Dr Muzafar Maqsood Wani
Dr Nazir Ahmad Palla
Vitamin D, also known as the “sunshine vitamin”, is a fat soluble vitamin, mostly produced in our body in response to sunlight. It is also found naturally in certain foods like egg yolk, fish and fortified dairy and grain products (in some countries). The daily requirements of vitamin D are 100 IU in adults, 200 IU in infants and children, 400 IU during pregnancy and lactation. Vitamin D, by itself, is metabolically inactive. It undergoes endogenous transformation into several active metabolites, first in liver and later in kidney. The major biologic function of activated vitamin D is to maintain normal blood levels of calcium and phosphorus, besides being involved in many diverse unspecified functions. Vitamin D works in concert with a number of other vitamins, minerals, and hormones to promote bone mineralization and thus stronger bones. Research suggests that vitamin D may help in maintaining a healthy immune system and help in regulating cell growth and differentiation.
People who avoid sun, have malabsorption or are strict vegetarians could be at risk for vitamin D deficiency. Overt vitamin D deficiency causes rickets in children and osteomalacia in elderly, in which bones can become thin, brittle, or misshapen and predisposed to bone fractures. In the absence of adequate sunlight exposure, supplementation becomes important. Vitamin D repletion in individuals with vitamin D deficiency has been shown to have a positive effect on bone biology, increases in bone mineral density measurements and reduced fracture rates.
Vitamin D deficiency is prevalent in Kashmir; with a study showing about 80% of healthy population has lower than the normal level of this important vitamin. It is established that about 25% of the population is severely vitamin D deficient; this includes elderly, women and children. These deficient people may come to medical attention because of diverse clinical manifestations including aches, bone pain and generalized debility.
Deriving from the 2011 Census it can be roughly estimated that about hundred thousand (100,000) elderly people will be severely vitamin D deficient in the valley and will need some form of replacement. The main vitamin D supplements available in Kashmir are oral vitamin D2 and D3 preparations usually in combination with calcium (contain 200 -600 IU), oral sachets (contain 60,000 IU), and injectable form (contain 3 lac/6 lac IU). Oral formulations can be purchased by anyone over the counter and at the dose they contain, they are safe. However, vitamin D preparations with doses above 1000 IU are considered as pharmaceutical agents, and should ideally be regulated by a much stricter code by the Drug Administration Committee. This is not the case in the valley, where higher doses of 300, 000 to 600,000 IU are being administered at very frequent intervals with or without a prescription.
Despite the contrary to what the medical community suggests, many in the field still use vitamin D, in “super-doses”. They perhaps wrongly convey that vitamin D can help against everything from cancer and hypertension, to diabetes and stroke. The present sales of vitamin D preparation are staggering at what the need is and what is being prescribed. 50,000 international units (IU) of vitamin D per week are safe and effective over an 8 week period, and could also be safe to use every other week as maintenance.  According to a market survey, the present estimate with about 4000 actively functioning registered chemist shops selling at least 20 units of injectable vitamin D monthly, the average sale of vitamin D in the valley is about 80,000 units/month. This is a huge number and many of the people seem to be unnecessarily given an excess of vitamin D. It is important to note that vitamin D is not like vitamin B complex which can be given on daily /weekly/monthly basis depending on the deficiency state (except if medically justified).
The side effects of vitamin D, oral or injectable are definite possibilities, but through prolonged use or with mega-doses. Excretion of vitamin D is negligible and hence excessive administration can lead to toxicity.  Symptoms may include - weakness, polyuria, intense thirst, weight loss, nausea, vomiting, difficulty in speaking and confusion. Patient may lapse into coma, while cardiac arrhythmias and renal failure may occur. These effects are due to hypercalcemia induced by increased intestinal absorption and mobilization of calcium from bone.
Over past few years it has become a routine of seeing about 2 patients per week, 6- 8 patients per month who come to various disciples at SKIMS and SMHS hospitals with evidence of hypercalcemia secondary to receiving multiple injections of Vitamin D on regular basis. We have seen many patients in whom acute renal failure resulted because of these injections. Over last one year about 50 such cases were admitted and successfully treated. This represents a preventable form of acute renal failure which can be avoided easily.
Our aim through this article is to educate the people that vitamin D deficiency is highly prevalent in the valley. The best way to correct it would be to fortify the food items, take recommended dose of oral vitamin D either in tablet or sachet form. In some groups, dietary supplements may be needed to meet the daily need for vitamin D. It may also be important to get injectable form of Vitamin D which should be strictly taken under the supervision of a doctor. And remember….. Sometimes too much of a good thing can be ... not such a good thing.

Dr Muzafar Maqsood Wani (Nephrologist)
& Dr Nazir Ahmad Palla (Senior Resident), 
Department of Nephrology, SKIMS, Soura.
Feedback: mmmwani@gmail.com

Lastupdate on : Thu, 17 Nov 2011 21:30:00 Makkah time
Lastupdate on : Thu, 17 Nov 2011 18:30:00 GMT
Lastupdate on : Fri, 18 Nov 2011 00:00:00 IST