Commonly recommended daily intake of vitamin D is not sufficient if sunlight exposure is limited
Authors: Glerup H. , Mikkelsen K. , Poulsen L. , Hass E. , Overbeck S. , Thomsen J. , Charles P. , Eriksen E. F. 
Published: March 2003

Abstract. Glerup H, Mikkelsen K, Poulsen L, Hass E, Overbeck S, Thomsen J, Charles P, Eriksen EF (University Hospital of Aarhus, and Primary Health Care Centre, City Vest, Aarhus, Denmark). Commonly recommended daily intake of vitamin D is not sufficient if sunlight exposure is limited. J Intern Med 2000; 247: 260–268.

Objectives. Sunlight exposure of the skin is known to be the most important source of vitamin D. The aims of this study were: (i) to estimate vitamin D status amongst sunlight‐deprived individuals (veiled Arab women, veiled ethnic Danish Moslem women and Danish controls); and (ii) through food intake analysis to estimate the oral intake of vitamin D necessary to keep a normal vitamin D status in sunlight‐deprived individuals.

Design. Cross‐sectional study amongst randomly selected Moslem women of Arab origin living in Denmark. Age‐matched Danish women were included as controls. To control for racial differences, a group of veiled ethnic Danish Moslem women (all Caucasians) was included.

Setting. Primary Health Care Centre, City Vest and Department of Endocrinology and Metabolism C, University Hospital of Aarhus, Aarhus Amtssygehus, Aarhus, Denmark.

Subjects. Sixty‐nine Arab women (60 veiled, nine non‐veiled) and 44 age‐matched Danish controls were randomly selected amongst patients contacting the primary health care centre for reasons other than vitamin D deficiency. Ten ethnic Danish Moslem women were included through a direct contact with their community.

Main outcome measures. Serum levels of 25‐hydroxyvitamin D were used as estimates of vitamin D status. Intact parathyroid hormone (PTH) was used to control for secondary hyperparathyroidism. Alkaline phosphatase and bone‐specific alkaline phosphatase were used as markers for osteomalacic bone involvement. Oral intake of vitamin D and calcium were estimated through a historical food intake interview performed by a trained clinical dietician.

Results. Veiled Arab women displayed extremely low values of 25‐hydroxyvitamin D: 7.1 ± 1.1 nmol L–1, compared with 17.5 ± 2.3 (P < 0.002) in ethnic Danish Moslems and 47.1 ± 4.6 (P < 10–17) in Danish controls. PTH was increased amongst veiled Arab women: 15.6 ± 1.8 pmol L–1, compared with 5.7 ± 1.4 in ethnic Danish Moslems and 2.7 ± 0.3 (P < 10–6) in Danish controls. The vitamin D intake (including food supplementation) was very low amongst Arab women: 1.04 µg day–1, compared with 13.53 amongst ethnic Danish Moslems and 7.49 amongst Danish controls (P < 0.0005).

Conclusions. Severe vitamin D deficiency is prevalent amongst sunlight‐deprived individuals living in Denmark. In veiled Arab women, vitamin D deficiency is the result of a combination of limitations in sunlight exposure and a low oral intake of vitamin D. The oral intake of vitamin D amongst veiled ethnic Danish Moslems was, however, very high, at 13.53 µg (approximately 600 IU), but they were still vitamin D‐deficient. Our results suggest that the daily oral intake of vitamin D in sunlight‐deprived individuals should exceed 600 IU; most probably it should be 1000 IU day–1 to secure a normal level of 25‐hydroxyvitamin D. This finding is in contrast with the commonly used RDA (recommended daily allowance) for adults in Europe: 200 IU day–1.