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Is ethnicity linked to incidence or outcomes of covid-19?

BMJ 2020; 369 20 April 2020 BMJ 2020;369:m1548 DOI: 10.1136/bmj.m1548 https://doi.org/10.1136/bmj.m1548 https://www.bmj.com/content/369/bmj.m1548

Concerns about a possible association between ethnicity and outcome were raised after the first 10 doctors in the UK to die from covid-19 were identified as being from ethnic minorities. Rapid response to: Is ethnicity linked to incidence or outcomes of covid-19? 24 April 2020 ''COVID-19 ’ICU’ risk – 20-fold greater in the Vitamin D Deficient. BAME, African Americans, the Older, Institutionalised and Obese, are at greatest risk. Sun and ‘D’-supplementation – Game-changers? Research urgently required.'' Robert A Brown et.al.

https://www.bmj.com/content/369/bmj.m1548/rr-6

Dr Hugh Sinclair almost 100 years ago observed; "The deficiency of any nutrient which is essential for every tissue will eventually lead to abnormal function in every tissue. That is so incontrovertibly obvious that I am continually astonished it must be repeatedly forcefully restated."

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Alipio’s results, viewed in the context of earlier recent vitamin D and COVID-19 publications,[2 9] must now lead to urgent research (Brown).[2, 13] Human nature is such that simple solutions to complex issues, for example vitamin C for scurvy, and hand washing prior to baby delivery, are often not readily embraced; but surely the scale and impact of the COVID-19 pandemic demands all avenues are fully explored; more so when no other effective treatment strategies as yet exist. A safe simple step, the correction of a deficiency state, vitamin D this time, convincingly holds out a potential, significant, feasible ‘COVID-19 mitigation remedy.

Int J Circumpolar Health. 2015; 74: 2015 May 13. Adequate vitamin D levels in a Swedish population living above latitude 63°N: The 2009 Northern Sweden MONICA study Anna Ramnemark, Margareta Norberg, Ulrika Pettersson-Kymmer, and Mats Eliasson

doi: 10.3402/ijch.v74.27963 PMCID: PMC4432023 PMID: 28417824

Results: Mean (median) level of vitamin D3 was 65.2 (63.6) nmol/l in men and 71.0 (67.7) nmol/l in women. Adequate levels were found in 79.2%, more often in women (82.7%) than in men (75.6%). Only 0.7% of the population were vitamin D3–deficient but 23.1% of men and 17.1% of women had insufficient levels. Levels of vitamin D3 increased with age and insufficient status was most common among those aged 25–34 years, 41.0% in men and 22.3% in women.

If subjects using vitamin D-supplementation are excluded, the population level of D3 is 1–2 nmol/l lower than in the general population across sex- and age groups. There were no differences between the northern or the southern parts, between urban or rural living or according to educational attainment. Those subjects born outside of Sweden or Finland had lower levels.

Conclusion: The large majority living close to the Arctic Circle in Sweden have adequate D3 levels even during the second half of the dark winter. Subjects with D3 deficiency were uncommon but insufficient levels were often found among young men. Eur J Clin Nutr 1995 Jun;49(6):400-7. ''Sunlight increases serum 25(OH) vitamin D concentration whereas 1,25(OH)2D3 is unaffected. Results from a general population study in Göteborg, Sweden (The WHO MONICA Project)'' K Landin-Wilhelmsen, L Wilhelmsen, J Wilske, G Lappas, T Rosén, G Lindstedt, P A Lundberg, B A Bengtsson

PMID: 7656883 https://pubmed.ncbi.nlm.nih.gov/7656883/

Results: The concentration of 25(OH)D3 was similar in both sexes whereas 1,25(OH)2D3 concentration was higher in women than in men (P = 0.01). 25(OH)D3 correlated positively to sun exposure, physical activity and negatively to intact parathyroid hormone (PTH) in both sexes, and also negatively to blood pressure in men. The remaining significant relationship for 25(OH)D3, when age and sun exposure were taken into account in multivariate analyses, was a negative correlation to intact PTH in both sexes. 1,25(OH)2D3 correlated positively to intact PTH in both men and women, negatively to height in men, positively to fibrinogen in men and positively to psychological stress and osteocalcin in women. When all variables were included in multivariate analyses 1,25(OH)2D3 concentration correlated negatively to age and positively to intact PTH and osteocalcin in both sexes together.

Conclusions: Sunlight was the only external factor that influenced 25(OH)D3 concentration whereas 1,25(OH)2D3 was unaffected by sun exposure. 1,25(OH)2D3 was not related to environmental or life style factors but declined by age and correlated positively to intact PTH and osteocalcin. Nutrition Reviews, Volume 66, Issue suppl_2, 1 October 2008, Pages S165–S169, 01 October 2008 Vitamin D requirement and setting recommendation levels – current Nordic view Jan I Pedersen

https://doi.org/10.1111/j.1753-4887.2008.00101.x

There is a strong seasonal variation in serum 25(OH)D. A Danish study illustrates the marked downward shift during the winter months, with levels falling below desirable vitamin D status in one half of the population

Under Nordic climatic conditions, exposure to sunlight is thus insufficient for enough vitamin D to be formed in the skin and for vitamin D status to be maintained during the winter months. A study from northern Finland in 1980 showed that vitamin D status was satisfactory during the summer months but that a large number of subjects had unsatisfactory vitamin D status during winter.8 On the other hand, more satisfactory serum levels of 25(OH)D and greater seasonal variation was found among adults in a similar study from Tromsö in northern Norway.9 The results of these studies indicate that the light intensity at 70 degrees north is sufficient during summer to elicit vitamin D formation in the skin. One explanation for the difference observed in vitamin D status between the two population groups during the winter months is that, at the time of these studies, the consumption of fish and margarine fortified with vitamin D was much higher in Norway than in Finland. Dietary vitamin D is thus essential to ensure satisfactory vitamin D status at northern latitudes, particularly during the winter months. The question is how much is needed and what intake should be recommended?

CONCLUSION: Vitamin D intake is at about the same low level in Norway and the other Nordic countries. It is slightly higher in Iceland due to widespread use of cod liver oil and slightly lower in Denmark because, until recently, food fortification has not been used. In all Nordic countries, steps are now taken to increase vitamin D intake at the population level in order to reach the new increased recommendations. In addition to disseminating information, increased fortification of foods is essential to reach this goal.

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As expected, there was considerable variation in prevalence of vitamin D deficiency among the European Union countries, which appeared to be dependent on age group. In studies of adult and older adult populations, the prevalence of vitamin D deficiency was much less in the more northerly latitude countries such as Norway, Iceland, and Finland, whereas more mid-latitude countries such as the United Kingdom, Ireland, Netherlands, and Germany had a higher prevalence, even accounting for ethnicity. The amplitude of an increase in prevalence in vitamin D deficiency in extended winter compared with extended summer was also much lower in the northerly latitude countries, which is likely attributable to higher rates of vitamin D supplement and/or food fortification use in these countries (49–51). In the case of the childhood population studies, the relatively mid-latitude countries (47–60°N) had a higher prevalence range (5–20%) than did southern countries (<41°N) at 4.2–6.9%.