Vitamin D deficiency & its prevention

Introduction

Vitamin D is an essential factor, not only for homeostasis of calcium and phosphorus but also for cell proliferation, differentiation and apoptosis, immune and hormonal regulation as well as other body processes.

Vitamin D also known as the sunshine vitamin as it is produced by the body in response to sunlight. It occurs naturally in a few foods including some fish, fish liver oils, and egg yolks and in fortified dairy and grain products.

Where to get vitamin D

The principal source of vitamin D is forming our own skin. A chemical compound called 7-dehydrocholesterol, naturally present in the superficial layers of the skin, is converted, on exposure to ultra violet B (UV-B) radiation, to a compound called pre vitamin D, which spontaneously changes in to cholecalciferol (vitamin D3).  Small quantity of vitamin Dis also available in food, but unlike the other vitamins most foods do not contain appreciable amount of this micronutrient.

There are two forms of vitamin D, known as D2 and D3

Vitamin D2, also known as ergocalciferol, comes from fortified foods, plant food, and supplements.

Vitamin D3 also known as cholecalciferol comes from fortified foods, animal foods (fish eggs and liver) and can be made internally when skin is exposed to ultraviolet radiation from the sun.

Vitamin D deficiency is common in India more than 90%of apparently healthy Indians have sub-normal vitamin D levels. The prevalence of vitamin D deficiency or insufficiency is very high in iron deficient women. this means that it is stored in our fat cells and is constantly being used for calcium metabolism and bone remodelling .if your exposure to sun is less suffer from milk allergies or adhere to a strict vegetarian diet you may be at risk for vitamin D deficiency .

Vitamin D deficiency & its prevention from tracking to treatment, prevention and relief.

What is active vitamin D?

The body converts vitamin D, whether taken orally or synthesized in the skin, to a compound called 25-hydroxyvitamin-D (0H)D The body converts up to 100mg of 25(OH)D each day in to a further compound called calcitriol, which is the active form of vitamin D that help the body to signal the decoding of dna blueprints for over 200 human genes.

Health maintenance and vitamin D

Vitamin D promotes calcium absorption in the gut and maintains adequate serum calcium and phosphate concentration to enable normal mineralization of bone and to prevent hypocacemic tetany. It is needed for bone growth and bone remodeling by osteoblast and osteoclast.

Vitamin D sufficiency prevents rickets in children and osteomalasia in adult. Together with calcium, vitamin D also helps to protect older adults from osteoporosis.

Causes –

Ø  Latitude, culture dress habits, season, sun avoidance, and sunscreen protection all limit vitamin D production

Ø  Gastrointestinal hepatic and renal disease may be related to low vitamin D levels

Ø  Hypo vitaminosis D results from lack of UVB exposure.

Ø  Dark skin as the pigment melanin reduces the skin ability to make vitamin D in response to sunlight exposure.

Ø  Certain medical problems including crohn s disease, cystic fibrosis, and celiac disease, can affect intestines ability to absorb vitamin D form the food.

Ø  obesity

Recovery time

Recovery from this deficiency may take about few months it mainly depends on the type of the treatment and lifestyle of the individual

Diagnosis

Diagnosis is done mainly by 25-hydroxy vitamin D blood test

Medicines are available in the form of oral tablets, injections and sachets.

Symptoms

There is no clear pattern of symptoms. Many people have no symptoms despite low levels .the common symptoms including

1.   Fatigue

2.   Chronic pain

3.   Weight gain

4.   General muscle pain, weakness and cramps

5.   Joint pain

6.   Sleep disturbances

7.   Poor concentration

8.   Headache

9.   Bladder problems

Diarrhoea or constipation

High blood pressure

Severe vitamin D insufficiency may cause rickets in children and osteomalascia and osteoporosis in adult.

To do

To increase vitamin D level in the body stay around 15-30 minutes a day in the summer sun without sunscreen.

Take a vitamin D3 supplement if you are in a low sunlight region

Women over 40 if deficient in vitamin D are at increased risk of osteoporosis, and should take vitamin D supplement if found deficient

Vitamin   D and general health

Beside treating and preventing A range of disease, vitamin D has been applied in managing minor abnormalities so as to improve quality of life .

Cancer – garland et al. were the first to propose that vitamin D deficiency may contribute to a higher risk of colon cancer mortality since vitamin D is formed in the skin through solar UV-B radiation. The protective relationship between sufficient vitamin D status and lower risk of cancer has been found in many studies.

It has been reported that breast and colorectal cancer can be reduced by50/ with the concentration of 25ohd

Tuberculosis- recently it was found that low vitamin D status resulting from a vegetarian diet is an independent risk factor for active TB.

One study measuring 192 healthy adult who came in contact with TB, showed that a single oral dose of 2.5mg vitamin D significantly enhanced participant whole blood ability to restrict functional whole blood

Vitamin D has also been found to play an important role in brain development and function

Periodontal disease is a common chronic inflammatory disease characterized by loss of periodontal attachment. A 3 year study showed that supplementation with vitamin D (700IU/d) plus calcium (500mg/d) significantly reduced tooth loss in older people.

Prevention 

Ø  Allow yourself limited, unprotected sun exposure

Ø  Eat a diet rich in whole foods

Ø  Take a top quality multivitamin every day

Ø  Take a vitamin D supplement

Discuss adding a vitamin D supplement to your diet with your doctor/healthcare provider

Key massages

·         Vitamin D is a vital link for human body to be healthy. Vitamin D is mainly available as D2 and D3

·         Vitamin D3 has higher potency and longer duration of action compared with vitamin D2

·         Adequate intake of vitamin D is directly linked to

·         Improvement in BMD and is important in preventing osteoporosis and osteopenia

·         Reduction in incidence of type 2 diabetes mellitus

·         Reduction I cancer incidence, cell differentiation, apoptosis and metastasis. Increased vitamin D and calcium intake decreases the risk of developing colon cancer

·         Vitamin D intake and exposure to UV_B radiation result in a substantial improvement in BMD and is important in prevention osteoporosis and increase in 25(OH)d concentration and has a positive effect in the management of hypertension in adults

·         Vitamin D is necessary to maintain fertility and reproductive health in women

·         Vitamin D is necessary to maintain fertility and reproductive health in women

·         Vitamin D has also been found to play an important role in brain development and function along with prevention of periodontal disease

·         A potential physiological role for vitamin D in regulating normal innate and adaptive immunity has been demonstrated in many studies which prevent RA and MS

·         Epidemiological and clinical studies indicate innumerable benefits of vitamin D. supplementation with vitamin D3 help in maintaining a healthy and disease free body.

Recommendation

·         Ideal sun exposure the best time for vitamin D synthesis is between 11 to 2 pm and it should be to the bare skin of as much body as possible e.g. face, neck hands forearms ect. The required duration of time required to turn the skin pink or to have burning sensation.

·         General shift workers should use the lunch hour and Sundays while employees with rotating duties can utilize evening & night shift days to get adequate sun exposure.

·         Milk intake through milk is not a great source regular intake of at least 500ml milk /day is recommended particularly for vegetarians

·         People with dark skin elderly smokers having chronic illness like DM, epilepsy are more likely to develop the deficiency .they should follow the recommendation s more mesticusly or they should take supplements on periodic basis.

·         Extra care should be taken for females in pregnancy & lactation phases, as there is high chance of developing insufficiency and it may have lasting effects on bone strength of the off springs.

·         Sunscreens shall be used very judiciously

Conclusion

Vitamin D deficiency and insufficiency Is very widely prevalent than once thought. It is under diagnosed in most health set ups. The possible reasons of low vitamin D levels are as follows

·         Reduced direct sun exposure – largely due to lifestyle changes and preferences for comforts has led to minimal time spent outdoors in the ideal times.

·         Job profile & demands – more and more time being spent inside buildings by most shop floors control room and office workers. The continuous monitoring required in control rooms shop floors leave very less chance of sun exposure for workers.

·         Smoking – smoking & use of sunscreens are known to increase the risk of vitamin D deficiency

·         Use of PPEs – as per safety  requirements all filed workers have to were mandatory PPEs including full sleeves , gloves helmets goggles leaving minimum skin exposed to direct sun light.

Know psoriasis to beat psoriasis

                            World psoriasis day 29th October

1-Psoriasis is a long-lasting autoimmune disease characterized by patches of abnormal skin.

2-There are five main types of psoriasis: plaque, guttate, inverse, postural,

3-Plaque psoriasis, also known as psoriasis vulgaris, makes up about 90% of cases

4-.Areas of the body most commonly affected are the back of the forearms, shins, around the belly button, and the scalp

5- to psoriasis. Symptoms often worsen during winter and with certain medications such as beta blockers or NSAIDs Infections and psychological stress may also play a role

6- Psoriasis is not contagious

7-There is no cure for psoriasis. However, various treatments can help control the symptoms. These treatments may include steroid creams, vitamin D3cream, ultraviolet light, and immune system suppressing medications such as methotrexate. About 75% of people can be managed with creams alone. The disease affects 2–4% of the population.Both males and females are affected with equal frequency. Psoriasis is associated with an increased risk of psoriatic arthritis, lymphomas, cardiovascular disease, Crohn's disease, and depression. Psoriatic arthritis affects up to 30% of individuals with psoriasis

8-More than 125 million people around the globe suffer from psoriasis

9-Psoriasis can affect anyone, anywhere

10-Psoriasis can be managed effect Psoriasis is generally thought to be a genetic disease which is triggered by environmental factors lively

11-Ayurvedic treatment very effective in psoriasis

12-If the clinical diagnosis is uncertain, a skin biopsy or scraping may be performed to rule out other disorders and to confirm the diagnosis. Skin from a biopsy will show

Psoriasis is estimated to affect 2–4% of the population of the western world. The rate of psoriasis varies according to age, gender, region and ethnicity; a combination of environmental and genetic factors is thought to be responsible for these differences. It can occur at any age, although it most commonly appears for the first time between the ages of 15 and 25 years. Approximately one third of psoriasis patients report being diagnosed before age 20. Psoriasis affects both sexes equally.

People with inflammatory bowel disease such as Crohn's disease or ulcerative colitis are at an increased risk of developing psoriasis Psoriasis is more common in countries farther from the equator. Persons of white European ancestry are more likely to have psoriasis and the condition is relatively uncommon in African Americans and extremely uncommon in Native American

Diagnosis-

A diagnosis of psoriasis is usually based on the appearance of the skin. Skin characteristics typical for psoriasis are scaly, erythematous plaques, papules, or patches of skin that may be painful and itch. No special blood tests or diagnostic procedures are needed to make the diagnosis

Varicose vein.

                        Varicose vein.

Definition 

The blood has to flow from the lower limbs in to the heart against gravity because of the upright posture of human beings.

Dilated, tortuous and elongated superficial vein of the limb are called as varicose veins.

Following are the examples of varicosity.

Ø  Long saphenous varicosity

Ø  Short saphenous varicosity

Ø  Oesophageal varices

Ø  Haemorrhoids

Ø  Varicococle

Varicose veins are vein that have become enlarged and twisted. The term commonly refers to the veins on the leg, although varicose veins can occur elsewhere. Veins have pairs of leaflet valves to prevent blood from flowing backwards. Leg muscles pump the veins to return blood to the heart (the skeletal-muscle pump), against the effects of gravity. When veins become varicose, the leaflets of the valves no longer meet properly, and the valves do not work (valvular incompetence). This allows blood to flow backwards and they enlarge even more. Varicose veins are most common in the superficial veins of the legs, which are subject to high pressure when standing. Besides being a cosmetic problem, varicose veins can be painful, especially when standing. Severe long-standing varicose veins can lead to leg swelling, venous eczema, skin thickening and ulceration.

                         

Type of varicose vein-

Primary varicose vein

They occur as a result of congenital weakness in the vessel wall

It can also be due to muscular weakness or due to congenital absence of valves.

Very often the valve at the saphenofemoral junction is incompetent / absent. The valves can also be absent where the superficial vein joins the deep veins.

Secondary varicose vein

Secondary varicose veins are those developing as collateral pathways, typically after stenosis or occlusion of the deep veins, a common sequel of extensive deep venous thrombosis (DVT). Treatment options are usually support stockings, occasionally sclerotherapy and rarely, limited surgery.

Varicose veins are distinguished from reticular veins (blue veins) and telangiectasias (spider veins), which also involve valvular insufficiency, by the size and location of the veins. Many patients who suffer with varicose veins seek out the assistance of physicians who specialize in vein care or peripheral vascular disease. These physicians include vascular surgeons, phlebologists or interventional radiologists

Women are more prone to varicose veins because of the following regions

Ø  Pregnancy and pelvic tumours

Ø  Pills

Ø  Progesterone’s dilate vessel wall

Distribution of valves

Inferior vena cava-      no valves

Common iliac vein -     no valves

Long saphenous vein - 10-14

Short saphenous vein -1 valve

Blood is returned to the heart from the lower limbs by the following mechanism.

Ø  Calf muscle pump

Ø  Competent valves

Signs and symptoms

1-   Aching, heavy legs (often worse at night and after exercise).

2-   Appearance of spider veins (telangiectasia) in the affected leg.

3-   Ankle swelling, especially in evening.

          4- A brownish-yellow shiny skin discoloration near the affected veins.

5-Redness, dryness, and itchiness of areas of skin, termed stasis dermatitis or venous eczema, because of waste products building up in the leg.

           6- Cramps

           7- Minor injuries to the area may bleed more than normal or take a long        time to heal.

           8-In some people the skin above the ankle may shrink (lipodermatosclerosis) because the fat underneath the skin becomes hard.

           9- Restless legs syndrome appears to be a common overlapping clinical syndrome in patients with varicose veins and otherchronic

          10-  Whitened, irregular scar-like patches can appear at the ankles. This is known as atrophie Blanche.

          Causes     

•       Varicose veins are more common in women than in men, and are linked with heredity.

Pregnancy, obesity, menopause, aging, prolonged standing, leg injury and abdominal straining.

  Post phlebitic obstruction or incontinence, venous and arteriovenous malformations

•       More recent research has shown the importance of pelvic vein reflux (PVR) in the development of varicose veins. Whiteley and his team reported that both ovarian and internal iliac vein reflux causes leg varicose veins and that this condition affects 14% of women with varicose veins or 20% of women who have had vaginal delivery and have leg varicose veins. In addition evidence suggests that failing to look for, and treat pelvic vein reflux can be a cause of recurrent varicose veins.

•       There is increasing evidence for the role of incompetent Perforator veins  in the formation of varicose veins. And recurrent varicose veins.

•       Varicose veins could also be caused by hyperhomocysteinemia in the body, which can degrade and inhibit the formation of the three main structural components of the artery: collagen, elastin and the proteoglycans. Homocysteine permanently degrades cysteine disulfide bridges and lysine amino acid residues in proteins, gradually affecting function and structure. Simply put, homocysteine is a 'corrosive' of long-living proteins, i.e. collagen or elastin, or lifelong proteins, i.e. fibrillin. These long-term effects are difficult to establish in clinical trials focusing on groups with existing artery decline. Klippel-Trenaunay syndrome and Parkes-Weber syndromeare relevant for differential diagnosis

Diagnosis

The tests for varicose veins

Ø  Cough impulse test-SF incompetence

Ø  Trendelenburg 1- SF incompetence

Ø  Trendelenburg 2-perforetor incompetence

Ø  Multiple tourniquet tests – site of perforator incompetence

Ø  Schwartz test –superficial column of blood

Ø  Modified perthes test –deep vein thrombosis

Ø  Fegan s test – to locate the perforators in the deep fascia

Investigations

Ø  Traditionally, varicose veins were investigated using imaging techniques only if there was a clinical suspicion of deep venous insufficiency, if they were recurrent, or if they involved the sapheno-popliteal junction. This practice is not now widely accepted. Patients with varicose veins should now be investigated using lower limbs venous ultrasonography.

Ø  Doppler ultrasound

Stages

According to the CEAP classification:

•       C0–no visible or palpable signs of venous disease

•       C1–telangectasia or reticular veins

•       C2–varicose veins (sub-divided into C2A = Varicose veins with no symptoms i.e.: asymptomatic; C2S = Varicose veins with symptoms)

•       C3–edema

•       C4a–skin changes due to venous disorders: pigmentation, eczema

•       C4b–skin changes due to venous disorders: lipodermatosclerosis, atrophie blanche

•       C5–as C4 but with healed ulcers

•       C6–skin changes with active ulcers (venous insufficiency ulceration

Treatment

Treatment can be either conservative or active. Active treatments can be divided into surgical and non-surgical treatments. Newer methods including endovenous laser treatment, radiofrequency ablationand foam sclerotherapy appear to work as well as surgery for varices of the greater saphenous vein.

Conservative

•       Elevating the legs often provides temporary symptomatic relief.

•       Advice about regular exercise sounds sensible but is not supported by any evidence.

•       The wearing of intermittent pneumatic compression devices have been shown to reduce swelling and increase circulation[medical citation needed]

•       Diosmin/Hesperidine and other flavonoids.

•       Anti-inflammatory medication such as ibuprofen or aspirin can be used as part of treatment for superficial thrombophlebitis along with graduated compression hosiery – but there is a risk of intestinal bleeding. In extensive superficial thrombophlebitis, consideration should be given to anti-coagulation, thrombectomy or sclerotherapy of the involved vein.[medical citation needed]

•       Topical gel application helps in managing symptoms related to varicose veins such as inflammation, pain, swelling, itching and dryness. Topical application-noninvasive has patient compliance.[medical citation needed]

Surgical treatment

Surgeries have been performed for over a century, from the more invasive saphenous stripping, to less invasive procedures like ambulatory phlebectomy and CHIVA.

Other surgical treatments are:

•       Ambulatory phlebectomy

•       Veinligation is done at sephenofemoral junction after ligating the tributeries at sephanofemoral junction without stripping the long sephenous vein provided the perforater veins are competent and absent DVT in the deep veins.With this method long sephenous vein is preserved.

•       Cryosurgery- A cryoprobe is passed down the long saphenous vein following saphenofemoral ligation. Then the probe is cooled with NO2 or CO2 to −85o F. The vein freezes to the probe and can be retrogradely stripped after 5 seconds of freezing. It is a variant of Stripping. The only point of this technique is to avoid a distal incision to remove the stripper.

Most varicose veins are reasonably benign, but severe varicosities can lead to major complications, due to the poor circulation through the affected limb.

•       Pain, tenderness, heaviness, inability to walk or stand for long hours, thus hindering work

•       Skin conditions / Dermatitis which could predispose skin loss

•       Skin ulcers especially near the ankle, usually referred to as venous ulcers.

•       Development of carcinoma or sarcoma in longstanding venous ulcers. Over 100 reported cases of malignant transformation have been reported at a rate reported as 0.4% to 1%.

•       Severe bleeding from minor trauma, of particular concern in the elderly.

•       Blood clotting within affected veins, termed superficial thrombophlebitis. These are frequently isolated to the superficial veins, but can extend into deep veins, becoming a more serious problem.

•       Acute fat necrosis can occur, especially at the ankle of overweight patients with varicose veins. Females are more frequently affected than males

•       Any condition that puts excessive pressure on the legs or abdomen can lead to varicosity.

•       Hormonal fluctuations during pregnancy and menopause may be responsible for the high proportion of varicosities among women. Dietary deficiencies or the loss of skin elasticity due to aging are the contributory factors. Prolonged standing or sitting, constipation, constructive clothing, lack of exercise, obesity, or repeated heavy lifting can interfere with normal circulation and can worsen existing varicosities.

Important things to be remember

        Regular massage can significantly alleviate discomfort associated with varicose veins. Never massage directly on varicose veins. For an additional benefit, you can apply Prasaarini tailam or Chandanabala laakshaadi tailam externally.

        Stop use of any tight clothing, especially if it constricts the waist area, and avoid use of high heel footwear, which stops normal muscle contraction in the lower leg, affecting circulation.

        Raise the foot of the bed by up to six inches (place wooden block under the feet). This is not uncomfortable and helps gravity to ease backpressure on the veins at night.

        Avoid standing still for lengthy periods. If your job requires you to be on your feet constantly, stretch and exercise your legs as often as possible to increase circulation and reduce pressure build-up. Use elasticized support hose if your job entails excessive standing, or when pregnant, or if you are overweight. This should support not just the calf, but also the entire thigh, and should be put on before getting out of bed. When sitting, do not cross legs as this restricts circulation. Try to have a footstool, which allow the feet to be, at least, level with the hips and ideally higher. If you like to sit with your legs crossed, cross them at the ankles rather than the knees for better circulation.

        Quit smoking. It may contribute to high blood pressure, which can aggravate varicosity.

        Stop using contraceptive pills. If you are pregnant, sleep on your left side rather than on your back. This minimises pressure from the uterus on the veins in your pelvic area. It also improves blood flow to the foetus.

•        Ayurvedic remedies

•       Reasonably, well-documented treatment for venous insufficiency is the tropical creeper Brahmi. In practice, four weeks of treatment with Brahmi frequently produces welcomed benefits in the discomfort of chronic venous insufficiency. The usual dosage of Brahmi is 10 to 20 ml, two times a day. Zinc, in the form of Jasad bhasma, assists healing and collagen formation and to help maintain proper concentration of vitamin E in blood. Punarnavaadi guggulu. Naagaarjunaabhra ras, Chandra prahbaa vati etc., are some of the popular prescribed medicines.

Ø  Ayurvedic treatment for varicose vein-

Ø  Leech therapy (jalaukawacharan)

Ø  Kaishor guggulu

Ø  Mahamanjisthadi kwatha

Ø  Sariwadyashwa

Ø  Bloodletting (rakt mokchan)

Ø  Brahami vati

Ø  Prsharini tailam

Ø  Rashayan therapy