New Vitamin D Guidelines by Endocrine Society- what they imply for Indians

hello and welcome to the print I am sui Suk data and we have with us today Dr amarish mitl chairman and head endocrinology and diabetes with Max Health Care the US endocrine Society earlier this month released the guidelines on the role of vitamin for the prevention of disease in Boston these guidelines have generated considerable interest as they propose some major changes from the current clinical practices in this context I I'll request Dr m m first of all welcome sir thank you so much for joining us in the conversation today I believe you were also in Boston for the release of the guidelines yes yes so could you please share why the uh the society needed to come up with these guidelines and what exactly do they entail see vitamin D research is a very Dynamic field the last guidelines by the society were in 2011 uh 2011 and there they looked primarily at patients coming to Clinic like what how should they be treated what kind of levels should be achieved and that kind of stuff uh this guideline is a population guideline this guideline actually talks of prevention of disease so it doesn't talk about treatment anywhere so vitamin D guidelines for prevention of disease that's the thing so that is one major difference in these 12 or 13 years lots of data has come out on the outcomes so one is that you improve vitamin D levels you improve calcium but are you looking at actual outcomes like diabetes like heart disease like cancer like mortality and of course at fractures and osteoporosis so these guidelines are more based on outcome on clinical outcomes does vitamin D impact Clinic clinical outcomes or not that's the reason why and this these are more sort of General Public guid Lin rather than patient based Clinic guidelines okay okay sir so what are the key takeaways could you please you know briefly tell us guide us through what exactly do they say so I think the important parts that they say uh is first is that testing for D levels is grossly over utilized and it really is not very useful because the correlation between testing and outcomes of disease has not been very strong so if you're going to give someone again we're not talking of treatment treatment we're talking of just for a population if there is no advantage in Universal screening for vitamin D by testing levels which is exactly what the Indian societies recommend and which is also what others recommend so there's nothing new but they emphasize this a lot Universal screening is not recommended so people getting their D levels just for the heck of it it doesn't really matter okay sometimes for instance people are feeling tired all the time then also the doctors recommend so all that do you think all that won't really be required no if you're feeling tired if you have any symptoms and the doctor feels it's required it should be done but if you're you know testing d as part of these packages or others where we don't know what the patient has and then chasing the vitamin D level without any symptoms at all is probably what is now not recommended a different aspect sorry mention is that measurement of vitamin D is also a big problem what I when I say that I mean that the technology for measurement of vitamin D has improved a lot over the years and unless and until people are following the best techniques to measure vitamin D levels we make a lot of mistakes so therefore that's another technical aspect but yes please go ahead yeah so I needed to understand for instance I a healthy person but I'm am going for this annual package health package that I take are you saying that you know I don't really need to unless I I have any specific symptoms I don't really need to take this vitamin D test among other tests that my package offers yes so what these guidelines strongly suggest is that we don't take any test for normal healthy people uh and I think that is because they've not been able to correlate the levels of vitamin D with General Health that is the issue now however they do say that some groups of people should take Vitamin D supplements without testing so on the one hand they are saying don't test and there some some they are saying just to just just take vitamin D without testing so the most important group in that is for example is is uh children so earlier on only very young children were given vitamin D now they are saying up to the age of 18 children should be supplemented with lowd dose vitamin D on a daily basis IDE now this is really important so this is actually a big change because you're really seeing that children in their growing age in the when the bones are actually forming then vitamin D is very important and I'm glad they've said this because all studies done in Delhi in India have shown that our school children at least half of them are significantly defent in vitamin D so if we need not test because tests cost a lot and I told you there's some question even about reliability so using lowd dose vitamin D is completely harmless and will possibly benefit many of these children for example in Indian studies 1,000 units a day was enough to correct d deficiency in our kids so this is one big change that you're saying okay use it in kids without even testing right right so that's a group the second group where they're saying that is in elderly so extremes of age now above 75 they are saying everyone should be given lowd dose vitamin D or most people should be given lowd dose vitamin D so I think it's important that these guidelines suggest uh that children up to the age of 18 1 to 18 should be given low dose vitamin D throughout on a daily basis actually and although this was a recommendation earlier also it was for very younger very much younger children only the you know up to two years or up to four years maybe you know but now they are seeing right through adolesence and I think that makes a lot of sense because we have also shown my colleagues have shown Dr Marva has shown that in Delhi school children the D deficiency is very common and 50% of such children may be below you know maybe severely deficient or significantly deficient so therefore this formula of not testing but giving all kids through the growing age low doses of vitamin D works well in India this dose is probably going to be around a th000 units I think in the west they recommend 600 to 800 but we talking of 1,000 units here that's a minor difference but the fact is that they're recommending this without testing so that is one group the second group where they are recommending D supplementation without perhaps even testing because again I mentioned the fallacies of testing is those above 75 those above 75 when if you give lowd dose vitamin you will find that you're reducing their overall mortality there's data to show that overall mortality goes down so again you need to give maybe th000 to 2,000 units per day in that group in the Indian setting those above 75 they're also the group that is most prone to osteoporosis and fractures so it makes a lot of sense what they are saying is don't measure and try to tight rate just give them this small dose you can't go wrong yeah right so one question we often yeah we one question we often face is that we are a country with abundant Sunshine for instance why do we need Vitamin D supplementation especially for our kids who uh spend a considerable amount of time playing outside for instance where they get where they get enough exposure to Sun but uh do these guidelines really apply in Indian context given our geographical conditions as well uh absolutely in fact India has some of the lowest D levels in the world India and Middle East which are actually also uh very it's a very sunny area you know Lebanon and other places around there they have very low are vitamin D why do they have why do we have low vitamin D there are two reasons well there are many but two broad reasons number one Indians don't like to go in the Sun so except for our manual workers so you will find normal D levels in you know people who work on the street people who work on construction sites people who pull Rick Shaws do those kind of things you will find normal D levels but in anybody else who stay indoors most of the day particularly during heat during summer we are always indorsing we avoid the sun like it's too hot and we Al also Indians have this sun phobia of getting dark and skin burn and all that so I think it's therefore D levels in Indians have consistently been shown to be low number one number two about children and the question is very relevant they are playing in outside but the atmospheric pollution that cities like Delhi have prevents the UV ray from reaching the skin and therefore again very clearly even in controlled exposure of children to sunlight especially during winter the D level doesn't go up so I think it's important that we realize that's because thetion level we are not getting enough dle enough D in our blood and that's why our bone health is suffering so this is the other point one other point is new in the guidelines is the fact that they've also advocated for pregnancy so they've advocated supplementing D throughout again which is very relevant for India and very significant it wasn't there in an earlier recommendation that that you know for pregnancy also pregnant women should be supplemented with lowd dose vitamin D on a daily basis to improve outcomes so again that's really really significant people are looking at oh vitamin is over but actually the recommendations say something else it's a testing that they have they have trashed they have said you don't really require testing so that is the main thing group of pre-diabetes which is very relevant for India if you want we can talk about it later okay so uh one question what I'll also take this this is not directly related to the guideline itself but I have come across some studies for instance which say that the reference range for vitamin D that we currently use is also debatable in Indian context we need to have our own reference range I would like you to please share your perspective on this as well so the reference range for vitamin D is debatable period it is not specific to India that is people are making that up you know is your cholesterol range different is your diabetes range different no it isn't certain things are good for health so they are good for health but the fact is that overall the reference rise is hugely debated which is why these guidelines stayed out of that area totally earlier guidelines have discussed so I can summarize in two lines for you a very acceptable reference range at the moment anything above 20 nanograms per mL of of vitamin d25 hydroxy D is normal or good for bones good for outcomes don't have to Target levels of 30 40 50 which people are trying to do which is wrong and you know people with 2 would come to us and say oh my God my D is so low you know I'm I'm dying of D deficiency so anything above 20 is normal 20 n perfectly fine there may be some specific situation where you you may want higher levels that's a doctor's call number one number two anything below 10 and some people say 12 nogs is deficient and clearly deficient so you can't say that a whole school has levels of five six seven nanograms per ml which we find sometimes in Delhi schools and that's okay that's not okay it's between 10 and 20 where the confusion lies so we would say that between 10 and 20 we would like people to be at 20 or above below 10 or below 12 maybe you should use we can we should certainly try to supplement people with d level with the vitamin D now one important point that is again relevant for the reference ranges that all the studies that have been used in this American guideline it's an American guideline right the Baseline D levels have been above 20 so if your Baseline 25 hydroxy D is above 20 nanograms how do you expect a real benefit from using too much vitamin D yeah absolutely that's the confusion the wherever Studies have shown in nursing home residents in the west and others that the D levels were low to start off their benefits were clearly evident in Europe also so I think this is important that Baseline D levels matter however one good formula that we have been recommending for a long time is don't even measure it unless you have a symptom and you come to the doctor and there's a reason to measure right otherwise just use 1,000 to 2,000 units daily particularly vulnerable groups and you'll be you be pretty safe but there if you're doing a study or in Indian environments where you're looking at we sometimes get really low levels then you may want to measure uh vitamin D level and anything below 10 or 12 nanograms should be regarded as deficient and above 20 no need to do anything so one highlight of this uh guideline is also the use of vitamin D supplementation for pre-diabetics now we have a huge burden of pre-diabetics in India what do you think is the message there for Indian pre- diabetics I think uh the message is important uh the there are there have been studies on vitamin D and cardiac outcomes vitamin D and cancer outcomes and some very elegant studies on vitamin D and development of diabetes so while the effect was modest it wasn't a very profound effect but the fact is the Studies have shown that when in people with pre-diabetes we supplement them with vitamin D there conversion to diabetes becomes a little less a little slower which for India is highly relevant because the fact is that there have been some Indian studies on this also some years ago from so so the important thing message here is that we actually talking of large groups of people who should be having vitamin D India has 135 million pre-diabetes right absolutely giving D to all our kids we are talking of giving D in pregnancy or prant women and we are talking of giving D to our pre-diabetics which itself is more than 13 crores of people so actually lowd dose Des supplementation becomes very important the final message yeah will we be giving vitamin D to all these people no the answer is only those that reach a particular segment you know of of of healthcare will probably get that the answer is widespread fortification of milk these countries why is why is America less deficient than India despite being at at a higher latitude is because there is fortification so India has initiated vitam fortification of milk and edible oil but it's not mandatory yet A and B it's not uh at levels that will really make a big difference it'll make a minor difference so that is the worked out by the fssi so fortification is of essence it's of great importance for a country like India which has such low Baseline levels so you mentioned fortification now adults maybe you 18 to 75 age group doesn't really need supplementation just I'm just curious if we for I as a he healthy adult for instance if I consume milk and I get vitamin D supplementation in in a way I want because vitamin D is Al also capable of uh creating or causing some sort of toxicity in people who don't really need it and they could be you know overuse so is that a possibility yeah so yeah so that's a very important and logical question the amounts that are added in fortification or even the kind of amounts we're talking about th to 2,000 units anybody can take anybody even if you have 30 nanogram level even if you have 40 nanogram level you can take those levels without risk safe there is a huge safety window we have a huge gap there's no way you're going to get to toxic R unless there is a technical error in fortification or you know 100 times more is added or someone take some you know things by mistake so I think this is uh fortification is a very very important tool for countries like India and they already started on that path so that's fantastic but we need to push it and we need to spread it and we need to also increase the amount and you know fssi is probably coning that also to really get maximum benefit I'll make one important Point uh I think you're running out of time if I can see the time uh one important point and that is that only major difference for us would be that 50 to 75 age group that has been excluded in the guidelines in the US is a group that we will not exclude here we will certainly see we see lot of bone disease in 50 to 75 age group we also have a life expectancy of 703 or 74 so where are we talking so for us that 50 to 75 age group is also important for using low doses of Vitamin D so instead of going to just 70 just 70 we just 75 we should probably consider lowering that age and the 50 to 75 Group which the American society has said is not doesn't really require I think in our environment given our longevity lifespan our D levels and our diabetes uh we are we are important that's an important group so that's the other difference so a key message that U you know from what I uh understood by your explanations is that people generally don't need Vitamin D screening but can you please clearly spell out is there still a subset of people who would still need Vitamin D uh screening if yes what exactly is that group so that's not vitamin D screening then that is case based uh you know approach so people who have any bony issues bony aches and pains muscle pains unexplained fatigue and you know muscle tiredness kind of thing yes they do those who have other conditions you know uh absorption issues GI issues who have chronic Dias they will require those who are on drugs like anti-epileptic drugs even anti-tubercular drugs they may also require so there's a large bunch of people who will require D levels but going out and testing everyone in the population is not required at all is not required that's the wrap then thank you so much sir it was wonderful talking to you thank you so much sir

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Length: 20min 27sec (1227 seconds)

Published: Mon Jun 17 2024