Vitamin D supplementation in Saudi Arabia: mothers’ knowledge, practices, and attitudes

Introduction

Vitamin D (VIT D), a fat-soluble vitamin, plays a key role in regulating the absorption and retention of essential minerals such as calcium and phosphorus, which are crucial for bone development (Wimalawansa, 2024). Sunlight exposure serves as the primary source of VIT D, while certain foods, including egg yolks, tuna, sardines, salmon, and cod liver oil, are also rich in this vitamin (Bischofova et al., 2018). Notably, human milk contains lower levels of VIT D compared to animal milk (Elnagar, Abd El Salam & Abdel-Sadik, 2020).

A deficiency in VIT D among newborns and adolescents can lead to conditions such as hypocalcemic seizures or convulsions. Additionally, infants and young children with VIT D deficiency may develop bone deformities or rickets (Bassam & Abd-Elmageed, 2022).

Moreover, VIT D deficiency has been associated with the development of cardiomyopathy, which can lead to heart failure and even death (Elnagar, Abd El Salam & Abdel-Sadik, 2020; Vincent, 2025).

VIT D deficiency can commonly occur among children with ages ranging 5 to 10 years due to various factors such as inadequate VIT D-rich food intake, limited sunlight exposure, wearing clothing that covers the entire body, ethnicity, and the VIT D status of their mothers during pregnancy (Ahmed et al., 2017). This deficiency is a global issue, and VIT D insufficiency or deficiency affects at least 75% of the global population (Siddiqee et al., 2021). It has been reported that approximately 254 million children worldwide suffer from VIT D deficiency (Abbas, Kassim & Hameed, 2022). Surprisingly, even in countries with ample sunlight, such as the Kingdom of Saudi Arabia (KSA) and Oman, the prevalence of VIT D deficiency remains high (Kavitha, 2015). Reduced ultraviolet (UV) light exposure amplifies the severity of VIT D deficiency.

A study conducted in Saudi Arabia on the prevalence of VIT D deficiency in children under two years of age indicated that the condition is common among this age group, particularly in infancy (Al-Qahtani et al., 2022). A recent systematic review in Saudi Arabia showed a high prevalence of VIT D deficiency among children and adolescents (Alahmadi, Morsi & AlNagshabandi, 2020).

VIT D deficiency remains prevalent in tropical countries such as Saudi Arabia, primarily due to insufficient intake of VIT D-fortified or VIT D-rich foods, as well as social customs that limit sunlight exposure, despite the abundance of sunlight (Pettifor, 2014). Another study suggests this deficiency contributes to several health conditions such as osteoporosis, anemia, and inflammatory bowel (Kumar et al., 2024).

Saudi Arabian national guidelines have recommended supplementation and food fortification programs for VIT D deficiency. The Saudi Food and Drug Authority (SFDA) recommends VIT D and other minerals be added to specific food products for high-risk groups such as infants, children, and older adults (SFDA, 2022). However, despite these efforts and recommendations, VIT D deficiency remains prevalent, with a recent review indicating that about 80% of the population has inadequate levels of VIT D (Alahmadi, Morsi & AlNagshabandi, 2020).

Lack of awareness is recognized as a significant contributing factor to this deficiency, emphasizing the importance of community-level awareness and educational campaigns to prevent serious adverse events associated with VIT D deficiency (Ahmed, 2015; Anjorin, 2020). Maternal education is strongly linked to children’s health, and mothers’ nutritional awareness also plays a crucial role in promoting children’s well-being. A mother’s nutritional and healthcare literacy significantly impacts the level of care she provides (Kaur, Grover & Kaur, 2015). Therefore, health education initiatives should prioritize equipping mothers with knowledge about VIT D, including its importance for health, the risks of deficiency, and preventative measures (Abate, Murugan & Gualu, 2016; Scotti et al., 2019).

To address the need for improved knowledge and awareness of the importance of VIT D and its deficiency, it is essential to explore mothers’ perceptions of VIT D supplementation in countries like Saudi Arabia. Unfortunately, there are no studies investigating mothers’ perceptions of VIT D in this context. Thus, the current study was designed to fill this knowledge gap by examining mothers’ perceptions of VIT D supplementation for them and their children in Saudi Arabia.

Methods

Results

Mothers’ knowledge about VIT D

Nearly all mothers (99%) reported awareness of VIT D. Healthcare professionals (66.0%) and social media (43.5%) were the primary sources of information about VIT D. Regarding dietary sources, mothers most correctly identified milk/dairy, fish, egg yolks, and liver as food sources of VIT D. Regarding other sources of VIT D, most respondents (83%) reported the sun as a primary source. However, a relatively lower percentage acknowledged the role of food (20%) and food supplements (25.0%) as additional sources of VIT D. In addition, the respondents demonstrated good awareness about the benefits of VIT D. The majority recognized its positive impact on bone health (88%), immunity-boosting qualities (62.5%), and significance for child health and development (80%). However, there were some misconceptions, with several respondents incorrectly associating VIT D with preventing stroke (10%), diabetes (10%), high blood pressure (9%), and arthritis (40%) (Table 2).

Table 2:

Mothers’ knowledge about VIT D in Saudi Arabia.

1. Have you heard of Vitamin D?
Yes	198 (99%)	1 (0)
No	2 (1%)
2. Is there vitamin D in breast milk?
Yes	115 (57.5%)	1 (1)
No	16 (8%)
I don’t know	68 (34%)
3. What is the source you learned about vitamin D? (You can choose more than one answer)
TV, radio, advertisements	37 (18.5%)	2 (2)
Social media (Snapchat, Instagram, Facebook...)	87 (43.5%)
Friends–family	68 (34%)
Doctor/Nurse	130 (65%)
Magazines	22 (11%)
Books	22 (11%)
From studying at school/university	56 (28%)
Other	1 (0.5%)
4. What are the benefits of vitamin D (you can choose more than one answer)
Bone health*	176 (88%)	5 (3)
Boosts immunity*	125 (62.5%)
Helps a healthy pregnancy*	62 (31%)
Prevents stroke*	20 (10%)
Prevents diabetes*	20 (10%)
Prevents high blood pressure*	18 (9%)
Prevents arthritis*	80 (40%)
Prevent depression*	101 (50.5%)
Important for hair health*	95 (47.5%)
Prevents obesity and weight gain*	48 (24%)
Important for skin health*	58 (29%)
Important for child health and development*	160 (80%)
5. What are the sources of Vitamin D? (You can choose more than one answer) 3
The sun*	167 (83.5%)	1 (0)
The food*	42 (21%)
Food Supplements*	50 (25%)
I do not know	2 (1%)
6.Where is Vitamin D found in food? (You can choose more than one answer)
Milk and dairy products*	123(61.5%)	2 (2)
Fruits	48 (24%)
Vegetables	52 (26%)
Fish*	101 (50.5%)
Egg Yolk*	94(47%)
Liver*	53 (26.5%)
I do not know	30 (15%)
Total	11 (7)

DOI: 10.7717/peerj.19781/table-2

Notes:

*Correct answer Data were presented as N (%) or Median (IQR).

The majority of mothers (74%) demonstrated poor knowledge, scoring 50%. However, 26% of the mothers exhibited good knowledge, scoring above 50% on the section regarding VIT D and its supplementation, with a median score of 11 (Siddiqee et al., 2021) (Fig. 1).

Discussion

This study assessed mothers’ perceptions of VIT D supplementation for them and their children in Saudi Arabia. The findings revealed that most of the participants had heard about VIT D, and almost two-thirds of them were aware of the sources of VIT D in breast milk. It also showed that exposure to sunlight and milk intake are the main resources of VIT D, and a large proportion of the study sample supported VIT D use during pregnancy and lactation. This was in alignment with the national recommendation for adding VIT D and other minerals to specific food products for high-risk groups such as children, pregnant women, and elderly people (SFDA, 2022).

However, greater than two-thirds of mothers reported that, beyond social media, doctors and nurses were information sources regarding VIT D. Our results are consistent with those of a recent study conducted in Egypt (Soliman et al., 2020). This similarity indicates that healthcare providers are the main source of information to increase and promote a patient’s adequate understanding of the important role of VIT D.

In regards of VIT D benefits, the majority of mothers reported that bone health is the most important benefit of VIT D, and more than two-thirds of them confirmed the important role VIT D plays in the development of child health. Most mothers agreed that the sun is the major source of VIT D, followed by food supplements. Almost two-thirds of the mothers confirmed that milk and dairy products are the most important food sources of VIT D. Moreover, the results of our study revealed that more than two-thirds of the mothers had poor knowledge and more than one-third of them had good knowledge about VIT D and its supplementation. These results also coincide with those of a study carried out in Iraq (Rasheed, Taha & Rasheed, 2017), which could be due to the similarity in the samples studied.

Regarding mothers’ practices towards their children in relation to VIT D and its supplementation, the results of our study showed that greater than half of the participants did not expose their child to the sun daily. Less than half of the participants reported exposing their child’s entire body to the sun, while less than one quarter of them did not expose their child to the sun at all. More than half of mothers reported that they exposed their child indirectly to the sun before 10 o’clock in the morning. As for the average exposure of children to weekly sun, less than half of mothers reported that they exposed their child to sun for less than one hour weekly, and almost one-third of them exposed their child to sun between 1 to 2 h daily. At the same time, more than two-thirds of mothers in this study did not know the appropriate dosage when exposing children to sunlight. These findings are also in agreement with the findings of a study carried out in Malaysia (Hussein et al., 2018).

Moreover, our results showed that there was interest and awareness regarding the important role of VIT D for children, as more than two-thirds of studied mothers give a daily fortified dose of VIT D, more than one-third reported that they are “sometimes” committed to giving oral VIT D drops, and almost one-quarter of mothers reported that they are “always” committed to giving oral drops. Regarding the reasons for not giving their children the recommended dose of VIT D, almost half of the mothers reported that they forgot, and less than one-third of them reported that they expose their child to the sun daily so there is no need to give a supplemental VIT D oral dose. These results are supported by a previous study (Hussein et al., 2018) that reported that nearly all of the study sample exposed their children to the sun. However, almost half of the children were fully covered during sun exposure, with an average time of twenty minutes of exposure per day, and most of the participants exposed their children to the sun early in the morning before 10 am. Moreover, our present study indicates that a minority of mothers had fair practices toward VIT D and its supplementation, while less than one-quarter of them had good practices, and more than one-third of mothers had poor practices. These results may be due to more than two-thirds of our sample poor knowledge of VIT D and its supplementation.

Regarding mothers’ attitude toward VIT D and its supplementation, the present study indicated that more than three-quarters of the mothers reported that they used VIT D during pregnancy. Additionally, the majority of mothers reported taking VIT D during breastfeeding, which indicates a high level of interest in and awareness of VIT D during pregnancy and breastfeeding. Almost all the participants in our study support the use of blood tests to detect the level of VIT D in the body. Furthermore, our study results found that more than three-quarters of the mothers reported that they supported giving their child VIT D starting at birth. However, our study findings indicated that two-thirds of mothers agreed to expose their child to the sun daily, and almost two-thirds of them supported the use of sunscreen while exposing their child to the sun. The current study revealed that most mothers had a positive attitude towards VIT D and its supplementation. This may be due to the majority of the participants previously hearing about VIT D, which may have contributed to their positive attitudes toward VIT D. Our study findings aligned with those of Dağhan et al. (2019), which identified prevalent practices of mothers who used VIT D during their pregnancies administering oral VIT D supplements to their infants and facilitating sun exposure for their children. Moreover, our findings were also congruent with a recent study conducted in Saudi Arabia by Babelghaith et al. (2017), who revealed that most of the studied sample were willing to do a VIT D blood test.

Regarding the practices of mothers toward taking VIT D and sunlight exposure, the current results found that greater than half of the participants did not take VIT D supplements, while almost have of them reported that they “sometimes” used VIT D supplements during their last pregnancy.

As for the breastfeeding period, more than one-third of mothers reported taking VIT D “sometimes” or “never”. Moreover, more than one-third of mothers in this study reported that they were “never” concerned about food rich in VIT D. Nearly all of the participants reported that sun exposure was common during outdoor activities. More than two-thirds of mothers were not exposed to sunlight daily, and were exposed less than 1 h per week. Half of the mothers reported exposing their hands and face, and more than two-thirds of them were exposed to the sun before 10 o’clock in the morning. Only 18.4% of the participants reported that between 10 am and 3 pm was the best time for sun exposure.

Finally, our results revealed that more than half of mothers “sometimes” used sunscreen, and less than half of them did not believe that there was a conflict between the use of sunscreen and exposure to sunlight. Moreover, this study’s findings suggest that a substantial proportion of participants demonstrated moderately appropriate behaviors regarding VIT D, while one-third of them had poor practices, and fewer than one-quarter of mothers had good practices towards VIT D and its supplements. The current study’s findings aligned with those of research conducted in India (2015), which reported limited VIT D supplementation among antenatal mothers, while also revealing that a significant portion received daily sun exposure exceeding 1 h. The majority of mothers did not know the best time for sun exposure, and they were not concerned about the VIT D content of food, and reported other poor practices (Kavitha, 2015). These similar results might be attributed to the mothers having limited knowledge of VIT D sources and its importance.

Regarding the factors affecting mothers’ knowledge, attitudes, and practices toward VIT D supplementation and importance, our study results indicate that there was a statistically significant correlation between mothers’ attitudes towards VIT D and both their educational level and functional status. Mothers who were employed and had higher level education had more positive attitudes than others in the sample. This study identified a statistically significant correlation between mothers’ monthly income and their knowledge of VIT D and its supplements.

Mothers with higher incomes demonstrated greater knowledge in this area. Additionally, the analysis revealed a statistically significant link between mothers’ age within the sample and their practices related to VIT D and supplementation. This finding aligns with prior research by Aljefree, Lee & Ahmed (2017) and Soliman et al. (2020), highlighting the influence of sociodemographic factors, such as age and income, on mothers’ behaviors and practices regarding VIT D supplementation.

Conclusion

The present investigation found that a large proportion of the studied population had clear knowledge of VIT D and its important role for infants. The results of the study also showed that mothers are aware that sunlight exposure and milk intake are the main sources of VIT D, and a large proportion of the study sample supported VIT D use during pregnancy and lactation. Sociodemographic factors, including monthly income, age, educational level, and employment status, were found to be significantly associated with mothers’ practices and attitudes towards VIT D.

Recommendations

The findings highlight the significance of assessing mothers’ knowledge, attitudes, and practices when administrating VIT D to their children. For mothers, ongoing training programs are recommended to enhance levels of knowledge and practices about VIT D, as well as improving awareness and practice of incorporating daily sources of VIT D and supplements. The researchers also recommend the need to conduct further extensive studies on other societies, groups, and ages to find out how important VIT D is to those communities. It is also highly recommended to conduct further research to identify the correlation between mothers’ knowledge of VIT D and children’s health status, and its consequences on child health and immune systems.

Strengths and limitations

The results of this study add to current research on VIT D supplementation use for mothers and their children, especially in Saudi Arabia. Furthermore, the participants were drawn from different cities in Saudi Arabia, which provide a general picture on mothers’ perceptions of VIT D supplementation for them and their children. The results could be resourceful for health organizations to develop guidelines on VIT D supplementation and educational programs to improve mothers’ knowledge and practice of VIT D. On the other hand, the study has some limitations including using a convenience sample on a selected number of mothers of children under five years which could result in lack of generalizability of the findings.

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