Whats All The Fuss About Vitamin D
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Whats All The Fuss About Vitamin D

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    Whats All The Fuss About Vitamin D Whats All The Fuss About Vitamin D Presentation Transcript

    • What’s all the fuss about vitamin D? Dr Margaret Oziemski Dermatologist Brisbane www.sunsafetyqld.com.au
    • Professor Michael Kimlin AusSun Research Lab QUT The Sunday Courier Mail 11/11/2009 75% of Brisbane residents are vitamin D deficient
    • Slip, Slop, Crack : The Vitamin D crisis The Age Dec 2007 Message to cover up has led to vitamin D deficiencies between 30% - 70% of the population Osteoporosis Australia link low levels of vitamin D to massive increase in osteoporosis related diseases costing $ 1.9 billion a year
    • The Challenge Australia has the highest rate of skin cancer in the world Over 1000 lives lost each year Skin cancer rates continuing to increase Melanoma is the commonest life threatening cancer in 15 – 25 year olds Costs to health budget significant – $ 264 million spent on nonmelanoma skin cancer in 2000-01
    • Our Lifestyle  Sun worshipping continues  People underestimate the intensity of the sun in the Sunshine State when timetabling activities for leisure, school, sport or work  Sunburn frequently reported
    • Public education - Prevention Slip, Slop, Slap UV Index/ UV Alert Protect in Five ways from skin cancer
    • What is Vitamin D? Bulk of vitamin D is made in the skin Small amount is obtained from food Vitamin D is more of a hormone than a vitamin Most tissues posses vitamin D receptor and can convert circulating vitamin D to active
    • Vitamin D insufficiency MUSCULOSKELETAL Rickets Bone pain Muscle aches Falls Fractures Osteomalacia Osteoporosis
    • A Place for Vitamin D Acne Eczema Immune system Nails Schizophrenia Alzheimers Epidermolysis bullosa Infertility Neonatal tetany SCC of head and AMI Epileptic drugs interfere Influenza neck Anti-bacterial with metabolism prevention SLE Asthma EPP Insulin resistance Systemic sclerosis Autoimmune Statin induced myalgia Bones Fall prevention Keratoderma Obesity Tuberculosis Bowel cancer Fatigue Kidneys Osteomalacia prevention and Breast cancer/ Folliculitis Osteoporosis treatment aromatase induced Ovarian cancer Transplant arthralgia patients Burns Cathelicidin GIT - UC/Crohns Lichen sclerosus Parkinson’s UC/Crohns Calciphylaxis Glucocorticosteroid Lymphomas - NHL Periodontitis Urticaria Cardiomyopathy induced osteoporosis Lung cancer PCOD Colorectal prevention Photoprotection adenomas Pre-ecclampsia Cystic fibrosis Pregnancy Crohns Prostate Psoriasis Dementia Hair growth Macrophages Respiratory tract Vulvitis Depression Headache Anti-melanoma infections Diabetes type 1 Heart Morphea Rickets and 2 HIV Muscles RhA Hypertension MS
    • Molecular basis of the potential of Vitamin D to prevent Cancer  1,25 (OH)2 D3 - Calcitriol - and functional VDR required for normal control of cell cycle  Calcitriol has antiproliferative effects related to cell cycle control involving p21, p27 and p53  Calcitriol influences genes affecting apoptosis  Calcitriol changes shape of cancer cells which become more adhesive ?reduces metastases  Calcitriol targets BRCA1 - breast cancer susceptibility protein involved in tumour suppression Current Medical Research and Opinion vol 24, No 1, 2008, p 139-149
    • Vitamin D and Melanoma 1,25 (OH)2 vitD3 is antiproliferative in melanoma cells Clin Cancer Res 2000 Feb;6(2):498-504 VDR polymorphism associated with occurrence and outcome of melanoma Br J Dermatol 2002
    • Vitamin D and Melanoma High vitamin D status associated with improved survival for melanoma Curr Opin Clin Nutr Metab Care 2007 Jan;10(1):6-11 Reduced serum 25 OH vitamin D levels in stage IV melanoma Anticancer Res 2009 Sep;29(9):3669-74
    • SMU Vit D and Melanoma ANZCTR 2009 http://www.anzctr.org.au/trial_view.aspx?ID=83884 75 patients, 23 months Randomised blind Vit D3 vs placebo Vit D3 level >75 nmol/l Primary, histologically resected stage Iib, Iic, IIIa(N1a) and IIIb(N1a,N2a) cutaneous melanoma 50,000IU D3 x10 on Day 1, then 50,000IU D3 once a month for the 23 months
    • Vitamin D Metabolism D3, D2 Time of day UVB Latitude Food Season Clothes Sunscreen Melanin Age 7-dehydrocholesterol Previtamin D3 Vit D Skin Thermal isomerisation Liver 1,25 (OH)2 Vit D3 Tissues 25 OH Vit D3 Kidney Chen et al Arch Biochem Biophys 2007(460);213-217 Calcitriol 1,25 (OH)2 Vit D3
    • Time of the Day Reproduced with permission from Nutrition and Bone Health ed. Michael Holick and Bess Dawson-Hughes, 2004
    • Month of the Year Reproduced with permission from Nutrition and Bone Health ed. Michael Holick and Bess Dawson-Hughes, 2004
    • Sunscreen effect Reproduced with permission from Nutrition and Bone Health ed. Michael Holick and Bess Dawson-Hughes, 2004
    • Effect of Age Reproduced with permission from Nutrition and Bone Health ed. Michael Holick and Bess Dawson-Hughes, 2004
    • Safe Sun concept Most Australians need sunprotection when the UV index is 3 or above. It is safe to go outside without sun protection in the early morning and late afternoon when the UV Index is below 3.
    • WHO Global Solar UV Index Brisbane Extreme Very high High Moderate Safe Sun Low
    • Can we make vitamin D when the UV is less than 3?” “Recent results from our lab and others suggest that not a lot of vitamin D is made when the UVB wavelengths of even as low as 311 nm, suggesting that not much if any D would be made if the UV index is <3”. Professor Rebecca Mason Head, Physiology Bosch Institute Sydney Email 4 June 2008
    • Womans Day July 2010
    • “few minutes of sunlight on either side of the peak UV periods on most days of the week”
    • WHO Global Solar UV Index When UV is over 3 practice sunprotection “few minutes of sunlight on either side of the peak UV periods on most days of the week”
    • Peak UV index in Melbourne in Low or Moderate range for 6 months of year Peak UV undex in Darwin in Extreme or Very High range on average
    • Problems in Policy The advice to sunprotect when the UV index is over 3 includes the time when vitamin D is made by the action on UVB on the skin
    • You do not make vitamin D when the UV index is less than 3
    • It is the same UVB which is needed to make vitamin D that causes damage to the skin longterm if the skin is overexposed
    • If we are not in the sun how can we achieve adequate Vitamin D levels?
    • Vitamin D and the diet  Salmon 360 IU  Mackerel 345 IU  Sardines 270 IU  Milk Physical approx100 IU  Berri Australian Fresh Tropical Fruit Juice 100 IU  Cereal 99 IU  Margarine* 40 IU  Cheese* 40 IU  Beef liver 30 IU  Egg yolk 25 IU Note: Cod liver oil 1 tbsp = 1360IU D3 but high vitamin A content can cause birth defects
    • Vit D3 Supplements Ostevit D or Ostelin 1000 IU D3 Balckmores D3 1000 IU D3 Elevit 500 IU D3 Citracal with D 500 IU D3 Caltrate with D 200 IU D3 Bioceuticals drops 333.3 IU D3 per drop
    • What should the Vitamin D blood level be?
    • Vitamin D status Vitamin D sufficiency > 75 nmol/l Sub-optimal levels 50 - 75 nmol/l Vitamin D insufficiency 25 - 50 nmol/l Vitamin D deficiency 15 - 25 nmol/l Severe Vitamin D deficiency < 15 nmol/l Joshi D, Center J and Eisman J. Australian Prescriber 2010 Aug vol 33 No 4 p103-106
    • Sufficient Vitamin D For Bone health Recommended Daily Intake (RDI) 19 - 50 yo 200 IU/d 51 - 70 yo 400 IU/d >70 yo 600 IU/d For Better bones vitamin D blood level over 80 nmol/l recommended
    • Vitamin D levels for Other Health Outcomes 50% of colon cancer incidence in Nth America could be prevented by vit D level of > 85 nmol/l 50% of breast cancer incidence in Nth America could be prevented by vit D level >130 nmol/l Garland et al Nutrition Reviews Aug 2007;65(8):S91-S95
    • Maintaining sufficient vitamin D Replacement with 1000 - 5000 IU a day vitamin D3 for 2 - 3 months and repeat 25 OH vitamin D level Titrate dose of vitamin D3 supplement to blood level at least over 80nmol/l May require 1000 - 5000IU a day maintenance Monitor 25 OH vit D3, calcium and U&E 3 - 6 monthly once stable
    • Can you have too much Vitamin D? Vitamin D toxicity: due to raised blood calcium: anorexia, nausea, headache, thirst, polyuria, constipation, twitching, soft tissue calcification, kidney stones, confusion, coma Reported if vitamin D blood level > 350 nmol/l Some side effects of supplements not related to hypercalcemia: itch, headache, upset digestion, cramps if Magnesium low
    • Vitamin D Conference 4 - 8 October,2009 Bruges, Belgium
    • “At Risk” Groups of Vitamin D Deficiency Dark skinned Religious/ Cultural covering Elderly Babies of vitamin D deficient mothers Housebound/ Institutionalised
    • Practice Audit Period of 6 months March to August 2007, Brisbane private dermatology practice Patients during consultation questioned about amount of time in the sun on day to day basis Sunprotective measures recorded
    • < 25 nmol/l < 50 nmol/l < 75 nmol/l Number 9/310 61/310 170/310 (2.9%) (19.7%) (54.8%) Sex F 8 47 120 M 1 14 50 Mean age 48.7 yrs 56.3 yrs 57.4 yrs (32 - 87) (30 - 93) (22 - 93) PH Melanoma, 4/9 34/61 101/170 NMSC, or both, (44.4%) (55.7%) (59.4%) DN, FH Mel Immunosuppressed/ 8/61 12/170 Photosensitive 0/9 (13.1%) ( 7.1%) Other 5/9 19/61 57/170 conditions (55.6%) ( 31.1%) (33.5%) DN - Dysplastic naevi NMSC - Non melanoma skin cancer
    • Additional “At risk” groups of Vitamin D deficiency Reported Past history of melanoma, non melanoma skin cancer, dysplastic naevi, or family history of melanoma Photosensitive conditions or medications Immunosuppressed conditions or medications Working indoors Check Vitamin D after Skin Cancer Diagnosis- Dr Margaret Oziemski Medical Observer 3 April 2008
    • Recent Practice Audit 1/1/04-25/8/09 2380 vitamin D tests, Brisbane private dermatology practice < 25 nmol/l 27 ( 1%) < 50 nmol/l 304 ( 13%) < 75 nmol/l 1047 ( 44%) < 150 nmol/l 2344 ( 99%)
    • The vitamin D status of Australian Dermatologists Bruce et al, Clin & Exp Dermatol 34;2009: 621-638 Southern Australia winter 2006 47 dermatologists 6 had levels > 50nmol/l 15% had levels <20 nmol/l
    • QML Clinical Audit Aug 09 1/11/08-28/1/09 in Brisbane 15,000 vitamin D studies 35% vit D level> 75 nmol/l 41% level 50 - 75 nmol/l 24% level in deficient range <50 nmol/l
    • Our Obligation If we advise sunprotection, we should monitor for vitamin D sufficiency If a patient is sunprotecting, we should monitor for vitamin D sufficiency If a patient is not in the sun, we should monitor for vitamin D sufficiency
    • A Tale of Two Sisters
    • A B 43 yo indoor worker 47 yo indoor worker Freckles, black hair Freckles, red hair Solar lentigos, DSAP DSAP Burned easily in Burned easily in childhood childhood 2004 Level 1 2006 BCC left cheek Melanoma on leg as as 45 yo 38 yo
    • FH Breast cancer mother aged 64
    • A (23/3/07) B (26/4/07) 25 OH D 21 25 OH D 28  Bone Density - Bone Density - mild osteopenia low normal L4 T -1.0 L4 T -0.3 Supplemental D3 Supplemental D3 15,000IU/d 4000IU/d 25 OH D 138 25 OH D 148
    • Summary Points It is important to maintain adequate Vitamin D levels for a whole host of Health Outcomes not only for Musculoskeletal health
    • It is possible to supplement vitamin D and monitor with blood levels rather than recommend sun exposure to achieve sufficiency
    • Vitamin D insufficiency is under reported and its impact on our health underestimated More clinical trials are needed to look at dosage, timing of supplementation and health outcomes
    • SLIP SLOP SLAP SLIDE ON SOME SHADES SWALLOW A SUPPLEMENT SEEK A SKIN CHECK