Assessing Vitamin D Status
Clinical Indicators. From a clinical perspective, a number of factors may suggest that chronic musculoskeletal pain and related problems may be due to inadequate vitamin D intake. Researchers have stressed that the gold standard for a presumptive diagnosis of inadequate vitamin D is a review of patient history, lifestyle, and dietary habits that might pose risks for deficiency.101 Along with this, indicators of defects in bone metabolism may include chronic muscle, bone, or joint pain, as well as persistent muscle weakness, fatigue, and possibly difficulty walking.20,101,102 Radiological changes potentially associated with osteomalacia are seen only in advanced stages.20,103
Signs/symptoms of calcium deficiency due to vitamin D deficiencies relate to neuromuscular irritability. Patients sometimes complain of paresthesias in their lips, tongue, fingertips, and/or toes, along with fatigue and anxiety. Muscles can be painfully achy, progressing to cramps or spasms.104-107 Lethargy, poor appetite, and mental confusion may be part of the syndrome.104
The diverse signs and symptoms may be erroneously attributed to other causes. Holick14,44 and others51,76 caution that osteomalacia due to vitamin D deficiency can be misdiagnosed as chronic fatigue syndrome, arthritis or rheumatic disease, depression, or fibromyalgia.
Biochemical Markers. Laboratory assessments usually pertain to the measurement of biomarkers that could denote osteomalacic processes, including:108
Bone Health Is Important
Dr Christine Haseler, a GP with a special interest in arthritis, says: The risk with arthritis is that you may not be mobile, so youre less likely to be spending long periods of time outdoors and topping up your vitamin D levels in the sun.
Vitamin D is essential for bone health. With osteoarthritis, especially as you get older, you may be more likely to be frail and prone to falling. If your bone health isnt good and you fall and fracture your hip, thats very serious.”
If youve had inflammatory arthritis throughout your life and if it has been persistent you may have had times without weight-bearing exercise. You may also have been on steroids, and both can lead to thinner bones and osteoporosis. Preventing thinning of the bones means you have some protection if you get into difficulty.
Bone Mineral Disease Management In Ra Patients And Others
Despite our cautionary notes, we recognize that the prescription of calcium and vitamin D supplements to those at high risk of osteoporosis is warranted according to current recommendations . RA, like age, lifestyle, and hormonal and nutritional factors, should be considered a risk factor for osteoporosis. The presence of one or more of these risk factors may lead to measurement of bone mineral density by dual x-ray absorptiometry , and should result in advice to the patient on adequate calcium and vitamin D intake , exercise, and lifestyle modification. Intervention for the prevention of bone loss should be considered when the DXA T score is less than approximately â1.0 to â1.5 in the presence of osteoporosis risk factors. This intervention may include vitamin D and calcium supplementation as well as lifestyle advice.
Presently the decision to treat a patient with vitamin D and calcium supplements is commonly based on simple osteoporosis risk factors and DXA results rather than serum 25D levels. This practice may be analogous to giving statins to individuals at high cardiovascular risk irrespective of their cholesterol level. Whether measurement of serum 25D helps to further improve stratification for risk of osteoporosis remains to be determined, although there is some evidence that a sizable proportion of postmenopausal women with osteoporosis are not necessarily vitamin D deficient .
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Will Your Patients With Knee Oa Benefit From Vitamin D Supplementation
Vitamin D supplementation did not reduce knee pain or volume of cartilage loss as measured by magnetic resonance imaging in individuals with knee osteoarthritis and hypovitaminosis D, according to a study published in JAMA.1
Knee OA is a musculoskeletal disorder that has significant impact on functional capacity. There are no current disease-modifying agents for OA, so medication management has largely been directed towards analgesia.
Vitamin D3 is synthesized in skin from 7-dehydrocholesterol during exposure to the ultraviolet rays in sunlight. Vitamin D3 derived from the skin or diet must then undergo 25-hydroxylation in the liver, then 1-hydroxylation in the kidneys to yield its active form, 1,25-dihydroxycholecalciferol .2
Low levels of vitamin D can lead to the reduced intestinal absorption of calcium and phosphorus. Hypocalcemia can occur with longstanding vitamin D deficiency, causing secondary hyperparathyroidism and bone cannibalism, which may lead to bone demineralization.3 Some studies in the past have suggested that vitamin D supplementation may help decrease pain and swelling associated with knee OA4, but evidence has not been conclusive thus far.
413 study participants were randomly assigned to receive monthly oral doses of vitamin D3 or placebo , over the course of 2 years.
There were also no differences in the change of tibiofemoral cartilage defects or bone marrow lesions between the vitamin D treatment group and the placebo group.1
Precautions Of Consuming Excess Vitamin D
Vitamin D is usually safe when taken at appropriate amounts. However when a higher dose is taken, then people can experience fatigue, weakness, headache, loss of appetite, nausea, and vomiting.
If more than 4000 units of vitamin D is taken per day, then it is unsafe as it can cause an increase in the level of calcium in the body.
People with the following conditions should consult a doctor before taking vitamin D supplements:-
- Vitamin D is unsafe for women who are pregnant or breastfeeding as it can harm the infant.
- People with kidney disease should avoid taking vitamin D because an increase in the level of calcium can harden the arteries and in turn cause more harm.
- People who already have a high level of calcium in the body should not consume more vitamin D as it can make the condition worse.
- People who have kidney stones should also avoid taking vitamin D supplements as an increase in the calcium level can worsen the situation.
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What To Know About The Link Between Vitamin D And Psoriatic Arthritis
Can vitamin D supplements help ease symptoms of joint pain in psoriatic arthritis patients? A rheumatologist weighs in.
If you have psoriatic arthritis, you may have heard that people with the conditionwhich causes painful, swollen, stiff jointsoften have low levels of vitamin D. In a 2015 study published in Arthritis Research & Therapy, researchers found that 40.9% of participants with psoriatic arthritis had a vitamin D deficiency, compared to 26.7% of control participants. Other autoimmune diseases have also been linked to low levels of the sunshine vitamin . In the same study as above, 40.5% of rheumatoid arthritis patients were found to have a deficiency, as did 57.8% of psoriasis patients in earlier research from the British Journal of Dermatology.
Experts believe inflammation may have something to do with this. Autoimmune diseases like psoriatic arthritis and psoriasis involve an inflammation process, explains Waseem Mir, MD, a rheumatologist at Lenox Hill Hospital in New York City. We think that inflammation causes a decrease in vitamin D, he told Health. not because dont have enough vitamin D in their body, but theyre not processing it correctly.
Vitamin D Benefits In Lupus
Lupus is an autoimmune disease that occurs when the immune system attacks its own cells.
People who are suffering from this disease are asked to avoid the sun because the rays of the sun can cause rashes and also worsen the disease.
This can lead to a deficiency in vitamin D which can cause many other chronic diseases in the joints, skin, lungs, brain, and heart.
Patients suffering from lupus disease tend to have more fractures and bone and joint diseases because of a lack of vitamin D.
In this study, it was seen that patients with arthritis have a higher level of homocysteine, lower bone mineral density, and more fractures.
This increase in homocysteine increases heart problems. This makes the consumption of vitamin D supplements a necessity.
A study published in Lupus assessed the level of vitamin D in patients suffering from lupus but have not received any treatment.
It was observed that if patients do not receive any treatment for lupus, they have a low level of vitamin D which increases the level of IL-17 and IL-23 .
Another study published in Integrative Medicine Insights reported that patients who are suffering from lupus have are deficient in vitamin D which worsens the condition. Hence regularly monitoring the level of vitamin D is essential.
A study was published in Immunologic Research in which it was reported that patients suffering from lupus have a lower level of vitamin D and a higher level of IL-17 .
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Is Vitamin D Good For Arthritis
Several scientific studies have identified a link between low vitamin D level and rheumatoid arthritis, and it is common for those with rheumatoid arthritis to have a vitamin D deficiency. Vitamin D receptor gene research reveals an association with RA susceptibility and severity.
Studies looking at vitamin D and rheumatoid arthritis have suggested that having higher levels of vitamin D may help prevent RA onset. A study that followed 29,368 women over 11 years found that greater intake of vitamin D was inversely associated with risk of developing rheumatoid arthritis.
Research also shows that lower serum vitamin D is associated with increased rheumatoid arthritis disease activity, pain and functional disability. One study of 1,191 RA patients found that lower levels of vitamin D were correlated with more severe disease activity and disability as measured by the Health Assessment Questionnaire Disability Index, Disease Activity Score , and Mobility Activities of Daily Living Score. Another study comparing 50 RA patients and 50 controls found that 84% of RA patients were vitamin D deficient versus only 34% of controls. Additionally, in this study vitamin D level was correlated to disease severity, with patients who had lower vitamin D levels having higher disease activity.
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Diseases Related To Vitamin D Deficiency
You can get vitamin D from sun exposure, foods that contain vitamin D , and supplements. Still, vitamin D deficiency is one of the most common nutrient deficiencies in the world. Vitamin D deficiency can cause muscle weakness, bone loss and increase risk of fractures. In children, lack of this nutrient can cause delays in growth as well as rickets, a disease where the bones become soft. In addition, vitamin D deficiency is also linked with several cancers, type 1 diabetes, multiple sclerosis, high blood pressure and thyroid problems.
How much vitamin D a person needs depends on many factors including age, race, latitude, season, sun exposure, clothing, and more.
The US Institute of Medicine recommends an average daily intake of 400 800 IU, or 10 20 micrograms, which it says is adequate for 97.5% of individuals. However, some studies suggest that a higher daily intake of 1000 4000 IU is needed to maintain optimal blood levels.
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The Effects Of Vitamin D Supplementation On Pain In Individuals With Knee Osteoarthritis Are Open To Interpretation And Warrant Further Investigation
In the December 2015 edition of The Clinical Journal of Pain , a team of researchers led by Dr. Toni L. Glover of the University of Florida, College of Nursing and investigators from the University of Alabama wrote about vitamin D, knee pain and problems associated with obesity in patients with knee osteoarthritis.
This study is part of a larger ongoing project at the University of Florida and the University of Alabama at Birmingham that aims to enhance the understanding of racial/ethnic differences in pain and limitations among individuals with osteoarthritic disease .
Here are the highlights of their study:
So what to make of this research?
Vitamin D May Prevent Progression Of Osteoarthritis
DOCTOR’S VIEW ARCHIVE
Osteoarthritis is considered a disease ofthe joint cartilage. Osteoarthritis is the most common form ofinflammation of the joints . Osteoarthritis is relatedto aging and affects more than 15 million people in the U.S.
As osteoarthritis weakens the cartilage of a joint,the bone underlying the cartilage undergoes changes. VitaminD assists the body in the absorption of calcium and has been usedfor the treatment and prevention of osteoporosis . It has been suggested that suboptimalvitamin D intake and blood levels might impair the body’s normalprotection from these bone changes.
Research published in the Annals ofInternal Medicine suggests that lowintake and blood levels of vitamin D are associated with an increasedrisk for progression of osteoarthritis.
Timothy E. McAlindon, M.D. and associates studied556 patients and found that the risk ofprogression of osteoarthritis of the knee for participants thathad low vitamin D intake and blood levels was increased threetimes over those without these deficiencies. Low blood levelsof vitamin D also correlated with loss of cartilage and degenerativebony spur formation.
From this study, it appears that the nature of thebone response in osteoarthritis may determine the ultimate conditionof the joint. If these results are confirmed by further studies,the authors conclude, patients with osteoarthritis who have modestvitamin D intake or low blood levels may benefit from increasedvitamin D intake or sunlight exposure.
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How Vitamin D Benefits In Health And Arthritis
The mechanism by which vitamin D gets absorbed in your body is very less understood. When we expose ourselves to the sun, the skin absorbs vitamin D and sends it to the liver.
If you take vitamin D via supplements or food, then the gut sends vitamin D to the liver. The liver then converts this vitamin D to a chemical.
This chemical gets distributed throughout the body where the different organs then turn it into an active and functional vitamin D. This form of vitamin D then performs its actions on the body.
One of the most important functions of vitamin D is to maintain the level of calcium absorption in the body to make the bones stronger and healthier.
Vitamin D Has Potential Benefits For People With Osteoarthritis
medwireNews: Vitamin D intake is inversely associated with cartilage degeneration among patients with osteoarthritis , and supplementation may have a protective effect, suggests an analysis of data from the Osteoarthritis Initiative.
In the cross-sectional part of their study, Gabby Joseph and colleagues found a significant inverse association between self-reported dietary vitamin D intake and cartilage degeneration among 1785 patients with a KellgrenLawrence score of 3 or lower in the right knee.
Specifically, higher vitamin D intake was significantly associated with a reduction in cartilage WORMS score a modified semi-quantitative whole-organ magnetic resonance imaging score, where lower scores indicate less degeneration with an estimated drop of 0.24 points for each standard deviation increase in vitamin D.
Moreover, daily vitamin D supplementation was significantly associated with lower cartilage WORMS score in the medial femur in the cross-sectional analysis.
The researchers also demonstrated a longitudinal association between vitamin D supplementation and reduced joint degeneration over 4 years of follow-up among individuals who took supplements consistently. This association was dose-dependent, with 300 IU taken at least 46 days per week being the smallest dose and lowest frequency to show a significant inverse association with WORMS progression.
The researchers note that their study was limited by its observational design and self-reported vitamin intake.
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Getting Enough Vitamin D
Vitamin D is naturally synthesized by the body when ultraviolet B rays from the sun reach your skin directly . The amount of sun time needed for adequate vitamin D synthesis depends on several factors: skin tone, time of year, distance from the equator and amount of skin exposed. Light-skinned people wearing a tank top and shorts in the Southern United States may need only 10 minutes of sun exposure per day. Dark-skinned people living in Canada may not be able to get enough UVB exposure to produce adequate vitamin D. Despite the importance of the sun to vitamin D synthesis, it is wise to limit exposure of skin to ultraviolet rays to lower your risk for skin cancer.
Vitamin D can be consumed in foods like fatty fish or in fortified products like milk, yogurt and some orange juices. If youre not getting enough through your food, supplements can be taken.
Overdosing on this fat-soluble vitamin, however, can be dangerous. Aim for the recommended 600 International Units of vitamin D per day, not more.
Q: How Much Vitamin D Do I Need
The NIH recommends 600 IU of vitamin D a day for those 70 and under, and 800 IU after that. But deficient adults may benefit from adding up to 2,000 IU a day . Dr. Yuan recommends her RA patients take a daily supplement of 2,000 IU of vitamin D3, the most easily absorbed kind. Pro tip: If youre on a calcium supplement, try taking both togetherthey work synergistically for bone health.
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Are Circulating 25d Levels Subject To Acute
We now know that many antioxidants and micronutrients follow acute-phase response behavior, an observation that further enhances the potential for reverse causality in some studies . Of interest, in a recent study of 34 patients undergoing elective knee replacement surgery, 25D concentrations fell by 30% within 6 hours after the surgery and stayed at this level for 5 days . Similar findings D levels following uncomplicated orthopedic surgery) have been described in another report . The inverse acute-phase response is a well-known effect of other circulating vitamins , and is also therefore a plausible mechanism for serum 25D . Thus, it may be that high-grade systemic inflammation leads to lower levels of circulating 25D.
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Dosage Of Vitamin D For Arthritis
The Institute of Medicine has reported that the general dose of vitamin D is dependent on age. People between 13 and 70 years of age can take 600 international units a day.
For adults older than 71 years old, 800 internal units of vitamin D daily is recommended.
However, it is very important to consult a doctor or general physician before taking any dose to prevent further harm to the body.
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