A review of the growing risk of vitamin D toxicity from inappropriate practice

Vitamin D and Acute Kidney Injury: A Reciprocal Relationship

Vitamin D is a sterol prohormone with no intrinsic biological activity. Calcitriol, the active form of vitamin D, is synthesized in the kidneys. It has well-known pleiotropic and cytoprotective properties. In addition to regulating parathyroid hormone secretion and enhancing gut calcium absorption, it exhibits antioxidant, anti-inflammatory, antiproliferative, and antineoplastic effects. However, the role of vitamin D in AKI is unclear, unlike in CKD. Thus, this review aimed to understand how dysregulated vitamin D homeostasis occurs in AKI, as well as to explore how vitamin D deficiency and excess influence AKI. A comprehensive literature search was conducted between January 2000 and June 2024 to uncover relevant works detailing vitamin D homeostasis in health as well as investigating the impact of vitamin D deficiency and excess in humans, animals, and in vitro cell models of AKI. According to the findings of this review, vitamin D appears to have a reciprocal relationship with AKI. Acute renal injury, among other factors, can cause hypo- or hypervitaminosis D. Conversely, AKI can also be caused by vitamin D deficiency and toxicity. Even though hypovitaminosis D is associated with AKI, it is uncertain how it impacts AKI outcomes in distinct clinical scenarios. Newer therapeutic options might emerge as a result of understanding these challenges. Vitamin D supplementation may ameliorate renal injury but needs further validation. Furthermore, hypervitaminosis D has also been implicated in AKI by causing hypercalcemia and hyperphosphatemia. It is crucial to avoid prolonged, uncontrolled, and unsupervised supraphysiological vitamin D administration, especially intramuscular injection.

Recent progress of artificial cells in structure design, functionality and the prospects in food biotechnology

Artificial cells have bridged the gap between non-living systems and biological cells. In recent years, artificial cells designed to simulate cellular structure and function have garnered significant attention. These artificial cells demonstrate vast potential for advancements in various biomedical areas, including simulating cell structure and function, creating innovative biosensors, facilitating bioactives transport, enabling micro and nanoreactors, and improving the targeted therapy for chronic foodborne diseases. In the interdisciplinary field of artificial cell construction, based on their constituent components, these systems can be categorized into lipid/polymer vesicles, coacervate, colloidosome, and metal-organic framework (MOF) artificial cells. They are anticipated to significantly enhance advancements in food science, particularly in cellular structure optimization, precise nutrition delivery, targeted nutrient release, and rapid detection methods. Consequently, this paper will comprehensively cover the historical background, fabrication techniques, and structural characteristics of artificial cells. From a functional design perspective, this review examines the growth and division mechanisms, energy production processes, encapsulation and reaction vessels, carriers, and information exchange systems of artificial cells. Ultimately, it provides a comprehensive evaluation of the safety of artificial cells from both biological and environmental viewpoints, to introduce and expand the application scenarios of this innovative biotechnology in food science.

Advertisements for prescription-free drugs and dietary supplements in the Deutsche Apotheker Zeitung (German Pharmacist Journal)

The Deutsche Apotheker Zeitung (DAZ, German Pharmacist Journal) is an independent pharmaceutical newspaper focusing on science and practice, mainly for the profession of pharmacist. In this study, drug advertising in the DAZ was analysed. To our knowledge, there is little scientific data available on drug advertising in professional journals. We assumed that professional journals provide particularly good background information on the advertised drugs because they are targeted to specialists. All non-prescription medicines and preparations that fall under the Medicines Advertising Law (Heilmittelwerbegesetz, HWG) were studied. The Medicines Advertising Law regulates the legal procedure for advertising medicinal products in Germany. The 167 product advertisements from the 52 issues of 2021 were analysed and checked for compliance with the Medicines Advertising Law. We identified significant deficiencies in compliance with the legislation. These included the lack of mandatory information required by the Medicines Advertising Law, for example the indication of adverse drug reactions and the listing of contraindications. There are very few peer-reviewed references on the efficacy of the advertised preparations. A scientific validation was carried out using the PubMed database, with the result that scientific information was available only for 1/3 of the advertisements. In addition, the appearance and target groups as well as social structures, images and feelings conveyed by the advertising were analysed. This study provides insights into the mechanisms of drug advertising in professional journals, which have not yet been researched to any great extent. Even in professional journals, pharmacological evidence plays a much smaller role than marketing, psychology and traditional social values. It seems that drug manufacturers deliberately ignore the German Medicines Advertising Law to advertise their products in the best possible way. Stricter legal controls should be put in place to prevent this practice and protect consumers from misinformation. This will increase drug safety.

Dietary supplementation use for outpatient treatment in children: A cross-sectional study

OBJECTIVE

Dietary supplements (DSs) are commonly used supplements among children to support disease treatment, however, overuse and inappropriate prescription of outpatient DS can negatively affect health and treatment costs. This study aimed to evaluate DS use in outpatient treatment in children.

METHODS

The present study used a cross-sectional descriptive retrospective method based on data from 188,579 outpatient prescriptions of children for 1 year.

RESULTS

DSs were commonly prescribed in pediatric patients ≤5 years old (63.48 %) with diagnosing respiratory, infectious, and gastrointestinal diseases (>50 %). DS costs account for a high proportion (24.86 %) of total outpatient prescription costs. In addition, pediatric prescriptions containing one DS product (88.16 %) showed a higher rate than prescriptions containing two DS products (11.84 %) with the main ingredients being vitamin D3 (80.55 %), vitamin B6 (63.01 %), vitamin B1 (60.22 %), and vitamin B2 (59.04 %), and calcium (51.0 %). The majority of DS products contained multivitamins (69.52 %) with DS containing ≥5 vitamins of 59.04 % and DS containing 2-4 vitamins of 10.48 %. Besides, non-compliance with DS prescribing guidelines for age (21.38 %), dose (14.13 %), and both age and dose (5.54 %) was found primarily in highly prescribed DSs (vitamin-amino acid-mineral ingredients), pediatric patients <2 years old, prescriptions containing one DS product or multivitamins, and respiratory disease group (J and R04-09 ICD). The univariate and multivariate regression analyses showed that vitamin-mineral products and groups <2 years old were significantly associated with guideline-adherent DS prescribing for age and/or dose. Meanwhile, foreign DSs and vitamin-mineral ingredients of prescription showed significant associations with guideline-adherent DS prescribing for age or dose.

CONCLUSION

Instructions for DS use regarding recommended age and maximum dosage may not be carefully considered by doctors due to belonging to an over-the-counter medicine group. Therefore, there is a strong need for a national public policy to prevent and control overprescribing and inappropriate prescribing of DS.

Survey on vitamin D supplementation in children in France: Evaluation of real-life practices following the new 2022 French recommendations

BACKGROUND AND OBJECTIVE

In 2022, recommendations for vitamin D supplementation in children were updated in France. The objective of this study was to assess real-life practices of vitamin D supplementation in children following these recommendations.

METHODS

A thirty-three-question questionnaire was distributed to members of the scientific societies of paediatrics and general medicine via an online platform.

RESULTS

There were 966 respondents, of whom 87 % were paediatricians and 13 % were general practitioners. About half of the physicians (47 %) were in private practice, 49 % worked in a hospital centre and 6 % worked in a maternal and child health centre. As recommended and regardless of the professional practice, vitamin D supplementation was almost systematically prescribed in all age groups (over 90 % of respondents), in daily doses up to 2 years of age (97 % of all respondents) and then every 3 months in older children (year-round in 38 % and winter/spring only in 40 %). Contrary to the new recommendations, loading doses of 200,000 units of vitamin D were prescribed by 5 % of respondents and non-pharmaceutical forms of vitamin D (e.g. unlicensed food supplements) were prescribed by 10 % of respondents. Although risk factors such as low sun exposure and dark skin were well known by respondents (75 % and 74 % respectively), obesity and veganism were only reported by half the respondents (40 % and 53 % respectively). Two-thirds (61 %) of respondents reported assessing calcium intakes when following children; however, only 10 % of them use specific questionnaires or calcium equivalence tables. Finally, the calcium content of foods and its bioavailability appeared to be poorly understood by health professionals.

CONCLUSION

This survey shows that the practice of paediatricians and general practitioners are in accordance with the new recommendations for vitamin D supplementation in very young children. The identification by this survey of knowledge gaps will allow targeted information campaigns.

Comparative Analyses of the Safety Profiles of Vitamin D Receptor Agonists: A Pharmacovigilance Study Based on the EudraVigilance Database

Background/Objectives: Vitamin D receptor (VDR) agonists are commonly used in clinical practice for their roles in calcium regulation and potential benefits in various diseases. However, their safety profiles, particularly for compounds available as food supplements, remain underexplored in real-world settings. This study aimed to analyze the safety profiles of VDR agonists using the EudraVigilance database, focusing on adverse drug reactions (ADRs) reported between 1 January 2004 and 23 June 2024. Methods: Data for ten VDR agonists were collected, de-duplicated, and analyzed to identify specific safety signals. Risk factors for specific ADRs were assessed using multiple logistic regression. Results: This study analyzed 5,369,581 reports in the EudraVigilance system, from which 17,947 reports (0.33%) involving 80,050 ADRs were linked to VDR agonists. The most-reported drugs were cholecalciferol (12,944 cases) and calcitriol (1355 cases). Serious ADRs were more prevalent with paricalcitol, alfacalcidol, and calcitriol than with cholecalciferol (p < 0.05). Hypercalcemia was a hallmark ADR for all VDR agonists, with the highest risk linked to dihydrotachysterol (ROR = 5668; 95%CI = 3332 to 9641; p < 0.0001), alfacalcidol (ROR = 965.7; 95%CI = 843.6 to 1106; p < 0.0001), and calcitriol (ROR = 726.0; 95%CI = 634.6 to 830.5; p < 0.0001). Logistic regression highlighted dehydration, overdose, and concomitant administration of calcium salts as major predictors of hypercalcemia. The co-administration of multiple VDR agonists was also found to increase hypercalcemia risk. However, the disproportionality analysis showed that only active VDR agonists (e.g., calcitriol, alfacalcidol) were associated with severe complications like renal and urinary disorders and cardiac issues due to hypercalcemia. Natural precursors (cholecalciferol, ergocalciferol) were more often linked to non-calcemic ADRs such as gastrointestinal symptoms, which were more prevalent in infants and children compared to adults. Conclusions: The safety profiles of VDR agonists differ significantly between compounds. Active derivatives require close monitoring for serious calcemia-related complications, whereas cholecalciferol is associated with less severe ADRs, primarily in at-risk populations. These findings highlight the need for targeted safety monitoring and further research into the real-world uses of VDR agonists.

Case Report: Nephrocalcinosis in an infant due to vitamin-D food supplement overdose

Background

Vitamin D is a vital lipophilic vitamin that plays a pivotal role in calcium regulation, bone metabolism, and overall health. It is of the utmost importance to maintain appropriate serum levels of vitamin D from the moment of birth. The recommended daily intake for infants under the age of 12 months is 400 IU. In Europe, vitamin D is available in two forms: as a medicinal product and as a food supplement. The food supplement market is experiencing rapid growth, yet it is characterised by a lack of harmonised regulations, which may give rise to potential risks associated with their widespread use. While food supplements are typically regarded as safe, there is a potential for adverse effects, particularly when dosages are not properly managed.

Case report and management

This report presents the case of a 22-month-old girl who developed nephrocalcinosis as a result of an overdose of vitamin D from a dietary supplement purchased online. The initial presentation was characterised by symptoms such as polydipsia, polyuria and decreased growth. It was subsequently revealed that the child had been receiving an excessively high dose of vitamin D, amounting to 25 times the recommended amount, over a period of seven months. Despite normal calcium levels and renal function at the time of presentation, ultrasound imaging revealed the presence of early-stage nephrocalcinosis. The treatment plan involved hospital admission, intravenous hydration, a thiazide diuretic, potassium citrate, and a low-calcium diet. The vitamin D supplement was ceased. Over the course of a year, the patient demonstrated recovery in growth and normalization of vitamin D levels, although nephrocalcinosis remained stable.

Conclusion

This case study highlights the potential dangers of unsupervised vitamin D supplementation, emphasising the importance of healthcare professionals exercising vigilance in prescribing and advising on vitamin D use, particularly in children. Furthermore, it underscores the necessity of establishing a database to track long-term outcomes in paediatric vitamin D intoxication cases, given the rarity of such incidents. This would facilitate the development of appropriate treatment protocols and provide valuable information to parents.

Effect of Consuming Salmon Products on Vitamin D Status of Young Caucasian Women in Autumn-A Randomized 8-Week Dietary VISA 2 (Vitamin D in Salmon Part 2) Intervention Study

BACKGROUND/OBJECTIVES

Young women are often at risk of vitamin D deficiency, while fatty fish can provide significant amounts of it, which is especially important when no vitamin D skin synthesis is possible due to limited sunshine exposure. This study aimed to analyze the impact of increasing the intake of salmon in various forms (smoked salmon, salmon sausages) on vitamin D status of young women in autumn.

METHODS

The 8-week intervention involved 120 non-obese women, aged 20-25 years. Participants were randomly assigned to one of three groups: smoked salmon (25 g/day), salmon sausage (100 g/day), or a control group. Both intervention products provided approximately 5 µg of vitamin D daily. Serum concentrations of 25(OH)D as well as vitamin D intakes were assessed pre-, mid-, and post-intervention.

RESULTS

The median vitamin D intake at baseline was 2.7-3.4 µg/day and did not differ between the groups (p > 0.05), while during the intervention, it was highest in the smoked salmon group (p < 0.001) and amounted to 7.3 µg/day. While all groups experienced a decrease in 25(OH)D serum concentrations, the decrease was significantly smaller in the salmon sausage group compared to the control group (-4.3 vs. -15.0 nmol/L, p < 0.05), and no significant difference was observed between the smoked salmon and control group after 8 weeks (p > 0.05). Moreover, in the salmon sausage group, the intervention was more effective among participants with an inadequate vitamin D status at baseline (25(OH)D change after the intervention: -3.0 vs. -5.4 nmol/L, p < 0.05; inadequate vs. adequate baseline vitamin D status).

CONCLUSIONS

Increasing the intake of salmon, and hence of vitamin D, was not enough to maintain the vitamin D status of young women in autumn. It seems that other, not-yet-fully-understood factors, may influence vitamin D absorption and/or metabolism, thereby affecting the outcomes of such interventions indicating that further research is needed. Nevertheless, it may be concluded that increasing salmon sausage intake might aid slow down the natural decline of 25(OH)D in young women in autumn.

Is vitamin D associated with disease activity in patients with axial or peripheral spondyloarthritis? A real-life study

Vitamin D plays important role in inflammatory rheumatic diseases, which in turn rose an interest for investigating association of its deficiency with disease activity. In this research we aimed to evaluate this matter in the context of spondyloarthritis (SpA), together with treatment modalities and bone density in people diagnosed with axial or peripheral SpA in real-life setting. In our study we enrolled 99 patients with diagnosis of SpA treated at the tertiary level rheumatology department. Serum 25(OH)D levels, treatment modality (NSAIR or DMARDs), disease activity, tobacco smoking habits, mineral density of bone, supplementation and seasonal variations were assessed. We used standardized questionnaires such as ASDAS-CRP, BASFI and joint count, among many others, to evaluate some of the mentioned parameters. Sixty-five percent of patients had vitamin D deficiency. We found marginaly higher activity of disease in subjects with low vitamin D. In cases of peripheral SpA, there was a significant association of higher number of swollen joints and lower vitamin D levels. Additionally, the significant correlation was seen between normal serum vitamin D and supplementation. In our real-life study of patients with SpA we found a significant percentage of vitamin D deficit, with a tendency of slightly higher disease activity in those patients.In order to clarify the impact of the vitamin on disease activity in SpA and the supplementation recommendations for patients with these conditions, the conduction of further studies is required.

Consensus Statement on Vitamin D Status Assessment and Supplementation: Whys, Whens, and Hows

The 6th International Conference, "Controversies in Vitamin D," was convened to discuss controversial topics, such as vitamin D metabolism, assessment, actions, and supplementation. Novel insights into vitamin D mechanisms of action suggest links with conditions that do not depend only on reduced solar exposure or diet intake and that can be detected with distinctive noncanonical vitamin D metabolites. Optimal 25-hydroxyvitamin D (25(OH)D) levels remain debated. Varying recommendations from different societies arise from evaluating different clinical or public health approaches. The lack of assay standardization also poses challenges in interpreting data from available studies, hindering rational data pooling and meta-analyses. Beyond the well-known skeletal features, interest in vitamin D's extraskeletal effects has led to clinical trials on cancer, cardiovascular risk, respiratory effects, autoimmune diseases, diabetes, and mortality. The initial negative results are likely due to enrollment of vitamin D-replete individuals. Subsequent post hoc analyses have suggested, nevertheless, potential benefits in reducing cancer incidence, autoimmune diseases, cardiovascular events, and diabetes. Oral administration of vitamin D is the preferred route. Parenteral administration is reserved for specific clinical situations. Cholecalciferol is favored due to safety and minimal monitoring requirements. Calcifediol may be used in certain conditions, while calcitriol should be limited to specific disorders in which the active metabolite is not readily produced in vivo. Further studies are needed to investigate vitamin D effects in relation to the different recommended 25(OH)D levels and the efficacy of the different supplementary formulations in achieving biochemical and clinical outcomes within the multifaced skeletal and extraskeletal potential effects of vitamin D.

The effects of vitamin D intake and status on symptom severity and quality-of-life in adults with irritable bowel syndrome (IBS): a systematic review and meta-analysis

IMPORTANCE

Many individuals with irritable bowel syndrome (IBS) have insufficient or deficient serum 25-hydroxyvitamin D [25(OH)D] status; however, it is not clear if improved vitamin D nutritional status through higher intake can improve symptom severity and quality of life.

OBJECTIVE

This systematic review and meta-analysis aimed to identify if changes in vitamin D intake or status affect symptom severity and quality of life in adults with IBS.Data Sources: MEDLINE®, Cochrane Central Register of Controlled Trials, Global Health, EMBASE, and Web-of-Science databases were systematically searched for relevant articles to August 12, 2024, in the English language.Study Selection: Clinical trials, prospective observational studies, and Mendelian randomization (MR) analyses reporting the effect of vitamin D intake or status on IBS-related outcomes were included.Data Extraction and Synthesis: Article review and data extraction were conducted by 2 authors following the PRISMA guidelines. Random effects meta-analyses and the Nutrition Quality Evaluation Strengthening Tools to assess risk of bias were employed for randomized controlled trials.Main Outcome(s) and Measure(s): Primary outcomes included measures of serum 25(OH)D status, symptom severity, and quality of life.

RESULTS

12 studies from 15 articles were included (n = 7 RCTs; n = 3 single-arm interventions; n = 2 MR). Seven study populations had deficient (<20 ng/mL) and three had insufficient (21-29 ng/mL) baseline serum 25(OH)D status. RCTs measured changes in serum 25(OH)D after 6-26 wks with 3,000 IU daily to 50,000 IU bi-weekly vitamin D dosages. Meta-analyses of low risk-of-bias RCTs revealed increased 25(OH)D levels in groups treated with oral vitamin D compared to placebo (n = 5; Pooled mean difference [95% CI]: 20.33 [12.91, 27.74] ng/mL; I2 = 97.9%). Quality of life scores improved significantly in deficient populations (n = 3; 3.19 [2.14, 4.24]; I2 = 0.0%). Non-significant decreased trends in IBS symptom severity were shown across populations (n = 6: -25.89 [-55.26, 3.48]; I2 = 92.8%).

CONCLUSION

Moderate level evidence indicate vitamin D supplementation may improve status in adults with IBS and quality of life in those with deficient status at baseline.

Hypervitaminosis D is correlated with adverse dental implant outcomes: A retrospective case-control study

OBJECTIVES

To investigate vitamin-D levels effect on the survival/success and on marginal bone levels of dental implants.

METHODS

Patients with peri-implant disease and healthy control patients with functionally loaded dental implants were included in this retrospective case-control study. Forty patients with 201 implants were in the diseased-cohort, while thirty-three patients with 90 implants were in the control-cohort. Patient blood 25(OH)D levels were assessed through quantitative blood test. The correlation between abnormal 25(OH)D levels and disease status of each patient was assessed using Fisher's exact tests. The correlation of each implant's outcomes with vitamin-D status was assessed using Kaplan-Meier survival analysis and Mann-Whitney U tests.

RESULTS

Patients with blood 25(OH)D levels >70 ng/mL (hypervitaminosis-D) had a 21.1-fold increase in the risk of implant failure or severe peri-implant bone loss regarding patients with intermediate (>30, ≤70 ng/mL) levels. Kaplan-Meier survival analysis revealed that implants in the hypervitaminosis-D cohort had a survival probability of 73.7 % (95 % CI:56.5-84.5 %) at 19-years after surgery, compared to 95 % for implants in patients with intermediate 25(OH)D levels (95 % CI:88.3-97.9 %). Additionally, implants in the hypervitaminosis-D cohort lost bone faster than implants in the intermediate cohort. These results were specific to the patient cohort with elevated blood 25(OH)D levels and not observed in patients taking vitamin-D supplementation. The impact of hypervitaminosis-D was enriched for implants in the maxilla, and not as apparent for implants in the mandible.

CONCLUSIONS

Blood 25(OH)D levels >70 ng/mL were correlated with adverse implant outcomes, including implant failure and peri-implant bone loss, especially in the maxilla.

CLINICAL RELEVANCE

These results suggest that hypervitaminosis D may be a previously unidentified risk factor for dental implant complications and should be further investigated to elucidate the underlying mechanism.

Natural products for the treatment of age-related macular degeneration

BACKGROUND

Age-related macular degeneration (AMD) is a chronic retinal disease that significantly influences the vision of the elderly.

PURPOSE

There is no effective treatment and prevention method. The pathogenic process behind AMD is complex, including oxidative stress, inflammation, and neovascularization. It has been demonstrated that several natural products can be used to manage AMD, but systematic summaries are lacking.

STUDY DESIGN AND METHODS

PubMed, Web of Science, and ClinicalTrials.gov were searched using the keywords "Biological Products" AND "Macular Degeneration" for studies published within the last decade until May 2023 to summarize the latest findings on the prevention and treatment of age-related macular degeneration through the herbal medicines and functional foods.

RESULTS

The eligible studies were screened, and the relevant information about the therapeutic action and mechanism of natural products used to treat AMD was extracted. Our findings demonstrate that natural substances, including retinol, phenols, and other natural products, prevent the development of new blood vessels and protect the retina from oxidative stress in cells and animal models. However, they have barely been examined in clinical studies.

CONCLUSION

Natural products could be highly prospective candidate drugs used to treat AMD, and further preclinical and clinical research is required to validate it to control the disease.

Significance of vitamin D responsiveness on the etiology of vitamin D-related diseases

Vitamin D resistance (VDRES) explains the necessity for higher doses of Vitamin D (VD) than those recommended for treatment success. VD receptor (VDR) signaling blockade, such as that caused by infections and poisons, is one basis for VDRES etiology. Mutations within genes affecting the VD system cause susceptibility to developing low VD responsiveness and autoimmunity. In contrast, VD hypersensitivity (VDHY) occurs if there is extra VD in the body; for example, as a result of an overdose of a VD supplement. Excess 1,25(OH)2D3 is produced in lymphomas and granulomatous diseases. The placenta produces excess 1,25(OH)2D3. Gene mutations regulating the production or degradation of 1,25(OH)2D3 enhance the effects of 1,25(OH)2D3. Increased 1,25(OH)2D3 levels stimulate calcium absorption in the gut, leading to hypercalcemia. Hypercalcemia can result in the calcification of the kidneys, circulatory system, or placenta, leading to kidney failure, cardiovascular disease, and pregnancy complications. The primary treatment involves avoiding exposure to the sun and VD supplements. The prevalence rates of VDRES and VDHY remain unclear. One estimate was that 25%, 51%, and 24% of the patients had strong, medium, and poor responses, respectively. Heavy-dose VD therapy may be a promising method for the treatment of autoimmune diseases; however, assessing its potential side effects is essential. To avoid VD-mediated hypercalcemia, responsiveness must be considered when treating pregnancies or cardiovascular diseases associated with VD. Furthermore, how VD is associated with the related disorders remains unclear. Investigating responsiveness to VD may provide more accurate results.

Shedding light on vitamin D in tuberculosis: A comprehensive review of clinical trials and discrepancies

Over the past few decades, there has been extensive research on the use of vitamin D as an adjunctive therapy in the treatment and prevention of tuberculosis. In vitro studies have provided valuable insights into the mechanisms by which vitamin D activates the immune response to combat Mycobacterium tuberculosis. These encouraging findings have spurred clinical investigations globally to assess the effectiveness of vitamin D as a preventive measure and as an adjunctive treatment for tuberculosis. However, the results from these clinical studies have been contradictory, with some demonstrating clear efficacy while others report only modest or no activity. In this review, we aim to analyze the clinical studies on vitamin D and examine the possible discrepancies observed in their outcomes.

The Role of Natural Products in Diabetic Retinopathy

Diabetic retinopathy (DR) is one of the most severe complications of diabetes mellitus and potentially leads to significant visual impairment and blindness. The complex mechanisms involved in the pathological changes in DR make it challenging to achieve satisfactory outcomes with existing treatments. Diets conducive to glycemic control have been shown to improve outcomes in diabetic patients, thus positioning dietary interventions as promising avenues for DR treatment. Investigations have demonstrated that natural products (NPs) may effectively manage DR. Many types of natural compounds, including saponins, phenols, terpenoids, flavonoids, saccharides, alkaloids, and vitamins, have been shown to exert anti-inflammatory, antioxidant, anti-neovascular, and antiapoptotic effects in vivo and in vitro. Nevertheless, the clinical application of NPs still faces challenges, such as suboptimal specificity, poor bioavailability, and a risk of toxicity. Prospective clinical studies are imperative to validate the therapeutic potential of NPs in delaying or preventing DR.

Vitamin D: A Bridge between Kidney and Heart

Chronic kidney disease (CKD) and cardiovascular disease (CVD) are highly prevalent conditions, each significantly contributing to the global burden of morbidity and mortality. CVD and CKD share a great number of common risk factors, such as hypertension, diabetes, obesity, and smoking, among others. Their relationship extends beyond these factors, encompassing intricate interplay between the two systems. Within this complex network of pathophysiological processes, vitamin D has emerged as a potential linchpin, exerting influence over diverse physiological pathways implicated in both CKD and CVD. In recent years, scientific exploration has unveiled a close connection between these two prevalent conditions and vitamin D, a crucial hormone traditionally recognized for its role in bone health. This article aims to provide an extensive review of vitamin D's multifaceted and expanding actions concerning its involvement in CKD and CVD.

The Power of Vitamin D: Is the Future in Precision Nutrition through Personalized Supplementation Plans?

In the last few decades, vitamin D has undeniably been one of the most studied nutrients. Despite our ability to produce vitamin D through sunlight exposure, its presence in several natural food sources and fortified foods, and its widespread availability as a dietary supplement, vitamin D deficiency is a serious public health problem, affecting nearly 50% of the global population. Low serum levels of vitamin D are being associated with increased susceptibility to numerous health conditions, including respiratory infections, mental health, autoimmune diseases, and different cancer types. Although the association between vitamin D status and health is well-established, the exact beneficial effects of vitamin D are still inconclusive and indefinite, especially when considering the prevention and treatment of different health conditions and the determination of an appropriate dosage to exert those beneficial effects in various population groups. Therefore, further research is needed. With constant improvements in our understanding of individual variations in vitamin D metabolism and requirements, in the future, precision nutrition and personalized supplementation plans could prove beneficial.

Accidental vitamin D3 overdose in a young man

Vitamin D3 (VD3) is a fat-soluble vitamin that can accumulate in the body and lead to toxicity by increasing 25(OH) D levels when consumed in large amounts. Maintaining 25(OH) D levels greater than 30 ng/mL is crucial for overall health due to the significant role of vitamin D in the body. The most common causes of VD3 intoxication are manufacturing errors or self-administration. Currently, there is no definitive data on the dose and duration of VD3 consumption that leads to toxicity. The maximum daily doses of VD3 that can be tolerated without causing adverse effects are not established. The maximum recommended amount for long-term supplementation is 2,000 units per day. Vitamin D3 toxicity (VDT) can present in various scenarios, ranging from asymptomatic to gastrointestinal, and in severe cases with neuropsychiatric and life-threatening symptoms. We report the case of a 29-year-old man who presented with symptoms of VDT following an accidental overdose of VD3 over 2 weeks.

Drug advertising in the German free-of-charge health magazine Apotheken Umschau (Pharmacy review): a critical analysis

In Germany, the Apotheken Umschau (Pharmacy review) is a very popular health magazine for lay people, which is available free of charge in pharmacies. In this study, drug advertising in the Apotheken Umschau was critically analyzed. To our knowledge, studies on drug advertisements in such magazines are scarce. For the analyses, a total of 123 different advertisements from all 48 issues of Apotheken Umschau in 2020 and 2021 were compared. Since 2021 is the first year that was completely characterized by the COVID-19 pandemic, it was thus also possible to work out pandemic effects. More preparations from the categories immune system, eyes and sleep were advertised in 2021. Accordingly, typical complaints home office workers were addressed. Advertisements provided only very modest scientific information, if at all. The Therapeutic Products Advertising Act (Medicines Advertising Law; Heilmittelwerbegesetz (HWG)) provides regulations regarding the handling of drug advertising. However, in various categories, we noted substantial deficiencies of the advertisements to comply to regulations, e.g. the disclosure of adverse effects and omission of the mandatory statement "For risks and adverse effects, read the package insert and ask your doctor or pharmacist (Für Risiken und Nebenwirkungen fragen Sie Ihren Arzt oder Apotheker oder lesen Sie die Packungsbeilage)". Fifty-one of the 123 advertisements featured females to appeal particularly to this target group. Furthermore, a homogeneous ethnic (Caucasian) picture and a traditional image of German society were presented although this clearly deviates from reality. In conclusion, this study provides insights into the yet poorly studied mechanisms of drug advertisement for lay people. Pharmacological evidence plays a much smaller role than psychology, marketing and traditional societal models. It appears that drug companies intentionally use the "grey area" of the Medicines Advertising Law to optimally promote their products and ignore mandatory statements. This practice must be stopped by stricter legal control to protect the consumer from misinformation. In this way, drug safety will be increased.

[A e-Hypercalcemia]

INTRODUCTION

Hypercalcemia is a common biological abnormality. The etiologies are mainly represented by hyperparathyroidism and neoplastic causes. The other causes, including poisoning, are rare, but should not be neglected.

OBSERVATION

An 82-year-old female patient presented to the emergency room for repeated falls at home, confusion, drowsiness and digestive symptoms. The initial assessment showed hypercalcemia above 3mmol/L. The etiological exploration revealed a very high concentration of 25OH-vitamin D. After repeated interrogations, it appeared that the cause of this intoxication was the intake of a food supplement purchased on the internet, following a prescription from her dentist.

CONCLUSION

Intoxication due to a food supplement containing vitamin D is possible and potentially serious. Raising the awareness of patients and healthcare professionals is necessary in order to prevent this type of poisoning and/or to diagnose it as soon as possible.

Vitamin D Abuse in Pursuit of "Gains" Resulting in Acute Kidney Injury

Vitamin toxicity represents an increasingly frequent clinical diagnosis and can be difficult to initially recognize given the plethora of over-the-counter supplements available. The young, active, and heavily male population of the military is especially susceptible to such supplementation pitfalls. Here we present the case of acute renal failure with hypercalcemia that was found to be secondary to unrecognized high-dose over-the-counter vitamin supplementation and subsequent vitamin D hypervitaminosis initiated by the patient in the hope of boosting testosterone production. This clinical scenario demonstrates the dangers of easily accessible, often seemingly benign supplements and the need for greater education and awareness of supplementation use.

Association Between Serum Vitamin D Levels and Body Mass Index Status: A Cross-Sectional Study at King Khalid Hospital, Jeddah, Saudi Arabia, From 2019 to 2020

Introduction Low vitamin D levels have been associated more with overweight and obese people in previous studies. One of the possible explanations behind this association is the lipophilic property of vitamin D that causes the vitamin to deposit in adipose tissue and reduces the serum concentration of the vitamin, which still warrants further evaluation. Objective This study estimated the association between serum vitamin D levels and body mass index (BMI) among male patients in Jeddah, Saudi Arabia. Methods This is a cross-sectional study of male patients that was carried out in King Khalid Hospital, Jeddah, Saudi Arabia. Patients were included between October 2019 and November 2020. Results We concluded that almost half of the patients, 1,132 (48.3%), had adequate vitamin D, followed by 773 (33%) with vitamin D inadequacy, and only 288 (12.3%) had vitamin D deficiency. There was a significant relationship between age and vitamin D levels; younger people had lower vitamin D levels compared to older people (p<0.001). It was found that there was no significant relationship between BMI categories and vitamin D levels (p>0.05). Conclusion According to the findings of the current study, there was no discernible relationship between serum vitamin D levels and BMI. However, there was a substantial correlation between age and vitamin D levels, with younger age groups having lower amounts than older individuals. Future studies should adopt a prospective design encompassing multiple centers and preferably include the risk factors for developing vitamin D deficiency, such as sun exposure, dietary habits, comorbidities, etc. Such studies can provide a more accurate assessment of the association between BMI and vitamin D levels.

Biologically Based Complementary and Alternative Medicine Use in Breast Cancer Patients and Possible Drug-Drug Interactions

Purpose

Biologically based complementary and alternative medicine (BB-CAM) is gaining importance. Cancer patients in particular are at risk of interactions between the prescribed medications (intravenous or oral anticancer therapy, concomitant medication, medication for pre-existing illnesses) and BB-CAM. This investigation aims to identify potentially clinically relevant interactions between both BB-CAM and conventional medicine and two BB-CAM products in breast cancer patients (n = 47).

Methods

From March 2020 to January 2021, consecutive breast cancer patients (n = 47) completed a questionnaire about their medication and BB-CAM intake at the beginning of a new intravenous or oral tumor therapy (time point 1) and again after 10 to 12 weeks (time point 2) at the LMU Breast Center in Munich. The collective was divided into two subgroups based on the time after initial diagnosis; a cutoff of 6 months was used. The survey was available through an eHealth application called CANKADO as electronic patient-reported outcome only. Lexicomp® and AiD Klinik® databases were used for evaluating potentially clinically relevant interactions. As part of routine care, the collected data were evaluated and cross-checked in interdisciplinary cooperation with the University Hospital Pharmacy LMU.

Results

43 of the 47 included breast cancer patients (91%) used BB-CAM at some point during their treatment period. We found a significant increase from time point 1 (n = 27) to time point 2 (n = 40) (p = 0.004). Moreover, in the subgroup of newly diagnosed patients, the number significant rose from 17 at time point 1 to 28 at time point 2 (p = 0.007). Overall, we found potentially clinically relevant interactions in 30 of 43 patients (70%). Sixty interactions were detected at both times of investigations. Twenty-three different kinds of BB-CAM-to-BB-CAM (time point 1 [n = 12], time point 2 [n = 11]) or conventional medicine-to-BB-CAM interactions (time point 1 [n = 15], time point 2 [n = 22]) were discovered. Importantly, there was not a single interaction between BB-CAM and an anticancer drug.

Conclusion

Breast cancer patients frequently use BB-CAM. Interactions were detected at both time points of investigation (time point 1 [n = 27], time point 2 [n = 33]). Interactions were particularly evident between BB-CAM substances as well as between BB-CAM and the patients' medication for pre-existing illnesses. Although no interaction between BB-CAM and an anticancer therapy was found, the use of BB-CAM should be evaluated at the beginning and regularly during therapy in view of the substantial number of interactions detected and the large number of upcoming targeted therapies.

Optimized vitamin D repletion with oral thin film cholecalciferol in patients undergoing stem cell transplant

Vitamin D deficiency is common in childhood, pervasive before and after bone marrow transplant, and is associated with increased incidence of graft-versus-host disease (GVHD) and decreased survival in patients undergoing hematopoietic stem cell transplant (HSCT). Numerous barriers impede replacement, including malabsorption secondary to gut GVHD, mucositis, inability to take capsules, kidney disease, liver disease, and infection; many patients remain refractory despite vitamin D therapy. We hypothesized that a different formulation of cholecalciferol, administered on the tongue as a readily dissolving oral thin film (OTF), would ease administration and facilitate therapeutic vitamin D levels (>35 ng/mL) in patients who are refractory. In this prospective pilot study, we evaluated 20 patients after HSCT (range, day +21 - day +428 at enrollment) with serum vitamin D levels ≤35 ng/mL. Cholecalciferol OTF strips were administered for 12 weeks. Dosing was based on patient body weight and titrated per individual pharmacokinetics. Wilcoxon matched-pairs signed-rank test demonstrated marked improvement in all 20 patients who were formerly refractory, increasing from a median baseline vitamin D level of 29.2 ng/mL to 58 ng/mL at end of study (P < .0001). All patients demonstrated improvement in serum vitamin D level by week 4 on study, some of whom had been refractory for years prior. Median dose was 1 OTF strip (40 000 IU) per week. No toxicity was observed. This formulation proved to be safe, effective, efficient, and well received. We are eager to explore other patient populations, which might benefit from this promising development, and other therapeutics that might be optimized using this mode of delivery. This trial was registered at www.clinicaltrials.gov as #NCT04818957.

Clinical Toxicology of Vitamin D in Pediatrics: A Review and Case Reports

Intoxication of vitamin D is not a common case in pediatrics. Vitamin D supplements are sold as OTC drugs; however, there is a lack of public education about the permissible limits of vitamin D intake which may lead to vitamin D toxicity (VDT). This review aims to give insights to readers or practitioners about the clinical toxicology of vitamin D in pediatrics, which includes the mechanism of VDT, case reports, and the management of vitamin D poisoning. VDT refers to serum 25(OH)D levels, particularly when the level exceeds 100 ng/mL (250 nmol/L) or is defined as hypervitaminosis D. Hypercalcemia is a common condition of vitamin D toxicity. Vitamin D and its metabolites in moderate levels can induce hypercalcemia, as indicated by the elevation of osteoclastic bone resorption, the presence of calcium in renal tubules, intestinal calcium intake (through increased production of calcium-binding protein in enterocytes), and the decrease of parathyroid hormone synthesis. VDT in pediatrics can be managed by discontinuing vitamin D intake; using activated charcoal, furosemide, prednisone, and calcitonin; rehydration using intravenous sodium chloride 0.9%; and dextrose fluid therapy. It is important for parents to be more careful when providing vitamin D to their children.

Safety Profile of Vitamin D in Italy: An Analysis of Spontaneous Reports of Adverse Reactions Related to Drugs and Food Supplements

Vitamin D (VitD) is largely used in Italy, often inappropriately; thus, an evaluation of its safety is a crucial issue. This study analyses the adverse reactions (ARs) associated with the use of products containing VitD (VitDps) reported to the Italian National Pharmacovigilance and Phytovigilance networks. From March 2002 to August 2022, a total of 643 and 127 reports concerning 903 and 215 ARs were retrieved from Pharmacovigilance and Phytovigilance networks, respectively. Overall, 332 (29.6%) ARs were classified as serious, and the most described ones were hypercalcaemia, renal failure and tachycardia. Serious AR risk was significantly higher for subjects using more than four concomitant products (OR 2.44 [95% CI 1.30-4.60]) and VitD doses higher than 1000 IU/day (OR 2.70 [95% CI 1.30-5.64]). In Italy, there was a modest decrease in AR reporting, despite the slightly increased use of VitD during the COVID-19 pandemic. To the best of our knowledge, this is the first study describing all VitDps-related ARs observed in the Italian general population. Since underreporting is the main limitation of the safety reporting systems, the necessity to continue ARs monitoring, also using real-world data on VitDps prescription, use and outcome patterns is highlighted.

Liposomes loaded with vitamin D3 induce regulatory circuits in human dendritic cells

Introduction

Nanomedicine provides a promising platform for manipulating dendritic cells (DCs) and the ensuing adaptive immune response. For the induction of regulatory responses, DCs can be targeted in vivo with nanoparticles incorporating tolerogenic adjuvants and auto-antigens or allergens.

Methods

Here, we investigated the tolerogenic effect of different liposome formulations loaded with vitamin D3 (VD3). We extensively phenotyped monocyte-derived DCs (moDCs) and skin DCs and assessed DC-induced regulatory CD4+ T cells in coculture.

Results

Liposomal VD3 primed-moDCs induced the development of regulatory CD4+ T cells (Tregs) that inhibited bystander memory T cell proliferation. Induced Tregs were of the FoxP3+ CD127low phenotype, also expressing TIGIT. Additionally, liposome-VD3 primed moDCs inhibited the development of T helper 1 (Th1) and T helper 17 (Th17) cells. Skin injection of VD3 liposomes selectively stimulated the migration of CD14+ skin DCs.

Discussion

These results suggest that nanoparticulate VD3 is a tolerogenic tool for DC-mediated induction of regulatory T cell responses.

Vitamin D status among infants and children in Shanghai, China: A hospital-based study

The variation in vitamin D status is still unclear. We aim to describe the vitamin D status among healthy infants and children in Shanghai (31° N latitude), one of the largest cities in China. We conducted a hospital-based, 2-year retrospective observational study and recruited children for health examination at the Tongren Hospital affiliated with Shanghai Jiao Tong University School of Medicine from January 2019 to December 2020. Serum 25-hydroxyvitamin D (25(OH)D) levels were measured using an enzyme-linked immunosorbent assay. A total of 6164 children aged 0-11 years were included. Of these, 94.4% of the serum 25(OH)D measurements at first assessment were within the range of 12-50 ng/mL. The median 25(OH)D level was 31.3 (IQR 25.6, 38.1) ng/mL, the percentages of 25(OH)D < 20 ng/mL and 25(OH)D < 30 ng/mL were 10.0% and 43.8%, respectively. Low vitamin D status (deficiency and insufficiency) differed significantly by age group (infants, toddlers, preschoolers, and schoolers) and seasonality (all p < .001), but not by gender. For the sub-group (n = 855) of children with repeated assessments, their low 25(OH)D levels increased significantly whether after about a 7-month (n = 351) or 12-month (n = 504) interval, and the increments of median 25(OH)D levels were 8.1 ng/mL and 2.1 ng/mL respectively (p < .001). This study documents the vitamin D status in Shanghai, showing that low vitamin D status is common in infants and children and suggesting that the assessment of 25(OH)D level is necessary for individuals who are at risk for deficiency or excess.

Effect of vitamin D vaginal suppository on sexual functioning among postmenopausal women: A three-arm randomized controlled clinical trial

OBJECTIVE

Vaginal atrophy, the second most common complication of menopause, can lead to sexual dysfunction. This study evaluated the effect of a vitamin D vaginal suppository on sexual functioning in postmenopausal women.

METHODS

This three-arm randomized controlled trial was conducted between August 2019 and August 2020. The sample comprised 105 postmenopausal women who were referred to comprehensive health service centers to receive postmenopausal care. The inclusion criteria were as follows: (i) being menopausal for at least 1 year, (ii) being married, (iii) being sexually active, and (iv) having sexual desire. Participants were randomly assigned to three groups for 8 weeks of treatment: intervention (vaginal suppository containing 1,000 units of vitamin D3), placebo (vaginal suppository placebo), or control (no treatment). The main outcome measure was sexual functioning, which was assessed using the Female Sexual Function Scale (FSFI) 4 times during the study (i.e., 1 month before the intervention, immediately after the intervention, 1 month after the intervention, and 2 months after the intervention).

RESULTS

Immediately and 1 month after the trial, the intervention group had the highest FSFI score, followed by the placebo group, both of which were significantly higher than those of the control group (P<0.05). At the 2-month follow-up, the intervention and placebo groups had similar FSFI scores (P=0.08), both of which were significantly higher than those in the control group (P=0.001 and P=0.03, respectively).

CONCLUSION

Vitamin D vaginal suppositories were more effective at improving sexual functioning among postmenopausal women in the short-term and appeared to prevent aging-related sexual functioning decline in the long term.

Difference in Levels of Vitamin D between Indoor and Outdoor Athletes: A Systematic Review and Meta-Analysis

Vitamin D, its importance in different processes taking place in the human body, the effects of abnormal levels of this hormone, either too low or too high, and the need for supplementation have been extensively researched thus far. Variances in exposure to sunlight can cause vitamin D levels to fluctuate. Indoor activity can be a factor for these fluctuations and can lead to a decrease in vitamin D levels. We conducted a systematic review and meta-analysis aiming to identify whether indoor compared to outdoor training has a significant influence on vitamin D levels; we also performed subgroup analyses and multivariate meta-regression. The type of training has an impact on vitamin D levels that is influenced by multiple cofounders. In a subgroup analysis not considering cofounders, the mean serum vitamin D was 3.73 ng/mL higher in outdoor athletes, a difference which barely fails to achieve significance (p = 0.052, a total sample size of 5150). The indoor-outdoor difference is only significant (clinically and statistically) when considering studies performed exclusively on Asian athletes (a mean difference of 9.85 ng/mL, p < 0.01, and a total sample size of 303). When performing the analyses within each season, no significant differences are observed between indoor and outdoor athletes. To control for multiple cofounders (the season, latitude, and Asian/Caucasian race) simultaneously, we constructed a multivariate meta-regression model, which estimated a serum vitamin D concentration lower by 4.446 ng/mL in indoor athletes. While a multivariate model suggests that outdoor training is associated with slightly higher vitamin D concentrations when controlling for the season, latitude, and Asian/Caucasian race, the type of training has a numerically and clinically small impact. This suggests that vitamin D levels and the need for supplementation should not be decided based on training type alone.

Vitamin D status among residents of Molidawa Daur Autonomous Banner, Inner Mongolia, North China

OBJECTIVES

To retrospectively analyze the vitamin D (VD) status of residents in northeastern Inner Mongolia and its relationship with the average monthly sunshine hours.

METHODS

Serum 25-hydroxyvitamin D[s-25(OH)D] samples from 4982 outpatients (2092 males) in Moli Dawa Daur Autonomous Banner People's Hospital, Hulunbuir, China from July 2018 to January 2022 were included in this study.

RESULTS

The overall median s-25(OH)D was 53.3 nmol/L, VD deficiency (<30 nmol/L), deficiency (30-50 nmol/L), sufficient (>50-250 nmol/L) and excess (>250 nmol/L) were 16% (796/4982), 30% (1495/4982), 53.4% (2658/4982) and 0.7% (33/4982). There were statistically significant differences in median s-25(OH)D by month, age-groups and gender (p<0.001). Low VD status (LVDS, including VD deficiency and insufficiency) in females was 54.6% and males was 33.9%, and the LVDS composition differed significantly by age-group and month (p<0.05). The changing trend of the median s-25(OH)D level was similar to the monthly average sunshine hours, with a slight lag.

CONCLUSION

Nearly half of residents live in LVDS. LVDS is affected by month, gender, and age.

Prevalence of Iatrogenic Vitamin D Toxicity Among the Saudi Population of Vitamin D Users Due to Overcorrection

Background Despite abundant sunlight exposure, vitamin D deficiency remains a major challenge in Saudi Arabia. Meanwhile, the widespread use of vitamin D supplements has prompted concerns about toxicity, which although rare, can have severe health consequences. Objective The objective of this cross-sectional study was to analyze the prevalence and associated factors of iatrogenic vitamin D toxicity among the Saudi population of vitamin D users due to overcorrection. Methods An online questionnaire was used to collect data from 1,677 participants across all regions of Saudi Arabia. The questionnaire included responses on the prescription, duration of vitamin D intake, dosage, frequency, history of vitamin D toxicity, symptom onset, and duration. Results One thousand six hundred and seventy-seven responses were included across all regions of Saudi Arabia. A majority of participants were female (66.7%) and around half were aged 18-25 years. A history of vitamin D use was reported by 63.8% of participants, and 48% were still using vitamin D supplements. Most participants (79.3%) consulted a physician, and 84.8% had taken a vitamin D test before using the supplement. Commonly reported motives for taking vitamin D included vitamin D deficiency (72.1%), lack of sun exposure (26.1%), and hair loss (20.6%). Symptoms of overdose were reported by 6.6% of participants, with 3.3% having an overdose and 2.1% experiencing both overdose and symptoms. Conclusion This study showed that although a large portion of the Saudi population is taking vitamin D supplements, the prevalence of vitamin D toxicity is relatively low. However, this prevalence should not be ignored, and further research is needed to understand the factors contributing to vitamin D toxicity in order to minimize its occurrence.

Susceptibility to COVID-19 Nutrition Misinformation and Eating Behavior Change during Lockdowns: An International Web-Based Survey

To understand the susceptibility to nutrition-health misinformation related to preventing, treating, or mitigating the risk of COVID-19 during the initial lockdowns around the world, the present international web-based survey study (15 April-15 May 2020) gauged participants' (n = 3707) level of nutrition-health misinformation discernment by presenting them with 25 statements (including unfounded or unproven claims circulated at the time), alongside the influence of information sources of varying quality on the frequency of changes in their eating behavior and the extent of misinformation held, depending on the source used for such changes. Results revealed widespread misinformation about food, eating, and health practices related to COVID-19, with the 25 statements put to participants receiving up to 43% misinformed answers (e.g., 'It is safe to eat fruits and vegetables that have been washed with soap or diluted bleach'). Whereas higher quality information sources (nutrition scientists, nutrition professionals) had the biggest influence on eating behavior change, we found greater misinformation susceptibility when relying on poor quality sources for changing diet. Appropriate discernment of misinformation was weakest amongst participants who more frequently changed their eating behavior because of information from poor quality sources, suggesting disparities in the health risks/safety of the changes performed.

Vitamin D Supply of Multivitamins Commercialized Online by Amazon in Western and Southern Europe: A Labeling Analysis

Multivitamins are commonly used by the general population, often without medical prescription. The purpose of this report is to inform on the daily vitamin D supply provided by multivitamins containing vitamin D that are commercialized online by Amazon in Western and Southern Europe. We surveyed multivitamins aimed at adults using the following marketplaces: amazon.es®, amazon.de®, amazon.it®, and amazon.fr®. We identified 199 vitamin D3-containing multivitamins sold by Amazon marketplaces: 77 from amazon.es®, 73 from amazon.de®, 33 from amazon.it®, and 16 from amazon.fr®. No multivitamin contained vitamin D2. The daily vitamin D3 supply ranged from 16 to 2000 IU: it was less than 400 IU daily in 108 (54%), 400−800 IU daily in 53 (27%), and more than 800 IU daily in the remaining 38 (19%) products. The vitamin D3 supply of products sold by amazon.it® was on average higher (p < 0.05) than that of products sold by amazon.de®, amazon.fr®, and amazon.es®. In conclusion, the vitamin D supply of multivitamins sold by Amazon may be insufficient, marginally sufficient, or adequate for subjects at high risk of hypovitaminosis D such as subjects 65 years or more of age, pregnant (or lactating) women, or patients on drug treatment or with an underlying disease, where a vitamin D supplementation is advocated.

Vitamin D: sources, physiological role, biokinetics, deficiency, therapeutic use, toxicity, and overview of analytical methods for detection of vitamin D and its metabolites

Vitamin D has a well-known role in the calcium homeostasis associated with the maintenance of healthy bones. It increases the efficiency of the intestinal absorption of dietary calcium, reduces calcium losses in urine, and mobilizes calcium stored in the skeleton. However, vitamin D receptors are present ubiquitously in the human body and indeed, vitamin D has a plethora of non-calcemic functions. In contrast to most vitamins, sufficient vitamin D can be synthesized in human skin. However, its production can be markedly decreased due to factors such as clothing, sunscreens, intentional avoidance of the direct sunlight, or the high latitude of the residence. Indeed, more than one billion people worldwide are vitamin D deficient, and the deficiency is frequently undiagnosed. The chronic deficiency is not only associated with rickets/osteomalacia/osteoporosis but it is also linked to a higher risk of hypertension, type 1 diabetes, multiple sclerosis, or cancer. Supplementation of vitamin D may be hence beneficial, but the intake of vitamin D should be under the supervision of health professionals because overdosing leads to intoxication with severe health consequences. For monitoring vitamin D, several analytical methods are employed, and their advantages and disadvantages are discussed in detail in this review.

Vitamin D in the news: A call for clear public health messaging during Covid-19

Background: The public are increasingly reliant on the internet and media to access healthcare related information during the Covid-19 pandemic. Vitamin D is essential for musculoskeletal and immune health, with daily supplementation advised by public health bodies. Several studies assessing a possible link between vitamin D and Covid-19 severity have arrived at conflicting results and news articles have been rapidly disseminating such research to the public. There has been little focus on studying the quality of information available. Aim: To identify if online search interest in vitamin D increased with pandemic burden and analyse the accuracy of public health messaging relating to vitamin D in online news articles. Methods: Online search interest data for vitamin D was correlated with pandemic burden, defined as the number of Covid-19 deaths. Online news articles discussing vitamin D and Covid-19 were analysed using qualitative coding. Results: Online search interest for vitamin D increased as pandemic burden increased (p < 0.0001, Spearman's rank). Of the 72 articles identified, most (50%) offered a mixed opinion on the benefit of vitamin D in Covid-19. From articles making a recommendation for vitamin D supplementation, 23% of articles gave mixed messaging or advised against supplementation. 16% of articles recommended a dose which exceeded the safe limit of 4000 IU/day, risking toxicity. Conclusion: A significant number of articles provided mixed messaging or incorrectly advised supratherapeutic doses. This study highlights an opportunity for public health bodies to utilise the increased interest in vitamin D during the pandemic to raise awareness with accurate information.

Associations of Prenatal Vitamin D status with Oral Health in Offspring: A Systematic Review

PURPOSE

The aim of this work is to evaluate the impact of prenatal vitamin D levels on oral health in offspring.

MATERIALS AND METHODS

The search was carried out in three databases: MEDLINE (PubMed), ResearchGate and Wiley Online Library. The inclusion criteria were randomised controlled trials and cohort studies published between June 16, 2017 and June 16, 2022, laboratory assessment of prenatal vitamin D status and evaluation of primary or mixed dentition for observation of dental caries and developmental defects of enamel. The risk of bias for randomised controlled trials was analysed according to the Cochrane risk-of-bias tool and Newcastle-Ottawa scale was used to assess risk of bias for cohort studies.

RESULTS

A total of 177 studies were identified, 11 were included in the data synthesis. Eight out of 11 studies were considered as high quality and the other 3 studies had moderate risk of bias. The synthesis of data revealed that the impact of prenatal vitamin D status on oral health in children is quite controversial and subsequent studies are necessary to examine whether vitamin D levels affect the risk of developing dental caries and enamel defects.

CONCLUSION

The effect of prenatal vitamin D on oral health in offspring is not entirely clear. Since disturbances in dental hard tissues have a polyetiological origin, health specialists need to notify mothers about other possible risk factors and emphasise the importance of eating habits and individual oral hygiene in early childhood.

Nephrocalcinosis in children who received high-dose vitamin D

BACKGROUND

Vitamin D supplements are readily available as over-the-counter preparations. However, although rare, cases of vitamin D overdose still occur and are associated with nephrocalcinosis and life-threatening hypercalcemia. Errors in manufacturing of nutritional supplements may be a cause of vitamin D intoxication in children. This study aimed to identify factors associated with vitamin D overdose-related nephrocalcinosis in children due to manufacturing errors in supplements.

METHODS

This retrospective study reviewed medical charts of pediatric patients with non-registered supplement-related vitamin D overdose at a tertiary referral hospital between 2006 and 2011. Clinical and laboratory characteristics of patients with or without nephrocalcinosis were evaluated. Receiver operating characteristics curve and area under the receiver operating characteristics curve were used to determine the most predictive value of each characteristic.

RESULTS

A total of 44 patients (males: 29; age: 7-62 months) were included. Age ≤ 16.5 months, body weight ≤ 10.25 kg, body height ≤ 78.5 cm, body surface area (BSA) ≤ 0.475 m², 25-hydroxyvitamin D₃ ≥ 143 ng/mL, and calcium ≥ 10.65 mg/dL were predictive of developing nephrocalcinosis with a sensitivity and specificity of > 60%. Univariant analysis revealed that BSA was the most significant anthropometric prognostic factor (odds ratio: 12.09; 95% confidence interval: 2.61-55.72; P = 0.001).

CONCLUSIONS

Children with smaller BSAs were more vulnerable to high-dose vitamin D₃-related nephrocalcinosis. Physicians and parents should be aware of the potential adverse effects of vitamin D overdose in children. A higher resolution version of the Graphical abstract is available as Supplementary information.

Vitamin D in gestational diabetes: a broadened frontier

Vitamin D deficiency is very common among women of reproductive age, even during pregnancy. Different studies have yielded vastly different results regarding whether vitamin D deficiency during pregnancy affects the development and progression of gestational diabetes mellitus (GDM), glycemic control in patients with hyperglycemia, and maternal-fetal outcomes. In addition, concerns, such as the mechanisms underlying the effect of vitamin D deficiency on glucose metabolism during pregnancy, efficacy of vitamin D supplementation in reducing the risk of developing GDM, and recommended supplemental dose of vitamin D, are yet to be elucidated. This article reviewed the latest domestic and international studies in this field, with a focus on the relationship between vitamin D deficiency and GDM, their underlying pathophysiological mechanisms, and the role of vitamin D intervention in the prevention and treatment of GDM. We recommend vitamin D supplementation as soon as possible for all pregnant women with vitamin D deficiency, especially those with GDM.

Evaluating and optimizing bone health in children with chronic health conditions

Paediatric health care providers (HCPs) play an important role in optimizing bone health. Early intervention is essential to maximize the accrual of peak bone mass in adolescence and young adulthood and to reduce osteoporosis and fracture risk later in life. Children and adolescents with chronic health conditions may have several risk factors for poor bone health, including underlying inflammatory conditions, reduced weight-bearing activity, delayed puberty, and inadequate intake of calcium and vitamin D. Some medications-particularly glucocorticoids-can compromise bone mass and place a child at risk for fragility fractures. This practice point describes a targeted approach to identifying bone health risk factors in children and youth with chronic health conditions, highlights office initiatives aimed at optimizing bone mass accrual, and links HCPs to useful web-based tools and medical references. Indications for referral to a bone health specialist and bone-specific pharmacotherapeutic interventions are also reviewed.

L'évaluation et l'optimisation de la santé osseuse chez les enfants ayant des affections chroniques

Les professionnels de la santé des enfants jouent un rôle important dans l'optimisation de la santé osseuse. Il est essentiel d'intervenir rapidement pour maximiser le pic de masse osseuse à l'adolescence et au début de l'âge adulte et d'ainsi réduire le risque d'ostéoporose et de fractures plus tard dans la vie. Les enfants et les adolescents ayant une affection chronique peuvent présenter plusieurs facteurs de risque de mauvaise santé osseuse, notamment des maladies inflammatoires sous-jacentes, des activités avec mise en charge limitées, un retard pubertaire et un apport insuffisant de calcium et de vitamine D. Certains médicaments, et particulièrement les glucocorticoïdes, peuvent compromettre la masse osseuse et exposer l'enfant à un risque de fractures de fragilisation. Le présent point de pratique décrit une approche ciblée pour déterminer les facteurs de risque liés à la santé osseuse chez les enfants et les adolescents ayant une affection chronique, expose les mesures à prendre en cabinet pour optimiser l'acquisition de la masse osseuse et propose des outils en ligne utiles et des références médicales à l'intention des professionnels de la santé des enfants. Les indications pour diriger les patients vers un spécialiste de la santé osseuse et pour procéder à des interventions pharmacologiques visant les os sont également abordées.

Vitamin D and calcium intakes in general pediatric populations: A French expert consensus paper

OBJECTIVES

Nutritional vitamin D supplements are often used in general pediatrics. Here, the aim is to address vitamin D supplementation and calcium nutritional intakes in newborns, infants, children, and adolescents to prevent vitamin D deficiency and rickets in general populations.

STUDY DESIGN

We formulated clinical questions relating to the following categories: the Patient (or Population) to whom the recommendation will apply; the Intervention being considered; the Comparison (which may be "no action," placebo, or an alternative intervention); and the Outcomes affected by the intervention (PICO). These PICO elements were arranged into the questions to be addressed in the literature searches. Each PICO question then formed the basis for a statement. The population covered consisted of children aged between 0 and 18 years and premature babies hospitalized in neonatology. Two groups were assembled: a core working group and a voting panel from different scientific pediatric committees from the French Society of Pediatrics and national scientific societies.

RESULTS

We present here 35 clinical practice points (CPPs) for the use of native vitamin D therapy (ergocalciferol, vitamin D2 and cholecalciferol, vitamin D3) and calcium nutritional intakes in general pediatric populations.

CONCLUSION

This consensus document was developed to provide guidance to health care professionals on the use of nutritional vitamin D and dietary modalities to achieve the recommended calcium intakes in general pediatric populations. These CPPs will be revised periodically. Research recommendations to study key vitamin D outcome measures in children are also suggested.

Nanocarriers for Drug Delivery: An Overview with Emphasis on Vitamin D and K Transportation

Mounting evidence shows that supplementation with vitamin D and K or their analogs induces beneficial effects in various diseases, e.g., osteoarticular, cardiovascular, or carcinogenesis. The use of drugs delivery systems via organic and inorganic nanocarriers increases the bioavailability of vitamins and analogs, enhancing their cellular delivery and effects. The nanotechnology-based dietary supplements and drugs produced by the food and pharmaceutical industries overcome the issues associated with vitamin administration, such as stability, absorption or low bioavailability. Consequently, there is a continuous interest in optimizing the carriers' systems in order to make them more efficient and specific for the targeted tissue. In this pioneer review, we try to circumscribe the most relevant aspects related to nanocarriers for drug delivery, compare different types of nanoparticles for vitamin D and K transportation, and critically address their benefits and disadvantages.

Is there a window of opportunity for the therapeutic use of vitamin D in multiple sclerosis?

Multiple sclerosis is an autoimmune treatable but not curable disease. There are a multiplicity of medications for multiple sclerosis therapy, including a class entitled disease-modifying drugs that are mainly indicated to reduce the number and severity of disease relapses. Not all patients respond well to these therapies, and minor to severe adverse effects have been reported. Vitamin D, called sunshine vitamin, is being studied as a possible light at the end of the tunnel. In this review, we recapitulated the similar immunopathogenesis of multiple sclerosis and experimental autoimmune encephalomyelitis, the immunomodulatory and neuroprotective potential of vitamin D and the state-of-art concerning its supplementation to multiple sclerosis patients. Finally, based on our and other groups’ experimental findings, we analyzed the need to consider the relevance of the route and the different time-point administration aspects for a more rational indication of this vitamin to multiple sclerosis patients.

Practices of vitamin D supplementation leading to vitamin D toxicity: Experience from a Low-Middle Income Country

Introduction

The trend of prescribing VD preparations for nonspecific body aches and self-medication has increased significantly. The importance of vitamin D toxicity (VDT) has been underestimated and under recognized. This study was done to determine the frequency toxicity (>150 ng/ml) in subjects for 25-hydroxyvitamin D (25OHD) and evaluate the vitamin D (VD) supplements used by these subjects.

Methodology

This descriptive cross-sectional study was conducted at the Section of Chemical Pathology, Aga Khan University Hospital Karachi from April 2020 to March 2021. Subjects with 25OHD toxicity were contacted and information related to history of calcium and VD supplementation were collected. The statistical analysis was performed using the Microsoft Excel 2016.

Results

Over a year period 105398 subjects were tested for serum 25OHD, of which 0.34% (n = 364) subjects had 25OHD level of >150 ng/ml. After satisfying exclusion criteria 186 subjects (78 were <18 years of age and 108 were adults) were included in final analysis. All of these were using VD supplements and the main indications were delayed growth/short height (43.7%, n = 34) and aches or pains in (54.6%, n = 59) in pediatric and adult subjects respectively.

Most of the subjects were taking supplements orally (74.1%, n = 138). Commonly prescribed preparation in adults and pediatric was 200,000 IU (70.4%, n = 76) and 400 IU (35.9%, n = 28) respectively. Most subjects took supplements for 1–3 months (68.3%, n = 127). Stated total supplementation ranged from 20,000 IU to 3600,000 IU in pediatric subjects and 200,000 IU to 96,00,000 IU in adults.

Conclusions

Supplementation is a leading cause of potential toxic levels of 25OHD. The condition can be prevented by careful use of VD supplements and consistent monitoring.

•

Vitamin D toxicity is extremely rare; but it may happen at high doses. The use of vitamin D supplementation should be guarded and monitored.

•

In this study we observed that vitamin D toxicity (>150 ng/ml) was prevalent, present in 0.34% (n=364) subjects.

•

Main indications of supplementation were delayed growth in children and aches or pains in adults

Successful Outpatient Management of Severe Ionized Hypercalcemia Secondary to Cholecalciferol Ingestion in a Puppy

A 4 mo old female intact boxer was presented because of polyuria, lethargy, and vomiting after ingestion of cholecalciferol rodenticide roughly 3 days prior. Blood work revealed an ionized hypercalcemia 2.23 mmol/L (reference range 1.04–1.33 mmol/L) on presentation. Because of financial limitations, the patient was unable to be hospitalized for standard of care. She was treated with a pamidronate infusion and discharged with medical management to include oral prednisone, furosemide, and subcutaneous fluids. The dog’s signs, body weight, and biochemical parameters were serially monitored over 3 wk as the ionized hypercalcemia resolved. To the authors’ knowledge, this is the first published report documenting a successful outpatient medical protocol for potentially life-threatening hypercalcemia secondary to cholecalciferol toxicosis in a puppy.