Demystifying Vitamin D Presented by Daniel Roytas Presented by Daniel Roytas www.humanley.com [email protected] About the Presenter D a n i e l R o y t a s M H S c ( N u t ) , B H S c (Nat) Dip.RM, MANTA • Naturopath, Nutritionist & Remedial Massage Therapist • 12 yrs clinical & 9 yrs lecturing experience • Published author & public speaker • Special interest in traditional naturopathy Presented by Daniel Roytas www.humanley.com [email protected] Vitamin D Setting the Stage • Despite living on the sunniest continent1, more than 25% of all Australians are thought to be vitamin D deficient (<25 nmol/L)2 • >40% of Australians are insufficient (<50 – 75 nmol/L)3 • A 128x increase in vitamin D testing from 2000 - 2014, with a cost to Medicare increasing from $1.02 million to $151 million by 20124 • To put things in perspective, government funding to the Cancer Council in 2012 was just $12.7 million4 Image source1 Presented by Daniel Roytas www.humanley.com [email protected] Vitamin D Supplement Industry It’s Big Business! • An ABS report in 2011, 5% of Australians report taking a vitamin D supplement daily1 • As of 2010, there were 89 vitamin D manufacturers, selling 195 different vitamin D products in Australia2 • Approximately 60 million vitamin D products were sold that year, totaling $89.3m2 • Is supplementation having a beneficial effect on health? Image source1 Presented by Daniel Roytas www.humanley.com [email protected] What is Vitamin D? Introduction • Discovered by Elmer V. McCollum in 19221 • Historically considered a fat soluble essential vitamin2,3 • Actually a fat soluble secosteroid pro-hormone & hormone2,3 2,3 • Present in two forms, D2 (calcidiol) & D3 (calcitriol) • Thought to be the substance responsible for many biological functions, primarily involved in calcium & phosphorous homeostasis2,3 • Possesses autocrine, paracrine and endocrine activates4 Image source1 Presented by Daniel Roytas www.humanley.com [email protected] Vitamin D Metabolism An Overview Info source1 Presented by Daniel Roytas www.humanley.com [email protected] Biological Mechanism of Vitamin D How Does it Work? References1 Presented by Daniel Roytas www.humanley.com [email protected] Causes of Vitamin D Deficiency More than Insufficient Sun Exposure Causes • Insufficient sun exposure1 • Infection5,9 • Obesity2,3,4 • Kidney disease10,11 • Inflammation5,6 • Liver disease12 • Chronic disease6,7 • COPD13 • Deteriorating health7 • Diabetes14 • Ageing8 • Skin colour15 Presented by Daniel Roytas www.humanley.com [email protected] Vitamin D & Health Exploring the Relationship • Inverse relationship between vitamin D status & numerous markers of health & disease prevalence is well established1,2 • Relationship established from epidemiological studies1,2 • Therefore supplementation must protect individuals against disease, right? Presented by Daniel Roytas www.humanley.com [email protected] Vitamin D & MSK Health What’s the Evidence? • Evidence shows an inverse relationship between vitamin D status, risk of falls, fracture, bone & muscle function1,2 • Many systematic reviews show that vitamin D supplementation (VDS) alone does not significantly reduce osteopenia, osteoporosis or fracture risk3,4,5 • Evidence suggests an increased risk of falls (15%) & fracture (26%) from high dose VDS6,7,8,9 • Long term, high dose VDS may reduce bone mineral density10 • Calcium plus vitamin D MAY reduce fracture risk11, but increases risk of kidney stones3 Presented by Daniel Roytas www.humanley.com [email protected] Vitamin D & Cardiovascular Health What’s the Evidence? • Vitamin D status has an inverse relationship with cardiovascular disease (CVD)1,2 • Supplementation is not associated with a reduced risk of CVD3,4 • A meta-analysis of 21 RCTs found supplementation did not reduce incidence of stroke or heart attack5 • Vitamin D alone or in combination with calcium may increase risk of heart attack by 25%6 Presented by Daniel Roytas www.humanley.com [email protected] Vitamin D & Cardiovascular Health Cont’d What’s the Evidence? • Increased vitamin D status through sunlight is associated with significantly reduced TC, LDL and HDL whereas VDS is associated with increased TC & HDL1 • Sunlight provides beneficial effects on the CVS above & beyond vitamin D including increased nitric oxide synthesis2, RAAS regulation3, reduced cortisol4 & dyslipidemia5 Presented by Daniel Roytas www.humanley.com [email protected] Vitamin D & Stroke A Deeper Look • Vitamin D deficiency is associated with an increased risk of stroke1 & below average sun exposure increases risk by 60%2 • Preliminary evidence suggests that vitamin D supplementation may increase the risk of stroke by 15-20%3,4 • Deficiency is associated with worse post-stroke outcomes5, however new evidence suggests deficiency is actually a consequence, not a cause of stroke6 Image source1 Presented by Daniel Roytas www.humanley.com [email protected] Vitamin D & Cancer What’s the Evidence? • Evidence suggests that vitamin D supplementation does not reduce the incidence of cancer1,2 including prostate2, breast3, or colorectal cancer4 • Vitamin D deficiency is associated with a increased risk of colorectal cancer (31%)4, a two-fold increased risk of prostate cancer5 & a 7.5 fold increase in breast cancer6 • Inverse relationship between sun exposure & breast (50%)7, colorectal8 & prostate cancer risk9 • Sun exposure protects against cancer independently of vitamin D, probably through regulating nocturnal melatonin peaks, which has an antiproliferative effect10 Presented by Daniel Roytas www.humanley.com [email protected] Vitamin D & Multiple Sclerosis What’s the Evidence? • Vitamin D deficiency is associated with an increased risk of multiple sclerosis1 • Current evidence suggests vitamin D supplementation may have a limited therapeutic effect2,3 or risk reduction effect4, however evidence is inconclusive • Several studies have shown sun exposure protects against multiple sclerosis via immunomodulatory mechanisms independent of vitamin D5,6,7 Presented by Daniel Roytas www.humanley.com [email protected] A Proxy Marker (Quotes 1) Barking Up The Wrong Tree? “The 25(OH)D level is simply a proxy for sun exposure, time outdoors or associated behaviours. Any positive non-vitamin D pathway effects of sun exposure will not be apparent in vitamin D supplementation trials and may explain the discrepancies between observational studies and clinical trials“. 1 “An alternative explanation for the discrepancy between observational and intervention studies is that the risks associated with low 25OHD are not linked, or only partly linked to vitamin D per se, and largely due to an associated exposure (or lack of sun exposure)”.2 Presented by Daniel Roytas www.humanley.com [email protected] A Proxy Marker (Quotes 2) Barking Up The Wrong Tree? “Vitamin D has long been considered the principal mediator of beneficial effects of sun exposure. However, oral vitamin D supplementation has not been convincingly shown to prevent disease; thus, serum 25(OH)D as an indicator of vitamin D status may be a proxy for and not a mediator of beneficial effects of sun exposure”.1 “Higher vitamin D concentrations (measured as serum 25-hydroxy vitamin D) are considered as a proxy for sun exposure so that their association with health benefits will be taken as indicating a beneficial effect of sunlight but not necessarily a benefit of vitamin D”.1 Presented by Daniel Roytas www.humanley.com [email protected] Effects Beyond Vitamin D Embrace the Sun Causes • Nitric oxide synthesis & release1 • Cytochrome oxidase induction4 • β-endorphin synthesis1 • TRPV induction4 • POMC gene expression (HPA axis)2 • CRH release5 • ACTH regulation2 • Melatonin regulation5 • Collagen synthesis / wound healing2 • Acetylcholine regulation5 • Cancer protective effects3 • Serotonin regulation6 Presented by Daniel Roytas www.humanley.com [email protected] Sun Exposure & Vitamin D How Much Do We Need? • One whole body minimum erythema dose (faint skin redness) generates the equivalent of 10 – 25000 IU of vitamin D1 • 7 minutes during Summer (outside of 10 am – 3 pm) & 7 – 40 minutes at midday in Winter with 15% of the skin exposed2 • 25(OH)D reflect sun exposure over the last 5 – 10 years3 • Serum levels from sun exposure plateau at 150 nmol/L4 • 340,000 deaths (US) & 480,000 deaths in Europe per year from insufficient exposure5 Image source1 Presented by Daniel Roytas www.humanley.com [email protected] Sun Exposure Cause For Concern? • Sun (UV light) exposure is associated with increased risk of malignant melanoma • Incidence of melanoma is greater in vitamin D deficient individuals (66%) compared to sufficient individuals (15%)1 • Intermittent sun exposure is associated with a higher risk of melanoma compared to a null or inverse association with regular sun exposure2,3 Image source1 Presented by Daniel Roytas www.humanley.com [email protected] Other Risk Factors For Melanoma More Than Just UV Causes • FM radio waves1,2 • Vitamin A insufficiency7,8 • Sunscreen use3,4,5 • Vitamin C insufficiency7,8 • Alcohol consumption6 • Vitamin E insufficiency7,8 • Low dietary antioxidant intake7 • Low beta-carotene7,8 Presented by Daniel Roytas www.humanley.com [email protected] Antioxidants for Sun Protection Supporting Natural Mechanisms • Beta carotene provides protection against sun induced skin damage • Dietary carotenoid intake for approximately 10 weeks provides systemic photoprotection1 • Supplemental beta-carotene (>12 mg/d / 7000 IU) provides photoprotection for >7