Vitamin D inadequacy in 2007: What it is and how to manage it

Current Opinion in Orthopaedics

Volumn 18, Issue 5, 2007, Pages 480-485

  Glowacki, Julie ^a  

^a BRIGHAM AND WOMEN S HOSPITAL   (United States)

Author keywords

Calcium vitamin D intake; Fractures; Osteoporosis; Vitamin D inadequacy

Indexed keywords

1,25-DIHYDROXY-VITAMIN D3; 25 HYDROXYVITAMIN D; BISPHOSPHONIC ACID DERIVATIVE; CALBINDIN; CALCIUM; CALCIUM CARBONATE; COLECALCIFEROL; ERGOCALCIFEROL; MULTIVITAMIN; PARATHYROID HORMONE; PLACEBO; UNCLASSIFIED DRUG; VITAMIN D;

AUTOIMMUNE DISEASE; CALCIUM HOMEOSTASIS; CHILD HEALTH; CLINICAL TRIAL; COMBINATION CHEMOTHERAPY; CONTROLLED CLINICAL TRIAL; DISEASE ASSOCIATION; DRUG MECHANISM; DRUG MEGADOSE; FALL RISK; FRAGILITY FRACTURE; HIP FRACTURE; HUMAN; INTESTINE ABSORPTION; OSTEOMALACIA; POSTMENOPAUSE; PREECLAMPSIA; PREVALENCE; PRIORITY JOURNAL; PSORIASIS; RANDOMIZED CONTROLLED TRIAL; REVIEW; RICKETS; SUN EXPOSURE; UNSPECIFIED SIDE EFFECT; VITAMIN BLOOD LEVEL; VITAMIN D DEFICIENCY; VITAMIN INTAKE;

EID: 34547892990     PISSN: 10419918     EISSN: None     Source Type: Journal    
DOI: 10.1097/BCO.0b013e3282ab992f     Document Type: Review

References (35)

1. Binkley N, Krueger D, Cowgill CS, et al. Assay variation confounds the diagnosis of hypovitaminosis D: a call for standardization. J Clin Endocrinol Metab 2004; 89:3152-3157.
2. 2 in a patient that was being treated with very high oral doses. It calls attention to the need for international standardization of vitamin D assays.
3. Heaney RP, Dowell MS, Hale CA, Bendich A. Calcium absorption varies within the reference range for serum 25-hydroxyvitamin D. J Am Coll Nutr 2003; 22:142-146.
4. 2, failed to achieve adequate serum 25(OH)D concentration, or had confounders to interpretation due to poor adherence to the study or to equivalent intakes in the control group.
5. Glowacki J, LeBoff MS. Vitamin D insufficiency and fracture risk. Curr Opin Endocrin Diabetes 2004; 11:353-358.
6. Bodnar LM, Simhan HN, Powers RW, et al. High prevalence of vitamin D insufficiency in black and white pregnant women residing in the northern United States and their neonates. J Nutr 2007; 137:447-452. This report indicates high prevalence of vitamin D deficiency and inadequacy among black and white pregnant women residing in the Northern US, even when compliant with prenatal vitamins. The authors use these data to support the recommendation for higher-dose supplementation. It also includes background on the associations between perinatal vitamin D deficiency and later development of a variety of problems including rickets, type 1 diabetes, and schizophrenia.
7. Lee JM, Smith JR, Philipp BL, et al. Vitamin D deficiency in a healthy group of mothers and newborn infants. Clin Pediatr (Phila) 2007; 46:42-44. This clinical investigation that took place during a Boston winter found vitamin D inadequacy in 50% of mothers and 65% of their newborn infants, with a positive correlation between maternal and infant 25(OH)D concentrations. The majority of the mothers were taking daily prenatal vitamins and they drank an average of 2 glasses of milk per day.
8. Hypponen E, Hartikainen AL, Sovio U, et al. Does vitamin D supplementation in infancy reduce the risk of preeclampsia? Eur J Clin Nutr 2007; [Epub ahead of print].
9. Hypponen E, Power C. Hypovitaminosis D in British adults at age 45 y: nationwide cohort study of dietary and lifestyle predictors. Am J Clin Nutr 2007; 85:860-868. This is a large British study of vitamin D status in the 1958 birth cohort when the participants reached 45 years of age. Prevalence of hypovitaminosis D was greatest in winter and spring, in those who resided further north, in those who avoided vitamin D supplements or oily fish, and in those who were obese. There was no benefit for those who consumed margarine more often. (In Great Britain, only infant formula and margarine are fortified with vitamin D.) The authors call for public health measures, such as fortification of foods and availability of effective over-the-counter dietary supplements.
10. Visser M, Deeg DJH, Puts MTE, et al. Low serum concentrations of 25-hydroxyvitamin D in older persons and the risk of nursing home admission. Am J Clin Nutr 2006; 84:616-622. This is a prospective cohort study of 1260 independent, community-dwelling persons aged ≥ 65 years in the Amsterdam Longitudinal Aging Study. Baseline serum 25(OH)D levels were measured and subjects were followed for 6 years. They found lower serum 25(OH)D concentrations were significantly associated with a greater risk of future nursing home admission and also tended to be associated with mortality.
11. 12 and MMSE. The article also reviews the literature reporting low vitamin D status in Alzheimer's disease and in schizophrenia and studies indicating that vitamin D supplementation may reduce seizure incidence in epileptic patients.
12. Holick MF. High prevalence of vitamin D inadequacy and implications for health. Mayo Clin Proc 2006; 81:353-373. This well written review with 264 references concerns vitamin D biology and the epidemiology of hypovitaminosis D. It includes a valuable table with hierarchy of evidence on the relationships between vitamin D and skeletal and nonskeletal pathologic conditions such as cancers, diabetes, multiple sclerosis, psoriasis, arthritis, inflammatory bowel disease, lupus, periodontal disease, and cardiovascular diseases. Dr Holick has been a vocal advocate of sensible sun exposure and states that 5 to 10 min exposure on the arms and legs between the hours of 10 am and 3 pm during the spring, summer and fall will prevent vitamin D inadequacy.
13. Grant WB. Epidemiology of disease risks in relation to vitamin D insufficiency. Prog Biophys Mol Biol 2006; 92:65-79. This comprehensive paper details epidemiologic and interventional evidence for diseases that are strongly or possibly vitamin D-sensitive.
14. Cutolo M, Otsa K, Laas K, et al. Circannual vitamin D serum levels and disease activity in rheumatoid arthritis: Northern versus Southern Europe. Clin Exp Rheumatol 2006; 24:702-704. This clinical investigation evaluated men and women with and without rheumatoid arthritis (RA) in Italy and Estonia. As expected, the analysis showed serum 25(OH)D concentrations were higher in the summer and at lower latitudes. Although no significant differences were found between groups with and without RA, 25(OH)D values showed a significant inverse correlation with RA clinical status, as assessed by a validated disease activity score in both North and South European RA patients. This adds evidence of possible effects of vitamin D among other factors on flare-ups in RA patients.
15. Plotnikoff GA, Quigley JM. Prevalence of severe hypovitaminosis D in patients with persistent, nonspecific musculoskeletal pain. Mayo Clin Proc 2003; 78:1463-1470.
16. LeBoff MS, Hawkes W, Yahiro Y, et al. Vitamin D-deficiency and postfracture changes in lower extremity function and falls in women with hip fractures. J Bone Miner Res 2005; 20:S267.
17. Bakhtiyarova S, Lesnyak O, Kyznesova N, et al. Vitamin D status among patients with hip fracture and elderly control subjects in Yekaterinburg, Russia. Osteoporos Int 2006; 17:441-446.
18. LeBoff MS, Kohlmeier L, Hurwitz S, et al. Occult vitamin D deficiency in postmenopausal US women with acute hip fracture. J Am Med Assoc 1999; 281:1505-1511.
19. Simonelli C, Weiss TW, Morancey J, et al. Prevalence of vitamin D inadequacy in a minimal trauma fracture population. Curr Med Res Opin 2005; 21:1069-1074.
20. Kolatkar N, LeBoff MS, Harris MB, Glowacki J. Effectiveness of osteoporosis care pathways for hospital patients with fragility fractures. J Bone Miner Res 2005; 20:S155.
21. 3 plus 500 mg of calcium citrate on the risk of falling at least once in 199 men and 246 women ≥ 65 years old and living at home. In the 3-year period, 55% of women and 45% of men reported at least 1 fall. The supplement reduced the odds of falling in women by 46%, with a greater effect (65%) in less active women; there was no significant effect in the participating men. The benefit for women occurred after 1-year of supplementation. This was a population that at baseline had fair dietary intake of calcium (∼ 700 mg/day) and serum 25(OH)D levels (∼30 ng/ml). This shows the benefit of supplements even in a healthy ambulatory population.
22. Jackson RD, LaCroix AZ, Gass M, et al. Calcium plus vitamin D supplementation and the risk of fractures. New Engl J Med 2006; 354:669-683. This is the report from the Women's Health Initiative that concluded that there was no fracture risk benefit from 7 years treatment with calcium and vitamin D. An accompanying editorial, subsequent letters, articles, meta-analyses, and reviews pointed out the weaknesses of the study design, including the low dose of vitamin D (400 IU/day), the confounding facts that 64% of the placebo subjects had a daily calcium intake of at least 800mg and that 42% had a daily intake of at least 400 IU/day, that half of all participants were receiving hormone-replacement therapy during the trial, and that adherence was not high. Another general comment is that the subjects were healthy and most had very good bone mineral density scores at enrollment; the number of fractures that occurred during this trial was small. Subgroup analyses were revealing. Among those subjects who were adherent, calcium and vitamin D supplementation significantly reduced the risk of hip fracture by 29%. Among those at least 60 years, there was a 21% reduction in fracture risk.
23. Bischoff-Ferrari HA, Willett WC, Wong JB, et al. Fracture prevention with vitamin D supplementation: a meta-analysis of randomized controlled trials. J Am Med Assoc 2005; 293:2257-2264.
24. 3 (200 IU, 400 IU, 600 IU, or 800 IU) in a nursing home setting, recognized as having a high risk of falls. The 800 IU group had 72% lower rate of falls than the placebo group, and none of the other doses had an effect at 5 months.
25. 3 than expected.
26. Heaney RP. Bone health. Am J Clin Nutr 2007; 85:300S-303S. This somewhat technical paper explains the biological importance of calcium and vitamin D interactions when interpreting published studies. It reviews the evidence that both nutrients are needed as supplements, given contemporary diets and sun exposure. As a case study to illustrate the distinction between oral intake of vitamin D and achieved levels of serum 25(OH)D, Heaney interpreted data in the WHI report [22•] to calculate that 2000 IU/day, and not 400 IU as used in the WHI study, is the dose needed to move individuals from the bottom quartile to the top quartile of 25(OH) concentration.
27. Institute of Medicine. Standing Committee on the Scientific Evaluation of Dietary Reference Intakes: Calcium, Magnesium, Phosphorus, Vitamin D, and Fluoride. Washington, DC: National Academy Press; 1977.
28. Vieth R, Bischoff-Ferrari H, Boucher BJ, et al. The urgent need to recommend an intake of vitamin D that is effective. Am J Clin Nutr 2007; 85:649-650. This is an editorial written by 15 international academic vitamin D specialists. It succinctly reviews safety and efficacy data and calls upon international agencies to change their dietary recommendations on the basis of available evidence. They recommend that 10000 IU/day be the upper intake level and point to ∼1700 IU/day as the intake needed to ensure adequacy on the basis of serum 25(OH)D.
29. 3Intake. http://www.nof.org/prevention/ calcium_and_VitaminD.htm.
30. Heaney RP. The vitamin D requirement in health and disease. J Steroid Biochem Mol Biol 2005; 97:13-19.
31. 2. Am J Clin Nutr 1998; 68:854-858.
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33. Gilchrest BA. Sun protection and vitamin D: three dimensions of obfuscation. J Steroid Biochem Mol Biol 2007; 103:655-663. This important article from a prominent academic dermatologist analyzes the pseudo-controversy between dermatologists and mainstream professionals concerned with vitamin D health. 'Safe sun' positions of dermatologic organizations are in accord with the limited exposure needed for vitamin D photosynthesis. She observes that the popular media have misused some statements that intentional sun exposure should be maximized in order to reduce risk of internal cancers, hypertension, diabetes, multiple sclerosis, and other diseases. She points to the $5 billion per year US indoor tanning industry as misleading when claiming health and safety benefits of indoor tanning (compared with natural tanning) in its advertising about the glamour of having a tan. Safe sun practices, she concludes, are fully compatible with achieving optimal vitamin D levels. There needs to be more clarity from involved professionals in public education activities.
34. Binkley N, Novotny R, Krueger D, et al. Low vitamin D status despite abundant sun exposure. J Clin Endocrinol Metab 2007; 92:2130-2135. These data support the view that there is a physiological ceiling of cutaneous synthesis of vitamin D that limits serum 25(OH)D levels. This paper also makes the point that it is still not possible to compare studies that use different 25(OH) assays because of poor correlations among them. Clinicians should not assume adequate D status in individuals with abundant unfiltered sun exposure.
35. Gonzalez G, Alvarado JN, Rojas A, et al. High prevalence of vitamin D deficiency in Chilean healthy postmenopausalwomen with normal sun exposure: additional evidence for a worldwide concern. Menopause 2007; 14:455-461. This investigation measured sun exposure, vitamin D status, markers of bone turnover in healthy Chilean pre and postmenopausal women. There was a greater prevalence of 25(OH)D inadequacy in postmenopausal than premenopausal women. Further, a marker of bone turnover (urinary deoxypyridinoline) was 75% higher in winter than in summer. The authors comment that vitamin D fortification of food should be considered in this nation.