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Vitamin d presentation military health symposium
1. Click to edit Master title style
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2. Health benefits of vitamin D
• Low 25(OH)D levels linked to
– Osteoporosis and osteopenia
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– Cancer
– Diabetes
– Cardiovascular disease
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– Autoimmune Master
– Multiple sclerosis
– Respiratory Illness
– Mental Health
3. Adequate vitamin D status
Vitamin D (nmol/L*)
Conventional
guidelines
Newer
recommendations+
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Severe Deficiency
Moderate deficiency
12.5-25
Mild deficiency
25-50
<50
>50
>75
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50-75
Insufficiency
Sufficiency
*2.5 nmol/L = 1 ng/ml
+Bischoff
Ferrari, AJCN 2006
4. Australian Studies
No. of
subjects
Overall
VIC
SE QLD
Latitude (0S) Mean
25(OH)D
Prevalence (%)
<28 nmol/L
Ref.
<50 nmol/L
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861
38
7.2
30.0
Pasco 2001
414
28
69.1
8.0
23.4
McGrath 2001
Winter
SE QLD
VIC
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-
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. 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,
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socioeconomic status, latitude and
longitude on vitamin D level
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
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4697
* *Matched
to ARIA,
SEIFA,
Latitude,
Longitude
Yes
24819
Inpatient
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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. Mean 25(OH)D by gender
75.0
70.0
74.0
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45%
reduction
by June
65.0
Male
65.5
Female
60.0
55.0
50.0
45.0
40.0
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P<.001
37%
reduction
by June
45.1
43.2
8. Mean 25(OH)D by patient setting
70.0
65.0
70.2
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63.4
60.0
Ambulatory
subject
55.0
Inpatient
50.0
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P<.001
44.9
45.0
40.0
42.9
9. Mean 25(OH)D by gender and
patient setting
80.0
75.0
70.0
79.1
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65.0
60.0
55.0
50.0
60.4
Ambulatory Male
Ambulatory Female
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48.6
Inpatient Male
Inpatient Female
45.0
40.0
Supporting Women with Breast
Cancer Today and Every Day
42.6
10. Mean 25(OH)D by age group
80.0
75.0
70.0
65.0
60.0
55.0
*77.0
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65.6
*61.2
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<20
20-39
40-59
60-79
≥80
50.0
*P<.001
45.0
40.0
40.7
11. Mean 25(OH)D by remoteness
80
70
60
*71
*66
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50
50
Ambulatory Male
40
30
20
Ambulatory Female
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style
Inpatient Female
10
0
*P<.05
Major
cities
Inner
Regional
Outer
Regional
Remote
Australia
Very
Remote
Australia
12. Vitamin D status for
females from a major city by age
group in spring
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edit
Ambulatory
Inpatient
68.8%
62.5%
40%
35%
30%
25%
20%
15%
10%
5%
0%
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Severely
Deficiency
Deficient
Deficient
Insufficient Sufficient
20-29 years
Severely
Deficient
Deficiency
Deficient
30-49 years
Insufficient
Sufficient
80 years and over
13. Vitamin D status in
ambulatory females by
socioeconomic status (IRSD)
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Spring
Summer
IRSD 1,2
40%
35%
IRSD 9,10
38.6 vs 21.2
40%
63.0 vs 51.8
35%
30%
30%
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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
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15. Results
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Bilinski & Boyages MJA 197 (2) · 16 July 2012
16. Requests per 100000 for FBC, bone
densitometry and vitamin D
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Bilinski & Boyages BMJ Open 2013;3: e002955
17. Frequency of repeated testing
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Bilinski & Boyages BMJ Open 2013;3: e002955
18. Implications for the Military
• Don’t assume that vitamin D levels are
adequate
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• Night operations and protective clothing
reduce vitamin D levels
• Some individuals may be at greater risk eg
females
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• Measure peak and trough levels
• Increased risk of respiratory illness
• Increased risk of mental health below a
certain threshold
22. 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
23. 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
24. 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
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edit 600
1-18
1000
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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
25. Health Implications
• Public health messages required to address
high prevalence of vitamin D deficiency
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• Australians are not adequately
supplementing - suitable guidelines are
required
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• Implications
of testing
26. 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)
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Institute of Clinical Pathology and Medical Research
Gary Ma (ICPMR)
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.
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: <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