Issue 136 vitamin d in the uk

PUBLIC HEALTH

VITAMIN D IN THE UK: AN OVERVIEW Emma Berry Associate Nutritionist (Registered)

Vitamin D is an important vitamin which is unique due to its production from sunlight exposure.1 It plays an important role in maintaining calcium and phosphorus levels within the body.1

Emma is working in Research and Development and is a freelance writer of nutrition articles.

Although vitamin D is produced in the skin after being exposed to UVB rays, there are also ways for this vitamin to be extracted from dietary sources. Vitamin D is then converted into 25-hydroxyvitamin D (25(OH) D) by hydroxylation 25(OH)D, before undergoing a further hydroxylation reaction into 1,25 dihydroxyvitamin D (1,25(OH)2D).1 D3 and D2 are the main forms of vitamin D. They are structurally very similar, but D2 has an additional side chain1 which remains during metabolism. Vitamin D3 is produced from skin exposure to UVB rays and some dietary sources, whereas vitamin D2 is provided from dietary sources.

25(OH)D3 can also be found from some dietary sources.1 The richest sources include egg yolk and oily fish, but it can also be found in wild mushrooms, animal meat, animal fat, animal liver and animal kidney.1 In the UK, many foods can also be found fortified with vitamin D, such as some margarines, breakfast cereals and evaporated milks.1

REFERENCES For full article references please CLICK HERE . . .

DIETARY SOURCES

Dietary sources are highly important when sun exposure isn’t possible, for example, due to long office working hours, or if the UVB rays are not able to reach the skin during the winter months.1 The UVB rays can also be influenced by many factors, such as sunscreen use, time of day and season. In the UK, vitamin D can only be produced by sunlight available between late March until September.1 The geographical

latitude also influences vitamin D, so an individual in Scotland will have a different exposure than an individual in Southern England.2 So, the vitamin D produced from sunlight could vary substantially between individuals.

The way that vitamin D is measured may also not be wholly accurate. Serum 25(OH)D is the main measure of vitamin D, as it is believed to reflect the vitamin and is widely used as a biomarker due to its long half-life of approximately two to three weeks.1 However, 25(OH) D concentration may be picked up differently by different assays.1 The measure of serum 25(OH)D concentration would represent a total of 25(OH)D3 and 25(OH)D2, and assumes a linear relationship between vitamin D and serum 25(OH)D.1 This relationship is not always so simple and a curvilinear relationship has been suggested instead.1 In 2016, the Scientific Advisory Committee for Nutrition (SACN) released a review of the vitamin D report originally published in 1991 by the Committee on Medical Aspects of Food and Nutrition Policy (COMA).1 This detailed the importance of vitamin D for health and the new recommended nutrient intake of 10 micrograms per day for all individuals aged over four years.1 This was developed to ensure the majority of the UK population could have an intake which would ensure musculoskeletal health all-year round regardless of location.1 This did not take into consideration the vitamin D produced from sunlight exposure, only intake from dietary sources or supplementation.1 www.NHDmag.com July 2018 - Issue 136

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REFERENCE: 1. Department of Health (1991) Dietary Reference Values for Food Energy and Nutrients for the United Kingdom. Report of the Panel on Dietary Reference Values of the Committee on Medical Aspects of Food Policy. HMSO, London.

NHD0718

Vitamin D is important for calcium and phosphorous regulation within the body.

This means that it plays an important role for musculoskeletal health.

VITAMIN D DEFICIENCY

Vitamin D is important for calcium and phosphorous regulation within the body.

This means that it plays an important role for musculoskeletal health. Deficiency in vitamin D has been linked to numerous musculoskeletal health conditions, such as rickets, as well as other health risks including in pregnancy and cancer.1 Recently, there have been many news articles discussing vitamin D deficiency ranging from an increase in vitamin D deficiency cases in Kent,3 to deficiency awareness and foods to boost intake.4 There have also been articles focusing on a recent study which has linked vitamin D deficiency to an increasing level of abdominal fat.5 The study by Rafiq et al (2018),6 was presented at the 20th European Congress of Endocrinology in May 2018 and carried out a cross-sectional analysis from data collected in the Netherlands Epidemiology of Obesity study. This data contained information from both male and female participants who were aged between 45 to 65 years, with the data adjusted for any perceived biases. They found that there were differences in body fat and vitamin D concentrations with gender. Women were found to have total body fat and fat surrounding internal organs inversely related to vitamin D concentration, whilst, in men, the fat surrounding internal organs and liver fat were related to vitamin D. For both genders, the fat which surrounded internal organs had the strongest association to vitamin D.6 This abstract by Rafiq et al was not the only study to discuss the relationship between obesity and vitamin D levels. A study by Athanassiou et al (2018)7 also explored the relationship between vitamin D and obesity, but established that morbidly obese patients were shown to have lower levels of vitamin D. They found that as BMI rose, the vitamin D levels decreased. The relationship between obesity and vitamin D deficiency is well documented, with a recent

systematic review and meta-analysis having a similar finding.8 With reports of an increasing level of obesity since the 90s,9 is this something that needs to be investigated as a growing public health concern?

HOW TO INCREASE VITAMIN D?

Although the relationship between obesity and low vitamin D levels hasn’t been fully researched, there are many groups which could benefit from increasing levels of vitamin D. From the SACN report,1 it is believed that the majority of adults will reach sufficient vitamin D levels. However, during the winter, all adults should consider taking a 10 microgram supplement of vitamin D.1 The report has also outlined that there are some special considerations: individuals who remain mostly indoors, or covered in clothes, should consider taking a supplement all-year round.1 Individuals from minority ethnic backgrounds with darker skin are also advised to take a supplement of vitamin D all-year round.1 Although supplementation is suggested for most people at some point during the year, these supplements can be costly. One high-street provider offers these supplements at a charge of over £8 for 250 x 10mg tablets (price correct as of 11th June 2018).10 Although there are some groups which could access the supplements for free, the majority of the public would have to pay. This creates an unbalanced health equality, as many might not be able to afford such supplements. Therefore, it would be beneficial to find a way to increase vitamin D levels without adding additional costs to the public.

One suggestion of a way to increase vitamin D concentrations would be the fortification of foods. Although there are dietary sources of vitamin D, it would be very difficult to achieve the RNI through diet alone. However, there www.NHDmag.com July 2018 - Issue 136

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PUBLIC HEALTH have been numerous studies discussing the fortification of food to increase vitamin D intake within the population. Margarines were at one point required to be fortified with vitamin D, but this is now no longer mandatory.11 Yet, fortification of margarine has the potential to be one of the major dietary contributors of vitamin D intake. A simulation study of the Netherlands, UK and Sweden found that fortified margarine could contribute up to 35% of daily vitamin D intake.12 In the UK, milk and milk products have been suggested as a food group which could be fortified with vitamin D, as it is in other countries. This may have a greater impact on vitamin D levels, as a large percentage of the UK population consume milk. However, this alone would not be enough to meet the recommended RNI.12 TOO MUCH D!

Although it is important to ensure that individuals are reaching the right levels of vitamin D, to reduce the risk of deficiency and associated diseases, it should be noted that there are risks to having too much vitamin D. It would be hard to overdose through diet or sunlight, but, nevertheless, taking too many vitamin D supplements for a long time could result in

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hypercalcaemia.1 We need to ensure that any fortification of foods and supplementation recommendations still keep the general population within a safe range of vitamin D. CONCLUSION

Vitamin D is an important micronutrient which has an impact on human health. Both excessive vitamin D and a lack of it can result in serious problems. However, individuals who are classified as obese are found to have a lower level of vitamin D. This requires further investigation to determine if this is a result of being obese, or if there are other factors involved.

There are various groups within the population at a higher risk of deficiency.

The recent SACN guidance encourages supplementation for all adults over the winter, but certain ‘at risk’ groups are advised to supplement all-year round. This guidance doesn’t take sunlight derived vitamin D into consideration, which seems appropriate given the variation that is likely between individuals.

However, supplementation may not allow all individuals an equal opportunity for health.

Food fortification may provide a better way to reach a larger range of the population, but this would need to be investigated further.

NHD CPD eArticle

icle eArt Although the adult level of obesity NHD CPD looks to still be increasing, childhood obesity seems to be holding steady.

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