Vitamin D is a fat-soluble vitamin. The fact that it dissolves in fat is important, because it means the body can store it for future use. Ultraviolet B (UVB) in sunlight rays convert cholesterol in the skin into vitamin D. Darker skins need more sun to get the same amount of vitamin D as a fair-skinned person. The sunlight needed has to fall directly on to bare skin (through a window is not enough). Traditionally it is thought that 2-3 exposures (each one 30 min) of sunlight per week in the summer months (April to September) are enough to achieve healthy vitamin D levels that last through the year. This does not seem to be true at present.

The main action of vitamin D is to help calcium and phosphorus in our diet to be absorbed from the gut. The calcium and phosphorus are essential for the structure and strength of our bones. So, vitamin D is really important for strong bones. In addition, vitamin D seems to be important for muscles/ligaments, also this is supposed to improve quality of life. Scientists have also found that vitamin D may also help to prevent other diseases such as cancer, diabetes and heart disease.

 Which foods contain vitamin D?

Surprisingly few foods contain vitamin D — unless it’s added to the food. That’s because your body is built to get vitamin D through your skin (from sunlight) rather than through your mouth (by food).

There are three vitamin D super foods:

• Salmon (especially wild-caught), Mackerel (especially wild-caught) , Mushrooms exposed to ultraviolet light to increase vitamin D

Other food sources of vitamin D include:

• Cod liver oil , Tuna canned in water, Sardines canned in oil, Milk or yogurt — regardless of whether it’s whole, non-fat, or reduced fat — fortified with vitamin D, Beef or calf liver, Egg yolks, Cheese.

How much vitamin D do I need?

This is tough question, we always thought the correct amount is what is need to prevent Rickets, now we know we need much more as vitamin D has more role in our good health. So you will be seeing our daily requirement is being increased depending on newer research coming day by day. A few years back, we told 400 iu is all that we need, but now we tell in adults around 2000 units is what is good for health.

Who gets vitamin D deficiency?

A very significant percentage of us is becoming vitamin deficient, this is mainly our indoor life-style (particularly urban population) there-by reducing the sunlight exposure, our dresses, use of Borkha in Muslim women, our skin which is not as good as white skin for making vitamin D. It is not clear atmospheric pollution has a role to play or not.

Particularly vulnerable people are growing children, pregnant and breast-feeding women, those in hospital for a long time, or housebound people, people using a lot of sunscreen (sun protection factor – 15 or above), elderly people (due to thinner skin than younger people) and some medical conditions like Crohn’s disease, coeliac disease, liver and kidney disease.

Vitamin D deficiency can also occur in people taking certain medicines – carbamazepine, phenytoin, primidone, barbiturates and some anti-HIV medicines.

What are the symptoms of vitamin D deficiency?

Many people have no symptoms, or only vague ones such as tiredness or general aches. Because symptoms of vitamin D deficiency are often very non-specific, the problem is often missed. The diagnosis is more easily reached in severe deficiencies with some of the classical (typical) symptoms and bone deformities.

Symptoms in adults

• General vague aches and pains are the common symptoms.

• In more severe deficiency, there may be more severe pain and also weakness. This may lead to difficulty standing up or climbing stairs, or can lead to the person walking with a ‘waddling’ pattern. This is known as osteomalacia.

• Bone pains may develop and are typically felt in the ribs, hips, pelvis, thighs and feet.

How is vitamin D deficiency diagnosed?

It may be suspected from your medical history, symptoms, or lifestyle. A simple blood test for vitamin D level can make the diagnosis. Blood tests for calcium and phosphate levels may also show changes linked to a low level of vitamin D. Sometimes, a wrist X-ray is done for a child. This can assess how severe the problem is by looking for changes in the wrist bones.

What is the treatment for vitamin D deficiency?

The treatment is to take vitamin D supplements. Vitamin D can be given as an injection or as a medicine (liquid or tablets). Your doctor will discuss the dose, and best treatment schedule, depending on your situation, age, severity of the deficiency, etc. Briefly, one of the following may be advised

Injection – This is a very effective and convenient treatment. It is useful for people who do not like taking medicines by mouth, or who are likely to forget to take their tablets.

Oral preparation – Vitamin D preparation is available in granules to take by mouth mixing with fruit juice or milk. Recently we have tablet preparation available in India which can be swallowed. Usual strength of tablet or granules is 60,000 units.

It is good to remember that we need to continue maintenance dose after deficiency is corrected. The exact dose is not clear, recommendation is changing everyday as all of us are learning; possibly we need around 2000 units daily for good health.

Our Experience and Protocol

In our department we are following a protocol to find out the correct supplement schedule of vitamin D, in case of severe deficiency we are giving initially injection every 2 weeks for 8 injections, and then checking level to continue replacement by oral tablet or granules. Most of the people in our protocol treatment are achieving expected level of vitamin D, till now we have not seen a single case of toxicity using our protocol.

How high should my vitamin D level be?

The recommended minimum vitamin D level is at least 32 ng/ml, best level is 40-80. The average 25(OH)D concentration of the confirmed cases of vitamin D toxicity reported in literature is 214 ng/ml.

Are there any side-effects from vitamin D supplements?

It is very unusual to get side effects from vitamin D if taken in the prescribed dose. However, very high doses can raise calcium levels in the blood. This would cause symptoms such as thirst, passing a lot of urine, nausea or vomiting, dizziness and headaches. If you have these symptoms, you should see your GP promptly, so that your calcium level can be checked with a blood test.

Outlook of vitamin D deficiency

The outlook for vitamin D deficiency is usually excellent. Both the vitamin levels and the symptoms generally respond well to treatment. However, it can take time (months) for bones to recover and symptoms such as pain to get better or improve.

Vitamin D is increasingly being linked to other diseases and illnesses. In recent years there have been associations with conditions such as cancer, heart disease, infectious disorders, autoimmune disease and diabetes. This does not mean that all people with vitamin D deficiency will get these problems. Nor does it mean that if you have one of these illnesses, a vitamin D deficiency is the cause. In these cases, vitamin D replacement is being shown beneficial.

DrSwaraj(swaraj_amit@yahoo.com), DrShailaB(Shailashamanur@gmail.com)

and DrArpandevBhattacharyya(Arpan@DiabetesEndocrinology.in),

Department of Diabetes and Endocrinology, Manipal Hospital, Bangalore.

A Bhattacharyya, S Brown, S Hughes and P.A.Vice.

Insulin Lispro (IL), an analogue of regular human insulin with a peak insulin achieved within an hour of injection, significantly improves post prandial hyperglycaemia. This is very important in diabetic pregnancy, whether gestational or pre-gestational. Patient acceptability has also been higher with IL, which is very helpful in maximizing glucaemic control in pregnancy.

Quaternary Journal of Medicine 2001;94:255-60.

A Bhattacharyya, J Macdonald, AA LAkhdar.

The adrenal cortex normally produces three principal steroid hormones: the glucocorticoid cortisol, the mineralocorticoid adosterone, and a small quantity of sex steroids. In primary adrenocortical insufficiency, there is a deficiency of both cortisol and aldosterone with characteristic clinical and laboratory findings. In contrast, with a pituitary disorder there is isolated hypocortisolism, because its production is dependant on pituitary adrenocortrophic hormone (ACTH), whereas aldosterone production is controlled by extracellular fluid volume, rennin and serum potassium. Acute adrenocortical crisis is an absolute medical emergency and its presentation is not always typical. We describe three recent cases of acute adrenocortical crisis in our hospital who presented in three different ways in three different wards.

International Journal of clinical Practice 2001;55:141-4.

A Bhattacharyya

Diabetes Mellitus (DM) is a group of metabolic disorders characterized by raised blood sugar due to defects in insulin secretion, action or both. The chronic hyperglycaemia of DM is associated with longterm damage, dysfunction and failure of organs, such as the eyes, kidneys, nerves, blood vessels and heart. The first organized attempt to develop diagnostic criteria was probably carried out by the National Diabetes Data Group in 1979. Later in 1985, the diagnostic criteria were modified by the World Health Organisation (WHO). These criteria were followed until the recent modification recommended by an expert committee.

Hospital Pharmacist 2001;85-9.

A Bhattacharyya

People with type 2 diabetes mellitus (DM) are characterized by a resistance to insulin and a relative, as opposed to absolute, insulin deficiency. At least initially, and often through out their lifetime, they do not need exogenous insulin for survival. Thus although insulin may be required for controlling hyperglycaemia, these patients do not develop diabetic ketoacidosis other than in rare situations.

Hospital Pharmacist 2001;8:10-6.

A Bhattacharyya, Frank Webb

A 62 year old patient with type 2 diabetes mellitus on insulin for the last 10 years was referred to our multidisciplinary foot clinic with cellulites of the right foot (figure1). He noted pain and discomfort for 7 days. There is no clinical evidence of osteomyelitis. An x-ray showed presence of a broken insulin needle in the foot (Figure2). He admitted the old habit of breaking the insulin needle after injection before discarding it into the bin.

Practical Diabetes Internatuional 2001;18:133

A Bhattacharyya, JD Wright, PA Vice

A 14 year old girl was referred to the paediatrician with symptoms of hypothyroidism. She had a smooth diffuse goiter with dysthyroid eye disease.(Proptisis, lid lag and lid retraction). Hyperthyroidism was confirmed biochemically (Protein bound iodine 18.8, normal 5-8 ug). She was treated with Carbimazole 30mg/day. Poor compliance resulted in inpatient care for treatment with carbimazole followed by subtotal thyroidectomy…………..

Postgraduate Medical Journal 2001;77:661-71

A Bhattacharyya, A Howell, A Lakhdar
Dreschfeld described the major comas in diabetes mellitus in an address to the Manchestor Medical Society in 1881 as three different syndromes:

Diabetic Collapse,

The alcoholic form of diabetic coma and

Coma from acetonemia.

He described diabetic collapse in those days as “occurs chiefly in older people,… still stout and well nourished. ..the course of disease slow and protracted…’’. The term hyperosmolar nonketotic State (HONK) is now used to describe this condition. It has been recognized recently that around 10% of cases of HONK are comatose at presentation and coma is a late feature that carries a poor prognosis (2-4) although HONK is a recognized complication in a middle aged and elderly people with type 2 diabetes mellitus, it can rarely occur in ketosis-prone young patients with diabetes mellitus (5,6).We report a middle-aged man with type 1 diabetes mellitus presented with HONK precipitated by chronic poor diabetic control.

Diabetes Today 2000;5:152-3.

A Bhattacharyya and HM Buckler.

The treatment of thyroid diseases is relatively straightforward. True thyroid problems should be distinguished from sick euthyroid syndrome and due consideration, should be given to the patient’s age, gender, family and wishes in making treatment decisions. Treatment of thyroid diseases falls in to three main categories.

• Treatment of functional thyroid state, such as hypo- or hyperthyroidism.
• Treatment of aetiology, as in thyroid carcinomas.
• Treatment of goiter as a space-occupy-ing leion,ie, its effect on surrounding structures.

Hospital Pharmacist 2000;7:14-9.

Bhattacharyya A, Vice PA

The mortality and morbidity in diabetic in diabetic patients with AMI is higher than in non – diabetic population (2). The proven benefit of a number of interventions (Aspirin, betablocker, thrombolysis, ACE inhibitor, etc) for the acute event implies a major advantage in terms of absolute gain in life expectancy. The DIGAMI study has shown a major advantage of improved glycaemic control, so much so that we need to treat only nine patients to save one life in the line of DIGAMI treatment protocols. We evaluated the impact of the DIGAMI study in our hospital and compared the morality and other outcomes for an 18 month period after the DIGAMI study was published, in comparison to an 18 months period before.

Diabetes Today 2000;3:120-23.