February 2015 Question 3
Generally speaking, dietitians encourage trying to get all of the recommended amounts of vitamins and minerals from food before attempting supplementation. With a high prevalence of deficiency world wide, is Vitamin D the exception to the rule?
posted by Unknown @ 1:19 PM
29 comments
29 Comments:
I believe when there is a deficiency for the person that vitamin D supplementation is justifiable. It is hard to obtain enough Vitamin D from food sources and supplements have been proven to increase serum levels without any harm. Taking the vitamin D supplement the way it is most useful is also important and the consumer should understand their dosage. For people living in climates without a lot of sun exposure it can be very helpful and improve health. However, I do not support many of the supplements on the market today with lack of evidence and false claims.
I agree with Haley. Vitamin D supplementation makes sense because it can be very difficult to get enough through our food, and many parts of the world do not have the privilege of obtaining adequate amounts through sun exposure. I wouldn't necessarily suggest that everyone take a Vitamin D supplement, but it may be something that is helpful to individuals who tend to be deficient.
I would encourage a client to still try to get vitamin D through food sources (mushrooms mostly) and spend as close to 15 minutes in the sun as possible with skin exposed (obviously difficult in the winter months), and then assess the situation from there. Like Haley mentioned, it is important to make sure if a client is going to take a supplement that they understand how it is best absorbed, a healthy dose, and that they check with a physician before starting it.
Similar to the thoughts of Haley and Susan, I agree that supplementation may be justified if there is a clinical deficiency. We know that Vitamin D deficiancies can cause harm including, but not limited to, rickets, osteomalacia and osteoporosis. According to the National Institutes of Health, Vitamin D is also important for cellular growth, immune function and reduction of inflammation. So with that in mind, supplementation may be necessary; especially considering that vitamin D is so hard to come by in the diet. Mushrooms and fatty fish are really the only "natural" sources in the diet. While it's true that many foods, such as milk, are fortified, we'd have to drink a fairly good amount of it to meet the AI. To make matters worse, we don't get much sun here in the Midwest for a good portion of the year, so it may be even more important for us northerners to supplement with vitamin D.
Like Susan said, it's important to take supplements under the guidance of a physician, especially if they diagnosed you with a deficiency and recommended the use of the supplement to begin with.
I believe that Vitamin D is acceptable to supplement when an individual is deficient, especially since Vitamin D is found in limited amounts in natural foods. Our level of Vitamin D is influenced mainly by the hormone version of Vitamin D that is activated through UV exposure. During winter months when sun exposure is limited, and in populations where outdoor sun exposure can be limited - such as the elderly - I certainly would recommend a Vitamin D supplement to assist individuals in meeting their daily requirements.
I certainly agree with Susan, though, to consult a physician in the proper dosage and recommendations to meet the individuals specific needs.
In response to Arthur, Vitamin D is now included in the list of RDAs as updated in 2010. There is now more extensive research in determining the daily recommendations for Vitamin D and it is clearly an area of research that is still in its early stages. As we learn more on the most effective routes for absorption of Vitamin D from oral sources, I am sure we will continue to see more published academic research on the topic.
I agree with what everyone else has stated. If a person is deficient in Vit. D, as many of us are, supplementation is a good way to go. I don't think it's an exception from trying to get more Vit.D into your system via food first, just like you would with any other nutrient. I wouldn't recommend supplements to those that don't need it. There are too many supplements out there that don't absorb as well as when they are digested as food. I agree that people should speak to a professional first when they are deficient to determine their best option.
Jenn, my apologies for mistakenly typing AI as opposed to RDA.
I also think that we will begin to see much more published research on vitamin D as there seems to be an increased interest in vitamin D, its uses/functions and also its absorption. It certainly is a micronutrient that is difficult to come by for many Americans, as it is not readily available in the food supply and also because many of us live in a climate where we spend half (or more) of the year mainly indoors. Even when we are outside in the late fall/winter/early spring months, we are usually covered head to toe with clothing, which leaves very little room for sunlight to work its magic. And, of course, we all lather up ourselves (and our kids) with sunscreen from head to toe, which may prevent sunburn, but isn't helping the vitamin D situation any. I am very interested to see where the literature goes from here.
I think we can all agree that we would encourage the food first approach in getting our vitamins and minerals, but considering the limited food sources, and the lack of sun exposure we have in the midwest, I would definitely encourage vitamin D supplementation, if not only during the winter months. Like Susan said, it's important to address appropriate dosage, but I think a large majority of the population would benefit from taking a vitamin D supplement. Even if there is no direct benefit, at an appropriate level, it wouldn't be harmful either.
This depends on which part of the world a person lives in and if they are able to consume the appropriate amounts of other vitamin D containing foods. For example, lactose intolerant would have to have other sources and if they had food aversions, this might not be an option for them. Deficiencies are always treated with food first, but extenuating circumstances would warrant supplementation, as with any macro or micronutrient.
Haley makes a great point that it's difficult to obtain enough from food, and the sun is not always available. For people who have problems with skin cancer, spending that time in the sun may not be the best idea. I agree with everyone who mentioned that it's best to get as many nutrients from food as possible, but especially with vitamin D, supplementation makes sense when there is a deficiency.
Vitamin D is definitely an exception to supplementation. Most people are deficient in Vitamin D, especially depending on where they live as they get little to no exposure to sunlight. Even people who live in warm areas in the summer may not get exposure during the winter months. School and work also limit many people from being outdoors during the fall, summer, and spring months as well. Even with the concept of sedentary activity increasing, more kids and adults are sitting inside on days off watching TV versus being outside in the sunlight on warm days. While I would advise patients or clients to still eat fatty fish, mushrooms, egg yolks, and fortified milk to try and get some Vitamin D from natural food sources, I would also recommend supplementation. Many people cannot reach the maximum amount of Vitamin D needed each day from eating just foods that contain Vitamin D, and the foods would have to be consumed in very large amounts. While I usually always recommend that patients and clients consume their nutrients through food sources, Vitamin D can pose a problem because the number of foods that contain Vitamin D is very limited as there are few. While 15 minutes in the sun is sufficient enough and is the best source of Vitamin D, many people cannot meet this requirement. And, as mentioned in comments above, it is also a smart idea to recommend a Vitamin D supplementation to those who suffer from skin cancer/skin allergies and cannot be in the sun. Skin cancer is something that is on the rise, and while it only takes 15 minutes to get the required amount of Vitamin D each day in the sun, I think that some people could be fearful of being outside unprotected without sunscreen on.
As others have previously mentioned, I think dietitians should encourage food before supplements whenever possible. However, if someone is deficient in Vitamin D, then supplementation is warranted. We can communicate to the public ways of obtaining Vitamin D before deficiencies occur and supplementation is necessary. Salmon, beef liver, and egg yolks are some foods that contain Vitamin D. Also, since Vitamin D can be synthesized from the sun, encouraging short sun exposure could reduce the need for supplementation. However, for people that have limited access to these foods or live in areas where sunlight is less prevalent, then supplementation may be necessary.
Susan made a great point about speaking with a doctor before starting any supplements. If someone has a deficiency and speaks with a doctor, understands how the supplement works, and takes the proper dose, then Vitamin D supplementation can be safe and justifiable.
I am going to go for it and say that, yes, vitamin D is the exception to the rule. With the chronic deficiency present world wide and the high levels that must be reached for toxicity to occur, I feel that recommending a vitamin D supplement, to be taken every couple of days, would do more good than harm. However, the exception to this exception may be places like Hawaii. Because of this, I believe it is up each RDN to make a judgement call when it comes to vitamin D.
Emma - You bring up an interesting point that certain geographical locations may serve as an exception to supplementation of Vitamin D. Certainly in the Midwest, Vitamin D supplementation may be necessary during the winter months. But as individuals live closer to the equator, Vitamin D supplementation is likely more uncommon. I'm curious if individuals who live near the poles are advised to take Vitamin D supplementation year round.
This happens to be a unique vitamin given the fact that UV rays are a better source of vit D than food. In other words, food first is not necessarily the best message for this particular vitamin. It's just not as available in food as are other vitamins & minerals, unless you're eating fatty fish every day. I would actually recommend sun exposure first, and supplementation second depending on a person's ability to get adequate exposure to sunlight.
Susan, I think the only caveat to recommending mushrooms as a source of vitamin D is that the vit D content seems to vary widely depending on how much sun exposure the mushrooms received during growth. If they don't get any, then the vit D content can be negligible. It might be difficult for a person to ensure that they are getting mushrooms that have significant levels of vit D. Maybe if we were able to identify some reputable brands that have high levels, that would make things easier for the client.
I would first suggest obtaining the vitamin D from food sources and provide nutrition-based counseling to educate the patient on good food sources of vitamin D. If the deficiency is not taken care of from food sources, I agree with the rest of the comments stating that a supplement would be a safe alternative to get sufficient vitamin D.
I agree with Jenn's comment that vitamin D is challenging to obtain during the winter months where sunlight exposure is limited and therefore is more reason to utilize supplements to fulfill the needed requirements of vitamin D.
I know people who are Vitamin D deficient who take supplements or get injections, and still remain deficient. It would be interesting to see a study that compares supplements and injections in addition to dietary sources and the differences in absorption for different cultures and lifestyles. For instance, would people who are more physically active (indoors counts) have better absorption since they typically are more health conscious and tend to have better diets? That affect has a name, but it is escaping me right now.
As many have already stated, with what we know about the importance of Vitamin D, I do think that supplementation is needed. Normally I would always strive to get all of the nutrients needed from food sources. However, realizing the prevalence of the deficiency and the concerns that come along with it (rickets, osteomalacia, and others that Arthur has listed), I do think that Vitamin D is the exception to the rule. Especially for people living in Northern regions where the sunlight is not as accessible year round. I would be interested in seeing studies where the Vitamin D intake from food sources versus supplement are compared to see how feasible it is to obtain the needed amount from food and how well it is absorbed.
I feel as though this is a question that can only ever be truly answered in retrospect. We can form opinions based on current literature, but it is hard to make assumptions about something that can take essentially a life time to see the effects of....especially when our culture is ever changing. How will we know if Vitamin D supplementation is the exception to the rule and truly the way to go? Well...[hypothetically] I think we would need to get a large sample of children and supplement them their entire lives (with a matched control group who never receives Vitamin D supplementation ever) and see if this ultimately has a more positive effect on identified health outcomes....or a negative effect. Of course, being able to do that is completely and totally unrealistic, and still the results would be hard to generalize to people who don't live their lives as test subjects!! So, in practice, I think it is most appropriate to base our recommendations on the most relevant (and current) research and then work with every individual client to interpret the research findings into realistic suggestions for them based on all of their life details (food preferences, socio-economic, nutritional status, age, gender, etc.....).
I strongly believe in Vitamin D supplementation in the winter months for those who are not getting the recommended amounts. After going to the doctor about two winters ago and being deficient in Vitamin D I started taking the supplementation only during the winter months and saw great improvement in my Vitamin D status. For the average person getting enough Vitamin D with limited sunlight is very hard and therefore I would rather have a client at an acceptable Vitamin D status using supplementation rather than a client with a poor Vitamin D status without using supplementation. Obviously, over supplementation is never recommended and only people that are lacking in Vitamin D should consider taking supplementation.
I also agree with Janelle that with the overwhelming number of skin cancer cases, more and more people are covering up from the sun year round and decreasing their exposure to Vitamin D. I would not be surprised if year round supplementation for Vitamin D becomes more prevalent as more people learn about the dangers of sun exposure.
I think this is an excellent question because I often find myself say 'food first' which I still believe it is important to rely on food sources instead of supplements but I haven't considered vitamins/minerals that may be difficult to consume enough through food. After looking up some sources of vitamin D in food, such as fatty fish, and beef liver, I would imagine my vitamin D levels are low especially during the winter months. I think getting vitamin D through the sun is realistic through the summer months, but is nearly impossible in the Midwest during the winter months. The other thing that is tricky about getting it through the sun is that everyone’s skin differs. It is not as easy as saying “expose your face, hands, and forearms, and you have your dose of vitamin D for the week.” I have very fair skin and burn easily, so I could get my dose of vitamin D more quickly, but I am also more susceptible for skin cancer. I would rather take a supplement.
Des I like your hypothetical thinking about the cohort study…if only right? Research is not black and white; there is a lot of grey area. Maybe years from now there will be a new study published with new but different findings on vitamin D. That is why as (future) RDNs it is important for us to stay up-to-date on the literature.
Supplementation for vitamin D is acceptable for individuals who are deficient in the vitamin. It is especially difficult for people to obtain adequate amounts during winter months when we are bundled up to cover our skin from the cold and the sunlight. Since it is difficult to meet our needs through dietary sources alone, I think vitamin D should be an exception to avoiding supplementation, especially in the colder weather.
However, I would encourage individuals to ditch the supplementation during the summer months when they can easily get some sun exposure for about 15 minutes and get some vitamin D from their food. I would still encourage clients to consume vitamin D rich foods (mushrooms and others as mentioned), to ensure they are meeting their needs.
Supplementation of Vitamin D can obviously have beneficial effects for those deficient. I believe that increasing Vitamin D status can be achieved through education and food choices. I also think your environment can play a large role in Vitamin D status, regarding sun light. Supplementation for Vitamin D should be considered when working with an at risk population not living in an optimal environment, otherwise Vitamin D consumption should be encouraged via food.
Arthur, Janelle, and a few others brought up a great point that I hadn't thought of originally. People can have more access to sunlight during the summer months, and I had said that supplementation should probably be encouraged during the winter months but not necessarily the summer. Hoewver, I hadn't considered how science also encourages the public to use sunscreen whenever they go outdoors or cover up to decrease their risk of skin cancer. Considering the contradiction of increasing sun exposure for improved vitamin D status, and using sun screen to protect against UV ray damage, it may just be a better idea to have year-round supplementation for those who are deficient and use sunscreen.
Obviously, the dosage in the supplements would be very important to pay attention to then, as to avoid Vitamin D toxicity.
Vitamin D is an exception to the rule. Food sources of vitamin D are relatively limited. If we are exposed to the sun this is not a big deal because we can make it. The problem is when we don’t get enough sun exposure. It is rare for individuals living north of the 37th parallel to make enough vitamin D from sun exposure, especially during winter because most of the sun’s rays being deflected by the atmosphere due to the angle of the earth’s axis. As awareness and recognition for the importance of vitamin D continues to grow, supplementation seems to be the best solution, given the limited selection of naturally vitamin D rich foods.
I feel that there may in fact be different special situations in which a Vitamin D supplement is warranted however, attempting to satisfy our needs through micronutrients found in food should still be our number one option. There are several different food options that are available which are rich in Vitamin D. I feel that educating individuals about these different choices and helping them to determine different ways to include more servings of each within their diet is perhaps the most significant impact that we as future Registered Dietitians can make with regards to this. It is also important to understand the importance of different lifestyle behaviors on Vitamin D status as well as other aspects of the diet before going forth with a supplement. Calcium intake of course plays a huge role in the absorption process related to Vitamin D. Increased levels of physical activity have also been shown to play a positive role among Vitamin D status as well. All avenues should be explored before Vitamin D supplementation is considered. I feel that it is still potentially more of a last resort.
Carly touched on something that I think is important to remember. Most healthy individuals who eat a good, balanced diet can still be Vitamin D deficient. It is extremely common to have a Vitamin D deficiency because of the lack of food sources that contain it. Again, I usually recommend food first, but Vitamin D supplementation may be something that becomes more common for dietitians to suggest to clients and patients as the number of people with Vitamin D increases with deficiencies on the rise.
While I did touch on skin cancer/skin allergies, Abby made a point that I did not even think of. Because I have olive toned skin that tans well, I did not consider that others have fairer skin that burns more easily. While some may argue that 15 minutes in the sun will not cause damage or sunburns to the skin, it really depends on how fair a person's skin is (albino) or the location the person is at. If you are near the Equator in a warmer. tropical area, the sun is more intense and even 15 minutes outside without sunscreen could cause harmful effects to the skin. Genetics also affect how well the skin takes to sunlight. It is safer to offer a supplementation which guarantees patients and clients are getting the recommended daily doses of Vitamin D without worrying about potential damage UV rays can cause (wrinkles, sunspots, skin cancer, etc.). It is recommended that people wear sunscreen daily (even in the winter), especially on their hands and faces, even suggesting women wear makeup with sunscreen in it, due to the sunlight exposure people get when driving their cars. Therefore, if people do follow this rule to keep their skin young and healthy looking, Vitamin D supplementation would be necessary.
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