To D or not to D that is the question? Vitamin D deficiency in Australia
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This document summarizes the results of a study investigating vitamin D status in over 24,000 individuals in New South Wales, Australia. The study found: 1) Over 40% of participants had insufficient or deficient vitamin D levels, with the highest rates in spring. 2) Younger women, inpatients, and those in major cities or of lower socioeconomic status were most at risk of deficiency. 3) Factors like being male, living rurally, and higher SES were protective against deficiency. 4) Season, gender, age, location, and SES explained over 30% of the variability in vitamin D levels.
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To D or not to D that is the question? Vitamin D deficiency in Australia
- 1. Click to edit Master title style Click to edit Master title style
- 2. Click to edit Master title style Click to edit Master title style Overview • Vitamin D status, recommendations and disease prevention • Aims • Methods • Results • Outcome and signifance
- 3. 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 – Cancer – Diabetes – Cardiovascular disease – Autoimmune disease – Multiple sclerosis – Respiratory Illness – Mental Health
- 4. Click to edit Master title style Click to edit Master title style Optimal serum 25(OH)D Serum 25(OH)D, nmol/L 15 20 25 28 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140 145 Adapted from Garland CF, Baggerly CA. www.grassrootshealth.org
- 5. Click to edit Master title style Click to edit Master title style Vitamin D intake recommendations *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 Age NHMRC IOM US Endo Society* 0-1 200 400 1000 1-18 200 600 1000 19-49 200 600 1500-2000 50-69 400 600 1500-2000 70 and over 600 800 1500-2000
- 6. Click to edit Master title style Click to edit Master title style Aims of study 1. Investigate vitamin D status in a large cohort of individuals residing in NSW 2. Determine the effect of patient setting, gender, season, remoteness, socioeconomic status, latitude and longitude on vitamin D level
- 7. Click to edit Master title style Click to edit Master title style Adequate vitamin D status Vitamin D (nmol/L*) Conventional guidelines Newer recommendations+ Severe Deficiency <12.5 Moderate deficiency 12.5-25 Mild deficiency 25-50 <50 Insufficiency 50-75 Sufficiency >50 >75 *2.5 nmol/L = 1 ng/ml +Bischoff Ferrari, AJCN 2006
- 8. Click to edit Master title style Click to edit Master title style Australian Studies No. of subjects Latitude (0S) Mean 25(OH)D Prevalence (%) Ref. <28 nmol/L <50 nmol/L Overall VIC 861 38 - 7.2 30.0 Pasco 2001 SE QLD 414 28 69.1 8.0 23.4 McGrath 2001 Winter SE QLD 28 - 40.5 McGrath 2001 VIC 861 38 59.1 11.3 43.2 Pasco 2001 VIC 287 38 17.6 60.3 Pasco 2004 TAS 404 43 36.2 ~7.4 50.7 Van der Mei 2007 QLD/VIC /TAS 1669 28-43 67.0/75.5/ 51.1 7.1/7.9/ 13.0 40.5/37.4/ 67.3 Van der Mei 2007 b (pooled analysis)
- 9. Click to edit Master title style Click to edit Master title style Season and vitamin D status • Previously assumed enough vitamin D synthesised and stored for winter requirements • Half life of vitamin D 1-2 months • Submariner study showed mean 25(OH)D levels declined from 78nmol/L to 48 nmol/L in 2 months in absence of sunlight (P < 0.0001). Diet included fortified milk and bread • Other studies show between 40% and 80% reduction Dlugos 1995; Veith 1999
- 10. Click to edit Master title style Click to edit Master title style 4697 31131 25(OH)D assays 1 July 2008 and 30 July 2010 Primary test, complete data available for gender, age, patient setting, date of test, postcode**, known breast cancer case, 25(OH)D ≤400 nmol/L Sample type 10839 13979 Diagnostic referral Outpatient Private outpatient Emergency Inpatient Private hospital patient Public hospital patient Private patient 29516 24819 Yes 680618012 Female Male 62016251 Summer Winter 61216245 Autumn Spring 1615 QC sample Research Miscellaneous Unknown * *Matched to ARIA, SEIFA, Latitude, Longitude
- 11. Click to edit Master title style Click to edit Master title style Demographics Patient setting No. (%) Outpatient 13979 (56.3) Inpatient 10839 (43.7) Gender Female 18012 (72.5) Male 6806 (27.4) Season Summer 6251 (25.2) Autumn 6245(25.2) Winter 6201 (25.0) Spring 6121 (24.7) Rural and remoteness index No. (%) Major city 16101 (67.3) Inner regional 3363 (14.1) Outer regional 3730 (15.6) Remote 446 (1.9) Very remote 281 (1.2) IRSD* Quintile 1 7507 (31.4) Quintile 2 4659 (19.9) Quintile 3 6152 (27.2) Quintile 4 1944 (8.1) Quintile 5 3296 (13.8) *Index of relative socioeconomic disadvantage
- 12. Click to edit Master title style Click to edit Master title style Mean 25(OH)D by gender 74.0 45.1 65.5 43.2 40.0 45.0 50.0 55.0 60.0 65.0 70.0 75.0 Male Female 45% reduction by June P<.001 37% reduction by June
- 13. Click to edit Master title style Click to edit Master title style Mean 25(OH)D by patient setting 70.2 44.9 63.4 42.9 40.0 45.0 50.0 55.0 60.0 65.0 70.0 Ambulatory subject Inpatient P<.001
- 14. Click to edit Master title style Click to edit Master title style 79.1 48.6 60.4 42.6 40.0 45.0 50.0 55.0 60.0 65.0 70.0 75.0 80.0 Ambulatory Male Ambulatory Female Inpatient Male Inpatient Female Supporting Women with Breast Cancer Today and Every Day Mean 25(OH)D by gender and patient setting
- 15. Click to edit Master title style Click to edit Master title style Mean 25(OH)D by age group *77.0 65.6 40.7 *61.2 40.0 45.0 50.0 55.0 60.0 65.0 70.0 75.0 80.0 <20 20-39 40-59 60-79 ≥80 *P<.001
- 16. Click to edit Master title style Click to edit Master title style Mean 25(OH)D by remoteness 0 10 20 30 40 50 60 70 80 Major cities Inner Regional Outer Regional Remote Australia Very Remote Australia *66 50 *71 Ambulatory Male Ambulatory Female Inpatient male Inpatient Female *P<.05
- 17. Click to edit Master title style Click to edit Master title style Vitamin D status by gender and season 9% 26% 34% 31% Female Summer 7% 21% 32% 40% Male Summer 18% 37% 27% 18% Male Spring 55 % 21% 37% 27% 15% Female Spring Severely Deficient Deficient Insufficient Sufficient 58 % 35 % 28 %
- 18. Click to edit Master title style Click to edit Master title style 18% 36% 30% 16% Ambulatory subject Spring 12% 27% 31% 30% Inpatients Summer 23% 39% 24% 14% Inpatients Spring Vitamin D status by patient setting by season 6% 22% 36% 36% Ambulatory subject Summer Severely Deficient Deficient Insufficient Sufficient 54 % 62 % 39 % 28 %
- 19. Click to edit Master title style Click to edit Master title style Vitamin D status for females from a major city by age group in spring 0% 5% 10% 15% 20% 25% 30% 35% 40% Severely Deficiency Deficient Insufficient Sufficient Ambulatory Subject Deficient Severely Deficiency Deficient Insufficient Sufficient Inpatient 20-29 years 30-49 years 80 years and over 68.8%62.5% Deficient
- 20. Click to edit Master title style Click to edit Master title style Vitamin D status in ambulatory females by socioeconomic status (IRSD) *Index of relative socioeconomic disadvantage 0% 5% 10% 15% 20% 25% 30% 35% 40% Severely Deficient Deficient Insufficient Sufficient Summer IRSD 1,2 IRSD 9,10 0% 5% 10% 15% 20% 25% 30% 35% 40% Severely Deficient Deficient Insufficient Sufficient Spring 38.6 vs 21.2 63.0 vs 51.8
- 21. Click to edit Master title style Click to edit Master title style Regression Model • Serum 25(OH)D controlled for gender, patient setting, season, age category, remoteness from capital city, socioeconomic disadvantage. • Overall regression model explained 31.8% of the variance (p<0.001) • Models stratified by gender and patient setting explained between 26.3 (inpatient females and 33.1% (ambulatory females) of variance • No effect of latitude or longitude
- 22. Click to edit Master title style Click to edit Master title style Regression model (overall) 95% CI Inpatient -7.1 -8.0-(-6.3) Female -3.9 -4.7-(-3.1) Season Summer 15.6 14.6-16.6 Autumn 13.9 13.0-15.0 Winter 3.8 2.8-4.9 Age category <20 7.7 6.1-9.3 40-59 3.0 1.8-4.2 60-79 2.7 1.6-3.8 ≥80 1.3 0.1-2.5 ARIA 95% CI Inner regional 5.2 4.0-6.3 Outer regional 8.8 7.4-10.2 Remote 13.1 8.8-17.5 Very remote 17.4 13.3-21.6 IRSD 3,4 5.9 4.7-7.2 5,6 4.8 3.8-5.8 7,8 5.1 3.6-6.6 9,10 7.9 6.6-9.1 *all P<.001
- 23. Click to edit Master title style Click to edit Master title style Strengths & Limitations • Size of study, diverse population, ability to control for month of blood draw, age, ARIA, IRSD, latitude and longitude • Non-random sample, inability to control for other factors that effect vitamin D such as skin pigmentation, body weight, sunlight exposure, sun protection habits
- 24. Click to edit Master title style Click to edit Master title style Conclusion • High prevalence of deficiency in all seasons but highest in spring • There is a marked seasonal reduction that continues into spring • Particular groups are more at risk of vitamin D deficiency – young women residing in major city from lower SES • Protective factors include living in rural areas, being male and from a higher SES
- 25. Click to edit Master title style Click to edit Master title style Health Implications • Public health messages required to address high prevalence of vitamin D deficiency • Australians are not adequately supplementing - suitable guidelines are required • Implications regarding frequency and timing of testing
- 26. Click to edit Master title style Click to edit Master title style 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) Institute of Clinical Pathology and Medical Research Gary Ma (ICPMR)
- 27. Table 1. Mean plasma 25(OH)D levels and baseline characteristics for cases and controls. 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
- 28. Table 2. Results of the conditional logistic regression analysis including covariates. 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
- 29. 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
- 30. 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
- 32. 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
Editor's Notes
- 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.
- All percentages reference a common baseline of 60 nmol/L as shown on the chart. %’s reflect the disease prevention % at the beginning and ending of available data. Example: Breast cancer incidence is reduced by 30% when the serum level is 85 nmol/L vs the baseline of 65 nmol/ml. There is an 83% reduction in incidence when the serum level is 125 nmol/L vs the baseline of 25 ng/ml. The x’s in the bars indicate ‘reasonable extrapolations’ from the data but are beyond existing data. All Cancers: Lappe JM, et al. Am J Clin Nutr. 2007;85:1586-91. Breast: Garland CF, Gorham ED, Mohr SB, Grant WB, Garland FC. Breast cancer risk according to serum 25-Hydroxyvitamin D: Meta-analysis of Dose-Response (abstract).American Association for Cancer Research Annual Meeting, 2008. Reference serum 25(OH)D was 5 ng/ml. Garland, CF, et al. Amer Assoc Cancer Research Annual Mtg, April 2008,. Colon: Gorham ED, et al. Am J Prev Med. 2007;32:210-6. Diabetes: Hyppönen E, et al. Lancet 2001;358:1500-3. Endometrium: Mohr SB, et al. Prev Med. 2007;45:323-4. Falls: Broe KE, et al. J Am Geriatr Soc. 2007;55:234-9. Fractures: Bischoff-Ferrari HA, et al. JAMA. 2005;293:2257-64. Heart Attack: Giovannucci et al. Arch Intern Med/Vol 168 (No 11) June 9, 2008. Multiple Sclerosis: Munger KL, et al. JAMA. 2006;296:2832-8. Non-Hodgkin’s Lymphoma: Purdue MP, et al. Cancer Causes Control. 2007;18:989-99. Ovary: Tworoger SS, et al. Cancer Epidemiol Biomarkers Prev. 2007;16:783-8. Renal: Mohr SB, et al. Int J Cancer. 2006;119:2705-9. Rickets: Arnaud SB
- Based on adequate sunlight exposure Developed for maintenance of calcium homeostasis and prevention of osteoporosis Call for new recommendations based on newly discovered actions
- 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.
- Limited information on prevalence of Vit D deficiency in Australians, most studies have been in high risk groups
- 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.
- Sunlight 1 MED = 20000 IU Hands, arms, neck (11%) for 20 minutes in summer early am = 1000 IU Salmon 160g fillet approx. 530 IU Fortified cheese slice 55 IU Regular milk 20 IU Margarine 12 IU Multivitamins ave.200 IU Caltrate with D 400 IU Specific D ave. 1000IU
- Study Design Explain patient status Define setting Aria; SEIFA. latitude obtained from postcode
- Based on visual inspection of vitamin D level by age we classified subjects into age groups: <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 inpatients Highest percentage of sufficiency in those aged 80 and over
- Although it may be a compromise between the negative effects of UVA exposure due to longer durations early and late in the day.
- 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; incidence rate ratio: 1.63; 95% CI: 1.15, 2.24; n = 628). The model was adjusted for smoking (n = 169) (Poisson regression analysis).