Vitamin D - Research Paper Example

Vitamin D as a necessary diet supplement in the context of UK Introduction For many years, the nutritionists have specified the necessity of calcium in the human bodyfor the prevention of osteoporosis. The need for vitamin D in the human body was discovered during the early twentieth century, when Sir Edward Mellanby, linked the fact that the amount of vitamin D found within a human body can be correlated to certain medical conditions like osteomalacia (soft/weak bones in humanadults) and rickets (a condition where children have bowed limbs owing to demineralisation of bones) (Hume, Lucas, and Smith, 1927).However, modern medical sciences have suggested possible connections between low serum levels of Vitamin D and the rise in incidences of other diseases associated with non-musculoskeletal chronic conditions, likecontagious autoimmune disorders, metabolic syndrome,and even cancer, are now being associated with the levels of vitamin D present in human body (Holick, 2008). The range of the aforementionedmedical disorders is of particular relevance to specific populations wheresome research papershave experimentallyproven that lack of vitamin D in human bodies is quite widespread in many countries lying in the northern hemisphere (Ford,et al, 2006; Ginde, Liu, and Camargo, 2009). This is seen in theincreasing number ofUK children reported as suffering from rickets every year, while observations also reveal thata large percentage of the UK populationsuffer from low vitamin D levels (Hyppönen,and Power,2007). Arecent survey in UK revealed that nearly 50% of the adult population here, suffer from lowvitamin D levels, and severe vitamin D deficiency (especially in the spring and winter seasons) is prevalent in almost 16% of the UK population (ibid). This survey also showed a slope in the condition across the country, where Northern Ireland, Scotland and the northern parts of England had the highest incidence (ibid). This review also showed that the high-risk individuals comprise of those having skin pigmentation, the elderly population,those with obesity problems,and individuals with short bowel, mal-absorption, liver or kidney problems.High-risk individuals also include those taking antiretroviral, rifampicin, or anticonvulsantstype ofmedicines (ibid). UKis a country that receives theminimumnumber of sunny daysamongst the developed countries(Godar, 2005),and this is primarily owing to its location in the high latitude.A persistent cloudy weather, and indoor living, produce low vitamin levels within human bodies, a condition referred as serum or plasma 25-hydroxyvitamin D [25(OH)D], seen commonly in UK and northern Ireland (Mithal, et al, 2009), thus making it necessary for the governments to establish policies vitamin D supplements considering the unfavourable weather. Until recentlyUK,had policies on the exposure to sun that followed globalguidelines created byUS and advocated byWHO (Reichrath, 2009), that primarily aim atalleviating the risks of skin cancer. Adopting these international guidelines, the UK governmentdid not advocatethe use of vitamin D supplement in normal daily diet for babies that are lessthan 6 months old (Vitamin D - an essential nutrient for all, 2009).Furthermore, it did not allow forthe fortification of milk and claimed that vitamin D supplement is not necessary for the adult UK population(SACN, 2007), thus denoting a lack of judicious approach to this issue. In this context, this paper will explore the notions that Vitamin D is often necessary as a diet supplement, in the context of UK. Discussion Sources of vitamin D and the optimal levels necessary to avoid deficiency related conditions: Vitamin D, a micronutrient,form to be the antecedents to the 25-dihydroxyvitamin D3 (25-OH2D3) and the secosteroid hormone 1, better referred to as calcitriol (1, 25-OH2D3) (Pittas, et al., 2010). The major natural source of vitamin D is the sunlight Box 1: Primary Sources of Vitamin D (Pearce and Cheetham, 2010, 142). as shown in box 1. Vitamin D is producedthrough skin biosynthesis after the solar irradiation of ultraviolet B (UVB) rays,and from the daily diet (UK Department of Health, 1998).Owing to an inadequate exposure to the sunlight, thereoccurs no dermal synthesis;leading to the transformation of vitamin D into an essential micronutrient. However, here it must be noted that there are considerable differences in thenutritionalrecommendation for the intake of vitamin D,as food supplement (Commission of the European Communities, 1993).In 1991, we find that the UK Committee on Medical Aspects of Food and Nutrition Policy or COMA,did notestablish anyguidelines for nutritional intake (RNI) of vitamin D, assuming that skin synthesis of vitamin D from sunlight is adequate for the age group 4–64 years (UK Department of Health, 1991); a stand which was reiterated in 1998 by the COMA subgroup,while preparing report on bone health (UK Department of Health, 1998). The adequate dose of vitamin D (around 2000 IU) in a fair-skinnedindividual is obtained from 20 - 30 minutes of being exposed to the sun (exposing the forearms and the face atthe middle of the day) (Schoenmakers, Goldberg, and Prentice, 2008). While the authors further opined that receiving 2-3 such exposures in one week are adequatefor achieving optimum vitamin D levels during theUK summers for any individual. However, the scenario is different during the non-summer months (October to April) forthe elderly population and thosewith pigmented (coloured) skin, where the frequency along with the exposure time must necessarily be two to ten times morethan the fair skinned people, to reach the optimal level of vitamin D (ibid). All of the western parts of Europe (including UK), the Scandinavian countries, and nearly half of the northern regions inUSare place at a higher latitude that does not allow the requisite exposure time to the ultraviolet B rays for adequate synthesis of vitamin D synthesis (Godar, 2005). This places a large number of people worldwideheavily dependent on an external supply of vitamin D, andowing to a lack ofskin biosynthesis at the high latitudes, it turns into a micronutrient. With the exception of cod liver oil and fish oil (farmed fish contain less oil than the natural variety), there arevery few foods that naturally contain a large dosage of vitamin D (UK Department of Health, 1998a). Foods like liver, egg yolk, and mushrooms contain traces of vitamin D, while most vegetablesdo not have the nutrient. The prescribed amounts of vitamin D necessary to maintain the optimal levels in UK is 340 IU each day for infants below 6 monthsof age, 280 IU for children that are between 6 months - 3 yearsof age, and 400 IU every day for an average UK adult(ibid). These prescribed amounts however, signifythe amount of vitamin D levels that are necessary to avoid the risks ofdeveloping rickets and osteomalacia (Vieth, et al., 2007),and these amounts, without skin synthesis, alone cannot derive theoptimumlevel; leading torecommendations for a higher intake of vitamin Dfrom the daily diet by many medical bodies (Lips, 2010). Thepolicy for recommendation of Vitamin D supplements though the daily intake of food, variesgreatlybetween the countries worldwide.Although milk is generally provided with vitamin D supplements in a majority of the countries, in UK however, obligatory vitamin D supplements are found in the formula milk for infants below 6 months of age (40-100 IUfor every 100 Kcal), and margarine (320 IUfor every 100 g) (Ford, Graham, Wall,and Berg, 2006). Thus,here it can be derived that the average diet pattern followed and recommended in UK (and in many other States, worldwide), lacksthe adequate dosage of vitamin D. Thislow intake of vitamin D in the daily dietalong with a serious lack of adequate exposure to the sunlight for six months in a year, results in high incidences of vitamin D deficiency, observed widely across UK (ibid).On the other hand, we find thatin the 1997 US Dietary Reference Intake (DRI) panel there are set guidelines for the Adequate Intake (AI) of calcium and nutrients,as regards vitamin D (Institute of Medicine Food and Nutrition Board, 1997).As per the reports of this panel,there were no definite evidencesthat prove the necessity to establish anestimate average requirements or EAR, to frame the recommended dietary allowances (RDA), while it also opined thatvitamin D received from food and from sunlight are not easy to quantify (ibid). While creating the AI for vitamin D, the US DRI panel took into account that there would be no skinbiosynthesis of the nutrientthrough the exposure to sunlight exposure (ibid). In the dietary recommendations as provided by the European Union (EU) dietary recommendation AI for vitamin D for the adults vary from 0 to 10 µg/d as per thewidely varying latitudes as is seen in Europe (35–70 °N) (Commission of the European Communities, 1993). Vitamin D is a necessary nutrient as for a human body, and when synthesized within the kidneys, the calcitriolmoves around the bodyin the form of a hormone, that controls the phosphorous and calcium levels in the bloodstream and promotes healthy growth and bone structure and development. Vitamin D, whichprevents the development of rickets in children and osteomalaciain adults, also whencombined with calcium helps to avoid osteoporosis in adult(especially women). It also helps in the various neuromuscular functions, while influencingmany genetic actionsthat control cell differentiation,cellproliferation, and cell apoptosis (Ross, et al, 2011).   Symptoms of vitamin D deficiency: In adults, the weakness of the proximal muscle and a persistent pain (in the feet hips, thighs, ribs, and pelvis), are the main clinical features of vitamin D deficiency. There are also diffused from of aches and pains seen in the various muscles and a general weakness of the muscles, especially in thehands, legs and the back, typically observed, a condition known as “fibromyalgia” (Sievenpiper, et al., 2008). According to Pearce, and Cheetham a “low bone density on the dual energy x ray absorptiometry scanning, or osteopenia on plain radiography, may also reflect osteomalacia, and these findings warrant assessment of vitamin D status (2010, 145). In children, vitamin D deficiency is observed through a variety of symptoms like tetany or seizures, noticed especiallyduring the neonatal stages and later again during adolescence, which is a stage of rapid growth and development of the human body.Children (6 months and above) showing a deficiency of vitamin D presentdeformities of the bony structure known as rickets). In this, bowed legs are the most commonly observed form of bone deformity,however knock knees are also seen quite frequently. Frequently seen are the anterior bending of the femur bones and the internal rotation of the ankles, while a soft skull (deformity), wrist swellings, and swellings at the costochondral joints, are common features of vitamin D deficiency (Wharton,and Bishop, 2003). Children who are deficient in vitamin D tend to be irritable in nature and are often reluctant to carry weights, while showing stunted or malformed growth of the bones and body.In vitamin D deficiency, it has been generally observed that height is more affected than a child’s body weight (Beck-Nielsen, et al., 2009). Besides showing a “rachitic lung,” where a child’s normal respiratory function is hampered owing to muscle weakness and aplastic rib cage,severe form of vitamin D deficiency can cause cardiomyopathy and a subsequentheart failure that may even lead to death (Misra, 2008). Often there are secondary causes for a vitamin D deficiency human bodies (both in adults and children), like not prominent type of cystic fibrosis causing malabsorption, or coeliac disease. Effective control of vitamin D deficiency: The expenses arising from the various vitamin D deficiency diseases (less AI of 2000–3000 IU of the vitamin D) in 17 of the European nationswith an estimated 363 million people, at an average are around 187000 million Euros each year (Grant, et al, 2009). In UK alone the expenses for vitamin D deficiency diseasesrange around £27000 million each year,a significantly large figure, when compared tothe highly publicised public health issue of tobacco related diseases that costs approximately around £5000 (Allender, et al., 2009). However,her it must be noted that the high costs seen in vitamin D related diseases in the UK,is mainly owing to the predominantly cloudy climate of UK,which is proving to be a much heavier burden in the issue of public health, than in any other European nations. From the perspective of public health issue, the active“prevention of vitamin D deficiency in a country such as the UK is socially as well as medically justifiable, [and] the key groups for healthcare professionals to target are infants, children, adolescents, and pregnant women, particularly those with dark skin” (Pearce, and Cheetham, 2010, 146). Non-white immigrant residents of UKthat reside northern parts of UK or in the Midlands are particularly vulnerable to vitamin D deficiency while the elderly population and patients who have been institutionalised also come under the high risk population segment (ibid). The white skinned UK residents that include in their diet oily fish at least twice in a week, or receive regular exposure to the sunlight ted to have adequate vitamin D levels; though a majority of the white skinned people show vitamin D deficiency, especially during the spring and winter months. Evident from the literature review the substantial number of diseases recently associated with medium levels of vitamin D deficiencyadequate information regarding adequate“sunlight exposure, the use of vitamin D supplements, and eating oily fish should be made available to the whole population. In particular, health visitors and midwives can implement current Department of Health recommendations by distributing children’s vitamin drops, which should be universally available through Healthy Start, Sure Start, and similar government schemes” (Pearce, and Cheetham, 2010, 146). Here the author further suggest thatUK needs a morefirm approach as regardsmaking vitamin D supplementary compulsory in various forms of food (like milk),as perceived in many other countries (having the same latitude) as UK, that have already adopted this technique of dietary supplementation of vitamin D. Conclusion Vitamin D deficiency diseases are very common in the UK and countries in the northern hemispheres that are located a higher altitude. However the health professionals and policy makers in UK have been undecided and slow to seek answer to this grave public health issue, even though various research papers have pointed out the problemmany times in the last few years. The vitamin D deficiency diseases like osteomalaciaand rickets can be prevented with necessary dietary intervention, yetin UK the diseases are rapidly becoming common. In the UKthe deficiency disease is now being linkedto various other common and chronic medical conditions, even though recently there arecertain local initiatives implemented to tackle this problem, yet the very number of individuals withsymptomatic vitamin D deficiency symptoms shows that the UK government must make more efforts to contain the threat. The basic vitamin D intake must be“increased to at least 800 IU of vitamin D3 per day. Unless a person eats oily fish frequently, it is very difficult to obtain that much vitamin D3 on a daily basis from dietary sources. Excessive exposure to sunlight, especially sunlight that causes sunburn, will increase the risk of skin cancer. Thus, sensible sun exposure (or ultraviolet B irradiation) and the use of supplements are needed to fulfil the body's vitamin D requirement” (Holick M., 2007, 279). Thus, undoubtedly one can derive that reform in the UK public health policy pertaining to dietary supplements of the vitamin D is long overdue, in the context of the overall public health of the country. References Allender, S., Balakrishnan, R., Scarborough, P., Webster, P., and Rayner, M., 2009.The burden of smoking-related ill health in the UK.Tob.Control., 18, 262–267. Beck-Nielsen, S., Jensen, T., Gram,J., Brixen, K., Brock-Jacobsen, B., 2009.Nutritional rickets in Denmark: a retrospective review of children’s medical records from 1985 to 2005.Eur J Pediatr;168:941-9. Boron, W., and Boulpaep , E., 2003. Medical Physiology: A Cellular AndPMolecularApproaoch.Philadelphia: Elsevier/Saunders. Commission of the European Communities, 1993.Vitamin D: In nutrient and energy intakes of the European Community.Report of the Scientific Committee for Food (31st series). Brussels, Luxembourg,132–139. Ginde, A., Liu, M., and Camargo, C., 2009.Demographic differences and trends of vitamin D insufficiency in the US population, 1988-2004. Arch Intern Med, 169:626-32. Godar, D., 2005.UV doses worldwide. Photochem.Photobiol.,81, 736–749. Grant, W., Cross, H., Garland, C., Gorham, E., et al., 2009. Estimated benefit of increased vitamin D status in reducing the economic burden of disease in western Europe. Prog.Biophys. Mol. Biol. 99, 104–113 Hume, E., Lucas, N., and Smith, H., 1927. On the Absorption of Vitamin D from the Skin. Biochemical Journal 21 (2): 362–367. Holick M., 2008.Vitamin D: a D-lightful health perspective. Nutrition Rev;66:S182-S194. Holick M., July 2007. Vitamin D Deficiency.N Engl J Med 2007; 357:266-281. Hyppönen, E., and Power, C., 2007.Hypovitaminosis D in British adults at age 45 y: nationwide cohort study of dietary and lifestyle predictors.Am J ClinNutr 85:860-868. Ford, L., Graham, V., Wall, A., and Berg, J., 2006.Vitamin D concentrations in a UK inner-city multicultural outpatient population. Ann ClinBiochem, 43:468-73. Institute of Medicine Food and Nutrition Board, 1997.Dietary reference intakes: calcium, magnesium, phosphorus, vitamin D, and fluoride. Washington, DC: National Academy Press. Lips, P., 2010.Worldwide status of vitamin D nutrition.The Journal of steroid biochemistry and molecular biology121 (1–2): 297–300. Misra, M., Pacaud, D., Petryk, A., Collett-Solberg, P., Kappy, M., 2008.Vitamin D deficiency in children and its management: review of current knowledge and recommendations. For the Drug and Therapeutics Committee of the Lawson Wilkins PediatricEndocrine Society.Pediatrics;122:398-417. Mithal, A., Wahl, D., Bonjour, J., Burckhardt, P., et al., 2009.Global vitamin D status and determinants of hypovitaminosis D. Osteoporos. Int., 20, 1807–1820. Pittas, A., Chung, M., Trikalinos, T., Mitri, J., Brendel, M., Patel, K., Lichtenstein, A., Lau, J., et al. March 2010. Systematic review: Vitamin D and cardiometabolic outcomes.Annals of Internal Medicine 152 (5): 307–14. Pearce, S., and Cheetham, T., 2010.Diagnosis and management of vitamin D deficiency.BMJ;340:b5664, 142-147. Reichrath, J., 2009. Skin cancer prevention and UV-protection: how to avoid vitamin D-deficiency? Br. J. Dermatol., 161, 54–60. Ross, C., Manson, J., Steven, A.,Abrams, J.,Aloia,  P., Brannon, S,. Clinton, R., etal.,2011. The 2011 Report on Dietary Reference Intakes for Calcium and Vitamin D from the Institute of  Medicine: What Clinicians Need to Know.The Journal of Clinical Endocrinology & MetabolismJanuary 1, 2011, vol. 96 no. 153-58. SACN, 2007.Update on Vitamin D. Position statement by the Scientific Advisory Committee on Nutrition, London. Schoenmakers, I., Goldberg, G., and Prentice, A., 2008.Abundant sunshine and vitamin D deficiency.British journal of nutrition 99 (6): 1171–3. Sievenpiper, J., McIntyre, L., Verrill, M., Quinton, R., and Pearce, S., 2008. Unrecognised severe vitamin D deficiency. BMJ; 336:1371-4. UK Department of Health, 1998.Nutrition and bone health: with particular reference to calcium and vitamin D. Report on Health and Social Subjects (49).London: The Stationary Office. UK Department of Health, 1998a.Nutrition and bone health: report of the subgroup on bone health, working group on the nutritional status of the population.London: Stationery Office. UK Department of Health, 1991.Dietary reference values for food energy and nutrients for the United Kingdom. Report on Health and Social Subjects (41). London: Her Majesty's Stationery Office. Vieth, R., Bischoff-Ferrari, H., Boucher, B., Dawson-Hughes, B., Garland, C., Heaney, R., et al., 2007.The urgent need to recommend an intake of vitamin D that is effective. Am J ClinNutr;85:649-50. Vitamin D - an essential nutrient for all, 2009.Important information for healthcare professionals.NHS publication 284015/vitamin D. Wharton, B., and Bishop N., 2003.Rickets. Lancet, 362:1389-400. Read More