Ariella Krapin

NTR 403

Research Article Summary

Spring 2016

Cystic fibrosis (CF) is an inherited, life threatening disease in which a defective

gene causes a thick buildup of mucus in the lungs, pancreas, and other organs. Along
with symptoms such as persistent lung infections and breathing limitations is the
increased frequency of fat mal-absorption due to pancreatic insufficiency. Thus, fatsoluble vitamins such as vitamin D are commonly deficient in those with CF. The article
Sunlight is an important determinant of Vitamin D serum concentrations in cystic
fibrosis explores this deficiency and hypothesizes the best possible treatment. In 2011,
this article was published in Belgium by the European Journal of Clinical Nutrition.
The articles purpose is to investigate the role of sunlight exposure (as oppose to
supplements) as an essential factor in the 25(OH) D levels of those with CF.
Additionally, the article compares these effects of sunlight on 25(OH) D with CF to
healthy people, along the same time span and time of year. Providers treating those with
CF may overlook the usefulness of their patients gaining vitamin D from sun exposure,
given that solely supplements are not effective due to mal-absorbed vitamin D in these
patients. The article strives to decrease the prevalence of bone fractures in those with CF
as well.
In this study, a total of 474 serum 25(OH) D concentrations were measured from
141 CF patients. Blood samples were taken and then 25(OH) D was extracted from the
samples by a radioimmunoassay technique. The results were specifically compiled over
the course of four years, at annual follow-up visits, between October 2001 and December
2005 at the Ghent University Hospital. Patients of every severity of CF were admitted
into this study and no transplanted patients were included. The median age was 15.6
years and fifty six percent of the patients were male. Fecal elastase, one measurement at
the hospital, determined that ninety one percent had pancreatic insufficiency (resulting in
fat mal-absorption), and were being treated with pancreatic enzyme replacement therapy
(PERT). Daily vitamin D supplements were prescribed to patients although not the focal
point of the study, and patients did not take them regularly. Healthy people with a median
age of twenty years were measured and served as a control. The control data was

compared for the CF data during the months of low UVB exposure (NovemberDecember).
These results determined that the lowest values of the 25(OH) concentrations of
those with CF were in February. Overall, the median 25(OH) concentrations during
months of high UVB exposure (May to October) were substantially higher than those in
the months with low UVB exposure. In comparison to the 25(OH) concentrations to those
of healthy peers, no significant difference was found during the low UVB exposure
months. Similarly, during the high UVB exposure months, the experimental values were
inferior to the control with no statistical significance. Over the course of four years, the
CF patients data regarding 25 (OH) D concentrations ran parallel with UVB exposure
noted from the previous 2-3 months.
When one is initially exposed to sunlight as a source of vitamin D as in the article,
UVB rays interact with 7-dehydrocholesterol in our skin due to its presence of conjugated
bonds that enable sunlight to absorb into the skin. The compound 7-dehydrocholesterol is
a steroid specifically synthesized in the sebaceous glands of the skin and secreted onto
the skins surface for it to be reabsorbed into its different layers. Due to some of 7dehydrocholesterol absorbing UVB photons, pre-vitamin D3 is synthesized. The process
of thermal isomerization steroid forms the cholecalciferol version of vitamin D (D3).
When one is metabolizing dietary vitamin D in the body, it is initially absorbed by
micelles in conjunction with fats since no digestion is required. Bile salts trigger dietary
vitamin D (D2 or D3) to be passively diffused into intestinal cells. The majority of
Vitamin D is absorbed in the distal small intestine. Once Vitamin D is absorbed, about
forty percent of it is incorporated into chylomicrons for transport. At this point,
cholecalciferol or D3 (earlier stated to form via thermal isomerization in the skin) as well
as ergocalciferol or D2 are diffused into the bloodstream. They are picked up by the
vitamin Dbinding protein (DBP) for transport via the bloodstream and into the liver. In
the liver D2 and D3 are converted to 25-(OH)-D3 or calcidiol with the enzyme 25hydroxylase and the coenzyme NADPH. Calcidiol is then secreted into the bloodstream,
its main storage site, and transports via DBP to the kidneys. In the kidneys, calcidiol
converts to its active form, calcitriol or 1,25-(OH)2 D. Target tissues take up this active
pro-hormone form as it travels in the blood via DBP.

Vitamin D influences the pathway of calcitriol hydroxylation as well as calcium and

phosphorus homeostasis.
I would not necessarily say that this study would be useful in the reconsideration
of dietary recommendations of vitamin D. This study is not addressing a specific
numerical adjustment to the RDA, but rather the best way to attain an RDA. Further
studies are required in order to measure adequate Vitamin D in CF; only at that time
could the RDA be reevaluated.

References
About Cystic Fibrosis. Cystic Fibrosis Foundation. Retrieved 2016-03-28.
Robberecht, E., Vandewalle, S., Wehlou, C., Kaufman, J. -., & De Schepper, J. (2011).
Sunlight is an important determinant of vitamin D serum concentrations in cystic
fibrosis. European Journal of Clinical Nutrition, 65(5), 574-9.
doi:http://dx.doi.org/10.1038/ejcn.2010.280