1

THE D-LIGHTFULVITAMIN

FOR HEALTHMichael F. Holick

Boston University Medical Center

Teaching Goals1. How to Dx Vitamin D Deficiency

A. Which Vitamin D metaboliteshould be ordered?

2. How to Tx Vitamin D DeficiencyA. Vitamin D2 vs Vitamin D3

3. What are the non-calcemic Benefits of Vitamin D?

Institute of MedicineIOM

2

“not intended to direct physicians on care of patients”

"it is up to professional associations to establish guidelines for care”

"used a population model, not a medical model"

Agency for Healthcare Research

AndQuality

Depended onRandomized Controlled Trials

RCTs

AHRQ

Ignored Association Studies

BadIdea !!!

Ignaz Semmelweis 1850

3

Dr HolickReceives support

From NIH&

UV Foundation

Consultant and SpeakerBayerQuest DiagnosticsMerckP&G,Aventis, WarnerNational Dairy CouncilAmgenNovartisDMIMushroom Council

8

And SupportFrom The

Sun

How much calcium do we need ?Who is at

Risk for

Vitamin D Deficiency

???

4

RICKETSOSTEOMALACIA

DM,MS,RA,

HBP,CHDINFECTIONS

CANCER

VITAMIN D DEFICIENCY

5

6

Do you know why I became

hypopigmented ????????

Rachitic PelvisNormal Female

Pelvis

7

7-DHC

HO

Vitamin D3HO

∆H

CH2

PreD3

HO

Solar UV Radiation

ΔH

7-DHC

HO

PreD3

HO

Vitamin D3

HO

UV

Lumisterol3

HO H

Tachysterol3

OH

H3C

UV

UV

Suprasterol I

OH

Transvitamin D3

OH

Suprasterol II

HO

UVUV

UV

CH2

YOU CANNOT BECOMEVITAMIN D TOXIC FROM

SUN EXPOSURE

Did you knowThe Vitamin D Made in skin Lasts 2X longerThan vitamin D From the diet ???

8

IOMSunlight playsLittle role in

Vitamin D Status

9

Sniadecki

1822

Association StudyRickets &Sunlight

“STRONG AND OBVIOUS IS THE INFLUENCE OF SUN ON THE CURE OF RICKETS AND THEFREQUENT OCCURANCE OF THE DISEASEIN DENSELY POPULATED TOWNS WERE

THE STREETS ARE NARROW AND POORLY LIT”

KOCH 1911

RICKETSCAUSED BY AN

INFECTIOUS DISEASE

Randomized Controlled StudyDogs Bacillus Infection

10

Huldschinsky1919

with

Mercury Arc Lamp

RicketsTreated

OCTOBER 1, 1918 NOVEMBER 12, 1918

UVR 1 Hr2/WK FOR6 WEEKS

11

1931 US GOVERNMENTPROVIDED RECOMMENDATIONSFOR SUN EXPOSURE

12

STEENBOCK 1920s

VITAMIN Dis

ESSENTIALFOR

BONE HEALTH

13

Case #1 • 7 month Old Female

• Muscle Weakness

• Tetanic seizures

• Serum calcium 4.2mg%•

14

BOSTON MEDICAL CENTER

MY DOCTOR SAIDBREAST MILK PROVIDESALL THE NUTRITIONMY INFANT NEEDS.

15

43

THERE IS LITTLE VITAMIN D

BREAST MILK

~ 25 IU/L

44

BOSTON MEDICAL CENTER

40 MOTHERS AND THEIR INFANTSAT BIRTH

MEASURED VITAMIN D STATUS25-HYDROXYVITAMIN D

45

70% MTVDRANK

2.3 GLASSESMILK/D

Daily Intake Vitamin D~600 IU

16

76% Mothers

Vitamin D Deficient

81% Newborns25(OH)D < 20NG/ML

47

Strong, inverse relation between maternal 25(OH)D at <22 weeks and risk of preeclampsia

Adjusted OR (95% CI) associated with a 50-nmol/l decline in 25(OH)D:

2.4 (1.1, 5.4))

20 ng/ml

Bodnar et al 07

0 20 40 60 80Mother’s 25(OH)D ng/ml

Probability C-Section

400 %

17

49

HOW MUCH VITAMIN D DOES MY MOM NEED TO PROVIDEME WITH ADQUATE VITAMIN D

??????

4000 IU/D

American Academy PediatricsBeginning at Birth

AllINFANTS need400 IU Vitamin D/d

Infants400-800 IU/d

Pregnant & LactatingWomen

2000 IU/d

18

IOM RDA UL

1-70YEARS 600IU/D 4000

No Need To Increase Intake Pregnancy

orLactation

Case #2 • 1 Year Old Female

• Muscle Weakness

• Boney Deformities

• Failure to Thrive

Case #3 • 25 Year Old Female

• Poor Dentition

• Osteoporosis

• Wrist Fracture

19

D-ficient

PeriodontitisTooth Loss

AJCN 2004;80,108

IOMYou can get your

Vitamin D from Diet

20

J Am Diet Assoc 2004;104:980

0.0%0.0%

% US POPULATION USUAL VITAMIN D INTAKEFROM DIET ALONE OR DIET + SUPPLEMENTS

200,400,600 IU

Vitamin D is Rare in Foods

21

Dairy Fortified with Vitamin D

100 IU/Serving

100 IU 100 IU 100 IU

100 IU 100 IU100 IU

600 IU Vitamin D

Did you KnowMushrooms

Make Vitamin D?????

22

Shrooms’ plant sterol - ergosterol -converts to vitamin D when exposed to light.

Growers can expose mushrooms to UV light to increase vitamin D levels.

OILY FISHSALMON

HOW MUCH?????

23

5-7 Times/Week

500-1000 IU/3.5 oz

100-250 IU/3.5 oz

10-25% VIT D in FARMEDVS

WILD CAUGHT SALMON

24

IOMSunlight playsLittle role in

Vitamin D Status

SUMMER

UVB

PRODUCE VITAMIN D

25

WINTERUVB

NO VITAMIN D

???????

Jul Aug Sep Oct Apr May JunNov Dec Jan Feb Mar

0

2

4

6

Month

Seasonal Effect on Cutaneous Vitamin D Synthesis in Boston

Vita

min

D S

ynth

esis

%

Webb et al

Nov-Feb0%

Can You Make Any??????

26

CannotMake

Vitamin DIn

WinterAbove32 N

77

Great for RomanceNot for Vitamin D

10am-3pm

27

-1 0 1 2 3 4 5 6 7 8 9 1 01 11 21 31 41 50

5

1 0

1 5

2 0

2 5

3 0

3 5

Days

Ser

um C

once

ntra

tion

of

Vit

amin

D (

ng/m

l)

Holick, 1987

Without Sunscreen

With Sunscreen

SPF30 99%

UVBUVB

Vitamin D3

Vitamin D3

~1%

SPF-30 -99%

28

90-95% of our Vitamin D comes

from Exposure to Sunlight

HOW MUCHSUN

EXPOSURE????????????

29

Total Body Irradiation1X1X

ORALVITAMIN D

Exposure to

1 Minimum Erythemal

Dose

~20,000 IU Vitamin D3

Does Sunlight ReallyProvide us with

Vitamin D

???????

30

Brot et al, Brit J Nutr (2001), 86, Suppl. 1, S97-S103

SUMMER35 ng/ml

WINTER 20 ng/ml

Did You KnowObesity Causes

Vitamin D Deficiency?

Wow !!!

31

50

40

30

20

10

0Ser

um

Vit

amin

D3 (n

mol

/L)

NormalWeight

*

Obese BMI>30

**

Serum Vitamin D Levels After ExposureOf Non-obese And Obese Adults To TheSame Amount Of Ultraviolet Radiation

55%

Is Vitamin DStored In Fat

??????

4-320ng/gVitamin D Both

D2&D3

Rx Obese pts need

2-3 X vitamin D 50,000 IU vitamin D/wk

32

Recommendation in Boston

5 to 15 Minutes Sunlight 2-3X/wk LEGS

ARMS

5-15 MINUTES THEN

SUNPROTECTION

Time (days)

Vit

amin

D (

ng/

ml)

Effect of UVB on Serum Vitamin D Levels in Caucasian and Black Subjects

0 5 1 0 1 5 2 0

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

Vit

amin

D (

ng/

ml)

54 mJ/cm2

Time (days)

0 5 1 0 1 5 2 0

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

320 mJ/cm2

Black

Black

Caucasian

5-10 X

CAUCASIAN

0 5 1 0 1 5 2 0

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

54 mJ/cm2

BLACK60 ng/ml

30 ng/ml

0 ng/ml

33

30-50% African Americans

Vitamin D Deficient

How Do You KnowWhat Your Vitamin D

Status Is ?????????

34

1,25(OH)2D

Serum 25(OH)D is

the barometer for

vitamin D status

Excess

Normal

Deficient

55 ng/ml

10 ng/ml

25(OH)DH

N

L

35

NormalDeficient10 ng/ml

25(OH)D

L

CU ORC

105

SERUM 25(OH)D (nmol/L)0 25 50 75 100 125 150 175 200

SERU

M iP

TH (p

g/m

L)

0

20

40

60

80

100

120

140

25(OH)D & SERUM iPTH*

10 20 30 40 50

25(OH)D ng/ml

PTH

pg/

ml 30-40 ng/ml

Chapuy et al

36

25(OH)D & SERUM PTH

Thomas MK, Lloyd-Jones DM, Thadhani RI, et al. N Engl J Med. 1998;338:777-783.

SERUM 25(OH)D (nmol/L)0 20 40 60 80 100S

ER

UM

PT

H (

pg/m

L)

20406080

100120

30 ng/ml >

Vitamin D Inadequacy (<30 ng/ml)Prevalence by Latitude

42 N

35 N

N=198/362(54.7%)

N=259/532(48.7%)

N=342/642(53.3%)

Sites also in Alaska and HawaiiP=NS for test of trend

Holick MF. ASBMR, 2004.

30 ng/ml>

37

CU ORC

109

VITAMIN D STATUS & THE Ca ECONOMY

· 31 women

· age: 63.2 + 9.3

· studied 2x – 1 yr apart in Spring

· given 10 g 25(OH)D/day (D+)

or

· no treatment (D–)

25(OH)D

D+ D–

nm

ol/

L

0

20

40

60

80

100

+65%25

(OH

)D n

g/m

l20

30

10

40

+D -DHeaney et al 2004

32 ng/ml

ExcessNormative

20-100 ng/ml

Deficient

>100 ng/ml

<20 ng/ml

25(OH)D

Preferred40-60 ng/ml

Definition of Vitamin D Deficiency

IOM

25(OH)D < 20 ng/ml

38

675 GermanMVA Victims

Bone Bx & 25(OH)D

39

Holick There is TOOMuch scatterFor the PTH

Plateau!!!

Serum 25(OH)D (ng/mL)20 25 30 35 40 45 50 55

OV/B

V (%

)

0

1

2

3

4

5

6IOM>202.5%

Priemel>30 ng/ml

8.5 %Osteomalacia

Is Vitamin D D-ficiency

AHealth Issue

?????

Is Vitamin DDeficiency

a Health Problemfor

adults 50+ yrs?????

40

0

40

20

60

80

% o

f vo

lunt

eers

< 2

0 ng

/ml 25

(OH)D

Percent ADULTS>50 YRS who were vitamin D Deficient <20 ng/ml in August

White

30%

Black

84%

Hispanic

42%

Sunlight Deprivation > 65 years

25(OH)D < 10 ng/ml

In

54% community dwellers

38% nursing home

Gloth et al JAMA, 1995

Vitamin D DeficiencyIs an

unrecognizedepidemic

inadults 50+ yrs

41

0

10

20

30

18-29

(n=69) (n=69

Inci

den

ce o

f V

itam

in D

Insu

ffic

ien

cy (

%)

% VITAMIN D INSUFFICIENT <20ng/mlBMC RESIDENTS & STUDENTS

32% END WINTER

Tangpricha et al Am J Med 2002

4% END SUMMER

0

20

40

60

80

100

120

Sep-00 Mar-01 Sep-01 Mar-02 Sep-02 Mar-03

Date

25(O

H)D

(n

mo

l/L)

0

1

0

2

0

30

40

48% D-DEFICIENT<20 ng/mlEND OF WINTER

MAINE GIRLS AGES 9-11

SULLIVAN,ROSEN,HOLICK

25(O

H)D

NG

/ML

42

0

20

40

60

80

100

120

Sep-00 Mar-01 Sep-01 Mar-02 Sep-02 Mar-03

Date

25(O

H)D

(n

mo

l/L)

0

1

0

2

0

30

40

SULLIVAN,ROSEN,HOLICK 2002

25(O

H)D

NG

/M

17% D-DEFICIENT<20 ng/ml

END OF SUMMER

MAINE GIRLS AGES 9-11

42% D-deficient

<20 ng/ml

43

1-5 yrs 50 %< 30 ng/ml

6-11 yrs 70 %< 30 ng/ml

Vitamin D Deficiency

• Osteomalacia

• Osteoporosis• 2º HPTH

SubclinicalVitamin D Deficiency

PRECIPITATES &

EXACERBATES OSTEOPOROSIS

44

Symptoms• Generalized bone pain

• Muscle aches

• Isolated bone pain

45

40-60% OSTEOMALACIA

Non-immigrant and Immigrant SubjectsSerum 25-Hydroxyvitamin D Levels (ng/ml) in

35

30

25

20

15

10

5

0

Non-immigrant Subjects Immigrant Subjects

150 aged 10-65 yrsBone & Muscle Pains

93% Vitamin D Deficient

46

Subjects With Undetectable 25-Hydroxyvitamin D

Rx NSAID, intermittent narcotic agents,

SSRI, TCA, Cardiovascular

Dysthymia/MDD,

DJD refractory to surgery, angina refractory to PTCA

Somatoform D/O?

Severe non-radicularlow back pain, intermittent chest pain,depressed mood, insomnia, weakness

AA58

Male

OTC NSAID, SSRI,

Neuroleptic agent

MDD/PTSDDiffuse MSK pain,

fatigue, insomnia,

headache, weakness

East

African

35

Female

OTC NSAID,

Pre-natal vitamins

Insulin

Pregnancy 3rd T.

Gestational DM

Severe non-radicularLBP, fatigue, depressed mood, insomnia, weakness

AA27

Female

OTC and

Rx NSAIDs, TCA

Dysthymia, stress reaction

Diffuse MSK pain,

Fatigue, insomnia

Asian26

Female

OTC and

Rx NSAIDs

Dysthymia, non-DJD low back pain

Non-radicular LBP, weakness, fatigue

Cauc23

Female

MedicationsDiagnosesSymptomsRaceAge/Sex

VITAMIN D DEFICIENT

138

78 Y/O MMUSCLE WEAKNESS

ATROPHY, DENERVATION

+EMG+NCS

47

139

ALS

Symptoms resolvedRx VITAMIN D

progressive painless muscle weakness with muscle atrophy,which manifests like lower motor neuron diseaseand improves after vitamin D supplementation

140

141

Time to Stand vs 25(OH)D Levels

Bischoff-Ferreri et al

~20-40 ng/ml

48

142

143

72% Less Falls800 IU/d 5 months

144

28-32 ng/ml

JCEM 2007

49

145

WHITE

Mex Am

BLACK

~20-40 ng/ml

147

25(OH)D > 30 ng/ml

Muscle strength, balance,

lower extremity function BMD

Fall risk Fxs

50

TREAT VITAMIN D DEFICIENCY

50,000 IU VITAMIN D2

ONCE/WEEK

8 WEEKS

6000 IU/d

Cut in halfAdd Milk etc

51

MAINTAIN VITAMIN D SUFFICIENCY

50,000 IU VITAMIN D

ONCE/ 2WEEKS3000 IU/d

DEFICIENT

INSUFFICIENT

SUFFICIENT

0

20

30

40

50

60

70

0 72Time (Months)

Mea

n 25

(OH

)D (

ng/d

L)

20 ng/ml

40 ng/ml6 yrs

MEAN 25(OH)D LEVELS IN PATIENTS RECEIVING 50,000 IU VITAMIN D2 EVERY 2 WEEKS FOR 6 YRS

3000 IU/d

Pietras Arch Int Med 2009

153

1000 IU Vitamin D3/dor

1000 IU Vitamin D2/d

52

10

15

20

25

30

35Mean Serum Total 25(OH)D Levels

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10 Week 11 Week 12

25(O

H)D

Lev

el (

ng/m

l)

P=0.45P=0.63

P=0.45P=0.75

P=0.65

P=0.27

P=0.59P=0.17 P=0.71

P=0.45 P=0.30P=0.54

Time (weeks)

PLACEBO

1000 IU D2

1000 IU D3

Time (weeks)

Mea

n 25

(OH

)D L

evel

s (n

g/m

l)

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

1 2 3 4 5 6 7 8 9 10 11 12

Mean Serum 25(OH)D2 and 25(OH)D3 in Subjects receiving Vitamin D2

1000 IU D2

25(OH)D2

25(OH)D3

156

1000 IU Vitamin D3/d

or500 IU Vitamin D3

+500 IU Vitamin D2/d

53

Time (weeks)

Mea

n 25

(OH

)D L

evel

s (n

g/m

l)

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

1 2 3 4 5 6 7 8 9 10 11 12

Mean Serum 25(OH)D2 and 25(OH)D3 in Subjects receiving Vitamin D2

1000 IU D2

25(OH)D2

25(OH)D3

Cha

nge

in S

erum

25(

OH

)D L

evel

s (n

g/m

l)

Time (weeks)

1 2 3 4 5 6 7 8 9 10 11 12

32

30

28

26

24

22

20

18

1000 IU Vitamin D

Sufficient

No one was sufficient

CU ORC

159

SAFETY AT HIGH DOSES

· 33 males

· aged 38.7 yr( 11.2 )

· dosed with vit D3 from October thru February

· 5,000 & 10,000 IU/d

Pre Post

SERU

M C

ALCI

UM (m

g/dL

)

8.0

8.5

9.0

9.5

10.0

10.5

11.0

Vieth et al 1998

10,000 IU/dIs Safe

54

1 MILLION IUVITAMIN D/DAY

1000 IU/TSP

KOUTIA et al NEJM 20002

Ca= 15.2 mg/dl

25(OH)D= 520 ng/ml

55

Skin

1,25(OH)2D3

25(OH)D3

Liver25-OHase

Kidney1α-OHase

VDR

VDR

VDR

VDR

VDR VDR

VDR

VDR

VDRVDR

VDRVDR

VDRVDR

VDR

VDREVERY TISSUE AND CELL HAS A VDR

WHAT ARE THE

FUNCTIONS???????

WHY?????

56

Suda et al 1979 RX -1,25(OH)2D3

1915 8X more likely to

DieWorked Indoors

Association Study

57

58

50% PROJECTED REDUCTIONCOLON CANCER WITH 1000 IU/D

Garland et al 2005

25(OH)D = 48 ng/ml

50% LOWER RISK

IOMLarge RCTs

59

WHI

60

<12 ng/ml

253%

INVASIVE COLORECTALCANCER

>23 ng/ml

Lappe et al AJCN 2007

60%LESS

CANCERS1179 PM WOMEN1200MG Ca +- D3ALL CANCERS

YEARS 0-4

1100 IU D3

Girls 10-19 yrs most sun 69%

Women 20-29 yrs most sun 51%

Women 45-54 yrs most sun 0.0%Cancer Epi Biomarkers & Prev 07

61

62

This is a REAL

CONUNDRUM!!!!!!!!!

1-OHase

25(OH)D 1,25(OH)2D

Autocrine Regulation of Cell Growth

Control of cell growth

CALCITROIC ACID

INACTIVE

63

Colon Cell

Gene Transcription

Apoptosis

Bcl-2Bcl-XLMcl-1

BAG1LXIAPcIAP1cIAP2 Differentiation

MATURATION

Nucleus

Cell-cycle Arrest

CDK2, p21, p27, p53Ki67, E-Cadherin

25(OH)D>30 ng/ml

RXRVDR

1-OHaseMitochondria

1,25(OH)2D3

1,25(OH)D3

~ 2000 Genes Affected

By 1,25(OH)2D

ACTIVATED MACROPHAGES

Metabolize 25(OH)D3 to 1,25(OH)2D3

25(OH)D3 1,25(OH)2D3

Adams et al JCEM 1987

64

25(OH)D

1,25(OH)2D

Death

Cathelicidin mRNA

TB

1-OHase mRNA

1-OHase

Cathelicidin

TLR2/1MACROPHAGE

Liu et al Science 2006

Why is fluSeason alwaysIn the WINTER

???????

65

1981 Edgar Hope-SimpsonSuggested a “SEASONAL STIMULUS”

Jan-Mar

Jan-Mar25(OH)D

winter

32 ng/ml

12 ng/ml

66

Aloia et al 2007

2000 IU/D

90% URIs

25(OH)D=38 ng/ml 2X

Influenza A + School ChildrenPlacebo 18.6%

+1200 IU Vitamin D 10.8%

42%

67

Type 1 Diabetes/100,000Boys<14 yrs

10X

15X

Garland et al 2008

Hypponen et al. Lancet 2001

68

Annual age-adjusted incidence rates of type 1 diabetes, children < 14 years old, per 100,000 population, Finland, 1965-2005

15

25

35

45

55

65

1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010

Year

Inci

den

ce r

ate 1964

RecommendedVitamin D intakeReduced from4500 to 2000 IU/d

1975RecommendedVitamin D intakeReduced from2000 to 1000 IU/d

1992RecommendedVitamin D intakeReduced from1000 to 400 IU/d

Beta-ISLET CELL1,25(OH)D3

VDR +VDR +

Insulin+

Metabolic Syndrome & Type 2 Diabetes

Ca<500 mg

> 1200 mg

< 400 IU

> 800 IU

D D+

Ca

0.67RR

Typ

e 2

DM R

R 33%

Ca > 1200 MG+

VIT D > 800 IUPittas et al JCEM 07

69

Scragg et al Diabetes Care 27:2813;04

DIABETES INVERSELY RELATED

SERUM 25(OH)D

WHITES-NH 75%

MEXICAN-AM 83%

BLACKSNO EFFECT

North-South Gradient in Mortality from MS

100%MS 35

Vitamin D Intake (>400IU/D) Inversely Related To MS

In Women

41%

70

Vitamin D Intake (>400IU/D) Inversely Related To RA

In Women

44%

OSTEOARTHRITIS

Rostand 1979Reported

Inverse ReationshipBetween

BP & Latitude

71

Association between Latitude

andBlood

Pressure

Hypertension 1997; 30:150-156

212

213

PVD & 25(OH)D80%

>29 ng/ml

PVD vs 25(OH)D

72

Quality Heath Care Worldwide

ABBOTT

RENAL GLOBALDevelopment

214

Vitamin D deficiency in humansis associated with heart failure.

RXRDNA binding

RNA Pol IICoReg

VDR

VDR

B

VDRERNA Pol II

Suppression of Renin Transcription by VDR

Activation

VDRRXR

↓ Renin

Blood Pressure

LVHRenin TGACCT TGACCT

Atherosclerosis,Inflammation,

oxidative stress

> 200 Genes inHeart & Vessels

RXR

First MI >50% Increase Associated

With Vitamin D Deficiency

73

Arch Int Med 2008

28 ng/ml

8-13 ng/ml

All108%

CV122%

What are the consequences of

Vitamin D Deficiency on

Our health ???

2.4 X HBP2.5 X Elevated BS4 X Metablolic Syndrome

50 Million TeensDeficient/Insufficient

74

49 NT Blacks 16 yrs400 vs 2000 IU/d 4 Mos

25(OH)D 11 to 24 ng/ml 400 IU/d

25(OH)D 11 to 34 ng/ml 2000 IU/dSignificant Decrease inArterial Wall Stiffness

Dong et al JCEM 95;2010

All Cause MortalityDecreased 7%On 528 IU Vitamin D

Highesttertile50± 15ng/mlMiddletertile29± 4ng/mlLowesttertile16±5ng/ml

75

IS A DISEASE OF NEGLECT

VITAMIN D

76

100 IU VITAMIN D3RAISES 25(OH)D

BY ONLY

1NG/ML.

Conquer Vitamin D Deficiency

77

What is theBest

Source ofVitamin D

?

78

MAY 04

I DO NOT ADVOCATETANNING !!!!!!!!!!!!

79

236

I should Avoid ALLSunlight to PreventMelanoma

!!!!!!

237

Did you KnowMost Melanomas

Occur on theLeast Sun Exposed Areas

???????

80

238

Occupationalsun exposure

Decreases riskmelanoma

Need more Randomized Controlled

AstronomicalTrialsRCATs

!!!!!!!!!!!!!!!!!!!

81

Instituted Hand WashingWith Chlorinated soda H2OPrevent Maternal & Infant

Mortality

82

Thought Leaders

Hand Washing

ALWAYS WEARA SUNSCREEN

DERMATOLOGIST ADVISING ABOUT SUN EXPOSURE

JOIN THEDARK SIDE

DO NOT BE EXPOSED TO

SUNLIGHT

UNENLIGHTENED DERMATOLOGISTON MEDICAL ROUNDS

83

NEVER BE EXPOSED

TO THE SUN !!!!!!!!!!!!!!!!!!!

Slip, Slap, Slop

84

87% < 20 ng/ml

87% Vitamin D Deficient end of Summer

Australian dermatologist

SchizopreheniaVitamin D Deficiency

Associated with:

DepressionDementia

25(OH)D <10 ng/ml

RR=31%

85

YOU CAN GET IT FROM

DIET !!!

YOU CANNOT GET IT FROM

DIET

86

If you and your familyare not taking at least

1000-2000 IU/dYou are

Vitamin D Insufficient

ARE YOU ALWAYS INDOORS WORKING

AndWEAR SUNSCREEN

ALL THE TIME??????

ARE YOU VITAMIN DDEFICIENT????????

258

WHAT IS YOUR 25(OH)D LEVEL

????????

87

What do I DO??????

THE PUBLIC NEEDS TO BEAWARE OF THE INSIDIOUS

CONSEQUENCES OF VITAMIN D DEFICIENCY

SPF 30

+ 2000 IU Vitamin D3+ MTV=400 IU+ 3 glasses milk += 300 IUMy Total Vitamin D ~ 3000 IU/d

My 25(OH)D = 52 ng/ml

88

Vitamin D Deficiency

Is TheMost COMMON

Medical Condition

VITAMIN D DEFICIENCYCAUSES CONSEQUENCES

SUN SUNSCREENMELANINLATITUDEWINTER

MALABSORPTIONCrohn’s Whipple’sCystic FibrosisCeliacLiver disease

Hepatic Failure

Renal FailureNephrotic syndrome

Obesity

MEDICATIONS AntiseizureGlucocorticoidsRifampinHAARTSt John’s Wart

SchizophreniaDepression

FEV1Wheezingillnesses

Muscle weaknessMuscle aches

OsteoporosisOsteomalaciaRickets

AutoimmuneType 1 DiabetesMSCrohn’sRA

AODMSyndrome X

HBPCHD

CANCERColonBreastProstateetc.

INFECTIONSURITB

Osteoarthritis

X

Holick NEJM July 07

There Is NoDownside

To IncreasingVitamin D Intake !!!!

89

We NeedSensible

Sun &

Vitamin D Supplementation

Recommendations !!!!!!!!

You Do Not Need To Be A Genius To Know

This is NOT

HYPOTHESIS

Do we need toScreen everyoneFor their 25(OH)D levels???????????????

No !!!!!!!

But YesBMI>30

MalabsorptionMeds/AEs., Glc

Sarcoidosis

90

DrHolick.com

IOM RDA UL0-0.5 YEARS0.5-1 YEARS

400 IU/D 10001500

1-8 YEARS9-12 YEARS

600 IU/D 25003000

13-70YEARS 600IU/D 4000

70+YEARS 800IU/D 4000

June 6,2011

Endocrine PracticeGuidelines CommitteeRecommendations

91

Recommended Intake

0-1 YEAR 600-1000 IU/D

1-18 YEAR 600-1000 IU/D

18+ YEARs1500-2000 IU/D

Obesity 2-3 Times more

SAFE UPPER LIMIT

0-1 YEAR 2000 IU/D

1-12 YEAR 4000 IU/D

13+ YEARs 10,000 IU/D

DrHolick.com