Vitamin D: to D or not to D?
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This presentation given to the International Society for Enzymology in Corfu details the extent of vitamin D deficiency in the largest state of Australia, NSW. It highlights the over=testing phenomenon that has occurred and how to correct the problem.
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Vitamin D: to D or not to D?
- 3. Nutrition Related Disorders Micronutrition Undernutrition PCM Minerals and Vitamins Folic Acid Vitamin D deficiency Vitamin A deficiency Fe deficiency Selenium deficiency Iodine deficiency Macronutrition Obesity Hyperlipidemia Insulin Resistance Diabetes Alcohol
- 4. Key questions 1. Are we vitamin D deficient and whose is at risk? 2. Are we over-diagnosing and over-testing? 3. How much vitamin D do we need and how should we supplement?
- 5. Vitamin D: Not a vitamin but a steroid hormone
- 6. Synthesis and Metabolism of Vitamin D in the Regulation of Calcium, Phosphorus, and Bone Metabolism Holick M. N Engl J Med 2007;357:266-281 Physiology: skeletal and non skeletal
- 7. Health benefits of vitamin D: Low levels of vitamin D linked to Osteoporosis and osteopenia Cancer Diabetes Cardiovascular disease Autoimmune disease Multiple sclerosis Respiratory Illness Mental Health Skeletal Non Skeletal
- 8. Sources of vitamin D
- 9. Factors affecting vitamin D levels Season Latitude UVR Cloud cover Age Skin colour Body fatness Fat malabsorption Geographical Physiological • Other factors – Sunscreen – Clothing
- 10. Causes of vitamin D deficiency Reduced skin synthesis Decreased bioavailability Malabsorption Obesity Increased catabolism Decreased synthesis eg liver failure Increased renal loss Decreased production of 1,25 OH vitamin D Heritable disorders Acquired disorders eg hyperthyroidism, hyperparathyroidism, tumour induced osteomalacia, granulomatous disorders
- 11. Adequate vitamin D status Vitamin D (nmol/L*) Conventional guidelines Newer recommendations+ Severe Deficiency <12.5 Moderate deficiency 12.5-25 Mild deficiency 25-50 <50 Insufficiency 50-75 Sufficiency >50 >75 *2.5 nmol/L = 1 ng/ml +Bischoff Ferrari, AJCN 2006
- 13. Australian Studies No. of subject s Latitude (0S) Mean 25(OH)D Prevalence (%) Ref. <28 nmol/L <50 nmol/L Overall VIC 861 38 - 7.2 30.0 Pasco 2001 SE QLD 414 28 69.1 8.0 23.4 McGrath 2001 Winter SE QLD 28 - 40.5 McGrath 2001 VIC 861 38 59.1 11.3 43.2 Pasco 2001 VIC 287 38 17.6 60.3 Pasco 2004 TAS 404 43 36.2 ~7.4 50.7 Van der Mei 2007 QLD/VI C/TAS 1669 28-43 67.0/75.5 / 51.1 7.1/7.9/ 13.0 40.5/37.4 / 67.3 Van der Mei 2007 b (pooled
- 14. 4697 31131 25(OH)D assays 1 July 2008 and 30 July 2010 Primary test, complete data available for gender, age, patient setting, date of test, postcode**, known breast cancer case, 25(OH)D ≤400 nmol/L Sample type 10839 13979 Diagnostic referral Outpatient Private outpatient Emergency Inpatient Private hospital patient Public hospital patient Private patient 29516 24819 Ye s 680618012 Femal e Mal e 62016251 Summe r Winter 61216245 Autumn Spring 1615 QC sample Research Miscellaneou s Unknown * *Matched to ARIA, SEIFA, Latitude, Longitude
- 15. Mean 25(OH)D by gender 74.0 45.1 65.5 43.2 40.0 45.0 50.0 55.0 60.0 65.0 70.0 75.0 Male Female 45% reduction by June P<.001 37% reduction by June
- 16. Mean 25(OH)D by patient setting 70.2 44.9 63.4 42.9 40.0 45.0 50.0 55.0 60.0 65.0 70.0 Ambulatory subject Inpatient P<.001
- 17. Mean 25(OH)D by gender and patient setting Supporting Women with Breast Cancer Today and Every Day 79.1 48.6 60.4 42.6 40.0 45.0 50.0 55.0 60.0 65.0 70.0 75.0 80.0 Ambulatory Male Ambulatory Female Inpatient Male Inpatient Female
- 18. Mean 25(OH)D by age group *77.0 65.6 40.7 *61.2 40.0 45.0 50.0 55.0 60.0 65.0 70.0 75.0 80.0 <20 20-39 40-59 60-79 ≥80 *P<.001
- 19. Mean 25(OH)D by remoteness 0 10 20 30 40 50 60 70 80 Major cities Inner Regional Outer Regional Remote Australia Very Remote Australia *66 50 *71 Ambulatory Male Ambulatory Female Inpatient male Inpatient Female *P<.0 5
- 21. Frequency of repeated testing Bilinski & Boyages BMJ Open 2013;3: e002955
- 22. Requests per 100000 for FBC, bone densitometry and vitamin D Bilinski & Boyages BMJ Open 2013;3: e002955
- 23. Results Bilinski & Boyages MJA 197 (2) · 16 July 2012
- 24. Google trends for vitamin D 6/30/201 ©2011 Healthcare Information and Management Systems Society24
- 25. Google Analytics-Google Trends 6/30/201 ©2011 Healthcare Information and Management Systems Society25
- 27. Vitamin D and its musical impact
- 29. What was the cause of Mozart’s death?
- 31. Vitamin D Test Medicare Benefit ($m) per annum: Australia 0 20,000,000 40,000,000 60,000,000 80,000,000 100,000,000 120,000,000 140,000,000 160,000,000 1994 1999 2004 2009 2014 $million Year Medicare Benefit ($m)
- 32. Vitamin D intake recommendations *Recommendations based on maintaining serum vitamin D > 75 nmol/L (30ng/ml) Recognition that individuals who are obese or on certain medications be give 2-3 times more vitamin D 40 IU = 1 µg Age NHMRC IOM US Endo Society* 0-1 200 400 1000 1-18 200 600 1000 19-49 200 600 1500-2000 50-69 400 600 1500-2000 70 and over 600 800 1500-2000
- 33. Health Implications Public health messages required to address high prevalence of vitamin D deficiency Australians are not adequately supplementing - suitable guidelines are required Implications regarding frequency and timing of testing Fortification of food may be a better approach
- 34. Acknowledgements Australia CJ Eastman JP Halpern John K Collins Li Mu China Indonesia The Netherlands Hemmo Drexhage USA, Atlanta GF Maberly Italy, Pisa Alessandro Antonelli
Notes de l'éditeur
- As part of a more specific study we are conducting to understand the relationship between vitamin D status and factors associated with breast cancer prognosis we wanted to assess vitamin D status in the a large population of individuals in and examine the relationship between vitamin D and other environmental factors. Australian studies to date have been limited. Most have sample sizes or examine vitamin D status in individuals at high risk of deficiency.
- Sunlight 1 MED = 20000 IU Hands, arms, neck (11%) for 20 minutes in summer early am = 1000 IU Salmon 160g fillet approx. 530 IU Fortified cheese slice 55 IU Regular milk 20 IU Margarine 12 IU Multivitamins ave.200 IU Caltrate with D 400 IU Specific D ave. 1000IU
- Current recommendations generally focus on bone health in older people. Evidence suggests that vitamin D intakes above current recommendations may be associated with better health outcomes although the optimal level is not known. The most advantageous serum concentrations of 25(OH)D of 75nmol/L (30ng/mL) are based on factors such as reduction in fractures rates, maximum suppression of PTH and maximum calcium absorption as well as non skeletal outcomes. An intake of at least 1000 IU is suggested to bring at least 50% of the population up to 75nmol/L
- Australian studies have included limited numbers of subjects.
- Study Design Explain patient status Define setting Aria; SEIFA. latitude obtained from postcode
- Based on visual inspection of vitamin D level by age we classified subjects into age groups: <20; 20-39. 40-59, 60-79, ≥80
- Inpatients always lower than ambulatory subjects except females in very remote Australia.
- The high frequency of testing in individuals suggest that better value could be derived. Subgroup analysis between 1 April 2006 and 31 October 2010 showed that although 49.5% of individuals had an average of two tests in that period, 14.5% had over four tests, and 8.2% had over five tests (with some individuals having up to 79 tests in that period).
- This increase in 25OHD testing has risen above the general trend of other common pathology tests such as full blood count
- The annual benefit for 25OHD testing subsidised by the MBS increased from $1.02 million in 2000 to $96.7 million in 2010, an average increase of approximately 59% per year
- Based on adequate sunlight exposure Developed for maintenance of calcium homeostasis and prevention of osteoporosis Call for new recommendations based on newly discovered actions