Vitamin D:

Evaluating the Adequacy of the Current RDA

Ian Lind, Marissa Potente, Katherine Ratlif
Introduction
In 2011 the RDA was established for vitamin D, tripling that of the previous AI from 200 IU to 600 IU for adults
age 19-70 (1). This RDA is based on the serum levels of 25 (OH)D that would prevent vitamin D deficiency and
maximize bone health (1). A serum level of 20 ng/mL of 25 (OH)D or above was considered sufficient, while
levels below 10 ng/mL were considered insufficient (2). Determining vitamin D status in regards to serum
levels involves analyzing sun exposure, BMI, age, and skin pigmentation (2). The primary source of vitamin D
for most individuals comes from cutaneous synthesis of UV-B irradiation. Food sources of vitamin D include
fatty fish, egg yolks, and fortified foods such as milk, orange juice, and breakfast cereals (3). Vitamin D has
been implicated for its benefits on both bone and neuromuscular health (3,4). However, the functions of
1,25(OH)2D, the biologically active form, extend far beyond these two benefits. Other cells expressing the
vitamin D receptor may also be influenced by 1,25-dihydroxyvitamin D (3). These include skeletal muscle,
breast, colon, prostate, and heart. Evidence suggests that vitamin D may play a role in immunomodulation,

Considerations for Increasing the RDA

When researching the efects of vitamin D on extra-skeletal health, it becomes clear that the serum level of
25(OH)D deemed sufficient by the IOM is not what is most often shown to optimize extra-skeletal health. In fact, a
common theme among this research is that attaining a level >30 ng/mL is optimal (1,6,7). In a prospective study
of >41,000 subjects followed for an average of 1.3 years, there was a significant correlation between vitamin D
status <30 ng/mL and risk of hypertension, hyperlipidemia, diabetes, and peripheral vascular disease (p <0.0001)
(7). Some of the mechanisms for such improvements in health attributed to vitamin D are inhibition of the reninangiotensin system, improved insulin secretion and sensitivity, inhibition of vascular smooth muscle proliferation,
protection of endothelial cell function, and regulation of inflammation (8). Interestingly, both Holick and BischofFerrari present data indicating that even for bone health, levels of 25(OH)D >30 ng/mL are necessary to optimally
reduce osteomalacia and increase overall bone mineral density (1,6). In addition, Bischof-Ferrari argues that
reducing fall-risk in older adults, via muscular health and balance, begins with at least >24 ng/mL, and prevention
of fracture increases most significantly at >30 ng/mL (6). Finally, it is clear that the current RDA is insufficient to
reach serum levels of >30 ng/mL of 25(OH)D (1,6,9). For example, in a study conducted in Toronto in winter,
supplementation of 4000IU/d for >1 month only brought 88% of the cohort, made up of healthy young men and
women, to >30 ng/mL 25(OH)D (6). Therefore, to achieve maximal biological activity of vitamin D, it is suggested
that a serum level of > 30 ng/mL of 25(OH)D be used to determine adequacy and that the RDA be increased to
match this new level.

Considerations for Maintaining the RDA

Serum levels of 25(OH)D are associated with bone health and according to the IOM the optimal serum level is 20
ng/mL (2). To determine the efect of the current RDA reccommenditons on serum 25(OH)D and skeletal health in
post-menopausal women a double blind dose response trial was conducted. Women were randomly assigned to 1
of 7 vitamin D3 doses ranging from 400 IU-4800 IU. The results showed that 97.5% of women were able to achieve
serum 25(OH)D levels of 20ng/mL with doses of 400 IU-800 IU. The results from this study show that the IOM
recommendations for vitamin D are able to achieve serum levels high enough to optimize bone health (2). The IOM
has not taken into account the efects of vitamin D status on extra-skeletal health because current research has
been inconsistent and optimal serum levels cannot be determined (2).
Although there has been studies that show low 25(OH)D levels are associated with cardiovascular disease
and diabetes there has been no determination of a causal relationship from several randomized trials and
treatment with high dose vitamin D has shown little efect on lipid and A1c levels (10). A double blind randomized
placebo controlled trial was conducted to determine the efect of vitamin D supplementation on HbA1c, and serum
lipids levels (10). The experimental groups took vitamin D supplements of either 10ug or 25ug daily for sixteen
weeks. After sixteen weeks the experimental groups average 25(OH) D levels increased to 20 ng/mL (p=0.0001),
but there was no diference seen in HbA1c, total cholesterol,
LDL, HDL, and triglyceride levels (10). Also, high dose
Conclusion
The current RDA is based on a serum level of vitamin D that prevents osteomalacia (1). No extra-skeletal benefits
were taken into account when determining vitamin D adequacy. Given the evidence suggesting the efficacy of
vitamin D beyond skeletal health, it is pertinent that we reconsider the serum level of 25(OH)D required to
maximize the biological activity of vitamin D. As the proportion of our population that is older and/or overweight
continues to rise, both of which predicate a higher vitamin D intake (9,12) and are associated with greater risk of
disease, it is of the utmost importance that we reevaluate the RDA necessary to optimize health, particularly as
it pertains to extra-skeletal health.

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