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“ You Light Up My Life ”

“ You Light Up My Life ”. The Importance of Vitamin D and Sunshine to Our Health. George Guthrie MD MPH CDE CNS www.aclm-articles.net. Sun Energy. What is Vitamin D. UV-B 290-315 nm Lumisterol, Tachysterol, and Previtamin D. What is Vitamin D. CMAJ April 25, 2006 174:9.

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“ You Light Up My Life ”

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  1. “You Light Up My Life” The Importance of Vitamin D and Sunshine to Our Health. George Guthrie MD MPH CDE CNS www.aclm-articles.net

  2. Sun Energy What is Vitamin D UV-B 290-315 nm Lumisterol, Tachysterol, and Previtamin D

  3. What is Vitamin D CMAJ April 25, 2006 174:9

  4. Primary Vitamin D Deficiency Dz • Rickets • Osteomalacia • Osteoporosis Fraser, D. and Scriver, C.R. Endocrinology, Grune and Stratton, 1994.

  5. Hyperparathyroidism Gastrointestinal: Thirst, polydipsia, polyuria,ulcers,pancratitis, constipation, vomiting, weight loss. Musculoskeletal: spontaneous fracture, vertebral collapse, osteoporosis, arthralgia, gout, pseudo gout, calcifications. Neurological:Fatigue, apathy, anxiety, depression, psychosis, somnulence, coma, muscle fatigue, weakness, hypotonia,. Cardiovascular: hypertension, short QT interval

  6. Psoriasis • In vehicle-controlled clinical trials, calcitriol 3 microg/g ointment has been shown to significantly improve the symptoms of psoriasis with a low incidence of adverse effects and without affecting calcium homeostasis Gold LF, Calcitriol ointment: optimizing psoriasis therapy.J Drugs Dermatol. 2009 Aug;8(8 Suppl):s23-7.

  7. Type 1 DM Prevention The Finnish Type 1 Diabetes Prediction and Prevention Study - 31 years 2000 IUof Vitamin D per day given to Finnish ChildrenDecreasedType 1Diabetes by80%. Hypponen E, et al. Intake of vitamin D and risk of type 1 diabetes: a birth-cohort study. Lancet 2001;358:1500-3.

  8. Decreased CA Risk • Cancers - Colon, Breast, Prostate, Ovarian, Lymphoma, Leukemia. 75% reduction in Colon Cancer with Vitamin D levels 27-32 ng/ml In 25,620 individuals followed fromAugust, 1975, to January, 1983 80% reduction in Colon Cancer with Vitamin D levels 33-41 ng/ml Garland CF, et al. 25-hydroxy-vitamin D and colon cancer: eight-year prospective study. Lancet 1989 Nov 18;2(8673):1176-8

  9. Decreased CA Risk • 1179 Rural Post Menopausal females - Nebraska • 4yr double-blind, Randomized Placebo Controlled Trial. • Outcomes: Primary - osteoporosis - Secondary Cancer • Ca (14-1500 mg); Ca + Vit D (1100 IU); Placebo • Results • Ca + D RR =.402 (P=.01) • Ca RR =.532 (P=.06) • Restriction to Cancers after 12 months • Ca + D RR =.232 (CI: .09,0.60, P<0.005) Lappe JM, et al. Vit D and calcium supplementation reduces cancer risk: results of a randomized trial. Am J Clin Nutr 2007;85:1586-91.

  10. Kaplan Meier Curves - CA Lappe JM, et al. Vit D and calcium supplementation reduces cancer risk: results of a randomized trial. Am J Clin Nutr 2007;85:1586-91.

  11. Multiple Sclerosis • Prospective, nested case-control study in 7 million US Military Personnel • 257 cases identified - matched with 2 others • White 145, black 77, hispanic/other 32 • Serum samples - 2-3 • Control for latitude and UV index - residence at entry • Whites only - Lowest to highest quintile - serum vit 25 OH D • 0.38 (CI .19-.75) 62% reduction in incidence • Low 6-9.6 ng/cc: 39.7-81.3 ng/cc High - p trend.02 Munger KL, et al. Serum 25-hydroxyvitamin D levels and risk of multiple sclerosis. JAMA, 2006 Dec 20;296(23):2832-8

  12. Rheumatoid Arthritis • Rheumatoid Arthritis - • Iowa Women’s Health Study - 29,386 • 30-35% reduction in RA in women 55-69 years over 11 years. Highest vs lowest tertile of Vitamin D intake - Supplements > Dairy Merlino LA. Et al, Vitamin D intake is inversely associated with rheumatoid arthritis: results from the Iowa Women's Health Study. Arthritis & Rheumatism. 50(1):72-7, 2004 Jan.

  13. Type 2 Diabetes • Increase in Insulin Secretion* • Protein synthesis increased(rats) • Pro-insulin to insulin increased • Decrease triglycerides • Increase in insulin sensitivity- 60% * *Chiu KC, et al. Hypovitaminosis D is associated with insulin resistance in Beta cell dysfunction. Am J Clin Nutr 2004; 79:820-5.

  14. Type 2 DM Prevention & Vit D • Finnish Cohort Study • 4097 subjects 40-69yrs old (1978-80) • 17 years of follow-up • 25 OH vit D quartiles • 9.0; 14.2; 19.2; 28.4 ng/cc • P for trend = 0.01 • adjusted for age, sex month of collection Matilla C, Et al. Serum 25-hydroxyvitamin D concentration and subsequent risk of type 2 diabetes. Diabetes Care 30:2569-2570, 2007

  15. Type 2 DM Prevention & Vit D • Ely Prospective Study- England • 524 randomly chosen non-DM • 10 years follow-up • Serum vit D <20;20-30;>30 • FBS P=0.19 • HOMA  p=0.005 • 2 hr PP p=.006 Forouhi NG, et al. Baseline serum 25-hydroxy vit D is predictive of future glycemic status and insulin resistance: the Medical Research Council Ely Prospective Study 1990-2000. Diabetes 57:2619-2625, 2008

  16. Congestive Heart Failure • Low vitamin D leads to increase PTH • Parathyroid hormone (PTH) also activates Protein Kinase - C (via Galphaq) in cardiomyocytes, and provokes the hypertrophic response. • May Result in Congestive Heart Failure • McCarty MF. Nutritional modulation of parathyroid hormone secretion may influence risk for left ventricular hypertrophy. Med Hypotheses. 2005;64(5):1015-21. • Zittermann A. Vitamin D insufficiency in congestive heart failure: Why and what to do about it? Heart Fail Rev. 2006 Mar;11(1):25-33.

  17. Musculoskeletal pain • 150 consecutive ED patients in Minneapolis, MN Feb-June, 2002. (45o lat north) • Results: • African American, East African, Hispanic, Native Americans - 100% deficient • All patients - 93% deficient (<20 ng/cc) • Diagnoses - fibromyalgia, chronic fatigue, depression. Plotnikoff GA, Quigley JM. Prevalence of severe hypovitaminosis D in patients with persistent, nonspecific musculoskeletal pain. Mayo Clin Proc 2003;78:1463-70

  18. Fall Prevention • Falls (Risk Factor in the elderly) Broe KE, et al. A higher dose of vitamin D reduces the risk of falls in nursing home residents: a randomized, multiple-dose study. J Am Geriatr Soc 2007;55:234-9.

  19. Performance, speed and proximal muscle strength in elderly population was markedly improved when 25 OH Vit D increased 4-16 ng/cc up to 40 ng/cc Ilse S. Wicherts1,2, etal. Vitamin D status predicts physical performance and its decline in older persons. J Clin Endocrin Metab. First published ahead of print March 6, 2007 as doi:10.1210/jc.2006-1525.

  20. Vitamin D deficiency and Pregnancy • 198 UK pregnancies • 31% insufficient • 18% deficient • Reduced whole body (p=.0088) and LS spine bone-mineral content (p=.03) at 9 years. • Low maternal vit D levels and child bone mass predicted by UVB exposure and supplements • Umbilical vein calcium predicted low childhood bone mass • Javaid MK. Et al. Maternal vitamin D status during pregnancy and childhood bone mass at age 9 years: a longitudinal study Lancet 2006; 367: 36–43

  21. Gestational Vit D Deficiency • Schizophrenia • Animal model gene disruption • Enlarged lateral ventricles • Decreased nerve growth factor • Epidemiologic association in humans Levenson CW, Figuerioa SM. Gestational vit D deficiecny: long-term effects on the brain. Nutritional Reviews Vol 66(12):726-729.

  22. Vitamin D and Survival Serum Vitamin D levels Archives of Internal Medicine 2008;168:1340-1349

  23. Seasonal Variation in Vitamin D Serum Vitamin D (ng/mL) • Average serum vitamin D levels varied by season: • March 12.0 ng/mL • August 22.7 ng/mL • This is an 89% difference, showing the need for supplementation during winter months. Archives of Internal Medicine 2008;168:1340-1349

  24. Prevalence of Low Vitamin D In this study of over 3,200 people: • One-fourth were deficient, less than 10 ng/mL • Two-thirds were rated “insufficient”, less than 20 ng/mL • 75% were less than the recommended level, 30 ng/mL Archives of Internal Medicine 2008;168:1340-1349

  25. Incidence in Populations • Estimated 1 billion people world wide • 40-100% elderly men and women • 50% of postmenopausal women have levels less than optimal (<30 ng/cc). • 52% of Hispanic and black adolescents in Boston (<20 ng/cc) • 48% of white preadolescent girls in Maine (<20ng/cc) • 42% of 15-49 y/o in US - NHANES (< 20 ng/cc) • 32% of healthy student, physicians and residents in Boston Hospital • despite daily glass of milk, daily multivit and salmon weekly Holick MF, Vitamin D Deficiency. NEJM 357:3 July 19, 2007. Pp 266-277.

  26. Emerging Serum Vitamin D Norms Serum vitamin D test results (25-Hydroxyviamin D) are shown in these two units.

  27. Sources of Vitamin D • Dairy • Cod liver Oil - eat lots of fish • Supplements • Toxicity - calcifications, HTN, anorexia, nausea, weakness, polyuria, polydypsia, kidney failure, kidney stones, death Chen TC, et al. An update on the vitamin D content of fortified milk from the United States and Canada. N Eng J Med 1993;329:1507

  28. Supplements Sources • Vit D2 - ergosterol from yeast - 30% as effective • Vit D3 - 7-dehy- cholesterol from lanolin (Rx in USA) Holick MF, Vitamin D Deficiency. NEJM 357:3 July 19, 2007. Pp 266-277.

  29. Sources of Vitamin D • Sunlight Never Causes Toxic Levels • Whole Body Minimal Erythema Dose gives 10-20,000 IU • RDA: 200-400-600 IU • Need: 6% of body exposed for 15 min 3 days a week

  30. Special Situations • Sun Screen -SPF 8 -> 98% decrease in Vit D formation • Winter>35 Degree Latitude • Dark Skin • Up to 50X exposure needed • 30-50% of Black Americans Deficient (Estimated)

  31. Special Situations • Black compared to White Health Professionals • Black - Low risk for Vit D deficiency • CA RR 95 (CI .6-1.51) • Mortality RR 1.55 (CI .91-2.62) • Black - High Risk for Vit D deficiency • CA RR 1.57 (CI 1.15-2.11) • Mortality RR 2.27 (CI 2.26-3.28) • “This pattern was even more pronounced for digestive system cancer. Our results suggest that the high frequency of hypovitaminosis D in Blacks may be an important, and easily modifiable, contributor to their higher risk of cancer incidence and mortality.” Giovannucci E, Liu Y, Willett WC. Cancer Incidence and Mortality and Vitamin D in Black and White Male Health Professionals. Cancer Epidemiol Biomarkers Prev. 2006 Nov 28

  32. Special Situations • Sun Screen -SPF 8 -> 98% decrease in Vit D formation • Winter >35 Degree Latitude • Dark Skin • Up to 50X exposure needed • 30-50% of Black Americans Deficient (Estimated) • Older Skin- need increases with age • By 70 y/o there is a 75% decrease in ability to make Pre-Vitamin D

  33. Special Situations • Obese Individuals • Less Available for Cells • Babies • No Vit D in Breast Milk unless Mother has adequate levels • Children • Rickets • 25% of children in Saudia Arabia Deficient in Vit D • Fibromyalgia - • 40-60% suffer from osteomalacia

  34. Recommendations • Sun every day - 15 + minutes • Sun block after sun exposure for 15 min. • Educate the Public as to risk factors. • Supplement in high risk individuals or situations • Diagnose and Treat to Target • Deficient < 20 ng/ml • Insuficiency 20-30ng/cc • Goal 40-60 ng/ml • Safe up to 150 ng/ml • (Lab "Normal" 8-60 ng/ml)

  35. Recommendations • Screen all High Risk Individuals • Aggressive Replacement for <20 ng/cc • 50,000 IU two or three times per week with meals ( 1 tsp oil with meal) • Recheck levels in one to two months • Treat to greater than 30 ng/cc to shut off PTH completely in osteoporisis • Consider Higher levels in special situations - autoimmune disease, malignancy. No toxicity to 150 ng/cc

  36. Maintenance Recommendations • RDA 200-400-600 IU - Inadequate oral maintenance • Complete oral replacement 1000 IU/day • Safe upper daily limits 2000 IU/day - Present RDA • Recommended increase to optimize health • RDA 1000-2000IU/day • Safe Upper Daily Limit to 10,000/day Bischoff-Ferrari HA, et al. Estimation of optimal serum concentrations of 25-hydroxyvitamin D for multiple health outcomes. Am J Clin Nutr 2006;84:18 –28.

  37. www.aclm-articles.net -- Lectures - Vit D 5-09 The End

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