The APHA Policy on Vitamin D
Susan J. Whiting, University of Saskatchewan
At the October 2008 APHA Annual Meeting, the Governing Council adopted a policy paper on vitamin D. The paper originated from the Community Health Planning and Policy Development Section, with input from FNS (Susan Whiting and Mona Calvo were co-authors). When this policy statement was being written, through the fall of 2007 and early winter 2008, there was a sense of urgency among the writing team, as numerous studies were being written about the role vitamin D can play in health, as well as the need to improve Americans’ vitamin D status. An excellent review of this was published just as we were finishing our report (1). In our minds, few organizations were acting on this information. In considering what could be done, we felt that education, research and policy change were ways to improve upon the issue of suboptimal vitamin D status. The rationale behind the action statements and how these might impact FNS members are described below.
Action Statement 1. APHA urges the CDC to advocate and provide funding for a coordinated and integrated approach to educating health care providers/practitioners about the science and benefit of adequate levels of vitamin D.
Rationale: Vitamin D’s role in noncalcemic pathways is a relatively new area of study that may be unknown to current health practitioners. Only recently has research indicated that vitamin D can reduce the risk of fracture and falls in older, especially institutionalized adults (2). African Americans are experiencing the lowest vitamin D status (3) yet the impact of low vitamin D status of African Americans, for whom osteoporosis is less of a health problem, might lead to a lack of concern about their higher risks for cancer and cardiovascular diseases that have been (but with less good evidence than osteoporosis), linked to poor vitamin D status.
Action Statement 2. APHA urges the USDA and other federal agencies to promote the 2005 Dietary Guidelines for Americans as the scientific basis for increased public awareness using current nutrition guidance for healthy eating, notably for populations at highest risk for vitamin D deficiency/insufficiency.
Rationale: The 2005 Dietary Guidelines have a recommendation for vitamin D (4). They state that older adults (age over 50 years), people with dark skin, and people exposed to insufficient ultraviolet radiation (i.e. sunlight, but refers also to lack of UVB in winter and through clothing and sunscreen use) should consume extra vitamin D from fortified foods and/or supplements, and state a daily goal of 1,000 IU vitamin D intake for those at risk. Having this guideline coming from the government actually means that we should be using it in appropriate circumstances.
Action Statement 3. APHA recommends to the Department of Health and Human Services and USDA that the APHA have organizational representation on the panel of the 2010 Dietary Guidelines for Americans for strategies to improve vitamin D intake.
Rationale: Since the 2005 Guidelines indicated a need for supplemental vitamin D under certain circumstances, it seems appropriate for the 2010 Committee to be apprised of the need to better highlight the recommendation. However, prior to the presentation of the policy at the 2008 APHA Annual Meeting, the Committee was selected. In general, APHA should attempt to influence important public health nutrition policies.
Action Statement 4. APHA requests that it become a participating organization in planning Healthy People 2020 to promote national awareness of the magnitude of the problem of poor vitamin D status; and the associated increased risk for chronic disease development by introducing specific objectives in planning Healthy People 2020 goals.
Rationale: As in the previous recommendations, it is important for APHA to involve itself in public health nutrition policy from the planning stages. Healthy People 2020 will set priority goals for action in public health, and we believe vitamin D status of Americans is a priority concern.
Action Statement 5. APHA urges Congress to appropriate funds to conduct research in diverse populations to determine population specific vitamin D intakes needed to produce and maintain optimal vitamin D status associated with reduced risk of chronic diseases.
Rationale: There is much to be studied regarding vitamin D. It was somewhat neglected through the 1980s when calcium was the higher profile bone health nutrient. Nutritionists believed vitamin D was adequate due to sun exposure, but at the same time, the American Cancer Society and others were waging public health campaigns against sun exposure. Now evidence is needed in order to set recommendations for people living in different geographic locations, with different skin types, at different stages of the life cycle, and with different lifestyles.
Action Statement 6. APHA recommends to the FDA to add vitamin D to the list of required nutrients appearing on the Nutrition Facts Panel that is required on all foods in the U.S. marketplace.
Rationale: The Nutrition Facts Panel requires labeling of some micronutrients but not vitamin D. There are food sources of vitamin D, such as oily fish, yet without labeling information, these go unnoticed by consumers. Having vitamin D on the label may encourage manufacturers to add vitamin D. There are many foods for which addition of vitamin D is currently permissible, but in practice, this is rarely done (5).
References:
1. Holick M (2007). Vitamin D deficiency. NEJM 357(3):266-281.
2. Cranney A, et al. (2007). Effectiveness and safety of vitamin D in relation to bone health. AHRQ Publication No. 07-E013. Rockville, MD: Agency for Healthcare Research and Quality.
3. Looker AC, et al. (2008). Serum 25-hydroxyvitamin D status of the US population: 1988–1994 compared with 2000–2004. Am J Clin Nutr 88:1519-1527.
4. Dietary Guidelines for Americans, 2005.
5. Calvo MS, Barton CN, Whiting SJ (2004). Vitamin D fortification in the US and Canada: Current status and data needs. Am J Clin Nutr 80:1710S-1716S.
Update on NIH Activities Related to Vitamin D
Rachel Fisher, MS, MPH, RD, Program Analyst, National Institutes of Health
The National Institutes of Health has implemented a multifaceted research initiative to respond to a growing body of evidence implicating vitamin D status in a number of adverse health conditions. Since the initiative’s conception in 2003, NIH has supported many activities across a range of issues related to vitamin D and health.
One part of the vitamin D initiative was a systematic evidence-based review, “Effectiveness and Safety of Vitamin D in Relation to Bone Health,” requested and funded by the NIH Office of Dietary Supplements (ODS) through the Agency for Healthcare Research and Quality Evidence-based Practice Center program (1). The review, published in August 2007, confirmed that vitamin D from ultraviolet-B exposure, fortified foods, and dietary supplements are all effective in raising the level of circulating vitamin D. However, the report identified a challenge in defining specific blood levels of markers for vitamin D status that indicate optimal levels for bone health. This is because the current method of quantifying vitamin D status (measuring serum 25-hydroxyvitamin D as the marker for vitamin D status) yields highly inconsistent results. As part of the broader NIH vitamin D initiative, ODS is working with laboratory testing facilities to standardize the quantification of vitamin D status.
In addition to the evidence-based review, NIH convened two conferences related to vitamin D in 2007. The first, “Vitamin D and Cancer: Current Dilemmas and Future Needs,” was held in May and was sponsored by the National Cancer Institute and the NIH ODS (2). While the conference shed much light on the existing body of evidence, it was determined that many unanswered questions remain. Specifically, many of the research gaps identified at the conference related to the need to develop predictive, validated and sensitive biomarkers.
The second conference, “Vitamin D and Health in the 21st Century: An Update” was held in September (3). The objective of the conference was to evaluate available evidence on the efficacy and safety of vitamin D. In doing so, the conference aimed to identify knowledge gaps in order to inform NIH and other federal agencies of research needs concerning vitamin D and health as well as to inform the broader nutrition community. Following the conference, the NIH ODS held a roundtable discussion that included 16 scientists with expertise in areas relevant to the conference topics and the evidence-based review. The goal of the roundtable was to gather additional input on research needs concerning vitamin D and health. The roundtable participants identified several specific research needs such as the long-term safety of pharmaceutical doses of vitamin D, further understanding of the interrelation between calcium and vitamin D toxicity, and the determination of specific safety endpoints (4).
Several other activities have also been funded under the NIH vitamin D research initiative. Examples include the development of standard reference materials for 25-hydroxyvitamin D by the National Institute of Standards and Technology, national monitoring of vitamin D status via the National Health and Nutrition Examination Survey, and the development of analytic methods to measure vitamin D content in foods and dietary supplements by the U.S. Department of Agriculture (USDA) (3).
The growing body of evidence and attention to vitamin D status among the medical and research communities has clearly necessitated an evaluation of the current Dietary Reference Intakes for vitamin D, which were most recently updated in 1997. The NIH, in addition to the Food and Drug Administration, the Department of Health and Human Services Office of Disease Prevention and Health Promotion, the USDA (Center for Nutrition Policy and Promotion, Agricultural Research Service), the U.S. Department of Defense (Telemedicine and Advanced Technology Research Center), and Health Canada, have provided support for this study. The Institute of Medicine’s Food and Nutrition Board at the National Academies will evaluate available evidence to determine if the Dietary Reference Intakes for vitamin D and calcium should be updated at this time. The committee's report is expected to be publicly released by the summer of 2010 (5).
References
1. Cranney A, et al. (2007). Effectiveness and safety of vitamin D in relation to bone health. AHRQ Publication No. 07-E013. Rockville, MD: Agency for Healthcare Research and Quality.
2. Davis, C. Vitamin D and cancer: current dilemmas and future research needs. Am J Clin Nutr 2008; 88(2): 565S-569S
3. Brannon PM, Yetley EA, Bailey RL, Picciano MF. Overview of the conference “Vitamin D and Health in the 21st Century: An Update.” Am J Clin Nutr 2008; 88(suppl): 483S-490S.
4. Brannon PM, Yetley EA, Bailey RL, Picciano MF. Summary of roundtable discussion on vitamin D research needs. Am J Clin Nutr 2008; 88(suppl): 587S-592S.
5. Dietary Reference Intakes for Vitamin D and Calcium.
Institute of Medicine Announces Vitamin D DRI Project Committee Composition
The Institute of Medicine Food and Nutrition Board has announced the committee composition for the Dietary Reference Intakes for vitamin D and calcium project. The committee will review the current literature to establish DRIs for these nutrients. Information on the project and the committee members are available online.