Vitamin D Deficiency

3/14/2010 — New information regarding Vitamin D comes out at an incredible rate.  There are three aspects of this story that are prominent in my mind at this time.  In July and September of 2008, I was concerned that too much vitamin D could be harmful for people with autoimmune problems or chronic lyme disease.  You can read those posts on the journal page and either use the search bar for “marshall protocol” or just find the posts in the archives.  I finally concluded that the weight of the evidence fell to the side of increasing vitamin D levels.  However, Trevor Marshall, Ph.D., who originated this hypothesis, was recently interviewed by Jeffrey Bland, Ph.D., as part of his service, Functional Medicine Update.  I have great respect for Jeff Bland, and so I am taking another look at this hypothesis.

Today, the latest issue of the Vitamin D Council newsletter contains the following:

Professor Michael Holick keeps increasing the amount of vitamin D he recommends.
As readers know, Professor Holick is one of the world’s foremost authorities on vitamin D. However, after being on the 1997 Food and Nutrition Board (FNB), he stuck with the FNB’s 200 IU/day recommendation well into the next century. Then he slowly went to 400 IU, then 800 IU, then 1,000 IU and now he is at 2,000 IU/day. Professor Holick is going in the right direction and is almost there.
Professor Robert Heaney of Creighton University just discovered that if you take 2,200 IU of vitamin D every day, you only have about 12 days supply of vitamin D in your body.
I love Robert Heaney’s papers. In a previous paper, Dr. Heaney discovered that at blood levels of 35 ng/ml, 50% of people are using up their vitamin D as quickly as they take it, that is, they are not storing any for future use and suffer from chronic substrate starvation. Obviously, one wants to take enough so the body has all it can use, which is why I recommend 25(OH)D levels of at least 50 ng/ml. At that level, no one should have chronic substrate starvation.
In the paper below, Dr. Heaney collaborated with two other Creighton scientists, Dr. Diane Cullen and Dr. Laura Armas, as well as one of the premier experts in measuring vitamin D in the world, Dr. Ron Horst of Heartland Assays. Ron runs tens of thousands of vitamin D samples a year as Heartland Assays performs vitamin D testing for most of the big studies and Dr. Horst is one of the few people in the world who can accurately measure cholecalciferol, and not just 25(OH)D.
Anyway, in his latest paper, Dr. Heaney found that if you regularly take 2,200 IU per day, you have about 12 days supply of vitamin D in your body. He explained, “What this indicates is that fat reserves of the vitamin are essentially running on empty and that . . . additional vitamin D inputs are [converted to 25(OH)D] almost immediately.” . . “The currently recommended intake of vitamin D needs to be revised upward by at least an order of magnitude.”
What is not known, at least by me, is what happens when cholecalciferol intake far exceeds the body’s requirement. We know it is stored in the body, mainly in fat and muscle, but what does the body do to control excess cholecalciferol from building up in the body? Professor Reinhold Vieth has written that much of it will simply be excreted unchanged in the bile, but how does that system work exactly, to get rid of excess cholecalciferol? We know it works because the few patients with vitamin D toxicity reported in the literature – almost always due to industrial errors – reduce their vitamin D levels rather quickly by simply stopping the vitamin D and staying out of the sun.

These studies strongly imply that the required dose in adult humans is higher than 2000U daily.  As everyone should know, I recommend 5000U daily during the wintertime, and especially in the run-up and during flu season.  There also appear to be genetic variations that determine how people respond to a given dose of Vitamin D, so that some people need more to get their blood levels up.
Thirdly, an article recently appeared in Family Practice News.  The link to the article is here, but I’m not sure that you will be able to access it without my passwords.  The upshot of the article is to suggest that especially in African American adults, levels considered “sufficient” may be associated with increased arteriosclerosis and the diseases associated with that condition (strokes, heart attack, etc.).  Even for Caucasians, there are findings that call current recommendations into question.
I want to be clear, that since the active form of Vitamin D is important to the function of over 900 genes, which in turn affect the function of many parts of our bodies including our immune system, our bones, brain function (in many ways), resistance to infection, and more, that looking at one “end-point” (such as arteriosclerosis) is not sufficient to make blanket recommendations.  The waters are somewhat muddied, however.
And in apparent contradiction to this data on carotid artery disease, is another excerpt from the above mentioned Vitamin D newsletter I received today:
Intensive treatment with vitamin D, statins, and omega-3 fish oil reverses coronary calcium scores.
The below open study by Dr. William Davis and colleagues studied 45 adults with evidence of calcified coronary arteries, treating them with high dose statins, niacin, fish oil (not cod liver oil) capsules, and enough vitamin D (average of about 4,000 IU/day) to obtain 25(OH)D levels of 50 ng/ml. They found that regimen reduced coronary calcium scores in 20 patients and slowed progression in 22 additional patients. That is, it reversed the coronary calcification process in about half of patients and slowed its progression in most of the rest.
Most studies have shown high dose statins on their own do not reverse coronary arthrosclerosis, so we know it was not the statins alone. What would vitamin D levels of 70 ng/ml do? So, if you have coronary artery disease: ask your cardiologist about statins and niacin, take 5-10 fish oil capsules per day, and at least 5,000 IU of vitamin D3 per day.
A word about fish oil is in order. Fish oil means fish body oil, not fish liver oil. And, four or five capsules of omega-3 fish oil a day will do very little if you do not limit your intake of omega-6 oils. Your ratio of omega-6 to omega-3 is the crucial number, your want that ratio at 2 or below, which means no chips, no French fries and no processed foods, a difficult diet. Omega-6 oils are vegetable oils such as corn oil, safflower oil, soybean oil, sunflower oil and cottonseed oil. Read the packages to see what is in them and if they contain the above oils do not eat them. In additions to taking fish oil capsules, try to eat wild-caught salmon three times a week.
At this time, I’m not changing my recommendations for vitamin D supplementation, but watch this page for further reports.

2/27/2010 — I just posted this on the journal page:

I’ve received a posting from Dr. Cannell, of the Vitamin D Council, regarding several studies on Vitamin D and Cancer.  While in general higher levels of Vitamin D are associated with lower risks of cancer, the effect appears to be blocked by high intakes of “pre-formed” vitamin A (retinol).  This form of vitamin A is found in high doses in Cod Liver oil.   Daily intake of 5000 Units of Retinol are probably OK (for adults,  correspondingly lower for children), for those who feel strongly that they should take Cod Liver Oil.

Beta-carotene is a form of vitamin A which must be converted in the body to the active state, and (as far as we presently know) is not a problem.

The newsletter from Dr. Cannell (available on the website above) also contains the statement that “it takes the elderly up to ten times more time in the sun that the young to make an equivalent amount of vitamin D.”   I’m not aware of the data that backs this statement up but do consider Dr. Cannell to be authoritative and certainly current on vitamin D research.

Original article:

Studies all over the world have demonstrated that deficiency of Vitamin
D is widespread. Particularly at risk are those with chronic illness,
the undernourished, home-bound individuals, and people who have migrated
to the north from equatorial countries.  Because of fear of skin cancer many people reduce their exposure through the use of sunscreens and by spending less time in the sun.

I have seen low levels of Vitamin D in several women whose bone density
readings were in the low range, and I suspect that even in my patient
population, the problem may be more common than was previously thought
likely. A 2002 study of healthy young adults showed at 36% of them,
screened at the end of winter, were deficient (Am J Med 2002;1122:659-662).
A 2003 study in Minneapolis showed that 93% of 150 otherwise healthy
adults from Minneapolis, who complained of non-specific musculoskeletal
disorders had some deficiency, at 28% had severe deficiency of Vitamin
D (Mayo Clin Proc 2003;78:1463-1470).

Vitamin D is necessary for calcium absorption and transport into bone,
making osteoporosis the best known consequence of Vitamin D deficiency
in adults. In children, deficiency leads to a condition called Rickets,
in which the bone is weakened by low level of calcium. In adults, the
corresponding condition is termed “osteomalacia,” which is
a condition similar to osteoporosis, and which can be attended with
symptoms of diffuse, dull, aching bony pains affecting many areas of
the body, including the ribs and sternum.

Vitamin D deficiency is associated with weakness and increased risk
of falling in the elderly population. In addition, recent work suggests
that Vitamin D deficiency may be associated with increased risk of several
common cancers, including breast, colon, prostate, and ovarian.

In addition, studies in animal models suggest that Vitamin D may also
prevent or arrest autoimmune diseases such as type 1 diabetes, rheumatoid
arthritis, inflammatory bowel disease, and multiple sclerosis.

Vitamin D is formed naturally in the skin on exposure to the ultraviolet
B rays in sunlight. Some foods, such as milk, some orange juices, and
bread are fortified with Vitamin D, but these sources are said to be
unreliable. The only significant food sources are oily fish (such as
salmon, mackerel, sardines), and fish oils (cod liver oil, etc.)

Vitamin D apparently does not pass into breast milk, so that supplementation could be considered for babies fed exclusively by breast and born in the fall.

Almost no ultraviolet B rays reach those living in latitudes greater
than 35-40 degrees from the equator during the winter months. My office
is at north latitude 41.99, therefore lying just outside this range.

Exposure to sunlight, during the summer, with 50% of the skin’s surface exposed, for 10-15 minutes a day will  generate meaningful amounts of vitamin D in the skin, but prolonged exposure may not increase this level significantly.  For an interesting discussion of this and other aspects of Vitamin D and sun exposure, see an article by Brian Diffey on page 62 of a conference report on “Sunlight, Vitamin D, and Health” generated in England in 2005.

Heavy air pollution filters out ultraviolet B rays, as does glass,
increasing the risk to the homebound who are unable to be outside.  Sunscreens with high protection factors also screen out UVB rays.  Women
in the Middle East, who wear extensive covering, may also be at risk.

There is controversy about the optimal level that is compatible with
good health. Current research suggests that 32 ng/ml should be the lower
limit of normal, in blood samples, rather than the standard recommendation
of 20 ng/ml. Discussions with my physician colleagues lead me to think that a blood level of 50 – 70 ng/ml is probably optimal for bone health and immune system function.

Correspondingly, the recommended daily intake of 200 IU (international
units) for children, adolescents, and adults up to 50 years, 400 IU
for adults aged 51-70 years, and 800 IU for adults over 71, may be too low.
For those with low or near-low levels, 2000 IU of Vitamin D-3 (cholecalciferol) taken daily is probably a good
level for supplementation. I may sometimes recommend up to 5000 IU daily for a period of a few months (especially during the winter) when blood levels are low and the clinical situation is very related to Vitamin D status.  Multiple Sclerosis and Osteoporosis are two examples of such clinical situations.  As Vitamin D is a fat-soluble vitamin, and
can accumulate in the body, it is potentially toxic, but one prominent
researcher in the field estimates that 10 times the usual amount in
supplements (normally 400 IU) should be safe for most individuals.

Sources of Vitamin D:

Cod liver oil, 1 tsp ………………………………. 1360 IU

Salmon, cooked, 3.5 oz. ………………………. 360 IU
Mackerel, cooked, 3.5 oz. ……………………. 345 IU
Sardines, canned in oil, drained, 3.5 oz. …… 270 IU
Milk, all types, fortified 1 cup …………………. 98 IU
Egg, 1 whole (Vit D present in yolk) ………… 25 IU

This article was summarized from the Journal of the American Medical
Association, 2004, — Vol 292, No. 12.

Another good source of information regarding vitamin D can be found at the National Institutes of Health dietary supplement information section.

Another source of information is the website of the Vitamin D Council.