Click to edit Master title style
Click to edit Master title style
Health benefits of vitamin D
• Low 25(OH)D levels linked to
– Osteoporosis and osteopenia
Click to edit Master title style...
Adequate vitamin D status
Vitamin D (nmol/L*)
Conventional
guidelines

Newer
recommendations+

Click to edit<12.5
Master t...
Australian Studies
No. of
subjects

Overall
VIC
SE QLD

Latitude (0S) Mean
25(OH)D

Prevalence (%)
<28 nmol/L

Ref.

<50 n...
Aims of study
1. Investigate vitamin D status in a large
Click to individuals residing instyle
cohort of edit Master title...
31131 25(OH)D assays
1 July 2008 and 30 July 2010
Sample type

Primary test, complete data
available for gender, age, pati...
Mean 25(OH)D by gender
75.0
70.0

74.0

Click to edit Master title style
45%
reduction
by June

65.0

Male

65.5

Female

...
Mean 25(OH)D by patient setting
70.0
65.0

70.2

Click to edit Master title style
63.4

60.0

Ambulatory
subject

55.0

In...
Mean 25(OH)D by gender and
patient setting
80.0
75.0
70.0

79.1

Click to edit Master title style

65.0
60.0
55.0
50.0

60...
Mean 25(OH)D by age group
80.0
75.0
70.0
65.0
60.0
55.0

*77.0

Click to edit Master title style
65.6
*61.2

Click to edit...
Mean 25(OH)D by remoteness
80
70
60

*71

*66

Click to edit Master title style
50

50

Ambulatory Male

40
30
20

Ambulat...
Vitamin D status for
females from a major city by age
group in spring
Click toSubject Master title style
edit
Ambulatory
I...
Vitamin D status in
ambulatory females by
socioeconomic status (IRSD)
Click to edit Master title style
Spring
Summer
IRSD ...
Click to edit Master title style
Click to edit Master title style
Results
Click to edit Master title style
Click to edit Master title style

Bilinski & Boyages MJA 197 (2) · 16 July 2012
Requests per 100000 for FBC, bone
densitometry and vitamin D

Click to edit Master title style
Click to edit Master title ...
Frequency of repeated testing
Click to edit Master title style
Click to edit Master title style

Bilinski & Boyages BMJ Op...
Implications for the Military
• Don’t assume that vitamin D levels are
adequate
Click to edit Master title style
• Night o...
The subjects with serum concentrations of 25-hydroxyvitamin D [25(OH)D] < 40 nmol/L (n =
24) had significantly (P = 0.004)...
Figure 1. Plot of the computed odds ratios (OR) for the 8 octiles of 25(OH)D concentration, locating
each at the mid-point...
Figure 2. Plot of the odds ratio for suicide for the top seven octiles, relative to the lowest octile.

Umhau JC, George D...
Vitamin D intake recommendations
Age

NHMRC

IOM

0-1

200

400

US Endo
Society*
1000

19-49

200

600

1500-2000

50-69
...
Health Implications
• Public health messages required to address
high prevalence of vitamin D deficiency
Click to edit Mas...
Acknowledgements
Westmead Breast Cancer Institute Vitamin D Research Group
John Boyages, (Supervisor, Oncologist, BCI)
Ste...
Vitamin d presentation military health symposium
Vitamin d presentation military health symposium
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Vitamin d presentation military health symposium

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Vitamin D; Understanding seasonal variation; impact on disease; understanding normal ranges; cost of testing and impact on military personnel.

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  • 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 IUSalmon 160g fillet approx. 530 IUFortified cheese slice 55 IURegular milk 20 IUMargarine 12 IUMultivitamins ave.200 IUCaltrate with D 400 IUSpecific 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.
  • 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.
  • Study Design Explain patient statusDefine settingAria; SEIFA. latitude obtained from postcode
  • Based on visual inspection of vitamin D level by age we classified subjects into age groups: &lt;20; 20-39. 40-59, 60-79, ≥80
  • Inpatients always lower than ambulatory subjects except females in very remote Australia.
  • See higher percentage of deficiency and severe deficiency in all age groups for both ambulatory and inpatientsHighest percentage of sufficiency in those aged 80 and over
  • 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
  • This increase in 25OHD testing has risen above the general trend of other common pathology tests such as full blood count
  • 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).
  • Based on adequate sunlight exposureDeveloped for maintenance of calcium homeostasis and prevention of osteoporosisCall for new recommendations based on newly discovered actions
  • Vitamin d presentation military health symposium

    1. 1. Click to edit Master title style Click to edit Master title style
    2. 2. Health benefits of vitamin D • Low 25(OH)D levels linked to – Osteoporosis and osteopenia Click to edit Master title style – Cancer – Diabetes – Cardiovascular disease Click to editdisease title style – Autoimmune Master – Multiple sclerosis – Respiratory Illness – Mental Health
    3. 3. Adequate vitamin D status Vitamin D (nmol/L*) Conventional guidelines Newer recommendations+ Click to edit<12.5 Master title style Severe Deficiency Moderate deficiency 12.5-25 Mild deficiency 25-50 <50 >50 >75 Click to edit Master title style 50-75 Insufficiency Sufficiency *2.5 nmol/L = 1 ng/ml +Bischoff Ferrari, AJCN 2006
    4. 4. Australian Studies No. of subjects Overall VIC SE QLD Latitude (0S) Mean 25(OH)D Prevalence (%) <28 nmol/L Ref. <50 nmol/L Click to edit- Master title style 861 38 7.2 30.0 Pasco 2001 414 28 69.1 8.0 23.4 McGrath 2001 Winter SE QLD VIC Click to edit Master title style - 59.1 40.5 McGrath 2001 11.3 43.2 Pasco 2001 17.6 28 60.3 Pasco 2004 ~7.4 50.7 Van der Mei 2007 40.5/37.4/ 67.3 Van der Mei 2007 b (pooled analysis) 861 38 VIC 287 38 TAS 404 43 36.2 QLD/VIC /TAS 1669 28-43 67.0/75.5/ 7.1/7.9/ 51.1 13.0
    5. 5. Aims of study 1. Investigate vitamin D status in a large Click to individuals residing instyle cohort of edit Master title NSW 2. Determine the effect of patient setting, gender, season, remoteness, Click to edit Master title style socioeconomic status, latitude and longitude on vitamin D level
    6. 6. 31131 25(OH)D assays 1 July 2008 and 30 July 2010 Sample type Primary test, complete data available for gender, age, patient setting, date of test, postcode**, known breast cancer case, 25(OH)D ≤400 nmol/L 29516 QC sample Research Miscellaneous Unknown 1615 Click to edit Master title style 4697 * *Matched to ARIA, SEIFA, Latitude, Longitude Yes 24819 Inpatient Click to edit Master title style Private hospital patient 10839 Public hospital patient Private patientFemale 18012 6251 Summer 6245 Autumn Diagnostic referral Outpatient Private outpatient Emergency Male Winter 13979 6806 6201 Spring 6121
    7. 7. Mean 25(OH)D by gender 75.0 70.0 74.0 Click to edit Master title style 45% reduction by June 65.0 Male 65.5 Female 60.0 55.0 50.0 45.0 40.0 Click to edit Master title style P<.001 37% reduction by June 45.1 43.2
    8. 8. Mean 25(OH)D by patient setting 70.0 65.0 70.2 Click to edit Master title style 63.4 60.0 Ambulatory subject 55.0 Inpatient 50.0 Click to edit Master title style P<.001 44.9 45.0 40.0 42.9
    9. 9. Mean 25(OH)D by gender and patient setting 80.0 75.0 70.0 79.1 Click to edit Master title style 65.0 60.0 55.0 50.0 60.4 Ambulatory Male Ambulatory Female Click to edit Master title style 48.6 Inpatient Male Inpatient Female 45.0 40.0 Supporting Women with Breast Cancer Today and Every Day 42.6
    10. 10. Mean 25(OH)D by age group 80.0 75.0 70.0 65.0 60.0 55.0 *77.0 Click to edit Master title style 65.6 *61.2 Click to edit Master title style <20 20-39 40-59 60-79 ≥80 50.0 *P<.001 45.0 40.0 40.7
    11. 11. Mean 25(OH)D by remoteness 80 70 60 *71 *66 Click to edit Master title style 50 50 Ambulatory Male 40 30 20 Ambulatory Female Click to edit Master titleInpatient male style Inpatient Female 10 0 *P<.05 Major cities Inner Regional Outer Regional Remote Australia Very Remote Australia
    12. 12. Vitamin D status for females from a major city by age group in spring Click toSubject Master title style edit Ambulatory Inpatient 68.8% 62.5% 40% 35% 30% 25% 20% 15% 10% 5% 0% Click to edit Master title style Severely Deficiency Deficient Deficient Insufficient Sufficient 20-29 years Severely Deficient Deficiency Deficient 30-49 years Insufficient Sufficient 80 years and over
    13. 13. Vitamin D status in ambulatory females by socioeconomic status (IRSD) Click to edit Master title style Spring Summer IRSD 1,2 40% 35% IRSD 9,10 38.6 vs 21.2 40% 63.0 vs 51.8 35% 30% 30% Click to edit Master title style 25% 25% 20% 20% 15% 15% 10% 10% 5% 5% 0% Severely Deficient Deficient Insufficient Sufficient 0% *Index of relative socioeconomic disadvantage Severely Deficient Deficient Insufficient Sufficient
    14. 14. Click to edit Master title style Click to edit Master title style
    15. 15. Results Click to edit Master title style Click to edit Master title style Bilinski & Boyages MJA 197 (2) · 16 July 2012
    16. 16. Requests per 100000 for FBC, bone densitometry and vitamin D Click to edit Master title style Click to edit Master title style Bilinski & Boyages BMJ Open 2013;3: e002955
    17. 17. Frequency of repeated testing Click to edit Master title style Click to edit Master title style Bilinski & Boyages BMJ Open 2013;3: e002955
    18. 18. Implications for the Military • Don’t assume that vitamin D levels are adequate Click to edit Master title style • Night operations and protective clothing reduce vitamin D levels • Some individuals may be at greater risk eg females Click to edit Master title style • Measure peak and trough levels • Increased risk of respiratory illness • Increased risk of mental health below a certain threshold
    19. 19. The subjects with serum concentrations of 25-hydroxyvitamin D [25(OH)D] < 40 nmol/L (n = 24) had significantly (P = 0.004) more days of absence from duty due to respiratory infections (median: 4; quartile 1–quartile 3: 2–6) than did controls (2; 0–4; incide... Laaksi I et al. Am J Clin Nutr 2007;86:714-717 ©2007 by American Society for Nutrition
    20. 20. Figure 1. Plot of the computed odds ratios (OR) for the 8 octiles of 25(OH)D concentration, locating each at the mid-point of the respective octiles. Umhau JC, George DT, Heaney RP, Lewis MD, et al. (2013) Low Vitamin D Status and Suicide: A Case-Control Study of Active Duty Military Service Members. PLoS ONE 8(1): e51543. doi:10.1371/journal.pone.0051543 http://www.plosone.org/article/info:doi/10.1371/journal.pone.0051543
    21. 21. Figure 2. Plot of the odds ratio for suicide for the top seven octiles, relative to the lowest octile. Umhau JC, George DT, Heaney RP, Lewis MD, et al. (2013) Low Vitamin D Status and Suicide: A Case-Control Study of Active Duty Military Service Members. PLoS ONE 8(1): e51543. doi:10.1371/journal.pone.0051543 http://www.plosone.org/article/info:doi/10.1371/journal.pone.0051543
    22. 22. Vitamin D intake recommendations Age NHMRC IOM 0-1 200 400 US Endo Society* 1000 19-49 200 600 1500-2000 50-69 400 600 1500-2000 Click to 200 Master title style edit 600 1-18 1000 Click to600 Master title style edit 800 1500-2000 70 and over *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
    23. 23. Health Implications • Public health messages required to address high prevalence of vitamin D deficiency Click to edit Master title style • Australians are not adequately supplementing - suitable guidelines are required Click toregarding frequency and timing edit Master title style • Implications of testing
    24. 24. Acknowledgements Westmead Breast Cancer Institute Vitamin D Research Group John Boyages, (Supervisor, Oncologist, BCI) Steven Boyages (Supervisor, Endocrinologist, CETI) Colin Dunstan (Animal Biologist, ANZAC) Rebecca Mason (Physiologist, Sydney University) Peter Talbot (Dietitian, Westmead Hospital) Elisabeth Black (Director of Research, BCI) Click to edit Master title style Click to edit Master title style Institute of Clinical Pathology and Medical Research Gary Ma (ICPMR)

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