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Vitamin D deficiency

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Vitamin D deficiency
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Hypovitaminosis D is a deficiency of vitamin D. It can result from inadequate nutritional intake of vitamin D coupled with inadequate sunlight exposure (in particular sunlight with adequate ultraviolet B rays), disorders that limit vitamin D absorption, and conditions that impair the conversion of vitamin D into active metabolites including certain liver, kidney, and hereditary disorders.[1] Deficiency results in impaired bone mineralization and leads to bone softening diseases including rickets in children and osteomalacia and osteoporosis in adults.[1]

Classifications

Mapping of several bone diseases onto levels of vitamin D (calcidiol) in the blood.[2]

Hypovitaminosis D is typically diagnosed by measuring the concentration in blood of the compound 25-hydroxyvitamin D (calcidiol), which is a precursor to the active form 1,25-dihydroxyvitamin D (calcitriol).[3] One 2008 review has proposed the following four categories for hypovitaminosis D:[4]

  • Insufficient 50–100 nmol/L (20–40 ng/mL)
  • Mild 25–50 nmol/L (10–20 ng/mL)
  • Moderate 12.5–25.0 nmol/L (5–10 ng/mL)
  • Severe < 12.5 nmol/L (< 5 ng/mL)

Note that 1.0 nmol/L = 0.4 ng/mL for this compound.[5] Other authors have suggested that a 25-hydroxyvitamin D level of 75–80 nmol/L (30–32 ng/mL) may be sufficient[2][3][6] although a majority of healthy young people with comparatively extreme sun exposure did not reach this level in a study done in Hawaii.[7]

Signs and symptoms

Calcitriol (1,25-dihydroxycholecalciferol). Active form. Note extra OH groups at upper right and lower right.

Vitamin D deficiency is known to cause several bone diseases[8] including:

  • Rickets, a childhood disease characterized by impeded growth, and deformity, of the long bones. The earliest sign of subclinical vitamin D deficiency is Craniotabes, abnormal softening or thinning of the skull.[9]
  • Osteomalacia, a bone-thinning disorder that occurs exclusively in adults and is characterized by proximal muscle weakness and bone fragility.
  • Osteoporosis, a condition characterized by reduced bone mineral density and increased bone fragility.
  • Muscle aches and weakness (in particular proximal limb girdle)[6]
  • Muscle twitching (Fasciculations)[citation needed]

The role of diet in the development of rickets was determined by Edward Mellanby between 1918–1920.[10] In 1921 Elmer McCollum identified an anti-rachitic substance found in certain fats that could prevent rickets. Because the newly discovered substance was the fourth vitamin identified, it was called vitamin D.[10] The 1928 Nobel Prize in Chemistry was awarded to Adolf Windaus, who discovered the steroid 7-dehydrocholesterol, the precursor of vitamin D.

Prior to the fortification of milk products with vitamin D, rickets was a major public health problem. In the United States, milk has been fortified with 10 micrograms (400 IU) of vitamin D per quart since the 1930s, leading to a dramatic decline in the number of rickets cases.[11]

Hypovitaminosis D is also considered a risk factor for the development of depressive symptoms in older persons.[12] One study found low serum vitamin D concentrations in patients with schizophrenia,[13] it is worth noting that the active metabolite of vitamin D3 (calcitriol) acts as a catalyst in glutathione production, and low glutathione levels have been implicated in several mental health disorders.

Risk factors

Age

The amount of vitamin D recommended for all infants, children, and adolescents has recently increased – from 400 to 600 IU per day. The Institute of Medicine released the Consensus Report on Dietary Reference Intakes for Calcium and Vitamin D on November 30, 2010. IOM recommends 600 IU of vitamin D a day for those 1-70 and 800 IU for those over 70 years of age.[14] As of October 2008, the American Pediatric Association advises vitamin D supplementation of 400 IU/day (10 μg/d) from birth onwards.[5][15] (1 IU Vitamin D is the biological equivalent of 0.025 μg cholecalciferol/ergocalciferol.) The daily dose of 400 IU is required to prevent rickets and possibly also a wide range of chronic nonskeletal diseases.[16] The Canadian Paediatric Society recommends that pregnant or breastfeeding women consider taking 2000 IU/day, that all babies who are exclusively breastfed receive a supplement of 400 IU/day, and that babies living above 55 degrees latitude get 800 IU/day from October to April.[17] Health Canada recommends 400IU/day (10 μg/d).[18] Infant formula is generally fortified with vitamin D.

Malnutrition

Although rickets and osteomalacia are now rare in Britain, there have been outbreaks in some immigrant communities in which osteomalacia sufferers included women with seemingly adequate daylight outdoor exposure wearing Western clothing.[19] Having darker skin and reduced exposure to sunshine did not produce rickets unless the diet deviated from a Western omnivore pattern characterized by high intakes of meat, fish and eggs, and low intakes of high-extraction cereals.[20][21][22] The dietary risk factors for rickets include abstaining from animal foods .[23][24] Vitamin D deficiency remains the main cause of rickets among young infants in most countries, because breast milk is low in vitamin D and social customs and climatic conditions can prevent adequate UVB exposure. In sunny countries such as Nigeria, South Africa, and Bangladesh where the disease occurs among older toddlers and children it has been attributed to low dietary calcium intakes, which are characteristic of cereal-based diets with limited access to dairy products.[22] Rickets was formerly a major public health problem among the US population; in Denver where ultraviolet rays are approximately 20% stronger than at sea level on the same latitude[25] almost two thirds of 500 children had mild rickets in the late 1920s.[26] An increase in the proportion of animal protein[24][27] in the 20th-century American diet coupled with increased consumption of milk[28][29] fortified with relatively small quantities of vitamin D coincided with a dramatic decline in the number of rickets cases.[11]

Obesity

Obese individuals have lower levels of the circulating form of vitamin D, probably because of reduced bioavailability, and are at higher risk of deficiency. To maintain blood levels of calcium, therapeutic vitamin D doses are sometimes administered (up to 100,000 IU or 2.5 mg daily) to patients who have had their parathyroid glands removed (most commonly renal dialysis patients who have had tertiary hyperparathyroidism, but also to patients with primary hyperparathyroidism) or with hypoparathyroidism.[30] Patients with chronic liver disease or intestinal malabsorption disorders may also require larger doses of vitamin D (up to 40,000 IU or 1 mg (1000 micrograms) daily).

It has been argued that there is little evidence to support the use of high dose therapy to attain thresholds for vitamin D deficiency that greatly exceed widely used definitions of vitamin D deficiency (25OHD <10 ng/ml or 25 nmol/L), and for vitamin D insufficiency (25OHD < 20 ng/ml or 50 nmol/L). Studies are potentially subject to confounding by frailty as people with poorer health are likely to remain indoors, receive less sun exposure, and have low 25OHD levels compared to their healthy peers (rather than low vitamin D levels causing ill health). Those leading sedentary lives are at increased risk of obesity, and increased fat mass is inversely associated with 25OHD levels.[31][32] This association may confound the reported relationships between low vitamin D status and conditions such as diabetes, ischaemic heart disease, hypertension, and cancer that occur more commonly in obesity.[33] Confounding by health status can be powerful, as evidenced by the disparate results of randomised controlled trials and observational studies of postmenopausal hormone replacement therapy. (see Hormone replacement therapy (menopause)).[34] Obesity remains a likely confounding factor for the associations between low 25(OH)D levels and poor health.[35] Some continue to argue the reverse – that obese and sedentary people are at high risk of many diseases specifically because they have low serum 25(OH)D levels [36]

Sun exposure

The use of sunscreen with a sun protection factor (SPF) of 8 can theoretically inhibit more than 95% of vitamin D production in the skin.[11][37] In practice, however, sunscreen is applied so as to have a negligible effect on vitamin D status.[38][39][40] The vitamin D status of those in Australia and New Zealand[41] is unlikely to have been affected by campaigns advocating sunscreen. Instead, wearing clothing is more effective at reducing the amount of skin exposed to UVB and reducing natural vitamin D synthesis.

Another risk factor arising from lack of sun exposure is clothing which covers a large portion of the skin. This clothing when worn on a consistent and regular basis, such as the burqa, is correlated with lower vitamin D levels and an increased prevalence of hypovitaminosis D.[42][43]

Darker skin color

It has been suggested the reduced pigmentation of light-skinned individuals results in higher vitamin D levels[2] and that, because melanin acts like a sun-block, dark-skinned individuals, in particular, may require extra vitamin D to avoid deficiency at higher latitudes. The natural selection hypothesis suggests that lighter skin color evolved to optimise vitamin D production in extreme northern and southern latitudes.[44]

Rickets is sometimes due to genetic disorders such as autosomal dominant hypophosphatemic rickets or X-linked hypophosphatemia and associated with consanguineous marriage,[45] and possibly founder effect.[46] In Kashmir, India patients with pseudovitamin D deficiency rickets had grossly raised 25-hydroxyvitamin D concentrations.[47] Skin colour has also been associated with low 25(OH)D, especially in Africans living in countries with a temperate climate. For example 25-OHD under 10 ng/mL (25 nmol/l) in 44% of asymptomatic East African children living in Melbourne[48][49] However a study of healthy young Ethiopians living in Addis Ababa (10 degrees N) found average 25(OH)D levels of 23.5nmol/L.[50] A review of vitamin D in Africa[51] gives the median levels for equatorial countries: Kenya 65.5 nmol/L and Democratic Republic of the Congo 65nmol/L, concluding that it remains to be established if associations between vitamin D status and health outcomes identified in Western countries can be replicated in African countries.

Vitamin D levels are approximately 30% higher in northern Europe than in central and southern Europe; higher vitamin D concentrations in northern countries may have a genetic basis.[52][53] In a meta-analysis of cross-sectional studies on serum 25(OH)D concentrations globally the levels averaged 54 nmol/l and were higher in women than men, and higher in Caucasians than in non-Caucasians. There was no trend in serum 25(OH)D level with latitude.[54] African Americans often have a very low circulating 25(OH)D level. However, those of African descent have higher parathyroid hormone and 1,25-Dihydroxycholecalciferol associated with lower 25-hydroxyvitamin D than other ethnic groups; moreover, they have the greatest bone density[55] and lowest risk of fragility fractures compared to other populations.[56][57][58] Deficiency results in impaired bone mineralization, and leads to bone softening diseases[59]

Diagnosis

The serum concentration of 25-hydroxy-vitamin D is typically used to determine vitamin D status. It reflects vitamin D produced in the skin as well as that acquired from the diet, and has a fairly long circulating half-life of 15 days. It does not, however, reveal the amount of vitamin D stored in other body tissues. The level of serum 1,25-dihydroxy-vitamin D is not usually used to determine vitamin D status because it has a short half-life of 15 hours and is tightly regulated by parathyroid hormone, calcium, and phosphate, such that it does not decrease significantly until vitamin D deficiency is already well advanced. **People with a granuloma disease such as sarcoidosis can have a high level of serum 1,25-dihydroxy-vitamin D but show a low testing level of serum concentration of 25-hydroxy-vitamin D because the granulomas, when active, produce serum 1,25-dihydroxy-vitamin D. The body is then protecting itself from a calcium dump ( high calcium level) by having a low 25-hydroxy-vitamin D. [5]

One study found that vitamin D3 raised 25-hydroxy-vitamin D blood levels more than did vitamin D2,[60] but this difference has been adequately disproved to allow reasonable assumption that D2 and D3 are equal for maintaining 25-hydroxy-vitamin D status.[61]

There has been variability in results of laboratory analyses of the level of 25-hydroxy-vitamin D. Falsely low or high values have been obtained depending on the particular test or laboratory used. Beginning in July 2009 a standard reference material became available which should allow laboratories to standardise their procedures.[5]

There is some disagreement concerning the exact levels of 25-hydroxy-vitamin D needed for good health. A level lower than 10 ng/mL (25 nmol/L) is associated with the most severe deficiency diseases: rickets in infants and children, and osteomalacia in adults. A concentration above 15 ng/ml (37.5 nmol/L) is generally considered adequate for those in good health. Levels above 30 ng/ml (75 nmol/L) are proposed by some as desirable for achieving optimum health, but there is not yet enough evidence to support this.[5][62][63]

Levels of 25-hydroxy-vitamin D that are consistently above 200 ng/mL (500 nmol/L) are thought to be potentially toxic, although data from humans are sparse. In animal studies levels up to 400 ng/mL (1,000 nmol/L) were not associated with toxicity.[5] Vitamin D toxicity usually results from taking supplements in excess. Hypercalcemia is typically the cause of symptoms, and levels of 25-hydroxy-vitamin D above 150 ng/mL (375 nmol/L) are usually found, although in some cases 25-hydroxy-vitamin D levels may appear to be normal. It is recommended to periodically measure serum calcium in individuals receiving large doses of vitamin D.[1]

In overweight persons increased fat mass is inversely associated with 25(OH)D levels.[64][65] This association may confound the reported relationships between low vitamin D status and conditions which occur more commonly in obesity[66] as the circulating 25(OH)D underestimates their total body stores.[67] However, as vitamin D is fat-soluble, excess amounts can be stored in fat tissue and used during winter months, when sun exposure is limited.[68]

A study of highly sun-exposed (tanned) healthy young skateboarders and surfers in Hawaii found levels below the proposed higher minimum of 30 ng/ml in 51% of the subjects. The highest 25(OH)D concentration was around 60 ng/ml (150nmol/L).[69] A similar <using the same data>study in Hawaii found a range of (11–71 ng/mL) in a population with prolonged extensive skin exposure while as part of the same study Wisconsin breastfeeding mothers were given supplements. The range of circulating 25(OH)D levels in women in the supplementated group was from 12–77 ng/mL. It is noteworthy that the levels in the supplemented population in Wisconsin were higher than the sun exposed group in Hawaii (which again included surfers because it was the same data set).[70]

Another study of African Americans found that blood levels of 25(OH)D decreased linearly with increasing African ancestry, the decrease being 2.5-2.75 nmol/L per 10% increase in African ancestry. Sunlight and diet were 46% less effective in raising these levels among subjects with high African ancestry than among those with low/medium African ancestry.[71] It could be possible that vitamin-D metabolism differs by ethnicity.[72]

Nutritional factors

Cancer

A US National Cancer Institute study analyzed data from the third national Health and Nutrition Examination Survey (NHANES) to examine the relationship between levels of circulating vitamin D in the blood and cancer mortality in a group of 16,818 participants aged 17 and older. It found no support for an association between 25(OH)D and total cancer mortality.[72] Unlike other studies, this one was carried out prospectively— meaning that participants were followed looking forward — and the researchers used actual blood tests to measure the amount of vitamin D in blood, rather than trying to infer vitamin D levels from potentially inaccurate predictive models.[73][74]

The molecular basis for thinking that vitamin D has the potential to prevent cancer lies in its role as a nuclear transcription factor that regulates cell growth, differentiation, apoptosis and a wide range of cellular mechanisms central to the development of cancer.[75] These effects may be mediated through vitamin D receptors expressed in cancer cells.[76] Polymorphisms of the vitamin D receptor (VDR) gene have been associated with an increased risk of breast cancer, although a study of 78 Turkish breast cancer patients showed that the prevalence of the VDR Taq I and Bsm I alleles and the genotype frequencies in patients with breast cancer was similar to that in the normal population.[77] Impairment of the VDR-mediated gene expression is thought to alter mammary gland development or function and may predispose cells to malignant transformation. Women with homozygous FOK1 mutations in the VDR gene had an increased risk of breast cancer compared with the women who did not. FOK1 mutation has also been associated with decreasing bone mineral density which in turn may be associated with an increase in the risk of breast cancer.[78] Research is also being done on the use of calcitriol in the medical treatment of patients with advanced prostate cancer.[79]

Correlation of the vitamin D levels of a population with the solar irradiance to which they are exposed can be confounded by other factors such as age, gender, skin pigmentation, latitude, sunscreen use, and clothing.[74][80][81][82] Moreover, there are genetic factors involved with cancer incidence and mortality which are more common in northern latitudes.[83][84]

A 2005 metastudy found correlations between serum levels of vitamin D and cancer, drawing from a meta-analysis of 63 observational studies of vitamin D status. The authors suggested that intake of an additional 1,000 international units (IU) (or 25 micrograms) of vitamin D daily reduced an individual's colon cancer risk by 50%, and breast and ovarian cancer risks by 30%.[85][86][87][88] Low levels of vitamin D in serum have been correlated with breast cancer disease progression and bone metastases.[77]

Another 2006 study found that taking the U.S. RDA of vitamin D (400 IU per day) cut the risk of pancreatic cancer by 43% in a sample of more than 120,000 people from two long-term health surveys.[89][90] However, in male smokers, a 3-fold increased risk for pancreatic cancer in the highest compared to lowest quintile of serum 25-hydroxyvitamin D concentration has been found.[91]

A randomized intervention study involving 1,200 women, published in June 2007, reports that vitamin D supplementation (1,100 international units (IU)/day) resulted in a 60% reduction in cancer incidence, during a four-year clinical trial, rising to a 77% reduction for cancers diagnosed after the first year (and therefore excluding those cancers more likely to have originated prior to the vitamin D intervention).[92][93] The study was criticized on several grounds[94] including lack of data, use of statistical techniques and comparison with a self-selected (i.e. non-randomized) observational study that found long term convergence of breast cancer incidence[95] The author's response provided the required data, explained their statistical usage and commented that even if the vitamin D merely delayed the appearance of cancer (which they did not believe, based on other studies), that that was still a considerable benefit.[94]

A study by Cedric F. Garland and Frank C. Garland of the University of California, San Diego analyzed the blood from 25,000 volunteers from Washington County, Maryland, finding that those with the highest levels of Calcifediol had one-fifth the risk of colon cancer compared to typical rates.[96]

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