2. TOPIC X

3. National Diet and Nutrition Survey

4. What is ‘vitamin’ D and what does it do? But… Vitamin D receptors are expressed on most cells and it appears to have effects on cell proliferation and differentiation, immune system function, cardiovascular tissue, CNS etc.

5. What are the results of low levels?

6. DesignNumber of participantsComparator Odds/hazard ratio or relative risk§ (95% CI) All cause mortality Autier and Gandini, 2007 10 Meta-analysis of 18 vitamin D supplementation studies 57 311Supplemented v unsupplemented RR 0.93 (0.87 to 0.99) Ginde et al, 2009 12 Prospective observational study in individuals >65 years* 3265Serum 25-OHD concentration >100 nmol/l v <25 nmol/l HR 0.55 (0.34 to 0.88) Dobnig et al, 2008 13 Prospective cohort study with coronary angiography† 3258Median serum 25-OHD concentration 70 nmol/l v 19 nmol/l‡ HR 0.48 (0.37 to 0.630 Cardiovascular mortality Ginde et al, 2009 12 Prospective observational study in individuals >65 years* 3265Serum 25-OHD concentration >100 nmol/l v <25 nmol/l HR 0.42 (0.21 to 0.85) Dobnig et al, 2008 13 Prospective cohort study with coronary angiography† 3258Median serum 25-OHD concentration 70 nmol/l v 19 nmol/l‡ HR 0.45 (0.32 to 0.64) Diabetes Type 1 Zipitis and Akobeng, 2008 18 Meta-analysis of four case-control studies of vitamin D supplementation 6455Supplemented v unsupplemented OR 0.71 (0.60 to 0.84) Type 2 Pittas et al, 2007 14 Meta-analysis of four observational studies 6784 (non-black)Serum 25-OHD concentration 63-95 nmol/l v 25-58 nmol/l OR 0.36 (0.16 to 0.80) Cancer Colorectal Yin et al, 2009 15 Meta-analysis of six case-control studies 3556Per 50 nmol/l increase in serum 25-OHD concentration OR 0.57 (0.43 to 0.76) Breast Chen et al, 2009 16 Meta-analysis of seven observational studies 11 330Highest quartile serum 25-OHD concentration v lowest quartile OR 0.55 (0.38 to 0.80) Multiple sclerosis Munger et al, 2006 17 Nested case-control study 444Per 50 nmol/l increase in serum 25-OHD concentration OR 0.59 (0.36 to 0.97) Diagnosis and management of vitamin D deficiency Simon Pearce, Tim Cheetham BMJ 2010; 340(11 January 2010)

7. Evidence of benefit? Cochrane April 2014 – Hip fractures in older adults Mean/median age 80yrs+ 53 trials, 91,791 participants Vitamin D AND Calcium supplements Results – Community residents. Risk from 8 to 7/1000/yr – Institution residents. Risk from 54 to 45/1000/yr

8. Cochrane: Vitamin D and mortality Jan 2014 56 randomised trials with 95,286 participants Mean 4.4 years of supplementation Most trials included women over 70years VitaminD3 only reduced all cause mortality 11.4% to 11.0% RR 0.94 (0.91-0.98) P0.002 150 treated for 5yrs to save one life 1000 treated for 5-7yrs to save 4 cancer deaths May decrease mortality in elderly people living independently but…substantial dropout of participants…risk of type 1 error…more RCTs needed.

9. Vitamin D and multiple health outcomes: umbrella review of systematic reviews and meta-analyses of observational studies and randomised trials BMJ April 2014

10. Scientific Advisory Committee on Nutrition Draft Vitamin D and Health Report 2015 – <25ng/ml Vitamin D is probably associated with poor musculoskeletal health – 10mcg/day is probably good for us and safe Limited data on health outcomes for treatment – Even for rickets and osteomalacia

11. However… Case control study within the WHI study Higher VitD levels (>30ng/mL) assoc. with… – Lower fracture risk in white women (OR.82) – Higher fracture risk in Black women (OR 1.45) Asian women (OR 2.78) “the optimal level of VitD for skeletal health may differ in white and black women” Serum 25-hydroxyvitamin D and clinical fracture risk in a multiethnic cohort of women: the Women's Health Initiative (WHI). J Bone Mine Res Oct 2011

12. “The diversity of opinions on this topic has created lively discussions because the conclusion based on randomized controlled trials (RCTs) differs from the conclusions based on the large body of observational studies.” Optimal Vitamin D Status: A Critical Analysis on the Basis of Evidence-Based Medicine. J Clin Endocrinl Metab Aug 2013

13. 20-30mins sunlight at midday on face and arms 2- 3times per week sufficient for fair skin (2000IU VitD per session) April-Sept 2-10 fold increase in exposure needed if pigmented skin. Eat oily fish Probably…

14. What should we do? NICE say: Offer supplementation to ‘at-risk’ groups – All pregnant and breastfeeding women (10mcg=400IU D3) – Infants and children under 5 years (5drops healthy start drops= 7.5mcg D3) – People over 65 – People who have low or no exposure to the sun. – People who have darker skin. Only test in symptomatic patients (and those at high risk according to NICE) Treat Vitamin D deficiency (<25nmol/L or <30nmol/L according to NOS) – Adults 300,000IU over 6-10weeks – Children 3000IU per day for 3months Offer 800IU with calcium to the elderly to reduce risk of fracture (over 80s in institutions?) Await Further research eg VITAL (2017) and VIDA (2016/17)

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