Vitamin D

Definition

Purpose

Description

Precautions

Interactions

Complications

Parental concerns

Resources

Definition

Vitamin D is a fat-soluble steroid compound that the body needs to remain healthy. In some ways, vitamin D is not a true vitamin because the skin can make vitamin D when exposed to sunlight. However, if the body does not make enough vitamin D, additional amounts must be acquired through diet.

Purpose

The main role of vitamin D is to regulate amount of calcium circulating in the blood. Calcium is a mineral acquired through diet that is involved in building bones, muscle contraction, and nerve impulse transtransmission.

(Illustration by GGS Information Services/Thomson Gale.)

mission. Vitamin D helps regulate the absorption of calcium from the small intestine. Too little vitamin D can cause weak, brittle, deformed bones. There is also evidence that vitamin D plays a role in controlling cell differentiation and may help to protect the body from developing some types of cancer.

Description

Vitamin D exists in several forms, two of which are important to humans. Vitamin D2, called ergocalciferol, is made by plants. Vitamin D2 can be manufactured synthetically by irradiating yeast. This type of vitamin D is most often found in dietary supplements and foods fortified with vitamin D. Vitamin D3, called cholecalci-ferol, is made naturally by the skin when it is exposed to ultraviolet rays in sunlight. Neither vitamin D2 nor D3 is active in the body. Both must be converted, first in the liver and then in the kidney, into an active form of vitamin D (1alpha, 25-dihydroxyvitamin D). Vitamin D in this topic means the active form of vitamin D.

Vitamin D's role in health

Although Vitamin D has been known to play a role in bone health for many years, only recently have researchers begun to explore its effects on cell differentiation and the immune system.

BONE HEALTH. The role of vitamin D and calcium are closely connected. The body needs calcium to build bones and teeth, contract muscles, transmit nerve

impulses, and help blood to clot. Vitamin D helps the body get the calcium it needs by increasing the amount of calcium absorbed in the small intestine. Vitamin D is an active part of the feedback loop that maintains a normal level of calcium in the blood.

To maintain health, the amount of calcium in the blood must stay within a very narrow range. When the amount of calcium in the blood falls below normal, the drop is sensed by the parathyroid glands. The parathyroid glands are four separate clusters of specialized cells in the neck. Low blood calcium levels stimulate the parathyroid glands to secrete parathyroid hormone (PTH). PTH travels through the bloodstream and stimulates the kidney to increase the conversion of vitamin D2 and D3 into its active form. Active vitamin D is released into blood and stimulates the cells lining the small intestine to increase the amount of calcium that they absorbed from digesting food. Vitamin D also causes the kidney to conserve calcium so that less is lost in urine. If these actions do not return the level of calcium in the blood to normal, vitamin D activates cells called osteoclasts that break down bone and return calcium from the bone to the bloodstream. People who do not have enough vitamin D absorb less calcium from the food they eat. To make up for this, calcium is taken from their bones and the bones weaken and break more easily.

CANCER PREVENTION AND TREATMENT. Vitamin D also helps regulate cell differentiation. During development, cells divide over and over again. At some point, they are triggered to specialize (differentiate) into different types of cells, for example, skin, muscle, blood, or nerve cells. Vitamin D joins with other compounds to turn on and off more than 50 different genes that stop cell growth and start cell differentiation.

One characteristic of cancer cells is that they grow wildly, dividing many times more than normal cells without differentiating. Since vitamin D can stimulate cells to stop dividing and begin differentiating, researchers are investigating whether vitamin D can protect people from getting certain cancers, especially colon, prostate, skin, and breast cancer. The research has produced mixed results. Some studies found that vitamin D protected against colon cancer, while other found it offered no protection. The official position of the American Cancer Society described in their 2006 Nutrition and Physical Activity Guidelines states,“There is a growing body of evidence from population studies (not yet tested in clinical trials) that vitamin D may have helpful effects on some types of cancer, including cancers of the colon, prostate, and breast.” However, the American Cancer Society makes no recommendations on the amount of vitamin D needed to have a beneficial effect. Clinical trials are underway to determine safety and effectiveness of vitamin D in a variety of situations. Individuals interested in participating in a clinical trial at no charge can find a list of open trials at <http://www.clinicaltrials.gov>

Normal vitamin D requirements

The United States Institute of Medicine (IOM) of the National Academy of Sciences has developed values called Dietary Reference Intakes (DRIs) for vitamins and minerals. The DRIs consist of three sets of numbers. The Recommended Dietary Allowance (RDA) defines the average daily amount of the nutrient needed to meet the health needs of 97-98 % of the population. The Adequate Intake (AI) is an estimate set when there is not enough information to determine an RDA. The Tolerable Upper Intake Level (UL) is the average maximum amount that can be taken daily without risking negative side effects. The DRIs are calculated for children, adult men, adult women, pregnant women, and breastfeeding women.

The IOM has not set RDA values for vitamin D because of incomplete scientific information and variability in the amount of vitamin D the body makes when the skin is exposed to sunshine. Instead, it has set AI and UL levels. Recently the UL level has become somewhat controversial and has been challenged by some researchers as being set too low. AI and UL levels are measured in both weight (micrograms or mcg) and international units (IU). The IU measurement is the measurement used on dietary supplement labels. For vitamin D, 1.0 mcg equals 40 IU.

The following are the AIs and ULs for vitamin D for healthy individuals:

• infants 0-12 months: AI 200 IU or 5 mcg; UL 1,000 IU or 25 mcg .
• children 1-18 years: AI 200 IU or 5 mcg; UL 2,000 IU or 50 mcg .
• adults 19-50 years: AI 200 IU or 5 mcg; UL 2,000 IU or 50 mcg .
• adults 51-70 years: AI 400 IU or 10 mcg; UL 2,000 IU or 50 mcg.
• adults 71 years and older: AI 600 IU or 15 mcg; UL 2,000 IU or 50 mcg .
• pregnant and breastfeeding women: AI 200 IU or 5 mcg; UL 2,000 IU or 50 mcg

Exposing the face, arms, and legs to sunshine for 15 minutes three or four times a week meets the dietary requirements for vitamin D for people with fair skin much of the time. However, people who live north of 40° latitude (approximately a line that extends from Philadelphia to San Francisco) may not get enough sun exposure to meet their dietary needs during winter months. Dark-skinned people may need to spend triple the amount of time in the sun as fair-skinned people to synthesize adequate amounts of vitamin D, since the increased amount melanin pigment in dark skin slows vitamin D production. Using sunscreen with an SPF of 8 or higher also slows the production of vitamin D in the skin.

Vitamin D is not found in large amounts in many foods. However, since the 1930s vitamin D has been added to about 99%: of all milk, and to some breakfast cereals, bread, orange juice, and infant formula. In addition, the Food and Drug Administration requires all foods containing olestra, a compound that reduces fat absorption, to be fortified with the fat-soluble vitamins A, D, E, and K.

The following list gives the approximate vitamin D content for some common foods:

• cod liver oil, 1 Tablespoon: 1,360 IU
• salmon, cooked, 3.5 ounces: 360 IU
• mackerel, cooked, 3.5 ounces: 345 IU
• tuna, canned in oil, 3 ounces: 200 IU
• milk, any type fortified, 1 cup: 100 IU
• orange juice, fortified, 1 cup: 100 IU
• cereal, fortified, 1 serving: 40 IU (average, serving sizes vary)
• egg, 1 whole: 20 IU

Precautions

Vitamin D deficiency

Vitamin D deficiency results in rickets in children and osteomalacia in adults. Rickets is a condition in which the bones do not harder because of a lack of calcium deposited in them. Instead they remain soft and become deformed. Osteomalacia is a weakening of bones in adults that occurs when they are broken down (demineralized) and calcium in the bones is returned to the blood. Vitamin D deficiency also can cause joint and muscle pain, and muscle spasm. Less severe cases can result in osteoporosis in older adults.

The vitamin D fortification program, along with the popularity of daily multivitamins, has greatly reduced the number of people in the United States who are vitamin D deficient. However some groups remain at risk of vitamin D deficiency. These include:

• infants who are exclusively breastfed. Breast milk provides only about 25 UL of vitamin D per quart (liter). The American Academy of Pediatrics recommends vitamin D supplements beginning no later than 2 months of age for babies who are only fed breast milk.
• institutionalized or homebound people who rarely go outside. One study found that 60% of nursing home patients were vitamin D deficient.
• people living in northern latitudes who cover almost all their body for much of the year due to climate or religious requirements
• people with gastrointestinal diseases such as Crohn's disease, celiac disease, or inflammatory bowel disease that interfere with the absorption of nutrients from the intestine
• people with disorders of the pancreas that interfere with the absorption of nutrients
• people with anorexia nervosa (self-starvation)
• people who have had part of their stomach or intestine surgically removed for weight loss or other reasons

Vitamin D excess

Vitamin D excess in healthy individuals occurs only when large quantities of vitamin D are taken as a dietary supplement over several months. This can result in high calcium levels in the blood (hypercalcemia). Symptoms of vitamin D excess include nausea, vomiting, excessive thirst, weakness, and high blood pressure. Calcium deposits may develop in the kidneys, blood vessels, heart, and lungs. The kidneys may be permanently damaged and eventually fail completely.

Interactions

Research suggests that the following types of medications may increase the available amount of vitamin D in the body. People taking these drugs should not take a vitamin D supplement without consulting their healthcare provider.

• birth control pills
• hormone replacement therapy/estrogen replacement therapy
• isoniazid (INH) used to treat tuberculosis
• thiazide diuretics

Research suggests that the following types of medications may decrease the available amount of vitamin D in the body. People taking these drugs should discuss with their healthcare provider whether a vitamin D supplement is right for them.

• antacids taken daily for long periods
• calcium-channel blockers used to treat heart conditions and high blood pressure
• certain cholesterol-lowering medications that block fat absorption
• phenobarbitol and similar anticonvulsants
• mineral oil taken on a daily basis
• orlistat, a weight loss drug marketed as Xenical or Alli

Complications

No complications are expected when vitamin D is used in the recommended amounts. The complications resulting from insufficient or excess use are discussed above.

Parental concerns

Parents should be aware that the RDA and UL for vitamins and minerals are much lower for children than for adults. Accidental overdose may occur if children are give adult vitamins or dietary supplements.

Resources

BOOKS

Gaby, Alan R., ed. A-Z Guide to Drug-Herb-Vitamin Interactions Revised and Expanded 2nd Edition: Improve Your Health and Avoid Side Effects When Using Common Medications and Natural Supplements Together. New York: Three Rivers Press, 2006.

Lieberman, Shari and Nancy Bruning. The Real Vitamin and Mineral Book: The Definitive Guide to Designing Your Personal Supplement Program, 4th ed. New York: Avery, 2007.

Pressman, Alan H. and Sheila Buff. The Complete Idiot's Guide to Vitamins and Minerals, 3rd ed. Indianapolis, IN: Alpha Books, 2007.

Rucker, Robert B., ed. Handbook of Vitamins. Boca Raton, FL: Taylor & Francis, 2007.

PERIODICALS

Carpenter, Kenneth J. and Ling Zhao.“Forgotten Mysteries in the Early history of Vitamun D.” Journal of Nutrition, 129 (1999):923-7.

ORGANIZATIONS

American Dietetic Association. 120 South Riverside Plaza, Suite 2000, Chicago, Illinois 60606-6995. Telephone: (800) 877-1600. Website: <http://www.eatright.org>

Linus Pauling Institute. Oregon State University, 571 Weniger Hall, Corvallis, OR 97331-6512. Telephone: (541) 717-5075. Fax: (541) 737-5077. Website: <http://lpi.oregonstate.edu>

Office of Dietary Supplements, National Institutes of Health. 6100 Executive Blvd., Room 3B01, MSC 7517, Bethesda, MD 20892-7517 Telephone: (301)435-2920. Fax: (301)480-1845. Website: <http://dietary-supplements.info.nih.gov>

OTHER

American Cancer Society.“Can Vitamin D Prevent Cancer?” American Cancer Society, December 29, 2005. <http://www.cancer.org/docroot/NWS/content/NWS_1_1x_Can_Vitamin_D_Prevent_Cancer.asp>

Finberg, Laurence.“Rickets.” emedicine.com, April 25, 2006. <http://www.emedicine.com/ped/topic2014.htm>

Harvard School of Public Health.“Vitamins.” Harvard University, November 10,2006.<http://www.hsph.harvard.edu/nutritionsource/vitamins.html>

Maryland Medical Center Programs Center for Integrative Medicine.“Vitamin D.” University of Maryland Medical Center, 2002. <http://www.umm.edu/altmed/ConsSupplements/VitaminDcs.html/Vitamin>

Medline Plus.“Vitamin D.” U. S. National Library of Medicine, August 1, 2006. <http://www.nlm.nih/gov/medlineplus/druginfo/natural/patient-vitamind.html>

Natural Standard.“Vitamin D.” MayoClinic.com, August 1, 2006. >http://www.mayoclinic.com/health/vitamin-d/NS_patient-vitamind>

Office of Dietary Supplements.”Dietary Supplement Fact Sheet: Vitamin D.“National Institutes of Health, April 12, 2006. <http://ods.od.nih.gov/factsheets/vitamind.asp>

Tangpricha, Vin.“Vitamin D Deficience and Related Disorders.” emedicine.com, December 22, 2006. <http://www.emedicine.com/med/topic3729.htm>

Trubo, Richard.“Researchers Conclude the ‘sunshine vitamin' is Good Medicine.” eMedicineHealth.com, February 14, 2006. <http://www.emedicinehealth.com/script/main/art.asp?articlekey=78080>

Tish Davidson, A.M.