Mallory Wescom

Micronutrients

9/18/2017

Vitamin D

Vitamin D is vitamin in which many people are deficient but has very important roles in the

body.
 Introduction

Along with vitamins A, E, and K vitamin D are all fat-soluble vitamins but vitamin D is

unique. Vitamin D promotes calcium absorption in the gut and maintains adequate calcium and

phosphate concentrations in homeostasis to enable normal mineralization of bone. 1 For people

under the age of 70 the recommended daily allowance, the RDA, is 600 and the RDA is 800 IU

for individuals over 70. 2 This is because as individuals age they lose 70 percent of the ability to

absorb vitamin D. The RDA for vitamin D is based on individuals with minimal sun exposure. The

upper limit, maximum daily intake unlikely to cause adverse health effects, is 4000 IU per day.1,2

And the daily value is 10 ug. Vitamin D is vitamin in which many people are deficient but has

very important roles in the body.

Metabolism

When vitamin D obtained from sun exposure, food, and supplements is biologically inert

and must undergo hydroxylation in the body for activation.1 Once consumed about 80 percent

of Vitamin D is incorporated with other dietary fats into micelle to be transported to the liver by

chylomicrons though the lymphatic system.2 Once vitamin D enters the circulatory system it

binds to a vitamin D-binding protein for transport to the muscle, adipose cells, liver, or kidneys.2

The liver vitamin D is hydrolyted to 25-hydroxyvitamin D [25(OH)D], also known as calcidiol. At

this point, the vitamin D is still in its inactive form and can circulate the body for several weeks

until needed. Once the calcidiol reaches the kidney the kidney forms the physiologically active

1,25-dihydroxyvitamin D [1,25(OH)2D], also known as calcitriol. 1 It is now in the active form

and can perform the functions of vitamin D.

 Sources of Vitamin D

Vitamin D can be acquired naturally from a few dietary sources, from fortified foods,

supplementation, and the sun. Ergocalciferol or vitamin D2, is the form of Vitamin D found in

foods. Fatty fish such as sardines, mackerel, herring, and salmon are high in Vitamin D 2. 2

Fortified milk, and some fortified breakfast cereals are also great sources.1,2 Some mushrooms

provide vitamin D2 in inconstant amounts but mushrooms can also have enhanced levels of

vitamin D2 from being exposed to ultraviolet light. 1 Vitamin D2 found in foods is less effective in

the human body when compared to Vitamin D3 formed by the body from sunlight. 1 Vitamin D

is not abundant in food sources but there are some ways of obtaining Vitamin D through the

diet.

Because it is not always possible to obtain adequate amounts of vitamin D from food

and sunlight, supplementation is a valid option to meet vitamin D needs. Vitamin D

supplements come in both D2 (ergocalciferol) and D3 (cholecalciferol) forms which only differ in

side chain structure. 1 At nutritional doses vitamins D2 and D3 are equivalent, but at high doses

vitamin D2 is less potent.1 Therefore either one would be an effective everyday supplement but

vitamin D3 should be used if taken in large doses to overcome a deficiency. Babies, especially

breast fed babies should receive Vitamin D supplementation. It is recommended that partially

breast fed babies and bottle fed babies receive 400 IU per day.1 Vitamin D supplementation is a

valid way to get vitamin D and avoid deficiencies.

The most unique thing about vitamin D is that it can either be obtained through the diet

or formed by the body from sunlight. Because of this unique characteristic vitamin D is
classified as a conditional vitamin or a prohormone meaning it is a precursor of vitamin D.2

When ultraviolet B radiation with a wavelength of 290320 nanometers touches uncovered

skin the transition from sunlight to vitamin D3 begins with 7-dehydrocholesterol, a precursor of

cholesterol synthesis located in the skin.1 In the presence of sunlight 1 ring on 7-

dehydrocholesterol undergoes a chemical transformation forming cholecalciferol and allowing

it to enter the bloodstream for transport to the liver and kidneys. There it converts to the active

form calcitriol. 2

Adequate sun exposure is essential for the conversion to vitamin D3. However, there are

many factors determining the amount of sun exposure that is needed to meet Vitamin D needs.

Time of day, the geographic location, season of the year, age, skin color, and use of sunscreen;

are all factors that affect sun exposure and my result in less vitamin D synthesis.2 Ten to fifteen

minutes of sun exposure to the hands, face, and arms at least 2 or 3 times a week is

recommended for adequate amounts of vitamin D3.2 But individuals with darker skin should be

exposed to the sun for 30 minutes or more due to the melatonin in their skin. In addition,

individuals who live above the 32nd parallel have less sun exposure and cannot made adequate

amounts of vitamin D in the winter months. Another factor that prevents the formation of

vitamin D is windows. Windows block all of the ultraviolet B radiation from reaching the skin.

Many factors affect the amount of vitamin D that can be produced.

Toxicity

Too much vitamin D can be a bad thing. Going over 50 ug/day or 2000 IU/day for adults

can have disastrous side effects.2 But good news a vitamin D toxicity can only occur from
excessive supplementation, especially from cholecalciferol, not from too much sun exposure or

natural sources.2 Sun exposure does not result in toxic levels of vitamin D because excess

amounts of previtamin D3 in the skin rapidly degrade.1 Above the suggested upper limit toxicity

can occur. A toxicity can result in an over absorption of calcium and hypercalcemic, increased

calcium in the blood. 1 The excess blood calcium leads to deposits of calcium in the kidneys,

heart, lungs. It can also attribute to anorexia, vomiting, bone demineralization, weakness, joint

pain, and kidney dysfunction.2 Good news is that in the early stages of toxicity if the symptoms

are treated if vitamin D intake is stopped the toxicity can be reversed. On the other hand, if

supplementation continues Vitamin D toxicity can be fatal.

Disease Process and Deficiencies

There are two major disease processes associated with vitamin D deficiencies are rickets

and osteomalacia.1,3 In children the deficiency is known as rickets. With rickets the skeleton

does not mineralize normally without adequate calcium and phosphorus in the blood. This

causes the bones to weaken and bow under pressure.3 Bowed legs, enlarged head joints and

ribcage, fractures, failure to grow, delays in motor development, abnormalities in the heart

muscle that can lead to heart failure, and life-threatening seizures caused by the bodys

inability to absorb calcium are all common signs of rickets. 2,3

Although rickets was not a common disorder in developed countries there has been

more and more cases of children with rickets. In fact a survey of over 2300 pediatricians found

that there were 104 cases of children with rickets from 2002 to 2004, for an annual incidence

rate of about 2.9 cases per 100 000 in Canada. 3 That is quite a few cases for a disease with a
simple and practical presentation of sun exposure or supplementation. The incidence of rickets

in Alaskan Native children increased two times for every four-degree increase in latitude. 3. In

addition to lack of sunlight, rickets is associated with food insecurity and the declining

consumption of traditional or country foods, such as seal, salmon, bowhead or beluga whale,

and caribou, which contain vitamin D. 3 Not only are the kids that are vitamin D deficient at risk

for rickets they are 38 times more likely to have been malnourished according to the case-

control study. 3 Even babies bottle-fed with enriched formula are now showing up with

deficiency. 3 The increase in incidences of rickets goes to show that more nutrition education on

vitamin D is need both to doctors and the general public.

In adults, a deficiency can result in osteomalacia. Osteomalacia is characterized by poor

calcification of newly synthesized bone which causes soft bones that can result in fractures of

the hip, spine, and other bones. 2 Adults that are at a higher risk of osteomalacia are those with

factors preventing them from sun exposure such as dark skin, living in northern climates or

nursing homes. 1 Also adults with kidney or liver disease or intestinal diseases that impair fat

absorption. 2 An untreated vitamin D deficiency can lead to osteomalacia.

EAL Topic

This article from the Evidence Analysis Library addresses the question: what is the

evidence regarding the effect of supplemental vitamin D on bone density in post-menopausal

woman and older adult men. This study is a meta-analysis of 19 studies, therefore they

gathered information from several different studies and compiled and analyzed the data. 4 Of

those 19 studies five RCTs and two cross-sectional studies found an association between
supplemental vitamin D and bone mineral density in post-menopausal woman and older adult

men.4 The Evidence Analysis Library compiled many studies to look for trends and get science

based evidence. This study was given a grade II rating which is considered fair. Grade II was the

highest rating found for topics relating to vitamin D.

One interesting study that was included in the meta-analysis was Daly, Brown et al,

2006. The purpose of this study was to determine whether supplementing with calcium or

vitamin D3 fortified milk for two years reduced bone loss at critically relevant sites.4 This study

was set up as a randomized control study with 167 adult men aging from 50 to 87. 4 They were

put into three groups; calcium, vitamin D3 fortified milk, and control.4 They concluded that

consumption of fortified milk may be a simple cost effective method for reducing loss of bone

mass density at several common fracture sites in older adult men.4 This was a good study

because it looked at a practical solution to a common problem of vitamin D deficiency.

One major problem with this meta-analysis was that each individual study had different

combinations of nutrients and dosages were used. This made it difficult to determine the

optimal dosage and the effect of just vitamin D. In addition, many studies only focused on

either older adult men or post-menopausal woman, therefore it may have been better for the

meta analysis to focus either on the men or woman but not both. It is also concerning that only

seven of the 19 studies found the association between supplemental vitamin D and bone

mineral density. Some things that this study did well was that it included some very well done

studies that had large amounts of participants in them.

 Journal Articles

The journal of BioMed Research International published an article on vitamin D entitled

Evidence for the Treatment of Osteoporosis with Vitamin D in Residential Care and in the

Community Dwelling Elderly. For this study they looked at previously performed studies from

An electronic search ofMedline (1970 to June 2010),EMBASE (1970 to June 2010) and the

Cochrane Library (1996 to June 2010), using search terms for osteoporosis and vitamin D. 5 The

13 studies that fit the criteria for inclusion were then grouped together and studied in groups.

Breaking up the studies into like groups enabled them to get more an accurate of certain

populations such as individuals in nursing homes,

After analyzing the collected data they concluded that the greatest benefit of vitamin D

on fractures and bone mass density occurs with cholecalciferol with additional calcium in frailer

residential care settings.5 Improved fracture outcomes in the residential care setting have only

been demonstrated by combining calcium and cholecalciferol at a dose of 800 IU daily in

patients who have poor calcium intake and are vitamin D deficient.5 None of the studies using

ergocalciferol with or without calcium demonstrated significant fracture reduction. 5 The

authors stated their position that people in elder care homes would most likely to benefit from

vitamin D and calcium treatment.5 Further research into fracture prevention with vitamin D is

required.

Some potential problems with this meta-analysis study are the variety of studies and the

limited to specific situations. There was diversity of treatment, with varying doses of both

cholecalciferol and ergocalciferol, the ways of administration, and dose frequency. The studies
were also complicated by the presence or absence of calcium supplementation in some studies

but not others. Overall, I liked that they addressed a very common problem that opens the door

to help the elderly population with a commonly overlooked problem by brining to light the

problem and a potential solution.

The journal PLoS ONE published by Public Library of Science entitled The importance of

body weight for the dose response relationship of oral vitamin D supplementation and serum

25-hydroxyvitamin D in healthy volunteers, discussed the differences in doses of vitamin D

needed for supplementation. 6 This was an observational study that examined the effect of

vitamin D supplementation and body weight on serum 25-hydroxyvitamin (25(OH)D) and serum

calcium in healthy volunteers. 6 They analyzed 22,214 recordings of vitamin D supplement use

and serum 25(OH)D from 17,614 healthy adult volunteers participating in a preventive health

program. 6 To conduct the study each participant had to fill out a lifestyle questionnaire with

height and weight, a medical history, assessment of serum 25(OH)D. 6 The questionnaire also

asked for the amount of vitamin D and calcium supplementation. The effects of vitamin D

supplementation on calcium levels and probability of hypercalcemia were analyzed using linear

and logistic regression. 6

The study concluded that BMI is the better measure relative to absolute body weight to

determine which vitamin D doses are needed for which body weight groups to achieve specific

serum 25(OH)D targets. 6 This was evidenced by the observed significant differences in serum

25(OH)D with BMI and absolute body weight categories. 6 Although there was an increase in the

amount of vitamin D supplementation there was no increase rick for hypercalcemia was

observed with overweight and obese individuals.6 Therefore the authors recommend vitamin D
supplementation be two to three times higher for obese subjects and 1.5 times higher for

overweight subjects relative to normal weight subjects.6

Overall this looks like a well done study. It had a large group of participants of 17,614

healthy adult volunteers.6 One question that I had was whether or not the participants had

adequate vitamin D levels at the beginning of the study or not because they were from the

Canadian province of Alberta which is located between the 49th and 60th parallel north. But

overall this was a well done study.

Conclusion

Vitamin D is a unique fat-soluble vitamin. Although vitamin D is not found naturally in very

many foods it can be added though the process of fortification to milks and cereals. Also the

body has a very unique ability to synthesize vitamin D from ultraviolet rays. Without adequate

amounts of vitamin D which is 600 IU for individuals under 70 and 800 IU for individuals over 70

it can have adverse health consequences. 2 It can cause rickets in children and osteomalacia in

adults. Many people such as the elderly in nursing homes and children could benefit from

vitamin D nutrition education and supplementation to avoid deficiencies. Vitamin D is vitamin

in which many people are deficient but has very important roles in the body.
 References

1. Vitamin D Fact Sheet for Health Professionals. NIH Office of Dietary Supplements.

https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/. Accessed September

13, 2017.

2. Bryd-Bredbenner C, Moe G, Berning J, Kelley D. The Fat-Soluble Vitamins. Wardlaws

Perspectives in Nutrition. New York, NY: McGraw-Hill Education; 2016: 412-421.

3. Eggertson L. Rickets re-emerges in northern Aboriginal children. Canadian Medical

Association Journal. 2015; 187(7): 1. doi:10.1503/cmaj.109-5027. Accessed September

10, 2017.

4. What is the evidence regarding the effect of supplemental vitamin D on bone density in

post-menopausal women and older adult men? Evidence Analysis Library.

https://www.andeal.org/topic.cfm?cat=3777&evidence_summary_id=250852&highligh

t=Vitamin D&home=1. Accessed September 14, 2017.

5. Geddes J, Inderjeeth C. Evidence for the Treatment of Osteoporosis with Vitamin D in

Residential Care and in the Community Dwelling Elderly. BioMed Research

International. 2013; 1-13. doi.org/10.1155/2013/463589. Accessed September 10,

2017.

6. Ekwaru JP, Zwicker JD, Holick MF, Giovannucci E, Veugelers PJ (2014) The Importance

of Body Weight for the Dose Response Relationship of Oral Vitamin D Supplementation

and Serum 25-Hydroxyvitamin D in Healthy Volunteers. PLoS ONE 9(11): e111265.

doi:10.1371/journal.pone.0111265