Vitamin D Deficiency and Management

This assignment delves into the multifaceted topic of vitamin D deficiency. It examines various aspects, including the definition, causes, diagnostic methods, and potential consequences of this deficiency. The focus is on understanding the role of vitamin D in human health and exploring effective strategies for its management. This involves discussing the importance of sunlight exposure, dietary sources of vitamin D, and the appropriate use of vitamin D supplements. Additionally, the assignment considers the specific considerations for different populations, such as children, older adults, and those with certain medical conditions.

Running head: PRINCIPLES OF HEALTH AND SOCIAL PRACTICE
Ministerial Briefing Paper (For a decision)
Name of the Student
Name of the University
Author Note

1PRINCIPLES OF HEALTH AND SOCIAL PRACTICE
Subject
Principles and Practice of Public Health
Executive summary
Vitamins are essential nutrients required by our body for optimal functioning. Reports
from the National Health Survey found that adequate amount of nutrients are not being utilized
by Australians from the food they consume. According to reports released by the Australian
Bureau of Statistics (ABS), the Australian Dietary Guidelines for daily fruit intake were met by
49.8% adults and that for vegetables by 7%. 4 million adults were found to be deficient
in Vitamin D in Australia, in 2011-12. Most of them suffered from mild to moderate
deficiencies. Moreover, recent cases of Scurvy have also been reported. The aim of this paper is
to evaluate the prevalence of several vitamin deficiencies among Australians and the effects of
dietary habits and migration patterns that increase the vulnerability. It will further discuss on the
several policies that are being implemented to reduce the recent resurgence of these conditions
and will establish certain recommendations for the same.
Background
There is a high prevalence of Vitamin C and D deficiencies among Australians. The
principal source of vitamin D, for most people, is exposure of the skin sunlight. Minimal
erythemal dose (MED) is referred to as the amount of exposure to Ultra Violet radiation that
leads to faint redness of the skin, condition commonly called erythema (Heckman et al., 2013) .
At lower UVB radiation wavelengths, erythema production action spectrum is almost similar to
the spectrum related to production of vitamin D. Less amount of vitamin D is synthesised in

2PRINCIPLES OF HEALTH AND SOCIAL PRACTICE
winter. This particularly occurs at regions located at latitudes farther from the equator. This leads
to lack of exposure of the skin to sunlight and leads to deficiency in the production of Vitamin D.
Short exposures to UV radiation have proved to be more efficient in producing vitamin D. Data
from several studies suggest that adult people are more vulnerable to vitamin D deficiency owing
to the less amount of (7-dehydrocholesterol substrate in their skin. Vitamin D deficiency in
adults is also attributed to the lower rates of skin exposure to the sun. Elevated presence of
melanin among dark skinned people helps in increasing the absorption of UV radiation. This
leads to a reduction in the production of Vitamin D. Dark skinned people require 3-6 times more
skin exposure than others. This deficiency is also observed among migrants, people who are
affected with any chronic health condition like multiple sclerosis, those who avoid exposure to
sun rays and are at a risk of skin cancer. Vitamin D deficiency is also prevalent among obese
people and those who work in enclosed environment like factories, warehouse and offices. The
Australian Bureau of Statistics has recommended certain levels of Vitamin D deficiencies in the
population.
The cut-off levels are:
 Adequate levels: ≥50 nmol/L
 Mild deficiencies: 30 – 49 nmol/L
 Moderate deficiencies: 13– 29 nmol/L
 Severe deficiencies: <13 nmol/L
 Total deficiencies: <50 nmol/L

3PRINCIPLES OF HEALTH AND SOCIAL PRACTICE
23% adults reported a deficiency that consisted of 17% people with a mild deficiency and
6% people with a moderate deficiency. Severe deficiency was found in less than 1% people. The
National Health Survey provided evidence for the prevalence of 31% Vitamin D deficiency
among people aged 18–34 years and 15% among those aged 65–74 years. Adults above 75 years
of age showed a deficiency of 20% (Daly et al., 2012). On the other hand, the survey reports
demonstrated relatively low deficiency levels among children in 2011–12. This deficiency was
observed in around 15% children who were 12-17 years old. The deficiency rates were almost
similar for both boys (15%) and girls (16%).
The NATSIHMS (National Aboriginal and Torres Strait Islander Health Measures
Survey) measured the levels of Vitamin D by performing a blood test. The test analyzed the
amount of vitamin D that a person obtained from the nutrients present in the food and through
exposure to sunlight. The survey utilized LCMS (Liquid Chromatography Mass Spectrometry)
method to assess the status of Vitamin D among the target population. The measurements were
highly specific and sensitive. On analysis, it was found that 1 out of 4 (26.5%) Aboriginal and
Torres Strait Islanders demonstrated a <50 nmol/L Vitamin D deficiency. Majority of these
adults showed a mild deficiency (21.9%). Remaining 4.6% demonstrated a severe to moderate
deficiency. There were no differences observed in the pattern among men and women. When the
age differences were taken into account it was found that, Vitamin D deficiency was less likely
to occur in non-indigenous adult population when compared to their Aboriginal and Torres Strait
Islander counterparts (rate ratio of 1.1). Furthermore, results from recent surveys also indicate
that the deficiency was more common in aboriginals who lived in remote locations during 2012–
13 (Maple-Brown et al., 2014). The prevalence was found to be in 4 out of 10 people (38.7%)
compared to 2 out of 10 people who lived in non-remote locations (23.0%).

4PRINCIPLES OF HEALTH AND SOCIAL PRACTICE
Results from several studies have suggested that Vitamin D deficiency creates a
significant burden in migrant population. Skin colour is reported to be a major determinant of the
deficiency rates among migrants (Jang et al., 2013). Dietary patterns of Australians also play a
significant role in increasing the prevalence of this deficiency. Vitamin D intakes are low among
most people due to the unique dietary patterns they follow. An average Australian diet contains
low consumption of milk, restricted use of dietary supplements, limited or reduced intake of
traditional fish and vegetables. Fatty fish like mackerel and tuna, soy milk, cereals, dairy
products, cheese and egg yolks act as rich sources of Vitamin D. Most people belonging to the
Australian population do not meet the recommended nutrient intake levels. This is believed to
contribute to Vitamin D deficiency (Truswell, 2017). Conflicting evidence are present, which
link obesity to this deficiency. Obese individuals generally have an increased likelihood of being
deficient due to lack of sunray exposure. This occurs due to low physical activity levels that lead
to reduced mobility. Serum levels of vitamin D among obese Australians were found to be 8.3-
9.5 nmol/L lower in both males and females when compared to the levels found in healthy
people. An AusDiab study, conducted throughout the country showed a reduction in serum levels
by 57% among obese people when compared to those with normal weight after being exposed to
same amount of UV radiations. Pregnancy is also considered to act as a contributing factor to
higher risk of vitamin D deficiency. Data from studies suggest that infants are directly affected
by the levels of vitamin D during the last stages of gestational period in their mothers (Wei et al.,
2013). Breastfeeding to infants in enclosed environment with minimum sunlight exposure
increases the risk of the deficiency. This can be attributed to the low levels of vitamin D in
human milk. Recent resurgence in scurvy among diabetic patients in Australia can be attributed
to poor food habits. Scurvy occurs due to lack of vitamin C in the body. This leads to the

5PRINCIPLES OF HEALTH AND SOCIAL PRACTICE
formation of defective connective tissues and collagen that contribute to bleeding gums, bruising,
bleeding gums, joint pain, and blood spots in the skin and impaired wound healing. On being
questioned the poor dietary habits of the patients were revealed that supposedly led to the
occurrence of the disease. , Most of the diabetic patients did not consume fresh fruits with the
fear of an elevated blood glucose level. Moreover, some of them overcooked the vegetables
before eating. This destroyed the nutritional value of vitamin C. Possible consequences of
vitamin C deficiency include scurvy, inflamed gums, gingivitis, nosebleeds, weakened immune
system, coiled hair and perifollicular hemorrhage (Shaik-Dasthagirisaheb et al., 2013). Bulbal
conjunctival hemorrhage and skin echymosses also develop. Inadequate levels of Vitamin D lead
to ricketsw (weakened bones), lower back pain and bone pain. Controlled trials have also
established the relationship between this deficiency and depression among older adults (Anglin
et al., 2013). Other consequences include impaired wound healing, hair loss and muscle loss.
Pre-existing policies/activities
The Australian and New Zealand Ministerial Forum on Food Regulation is held
responsible for maintaining strong food regulation systems in the country based on evidence
collected scientific research. The forum focuses on protecting and safeguarding the safety and
health of all people. To reduce the incidence of Vitamin D deficiencies among people, a draft
standard was approved by the FSANZ Board. The draft was considered by the forum and seeked
to allow voluntary addition of the nutrient to breakfast cereals (Neal, 2016). These
recommendations were in accordance to the Ministerial Policy Guideline for the Fortification of
Food with Vitamins and Minerals. The forum permitted the voluntary fortification of breakfast
cereals using 2 existing forms of vitamin D. Vitamin D2 and D3 were selected based on their
equivalence and safety. Moreover, the forum also established a maximum claim of 2.5 μg per

6PRINCIPLES OF HEALTH AND SOCIAL PRACTICE
normal serving of breakfast cereal that was fortified with vitamin D (25% rRDI). It did not any
maximum permitted amounts. The FSANZ conducted a survey to evaluate the response of
customers to fortified foods. The consumer survey results showed that purchase of voluntary
foods depended on the vitamins or minerals that were added to the product. The responses
showed that people were more likely to purchase or consume a particular breakfast if it contained
minerals and vitamins (21%). The survey results also suggested that most often the purchase of
fortified food was based on the notion that they were healthy. The FSANZ proposed the decision
of Vitamin D fortification based on the insufficient status of the nutrient in the population. It also
investigated the potential of vitamin D fortification to address the issue (Black et al., 2012). June
20 is celebrated as the National Vitamin D awareness day. This health initiative aims to address
the increasing number of Vitamin D deficiencies in Australia. The awareness campaign also
illustrates the potential impact this deficiency can have on the health and wellbeing of the
population. People are encouraged to step out in sunlight regularly for a daily exposure to the
rays of sun and Vitamin D.
Considerations
Possible course of action can be taken to delineate the existing situation. One of the
potential course of action is to restore the normal vitamin D levels in children, and adolescents
identified with low vitamin D. Therefore, low dose supplements can be administered (vitamin
D2 or D3) as they are now commercially available and is recommended to minister for increase
its access among Australian population. Dietary intake is an effective measure in this regard for
children (Holick et al., 2011). This option is recommended because children are in urgent need of
specialist assessment and management and elderly people are less likely to get sun exposure. The
normal range of vitamin D for them is ≥ 50 nmol/. Therefore, low dose supplements can be given

7PRINCIPLES OF HEALTH AND SOCIAL PRACTICE
either daily or a high dose intermittent therapy. For children and adolescents 200 IU daily was
found necessary. For children 1-18 years 150,000 IU start of autumn (moderate or severe) or
400 IU daily (mild deficiency) as per The National Health & Medical Research Council
(Balasubramanian et al., 2013). The advantage of the vitamin D supplements is to foster normal
development (of bones and teeth) and growth. It will protect against muscle weakness and
support immune function. The disadvantage includes risk of overdose that may lead to
calcification of bones, headaches, weakness and calcification of soft tissues (Reid et al., 2014).
Sun exposure is an undeniable solution for eliminating the vitamin D deficiency. Health
literacy is crucial for increasing the sun exposure behaviors among people who are vulnerable.
The advantage includes creating awareness among people about way to supplement vitamin D by
sunlight exposure. Simply informing doctor’s recommendation is not considered effective. This
is considerable course of action for minister as study by Leung et al. (2014) highlighted that
assessing and enhancing the health literacy level of public especially older adults is crucial in
educating about vitamin D supplements. The disadvantage includes overexposure and risk of
skin burn or cancer. It is not effective for photosensitive patients.
Increase in health literacy programs for rs dietary intervention to prevent the vitamin B
and C deficiency in addition to education on sun exposure is recommended. There are various
foods rich in vitamin B (egg, youghurt) and C (such as citrus and vegetables like cauliflower)
unlike vitamin D. Simple educating people about the essential dietary resources to overcome
vitamin B and C deficiency is a quick way to fight deficiency. Thus, in addition to educating
people about sun exposure for vitamin D deficiency, people should be able to consume proper
diet to prevent deficiency of other vitamins (Xu et al., 2015). Health education by health care

8PRINCIPLES OF HEALTH AND SOCIAL PRACTICE
providers is advantageous in learning the benefits of diet. Language and cultural barriers are
disadvantages to this approach.
Another effective public health strategy recommended to increase uptake of vitamin D
and circulating 25-hydroxyvitamin D is food fortification. The intervention includes vitamin D-
fortified foods in free-living adults. It is recommended as it is safe and effective food based
strategy that can increase potential benefits by preventing vitamin D deficiency. Results of
randomized control trial by Black et al., (2012) showed statistically significant results on
increase 25(OH)D across the population by this food based strategy. The advantage includes
faster reduction in vitamin D deficiency. There is a lack of sufficient literature evidence on
efficacy of this option. According to Brown et al. (2013) Germany based study showed daily
vitamin D intake of 23.7 μg can be achieved by fortifying 100g bread with 11.3 μg of vitamin D.
Overdose risk with a single fortified product is high when compared to several fortified carriers,
which is a disadvantage. However, it is a considerable option for minister.
Recommendations
Based on the literature review, the option of vitamin D supplements orally or injection
along with the health literacy for children, adolescents and elderly is recommended to the
minister. Therefore, the first option should be paired with the health education and is
recommended to the minister. This option is recommended as along with the intake of the
vitamin D supplements, the children and the young people must be aware of the need of sun
protection, level of outside activity needed or the required sun exposure. Thus, the health literacy
should focus on teaching people about require daily sun exposure. They must know the level of
intermittent sun exposure that can be tolerated, without the need of sunscreen. Administering the

9PRINCIPLES OF HEALTH AND SOCIAL PRACTICE
vitamin D supplements along with the health education would better help manage the vitamin
deficiency. Awareness of the long-term consequences of vitamin D deficiency will help public
adhere to the guidelines. Awareness of taking correct dosage of commercially available
supplements will help avoid the deficiency, and prevent the consequences of overdose. People
must be aware on the consequences of long-term sun exposure such as skin burn and cancer
(Leung et al., 2015). The option is advantageous for elderly who are less likely to receive sun
exposure. The benefit includes mass awareness and future prevention of vitamin deficiency. The
health education must also focus on the need of other vitamins such as vitamin B and C and its
dietary supplements instead of only focusing on vitamin D. The disadvantage of the health
literacy programs as per the Australian New Zealand Clinical Trials Registry, are inefficient,
lack of translating, and scaling up health literacy education for vulnerable populations with low
literacy. The major limitations of this approach are the linguistic barrier, and increasing ageing
population in Australia. The other disadvantage is the low educational status among
socioeconomically disadvantage people (McCaffery et al., 2016). However, the advantages
outweighs the disadvantages and is thus recommended to the minister.

10PRINCIPLES OF HEALTH AND SOCIAL PRACTICE
Sources consulted
Heckman, C. J., Chandler, R., Kloss, J. D., Benson, A., Rooney, D., Munshi, T., ... & Oslin, D.
W. (2013). Minimal erythema dose (MED) testing. Journal of visualized experiments:
JoVE, (75).
Ultraviolet radiation therapy is often used as a form of treatment for common skin disorders,
including acne, psoriasis and eczema. Depending on the skin sensitivity of an individual, the
dosage of prescribed UV light varies. This study described the process of minimal erythema
dose (MED) screening of a patient to determine the amount of UV light that should be
administered.
Black, L. J., Seamans, K. M., Cashman, K. D., & Kiely, M. (2012). An updated systematic
review and meta-analysis of the efficacy of vitamin D food fortification. The Journal of
nutrition, 142(6), 1102-1108.
Food fortification is considered to be a potentially useful public health strategy that increases the
intake of vitamin D and concentration of 25-hydroxyvitamin D [25(OH)D].The study updated a
systematic review and evaluated randomized controlled intervention based evidences on effects
of fortified food on 25(OH)D concentrations among adults living in the community.
Daly, R. M., Gagnon, C., Lu, Z. X., Magliano, D. J., Dunstan, D. W., Sikaris, K. A., ... & Shaw,
J. E. (2012). Prevalence of vitamin D deficiency and its determinants in Australian adults
aged 25 years and older: a national, population‐based study. Clinical
endocrinology, 77(1), 26-35.

11PRINCIPLES OF HEALTH AND SOCIAL PRACTICE
The study evaluated the status of vitamin D among Australian adults aged more than 25 years.
The study also illustrated the risk factors that were associated with the deficiency. 11,247
Australian adults were enlisted in the Australian Diabetes, Obesity and Lifestyle (AusDiab)
study. The recruitment was done from randomly selected 42 districts. Immunoassay was used to
measure the 25-hydroxyvitamin D [25(OH)D] serum concentrations.
Maple-Brown, L. J., Hughes, J. T., Lu, Z. X., Jeyaraman, K., Lawton, P., Jones, G. R., ... &
Jerums, G. (2014). Serum vitamin D levels, diabetes and cardio-metabolic risk factors in
Aboriginal and Torres Strait Islander Australians. Diabetology & metabolic
syndrome, 6(1), 78.
Limited data on the serum concentrations of 25(OH)D was available for Indigenous Australians.
The study aimed to measure the levels of serum 25(OH)D among Aboriginal and Torres Strait
Islander Australians and explored the relationships between 25(OH)D and other diseases.
Jang, H., Koo, F. K., Ke, L., Clemson, L., Cant, R., Fraser, D. R., ... & Brock, K. (2013). Culture
and sun exposure in immigrant East Asian women living in Australia. Women &
health, 53(5), 504-518.
In the qualitative study, attitudinal and cultural factors that were related to behavior of sun
exposure among East Asian women, who lived in Australia, were examined. The study revealed
that limited exposure to the sun or excessive protection from the sunrays had implications in
formulating health promotion programs to address the incidence of this deficiency among
immigrants.
Truswell, S. (Ed.). (2017). Essentials of human nutrition. Oxford University Press.

12PRINCIPLES OF HEALTH AND SOCIAL PRACTICE
It deals with the essential aspects of human nutrition. It elaborates on the physiological and
biological process involved with nourishment and illustrates on the diseases that can occur due to
insufficient nutrient in the diet
Anglin, R. E., Samaan, Z., Walter, S. D., & McDonald, S. D. (2013). Vitamin D deficiency and
depression in adults: systematic review and meta-analysis. The British journal of
psychiatry, 202(2), 100-107.
The study established an association between low concentrations of vitamin D with increased
incidence of depression among adults.
Shaik-Dasthagirisaheb, Y. B., Varvara, G., Murmura, G., Saggini, A., Caraffa, A., Antinolfi,
P., ... & Toniato, E. (2013). Role of vitamins D, E and C in immunity and
inflammation. Journal of biological regulators and homeostatic agents, 27(2), 291-295.
The study emphasized on the role of vitamin D on remodeling and inflammation of tissues. It
also elaborated the anti-scurvy action of vitamin C owing to its anti-oxidant effect.
Wei, S. Q., Qi, H. P., Luo, Z. C., & Fraser, W. D. (2013). Maternal vitamin D status and adverse
pregnancy outcomes: a systematic review and meta-analysis. The Journal of Maternal-
Fetal & Neonatal Medicine, 26(9), 889-899.
It estimated associations between adverse pregnancy outcomes and low vitamin D levels. Low
maternal levels during pregnancy were associated with increased risk of preterm birth,
preeclampsia, and SGA.
Neal, G. (2016). FSANZ update. Food New Zealand, 16(4), 18.

13PRINCIPLES OF HEALTH AND SOCIAL PRACTICE
The FSANZ update investigated whether the population met the proposed nutritional
requirements and approved implementation of legislations for food fortifications.
Holick, M. F., Binkley, N. C., Bischoff-Ferrari, H. A., Gordon, C. M., Hanley, D. A., Heaney, R.
P., ... & Weaver, C. M. (2011). Evaluation, treatment, and prevention of vitamin D
deficiency: an Endocrine Society clinical practice guideline. The Journal of Clinical
Endocrinology & Metabolism, 96(7), 1911-1930.
Recommended supplementation of vitamin D at suggested daily intake for children and
adolescents. Treatment with either vitamin D2 or vitamin D3 for deficient patients is also
recommended
Balasubramanian, S., Dhanalakshmi, K., & Amperayani, S. (2013). Vitamin D deficiency in
childhood—A review of current guidelines on diagnosis and management. Indian
pediatrics, 50(7), 669-675.
The paper updates information on routine vitamin D supplements for children as daily or weekly
oral regimens. It highlights that the prevention of the vitamin D deficiency can be achieved by
sensible sunlight exposure and food fortification.
Reid, I. R., Bolland, M. J., & Grey, A. (2014). Effects of vitamin D supplements on bone mineral
density: a systematic review and meta-analysis. The Lancet, 383(9912), 146-155.
Based on the cohort study it was identified that the inappropriate doses would not prevent
deficiency and may lead to fractures. It highlights on co-administration of vitamin D together
with the calcium for future prevention. Vitamin D supplements were found to effect bone
mineral density.

14PRINCIPLES OF HEALTH AND SOCIAL PRACTICE
Leung, A. Y. M., Cheung, M. K. T., & Chi, I. (2014). Supplementing vitamin D through sunlight
exposure: health literacy initiates behavior. In Annual Health Literacy Research
Conference, HARC 2014.
Acknowledging older adults’ health literacy is crucial when educating about the vitamin D
supplements. Other than knowing functions and sources of vitamin D, people must be aware of
how to be exposed to sun.
Xu, X., Byles, J. E., Shi, Z., & Hall, J. J. (2015). Evaluation of older Chinese people's
macronutrient intake status: results from the China Health and Nutrition Survey. British
Journal of Nutrition, 113(1), 159-171.
Dietary intake of vitamins prevent deficiency of essential vitamins is recommended that the
health care providers inform patients on dietary recommendations appropriate for age.
Leung, A. Y. M., Cheung, M. K. T., & Chi, I. (2015). Supplementing vitamin D through
sunlight: associating health literacy with sunlight exposure behavior. Archives of
gerontology and geriatrics, 60(1), 134-141.
Tested and identified that the health literacy determines the sunlight exposure behavior. The
paper highlighted that it is necessary to train individuals health literacy skills for increasing the
chance of sunlight exposure.
McCaffery, K. J., Morony, S., Muscat, D. M., Smith, S. K., Shepherd, H. L., Dhillon, H. M., ...
& Nutbeam, D. (2016). Evaluation of an Australian health literacy training program for
socially disadvantaged adults attending basic education classes: study protocol for a
cluster randomised controlled trial. BMC public health, 16(1), 454.

15PRINCIPLES OF HEALTH AND SOCIAL PRACTICE
The study findings identified that in an Australian adult education setting, implementation of a
health literacy-training program is beneficial in improving the health outcomes. There is a
greater need of translating and scaling up health literacy education for people with low literacy
and vulnerable health wise.
Brown, J., Sandmann, A., Ignatius, A., Amling, M., & Barvencik, F. (2013). New perspectives
on vitamin D food fortification based on a modeling of 25 (OH) D
concentrations. Nutrition journal, 12(1), 151.
Germany based study showed daily vitamin D intake of 23.7 μg can be achieved by fortifying
100g bread with 11.3 μg of vitamin D.

16PRINCIPLES OF HEALTH AND SOCIAL PRACTICE