1. Vitamin D Deficiency

2. Contents Background Risk factors for vitamin D deficiency
Clinical features
The association between vitamin D and ill health
Who should we test
Vitamin D supplementation
Who should we treat?
Summary

4. Risk factors for Vitamin D deficiency
Lack of UVB sunlight exposure
Northern latitude (90% UK too far north to have adequate levels for 6 months of the year!)
Occlusive garments
Pigmented skin
Sunscreen with SPF 15+ blocks 99% vitamin D synthesis
Poor oral intake
Elderly
Liver disease

5. Epidemiology 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%

6. Clinical features Symptom/Sign Children Adult Seizures  Tetany
Hypocalcaemia
Irritability
Leg Bowing
Knock knees
Impaired linear growth
Delayed Walking
Limb girdle pain
Proximal myopathy
Muscle pain

7. What is the association between low vitamin D and ill- health?
Low concentrations of Vitamin D have been associated with many non-skeletal diseases
CVD, weight gain, diabetes, infectious disease, MS, depression, dementia, declining physical status and muscle strength and all cause mortality
Conclusion: 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 mortality
Supplementation reduces falls and fracture risk

8. Who should we test
Patients with bone disease whose outcomes may be improved with Vitamin D treatment
osteomalcia and Paget’s
Patients 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

9. What about testing in asymptomatic patients?
Routine testing of higher risk individuals is NOT recommended
They should take routine supplementation
No evidence for screening or treatment in asymptomatic patients found to be deficient

10. Vitamin D Supplementation
In 2012 the CMOs for the UK wrote to all GPs
Lifestyle:
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!
Diet
Exposure of the face and arms to midday sun for 20-30minutes 2-3 times each week from April to September

11. AKT 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 11
Which one of the following food has the highest vitamin D content?
A : Cup of mushrooms
B : Herring 100g
C : Large boiled egg
D : Mackerel 100g
E : Vitamin D fortified cereal 30g

12. All pregnant and breastfeeding Women - Especially young women
Group
Recommended daily dose of supplementation
Example products
All pregnant and breastfeeding
Women - Especially young women
10mcg 400IU daily
Healthy Start or Pregnacare
vitamin tablets
Children - aged 6months-5years
Breast-fed infants from 1month of age IF mother has not taken supplements in pregnancy
Babies fed infant formula (which is fortified) do NOT need supplementation until receiving <500ml formula daily
7-8.5mcg 300IU daily
Healthy Start vitamin drops
(contain 7.5mcg per 5 drops) or
Abidec drops (contain 10mcg per
0.6ml)
Adults
Everyone aged over 65
Other adults who may be at risk eg. Darker skin, poor sun exposure etc.
Standard combinations of calcium and vit D containing 10mcg 400IU daily
Vitamin D alone supplements available OTC eg. Boots, Holland & Barrett etc (10mcg/400IU and
25mcg/1,000IU)

13. Test 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.

14. Who do we treat? Deficient – treatment recommended
Inadequate – treatment advised if:
Symptomatic
Bone disease
Bone risk factors e.g steroids
Increase risk of deficiency in future eg dark skin, malabsorption
Sufficient – No treatment required

15. How 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 weeks
eg cholecalciferol – 2 weekly for 7 weeks
Then for maintenance dose IU daily

16. Monitoring
Serum 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 advice
Further 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.

17. Summary 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 cause
Test if you suspect osteomalacia, and in at risk patients with musculoskeletal and widespread body pain
The evidence supports routine supplementation in at risk groups.
There is evidence that routine supplementation of older people prevents falls and fractures

18. References
Vitamin D and Bone Health: A Practical Clinical Guideline for Patient Management, National Osteoporosis Society, April 2013
Vitamin D status and ill health: a systematic review; Autier et Al. The Lancet Diabetes & Endocrinology,January 2014
DoH 2012 guidelines