This document discusses vitamin D deficiency in Australia. It notes that 75% of Brisbane residents are vitamin D deficient, and links low vitamin D levels to increased rates of osteoporosis and related diseases. While sun exposure is needed to produce vitamin D, Australia has high skin cancer rates due to sun exposure. The document examines the challenges of obtaining adequate vitamin D levels through diet and supplements while still practicing sun protection. It emphasizes the importance of monitoring vitamin D levels, especially in high risk groups.
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Whats All The Fuss About Vitamin D
1. What’s all the fuss
about vitamin D?
Dr Margaret Oziemski
Dermatologist
Brisbane
www.sunsafetyqld.com.au
2. Professor Michael Kimlin
AusSun Research Lab QUT
The Sunday Courier Mail 11/11/2009
75% of Brisbane residents are vitamin D deficient
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. 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. 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. Public education - Prevention
Slip, Slop, Slap
UV Index/ UV Alert
Protect in Five ways from skin cancer
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
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. 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. 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. 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. 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. 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. Time of the Day
Reproduced with permission from Nutrition and Bone Health ed. Michael Holick and Bess Dawson-Hughes, 2004
16. Month of the Year
Reproduced with permission from Nutrition and Bone Health ed. Michael Holick and Bess Dawson-Hughes, 2004
18. Effect of Age
Reproduced with permission from Nutrition and Bone Health ed. Michael Holick and Bess Dawson-Hughes, 2004
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. WHO Global Solar UV Index
Brisbane
Extreme
Very high
High
Moderate
Safe Sun
Low
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
24. “few minutes of sunlight on either side of the
peak UV periods on most days of the week”
25. 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”
26. 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
27. 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
28. You do not make vitamin D when the
UV index is less than 3
29. It is the same UVB which is
needed to make vitamin D that
causes damage to the skin
longterm if the skin is
overexposed
30. If we are not in the sun how
can we achieve adequate
Vitamin D levels?
31. 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
32. 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
34. 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
35. 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
36. 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
37. 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
38. 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
40. “At Risk” Groups of
Vitamin D Deficiency
Dark skinned
Religious/ Cultural covering
Elderly
Babies of vitamin D deficient
mothers
Housebound/ Institutionalised
41. 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
42. < 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
43. 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
45. 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
46. 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
47. 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
49. 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
51. 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
52. Summary Points
It is important to maintain
adequate Vitamin D levels for a
whole host of
Health Outcomes
not only for Musculoskeletal health
53. It is possible to supplement
vitamin D and monitor with
blood levels rather than
recommend sun exposure to
achieve sufficiency
54. 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
55. SLIP
SLOP
SLAP
SLIDE ON SOME SHADES
SWALLOW A SUPPLEMENT
SEEK A SKIN CHECK