What’s all the fuss about vitamin D? Dr Margaret Oziemski Dermatologist Brisbane www.sunsafetyqld.com.au
What’s all the fussabout vitamin D?
Dr Margaret OziemskiDermatologist
Brisbane
www.sunsafetyqld.com.au
Professor Michael KimlinAusSun Research Lab QUT
The Sunday Courier Mail 11/11/2009
75% of Brisbane residents are vitamin D deficient
Slip, Slop, Crack :The Vitamin D crisis
The Age Dec 2007
Message to cover up has led to vitaminD deficiencies between 30% - 70% ofthe population
Osteoporosis Australia link low levels ofvitamin D to massive increase inosteoporosis related diseases costing$ 1.9 billion a year
The Challenge
Australia has the highest rate of skincancer in the world
Over 1000 lives lost each yearSkin cancer rates continuing to increaseMelanoma is the commonest life
threatening cancer in 15 – 25 year oldsCosts to health budget significant –
$ 264 million spent on nonmelanoma skincancer in 2000-01
Our Lifestyle
Sun worshipping continues People underestimate the intensity of the sun
in the Sunshine State when timetablingactivities for leisure, school, sport or work
Sunburn frequently reported
Public education - Prevention
Slip, Slop, SlapUV Index/ UV AlertProtect in Five ways from skin cancer
What is Vitamin D?
Bulk of vitamin D is made in the skinSmall amount is obtained from foodVitamin D is more of a hormone than a
vitaminMost tissues posses vitamin D receptor
and can convert circulating vitamin D toactive
Vitamin D insufficiency
MUSCULOSKELETALRicketsBone painMuscle achesFallsFracturesOsteomalaciaOsteoporosis
A Place for Vitamin D
VulvitisRespiratory tractinfectionsRicketsRhA
MacrophagesAnti-melanomaMorpheaMusclesMS
Hair growthHeadacheHeartHIVHypertension
DementiaDepressionDiabetes type 1and 2
UC/CrohnsUrticaria
Parkinson’sPeriodontitisPCODPhotoprotectionPre-ecclampsiaPregnancyProstatePsoriasis
Lichen sclerosusLymphomas - NHLLung cancer
GIT - UC/CrohnsGlucocorticosteroidinduced osteoporosisprevention
CathelicidinCalciphylaxisCardiomyopathyColorectaladenomasCystic fibrosisCrohns
Tuberculosisprevention andtreatmentTransplantpatients
ObesityOsteomalaciaOsteoporosisOvarian cancer
KeratodermaKidneys
Fall preventionFatigueFolliculitis
BonesBowel cancerBreast cancer/aromatase inducedarthralgiaBurns
SchizophreniaSCC of head andneckSLESystemic sclerosisStatin inducedmyalgia
NailsNeonatal tetany
Immune systemInfertilityInfluenzapreventionInsulin resistance
EczemaEpidermolysis bullosaEpileptic drugs interferewith metabolismEPP
AcneAlzheimersAMIAnti-bacterialAsthmaAutoimmune
Molecular basis of the potentialof Vitamin D to prevent Cancer
1,25 (OH)2 D3 - Calcitriol - and functional VDRrequired for normal control of cell cycle
Calcitriol has antiproliferative effects related to cellcycle 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
Vitamin D and Melanoma
1,25 (OH)2 vitD3 is antiproliferative inmelanoma cellsClin Cancer Res 2000 Feb;6(2):498-504
VDR polymorphism associated withoccurrence and outcome of melanomaBr J Dermatol 2002 Aug;147(2):197-213
Vitamin D and Melanoma
High vitamin D status associated withimproved survival for melanomaCurr Opin Clin Nutr Metab Care 2007 Jan;10(1):6-11
Reduced serum 25 OH vitamin D levels instage IV melanomaAnticancer Res 2009 Sep;29(9):3669-74
SMU Vit D and MelanomaANZCTR 2009
http://www.anzctr.org.au/trial_view.aspx?ID=83884
75 patients, 23 monthsRandomised blind Vit D3 vs placeboVit D3 level >75 nmol/lPrimary, histologically resected stage Iib, Iic,
IIIa(N1a) and IIIb(N1a,N2a) cutaneousmelanoma
50,000IU D3 x10 on Day 1, then 50,000IU D3once a month for the 23 months
Vitamin D Metabolism
7-dehydrocholesterol
UVB
Previtamin D3 Vit D Thermalisomerisation
Chen et al Arch Biochem Biophys2007(460);213-217
Time of dayLatitudeSeasonClothesSunscreenMelaninAge
Skin Liver
Kidney
25 OH Vit D3
1,25 (OH)2 Vit D3
FoodD3, D2
Calcitriol
Tissues1,25 (OH)2 Vit D3
Time of the Day
Reproduced with permission from Nutrition and Bone Health ed. Michael Holick and Bess Dawson-Hughes, 2004 2004
Month of the Year
Reproduced with permission from Nutrition and Bone Health ed. Michael Holick and Bess Dawson-Hughes, 2004 2004
Sunscreen effect
Reproduced with permission from Nutrition and Bone Health ed. Michael Holick and Bess Dawson-Hughes, 2004
Effect of Age
Reproduced with permission from Nutrition and Bone Health ed. Michael Holick and Bess Dawson-Hughes, 2004
Most Australians needsunprotection when the UV index is3 or above.
It is safe to go outside without sunprotection in the early morning andlate afternoon when the UV Indexis below 3.
Safe Sun concept
WHO Global Solar UV Index
Safe Sun
Brisbane
Extreme
Very high
High
Moderate
Low
Can we make vitamin D when theUV is less than 3?”
“Recent results from our lab and others suggestthat not a lot of vitamin D is made when the UVBwavelengths of even as low as 311 nm,suggesting that not much if any D would bemade if the UV index is <3”.
Professor Rebecca MasonHead, Physiology Bosch Institute SydneyEmail 4 June 2008
Womans DayJuly 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 over3
practicesunprotection
“few minutes of sunlight on either side of the peak UV periods on most days of the week”
Peak UV undex in Darwin in Extreme or VeryHigh range on average
Peak UV index in Melbourne in Low orModerate range for 6 months of year
Problems in Policy
The advice to sunprotect when theUV index is over 3 includes the
time when vitamin D is made bythe action on UVB on the skin
You do not make vitamin D when theUV index is less than 3
It is the same UVB which isneeded to make vitamin D that
causes damage to the skinlongterm if the skin is
overexposed
If we are not in the sun howcan we achieve adequate
Vitamin D levels?
Vitamin Dand 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
Vit D3 Supplements
Ostevit D or Ostelin 1000 IU D3Balckmores D3 1000 IU D3Elevit 500 IU D3Citracal with D 500 IU D3Caltrate with D 200 IU D3Bioceuticals drops 333.3 IU D3 per drop
What should the Vitamin Dblood level be?
Vitamin D status
Vitamin D sufficiency > 75 nmol/lSub-optimal levels 50 - 75 nmol/lVitamin D insufficiency 25 - 50 nmol/lVitamin D deficiency 15 - 25 nmol/lSevere Vitamin D deficiency < 15 nmol/l
Joshi D, Center J and Eisman J.Australian Prescriber 2010 Aug vol 33 No 4 p103-106
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 over80 nmol/l recommended
Vitamin D levels for OtherHealth Outcomes
50% of colon cancer incidence in NthAmerica could be prevented by vit D levelof > 85 nmol/l
50% of breast cancer incidence in NthAmerica could be prevented by vit D level>130 nmol/lGarland et alNutrition Reviews Aug 2007;65(8):S91-S95
Maintaining sufficient vitamin D
Replacement with 1000 - 5000 IU a dayvitamin D3 for 2 - 3 months and repeat25 OH vitamin D level
Titrate dose of vitamin D3 supplement toblood level at least over 80nmol/l
May require 1000 - 5000IU a daymaintenance
Monitor 25 OH vit D3, calcium and U&E3 - 6 monthly once stable
Can you have too muchVitamin 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/lSome side effects of supplements not related to
hypercalcemia: itch, headache, upset digestion,cramps if Magnesium low
Vitamin D Conference4 - 8 October,2009Bruges, Belgium
“At Risk” Groups ofVitamin D Deficiency
Dark skinnedReligious/ Cultural coveringElderlyBabies of vitamin D deficient
mothersHousebound/ Institutionalised
Practice Audit
Period of 6 months March to August2007, Brisbane private dermatologypractice
Patients during consultation questionedabout amount of time in the sun on dayto day basis
Sunprotective measures recorded
57/170(33.5%)
19/61( 31.1%)
5/9(55.6%)
Otherconditions
12/170( 7.1%)
8/61(13.1%)0/9
Immunosuppressed/Photosensitive
101/170(59.4%)
34/61(55.7%)
4/9(44.4%)
PH Melanoma,NMSC, or both,
DN, FH Mel
57.4 yrs(22 - 93)
56.3 yrs(30 - 93)
48.7 yrs(32 - 87)
Mean age50141 M
120478 Sex F
170/310(54.8%)
61/310(19.7%)
9/310(2.9%)
Number< 75 nmol/l< 50 nmol/l < 25 nmol/l
DN - Dysplastic naevi
NMSC - Non melanoma skin cancer
Additional “At risk” groups ofVitamin D deficiency Reported
Past history of melanoma, non melanomaskin cancer, dysplastic naevi, or family historyof melanoma
Photosensitive conditions or medicationsImmunosuppressed conditions or medicationsWorking indoors
Check Vitamin D after Skin Cancer Diagnosis- Dr Margaret OziemskiMedical Observer 3 April 2008
Recent Practice Audit1/1/04-25/8/09
2380 vitamin D tests, Brisbane privatedermatology practice
< 25 nmol/l 27 ( 1%)< 50 nmol/l 304 ( 13%)< 75 nmol/l 1047 ( 44%)< 150 nmol/l 2344 ( 99%)
The vitamin D status ofAustralian Dermatologists
Bruce et al, Clin & Exp Dermatol 34;2009: 621-638
Southern Australia winter 200647 dermatologists6 had levels > 50nmol/l15% had levels <20 nmol/l
QML Clinical Audit Aug 09
1/11/08-28/1/09 in Brisbane15,000 vitamin D studies35% vit D level> 75 nmol/l41% level 50 - 75 nmol/l24% level in deficient range <50 nmol/l
Our Obligation
If we advise sunprotection, we shouldmonitor for vitamin D sufficiency
If a patient is sunprotecting, we shouldmonitor for vitamin D sufficiency
If a patient is not in the sun, we shouldmonitor for vitamin D sufficiency
A Tale of Two Sisters
43 yo indoor workerFreckles, black hairSolar lentigos, DSAPBurned easily in
childhood2004 Level 1
Melanoma on leg as38 yo
47 yo indoor workerFreckles, red hairDSAPBurned easily in
childhood2006 BCC left cheek
as 45 yo
A B
FH
Breast cancer mother aged 64
A (23/3/07) B (26/4/07)
25 OH D 21
Bone Density - mild osteopeniaL4 T -1.0
Supplemental D315,000IU/d25 OH D 138
25 OH D 28
Bone Density -low normalL4 T -0.3
Supplemental D34000IU/d
25 OH D 148
It is important to maintainadequate Vitamin D levels for a
whole host ofHealth Outcomes
not only for Musculoskeletal health
Summary Points
It is possible to supplementvitamin D and monitor with
blood levels rather thanrecommend sun exposure to
achieve sufficiency
Vitamin D insufficiency is underreported and its impact on our health
underestimated
More clinical trials are needed to look atdosage, timing of supplementation and
health outcomes
SLIP SLOP SLAP
SLIDE ON SOME SHADES SWALLOW A SUPPLEMENT
SEEK A SKIN CHECK