Vitamin D Deficiency in Australia: Public Health Actions and Analysis

This report investigates Vitamin D deficiency as a significant public health concern in Australia. It begins by defining Vitamin D's crucial role in regulating calcium and phosphorus, supporting bone health, and its global deficiency prevalence. Despite ample sunlight, Australia faces this issue due to factors like limited sun exposure, skin pigmentation, and lifestyle choices. The report presents findings from national studies revealing the prevalence of deficiency across various demographics, emphasizing the need for public health action. It then details governmental responses, including policy changes for food fortification, dietary guidelines, and screening programs for pregnant women. The report also examines the impact of supplementation, awareness campaigns, and their effects on cancer incidence. Finally, it discusses the strengths and weaknesses of these public health initiatives, offering future strategies like improving supplementation guidelines and raising awareness about sun exposure to reduce the burden of Vitamin D deficiency and improve overall public health outcomes. The report is contributed by a student and published on Desklib, a platform offering AI-based study tools for students.

Running head: FOUNDATION OF PUBLIC HEALTH
Foundation of public health
Name of the student:
Name of the University:
Author’s note:

1FOUNDATION OF PUBLIC HEALTH
Introduction:
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

2FOUNDATION OF PUBLIC HEALTH
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

3FOUNDATION OF PUBLIC HEALTH
 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.

4FOUNDATION OF PUBLIC HEALTH
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

5FOUNDATION OF PUBLIC HEALTH
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

6FOUNDATION OF PUBLIC HEALTH
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.

7FOUNDATION OF PUBLIC HEALTH
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

8FOUNDATION OF PUBLIC HEALTH
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.
Conclusion:
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.

9FOUNDATION OF PUBLIC HEALTH
1. 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:
http://www.who.int/nutrition/events/2015_vit_d_workshop_pregnantwomen_21to24Apr
15/en/
2. 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.
3. Vitamin D | Osteoporosis Australia [Internet]. Osteoporosis.org.au. 2017 [cited 1
September 2017]. Available from: https://www.osteoporosis.org.au/vitamin-d
4. Vitamin D deficiency strikes one-third of Australians [Internet]. Deakin.edu.au. 2017
[cited 1 September 2017]. Available from: http://www.deakin.edu.au/research/research-
news/articles/vitamin-d-deficiency-strikes-one-third-of-australians
5. 4364.0.55.006 - Australian Health Survey: Biomedical Results for Nutrients, 2011-12
[Internet]. Abs.gov.au. 2017 [cited 1 September 2017]. Available from:
http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/4364.0.55.006Chapter2002011-12
6. 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.
7. 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/

10FOUNDATION OF PUBLIC HEALTH
8. 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.
9. Department of Health | 8.9 Vitamin D deficiency [Internet]. Health.gov.au. 2017 [cited 4
September 2017]. Available from:
http://www.health.gov.au/internet/publications/publishing.nsf/Content/clinical-practice-
guidelines-ac-mod1~part-b~maternal-health-screening~vitamin-d-deficiency
10. Vitamin D Deficiency in Pregnancy [Internet]. 2017 [cited 4 September 2017]. Available
from: http://www.kemh.health.wa.gov.au/development/manuals/O&G_guidelines/
sectionb/1/b1.1.9.pdf
11. 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.
12. 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.
13. 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.