Chinese have very low vitamin D
Update: Vitamin D levels are correlated with 6 environmental variables in China – July 2022
A glimpse of vitamin D status in Mainland China
NutritionVolume 29, Issues 7–8, July–August 2013, Pages 953–957
Weiguo Zhang, M.D., Ph.D.{ANAME()}bcor1|
{ANAME}, ,weiguo.zhang@dsm.comElisabeth Stoecklin, M.D.,
Manfred Eggersdorfer, Ph.D.
DSM Nutritional Products, Human Nutrition and Health, Beijing, China and Kaiseraugst, Switzerland
http://dx.doi.org/10.1016/j.nut.2013.01.010, How to Cite or Link Using DOI
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Abstract
As an essential dietary micronutrient, vitamin D plays a pivotal role in promoting calcium absorption in the intestine and maintaining a healthy skeletal system throughout life. Beyond bone health, an emerging volume of scientific studies shows that vitamin D also may provide cardiovascular, metabolic, and immunologic benefits and reduce mortality. To our knowledge, in mainland China no national surveys have been conducted to date to depict the overall vitamin D status in the population. Therefore, the purpose of this contribution was to provide the best possible evaluation of vitamin D deficiency/insufficiency in China by reviewing publications that measured plasma/serum 25-hydroxyvitamin-D (25[OH]D) levels in various age groups and in different areas of China from January 2000 to June 2012. From these investigations conducted throughout the country and from newborns to adults to the elderly, it has been found that vitamin D deficiency/insufficiency is prevalent in the Chinese population in almost all age groups and areas if individuals are not taking vitamin D–fortified products/supplements or are lacking sufficient sunshine exposure. Some studies showed severe deficiency (25[OH]D <25 nmol/L) in Nanjing (north latitude 31) during the winter months and in Beijing (north latitude 40) in the fall. This unoptimistic situation represents a significant but modifiable public health risk that deserves greater attention and more efficient and timely management.
Keywords
Blood;
25-Hydroxyvitamin D;
Bone;
Nutrient deficiency;
Nutritional status;
Population;
Public health
Introduction
Vitamin D is an essential dietary micronutrient because it plays a pivotal role in aiding intestinal absorption of calcium and phosphorus, therefore, exerting a favorable effect on bone mineralization and musculoskeletal health. Other than the classical effects of vitamin D on calcium and phosphorus metabolism and on bone health and muscle strength, an emerging volume of scientific studies also shows that vitamin D deficiency/insufficiency may increase the risks for developing non-skeletal disorders such as cardiovascular disease, type 2 diabetes, autoimmune disease, selected cancers, high blood pressure, depression, and overall mortality [1] and [2].In Mainland China, there has, to our knowledge, been no systematic national survey to depict the landscape of vitamin D deficiency, insufficiency, and adequacy. However, research interests in the topic developed and continued to mount over the past decade(s), and as a result, circulating vitamin D status has been examined in various populations and regions.The purpose of this contribution is to provide best possible overview from these studies that measured circulating 25-hydroxyvitamin-D (25[OH]D) levels in Mainland China. Serum or plasma 25(OH)D concentration is widely accepted as the best biomarker to define vitamin D status, because it reflects both the endogenous vitamin D photosynthesis by skin in response to sun exposure and vitamin D ingestion via digestive track from dietary sources [3]. To this end, peer-reviewed original English publications from January 2000 to November 2012, which examined 25(OH)D values, were retrieved from databases and analyzed. Studies were not included when the number of participants was less than 30 and when they had known overt vitamin D intake. A deficient vitamin D level is defined as being 25(OH)D <25 nmol/L; insufficient <50 nmol/L; desirable >75 nmol/L (as recommended by International Osteoporosis Foundation [IOF], the Endocrine Society, and many scientists in the field) [4]. Therefore, levels between 50 nmol/L and 75 nmol/L were defined as inadequate (although they are defined as adequate by the Institute of Medicine). These cut-off points are also in line with the recently published global vitamin D status map by the IOF [5] (http://www.iofbonehealth.org/facts-and-statistics/vitamin-d-studies-map).
Vitamin D status in the youth
As shown in Table 1[6], [7], [8], [9], [10], [11] and [12], vitamin D deficiency was phenomenal in the youth. There was no group with desirable 25(OH)D levels and as many as 40% to 90% had blood 25(OH)D levels lower than 50 nmol/L. A study in Beijing showed even worse vitamin D status: More than 40% of school-aged girls had 25(OH)D levels below 12.5 nmol/L in January. This significant vitamin D deficiency remained in 5% to 9% of them even in September and October [9].:Table 1. Vitamin D status in the youth
:
| PublicationAge (yrs)NumberPlaceLatitude (north)SeasonD UseAssay method 25-OH-D ( nmol/l) Deficiency (%) | ||||||||||||||
| --- | ||||||||||||||
| <12.5<25<37.5<50<75<80 | ||||||||||||||
| Wang J. 2010 | Newborn | 77 (MF) | Chengdu | 30 | Sept | Unknown | Enzyme immunoassay | 41.0 ± 18.9 | 44.2 | 96.1 | ||||
| Song S. 2012 | Newborn | 58 (MF) | Beijing | 40 | Apr-May | No | ELISA | 27.9 ± 1.6* | 46.6 | 93.2 | 100 | |||
| Zhu Z. 2012 | 6-11 | 1440 (MF) | Hangzhou | 30 | All | Unknown | ELISA | 56.1 ± 19.9 | 2.0 | 40.3 | 88.3 |
| 12-16 | 183 (MF) | Hangzhou | 30 | All | Unknown | ELISA | 52.1 ± 17.0 | | 3.3 | | 46.4 | 89.6 | | | Du X. 2001 | 12.7 | 108 (F) | Beijing | 40 | Jan | Unknown | Competitive protein assay | 13.9 ± 9.6 | 42.5 | | | | |
| | | | | Sept-Oct | Unknown | Competitive protein assay | 30.2 ± 11.9 | 5.1 | | | | |
| 13.0 | 57 (F) | Beijing | 40 | Jan | Unknown | Competitive protein assay | 12.7 ± 5.9 | 49.6 | | | | |
| | | | | Sept-Oct | Unknown | Competitive protein assay | 24.7 ± 10.6 | 6.6 | | | | |
| 13.2 | 64 (F) | Beijing | 40 | Jan | Unknown | Competitive protein assay | 12.8 ± 6.7 | 45.1 | | | | |
| | | | | Sept-Oct | Unknown | Competitive protein assay | 23.8 ± 8.7 | 9.2 | | | | | | | Foo L. 2009 | 15.0 | 301 (F) | Beijing | 40 | Mar-Apr | No | RIA | 34.0 | | 32.8 | 68.4 | 89.2 | | | | Arguelles L. 2009 | 16.4 | 226 (FM) | Anqing | 31 | All | Unknown | HPLC | 45.0 ± 23.5 | | | | | | 90.3 |
:M, male; F, female; All, the blood samples were collected in all seasonsThe 25-OH-D values are expressed in mean ± SD (or mean ± SE when with *) or median, and are converted if not in nmol/l. Different deficiency/insufficiency cutoffs and rates were provided by investigators
Poor vitamin D status was not seen in participants taking vitamin D–fortified products or supplementation (Table 2A) [8] and [13], unequivocally suggesting that vitamin D supplementation improved 25(OH)D status. Additionally, exposure to sunshine, thus allowing individuals to receive ultraviolet B (UVB), in the summer months improved 25(OH)D status in the same children who were previously deficient (Table 2B) [14]. Consequently, clinical rickets declined from 41.6% to 17%.:Table 2. Vitamin D status can be improved in children
:
| A. Effect of supplementation | |||||||||||
| --- | |||||||||||
| PublicationAge (yrs)NumberPlaceLatitude (north)SeasonD UseAssay method25-OH-D (nmol/l)Deficiency (%) | |||||||||||
| --- | |||||||||||
| <25<50<75 | |||||||||||
| Zhu Z. 2012 | 0–1 | 2116 (MF) | Hangzhou | 30 | All | Yes | ELISA | 98.7 ± 47.1 | 0.4 | 5.4 | 33.6 |
| 2–5 | 2269 (MF) | Hangzhou | 30 | All | Yes | ELISA | 69.6 ± 30.4 | 1.1 | 21.9 | 68.6 | | Liang GY. 2011 | 0–10 | 76 (MF) | Nanjing | 32 | Nov-Mar | Yes | EIA | 80.5 ± 29.3 | 1.3 | 10.5 |
| 0–10 | 66 (MF) | Nanjing | 32 | Nov-Mar | Yes | EIA | 65.7 ± 32.3 {ANAME()}ancbtbl2fnlowast | * {ANAME} | 16.7 | 30.8 | | | B. Effect of sunshine exposure | | Publication | Age (month) | Number | Place | Latitude (north)/Elevation(meter) | Season | D Use | Assay method | 25-OH-D (nmol/l) | Deficiency (%) | | <12.5 | <30 | <50 | | Strand MA. 2009 | 18.2 | 177 (MF) | Yuci | 37/797 | Apr | Unknown | Radioimmunoassy | 34.5 ± 74.3 | 33.5 | 65.3 | 84.3
| 23.3 | 172 (MF) | Yuci | 37/797 | Sept | 4.2% | Radioimmunoassy | 127.8 ± 143.5 | 0 | 2.9 | 8.1 |
:For footnote: please see Table 1
:;∗With respiratory infection.
Vitamin D status in adults
A larger percentage of adults had blood 25(OH)D levels below 50 nmol/L (Table 3) [6], [7], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26] and [27]. The best 25(OH)D levels (67.2 nmol/L) in adult groups were reported in Jinan [22]; whereas the worst (<25 nmol/L) was found in pregnant women in Nanjing and pregnant women with gestational diabetes mellitus in Beijing [15] and [20].:Table 3. Vitamin D status in adults
:
| PublicationAge (yrs)NumberPlaceLatitude (north)SeasonD UseAssay method 25-OH-D (nmol/l) Deficiency (%) | |||||||||||
| --- | |||||||||||
| <25<50<75<80 | |||||||||||
| Jiang L. 2012 | 26.3 | 78 (F) | Nanjing | 31 | Winter | 99 IU | ELISA | 22.6 ± 12.7 | 65.8 | 96.1 |
| 27.7 | 78 (F) | Nanjing | 31 | Summer | 117 IU | ELISA | 31.8 ± 9.2 | 22.4 | 94.7 | | | | Woo J. 2008 | 26.9 | 220 (F) | Beijing | 40 | Feb-May | No | Radio-immunoassay | 29 | 40 | 94 | |
| 27.9 | 221 (F) | Hong Kong | 22 | Feb-May | No | Radio-immunoassay | 34 ∗ | 18 | 92 | | | | Shao H. 2012 | 26.8 | 130 (F) | Shanghai | 31 | Jul-Dec | No | Chemiluminescence | 30.2 {ANAME()}ancbtbl3fndagger | † {ANAME} | | | |
| 27.3 | 139 (F) | Shanghai | 31 | Jul-Dec | No | Chemiluminescence | 29.7 | | | | | | Wang J. 2010 | End preganacy | 77 (F) | Chengdu | 30 | Sept | Unknown | Enzyme immunoassay | 36.0 ± 18.9 [http://www.sciencedirect.com/science/article/pii/S089990071300052X#tbl3fndagger|] † ] | | | | 97.4 | | Tao M. 2012 | 28.1 | 1695 (F) | Shanghai | 31 | All | No | Chemiluminescence | 43.9 ± 28.6 [http://www.sciencedirect.com/science/article/pii/S089990071300052X#tbl3fndagger|] † ] | | 69.0 | 91.0 | | | Yang B. 2012 | 29.4 | 41 (M) | Xi’an | 34 | All | Unknown | ELISA | 52.5 ± 15.9 | | | |
| 30.3 | 314 (M) | Xi’an | 34 | All | Unknown | ELISA | 53.3 ± 14.5 | | | |
| 30.5 | 195 (M) | Xi’an | 34 | All | Unknown | ELISA | 54.1 ± 14.3 | | | | | | Song S. 2012 | 29.9 | 70 (F) | Beijing | 40 | Apr-May | No | ELISA | 28.6 ± 1.4 [http://www.sciencedirect.com/science/article/pii/S089990071300052X#tbl3fndagger|] † ] | 54.3 | 90.2 | 100 | | | Yan L. 2000 | 30.9 | 48 (F) | Shenyang | 42 | Apr-May | No | Radio-immunoassay | 40.7 ± 14.1 | 13.0 | | |
| 31.1 | 48 (M) | Shenyang | 42 | Mar-May | No | Radio-immunoassay | 31.4 ± 10.4 | 29.0 | | | | | Wang O. 2012 | 31.0 | 200 (F) | Beijing | 40 | All | Unknown | ELISA | 25.9 [http://www.sciencedirect.com/science/article/pii/S089990071300052X#tbl3fndagger|] † ] | | | |
| 32.0 | 200 (F) | Beijing | 40 | All | Unknown | ELISA | 22.4 {ANAME()}ancbtbl3fnddagger | ‡ {ANAME} | 53.8 | 96.3 | | |
| Lu H. 2012 | 43.0 | 2588 (MF) | Shanghai | 31 | Feb-Mar | No | Chemiluminescence | 52.2 | | 30 (M)
46 (F) | 84 (M)
89 (F) | |
| Yin X. 2012 | 49.4 | 601 (MF) | Jinan | 37 | Nov-Dec | No | RIA | 67.2 ± 25.3 | | 28.6 | 66 | |
| Lin S. 2012 | 56.5 | 1101 (MF) | Linxian | 36 | Spring | No | Enzyme immunoassay | 31.7 | | | | |
| Li L. 2012 | Adults | 1420 (MF) | Dali | 25 | Mar-May | No | RIA | 54.9 | | | | |
| Ren C. 2012 | Adults | 197 (MF) | Guangzhou | 23 | All | No | ELISA | 48.9 ± 23.7 {ANAME()}ancbtbl3fnsection | § {ANAME} | | 57.9 | 91.9 | |
| Huang Y. 2012 | Adults | 49 (F) | Shanghai | 31 | Jan-Apr | No | Chemiluminescence | 29.4 | | | | |
:Footnote: please see Table 1The elevation in Dali is 2007 meters
:;∗The data from Hong Kong were used for head-to-head comparison with Beijing.;†Pragnancy.;‡Pragnancy with gestational diabetes.;§Gastric cancer.
Surprisingly, in women of childbearing age, a lower 25(OH)D level also was found in lower latitude regions (29 nmol/L in Beijing versus 34 nmol/L in Hong Kong where the latitude is 22 north) [18].
Vitamin D status in the elderly
The elderly are fourfold less efficient in cutaneous vitamin D photosynthesis than youth [28] and [29] and are particularly vulnerable to bone fracture or mobility disorders. The 25(OH)D status was alarming in the fast-growing aging Chinese population (Table 4) [17], [30], [31], [32], [33], [34], [35] and [36]. There was no any study showing average 25(OH)D above 50 nmol/L. In two large-scale investigations in Beijing and Shanghai, as high as 70% to 90% of the participants had blood 25(OH)D levels below 50 nmol/L [30] and [35]. In 1460 elderly urban Shanghai residents, only 3.9% had plasma 25(OH)D levels >75 nmol/L [31]. Oral cholecalciferol (vitamin D{SUB()}3{SUB}) at 925 IU/d, raised serum 25(OH)D from 40 nmol/L to 50 nmol/L in 3 mo in 45 postmenopausal women [34].:Table 4. Vitamin D status in the elderly
:
| PublicationAge (yrs)NumberPlaceLatitude (north)SeasonD UseAssay method25-OH-D (nmol/l)Deficiency (%) | |||||||||||
| --- | |||||||||||
| <25<50<75 | |||||||||||
| Lu L. 2009 | 50-70 | 3262 (MF) | Shanghai Beijing |
31 40 |
Apr-Jun | Unknown | Radio-immunoassay | 40.4 | 69.2 | ||
| Dorjgochoo T. 2012 | 61 | 1460 (MF) | Shanghai | 31 | All | Unknown | chemiluminescence | 34.7 | 96.1 | ||
| Kruger M. 2012 | 61.5 | 32 (F) | Beijing | 40 | Feb-May | No | Chemiluminescence | 33.1 ± 15.5 |
| 62.7 | 31 (F) | Beijing | 40 | Feb-May | No | Chemiluminescence | 29.3 ± 12.0 | | | | | Zhou X. 2012 | 62.1 | 181 (MF) | Beijing | 40 | All | No | ELISA | 35.8 ± 12.4 | 20.4 | 86.1 | 100
| 63.6 | 193 (MF) | Beijing | 40 | All | No | ELISA | 32.1 ± 10.8 {ANAME()}ancbtbl4fnlowast | * {ANAME} | 21.2 | 94.3 | 100 | | Zhang H. 2012 | 63.8 | 100 (F) | Shanghai | 31 | Dec-Mar | <600IU | Chemiluminescence | 42.0 ± 13.5 | | | | | Zhao J. 2011 | 64.1 | 1724 (F) | Beijing | 40 | Unknown | Unknown | Chemiluminescence | 33.0 ± 13.5 | | 89.7 | 99.4 | | Yan L. 2003 | 65.2 | 110 (F) | Shenyang | 42 | Feb-Apr | 14.5% | Radio-immunoassay | 30.9 ± 13.5 | 39.1 | |
| 67.9 | 108 (M) | Shenyang | 42 | Feb-Apr | 9.3% | Radio-immunoassay | 27.1 ± 11.5 | 52.8 | | | | Yan L. 2000 | 66.9 | 48 (F) | Shenyang | 42 | Apr-May | No | Radio-immunoassay | 42.9 ± 21.2 | 15.0 | |
| 68.9 | 50 (M) | Shenyang | 42 | Mar-May | No | Radio-immunoassay | 28.4 ± 12.5 | 48.0 | | |
:Footnote: please see Table 1
:;∗With COPD.
Discussion
The data presented in this contribution are likely epitomic for the nation because the investigations were conducted in the east part of Hu’s line (Fig. 1), which has been with <40% of the land and >90% of the population since 1930s [37]. In the global map of vitamin D deficiency/insufficiency [3] and [38], these data from China would stand for a sizable geographic area and the largest population.;
:Fig. 1. Distribution of studies. In some places like Beijing and Shanghai, multiple studies were conducted. The original blank map is from http://en.wikipedia.org/wiki/File:Chinaedcprelieflocationmap.jpg#file. The map is licensed under Creative Commons ShareAlike 3.0 http://creativecommons.org/licenses/by-sa/3.0/deed.en.
Vitamin D deficiency/insufficiency in China might have been caused by multiple factors, some of which are unique and worthy of being recognized. First, with the rapid transformation from an agrarian to an industrialized society, the urban proportion of population increased from 33% in 2000 to 50% in 2013 (the fifth and sixth National Population Survey http://www.stats.gov.cn). Accordingly, the number of people engaged in an outdoor profession with sun exposure has dramatically decreased. Second, due to air pollution accompanied by industrialization and urbanization, people were discouraged from spending time outdoors and UVB was prevented from penetrating the atmosphere; Third, the preference for lighter skin color (fair skin) in the society remains unchanged, leading to popular use of hats, umbrellas, and sunscreens when outdoors. UVB radiation–related skin carcinomas also are increasingly a concern. Fourth, despite massive and successful improvements in macronutrient intakes in the Chinese population, micronutrient intake did improve in parallel [39]. In fact, natural food rich in vitamin D in the Chinese diet remain scarce, and food and beverages fortified with vitamin D are limited in the market.Over the past several decades, the life span and life expectancy of the Chinese people has increased significantly, which brought the consequences of vitamin D deficiency, like osteoporosis and bone fracture, into greater prominence [40]. Accompanied by poor 25(OH)D status, a bone mineral density (BMD) survey with dual-energy X ray absorptiometry (DXA) in 10 Chinese cities estimated that the proportion of osteoporosis in men and women over age 50 y was 10.4% and 31.2%, respectively [41]. Furthermore, the incidence of hip fracture in Beijing in the period 2002 to 2006 escaladed much more rapidly compared with 1990 to 1992 [42]. Vitamin D deficiency increases the risk for both osteoporosis and falls [43] and [44], which are the two major risks for bone fracture.In summary, from published investigations in Mainland China since the year 2000, vitamin D deficiency/insufficiency was found to be widely prevalent, which constitutes a significant but modifiable public health risk that deserves greater awareness and more efficient and timely management. To attain a desirable vitamin D status at the population level, it requires multiple approaches (e.g., promotion of a healthy lifestyle, implementation of recommended daily intake, development of voluntary and mandatory fortification programs, and regulation establishment and reinforcement).(References are in PDF at the bottom of this page) See also VitaminDWiki