmatics 
[Table 3]. Exacerbations and use of health services 
were equally high, and limitations of daily activities 
due to asthma were widespread both in children 
and adult asthmatics. One in three asthmatics had 
never had their lung function tested and few owned 
a peak flow meter.

A total of 32.6% of children reported school 
absence due to asthma during the previous year, 
with a mean standard deviation (SD) of 6.1 (8.5) 
days. In adults 34.8%  reported work absence due 
to asthma during the past year, with a mean SD 
of 9.9 (9.8) days [Table 4]. Use of health services 
was similarly high compared to other AIRGNE 
participating countries, with 30% of hospitalisations 
and 58% of emergency (unscheduled) medical visits.

Finally, current use of preventive inhaled 
corticosteroids was 5.0%, one of the lowest even 
within the AIRGNE study, with a mean of 14.6%.  
Most (92%) patients relied rather upon quick relief 
medications, producing an unacceptable ratio ICS/
SABA (inhaled corticosteroid/short acting beta-
agonist) of 0.054 [Table 5]. As mentioned above, 
there was a low prevalence of both ownership of a 
peak flow meter (25.4%) and ever having had a lung 
function test (35.0%) in the Omani asthmatics in 
this study.

Discussion
AIRGNE-Oman was the first survey in the country 
to assess objectively the level of control and 
severity of asthma. It demonstrated that asthma 
management was poor in 2007–2008 compared to 
recommendations in published guidelines. As in 

Table 1: Demographic characteristics of asthma patients. 
Values correspond to numbers (percentages) of patients 
in the corresponding category except for age of adults 
and children at inclusion and age at diagnosis which are 
represented as means ± standard deviation (13.5 ± 6.7) 

Parameter Population N = 201

Interval age distribution

5–15 years 43 (21%)

16-29 years 67 (33%)

30-49 years 71 (35%)

> 50 years 20 (10%)

Age at diagnosis, mean; 13.5 

Gender

M 115 (57%)

F 86 (43%)

Level of education

Primary 77 (38%)

Secondary 62 (30%)

University 62 (30%)

Income

<1000 $ 152 (75%)

1000-2000 $ 36 (18%)

>2000 $ 13 (6%)

Region

Muscat 121 (60%)

Sohar 50 (25%)

Nizwa 30 (15%)

Smoking habits in adults

Never smoked 173 (96%)

Former smokers 7 (3%)

Table 2: Comparison between objective and subjective 
evaluation of asthma control

Subjective 
asthma 
control§

Objective 
asthma 
control*

P value

Poorly and 
not well 
controlled

68 (43%) 86 (54%) <0.05

Well/
completely 
controlled

90 (57%) 72 (46%)

Note: § = Adult responders only (n=158); *= objective evaluation of 
asthma control relies on the asthma control test (ACT). An ACT of 5 
to 19 corresponds to a poorly and or not well controlled asthma, and 
an ACT of 20 to 25 corresponds to a well controlled asthma for adult 
responders only (n=158).



Nasser Al-Busaidi and Joan B Soriano

Clinical and Basic Research | 49

all previously published international AIR studies, 
asthma is poorly managed in Oman with the 
performance far below the recommended goals of 
any guidelines. This was obvious when the actual 
GINA recommendations of control were compared 
to the AIRGNE-Oman findings [Table 2], clearly 
showing that guideline-based control was not 
achieved at the time in of our study. 

In the European and Asia Pacific AIR studies 
approximately half of the adult patients reported 
daytime symptoms. The overall figure in the 
AIRGNE study was 68%, and it was equally high 
in Oman (71%) in the present study. These results 
are close to the findings of Rawas et al. as they 
found nearly 60% of all current wheezers reported 
at least one of the symptoms indicating severe or 
uncontrolled asthma.14 Night awakenings were 
also frequent in the AIRGNE-Oman study (44%), 
and this finding is compatible with the study of 

Al-Riyami et al.4 where the prevalence of sleep-
disturbing wheeze in Oman was nearly four times 
that of Iran (3.5% versus 0.9%) and more than double 
that of Malta (3.5% versus 1.5%). It was even higher 
than that of Australia (3.5% versus 2.8%), a country 
with the highest prevalence rate of wheeze among 
all ISAAC participating countries, being more than 
three times that of Oman. 

The frequency of hospitalisation in Oman in 
the previous twelve months was also high, reaching 
30%. Emergency department visits were high in 
Oman, as in other AIRGNE countries, the figures 
being 58% and 51% respectively. These figures were 
much higher than those in the study conducted by 
Al Rawas et al.12

 
Of the asthmatic patients in his 

study, who were attending asthma specialty clinics, 
only 31.9% had visited the emergency department 
and 15.0% patients had been hospitalised at least 
once during the previous year.

Table 3: The Global Initiative for Asthma (GINA) recommendations for asthma control and the Asthma Insights and 
Reality in Oman (AIRO) results

GINA definition 
for control of 
asthma

AIRO findings Adults (%) Children (%) All (%)

Minimal (ideally no) 
chronic symptoms, 
including nocturnal 
symptoms

Asthma symptoms
During day (past 4 
weeks)
Night wakening (past 4 
weeks)
Exercise-induced 
asthma (past 12 
months)

 
73
 

45
 
 

51

 
81
 

60
 
 

60

 
71
 

44
 
 

47

Minimal 
exacerbation

Sudden severe episodes 
in past 12 months

 
95

 
84

 
93

No emergency visit 
for asthma

Hospitalisation (past 12 
months)
Emergency department 
visit (past 12 months)

 
35
 

18

 
42
 

36

 
30
 

21

Minimal need for 
short-acting β2- 
agonists

Current use of quick-
relief bronchodilators

 
-

 
-

 
85

No limitation on 
activities, including 
exercise

Asthma restricts
Sports and recreation
Normal physical 
Activity
Choice of jobs/careers
Social activities
Sleeping
Lifestyle
Household chores

38
35
18
32
22
21
20

77
70
14
42
56
49
49

46
43
17
34
29
27
26

Normal or near-
normal lung 
function (PEF 
variability 20%)

Never had a lung-
function test
Owns a peak flow 
meter

 
42
 

17

 
19
 

35

 
35
 

25

Legend: PEF = peak expiratory flow.



Asthma Control in Oman 
National Results within the Asthma Insights and Reality in the Gulf and the Near East (AIRGNE) Study 

50 | SQU Medical Journal, February 2011, Volume 11, Issue 1

On the other hand, school absence in children 
was significantly less frequent in Oman than in other 
AIRGNE countries (32.6% versus 51%; P <0.05, Chi 
2 p statistic when compared to AIRGNE results.) 
Another positive finding among adult asthmatics in 
AIRGNE-Oman study was the very low prevalence 
of smoking, with only 3% of respondents reporting 
either a current or previous smoking habit. This 
is probably one of the lowest figures recorded 
worldwide,13

 
and indeed an achievement to be 

sustained in the future.
The current use of asthma medications in 

Oman is disappointing. According to the findings 
in this study, only 5% of asthmatics were using 
inhaled corticosteroids compared to 14.6% in 
other AIRGNE countries (P <0.05). On the other 
hand, the use of rescue medication was strikingly 
high, with 92% of asthma patients reporting daily 
use of them compared to 55.5% in other AIRGNE 
countries. Interestingly, these findings totally differ 
from Al Rawas et al. where 92% of asthma patients 
attending asthma specialty clinics used inhaled 
corticosteroids.12

 
The discrepancy is likely due to 

the fact that patients in asthma specialty clinics are 
seen by chest specialists who are aware that steroid 
inhalers are the cornerstone of asthma treatment; 
it is also possibly due to the fact that these patients 
have more severe asthma.  

Most patients overestimated their level of 
control and underestimated their disease severity, 
as there was a disparity in the patient subjective 
versus objective asthma severity perception. While 
90 (57%) of asthmatics perceived their asthma as 
well or completely controlled, actually 54% had 
poorly or not well controlled asthma as objectively 
identified by an ACT score of 5 to 19 (P <0.05 ). The 
frequency of lung function tests was generally low 
in Oman, being at similar levels to other AIRGNE 
countries, as only 35% reported their lungs ever 
tested, and only 25% owned a peak flow meter. 

Overall, when comparing the Omani results 
with the AIRGNE average, the management of 
asthma in Oman was worse in terms of reporting a 
higher use of rescue medications and very low uses 
of inhaled corticosteroids, as well as unacceptably 
frequent visits to emergency departments. 

Table 4: Evaluation of asthma burden in the past year in Oman by comparison to Asthma Insights and Reality in the 
Gulf and Near East (AIRGNE) study results

Oman  
(N = 201)

AIRGNE  
(N= 1,000)

P value

Asthma burden in the past year

School absence in children, %
     Mean number of days (SD)
Work absence in adults, %
     Mean number of days (SD)

32.6
6.1 (8.5)

34.8
9.9 (9.8)

51.7
7.9 (9.6)

29.7
7.3 (8.1)

<0.05

0.420

Use of health services in the past year

Hospitalisation, %
Emergency medical visit, %

30.0
58.0

22.5
51.5

0.723
0.571

Legend: SD= standard deviation.

Table 5: Current use of preventive inhaled corticosteroids and quick relief medications, and evaluation of lung function 
in Oman by comparison to Asthma Insights and Reality in the Gulf and Near East (AIRGNE) study results

Oman  
(N = 201)

AIRGNE  
(N= 1,000)

P value*

Current use of medication (previous 4 weeks)

Use of ICS, %
Use of quick relief, %
Ratio ICS/SABA

5.0
92.0

0.054

14.6
55.5
0.26

<0.05
<0.05
<0.05

Lung function

Own a peak flow meter, %
Ever had a lung function test, %

25.4
35.0

17.1
32.7

<0.05
0.746

Legend: ICS= inhaled corticosteroids; SABA= short acting beta-agonist.



Nasser Al-Busaidi and Joan B Soriano

Clinical and Basic Research | 51

There are some potential limitations of this 
survey. First, sampling was not performed according 
to Random Digit Dialing (RDD) as in most other AIR 
surveys. In countries where telephone ownership 
levels approach 100% and comprehensive databases 
are available, RDD can approximate a representative 
random sample of the population. However, RDD 
was not considered appropriate in Oman, and 
overall in the GNE, because of the low penetration 
of telephone coverage. 

Second, there are problems associated with 
the term asthma in our country, therefore many 
doctors avoid using this term, and use instead the 
term allergy, with an intention to making it milder 
and more acceptable to patients themselves or 
to their parents. Perhaps third, the sample size of 
201, while being considerable enough, gives some 
subgroup analyses (by young children or in severe 
asthma) reduced statistical power. Therefore, more 
studies are needed to monitor all trends and assess 
current interventions. 

Conclusion 
The AIR study in Oman highlights the gap between 
the recommended long-term asthma management 
guidelines and the reality in Oman. International 
guidelines recommend treating inflammation 
and not symptoms, but the trend of poor inhaled 
corticosteroid utilisation among Omani patients 
with persistent asthma suggests undertreatment. 
This implies an immediate need to improve 
communication and awareness among patients 
and physicians, specifically to reinforce the use of 
anti-inflammatory medications. Underestimation 
of the severity of asthma and overestimation of 
asthma control by both patients and physicians 
are important factors contributing to poor asthma 
control.

c o n f l i c t o f i n t e r e s t
The AIRGNE survey was sponsored by 
GlaxoSmithKline. All authors had access to the 
database and discussed and drafted this report 
independently from the sponsor.

References
1. Global Initiative for Asthma (GINA). Global strategy 

for asthma management and prevention. NHLBI/
WHO workshop report. National Institute of Health, 
National Heart, Lung and Blood Institute; 1995. 
National Institute of Health publication no. 95-3659.

2. Bateman ED, Hurd SS, Barnes PJ, Bousquet J, Drazen 
JM, FitzGerald M, et al. Global strategy for asthma 
management and prevention: GINA executive 
summary. Eur Respir J 2008; 31:143–78.

3. Bateman ED, Boushey HA, Bousquet J, Buss WW, 
Clark TJ, Pauwels RA, et al. Can guideline-defined 
asthma control be achieved? The Gaining Optimal 
Asthma Control study. Am J Respir Crit Care Med 
2004; 170:836–41.

4. Al-Riyami BMS, Al-Rawas OAS, Al-Riyami AA, 
Jasim LG, Mohammed AJ. Relatively high prevalence 
and severity of asthma, allergic rhinitis and atopic 
eczema in schoolchildren in the Sultanate of Oman. 
Respirology 2003; 8:69–76.

5. Al-Busaidi N, Al Mokhaini S. Level of control of 
asthma patients in chest specialist clinics. Oman 
Med J 2009; 24:195–8. doi:10.5001/omj.2009.38.

6. Rickard KA, Stemple DA. Asthma survey 
demonstrates that the goals of the NHLBI have not 
been accomplished. J Allergy Clin Immunol 1999; 
103:S171.

7. Largelov P, Veninga CC, Muskova M. On behalf of 
the Drug Education Project (DEP) group. Asthma 
management in five European countries: Doctors’ 
knowledge, attitudes and prescribing behavior. Eur 
Respir J 2000; 15:25–9.

8. Khadadah M, Mahboub B, Al-Busaidi NH, Sliman 
N, Soriano JB, Bahous J. Asthma insights and reality 
in the Gulf and the near East. Int J Tuberc Lung Dis 
2009; 13:1015–22.

9. Ferris BG. Epidemiology standardization project. 
Am Rev Respir Dis 1979; 118:S1–120.

10. International Journal of Tuberculosis & Lung 
Disease. GINA questionnaire. From: http://www.
theunion.org/about-the-journal/about-the-journal.
html Accessed: July 2010.

11. Rabe KF, Vermeire PA, Soriano JB, Maier WC. 
Clinical management of asthma in 1999: the Asthma 
Insights and Reality in Europe (AIRE) study. Eur 
Respir J 2000; 16:802–7.

12. Schatz M, Sorkness CA, Li JT, Marcus P, Murray JJ, 
Nathan RA, et al. Asthma Control Test: reliability, 
validity, and responsiveness in patients not 
previously followed by asthma specialists. J Allergy 
Clin Immunol 2006; 117:549–56.

13. Rabe KF, Vermeire PA, Soriano JB, Maier WC. 
Clinical management of asthma in 1999: the Asthma 
Insights and Reality in Europe (AIRE) study. Eur 
Respir J 2000; 16:802–7.



CLINICAL & BASIC RESEARCH

SQU Med J, February 2011, Vol. 11, Iss. 1, pp. 52-55, Epub. 12th Feb 11
Submitted 24th Nov 10
Revision ReQ. 3rd Jan 11, Revision recd. 10th Jan 2011
Accepted 11th Jan 11

Departments of 1Obstetrics & Gynaecology and 2Medicine, Sultan Qaboos University Hospital, Muscat, Oman; 3Industrial Innovation 
Center, Rusayl, Oman; 4Department of Medicine, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman.
*Corresponding Author email: omayma0@hotmail.com

ÿ⁄]Á£]<l^Èfi^€�√÷]<Çfl¬<DÅE<∞⁄^fljÈ <<Ì÷^u
–◊œ÷]<4ni<<l^ñËÜπ]<‡⁄<ÌÈ÷^¬<Ìfäfi<Çfl¬<DÅE<∞⁄^jÈ <‡⁄<ÌñÀ~fl⁄<<Ìfäfi<ÅÁqÊ<


 25 
  100
2010 ––
 25%69 67 25 ≥%35 34
 75< 5025

 10003
3 25 :مفتاح الكلمات

aBStract: Objectives: The objective of this study was to determine the vitamin D status of pregnant Omanis by 
measurement of their circulating 25 hydroxy vitamin D levels. Methods: Blood samples were obtained from a cohort 
of 103 consecutive healthy pregnant Omanis at the Armed Forces Hospital, Muscat, on their first antenatal visit. 
The study took place in May, June and July 2010. Results: Vitamin D deficiency was present in 34 (33%) of patients 
(25OHD3 <25 nmol/L), ‘at risk’ levels were found in 67 (65%) patients (25OHD3 25–50 nmol/L); two patients (1.9%) 
had values between 50 and 75 nmol/L, and no patients in the optimal range >75 nmol/L. Conclusion: If confirmed, 
these findings indicate the need for vitamin D replacement during pregnancy and lactation. Although not evidence 
based we recommend at least 1000 IU of cholecalciferol, (vitamin D3) daily.

Keywords: Pregnancy; Oman; 25 hydroxyvitamin D3 (25OHD3); Vitamin D deficiency

Vitamin D Status in Pregnant Omanis
A disturbingly high proportion of patients with low vitamin D stores

Moza Al Kalbani,1 *Omayma Elshafie,2 Mohammed Rawahi,2 Ali Al-Mamari,2 Abdullah Al-Zakwani,3 
Nicholas Woodhouse4

CLINICAL & BASIC RESEARCH

ADVanceS in KnoWleDGe
This article is the first to draw attention to the possibility of widespread vitamin D deficiency among pregnant women in Oman. 
Application to Patient Care
Until more is known about the vitamin D status in Omanis, we recommend that all pregnant women and lactating mothers should receive
vitamin D supplements with at least 1000 IU vitamin D3 daily.

Deficiency of vitamin D is common worldwide1 including the Gulf states.2,3 The latter is surprising as sunlight is 
abundant in the Middle East. More than 90% of our 
vitamin D is provided by sunlight4 and it is therefore 
obvious that those persons affected in Arabian 
countries have little sunlight exposure and a diet 
deficient in vitamin D. 

The role of vitamin D in normal physiology 
is complex and wide ranging. It has important 

immune modulating effects protecting against 
infection,4,5,6 autoimmune disorders7 and certain 
cancers, in addition to its well documented effects 
on the prevention of osteoporosis, fractures, falls in 
the elderly4,5 and impaired cognitive function.8 

As we continually see patients with vitamin D 
deficiency in our clinics, it became important to 
establish whether or not vitamin stores (25OHD) 
are normal in a healthy Omani population. For this 
reason, we chose patients in their first and second 



 Moza Al Kalbani, Omayma Elshafie, Mohammed Rawahi, Ali Al-Mamari, Abdullah Al-Zakwani,  
and Nicholas Woodhouse

Clinical and Basic Research | 53

trimester of pregnancy as pregnancy and lactation 
are associated with profound alterations in calcium 
absorption and skeletal remodelling necessitating 
increased utilisation of vitamin D. Our findings are 
reported below.

Methods
Blood samples were obtained from a cohort of 103 
consecutive healthy Omani patients at their first 
antenatal visit, usually in the first, but sometimes 
the second trimester. They were then assayed for 
serum calcium (Ca), phosphate (Phos), and serum 
alkaline phosphatase (ALP), which were measured 
by spectrophotometry, (COBAS Integra 800, Roche 
Diagnostics, Indianapolis, USA) on the same day. 
Serum samples for parathyroid hormone (PTH)
were measured by immunochemiluminesence 
(Access 2, Beckman Coulter, Inc., CA, USA), and 
25(OH)D3 by the LB211 gamma counter (Berthold 
GmBH & Co. KG, Bad Wilbad, Germany), having 
been centrifuged and deep frozen at –40º C . PTH 
and 25(OH)D3 were then measured on the same day 
at the end of the study.

Statistical analysis was performed to determine 
the relationship between the level of serum Ca, 
Phos, ALP and PTH versus the level of serum 
25(OH)D. We used a correlation test to calculate the 
significance of these relationships. As this showed  
no significant linear correlation, a polynomial trend 
curve was employed. The calculations were made 

for all groups of patients.
Fully informed consent was obtained from each 

patient to extract the blood needed for the above 
procedures in addition to that required for routine 
antenatal screening. The study was approved by the 
Armed Forces Hospital authorities.

Results
Serum 25OHD3 levels were deficient (<25 nmol/L) 
in 34 patients, between 25 and 50 nmol/L in 67 
patients (at risk) and two patients had values 
between 50 and 75 nmol/L. There was no  
significant linear correlation between 25(OH)
D3 and serum Ca, Phos or ALP levels or parity. 
However, a significant relationship between 
PTH and 25(OH)D3 was observed which differed 
between the ‘deficient’ and the ‘at risk’ groups. This 
was confirmed using a polynomial curve, which had 
a significant correlation value of 0.55 [Figure 1].

Discussion
This is the first study to report vitamin D status 
in normal pregnant Omanis. The results are  
alarming: 34% of these apparently healthy women 
were vitamin D deficient and a further 64% ‘at risk’ 
at a time when there is a critical need for calcium 
metabolism to be normal. A pregnant woman must 
provide 25 to 30 gm of calcium to support the 
developing foetal skeleton. Much of this demand 

Figure 1: Relationship between PTH (normal range 1.6–9.3 pmol/L) and 25(OH)D3 levels. There was no linear correlation 
between PTH and 25OHD3 levels, but using a polynomial curve, the correlation coefficient was significant at 0.55.
Legend: PTH = parathyroid hormone; 25(OH)D3 = vitamin D3.



Vitamin D Status in Pregnant Omanis 
A disturbingly high proportion of patients with low vitamin D stores

54 | SQU Medical Journal, February 2011, Volume 11, Issue 1

occurs in the third trimester when the foetal 
skeleton undergoes mineralisation. This demand 
is compensated for by an increased absorption of 
calcium from the gut induced by rising levels of 
PTH and the active metabolite of vitamin D, 1,25 
dihydroxy vitamin D (1,25(OH)2D).9  At this point 
25(OH)D will be utilised to make more 1,25(OH)2D 
and those patients with low stores will be at 
considerable risk for the development of vitamin D 
deficiency and osteoporosis in old age.10

To compound this problem, many Omani 
women have 6 or more children and breast feed for 
up to 2 years. During lactation, hyperabsorption 
of calcium does not occur and remineralisation 
of the maternal skeleton only starts after weaning 
when PTH, and 1,25(OH)2D levels rise, calcium 
absorption increases and urinary calcium levels fall, 
a process that may persist for months.11 Obviously, 
adequate stores of 25(OH)D are vital during this 
period, otherwise skeleton remineralisation will 
be seriously impaired and possibly result in the 
development of osteoporosis in old age.4,5

Interestingly, none of the patients in the 
25(OH)D3 deficiency group were symptomatic 
and serum PTH and ALP levels were still within 
the normal range. However there was a significant 
increase of the percentage rise in PTH in the face 
of a declining 25(OH)D level suggesting the early  
stages of a biological response to vitamin D 
deficiency in the “at risk” group. In the deficiency 
group the reverse response was seen. Our 25(OH)
D3 immunoassay results have been carefully 
checked and are correct. It is possible therefore 
that an overt rise of PTH and ALP levels has been 
suppressed by an oral intake of calcium in excess 
of 1 gm daily as this will delay the development of 
secondary hyperparathyroidism.12,13 Other factors 
such as body mass index may also be relevant14 but 
this was not examined here.

In addition to its musculo-skeletal actions, 
vitamin D deficiency is reportedly associated with 
the development of certain cancers, the metabolic 
syndromes and infections, as well as type 1 and 
type 2 diabetes,4,5 disorders which are common in  
Oman. 

Our results confirm that vitamin D3 stores are  
low even in Omanis of reproductive age. These 
findings are similar to those reported in Saudi 
Arabians more than 25 years ago2 and more  
recently in the UAE and Qatar.3,12 It therefore seems 

sensible to advocate vitamin D supplementation 
for all pregnant women in the Middle East.  
At the present time, there are no clear cut 
recommendations as to the dose, but we 
recommend at least 1000 IU of vitamin D3 a day 
which should be continued throughout lactation. 
Until more is known about the daily calcium intake 
of Omanis, it would be prudent to advocate calcium 
supplementation as well.15

Conclusion
This study shows that vitamin D3 scores are low in 
pregnant Omanis. Further studies are required to 
confirm these findings. Until then, we recommend 
supplementation with vitamin D3 (cholecalciferol) 
for all pregnant and lactating mothers.

c o n f l i c t o f i n t e r e s t
The authors reported no conflict of interest.

References
1. Thacher TD, Fisher PR, Strand MA, Pettifor JM.  

Nutritional rickets around the world: causes and 
future directions. Ann Tropical Paediatr 2006;  
26: 1–16.

2. Woodhouse NY, Norton W. Low vitamin d levels in 
Saudi Arabians.  King Faisal Spec Hosp Med J 1982; 
2:127–31.

3. Saadi HF, Dawodu A, Afandi BO, Zayed R, Benedict 
S, Nagelkerke N. Efficacy of daily and monthly high 
dose calciferol in vitamin D deficient nulliparous  
and lactating women. Am J Clin Nutr 2007; 85:1565–
71.

4. Holick MF. Vitamin D: A delightful health 
perspective.  Nutrition Rev 2008; 66:5182–94.

5. Pearce SHS, Cheetham TD. Diagnosis and 
management of vitamin D deficiency. BMJ 2010; 
340:b5664.

6. Holick MF. Vitamin D deficiency. Review article. N 
Engl J Med 2007; 357:266–81.

7. Hyponen E, Laara E, Reunanen A, Jarvelin M-R, 
Vertanen SM. Intake of vitamin D and risk of type 
1 diabetes. A birth cohort study. Lancet 2001; 
358:1500–03.

8. Llewellyn DJ, Lang IA, Langa KM, Muniz-Terrera G, 
Phillips CL, Cherubini A, et al. Vitamin D and risk 
of cognitive decline in elderly persons. Arch Intern 
Med 2010; 170:1099–100.

9. Affinito P, Tommaselli GA, di Carlo C, Guida F, 
Nappi C. Changes in bone mineral density and 
calcium metabolism in breastfeeding women: A one-



 Moza Al Kalbani, Omayma Elshafie, Mohammed Rawahi, Ali Al-Mamari, Abdullah Al-Zakwani,  
and Nicholas Woodhouse

Clinical and Basic Research | 55

year follow-up study. J Clin Endocrinol Metab 1996; 
81:2314–18.

10. Javaid MK, Crozier SR, Harvey NC, Gale CR, 
Dennison EM, Boucher BJ. Maternal vitamin D 
status during pregnancy and childhood mass at  
age 9 years: a longitudinal study. Lancet 2006; 
367:36–43.

11. Kalkwarf HJ, Specker BL, Heubi JE, Viera NE, 
Yergey AL. Intestinal calcium absorption of  
women during lactation andafterweaning. AM J  
Clin Nutr 1996; 63:526–31.

12. Saadi HF, Nagelkerke N, Benedict S, Qazaq HS, 
Zilahi E, Mohamadiyeh MK, et al. Predictors 
and relationships of serum 25 hydroxyvitamin 
D concentration with bone turnover markers,  

bone mineral density and vitamin D receptor 
genotype in Emirati women. Bone 2006; 39: 
1136–43. Epub 2006 June 30. 

13. Steingrimsdottir L, Gumarsson O, Indridason 
OS, Franzson L, Sigurdsson G. Relationship 
between serum parathyroid hormone levels, 
vitamin D sufficiency and calcium intake. JAMA  
2005; 294: 2336–41.

14. Paik J, Curhan G, Forman J, Taylor E. Determinant 
of plasma parathyroid hormone levels in young  
women. Calcified Tissue Int 2010; 87:211–17. 

15. Abrahamsen B. Patient level pooled analysis of 
68,500 patients from seven major vitamin D fracture 
trials in US and Europe. (The DIPART group)  
BMJ 2010; 340:b5463.