Vitamin D supplementation: Choose vitamin D3 over D2

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Vitamin D deficiency is highly prevalent in India, almost in epidemic proportions. There are several reasons for deficiency of vitamin D. Lack of food fortification policies and more commonly our sociocultural practices, ‘sun-fleeing’ behavior, are major factors contributing to deficiency of this ‘sunshine vitamin’ in India which has abundant sunshine. Many people are unaware that they are vitamin D deficient.

Vitamin D, as we know, is essential for bone health. Evidence has also demonstrated its role in chronic diseases such as cardiovascular disease, cancer, diabetes, infertility, dementia and autism, among others.

There are two forms of vitamin D: vitamin D2 (ergocalciferol) and vitamin D3 (cholecalciferol). D2 is plant-based and D3 is derived from animal sources.

Vitamin D levels below 20 ng/ml need to be treated and are an indication for vitamin D supplementation.

The question arises which one to choose: vitamin D2 or D3?

Several international guidelines have recommended either D2 or D3 for vitamin D deficient patients stating that the two forms of vitamin D are equivalent and are equivalent in their effectiveness in treating patients with low vitamin D levels.

However, findings of a new randomized-controlled trial from the UK have raised questions on these recommendations as the study found that vitamin D3 was twice as effective in increasing levels of serum 25-hydroxyvitamin D (25[OH]D) compared to vitamin D2 at a low dose of 15 μg daily.

In the study published online July 5, 2017 in the American Journal of Clinical Nutrition, vitamin D3 fortified foods (juice, biscuits) during winters led to higher serum 25[OH]D levels after 12 weeks of supplementation compared to D2 fortified foods (juice, biscuits) in healthy South Asian and white European women.

Vitamin D levels in women who received vitamin D3 via juice or a biscuit increased by 75% and 74%, respectively vs those who were given D2 through the same methods. Those given D2 saw an increase of 33% and 34% over the course of the 12-week intervention.

Therefore, D3 should be the preferred form when advising vitamin D supplementation as it is the most effective form of increasing vitamin D levels in the body.

Even low doses of vitamin D3 are effective in achieving the desired levels as demonstrated in this study.

Sources

1. University of Surrey, Eurekalert Press Release, July 5, 2017.
2. Tripkovic L, et al. Am J Clin Nutr. 2017 Jul 5. Epub ahead of print

Dr KK Aggarwal
National President IMA & HCFI

Recipient of Padma Shri, Dr BC Roy National Award, Vishwa Hindi Samman, National Science Communication Award & FICCI Health Care Personality of the Year Award
Vice President Confederation of Medical Associations of Asia and Oceania (CMAAO)
Past Honorary Secretary General IMA
Past Senior National Vice President IMA
President Heart Care Foundation of India
Gold Medalist Nagpur University
Limca Book of Record Holder in CPR 10
Honorary Professor of Bioethics SRM Medical College Hospital & Research Centre
Sr. Consultant Medicine & Cardiology, Dean Board of Medical Education, Moolchand
Editor in Chief IJCP Group of Publications & eMedinewS
Member Ethics Committee Medical Council of India (2013-14)
Chairman Ethics Committee Delhi Medical Council (2009-15)
Elected Member Delhi Medical Council (2004-2009)
Chairman IMSA Delhi Chapter (March 10- March 13)
Director IMA AKN Sinha Institute (08-09)
Finance Secretary IMA (07-08)
Chairman IMAAMS (06-07)
President Delhi Medical Association (05-06)

CT follow-up of a solitary pulmonary nodule: New recommendations

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Finding a solitary pulmonary nodule on a chest x-ray is common and once detected, it needs to be evaluated promptly and managed because many such nodules can be malignant in nature. A large majority are picked up as asymptomatic lesions.

A solitary pulmonary nodule has been referred to as “coin” lesion, a nomenclature first devised by John Steel way back in the 60s. Some of its major characteristic features include solitary nature, circumscribed margins, diameter double the cross-sectional diameter of an adjacent blood vessel adjacent (1.5 cm), homogeneous density and completely surrounded by lung with no regional lymph node enlargement or satellite lesions.

There is a long list of conditions that are to be considered in the differential diagnosis of a solitary pulmonary nodule. The most common include lung cancer, benign lung tumor, tuberculoma, fungal granuloma, lung abscess and metastasis.

“Wait and Watch”, biopsy of the nodule or immediate thoracotomy are the management options. A thin slice CT (1 mm) is done to accurately describe the characteristics of the nodule and decision is taken on CT findings.

The updated 2017 Fleischner Society Guidelines for management of incidental pulmonary nodules detected on CT published in the July 2017 issue of the journal Radiology have recommended a range of time for follow-up CT scans, rather than a precise time period based on estimations of the individual risk of malignancy.

According to these guidelines, no routine follow-up is required for patients with a solid or subsolid (pure ground glass or part-solid) solitary pulmonary nodule <6 mm in low risk patients. While, no further diagnostic testing is recommended for patients with solid solitary pulmonary nodules that have remained stable over two years, or subsolid SPNs that have been stable over five years on serial CT scans.

A word of caution here. These recommendations do not apply to patients with known cancers at risk for metastases, immunocompromised patients, who are at risk of infections.

As these guidelines are Level 1 evidence, these recommendations should be followed (Evidence from a systematic review or meta-analysis of all relevant RCTs or evidence-based clinical practice guidelines based on systematic reviews of RCTs or three or more RCTs of good quality that have similar results).

Source

1. Keerat Kaur Sibia et al. Chapter 46. How to manage solitary pulmonary nodule (SPN). Medicine Update. 2017. http://www.apiindia.org/pdf/medicine_update_2017/mu_046.pdf.
2. Gaude GS, et al. Evaluation of solitary pulmonary nodule. J Postgrad Med. 1995;41(2):56-9.
3. MacMahon H, et al. Guidelines for management of incidental pulmonary nodules detected on CT Images: From the Fleischner Society 2017. Radiology. 2017 Jul;284(1):228-243.

National Health Policy 2017 approved by Cabinet

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Focus on Preventive and Promotive Health Care & Universal access to good quality health care services
The Health Ministry has formulated the National Health Policy 2017, after a gap of 14 years, to address the current and emerging challenges necessitated by the changing socio-economic and epidemiological landscapes since the last National Health Policy was framed in 2002. The Cabinet has approved the National Health Policy 2017.

The policy informs and prioritizes the role of the Government in shaping health systems in all its dimensions investment in health, organization and financing of healthcare services, prevention of diseases and promotion of good health through cross-sectoral action, access to technologies, developing human resources, encouraging medical pluralism, building the knowledge base required for better health, financial protection strategies and regulation and progressive assurance for health.

The roadmap of this new Policy is predicated on public spending and provisioning of a public healthcare system that is comprehensive, integrated and accessible to all. The Policy seeks to reach everyone in a comprehensive integrated way to move towards wellness. It aims at achieving universal health coverage and delivering quality health care services to all at affordable cost.

The policy is patient centric and empowers the patient for resolution of all their problems. The policy, has at its centre, the person, who seeks and needs medical care.

The policy also looks at reforms in the existing regulatory systems both for easing manufacturing of drugs and devices, to promote Make in India, as also for reforming medical education.

The policy envisages a time-bound Implementation Framework with clear deliverables and milestones to achieve the policy goals.

It also seeks to ensure improved access and affordability of quality secondary and tertiary care services through a combination of public hospitals and strategic purchasing in healthcare deficit areas from accredited non-governmental healthcare providers, achieve significant reduction in out of pocket expenditure due to healthcare costs, reinforce trust in public healthcare system and influence operation and growth of private healthcare industry as well as medical technologies in alignment with public health goals.

The policy emphasizes reorienting and strengthening the Public Health Institutions across the country, so as to provide universal access to free drugs, diagnostics and other essential healthcare.

• The broad principles of the Policy are centered on professionalism, integrity and ethics, equity, affordability, universality, patient-centered and quality of care, accountability and pluralism.

• The main objective of the National Health Policy 2017 is to achieve the highest possible level of good health and well-being, through a preventive and promotive health care orientation in all developmental policies, and to achieve universal access to good quality health care services without anyone having to face financial hardship as a consequence.

• The policy seeks to move away from Sick- Care to Wellness, with thrust on prevention and health promotion.
• It envisages providing larger package of assured comprehensive primary health care through the ‘Health and Wellness Centers’ and denotes important change from very selective to comprehensive primary health care package which includes care for major NCDs, mental health, geriatric health care, palliative care and rehabilitative care services.
• It advocates allocating major proportion (two-thirds or more) of resources to primary care followed by secondary and tertiary care.
• It also aspires to provide at the district level most of the secondary care which is currently provided at a medical college hospital.
• In order to provide access and financial protection at secondary and tertiary care levels, NHP 2017 proposes free drugs, free diagnostics and free emergency care services in all public hospitals.
• National Health Policy 2017 affirms commitment to pre-emptive care (aimed at pre-empting the occurrence of diseases) to achieve optimum levels of child and adolescent health. It envisages school health programmes as a major focus area as also health and hygiene being made a part of the school curriculum.

• The policy looks at stronger partnership with the private sector and advocates a positive and proactive engagement with the private sector for critical gap filling towards achieving national goals. It envisages private sector collaboration for strategic purchasing, capacity building, skill development programmes, awareness generation, developing sustainable networks for community to strengthen mental health services, and disaster management.
The policy also advocates financial and non-incentives for encouraging the private sector participation.
• The policy proposes raising public health expenditure to 2.5% of the GDP in a time bound manner.
• It aims to ensure availability of 2 beds per 1000 population distributed in a manner to enable access within golden hour.
• The Policy advocates a progressively incremental assurance-based approach.
• The policy envisages a three dimensional integration of AYUSH systems encompassing cross referrals, co-location and integrative practices across systems of medicines. This has a huge potential for effective prevention and therapy that is safe and cost-effective.
• Yoga would be introduced much more widely in school and work places as part of promotion of good health.
• It seeks to strengthen the health surveillance system and establish registries for diseases of public health importance, by 2020.
• It also seeks to align other policies for medical devices and equipment with public health goals.
• Under a ‘giving back to society’ initiative, the new Health Policy supports voluntary service in rural and under-served areas on pro-bono basis by recognized healthcare professionals.
• It also advocates extensive deployment of digital tools for improving the efficiency and outcome of the healthcare system and proposes establishment of National Digital Health Authority (NDHA) to regulate, develop and deploy digital health across the continuum of care.
• The Policy has also assigned specific quantitative targets aimed at reduction of disease prevalence/incidence under 3 broad components viz.
a) Health status and programme impact,
b) Health system performance and
c) Health systems strengthening, aligned to the policy objectives.
Some key targets that the policy seeks to achieve are -
• Life Expectancy and healthy life
a. Increase Life Expectancy at birth from 67.5 to 70 by 2025.
b. Establish regular tracking of Disability Adjusted Life Years (DALY) Index as a measure of burden of disease and its trends by major categories by 2022.
c. Reduction of TFR to 2.1 at national and sub-national level by 2025.
• Mortality by Age and/ or cause
a. Reduce Under-Five Mortality to 23 by 2025 and MMR from current levels to 100 by 2020.
b. Reduce infant mortality rate to 28 by 2019.
c. Reduce neo-natal mortality to 16 and still birth rate to “single digit” by 2025.
• Reduction of disease prevalence/ incidence
a. Achieve global target of 2020 which is also termed as target of 90:90:90, for HIV/AIDS i. e,- 90% of all people living with HIV know their HIV status, – 90% of all people diagnosed with HIV infection receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression.
b. Achieve and maintain elimination status of Leprosy by 2018, Kala-Azar by 2017 and Lymphatic Filariasis in endemic pockets by 2017.
c. To achieve and maintain a cure rate of >85% in new sputum positive patients for TB and reduce incidence of new cases, to reach elimination status by 2025.
d. To reduce the prevalence of blindness to 0.25/ 1000 by 2025 and disease burden by one third from current levels.
e. To reduce premature mortality from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases by 25% by 2025.
(Source: Press Information Bureau, 16th March, 2017)

Dr KK Aggarwal
National President IMA and HCFI

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