Vitamin D: New Information about an Essential Nutrient

1
Vitamin D New Information about an Essential
Nutrient

• At the end of this workshop, participants will be
  able to
• Understand the current concepts of the role
  Vitamin D plays in human health, the rational for
  Vitamin D supplements, and not be afraid to claim
  their place in the sun.

2
Resources and references

• Galland, Leo. Power Healing. 1997. Random House.
  New York, NY
• Holick, Michael. The UV Advantage. 2003 Ibooks.
  New York, NY
• Kuhn,Thomas. The Structure of Scientific
  Revolutions. 1970 University of Chicago Press.
  Chicago, IL
• Vasquez A et al The Clinical Importance of
  Vitamin D (Cholecalciferol) A Paradigm Shift
  with Implications for All Healthcare Providers.
  Alternative Therapies in Health and Disease.
  Sept/Oct 2004. Vol. 10 No 5
• Willett, Walter Eat Drink and Be Healthy. 2001
  Simon and Shuster. New York, NY

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Vitamin D is the most common nutritional
deficiency in the US

• What percent of the following groups are Vitamin
  D deficient?
• Free-living and institutionalized elders__
• Boston medical students and residents at the end
  of winter__
• African American women of childbearing age at the
  end of winter__

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The Answers

• What percent of the following groups are Vitamin
  D deficient?
• Free-living and institutionalized elders__gt50
• Boston medical students and residents at the end
  of winter__32
• African American women of childbearing age at the
  end of winter__41

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Forms of Vitamin D

• Cholecalciferol (D3) is the naturally occurring
  form of Vitamin D in the skin and in food. It is
  converted in the liver to
• Calcidiol (25-hydroxy Vitamin D), which is
  considered a prehormone. The calcidiol blood
  level is measured to assess Vitamin D stores in
  the body. Calcidiol is converted in the kidneys,
  breast, prostate, ovary, pituitary, brain, etc
  to
• Calcitriol 1,25 hydroxy Vitamin D, which
  maintains calcium in the blood and has an array
  of effects in the bodys organs.
• Ergocalciferol (D2) is a synthetic form of
  Vitamin D used as a supplement.

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Calcitriol, the most biologically active form of
vitamin D does the following

• Controls bone metabolism
• Modulates neurotransmitter and neurological
  function
• Has immunoregulatory function and can decrease
  inflammation (Autoimmune disease such as multiple
  sclerosis)
• Modulates transcription of several genes,
  particularly those effecting differentiation and
  proliferation (Cancer mortality)

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Controls Bone Metabolism, cont.

• Increases calcium and phosphorous absorption in
  the gut
• Induces osteoclast maturation for bone remodeling
• Promotes calcium deposition in bone (osteoblasts)
• Causes reduction in parathyroid hormone (lower
  PTH levels correlate with reduced risk of HTN, MI
  and stroke)

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How much Vitamin D do we need?RDA (Recommended
Daily Allowance) vs. DRIs (Optimal Intake)

• The advent of the new dietary reference intakes
  (DRIs) has redefined the role of recommended
  micronutrient intakes and shifted the focus from
  prevention of nutrient deficiency to reduction of
  disease risk. A key component of this new
  approach is establishing reliable functional
  indicators of nutrient status that may predict
  disease risk before a severe nutrient deficiency
  ensues. The identification and use of functional
  indicators is also important in the determination
  of nutrient intakes adequate to support key
  metabolic functions
• Reference Rampersaud G et al Genomic DNA
  methylation decreases in response to moderate
  folate depletion in elderly women American
  Journal of Clinical Nutrition, Vol. 72, No. 4,
  998-1003,

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Vitamin D and Cancer

• Research scientists in the 1980's had already
  discovered that calcitriol had profound
  anti-cancer effects, both in the test tube and in
  animals, through the following mechanisms. Check
  which apply.
• __reduced the unregulated growth of cancer cells
  by promoting normal cell death (apoptosis)
• __prevented new cells from becoming cancerous
  (promoted differentiation).
• __helped prevent cancer cells from spreading
  (metastasis)
• __inhibited cancer cells from developing new
  blood supply (angiogenesis). In short, calcitriol
  seemed like the perfect anticancer drug
• Answer All are true

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Sun exposure, Vitamin D and cancer

• Increased sun exposure is associated with what
  change in risk of the following cancers
  (increase /decrease/no effect)
• __Breast cancer
• __Squamous cell cancer (1,500 deaths/year)
• __Prostate Cancer (40,000 deaths/year)
• __Lung Cancer
• __Breast Cancer (50,000 deaths per year)
• __Colon Cancer
• __Malignant Melanoma (7,000 deaths per year)
• __Ovarian Cancer

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The Answers

• Increased sun exposure is associated with what
  change in risk of the following cancers
  (increase /decrease/no effect)
• Decrease__Breast cancer
• Increase__Squamous cell cancer (1,500
  deaths/year)
• Decrease__Prostate Cancer (40,000 deaths/year)
• No Change__Lung Cancer
• Decrease__Breast Cancer (50,000 deaths per year)
• Decrease__Colon Cancer
• Increase__Malignant Melanoma (7,000 deaths/year)
• Decrease__Ovarian Cancer

12
Higher Vitamin D levels provide protection
against what other diseases? (Check all that are
true)

• _Diabetes mellitus type 1
• _osteoporosis
• _osteoarthritis
• _hypertension
• _cardiovascular disease
• _metabolic syndrome and type 2 diabetes
• _depression (especially SAD)
• _certain autoimmune diseases (esp. MS)

13
Higher Vitamin D levels provide protection
against what other diseases?

• x_Diabetes mellitus and metabolic syndrome
• Hypovitaminosis D is associated with increased
  insulin resistance in diabetics and healthy
  adults
• Vitamin D supplementation was more effective than
  metformin in improving insulin sensitivity in
  Type II diabetics
• Vitamin D supplementation in infants and children
  reduced the incidence of Type I diabetes by 80
• x_osteoarthritis
• Progression of knee and hip arthritis is slowed
  by adequate levels of Vitamin D (Framingham
  Study)
• x_cardiovascular disease
• Cardiovascular deaths are more common in the
  winter, at higher latitudes, and lower altitudes.
• Heart attack risk is higher for those with lower
  Vitamin D blood levels
• Vitamin D deficiency can contribute to congestive
  heart failure and hypertension
• x_depression (especially seasonal affective
  disorder (SAD)

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Sunlight and Multiple Sclerosis

• An estimated 330,000 Americans have Multiple
  sclerosis, a chronic debilitating disease that
  affects the brain and spinal cord. Which of the
  following statements are true
• There is a genetic component to MS risk, with
  Northern Europeans being at higher risk.
• You are 2 times more likely to get MS if you live
  in Europe or North America than in the tropics
• The prevalence rate for MS is twice as high in
  the US above the 37th parallel, then below.
• Exposure to the sun at any age decreases the
  likelihood of developing MS
• Norwegians who live along the coast have a lower
  risk of MS than those who live inland, and
  Eskimos who eat a traditional diet (bear liver
  whale, seal blubber, oily fish) have almost no
  MS.

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Sunlight and Multiple Sclerosis

• There is a genetic component to MS risk, with
  Northern Europeans being at higher risk. TRUE
• You are 2 times more likely to get MS if you live
  in Europe or North America than in the tropics.
  FALSE. Your are actually at a 5 times higher
  risk.
• The prevalence rate for MS is twice as high in
  the US above the 37th parallel, then below. TRUE.
  (The 37th parallel runs through Virginia)
• Exposure to the sun at any age decreases the
  likelihood of developing MS. FALSE. Exposure to
  the sun before age 15 reduces the risk of MS.
• Norwegians who live along the coast have a lower
  risk of MS than those who live inland. TRUE.
  Coastal inhabitants eat more fish,
• Eskimos who eat a traditional diet (bear liver
  whale, seal blubber, oily fish) have almost no
  MS. TRUE

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Sources of Vitamin D

• TRUE OR FALSE You can get adequate Vitamin D by
• __Exposure to UV rays for ¼ the time it would
  take your skin to redden
• __Walking in the moonlight during a full moon
• __Studying under bright fluorescent lights
• __Spending Spring and Winter breaks snorkelling
  in the Bahamas
• __Taking 1000 units (25 mg) of cholecalciferol
  (Vitamin D3) daily
• __Taking the RDA (400 units per day) of
  ergocalciferol Vitamin D3) daily
• __Drinking 10 glasses of milk per day
• __Taking 2 tsp of Cod Liver Oil daily
• __Taking one tsp of Concentrated Fish Oil (Omega
  3 Fatty Acids) daily
• __Eating a 3 ½ oz serving of salmon per day
• __Visiting a tanning salon regularly

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The Answers

• TRUE OR FALSE You can get adequate Vitamin D by
• T Exposure to UV rays for ¼ the time it would
  take your skin to redden (4000-10000 IU)
• __Walking in the moonlight during a full moon
• __Studying under fluorescent lights
• T Spending Spring and winter breaks in the
  Bahamas
• T Taking 1000 units (25 mg) of cholecalciferol
  (Vitamin D3) daily
• __Taking the RDA (400 units per day) of
  ergocalciferol Vitamin D2) daily
• T Drinking 10 glasses of milk per day (100 u
  Vitamin D/glass)
• T Taking 2 tsp of Cod Liver Oil daily (453 u
  Vitamin D/tsp)
• __Taking one tsp of Concentrated Fish Oil (Omega
  3 Fatty Acids) daily
• __Eating a 3 ½ oz serving of salmon/day (360 u
  Vitamin D)
• T Visiting a tanning salon regularly (4000-10000
  IU)

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What is a toxic level of Vitamin D?

• A. 1,000 units per day
• B. 2,000 units per day
• C. 10,000 units per day
• D. Greater than 10,000 units per day

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What is a toxic intake of Vitamin D

• A. 1,000 units per day is at the lower end of a
  realistic therapeutic intake for someone with
  limited sun exposure
• B. 2,000 units per day. This is the Food and
  Nutrition Boards previously defined upper limit
  which most, if not all Vitamin D experts feel is
  far too low
• C. 10,000 units per day. Total-body sun exposure
  easily provides the equivalent of 250 microg
  (10000 IU) vitamin D per day/d, suggesting that
  this is a physiologic limit.
• D. More than 10,000 units/day, over a period of
  2-3 months
• Reference Vieth R, Vitamin D supplementation,
  25-hydroxyvitamin D concentrations, and safety.
  Am J Clin Nutr. 1999 May69(5)842-56.

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What is a toxic intake of Vitamin D

• The assembled data from many vitamin D
  supplementation studies reveal a curve for
  vitamin D dose versus serum 25-hydroxyvitamin D
  25(OH)D response that is surprisingly flat up
  to 250 microg (10000 IU) vitamin D/d.
• Except in those with conditions causing
  hypersensitivity, there is no evidence of adverse
  effects with serum 25(OH)D concentrations lt140
  nmol/L, which require a total vitamin D supply of
  250 microg (10000 IU)/d to attain
• Published cases of vitamin D toxicity with
  hypercalcemia, for which the 25(OH)D
  concentration and vitamin D dose are known, all
  involve intake of gt or 1000 microg (40000
  IU)/d.
• Because vitamin D is potentially toxic, intake of
  gt25 microg (1000 IU)/d has been avoided even
  though the weight of evidence shows that the
  currently accepted, no observed adverse effect
  limit of 50 microg (2000 IU)/d is too low by at
  least 5-fold.

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Vitamin D from sun exposure

• Judiciously expose as much skin as possible to
  direct midday sunlight for 1/4 the time it takes
  for the skin to turn red, during those months
  when the proper ultraviolet light occurs at their
  latitude (usually late spring, summer and early
  fall).
• Do not get sunburned. Vitamin D production is
  already maximized before your skin turns pink and
  further exposure does not increase levels of
  vitamin D but may increase your risk of skin
  cancer.
• Black persons may need five to ten times longer
  in the sun than whites, depending on skin type.
• Topical application of an SPF of 8 will reduce
  the cutaneous production of Vitamin D3 by 97.5

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Laboratory values of Vitamin D

• Vitamin D 25Hydroxy is the important level for
  nutritional adequacy (not Vitamin D1,25)
• Deficiency
• UVA norm 10-100 ng/ml
• MJH norm 20-100 ng/ml
• generally lt20 ng/ml or lt30ng/ml (Holick)
• Insufficiency lt40 ng/ml
• Below level of 40-50 tissue levels are depleted
  and PTH hormone levels begin to increase
• Optimal Vitamin D status 40-65 ng/ml (100-160
  nmol/L)
• Some experts propose 80-100ng/ml as upper range
• Vitamin D excess
• May occur with levels gt125 ng/ml

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Vitamin D Supplementation

• Use D3 (cholecalciferol) rather than D2
  (ergocalciferol)
• D3 is more efficient than D2 in raising and
  sustaining Vitamin D levels.
• For correcting deficiency Dosages should
  reflect physiologic requirements and natural
  endogenous production and should be in the range
  of 2,000-10,000 units per day
• Supplementation should be continued for 3-9
  months
• Vitamin D levels do not plateau until 3-4 months.
  
• Most studies of Vitamin D supplementation have
  been flawed due to insufficient therapeutic
  intervention
• Vitamin D levels should be monitored to assess
  effectiveness of therapy, by measuring Vitamin D
  25-hydroxy
• Vitamin D 1,25 levels do no reflect body stores
  of Vitamin D
• Supplements should be used that have been tested
  for potency

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Vitamin D Supplementation

• For Maintenance (Persons with adequate Vitamin D
  levels)
• Adults without sun exposure should receive 1000
  units of Vitamin D daily, possibly more
• Pregnant women without sun exposure should
  receive 1000 units of Vitamin D daily, possibly
  more
• Present recommendations of 200-600 units are
  woefully inadequate
• Apart from fish and milk, there is very little
  Vitamin D in food. Cheese, yogurt, ice cream,
  butter, etc. do not contain significant amounts
  of Vitamin D,
• and 1/3 of milk samples contains none or less
  than stated on the label.