Vitamin D supplementation

The term “vitamin D” refers to two vitamers:

• Cholecalciferol (vitamin D3) which is synthesized in the skin through the action of ultraviolet solar radiation on 7-dehydrocholesterol (provitamin D3).
• Ergocalciferol (vitamin D2) which is formed through solar irradiation of plant-based ergosterol (provitamin D2).

Vitamin D3 is the most bioavailable form and the one that keeps plasma levels high for the longest time.

• Vitamin D has an excellent safety profile, with no side effects, in the recommended forms and doses.

Foods with vitamin D

Vitamin D is found in very few foods. Natural sources include (Anonymous 2004): fish liver oils (cod, for example), oily fish (cooked and especially canned), whole eggs, livers of land mammals, etc.

Vitamin D is found in very few foods:

• Oily fish species.
• Margarine.
• Whole eggs and egg yolks.
• Liver.

Intake and deficiencies

Vitamin D deficiency is very common in the population.

• Low vitamin D levels are common in obesity, osteomuscular pain, fibromyalgia, diabetes, asthma, pulmonary fibrosis, and heart disease.
• In high blood pressure, dyslipidemia, osteomuscular pain, fibromyalgia, asthma, heart disease, COPD, pulmonary fibrosis, and respiratory infections, vitamin D can help improve their control and evolution.
• Vitamin D needs the “team” of basic nutrients to achieve its maximum therapeutic potential in chronic diseases.
• Vitamin D has anti-inflammatory action and is an inhibitor of the pro-inflammatory response, with anti-proliferative, pro-differentiator, and immunomodulatory functions. (Nagpal, Na et al. 2005; Richards, Valdes et al. 2007).

Types of vitamin D. “Vitamin D” defines a group of lipophilic prohormones, the most important forms of which are vitamin D2 (ergocalciferol) and vitamin D3 (cholecalciferol) (Anonymous 2004). Vitamin D2 comes exclusively from plant-based foods, while D3 comes from foods of animal origin and can also be synthesized in the skin. It is also is more toxic than D2. The body produces vitamin D3 from cholesterol through the action of the sun’s ultraviolet B rays on the skin, with this being the main source of vitamin D.

Vitamin D must be activated in the body through two hydroxylation reactions. Calcitriol, the product of this double hydroxylation, is the active form of vitamin D in the body. The term “vitamin D” also refers to these metabolytes and the analogues of these substances. Calcitriol plays an important role in multiple organisms, mainly in relation to calcium homeostasis, preventing hypocalcemic states, promoting its absorption—along with phosphorous absorption—in the intestine, its reabsorption in the kidneys, and in this way facilitating bone growth and remodeling (van den Berg 1997; Cranney, Horsley et al. 2007).

Synthesis. Other parameters that can indicate a vitamin D deficiency are low serum phosphorous and high serum alkaline phosphatase levels.0he skin of the human body is capable of producing vitamin D when exposed to sunlight. Factors such as the season, latitude, fog or smog, age, darker skin tone, excess weight, and the application of sunscreen products, as well as spending most of the day indoors with little access to sunlight, can affect exposure to ultraviolet rays and, as a result, vitamin D synthesis. This accounts for the importance of diet or dietary supplements rich in vitamin D to prevent deficiency states when the aforementioned factors limit endogenous production. Because of the high risk of deficiency, intake of 25 μg (1,000 IU) is recommended to maintain adequate plasma levels (Anonymous 2004).

Intake. Deficiency can be due not only to lack of exposure to sunlight but also to inadequate intake; problems that limit absorption (including the use of certain drugs); conditions that interfere with conversion of vitamin D to the active metabolytes, such as liver or kidney problems; or, rarely, hereditary problems (Johnson 2007).

Deficiencies. The latest studies indicates that there is an alarming vitamin D deficiency in the population worldwide. In Spain, 20% to 41% of people between the ages of 20 and39 and 60% to 83% of people from 40 to 64 have vitamin D deficiency. Above the age of 65, vitamin D deficiency affects 68% of 88% of the population living in their own homes and 100% of those living in nursing homes (Anonymous, 2010).

According to the ENIDE survey, the median habitual intake of this vitamins in men falls with age and is slightly higher than that of women, regardless of age. The percentages of the population at risk of inadequate intake can be as high as 80% to 90%, and none exceeds the UL (AESAN, 2011).

Deficiency symptoms include the following: musculoskeletal pain, burning sensation in the mouth and throat, loss of appetite, diarrhea, insomnia, and impaired vision (Nair S. 2010).

The serum level of 25-HO-vitamin D is the best indicator of deficiency, and levels below 30 µg/ml (75 mmol/l) should be considered deficient for for it to carry out its functions properly. Severe deficiency with levels below 10 µg/ml, moderate deficiency with levels between 10–20 µg/ml, and suboptimal levels between 20–30 µg/ml. Most experts agree on levels of 35–40 µg/ml for preventive health, and some suggest that optimal levels for protection against cancer and heart disease are 50–70 µg/ml (Medine Plus, 2010). Other parameters that can indicate a vitamin D deficiency are low serum phosphorous and high serum alkaline phosphatase levels.

Common medications. Orlistat (Xenical), laxatives, H2 antagonists (cimetidine, ranitidine, etc.), cholestyramine, and corticosteroids can accentuate a marginal vitamin D deficiency.

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Reference values

NRV, PRI, UL for vitamin D

In the United States, adequate intake (AI) is defined as 200 IU/day (5 µg) from childhood to the age of 50, 400 IU/day from 51 to 70, and 600 IU/day after the age of 70, although the American Academy of Pediatrics considers these recommendations insufficient and establishes a minimum of 400 IU, even for children (Wagner 2008). The Institute of Medicine continues to update its recommendations for vitamin D and calcium with new reports expected to be released in the summer of 2010 (Anonymous 2010).

The NRV is 5 µg(200 IU).

The NRV is 5 µg(200 IU).

According to EFSA, the NRV is 100 µg (4,000 IU). Many experts have increased their recommendations for vitamin D supplementation by at least 1,000 IU (Harvard School of Public Health Nutrition Source, Vitamin D, 2010).

High doses of vitamin D are toxic, but vitamin D toxicity is rare and leads to hypercalcemia due to increased intestinal absorption of vitamin D. Other symptoms of toxicity include anorexia, nausea, and vomiting, which are often followed by polyuria, polydipsia, weakness, nervousness, itching, and, rarely kidney failure (Johnson 2007). Cases of hypercalciuria, bone loss (Adams and Lee 1997) and ischemic coronary accidents have also been reported (Rajasree, Rajpal et al. 2001). Prolonged exposure to sunlight normally does not produce vitamin D toxicity (Vieth 1999). This is because after “normal” exposure to sunlight (around 20 minutes for lightly pigmented skin), the concentration of the precursors in the skin reach equilibrium, which leads to degradation of the excess vitamin D (Holick 1995).

NRV: Nutrient Reference Value. These are the daily amounts recommended for vitamins and minerals (micronutrients only) considered sufficient in the European Union to prevent a deficit in most healthy individuals in the population. They are the values used for labeling and claims.

PRI: Population Reference Intake. These are the reference values for a specific population group, defined as the amount of energy and/or nutrients (macronutrients and micronutrients) recommended to cover the nutritional needs of practically the entire population. They refer to healthy population groups. The values are expressed per person per day, as a 15-day average. To account for individual differences in digestive and metabolic processes, the PRI figure used for each nutrient is the average plus twice the standard deviation (except for energy, for which the average is used), thereby including almost all healthy individuals in the group (97.5%).

UL: Tolerable Upper Intake Level: the maximum level of total daily intake of a nutrient in a context of long-term or chronic consumption which does not pose a risk to health.