What are some current issues and controversies about vitamin D?

Vitamin D and osteoporosis:

It is estimated that over 25 million adults in the United States have, or are at risk of developing, osteoporosis. Osteoporosis is a disease characterized by fragile bones, and it significantly increases the risk of bone fractures. Osteoporosis is most often associated with inadequate calcium intake. However, a deficiency of vitamin D also contributes to osteoporosis by reducing calcium absorption. While rickets and osteomalacia are extreme examples of vitamin D deficiency, osteopororsis is an example of a long-term effect of vitamin D insufficiency. Adequate storage levels of vitamin D help keep bones strong and may help prevent osteoporosis in older adults, in non-ambulatory individuals (those who have difficulty walking and exercising), in post-menopausal women, and in individuals on chronic steroid therapy. 

Researchers know that normal bone is constantly being remodeled, a process that describes the breakdown and rebuilding of bone. During menopause, the balance between these two systems changes, resulting in more bone being broken down or resorbed than rebuilt. Hormone therapy (HT) with sex hormones such as estrogen and progesterone may delay the onset of osteoporosis. However, some medical groups and professional societies such as the American College of Obstetricians and Gynecologists, The North American Menopause Society, and The American Society for Bone and Mineral Research recommend that postmenopausal women consider using other agents to slow or stop bone-resorption because of the potential adverse health effects of HT.

Vitamin D deficiency, which is often seen in post-menopausal women and older Americans, has been associated with greater incidence of hip fractures. In a review of women with osteoporosis hospitalized for hip fractures, 50 percent were found to have signs of vitamin D deficiency. Daily supplementation with 20 μg (800 IU) of vitamin D may reduce the risk of osteoporotic fractures in elderly populations with low blood levels of vitamin D. The Decalyos II study examined the effect of combined calcium and vitamin D supplementation in a group of elderly women who were able to walk indoors with a cane or walker. The women were studied for two years, and results suggested that such supplementation could reduce the risk of hip fractures in this population. 

All women are encouraged to consult with a physician about their need for vitamin D supplementation as part of an overall plan to prevent and/or treat osteoporosis. 

Vitamin D and cancer:

Laboratory, animal, and epidemiologic evidence suggests that vitamin D may be protective against some cancers. Epidemiologic studies suggest that a higher dietary intake of calcium and vitamin D, and/or sunlight-induced vitamin D synthesis, correlates with lower incidence of cancer. In fact, for over 60 years researchers have observed an inverse association between sun exposure and cancer mortality. The inverse relationship between higher vitamin D levels in blood and lower cancer risk in humans is best documented for colon and colorectal cancers. Vitamin D emerged as a protective factor in a study of over 3,000 adults (96% of whom were men) who underwent a colonoscopy between 1994 and 1997 to look for polyps or lesions in the colon. About 10% of the group was found to have at least one advanced neoplastic (cancerous) lesion in the colon. There was a significantly lower risk of advanced cancerous lesions among those with the highest vitamin D intake.  

Additional well-designed clinical trials need to be conducted to determine whether vitamin D deficiency increases cancer risk, or if an increased intake of vitamin D is protective against some cancers. Until such trials are conducted, it is premature to advise anyone to take vitamin D supplements for cancer prevention. 

Vitamin D and steroids:

Corticosteroid medications such as prednisone are often prescribed to reduce inflammation from a variety of medical problems. These medicines may be essential for medical treatment, but they have potential side effects, including decreased calcium absorption. There is some evidence that steroids may also impair vitamin D metabolism, further contributing to the loss of bone and development of osteoporosis associated with long term use of steroid medications. One study demonstrated that patients who received 0.25 μg of active vitamin D and 1000 mg calcium per day in addition to corticosteroid therapy after a kidney transplant avoided rapid bone loss commonly associated with post-transplant therapy. For these reasons, individuals on chronic steroid therapy should consult with a qualified health care professional about the need to increase vitamin D intake through diet and/or dietary supplements.

Vitamin D and Alzheimer's disease:

Alzheimer's disease is associated with an increased risk of hip fractures. This may be because many Alzheimer's patients are homebound, frequently sunlight deprived, and older. With aging, less vitamin D is converted to its active form. One study of women with Alzheimer's disease found that decreased bone mineral density was associated with a low intake of vitamin D and inadequate sunlight exposure. Physicians should evaluate the need for vitamin D supplementation as part of an overall treatment plan for adults with Alzheimer's disease.

Vitamin D and caffeine:

High caffeine intake may accelerate bone loss. Caffeine may inhibit vitamin D receptors, thus limiting absorption of vitamin D and decreasing bone mineral density. A study found that elderly postmenopausal women who consumed more than 300 milligrams per day of caffeine (which is equivalent to approximately 18 oz of caffeinated coffee) lost more bone in the spine than women who consumed less than 300 milligrams per day. However, there is also evidence that increasing calcium intake (by, for example, adding milk to coffee) can counteract any potential negative effect that caffeine may have on bone loss. More evidence is needed before health professionals can confidently advise adults to decrease caffeine intake as a means of preventing osteoporosis. 

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