Vitamin D, calcium and covering up

Two nutrients that work as a pair. Calcium is what bones are built from. Vitamin D, says the NHS, helps the body control how much calcium and phosphate it holds, and both are needed for healthy bones, teeth and muscles.

Calcium comes from food. Vitamin D mostly does not: Women's Health Concern, the patient arm of the British Menopause Society, says direct sunlight on the skin is the main source, and that foods such as oily fish, egg yolks and fortified spreads and cereals carry some but are unlikely to give you enough.

After the menopause, bone is lost faster. The NHS bone health page says women lose bone more rapidly for a number of years after the menopause, when the ovaries almost stop making estrogen, which helps protect the bones. Lose enough and it becomes osteoporosis, where bones break more easily.

Vitamin D is where covering up comes in. The NHS lists two groups who may not make enough from sunlight: people who usually wear clothes that cover most of their skin when outdoors, and people with dark skin, including those of South Asian background. Many women reading this are in both. The Pakistan Menopause Society makes the same link for Pakistan, pointing to indoor lifestyles and purdah when it says vitamin D supplements are strongly indicated (Table 5).

It is not only Pakistan. A 2019 review of 21,236 women after the menopause, by Valladares and colleagues, found low vitamin D in about 90% of women in Asia and 82% in the Middle East. The European Menopause and Andropause Society (EMAS) cites it in its 2023 position statement. The review counted as low anything under a higher line than the one EMAS now uses for deficiency, so not every one of those women was deficient.

Roshara is not telling you to dress differently. That is your decision. But if your skin rarely sees the sun, the guidance suggests looking at vitamin D another way, with your doctor.

• The NHS lists sources of calcium: milk, cheese and other dairy, green leafy vegetables such as curly kale and okra, soya drinks with added calcium, bread made with fortified flour, and fish where you eat the bones. Bhindi and dahi are on that list in all but name.
• EMAS adds nuts, almonds in particular, seeds, sesame in particular, dried fruit and pulses. Badam, til, dried fruit and daal: most Pakistani kitchens already have them.
• The Pakistan Menopause Society also names milk, yogurt, cheese and fortified foods, and says calcium supplements are needed if the diet falls short (Table 5).
• For vitamin D, UK health advice recommends a year-round supplement for people who cover most of their skin outdoors, and says people with dark skin should consider one. The NHS page sets out the amount. The British Menopause Society's tool for clinicians names vitamin D as the only supplement it recommends at this stage.
• Writing for Pakistan, where deficiency is endemic, the PMS asks for vitamin D levels to be checked regularly where feasible, which is a blood test your doctor can order.

The NHS vitamin D and calcium pages are written for the UK, where winter sun is too weak to make vitamin D. Open the NHS vitamin D page for the figures and take them to your doctor.

Ask about vitamin D at your next appointment if you cover up outdoors, spend most of the day inside, or both.

See a doctor about aches in your bones. The NHS says a lack of vitamin D can lead to bone pain in adults, from a condition called osteomalacia. Ask about your bone health too if you have ever broken a bone; fracture history is on the PMS checklist (Table 2).

Talk to your doctor before starting supplements, especially if you have another condition or take other medicines. The NHS says some medical conditions mean a person may not be able to take as much vitamin D safely.

Hijab, chador and purdah are part of many women's faith and identity, and no health page should be asking you to trade them for sunshine. Questions about dress belong with a scholar you trust; questions about vitamin D belong with your doctor.

Family matters in another way. If your mother or an older sister had osteoporosis, tell your doctor. The Pakistan Menopause Society asks doctors to record a family history of it (Table 2).