well welcome to this talk we're going to
be looking at vitamin d deficiency
particularly
in india now india is a sunny country
so it might surprise you that there's a
very high prevalence of vitamin d
deficiency
in india but indians very often don't
spend time in the sun it's not really
cultural to spend time in the sun and a
lot spend a lot of time
indoors and work indoors i've actually
uh
when i've been in india i've actually
cajoled some of my indian friends to do
a bit of sunbathing and
they might do it to human me but it's
really not part of their culture
and of course our very often a lot of
body surface area is not exposed so
there's not a lot of
body surface skin exposed to get the
vitamin d
and we know that 90 of our vitamin d
comes from the skin
from the synthesis in the skin from the
sunlight not from the diet
and vitamin d is very important because
it's an immunomodulator
it will lack of vitamin d definitely in
impairs the efficiency of the immune
system so we need vitamin d for good
immunity
and also there's a lack of vitamin d we
can get too much inflammation this
immunomodulatory effect
and of course we know that excess
inflammation
especially in the second week after
initial symptoms and covered
can cause this acute respiratory
distress syndrome where the fluid
collects and the alveoli
and the reason this fluid collects in
the alveoli is because of
inflammation this is an inflammatory
process
and we know that all the immune cells
that we see here
have um vitamin d receptors
in them they need vitamin d for normal
function
and uh these are liz gould's graphics
from last year are you getting enough
vitamin d
studies have found many people in
northern latitudes are deficient in
vitamin d
this deficiency is even more pronounced
in
people northern latitudes with darker
skin pigmentation
and even in india where it is very sunny
so the darker the coloured skin the more
you're protected from sunburn that is
very good
but of course the more slowly you will
make vitamin d
the lighter the skin the more prone you
are to sunburn
but the more quickly you will make
vitamin d
and of course most people in india are
darker colored than people in
people with european ancestry
so making vitamin d more slowly
so um important cultural and uh
and genetic factors in vitamin d now
i want to refer to the evidence here
here we've got this paper vitamin d
deficiency in india
this is from the journal of the family
med family medicine in primary care it's
written by uh
indian clinicians mostly based in
delhi mostly from delhi now it's the
the figures here are really quite
amazing vitamin d
is the deficiency is incredibly
prevalent in india
and this has got to adversely affect a
mutant function of people
in india and it's a variable that would
be so
easy to correct and
i i know i've talked to a lot of friends
in india and that they've all topped up
on vitamin d
a lot lately so the message is starting
to get through but but
certainly we needed to get through much
more so if you're in india put this on
your facebook page you know the simple
fact of the matter is that people that
are deficient in vitamin d
are going to be immunocompromised and
more likely to get severe inflammation
and therefore many many studies have
shown more likely to get
sick so do do publicize this it
is really important at the moment but
it's important anytime
now this article i'm reviewing here was
actually written in 2018
and the situation i don't believe is any
any better so this is a pre-covered
article but it just shows
how important this is so prevalence of
vitamin d deficiency and they looked at
about 30 studies
range from 40 to 99 i mean these are
horrendously high levels
most studies clustered around the
reporting that uh
a prevalence of 80 to 90 percent of
people in india are deficient in vitamin
d
now this is really quite a startling
figure
very high levels of deficiency in
vitamin d therefore
it's reasonable to assume that very high
levels of immunocompromise simply
through
lack of vitamin d
and of course the population as i said
largely vegetarian so
not getting a lot of vitamin d from the
diet if they're not getting it from the
sun
prevalent in all age groups and
high-risk groups
alike and i i know um
doing some clinics in india you actually
see a lot of children who actually have
rickets that they they have bendy bones
and they have reduced
growth because of the lack of vitamin d
and calcium and of course this is
very easy to correct you actually see
this
it is it is around and of course with
adults it's harder to detect but these
studies show
uh that it is there so factors
so major source of vitamin d is uh
synthesis on the skin due to exposure
ultraviolet b uvb radiation
wavelength 290 to 320
nanometers not much of a physicist but
that's what it is
so that this is the higher wavelength so
the the ultra
the the infrared is at the lower end of
the wavelength then we have all the
richard of york gay battle in vain red
orange yellow green
indigo violet and then beyond that we
have the
ultraviolet this is where this comes in
um now um you get it in fish to some
extent
fortified foods with vitamin d and
vitamin d supplements now
this is interesting fish um
because we have looked on this channel
that people in kerala
where they eat a lot of fish it was
rahul's research that showed this we had
rahul on a few times
that people in kerala who ate a lot of
fish died
less in the 1918 1919 pandemic
now can we say that that was the the the
decreased death rate was as a result of
less vitamin d deficiency well we can't
say that
but it is an interesting correlation so
it's certainly
and as i say it's a variable that's easy
to correct
vegetables and grains which are actually
the main source of food in india
i mean in india in in the south of india
especially in poor communities basically
you eat rice and
rice and lentils rice and dal and in
northern india you tend to eat a lot of
uh chapati or roti that that's like the
flat bread and
and dal and these foods basically don't
contain
well essentially no vitamin d actually
and combine that with not getting it in
the uh
not getting it from the sunshine and the
deficiency is inevitable
um so other factors latitude
so even though it's fairly far south we
looked at those behavioral issues solar
zenith angle
so basically the sun needs to be higher
than 45 degrees in the sky to make any
vitamin d
so um where i live in the north of
england uh just just in the past week or
two
uh towards the end of april that the
sun's been more than 45 degrees in the
sky and we actually make some vitamin d
so we're only really making vitamin d
for six months of the year
in in scotland and northern england
and uh even though there's so much
sunshine in india
a lot of it is not being used to make
human vitamin d in human skin uh
atmospheric pollution huge factor in
india um
it's getting better now but the cities
in india i mean new delhi and
mumbai terribly polluted ozone layer
we looked at mat in new zealand who can
make vitamin d much quicker because
they've got a depleted
ozone layer unfortunately and of course
melanin melon in
pigmentation as we saw on that uh
on that graphic from liz now the thing i
like about this study is it defines the
levels um pretty straightforward but um
always worth remembering ourselves
threshold level
um serum vitamin d so that's the vitamin
d in the blood the 25
vitamin d in the blood uh required to
optimize
effects may vary in various target
organs now what this is saying is
the the levels of vitamin d in the blood
uh the normal levels were very often
dictated by the levels which were
needed that the levels were high enough
so that people didn't get rickets
but it could be that other organs which
need vitamin d need higher levels
so the heart might like one particular
level the the brain might like another
level the immune system might like
another level
so we have to have it high enough to
cover these levels not just to stop
rickets is the is the important thing
so they're defects saying deficiency is
less than 20 nanograms per meal which is
50 nanomoles per liter insufficiency
they're saying is 21 to 29
nanograms per mil sufficiency is more
than 30
and toxicity is more than 150 so very
high
toxicity threshold for vitamin d and
desirable and safe range of serum
vitamin d
levels would be they say 30 to 100.
nanograms per ml which is 7259 moles per
liter
so that's what they're saying is
desirable and deficiency which they've
said is so common
is is actually very low so when they're
quoting these deficiency figures
the deficiency of vitamin d these are
people with
really very low levels less than 20
nanograms
per mill and that is what is very
prevalent so this study is saying that
this is the optimum
range so uh ideally
everyone in the world will get their
vitamin d levels tested
uh and uh by their doctors and then it
will be titrated accordingly but
unfortunately that doesn't always
well that very rarely happens um
all right metabolism vitamin d's need to
facilitate calcium absorption from the
gut
so if you're low in vitamin d you're not
going to absorb calcium so vitamin d
encourages the transport of calcium from
inside the gut from foods that we've
eaten it in
into the blood the vitamin d is
necessary for gastrointestinal
absorption
and parathyroid hormone is secreted in
response
to low blood serum calcium so these
parathyroid glands that there's four
parathyroid glands they're embedded in
the back of the uh
the thyroid gland and um what they
actually do
is when when the blood levels of calcium
are low
para thormone will be released so
parathyroidis is secreted in response to
low blood serum calcium
and what the parathyroid hormone will do
is we'll take calcium from the bones and
put it into the blood
because you need to maintain the calcium
in the blood because it's an electrolyte
but of course that's going to deplete
the calcium in the bones and that's
going to
that's going to cause rickets in
children and potentially osteoporosis
and bone thing in thinning in adults
whereas the vitamin d
will make sure you're producing you're
absorbing plenty of calcium so you don't
need to produce the parathorma
so that maintains serum calcium levels
by moving calcium from the bones to the
blood
therefore the bones can become
demineralized
at less than 20 nanograms per ml of
serum vitamin d
parathyroid is elevated to maintain
cerium calcium from bony reserves
so when you're deficient the parathyroid
hormone is released
that takes the calcium from the bones to
maintain the amount in the blood which
is necessary
at serum vitamin d levels uh of uh
inter intestinal calcium absorption
reaches its peak
now now one of the reason i'm hesitating
there is i've left that out so
at that serum levels of 30. so so when
serum levels reach 30 nanograms per ml
when same levels reach 39 grams per mil
in most people
that the parathormone will not be
produced and therefore the bones will
not be demineralized
that's why they're saying that 30 is the
necessary amount and that's consistent
with what they're saying here so that's
so uh sufficiency is more than 30.
so if it's less than 30 you will produce
parathyroid hormone
which will essentially be transporting
the calcium from the bones
into the blood so that's a very good
physiological rationale for saying that
uh below 30 nanograms per mill is an
insufficiency
but that's actually saying frank
deficiency is less than
20 nanograms per ml
so that makes physiological sense so you
will want to avoid
the release of the parathyroid hormone
which essentially is the emergency level
for keeping calcium up
and the parathyroid hormone will go down
as the vitamin d goes from 20 up to 30
till we get to 30
then the parathyroid hormones will be
low and that means you're maintaining
the calcium
in the bones so that that's quite a
useful physiological
indicator but of course other other
tissues may need
higher levels of vitamin d but the
tissues need higher levels of vitamin d
that's why their sense efficiency is
more than
more than 30. and they're saying
toxicity is not occurring to 150
and serum levels would ideally be 30 to
100 so
that actually makes quite a lot of
physiological
sense
right so yeah that's what we've said so
by the time you get to 30 the
parathyroid hormone level shouldn't be
raised maintaining the calcium in the
bones because
the vitamin d is making sure you're
absorbing all of the calcium you need
from your gastrointestinal tract as long
as there is some in the diet of course
consequences of vitamin d rickets of
course we know about
the bendy bones in children muscle
strength reduction
lack of vitamin d reduces muscle
strength reduction but lack of vitamin d
is also associated with autoimmune
disease where the immune system attacks
the body's own tissues
cardiovascular disease psychological
depression which can lead to suicide
parkinson's disease cancers infections
tuberculosis which of course is a
chronic infection
it's an associate associated with
obesity and diabetes mellitus type 2.
so all of these things are associated
with
and may well be caused by
lack of vitamin d
so quite profound um
things there now we know there's an
association between obesity and vitamin
d but is that causal
um are people that are low in vitamin d
more likely to be obese it's an
interesting association
but certainly the the there is suggests
very strong suggestions and and data
that
points towards the fact that vitamin d
deficiency
can cause all of these conditions
and with severe vitamin d deficiency i
think a lot of people would agree that
these
can be caused so
increasing vitamin d levels it's just a
variable to eliminate for possible
spectrum of diseases vitamin d is
important for immune function
regulation of inflammation and cellular
proliferation and differentiation
and of course we know that cancer is a
disease of excess cellular
proliferation so this paper really is
very concerned and you'll see this is
this is a pre-copied paper
but you know it's definitely saying that
vitamin d is necessary
for immuno
protection immune function and
the prevalence in india is most that is
indicate 80 to 90 percent of people are
deficient
so ironic in such a sunny country
so what the heck to do about this
um the authors want to do the following
create awareness amongst the public and
health care providers about the
importance of vitamin d so you can do
that you can share this information
there is a pressing need in india at the
moment and indeed in other countries
so publicize the consequences of
deficiency
indian diet generally fails to satisfy
the daily requirements of vitamin d for
normal adults therefore
they are advising that indian
manufacturers need to fortify various
foods with vitamin d through national
programs
but of course we also know that vitamin
d supplements
we know that vitamin d supplements will
increase serum vitamin d levels
in the blood and until the
until it wasn't cut down on my vitamin d
now because i've been out on the sun
but before then i was taking 4 000 units
a day which is 100
micrograms of vitamin d a day
this silent epidemic should be addressed
appropriately with concrete public
health action
the paper advises direct quotes
we can imagine the burden this silent
pandemic will cause the development of
the
country so strong words
silent epidemic and probably a silent
pandemic
of vitamin d deficiency
so the amounts of supplements that are
being recommended in the uk at the
moment many think are low
i've told you what i'm taking you'll
have to look at the evidence and decide
what's appropriate for you
go to your own doctor get your blood
tested titrate your vitamin d levels
accordingly is the ideal way
to do that but given that this isn't
really an option for many poor people in
india this
paper is advising uh fortification of
foods with vitamin d in in
india because really things are bad and
we need to do
something and this is a variable that
could be
could actually be relatively easily
uh eliminated
now we're going to do some more vitamin
uh on vitamin d
on india shortly uh so so hang hang five
fat because i am i am quite um
well i'm sure many of us are quite quite
distressed by the situation in india so
um
but that's information on vitamin d look
at the paper yourself
it's it's actually it's it's although
it's in a medical journal
um and it's written by clinicians in
india it's actually quite an accessible
article so click on the link take you
straight to it read it for yourself
follow the evidence wherever it leads
but don't take my word for the evidence
always check it out and look it up for
yourself
okay thank you for watching sorry that
was a bit longer than i meant it to be