The Impact of Vitamin D Deficiency

on the
Development and Progression
of Disease

Angela Ferguson
Diploma of Nutrition
Faculty of Naturopathy &
Nutrition
26 November 2012
Table of Contents

Introduction ......................................................................................................................3
Background .....................................................................................................................4
Research on Subject .......................................................................................................7
Latitude and Vitamin D .................................................................................................9
Cancer ........................................................................................................................ 11
Systemic Lupus Erythematosus (SLE) ....................................................................... 15
Osteoporosis .............................................................................................................. 16
Hyperparathyroidism .................................................................................................. 18
Multiple Sclerosis (MS) ............................................................................................... 19
Mental Health ............................................................................................................. 20
Conclusion ..................................................................................................................... 21
Reference List ............................................................................................................... 22

Angela Ferguson Faculty of Naturopathy and Nutrition Page 2 of 26

Introduction

There is thought to be correlation between vitamin D deficiency and the prevalence of

autoimmune disease and cancer development and there is mounting evidence (see
Holick 2007, Garland & Garland 2005) to support this theory. Vitamin D deficiency is
thought to be higher in latitudes further from the equator such as New Zealand and
Australia (Boyages & Bilinski (2012). This review examines the role of vitamin D
deficiency and latitude along with the incidence of cancer and other autoimmune
diseases.

This review will look at the extant research and research in progress on vitamin D and
its association with health. Research in New Zealand is limited due to the countrys
small size and limited funding for research. Recent years have seen more emphasis on
research into vitamin D, and have seen larger scale randomised control studies being
completed worldwide.

The link between cancer and vitamin D deficiency is the primary objective of this
literature review; however some autoimmune diseases have been discussed as there is
relevance between the prevalence of these in regards to cancer. Cancer is the leading
cause of death in New Zealand with one in three people being affected by it (Ministry of
Health, 2011); it also poses a high cost to the government for the treatment of the
disease. Vitamin D has been more recently researched to play a role in overall
immunity and a deficiency has been linked with the development of autoimmune
conditions (Handunnetthi, 2010). Briefly touched on is the association with mental
health and Vitamin Ds role in maintaining cognitive function.

This literature review will examine if vitamin D deficiency impacts on the

development and progression of disease?

Angela Ferguson Faculty of Naturopathy and Nutrition Page 3 of 26

Background

Cholecalciferol which is also known as Vitamin D3 is produced in the body as well as

being available through dietary sources. It is synthesised in the body when UVB rays
penetrate the skin and is converted through a cholesterol based precursor, this is called
7-dehydrcholestrol which is produced in sebaceous gland in the skin. It then transfers
to the liver and kidneys where it is converted over a 2-3 day period into cholecalciferol
(Vitamin D3). It is then further converted into the main circulating forms of vitamin D.
The inactive form is 25-hydroxycholecalciferol (25(OH)D) and the active form is 1,25-
dihydroxycholecalciferol (1,25(OH)2D). It is believed that renal hydroxylation of
25(OH)D produces 1,25(OH)2D which is involved in its traditional endocrine role. Some
of 25(OH)D is stored in adipose tissue and can be mobilised out of storage during low
times of UVB exposure which is generally over the winter and spring months (Braun &
Cohen, 2010).

Cutolo (2009, p. 210) explains that vitamin D is "classified as a secosteroid in which one
of the rings has been broken, in this case by ultraviolet B radiation and the main source
of vitamin D is de novo synthesis in the skin". He believes that dietary intake alone is
insufficient and would account for a maximum of 20% of the bodys requirements. It has
been discovered in recent years that vitamin D receptors in the immune system cells
produce vitamin D hormone which suggests that it can have immunological effects
(Cutolo, 2009).
Cutolo and Otsa (2008) also support the notion that Vitamin D receptors in cells are
involved with immune response, these receptors have been identified, these activated
'dendric cells' produce vitamin D hormone which implies that they could provide some
immunoloregulatory effects. Zuckerman (2010) believes that there are valuable effects
of vitamin D in regards to mineral metabolism, skeletal health, immune and
cardiovascular systems.

The Australian and New Zealand Bone and Mineral Society (2005) has noted deficiency
levels of vitamin D as being the following: Blood Serum Vitamin D (25-OHD) mild
deficiency 25-50 nmol/L, moderate 12.5-25 nmol/L and severe as <12.5 nmol/L.
Abiding by this classification approximately 5% of New Zealanders are deficient in
vitamin D according to a Ministry of Health study completed in 2008/9 (Ministry of
Health, 2012). A further 27% of people are below the recommended levels for vitamin
D (Daly, Gagnon, Lu, Magliano, Dunstan, Sikaris, Zimmet, Ebeling & Shaw, 2012).
Holick (2007) states that adequate vitamin D intakes are set too low by governments

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and this requires further investigation. Lauri, Pelajo, Lopez &Laurie (2010) also suggest
that a much higher amount of vitamin D needs to be supplemented than current
guidelines suggest to maintain 25(OH)D levels in the absence of UVB radiation on the
skin. In agreeance with this is Boyages & Bilinski (2012) who undertook the largest
study in Australia noting that of 24,819 people tested the mean deficiency was recorded
at 45% which is they consider high. In the below table Boyages & Bilinski (2012) have
highlighted the studies completed throughout Australia where many of these also show
high deficiency levels.

Table 1. Mean vitamin D level and prevalence of deficiency in a cohort of 24 819 subjects primarily
residing in NSW compared to other Australian studies overall and in winter
Mean Prevalence (%)
Latitude No. of
Location Patient group 25(OH)D References
(S) subjects <25 nm <50 nm
(nm)
Women randomly selected
from electoral roll, 99% Pasco et al.
VIC 38 861 70 72a 30
European descent, none 2001
wore veil
Random sample of patient
with psychosis, control group McGrath et al.
SE QLD 28 414 691 8 234
from same area (no. not 2001
provided)
Cross-sectional national
sample of adults enrolled in
the 1999/2000 Australian Daly et al.
Australia 1243 11 247 628 41 31
Diabetes, Obesity and 2011
Lifestyle (AusDiab) study
from 42 districts
54
NSW 34 24 819 ICPMR cohort 15 45
(median)
Random sample of patient
with psychosis, control group McGrath et al.
SE QLD 28 405
from same area (no. not 2001
provided)
NSW 34 6201 ICPMR Cohort 47 19 52
Cross-sectional national
sample of adults enrolled in
the 1999/2000 Australian Daly et al.
Australia 1243 11 247 577 63 403
Diabetes, Obesity and 2011
Lifestyle (AusDiab) study
from 42 districts
Women randomly selected
from electoral roll, 99% Pasco et al.
VIC 38 861 58 113a 432
European descent, none 2001
wore veil
Women randomly selected
Pasco et al.
VIC 38 287 from electoral roll; 90% 50 176a 603
2004
white, none wore veil
136 MS cases, 272
Van der Mei
TAS 43 404 community controls matched 362 ~74 507
et al. 2007
on sex and year of birth
Pooled analysis; 310 cases
with psychosis and 303
controls(QLD); 561 women
<60 years free from disease
known to effect calcium
QLD/VIC/T 670/755 71/79/1 405/374 Van der Mei
2843 1669 metabolism (VIC); 272
AS /511 30 /673 et al. 2007
controls from Van der Mei
a
2007 and 469 subjects aged
5079 randomly selected
from the electoral roll (from
TasOAC cohort)
(Boyages & Bilinski, 2012, p. 2)

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Supplementing vitamin D is not a traditional approach; supplements were discovered in
the 1930s and have been used since then (Nutrilite, 2012). The long term affects are
generally unknown however getting more sunshine is a traditional approach to getting
adequate levels of vitamin D. With the shift of rural people to larger cities and more
people having office based careers the amount of vitamin D absorbed through sun
exposure is reduced (Daly et al, 2011). By getting more sun exposure or supplementing
vitamin D it can be used complementarily to allopathic medicine. According to Gorham,
Garland, Garland, William, Sharif, Lipkin, Newmark, Giovannucci, Wei & Holick, (2007)
supplementing 1000-2000 IU a day of vitamin D3 could be done with minimal risk to the
patient.

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Research on Subject
A deficiency in vitamin D has been implicated in the causation of cancer, autoimmune
diseases, and depression (Huotari & Herzig, 2008). Adorinin and Penna (2008, p. 404)
believe that vitamin D contains antiproliferative, prodifferntiative, antibacterial,
immunomodulatory and anti-inflammatory properties and that synthetic vitamin D could
be used to treat autoimmune diseases which has regulated growth and differentiation of
different cells. Vitamin D plays an important role in the prevention of Rheumatoid
Arthritis (RA), Multiple Sclerosis (MS) and Type 1 Diabetes, it is believed that it has not
been well studied in Systemic Lupus Erythematosus (SLE) (Kamen, Cooper, Bouali,
Shaftman, Hollis & Gilkeson, 2006).

Another risk factor for vitamin D deficiency is obesity as the vitamin is stored in adipose
tissue. Studies show that serum levels of vitamin D increased 50% less in obese
patients rather than non-obese patients who were exposed to the same amount of
vitamin D (Lauri, et al 2010).

Where vitamin D has been linked to the development of autoimmune disorders including
MS and Type 1 Diabetes, it has more recently been shown to modulate the immune
system (Lauri et al, 2010). It is discussed that supplementation may be needed for
sufferers of autoimmune conditions as they are usually low in vitamin D. In a study of
1029 patients all with existing autoimmune disorders including Systemic Lupus
Erythematosus and Rheumatoid Arthritis it was noted that they all had lower levels of
25(OH)D than the controls (Lauri et al, 2010).

In a study of Australians aged 25 years and older 11,247 people who were enrolled in
the 1999/2000 Australian Diabetes and Lifestyle Study had their 25(OH)D levels tested.
It was noted that 42% of women and 27% of men were deficient through summer and
autumn, this increased to 58% and 35% respectively in the winter and spring months. It
was noted that living in the city and being a young female was a greater risk factor for
deficiency. Living in a remote or a rural location was beneficial to levels of 25(OH)D. It
is also recommended that supplementation be considered throughout the winter months
to prevent deficiency (Daly et al, 2011).

Similar results were achieved in the largest study undertaken in Australia by Boyages
and Bilinski (2012). Serum vitamin D levels were tested over a two year period from
2008 to 2010 of 24,819 people. Deficiency is defined as 25(OH)D <50 nm, throughout
their study they recorded that 36% of participants over summer and 58% over spring

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had a serum level classified as deficient. This amount was higher in women with
percentages being 42% in summer and 62% in spring. Women most at risk from
vitamin D deficiency are females aged 20-39 or over 79. They also agreed with Daly et
al (2011) that living in an urban environment is more of a risk factor for deficiency than
living rurally.

Research is also being undertaken in New Zealand by Professor Scragg of Auckland

University. He is leading the ViDA (Vitamin D Assessment) study with anticipated
participation of 5,100 patients over the next four years. The main aim of this
randomised control trial is to determine whether vitamin D supplementation reduces the
incidence of common diseases (Scragg, 2012, p. 1), this includes cardiovascular and
respiratory disease along with fractures. The Canadian Cancer Society (2011) have
also stated that there are more clinical trials underway, one of particular interest is a
study involving 20,000 participants. This study is assessing whether supplementing
vitamin D or fish oil can reduce the risk of cancer or cardiovascular disease. The study
has a duration of five years so the results will not be known for some time.

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Latitude and Vitamin D
There is a hypothesis which has been posed in much of the research investigated, that
vitamin D has a central role in the aetiology of the development of autoimmune
diseases (Handunnetthi, 2010). Multiple Sclerosis (MS) has a geographical distribution
which supports the latitude hypothesis in regards to UVB exposure. A newly identified
"gene-environment interaction between vitamin D and the main MS-linked HLA-
DRB1*1501" show that vitamin D levels are significantly lower in MS patients compared
to controls (Handunnetthi, 2010, p. 1905). It was also noted in several studies that
vitamin D levels are under control of vitamin D receptor genes which shows their
importance in the prevention of MS. Further studies need to be completed to provide
more information in regards to the role of vitamin D in MS. More observations also
need to be completed to decide if supplementation can help in the prevention and
treatment of the disease (Handunnetthi, 2010).

Living in latitudes far north and south can be detrimental to vitamin D stores in the body.
Vitamin D is synthesised in the body when UVB rays reach the skin and is converted
into a steroid like hormone which is used in the body for many roles. It plays an
important role in calcium and phosphorus homeostasis and there are thought to be
vitamin D receptors on many cells in the body (Huotari & Herzig, 2008). Vitamin D
deficiency has been linked to cancer and autoimmune diseases. It is noted that
autoimmune diseases such as rheumatoid arthritis, systemic lupus, dementia, multiple
sclerosis are more prevalent in extreme latitudes.
In areas in latitudes above about 37 north or below 35 south there is marked decrease
in UVB incidence during winter months, increasing the risk of vitamin D deficiency (Lauri
et al, 2010). Areas that are above 37 North begin around South Korea, San Francisco,
Portugal, Italy and areas below 35 South begin at Adelaide, Argentina, Auckland and
Chile. These areas are thought to suffer greater incidence of autoimmune diseases.
The correlation between autoimmune disease and latitudes is due to the incidence of
ultra violet B (UVB) rays being low in the winter season hence people living near the
equator are at a decreased risk of developing autoimmune diseases (Lauri et al, 2010).
Vitamin D deficiency was first linked with autoimmune disease due to the incidence of
these developing around the equator where UVB radiation is high. It was shown that
there is a decreased risk of developing these disorders at this latitude (Lauri et al, 2010).
It is explained that there are difficulties in establishing a solid relationship between
vitamin D deficiency and autoimmune rheumatologic disorders in humans (Lauri et al,
2010, p. 508). They state that there are different levels of deficiency used in different
studies; some studies are tested on intake rather than serum levels. Another factor that

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needs to be observed is the use of sunscreen, photosensitivity and prednisone intake
(Lauri et al, 2010).
Handunnetthi (2010) also supports this by stating that Multiple Sclerosis has a
geographical distribution which supports the latitude hypothesis in regards to UVB
exposure. He explains there have been studies completed show that vitamin D has a
protective effect and contributes to prevention of Multiple Sclerosis developing. It has
been noted that latitude, smoking and other nutrients can have an effect on the
development of the disease (Ascherio, Munger, Simon &Claire, 2010). Huotari and
Herzig (2008) believe anyone living at more extreme latitudes should be supplementing
vitamin D in the winter season.
However in a study conducted of midwestern Caucasian women from America which is
below latitude 37 North and not linked with vitamin D deficiency, it showed that of the
539 people screened only 9% of them have low levels of 25(OH)D which is not a
substantial amount, It was noted that more research of women from other latitudes may
in fact produce a higher percentage as this study was not a good cross section of
people (Villareal, Civitelli, Chines &Aviolo, 1991).

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Cancer
Cancer is a health risk where it has the possibility to cause mortality in sufferers. In
New Zealand cancer is the leading cause of death at a rate of 29.8% of all deaths
recorded for 2011 as noted by the Ministry of Health (2012). In 2008 there were 20,317
people diagnosed with cancer, it is a major cause of hospitalisation and there were
8566 deaths. The cost to the government in New Zealand was $511 million in 2008/09
(Ministry of Health, 2012). This cost has excluded screening programs and supported
care. One in three people will be affected with cancer, either directly suffering from it or
having a relative or friend who suffers with it according to Ministry of Health (2011).
Colon cancer mortality rates are higher where there were the least amount of natural
light such as in major cities and areas with the more extreme latitudes (Garland
&Garland, 2005). The cost of supplementing vitamin D3 has been estimated by Garland,
Garland, Gorham & Lipkin (2006) as being under five cents per person which in
comparison to the amount spent by the Ministry of Health is of significance.

While the New Zealand Ministry of Health (2011) does not acknowledge the links
vitamin D deficiency can have with cancer prevention the Canadian Cancer Society has
begun recommending vitamin D supplementation. The Canadian Cancer Society
(2011) state on their website that due to growing evidence that vitamin D may reduce
the risk of some times of cancer they recommend supplementing 1000 iu during autumn
and winter months. Of particular note is the possibility of its assistance in reducing
colorectal and breast cancer. It also noted that there was an association between low
levels of vitamin D and the development of other health conditions such as heart
disease, diabetes and multiple sclerosis. The Institute of Medicine which provides
advice to the governments in Canada and the USA updated their recommendations in
2011 concluding that vitamin D is important in regards to bone health, but they advised
there was not enough evidence to 'be certain' that it plays a role in other health
outcomes. Regardless of this the Canadian Cancer Society (2011) recommends
supplementing vitamin D in autumn and winter. They concluded by stating that there is
consistent evidence to support a vitamin D deficiency and cancer relationship but they
cannot advise that vitamin D is the cause.

In 1937 Peller and Stephenson proposed that sunlight played a role in preventing some
types of cancer. Their subjects were in the US Navy and while some suffered skin
cancer, it appeared that they had a lower instance of other cancers. Apperly (1941, p.
192) also linked latitude and lack of sunlight with incidence of cancers, he stated that
sunlight somehow conferred a relative cancer immunity to non-skin cancers.

Angela Ferguson Faculty of Naturopathy and Nutrition Page 11 of 26

Giovannucci (2007) then states these observations were ignored, it wasnt until four
decades later that Dr Cedric Garland and his colleagues began drawing associations
with vitamin D and cancer incidence. Garland appears to be the only medical
professional who has tested this subject extensively. These earlier studies show that
the current medical world needs to investigate historical research further to develop
future research.

A deficiency in vitamin D is being associated with increased cancer risk. It was once
thought that carcinogens were the main cause of cancer, this is now shifting with
thoughts that perhaps a deficiency could be one causative factor. Garland & Garland
(2005) acknowledge that there is more research needed in this area before the medical
world will take notice. They produced a paper where the first sentence stated It is
proposed that vitamin D is a protective factor against colon cancer (Garland & Garland
2005, p. 217). The paradigm that sunlight was dangerous would have to shift for the
general public to believe that they were safe to enjoy small levels of exposure to UVB
light; this would possibly see way for more research to be produced on cancer incidence
decreasing.

Vitamin D is involved in cell growth and maturation; it has also shown anti-cancer
properties according to research completed by Martinez, Giovannucci & Colditz (1996).
A deficiency in vitamin D would result in cell junctions becoming loose and their
communication with each other would be more difficult or would cease. This would also
possibly make way for overgrowth of cells where the junctions were too loose, therefore
cancer growth could happen with ease (Garland & Garland, 2005). By supplementing
vitamin D3 it would improve tight cell junctions so that correct intercellular
communication could take place (Garland & Garland, 2005). Holick (2007) suggests
that postmenopausal women may reduce their rate of cancer by 60-77% by
supplementing 1100 IU of vitamin D3 daily. He points out that that there is a high risk of
vitamin D deficiency among this group of women and a lowered risk of cancer through
supplementation. He explains that it is unlikely that persons are able to obtain sufficient
vitamin D through dietary sources only; exposure to sunlight must be achieved.

Simone, Simone, Simone & Simone (2007) conducted 50 studies involving 8,521
patients, of which 5,081 of them were given the following nutrients: beta-carotene;
vitamins A, C, and E; selenium; cysteine; B vitamins; vitamin D3; vitamin K3; and
glutathione either singularly or in combination. This study was conducted because
some scientists believed antioxidants interfered with radiation and some

Angela Ferguson Faculty of Naturopathy and Nutrition Page 12 of 26

chemotherapies because those modalities kill by generating free radicals that are
neutralised by antioxidants, and that folic acid interferes with methotrexate (Simone et
al, 2007, p. 22). These studies have consistently found that non-prescription
antioxidants and other nutrients do not interfere with cancer treatments. The promising
fact is they enhance current cancer treatments, decrease side effects and protect
normal tissue.

Many of the studies that have been performed have produced similar results where they
were inconclusive and required more research to be performed. Garland, Garland,
Gorham & Mohr (2009, p. 469) believe that a daily intake of 2000 IU of vitamin D3
would reduce breast cancer by 25% and colon cancer by 27% in North America.
Bischoff-Ferrari (2007) proposed that an adequate intake of vitamin D would reduce
cancer incidence by approximately 17% and mortality by around 33%. There is also
counter research to suggest that vitamin D has no relationship with cancer formation. In
one completed study inconsistent results were provided in regards to the relationship
between vitamin D deficiency and cancer growth. They even went as far to suggest that
higher circulating concentrations of vitamin D may be associated with increased risk of
aggressive disease (Ahn et al, 2008, p. 796).

Researchers from the World Health Organisation International Agency for Research on
Cancer prepared a report in 2008 in regards to vitamin D and cancer association.
Barry, De Vries, English, Giovannucci, Lehmann, Carus, Moller, Muti, Negri, Peto,
Schatzkin, Vatten & Walter (2008) concluded that evidence on the link between low
25(OH)D levels and colorectal cancer was persuasive. They stated that it was only
limited evidence showing that this may be a possible cause and there were several
other dietary and lifestyle factors affecting its development. They also concluded that
there was a link between breast cancer and vitamin D deficiency but this link was not as
strong as the association with colorectal cancer and vitamin D deficiency. They stated
that other cancers showed little association as there was limited research into this area.
Barry et al (2008) stated that vitamin D supplements may lower mortality in all areas of
health.

Another point of interest is the season of diagnosis, this has also been associated with
predicted survival from cancer, and it does however remain to be established and may
be a casual association (Barry et al 2008). Also stated is the association between other
serious health conditions and their mortality may follow a similar seasonal pattern. It is

Angela Ferguson Faculty of Naturopathy and Nutrition Page 13 of 26

suggested that other non-cancerous conditions could influence the survival of cancer
patients (Barry et al, 2008, p. 132).

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Systemic Lupus Erythematosus (SLE)
Patients with autoimmune disease show low 25(OH)D serum levels, Cutolo & Otsa
(2008) believe that Systemic Lupus Erythematosus (SLE) sufferers have extra risk
factors for vitamin D deficiency and it appears that the severity seems to correlate to
lower serum levels of vitamin D. Cutolo (2009) believes that vitamin D may play a role
in the homeostatic of B cells in the immune system which in turn may have a role in the
treatment of B-cell mediated disorders such as SLE. Patients with SLE avoid the sun
as it aggravates the rashes which in turn lowers vitamin D levels even further, it must be
supplemented to ensure levels are not depleted entirely (Zuckerman, 2010).
A study of 25 SLE and 25 fibromyalgia (FE) patients in London and Ontario in winter
found that half of the patients had 25(OH)D levels that are considered deficient. They
also had their parathyroid hormone levels tested, it was observed that
hydroxychloroquine may inhibit conversion of 25(OH) to 1,25(OH)2 vitamin D in SLE
patients as levels of 1,25(OH)2 was lower in SLE patients compared to FE patients
suggesting that they may lack the ability to convert vitamin D in the body (Huisman,
White, Algra, Harth, Vieth, Jacobs, Bijlsma & Bell, 2001).
In another study of 123 recently diagnosed SLE patients found a trend toward lower
25(OH)D levels compared to the control group of 240 people. 67% of the patients were
deficient in vitamin D and levels were lower in African Americans compared to
Caucasians. They believed the levels were critically low in 22 of the 123 patients. The
authors state that vitamin D deficiency is a possible risk factor for SLE (Kamen, Cooper,
Bouali, Shaftman, Hollis & Gilkeson, 2006).

Toloza, Cole, Ladman, Ibanez & Urowitz (2009) state that vitamin D plays an important
role in the immune system where it is thought to have immunosuppressant effects. It
therefore plays a role not just in bone health but also in non-skeletal health which is
indicated in the link between autoimmune diseases and low serum levels of vitamin D.
In a study of women in Canada it was discovered that 66.7% of the participants with
SLE had suboptimal levels of vitamin D whereas a deficiency in vitamin D was only
present in 17.9% of the women studied. It was also explained that there may be several
reasons for the sub optimal levels including participants avoiding sunlight, having a low
intake of vitamin D foods and having antibodies against vitamin D. Also noted was that
vitamin D deficiency is also prevalent in 36-57% of the Canadian population. It is
recommended that supplementation be advised to the general public of 2000 IU of
vitamin D per day to reduce the likelihood of suboptimal vitamin D levels and the
possibility it may reduce the incidence of SLE and other autoimmune diseases (Toloza
et al (2009).

Angela Ferguson Faculty of Naturopathy and Nutrition Page 15 of 26

Osteoporosis
Vitamin D is important for calcium and phosphorus homeostasis and musculoskeletal
health. In children, severe vitamin D deficiency (25[OH]D, <10 ng/mL [24.9 nmol/L])
manifests as rickets, and vitamin D inadequacy (25[OH]D, 10-29 ng/mL [24.9-72.4
nmol/L]) can impair or retard attainment of peak bone mass (Holick, 2006, p. 15).
It is important to gain sufficient bone mass during infancy and adolescence and vitamin
D levels need to be adequate to ensure that bone homeostasis is achieved (Holick,
2006). Vitamin D levels were studied in children to assess if adequate amounts were
obtained throughout the year for this. It was found that 80% of the 21children studied
had less than 20ng/mol which is considered suboptimal. This in turn may hamper the
ability to achieve adequate bone mass. There is lack of long term studies of children
and optimal vitamin D levels, by having adequate levels it is thought that perhaps it may
help in preventing osteoporosis in later life. The author considers administering a single
dose of 150,000 IU in early winter to maintain adequate levels of 25(OH)D (Docio,
Riancho, Perez, Olmos, Olmos & Gonzalez-Marcias, 1998).
In the study above in regards to latitude the study was conducted with 539 women aged
52-77 who were screened for osteoporosis low 25(OH)D was found in 49 participants.
They found that insufficient vitamin D levels contribute to reduced bone mass. It was
also noted that the 49 women had lower serum levels of calcium and increased
immunoreactive parathyroid hormone (PTH) which they believe suggests
hyperparathyroidism. They also noted that those with reduced vertebral bone density
also had increased PTH. Only 9% of the screened women showed insufficient levels of
vitamin D which indicates that latitude may have an impact on levels and further studies
need to be completed at different latitudes (Villareal, Civitelli, Chines & Avioli, 1991).

In a study of both young and older women, the young women were found to have an
association between low 1,25(OH)2D and low skeletal mass. This shows that having
adequate levels of vitamin D at a younger age may be of importance in reducing the
likelihood of developing osteoporosis at an older age. However they believe that
25(OH)D supplementation may in fact support neuromuscular function rather than
muscle strength and believe that further investigation into this is warranted (Marantes,
Achenbach, Atkinson, Khosla, Melton & Amin, 2011).

Binkley (2012) believes there is controversy surrounding the amount at which vitamin D
levels are adequate. He states that doctors should look to target a level of 30-40 ng/ml
of 25(OH)D in the blood for sufferers of osteoporosis. He also advises that it should be
administered daily rather than in high dose treatment which only occurs intermitted

Angela Ferguson Faculty of Naturopathy and Nutrition Page 16 of 26

which has been recommended by Docio et al (1998). This approach has come from his
study of the Palaeolithic model which he believes helps define the 'normal' level of
which 25(OH)D should be. The Palaeolithic model shows that humans have been
exposed to sunlight as they have lived outdoors for much of their existence and it is
thought that there was not an issue of vitamin D levels becoming inadequate in this era.
Binkley (2012) also states that osteoporosis related fractures are very common in older
people, approximately 40-50% of postmenopausal women suffer fractures and 25% of
older men will have this occur as well. He believes that supplementation reduces the
risk of fracture but more clinical trials need to be performed.

Patients with congestive heart failure were shown to have significantly lower levels of
vitamin D and higher bone turnover. It was also shown that osteoporosis was observed
in approximately half of the patients with congestive heart failure. It is believed that
abnormal concentrations of calciotropic hormones were related to the severity of
cardiovascular compromise (Shane, Mancini, Aaronson, Silverber, Seibel, Addesso &
McMahon, 1997, p. 198).
They stated that persons treated for congestive heart failure who had osteoporosis
should receive supplementation for vitamin D after treatment (Shane et al, 1997).

Angela Ferguson Faculty of Naturopathy and Nutrition Page 17 of 26

Hyperparathyroidism
It is described as a metabolic disorder resulting from the overproduction of parathyroid
hormone by the enlargement of the parathyroid gland which causes hypercalcemia. 50%
of cases are asymptomatic and are only found through testing for other reasons. It is
more common for women to be affected from this and having the parathyroid removed
is 95% effective in symptomatic cases (Salen, 2000).
In adults, inadequate vitamin D can result in secondary hyperparathyroidism, decreased
bone mass density (BMD), osteoporosis, osteomalacia, and increased risk of fragility
fractures Despite some negative studies, the prevalence of evidence from RCTs
supports a reduction in the risk of vertebral and non-vertebral fractures with vitamin D
(given in combination with calcium in most trials), especially in populations with low
vitamin D status and low calcium intake at baseline (Holick, 2006). Similarly, results of a
meta-analysis of RCTs suggest that vitamin D can reduce the risk of falls (Holick, 2006).
Another study which assessed bone mineral density, it was measured in 46 elderly
women where it was found that BMD was significantly less than in age matched controls.
PTH was also higher in patients studied (Sato, Asoh & Oizumi, 1998).
Another important factor to consider is that abnormal concentrations of calciotropic
hormones were related to the severity of cardiovascular disease (Shane et al, 1997).
Acherio, Munger, Simon, Claire (2010) state that smoking affects the parathyroid
hormone concentrations which are said to contribute to the development of Multiple
Sclerosis.

Angela Ferguson Faculty of Naturopathy and Nutrition Page 18 of 26

Multiple Sclerosis (MS)
It appears that there have been two major studies undertaken in New Zealand in
regards to the incidence of multiple sclerosis, both studies were undertaken over twenty
years ago so the true incidence rate of Multiple Sclerosis (MS) in New Zealand is
unknown (Multiple Sclerosis Society of New Zealand, 2012). Acherio et al (2010) state
that smoking affects the parathyroid hormone concentrations which are said to
contribute to the development of MS. However MS has a geographical distribution
which supports the latitude hypothesis in regards to UVB exposure. A newly identified
"gene-environment interaction between vitamin D and the main MS-linked HLA-
DRB1*1501" show that vitamin D levels are significantly lower in MS patients compared
to controls (Acherio et al 2010, p. 610). It was also noted in several studies that vitamin
D levels are under control of vitamin D receptor genes which shows their importance in
the prevention of MS. Further studies need to be completed to provide more
information in regards to the role of vitamin D in MS. More observations also need to be
completed to decide if supplementation can help in the prevention and treatment of the
disease (Handunnetthi, 2010).

Angela Ferguson Faculty of Naturopathy and Nutrition Page 19 of 26

Mental Health
It is considered that low mood, depression, Alzheimers and dementia may be
associated with low serum levels of vitamin D (Wilkinson, Sheline, Roe, Birge & Morris,
2006). In a study of 80 participants, 40 had mild Alzheimer Disease (AD) and 40 did not,
cognitive function and mood was assessed using a range of different tests. It was noted
that the average amount of serum 25(OH)D was 18.58ng.ml, 58% of the participants
had abnormally low levels of vitamin D which is defined as less than 20 ng/ml. It was
concluded that vitamin D deficiency was associated with low mood, it was also noted
that it impaired cognitive function by 50% (Wilkinson et al, 2006). In another study
25(OH)D was tested on 752 patients who were over 75 years of age, it was discovered
that serum levels of vitamin D was associated with cognitive impairment (Annweiler,
Schott, Allali, Bridenbaugh, Kressig, Allain, Herrmann & Beauchet, 2009). Bone
mineral density was measured in 46 elderly women with Alzheimers Disease (AD)
where it was found that bone mineral density was significantly less than in age matched
controls. PTH was also higher in patients studied. Many of these AD patients were sun
deprived and consumed less than 100 IU of vitamin D per day. It was concluded that
vitamin D deficiency along with hyperparathyroidism contributes significantly to bone
mineral density reduction in patients with AD. It increases the risk of hip fractures and
falls in patients with AD as well which may be improved with supplementation (Sato et al,
1998).

Angela Ferguson Faculty of Naturopathy and Nutrition Page 20 of 26

Conclusion
Given the current available research, encouraging New Zealanders to get more
sunshine over the summer months may assist with general immunity. Due to New
Zealands low latitude exposure during winter months may not be adequate for vitamin
D stores in the body. Huotari et al (2008) believe that anyone living at extreme latitudes
should be supplementing vitamin D3 throughout the winter months in order to maintain
levels of 25(OH)D in the body. The high prevalence of autoimmune disease and cancer
in extreme latitudes is possibly not a coincidence and more research needs to be
completed in this area specific to New Zealand and Australia.

While The Ministry of Health does not acknowledge links between vitamin D deficiency
and health conditions in the foreseeable future the scientific community is predicting that
this view must shift. It would be wise for The Ministry of Health to investigate the
supplementation of vitamin D3 for cancer patients and conduct clinical trials. The cost of
supplementing vitamin D3 has been estimated by Garland et al (2006) as being less
than five cents per person. The current research is supportive of vitamin D3 being
beneficial to reducing the incidence of cancer. Comparing the amount spent currently
by the Ministry of Health it would be of benefit to the New Zealand public to being
supplementation trials. It is promising to see the Canadian Cancer Society
acknowledge and now recommend vitamin D supplementation through winter months.

The studies discussed do show correlation between Vitamin D deficiency and the
development and progression of disease. It was originally thought that vitamin D levels
were only associated with bone health but through the above research conducted it is
apparent that it has a far wider effect on health. When more research is completed it
would be interesting to know if vitamin D levels could be increased sufficiently by
adequate sun exposure therefore eliminating the need for supplementation for most
people. This would need to be compared against increased risk of skin cancer if this
was to be encouraged by the government.

The extant literature shows that vitamin D deficiency impacts on the development and
progression of disease, however more empirical research needs to be completed to fully
understand the effects of vitamin D deficiency, and how supplements can help reduce
the development and progression of diseases.

Angela Ferguson Faculty of Naturopathy and Nutrition Page 21 of 26

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