VIT D

1. Presented by – Dr. Rishika Gaur
Jr2
Internal medicine ,
KGMU

2.  Principal Guide
• Dr. Madhukar Mittal
 Co-Guides
• Prof Ravi Misra
• Prof Arvind Mishra
• Dr. Vivek Kumar
• Prof A.A.Mahdi

3.  Known since years:
The adverse association between low serum vitamin D
levels and bone and calcium metabolism
 Recently researched:
Inverse relation between serum vitamin D levels and
metabolic syndrome, diabetes mellitus , hypertension
and cardiovascular disease

4.  Insulin secretion
Research shows that severe vitamin D deficiency may inhibit
insulin secretion
 Insulin Resistance
Vitamin D deficiency also associated with insulin resistance in
humans
 Vitamin D supplementation
Conflicting data on whether supplementation improves glycemic
control in T2D
Inconsistent results regarding supplementation and prevention of
progression of prediabetes to diabetes

5.  IL-6 levels correlate negatively with insulin sensitivity
 TNF α levels increase with insulin resistance
 hsCRP-directly associated with insulin resistance
 Fetuin A
 Fetuin A
Peptide molecule
Secreted from hepatocytes
Binds to Insulin receptor present on adipose cells and
muscles
Higher serum Fetuin A levels are associated with
insulin resistance

6.  Comparison of 25(OH)D and Fetuin A levels
• Impaired Fasting Glucose/Impaired Glucose
Tolerance(IFG/IGT)
• Type 2 Diabetes mellitus(T2D), No CAD
• Type2 Diabetes Mellitus with Coronary artery
disease
 Effect of Vitamin D supplementation on
glycemic parameters

7.  Study Design-
• Observational Cross sectional study
• Prospective open label study
 Duration of study-one year
 Study population- 3 groups
• IFG/IGT
• T2D, No CAD
• T2D with CAD

8.  Age : >18 and <70 years
 Blood sugar
 CAD: Coronary artery disease- previous h/o myocardial
infarction, cardiomyopathy, stable angina, unstable angina
IFG: FBS -100-125
IGT: PPBS-140-199
T2D 1.FBS: ≥ 126
2.PPBS: ≥200
3.RBS: ≥200 with symptoms

9. Holick’s Classification Lip’s Classification
 1.Sufficiency :≥ 30 ng/ml
 2.Insufficiency: 20-29 ng/ml
 3.Deficiency :<20 ng/ml
 1. Mild- 25-50 ng/ml
 2. Moderate- 12.5-25 ng/ml
 3. Severe- <12.5ng/ml

10. • Chronic kidney disease
• Vitamin D Supplementation in last 3 month
• Vitamin D Fortified food
• Malabsorption
• Primary hyperparathyroidism
• Pregnancy
• Breast feeding
• Antiepileptics, Steroids, Antifungal, ATT, ART

11. • Complete Blood Count
• Liver function test
• Kidney function test
• HbA1c
• 25(OH) D : Chemiluminescence (CLIA)
• Fetuin A: Human Fetuin A ELISA kit(Booster
Immunoleader)
• ECG and USG

12. Sno. Publication Study design Interventi
on
Effect Remarks
1. Mittal M et al.
(Journal of diabetes
&metabolic
disorder)
Systematic
review
- - No improvement with
vitamin D supplementation
on glycemic parameters
2. George PS, Pearson
ER,Witham Md et
al(2012)
Systematic
review and
meta analysis
- - Further studies need to
establish relation between
25(OH) D and T2D

13. S No. Publication Study design Intervention Change in
glycemic
parameters
REMARKS
1. Jehle et al, 2014,
Switzerland
RCT, N=55 300,000 IU
IM once in 3
month x 6mo
HOMA-IR - ↓ by
12.8% ± 5.6% in
the D3 group and ↑
by 10% ± 5.4% in
placebo group
(p = 0.032) 0
Improved
HOMA-IR
2. Al-Daghri et al,
2012, Saudi
Prospective
longitudinal,
N=92
Vitamin D3
oral 2000 IU
daily for 18
months
HOMA-B: 52 ± 9
vs. 97 ± 15
(p=0.002)

14. S No. Publication Study design Intervention Change in
glycemic
parameters
Remarks
3. Talaei et al,
2013, Iran
Longitudinal
study, N=100
50,000 U
vitamin
D3
orally/weekly
for 8 weeks
HOMA-IR:
3.57±3.18
and
2.89±3.28
(P=0.008)
4. Nikooyeh et al
, 2011, Iran
RCT,N = 90 500 IU
vitamin D+
calcium
twice daily
for12 weeks
HbA1c(8.7±
1.4 v/s
7.3±1.3(p<0.
001) and
HOMA-IR
(5.5±3.7 v/s
3.0±1.5)(p<
0.001)
Significant
improvemen
t in
HbA1c and
HOMA-IR

15. S No. Publication Study
design
Intervention Change in glycemic
parameters
Remarks
5. Tabesh et al ,
2014, Iran
RCT, N =
70
Cholecalcifero
l for 8 weeks
changes from baseline,
HbA1c (-0.70 ± 0.19%,
(p = 0.02), HOMA-IR (-
0.46 ± 0.20, p = 0.001)
QUICKI (0.025 ± 0.01,( p
= 0.004)
improved
HbA1c,
HOMA-IR
6. Shab-bidar et
al, 2011, Iran
RCT, N =
100
1,000 IU
vitamin
D3 orally daily
for12 weeks
QUICKI- 0.27±0.02 V/S
0.30±0.02,HBA1c-
8.7±1.8 v/s
7.8±1.3(p=0.015)
QUICKI only
showed
improvement,
rest no
significant
change.

16. S No. Publication Study
design
Interventio
n
Change in glycemic
parameters
Remarks
7. Chan et al ,
2013, Hong
Kong
RCT, N =
100
5000 IU
Vitamin
D3 daily
for 12
weeks
HbA1c -7.35 vs.
7.20,
p = 0.08
No change in
HBA1C and
other
glycemic
parameters
8. Hassan et al,
2011, Iran
RCT, N =
70
Calcitriol
0.25 μg
daily
orally for
12 weeks
HbA1c -7.1 ± 1.6
vs. 7.9 ± 2.1,
p=0.004,QUICKI-
0.33±0.03
v/s0.31±0.02
(p=0.002)
Attenuated the
increase
in glycemic,
and QUICKI

17. 1. N, % 14 (87.5)
2.BMI 27.21±4.37 27.57(23.84-30.36)
3.25(OH)D,
ng/ml
15.29±14.69 9.03(4.45-24.44)
4.HBA1c, % 6.31±0.86 6.30(5.62-6.87)
5.Fasting insulin,
mU/L
11.04±7.43 9.92(5.79-13.20)
6.HOMAIR
2.893±1.914 2.642(1.68-3.29)
7.QUICKI 0.341±0.040 0.330(0.320-0.352)
Values are means ± SD or median (inter-quartile range)

18. 1. N,% 43(63.2)
2.BMI 27.24±6.50 25.77(22.56-31.00)
3.25(OH)D,
ng/ml
14.62±9.67 12.67(7.277-19.91)
4.HBA1c,% 9.16±2.63 8.65(6.70-11.28)
5.Fasting insulin,
mU/L
13.12±18.65 8.17(4.60-14.70)
6.HOMAIR
4.201±6.561 2.57(1.28-4.00)
7.QUICKI 0.339±0.0488 0.331(0.311-0.368)
Values are means ± SD or median (inter-quartile range)

19. 1. N,% 5(31.2)
2.BMI 27.55±7.27 25.96(25.00-27.63)
3.25(OH)D, ng/ml 16.12±13.25 12.56(5.89-24.47)
4.HBA1c,% 9.54±2.25 9.50(8.80-10.60)
5.Fasting insulin,
mU/L
7.16±4.17 5.46(4.60-10.76)
6.HOMAIR
2.297±1.566 1.600(1.30-3.68)
7.QUICKI 0.354±0.047 0.355(0.315-0.368)
Values are means ± SD or median (inter-quartile range)

20. Characteristic Deficient
(N=92)
Non
deficient
(N=8)
P
value
1. N,% 57(91.93) 5(8.06) 0.976
2.BMI 27.48±6.42 25.96(23.68-
30.08)
25.20±4.65 25.61(21.22-
27.18)
0.332
3.25(OH)D, ng/ml 12.57±7.30 10.97(5.8-
18.77)
42.55±10.01 40.91 0.00
4.HBA1c,% 8.89±2.64 8.60(6.6-
10.7)
7.30±1.60 6.70(6.07-8.35) 0.097
5.Fasting insulin,
mU/L
10.933±9.425 8.38(4.81-
13.5)
22.422±47.21
3
5.56(4.18-10.75) 0.049
6.HOMAIR
3.262±2.933 2.57(1.38-
3.80)
6.822±15.016 1.60(0.94-2.77) 0.074
7.QUICKI 0.340±0.043 0.331(0.313-
0.36)
0.359±0.074 0.355(0.328-
0.387)
0.272
Values are means ± S D or median (inter-quartile range)

21. Characteristic Female
(N=62)
Male
(N=38)
P value
1. N, % 62(100) 8(0)
2.BMI 28.54±6.89 26.66(18.00-
27.00)
25.22±4.59 25.39(21.98-
27.38)
0.012
3.25(OH)D, ng/ml 15.38±11.58 12.76(5.48-
21.52)
14.28±10.34 11.68(6.96-
19.03)
0.631
4.HBA1c,% 8.72±2.44 8.45(6.47-
10.72)
8.83±2.88 8.60(6.50-
10.45)
0.844
5.Fasting insulin,
mU/L
13.49±19.36 8.80(4.66-
15.05)
9.18±6.55 6.94(4.43-
12.79)
0.194
6.HOMAIR
4.299±6.522 2.72(1.368-
4.454)
2.44±1.83 1.925(1027-
3.334)
0.134
7.QUICKI 0.336±0.045 0.328(0.307-
0.364)
0.352±0.048 0.346(0.319-
0.368)
0.123
Values are means ± SD or median (inter-quartile range)

22. Characteristic IFG
(N=16)
T2D
(N=84)
pvalue
1. N , % 14(87.5) 48(57.14) 0.025
2.BMI 27.21±4.37 27.57(23.84-
30.36)
27.30±6.60 25.77( 22.91-
29.47)
0.961
3.25(OH)D, ng/ml 15.29±14.69 9.03(4.45-
24.44)
14.90±10.37 12.76(6.44-
19.91)
0.899
4.HBA1c,% 6.31±0.86 6.30(5.62-6.87) 9.23±2.56 8.90(6.70-
11.24)
0.00
5.Fasting insulin,
mU/L
11.04±7.43 9.92(5.79-
13.20)
12.03±17.08 7.42,(4.51-
13.46)
0.822
6.HOMAIR
2.893±1.914 2.642(1.68-
3.29)
3.791±5.895 2.233(1.32-
3.80)
0.551
7.QUICKI 0.341±0.0404 0.330(0.320-
0.352)
0.3427±0.0485 0.338(0.3138-
0.3665)
0.895
Values are means ± SD or median (inter-quartile range)

24. Sno. Publication Study design Fetuin A levels REMARKS
1. Liang Yin et al,
China ,2015
Cross Sectional
Study
T2D v/s NGT (368.5±15.6
vs. 152.7±7.1 mg/l (P<0.01)
2. Aiyun Song et
al,China,2011
Cross Sectional
Study
NGT v/s IFG/IGT v/s T2D
285.3 v/s291.0 v/s 307.7 (p
value= 0.0008)
Significant
difference
among three
group.