What’s all the fuss
about vitamin D?
   Dr Margaret Oziemski
         Dermatologist
           Brisbane

   www.sunsafetyq...
Professor Michael Kimlin
         AusSun Research Lab QUT
        The Sunday Courier Mail 11/11/2009



75% of Brisbane re...
Slip, Slop, Crack :
     The Vitamin D crisis
                         The Age Dec 2007


Message to cover up has led to ...
The Challenge

Australia has the highest rate of skin
 cancer in the world
Over 1000 lives lost each year
Skin cancer r...
Our Lifestyle
 Sun worshipping continues
 People underestimate the intensity of the sun
  in the Sunshine State when tim...
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 hor...
Vitamin D insufficiency
    MUSCULOSKELETAL
     Rickets
     Bone pain
     Muscle aches
     Falls
     Fractures
...
A Place for Vitamin D
Acne                Eczema                      Immune system        Nails               Schizophren...
Molecular basis of the potential
of Vitamin D to prevent Cancer
 1,25 (OH)2 D3 - Calcitriol - and functional VDR
  requir...
Vitamin D and Melanoma


1,25 (OH)2 vitD3 is antiproliferative in
 melanoma cells
  Clin Cancer Res 2000 Feb;6(2):498-504...
Vitamin D and Melanoma

High vitamin D status associated with
 improved survival for melanoma
  Curr Opin Clin Nutr Metab...
SMU Vit D and Melanoma
       ANZCTR 2009
 http://www.anzctr.org.au/trial_view.aspx?ID=83884

75 patients, 23 months
Ran...
Vitamin D Metabolism
                                                                          D3, D2
                   T...
Time of the Day




Reproduced with permission from Nutrition and Bone Health ed. Michael Holick and Bess Dawson-Hughes, 2...
Month of the Year




Reproduced with permission from Nutrition and Bone Health ed. Michael Holick and Bess Dawson-Hughes,...
Sunscreen effect




Reproduced with permission from Nutrition and Bone Health ed. Michael Holick and Bess Dawson-Hughes, ...
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...
WHO Global Solar UV Index
                      Brisbane




                   Extreme

                   Very high

   ...
Can we make vitamin D when the
        UV is less than 3?”

“Recent results from our lab and others suggest
that not a lot...
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
 ...
Peak UV index in Melbourne in Low or
                     Moderate range for 6 months of year




Peak UV undex in Darwin ...
Problems in Policy

The advice to sunprotect when the
   UV index is over 3 includes the
  time when vitamin D is made by
...
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
      ...
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 ...
Vit D3 Supplements

Ostevit D or Ostelin   1000      IU D3
Balckmores D3          1000      IU D3
Elevit               ...
What should the Vitamin D
     blood level be?
Vitamin D status


Vitamin D sufficiency                       > 75 nmol/l
Sub-optimal levels                          5...
Sufficient Vitamin D
For Bone health Recommended Daily Intake
 (RDI)

      19 - 50 yo              200 IU/d
      51 - 7...
Vitamin D levels for Other
         Health Outcomes
50% of colon cancer incidence in Nth
America could be prevented by vit...
Maintaining sufficient vitamin D
Replacement with 1000 - 5000 IU a day
 vitamin D3 for 2 - 3 months and repeat
 25 OH vit...
Can you have too much
             Vitamin D?
Vitamin D toxicity: due to raised blood calcium:
 anorexia, nausea, headach...
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 def...
Practice Audit

Period of 6 months March to August
 2007, Brisbane private dermatology
 practice
Patients during consult...
< 25 nmol/l     < 50 nmol/l   < 75 nmol/l
               Number               9/310        61/310       170/310
          ...
Additional “At risk” groups of
Vitamin D deficiency Reported

Past history of melanoma, non melanoma
 skin cancer, dyspla...
Recent Practice Audit
        1/1/04-25/8/09

2380 vitamin D tests, Brisbane private
 dermatology practice

<   25 nmol/...
The vitamin D status of
Australian Dermatologists
  Bruce et al, Clin & Exp Dermatol 34;2009: 621-638




Southern Austral...
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 5...
Our Obligation

If we advise sunprotection, we should
 monitor for vitamin D sufficiency
If a patient is sunprotecting, ...
A Tale of Two Sisters
A                     B

43 yo indoor worker    47 yo indoor worker
Freckles, black hair   Freckles, red hair
Solar l...
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...
Summary Points


    It is important to maintain
 adequate Vitamin D levels for a
            whole host of
          Heal...
It is possible to supplement
 vitamin D and monitor with
   blood levels rather than
recommend sun exposure to
       achi...
Vitamin D insufficiency is under
 reported and its impact on our health
           underestimated


More clinical trials a...
SLIP
          SLOP
          SLAP
SLIDE ON SOME SHADES
SWALLOW A SUPPLEMENT
  SEEK A SKIN CHECK
Whats All The Fuss About Vitamin D
Whats All The Fuss About Vitamin D
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Whats All The Fuss About Vitamin D

  1. 1. What’s all the fuss about vitamin D? Dr Margaret Oziemski Dermatologist Brisbane www.sunsafetyqld.com.au
  2. 2. Professor Michael Kimlin AusSun Research Lab QUT The Sunday Courier Mail 11/11/2009 75% of Brisbane residents are vitamin D deficient
  3. 3. 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
  4. 4. 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
  5. 5. 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
  6. 6. Public education - Prevention Slip, Slop, Slap UV Index/ UV Alert Protect in Five ways from skin cancer
  7. 7. 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
  8. 8. Vitamin D insufficiency MUSCULOSKELETAL Rickets Bone pain Muscle aches Falls Fractures Osteomalacia Osteoporosis
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. Time of the Day Reproduced with permission from Nutrition and Bone Health ed. Michael Holick and Bess Dawson-Hughes, 2004
  16. 16. Month of the Year Reproduced with permission from Nutrition and Bone Health ed. Michael Holick and Bess Dawson-Hughes, 2004
  17. 17. Sunscreen effect Reproduced with permission from Nutrition and Bone Health ed. Michael Holick and Bess Dawson-Hughes, 2004
  18. 18. Effect of Age Reproduced with permission from Nutrition and Bone Health ed. Michael Holick and Bess Dawson-Hughes, 2004
  19. 19. 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.
  20. 20. WHO Global Solar UV Index Brisbane Extreme Very high High Moderate Safe Sun Low
  21. 21. 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
  22. 22. Womans Day July 2010
  23. 23. “few minutes of sunlight on either side of the peak UV periods on most days of the week”
  24. 24. 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”
  25. 25. 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
  26. 26. 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
  27. 27. You do not make vitamin D when the UV index is less than 3
  28. 28. It is the same UVB which is needed to make vitamin D that causes damage to the skin longterm if the skin is overexposed
  29. 29. If we are not in the sun how can we achieve adequate Vitamin D levels?
  30. 30. 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
  31. 31. 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
  32. 32. What should the Vitamin D blood level be?
  33. 33. 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
  34. 34. 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
  35. 35. 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
  36. 36. 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
  37. 37. 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
  38. 38. Vitamin D Conference 4 - 8 October,2009 Bruges, Belgium
  39. 39. “At Risk” Groups of Vitamin D Deficiency Dark skinned Religious/ Cultural covering Elderly Babies of vitamin D deficient mothers Housebound/ Institutionalised
  40. 40. 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
  41. 41. < 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
  42. 42. 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
  43. 43. 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%)
  44. 44. 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
  45. 45. 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
  46. 46. 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
  47. 47. A Tale of Two Sisters
  48. 48. 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
  49. 49. FH Breast cancer mother aged 64
  50. 50. 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
  51. 51. Summary Points It is important to maintain adequate Vitamin D levels for a whole host of Health Outcomes not only for Musculoskeletal health
  52. 52. It is possible to supplement vitamin D and monitor with blood levels rather than recommend sun exposure to achieve sufficiency
  53. 53. 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
  54. 54. SLIP SLOP SLAP SLIDE ON SOME SHADES SWALLOW A SUPPLEMENT SEEK A SKIN CHECK
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