Vitamin D and Your Health Treatment

by Dr. John Jacob Cannell MD of the Vitamin D Council

Treating Disease With Vitamin D

We predict the future recommended daily allowance (RDA) for vitamin D, for otherwise healthy people, will be at least 1000 IU/day (in the new official units for vitamins, this translates to 25 ug/day). This amount is already the consensus of nutrition experts in the field of osteoporosis and vitamin D. Such recommendations only apply to healthy people. If you have vitamin D deficiency, or the diseases of vitamin D deficiency, you need to be under the care of a physician.

Monitoring 25(OH)D Levels

In-Home ZRT Vitamin D Blood Test Kit Take control of your health by monitoring your own vitamin D levels! We predict that treatment with physiological doses of vitamin D3 (between 4,000–10,000 IU/day from all sources, including sun, food and supplements) along with periodic monitoring of blood calcidiol and calcium levels will become routine. Zittermann A. Vitamin D in preventive medicine: are we ignoring the evidence? Br J of Nutr. 2003;89:552–572. Holick M. Vitamin D: A Millennium Perspective . J Cell Biochem. 2003;88:296–307. Research indicates it will help several vitamin D deficiency-associated diseases such as: autism, autoimmune illness, cancer, chronic pain, depression, diabetes, heart disease, hyperparathyroidism, hypertension, influenza, myopathy (neuromuscular disorders), and osteoporosis.

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. If you have little, or no, sun exposure you will need to take at least 5,000 IU per day. How much more depends on your latitude of residence, skin pigmentation, and body weight. Generally speaking, the further you live away from the equator, the darker your skin, and/or the more you weigh, the more you will have to take to maintain healthy blood levels.

For example, Dr. Cannell lives at latitude 32 degrees, weighs 220 pounds, and has fair skin. In the late fall and winter he takes 5,000 IU per day. In the early fall and spring he takes 2,000 IU per day. In the summer he regularly sunbathes for a few minutes most days and thus takes no vitamin D on those days in the summer. The only way you can know how much you vitamin D you need to take is by repeatedly getting your blood tested—known as a 25(OH)D test—and seeing what you need to do to keep your level around 50 ng/mL.

Infants and Children

Infants and children under the age of one, should obtain a total of 1,000 IU (25 mcg) per day from their formula, sun exposure, or supplements. As most breast milk contains little or no vitamin D, breast-fed babies should take 1,000 IU per day as a supplement unless they are exposed to sunlight. The only exception to this are lactating mothers who either get enough sun exposure or take enough vitamin D (usually 4,000–6,000 IU per day) to produce breast milk that is rich in vitamin D. Formula fed babies should take an extra 600 IU per day until they are weaned and then take 1,000 IU a day, as advised below.

Children over the age of 1 year, and less than 4 years of age, should take 2,000 IU vitamin D per day, depending on body weight, latitude or residence, skin pigmentation, and sun exposure.

Children over the age of 4, and less than 10 years of age, should take 3,000 IU per day, unless they get significant sun exposure. On the days they are outside in the sun, they do not need to take any; in the winter they will need to take 3,000 IU every day.

Children over the age of 10 years old should follow instructions for adults detailed above.

Vitamin D Upper Limit

If you absolutely avoid the sun, you should have your 25(OH)D level measured and remember that a maximum of two pills a day (50 ug or 2,000 IU) is the upper limit (UL) currently listed by the Food and Nutrition Board as the amount not to exceed unless under the care of a physician. When it comes to vitamin D, the right amount is good—a lot is not better and can be dangerous. However, 2,000 IU a day is simply not enough for many people to get the full benefit of vitamin D, nor is it enough to keep vitamin D levels around 50 ng/mL, especially in the winter.

Maintaining 25(OH)D Levels

If you are suffering from any of the diseases associated with vitamin D deficiency you need to be under the care of a knowledgeable physician. Your physician needs to replete your vitamin D system with sunlight, artificial light, oral vitamin D, or a combination of the three, while treating your vitamin D deficiency illnesses using conventional means. Regardless of the method used, we believe your physician should be certain your 25(OH)D levels are maintained between 50–80 ng/mL.

For those who do not fear the sun, judiciously expose as much skin as possible to direct midday sunlight for 1/4 the time it takes for one's skin to turn red during those months when the proper ultraviolet light occurs at one's latitude (usually late spring, summer and early fall). Do not get sunburned. Vitamin D production is already maximized before your skin turns pink and further exposure does not increase levels of vitamin D but may increase your risk of skin cancer. Black patients may need 5–10 times longer in the sun than white patients, depending on skin type. After several months of judicious sun exposure, a 25(OH)D level should again be obtained to ensure levels between 50–80 ng/mL…

…As far as vitamin D supplements are concerned, we believe cholecalciferol is the preferred oral form of vitamin D, as it is the compound your skin makes naturally when you go in the sun. It is more potent and perhaps even safer than the synthetic analog, ergocalciferol, in more common use. 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. Cholecalciferol is 1.7 times more efficient at raising 25(OH)D levels than is ergocalciferol. Trang HM, Cole DE, Rubin LA, Pierratos A, Siu S, Vieth R Evidence that vitamin D3 increases serum 25-hydroxyvitamin D more efficiently than does vitamin D2 Am J Clin Nutr. 1998 Oct;68(4):854–8.

Calcitriol Contraindicated in Vitamin D Deficiency

Ergocalciferol has been used safely by physicians for years for a variety of indications. Unfortunately, when doctors don't prescribe ergocalciferol, they sometimes prescribe calcitriol or newer analogs of calcitriol, costing thousands of times more than cholecalciferol. Calcitriol, and its analogs, are contraindicated in vitamin D deficiency because they may cause hypercalcemia and they fail to address the real problem: low stores of 25(OH)D. Cholecalciferol repletes the vitamin D system by filling up your vitamin D tank with 25(OH)D, the vitamin D fuel. Vieth R. The pharmacology of vitamin D, including fortification strategies. In:Feldman D, Glorieux F, eds. Vitamin D, Chapter 61, in press, 2nd ed. Academic Press, San Diego.

Giving calcitriol, or its analogs, for vitamin D deficiency is like shooting ether into your engine to keep your car running. In addition, they pose a significant risk of hypercalcemia (high blood calcium). If you have a simple vitamin D deficiency and your doctor insists on prescribing calcitriol or an expensive analog of vitamin D (other than cholecalciferol or ergocalciferol), find another doctor.

Hypersensitivity Not Toxicity

Vitamin D hypersensitivity syndromes are often mistaken for vitamin D toxicity. This rare syndrome occurs when abnormal tissue subvert the kidney's normal regulation of endocrine 1,25(OH)2D3 (calcitriol) production. Aberrant tissues, usually granulomatous in nature, convert 25(OH)D into 1,25(OH)2D3 causing high blood calcium. The most common of such conditions are sarcoidosis, oat cell carcinoma of the lung, and non-Hodgkin's lymphoma although other illness, such as primary hyperparathyroidism, can cause the syndrome. Periodic measurements of 25(OH)D levels and serum calcium will alert the physician to the need to do more tests, such as 1,25(OH)2D3 or PTH.

Toxicity is simply not a concern in doses below 10,000 units a day. Restoring physiological serum levels of 25(OH)D will help many more patients than it will hurt.

John Jacob Cannell MD Executive Director 2004.12.14

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