Vitamin D got considerable attention at the American Association of Clinical Endocrinologists “sunshine state” 2008 annual meeting. Presentations included one documenting hypocalcemia due to vitamin D deficiency in a patient adhering to a vegan diet, a second showing widespread underdiagnosis of vitamin D deficiency in patients with osteoporosis, and a third reporting high rates of continuing vitamin D deficiency in patients who have had a previous hip fracture.
Bad news for vegans: hypocalcemia and vitamin D deficiency from a “healthy” diet
Kateryna Komarovskiy, MD, and Nathaniel Winer, MD, described hypocalcemia due to vitamin D deficiency in a patient who had followed a strict vegan diet.1 The authors are at St. Vincent's Catholic Medical Center, Staten Island, NY.
The patient, who was from Grenada, was a 44-year-old male without significant past medical history. He presented with generalized weakness and bone pain for 2 to 3 months. He was practicing Rastafarian culture, including strict vegan diet, which included only unprocessed food of nonanimal origin. He was working night shifts.
Laboratory tests showed significant abnormalities for calcium, corrected by albumin of 6.6 mg/dL, phosphorus 2.8 mg/dL, intact PTH (parathyroid hormone) 214 pg/mL, creatinine 0.4 mg/dL, magnesium 2 mg/dL, vitamin D 25 level <4 (20-100) ng/mL, vitamin D1-25 8 (19-67) pg/mL. There was no evidence of malabsorption.
Because of the bone pain, plain film radiography was done and showed poorly healed old fractures of multiple ribs, and pelvic bones with evidence of severe osteopenia. The patient was diagnosed with secondary hyperparathyroidism and hypocalcemia due to vitamin D deficiency. The investigators believe this resulted from a combination of his diet, minimal exposure to sunlight, and race (hyperpigmented skin). “After dietary counseling, calcium and vitamin D supplementation, his calcium level normalized, and his generalized weakness and bone pain improved,” Dr. Komarovskiy said.
Dr. Komarovskiy explained that vegetarians consume food rich in oxalic (chives, parsley, spinach) and phytic acids (flaxseed, whole grains, nuts). These compounds interfere with calcium absorption from vegetable sources. Furthermore, the typical vegetarian diet contains less protein and may reduce calcium excretion.
“Our patient presented with hypocalcemia secondary to vitamin D deficiency and decreased calcium consumption. As a 44-year-old adult, he should have been consuming about 1000 mg/day of dietary calcium and 200 IU of vitamin D. By following the vegan diet, our patient believed that his healthy eating habits would protect him from obesity, diabetes, and dyslipidemia, which are common to the typical Western die,” Dr. Komarovskiy said.
Because ~2.5% of adults in the United States follow vegan diet, the study has important public health implications. A well-balanced vegan diet can provide an adequate source of the necessary vitamins and minerals, but this patient's did not.
“Clinicians should emphasize the importance of a well-balanced diet to their vegan patients, educate them about diet supplementation and vegetable-based sources of calcium and vitamin D, and provide early screening for osteoporosis,” Dr. Komaroskiy said.
Even osteoporosis patients taking calcium and vitamin D need routine vitamin D testing
Harinder Singh, MD, and colleagues reported retrospective data showing that >30% of osteoporosis patients who were regularly taking recommended levels of vitamin D and calcium supplements had low vitamin D levels.2 “Our observations suggest that vitamin D deficiency in patients diagnosed with osteoporosis by DEXA scanning is underdiagnosed. We suggest vitamin D levels as part of initial evaluation of patients with osteoporosis,” Dr. Singh said.
The chart review study was conducted at the outpatient endocrinology clinic in Las Vegas, which included osteoporosis patients diagnosed on DEXA scan who had documented vitamin D levels, irrespective of race, gender, age, or other underlying diagnoses. The researchers analyzed data for 71 patients, all of whom were on vitamin D 800 IU and calcium 1200 mg/day. Laboratory data showed that 18.3% of subjects were vitamin D deficient (<20ng/mL) and 22.5% (16) were vitamin D insufficient (20-30 ng/mL). Furthermore, 9.86% of patients were hypocalcemic (<9 mg/dL).
“Our study demonstrates that many patients with osteoporosis who were on vitamin D and calcium had low vitamin D levels, which in turn contributes to increased risk of fractures. Therefore, all patients with osteoporosis should have vitamin D levels measured, and replaced adequately,” Dr. Singh said.
Vitamin D also overlooked after hip fracture
Even after a hip fracture, vitamin D deficiency is often overlooked, according to Akta Patel Mukherjee, MD, and Suzanne Rieke, MD. Their retrospective analysis of 117 patients who presented with acute hip fracture from November 2004 to January 2006 to Lahey Clinic in Burlington, Massachusetts, showed that 90.6% presenting were vitamin D insufficient, including 48% of patients who had been previously diagnosed with osteopenia or osteoporosis and 68% of those who had suffered previous fractures.
“The majority of patients presenting to our hospital with hip fracture, even with history of a previous fracture, were vitamin D deficient,” Dr. Mukerjee said. The investigators noted that history of fracture is not routinely identified as an osteoporosis risk equivalent that should be is aggressively treated with vitamin D.
References
1. Komarovskiy K and Winer N. Unhealthy outcome from a “healthy” diet. Presented at: AACE 2008 annual meeting; May 14-17, 2008; Orlando, Fla. Presentation 706.
2. Singh H, Karmegan S, Manandhi A, et al. Vitamin D deficiency in patients with osteoporosis. Presented at: AACE 2008 annual meeting; May 14-17, 2008; Orlando, Fla. Presentation 520.
3. Mukherjee AP, Rieke S, Prevalence of vitamin D deficiency among acute hip fracture patients in a New England hospital. Presented at: AACE 2008 annual meeting; May 14-17, 2008; Orlando, Fla. Presentation 500.
I've been vitiamin D deficient recently. My OB found it and had me to a large dose over a three month period. When My RD tested it this last time the level was back to normal.
Board certified in internal medicine, Dr. Soram Khalsa is a clinical
professor of medicine and Chairman of the Advisory Committee for the
Environmental Medicine Center of Excellence at Southwest College of
Naturopathic Medicine in Phoenix, Arizona. He is a member of the Bureau
of Naturopathic Medicine Advisory Council for the State of California.
He also serves as Medical Director for the East-West Medical Research
Institute.
Vitamin D deficiency is probably the most frequent vitamin deficiency in America. I am writing this article to encourage you to go to the health food store and start taking 1000 International Units (IU) of Vitamin D everyday.
It is estimated that anywhere from 30 to 100% of Americans, depending upon their age and community living environments, are deficient in Vitamin D.
Studies have shown that more than 50,000 post-menopausal women taking medication for osteoporosis have sub-optimal levels of Vitamin D. 48% of white, pre-adolescent girls in a study in Maine had Vitamin D deficiency, and 32% of healthy students, physicians in residence, in a Boston Hospital, were found to be Vitamin D deficient, despite drinking milk and taking a multiple vitamin and eating salmon at least once a week.
In all, it is estimated that one billion people worldwide have Vitamin D deficiency or insufficiency.
We primarily get our Vitamin D from exposure of our skin to sunlight. Given our modern lifestyles of indoor or in-car living, and the continuous use of sun blocking creams (which block Vitamin D manufacture), most of us are getting very little Vitamin D absorption from sunlight on our skin. The little bit that we get from fortified milk and the fatty fishes does not provide us nearly what we need.
So how do we know if we have enough Vitamin D? The best way is to go to your personal physician and ask him or her to draw a 25-hydroxy Vitamin D blood test on you. This will tell you approximately what dose you need to get yourself into the normal range.
Very deficient people will need a prescription-strength Vitamin D on average for 8 weeks in order to bring them up to the normal range. Then it is simple to maintain your levels with 1,000 IU of Vitamin D which you can get at any health food store.
In the absence of getting a blood test, you can just start yourself on 1,000 IU of Vitamin D everyday.
Vitamin D deficiency has been shown to play a role in every major
disease that we see in our country. This includes 17 varieties of
cancer, heart disease, high blood pressure, stroke, autoimmune disease,
diabetes, osteoporosis, chronic pain and periodontal disease. One study
has shown that women in the lowest quartile of Vitamin D have five
times the incidence of cancer compared to women in the highest
quartile. 600,000 cases of breast and colo-rectal cancer could be
prevented each year by adequate intake of Vitamin D, according to
Cedric Garland DrPH. People deficient in Vitamin D have been found to
get influenza in winter more frequently than those with normal Vitamin
D levels. Vitamin D deficiency is now, most recently, being linked with
autism.
If you live north of 37 degrees latitude (approximately a line drawn
horizontally connecting Norfolk, Virginia to San Francisco, California)
sunlight is not sufficient to create Vitamin D in your skin in the
winter months, even if you are sitting in the sun in a bathing suit on
a warm January day! However, given our indoor lifestyle and extreme use
of sun blocking agents, living in the south is not even a guarantee
that Vitamin D deficiency won't occur. A study that was conducted in
Miami, Florida showed that approximately 40% of 212 adults were
deficient in Vitamin D in the winter.
The normal range for the blood test for Vitamin D is currently being actively discussed in the medical literature. It appears that a minimum of 30 nanograms per milliliter, (that's ng/mL), of 25 hydroxy Vitamin D is necessary. Complementary and alternative physicians often end to get their patient's blood levels over 50 ng/mL. This is especially true when treating patients with chronic diseases, including cancer, diabetes and osteoporosis.
In my own practice in Southern California, because the majority of my patients are very busy executives, I find an approximate 80-90% insufficiency of Vitamin D. That is, the patient's blood levels are below 30 ng/mL.
In summary, Vitamin D deficiency is extremely common and affects almost all chronic diseases of the modern world. Please start yourself on 1000 IU of Vitamin D per day and discuss this with your physician. Even better get the blood test and see exactly what your dose should be!