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Medication Administration

Vol. 15 Issue 5 May 2014

Nutrition Therapy: The Importance of Vitamin D

Peak Development Resources P.O. Box 13267 Richmond, VA 23225 Phone: (804) 233-3707 Fax: (804) 233-3705 Email: editor@peakdev.com

Peak Development for Medication Administration and Competency Assessment Tool for Medication Administration are components of a site license for the Peak Development Resources Competency Assessment System for Medication Administration and may be reproduced for this individual facility only. Sharing of these components with any other freestanding facility within or outside the licensees corporate entity is expressly prohibited.

After completion the learner should be able to: 1. Identify actions of vitamin D in the body. 2. Relate general characteristics of vitamin D to specific patient situations. 3. Apply nursing process considerations for vitamin D to specific patient situations. Vitamin D is a vital nutrient whose properties and actions in the body are now becoming increasingly recognized. It is a fatsoluble vitamin, commonly called the sunshine vitamin, since it can be manufactured by the action of sunlight on the skin. Along with the knowledge of this nutrients many benefits in the body is the realization that Vitamin D deficiency occurs in epidemic proportions in the US and worldwide. Reports from the CDC indicate that over 30% of Americans have vitamin D levels below recommended levels. Role and Sources of Vitamin D Vitamin D is a steroid hormone that orchestrates many complex physiologic functions. It enhances the absorption of calcium and phosphorus in the intestine, promoting normal bone growth and maintenance. Vitamin D receptors are also located throughout many body tissues, however. Recent studies suggest that the physiologic effects of vitamin D are widespread, including support of immune function, promotion of cardiovascular health, regulation of cell growth and reduction of systemic inflammation. Vitamin D is synthesized in the skin, when exposure to ultraviolet B radiation from sunlight occurs. The UVB rays convert a chemical in the skin to a form of vitamin D, which is converted by the liver and kidneys to an active form of vitamin D3 called 25-hydroxyvitamin D, or 25 (OH)D. Vitamin D is also found naturally in a few foods, including fatty fish, such as salmon and tuna, beef liver, cod liver oil and egg yolk.

Due to the lack of this nutrient in most foods, vitamin D is commonly added to foods such as milk, cereal, yogurt and orange juice. According to the NIH, the majority of vitamin D in the body is obtained from sunlight, rather than from foods. Vitamin D is also available in oral supplements, in the form of either D2 or D3. Based on knowledge of the benefits of vitamin D and the high prevalence of deficiency, the Institute of Medicine (IOM) has increased the daily recommended amounts of vitamin D for all age groups. The current recommended dietary allowances are: Up to age 1 year: 400 IU (10 mcg) Age 170 years: 600 IU (15 mcg) (includes pregnant and breastfeeding women) Over age 70 years: 800 IU (20 mcg) Vitamin D Deficiency When the body cannot synthesize, take in or process adequate amounts of vitamin D, a deficiency may occur, along with adverse health issues. To identify a deficiency, the preferred method is a blood laboratory test to measure serum 25-hydroxyvitamin D. In determining the appropriate serum level of vitamin D for adequate health, the IOM indicates that a measurement of at least 50 nmol/L, or 20 ng/ml, is adequate for the large majority of people. The Endocrine Society has set a higher minimum of at least 75 nmol/L, or 30 ng/ml. A deficiency of vitamin D in children can result in rickets, a disease caused by improper mineralization of the bone. Bones become soft, weak, deformed and prone to fractures. In adults, this can cause osteomalacia, weakening of the bone structure and muscles that can cause osteoporosis, falls and fractures. Deficiency of vitamin D has also been linked to a number of other health issues, including atherosclerosis, hypertension, autoimmune

The information contained in Peak Development for Medication Administration is intended only as a guide for the practice of licensed nursing personnel who administer medications. Every effort has been made to verify the accuracy of the information herein. Because of rapid changes in the field of drug therapy, the reader is advised to consult the package insert, facility pharmacist or patients physician for relevant information. This is particularly important for new or seldom used drugs. Use of professional judgment is required in all patient care situations. It is the readers responsibility to understand and adhere to policies and procedures set forth by the employing institution. The editor and publisher of this newsletter disclaim any liability resulting from use or misuse of information contained herein. Copyright 2014

disorders, type 1 and type 2 diabetes, cognitive dysfunction, depression and some cancers, such as colorectal, prostate and breast. Vitamin D deficiency usually produces no symptoms. If symptoms do occur, they are commonly musculoskeletal, such as low back pain, muscle aches and weakness, and bone pain. Risk factors for vitamin D deficiency include: Advancing age: Those over age 65 are at increased risk, as the skin becomes less effective in synthesis of vitamin D. Also, the kidneys become less efficient in converting vitamin D to its active form. Dark skin: Those with dark skin, particularly AfricanAmerican and Hispanic persons, are at high risk for vitamin D deficiency. They require much more sun exposure than persons with lighter skin to manufacture the same amount of vitamin D. Limited sun exposure: As people spend more time indoors working, watching TV, using computers or playing video games, their vitamin D levels decrease. Other risk factors include living in the northern half of the US, as well as liberal use of sunscreen and sun-protective clothing, and avoidance of sun exposure to prevent premature aging and skin cancers. UVB rays do not penetrate glass, therefore vitamin D is not synthesized when sitting in a sunny window or a car with the windows rolled up. Vitamin D levels may also be decreased due to heavy smog or other pollution that blocks UVB rays. Breastfeeding infants: Infants who are exclusively breastfed and do not receive vitamin D supplements are at high risk for vitamin D deficiency. Obesity: Vitamin D is fat-soluble and stored in body fat. Those with excess body fat tend to have lower vitamin D levels. One explanation may be that obesity causes larger amounts of vitamin D to be stored in fat, making it more difficult to release into the bloodstream. Absorption issues: Those who have conditions that affect their ability to absorb fat, such as cystic fibrosis, celiac disease, gastric bypass surgery and inflammatory bowel disease are at risk for vitamin D deficiency. Use of certain medications: Medications such as antiseizure drugs, antifungals, corticosteroids and antiretrovirals can decrease vitamin D levels by blocking the action of vitamin D or enhancing its breakdown. Those with risk factors for vitamin D deficiency should have serum levels measured. If deficient, they may require oral supplementation at higher levels than normal to achieve desired serum levels. Universal testing of all persons for vitamin D deficiency is not recommended by the IOM or the Endocrine Society.

Vitamin D Supplementation Physicians may recommend vitamin D supplements for patients who have deficient levels, as measured by laboratory testing, and for those who have limited sun exposure or do not eat foods high in vitamin D on a regular basis. Supplements may also be recommended for patients over age 65 and those with obesity, dark skin, absorption issues, osteoporosis, or who use medications that may lower vitamin D levels. Because breast milk contains low amounts of vitamin D, the American Academy of Pediatrics recommends that breastfeeding infants receive 400 IU of oral vitamin D supplement daily, beginning soon after birth. Formula-fed infants taking in less than 1,000 ml of formula daily should also receive this amount, since they are receiving less than the recommended 400 IU of vitamin D in the formula. There are two forms of vitamin D supplement, D2 (ergocalciferol) and D3 (cholecalciferol). Both forms act similarly and are effective in raising deficient vitamin D levels. D2 is available by prescription for high-dose treatment of vitamin D deficiency. It may be taken in doses of 50,000 IU daily or weekly for a specified period, along with continued medical supervision and serum monitoring of vitamin D levels. D3 is available over the counter. Possible drug interactions with vitamin D include the chronic use of aluminum and magnesium-containing antacids, whose absorption may be increased by vitamin D, leading to toxic levels. Use of large doses of vitamin D with calcium channel blockers, such as verapamil or diltiazem, may decrease the effectiveness of these drugs. Vitamin D can also enhance the effects of digoxin, leading to toxicity and cardiac dysrhythmias. Just as low amounts of vitamin D can cause health problems, high amounts can also be dangerous. Vitamin D toxicity occurs almost exclusively from taking supplements, as it is nearly impossible to consume enough fatty fish, fortified milk or other foods to cause it. Excessive sun exposure does not cause vitamin D toxicity, as the body regulates the amount converted to active vitamin D. Symptoms of vitamin D toxicity may include weakness, polyuria, anorexia, nausea/vomiting, weight loss and cardiac dysrhythmias. High serum levels have been associated with pancreatitis, pancreatic cancer, and possible damage to the kidneys, heart and blood vessels caused by high calcium levels. The IOM has set the maximum daily dose of vitamin D at 4,000 IU. However, patients who are deficient may take doses much higher than this, under a doctors supervision, until normal serum levels are achieved. Safe and effective supplementation of vitamin D is promoted by careful screening for risk factors and medication history, appropriate administration of the ordered form, and monitoring for signs of toxicity during therapy.

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Peak Development for ... Medication Administration Competency Assessment Tool

Vol. 15 Issue 5 May 2014

Nutrition Therapy: The Importance of Vitamin D

NAME: DATE: UNIT:

Directions: Place the letter of the one best answer in the space provided.
_____1. Vitamin D is classified as a: A. water-soluble vitamin B. steroid related to amino acids C. mineral that makes hormones D. fat-soluble vitamin _____2. Vitamin D promotes: A. calcium absorption in the intestine B. phosphorus absorption in the intestine C. normal bone growth and maintenance D. all of the above _____3. Vitamin D is found naturally in: A. whole milk B. salmon C. orange juice D. cereal _____4. Most of the vitamin D in the body is made from the action of sunlight on the skin, rather than from eating it in foods. A. True B. False _____5. According to recommendations from the Institute of Medicine, people in which of the following groups require the highest daily amount of vitamin D? A. up to 1 year of age B. age 1 to 70 C. pregnant and breastfeeding women D. over age 70

_____6. Which of the following disorders is caused by a deficiency of vitamin D in children: A. scurvy B. osteogenesis imperfecta C. rickets D. Kawasaki disease _____7. Persons with light skin are at higher risk for vitamin D deficiency than are persons with dark skin. A. True B. False _____8. Which of the following infants does NOT require a vitamin D supplement, based on guidelines of the American Academy of Pediatrics: A. Baby O, who takes in 1200 ml of formula daily B. Baby J, who takes in 800 ml of formula daily C. Baby R, who breastfeeds exclusively D. Baby S, who breastfeeds at home and takes in 400 ml of formula at daycare daily _____9. Because of the serious health issues caused by vitamin D deficiency, the Endocrine Society recommends universal testing of vitamin D levels for all persons. A. True B. False _____10. Which of the following is likely to result in vitamin D overdose: A. getting excessive sun exposure B. eating foods high in vitamin D C. taking too much vitamin D in supplements D. all of the above

Competency Assessment Tool Nutrition Therapy: The Importance of Vitamin D Page 2

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