1. Dr Katy Gardner (Chair, Liverpool Vitamin D group) katyagarnder@btinternet.com June 2012

2.  Works with Calcium to build bones/skeleton  Role in muscle function  Recent evidence: heart disease, diabetes, Multiple Sclerosis, cancer and TB: recent conference.... 40 diseases!!  MS in Scotland: evidence increasing  BUT NB almost all = ecological studies “association”

3.  Sunlight (90 %) - UVB converted in skin to Vit D3:  At least 15 minutes a day on arms/face from April to October: NB more if darker skin  Diet (10 %) includes :  Oily fish  Dairy products, esp. Fortified marge  Eggs  Breakfast cereal (fortified)  Liver and red meat  Green veg (small amount) and mushrooms

5.  Bone Pain,  Muscle Weakness,  Waddling gait  OSTEOMALACIA  Also:  Hyperalgesia,  Lethargy/ tiredness  Falls and fractures in older people

6.  Babies: irritability, twitching, convulsions.  Rickets…early: delayed closure of fontanelles  Rickets…..later: bow legs or knock knees, bone pain, poor growth, delayed walking, tender swollen joints (wrists)  Delayed eruption of teeth.  Lethargy... may be assoc with anaemia

7.  Skin colour: darker…..in UK: African origin (e.g. Somali), South Asian (e.g. Bangladeshi) or Arabic (e.g. Yemen), Chinese  Low exposure to sunlight:  e.g. dark skin, mostly covered, spend most time indoors (modern life!!!), fear of sun  Diet low in Vitamin D:  vegan/vegetarian, lack of fortified foods, use of chapatti flour, unleven bread  Medical conditions: Coeliac, Crhons

8.  Older people: esp. if mostly indoors  Pregnancy and breastfeeding  People coming from abroad may be fine for several months........  Winter is the worst time  Obesity BMI >30  (Diagnosis and management of vitamin D deficiency : Pearce S, Cheetham T. BMJ 2010;340:b5664)

9.  Eg: Mother not identified when pregnant, not picked up again when breast feeding, child not identified till symptoms  2 cases in 2011 in my practice of 4000 patients  NB one child: Rickets =family at risk

10.  Congenital rickets, mother Vitamin D deficient in pregnancy, parents cleared of murder  Missed at post mortem: the severity of his condition and its manifestations were “effectively outside the clinical experience of any of the medical witnesses” (BMJ 2012)  Could it happen here?

11.  Dept of Health. Vitamin D- advice on supplements for at risk groups. CMO letter 2012  www.dh.gov.uk/health/2012/02/advice- vitamin-d/ www.dh.gov.uk/health/2012/02/advice- vitamin-d/

12.  Liverpool Somali study 2004  292 Somalis in L’pool all ages >age 2  82% deficient  Community supplement study: low uptake, unpleasantness of Calcium was a main factor  (J Bunn, K Gardner, K Vithlani, B Brabin, M Mohamud, S Salah, I Kahin, J Dutton, B Durham, W D Fraser (2004) “The prevalence of vitamin D deficiency in the Somali community of Liverpool: a significant problem” )

14.  Health promotion messages did not correspond to people’s diet  Somalis ate little food containing Vitamin D  75% had someone in family suffering from bone and muscle pain  (Maxwell S, Salah S, Bunn J. (2006) Journal of Human Nutrition and Dietetics, 19 (2), p.125-7.)

16.  Neighbouring practices very different knowledge and testing rates  Guidelines distributed  Re audit 2009: increased numbers diagnosed!

17.  Test people at risk/with symptoms and treat if deficient  Implement DOH, NICE re prevention ensure full uptake of Healthy Start and......beyond  Educate:/lifestyle NB: not enough evidence to treat insufficiency

18. Available at www.northmerseyammc.nhs.uk/publicationswww.northmerseyammc.nhs.uk More info from: katyagardner@btinternet.com Future action: audit uptake and continuing awareness, aim to roll out Healthy Start to all

19. ≤30 nmol/L deficiency 31–50 nmol/L insufficiency >50 nmol/L adequate >150 nmol/L possible evidence of adverse effects  BUT remember time of year!!!! Autumn beware false high reading!

20.  Loading dose: 300,000 units  Colecalciferol 20,000 units daily for 15 days or  Colecalciferol 20,000 units 5 x daily for 3 days  OR Ergocalciferol 300,000IU IM injection once or twice a year (variable availability)  Check levels after 6 months  Maintenance: tricky!!! Equiv 800 units daily for life  Read Code.C28 Vitamin D deficiency

21.  NICE: Maternal and child nutrition 2009  “People at risk of low sun exposure should take 10mcg/400units Vit D daily” (consensus statement 2010)

22.  If ineligible for Healthy Start advise 10mcg Vitamin D (400IU) daily – OTC (COMA)  Pregnant women at risk should be tested  Treat if deficient (follow local guidelines), continue while breast feeding  Family members need to be supplemented if woman is deficient

23.  Seamless transition from midwives to health visitors and to GPs (recent local audit showed this not always the case)  Ideally supplement children under 5 (Healthy Start misses many at risk and uptake low)  ABIDEC and DALVIT fine  Childrens treatment guidelines expected soon

25.  What is the optimal Vit D level?  Does it effect pregnancy outcomes? (BMJ 2012)  Can higher levels reduce risk of cancer and other chronic diseases?  How much sun exposure needed to optimise levels in different skin types?  What is the role of diet and supplements in achieving optimum Vit D?  Who should we test and treat?  How can we ensure that we don’t have our own baby Jayden here?