Copyright © 2007 Royal Australian College of General Practitioners Copyright to Australian Family Physician. Reproduced with permission. Permission to reproduce must be sought from the publisher, The Royal Australian College of General Practitioners.BACKGROUND It has been well established that women who wear a veil for cultural reasons and dark skinned migrants from Africa have an increased prevalence of vitamin D deficiency. Many refugee patients also come from countries where their skin is covered or they are indoors for most of the day. OBJECTIVE This article explores the risk, diagnosis and management of vitamin D deficiency in the Australian refugee population. DISCUSSION In 2004–2005, 75% of the 7000 refugees settling in Australia were from African countries and 20% were from the Middle East. Refugees may be exposed to less sunlight in Australia than in their country of origin because of an indoor lifestyle or an increased latitude. Refugee health centres confirm that vitamin D deficiency is present in 40–80% of refugee patients. Importantly, this is often asymptomatic. General practitioners are encouraged to test for vitamin D deficiency in refugees, especially as part of the initial health assessment.Jill Benson; Sue Skul

Benson, J.

Skull, S.

Adelaide Research & Scholarship

No one would contest that Australia is a country that has plenty of sun. We pay for this with the highest prevalence of skin cancer in the world with two out of three Australians being treated for skin cancer in their lifetime.1 However, public health messages to reduce sun exposure must be balanced with maintaining adequate vitamin D levels,2 especially given Australia’s multicultural and aging population. People who come to Australia as refugees are particularly at risk, with approximately 40–80% prevalence of vitamin D deficiency in refugee health centres across Australia.3 	There	 is	 a	 growing	 body	 of	 Australian	 research	 on	asymptomatic	 vitamin	D	deficiency	 in	 the	elderly,	women	who	wear	 a	 veil	 for	 cultural	 reasons,	 and	migrants	 from	Africa	as	well	 as	 in	healthy	children	who	spend	more	 time	indoors.4,5	One	study	of	 veiled	 and	dark	 skinned	pregnant	women	 in	an	antenatal	 clinic	 in	Melbourne,	Victoria,	 found	that	80%	were	deficient	in	vitamin	D.6	For	reasons	including	fear	of	physical	harm,	many	refugees	have	not	been	outdoors	for	a	long	time	and	so	have	had	very	little	sun	exposure.	This	seems	 to	 be	 particularly	 common	 in	 refugees	 from	East	Africa	who	have	spent	time	in	Egypt	where	the	prevalence	of	vitamin	D	deficiency	has	been	found	to	be	100%.3	 Vitamin	D	 is	 not	 really	 a	 vitamin	but	 a	 neurohormone	that	 is	 important	 for	 calcium	metabolism,	 bone	 growth,	immune	 function,	gene	stability,	muscle	 function	and	brain	development.	It	is	derived	predominantly	through	the	action	of	 ultraviolet	 (UV)	 light	 on	precursors	 in	 the	 skin	but	may	also	be	absorbed	 through	 the	gut	 from	oily	 fish	and	eggs.	It	 is	 then	 further	metabolised	 in	 the	 liver	 and	 kidney.	The	two	forms	of	vitamin	D	are	cholecalciferol	 (vitamin	D3)	and	ergocalciferol	 (vitamin	D2).	Levels	of	 serum	25-OH	vitamin	D3	 are	 used	 as	 the	 indicator	 of	 vitamin	D	 status.7	 Lips	classifies	a	 level	of	25-OH	vitamin	D	above	50	nmol/L	 (20	ng/mL)	 as	normal,	 26–50	nmol/L	 (10–20	ng/mL)	 as	 a	mild	deficiency,	12.5–25	nmol/L	 (5–10	ng/mL)	 as	moderate	 and	<12.5	nmol/L	(<5	ng/mL)	as	a	severe	deficiency.8	 People	with	darker	pigmentation	or	keratinisation	causing	darker	coloured	skin	have	decreased	sunlight	penetrating	to	the	deeper	layer	of	the	skin	where	vitamin	D	is	produced.9–13	Other	populations	at	 risk	of	deficiency	 include:	 those	with	decreased	 sun	 exposure	 because	 of	 lack	 of	 time	 spent	outdoors	 (an	 increasingly	 common	situation	 in	 developed	settings),	 those	 covered	extensively	 by	 clothing,	 as	 seen	most	 profoundly	 in	women	observing	 purdah,	 and	 those	with	gut	absorption	problems	or	who	have	a	diet	deficient	in	 vitamin	D.6,7,14–17	Up	 to	 2.5	 hours	 of	 sun	 exposure	 per	day	may	be	needed	to	supply	enough	vitamin	D	for	people	with	darker	skin.17	Most	commentators	also	agree	 that	 the	current	western	diet	is	inadequate	with	respect	to	vitamin	D	intake,	especially	in	countries	such	as	Australia	where	most	food	is	no	longer	fortified	with	vitamin	D.2,7,16–19	Presentation and diagnosisVitamin	 D	 deficiency	 most	 commonly	 presents	asymptomatically.	 However,	 it	 may	 also	 present	as	 osteoporosis	 or	 its	 complications,	 particularly	 in	BACKGROUNDIt has been well established that women who wear a veil for cultural reasons and dark skinned migrants from Africa have an increased prevalence of vitamin D deficiency. Many refugee patients also come from countries where their skin is covered or they are indoors for most of the day. OBJECTIVEThis article explores the risk, diagnosis and management of vitamin D deficiency in the Australian refugee population.DISCUSSIONIn 2004–2005, 75% of the 7000 refugees settling in Australia were from African countries and 20% were from the Middle East. Refugees may be exposed to less sunlight in Australia than in their country of origin because of an indoor lifestyle or an increased latitude. Refugee health centres confirm that vitamin D deficiency is present in 40–80% of refugee patients. Importantly, this is often asymptomatic. General practitioners are encouraged to test for vitamin D deficiency in refugees, especially as part of the initial health assessment.Hiding from the sun Vitamin D deficiency in refugeesJill Benson MBBS, DCH, FACPsychMed, is Director, Health in Human Diversity Unit, Discipline of General Practice, University of Adelaide, and Medical Officer, Migrant Health Service, Nunkuwarrin Yunti and Parklands Medical Practice, South Australia. jill.benson@adelaide.edu.auSue Skull MBBS, FRACP, FAFPHM, MAppEpid, is Senior Lecturer, Department of Paediatrics, University of Melbourne, and Honorary Senior Lecturer, Menzies School of Health Research, Northern Territory. CLINICAL PRACTICE Refugee health series Reprinted from Australian Family Physician Vol. 36, No. 5, May 2007  355Hiding from the sun – vitamin D deficiency in refugeesCLINICAL PRACTICEpostmenopausal	women	and	 the	elderly,	 and	as	rickets,	 delayed	walking,	 leg	 bowing,	 seizures	or	 failure	 to	 thrive	 in	 children.2,16,17,20	 Infants	 of	women	 who	 are	 vitamin	 D	 deficient	 during	pregnancy	will	usually	also	be	vitamin	D	deficient	and	 hence	 at	 an	 increased	 risk	 of	 both	 short	and	 long	 term	 sequelae.2,6,21	 In	 addition	 to	 the	well	established	dysfunction	of	bone	and	muscle	metabolism,	 vitamin	 D	 has	 been	 linked	with	a	wide	 range	 of	 other	 illnesses.	These	 include	diabetes,	schizophrenia,	prostate	cancer,	multiple	sclerosis	and	autoimmune	disorders.15,22–25	 Less	 well	 known,	 but	 well	 established	in	 the	 literature,	 is	 the	 prevalence	 of	muscle	pain	 and	weakness	 as	 a	 result	 of	 vitamin	 D	deficiency.14,16,17,26,27	 In	Australia,	muscle	 pain	 in	particular	 appears	 to	 be	 a	 problem	 in	 refugee	and	 immigrant	 communities,	 especially	 those	from	Africa	 and	 the	Middle	East.7,14,16,17,19,21	The	diagnosis	of	vitamin	D	deficiency	associated	with	muscle	pain,	however,	is	often	missed.	One	study	reported	an	average	duration	of	59	months	before	the	correct	diagnosis	of	vitamin	D	deficiency	was	made	in	a	group	of	patients	with	musculoskeletal	symptoms,	with	 a	 range	of	 ‘serious	 therapeutic	consequences’	for	some.28	Treatment Up	 to	500	000	 IU	of	 vitamin	D	may	be	needed	to	replenish	stores	in	those	who	are	deficient.2,29	Recent	Australian	 studies	 on	 the	 efficacy	 and	safety	 of	 ‘stoss	 therapy’	 –	 which	 involves	megadoses	of	cholecalciferol	given	intramuscularly	or	 orally	 according	 to	 a	 standard	 protocol	 –	 to	treat	 vitamin	D	deficiency	concluded	 that	 this	 is	safe,	 effective	 and	 cost	 beneficial	 compared	 to	the	 oral	 ergocalciferol	 currently	 available.2,29,30	Treatment	protocols	are	also	available	 for	 infants	and	pregnant	women	who	are	vitamin	D	deficient	using	 higher	 doses	 of	 vitamin	 D.2,21	 Other	studies	have	shown	 that	 complete	 resolution	of	symptoms,	including	muscle	pain	and	weakness,	can	 be	 rapid	when	 adequate	 doses	 are	 given	to	 those	with	moderate	 to	 severe	 deficiency.26	Both	 in	 this	 author’s	 clinical	 experience	 and	 in	case	 reports	 from	 the	 literature,	 patients	 have	‘left	 their	wheelchair’	 after	 only	 3–6	weeks	 of	treatment	of	 their	muscular	weakness	with	high	dose	cholecalciferol	(see	Case study).	However,	in	Australia,	vitamin	D	is	currently	only	available	over-the-counter	as	up	 to	1000	 IU	of	ergocalciferol	or	cholecalciferol	and	is	not	available	at	a	subsidised	rate	through	the	Pharmaceutical	Benefits	Scheme.	Some	hospitals	 and	 compounding	 pharmacies	are	 able	 to	 supply	 higher	 dose	 preparations	of	vitamin	D.ConclusionSome	refugees	are	at	substantially	increased	risk	of	developing	vitamin	D	deficiency	and	 its	short	and	 long	 term	 sequelae.	Often	 the	 deficiency	is	 asymptomatic	 or	 presents	with	 symptoms	such	 as	muscle	 pain,	 therefore	 it	 is	 important	that	general	practitioners	consider	 the	diagnosis	based	on	 risk	 factors	 and	maintain	 a	high	 index	of	suspicion.	In	particular,	serum	vitamin	D	levels	should	 be	part	 of	 the	 initial	 health	 assessment	of	 all	 refugees	 and	 health	 providers	 should	be	 prepared	 to	 provide	 adequate	 long	 term	treatment	and	follow	up	in	patients	with	vitamin	D	deficiency	(Table 1).	Conflict	of	interest:	none	declared.Case studyA 38 year old Middle Eastern refugee with severe postnatal depression spent 12 months in and out of psychiatric hospitals and immigration detention centres. She had been immobile in bed or in a wheelchair for 8 months with severe pain, weakness and allodynia (extreme sensitivity to touch) such that it was difficult to distinguish if her condition was physical or psychological. Her 25-OH vitamin D was 15 nmol/L (60–160), alkaline phosphatase 342 U/L (30–110), and parathyroid hormone 34.3 pmol/L (0.8–5.5). She was treated with Ostelin 1000 (ergocalciferol) twice per day, and because she had pseudofractures, she was also given calcium carbonate 1500 mg (Caltrate, equivalent to 600 mg calcium) twice per day and alendronate 70 mg (Fosamax) weekly. Six months after beginning this regimen she was still wheelchair bound and was taking morphine in the form of MS Contin 30 mg twice per day for her severe leg pain. She had not left the house and was being visited at home by her psychiatrist and physiotherapist. She was given cholecalciferol powder 50 000 IU from the hospital for three doses at two weekly intervals for her inadequately treated vitamin D deficiency. Her improvement was dramatic and 6 weeks later she had stopped her MS Contin and was walking unaided. Twelve months later, she has had another child and has remained well, with a normal vitamin D level of 59 nmol/L, ALP 188 U/L, and PTH 6.1 pmol/L.Table 1. Vitamin D deficiency screening and follow up Measure serum 25-OH vitamin D/ALP/Ca/phosphate25-OH vitamin D >50 nmol/LNo treatment necessary25-OH vitamin D 25–50 nmol/L 100 000 IU–150 000 IU stat vitamin D orally or IMI if available2,29,30OR500–1000 IU/day oral cholecalciferol or ergocalciferol (this dose is also safe for newborns and pregnant women)2,21Repeat vitamin D level/ALP/PTH after 2–3 months and repeat dose as necessary until blood tests are normal 25-OH vitamin D <25 nmol/LTreatment and follow up as above, plus:•  If over 40 years of age or any suspicion of pathological fractures do bone density studies•  If less than 15 years of age or any evidence of rickets or abnormal bone growth do hand/wrist/knee X-rays and refer to a children’s hospital356  Reprinted from Australian Family Physician Vol. 36, No. 5, May 2007Hiding from the sun – vitamin D deficiency in refugees CLINICAL PRACTICEReferences1. Marks R. Two decades of the public health approach to skin cancer control in Australia: why, how and where are we now? Australas J Dermatol 1999;40:1–5.2. Munns C, Zacharin M, Rodda C, et al. Prevention and treatment of infant and childhood vitamin D deficiency in Australia and New Zealand: a consensus statement. Med J Aust 2006;185:268–72.3. Johnson D. Rates of infectious diseases and nutritional deficiencies in newly arrived African refugees presenting to the Migrant Health Service, South Australia in 2005. Adelaide: Central Northern Adelaide Health Service, 2006.4. Jones G, Dwyer T, Hynes KL, Parameswaran V, Greenaway TM. Vitamin D insufficiency in adolescent males in Southern Tasmania: prevalence, determinants, and relationship to bone turnover markers. Osteoporo Int 2005;16:636–41.5. Rockell J, Green T, Skeaff C, et al. Season and ethnicity are determinants of serum 25-hydroxyvitamin D concen-trations in New Zealand children aged 5–14 y. J Nutr 2005;135:2602–8.6. Grover S, Morley R. Vitamin D deficiency in veiled or dark skinned pregnant women. Med J Aust 2001;175:251–2.7. Nowson CA, Margerison C. Vitamin D intake and vitamin D status of Australians. Med J Aust 2002;177:149–52.8. Lips P. Which circulating level of 25-hydroxyvitamin D is appropriate? J Steroid Biochem Mol Biol 2004;89–90:611–4.9. Harris SS, Dawson-Hughes B. Seasonal changes in plasma 25-hydroxyvitamin D concentrations of young American black and white women. Am J Clin Nutr 1998;7:1232–6.10. Norman AW, Sunlight, season, skin pigmentation, vitamin D, and 25-hydroxyvitamin D: integral compo-nents of the vitamin D endocrine system. Am J Clin Nutr 1998;67:1108–10.11. Holick MF, MacLaughlin JA, Doppelt SH. Regulation of cutaneous previtamin D3 photosynthesis in man: skin pigment is not an essential regulator. Science 1981;211:590–3.12. Holick MF, MacLaughlin JA, Clark MB, et al. Photosynthesis of previtamin D3 in human skin and the physiologic consequences. Science 1980;210:203–5.13. Loomis WF. Skin-pigment regulation of vitamin D biosyn-thesis in man. Science 1967;157:501–6.14. Nowson CA, Diamond TH, Pasco JA, Mason RS, Sambrook PN, Eisman JA. Vitamin D in Australia. Issues and recommendations. Aust Fam Physician 2004;33:133–8.15. Calvo MS, Whiting SJ, Barton CN. Vitamin D intake: a global perspective of current status. J Nutr 2005;135:310–6.16. Brock K, Wilkinson M, Cook R, Lee S, Bermingham M. Associations with Vitamin D deficiency in ‘at risk’ Australians. J Steroid Biochem Mol Biol 2004;89–90:581–8.17. Working Group of the Australian and New Zealand Bone and Mineral Society. Vitamin D and adult bone health in Australia and New Zealand: a position statement. Med J Aust 2005;182:281–5.18. Pettifor JM. Nutritional rickets: deficiency of vitamin D, calcium, or both? Am J Clin Nutr 2004;80(6 Suppl):1725S–9S.19. Charlton K. Prevention of vitamin D deficiency in Auckland’s refugee community. Available at www.otago.ac .nz/humannut r i t ion/d ietet ics/Summary%20of%20Findings/KCharlton.pdf [Accessed 7 April 2005].20. Davidson N, Skull S, Chaney G, et al. Comprehensive health assessment for newly arrived refugee children in Australia. J Paediatr Child Health 2004;40:562–8.21. Nozza JM, Rodda CP. Vitamin D deficiency in mothers of CORRESPONDENCE email: afp@racgp.org.auinfants with rickets. Med J Aust 2001;175:253–5.22. Grant W. Sunlight, Nutrition and Health Research Center (SUNARC), 2004. Available at www.sunarc.org/ [Accessed 13 July 2005].23. McGrath J. Does ‘imprinting’ with low prenatal vitamin D contribute to the risk of various adult disorders? Med Hypotheses 2001;56:367–71.24. McGrath J, Saari K, Hakko H, et al. Vitamin D supplementa-tion during the first year of life and risk of schizophrenia: a Finnish birth cohort study. Schizophr Res 2004;67:237–45.25. Mackay-Sim A, Feron F, Eyles D, Burne T, McGrath J. Schizophrenia, vitamin D, and brain development. Int Rev Neurobiol 2004;59:351–80.26. de Torrente de la Jara G, Pecoud A, Favrat B. Musculoskeletal pain in female asylum seekers and hypovitaminosis D3. BMJ 2004;329:156–7.27. Plotnikoff GA Quigley JM. Prevalence of severe hypovitamino-sis D in patients with persistent, nonspecific musculoskeletal pain. Mayo Clin Proc 2003;78:1463–70.28. Nellen JF, Smulders YM, Jos Frissen PH, Slaats EH, Silberbusch J. Hypovitaminosis D in immigrant women: slow to be diagnosed. BMJ 1996;312:570–2.29. Wigg A, Prest C, Slobodian P, Need AG, Cleland LG. A system for improving vitamin D nutrition in residential care. Med J Aust 2006;85:195–8.30. Diamond TH, Ho KW, Rohl PG, Meerkin M. Annual intra-muscular injection of a megadose of cholecalciferol for treatment of vitamin D deficiency: efficacy and safety data. Med J Aust 2005;183:10–2.Reprinted from Australian Family Physician Vol. 36, No. 5, May 2007  357

Hiding from the sun - Vitamin D deficiency in refugees

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Hiding from the sun - Vitamin D deficiency in refugees

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