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Global Epidemic
Vitamin D deficiency is a world-wide epidemic,
1
2
3 with recent estimates indicating greater than 50% of the global population is at risk.
4
A high prevalence of vitamin D deficiency has been found across all age groups in all populations studied in countries around the globe.
5 6 7 8
9 10 11 12
13 14 15 16
17 18 19
Even those who are otherwise healthy are not immune to deficiency. 10 20 21
22
In addition, the scope of vitamin D deficiency is actually far greater than the numbers indicate. Published estimates and studies grossly underestimate the
extent of the problem as a result of using an outdated 25(OH)D threshold (cut off point) of 30 ng/mL (70 nmol/L) for determining deficiency.
Recent evidence reveals beneficial effects of vitamin D at serum levels around 50 ng/mL (125 nmol/L) 23 24 25 or higher - effects not seen at levels below 40 ng/mL (120 nmol/L), indicating a need for
upward revision of the deficiency reference threshold.
Based on the data, it is reasonable to assume that, should the threshold for vitamin D deficiency be raised to a level of 50 ng/mL (125 nmol/L), the
percentage of the population determined to be deficient would most-likely be closer to 90% or greater.
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Last Updated: 17 December 2011 |
Notes on Vitamin D
References and Resources |
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This page presents selected references and resources on the importance of Vitamin D in the maintenance of health, on prevalence and problems associated with Vitamin D deficiency, and on
the potential of Vitamin D supplementation in the prevention and treatment of a broad ranges of diseases and conditions.
The Institute of Medicine released the long-awaited
Dietary Reference Intakes for Calcium and Vitamin D on 30 November 2010, detailing new guidelines by the
Food and Nutrition Board. Focused on bone
health, the report asserts that there is insufficient evidence vitamin D helps protect against autoimmune diseases, diabetes, heart disease, cancer, and others diseases. It sets 400 IU/day
as the Estimated Average Requirement (EAR) for adults, 600 IU/day as the Recommended Dietary Allowance (RDA) for adults, and 800 IU/day as the appropriate amount for those aged 71+. These details are assessed by
several authorities, below.
In Canada, several provinces now have delisted serum 25(OH)D [25-hydroxyvitamin D] testing because the demand and associated costs have risen dramatically. Health insurance will cover only certain conditions,
making it difficult for physicians and patients to monitor treatment and proactive regimens with respect to other conditions. The argument is that this delisting is "evidence-based", but
evidence of the importance of Vitamin D, both with respect to treatment and prevention, is already compelling for most researchers, and is growing rapidly.
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Vitamin D Council
Vitamin D Council provides a wealth of information on the critical importance of vitamin D
in the development, growth, and maintenance of a healthy body, from birth until death. The navigation boxes below will take you to sections of the site, and to compiled studies in specific areas of research.
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[...] The study was based on data on almost 2000 adults aged 65 and over who participated in the Health Survey for England in 2000 and whose
levels of cognitive function were assessed. The study found that as levels of Vitamin D went down, levels of cognitive impairment went up.
Compared to those with optimum levels of Vitamin D, those with the lowest levels were more than twice as likely to be cognitively impaired. [...]
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New Daily Recommended Intakes (DRIs) — Food and Nutrition Board
Dietary Reference Intakes for Calcium and Vitamin D
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After 13 years of silence, the quasi governmental agency, the Institute of Medicine's (IOM) Food and Nutrition Board (FNB), yesterday recommended that a
three - pound premature infant can take virtually the same amount of vitamin D as a 300 pound pregnant woman. While that 400 IU/day dose is close to
adequate for infants, 600 IU/day in pregnant women will do nothing to help the three childhood epidemics most closely associated with gestational and early
childhood vitamin D deficiencies: asthma, auto-immune disorders, and, as recently reported in the largest pediatric journal in the world, autism1.
Professor Bruce Hollis of the Medical University of South Carolina has shown pregnant and lactating women need at least 5,000 IU/day, not 600.
The FNB also reported that vitamin D toxicity might occur at an intake of 10,000 IU/day (250 micrograms), although they could produce no reproducible
evidence that 10,000 IU/day has ever caused toxicity in humans and only one poorly conducted study indicating 20,000 IU/day may cause mild elevations in
serum calcium but not clinical toxicity.
Viewed with different measure, this FNB report recommends that an infant should take 10 micrograms/day (400 IU) and the pregnant women 15 micrograms/day
(600 IU). As a single 30 minutes dose of summer sunshine gives adults more than 10,000 IU (250 micrograms), the FNB is apparently also warning that natural
vitamin D input – as occurred from the sun before the widespread use of sunscreen – is dangerous. That is, the FNB is implying that God does not
know what she is doing.
Disturbingly, this FNB committee focused on bone health, just like they did 14 years ago. They ignored the thousands of studies from the last ten
years that showed higher doses of vitamin D helps: heart health, brain health, breast health, prostate health, pancreatic health, muscle health, nerve health,
eye health, immune health, colon health, liver health, mood health, skin health, and especially fetal health. Tens of millions of pregnant women and their
breast-feeding infants are severely vitamin D deficient, resulting in a great increase in the medieval disease, rickets. The FNB report seems to reason
that if so many pregnant women have low vitamin D blood levels then it must be OK because such low levels are so common. However, such circular logic
simply represents the cave man existence of most modern day pregnant women.
Hence, if you want to optimize your vitamin D levels – not just optimize the bone effect – supplementing is crucial. But it is almost impossible to
significantly raise your vitamin D levels when supplementing at only 600 IU/day (15 micrograms). Pregnant women taking 400 IU/day have the same blood
levels as pregnant women not taking vitamin D; that is, 400 IU is a meaninglessly small dose for pregnant women. Even taking 2,000 IU/day of
vitamin D will only increase the vitamin D levels of most pregnant women by about 10 points, depending mainly on their weight. Professor Bruce Hollis
has shown that 2,000 IU/day does not raise vitamin D to healthy or natural levels in either pregnant or lactating women. Therefore supplementing with
higher amounts -- like 5000 IU/day -- is crucial for those women who want their fetus to enjoy optimal vitamin D levels, and the future health benefits that go
along with it.
For example, taking only two of the hundreds of recently published studies, Professor Urashima and colleagues in Japan gave 1,200 IU/day of vitamin D3 for
six months to Japanese 10 year-olds in a randomized controlled trial. They found vitamin D dramatically reduced the incidence of influenza A as well as the
episodes of asthma attacks in the treated kids while the placebo group was not so fortunate. If Dr. Urashima had followed the newest FNB recommendations,
it is unlikely that 400 IU/day treatment arm would have done much of anything and some of the treated young teenagers may have come to serious harm without
the vitamin D. Likewise, a randomized controlled prevention trial of adults by Professor Joan Lappe and colleagues at Creighton University, which
showed dramatic improvements in the health of internal organs, used more than twice the FNB's new adult recommendations.
Finally, the FNB committee consulted with 14 vitamin D experts and – after reading these 14 different reports – the FNB decided to suppress their reports.
Many of these 14 consultants are either famous vitamin D researchers, like Professor Robert Heaney at Creighton, or in the case of Professor Walter Willett
at Harvard, the single best-known nutritionist in the world. So, the FNB will not tell us what Professors Heaney and Willett thought of their new report?
Why not? Yesterday, the Vitamin D Council directed our attorney to file a federal Freedom of Information (FOI) request to the IOM's FNB for the
release of these 14 reports.
I, my family, most of my friends, hundreds of patients, and thousands of readers of the Vitamin D Council newsletter, have been taking 5,000 IU/day
for up to eight years. Not only have they reported no significant side-effects, indeed, they have reported greatly improved health in multiple organ systems.
My advice: especially for pregnant women, continue taking 5,000 IU/day until your (OH)D] is between 50 ng/ml and 80 ng/ml (the vitamin D blood levels
obtained by humans who live and work in the sun and the mid-point of the current reference ranges at all American laboratories). Gestational vitamin D
deficiency is not only associated with rickets, but a significantly increased risk of neonatal pneumonia2, a doubled risk for preeclampsia3, a tripled
risk for gestational diabetes4, and a quadrupled risk for primary cesarean section5.
Yesterday, the FNB failed millions of pregnant women whose as yet unborn babies will pay the price. Let us hope the FNB will comply with the spirit
of "transparency" by quickly responding to our freedom of Information requests.
John Cannell, MD
The Vitamin D Council
1241 Johnson Avenue, #134
San Luis Obispo, CA 93401
+1-805-468-2061, +1-805-712-0440
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[...]
The report, released Tuesday, concluded that most people in Canada and the U.S. need 600 international units of vitamin D per day, triple Health Canada's current recommendation of 200 IU for
adults aged 19 to 50. People 71 and older may require as much as 800 IUs per day because of potential physical and behavioural changes related to aging.
The recommendations are not just for a supplement or diet but for the combination of both sources, said committee chair Catherine Ross, who is also a professor of nutritional science at
Penn State University, University Park.
The recommendations assume minimal exposure to the sun, which naturally boosts vitamin D levels.
There isn't enough evidence that vitamin D helps protect against cancer, heart disease, autoimmune diseases and diabetes, but further investigation is warranted, the group said.
"The committee emphasizes that, with a few exceptions, all North Americans are receiving enough calcium and vitamin D," the report concluded.
"Higher levels have not been shown to confer greater benefits, and, in fact, they have been linked to other health problems, challenging the concept that 'more is better.'"
The panel set an upper limit for vitamin D, concluding that once intake exceeds 4,000 IU per day, the risk for harm starts to increase.
Very high levels of vitamin D, above 10,000 IUs per day, are known to cause kidney and tissue damage, according to the report.
'Stunning disappointment'
[...]
"This is a stunning disappointment," said Dr. Cedric Garland of the University of California, San Diego, who wasn't part of the institute's study and says the risk of colon cancer in particular could be
slashed if people consumed even more vitamin D.
"I believe we should be using significantly more," agreed Dr. Gerry Schwalfenberg, a family physician in Edmonton and an assistant clinical professor in the department of family medicine at the University of Alberta. [See Schwalfenberg letter and references below.]
"I would be suggesting, at least for our latitude, and our amount of sun that we're getting, a minimum of 1,000 [IU] and probably 2,000 [IU] would be where I find most people would get levels that would help to
prevent chronic disease," added Schwalfenberg, who has written several papers on vitamin D. [...]
→ Read more |
The Council for Responsible Nutrition (CRN), the dietary supplement industry's leading trade association, today called the National Academy of Sciences Institute of Medicine's (IOM) newly
released report on the Dietary Reference Intake (DRI) levels for vitamin D "a modest step in the right direction that fell short of truly capturing the extensive and positive research that
has consistently supported the need for people to significantly raise their vitamin D levels."
The IOM Committee to Review Dietary Reference Intakes for Vitamin D and Calcium today established new DRIs for vitamin D, resulting in a conservative increase in the recommended intakes by establishing
an Estimated Average Requirement (EAR) for adults of 400 IU/day and a Recommended Dietary Allowance (RDA) for adults of 600 IU/day (800 IU/day for those aged 71+). In addition, the Tolerable Upper Intake
Level (UL) — representing the dose at which there are no known adverse effects, not a recommended daily suggestion — was doubled from 2,000 to 4,000 IU/day for adults. [...]
"While an increase in the recommendations for vitamin D will benefit the public overall, such a conservative increase for the nutrient lags behind the mountain of research demonstrating a need for vitamin D
intake at levels possibly as high as 2,000 IU/day for adults," according to Andrew Shao, Ph.D., senior vice president, scientific and regulatory affairs, CRN. "However, CRN recognizes the challenges associated
with the DRI process, and the difficulty in making broad-based recommendations for an entire population. That is why it is so important for consumers to talk with their doctors or other healthcare professionals,
to get their vitamin D levels tested, and determine personalized recommendations that would enable them to increase blood levels of vitamin D as appropriate." [...] |
But in Canada...
Provinces delisting Vitamin D test
Ontario is following the advice of experts and will be funding vitamin D testing for patients where medical evidence indicates that there is a need.
Beginning December 1, the Ontario Health Insurance Plan (OHIP) will cover the costs of a vitamin D test for people with the following conditions:
- Osteoporosis and Osteopenia
- Rickets
- Malabsorption Symdromes
- Renal Disease
- Patients on medications that affect vitamin D metabolism.
In June, Ontario's Health Technology Advisory Committee concluded that the routine use of vitamin D testing for the general population could not be
justified based on current evidence, and that people should follow Health Canada's recommendations on diet and vitamin D supplementation.
Since 2004, vitamin D testing has grown by 2,500 per cent - jumping from 29,000 tests to more than 700,000 in 2009.
The change in vitamin D testing will result in resources being redirected to other laboratory services.
QUICK FACTS
- This year, it is expected that the Ontario government will be billed up to $66 million on vitamin D tests - compared to $1.7 million 2004
- Manitoba, Nova Scotia, Newfoundland, Prince Edward Island and Saskatchewan have all moved to limit unnecessary vitamin D testing.
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I applaud the new vitamin D in adult health and disease guideline statement. Average 25(OH)D levels in all studies in Canada1 including Health Canada's household studies are consistently below the recommended 75-80nmol/l.
Supplementation with 1000IU of vitamin D3 in the general population would result in a mean 25(OH)D level slightly above 85nmol/l still leaving 20- 30% of
Canadians below the suggested 75nmol/l. That's not good enough. These studies show that children and teens have significant insufficiency and some are frankly
deficient. This is the time to address osteoporosis since this will influence peak bone mass and result in stronger bones for the future.
Supplementation with 2000IU of vitamin D3 in an institutionalized group (tested after a minimum of 5 months of supplementation) did not result in
toxicity and did not achieve normal levels for everyone (94%>80 nmol/l)2.
The use of 2000IU in the first year of life reduced the risk of developing type 1 diabetes over the next 30 years.3
There is emerging evidence of the benefit of vitamin D in the immune system for oral health, tuberculosis, influenza, hepatitis C, eczema, wound healing
etc. Vitamin D levels required may be significantly higher than 75nmol/l.4
Should we not be looking at using 2000IU for all Canadians since the authors suggest this is safe and does not require monitoring? In implementing this
strategy the economic benefit to the Canadian population has been estimated in the billions of dollars.5
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Vitamin D status of Canadians
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[...]
Higher levels desirable to prevent disease
In the study, 90 per cent of Canadians aged six to 79 had concentrations of vitamin D in their blood that were considered adequate for bone health.
But 10 per cent or roughly three million people had concentrations considered inadequate. Of these, 1.1 million were considered vitamin D deficient.
The agency defined vitamin D deficiency as a concentration below 27.5 nanomoles per litre (nmol/L) — a measurement of concentration based on the number of molecules per litre of blood.
The report's authors said there is growing consensus that much higher concentrations, above 75 nmol/L, are desirable for overall health and disease prevention.
"This higher level has been found to be associated with a lower risk of breast and colon cancer, some cardiovascular disease and other diseases like multiple sclerosis," said Kellie Langlois of
Statistics Canada's health analysis division.
Between April and October, 38.6 per cent of Canadians tested had concentrations above 75. Between November and March, the percentage who met that concentration in their blood or serum fell to
30.3 per cent, according to the report.
"If you look at the reference values that your doctor would expect you to have when they measure your serum 25 hydroxy D, one-third of Canadians would have enough, and two-thirds of
Canadians would be told they should probably be taking a vitamin D supplement," said Reinhold Vieth, a clinical chemist at Toronto's Mount Sinai Hospital.
Men were more likely than women to have inadequate concentrations. The highest prevalence of deficiency occurred among men aged 20 to 39 — about seven per cent of this group
were considered vitamin D deficient. [...] | |
ABSTRACT
Background
Vitamin D deficiency is a global health problem, but little is known about the vitamin D status of Canadians.
Data and methods
The data are from the 2007 to 2009 Canadian Health Measures Survey, which collected blood samples.
Descriptive statistics (frequencies, means) were used to estimate 25-hydroxyvitamin D [25(OH)D] concentrations among a sample of 5,306 individuals
aged 6 to 79 years, representing 28.2 million Canadians from all regions, by age group, sex, racial background, month of blood collection, and frequency
of milk consumption. The prevalence of deficiency and the percentages of the population meeting different cut-off concentrations were assessed.
Results
The mean concentration of 25(OH)D for the Canadian population aged 6 to 79 years was 67.7 nmol/L. The mean was lowest among men aged 20 to 39 years
(60.7 nmol/L) and highest among boys aged 6 to 11 (76.8 nmol/L). Deficiency (less than 27.5 nmol/L) was detected in 4% of the population. However, 10% of
Canadians had concentrations considered inadequate for bone health (less than 37.5 nmol/L) according to 1997 Institute of Medicine (IOM) Standards
(currently under review). Concentrations measured in November-March were below those measured in April-October. White racial background and frequent
milk consumption were significantly associated with higher concentrations.
Interpretation
As measured by plasma 25(OH)D, 4% of Canadians aged 6 to 79 years were vitamin D-deficient, according to 1997 IOM standards (currently under
review). Based on these standards, 10% of the population had inadequate concentrations for bone health.
Vitamin D deficiency is a worldwide health problem.2 Vitamin D promotes calcium and phosphorous absorption, which is necessary to build and maintain
bones and teeth, and is also a transcription factor in most cells in the body.3,4 Although the optimal concentration for overall health is currently under debate,
lower levels of vitamin D have been associated with a greater risk of rickets in children or osteomalacia in adults;5 increased risk of fractures,6 falls,7
breast cancer,8 colorectal cancer and adenoma;9 poor immunity;4 and cardiovascular10
and other diseases such as multiple sclerosis.11 [...]
Conclusion
This study identifies population groups that are likely to have lower concentrations of vitamin D and factors associated with vitamin D status. The
factors related to low concentrations are winter season, racial backgrounds other than White, and less frequent intake of milk. Future analyses of CHMS data will
investigate additional factors that may influence vitamin D concentrations, such as supplement consumption, body mass index, pregnancy, fish consumption and
sunscreen use. |
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How much vitamin D should I take?
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How much vitamin D should I take?
The Food and Nutrition Board set the current Upper Limit for medically-unsupervised intake by infants and babies (up to the age of 1 years-old) at 1,000 units/day.
This means the government says it is safe to give infants and babies up to 1,000 units a day without getting a blood test. Of course, with correct sun exposure in
the summer this is not necessary, but it will be in winter. Children over 1 years of age, according to the Food and Nutrition Board, may safely take 2,000 units/day — again,
without requiring a blood test.
For adolescents, pregnant women, and other adults, the government's Upper Limits are a problem. While a 2,000-unit Upper Limit is entirely appropriate for
younger children, such limits in heavier adolescents, adults, and pregnant women limit effective treatment of vitamin D deficiency. However, these limits no more
impair a physician's ability to treat vitamin D deficiency with higher doses than comparable Upper Limits for
calcium or magnesium impair
their ability to treat calcium or magnesium deficiencies with higher doses, should those deficiencies be diagnosed.
In the absence of sun exposure and in winter, heavier children, adults, and pregnant women may require doses above 2,000 units daily (depending on
pre-existing blood levels, body weight, degree of skin pigmentation, age, and latitude of residence) in order to obtain and maintain levels of
50–80 ng/mL. For example, Professor Heaney at Creighton University has
estimated that about 3,000 units/day is required simply to assure that 97% of adult Americans obtain levels greater than 35 ng/mL. Healthy adult men utilize up to 5,000 units of vitamin D per day, if present in the body. Professors Bruce Hollis and Carol Wagner, in South Carolina, have been giving pregnant women
4,000 units/day for years. Professor Vieth, at the University of
Toronto, found that actual vitamin D toxicity, with systemic symptoms,
is exceedingly rare and requires much higher doses than those discussed above. When exceeding the Upper Limit, periodic serum 25(OH)D and calcium levels will reassure both
physician and patient that such amounts are safe as well as convince all concerned that the government should revise their 10-year-old (yet most current) recommendations — the sooner the better.
In the August 2010 Vitamin D Newsletter, Cannell considers the question of vitamin D toxicity and reviews selected papers describing massive doses administered to patients
in clinical trials as early as 1935. See Gary Null and Vitamin D Toxicity.
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Vitamin D needs
Vitamin D from both capsules and liquid is equally effective in treating vitamin D deficiency.
Much individual variation exists in response to supplemental vitamin D. The amount needed to raise and/or maintain blood serum levels for one person may not
be enough for another. This is due to various factors such as age, weight, absorption, overall health, and amount of sun exposure. Recent research has determined that genetic variants are also a
factor. 1
The only way to know for sure if a certain dosage is working for you is to have your
vitamin D levels tested.
Occasional monitoring of these levels will one determine what dose is right for them.
[...] For proper functioning, a healthy human body utilizes around 3,000-5,000 IU of vitamin D per day — indicating the current recommended intakes are not high
enough to raise and/or maintain the vitamin D levels necessary for proper health. 4
Vitamin D Council recommended amounts
Based on the body's indicated daily vitamin D usage, Vitamin D Council recommends the following amounts of supplemental vitamin D3 per day in the
absence of proper sun exposure. Due to the variable response discussed above, these are only estimated amounts.
- Healthy children under the age of 1 years
— 1,000 IU.
- Healthy children over the age of 1 years
— 1,000 IU per every 25 lbs of body weight.
- Healthy adults and adolescents
— at least 5,000 IU.
- Pregnant and lactating mothers
— at least 6,000 IU.
Additionally, children and adults with chronic health conditions such as autism, MS, cancer, heart disease, or obesity may need as much as double these amounts.
Tolerable Upper Intake Level
The US Government’s Tolerable Upper Intake Level (UL) for vitamin D is set at 4,000 IU per day. While this is a step in the right direction from the previous
UL at 2,000 IU per day, in some situations — such as with those who are obese — it may still be too low. An upper limit this low will also result in the
prevention of adequate doses from being used in studies, greatly curtailing our understanding of vitamin D’s physiological effects as well as the true extent of
its treatment potential. 5 6 7
Current expert consensus is that the US Government UL for vitamin D is too low and that it should be raised to 10,000 IU per day.
6 7 8 Since this is the amount one would naturally
produce in their skin from sun exposure, it is considered safe. 9
Can I take more than 10,000 IU per day?
Wanting to raise vitamin D levels quickly, some people choose to supplement with amounts higher than 10,000 IU per day until target levels are achieved. When using vitamin D in
these amounts, frequent monitoring of blood levels, as well as adequate magnesium intake, are advised. Once
blood serum levels are optimized, daily amount should be lowered to a maintenance dose, somewhere around 5,000 IU per day. [...]
How should I take my vitamin D?
Both forms of vitamin D [water-soluble and fat-soluble vitamin D are equally absorbed and metabolized by the body, are equally effective, and] may be taken any time of day with,
or without, any other food or supplement and still remain effective. If one is concerned about absorption, they may take their
vitamin D at mealtime, though there is no evidence to indicate this is more effective.
Most people take their vitamin D daily, yet there are some who opt to take it weekly at a higher dose. Since the body is designed to store vitamin D for
future use, a weekly interval should produce the same results as daily use. 11
Mixing sun exposure and supplements
If one would like to use both sun exposure and supplementation to receive their vitamin D, it is safe to do so. Simply do not take any supplemental
vitamin D on the days when proper sun exposure is received.
Precautions
People with the following conditions should only take vitamin D with the
guidance of a knowledgeable physician:
- primary hyperparathyroidism
- sarcoidosis
- granulomatous TB
- some cancers
Those with primary hyperparathyroidism should only use vitamin D when under the care of a knowledgeable endocrinologist.
Interactions with medications
There have yet to be any documented instances of an adverse interaction of vitamin D with any medications. There are, however, medications which have been
found to interfere with the body’s proper utilization of vitamin D. They are: 2
- Steroids - impair vitamin D metabolism, contributing to bone loss and development of osteoporosis.
- Xenical®, alli™, Questran®, LoCholest®, and Prevalite® - reduce vitamin D absorption.
- Dilantin®) - increases hepatic metabolism of vitamin D to inactive compounds.
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