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Rapid Responses: Rapid Responses published:
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Deficiency of sunlight and vitamin D
- Edward Hutchinson (13 June 2008)
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More evidence is needed before supplementation
- Miles D Witham (16 June 2008)
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Frustrations with Vitamin D treatments
- Avril Danczak (16 June 2008)
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Widespread severe vitamin D-deficiency in Scotland
- Helga M Rhein (17 June 2008)
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Vitamin D deficiency in Asylum seekers and refugees
- Anan Raghunath, Rena Downing, Jezz Thompson and Peter Campion (18 June 2008)
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Re: More evidence is needed before supplementation
- Eddie Vos (18 June 2008)
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Edward Hutchinson, Patient Retired
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In "Circulating Vitamin D3 and 25-hydroxyvitamin D in Humans": Hollis, Wagner,Drezner, Binkley show only when circulating 25(OH)D levels are above 50ng 125nmol/l are the body's basic daily need met and surplus D3 can be stored. "Hypovitaminosis D in British adults at age 45y" Hyppönen, Power show half of the adult UK population had 25(OH)D concentrations <40nmol/L during the winter and spring and remain <75nmol/l throughout the year. "The urgent need to recommend an intake of vitamin D that is effective" (authors too numerous to list here) explains supplemental intake of 400 IU vitamin D3/d has only a modest effect on blood concentrations of 25(OH)D, raising them by 7–12 nmol/L, depending on the starting point. While 2000iu/daily/D3 may raise 25(OH)D from 50 to 80 nmol/L it will not and cannot raise 25(OH)D to attain and maintain levels between 125- 150nmol/l necessary to enable the body to build a reserve. "The case against ergocalciferol (vitamin D2) as a vitamin supplement" Houghton Vieth show many people do not use D2 as effectively as D3. Although Holick's paper "Vitamin D2 is as effective as vitamin D3 in maintaining circulating concentrations of 25-hydroxyvitamin D." shows at low levels, using assured quality, D2 may be as effective as D3 in some individuals, while D3 remains cheaper and more effective the logic of using D2 rather than D3 remains suspect. Competing interests: None declared |
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Miles D Witham, Clinician Scientist, Ageing and Health University of Dundee, Ninewells Hospital, Dundee DD1 9SY
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Editor, Holick [1] is right to highlight the high prevalence of vitamin D insufficiency in many groups of people living at higher latitudes. However, the evidence base to support general supplementation, including aggressive fortification, does not currently exist. There are now indeed an impressive array of observational data that suggest that low vitamin D levels are associated with a wide variety of diseases, including diabetes, cardiovascular disease and cancer. This does not necessarily mean that intervention with vitamin D supplementation will improve health outcomes – witness the problems of hormone replacement therapy despite encouraging observational data, not to mention the lack of effect and possible harms surrounding vitamins A,E and beta-carotene supplementation [2]. Whilst traditional vitamin D toxicity may be unlikely even with relatively large doses of vitamin D, we cannot be sure that long-term vitamin D supplementation does not in fact cause some harms – and the case for benefits is far from proven. The recent WHI study of low-dose calcium and D supplementation [3] showed no change in risk of colorectal cancer, diabetes, stroke or cardiovascular disease, but did produce an increase in the number of renal stones. Recent observational data from the Framingham study [4] suggests that the risk of cardiovascular events may be lowest at 25 hydroxy D levels of around 60nmol/L, possibly increasing slowly at levels above this. The only way to resolve these uncertainties is to conduct large- scale, randomised controlled trials comparing different doses of vitamin D versus placebo. Only then will we be able to weigh up the balance of benefit and risk, decide which groups of people would gain net benefit, and thus make safe and sensible recommendations on vitamin D supplementation. Dr Miles D Witham
References: 1. Holick MF. Deficiency of sunlight and vitamin D. BMJ 2008; 336: 1318-9. 2. Bjelakovic G et al. Antioxidant supplements for prevention of mortality in healthy participants and patients with various diseases. Cochrane Database Syst Rev 2008 Apr 16;(2):CD007176. 3. Hsia J et al. Calcium/vitamin D supplementation and cardiovascular events. Circulation 2007;115(7):846-54. 4. Wang TJ et al. Vitamin D deficiency and risk of cardiovascular disease. Circulation. 2008;117(4):503-11. Competing interests: Dr Witham has received grant income from the Scottish Government, Chest Heart and Stroke Scotland, Diabetes UK and Heart Research UK to investigate the effects of vitamin D on the cardiovascular system |
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Avril Danczak, General Practitioner The Alexandra Practice, 365 Wilbraham Road Manchester M16 8NG
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I welcome the interest in Vitamin D deficiency as it is extremely common in our mixed inner city population, and many doctors seem unaware of the problem and fail to consider it in their differential diagnoses. I have commonly noticed Vitamin D deficiency in association with plantar fasciitis, fatigue,low mood,muscular pains in pregnancy and low birth weight,as well as the expected musculoskeletal pains, which can be non specific, assymetrical and without radiological or bone enzyme abnormalities. The children of mothers with low vitamin D levels commonly feed poorly and can be lethargic,unhappy toddlers even before they develop late signs of frank rickets.Symptoms are also common in at risk men..ie those with inadequate sunlight exposure. Asian populations have high rates of heart disease, diabetes and TB. These are all associated with Vitamin D deficiency, which is especially common in those communities. Fustratingly, suitable oral treatments have become unavailable in the last year and it can be hard to get sufficient replacement levels in many patients. There is no suitable daily supplement of Vitamin D alone listed in the BNF, and over the counter vitamins are usually mixtures, with doses of Vitamin D too low to replenish stores in the severely deficient patient.Preparations of Vitamin D for daily use contain calcium, which often causes constipation and hence poor adherence. High dose oral Ergocalciferol preparations are effective and popular with patients,but these have been not available in pharmacies locally for some time due to "manufacturing difficulties".No one seems to be responsible for ensuring supplies of Vitamin D are adequate. Injections are painful, use more staff time and require medical input. It is also fustrating that almost all the Vitamin D preparations contain gelatine, which makes them unsuitable for those who wish to observe Halal principles. Vitamin D deficiency is usually a whole family problem. All family members need encouragement to get sun exposure and take appropriate supplements. All health professionals need to be aware that Vitamin D metabolism is complex and linked to cancers, heart disease and diabetes. The reduction in all cause mortality seen with Vitamin D supplementation (referred to by Sievenpiper et al in their article BMJ 2008;336:1371-4) is not matched by statins.We spend millions ensuring that people get their statins, shouldnt we do the same for vitamin D? I remember debates about supplementing foods etc when I was a medical student 30 years ago. Isnt it time to be proactive about this problem, at all levels of the NHS? Competing interests: None declared |
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Helga M Rhein, General Practitioner Sighthill Health Centre, 380 Calder Road, Edinburgh EH11 4AU
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15 June 2008 I couldn’t agree more with Holick (BMJ, 14/6/2008, editorial, p.1318) and Sievenpiper et al (BMJ, 14/6/2008, Lesson of the week, p.1371) about the urgent need to highlight the neglected subject of vitamin D deficiency in the UK. We have found in our General Practice in Edinburgh a (to us) surprisingly high prevalence of gross vitamin D deficiency and continue to do so. The deficiency affects not only our South Asian patients but also a considerable number of those with white skin colour. The following are our yet unpublished figures from Sept 07: Between 2005 and 2007, bloods were taken from 99 patients, aged 15 to 85, suspected of having a possible vitamin D deficiency, those of South Asian origin or other ethnic minorities, those with vague musculo-skeletal symptoms or who are overweight, on anti-epileptic drugs, use sunscreen or make up, are house-bound or get little exposure to sun light. According to the definitions of most vitamin D researchers, insufficient vitamin D concentrations are those below 75 nmol/l. In our sample, there are only 2% with a sufficient vitamin D level. Levels below 25nmol/l are defined as severe deficiency, in our sample 47%. Hyppoenen et al have recorded similar figures for Scotland, Am J Clin Nutr, 2007.
Helga Rhein (GP) Sighthill Health Centre 380 Calder Road Edinburgh EH11 4AU helga.rhein@lothian.scot.nhs.uk Competing interests: None declared |
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Anan Raghunath, General Practitioner The Quays, Hull, East Yorkshire, Rena Downing, Jezz Thompson and Peter Campion
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We undertake clinical sessions in a specialist community GP unit that provides medical care for refugees and asylum seekers. The majority of such clients we deal with come from the Asian and middle-eastern countries. They often present with a multitude of physical and psychological symptoms many of which is taken to represent their traumatic past experiences in their own countries. In recent months there has been a both an increased request for as well as positive results of low 25-hydroxy vitamin-D levels in these patients presenting with non-specific symptoms of muscluo-skeletal pains and "somatisation disorders". The tests had been mainly instigated by one GP with experience of working abroad with similar patient groups. We feel that with increasing influx of ethnic minority groups in UK, there is now a case for routine testing of Vitamin D levels in these patients, particularly women and children, presenting to their GP with vague unexplained symptomatology. There is also a urgent need for primary care research in this area to both to raise awareness amogst health professionals of the rapid "re-emergence" of this clnical entity in UK and to help produce guidelines for diagnosis and management. Competing interests: None declared |
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Eddie Vos, maintains www.health-heart.org Sutton (Qc) Canada J0E 2K0
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Dr. Witham agrees there is "widespread deficiency"
and unlikely harm from "relatively large doses of vitamin D", and
likely benefit in many age-related diseases yet he proposes more and by
necessity extremely long-duration trials before recommending supplementation.
He cites examples of negative but non related nutrient or hormone studies as an excuse for NOT now taking steps to resolve this recognized deficiency.
Clearly, it is time to act if only on the basis of this one trial in an over age 65 U.K. population and where 22% of first fractures were prevented by vitamin D supplementation. This involved a total of 37.5 mg cholecalciferol, taken every 4 month as a 100,000 IU [2.5 mg D3] pill, during 5 years. Harm is hypothetical; the harm from bone fractures is a painful reality. Such trials would thus be unethical. While 50,000 IU pills may currently be hard to obtain in the U.K., in the U.S. 100 such pills are a simple $30 mail-order purchase [product source: Bio-Tech-Pharm.com] and where the taking of 1 pill every 2 months would reach the level of the above trial [cost ~$10/5 years], and go a long way resolving deficiency. Competing interests: None declared |
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