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 A new study from the University of Colorado Denver’s School of Pharmacy has found that a simple educational intervention provided by a pharmacist can make a significant impact in the amount of vitamin D intake in geriatric outpatients, resulting in increased serum, or blood levels of this key nutrient. Surprisingly, the study also found that the overall increase in serum levels in the patients who received the intervention were still not in the target range, indicating that current national recommendations for vitamin D intake may be insufficient. The study is published this month in the July/August issue of the Journal of the American Pharmaceutical Association.“The educational intervention was simple to administer and can be reproduced by pharmacists in a variety of settings, including a community pharmacy or a clinical practice site,” said Joseph Vande Griend, PharmD, assistant professor in the Department of Clinical Pharmacy at the UC Denver School of Pharmacy and lead author of the paper. “Geriatric patients are at risk of medical complications from vitamin D insufficiency, including osteoporosis, and pharmacists, physicians, and other point-of-contact health care representatives can make a difference by recognizing vitamin deficiencies in their patients and taking the time to talk about the importance of key nutrients like vitamin D.”The Pharmacist’s Findings and an Educational Intervention Vitamin D concentrations were studied in older adults, ages 65 to 89 years, during clinic visits to the University of Colorado Hospital from December 2005 to January 2006. Eighty patients completed the study and 59 of them, 74 percent, were found to have vitamin D insufficiency. The majority of patients who were vitamin D insufficient consumed more than the recommended 400 to 600 IU per day of vitamin D.

The UC Denver pharmacists practicing in geriatric medicine then created a vitamin D informational sheet that was given to those geriatric outpatients who had insufficient vitamin D intake. A pharmacist reviewed the sheet with the participant during a 15-minute, one-on-one educational session about vitamin D, in which it was recommended the participant consume a total of 1,200 IU per day of vitamin D. A recommendation of 1,200 IU was chosen because the amount was estimated to increase patient serum levels to the study-defined sufficient vitamin D concentration of 32 ng/mL. The 1200 IU per day of vitamin D is also easy to obtain from over-the-counter resources; it is higher than the current Institute of Medicine recommendation (400 IU/day under age 70 and 600 IU/day over age 70) but below the upper daily intake limit (2,000 IU/day).

The handout covered the importance of vitamin D in maintaining good health, provided a listing of food sources with vitamin D, and a listing of over-the-counter supplements containing vitamin D3 along with their general cost. The handout is available online at http://www.japha.org/ .

At the conclusion of the educational session, the clinical pharmacist helped the participant choose which foods and/or supplements to use to increase daily vitamin D intake and provided the participant with a written, personalized plan to consume 1,200 IU per day of vitamin D. No supplements were provided to the study participants.

Two weeks after the educational session, the pharmacist followed-up with participants via telephone. During the call, the importance of vitamin D in maintaining optimal health and the details of the personalized vitamin D plan were reiterated. Participants were then asked whether they had obtained the agreed upon vitamin D product(s) and whether they were actually using the products. If not, the recommendation was reviewed and the participant was encouraged to obtain the product(s) and try to increase vitamin D intake.

The Outcome of the Educational Intervention After 12 weeks, a higher proportion of participants in the educational intervention group (55 percent) achieved the desired vitamin D blood level concentration of 32 ng/mL compared with the nonintervention group (24 percent). The change in dietary and over-the-counter vitamin D intake was also evaluated. Self-reported total vitamin D intake increased by a mean of 647 IU/day in educational intervention participants and 67 IU/day in the nonintervention group. Participants in the educational intervention group reported consuming an average of more than 1,400 IU/day vitamin D.

It’s just before noon, and the emergency room already is filling with patients.

John Whitcomb, a lanky, high-octane physician, scurries from exam room to exam room, keeping pace with an onslaught of people coming in with chest pain, ankle injuries, seizures and stomachaches. The ER at Aurora Sinai Medical Center in Milwaukee isn’t the most likely place to get a friendly lecture about vitamin D.

But Whitcomb, one of a small but growing number of physicians who think deficiency of the sunshine vitamin is its own public health emergency, preaches to anyone who will listen.

A growing body of research suggests that inadequate vitamin D can substantially increase the risk of a variety of diseases, including several cancers, heart disease, high blood pressure, diabetes, depression and multiple sclerosis as well as the risk of falling and infections.

In northern regions like Wisconsin, where vitamin D levels are low, the concern is even more pronounced because of a lack of ultraviolet radiation during much of the year.

Now pockets of physicians here and around the country are making vitamin D a high priority.

Steve Trapp, 38, was on a bus from Chicago to Seattle last month when he began vomiting at the Milwaukee bus station. He was taken to the ER at Aurora Sinai. Whitcomb diagnosed the problem as a bout of stomach flu and dispensed nausea medicine — and an ample dose of vitamin D advice.

As Trapp lay in an exam room, Whitcomb rattled off a few recent research findings on how vitamin D can reduce the risk of various diseases. He told the couple how there really is no food source that can provide ample levels of the vitamin.

He said the sun’s angle drops in winter, and with that shift, vitamin D levels in the blood decrease from an average of about 40 nanograms per milliliter to less than 20 ng/ml.

“When the level drops below 32, many of the body’s functions don’t work right,” he said.

Only supplements or ultraviolet light can prevent that from happening.

Over the past two years, Whitcomb estimates that he has talked to more than 1,000 patients about vitamin D in the ER or other urgent care facilities in the area. He’s written about vitamin D in newsletters and given talks to other doctors.

He’s even tested the blood of ER patients to find out their vitamin D levels. Invariably, the levels are extremely low.

While there is not unanimous agreement on what is the optimal vitamin D blood level, many researchers say it should be at least 30 ng/ml and preferably between 40 and 60.

No large clinical trials

Exposure to intense sunlight was mostly a year-round occurrence for our prehistoric ancestors who, for thousands of years, existed naked near the equator.

It has been only in relatively recent human evolutionary history that people moved north, began wearing clothing and spent more time indoors, resulting in vitamin D deficiencies.

The vitamin actually is a hormone that plays a role in the regulation of more than 100 genes, many of which are involved in preventing diseases.

However, while that theory sounds attractive to vitamin D advocates, much of the research pointing to the vitamin’s disease-preventing ability is observational in nature. While most of those studies show a benefit, some do not.

Nevertheless, observational studies pointing to potential health benefits from the vitamin continue to pile up.

A study released late last month found higher rates of death from all causes and from cardiovascular disease among a group of 3,258 heart patients with low levels of vitamin D in their blood, compared with heart patients with higher levels of vitamin D.

Also in June, a study involving 18,225 men found that those with vitamin D levels below 15 ng/ml were 2.4 times more likely to have a heart attack than those with levels above 30 ng/ml.

Last year, an analysis involving 1,760 women found a 50% reduction in breast cancer risk in those whose vitamin D levels were more than 52 ng/ml, compared with levels of less than 13.

After reading a variety of vitamin D studies, Tara Rakowski, an east side family practice physician with Columbia St. Mary’s, began testing for the vitamin in her patients. In more than 60% of the approximately 500 patients, vitamin D levels were less than 20 ng/ml, she said. Now, “there isn’t a patient I don’t check it on,” she said.

Typically she will put patients with low vitamin D levels on a prescription regimen of 50,000 international units of vitamin D a week. After that, they usually take 2,000 IU a day in the form of vitamin D3, which is inexpensive. That’s the dose many vitamin D proponents now are recommending, although it is considerably more than the current recommended intake, which ranges from 200 IU in children to 600 IU in the elderly.

Rakowski said her patients often feel better after boosting their vitamin D levels.

Jaishree Hariharan, an internal medicine physician who practices at Froedtert Hospital, said she had checked vitamin D levels in about 200 patients in the past year. Most have levels below 20 ng/ml, she said.

“The big misnomer that most physicians are worried about is vitamin D toxicity,” said Hariharan, an associate professor of medicine at the Medical College of Wisconsin. However, with doses of 2,000 IU a day, “there is no downside,” she said.

Upping her dose

Alice Carter, a 63-year-old from Milwaukee, is lying on a bed with chest pain in the ER at Sinai Medical Center.

After Whitcomb determines the Milwaukee woman is having a bout of angina, he begins telling her about vitamin D.

He seems pleasantly surprised when she tells him that she started taking 1,000 IU a day about a year ago, but he says she should up the dose to 2,000.

“Your skin pigment protects you from sunburn, but it also means you need to get three to four times as much sunlight to make the same amount of vitamin D,” he tells Carter, who is African-American.

He tells her that many African-Americans he has tested have vitamin D levels of less than 10, but blacks living near the equator in Africa have levels near 60, he says.

“So are you saying I need to move down South?” she jokes.

Whitcomb says that won’t be necessary if she increases her summertime dose to 2,000 IU and her wintertime dose to 4,000.

Jul. 9–Vitamin D deficiency has been linked in recent studies to problems ranging from a greater risk of heart attack among men to a lower likelihood of survival among women with breast cancer. Now a new finding suggests that low levels of vitamin D for pregnant mothers may translate to more cavities for their babies.

Canadian researchers measured vitamin D levels of 206 pregnant women and then examined their infants at a followup appointment. Ninety percent of all the mothers in this largely aboriginal group had inadequate vitamin D concentrations; various other studies have estimated that perhaps half of all Americans are deficient.

About a third of the 135 babies in the study had cavities when they were examined at an average 16 months of age. When the researchers looked back at pregnancy records, they found that the mothers of those infants were significantly more likely to have had lower levels of vitamin D.

Baby teeth begin developing as early as six weeks in utero, and vitamin D is known to be involved with the formation of protective tooth enamel, lead author Robert Schroth explained in a phone interview yesterday. And although that enamel disappears when adult teeth come in, there is evidence that poor dental health follows children into adulthood.

Cognizant of a huge run on vitamin D tests in Canada, Schroth, an assistant professor on the dentistry faculty at the University of Manitoba, does not automatically recommend screening. But he does advise pregnant women to raise the issue with their doctors, to take prenatal vitamins, drink milk fortified with vitamin D and get a “small amount” of sunlight. “I think mums should be aware that prenatal diets can go a long way toward improving [infants’] dental health,” Schroth said.

The study was presented at the recent International Association for Dental Research annual meeting in Toronto. It was funded by several government and medical organizations and the Dairy Farmers of Canada.

The June 23, 2008 issue of the American Medical Association journal Archives of Internal Medicine published the discovery of Austrian and German researchers that men and women with higher serum levels of vitamin D have a reduced risk of dying from all causes as well as specifically from cardiovascular disease over a seven year period, compared with individuals whose blood levels are low.

Harald Dobnig, MD, of Medical University of Graz, Austria, and colleagues evaluated data from 3,258 participants scheduled for coronary angiography who enrolled in the Ludwigshafen Risk and Cardiovascular Health Study between 1997 and 2000. Serum levels of 25-hydroxyvitamin D and 1,25-dihydroxyvitamn D, which is converted from 25-hydroxyvitamin D in the body, were measured in blood samples collected prior to the angiographic procedure.

Over an average 7.7 years of follow-up, 737 deaths occurred, of which 62.8 percent were from cardiovascular causes. Approximately two-thirds of the patients were found to have low serum 25-hydroxyvitamin D levels of under 20 nanograms per milliliter. Cardiovascular risk markers, including C-reactive protein levels and interleukin 6 levels (which evaluate inflammation), oxidative burden, and cell adhesion markers, were greater among individuals with lower serum 25-hydroxyvitamin D levels than in those whose levels were higher. Participants whose serum 25-hydroxyvitamin D levels were among the lowest one-fourth of participants, at a median of 7.6 nanograms per milliliter, had an adjusted risk of dying from all causes or cardiovascular disease that was twice that of subjects whose levels were among the highest fourth at 28.4 ng/mL. When 1,25-dihydroxyvitamin D levels were evaluated, similar associations were found.

“This prospective cohort study demonstrates for the first time, to our knowledge, that low 25-hydroxyvitamin D and 1,25-dihyroxyvitamin D levels are associated with increased risk in all-cause and cardiovascular mortality compared with patients with higher serum vitamin D levels,” the authors write. “Apart from the proved effects that vitamin D has on bone metabolism and neuromuscular function, appropriate serum levels (that may also be higher than in the present investigation) are associated with a decrease in mortality. Although not proved, it seems possible that at least part of this effect may be due to lowering of a risk profile promoting atherosclerosis and preventing cardiovascular end points.”

“Based on the findings of this study, a serum 25-hydroxyvitamin D level of 20 nanograms per milliliter or higher may be advised for maintaining general health,” they conclude.