Natalie Vicca Good Food for New Arrivals Project ASeTTS Vitamin D Natalie Vicca Good Food for New Arrivals Project ASeTTS

ASeTTS Association for Services to Torture and Trauma Survivors Free & Confidential service Counselling, advocacy, support, group and community activities

Good Food for New Arrivals Funded by Australian Government under the Stronger Families and Communities Invest to Grow Program.

Services at ASeTTS www.asetts.org.au Counselling & Advocacy Community development programs and support groups Personal Support Program Volunteer program Settlement grants program Training, professional development & consultation Strength to Strength Relationship support Good Food for New Arrivals Nutrition Project Integrated service centre MDT at selected Primaries Newly Arrived Youth Support Service Sessional psychiatrist

Australia’s Humanitarian Programme Nationally 13,000 accepted each year 2006 Total under 18 years = 56% Under 9 years old = 27% 200 visa is refugee visa or 204 woman at risk The SHP includes those that are sponsored to come by other family members and PPV and TPV as well as the onshore processed visas Numbers from 2006 =12144 Total under 18 years = 56% = 6735 Under 9 years old = 27% = 3262

Learning Objectives Be aware of sources and function of Vit D Be aware of the effects of Vit D deficiency Recognise groups at risk of deficiency The situation in WA Identify screening/treatment strategies

Sources Sunlight -D3 cholecalciferol Diet -D2 ergocalciferol Fish, Eggs, Margarine, Milk, some meats Requirements = 5-15 Micrograms/day (Nutrient Reference Values for Australia and New Zealand 2006) Where do we get the stuff and how much do we need? 19-50yrs = 5mcg 51-70yrs = 10 mcg >70yrs = 15mcg

Function Variety of neuromuscular and physiological functions Maintains serum calcium and phosphorus Role in enhancing immune function

sunlight skin 7 -dehydrocholesterol cholecalciferol Vitamin D3 (fish, meat) Vitamin D2 (supplements) liver The vitamin is activated through multiple organ systems When anything is wrong with these systems there may be issues with Vitamin D i.e kidney failure, bowel disease 25 dihydroxyvitamin D3 1,25-dihydroxyvitamin D3 ↑Ca absorption small intestine ↑Urinary calcium reabsorption (kidney) ↑Bone mineralisation kidney

Deficiency Rickets in children Osteoporosis and Osteomalacia adults Implicated in development of Psoriasis Type 1 Diabetes Mellitus Multiple Sclerosis Gastrointestinal Cancers Difference due to pathogenesis of growing versus mature bone

WA Situation Migrant Health found approx 16% of children and 11% of adults have moderate to severe vitamin D deficiency Many more with mild deficiency - 40% Have been emergency presentations due to hypocalcaemic seizures 40% of all those seen have inadequate levels of vitamin D

Who is at risk? Those who do not get enough sunlight. Covered for cultural reasons Dark skin needs longer exposure Elderly Breastfed babies of deficient mothers Babies not introduced to solids appropriately Who are we talking about? Insufficient sun exposure Elderly do not metabolise as efficiently

Sun exposure Outside of peak hours Without sun screen for short periods only Hands, arms and face if possible Darker skins require longer exposure 7 minutes in summer for moderate to fair skin, up to 3-4 times longer for highly pigmented skins.

Symptoms and Signs Young Infants Restlessness Poor sleep Craniotabes (Soft posterior skull due to reduced mineralisation) Obviously difficult to assess!!

Older infants Delayed sitting/crawling Delayed closure fontanelle Bossing of skull Costochondral beading Delayed tooth development Photos courtesy of Tom D Thacher, MD

Children (1-4 yrs) Enlarged Epiphysial cartilages wrists/ankles Kyphoscoliosis Delayed walking Abnormal teeth excessive caries

Bow leg abnormality Knock knees Photos courtesy of Tom D Thacher, MD

Marion Post Wolcott. Corbis www.fags.org

Older children and adolescents Painful walking Bowlegs Knock knees Abnormal teeth Excessive caries Neuromuscular hyperactivity muscle weakness

Adults Weak bones Bone pain (spinal, pelvic, legs) Muscle weakness Hypocalcaemia Compressed vertebrae Pelvic flattening Easy fracturing

What can be done? Screening Blood test – vitamin D, U&E’S, PTH, Ca, LFT’s Signs or symptoms screened by GP

Treatment Children Adults Managed via PMH due to sole access to supplementation Adults Managed by GP E.g. Ostelin 1000 3-5 tablets/d

After 2 years of treatment Photos courtesy of Tom D Thacher, MD

Summary Slip Slap Slop Still stands but…. SPOT – those at risk SCREEN - those likely to be deficient SUPPLEMENT – those with low levels

Questions?