The Vitamin D Deficiency Dilemma and What It Means to Bones…and Our Health

Shedding some light on the high and low of it

Vitamin D deficiency has become a growing trend in the United States and is now prompting physicians in different areas of specialty to test Vitamin D levels in patients.Our Need for Vitamin D

While low Vitamin D levels have always played an important role in orthopedics, insufficient levels are now also linked to a wide range of other health issues – from Diabetes and Cardiovascular Disease to cancer (1).

Measuring Vitamin D status in blood levels of a form known as 25-hydroxyvitamin D [25(OH)D] has become an important part of health screenings.

While orthopedic specialists treating patients for a bone fracture today routinely test Vitamin D levels in patients, increasingly physicians in other areas of specialty are including such tests for their patients as well.

A Growing Trend in Vitamin D Deficiencies

A growing trend in low Vitamin D levels among a broad range of ages has prompted the National Institutes for Health (NIH) and Centers for Disease Control and Prevention (CDC) to assess possible causes, further exploring the link between Vitamin D in not only bone health but other diseases as well.  The growing trend, which is seen not only in the United States but worldwide, has been called a pandemic and prompted researchers to launch studies into the causes and the implications on overall health (2).

It is believed that lifestyle changes, growth in obesity, increase use of medication and changes in diet (reduction in nutrient rich foods and increase in processed, packaged nutrient deficient) are all contributors to this trend.

While some study results have caused daily intake recommendations to increase from 200 IU to 400 to 600 IU to address the deficiencies, many believe much higher amounts are required (4,000 to 10,000 IU daily) to reach optimal levels and achieve maximum health benefits.  Recommended daily intake and appropriate supplementation for those showing a deficiency continue to evolve. Recommendations established by the Institute of Medicine, 2011 are used as a general guideline. Ongoing research will continue to fuel this discussion.

Vitamin D and its Role in Bone Health

Vitamin D is a fat-soluble vitamin, which is essential for maintaining mineral balance in the body. Its most active form in humans is Vitamin D3 (cholecalciferol), which can be synthesized in the skin with exposure to ultraviolet-B (UVB) radiation from sunlight.

Vitamin D3 conversion and use within our body.

Vitamin D3 metabolism and use within our body.

Plants can synthesize ergosterol by ultraviolet light, which is converted to vitamin D2 (ergocalciferol), but is a less active form of vitamin D (less than 30% of Vitamin D3) (3).

Vitamin D is necessary for the proper absorption of calcium, which together have shown to reduce risk of osteoporosis, assist in the healing of bone fractures and decrease risk of future bone breaks. Vitamin D has other roles in the body as well, including modulation of cell growth, neuromuscular and immune function and reduction of inflammation (4).

When exposure to UVB radiation is insufficient, adequate intake of vitamin D from the diet (Vitamin D-fortified foods and supplements) is essential for optimal health.

After Vitamin D is consumed in the diet or synthesized in the skin, the biologically inactive form then enters the circulation and is transported to the liver, where 25(OH)D is formed.  This is the major circulating form of vitamin D and the indicator of vitamin D status in the body. Increased exposure to sunlight or increased dietary intake of Vitamin D-enriched foods and/or Vitamin D3 supplements increases blood levels of 25(OH)D, making the blood 25(OH)D concentration an effective indicator of Vitamin D nutritional status.

Causes of Vitamin D Deficiency

While studies continue to explore possible causes of the widespread Vitamin D deficiency, a number have already been identified.  Some are the result of societal changes such as increased use of sun blocks/sun screens for fear of skin cancer (limiting unprotected sun exposure) and changes in our diet (processed, nutrient deficient foods versus nutrient and Vitamin D-rich foods). Both of which have gradually reduced the amount of Vitamin D intake we receive.

 Other possible causes of Vitamin D Deficiency include:

1.) Obesity

Some studies suggest that a higher BMI leads to lower 25(OH) D (4). Greater amounts of subcutaneous fat sequesters more of the vitamin and alter its release into circulation (5).

2.) Naturally dark-skinned individuals

Greater amounts of the pigment melanin in the epidermal layer (resulting in darker skin) reduces the skin’s ability to produce Vitamin D from sunlight.

3.) Certain Medications

Corticosteroid medications such as prednisone (often prescribed to reduce inflammation) can reduce calcium absorption and hinder Vitamin D metabolism. Other weight-loss, cholesterol-lowering and epileptic seizure medications have also been implicated in reduced calcium absorption and Vitamin D levels.

4.)  Age

As we age, our skin cannot synthesize Vitamin D as efficiently. The elderly are also likely to spend more time indoors, leading to inadequate intakes of the vitamin.

Increasing Vitamin D Levels

While it is difficult today to reach the recommended levels of Vitamin D without supplementation, below are some of the best sources that may reduce the quantity of supplements required.

Calcium and Vitamin D-rich foods can help support strong bones, decrease risk of disease.

Calcium and Vitamin D-rich foods can help support strong bones, decrease risk of disease.

  •  Unprotected sun exposure (10 – 20 minutes several times a week depending on skin color and geographical location).
  • Vitamin D-rich foods such as fatty fish (salmon, tuna, mackerel), beef liver, cheese and egg yolks.
  • Vitamin D-fortified foods such as milk, orange juice, margarine and butter.
  • Vitamin K2, which is linked toimproved use of Vitamin D3 and calcium (6).

 

References

  1. Holick MF. Vitamin D: importance in the preventioin of cancers, type 1 diabetes, heart disease, and osteoporosis.  Am J Clin Nutr. 2004;79(3):362-371.
  2. Holick MF. The vitamin D Deficiency pandemic and consequences for nonskeletal health: mechanisms of action. Mol Aspects Med. 2008;29(6):361-8.
  3. Armas LA, Hollis BW, Heaney RP. Vitamin D2 is much less effective than vitamin D3 in humans. J Clin Endocrinol Metab. 2004;89(11):5387-5391.
  4. Institutes of Health, Office of Dietary Supplements – https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/ .
  5. Vimaleswaran KS, Berry DJ, Lu C et al. Causal relationship between obesity and Vitamin D status:  bi-directional Mendelian randomization analysis of multiple cohorts. 2013 – http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001383.
  6. National Institutes of Health, Office of Dietary Supplements – https://ods.od.nih.gov/factsheets/VitaminK-HealthProfessional/

 

Dr. Korsh Jafarnia is one of Houston’s leading board certified, fellowship trained hand and upper extremity specialists.  A member of UT Physicians, Dr. Jafarnia is affiliated with Memorial Hermann IRONMAN Sports Medicine Institute at Memorial City and the Texas Medical Center.  He also serves as an assistant professor in the Department of Orthopedic Surgery at McGovern Medical School. Call 713.486.1700 for an appointment, or go to www.korshjafarniamd.com to

Protecting Fingers in Fall Sports

Behind the catches, interceptions, tips, tackles and returns are some of the most commonly reported sports injuries in football, as well as other fall and winter sports – finger injuries.Football Finger Injuries

Finger injuries actually represent one of the most common body injuries in sports in general and include sprains, dislocations, tendon damage and fractures. They are very common in football, basketball and volleyball.

Rarely does a finger injury go unnoticed.  They can be very painful and more challenging to heal, as our hands are constantly in use in everyday activity.Basketball Finger Injuries

Some of the most common causes of a finger sports injury include:

  • Struggle to maintain (as well as strip) a football
  • Clashes with teammates and opponents
  • Awkward and sudden impact with a ball
  • Catching or pulling on a jersey
  • Falls onto a hard surface

Sprains and DislocationsVolley Ball Finger Injuries

Finger sprains generally represent damage to the collateral ligaments, which are band-like structures that stabilize the finger and prevent side to side movement. It most frequently occurs in the mid finger. The little finger, middle finger and thumb are the fingers most affected in such injuries.

A finger sprain can vary in severity and is graded on a scale of 1-3. Grade 1 represents the mildest type of sprain, a stretched ligament.  Grade 2 is a partially torn ligament, and Grade 3 represents one that is completely torn.  When a Grade 3 finger sprain is sustained and bones are also out of place, altering joint surface contact, it is diagnosed as a finger dislocation.

A finger dislocation may be identified as an MCP (metacarpophalangeal), DIP (distal interphalangeal) or PIP (proximal interphalangeal) dislocation depending on the finger joint and bone it affects.

Finger sprains are also often referred to as a “jammed finger.”

Depending on the severity of a “jammed finger,” symptoms may include:

Finger Anatomy

 

  • Pain and immediate swelling
  • Bruising and pain during activity
  • Impaired function
  • Deformity
  • Stiffness and difficulty during gripping activity

Tendon Injuries

Tendons in the hand are tissues connecting muscle to bone, which when contracted pull on bones causing fingers to move. These muscles moving the fingers and thumb are located in the forearm – long tendons extending through the wrist and attaching to the small bones of the fingers and thumb.

The tendons on the top of the hand straighten the fingers and are known as extensor tendons. Those on the palm side bend the fingers and are known as the flexor tendons.

When fingers are bent or straightened, the flexor tendons slide through snug tunnels, called tendon sheaths, keeping the tendons in place next to the bones.  A tendon rupture disrupts this natural flow.

A relatively common tendon injury of the hand diagnosed in fall sports is a tendon rupture, also called a “Jersey Finger.”  This occurs in a “tear-away” type of activity, such as grasping a jersey with finger(s) in a flexed position – and then forced straight as the player quickly moves in another direction.  The result is loss of flexion at the DIP joint because of damage to the flexor tendon.

An injury to the tip of the finger may result in extensor tendon damage, which is also known as a “Mallet Finger.”

Symptoms of a flexor or extensor tendon rupture may include:

Flexor

  • An inability to bend one or more joints of your finger
  • Pain when your finger is bent
  • Tenderness along your finger on the palm side of your hand
  • Swelling of the finger

Extensor

  • Inability to open or extend the hand or fingers
  • Pain
  • Swelling or weakness of the finger
  • Cut to the back of the hand or fingers

Finger Fractures

Among the more severe finger injuries occurring in sports are finger fractures.  This is a break in one of the small bones of the finger.  Finger fractures may be stable or unstable.  Among the most common finger fractures include; distal phalanx (also known as a Tuft Fracture and associated with “crush” injuries), mallet, flexor digitorum profundus avulsion, and middle and proximal phalanx fractures (non-displaced, unstable, or displaced – which are usually more complex fractures to treat).

The correct diagnoses and treatment of a finger fracture, which can often mimic a finger sprain or dislocation in pain and symptoms, is imperative in ensuring optimal long-term function.

DIAGNOSIS

While many finger injuries can be diagnosed with a physical examination, an x-ray is indicated to more thoroughly assess the injured area or possible fracture – and severity of the injury. A CT scan may also be used to evaluate complex fractures. An MRI is often used when the soft tissues are involved (such as with tendon ruptures).

TREATMENT

Treatment for most finger injuries is nonsurgical, conservative approach that may involve RICE (rest, ice, compression, elevation), splinting, anti inflammatory medications for swelling/pain, and rehabilitation exercises.  Reduction may be performed on some simple fractures and supported with splinting or “buddy taping” (practice of taping the injured finger to a nearby uninjured finger to limit mobility and provide splint-like support).

More serious injuries and those unresponsive to conservative treatment may require surgical repair and an aggressive post-surgical hand and upper extremity therapy program.

PREVENTING INJURY

Injury prevention is always preferable for athletes wanting to give it their all during the sports season.  There are some things you can do to reduce risk of injury during sports this fall and the seasons to come:

  • Avoid wearing rings or other jewelry when playing.
  • Opt for closed fist rather than open hand approaches in volleyball and blocking in football.
  • Buddy taping (as mentioned above) can also be effective in preventing finger injury in a number of different sports.
  • Finger bracing should be worn in both practice and games until symptoms of a mildly injured/painful finger resolves, to avoid more serious injury/damage.
  • Finger and hand strengthening exercises can be beneficial.