Dr Nay Lin
2012021
Word Count-1100
Strategic plan for combating problems of Vitamin D
deficiency among the elderly
Introduction
Vitamin D deficiency is the most common vitamin deficiency in the world. Vitamin D for
humans has 2 major precursors form, 7-dehydrocholesterol, and ergosterol. Vitamin D2
derives from ergosterol which is of plant origin. Vitamin D3 is synthesis photochemically
by the action of sunlight from the precursor, 7-dehydrocholesterol. When the body does not
get enough of these precursors, it leads to Vitamin D deficiency. Vitamin D level in the
body is controlled by PTH hormone and its mechanism is associated with calcium and
phosphate level.
1. Magnitude of the problem
One billion people are suffered from Vitamin D deficiency in the world and 50% of the
world population are insufficient in Vitamin D.(Lopez Payares and Ali, 2015) 69% -82% of
South Asian populations in India had 25(OH)D levels are less minimum acceptable level.
Vitamin D deficiency affects a huge portion of the population of elderly people. (Masood
and Iqbal, 2008). Very severe vitamin D deficiency is more likely suffered in the elderly.
The key reasons for vitamin D deficiency in the elderly are lack of physical activities and
sun exposure. (Kweder and Eidi, 2018)
1.1 Common causes of Vitamin D Deficiency in elderly
Generally, vitamin D production from the body declines with age. In the comparison of
vitamin D 3 production, young people's D3 production is 4 times greater than old people's
production. It is because the elderly have limited physical activity who have multiple co-
morbidities. Prolong period, staying in the home reduce D3 production in the
elderly.(Nimitphong and Holick, 2013)
The risk of vitamin D deficiency in the elderly is increased by sociodemographic factors
that include smoking, poor health, obesity, low education level, and low economic status
which all cause a reduction of skin exposure to sunlight. (Wyskida, Wieczorowska-Tobis
and Chudek, 2017)But it also showed that obesity in the elderly does not worsen Vitamin D
deficiency. (Kweder and Eidi, 2018)
1.2 Impaction of Vitamin D deficiency in elderly
A clear cross-sectional and prospective study showed vitamin D deficiency was associated
with higher depressive symptom scores. (Brouwer-Brolsma et al., 2016) A higher PTH
level and lower 25(OH)D can increase the risk of sarcopenia (Visser, Deeg, and Lips,
2003) Deficiencies is associated with cognitive decline, depression, osteoporosis,
cardiovascular disease, hypertension, type 2 diabetes, and cancer. (Meehan and Penckofer,
2014) So, the impaction of vitamin D deficiency in the elderly is pretty huge.
2. Pathophysiological requirements
The recommended dietary intake (RDAs) of Vitamin D in adults is 15 mcg (600IU) and the
elderly is 20 mcg (800 IU) for both gender. Vitamin D can get sufficiently from the
sunlight between 10 am and 4 pm. (National Institute of Health, 2016) But Southeast Asia
countries like Myanmar, MOHS advises that to take sunlight exposure 10 to 20 minutes
daily to the face, arms, hands, and legs without sunscreen except between 10 am to 2 pm
because sunlight in that time in Myanmar is very high UV that can destroy skins. Animalbased food like cod liver, animal liver, eggs, oily fish such as salmon and sardines, butter,
and plant-based food only in mushroom provide vitamin D in the form of 25(OH)D in
addition to vitamin D3. (MOHS Myanmar, 2019) Fortified food is one of the ways to
provide Vitamin D but it is not widely performed in developing countries yet.
3. Biochemical assessments
25(OH)D serum level is the main assessment to detect vitamin D deficiency. Serum 25
(OH) D concentrations less than 30nmol/L(12ng/ml) can cause vitamin D deficiency, that
prone to get rickets in infants and children and osteomalacia in adults and elderly.
Inadequacy level, between 30-50 nmol/L (12-20 ng/ml) considered insufficient for bone
and overall health for individuals. A concentration level of 50 nmol/l (20ng/ml ) or more is
adequate levels for healthy people. More than a level of 125nmol/l (50ng/ml) is
hypervitaminosis that can cause adverse effects. (National Institute of Health, 2016)
There have additional biomarkers to assess the status of vitamin D in the body. They are
serum 24R,25-dihydroxyvitamin D, serum 1,25-dihydroxyvitamin D, Parathyroid hormone,
and Vitamin D binding proteins.(Couchman and Moniz, 2017) But they are not common as
serum 25(OH) D. However, a low in 25(OH) D serum level alone is not sure to consider as
vitamin D deficiency. It is better considered with clinical signs and symptoms and
additional biomarkers to ensure vitamin D deficiency.
4. Feasibility of intervention
4.1 Prevention of Vitamin D deficiency
In elderly, above 65 years of age should take vitamin D3 800 to 1000 units daily not to
happen vitamin deficiency and to reduce osteomalacia and osteoporosis. (Sizar et al., 2020)
All elderly need to take Vitamin D rich foods as RDA and to take sun exposure daily. 290320 nanometer type B UV radiation with a wavelength sunlight exposure 10 to 20 minutes
daily to the face, arms, hands, and legs without sunscreen in western countries. In
Myanmar, an Asia country, sunlight exposure can be taken from morning sunlight and
afternoon sunlight except 10 am to 4 pm.
In elderly who go outdoors rarely should take daily vitamin D intake according to RDA. It
is better either they can go outdoors to exposure sunlight or they take dietary food
according to RDA. Therefore, it will reduce the chance of vitamin D deficiency in the
elderly.
4.2 Treatment of Vitamin D deficiency
Treatment depends on the severity of the deficiency and underlying risk factors. Initial dose
Vitamin D3 either 6000 IU daily or 50000 IU weekly for 8 weeks can be considered. When
serum 25(OH)D level exceeds 30ng/ml, 1000-2000 IU daily maintenance dose is
recommended.(Sizar et al., 2020)
Serial monitoring of 25(OH)D levels and serum calcium levels should be monitored during
treatment with vitamin D in patients with extrarenal production of 1,25(OH)2D to prevent
hypercalcemia. For patients with primary hyperparathyroidism and vitamin D deficiency, it
must be treated with vitamin D and serum calcium levels should be monitored. (Aye and
Myint, 2018)
Summary
Vitamin D deficiency affects a huge portion of the population of elderly people in the
world. It is associated with cognitive decline, depression, osteoporosis, cardiovascular
disease, hypertension, type 2 diabetes, and cancer in the elderly. The recommended dietary
intake (RDAs) of Vitamin D in the elderly is 20 mcg (800 IU) for both genders. 25(OH)D
serum level is the main assessment to detect vitamin D deficiency that should consider with
clinical signs and symptoms. The prevention dose is 800-1000 IU daily and to take sun
exposure 10 to 20 minutes daily. The Latest recommended treatment is an initial dose of
Vitamin D3 either 6000 IU daily or 50000 IU weekly for 8 weeks and 1000-2000 IU for a
daily maintenance dose.
References
Anonymous (2019) Vitamin D Nutrients(
), MOHS, Myanmar.
Available at: https://www.mohs.gov.mm/page/697.
Aye, T. T. and Myint, Y. (2018) Vitamin D Rational Prescription of Vitamin D In General
Practice, MOHS, Myanmar. Available at: https://www.mohs.gov.mm/page/8237.
Brouwer-Brolsma, E. M. et al. (2016) ‘Low vitamin D status is associated with more
depressive symptoms in Dutch older adults’, European Journal of Nutrition, 55(4), pp.
1525–1534. doi: 10.1007/s00394-015-0970-6.
Couchman, L. and Moniz, C. F. (2017) ‘Analytical considerations for the biochemical
assessment of vitamin D status’, Therapeutic Advances in Musculoskeletal Disease, 9(4),
pp. 97–104. doi: 10.1177/1759720X17692500.
Kweder, H. and Eidi, H. (2018) ‘Vitamin D deficiency in elderly: Risk factors and drugs
impact on vitamin D status’, Avicenna,Journal of Medicine, pp. 139–146. Available at:
https://www.avicennajmed.com/article.asp?issn=22310770;year=2018;volume=8;issue=4;spage=139;epage=146;aulast=Kweder (Accessed: 21
November 2020).
Lopez Payares, G. M. and Ali, F. A. (2015) ‘Vitamin D deficiency’, The 5-Minute Clinical
Consult Standard 2016: Twenty Fourth Edition, pp. 266–281.
Masood, S. H. and Iqbal, M. P. (2008) ‘Prevalence of Vitamin D’, Journal of Medicine
(Cincinnati), 24(6), pp. 891–897.
Meehan, M. and Penckofer, S. (2014) ‘The Role of Vitamin D in the Aging Adult.’,
Journal of Aging and Gerontology, 2(2), pp. 60–71. doi: 10.12974/23096128.2014.02.02.1.
National Institute of Health (2016) Vitamin D Health Professional Fact Sheet, Nih.
Available at: https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/ (Accessed: 23
November 2020).
Nimitphong, H. and Holick, M. F. (2013) ‘Prevalence of Vitamin D Deficiency in Asia
Vitamin D status and sun exposure in Southeast Asia’, Dermato-endocrinology, 5(1), pp.
34–37.
Sizar, O. et al. (2020) Vitamin D deficiency, StatPearls. Available at:
https://www.ncbi.nlm.nih.gov/books/NBK532266/?report=classic.
Visser, M., Deeg, D. J. H. and Lips, P. (2003) ‘Low Vitamin D and High Parathyroid
Hormone Levels as Determinants of Loss of Muscle Strength and Muscle Mass
(Sarcopenia): The Longitudinal Aging Study Amsterdam’, Journal of Clinical
Endocrinology and Metabolism, 88(12), pp. 5766–5772. doi: 10.1210/jc.2003-030604.
Wyskida, M., Wieczorowska-Tobis, K. and Chudek, J. (2017) ‘Prevalence and factors
promoting the occurrence of vitamin D deficiency in the elderly’, Postepy higieny i
medycyny doswiadczalnej (Online), 71, pp. 198–204. doi: 10.5604/01.3001.0010.3804.