New Vitamin D Guidelines by Endocrine Society- what they imply for Indians

Summary

In this insightful discussion, Dr. Amarish Mitl, Chairman and Head of Endocrinology and Diabetes at Max Health Care, addresses the recent guidelines released by the Endocrine Society on vitamin D's role in disease prevention. The guidelines, a significant departure from those of 2011, emphasize the overuse of vitamin D testing and advocate for supplementation without testing in specific groups, such as children up to 18 and the elderly above 75. Dr. Mitl highlights the importance of these recommendations in the Indian context, where vitamin D deficiency is prevalent despite abundant sunshine, and discusses the significance of supplementation in pre-diabetics and pregnant women.

Takeaways

• 😀 The new guidelines by the Endocrine Society focus on the prevention of disease rather than treatment, emphasizing the role of vitamin D in improving clinical outcomes.
• 🔍 Testing for vitamin D levels is deemed over-utilized and not strongly correlated with disease outcomes, suggesting that universal screening is not necessary.
• 👶 For children up to the age of 18, the guidelines recommend daily supplementation with a low dose of vitamin D without the need for testing, addressing the common deficiency in this age group.
• 👴 Individuals over 75 are advised to take a low dose of vitamin D daily as well, to reduce overall mortality and the risk of osteoporosis and fractures.
• ☀ Despite abundant sunshine, India has some of the lowest vitamin D levels globally due to cultural practices and high atmospheric pollution blocking UV rays.
• 🤰 The guidelines also advocate for vitamin D supplementation during pregnancy to improve outcomes, which is significant for India.
• 📉 The reference range for vitamin D is debated, with the guidelines suggesting that levels above 20 nanograms per mL are considered normal for bones and general health.
• 🚫 The guidelines discourage setting target levels of 30-50 nanograms per mL, as it may not be necessary and could lead to overtreatment.
• 💊 For pre-diabetics, vitamin D supplementation can slow the progression to diabetes, which is particularly relevant for India's large pre-diabetic population.
• 🥛 Fortification of milk and edible oil with vitamin D is recommended, as it can help address the widespread deficiency in countries like India.
• 👉 For the 50 to 75 age group, which is not excluded in the US guidelines, there is a suggestion to consider this age group for vitamin D supplementation in the Indian context due to specific health concerns.

Q & A

What are the new guidelines released by the Endocrine Society regarding vitamin D?

The new guidelines focus on the role of vitamin D for the prevention of diseases rather than treatment. They emphasize that improving vitamin D levels can lead to better clinical outcomes such as reduced risks of diabetes, heart disease, cancer, mortality, fractures, and osteoporosis.

Why were the guidelines updated in 2023 compared to the previous 2011 version?

The field of vitamin D research is dynamic, and since the last guidelines in 2011, there has been a significant amount of new data on the outcomes of vitamin D levels on various diseases, prompting the update.

According to the new guidelines, is testing for vitamin D levels recommended for the general population?

No, the guidelines suggest that testing for vitamin D levels is over-utilized and not very useful for the general population due to weak correlation between testing and disease outcomes.

What are the key takeaways from the guidelines regarding vitamin D testing and supplementation?

The key takeaways are that universal screening for vitamin D is not recommended, and for certain groups like children up to the age of 18 and elderly above 75, low-dose vitamin D supplementation is advised without the need for testing.

Why is vitamin D supplementation important for children up to the age of 18 according to the guidelines?

Vitamin D is crucial for bone development, and studies have shown that many school children are significantly deficient in vitamin D. Supplementation can help correct this deficiency and support bone health.

What is the recommended daily dosage of vitamin D for children according to the Indian context?

In the Indian context, the recommended daily dosage of vitamin D for children is around 1,000 units, which has been found to be effective in correcting deficiency.

Why might vitamin D levels be low in India despite abundant sunshine?

Two main reasons are that Indians generally avoid sun exposure due to heat and concerns about skin darkening, and atmospheric pollution in cities like Delhi prevents UV rays from reaching the skin effectively.

What does the guidelines say about vitamin D supplementation during pregnancy?

The guidelines now advocate for supplementing vitamin D throughout pregnancy to improve outcomes, which is a significant change from previous recommendations.

How do the guidelines view the use of vitamin D supplementation for pre-diabetics?

The guidelines suggest that supplementing pre-diabetics with vitamin D can slow down the conversion to diabetes, which is particularly relevant for countries like India with a high burden of pre-diabetes.

What is the position of the guidelines on the reference range for vitamin D levels?

The guidelines do not focus on the reference range debate, but it is generally accepted that levels above 20 nanograms per mL are considered normal or good for bones and outcomes, while levels below 10 or 12 nanograms per mL are considered deficient.

What is the potential risk of vitamin D toxicity from supplementation, and how can it be avoided?

The risk of vitamin D toxicity is very low with the recommended dosages of 1,000 to 2,000 units daily, as there is a large safety window. Toxicity is only a concern with extreme overuse or errors in supplementation.

Which age group between 50 to 75 years is considered important for vitamin D supplementation in the Indian context, and why?

The 50 to 75 age group is considered important in India due to the prevalence of bone disease in this demographic, the life expectancy, and the low baseline vitamin D levels, which differ from the US guidelines that exclude this group.

Outlines

00:00

📜 Release of New Vitamin D Guidelines

The American Endocrine Society has released new guidelines focusing on the role of vitamin D in disease prevention rather than treatment. The guidelines, a significant update from the 2011 version, emphasize the importance of clinical outcomes related to vitamin D levels, such as impacts on diabetes, heart disease, cancer, mortality, fractures, and osteoporosis. Dr. Amar Mishra discusses the shift from treating patients to preventing disease in a population-wide context and the over-utilization of vitamin D level testing, which the guidelines argue is not strongly correlated with disease outcomes.

05:01

👶 Vitamin D Supplementation for Children and Elderly

The guidelines recommend universal supplementation of vitamin D for children up to the age of 18 and for individuals above 75, without the need for testing. This is a significant change, as previous guidelines focused on very young children. The importance of vitamin D in bone formation during childhood and its role in reducing overall mortality in the elderly is highlighted. The summary points out the common deficiency of vitamin D among school children in India and the benefits of supplementation, even without testing, to improve bone health and potentially reduce the risk of developing diabetes.

10:03

🌞 Vitamin D Deficiency in Sun-Rich Regions

Despite abundant sunshine, regions like India and the Middle East suffer from some of the lowest vitamin D levels globally. This paradox is attributed to cultural avoidance of sun exposure and high levels of atmospheric pollution that block UV rays. The guidelines advocate for supplementation, especially for vulnerable groups, and the importance of not relying solely on sunlight for vitamin D synthesis. The discussion also touches on the significance of vitamin D supplementation during pregnancy to improve health outcomes.

15:03

🍼 Fortification and Supplementation Strategies

The guidelines suggest that widespread fortification of foods, such as milk, is a crucial strategy for improving vitamin D levels in populations with low baseline levels, like India. While India has initiated milk fortification, it is not yet mandatory or at levels that significantly impact vitamin D intake. The conversation highlights the need for increased efforts in fortification and the potential benefits for various age groups, including pre-diabetics, where supplementation may slow the progression to diabetes.

20:04

🧪 Vitamin D Testing and Supplementation in Specific Groups

While the guidelines discourage universal vitamin D testing, they identify specific groups that may benefit from supplementation and, in some cases, targeted testing. These include individuals with bone or muscle issues, unexplained fatigue, absorption problems, or those on certain medications. The summary emphasizes the importance of a case-based approach rather than population-wide screening and the safety of supplementation within recommended doses.

Keywords

💡Vitamin D

Vitamin D is a fat-soluble vitamin that plays a crucial role in calcium homeostasis and bone health. In the video, it is discussed as a focus of new guidelines for disease prevention rather than treatment. The script mentions the importance of vitamin D for various age groups, including children and the elderly, and its supplementation to prevent deficiencies that could lead to diseases like diabetes, heart disease, and osteoporosis.

💡Guidelines

The term 'guidelines' refers to the recommendations released by the Endocrine Society for the role of vitamin D in disease prevention. These guidelines are significant as they propose major changes from the previous ones, primarily focusing on population health outcomes rather than individual patient treatment. The script emphasizes the shift from treatment to prevention and the implications for clinical practice.

💡Endocrinology

Endocrinology is a branch of medicine that deals with the endocrine system, which includes the hormones and glands that produce them. Dr. Amarish Mithal, the guest in the video, is an endocrinologist, and the discussion revolves around the endocrine system's role in vitamin D regulation and its impact on various diseases.

💡Diabetes

Diabetes is a chronic condition characterized by high blood sugar levels. The script discusses how vitamin D supplementation can impact the development of diabetes, particularly in pre-diabetic individuals. It highlights the potential for vitamin D to slow the progression to diabetes, which is relevant for India's large pre-diabetic population.

💡Mortality

Mortality refers to the state of being subject to death. In the context of the video, it is mentioned that improving vitamin D levels can lead to better health outcomes, including reduced overall mortality rates, especially in the elderly population.

💡Osteoporosis

Osteoporosis is a condition characterized by weakened bones that are prone to fracture. The script mentions osteoporosis in relation to the importance of vitamin D for bone health, particularly in the elderly, where supplementation can reduce the risk of fractures.

💡Prevention

Prevention is the act of stopping something, especially the occurrence of disease, before it begins. The new guidelines emphasize the preventive role of vitamin D, aiming to reduce the incidence of diseases like diabetes, heart disease, and certain cancers by maintaining adequate vitamin D levels in the population.

💡Supplementation

Supplementation refers to the act of providing a substance, such as vitamin D, in addition to what is obtained through diet or produced by the body. The script discusses the recommendation for certain groups, like children and the elderly, to take vitamin D supplements without the need for testing, to ensure adequate levels for health.

💡Testing

Testing, in this context, refers to the measurement of vitamin D levels in the blood. The guidelines suggest that universal screening for vitamin D levels is not recommended, as it is not strongly correlated with health outcomes. The script explains that testing should be reserved for specific cases where symptoms or conditions warrant it.

💡Fortification

Fortification is the process of adding essential nutrients to food. The script mentions the importance of fortifying foods like milk and edible oil with vitamin D to improve population health, especially in countries like India where baseline vitamin D levels are low.

💡Pre-diabetes

Pre-diabetes is a state where blood sugar levels are higher than normal but not high enough to be classified as diabetes. The script discusses the relevance of vitamin D supplementation for individuals with pre-diabetes, as it can potentially slow the progression to full-blown diabetes.

Highlights

The US Endocrine Society released new guidelines focusing on the role of vitamin D for disease prevention rather than treatment.

The new guidelines emphasize a shift from treating patients to preventing diseases through vitamin D.

Testing for vitamin D levels is deemed over-utilized and not strongly correlated with disease outcomes.

Universal screening for vitamin D is not recommended, except in cases with specific symptoms or requirements.

The reliability of vitamin D measurement has improved, but mistakes can still be made if best techniques are not followed.

Healthy individuals do not require routine vitamin D testing as part of general health check-ups.

Children up to the age of 18 are recommended to take daily low-dose vitamin D supplements without testing.

Indian children have been found to be significantly deficient in vitamin D, emphasizing the need for supplementation.

Elderly individuals above 75 are advised to take low-dose vitamin D to reduce overall mortality and improve bone health.

India has some of the lowest vitamin D levels in the world, despite abundant sunshine, due to cultural and environmental factors.

Atmospheric pollution in cities like Delhi prevents adequate UV ray exposure, affecting vitamin D synthesis.

Pregnant women are now recommended to take low-dose vitamin D supplements daily to improve outcomes.

The reference range for vitamin D is debated, with any level above 20 ng/mL considered normal for bones and health outcomes.

Levels below 10 or 12 ng/mL are considered deficient, and supplementation is advised in such cases.

Vitamin D supplementation for pre-diabetics has been shown to slow the progression to diabetes.

Fortification of milk and edible oil with vitamin D is an essential strategy for improving population health in India.

The 50 to 75 age group in India may also benefit from low-dose vitamin D supplementation, unlike the US guidelines.

Vitamin D supplementation is safe up to 1,000 to 2,000 units daily, with a wide safety margin to avoid toxicity.

Transcripts

hello and welcome to the print I am sui

Suk data and we have with us today Dr

amarish mitl chairman and head

endocrinology and diabetes with Max

Health Care the US endocrine Society

earlier this month released the

guidelines on the role of vitamin for

the prevention of disease in Boston

these guidelines have generated

considerable interest as they propose

some major changes from the current

clinical practices in this context I

I'll request Dr m m first of all welcome

sir thank you so much for joining us in

the conversation today I believe you

were also in Boston for the release of

the guidelines yes yes so could you

please share why the uh the society

needed to come up with these guidelines

and what exactly do they

entail see vitamin D research is a very

Dynamic field the last guidelines by the

society were in

2011 uh 2011 and there they looked

primarily at patients coming to Clinic

like what how should they be treated

what kind of levels should be achieved

and that kind of stuff uh this guideline

is a population guideline this guideline

actually talks of prevention of disease

so it doesn't talk about treatment

anywhere so vitamin D guidelines for

prevention of disease that's the thing

so that is one major difference in these

12 or 13 years lots of data has come out

on the outcomes so one is that you

improve vitamin D levels you improve

calcium but are you looking at actual

outcomes like diabetes like heart

disease like cancer like mortality and

of course at fractures and osteoporosis

so these guidelines are more based on

outcome on clinical outcomes does

vitamin D impact Clinic clinical

outcomes or not that's the reason why

and this these are more sort of General

Public guid Lin rather than patient

based Clinic guidelines okay okay sir so

what are the key takeaways could you

please you know briefly tell us guide us

through what exactly do they

say so I think the important parts that

they say uh is first is that testing for

D levels is grossly over

utilized and it really is not very

useful because the correlation between

testing and outcomes

of disease has not been very strong so

if you're going to give someone again

we're not talking of treatment treatment

we're talking of just for a population

if there is no advantage in Universal

screening for vitamin D by testing

levels which is exactly what the Indian

societies recommend and which is also

what others recommend so there's nothing

new but they emphasize this a lot

Universal screening is not recommended

so people getting their D levels just

for the heck of it it doesn't really

matter okay sometimes for instance

people are feeling tired all the time

then also the doctors recommend so all

that do you think all that won't really

be

required no if you're feeling tired if

you have any symptoms and the doctor

feels it's required it should be done

but if you're you know testing d as part

of these packages or others where we

don't know what the patient has and then

chasing the vitamin D level without any

symptoms at all is probably what is now

not

recommended a different

aspect sorry mention is that measurement

of vitamin D is also a big problem what

I when I say that I mean that the

technology for measurement of vitamin D

has improved a lot over the years and

unless and until people are following

the best techniques to measure vitamin D

levels we make a lot of mistakes so

therefore that's another technical

aspect but yes please go ahead yeah so I

needed to understand for instance I a

healthy person but I'm am going for this

annual package health package that I

take are you saying that you know I

don't really need to unless I I have any

specific symptoms I don't really need to

take this vitamin D test among other

tests that my package offers yes so what

these guidelines strongly suggest is

that we don't take any test for normal

healthy people uh and I think that is

because they've not been able to

correlate the levels of vitamin D with

General Health that is the issue now

however they do say that some groups of

people should take Vitamin D supplements

without testing so on the one hand they

are saying don't test and there some

some they are saying just to just just

take vitamin D without testing so the

most important group in that is for

example is is uh children so earlier on

only very young children were given

vitamin D now they are saying up to the

age of

18 children should be supplemented with

lowd dose vitamin D on a daily basis IDE

now this is really important so this is

actually a big change because you're

really seeing that children in their

growing age in the when the bones are

actually forming then vitamin D is very

important and I'm glad they've said this

because all studies done in Delhi in

India have shown that our school

children at least half of them are

significantly defent in vitamin D so if

we need not test because tests cost a

lot and I told you there's some question

even about reliability so using lowd

dose vitamin D is completely

harmless and will possibly benefit many

of these children for example in Indian

studies 1,000 units a day was enough to

correct d deficiency in our kids so this

is one big change that you're saying

okay use it in kids without even testing

right right so that's a group the second

group where they're saying that is in

elderly so extremes of age now above 75

they are saying everyone should be given

lowd dose vitamin D or most people

should be given lowd dose vitamin D so I

think it's important that these

guidelines suggest uh that children up

to the age of 18 1 to 18 should be given

low dose vitamin D throughout on a daily

basis actually and although this was a

recommendation earlier also it was for

very younger very much younger children

only the you know up to two years or up

to four years maybe you know but now

they are seeing right through adolesence

and I think that makes a lot of sense

because we have also shown my colleagues

have shown Dr Marva has shown that in

Delhi school children the D deficiency

is very common and 50% of such children

may be below you know maybe severely

deficient or significantly deficient so

therefore this formula of not testing

but giving all kids through the growing

age low doses of vitamin D works well in

India this dose is probably going to be

around a th000 units I think in the west

they recommend 600 to 800 but we talking

of 1,000 units here that's a minor

difference but the fact is that they're

recommending this without testing so

that is one group the second group where

they are recommending D supplementation

without perhaps even testing because

again I mentioned the fallacies of

testing is those above

75 those above 75 when if you give lowd

dose vitamin

you will find that you're reducing their

overall mortality there's data to show

that overall mortality goes down so

again you need to give maybe th000 to

2,000 units per day in that group in the

Indian setting those above 75 they're

also the group that is most prone to

osteoporosis and fractures so it makes a

lot of sense what they are saying is

don't measure and try to tight rate just

give them this small dose you can't go

wrong yeah right so one question we

often yeah we one question we often face

is that we are a country with abundant

Sunshine for instance why do we need

Vitamin D supplementation especially for

our kids who uh spend a considerable

amount of time playing outside for

instance where they get where they get

enough exposure to Sun but uh do these

guidelines really apply in Indian

context given our geographical

conditions as

well uh absolutely in fact India has

some of the lowest D levels in the world

India and Middle East which are actually

also uh very it's a very sunny area you

know Lebanon and other places around

there they have very low are vitamin D

why do they have why do we have low

vitamin D there are two reasons well

there are many but two broad

reasons number one Indians don't like to

go in the Sun so except for our manual

workers so you will find normal D levels

in you know people who work on the

street people who work on construction

sites people who pull Rick Shaws do

those kind of things you will find

normal D levels but in anybody else who

stay indoors most of the day

particularly during heat during summer

we are always indorsing we avoid the sun

like it's too hot and we Al also Indians

have this sun phobia of getting dark and

skin burn and all that so I think it's

therefore D levels in Indians have

consistently been shown to be low number

one number two about children and the

question is very relevant they are

playing in outside but the atmospheric

pollution that cities like Delhi have

prevents the UV ray from reaching the

skin and therefore again very clearly

even in controlled exposure of children

to sunlight especially during winter the

D level doesn't go up so I think it's

important that we realize that's because

thetion

level we are not getting enough dle

enough D in our blood and that's why our

bone health is suffering so this is the

other point

one other point is new in the guidelines

is the fact that they've also advocated

for

pregnancy so they've advocated

supplementing D throughout again which

is very relevant for India and very

significant it wasn't there in an

earlier recommendation that that you

know for pregnancy also pregnant women

should be supplemented with lowd dose

vitamin D on a daily basis to improve

outcomes so again that's really really

significant people are looking at oh

vitamin is over but actually the

recommendations say something else it's

a testing that they have they have

trashed they have said you don't really

require testing so that is the main

thing group of pre-diabetes which is

very relevant for India if you want we

can talk about it

later okay so uh one question what I'll

also take this this is not directly

related to the guideline itself but I

have come across some studies for

instance which say that the reference

range for vitamin D that we currently

use is also debatable in Indian context

we need to have our own reference range

I would like you to please share your

perspective on this as

well so the reference range for vitamin

D is debatable period it is not specific

to India that is people are making that

up you know is your cholesterol range

different is your diabetes range

different no it isn't certain things are

good for health so they are good for

health but the fact is that overall the

reference rise is hugely debated which

is why these guidelines stayed out of

that area totally earlier guidelines

have discussed so I can summarize in two

lines for you a very acceptable

reference range at the moment anything

above 20 nanograms per mL of of vitamin

d25 hydroxy D is normal or good for

bones good for outcomes don't have to

Target levels of 30 40 50 which people

are trying to do which is wrong

and you know people with 2 would come to

us and say oh my God my D is so low you

know I'm I'm dying of D deficiency so

anything above 20 is normal 20 n

perfectly fine there may be some

specific situation where you you may

want higher levels that's a doctor's

call number one number two anything

below 10 and some people say 12 nogs is

deficient and clearly deficient so you

can't say that a whole school has levels

of five six seven nanograms per ml which

we find sometimes in Delhi schools and

that's okay that's not okay it's between

10 and 20 where the confusion

lies so we would say that between 10 and

20 we would like people to be at 20 or

above below 10 or below 12 maybe you

should use we can we should certainly

try to supplement people with d level

with the vitamin D now one important

point that is again relevant for the

reference ranges that all the studies

that have been used in this American

guideline it's an American guideline

right the Baseline D levels have been

above

20 so if your Baseline 25 hydroxy D is

above 20 nanograms how do you expect a

real benefit from using too much vitamin

D yeah absolutely that's the confusion

the wherever Studies have shown in

nursing home residents in the west and

others that the D levels were low to

start off their benefits were clearly

evident in Europe also so I think this

is important that Baseline D levels

matter however one good formula that we

have been recommending for a long time

is don't even measure it unless you have

a symptom and you come to the doctor and

there's a reason to measure right

otherwise just use 1,000 to 2,000 units

daily particularly vulnerable groups and

you'll be you be pretty safe but there

if you're doing a study or in Indian

environments where you're looking at we

sometimes get really low levels then you

may want to measure uh vitamin D level

and anything below 10 or 12 nanograms

should be regarded as deficient and

above 20 no need to do anything so one

highlight of this uh guideline is also

the use of vitamin D supplementation for

pre-diabetics now we have a huge burden

of pre-diabetics in India what do you

think is the message there for Indian

pre-

diabetics I think uh the message is

important uh the there are there have

been studies on vitamin D and cardiac

outcomes vitamin D and cancer outcomes

and some very elegant studies on vitamin

D and development of diabetes so while

the effect was modest it wasn't a very

profound effect but the fact is the

Studies have shown that when in people

with pre-diabetes we supplement them

with vitamin D there conversion to

diabetes becomes a little less a little

slower which for India is highly

relevant because the fact is that there

have been some Indian studies on this

also some years ago from so so the

important thing message here is that we

actually talking of large groups of

people who should be having vitamin D

India has 135 million pre-diabetes right

absolutely giving D to all our kids we

are talking of giving D in pregnancy or

prant women and we are talking of giving

D to our pre-diabetics which itself is

more than 13 crores of people so

actually lowd dose Des supplementation

becomes very important the final message

yeah will we be giving vitamin D to all

these people no the answer is only those

that reach a particular segment you know

of of of healthcare will probably get

that the answer is widespread

fortification of milk these countries

why is why is America less deficient

than India despite being at at a higher

latitude is because there is

fortification so India has initiated

vitam fortification of milk and edible

oil but it's not mandatory yet A and B

it's not uh at levels that will really

make a big difference it'll make a minor

difference so that is the worked out by

the fssi so fortification is of essence

it's of great importance for a country

like India which has such low Baseline

levels so you mentioned fortification

now adults maybe you 18 to 75 age group

doesn't really need

supplementation just I'm just curious if

we for I as a he healthy adult for

instance if I consume milk and I get

vitamin D supplementation in in a way I

want because vitamin D is Al also

capable of uh creating or causing some

sort of toxicity in people who don't

really need it and they could be you

know overuse so is that a

possibility yeah so yeah so that's a

very important and logical question the

amounts that are added in fortification

or even the kind of amounts we're

talking about th to 2,000 units anybody

can take anybody even if you have 30

nanogram level even if you have 40

nanogram level you can take those levels

without

risk safe there is a huge safety window

we have a huge gap there's no way you're

going to get to toxic R unless there is

a technical error in fortification or

you know 100 times more is added or

someone take some you know things by

mistake so I think this is uh

fortification is a very very important

tool for countries like India and they

already started on that path so that's

fantastic but we need to push it and we

need to

spread it and we need to also increase

the amount and you know fssi is probably

coning that also to really get maximum

benefit I'll make one important Point uh

I think you're running out of time if I

can see the time uh one important point

and that is that only major difference

for us would be that 50 to 75 age group

that has been excluded in the guidelines

in the US is a group that we will not

exclude here we will certainly see we

see lot of bone disease in 50 to 75 age

group we also have a life expectancy of

703 or 74 so where are we talking so for

us that 50 to 75 age group is also

important for using low doses of Vitamin

D so instead of going to just 70 just 70

we just 75 we should probably consider

lowering that age and the 50 to 75 Group

which the American society has said is

not doesn't really require I think in

our environment given our longevity

lifespan our D levels and our diabetes

uh we are we are important that's an

important group so that's the other

difference so a key message that U you

know from what I uh understood by your

explanations is that people generally

don't need Vitamin D screening but can

you please clearly spell out is there

still a subset of people who would still

need Vitamin D uh screening if yes what

exactly is that group so that's not

vitamin D screening then that is case

based uh you know approach so people who

have any bony issues bony aches and

pains muscle pains unexplained fatigue

and you know muscle tiredness kind of

thing yes they do those who have other

conditions you know uh absorption issues

GI issues who have chronic Dias they

will require those who are on drugs like

anti-epileptic drugs even

anti-tubercular drugs they may also

require so there's a large bunch of

people who will require D levels but

going out and testing everyone in the

population is not required at all is not

required that's the wrap then thank you

so much sir it was wonderful talking to

you thank you so much sir