Public Health Consequences of Vitamin D Deficiency

Despite the earlier belief that these classical defiency diseases had been eliminated, the surprising increase in incidence of rickets and osteomalacia places the burden on society to be ever more vigilant in assessing for vitamin D deficits. Two obvious explanations exist for the rise in vitamin D deficiency in the US: reduced consumption of vitamin D-fortified milks and reduced skin exposures to sunlight because of greater indoor activities. The deficit in vitamin D has possibly even greater consequences as the average age at death is extending in our populations. Low vitamin D intakes in later life, often coexisting with low dietary calcium, may increase the risk of osteoporotic fractures.

Supplements of vitamin D (400 IU or greater) are recommended for the elderly by health professionals in order to ensure adequate intakes, but even higher amounts are considered safe. The tolerable upper level of safety (UL) established in the US by the Institute of Medicine has been set at 50mgday-1 (equivalent to 2000IU day-1). Supplemental vitamin D becomes increasingly important as skin biosynthesis capability declines with age. Oral capsules of vitamin D containing up to 100 000IU have been found to be safe and effective in reducing fractures. An alternative approach is injection of a depot of vitamin D (-200 000 IU) in the late autumn for slow release over the winter months when sunlight, especially UV-B, is limited or unavailable.

Rising Prevalence of Rickets

The increase in rickets in the US is occurring primarily in African-American and Hispanic children who have gone off breast-feeding and are not getting sufficient calcium and vitamin D in their diets. This problem has been more common in the southern US despite greater availability of sunlight. In large part, rickets is an educational issue that requires input from both medical and public health professionals.

Rising Prevalence of Osteomalacia

The increase in low serum 25(OH)D3 found in so-called ordinary adults in a hospital survey of surgical patients in Massachusetts opened the eyes of health authorities who did not expect to find such low blood concentrations, which indicate future osteomalacia and also osteoporosis. This evidence suggests that many adults in the US are not consuming adequate amounts of vitamin D and calcium in their usual patterns of food selection and that supplementation of these two nutrients is probably inadequate among adults. Low intakes among the elderly result from the same type of eating pattern, but typically with even lower caloric consumption (see below).

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