The Dos and Doses of Vitamin D

D-efinition
Vitamin D has been  garnering a lot of media attention. Why all the fuss? Research has shed light on the various functions of vitamin D, its role in health maintenance, and the fact that many people may not consume or produce adequate amounts, which results in subpar vitamin D status.

What exactly is vitamin D?  It is not a vitamin, but a prohormone that can be made from the skin in the presence of sunlight.  Vitamin D, like A, E, and K, are fat-soluble vitamins, meaning that they are typically stored over longer periods in body tissues compared to water-soluble vitamins.

Vitamin D exists in two forms—vitamin D2 (ergocalciferol) and vitamin D3 (cholecalciferol).  Vitamin D2 is added to foods, whereas vitamin D3 is synthesized in the skin and occurs naturally in a few animal foods.

What makes vitamin D unique is that we can actually synthesize it with sunlight, which activates the pre-vitamin D3 in our body to the active form (calcitriol).  This conversion happens in the liver and kidneys.

To keep vitamin D levels from getting too high, the body has a very efficient “checks and balances” system in place. If calcitriol levels are high, the kidneys don’t activate as much vitamin D.  The body can also inactivate what is not needed so that excess vitamin D is excreted . However, this system can be overridden by extremely high doses, so it is important to follow proper dosage recommendations on labels or as directed by a health care professional.

D-o
Vitamin D is best known for its role in the maintenance, mineralization, growth and remodeling of bone.  Vitamin D deficiency can result in thin, brittle bones.  It aids in calcium and phosphorus balance and promotes calcium absorption in the gut.  It also influences gene expression.  Vitamin D also maintains many other aspects of health, including:*

  • Cardiovascular and metabolic health*
  • Skeletal muscle function*
  • Immune function*
  • Memory and cognition*
  • Digestive health*

D-eficiency
Vitamin D deficiency is an increasingly recognized global public health concern.  It is impossible to know whether your levels are low unless you get a blood test.  The best marker of vitamin D status is the serum concentration of 25-hydroxy vitamin D, or 25(OH)D, which is also known as calcidiol.

About half of Americans are estimated to have suboptimal levels.  According to a 2011 study, 41.6% of adults in the U.S. were deficient in vitamin D.  Prevalence is higher among Hispanics (69.2%) and African-Americans (82.1%).  The Institutes of Medicine defines a Vitamin D-ficiency as serum calcidiol levels below 20 nmol/L.  Insufficiency is defined as < 50 nmol/L.  Achieving 80 nmol/L through supplementation may help to maintain healthy levels during the winter months.

Why do people have such low levels of vitamin D?

  • Little to no sun exposure
  • Other aspects of health, such as glucose levels, obesity, and kidney function can affect vitamin D status
  • Aging reduces the skin’s ability to produce Vitamin D
  • Darker skin reduces vitamin D synthesis from sunlight
  • Impact of genetic factors
  • Low fat diets reduce absorption

It is important to have your vitamin D levels measured.  We don’t wear a D-ficiency externally.

Status ng/mL nmol/L
Deficient <20 50
Insufficient 21-29 52-72
Sufficient ≥30 (>40 for bone health) 90-100
Toxicity >150 with hypercalcemia >374 with hypercalcemia

D-Bate
So how much vitamin D do we need? The RDA (Recommended Dietary Allowance) is the average daily level to meet the nutrient requirements of healthy people.  The Institutes of Medicine suggests 400 IU/day for first year of life, 600 IU/day until age 70 and then 800 IU/day . The Endocrine Society suggests children and adolescents may need up to 1000 IU/day and those over the age of 18 may need 1500-2000 IU/day to achieve serum D levels above 30 nmol/L.  So, is it realistic to meet our needs through food?  On average, vitamin D intake from foods in males is 204-288 IU/day, and for females it is 144-278 IU/day.

De-mand
Who is at risk for low vitamin D Levels?

  • Those who consume little or no milk or fish
  • Vegans
  • Individuals who are sensitive to the sun (photosensitivity)
  • Those who have difficulty absorbing fat
  • Heavy sunblock users (SPF > 8 blocks 98% of vitamin D synthesis)
  • Those residing at high latitudes: Locations above 35 degrees N generally do not support vitamin D synthesis during the winter months
  • Individuals taking certain medications, such as anticonvulsants, antifungals, corticosteroids, histamine type 2 receptor blockers and theophylline

Supplemental vitamin D may be contraindicated with the following medications, which may increase serum concentrations to a potentially toxic level:

  • Thiazide diuretics
  • Some statins for cholesterol (Lipitor and Crestor, but not Zocor)

D-iet
Food is important for fuel, but diet alone cannot correct a D-ficiency.  The following table lists food sources and amounts of vitamin D. Not everyone loves cod liver oil, has access to wild salmon or likes mushrooms. If foods on this list do not appeal, and your are D-ficient, a supplement is the way to get your needs met.

Food sources of Vitamin D

FOOD AMOUNT Vitamin D/serving (IU)
Cod liver oil 1 TBSP 1360
Wild salmon 3.5 oz 980
Raw maitake mushrooms, sliced 1 cup 786
Swordfish, cooked 3 ounces 706
Sockeye salmon, cooked 3 ounces 447
Sun dried shiitake mushrooms 1 oz 400-500
Canned sardines 3.5 oz 270
Farmed salmon 3.5 oz 250
Skim milk with D added 8 ounces 120
Orange juice with D added 8 ounces 100

D-osing
Groups who may want to consider vitamin D supplementation include those who:

  • Train/work indoors or outdoors in early morning/evening in the winter
  • Live at >35 degrees N or S latitude
  • Reside in cloudy, polluted environments
  • Wear sunscreen regularly and protective clothing
  • Have very dark or very light skin
  • Carry excess body fat
  • Are seeking support for immune function*
  • Have difficulty absorbing fat-soluble nutrients

Individuals with limited sun exposure require at least 1500-2000 IU/day to keep serum vitamin D in the sufficient range (>30 ng/mL).   People who have digestive issues,  excess body fat, or are taking medications affecting vitamin D metabolism, may require more.  Individuals with deficiency may need 50,000 IU/week x 8 weeks to achieve a serum concentration of >30ng/ML followed by maintenance therapy of 1500-2000 IU/day.

Too much D may result in anorexia, weight loss, polyuria, and heart arrhythmia. In addition, vitamin D toxicity can increase blood levels of calcium, resulting in arterial calcification and damage to the heart and kidneys.

D-liver
For athletes and active individuals, a healthy body is your best bet for optimizing performance. If your Vitamin D levels are less than optimal, you may be weaker, slower, and more prone to injury. In addition, frequent vigorous and/or high intensity exercise or two-a-day training sessions can adversely affect the immune system. An ill athlete cannot train and/or compete at optimal levels. For the athlete who travels, has erratic meal times or is not a regular consumer of fatty fish, dairy and mushrooms, it is extremely challenging to meet Vitamin D through diet. For these reasons, optimizing Vitamin D is a must for athletes and active individuals. Even in Filling the D gap can help athletes capitalize on a healthy supporting structure, and healthy immune system so you can give it 100% every day.*

D-tail
No matter which supplement or level of D you choose, it is still important to have levels monitored to see the impact of supplementation.  More is appropriate in the absence of enough, but is not necessary in the presence of optimal.  To get the most out of your D supplement, remember that the presence of fat in a meal enhances absorption.*

Do your due diligence, know your D levels, and consider dietary changes and supplementation to customize and optimize your health.

References

  1. Forrest KYZ, Stuhldreher WL. Prevalence and correlates of Vitamin D deficiency in US adults. Nutrition Research. 2011;31(1):48-54.

CAN BROCCOLI MAKE YOU BEAUTIFUL?

As a registered dietitian I am always encouraging my clients to not just wear color, but eat it! Fruits and vegetables owe their beautiful hues to phyto ( plant nutrients)- so the vibrant red, orange, yellow, green, purple, blue and even white produce you eat is not just nice to look at but also provide head to tow benefits.

The US News and World Report ranking of the best diets of 2016 selected the DASH ( Dietary Approaches to Stop Hypertension), Mediterranean and Flexitarian among the top picks. One of the similarities of these three plans is the emphasis on fruits and vegetables.

Ok, we all know that fruits and vegetables are good for our hearts, our waistline and our eyes, and our bones, BUT our skin can also benefit from an abundance of produce on the plate.

The skin’s wish list is for caloric balance- not too much but not too little, optimal intake of protein, carbohydrate, fat, vitamins, minerals, antioxidants and fluid. At the same time, overconsumption of sugar may affect not just our waistline but our jawline, as excess sugar intake may increase the likelihood of collagen breakdown so the skin is not as elastic as it should be. Does this mean you can never have a cupcake? Of course not, but perhaps satisfying some of the sweet craving with fruits and vegetables can help your skin as well as what is within.

Antioxidants which are substances in fruits, vegetables, whole grains, nuts, seeds and oils protect cells from damage and disintegration. One of the antioxidants is carotene. Think carrots and sweet potatoes and that beautiful orange color. WE have a high concentration of carotenoids in the skin and they function to reduce UV light sensitivity. The skin carotenoids actually give us a healthy color that is a lot safer than tanning beds. Of note, if you eat a diet that is loo low in fat, you may not store enough carotenoids and your skin may take on yellow/gray tones. Ugh.

Studies have shown that eating enough fruits and veggies over an 8 week period of time results in measurable skin color changes. Ever notice that when you make the effort to eat well, people comment on how good you look? That is much more than your waist size!

The increase in fruits and vegetables results in increased skin redness which contributes to a healthy skin appearance. This can be due to the effect of lycopene ( a plant nutrient in fruits and veggies) and/or the effect fruits and vegetables on the skin’s blood perfusion. In addition the polyphenols in grapes, peanuts, tea and even wine may contribute beneficially to the health of the elasticity of the arteries as well as endothelial health. So to put it another way, 1 additional serving of fruit or vegetable daily ( ½ cup or a piece of fruit the size of a tennis ball) can change skin color in only 6 weeks.

We all know that drinking enough fluid is important. Dehydration or subhydration increases skin dryness. I always recommend minimizing calories in beverages so best choices are: water, milk, unsweetened coffee/tea, small amounts of fruit juice, vegetable juice. So what about alcohol? Excess consumption can increase the production of free radicals and increase the breakdown of collagen. Plus, excess alcohol is a source of calories, can elevate triglycerides ( blood fats) and increase the risk of breast cancer as well as compromise liver health.

I have a lot of clients who pride themselves on keeping their fat intake to a minimum. NOT good for the skin. Monounsaturated fats in nuts, seeds, olive oil and avocados decrease oxidative stress. Studies have shown that olive oil lowers the risk of severe photoaging and that the omega- 3 fatty acids in salmon, sardines, flaxseed keeps skin cell membranes strong and elastic. If you eat a very high carbohydrate and very low fat diet you may have a more wrinkled appearance and skin atrophy.

In a review of the NHANES ( National Health and Nutrition Examination study) women who had a more wrinkled appearance had significantly lower intakes of protein, dietary cholesterol, phosphorous, vitamins C,A, K, and linoleic acid. Take home message here- don’t nutritionally disrespect your body or your skin may show the neglect.

GREAT EXPECTATIONS

The end of 2016 was tough for a lot of us. Uncertainty about the future, a slew of tragic events and the roller coaster of emotions that often accompany the holidays. For me, the end of 2016 heralded a new beginning, the birth of our first grandchild..

We were visiting our kids in Boston over Father’s day when they told us we were going to be grandparents. In that moment, I think I experienced every possible emotion. The reality of becoming a grandmother and the realization that there is a certain connotation attached to grandma- old, comfortable, doting?

Worry that my own parents will be able to be participatory great grandparents due to declines in their physical and mental health.

Sadness that my only sibling who was a doting uncle will not be able to be a great uncle.

Guilt that we live in Pennsylvania and they reside in Massachusetts.

Envy that my daughter-in-law’s family lives in Massachusetts.

Fear that being a grandma results in targeted ageism that may make me less desirable in my professional world.

So now that he has entered our lives I have looked at this list again and have answered some of these questions.

With Face time, my parents have been engaged daily with their grandchildren and great grandchildren and it is amazing what even a small amount of screen time has done to boost their mental well-being

Quality is not necessarily dictated by quantity. We are learning to make the most of each visit with this little man, reveling in every moment and eagerly planning each additional trip. Oh and texts, photo sharing and Skype help too!

I am redefining not maligning myself. To be a grandmother is a privilege and an honor. To be able to have a lifetime of experience in raising two boys brings expertise to the table. Age is just a number not a character trait. Being active, finding fun, surrounding oneself with positivity are all ways to live life to the fullest.
I want to rock that rocking chair. Physical fitness is very important to me. Getting out every day keeps my mind sharp, my body fit, my heart strong and my mood bright. Lifting keeps muscles and bones healthy so that I can pick him up when I want or need to without aches or pains.
Flexibility through yoga will allow me to crawl on the floor with him without fear of achy joints or back a few hours later.

As I hold this precious little boy and experience all the joy, here are the words that come to mind.

Sweat equity is a good thing. We learn to appreciate when we actually participate

Life is not supposed to be easy- challenging oneself increases the enjoyment and emotional fulfillment

Be selective with your entourage. People who discriminate based on age, religion, gender, economic status are not part of my inner circle.

No one has to change the world, control what you can and find ways to make the best of every day.
Get your sleep, move your body, choose to nourish well, find the time to relax.

Wellness checkups are not only for infants. Do your due diligence and make sure your parts are in working order. Medical, dental, vision, hearing checkups are essential. It is not always obvious by how one feels if someone is in good health. Being proactive about health care can prevent a health scare.

Decide what skills and lessons you can pass on. For me, it is the concept of Big Gram’s hands- rescuing the recipes from the heart to fill a child’s food bowl with love. Teaching a child to cook by having them be an active participant in the kitchen, chopping, measuring, stirring, tasting is invaluable and has more tenacity than any toy ever will. Maybe it is a craft, or storytelling or the skill of playing the piano. We all have unique skill sets to offer and opportunities to enrich the lives of others, young or old.

So Joshua Jay Bonci, you have made Glamma ‘s heart so full. I am looking forward to being a part of your life in the kitchen, in the park and throughout your life. There will be some rocky roads, challenges, and obstacles, but know that my love for you will never waver. Thank you little boy for all of this joy.

WHITE IS THE NEW BLACK- DON’T PUT YOUR WHITE AWAY AFTER LABOR DAY

Fashion and food are inundated with rules. Don’t wear this, don’t eat this. Let’s find a way to wear what flatters with food that matters. A “foodista” understands the appeal of fashion/food trends, the “look” on the body or in the bowl and the entire outfit/plate.

If we think of the plate as an undressed body, the goal is to pick the outfit, accessorize and complement with texture, color and personal taste. Start with plain Greek yogurt, add vanilla, a splash of lemon juice, and a drizzle of honey for taste, sprinkle in slivered almonds for texture and stir in sliced strawberries for color. As you are creating your food outfit, think about your salary and calorie cap. Dairy foods are available, affordable and there is minimal to little preparation with no waste.

Dairy never goes out of style. I love the idea of a white food or beverage as a stand-alone or add to. We can enjoy milk in a long lean glass, or throw that milk into a blender, add some ice and berries and create a feast for the eyes in a delicious fruit smoothie. We can enjoy a cup of vanilla yogurt, or we can take plain Greek yogurt, add taco seasoning and serve with cut up vegetables for the crunch, the gut ill and the eye thrill.

Fashion goes by the season, so why not apply some of these trends to eating. As the weather gets cooler, our milk can go into a pan, heated with vanilla extract and cinnamon for a delicious comforting treat. The summer Caprese salad with fresh mozzarella and tomatoes from the garden can become the winter thin crust pizza with a tomato sauce, shredded mozzarella and spinach.
A warm weather cottage cheese and peaches can be a cooler weather baked apple with cottage cheese, raisins and ginger.

Fashion can also be prohibitively expensive and if it is too trendy, the garment is more likely to be in the closet than on you. Everyone has their old favorites that they feel most comfy in. That is also true of food. Fancier is not always better, what tastes good to us is the most satisfying. Think oatmeal with milk, walnuts and berries, or a bean and cheese quesadilla with salsa, YUM!

And finally, repurpose. The sweater you’ve had for years, looks like a brand new top with a different belt or scarf. All of us can get in a food rut, so change the plate, bowl or glass. A smoothie can become a frozen dessert, canned black beans, plain Greek yogurt, salsa and seasonings is higher protein alternative to hummus.

So don’t put your white away after Labor Day. Dairy can help you streamline your prep time, lean up your bottom line and taste just fine.

FROM FEUDIES TO FOODIES

Although nutrition is a hot topic, it as an area fraught with confusion, crowding and confrontation. Food blaming, body shaming, and food phobia have created an environment of feud over food resulting in consumer distrust and mistrust.

As a registered dietitian, I spend a great deal of time translating nutrition recommendations and science into communicable, easily digestible bites. Credibility is key, but empathy, reality and practicality are all important as well.

What are some of the issues?

There is too much easily accessible nutrition information available 24/7
Just because we eat doesn’t mean that we are all experts in nutrition
What is trendy in food is not always the most nutritious nor is it always necessary
Good vs bad food mentality
Self diagnosed nutrition concerns without medical justification
Too much emphasis placed on external look vs internal health
Culinary incompetency
Sensationalism over science
Highlighting individual micro, phyto or macronutrients rather than entire food emphasis
Desire for immediate results with minimal effort
Shift away from shopping and meal preparation in favor of dining out, prepared meals or ready to eat/heat
Elimination without discrimination
Focus on what to take off the plate rather than what is on the plate
Not thinking beyond the food to the eating environment and food habits

Let me offer some suggestions to create a better attitude about what we eat, and gratitude for our bodies

Foods that provide the good for you: palate, physical benefits
Affordability and accessibility
Minimize waste
Get in the kitchen with food
Focus on what your body allows you to do
Don’t be a slave to the scale or a clothing size
Challenge yourself to be kind to your body, be mindful of what you choose to eat and find what gives you happiness, enjoyment and fun!

STRATEGIES TO OPTIMIZE HEALTHY BONES WITH PRUNES AND EXERCISE

The recipe for living well is a combination of eating habits, food choices, fitness and stress management. We often heard about heart health and cancer awareness but not enough about taking care of our supporting structure. Our bone health is something we can control, but to do so we must be proactive and preventive.

The GAME OF BONES

It takes a team to optimize bone health. Our diet supplies the nutrients that nourish bone to encourage bone formation rather than resorption. Weight bearing and strength training exercise stimulate the skeletal muscles that provides positive stress on the bones to encourage bone formation. Both diet and exercise are equal partners in bone health. At the same time, it is important to minimize bone robbers such as inactivity, excess alcohol, extreme dieting and smoking.

So why is it so essential to take care of our bones? Having a strong skeletal structure decreases the risk of falls, and may allow us to live independently throughout our lives. Being able to walk unaided, raking leaves, mowing the lawn, shoveling the snow in the winter, or lugging heavy groceries requires muscle and bone strength. Exercise is critically important, but the foods we choose also have a role to play in helping out bones stay healthy.

WHAT FOODS SUPPORT BONE HEALTH?
Consuming adequate protein is the most important food item for our bones. Ideally, protein should be part of each meal through lean meat, poultry, fish, eggs, dairy foods, beans, soy foods, nuts and seeds. Calcium containing foods such as dairy, fish with bones and calcium fortified foods are essential. Vitamin D is also vital for healthy bones and it is not easy to meet needs through food so a Vitamin D supplement may be warranted is Vitamin levels are low. Vitamin C is a component of collagen the protein in bones and can be found in citrus foods, potatoes, tomatoes,, peppers and berries.

WHY PRUNES?
When people think of prunes, they often think of digestive benefits. Yes prunes can help with regularity, but they do so much more. Prunes are a powerhouse of micronutrients that have a role to play in bone health. Prunes may help to reverse bone loss. They can increase the bone mineral density (BMD) of the ulna and spine, and can help with bone formation.

So what is in them that confers these bone preserving benefits?
When people think about bone nutrients they typically say calcium. Calcium is critically important for bone health but is only one player. Prunes contain many minerals that are important for bone formation such as potassium, boron, and Vitamin K.
Prunes are high in potassium, a mineral that can counter the acid residue from a meat- centric diet, which increases calcium excretion. Consuming more potassium is bone protective. Most American do not consume enough potassium. Prunes are also one of the few fruits that are high in boron, which plays an important role in bone and calcium metabolism.
Vitamin K is necessary for bone formation and mineralization. In addition, Vitamin K may have a role to play in ensuring that calcium ends up in the bones instead of blood vessels. Vitamin K may also decrease the risk of bone fracture and has a role to play in positively affecting calcium balance.

A daily serving of prunes (4-5) provides a good source of potassium and an excellent source of magnesium.

GET MOVING

Why is physical activity so important.? In adolescents and young adults, exercise builds strong bones and helps to achieve peak bone mass. The recommendations for weight bearing exercise 3-4 days/week, 20 to 30 minutes.

In our 20s to 50s we need a combination of cardio exercise, strength training, and flexibility. For older adults, exercise helps to maintain muscle mass to preserve and strengthen bone. Balance training decreases the risk of both falls and hip fractures.

So what is the best type of exercise?
Weight bearing exercise runs the gamut from walking/hiking/jogging/running to dancing, tennis, soccer, stair climbing and walking the golf course. All of these exercises are impact, which creates a force against the bone to keep them healthy. Although swimming is not weight bearing, it does have a positive impact on muscle strength.

In addition to weight bearing exercise, we also need to do weight training exercise. This can be using our own body weight such as push ups and pullups, free weights ( dumbbells), machines, or resistance bands.

Last but not least, core training through planks, crunches, and sit ups strengthens the spine to provide more support and also improves balance.

BOTTOM LINE
To live well, stay well and age well we need to
Strategize to create a bone friendly plate that is optimal in quality and quantity
Optimize our exercise with cardio, strength, core and flexibility workouts
Minimize bone robbers such as alcohol and tobacco.