1. Vitamin D Deficiency in Scotland

2. We must inform the Public! 80% Vitamin D deficient of Scottish Population Many diseases linked to low vitamin D Rickets - osteomalacia - muscle weakness - depression - dementia - infections - multiple sclerosis - osteoporosis - fractures - cancer prevention - cancer progression - diabetes - cardio-vascular disease - falls - tuberculosis - inflammatory bowel disease

3. Helga Rhein GP Sighthill Health Centre Edinburgh March 2013

4. 1. Vitamin D’s function 2. Definition of deficiency 3. Scottish average levels 4. Linked diseases 5. Solutions

5. What is vitamin D? Nutrient Produced in skin exposed to sun Fish, supplements

6. Modern findings - last decade: Hormone ( - different from all other vitamins) Bones, immune system, up- and down regulation of genes, insulin production, nerve and brain... influence on cancer cells... vitamin D receptor in every organ Only if sufficient vitamin D around are organs in best running order optimal levels around 4 times as much

8. What is deficiency?

9. adequate blood level Normal Outdoor workers 120 nmol/l UK old guidelines25 nmol/l Most vitamin D experts 100 nmol/l ALL World Health Org. 2003, US Institute of Medicine 2010 50 nmol/l as Edinburgh Royal Infirmary new guidelines awaited

10. Scotland’s levels?

11. . Hyppönen et al 2007 <40 nmol/L 7437 participants, aged 45

12. Edinburgh University study: 84% < 50 nmol/l (Zgaga 2011, 2230 participants, Scotland-wide, aged 21-80) Aberdeen 100% < 50 nmol/l (Macdonald 2009, 338 post-menopausal women) My practice 70 % < 50 nmol/l (of 350 people tested by May 2011)

13. Scottish Problems: Northern latitude 55º - 60º Clouds, Wind Clothes

14. INDOOR LIVING + WORKING Sunscreen Avoidance of midday sun

16. Diseases linked to low levels

17. 20 - 30 % of Scottish people severely deficient and often symptomatic: tired achy legs and back low mood frequent colds

18. IF we did avoid deficiency would prevention of diseases be possible?

19. 1. Rickets 2. Infections, pre-eclampsia, pre-term birth 3. MS, autism, schizophrenia.... Pregnancy and Babies

20. MS

21. Pooled analysis of observed/expected births in people with multiple sclerosis in Canadian, British, Danish, and Swedish studies (n=42 045) with 95% confidence intervals. Willer C J et al. BMJ 2005;330:120 ©2005 by British Medical Journal Publishing Group MS

22. Staples, 2010, BMJ Australia 1524 patients with MS born in Australia from a total population of 2,648,779 MS

23. “Thus, there are now innumerable, experimental, epidemiological, immunological, genetic and clinical arguments in support of the notion that vitamin D insufficiency is one of the risk factors for MS.....” Pierrot-Deseilligny C, Souberbielle JC. Contribution of vitamin D insufficiency to the pathogenesis of multiple sclerosis published online 23 January 2013 Therapeutic Advances in Neurological Disorders

24. Many diseases linked to low vitamin D Rickets - osteomalacia - muscle weakness - depression - dementia - infections - multiple sclerosis - osteoporosis - fractures - cancer prevention - cancer progression - diabetes - cardio-vascular disease - falls - tuberculosis - inflammatory bowel disease ???

25. Many diseases linked to low vitamin D Rickets - osteomalacia - muscle weakness - depression - dementia - infections - multiple sclerosis - osteoporosis - fractures - cancer prevention - cancer progression - diabetes - cardio-vascular disease - falls - tuberculosis - inflammatory bowel disease ???

26. Vacec 2011, 10,899 patients “Vitamin D supplementation was significantly associated with better survival, specifically in patients with documented deficiency.” CVD ≥75 nmol/l <75 nmol/l

27. Figure 2 Source: American Journal of Cardiology 2010; 106:963-968 (DOI:10.1016/j.amjcard.2010.05.027 ) Copyright © 2010 Elsevier Inc. Terms and Conditions Anderson et al 2010 41,504 patients CVD

28. Parker 2010: Levels of vitamin D and cardiometabolic disorders: Systematic review and meta-analysis. 28 studies, 99,745 participants Highest levels of serum 25OHD were associated with a 43% reduction in Heart disease and Diabetes CVD

29. Jenar et al. BMJ 2010: 520 000 participants from 10 western European countries 1248 cases of incident colorectal cancer and 1248 controls “.....patients in the highest quintile had a 40% lower risk of colorectal cancer than did those in the lowest quintile” Cancer

30. Copyright Robert P. Heaney, 2006 Lappe 2009: 1000 women Cancer

31. Tumor-suppressive effects Cancer

32. ...... Cancer

33. May et al 2010: 7,358 patients Lowest levels compared to highest levels 3 times more likely to develop depression Mental Health

34. Randomised controlled trial: Jorde 2008. significant improvement in depression scores after 1 year. Systematic review: Anglin 2013. Twice as likely to be depressed if vitamin D low. Mental Health

35. Umhau, 2013: Of 500 suicides in US military service members : those with lowest Vit D had highest risk <37 nmol/l Suicide rates: US: 12 per 100,000 (2010) England: 11 per 100,000 (2006) Scotland: 19.8 per 100,000 (2006) Scots aged 15-44 double the rate compared to English counterparts Mental Health

36. Berry et al, July 2011. Vitamin D status has a linear association with seasonal infections and lung function in British adults. British Journal of Nutrition 6789 participants UK 45-year olds July 2011 Colds and flu

37. Summary of 5 randomised trials: 10 mcg/day to 50 mcg/day 1/3 fewer colds, coughs, flus, pneumonias Colds and flu Charan,, JC. et al. Vitamin D for prevention of respiratory tract infections: A systematic review and meta-analysis. 20122012

38. Strong associations of 25-hydroxyvitamin D concentrations with all-cause, cardiovascular, cancer, and respiratory disease mortalityin a large cohort study 9578 German population-based cohort aged 50–74 y9.5 y of follow-up Schöttker 2013

39. Autier 2007 Meta-analysis of 18 randomised placebo controlled trials 57,000 participants 7.5 - 50 mcg daily 7% reduction in mortality Bjelakovic 2011 Cochrane Systematic Review: 50 randomised placebo controlled trials 94,148 participants 6% reduction in mortality All cause mortality

40. “...UK’s five avoidable big killers - cancer, heart, stroke, respiratory and liver disease....”

42. Country starved of a nutrient. Much greater importance than previously thought Linked to many diseases including mental health Scottish ailments: MS Depression, suicides Cancer incidence and mortality Cardio-vascular disease Total mortality Vitamin D supplements are cheap and safe.

43. Available solutions? 1. Sun? 2. Fish? 3. Supplements?

44. One day exposed in sunshine: 250 mcg

45. Ferguson installed tanning booths so United players could top up their Vitamin D levels PUBLISHED: 08:56, 19 December 2012 | UPDATED: 13:41, 19 December 2012

46. oil-rich only (herring, mackerel, sardines, salmon) Several portions daily Fish

47. Supplements 1. How much? 50 - 100 mcg daily for adults 50 mcg daily for pregnant women 25 mcg daily for children aged 5-12 10 mcg daily for babies and young children 2. Overdose? only if high doses consumed long term, for instance 500 mcg daily for several months 3. Side effects: none known (people with sarcoidosis (a rare condition) should avoid it)

48. 10 mcg is sufficient for a baby but not for a 20 - 30 times heavier adult 10 mcg is not enough for adults

49. informed Times reader level of education little financial constraints individual health is priority will accept own GP’s advice many don’t read some cannot read English tight budgets disengaged health not top priority it sounds like complementary medicine vs. Inequalities in Health but all will accept prescriptions as done in our practice

50. While waiting for UK guidelines.... greater urgency in Scotland.... Scottish politicians: 1. Inform the Scottish Public (for instance through www.scots4vitd)www.scots4vitd Radio? TV? Buses/taxis/billboards? mail-shots? 2. Inform all MS - families

51. Help improve your constituents health

52. Many researchers and physicians have published guidelines or “Calls for Action” Vieth R, Bischoff-Ferrari H, Boucher BJ, Dawson-Hughes B, Garland CF, Heaney RP et al. The urgent need to recommend an intake of vitamin D that is effective. Am.J Clin.Nutr. 2007;85(3):649-50 Scientists’ Call to D*action. 2011. 42 Scientists called to aim for blood levels of 100 -150 nmol/l Endocrine Society Clinical Practice Guideline, US and Canada. 2011 International Physicians and Vitamin D Scientists’ Call to Action. Febr 2010. 32 scientists signed. 14th Vitamin D Workshop consensus on vitamin D nutritional guidelines. 2010 Vitamin D nutritional policy in Europe. CPME. 2009

53. Professor Joan Lappe, Canadian researcher. The Role of Vitamin D in Human Health: A Paradigm Shift. 2011. “....However, since we are experiencing a global epidemic of vitamin D insufficiency, it is unacceptable to continue the status quo pending the outcome of long-term clinical trials. It is imperative that all individuals be encouraged to obtain vitamin D from either sunlight or supplementation.....Vitamin D is truly remarkable in that it plays a key role in a wide range of physiologic functions. As scientists continue to solve the remaining mysteries related to vitamin D function and provide approaches for optimizing vitamin D status, we can expect dramatic improvement in a broad spectrum of human disorders.” George J, Khazrik H, Youssef D, Peiris A: Vitamin D Deficiency: Awaiting Final Proof? 2013: “...it appears prudent to provide at least a replacement of 1000-2000 units per day pending the “final proof” of long-term randomised studies...” Some researcher’s conclusions:

54. Professor Barbara Boucher, UK, personal e-mail 26/3/13: “...So, in my view a randomised controlled trial to trust would look at people who are perfectly fit and who are normal in all respects of interest and follow them over several years, 5 or more. But, why should bone disease be allowed to persist while one waits, hence the need to make a start with some food fortification to protect against rickets, osteomalacia and the very real and very large problem of the complications of osteoporosis. Oh dear, as Lilli Marlene sang, ‘ when will they ever learn?’ Professor Edward Giovannucci, MD, ScD Harvard School of Public Health. Vitamin D and Health: Are Randomized Controlled Trials the Final Arbitrator? Talk at 15th Vitamin D workshop 2012 Houston,TX. “... There are many examples where broad health recommendations and policy are based on a combination of our biologic understanding and on observational data with minimal relevant randomised trial data - some examples include tobacco control, body weight, physical activity, basic dietary patterns, safe sex practices, sun avoidance, alcohol use, adequate sleep and seat belt use.....However, an important question to consider is what type of information is required for broad recommendations for life-long status of vitamin D, since there will never be a randomised trial to test this scenario....”