Vitamin D Deficiency Causes

Vitamin D Deficiency Causes

Osteoporosis  is a growing issue for a wide population of the elderly community, it is referred to as the “silent disease”. You may not know anything is wrong until a bone fracture, commonly hip fractures . Physicians and patients commonly address this issue with vitamin D3 and calcium supplementation.

However, a close look at the literature and you suddenly realize that vitamin D deficiency is not just among the elderly but much closer to home and among all the population old or young. The overall prevalence rate of vitamin D3 deficiency in the United States is reported at a staggering 41.6%, and it can be more among minorities or people with certain disease conditions.

People can develop vitamin D deficiency when usual intakes are lower over time than recommended levels, exposure to sunlight is limited, the kidneys cannot convert 25(OH)D to its active form, or absorption of vitamin D from the digestive tract is inadequate. Older adults are at increased risk of developing vitamin D insufficiency, partly because the skin’s ability to synthesize vitamin D declines with age [1]. In addition, older adults are likely to spend more time than younger people indoors, and they might have inadequate dietary intakes of the vitamin [2].

Prolonged exclusive breastfeeding without vitamin D supplementation can cause rickets in infants, and, in the United States, rickets is most common among breastfed Black infants and children [3]. In one Minnesota county, the incidence rate of rickets in children younger than 3 years in the decade beginning in 2000 was 24.1 per 100,000 [4]. Rickets occurred mainly in Black children who were breastfed longer, were born with low birthweight, weighed less, and were shorter than other children. The incidence rate of rickets in the infants and children (younger than 7) seen by 2,325 pediatricians throughout Canada was 2.9 per 100,000 in 2002–2004, and almost all patients with rickets had been breastfed [5]. The big variation between the American and Canadian population can stem from better supplementation of mothers with vitamin D prior to the start of breastfeeding. However, the most important message here is that even in the 21st century vitamin D deficiency is a major health issue. 

What is Vitamin D3?

Vitamin D is a group of fat-soluble secosteroids responsible for increasing intestinal absorption of calciummagnesium, and phosphate, and many other biological effects. In humans, the most important compounds in this group are vitamin D3 (also known as cholecalciferol) and vitamin D2 (ergocalciferol). National Institute of Health (NIH) states that Vitamin D3 is considered a fat-soluble prohormone which is involved in many aspects of our wellbeing and regulatory functions just like a hormone.

Vitamin D is a nutrient your body needs for building and maintaining healthy bones. That's because your body can only absorb calcium, the primary component of bone, when vitamin D is present. “Vitamin D also regulates many other cellular functions in your body. Its anti-inflammatory, antioxidant and neuroprotective properties support immune health, muscle function and brain cell activity.”

What is a good source of vitamin D?

Vitamin D isn't naturally found in many foods, but you can get it from fortified milk, fortified cereal, and fatty fish such as salmon, mackerel and sardines. Your body also makes vitamin D when direct sunlight converts a chemical in your skin into an active form of the vitamin (calciferol).

The amount of vitamin D your skin makes depends on many factors, including the time of day, season, latitude, and your skin pigmentation. Depending on where you live and your lifestyle, vitamin D production might decrease or be completely absent during the winter months. Sunscreen, while important to prevent skin cancer, also can decrease vitamin D production.

Vitamin D Content of Selected Foods [6]

Food

Micrograms (mcg) per serving

International Units (IU) per serving

Percent DV*

Cod liver oil, 1 tablespoon

34.0

1,360

170

Trout (rainbow), farmed, cooked, 3 ounces

16.2

645

81

Salmon (sockeye), cooked, 3 ounces

14.2

570

71

Mushrooms, white, raw, sliced, exposed to UV light, ½ cup

9.2

366

46

Milk, 2% milkfat, vitamin D fortified, 1 cup

2.9

120

15

Soy, almond, and oat milks, vitamin D fortified, various brands, 1 cup

2.5-3.6

100-144

13-18

Ready-to-eat cereal, fortified with 10% of the DV for vitamin D, 1 serving

2.0

80

10

Sardines (Atlantic), canned in oil, drained, 2 sardines

1.2

46

6

Egg, 1 large, scrambled**

1.1

44

6

Liver, beef, braised, 3 ounces

1.0

42

5

Tuna fish (light), canned in water, drained, 3 ounces

1.0

40

5

Cheese, cheddar, 1 ounce

0.3

12

2

Mushrooms, portabella, raw, diced, ½ cup

0.1

4

1

Chicken breast, roasted, 3 ounces

0.1

4

1

Beef, ground, 90% lean, broiled, 3 ounces

0

1.7

0

Broccoli, raw, chopped, ½ cup

0

0

0

Carrots, raw, chopped, ½ cup

0

0

0

Almonds, dry roasted, 1 ounce

0

0

0

Apple, large

0

0

0

Banana, large

0

0

0

Rice, brown, long-grain, cooked, 1 cup

0

0

0

Whole wheat bread, 1 slice

0

0

0

Lentils, boiled, ½ cup

0

0

0

Sunflower seeds, roasted, ½ cup

0

0

0

Edamame, shelled, cooked, ½ cup

0

0

0

* DV = Daily Value. The FDA developed DVs to help consumers compare the nutrient contents of foods and dietary supplements within the context of a total diet. The DV for vitamin D is 20 mcg (800 IU) for adults and children aged 4 years and older. The labels must list vitamin D content in mcg per serving and have the option of also listing the amount in IUs in parentheses. Foods providing 20% or more of the DV are considered to be high sources of a nutrient, but foods providing lower percentages of the DV also contribute to a healthful diet.

** Vitamin D is in the yolk.

Best way to absorb Vitamin D

Everyone is aware that calcium absorption and bone health are major parts of vitamin D benefits. However, most people may not know that Vitamin D is also involved in control of inflammation, sugar control, proper cell death, proper cell growth, and many other cellular and bodily regulations. 

Vitamin D is found in two forms in humans, the most important compounds in this group are vitamin D3 (also known as cholecalciferol) and vitamin D2 (ergocalciferol). Most people in the western hemisphere do not obtain their vitamin D3 from sun exposure or food sources and need to be supplemented to obtain optimal levels.  D3 is at times difficult to absorb without a large fatty meal. Hence many find that they are D3 deficient even though they have been taking their supplements or multivitamin regularly. 

As stated above if you are taking your vitamin D3 in pill form, experts recommend taking the pill with a full meal – preferably a fatty meal – to maximize absorption. If you take vitamin D3 tablets under the tongue for better absorption, you do not need to worry about any of the above since it absorbs under your tongue and directly into your bloodstream. No need to plan a fatty meal or worry about an upset stomach because under the tongue D3 absorbed directly into the bloodstream from the tongue blood plexus and avoids the passage through the gastrointestinal tract.

There is also debate about when is the best time of day to take your vitamin D3 – there is some research that suggests vitamin D3 may negatively impact your sleep. Until further research is available, we recommend you consume your Vitamin D3 supplements first thing in the morning. Make it part of your morning ritual. It is easier than having to remember to take them later in your busy day.

Vitamin D in Health & Disease

In 2014 publication, “the Institute of Medicine/Food and Nutrition Board (FNB) constituted a Dietary Reference Intakes (DRI) committee to undertake a review of the evidence that had emerged on the relationship of vitamin D and calcium, both individually and combined, to a wide range of health outcomes, and potential revision of the DRI values for these nutrients. To support that review, several United States and Canadian Federal Government agencies commissioned a systematic review of the scientific literature for use during the deliberations by the committee. The intent was to support a transparent literature review process and provide a foundation for subsequent reviews of the nutrients. The committee used the resulting literature review in their revision of the DRIs. The FNB committee that established DRIs for vitamin D found that the evidence was inadequate or too contradictory to conclude that the vitamin had any effect on a long list of potential health outcomes (e.g., on resistance to chronic diseases or functional measures), except for measures related to bone health. Similarly, in a review of data from nearly 250 studies published between 2009 and 2013, the Agency for Healthcare Research and Quality concluded that no relationship could be firmly established between vitamin D and health outcomes other than bone health [7]. However, because research has been conducted on vitamin D and numerous health outcomes, this section focuses” on four diseases, conditions, and interventions in which vitamin D might be involved: bone health and osteoporosis, cancer, multiple sclerosis (MS), and Covid 19 infections [7]. 

1. Vitamin D in Bone Health and Osteoporosis

Osteoporosis is a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes. This can lead to a decrease in bone strength that can increase the risk of fractures (broken bones) [12]. The risk of osteoporosis is real, but it can also be prevented.

2. Vitamin D and Cancer.

Early epidemiological studies on vitamin D3 showed that death rates from certain cancers were lower in individuals who lived in the southern latitudes with more sunlight vs northern latitudes where levels of sun exposure are lower. Then experimental evidence in mice showed increased levels of vitamin D3 improved cancer cell death, reduced cancer cell growth and blood supply. However, the most important randomized study currently being done in the nation by Harvard University is the VITAL study which will evaluate the benefit of vitamin D3 in prevention of breast, colon and prostate cancer. Some observational studies show associations between low serum levels of 25(OH)D and increased risks of cancer incidence and death [15]. In a meta-analysis of 16 prospective cohort studies in a total of 137,567 participants who had 8,345 diagnoses of cancer, 5,755 participants died from cancer [8].Anecdotal information appears to show a possible cancer risk reduction in certain types of cancer with daily intake of vitamin D3; however, everyone must consult with their doctor before starting on any vitamin regimen and these studies are not randomized trials and should only be looked at possible health benefits and not facts.

3. Vitamin D and Covid Infection Based on Country.  

The recent study in Ireland  shows that countries such as Spain and Italy that rely solely on sunlight for their D3 supplementation have overall lower rates of vitamin D3 levels in their population vs. countries such as Sweden and Finland that use supplementation as their main means of D3 nutrition. What is also observed that the populations that suffer lower levels of D3 had a worse outcome overall with Covid-19 infections. Hence the authors of the study recommend optimizing vitamin D3 levels in all populations as a means of preventing morbidity and mortality. One of the biggest issues with Covid-19 infection is its pulmonary side effects and severe pulmonary edema causing need for ventilator support. Research has begun to show that this inflammatory response is more to do with the bodies over recruitment of inflammatory white blood cells than the viral load. It appears that vitamin D3 plays an important role in suppressing and controlling this overdrive of the immune system and slowing the pulmonary issues in patients with normal D3 levels.

4. Vitamin D and Multiple Sclerosis 

Multiple Sclerosis (MS) is an autoimmune disease of the central nervous system that damages the myelin sheath surrounding and protecting nerve cells in the brain and spinal cord [9]. This damage hinders or blocks messages between the brain and body, leading to clinical features, such as vision loss, motor weakness, spasticity, ataxia, tremor, sensory loss, and cognitive impairment.  Some people with MS eventually lose the ability to write, speak, or walk.

The geographical distribution of MS around the world is unequal. Few people near the equator develop the disease, whereas the prevalence is higher further north and south. This uneven distribution has led to speculation that lower vitamin D3 levels in people who have less sunlight exposure might predispose them to the disease [10].

Many epidemiological and genetic studies have shown an association between MS and low 25(OH)D levels before and after the disease begins [13]. One study, for example, tested 25(OH)D levels in 1,092 women in Finland an average of 9 years before their MS diagnosis and compared their outcomes with those of 2,123 similar women who did not develop MS [11]. More than half the women who developed MS had deficient or insufficient vitamin D levels. Women with 25(OH)D levels of less than 30 nmol/L (12 ng/mL) had a 43% higher MS risk than women with levels of 50 nmol/L (20 ng/mL) or higher. Among the women with two or more serum 25(OH)D samples taken before diagnosis (which reduced random measurement variation), a 50 nmol/L increase in 25(OH)D was associated with a 41% reduced risk of MS, and 25(OH)D levels less than 30 nmol/L were associated with an MS risk that was twice as high as levels of 50 nmol/L or higher.

Vitamin D interactions with medications

  1. Cholesterol Lowering medications:
    Statin medications reduce cholesterol synthesis. Because endogenous vitamin D3 is derived from cholesterol, statins may also reduce vitamin D3 synthesis [12]. In addition, high intakes of vitamin D3, especially from supplements, might reduce the potency of atorvastatin (Lipitor®), lovastatin (Altoprev® and Mevacor®), and simvastatin (FloLipid™ and Zocor®), because these statins and vitamin D3 appear to compete for the same metabolizing enzyme in the liver.
  2. Steroid Usage:
    Corticosteroid medications, such as prednisone (Deltasone®, Rayos®, and Sterapred®), are often prescribed to reduce inflammation [13]. These medications can reduce calcium absorption and impair vitamin D metabolism. In the NHANES 2001–2006 survey, 25(OH)D deficiency (less than 25 nmol/L [10 ng/mL]) was more than twice as common among children and adults who reported oral steroid use (11%) than in nonusers (5%) [14].

Since it is very likely that you are going to be playing catch up from the time you didn’t have enough Vitamin D3 in your body. We recommend talking to your doctor about your blood levels and finding the right Vitamin D3 dosage for you.

How much vitamin D supplements should you take?

All adults should consume recommended amounts of vitamin D and calcium from foods and supplements if needed. Older women and men should consult their healthcare providers about their needs for both nutrients as part of an overall plan to maintain bone health and to prevent or treat osteoporosis and possibly other medical issues.

Women of childbearing age should consult their primary care doctor to obtain vitamin D levels and try to optimize their level to around 50 to 70 ng/ml (normal levels are considered 30 to 100ng/ml).

This information is only for educational purposes and is not medical advice or intended as a recommendation of any specific products. Consult your health care provider for more information. These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure, or prevent any disease.

References:

  1. Chalcraft JR, Cardinal LM, Wechsler PJ, Hollis BW, Gerow KG, Alexander BM, et al. Vitamin D synthesis following a single bout of sun exposure in older and younger men and women. Nutrients 2020; 12, 2237; doi:10.3390/nu12082237.
  2. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academy Press, 2010.
  3. Weisberg P, Scanlon KS, Li R, Cogswell ME. Nutritional rickets among children in the United States: Review of cases reported between 1986 and 2003. Am J Clin Nutr 2004;80:1697S-705S.
  4. Thacher TM, Fischer PR, Tebben PJ, Singh RJ, Cha SS, Maxson JA, Yawn BP. Increasing incidence of nutritional rickets: A population-based study in Olmsted County, Minnesota. Mayo Clin Proc 2013;88:176-83.
  5. Ward LM, Gaboury I, Ladhani M, Zlotkin S. Vitamin D-deficiency rickets among children in Canada. CMAJ 2007;177:161-6. 
  6. U.S. Department of Agriculture, Agricultural Research Service
  7. Newberry SJ, Chung M, Shekelle PG, Booth MS, Liu JL, Maher AR, et al. Vitamin D and calcium: A systematic review of health outcomes (update). Evidence Report/Technology Assessment No. 217. (Prepared by the Southern California Evidence-based Practice Center under Contract No. 290- 2012-00006-I.) AHRQ Publication No. 14-E004-EF. Rockville, MD: Agency for Healthcare Research and Quality. September 2014.
  8. Yin L, Ordonez-Mena JM, Chen T, Schottker B, Arndt V, Brenner H. Circulating 25-hydroxyvitamin D serum concentration and total cancer incidence and mortality: A systematic review and meta-analysis. Preventive Medicine 2013;57:753-64. 
  9. National Institutes of Health Osteoporosis and Related Bone Diseases National Resource Center.
  10. Jagannath VA, Filippini G, Di Pietrantonj C, Asokan GV, Robak EW, Whamond L, Robinson SA. Vitamin D for the management of multiple sclerosis (review). Cochrane Database of Systematic Reviews 2018, issue 9, Art. No.: CD008422. DOI: 10.1002/14651858.CD008422.pub3
  11. Munger K, Hongell K, Aivo J, Soilu-Hanninen M, Surcel H-M, Ascherio A. 25-hydroxyvitamin D deficiency and risk of MS among women in the Finnish Maternity Cohort. Neurology 2017;89: 1578-83.
  12. Robien K, Oppeneer SJ, Kelly JA, Hamilton-Reeves JM. Drug-vitamin D interactions: A systematic review of the literature. Nutr Clin Pract 2013;28:194-208. 
  13. Lukert BP, Raisz LG. Glucocorticoid-induced osteoporosis: pathogenesis and management. Ann Intern Med 1990;112:352-64
  14. Skversky AL, Kumar J, Abramowitz MK, Kaskel FJ, Melamed ML. Association of glucocorticoid use and low 25-hydroxyvitamin D levels: Results from the National Health and Nutrition Examination Survey (NHANES): 2001-2006. J Clin Endocrinol Metab 2011;96:3838-45.
  15. JoAnn E. Manson, MD, Brigham and Women's Hospital. The VITamin D and OmegA-3 TriaL (VITAL)Trial., posted Feb 12, 2021.
  16. E. Laird, J. Rhodes, R.A. Kenny, Vitamin D and inflammation: Potential Implications for Severity of Covid 19. Irish Medical Journal 2020; Vol 112; No. 5: 81.
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