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Does vitamin D make the world go ‘round?

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

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Does vitamin D make the world go ‘round?

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  1. 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

  2. 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

  3. 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

  4. 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: < 20 ng/mL • Insufficient: 20-31 ng/mL • Adequate: >= 32 ng/mL • “Normal”: 54-90 ng/mL • Based on levels in people who live and work in sun-rich environments

  5. 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:

  6. 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

  7. 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!

  8. What are the sources of vitamin D? • Sun exposure • Supplements • Food (very limited)

  9. Food Sources of Vitamin D Food Sources of Vitamin D

  10. 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

  11. 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 Why do we need vitamin D? Correlation v. causality

  12. 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

  13. Season, Sunlight & Race (Charleston, SC) Season, Sunlight & Race (Charleston, SC) 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)

  14. 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 <20 ng/mL (deficiency): • 88/117 (75.2%) African American • 63/195 (32.3%) Hispanic • 16/145 (11%) Caucasian

  15. Evidence of an Epidemic Evidence of an Epidemic • 366 women had a baseline 25(OHD) <32 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) <32 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

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

  17. Hypovitaminosis D during Pregnancy Hypovitaminosis D during Pregnancy • As currently defined (<80 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

  18. Why is there an epidemic of vitamin D deficiency?

  19. 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

  20. Normal shape of female pelvis 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 Vieth 2001. Nutritional Aspects of Osteoporosis, Chapter 17, ed P Burckhardt, RP Heaney, B Dawson-Hughes; Academic Press

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

  22. London 1889 Idaho 1989

  23. 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?

  24. What affects your vitamin D level? • Time spent outdoors • Amount of skin exposed • Skin color • Clothing • Body fat • Latitude • Season and time of day

  25. Vitamin D Synthesis and Latitude Vitamin D Synthesis and Latitude

  26. 20 minutes 20 minutes 120 minutes 120 minutes Effect of UVB exposure time and skin color on Vitamin D production Effect of UVB exposure time and skin color on Vitamin D production WhiteSkin Dark Skin White Skin Dark Skin Yield of Vitamin D Yield of Vitamin D Same capacity for Vitamin D, different exposure-time requirements

  27. Breast Cancer Mortality Rates Breast Cancer Mortality Rates Map:http://www3.cancer.gov/atlasplus/type.html

  28. Type 1 Diabetes, Children by latitude of population centroid, reporting countries, Source: WHO data by latitude of population centroid, reporting countries, Source: WHO data Type 1 Diabetes, Children 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

  29. Multiple Sclerosis Multiple Sclerosis MS Prevalence rate per 100,000 MS Prevalence rate per 100,000 Latitude Latitude

  30. Vitamin D & C-sections • Boston University Medical Center • 253 women enrolled; 43 had primary c-section • 28% of those with 25(OH)D < 15 ng/mL had a c-section compared to 14% with higher 25(OH)D levels • In multivariate analysis, women with 25(OH)D < 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

  31. 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

  32. 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

  33. 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.

  34. 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 (N=63): • 400 IU vitamin D3/day for mother and 400 IU vitamin D3/day for baby • 2. Low-dose group (N=63): • 2400 IU vitamin D3/day for mother and 0 IU/day (placebo) for baby • 3. High-dose group (N=63): • 6400 IU vitamin D3/day for mother and 0 IU/day (placebo) for baby

  35. 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

  36. Questions? Questions?

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