4Risk factors for Vitamin D deficiency Lack of UVB sunlight exposureNorthern latitude (90% UK too far north to have adequate levels for 6 months of the year!)Occlusive garmentsPigmented skinSunscreen with SPF 15+ blocks 99% vitamin D synthesisPoor oral intakeElderlyLiver disease
5Epidemiology Vitamin D deficiency is common in children and adults. It has been estimated that 1 billion people worldwide have vitamin D deficiency.A recent survey in the UK showed that more than 50% of the adult population have insufficient levels of vitamin D and that 16% have severe deficiency during winter and spring. The highest rates were found in Scotland, Northern England and Northern Ireland.One study found the prevalence of rickets in non-Caucasian children to be 1.6%
6Clinical features Symptom/Sign Children Adult Seizures Tetany HypocalcaemiaIrritabilityLeg BowingKnock kneesImpaired linear growthDelayed WalkingLimb girdle painProximal myopathyMuscle pain
7What is the association between low vitamin D and ill- health? Low concentrations of Vitamin D have been associated with many non-skeletal diseasesCVD, weight gain, diabetes, infectious disease, MS, depression, dementia, declining physical status and muscle strength and all cause mortalityConclusion: The discrepancy between observational and intervention studies suggest that low Vitamin D status is a marker of ill health i.e. it is consequence rather than cause.There is evidence to support routine supplementation of frail older people to reduce all cause mortalitySupplementation reduces falls and fracture risk
8Who should we testPatients with bone disease whose outcomes may be improved with Vitamin D treatmentosteomalcia and Paget’sPatients with musculoskeletal symptoms that could be attributed to Vitamin D deficiency e.g. osteomalacia is associated with bone, joint and muscle pain and hyperalgesia.We should consider testing patients with chronic widespread pain.Routine testing is not necessary in patients with osteoporosis or fragility fracture who will be treated with oral drugs and co-prescribed Vitamin D supplementation
9What about testing in asymptomatic patients? Routine testing of higher risk individuals is NOT recommendedThey should take routine supplementationNo evidence for screening or treatment in asymptomatic patients found to be deficient
10Vitamin D Supplementation In 2012 the CMOs for the UK wrote to all GPsLifestyle:How much sunshine should we be recommending to our patients?Sunscreen should be used only after an initial short period, while of course stressing the importance of avoiding sunburn!DietExposure of the face and arms to midday sun for 20-30minutes 2-3 times each week from April to September
11AKT Question: You speak to a 56 year old lady following a # distal radius to discuss dietary modifications. Her bloods are: Calcium 2.44, Vitamin D 11Which one of the following food has the highest vitamin D content?A : Cup of mushroomsB : Herring 100gC : Large boiled eggD : Mackerel 100gE : Vitamin D fortified cereal 30g
12All pregnant and breastfeeding Women - Especially young women GroupRecommended daily dose of supplementationExample productsAll pregnant and breastfeedingWomen - Especially young women10mcg 400IU dailyHealthy Start or Pregnacarevitamin tabletsChildren - aged 6months-5yearsBreast-fed infants from 1month of age IF mother has not taken supplements in pregnancyBabies fed infant formula (which is fortified) do NOT need supplementation until receiving <500ml formula daily7-8.5mcg 300IU dailyHealthy Start vitamin drops(contain 7.5mcg per 5 drops) orAbidec drops (contain 10mcg per0.6ml)AdultsEveryone aged over 65Other adults who may be at risk eg. Darker skin, poor sun exposure etc.Standard combinations of calcium and vit D containing 10mcg 400IU dailyVitamin D alone supplements available OTC eg. Boots, Holland & Barrett etc (10mcg/400IU and25mcg/1,000IU)
13Test results Serum 25OHD < 30 nmol/L is deficient. Serum 25OHD of 30–50 nmol/L may be inadequate in some people.Serum 25OHD > 50 nmol/L is sufficient for almost the whole population.
14Who do we treat? Deficient – treatment recommended Inadequate – treatment advised if:SymptomaticBone diseaseBone risk factors e.g steroidsIncrease risk of deficiency in future eg dark skin, malabsorptionSufficient – No treatment required
15How do we treat?Oral vitamin D3 (cholecalciferol) is recommended with high fixed loading dose, followed by supplementation.Should be taken with food to maximise absorption.A total loading dose of IU over 6-10 weekseg cholecalciferol – 2 weekly for 7 weeksThen for maintenance dose IU daily
16MonitoringSerum calcium should be checked 1 month after completing the loading regimen (as treatment may unmask undiagnosed primary hyperparathyroidism). If hypercalcaemic, then stop the Vit D and get specialist adviceFurther routine monitoring of serum 25OHD is unnecessary, but it may be appropriate in some cases (e.g. still symptomatic, malabsorption, poor compliance etc). It takes 3 to 6 months of treatment to reach new steady state levels, so there is no point in re-testing levels sooner.
17Summary There is no rationale for testing asymptomatic patients Low levels of Vitamin D are associated with a wide range of diseases, but this is likely to be consequence rather than causeTest if you suspect osteomalacia, and in at risk patients with musculoskeletal and widespread body painThe evidence supports routine supplementation in at risk groups.There is evidence that routine supplementation of older people prevents falls and fractures
18ReferencesVitamin D and Bone Health: A Practical Clinical Guideline for Patient Management, National Osteoporosis Society, April 2013Vitamin D status and ill health: a systematic review; Autier et Al. The Lancet Diabetes & Endocrinology,January 2014DoH 2012 guidelines