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Medical Forum / General / Nutrition / March 2007Prevalence of hypovitaminosis D in UK and Holland alarmingly high in winter, urgent need to recommend EFFECTIVE doses
The study 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 Mar;85(3):860-8. PMID: 17344510 [PubMed - in process] <http://www.ajcn.org/cgi/content/abstract/85/3/860> published in the latest issue of AJCN investigated vitamin D status (serum calcidiol a.k.a (25(OH)D concentrations) of British adults at age 45 and found that the prevalence of hypovitaminosis D was alarmingly high during the winter and spring. Below the abstract of the study: "BACKGROUND: Increased awareness of the importance of vitamin D to health has led to concerns about the prevalence of hypovitaminosis D in many parts of the world. OBJECTIVES: We aimed to determine the prevalence of hypovitaminosis D in the white British population and to evaluate the influence of key dietary and lifestyle risk factors. DESIGN: We measured 25- hydroxyvitamin D [25(OH)D] in 7437 whites from the 1958 British birth cohort when they were 45 y old. RESULTS: The prevalence of hypovitaminosis D was highest during the winter and spring, when 25(OH)D concentrations <25, <40, and <75 nmol/L were found in 15.5%, 46.6%, and 87.1% of participants, respectively; the proportions were 3.2%, 15.4%, and 60.9%, respectively, during the summer and fall. Men had higher 25(OH)D concentrations, on average, than did women during the summer and fall but not during the winter and spring (P = 0.006, likelihood ratio test for interaction). 25(OH)D concentrations were significantly higher in participants who used vitamin D supplements or oily fish than in those who did not (P < 0.0001 for both) but were not significantly higher in participants who consumed vitamin D-fortified margarine than in those who did not (P = 0.10). 25(OH)D concentrations <40 nmol/L were twice as likely in the obese as in the nonobese and in Scottish participants as in those from other parts of Great Britain (ie, England and Wales) (P < 0.0001 for both). CONCLUSION: Prevalence of hypovitaminosis D in the general population was alarmingly high during the winter and spring, which warrants action at a population level rather than at a risk group level." In the same issue of AJCN there is a Dutch vitamin D study van Dam RM, Snijder MB, Dekker JM, Stehouwer CD, Bouter LM, Heine RJ, Lips P. Potentially modifiable determinants of vitamin D status in an older population in the Netherlands: the Hoorn Study. Am J Clin Nutr. 2007 Mar;85(3):755-761. PMID: 17344497 [PubMed - as supplied by publisher] <http://www.ajcn.org/cgi/content/abstract/85/3/755>, which found that low vitamin D status among elderly people is very common also in Holland. Here's its abstract: "BACKGROUND: Inadequate vitamin D status is common in many populations around the world. OBJECTIVE: The aim was to evaluate potentially modifiable determinants of vitamin D status in an older population. DESIGN: This was a cross- sectional study from a population-based cohort including 538 white Dutch men and women aged 60-87 y. Vitamin D status was assessed by plasma 25-hydroxyvitamin D [25(OH)D] concentrations. RESULTS: In the winter period, 51% of the subjects had 25(OH)D concentrations <50.0 nmol/L. Greater body fatness and less time spent on outdoor physical activity were associated with worse vitamin D status. Regular use of vitamin D-fortified margarine products [odds ratio (OR) in a comparison of intake of >/=20 g/d with none: 0.41; 95% CI: 0.20, 0.86; P for trend < 0.001], fatty fish (OR for servings of >/=2/mo versus none: 0.41; 95% CI: 0.16, 1.04; P for trend = 0.01), and vitamin D-containing supplements (OR for >/= 1/d versus none: 0.33; 95% CI: 0.17, 0.63; P for trend < 0.001) were inversely associated with vitamin D inadequacy [25(OH)D <50.0 nmol/L]. We estimated that combined use of margarine products (20 g/d), fatty fish (100 g/wk), and vitamin D supplements (>/=1/d) was associated with a 16.8 nmol/L higher 25(OH)D concentration than was the use of none of these. However, none of the participants reached these intakes for all 3 factors. CONCLUSION: Because few foods are vitamin D- fortified and the amounts of vitamin D in supplements are low, it is difficult to achieve adequate vitamin D status through increasing intakes in the Netherlands and in countries with similar policies." The editorial of the same issue, Vieth R, Bischoff-Ferrari H, Boucher BJ, Dawson-Hughes B, Garland CF, Heaney RP, Holick MF, Hollis BW, Lamberg-Allardt C, McGrath JJ, Norman AW, Scragg R, Whiting SJ, Willett WC, Zittermann A. The urgent need to recommend an intake of vitamin D that is effective. Am J Clin Nutr. 2007 Mar;85(3):649-50. PMID: 17344484 [PubMed - in process] <http://www.ajcn.org/cgi/content/full/85/3/649>, whose list of authors is packed with the most famous and appreciated vitamin D researchers and also includes Harvard's Walter C. Willett, comments the study by Hyppönen and Power, states the urgent need to raise vitamin D recommendations, and appeals to the authorities and other policy makers, media, vitamin manufacturers, etc., to work for this goal to get that done as soon as possible. Below a couple of excerpts from this article: "The report by Hyppönen and Power in this issue of the Journal (1) highlights a frustrating and regrettable situation for nutrition researchers. In the early 1970s, the same serum 25-hydroxyvitamin D [25(OH)D] concentrations reported by Hyppönen and Power were thought to be indicative of "healthy" white adults in the United Kingdom (2). However, during those early years after the discovery of 25(OH)D, the adequacy of its serum concentration was based simply on whether the concentration was enough to prevent osteomalacia or rickets. Three decades later, we know that 25(OH)D concentrations relate to many other aspects of health, including fracture risk, bone density, colon cancer, and even tooth attachment (3); we also know that much higher concentrations of 25(OH)D are needed to prevent adverse outcomes. Indeed, in the 1958 British birth cohort, lower 25(OH)D is associated with a higher percentage of hemoglobin A1C (a measure of long-term glucose concentration), which further emphasizes the need to maintain optimal 25(OH)D concentrations (4). [...] It is important for major journals such as the AJCN to publish evidence of a widespread nutrient deficiency. Regrettably, we are now stuck in a revolving cycle of publications that are documenting the same vitamin D inadequacy (1-3, 5, 7-9, 13-17). This phenomenon has been referred to as "circular epidemiology" (18), and, for vitamin D, the phenomenon will continue for as long as the levels of vitamin D fortification and supplementation and the practical advice offered to the public remain essentially the same as they were in the era before we knew that 25(OH)D even existed. As scientists, the purpose of our work is to improve the health of the public. We know the realities of serum 25(OH)D concentrations in populations around the world, and we have come to the conclusion that public health will benefit from improved vitamin D nutritional status. We know the intakes of vitamin D needed to bring about desirable 25(OH)D concentrations, so why is the science not making a difference to public health? A major reason is that there is little public pressure on policy makers to support efforts to update recommendations about nutrition. Public pressure is generally rooted in the media, but we do not think that the public media present the vitamin D story in a complete and accurate manner. Reports about vitamin D inadequacies are presented straightforwardly, but, when it comes to discussing the intake of vitamin D needed to correct the situation, outdated official recommendations for vitamin D are propagated by the public media. This probably occurs because of restrictive editorial policies driven by concern about possible litigation if media were to advise a "toxic" intake greater than the UL. The unfortunate result is that there is minimal motivation for policy makers to implement the relatively simple steps that could correct this nutrient deficiency. Because of the convincing evidence for benefit and the strong evidence of safety, we urge those who have the ability to support public health - the media, vitamin manufacturers, and policy makers - to undertake new initiatives that will have a realistic chance of making a difference in terms of vitamin D nutrition. We call for international agencies such as the Food and Nutrition Board and the European Commission's Health and Consumer Protection Directorate-General to reassess as a matter of high priority their dietary recommendations for vitamin D, because the formal nationwide advice from health agencies needs to be changed."  SignatureMatti Narkia >The study > [quoted text clipped - 9 lines] >age 45 and found that the prevalence of hypovitaminosis D >was alarmingly high during the winter and spring. [snip] >The editorial of the same issue, > [quoted text clipped - 12 lines] >other policy makers, media, vitamin manufacturers, etc., to work for >this goal to get that done as soon as possible. A related news article: Vitamin D level reassessment high priority, say experts <http://www.nutraingredients-usa.com/news/ng.asp?n=74831-vitamin-d-supplements-to lerable-upper-intake-level> "3/9/2007 - International agencies should reassess as a matter of high priority dietary recommendations for vitamin D, experts have said, because current advice is outdated and puts the public at risk of deficiency. Fifteen experts from universities, research institutes, and university hospitals around the world, led by Reinhold Vieth from Toronto's Mount Sinai Hospital wrote in the American Journal of Clinical Nutrition: "We call for international agencies such as the Food and Nutrition Board and the European Commission's Health and Consumer Protection Directorate-General to reassess as a matter of high priority their dietary recommendations for vitamin D, because the formal nationwide advice from health agencies needs to be changed." "The balance of the evidence leads to the conclusion that the public health is best served by a recommendation of higher daily intakes of vitamin D. Relatively simple and low-cost changes, such as increased food fortification or increasing the amount of vitamin D in vitamin supplement products, may very well bring about rapid and important reductions in the morbidity associated with low vitamin D status," they said. The editorial was written in response to a UK-based study, published in the same journal, which reported that there exists an alarmingly high prevalence of hypovitaminosis D in the general population during the winter and spring. Vitamin D refers to two biologically inactive precursors - D3, also known as cholecalciferol, and D2, also known as ergocalciferol. The former, produced in the skin on exposure to UVB radiation (290 to 320 nm), is said to be more bioactive. The latter is derived from plants and only enters the body via the diet. Both D3 and D2 precursors are hydroxylated in the liver and kidneys to form 25- hydroxyvitamin D (25(OH)D), the non- active 'storage' form, and 1,25-dihydroxyvitamin D (1,25(OH) 2D), the biologically active form that is tightly controlled by the body. The study, by Elina Hyppönen and Chris Power from the Institute of Child Health in London, measured the level of 25(OH)D in 7437 whites from the 1958 British birth cohort when the subjects had reached the age of 45. Hyppönen and Power report that prevalence of low vitamin D levels was highest during the winter and spring, when 46.6 per cent of participants had 25(OH)D concentrations of less than 40 nanomoles per litre while this fell to 15.4 per cent during the summer and autumn. Vitamin D is produced in the skin on exposure to UVB radiation and can also be consumed in small amounts from the diet. However, recent studies have shown that sunshine levels in some northern countries are so weak during the winter months that the body makes no vitamin D at all, leading some to estimate that over half of the population in such countries have insufficient or deficient levels of the vitamin. "Prevalence of hypovitaminosis D in the general population was alarmingly high during the winter and spring, which warrants action at a population level rather than at a risk group level," concluded the researchers. Vieth and his collaborators said the study was yet another publication in a series that document low vitamin D levels, and this will continue while recommended levels of vitamin D intake remain outdated. "Because of the convincing evidence for benefit and the strong evidence of safety, we urge those who have the ability to support public health-the media, vitamin manufacturers, and policy makers-to undertake new initiatives that will have a realistic chance of making a difference in terms of vitamin D nutrition," wrote Vieth and collaborators. A recent review of the science reported that the tolerable upper intake level for oral vitamin D3 should be increased five-fold, from the current tolerable upper intake level (UL) in Europe and the US of 2000 International Units (IU), equivalent to 50 micrograms per day, to 10,000 IU (250 micrograms per day). Source: The American Journal of Clinical Nutrition March 2007, Volume 85, Number 3, Pages 860-868 "Hypovitaminosis D in British adults at age 45 y: nationwide cohort study of dietary and lifestyle predictors" Authors: E. Hyppönen and C. Power Editorial: The American Journal of Clinical Nutrition March 2007, Volume 85, Number 3, Pages 649-650 "The urgent need to recommend an intake of vitamin D that is effective" Authors: R. Vieth, H. Bischoff-Ferrari, B.J. Boucher, B. Dawson- Hughes, C.F. Garland, R.P. Heaney, M.F. Holick, B.W. Hollis, C. Lamberg-Allardt, J.J. McGrath, A.W. Norman, R. Scragg, S.J. Whiting, W.C. Willett, and A. Zittermann" SignatureMatti Narkia >>The study >> [quoted text clipped - 33 lines] >Vitamin D level reassessment high priority, say experts ><http://www.nutraingredients-usa.com/news/ng.asp?n=74831-vitamin-d-supplements-to lerable-upper-intake-level> Another related news article: SUNSHINE CAN SAVE YOUR LIFE 10/03/07 By Victoria Fletcher <http://www.express.co.uk/news_detail.html?sku=1357> "BRITONS must spend more time in the sun to improve their health, doctors urged yesterday. In a stark message, experts said many people are putting themselves at risk of illnesses from brittle bones to heart problems because they are not spending enough time outdoors. The warning comes after scientists uncovered alarmingly high rates of Vitamin D deficiency among Britons during winter and spring. The greatest source of vitamin D - which helps strengthen bones and protects the heart - comes from being exposed to ultraviolet rays from the sun. Experts are so worried about the findings that they said there was a "substantial" public health problem. The news comes after years of health warnings over the dangers of going out in the sun and developing cancer. Now scientists say people must spend more time outdoors and take sensible precautions like using sun creams to filter out harmful rays. Almost nine in ten middle-aged men and women have been found to suffer from low levels of vitamin D, a study of more than 7,000 people discovered. And the condition, called hypovitaminosis D, can lead to bone problems, cancer, heart disease and diabetes. Last night, the gloomy winter weather was blamed for the epidemic which means people are spening too much time indoors. And scientists said that health officials should seriously consider fortifying milk with the vitamin in order to boost public intake. The Government's foods watchdog said it was now examining whether more foods should be added to the list. "The Scientific Advisory Committee on Nutrition is currently considering the links between vitamin D status and health. Their position statement will be available in the summer," a Food Standards Agency spokesperson said. It said that spreads were already fortified and some cereal- makers also added it to their foods. The study, published in the American Journal of Clinical Nutrition concluded: "Hypovitaminosis D is a substantial public health problem that exists in British whites. To improve the situation, action is required at a population level. Immediate action is needed to improve the vitamin D status of the British population." Doctors took blood samples from 7437 white British men and women aged 45. The tests were repeated in the spring, summer, autumn and winter months and the height and weight of each participant was also measured. It found that during the winter and spring a staggering 87.1 per cent of people had levels of vitamin D lower than recommended for good health. Of these, 15 per cent of people had dangerously low levels which would lead to the softening of bone tissue. In summer and autumn after sunshine holidays and time in the garden, the situation was still not as good as it should have been. Figures showed that 60 per cent of Britons did not have vitamin D levels high enough for optimum bone health while three per cent still had dangerously low levels. Dr Elina Hypponen, from the Centre for Paediatric Epidemiology and Biostatistics at the Institute of Child Health in London said: "The reason people have such low levels of vitamin D is that there are not enough sunny days and people spend a lot of time indoors. "The sunlight in winter does not come at the right angle to properly boost vitamin D levels so people are living of their reserves from the summer before. People must try and get more vitamin D through their diet but also get outside. "You do not have to grill yourself to get enough sunshine, just sensible exposure with sun cream will be enough." The study also found that people who are obese are twice as likely to have low levels of vitamin D, because the compound is fat soluble. Ten years ago, most health experts thought vitamin D was only needed to protect against diseases such as rickets. But more recently, it has been found to play a far greater role in our overall health. Low levels have been linked to an increased risk of osteoporosis, diabetes and cancer. Most recently there have been reports linking deficiency with heart disease. Most of our vitamin D comes from the sun, but it can also come through the diet in the form of oily fish. Although margarine is fortified with vitamin D, this is only to bring it up to a relatively low level, similar to that found in butter. In the UK, vitamin D-only supplements are not routinely sold. But it is included in many multi-vitamin tablets. However, studies from America suggest the amount in these tablets is still between five and ten times lower than the amount the body actually needs. And there are calls for the UK to follow America, Canada and Finland by introducing vitamin D to milk to improve public health. Last night, charities said they were amazed by the high rates of hypovitaminosis D in this country. Sarah Leyland, from the National Osteoporosis Society said: "Weight bearing exercise, such as brisk walking, is excellent as part of an active lifestyle for building bone strength. "The NOS would encourage anyone, particularly those concerned about bone health, to go out for a walk each day, which would not only increase general fitness levels, but would help strengthen bones and top up your daily dose of vitamin D from the sunshine. "For those who can't get out into the sun, oily fish, such as sardines, mackerel and salmon are packed with vitamin D."" SignatureMatti Narkia Vitamin D is best obtained from sunlight. Your body can manufacture vitamin D so quickly that skin damage and subsequent skin cancer risk is negligible. One study I read found that sun exposure reduced overall cancer risk. It shifts the immune profile to a more favourable state, reducing inflammation, has strong anti-cancer qualities, and can play an important role in moderating inflamamtory conditions and facilitating bone regrowth post injury. Professor M Holick listed in the authors below, has written a book about it all. The UV Advantage. > The study > [quoted text clipped - 170 lines] > -- > Matti Narkia Why not just take, for instance, a few thousand IU of a vitamin D supplement daily and not even worry about the sunlight exposure? Vitamin D supplements are dirt cheap! > Why not just take, for instance, a few thousand IU of a vitamin D > supplement daily and not even worry about the sunlight exposure? > Vitamin D supplements are dirt cheap! That's an important point! People began reducing exposure to the Sun because of concern over skin cancer. Why should people now take the risk of increasing Sun exposure when there's another easy way to get the vitamin D they need? Problems also exist with trying to combat the problem by fortifying foods with vitamin D. It certainly makes sense to replace vitamin D that may have been removed through food processing, but trying to give people the vitamin D they need by fortifying foods requires that you be able to successfully guess what foods people are going to eat, and in what quantities. Bob One advantage of obtaining your Vitamin d from sunlight is your skin will benefit from the photoprotection it offers.http:// www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus& list_uids=17223553 and it will also benefit from vitamin d's antibiotic properties http://www.sciencenews.org/articles/20061111/bob9.asp so you will find any wounds heal faster. While the risks from taking high strength Vitamin d3 are virtually non existant at the amounts needed to correct insufficiency see http://www.ajcn.org/cgi/content/abstract/85/1/6 Risk Assessment Vitamin D3. it is still the case that overdose from sun exposure doen't happen at all. On Mar 14, 6:19 pm, "swabyma...@googlemail.com" <swabyma...@googlemail.com> wrote: > One advantage of obtaining your Vitamin d from sunlight is your skin > will benefit from the photoprotection it offers.http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Ab... But this mechanism of photoprotection is a direct response to cellular *damage* from UV radiation. Preventing the damage in the first place is obviously a better way to go. > and it will also benefit from vitamin d's antibiotic propertieshttp://www.sciencenews.org/articles/20061111/bob9. There's nothing to suggest that supplements would not produce the same effect. In fact, that's what the article you quoted is all about! > While the risks from taking high strength Vitamin d3 are virtually non > existant at the amounts needed to correct insufficiency seehttp://www.ajcn.org/cgi/content/abstract/85/1/6Risk Assessment > Vitamin D3. it is still the case that overdose from sun exposure > doen't happen at all. But a different kind of sun exposure overdose most certainly does happen........sunburn, and it dramatically raises the risk of skin cancer. Not to mention that life-long cumulative exposure to UV radiation (sunburns or not) is a major cause of skin aging and wrinkling. Any amount of color change in the skin due to UV radiation, whether a light "tan" or a deep burn, is a direct result of skin damage from UV radiation and the ensuing activation of melanin production. > But a different kind of sun exposure overdose most certainly does > happen........sunburn, and it dramatically raises the risk of skin [quoted text clipped - 4 lines] > skin damage from UV radiation and the ensuing activation of melanin > production. But there may be benefits to obtaining most of your Vitamin D from direct exposure to sunlight see http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstra ctPlus&list_uids=16616326 Considering the potential benefits as well as adverse effects of sun exposure: can all the potential benefits be provided by oral vitamin D supplementation? we will need to have a re-evaluation of current sun exposure policy and try to educate people to adjust their supplement intake in relation to their sunlight exposure. The fact is, that despite people taking supplements at the official level, they remain insufficient if not deficient. See the article here. http://www.sciencedaily.com/releases/2007/02/070227105140.htm showing " 80 percent of African-American women and nearly half of white women tested at delivery had levels of vitamin D that were too low, even though more than 90 percent of them used prenatal vitamins during pregnancy,"......"92.4 percent of African-American babies and 66.1 percent of white infants were found to have insufficient vitamin D at birth." Increasing the RDA to the actual amount of vitamin d the body actually uses daily, see Heaney http://www.ajcn.org/cgi/content/full/77/1/204 Human serum 25-hydroxycholecalciferol response to extended oral dosing with cholecalciferol would be a step in the right direction. There is no excuse ever for getting sunburnt. The process of vitamin d synthesis is explained fairly clearly here http://www.uvguide.co.uk/vitdpathway.htm and from this you can see that spending longer in the sun than is necessary is counterproductive. There is no need for burning or even tanning to occur however Photoprotection by 1,25 dihydroxyvitamin D3 is associated with an increase in p53 and a decrease in nitric oxide products. These results are consistent with the proposal that the vitamin D system in skin may be part of an intrinsic protective mechanism against UV damage. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstra ctPlus&list_uids=17170736 |
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