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Vitamin D: when to measure, what supplement?
Prof. Dr. H. Bischoff-Ferrari, Zürich
Friday, May 13, 2022 · 2:13 p.m. · 28m 47s
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what i like well thank you very much christian and
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i would like to uh congratulate that e. bay tours
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i thought it was an excellent i a very lively very fun
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uh thank you so much and uh i i also think uh at least yeah and for
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giving me the opportunity to update you on vitamin e. d. i. have to cover quite elites
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and i have to say excuse myself already now that i have to
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run out at two forty to catch a train to go to another
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a meeting uh but we will have time to us
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so uh you have to stop us um it's o.
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d. um uh these are the topics we will cover
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today um and quick update on by to mean t. metabolism
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uh there is really a little important news
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to tell it that could explain uh uh
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you know how to treat with my tummy d. or prevent with vitamin d. in the future
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i will address the debate on bowlers versus daily vitamin d.
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i'm also um went to measure vitamin d.
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um yeah i think that's an important thing to
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look at what to supplement and how much
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so uh here you see the classic by to me the metabolism this
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is just to update us all the main source of vitamin d. is sunlight
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the problem is it's not reliable uh
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between uh the months of november till may
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in all of your uh sunlight exposure is insufficient
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to get enough vitamin d. the alternative is nutrition
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and here we have very rare sauces of vitamin d. such as fatty fish so uh
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vitamin d. supplements and that's generally cool like
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i'd say for the whole isn't important assaults
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and then after getting a vitamin d.
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either so sunlight or supplement or nutrition
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it all goes the same way we get high trucks elation
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in the liver to twenty five psi proxy vitamin d. and
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actually this step as you all know uh
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it's actually done in many cells um and um
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then the next step again also not only indicate
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anybody many celsius to step to one twenty five
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the high proxy vitamin d. which we call inserted a d. by to mean the whole moaned
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and i think that the important now update
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to the metabolism is that vitamin d. itself cool
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like i'd say for all it is actually a entering the cell and a cell that has
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the height rocks elation option can actually use a by to me d. directly
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and um as most cells have the twenty five by proxy by a lace
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uh they can all utilise utilise vitamin d.
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and it's also important to know that ninety nine percent
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of twenty five high proxy vitamin d. that we measure
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uh in plot is uh either pound or d. policy to in fact
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and another really important update is that correlate kites if it
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was so the vitamin d. we get from sunshine on nutrition
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uh has been suggested uh to have greater cellular effect
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ten twenty five five proxy d. and one twenty five the high proxy vitamin d. so this is
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important because we have different hoff lives and that could
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explain differences in outcomes that we work discussed today so cool
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like i'd say for all the plane vitamin d. and
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that's really key has only a half life of twenty hours
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what does that mean that means we needed need to take it daily to have to full advantage
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twenty five five proxy vitamin d. has a half life of three to six weeks and very short
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it's one twenty five the high proxy vitamin d. eight to twelve hours
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so daily intake for vitamin d. uh is key
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and that brings us to the next discussion i will
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focus fall well willow is worse this daily on bone and muscle as
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you know these are two key target organs for moscow's clique ill health
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and uh it now you see the daily the old data a meta analysis
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than a quite a long time ago uh looking at daily vitamin d. in adults
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age sixty five and older at risk for the deficiency at the time we
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didn't know uh is four hundred units enough or does it need more than that
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um and you see a nicely the relative risk for individual trials
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listed by the was indicates that there is a too low doze
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to influence fall risk twisty in at all set out the deficient
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and that is below seven hundred units per day and after that
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you see a consistent reduction based on these double blind randomised control trials
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and when you take though was that did test the higher doses there was a thirty four percent
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reduction in older adults with the deficiency and daily treatment
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a a very similar pattern for hip fractures this was also
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an older people would analysis all double blind randomised control trials
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um uh also again targeting older adults with the deficiency
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and there was a thirty percent reduction of hip fracture risk around that recommended
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eight hundred units of vitamin d. per day and then came the first study
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that showed something different and that was the sender erstwhile
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actually just before this mistrial from the u. k. a.
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both of them showing that a lot and you'll know lustre was
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senders used five hundred thousands smith
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used three hundred thousand actually did not
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reduce fall in fracture is but increased
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fall and fracture risk um and um
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that was shortly after followed by one started giving up bowlers doze
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once per mons and that is to gain the study in nursing home
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inhabitants showing at two point three fold increased
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risk in the risk of falling very interestingly
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they showed in the same study of reduction in acute respiratory infections
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um and then we did a study on months lido signified
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to mean d. we saw also an increased risk with monthly d.
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and you see here the results of this study show
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when the achieved levels off twenty five hard rock c. d.
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in the study after the first six months then the second six months and then overall
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and you see there is also a target range that may
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relate to fall risk when we treat older at all so
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and here in green the optimal target range
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is speech we is at at a medium of twenty seven and
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o. gram so between twenty and thirty now and no crime per millilitre
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and actually exactly that range was recently confirmed by a study from
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a boston based dawson used to stop a trial shows exactly the same thing
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so uh um and and and a target range and then
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an increased risk if we go very high in the chief levels
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um now notably and this is really key for treatment
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if we want to get to that target frame so between twenty two to thirteen
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and o. cramp uh may lead to all fifty to seventy five nine normal per leader
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uh we are that we good by the daily recommendations we
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have two days so there is a lot of literature showing
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if we treat with eight hundred two thousand units of vitamin d.
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we we we uh um we we we prevent
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or revise deficiency in ninety seven percent of cases
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and uh this is just to visually uh um
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keep you would this memory uh a false falls
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and fractures the differential effects we see between powerless
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and daily dosing uh with my to mean d.
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and that there has been an update uh
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off for recent mate analyses uh we don't have
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enough time to discuss each one of them but the summary
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of the reason for meta analysis is that the one made analysis
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by lever and colleagues would tested the combined effect
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of calcium and vitamin d. which of course was always the
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daily treatment and the channel dose of the was eight hundred
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showed a significant benefit uh on the production of total fractures
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and hip fractures and then we had the meta analysis following that
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bites ow ow ow to us preventive task force and then by poland
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and they mixed the powerless and the daily dosing and um uh
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with the bowlers with with some read the poems trial also include excluded
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all the calcium and vitamin d. trials and all of them eight analyses
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why negative so we commented on all of them and i show you were re analysis
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uh that was published um on the pole and analysis
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where we took the same studies so all of those trials
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treated with vitamin d. only and um but excluding the bowlers trials
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and also uh looking at and t. runs off more than fifty percent
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and uh so the result was a twelve percent reduction of
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fall so i'm not no will benefit and the same for fractures
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if the powerless trials were excluded a fourteen percent reduction
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uh of fractures with vitamin d. alone come payout uh to placebo
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and i'm sort of starting seeing that pattern
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in moscow scully told it's easy slept uh uh
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colleagues of mine uh take macy's and best
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dawson used to this recent rescue off to literature
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comparing other outcomes that uh where we had daily and uh
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but will as a clinical trials and actually we have fractures
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any cancer cancer mortality acute respiratory
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infections and even called it nineteen
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and we saw the same pattern that bowlers
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dozing off item e. d. has no benefit
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and for falls and fractures even an increased risk um uh for these outcomes
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so um when to measure vied to mean d. and
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uh i think that has been a recent e. bay
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because um you know we we saw a lot of
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twenty five five proxy d. assessments especially among the cheap piece
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uh in switzerland i think in here is is really important to call rock to recall
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uh what the recommendations say and why we treat with vitamin
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d. or prevented the deficiency and that's on the one hand based
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on the fact that um a lot of adults r. e. d.
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d. fish and um you know this is data from around the world
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showing that fifty percent of the population be even have data
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from the kick start even children from germany showing that fifty percent
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i'll be load the trash hold a off twenty nine of crime per millilitre
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and it's even worse of course in a
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in frail old uh dolls with a hip fractures
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uh uh where are uh most of them are actually a t. v. fish and so
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the key motivation should be to treat a vitamin d. deficiency
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and um current guidelines and
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this includes the swiss guidelines recommend
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to treat a a vitamin d. deficiency turkey give my to mean
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d. to all the adults pest risk of vitamin d. deficiency so we
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i recommend the eight hundred units of fly to mean the the iowa have
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goes up to the thousand units of vitamin d. and very importantly if we
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applied this still was at the population paces and this is how
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the guidelines were built a it is a preventive measure that is safe
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and it the benefit is to shift ninety seven percent of
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the words that are deficient to to to to rear replete state
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and we don't put people while not deficient in danger
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and uh oh the recommendations in switzerland but also ah u. m.
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do not recommend in the situation of prevention of the deficiency
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to assess twenty five hike rock c. d. labels
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we should assess twenty five five proxy t. levels
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when we are concerned about the patient to have very low levels or neat
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a treat meant beyond what would be recommended in that preventive state
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so this off for example patients with fractures where we really wanna
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should work be sure that they have to write those of vitamin d.
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and also people who tend to need small bike to mean d.
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uh these are of for example patients with a high b. in my or a darker skin tone
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or we are concerned a patient cannot resold by
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to me d. well then we want to measure
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and that that the dough was accordingly or patients with a c. v. your kidney d. c. c.
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um so what i'm uh to supplement
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um and i think that goes back to that initial slide
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uh at this point in time uh everything speaks for playing by
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to mean d. with the argument that vitamin d. itself can be utilised
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by all or by a lot of cells because they have to twenty five five proxy
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ladies and here again it's important to uh
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to get that benefit through with daily application
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now um how much uh and uh i think uh again how
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much um the key strategy is to prevent the deficiency and be
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can very much achieved that with current guidelines
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and um we need to uh you know
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in our patients realised that all the adults
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have a very high risk of the deficiency
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but even independent of h. two two seasonality
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uh d. deficiency um you know it's price
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and independent of h. in the winter season
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and um we have good evidence uh for daily dosing
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of flight to mean d. as shown to you fall fall
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and fracture prevention in adults that are t.
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deficient and at risk or false and fracturing
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according to the recent data analysis however also
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influenced by the putting together of daily and powerless
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such as that people will not be deficient do not benefit from a
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vitamin d. or while not at
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risk of osteoporosis now um uh the
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the next question is so what about
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outcomes outside uh falls and fractures and
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i think one document could be here and that's really evolving
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in the most recent papers on the two health and the vital studies
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you probably know these studies uh they both tested
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two thousand units of vitamin d. and one prime of omega three for vital
00:16:58
that was it and the two wells study the
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european uh uh to hell study also included exercise and
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the argument that i want to make is that maybe that hired or was tested
00:17:14
in both trials with generally healthy adults into into hell
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seventy and older in vital fifty five years and older
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there may be a benefit for the immune function
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and regarding to health to hell's before i start
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that was the teamwork of many investigators um
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around europe and the us and uh and the trend sure still ongoing
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and uh also want to thank the team at the department of raging mad
00:17:48
this in at the university of steering for the coordination of this european trial and
00:17:54
before we start uh on the findings related to commune function
00:18:00
this was the study design off to health so it was
00:18:03
an eight on study two by two by two factorial design
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and the motivation to do that a trial design
00:18:13
was based on the inside assumption that each of these uh
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preventive strategies have and have a different haas way of action
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um and um and the assumption if that's the assumption
00:18:29
uh you assume and added to spend a feed
00:18:32
that becomes speaker or in combinations so west it's trial
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a design you can investigate the individual benefit
00:18:41
of each treatment but also the benefit in combination
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um so you may have seen the recent publication
00:18:50
uh out of two health regarding the three your risk
00:18:54
of invasive cancer so that's of course and outcome of a immunity
00:19:01
and i show you the findings so uh the total number of participants in road was
00:19:06
two thousand one hundred and fifty seven the mean age was seventy four point nine years
00:19:12
uh sixty two percent for women and forty one percent were t. deficient
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uh it was a very healthy population actually
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eighty three percent well at least moderately physically active
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when they started and during the three year follow up off to health
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uh we had eighty one new invasive cancer cases
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and here you see that vitamin d.
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contributed to the reduction of invasive cancer rates
00:19:45
uh you see here uh the the combinations so by to me d. alone
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uh a small non significant benefit the same for all make a three
00:19:56
and the same for shape shape was the simple exercise program
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and then combining omega three and by to mean d. already showing
00:20:06
a stronger and reaching significant appended
00:20:10
fate and then the combination of three
00:20:13
actually showed a sixty one a percent reduction
00:20:18
uh in a invasive cancer risk uh into health
00:20:23
and now we go to the vital study so the
00:20:27
vital study regarding uh immune outcomes was the same doze
00:20:32
um recently plop published in the b. and shady as significant reduction
00:20:38
uh by twenty two percent of any or to immune deceased over the course
00:20:44
of five years which was the followup five
00:20:46
point three three years uh in the vital study
00:20:50
and they also looked at cancer so the uh
00:20:54
the vitamin d. um uh in the bible study
00:20:59
but didn't reduce total cancer however there was a indication
00:21:05
that a vitamin d. in that those which uses cancer mortality
00:21:11
and actually that that triggered a
00:21:13
meta analysis of several randomised controlled trials
00:21:17
in total showing a thirteen percent reduction of
00:21:22
cancer mortality with my tummy d. uh compared
00:21:26
uh to placebo and and vital uh went on to look at
00:21:31
at bonds cancer cases um in
00:21:34
their study and again showed a significant
00:21:38
a reduction by seventeen percent so
00:21:44
um so so cancer or two in new indices uh our our arguments for
00:21:50
the higher daily there was and then sort of
00:21:53
including now the two health data you probably saw
00:21:57
uh the recent publication uh on
00:22:00
any uh acute respiratory infections on
00:22:04
vitamin d. and i showed this because this is another example where
00:22:09
any oh lustre was did not contribute to the reduction of end of
00:22:15
acute respiratory infections so when the also
00:22:18
was put together all forty six trials
00:22:21
there was a eight percent reduction in acute respiratory infections and
00:22:27
when they looked at the daily go sing oh would be there
00:22:30
was a significant twenty two percent reduction uh in any respiratory infections
00:22:36
and when they went down and they had any age group included
00:22:40
to current recommendation there was a thirty percent reduction
00:22:45
with my to mean d. come play out to placebo
00:22:48
so um i summarise uh um the the key point
00:22:55
uh regarding the update on the vitamin d. metabolism
00:22:59
based on um current evidence um daily is key and um
00:23:06
with the bow lustre was saying we have no evidence not
00:23:11
only for falls and fractures where we even see a detrimental effect
00:23:16
but it's going beyond i'm also into outcome
00:23:20
such as cancer um a risky and cancer mortality
00:23:26
so bowlers dozing off vitamin d. um uh should be avoided
00:23:32
and uh the daily dosing as recommended in our guidelines is preferable
00:23:38
uh went to measure vied to mean d. so never
00:23:41
for prevention so if you are concerned about the deficiency
00:23:45
uh given the eight hundred units of vitamin d. uh does not need a prior assessment
00:23:51
of light levels you would measure plot levels
00:23:55
if you assume that the current treatment joe was
00:23:58
uh is insufficient at needs fine tuning
00:24:02
for this patients so and individualised approach
00:24:05
what supplement claim vitamin d. uh at this point in time
00:24:10
there is no joachim and to go to another may temple light
00:24:14
uh however based on the half life remember it's good to do with daily and how much
00:24:21
so we have a um most added tons especially for falls
00:24:25
and fractures forty eight hundred units according to current guidelines however
00:24:32
based on these last findings on immunity cancer prevention or to immune
00:24:38
diseases cancer mortality there is a hint that based on do howls
00:24:44
and especially the vital trial that a higher daily joe
00:24:48
was uh it may be beneficial and you need to relies
00:24:52
that in those studies most participants were not the
00:24:56
deficient um as an important fact uh to consider
00:25:02
and i now thank you very much for your attention sorry for pushing the stroller little based
00:25:18
oh discussion questions
00:25:27
uh_huh
00:25:29
she could see us
00:25:37
uh thank you very much because i i i um i didn't show
00:25:41
that so i'm in that paper or uh mm actually the title is
00:25:47
well let's it's bogus we we we have a really nice craft to explain that so
00:25:54
when we get a high dose of vitamin d. maybe
00:25:57
the first thing to say you we have um um
00:26:03
what we call that a
00:26:06
so if you give fly to mean d. uh that there is a a sort of level laying off
00:26:12
so uh indicating that our party once
00:26:15
a certain amount and not more that's important
00:26:19
and then uh based on several trials when you give a lot of vitamin d.
00:26:23
you trick accountable weighting factors so one of them being f. t. f. twenty three
00:26:29
and the other one being and operate relation of the twenty four twenty five five proxy lays
00:26:35
bringing down the active one twenty five the high proxy going to
00:26:39
mean these uh these are so basically all forty has a natural way
00:26:44
to protect us from too much like to mean the and the
00:26:48
immune system uh maybe most relevant
00:26:52
um uh in that respect too neat
00:26:55
just the right amount and then in the data was
00:27:07
nick
00:27:08
so uh um
00:27:15
so the the senders trial or all over the idols at risk
00:27:20
of a hip fracture they have set some risk factor for hip fracture
00:27:24
and they gave the annual there was and most
00:27:27
of the fractures occurred in the first three months
00:27:31
of giving a the powerless showing that probably this is the time
00:27:36
when there was this counter regulation christian unfortunately i have to leave
00:27:43
sue
00:27:49
i have a very quick question thank you for your presentation
00:27:53
so we're only talking about gay versus monthly or yearly progress
00:27:58
what i encounter various cases that eh sixty family characteristics substitutions
00:28:05
once weekly yeah do you have any k. text is also has a negative effect
00:28:11
it's an excellent question and the only document could be
00:28:15
derived from that um made analysis on the forty six
00:28:20
randomised controlled pro trials for the acute respiratory infection in point
00:28:26
and they're even the weekly to bow let's was less effective if uh compared to daily
00:28:33
but this is really the key indicator that we
00:28:35
have today that weekly may already be a sub optimal
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