Does vitamin D make the world go

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Does vitamin D make the world go round?
Does vitamin D make the world go round?

• Cynthia Childs, MFA, MPH, CLC
• Some slides borrowed (with permission) from Cindy
  Howard, MD, MPH and Carole Baggerly, Grassroots
  Health
• Title borrowed (with permission) from Carol
  Wagner, MD, Medical University of South Carolina

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Objectives
Objectives

• Develop an understanding of vitamin D
• what it is, how we get it, and why we need it
• Review current research on vitamin D
• Highlight research on vitamin D during the
  perinatal period
• Briefly describe the study, Establishing the
  Vitamin D Requirements during Lactation

• Develop an understanding of vitamin D
• what it is, how we get it, and why we need it
• Review current research on vitamin D
• Highlight research on vitamin D during the
  perinatal period
• Briefly describe the study, Establishing the
  Vitamin D Requirements during Lactation

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What is vitamin D?

• Vitamin D is not technically a vitamin it is a
  pro-hormone
• It is biologically inert and must undergo two
  hydroxylations in the body for activation
• occurs in the liver and converts vitamin D to
  25-hydroxyvitamin D 25(OH)D
• occurs primarily in the kidney and forms the
  physiologically active 1,25-dihydroxyvitamin D
  1,25(OH)2D

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How do we measure vitamin D?

• The most reliable measure of vitamin D status is
  serum 25(OH)D level
• The half-life of 25(OH)D in your system is 2-3
  weeks
• Deficient lt 20 ng/mL
• Insufficient 20-31 ng/mL
• Adequate gt 32 ng/mL
• Normal 54-90 ng/mL
• Based on levels in people who live and work in
  sun-rich environments

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How much Vitamin D do we need?
How much Vitamin D do we need?

• According to the National Institutes of Health
  Office of Dietary Supplements, we need

• According to the National Institutes of Health
  Office of Dietary Supplements, we need

Birth 50 years 200 IU
Pregnancy Lactation 200 IU
51 70 years 400 IU
Over 70 years 600 IU
Birth 50 years 200 IU
Pregnancy Lactation 200 IU
51 70 years 400 IU
Over 70 years 600 IU
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Vitamin D requirements

• In 1989, the adult AI of 200 IU was considered
  generous
• - The adult requirement was originally estimated
  to be half what infants and children needed
• At 200 IU per day vitamin D levels remain
  unchanged or decline, especially in the winter
  months

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AAP Recommendations
AAP Recommendations

• The American Academy of Pediatrics recommends
  that all breastfed infants receive 400 IU of
  vitamin D per day
• In November 2008, the AAP doubled its
  recommendation for vitamin D for all children
  through adolescence to 400 IU per day

The original recommendation for vitamin D is
based on the amount of vitamin D in a teaspoon
of cod liver oil!
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What are the sources of vitamin D?

• Sun exposure
• Supplements
• Food (very limited)

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Food Sources of Vitamin D
Food Sources of Vitamin D
Food IUs per serving
Cod liver oil, 1 tablespoon 1,360
Salmon, cooked, 3.5 ounces 360
Mackerel, cooked, 3.5 ounces 345
Tuna fish, canned in oil, 3 ounces 200
Milk, vitamin D-fortified, 1 cup 98
Margarine, fortified, 1 tablespoon 60
Ready-to-eat cereal, fortified with vitamin D, 0.75-1 cup 40
Egg, 1 whole (vitamin D is found in yolk) 20
Liver, beef, cooked, 3.5 ounces 15
Cheese, Swiss, 1 ounce 12
Food IUs per serving
Cod liver oil, 1 tablespoon 1,360
Salmon, cooked, 3.5 ounces 360
Mackerel, cooked, 3.5 ounces 345
Tuna fish, canned in oil, 3 ounces 200
Milk, vitamin D-fortified, 1 cup 98
Margarine, fortified, 1 tablespoon 60
Ready-to-eat cereal, fortified with vitamin D, 0.75-1 cup 40
Egg, 1 whole (vitamin D is found in yolk) 20
Liver, beef, cooked, 3.5 ounces 15
Cheese, Swiss, 1 ounce 12
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Vitamin D from the sun
A single initial minimal erythemic dose (whole
body) of UVB radiation will release approximately
10,000-25,000 IU vitamin D3 into the circulation
within 24 hours Darker skinned individuals may
need 10 times the UV exposure of light skinned
people
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Why do we need vitamin D?

• Having a healthy vitamin D level appears to help
  prevent
• Cancer
• Cardiovascular disease
• Hypertension
• Stroke
• Colds and influenza
• Diabetes
• Depression / SAD
• Athletic performance
• Multiple sclerosis
• Rheumatoid arthritis

• Autism
• Chronic pain
• Macular degeneration
• Inflammatory bowel disease
• Periodontal disease
• Rickets
• Osteoporosis
• Osteomalacia
• Falls in the elderly
• Tuberculosis
• Overall mortality

Correlation v. causality
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Prevalence of vitamin D deficiency

• 25(OH)D concentrations by age group, NHANES
  2000-2004

• Females are more likely to have low 25(OH)D
  levels than males
• Vitamin D levels vary by race/ethnicity

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Season, Sunlight Race (Charleston, SC)
Season, Sunlight Race (Charleston, SC)
Season Caucasian African-American
Winter 15.8 2.0 6.1 1.1
Summer 27.0 6.9 12.3 1.1
P-value lt0.05 lt0.01
Season Caucasian African-American
Winter 15.8 2.0 6.1 1.1
Summer 27.0 6.9 12.3 1.1
P-value lt0.05 lt0.01
Circulating 25(OH)D ng/mL Men and Women in
Charleston, SC (Personal communication Dr. Bruce
Hollis)
Circulating 25(OH)D ng/mL Men and Women in
Charleston, SC (Personal communication Dr. Bruce
Hollis)
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Evidence of an Epidemic
Evidence of an Epidemic

• As of May 2007, 461 women were enrolled in an
  MUSC ongoing vitamin D supplementation trial of
  pregnant women
• 167 women had a baseline circulating 25(OH)D lt20
  ng/mL (deficiency)
• 88/117 (75.2) African American
• 63/195 (32.3) Hispanic
• 16/145 (11) Caucasian

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Evidence of an Epidemic
Evidence of an Epidemic

• 366 women had a baseline 25(OHD) lt32 ng/mL, and
  thus, were either deficient or with marginal
  vitamin D status
• 112/117 (95.7) African American
• 157/195 (80.5) Hispanic
• 97/145 (66.9) Caucasian women

• 366 women had a baseline 25(OHD) lt32 ng/mL, and
  thus, were either deficient or with marginal
  vitamin D status
• 112/117 (95.7) African American
• 157/195 (80.5) Hispanic
• 97/145 (66.9) Caucasian women

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Evidence of an Epidemic
Evidence of an Epidemic

• Overall, 79.8 of women enrolled since January
  2004 were vitamin D deficient (25(OH)D lt 20
  ng/mL) or had marginal vitamin D status (25(OH)D
  lt 32 ng/mL)
• This is in sunny South Carolina!
• Speaks to the serious and widespread nature of
  the problem

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Hypovitaminosis D during Pregnancy
Hypovitaminosis D during Pregnancy

• As currently defined (lt80 nmol or 32 ng/mL),
  almost 100 of women of color are vitamin D
  insufficient during pregnancy.
• Vitamin D status during pregnancy is the
  forerunner of vitamin D status during lactation
• If a woman is deficient during pregnancy, then
  she will be deficient during lactation

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Why is there an epidemic of vitamin D deficiency?
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Evolutionary Perspective
Evolutionary Perspective

• Humans originated at the equator in Africa
• Northern migration caused decreased sunlight
  exposure which caused decreased skin pigmentation
• Populations that did not de-pigment would have
  died in childbirth due to malformation of the
  pelvis

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Contracted pelvis, in a case of osteomalacia
(adult rickets) normal childbirth would be
impossible
Normal shape of female pelvis
Contracted pelvis, in a case of osteomalacia
(adult rickets) normal childbirth would be
impossible
Normal shape of female pelvis
Vieth 2001. Nutritional Aspects of Osteoporosis,
Chapter 17, ed P Burckhardt, RP Heaney, B
Dawson-Hughes Academic Press
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Childhood rickets

• Epidemic with industrialization in 19-20th
  centuries
• With discovery of vitamin D and fortification,
  rickets was almost entirely eliminated
• Until now

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London 1889
Idaho 1989
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Vitamin D Status in Primates and Early Humans
64
48
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Serum 25(OH)D ng/ml
Serum 25(OH)D ng/ml
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0
Old-World Primates
Old-World Primates
Sources, include Cosman, Osteoporosis Int 2000
Fuleihan NEJM 1999 Scharla Osteoporosis Int
1998 Vieth AJCN 1999, 2000
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Recent lifestyle changes

• According to a 1989 study of Indoor Air Quality,
  Americans spent 93 of every 24-hour day INDOORS
• What has changed since 1989?

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What affects your vitamin D level?

• Time spent outdoors
• Amount of skin exposed
• Skin color
• Clothing
• Body fat
• Latitude
• Season and time of day

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Vitamin D Synthesis and Latitude
Vitamin D Synthesis and Latitude
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Effect of UVB exposure time and skin color on
Vitamin D production
Effect of UVB exposure time and skin color on
Vitamin D production
White Skin
Dark Skin
White Skin
Dark Skin
Yield of Vitamin D
Yield of Vitamin D
Same capacity for Vitamin D, different
exposure-time requirements
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Breast Cancer Mortality Rates
Breast Cancer Mortality Rates
Maphttp//www3.cancer.gov/atlasplus/type.html
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Type 1 Diabetes, Children
Type 1 Diabetes, Children
by latitude of population centroid, reporting
countries, Source WHO data
by latitude of population centroid, reporting
countries, Source WHO data
Incidence Rate per 100,000
Incidence Rate per 100,000
Latitude
Latitude
Mohr SB, Garland CF, Gorham ED, Garland FC. The
association between ultraviolet B irradiance,
vitamin D status and incidence rates of type 1
diabetes in 51 regions worldwide.Diabetologia.
2008 Jun 12
Mohr SB, Garland CF, Gorham ED, Garland FC. The
association between ultraviolet B irradiance,
vitamin D status and incidence rates of type 1
diabetes in 51 regions worldwide.Diabetologia.
2008 Jun 12
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Multiple Sclerosis
Multiple Sclerosis
MS Prevalence rate per 100,000
MS Prevalence rate per 100,000
Latitude
Latitude
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Vitamin D C-sections

• Boston University Medical Center
• 253 women enrolled 43 had primary c-section
• 28 of those with 25(OH)D lt 15 ng/mL had a
  c-section compared to 14 with higher 25(OH)D
  levels
• In multivariate analysis, women with 25(OH)D lt 15
  ng/mL had almost 4 times the rate of c-section
• One consequence of vitamin D deficiency is poor
  muscular performance and strength

Merewood et al, J Clin Endocrin Metab. March 2009
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Vitamin D Lactation

• Historically, breast milk was thought to be an
  adequate source of vitamin D for the infant
• Vitamin D status of the breastfed infant is
  directly related to the vitamin D status of the
  mother
• About 20 of maternal vitamin D is transferred in
  breast milk
• In mothers taking 400 IU of vitamin D, their
  breast milk contained 33-68 IU per liter
• Recent cases of rickets have been among
  exclusively breastfed dark skinned babies

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Establishing the Vitamin D Requirements during
Lactation
Establishing the Vitamin D Requirements during
Lactation
South Carolina PI Bruce Hollis, Carol
Wagner Rochester PI Cindy Howard, Ruth
Lawrence Project Coordinator Cynthia Childs

• South Carolina PI Bruce Hollis, Carol Wagner
• Rochester PI Cindy Howard, Ruth Lawrence
• Project Coordinator Cynthia Childs

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Objective
Determine the efficacy, effectiveness and safety
of maternal and infant vitamin D supplementation
as a function of maternal vitamin D status,
lactation status, ethnicity, and latitude in the
prevention of hypovitaminosis D.

• Determine the efficacy, effectiveness and safety
  of maternal and infant vitamin D supplementation
  as a function of maternal vitamin D status,
  lactation status, ethnicity, and latitude in the
  prevention of hypovitaminosis D.

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Methods Rochester Cohort
Methods Rochester Cohort

• 189 Women and their fully breastfed infants will
  be enrolled at 4-6 weeks postpartum. They will
  be randomized to one of three two groups
• Control group (N63)
• 400 IU vitamin D3/day for mother and 400 IU
  vitamin D3/day for baby
• 2. Low-dose group (N63)
• 2400 IU vitamin D3/day for mother and 0 IU/day
  (placebo) for baby
• 3. High-dose group (N63)
• 6400 IU vitamin D3/day for mother and 0 IU/day
  (placebo) for baby

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Methods
Methods

• Mother and infant recruited by 1 month postpartum
• Seven study visits at the Clinical Research
  Center at Strong Hospital, 1 per month
• At every visit
• Questionnaires about health and feeding
• Collect blood, milk and urine from mom
• Collect urine from the baby
• Height weight measurements of mom and baby
• At visits 1, 4, 7
• DEXA scan
• Blood draw on infant

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Questions?
Questions?