Vitamin D in New Zealand

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Presentation for our departmental journal club about the significance of vitamin D in New Zealand

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  • 11/02/11 09:35
  • 11/02/11 09:35
  • 11/02/11 09:35
  • 11/02/11 09:35
  • Vitamin D in New Zealand

    1. 1. Nathan Billing
    2. 3. <ul><li>Brief overview of dietary sources of vitamin D </li></ul><ul><li>Defining Vitamin D status </li></ul><ul><li>Vitamin D in New Zealand </li></ul><ul><li>Biochemistry of metabolism of vitamin D </li></ul><ul><li>Key conditions affected by Vitamin D </li></ul><ul><ul><li>Osteoporosis </li></ul></ul><ul><ul><li>Influenza </li></ul></ul><ul><ul><li>Cardiovascular disease </li></ul></ul><ul><ul><li>Cancer </li></ul></ul><ul><li>Supplementation </li></ul>
    3. 4. In Australia but not New Zealand, all table margarines are fortified with vitamin D,
    4. 5.  A blood calcidiol (25-hydroxy-vitamin D) level is the accepted way to determine vitamin D nutritional status, and shows considerable variation. Primates Humans Canadians 1000 IU 4000 IU in sun in winter supplement supplement 140 130 40 70 100 Old-World Primates Humans with UV Canadian Winter Canadian + 25 ug/d Canadian + 100 ug/ d 0 40 80 120 160 Serum 25(OH)D nmol/L
    5. 6. 20 40 60 80 100 120 Serum 25(OH) D nmol/L Insufficiency
    6. 7. According to Dietitian’s NZ clinical handbook 2010 25OH-vitamin D <25nmol/L 25-50nmol/L 50-150nmol/L <250nmol/L Moderate-severe deficiency Mild deficiency Optimal target for bone health Intoxication reported 1,25OH-vitamin D 65-175pmol/L Interpretation is specific to clinical context
    7. 8. <ul><li>Vitamin D deficiency: an emerging public health problem in Australia 1 (all over the world) </li></ul><ul><li>Deficiency  bone pain, muscle weakness, osteoporosis, falls, fractures 1 </li></ul><ul><li>60% of postmenopausal Australian women with osteoporosis had low serum vitamin D (<30 ng/mL) 2* </li></ul><ul><li>* International study of 2606 postmenopausal women with osteoporosis, including 204 women from Australia </li></ul>1. Osteoporosis Australia. Calcium, Vitamin D and Osteoporosis – A Guide for GPs 2 nd edn 2. Lips P et al. J Int Med 2006; 260:245-254.
    8. 9. New Zealand has one of the highest incidences of skin cancer in the world. Vitamin D is not a problem here. Or is it??
    9. 10. <ul><li>378 men aged >40 years ( mean age 57 yrs) </li></ul><ul><li>serum 25-hydroxyvitamin D [25(OH)D] <50 nmol/L </li></ul><ul><ul><li>4–17% in Summer </li></ul></ul><ul><ul><li>0–20% in Winter </li></ul></ul><ul><li>92% European dissent </li></ul><ul><li>1,606 women aged >55 years (mean age 74 yrs) </li></ul><ul><li>serum 25-hydroxyvitamin D [25(OH)D] <50 nmol/L </li></ul><ul><ul><li>20–30% in Summer </li></ul></ul><ul><ul><li>50–75% in Winter </li></ul></ul><ul><li>99.8% of European dissent </li></ul>Lucas JA, Bolland MJ, Grey AB et al (2005) Determinants of vitamin D status in older women living in a subtropical climate. Osteoporos Int 16:1641–1648 Bolland MJ, Grey AB, Ames RW et al (2006) Determinants of vitamin D status in older men living in a subtropical climate. Osteoporos Int 17:1742–1748
    10. 11. Bolland MJ, Grey AB, Ames RW et al., (2007) The effects of seasonal variation of 25-hydroxyvitamin D and fat mass on a diagnosis of vitamin D sufficiency. Am J Clin Nutr 86:959–964
    11. 12. <ul><li>These results similar to National nutrition survey </li></ul><ul><li>2,946 adults aged over 18 years had a measurement of 25(OH)D 1 </li></ul><ul><ul><li>52% of adult women <50 nmol/l </li></ul></ul><ul><ul><li>45% of adult men <50 nmol/l </li></ul></ul><ul><li>1,585 children aged 5–14 years, had a measurement of 25(OH)D 2 </li></ul><ul><ul><li>4% girls and 3% boys <17.5 nmol/l </li></ul></ul><ul><ul><li>36% girls and 27% boys <37.5 nmol/l </li></ul></ul><ul><li>So despite a warm and sunny climate with high UV exposure in the summer months, many in New Zealand have suboptimal vitamin D status. </li></ul>1. Rockell JE, Green TJ, Skeaff CM et al (2005) Season and ethnicity are determinants of serum 25-hydroxyvitamin D concentrations in New Zealand children aged 5–14 year. J Nutr 135:2602–2608 2. Rockell JE, Skeaff CM,Williams SM et al (2006) Serum 25-hydroxyvitamin D concentrations of New Zealanders aged 15 years and older. Osteoporos Int 17:1382–1389
    12. 13. <ul><li>Lower atmospheric ozone concentrations over New Zealand because of the Antarctic ozone hole. </li></ul><ul><li>Less polluted air over New Zealand </li></ul><ul><li>Sun is slightly closer to the Earth in December than in June. </li></ul><ul><li>These contribute to high UV levels and warm climate </li></ul><ul><li>Which in turn => Increased skin cancer. </li></ul>
    13. 14. John Cannell and Bruce Hollis, Alternative Medicine Review Volume 13, Number 1 March 2008
    14. 15. <ul><li>HORMONE </li></ul><ul><li>A messenger produced and secreted by specific glands or cells within the body of animals. </li></ul><ul><li>Transported through the blood stream to designated target organs. </li></ul><ul><li>Binds to its specific receptor delivering its message to a specific set of cells. </li></ul><ul><li>VITAMIN </li></ul><ul><li>A substance regularly required by the body in small amounts. </li></ul><ul><li>The body cannot make vitamins. </li></ul><ul><li>Must be supplied in diet. </li></ul>Vitamin D : A Hormone & A Vitamin
    15. 16. Formation of Active Vitamin D
    16. 17. Holick, M.F., 2007. Vitamin D Deficiency. N Engl J Med 357 pp266-81
    17. 18. <ul><li>Season </li></ul><ul><li>Geographic latitude </li></ul><ul><li>Time of day </li></ul><ul><li>Cloud /fog </li></ul><ul><li>Sun screen </li></ul><ul><li>Ageing skin </li></ul><ul><li>Excess skin cover </li></ul><ul><li>Window glass </li></ul><ul><li>Indoor life style </li></ul>
    18. 20. <ul><li>25(OH)D levels are: </li></ul><ul><li>strongly related to measures of fat mass, </li></ul><ul><li>moderately related to BMI or body weight, </li></ul><ul><li>and not related to lean mass. </li></ul><ul><li>The inverse relationship between 25(OH)D and fat mass has been attributed to increased sequestration of fat-soluble vitamin D in adipose tissue in obese individuals </li></ul>Other factors contributing to low levels
    19. 21. <ul><li>the month of blood sample, age, fat mass, and physical activity were significantly related to 25(OH)D in women </li></ul><ul><li>month of the blood sample, percentage body fat, serum albumin, and physical activity were significantly related to 25(OH)D </li></ul>From New Zealand Surveys
    20. 22. Effect of fat Mass on Vitamin D
    21. 24. Research associated Vitamin D to <ul><li>All cause mortality </li></ul><ul><li>Heart disease </li></ul><ul><li>Diabetes </li></ul><ul><li>Cancer </li></ul><ul><li>Osteoporosis </li></ul><ul><li>Athletic ability </li></ul><ul><li>Depression </li></ul>
    22. 25. Vitamin D and Osteoporosis
    23. 26. <ul><li>“ Osteoporosis is defined as a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture” </li></ul><ul><li>NIH Consensus Development Panel, JAMA 2001;285:785-795 </li></ul>Osteoporosis
    24. 27. Bone Mineral Density Over the Lifespan <ul><li>Minimal in healthy young men and premenopausal women </li></ul><ul><li>Accelerates at menopause due to estrogen deficiency </li></ul><ul><li>Continues throughout life </li></ul><ul><li>Increases in old age </li></ul><ul><li>Influenced by other factors – </li></ul><ul><ul><li>nutrition </li></ul></ul><ul><ul><li>Diseases </li></ul></ul><ul><ul><li>Medications </li></ul></ul><ul><ul><li>Activity </li></ul></ul><ul><ul><li>etc </li></ul></ul>Adapted from Wasnich RD, et al. Osteoporosis: Critique and Practicum . Honolulu, Banyan Press, 1989:179-213 Recker R, et al. J Bone Miner Res. 2000;15:1965-73
    25. 28. Vitamin D and Influenza
    26. 29. Vitamin D Effects immunity <ul><li>Vitamin D modulates the macrophage response, preventing the release of excessive inflammatory cytokines and chemokines </li></ul><ul><li>Hewison M, et al. Molecular and Cellular Endocrinology 2004; 215: 31-38. Helming L, et al. Blood 2005; 106: 4351-4358. </li></ul><ul><li>Vitamin D promotes macrophage production of specific surface antigens, the lysosomal enzyme acid phosphatase, and the secretion of H 2 O 2 (which is antimicrobial), but vitamin D deficiency decreases these functions. </li></ul><ul><li>Abu-Amer Y, Bar-Shavit Z. Cellular Immunology 1993; 151: 356-368. Cohen MS, et al . Journal of Immunology 1986; 136: 1049-1053. </li></ul><ul><li>Vitamin D stimulates genetic expression of antimicrobial peptides, which have broad-spectrum antimicrobial activity and inactivate influenza virus. </li></ul><ul><li>Wang TT, et al . Journal of Immunology 2004; 173: 2909-2912. Gombart AF et al, The FASEB Journal 2005; 19: 1067-1077. </li></ul><ul><li>Liu PT, et al . 2006; 311: 1770-1773. Reddy KV et al, International Journal of Antimicrobial Agents 2004; 24: 536-547. </li></ul><ul><li>Hiemstra PS, et al . Current Pharmaceutical Design 2004; 10: 2891-2905. Daher KA et al, Journal of Virology 1986; 60: 1068-1074. </li></ul>
    27. 30. Influenza is a seasonal illness Weekly consultation rates for clinically diagnosed flu Cannell JJ, Vieth R, Umhau JC,et al. Epidemiol Infect. 2006
    28. 31. (WHO Data) Remember New Zealand latitude 34–47◦S
    29. 32. Historical studies with cod liver oil <ul><li>In the 1930’s, Vitamin A was investigated for its anti-infective properties using Cod liver oil, (which is also abundant in Vitamin D) </li></ul><ul><li>Five studies using cod liver oil, (involving over 7,000 subjects), showed that cod liver oil reduced respiratory infections </li></ul><ul><li>Cod liver oil given to 185 adults for four months reduced colds by 50%; Holmes AD, et al. Journal of Industrial and Engineering Chemistry 1932; 24; 1058-1060. </li></ul><ul><li>In a five year study, cod liver reduced industrial absenteeism caused by colds and respiratory illness; days of missed work was reduced by 30%. (n=3031) </li></ul><ul><li>Homes AD, et al. Industrial Medicine 1936; 5: 359-361. </li></ul>
    30. 33. Vitamin D and Insulin response and Diabetes?
    31. 34. <ul><ul><li>Low serum 25-hydroxyvitamin D (25(OH)D) concentrations have been shown to correlate with impaired glucose tolerance and an increased risk of type 2 diabetes </li></ul></ul><ul><ul><li>Found </li></ul></ul><ul><ul><li>Insulin sensitivity did improve in these insulin-resistant women with vitamin D supplementation </li></ul></ul>
    32. 35. Vitamin D and Cancer
    33. 38. Vitamin D sources, metabolites, and mechanisms of action with respect to carcinogenesis. VDR: vitamin D receptor. VDRE: vitamin D response element. RXR: retinoid X receptor
    34. 39. Vitamin D and Cardiovascular disease
    35. 43. How much vitamin D results from sun exposure <ul><li>Serum 25(OH)D levels indicate the average American gets between 50 and 1000 IU units </li></ul><ul><li>5 minutes in a bathing suit in the summer noon day sun provides about 3,000 IU. </li></ul><ul><li>Melanin in the skin reduces production of vitamin D by sunlight, and African Americans have much lower 25(OH)D levels than whites </li></ul><ul><li>90% of vitamin D is obtained from the sun. </li></ul>
    36. 44. New Zealand Dietary reccomendations <ul><li>The recommended nutrient intakes or Adequate Intakes (AIs) for vitamin D, which assume minimal exposure to sunlight, are: </li></ul><ul><li>5 [micro]g/day (200IU) for infants, children and adults 50 years of age or less; </li></ul><ul><li>10 [micro]g/day (400IU) for adults 51-70 years of age </li></ul><ul><li>15 [micro]g/day (600IU) for adults >70 years of age </li></ul>Ministry of Health (NZ), National Health and Medical Research Council . Nutrient Reference Values for Australia and New Zealand.2004
    37. 45. Vitamin D 2 vs Vitamin D 3 <ul><li>Time course of the rise in serum 25OHD after a single oral dose of 50,000 IU of either cholecalciferol (vitamin D3) or ergocalciferol (vitamin D2) to two groups of 10 normal men each </li></ul>Armas, L. A. G. et al. J Clin Endocrinol Metab 2004;89:5387-5391
    38. 46. <ul><li>Use formulations with sufficient dose: </li></ul><ul><li>Ostelin (ergocalciferol 25 µ g = D2 1000 IU) </li></ul><ul><li>Ostevit D, Blackmores Vitamin D (cholecalciferol =D3 1000 IU) </li></ul><ul><li>Ostelin Vitamin D & Calcium (cholecalciferol = D3 500 IU) </li></ul><ul><ul><li>Doses in calcium and multivitamin preparations too low for treatment of deficiency </li></ul></ul><ul><ul><li>Cod liver oil contains vitamin A, which may increase fracture risk </li></ul></ul><ul><li>Dosing </li></ul><ul><ul><li>Supplementation: 1000 IU per day </li></ul></ul><ul><ul><li>Moderate-severe deficiency: 3000–5000 IU per day for 6–12 weeks then maintenance. Check blood level at 3 months </li></ul></ul><ul><li>Costs approximately 24 cents/day for supplementation </li></ul>Vitamin D supplementation ANZBMS Med J Aust 2005; 182: 281-285 .
    39. 48. Toxicity <ul><li>Vitamin D is fat soluble, and accumulation (from diet) in the body can be toxic. </li></ul><ul><li>The long-term safe dose of vitamin D is not known, however, 10,000 IU /day is safe in healthy adults </li></ul><ul><li>All known cases of vitamin D toxicity have involved intake of or over 40,000 IU/day. </li></ul><ul><li>The LD 50 in man is unknown – there are no reported deaths from acute toxicity. </li></ul>
    40. 49. Questions/ Discussion
    41. 50. Hollick 2008 link
    42. 51. <ul><li>The 1903 Nobel prize was awarded for the discovery that vitamin D from sunlight could cure cutaneous TB…. </li></ul>

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