Vitamin D A Superhero ? By Dr. Javier Cardenas, Hospitalist, AVH Surgical Associates and Dean Stockwell, AVH Nutrition Professional

Vitamin D Metabolism

What May Vitamin D Improve? -Improved bone health -Increased absorption of calcium -Reduced risk of falls and bone fractures -Reduced coronary artery disease -Improved muscular function -Lowering of high blood pressure -Improved blood sugar tolerance -Improved nerve function -Improved kidney function -Reduced risk of 17 cancers -Reduced influenza, cold infections, tuberculosis -Reduced risk of some types of dementia

Low Vitamin D Risks Increased blood pressure - 2.4 times High blood sugar - 2.5 times Metabolic syndrome – 4.0 times

Vitamin D and Bones Rickets prevention requires the least 20 ng/ml of storage version, 25(OH)D. Calcium absorption increases from 10-15% at low 25(OH)D levels to 30-40% at 32 ng/ml to 40 ng/ml. Optimum level was 40 ng/ml or higher.

Vitamin D and the Heart Low levels of vitamin D associated with increased risk of cardiovascular disease and mortality. One study: Low vitamin D risk increase of Coronary Artery Disease - 45% Stroke - 78% Heart attack - 50% Death – 77-100% 25-57% USA adults may be deficient

Vitamin D and Critical Illness For critically ill patients in the hospital, low vitamin D levels have been found to be related to Organ malfunction Length of stay Infection rates

Vitamin D and MS Multiple Sclerosis: Vitamin D levels of 40 ng/ml or higher may confer some protection against MS. Patients receiving Magnesium, Calcium and 5000 IU vitamin D significantly reduced MS exacerbations (14 vs 32).

Vitamin D and MS: Is there any connection? Is there any proof that vitamin D supplements can prevent MS or keep symptoms of MS from worsening? Several studies have suggested that maintaining adequate levels of vitamin D may have a protective effect and lower the risk of developing multiple sclerosis (MS). Other studies suggest that for people who already have MS, vitamin D may lessen the frequency and severity of their symptoms. More research is needed to assess these findings. When a person has MS, his or her immune system attacks the coating that protects the nerve cells. Research suggests that a connection between vitamin D and MS could be tied to the positive effects vitamin D has on the immune system. The link between vitamin D and MS is strengthened by the association between sunlight and the risk of MS. The farther away from the equator a person lives, the higher the risk of MS. Sunlight is the body's most efficient source for vitamin D — suggesting that exposure to sunlight may offer protection from MS. The Institute of Medicine recommends 600 international units (IUs) of vitamin D a day for adults ages 19 to 70. The recommendation increases to 800 IUs a day for adults age 71 and older. Some doctors question whether these levels are adequate and think that getting more vitamin D would benefit many people. However, the Institute of Medicine recommends that adults avoid taking more than 4,000 IUs a day.

Vitamin D and Falls Low vitamin D may result in more falls and fractures since muscles contain vitamin D receptors. Vitamin D activation increases protein synthesis in muscles. 13 studies using 800-1000 IU consistently demonstrated beneficial effects on muscle strength and balance with aged 60 or older.

Vitamin D and Cancer Inverse correlation between incidence, mortality and or survival rates for many cancers including breast, colorectal, ovarian, and prostate cancers. Emerging evidence that more than 17 cancers are likely to be vitamin D sensitive. 1000 IU/day could reduce cancers 7% for men, 9% for women in US. 25(OH)D level of 52 ng/ml reduced breast cancer by 50% 60-80 ng/ml may be optimal for most individuals 25(OH)D level increase from 29 to 39 reduced cancer risk by 60% after 4 years.

Vitamin D and the Lungs Asthma: Early studies indicate may reduce severe exacerbations, exercise induced bronchoconstriction Lower respiratory tract infections are more frequent in those with low 25(OH)D levels. 2000 IU Vitamin D abolished the seasonality of influenza and dramatically reduced the self-reported incidence. Vitamin D reduces inflammation and viral pathogens.

Vitamin D and the Lungs 334 children 6-15 years One Vitamin D Influenza study showed: 334 children 6-15 years 50% -1200 D3 4 months vs placebo Flu: 10.8% (with D) vs 18.6% Asthma children – 93% reduced attacks Low vitamin D adults: double risk of viral infections

Vitamin D and Dementia Vitamin D may be primarily associated with cognitive domains other than memory , such as executive cognitive functions, depression, bipolar disorders, and schizophrenia. Low 25(OH)D may be a risk factor for cognitive impairment (41-60%). Receptors for Vitamin D are present in brain cells. Increased Vitamin D may improve cognitive function in patients with Alzheimer's

Vitamin D Controls Genes Gene direct or indirect control by vitamin D 200 – 2000 genes which regulate: Regulate cell growth and prevent malignancy Enhance immune system (multiple mechanisms) Improve insulin production and sensitivity Heart contraction Maximize bone health

Sun exposure pros and cons: Vitamin D From the SUN Sun exposure pros and cons: 5-6 times more deaths from internal cancers related to low vitamin D levels than skin cancers Regular moderate outdoor UV exposure increases survival of melanoma patients

Current Vitamin D Recommendations Institute of Medicine recommendations: 400 IU: infants 0 to 12 months 600 IU: age 1 – 70 years 800 IU: age above 70 4000 IU upper limit Endocrine Society's Clinical guidelines 400 IU - 1000 IU: infants 0 to 12 months 600 IU – 1000 IU: age 1 – 18 years 600 IU – 2000 IU: 19 - 70 years 800 IU – 2000 IU: above 70 1000 IU to 6 mo, 4000 IU over 8 yrs upper limit

Malabsorption Drug Interactions and Storage Patients who may require more vitamin D intake include those with: Intestinal fat-malabsorption syndromes Anticonvulsive medications Glucocorticoids and related medications Less ability to absorb sunlight (elderly) Excess fat (vitamin D stored in fat is not available)

Vitamin D Sources The Sunshine Vitamin Fortified foods: Typically supply 150 IU per day, but highly variable (100 - 400 IU per day). Supplements: -Over-the-counter usually vitamin D3 -Prescription versions are usually vitamin D2 (synthetic). -Vitamin D3 is more than three times powerful than D2.

Vitamin D Sources

How Much Vitamin D is Needed? Estimated body requirements per day are 3000-5000 IU. Obese and elderly may need the higher levels. 10,000 IU per day may be the new recommended upper limit.(10) The only way to know how much is needed is to test 25(OH)D. Everyone should be tested! Goal: 25(OH)D between 60-80 ng/ml after a consistent intake level over 2 months. 100 IU of vitamin D raises 25(OH)D about 1 ng/ml.

Who is at risk to overdose on Vitamin D? Anyone who takes Vitamin D supplements CAN take too much Vitamin D. But the majority of documented overdose on vitamin D are from: • Children whose parents accidentally give them massive doses of vitamin D • Elderly people who incorrectly take massive vitamin D dosages • Adults who take more than 10,000 IU's per day for long periods of time. • 'Industrial Accidents' where massive quantities of vitamin D are put into fortified foods in error These categories comprise nearly all people who have had an overdose on Vitamin D.

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