Unrecognized Vitamin D deficiancy due to lack of sun exposure

English: Suggested mapping of several bone dis...

English: Suggested mapping of several bone diseases onto a person’s Vitamin D level (as estimated from the serum concentation of calcidiol). Based on Heaney RP (Dec 2004). “Functional indices of vitamin D status and ramifications of vitamin D deficiency Full Text”. Am J Clin Nutr 80 (6 Suppl) : 1706S–9S. PMID 15585791. (Photo credit: Wikipedia)

This child is suffering from malnutrition and ...

This child is suffering from malnutrition and has manifested symptoms of the disease Nutritional Rickets. Note the bowed legs and enlarged right wrist. Nutritional Rickets is a condition in which children’s bones are too soft, and do not develop properly due to a deficiency of vitamin D. (Photo credit: Wikipedia)

Vitamin D Deficiency & Fibromyalgia First published in August and October 2008 in “Renewed and Ready,” a journal for Christians over age 50. Unfortunately it has not survived this economic downturn and is no longer in publication. References are at the very end of Part II. Vitamin D Deficiency – Part I Fibromyalgia’s Relationship to Vitamin D Deficiency Vitamin D Deficiency – Part II Vitamin D Deficiencies: a New Pandemic by Scott Grivas, M.D. and Bonnie Mattheus, R.N. Vitamin D has been much in the news in the last few years as researchers around the world study what it is, what it does, and what health problems occur with insufficient amounts; surprise findings keep coming. Much we thought we knew about vitamin D is now proving to be untrue; many things we never suspected are now proven to be the result this deficiency. But let’s back up. Grandma always told us that vitamin D is the sunshine vitamin. Her remedy to insure we got enough of it was, “Go along outside and play.” Grandma didn’t graduate from college, but she sure was rich in common sense. (Grandmas usually are.) Then research found that, “people who worshiped the sun by sunbathing and being sunburned multiple times have an increased risk of developing skin cancer.” Suddenly our doctors began telling us, “Stay out of the sun and wear sun screen.” That made sense. It really didn’t feel good to be sun burned. And besides, who wants cancer anyway? Meanwhile the American population left the farms in a mass exodus to the industrial cities. Today, few Americans can sustain themselves on the idyllic family farm of yesteryear. There are fewer farms such as the one where Mom grew a wonderful vegetable garden and dad planted huge fields of grain and an orchard of fruit trees. Gone are farms where the family tended the chickens and cows, ate fresh eggs and milk from animals allowed to roam the pasture. It was a farm where virtually no insecticides, pesticides, or chemicals were used. Americans Moved Indoors The city held a very different way of life. Apartment buildings were the cheap housing. The air became polluted from the industries that provided adults with good employment opportunities. Television exploded into homes providing something new and exciting, enticing adults and children to sit inside and watch instead of going outside to work and play. Exercise too was disdained by many. It was replaced by T.V., the computer and the Internet (with their indoor hypnotic influences). With these changes came obesity; a new and major health concern from the Federal level, on down. But let’s get back to the vitamin D connection. There is scientific agreement that vitamin D is essential for life and health, and that its’ production is related to exposure to sunshine. Taking a New Look at Vitamin D Michael Holick, a leading authority on vitamin D, writing for multiple professional journals and the Encyclopedia of Human Nutrition says that the truth about vitamin D is that it is not a vitamin at all. A vitamin is a nutrient that is considered to be a co-enzyme. A co-enzyme isn’t a nutrient itself, but a naturally occurring substance essential in the regulation of metabolic processes. Vitamin D, produced by sunshine, is neither a vitamin nor a nutrient. Ideally sunshine hits the skin converting cholesterol (yes, cholesterol, the stuff with such a bad reputation) into pro-vitaminD, a molecule that can be made by the body into vitamin D. Vitamin D is a steroid hormone that regulates multiple actions at the cellular level, including the maintenance of calcium balance in the human body. Hormones are powerful cell directors. A critical job for vitamin D is to enable the calcium we ingest to be absorbed through the intestines, so the body can use it. Without vitamin D, the body can only absorb thirteen percent of the dietary calcium intake. With sufficient vitamin D, calcium absorption in the body increases up to thirty percent. Generally, this is the best absorption the body can do except during pregnancy, lactation, or growth spurts when absorption can increase up to eighty percent when needed. The changing rates of calcium absorption, due to need, is yet another evidence of the Intelligent Design by a wise, loving, and powerful Creator. The Seriousness of Vitamin D Deficiency The seriousness of the vitamin D deficiency problem depends on which research you look at. But all researchers are finding that vitamin D deficiency is now pandemic in huge proportions all over the world. The farther the population lives from the equator, the less sunshine they receive and the greater the risk of vitamin D deficiency. James Richardson cited many studies in the January 2005 American Family Physician, studies that found deficiency in 21 percent to 58 percent of adolescents and adults in the United States, 54 percent of home bound older adults were deficient, and 84 percent were deficient in elderly black women. The elderly are at increased risk as their skin ages and ceases to be as efficient in converting cholesterol into this essential hormone. The September 2006 journal, Johns Hopkins Advanced Studies in Medicine, cited research that found in the United States fifty-seven percent of all hospital patients tested were deficient in vitamin D. In Europe, up to 100 percent of hospitalized patients were found to be deficient. Yes, vitamin D deficiency is becoming a problem that more and more physicians are recognizing and treating. And it is pandemic (around the world.) Signs and Symptoms Because calcium is essential for nerve and muscle function, as well as bone strength, severe vitamin D inadequacy or deficiency would naturally be expected to result in one or more of the following clinical problems. Rickets in children, resulting in bone deformities. We all knew that here in America, the chances are that we have only seen rickets in pictures. Osteoporosis, lack of bone density. We do have a lot of osteoporosis. In fact, many of us have been diagnosed or have family members diagnosed with it (usually older females). Osteomalacia, defective bone mineralization in adults, associated with bone pain. Numbness and paresthesias (tingling or a sensation of crawling on the skin). Muscle cramps (including “Charlie Horses”). Hypocalcemia (low blood calcium levels) with its resultant problems. Muscle weakness and decreased muscle mass (Sarcopenia). The patient comes to the doctor and says “I just feel so weak.” There may be no other symptoms. Laryngospasm (muscle spasms of the voice box which may impair speech). Tetany, severe sustained muscle spasms, and seizures. Fortunately these are rare. These symptoms are nothing more than manifestations of nerve excitation (irritability) due to insufficient calcium concentrations in the fluids bathing the nerve cells. Secondary hyperparathyroidism. The vitamin D deficiency causes impaired absorption of calcium from the intestinal tract. This leads to lowers serum calcium levels which are recognized by the parathyroid gland. The parathyroid then releases parathormone which draws calcium from the bones to restore calcium levels in the blood. Unfortunately, this depletes bone stores of calcium resulting in osteoporosis. From this sequence, we can see that disease is an effort on the part of nature to correct wrong conditions and preserve the functionality of the organism. Common Look-a-likes Many who are labeled as having fibromyalgia and/or chronic fatigue are turning out to be vitamin D deficient. The original diagnosis may be a misdiagnosis, or there may be more than one diagnosis to deal with. Vitamin D deficiency may account for symptoms of nonspecific musculoskeletal pain. That can be really comforting to people who know that even though they are hurting, and no one can figure out why. It is not all in their heads. Correct diagnosis leads to proper therapy and improved health. In one study of supposedly healthy adults in Minneapolis with persistent, nonspecific musculoskeletal pain found 93 percent of the participants to be vitamin D deficient says Gregory Rouan in September 2006 issue of the John Hopkins Advanced Studies in Medicine. Ninty-three percent is a staggering number. And the problem is now pandemic. Fibromyalgia, Multiple Sclerosis, and Vitamin D Deficiency by Scott Grivas, M.D. and Bonnie Mattheus, R.N. “Almost Sunshine” Vegan Vitamin D sm-bh-vitd2-t105.png ORDER NOW Misdiagnosis of Fibromyalgia and Nonspecific Chronic Pain Dr. James Richardson noted in his editorial in the American Family Physician in Jan. 2005 that “Until Vitamin D deficiency is quite severe, adults who are deficient in vitamin D may have chronic pain and lower extremity weakness. Indeed, women who are deficient in Vitamin D often are misdiagnosed with fibromyalgia or even somatization syndromes.” Add to that what authority Michael Horlick wrote in the American Journal of Clinical Nutrition in 2004, that “more than 90% of 150 (people) who presented with nonspecific muscle aches and bone aches and pains at a Minnesota hospital were found to be vitamin D deficient.” Bonnie Mattheus: My Story But when my story began, I didn’t know the facts above. It would have made me feel better mentally and have given direction to therapy, but I’m getting ahead of myself. Over a year ago I was having a medical visit with my doctor, Scott Grivas. He knew I had been struggling with what had been diagnosed as post-traumatic fibromyalgia, (in other words, after a whip lash injury, the doctor found I was “positive” for pain in 18 of the 18 trigger points used to identify “fibromyalgia”). I have forgotten why I had an appointment that day, but I know it wasn’t for the fibromyalgia. As he went over my symptoms, Dr. Grivas decided to do a test for vitamin D deficiency. Now I’m a nurse, and it was the end of summer. Nearly every day I worked outside in my acre of yard. I had also been ingesting two times the normal MDR (minimal daily requirement) of vitamin D in my multiple vitamin. So, I persuaded Dr. Grivas not to do the test since my risk was so minimal (and I don’t like needles.) Six months later, I had to visit my gynecologist who also focused on preventing and treating osteoporosis. She didn’t discuss, but simply ordered a blood draw; among the tests she ordered was a vitamin D level. To my surprise, when I went back in for the results, she found that I was vitamin D deficient and started me on an aggressive supplementation program. Dr. Grivas had been right! I should have listened to him months earlier and had the test. What he knew, and what I had not thought of, was my older age(which reduces skin efficiency in producing vitamin D). In addition, I live in the northern hemisphere where U.V. sun rays are not very available for large portions of the year.With vitamin D supplementation, my “fibromyalgia” has not completely disappeared, but my pain level has gone down so much I rarely notice it any more. What’s strange is that my allergies are also much less problematic now too. Dr. Grivas’ Turn I recall a couple of rather dramatic cases. A middle aged lady came to me complaining of miserable body aches and pains, with no apparent reason. She had been diagnosed with fibromyalgia. We just couldn’t identify the problem. She could barely get around, and her movement was difficult, with diffuse musculoskeletal aches. I had blood drawn for a vitamin D level test. When the results came back, she had so little that it was almost non-detectable. I supplemented her with an oral vegetable based vitamin D. Her relief was remarkable. Suddenly life took on a whole new meaning for her. A second interesting case was a middle aged female with Multiple Sclerosis who came to see me complaining of weakness, numbness, and tingling of her right arm. After lab evaluation, she was discovered to have coincidental vitamin D deficiency. After vitamin D supplemental therapy, hydrotherapy, and anti-inflammatory herbal agents, she dramatically improved in neuromuscular function. Does she still have M.S.? Yes, but she is so very much better. (Having one diagnosis does not protect us from other diseases or nutritional deficiencies. In fact, it may predispose us to them.) This is particularly true with vitamin D deficiency. As a person becomes sicker, the tendency is to stay indoors. That is when what you really need is to get outdoors into the sunshine. Scott Grevis is the Medical Director for Wildwood Lifestyle Center and Hospital, Wildwood, Georgia. He not only sees patients but is active in teaching physicians in America and around the world . Bonnie Mattheus, a RN, adjunct faculty member of Southern Adventist Univeristy, and president of Bon Herbals and Wonderful Things, Inc. writes from Collegedale, Tennessee. Vitamin D Deficiencies: a New Pandemic Part II by Scott Grivas, M.D. and Bonnie Gibson Mattheus, R.N. Recap and intro: In the first part of this article, vitamin D was noted to be a hormone and not a vitamin at all. Researchers currently find vitamin D deficiency around the world in 20-100% of the population. This is markedly related to where the study was conducted and how much sun gets through at that latitude. Vitamin D is essential for the absorption of calcium, which is, itself, indispensable for nerve and muscle function. Therefore, severe vitamin D deficiency may be associated with osteoporosis and a variety of musculoskeletal (muscle and bone) complaints. Today, many physicians are testing patients suffering with chronic musculoskeletal pain for vitamin D deficiency and are often finding that this is a contributing factor to the pain. For example, “fibromyalgia” and “chronic fatigue syndrome” are often associated with vitamin D deficiency and may improve with sunshine and vitamin D supplementation. Who are the people most at risk for developing Vitamin D deficiency: The fastest growing population group in America: The elderly. The skin loses its ability to synthesize vitamin D by as much as 75% by age 70, Michael Holick reported in 2004. Home bound older adults are particularly at risk, says James Richardson (2005). The chronically ill. As soon as people get sick, they tend to crawl into bed and stay indoors. “Every patient should be taken out-of-doors daily if there is any way possible,” Dr Grivas says. “Get them out-of-doors in the sunshine and fresh air, the true physicians.” Malnutrition. Malnutrition caused by inadequate dietary intake of nutrients, inflammatory diseases of the small bowel or pancreas, resection of the bowel, or by-pass procedures may result in significant deficiencies of calcium and vitamin D. The obese. This is also a group that is growing rapidly in America. The CDC recognizes obesity as a national epidemic and a major health concern. Vitamin D is a fat soluble substance that is accumulated in the large body fat stores making it unavailable for easy utilization. Anyone with limited sunlight exposure: Clothing, sunscreen usage, staying indoors for work and leisure, glass shielding or living above or below the 37 degree latitude either north or south have reduced penetration of the U.V. ray. These all have their effect in limiting sunlight activation of vitamin D precursors in the skin, thus contributing to vitamin D deficiency. (Holick, 2006). Persons with darkly pigmented skin require 3-6 times more sun exposure than fair skinned persons. Michael Holick noted that the person most at risk was the older female, of African-American descent, at the end of winter, particularly if they stay mostly indoors. In the American Family Physician, January 2005, James Richardson, M.D., M.P.H., chief of geriatric medicine at Union Memorial Hospital, said up to 84% of elderly black females are found to be Vitamin D deficient. Persons with a history of kidney or liver disease are at increased risk for vitamin D deficiency because both of these organs play a critical role its manufacture. Those using certain medications such as anticonvulsants (like Dilantin and Phenobarbital), corticosteroids (like Prednisone and Cortisone), Rifampin (a bactericidal, anti- tubercular drug.) Now go back and count how many of these factors apply to you. Any one is a major factor, but if you have several factors, your risk for vitamin D deficiency is multiplied. Other diseases related to vitamin D deficiency: M.F. Holick, PhD, M.D., one of many authors who contributed to the second edition of the Encyclopedia of Human Nutrition, wrote “Essentially every cell and organ in the body requires vitamin D, i.e., they all have a VDR ( a vitamin D receptor).” And that gives us an explanation as to all the other things that research is learning about this amazing essential hormone. In 2006, Holick reviewed 264 published research findings in the Mayo Clinic Proceedings. He concluded that adequate vitamin D levels aide in preventing cancer. That is interesting, as the elderly have the greatest risk of vitamin D deficiency and the highest risk of cancer. Vitamin D deficiency is related to an increased risk of hypertension, cardiovascular diseases, diabetes, psoriasis, and multiple sclerosis. Interestingly, increased risk for multiple sclerosis is also related to a lack of vitamin D during childhood. (5) Apparently adequate sunshine in childhood is protective against this disease which currently has no cure.Vitamin D deficiency is implicated in rheumatoid arthritis, inflammatory bowel disease, systemic lupus erythematosus, osteoarthritis, and periodontal disease. Who would have guessed? But then Holick did say that it was related to “every cell in the body.” How is vitamin D measured? A laboratory test done on the blood can measure the amounts of available vitamin D in the body. Usually it will measure the vitamin D2 and the vitamin D3 to give a combined result of total vitamin D in the blood. Old standards of interpretation considered anything from 20-100 ng/mL was normal. Newer standards are suggesting that a score below 32 is a deficiency, and as always, going for the middle of the range is a good target goal.Dr. Grivas recommends the 40-50 range as a target. Stay in the middle of the road. What can be done about vitamin D deficiency or insufficiency? Sunshine. No doctor’s order is required for the simplest, cheapest solution of all. Get out into the sunshine every day that you can. This will meet the needs of most people. How much sunshine do you need? The old recommendations suggested exposure of the hands and face for ten to fifteen minutes a day. Researchers now suggest that is less than adequate. Michael Holick in 2006 compiled multiple findings and concluded that the arms and legs need to be exposed to sunshine, not just the face and hands. Remember when the skin produces what we need, increased sun exposure does not create Vitamin D toxicity, though sun burn is a risk and should be avoided. Mrs. E. G. White, a health reformer in her day, said over a hundred years ago, “If all our workers were so situated that they could spend a few hours each day in outdoor labor, and felt free to do this, it would be a blessing to them; they would be able to discharge more successfully the duties of their calling. If they have not time for complete relaxation, they could be planning and praying while at work with their hands, and could return to their labor refreshed in body and spirit.” {Gospel Workers, p 240.2} While this applies to vitamin D production, it also applies to much broader beneficial effects of sunshine and time spent out of doors. Nutrition, what you eat, can also be a non-prescription source of vitamin D. However, Dr. Holick noted that very few foods contain Vitamin D naturally. Oily fish such as salmon contains 400 IU per 3.5 oz, cod liver oil 400 IU/teaspoon; and mackerel and sardines have long been recognized as a source of vitamin D. The use of fish products carries its own risk of increased incidence of disease. Irradiated mushrooms are considered a good source. There are some foods fortified with vitamin D. This includes milk, some orange juice, some breads and cereals. Egg yolks have 20 IU (plus cholesterol). Fortified milk has 100 IU per 8 ounces. Some yogurts contain 100 IU per serving. With the increase in BSE (Bovine Spongiform Encephalopathy), also called “mad cow” disease, and its counterpart in the human, CJD (Variant Creutzfeldt-Jakob Disease,) many people feel this dairy source for vitamin D poses too great a risk. Read the labels on foods you buy. As a general rule, dietary availability of this hormone is limited in foods. Further, the labels do not always say which form of vitamin D has been added. Supplementation and prescription vitamin D can be used. We suggest that the source be considered when choosing to use supplements. While vitamin D2 (ergocalciferol) and Vit D3 (cholecalciferol) both lead to increased blood levels of vitamin D, Dr. Grivas recommends the plant-derived vitamin D2 as being the safer product with decreased risk of animal-carried disease. There is some evidence that D3 in the same doses increases 25(OH) Vitamin D (calcidiol) more than D2. However, Dr. Grivas does not feel that the difference is great enough to warrant going to an animal based vitamin D. Linus Pauling Institute at Oregon State University at http://lpi.oregonstate.edu/infocenter/vitamins/vitaminD/ may be of interest if you want to check things out for yourself. It has 100 of the top research articles and is recently updated. How Much? In 2005, Holick felt there was consensus that the range of need for vitamin D was still estimated as 200 IU for infants under 6 months of age up to 600 IU for persons over 70 years of age (average of 400 I.U., regardless of age). He felt that sunshine should be the first thing to try, not oral supplementation. Vitamin D toxicity Vitamin D is considered to be fat soluble and fat stored, creating a potential for toxicity. Toxicity has only been observed when dietary or supplemental intake exceeded daily doses of 5,000 IU over several months, Holick said. Doses of 4000 IU per day for 3 months and 50,000 IU per week for 2 months have been administered without toxicity. Excessive amounts of vitamin D can cause hypercalcemia and hypercalciuria with an increased risk of kidney stones and soft tissue calcification. And again, remember that sunshine produced vitamin D does NOT result in toxicity. 12-9-09 (latest update) The amount of supplementation needed is the object of much research and the amounts that are recommended keep rising. It is an issue of much debate. Today, Dr. Grivas says that you can safely take 2,000 IU every day year round without a doctor to supervise. Many researchers are calling for the MDR (minimal daily requirement) to be raised to 5,000 IU of vitamin D daily. Dr. Grivas feels that if you need to use the higher dosages, that for the sake of safety, a knowledgeable physician should periodically check the blood level of vitamin D and adjust the amounts. Naturally we need more in the winter months in the Northern hemisphere. Look at a map of the United States. Find Atlanta, Georgia. If you live further north than Atlanta, the essential UV rays can’t get to you in winter because of the tilt of the earth. Smog and clouds may also interfere with UV penetration of the atmosphere. Increased clothing for warmth, obviously also covers the skin so that it cannot receive the sunshine and convert cholesterol into vitamin D. In Summary: Vitamin D deficiency is in the differential diagnosis list (you ought to check for it) for persons presenting with diffuse musculoskeletal pain and/or weakness, including a diagnosis of fibromyalgia & chronic fatigue syndrome. Vitamin D deficiency must be suspected in any patient with osteopenia, osteoporosis or bone fragility, in hospitalized patients, and those who are chronically ill. High risk groups include the elderly, those working primarily indoors, and those who are dark-skinned. If you have increased risk for vitamin D deficiency, your doctor can order a blood level to check. Sunshine is the cheapest and usually best method of treatment, as it does not create toxicity. Being outside to get the sunshine has many additional beneficial side effects related to mood and general health. The wise man said “Truly the Light is sweet, and a pleasant thing it is for the eyes to behold the sun” Ecclesiastes 11:7 When you can, go enjoy it. Read the Vitamin D Update in the drop down menu for the latest findings. REFERENCES Holick, Michael F. Vitamin D: importance in the prevention of cancers, type 1 diabetes, heart disease, and osteoporosis. American Journal of Clinical Nutrition, March 2004. Vol. 79,No. 3, 362-371. Holick, Michael F. Sunlight and vitamin D for bone health and prevention of autoimmune diseases, cancers, and cardiovascular disease. American Journal of Clinical Nutrition 2004:80 (suppl): 1678S-1688S. Holick, Michael F. High prevalence of vitamin D inadequacy and implications for health. Mayo Clinic Proceedings. March 2006:81 (3):353-373 Holick, Michael F.(2005), Vitamin D: Physiology, Dietary Sources and Requirements, Encyclopedia of Human Nutrition(2nd ed), Editor-in-chief Caballero, Benjamon et al. Elsevier Academic Press, Oxford, UK Kiefer, David. Vitamin D supplementation to prevent colorectalcCancer. Alternative Medicine Alert, May 2006. 55-59 Lyman, David. Undiagnosed vitamin D deficiency in the hospitalized patient. American Family Physician, Jan. 15, 2005. Vol 71, Number 2, p 299-304 Linus Pauling Institute: http://lpi.oregonstate.edu/infocenter/foods/coffee/ National Institutes of Health: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1115660 Rane, Preeti, et al. John Hopkins Advanced Studies in Medicine. Sept 2006. Vol. 6, No.8, 371-72 Richardson, James P. Vitamin D deficiency- the once and present epidemic. American Family Physician, January 15, 2005. Vol. 71, No 2, p 241-242 White, E.G. (revised 1948) Gospel Workers. Review& Herald Publishing Assoc. Washington, D.C. p 240 Copyright Aug.2008 and Oct. 2008




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