Vitamin D fortification of foods in India: present and past scenario

Vitamin D fortification of foods - sensory, acceptability, cost, and public acceptance considerations

In terms of vitamin D food fortification, there are a number of important considerations in relation to selection of the food vehicle and fortificant. While there has been much research focus on the ability of fortified foods to improve vitamin D status, other considerations, such as sensory properties and acceptability, cost, and public attitudes around vitamin D-fortified foods, have received less attention. Thus, the present narrative review aimed to summarize the existing knowledge around these important considerations. In summary, its findings suggest that: i) vitamin D addition to various food vehicles, at levels consistent with the supply of part or all the recommended intake, does not alter their sensory characteristics or overall acceptability; ii) overall, vitamin D fortification of foods is relatively cost-effective, despite the fact that some attitudinal studies highlighted participant concerns about the potential cost/expense of vitamin D-fortified foods; iii) evidence from various attitudinal studies suggest a high level of acceptance and/or purchase intention (i.e., extent to which customers are willing and inclined to buy) of vitamin D-fortified food products by the general public; and iv) there have been repeated calls for vitamin D public health educational/information campaigns to help educate consumers about the health risks associated with vitamin D deficiency and nutritional benefits associated with consumption of vitamin D-fortified foods. Such campaigns could positively mediate attitudes and acceptance of vitamin D-fortified foods amongst the public, and could also help address misconceptions and allay fears around vitamin D for concerned individuals. Lastly, the findings of the present review also highlight the existence of between-country differences, even within Europe, in relation to attitudes and purchase intention of vitamin D-fortified foods and the perceived appropriateness of certain food vehicles for vitamin D fortification, as well as the best mix of communication channels for a vitamin D public health educational/information campaign.

Calcifediol: Mechanisms of Action

Due to its essential role in calcium and phosphate homeostasis, the secosteroid hormone calcitriol has received growing attention over the last few years. Calcitriol, like other steroid hormones, may function through both genomic and non-genomic mechanisms. In the traditional function, the interaction between the biologically active form of vitamin D and the vitamin D receptor (VDR) affects the transcription of thousands of genes by binding to repeated sequences present in their promoter region, named vitamin D-responsive elements (VDREs). Non-transcriptional effects, on the other hand, occur quickly and are unaffected by inhibitors of transcription and protein synthesis. Recently, calcifediol, the immediate precursor metabolite of calcitriol, has also been shown to bind to the VDR with weaker affinity than calcitriol, thus exerting gene-regulatory properties. Moreover, calcifediol may also trigger rapid non-genomic responses through its interaction with specific membrane vitamin D receptors. Membrane-associated VDR (mVDR) and protein disulfide isomerase family A member 3 (Pdia3) are the best-studied candidates for mediating these rapid responses to vitamin D metabolites. This paper provides an overview of the calcifediol-related mechanisms of action, which may help to better understand the vitamin D endocrine system and to identify new therapeutic targets that could be important for treating diseases closely associated with vitamin D deficiency.

A Systematic Review and Meta-Analysis of Vitamin D Status of Patients with Severe Obesity in Various Regions Worldwide

INTRODUCTION

Managing nutritional deficiencies is an essential component in the treatment of severe obesity. Vitamin D deficiency is often reported in investigations in severely obese cohorts. However, no prior study has summarized findings on this topic. Consequently, the aim of this systematic review and meta-analysis was to investigate the 25-hydroxyvitamin D [25(OH)D] status in individuals with severe obesity in different regions worldwide. We also evaluated levels of calcium, parathyroid hormone (PTH), and magnesium as secondary outcome measures.

METHODS

We searched Medline, PubMed, Scopus, the Cochrane Library, and EMBASE for relevant observational studies published in English from 2009 to October 2021. The heterogeneity index among the studies was determined using the Cochran (Q) and I2 tests. Based on the heterogeneity results, the random-effect model was applied to estimate the prevalence of vitamin D deficiency.

RESULTS

We identified 109 eligible observational studies. Overall, 59.44% of patients had vitamin D deficiency [25(OH)D <20 ng/mL], whereas 26.95% had vitamin D insufficiency [25(OH)D 20-30 ng/mL]. Moreover, the mean 25(OH)D level was 18.65 ng/mL in 96 studies. The pooled mean estimate of the serum calcium, PTH, and magnesium was 9.26 mg/dL (95% confidence interval [CI]: 9.19-9.32, I2 = 99.7%, p < 0.001), 59.24 pg/mL (95% CI: 54.98, 63.51, I2 = 99.7%, p < 0.001), and 0.91 mg/dL (95% CI: 0.84, 0.98, I2 = 100.0%, p < 0.001), respectively. The results of the subgroup analysis indicated that the mean estimates of 25(OH)D were highest in North America (21.71 ng/mL [19.69, 23.74], [I2 = 97.2%, p < 0.001]) and lowest in Southeast Asia (14.93 ng/mL [14.54, 15.33], [I2 = 0.0%, p = 0.778]).

CONCLUSION

The results obtained showed a significant prevalence of vitamin D deficiency among severely obese individuals in various geographical regions, whereas the highest and lowest mean estimates were reported for North America and Southeast Asia, respectively.

Calcifediol: a review of its pharmacological characteristics and clinical use in correcting vitamin D deficiency

BACKGROUND

In addition to the role of vitamin D in bone mineralization, calcium and phosphate homeostasis, and skeletal health, evidence suggests an association between vitamin D deficiency and a wide range of chronic conditions. This is of clinical concern given the substantial global prevalence of vitamin D deficiency. Vitamin D deficiency has traditionally been treated with vitamin D₃ (cholecalciferol) or vitamin D₂ (ergocalciferol). Calcifediol (25-hydroxyvitamin D₃) has recently become available more widely.

METHODS

By means of targeted literature searches of PubMed, this narrative review overviews the physiological functions and metabolic pathways of vitamin D, examines the differences between calcifediol and vitamin D₃, and highlights clinical trials conducted with calcifediol in patients with bone disease or other conditions.

RESULTS

For supplemental use in the healthy population, calcifediol can be used at doses of up to 10 µg per day for children ≥ 11 years and adults and up to 5 µg/day in children 3-10 years. For therapeutic use of calcifediol under medical supervision, the dose, frequency and duration of treatment is determined according to serum 25(OH)D concentrations, condition, type of patient and comorbidities. Calcifediol differs pharmacokinetically from vitamin D₃ in several ways. It is independent of hepatic 25-hydroxylation and thus is one step closer in the metabolic pathway to active vitamin D. At comparable doses to vitamin D₃, calcifediol achieves target serum 25(OH)D concentrations more rapidly and in contrast to vitamin D₃, it has a predictable and linear dose-response curve irrespective of baseline serum 25(OH)D concentrations. The intestinal absorption of calcifediol is relatively preserved in patients with fat malabsorption and it is more hydrophilic than vitamin D₃ and thus is less prone to sequestration in adipose tissue.

CONCLUSION

Calcifediol is suitable for use in all patients with vitamin D deficiency and may be preferable to vitamin D₃ for patients with obesity, liver disease, malabsorption and those who require a rapid increase in 25(OH)D concentrations.

The Pandemic and Your Skin—Direct and Indirect Impact of COVID-19

Apart from well-known respiratory symptoms, less frequent symptoms also appear as a direct result of COVID-19 infection, or as indirect effects of the recommended quarantine and related lifestyle changes. The impact of the COVID-19 pandemic on human skin is predominantly focused on in this article. Cutaneous manifestations, including redness, chilblain-like symptoms (COVID toes), hives or urticaria rash, water blisters, and fishing net-like red-blue patterns on the skin, may appear as accompanying or as systemic COVID-19 symptoms with potential lesions at different skin sites. These symptoms were related to skin phototypes and vitamin D deficiency. Moreover, Black, Asian, and minority ethnic origin patients are found to be more sensitive to COVID-19 infection than Caucasians because of vitamin D deficiency. The region of population with lighter skin phototypes have a significantly higher chance to develop cutaneous manifestations than population with dark skin. In addition, adverse effects, such as skin barrier damage and irritation, may also occur due to extensive personal protective equipment usage (e.g., masks, protective suits, and a few others) and predominately alcohol-based sanitizers. This manuscript covers various aspects of COVID-19 and its clinical skin manifestations.

Vitamin D Fortification and Its Effect on Athletes' Physical Improvement: A Mini Review

Poor vitamin D status is a widespread problem regardless of age and sex, emphasizing the necessity of new food sources to improve vitamin D levels. Currently, approximately 60% of dietary vitamin D consumption occurs via fortified foods. Vitamin D insufficiency (50-90%) is widespread according to age and region, despite different levels of sunlight exposure. The food industry must identify more effective strategies to increase normal dietary vitamin D intake and improve overall health. Strategies for vitamin D fortification include bioaddition, wherein a vitamin D-rich food source is added to staple foods during processes. These bioadditive strategies expand the range of vitamin D-containing foods and appeal to different preferences, cultures, and economic statuses. In several countries, vitamin D deficiency places athletes at a high risk of disease susceptibility. Due to low sun exposure, athletes in countries with higher and lower levels of sunlight have similar risks of vitamin D deficiency. In this review, we summarize recent technical advances to promote vitamin D utilization by humans during sports activities and in relation to the normal practices of athletes.

Improving nutrition through biofortification-A systematic review

Nutritious foods are essential for human health and development. However, malnutrition and hidden hunger continue to be a challenge globally. In most developing countries, access to adequate and nutritious food continues to be a challenge. Although hidden hunger is less prevalent in developed countries compared to developing countries where iron (Fe) and zinc (Zn) deficiencies are common. The United Nations (UN) 2nd Sustainable Development Goal was set to eradicate malnutrition and hidden hunger. Hidden hunger has led to numerous cases of infant and maternal mortalities, and has greatly impacted growth, development, cognitive ability, and physical working capacity. This has influenced several countries to develop interventions that could help combat malnutrition and hidden hunger. Interventions such as dietary diversification and food supplementation are being adopted. However, fortification but mainly biofortification has been projected to be the most sustainable solution to malnutrition and hidden hunger. Plant-based foods (PBFs) form a greater proportion of diets in certain populations; hence, fortification of PBFs is relevant in combating malnutrition and hidden hunger. Agronomic biofortification, plant breeding, and transgenic approaches are some currently used strategies in food crops. Crops such as cereals, legumes, oilseeds, vegetables, and fruits have been biofortified through all these three strategies. The transgenic approach is sustainable, efficient, and rapid, making it suitable for biofortification programs. Omics technology has also been introduced to improve the efficiency of the transgenic approach.

Nutraceuticals and COVID-19: A mechanistic approach toward attenuating the disease complications

Nutraceuticals have emerged as potential compounds to attenuate the COVID-19 complications. Precisely, these food additives strengthen the overall COVID treatment and enhance the immunity of a person. Such compounds have been used at a large scale, in almost every household due to their better affordability and easy access. Therefore, current research is focused on developing newer advanced formulations from potential drug candidates including nutraceuticals with desirable properties viz, affordability, ease of availability, ease of administration, stability under room temperature, and potentially longer shelf-lives. As such, various nutraceutical-based products such as compounds could be promising agents for effectively managing COVID-19 symptoms and complications. Most importantly, regular consumption of such nutraceuticals has been shown to boost the immune system and prevent viral infections. Nutraceuticals such as vitamins, amino acids, flavonoids like curcumin, and probiotics have been studied for their role in the prevention of COVID-19 symptoms such as fever, pain, malaise, and dry cough. In this review, we have critically reviewed the potential of various nutraceutical-based therapeutics for the management of COVID-19. We searched the information relevant to our topic from search engines such as PubMed and Scopus using COVID-19, nutraceuticals, probiotics, and vitamins as a keyword. Any scientific literature published in a language other than English was excluded. PRACTICAL APPLICATIONS: Nutraceuticals possess both nutritional values and medicinal properties. They can aid in the prevention and treatment of diseases, as well as promote physical health and the immune system, normalizing body functions, and improving longevity. Recently, nutraceuticals such as probiotics, vitamins, polyunsaturated fatty acids, trace minerals, and medicinal plants have attracted considerable attention and are widely regarded as potential alternatives to current therapeutic options for the effective management of various diseases, including COVID-19.

Micronutrient interventions among vulnerable population over a decade: A systematic review on Indian perspective

Background: Micronutrient deficiency has long been recognized as a public health problem, particularly among vulnerable groups such as children, adolescents, pregnant and lactating women. Micronutrient deficiency could not be ruled out in spite of the implementation of various intervention strategies. Different interventions are being used to prevent and treat micronutrient deficiencies at the national and global level. The aim of this study is to systematically review the intervention strategies among different vulnerable age groups in India.

Methods: The review was focused on identifying various interventions published based on the internet databases and the peer-reviewed papers from 2011 to 2021, on the predefined inclusive/exclusive criteria. The major intervention strategies implemented in India were recognized and evaluated based on dietary supplementation, micronutrient supplementation, knowledge interventions and food fortification among various age groups.

Results: The results show that there are still considerable gaps in identifying the effective intervention strategies, research initiatives, programs and policies addressing to tackle micronutrient deficiencies in India. Multiple interventions are effective that could lead the road to innovations in approaches with diverse dietary intake, developing multiple micronutrient supplements, fortifying foods and nutrition interventions to address calcium, zinc, iodine, vitamin D and vitamin A deficiencies among the vulnerable population.

Conclusion: Evidence-based multiple intervention studies covering a large population, in the long term cross-sectional, is the need for the hour to design policies and programs for improving the micronutrient status of vulnerable population in the community.

Effect of Vitamin-D-Enriched Edible Mushrooms on Vitamin D Status, Bone Health and Expression of CYP2R1, CYP27B1 and VDR Gene in Wistar Rats

Vitamin D deficiency is highly prevalent in India and worldwide. Mushrooms are important nutritional foods, and in this context shiitake (Lentinula edodes), button (Agaricus bisporus) and oyster (Pleurotus ostreatus) mushrooms are known for their bioactive properties. The application of ultraviolet (UV) irradiation for the production of substantial amounts of vitamin D2 is well established. Levels of serum 25-hydroxy vitamin D (25-OHD), parathyroid hormone (PTH), calcium, phosphorus and alkaline phosphatase (ALP) were significantly (p < 0.05) improved in vitamin-D-deficient rats after feeding with UVB irradiated mushrooms for 4 weeks. Further, microscopic observations indicate an improvement in the osteoid area and the reduction in trabecular separation of the femur bone. In addition, the level of expression of the vitamin D receptor (VDR) gene and genes metabolizing vitamin D were explored. It was observed that in mushroom-fed and vitamin-D-supplemented groups, there was upregulation of CYP2R1 and VDR, while there was downregulation of CYP27B1 in the liver. Further, CYP2R1 was downregulated, while CYP27B1 and VDR were upregulated in kidney tissue.

How Much Does Serum 25(OH)D Improve by Vitamin D Supplement and Fortified Food in Children? A Systematic Review and Meta-Analysis

OBJECTIVES

This study was conducted to respond certain important questions regarding the efficacy of vitamin D fortification and supplementation in children using a meta-analytical approach.

METHODS

MEDLINE, PubMed, Embase, Cochrane Library, and Google Scholar were searched, and 2341 studies were found in a preliminary search. After screening of titles and abstracts, 31 studies were selected.

RESULTS

Significant raises in circulating 25-hydroxy vitamin D (25(OH)D) concentrations were observed in both groups that took vitamin D supplement (mean difference [MD] 28.7, 95% confidence interval [CI] 22.5-34.9) and vitamin D-fortified foods (MD 20.29, 95% CI 13.3-27.2). The meta-regression revealed a significant association between age of participants (B -1.4, 95% CI -2.8, -0.02, P = 0.047) and dose of vitamin D (B 0.007, 95% CI 0.003, 0.01, P < 0.001), with the effect on serum 25(OH)D concentrations. The analysis showed that serum 25(OH)D concentration increases by 0.7 nmol/L for every 100 IU of vitamin D intake after adjustment for age, baseline serum 25(OH)D and latitude which is far less than the reported amount in adults.

CONCLUSIONS

Altogether, these findings indicate that in a mass vitamin D fortification program, circulating 25(OH)D concentration response in children may be lower in children than in adults and vitamin D supplementation may still be needed in this subpopulation.

Global View of Per Capita Daily Vitamin D Supply Estimates as Proxy Measures for Vitamin D Intake Data

Nationally representative data on vitamin D intake can inform on the adequacy of dietary supply of vitamin D in a population, but such data is lacking for a majority of countries. Estimates of average per capita supply of vitamin D, as calculated using information from the Food and Agriculture Organisation of the United Nations (FAO) national food balance sheets (FBSs) can be used as proxy measures for vitamin D intake within a population. In the present work, FAO national FBSs (from 2004 to 2017) for 173 to 178 countries around the globe were used to generate such average per capita vitamin D supply estimates. For countries where food fortification with vitamin D was common, the estimates accounted for this. Using the 2004–2013 FBS data, there was a large range in average per capita vitamin D supply ranging from 0.3 (Ethiopia) to 17.8 (Maldives) μg/d. Globally, 40, 60, 70, four, two, and two countries had average per capita vitamin D supply estimates <1.5, 1.6–3, 3.1–5.5, 5.6–7.5, 7.6–10, and >10 μg/d, respectively. Pelagic fish was the major contributory food commodity (supplying 53%–86%) in countries with supply >7.6 μg/d. Median per capita vitamin D supply estimates for constituent countries within Africa, Americas, Asia, Europe, and Oceania were 1.4, 2.7, 2.8, 4.1, and 4.7 μg/d, respectively. These overall supply trends were mirrored in the newer, 2014–2017 FBS data. Fortification of milk and dairy or wheat flour with vitamin D had an important impact on the vitamin D supply estimates (average increments of 1.6 and 3.1 μg/d, respectively). Overall, the work showed how the per capita daily vitamin D supply estimates, as surrogate for vitamin D intake data, can highlight countries where inadequacy of supply may be of concern. It also shows how fortification of food with vitamin D can have an important impact on addressing low vitamin D intake. © 2021 The Author. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Trends in Vitamin D Status Around the World

Vitamin D status varies across all continents and countries. Vitamin D status usually is adequate in Latin America and Australia, but in contrast it is very low in the Middle East and some countries in Asia. Trends in vitamin D status, whether it improves or declines over the years, carry important messages. Trends usually are small, but can be predictors and indicators of general health. Vitamin D status has improved in the older population in the United States, and improvement relates to dairy use and vitamin D supplements. To the contrary, vitamin D status has declined in the Inuit population of Canada due to a change from a traditional fish diet to a Western diet. A large improvement was seen in Finland after mandatory fortification of dairy products was introduced. Determinants of decline are less sun exposure, increased use of sunscreen, increase of body mass index (BMI), less physical activity, and poor socioeconomic status. Determinants of increase are food fortification with vitamin D and vitamin D supplements. Food fortification can lead to a population-wide increase in vitamin D status as shown by the Finnish example. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Vitamin D assessment and precision of clinical referrals: Insights gained from a teaching hospital in southern India

Objective:

Vitamin D deficiency is widely prevalent worldwide. This has led to a significant surge in referrals for vitamin D assessment in recent years. The cost-effectiveness and rationalization of this practice is uncertain. This study aimed to evaluate the referral pattern for vitamin D testing from a tertiary center in southern India.

Materials and Methods:

This was a cross-sectional study done over a period of one year (2017). A total of 95,750 individuals, referred for vitamin D screening were included in this study. Details regarding referring departments and indications for referral were obtained from the computerized hospital information processing system (CHIPS).

Results:

The study population exhibited a female preponderance (54.1%) with mean (SD) age of 40.3 (18.5) years. Overall, 44% were found to have vitamin D deficiency. Most of the referrals were from nephrology (15.4%), neurology (10.1%), and orthopedics (9.1%). Nevertheless, dermatology, the staff-clinic, and hematology which contributed to 3.3%, 1.7%, and 1.7% of referrals, had a higher proportion of vitamin D deficiency of 59.1%, 57.7%, and 64.6%, respectively. Although the most common indications for referral were generalized body aches (20.5%) and degenerative bone disorders (20.1%), the proportion of subjects with vitamin D deficiency referred for these indications were 46.1% and 41.6%, respectively. In contrast, chronic steroid use that accounted for 3.3% of the referrals had 59.1% of subjects who were deficient in vitamin D.

Conclusion:

To ensure a rational approach to vitamin D testing, clinicians ought to use their discretion to screen those truly at risk for vitamin D deficiency on a case to case basis and avoid indiscriminate testing of the same.