Osteoporosis and Vitamin D deficiency
Vitamin D deficiency is quite common in cases of hip fractures. A look-back study of 548 patients older than 60 years of age who were admitted at South Glasgow University Hospital in Scotland in the previous 4 years, showed that 97 percent of the patients had vitamin D levels below normal. Dr. Stephen Gallacher, lead researcher and consultant endocrinologist at the hospital said: ''Although the numbers were too small to justify extensive subgroup analyses the study appears to demonstrate that vitamin D inadequacy represents a significant correctable risk factor for fragility fracture and perhaps specifically for the hip."
   Older men and women who fail to get enough vitamin D -- either from their diets or exposure to the sun -- are at heightened risk for muscle weakness and poor physical performance. This is troubling given the high numbers of older folks who are deficient in vitamin D. However, even good sun exposure does not guarantee adequate blood levels of vitamin D. In many individuals, vitamin D level can remain low despite abundant exposure to sunlight.
    Dr. Sahelian comments: Most elderly patients have a vitamin D deficiency due to lack of adequate sun exposure, particularly in cold climates with long winters. And there could be a deficiency even with many hours of sun exposure a week. Vitamin D can be supplemented by taking a multivitamin and mineral complex, or through cod liver oil. A dosage of 400 to 800 units should be adequate. Sitting by the window or taking walks outside could be helpful. Osteoporosis risk can be reduced. Low vitamin D status is defined as 25-hydroxyvitamin D concentrations below 30 ng/mL. A good blood level of 25-hydroxyvitamin D is between 50 to 60 ng/mL.
   Vitamin D levels in the body vary according to the season the blood test is done. Seasonal variation significantly affects the diagnosis of vitamin D sufficiency, which requires seasonally adjusted thresholds individualized for different locations. Doctors should consider the month of sampling and the amount of body fat when interpreting vitamin D measurements.

Do not use once-a-year single high dose
A single yearly oral dose of 500,000 international units of cholecalciferol does not protect generally healthy older women from falls and fractures. On the contrary, it appears to increase the risk of falls and fractures. Dr. Geoff C. Nicholson, from Barwon Health and the University of Melbourne in Geelong, recruited community-dwelling women, aged 70 and older, who were considered to be at high risk for fracture. The women were given a single oral dose of 500,000 IU of vitamin D taken in the autumn or winter for 3 to 5 years. Women in the annual high-dose vitamin D group experienced 15% more falls and had more fractures. JAMA 2010;303.

Parathyroid hormone influence
In a four month study on older individuals with vitamin D deficiency, serum 25(OH)D concentrations rose significantly (from 14 to 26 ng/mL) in patients treated with 8400 IU vitamin D3 once weekly, but not in patients treated with placebo. Adverse experiences and incidences of hypercalcemia, hypercalciuria, and elevated creatinine were similar with both treatments. In patients treated with 8400 IU vitamin D3, but not in placebo-treated patients, parathyroid hormone decreased significantly. American Journal of Clinical Nutrition, April 2010.

Vitamin D Research study
Boston researchers report a link between low serum levels of vitamin D and decreased knee function in patients with osteoarthritis of the knee. At the annual meeting of the American College of Rheumatology in San Antonio, researchers presented findings from 221 subjects recruited from the Boston VA Medical Center. All had knee arthritis and reported knee pain on most days in the month before they joined the study. The investigators measured blood levels of vitamin D at the start and again after 15 and 30 months. They compared change in vitamin D levels with changes in knee pain, physical function and muscle strength during the 30-month study period. Low levels were associated with higher levels of pain and disability and to a lesser extent muscle weakness. The researchers also found that about 50 percent of the population were deficient in vitamin D.

People with higher blood levels of vitamin D may be less likely to develop gum disease. Using data from a national U.S. health survey, researchers found that teenagers and adults with the highest blood levels of vitamin D were 20 percent less likely than those with the lowest levels to show signs of gingivitis -- a milder form of gum disease in which the gums become swollen and bleed easily. The study can only show that there's an association between vitamin D status and gum health, and not that the vitamin is providing the benefit.

People on strict raw food vegetarian diets are thin but healthy. Although nutritionists and the food industry have warned that a diet without dairy foods can lead to the bone-thinning disease osteoporosis, a team at Washington University School of Medicine in St. Louis found the vegans they studied had many of the signs of strong bones. Raw food vegetarians believe in eating only plant-derived foods that have not been cooked, processed, or otherwise altered from their natural state. Researchers expected the vegans to have low vitamin D levels because they avoid dairy products, which are fortified with the vitamin. But in fact their vitamin D levels were "markedly higher" than average. Vitamin D is made by the skin when the body is exposed to sunlight and is key to keeping strong bones. And the vegans had low levels of C-reactive protein, an inflammatory molecule that is linked with the risk of heart disease, diabetes and other chronic disease. Furthermore, they had lower levels of IGF-1, a growth factor linked to risk of breast and prostate cancer.

People who try to stay bronze with the help of a tanning bed tend to have higher blood levels of vitamin D than those shun the salon. The study of 156 adults found those who regularly soaked up the artificial rays of a tanning bed had a 90 percent higher average vitamin D concentration in their blood. The tanners, who frequented the salon at least once a week for 6 or more months, also had greater bone density in the hips. The study, published in the American Journal of Clinical Nutrition, was partially financed by the UV Foundation, which is funded by the Indoor Tanning Association, an industry group. A precursor to vitamin D exists naturally in the skin, and exposure to the sun's ultraviolet (UV) rays touches off a chemical process that creates the usable form of the vitamin. Because vitamin D is needed for proper calcium absorption, the nutrient is vital to bone health. There is also a body of research suggesting vitamin D helps protect against certain cancers and some autoimmune diseases, such as type 1 diabetes and multiple sclerosis. But the fact that UV radiation is the major cause of skin cancer, as well as the major source of vitamin D, has made for a controversy over how much sun -- or artificial sun -- people should get.

Tanning is associated with optimal vitamin D status (serum 25-hydroxyvitamin D concentration) and higher bone mineral density
American Journal of Clinical Nutrition, Vol. 80, No. 6, 1645-1649, December 2004
Subjects who use a tanning bed that emits ultraviolet B radiation (290–315 nm) are likely to have higher 25-hydroxyvitamin D [25(OH)D] concentrations than do subjects who do not regularly use a tanning bed. Objective: The first objective of this study was to ascertain whether subjects who regularly use a tanning bed have higher 25(OH)D concentrations than do subjects who do not use a tanning bed. The second objective was to ascertain whether higher 25(OH)D concentrations correlated positively with bone mineral density. Design: This cross-sectional analysis examined 50 subjects who used a tanning bed at least once a week and 106 control subjects. Each subject gave a blood specimen for measurement of serum 25(OH)D and parathyroid hormone concentrations. Each subject underwent bone mineral density testing of the hip and spine. Results: Subjects who used a tanning bed had serum 25(OH)D concentrations 90% higher than those of control subjects. Subjects who used a tanning bed had parathyroid hormone concentrations 18% lower than those of control subjects. Tanners had significantly higher BMD and z scores at the total hip than did nontanners. The regular use of a tanning bed that emits vitamin D–producing ultraviolet radiation is associated with higher 25(OH)D concentrations and thus may have a benefit for the skeleton.

Why the optimal requirement for Vitamin D(3) is probably much higher than what is officially recommended for adults.
J Steroid Biochem Mol Biol. 2004 May;89-90:575-9.
The physiologic range for circulating 25-hydroxy-vitamin D3 [25(OH)D; the measure of Vitamin D nutrient status] concentration in humans and other primates extends to beyond 200nmol/L (>80ng/mL). This biologic "normal" value is greater than current population norms for vitamin D. Concentrations of vitamin D that correlate with desirable effects extend to at least 70nmol/L, with no obvious threshold. Randomized clinical trials using 20mcg (800IU) per day of Vitamin D show that this suppresses parathyroid hormone, preserves bone mineral density, prevents fractures, lowers blood pressure and improves balance. Calcium absorption from diet correlates with vitamin D in the normal range. Health effects of Vitamin D beyond osteoporosis are mostly supported by the circumstantial evidence of epidemiologic studies and laboratory research. These include prevention of cancer and the autoimmune diseases, insulin-dependent diabetes and multiple sclerosis. One mcg per day of Vitamin D(3) (cholecalciferol) increases circulating vitamin D by about 1nmol/L (0.4ng/mL). A recommended dietary allowance (RDA) is the long-term daily intake level that meets the total requirements for the nutrient by nearly all healthy individuals (it would presume no sunshine). If 70nmol/L is regarded as a minimum desirable target vitamin D concentration, then current recommendations of 15mcg per day do not meet the criterion of an RDA.

Vitamin D Council - should you trust their opinion?
I'm writing to you regarding the information you have presented on this topic and to let you know about the Vitamin D Council. Dr. John Cannell, MD has THE most up-to-date info on "which lab to be tested by, EXACTLY what are the levels that should be in the blood, dosage amounts (including the ridiculous hysteria about over-dosing with vitamin D) and the latest research findings on this subject." I've read his site from front to back and looked at the research. They say, "At this time, we advise even healthy people (those without the diseases of vitamin D deficiency) to seek a knowledgeable physician and have your 25(OH)D level measured. If your levels are below 50 ng/mL you need enough sun, artificial light, oral vitamin D3 supplements, or some combination of the three, to maintain your 25(OH)D levels between 50–80 ng/mL year-round. How Much Vitamin D? If you refuse to see a physician, or can't find a knowledgeable one, purchase the 1000 IU/day vitamin D3 cholecalciferol pills that are available over-the-counter in North America or a 5,000 IU capsule. Take an average of 5,000 IU a day, year-round, if you have some sun exposure."
    I am much more cautious. I have learned over my more than 3 decades of studying nutrition and medicine that some researchers and medical doctors make wide ranging recommendations to the general public without a full understanding of the long term consequences. For decades doctors recommended hormone replacement therapy to their menopausal patients only to discover decades later that more harm than good was being done. I am not saying the vitamin D supplementation is as much of a concern as estrogen and progesterone replacement, but just to point out that it takes decades of research to learn the consequences of supplementing with medications or natural supplements. After so much time studying calcium supplementation for osteoporosis prevention or treatment, we still don't have a full understanding of the benefits, risks, and proper dosage. Therefore, for the Vitamin D council to make such confident statement about how much the general public should supplement, in my opinion, is quite premature. It is up to each individual to read all the info they can on this topic and make their own decision. What if we find out years from now that taking such high amounts as recommended by the people who run the Vitamin D Council actually shortens lifespan by calcifying various tissues in the body, including the brain and blood vessels? By the way, has links from its site to sites that sell the supplement, and they make money from such sales. They also promote blood level testing and sell vitamin D kits. Hence they are not an independent source of information.

Can you comment on this article by Dr. John Cannell, M.D. "The Truth About Vitamin D Toxicity. Vitamin D Toxicity Fears Unwarranted. Is vitamin D toxic? Not if we take the same amount nature intended when we go out in the sun. Vieth R. Vitamin D supplementation, 25-hydroxyvitamin D concentration, and safety. Am J Clin Nutr. 1999;69:842–56. Vieth attempted to dispel unwarranted fears in medical community of physiological doses of vitamin D in 1999 with his exhaustive and well-written review. D-Lite, Renew, & Sun Splash UV/Tanning Systems Is toxicity a concern for you? If so, then increase your levels the way nature intended, with ultraviolet B light! His conclusions: fear of vitamin D toxicity is unwarranted, and such unwarranted fear, bordering on hysteria, is rampant in the medical profession. Vieth R, Chan PC, MacFarlane GD. Efficacy and safety of vitamin D3 intake exceeding the lowest observed adverse effect level. Am J Clin Nutr. 2001 Feb;73(2):288–94. Even Ian Monroe, the chair of the relevant IOM committee, wrote to the Journal to compliment Vieth's work and to promise his findings will be considered at the time of a future Institute of Medicine review. Munro I. Derivation of tolerable upper intake levels of nutrients. Letter, Am J Clin Nutr. 2001;74:865. That was more than two years ago. In 1999, Vieth indirectly asked the medical community to produce any evidence 10,000 units of vitamin D a day was toxic, saying "Throughout my preparation of this review, I was amazed at the lack of evidence supporting statements about the toxicity of moderate doses of vitamin D." He added: "If there is published evidence of toxicity in adults from an intake of 250 ug (10,000 IU) per day, and that is verified by the 25(OH)D concentration, I have yet to find it." Vieth R. Vitamin D supplementation, 25-hydroxyvitamin D concentration, and safety. Am J Clin Nutr. 1999;69:842–56.
   I recommend for the time being 400 to 2000 units a day for most people. There is a significant difference between short term acute and noticeable toxicity versus potential long term slow damage to tissues that occur without much obvious signs over years and decades of supplementation. It is up to each individual to determine whose opinion they trust.

Vitamin D supplement use emails
Q. I am a vegetarian (not a vegan). Do you know of any Vitamin D3 supplements (400 IU) which use only sheep's wool (lanolin) and not any products that are derived by killing the source animal? One of Dr. Sahelian's articles features a picture of Nature's Way version of Vitamin D3, but I can find no documentation as to what is the source of the D3 in that product.

Q. I have a question regarding the source of Vitamin D. I understand cholecalciferol or D3 has the origin from animal products such as sheep wool and hides. Also, I read somewhere that vegans usually obtain vitamin D from the action of sunlight on the skin or by taking fortified foods such as soya milk, margarine, breakfast cereals and vitamin supplements which are made from yeast or other fungi. Fortified vegan products contain D2 ( ergocalciferol ). Vegans are careful about their source of Vitamin D as D3 ( Cholecalciferol ) which is animal-derived.
   A. It appears to be true that Vitamin D in the form of cholecalciferol is derived from sheep wool. Therefore, this would make it fine for a vegetarian but not for a strict vegan. The sheep are not killed. The wool is sheared, and lanolin from the sheep wool is chemically altered in the lab to produce vitamin D3 or cholecalciferol.

Q. Can you explain the difference between vitamin D deficiency symptoms and signs?
   A. Vitamin D deficiency symptoms refer to various symptoms that a patient notices, but the phrase Vitamin D deficiency signs refers to those signs noticeable by a doctor.

Q. I live in the UK and due to the lack of sunshine, would like to buy a Vitamin D supplement. However, i am now completely confused ! I have just read the new study from Australia ( Science Daily Jan. 27, 2008 ) that suggests taking a Vitamin D supplement ORALLY is BAD for you. Its actually a pretty damning study regarding ORAL Vitamin D. It says: "ingested vitamin D is immunosuppressive and that low blood levels of vitamin D may be actually a result of the disease process. Supplementation may make the disease worse. Vitamin D deficiency, long interpreted as a cause of disease, is more likely the result of the disease process, and increasing intake of vitamin D often makes the disease worse We have found that vitamin D supplementation, even at levels many consider desirable, interferes with recovery in these patients. Vitamin D is a secosteroid hormone, and the body regulates the production of all it needs. In fact, the use of supplements can be harmful, because they suppress the immune system so that the body cannot fight disease and infection effectively. The comprehensive studies are just not showing that supplementary vitamin D makes people healthier. The Science Daily article, dated 28 Jan 08. What is your opinion on this new study ? This has put me off buying any Vitamin D supplements completely and would appreciate your thoughts.
   A. Different scientists have different opinions regarding nutrition and supplement use. The reason is that this field is extremely complicated and it is difficult to do well-controlled long term studies. Furthermore, different results could be obtained depending on the dosage used for the vitamin or supplement or in different populations or groups of patients. For instance, it is possible that opposite results could be obtained by providing vitamin D at 200 units a day versus 1,000 units a day, even though it is the same vitamin. For the time being, I think taking a vitamin D supplement at 400 units a few times a week probably provides more benefits than harm to those who live in climates where there is little sun exposure or little vitamin D in the foods people ingest.
   There is a four year long vitamin D study that has interesting results.

Vitamin D and calcium supplementation reduces cancer risk: results of a randomized trial.
Am J Clin Nutr. 2007 June;85(6):1586-91.Lappe JM, Travers-Gustafson D, Davies KM, Recker RR, Heaney RP. Osteoporosis Research Center, Creighton University, Omaha, NE 68131, USA.
The purpose of this analysis was to determine the efficacy of calcium alone and calcium plus vitamin D in reducing incident cancer risk of all types. This was a 4-y, population-based, double-blind, randomized placebo-controlled trial. The primary outcome was fracture incidence, and the principal secondary outcome was cancer incidence. The subjects were 1179 community-dwelling women randomly selected from the population of healthy postmenopausal women aged >55 y in a 9-county rural area of Nebraska centered at latitude 41.4 degrees N. Subjects were randomly assigned to receive 1400-1500 mg supplemental calcium/d alone (Ca-only), supplemental calcium plus 1100 IU vitamin D3 / d (Ca + D), or placebo. Cancer incidence was lower in the Ca + vitamin D women than in the placebo control subjects. In conclusion, Improving calcium and vitamin D nutritional status substantially reduces all-cancer risk in postmenopausal women.

Q. I read with interest your take on potential problems with higher supplemental doses of Vitamin D and calcium. I, myself, have been diagnosed with very low bone density and, at the time of diagnosis, my Vitamin D (25-OH) was 10 nanograms per ml. I have subsequently -- and under monitoring -- taken 4,000 I.U. of D3 and still only managed to raise my levels to 39. I am now taking 5,000 I.U. and due to be tested soon. I know of several people who are taking Vitamin D3 doses in the 4-6,000 I.U. range and still maintaining what are considered to be barely adequate levels of D (around 50). One is having her parathyroid levels measured at the same time and, at 6,000 I.U., has noticed no problems. In a study in Hawaii of subjects who reported 22.4 hours average sun exposure without sunscreen, 51% were reported to be Vitamin D deficient. My question is: if even "heroic" doses of Vitamin D3 are merely maintaining what are considered desirable levels, can these doses still pose potential health problems?
   A. It's difficult to say. Blood levels of vitamin D may not necessarily reflect what is actually going on in bone tissue, brain tissue, or other parts of the body. Many doctors overly rely on blood levels to determine the proper dosage of vitamins, drugs, and hormones, but blood tests do not always reflect accurately the levels or effects of these medications in various tissues of the body or what is actually going on within each cell. There could be a normal level of the vitamin or medication in the blood stream yet untoward effects could be going on in some part of the body. For instance, if a person takes DHEA and their blood test shows the level to be within the normal range, it is possible that the levels in hair tissue could be high causing hair loss. Same with vitamin D. It is possible that blood levels could be low or normal, yet untoward reactions could be occurring in other tissues, such as brain tissue.

Q. This note is just to let you know that there is another side-effect of high vitamin D supplementation, that you may not be aware of: whole-body anxiety. (This was a surprise to my doctor.) My medical history is that I acquired hypothyroidism due to destruction of my thyroid by Hashimoto's autoimmune thyroiditis; the Hashimoto was perhaps caused by gluten. I also acquired multiple nutritional deficiencies as the result of gluten enteropathy. Autoimmune problems and enteropathy are commonly found in persons, like me, whose gluten sensitivity is not promptly diagnosed. After getting off gluten in 2003, the process of
finding and fixing the many nutritional deficiencies the enteropathy caused, has been lengthy. Early in 2008 I discovered that taking vitamin D3 caused me to go into diagnosed hyperthyroidism (TSH < 0.015). I had to lower my T4 dose from its high of 118mcg. After taking up to 3000 IU D3 daily for 5 months and finally achieving D sufficiency at 50ng/ml, I dropped back to about 600 IU D3 daily. Reducing the level of D supplementation, improved the way I feel. Apparently high blood levels of vitamin D are excitatory for some people, because the 3000 IU vitamin D supplementation had created a whole-body anxiety situation. It had also interfered with my thyroid treatment; taking T4 while I also had a high blood level of D3, would cause intense anxiety, so I had throttled back my T4 dose to a low level (usually 12mcg per day) that wasn't sufficient to keep my TSH reasonably low and my FT3 and FT4 both within the normal ranges. Based on what you said in your column, I've taken your advice and also reduced my calcium supplementation.
   I have a friend whose son was put on high vitamin D supplementation after he was found to have gluten sensitivity, and have multiple deficiencies. The doc put him on a dose of 8000 IU D3 as drops, once per week. When I talked to his mom about my experience with high-dose vitamin D supplementation, she found it interesting. She told me that when she gives her son his 8000 IU D3 on Sunday, he acts "crazy" on Monday. So evidently I'm not the only person who finds that high blood levels of vitamin D3 are excitatory.

Q. I recently went to see a new Internist that practices Integrative Medicine (combines Eastern and Western Medicine). He has his own line of nutraceuticals. His name is Dr. Michael Hirt out of Tarzana, Ca. Dr. Michael Hirt came highly recommended. At my first visit recently he drew my blood and said that I am deficient in Vitamin D. He recommends that I take 3,000 i.u. per day. It sounds like it's too much, since your website says to take from 200-600 i.u. per day and every one else recommends around 400 i.u. per day. What is your take on this? Is this way too much? I am 48 y.o. and suffer from Type 2 diabetes, chronic fatigue syndrome, obstructive sleep apnea, obesity and a whole host of other health problems. I have no energy. I just don't want to take such high doses of vitamin D if its truly not warranted and maybe end up with other health problems due to vitamin D overdose.
   A. Research regarding the ideal dosage of vitamin D supplementation is still in its early stages and different doctors have different opinions regarding the right vitamin D dosage to prescribe to their patients. It also depends on the blood studies as to how deficient a person is, and how long the vitamin D treatment needs to continue. Personally I prefer to use lower dosages of prescription medications and supplements than other doctors but this is my approach. Other doctors have different viewpoints.

Q. I am an older male with a prostate enlargement and I use saw palmetto herb daily along with a pygeum africanum extract. Just wondering whether 400 units of vitamin D has any interactions with other supplements. I also occasionally use a potent aphrodisiac called tongkat ali herb.
   A. This low vitamin D dosage should not interfere with other herbal products.

I read Dr. Sahelian's comments about supplements regularly, but I was intrigued by his recommendations for D3. That low recommendation of 400 I.U. for adults has been considered too low for some time now, especially with the research he is certainly aware of, by well known researchers like Michael Holick and Reinhold Veith, as examples. As is often the case in medicine with nutritional supplementation, vitamin D supplementation has been considered most conservatively, despite the rare instances of toxicity. Holick and other researchers are now suggesting, due to widespread evidence, that up to 10,000 I.U. is a safe daily dose. Perhaps, rather than just recite outdated recommendations which completely confuse the otherwise uninformed reader, as occurred in the questions and comments on the webpage, there should be a caveat that guides the reader to consider supplementation levels after they have their serum levels checked. After all, latitude, occupation, and general health status, and most certainly genetics will certainly produce a widely divergent initial serum level. For example, a Puerto Rican farmer had a serum level of 220 nmole/L and had no evidence of hypercalcemia, while up here in the Pacific NW, most of my patients are tested and reveal a level below 20 nmole/L. I am a chiropractor in Arlington, VA. A few articles apropos of this email: Webb AR, Kline L, Holick MF. Influence of season and latitude on the cutaneous synthesis of vitamin D3: exposure to winter sunlight in Boston and Edmonton will not promote vitamin D3 synthesis in human skin. J Clin Endocrinol Metab.
1988;67:373-378. Vieth R, Bischoff-Ferrari H, Boucher BJ. The urgent need to recommend an intake of vitamin D that is effective. Am J Clin Nutr. 2007;85:649-650. Vieth R, Ladak Y, Walfish PG: Age-Related Changes in the 25-Hydroxyvitamin D Versus Parathyroid Hormone Relationship Suggest a Different Reason Why Older Adults Require More Vitamin D. J Clin Endocrinol Metab 2003, 88:185-191. Vieth R, Kimball S, Hu A, Walfish PG. Randomized comparison of the effects of the vitamin D3 adequate intake versus 100 mcg (4000 IU) per day on biochemical responses and the wellbeing of patients. Nutrition J. 2004;3:8.
    Throughout medical and nutritional research history there are countless examples of medications or supplements that researchers have been excited about and began recommending large dosages only later to find out that there were unknown long term side effects that did not appear initially. As to vitamin D, I suggest, as a general guideline, a supplement dosage of 400 to 1000 units a day for most people with exception regarding sun exposure and dietary intake. See my section on potential vitamin D side effects.

I respectively disagree with your evaluation of Vitamin D3 supplements. I have taken Centrum Silver Supplements for many years. In July 2008 I was tested for Vitamin D and the level was 22 ng/ml. According to all sources I can find, a minimum level of 30 ng/ml is required. Many Canadian studies, and those in the US indicate that blood levels higher than 30ng/ml, closer to 50 or 60 ng/ml are beneficial in preventing heart attacks, colon cancer, slowing prostate cancer, and increasing both bone health and the immune system functoin. I currently live in NYC, and take 4500 IU vitamin D/day. My vitamin D level is 57ng/ml as of October 2009. I have my doctor's approval. I also have metastatic prostate cancer with very low PSA readings.
    Each person is entitled to their own opinion on this topic and all others.

I read your latest newsletter with interest. In general, I have appreciated your conservative approach to vitamins and supplements. On vitamin D, however, I'm not sure I agree with you. No question, we need longer term tests in humans. However, the present evidence shows that high doses of D-3 may prevent cancers, colds, the flu, etc. Testing (at Labcorp only) prevents overdoses. Another alternative, although expensive, is to use tanning beds. I am aware of the UVA, UVB issues.
    Some doctors and people are more cautious than others in terms of recommended dosages. I am not sure anyone as of 2009 knows for certain the appropriate dosages that would apply to everyone.

From your October 2009 newsletter: "Vitamin D taken in high amounts can cause excessive calcification of bone, calcification of soft tissue, kidney stones, headaches, weakness, nausea, and vomiting." Are you talking about increasing Vit D levels to over the 'normal' range, or taking doses that are in excess, like 10,000 to 20,000 units at once? What about sun exposure, where one may produce the same amount at once? In practice I am seeing that most of my chronic pain, depressed, fatigued, patients are very low in Vit D (15-25, with "normal" being 40-80). Are these people better off with these low levels, or supplementing to increase these levels?
    The above side effects you mention are due to excessive intake of 20,000 units or more taken for several weeks. I am concerned about the long term side effects of taking more than 2000 units for several years.

Thank you for addressing this matter of vitamin D, an often misunderstood vitamin / hormone. I would like point out that UVB light (which promotes vitamin D production) is not available above 38 degrees N latitude (as in the Bay Area and northward) during the dark months (November through February). Also, dark-skinned folk living at these latitudes above 30 degrees may need more exposure to the sun than their paler colleagues. Finally, if one measures 25 hydroxy vitamin D3 as a reference point for adequate vitamin D levels in the body, and regularly finds them pitifully low, would not that suggest that 400 IU is rather low for daily intake? There is some consideration now being given that 1000 IU should be the new RDA (not that RDAs represent optimal levels). Drs. John Cannell, Michael Holick, Reinhold Vieth, and William Grant have done extensive research on vitamin D, which I hope you have had the opportunity to review.
    It is possible that 1,000 units should be the new RDA but I prefer waiting a few more years for additional research before making widespread recommendations.

Apparently, as of November 2009, you consider supplementation beyond 1000 IUs of vitamin D to be excessive. I have a question: do you have an objective basis to assert that larger amounts, for sake of example let's say 4000 IUs, are excessive? I ask because 4000 IUs of vitamin D is a mere one ten-thousandths of a gram of the vitamin. Is that really a large amount? One ten-thousandths of a gram doesn't sound to me even remotely as large as 4000! Are you, perhaps, suffering from being unreasonably impressed about the large numbers when quoted in IUs as SOUNDING like they are large numbers? If the dosage amounts were, instead, being quoted in micrograms, would you still hold the same view? As I am sure you realize, those on the opposite side of the fence claim that the tiny amounts of the vitamin currently recommended in the RDAs are adequate only to prevent rickets. While, they say, there is other serious evidence which demonstrates that appreciably larger intakes are necessary to prevent quite a few other very serious health issues. They also point out that people taking even much larger amounts than 4000 IUs daily have serum levels that are nowhere remotely close to those that have been found to represent toxicity. I am truly open-minded about this, and am very happy to listen to evidence on both sides.
    Each vitamin, mineral, herb, nutrient and medication has to be evaluated individually as to its appropriate dosage as opposed to comparing it dosage-wise to others. Some poisons can kill in less than microgram amounts whereas other chemicals are safe in mg or gram amounts. The use of microgram or mg has nothing to do with the consideration of safety. Those who advocate large dosage use of vitamin D are the ones who are responsible in providing evidence of safety over years and decades of use and they need to provide evidence that longevity is increased by the use of this vitamin in the daily range of thousands of IUs. Thus far there are no studies to show whether the general population in the United States would be better off ingesting several thousand units of this vitamin. There are no longer term studies that indicate that having a particular blood level of vitamin D will make you live longer. A reasonable and cautious medical doctor or scientist does not make haphazard and careless recommendations of high dose supplement use without adequate evidence of long term safety. There are countless dietary supplements that have shown to have a positive role to play in improving health, at least in the short term. If you read all these enthusiastic reports on certain websites you will end up being convinced that you need to take dozens or hundreds of vitamins, nutrients, and various herbs, fruit and vegetable extracts, amino acids, hormones, etc in high dosages. Not only is this expensive, but we have no idea of all the interactions that could occur, positive or negative.

I'm a health talk radio host in New York City and I've been carefully charting my D3 levels. I thought you might have an interest in my experiment:
2,400 IU of D3 got me to 46 ng/ml
5,400 IU = 57 ng/ml
10,400 IU = 61 ng/ml
The Grassroots Health Vitamin D organization recommends 2,000 IU to get us to the 40-60 ng/ml range. The 60 level offers the most overall health protection as displayed on the chart posted on their website. Additionally, many integrative physician's think the optimal level is over 70 or 80 ng/ml, so I'm now taking 15,400 IU. The 400-800 IU you're recommending wouldn't bring me to even 40 ng/ml.
     Let us know over the next few weeks, months, or years what kind of benefits or harm you encounter, we would be quite interested. I am not sure where and how The Grassroots health Vitamin D organization came up with 60 plus as the ideal blood level since no such long term human studies have been published.

I have a tendacy to form calcium deposits in my feet. (lumps or nodules on the tendons) I have recently wondered if taking the vitamin D supplement I take has led to the same thing happening in my hands. I have quit taking the supplement recently just in case. Any thoughts?
    It's not possible for me to know based on this limited information.

I am a chiropractor who thinks higher dosages of vitamin D supplements should be taken. Reinhold Vieth and other researchers have recommendations about D3. Certainly a few hundred I.U. D3 is better than none, it leaves most people in North America with low serum levels, which becomes obvious with testing. Perhaps you could recommend people have their serum levels checked, and act accordingly with a willing, up-to-date provider. Here in the Northwest supplementation needs are higher, and my doctor follows me with 25(OH)D serum levels. While everyone agrees that <20 nmol/L is a deficiency, it is only becoming accepted that optimal levels reduce many other risk factors. Optimum being >85 nmol/L. My original serum level was below 30 nml/L. After several months of 6000 I.U. a day, the recheck was only in the lower 40s. During the winter I am taking 10,000 IU to try and keep levels up -- hopefully to 60 or higher. Cost? 15 cents a day. In 1999, Reinhold Vieth indirectly asked the medical community to produce any evidence 10,000 units of vitamin D a day was toxic, saying "Throughout my preparation of this review, I was amazed at the lack of evidence supporting statements about the toxicity of moderate doses of vitamin D." He added: "If there is published evidence of toxicity in adults from an intake of 250 ug (10,000 IU) per day, and that is verified by the 25(OH)D concentration, I have yet to find it."
    There is a difference between short term toxicity and long term health damage. Until there is proof that taking 10000 units of vitamin D increases lifespan, it is premature to make recommendations to patients to take excessively high dosages. There is no proof that testing for vitamin D levels, or levels of many other vitamins, necessarily tells us the ideal dosage of the vitamin to supplement with or whether overall health is improved by such testing. Too many tests are being done in this country with no proof that such testing increases longevity.

I am a medical doctor and really respect your balance and wisdom, which I find very professional. However I have a different opinion about your recent discussions about Vitamin D as multiple authorities have recommended increasing the RDA dramatically. We are dealing with a hormone here, not a vitamin, and this needs to be emphasized by enlightened authors. In sunny climates women produce 8000 units a day, and men 10000. An English study gave 10000 U daily IM for 120 days with no side effects. CM Heaney and a large group of respected researchers recommended to governments that 2400 U gave even elderly women with poor absorption a modest level, and 6000 U in those working in full sun gave no-one too much. One potential issue is supplementing with magnesium to reduce renal excretion of calcium.
    Until we see studies that show giving people several thousands of units a day for 10 to 20 years or longer provides benefits that are superior to giving 400 to 1000 units a day, I will stay on the cautious side. Over the past few decades I have seen too many enthusiastic doctors prescribe high dosages of certain vitamins, herbs, supplements and hormones only to later realize that adverse effects occurred that were not initially easy to predict.

In your last newsletter, you were discussing the lack of evidence for the safety of high-dose vitamin D treatments. Granted, a single 86-patient study does not prove the case, but for what it is worth, here is something I came across on the Web. Long-term high dose vitamin D well tolerated: A research letter published in the October 26, 2009 issue of the American Medical Association Journal Archives of Internal Medicine revealed that treatment with 50,000 international units (IU) of vitamin D2 per week was safe and effective over an 8 week period, and could also be safe to use every other week as maintenance. In their introduction to the article, the authors, from Boston University School of Medicine, note that "The worldwide prevalence of vitamin D deficiency is striking, and more than 40 percent of the population may be vitamin D deficient. Despite this, to our knowledge, there are no long-term studies of the safety and efficacy of giving pharmacologic doses of vitamin D (50,000 IU of ergocalciferol) to treat and prevent vitamin D deficiency." "To prevent recurrent vitamin D deficiency and also to maintain adequate levels in patients who are vitamin D sufficient, we treat with 50,000 IU ergocalciferol every other week indefinitely, a regimen that, to our knowledge, has not been published to date," they write. The researchers, including well-known vitamin D authority Michael F. Holick, PhD, MD, reviewed medical records of 86 patients aged 18 to 91 who had received two or more blood tests for 25-hydroxyvitamin D levels and were treated for vitamin D deficiency or insufficiency. Pretreatment 25-hydroxyvitamin D levels of 92 percent of the patients were below 30 nanograms per milliliter (ng/mL). Forty-one subjects received 50,000 IU vitamin D2 (ergocalciferol) weekly for 8 weeks followed by a maintenance dose of 50,000 IU every other week for up to 6 years. The remainder of the patients received every other week maintenance therapy without the initial weekly treatment. For the 41 patients who received the weekly 50,000 IU starting therapy, average 25-hydroxyvitamin D levels rose from 19 ng/mL to 37 ng/mL after 8 weeks. Maintenance therapy increased these levels to an average of 46 ng/mL. For the patients who received only maintenance therapy, 25-hydroxyvitamin D levels increased from an average of 26 ng/mL to 47 ng/mL. Serum calcium levels, which could be an area of concern when high amounts of vitamin D are ingested, did not change over the course of treatment. No kidney stones or other signs of vitamin D toxicity were observed. "Vitamin D2 is effective in raising 25-hydroxyvitamin D levels when given in physiologic and pharmacologic doses and is a simple method to treat and prevent vitamin D deficiency," noted Dr Holick, who is a director of the General Clinical Research Unit and professor of medicine, physiology and biophysics at Boston University School of Medicine. "While treating and preventing vitamin D deficiency, these large doses of vitamin D2 do not lead to vitamin D toxicity," he concluded.
    Thanks for sharing this information. It appears the daily dosage is about 3500 iu a day. Several questions still remain: Is longevity enhanced by such dosages or are there certain potential medical problems that have not been noticed, for instance increased calcification in arteries? Would lower dosages have similar benefits with fewer side effects? Just because one does not notice an obvious toxicity does not mean no harm is occurring in certain parts of the body. It took the medical community several decades to realize that hormone replacement therapy was actually increasing the risk for heart disease, blood clots and cancer. High dosage vitamin D use is just beginning now in the US by many people and it may take a long time before we find out the full consequences, good and bad.

i just wanted to mention that i've been taking between 5000 and 6,000 i.u a day for many yrs and recently my doctor did tests and said that my vitamin D levels were great, I know that i seem to feel better when I take this amount, rather than less, the test was labeled Vitamin D, 25-Hydroxy 'm not sure what this represents, my doctor doesn't test for just the normal stuff, I've had many tests in my life, i'm 57.

Thank you for the wonderful and balanced medical advice you provide. I would like to comment on Vitamin D. It seems from my experience and the studies I have read about it that levels are increasingly running low. Several female friends of mine, my mother and myself have all been found to have low vitamin D levels. While I like your cautious approach in discouraging people from randomly taking high doses for an extended period of time, I do feel it is vitally important for women, especially menopausal women who are prone to osteoporosis, or have it, to automatically be tested. I have been being treated for osteoporosis with no sign of improvement for years. We then found out how low my D levels were. I am hoping that bringing them up will help the absorption of calcium and the Boniva for the treatment of the osteoporosis.
    Each person is free, if they can afford it or have insurance, to get tested for vitamin D levels. However, there is no evidence that testing tells a medical doctor with the appropriate dosage that should be used for supplementation. For instance, if the blood levels comes back as 25 ng/ml, one doctor may feel a person needs no additional supplementation, whereas another doctor may think it would be a good idea to take 1000 units and a third doctor may think 2000 units is best while another opinion may be to take 5000 units. When should a person be tested again and how often? Adding the doctors visits and the testing can result in several hundred dollars or a thousand dollars more a year to health care costs. Plus, how do we know in the long run whether taking such additional amounts will be helpful or harmful? What if we find out years from now that taking these high amounts leads to calcification of arteries in the brain that accelerates dementia? Many people think that the more testing they do and the more results they have about the various levels in their blood of certain vitamins, hormones, liver function, kidney functions, Chest X-rays, mammograms, bone density tests, etc., the healthier they will be. There is no evidence that excessive testing improves health or longevity. In fact, excessive testing can be counterproductive. There is too much testing done in this country as if there is no limit on money we have to spend on health care.  The amount of money that we spend on unnecessary testing raises insurance costs for everyone and everyone's taxes if such testing is done for those on Medicare. As Americans we have to start changing our viewpoints that all testing is good. It's not, unnecessary testing has drawbacks, both for health reasons and finances.

I have studied your book Mind Boosters and now read your newsletter for a more cautious, low dose, approach to supplements. My Kaiser doctor is biased against supplements recommending only drugs and surgery for my last five medical conditions - from osteoarthritis in the knee to tachycardia and even a small brain tumor (acoustic neuroma). I manage all five conditions quite nicely thank you, using diet, exercise, and supplements - somewhere around 20, but larger in dose than you seem to recommend. For example I consume almost 20 grams of soluble oat fiber per day plus supplements that claim to stimulate bile flow. On this protocol my lipid profile changed so dramatically that I now find my HDL (at 95) greater than my LDL (at 70). With regard to vitamin D. I rely on the work of Dr John Cannell at the Vitamin D Council. He has written several papers. All the patients in his ward in a mental hospital were replete with vitamin D because of a experiment he was conducting to see if there was any affect on schizophrenia. A flu ravaged the hospital but none of his patients got it. He talks about lifeguards producing 10,000 IU of vitamin D per day. He recommends a protocol of 50,000 per day for three days at the first sign of the flu. My daughter, a 32 year old waitress in NYC, followed this and felt well enough to go out partying 36 hours after onset of fever, chills etc. Because of my Melanoma (and widespread cancer in the family) I avoid the sun. I have dosed at 5000 IU daily for a year and my vitamin D only rose from 40 to 50 ng/dL. Over at Grass roots health website you can see a chart of levels and read about levels above 60 for cancer protection. I am swinging on the information in books like yours and these pages and wanted your rebuttal to the orthomolecular logic that just as a 150 lb goat will produce 10,000 units of vitamin C in response to a pathogen and humans produce 10,000 IU of vit D in summer, then it is safe to dose at these levels for extended periods?
    There are several points to keep in mind. Firstly, the amount of vitamin D made by sun exposure is done so gradually throughout the day as opposed to taking a 10,000 unit pill that raises blood levels excessively high right away. Second, is there any evidence that people who are exposed to such high amounts daily are healthier and live longer? Thirdly, Is it possible that a daily intake of 1000 units is just as beneficial as taking 10,000 units and probably with fewer side effects?

About your ultra-caution when it comes to vitamin D3: Is there any evidence at all that there is a connection between vitamin D3 and blood vessel calcification? Do people who spend a great deal of time absorbing sunlight have a greater degree of calcification than those who do not? And what of the evidence recently from Scotland that increased sunlight alleviates MS symptoms, sometimes to the point of reversal of the disease? Does one trade MS for later calcification?
    I am not sure my position is ultra-cautious since I am advocating supplementation but not as much as some doctors who are advocating the use of massive dosages. Earlier on this page I review the potential adverse long term reactions that could occur with excessive use. There are many unanswered questions regarding the ideal dosage of this natural hormone for long term use and there are no clear cut answers at this time.

I agree with your position on vitamin D, especially in high dosages. Having worked with antiopiates in treating autoimmune diseases while working on my PhD, I am sure that the opiate modulating effects of sun exposure play a significant factor in the observed clinical benefits attributed to vitamin D. In fact, I would personally bet that vitamin D is likely a biomarker for opiate modulation through ultraviolet exposure, and thus simply taking vitamin D may only be emulating one measurable biological change associated with this exposure. I don't deny that vitamin D has beneficial effects on health, but not to the extent that is currently attributed to this vitamin. Keep up the good work! While we are in the honeymoon stage in the medical profession’s embrace of Vitamin D supplementation for a whole host of conditions, and prevention of even more conditions, this love affair should perhaps be tempered, especially for those that advocate chronic administration of high dosages. Many, if not most, of the heath benefits currently attributed to Vitamin D are immunological in nature, or rely on changes in immunological functioning. It is likely best to temper sweeping medical claims currently attributed to this vitamin, at least those made simply by measuring Vitamin D and correlating these levels with positive health benefits. Studies have shown increased calcification of soft tissues associated with increased Vitamin D intake, which should not be overlooked, especially with long term use at high dosages. Many chronic tanning booth users show classical opiate withdrawal symptoms when given an opiate antagonist such as naltrexone, clearly demonstrating that opioids role in maintaining health should not be a factor to be dismissed so readily.

On several occasions I have tried vitamin D3 in different forms - gel capsules and sublingual tablets - and different dosages. After each dose, with as little as 200 IU, within approximately 1 hour, I experience spasms under my right rib cage in the area of my liver. I've never experienced this effect before with anything else. I am in my 40s, have no known health problems or complaints, and am in excellent physical condition.

I read the letter from Nyles Bauer regarding Vitamin D, tanning booth users, etc, and a thought came to mind. Are there any benefits to tanning booth use, in great moderation, of course? I ask this because several years ago in January (I live in Delaware), I was suffering from a sinus infection and a general feeling of malaise. Having read extensively about "light" therapy, I decided to try a stand-up tanning booth. (I refused to use those beds reminds me of a coffin, not to mention the bacteria that may be lingering there.) I tried only 4 minutes and the effect was fairly intense. The sinus infection cleared up the next day (without antibiotic use or other medication), and the feeling of euphoria I experienced helped markedly with the malaise. I used the booth two more times that winter, each time at four minutes, with good results. What is your opinion regarding tanning booths in moderation?
    As long as you stay in them for a short period of time and infrequently I think they are safe, and it appears in your case the experience has been beneficial.