1. Vitamin D-lemma: Risk Factors and Strategies for Combating Vitamin D Deficiency YaQutullah Ibraheem Muhammad MS, RDN, LD

2. TRUE OR FALSE Populations at risk for Vitamin D deficiency do not include geriatric patients, women and children.

3. FALSE

4. Name three risk factors for Vitamin D deficiency: A. Skin Pigmentation B. Family history C. Diet D. Conservative attire

5. 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

6. Objectives  Identify different populations at risk  Address strategies for combating vitamin D deficiency  Review meal planning

7. 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

8. 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)

9. 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.

10. 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.

11. 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

13. 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

14. 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

15. 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

16. 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

17. 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.

18. 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.

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