Wednesday, December 17, 2008

Physiologic Actions and Benefits of Vitamin D: DOSING

Many practitioners may be 'shy' when initiating vitamin D therapy for replacement. They may have learned in school (20-40 yrs ago) about risks of hypercalcemia (high blood calcium), kidney stones and other horrific adverse effects associated with toxicity. We'll debunk this myth in the next post.

Goal Vitamin D [25(OH)D]: 60 - 80 ng/ml

Magnesium goal: upper end of normal about 2.2 to 2.3 mg/dl (range 1.7 mg/dl-2.3 mg/dl)
Calcium goal: lower end of normal about 8.5 to 9.5 mg/dl (range 8.5-10.3 mg/dl)
Parathyroid hormone (PTH) goal: lower end of normal 10 to 20 pg/ml (range 10-65 pg/ml)


OTC Vitamin D costs me about $2 per month (Carlson's Solar D Gems 4000 IU-capsules ~$30/360 or NOW brand 5000 IU-capsules ~$8/120. Roughly 7 to 8 cents per day.

I don't need a doctor's prescription (so convenient for me).

For optimal multi-organ functioning and longevity, hey!, 7-8 cents/day is a fraction of the cost of the triple-shot-latte from Peet's coffee (~$5 + gas) I frequently indulge in (though much much less now BTW).

Of course Dr. Davis has already talked about the non-toxicity of Vitamin D in his practice (consisting of thousands of patients). Personally, I have never witnessed an elevated blood calcium (unless the patient had a parathyroid tumor and/or had very low Magnesium (less than 1.6-1.8 mg/dl) and/or low Free T4 T3).

Another expert on Vitamin D dosing is Dr. Cannell of the non-profit Vitamin D Council in California. Several years ago, he co-authored a fabulous CME (continuing medical education) piece for health care providers. Physicians (like RNs and PharmDs and RDs) need to collect educational units called CMEs annually to keep up with medical advances and treatments.

Great reference for Vitamin D:
THE CLINICAL IMPORTANCE OF VITAMIN D (CHOLECALCIFEROL): A PARADIGM SHIFT WITH IMPLICATIONS FOR ALL HEALTHCARE PROVIDERS (CME)
By Alex Vasquez, DC, ND, Gilbert Manso, MD, John Cannell, MD


Here, Dr. Cannell reviews some basics about dosing and the studies that support using Vitamin D doses that are 10-fold higher than current recommendations (only 400 IU/day). He writes...

"Based on the research reviewed in this article, the current authors believe that assessment of vitamin D status and treatment of vitamin D deficiency with oral vitamin D supplements should be come routine component of clinical practice and preventive medicine. Vitamin D supplementation with doses of 4,000 IU/day for adults is clinically safe and physiologically reasonable since such doses are consistent with physiologic requirements. Higher doses up to 10,000 IU/day appear safe and produce blood levels of vitamin D that are common in sun-exposed equatorial populations. Periodic assessment of serum 25-OH-vitamin D [25(OH)D] and serum calcium (and I'd add M-A-G-N-E-S-I-U-M *wink*) will help to ensure that vitamin D levels are sufficient and safe for health maintenance and disease prevention."




If you live at the equator and stay outdoors the great majority of the time, then there is a slim chance you are NOT deficient. Even Hawaiians (who did not wear sunscreen for 30min daily) were found to be deficient.

Low vitamin D status despite abundant sun exposure.
Binkley N, Novotny R, Krueger D, Kawahara T, Daida YG, Lensmeyer G, Hollis BW, Drezner MK.
J Clin Endocrinol Metab. 2007 Jun;92(6):2130-5.
PMID: 17426097


Severe vitamin D deficiency in Hawai'i: a case report.
Bornemann M.
Hawaii Med J. 2006 Jan;65(1):16-17, 20.
PMID: 16602611


Serum vitamin D metabolite levels and the subsequent development of prostate cancer (Hawaii, United States)
Nomura AM, Stemmermann GN, Lee J, Kolonel LN, Chen TC, Turner A, Holick MF.
Cancer Causes Control. 1998 Aug;9(4):425-32.
PMID: 9794175


A prospective investigation of serum 25-hydroxyvitamin D and risk of lymphoid cancers.
Lim U, Freedman DM, Hollis BW, Horst RL, Purdue MP, Chatterjee N, Weinstein SJ, Morton LM, Schatzkin A, Virtamo J, Linet MS, Hartge P, Albanes D.
Int J Cancer. 2008 Sep 9;124(4):979-986. [Epub ahead of print]
PMID: 19035445



Contraindications to Vitamin D Supplementation
Certain conditions may exist where vitamin D is contraindicated. Dr. Cannell talks about Sarcoidosis, a granulomatous condition where the certain cells over produce activated vitamin D metabolites (1,25-OHD), which can lead to hypercalcification of soft-tissues.

Another condition would be where blood testing cannot be readily done. It is important to follow up and have blood level 'tracking' to not only make sure the levels are adequate but also to avoid excessive over-supplementation.



Dosing
Individual variations, sunlight exposure, stress (mental, physical) and illnesses affect vitamin D levels. Individual genetic variations play a great role as well. Vitamin D is a hormone and the dosing appears to me widely variable when hormone imbalances exist (obesity, high cortisol, high wheat intake, disruption of omega-3 to omega-6 balance, high estrogen in men, high testosterone in women, etc). Optimal dosing depends on the initial blood vitamin D concentration (eg, [25(OH)D]) and then a repeat test in 8-12 weeks. The 1,25-OHD blood test is incorrect. This is a very short-lived metabolite and typically does not correspond to vitamin D blood levels (it may however be elevated in Sarcoidosis).


Blood Testing
How do you know you are vitamin D deficient (eg, blood level less than 60 ng/ml)? You don't. Testing is paramount. LEF offers a blood test which is sometimes on sale for $20. Otherwise most insurance companies cover this test now if the doctor orders it.
http://www.lef.org/Vitamins-Supplements/ItemLC081950/Vitamin-D-25-Hydroxy-Blood-Test.html


Magnesium Supplementation
As bones mineralize and become stronger, crosslinked and denser, minerals from our blood are drawn out to fortify the skeleton. A notably co-factor for about 375 different enzymatic reactions is Magnesium. Do you remember Mg++ ATPase from biology? (Mg is the elemental abbreviation) Magnesium it turns out acts like a STATIN -- yes indeedy -- it raises HDL cholesterol (the 'good' stuff), lowers sdLDL cholesterol and TG by affecting the rate-limiting step in cholesterol synthesis and desaturases (Seelig MS et al J Am Coll Nutr. 2004 Oct;23(5):501S-505S.). At this time in fact, Dr. Davis is debunking statins: Statin Drug Revolt. Do we all have a 'Statin-Deficiency'? No, but perhaps a Magnesium one! Magnesium also relaxes muscles including the light/thin muscle sheaths lining our arteries, which subsequently lead to lowering and modulation of the blood pressures. Magnesium is also important in other muscles like a major one, the heart which beats 100,000+ per day. A recent study showed that Magnesium supplementation alone prevented more mortality than conventional heart failure treatment (MACH study Int J Cardiol. 2008 Feb 15.). We deplete Mag in various ways: breathing, living, urinating, sweating to name a few. Magnesium is rapidly depleted via use of 'water pills' or diuretics (including...uuuummm.. caffeine...alcohol...uummm, haven't had any of these lately no000OOsirrreeee *ha*)

Signs of Magnesium depletion or insufficiency may include: headaches, migraines, restless leg syndrome, muscle cramping, Charley horses, irregular heart rates, chronic constipation, etc.

At TYP, various salt forms of Magnesium are used (orotate, oxide, amino acid chelate $$$, malate, citrate, et cetera). My sister likes CALM for its citrusy taste. Yes, MOM (milk of magnesia) and Citrate of Magnesia are laxatives -- so if you take too much, you'll be warming the loo/WC!

Remember to check your calcium and magnesium levels along with vitamin D later and periodically.



Financial Incentives For Health Insurance
There are financial incentives for health insurance companies to NOT ignore vitamin D Deficiency -- costs for treating 'expensive' conditions like cancer, autoimmune diseases and diabetes are estimated to be reduced by many experts, epidemiologists and scientists.


Avoidance of Prescription SYNTHETIC Vitamin D2 (Ergocalciferol)
All synthetic hormones and vitamins should be suspect. They are not identified, metabolized, activated or eliminated in the human/mammalian body as well as the naturally-occurring structures. In a few anecdotal references, Vitamin D2 (synthetic, fake) has been reported to not only less therapeutic in correcting and ameliorating secondary hyperparathyroidism (elevated PTH due to low vitamin D), but also in producing higher blood glucoses in individuals with a certain vitamin D polymorphism. Toxicity (when it does occur) is also reported significantly more with synthetic vitamin D2 compared with natural D3.
Vieth 1998 Am J Clin Nut Vitamin D3 1.7x more potent than D2 (but reported potency outdated)
Vieth R The Case Against Ergocalciferol (eg, Vitamin D2 fake/synthetic stuff)



Disclaimer: I have no financial ties to NOW, Carlson's, or LEF.

17 comments:

Andrew said...

I read an article recently about Vitamin E not being as good for you as common beliefs say it is. I was wondering if you had read that or heard anything like that and could comment on it.

Anna said...

You are so right about the Vit D doses generally being too low. My tests were still in the low 40s with either a dose of 2000-3000 iU or now supplementing but with more summer sun, so I have raised my dose to 5000/day this fall and winter.

I began giving my 75 lb 10 yo son 3000 iu/day (based on the Vit D Council's recommendation) when school began because he's outdoors far less. Not long ago he had to have some blood drawn for something else, so I asked to have the 25 (OH)D test done, too. He tested at a great level, 72! I'll back off the Vit D supplements when school ends for the summer.

Nearly everyone I know locally in the San Diego region of Southern CA (sunny!) who has had their levels tested was either deficient or very low in the reference range (lower than my levels). Not all of them avoid the sun either, but al work indoors, etc. One just can't assume living in a sunny climate is enough for adequate levels.

We're waiting to see what my husband's Vit D level is. Not long ago we had a sort of unexpected experiment for Vit D's immune boosting potential. My husband was out of town with our son Thurs-Sun (attending the last nighttime space shuttle launch). Sunday night he had a flare-up of diverticulitis (I suspect antibiotic residue-laden feedlot beef from an airport TGIFridays killed off his good gut bacteria) so we went to Urgent Care that evening (son stayed with neighbors). Tuesday morning my husband and I had symptoms of a cold developing, most likely picked up in the Urgent Care waiting room (and we used the alcohol-based hand sanitizer dispenser on the wall on the way out but those are ineffective on viruses anyway). I immediately started taking 12,000iU Vit D per day for about a week (3 x Carlson 4,000 iU Solar Gems) and the cold stalled, then subsided in about 2-3 days.

My husband just took his usual 4,000 iU Vit D a day and he got the full, miserable cold and still has a lingering cough from it. Granted his immunity wasn't great due to the antibiotics he needed to take for the diverticulitis (but he also took probiotics with them), but still, he wants the Vit D mega-dose next time he thinks a cold is coming. I've been doing this high dose for colds for almost 2 years and if I start at the first sign, don't miss a day, and keep the dose high enough, the cold doesn't progress and subsides.

Since the cold, he's agreed now to take 8,000iU a day, per the Vit D Council's recommendation of 1000 iU per ea 25 lbs body weight.

Dr. B G said...

The HATS trial had an arm with antioxidants including Vitamin E. I'm pretty sure synthetic Vitamin E was used (like most trials). The researchers found that Vitamin E + C negated some of the benefits found with regression/stabilization that occurred in the niacin arm (90% reduction in mortality, CAD events).

Hope that helps.

Dr. B G said...

Anna,

No matter where we are geographically, it appears Vitamin D deficiency is pandemic! My father-in-law will be getting his level back soon. His dose is 12,000 IU daily in the AM and I'm not even sure if the dose corrected his deficiency yet. Last checked it was only 46 ng/ml on 8000 IU daily.

My children need a blood test but I'm more worried about the trauma than they are...*sigh* I'm hoping the LEF test will be less painful (psychologically speaking, for all involved).

Hope the shuttle launch was neat!!

Like you, I triple/quadruple up on the vitamin D dose as I feel a cold coming on -- didn't hit it right either this past cold however! But I was already low on my dose as I did an experiment with stopping it completely over the summer. Last week, the vitamin D was only 60 ng/ml and that explains why I haven't felt super-optimal (and why I still succumbed to a cold). I feel best at 75 ng/ml.

I like n=2 experiment! (sorry about the TGIF-induced diverticulitis)
You'll appreciate my little experiment: I gained about 5-10 lbs when the vitamin D level dropped this summer (no it wasn't just the Alaskan cruise delish food!). I stopped for 1mon to see what happened (no labs drawn). Do you think that signalled hibernation? I typically lose weight in the summers -- not so this summer (though I have a fair bit of hormone issues going on). I worked a little harder/more (and took my D again) and now I've lost 7 lbs *pphhheeewff* finally.

Like your hubby, I won't be dilly dallying around with my vitamin D dose AGAIN. ever! I learned the hard way.
-G

Anonymous said...

TYPO Report: "heart which beats 100,000+ per minute."

Anonymous said...

Andrew: Here are some links to some good articles on Vitamin E to help dispel any doubts you may have to its effectiveness:

www.lef.org/magazine/mag2006/apr2006_report_gamma_01.htm

www.lef.org/featured-articles/Rebuttal-to-Recent-Attacks-Against-Dietary-Supplements.htm

Dr. B G said...

Thanks for the TYPO correction!

AND thanks also the vitamin E info!!

Anonymous said...

Andrew, my vitamin E/gamma tocopherol link earlier was not correct. Here is the correct one:

http://www.lef.org/magazine/mag2006/apr2006_report_gamma_01.htm

George must lose weight said...

"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."

http://www.sciencedaily.com/releases/2008/01/080125223302.htm

Vitamin recommended daily Allowances:

http://www.vitalhealthzone.com/nutrition/vitamins/vitamin_D.html#7

Toxic levels are defined as 10,000 IU - less than some of you dose!

How does one know who to trust as the RDA seem to vary from country to country

Dr. B G said...

George,

Some of the links are not in context with what has already been published. Vitamin D is a hormone regulated by demand/supply. We use it readily under certain circumstances. Are you off of grains primarily wheat? Wheat reduces the P450 metabolism of vitamin D activitation in our tissues, so basically it blocks the formation. Additionally eating wheat is pro-inflammatory which requires more vitamin D and other hormones to deal with.

-G

George must lose weight said...

I have stopped wheat but....my breakfast used to consist of porridge and apricots plus tea.

I then replaced that with fruit (banana, orange, mixed frozen, apple plus two spoons of whey protein.)

Now, if I don't have either of those and get bored with eggs every day what does that leave?

Also would a simple remedy not just for breakfast but generally be to buy a low carb cookbook and look for recipes high in saturated?

Anna said...

George,

Shake things up for breakfast - don't limit yourself to breakfast clichés. I love my daily eggs, but I know what you mean about needing a break. Think outside the breakfast box.

Leftover salmon is great for breakfast, as is smoked salmon (I often make extra specifically for breakfast or lunch. Cheese, (if you can eat cheese) is also great for breakfast (my favorite is a really good aged cheddar with a half an apple or pear). I like the German hotel idea of breakfast: cold cuts like salami or cured ham or prosciutto with melon. Liverwurst is good too if you can find a good one (with good clean liver).

When I'm in a rush, a few spoonfuls of cottage cheese is good, too (full fat, of course). Chopped fresh figs on top when my tree is in season. Berries are a good topping when they are in season, too.

Go Japanese and have sashimi and sea vegetable salad for breakfast!

Even a cup of steaming homemade chicken bone broth is a great way to start the day. Drop in some cubes of avocado, and diced tomato and chicken meat if plain broth is too boring.

This morning I wasn't in the mood for my usual sunny side up eggs, but instead I had two chopped hardboiled with lots of rich homemade mayonnaise mixed with mustard and lacto-fermented pickle relish. Yum! Sometimes I add fish roe (fish eggs, like caviar, but cheaper) - the little red beads of crunch are out of this world - eggs "squared".

I hope that gets you thinking about breakfast in a new way.

Dr. B G said...

Lovely brilliant Anna!

Your ideas are ALWAYS so spectacular!!!

OK I'm drooling with hunger now...

I can't wait for your cookbook *wink* I'll be one of the first in line to order a CASE.

-G

Anonymous said...

Hi Dr. G -

So I've been supplementing with Nat Calm magnesium for a few weeks now and over this past week I have developed some rumbling/cramping/bloating...do you think I'm taking too much (500ish mg)? Also, I'm currently taking a liquid D from Vitamin Shoppe and just ran out of a tablet iodine. I'm sure there are higher quality forms/brands of these out there - any that you recommend?

Thanks for all you do.

Jessica

Dr. B G said...

Hey Jessica,

Good hearing from you!

Yes -- too much Mag can induce stomach symptoms, loose stools and even explosive diarrhea. In pharmacy school we'd remember the effects of (too much) Mag by the abbreviation Mg... 'must go'. Calcium on the other hand is Ca...'constipating always'.

Personally I don't take it daily but those with symptoms of deficiency -- Charley horse cramps, restlessleg syndrome, migraines/daily headaches, athletes, those with heavy metal toxicity, diabetes, high insulin resistance, those on water pills (diuretics) or injectable insulin probably require daily dosing.

Iodine probably should not be taken without other trace minerals... like selenium, adequate zinc and others. There is a balance. Iodine alone without the others actually may be harmful in some reports that I've read. Like vitamins ADEK2 -- an adequate amount of all is the most beneficial for optimal functioning. Liquid vit D is fine -- I believe Kurt uses it.

For stomach upset, many find Mag Malate one of the best forms. If you have $$$ Mag Taurate is awesome :)

I like:
NOW vitamin D3
Thorne Trace minerals
NOWs ZMA (mag+zinc) rotated with Zinc glycinate and Mag Citrate
Calm (like yours, but I don't prefer the taste)
Iodaral tab or Iosal drops (must buy from their respective websites or iherb.com)

I found some other resources that you might find helpful! I sure did to help me to understand the female cycle better and some proven nutraceutical strategies.

http://coastherbal.com/web_standard/adrenal_stress.html
http://coastherbal.com/web_standard/female_cycle_difficulties.html

The author is fantastic!

Hope that helps and will look forward to hearing your progress and questions,

-G

trinkwasser said...

Best plan with msgnesium is to up the dose until you get the squits, then back off.

Our plumber tested our water as the hardest he'd ever some across, almost purely calcium. I was already doing 300mg magnesium citrate per day whch fixed my leg cramps without moving my bowels more thsn average and pretty well nailed my electrolytes. Now I know why.

Calcium and magnesium come as a matched pair, like sodium vs. potassium.

Dr. B G said...

hey Trinkwasser,

Thank you for reading!

Isn't it funny how there are easy solutions sometimes for our ails?

Recently I added bone broths to our diet as a calcium source. My mother always told me to chew on the bones but I have not enforced with my own kids. Sounds like your water is a great natural source, much like a natural mineral spring!

-G