Surprisingly, many Israelis don't' have enough of the 'sunshine vitamin.'
By JUDY SIEGEL-ITZKOVICHsunrise 88(photo credit: )
Israel is a sunny country, and exposure to the sun's ultraviolet light helps the skin produce vitamin D. So it's ridiculous to insist that all the country's milk products be fortified with the vitamin to take advantage of its many benefits, right? Wrong!
That's the view of Prof. Theodore (Ted) Tulchinsky, formerly a senior Health Ministry official (including head of preventive health services and supervisor of health in the West Bank and Gaza, especially regarding immunization, nutrition and primary care for maternal and child health) for 26 years. Today he is an expert on food fortification, the organization of public health services, ethics and vaccine-preventable diseases at Jerusalem's Hebrew University-Hadassah Braun School of Public Health and Community.
Born in Canada, he received his medical degree from the University of Toronto and master's of public health from Yale, and also served as a deputy minister of health and social development in Manitoba.
Based on his research and that of others, he is certain that Israelis - not only children but also religious Jews and Arabs who cover themselves from head to toe for reasons of modesty and Ethiopian Jews with dark skin - are at high risk of vitamin D deficiency. A foreign study of adolescent haredi boys showed many suffered from such a deficiency, he said. But other sectors in the population, including the elderly, also need enrichment.
Children used to play outdoors, but today most of them are in front of their computers or watching TV. Most working women rush to their jobs early in the morning and go home when there is little sun. In addition, unlike men, they work indoors and many are at high risk of osteoporosis. One of the causes is a lack of vitamin D, and the other is a lack of calcium; the two bind together in bones.
In addition, exposure to the sun is not the same during every season; there are different angles when exposure it not so strong. Also, due to concern about skin cancer, many people stay out of the sun completely. But Tulchinsky says 15 minutes or so - spread out during each day - is not dangerous and is enough to do the job. Asked about the fact that vitamin D is oil soluble and thus can accumulate in body fat, Tulchinsky said toxic levels can theoretically be stored in the body if people consume a very large amount of the vitamin from multiple sources, but he added that "this has not been identified as a public health problem."
THE US, he told The Jerusalem Post in an interview, has mandated fortification of virtually all milk since 1941. It was made mandatory during World War II but then stopped until cases of rickets (soft, deformed bones) were diagnosed, and it was reinstated in 1979. Britain also enriched its milk, but after a rare untoward overdose in a hospital caused complications, the government "threw out the baby with the bath water" and the whole fortification program was halted.
In Israel, margarine has been fortified for decades, said Tulchinsky. In addition, low-fat (1%) milk is enriched with recommended levels of vitamin A and D. But the standard 3%-fat milk, which is the most commonly purchased, is not enriched. "The label on the cartons say 3%-fat milk 'contains vitamin D to the level of natural milk' but nobody has examined the level for many years," Tulchinsky declared. About a decade ago, the ministry did examine it, and no vitamin D was found, Tulchinsky said, noting that decades ago, cows grazed in pastures and were exposed to the sun. But today (except for dairies selling organic milk), they are raised indoors, so they don't produce the vitamin in their milk.
In 2003, the AAP had recommended that infants get 200 International Units (IU), and then it recommended double the amount. A couple of weeks ago, it informed all its pediatrician members that everyone from birth through 18 years should get 400 IU per day. "We are doubling the recommended amount of vitamin D children need each day [and adding adolescents] because evidence has shown this could have lifelong health benefits," reported co-author Dr. Frank Greer in a statement. However, the Health Ministry in Jerusalem has so far only accepted the recommendation to give newborns 400 IU until the age of one year.
"Following the AAP guidelines would change the approach to fortification," commented Tulchinsky. "I know the ministry - especially Dr. Ziva Stahl, head of nutrition in the Food Service - is working hard on the issue and wants to raise the recommended rate, but it hasn't happened, and milk product enrichment is still not mandatory."
IT ISN'T high cost that has prevented dairies from adding vitamin D to all their milk products, the public health expert said. The vitamin is very cheap. "I've been in touch with the major milk companies for years. They were asked to fortify milk with vitamin D voluntarily, but would do so only if they were ordered to. I can't explain why they don't do it on their own. After all, they do add it to 1% fat milk."
Tulchinsky stressed that consuming vitamin D in milk is considered "more efficient" than taking vitamin D supplements.
Some of the milk companies already put vitamin D in some cheese products. But not in cottage cheese or yogurt, which is consumed also by people who have lactose deficiency and can't drink regular milk, Tulchinsky pointed out. Some dairies are promoting "specialized milk" in cartons that has extra calcium and vitamin D, but these are priced beyond the grasp of the poor. Perhaps the fact that milk fortified with vitamin D is sold by dairies in cartons rather than bags as specialized, more expensive milk is a reason why the companies are not eager to add it to the cheapest milk.
But many children don't drink milk. In fact, milk consumption is going down in Israel, as it earned a bad reputation because of its saturated fats and the connection between cholesterol and heart disease, but this is certainly not a problem with 1%-fat milk.
BREAD IS not a good vehicle for vitamin D fortification, said Tulchinsky. Breakfast cereals have some, but these products are relatively expensive. "Our grandparents gave their children cod liver oil, which is rich in vitamin D, and they were right. But nobody does this anymore," he said.
Baby formula, however, does contain vitamin D, and the ministry and tipat halav (well-baby) clinics have long recommended that infants up to the age of one get daily vitamin D drops at a concentration of 100 IU. However, babies who are completely breast fed need more vitamin D than those who get all or some of their nutrition from formula, which is fortified.
Asked for comment, ministry spokesman Einav Shimon-Greenboim remarked instead that "there is an official Israeli standard for pasteurized milk that requires vitamins A and D to be added to restore the level to that of their original concentration [that in 3%-fat milk]. Milk producers voluntarily enrich some other milk products that they are not required to fortify. Enrichments turns them into 'milk drinks' not included under the official standard. As part of the discussion of food fortification, we are considering fortifying standard milk with vitamins and minerals, especially vitamin D."
But Tulchinsky, who knows the ministry well from the inside, suggests that the reason for failing to implement the entire AAP policy is "lethargy, apathy and conservatism. The vitamin manufacturers don't make big money from it. The ministry didn't get around to it. But I am hopeful that Dr. Stahl will do it; she is very competent. Deciding whether to implement the AAP recommendations here is a no-brainer."
VITAMIN-D fortified food is not only good for children and teenagers. It seems to have the potential to benefit everyone's health, according to dozens of studies in recent years. Missing out on the "sunshine vitamin" has consequences for more than just bone health, reports the September 2008 issue of Harvard Women's Health Watch. Researchers have found that it's active in many other tissues and cells, and controls many genes, including some associated with cancer, autoimmune disease and infection.
"Hardly a month goes by without news about the risks of too little vitamin D, or about a potential role for the vitamin in warding off diseases, including breast cancer, multiple sclerosis and even schizophrenia. More trials are needed to confirm vitamin D's benefits and risks," the publication said. "In the meantime, the evidence is so compelling that some experts already recommend at least 800 IU per day for adults."
Meanwhile, a researcher at the University of California at Riverside recently called for "a sea change in how government agencies advise people to take vitamin D." Dr. Anthony Norman wrote in the American Journal of Clinical Nutrition that about half of the elderly in North America are not getting enough vitamin D to maintain healthy bone density, lower their fracture risk and improve tooth attachment.
"It is becoming increasingly clear to researchers that vitamin D is strongly linked to several diseases. The nutritional guidelines must be carefully re-evaluated to determine adequate intake, balancing sunlight exposure with dietary intake to achieve good health by involving all 36 target organs" that require the vitamin, Norman said. Deficiency is associated with decreased muscle strength, higher risk for falls and increased risk of colorectal, prostate, breast and other cancers.
Vitamin D deficiency has also been linked by researchers at the Medical College of Wisconsin to inflammatory bowel disease and chronic liver disease. Researchers at the New Jersey Medical School have published evidence showing that the vitamin - the principal regulator of calcium in the body - may prevent the production of malignant cells and protect against specific autoimmune disorders such as multiple sclerosis (MS). The researchers wrote that high serum levels of vitamin D have been shown to correlate with a reduced risk of MS. "This suggests that the vitamin may regulate the immune response, and may promote a host's reaction to a pathogen."
Vitamin D deficiency has been associated with chronic pain in women, according to British research published recently in Annals of the Rheumatic Diseases. The findings were not explained by gender, differences in lifestyle or factors such as levels of physical activity and time spent outdoors. Another major study linked it to chronic back pain in both sexes. An article published last June in the prestigious Archives of Internal Medicine maintained that people with vitamin D deficiency have an increased overall risk of death from cardiovascular causes, and that 800 to 1,000 IU daily is likely to benefit most adults. A University of Michigan team reported in the Journal of the American Society of Nephrology that vitamin D supplements reduce the risk of death in patients with chronic kidney disease, while another study showed it strengthens heart muscle cells and minimizes the risk of heart failure.
The list of the vitamin's potential health benefits is endless. Perhaps the ministry should start by asking its chief statistics expert to do a cost-benefit study on how much money vitamin D fortification of all milk products would save the health system. Even if the vitamin were proven useful for fewer bodily organs and fewer people, it would be worth it for the Health Ministry to conduct a serious discussion of the issue and consider the need for new regulations, official standards and legislation to benefit public health.
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