Vitamin D Deficiency, Remedies (JR 162)

Vitamin D Deficiency, Remedies (JR 162)

Introduction                                                                                                               

If you shun the sun, suffer from milk allergies, or adhere to a strict vegan diet, you may be at risk for vitamin D deficiency. Known as the sunshine vitamin, vitamin D is produced by the body in response to skin being exposed to sunlight. It is also occurs naturally in a few foods -- including some fish, fish liver oils, and egg yolks -- and in fortified dairy and grain products. Vitamin D is essential for strong bones, because it helps the body use calcium from the diet. Traditionally, vitamin D deficiency has been associated with rickets, a disease in which the bone tissue doesn't properly mineralize, leading to soft bones and skeletal deformities. But increasingly, research is revealing the importance of vitamin D in protecting against a host of health problems.

Symptoms of Low Vitamin D

 10 common signs you’re not getting enough vitamin D: Depression or anxiety; Bone softening (low bone density) or fractures; Fatigue and generalized weakness; Muscle cramps and weakness; Joint pain (most noticeable in the back and knees);Blood sugar issues; Low immunity; Low calcium levels in the blood; Mood changes and irritability; Weight gain

Symptoms of bone pain and muscle weakness can mean you have a vitamin D deficiency. However, for many people, the symptoms are subtle. Yet, even without symptoms, too little vitamin D can pose health risks. Low blood levels of the vitamin have been associated with the following:

• Increased risk of death from cardiovascular disease
• Cognitive impairment in older adults
• Severe asthma in children
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Causes of Vitamin D Deficiency

Vitamin D deficiency can occur for a number of reasons:

You don't consume the recommended levels of the vitamin over time. This is likely if you follow a strict vegan diet, because most of the natural sources are animal-based, including fish and fish oils, egg yolks, fortified milk, and beef liver.

Your exposure to sunlight is limited. Because the body makes vitamin D when your skin is exposed to sunlight, you may be at risk of deficiency if you are homebound, live in northern latitudes, wear long robes or head coverings for religious reasons, or have an occupation that prevents sun exposure.

You have dark skin. The pigment melanin reduces the skin's ability to make vitamin D in response to sunlight exposure. Some studies show that older adults with darker skin are at high risk of vitamin D deficiency.

How Vitamin D Deficiency Can Affect Us

If left untreated, vitamin D deficiency can cause: Osteopenia or osteoporosis; Rickets in children; Weakened immune system; Asthma; Tuberculosis ;Diabetes; Periodontal  disease; Cardiovascular  disease; Major depressive disorder or seasonal affective disorder; Multiple sclerosis; Cancer B Fatigue and generalized weakness

 What Is Vitamin D?

 Vitamin D’s primary job is to ensure that your body absorbs the calcium it needs from foods and supplements. Once vitamin D has been ingested or absorbed through your skin, the liver and kidneys convert it to hormonal forms that ensure a proper blood level of calcium and phosphorus for bone health. Without adequate vitamin D, the body obtains calcium directly from the bones, leading to weakened bones, osteoporosis, and rickets. According to the Endocrine Society, vitamin D is a prohormone, a substance the body makes into a hormone. Our bodies convert vitamin D to several different forms:

➧  Calcidiol,  or  25-Hydroxyvitamin  D  (25  (OH)D):  The major circulating form of vitamin D. (Blood tests measure this substance to determine whether vita- min D levels are low.)

➧  Calcitriol, or 1,25-dihydroxyvitamin D: The active hormone form of vitamin D.

Calciferol or Ergocalciferol (vitamin D2): A form of vitamin D produced by plant life, such as that found in almond milk.

➧    Cholecalciferol  (vitamin  D3):  An  antirachitic  (curing/preventing rickets) form of vitamin D.

Vitamin D is a fat-soluble vitamin. Excesses of fat- soluble vitamins remain in our bodies and can reach toxic levels. Vitamins A, E, and K are also fat-soluble. Other vitamins, such as the Bs and vitamin C, are water-soluble, which means excesses are excreted.

It’s important to understand that actual vitamin D excesses in the body are rare. The most com- mon exception occurs when people take excessive amounts of a vitamin D supplement. The Vitamin D Council says that an intake of more than 10,000 IUs daily for three months or more can lead to a toxic level of vitamin D. The result ? The liver takes vitamin D and produces an excess of the chemical calcidiol, or 25-hydroxyvitamin D, which is abbreviated as 25(OH)D. (It is also known as calcif idiol.) When an excess of this chemical gets in our blood, it increases the amount of calcium in our blood, leading to hypercalcemia.

Symptoms of hypercalcemia include: Loss of appetite; Excess thirst; frequent urination; Changes in bowel habits; abdominal pain; Confusion; Weakness

What Constitutes Low Vitamin D?

Too much vitamin D can be dangerous to our health, but it’s rare. Low vitamin D, however, is common and worrisome. Research has shown a link between vita- min D deficiency and your risk of developing: Asthma; Cancer; Cardiovascular disease; Depression; Diabetes; Incontinence; Multiple sclerosis; Periodontal disease; Risk of getting a cold or the flu; Tuberculosis; Weakened bones and muscles.

A “link” means that a statistically significant number of people with these conditions may show low blood levels of vitamin D. It doesn’t mean that sub- optimal vitamin D levels can cause these problems, or that a lack of vitamin D won’t cause these problems—nor does it mean that increasing vitamin D will cure these problems. The link here is simply a statistical connection between low vitamin D and the list of conditions.

The Endocrine Society contends that chronic low vitamin D may raise the risk of developing some dis- eases. However, the Society does not state there is a cause-and-effect link, nor does the organization say that adding vitamin D will lower your risk of developing disease. More research is needed to make such determinations.

Making Sense of Vitamin D Levels

One common criticism of vitamin D studies is the definition of “low” vitamin D. There’s variation among experts as to what blood levels define deficiency and what levels are an insufficiency, because there’s no universally set “optimal” level of vitamin D.

●     The International Osteoporosis Organization and the U.S. Endocrine Society both say optimal levels are at least 30 nanograms per milliliter (ng/mL). Dr. Holick believes blood levels of 25 (OH)D should be between 30 and 100 ng/mL to avoid long-term negative health consequences and between 40 and 60 ng/mL for optimal health.

●  Most everyone agrees that the definition of a deficiency is a level at which diseases such as rickets can occur. A vitamin D blood level below 10 ng/mL is considered deficient by all standards and requires supplementation. From there, it gets a little murky.

An insufficiency (also called a potential deficiency) means you may be at risk for health complications due to low vitamin D.

The Endocrine Society maintains that chronic low vitamin D may raise the risk of developing some diseases, acknowledging that a link between vitamin D and many diseases has been found. However, the Society doesn’t state that there’s a cause-and-effect link, nor does it say that adding vitamin D will lower your risk of developing disease.

The Centers for Disease Control and Prevention (CDC) has no common definition for adequate vitamin D status. The CDC does, however, allow that some scientists have suggested that the criteria used to define adequate status should be revised upward and that concentrations between 20 ng/mL and 32 ng/ mL have been defined as sufficient.

If your blood test reveals a level between 20 and 30 mg/mL, the Vitamin D Council would call this “deficient.” Others call the level “insufficient,” meaning you need more vitamin D but aren’t considered to be a serious health risk. So what’s the right vitamin D level? Your health, age, and lifestyle may affect what your ideal level should be; your physician will point you in the right direction.

VITAMIN D LEVELS 25 Hydroxy D Test, or 25 (OH)D

Less than 30 ng/mL                Deficient

30 to 39 ng/mL                   Adequate

40 to 59 ng/mL                     Optimal

60 to 100 ng/mL                 Therapeutic

Greater than 100                   Excess

ng/mL: nanogams per milliliter Note: There is no consenus standard for vitamin D levels.

But ultimately, the most commonly accepted range for “adequate” vitamin D levels is 30 to 39 ng/mL, while the most common recommendation for an “optimal” range is 40 to 49 ng/ML.

Why is our vitamin D level—and how it’s defined— important? A 2006 study in the American Journal of Public Health found that low blood serum levels are linked to higher mortality rates. Those with vitamin D concentrations in the lowest quartile (less than 9 ng/ mL) had twice the death rate as those in the highest quartile (greater than 35 ng/mL) after adjusting for age. The authors determined that serum 25 (OH)D concentrations of less than 30 ng/mL may be too low for safety.

However, until research prompts enough of a con- sensus to establish absolute values for adequate and inadequate blood vitamin D levels, a dose of common sense and advice from your medical doctor are your best bets. “Most Americans have insufficient levels of vitamin D, which has been linked to a number of health problems,” says Samuel S. Badalian, M.D., Ph.D., D.Med.Sc., director of the Gynecology-Urogyne- cology Center in Syracuse, N.Y.

“However,” Dr. Badalian says, “it’s important to realize that upping your vitamin D won’t fix existing problems and it can’t completely prevent a problem. Adequate vitamin D is needed for prevention, which means to help lower your risk of developing disease.”

If you’re suspicious that you have symptoms that could be related to low vitamin D levels, you may want to undergo a blood test. Serum blood levels of vitamin D are believed to be stable for weeks, serving as a good biomarker for vitamin D adequacy, which is why physicians often use a simple blood test

.

The symptoms associated with low vitamin D are so general they can just as easily be associated with a number of other ailments. This can make it difficult for physicians to substantiate medical necessity for a vitamin D test.  

So what are the symptoms of low vitamin D levels? They often include:

●    Weight gain

●    Low bone density

●    Fatigue

●    Muscular cramps and weakness

●    Joint pain, especially in the back and knees

●    Blood sugar issues

●    Low calcium levels in the blood

●    Irritability

●    Depression

Vitamin D Screening Tests

The most accurate way to measure how much vitamin D is in your body is the 25-hydroxy vitamin D blood test. A level of 20 nanograms/milliliter to 50 ng/mL is considered adequate for healthy people. A level less than 12 ng/mL indicates vitamin D deficiency.

When multiple studies about the benefits of vitamin D started to appear in the late 1990s, a large number of doctors began conducting regular screening tests. A screening test means there’s no known medical reason for doing the test. It’s basically to check—because of the seemingly wide-reaching health benefits of vitamin D—that a patient’s levels are acceptable

“Blood tests for vitamin D levels—not advised unless problems like bone loss is suspected—are soaring,” U.S. News & World Report noted on Nov. 16, 2016. “Under Medicare, there was an 83-fold increase from 2000 to 2010, to 8.7 million tests last year [2015], at $40 apiece. It’s Medicare’s fifth most common test, just after cholesterol levels and ahead of blood sugar, urinary tract infections, and prostate cancer screening.”

Enter the U.S. Preventative Services Task Force. This group of independent medical experts was formed in 1984 to improve healthcare by making evidence-based recommendations about preventive services like screening, counseling, and preventive medications. All 16 members are volunteers, and most are practicing physicians.

When insurance companies write medical policies on the coverage of certain services, such as screen- ing for vitamin D deficiency, they consult research studies, policies from the CMS (Centers for Medicare and Medicaid Services), and the U.S. Preventative Task Force.

In November 2014, the Task Force concluded that “the current evidence is insufficient to assess the bal- ance of benefits and harms of screening for vitamin D deficiency in asymptomatic adults.” They stated that research did not support a clear definition of what defines vitamin D deficiency.  

The reason vitamin D has been dubbed the “Sun- shine Vitamin” is fairly obvious. The sun is your best, most natural form of supplementing vitamin D. When the sun’s UVB rays (ultraviolet B rays) hit your skin, cholesterol in your body converts to vitamin D. Your body—arms, legs, face, trunk—needs direct exposure to sunlight. You can absorb enough vitamin D during a period of 20 to 30 minutes in the midday sun, defined as between the hours of 10 a.m. and 3 p.m. The reason for that timeframe? The sun has to be at the proper angle in order for your body to absorb the rays and make a maximum amount of vitamin D. People who live in the northern latitudes (at 40° latitude and above) cannot absorb enough sunlight from October through May due to the angle of the sun. The Vitamin D Council advises that if your shadow is longer than you are tall, you’re not getting enough sun. Another reason associated with a lack of sunshine is the skin cancer scare, which has caused people to go overboard with sunscreen and sun blocks. Sun- screen and clothing stop your body from absorbing the sunshine necessary to make vitamin D.

While the threat of skin cancer from overexposure to the sun is serious, the limited amount of sun you need for your vitamin D levels is not likely to cause skin cancer. Those with dark complexions are also at risk of not absorbing enough sunlight for vitamin D.

The Vitamin D Council says you may be able to get vitamin D from an indoor tanning bed. Common sense, however, is important; it takes just a few minutes for you to absorb vitamin D via tanning bed rays. If possible, the Council advises, choose a low-pressure bed with a good amount of UVB light rather than high- intensity UVA light.

Do Vitamin D Supplements Help?

For those who cannot get enough sun exposure due to the limitations of climate, geographic location, or physical problems, a vitamin D supplement may help. A supplement is also the most consistent way to ensure adequate intake.

If your latest blood test indicates deficient or insufficient vitamin D levels, your physician will likely give you a prescription for a weekly dose of 50,000 IUs for a limited time period—eight to 12 weeks, for example. (It is not recommended that you try to duplicate this amount with over-the-counter supplements.). You will then be advised about how much vitamin D you should take as a supplement to prevent another deficiency.

For those of us who simply want to ensure adequate vitamin D levels in our bodies’   vitamin D can be taken as:

●    3,000 IUs daily, or

●    21,000 IUs weekly, or

●    90,000 IUs monthly.

Some research indicates you must supplement between 3,000 IUs per day and 4,000 IUs per day to maintain blood levels around  50 ng/mL. That said, an acceptable approach for many people is 2,000 IUs per day, experts say, with a blood test two months later to see how you’re doing. From there, you can adjust your dosage. Higher levels of vitamin D are often recommended for those with autoimmune disease, although you’ll want to consult your physician if you’re considering taking supplements at a rate of 5,000 IUs per day. If you’re buying an over-the-counter supplement, experts recommend using vitamin D3. While all forms of vitamin D must be converted in the body to a more active form (calcitriol), research has shown that vitamin D3 is converted 500 percent faster than vitamin D2

Vitamin D3 (cholecalciferol) is found in food and in sunshine. A study from the Osteoporosis Research Center at Creighton University said that vitamin D3 is about 87 percent more potent in raising and main- taining vitamin D concentrations in the body than vitamin D2.

Vitamin D2 (ergocalciferol) is not naturally produced by your body; it’s a synthetic vitamin D, commonly found in plants. Researchers at the Appalachian State University’s Human Performance Lab found that vitamin D2 supplementation is associated with higher muscular damage.

In a double-blind study, researchers further found that taking vitamin D2 decreased levels of vitamin D3 in the body. Lead author David Nieman theorized that vitamin D2 causes something to occur at the muscle level that worsens damage following stressful exercise. As a result, he advised athletes in particular not to take vitamin D2.

Additional studies showing a weakness in vitamin D2 include:

●    The American Journal of Clinical Nutrition found vitamin D2 does not help prevent fractures.

●    Harvard Medical School found that multiple sclerosis symptoms—numbness, tingling, pain, vision disturbances, fatigue, dizziness—were worsened when the person was on vitamin D2 but improved with vitamin D3.

●    A study published in the Journal of Clinical Endocrinology & Metabolism found that while vitamin D3 reduces death rates in adults, vitamin D2 does not.

Finally, when it comes to nutritional supplements, it’s important to note that the Food and Drug Adminis- tration (FDA) does not regulate them. The FDA watches the supplement industry to be certain no nutritional product claims that it can cure, mitigate, or prevent a disease. Products that make those types of claims must be approved by the FDA as drugs.

Multiple studies on over-the-counter bottles of supplements have shown that not all contain what the label claims. A study led by Erin S. LeBlanc M.D.,

MPH, found that slightly more than half of the vita- min D over-the-counter pills and a third of the vitamin D compounded pills met U.S. Pharmacopeial (USP) convention standards. While the researchers agreed that the lack of accuracy was not likely to cause harm, the supplementation was less accurate and therefore less likely to be effective.

The USP’s mission is to “improve global health through public standards and related programs that help ensure the quality, safety, and benefit of medicines and foods.” It is a non-profit scientific organization that “sets standards for the identity, strength, quality, and purity of medicines, food ingredients, and dietary supplements manufactured, distributed and consumed worldwide.”

Food Sources of Vitamin D

Few foods contain natural vitamin D, but fish does. The exact amount can vary widely. Wild salmon tend to have the highest vitamin D content—as much as 1,500 IU per 3.5-ounce serving. Farmed salmon has about 25 percent of that. Farmed trout, blue fish, swordfish, and Mahi have about half. Cod, grey sole, haddock, and squid have less than 10 percent of that found in wild salmon. Cooking can affect the amount of vitamin D found in foods. For instance, frying salmon can decrease its vitamin D content by 50 percent. Canning, freezing, and baking fish, however, does not make a lot of difference. Raw fish contains the highest level of vitamin D.

Fortified foods are generally a consistent source of vitamin D, with an average of 100 IUs per serving. Fortified foods include some breads, orange juices, cereals, yogurts, and cheeses. Mushrooms form vitamin D when exposed to either natural sunlight or artificial UV light. Wild mushrooms.  Fresh or dried, are typically very high in vitamin D.  Commercially produced mushrooms, grown in the dark, are not high in vitamin D unless they have been purposely exposed to light, so mushroom producers are trying to change that. Natural vitamin D is in egg yolks, organ meat, and high fat dairy. Most milk and dairy products are low in vitamin D unless fortified. In recent years, studies have linked vitamin D deficiency to a variety of disorders.

 Your kidneys cannot convert vitamin D to its active form. As people age, their kidneys are less able to convert vitamin D to its active form, thus increasing their risk of vitamin D deficiency.

Your digestive tract cannot adequately absorb vitamin D.Certain medical problems, including Crohn's disease, cystic fibrosis, and celiac disease, can affect your intestine's ability to absorb vitamin D from the food you eat.

You are obese. Vitamin D is extracted from the blood by fat cells, altering its release into the circulation. People with a body mass index of 30 or greater often have low blood levels of vitamin D.

Treatment for vitamin D deficiency involves getting more vitamin D -- through diet and supplements. Although there is no consensus on vitamin D levels required for optimal health -- and it likely differs depending on age and health conditions -- a concentration of less than 20 nanograms per milliliter is generally considered inadequate, requiring treatment.

Guidelines from the Institute of Medicine increased the recommended dietary allowance (RDA) of vitamin D to 600 international units (IU) for everyone ages 1-70, and raised it to 800 IU for adults older than age 70 to optimize bone health. The safe upper limit was also raised to 4,000 IU. Doctors may prescribe more than 4,000 IU to correct a vitamin D deficiency.

If you don't spend much time in the sun or always are careful to cover your skin (sunscreen inhibits vitamin D production), you should speak to your doctor about taking a vitamin D supplement, particularly if you have risk factors for vitamin D deficiency.

Cancer

A study of more than 17,000 cancer patients, published in the Journal of Clinical Endocrinology and Metabolism, found that a high vitamin D level when you’re diagnosed with cancer means you will more likely survive and stay cancer free. Researchers looked at the results from 25 different studies involving 17,732 patients with cancer. They measured vitamin D levels at the time of the cancer diagnosis and tracked survival rates.

The study showed benefits from high vitamin D levels in surviving lung, stomach, prostate, colon/ rectal, and breast cancer. They also saw benefits for lymphoma and leukemia. Overall, the study found that for every 4 mg/ml increase in vitamin D levels, cancer survival increased by 4 percent. The most impressive levels were:

●    45% more likely to survive colon/rectal cancer

●    37% more likely to survive breast cancer

●    52% more likely to survive lymphoma

●    “Considering that vitamin D deficiency is wide- spread around the world, our suggestion is to ensure everyone has sufficient levels of this important nutrient,”  

●    Research at the Cancer Epidemiology Research Unit in Sydney, New South Wales, Australia, found that adequate levels of vitamin D are important for the integrity of your DNA, helping to protect it from oxidative damage.

●     

●    Depression

Depression is linked to a deficiency of D3, the same form obtained via the sun. Sunlight is the best source of vitamin D3, the type that increases levels dopamine and serotonin, the feel-good chemicals in the brain. A University of Bristol study published in the January 2012 Journal of Child Psychology and Psychiatry looked at vitamin D levels in children when they were 9 years old and found that those with higher levels of vitamin D were 10 percent less likely to show signs of depression when they were tested again at 13. (Note: Vitamin D supplements are not recommended for children without information from your pediatrician.)

In 2013, researchers from McMaster University in Ontario, Canada, determined that low vitamin D levels are associated with depression. The study was published in the British Journal of Psychiatry. After screening thousands of studies, the researchers found 16 with a total of 31,424 participants that met the study’s criteria for a meta-analysis. Their conclusion: That overall, people with depression had lower vitamin D levels than controls without depression. The lowest vitamin D levels had a significantly increased risk of becoming depressed.

After the McMaster study, researchers from the Amsterdam University Medical Center in the Netherlands published a study that found low vitamin D levels are associated with depression and linked it to depression severity. The study included 1,102 people with current depression. Of those, 33.6 per- cent had deficient or insufficient vitamin D, defined as a serum 25 (OH)D level less than 20 ng/ml. The study found that the more severe the symptoms of depression, the lower their vitamin D levels. In addition, the Amsterdam research found that the lower the vitamin D levels, the more at risk the participant was of having a depressive disorder two years later. People with the lowest levels of vitamin D were 11 times more prone to be depressed than those with normal levels.

Fatigue

Researchers at Newcastle University in the United Kingdom compared muscle function and recovery in 12 patients with vitamin D deficiency and 15 con- trols with normal vitamin D levels using magnetic resonance spectroscopy (NRS). NRS shows in real time how mitochondria inside muscle cells function.

Mitochondria manufacture ATP, the body’s main energy currency. ATP, or adenosine triphosphate, is an energy storage molecule. Suboptimal mitochon- dria function has been implicated in several fatigue- related disorders, as has low vitamin D. Researchers wanted to see how vitamin D treatment affected mus- cle energy metabolism.

Mitochondrial function in the vitamin D-deficient patients’ muscles improved after vitamin D supple- mentation. The improvement in the mitochondria’s ability to generate energy correlated with the improve- ments in vitamin D levels. All patients reported an improvement in fatigue after vitamin D therapy.

A study by the Endocrinology Department at St. George Hospital in Australia explored the effects of dif- ferent doses of vitamin D on a test subject’s strength and muscle function. Researchers randomly assigned 30 vitamin D deficient patients either 2,000 or 5,000 IU of vitamin D per day for three months.

At the end of the study, only five subjects (45 per- cent) in the 2,000 IU group—compared to 14 (93 percent) in the 5,000 IU group achieved a final concentration of at least 30 ng/mL. Muscle strength improved in both groups. Researchers concluded 5,000 IU daily is more effective than 2,000 IU for vitamin deficiency. Your muscle will function better and procure more energy with vitamin D supplements because it helps improve the mitochondria’s ability to generate ATP. You may also see improvements in your mood, brain function, and other physical symptoms.

Female Pelvic Floor Disorders

A 2010 study by Samuel S Badalian M.D., Ph.D., director of the Gynecology-Urogynecology Center in Syracuse, N.Y., and Paula Rosenbaum, Ph.D., found that higher vitamin D levels were linked to a lower risk for such female pelvic floor disorders as uterine prolapse and urinary incontinence.

The study data included 1,881 non-pregnant women over 20 years old in whom pelvic floor dis- orders and vitamin D measurements were available. Data were analyzed regarding demographics, pelvic floor disorders, and vitamin D levels. After controlling for known risk factors, the researchers calculated odds ratios to determine associations between vita- min D levels and pelvic floor disorders.

Findings showed one or more pelvic floor disorders in 23 percent of the participants. Women reporting at least one pelvic floor disorder and those with urinary incontinence had significantly lower mean vitamin D levels. With increasing vitamin D levels, risks for pelvic floor disorders were significantly decreased. In women at least 50 years old with vitamin D levels at or less than 30 ng/mL (i.e., not insufficient), the risk of urinary incontinence was significantly reduced. the prevalence of pelvic floor disorders, including urinary incontinence.

Graves’ Disease/Hyperthyroidism

Graves’ disease is an autoimmune condition that leads to an overproduction of thyroid hormones. It is the most common autoimmune disorder in the United States. Symptoms include rapid heartbeat, sweating, muscle weakness, tremor, and anxiety. People with Graves’s disease are more likely to be deficient in vitamin D, and low vitamin D levels increase the risk of Graves’ disease.

Certain mutations in the vitamin D receptor gene are linked to a higher incidence of autoimmune thyroid diseases, including Graves’ disease. Vitamin D exerts hormone-like actions on the cells of the immune sys- tem, generating anti-inflammatory effects and helping to regulate the immune system.

High Blood Pressure

A study presented at the European Human Genetics Conference in 2013 made a discovery showing that vitamin D deficiency can cause high blood pressure. Although other studies had shown a link, this large- scale study showed cause and effect, which is a sig- nificant finding. Data was used from 35 studies that included 155,000 participants.

The study found that for every 10 percent increase in vitamin D levels, there was an 8 percent decrease in the risk of developing hypertension. This study data suggests that some types of cardiovascular disease could be prevented through vitamin D supplements or increased vitamin D consumption through food.

A study by a team of doctors from Brigham and Women’s Hospital in Boston showed that taking vita- min D3 supplements for three months significantly lowers blood pressure readings.

The participants received a placebo, 1,000, 2,000, or 4,000 IUs of vitamin D daily for three months. The results, which were published in the medical publication Hypertension, showed that as vitamin D supplement levels went up, systolic blood pressure went down.

In fact, the higher the dose, the more blood pres- sure was reduced:

●    Those taking 1,000 IUs decreased by 0.7 mmHg.

●    Those taking 2,000 IU decreased by 3.4 mmHg.

Those taking 4,000 IU decreased by 4.0 mmHg

Overall, researchers found that systolic (top reading) blood pressure decreased by an average of -1.4 mmHg for each additional 1,000 IU per day of vitamin D3 taken.

Muscle Strength

A 2015 study showed that postmenopausal women with type 2 diabetes who had vitamin D levels below 30 ng/mL were given 6,600 IU of vitamin D per week or a placebo for three months. At the end of the study, those women given vitamin D showed significant improvements in grip strength over the control group.

In another study, women taking 1,000 IUD vita- min D daily had a 25.3percent increase in muscular strength, while women receiving placebo had a 6.8 percent loss in lean muscle mass. Women who received no vitamin D were twice as likely to fall.

Osteoporosis

The annual incidence of fractures due to osteoporosis in women over 50 is greater than the combined chances of heart attack, stroke, and breast cancer— and vitamin D deficiency may be a factor.

In patients with osteoporosis, wrist fractures tend to occur 15 years earlier than hip fractures. A study presented at the American Academy of Orthopaedic Surgeons’ 2012 annual meeting reported that low levels of vitamin D were found in 44 percent of post- menopausal women with wrist fracture.

Vertigo

A 2013 study published in The Journal of Neurology found vitamin D levels in people with benign paroxysmal positional vertigo (BPPV) to be 4.5 ng/ mL lower than healthy controls. BPPV is a state of dizziness and spinning that can be debilitating, has been associated with osteoporosis and poor bone health. Very low levels have also been associated with the recurrence of BPPV. Given that problems with calcium metabolism is what causes our bones to lose density, it makes sense when you realize that BPPV is caused by degradation of calcium deposits in the ear.

Weight Gain

A 2012 study by Dr. Erin LeBlanc, an endocrinologist and researcher at the Kaiser Permanente Center for Health Research in Portland, Ore., showed that women with low levels of vitamin D may be more susceptible to weight gain. The study was reported in the Women’s Journal of Health.

Weight Loss

A study published in the Journal of the American Geriatrics Society, selected 218 women, ages 50 to 75, all overweight or obese and with insufficient vitamin D levels. The participants underwent a weight-loss program that combined calorie reduction of 500 to 1,000 fewer calories per day and 225 minutes a week of moderate to fibrous aerobic exercise. Participants were also assigned either a placebo or 2,000 IU of vitamin D daily.

Both groups lost a little over 8 percent of body weight. The extra vitamin D did boost blood levels of vitamin D in the supplement group, but little dif- ference was found for muscles and bones. A small subgroup with sarcopenia (frailty associated with loss of lean muscle mass) did seem modestly more favor- able changes.

Obese individuals are more likely to have low levels of vitamin D, which is known to benefit muscles and bones, so some people take supplemental vitamin D during weight loss. Turns it out that doesn’t necessarily make sense. Obese women who lose weight also lose lean muscle mass and bone mineral density, particularly if they are inactive, putting them at greater risk of frailty and falls.

Vitamin D Deficiency in Pakistan:

South Asian population seems to be especially prone to vitamin D deficiency and its consequences as much as 69%-82% of the South Asian populations in India had 25(OH)D levels in plasma less than the minimum acceptable levels of 20 ng/ml. This deficiency/insufficiency is not confined to the South Asians living in India and Pakistan, but even the immigrants of South Asian origin in UK, Denmark and Norway have been found to be having very low serum/plasma levels of 25(OH)D. This indicates that poverty alone cannot be the major reason for hypovitaminosis D in South Asians. Therefore, other causes, such as use of unbalanced diet, excessive cooking of food and limited exposure to the sunshine must be taken into account.

Powell and Greenberg have pointed out some of the secondary causes. These include: decreased synthesis from skin due to dark skin pigmentation or excessive clothing, gastrointestinal problems leading to mal absorption, impaired hepatic 25 hydroxylation of vitamin D3 (due to anticonvulsant drugs, theophylline, isoniazid or severe liver disease), impaired renal hydroxylation of 25-hydroxy vitamin D3 due to chronic renal failure or hypoparathroidism. Major causes of vitamin D deficiency,23 which could be specific to South Asian populations, must be highlighted.

Causes of vitamin D deficiency in South Asians:

Social and religious customs: The women folks largely stay at home which is almost closed to sunlight. The Muslim women of the region wear clothes which apart from face and hands cover all other parts of their bodies. Even if they go out, opportunity to expose their bodies in sunlight is not available in the all encompassing "Burqa" (a head to toe covering which only has small openings for the eyes). Infants dependent on their mothers also stay indoors and receive little or no exposure to sunlight. The old and weak also have no exposure to sunlight as they spend almost all of their time inside the tiny huts or houses. The middle class urban population is now increasingly living in densely populated apartment blocks with very little natural light.

Poverty and illiteracy: Poverty is one of the major reasons for most of the ills of the society including poor health. The governments’ claims of only a third of the population being below the poverty line in this region are doubtful. Even those who actually live above this arbitrary line cannot afford to eat a proper diet due to the high cost of foods rich in vitamin D. A vast majority of people are illiterate and are not aware of the importance of balanced diet. Moreover, the dietary habits are also to blame as food is often overcooked destroying most of the vitamins and micronutrients in it.

Skin pigmentation of South Asian population: The color of skin of South Asian population varies from light brown to almost dark. Dark pigmentation has been found to decrease skin synthesis of vitamin D because UV light cannot reach the appropriate layer of the skin. Compared to the Caucasian population, healthy African Americans have also been found more likely to be vitamin D deficient regardless of age.

Addictive Habits: A recent study on South Asian communities in UK by Ogunkolade et al has shown that chewing betel nut (Areca catechu), an addictive habit common among South Asians, contributes to hypovitaminosis D by modulating the enzymes which regulate circulating levels of 1,25di(OH)D.

Impact of vitamin D deficiency on South Asian population

Vitamin D deficiency and bone mineral density: Vitamin D deficiency is associated with secondary hyperparathyroidism with consequent ill effects on bone mineral density. Marwah et al,27studied vitamin D deficiency and its effects on bone mineral density in Indian adolescents of 10-18 years of age and concluded that metabolic bone disorders secondary to vitamin D deficiency continue to be prevalent in the Indian subcontinent and are more prevalent in lower socio economic population.

Vitamin D deficiency and osteoporosis: Postmenopausal women are known to be prone to vitamin D deficiency causing an early onset of osteoporosis. The tendency to the deficiency is universal as 28.4% post -menopausal women have been found to be deficient in vitamin D [25(OH)D, < 20 ng/ml] in most part of the world. However, this percentage increased to 30% in a population from Southern India.

Osteomalacia and rickets due to vitamin D deficiency: While rickets is a consequence of vitamin D deficiency in infants and children, older adults can suffer from osteomalacia due a loss of bone density causing pain and soft bones.The problem of rickets among infants and children is widespread in cooler northern areas of South Asia. Rickets remains one of the major causes of infant mortality in South Asia.

Vitamin D deficiency in infants can often be traced to maternal nutritional status. Neonatal concentrations are normally 60-70% of maternal vitamin D levels. In case of maternal deficiency, the neonate’s low reserves of vitamin D can cause hypocalcaemic symptoms in the first six months of infant’s life.Pregnant women in South Asia are advised 400 IU (10µg) daily intake of vitamin D but compliance to this recommendation is often very poor.31 Experience with Indian and Pakistani populations in developed countries and in India and Pakistan suggests that for conventionally dressed pregnant women receiving insufficient sunlight, a 1000 IU (25 µg) daily intake of vitamin D is more appropriate.

Due to low level of compliance to recommended daily intake of vitamin D, Lawson and Thomas advocate an annual intramuscular booster of 150,000 IU for children of Asian origin up to the age of five years. In order to build vitamin D store of infants, it is now a standard practice in France is to give pregnant women a single large intramuscular dose of vitamin D of 100,000 to 150,000 IU during the 7^th month of pregnancy. A similar policy for children and pregnant women in India and Pakistan needs to be considered.

Roy et al have reported that in South Asian women, a decrease in serum 25(OH)D level <15 ng/ml is associated with a progressive reduction in bone mass at the hip and wrist. Finch et al35claimed that osteomalacia was under-diagnosed in South Asians living in UK. They found that 22% of subjects in their study had varying degrees of osteomalacia.

Vitamin D deficiency and other diseases: Over 200 of human genes have receptors for vitamin D, making vitamin D deficiency a contributory factor to a wide variety of other human diseases. Johnson argues "that vitamin D is important for much more than just bones; the vitamin seems to have a role in preventing colorectal and other cancers, diabetes, arthritis and even multiple sclerosis (MS)".

In vitro studies have shown that the active vitamin D metabolite - 1,25 di(OH))D3 may arrest the cell cycle progression, induce apoptosis as well as regulate T cells and antigen presenting cells function. They point to the evidence that vitamin D deficiency accelerates development of autoimmune disease and cancers.

Recently, an inverse association between plasma 25(OH) D levels and risk of hypertension has been reported. Richard and his associates have shown beneficial effects of vitamin D against aging and inflammation. In a study at the Alzheimer’s Disease Research Center, St Louis, USA, vitamin D deficiency was found to be associated with psychiatric and neurological disorders.40 In another report, vitamin D deficiency was implicated in depression.

Bottela-Carretero et al found an association between vitamin D deficiency and metabolic syndrome in obese patients. Patients with vitamin D deficiency had significantly lower levels of HDL-cholesterol and hypertriglyceridemia compared to patients with normal levels of vitamin D. Wang et al more recently, in a prospective study on 1739 participants and a mean follow-up of 5.4 years, showed vitamin D deficiency to be a risk factor for cardiovascular disease in participants with hypertension. Cardiomyopathy due to vitamin D deficiency in infants is a rare but potentially fatal manifestation of hypovitaminosis D.

Adequate intake of vitamin D: The mean serum concentration of 25(OH)D of 30 ng/ml is considered desirable for health.1 A level of 20 ng/ml is considered as minimum acceptable.The recommended daily intakes for vitamin D for infants, children and adults upto 50 years is 200 IU (5 µg) per day, and for adults between 50-70 years, it should be 400 IU (10 µg). Several investigators have suggested that these values are insufficient especially for pregnant females, sick adults and older adults. Perhaps all the adults need 800-1000 IU daily. 

Toxicity of Vitamin D:Excess of vitamin D can cause hypercalcemia and hypercalcuria. However, these complications do not occur at the recommended intake amounts of vitamins D.Toxicity is not likely to occur at doses less than 2400 IU (60µg) per day.Studies have reported no observed adverse effects of vitamin D at an intake of 20µg/day.

Conquering vitamin D deficiency:Vitamin D deficiency in South Asia has acquired epidemic proportions. It is surprising that in South Asia, where as much as 80% of the apparently healthy population is deficient in vitamin D (<20ng 11.1="" 40="" a="" advocate="" affected="" all="" almost="" and="" approximately="" are="" asia="" at="" awareness="" be="" been="" being="" board="" body.="" body="" by="" cold="" common="" community="" conservative="" could="" d.="" d="" daily="" deficiency="" deficient="" developing="" development="" enough="" even="" exposure="" factors="" fears="" food="" foodstuff="" for="" fortification="" governments.="" grains="" had="" have="" hawaian="" hour="" however="" human="" hypovitaminosis="" implemented="" impress="" improve="" in="" incumbent="" institute="" intakes="" is="" it="" levels="" low="" makers="" mandatory="" medicine="" mild="" minutes="" ml="" necessary="" need="" needs="" ng="" no="" northern="" not="" number="" nutrient="" nutrition="" o:p="" of="" on="" or="" order="" parts="" per="" perhaps="" pigmentation="" policy="" population.="" population="" populations="" prevent="" program="" proved="" provide="" public="" recent="" recommendations="" recommended="" related="" resulted="" revealed="" revised="" risk="" scientific="" severe="" severely="" shows="" skin="" social="" societies.="" south="" status="" study="" suggested="" sunlight="" sunscreen="" supplementation="" synthesis="" that="" the="" therefore="" these="" thirty="" this="" to="" too="" total="" toxicity="" unfounded="" unknown.="" up="" upon="" upward="" usa="" vitamin="" was="" week="" western="" where="" winters="" with="" without="" would="" yet="">

Recommendation:

Vitamin D deficiency is wide spread in South Asian population and is contributing to burden of disease in this region. It is suggested that the governments in South Asia should implement a mandatory vitamin D supplementation program of selected foodstuff, at least during the winter months. Vitamin D supplement and an annual intramuscular injection of a large single dose of vitamin D need to be considered for the special risk groups. The program needs to be reinforced through a mass awareness campaign over the electronic media of the importance of absorbing direct sunlight for at least 30 minutes a day. The adequate vitamin D daily intake for South Asians also needs to be set at least twice that of the recommended intakes for Western populations.