Running head: VITAMIN D DEFICIENCY Vitamin D Deficiency Ernesto Garcia Abstract, Literature Review, Formatting Angela Gomez Summary, Literature Review, Editing Emily Montes Introduction, Literature Review, Revising Valerie Obarski Description of Population, Literature Review, Proofreading NTRS 417 B Winter Quarter 2015 California State University, Los Angeles
VITAMIN D DEFICIENCY 2 Table of Contents Abstract..3 Introduction 4 6 Literature Review...7 9 Description of Population of Interest.10 Summary/ Overview of Proposed Work...10 Reference List 11 12 Appendices 13
VITAMIN D DEFICIENCY 3 I. Abstract Vitamin D can be the most easily absorbed vitamin because it requires daily limited sun exposure. It is easy to obtain naturally without supplementation yet we find a prevalent deficiency in regions north of the equator where there is limited sunlight and shorter days. In particular, there is a high vitamin D deficiency in the elderly population which can be due to even more limited sun exposure. Many elderly people are placed in institutions such as nursing homes or hospitals where they are kept indoors for recreational activity. This is problematic because it can cause osteomalacia or osteoporosis and cause falls or fractures. Dietary supplementation is then required amongst the many other vitamins and nutrients that they may be lacking. In order to help rid this deficiency and limit supplementation in this population, we can control variables such as promotion of direct sun exposure through creating outdoor activities. Obtaining direct sunlight on the arms and legs for a minimum of fifteen to a maximum of twenty minutes, every day will be sufficient in obtaining enough vitamin D. Consumption of fortified foods will also be incorporated along with education on recommended foods as a good source of vitamin D. These variables will help increase vitamin D synthesis in the body in elders, but will still require some supplementation of it to a lesser extent. The impact of this initiative is applicable to all elderly persons as well as others who are deficient in vitamin D.
VITAMIN D DEFICIENCY 4 II. Introduction A. State the problem: Vitamin D deficiency is more prevalent in cities located at higher latitudes as well as, cities that are greatly exposed to air pollution and a cities where citizens are less exposed to ultraviolet radiation which is utilized for dermal production (Chao al et., 2013) (Naugler al et., 2013). High latitude countries such as Canada experience this issue resulting from winter climate changes between months of November through March where citizens experience less sun exposure (Mithal al et., 2009). Elders experiencing less sun exposure places them at a disadvantages because 80 90% of the needed vitamin D is obtained from solar ultraviolet B radiation that is synthesized in the body (Naugler al et., 2013)(Yan al et., 2014). Elders who are hospitalized, housebound or have disabilities spend limited amount of time outdoors which affect vitamin D levels (Mithal al et., 2009). B. State your aims: i. Goals: Our main purpose is to reduce Vitamin D deficiency amongst the elderly population who are at higher risk due to immobility, decreased sun exposure and whom suffer weakened bone related injuries due to this deficiency. By educating Canadian elders on vitamin D specific food sources, its importance and its function within the body, we can stress the severity of vitamin D deficiency. Vitamin D presentations, food demonstrations, one on one counseling, and flyers can be used to disseminate information on increasing vitamin D levels amongst the elderly population with sedentary lifestyles, and reduced sun exposure in order to improve their bone health and decrease injuries.
VITAMIN D DEFICIENCY 5 ii. Expected Outcomes Educating elders about the importance of vitamin D we expect that elders will recognize the necessity that s involved in including vitamin D into their daily diet. By explaining the risk factors related to osteoporosis, bone fractures, sarcopenia and other bone related disease we hope that elders incorporate vitamin d by increasing their vitamin d consumption by including non fortified and fortified foods and lastly increase their exposure to sunlight. iii. Expected Impact: Implementing educational programs to elders and in the near future to children and adults regarding vitamin D will aid in reducing the prevalence of vitamin D deficiency worldwide. These changes can help other countries avoid vitamin D deficiencies which in return eliminates factors that are associated with other bone related diseases. iv. Objectives: Conduct bi yearly Vitamin D serum testing, once in April which would determine the baseline and once again in November which would indicate the levels before entering winter. Testing would help determine if elders could benefit from vitamin supplementation. If extra supplementation was needed, we can propose all elderly patients to supplement accordingly to the RDAs specifications. Encourage outdoor activities such as walking, sitting, or playing board games outside in direct sunlight for at least 15 minutes 3 4 times a week to obtain natural Vitamin D from the sun.
VITAMIN D DEFICIENCY 6 Encourage consumption of foods high in Vitamin D or foods that are fortified to boost deficient levels. We would educate elders on the benefits of consuming multiple sources of Vitamin D containing foods in their diet: salmon (3 oz.), tuna (3 oz.), shiitake mushrooms (3 oz.), egg yolks (1 2), fortified yogurt (6 oz.)/milk (1 cup)/cheese (1 oz.) and fortified orange juice (1 cup). Enforce strict federal monitoring of fortified food and ensure that fortified products are advertised and properly labeled to help elders indicate the presence of added vitamin D. For example milk needs to be fortified by Canadian Law to contain 35 40 IU per 100 ml. We would also educate elders on reading and interpreting nutritional facts labels in order to help them determine if specific food items provide adequate levels. Ex: If 1 cup of milk contains 25% of the Vitamin D and the required amount of Vitamin D in IU for elderly is 600 IU 800 IU: then the 1 cup of milk would have 150 IU 200 IU. C. Search Criteria for III: Inclusions: French/English language, older than 50, male and female, community dwelling individuals, multicultural, residing in Canada, and articles within last 5 years. Exclusions: Children/Pediatric, languages other than French/English, under age 50, residing outside Canada and articles older than 5 years. Databases used: Ageline, Cochrane Library, MEDLINE, and Pubmed. Keywords: Vitamin D, Vitamin D deficiency, Canadians, elderly, seniors, osteomalacia
VITAMIN D DEFICIENCY 7 Critical appraisal plan: First, reviewed the articles and checked for appropriate keywords, databases, inclusions, and exclusions. Second, reviewed the abstract in the articles in order to tell if article contained information needed for research. Lastly, reviewed results and/or discussion to determine if studies pertained to our specific population. III. Literature Review Normal Vitamin D levels: Currently, the Institute of Medicine has a normal range at 50 nmol/l, while anything below would be considered hypovitaminosis D or vitamin D deficiency. Although the Endocrine Society, the National Osteoporosis Foundation and Osteoporosis Canada believe the normal range should be set at 75 nmol/l, 25 nmol/l from the Institute of Medicine (Ginter al et., 2013). Vitamin D synthesis in the skin: Vitamin D synthesis in the skin from solar ultraviolet B radiation accounts for 80 90% of the needed Vitamin D needed in the body(naugler al et., 2013)(Yan al et., 2014). Cultural behavior as well as skin color provide additional obstacles for obtaining Vitamin D from the sun. Melanin, the main skin pigment, varies from people of different origins. When comparing dark skinned individuals to light skinned individuals exposed to equivalent UV lights, dark skinned individuals created less vitamin D than light skinned individuals. Therefore dark skinned individuals would be required to spend more time outdoors in direct sunlight (Ginter al et. 2013) (Mithal al et. 2009). Age related Vitamin D malabsorption: As adults age, their ability to transform cutaneous products of vitamin D3 into vitamin (25)OH D reduces. Additionally, elderly people spend a significant amount of time indoors which decreases their exposure to sunlight. On comparing
VITAMIN D DEFICIENCY 8 vitamin D levels from adults to elderly, it is found that elderly have lower amounts of vitamin D compared to adults located in the same location (Mithal al et., 2009). Diseases associated with Vitamin D deficiency: There is a positive relationship between Vitamin D status and muscles strength. Sarcopenia is a disease which affects skeletal muscle wasting in association with aging, and is enhanced with poor nutrition, limited physical activity and risk factors; these all lead to the risk of falls and fractures. It has been found that patients with higher levels of serum 25(OH)D performed faster on a 8 foot walk and five chair stand test compared to patients with low serum 25(OH)D. Higher levels of vitamin D were obtained through supplementation of Vitamin D; patients also showed overall improvement in muscle strength and hip bone density. Adequate Vitamin D in association with appropriate dietary protein and resistance training are all ways of keeping muscles and delaying effects of sarcopenia (Mithal al et. 2009). Vitamin D deficiency is associated with low bone mineral density which heightens the risk for osteoporotic fracture. Studies have shown that serum 25(OH)D between 40 90 nmol/l is associated with higher bone mineral density and decreases risk for hip and nonvertebral fractures. It appears that supplement of 20 mcg (800 IU) of vitamin D in combination with calcium can bring elderly patients up to these levels. Vitamin D in the diet: In Canada dietary sources of vitamin D are found in fish and eggs, whereas milk and margarine are fortified with vitamin D. In one study, Canadian aboriginal communities who were normally low in serum 25(OH) D that ingested local fish 2 or mores times a week or consumed 5 or more serving of milk per week reported significantly higher vitamin D intakes during winter and summer (Slater et al, 2013).
VITAMIN D DEFICIENCY 9 Locations affect on Vitamin D : Vitamin D deficiency is seen in cities located at higher latitudes, exposed to air pollution, or excess cloud cover, and in higher latitudes where less exposure to ultraviolet radiation is available for dermal production (Chao al et., 2013) (Naugler al et., 2013). Studies have shown low serum 25(OH) is greater in winter months (November to March) for all age groups in Northern America. The elderly population including hospitalized, institutionalized, housebound and those with disabilities have limited time spent outdoors which further hinder vitamin D status (Mithal al et., 2009). Vitamin D and socioeconomic status: According to the studies, income has a minor association with serum 25(OH) D levels whereas post secondary education seen in the elderly represent higher serum 25(OH) D through supplementation (Naugler al et., 2013). Vitamin D and risk factors: Smoking, obesity and gender are all associated with increased risk of vitamin D deficiency. A vitamin D supplement was the strongest risk factor in changing levels of 25(OH)D (Chao al et. 2014). Gaps in research of appropriate dose related levels to specific disease is still needed. Currently, there is only estimated intake provided to prevent severe deficiency states (Hanley al et. 2010). Studies have revealed that institutionalized groups of elderly people are more at risk for Vitamin D deficiency compared to the healthier elder population. This is thought to be the case because they are not receiving supplement or exposure to UVB light like the non institutionalized group of elderly people (Barake al et., 2010).
VITAMIN D DEFICIENCY 10 IV. Description of Population of Interest A. i. Elderly Canadian men and women ii. Canadians are exposed to environmental factors such as higher latitude, less sunlight exposure and long winter seasons. The elderly population spend less time outdoors due to limited mobility or chronic disease. Elderly populations are more likely to suffer from age related disease such as osteoporosis, sarcopenia, fracture and decrease muscle strength. V. Summary/ Overview of Proposed Work A. This initiative is important because it will help the elderly population in reducing their risk of bone demineralization which can cause osteomalacia or lead to osteoporosis. It will also help reduce the amount of supplementation of vitamin D and will provide a more natural exposure and synthesis of it. Although the skin in elderly synthesizes vitamin D less, increasing sun exposure from almost none to some will still assist in its absorption. B. Vitamin D is an important nutrient in the body because it also works with calcium absorption to help maintain bone health. Therefore, it is important to remain sufficient in this nutrient to help sufficiency of calcium. C. This proposal will help contribute to improving the health status of elders because it will decrease the risk of falls and fractures by also decreasing the chances of bone conditions such as osteomalacia. Education on foods high in vitamin D will also contribute to an increase in vitamin D status and absorption which will lower the amount of persons suffering a vitamin D deficiency.
VITAMIN D DEFICIENCY 11 VI. Reference List (APA format) Baraké, R., Weiler, H., Payette, H., & Gray Donald, K. (2010). Vitamin d status in healthy free living elderly men and women living in quebec, canada. Journal of the American College of Nutrition, 29 (1), 25. Chao, Y., Brunel, L., Faris, P., & Veugelers, P. (2013). Vitamin d status of canadians employed in northern latitudes. Occupational Medicine (Oxford, England), 63 (7), 485. Chao, Y., Ekwaru, J., Ohinmaa, A., Griener, G., & Veugelers, P. (2014). Vitamin d and health related quality of life in a community sample of older canadians. Quality of Life Research, 23 (9), 2569 2575. Ginter, J., Krithika, S., Gozdzik, A., Hanwell, H., Whiting, S., et al. (2013). Vitamin d status of older adults of diverse ancestry living in the greater toronto area. BMC Geriatrics, 13, 66 131. Hanley, D., Cranney, A., Jones, G., Whiting, S., Leslie, W. (2010). Vitamin D in adult health and disease: guideline statement from Osteoporosis Canada. Mithal, A., Bonjour, J., Boonen, S., Burckhardt, P., Degens, H., et al. (2013). Impact of nutrition on muscle mass, strength, and performance in older adults. Osteoporosis International, 24 (5), 1555 1566. Canadian Medical Association Journal, 182(12), 1315. Mithal, A., Wahl, D., Bonjour, J., Burckhardt, P., Dawson Hughes, B., et al. (2009). Global vitamin d status and determinants of hypovitaminosis d. Osteoporosis International : A
VITAMIN D DEFICIENCY 12 Journal Established as Result of Cooperation Between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA, 20 (11), 1807 1820. Naugler, C., Zhang, J., Henne, D., Woods, P., & Hemmelgarn, B. (2013). Association of vitamin d status with socio demographic factors in calgary, alberta: An ecological study using census canada data. BMC Public Health, 13 (1), 316. Slater, J., Larcombe, L., Green, C., Slivinski, C., Singer, M., et al. (2013). Dietary intake of vitamin d in a northern canadian dené first nation community. International Journal of Circumpolar Health, 72, 1 8. Yan, J., Liu, L., Roebothan, B., Ryan, A., Chen, Z., et al. (2014). A preliminary investigation into diet adequacy in senior residents of newfoundland and labrador, canada: A cross sectional study. BMC Public Health, 14 (1), 302.
VITAMIN D DEFICIENCY 13 VII. Appendices A. No appendices available.