Vitamin D: the sunshine vitamin

Catherine Quinn

Abstract
Vitamin D has recently attracted a considerable amount of media attention. This article investigates whether the notion of a widespread vitamin D deficiency is justified in the UK, and what effect it might have on the general populace. Also considered are which physiological systems vitamin D affects in addition to bone remodelling, as well as the latest findings as to how this vitamin can benefit the body. Reasers are also given information as to which medications might adversely affect vitamin absorption, which patient groups are most at risk of deficiency, and the most practical and cost-effective means to treat patients suffering from a lack of vitamin D. Key Words: Vitamin D
n

Bone remodelling

Osteoporosis

Sunshine

nowledge and studies into the benefits of vitamin D seem to have proliferated over recent months, and now associated with everything from the prevention of dementia the treatment of to flu, this nutritional darling looks set to oust former favourite vitamin C. However, where the issue becomes complicated for nurses is that vitamin D is readily synthesized from sunlight, which to many suggests that the medical professions effusive sun-protection campaigns may have actually worked to deprive patients of vitaminD. So, with skin cancer on one side of the spectrum and deficiency disorders on the other, what exactly should nurses be advising to patients?

Vitamin D in the body

Vitamin D has leapt into the spotlight recently, with a seemingly endless list of disorders that correct intakes can remedy (Table 1). The main reason for this is that rather than a vitamin, vitamin D is technically a hormone (or fat-soluble steroid), and like most hormones is associated with
Catherine Quinn is s a freelance journalist writing on health issues for major national publications such as The Guardian and The Telegraph Accepted for publication: September 2010

a whole host of applications throughout the body. Research throughout most of the last century on the vitamin linked it to a positive effect on skeletal healththe wellknown regulatory effect of calcium which promotes the mineralization in bones. It has only been in the last decade or so that scientists realized it had applications beyond bone health, and general calcium and phosphate balancing. This means that what many staff learned during their medical training is now outdated, and the notion that this vitamin has important uses other than preventing rickets and osteoporosis is only just becoming common knowledge. Vitamin D has many uses which people arent necessarily aware of, explains Dr Garry Savin, Medical Director of vitamin deficiency testing clinic, Preventicum. Aside from bone health there is evidence to suggest it is involved in regulating cardiovascular health, reducing the risk of type 2 diabetes and also some cancers. There is evidence it can reduce occurrences of MS [multiple sclerosis] and Parkinsons disease. There is even a direct link between children who stay indoors more and contraction of respiratory diseases such as tuberculosis, and vitamin D is linked with a healthy immune system which has implications for all kinds of illnesses. Anyone who has followed the many published reports (Schwarz et al, 1998;

Shaw and Pal, 2002; Bodnar et al, 2007; Hyppnen and Power, 2007; Mytyon et al, 2007; Piirainen et al, 2007; Hobbs et al, 2009; Holick, 2010; Hyppnen and Boucher, 2010; Pearce and Cheetham, 2010) on the effects of vitamin D over the past few years will be well aware that this itemization of treatments is potentially only the tip of the iceberg, but while the possibilities for this vitaminhormone might seem confusing in their extensive nature, an understanding of recent discoveries on its interaction in the body goes a long way to explaining the likely effects in a logical fashion. In the 1990s scientists knew that vitaminD has both a circulating form (known as 25-vitamin D, or vitamin D2) and an activated form (1,25-dihydroxyvitamin D3, or vitaminD3). The activated form is made by the kidneys, which manufacture it from either sunlight or foodstuffs, and these organs can only make a finite quantity, no matter how much sunlight exposure or vitamin-rich foods are consumed. Vitamin D3 made by the kidneys is secreted into the bloodstream where it is relatively easily tested for, and in this area of the body its application is well-known to most medical professionals for its interplay with the parathyroid gland to release and absorb calcium for bone health and in the regulation of cardiac impulses. However, what was puzzling scientists until relatively recently was that healthy intakes of vitamin D seemed to have a much higher correlation with other health benefits than the finite capacity of the kidney would suggest. In other words, doses which should outpace the kidneys capacity to convert it to the active form seemed to have an effect on everything from curing psoriasis to preventing dementia. Then in 1998 a breakthrough occurred. Researchers at the Boston University Medical Centre, in collaboration with Wake Forest University, discovered that the activated form of vitamin D can be manufactured by many tissues other than the kidneys, but rather than making D3 and circulating it for the use of

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bone remodelling, these tissues and organs use up the activated vitamin immediately for their own purposes (Swartz et al, 1998). This answered both the question as to how the vitamin D was being used, and why it was not showing up in a circulating form in the bloodit wasnt just the kidney which could convert D2 to D3. The kidney was the only converter which sent out a supply of active vitamin D for use in other parts of the body, but many other tissues could make a source of D3 for their own use.

Table 1. Disorders and drugs which can affect vitamin D levels

A handful of medical disorders should be considered by nurses who suspect vitamin D deficiency, as they may impact on absorption. Pharmaceutical drugs can also affect both the catabolism and the absorption of vitamin D. Generally, any medication which is metabolized by hepatic p450 enzymes will speed up the catabolism of vitamin D, and these include: n Some anticonvulsants n Anti-seizure medications, such as those taken for epilepsy (those on these medications long-term have been shown to be at risk of rickets) n Corticosteroids n Immunotherapy, such as patients receiving organ transplants or medication for AIDS n Nicotine n Other specific drugs, such as anti-coagulate Heparin and heart-burn treatment Cimetidine. As vitamin D is fat-soluble, dietary intakes will be impaired by any medication which prevents the absorption of lipids in the gut. This does not affect vitamin D synthesized by sunlight, and as UVB is likely a precursor, the vast bulk of natural intake in many cases is not significant. It will, however, affect supplementation absorption, and so if a patient is using this method to address a deficiency it will form a highly relevant factor and intakes should be increased. The same applies for medical conditions which affect gut absorption, and nurses should also be aware of the implications of: n Coeliac disease n Fat malabsorption n Crohns disease n Kidney failure.

Which parts of the body are able to use D3 immediately and locally?
The answer to this question goes some way to explaining why the effects of this vitamin have suddenly exploded in a wealth of potential benefits. The prostate gland, breast, colon, parathyroid glands and immune cells all have this capacity, and given that D3 has a number of uses from the kidney alone, it is possible to understand how this hormone may have been grossly underplayed in human health. For nurses, this is also a helpful chart in recognizing potential health complaints as they relate to vitamin D. The reason for this is that while D3 from the kidney addresses bone and cardiac health, this collection of glands, organs and cells all have their own unique functions which could be affected by deficiency. As the body of research grows, however, it looks as though the evidence is mounting up to suggest vitamin D could soon be suggested to offer an even wider gamut of health benefits. Every tissue and cell in our body has a vitamin D receptor, and theres no reason for them to be there unless they were having an effect, explains Professor Michael Holick, who has specialized in vitamin D research for over three decades, and was recently awarded the Linus Pauling Institute Prize for his work in the field. Vitamin D can reduce the risk of heart attack by as much as 50%, reduce the risk of common cancers of the colon, prostate, and breast by as much as 50%; reduce the risk of infectious diseases, including influenza by as much as 90%; reduce the risk of type 1 diabetes by 78% in a child who gets 2000iu of vitamin D a day in the first year of life; decrease the risk of dementia and depression; wipe out cases of fibromyalgia which have been misdiagnosed; and dramatically reduce the risk of multiple sclerosis and other autoimmune diseases.

Is there a deficiency?

This is high praise indeed for a vitamin which so many of us assume is readily available, but before considering the health implications of these impressive claims, it seems sensible to seriously address the notion of deficiency. And what will naturally concern most nurses is whether there is sufficient evidence to show that a lack of vitamin D is a common problem. Perhaps the most important factor to emphasize here is that vitamin D is not technically a vitamin. And it may be surprising to many to realize that food sources alone are likely to be inadequate to meet daily requirements. Most vitamins youd expect to be able to consume adequate quantities of through your food, but vitamin D is different, explains Dr Savin. Youd need to consume quite an unfeasible quantity of food rich in vitamin D to be reaching your daily intakes. It would be something like 10 pints of milk, or 20 cans of tuna. Generally speaking, youd expect to get about 90% of your vitamin D from sunshine and 10% from food. Other experts agree, and Professor Holick also points out that vitamin D absorbed by sunshine is also stored longer in the body than that ingested from food or supplements. The point here is almost an evolutionary one. Humans are designed to use UVB rays for nutritional purposes, in the same way that almost all other life forms

on earth have evolved to use sunlight. And while we may feel a long way away from this function in our bulb-lit homes and offices, our bodies still have a genuine need for that exposure. However, given that we have this requirement, surely it is possible for most of us to synthesize enough vitamin D within minutes during the summer months, and store it indefinitely throughout winter? Sadly, while in theory at least 1020minutes should be enough to generate large quantities of vitamin D, the message does not seem to be getting through to the general populace, a great number of whom, it would seem, are deficient. As the sunshine vitamin deficiency is naturally related to areas which get less sunlight, it will surprise few to find that far northern countries such as Finland report substantial deficiencies, and even the emergence of conditions such as rickets in children (Piirainen et al, 2007). However, this sunlight problem also tracks as far south as the UK. In fact, the geographical location of the UK brings the country under the same highlatitude sun angle as Scandinavia, meaning that no vitamin D at all is generated during the months of October to March. The evidence seems to suggest that not only is lack of sunshine a problem during winter months, but nutritional intakes and even standard supplements are often not enough to mitigate this lack.

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Almost everyone who spends most of their time indoors should be supplementing with at least 1000iu of vitamin D

Currently, the NHS website now proclaims deficiency to be far more widespread than was once thought, citing a study from the Centre for Paediatric Epidemiology and Biostatistics, Institute of Child Health (Hyppnen and Power, 2007), which shows that approximately 60% have hypovitaminosis D (sub-optimal levels) during the summer months, with the figure rising to 90% in winter and spring. A more recent study by researchers at the Institute of Human Genetics at the University of Newcastle and the Royal Victoria Infirmary have reported that more than 50% of the adult population in the UK have insufficient levels of vitamin D and 16% have severe deficiency during winter and spring (Pearce and Cheetham, 2010). Furthermore, the evidence was so compelling that the authors of the report have subsequently written to the Department of Health proposing vitamin D be added to milk. As a result of such studies, sunscreen has become something of a contentious issue, with many in the sensible sun exposure for vitamin D camp blaming the dermatology industry for keeping people quite literally in the dark as to their sunshine requirements in order to sell sunblock (Holick, 2010). 1162

Many UK experts such as Dr Henderson and Dr Savvin, however, believe the problem is simply the result of advent of a long-hours culture where few British adults or children see as much sunlight as they should. Long working hours out of the sun and computer-obsessed children spending too much time inside, with little exposure to sunlight are likely causes, says GP Dr Roger Henderson, of NetDoctor. Excessive sunscreen could also be a factor, but I think many hours indoors are more likely to be the main culprit.

climates such as the UK would need between 1520 minutes of summer sun to generate maximum vitamin D levels, while a Type 6 would need almost a full hour of exposure. Add to this that the Type 3sthose with Mediterranean skinneed 3050 minutes and it becomes clear that certain people are highly likely to become deficient in the UK. In fact, the research shows that Type 5 skin types are at particular risk for deficiency in darker climates, such as the UK (Mytton et al, 2007), and it has been estimated at some threetimes higher for black women than for white women (Bodnar et al, 2007). The other big consideration is cultural ethnicity. Women who wear concealing clothing for religious reasons are not only depriving themselves of vitamin D, but are also more likely to be darker skinned and at risk of deficiency for this reason alone. It has been found that women who cover up their skin for religious reasons when venturing outside have a considerably heightened risk of vitamin D deficiency (Hobbs et al, 2009), and the risk in the UK is now considered so great that the NHS launched a campaign in 2008 aimed at Muslim women, particularly Bangladeshi, Pakistani and Somalian, to encourage them to increase their vitamin D intake after studies showing Muslim children are more likely to be vitaminDdeficient (Shaw and Pal, 2002).

Other reasons for deficiency

General risk categories for bone disorders include older patients, young children and pregnant women, all of whom may have increased requirements for vitamin D. The elderly are a well-known problem category for fractures and osteoporosis, and most nurses are all too aware that bone mass decreases with age. However, young children may now be more likely to be deficient compared with previous years, and shockingly, conditions such as rickets seems to be remerging. Rickets does seem to be creeping back, says Dr Henderson. And I would encourage nurses to be aware that just because a child doesnt have the bowed legs, doesnt mean they dont have it. Signs to look out for include poor growth, teeth problems and joint pain, which can make the child uncomfortable. Pregnancy is also a key group, and the NHS advises pregnant women to supplement with 400iu of vitamin D daily. To many, however, this campaign seems to have gained little publicity in contrast with the widely known advice to supplement with folic acid, which most nurses are now well aware of.
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Deficiency and ethnicity

With vitamin D deficiency affecting such a large cohort, there are other reasons for the problem which nurses should be looking out for. Non-white ethnicities tend to be at greater risk because melanin in the skin acts as a natural block to the UVB rays which generate vitamin D, and the darker the skin the less of the vitamin that will be manufactured by the skin on any given exposure. The dermatological chart tends to rate skin from Type 1, as very fair with red or blond hair, to Type 6 of the kind of black skin associated with AfricanCaribbean origins. Generally, fair-skinned Type 1s in high latitude

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Considering that a recent study by the University College London Institute of Child Health shows that vitamin D levels are unacceptably high in pregnant women (Hyppnen and Boucher, 2010), nurses should ensure patients in this cohort are aware of the risks. that doses of up to 5000iu can be safely given, and he has monitored this quantity in healthy patients over 5 months, with no signs of intoxication. Currently, however, medical bodies suggest the recommended daily requirement is 200iu, and even pregnant women are advised to take a supplement of only 400iu. This is frustrating to many experts who have voiced their exasperation that such low amounts are suggested, contrary to what they believe is optimal health supplementation, and overlycautious for a vitamin which is extremely difficult to over-consume. Vitamin D in sunlight, they argue, is impossible to overdose on, and so a supplement programme of far larger quantities than currently suggested need not pose a risk. Other researchers are more cautious, however, with Dr Elina Hyppnen, who authored a recent paper on deficiency in pregnant women (Hyppnen and Boucher, 2010) believing there is no case for supplementation at all. Rather, she advocates a programme of informing the public as to the merits of safe sunshine. may seem to fly in the face of common sense at first, and could even feel that this advice runs counterintuitive to their own learning. As the safe-sun message took a number of decades to drip through to general understanding, however, so we might expect the notion of moderate sun exposure to take a similarly long time to get through to BJN patients.  Conflict of interest: none All interviews in this article were conducted by the author.
Bodnar LM, Simhan HN, Powers R W , Frank MP , Cooperstein E, Roberts JM (2007) High prevalence of vitamin D insufficiency in black and white pregnant women residing in the northern United States and their neonates. J Nutr 137(2): 44752 Hobbs RD, Habib Z, Alromaihi D et al (2009) Severe vitamin D deficiency in Arab-American women living in Dearborn, Michigan. Endocr Pract 15(1): 3540 Holick MF (2010) The Vitamin D Solution. Penguin, London Hyppnen E, Boucher BJ (2010) Avoidance of vitamin D deficiency in pregnancy in the United Kingdom: the case for a unified approach in National policy. Br J Nutr 104(3): 30914 Hyppnen E, Power C (2007) Hypovitaminosis D in British adults at age 45 y: nationwide cohort study on dietary and lifestyle predictors. Am J Clin Nutr 85(3): 8608 Pearce SH, Cheetham TD (2010) Diagnosis and management of vitamin D deficiency. BMJ 340: b5664 Piirainen T, Laitinen K, Isolauri E (2007) Impact of national fortification of fluid milks and margarines with vitaminD on dietary intake and serum 25-hydroxyvitamin D concentration in 4-year-old children. Eur J Clin Nutr 61(1): 1238 Mytton J, Frater AP , Oakley G, Murphy E, Barber MJ, Jahfar S (2007) Vitamin D deficiency in multicultural primary care: a case series of 299 patients. Br J Gen Pract 57(540): 5779 Schwartz GG, Whitlatch LW , Chen TC, Lokeshwar BL, Holick MF (1998) Human prostate cells synthesize 1,25-dihydroxyvitamin D3 from 25-hydroxyvitamin D3. Cancer Epidemiol Biomarkers Prev 7: 3915 Shaw NJ, Pal BR (2002) Vitamin D deficiency in UK Asian families: activating a new concern. Arch Dis Childhood 86(3): 1479

How much vitamin D should patients be getting?

Blood levels of vitamin D should measure above 50 nanograms per litre, says Roger Henderson. Below 25 I would consider a deficiency. This is the level widely agreed on throughout the worldwide medical profession and raises little debate among experts. Although there is some contention about which tests will effectively measure deficiency; current wisdom is to ensure blood is tested for the D2 inactive form or vitamin D, as conversely this gives a better indication of deficiency levels than testing for the active D3 form made and circulated by the kidneys. And as experts such as Professor Holick suggest many doctors order the wrong test and find sufficient levels where deficiency exists. This is something worth clarifying with whoever carries out these tests. The problem for many, however, is that there is still some dispute and controversy about how much vitamin D can be safely administered to ensure healthy levels, which can make it difficult for nurses to advise. The main message should be for sensible exposure to sunlight, as this should comprise around 90% of intakes, says Roger Henderson. Patients should be encouraged to get out in the sunshine during summer months for short periods of time without sunblock. With countries in high latitudes generating exactly zero vitamins from October to March, however, many experts argue that supplementation is also necessary to ensure that healthy levels are met. According to Professor Holick, almost everyone who spends most of their time indoors should be supplementing with at least 1000iu of vitamin D, with at-risk groups such as pregnant women, very young children and the elderly requiring higher doses. In the case of those who are already deficient, he advises

Conclusions
The message to nurses is clear: spreading the vitamin D word of healthy sun exposure is essential as far more people are at risk of deficiency than is acceptable in a modern healthcare system. And with the vast array of benefits vitamin D can confer for health, it is vital that no patients are kept in the dark. Nurses will find that recommending patients get out in the sun without sun-block

KEY PoiNtS
n Vitamin D deficiency is widespread in the UK, and the emergence of problems such as rickets in children seems to be increasing n Vitamin D is technically a hormone, and is not limited to bone health. Every cell in the body has a vitamin D receptor and it is manufactured in significant quantities by the prostate, breast, colon, parathyroid glands, and immune cells n Advice on safe sun exposure has been overstated, and people should aim to get out regularly in summer sunlight with no sun block on at all for periods from ten minutes to an hour depending on their skin type

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