Vitamin D Measurement the Key to Change

Just another WordPress site

Vitamin D Measurement the Key to Change

this ucsd-tv program is presented by university of california television like what you learn visit our website or follow us on Facebook and Twitter to keep up with the latest programs I’m gonna give you a kind of a broad overview about from my perspective measurement and some of the important healthy benefits of vitamin D and I already told you what my conflict of interests were but not really for this presentation so I thought I’d bring you in Italy a case and that is here’s a seven month old female muscle weakness seizures her calcium was half normal and got a lot of publicity in Boston because it turns out it’s the first lowland gorilla born in captivity to mom at the Franklin Zoo and about to die talking about measurement they actually had a pediatrician come in evaluated the infant decided that maybe had rickets okay 400 units and it did do any good and so concluded the infant had some rare genetic disorder and wished the caretaker good luck well the if it’s complaining a mom dad’s upset he’s knows his daughters in deep trouble have you ever wondered what he was really trying to say that’s what he was trying to say so indeed that’s what they did they got to call me and I got to see the infant and infant has classic widen Fasil plate so talk about a measurement here’s a classic skeletal measurement for rickets and how do you treat aggressively so I gave this infant five thousand units of vitamin D a day and the infant’s feeling great in fact I was the guest of honor for her first birthday but what is the what’s the message here mommy well my growth be stunted if you go to the zoo and saw her for the first couple of years of her life her growth was stunted because of in utero and her first few weeks of life of vitamin D deficiency and you’ll be hearing a lot more about this from Carol Wagner in a little bed but we estimate probably 50% of infants born in the United States today are still being born in a deficient or insufficient state 1889 of Boston rickets was common right is it a problem today you better believe it indeed we see on average a dozen cases a year at our hospital and again talking about measurement I mean you don’t need a 20-buck CD to tell you that infant is vitamin d deficient and indeed the problem is this that you’re going to be hearing about more from that yes docks and been telling patients to give your infant ubud breast milk because the sole source of nutrition as you’ve heard there’s essentially no vitamin D in human breast milk unless you give them an adequate amount of vitamin D that you heard from dr. Halas yesterday and you’ll be hearing from dr Wagner today and so we did a study I went to our neonatologists I said I betcha that you’re pregnant women are vitamin D deficient and her response was instantaneous get out of my office Holly we take care of our patients they take their prenatal vitamin and in fact they’re taking also two classes of milk a day and sure enough when we looked at 40 mother infant pears 70% taken a multivitamin two glasses of milk a day 600 units a day this is what is recommended by the Institute of Medicine for all adults up to the age of 70 including pregnant women and we had published this before they met and we showed 76% of moms 81% of newborns were vitamin D deficient at the time they gave birth but they considered a small study even though it was a prospective study also we went out to show it Lisa Bodnar preeclampsia as you’ve heard a little while ago is associated with vitamin D deficiency now who are they these are three children born by caesarean section you heard yesterday about the flat pelvis of women who are vitamin D deficient in utero in the first few years of life c-section became popular because of rickets because women could not have normal childbirth thing so they were born by c-section by murder Cameron 1889 but you could see how severely gross as gross retardation that they have because they still were vitamin D deficient in Glasgow Scotland and so we did a study because we also know vitamin D is critically important for muscle function which of course is important for the birthing action and when we looked at over 200 women at our hospital having their giving birth we realized that if they were simply vitamin D sufficient 400 percent reduced risk of requiring a c-section so what we usually recommend

to pregnant women 2,000 units of vitamin D a day on top of their prenatal vitamin on top of vitamin D coming from other dietary sources so to they’re getting around three to four thousand units a day just like dr. Halas and dr. Wagner have shown very nicely now this is cliff Rosen and I think you’ve heard his name many times he’s actually a close personal friend and he was on the IOM committee and he asked me to participate in that NIH conference and he wanted to know what process did The Endocrine Society use to make his recommendations which you heard yesterday were a lot different than what the IOM recommended and so I chaired that committee I was fortunate enough to be asked to chair it and every one of these members are experts in the field of vitamin D and it turns out that the objective was clear to evaluate treat and prevent vitamin D deficiency with emphasis on care of patients who are at risk the Institute of Medicine came out of course in 2010 and all of these members are certainly well known in the nutrition field and in bone metabolism but they don’t really have a focused expertise in the field of vitamin D and the IOM was not intended to direct physician for patient care it was up to professional associations to make these guidelines and they used a population model not a medical model for their recommendations so it’s not a surprise that we would have different recommendations the IOM and realized that the RDA from the adequate intake should be three times what was originally thought so they now recommend it for most children and adults not 200 a day but 600 units a day and they also recognize vitamin D is not as toxic recommending up to 4,000 units a day for older children and adults but did they get it right that’s the question and so IOM says that you could get it from your diet but this is the problem it’s rare in foods as you heard about yesterday right yes there’s 100 units and some dairy products as well as in fortified orange juice but basically no one in the United States can get even the IOM recommendation from dietary sources you’d have to drink six glasses of milk a day in order to be successful and when we did a study from the National Health Survey back in 2002 we showed that for children and adults where they were in the United States they could not get enough vitamin D from their diet to satisfy the new IOM recommendations so you can’t get it from your diet so IOM sunlight plays little role in vitamin D status well sunlight is the major source I think everybody agrees in fact here in Denmark even no matter what your ethnicity the peak blood levels are at the end of the summer the nadir is always at the end of the winter so we did a study and you’ve heard about this over and over again where we took healthy adults and put them in our tanning bed and gave them an oral dose of vitamin D separately to ask the question if you get one minimal irredeemable dose in a bathing suit how does that relate to how much oral vitamin D you’re taking and this was the data so here’s a ten thousand unit dose here’s a twenty five thousand unit dose that would you could see very nicely as dr. Heaney pointed out is that when you take vitamin D orally it rapidly goes up and comes right back down but when you’re making it in your skin it slowly increases because pre D is converting to D and then the D is slowly exiting the epidermis of bloodless tissue into the circulation so you’re maintaining a blood levels of vitamin D for a prolonged period of time and that’s why we can conclude that the area under the curve is in fact equivalent to about 20,000 units of vitamin D and your being able to maintain your vitamin D level much better than taking it as a supplement at least twofold so one exposure equivalent to about ten to 20,000 units of vitamin D and we showed over and over again if you give a half an MD three times a week to young and middle-aged Caucasian volunteers one hundred and fifty five percent increase that then begins to Plateau after about four to six weeks also burns a year right being older right and we know aging markedly decreases your capacity but we took some elders their blood level on average 28 because they were taking a multivitamin and when we put them in our tanning bed a half an MD three times a week we could show very nicely 98 percent increase plateaued at around fifty five nanograms per ml right we also looked at both typed one two three four and five and we could show very nicely type two up with sixty nanograms per ml we could achieve a thousand units a day is what you would get right here that you would raise it from about 15 to 18 to about twenty-eight nanograms per ml and so one-half meed three times a week in elderly Caucasians increased by 98% now people keep asking so when do you want to measure 25 with Roxie D because people just say just measure it well

what if you measured in the summer and a winner is it going to make any difference and quest Diagnostics which is one of the major reference labs in the United States and I’ve consulted for them for over 35 years helped him develop both the 125 D and 25 drug CDSA but I have no conflict because I don’t benefit from them doing those assays we looked at 3.3 million sample data and what did we find what we found was that you could have about 3.3 million samples typically in the United States right is that men and women and and you could see here that males are a little bit lower than females is that 19 on average in the wintertime 27 is the peak in the summer time but look at this PTH in the north much bigger variation again because in the south you’re making vitamin D for a longer period of time than you are in the north compared to the south also 25 hydroxy deep peaks at the summer time here over a 3-year period of time PTH levels peak in the winter time there’s almost a mirror image and in fact if you want to look at the PTH levels when they’re at their nadir it’s about 4 weeks later than when the 25 doxy vitamin D is up so if you’re going to get a 25 hydroxy vitamin D you really want to get it at its nadir because if it is 30 in the summertime you’re likely to be at around 21 or 25 and wintertime so this is one of the questions that nobody seems to ever ask probably a hunter-gatherer for fallers every day making vitamin D constantly probably may a steady level of PTH but we now know in the United States that essentially everyone has a suction PTH levels and no one knows what the potential impact is we know that PTH actually has effects on your immune system and it has of course effects on calcium and bone metabolism as well as a whole variety of other physiologic processes tanning 10-million tanners in the United States it’s estimated about 1 million tan in the United States every day so we asked a question Tanner’s in Boston what are their blood levels at the wintertime and we know from the National Health Survey data that whether you’re white Caucasian or white or a mexican-american or black you have higher bone density for a higher 2500 CD so we wondered with Tanner’s have higher levels of 25lakhs CD and have higher bone density so we did an analysis of their bone density and look at this 9 Tanner’s and this wintertime just about right about 18 anagrams for ML Tanner’s usually going to a tanning bed maybe once a week average 48 nanograms per ml when we looked at their bone density we showed very nicely that they had a statistically significant increase in their femoral neck bone density just based on their higher blood level of 25 hydroxy vitamin D so how do you know your vitamin D status well we know of course you want to measure 25 hydroxy D and you never want to order the active form because it tells you nothing about vitamin D status it’s normal or elevated and a vitamin D deficient state why it circulates a 1000 times less concentration as you heard from dr Heaney the half-life is very short only 2 to 4 hours and also PTH as it’s going up it’s telling the kidneys to activate more vitamin D but the Institute of Medicine what they cared about was this study which is 675 German adults that died in an accident they got their bones and their blood and they looked at the biopsies and sure enough here’s normal trabecular bone here you see hardly any black areas this is low bone density poor connectivity osteoporosis and you see this pink stuff here this is classic men unmanned realized osteoid classic for vitamin D deficiency so even though reasonable amount of trabeculae it’s mainly vitamin D deficient so the Institute of Medicine said well hmm maybe we could relate 25 drops of vitamin D levels to the degree of osteomalacia and give us an estimate of how important 25 hydroxy D is regarding bone health the authors had said up to 25 percent up to 36 percent had some evidence of vitamin D deficiency these are otherwise healthy adult Germans ages 20 to 70 to 90 years of age so the authors concluded to guarantee sufficiency you need to be above 30 but the instruments has done it we’d looked at your data much more carefully and we concluded that you didn’t have to worry about this if you were above 20 and this is what they said they took this group here between 21 and 29 over this group here and they concluded is less than 1% so therefore you don’t need to be above 20 but they

made a seventh grade high school error right mathematical error they should have taken this group here over this group here if you do that 24 percent of otherwise healthy adult Germans had evidence of vitamin D deficiency bone disease and that’s what they should have concluded and that’s why the author suggested and the endocrine society recommended at a minimum for bone health you should be greater than 30 nanograms per ml PTH levels we talked about briefly right there’s a lot of scatter so people said well if there’s so much scatter how could you really make any sense out of this but studies have shown that PTH levels really begin to plateau at around 30 nanograms per ml we did a study throughout the entire United States of postmenopausal women and these are within standard error of the mean levels right so these are very tight levels of 1,500 women again around 30 nano grams per ml with plateaus and we went on to show if you’re a 21 you have a three times higher risk of having secondary hyperparathyroidism than if you’re above 30 so all of this information that was gathered the endocrine practice skyline’s committee recommended at a minimum for bone health your blood level should be above thirty-nine of grams per ml but because of the variability in the assays that are out there to guarantee sufficiency we thought a good range was minimum forty up to sixty is really quite reasonable but a hundred is certainly perfectly safe indeed that’s you’ve heard this over and over again is that Maasai warriors and we’ve done a study now in African children found exactly the same thing on average their levels are about forty to fifty nanograms per ml is vitamin D deficient a health issue you’ve already heard this very nicely from dr. Gorman right but here is a study that I worked with with Clifford Rosen up in Bangor Maine young white girls taken a Flintstone vitamin two glasses of milk a day six hundred units a day forty eight percent were vitamin D deficient right here Kathryn Gordon showed in Boston forty-two percent of teenagers vitamin D deficient and even the CDC says 32 percent of all children and adults vitamin D deficient right they even published their data showing very nicely at every age group that vitamin D deficiency was common indeed if you pick 30 as the cutoff from the National Health Survey fifty percent of our children are vitamin D deficient one to five years of age 70 percent six to eleven years of age globally we now recognize basically 40 percent of the population is deficient and sixty percent is insufficient whether you’re in Australia or Canada or Korea basically you see the same thing and it’s all because you basically can’t get vitamin D from significant amounts from your diet and as a result everybody has vitamin D deficiency how do you treat and prevent it well what we do is when you treat vitamin D deficiency is 50,000 units of d2 or d3 and we can talk about this during our break in terms of d2 issues eight weeks so that’s basically sixty five hundred years of vitamin D a day and then to prevent recurrence I put them on to 50,000 units every two weeks and I do it for a couple reasons one is patients that come to me want a prescription they’re more likely to follow the doctor’s advice rather than telling him to go and buy a supplement they may remember that for a couple of months but then I can remember that year after year so I agree with Bruce that is probably better to be taking it on a daily basis but it’s certainly better to at least have something rather than nothing and that’s why most of my patients are on this program about 3,000 units a day we’ll talk a little bit about toxicity in a minute but here Einstein just like everyone else thinks vitamin D is toxic and maybe it’s gonna build up in your body fat over time so yeah maybe a couple of weeks or months or even a year you’re not gonna see toxicity but what about year after year so we published a paper in our kinds of internal medicine and o.9 after six years on 3,000 units a day the blood levels plateau and are maintained at around forty to sixty nanograms 4ml also recommendation for children is a six hundred to a thousand units for adults Medical Society said fifteen hundred to two thousand if you ever wonder what he was trying to say that’s a real problem right and so here Barney’s even amazed to hear this right and reason is that that vitamin D is fat soluble and it gets corporate in your body fat and as a result the higher your BMI lower is your vitamin D status and we and others have shown very nicely that there’s lots of vitamin D in your fat if you take obese people give them an oral dose or put them on a tanning bed compared to an obese person normal weight versus that obese person about a 55% reduction just

in the blood level of vitamin D and this study out of pure north shows very nicely if you look at say the 14 anagram cutoff for underweight overweight and obese that here 2,000 units a day we’ll get to 40 if your normal weight you need at least 6,000 if you’re obese and so the conclusion of the study of over several thousand people 2.5 to 3 times more vitamin D if you have a BMI of greater than 30 to satisfy your vitamin D requirement and it’s no question that is there we and others have shown very nicely that vitamin D is certainly in body fat so obese people need two to three times more now I’m sure what he’s thinking about here but I tell you what do you know why vitamin D is so regulated and so considered to be so toxic you had heard already from John canal yesterday that yes patients with rheumatoid arthritis were treated with hundreds of thousands of units of vitamin D they became toxic and because now this huge amount was in the body fat and being released they remain toxic for years but it was this observation that really got everybody’s attention before 1950 even in England custard was fortified with vitamin D and in Chicago hot dogs fortified with vitamin D everything in the world was being fortified with vitamin D because it was thought to be kind of miracle nutrient and then in the 1950s all of a sudden there appeared infants with high blood calcium altered faces mental retardation heart problems and so now those hysteria and so now the experts wanted to find out what was the reason so the legislative body brought in the experts and they looked at the literature they had not a clue what this could be and so they decided that if you give pregnant rats intoxicating doses of vitamin D guess what they have high blood calcium and their pups funny altered faces heart problems they couldn’t figure out if they were mentally and it turns out that the experts concluded that the outbreak was due to over fortification of milk with vitamin D they had no evidence for this but they assumed this based on that rodent data so you’re banned all vitamin D fortification and dairy and all products in England you cannot put vitamin D in a skin cream it is against the law still today it’s likely though that what they had was Williams syndrome it’s a rare genetic disorder curiously they have elfin faces and they have heart problems they have mild retardation and guess what they have a hyper sensitivity to vitamin D causing hypercalcemia we know that this is the likely cause but no one in Europe is still taking this seriously and thinking about changing the health recommendations in most of European countries so vitamin D fortification continues to be a major issue in many countries around the world so what about the intoxication it turns out like you’ve heard before up to 10,000 units is perfectly safe and many have shown this but this study coming out of pure North I think says it very nicely and that is here 15,000 units a day 20,000 units a day if you think 25 bucks CD levels on average of about 60 right with the upper limit certainly being a hundred you need to take huge amounts of vitamin D to get above a hundred so that kind conversation that we had yesterday about being a hundred to two hundred is really very difficult to get there and these data really show very nicely what happens when you increase your vitamin D intake and that no way will you become toxic but this is the other issue right you’ve heard about the mortality issue in a very nice study from Cedric right and here our study out of Germany showed again 25 percent reduction in all cause of mortality with the higher blood levels of 25 hydroxy D and you already saw this from Cedric Garland’s work but the IOM said wait a second we agree if your vitamin D deficient that you are at increased risk for mortality but there’s this J curve when you get around 13 anagrams for ml we say that you now have an increased risk well we went back and looked at some of this data and this is one of the papers that they actually quoted as part of that data set and guess what the authors suggested actually lower risk for mortality up to 49 nanograms per ml and only greater in 50 nanograms per ml for mortality in women right that’s a lot different that what the IOM concluded but this is where you what you need to ask who is having a blood level three four years ago of greater than 50 there has to be a reason right there not simply all of a sudden having a light turned on saying they’re taking lots of vitamin D and they’re now capturing this group most likely they’re being treated for vitamin D deficiency and maybe taking mega doses of other stuff how can you figure that out turns

out go back to the 3.3 million samples from quest because we could show very nicely that if you can detect vitamin d2 in the circulation it’s likely coming from being treated for vitamin D deficiency and sure enough fifty-nine percent of the total 25 hydroxy D levels greater than 50 had detectable levels of 25 hydroxy d2 suggesting that this so-called j-curve may actually be due to the fact that they were D deficient in the first place so those would a 24 CT of greater than 50 most had detectable levels thus being treated for vitamin D deficiency IOM bottom line they’re recommending 400 units for infants 600 units for children and 600 units for adults and to your 70 and then they give you a little boost of 800 right now this paper just came out again from the pure north group and they said hey guys at the LM if you’re saying that this is an RDA that means it has to be ninety seven point five percent upper limit and lower limit and they said that this is where you really need to be to get 30 nanograms per ml by the IOM at 2,000 units a day but then pure North group said no no no if you actually take the ninety seven point five percent confidence limit you have a group down here you would need six to eight thousand 6,000 to 8,000 units a day to be able to reach that level which is now we all recognize is right on target bottom line there’s no downside to increasing your vitamin D intake and we don’t need to be a genius to know this right indeed this is not a hypothesis the issue is gonna be this though because it’s extremely expensive and time-consuming to get a blood level drawn and so both the Institute of Medicine and the intricate Society and most other societies don’t recommend screening simply increase your vitamin D intake it’s a much more effective and cheaper way but if you’re obese malabsorption if you have sarcoid no question you should be followed recommendation from the endocrine society four hundred to a thousand for neonates six hundred to a thousand for children teenagers probably need at least 1500 to 2,000 like adults and certainly we recommend adults at least 1,500 to 2,000 and recognized that if you’re obese two to three times more and upper limit easily for neonates 2,000 units a day based on opponens data basically one to 18 years of age easily 4,000 and for adults easily 10,000 units a day and if you’re over 70 the same thing long story short we show a thousand units a day to healthy students at our medical school not one person basically was sufficient a thousand units a day will not make you sufficient indeed I typically recommend it’s just easy for adults to take 2,000 units a day and I tell my friends that get their children to take a thousand units a day vitamin D is really good for your health and thank you for your kind attention Karol Bagh Ali asked me to do another short presentation on measurement after she had put me on the website in a way she made me an offer I could not refuse yes so this time I think it’s essential to look again at the disclosures since two of these companies are manufacturers of tanning beds and some of the measurements I did are only able with funding from the industry because taking the vitamin D levels of 80 subjects six times costs quite a lot of money so but this is the only way to learn about the particular properties of these units and in order to improve them so why is it important to measure there are a lot of words around for example full spectrum have you ever stumbled across full-spectrum lamps who has full spectrum lamps in use and in the office for example so some of you for that reason I want to start with an example which focuses on sunlight on the

spectral measurement of sunlight here we have a spectral distribution which is kind of typical for direct sunlight we see the color temperature the CCT stands for correlated color temperature which means we have glowing bodies which give off a kind of thermal spectrum light from heat and this is the case in the Sun so with sunlight we have the the correlated color temperature of five thousand two hundred or five thousand five hundred Kelvin equals the real physical temperature of this glowing body and by the way the color rendering index of sunlight is 99 it’s an index it’s not percent but it’s a value of 99 from 100 so yesterday we saw this spectral distribution curve of sunlight and when we put these two curves together we find it’s somehow identical or it’s it’s at least similar and just to give you an idea what is possible today in terms of spectrum analysis or measuring the quality of sunlight I want to show you this slide and do you have any idea what this slide could represent it’s a very high-resolution spectral analysis of sunlight and who has an idea what these so these are 50 lines you have to put them all together to get the full spectrum in the visible part of the electromagnetic radiation which is given off from our Sun and who has an idea these black lines we find dissecting the this spectrum there are there are some some frequencies or some wavelengths absent so these black lines they are called Fraunhofer lines according to the to the optician the famous German optician Yosef von Fraunhofer and when I said yesterday that we will never be able to mimic or to produce sunlight in its real quality art if in artificial manner then these Fraunhofer lines are kind of explanation for this claim because this is really it’s like a barcode it’s very complicated and it carries a very specific information and what we can even tell from astronomical or Astrophysical solar physics measurements that these round off aligns they shift in the spectrum with the breathing rhythm of the Sun this is about five minutes and within these five minutes the these colorful lines move in their position in their relative position so this information can never be produced artificially just one suggestion when you think about what dr Holick told us yesterday that sunlight was known in the 19th 20s and 30s to cure more than 165 165 different diseases and we had kind of hyper activities and hype or activities and what these doctors from from 80 years ago had to learn that sunlight balances the situation in the body and when I think about the tenth of a millimeter and I think about the bloodstream under the surface of the skin which is reached by this kind of radiation and by the way we have to explain another thing these Fraunhofer lines they come from all the elements which are in the outermost layer in the Sun in the solar atmosphere so in a way we have all these chemical elements in our body in our bloodstream and sunlight

produces a kind of photonic pressure in these zones where we have color here and in the zones where we have the black lines there is nothing no pressure no photonic pressure maybe sunlight is even able to regulate the distribution extracellular in intracellular distribution of chemical elements it’s in hypothesis it’s not proven but when you look at this you might get a better understanding about the special constitution of sunlight and we can tell this today and maybe explain things our ancestors discovered in a phenomenological way coming back to this more simple measurement this is sunlight measured directly we about anything in between this is sunlight behind modern window panes in order to is do you see any difference between this and that here in the near in the red and in the near infrared part of the spectrum we have some filtering which comes from the window technology because when when the architects don’t use this kind of window technology the building will heat up much more so they need more energy for cooling purposes so everything in the lighting industry and daylight technology seems to be driven by an energy efficiency ideas and now I will come to this particular spectrum this is a so-called full spectrum fluorescent lamp spectrum we can see kind of similar correlated color temperature but it comes from a cold light source and you can say you can see in the spectral distribution that this really does not deserve the name full spectrum it’s too much disrupted and there are wavelengths missing especially in the longer wavelength range where we already talked about the benefits of near-infrared yesterday this near-infrared is lacking completely more or less completely in fluorescent lamps and it’s just a quantitative difference between a standard compact fluorescent lamp and this so-called full spectrum fluorescent lamp but what they would tell you it is a sun-like spectrum why because the correlated color temperature is similar to the real temperature of our glowing star and sometimes the logic is even if we have more if we have a higher cut color temperature then we are even better than the Sun but this you might believe this as long as you do not measure the spectra we are talking about and this by the way is a typical spectrum of a white fluorescent LED light emitting diode which is featured at the moment and which can be found for example in our hotel who is staying at this at the Estancia hotel have you registered or realized that this lighting there is some LED lighting with high color temperatures it’s not very comfortable and cozy in the afternoon or in the evening and this is the spectrum you find in this particular kind of technology and I would dare to say this is not better than the Sun so what I wanted to show you in this section of my short presentation when you start measuring you go beyond the words full spectrum what a pretty word but as long as you didn’t measure you will never understand what lies behind coming now to the measurement of blood levels of vitamin D the measurements enable us to make research for example to improve in order to improve the technology in

artificial insulation or for producing artificial sunlight artificial UV and probably fuller spectrum light and for me as a physician I see patients and when I draw blood from a patient of mine especially if it’s a chronic patient then I take the vitamin D in order to monitor how the patients react if I administer vitamin D orally I really want to know but I’m I have I run a private practice so I don’t have to look at the financial aspects and if you give recommendations to the public we are talking about millions and millions of people and in this context it’s not so easy to take to make measurements of the blood levels on a regular basis for example twice a year but I think this is for me as a as a physician it’s just part of being precise that I control what the intervention will result in in my individual cases so here this is a word I like very much it’s the civilization or an Helio TSA’s it’s the lack of sunlight caused by civilization and this is kind of optimal prophylaxis of the civilizational unhit OSIS but who is able to practice this kind of prevention would you please raise your hands high noon every day because regular exposure is better than intermediate exposure intermittent exposure so who is able to practice it in a proper way 5% in the audience maybe this might be a problem we saw this slide yesterday and what this chart explains is a lot about the technique of failure therapy and what you can see here time measured in minutes is a crucial factor to perform proper helio therapy in in the right way because this patient needs a blanket and this blanket has to be moved from the feet up to the upper parts of the body in a timeline of 5 minutes every 5 minutes you have to shift or pull up the blanket a little bit more so for proper Hillyer therapy the most important measurement under the Sun is to measure the time and we heard that avoiding sunburn avoiding over dosage is essential and when we look at different effects of sunlight it acts upon the body but it is well acts upon mind and soul so the mind starts wandering you feel cozy you feel comfortable you start kind of dreaming you go into a theta rhythm in your brain and suddenly you go into the Delta rhythm of your brain what does this mean you fall asleep so many of the sunburn cases come from falling asleep in the Sun so don’t fall asleep a smartphone is not resistant to sunlight it will heat up I experienced myself that my smartphone switched off before I before it could alert me that the time is over thankfully I have an inner clock I can rely upon as long as I didn’t travel to the u.s. in the six weeks before but now it’s not a problem because we have winter in Germany no risk my circadian rhythms at least are not travel proof so I come to the last part of my measurement presentation talking

about technologies which automatically provide the right dose and stop when the time is over here is a publication of paper on the effect of small sub everything mitosis in a medical ultrasound at but medical cabinets are not limited in output so it’s clear that they can help to build up vitamin D but they are not available to the public not freely available these are not over-the-counter units so here is a paper published in 2012 so this was before we had the regulation in the European Union which limits the fluence the energy density the energy output of the tanning beds to 0.3 watts per square meter so the question has to be raised do these limitations in output performance have a negative impact on the mmm potential to build up vitamin D here we see this paper which which has been examining a commercial tanning bed which was not restricted in output that much then we compared to those we have to use today we have an energy density of 375 to 520 25 Joule per square meter and this was a single exposition exposure and the mean increase was about 1.8 nanograms per milliliter which is not much but you at least can prevent the vitamin D from decreasing and here I would like to present some numbers from trial I performed last year the data you saw from dr. Holick before may be difficult to achieve nowadays because as I said nowadays we have different conditions we have much lower output of the units but what we can see here in the interventional group the vitamin D level rose from about 16 nanograms per milliliter to nearly 26 after 16 treatments here you see the changes in percent compared to baseline and here we asked our subjects do they tan regularly sometimes only rarely or never and what you can tell from from this chart is that the never tanners they had value around twelve point five nanograms per milliliter and nearly double double the amount was found in the regular tannin group so we applied a total dose which lay in between the 375 and 525 we applied independent from the skin type here for four treatments 462 per square meter and to make I learned from you Paul from your presentation yesterday I just changed the logic of sorting these data you can say that those with the lowest levels at baseline these are the the blue blocks they had the highest benefit in terms of increase in vitamin D this was after for treatments with around 100 jewel per square meter each but what is interesting to me when we look at those with a higher level then we find significant decreases from baseline to the values after four treatments and I asked dr. Holick this morning if he has any explanation and you hadn’t I have not but this slide with these examples

is good for highlighting again how important measurement in fact is because there are cases in which we are unable to predict the individual reaction so it’s very important to monitor what you do the next step study by the way I have planned measures of the effect of treatments with so called hybrid tanning beds it’s one step closer to a kind of full-spectrum artificial tanning we reduce the dose of ultraviolet radiation by a factor of two again but we add long wave radiation in the orange red part of the spectrum and we know from the reports from users that it it’s much better it’s much more comfortable and smoother and easier for the skin and at least the tanning performance is comparable to the standard UV beds and now we will apply our idea our principle of measurement again in order to find out if there is also an effect on the vitamin D production if we treat not only with the short wavelengths but with the long wavelength as well so here is an Internet address where you can find I think four or five audio-visual presentations of mine which are in English so if you are interested to go into other topics maybe you can visit this page and have a look for free so thank you very much for your kind attention