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Public Health Problem Of Vitamin D

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Public Health Problem Of Vitamin D

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Discuss about the Public Health Problem Of Vitamin D Deficiency In Australia.

Vitamin D is an essential component for the regulation of calcium and phosphorus in human body. It supports bone mineralization and strengthens bone. Appropriate level of Vitamin D in human body has been found to decrease the likelihood of bone disorders like rickets and osteoporosis in children. However, the Vitamin D deficiency has become a major public health issue globally due to limited exposure to sunlight. Vitamin D deficiency has been found to contribute to adverse health consequences such as cardiovascular disease, obesity and complication in pregnancy (1). This report particularly examines the public health problem of Vitamin D deficiency in Australia and examines the actions taken in the country to address the issue at population level.
Is Vitamin deficiency a public health problem in Australia
Vitamin D is an essential fat soluble vitamin for bone health because it helps in the regulation and absorption of calcium level in blood. It is also regarded as important to maintain bone health and prevent fractures. The review of the prevalence of Vitamin D deficiency has shown that it is prevalent in many countries worldwide particularly those falling in low latitudes. About 1 billion people have been found to have low vitamin D levels and the disease is common mostly in all age groups (2).
It is also linked to other diseases like hypertension, diabetes, cancer and autoimmune disease because Vitamin D is needed for healthy cardiovascular system, hormones and immunity. The human body get most the Vitamin D from regular exposure to sunlight as the skin produces the vitamin when exposed to ultraviolet B (UVB) light from the sun. However, Vitamin D deficiency is also public health burden in Australia despite receiving plenty of sunlight. The most common cause for this is that people are not adequately exposed to enough sunlight on a daily basis. People with naturally very dark skin are at high risk of Vitamin D deficiency because dark skin pigment has lesser ability to produce Vitamin D. Secondly, exposure time decreases in people due to location, season and amount of skin exposed to sunlight. For example, people working indoor environment, older and weak adults, and those who avoid the due to health issues get little or no sun exposure at all and become prone to Vitamin D deficiency risk. A mother who is low in Vitamin D also increases the risk in breastfed babies. In addition, certain health conditions and medication also cause low Vitamin D in an individual (3).
National study has confirmed that Vitamin D deficiency has become an emerging heath issue in Australia. In a study done with 11000 adults in Australia, one-third of them were found to be deficient in Vitamin D. It highlighted the Vitamin D status of Australia by stating that women, elderly, obese, non-European background people and people with less amount of physical activity are at greater risk of deficiency (4). The negative point for public health system of Australia is that they have abundance of rich sunlight, still Vitamin D deficiency is turning out to be a major health issue in the country. The proportion of risk differs on the basis of level of deficiency. For instance, low level of deficiency leads to soft bones and frequent fractures and high level of deficiency leads to life threatening diseases like osteoporosis, cancer, diabetes and cardiovascular disease.
According to the Australian Bureau of Statistics National Health Measures Survey (NHMS), the level of deficiency is determined based on the following cut off:

Mild deficiency for Vitamin D level of 30-49 nmol/L
Moderate deficiency for 13-29 nmol/L vitamin D
Severe deficiency for less than 12nmol/L
Total deficiency for less than 50 nmol/L
Sufficient level at greater than 50nmol/L

On the basis of above definition for severity, the survey done in 2010-2012 showed that majority of Australian adults had good levels of Vitamin D. 23% had mild deficiency to moderate deficiency and only 1% has severe deficiency. Hence, 23% or one in every four adults in Australia were found to suffer from Vitamin D deficiency. The deficiency was found more in older adults than younger people. The rate of deficiency varied with season too with low rate in winter and high rate in summer. The survey also revealed that risk of Vitamin D deficiency was higher for people born in Southern and Central Asia compared to those born in Australia. People who were physically inactive and obese were also found to have low levels of the vitamin.  (5). A study also points out to Vitamin D deficiency in South Australian population and high burden of dealing with the condition (6). There is a need to take future actions to reduce the risk factor for the disease and improve Vitamin D level.
Action being taken in Australia to address Vitamin D deficiency:
The publication of the ABS report for Vitamin D deficiency in Australia was associated with many issues and controversies, which finally led to health service or policy related changes. Firstly, a new indication for Vitamin D supplementation was identified after a study showed that vitamin D supplementation reduces the risk of respiratory tract infection. The impact of Vitamin D supplementation on reducing Vitamin D deficiency was also studied by various researchers and many health professional were confused about the health benefits of supplementation. However, tone study showed that sun exposure and Vitamin D have independent effects on disease risk and more research is needed to identify the true benefits of supplementation of reducing the risk of immune function impairment and cardiovascular disease (8).
In response to the ABS report for 2011-12, many public health actions has been taken to address the prevalence of Vitamin D deficiency in Australia. Firstly, changes in many policies were also done to maintain Vitamin D levels in different food items because many foods were found to have less amount of Vitamin D. As indicated by the Australian Standard, it mandated the food manufacturing company to maintain the limit of 55mm/kg of Vitamin D in butter and fortified food products. In response to the low level of vitamin D in children and adults, dietary Vitamin D consumption per day for children were also provided. Hence, public health agency took the initiative of supplementing the food supply with vitamin D to maintain the level of deficiency in Australian people. Focusing on the dietary source of Vitamin D was also considered important because of the lifestyle choices of the Australian population. Many people remain indoor or use sunscreen while going to prevent risk of skin cancer and so the Vitamin D limits supplementation from food items is considered a good step by the government. Mandatory fortification of milk and yoghurt was also proposed to reduce the risk of Vitamin D deficiency in the population (7). However, there is no clarity regarding whether food products fortification should be made voluntary or mandatory. Taking strong decision and policy reform in this area may help to reduce the public health burden associated with the disease.
Public health action was also taken to support screening of all women with Vitamin D deficiency during pregnancy. Observational studies in Australia had showed that among women attending antenatal care in Sydney, 15% had serum HD lower than 25nmol/L. Taking action for pregnant women was particularly considered important due to the high associated with the deficiency for them. Vitamin D deficiency in newborn has been found to led to low serum calcium level, rickets and defective tooth enamel in newborn baby. Impact on fetal growth is also seen as children with vitamin D deficient mothers has been found to have lower birth weight and low mineral density. It also increases the likelihood of diseases like cancer, multiple sclerosis and schizophrenia because of the affect on the functioning of different body tissues (9). In response to address this issue in pregnant women, Vitamin D supplementation was considered important to improve maternal vitamin D status during pregnancy. The clinical practice guideline showed that screening for the deficiency in women was important if they has dark skin, limited exposure to sunlight and pre pregnancy BMI of greater than 402.. Dosage and forms of supplementation was decided and calcium intake level was fixed. For women below 18 years, it was 1300 mg calcium and for women above 18 years, it was 1000 mg. The recommendation for health staff was to maintain the dose of Vitamin D in women and dietary source of calcium and Vitamin D was planned which included milk, bony fish, nuts, margarine, eggs and soy beverages (10). Hence, this step was found to be effective in reducing the risk and identifying at risk person effectively.
A peer-reviewed research article also examined the implications of vitamin D supplementation in Australia. After the report on high rates of Vitamin D deficiency, very few studies evaluated the impact of Vitamin D supplements on health outcome. Although between the year 2000-2011, about $94 million supplement were sold in Australia, however there was lack of study regarding analyzing the way supplementation is used. The research study investigated about the effects of vitamin D supplementation to improve and further develop the supplementation process. Vitamin D requirement was not met from diet because very few food items in Australia has adequate vitamin D levels. Despite the fortification of edible oil and spreads, the vitamin D level was not met by many food producing agencies. However, those who took supplements led a healthier lifestyle and their quality of diet was also good. They were also found to be aware about the need for sun exposure and eating foods containing Vitamin D. Such people were healthier compared to those who did not used supplements. The  implication from the study is that after the first decade of vitamin D supplementation, awareness about risk and testing has increased among public. However, one negative result seen from the study is that Australia is spending too much on supplementation in other areas too where it is not necessary (11). Hence, to reduce unnecessary spending, development of appropriate vitamin D supplementation guideline is necessary. This will help to correct the dose required and prevent unnecessary use too.
Taking action regarding preventing vitamin D deficiency was also found to improve the cancer incidence in Australia. Cancer has been a common public threat in Australia and WHO recommendation was that this can be prevented by addressing the risk factors such as tobacco smoking, diet, physical inactivity, sun exposure and  alcohol consumption. Although this study considered many other elements apart from sun exposure and Vitamin D intake, the information related to Vitamin was only analyzed for this study. The strength of this study was that it pointed out to the recent rise in vitamin D deficiency due to the influence of the sun protection programs. Adequate level of Vitamin D can be maintained only when skin is exposed to the sun followed by receiving small proportion of vitamin D through diet (12). Hence, the public health action of increasing the awareness about risk and benefits of sun exposure became important to reduce the deficiency and public health burden related to Vitamin D deficiency. Currently, people still has doubts regarding the role of sun protection and effective public health action in this area is considered important.
Strategies or recommendation for future focus to reduce burden from Vitamin D deficiency:
The review of the Australian Government’s action to reduce vitamin D deficiency pointed out to many strength and weakness of the Public Health Agency. For instance, the fortification of the food items and the policy development regarding it was a beneficial step for the country considering the lack of vitamin D level in different food items. Secondly, the guideline regarding Vitamin D supplementation and Vitamin D supplementation was considered as an important step to reduce the risk in pregnant women and new born babies too. However, the analysis of the public level action also pointed out to certain areas of improvement. For instance, lot of unnecessary investment in Vitamin D supplementation was also seen because of poor knowledge regarding Vitamin D supplementation and its daily intake among public. The sun protection program and the tendency to remain indoors was also regarded as a factor leading to high rate of vitamin D deficiency. Over-screening and over-diagnosis was also considered as an issue in preventing the health issue. Hence, in future more action is required regarding educating the public about importance of sun exposure, improving the screening process and maintaining a health life style along with good diet to reduce the health burden associated with Vitamin D deficiency.
The future recommendation to improve Vitamin D testing in Australia is that unnecessary labeling and overtreatment in healthy individual needs to be reduced. The rate of increase in testing has increased the cost for 25-hydroxyvotamin D deficiency in the country (24(OH)D). Variation in frequency of testing and adapting international testing guideline was found. Hence, the recommendation is to separate individuals who are at high risk of deficiency such as elderly people or people with dark skins. It is necessary to follow the Australian Bone and Mineral Society recommendation of testing every three months after a loading dose 25(OH)D has been given to affected people (13). In addition, to track the benefits of the supplementation, it is necessary to monitor the performance of the replacement therapy on health outcome of people. Adoption of specific guideline for 25(OH)D testing may also improve the efficiency of testing.   
The report summarized the prevalence of the Vitamin D deficiency in Australia and pointed out to public health burden by means of present risk and inefficiency in the public health system of the country. In response to the data or report presented on the rise in rate of Vitamin D deficiency, the public health action implemented in Australia to reduce the health risk was discussed. It gave the idea about the benefits of supplemented program and also pointed out to future action due to the identification of improvement in testing and screening process for Vitamin D deficiency.

WHO | Vitamin D nutrition with a focus on the prevention of rickets and vitamin D deficiency in pregnant women [Internet]. Who.int. 2017 [cited 1 September 2017]. Available from: https://www.who.int/nutrition/events/2015_vit_d_workshop_pregnantwomen_21to24Apr15/en/
Palacios C, Gonzalez L. Is vitamin D deficiency a major global public health problem?. The Journal of steroid biochemistry and molecular biology. 2014 Oct 31;144:138-45.
Vitamin D | Osteoporosis Australia [Internet]. Osteoporosis.org.au. 2017 [cited 1 September 2017]. Available from: https://www.osteoporosis.org.au/vitamin-d
Vitamin D deficiency strikes one-third of Australians [Internet]. Deakin.edu.au. 2017 [cited 1 September 2017]. Available from: https://www.deakin.edu.au/research/research-news/articles/vitamin-d-deficiency-strikes-one-third-of-australians
0.55.006 – Australian Health Survey: Biomedical Results for Nutrients, 2011-12 [Internet]. Abs.gov.au. 2017 [cited 1 September 2017]. Available from: https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/4364.0.55.006Chapter2002011-12
Gill TK, Hill CL, Shanahan EM, Taylor AW, Appleton SL, Grant JF, Shi Z, Dal Grande E, Price K, Adams RJ. Vitamin D levels in an Australian population. BMC public health. 2014 Sep 26;14(1):1001.
Nutrition D. Food fortification with vitamin D: a public health issue for Australians [Internet]. Deakin Nutrition. 2017 [cited 1 September 2017]. Available from: https://deakinnutrition.wordpress.com/2013/07/04/food-fortification-with-vitamin-d-a-public-health-issue-for-australians/
Hartley M, Hoare S, Lithander FE, Neale RE, Hart PH, Gorman S, Gies P, Sherriff J, Swaminathan A, Beilin LJ, Mori TA. Comparing the effects of sun exposure and vitamin D supplementation on vitamin D insufficiency, and immune and cardio-metabolic function: the Sun Exposure and Vitamin D Supplementation (SEDS) Study. BMC public health. 2015 Feb 10;15(1):115.
Department of Health | 8.9 Vitamin D deficiency [Internet]. Health.gov.au. 2017 [cited 4 September 2017]. Available from: https://www.health.gov.au/internet/publications/publishing.nsf/Content/clinical-practice-guidelines-ac-mod1~part-b~maternal-health-screening~vitamin-d-deficiency
Vitamin D Deficiency in Pregnancy [Internet]. 2017 [cited 4 September 2017]. Available from: https://www.kemh.health.wa.gov.au/development/manuals/O&G_guidelines/sectionb/1/b1.1.9.pdf
Bilinski K, Talbot P. Vitamin D supplementation in Australia: implications for the development of supplementation guidelines. Journal of nutrition and metabolism. 2014 Aug 19;2014.
Youl P, Baade P, Meng X. Impact of prevention on future cancer incidence in Australia. InCancer Forum 2012 Mar (Vol. 36, No. 1, p. 37). The Cancer Council Australia.
Bilinski K, Boyages S. Evidence of overtesting for vitamin D in Australia: an analysis of 4.5 years of Medicare Benefits Schedule (MBS) data. BMJ open. 2013 Jan 1;3(6):e002955.

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