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• Re: Vitamin D deficiency in UK Asian families: activating a new concern
  Michael Coren
  Published on: 8 May 2002
• Vitamin D deficiency in children in the UK
  Bimal M Mehta
  Published on: 29 April 2002
• Replete or insufficient Vitamin D?
  Nick J Shaw
  Published on: 3 April 2002
• Vitamin D in pregnant women.
  Ruth Morley
  Published on: 5 March 2002

• Published on: 8 May 2002

  Re: Vitamin D deficiency in UK Asian families: activating a new concern

  • Michael Coren, Paediatrician
  • Other Contributors:
    • Deepa Krishnakumar, Paediatric Registrar, St. Mary's Hospital

  Dear Editor

  In response to the review article by Shaw and Pal [1] we would like to contribute our experience of rickets in children in a inner city population over the last 24 months. During this period 14 children were seen fulfilling clinical/radiological and biochemical criteria for vitamin D deficient rickets.

  The children were between the ages of 5-36 months(mean age 15.3 months)

  4 were white...

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  Dear Editor

  In response to the review article by Shaw and Pal [1] we would like to contribute our experience of rickets in children in a inner city population over the last 24 months. During this period 14 children were seen fulfilling clinical/radiological and biochemical criteria for vitamin D deficient rickets.

  The children were between the ages of 5-36 months(mean age 15.3 months)

  4 were white children, 3 British Asians/Asians, 2 middle eastern and 5 African/Afro-Caribbean. These children presented in various ways.

  Delayed walking	1
  Bow legs	6
  Hypocalcemic fits	3
  Cough-Xray changes noted	3
  Incidental finding on blood test	1

  The most important dietary factor was prolonged exclusive breast feeding. 7 children (50 %) were breast fed for more than 12 months at the time of diagnosis, 3 were breast-fed for 6-12 months, and 2 for 3-6 months. None of the mothers received vitamin D during pregnancy. Only one child had clear evidence of failure to thrive. 8/14 children had iron deficiency.

  All had a good clinical response to vitamin D therapy . 8/14 children were treated with alfacalcidol, 4 were treated with ergocalciferol, and 1 child with cholecalciferol. 2 babies were given multivitamins only. All families received specialist dietetic advice. Treatment was continued for a mean of 3.6 months(range 2-6 months).

  We strongly agree with Shaw and Pal that there should be increased awareness of this condition, which has lapsed from attention to some extent. Our experience suggests that all ethnic groups in inner London have high levels of vitamin D deficiency especially Asian and African groups. Vitamin D should be offered to high-risk groups during pregnancy and a vitamin D containing multivitamin given to their infants. The message to introduce a mixed diet from 4-6 months of age needs to be re-enforced.

  Reference

  (1) Shaw NJ, Pal BR. Vitamin D deficiency in UK Asian families: activating a new concern. Arch Dis Child 2002;86:147-9.

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  Conflict of Interest:
  None declared.

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• Published on: 29 April 2002

  Vitamin D deficiency in children in the UK

  • Bimal M Mehta, Paediatric Specialist Registrar
  • Other Contributors:
    • Roy F. Harris

  Dear Editor

  We read the review of vitamin D deficiency in UK Asian families with interest.[1] While we agree with their recommendations, our own experience, and a review of the literature, highlights another sub population of the UK at risk of nutritional rickets.

  A three-month-old Afro Caribbean male presented with a two-day history of brief, generalised tonic-clonic seizures. Physical examination was...

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  Dear Editor

  We read the review of vitamin D deficiency in UK Asian families with interest.[1] While we agree with their recommendations, our own experience, and a review of the literature, highlights another sub population of the UK at risk of nutritional rickets.

  A three-month-old Afro Caribbean male presented with a two-day history of brief, generalised tonic-clonic seizures. Physical examination was normal in between seizures and he was growing and developing normally.

  Investigations revealed a low serum calcium, slightly low serum magnesium, raised alkaline phosphatase, raised serum parathyroid hormone, low serum vitamin D level and absent urinary calcium excretion. X-ray of the left wrist showed fraying and cupping of the radial and ulnar metaphyses consistent with a diagnosis of rickets. Other investigations for seizures in infancy were normal.

  The patient was the third child of unrelated parents and had been born at full term after an uneventful pregnancy. There had been no concerns until the day before presentation when the first fit had occurred. The patient was exclusively breast fed and had not received any vitamin supplementation. Maternal diet is varied with an adequate vitamin D intake as judged by food diary analysed by a dietician. There had been no dietary restrictions during pregnancy or lactation. Investigations showed maternal serum parathyroid hormone, calcium, phosphate and alkaline phosphatase to be normal.

  Treatment with calciferol 1000 IU daily was commenced together with potassium acid phosphate because of a falling serum phosphate. He continued to breast feed but was later weaned onto formula feeds and then a varied and mixed diet of solids. After three months of treatment the biochemical and radiological abnormalities had all resolved and there have been no further seizures. Treatment has been discontinued and the patient remains well at follow up.

  Our patient’s mother’s dietary intake of vitamin D is greater than the adult mean daily intake of 2.5 micrograms but less than the recommended intake for pregnant and lactating women. This, together with dark skin and winter months may have conspired to increase the need for supplementary vitamin D in our patient.

  Guidelines based on recommendations from the Department of Health’s Committee on Medical Aspects of Food Policy on breast feeding and infant nutrition advise vitamin D supplementation to breast fed infants only after six months of age, except where there are specific concerns about the mother’s diet when supplementation is recommended from one month of age.[2] These present recommendations may be inadequate.

  We would recommend that all breast fed children with dark skin should receive 400 IU of vitamin D supplements daily.

  References

  (1) Shaw NJ, Pal BR. Vitamin D deficiency in UK Asian families: activating a new concern. Arch Dis Child 2002;86:147-9.

  (2) Department of Health.Weaning and the weaning diet. Report of the working group on the weaning diet of the Committee on Medical Aspects of Food Policy, 45. 1994. London: HMSO.

  RF Harris, BM Mehta
  Department of Paediatrics, King’s Mill Hospital
  Mansfield Road, Sutton-in-Ashfield, NG17 4JL

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  Conflict of Interest:
  None declared.

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• Published on: 3 April 2002

  Replete or insufficient Vitamin D?

  • Nick J Shaw, Paediatric Endocrinologist
  • Other Contributors:
    • Rani Pal

  Dear Editor

  We are grateful to Ruth Morley and her colleagues for their interest in our article which as stated in the abstract was focusing on symptomatic Vitamin D deficiency. The recommendations we have given are based on those advocated by the Committee on Medical Aspects of Food Policy(COMA)[1]in 1991 which were reiterated in their later publication in 1998[2]despite further evidence at that time suggesting that...

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  Dear Editor

  We are grateful to Ruth Morley and her colleagues for their interest in our article which as stated in the abstract was focusing on symptomatic Vitamin D deficiency. The recommendations we have given are based on those advocated by the Committee on Medical Aspects of Food Policy(COMA)[1]in 1991 which were reiterated in their later publication in 1998[2]despite further evidence at that time suggesting that PTH levels could be used to define adequate Vitamin D status. We would have reservations about advocating an insufficient Vitamin D level based entirely on minimising serum PTH concentrations as there is inconsistent evidence of a direct relationship between elevated PTH levels and 25OHD deficiency. Brot et al[3] in their study of perimenopausal women identified that PTH was not a sensitive marker of hypovitaminosis D as only 16% of those with 25OHD levels less than 25 nmol/l(10ng/ml) had PTH values above the normal range. There is also likely to be variation between populations as to which level of 25OHD suppresses PTH concentrations as this will be influenced by dietary calcium intake which will add to the difficulty in comparing prevalence of Vitamin D deficiency worldwide.

  As indicated earlier we feel that as a minimum we should be aiming to return to the Vitamin D intakes advocated by COMA to prevent symptomatic Vitamin D deficiency in infants.We feel it is the remit of COMA to reconsider any new evidence defining Vitamin D deficiency and adjusting the national recommendations if they see appropriate. We are pleased that our article has stimulated discussion on this important issue.

  References

  (1) Department of Health.Dietary reference values for food energy and nutrients for the United Kingdom.Report on health and social subjects 41.London:HMSO,1991.

  (2) Department of Health.Nutrition and Bone Health:with particular reference to calcium and vitamin D.Report on health and social subjects 49.London:HMSO,1998.

  (3) Brot C,Vestergaard P,Kolthoff N,Gram J,Hermann AP,Sorensen OH. Vitamin D status and its adequacy in healthy Danish perimenopausal women:relationships to dietary intake,sun exposure and serum parathyroid hormone.Br J Nutr 2001;86(Suppl 1):S97-103.

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  Conflict of Interest:
  None declared.

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• Published on: 5 March 2002

  Vitamin D in pregnant women.

  • Ruth Morley, Senior Research Fellow
  • Other Contributors:
    • Sonia Grover, Julie Pasco, Geoffrey Nicholson and John McGrath (Australia), Reinhold Vieth (Canada)

  Dear Editor,

  We agree with Shaw and Pal [1] that maternal vitamin D insufficiency during gestation probably has important long-term implications for the health of the offspring. [2] However, although the amount of vitamin D that women need for optimal fetal development is not known, we would like to point out that recent evidence indicates that the intake recommendations outlined in their review will not solve the pr...

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  Dear Editor,

  We agree with Shaw and Pal [1] that maternal vitamin D insufficiency during gestation probably has important long-term implications for the health of the offspring. [2] However, although the amount of vitamin D that women need for optimal fetal development is not known, we would like to point out that recent evidence indicates that the intake recommendations outlined in their review will not solve the problem.

  The criteria used to define vitamin D deficiency and insufficiency continue to focus only on the health of bone, but even from that perspective, the target value for desirable 25-hydroxyvitamin D (25(OH)D) concentration has been going up in recent years, from the 25 nmol/L (10 ng/ml) cited by Shaw and Pal, toward levels that will minimise serum PTH concentrations: i.e. between 50 and 80 nmol/ L (20-32 ng/ml) as the threshold. [3,4] Thus, people are likely to be vitamin D insufficient at levels well above Shaw and Pals suggested thresholds of 8 ng/ml in winter and 10nmol/L in summer.

  We now know that the recommended intake of 400 IU per day vitamin D for pregnant women before the third trimester is not enough to provide a measurable benefit. There is little evidence on the gestational age when vitamin D receptors are first expressed, but it is likely to be early in fetal life. For Finnish girls in winter, 400 IU/day did not prevent deficiency [5] and for Muslim women in Denmark an intake of 600 IU/day was not enough to maintain vitamin D levels above 40 nmol/L. [6] In Melbourne we give deficient women [7] 2000 IU/day for two months, then 1000 IU/day as a maintenance dose, whatever the stage of pregnancy. This dose of vitamin D, preferably as D3 and not D2 [8], is safe, and is the intake needed to ensure that 25(OH)D concentrations exceed 40 nmol/L. [9]

  While people of Asian descent or with pigmented skin living in the UK are at high risk of vitamin D deficiency, many Caucasian women are also likely to be at risk, particularly in winter. We measured 25(OH)D levels in Australian women aged 20-45 years who participated in community based samples in predominantly Caucasian populations in Geelong, at 38.2 degrees South [10] and Brisbane at 27.3 degrees South. [11] Data in the table show that even in a sunny country like Australia, a significant proportion of women of reproductive age living an urban lifestyle have suboptimal supplies of vitamin D, especially in winter. The implications for countries like the UK (at 50-57 degrees North) are likely to be very much greater.

  	Winter/spring (May to October)		Summer/Autumn (November to April)
  Site	Geelong	Brisbane	Geelong	Brisbane
  Sample size	N = 207	N = 55	N = 225	N = 40
  Serum 25(OH)D % (n) <_38 nmol="nmol" lbr="lbr"/><_50 nmol="nmol" l="l" _="_" p="p"/>	14.0% (29) 34.8% (72)	10.9% (6) 34.5% (19)	3.1% (7) 9.3% (21)	0% (0) 12.5% (5)

  
  We suggest that both the 25(OH)D threshold for concern and the amount of dietary vitamin D recommended, particularly for high risk individuals, should be raised considerably. Depending on how it is defined, vitamin D insufficiency may be endemic in the UK. Prevention and treatment is simple, safe and cheap.

  References
  (1) Shaw NJ, Pal BR. Vitamin D deficiency in UK Asian families: activating a new concern. Arch Dis Child 2002;86:147-9.
  (2) McGrath J. Does 'imprinting' with low prenatal vitamin D contribute to the risk of various adult disorders? Med Hypotheses. 2001;56:367-71.
  (3) Meunier P. Vitamin D insufficiency: reappraisal of its definition threshold and bone consequences. In: Burckhardt P, Dawson-Hughes B, Heaney R, eds. Nutritional Aspects of Osteoporosis. San Diego: Academic Press, 2001: 152-172.
  (4) Vieth R. Would prehistoric human 25-hydroxyvitamin D concentrations be beneficial, and how much vitamin D do we need to ensure desirable nutritional targets? In: Burckhardt P, Heaney R, Dawson-Hughes B, eds. Nutritional Aspects of Osteoporosis. San Diego: Academic Press 2001:173-95.
  (5) Lehtonen-Veromaa M, Mottonen T, Irjala K, Karkkainen M, Lamberg-Allardt C, Hakola P, Viikari J. Vitamin D intake is low and hypovitaminosis D common in healthy 9- to 15-year-old Finnish girls. Eur J Clin Nutr. 1999;53:746-51.
  (6) Glerup H, Mikkelsen K, Poulsen L, Hass E, Overbeck S, Thomsen J, Charles P, Eriksen EF. Commonly recommended daily intake of vitamin D is not sufficient if sunlight exposure is limited. J Intern Med. 2000;247:260-8.
  (7) Grover S, Morley R. Vitamin D deficiency in veiled or dark-skinned women. Med J Aust 2001;175:286-90
  (8) Trang HM, Cole DE, Rubin LA, Pierratos A, Siu S, Vieth R. Evidence that vitamin D3 increases serum 25-hydroxyvitamin D more efficiently than does vitamin D2. Am J Clin Nutr. 1998;68:854-8.
  (9) Vieth R, Chan PC, MacFarlane GD. Efficacy and safety of vitamin D(3) intake exceeding the lowest observed adverse effect level. Am.J.Clin.Nutr. 2001;73:288-294.
  (10) Pasco JA, Henry MJ, Nicholson GC, Sanders KM, Kotowicz MA. Vitamin D status of women in the Geelong Osteoporosis Study: association with diet and casual exposure to sunlight. Med J Aust. 2001;175:401-5.
  (11) McGrath JJ, Kimlin MG, Saha S, Eyles DW, Parisi AV. Vitamin D insufficiency in south-east Queensland. Med J Aust. 2001;174:150-1.
  

  Ruth Morley
  The University of Melbourne Department of Paediatrics and Murdoch Childrens Research Institute.
  Flemington Road
  Parkville 3052
  Australia

  Sonia Grover
  Royal Women's Hospital
  Carlton
  Australia

  Julie Pasco and Geoffrey Nicholson
  The University of Melbourne
  Department of Clinical and Biomedical Sciences - Barwon Health
  Geelong
  Australia.

  John McGrath
  Queensland Centre for Schizophrenia Research
  Wacol 4076
  Australia

  Reinhold Vieth
  Pathology and Laboratory Medicine
  Mount Sinai Hospital
  Toronto
  Canada

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  Conflict of Interest:
  None declared.

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