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Vitamin D Deficiency in Primary Care

Vitamin D Deficiency in Primary Care. By James Gray. Vitamin D . Insufficiency/Deficiency is hot topic and has been cited to be associated with many medical conditions inc cancer, autoimmune diseases, and metabolic syndrome Rickets/ osteomalacia well recognised with profound deficiency.

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Vitamin D Deficiency in Primary Care

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  1. Vitamin D Deficiency in Primary Care By James Gray

  2. Vitamin D • Insufficiency/Deficiency is hot topic and has been cited to be associated with many medical conditions inc cancer, autoimmune diseases, and metabolic syndrome • Rickets/osteomalacia well recognised with profound deficiency

  3. Insufficiency or Deficiency? • Vit D Deficiency- associated with clinical disease rickets/osteomalacia • Vit D insufficiency- vaguer presensation of myalgia, proximal myopathymay be associated with increased risk of other diseases- no clear evidence.

  4. Physiology Food +Sunlight

  5. Physiology • Humans get vit D from 2 sources: • Vit D2 (ergocalciferol) ingested form and is synthesised by invertebrates, fungi, plants in response to UV light • Vit D3 (cholecalciferol) synthesised in the skin with exposure to UVB light - 90% • Vit D 2/3 1,25(OH)VitD 1,25(OH)2 vit D (inactive)liverkidneys (calcitriol-active)

  6. Physiology 1 ! 33 2

  7. Physiology • Vitamin D essential for maintaining calcium within normal range working with parathyroid hormone, and calcitonin

  8. Why do people become Vit D deficient • Found in small quantities in food • Fair skinned young person requires 20-30 mins of UVB exposure at midday to face and forearms 3 x/week for healthy vit D levels (each exposure = 2000IU, recommended daily requirement for adult = 400IU) • Elderly those with pigmented skin need more frequent and longer sun exposure to achieve same levels) • UVB sunlight exposure -90%, (For 6 months of year 90% UK is too north to get enough UVB for vit D production) • Suncream with SPF 15+ blocks 99% of vit D synthesis

  9. Main sources of Vit D (10%) • Oily fish (mackerel, sardines, trout, salmon, herring, anchovies, pilchards, fresh tuna) • Cod liver oil (15 mls =1360IU) • Egg yolk (20IU per yolk) • Wild mushrooms • Fortified breakfast cereals • Margarine • Infant formula milk • RECOMMENDED DAILY INTAKE- 400IU

  10. Those at risk • Pigmented skin • Those who cover skin due to tradition • Housebound elderly • Obese individuals • Exclusively breastfed infants • Mothers with multiple pregnancies in short succession • Malabsorption, short bowel, cholestatic liver disease • Drugs- anticonvulsants, rifampicin, cholestyramine, HAART, glucocorticoids

  11. How can Vit D deficiency be determined • Estimated that 50% of UK adults are insufficient, and 16% deficient during winter and spring • Measure serum 25-hydroxyvitamin D (25-OHD) £41.50

  12. Vitamin D levels

  13. Clinical manifestations of Vit D deficiency • Children: hypocalcaemia, tetany/seizures, bony deformity (knock knees), irritability, and reluctance to weight bear, impaired growth • Adults: aches + pains (often labelled as fibromyalgia/depression/somatisation), proximal muscle weakness

  14. Treatment of deficiency • No UK licensed oral preparation of high dose Vit D for trx of deficiency • The aim is to replenish the Vit D stores then to maintain them • Advised to avoid long term maintenance with combined calcium and vitamin D because the calcium is unnecessary and makes supplement less palatable, also we are giving too much ca.

  15. Adult Pathway for Vitamin D Deficiency in Primary Care • http://www.pennine-gp-training.co.uk/Vitamin_D_prescribing_guidelinespdf.pdf

  16. Children deficient • Under 6 months: 3000IU calciferol OD 8-12 weeks • Over 6 months: 6000IU calciferol OD for 8-12 wks • >1 yr: 300000 IU one off high dose followed by maintenance • Calcium supplementation is advisable of 50mg/kg/day is advisable in growing children

  17. Should we treat insufficiency • Estimated to effect 50% of the population-should be seen as a public health issue (should tell everyone re sunlight, diet, and supplementation) • Adults 1000-2000IU calciferol daily or 10000IU calciferol weekly • Children <6 months 200-400IU calciferol daily, >6 months 400-800IU calciferol daily (healthy start vitamin drops contain 300IU vit daily at recommended dose of 5 drops daily)

  18. Department of health Recommend • All pregnant and breast feeding womenshould take daily supplement • All infants and children aged 6 months to 5 years should take daily supplement (not those on formula) • People over 65 yrs, and those not exposed to much sun. • Vitamins should be free to eligible families on the Governments healthy start scheme.

  19. Recommendations • Should we code Vitamin D lifestyle advice, for >65 yrs, postnatal/6 week baby check, ask midwifes about booking visit, others at risk • What should we advise to give cod liver oil? • What to prx as maintenance or do we just advise where we can get them from, what about those who don’t pay • ?just give lifestyle advise • Lots of unanswered questions, audit.

  20. Conclusion • Not very well understood, or implemented • A lot of people are at risk • We can do a lot to promote awareness of this important issue.

  21. Questions

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