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Vitamin D deficiency a threat to bone health Sourcing ‘D’ only from food not feasible

When considering exposure to the sun, the health risks are often overemphasized and the benefits forgotten. Living in the shadows has dire consequences for Kuwait; Dr Kashif Rizvi, Consultant Physician & Endocrinologist at the Specialized British Medical Unit, shares how a combination of factors has led to the alarming statistic of roughly the entire population being Vitamin D deficient.

Question. Let us begin by discussing what Vitamin D really is.
Answer: Vitamin D is actually not a vitamin, it is a hormone. That is the most important thing to remember. In general, Vitamins are trace elements that are needed in small amounts and sourced from food. For example, you can eat an orange and get your Vitamin C. Vitamin D however is unique because it is predominantly made inside the body, with resulting hormones functional across the entire body, so its supply from external extraction i.e. food is not enough and simplistic to think it is one dimensional in its affect.

Q: Is the Vitamin D deficiency a recent occurrence?
A: If you look historically, even in the pre industrial age, there was extensive deficiency of Vitamin D and people used to suffer from the condition of very weak and painfully deformed bones. This in smaller children was called Rickets and in adults, known as Osteomalacia.
The problem was recognized and in the 1920s, in US there was a national drive that sought to increase the time children spent outside in the sun. With that and supplementation with the so called cod liver oil which had Vitamin D the severe deficiency went off radar for a few decades, Rickets and Osteomalacia subsided but the subtler features of Vitamin D deficiency other than bone health resurfaced again with the onset of industrial age when people began to spend more time indoors and a general feeling arose that the sun may damage their skin.

Q: What is the prevalence of the deficiency in Kuwait? Why is it so widespread?
A: It is difficult to collect exact data in Kuwait due to multiplicity of factors; but we have a unique set of circumstances here and in broader Middle East which act as a perfect storm for Vitamin D deficiency. It will not be an exaggeration to say that the figures of Vitamin D deficiency in Kuwait will be nearing 100 percent. There are several good studies in Kuwait that depict this. In one study two groups of women were looked at, those who concealed their bodies and those who wore western clothes. Both groups were deficient in Vitamin D but the level of the deficiency was proportional to the degree of covering of the face and limbs. Other studies have looked at children and students in Kuwait, and there appears to be a universal deficiency in whatever segment of population is analyzed.

Even in countries like the US where the lifestyle is more outdoorsy, in the states away from the equator there is an 86 percent deficiency in the winter months which then improves to 60 percent in the summer months.
There are certain clinical pointers which make one vulnerable to a Vitamin D deficiency. Since it is a fat soluble substance so in cases where people are overweight and carrying more fat in the body, the fat will absorb their Vitamin D and keep it is an unusable store. As a result an overweight person will almost certainly be depleted in it.
It is important to note then that in Kuwait we have one of the highest incidences of obesity in the world.
Secondly, people with darker skin block the conversion of Vitamin D synthesis from cholesterol. It’s akin to wearing sun-block making it difficult to take in the required ultraviolet B rays from the sunshine.
At least 10-15 minutes of face and limbs exposure to the sun is required to convert Vitamin D into its active form. In Kuwait, due to the harsh weather, on top of a general aversion to the sun even windows are kept closed, with the glass blocking the UVB rays. Additionally there are cultural & religious reasons to cover up the entire body including the face. Also there are special groups like pregnant mothers needing additional vitamin, small babies who require supplements due to low vitamin D in breast milk but not aware due to lack of health education.
Hence, indoor life, obesity, darker skin and concealing the body, aversion to sun factor into creating a Vitamin D deficiency and these would perhaps include virtually everyone in Kuwait.

Q: What is the optimal amount of Vitamin D needed?
A: The optimal range depends on which methodology is used and it should be more than 50 nanograms per milliliter (ng/ml) in the body (the American method). Some labs use nanomols per liter (nmols/l), which is ng/ml x 2.5. Ideally, it (ng/ml) should be about 60 or 70, anything below 50 should be considered suboptimal and less than 20 significantly deficient.

Q: What are the consequences of being Vitamin D deficient?
A: If Vitamin D is severely low, it will affect bone health. One of the major functions of Vitamin D is to absorb calcium and help with the bone health and to deposit mineral upon its matrix of protein.
A simpler way to understand its depletion perhaps would be to think of the bone screaming in the way of non-specific aches and pains. Particularly affecting long bones, joints and muscles where they join the bones via tendons. Additionally chronic fatigue, irritability and mood disturbances will occur affecting sleep quality and even depression in some.
When we speak of bone health today, we are not referring to Rickets or Osteomalacia because that is now rarely seen. Instead we mean aches and pains and more seriously even in young people, the lowering in the density of the bone. it will pre-dispose them to the silent disease of the bone, osteoporosis, which has no clinical symptom until the bone becomes vulnerable to fractures without trauma, the so-called fragility fractures.
The incidence of osteoporosis is higher than that of Diabetes — one in two women & one in four men will have an osteoporotic fracture over 50 years of age. So in Kuwait it is very important to raise this awareness that along with the quality of life that is impaired with vitamin d depletion, there is a great threat to bone health. There are a myriad of other problems that Vitamin D is connected to.

Q: What other problems is a Vitamin D deficiency connected to?
A: As mentioned at the outset, vitamin D is a hormone. It has receptors on every cell of the body. Its deficiency manifests everywhere in the body. In the bone health, in the immune system modulation, i.e. helping our body’s defenses against various infections like influenza, TB and also enhancing our body’s responses against diseases caused by our own immune system like type 1 diabetes, rheumatoid arthritis, multiple sclerosis and asthma
Data is emerging on the protective role vitamin D may play against heart disease, stroke and various cancers

Q: What is the ideal way of sourcing Vitamin D? How is it processed in the body?
A: When we get exposed to the sun, for ten-fifteen minutes, (face and limbs) it will create about 15 to 20,000 IU of Vitamin D in your body. The ultraviolet B rays of the sun will capture the Cholesterol under your skin and convert it into the precursor of Vitamin D. So, not getting enough Vitamin D maybe a risk factor for heart disease and high blood pressure due to accumulating unused cholesterol. Next the liver then converts it into Vitamin D3 (also called cholecalciferol) which is the store or the major portion of Vitamin D in the body. The liver also uses some Vitamin D (D2) coming from the diet.
The final piece of this jigsaw is the kidney which will make its activated form called Calcitriol or 1, 25-dihydroxyvitamin D3. This absorbs calcium and also performs a lot of other functions as alluded earlier

Q: Can diet provide enough Vitamin D?
A: In brief – No, A person would have to eat a hundred eggs a day six oil fish like salmon or sardines in a day to get enough Vitamin D which you can make with ten minutes of exposure to sunshine so sourcing Vitamin D only from food is improbable
There are some types of milks & cereals that are fortified with Vitamin D which is Vitamin D2 a slightly inferior form of Vitamin D of plant origin. The dietary component is less than 10 percent; with more than 90 percent coming from the sun.

Q: What are the benefits of Vitamin D?
A: As mentioned Vitamin D receptors are found on every cell of the body – the nerve cells, brain cells, bone, heart, and blood vessels. For example, the converted Vitamin D will go to the nerve cell and protect the nerve cell; it will go to the immune system and enhance your immune system activity.
If you go back in time to when tuberculosis was prevalent, people used to be sent to sunnier climates to get better. There is a lot of evidence now that Vitamin D will actually act as a treatment adjunct in tuberculosis and its prevention
In modern times, Vitamin D will protect against asthma. It has been found that there is a 6 percent less incidence of asthmatic attacks among children whose Vitamin D is normal. It also effectively protects against influenza. It is common for people to take a flu shot in the winter season but other scientists argue that influenza occurs mostly in the winter season because there is less Vitamin D. There are studies is California of people who have a decreased incidence of flu on getting vitamin d replacement.
Then there is reduction in significant conditions like Type 1 Diabetes. There is a study in Finland that found that children who were treated with Vitamin D in their infancy will have more than 50 percent reduction in the incidence of Type 1 diabetes. Similar data emerging in Multiple Sclerosis, a very serious debilitating illness, and Parkinson’s disease.

Q: What about Type 2 Diabetes?
A: Type 2 diabetes, in Kuwait, is almost always related with central obesity. With increasing waistline & the fat sponging your vitamin D you also are at risk for acquiring metabolic syndrome which is central weight gain, insulin resistance, diabetes, hypertension, increased cholesterol, depletion of Vitamin D and reduced bone density. So we replace Vitamin D actively in everybody who has type 2 diabetes. They feel better and then they have more energy to alter their lifestyle to eat less/walk more in order to make everything else better in their syndrome.
There is a new study recently showing a link between forgetfulness and vitamin D deficiency in type 2 diabetics

Q: So, when Vitamin D is declared a simple solution to a variety of problems, it is not an exaggeration?
A: Absolutely not! It will not be an exaggeration to suggest that people should become aware of their Vitamin D status because it is easy to check and replace. A person can take up to 1000-1200 units a day or a dose of 5000 units per week in tablet form. We normally replace it with an injection of 600,000 units every month for three to five months. This helps compliance, is cost effective, rapidly improves their symptoms and achieves target levels. Subsequently it could be maintained with tablets or periodic shots
Once people have received the injections, they can have a maintenance dose every few months to keep it in a normal range or supplement it orally with tablets.

Q: Is there a national programme in place in Kuwait for Vitamin D?
A: I am not aware of any such thing in Kuwait. In the US and Western countries, there are drives for this based on national programmes but I am not aware of anything in Kuwait. Here, it is difficult to collect data because there is a heterogeneous group of people. This makes it difficult to enact any one programme. Nonetheless it is important to continually strive to raise awareness via discussion like these. We arrange regular public awareness seminars in this regard with the next one scheduled with the American Women’s League in a couple of months.

Q: What areas of current research on Vitamin D are the most significant?
A: A lot of research is taking place to determine its effect on high blood pressure and heart disease, and on cancer prevention i.e. breast and colorectal. Recently there are many exciting studies showing vitamin D is important in regulating genes implicated in autism, in breast cancer, in more mundane but important issues of ear infections, respiratory and gastric infections in young children. Consequently Leeds a city in UK making vitamin D supplement available for free for all children under 4 years of age.

Q:  How does ageing factor in the absorption of Vitamin D?
A: As a person gets older, they tend to be less active and less outdoorsy. They may also have weaker/thinner skin allowing reduced sun exposure. Additionally they may have co existing diseases and other deficiencies to manage as well. There is evidence of Vitamin D’s protective role in Alzheimer’s disease too.

Q:  Does the required amount differ from men, women, and children?
A: The American government’s recommendation is 400 IU for a child, 800 for an adult and 1200 for a breast feeding woman. But if you get exposed to the sun for fifteen minutes, you make 20,000 IU. This is a big difference. So exposure to the sun is key to life, it creates happiness, vitality and energy.
Pregnant and breast feeding women need more Vitamin D. Guidelines suggest up to 1200 IU a day but we give a larger dose because we want to normalize the Vitamin D to above 50 ng/ml. All the evidence points that if it is kept above this level, the symptoms disappear. People feel tremendously better.

Q. Why is exposure to the early morning sun always recommended?
A: That is because the sun is not harsh in the morning or evenings. So in places like Kuwait although it is available around the year we need to exercise precaution against sunburn and especially protect our face. It would be better to utilize the sun away from the hotter hours of 11 till 3 and to keep ourselves hydrated.

Q: Is there a possibility of excess Vitamin D levels leading to toxicity?
A: Like every supplement or every therapeutic intervention, there is a possibility of intoxication, but that is very unusual. A person would have to take an exceedingly large amount for a long period of time which would create too much calcium in the body and lead to hypervitaminosis. It’s rare in medical practice
At the same time, one has to guard against over-replacement which is a theoretical possibility. You can get it checked easily; it is a one off test. But I have hardly ever seen, in my clinical practice in Kuwait, anybody whose vitamin d is normal let alone above normal

Q: What are the most commonly held misperceptions of Vitamin D?
A: People often confuse Vitamin D with Calcium. They drink milk, eat cheese, and think that they will get Vitamin D. Although some milk is fortified with Vitamin D, it cannot supply you with the required amount. Calcium and Vitamin D are two different substances and people when they eat poultry and other products; mistakenly think that they are getting Vitamin D when they are not.
Secondly it is considered as a vitamin when it really is a hormone. A hormone is something which has effects on many systems of the body. So Vitamin D should be thought of as a hormone that must be replaced, rather than a trace element which ‘may’ be replaced.
Thirdly, people’s unawareness about exposure to the sun is skewed. There was a study in Kuwait where people were found to be very aware of the dangers of exposure to sun but not aware of missing out on it.
Also, sun-block will block the conversion of Vitamin D as well. Better to put it on face and not on the limbs. There is no harm in being in the sun for a little while, that’s the message.

Q: How would replacing Vitamin D levels impact healthcare costs?
A: I don’t know the answer to that because it is impossible to calculate. There are so many effects from it that the simple replacement itself can act as a pivotal part of preventative medicine. If a country was aware of its deficiency and takes steps to replace it, there will be innumerable direct and indirect costs saving from it.

Q: Tell us about your centre
A: We here at Mazaya Clover centre are practicing internal medicine, endocrinology, metabolic medicine, bone disease and managing Diabetes in an evidenced based international protocol driven methodology and modeled like a UK centre with a multidisciplinary team approach
We treat a lot of people in our centre for Vitamin D deficiency, with assessment of various parameters including bone density and make a program for the replacement. I am not aware of a single patient who has failed to turn up for their treatment schedule. That really tells you that they must feel better. For anything else, people sometimes cancel or reschedule things. But for Vitamin D replacement, they seldom reschedule — the proof is in the results.


Dr Kashif Rizvi
MD, FRCP, CCST (UK dual board certified)
Consultant Physician & Endocrinologist
Specialized British Medical Unit,
Mazaya Clover Centre
Former Director New Mowasat Hospital Diabetes & Medical Centre, Kuwait.
Former Head of department of Endocrinology and Diabetes - Kettering, UK
Certificate of Completion of Specialist Training) — UK Accredited Endocrinologist
General Medical Council — UK
Member of Royal College of Physicians (London — UK)
Member of British Diabetes Association
Member of British Endocrine Society
Member of Association of British Clinical Diabetologists
Author of Several Peer Reviewed Research Papers
Tutor of Royal College of Physicians

By Cinatra Fernandes
Arab Times Staff

By: Dr Kashif Rizvi

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