Vitamin D and Health - GOV.UK

1 I Vitamin D and Health 2016ii Published July 2016 Crown copyright 2016 This report is available online at: iii Contents Preface .. v Membership of Scientific Advisory Committee on Nutrition: Working Group on Vitamin D .. vi Membership of Scientific Advisory Committee on Nutrition .. viii Summary .. x 1. Introduction .. 1 2. Biology and metabolism .. 5 3. Photobiology of Vitamin D .. 18 4. Measuring Vitamin D exposure (from diet and skin synthesis) .. 28 5. Relationship between Vitamin D exposure (from diet & skin synthesis) and serum 25(OH)D concentration .. 34 6. Vitamin D and Health outcomes .. 41 Musculoskeletal Health outcomes .. 42 45 Osteomalacia .. 47 Other musculoskeletal Health outcomes (beyond rickets and osteomalacia) by life stage .. 48 Conclusions - Vitamin D and musculoskeletal outcomes .. 67 Non-musculoskeletal Health outcomes .. 69 Pregnancy and lactation: non-skeletal outcomes in mother and baby.

2 69 Cancers .. 74 Cardiovascular disease & hypertension .. 76 All-cause mortality .. 80 Immune modulation .. 81 Infectious diseases .. 86 Neuropsychological functioning (cognitive function, depression, dementia, autism, schizophrenia) .. 91 Oral Health .. 94 Age-related macular degeneration .. 96 Conclusions non-musculoskeletal Health outcomes .. 97 Selection of Health outcomes to inform the setting of DRVs for Vitamin D .. 98 7. Potential adverse effects of high Vitamin D intakes/serum 25(OH)D concentration .. 101 8. Dietary Vitamin D intakes and serum/plasma 25(OH)D concentrations in the UK .. 108 9. Review of DRVs for Vitamin D .. 116 10. Overall summary and conclusions .. 130 iv 11. Recommendations .. 140 12. Research recommendations .. 141 References .. 142 Annexes ..174 (1) SACN working procedures ..174 (2) Studies considered in relation to Vitamin D and Health outcomes .. 176 (3) Dietary Vitamin D intakes and serum/plasma 25(OH)D concentrations in the UK.

3 245 (4) Glossary .. 285 v Preface The Scientific Advisory Committee on Nutrition (SACN) previously considered the evidence on Vitamin D and Health in 2007. It concluded that there were insufficient data at that time to reconsider the Dietary Reference Values (DRVs) for Vitamin D set by the Committee on Medical Aspects of Food and Nutrition Policy (COMA) in 1991. Since Vitamin D is synthesised in the skin when it is exposed to sunlight, COMA considered that dietary intakes of Vitamin D were not necessary for most of the UK population (aged 4-64y). It was assumed that skin synthesis of Vitamin D in the summer would be enough to cover requirements during the winter. Reference Nutrient Intakes (RNI) were therefore set only for groups considered at risk of Vitamin D deficiency . In 2010, SACN agreed to consider whether the DRVs for Vitamin D intake were still appropriate in the context of public Health advice to stay out of the sun and to wear sunscreen and because a substantial amount of new evidence had accumulated since its previous considerations.

4 In a change to previous advice, SACN is now recommending an RNI for Vitamin D of 10 g/d (400 IU/d), throughout the year, for everyone in the general UK population aged 4y and above. The RNI of 10 g/d (400 IU/d) for the general UK population includes pregnant and lactating women and population groups at increased risk of Vitamin D deficiency . Since there were insufficient data to set RNIs for children aged under 4y, Safe Intakes1 are being recommended for this age group ( g/340-400 IU per day for all infants aged under 1y and 10 g/400 IU per day for ages 1 up to 4y). The RNI/Safe Intakes have been developed to ensure that the majority of the UK population has a satisfactory Vitamin D status (as measured in the blood) throughout the year, in order to protect musculoskeletal Health . It was not possible to quantify and take account of sunlight exposure in setting the DRVs because of the number of factors that affect endogenous Vitamin D synthesis.

5 Since it is difficult to achieve the RNI/Safe Intakes from natural food sources alone, SACN is also recommending that the Government considers strategies to help the UK population consume the recommended intakes of Vitamin D. I would like to thank all those individuals and organisations who provided comments on the draft version of this report during the public consultation. All the comments were carefully considered before the report was finalised and the process assisted SACN in refining and clarifying the text. Completion of this report has been a long and challenging task for SACN because consideration of the evidence was complicated by the fact that Vitamin D is obtained from sunlight exposure as well as from food and supplements. I want to thank the members of the SACN Working Group on Vitamin D for their continuing commitment and their contributions to the report, especially the Chair, Professor Hilary Powers, and the secretariat.

6 I also want to thank Professor Ann Webb (Manchester University) and Professor Antony Young (King s College, London) for providing helpful advice and information on the photobiology of Vitamin D. Dr Ann Prentice Chair, Scientific Advisory Committee on Nutrition 2016 1 Safe Intakes were set by COMA if there were insufficient reliable data to set DRVs. vi Membership of Scientific Advisory Committee on Nutrition: Working Group on Vitamin D Chair Professor Hilary Powers SACN member; Professor of Nutritional Biochemistry and Head of Human Nutrition Unit, University of Sheffield. Members Professor Kevin Cashman Professor of Food and Health , School of Food and Nutritional Sciences, University College Cork. Professor Roger Francis Consultant Physician, Metabolic Bone Service, The Newcastle upon Tyne Hospitals. Professor Timothy Key SACN member; Professor in Epidemiology and Deputy Director, Cancer Epidemiology Unit, University of Oxford.

7 Professor Susan Lanham-New SACN member; Head of Department of Nutritional Sciences, University of Surrey. Professor Harry McArdle SACN member; Professor of Biomedical Sciences, University of Aberdeen; Honorary Professor of Biomedical Sciences, University of Nottingham. Dr Ann Prentice Chair of SACN; Director, MRC Human Nutrition Research, Cambridge. Dr Stella Walsh SACN member; Consumer representative. Dr Anthony Williams SACN member; Formerly, Reader in Child Nutrition and Consultant in Neonatal Paediatrics, St George s, University of London. Professor Ian Young SACN member; Professor of Medicine, Queen s University Belfast. vii Adviser (Ultraviolet radiation exposure) Dr John O Hagan (Public Health England) Secretariat Public Health England Ms Mamta Singh (Scientific) Dr Alison Tedstone (Scientific) (until October 2014) Ms Emma Peacock (Scientific) (February 2013 - December 2015) Dr Vivien Lund (Scientific) (since June 2014) Mr Heiko Stolte (Scientific) (until January 2013) Ms Margie van Dijk (Scientific) (since October 2015) Mr Michael Griffin (Administrative) Contributions from Professor Angus Walls (SACN) Ms Cath Mulholland (Scientific) (Food standards Agency) Ms Gillian Swan (Scientific) (Public Health England) Ms Jennifer Lynas (Scientific) (Public Health England)

8 Observers Food Standards Scotland Dr Fiona Comrie Ms Anne Milne Dr Gillian Purdon Department of Health Dr Stuart Conney Mr Ian Chell Ms Pat Keep National Institute for Health and Care Excellence Dr Adrienne Cullum viii Membership of Scientific Advisory Committee on Nutrition Chair Dr Ann Prentice Director, MRC Human Nutrition Research, Cambridge. Members Professor Peter Aggett Honorary Professor, School of Medicine and Health , Lancaster University; Emeritus Professor and Past Head of School of Postgraduate Medicine and Health . Ms Gill Fine Public Health Nutritionist. Ms Christine Gratus (until March 2013) Lay representative; retired advertising and marketing research director. Professor Paul Haggarty Head of Lifelong Health , Rowett Institute of Nutrition and Health , University of Aberdeen. Professor Timothy Key Professor in Epidemiology and Deputy Director, Cancer Epidemiology Unit, University of Oxford. Professor Susan Lanham-New Head of Department of Nutritional Sciences, University of Surrey.

9 Professor Julie Lovegrove Professor of Metabolic Nutrition and Deputy Director, Institute of Cardiovascular & Metabolic Research, University of Reading. Professor Ian Macdonald Professor of Metabolic Physiology, University of Nottingham and Director of Research in the Faculty of Medicine and Health Sciences. Professor Harry McArdle Professor of Biomedical Sciences, University of Aberdeen; Honorary Professor of Biomedical Sciences, University of Nottingham. Dr David Mela Industry representative; Science Leader, Unilever R&D Vlaardingen, The Netherlands. ix Ms Gemma Paramor Lay representative; finance professional in accounting and fund management. Professor Hilary Powers Professor of Nutritional Biochemistry and Head of Human Nutrition Unit, University of Sheffield. Professor Monique Raats Director of the Food, Consumer Behaviour and Health Research Centre, University of Surrey. Professor Angus Walls Professor of Restorative Dentistry and Director, Edinburgh Dental Institute.

10 Dr Stella Walsh Consumer representative. Dr Anthony Williams Formerly, Reader in Child Nutrition and Consultant in Neonatal Paediatrics, St George s, University of London. Professor Charlotte Wright (since June 2015) Professor of Community Child Health , University of Glasgow. Professor Ian Young Professor of Medicine, Queen s University Belfast. x Summary Background Vitamin D is required for regulation of calcium and phosphorus metabolism and is therefore important for musculoskeletal Health . It is synthesised in the skin upon exposure to sunlight containing sufficient ultraviolet B (UVB) radiation and this is the main source for most people. It can also be obtained from foods or dietary supplements. Dietary sources are essential when sunlight containing UVB radiation is limited ( , during the winter months) or exposure to it is restricted ( , due to lack of time spent outdoors or little skin exposure). Dietary Reference Values (DRVs) for Vitamin D were set by the Committee on Medical Aspects of Food Policy (COMA) in 1991 and were based on prevention of rickets in children and osteomalacia in adults.