The setright letter vitamin D

Setright R, Is There A Vitamin D Deficiency Epidemic In Australia, And If So, Is This A Major Contributing Factor To Disease? Setright Letter, 2010 April;05:12:1-10------------------------------------------------------------------------------------------------------------------------------------------

Vitamin D3, The Super Nutrient.An Independent review of Complementary Medicine EvidenceBy Russell Setright

-------------------------------------------------------------------------------------------------------Russell Setright is an accredited Naturopath, Medical Herbalist, Acupuncturist and an educator in Advanced Life Support, First Aid, Emergency Care and Rescue. He is an Honorary Life Member of St John Ambulance and member of ATMS,ANTA,AMWA and AREMT and is Director of Training for Life Survival Training. He was registered in the Northern Territory under the Health Practitioners and Allied Professionals Registration Act in 1986 and was the Editor in Chief of the Journal of Health Sciences. Russell is also the past Dean of Naturopathic Medicine and Fellow at the Academy of Natural Therapies. He Chaired the Symposium at the International Conference On The Use of Traditional Medicine and Other Natural Product In Health Care at The School of Pharmaceutical Sciences, University of Science Malaysia where he also presented his paper and was appointed to the Panel of Consultants at The Nury Institute of Family & Child Development, Malaysia. Over the years, Russell has presented papers and GP update seminars at the University of NSW, Royal Women’s Hospital, Natural Therapies Unit NSW and was also the Naturopathic Director Blackmores Ltd. Russell has been on a number of Government assessment panels for degree programs in Australia and New Zealand and is currently a member of the advisory committee NSW Oncology Group, Cancer Institute, NSW Health.Russell is the author of seven books on complementary medicine with one published in the Chinese and Malay languages and he currently has a Health Talk Back Radio Show with Brian Wilshire on Sydney’s Radio 2GB, Michael McLaren on 2GB weekends, Leon Byner on 5AA Adelaide, Richard Perno in Country NSW and The Panacea Health Program on 2SER

************************Is There a Vitamin D Deficiency Epidemic in Australia, and if So, Is This a Major Contributing Factor to Disease and is vitamin D3 the new super nutrient? A summary of evidence.

AbstractA review of published studies found that a significant number of Australians and New Zealanders have less than optimal serum vitamin D levels, with mild to moderate deficiency ranging from 33 to 84% depending on age, skin colour and/or those in residential care. These studies have also reported a significant relationship between low vitamin D status and an increase in the prevalence of diseases including; diabetes, CVD, metabolic syndrome, osteoporosis, hypertension, certain cancers, several autoimmune diseases the Flu and all cause mortality. The data also suggest that normalising blood 25(OH)VitD levels by supplementation with vitamin D3 may have a positive effect in disease prevention.

Methods The literature up to April 2010 was searched without language restriction using the following databases: PubMed, ISI Web of Science (Science Citation Index Expanded), EMBASE, and the Cochrane Library.

Background

Ecological studies have suggested that mortality from several potentially life-threatening chronic diseases increase in incidence with a decreased exposure to sun light (Grant WB. Ecologic studies of solar UV-

B radiation and cancer mortality rates. Recent Results Cancer Res. 2003;164:371-377) Because sun exposure is necessary for the synthesis of vitamin D in the skin, this review will show that the associations found between sun exposure, vitamin D intake and mortality(death) from several

© Russell Setright The Setright Letter, 2010

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chronic conditions could be owing to variations in vitamin D status.

There are two forms of vitamin D that are important in humans: ergocalciferol (vitamin D2) and cholecalciferol (vitamin D3). Vitamin D2 is synthesized by plants and obtained by humans through diet. Vitamin D3 is made in the skin when 7-dehydrocholesterol reacts with ultraviolet-B (UVB) rays from sunlight at wavelengths between 270–300 nm and stored in the blood as calcidiol (25-hydroxy-vitamin D). Both D2 and D3 precursors are hydroxylated in the kidneys and liver to form 25- hydroxyvitamin D (25(OH)vit.D), the non-active 'storage' form, and 1,25-dihydroxyvitamin D. 1,25 (OH)2D, the biologically active (hormone) form that is tightly controlled by the body.

One of the functions of vitamin D is to maintain normal blood levels of calcium and phosphorus which helps form and maintain strong bones.

However, research also suggests that increased blood levels of 25(OH)VitD may provide protection from CVD, diabetes, osteoporosis, hypertension, certain cancers, and several autoimmune diseases.

The sun is a significant contributor to our daily production of vitamin D3. However, the amount of sun exposure required to produce enough vitamin D3 is dependent on a number of factors including, skin colour, latitude, types of clothing, body mass, age, cloud cover, atmospheric pollution.

In Australia we are exposed to around 40% more UV rays than the equivalent latitude in the Northern Hemisphere and this creates a dilemma (Madronich S, et al. Changes in biologically active ultraviolet radiation reaching the earth's surface. Photochem Photobiol B 1998;46:5-19).

Is this increased UV exposure in the Southern Hemisphere and the resulting skin sun damage more detrimental to overall health than vitamin D deficiency?There is evidence that excessive sun exposure increases the risk of skin damage, ageing and skin cancers. Excessive exposure to sunlight causing sunburn at any time in life increases a person's risk of developing skin cancer. However, people who experience intermittent exposure to high levels of UV radiation such as tanning on the beach on the weekend, appear to be at greater risk while those who experience continual exposure to lower levels even if the total dose of UV radiation is the same, have the lowest incidence of melanoma. That is, non-burning regular sun exposure such as obtained in the early morning and later in the afternoon seems to have a protective effect against skin cancer (Article, Prevention & Early Detection, Memorial Sloan-Kettering Cancer Centre 2008). And, a moderate amount of unblocked sunlight may actually be beneficial to most people, and could reduce the risk of many other diseases – including, paradoxically, melanoma itself.

Another example of this paradox is research from the University Of California School Of Medicine. This study found that higher incidence of melanoma occurred among Navy desk workers than among sailors who worked outdoors (Garland FC. et al. Occupational sunlight exposure and melanoma in the U.S. Navy. Arch Environ Health. 1990 Sep-Oct;45(5):261-7).

Also, a study (Nürnberg B, et al. 2008) from the Department of Dermatology, The Saarland University Hospital, Homburg, Germany that examined the progression of malignant melanoma reported. Basal 25-hydroxyvitamin D levels were lower in melanoma patients as compared to the control group. And progression of malignant melanoma was associated with significantly reduced 25(OH)vit D serum levels. Their findings add to the growing body of evidence that 25(OH)vit D serum levels may be of importance for




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pathogenesis and progression of malignant melanoma (Nürnberg B, et al. Progression of malignant melanoma is associated with reduced 25-hydroxyvitamin D serum levels.Exp Dermatol. 2008 Jul;17(7):627).

As, the growing body of evidence supports the theory that low blood serum levels of 25(OH)vit D is also associated with an increase of many diseases including CVD, diabetes, certain cancers, osteoporosis, muscular and bone strength and death from all causes (Dobnig H, et al. Independent association of low serum 25-Hydroxyvitamin D with all cause mortality. Archives of Internal Medicine. 2008 Jun 23;168:1340-1349).

A strategy of timed low dose sun exposure needs to be developed to maintain adequate vitamin D levels. However, given the vast difference in geographical location, skin type and ethnic origin we have in Australia a “One Fits All” program would be improbable.

As the data are supportive of maintaining adequate serum vitamin D levels, while at the same time reducing the risk of overexposure of UV rays from the sun.Supplementation with vitamin D3 may be the best way of achieving both goals.

Vitamin D deficiencies in Australia

The data are consistent in that low blood serum levels of 25(OH)VitD (25-hydroxyvitamin D) is at an alarming rate in Australia. Those people with dark or olive skin, the elderly and veiled (80% may have mild deficiency) as well as those who wear protective clothing and always use sun screen have the greatest risk of vitamin D deficiency (FIG 1). In addition, those taking anticonvulsant medication or suffer from renal, hepatic or cardiopulmonary disease or those who have fat malabsorption syndromes (e.g., cystic fibrosis) or inflammatory bowel disease such as Crohn's disease, are at risk. (Vitamin D, National Health and Medical Research Council 2010, Ministry of Health. Australian Government).FIG. 1

Nozza J et al. MJA 2001; 175: 253-255

What are Serum 25(OH)VitD Norms?

It has already been established that low serum levels of vitamin D that is below 27.5nmol/Lt results in inadequate mineralisation / demineralisation of the skeleton that is a contributing factor to rickets in young children. (Vitamin D, National Health and Medical Research Council 2010, Ministry of Health. Australian Government) . In a position statement, a Working Group from

the Australian and New Zealand Bone and Mineral Society, the Endocrine Society of Australia and Osteoporosis Australia




2: Proportion of women with serum vitamin D (25-hydroxyvitamin D3) levels under 22.5nmol/L, according to skin covering and skin colour

Skin colour

Skin covering*

Very dark

Intermediate Light Total

Consistently covered

6/6 (100%)

1/2 (50%)23/25 (92%)

30/33 (91%)

Inconsistently covered

3/5 (60%)

1/3 (33%)18/24 (75%)

22/32 (69%)

Uncovered2/2 (100%)

2/3 (67%) 0 (0)4/5 (80%)

Total11/13 (85%)

4/8 (50%)41/49 (84%)

56/70 (80%)

*Consistently covered - women always covered up, including arms, hair and neck, when outdoors; inconsistently covered - women did not usually cover fully in their own garden; and uncovered - women did not generally cover their arms, hair and neck when outdoors.

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(2005) defined mild deficiency for adults as serum 25-OHvitD levels between 25 and 50nmol/L which may contribute to an increased risk of osteoporosis and less commonly osteomalacia in adults (NHMRC).

The question often asked is, what blood serum 25(OH)VitD level is considered to be adequate?

Any level below 50nmol/Lt may also place an individual at high risk of vitamin D associated deficiency diseases and all cause mortality. Levels of vitamin D between 73 – 100 nmol/Lt would appear to be adequate.One Prospective cohort study of 3258 consecutive male and female patients found that those with low levels of serum vitamin D had a 54% to 2.34 times increased risk mortality from any cause when compared to people with adequate levels of around 72nmol/Lt. (Fig. 2)Also, this study found that 25-hydroxyvitamin D levels that are in the lower 50% of the vitamin D range of the study population have an increased risk for all-cause mortality after adjustment for traditional cardiovascular risk factors. In subgroup analysis, the relationship of low 25-hydroxyvitamin D levels to mortality is consistent regardless of co-morbidity, physical activity level.

The researchers concluded that a low 25-hydroxyvitamin D level can be considered a strong risk indicator for death from any cause in men and women (Dobnig H, et al. Independent association of low serum 25-Hydroxyvitamin D with all cause mortality. Archives of Internal Medicine. 2008 Jun 23;168:1340-1349).

25(OH)VitD blood levels (Dobnig H et al 2008)Fig. 2

CVD and Diabetes

Recent research has found significant association between low serum levels of 25(OH)vit D and an increase in the incidence of diabetes, CVD and metabolic syndrome. This research examined 28 studies that included 99,745 men and

women across a variety of ethnic groups. The studies revealed a significant association between high levels of vitamin D (25(OH)VitD) and a decreased risk of developing cardiovascular disease (33% compared to low levels of vitamin D), type 2 diabetes (55% reduction) and metabolic syndrome (51% reduction) ( Levels of vitamin D and cardiometabolic disorders: Systematic review and meta-analysis J.Maturitas Volume 65, Issue 3, 225-236, March 2010).

Further evidence relating to the befits of adequate vitamin D levels was presented at the American College of Cardiology’s annual scientific session in Atlanta March 2010. Researchers from the Intermountain Medical Center Heart Institute in Murray, Utah, reviewed 31,000 of their patients aged 50 or older found that those with the lowest levels of serum 25(OH)vitD had a 170-per-cent greater risk of heart attacks than those with the highest serum levels.

Also, according to the authors of this study, the benefits of having more vitamin D were not limited to a cut in heart-attack risk. Those with the lowest readings also had an 80-per-cent greater risk of death, a 54-per-cent higher risk of diabetes, a 40-per-cent higher risk of coronary artery disease, a 72-




25(OH)VitD Status

nmol/Lt

DeficientHighest Risk

‹ 37.4

DeficientHigh Risk

37.4 - 50

InsufficientModerate Risk

50-72

AdequateLow Risk

›73

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per-cent higher risk of kidney failure and a 26-per-cent higher risk of depression.

Diabetes

The incidence of diabetes in Australia is increasing and, at the same time we are seeing a corresponding deficiency in vitamin D levels. As the above studies show there is a strong link between the development of diabetes type-2 and vitamin D deficiency. The following study examines the link in childhood type-1 diabetes and vitamin D supplementation. A review and meta-analysis of the data from five trials that included 6455 infants, of which 1429 were cases and 5026 controls was published in the Archives of Disease in Childhood. The data from the five observational studies, found that infants who received vitamin D supplements were 29 per cent less likely to develop type-1 diabetes than non-supplemented infants (Zipitis C et al. "Vitamin D supplementation in early childhood and risk of type 1 diabetes: a systematic review and meta-analysis" Archives of Disease in Childhood (British Medical Journal) .2007).

Also, a study, published in the Journal of the American Medical Association, September 2007 looked at 1770 children at high risk of developing type-1 diabetes.Their study reported that an increased intake of omega-3 fatty acids from marine sources may reduce a child's risk of developing type-1 diabetes by 55 per cent.Vitamin D found in cod liver oil, a popular marine supplement, may have been a contributing factor.

Cardio Vascular Disease

Results of a large case-control study (Health Professionals Follow-up Study) was conducted in 18, 225 men. During the proceeding 10 years of follow-up, 454 men developed nonfatal myocardial infarction or fatal coronary heart disease. After adjustment for matched variables, men deficient in 25(OH)D less than 37.4nmol/Lt

were at increased risk for MI (heart attack) compared with those considered to be sufficient in 25(OH)D 74nmol/mL. And, after additional adjustment for family history of myocardial infarction, body mass index, physical activity, alcohol consumption, history of diabetes mellitus and hypertension, ethnicity, region, marine n-3 intake, low- and high-density lipoprotein cholesterol levels, and triglyceride levels, this relationship remained significant.

Even men with intermediate 25(OH)D levels were at elevated risk relative to those with sufficient 25(OH)D levels .The authors concluded that Low levels of 25(OH)D are associated with higher risk of myocardial infarction, even after controlling for factors known to be associated with coronary artery disease (Giovannucci, E. et al. 25-Hydroxyvitamin D and Risk of Myocardial Infarction in Men, Arch Intern Med. 2008;168(11):1174-1180).

These benefits in part may be explained by maintaining optimal vitamin D can slow the turnover of leukocytes by inhibiting pro-inflammatory overreaction resulting in a reduction of leukocyte telomere shortening. Shortening of leukocyte telomeres is a marker of aging and a predictor of aging-related disease. Length of these telomeres decreases with each cell division and with increased inflammation.

A study that examined whether vitamin D levels would attenuate the rate of telomere attrition in leukocytes, such that higher vitamin D concentrations would be associated with longer LTL. The results of this study suggested that higher vitamin D (25(OH)VitD) concentrations, which can be modified through vitamin D supplementation, are associated with longer LTL, would explain the potentially beneficial effects of vitamin D on aging and age-related diseases.(Richards J, et al. Higher serum vitamin D concentrations are associated with longer leukocyte telomere length in women, American Journal of Clinical Nutrition, Vol. 86, No. 5, 1420-1425, November 2007)




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Vitamin D Statins and Cholesterol.

Studies have found that statins, medications used to lower cholesterol, decrease the risk of CVD. However, the dietary-heart-cholesterol hypothesis may need to be questioned as statins may reduce this risk in ways other than lowering cholesterol.

A study examining this hypothesis and benefits produced by statins reports that based on published observations, the unexpected and unexplained clinical benefits produced by statins have also been shown to be properties of vitamin D. It seems likely that statins act as vitamin D analogues(Grimes D, Are statins analogues of vitamin D? The Lancet, Volume 368, Issue 9529, Pages 83 - 86, 1 July 2006).

Further evaluation of this proposed action needs to be undertaken as it could explain in part the reduced incidence of CVD associated with an increase in serum vitamin D levels.

Immune Function

Basically there are two types of immune -functions; our adaptive immune system, which is activated when we mount a defence against a new invader and then retain antibodies and memory for immunity in the future. And our innate immune system, the almost immediate reaction your body has, for instance, when you get a cut or a skin infection.

In primates, this action of "turning on" an optimal response to microbial attack only works properly in the presence of adequate vitamin D.

Vitamin D is vital for the innate immune system to function properly. T cells signal the immune systems killer cells to activate and to do this they require vitamin D. When T cells find an invading pathogen their vitamin D receptor is extended, similar to an aerial.

This receptor searches for available vitamin D and if not found the T cell will not activate. These T cells, once activated will either become killer cells which will attack the invading virus or bacteria or become helper cells that assist the immune system (Von Essen M, et al. Vitamin D controls T cell antigen receptor signalling and activation of human T cells, Nature Immunology, March 2010)

Also, other recent research has underlined an important key role of vitamin D signalling in regulation of innate immunity in humans.

When cells of the immune system such a macrophages sense a bacterial infection they acquire the capacity to convert circulating 25(OD)vitD into 1,25(OH)2

vitD. This production is a direct inducer of expression of genes encoding antimicrobial peptides, in particular cathelicidin antimicrobial peptide (CAMP). These antimicrobial peptides are vanguards of innate immune responses to bacterial infection and can act as signalling molecules to regulate immune system function (White JH. et al. Vitamin D as an inducer of cathelicidin antimicrobial peptide expression: Past, present and future. J Steroid Biochem Mol Biol. 2010 Mar 17)

Adrian Gombart, Associate Professor of biochemistry and a principal investigator with the Linus Pauling Institute at Oregon State University commenting on the research conducted by OSU and the Cedars-Sinai Medical Centre stated. “The fact that this vitamin-D mediated immune response has been retained through millions of years of evolutionary selection, and is still found in species ranging from squirrel monkeys to baboons and humans, suggests that it must be critical to their survival”.

"It's essential that we have both an innate immune response that provides an immediate and front line of defence, but we also have protection against an overreaction by the immune system, which is what you see in sepsis and some




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autoimmune or degenerative diseases," Gombart said. "This is a very delicate balancing act, and without sufficient levels of vitamin D you may not have an optimal response with either aspect of the immune system." (Oregon State University. "Key Feature Of Immune System Survived In Humans, Other Primates For 60 Million Years." Science Daily 22 August 2009)

Vitamin D and Cancer

A four year, population-based, double-blind, randomized placebo-controlled trial was conducted at the Creighton University School of Medicine in Nebraska. The study’s primary outcome was fracture incidence, and the principal secondary outcome was cancer incidence. The results of the study found that supplementation with vitamin D3 1100iu and calcium 1500mg or placebo daily after three years produced a 77 percent reduction in breast cancer, colon cancer, skin cancer and other forms of cancer risk among the supplemented group when compared to the placebo group.The subjects were 1179 community-dwelling women randomly selected from the population of healthy postmenopausal women.

The authors of the study concluded that improving calcium and vitamin D nutritional status substantially reduces all-cancer risk in postmenopausal women. (Lappe JM, et al. Vitamin D and calcium supplementation reduces cancer risk: results of a randomized trial. Am J Clin Nutr. 2007 Jun;85(6):1586-91).

Vitamin D deficiency is more common in black men, and it may be a contributor to their higher risk of cancer when compared with whites. From 1986 and 2002, a total of 99 out of 481 black men and 7019 out of 43,468 white men were diagnosed with cancer.

In analyses adjusted for multiple dietary, lifestyle, and medical risk factors for cancer, black men had a 32 percent higher risk than white men of developing any

cancer and an 89 percent greater likelihood of dying from cancer, particularly from cancer of the digestive system cancer.

This study identified vitamin D deficiency as the relevant factor in the higher cancer risk among blacks (Giovannucci E, et al. Cancer Incidence and Mortality and Vitamin D in Black and White Male Health Professionals, Cancer Epidemiol Biomarkers Prev 2006;15(12):2467–72).

Breast Cancer

A study of 972 women with newly diagnose invasive breast cancer and 1,135 randomly selected healthy controls were evaluated to assess vitamin D / sun exposure variables and found that increased exposure to sunlight during adolescence was associated with a 35 per cent reduction in the risk of breast cancer later in life.

The researches concluded that there is strong evidence to support the hypothesis that vitamin D could help prevent breast cancer. However, their results suggest that exposure earlier in life, particularly during breast development, maybe most relevant (Knight J et al. "Vitamin D and Reduced Risk of Breast Cancer: A Population-Based Case-Control Study"Cancer Epidemiology Biomarkers & Prevention March 2007, Volume 16, Pages 422-429)Another study conducted by Harvard Medical School examined data on more than 10,500 premenopausal and 21,000 postmenopausal women over 45 years of age and the incidence of breast cancer. The study included information on supplementation and dietary sources of vitamin D and calcium over an average of ten years.

The results reported that a high dietary intake of vitamin D was associated with a 30 per cent reduction in the risk of breast cancer among premenopausal women. However, postmenopausal women didn’t experience the same reduction. This may be the result of reduced ability of vitamin D synthesis from sun exposure with aging and its contribution to overall vitamin D




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status. Sunlight exposure was not taken into account in this study. (Lin J et al. Intakes of Calcium and Vitamin D and Breast Cancer Risk in Women Arch Intern Med. 2007;167:1050-1059).

Also, Women with breast cancer who had adequate serum vitamin D levels (72+ nmol/mL) double the survival rate after 12 years of follow-up than vitamin D deficient (<50 nmol/mL) women. (Fig. 3) (Study Sees Link Between Vitamin D, Breast Cancer Prognosis A Cancer Journal for Clinicians. 2008 Sep/Oct ;58:264-265)

Fig. 3 Cancer Free Survival (RR) 12 years

Serum Vitamin D Status

These studies have found that maintaining vitamin D levels from an early age may reduce the incidence of breast cancer by around 35 per cent. And if breast cancer is diagnosed may increase 12 year Survival by around 50 per cent.

Also, In a recent study that evaluated dietary and supplementary vitamin D and calcium intake among 3,101 breast cancer patients and 3,471 healthy controls.The researchers found no relationship between dietary vitamin D or calcium intake and breast cancer risk. However, women who reported taking supplemets of vitamin D, at least 400iu daily were at 24 percent lower risk of developing breast cancer.(Anderson L et al. American Journal of Clinical Nutrition, online April 14, 2010).

Prostate Cancer

There have been a number of studies that have reported a decrease in the incidence of prostate cancer associated with higher sun exposure and or serum vitamin D levels.( Schwartz GG, Hulka BS. Is vitamin D deficiency a risk factor for prostate cancer? (Hypothesis). Anticancer Res. (1990) 10(5A):1307–1311)and (Deeb KK, Trump DL, Johnson CS. Vitamin D signalling pathways in cancer: potential for anticancer therapeutics. Nat Rev Cancer (2007) 7(9):684–700) However, other studies have found non-significant difference in the incidence of prostate cancer and vitamin D serum levels in certain age groups.

A recent case-controlled analysis of serum vitamin D levels and the incidence of prostate cancer, found that a statistically significant decrease in risk of prostate cancer was associated with high serum 25(OH)vitD levels in men under 60 years of age( Ruth C Serum Vitamin D and Risk of Prostate Cancer in a Case-Control Analysis Nested Within the European Prospective Investigation into Cancer and Nutrition (EPIC) American Journal of Epidemiology 2009 169(10):1223-1232). However, there was not a marked difference in incidence in men over the age of 60 years.

Another study investigated whether serum levels of 25(OH)D are associated with the prognosis in patients with prostate cancer. This study found that serum 25(OH)D at medium (around 50 - 70 nmol/lt) or high levels (over 70 nmols/Lt) were significantly related to increased survival compared with the low vitamin D levels. Also, patients receiving hormone therapy gave a stronger association. The serum level of 25(OH)D was involved in disease progression and is a potential marker of prognosis in patients with prostate cancer (Tretli S, et al Association between serum 25(OH)D and death from prostate cancer. Br J Cancer. 2009 Feb 10;100(3):450-4).

Although the data are not as conclusive as breast cancer in women, it would appear that like breast cancer early maintenance of vitamin D levels is the most beneficial in




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reduced incidence and improved prognosis. Vitamin D and Swine Flu Prevention

Studies show promise that vitamin D may be effective in protecting against swine flu. Vitamin D promotes the production of antimicrobial substances that have the ability to neutralize the activity of various disease-causing agents, including the influenza virus (Doss M et al. Journal of Immunology 2009 Jun 15; 182(12): 7878-87). A study of 19,000 individuals and found that those who had lowest levels of vitamin D (25OHVitD) were about 40 percent more likely to have recent respiratory infection, including flu, compared to those who had higher levels of vitamin D(Ginde AA et al. Archives of Internal Medicine 2009 Feb 23; 169(4): 384-90) A recent randomised double-blind, placebo-controlled trial among School Children in Japan was conducted. The Children were randomly divided into two groups: One group received daily supplements of 1200iu daily of vitamin D3, while the other group received a placebo. The children were then assessed for the incidence of influenza over the 2008 to 2009 winter period. The study found that the incidence of influenza was 10.8 per cent in the vitamin D3 supplemented group, compared with 18.6 per cent in the placebo group; this reduction was even greater for those who had low vitamin D (25OHVitD), with a 74 per cent reduction in the incidence of influenza. Also, asthma attacks were significantly reduced in asthmatic children in the vitamin D3 supplemented group. (Urashima U, et al. “Randomized trial of vitamin D supplementation to prevent seasonal influenza A in schoolchildren” American Journal of Clinical Nutrition, March 10, 2010).Published Online

Given this type of information the Canadian Government, Public Health Agency is

investigating the use of vitamin D as a protective measure against Swine flu; just as our Grandmothers did using cod liver oil.

Vitamin D and Falls

Falling among the elderly is a major contributing factor to loss of enjoyment of life and increased mortality. A meta-analysis of randomised controlled trials examined the roll of vitamin D supplementation and the incidence of falls.

Both vitamin D2 and Vitamin D3 were investigated and the results found that 700-1000 IU supplemental vitamin D per day (vitamin D2 or vitamin D3) reduced falls by 19% for vitamin D2 and up to 26% with vitamin D3.

To reduce the risk of falling, a daily intake of at least 700-1000 IU supplemental vitamin D3 is warranted in all individuals aged 65 and older.(Bischoff-Ferrari H A et al. Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trials BMJ-British Medical Journal 339:b3692, 2009).

Multiple Sclerosis

Epidemiologic studies have shown a positive correlation of multiple sclerosis (MS) associated with latitude (amount of sun exposure) and increased dietary intake and increased serum levels of vitamin D. An increased dietary intake of vitamin D and increased exposure to UV rays was found to be protective for the development of MS (Beretich BD et al. Explaining multiple sclerosis prevalence by ultraviolet exposure: a geospatial analysis. Mult Scler. 2009 Aug;15(8):891-8).

Dosage safety in MS patients.

A study examining high dose vitamin D supplementation was undertaken among 52 MS patients to examine its effect on calcium metabolism. Their conclusion found that high-dose vitamin D




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( approximately 10,000 IU/day) in multiple sclerosis is safe, with evidence of immunomodulatory effects.

Classification of evidence: This trial provided Class II evidence that high-dose vitamin D use for 52 weeks in patients with multiple sclerosis does not significantly increase serum calcium levels when compared to patients not on high-dose supplementation. The study also reported that patients in the high-dose supplementary group reported less relapse. (Burton JM et al. A phase I/II dose-escalation trial of vitamin D3 and calcium in multiple sclerosis Neurology. 2010 Apr 28. [Epub ahead of print])

Dosage and Type, Vitamin D2 or Vitamin D3 ?

From examination of the studies the average recommendation for vitamin D supplementation is around 1000iu daily with the majority recommending vitamin D3. This dose is within the safety guidelines established by the National Academy of Sciences and the National Institute of Health, Office of Dietary Supplements, USA state that 2,000iu of vitamin D daily is the tolerable upper limit for adults. However, The USA Food and Nutrition Board are currently reviewing data to determine whether updates to the DRIs (including the upper limits) for vitamin D are needed.

Supplementary Dosage Examples include;

1. Evidence from data suggests that vitamin D3 supplements at moderate to high doses 1000iu daily may reduce CVD risk (Wang L, et al. Ann Intern Med. 2010 Mar 2;152(5):327-9).

2. The risk of falling in the elderly and vitamin D intake was evaluated. The results found that 1000 IU supplemental vitamin D per day (vitamin D2 or vitamin D3) reduced

falls by 19% and up to 26% with vitamin D3 (BMJ-British Medical Journal 2009, October).

3. Supplementation with vitamin D3 1100iu and calcium 1500mg or placebo daily after three years produced a 77 percent reduction in breast cancer, colon cancer, skin cancer and other forms of cancer risk(Lappe JM, et al. Vitamin D and calcium supplementation reduces cancer risk: results of a randomized trial. Am J Clin Nutr. 2007 Jun;85(6):1586-91).

Holick MF, Vitamin D Deficiency, N Engl J Med 357:266, July 19, 2007

Estimate Health Care benefit of vitamin D in Dollars.

A recent study in Germany found that around 45 per cent of Germans were vitamin D insufficient with around 15 to 30 per cent being deficient. This study also pointed out that present sun safety and dietary recommendations would lead to vitamin D deficiency.

The authors claim that this would lead to a increased health Care cost of EU 37 billion annually(Zittermann A et al. The estimated benefits of vitamin D for Germany. Molecular Nutrition & Food Research, 10.1002 April 2010)

This would roughly equate to around 15 to 20 billion dollars Australian annual saving in the health budget expenditure, if population vitamin D levels were




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http://search.nejm.org/search?p=R&srid=S9-6&lbc=nejm&w=Vitamin%20D%20Deficiency&url=http%3A%2F%2Fcontent.nejm.org%2Fcgi%2Fcontent%2Fshort%2F357%2F3%2F266&rk=1&uid=991266576&sid=2&ts=subs&rsc=RQOGbtBoHKKVXMZs&method=and&isort=score&start_year=2000&start_month=5

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Lappe%20JM%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed/20194240

http://www.ncbi.nlm.nih.gov/pubmed/20194240

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Wang%20L%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Burton%20JM%22%5BAuthor%5D


normalised. This would go a long way in helping improve the budget and other problems experienced by Hospitals in Australia. Discussion

Although I have only included a few of the many studies that were evaluated, the message is consistent and clear in all of the studies. Vitamin D deficiency is a major health issue and must be addressed.

Excessive sun exposure causes skin damage and in an endeavour to curb the incidence of skin cancer, the advice to cover up, apply sun screen and keep out of the sun is widely being practised. OH&S legislation has made this policy mandatory for workplace and schools. However, this practise has in part contributed to the vitamin D dilemma in Australia and diseases associated with this deficiency, including melanoma are on the increase and of major concern.

Governments and Health Care Professionals urgently need to examine the role that vitamin D deficiency plays in their disease treatment and prevention plans and consider supplementation and dietary changes as an effective alternative to dangerous sun exposure practises.

Also, periodic 25(OH)VitD blood tests would be advisable.

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The setright letter vitamin D