1. Vitamin D Deficiency in Scotland

2. Right to be informed 80% Vitamin D deficient of Scottish Population Many diseases linked to low vitamin D Rickets - osteomalacia - muscle weakness - depression - dementia - infections - multiple sclerosis - osteoporosis - fractures - cancer prevention - cancer progression - diabetes - cardio-vascular disease - falls - tuberculosis - inflammatory bowel disease

3. Helga Rhein GP Sighthill Health Centre Edinburgh February 2013

4. 1. Vitamin Ds function 2. Deficiency 3. Scottish average levels 4. Linked diseases 5. Solutions

5. What is vitamin D? Nutrient produced in skin exposed to sun fish, supplements

6. Modern findings - last decade: transformation in the body in several steps into a powerful hormone (this is different from all other vitamins) in addition to bone health: immune system, up- and down regulation of genes insulin production influence on cancer cells... vitamin D receptor in every organ organs only in best running order if sufficient vitamin D optimal levels around 4 times as much or above

8. Normal natural blood levels of outdoor workers: around 120 nmol/l Barger-Lux, US, 120 nmol/l, 2002. Binkley, Hawaian surfers, 80 nmol/l 2007, Aydin, Turkish children, 180 nmol/l, 2010. Rajasree, Indian fishermen 270 nmol/l, 1999. Luxwolda, traditional living populations East Africa, 115 nmol/l 2012 Maximal calcium absorption: above 80-90 nmol/l Heaney, 2005

9. adequate blood level Normal Outdoor workers 120 nmol/l UK old guidelines25 nmol/l Most vitamin D experts 100 nmol/l Compromise WHO 2003, US Institute of Medicine 2010 50 nmol/l as Edinburgh Royal Infirmary

10. Scotlands levels?

11. . Hyppönen et al 2007 <40 nmol/L 7437 participants, aged 45

12. Edinburgh University study: 84% < 50 nmol/l (Zgaga, 2011, - 2230 participants, Scotland-wide, aged 21-80) Aberdeen 100% < 50 nmol/l (Macdonald et al, 2009, 338 post-menopausal women) My practice: 70 % < 50 nmol/l (of 350 people tested by May 2011)

13. Scottish Problems: Northern latitude 55º - 60º Clouds, Wind Clothes

14. INDOOR LIVING + WORKING Sunscreen Avoidance of midday sun

16. Diseases linked to low levels

17. 1. Rickets 2. Infections, pre-eclampsia, pre-term birth 3. MS, autism, schizophrenia....

18. Pooled analysis of observed/expected births in people with multiple sclerosis in Canadian, British, Danish, and Swedish studies (n=42 045) with 95% confidence intervals. Willer C J et al. BMJ 2005;330:120 ©2005 by British Medical Journal Publishing Group MS

19. Staples, 2010, BMJ Australia 1524 patients with MS born in Australia from a total population of 2,648,779 MS

20. Thus, there are now innumerable, experimental, epidemiological, immunological, genetic and clinical arguments in support of the notion that vitamin D insufficiency is one of the risk factors for MS..... Pierrot-Deseilligny C, Souberbielle JC. Contribution of vitamin D insufficiency to the pathogenesis of multiple sclerosis published online 23 January 2013 Therapeutic Advances in Neurological Disorders

21. Many diseases linked to low vitamin D Rickets - osteomalacia - muscle weakness - depression - dementia - infections - multiple sclerosis - osteoporosis - fractures - cancer prevention - cancer progression - diabetes - cardio-vascular disease - falls - tuberculosis - inflammatory bowel disease ???

22. Vacec 2011, 10,899 patients normal (75 nmol/l) or deficient (<75 nmol/l). In conclusion, vitamin D deficiency was associated with a significant risk of cardiovascular disease and reduced survival. Vitamin D supplementation was significantly associated with better survival, specifically in patients with documented deficiency. CVD

23. Jenar et al. BMJ 2010: 520 000 participants from 10 western European countries 1248 cases of incident colorectal cancer and 1248 controls.....patients in the highest quintile had a 40% lower risk of colorectal cancer than did those in the lowest quintile Cancer

24. Kaplan–Meier survival curves (ie, free of cancer) for the3 random treatment groups in the cohort of women free of cancerat 1 year of intervention (N 1/4 1,085). Sample sizes are 266 for placebo,416 for calcium only, and 403 for calcium plus vitamin D. The survivalat the end of study for the Ca+D group is significantly higher than thatfor placebo, by logistic regression. (Copyright Robert P. Heaney, 2006) Lappe 2009: approx 1000 white women, good baseline vit D levels, supplemented with either a modest amount of vit D, or Calcium + same amount Vit D, or placebo Cancer

25. Hepatogastroenterology.Hepatogastroenterology. 2013 Jan 9;60(126). doi: 10.5754/hge121003. [Epub ahead of print] Tumor-suppressive effects of 1,25- dihydroxyvitamin D3 in gastric cancer cells. Bao A, Li Y, Tong Y, Zheng H, Wu W, Wei C.eng H Wei Abstractstract It has been previously demonstrated that vitamin D acts as a prognostic indicator of gastric cancer and may be correlated with the incidence risk of gastric cancer. However, the effect of 1,25-dihydroxyvitamin D3 on the apoptosis of human gastric cancer cells is unclear. The aim of this study was to determine whether 1,25- dihydroxyvitamin D3 induced the cellular apoptosis of BGC-823 gastric cancer cells and to determine the potential mechanism of action. We demonstrate that 1,25-dihydroxyvitamin D3 induced the apoptosis of gastric cancer cells via the processing of PARP and cleavage of caspase 3. Additionally, an increase in BAX expression and a decrease in ERK1/2 and AKT phosphorylation were associated with 1,25-dihydroxyvitamin D3-induced apoptosis. The mRNA expression levels of VDR, CYP24A1, and p21 were increased significantly following 1,25-dihydroxyvitamin D3 treatment. These findings suggest that 1,25- dihydroxyvitamin D3 exerts tumor-suppressive effects on BGC-823 human gastric cancer cells.been prdemoed th Cancer

27. May 2010: 7,358 Cardio-vascular patients. Lowest levels, below 37 nmol/l were nearly 3 times more likely to develop depression compared to highest levels of above 125 nmol/l. Mental Health

28. Maddock J et al.Vitamin D and common mental disorders in mid-life: cross- sectional and prospective findings.Clinical Nutrition, Jan 2013 7,401 participants UK aged 45 5 years later higher vitamin D = less risk of depression Mental Health

29. Randomised controlled trial: Jorde 2008: Effects of vitamin D supplementation on symptoms of depression in overweight and obese subjects. In the two groups given vitamin D, but not in the placebo group, there was a significant improvement in BDI scores after 1 year. Systematic review: Anglin R et al. 2013. Vitamin D deficiency and depression in adults.Anglin R et al Twice as likely to be depressed if vitamin D low. Mental Health

30. Umhau, 2013: Of 500 suicides in US military service members : those with lowest vit D - <37 nmol/l - had highest risk It may be that in a young, sometimes aggressive population such as military, impulsivity plays more of a role than depression in risk for suicide... Suicide rates: US: 12 per 100,000 (2010) England: 11 per 100,000 (2006) Scotland: 19.8 per 100,000 (2006) Scots aged 15-44 double the rate compared to English counterparts Mental Health

31. Berry et al, July 2011. Vitamin D status has a linear association with seasonal infections and lung function in British adults. British Journal of Nutrition 6789 participants UK 45-year olds July 2011 Colds and flu

32. ...vitamin D significantly reduces the respiratory tract infection... 10 mcg/day to 50 mcg/day 1/3 less colds, coughs, flus, pneumonia Charan,, JC. et al. Vitamin D for prevention of respiratory tract infections: A systematic review and meta-analysis. J Pharmacol Pharmacother. 2012 Oct-Dec; 3(4): 300–303.J Pharmacol Pharmacother. 2012 Oct-Dec; 3(4): 300–303. Colds and flu

33. Autier 2007 Meta-analysis of 18 randomised placebo controlled trials 57,000 participants 7.5 - 50 mcg daily 7% reduction in mortality Bjelakovic 2011 Cochrane Systematic Review: 50 randomised placebo controlled trials 94,148 participants 6% reduction in mortality All cause mortality

34. 20 - 30 % of Scottish people severely deficient and symptomatic: tired achy legs and back low mood frequent colds wait few months for improvement

36. Country starved of a nutrient. Much greater importance than previously thought Linked to all kinds of diseases Scottish ailments: MS Depression, suicides Cancer incidence and mortality Cardio-vascular disease Total mortality Vitamin D is cheap and safe.

37. What can we do?

38. information website: www.scots4vitd www.scots4vitd What else can we do?

39. One day exposed in sunshine: 250 mcg

40. Ferguson installed tanning booths so United players could top up their Vitamin D levels PUBLISHED: 08:56, 19 December 2012 | UPDATED: 13:41, 19 December 2012

41. 10 mcg to all babies, starting after birth 25 mcg for children aged 1 to 18 50 mcg for all adults over 18 50 mcg for pregnant women (25 mcg for pregnant women aged 14 -18) Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, M. Murad H, Weaver CM. Evaluation, Treatment, and Prevention of Vitamin D Deficiency: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab, July 2011, 96(7)

42. 10 mcg is sufficient for a baby but not for a 20 - 30 times heavier adult 10 mcg is not enough

43. In our practice on prescription to all: Adults, Teenagers over 12: weekly 500 mcg (= 20,000 IU) Children aged 5 - 12: daily 25 mcg (= 1,000 IU) Children aged 0 - 5: daily 10 mcg (= 400 IU) Pregnant women: daily 50 mcg (= 2,000 IU)

44. When living in Scotland: take vitamin D 50 -100 mcg daily (Adults) Read up on rare conditions when you should not take vitamin D or check with your doctor