Vitamin D Status

The Importance of Getting It Right

dr. Arti Indira, MGizi, SpGK, FINEM
IG @dr_artiindira
 Vitamin D History

Mid 1600s :Rickets identified as major health problem

1822 : First published observation that lack of sun exposure could
be the cause of rickets
1824 :First report on the use of cod liver oil to prevent rickets
1922
• McCollum coined term “vitamin D” to describe antirachitic factor
in cod liver oil
• Antirachitic properties of UV light demonstrated in rats

Mozolowski W. Nature. 1939;143:121–124

McCollum EV. J Biol Chem. 1922;53:293– 312
 Vitamin D History (2)

1927
• Quaker Oats begins manufacturing vitamin D enriched cereals
• Pharmaceutical companies begin to manufacture a product
called Viosterol (irradiated ergosterol)
1934 and on…
• Irradiation used to produce vitamin D enriched milk
• Eradication of rickets

SOLAR Ultraviolet Radiation AND Vitamin D. Am J Public Health. 2007 October; 97(10): 1746–1754.
 Rickets

• Mineralization defect
Hypertrophy of Chondrocytes (cartilage)
• Short stature
• Bony deformities
• In children: bowed legs
defects in rib cage
 Vitamin D

• Vitamin D3 = Cholecalciferol
Produced in animals
• Vitamin D2 = Ergocalciferol
Derived from a precursor found in plants and mushroom
Holicks M. J Clin Endocrinol Metab, July 2011, 96(7):1911–1930
 Factors Affecting Absorption

Maurya VK.J Food Sci Technol (November 2017) 54(12):3753–3765

 Vitamin D Level

<50 nmol/L 75nmol/L 250 nmol/L

 IOM Guidelines
• Not intented to direct
physician on care of
patients
• It is up to professional
associations to establish
guidelines for care
• Used a population model,
not a medical model
Objective:
The objective was to provide
guidelines to clinicians for the
evaluation, treatment, and
prevention of vitamin D
deficiency with an emphasis
on the care of patients who
Holicks M. J Clin Endocrinol Metab, July 2011, 96(7):1911–1930 are at risk of deficiency
Wacker M. Nutrients 2013, 5, 111-148 ad
 Vitamin D

Nutrients 2014, 6, 4472-4475;

Antonucci P. J Pediatr Endocrinol Metab 2018; 31(3): 247–260
 Indonesia

J Indon Med Assoc, Volum: 69, Nomor: 2, Februari 2019 Jurnal Penyakit Dalam Indonesia | Vol. 2, No. 1 | Januari 2015
 Risk of Vitamin D
Deficiency

Amrein, K. Eur J Clin Nutr (2020).

 Food Sources

Holicks M. Rev Endocr Metab Disord (2017) 18:153–165

 Sun Exposure

Ichihashi M. Anti-Aging Medicine 6 (6) : 46-59, 2009

Sun Exposure
 Sun Exposure

McKenzie RL. Photochemistry and Photobiology, 2009, 85: 88–98

 Sun Exposure

Chen TC. Arch Biochem Biophys. 2007 April 15; 460(2): 213–217
 PERDOSKI SATGAS COVID-19
• Berjemur untuk orang Indonesia dewasa pukul 09.00 (UVI 5-6)
selama 5-15 menit, 2-3 kali seminggu)
• Berjemur dengan kedua lengan, tungkai, hindari area kepala dan
leher

Ibu Hamil à suplementasi ?

Judistiani et al. BMC Pregnancy and Childbirth (2019) 19:209

 Supplementation Vitamin D

Garland et al: Anticancer Research 31: 607-612 (2011)

Treatment Recommendations for Vitamin D Deficiency

Lee. JACC Vol. 52, No. 24, 2008

 Vitamin D Toxicity
normal range
8.4–10.2 mg/dL

Galior, K. Nutrients 2018, 10, 953.

 Figure 1. Factors that can influence vitamin D supplementation efficacy and vitamin D status.

Stokes CS and Lammert F. F1000Research 2016, 5:2017

 Genetic Regulation of Vitamin D Levels

Dastani Z. Calcif Tissue Int (2013) 92:106–117

 Genetic Regulation of Vitamin D Levels (2)

Dastani Z. Calcif Tissue Int (2013) 92:106–117

Xia Jiang et al. Nature Communication (2018)9-260
L Duan et al. Gene 678 (2018) 361–369
Hossein-nezhad A. PLoS ONE 8(3): e58725.
Holicks M. J Investig Med. 2011 August ; 59(6): 872–880
 1
Serum Level
Disease Incidence Prevention by Serum 25(OH)D Level
Serum 25(OH)D, ng/ml 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68

40-60 ng/ml suggested range

Studies of Individuals
Cancers, all combined 77% with calcium

Breast Cancer 30% X X X X X X X X 83%

Ovarian Cancer 12% 17% 40-60 ng/ml to Prevent
Colon Cancer 31% X38%
X X X 60% Majority of Diseases
3

Serum Reference Level

Non-Hodgkins Lymphoma 12% 18%
Type 1 Diabetes 25% 66%

Fractures, all combined 2 25% 50%

Falls, women Only Rickets Prevented 72%
at 20 ng/ml
Multiple Sclerosis 33% X 46%
X X 54%
Heart Attack (Men) 30%
Natural Experiments
Kidney Cancer 23% 49%

Endometrial Cancer 37%

Rickets 50%
99%

US & Canadian Average Outdoor Workers

Legend: in Late Summer
All percentages reference a common baseline of 25 ng/ml as shown on the chart.

Example: Breast cancer incidence is reduced by 30% when the serum level is 34 ng/ml vs the baseline of 25 ng/ml. Tribal East
There is an 83% reduction in incidence when the serum level is 50 ng/ml vs the baseline of 25 ng/ml. Africans
The x’s in the bars indicate ‘reasonable extrapolations’ from the data but are beyond existing data.
References:
All Cancers: Lappe JM, et al. Am J Clin Nutr. 2007;85:1586-91. Breast: Garland CF, Gorham ED, Mohr SB, Grant WB, Garland FC. Breast cancer risk according to serum 25-Hydroxyvitamin D: Meta-analysis of Dose-Response
(abstract).American Association for Cancer Research Annual Meeting, 2008. Reference serum 25(OH)D was 5 ng/ml. Garland, CF, et al. Amer Assoc Cancer Research Annual Mtg, April 2008,. Colon: Gorham ED, et al. Am J Prev

2005;293:2257-64. Heart Attack: Giovannucci et al. Arch Intern Med/Vol 168 (No 11) June 9, 2008. Multiple Sclerosis: Munger KL, et al. JAMA. 2006;296:2832-8. Non-Hodgkin’s Lymphoma: Purdue MP, et al. Cancer Causes Control.
2007;18:989-99. Ovary: Tworoger SS, et al. Cancer Epidemiol Biomarkers Prev. 2007;16:783-8. Renal: Mohr SB, et al. Int J Cancer. 2006;119:2705-9. Rickets: Arnaud SB, et al. Pediatrics. 1976 Feb;57(2):221-5. Canadians: Janz T.
Pearson C. Vitamin D blood levels of Canadians. Statistics Canada. 2013 January; ISSN 1925-6493. US: Al-khalidi et al., Standardized serum 25-hydroxyvitamin D concentrations are inversely associated with cardiometabolic disease
in U.S. adults: a cross-sectional analysis of NHANES, 2001-2010. Nutrition Journal. 2017, 16:16. Tribal Africans: Luxwolda M.F. et al. Traditionally living populations in East Africa have a mean serum 25-hydroxyvitamin D concentration

Metab. 2002 November. 87(11):4952-6

Copyright GrassrootsHealth, 05/11/2017 www.grassrootshealth.net Chart prepared by: Garland CF, Baggerly CA
 Take Home Messages
• Vitamin D is clearly not a panacea, but may be an important,
inexpensive, and safe adjuvant therapy for many diseases and stages of
life, including pregnancy, childhood, and old age.

• The vitamin D field clearly has ongoing controversies that still need to be
resolved in order to more effectively guide research and clinical practice with
regard to vitamin D supplementation.

• A consensus on acceptable cutoffs and on what constitutes adequate vitamin

D levels is also needed, possibly avoiding a one-value-fits-all approach but
rather tailoring it to the specific background conditions or disease states.
Thank You