Should You Supplement With Vitamin D In The Winter?

Feb 27, 2023 | General, Nutrition | 0 comments

A woman walking her dog in a snowy forest looking towards the sunlight.

Public Health England and the National Institute for Health and Care Excellence (NICE) recommend that everyone in the UK should supplement with vitamin D through the winter. A daily intake of at least 400 International Units (IU) is advised to prevent deficiencies. Vitamin D deficiencies are common in winter and this can impact bone health, immune system function, and affect the rate of relapse of some illnesses. In this article, we will explain why this is the case, with reference to the scientific evidence. [1]

Vitamin D And Sunlight

Vitamin D is best known for it’s association with sunlight, and there is increasing awareness that due to low levels of sunlight in the winter, supplementation is often required to prevent vitamin D deficiencies. To understand this connection, it must be noted that the sun emits three distinct wavelengths of ultraviolet light; ultraviolet-A (UVA), ultraviolet-B (UVB), and ultraviolet C (UVC). Of the three, it is UVB light that plays a key role in the vitamin D production process.

UVB light penetrates the skin, and is the type of UV light responsible for immediate sunburning on very hot, sunny days. Crucially however, it is UVB light which also powers the synthesis of vitamin D3 in our bodies. Our epidermis contains a photosensitive cholesterol-like compound called 7-DHC, which reacts with ultraviolet B rays from the sun to produce pro-vitamin D3. [2]

Due to this process, getting out in the sunshine is a great way for us to get our vitamin D intake. A 2010 study suggested that “to prevent vitamin D deficiency, one should spend 15 to 20 minutes daily in the sunshine with 40% of the skin surface exposed”. It is impossible to ‘overdose’ on vitamin D from sunlight exposure, as our bodies only produce as much as we need, and this process automatically stops if we have reached our natural capacity. [3] [4]

A woman in a winter hat smiling as she looks at a setting sun
Vitamin D3 Is Synthesised Naturally By The Body When Certain Wavelengths Of Ultraviolet B Light Hit The Skin

What about the other two forms of UV light? UVC radiation is a shorter wavelength, and is mostly blocked by the Earth’s atmosphere. UVA rays are a longer wavelength, and so pass through the epidermis and penetrate deeper in to the skin, and therefore do not trigger the conversion of 7-DHC. Many forms of artificial UV lighting tend to emit UVA, which make them unsuitable for as a subsitute for sunlight as far as vitamin D production is concerned.

With vitamin D being provided for free by sunlight, it would perhaps be tempting to think we must all be getting all the vitamin D we need. In fact, this is very much not the case, and it is estimated that around half of the population of the world has either low levels of vitamin D or a clinical deficiency. This shocking situation is caused by numerous factors, and is exacerbated during winter time. In the next section, we will look at why this is, and what the potential health implications are. [5]

Do Vitamin D Levels Decrease In Winter?

Numerous studies have demonstrated reliably that in many countries, the vitamin D levels of the population decrease in the winter. One of the major causes of vitamin D deficiencies is of course the seasonal variations in daylight. When daylight hours are reduced, so does the potential for sunlight exposure to our skin, and so vitamin D levels decline. In many locations, winter sunlight is often obscured for weeks due to rainy or overcast conditions, and on some latitudes even a sunny day in winter only provides weak sunlight. Lower temperatures also lead to (most of) us wrapping up warm in trousers and long sleeves, which further reduces the amount of UVB light reaching the skin.

A photo of the sun through the fog on a winters day.
The Weak Sunlight And Short Days Of Winter Reduce The Amount Of Vitamin D We Can Synthesise From UV Light

Due to a combination of all these factors, even being outdoors regularly in the winter may not be enough to keep vitamin D levels sufficiently high. A study analysing the serum vitamin D levels of footballers in Russia revealed that even though they spent large amounts of time outdoors with skin exposed, their vitamin D levels still dropped significantly in the winter. Perhaps unsurprisingly, the Russian winter sun didn’t provide enough UVB to trigger sufficient Vitamin D synthesis. The researchers of this study found that a daily vitamin D supplement of 5000 IU was able to address the seasonal deficiency, and bring levels back in to normal ranges. [6]

The seasonal dip in serum vitamin D levels has also been noted in Poland. Research has revealed that the majority of the Polish population is vitamin D deficient, with the highest rates of deficiency occuring during winter and spring. Preventive strategies such as supplementation have been recommended to improve the vitamin D status in the population. [7]

The seasonal decline in vitamin D levels can have tangible effects to our health. As we discussed in our article on it’s various biological functions, vitamin D plays a key role in the regulation of bone density, and supports our immune system. The seasonal decline in Vitamin D levels has been linked to many health implications, including;

Increased intensity and duration of upper respiratory tract infections. Seasonal decreases of Vitamin D serum levels have been linked to “significantly longer and more severe upper respiratory tract infection episodes”. A 2018 study found that daily Vitamin D3 supplementation of 5000 IU may be effective in reducing the symptoms of upper respiratory tract infections during winter training in vitamin D-insufficient taekwondo athletes. [8] [9]

Seasonal changes in bone density and bone loss in healthy adults. Bone metabolism follows a seasonal pattern with high bone turnover and bone loss during the winter. Dietary and supplemental vitamin D intake through the winter has been shown to be able to help reduce the extent of this reduction in bone density. [10]

Relapses in patients with Multiple Sclerosis (MS). Low ultraviolet-B radiation and the subsequent decrease in vitamin D levels is a known risk factor for MS and is associated with an increase in MS disease activity. Vitamin D supplementation has been shown to be able to modulate seasonal MS activity and reduce the relapse rate in late winter and early spring. Data indicates a beneficial effect of supplementing MS patients with vitamin D during winter. [11]

These studies reveal that the seasonal decline in vitamin D levels that occurs during winter and early spring has an impact on our overall health and wellbeing. Without sunlight, individuals must get their vitamin D through other routes. Unfortunately, vitamin D does not occur naturally in many foods, with a few notable exceptions. Furthermore, plant food sources of vitamin D are often in the form of vitamin D2, rather than vitamin D3. It is known that whilst there is some overlap in function, vitamin D2 and D3 play slightly different roles in the body. [12]

Could supplementation be the key to keeping our winter vitamin D levels high?

Vitamin D Winter Supplementation

Supplementation can play a key role in fighting off vitamin D deficiencies, and is perhaps even more important for those on a vegetarian or vegan diet, as so many of the dietary sources of vitamin D are off limits within such diets. Vitamin D is fairly elusive in food sources, especially if one does not eat oily fish. Fortunately, vegan friendly vitamin D supplements do exist and can help to improve serum vitamin D levels, especially in the winter. Winter supplementation of vitamin D is recommended by the UK Department of Health for vulnerable groups, including the elderly. [13] [14]

A woman in a snowy forest looking towards the sunlight.
Vitamin D Supplementation Could Improve Many Health Outcomes During Periods Of Low UV Light Exposure

Pregnant and breast feeding mothers are also ecommended to supplement with vitamin D when sunshine exposure is restricted. Some doctors suggest that in order to tackle vitamin D deficiencies, mothers should begin supplemental vitamin D during pregnancy, as vitamin D deficiencies can often present during the first year of a child’s life. [15]

Many modern studies use 5000 IU when testing the effects of supplementation, but the European Food Commission and the NHS both currently recommend not exceeding a dietary vitamin D intake of 4000 IU per day. We sell our own Keymer Health vegetarian friendly daily vitamin D supplement, and our own formula provides a dosage of 3000 IU, with added vitamin K2.

When we get vitamin D from sunlight, our bodies naturally do not produce more than we need. When consuming vitamin D through diet or supplements however, more does not always equal better! This is because vitamin D is a fat soluble vitamin, and therefore can be stored and accumulate in fatty tissues over time. Excess levels of vitamin D can cause unpleasant effects such as softening bones and increasing the likelihood of kidney stone formation.

Thankfully, vitamin D toxicity is rare, and usually only presents in individuals that have been taking vitamin D supplements far above the recommended dosage level for several months. For one such example, we can look the case study of a 56 year old woman who became ill after consuming a daily mean of 130,000 IU of supplemental vitamin D over a 20 month period. That’s over 32 times the current daily recommended limit! [16] [17]

Vitamin D deficiency is much more common than cases of high-dose toxicity. Let’s now discuss how widespread the problem of vitamin D deficiency is around the world.

Vitamin D As A Common Global Deficiency

Whilst vitamin D levels do decline in winter months for much of the world, there is growing evidence that supplementation can play a role during the rest of the year too. For various reasons, simply getting all our vitamin D from the sunlight might not be as simple as it sounds.

A public square in the city of Santiago de Chile, with exotic plants and palm trees.
Vitamin D Deficiency Is Common Even In Sunny Locations Such As Santiago de Chile

To further illustrate how pervasive vitamin D deficiency is, we can also look at the results of a study of inhabitants aged 60 to 98 years old in Santiago de Chile. Santiago de Chile is a city on the latitude of 33° South of the equator, and receives an average of around 2750 sunshine hours per year. Despite this abundant sunshine, 83% of females and 55.3% of males in the study displayed vitamin D serum levels below 20 ng/mL – the cutoff point for clinical deficiency. [18]

● Prevelance of vitamin D deficiency is more than 50% during winter in many European countries. Mean vitamin D intake in most European countries is less than 5 μg per day (200 IU per day). [19]

● Roughly 90% of the infants in Iran, India and Turkey are living with at least some level of vitamin D deficiency. [20]

● The prevalence of Vitamin D deficiency is high in all age groups in India at a rate of  70%-100%, despite the fact that most of the Indian population live in areas with adequate sunlight throughout the year. [21] [22]

● Spanish women have high rates of vitamin D deficiency despite the country’s Mediterranean climate. [23]

● Vitamin D deficiency is endemic amongst Middle Eastern athletes and Qatari footballers, and the majority of Northern Indian athletes show some level of vitamin D deficiency. [24] [25]

● Vitamin D deficiency is common among African populations, with the highest prevalences reported in northern African countries. Elderly populations in South Africa also show high rates of vitamin D deficiency. [26] [27]

● A 2020 analysis found that as a continent, Africa exhibits the highest percentage of vitamin D deficiency per person. [28]

The data is overwhelming that vitamin D deficiencies can affect nearly anyone, at any time, and at any place. Clearly, it is not only cold winters that are responsible for this, and there are many other factors we need to consider. In the next section we will discuss a few of the most common reasons for vitamin D deficiency, and explain why even warm and sunny countries often have higher rates of vitamin D deficiency than colder locations.

Common Reasons For Vitamin D Deficiency

Vitamin D deficiency is endemic across all races, climates, continents, and skin tones. Whilst all of these factors do have some impact in the full extent of the deficiency, the underlying causes can be very different. In the modern digitised world, it is common for many people to now increasingly work from their bedrooms, or in poorly lit offices. The lack of natural light provided by modes of work mean that many people do not get sufficient exposure to sunlight. Working night shifts also greatly reduces the opportunity to derive natural vitamin D from sunlight.

A man sitting in a dark room at his computer
Working From Home, Night Shifts, And Office Work Can All Impact Vitamin D Intake From The Sun

Elderly populations in all countries are among the most likely to be vitamin D deficient. This is likely due to lifestyle factors such as spending an increased amount of time indoors.

People with pale or sensitive skin types often avoid sun exposure in the summer, as even short periods of strong UV exposure could lead to painful and damaging sunburn. The UVB rays required for natural vitamin D3 synthesis are also responsible for causing sunburn. The good news is that those with paler skin tones are able to produce vitamin D efficiently and quickly from sunlight exposure. As those of us with pale skin know however, staying outside too long on a summers day can lead to painful burns, and it is now well known that repeated sunburning over extended periods can lead to to skin damage and skin cancer.

On the other side of the coin, individuals with darker skin and higher levels of melanin require longer periods of sun exposure to produce vitamin D. As melanin levels in the skin increase, so does the amount of protection offered against the negative and damaging effects of UV radiation, but it also means that less UVB light makes it through to power the synthesis of vitamin D in the body. This effect is magnified for individuals with high melanin content living on latitudes with very little winter sunlight. [29] [30]

A photo of young Indian men playing football on a summers day.
Vitamin D Deficiency Is Common In Groups That May Seem Unlikey Such As Athletes From India and Qatar

Regardless of one’s skin tone, clothing also plays a role our vitamin D production capacity. Garments and clothing that cover the skin such as long sleeved tops, trousers, or certain religious coverings can also lower the amount UVB light reaching the skin, which in turn leads to a reduction in vitamin D synthesis.

In some locations, individuals are subject to many of these conditions simultaneously. In extremely hot locations including parts of Africa, the Arabian peninsula, and the Indian Subcontinent, people may stay indoors to avoid the hottest part of the day. As the native populations of these regions also tend to have reasonably high melanin content in the skin, this can lead to vitamin D deficiencies emerging even in the middle of hot summers with abundant sunshine. [31]

Finally, it is worth mentioning that diet plays a factor too. Many of the foods rich in vitamin D are oily fish, and cod liver is one of the highest natural sources of vitamin D. In locations where fish, eels, or cod liver constitute a large part of the diet, this greatly reduces the dependency on sunlight exposure to keep vitamin D levels in normal ranges. In inland areas that do not have access to fresh seafood, supplmentation becomes a much more important factor.

Conclusion

Whatever race or skin type you have, vitamin D deficiencies are common and widespread. Increased education and cultural awareness of vitamin D supplementation could play a key part in addressing this worldwide hypovitaminosis. The importance of public education on the matter can be revealed by the positive results obtained by countries with very little in the way of winter sunlight.

A woman smiling in a snowy winter scene.
Vitamin D Supplementation Strategies Can Reduce Public Health Burden

Many high latitude European countries such as Norway, Iceland, and Finland, actually have less vitamin D deficiency on average than the lower latitude countries of Ireland, Netherlands, Germany, and the United Kingdom. These results remain even when statistically accounting for ethnicity and skin tones. It is likely that better public awareness of the seasonal fluctuations of vitamin D levels, dietary awareness, plus a culture of supplementation and food fortification are all factors that contribute to this. [32]

Winter vitamin D levels are lower than during the rest of the year, and a supplementation programe can help reduce the risk of many seasonal ailments. Given the widespread and endemic nature of vitamin D deficiency in in many warm climates, many of us can benefit from supplementing during the rest of the year too.


[References]

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Written by Keymer Health

27th February, 2023

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