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Test Vitamin D, get a tiny dose, no benefit, conclusion: should not have tested (Australia this time) – Aug 2022


Health, financial and environmental impacts of unnecessary vitamin D testing: a triple bottom line assessment adapted for healthcare

BMJ Open 2022;12:e056997. doi:10.1136/ bmjopen-2021-056997
Matilde Breth-Petersen ,1 Katy Bell ,1 Kristen Pickles,1 Forbes McGain,2,3
Scott McAlister,2 Alexandra Barratt1

Objective To undertake an assessment of the health, financial and environmental impacts of a well-recognised example of low-value care; inappropriate vitamin D testing.

Design Combination of systematic literature search, analysis of routinely collected healthcare data and environmental analysis.

Setting Australian healthcare system.

Participants Population of Australia.

Outcome measures We took a sustainability approach, measuring the health, financial and environmental impacts of a specific healthcare activity. Unnecessary vitamin D testing rates were estimated from best available published literature; by definition, these provide no gain in health outcomes (in contrast to appropriate/necessary tests). Australian population-based test numbers and healthcare costs were obtained from Medicare for vitamin D pathology services. Carbon emissions in kg CO2e were estimated using data from our previous study of the carbon footprint of common pathology tests. We distinguished between tests ordered as the primary test and those ordered as an add-on to other tests, as many may be done in conjunction with other tests. We conducted base case (8% being the primary reason for the blood test) and sensitivity (12% primary test) analyses.

Results There were a total of 4 457 657 Medicare- funded vitamin D tests in 2020, on average one test for every six Australians, an 11.8% increase from the mean 2018-2019 total. From our literature review, 76.5% of Australia's vitamin D tests provide no net health benefit, equating to 3 410 108 unnecessary tests in 2020. Total costs of unnecessary tests to Medicare amounted to >$A87 000 000. The 2020 carbon footprint of unnecessary vitamin D tests was 28 576 kg (base case) and 42 012 kg (sensitivity) CO2e, equivalent to driving ~160 000 - 230 000 km in a standard passenger car.

Conclusions Unnecessary vitamin D testing contributes to avoidable CO2e emissions and healthcare costs. While the footprint of this example is relatively small, the potential to realise environmental cobenefits by reducing low-value care more broadly is significant.
 Download the PDF from VitaminDWiki


Australia considered Vitamin D RDA = 200 IU (adding 200 IU has never been proven to help anything)

see for example wikipage: http://www.vitamindwiki.com/tiki-index.php?page_id=2322

Nutrient Reference Values for Australia and New Zealand 2022


Australia considers >20ng to be adequate, so many summer tests were worthless


Process should be: 1) Vitamin D loading dose, 2) See how it feels in the next 4 weeks

If feel better:
3) start maintenance dose (bi-weekly 50,000 IU)
4) consider vitamin D test in 4 months to see if mainenance dose is enough
If increase Dose, adjust co-factors


Many groups recommend 30, 40, 50 ng of Vitamin D

Vitamin D Treats
150 ng Multiple Sclerosis *
80 ng Cluster Headache *
Reduced office visits by 4X *
70 ngSleep *
60 ngBreast Cancer death reduced 60%
Preeclampsia RCT
50 ng COVID-19
Fertility
Psoriasis
Infections Review
Infection after surgery
40 ng Breast Cancer 65% lower risk
Depression
ACL recovery
Hypertension
Asthma?
30 ng Rickets

* Evolution of experiments with patients, often also need co-factors


History of US Vitamin D RDA: 200, 400, 600, and now 1200 IU for average male


Australia

Examples of countries which believe in Vitamin D

Vitamin D consensus: 400 IU for infants, less than 10 ng is too low, if low sun need to supplement – April 2017 has nice summary chart

+Image

Rapid response: Vitamin D testing should be aimed at raising vitamin D levels to optimal values (Dr. Grant)

https://bmjopen.bmj.com/content/12/8/e056997

The article by Breth-Petersen et al. 1 claimed that 77% of Australia’s vitamin D tests provide no health benefit. The primary basis for this claim was an article from Australia in which bone-centric vitamin D values <50 nmol/L were considered the sole basis for health benefits 2. The second reference in that paper was by Pludowski et al. 3. It stated: The bone-centric guidelines recommend a target 25(OH)D concentration of 20 ng/mL (50nmol/L), and age-dependent daily vitamin D doses of 400-800 IU. The guidelines focused on pleiotropic effects of vitamin D recommend a target 25(OH)D concentration of 30 ng/mL (75 nmol/L), and age-, body weight-, disease-status, and ethnicity dependent vitamin D doses ranging between 400 and 2000 IU/day.
Certainly pleiotropic effects of vitamin D are important health effects. Pleiotropic effects are those involving the hormonal metabolite of vitamin D, 1,25-dihydroxyvitamin D, binding to vitamin D receptors linked to chromosomes in nearly every cell in the body, thereby affecting gene expression.
A study involving 30 adults found that supplementation with 600, 4,000 or 10,000 IU/d of vitamin D3 for 6 months resulted in 162, 320 and 1289 genes up- or down-regulated in the participants’ white blood cells, respectively 4. It should be noted that the health benefits are usually better determined from observational studies rather than randomized controlled trials (RCTs). Observational studies can examine health outcomes over a large range of vitamin D levels.
The main problems with RCTs is that they generally

  • enroll participants with high vitamin D levels,
  • give relatively low vitamin D doses, and
  • analyze results only in terms of intention to treat 5.

As a result, most major vitamin D RCTs failed to find benefits of vitamin D supplementation. However, when the results of RCTs are analyzed with respect to achieved vitamin D level, significant benefits can be found. A good example is the D2d study using vitamin D3 supplementation of 4000 IU/d regarding progression from prediabetes to diabetes 6. No significant benefit was found for intention to treat, but a 25% (95% confidence interval, 18-32%) reduction was found for each vitamin D level increase by 25 nmol/L from 75 nmol to >125 nmol/L in the treatment arm. Here are a few examples of health benefits for higher vitamin D levels:
Significant reductions in incidence and death from many types of cancer for vitamin D levels up to at least 100 nmol/L 7 8. Significant reduction in myocardial infarction and all-cause mortality rate for vitamin D level >75 nmol/L compared to <50 nmol/L 9. Significant reduction in incidence of COVID-19 for vitamin D level >75 nmol/L compared to <50 nmol/L 10. A better criterion for the goal of vitamin D testing would be to help patients achieve optimal health. The general finding in a recent review is that optimal vitamin D levels to support health and wellbeing are above 75 nmol/L for cardiovascular disease and all-cause mortality rate, whereas the thresholds for several other outcomes appear to range up to 100 to 125 nmol/L 11.
References

  • 1. Breth-Petersen M, Bell K, Pickles K, et al. Health, financial and environmental impacts of unnecessary vitamin D testing: a triple bottom line assessment adapted for healthcare. BMJ Open 2022;12(8):e056997. doi: 10.1136/bmjopen-2021-056997
  • 2. Gonzalez-Chica D, Stocks N. Changes to the frequency and appropriateness of vitamin D testing after the introduction of new Medicare criteria for rebates in Australian general practice: evidence from 1.5 million patients in the NPS MedicineInsight database. BMJ Open 2019;9(3):e024797. doi: 10.1136/bmjopen-2018-024797
  • 3. Pludowski P, Holick MF, Grant WB, et al. Vitamin D supplementation guidelines. J Steroid Biochem Mol Biol 2018;175:125-35. doi: 10.1016/j.jsbmb.2017.01.021
  • 4. Shirvani A, Kalajian TA, Song A, et al. Disassociation of Vitamin D's Calcemic Activity and Non-calcemic Genomic Activity and Individual Responsiveness: A Randomized Controlled Double-Blind Clinical Trial. Sci Rep 2019;9(1):17685. doi: 10.1038/s41598-019-53864-1
  • 5. Pilz S, Trummer C, Theiler-Schwetz V, et al. Critical Appraisal of Large Vitamin D Randomized Controlled Trials. Nutrients 2022;14(2):303. doi: 10.3390/nu14020303 8
  • 6. Dawson-Hughes B, Staten MA, Knowler WC, et al. Intratrial Exposure to Vitamin D and New-Onset Diabetes Among Adults With Prediabetes: A Secondary Analysis From the Vitamin D and Type 2 Diabetes (D2d) Study. Diabetes Care 2020;43(12):2916-22. doi: 10.2337/dc20-1765
  • 7. Manson JE, Cook NR, Lee IM, et al. Vitamin D Supplements and Prevention of Cancer and Cardiovascular Disease. N Engl J Med 2019;380(1):33-44. doi: 10.1056/NEJMoa1809944 8. Muñoz A, Grant WB. Vitamin D and Cancer: An Historical Overview of the Epidemiology and Mechanisms. Nutrients 2022;14(7):1448. doi: 10.3390/nu14071448
  • 9. Acharya P, Dalia T, Ranka S, et al. The Effects of Vitamin D Supplementation and 25-Hydroxyvitamin D Levels on the Risk of Myocardial Infarction and Mortality. J Endocr Soc 2021;5(10):bvab124. doi: 10.1210/jendso/bvab124
  • 10. Oristrell J, Oliva JC, Casado E, et al. Vitamin D supplementation and COVID-19 risk: a population-based, cohort study. J
  • 11. Grant WB, Al Anouti F, Boucher BJ, et al. A Narrative Review of the Evidence for Variations in Serum 25-Hydroxyvitamin D Concentration Thresholds for Optimal Health. Nutrients 2022;14(3) doi: 10.3390/nu14030639 Endocrinol Invest 2022;45(1):

Disclosure: I receive funding from Bio-Tech Pharmacal, Inc. (Fayetteville, AR, USA).167-79. doi: 10.1007/s40618-021-01639-9


Created by admin. Last Modification: Friday August 26, 2022 13:47:18 GMT-0000 by admin. (Version 17)

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