If, like me, you are doc who is increasingly screening for and finding vitamin D deficiency, you’re probably wondering the best way to replenish body stores of this essential vitamin.
I have found that simply telling my vitamin D deficient patients to increase their daily intake of Vitamin D3 to 800-1200 IU does not result in adequate levels. I have had success using 50,000 IU Ergocalciferol (Vit D2) weekly for 12 weeks, transitioning to 1000-1200 IU Vit D3 daily after that for long term replacement.
Now a study has been published showing that a regimen of 50,000 IU ergocalciferol weekly for 8 weeks, followed by 50,000 IU ergocalciferol every other week is effective for up to 6 yrs at restoring and maintaining adequate vitamin D levels in most vitamin D deficient patients. For those with normal levels to start, the every other week regimen alone is sufficient to maintain them. This regimen is fairly cheap, about $6 a month here in NYC.
This study reinforces the results of another recent study showing that, for most patients, Vitamin D2 is as effective as D3 in restroing and maintaining normal levels of vitamin D.
That’s good to know.
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11/30/10 UPDATE – New IOM guidelines tell us that levels of Vitamin D at or above 20ng/dL are normal, levels above 30 ng/dL have no proven benefit, and levels above 50ng/dL may be harmful. Most of my patients have levels in the mid 20’s, even with treatment, so I find this very reassuring.
Hi 🙂 I'm a dietitian in NJ. For someone who isn't experiencing a deficiency (i.e. symptoms) but just wants to cover their bases, do you feel 800-1200 IU is adequate?
I generally recommend 1000 IU supplemental D to my clients preventatively, in light of the difficulty obtaining vitamin D from food.
Thanks for the great blog 🙂
Georgie Fear RD
I would never dispute that low D levels are associated with illness. However you may recall the case of antioxidants, there is a precedent for such an association misleading researchers as to the effect of supplements. When the results the results of well designed longitudinal studies are in we will know if vitamin D is different.
Mad dogs and ….
"It looks like natural selection has aimed for an optimal vitamin D level substantially lower than the recommended minimum of 75-150 nmol/L. This in turn implies some kind of disadvantage above the optimal level.[…]
High vitamin D intake is associated with brain lesions in elderly subjects, possibly as a result of vascular calcification (Payne et al., 2007). Genetically modified mice with high vitamin D levels show signs of premature aging: retarded growth, osteoporosis, atherosclerosis, ectopic calcification, immunological deficiency, skin and general organ atrophy, hypogonadism, and short lifespan (Tuohimaa, 2009). Vitamin D supplementation during infancy is associated with asthma and allergic conditions in adulthood (Hyppönen et al., 2004)"
The 4 subsequent posts on vitamin D are also relevant.
Lere – I agree that caution is advised in terms of any vitamin treatment, including D, and I would never use pharmacologic doses of vit D except in those diagnosed as deficient, usually in my practice, with accompanying osteopenia or osteoporosis. I follow levels in those I treat. I have seen rebounding of bone mass with restoration of normal vit D levels in these individuals.
I tend to use the 10,000 IU weekly or 1000-1200 IU daily for maintenance of levels, but have not seen it work in everyone.
I tend to use the 10,000 IU weekly or 1000-1200 IU daily for maintenance of levels, but have not seen it work in everyone.
Surely if someone is deficient their body would hoover the stuff into the blood. Doesn't that make you make you wonder …
Quote:
"Two studies showed that in response to a given set of ultraviolet light treatment sessions, the absolute rise in serum 25(OH)D concentration was inversely related to the basal 25(OH)D concentration. In the study by Mawer et al (34), the increase in 25(OH)D in subjects with initial 25(OH)D concentrations <25 nmol/L was double the increase seen in subjects with initial concentrations >50 nmol/L. Snell et al (27) showed that in subjects with initial 25(OH)D concentrations <10 nmol/L, ultraviolet treatments increased 25(OH)D by 30 nmol/L, but in those with initial 25(OH)D concentrations approaching 50 nmol/L, the increase was negligible."(Vieth 99)
Why are Europeans white?
"First, if lack of this vitamin created the selection pressure that led to white European skin, why are Europeans genetically polymorphic in their ability to maintain blood levels of vitamin D? At least two alleles reduce the effectiveness of the vitamin-D binding protein, and their homozygotes account for 9% and 18% of French Canadians (Sinotte et al., 2009). If lack of this vitamin had been so chronic, natural selection would have surely weeded out these alleles. And why does European skin limit vitamin-D production after only 20 minutes of UV-B exposure? (Holick, 1995). Why is such a limiting mechanism necessary?"
Use of pharmacologic doses of vitamin D by an MD to treat osteopenia or osteoporosis is something I'm not going to comment on; I don't know enough about it.
However I am confident that the current recomendations for 25(OH)D concentrations are far too high and are deleterious, especially when they're reached by ingesting 'D' in evolutionarily unprecedented megadoses.
Lere –
Note please that I am speaking about treatment of deficient individuals, not current recommendations for RDA which at present is 400-600 IU daily, depending on age. Most patients on the regimens I use attain levels between 35-40 nmol/L.
Georgie-
For individuals whose vit D levels are normal, I tend not to recommend much since whatever they are doing seems to be working just fine, whether it's getting sunshine or taking a multivitamin. Usually that's the RDA.
Don't forget that vit D levels vary with the season, and are lower in winter.
Most experts think the current RDA's are too low, and will end up somewhere in the 1000-1200 range when it all shakes out, but we will have to see.
40 ng/mL X 2.5 = 100 nmol/L
Clearly you are cautious about boosting vit D. I'm sceptical about the current recomendations as to the desirable range for serum vitamin D levels. It's simply not credible that higher D level are beneficial but the body fights attaining them.
'Most experts' were 100% wrong about antioxidants and the 'shaking out' came in the form of excess mortality that stopped several of the trials.
Vitamin D and homeostasis
"Robins (2009) goes on to note that nearly half of all African Americans are vitamin-D deficient but show no signs of calcium deficiency. Indeed, they “have a lower prevalence of osteoporosis, a lower incidence of fractures and a higher bone mineral density than white Americans, who generally exhibit a much more favourable vitamin D status".”
I don't doubt that someone with the beginings of osteoporosis might not have any choice but to raise their 25(OH)D concentration – but that's vitamin D as a medicine.
For the average people who get an average amount of sun their natural level is the heathiest level for them. Europeans have been living though their winters for 25,000 years and Britain for example is at a higher latitude than the Canadian border.
Dr. Polaneczky,
It is great that you are following patients for osteoporosis even though you're a gyn. Do most women tend to turn to their gyn as their primary care doctor? I myself haven't been to a primary doctor in quite a while.
Umm, what about the sun?
Lere – sorry – wrong units – I meant ng/ml. But you knew that. You were just being a smarty pants.
Still not sure why all the comments – seems you and I pretty much agree. I"m talking about treat ing vit D deficiency in folks with consequenced of that deficiency – namly bone loss. I am NOT talking about what everyone should take as a daily supplement. I thought my post title makes that pertty clear, in fact, I was caeful to address it to docs who are treating vit D deficiency.
Cecilia –
Lots of docs screen and treat for bone loss – internists, family practice docs, gyns, oncologists, endorcinologists, GI docs.
Anonymous – that's why I have MR SUN up there in the picture (which I made myself, thank you very much….). Easiest way to get vit D that I know of. Problem is, some of use (see my posts about my basal cell cancer on my nose) need to avoid sun.
Thanks for reading.
So, wow, cook, physician, and now artist! 🙂 Great pic!
bardiac-
I actually didn't exactly "draw" every part of it – that's why god made clip art. I did draw the liver, the kidney and the intestine.
Yes, I agree that evidence seems to indicate that 400 IU for the RDA may not be quite enough, and seldom do I meet someone who gets even that much from food. I think raising the RDA would be a good step, but that alone wouldn't increase most people's intake.
I'm interested too to see where it ends up. And also kind of glad I don't have to make those decisions, haha.
Georgie Fear
http://www.askgeorgie.com
As a pharmacist, I would caution you to be careful in prescribing ergocalciferol. As an OB-GYN, you might not get into problems with young women who don't take many medications, you could seriously cause issues with older women who are being seen by other physicians. However, your young pregnant patient could cause fetal damage with too much Vit D.
Ergocalciferol interacts with digoxin, diltiazem, verapamil & others. It also is associated with stiffening of arteries, particularly those in the kidney.
I agree with the individual who suggested this phase of Vit D replacement is being over-done. It only takes 20 min of sunlight 2-3 times a week to obtain enough Vit D. (You don't need it on your face, although indirect sunlight on your retinas have shown to help with circadian rhythm dysfunction. It is best on arms & legs – larger surface area.) Additionally, the body stores it in fat, so folks don't need that sunlight every week – speaks to the poster who suggested we have evolved to maintain the normal levels we need and why people in Canada, Norway & England function just fine.
The best treatment for osteopenia is excercise – impact excersie – walking, running, tennis, treadmills, running up & down stairs with the laundry, etc…. Also – a good varied diet helps – dark green leafys & milk.
The less medication – the better off you are!
Anonymous –
Appreciate your comments, and your cautions are appropriate.
Please remember that the individuals I am treating are those with osteoporosis and osteopenia and vitamins D levels well below normal, who have failed to respond to standard replacement, many of whom are already doing the kinds of exercise you are talking about. I don't prescribe vitamin D will-nilly – that is why it is a presciption, and not over the counter at these doses. I always check for interactions with medications in my patients. I can tell you that I have had problems getting folks back to normal, despite giving the advice about sunlight, which is in all the written material I give my patients.
I do agree that the hype on vitamin D is sure to die down over time, as yet another miracule cure-all proves its limitations. But in the case of bone loss, it is a welcome alternative to the bisposphonates, which in my opinion are being overused.
BTW, the studies discussed by Lere above relating to the brain did not separate calcium from vitamin d intake – Excess calcium appears to be the culprit rather than vit D itself. One must use caution with calcium, especially when taking adequate vitamin D. (Note a previous post I did on calcium over there in my tasting menu…)
I spend a lot of time with my patients getting them to cut back on their calcium. Many are taking upwards of 1000 mg of calcicum daily in addition to dietary sources, and that is just too much.
Remember you have to be smart and tally up how much calcium you are getting in your diet, then only take the difference between that and the RDA. If you are getting enough D, I would aim for the lower range of the calcium RDA.
Eep, now I'm going to have to do the math… multi vitamin + calcium with D… hmmmm.
I have to admit, it never occured to me that I could be taking too much calcium; everyone always stresses taking enough.
My capcha is "twinge."
Vitamin D is not a Vitamin as such; it is a hormone. As a hormone it is a signal. My conjecture is that Hormone D is a clock signal which is supposed to vary up and down synchronizing the body with the season. If so, it would be the differential effect of Hormone D which is important, rather than the absolute level. Stopping your Hormone D at a particular level might therefore be equivalent to stopping your body clock creating a plethora of pathological effects depending on each individual. Have any studies been done on this?
Winter season is also a season of flu. Taking vaccine is not the only way to resist it but boosting the immune system. Taking food supplement that consists of all essential vitamins, minerals and antioxidants can help our body to defend viruses. Plus, eating nutritious food and taking regular workout should be part of the routine.
Abstract presented at the AACR International Conference on Frontiers in Cancer Prevention Research– Dec 6-9, 2009; Houston, TX
Vitamin D: Panacea or a Pandora's box for prevention?.
Among women, an increased rate of mortality was observed both for deficient concentrations and very high concentrations (>124nmol/L). Results suggest that caution should be exercised in using very high dose vitamin D supplementation in prevention trials that may result in high concentrations of vitamin D (>100nmol/L). "
'Vitamin D Caveat. ( YouTube, March 02, 2010)
'
"High-dose vitamin D supplementation may increase cardiovascular risks ("increase in calcification plaques [for] African Americans and other ethnic groups") , rheumatologist Lenore M. Buckley cautions
'Skepticism Grows Regarding Widespread Vitamin D Supplementation.
Serious questions exist about the safety and efficacy of the popular practice of high-dose vitamin D supplementation across a broad swathe of the population.
One of these concerns is that not all of the extra calcium absorption promoted by boosting vitamin D is going into bone to prevent fractures. Some of it may actually be taken up by atherosclerotic plaque, increasing the risk of cardiovascular events, Dr. Lenore M. Buckley cautioned at a symposium sponsored by the American College of Rheumatology,
This is of particular concern in patients with known coronary disease and for those at high risk, including individuals with rheumatoid arthritis, systemic lupus erythematosus, diabetes, or psoriasis, added Dr. Buckley, professor of medicine at Virginia Commonwealth University, Richmond.
Discussing findings from a recent cross-sectional study involving 340 African Americans with type 2 diabetes, Dr. Buckley said that serum 25-hydroxyvitamin D levels were positively associated with increased calcified atherosclerotic plaque in the aorta and carotid arteries (J.Clin.Endo.Metab. Jan. 8, 2010; Epub ahead of print PMID:20061416).
“The effects of supplementing vitamin D to raise the serum 25-hydroxyvitamin D level on atherosclerosis in African Americans are unknown. Prospective trials are needed,” according to the investigators.
Recently, a large prospective randomized trial assessed the effects of using calcium supplements on vascular event rates, but it did not involve African Americans. The trial involved 1,471 healthy postmenopausal New Zealand women who were randomized to receive either supplemental calcium or placebo. By 5 years of follow up, there were a total of 101 myocardial infarctions, strokes, and sudden deaths in 69 women in the supplemental calcium group compared to 54 such events in 42 control subjects (Br. Med. J. 2008;336:262-66).
[cont.]
There is intriguing evidence to indicate the optimal level of vitamin D to promote bone health, muscle strength, immunity, and other key functions may vary by race. Data from the U.S. National Health and Nutrition Examination Survey show that very few Caucasian children ages 1-12 years are vitamin D-deficient using the classic threshold of 15 ng/mL. In contrast, about 10% of non-Hispanic black 1- to 6-year olds are vitamin D-deficient, as are close to 30% in the 7-12 age bracket (Pediatrics Sept. 2009; e362-370; doi:10-1542/peds.2009-0051).
Many observers see this racial disparity as a public health problem reflecting unequal access to services. But there is a conundrum here: If vitamin D deficiency is rampant in black children, why do they have greater bone strength and muscle mass than Caucasians?
“It makes one wonder whether the definition of normal levels should vary by race,” according to the rheumatologist.
Support for this notion comes from studies showing that pushing serum vitamin D levels to 30 ng/mL or higher in Caucasians reduces their parathyroid hormone levels, while pushing levels above 20 ng/ml in African Americans – young or old – doesn’t further decrease parathyroid hormone or increase bone density.
Asked by audience members what she does about vitamin D in her own practice, Dr. Buckley said she generally tries to get patients into the 20-29 ng/mL range, while in African Americans and patients with known cardiovascular disease she aims for 15 ng/mL or slightly more “and I worry that might be too high sometimes.”
She reserves expedited supplementation – 50,000 IU weekly for 8 weeks – mainly for vitamin D-deficient elderly patients at high risk for fracture or fall. That’s where there is supporting evidence of benefit. There is no evidence to support supplementation in young or middle-aged patients, whose increased fracture risk is decades away.
Like many others, Dr. Buckley eagerly awaits fresh guidance in the form of updated recommendations on vitamin D from the U.S. Institute of Medicine. Rumor has it that the IOM report, due this spring, will recommend an increase in the currently recommended supplemental 400 IU/day for 50- to 70-year-olds not getting sufficient vitamin D from the sun. Her hope is the IOM will address the thorny issues of who should receive supplementation, and how fast it should be done.
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