Does Vitamin D Deficiency Pose a Special Risk for Black People?
Compared to people with lighter skin, Black people have more melanin in their skin, which affects the body's ability to synthesize vitamin D.
Vitamin D is important to the health of every system in the body, and yet many people do not get the recommended amount. “Many, many Americans — almost half — are vitamin D deficient,” says David O. Meltzer, MD, PhD, the chief of hospital medicine at University of Chicago Medicine. “But we know that in excess of three quarters of people with darker skin, including African Americans and Hispanics, are vitamin D deficient.”
Now a new spotlight has been trained on that racial gap, with emerging research into possible associations between vitamin D deficiency and the risk of serious COVID-19 disease, including a study led by Dr. Meltzer. Celebrities such as Tyler Perry and Angela Bassett have joined a chorus of voices seeking to publicize these potential links. Meanwhile, other research suggests that current standards used in testing may actually lead to an overdiagnosis of vitamin D deficiency in Black people.
Read on to learn about vitamin D deficiency, how Black people in the United States are at highest risk, what that means for their health, and how, if you fall into this group, to get enough of the vital nutrient.
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Being Low in Vitamin D Can Pose Health Risks
“Most of us grew up learning about the importance of vitamin D for bone health, but it may also play a role in immune system support and a number of chronic health conditions,” says Marisa Moore, RDN, a registered dietitian nutritionist in Atlanta. Besides helping your body absorb and use calcium to grow and maintain bone, vitamin D is involved in cell growth and blood sugar regulation. Plus, the functioning of your muscles, nerves, and immune system all get an assist from the nutrient, according to the National Institutes of Health's Office of Dietary Supplements (ODS).
A walk in the sun after breakfast may get you on your way to the amount of vitamin D you need for the day. That’s because your body makes a form of the nutrient, cholecalciferol (also known as D3) when your skin is exposed to sunlight, according to the ODS. You can also get it from certain foods, such as eggs and fortified milk and orange juice. Other sources of vitamin D3 include fatty fish such as salmon, herring, and halibut; and you can get the plant-based form known as vitamin D2 (ergocalciferol) in mushrooms treated with ultraviolet light, says the agency.
People with mild deficiency typically will not have symptoms, but when the deficiency is more severe, they may show signs such as soft and weak bones, which are hallmarks of osteomalacia in adults and (along with malformed bones) rickets in children, according to ODS.
Severe rickets can cause pain, seizures, muscle spasms, and developmental delays. Black children who are breastfed without vitamin D supplementation are at especially high risk for rickets, says ODS.
Osteomalacia can lead to aches and pain in the lower back, pelvis, hips, legs, and ribs, as well as decreased muscle tone and difficulty walking, according to the Mayo Clinic.
Vitamin D also works with calcium to help prevent osteoporosis in older adults, a disease that causes bones to lose density and fracture more easily. Post-menopausal women are at especially high risk for osteoporosis, ODS explains.
Low vitamin D status has also been linked to?type 2 diabetes and insulin resistance, according to a review published in September 2019 in Current Diabetes Reports. Both conditions are more prevalent among Black people in the United States than in other groups, according to the Centers for Disease Control and Prevention (CDC). But, as the authors of this study stress, a cause-and-effect relationship has not yet been firmly established in humans.
Vitamin D Deficiency Prevalence in Black Americans
The answer to how much vitamin D is enough varies among respected standard-setting organizations. It is measured according to the concentration of the pre-hormone 25-hydroxyvitamin D in your blood, as the ODS explains. In 2011 an expert committee of the Food and Nutrition Board (FNB) at the Institute of Medicine of the National Academies advised that adults are:
- Sufficient at levels of 20 nanograms per milliliter (ng/mL) or 50 nanomoles per liter (nmol/L) and above
- Insufficient at between 12 and 20 ng/mL (30 and 50 nmol/L)
- Deficient at levels below 12 ng/mL (30 nmol/L)
That same year, however, the Endocrine Society raised the threshold of sufficiency to 30 ng/mL (75 nmol/L) and deemed anything below 20 ng/mL (50 nmol/L) to be deficient.
Using the Endocrine Society’s higher threshold, up to 42 percent of adults in the United States are deficient, according to a 2011 analysis of data collected by the CDC. For Black people that nearly doubles to 82 percent, followed by 69 percent of Hispanic people.
A study published in October 2019 in the Journal of Investigative Medicine drilled into the risk factors for Black people in the United States and found that fitness and weight were linked to vitamin D status. Black people with moderate or high fitness levels were 45 percent less likely to be vitamin D deficient than those with low fitness levels. Meanwhile, Black people with obesity were 70 percent more likely to have vitamin D deficiency than those of normal weight. The study authors noted prior research linking vitamin D status to some cardiovascular diseases, as well as the role that the nutrient is known to play in skeletal-muscle function. They said more research is needed to determine whether fitness and weight can cause a change in vitamin D status.
Why Do Black People Have the Highest Risk of Vitamin D Deficiency?
While it’s well known that Black people have the highest rates of vitamin D deficiency the United States, the reasons why may be complex and warrant more study, says Meltzer.
Melanin is the pigment that provides skin color, and individuals with darker skin have more of it than those with lighter skin. Having more melanin reduces your ability to synthesize vitamin D from the sun, resulting in lower 25-hydroxyvitamin D levels, according to the ODS. Further compounding that can be age, clothing that covers up your skin, sunscreen, and seasonal variations in sunlight exposure.
Another factor affecting the amount of vitamin D in your body and how it is used is the presence of vitamin D binding proteins, which carry the nutrient through your bloodstream to various organs, according to the FNB. “There are reasons to believe that African Americans not only need more sun to produce vitamin D, but they could well have different vitamin D binding proteins that might make them more vulnerable to variations in sunlight,” says Meltzer.
Yet, being “deficient” according to current standards may not have the same health implications for Black people. In 2013 a group of researchers looked into vitamin D binding proteins in Black people and published the results in the New England Journal of Medicine. They found that Black participants had lower levels of both vitamin D and vitamin D binding proteins. Yet, Black people had “levels of bioavailable 25-hydroxyvitamin D that are equivalent to those in whites.” In other words, the lower levels of binding proteins may work in balance with the lower levels of 25-hydroxyvitamin D to allow similar amounts of the nutrient to be available for use by the body, they suggested. “Low levels of total 25-hydroxyvitamin D probably do not indicate true vitamin D deficiency when levels of vitamin D–binding protein are also low, as in many Black Americans,” they said, adding that other factors must be considered when diagnosing vitamin D deficiency, such as whether a person exhibits symptoms.
The study authors further noted that despite being diagnosed more frequently with vitamin D deficiency, Black people have higher bone mineral density and a lower risk of fractures due to fragile bones compared with white people. As the FNB describes it, “Despite lower serum 25OHD concentrations, African Americans have a superior ‘calcium economy’ compared with whites in North America and have less risk for osteoporosis and fracture.”
“It may well be that some people have vitamin D binding proteins that are better able to release vitamin D when you're not producing it through sun exposure or not taking it in,” says Meltzer, not in direct response to the NEJM study.
How Vitamin D May Affect COVID-19 Disease, Which Is More Severe in Black Americans
In addition to being at higher risk for vitamin D deficiency, Black people in the United States experience higher rates of death and illness than white people from a number of diseases, including diabetes, heart disease, stroke, and high blood pressure, according to the CDC. The advent of the COVID-19 pandemic added yet another disease to that list, with Black people being hospitalized for COVID-19 at a rate that is four times that of white people, with a death rate twice as high, according to the agency.
Some researchers are looking at how vitamin D might affect COVID-19 disease. Meltzer led a study published online in September 2020 by?JAMA Network Open that examined that relationship in a cohort of 489 patients who had tested positive for COVID-19 at University of Chicago Medicine. They found that patients with likely vitamin D deficient status (based on their medical records) had a 1.77 times greater risk of testing positive than those who were likely not deficient.
Meltzer notes that a majority of the patients in the cohort were Black. “Since African American and Hispanic populations in the U.S. have both high rates of vitamin D deficiency and bear a disproportionate burden of morbidity and mortality from COVID-19, they may be particularly important populations to engage in studies of whether vitamin D can reduce the incidence and burden of COVID-19,” he and his coauthors wrote.
For now, vitamin D deficiency is only linked to higher COVID-19 risk; no study has proven a cause-and-effect relationship. Research is underway to find out if vitamin D can help prevent or treat COVID-19. “We're just getting ready to launch several randomized trials, which will give people the option to be randomized to different doses of vitamin D and then see experimentally whether that makes a difference,” Meltzer says. The University of Chicago has a website to recruit study participants.
Hollywood has already taken note. As mentioned, the filmmaker and studio head Tyler Perry, along with the Golden Globe–winning actor Angela Bassett, and Pearl Grimes, MD, a dermatologist, are among those pointing to study results such as these in a recent YouTube video titled The Colors of COVID. They urge Black people to take more vitamin D, along with zinc and vitamin C, in food and supplements, to help improve their outcomes. Zinc and vitamin C are two other nutrients that have been linked with a shorter duration of respiratory illness in past research, yet the medical community is divided on this recommendation. Consult your healthcare team to find out if supplementing your diet with vitamin C or zinc is right for your individual health. “It’s about helping our bodies fight COVID-19,” Bassett says in the video, while stressing the importance of good overall nutrition and exercise.
Still, as Meltzer says, there isn’t yet a “home run” study regarding the association between COVID-19 and vitamin D deficiency. “I think the most important message is that there is a lot we really don't understand, and there's a tremendous need for research.”
How to Take Charge of Your Nutrition and Get Adequate?Vitamin?D
There’s no downside to getting enough vitamin D through food, and minimal risk to vitamin D supplementation at recommended doses. “There are many reasons to work with your healthcare provider to get your levels checked at least once a year and increase vitamin D rich foods or supplements as needed,” says Moore. As with all supplements, discuss the possibility of taking a vitamin D supplement with your healthcare team, asking about the benefits versus risks, and whether you can get a blood test to see where your current vitamin D levels are.
Request a?Vitamin?D?Status Test
Your doctor might order a blood test to check your 25-hydroxyvitamin D levels in order to screen for or keep tabs on bone disorders such as osteoporosis, osteomalacia, and rickets, according to the U.S. National Library of Medicine’s MedlinePlus guide. People with asthma, psoriasis, and some autoimmune diseases may also be tested.
As mentioned, you may be diagnosed with vitamin D deficiency if your reading is below 12 ng/mL (30 nmol/L) according to FNB standards, or below 20 ng/mL (50 nmol/L) according to Endocrine Society standards. A low result could indicate that your body is having problems using the nutrient because of kidney or liver disease.
On the other hand, it is possible to have too much vitamin D in your blood. According to ODS, a result above 150 ng/mL (375 nmol/) indicates toxic levels, which in turn can result in hypercalcemia, or too much calcium in the blood. Hypercalcemia can cause kidney stones and gastrointestinal problems, bone pain, muscle weakness, as well as disrupt the functioning of your brain and heart. Very high amounts of vitamin D supplements are usually the culprit when your levels are too high, says the agency.
Get More Vitamin D Through Diet and Supplements
“I think that people still widely believe that we get enough vitamin D from sun exposure. But that’s not always the case — especially since we spend most of our time indoors and darker skin tones tend to produce less vitamin D from sun exposure,” says Moore. “There are a few foods high in vitamin D, including salmon and sardines, eggs with the yolk, and mushrooms exposed to UV light. You can also get it from fortified foods such as plant milk, cereal, and some orange juice.”
The FNB recommends that these age groups get the following amounts of vitamin D daily:
- Under age 1: 400 international units (IU)
- Ages 1–70: 600 IU
- Over age 70: 800 IU
And it is difficult to get that much from food alone. Most men take in only 204 IU daily from food and drink, while women take in 168 and children take in 196, according to ODS. Keep in mind that a cup of vitamin D–fortified low-fat milk will give you only 100 IU, per the U.S. Food and Drug Administration (FDA). Yet when vitamin D supplements are factored in, the average daily intake rises to 796 IU in people ages 2 and older, says the ODS.
In his clinical practice, Meltzer advises everyone to take supplements, regardless of background. Your doctor may disagree on the basis of your individual health, so be sure to ask.
Recommendations vary on how much to supplement, but the Endocrine Society notes that adults age 19–50 need 600 IU (15 mcg) per day but may need 1,500–2,000 IU daily (up to 50 mcg) to maintain sufficient levels, and that infants (0–1 year old) should take at least 400 IU daily (10 mcg) and children (1 to 18 years old) should take 600 IU daily (15 mcg) and may need as much as 1,000 IU (25 mcg). To avoid toxicity, the FNB places the upper limit for people over age 9 at 4,000 IU (100 mcg) per day, and 1,000–3,000 IU (25–75 mcg) for babies and children up to age 8.
“Most multivitamins have about 400 international units in them,” says Meltzer. “People who take them for osteoporosis probably take about 1,000 IU a day.”
Again, consult your healthcare team to determine your vitamin D needs.
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Don’t Completely Avoid the Sun
While it’s nearly impossible to get enough vitamin D from sun exposure, Meltzer says sunlight can add to the diet and supplements to help boost your levels. The longer you can manage it on a daily basis, the better, he says, acknowledging the challenges posed by seasonally cold temperatures, indoor working environments (sunlight passing through glass doesn’t produce vitamin D), and stay-at-home pandemic measures. At the same time, he cautions that you should avoid sunburn, which is a risk factor for skin cancer. Ultraviolet-ray damage from the sun can happen in as little as 15 minutes, according to the CDC;?they recommend wearing sunscreen of SPF 15 or higher, among other protective measures.