tag:theconversation.com,2011:/us/topics/vitamin-deficiency-4812/articlesVitamin deficiency – The Conversation2023-12-22T10:16:26Ztag:theconversation.com,2011:article/2200692023-12-22T10:16:26Z2023-12-22T10:16:26ZMost expectant mothers miss out on vitamins important for their health and their baby’s, study finds<figure><img src="https://images.theconversation.com/files/566580/original/file-20231219-23-vklpav.jpg?ixlib=rb-1.1.0&rect=11%2C11%2C7704%2C5151&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Certain micronutrients are important for the health of the mother and baby during pregnancy.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pregnant-woman-reading-label-on-bottle-2117288603">Dragana Gordic/ Shutterstock</a></span></figcaption></figure><p>Our bodies require many important vitamins and minerals in order to function well. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9662251/">B vitamins</a>, for example, are particularly important for many of our everyday functions – including energy levels, cell health and nerve function. </p>
<p>These vitamins become even more important when a mother is pregnant, as low levels of some vitamins (such as folic acid, also known as vitamin B9) are associated with <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3218540/#:%7E:text=of%20the%20fetus.-,Folate%20deficiency%20has%20been%20associated%20with%20abnormalities%20in%20both%20mothers,(NTDs)%20in%20the%20offspring.">poor health outcomes</a> during pregnancy and for the infant after birth.</p>
<p>Since our body only makes many of these micronutrients in small amounts (if at all), we get the bulk of them from our diet. But <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004260">our recent study</a> showed that the majority of expectant mothers are missing out on many important vitamins – which could potentially have an affect on, not only their health, but their infant’s too.</p>
<p>We conducted a large study of over 1,700 women aged 18-38 in the UK, Singapore and New Zealand. We studied their health before, during and after pregnancy. </p>
<p>Before pregnancy, we found that nine in ten of the women had low blood levels of many important vitamins, including folic acid, riboflavin, vitamin B12 and vitamin D. <a href="https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-depth/prenatal-vitamins/art-20046945">These vitamins are needed</a> to support the mother’s health during pregnancy, and are important for the unborn baby’s development.</p>
<p>For the next part of the study, we randomly placed participants into two different groups. One group received a standard pregnancy vitamin supplement, which contained folic acid. The other group received an “enhanced” supplement, which contained folic acid, as well as riboflavin, vitamins B6, B12 and D. The amount of vitamins in the enhanced supplement was similar to what you can buy from pharmacies and supermarkets without a prescription.</p>
<p>Both groups took these supplements daily starting from when they were trying to get pregnant and throughout their pregnancy. They stopped taking them after delivering the baby.</p>
<p>We found that the enhanced supplement helped improve blood vitamin levels and reduced the prevalence of vitamin deficiency during pregnancy – especially when it came to riboflavin, vitamin B6 and vitamin D. The standard supplement increased levels of folic acid, but levels of other vitamins worsened during pregnancy. This was probably because of the increased needs during this time.</p>
<p>Riboflavin is important during pregnancy as low levels can mean a higher chance of having a <a href="https://doi.org/10.1017/S002966512100046X">low blood count and anaemia</a>.</p>
<p>For vitamin B6, the group taking the standard supplement had lower levels in the later part of pregnancy, meaning they might not have enough of this vitamin. Previous research has suggested vitamin B6 may <a href="https://pubmed.ncbi.nlm.nih.gov/27701665/">provide some relief</a> from pregnancy-related nausea and vomiting. </p>
<figure class="align-center ">
<img alt="A nauseous pregnant woman lays on a couch." src="https://images.theconversation.com/files/566581/original/file-20231219-21-8ht821.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/566581/original/file-20231219-21-8ht821.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/566581/original/file-20231219-21-8ht821.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/566581/original/file-20231219-21-8ht821.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/566581/original/file-20231219-21-8ht821.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/566581/original/file-20231219-21-8ht821.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/566581/original/file-20231219-21-8ht821.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">B6 may help with pregnancy nausea.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/depressed-pregnant-woman-resting-home-alone-2273536815">christinarosepix/ Shutterstock</a></span>
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</figure>
<p>In both groups we saw a drop in homocysteine levels, with this being particularly marked in those taking the enhanced supplement. A lower homocysteine level is actually a good thing as it indicates a lower likelihood of vitamin deficiency. <a href="https://pubmed.ncbi.nlm.nih.gov/11641651/">High homocysteine levels</a> are linked with early pregnancy loss and a range of pregnancy complications, including preeclampsia. </p>
<p>The benefits of the enhanced supplement on the participants’ vitamin B12 levels lasted six months after having a baby. This is probably important for the mother’s ability to supply her baby with vitamin B12 if she breastfeeds. B12 helps children’s <a href="https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/diet-and-micronutrients/vitamin-b12.html#:%7E:text=Vitamin%20B12%20is%20transferred%20through,will%20receive%20enough%20vitamin%20B12.">brain development and growth</a>.</p>
<h2>Important micronutrients</h2>
<p>Though our study included women from three different countries and various ethnic backgrounds, few black and American Indian women were included in the research. This means the results might not represent the experiences of women from these specific ethnic groups. It will be important for future studies to investigate vitamin levels in these groups.</p>
<p>The precise benefits of the improved vitamin levels will also need to be investigated further in future studies. But, we might speculate that the supplements will have additional benefits, based on what previous studies have shown.</p>
<p>For example, our <a href="https://pubmed.ncbi.nlm.nih.gov/33782086/">previous research</a> has shown that women taking the same enhanced supplement had lower rates of pre-term delivery, and also a lower risk of major haemorrhage after delivery of the baby.</p>
<p>It’s also well-known that <a href="https://pubmed.ncbi.nlm.nih.gov/1677062/">folic acid</a> is important during pregnancy, as it can help prevent major defects to the developing baby’s brain and spine. Taking a folic acid supplement before conception and in the first part of pregnancy is routinely recommended. </p>
<p>But many pregnancies are unplanned and a significant number of women do not take folic acid supplements in early pregnancy. This is why around 80 countries have introduced mandatory fortification of staple foods. But many experts feel that the level of fortification in foods <a href="https://jamanetwork.com/journals/jama/article-abstract/2807770">may not be enough</a> for pregnant women, which is why a supplement will still be important. </p>
<p>Taking vitamin D supplements before and during pregnancy may also have benefits, including reducing the chances of <a href="https://pubmed.ncbi.nlm.nih.gov/35763390/">infantile atopic eczema</a> (a condition which causes patches of itchy, cracked and sore skin) and <a href="https://pubmed.ncbi.nlm.nih.gov/35866154/">improving bone health</a> in children.</p>
<p>Overall, our study showed that most women living in high-income countries don’t get enough essential vitamins in their diet – even before they get pregnant. Several of these vitamins are <a href="https://pubmed.ncbi.nlm.nih.gov/30673669/">crucial for the infant’s development</a> in the womb. </p>
<p>Although some of these vitamins can be found in meat and dairy products, it’s clear that the majority of women still aren’t getting enough of them regardless of what sort of diet they follow. As more people choose to eat more plant-based foods, better advice about vitamin-rich foods will be needed. Many women may probably need to start taking supplements to ensure they get the vitamins they and their baby need.</p><img src="https://counter.theconversation.com/content/220069/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Keith Godfrey has received funding from the UK Medical Research Council, the National Institute for Health and Care Research and the European Union. He has received reimbursement for speaking at conferences sponsored by companies selling nutritional products, and is part of an academic consortium that has received research funding from Abbott Nutrition, Nestec, BenevolentAI Bio Ltd. and Danone. He is Co-Chair of the not-for-profit UK Preconception Partnership. </span></em></p><p class="fine-print"><em><span>Sarah El-Heis has received funding from the National Institute for Health and Care Research.</span></em></p>Our study found that before pregnancy, nine in ten women had low blood levels of many important vitamins.Keith Godfrey, Professor of Epidemiology and Human Development, University of SouthamptonSarah El-Heis, Associate Professor of Dermatology, University of SouthamptonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1983452023-02-02T12:23:35Z2023-02-02T12:23:35ZVitamins and supplements: what you need to know before taking them<figure><img src="https://images.theconversation.com/files/507046/original/file-20230130-20-x1ljxi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Supitcha McAdam/Shutterstock </span></span></figcaption></figure><p>If you were to open your medicine cabinet right now, there’s a fair chance that you’d find at least one bottle of vitamins alongside the painkillers, plasters and cough syrup.</p>
<p>After all, people are definitely buying vitamins: in 2020, the global market for complementary and alternative medicines, which includes multivitamin supplements, had an estimated value of <a href="https://www.grandviewresearch.com/industry-analysis/complementary-alternative-medicine-market">US$82.27 billion</a>. The use of natural health products such as minerals and amino acids has <a href="https://journals.lww.com/nutritiontodayonline/Abstract/2007/03000/Why_People_Use_Vitamin_and_Mineral_Supplements.4.aspx">increased</a> – and continues to rise, partly driven by consumers’ buying habits during the COVID-19 pandemic.</p>
<p>People <a href="https://www.businesslive.co.za/bd/companies/healthcare/2021-02-08-native-sales-of-sas-vitamins-and-nutritional-supplements-boom/">sought out</a> vitamins C and D, as well as zinc supplements, as potential preventive measures against the virus – even though the <a href="https://www.health.harvard.edu/blog/do-vitamin-d-zinc-and-other-supplements-help-prevent-covid-19-or-hasten-healing-2021040522310">evidence</a> for their efficacy was, and <a href="https://pubmed.ncbi.nlm.nih.gov/35888660/#:%7E:text=Concluding%2C%20available%20data%20on%20the,trials%20(RCTs)%20are%20inconsistent">remains</a>, inconclusive. </p>
<p>Multivitamins and mineral supplements are easily accessible to consumers. They are often marketed for their health claims and benefits – sometimes unsubstantiated. But their potential adverse effects are not always stated on the packaging.</p>
<p>Collectively, vitamins and minerals are known as micronutrients. They are essential elements needed for our bodies to function properly. Our bodies can only produce micronutrients in small amounts or not at all. We get the bulk of these nutrients <a href="https://www.iprjb.org/journals/index.php/IJF/article/view/1024">from our diets</a>. </p>
<p>People usually buy micronutrients to protect against disease or as dietary “insurance”, in case they are not getting sufficient quantities from their diets. </p>
<p>There’s a common perception that these supplements are harmless. But they can be dangerous at incorrect dosages. They provide a false sense of hope, pose a risk of drug interactions – and can delay more effective treatment. </p>
<h2>Benefits</h2>
<p>Vitamins are beneficial if taken for the correct reasons and as prescribed by your doctor. For example, folic acid supplementation in pregnant women has been shown to prevent neural tube defects. And individuals who reduce their intake of red meat without increasing legume consumption require a vitamin B6 supplement. </p>
<p>But a worrying trend is increasing among consumers: intravenous vitamin therapy, which is often punted by celebrities and social media marketing. Intravenous vitamins, nutrients and fluids are administered at pharmacies as well as beauty spas, and more recently “<a href="https://www.health.harvard.edu/blog/drip-bar-should-you-get-an-iv-on-demand-2018092814899">IV bars</a>”. Users believe these treatments can quell a cold, slow the effects of ageing, brighten skin, fix a hangover or just make them feel well. </p>
<p>Intravenous vitamin therapy was previously only used in medical settings to help patients who could not swallow, needed fluid replacements or had an electrolyte imbalance. </p>
<p>However, the evidence to support other benefits of intravenous vitamin therapy is limited. No matter how you choose to get additional vitamins, there are risks. </p>
<h2>Warning bells</h2>
<p>Most consumers use multivitamins. But others take large doses of single nutrients, especially vitamin C, iron and calcium. </p>
<p>As lecturers in pharmacy practice, we think it’s important to highlight the potential adverse effects of commonly used vitamins and minerals: </p>
<ul>
<li><p><a href="https://www.hsph.harvard.edu/nutritionsource/vitamin-a/">Vitamin A/retinol</a> is beneficial in maintaining good eye health. But it can cause toxicity if more than 300,000IU (units) is ingested. Chronic toxicity (hypervitaminosis) has been <a href="https://www.ncbi.nlm.nih.gov/books/NBK532916/">associated</a> with doses higher than 10,000IU a day. Symptoms include liver impairment, loss of vision and intracranial hypertension. It can cause birth defects in pregnant women.</p></li>
<li><p><a href="https://www.hsph.harvard.edu/nutritionsource/niacin-vitamin-b3/">Vitamin B3</a> is beneficial for nervous and digestive system health. At moderate to high doses it can cause peripheral vasodilation (widening or dilating of the blood vessels at the extremities, such as the legs and arms), resulting in skin flushing, burning sensation, pruritis (itchiness of the skin) and hypotension (low blood pressure). </p></li>
<li><p><a href="https://www.hsph.harvard.edu/nutritionsource/vitamin-b6/">Vitamin B6</a> is essential for brain development and in ensuring that the immune system remains healthy. But it can result in damage to the peripheral nerves, such as those in the hands and feet (causing a sensation of numbness and often referred to as pins and needles) at doses over 200mg/daily.</p></li>
<li><p><a href="https://www.hsph.harvard.edu/nutritionsource/vitamin-c/">Vitamin C</a> is an antioxidant and assists in the repair of body tissue. Taken in high doses it can cause kidney stones and interactions with drugs, such as the oncology drugs doxorubicin, methotrexate, cisplatin and vincristine. </p></li>
<li><p><a href="https://www.hsph.harvard.edu/nutritionsource/vitamin-d/">Vitamin D</a> is essential for bone and teeth development. At high doses it can cause hypercalcaemia (calcium level in the blood is above normal) that results in thirst, excessive urination, seizures, coma and death.</p></li>
<li><p><a href="https://www.hsph.harvard.edu/nutritionsource/calcium/#:%7E:text=Calcium%20is%20a%20mineral%20most,heart%20rhythms%20and%20nerve%20functions">Calcium</a> is essential for bone health, but can cause constipation and gastric reflux. High doses can cause hypercalciuria (increased calcium in the urine), kidney stones and secondary hypoparathyroidism (underactive parathyroid gland). It can have drug interactions with zinc, magnesium and iron. </p></li>
<li><p><a href="https://www.hsph.harvard.edu/nutritionsource/magnesium/">Magnesium</a> is important for muscle and nerve functioning. At high doses it can cause diarrhoea, nausea and abdominal cramping, and can interact with tetracyclines (antibiotics).</p></li>
<li><p>Zinc <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7781367/">can impair</a> taste and smell, and doses over 80mg daily have been <a href="https://link.springer.com/article/10.1007/s10654-022-00922-0#:%7E:text=Zinc%20supplementation%20of%20more%20than,zinc%20supplements%20among%20adult%20men.">shown</a> to have adverse prostate effects.</p></li>
<li><p><a href="https://www.hsph.harvard.edu/nutritionsource/selenium/">Selenium</a> can cause hair and nail loss or brittleness, lesions of the skin and nervous system, skin rashes, fatigue and mood irritability at high doses.</p></li>
<li><p><a href="https://www.sciencedirect.com/science/article/pii/S0098299720300364#:%7E:text=Expert%20guidelines%20for%20oral%20iron%20supplementation&text=Traditionally%2C%20the%20recommended%20daily%20dose,iron%20(Brittenham%2C%202018).">Iron</a> at 100-200mg/day can cause constipation, black faeces, black discoloration of teeth and abdominal pain.</p></li>
</ul>
<h2>Recommendations</h2>
<p>People need to make <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8377299/">informed decisions</a> based on evidence before consuming health products. </p>
<p>Regular exercise and a well-balanced diet are more likely to do us good, as well as being lighter on the pocket.</p>
<p>Seeking advice from a healthcare professional before consuming supplements can reduce the risk of adverse effects.</p>
<p>Be aware of the potential adverse effects of vitamins and seek a healthcare professional’s guidance if you have symptoms.</p><img src="https://counter.theconversation.com/content/198345/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There’s a common perception that supplements are harmless. But they can be dangerous at incorrect dosages.Neelaveni Padayachee, Senior Lecturer, Department of Pharmacy and Pharmacology, University of the WitwatersrandVarsha Bangalee, Associate Professor, Pharmaceutical Sciences, University of KwaZulu-NatalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1927142022-11-23T13:18:04Z2022-11-23T13:18:04ZVitamin B12 deficiency is a common health problem that can have serious consequences – but doctors often overlook it<figure><img src="https://images.theconversation.com/files/494905/original/file-20221111-12-d6vtg1.jpg?ixlib=rb-1.1.0&rect=61%2C12%2C7983%2C5395&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Fatigue can be a sign of a potential B12 deficiency.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/unhappy-african-american-woman-suffering-from-royalty-free-image/1387710368?adppopup=true">Maca and Naca/E+ via Getty Images</a></span></figcaption></figure><p>For several months during the summer of 2022, my dog Scout vomited at 3 a.m. nearly every day. If you have a dog, you know the sound. And each time, she gobbled up her mess before I could get to it, making diagnosis of the cause difficult.</p>
<p>The vet and I eventually settled on my hydrangeas as the source of the problem – but keeping Scout away from them didn’t work. She started to seem tired all the time – highly concerning in a typically hyper yellow Lab puppy. </p>
<p>Then one day Scout vomited up a hairball – but not just any hairball. In dogs, hair normally passes easily through the digestive system, but this hairball was wrapped around a brillo pad that was too big to move through. Once this foreign object was removed, the overnight vomiting ended. Scout still needed treatment, though, for a different and surprising reason: The object had inhibited a step in her body’s absorption of vitamin B12. B12 is an essential nutrient involved in proper functioning of blood cells, nerves and many other critical processes in the body. </p>
<p>I’m a registered dietitian, and <a href="https://s.wayne.edu/cress/">I teach nutrition and food science</a> to college students, but still I missed the B12 deficiency that was causing my puppy’s fatigue. Doctors can just as easily be blind to it in people – even though B12 deficiency is a common health problem that affects an estimated <a href="https://ods.od.nih.gov/factsheets/VitaminB12-HealthProfessional/">6% to 20%</a> of the U.S. population. </p>
<p>B12 is scarce in the diet, and it is found only in foods from animal sources. Fortunately, humans need only <a href="https://ods.od.nih.gov/factsheets/VitaminB12-HealthProfessional/">2.4 micrograms of B12 daily</a>, which is equivalent to one ten-millionth of an ounce – a very, very small amount. Without adequate B12 in the body, overall health and quality of life are negatively affected. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/496595/original/file-20221121-22-n793sh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An overhead shot of an array of B12-containing foods, including oysters, fish, eggs, red meat and more." src="https://images.theconversation.com/files/496595/original/file-20221121-22-n793sh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/496595/original/file-20221121-22-n793sh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=417&fit=crop&dpr=1 600w, https://images.theconversation.com/files/496595/original/file-20221121-22-n793sh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=417&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/496595/original/file-20221121-22-n793sh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=417&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/496595/original/file-20221121-22-n793sh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=524&fit=crop&dpr=1 754w, https://images.theconversation.com/files/496595/original/file-20221121-22-n793sh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=524&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/496595/original/file-20221121-22-n793sh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=524&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">An array of vitamin B12-rich foods – all of which come from animals.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/vitamin-b12-containing-foods-royalty-free-image/511052342?phrase=B12%20foods&adppopup=true">photka/iStock via Getty Images Plus</a></span>
</figcaption>
</figure>
<h2>Signs and symptoms</h2>
<p>One primary symptom of B12 deficiency is fatigue – a level of tiredness or exhaustion so deep that it affects daily life activities. </p>
<p>Other symptoms are neurological and may include tingling in the extremities, confusion, memory loss, depression and difficulty maintaining balance. Some of these <a href="https://doi.org/10.1182/blood-2016-10-569186">can be permanent</a> if the vitamin deficiency is not addressed.</p>
<p>However, since there can be so many causes for these symptoms, health care providers may overlook the possibility of a B12 deficiency and fail to screen for it. Further, having a healthy diet may seem to rule out any vitamin deficiency. Case in point: Because I knew Scout’s diet was sound, I didn’t consider a B12 deficiency as the source of her problems. </p>
<h2>How B12 is absorbed</h2>
<p>Research is clear that people who consume plant-based diets <a href="https://doi.org/10.1080/10408398.2022.2107997">must take B12 supplements</a> in amounts typically provided by standard multivitamins. However, hundreds of millions of Americans who do consume B12 may also be at risk because of conditions that could be hampering their body’s absorption of B12.</p>
<p>B12 absorption is a <a href="https://doi.org/10.1038/nrgastro.2012.76">complex multistep process</a> that begins in the mouth and ends at the far end of the small intestine. When we chew, our food gets mixed with saliva. When the food is swallowed, a substance in saliva called <a href="https://doi.org/10.3390/nu12123838">R-protein</a> – a protein that protects B12 from being destroyed by stomach acid – travels to the stomach along with the food. </p>
<p>Specific cells in the stomach lining, called parietal cells, secrete two substances that are important to B12 absorption. One is stomach acid – it splits food and B12 apart, allowing the vitamin to bind to the saliva’s R-protein. The other substance, called intrinsic factor, mixes with the stomach’s contents and travels with them into the first part of the small intestine – the duodenum. Once in the duodenum, pancreatic juices release B12 from R-protein and hand it to intrinsic factor. This pairing allows B12 to be absorbed into cells, where it can then help maintain nerve cells and form healthy red blood cells.</p>
<p>A B12 deficiency typically involves a breakdown at one or more of these points on the way to absorption.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/ANd8trfNvKQ?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Dr. Darien Sutton explains symptoms of B12 deficiency in this December 2021 segment of the ABC TV show ‘Good Morning America.’</span></figcaption>
</figure>
<h2>Risk factors for B12 deficiency</h2>
<p>Without saliva, B12 will not bind to the saliva’s R-protein, and the body’s ability to absorb it is inhibited. And there are hundreds of different <a href="https://ostrowon.usc.edu/medications-that-cause-dry-mouth/">drugs that can cause dry mouth</a>, resulting in too little saliva production. They include opioids, inhalers, decongestants, <a href="https://doi.org/10.3389/fpsyt.2020.00035">antidepressants</a>, <a href="https://www.cdc.gov/mmwr/volumes/69/wr/mm6914a1.htm">blood pressure drugs</a> and <a href="https://doi.org/10.1176%2Fappi.ps.201800321">benzodiazepines</a>, like Xanax, used to treat anxiety. </p>
<p>The last three categories alone account for easily 100 million prescriptions in the U.S. each year. </p>
<p>Another potential contributor to B12 deficiency is low levels of stomach acid.
Hundreds of millions of Americans take <a href="https://www.drugs.com/condition/gastric-ulcer.html?page_number=2">anti-ulcer medications</a> that reduce ulcer-causing stomach acids. Researchers have firmly linked the use of these drugs to <a href="https://doi.org/10.1093/advances/nmy023">B12 deficiency</a> – although that possibility <a href="https://doi.org/10.1053/j.gastro.2017.01.031">may not outweigh the need for the medication</a>. </p>
<p>Production of stomach acid <a href="https://doi.org/10.1093/ajcn/nqab193">can also decrease with aging</a>. More than 60 million people in the U.S. are <a href="https://acl.gov/sites/default/files/aging%20and%20Disability%20In%20America/2020Profileolderamericans.final_.pdf">over age 60</a>, and some 54 million are over the age of 65. This population faces a higher risk of B12 deficiency – which may be further increased by use of acid-reducing medications. </p>
<p>Production of gastric acid and intrinsic factor by the specialized parietal cells in the stomach is critical for B12 absorption to occur. But damage to the stomach lining can prevent production of both. </p>
<p>In humans, impaired stomach lining stems from gastric surgery, chronic inflammation or <a href="https://doi.org/10.1038/ajg.2009.231">pernicious anemia</a> – a medical condition characterized by fatigue and a long list of other symptoms.</p>
<p>Another common culprit of B12 deficiency is inadequate <a href="https://doi.org/10.1172/jci108924">pancreas function</a>. About one-third of patients with poor pancreas function <a href="https://doi.org/10.1097/00006676-199009000-00011">develop a B12 deficiency</a>. </p>
<p>And lastly, Metformin, a drug used by around <a href="https://www.statista.com/statistics/780332/metformin-hydrochloride-prescriptions-number-in-the-us/">92 million Americans</a> to treat Type 2 diabetes, has been associated with <a href="https://doi.org/10.1136%2Fbmj.2.5763.685">B12 deficiency for decades</a>.</p>
<h2>Treatment for B12 deficiency</h2>
<p>While some health care providers routinely measure B12 and other vitamin levels, a typical well-check exam includes only a complete blood count and a metabolic panel, neither of which measures B12 status. If you experience potential symptoms of a B12 deficiency and also have one of the risk factors above, you should see a doctor to be tested. A proper lab workup and discussion with a physician are necessary to discover or rule out whether inadequate B12 levels could be at play.</p>
<p>In the case of my dog Scout, her symptoms led the vet to run two blood tests: a complete blood count and a B12 test. These are also good starting points for humans. Scout’s symptoms went away after a few months of taking oral B12 supplements that also contained an active form of the B vitamin folate.</p>
<p>In humans, the type of treatment and length of recovery depend on the cause and severity of the B12 deficiency. Full recovery can take up to a year but is very possible with appropriate treatment. </p>
<p><a href="https://doi.org/10.3389/fphar.2022.972468">Treatment for B12 deficiency</a> can be oral, applied under the tongue or administered through the nose, or it may require various types of injections. A B12 supplement or balanced multivitamin may be enough to correct the deficiency, as it was for Scout, but it’s best to work with a health care provider to ensure proper diagnosis and treatment.</p><img src="https://counter.theconversation.com/content/192714/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Diane Cress does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The symptoms of B12 deficiency resemble a lot of other health problems, putting millions of Americans at risk of a misdiagnosis.Diane Cress, Associate Professor of Nutrition and Food Science, Wayne State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1827262022-07-19T17:34:43Z2022-07-19T17:34:43ZWarsaw Ghetto’s defiant Jewish doctors secretly documented the medical effects of Nazi starvation policies in a book rediscovered on a library shelf<figure><img src="https://images.theconversation.com/files/474632/original/file-20220718-76232-8ep20p.jpg?ixlib=rb-1.1.0&rect=120%2C111%2C1165%2C793&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The book includes haunting photos from inside the ghetto, along with its record of the medical effects of starvation.</span> <span class="attribution"><span class="source">'Maladie de Famine," American Joint Distribution Committee</span></span></figcaption></figure><p>In 1942, a group of starving Jewish scientists and doctors in the Warsaw Ghetto were collecting data on their starving patients. They hoped their research would benefit future generations through better ways to treat malnutrition, and they wanted the world to know of Nazi atrocities to prevent something similar from ever happening again. They recorded the grim effects of an almost complete lack of food on the human body in a rare book titled “<a href="https://www.worldcat.org/title/maladie-de-famine-recherches-cliniques-sur-la-famine-executees-dans-le-ghetto-de-varsovie-en-1942/oclc/613124708">Maladie de Famine</a>” (in English, “The Disease of Starvation: Clinical Research on Starvation in the Warsaw Ghetto in 1942”) that we <a href="https://dl.tufts.edu/concern/pdfs/h415pr96d">rediscovered in the Tufts University library</a>.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/474374/original/file-20220715-4647-pxtnux.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="yellowed frontispiece of a book" src="https://images.theconversation.com/files/474374/original/file-20220715-4647-pxtnux.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/474374/original/file-20220715-4647-pxtnux.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=830&fit=crop&dpr=1 600w, https://images.theconversation.com/files/474374/original/file-20220715-4647-pxtnux.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=830&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/474374/original/file-20220715-4647-pxtnux.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=830&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/474374/original/file-20220715-4647-pxtnux.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1042&fit=crop&dpr=1 754w, https://images.theconversation.com/files/474374/original/file-20220715-4647-pxtnux.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1042&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/474374/original/file-20220715-4647-pxtnux.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1042&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">This French translation was donated to the Tufts University library in 1948.</span>
<span class="attribution"><span class="source">'Maladie de Famine,' American Joint Distribution Committee</span></span>
</figcaption>
</figure>
<p><a href="https://scholar.google.com/citations?user=HyTsVigAAAAJ&hl=en&oi=ao">As scientists who</a> <a href="https://scholar.google.com/scholar?q=irwin%20rosenberg&btnG=&hl=en&as_sdt=0%2C22">study starvation</a>, its biological effects and its use as a weapon of mass destruction, we believe the story of how and why Jewish scientists conducted this research in such extreme conditions is as important and compelling as its results. </p>
<p>The clandestine project’s lead doctor, Israel Milejkowski, wrote the books’s foreword. In it, he explains:</p>
<blockquote>
<p>“The work was originated and pursued under unbelievable conditions. I hold my pen in my hand and death stares into my room. It looks through the black windows of sad empty houses on deserted streets littered with vandalized and burglarized possessions. … In this prevailing silence lies the power and the depth of our pain and the moans that one day will shake the world’s conscience.”</p>
</blockquote>
<p>Reading these words, we were both transfixed, transported by his voice to a time and place where starvation was being used as a weapon of oppression and annihilation as the Nazis were systematically exterminating all Jews in their occupied territories. As scholars of starvation, we were also well aware that this book catalogs many of the justifications for the <a href="https://www.icrc.org/en/doc/war-and-law/treaties-customary-law/geneva-conventions/overview-geneva-conventions.htm">1949 Geneva Conventions</a>, which made starvation of civilians a war crime.</p>
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<h2>A defiant medical record</h2>
<p>Within months of their 1939 invasion of Poland, Nazi forces created the infamous Warsaw Ghetto. At its peak, more than <a href="https://www.jstor.org/stable/26627292">450,000 Jews were required to live in this small, walled-off area</a> of about 1.5 square miles (3.9 square kilometers) within the city, <a href="https://doi.org/10.2307/4065270">unable to leave even to look for food</a>.</p>
<p>Although Germans in Warsaw were allotted a <a href="https://hekint.org/2022/01/06/the-warsaw-ghetto-hunger-study/">daily ration of about 2,600 calories</a>, physicians in the ghetto estimated that Jews were able to consume only about 800 calories a day on average through a combination of rations and smuggling. That’s about half the calories volunteers consumed in <a href="https://doi.org/10.1093/jn/135.6.1347">a study on starvation</a> conducted near the end of World War II by researchers at the University of Minnesota, and less than a <a href="https://www.dietaryguidelines.gov/sites/default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf">third of the average energy needs of an adult male</a>.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/474375/original/file-20220715-16-4kqicm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="emaciated naked patient sits on hospital bed with nurse behind" src="https://images.theconversation.com/files/474375/original/file-20220715-16-4kqicm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/474375/original/file-20220715-16-4kqicm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=742&fit=crop&dpr=1 600w, https://images.theconversation.com/files/474375/original/file-20220715-16-4kqicm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=742&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/474375/original/file-20220715-16-4kqicm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=742&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/474375/original/file-20220715-16-4kqicm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=932&fit=crop&dpr=1 754w, https://images.theconversation.com/files/474375/original/file-20220715-16-4kqicm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=932&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/474375/original/file-20220715-16-4kqicm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=932&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Even before mass deportations to death camps, many thousands of Jews died because of conditions within the Warsaw Ghetto.</span>
<span class="attribution"><span class="source">'Maladie de Famine,' American Joint Distribution Committee</span></span>
</figcaption>
</figure>
<p>When the Nazis designated the district of the Warsaw Ghetto, it enclosed two hospitals, one serving Jewish adults and another for Jewish children. The hospitals were allowed to continue to treat patients with whatever resources they could obtain, but Jews in general were <a href="https://www.archives.gov/publications/prologue/2010/winter/nuremberg.html">forbidden from conducting research</a>. Nevertheless, starting in February 1942, a group of Jewish doctors in the ghetto defied their captors by meticulously and secretly gathering data and observations on multiple biological aspects of starvation.</p>
<p>Then on July 22, 1942, Nazi forces entered the ghetto and destroyed the hospitals and other critical services. Patients and some of the doctors were killed outright or deported to be gassed, their laboratories, samples and some of their research destroyed.</p>
<p>With their own demise approaching, the remaining doctors spent the last nights of their lives meeting secretly in the cemetery buildings, transforming their data into a series of research articles. By October, as they put the finishing touches on the book, about <a href="https://encyclopedia.ushmm.org/content/en/article/deportations-to-and-from-the-warsaw-ghetto">300,000 Jews from the ghetto had already been gassed</a>. The physicians’ own data showed that another 100,000 had been killed through forced starvation and disease.</p>
<p>With final deportations of the few surviving Jews underway and his own death imminent, Milejkowski wrote of the dark, yawning emptiness of the ghetto at that moment, and the horrifying conditions the doctors had labored under to conduct and record the research. </p>
<p>Milejkowski had words for not only the reader, but also his dear colleagues, many of whom had already been executed.</p>
<blockquote>
<p>“What can I tell you, my beloved colleagues and companions in misery. You are a part of all of us. Slavery, hunger, deportation, those death figures in our ghetto were also your legacy. And you, by your work, could give the henchman the answer ‘Non omnis moriar,’ [I shall not wholly die].”</p>
</blockquote>
<p>The team’s act of resistance through science was its way to wring something good out of an evil situation, to show the world the quality of the Jewish doctor, but mostly to defy the Nazis’ intent to erase their existence.</p>
<p>With death knocking on the door, the doctors smuggled their precious research out of the ghetto to a sympathizer who buried it in the cemetery of the Warsaw hospital. Less than a year later, all but a few of the 23 authors were dead.</p>
<p>Immediately after the war, the manuscript was dug up and taken to one of the few surviving authors, Dr. Emil Apfelbaum, and the American Joint Distribution Committee in Warsaw, a charity whose main purpose at the time was to help <a href="https://www.jdc.org/video/75-years-later-remembering-jdcs-role-in-saving-wwii-survivors">Jewish survivors</a>. Together, they made the final edits and printed the six surviving articles, binding them into a book along with photos taken in the ghetto. Apfelbaum died just a couple of months before the final printing, broken by his years in the ghetto.</p>
<p>In 1948 and 1949, the American Joint Distribution Committee disseminated 1,000 copies of the French translation to hospitals, medical schools, libraries and universities across the U.S. It was one humble, crumbling copy of this book that waited to be “rediscovered” about 75 years later in the basement of a Tufts University library.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/474631/original/file-20220718-61161-bd2k07.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="black and white photo of an emaciated boy lying on a bed" src="https://images.theconversation.com/files/474631/original/file-20220718-61161-bd2k07.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/474631/original/file-20220718-61161-bd2k07.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=453&fit=crop&dpr=1 600w, https://images.theconversation.com/files/474631/original/file-20220718-61161-bd2k07.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=453&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/474631/original/file-20220718-61161-bd2k07.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=453&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/474631/original/file-20220718-61161-bd2k07.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=569&fit=crop&dpr=1 754w, https://images.theconversation.com/files/474631/original/file-20220718-61161-bd2k07.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=569&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/474631/original/file-20220718-61161-bd2k07.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=569&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Many of the ghetto’s inhabitants had no other diseases beyond the effects of starvation.</span>
<span class="attribution"><span class="source">'Maladie de Famine,' American Joint Distribution Committee</span></span>
</figcaption>
</figure>
<h2>The book’s grim descriptions</h2>
<p>Based on observations of thousands of deaths from starvation, this research from the Warsaw Ghetto provides insight into the biological progression of starvation that scientists now are just beginning to understand.</p>
<p>For example, many Warsaw Ghetto residents who died of starvation were otherwise free of disease. The ghetto researchers found that while an otherwise healthy body diminished through starvation apparently had a decreased need for vitamins, the need for certain minerals remained. They saw few cases of scurvy (vitamin C deficiency), night blindness (vitamin A deficiency) or rickets (vitamin D deficiency). But they did see significant osteomalacia, a softening of the bones, as the body mined them for their stores of minerals.</p>
<p>When the doctors provided sugar to the severely malnourished, their energy-starved cells quickly absorbed it. This demonstrated that the ability to quickly absorb and use energy remained to the end, suggesting that energy was the single most important factor in starvation, not other micro- or macronutrients.</p>
<p>Each of these observations invites us as scientists to explore further. And with these lessons we can hope to prevent deaths or long-term harm from starvation through better treatment for the severely malnourished.</p>
<p>As scientists studying starvation today, it would be <a href="https://www.ama-assn.org/system/files/2019-01/code-of-medical-ethics-chapter-7.pdf">unthinkable and unethical to starve people</a> to learn how the human body adjusts and changes during the end stages of extreme starvation. Even if researchers go into a famine-stricken population to learn about starvation, they immediately treat the victims, erasing the very object of their research.</p>
<p>Partly as a result of the experience of the Warsaw Ghetto, the Geneva Conventions made <a href="https://ihl-databases.icrc.org/applic/ihl/ihl.nsf/Article.xsp?action=openDocument&documentId=ACF5220D585326BCC12563CD0051E8B6">intentional mass starvation a crime</a>, further strengthened by a U.N. Security Council Resolution <a href="https://www.un.org/press/en/2018/sc13354.doc.htm">as recently as 2018</a>. Nevertheless, this inhumane aspect of war <a href="https://theconversation.com/starving-civilians-is-an-ancient-military-tactic-but-today-its-a-war-crime-in-ukraine-yemen-tigray-and-elsewhere-184297">remains to this day</a>, as evidenced by current events in <a href="https://www.politico.eu/article/the-starvation-of-a-nation-how-putin-is-using-hunger-as-a-weapon-in-ukraine/">Ukraine</a> and <a href="https://www.economist.com/leaders/2021/10/09/ethiopia-is-deliberately-starving-its-own-citizens">Tigray</a>, Ethiopia.</p>
<p>Though “Maladie de Famine” has never been totally lost or forgotten, the lessons from the doctors’ research have faded to semi-obscurity. Eight decades after the destruction that ended their studies, we hope to shine a renewed light on this work and its enduring impact on physicians’ understanding of starvation and how to treat it. The unique data and observations regarding severe starvation that the Warsaw Ghetto doctors, despite their own suffering, presented in this precious book can even now help safeguard others from that same fate.</p>
<hr>
<p><em>The Joint Distribution Committee, which holds the copyright for “Maladie de Famine,” has allowed Tufts University to post a freely accessible <a href="https://dl.tufts.edu/concern/pdfs/h415pr96d">scan of the book</a> online.</em></p><img src="https://counter.theconversation.com/content/182726/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The story behind the research can be as compelling as the results. Recording the effects of starvation, a group of Jewish doctors demonstrated their dedication to science – and their own humanity.Merry Fitzpatrick, Research Assistant Professor of Nutrition Science and Policy, Tufts UniversityIrwin Rosenberg, Professor Emeritus of Nutrition and Medicine, Tufts UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1521262020-12-17T12:52:08Z2020-12-17T12:52:08ZArfid: the eating disorder that makes people fear food<figure><img src="https://images.theconversation.com/files/375647/original/file-20201217-17-1iqpsaj.jpg?ixlib=rb-1.1.0&rect=17%2C0%2C5734%2C3837&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">ARFID sufferers have an inherent fear of food and the act of eating.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/picky-eater-child-eating-soup-disgust-335893991">Photographee.eu/ Shutterstock</a></span></figcaption></figure><p>Most of us are picky about some foods – and that’s normal – but for some people, pickiness can be dysfunctional. A little-known eating disorder – called avoidant restrictive food intake disorder (Arfid) – can have a severe, lifelong impact on eating habits.</p>
<p>This condition gained a lot of attention in 2019 after it emerged that a <a href="https://theconversation.com/poor-diet-can-lead-to-blindness-122812">teenage boy</a> in the UK suffered irreversible sight and hearing loss after years of only eating crisps, chips, and white bread. More than just a case of “picky eating”, the teen suffered from Arfid and stuck to his narrow diet because the texture of other foods was difficult for him to tolerate. While an extreme example, it nonetheless shows how harmful this eating disorder can be for those who suffer from it.</p>
<p>Avoidant restrictive food intake disorder is a <a href="https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t18/">relatively newly recognised condition</a>, first recognised by the American Psychiatric Association in 2013. It’s thought to affect around <a href="https://pubmed.ncbi.nlm.nih.gov/25165558/">5-15% of children</a> admitted to hospital with eating problems and <a href="https://pubmed.ncbi.nlm.nih.gov/33283329/">less than 1%</a> of adults. </p>
<p>Arfid is different from other restrictive eating disorders, such as anorexia and bulimia. People with the condition aren’t trying to control their weight. Rather, they have an inherent fear of food and the act of eating. While certain foods, sights, or smells may evoke disgust or fear in many of us, people with Arfid feel like this every day, about many of the food they encounter.</p>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/30053436/">Many experience</a> incredible anxiety towards foods they consider unsafe – causing diets to lack nutrition as a result. Many also have no motivation to change their eating habits as the psychological discomfort of trying to include “unsafe foods” is difficult to manage. </p>
<p>Given the newness of this disorder, much remains unknown about it. However, psychologists typically agree that someone with avoidant restrictive food intake disorder will have one or more of the following characteristics:</p>
<ul>
<li>An absence of hunger or apparent lack of interest in eating or food.</li>
<li>Avoiding foods because of their sight, smell or taste.</li>
<li>Worry from a parent or child about the limited number and types of food eaten.</li>
<li>Not eating enough calories, protein, vitamins or minerals.</li>
</ul>
<p>Diagnosing Arfid can be difficult, but typically, doctors will look at the amount and number of food types a person eats, how long avoidance of certain foods has been a problem, whether a person has lost weight or if their growth is stunted. </p>
<p>They will also look for signs of nutritional deficiencies – such as brittle nails and hair, skin changes, bleeding gums or lips, unexplained bruising, changes in eyesight, chronic fatigue and forgetfulness, and poor growth. They will also look at whether the condition causes distress or interferes with daily life.</p>
<h2>Dangers of ‘picky eating’</h2>
<p>Most parents of toddlers will probably say their child is a “picky eater”. This is a normal stage of child development, and most children will grow out of it by four to six years of age. But Arfid is distinct, and children often develop it after previous <a href="https://pubmed.ncbi.nlm.nih.gov/24506978/">negative experiences</a> with types of food that may have caused them to gag or retch as young children. Fear of choking or vomiting, aversion to certain tastes or textures, or a lack of drive to eat are all thought to be causes. Adults with Arfid can often relate their feelings about food to experiences as a young child and experience the same avoidant feelings as children.</p>
<figure class="align-center ">
<img alt="Child eating a slice of white bread." src="https://images.theconversation.com/files/375649/original/file-20201217-23-dcrzru.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/375649/original/file-20201217-23-dcrzru.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=372&fit=crop&dpr=1 600w, https://images.theconversation.com/files/375649/original/file-20201217-23-dcrzru.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=372&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/375649/original/file-20201217-23-dcrzru.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=372&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/375649/original/file-20201217-23-dcrzru.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=467&fit=crop&dpr=1 754w, https://images.theconversation.com/files/375649/original/file-20201217-23-dcrzru.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=467&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/375649/original/file-20201217-23-dcrzru.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=467&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">People with ARFID may only eat a few types of food – such as white bread or rice.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/children-poor-nutrition-kid-eating-white-1036407973">FotoHelin/ Shutterstock</a></span>
</figcaption>
</figure>
<p>Children who are picky eaters will not usually lose weight or rely on nutritional drinks or feeding tubes. They will also not have fear or phobias around vomiting, choking or limit their food intake to such an extent they lose weight and develop signs of vitamin and mineral deficiencies.</p>
<p>And unlike your average picky eater, people with Arfid may only eat less than 20 different types of food – typically “white” or “beige” foods, such as bread, boiled rice and crackers. This can lead to weight loss or growth faltering in children, deterioration of psychological function, and nutritional deficiencies. </p>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/33221247/">A recent systematic review</a> of case reviews of patients with both Arfid and autism, found that almost 70% of those with Arfid had scurvy (vitamin C deficiency), while 17% had eye disorders as a result of vitamin A deficiency. Vitamin D, B12, and thiamine deficiencies were also reported. These vitamins and minerals are essential for helping the body function properly. It’s recommended that those with suspected Arfid be referred to specialist care to ensure they have help to manage their condition.</p>
<p>Eating is an important social activity for many worldwide. But avoidant restrictive food intake disorder can leave many feeling isolated as a result. Given this is a relatively new disorder, it will be important for research to continue working to understand why the condition develops, and how to better help patients recover.</p><img src="https://counter.theconversation.com/content/152126/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Luise Marino does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Avoidant restrictive intake food disorder is a relatively new condition that researchers are only beginning to understand.Luise Marino, Programme Lead Nutrition and Dietetics, University of WinchesterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1253892019-10-25T12:23:44Z2019-10-25T12:23:44ZVitamin B12 deficiency: what is pernicious anaemia, and why can it be so dangerous?<figure><img src="https://images.theconversation.com/files/298591/original/file-20191024-170467-sbfioq.jpg?ixlib=rb-1.1.0&rect=70%2C10%2C6639%2C4456&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Typical symptoms include extreme tiredness, lack of energy, muscle weakness, and even problems with memory. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/tired-woman-touching-her-eyes-694175920?src=8wvRDoVdLZvpWkTVM2arpw-1-63">sebra/ Shutterstock</a></span></figcaption></figure><p>An estimated <a href="https://www.bmj.com/content/349/bmj.g5226">6% of people</a> in the US and UK suffer from vitamin B12 deficiency. The condition is recognised by the World Health Organisation as a <a href="https://www.who.int/nutrition/publications/micronutrients/FNBvol29N2supjun08.pdf">global health problem</a> that could impact millions of lives. B12 deficiency is <a href="https://www.nhs.uk/conditions/vitamin-b12-or-folate-deficiency-anaemia/">typically characterised</a> by symptoms such as extreme tiredness, lack of energy, muscle weakness, and even problems with memory. Not only that, but it can cause a number of serious health problems, such as irreversible nerve damage, anxiety or depression, or disorders which <a href="https://www.nhs.uk/conditions/ataxia/">affect coordination, balance, and speech</a>. </p>
<p>While some B12 deficiencies are caused by diet, the most common reason for low B12 levels worldwide is an <a href="https://www.hammersmithbooks.co.uk/product/what-you-really-need-to-know-about-vitamin-b12-deficiency-and-pernicious-anaemia/">autoimmune disorder called pernicious anaemia</a>. This is a chronic form of low B12 that can have serious consequences on health if left untreated long-term. However, because symptoms of the condition typically look like other common conditions, it’s often misdiagnosed as depression or anxiety. Not only does the condition cause physical distress, the stigma of living with this chronic condition can also <a href="https://www.sciencedirect.com/science/article/pii/S0022399918306111?via%3Dihub">cause serious psychological harm</a>, as I’ve shown in my research. </p>
<p>Vitamin B12 – otherwise known as <em>cobalamin</em> – is a water-soluble vitamin found in animal by-products, such as meat, fish and dairy. Other sources include fortified cereal, breads and plant milks. People who don’t regularly consume animal products are at risk of becoming deficient in B12. To reduce this risk, vegans are recommended to consume at least three micrograms of B12 daily through fortified foods, or by <a href="https://www.vegansociety.com/resources/nutrition-and-health/nutrients/vitamin-b12/what-every-vegan-should-know-about-vitamin-b12">taking a regular B12 supplement</a>.</p>
<p>However, most low B12 levels are more caused by pernicious anaemia. The condition makes it difficult for people to process vitamin B12 because the immune system impacts on the functioning of important parietal cells within the stomach. These cells produce a protein called “intrinsic factor” which is <a href="https://www.ncbi.nlm.nih.gov/pubmed/9358143">essential for vitamin absorption</a>. People with pernicious anaemia will produce an antibody to Intrinsic Factor that destroys any Intrinsic Factor that has been produced. And so, without any Intrinsic Factor to bind to food, they are unable to extract any B12. Without B12, the body isn’t able to produce enough healthy red blood cells. The condition can also be caused by a <a href="https://www.emjreviews.com/gastroenterology/article/atrophic-body-gastritis-clinical-presentation-diagnosis-and-outcome/">weakened stomach lining</a>. This may happen because of atrophic gastritis, chronic inflammation in the stomach that eventually weakens the lining. </p>
<h2>A lifelong condition</h2>
<p>An estimated five in every 100,000 people in the UK have pernicious anaemia. It <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/bjh.12959">effects people of all ages</a>, and symptoms can start at any time. However, the condition is <a href="https://www.ncbi.nlm.nih.gov/pubmed/25189324">more common in people over 60</a>, as older adults are more likely to develop atrophic gastritis, which increases the risk of B12 deficiency. The number of people with the condition worldwide might be higher than estimated. However, it’s difficult to reliably estimate levels of B12 deficiency because there’s no agreed definition of how low B12 levels must be to be classified as deficient. </p>
<p>New guidelines have been made to address problems with <a href="https://b-s-h.org.uk/guidelines/guidelines/diagnosis-of-b12-and-folate-deficiency/">current diagnosis methods</a>. They state that a patient’s symptoms are the best indicator of any deficiency. It also states that if there’s inconsistency with the test result and the patient’s reported symptoms, the patient should still be treated with replacement B12 to prevent any potential irreversible damage. </p>
<p>B12 deficiency causes a wide range of debilitating neurological and physical symptoms. The <a href="https://www.ncbi.nlm.nih.gov/pubmed/24732991">most common symptoms</a> of pernicious anaemia are fatigue, memory loss and problems with concentration. However, the subtle, nonspecific nature of the condition’s initial symptoms can make it difficult to properly diagnose people. One study interviewing members of the Pernicious Anaemia Society found that nearly <a href="https://www.ncbi.nlm.nih.gov/pubmed/24732991">half had been misdiagnosed</a>. A further 20% had waited two years or more for a proper diagnosis. For many, symptoms were initially attributed to a hectic lifestyle or <a href="https://repository.cardiffmet.ac.uk/handle/10369/10769?locale-attribute=cy">diagnosed as anxiety or depression</a>.</p>
<p>Low levels of B12 can lead to nerve damage, as the vitamin is essential to producing myelin, which protects nerve cells from damage. Symptoms of low B12 might initially feel like tingling or numbness in hands and feet, or difficulty with balance. If pernicious anaemia is left untreated, symptoms can become debilitating and nerve damage irreversible. The term “pernicious” was used to describe the condition as historically it resulted in death. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/298595/original/file-20191024-170449-863v7x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/298595/original/file-20191024-170449-863v7x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=427&fit=crop&dpr=1 600w, https://images.theconversation.com/files/298595/original/file-20191024-170449-863v7x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=427&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/298595/original/file-20191024-170449-863v7x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=427&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/298595/original/file-20191024-170449-863v7x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=537&fit=crop&dpr=1 754w, https://images.theconversation.com/files/298595/original/file-20191024-170449-863v7x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=537&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/298595/original/file-20191024-170449-863v7x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=537&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Regular injections or B12 tablets are essential for managing the condition.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/closeup-needle-vials-preparing-inject-vitamin-1083680702?src=ErAAnKRbbKg5LW-HamKy_A-1-1">Kristen Prahl/ Shutterstock</a></span>
</figcaption>
</figure>
<p>When Vitamin B12 deficiency is caused by poor diet, it’s treated by <a href="https://cks.nice.org.uk/anaemia-b12-and-folate-deficiency">prescribing B12 tablets or injections of hydroxocobalamin</a>. Once the deficiency has been corrected, levels can be managed by changing diet or regularly taking a supplement. </p>
<p>However, treatment is lifelong for people with pernicious anaemia. In the UK, many need frequent injections every 8 to 12 weeks to replace the vitamin. Despite this, many people continue experiencing debilitating symptoms, or find their symptoms return before their next scheduled injection because their treatment hasn’t been sufficient. </p>
<p>When patients raised concerns about insufficient treatment or requested more frequent injections, <a href="https://repository.cardiffmet.ac.uk/handle/10369/10769?locale-attribute=cy">our research found</a> that many health care professionals responded negatively, even questioning the legitimacy of the patient’s illness. These kinds of questions can increase psychological distress and <a href="https://www.ncbi.nlm.nih.gov/pubmed/21977499">impact on quality of life</a>.</p>
<p>Patients with pernicious anaemia also anticipated high levels of health-related stigma. Many people with chronic health conditions fear that their health
status will lead them to be devalued by wider society, or be a source of discrimination. Stigma not only impacts on relationships with health care providers, but can cause <a href="https://www.sciencedirect.com/science/article/pii/S0022399918306111?via%3Dihub">increased incidence of anxiety and depression</a>.</p>
<p>The lack of appropriate guidelines for diagnosis and treatment of pernicious anaemia is problematic and there is an urgent need for this to be reviewed. It is important that both the general public and health professionals have increased awareness of the symptoms that arise from inadequate levels of B12 so that the condition can be diagnosed before long term damage occurs.</p><img src="https://counter.theconversation.com/content/125389/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Heidi Seage is affiliated with Pernicious Anaemia Society (Research Group Member)</span></em></p>Pernicious anaemia is a lifelong condition that affects nearly 5 in 100,000 people in the UK.Heidi Seage, Senior Lecturer in Psychology, Cardiff Metropolitan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/228872014-03-31T03:48:50Z2014-03-31T03:48:50ZHealth Check: four myths about vitamin supplements<figure><img src="https://images.theconversation.com/files/44173/original/j5hkghtf-1395117676.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">No one really knows whether taking large amounts of vitamins in tablet form is even the best way delivering them to the body.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/shannonkringen/5182061073/sizes/l/">Shannon Kringen/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>People take vitamin supplements for all kinds of reasons, from maintaining general health to preventing cancer. But there’s no convincing evidence that vitamin supplementation benefits people who don’t actually have a vitamin deficiency.</p>
<p>For starters, <a href="http://jama.jamanetwork.com/article.aspx?articleid=1820428">clinical trials of large numbers of people</a> in multiple locations and contexts show vitamin supplements don’t prevent cancer. Rather, <a href="http://news.sciencemag.org/biology/2014/01/antioxidants-could-increase-cancer-rates">there’s emerging evidence</a> (as yet only in mouse models) that some vitamin supplements may actually slightly increase the risk of some cancers. </p>
<p>Still, the appeal of vitamin supplementation in the community seems to be greater than ever. And in an era where conventional therapies are being subjected to increasingly more strenuous tests of efficacy, toxicity and cost effectiveness, the vitamin industry remains outside the mainstream of therapeutic evaluation.</p>
<p>One cause for this mismatch may be the political and financial influence of the vitamin supplements industry. But it’s also worth considering why western society has so enthusiastically embraced dietary supplements, nutriceuticals and complementary medicine.</p>
<h2>Four vitamin myths</h2>
<p>Vitamin supplements appeal to an ever-increasing number of people based on what may appear to be common-sense ideas. But most people completely misunderstand the nature of vitamins and how our bodies absorb them. </p>
<p>Here are some common myths about vitamins and why they’re wrong.</p>
<p><strong>Myth one</strong>: If vitamin deficiency causes disease, supplements must therefore prevent disease. </p>
<p>Put simply, if less is bad, that doesn’t mean more is good. Take profound vitamin A deficiency, which can cause abnormal cell growth in the lining of the mouth and food pipe (oesophagus). There’s no evidence that vitamin A supplements prevent such abnormalities in those at risk, such as smokers and heavy drinkers. </p>
<p>Now consider people who have severe vitamin B12 deficiency due to a condition called pernicious anaemia. They are at increased risk of stomach cancer but this has nothing to do with the vitamin itself. These people have an autoimmune disorder that causes inflammation and cancer in the stomach at the same time as it blocks vitamin B12 uptake in the gut.</p>
<p><strong>Myth two</strong>: Low vitamin “levels” indicate deficiency. </p>
<p>For starters, vitamin deficiency in someone who has a normal balanced diet is extremely rare. </p>
<p>The current trend towards vitamin D supplementation is largely based on the idea that blood levels of the vitamin are below the “normal” range. But whether <a href="https://theconversation.com/six-things-you-need-to-know-about-your-vitamin-d-levels-15814">blood levels accurately reflect</a> total body vitamin D stores in body is still contentious.</p>
<p>The jury is still out on the benefits of supplementation in people with low vitamin D “levels”, and there’s no evidence that routine supplementation is useful in people with normal diets and levels of sun exposure.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/44174/original/fhkx6wxs-1395117804.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/44174/original/fhkx6wxs-1395117804.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/44174/original/fhkx6wxs-1395117804.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/44174/original/fhkx6wxs-1395117804.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/44174/original/fhkx6wxs-1395117804.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/44174/original/fhkx6wxs-1395117804.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/44174/original/fhkx6wxs-1395117804.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">There’s no evidence that routine vitamin D supplementation is useful in people with normal diets.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/healthgauge/7474848656/sizes/l/">Health Gauge/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p><strong>Myth three</strong>: Vitamins are safe.</p>
<p>Actually, this one is correct on the whole. But there are always extreme cases where an excess of vitamins can cause harm, such as toxicity due to the excess intake of vitamin A, particularly in children. </p>
<p>And when vitamins harm, they can go to town. Manifestations of vitamin A toxicity include abnormal bone growth, swelling of the brain, increases in blood calcium concentrations, hair loss, and liver damage. </p>
<p>What happens is because fat-soluble vitamins, such as A,D,E and K, are more difficult to excrete, they can accumulate in the body with excessive intake. Water-soluble vitamins, such as vitamins C, are safer in this regard as people with normal kidney function usually pass excess amounts in urine rather than have it stored in their body. </p>
<p><strong>Myth four</strong>: Vitamins are “natural” compounds, not drugs.</p>
<p>First of all, it’s important to remember that natural doesn’t mean good for you. Consider the taxane family of chemotherapeutics used for treating breast cancer. Taxanes are naturally-occurring molecules extracted from the bark of the pacific yew tree that are able to kill rapidly dividing cancer cells. But they also have potentially life-threatening side effects, such as bone marrow suppression. Nonetheless, taxanes are 100% natural.</p>
<p>Producing supplements requires a combination of purification from natural sources or chemical synthesis – or both – in the same way as many commonly used pharmaceuticals. </p>
<p>Penicillin, for instance, was initially purified from a fungus with natural antibacterial activity. With the exception of an allergy and rare cases of anaphylaxis, penicillin is an extremely safe natural compound, but it’s very much a drug.</p>
<h2>Parting thoughts</h2>
<p>We ingest vitamins from food, or get our gut bacteria to make them for us and then absorb them. In some cases, we make our own in the liver. Either way, we constantly replenish our vitamin stores without realising it. </p>
<p>No one really knows whether taking large amounts of vitamins in tablet form is even the best way delivering them to the body. And even if we choose accept that vitamin supplements largely are safe but have marginal benefit, they still have an economic cost.</p>
<p>If they were regulated as therapeutic products, vitamins would certainly not receive government subsidies since there’s no evidence they work, or that they are cost-effective. </p>
<p>Since people pay for supplements themselves, it’s important they re-evaluate whether the cost of vitamins is really worth it. Based on all the available evidence, a healthy diet and lots of exercise are a much better way to promote good health.</p><img src="https://counter.theconversation.com/content/22887/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Neil Watkins receives funding from the National Health and Medical Research Council of Australia and the
Victorian Cancer Agency.</span></em></p>People take vitamin supplements for all kinds of reasons, from maintaining general health to preventing cancer. But there’s no convincing evidence that vitamin supplementation benefits people who don’t…Neil Watkins, Petre Chair in Cancer Biology, Lab Head - Cancer Developmental Biology, Garvan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/217382014-01-13T19:43:53Z2014-01-13T19:43:53ZMy vitamin D levels are low, should I take a supplement?<figure><img src="https://images.theconversation.com/files/38901/original/bwrk6htk-1389575565.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">If your levels are a little low, ten minutes of mid-morning or mid-afternoon sunshine could get you back to normal.</span> <span class="attribution"><span class="source">Image from shutterstock.com</span></span></figcaption></figure><p>If your blood test results suggest you’re low on vitamin D, you’re not alone – nearly <a href="http://www.ncbi.nlm.nih.gov/pubmed/22168576">one-third</a> of the Australian population isn’t getting enough of the sunshine vitamin. But this doesn’t necessarily mean you need to take a supplement. </p>
<p>Contrary to some reports, there is <a href="http://www.thelancet.com/journals/landia/article/PIIS2213-8587(13)70165-7/fulltext#">no evidence</a> that taking vitamin D supplements reduces your risk of developing diabetes, colon cancer, arthritis or infections, or that supplements help you live longer. </p>
<p>In some cases, taking a supplement merely means you’re wasting your money. But if you’re taking high doses, you may be doing <a href="http://www.ncbi.nlm.nih.gov/pubmed/23250508">more harm</a> than good.</p>
<h2>What is vitamin D?</h2>
<p>Vitamin D is a fat soluble vitamin that is not readily available in the diet, apart from in fatty fish, ultraviolet (UV) light-irradiated and mushrooms*. In fact, an average diet only provides one-sixth of the daily requirement for vitamin D, or about 110 international units (IU). </p>
<p>In many countries, including the United States and Philippines, there is widespread vitamin D fortification of foods, including milk, bread, cereals and orange juice. This does not occur in Australia. </p>
<p>Instead, most circulating vitamin D is generated via the effects of sunlight and UV “B” radiation on a cholesterol precursor in the skin. This then circulates in the blood and is activated in the liver and kidneys to become a hormone. </p>
<p>Anyone with less than 50 nanomoles of vitamin D per litre (nmol/L) at the end of winter or in early spring are categorised as having low levels.</p>
<h2>Vitamin D and health</h2>
<p>Vitamin D aids the absorption of calcium from the gut and is very important for healthy bones and muscles in both children and adults. Low vitamin D levels cause rickets in children, and soft (<a href="http://www.mayoclinic.org/diseases-conditions/osteomalacia/basics/definition/con-20029393">osteomalacia</a>) or thin bones (<a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Osteoporosis">osteoporosis</a>) in adults.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/38930/original/75d4rjm4-1389586637.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/38930/original/75d4rjm4-1389586637.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/38930/original/75d4rjm4-1389586637.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/38930/original/75d4rjm4-1389586637.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/38930/original/75d4rjm4-1389586637.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/38930/original/75d4rjm4-1389586637.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/38930/original/75d4rjm4-1389586637.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Boosting your vitamin D levels will help ensure your bones remain healthy as you get older.</span>
<span class="attribution"><span class="source">Image from shutterstock.com</span></span>
</figcaption>
</figure>
<p>What is less clear is whether low vitamin D levels are associated with other chronic diseases such as bowel cancer, diabetes, heart disease, arthritis, infections and the overall risk of dying. This is because these low vitamin D levels could either be the cause or result of ill health.</p>
<p>A recent study in <a href="http://www.thelancet.com/journals/landia/article/PIIS2213-8587(13)70165-7/fulltext#">Lancet Diabetes and Endocrinology</a> shows that earlier findings, derived from studies in which patients with several different chronic diseases had low vitamin D levels, were not reinforced by higher-level evidence resulting from clinical trials using vitamin D supplements. </p>
<p>In these trials, vitamin D supplements were given to correct low levels and to reduce effects of these diseases. The only exception was that vitamin D supplements slightly reduced the risk of dying in the elderly.</p>
<p>This apparent disconnect between the two levels of evidence may mean that low vitamin D levels are a marker of ill health, but not a causative factor for these chronic diseases.</p>
<h2>The research solution</h2>
<p>Large trials of vitamin D supplements in people with low vitamin D levels are now underway. Our study is based at the Berghofer Queensland Institute of Medical Research and the University of Melbourne, and will track participants over ten years.</p>
<p>We will treat 25,000 people aged from 60 to 79 years with low vitamin D levels to see whether vitamin D supplements will reduce the risk of dying. We will also see whether supplements reduce the risk of developing chronic diseases such as colon cancer, arthritis, infections and diabetes, as well as falls and fractures. </p>
<p>Studies such as ours will also need to look at markers of underlying disease activity.</p>
<h2>The answer</h2>
<p>So while we are waiting for this new evidence, what can you do about your low vitamin D level? </p>
<p>If the level is mildly decreased, rolling up your sleeves and getting outside in the sun more often — say, for about ten minutes at 10am or 2pm in summer, or for about 30 minutes at midday in winter — might help. </p>
<p>At these times, the UV index is likely to be less than three, indicating such limited sun exposure will be relatively safe. You can check how much sun you need on the <a href="http://healthybonesaustralia.org.au">Healthy Bones Australia</a> website.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/38925/original/k26yb56v-1389586115.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/38925/original/k26yb56v-1389586115.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/38925/original/k26yb56v-1389586115.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/38925/original/k26yb56v-1389586115.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/38925/original/k26yb56v-1389586115.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/38925/original/k26yb56v-1389586115.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/38925/original/k26yb56v-1389586115.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Vitamin D doses of 1,000 or 2,000 international units (IU) per day are safe.</span>
<span class="attribution"><span class="source">Image from shutterstock.com</span></span>
</figcaption>
</figure>
<p>Boosting your vitamin D levels, combined with a good dietary calcium intake of at least three serves per day and weight-bearing exercise (which includes brisk walking) for 20 minutes four times a week, will also help ensure your bones remain healthy as you get older.</p>
<p>If you are unable to get outdoors, or you cover your skin for cultural reasons, have dark skin, osteoporosis or low bone density (thin bones), you may need to take a supplement. The usual dose is 1,000 or 2,000 international units (IU) per day for most people. </p>
<p>After taking daily vitamin D supplements for three months, your doctor can check if the levels have increased above the recommended level of 50 nanomoles per litre (nmol/L). Such doses are safe, but very large yearly doses are not recommended because they can actually <a href="http://www.ncbi.nlm.nih.gov/pubmed/23250508">increase the risk</a> of falls and fractures.</p>
<p><em>* The original article incorrectly claimed green leafy vegetables were a source of vitamin D. This has now been corrected.</em> </p><img src="https://counter.theconversation.com/content/21738/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Ebeling receives funding from NHMRC.</span></em></p>If your blood test results suggest you’re low on vitamin D, you’re not alone – nearly one-third of the Australian population isn’t getting enough of the sunshine vitamin. But this doesn’t necessarily mean…Peter Robert Ebeling, Professor of Medicine, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/197902013-11-01T17:46:53Z2013-11-01T17:46:53ZGolden rice naysayers ignore the world’s need for nutrition<figure><img src="https://images.theconversation.com/files/34256/original/zmmjkd2p-1383323083.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Golden rice, texture like sun.</span> <span class="attribution"><span class="source">International Rice Research Institute</span></span></figcaption></figure><p>Recently Zac Goldsmith MP – a former editor of The Ecologist, no less – <a href="http://www.theguardian.com/commentisfree/2013/oct/24/owen-paterson-minister-gm-hype">branded</a> the views of Environment Secretary Owen Patterson as “grotesque” after the minister called anti-GM campaigners “wicked”. Mr Goldsmith stated:</p>
<blockquote>
<p>GM has never been about feeding the world, or tackling environmental problems. It is and has always been about control of the global food economy by a tiny handful of giant corporations. It’s not wicked to question that process. It is wicked not to.</p>
</blockquote>
<p>By saying as much Mr Goldsmith drags up arguments that are out of date and out of place. <a href="http://www.goldenrice.org/">Golden rice</a> is a bio-fortified, genetically modified <em>Oryza sativa</em> rice crop that offers a nutritionally enriched staple for those who cannot afford or obtain a balanced diet rich in fruit and vegetables. Golden rice can be produced by subsistence farmers in developing countries using varieties adapted to local conditions. Access to the technology <a href="http://www.goldenrice.org/Content2-How/how9_IP.php">is free</a>.</p>
<p>Lack of vitamin A <a href="http://www.who.int/nutrition/topics/vad/en/">causes blindness and death</a> in over a million children under five that do not have access to a balanced diet, every year. For many their staple diet is rice, but rice does not produce vitamin A in the grain even though it has all the genes necessary to do so (and in fact does so in the leaves).</p>
<p>The inventors of golden rice, <a href="http://fbae.org/2009/FBAE/website/governing-body_ingo.html">Ingo Potrykus</a> of the Swiss Federal Institute of Technology and <a href="http://www.bioss.uni-freiburg.de/cms/92.html">Peter Beyer</a> of the University of Freiburg, worked out how to “turn on” the synthesis of vitamin A in the edible grain itself by inserting two genes, resulting in a rice variety with boosted vitamin A levels. Widespread adoption of golden rice could decrease deaths due to vitamin A deficiency by an estimated 25% or more. This is a result, and a crop, that could not be achieved using conventional breeding.</p>
<p>From the outset golden rice was a public good project governed by the <a href="http://www.goldenrice.org/Content1-Who/who1_humbo.php">Golden Rice Humanitarian Board</a>. Swiss biotech company <a href="http://www.goldenrice.org/Content3-Why/why3_FAQ.php#Syngenta">Syngenta</a> contributed to the project by developing improved varieties in their labs but arranged that any intellectual property associated with golden rice was licensed free of charge to allow the technology to be available to resource-poor farmers who are permitted to save seed.</p>
<p>There is no catch or hidden agenda, yet anti GM campaigners continue to have a blanket condemnation on the technology, linking it to corporate conspiracies and control of the global food economy. The science of genetic modification has moved on considerably over the last 15 years and has answered many of the concerns raised about GM and its commercial applications.</p>
<p>Indeed golden rice nullifies all the arguments against GM: it has not been developed for commercial profit; it fulfils an urgent need by complementing traditional interventions; it presents a sustainable, cost-free solution, not requiring other resources; those who benefit are poor and disadvantaged; it is given free of charge and without restrictions to subsistence farmers; it does not create any new dependencies and can be grown without any additional inputs; it does not create advantages to rich landowners; it can be resown every year from the saved harvest; it does not reduce agricultural or natural biodiversity; and there is no conceivable threat to the environment or to human health.</p>
<p>Yet protestors continue to promote misinformation and <a href="http://www.bbc.co.uk/news/science-environment-23632042">destroy field trials</a>. Many refuse to engage in a meaningful dialogue and discuss GM issues on a case-by-case, evidential basis. For the first time since the introduction of GM crops almost two decades ago, developing countries now grow more than industrialised countries, contributing to food security and alleviating poverty in some of the world’s most vulnerable regions. The technology is not forced onto growers. Today <a href="http://www.isaaa.org/kc/cropbiotechupdate/pressrelease/2012/">over 17m farmers</a> in 29 countries grow GM crops.</p>
<p>Paradoxically, in many examples of genetic modification, through their actions anti-GM campaigners have shot themselves in the foot and driven some of the technology into the hands of ever-larger companies. Only these firms can afford the excessive, expensive and needless regulatory processes that must be repeated in every country due to the lack of internationally accepted standards. Subsistence farmers and starving children are the collateral victims.</p>
<p>In the case of golden rice, there is no giant corporate conspiracy – merely a desire by motivated scientists to address global health issues within a framework of subsistence farming. Mr Goldsmith is trying to resurrect a debate that might have had currency 15 years ago but which is no longer relevant in scientific or socioeconomic terms. Were he to look at the evidence, he might embrace technology for the contribution it can make to producing food that is healthier for humans and for the environment.</p><img src="https://counter.theconversation.com/content/19790/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dale Sanders has received funding from the European Union for research on biofortification of cereal grain with the essential micronutrient zinc.</span></em></p>Recently Zac Goldsmith MP – a former editor of The Ecologist, no less – branded the views of Environment Secretary Owen Patterson as “grotesque” after the minister called anti-GM campaigners “wicked…Dale Sanders, Professor and Director, Metabolic Biology, John Innes CentreLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/197292013-10-31T14:29:23Z2013-10-31T14:29:23ZVitamin D needed to fight comeback of childhood rickets<figure><img src="https://images.theconversation.com/files/34177/original/zvs2g34f-1383220946.jpg?ixlib=rb-1.1.0&rect=4%2C0%2C1019%2C685&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Diet and a little bit of sun can give us vitamin D. </span> <span class="attribution"><span class="source">Julian Colton</span></span></figcaption></figure><p>For most people, <a href="http://www.bbc.co.uk/programmes/p01dgd9c/features/supplements">our standard diet</a> provides all the necessary vitamins we need. However, childhood vitamin D deficiency in the UK – something that should be a headline from the distant past – has made a comeback. </p>
<p>And with that has come a rise in cases of <a href="http://www.nhs.uk/conditions/Rickets/pages/introduction.aspx">rickets</a>, a disease in which the bones become soft, weak and can become deformed without essential calcium. Sally Davies, England’s chief medical officer, has called for all children under five (not just those from low-income families) to be <a href="http://www.bbc.co.uk/news/health-24641796">offered free supplements</a>.</p>
<p>We need vitamin D to effectively absorb calcium and phosphorous and to move these chemicals around the body and provide such essential elements for bones and teeth. Fat-soluble vitamin D is found in oily fish while smaller amounts are present in eggs and dairy products. </p>
<p>Counter to what you may think of a vitamin as an essential nutrient, vitamin D can be made by the body. This is where the “sunshine vitamin” moniker comes from since it is made in the skin on exposure to the UV spectrum of sunlight. </p>
<p>Unfortunately, we don’t live in the Sunshine State – and in the UK we only really make vitamin D from skin exposed to sunlight in the <a href="http://www.bda.uk.com/foodfacts/VitaminD.pdf">middle of the day from April to September</a> when ultraviolet light is strong enough. Getting out into the sun two to three times a week <a href="http://www.nhs.uk/Livewell/Summerhealth/Pages/vitamin-D-sunlight.aspx">for a few minutes</a> without suncream can give you enough vitamin D to last you a year. But on the whole we are very dependent on diet for our vitamin D. And a severe lack of it causes rickets.</p>
<h2>The return of a ‘Victorian’ disease</h2>
<p>One of the best early description of rickets came in 1644 from Daniel Whistler, a Cambridge doctor. Unfortunately it wasn’t as accurate on the cause, suggesting a <a href="http://pediatrics.aappublications.org/content/112/2/e132.full">“paucity of and stupefaction of spirits”</a>. Some 200 years later, without a more useful understanding of its cause and in the rapidly growing industrialised and polluted cities in the west, a large proportion of infants of the underprivileged showed signs. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/34176/original/whcqrbv3-1383220691.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/34176/original/whcqrbv3-1383220691.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=430&fit=crop&dpr=1 600w, https://images.theconversation.com/files/34176/original/whcqrbv3-1383220691.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=430&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/34176/original/whcqrbv3-1383220691.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=430&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/34176/original/whcqrbv3-1383220691.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=541&fit=crop&dpr=1 754w, https://images.theconversation.com/files/34176/original/whcqrbv3-1383220691.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=541&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/34176/original/whcqrbv3-1383220691.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=541&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Family with rickets in 1900.</span>
<span class="attribution"><span class="source"> National Institutes of Health</span></span>
</figcaption>
</figure>
<p>Some realised that something was missing in the diet because people living in coastal areas found that cod liver oil provided protection. And in the early 20th century, the study of the individual chemical components of cod liver oil revealed a lipid they named vitamin D. Now that the cause was known, widespread supplementation was used to almost wipe out the disease.</p>
<p>Jeremy Allgrove wrote on <a href="http://adc.bmj.com/content/89/8/699.full?ijkey=6af30583ca50c5e49d785883a39c2305d7d2ebb8&keytype2=tf_ipsecsha">past resurgences of nutritional rickets</a> in the UK in which he observed an increase, several decades ago, in immigrants from the West Indies and the Indian subcontinent. People with higher pigmentation in their skin, which provides protection from UV, are unfortunately worse off than those with paler skins when it comes to making vitamin D in low-light conditions. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/34174/original/sbpj6q94-1383220199.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/34174/original/sbpj6q94-1383220199.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=809&fit=crop&dpr=1 600w, https://images.theconversation.com/files/34174/original/sbpj6q94-1383220199.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=809&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/34174/original/sbpj6q94-1383220199.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=809&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/34174/original/sbpj6q94-1383220199.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1017&fit=crop&dpr=1 754w, https://images.theconversation.com/files/34174/original/sbpj6q94-1383220199.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1017&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/34174/original/sbpj6q94-1383220199.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1017&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Glasgow: in the dark.</span>
<span class="attribution"><span class="source">Glasgow Amateur</span></span>
</figcaption>
</figure>
<p>Of course this was even worse in northern areas of the UK such as Scotland; however this was dealt with effectively in areas like <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1416851/">Glasgow by use of low-dose vitamin D supplements</a>.</p>
<p>But now cases of rickets are creeping back in children. It seems to have been forgotten that diet does not necessarily provide sufficient vitamin D for the growing body, especially during winter months. <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2082851">Research in Birmingham</a> found a 7.5% incidence of vitamin D deficiency in children. While, in 2010, there was an incidence of the disease <a href="http://www.ncbi.nlm.nih.gov/pubmed/21926880">in Southampton</a>. An astonishing 32% of children showed vitamin D insufficiency and 8% had full deficiency. This was among not only poorer children but also middle class ones.</p>
<p>The UK isn’t the only developed country that has seen incidents of rickets. <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3206624/">A study in Boston, Massachusetts</a>, also found deficiency in the seemingly healthy young and noted other incidences across the US. </p>
<p>Reasons point to deficiencies in diet and skin pigmentation in some cases, but also <a href="http://www.telegraph.co.uk/health/children_shealth/10052972/Six-year-old-diagnosed-with-rickets-after-using-sunscreen.html">the use of suncreams</a> - which also prevent skin damage and cancer.</p>
<p>So something classified by the average GP as a disease of the Victorian era, is now back among children.</p>
<h2>Battle cries and benefits</h2>
<p>The battle cry against this upsurge is being led by Davies. <a href="https://www.gov.uk/government/publications/chief-medical-officers-annual-report-2012-our-children-deserve-better-prevention-pays">Her report</a> on the health of the young in England makes for some grim reading. English children are not well when compared to top countries such as Sweden - and they show higher mortality, morbidity and inequality. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/34175/original/892ds2kr-1383220575.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/34175/original/892ds2kr-1383220575.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=952&fit=crop&dpr=1 600w, https://images.theconversation.com/files/34175/original/892ds2kr-1383220575.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=952&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/34175/original/892ds2kr-1383220575.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=952&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/34175/original/892ds2kr-1383220575.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1196&fit=crop&dpr=1 754w, https://images.theconversation.com/files/34175/original/892ds2kr-1383220575.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1196&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/34175/original/892ds2kr-1383220575.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1196&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Rickets in modern era.</span>
<span class="attribution"><span class="source">Michael L Richardson</span></span>
</figcaption>
</figure>
<p>One of the report’s many recommendations includes better nutrition. And among the proposals, Davies has asked health regulator NICE to determine whether vitamin A, D and C supplements should be provided. These are already available on the NHS for children from families on welfare benefits, but the idea will be to make them free to all children between the ages of six months and five years. It also discusses how these supplements <a href="http://www.ncbi.nlm.nih.gov/pubmed/?term=Moy+RJ+et+al.+Arch+Dis+Child+2012%3B97%3A952%E2%80%9395">helped to combat</a> the resurgence of rickets in Birmingham. The lives of many children can be helped easily and cheaply by keeping it simple, and doing it now.</p>
<p>But why are vitamins A and C mentioned in Davies’ report? This is a great surprise as there’s no evidence for a current deficiency in these vitamins. Just because children are deficient in D, <a href="http://www.feedingforlifefoundation.co.uk/media/16095/feeding%20for%20life%20report_2012_web_singles.pdf">doesn’t mean they are deficient</a> in A and C. </p>
<p>To ensure the success of Davies’ idea, we must consider the data and stay focused. Treat the growing incidence of vitamin D deficiency in children and leave the other vitamins alone. This isn’t a time to panic, or to pay for unnecessary, and <a href="http://theconversation.com/taking-high-doses-of-vitamins-can-do-more-harm-than-good-15388">potentially harmful</a>, supplements. There is the need though for vitamin D supplementation in those children who are deficient. This shouldn’t be confused with the case for adults, or whether vitamin D supplementation <a href="http://theconversation.com/why-eat-your-vitamins-when-you-can-now-shoot-them-up-16298">is necessary beyond</a> eating well. </p>
<p>These separate questions continue to be debated and researched – but don’t hold your breath for a definitive answer anytime soon.</p><img src="https://counter.theconversation.com/content/19729/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter McCaffrey receives funding from the Biotechnology and Biological Sciences Research Council (BBSRC)</span></em></p>For most people, our standard diet provides all the necessary vitamins we need. However, childhood vitamin D deficiency in the UK – something that should be a headline from the distant past – has made…Peter McCaffery, Professor of Biochemistry, University of AberdeenLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/184632013-10-13T19:27:59Z2013-10-13T19:27:59ZWant a better world? You can’t look at GMOs in isolation<figure><img src="https://images.theconversation.com/files/32804/original/gtsqgzvq-1381384511.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Workers attend to the seedlings in a confined Golden Rice field trial.</span> <span class="attribution"><span class="source">IRRI Images</span></span></figcaption></figure><p>The Philippines (also known as the rice-bowl of Southeast Asia) has become a test bed for genetically modified (GM) crops. Proponents argue GM grains and vegetables can improve the life of farmers and malnourished locals. </p>
<p>But is this technical approach the right one? Does it take account of the bigger picture, of a socio-political model that keeps many people in poverty?</p>
<p>It hasn’t been all smooth sailing for genetically modified organisms (GMOs) in the Philippines. The Philippines’ Court of Appeals struck a blow to proponents of genetically modified crops on May 17 this year, <a href="http://www.greenpeace.org/seasia/ph/PageFiles/126313/ca-decision-doc.pdf">ruling</a> that field trials for genetically modified, pest-resistant <em>Bacillus thuringiensis</em> (Bt) talong (eggplant) have not yet proved the plants safe for humans and the environment and must stop.</p>
<p>Following the Court of Appeals’ decision, organic farming advocates are also calling for a ban on a genetically modified breed of rice known as Golden Rice.</p>
<h2>Golden Rice and Vitamin A deficiency</h2>
<p>The force behind Golden Rice is the International Rice Research Institute (<a href="http://irri.org">IRRI</a>), which has created a “<a href="http://www.goldenrice.org/Content1-Who/who1_humbo.php">Humanitarian Board</a>” comprising scientists, food security specialists, and representatives from industry, USAID, US Department of Agriculture and the Rockefeller Foundation.</p>
<p>According to IRRI, malnutrition is common in white rice-eating populations and the Golden Rice Project could constitute a <a href="http://irri.org/index.php?option=com_k2&view=item&id=12654:golden-rice-research-at-irri-ethical-and-approved&lang=en">major contribution</a> towards sustainable vitamin A delivery. This vitamin is essential for eye health and the proper functioning of the immune system.</p>
<p>A World Health Organisation report titled <a href="http://whqlibdoc.who.int/publications/2009/9789241598019_eng.pdf">Global prevalence of Vitamin A deficiency in populations at risk 1995–2005</a> suggests that worldwide nearly 190 million children are at risk for diseases related to <a href="http://www.who.int/vmnis/indicators/retinol.pdf">Vitamin A deficiency</a>. Some 5.2 million preschool age children suffer from eye damage (<a href="http://en.wikipedia.org/wiki/Xerophthalmia">xerophthalmia</a>).</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/32799/original/z3xxb38h-1381380938.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/32799/original/z3xxb38h-1381380938.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/32799/original/z3xxb38h-1381380938.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/32799/original/z3xxb38h-1381380938.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/32799/original/z3xxb38h-1381380938.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/32799/original/z3xxb38h-1381380938.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/32799/original/z3xxb38h-1381380938.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A 12-year-old girl who has corneal blindness as a result of suffering from vitamin A deficiency.</span>
<span class="attribution"><span class="source">Community Eye Health</span></span>
</figcaption>
</figure>
<p>Rice produces beta-carotene in leaves but not in the grain, where the biosynthetic pathway is turned off during plant development. Beta-carotene is important as it’s changed into vitamin A (retinol) in the human body. </p>
<p>In Golden Rice, two genes inserted into the rice genome by genetic engineering restart the carotenoid biosynthetic pathway leading to the production and accumulation of beta-carotene in the grains.</p>
<h2>Scientists speak out</h2>
<p>As the emotions about the introduction of GMO into rice production run high, a group of activists destroyed a trial GM rice crop in the Philippines on August 8 this year, prompting a strong condemnation from scientists and proponents of GMO. </p>
<p>The authors of an <a href="http://www.sciencemag.org/content/341/6152/1320.full?sid=c3807cc0-e99c-40f9-b676-558e3f762f8d">editorial</a> published in the journal Science on September 20 claimed:</p>
<blockquote>
<p>protests like this are anti-science; the anti-GMO fever still burns brightly, fanned by electronic gossip and well-organized fear-mongering that profits some individuals and organizations.</p>
</blockquote>
<p>And in a letter written to the editor of the <a href="http://www.goldenrice.org/PDFs/Daily_Mail_Letter_Feb_2009.pdf">Daily Mail</a>, London on February 20 2009 in support of Golden Rice, seven scientists claimed:</p>
<blockquote>
<p>the best available evidence supports the conclusion that GM crops are as safe as, or safer than conventional and organic crops. At a time of increasing poverty globally, and reduced food security generally, all possible technologies capable of improving the quantity and quality of food should be embraced.</p>
</blockquote>
<p>So, should we believe that one food staple – genetically modified – could resolve Vitamin A deficiency and address development problems?</p>
<h2>Creating a bigger problem for farmers</h2>
<p>IRRI says Golden Rice seeds will be <a href="http://www.goldenrice.org/Content3-Why/why3_FAQ.php#Commercial_interest">freely available</a> to poor farmers in the Philippines. </p>
<p>This assertion brings to mind the stories of many small farmers in Africa and South America whose livelihood and independence have been shattered by the harsh conditions imposed by GM seeds suppliers.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/32800/original/xpmrs67n-1381381127.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/32800/original/xpmrs67n-1381381127.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/32800/original/xpmrs67n-1381381127.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/32800/original/xpmrs67n-1381381127.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/32800/original/xpmrs67n-1381381127.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/32800/original/xpmrs67n-1381381127.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/32800/original/xpmrs67n-1381381127.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Golden Rice grains compared to white rice grains.</span>
<span class="attribution"><span class="source">IRRI Images</span></span>
</figcaption>
</figure>
<p>Seed companies require farmers to sign contracts that aggressively protect the biotechnology company’s rights to the seeds, significantly limiting the farmers’ rights to the purchased seeds. The contracts generally contain a “no saved seed” provision so farmers cannot save or reuse seed from GM crops. </p>
<p>It is company policy for Monsanto, which <a href="http://www.monsanto.com/whoweare/Pages/default.aspx">describes</a> itself as a “sustainable agriculture company”, to sue farmers who <a href="http://www.monsanto.com/newsviews/Pages/why-does-monsanto-sue-farmers-who-save-seeds.aspx">breach this provision</a>. In effect, the provision requires growers of GM crops to make an annual purchase of GM seeds.</p>
<p>While the farmers struggle, corporations supplying the GM seeds – and their consultants – are making handsome profits. </p>
<p>What started as a humanitarian endeavour has turned into exploitation.</p>
<h2>Not everyone accepts the benefits</h2>
<p>Some are sceptical about GMO proponents’ claims. </p>
<p>In a recent televised <a href="http://www.abc.net.au/tv/qanda/txt/s3841115.htm">Q&A debate</a> in Australia, Professor David Suzuki told a live audience that “scientists in genetics are no longer open to the possibility of harmful effects – and it is far too early to say what the effects of GMO will be with certainty”.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/32802/original/ngjjmm3z-1381383863.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/32802/original/ngjjmm3z-1381383863.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/32802/original/ngjjmm3z-1381383863.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/32802/original/ngjjmm3z-1381383863.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/32802/original/ngjjmm3z-1381383863.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/32802/original/ngjjmm3z-1381383863.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/32802/original/ngjjmm3z-1381383863.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">Antoine.Couturier</span></span>
</figcaption>
</figure>
<p>Like Suzuki, the International Service for the Acquisition of Agri-biotech Applications (<a href="http://www.isaaa.org/">ISAAA</a>), based in Ithaca, New York, does not share the view that GMOs are entirely safe.</p>
<p>In a report titled <a href="http://www.isaaa.org/kc/Publications/pdfs/isaaabriefs/Briefs%2020.pdf">The Intellectual and Technical Property Components of pro-Vitamin A Rice</a>, funded by the Rockefeller Foundation and published in 2000, the organisation stated that:</p>
<blockquote>
<p>Given the ever-changing biotechnology and IP environment in which every plant breeding and biotechnology institution operates today, virtually no transfer of germplasm or research is without some degree of risk. As transgenic strategies begin to dominate crop improvement practices, both the risks and rewards of transferring and releasing products by national programs can be expected to rise.</p>
</blockquote>
<p>And in contradiction with its early claims, IRRI issued a statement on February 21 2013 <a href="http://www.irri.org/index.php?option=com_k2&view=item&id=12483&lang=en">clarifying</a> that:</p>
<blockquote>
<p>it has not yet been determined whether daily consumption of Golden Rice – genetically-modified rice – does improve the vitamin A status of people who are vitamin A deficient and could therefore reduce related conditions such as night blindness.</p>
</blockquote>
<h2>Science doesn’t exist in a vacuum</h2>
<p>Malnutrition is not merely a health problem; it is also a social problem. It reflects an overall impact of multiple causative factors, and these are also experienced in other developing countries where rice is not a major staple.</p>
<p>Nutritive deficiencies and malnutrition occur because of poverty and lack of purchasing power. Lack of adequate public health systems and education, environmental degradation, social disparity, depletion of fish stocks by large foreign trawlers (operating often illegally with impunity), corruption among local officials and conflicts are some of the underlying reasons. </p>
<p>The already considerable gap between the rich and the poor is rapidly growing. So is the highly unequal distribution of resources, especially in rural areas where the poorest live.</p>
<p>Golden Rice and other GMOs can never fully resolve these underlying issues.</p>
<p>As a human rights advocate – with extensive experience in the area – I can’t help but wonder what future awaits those less fortunate people in the Philippines whose health could now be turned over to the hands of an international scientific community eager to medicate them at the source with genetically modified products.</p>
<p>This is in a country where the church is still denying these same people access to basic contraception. World population and consumption are still growing and some central issues in this discourse are ignored.</p>
<p>Suggesting that GMO will change all people’s lives for the better merely shows how disconnected the proponents of GMO are from the realities on the ground and the needs of the population. What is lacking is the political will and determination to address these socio-political issues, on a local level and internationally.</p><img src="https://counter.theconversation.com/content/18463/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jean Bogais does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Philippines (also known as the rice-bowl of Southeast Asia) has become a test bed for genetically modified (GM) crops. Proponents argue GM grains and vegetables can improve the life of farmers and…Jean Bogais, Adjunct Associate Professor, School of Social and Political Sciences - Associate, Institute for Democracy and Human Rights, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/158142013-08-06T20:14:39Z2013-08-06T20:14:39ZSix things you need to know about your vitamin D levels<figure><img src="https://images.theconversation.com/files/28142/original/mqxj7rpy-1374817267.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Even if sunscreen is applied very thickly, vitamin D production is reduced but not stopped.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Vitamin D has emerged as “the vitamin of the decade”, with a long and growing list of maladies supposedly caused through its absence or prevented through its bountiful supply. </p>
<p>But is there adequate evidence for the wonders claimed for vitamin D or are we getting a bit carried away? </p>
<p>Before you answer that, here are some common misconceptions about vitamin D that you should know about.</p>
<ol>
<li>Everybody knows their vitamin D level should be above …?</li>
</ol>
<p>It’s a fairly universal agreement that a blood concentration of 25-hydroxyvitamin D (the usual measure of vitamin D status) below 25 nanomoles/litre (nmol/L) should be considered a serious deficiency.</p>
<p>Anyone who is tested and returns results like that needs to talk to their doctor about proper management. But knowing what levels are sufficient is trickier. </p>
<p>In 2010, the <a href="http://www.iom.edu/Reports/2010/Dietary-Reference-Intakes-for-calcium-and-vitamin-D.aspx">Institute of Medicine</a> in the United States concluded that bone health is the only condition for which there’s an established causal association with vitamin D. They found:</p>
<blockquote>
<p>health benefits beyond bone health — benefits often reported in the media — were from studies that provided often mixed and inconclusive results and could not be considered reliable.</p>
</blockquote>
<p>So there’s clearly contention about how much is enough. A level of 50nmol/L is sufficient to optimise the bone health of the majority of the population. But other groups recommend 75nmol/L, <a href="http://www.vitamindcouncil.org/about-vitamin-d/testing-for-vitamin-d/">100nmol/L or higher</a> (note that US sites provide recommendations in nanograms per millilitre or ng/ml – multiply by 2.5 to convert to nmol/L). </p>
<ol>
<li>There’s a vitamin D deficiency epidemic in Australia. </li>
</ol>
<p>Actually, what is most clear is that there’s an epidemic of vitamin D testing in Australia – a <a href="http://www.ncbi.nlm.nih.gov/pubmed/23794593">94-fold</a> increase from 2000 to 2010. Costs to Medicare have gone from $1.3 million in 2000/2001 to <a href="https://www.medicareaustralia.gov.au/statistics/mbs_item.shtml">$140.5 million in 2012/2013.</a></p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/28143/original/7z8fjxg2-1374817455.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/28143/original/7z8fjxg2-1374817455.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=662&fit=crop&dpr=1 600w, https://images.theconversation.com/files/28143/original/7z8fjxg2-1374817455.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=662&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/28143/original/7z8fjxg2-1374817455.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=662&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/28143/original/7z8fjxg2-1374817455.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=832&fit=crop&dpr=1 754w, https://images.theconversation.com/files/28143/original/7z8fjxg2-1374817455.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=832&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/28143/original/7z8fjxg2-1374817455.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=832&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Rather than an epidemic of deficiency, there’s currently an epidemic of vitamin D testing in Australia.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>Some populations are clearly at risk of vitamin D deficiency. People who habitually cover their skin while in public for cultural or other reasons, for instance, and the immobile elderly who are rarely sun exposed. But the evidence of population-wide vitamin D deficiency is thin and unconvincing, at least in part because vitamin D tests are problematic and the desired level is hotly debated. </p>
<p>If an unreliable test is used and the “sufficient” bar is set too high and more people are tested, then vitamin D “deficiency” will seem more common.</p>
<ol>
<li><p>A vitamin D test gives a simple answer and is accurate and reliable. </p>
<p>This is definitely not so.</p></li>
</ol>
<p>If you take blood from one person and split it up into several samples and test these, you can get very different results between the samples. And it’s not just a little bit different. </p>
<p>A recent Australian study assessing the consistency and accuracy of <a href="http://www.ncbi.nlm.nih.gov/pubmed/21395958">vitamin D tests</a> found that between one-in-five and one-in-three participants were misclassified as “deficient”. The vitamin D test results for a single blood sample returned enormously different results depending on which type of test was used and where the sample was analysed.</p>
<p>Four samples (out of approximately 800) differed by more than 100nmol/L (that’s double the usual “sufficient” level of 50nmol/L) across two different tests, and 10% of the results differed by more than 50nmol/L. These are different measurements of the same sample!</p>
<p>Fortunately work is underway to improve this abysmal situation. A group of international agencies are developing a reference measurement procedure and laboratories will be able to assess the performance of their test against this new standard.</p>
<ol>
<li>Vitamin D is the elixir of life, which is sometimes presented as vitamin D deficiency will kill us all.</li>
</ol>
<p>Given the challenges of accurately measuring levels of this vitamin and the disagreement on where the goalposts are, doing good consistent research to determine the benefits and detriments of high or low vitamin D is pretty difficult. </p>
<p>There’s no doubt that severe vitamin D deficiency causes rickets in children, and an equivalent condition known as osteomalacia in adults. Old pictures of children with bowed legs or knock knees were often of children with rickets. </p>
<p>And there’s pretty good evidence that supplementation with vitamin D <em>and</em> calcium, in combination with weight-bearing exercise, can decrease the risks of fractures in the elderly. Particularly in people who have low levels of vitamain D or calcium (or both) before starting supplementation.</p>
<p>But most evidence for the other reported benefits of vitamin D comes from weak studies, and there’s little support from better studies. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/28145/original/nv87v5h5-1374817852.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/28145/original/nv87v5h5-1374817852.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/28145/original/nv87v5h5-1374817852.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/28145/original/nv87v5h5-1374817852.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/28145/original/nv87v5h5-1374817852.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/28145/original/nv87v5h5-1374817852.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/28145/original/nv87v5h5-1374817852.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">There’s good evidence that supplementation with vitamin D and calcium, in combination with weight-bearing exercise, can decrease the risks of fractures in the elderly.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<ol>
<li>Given it is such good stuff, the higher my vitamin D level, the better.</li>
</ol>
<p>Vitamin D has traditionally been thought to be safe, requiring very high levels (greater than 400nmol/L) to reach toxicity. This toxicity cannot occur through sun exposure, but can through excessive supplementation. </p>
<p>But as we delve more into the vitamin D story, studies are <a href="http://www.ncbi.nlm.nih.gov/pubmed/23666975">reporting risks to health</a> at even modestly high levels, such as 80-100nmol/L. </p>
<p>The evidence is not yet strong (much like the evidence of vitamin D’s benefits) but this type of association is typical of many vitamins and nutrients, where both <a href="http://www.ncbi.nlm.nih.gov/pubmed/23609334">too little and too much are bad for you</a> . </p>
<ol>
<li>Sunscreen stops vitamin D production.</li>
</ol>
<p>The majority of vitamin D your body needs comes through exposure to the sun, specifically from shorter wavelength UVB radiation that is also the main cause of skin cancers. It may seem logical that if sunscreen stops the damaging UVB reaching sensitive skin cells, it will also stop vitamin D production by those same cells. </p>
<p>But even if sunscreen is applied very thickly, vitamin D production is reduced but not stopped. And, of course, who puts it on that thickly? </p>
<p>Most of us apply sunscreen because we are going to be in the sun. We put on a thin layer that is not too icky. Under these conditions, <a href="http://www.ncbi.nlm.nih.gov/pubmed/7726582">sunscreen actually doesn’t seem to make a lot of difference</a> to vitamin D production. </p>
<p>There’s a lot we don’t know about vitamin D. But we do know that Australia has the highest skin cancer incidence in the world: hundreds of thousands of skin cancers are removed each year at a cost of <a href="http://www.ncbi.nlm.nih.gov/pubmed/?term=sinclair+r+nmsc">more than $700 million</a> and there are over <a href="http://www.aihw.gov.au/acim-books/">2,000 deaths</a> from it. </p>
<p>Excessive sun exposure is the <a href="http://www.ncbi.nlm.nih.gov/pubmed/15753968">main cause of that problem</a>. Getting the balance between vitamin D levels and sun protection right is an important health goal. </p>
<p>More research is needed and it should be Australian research because our circumstances are different to those in the United States and Europe. We can’t just take results from there and use them here. </p>
<p>While a <a href="https://theconversation.com/theres-a-very-simple-solution-to-your-lack-of-vitamin-d-15409">simple solution</a> would be nice, an evidence-based one is preferable and worth pursuing. Stories about our epidemic of vitamin D deficiency drive excessive testing at high cost and unknown value. And they probably just end up selling more vitamin supplements. </p>
<p>But they also <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3705326/pdf/nutrients-05-00915.pdf">create confusion</a> and diminish people’s confidence and resolve to reduce excessive UV exposure. </p><img src="https://counter.theconversation.com/content/15814/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Robyn Lucas receives funding from National Health and Medical Research Council and Cancer Australia.</span></em></p><p class="fine-print"><em><span>Terry Slevin receives funding from Cancer Australia as an Associate Investigator on a study examining the impact of vitamin D supplementation and sun exposure and their impact on vitamin D levels. He is affiliated with Cancer Council Australia as Chair of the National Skin Cancer Committee. His employer, the Cancer Council Western Australia also sells sunscreen within its range of sun protection products.</span></em></p>Vitamin D has emerged as “the vitamin of the decade”, with a long and growing list of maladies supposedly caused through its absence or prevented through its bountiful supply. But is there adequate evidence…Robyn Lucas, Associate Professor of Epidemiology, Australian National UniversityTerry Slevin, Honorary Senior Lecturer in Public Health at Curtin University; Education & Research Director, Cancer Council WA; Chair, National Skin Cancer Committee, Cancer Council AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/162982013-07-28T20:00:34Z2013-07-28T20:00:34ZWhy eat your vitamins when you can now shoot them up?<figure><img src="https://images.theconversation.com/files/28155/original/45ybg2nt-1374821183.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">For a large amount of money, you can now get vitamins through an intravenous drip.</span> <span class="attribution"><span class="source">Toshiyuki IMAI/Flickr</span></span></figcaption></figure><p>Now appearing in a tabloid near you, <a href="http://www.smh.com.au/lifestyle/diet-and-fitness/youre-so-vein-20130710-2ppye.html">reports of the latest fad</a> – infusion of intravenous vitamins, which, exactly as described, is vitamins applied through an intravenous drip. Sounds a little extreme considering these are chemicals we used to get through crunching a carrot or sucking on an orange. </p>
<p>But celebrities, the rich and the famous are arriving at clinics to sit (sometimes for hours at a time) and have high doses of vitamins delivered straight into their veins. </p>
<p>And rich is the operative word since these sessions can be in the US$1,000 range. This seems like a large fee for chemicals that are cheap to purchase, even in the sterile form necessary for intravenous delivery. </p>
<p>Now the notion has reached Australian shores and is being offered in clinics in Sydney. But is it a good idea?</p>
<h2>Of use?</h2>
<p>My first thoughts are no. Claims of the use of mega-doses of vitamins, once touted as the cure for cancer and the common cold, seem not to have turned out to be true. Some reports even suggest they cause <a href="https://theconversation.com/taking-high-doses-of-vitamins-can-do-more-harm-than-good-15388">long-term harm</a>.</p>
<p>Certainly, high doses of the lipid soluble vitamins, such as vitamin A and vitamin D, are very inadvisable for the normal individual. These are not easily excreted and they build up in the body to have toxic effects.</p>
<p>Expect headaches, nervous system problems and nausea for <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3276716/">vitamin A</a>. While for <a href="http://www.vitamindcouncil.org/about-vitamin-d/am-i-getting-too-much-vitamin-d/">vitamin D</a>, problems result from excess calcium in the blood and include nausea, muscular weakness, pain and kidney problems.</p>
<p>In the 1980s, <a href="http://www.nytimes.com/1984/05/27/weekinreview/the-tragic-case-history-of-intravenous-vitamin-e.html">intravenous application of vitamin E</a> in premature babies led to the death of 38 infants in the United States. I should add that the preparation being used had not been approved by the US medicines regulator, the Food and Drug Administration (FDA). </p>
<p>Needless to say, similar mistakes with synthetic drugs have no doubt led to many deaths but I mention this case to underline that just because vitamins are “natural”, it doesn’t mean they are safe at any dose.</p>
<p>Certainly, intravenous application can add further problems. Injecting any substance into the body creates an inherently greater risk than the route we have evolved to take in vitamins, as part of our diet. This is especially the case if vitamins are self-administered, though even with a trained professional mistakes can occur.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/28156/original/xbk5fdbn-1374821421.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/28156/original/xbk5fdbn-1374821421.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/28156/original/xbk5fdbn-1374821421.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/28156/original/xbk5fdbn-1374821421.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/28156/original/xbk5fdbn-1374821421.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/28156/original/xbk5fdbn-1374821421.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/28156/original/xbk5fdbn-1374821421.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">There are plenty of ways to get your vitamin doses naturally.</span>
<span class="attribution"><span class="source">Keith Williamson</span></span>
</figcaption>
</figure>
<p>But there are some people for whom vitamin supplementation will be beneficial. These include people deficient in vitamins due to a genetic predisposition that prevents proper absorption from their diet. For them, vitamin supplements are essential for a normal life. </p>
<p>For dire need, intravenous supply will provide vitamins more rapidly and at a higher direct level to tissues and organs when compared to vitamin tablets.</p>
<h2>Exceptions to the rule?</h2>
<p>It may be no revelation that vitamins are beneficial for vitamin deficiency disease, but the recent surprise is that new results suggest intravenous vitamins, specifically vitamin C, may be beneficial for other disorders. </p>
<p>Its action as an antioxidant, removing reactive oxygen species that otherwise cause havoc in cells, may be effective when carefully used at the right dose. It has <a href="http://www.ncbi.nlm.nih.gov/pubmed/23208525">been reported</a> that a high-dose intravenous vitamin C treatment in combination with steroids is beneficial for treating certain types of hearing loss.</p>
<p>There is <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3293508">growing evidence</a> that vitamin C can protect against sepsis (the inflammatory condition that results from severe infection) by acting through various mechanisms to prevent oxidative stress.</p>
<p>Perhaps the biggest shock is a study that supports one of the reasons that celebrities are lining up for their hit of intravenous vitamins - the claim that they help reduce fatigue. </p>
<p><a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3273429/pdf/1475-2891-11-7.pdf">A single moderate-sized study</a> of office workers (certainly a highly stressed bunch of people) found that intravenous vitamin C led to at least a short term (one-day) reduction in the subjective feeling of fatigue. There is always the concern of a placebo effect but this was a double-blind randomised controlled study compared to a saline drip which should remove such a possibility. </p>
<p>Such is the peculiarity of the world that intravenous vitamins, a technique that can be used to milk celebrities of their excess money, may also be a technique that provides a treatment for some diseases. </p>
<p>Of course, all this has to be treated with caution. </p>
<p>Vitamin C is no panacea and <a href="https://theconversation.com/taking-high-doses-of-vitamins-can-do-more-harm-than-good-15388">does not appear to be effective</a> for cancer treatment as is sometimes claimed. Indeed, it <a href="http://cancerres.aacrjournals.org/content/68/19/8031.full.pdf">may block</a> the action of certain drugs used to treat cancer.</p>
<p>It will require a fair bit of rigorous research to tell us the difference between fact and fad, but there are hints that there is some benefit for this treatment.</p><img src="https://counter.theconversation.com/content/16298/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter McCaffrey receives funding from the Biotechnology and Biological Sciences Research Council (BBSRC)</span></em></p>Now appearing in a tabloid near you, reports of the latest fad – infusion of intravenous vitamins, which, exactly as described, is vitamins applied through an intravenous drip. Sounds a little extreme…Peter McCaffery, Professor of Biochemistry, University of AberdeenLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/154092013-07-02T04:32:40Z2013-07-02T04:32:40ZThere’s a very simple solution to your lack of vitamin D<figure><img src="https://images.theconversation.com/files/26407/original/p9j5zfrd-1372394736.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There are sensible ways to sunbathe that allow for protection against skin cancer as well as helping you get enough vitamin D.</span> <span class="attribution"><span class="source">Phil Hatchard</span></span></figcaption></figure><p>Despite living in a famously sunny country, we’ve been getting reports of widespread vitamin D deficiency for some time now. The solution to this problem is simply the judicious use of a plentiful, if somewhat maligned, natural resource. </p>
<p>As an ardent Beatles fan, I became aware of the lesser-known fact that John Lennon and Paul McCartney used to sunbathe in Liverpool’s Strawberry Fields cemetery. This behaviour probably seems extraordinary for people in present day Australia where we’re used to being lectured about the importance of protecting ourselves from the sun.</p>
<p>I also knew that old family friends who grew up in England after the Second World War were forced to swallow cod liver oil. This is also unusual today; some of us do dole out fish-oil tablets in the morning, but usually because of dubious advertising claims that they’ll enhance our childrens’ performance on school tests. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/26387/original/vx89v9m7-1372392418.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/26387/original/vx89v9m7-1372392418.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=766&fit=crop&dpr=1 600w, https://images.theconversation.com/files/26387/original/vx89v9m7-1372392418.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=766&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/26387/original/vx89v9m7-1372392418.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=766&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/26387/original/vx89v9m7-1372392418.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=963&fit=crop&dpr=1 754w, https://images.theconversation.com/files/26387/original/vx89v9m7-1372392418.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=963&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/26387/original/vx89v9m7-1372392418.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=963&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Children in post-war England were not thrilled to swallow cod liver oil.</span>
<span class="attribution"><span class="source">Ian Renton</span></span>
</figcaption>
</figure>
<p>These otherwise seemingly disconnected post-war temperate zone activities (sunbathing and consuming cod liver oil) are linked by their capacity to supply people with vitamin D3 (cholecalciferol). Around 90% of our vitamin D3 is produced in the skin by ultraviolet irradiation B (UVB) of its precursor 7-dehydrocholesterol. </p>
<p>Between 10,000 and 20,000 international units (IU) of vitamin D3 can be made by direct exposure of large areas of human skin (such as your tummy, back or legs) to UVB in the middle of the day (when UV index is greater than three). </p>
<p>Vitamin D3 is also found in oily fish and cod liver oil, but the capsules commonly taken as supplements contain only about 1,000 IU each. The body self-regulates production of vitamin D, some is stored in fat and you cannot produce too much.</p>
<h2>Low vitamin D epidemic</h2>
<p>Australia is facing an epidemic of <a href="http://en.wikipedia.org/wiki/Hypovitaminosis_D">vitamin D deficiency</a>, with as much as a third of the population having less than recommended levels. Even people such as gardeners, who are outside all day but lathered in sunscreens and wearing long-sleeved shirts and broad hats have chronically low vitamin D3 levels. </p>
<p>Vitamin D is important for maintaining calcium and phosphate levels for bone formation, and allowing proper functioning of parathyroid hormone. Low levels of this hormone can produce fatigue, muscle pain and weakness, weight gain, poor sleep and concentration and bone diseases.</p>
<p>Low vitamin D levels have been implicated in forms of cancer, high-blood pressure and autoimmune disease, such as <a href="http://en.wikipedia.org/wiki/Multiple_sclerosis">multiple sclerosis</a>. Indeed, multiple sclerosis is an interesting example here. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/26391/original/4fmznpfn-1372392699.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/26391/original/4fmznpfn-1372392699.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/26391/original/4fmznpfn-1372392699.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/26391/original/4fmznpfn-1372392699.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/26391/original/4fmznpfn-1372392699.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/26391/original/4fmznpfn-1372392699.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/26391/original/4fmznpfn-1372392699.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Windows do not protect us from harmful UVA rays, but they block out beneficial UVB rays.</span>
<span class="attribution"><span class="source">Bearfaced</span></span>
</figcaption>
</figure>
<p>It has long been known that the incidence of <a href="http://www.livescience.com/35454-sunlight-lowers-multiple-sclerosis-risk.html">multiple sclerosis is much lower at the equator than in temperate zones</a>. Many have wondered whether the difference can be explained by the higher levels of UVB and light clothing worn at the equator that combine to <a href="http://online.wsj.com/article/SB10001424127887323353204578129280745162230.html">elevate vitamin D3 levels</a>. </p>
<p>The overall health impact of even mild vitamin D deficiency is unlikely to be positive, so this is not an issue we can afford to ignore. It just so happens that Australian health professionals are already <a href="http://www.abc.net.au/classic/content/2011/10/06/3332114.htm">raising awareness</a> of the problem.</p>
<h2>Sun phobia and low vitamin D</h2>
<p>There is such a fear of skin cancer in Australia that many health professionals are reluctant to recommend any direct exposure to sunlight in the middle of the day, when vitamin D3 stimulating UVB are strongest. </p>
<p>We routinely seek removal of <a href="https://en.wikipedia.org/wiki/Actinic_keratosis">solar keratoses</a>, and <a href="http://en.wikipedia.org/wiki/Basal-cell_carcinoma">basal</a> and <a href="https://en.wikipedia.org/wiki/Squamous-cell_carcinoma">squamous cell carcinomas</a> from our face and hands. And it is appropriate to protect those heavily exposed areas with sunscreens. </p>
<p>Yet, our capacity to make vitamin D is also restricted by sunscreens and our inability to open windows in our workplaces. Applying suncreens commonly blocks 95% of vitamin D-stimulating UVB light, as does glass. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/26389/original/vv7n3yd3-1372392521.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/26389/original/vv7n3yd3-1372392521.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=899&fit=crop&dpr=1 600w, https://images.theconversation.com/files/26389/original/vv7n3yd3-1372392521.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=899&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/26389/original/vv7n3yd3-1372392521.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=899&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/26389/original/vv7n3yd3-1372392521.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/26389/original/vv7n3yd3-1372392521.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/26389/original/vv7n3yd3-1372392521.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Gardeners are careful to keep themselves covered up and protected from harmful UV rays.</span>
<span class="attribution"><span class="source">Oriol Salvador</span></span>
</figcaption>
</figure>
<p>Sunbathing before a closed window that allows through damaging UVA, but not beneficial UVB, is much more risky than exposing your tummy, back or legs to direct sun.</p>
<p>To maintain vitamin D levels, all most of us need to do is expose one of these large areas of our body to direct midday sunshine in winter (or mid-morning or mid-afternoon sun in summer) for 10 to 15 minutes or until the skin is lightly pink. </p>
<p>Meanwhile, continue to protect your face and hands with sunscreens for cosmetic purposes and to limit chronic over-exposure. </p>
<p>Darker skinned people and those living further away from the equator (Hobart instead of Cairns, for instance) will require slightly longer exposure. It’s as simple as sitting in your garden or before an open window, letting direct sunlight onto skin exposed through rolling up your sleeves, trouser legs, or the bottom of your shirt. </p>
<p>It’s time we had a conversation about sensible sunlight exposure of our otherwise hidden bodies; particularly since this potential antidote to the epidemic of autoimmune diseases of various types raging in our community is so readily available and inexpensive. </p>
<p>It’s not your face and hands, but your tummy and back that need to be exposed more often to direct sunlight for brief periods. It’s a question of using sunlight appropriately and getting your gear off in sensible moderation.</p><img src="https://counter.theconversation.com/content/15409/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Thomas Faunce receives funding from the Australian Research Council under a Future Fellowship.</span></em></p>Despite living in a famously sunny country, we’ve been getting reports of widespread vitamin D deficiency for some time now. The solution to this problem is simply the judicious use of a plentiful, if…Thomas Faunce, ARC Future Fellow, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/122012013-02-17T19:29:52Z2013-02-17T19:29:52ZVitamin D target level surrounded by uncertainty<figure><img src="https://images.theconversation.com/files/20298/original/kj3c2c4h-1360907586.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Most Australians get more than 90% of their vitamin D through sun exposure of the skin.</span> <span class="attribution"><span class="source">Tricia Wang</span></span></figcaption></figure><p>A new joint position statement on target levels for vitamin D, published in the <a href="https://www.mja.com.au/">Medical Journal of Australia</a> (MJA) by the <a href="http://www.anzbms.org.au/">Australian and New Zealand Bone and Mineral Society</a> and <a href="http://www.osteoporosis.org.au/news/latest-news/new-guidelines-released-in-mja-open/">Osteoporosis Australia</a> today, maintains the currently accepted vitamin D target level, despite recent calls for it to be raised. This is a hotly debated issue, with considerable support worldwide for target levels, at least in adults, to be raised to much higher levels than many researchers believe are required for good health.</p>
<p>The position statement is explicitly aimed at vitamin D levels during pregnancy and in infants, children and adolescents. Low vitamin D levels are common in Australia: 48% of pregnant women whose vitamin D status was tested had low levels, and the vitamin D levels of babies reflect those of their mother during pregnancy and at birth. Importantly, the position paper provides well-rounded advice about appropriate sun exposure as well as vitamin D supplementation for these populations.</p>
<p>Most Australians get more than 90% of their vitamin D through sun exposure of the skin. Once formed in the skin, vitamin D is taken up into the blood stream and then has to go through two biochemical reactions – firstly in the liver to form 25-hydroxyvitamin D (25(OH)D) and then in the kidney to form the active hormone. It’s the concentration of 25(OH)D that’s measured in blood when you have a vitamin D test, and this is expressed in terms of nanomoles per litre (nmol/L).</p>
<p>In the new position paper, the two bodies conclude that the target blood level for adequate vitamin D is a 25(OH)D concentration of 50nmol/L or greater. Nevertheless, many <a href="http://www.ncbi.nlm.nih.gov/pubmed/17634462?dopt=Citation">experts around the world advocate</a> for higher minimum targets, such as 75 or 80nmol/L. Opinions differ according to how the research evidence is interpreted, and it is worth thinking about how decisions are made on what constitutes the appropriate target levels.</p>
<p>The link between <a href="http://ajcn.nutrition.org/content/60/4/619.full.pdf">sun exposure and healthy bones</a> was first noted in 1822, based on observations of rickets in urban Polish children. Rickets is a bone disease of young children, seldom seen in developed countries today, that causes weakening of the bones and typically results in bowing of the legs </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/20300/original/8r5gpnpg-1360907978.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/20300/original/8r5gpnpg-1360907978.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=848&fit=crop&dpr=1 600w, https://images.theconversation.com/files/20300/original/8r5gpnpg-1360907978.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=848&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/20300/original/8r5gpnpg-1360907978.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=848&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/20300/original/8r5gpnpg-1360907978.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1065&fit=crop&dpr=1 754w, https://images.theconversation.com/files/20300/original/8r5gpnpg-1360907978.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1065&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/20300/original/8r5gpnpg-1360907978.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1065&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A Mississippi sharecropper’s child suffering from rickets and malnutrition, photographed in 1935.</span>
<span class="attribution"><span class="source">Children's Bureau Centennial</span></span>
</figcaption>
</figure>
<p>The link between sun exposure and rickets was later shown to be vitamin D. And so the <a href="http://www.ncbi.nlm.nih.gov/pubmed/8092101">first vitamin D target</a> proposed was at a level sufficient to avoid rickets. We now know that rickets is seldom seen before vitamin D levels are very low, what we would call severe deficiency of levels well below 20nmol/L.</p>
<p>In 1997, the <a href="http://www.ncbi.nlm.nih.gov/books/NBK45188/">Standing Committee on the Scientific Evaluation of Dietary Reference Intakes</a> described the <a href="http://pediatrics.aappublications.org/content/31/3/512.full.pdf">normal range of vitamin D levels</a> in terms of the average in the population for a group of healthy individuals. These were “usual” levels, rather than a definition based on health or disease. </p>
<p>One problem with this definition is that, because vitamin D levels reflect how much sun exposure people have had, “usual” levels vary according to season and to location. Higher latitude regions typically have lower sun exposure and therefore lower vitamin D levels than lower latitude regions, and levels are lower in winter than in summer. Target levels would differ in Australia depending whether you lived in Hobart or Brisbane!</p>
<p>The primary role for vitamin D in the body is to maintain serum calcium levels. Calcium is critically important in the physiology and biochemistry of cells and blood levels must be maintained within a narrow range. </p>
<p>When calcium levels fall, parathyroid hormone is released and this stimulates conversion of inactive vitamin D into the active hormone. This increases absorption of calcium from the diet in the gut and draws the mineral out of the bones to bring its level back to normal. The latter can weaken the bones and that eventually results in diseases such as rickets.</p>
<p>More recently, the target level for vitamin D has been focused on the levels required to minimise withdrawal of calcium from bones. Many studies have looked at the vitamin D levels required to minimise levels of parathyroid hormone – but the results have varied from optimal level being 30nmol/L to more than 100nmol/L. </p>
<p>This wide variation may be due to high variability in the tests (assays) for both vitamin D and parathyroid hormone; different methods of statistical analysis of the data; or different population groups being tested.</p>
<p>The <a href="http://www.iom.edu/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D.aspx">most recent report</a> from the US <a href="http://www.iom.edu/">Institute of Medicine</a> (IOM) reviewed a wide range of other markers of bone health, including measures of calcium absorption in the gut, bone density measurements and risk of fracture. But none of these provided a clear answer to the desirable target for vitamin D. </p>
<p>The report also raised questions about whether the target level was the same for all people, at all times of the year, and in relation to all health outcomes. After their comprehensive review, the authors of the IOM report concluded that, for the moment, in the absence of any better evidence to the contrary, a level of 50nmol/L or greater, should be the target for vitamin D.</p>
<p>Today’s position statement reflects what the IOM also settled at, but clearly, many questions remain.</p>
<p>Challenges to redefining an optimal level for vitamin D – if a universal target is even possible – include better understanding individual and ethnic variability in vitamin D needs in relation to bone health, whether there are disease-specific optimal target levels, whether seasonal variability is healthy or unhealthy, and, particularly relevant here, whether infants, children, adolescents, adults and the elderly all have the same target levels.</p><img src="https://counter.theconversation.com/content/12201/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Robyn Lucas receives funding from NHMRC.</span></em></p>A new joint position statement on target levels for vitamin D, published in the Medical Journal of Australia (MJA) by the Australian and New Zealand Bone and Mineral Society and Osteoporosis Australia…Robyn Lucas, Associate Professor of Epidemiology, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.