Name three risk factors for Vitamin D deficiency: A. Skin Pigmentation B. Family history C. Diet D. Conservative attire
What are three behavioral /lifestyle strategies that can be used to improve vitamin D levels? A. Increasing sun exposure 15-20 minutes daily B. Including Vitamin D fortified foods with meals and snacks C. Supplementation D. Only A and B E. All of the above
Objectives Identify different populations at risk Address strategies for combating vitamin D deficiency Review meal planning
The Sunshine Vitamin Overview Naturally synthesized vitamin with daily exposure to sunlight. Fat Soluble Two forms of Vitamin D D2 is the supplemental form D3 is naturally occurring, found in foods and synthesized in the skin with sunlight exposure. Absorbed in the small intestine
Vitamin D Deficiency in Specific Populations Women Multiple pregnancies Breastfeeding with little sun exposure sun Community-dwelling geriatric patients With age, the skin doesn’t synthesize vitamin D as efficiently An increased risk for fractures Children Infants with prolonged breastfeeding without supplementation (AAP) (1) Children with inadequate intake of fortified foods (rickets) Children on anticonvulsant therapy for epilepsy (2)
Vitamin D Deficiency in Specific Populations Vitamin D deficiency and Pigmentation With increased melanin pigmentation, the skin's ability to synthesize vitamin D from sunlight is limited. African ancestry, Latino, South Asian, Aborigines and others Lowered serum 25(OH)D levels with increased melanin It’s unclear whether lower levels of 25(OH)D in persons with darker skin have significant health consequences. (Lower rates of osteoporosis and bone fractures when compared to counterparts) Strategies: 15-30 minutes of midday sun exposure (without sunblock) Take measures to prevent sun damage to skin, and avoid sun burns. Spring, Summer & Fall Vitamin D from Fortified foods and supplements as needed.
Vitamin D Deficiency and Cultural Sensitivity Conservative attire Religious Mandates: Orthodox Muslims, Jews, Christians In Northern Latitudes where sun exposure is limited and one must wear clothing to protect against the cold for large parts of the year. Observing conservative attire that may limit sun exposure (face, hands, arms, legs). Strategies: Consider light/colored fabric to allow the sun to permeate the cloth and allow your skin to absorb some of the sun’s rays. Private area to access to sunlight (patio, solarium area) Vitamin D supplements/fortified foods.
Vitamin D Deficiency in Specific Populations Gastric Bypass Patients BMI ≥30 is associated with lower serum 25(OH)D levels compared with non-obese individuals (3). Developed deficiency with decreased absorption Part of the upper small intestine is bypassed where Vitamin D is absorbed (4,5). Strategy: An additional 800 IU to 2000 IU daily to maintain adequate serum levels along with long-term post surgical screening (6). Certain Medical Conditions Some liver diseases, Cystic Fibrosis, celiac disease, and Crohn's disease can result in fat malabsorption (Vitamin D is fat soluble) Intolerance of fortified dairy products Strategy: Exploring alternative sources of vitamin D
Vegans, Vegetarians and Vitamin D Fortified vegan products contain D2 (ergocalciferol). Yeast, mushrooms exposed to ultraviolet light (1-2 seconds of a pulsed UV light) Usually obtained from fortified foods and vitamin supplements made from yeast or other fungi. Sunlight
Vitamin D in Meal Planning Fortified foods provide most of the vitamin D in the American diet. Soy, rice and nut milks, yogurt Mushrooms exposed to pulsed ultraviolet light 384-634 IUs per cup
Meal Planning Ideas Recommended Dietary Allowances (RDAs) for Vitamin D is 600 IU or about 15 mcg for ages 1-70 yrs (3). TOTAL: 1480 IUs USDA Nutrient Database Vitamin D Food Values USDA Nutrient Database Vitamin D Food Values Lunch: 4 oz canned tuna salad in oil, 8 oz fortified chocolate or vanilla soy milk 354 IUs Dinner: 3 oz Sockeye salmon, mixed green salad with 1 cup grilled Portabella mushrooms 747 IUs Breakfast: Two soft scrambled eggs, 1 Tbsp fortified margarine, 8 oz glass orange juice fortified with calcium and vitamin D 248 IUs Snack: 8 oz reduced- fat milk, 1 slice fortified American cheese 175 IUs
Halal/Kosher/Vegan Supplementation The majority of the commercial multivitamins supplements contain pork- based or other non-Halal/Kosher/Vegan ingredients. For ex. Gelatin capsules Questionable ingredients A tablet or liquid supplement option Calcium Citrate With Vitamin D Look for Kosher/Halal/Vegan friendly options on the market and be sure to check for the certification seal. NSF Certified Dietary Supplements NSF Certified Dietary Supplements USP Verified Mark USP Verified Mark
The Take Away… Vitamin D has a protective effect against chronic conditions, including heart disease, diabetes, and some cancers. As health professionals, we want to review Vitamin D labs in at risk patient/client populations. Encourage adequate Vitamin D consumption, supplementation and sunlight exposure as necessary for optimal health. Don’t over supplement as toxicity can result.
References 1. Wagner CL, Greer FR; American Academy of Pediatrics Section on Breastfeeding; American Academy of Pediatrics Committee on Nutrition. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics 2008;122:1142- 1152. 2. J. Child Neurol. 2006 Mar;21(3):205-9 3. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academy Press, 2010. 4. Malone M. Recommended nutritional supplements for bariatric surgery patients. Ann Pharmacother 2008;42:1851-8. 5. Compher CW, Badellino KO, Boullata JI. Vitamin D and the bariatric surgical patient: a review. Obes Surg 2008;18:220-4. 6. Flores L, Osaba MJ, Andreu A, et al. Calcium and Vitamin D Supplementation after Gastric Bypass should be Individualized to Improve or Avoid Hyperparathyroidism. Obes Surg. 2010 Jun;20(6):738-43.