Professional Documents
Culture Documents
Contents
• Background
• Risk factors for vitamin D deficiency
• Clinical features
• The association between vitamin D and ill
health
• Who should we test
• Vitamin D supplementation
• Who should we treat?
• Summary
Risk factors for Vitamin D
deficiency
• Lack of UVB sunlight exposure
– Northern latitude (90% UK too far north to have adequate
levels for 6 months of the year!)
– Occlusive garments
– Pigmented skin
– Sunscreen with SPF 15+ blocks 99% vitamin D synthesis
• Poor oral intake
• Elderly
• Liver disease
Epidemiology
• Vitamin D deficiency is common in children and adults.
• It has been estimated that 1 billion people worldwide have
vitamin D deficiency.
• A recent survey in the UK showed that more than 50% of the
adult population have insufficient levels of vitamin D and that
16% have severe deficiency during winter and spring. The
highest rates were found in Scotland, Northern England and
Northern Ireland.
• One study found the prevalence of rickets in non-Caucasian
children to be 1.6%
Clinical features
Symptom/Sign Children Adult
Seizures
Tetany
Hypocalcaemia
Irritability
Leg Bowing
Knock knees
Impaired linear growth
Delayed Walking
Limb girdle pain
Proximal myopathy
Muscle pain
What is the association between
low vitamin D and ill- health?
• Low concentrations of Vitamin D have been associated with
many non-skeletal diseases
– CVD, weight gain, diabetes, infectious disease, MS,
depression, dementia, declining physical status and muscle
strength and all cause mortality
• Conclusion: The discrepancy between observational and
intervention studies suggest that low Vitamin D status is a
marker of ill health i.e. it is consequence rather than cause.
• There is evidence to support routine supplementation of frail
older people to reduce all cause mortality
• Supplementation reduces falls and fracture risk
Who should we test
• Patients with bone disease whose outcomes may be improved
with Vitamin D treatment
– osteomalcia and Paget’s
• Patients with musculoskeletal symptoms that could be
attributed to Vitamin D deficiency e.g. osteomalacia is
associated with bone, joint and muscle pain and hyperalgesia.
• We should consider testing patients with chronic widespread
pain.
• Routine testing is not necessary in patients with osteoporosis
or fragility fracture who will be treated with oral drugs and co-
prescribed Vitamin D supplementation
What about testing in asymptomatic
patients?
• Routine testing of higher risk individuals is
NOT recommended
– They should take routine supplementation
• No evidence for screening or treatment in
asymptomatic patients found to be deficient
Vitamin D Supplementation
• In 2012 the CMOs for the UK wrote to all GPs
• Lifestyle:
– How much sunshine should we be recommending
to our patients?
• Sunscreen should be used only after an initial short
period, while of course stressing the importance of
avoiding sunburn!
• Diet
AKT Question:
You speak to a 56 year old lady following a # distal
radius to discuss dietary modifications. Her bloods
are: Calcium 2.44, Vitamin D 11
• Which one of the following food has the
highest vitamin D content?
• A : Cup of mushrooms
• B : Herring 100g
• C : Large boiled egg
• D : Mackerel 100g
• E : Vitamin D fortified cereal 30g
Group Recommended daily Example products
dose of
supplementation
All pregnant and breastfeeding 10mcg 400IU daily Healthy Start or Pregnacare
Women - Especially young vitamin tablets
women
Children - aged 6months-5years 7-8.5mcg 300IU daily Healthy Start vitamin drops
Breast-fed infants from 1month (contain 7.5mcg per 5 drops)
of age IF mother has not taken or
Abidec drops (contain 10mcg
supplements in pregnancy
per
Babies fed infant formula
0.6ml)
(which is fortified) do NOT need
supplementation until receiving
<500ml formula daily