Vitamin D Breakfast of Champions. Chad Deal, MD Head, Center for Osteoporosis and Metabolic Bone Disease Cleveland Clinic
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1 Vitamin D Breakfast of Champions Chad Deal, MD Head, Center for Osteoporosis and Metabolic Bone Disease Cleveland Clinic
2 Vitamin D Primer Majority vitamin D produced in the dermis (D3) UVB exposure Ability to manufacture vitamin D inversely proportional to skin pigmentation (SPF 8) and age Ability to manufacture vitamin D above 35 o N limited Sun exposure can t cause vitamin D toxicity Vitamin D is really a hormone, monokine not a vitamin vitamin when it cannot be synthesized in sufficient quantities by an organism, and must be obtained from the diet. 1-25D crosses cell membrane and nuclear membrane to attach to VDRE in DNA Increases expression of > 200 genes 1-25D increases calcium absorption GI tract, mobilizes calcium from the skeleton (PTH) Decrease in vit D, increases PTH which increases production of 1-25 vitamin D
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4 Skin Color Evolutionary selection of skin color caused by the sun Evolved with loss of pelts to allow for heat dissipation, increased sun exposure darkened skin color Sun produces vitamin D (deficiency decreases fertility) but destroys folate (deficiency causes neural tube defects in pregnancy) 1.2 million years ago all skin was dark and remained so for the next 1.1 million years As humans moved out of tropics all the way to Arctic darkskinned people could not produced vitamin D Estimate about 20,000 yrs to evolve dark to light skin Tanning evolved to protect humans from sun in summer, multiple genes control melanin production
5 Skin Color and Latitude Dark skin Inuit people have high dietary vitamin D
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8 (PERSCRIPTION) (OTC)
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10 Vitamin D and Infection Niels Ryberg Finsen Awarded the Nobel Prize in Medicine and Physiology in 1903 "in recognition of his contribution to the treatment of diseases, especially lupus vulgaris, with concentrated radiation, whereby he has opened a new avenue medical science for disease treatment Darby in 1776 used cod liver oil to treat TB Major cause of death in the rickets epidemics of the late 1800 s was TB Finsen lamp delivered 100IU vitamin D sq/cm = oral dose of 500,000IU Direct effect of UV light on bacterial killing Charpy in 1950 treated pulmonary TB with 1,200,000 IU qwk Streptomycin, INH 1957, vitamin D therapy remained an adjunct Liu 2006 vitamin D upregulated cathelicidin, an antimicrobial peptid which decreases mtb viability in macrophages Liu et al, Science 2006
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12 Disorders Related to Vitamin D Deficiency Heaney RP. Clin J Am Soc Neph 2008;3:1535
13 THE 25(OH)D CONTINUUM deficiency insufficiency normal (ng/ml) 60 (ng/ml) (nmol/l) modified after Heaney
14 Institute of Medicine 2011 Report on Vitamin D and Calcium Requirements RDA: IU/d (covers needs of >97.5%) Ages Serum Levels Tolerable 0-12m : 400IU 20ng/ml IU 1-70yr : 600IU 20ng/ml IU 71+yr : 800IU 20ng/ml 4000IU Why 20ng/ml not 30ng/ml 20ng/ml supports maximal GI calcium absorption PTH plateau ranges from 10-50ng/ml 1% patients with osteomalacia with level >20ng/ml Fracture incidence increased at levels < 20ng/ml
15 Causes of Vitamin D Deficiency Reduced skin synthesis Sunscreen Skin pigment Aging Season, latitude, time of day Decreased bioavailability Malabsorption (GI, GI surgery) Obesity Increased catabolism Anticonvulsants, HAART, antirejection meds Hyperthyroidism Breast feeding Low vit D in milk
16 Causes of Vitamin D Deficiency Decreased synthesis 25OHD Liver failure (>90%) Increased urinary loss Nephrotic syndrome Decreased synthesis 1-25OHD Kidney disease Acquired disorders Primary hyperparathyroidism Granulomatous diseases
17 Vitamin D Primer Treatment 20 minutes sun, 5 minutes in tanning bed generated 5x s vitamin D as 3.5oz salmon Vitamin D3 (cholecalciferol animal based ) more potent than vitamin D2 (ergocalciferol - plant based) Vitamin D2 50,000IU prescription Vitamin D3 400, 1000, 2000, 5000, 50,000IU In calcium supplements
18 Vitamin D and Sunlight Skin Type Fitzpatrick scale UVB exposure 0.5 MED once weekly for 11 weeks II always burns sometimes tans 50% increase = 10ng/ml V never burns always tans Holick MF. Am Soc Neph 2008; 3: 1548
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20 The End
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