Vitamin D3

Super Sun Vitamin

Super Sun Vitamin

Vitamin D3, a Silent Epidemic

Vitamin D3, a Silent Epidemic

Vitamin D3 deficiency is a world-wide epidemic, with recent estimates indicating greater than 50% of the global population at risk. Recent evidence reveals beneficial effects of vitamin D3 at serum levels around 50 ng/mL (125 nmol/L) or higher - effects not seen at levels below 40 ng/mL (120 nmol/L), indicating a need for upward revision of the deficiency reference threshold. The percentage of the population determined to be deficient(less than 50 ng/mL) would most-likely be closer to 90% or greater.

What is Vitamin D3?

Fat-soluble vitamin and serves as a hormone in the body.1 The only vitamin, human body makes itself. Vitamin D3 is naturally present in few selective foods, such as oily fish & in very low amount in cow's milk.

Curr Opin Endocrinol Diabetes Obes. 2008;15:489494.

Types of Vitamin D
Vitamin D3 (Cholecalciferol) Produced in skin with direct sunlight UVB Preferred form of supplementation Vitamin D2 (Ergocalciferol) Found in plants Supplements

Vitamin D3 Metabolism

(Calcitriol: Active form of Vit D3)

What affects vitamin D3 level?

Time spent outdoors

Age - 70 y/o produces 4 x less than 20 y/o

Amount of skin exposed Skin color

Clothing - Cultural Practices

Body fat Latitude - > 37 in winter, Early and late hours

Season and time of day

Drugs - Anticonvulsants, corticosteroids, rifampicin

Vitamin D3 Physiology
Vitamin D3 (cholecalciferol) is formed in the skin from exposure to sunlight. Then it is converted in the liver to 25hydroxy-vitamin D (calcidiol, 25(OH)D3) by the enzyme vitamin D-25-hydroxylase. 25(OH)D3 then is transformed in the kidney to 1,25-dihydroxyvitamin D (calcitriol) by 25hydroxy-vitamin D3-1alpha-hydroxylase (1OHase).

Vitamin D3 Status

Vitamin D3 insufficiency, 25(OH)D levels <30ng/ml is prevalent, worldwide, especially in Middle East and South Asia.2

J Am Coll Cardiol. 2008;52:19491956. Osteoporos Int. 2010 Jul;21(7):1151-4.

Signs and symptoms of Vitamin D3 deficiency

Musculoskeletal disorders

Low back pain, joint pain

Fatigue and Muscular Weakness Increased susceptibility to infections It thus adversely effects Quality of Life

Vitamin D3 Deficiency Affects Quality of Life

Immediate Quality of Life Future Quality of Life

Muscle pain and weakness

Osteomalacia (Adults)

Osteoporosis & Fractures Other Chronic Disorders

Diabetes type 1 & 2 Recurrent infections CVD & HTN

Rickets (Children)

Autoimmune Diseases
Cancers

RDA
Calcium Life Stage Group Estimated Average Requirement (mg/day)
* *

Vitamin D3 Recommended Dietary Allowance (mg/day)

1000 1500

Upper Level Intake (mg/day)

* *

Estimated Average Requirem ent (IU/day)

** **

Upper Level Intake (IU/day)

** **

Recommended Dietary Allowance (IU/day)

1000 1500

Infants 0-6 months Infants 6-12 months

1-3 years
4-8 years 9-13 years 14-18 years 19-30 years 3150 years

500
800 1100 1100 800 800

700
1000 1300 1300 1000 1000

2500
2500 3000 3000 2500 2500

400
400 400 400 400 400

600
600 600 600 600 600

2500
3000 4000 4000 4000 4000

5170 year, males

5170 year, females >70 years 1418 years, pregnant/lactating 1950 years, pregnant/lactating

800
1,000 1,000 1,100 800

1000
1200 1200 1300 1000

2000
2000 2000 3000 2500

400
400 400 400 400

600
600 800 600 600

4000
4000 4000 4000 4000

*For infants, Adequate Intake is 200 mg/day for 0 to 6 months of age and 260 mg/day for 6 to 12 months of age.

**For infants, Adequate Intake is 400 IU/day for 0 to 6 months of age and 400 IU/day for 6 to 12 months of age.

Functions of Vitamin D3

Ca & Vitamin D3 Deficiency Causes Fractures

Osteomalacia

Osteoporosis

Muscle Weakness

Increases risk & Rate of Fall

Increases risk of Fracture

Over 90% of Fractures occur after fall and fall rate increases due to poor muscle strength and function.1 Adequate dose of Vitamin D found to be useful in reduction of persistent non specific pain & Fractures
Medicographia. 2010;32(4):384-390

Vitamin D3 Deficiency : Summary

Vitamin D deficiency Calcium in the serum

Muscle weakness

Osteomalacia

PTH Risk of falls Osteoblastic activity Osteoclastic activity

calcium efflux from bone

Risk of Fracture

OSTEOPOROSIS

Vitamin D3 supplementation in deficiency state

Vitamin D Calcium in the serum Osteomalacia

Muscle Strengthens

PTH
Risk of falls Osteoblastic activity Osteoclastic activity

calcium efflux from bone Risk of Fracture

OSTEOPOROSIS

How Much Vitamin D3

Supplementation?

100 I.U./day of Vitamin D3 increases circulating 25(OH)D by 1 ng/ml when taken for 2 months If the typical serum 25 (OH)D level in is 10 ng/ml And if the target serum 25 (OH)D level is 30 ng/ml

Patients would require about 2000 IU/Day or 60000 IU per month

50-60% fractures can be reduced at ~30 ng/ml serum Vitamin D.1

1. Alt Med Rev. 2008;13(1):21-33

Vitamin D3 epidemic in pregnancy & lactation ?

Vitamin D3 Epidemic in Pregnant & Lactating Women

Pregnant women with low serum 25(OH)D levels had 46% higher risk of developing anemia.1

1. Plos One2010;5(1):e8770

Impact Vitamin D3 Epidemic on the health of Pregnant women

Gestational Diabetes
Presence of diabetes during pregnancy

Pre-term birth
More than 2 fold increase in risk of preterm birth

Preeclampsia
Development of hypertension in
Pregancy (PIH) along with excretion of protein in urine (proteinuria).

Maternal Mortality

Prevalence of Osteomalacia
Results in low back pain during pregnancy and post delivery

1. Am J Obstet Gynecol 2010;202:429.e1-9.

Impact of Vitamin D3 Epidemic in infants

1. 2. 3. 4. 5. 6. 7. 8. 9.

Congenital rickets Low birth weight Poor postnatal growth Neonatal Hypocalcemia Compromised Immunity : recurrent infections Perinatal Mortality Impaired brain development Type 1 diabetes in neonates Asthma

How Much Vitamin D in Pregnancy & Lactation ?

1000 IU/day is necessary to achieve 25(OH)D levels more than 20 ng/ml in pregnant women.1, 2

Safety upper limit in Pregnancy & Lactation: 4000 IU/day

1. Indian J Med Res. 2011;133:250-252 2. Clinical protocols & guidelines, 2009 3. Vitamin D by Michael H. Holick, II Ed. 2010

Benefits of Vitamin D3
The prenatal maternal nutritional requirement for vitamin D, that is, the amount required to elevate circulating 25(OH)D, will be substantially greater in darkly pigmented pregnant women due to limited cutaneous synthesis of vitamin D3.

High-dose (2,000 or 4,000 IU/day) vitamin D supplementation of pregnant mothers will provide sufficient anti-rachitic activity to prevent hypovitaminosis D in the pregnant mother and her fetus, regardless of ethnicity and sunlight exposure of the subject. Further, this supplementation level will be safe and efficacious without any adverse side effects or health consequences in the mother or fetus.

Vitamin D3 & Polycystic Ovarian Syndrome

Small study of 13 PCOS pts
9 of 13 w/ Vit D deficiency Ca 1500mg/day + Vitamin D3 50,000iu/week 9 of 9 pts with normalization of menses and/or fertility within 3 months
Thys-Jacobs S. Steroids. 1999;64(6):430.

Vitamin D3 & Pain

Study with 150 pts with persistent, nonspecific musculoskeletal pain
93% had Vit D3 deficiency
Plotnikoff, Quigley. Mayo Clin Proc. 2003;78(12):1463.

Children w/ limb pain improved in 3 months Low Back Pain

83% of 299 LBP pts had Vit D3 def
5000-10,000iu/day Decrease in pain medication in nearly 100% after 3 months
Al Faraj, Al Mutairi. Spine 2003;28(2):177.

Overview
Vitamin D receptors found in gut, bone, brain, breast, prostate, lymphocytes, placenta, and other tissues Routine screening is appropriate Safe up to 4000iu/d without monitoring Safe up to 10,000iu/d with monitoring Supplementation helpful in:
DM, metabolic syndrome, CAD, depression, autoimmune diseases, various cancers, HTN, osteoporosis, fall prevention, PCOS, pregnancy & lactation, periodontal disease, URI and influenza, and decreasing all-cause mortality