What is Vitamin D

The human body naturally synthesises vitamin D3 in the skin through exposure to direct sunlight and also obtained through the diet from fish liver oils and saltwater fish. In many developed countries, milk and other foods are fortified with vitamin D.

Vitamin D3 levels also decrease with age because skin synthesis declines. The use of sunscreen, as well as dark skin pigmentation, can also reduce the amount of vitamin D3 the body produces.

Vitamin D affects many organ systems, but it primarily helps to increase calcium and phosphate absorption from the intestines and promotes the formation of mineralisation within the bones.

A deficiency in vitamin D can be the result of the following:

• Lack of exposure to sunlight
• Reduced intake of vitamin D in the diet
• A reduction in the absorption of vitamin D
• Vitamin D is unable to be metabolised by the body
• The body becomes resistant to the effects of vitamin D

The benefits of Vitamin D

• Vitamin D plays an important role in the health of muscles and bones. It helps with the absorption of calcium and phosphorus from the intestines, which has a direct effect on the muscles and bones. An increase in vitamin D can help with aches and pains in the bones and muscles as well as help with chronic fatigue and osteoporosis.
• It has a vital role in the normal functioning of the immune system and can prevent and treat immune disorders such as rheumatoid arthritis, type 1 diabetes, Crohn’s disease and asthma. It can also help to prevent and treat colds, flu and other infections of the body.
• Vitamin D controls the growth of normal and cancerous cells. It can act as a prevention and treatment of certain cancers such as colon, pancreas, breast and prostate cancer.
• It stimulates the production of insulin by producing cells in the pancreas. It also helps to reduce insulin resistance and can help to prevent type 2 diabetes.
• It helps to regulate blood pressure by aiding the production of angiotensin. Vitamin D also helps to prevent hypertension, kidney disease and heart failure.
• Reduces the chances of developing coronary heart disease by reducing inflammation in the blood vessel wall.
• Helpful in the treatment of skin conditions like psoriasis as it aids in normal skin function.
• Beneficial for the health of the teeth and preventing many dental problems.
• Boosts the mood and helps to treat depression.
• Reduces the risks of neurological disorders such as Multiple Sclerosis (M.S), Parkinson’s disease, Autism and Alzheimer’s by aiding the development and function of the brain.

Vitamin D the Hormone

Vitamin D is a hormone that is produced in the skin from 7-dehydrocholesterol (pro-vitamin D3), which is derived from cholesterol. Cholesterol is a precursor for most hormones of the body.

Type B Ultraviolet rays (UVB) act on pro-vitamin D3 and convert it into pre-vitamin D3, which is then converted into vitamin D3. Vitamin D3 then leaves the skin and enters into the bloodstream, where it travels on a special protein called a vitamin D-binding protein (VDBP).

Like other hormones, vitamin D exerts its biologic effects through a specific chemical structure inside the cell, called vitamin D receptor (VDR), which has been discovered inside the nucleus of nearly every cell in the human body.

Vitamin D deficiency has been found to be more prevalent than previously thought and in pandemic proportions. It is presumed this may explain the rise of chronic fatigue, heart disease, hypertension, diabetes, cancer, osteoporosis, asthma and other immunologic diseases.

History of Vitamin D deficiency

History tells us that the human race started their journey in Africa, where there is regular sunshine all year round. The earliest humans also wore very little, if any, form of clothing. After a slow migration north over thousands of years, skin evolved to adapt to the colder climates by reducing the melanin levels in the skin and its natural sun protection, and consequently, skin became lighter in colour. This evolution allowed humans to synthesise enough vitamin D in shorter exposure times.

Deficiency in vitamin D is a relatively new discovery, first recognised by scientists in the 17th century in the UK. It began to be discovered around the time of the industrial revolution when people migrated to industrial cities and lived and worked in multistorey buildings with narrow and dark passageways, teamed with pollution from the coal-burning factories. This affected the sunlight penetrating towards the lower ground reducing exposure to sunlight as well as long, cold and dark winters.

In the 1900s, a new disease emerged amongst children living in big industrial cities like London. These children had stunted growth, muscle wasting and deformed legs. This disease was named rickets by physicians, but no one understood the cause of this crippling disease. Children had little exposure to sunshine, and consequently, severe vitamin D deficiency developed, and children were particularly affected as their developing bones suffered severely. By the 1930s, the link between rickets and vitamin D deficiency was well established. This discovery led to the fortification of milk with vitamin D. In the countries that adopted this practice mostly eradicated rickets.

Now migration can occur even quicker, in a matter of hours by plane. With the rise of people living in Europe from Asia and Africa, who haven’t had thousands of years to adapt to this climate change like their ancestors, are particularly prone to vitamin D deficiencies.

Those with fairer skin tones which now adapted to the colder and darker climates of the north started to holiday in the south. This caused a rise in skin cancer, starting a campaign of sun avoidance and people of all races, applying sunscreen to block these harmful rays. We are now trained to avoid the sun at certain times of the day, wear sunscreen all year round and cover up to avoid the risk of cancer. This also has the damaging side effect of a reduction of vitamin D production.

People also spend more time indoors than ever before, further reducing their exposure to the vital rays of the sun that produce vitamin D in the skin.

Sources of Vitamin D

Vitamin D can be obtained from several sources, but for many people, they are unable to make enough vitamin D required by any of the sources.

Sun Exposure

It is incredibly difficult for anyone to make enough vitamin D from sun exposure alone. Anyone Fitzpatrick 1-3 would need to sunbathe for around 2-4 hours a day in summer to achieve a good level of vitamin D. Fitzpatrick 4 and above need ten hours a day. This is unobtainable for many people around the world.

The use of a sunscreen that blocks UVB rays will prevent the synthesis of vitamin D; however, the risk of skin cancer is high for many people who over-expose themselves to the sun’s harmful rays.

Diet

Diet is not the best source of vitamin D; however, you can get some of your daily requirement from selective foods. Many foods have vitamin D added to them, such as milk, yoghurt and cereals. Oily fish such as salmon and mackerel contain reasonable amounts of vitamin D. How the fish is cooked will determine the amount of vitamin D that is absorbed by the body. Fish that is fried decreases in vitamin D content by around 50%.

Eggs, meat and vegetables contain very small amounts of vitamin D.

Vitamin D Supplements

Taking a vitamin D supplement can help to increase the body’s natural vitamin D levels; however, many people are taking too low a dose for their weight, as vitamin D is fat-soluble and gets trapped in fat. Consequently, less is then available for the rest of the body. Medications can also decrease vitamin D reserves in the body.

Many people will assume that they are taking their daily recommended allowance of vitamin D as they are taking multivitamin supplements that claim they contain 100% of the daily requirement.

Many specialists within the field of nutrition recommend taking a daily dose of vitamin D of 1000 I.U for every 20lbs of body weight.

Types of Vitamin D

There are two types of vitamin D.

Vitamin D2, also known as ergocalciferol which is of plant origin.

Vitamin D3, also known as cholecalciferol which is of animal origin.

In the natural state, humans synthesise vitamin D3 in their skin when exposed to the sun; therefore, this is a more beneficial type of Vitamin D to use.

Symptoms of Vitamin D deficiency

• Fatigue or tiredness
• Bone pain
• Joint pain
• Muscle pain
• Sour mood
• Low energy
• More frequent illness
• Anxiety
• Irritability
• Weight gain
• Hair loss
• Sweaty Scalp
• Fertility issues

Risks leading to vitamin D deficiency

• Vegans
• Indoor workers
• Nursing mums
• Over 50’s
• Fitzpatrick 4 and above
• Obesity
• Geographic location
• Season of the year, i.e. winter months

Vitamin D toxicity

It is quite common for magazines and news articles to discuss the dangers of vitamin D toxicity, and these stories may put people off taking any form of supplementation.

Vitamin D toxicity is defined as ‘too much vitamin D, causing harm to the body.’

According to a review from Queen’s University in Kingston, Canada, the author concluded that a blood level of more than 300ng/ml is considered to caused toxicity. The upper limit of vitamin D was set at 30-100ng/ml to provide a large safety net.

The University of Toronto, Canada, reported two cases of high doses of vitamin D. The first was a gentleman that had been taking 4,000 I.U./day for three years followed by three years of 8,000 I.U./day. On investigation, his blood levels remained around 52ng/ml while taking 4,000 I.U./day and 104ng/ml while taking 8,000 I.U./day. There was no evidence of toxicity, and he maintained normal levels of calcium in his blood and urine over the six years he was taking vitamin D3.

The second gentleman was a 39-year-old diagnosed with multiple sclerosis. He started to initiate his own dose of vitamin D3, starting from 8,000 and increasing to 88,000 I.U./day over a period of 4 years. At the highest dose, his blood vitamin levels were 450 ng/ml, and his blood calcium was 2.63 mmol/L (range should be 2.2-2.6 mmol/L). Even at the higher doses of vitamin D, his calcium levels were only slightly above the upper limit of normal, without any symptoms of toxicity.

In medical literature, cases of vitamin D toxicity are rare.

A case of vitamin D toxicity was reported from the All India Institute of Medical Sciences, India. The patient was a 70-year-old woman with a history of hypertension and diabetes. She presented with decreased appetite, constipation and a transient loss of consciousness.

Her blood calcium levels were 12.4 mg/dl (normal range 8.5-10.5 mg/dL) and vitamin D level was 2016 ng/mL. The patient had received four intramuscular injections of Architol (vitamin D3), each of 600,000 I.U., prior to admission to the hospital. She fully recovered with treatment.

The Sheri Kashmir Institute of Medical Sciences, India, described 10 cases of vitamin D toxicity over a decade. The dose of vitamin D ranged from 3.6 million I.U. to 210 million I.U. over a period of 1-4 months. These patients presented with excessive thirst, vomiting, excessive urination, kidney failure and confusion. Nine patients recovered whilst one died due to overwhelming infection.

Risk of toxicity from intramuscular injections

There are several different preparations or vitamin D supplements. These include Vitamin D3 (cholecalciferol), Vitamin D2 (ergocalciferol), Calcidiol and Calcitriol. Calcitriol is also known as Rocaltrol.

Calcitriol is a synthetic form of vitamin D and is a drug rather than a supplement. Therefore, it requires a prescription from a GP or prescriber. It is typically given to patients with kidney failure who are on dialysis. It can also be prescribed to patients whose parathyroid glands have been removed. Calcitriol is more potent than natural vitamin D3 or D2 and can sometimes result in vitamin D toxicity.

It is impossible to get vitamin D deficiency from too much sun exposure. The skin forms as much vitamin D as the body needs, and beyond this, it degrades the excess into inactive metabolites.

Signs of Vitamin D toxicity

Excessive amounts of vitamin D in the body can cause calcium levels in the blood to rise. This can lead to a condition called hypercalcemia (too much calcium in the blood); symptoms include:

• Loss of appetite
• Weight loss
• Excessive thirst
• Excessive urination
• Dehydration
• Fatigue
• Constipation
• Ringing in the ear
• Nausea, vomiting
• Dizziness
• Irritability, nervousness
• High blood pressure
• Confusion, disorientation
• Heart arrhythmias

Long-term, untreated complications include:

• Kidney failure
• Kidney stones
• Kidney damage
• Excess bone loss
• Calcification (hardening) of arteries or soft tissues.

Treatment of vitamin D toxicity

Treatment usually involves stopping vitamin D intake and reducing calcium intake.

Client Consultation

A client consultation is a one to one talk with your client. During this time, you will find out very important and confidential information that will allow you to advise and provide the best treatment for the client.

It is important to always introduce yourself to the client as this removes any barriers and relaxes them. Consultations should always be undertaken in a private room or area where you cannot be overheard by others.

A client should first fill out a client consultation which helps identify any contra-indications that may mean you have to alter the treatment or be unable to treat them at all. If their form shows no reason why they cannot proceed with the treatment, then you can move onto verbal questioning.

Verbal questions would be to establish why the client has visited the salon and what their expectations and outcome of the treatment may be. Asking what they want ensures you can provide customer satisfaction as the client should be pleased with the outcome of their treatment. It is good practice to speak to the client in front of a mirror and explain the treatment to them and see if that meets their requirements.

Once you have established what the client is after, then a physical examination should be undertaken. This allows you to further check for any undeclared contra-indications and get a better overview of any issues that you may face during the procedure.

Allow around 15 minutes for the client's first salon visit. Ideally, you should sit face to face or next to the client to create an open atmosphere. Avoid barriers such as a couch or table between you.

Use open questions to tactfully encourage the client to give you information that you may need rather than using interrogating questioning techniques. Use the consultation form to work from and record anything you may discuss.

Record Keeping

Records must be maintained and updated for a number of reasons.

• They provide contact details in case you need to alter or cancel an upcoming appointment.
• So that you can track client’s progression.
• To record the products used and timings so you can use these at further visits and adjust the treatment plan if required.
• Tracks any aftercare you provide the client.
• Records patch test history.
• As a backup in case, the client has an adverse reaction to treatment.
• For legal reasons if the client brings a claim against you.

Client records can be stored electronically or filed away manually and should be updated at every visit. If consultation forms are not updated and do not contain a history of services and dates, then you may find your insurance invalid.

Forms should be kept for the timeframe suggested by your insurance company. This may be for up to six years. If a client is under 21 at the time of service, then it is recommended to keep the forms for six years past their 21st birthday.

Client confidentiality must be protected at all times. Forms need to be locked away in a secure cabinet, and electronic records should be held on a password-protected computer. You may also need to register with the ICO as a data controller.

• All information must be accurate and necessary for the service or treatment being performed.
• Individual client records must be available for the clients to view if requested.
• Data should not be passed on or sold without the client’s prior written permission.

The following details should be recorded on the client consultation form:

• Personal details – name, address, contact details
• Results of any patch tests
• Contra-indications
• Contra-actions
• Reasons for the treatment
• Any reactions to treatments/previous treatments
• Home care advice/suggested retail items.
• Any sales
• Treatment timings/products used etc.
• Next appointment or recommendations

Any contra-indications and possible contra-actions should be identified and discussed prior to the treatment. In the case of a medical referral, the therapist should keep a copy of the GP's letter with the client's record card.

Consultation forms must be signed and dated to prove that you have covered everything and given the correct advice and treatment plan.

Contra-indications

A contraindication is the presence of a condition which may make the client unsuitable for the treatment. The treatment may not be able to take place, or the treatment will need to be adapted.

When treating a client, if they show any signs of contra-indications, you should tactfully refer them to their GP for treatment or advice. You should never make a diagnosis even if you are certain of the condition as you may be wrong.

If you are unsure about any contra-indications, then do not treat the client and refer them to their GP.

Be careful if you deal with a contra-indication, and they can often be contagious. Make sure you clean the work area and any implements between clients to prevent cross-infection.

Contra-indications

• Pregnancy
• Breastfeeding
• Allergy to any of the products' ingredients
• Hypersensitivity to Calcitriol
• Hypercalcemia
• If under close medical supervision
• Cardiac disease
• Renal failure

Side effects

Vitamin D injections are intramuscular (into the muscle) injections that provide a large dose of Vitamin D. After the injection, the muscle gradually releases the Vitamin D into the bloodstream.

Studies show that after one injection, Vitamin D levels continue to rise for several weeks and will remain improved for several months.

After the injection, clients may experience constipation as a side effect, stomach irritation or discomfort may arise following treatment. Elevated vitamin D levels may induce nausea or vomiting, which may also result in a diminished appetite, weight loss or unusual weakness.

Rarely high vitamin D blood levels caused by the treatment with this type of supplement may increase the amount of calcium in the body. This side effect, called hypercalcemia, may have serious consequences. Symptoms associated with high calcium levels include confusion, frequent urination, increased thirst, fatigue, dry mouth, headaches or instability while walking.

Equipment Needed

• 2.5ml Syringe
• 23g, 30mm blue needle
• 21g, green drawing needle
• Vitamin D – Calcitriol 1mcg/1ml
• Antiseptic skin wipes
• Gauze or cotton wool
• Gloves
• Kidney dish
• Glass ampoule opener

Calcitriol

Calcitriol is a man-made active form of vitamin D3. Bioactive vitamin D or calcitriol is a steroid hormone that has long been known for its important role in regulating body levels of calcium and phosphorus and in the mineralisation of bone. More recently, it has become clear that receptors for vitamin D are present in a wide variety of cells and that this hormone has biologic effects which extend far beyond the control of mineral metabolism.

1 x 1ml vial should be drawn and administered intramuscularly.

Calcitriol is an injection designed to be administered in the clinic once a week for six weeks, then maintained with one further injection every six weeks thereafter.

Intramuscular Injections

Intramuscular (IM) injections deposit medications into the muscle fascia, which has a rich blood supply, allowing medications to be absorbed faster through muscle fibres than they are through the subcutaneous route. The IM site is used for medications that require a quick absorption rate but also a reasonably prolonged action. Due to their rich blood supply, IM injection sites can absorb larger volumes of solution. In addition, muscle tissue is less sensitive than subcutaneous tissue to irritating solutions and concentrated and viscous medications.

Intramuscular injections must be done carefully to avoid complications. Complications with IM include muscle atrophy, injury to the bone, cellulitis, sterile abscesses, pain, and nerve. With IMs, there is an increased risk of injecting the medication directly into the patient’s bloodstream. In addition, any factors that impair blood flow to the local tissue will affect the rate and extent of drug absorption.

Sites for intramuscular injections include the ventrogluteal, vastus lateralis, and deltoid site. There is sufficient evidence that the ventrogluteal IM site is the preferred site whenever possible. The ventrogluteal site is free from blood vessels and nerves and has the greatest thickness of muscle when compared to other sites. A longer needle with a larger gauge is required to penetrate deep muscle tissue. The needle is inserted at a 90-degree angle perpendicular to the client’s body or at as close to a 90-degree angle as possible. Use a quick, darting motion when inserting the needle.

Aspiration refers to the action of pulling back on the plunger for 5 seconds prior to injecting medication. The current practice is to aspirate IM injections to checking for blood return in the syringe. Lack of blood in the syringe confirms that the needle is in the muscle and not in a blood vessel. If blood is aspirated, remove the needle, discard it appropriately, and re-prepare and administer the medications.

The dorsogluteal site

The dorsogluteal (buttock) site is not routinely used due to its location near major blood vessels and nerves, as well as having an inconsistent depth of adipose tissue. Many injections in this site do not penetrate deep enough under the skin to be correctly administered in the muscle.

Since the dorsogluteal site is in close proximity to the sciatic nerve, significant injury, pain, and temporary or permanent paralysis can occur if medication damages the sciatic nerve. Damage can occur if the injection site is not mapped correctly.

IM injection into the Gluteus medius site (buttock)

• Find the trochanter. It is the knobbly top portion of the long bone in the upper leg (femur). It is the size of a golf ball.
• Find the posterior iliac crest. Many people have ‘dimples’ over this bone.
• Draw an imaginary line between the two bones
• After locating the centre of the imaginary line, find a point one inch toward the head. This is where (X) to insert the needle.
• Stretch the skin-tight
• Hold the syringe like a pencil or dart. Insert the needle at a right angle to the skin
• Up to 3ml of fluid can be given in this site.

The ventrogluteal site

Giving an IM injection into the ventrogluteal site

The Ventrogluteal site provides the greatest thickness of gluteal muscle (consisting of both the gluteus medius and gluteus minimus), is free of penetrating nerves and blood vessels, and has a narrower layer of fat of consistent thinness than is present in the dorsogluteal.

Giving an IM injection into the ventrogluteal site

• Find the trochanter. It is the knobbly top portion of the long bone in the upper leg (femur). It is about the size of a golf ball.
• Find the anterior iliac crest
• Place the palm of your hand over the trochanter. Point the first or index finger toward the anterior iliac crest. Spread the second or middle finger toward the back, making a ‘V’. The thumb should always be pointed toward the front of the leg. Always use the index finger and middle finger to make the ‘V.’
• Give the injection between the knuckles on your index and middle fingers.
• Stretch the skin-tight
• Hold the syringe like a pencil or dart. Insert the needle at a right angle to the skin (90°)
• Up to 3ml of fluid may be given in this site.

The deltoid site

The ease of access, especially in an outpatient setting, possibly adds to the frequency with which the deltoid site is used for IM injections. This site is used for immunisations/non-irritating medications; hence vaccines that are usually small in volume tend to be administered into the deltoid site. This is a relatively small area and muscle mass, especially in atrophied clients compounded by the close proximity of the radial nerve, brachial artery and bony processes to this site, means that more substantial injuries can occur.

• Find the knobbly top of the arm (acromion process)
• The top border of an inverted triangle is two finger widths down from the acromion process
• Stretch the skin and then bunch up the muscle
• Insert the needle at a right angle to the skin in the centre of the inverted triangle

Caution: This is a small site – give only 1-2ml or less of fluid in this site

• Prepare everything, ensure you have your syringe, drawing needle, injection needles and vitamin vile ready, along with your sharps bin.
• Open your syringe and drawing needle, keeping the packaging on where possible in order to not contaminate the needle.
• We recommend using a 21g Gauge drawing.
• Attach the drawing needle onto the syringe, leaving the protection cap on the needle.
• Open your vitamin ampoule. Break the top off the ampoule from the dot and dispose of the top.
• Take the top protection cap off the drawing needle and draw up from the ampoule the correct dose as recommended or suggested by your prescriber.
• Dispose of the single-use ampule, do not use any further product from it.
• Open the packing for your injection needle; we recommend the 23 Gauge needle.
• Take your syringe and untwist the drawing needle with the cap off, and put it in your sharps bin.
• Put your injection needle with packaging left on onto the syringe; once secured, remove the packaging and push up all the air out of the syringe until you hit your dosage marker on the syringe.
• Clean the injection area using an alcohol wipe once you have located it.
• Dart the needle into the muscle and push in relatively quickly.
• Press and wipe the area with an alcohol wipe and dispose of your injection needle into the sharps bin.