Vitamin D the sunshine vitamin by Dr Aishah Knight

I recently had the privilege of working with a vitamin D scientist while I was on sabbatical at Queen Mary University of London. Vitamin D has recently been in a lot of scientific journal articles where there have been reports of apparent links between certain diseases and low vitamin D levels. It has even been reported that vitamin D researchers were taking extra supplements of vitamin D [higher than the recommended dosage] because they were all convinced about the benefits of vitamin D. The research team that I joined was no exception, every team member was on large dose vitamin D supplements except for the new recruit from Malaysia who thought her vitamin D levels were adequate having come from a land where there is abundant sunshine all year round. However as winter set in and the days grew shorter, I started to take supplements especially as I had succumbed to a bad bout of chest infection about a month after I arrived. After that one period of ill-health, I felt extremely healthy for the rest of my sabbatical despite the hectic schedule; I do not know whether that was simply a coincidence.

What is it about vitamin D that has made all the scientists so excited? The effects of vitamin D deficiency have long been known although at the time the exact disease processes had not been fully elucidated. An ailment affecting children between the ages of 6 months and two and a half years had been described as early as 1645.(2) This ailment was called rickets and the main cause of this in patients whose diet contain adequate calcium and protein intake is vitamin D deficiency. From the 1700s onwards, a spectrum of ailments due to vitamin D deficiency became known as the English Disease as it was common in England.(3) Industrialisation in England led to increasing amounts of smoke spewing from chimneys which blocked the suns rays; furthermore, workers spent long hours indoors compared to agricultural workers who would have been outdoors working on the farm land.(4). However the link between sunshine and vitamin D had yet to be understood and explained at that time.

It was only in 1919 that rickets was artificially induced in dogs and this led to the discovery of Vitamin D which was named by a research group in USA. (2)(4) Vitamin D is a fat-soluble vitamin and it can be stored in the fat stores of our bodies but at any time we can really only store enough of vitamin D to last a few weeks. We get vitamin D whenever we expose our skin to the sun as ultra-violet rays act on a fat molecules in our skin [7-dehydrocholesterol] to produce cholecalciferol [also known as vitamin D3]. We can also ingest vitamin D either as cholecalciferol [vitamin D3] when we eat animal products or as ergocalciferol [vitamin D2] which is produced when ultra-violet rays convert a fat molecule found in plant cell membranes. Good dietary sources of vitamin D are fish liver oils [vitamin D3] and mushrooms or yeasts that have been irradiated with ultra-violet rays [vitamin D2].

There is still a debate whether vitamin D2 or vitamin D3 is better - the effects of either one in our bodies are the same but the time that the vitamin remains in the body is thought to be different. What

is known is that many people in areas that do not get abundant sunshine all year round have low vitamin D levels. During the winter season, areas at latitude above 35N [example: Northern Europe] or below 35S [example: parts of Australia and New Zealand] simply do not get sufficient amounts of ultra violet radiation at land level as the energy has dissipated because the light rays travel longer through the atmosphere due to the angle of the sun. Furthermore, the ability of our skin to make vitamin D deteriorates with age and the colour of our skin also determines the amount of vitamin D that is produced whereby a darker skin is less efficient at producing vitamin D. Customs that limit skin exposure to the sun [such as dress and sun avoidance] will also impact the amount of natural vitamin D that one makes. (5) It is not surprising that even in countries with no vitamin D winter there are pockets of the populations where a lack of vitamin D is common especially among the elderly who not only have skin that produces less vitamin D but may also suffer from mobility problems that limit their sun exposure.
th

Since the latter half of the 20

century we have learnt much more about the biochemistry and

physiology of vitamin D.(6) We now know that the vitamin D that we produce in our skin or consume in our food and drink will be changed by our liver and kidneys into active forms that are responsible for the physiological effects. The active forms are transported to all parts in our blood and thus function like hormones giving rise to the term sunshine hormone. We already know that vitamin D is essential for healthy and strong bones, rickets is the condition that occurs in children if there is a lack of vitamin D or calcium. A lack of vitamin D in adults can give rise to a condition known as osteomalacia which can cause vague aches and pains in bones. Low vitamin D levels have been linked to an increase in the number of falls and hip fractures in the elderly as well as an increase in the occurrence of coughs and colds. Some researchers have suggested that as the active forms of vitamin D has been shown to act on immune cells, a lack of vitamin D can affect the strength of the immune system. This in turn could lead to a higher risk of cancer developing or increasing the severity of any infections because the immune system is not functioning optimally. Exposure to fresh air and sunshine were important in the treatment of tuberculosis in the 19
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century, it was observed that

patients who were treated thus did much better perhaps because their levels of vitamin D were boosted by sun exposure! There were no antibiotics at that time and patients were unlikely to have been cured of the disease but many certainly felt better. More recently researchers have reported links between vitamin D and our mood and it has been suggested that a lack of vitamin D is associated with depression.(7)

Having spent a number of months reading up on vitamin D research and finding scientific articles (810) reporting low vitamin D levels among the Malaysian population, it occurred to me that patients who are receiving palliative care most of whom are elderly, many may have mobility problems, some may be on a limited diet are likely to have low vitamin D levels. One simple way to increase vitamin D levels is to have some sun exposure, failing that an oral supplement of vitamin D in the form of fish liver oil could be taken. The possibility of overdosing on vitamin D is very remote and the possibility of having insufficient vitamin D is quite high. The doses of vitamin D supplement commonly

available in this country is much lower than the amount recommended as the daily intake by vitamin D researchers. References: 1. Mittelstaedt M. Scientists taking vitamin D in droves

http://www.theglobeandmail.com/life/health/scientists-taking-vitamin-d-indroves/article1649132/ 2. Frankenburg FR. Vitamin Discoveries and Disasters, History, Science, and Controversies. Santa Barbara, California : Praeger, ABC-CLIO, LLC, 2009. 3. Glisson F, Bate G, Regemorter A. A treatise of the rickets: being a disease common to children. London : P.Cole, 1651. 4. Feldman D, Pike JW, Glorieux FH. Vitamin D Second Edition. Burlington, San Diego, London : Elsevier Academic Press, 2005. 5. Holick MF, Chen TC, Lu Z, Sauter E. Vitamin D and Skin Physiology: A D-lightful Story . Boston : Journal of Bone and Mineral Research, 2007, Vol. 22. Supplement 2:28-32 6. Holick MF. Vitamin D Physiology, Molecular Biology, and Clinical Applications. New York : Springer, 2010. 7. Berk, M., et al., Vitamin D deficiency may play a role in depression. Med Hypotheses, 2007. 69(6): p. 1316-9. 8. Moy, F.M., Vitamin D status and its associated factors of free living Malay adults in a tropical country, Malaysia. J Photochem Photobiol B, 2011. 9. Khor, G.L., et al., High prevalence of vitamin D insufficiency and its association with BMI-forage among primary school children in Kuala Lumpur, Malaysia. BMC Public Health, 2011. 11: p. 95. 10. Green, T.J., et al., Vitamin D status and its association with parathyroid hormone concentrations in women of child-bearing age living in Jakarta and Kuala Lumpur. Eur J Clin Nutr, 2008. 62(3): p. 373-8.