Vitamin D Supplementation: Clinical Guidelines

Chelsea Small, Dietetic Intern 2014

Function Vitamin D is well known for its role in bone growth and regulation as well as calcium balance. Current research is suggesting that vitamin D may also play a prominent role in cell differentiation, immunity, insulin secretion, and blood pressure regulation.1 Deficiency In vitamin D deficiency, calcium absorption cannot be increased enough to satisfy the bodys calcium needs. Consequently, PTH production by the parathyroid glands is increased and calcium is mobilized from the skeleton to maintain normal serum calcium levelsa condition known as secondary hyperparathyroidism. Although it has long been known that severe vitamin D deficiency has serious consequences for bone health (such as rickets, osteoporosis, and ostoemalacia), recent research suggests that less obvious states of vitamin D deficiency are common and increase the risk of osteoporosis and other health problems.2 Risk factors for Vitamin D Deficiency Exclusively breast-fed infants Dark skin Aging Covering all exposed skin or using sunscreen whenever outside Fat malabsorption syndromes Inflammatory bowel disease Obesity

Assessing Vitamin D Nutritional Status Serum 25-hydroxyvitamin D level is the best indicator of vitamin D deficiency and sufficiency. In general, serum 25-hydroxyvitamin D values less than 20-25 nmol/L (8-10 ng/mL) indicate severe deficiency associated with rickets and osteomalacia . Although 50 nmol/L (20 ng/mL) has been suggested as the low end of the normal range, more recent research suggests that PTH levels and calcium absorption are not optimized until serum 25-hydroxyvitamin D levels reach approximately 80 nmol/L (32 ng/mL).1 Research suggests that the most advantageous target concentration of 25(OH)D begins at 75 nmol/L (30 ng/mL) and that the best concentrations are between 90 and 100 nmol/L (3640 ng/mL). This is based on a review looking at the optimal blood 25(OH)D concentrations for mineral bone disease and fracture risk reduction, lower-extremity function, dental health, and colorectal cancer prevention. 3

Food Sources of Vitamin D

Food Pink salmon, canned Sardines, canned Mackerel, canned Quaker Nutrition for Women Instant Oatmeal Cow's milk, fortified with vitamin D Soy milk, fortified with vitamin D Orange juice, fortified with vitamin D Cereal, fortified Egg yolk

Serving 3 ounces 3 ounces 3 ounces 1 packet 8 ounces 8 ounces 8 ounces 1 serving (usually 1 cup) 1 large

Vitamin D (IU) 530 231 213 154 98 100 100 40-50 21

Vitamin D (mcg) 13.3 5.8 5.3 3.9 2.5 2.5 2.5 1.0-1.3 0.53

Recommended Dietary Allowance (RDA) for Vitamin D Set by the Institute of Medicine
Life Stage Infants Infants Children Children Children Adolescents Adults Adults Adults Pregnancy Breast-feeding Age 0-6 months 6-12 months 1-3 years 4-8 years 9-13 years 14-18 years 19-50 years 51-70 years 71 years and older all ages all ages Males mcg/day (IU/day) 10 mcg (400 IU) (AI) 10 mcg (400 IU) (AI) 15 mcg (600 IU) 15 mcg (600 IU) 15 mcg (600 IU) 15 mcg (600 IU) 15 mcg (600 IU) 15 mcg (600 IU) 20 mcg (800 IU) Females mcg/day (IU/day) 10 mcg (400 IU) (AI) 10 mcg (400 IU) (AI) 15 mcg (600 IU) 15 mcg (600 IU) 15 mcg (600 IU) 15 mcg (600 IU) 15 mcg (600 IU) 15 mcg (600 IU) 20 mcg (800 IU) 15 mcg (600 IU) 15 mcg (600 IU)

Recommendations Based on Current Research Data from supplementation studies indicate that vitamin D intakes of at least 800-1,000 IU/day are required by adults living in temperate latitudes to achieve serum 25-hydroxyvitamin D levels of at least 80 nmol/L. 1 Daily supplementation with 2,000 IU (50 mcg) of vitamin D is important for older adults because aging is associated with a reduced capacity to synthesize vitamin D in the skin upon sun exposure. 1

Vitamin D Recommendations for the Prevention of Specific Disease Conditions

Osteoporosis Vitamin D3 supplementation can slow bone density losses or decrease the risk of osteoporotic fracture in men and women who are unlikely to be getting enough vitamin D. Research suggest that daily intakes of at least 800 IU of vitamin D is be necessary to optimize serum concentrations of 25-hydroxyvitamin D and thus reduce fracture risk.3 . In order for vitamin D supplementation to be effective in preserving bone health, adequate dietary calcium (1,000 to 1,200 mg/day) should also be consumed. Vitamin D2 (ergocalciferol) has not been found effective at preventing fractures

Colorectal Cancer Research suggests that 1,000 IU of oral vitamin D daily would lower one's risk of colorectal cancer by 50%. 1

Breast Cancer 4,000 IU of vitamin D3 daily or 2,000 IU plus moderate sun exposure has been found to be beneficial in the prevention of breast cancer. 1

Hypertension (High Blood Pressure) The results of epidemiological and clinical studies suggest an inverse relationship between serum 1,25-dihydroxyvitamin D levels and blood pressure, which may be explained by recent findings that 1,25-dihydroxyvitamin D decreases the expression of the gene encoding renin.1 Although more research is needed in this area, it has been found that a combination of 1,600 IU/day of vitamin D and 800 mg/day of calcium may be able to decrease systolic BP. 4

Diabetes For type 1 diabetes, 2,000 IU of vitamin D taken by mouth daily for a year was associated with a reduced risk of type 1 diabetes. 5

Toxicity Vitamin D toxicity (hypervitaminosis D) induces abnormally high serum calcium levels (hypercalcemia), which could result in bone loss, kidney stones, and calcification of organs like the heart and kidneys if untreated over a long period of time. Hypercalcemia has been observed following daily doses of greater than 50,000 IU of vitamin D. Overall, research suggests that vitamin D toxicity is very unlikely in healthy people at intake levels lower than 10,000 IU/day. The Food and Nutrition Board of the Institute of Medicine conservatively set a tolerable upper intake level (UL) of 4,000 IU/day (100 mcg/day) for all adults (see table below).

Certain medical conditions can increase the risk of hypercalcemia in response to vitamin D, including primary hyperparathyroidism, sarcoidosis, tuberculosis, and lymphoma. People with these conditions may develop hypercalcemia in response to any increase in vitamin D nutrition and should thus consult a qualified health care provider regarding any increase in vitamin D intake. 1

Tolerable Upper Intake Level (UL) for Vitamin D Set by the Institute of Medicine
Age Group Infants 0-6 months Infants 6-12 months Children 1-3 years Children 4-8 years Children 9-13 years Adolescents 14-18 years Adults 19 years and older mcg/day (IU/day) 25 mcg (1,000 IU) 37.5 mcg (1,500 IU) 62.5 mcg (2,500 IU) 75 mcg (3,000 IU) 100 mcg (4,000 IU) 100 mcg (4,000 IU) 100 mcg (4,000 IU)

References: 1. http://lpi.oregonstate.edu/infocenter/vitamins/vitaminD/ 2. Heaney, Robert . "Long-latency deficiency disease: insights from calcium and vitamin D." The American Journal of Clinical Nutrition 78 (): 912-919. http://ajcn.nutrition.org/content/78/5/912.full 3. Bischoff-Ferrari, Heike, Edward Giovannucci, and Walter Willett. "Estimation of optimal serum concentrations of 25-hydroxyvitamin D for multiple health outcomes." The American Journal of Clinical Nutrition 84 (): 18-28. http://ajcn.nutrition.org/content/84/1/18.full 4. Margolis, Karen, Roberta Ray, and Linda Van Horn. "Effect of Calcium and Vitamin D Supplementation on Blood Pressure." Hypertension 52 (): 847-855. http://hyper.ahajournals.org/content/52/5/847.full 5. http://www.mayoclinic.org/drugs-supplements/vitamin-d/dosing/hrb-20060400