Hypovitaminosis D in Costa Rica: initial report on a case control study

None; None; None

Abstracts

Objective: To describe for the first time in Costa Rica, the clinical characteristics of patients with Hypovitaminosis D.   Materials and methods: Retrospective study, in which17 patients with subnormal levels of 25-hydroxivitamin D25 (OH)VD (<75 nmol/L) were identified amongst the reports from the Hormone Laboratory at the San Juan de Dios Hospital. Also, 15 controls with normal levels, and similar age and gender were identified.   Results: There was no difference in age (52.76±20.88 years in cases vs. 46.33±12.50 in controls), gender (58.85% in cases vs. 80% in controls were females).In the group with Hypovitaminosis, mean levels of 25(OH)VD(59.2±10.37 nmol/L) were lower and those of PTH were higher (146.86±103.76 vs. 47.82±13.77 ng/ml in controls, p=0.004). There was no difference in calcium levels (8.98 cases vs. 9.38 mg/dl controls p=.352), phosphorus (4.09 cases vs. 2.99 mg/ dl controls p=.104) nor BMD at hip and lumbar spine. There were no differences in the prevalence of nephrotic syndrome, chronic liver failure, chronic renal disease and of sun block use between both groups. There were no hospitalized patients in either group. Subjects with hypovitaminosis on the cases group indicated an average of 0.6 hours of sun exposure per week, compared with 1.46 in the control group (p=0.297). In the cases group, we observed a higher prevalence of falls (23.5% vs. 6.7% p=0.039), fractures (17.6% vs. 0%, p=0.024), diabetes (17.6% vs. 6.7% p=0,158), fatigue (29.4% vs. 13.3% p=0.012), weakness (41.2% vs. 33% p=0.010), and use of inducers of cytochrome P450 pathway (29.3% vs. 0% p=0.009). Body weight was less in cases with deficiency of25(OH)VD (26.6% with overweight or obesity vs. 66.7% p=0.009).   Conclusions: Hypovitaminosis D may occur in tropical countries, such as Costa Rica. It is characterized by higher levels of PTH, low body weight, a high number off alls and fractures, fatigue, weakness, diabetes and use of inducers of liver enzymatic activity. Both groups had low sun exposure

Vitamin D deficiency; vitamin D; hyperparathyroidism

Objetivo: describir, por primera vez en Costa Rica, las características clínicas de pacientes con hipovitaminosis D. Materiales y métodos: estudio retrospectivo, en donde se detectó, entre los reportes del Laboratorio de Hormonas del Hospital San Juan de Dios, a 17 pacientes con niveles de 25-hidroxivitamina D (25(OH)VD)en rangos subnormales (<75 nmol/L), así como 15 controles con niveles normales, grupos con edades y sexos similares. Resultados: no se encontró diferencias con respecto a la edad (52,76±20.88 años en casos vs. 46,33±12.5 en controles), sexo (58,85% en casos vs. 80% en controles, fueron mujeres). En el grupo de hipovitaminosis fueron inferiores los niveles promedio de 25(OH)VD (59,2±10,37 nmol/L) y mayores los de PTH (146,86±103,76 vs. 47,82±13,77 pg/mL en controles, p=0.004). No hubo diferencia en calcemias (8,98 casos vs. 9,38 mg/dl controles, p=,352), fósforo (4,09 casos vs. 2,99 mg/dl controles, p=.104), ni densidad mineral ósea en cadera y columna lumbar. No hubo diferencia en la prevalencia de síndrome nefrótico, falla renal o hepática, y utilización de bloqueadores solares. Ningún grupo presentaba pacientes institucionalizados. Las personas con hipovitaminosis indicaron un promedio de 0,6 horas semanales de exposición solar, comparadas con 1,46 en grupo control (p=0,297), una prevalencia mayor de caídas (23,5% vs. 6,7%, p=0,039), fracturas (17,6% vs. 0%, p=0,024), diabetes (17,6% vs. 6,7%, p=0,158), fatiga (29,4% vs. 13,3%, p=0,012), debilidad (41,2% vs. 33%, p=0,010), y utilización de inductores de la vía del citocromo P450 (29,3% vs. 0%, p=0,009). El peso fue menor entre los insuficientes de 25(OH)VD (26,6% con sobrepeso u obesidad vs. 66,7%, p=0,009). Conclusiones: la hipovitaminosis D puede presentarse en países tropicales como Costa Rica. Se caracteriza por niveles altos de PTH, bajo peso, elevado número de caídas y fracturas, fatiga, debilidad, diabetes y utilización asociada de inductores de actividad enzimática hepática. Ambos grupos poseen baja exposición solarla hipovitaminosis D puede presentarse en países tropicales como Costa Rica. Se caracteriza por niveles altos de PTH, bajo peso, elevado número de caídas y fracturas, fatiga, debilidad, diabetes y utilización asociada de inductores de actividad enzimática hepática. Ambos grupos poseen baja exposición solar

deficiencia de vitamina D; vitamina D; hiperparatiroidismo

Objective: To describe for the first time in Costa Rica, the clinical characteristics of patients with Hypovitaminosis D. Materials and methods: Retrospective study, in which17 patients with subnormal levels of 25-hydroxivitamin D25 (OH)VD (<75 nmol/L) were identified amongst the reports from the Hormone Laboratory at the San Juan de Dios Hospital. Also, 15 controls with normal levels, and similar age and gender were identified. Results: There was no difference in age (52.76±20.88 years in cases vs. 46.33±12.50 in controls), gender (58.85% in cases vs. 80% in controls were females).In the group with Hypovitaminosis, mean levels of 25(OH)VD(59.2±10.37 nmol/L) were lower and those of PTH were higher (146.86±103.76 vs. 47.82±13.77 ng/ml in controls, p=0.004). There was no difference in calcium levels (8.98 cases vs. 9.38 mg/dl controls p=.352), phosphorus (4.09 cases vs. 2.99 mg/ dl controls p=.104) nor BMD at hip and lumbar spine. There were no differences in the prevalence of nephrotic syndrome, chronic liver failure, chronic renal disease and of sun block use between both groups. There were no hospitalized patients in either group. Subjects with hypovitaminosis on the cases group indicated an average of 0.6 hours of sun exposure per week, compared with 1.46 in the control group (p=0.297). In the cases group, we observed a higher prevalence of falls (23.5% vs. 6.7% p=0.039), fractures (17.6% vs. 0%, p=0.024), diabetes (17.6% vs. 6.7% p=0,158), fatigue (29.4% vs. 13.3% p=0.012), weakness (41.2% vs. 33% p=0.010), and use of inducers of cytochrome P450 pathway (29.3% vs. 0% p=0.009). Body weight was less in cases with deficiency of25(OH)VD (26.6% with overweight or obesity vs. 66.7% p=0.009). Conclusions: Hypovitaminosis D may occur in tropical countries, such as Costa Rica. It is characterized by higher levels of PTH, low body weight, a high number off alls and fractures, fatigue, weakness, diabetes and use of inducers of liver enzymatic activity. Both groups had low sun exposure Hypovitaminosis D may occur in tropical countries, such as Costa Rica. It is characterized by higher levels of PTH, low body weight, a high number off alls and fractures, fatigue, weakness, diabetes and use of inducers of liver enzymatic activity. Both groups had low sun exposure

Vitamin D deficiency; vitamin D; hyperparathyroidism

HypovitaminosisCosta Rica: initial report on a case control study

Chih Hao Chen-Ku¹, Manuel Jiménez-Navarrette², Laura Ulate Oviedo

¹Department of Endocrinology, San Vicente de Paúl Hospital, Heredia²

Abbreviations: 25(OH) VD; 25-Hydroxi-vitamin D; BMD, Bone mineral density; USA; United States of America; UVI, Ultraviolet index; PTH, Parathormone;VD,Vitamin D.

chenku 2409@gmail.com
Department of Endocrinology, San Juan de Dios Hospital

Aim: To describe for the first time clinical characteristics of patients with vitamin D insufficiency in Costa Rica.

Materials and methods: 17 patients with low levels of 25(OH)VD (<75 nmol/L) were selected from the laboratory reports at the Hospital San Juan de Dios. 15 controls were selected with normal 25(OH) VD levels and the same age and gender.

Results: There was no difference in age (52.76±20.88 years in cases vs 46.33±12.50 in control), gender (58.85% cases were females vs 80% in controls) or ethnic background (almost all patients were Hispanic). Mean 25(OH)VD levels in cases were 59,2±10,37 nmol/L. PTH levels were higher in cases (146.86±103.76 vs 47.82±13.77 ng/ml, p=0.004). There was no difference in calcium levels (8.98 cases vs 9.38 mg/dl controls p=.352), phosphorus (4.09 cases vs 2.99 mg/dl control p=.104). BMD at hip and lumbar spine were comparable. There were no differences in the prevalence of nephrotic syndrome, chronic liver failure, chronic renal disease and sun blockers use between both groups. There were no patients in nursing homes in either group. Subjects on the cases group received an average of 0.6 hours of sun exposure per week compared with 1.46 in the control group (p=0.297). In the cases group, we observed a higher prevalence of falls (23.5% vs 6.7% p=0.039), fractures (17.6% vs 0%, p=0.024), diabetes (17.6% vs 6.7% p=0,158), fatigue (26.7% vs 13.3% p=0.012), weakness (40% vs 33% p=0.010), and use of inducers of cytochrome P450 pathway (29.3% vs 0% p=0.009). Body weight was lower in cases (26.6% with overweight or obesity vs 66.7% p=0.009).

Conclusions: Vitamin D insufficiency may present even in tropical countries such as Costa Rica. It is characterized by higher levels of PTH, a lower body weight, use of inducers of liver enzymatic activity, a higher for falls and fractures, fatigue, weakness and diabetes. Both groups had a low sun exposure.

Key words: vitamina D deficiency, vitamina D, hyperparathyroidism

¹

Recife (Brazil), populations have being found with VD deficiency.^2-3

^4,5American NHANES III results, show an increase of total mortality when the 25(OH) VD is less than 44,5 nmol/L.⁶

^7,8

Costa Rica is a tropical country in Central America, which geographical position is as follows (external points): latitudes (north: 11°13´12´´ and south: 08°02´26´´ longitudes (east: 82°33´48´´ y west: 85°57´57´´.⁹The solar exposure of its habitants is abundant throughout the year. However, this has been decreased considerably in the recent years due to protective measures against various pathologies of the skin.

.¹⁰In Costa Rica, the UVI varies throughout the year, with average of 6, during summer months, in Central Valley (moderated category risk), until 11 and 12 in the rest of the country (high¹⁰category risk)¹¹.

^12-14

¹⁵

^16-18

Costa Rica, clinical characteristics of Hypovitaminosis D patients.

Table 1).

Thumbnail

Table 1

table 2).

Thumbnail

table 2

¹⁹

²⁰The lack of adequate sun exposure is a risk factor to present Hypovitaminosis D. The study identified a trend to low amounts of this hormone, although not statistically significant.

^21-23

²⁴

²⁵In the presence of renal insufficiency; the 1-hydroxylase activity is less, so there is a lower activation of Vitamin D, leading to secondary hyperparathyroidism. In this research, the only statistically significant risk factor was the use of hepatic-enzyme induce drugs.

²⁶

²⁷worsening insulin resistant getting and glycemic control,²⁸more prevalence of autoimmune diseases like diabetes mellitus type 1 and multiple sclerosis. Even some early studies have shown that supplementation before the first year of live is associated to a low risk to developed diabetes mellitus type 1 during childhood.²⁹

Costa Rica. The second limitation relates to the fact that is a descriptive study and is not known whether replacement therapy of Vitamin D may reverse some of the symptoms studied.

Costa Rica, once it is more accessible to determinate. In first place, it can recognize that Hypovitaminosis D occurs in tropical countries, including this one. Second place, to be involved this Hypovitaminosis in multiples diseases, VD correction, being inexpensive, may have implications in preventing falls, fractures, cancer, diabetes improved control and insulin resistance and immunologic diseases, although not features such randomized studies that show dose benefits.

References

References

1. Holick MF, Chen TC. Vitamin D deficiency: a worldwide problem with health consequences. Am J Clin Nutr 2008; 87 (Suppl): 1080S-86S.
2. Binkley N, Novotny R, Krueger D, Kawahara T, Daida YG, Lensmeyer G, Hollis BW, and Drezner MK. Low Vitamin D Status despite Abundant Sun Exposure. J Clin Endocrinol Metab2007; 92: 2130–35.
3. Bandeira ZF, Griz L, Freese E, Castro-Lima D, Thé AC, Trovão-Diniz E, Fontenele T, Salgado C. Vitamin D deficiency and its relationship with bone mineral density among postmenopausal women living in the tropics. Arq Bras Endocrinol Metab. 2010;54(2):227-32.
4. Bikle D. Nonclassic Actions of Vitamin D. J Clin Endocrinol Metab2009; 94: 26–34.
5. Giovanucci E, Lui Y, Hollis BW and Rimm EB. 25-Hydroxivitamin D and Risk of Myocardial Infarction in Men.Arch Intern Med 2008; 168 (11): 1174-80.
6. Michos ED, Melamed ML, Post W, AstorBC. 25-OH Vitamin D Deficiency and the Risk of All Cause Mortality in the General Population:Results from the Third Nationa Health and Nutrition Examination Survey Linked Mortality Data. Circulation. 2007; 116: II_826.
7. Calatayud M, Jódar E, Sánchez R, Guadalix S y Hawkins F. Prevalencia de concentraciones deficientes e insuficientes de vitamina D en una población joven y sana. Endocrinol Nutr2009; 56 (4): 164-9.
8. Steingrimsdottir L,Gunnarsson,O,Indridason OS, Franzson L and Sugurdsson G. Relationship Between Serum Parathyroid Hormone Levels, Vitamin D Sufficiency, and Calcium Intake. JAMA 2005; 294: 2336-41.
9.Instituto Geográfico Nacional de Costa Rica. Aspectos geográficos. http://www.mopt.go.cr/ign/IGN-Aspectos-Geográficos.html. Consultado junio de 2010.

» http://www.mopt.go.cr/ign/IGN-Aspectos-Geográficos.html
10. Instituto Meteorológico Nacional (Costa Rica). ¿Qué es el índice ultravioleta? http://www.imn.ac.cr/educacion/UV/UVMAS2. html,consultado durante el mes de junio del 2010.

» http://www.imn.ac.cr/educacion/UV/UVMAS2. html
11. Instituto Meteorológico Nacional (Costa Rica). Mapa del índice ultravioleta máximo por regiones climáticas del país. http://www.imn.ac.creducacion/UV/INDICEUV.html, consultado en marzo de 2010.

» http://www.imn.ac.cr/educacion/UV/INDICEUV.html
12. Rejnmark L, Vestergaard P, Heickendorff L and Mosekilde L. Plasma 1,25(OH)2D levels decrease in postmenopausal women with hypovitaminosis D. Eur J Endocrinol2008; 158: 571-76.
13. Holick MF. The vitamin D epidemic and its health consequences.Journal of Nutrition 2005; 135: 39S-48S.
14. Bischoff-Ferrari HA, GiovannucciE, Willet WC, Dietrich T & Dawson-Hughes B. Estimation of optimal serum concentrations of 25-hydroxivitamin D for multiple health outcomes. American Journal of Clinical Nutrition 2006; 84: 18-28.
15. Bischoff-Ferrari HA, Giovannucci E, Willett WC, Dietrich T and Dawson-Hughes B. Estimation of optimal serum concentrations of 25-hydroxyvitamin D for multiple health outcomes. Am J Clin Nutr 2006; 84:18 –28.
16. Chapuy MC, Preziosi P, Maamer M, Arnaud S, Galan P, Hercberg S et al. Prevalence of Vitamin D insufficiency in an adult normal population. Osteoporosis Int1997; 7: 439-43.
17. Malabanan A, Veronikis IE, Holick MF. Redefining vitamin D insufficiency. Lancet 1998; 351: 805-6.
18. Dawson-Hughes B, Heaney RP, Holick MF, Lips P, Meunier PJ, Vieth R. Estimates of optimal vitamin D status. Osteoporosis Int2005; 16: 713-16.
19. Binkley N, Ramamurthy R, Krueger D. Low vitamin D status: definition, prevalence, consequences and correction. Endocrinol Metab ClinN Am. 2010; 39: 287-301.
20. Zargar AH, Ahmad S, Masoodi SR, Wani AI, Bashir MI, Laway BA, Shaz ZA. Vitamin D Status in Apparently Healthy Adults in KashmirValley of Indian Subcontinent. Postgrad Med J. 2007;83: 713-16.
21. Rajakumar K, Greenspan SL, Thomas SB, and Holick MF. Solar Ultraviolet Radiation and Vitamin D. An historical perspective.Am J Public Health; 2007; 97: 1746-54.
22. Carbonea LD, Rosenbergb EW, Tolleyc EA, Holick MF, Hughesb TA, Watskye MA, Barrowb KD, Chend TC, Wilkinb NK, Bhattacharyab SK, Dowdyf JC, Sayreb RM, Weber KT. 25-Hydroxyvitamin D, cholesterol, and ultraviolet irradiation. Metab Clin Exper; 2008; 57: 741–748.
23. Chel VGM, Ooms ME, Popp-Snijders C, Pavel S, Schothorst AA, Meulemans CCE and Lips P. Ultraviolet Irradiation Corrects Vitamin D Deficiency and Suppresses Secondary Hyperparathyroidism in the Elderly. J Bone Miner Res 1998;13:1238–1242.
24. Wang TJ, Zheng F, Richard B, Kestenbaum B, van Meurs JB, Berry D et al. Common genetic determinants of vitamin D insufficiency: a genome wide association. Lancet. 2010. Publicado en línea 10 de junio 2010. DOI:10.1016/S0140-6736(10)60588-0.
25. Lee JH, O’Keefe JH, Bell D, Hensrud DD, Holick MF. Vitamin D Deficiency. J Am Coll Cardiol. 2008; 52:1949-56.
26. Binkley N, Ramamurthy R, Krueger D. Low vitamin D status: definition, prevalence, consequences and correction. Endocrinol Metab Clin N Am. 2010;39:287-301.
27. Krishnan AV, Trump DL, Johnson CS, Feldman D. The role of vitamin D in cancer prevention and treatment. Endocrinol Metab Clin N Am. 2010;39:401-418.
28. Takiishi T, Gysemans C, Bouillon R, Mathieu C. Vitamin D and diabetes. Endocrinol Metab Clin N Am. 2010;39:419-446.
29. The EURODIAB Substudy 2 Study Group. Vitamin D supplementation in early childhood and risk for type 1 (insulin dependent) diabetes mellitus. Diabetologia. 1999;42:51-4.

en_bart4

Receiving date: August 9th, 2011 Accepted date: May 28th, 2012

References

1. Holick MF, Chen TC. Vitamin D deficiency: a worldwide problem with health consequences. Am J Clin Nutr 2008; 87 (Suppl): 1080S-86S.
2. Binkley N, Novotny R, Krueger D, Kawahara T, Daida YG, Lensmeyer G, Hollis BW, and Drezner MK. Low Vitamin D Status despite Abundant Sun Exposure. J Clin Endocrinol Metab2007; 92: 2130–35.
3. Bandeira ZF, Griz L, Freese E, Castro-Lima D, Thé AC, Trovão-Diniz E, Fontenele T, Salgado C. Vitamin D deficiency and its relationship with bone mineral density among postmenopausal women living in the tropics. Arq Bras Endocrinol Metab. 2010;54(2):227-32.
4. Bikle D. Nonclassic Actions of Vitamin D. J Clin Endocrinol Metab2009; 94: 26–34.
5. Giovanucci E, Lui Y, Hollis BW and Rimm EB. 25-Hydroxivitamin D and Risk of Myocardial Infarction in Men.Arch Intern Med 2008; 168 (11): 1174-80.
6. Michos ED, Melamed ML, Post W, AstorBC. 25-OH Vitamin D Deficiency and the Risk of All Cause Mortality in the General Population:Results from the Third Nationa Health and Nutrition Examination Survey Linked Mortality Data. Circulation. 2007; 116: II_826.
7. Calatayud M, Jódar E, Sánchez R, Guadalix S y Hawkins F. Prevalencia de concentraciones deficientes e insuficientes de vitamina D en una población joven y sana. Endocrinol Nutr2009; 56 (4): 164-9.
8. Steingrimsdottir L,Gunnarsson,O,Indridason OS, Franzson L and Sugurdsson G. Relationship Between Serum Parathyroid Hormone Levels, Vitamin D Sufficiency, and Calcium Intake. JAMA 2005; 294: 2336-41.
9.Instituto Geográfico Nacional de Costa Rica. Aspectos geográficos. http://www.mopt.go.cr/ign/IGN-Aspectos-Geográficos.html. Consultado junio de 2010.

» http://www.mopt.go.cr/ign/IGN-Aspectos-Geográficos.html
10. Instituto Meteorológico Nacional (Costa Rica). ¿Qué es el índice ultravioleta? http://www.imn.ac.cr/educacion/UV/UVMAS2. html,consultado durante el mes de junio del 2010.

» http://www.imn.ac.cr/educacion/UV/UVMAS2. html
11. Instituto Meteorológico Nacional (Costa Rica). Mapa del índice ultravioleta máximo por regiones climáticas del país. http://www.imn.ac.creducacion/UV/INDICEUV.html, consultado en marzo de 2010.

» http://www.imn.ac.cr/educacion/UV/INDICEUV.html
12. Rejnmark L, Vestergaard P, Heickendorff L and Mosekilde L. Plasma 1,25(OH)2D levels decrease in postmenopausal women with hypovitaminosis D. Eur J Endocrinol2008; 158: 571-76.
13. Holick MF. The vitamin D epidemic and its health consequences.Journal of Nutrition 2005; 135: 39S-48S.
14. Bischoff-Ferrari HA, GiovannucciE, Willet WC, Dietrich T & Dawson-Hughes B. Estimation of optimal serum concentrations of 25-hydroxivitamin D for multiple health outcomes. American Journal of Clinical Nutrition 2006; 84: 18-28.
15. Bischoff-Ferrari HA, Giovannucci E, Willett WC, Dietrich T and Dawson-Hughes B. Estimation of optimal serum concentrations of 25-hydroxyvitamin D for multiple health outcomes. Am J Clin Nutr 2006; 84:18 –28.
16. Chapuy MC, Preziosi P, Maamer M, Arnaud S, Galan P, Hercberg S et al. Prevalence of Vitamin D insufficiency in an adult normal population. Osteoporosis Int1997; 7: 439-43.
17. Malabanan A, Veronikis IE, Holick MF. Redefining vitamin D insufficiency. Lancet 1998; 351: 805-6.
18. Dawson-Hughes B, Heaney RP, Holick MF, Lips P, Meunier PJ, Vieth R. Estimates of optimal vitamin D status. Osteoporosis Int2005; 16: 713-16.
19. Binkley N, Ramamurthy R, Krueger D. Low vitamin D status: definition, prevalence, consequences and correction. Endocrinol Metab ClinN Am. 2010; 39: 287-301.
20. Zargar AH, Ahmad S, Masoodi SR, Wani AI, Bashir MI, Laway BA, Shaz ZA. Vitamin D Status in Apparently Healthy Adults in KashmirValley of Indian Subcontinent. Postgrad Med J. 2007;83: 713-16.
21. Rajakumar K, Greenspan SL, Thomas SB, and Holick MF. Solar Ultraviolet Radiation and Vitamin D. An historical perspective.Am J Public Health; 2007; 97: 1746-54.
22. Carbonea LD, Rosenbergb EW, Tolleyc EA, Holick MF, Hughesb TA, Watskye MA, Barrowb KD, Chend TC, Wilkinb NK, Bhattacharyab SK, Dowdyf JC, Sayreb RM, Weber KT. 25-Hydroxyvitamin D, cholesterol, and ultraviolet irradiation. Metab Clin Exper; 2008; 57: 741–748.
23. Chel VGM, Ooms ME, Popp-Snijders C, Pavel S, Schothorst AA, Meulemans CCE and Lips P. Ultraviolet Irradiation Corrects Vitamin D Deficiency and Suppresses Secondary Hyperparathyroidism in the Elderly. J Bone Miner Res 1998;13:1238–1242.
24. Wang TJ, Zheng F, Richard B, Kestenbaum B, van Meurs JB, Berry D et al. Common genetic determinants of vitamin D insufficiency: a genome wide association. Lancet. 2010. Publicado en línea 10 de junio 2010. DOI:10.1016/S0140-6736(10)60588-0.
25. Lee JH, O’Keefe JH, Bell D, Hensrud DD, Holick MF. Vitamin D Deficiency. J Am Coll Cardiol. 2008; 52:1949-56.
26. Binkley N, Ramamurthy R, Krueger D. Low vitamin D status: definition, prevalence, consequences and correction. Endocrinol Metab Clin N Am. 2010;39:287-301.
27. Krishnan AV, Trump DL, Johnson CS, Feldman D. The role of vitamin D in cancer prevention and treatment. Endocrinol Metab Clin N Am. 2010;39:401-418.
28. Takiishi T, Gysemans C, Bouillon R, Mathieu C. Vitamin D and diabetes. Endocrinol Metab Clin N Am. 2010;39:419-446.
29. The EURODIAB Substudy 2 Study Group. Vitamin D supplementation in early childhood and risk for type 1 (insulin dependent) diabetes mellitus. Diabetologia. 1999;42:51-4.

en_bart4

Receiving date: August 9th, 2011 Accepted date: May 28th, 2012

Publication Dates

Publication in this collection
07 May 2013
Date of issue
Sept 2012

History

Received
08 Sept 2011
Accepted
28 May 2012

[1] 1. Holick MF, Chen TC. Vitamin D deficiency: a worldwide problem with health consequences. Am J Clin Nutr 2008; 87 (Suppl): 1080S-86S.

[2] 2. Binkley N, Novotny R, Krueger D, Kawahara T, Daida YG, Lensmeyer G, Hollis BW, and Drezner MK. Low Vitamin D Status despite Abundant Sun Exposure. J Clin Endocrinol Metab2007; 92: 2130–35.

[3] 3. Bandeira ZF, Griz L, Freese E, Castro-Lima D, Thé AC, Trovão-Diniz E, Fontenele T, Salgado C. Vitamin D deficiency and its relationship with bone mineral density among postmenopausal women living in the tropics. Arq Bras Endocrinol Metab. 2010;54(2):227-32.

[4] 4. Bikle D. Nonclassic Actions of Vitamin D. J Clin Endocrinol Metab2009; 94: 26–34.

[5] 5. Giovanucci E, Lui Y, Hollis BW and Rimm EB. 25-Hydroxivitamin D and Risk of Myocardial Infarction in Men.Arch Intern Med 2008; 168 (11): 1174-80.

[6] 6. Michos ED, Melamed ML, Post W, AstorBC. 25-OH Vitamin D Deficiency and the Risk of All Cause Mortality in the General Population:Results from the Third Nationa Health and Nutrition Examination Survey Linked Mortality Data. Circulation. 2007; 116: II_826.

[7] 7. Calatayud M, Jódar E, Sánchez R, Guadalix S y Hawkins F. Prevalencia de concentraciones deficientes e insuficientes de vitamina D en una población joven y sana. Endocrinol Nutr2009; 56 (4): 164-9.

[8] 8. Steingrimsdottir L,Gunnarsson,O,Indridason OS, Franzson L and Sugurdsson G. Relationship Between Serum Parathyroid Hormone Levels, Vitamin D Sufficiency, and Calcium Intake. JAMA 2005; 294: 2336-41.

[9] 9.Instituto Geográfico Nacional de Costa Rica. Aspectos geográficos. http://www.mopt.go.cr/ign/IGN-Aspectos-Geográficos.html. Consultado junio de 2010.

» http://www.mopt.go.cr/ign/IGN-Aspectos-Geográficos.html

[10] 10. Instituto Meteorológico Nacional (Costa Rica). ¿Qué es el índice ultravioleta? http://www.imn.ac.cr/educacion/UV/UVMAS2. html,consultado durante el mes de junio del 2010.

» http://www.imn.ac.cr/educacion/UV/UVMAS2. html

[11] 11. Instituto Meteorológico Nacional (Costa Rica). Mapa del índice ultravioleta máximo por regiones climáticas del país. http://www.imn.ac.creducacion/UV/INDICEUV.html, consultado en marzo de 2010.

» http://www.imn.ac.cr/educacion/UV/INDICEUV.html

[12] 12. Rejnmark L, Vestergaard P, Heickendorff L and Mosekilde L. Plasma 1,25(OH)2D levels decrease in postmenopausal women with hypovitaminosis D. Eur J Endocrinol2008; 158: 571-76.

[13] 13. Holick MF. The vitamin D epidemic and its health consequences.Journal of Nutrition 2005; 135: 39S-48S.

[14] 14. Bischoff-Ferrari HA, GiovannucciE, Willet WC, Dietrich T & Dawson-Hughes B. Estimation of optimal serum concentrations of 25-hydroxivitamin D for multiple health outcomes. American Journal of Clinical Nutrition 2006; 84: 18-28.

[15] 15. Bischoff-Ferrari HA, Giovannucci E, Willett WC, Dietrich T and Dawson-Hughes B. Estimation of optimal serum concentrations of 25-hydroxyvitamin D for multiple health outcomes. Am J Clin Nutr 2006; 84:18 –28.

[16] 16. Chapuy MC, Preziosi P, Maamer M, Arnaud S, Galan P, Hercberg S et al. Prevalence of Vitamin D insufficiency in an adult normal population. Osteoporosis Int1997; 7: 439-43.

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<b>Hypovitaminosis D in Costa Rica</b>: <b>initial report on a case control study</b>

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