1. Vitamin D Supplementation Emily Sedlock PA-S Lock Haven University of PA Physician Assistant Program Emily Sedlock PA-S Lock Haven University of PA Physician Assistant Program

2. Why Vitamin D?  Vitamin D receptors have been found in most tissues not only the classical sites like the bone, gut, and kidneys.  These findings have sparked research involving these new receptor sites.  Areas of research include cancer, autoimmune, and cardiovascular disease.  Vitamin D receptors have been found in most tissues not only the classical sites like the bone, gut, and kidneys.  These findings have sparked research involving these new receptor sites.  Areas of research include cancer, autoimmune, and cardiovascular disease.

3. Where do we get vitamin D?  Foods we eat such as fatty fish, nuts, and mushrooms along with those that are fortified such as milk & cereals.  Sunlight, when skin is exposed to ultra-violet radiation vitamin D is synthesized by the body.  Foods we eat such as fatty fish, nuts, and mushrooms along with those that are fortified such as milk & cereals.  Sunlight, when skin is exposed to ultra-violet radiation vitamin D is synthesized by the body.

4. The Problem  Even with all these ways to get vitamin D most people are deficient.  Researchers at the Albert Einstein College of Medicine and Johns Hopkins School of Public Health outlined the most at-risk populations for vitamin D deficiency.  Even with all these ways to get vitamin D most people are deficient.  Researchers at the Albert Einstein College of Medicine and Johns Hopkins School of Public Health outlined the most at-risk populations for vitamin D deficiency.

6. Drugs can also deplete Vitamin D  Anticonvulsants  Anti-Inflammatories  Anti-ulcer medications  They do so by inhibiting absorption, synthesis, transport, storage, metabolism, or excretion of vitamin D.  Anticonvulsants  Anti-Inflammatories  Anti-ulcer medications  They do so by inhibiting absorption, synthesis, transport, storage, metabolism, or excretion of vitamin D.

7. Diagnosing Deficiency  Serum 25OHD is a reliable indicator of vitamin D status.  “Normal” lab values are usually between 32-150 ng/ml.  Optimal lab values, as the following studies will show, are likely around 52 ng/ml.  Serum 25OHD is a reliable indicator of vitamin D status.  “Normal” lab values are usually between 32-150 ng/ml.  Optimal lab values, as the following studies will show, are likely around 52 ng/ml.

8. Supplementation  This is one way to raise serum 25OHD levels when other methods are not feasible, I.e. winter months with little sunlight.  There are two types of vitamin D available in supplement form, D2 & D3. The latter is more effective in raising serum levels.  This is one way to raise serum 25OHD levels when other methods are not feasible, I.e. winter months with little sunlight.  There are two types of vitamin D available in supplement form, D2 & D3. The latter is more effective in raising serum levels.

9. PICO Question:  In adults ages 18 years and over does vitamin D supplementation reduce overall mortality?

10. Breast Cancer  Investigators evaluated the dose-repsonse relationship between 25OHD and risk of breast cancer. They concluded that serum levels of 52 ng/ml provided a 50% reduction in one’s risk of breast cancer.

11. How much supplementation is necessary to meet 52 ng/ml?  It is approximated that it would require 4,000 IU/day to produce a serum level of 52 ng/ml.  This is 2,000 IUs above the National Academy of Sciences current upper limit.  It is approximated that it would require 4,000 IU/day to produce a serum level of 52 ng/ml.  This is 2,000 IUs above the National Academy of Sciences current upper limit.

12. Myocardial Infarction  Researchers investigated whether vitamin D deficiency was related to the development of atherosclerosis and coronary heart disease.  They found that levels of at least 30 ng/ml cut the risk of MI in half, independent of other CVD factors.  Currently recommended dietary requirements are not sufficient to achieve these levels.  They found it would take approximately 3,000 IU/daily to reach these levels.  Researchers investigated whether vitamin D deficiency was related to the development of atherosclerosis and coronary heart disease.  They found that levels of at least 30 ng/ml cut the risk of MI in half, independent of other CVD factors.  Currently recommended dietary requirements are not sufficient to achieve these levels.  They found it would take approximately 3,000 IU/daily to reach these levels.

13. Colorectal Cancer (Gorham, 2007)  The goal of this meta analysis was to provide guidelines for changing the recommended daily values, especially for the prevention of colorectal cancer.  Researchers found that a daily intake of 1000-2000 IUs were necessary to reduce one’s risk of colorectal cancer.  The goal of this meta analysis was to provide guidelines for changing the recommended daily values, especially for the prevention of colorectal cancer.  Researchers found that a daily intake of 1000-2000 IUs were necessary to reduce one’s risk of colorectal cancer.

14. Conclusions  Collectively these studies inform us that vitamin D levels need to be checked and supplementation provided to all patients to prevent morality.  New reference ranges of normal need to be established that will prevent morality as opposed to merely avoiding signs of deficiency.  Collectively these studies inform us that vitamin D levels need to be checked and supplementation provided to all patients to prevent morality.  New reference ranges of normal need to be established that will prevent morality as opposed to merely avoiding signs of deficiency.

15. Conclusions continued…  Supplementation provided must be adequate to raise serum levels above at least 52 ng/ml.  Levels must be rechecked to establish that this serum goal is met and maintained or supplementation doses must be raised.  Supplementation should continue indefinitely.  Supplementation provided must be adequate to raise serum levels above at least 52 ng/ml.  Levels must be rechecked to establish that this serum goal is met and maintained or supplementation doses must be raised.  Supplementation should continue indefinitely.

16. Conclusions cont…  These findings should be applied to the daily practice of medicine in family practice.  Research should continue with randomized controlled experimental studies.  These findings should be applied to the daily practice of medicine in family practice.  Research should continue with randomized controlled experimental studies.

17. Questions???

18. References  Bjelakovic, G., Gluud, L., Nikolova, D., Whitfield, K., Wetterslev, J., Gluud, C. (2008). Vitamin D supplementation for prevention of mortality in adults. Cochrane Database of Systematic Reveiws, 4: CD007470.  Garland, C., Gorham, E., Mohr, S., Grant, W., Giovannucci, E., Lipkin, M., Newmark, H., Holick, M., Garland, F. (2007). Vitamin D and prevention of breast cancer: pooled analysis. Journal of Steroid Biochemistry & Molecular Biology. 103, 708-711.  Giovannucci, E., Liu, Y., Hollis, B., Rimm, E. (2008). 25-hydroxyvitamin D and risk of myocardial infarction in men. Arch Inter Med. 168(11), 1174-1180.  Bjelakovic, G., Gluud, L., Nikolova, D., Whitfield, K., Wetterslev, J., Gluud, C. (2008). Vitamin D supplementation for prevention of mortality in adults. Cochrane Database of Systematic Reveiws, 4: CD007470.  Garland, C., Gorham, E., Mohr, S., Grant, W., Giovannucci, E., Lipkin, M., Newmark, H., Holick, M., Garland, F. (2007). Vitamin D and prevention of breast cancer: pooled analysis. Journal of Steroid Biochemistry & Molecular Biology. 103, 708-711.  Giovannucci, E., Liu, Y., Hollis, B., Rimm, E. (2008). 25-hydroxyvitamin D and risk of myocardial infarction in men. Arch Inter Med. 168(11), 1174-1180.

19. References cont…  Gorham, E., Garland, C., Garland, F., Grant, W., Mohr, S., Lipkin, M., Newmark, H., Giovannucci, E., Wei, M., (2007). Optimal vitamin D status for colorectal cancer prevention. American Journal of Prev Med. 32(3), 210- 216.  Melamed, M., Michos, E., Post, W., Astor, B., (2008). 25-hydroxyvitamin D levels and the risk of mortality in the general population. Arch Intern Med. 168(15), 1629- 1637.  LaValle, J., (2005). Metabolic consequences of drug induced nutrient depletions.  Gorham, E., Garland, C., Garland, F., Grant, W., Mohr, S., Lipkin, M., Newmark, H., Giovannucci, E., Wei, M., (2007). Optimal vitamin D status for colorectal cancer prevention. American Journal of Prev Med. 32(3), 210- 216.  Melamed, M., Michos, E., Post, W., Astor, B., (2008). 25-hydroxyvitamin D levels and the risk of mortality in the general population. Arch Intern Med. 168(15), 1629- 1637.  LaValle, J., (2005). Metabolic consequences of drug induced nutrient depletions.