Olive Oil Vitamin D

Olive Oil Vitamin D

Vitamin D3 5000 iu Capsules with Olive Oil, Vitamin D Supplements for Immune System, Bones & Muscle Function

Naturplus Vitamin D3 5000IU in Olive Oil, high potency softgel capsules.
Vitamin D is essential for several functions within our bodies. We get some from our diet, but much is synthesised by our bodies from exposure of our skin to direct sunlight.
Many of us are low in Vitamin D, thought to be as many as 1 in 5, particularly during the shorter days of autumn and winter when levels of sunshine are reduced.
Generally between October and early March UK sunlight does not contain enough of the ultraviolet B (UVB) rays – the ones we need to make Vitamin D.
Sitting indoors by a sunny window doesn't help either, at any time of year, as the sunshine component we need does not pass through glass.

Sizes available: 180, 365 and 1000.

WHY BUY YOUR VITAMIN D3 FROM NATURPLUS?

QUALITY COVERAGE - At Naturplus we aim to provide you with high quality supplements at fair prices – to this end we supply our Vitamin D3 5000IU in 180, 365 and 1000 softgel resealable bags, giving you the option of up to a full year's supply, at the 1 capsule per day serving.

SEALED & DELIVERED - Naturplus food supplements are delivered to your door or place of collection in resealable labelled bags for freshness and protection of the capsules or tablets.

NUTRITIONAL INFORMATION
One softgel capsules contains:
Vitamin D3 (cholecalciferol) - 125μg     *NRV% - 2500%
*Nutrient Reference Value

Directions: For adults. Take one softgel daily, or as directed by a healthcare professional.

Ingredients: Olive Oil, Vitamin D3 5000iu (cholecalciferol). Capsule: Gelatin (from beef), glycerol, water.

Please remember: Whilst every effort is made to ensure that the information on our product pages is up to date, please make sure to always read the labels, warnings, and directions provided on or with the product before using or consuming it.

Olive Oil Vitamin D

Source: https://www.naturplus.uk/products/np317

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Vitamin D Serum

Vitamin D Serum

Mayo Clin Proc. 2010 Aug; 85(8): 752–758.

Vitamin D Deficiency in Adults: When to Test and How to Treat

This article has been cited by other articles in PMC.

Abstract

Recent evidence for the nonskeletal effects of vitamin D, coupled with recognition that vitamin D deficiency is common, has revived interest in this hormone. Vitamin D is produced by skin exposed to ultraviolet B radiation or obtained from dietary sources, including supplements. Persons commonly at risk for vitamin D deficiency include those with inadequate sun exposure, limited oral intake, or impaired intestinal absorption. Vitamin D adequacy is best determined by measurement of the 25-hydroxyvitamin D concentration in the blood. Average daily vitamin D intake in the population at large and current dietary reference intake values are often inadequate to maintain optimal vitamin D levels. Clinicians may recommend supplementation but be unsure how to choose the optimal dose and type of vitamin D and how to use testing to monitor therapy. This review outlines strategies to prevent, diagnose, and treat vitamin D deficiency in adults.

AI = adequate intake; CKD = chronic kidney disease; D2 = vitamin D₂; D3 = vitamin D₃; 1,25(OH)2D = 1,25-dihydroxyvitamin D; HPT = hyperparathyroidism; 25(OH)D = 25-hydroxyvitamin D; PTH = parathyroid hormone; UVB = ultraviolet B

Vitamin D has been appreciated for its role in calcium homeostasis and bone health since its identification in 1921.¹ Even so, 25% to 50% or more of patients commonly encountered in clinical practice are deficient in vitamin D. Recent advances in biochemical assessment, therapeutic goals for vitamin D nutrition for optimal bone health, and the association of vitamin D deficiency with nonskeletal disease have revived interest in this hormone.

Vitamin D consists of 2 bioequivalent forms. Vitamin D₂ (D₂), also known as ergocalciferol, is obtained from dietary vegetable sources and oral supplements. Vitamin D₃ (D₃), also known as cholecalciferol, is obtained primarily from skin exposure to ultraviolet B (UVB) radiation in sunlight, ingestion of food sources such as oily fish and variably fortified foods (milk, juices, margarines, yogurts, cereals, and soy), and oral supplements. Aside from rich sources such as oily fish, the vitamin D content of most foods is between 50 and 200 IU per serving. This value varies greatly by region of the world because fortification markedly improves the availability of vitamin D through diet. Both D₂ and D₃ are biologically inert. Once absorbed from the intestine, they are metabolized in the liver to 25-hydroxyvitamin D [25(OH)D], composed of 25(OH)D₂ and 25(OH)D₃; 25(OH)D (also called calcidiol) is subsequently converted to 1,25-dihydroxyvitamin D [1,25(OH)₂D], also known as calcitriol, in the kidney and select other tissues by the action of the 1α-hydroxylase enzyme. The predominant effects of vitamin D are exerted through the endocrine and autocrine actions of calcitriol via activation of the vitamin D receptor in cells.

TESTING AND INTERPRETING VITAMIN D STATUS

How Prevalent Is Vitamin D Deficiency And Who Is At Risk?

Worldwide, naturally occurring dietary sources of vitamin D are limited, and food fortification is optional, inconsistent, inadequate, or nonexistent. Therefore, for most people, vitamin D is primarily obtained by cutaneous production from sun exposure. However, many variables influence the amount of UVB from sunlight that reaches the skin and its effectiveness. These include time of day, season, latitude, altitude, clothing, sunscreen use, pigmentation, and age. In Minnesota in 2008, less than half of days provided enough solar UVB radiation at noon to effect cutaneous vitamin D production.² Even those who normally reside in sunny climates are commonly found to be deficient in vitamin D, probably due to cultural habits and/or dress.³ Even if regularly exposed to sunlight, elderly people produce 75% less cutaneous D₃ than young adults.⁴ Further barriers to cutaneous vitamin D production are ongoing public health campaigns promoting sunscreen use, as advocated by the American Academy of Dermatology (http://www.aad.org/forms/policies/ps.aspx, accessed December 24, 2009). Unfortunately, commonly recommended daily intakes of vitamin D are known to be insufficient if sunlight exposure is limited.⁵

Vitamin D deficiency is more common than previously thought. The Centers for Disease Control and Prevention has reported that the percentage of adults achieving vitamin D sufficiency as defined by 25(OH)D of at least 30 ng/mL (to convert to nmol/L, multiply by 2.496) has declined from about 60% in 1988-1994 to approximately 30% in 2001-2004 in whites and from about 10% to approximately 5% in African Americans during this same time. Furthermore, more people have been found to be severely deficient in vitamin D [25(OH)D <10 ng/mL].⁶ Even when using a conservative definition of vitamin D deficiency, many patients routinely encountered in clinical practice will be deficient in vitamin D, as shown in Table 1.

TABLE 1.

Prevalence of Vitamin D Deficiency in Commonly Encountered Clinical Patient Populations

Who Should Be Tested For Vitamin D Deficiency?

Although vitamin D deficiency is prevalent, measurement of serum 25(OH)D levels is expensive, and universal screening is not supported. However, vitamin D testing may benefit those at risk for severe deficiency (Table 2) or those with laboratory or radiographic findings commonly associated with vitamin D deficiency (Table 3). In these patients, knowledge of the 25(OH)D blood level provides an accurate assessment of vitamin D body stores, helps identify the need for vitamin D therapy, and may help to determine an effective dose. Alternatively, empiric vitamin D supplementation without testing can be justified for patients who have no overt risk factors or evidence of deficiency but are thought to have inadequate sun exposure or dietary intake.

TABLE 2.

Clinical Risk Factors for Vitamin D Deficiency

TABLE 3.

Laboratory and Radiographic Findings That suggest Possible Vitamin D Deficiency

Vitamin D deficiency can contribute to bone loss from decreased vitamin D–mediated intestinal calcium absorption and resultant secondary hyperparathyroidism (HPT). Vitamin D supplementation can improve muscle strength and reduce fall frequency by approximately 50%.⁷ Thus, patients who have low bone mineral density or a prior low-impact (fragility) skeletal fracture and those at risk of falling should be evaluated for vitamin D deficiency to reduce the risk of all types of skeletal fractures.^8,9

Patients with chronic kidney disease (CKD) have decreased conversion of 25(OH)D to 1,25(OH)₂D as a result of impaired renal 1-α hydroxylase activity. This contributes to secondary HPT and metabolic bone disease. Superimposed nutritional deficiency may aggravate secondary HPT both directly (as a result of low vitamin D levels) and indirectly (as a result of impaired vitamin D–mediated intestinal calcium absorption). Patients with stage I to III CKD should be tested and supplemented with vitamin D as needed to achieve optimal levels of 25(OH)D in addition to modifying calcium and phosphate intake. Emerging evidence is challenging our understanding of bone and vascular health in stage IV to V CKD, such that vitamin D, calcitriol, or vitamin D analogs should be used according to current CKD guidelines and under the guidance of a nephrologist.

It has been suggested that clinicians should routinely test for hypovitaminosis D in patients with musculoskeletal symptoms, such as bone pain, myalgias, and generalized weakness, because these symptoms are often associated with hypovitaminosis D and might be misdiagnosed as fibromyalgia, chronic fatigue, age-related weakness, or even depression.¹⁰ Some studies and numerous anecdotal observations report vitamin D deficiency in 80% to 90% of children and adults with pain, myalgias, and weakness.¹¹ However, few high-quality interventional studies support a causal relationship between vitamin D deficiency and pain. Furthermore, vitamin D status can be a surrogate marker of poor nutritional status such that the high prevalence of vitamin D deficiency in these populations may reflect suboptimal nutrition and lack of outdoor activity associated with chronic illness. Indeed, a recent randomized, blinded, placebo-controlled trial showed no benefit of vitamin D supplementation for such symptoms.¹² The role of vitamin D testing in pregnant or lactating women may be refined by data from ongoing interventional trials.

Which Test Best Measures Vitamin D Status?

Ingested and cutaneously produced vitamin D is rapidly converted to 25(OH)D, but in serum only a fraction of 25(OH)D is converted to its active metabolite 1,25(OH)₂D. Thus, measurement of the total 25(OH)D level is the best test to assess body stores of vitamin D. The total 25(OH)D level allows for the diagnosis and monitoring of vitamin D deficiency, whereas quantification of 25(OH)D₂ and 25(OH)D₃ fractions may facilitate treatment monitoring. For example, in patients without clinical improvement after D₂ or D₃ supplementation, lack of increase in the corresponding 25(OH)D₂ or 25(OH)D₃ and total 25(OH) D levels may indicate inadequate dosing, nonadherence, or malabsorption. Some laboratory assays for vitamin D cannot differentiate between 25(OH)D₂ and 25(OH)D₃ and will only report a total 25(OH)D level. Some laboratory assays underdetect D₂ metabolites, which may give the appearance of ineffective D₂ supplementation.

In people with healthy kidneys and bones, normal serum levels of calcium and phosphorus are maintained predominantly through the interaction of 2 hormones: parathyroid hormone (PTH) and calcitriol. In the setting of vitamin D deficiency, secondary HPT causes both release of calcium stored in bone and resorption of calcium by the kidney to maintain normal serum calcium and phosphorus levels. Thus, vitamin D deficiency is usually accompanied by normal blood levels for calcium and phosphorus, high-normal or elevated levels of PTH, normal to elevated levels of total alkaline phosphatase, a low 24-hour urine calcium excretion rate, and low levels of total 25(OH)D. Patients with severe and long-standing vitamin D deficiency may present with overt hypocalcemia and/or hypophosphatemia, but this is the exception. Clinicians should not measure 1,25(OH)₂D levels to diagnose hypovitaminosis D. Doing so can lead to an erroneous interpretation of vitamin D status because calcitriol levels are often normal or even elevated in patients with vitamin D deficiency as a result of elevated PTH levels.

What Is an Optimal 25(OH)D Level?

A wide "optimal" range for 25(OH)D is reported (25-80 ng/mL), and differences of opinion exist as to the definitions of vitamin D insufficiency (sometimes reported as <30 ng/mL) and deficiency (<20 ng/mL). Mild-to-modest deficiency can be associated with osteoporosis and/or secondary HPT. Severe deficiency may lead to failure to mineralize newly formed osteoid in bone, resulting in rickets in children and osteomalacia in adults. Most cells have vitamin D receptors. The consequences of vitamin D deficiency for organs other than bone are not fully known but may include impaired immunity, increased autoimmunity, myopathy, diabetes mellitus, and an increased risk of colon, breast, and prostate cancers.¹³ Higher vitamin D levels have also been associated with increased longevity.^14,15 Thus, an optimal vitamin D level might depend on the health outcome in question. The vitamin D levels in Table 4 are those reported by Mayo Medical Laboratories and represent clinical decision-making values that apply to men and women of all ages rather than population-based reference values.

TABLE 4.

Mayo Medical Laboratories Reference Ranges for Total Serum 25-hydroxyvitamin D [25(OH)D]^a

Population reference ranges for vitamin D vary widely depending on ethnic background, age, geographic location of the population, and the sampling season. In northern latitude locations in particular, up to 73% of the population may have levels of less than 20 ng/mL during winter.¹⁶ Thus, it is important to be aware that vitamin D levels are affected by both geographic and seasonal variability and that a person with an "optimal" level in the summer may well become "deficient" in the winter without any change in diet and as a result of changes in sun exposure.

HOW TO PREVENT AND TREAT VITAMIN D DEFICIENCY

Many patients and physicians think that adequate vitamin D intake can be obtained via diet alone. This assumption is erroneous. With the exception of fatty fish, the vitamin D content of most foods, including fortified dairy products, is relatively low to nonexistent. Even some dairy products in the United States are not fortified, making it important to read food labels to ensure the vitamin D content of foods.

Vitamin D supplementation is safe¹⁷ and inexpensive, but vitamin D deficiency often remains undiagnosed or is undertreated. Possible explanations for this disparity include (1) the recommended age-dependent adequate intake (AI) of vitamin D was established before publication of studies suggesting that 25(OH)D levels of greater than 30 ng/mL are needed to ensure PTH suppression into the normal range; (2) the current AI for vitamin D can easily be met by diet and/or a daily multivitamin,¹⁸ but this intake level may still be inadequate to reach optimal levels in many people, especially those at risk; and (3) physicians may be uncomfortable recommending larger doses of vitamin D. That fear is generally unmerited given the dearth of reports of vitamin D toxicity compared with the expansive literature on vitamin D deficiency. The rarity of reports of vitamin D toxicity can be explained in part by the kidney's ability to limit production of active calcitriol. Increased calcitriol levels inhibit PTH both directly (through the vitamin D response element on the PTH gene) and indirectly (by increasing intestinal calcium absorption), causing calcitriol production in the kidney to decrease. Renal 24-hydroxylase activity further limits the availability of calcitriol by creating inert metabolites of both calcitriol (1,24,25-trihydroxyvitamin D) and calcidiol (24,25-dihydroxyvitamin D). The 24-hydroxylase gene is under the transcriptional control of calcitriol, thereby providing tight negative feedback.

Vitamin D₂ Vs Vitamin D₃ Supplements: How Much Is Enough?

Both D₂ (ergocalciferol) and D₃ (cholecalciferol) are available as dietary supplements. The relative efficacy of D₂ vs D₃ in humans continues to be debated, although both appear to be effective for preventing or treating disease, provided that an adequate total 25(OH)D blood level is obtained. The variable efficacy of D₂ vs D₃ may relate primarily to differences in serum half-life and is clinically relevant for dosing and monitoring frequency. A single dose of 50,000 IU of D₂ or D₃ produces a similar increase in the total 25(OH)D concentration, but the apparent longer half-life of D₃ suggests that less frequent dosing may be needed.¹⁹ A daily dosing study of 1000 IU of D₂ vs D₃ showed no difference in any resulting vitamin D level [25(OH)D₂, 25(OH)D₃, or total 25(OH)D].²⁰ However, a recent study comparing 1600 IU of D₂ once daily vs 1600 IU of D₃ once daily vs 50,000 IU of D₂ once monthly vs 50,000 IU of D₃ once monthly suggested that D₃ is superior in that it showed slightly higher levels of 25(OH)D₃ at the end of 1 year. An important caveat of this study was that the mean total 25(OH)D level at the beginning of the study was already in the reference range (33 ng/mL), and those with hypovitaminosis D may respond differently.²¹ We recommend the use of D₃, particularly if dosing is infrequent (ie, less than once weekly). One situation in which D₂ may be preferred is a vegetarian or vegan diet. It is recommended that both D₂ and D₃ be taken with a meal containing fat to ensure maximum absorption.

Since 1997, the Food and Nutrition Board has advised an AI of vitamin D of 200 to 600 IU/d.¹⁸ The AI is "believed to cover the needs of all individuals" but "lack of data or uncertainty in the data" limit the ability to confidently determine a recommended daily allowance. The AI for vitamin D is based on maintenance of a total serum 25(OH)D level of at least 11 ng/mL.¹⁸ Although these recommendations are the basis for the amounts of vitamin D used to fortify foods and provided in many supplements, it is widely accepted that they are outdated.²² Revised dietary reference intakes from the Institute of Medicine are expected in 2010.

How much vitamin D is needed to correct severe vitamin D deficiency (<10 ng/mL)? Although not validated by clinical trials, a commonly applied strategy is to prescribe a "loading dose" (eg, 50,000 IU of vitamin D orally once weekly for 2-3 months, or 3 times weekly for 1 month). A review of multiple loading algorithms suggested that a minimum total dose of 600,000 IU best predicted an end-of-treatment 25(OH)D level greater than 30 ng/mL.²³ It is important to note that none of the studied patients developed hypercalcemia. For mild to moderate deficiency (11-25 ng/mL), a shorter treatment interval or lower dose may be effective. Although many different strategies may be used in treating vitamin D deficiency, a common oversight in management is to stop treatment or provide inadequate vitamin D maintenance dosing once the 25(OH)D level reaches the optimal range. Regardless of initial vitamin D therapy, and assuming no change in lifestyle or diet, a maintenance/prevention daily dose of 800 to 2000 IU or more will be needed to avoid recurrent deficiency (Table 3).²⁴ A maintenance dose averaging 2000 IU/d meets the current safe upper limit guidelines and is well below safe upper limits reported by others.¹⁷

Special mention is needed for patients who have malabsorption or require tube feeding or parenteral nutrition. Patients receiving tube feeding (but without malabsorption) have vitamin D dosing requirements similar to persons with oral intake. However, ergocalciferol capsules contain D₂ in oil, which can clog the feeding tube and therefore should not be used. Cholecalciferol capsules and tablets contain D₃ in powder form and can be used without clogging the feeding tube. Patients with malabsorption often require larger maintenance dosing of vitamin D. For example, patients with malabsorptive gastric bypass procedures may require 50,000 IU of D₂ or D₃ maintenance dosing from once weekly to as frequently as daily to maintain sufficiency. Standard multivitamin preparations for intravenous parenteral nutrition provide only 200 IU, a dose that helps maintain normal 25(OH)D levels in the short term but may not correct vitamin D deficiency. In extreme malabsorptive states, UVB exposure (ie, sunlight or phototherapy) can be effective for those who do not respond to large oral doses.²⁵ Vitamin D for intramuscular administration is not commercially available in the United States; however, it can be compounded in specialty pharmacies for limited local use.²⁶

THE IMPORTANCE OF CALCIUM AND VITAMIN D TOXICITY

What Role is Played by Calcium Nutrition?

Maintenance of normal serum calcium levels results from an array of interrelated processes, including intestinal calcium absorption, calcium uptake and release from the skeleton, and renal calcium handling. As previously noted, vitamin D plays a critical role in each of these processes. Hypovitaminosis D impairs intestinal calcium absorption and leads to secondary HPT and risk of bone loss. Heaney et al²⁷ found that maximal calcium absorption in men occurs when 25(OH)D levels are in the range of 30 to 40 ng/mL, consistent with vitamin D levels needed to suppress PTH. However, even in the presence of vitamin D sufficiency, inadequate oral calcium intake may cause secondary HPT. The National Osteoporosis Foundation guidelines recommend that men and women younger than 50 years ingest 1000 mg/d of elemental calcium, and those older than 50 years ingest 1200 mg/d (http://www.nof.org/prevention/calcium_and_VitaminD.htm, accessed December 24, 2009).

Clinicians should be mindful of several important caveats when considering calcium supplementation.

First, up to 500 to 600 mg of elemental calcium can be efficiently absorbed in any single dose, with excess calcium passing unabsorbed through the gut.

Second, gastric acidity is necessary for calcium absorption. However, even in patients with achlorhydria, calcium absorption is reported to occur adequately if taken with meals. For patients with achlorhydria due to gastric reduction or bariatric surgery, or during gastric acid suppressive therapy (eg, protein pump inhibitor use), calcium supplementation with the more acidic calcium citrate is preferred over calcium carbonate. However, calcium citrate can clog feeding tubes and should not be administered via any feeding tube.

Third, during vitamin D sufficiency, approximately 30% of calcium intake is normally absorbed regardless of the dietary or supplement source.²⁷ Thus, if 1000 mg of calcium is ingested and 30% (300 mg) is absorbed, and assuming that 50 mg is required for daily bone health, the remaining 250 mg will be renally excreted (normal 24-hour urine calcium excretion approximates 100-250 mg/d). With vitamin D deficiency, as little as 10% of ingested calcium may be absorbed. Thus, calcium excretion would be low (only 50 mg for a dose of 1000 mg). Although cumbersome, 24-hour urine calcium excretion is an effective test to assess adequacy of both calcium and vitamin D intake. When assessing urine calcium values, it is important to note that thiazide diuretics, lithium, and a low-sodium diet decrease renal calcium excretion, whereas excess sodium intake increases it.

Fourth, as already noted, low 25(OH)D levels may be associated with secondary HPT and abnormal bone mineralization. Thus, increased levels of PTH, increased total or bone alkaline phosphatase levels, and low 24-hour urine calcium levels should prompt suspicion for vitamin D deficiency in some patients. For example, vitamin D deficiency should be suspected in an otherwise healthy person found to have an elevated alkaline phosphatase level, especially if findings on other liver enzyme tests are normal.

What About Vitamin D Toxicity?

Vitamin D toxicity should not be diagnosed solely on the basis of an elevated 25(OH)D level; instead, it should be recognized as a clinical syndrome of both hypervitaminosis D and hypercalcemia, in which hyperphosphatemia and hypercalciuria also commonly (although not always) occur. Patients with vitamin D toxicity could present with clinical symptoms and signs of hypercalcemia (eg, nausea, dehydration, and constipation) and hypercalciuria (eg, polyuria and kidney stones). Hypervitaminosis D in the absence of hypercalcemia may prompt further investigation to evaluate the etiology of increased vitamin D levels; however, unlike hypercalcemia, it is not a medical emergency. Although excess vitamin D supplementation can lead to hypercalcemia, vitamin D toxicity is extremely rare and generally occurs only after ingestion of large doses of vitamin D (>10,000 IU/d) for prolonged periods in patients with normal gut absorption or in patients who may be concurrently ingesting generous if not excessive amounts of calcium. A 25(OH)D level of 80 ng/mL is the lowest reported level associated with toxicity in patients without primary HPT with normal renal function. Most patients with vitamin D toxicity have levels greater than 150 ng/mL.²⁸ Binkley et al²¹ have recently reported that vitamin D supplementation with 1600 IU/d or 50,000 IU monthly was not associated with any laboratory parameters of toxicity [eg, 25(OH)D, PTH, bone alkaline phosphatase, and 24-hour urine calcium] and even failed to increase total 25(OH)D levels above 30 ng/mL in 19% of participants.

CONCLUSION

Vitamin D is important for skeletal and nonskeletal health. It is now well established that many people have vitamin D levels that are less than currently recommended for optimal health. Worldwide, vitamin D is predominantly obtained through exposure to UVB radiation in the form of sunlight and cutaneous vitamin D production. Latitude, cultural dress habits, season, sun avoidance, and sunscreen protection can all limit vitamin D production. Gastrointestinal, hepatic, and renal disease may be related to low vitamin D levels, but hypovitaminosis D most commonly results from inadequate intake. Hypovitaminosis D resulting from lack of UVB exposure is not easily corrected by dietary intake alone in the absence of supplementation. Food fortification with vitamin D is based on outdated recommendations for daily AI. Supplementation with 800 to 1000 IU/d of vitamin D or 50,000 IU monthly is safe for most people and can ensure levels of vitamin D within the optimal range. This intake is within the currently recommended safe upper tolerable limit for vitamin D of 2000 IU/d for those aged 1 year and older. Revised recommended dietary intake values for vitamin D, which are needed to guide patients and physicians alike, are expected to be published in 2010.

Supplementary Material

Notes

On completion of this article, you should be able to (1) recognize patients at risk for vitamin D deficiency, (2) optimally use and interpret serum vitamin D testing, and (3) determine the optimal vitamin D therapy required to treat or prevent vitamin D deficiency in adults.

CME Questions About Vitamin D Deficiency in Adults

1. Which one of the following patients is at greatest risk for vitamin D deficiency?

   1. A formula-fed infant

   2. A teenaged girl eating an unrestricted diet and taking a multivitamin

   3. A 30-year-old male nursing home resident treated with phenytoin for epilepsy

   4. A 70-year-old woman with osteopenia taking a calcium carbonate with vitamin D supplement

   5. A 43-year-old male farmer

2. Which one of the following biochemical tests provides the best initial assessment of a person's vitamin D status?

   1. Serum parathyroid hormone (PTH)

   2. Serum 25-hydroxyvitamin D (calcidiol) [25(OH)D]

   3. Serum 1,25-dihydroxyvitamin D (calcitriol) [1,25(OH)₂ D]

   4. Serum bone alkaline phosphatase

   5. 24-hour urine calcium excretion

3. Which one of the following sets of laboratory test findings (reference ranges provided parenthetically) is most suggestive of vitamin D toxicity?

   1. Serum calcium, 9.7 mg/dL (8.9-10.1 mg/dL); serum phosphorus, 4.0 mg/dL (2.5-4.5 mg/dL); 24-hour urine calcium, 250 mg/spec (25-300 mg/spec); 25(OH)D, 120 ng/mL (25-80 ng/mL); and PTH, 30 pg/mL (15-50 pg/mL)

   2. Serum calcium, 10.4 mg/dL (8.9-10.1 mg/dL); serum phosphorus, 4.8 mg/dL (2.5-4.5 mg/dL); 24-hour urine calcium, 450 mg/spec (25-300 mg/spec); 25(OH)D, 120 ng/mL (25-80 ng/mL); and PTH, 20 pg/mL (15-50 pg/mL)

   3. Serum calcium, 11.0 mg/dL (8.9-10.1 mg/dL); serum phosphorus, 2.2 mg/dL (2.5-4.5 mg/dL); 1,25(OH)₂D, 85 pg/mL (22-67 pg/mL); and PTH, 95 pg/mL (15-50 pg/mL)

   4. Serum calcium, 10.6 mg/dL (8.9-10.1 mg/dL); serum phosphorus, 4.0 mg/dL (2.5-4.5 mg/dL); 24-hour urine calcium, 450 mg/spec (25-300 mg/spec); 25(OH)D, 26 ng/mL (25-80 ng/mL); 1,25(OH)₂D, 85 pg/mL (22-67 pg/mL); and PTH, 12 pg/mL (15-50 pg/mL)

   5. Serum calcium, 15 mg/dL (8.9-10.1 mg/dL); serum phosphorus, 4.0 mg/dL (2.5-4.5 mg/dL); 24-hour urine calcium, 450 mg/spec (25-300 mg/spec); 25(OH)D, 35 ng/mL (25-80 ng/mL); 1,25(OH)₂D, <10 pg/mL (22-67 pg/mL); and PTH, <6 pg/mL (15-50 pg/mL)

4. Which one of the following treatment strategies is most likely to be safe and effective to achieve optimal vitamin D levels in a person with little sun exposure?

   1. Daily supplementation with 400 IU of vitamin D₃ (D₃) via a multivitamin

   2. Daily supplementation with 800 to 1000 IU of vitamin D₂ (D₂) or D₃

   3. Daily supplementation with 50,000 IU of D₃

   4. Monthly supplementation with 50,000 IU of D₂

   5. One daily serving of fortified milk

5. Which one of the following statements about measuring 25(OH)D levels is correct?

   1. All patients should be tested for vitamin D deficiency before supplementation

   2. A patient with a 25(OH)D level of 10 ng/mL who is beginning treatment with 800 IU/d of D₃ should be rechecked after 1 month

   3. A patient with a 25(OH)D level of 10 ng/mL who is beginning treatment with 50,000 IU of vitamin D 3 times weekly for 1 month to be followed by 50,000 IU once monthly should be rechecked after 1 month

   4. A patient with a 25(OH)D level of 10 ng/mL who is beginning treatment with 2000 IU/d of D₃ should be rechecked after 6 months

   5. A patient with generous summertime sun exposure living at a high latitude with a low 25(OH)D level in spring should be supplemented and retested in the fall

This activity was designated for 1 AMA PRA Category 1 Credit(s).™

Because the Concise Review for Clinicians contributions are now a CME activity, the answers to the questions will no longer be published in the print journal. For CME credit and the answers, see the link on our Web site at mayoclinicproceedings.com.

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Articles from Mayo Clinic Proceedings are provided here courtesy of The Mayo Foundation for Medical Education and Research

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John D. Rockefeller: The Wealthiest American of All Time

Photo Courtesy: Oscar White/Wikimedia Commons

John D. Rockefeller's name is synonymous with wealth, and he's one of the most controversial business tycoons in America's history. From his monopolistic Standard Oil to various ventures in banking and shipping, Rockefeller's empire continued to thrive, even after infamous antitrust suits.

Regardless of opinions about his ethics, John D. Rockefeller was able to overcome times of war and turmoil to turn a considerable profit. Determining how he became so accomplished involves taking a more in-depth look into the life of America's wealthiest man.

Son of a Con Artist

John D. Rockefeller was the son of William Avery "Devil Bill" Rockefeller, who was a businessman and lumberman before becoming a well-known con artist. He claimed to be a "botanic physician" who sold various elixirs to unsuspecting customers. Devil Bill was also involved with swindling customers using his other business of land speculation.

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Bill found desperate farmers who could barely bring in sufficient income. He gave them loans with a 12% interest rate. The high-risk borrowers often fell to foreclosure, allowing Rockefeller to swoop in and take their farms.

Scammed by His Father

Devil Bill lived the life of a vagabond and was away from home for extended periods. Bill's mistress was also the family housekeeper; he fathered two children with her. A patient homemaker, Devil Bill's wife (John's mother) put up with his double life, including bigamy with his mistress.

Photo Courtesy: Library of Congress/Flickr

John and his brothers were also victims of their father's grifting. Bill even said, "I cheat my boys every chance I get. I want to make them sharp." The only business trait John earned from his father was to enter a deal that was a sure thing.

Mentored by His Mother

Because Bill was rarely home, John helped his mother, Eliza, as much as he could. He completed various household chores and earned money raising turkeys and selling potatoes and candy. Eliza, a devout Baptist, taught John to be prudent with his income as "willful waste makes woeful want."

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Eliza was a far more significant influence on John than his father was. She inspired him to share his wealth, and he later became an ardent philanthropist. "From the beginning, I was trained to work, to save and to give," he claimed. His respect for money led to his training as a bookkeeper.

Beginnings in Bookkeeping

Before becoming an oil tycoon, John D. Rockefeller attended the first public high school in Cleveland, Ohio. Following graduation, his interest in money led to the completion of a 10-week business course studying bookkeeping. John was an academic and took his education seriously.

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He earned his first financial role for a produce company when he was only 16 years old. He had a penchant for transportation costs and business operations. John began earning $16 per month as an apprentice, and eventually, he received $58 each month based on his successful collections capabilities.

A Musical Background

John possessed an innate business understanding that his mother helped nurture. He was honest yet firm. A skilled communicator, Rockefeller became known for his ability to negotiate transportation rates with canal owners, ship captains and freight agents based on market conditions.

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If he hadn't been such an expert at debt collection and negotiation, leading to significant earnings, Rockefeller might have wound up in a completely different place. He had a passion and fondness for music and once considered it for a career.

Rockefeller's Personal Loan Shark

Following his time as a bookkeeper, John D. Rockefeller decided to improve his odds of success. Taking what he had learned from his time in the produce-commission business, he joined forces with his partner, Maurice B. Clark. Clark contributed $2,000 of their total $4,000 capital, but John only had $800 saved.

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Rockefeller borrowed the rest from his father; Devil Bill gave John a loan of $1,000. Even though it was for his son, he still charged an interest rate. Lower than his standard 12%, Bill offered the loan at 10% interest.

Abolitionist Draft Dodger

The Civil War caused massive food shortages due to the need for military supplies. Rockefeller's business boomed as the war dragged on. John's brother Frank fought for the North, but John was able to avoid service. He did so by donating to the Union army. It was a common practice for wealthy people to stay off the battlefield.

Photo Courtesy: Library of Congress/Wikimedia Commons

John was a Republican and robust abolitionist who voted for Abraham Lincoln. He considered it his duty as a wealthy American patriot to donate to the Northern cause, something that was instilled upon him by his mother.

The Civil War and Oil

The federal government began subsidizing oil, which drove the price from $0.35 a barrel to $13.75 a barrel in 1862. Even with high transportation costs and additional levies on refined oil, Rockefeller and his partner decided to enter this new boom. They switched from produce to oil in 1863 with the purchase of a refinery near Cleveland.

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Most companies kept 60% of the oil product as kerosene and dumped the rest. A thrifty Rockefeller sold the remaining 40% for other uses. In 1865, he bought out his partners, which he said determined his career.

Oil Profits Grow

Unlike today, the oil industry was relatively small. Consumers used whale oil to light candles and heat homes, although the product was far too expensive for middle class consumers. Throughout the 1870s, kerosene became far more accessible and easier to transport due to reduced freight rates.

Photo Courtesy: State Library of South Australia/Flickr

Rockefeller's thrifty nature and use of the entirety of his oil led to cheaper availability of kerosene and other oil byproducts. Rockefeller became the most profitable oil refiner and the largest shipper in Ohio. He made his product accessible to consumers, no matter their socioeconomic class.

The Cleveland Massacre

John D. Rockefeller's keen business nature led to Standard Oil's exponential growth. As a practice, John pinpointed his least-efficient competitors and targeted them for purchase. Based on his low costs and ability to raise capital, he was able to undercut his competitors and force them to sell.

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He went through a brief period known as "The Cleveland Massacre" in which he made secret deals leading to Standard Oil's attainment of 22 out of 26 Ohio competitors within four months. The remaining competitors realized that resistance was futile and made deals with him for the purchase of their companies.

Vertical Integration Creation

Some people picture business tycoons as ruthless businessmen who want to destroy their competition. John D. Rockefeller's view was far more messianic. He thought of himself more as a savior to the industry rather than its sole leader. His ownership of pipelines and other delivery methods kept prices low and increased competition.

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As Rockefeller's successor put it, "That orderly, economic, efficient flow is what we now, many years later, call 'vertical integration.' I do not know whether Mr. Rockefeller ever used the word 'integration.' I only know he conceived the idea."

Other Than Oil...

By the late 1870s, Standard Oil was responsible for 90% of the United States' refined oil. The company was growing both vertically and horizontally. Its products had found their way into nearly every American household. Standard Oil's increased market share and profits allowed the company to expand and begin marketing other products.

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Because Standard Oil was using nearly 100% of the oil it produced, the company developed over 300 other oil-based products. It was responsible for introducing everything from chewing gum and petroleum jelly to paint and tar. Rockefeller had become a millionaire at this point, worth $26 million by today's exchange rates.

Standard Oil vs. Pennsylvania Railroad

Because Standard Oil was investing in oil pipelines as a less-expensive transportation method, railroad companies began to notice — especially Standard Oil's principal hauler, Pennsylvania Railroad. The railroad formed a subsidiary to enter the oil-refining industry, leading to a considerable business battle and price war.

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Standard held back its shipments and reduced prices with the help of other railroads. After a hard-fought battle, Pennsylvania Railroad had to concede. The company sold its oil interests to Standard Oil, increasing Standard's stranglehold on the industry. The fight led to the first of many legal battles in Standard's existence.

Developing Anxiety

In the wake of Standard Oil's battle with Pennsylvania Railroad, the Commonwealth of Pennsylvania took action and indicted John D. Rockefeller for monopolizing the oil industry. Lawsuits from other states trickled in, causing Standard Oil to receive a large amount of media attention, and subsequent criticism, for its business practices.

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Standard's legal conflicts lasted through the end of the 1880s. Under considerable stress, Rockefeller could not sleep. The constant attacks from the press caused him to say, "All the fortune that I have made has not served to compensate me for the anxiety of that period."

Standard Oil Trust

Standard Oil already gained a 90% market share of the American oil industry, even though hundreds of competitors existed. The criticisms of Standard Oil underselling, pricing and offering transportation rebates had allowed the company to enter a majority of American households. New York World called the company "the most cruel, impudent, pitiless and grasping monopoly that ever fastened upon a country."

Photo Courtesy: Public Domain/Wikimedia Commons

Standard achieved this by creating different corporations; it was difficult for companies to operate in multiple states at the time. Standard Oil's lawyers centralized the company's 41 holdings by creating the Standard Oil Trust.

The Largest Company in the World

Criticized by competitors and consumers, the Standard Oil Trust caused the company to become the wealthiest and largest business in the world. Standard Oil was seemingly unstoppable and made large profits year over year. Many other companies saw Standard's invincibility and formed trusts of their own.

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At its peak, Standard Oil boasted over 100,000 employees and owned 20,000 wells and 5,000 tank cars with 4,000 miles of pipeline. Increased public scrutiny caused Rockefeller to realize he would never own 100% of the country's oil. Standard's market share began to drop.

Creating the Oil Futures Market

During Standard Oil's market share drop, John D. Rockefeller's innovative business mind continued to grow. He changed the way the company charged for oil storage based on market conditions. Rockefeller traded certificates to speculators against any oil that was stored in his pipelines, leading to the first oil futures market.

Photo Courtesy: The Rockefeller Archive Center/Wikimedia Commons

The new and innovative market established all oil prices for the foreseeable future. In 1882, the National Petroleum Exchange opened to facilitate this trading. The oil industry was now an international phenomenon with oil fields discovered in Russia and Asia.

Other Oil-based Products

Kerosene was finally on its way out as a source of illumination due to the invention of the light bulb. Standard Oil began to develop the natural gas market in the United States. Cheaper oil fields in Russia, the development of the world's first oil tanker and wealthy financiers, including the Rothschilds, forced Rockefeller to adapt.

Photo Courtesy: Public Domain/Early American Automobiles

Primarily considered a waste product, automobile gasoline wasn't a common product for many oil companies at the time. As it had always done, Standard Oil found a niche market and proved once again that it wasn't going to bow to market pressures.

Relocation to the Big Apple

In the early 1880s, Standard Oil's headquarters relocated to New York City, and Rockefeller became a central business icon. He purchased a house near the mansion of William Henry Vanderbilt on 54th Street. Even with his expansive wealth and highly recognizable face, John D. Rockefeller took the elevated train to his office each day.

Photo Courtesy: Internet Archive Book Images/Flickr

He was unable to keep himself from the masses. On a regular basis, Rockefeller received threats to his life. Countless residents knew how much money he had and continually asked for charity, yet he kept utilizing public transportation.

The Beginning of Standard Oil's End

Businesses were getting out of hand by the late 1890s. Unions formed to protect workers, but the unions themselves weren't immune to corruption. Congress passed the Sherman Antitrust Act of 1890 to regulate the unions. States used the law to fight against Standard Oil's trust.

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Ohio took the first step by using its antitrust laws to force Standard Oil of Ohio from the rest of the corporation. From there, other states followed, and the official breakup of Standard Oil's trust had begun. Rockefeller did everything he could to keep his company relevant.

Rockefeller vs. Carnegie

Because of the breakup of Standard Oil's trust, the conglomerate entered the iron ore industry, including its means of transportation. The new venture caused a clash with American steel tycoon Andrew Carnegie, who was no stranger to competition. Newspaper cartoonists aimed their criticisms at the two millionaires during that period.

Photo Courtesy: Library of Congress/Wikimedia Commons

Not ready for another round of business and legal battles, Rockefeller began to consider his retirement. J.P. Morgan swooped in and purchased both Carnegie's steel and Rockefeller's iron interests. Rockefeller earned a place on the board of directors and $58 million in total investments.

Tarnishing Rockefeller's Legacy

In 1904, Ida Tarbell wrote a work describing the various shady dealings and practices of John D. Rockefeller and Standard Oil. She wrote about the price wars, marketing techniques and legal battles in the publication "The History of the Standard Oil Company." It all but tarnished the legacy of America's richest man.

Photo Courtesy: J. Ottmann Lith, Co., 1904/Wikimedia Commons

The backlash against Rockefeller was staggering, and even Tarbell herself was surprised by the outcome. "I never had an animus against their size and wealth, never objected to their corporate form," she said, "but they had never played fair, and that ruined their greatness for me."

Changed Opinions

The backlash from Ida Tarbell's "The History of the Standard Oil Company" had a personal effect on Rockefeller. He never publicly shamed "that misguided woman" who wrote the publication. Still, Rockefeller's private account of the writer, whose father he had driven out of the oil business, was quite harsh.

Photo Courtesy: Library of Congress/Wikimedia Commons

John D. Rockefeller was notorious for avoiding the press. He took this opportunity to conduct a press tour to improve his public perception. The views that his company followed established laws and ethical business practices fell upon deaf ears.

The U.S. vs. Standard Oil

John D. Rockefeller's tenacity continued into the 20th century, and John and his son furthered their fight to consolidate their oil business. The state of New Jersey's laws changed in 1909 and allowed for them to incorporate their holdings under one company, and Rockefeller was temporarily back in business.

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The Supreme Court of the United States had something else in mind. In 1911, the high court found that Standard Oil had violated the Sherman Antitrust Act. The court forced the illegal monopoly to break up. Standard Oil was no longer the largest oil company in the world.

Breaking Up Standard Oil

Because the Supreme Court had ruled that Standard Oil was an illegal monopoly, the Sherman Antitrust Act forced it to break up its assets. Standard Oil was to become 34 new companies. Many of those companies are still in existence today and are quite recognizable.

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These include ConocoPhillips, Amoco (which is part of British Petroleum), Chevron, ExxonMobil and Pennzoil. Rockefeller held on to significant shares in each of the companies. Although he was no longer in control of the oil industry, he profited tremendously.

The Rockefeller Dynasty

John D. Rockefeller was married to Laura Celestia Spelman in 1864. From 1866 through 1874, the couple had four daughters, Elizabeth, Alice, Alta and Edith, and one son, John Jr. The kids also had children, many of whom went on to lead very successful lives in public service and business.

Photo Courtesy: Library of Congress/Wikimedia Commons

John Jr.'s youngest son, David, served as CEO of Chase Manhattan Bank for over 20 years. His second son, Nelson, was elected governor of New York before becoming the 41st Vice President of the United States. Another son, Winthrop, served as the Governor of Arkansas.

Family Philanthropy

John D. Rockefeller was the original creator of the conditional grant. The beneficiary was required to "root the institution in the affections of as many people as possible who, as contributors, become personally concerned, and thereafter may be counted on to give the institution their watchful interest and cooperation."

Photo Courtesy: Library of Congress/Wikimedia Commons

John's wife, Laura, was also a supporter of civil rights and equality. They offered a massive donation to the Atlanta Baptist Female Seminary in Atlanta. The college for African-American women was later named Spelman College in honor of his wife's family name.

Religious Views

During John D. Rockefeller's adolescent years, the Second Great Awakening drew people to various Protestant churches. He attended the Erie Street Baptist Church with his mother, Eliza. The revival period promoted values such as hard work and good deeds, something Rockefeller attributed his philanthropic work to in his later years.

Photo Courtesy: National Archives/Wikimedia Commons

His mother encouraged him to put a few cents into the offering basket each Sunday. He ultimately related charity to the church. Later, he would remember, "It was at this moment that the financial plan of my life was formed."

Health Issues and Death

John D. Rockefeller suffered from moderate depression. During the stressful period of his life, while he was dealing with negative press and lawsuits, he developed alopecia. The condition led to considerable hair loss. To cover it up, he began to wear toupeés.

Photo Courtesy: Library of Congress/picryl.com

Rockefeller was a workhorse, and his health improved as his work decreased. Despite his ambition to live until he was 100 years old, John D. Rockefeller passed away due to complications related to arteriosclerosis just shy of his 98th birthday in 1937. He died in Florida, and his body rests in Lake View Cemetery in Cleveland.

The Rockefeller Legacy

John D. Rockefeller is known as the richest man in United States history. A real example of the American Dream, the name Rockefeller will forever be associated with wealth and success. Regardless of his controversies, no one can dispute his ability to make a business thrive, even during wartime and economic downturns.

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By the beginning of World War I, Rockefeller was worth around $900 million. According to his obituary, the business tycoon amassed nearly $1.5 billion from Standard Oil and other businesses in banking, shipping, mining, railroads and various other enterprises.

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Source: https://www.life123.com/lifestyle/john-rockefeller-wealthiest-american?utm_content=params%3Ao%3D740009%26ad%3DdirN%26qo%3DserpIndex

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