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Vitamin D deficiency affects up to 58% of people by the end of winter in an Australian population
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Vitamin D:To D or not to D that is the
question?
Military Health Symposium 2013Steven Boyages and Kellie Bilinski
The University of Sydney
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Overview
• Vitamin D status, recommendations and disease prevention
• Aims• Methods• Results • Outcome and signifance
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Health benefits of vitamin D
• Low 25(OH)D levels linked to – Osteoporosis and osteopenia– Cancer– Diabetes– Cardiovascular disease– Autoimmune disease– Multiple sclerosis– Respiratory Illness– Mental Health
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Optimal serum 25(OH)D Serum 25(OH)D, nmol/L 15 20 25 28 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140 145
Adapted from Garland CF, Baggerly CA. www.grassrootshealth.org
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Vitamin D intake recommendations
*Recommendations based on maintaining serum vitamin D > 75 nmol/L (30ng/ml)
Recognition that individuals who are obese or on certain medications be give 2-3 times more vitamin D
40 IU = 1 µg
Age NHMRC IOM US Endo Society*
0-1 200 400 10001-18 200 600 100019-49 200 600 1500-200050-69 400 600 1500-200070 and over 600 800 1500-2000
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Aims of study
1. Investigate vitamin D status in a large cohort of individuals residing in NSW
2. Determine the effect of patient setting, gender, season, remoteness, socioeconomic status, latitude and longitude on vitamin D level
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Adequate vitamin D statusVitamin D (nmol/L*)Conventional guidelines
Newer recommendations+
Severe Deficiency <12.5
Moderate deficiency 12.5-25
Mild deficiency 25-50 <50
Insufficiency 50-75
Sufficiency >50 >75
*2.5 nmol/L = 1 ng/ml
+Bischoff Ferrari, AJCN 2006
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Australian StudiesNo. of subjects
Latitude (0S) Mean 25(OH)D
Prevalence (%) Ref.
<28 nmol/L <50 nmol/L
Overall
VIC 861 38 - 7.2 30.0 Pasco 2001
SE QLD 414 28 69.1 8.0 23.4 McGrath 2001
Winter
SE QLD 28 - 40.5 McGrath 2001
VIC 861 38 59.1 11.3 43.2 Pasco 2001
VIC 287 38 17.6 60.3 Pasco 2004
TAS 404 43 36.2 ~7.4 50.7 Van der Mei 2007
QLD/VIC/TAS
1669 28-43 67.0/75.5/ 51.1
7.1/7.9/ 13.0
40.5/37.4/ 67.3
Van der Mei 2007 b (pooled analysis)
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Season and vitamin D status• Previously assumed enough vitamin D
synthesised and stored for winter requirements • Half life of vitamin D 1-2 months• Submariner study showed mean 25(OH)D levels
declined from 78nmol/L to 48 nmol/L in 2 months in absence of sunlight (P < 0.0001). Diet included fortified milk and bread
• Other studies show between 40% and 80% reduction
Dlugos 1995; Veith 1999
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4697
31131 25(OH)D assays1 July 2008 and 30 July 2010
Primary test, complete data available for gender, age, patient setting, date of test, postcode**, known breast cancer case, 25(OH)D ≤400 nmol/L
Sample type
10839 13979
Diagnostic referralOutpatientPrivate outpatientEmergency
InpatientPrivate hospital patientPublic hospital patientPrivate patient
29516
24819Yes
680618012Female Male
62016251Summer Winter
61216245Autumn Spring
1615
QC sampleResearchMiscellaneousUnknown
* *Matched to ARIA, SEIFA, Latitude, Longitude
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DemographicsPatient setting No. (%)Outpatient 13979 (56.3)Inpatient 10839 (43.7)Gender
Female 18012 (72.5)Male 6806 (27.4)Season
Summer 6251 (25.2) Autumn 6245(25.2)Winter 6201 (25.0)Spring 6121 (24.7)
Rural and remoteness index No. (%)
Major city 16101 (67.3)
Inner regional 3363 (14.1)Outer regional 3730 (15.6)Remote 446 (1.9)Very remote 281 (1.2)IRSD*
Quintile 1 7507 (31.4)
Quintile 2 4659 (19.9)
Quintile 3 6152 (27.2)
Quintile 4 1944 (8.1)
Quintile 5 3296 (13.8)*Index of relative socioeconomic disadvantage
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Mean 25(OH)D by gender
January
February
March AprilMay
JuneJuly
AugustSept
October
November
December
40.0
45.0
50.0
55.0
60.0
65.0
70.0
75.0 74.0
45.1
65.5
43.2
Male
Female
45% re-duction
by June
P<.001
37% reduction
by June
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Mean 25(OH)D by patient setting
January
February
March
AprilMay
JuneJuly
August
Sept
October
November
Decem
berTo
tal40.0
45.0
50.0
55.0
60.0
65.0
70.0 70.2
44.9
63.4
42.9
Ambulatory sub-ject
Inpatient
P<.001
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January
February
March AprilMay
JuneJuly
AugustSept
October
November
December
40.0
45.0
50.0
55.0
60.0
65.0
70.0
75.0
80.0 79.1
48.6
60.4
42.6
Ambulatory MaleAmbulatory FemaleInpatient MaleInpatient Female
Supporting Women with Breast Cancer Today and Every Day
Mean 25(OH)D by gender and patient setting
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Mean 25(OH)D by age group
January
Febr...
Marc
hApril
May
June
July
August
Sept
Oct
Nove...
Dece...
40.0
45.0
50.0
55.0
60.0
65.0
70.0
75.0
80.0
*77.0
65.6
40.7
*61.2
<2020-3940-5960-79≥80
*P<.001
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Mean 25(OH)D by remoteness
Majo
r cities
Inner Regio
nal
Outer Regio
nal
Remote Australi
a
Very Remote Austr
alia
01020304050607080
50
*71*66
Ambulatory MaleAmbulatory FemaleInpatient maleInpatient Female
*P<.05
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Vitamin D status by gender and season
10%26%
34%
31%
Female Summer
7%21%
32%
40%
Male Summer
18%
37%27%
18%Male Spring
55%
21%
37%27%
15%
Female Spring
Severely Deficient
Deficient
Insufficient
Sufficient
58%
35%
28%
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18%
35%30%
16%
Ambulatory subject Spring
12%
27%
30%
30%
Inpatients Summer
23%
39%
24%
14%
Inpatients Spring
Vitamin D status by patient setting by season
6%22%
36%
36%
Ambulatory subject Summer
Severely Deficient
Deficient
Insufficient
Sufficient
54%
62%
39%
28%
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Vitamin D status forfemales from a major city by age
group in spring
Inpatient aged ≥80
Severely De-ficiency
Deficient Insufficient Sufficient0%
5%
10%
15%
20%
25%
30%
35%
40%
Ambulatory Subject
Deficient
Severely De-ficiency
Deficient Insufficient Sufficient
Inpatient
20-29 years 30-49 years 80 years and over
68.8%62.5%
Deficient
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Vitamin D status in ambulatory females by
socioeconomic status (IRSD)
*Index of relative socioeconomic disadvantage
Severely De-ficient
Deficient Insufficient Sufficient0%
5%
10%
15%
20%
25%
30%
35%
40%
SummerIRSD 1,2
IRSD 9,10
Severely De-ficient
Deficient Insufficient Sufficient0%
5%
10%
15%
20%
25%
30%
35%
40%
Spring
38.6 vs 21.2
63.0 vs 51.8
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Regression Model• Serum 25(OH)D controlled for gender, patient
setting, season, age category, remoteness from capital city, socioeconomic disadvantage.
• Overall regression model explained 31.8% of the variance (p<0.001)
• Models stratified by gender and patient setting explained between 26.3 (inpatient females and 33.1% (ambulatory females) of variance
• No effect of latitude or longitude
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Regression model (overall) 95% CIInpatient -7.1 -8.0-(-6.3)Female -3.9 -4.7-(-3.1)
Season
Summer 15.6 14.6-16.6Autumn 13.9 13.0-15.0Winter 3.8 2.8-4.9
Age category
<20 7.7 6.1-9.340-59 3.0 1.8-4.260-79 2.7 1.6-3.8≥80 1.3 0.1-2.5
ARIA 95% CIInner regional 5.2 4.0-6.3Outer regional 8.8 7.4-10.2Remote 13.1 8.8-17.5Very remote 17.4 13.3-21.6
IRSD
3,4 5.9 4.7-7.25,6 4.8 3.8-5.87,8 5.1 3.6-6.69,10 7.9 6.6-9.1
*all P<.001
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Strengths & Limitations
• Size of study, diverse population, ability to control for month of blood draw, age, ARIA, IRSD, latitude and longitude
• Non-random sample, inability to control for other factors that effect vitamin D such as skin pigmentation, body weight, sunlight exposure, sun protection habits
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Conclusion
• High prevalence of deficiency in all seasons but highest in spring
• There is a marked seasonal reduction that continues into spring
• Particular groups are more at risk of vitamin D deficiency – young women residing in major city from lower SES
• Protective factors include living in rural areas, being male and from a higher SES
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Health Implications• Public health messages required to
address high prevalence of vitamin D deficiency
• Australians are not adequately supplementing - suitable guidelines are required
• Implications regarding frequency and timing of testing
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AcknowledgementsWestmead Breast Cancer Institute Vitamin D Research Group
John Boyages, (Supervisor, Oncologist, BCI)
Steven Boyages (Supervisor, Endocrinologist, CETI)
Colin Dunstan (Animal Biologist, ANZAC)
Rebecca Mason (Physiologist, Sydney University)
Peter Talbot (Dietitian, Westmead Hospital)
Elisabeth Black (Director of Research, BCI)
Institute of Clinical Pathology and Medical Research
Gary Ma (ICPMR)
Table 1. Mean plasma 25(OH)D levels and baseline characteristics for cases and controls.
Umhau JC, George DT, Heaney RP, Lewis MD, et al. (2013) Low Vitamin D Status and Suicide: A Case-Control Study of Active Duty Military Service Members. PLoS ONE 8(1): e51543. doi:10.1371/journal.pone.0051543http://www.plosone.org/article/info:doi/10.1371/journal.pone.0051543
Table 2. Results of the conditional logistic regression analysis including covariates.
Umhau JC, George DT, Heaney RP, Lewis MD, et al. (2013) Low Vitamin D Status and Suicide: A Case-Control Study of Active Duty Military Service Members. PLoS ONE 8(1): e51543. doi:10.1371/journal.pone.0051543http://www.plosone.org/article/info:doi/10.1371/journal.pone.0051543
Figure 1. Plot of the computed odds ratios (OR) for the 8 octiles of 25(OH)D concentration, locating each at the mid-point of the respective octiles.
Umhau JC, George DT, Heaney RP, Lewis MD, et al. (2013) Low Vitamin D Status and Suicide: A Case-Control Study of Active Duty Military Service Members. PLoS ONE 8(1): e51543. doi:10.1371/journal.pone.0051543http://www.plosone.org/article/info:doi/10.1371/journal.pone.0051543
Figure 2. Plot of the odds ratio for suicide for the top seven octiles, relative to the lowest octile.
Umhau JC, George DT, Heaney RP, Lewis MD, et al. (2013) Low Vitamin D Status and Suicide: A Case-Control Study of Active Duty Military Service Members. PLoS ONE 8(1): e51543. doi:10.1371/journal.pone.0051543http://www.plosone.org/article/info:doi/10.1371/journal.pone.0051543
The subjects with serum concentrations of 25-hydroxyvitamin D [25(OH)D] < 40 nmol/L (n = 24) had significantly (P = 0.004) more days of absence from duty due to respiratory infections
(median: 4; quartile 1–quartile 3: 2–6) than did controls (2; 0–4; incide...
Laaksi I et al. Am J Clin Nutr 2007;86:714-717
©2007 by American Society for Nutrition