Vitamin D Analogues in Insulin-Dependent Diabetes Mellitus and Other Autoimmune Diseases: A Therapeutic Perspective

Comprehensive Review on Diabetes Associated Cardiovascular Complications - The Vitamin D Perspective

Vitamin D, a steroid hormone is primarily known for its role in calcium and bone mineral homeostasis. Over the years, vitamin D has been implicated in various non-skeletal diseases. The extraskeletal phenomenon can be attributed to the presence of vitamin D receptors (VDRs) in almost all cells and identification of 1-α hydroxylase in extrarenal tissues. The vitamin D deficiency (VDD) pandemic was globally reported with increasing evidence and paralleled the prevalence of diabetes, obesity and cardiovascular diseases (CVDs). A dependent link was proposed between hypovitaminosis D glycemic status, insulin resistance and also the other major factors associated with type 2 diabetes leading to CVDs. Insulin resistance plays a central role in both type 2 diabetes and insulin resistance syndrome. These 2 disorders are associated with distinct etiologies including hypertension, atherogenic dyslipidemia, and significant vascular abnormalities that could lead to endothelial dysfunction. Evidence from randomised clinical trials and meta-analysis, however, yielded conflicting results. This review summarizes the role of vitamin D in the regulation of glucose homeostasis with an emphasis on insulin resistance, blood pressure, dyslipidaemia, endothelial dysfunction and related cardiovascular diseases and also underline the plausible mechanisms for all the documented effects.

Calcium plus vitamin D supplementation influences biomarkers of inflammation and oxidative stress in overweight and vitamin D-deficient women with polycystic ovary syndrome: a randomized double-blind placebo-controlled clinical trial

OBJECTIVE

This study was conducted to determine the effects of calcium plus vitamin D supplementation on inflammatory factors and biomarkers of oxidative stress among overweight vitamin D-deficient women with polycystic ovary syndrome (PCOS).

DESIGN, PATIENTS AND MEASUREMENTS

This randomized double-blind placebo-controlled clinical trial was performed among 104 overweight vitamin D-deficient women diagnosed with PCOS aged 18-40 years. Participants were randomly divided into four groups. Group A received 1000 mg calcium daily and vitamin D placebo weekly (N = 26), group B 50000 IU vitamin D weekly and calcium placebo daily (N = 26), group C 1000 mg calcium daily plus 50000 IU vitamin D weekly (N = 26) and group D calcium placebo daily plus vitamin D placebo weekly (N = 26) for 8 weeks. Fasting blood samples were taken at baseline and 8 weeks after intervention to measure inflammatory factors and biomarkers of oxidative stress.

RESULTS

After 8 weeks, individuals taking calcium plus vitamin D supplements had greater decreases in homoeostatic model assessment beta-cell function (HOMA-B) score (-11·1 vs -8·6, -3·4 and 13·7, respectively, P = 0·03), serum high-sensitivity C-reactive protein (hs-CRP) (-948·3 vs 802·3, -383·8 and 618·2 ng/ml, respectively, P = 0·04) and plasma malondialdehyde (MDA) concentrations (-0·6 vs -0·5, -0·1 and 0·6 μmol/l, respectively, P = 0·009), and significant increases in plasma total antioxidant capacity (TAC) (35·2 vs 21·1, 22·5 and -153·8 mmol/l, respectively, P = 0·006) and glutathione (GSH) levels (216·0 vs 3·9, -47·5 and -160·8 μmol/l, respectively, P = 0·001) compared with calcium alone, vitamin D alone and placebo groups. Calcium plus vitamin D cosupplementation did not influence plasma NO and catalase levels.

CONCLUSIONS

We found that calcium plus vitamin D cosupplementation for 8 weeks among overweight and vitamin D-deficient women with PCOS had beneficial effects on inflammatory factor and biomarkers of oxidative stress.

Vitamin D and diabetes mellitus

The vitamin D endocrine system in now recognized as subserving a wide range of fundamental biological functions in cell differentiation, inhibition of cell growth as well as immunomodulation. Both forms of immunity, namely adaptive and innate, are regulated by 1,25(OH)2D3. The immune-modulatory properties of vitamin D suggest that it could play a potential therapeutic role in prevention of type 1 diabetes mellitus (T1DM). It is postulated that large doses of vitamin D supplementation may influence the pattern of immune regulation and subsequent progression to T1DM in a genetically susceptible individual. More studies are required to substantiate the relation between T1DM and vitamin D/vitamin D analogues in the pattern of immune regulations in susceptible individuals. In type 2 diabetes mellitus (T2DM), vitamin D may influence both insulin secretion and sensitivity. An inverse relationship between T2DM and vitamin D is postulated from cross-sectional and prospective studies, though conclusive proof is as yet lacking. Available studies differ in their design and in the recommended daily allowances (RDA) of vitamin D in non-skeletal diseases and β-cell function. Large, well designed, controlled, randomized interventional studies on the potential role of vitamin D and calcium in prevention and management of T2DM are required to clarify the relationship between vitamin D and glucose homeostasis in T2DM.

Correlation between vitamin D and cardiovascular disease predictors in overweight and obese Koreans

Although there is evidence that vitamin D deficiency relates to expression of chronic disease, relationship between vitamin D and cardiovascular disease predictors have not been clearly demonstrated in Korean. Our objective was to assess the correlation between vitamin D and the cardiovascular and inflammatory markers in overweight and obese people who had not been exposed to a particular disease. We enrolled 171 healthy adults (159 men and 12 pre-menopausal women) with no history of cardiovascular disease and with a body mass index >23 kg/m(2) in this study. In addition, levels of serum vitamin D and concentrations of the inflammatory markers hs-CRP, interleukin-6, and adiponectin were measured. The average age of our study subjects was 48.53 years old, and 64.8% of all male subjects and 91.9% of all female subjects were in the vitamin D deficient status. Serum vitamin D levels showed a positive correlation with age (p<0.05), HDL-cholesterol (p<0.05), and adiponectin (p<0.05) levels. However, there was a negative correlation of vitamin D with triglyceride (p<0.01) and interleukin-6 levels (p<0.05). In addition, even after adjusting for factors that may affect the cardiovascular index (age, sex, body mass index, smoking, and alcohol intake), serum vitamin D levels showed a significant correlation with triglyceride (p<0.05), HDL-cholesterol (p<0.05), and adiponectin (p<0.05) levels. Therefore, the results of this study suggest that vitamin D may be a predictor of cardiovascular disease for overweight and obese people who are likely to be at a risk for cardiovascular disease.

Vitamin D supplementation during exercise training does not alter inflammatory biomarkers in overweight and obese subjects

The purpose of this study was to examine the effects of vitamin D supplementation on inflammatory biomarkers in overweight and obese adults participating in a progressive resistance exercise training program. Twenty-three (26.1 ± 4.7 years) overweight and obese (BMI 31.3 ± 3.2 kg/m2) adults were randomized into a double-blind vitamin D supplementation (Vit D 4,000 IU/day; female 5, male 5) or placebo (PL, female 7; male 6) intervention trial. Both groups performed 12 weeks (3 days/week) of progressive resistance exercise training (three sets of eight exercises) at 70-80% of one repetition maximum. Whole-blood lipopolysaccharide (LPS)-stimulated tumor necrosis factor (TNF) α production as well as circulating C-reactive protein (CRP), TNFα, interleukin 6 (IL-6), and alanine aminotransferase (ALT) were assessed at baseline and after the 12-week intervention. No main effects of group or time were detected for circulating CRP, TNFα, IL-6, and ALT. As expected, when PL and Vit D groups were combined, there was a significant correlation between percent body fat and CRP at baseline (r = 0.45, P = 0.04), and between serum 25OHD and CRP at 12 weeks (r = 0.49, P = 0.03). The PL group had a significant increase in 25 μg/ml LPS + polymixin B-stimulated TNFα production (P = 0.04), and both groups had a significant reduction in unstimulated TNFα production (P < 0.05) after the 12-week intervention. Vitamin D supplementation in healthy, overweight, and obese adults participating in a resistance training intervention did not augment exercise-induced changes in inflammatory biomarkers.

Is plasma 25(OH) D related to adipokines, inflammatory cytokines and insulin resistance in both a healthy and morbidly obese population?

To analyse in a cohort of healthy subjects and in a group of morbidly obese patients, we studied the association amongst 25(OH) D and plasma concentrations of adipocytokines, inflammatory cytokines and insulin resistance. We also aimed to determine whether vitamin D-deficient patients showed a greater inflammatory profile. In the observational study that the authors conducted, plasma concentrations of 25(OH) D, leptin, resistin, adiponectin and interleukine-18 were determined in 134 healthy men and 127 women. In the population consisting of 44 patients with morbid obesity, plasma concentrations of 25(OH) D, leptin, resistin, adiponectin, interleukine-18, soluble tumor necrosis factor receptors 1 and 2 and C-reactive protein were analysed. In the healthy population, plasma 25(OH) D showed a negative correlation with body mass index, body fat, waist, hip circumference and with leptin. However, no significant associations were found amongst 25(OH) D and plasma concentrations of resistin, adiponectin or interleukine-18. Patients with vitamin D deficiency showed higher body mass index, fat mass percentage and higher leptin concentrations compared with subjects with normal 25(OH) D concentrations. In the morbidly obese subjects, 25(OH) D did not correlate with leptin, resistin, adiponectin, interleukine-18, soluble tumor necrosis factor receptors 1 and 2 or with C-reactive protein. In patients with morbid obesity, no differences were found in adipokines and inflammatory cytokines concentrations regarding 25(OH) D status. No associations were found either between 25(OH) D and plasma glucose and insulin resistance or with lipid profile. Plasma 25(OH) D concentrations are associated with adiposity markers but not with adipocytokines implicated in inflammation. This lack of association does not support a major role of 25(OH) D in the pro-inflammatory environment observed in morbidly obese subjects. In addition, subjects with vitamin D deficiency are not characterized by a greater inflammatory state.

The effect of 1alpha,25(OH)2D3 vitamin over oxidative stress and biochemical parameters in rats where Type 1 diabetes is formed by streptozotocin

INTRODUCTION

The 1alpha,25-dihydroxyvitamin D(3) [1alpha,25(OH)(2)D(3)] plays an essential role in mineral balance but has also been recognized as a powerful modulator of immune response. We aimed to examine the effect of the 1alpha,25(OH)(2)D(3) treatment on insulin/c-peptide, catalase, superoxide dismutase (SOD), and blood glucose in rats that take streptozotocin (STZ).

METHODS

Forty pieces of male rats of Albino family whose average weights were 261.00+/-07.62 g were used in the study. Rats were made diabetic by giving STZ of 40 mg/kg during 5 days through intraperitoneal path. Some of the diabetic group and nondiabetic group were received 1alpha,25(OH)(2)D(3). The levels of SOD, insulin, c-peptide, glucose, SOD, and catalase were measured at the zero, second, fourth, and sixth weeks.

RESULTS

Erythrocyte SOD levels didn't show a significant difference at the end of the sixth week in all groups when compared to the beginning. While erythrocyte catalase levels didn't show a significant difference in nondiabetic control and nondiabetic with vitamin D, and diabetic with vitamin D groups at the end of sixth week when compared to the beginning, a significant measurement was made in diabetic without vitamin D group. Maximal insulinitis scoring values were observed in diabetic without vitamin D that didn't receive 1alpha,25(OH)(2)D(3) treatment.

CONCLUSION

The highness of insulin and c-peptide levels in the group that received treatment when compared to other groups and the lowness of oxidative markers such as SOD, catalase in this study can be explained by the fact that 1alpha,25(OH)(2)D(3) treatment prevents the intervention of apoptosis mechanism.

Vitamin D and diabetes mellitus

Better understanding of the physiological role of the vitamin-D system, in particular its potential effects on inflammatory and autoimmune conditions as well as on insulin secretion and possibly also on insulin resistance, increased the interest in its potential role in prevention and control of the diabetic condition, both type-1 and -2 diabetes. Both these conditions are associated with inflammation and type-1 diabetes also with an autoimmune pathology. Indeed, animal and human studies support the notion that adequate vitamin-D supplementation may decrease the incidence of type-1 and possibly also of type-2 diabetes mellitus and may improve the metabolic control in the diabetes state. However, the exact mechanisms by which vitamin-D and calcium supplementation exert their beneficial effects are not clear and need further investigation.

Noncalcemic actions of vitamin D receptor ligands

1alpha,25-Dihydroxyvitamin D(3) [1,25-(OH)(2)D(3)], the active metabolite of vitamin D(3), is known for the maintenance of mineral homeostasis and normal skeletal architecture. However, apart from these traditional calcium-related actions, 1,25-(OH)(2)D(3) and its synthetic analogs are being increasingly recognized for their potent antiproliferative, prodifferentiative, and immunomodulatory activities. These actions of 1,25-(OH)(2)D(3) are mediated through vitamin D receptor (VDR), which belongs to the superfamily of steroid/thyroid hormone nuclear receptors. Physiological and pharmacological actions of 1,25-(OH)(2)D(3) in various systems, along with the detection of VDR in target cells, have indicated potential therapeutic applications of VDR ligands in inflammation (rheumatoid arthritis, psoriatic arthritis), dermatological indications (psoriasis, actinic keratosis, seborrheic dermatitis, photoaging), osteoporosis (postmenopausal and steroid-induced osteoporosis), cancers (prostate, colon, breast, myelodysplasia, leukemia, head and neck squamous cell carcinoma, and basal cell carcinoma), secondary hyperparathyroidism, and autoimmune diseases (systemic lupus erythematosus, type I diabetes, multiple sclerosis, and organ transplantation). As a result, VDR ligands have been developed for the treatment of psoriasis, osteoporosis, and secondary hyperparathyroidism. Furthermore, encouraging results have been obtained with VDR ligands in clinical trials of prostate cancer and hepatocellular carcinoma. This review deals with the molecular aspects of noncalcemic actions of vitamin D analogs that account for the efficacy of VDR ligands in the above-mentioned indications.

Nutritional Supplements and Upper Respiratory Tract Illnesses in Young Children in the United States

Key Points

In the United States, children have lower blood levels than adults of eicosapentaenoic acid (EPA), an important ω-3 fatty acid that helps decrease inflammation; vitamin A, the “anti-infective” vitamin; and selenium (Se), a trace metal that is an intrinsic part of glutathione peroxidase, an important free-radical scavenging enzyme.

EPA, vitamin A, and Se are important in controlling inflammation and can be supplied by oral nutritional supplements.

Cod liver oil contains EPA (and other important ω-3 fatty acids), and vitamin A as well as vitamin D.

Fish oil contains ω-3 fatty acids (including EPA) but no vitamins.

Our clinical research demonstrates that daily supplementation with a flavored cod liver oil (which meets European purity standards) and a children’s multivitamin-mineral with trace metals, including Se, can decrease morbidity from upper respiratory tract illnesses, otitis media, and sinusitis in young children living in the United States.

These supplements can be used by practitioners on an individual basis, when clinically indicated; the supplements can be purchased in the United States without a prescription.

Socioeconomically disadvantaged children are at risk for micronutrient deficiencies. However, their families may not be able to afford to purchase these supplements, which are not available through Medicaid, The Special Supplemental Nutrition Program for Women, Infants and Children, or the Food Stamp Program.

If our results are confirmed in larger studies, a system change will be needed to provide these supplements to nutritionally vulnerable, socioeconomically disadvantaged children living in the United States.

Use of cod liver oil during the first year of life is associated with lower risk of childhood-onset type 1 diabetes: a large, population-based, case-control study

BACKGROUND

In Norway, cod liver oil is an important source of dietary vitamin D and the long-chain n-3 fatty acids eicosapentaenoic acid and docosahexaenoic acid, all of which have biological properties of potential relevance for the prevention of type 1 diabetes.

OBJECTIVE

The main objective was to investigate whether the use of dietary cod liver oil or other vitamin D supplements, either by the mother during pregnancy or by the child during the first year of life, is associated with a lower risk of type 1 diabetes among children.

DESIGN

We designed a nationwide case-control study in Norway with 545 cases of childhood-onset type 1 diabetes and 1668 population control subjects. Families were contacted by mail, and they completed a questionnaire on the frequency of use of cod liver oil and other vitamin D supplements and other relevant factors.

RESULTS

Use of cod liver oil in the first year of life was associated with a significantly lower risk of type 1 diabetes (adjusted odds ratio: 0.74; 95% CI: 0.56, 0.99). Use of other vitamin D supplements during the first year of life and maternal use of cod liver oil or other vitamin D supplements during pregnancy were not associated with type 1 diabetes.

CONCLUSION

Cod liver oil may reduce the risk of type 1 diabetes, perhaps through the antiinflammatory effects of long-chain n-3 fatty acids.

Upregulation of lymphocyte apoptosis as a strategy for preventing and treating autoimmune disorders: a role for whole-food vegan diets, fish oil and dopamine agonists

Induced apoptosis of autoreactive T-lymphocyte precursors in the thymus is crucial for the prevention of autoimmune disorders. IGF-I and prolactin, which are lymphocyte growth factors, may have the potential to suppress apoptosis in thymocytes and thus encourage autoimmunity; conversely, dietary fish oil rich in omega-3 fats appears to upregulate apoptosis in lymphocytes. Since whole-food vegan diets may downregulate systemic IGF-I activity, it is proposed that such a diet, in conjunction with fish oil supplementation and treatment with dopamine agonists capable of suppressing prolactin secretion, may have utility for treating and preventing autoimmune disorders. This prediction is consistent with the extreme rarity of autoimmune disorders among sub-Saharan black Africans as long as they followed their traditional quasi-vegan lifestyles, and with recent ecologic studies correlating risks for IDDM and for multiple sclerosis mortality with animal product and/or saturated fat consumption. Moreover, there is evidence that vegan or quasi-vegan diets are useful in the management of rheumatoid arthritis, multiple sclerosis, and possibly SLE. The dopamine agonist bromocryptine exerts anti-inflammatory effects in rodent models of autoimmunity, and there is preliminary evidence that this drug may be clinically useful in several human autoimmune diseases; better tolerated D2-specific agonists such as cabergoline may prove to be more practical for use in therapy. The moderate clinical utility of supplemental fish oil in rheumatoid arthritis and certain other autoimmune disorders is documented. It is not unlikely that extra-thymic anti-inflammatory effects contribute importantly to the clinical utility of vegan diets, bromocryptine, and fish oil in autoimmunity. The favorable impact of low latitude or high altitude on autoimmune risk may be mediated by superior vitamin D status, which is associated with decreased secretion of parathyroid hormone; there are theoretical grounds for suspecting that parathyroid hormone may inhibit apoptosis in thymocytes. Androgens appear to up-regulate thymocyte apoptosis, may be largely responsible for the relative protection from autoimmunity enjoyed by men, and merit further evaluation for the management of autoimmunity in women. It will probably prove more practical to prevent autoimmune disorders than to reverse them once established; a whole-food vegan diet, coupled with fish oil and vitamin D supplementation, may represent a practical strategy for achieving this prevention, while concurrently lowering risk for many other life-threatening 'Western' diseases.

The HLA-DQB alleles and amino acid variants of the vitamin D-binding protein in diabetic patients in Alsace

BACKGROUND

The HLA-DQB1 chain, in particular the amino acid in position 57, and genetic variants of the vitamin D-binding protein (DBP) have been reported to be associated with type 1 diabetes. There are two known polymorphisms in exon 11 of the DBP gene resulting in amino acid variants: codons 416 GAT --> GAG (Asp --> Glu) and 420 ACG --> AAG (Thr --> Lys). We compared distribution of DQB1 alleles and amino acid variants of DBP in type 1 diabetic patients (n = 44) in the Alsacian population and in healthy controls (n = 58).

METHODS

The second exon of the DQB1 gene and exon 11 of DBP were analyzed by restriction mapping after polymerase chain reaction.

RESULTS

A significant enrichment in DQB1 alleles encoding for an amino acid different from Asp in position 57 (NA) was observed in diabetic subjects as compared to controls (94.3 vs. 32.8%; p < 0.001). Combinations other than Ala/Ala carried the highest relative risk (OR = 52; p < 0.001). The analysis of the polymorphism in exon 11 of DBP showed a significant difference in the allele frequency of the HaeIII site, but not of the StyI site between patients and controls. Allele frequencies of HaeIII in diabetic subjects were 36% and 64% for Asp and Glu respectively (p < 0.001; chi(2) = 29.5). The frequency of Asp/Asp and Glu/Glu genotypes was increased in controls and diabetic subjects respectively. DBP alleles in individuals carrying the DQB1 NA combination revealed that 46.6% of diabetics were DBP Asp/Glu, but this was not statistically significant using the Fisher exact test (16/31 vs. 0/3; p = 0.23).

CONCLUSIONS

The study of the DQB1 chain confirmed the value of alleles encoding for an amino acid different from Asp in position 57 (NA) in the susceptibility to type 1 diabetes. The allele frequency of the HaeIII site, but not of the StyI site, differed between patients and controls (HaeIII p < 0.001; StyI p > 0.05).

Vitamin D binding protein alleles and susceptibility for type 1 diabetes in Germans

Vitamin D has been shown to modulate the immune system thereby preventing the development of diabetes in NOD mice. Since the vitamin D binding protein (DBP) is the main transporter for vitamin D and DBP has immunomodulatory properties itself, we investigated three polymorphic sites within the DBP gene as candidates for type 1 diabetes susceptibility for the first time. 152 Caucasian families with at least one affected offspring were genotyped for intron 8 [(TAAA)n repeat] and exon 11 (HaeIII, StyI) polymorphisms. Transmission disequilibrium testing was used to detect preferential transmission to affected offspring. We found no significant transmission disequilibrium for DBP alleles. The strongest deviation from expected values was observed for the "10" allele (relative risk = 0.57, transmitted 13 of 36 times (corrected p = 0.249)). Although we cannot exclude an association of the studied DBP alleles with type 1 diabetes at present, these data do not suggest their contribution to this disease in Germans.