Vitamin D is a fat-soluble hormone involved in the intestinal absorption and regulation of calcium. It plays a vital role in the formation and maintenance of strong, healthy bones. Insufficient vitamin D levels have long been associated with rickets in children and osteomalacia in adults, and long-term insufficient vitamin D calcium absorption leads to osteoporosis. However, in recent years, the vitamin D immunoassay has become known as an indicator of general health status, and there have been multiple publications linking low vitamin D test scores to several disease states, such as cancer, cardiovascular, diabetes, and autoimmune diseases.1
The Siemens Healthineers calcium vitamin D testing portfolio enables medical professionals to evaluate total amount of 25-hydroxy-vitamin D (both D2 and D3) in the blood. This ensures patients have the most accurate result regardless of level and whether or not they are supplemented over-the-counter or by prescription.
Vitamin D Deficiency
Globally, over 1 billion people are vitamin D deficient,2 and in the United States the NHANES III study from 2001 to 2004 indicated that 77% of U.S. adults are insufficient or deficient. Deficiency of vitamin D rates have increased as people have limited their sun exposure due to the risk of skin cancer. People living near the equator who are exposed to sunlight without sun protection have robust levels of vitamin D; however, vitamin D deficiency is found in regions where skin exposure is limited and where sun protection is promoted to avoid UV injury to skin.
Groups at Higher Risk for Vitamin D Deficiency3
There are several groups at higher risk of vitamin D deficiency including:
- Breastfed Infants: Sufficiency is dependent on the mother’s vitamin D sufficiency level. Mother's milk typically contains about 25 IU/L of vitamin D.
- Older Adults: As people age, the skin is not able to synthesize vitamin D as effectively, and reduced kidney function impacts the ability to convert vitamin D.
- Dark Skinned People: Melanin in darker skin reduces the ability to produce vitamin D from sunlight exposure.
- Limited Sun Exposure: Eliminates one of the two possible sources of vitamin D.
- Obesity: Vitamin D is fat soluble, which does not allow it to circulate as freely.
- Other: Gastric bypass patients have less small intestine available to absorb vitamin D.
Vitamin D Sufficiency Levels
Most experts4,5,6 agree that vitamin D sufficiency is above 30 ng/mL (75 nmol/L), an insufficient level is between 20 and 30 ng/mL (50 to 75 nmol/L), and a deficient level is any value below 20 ng/mL (50 nmol/L).
Vitamin D Supplementation3
Oral vitamin D supplementation has proven to be very effective at raising vitamin D levels. Recommendations vary by subgroup:
Types of Vitamin D
Types of Vitamin D and How Vitamin D is Metabolized
There are two major types of vitamin D1,3:
- Vitamin D2 (ergocalciferol) – which is synthesized by plants and is not produced by the human body
- Vitamin D3 (cholecalciferol) – which is made in large quantities in the skin when sunlight strikes bare skin. It can also be ingested from animal sources
Factors that impact the ability of the body to synthesize vitamin D through the skin are geographic latitude, time of year, time of day, presence of clouds and/or smog, skin melanin content, and whether or not sunscreen has been applied. For example, residents at 42° N latitude or higher are unable to synthesize vitamin D via the skin during the winter months (from November through February).
In supplements and fortified foods, vitamin D can be either D2 or D3. The two forms have traditionally been regarded as equivalent based on their ability to cure rickets, but evidence suggests that vitamin D3 is approximately three times more effective at maintaining serum concentrations because the binding protein has a higher affinity to vitamin D3 than vitamin D2. This allows vitamin D3 to reside in the circulatory system longer and increase the concentration to sufficient levels more quickly. The major preparations of vitamin D for prescription use in North America are in the form of vitamin D2, while more over-the-counter vitamin / multivitamin preparations use vitamin D3.
Whether it is absorbed through unprotected skin or ingested then absorbed by the intestines, vitamin D is bound to the binding protein (both albumin and vitamin D binding protein) and carried to the liver via the bloodstream. From there it begins two hydroxylation processes. Beginning in the liver it is transformed into 25(OH)vitamin D (calcidiol), which is the primary circulating form of Vitamin D and the most commonly measured form in serum. Then in the kidneys it is transformed into 1,25 dihydroxy-vitamin D (calcitriol), which is the biologically active form of vitamin D.
1,25 dihydroxy-vitamin D is the primary steroid hormone involved in mineral homeostasis. When serum calcium dips to below 8.8 mg/dL it prompts a proportional increase in the secretion of parathyroid hormone (PTH). PTH signals to the kidneys to increase the production of 1,25 dihydroxy-vitamin D by increasing the production of 25(OH)vitamin D-1α-hydroxylase. Subsequently, the increase in 1,25 dihydroxy-vitamin D stimulates the increased absorption of calcium in the intestines to stimulate bone remodeling. When phosphorous and bone genes levels signal a normal state of bone remodeling, the kidney reduces the production of 1,25 dihydroxy-vitamin D to a normal level.
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1Dietary Supplemental Fact Sheet: Vitamin D. Office of Dietary Supplements. National Institutes of Health. Updated 11/13/2009. Accessed 08/17/2010.
2Holick MF "Vitamin D deficiency". N. Engl. J. Med. (2007) 357 (3): 266–81.
3Bringhurst FR, et.al., “Bone and Mineral Metabolism in Health and Disease”; Chapter 23 of “Harrison’s Endocrinology”, J. Larry Jameson, editor, McGraw-Hill Medical Publishing Division, copyright 2006.
4Bischoff-Ferrari HA, et al. Estimation of optimal serum concentrations of 25-hydroxyvitamin D for multiple health outcomes. Am J Clin Nutr 2006;84:18-28.
5Malabanan A, et al. Redefining vitamin D insufficiency. Lancet 1998;351:805-6.
6Souberbielle JC et al. Vitamin D and musculoskeletal health, cadiovascular disease, autoimmunity and cancer: Recommendations for clinical practice. Autoimmunity Reviews 9 (2010) 709-715.
7Phinney KW. Development of a standard reference material for vitamin D in serum. Vitamin D and Health in the 21st Century: an Update American Journal of Clinical Nutrition. Vol. 88, No. 2. 511S-512S. August 2008.