{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,18]],"date-time":"2026-04-18T00:16:10Z","timestamp":1776471370714,"version":"3.51.2"},"reference-count":53,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2023,7,17]],"date-time":"2023-07-17T00:00:00Z","timestamp":1689552000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100004919","name":"King Abdulaziz City for Science and Technology","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100004919","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Nutr."],"abstract":"<jats:sec><jats:title>Background<\/jats:title><jats:p>Dietary intake is widely known to play a crucial role in achieving peak bone mass among children and adolescents. Unfortunately, this information is lacking among Arab adolescents, an understudied demographic that has recently been observed to have a high prevalence of abnormal mineralization markers [low serum 25(OH)D, high serum alkaline phosphatase (ALP), low calcium (Ca) and\/or inorganic phosphate (Pi)] suggestive of biochemical osteomalacia (OM, defined as any 2 of the 4 parameters). In order to fill this gap, we aimed to evaluate the associations of serum markers of biochemical OM with dietary intake of macronutrients, vitamins and trace minerals.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Saudi adolescents (<jats:italic>N<\/jats:italic>\u2009=\u20092,938, 57.8% girls), aged 12\u201317\u2009years from 60 different schools in Riyadh, Saudi Arabia were included. Dietary intake of nutrients was calculated following a semi-quantitative 24\u2009h dietary recall over 3 weekdays and 1 weekend-day using a validated food frequency questionnaire. Compliance to reference daily intake (RDI) of macronutrients, vitamins and trace minerals were calculated. Fasting blood samples were collected and circulating levels of 25(OH)D, ALP, Ca, and Pi were analyzed.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>A total of 1819 (1,083 girls and 736 boys) adolescents provided the dietary recall data. Biochemical OM was identified in 175 (9.6%) participants (13.5% in girls, 3.9% in boys, <jats:italic>p<\/jats:italic>\u2009&amp;lt;\u20090.01) while the rest served as controls (<jats:italic>N<\/jats:italic>\u2009=\u20091,644). All participants had serum 25(OH)D levels &amp;lt;50\u2009nmoL\/L. Most participants had very low dietary intakes of Ca (median\u2009~\u2009290\u2009mg) and vitamin D (median\u2009~\u20094\u2009\u03bcg) which are far below the RDI of 1,300\u2009mg\/day and 20\u2009\u03bcg\/day, respectively. In contrast, excess dietary intakes of Pi, Na, K, and Fe were observed in all participants. In the biochemical OM group, thiamine and protein intake were significant predictors of serum 25(OH)D, explaining 4.3% of the variance perceived (<jats:italic>r<\/jats:italic>\u2009=\u20090.23, adjusted <jats:italic>r<\/jats:italic><jats:sup>2<\/jats:sup>\u2009=\u20094.3%, <jats:italic>p<\/jats:italic>\u2009=\u20090.01). Among controls, dietary vitamin C and vitamin D explained 0.6% of the total variation in serum 25(OH)D (<jats:italic>r<\/jats:italic>\u2009=\u20090.09, adjusted <jats:italic>r<\/jats:italic><jats:sup>2<\/jats:sup>\u2009=\u20090.6%, <jats:italic>p<\/jats:italic>\u2009=\u20090.004).<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>Arab adolescents do not meet the RDI for dietary Ca and vitamin D, and none have sufficient vitamin D status (25(OH)D levels &amp;gt;50\u2009nmol\/L) but they exceed the RDI for dietary Pi. Interpreting these data in the light of the increased prevalence of rickets in Arab countries, food fortification to optimise vitamin D and Ca intake in Saudi adolescents should be considered.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fnut.2023.1206711","type":"journal-article","created":{"date-parts":[[2023,7,17]],"date-time":"2023-07-17T11:15:02Z","timestamp":1689592502000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":6,"title":["Association of bone mineralization markers with dietary nutrient intake in adolescents with and without biochemical osteomalacia"],"prefix":"10.3389","volume":"10","author":[{"given":"Nasser M.","family":"Al-Daghri","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Shaun","family":"Sabico","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kaiser","family":"Wani","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Syed Danish","family":"Hussain","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sobhy","family":"Yakout","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Naji","family":"Aljohani","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Suma","family":"Uday","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Wolfgang","family":"H\u00f6gler","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2023,7,17]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"3","DOI":"10.1016\/j.nutres.2018.06.002","article-title":"The importance of healthy dietary patterns in chronic disease prevention","volume":"70","author":"Neuhouser","year":"2019","journal-title":"Nutr Res"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"1958","DOI":"10.1016\/S0140-6736(19)30041-8","article-title":"Health effects of dietary risks in 195 countries, 1990\u20132017: a systematic analysis for the global burden of disease study 2017","volume":"393","year":"2019","journal-title":"Lancet"},{"key":"ref3","year":""},{"key":"ref4","doi-asserted-by":"publisher","first-page":"191","DOI":"10.1038\/s43016-023-00705-0","article-title":"Author correction: global dietary quality in 185 countries from 1990 to 2018 show wide differences by nation, age, education, and urbanicity","volume":"4","author":"Miller","year":"","journal-title":"Nat Food"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"9","DOI":"10.1007\/s40520-021-01970-4","article-title":"Dairy products and bone health","volume":"34","author":"Rizzoli","year":"2022","journal-title":"Aging Clin Exp Res"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"606","DOI":"10.1016\/S2213-8587(21)00119-4","article-title":"Nutritional intake and bone health","volume":"9","author":"Rizzoli","year":"2021","journal-title":"Lancet Diabetes Endocrinol"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"229","DOI":"10.3390\/nu9030229","article-title":"The prevalence of micronutrient deficiencies and inadequacies in the Middle East and approaches to interventions","volume":"9","author":"Hwalla","year":"2017","journal-title":"Nutrients"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"105920","DOI":"10.1016\/j.jsbmb.2021.105920","article-title":"Decreasing prevalence of vitamin D deficiency in the central region of Saudi Arabia (2008\u20132017)","volume":"212","author":"Al-Daghri","year":"2021","journal-title":"J Steroid Biochem Mol Biol"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"551","DOI":"10.3390\/nu15030551","article-title":"Improved HDL cholesterol through vitamin D status correction substantially lowers 10-year atherosclerotic cardiovascular disease risk score in vitamin D-deficient Arab adults","volume":"15","author":"Sabico","year":"2023","journal-title":"Nutrients"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"2805","DOI":"10.3390\/ijerph18062805","article-title":"Is 25-Hydroxyvitamin D associated with glycosylated hemoglobin in patients with type 2 diabetes mellitus in Saudi Arabia? 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concerning dietary supplement use among Saudi adolescents","volume":"17","author":"Alfawaz","year":"2020","journal-title":"Int J Environ Res Public Health"},{"key":"ref45","doi-asserted-by":"publisher","first-page":"346","DOI":"10.1111\/j.1365-2265.2011.04219.x","article-title":"Increased vitamin D supplementation recommended during summer season in the gulf region: a counterintuitive seasonal effect in vitamin D levels in adult, overweight and obese middle eastern residents","volume":"76","author":"Al-Daghri","year":"2012","journal-title":"Clin Endocrinol"},{"key":"ref46","doi-asserted-by":"publisher","first-page":"667","DOI":"10.1530\/EC-17-0193","article-title":"Variations in infant and childhood vitamin D supplementation programmes across Europe and factors influencing adherence","volume":"6","author":"Uday","year":"2017","journal-title":"Endocr Connect"},{"key":"ref47","doi-asserted-by":"publisher","first-page":"373","DOI":"10.3389\/fendo.2018.00373","article-title":"Rationale and 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the UK: political action overdue","volume":"103","author":"Uday","year":"2018","journal-title":"Arch Dis Child"}],"container-title":["Frontiers in Nutrition"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fnut.2023.1206711\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,7,17]],"date-time":"2023-07-17T11:15:06Z","timestamp":1689592506000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fnut.2023.1206711\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,7,17]]},"references-count":53,"alternative-id":["10.3389\/fnut.2023.1206711"],"URL":"https:\/\/doi.org\/10.3389\/fnut.2023.1206711","relation":{},"ISSN":["2296-861X"],"issn-type":[{"value":"2296-861X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,7,17]]},"article-number":"1206711"}}