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Vitamin D Deficiency more common than you might imagine

Vitamin D Deficiency more common than you might imagine. Dr Katy Gardner (Chair, Liverpool Vitamin D group) katyagarnder@btinternet.com June 2012 . Vitamin D: what does it do? . Works with Calcium to build bones/skeleton Role in muscle function

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Vitamin D Deficiency more common than you might imagine

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  1. Vitamin D Deficiencymore common than you might imagine Dr Katy Gardner (Chair, Liverpool Vitamin D group) katyagarnder@btinternet.com June 2012

  2. Vitamin D: what does it do? • 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. Where do we get it from? • 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

  4. Northern latitude....... North of Birmingham

  5. Symptoms of deficiency: (adults) • Bone Pain, • Muscle Weakness, • Waddling gait • OSTEOMALACIA • Also: • Hyperalgesia, • Lethargy/ tiredness • Falls and fractures in older people

  6. Symptoms of deficiency: (children) • 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. Who is at risk...could it be you? • 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. Who is at risk.... • 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. Cases of Rickets in Merseyside • 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. Baby Jayden • 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. CMO letter to health professionals • 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/

  12. What has been done locally? • 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” )

  13. Liverpool Somali study 2004

  14. Dietary study Somali community • 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.)

  15. Somali Food plate: example of dietary adaptation by Samsam Salah and Shirley Judd (PCT)

  16. Audit of local practices 2008 • Neighbouring practices very different knowledge and testing rates • Guidelines distributed • Re audit 2009: increased numbers diagnosed!

  17. So what can we do? • 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. Launch of North Mersey Guidelines and Liverpool leaflet Available atwww.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

  19. Vitamin D Levels ≤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. Treatment for adults (Mersey) • 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. Prevention guidelines • NICE: Maternal and child nutrition 2009 • “People at risk of low sun exposure should take 10mcg/400units Vit D daily” (consensus statement 2010)

  22. Pregnancy • 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. ........and children • 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

  24. Community education.......

  25. Questions remain e.g.... • 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?

  26. “Vitamin D deficiency: the time to ignore it has passed.”Int J Rheum Dis. 2010 Oct;13(4):318-23. doi: 10.1111/j.1756-185X.2010.01559.x

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