Dr Katy Gardner (Chair, Liverpool Vitamin D group)
katyagarnder@btinternet.com
June 2012
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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”
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Sunlight (90 %) - UVB converted in skin
to Vit D3:
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At least 15 minutes a day on arms/face from April
to October: NB more if darker skin
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Diet (10 %) includes :
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Oily fish
Dairy products, esp. Fortified marge
Eggs
Breakfast cereal (fortified)
Liver and red meat
Green veg (small amount) and mushrooms
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Bone Pain,
Muscle Weakness,
Waddling gait
OSTEOMALACIA
Also:
Hyperalgesia,
Lethargy/ tiredness
Falls and fractures in older people
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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
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Skin colour: darker…..in UK: African
origin (e.g. Somali), South Asian (e.g.
Bangladeshi) or Arabic (e.g. Yemen), Chinese
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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
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
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(Diagnosis and management of vitamin D deficiency : Pearce
S, Cheetham T. BMJ 2010;340:b5664)
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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
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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?
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Dept of Health. Vitamin D- advice on
supplements for at risk groups. CMO
letter 2012
www.dh.gov.uk/health/2012/02/advicevitamin-d/
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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” )
6%
Vitamin D3 levels
11%
deficient<14 ng/ml
82.4%
insuficiency15-24
adequacy>25
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Health promotion messages did not
correspond to people’s diet
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Somalis ate little food containing
Vitamin D
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75% had someone in family suffering
from bone and muscle pain
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(Maxwell S, Salah S, Bunn J. (2006)
Journal of Human Nutrition and Dietetics, 19 (2), p.125-7.)
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Neighbouring practices very
different knowledge and testing
rates
Guidelines distributed
Re audit 2009: increased
numbers diagnosed!
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Test people at risk/with symptoms
and treat if deficient
Implement DOH, NICE re prevention
ensure full uptake of Healthy Start
and ......beyond
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Educate:/lifestyle NB: not enough
evidence to treat insufficiency
Available at www.northmerseyammc.nhs.uk/publications
More info from:
katyagardner@btinternet.com
Future action: audit uptake and continuing
awareness, aim to roll out Healthy Start to all
≤30
nmol/L
31–50 nmol/L
>50
nmol/L
>150 nmol/L
effects
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deficiency
insufficiency
adequate
possible evidence of adverse
BUT remember time of year!!!! Autumn beware
false high reading!
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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
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Maintenance: tricky!!! Equiv 800 units daily for life
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Read Code
.C28
Vitamin D deficiency
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NICE: Maternal and child nutrition 2009
“People at risk of low sun exposure should
take 10mcg/400units Vit D daily” (consensus
statement 2010)
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If ineligible for Healthy Start advise 10mcg
Vitamin D (400IU) daily – OTC (COMA)
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Pregnant women at risk should be tested
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Treat if deficient (follow local guidelines),
continue while breast feeding
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Family members need to be supplemented
if woman is deficient
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
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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?