Recently, a New York Times (NYT) article, Why are So Many People Popping Vitamin D?, suggested that taking vitamin D is a waste of time and money. Gina Kolata, a medical journalist for the NYT, highlighted two new studies concluding that vitamin D does not prevent cardiovascular disease (CVD) or cancer.
In the article, the journalist makes the argument early on, “Millions of people are popping supplements in the belief that vitamin D can help turn back depression, fatigue, muscle weakness, even heart disease or cancer. In fact, there has never been widely accepted evidence that vitamin D is helpful in preventing or treating any of those conditions.” When I read articles like this, which include guidance from a journalist, it is like taking five steps back after getting my patients to understand the value of vitamin D supplementation.
Kolata also references one doctor, not in favor of vitamin D testing and supplementation, who calls vitamin D a “religion.” Another physician says “just about everyone needs supplementation.” While this could be considered good journalism – multiple sources and differing opinions – this is the kind of advice that makes my job, and perhaps yours, even more difficult.
In case you didn’t see the article, here is a quick run through of the two studies Kolata reviewed.
- 5110 participants were randomized to receive vitamin D3 (n = 2558) or placebo (n = 2552) in Auckland, New Zealand, from April 5, 2011, through November 6, 2012, with follow-up until July 2015.
- Oral vitamin D3 in an initial dose of 200 000 IU, followed a month later by monthly doses of 100 000 IU, or placebo for a median of 3.3 years (range, 2.5-4.2 years).
- Main outcomes measured; 1) number of participants with CVD and death. 2) number of myocardial infarction (heart attack), angina, heart failure, hypertension (high blood pressure), arrhythmias, arteriosclerosis (hardening of arteries_, stroke, and venous thrombosis (blood clots).
- Baseline 25-hydroxyvitamin D (the standard blood marker measured by doctors) levels <20 ng/mL.
Study conclusion: Monthly high-dose vitamin D supplementation does not prevent CVD. This result does not support the use of monthly vitamin D supplementation for this purpose.
- 2303 randomized white women, average age 65.2 years from Nebraska
- Average serum 25-hydroxyvitamin D level, 32.8 ng/ml at the beginning of the study
- At year 1, serum 25-hydroxyvitamin D levels were 43.9 ng/mL in the vitamin D3 + calcium group and 31.6 ng/mL in the placebo group.
- Cancer was diagnosed in 109 participants, 45 (3.89%) in the vitamin D3 + calcium group and 64 (5.58%) in the placebo group (P = .06)
Study conclusion: Supplementation with vitamin D3 and calcium compared with placebo did not result in a significantly lower risk of all-type cancer at four years in healthy postmenopausal older women.
How the NYT Could and Should Have Positioned These Studies
The vitamin D cancer and CVD studies cited by Kolata do not prove that supplementation of this “vitamin” is a waste. First, vitamin D is not a “vitamin,” it’s a hormone. Vitamins are vital (thus the prefix, vita) nutrients that come from food or other external methods like dietary supplements not made by your body. As an example, the human body does not make vitamin C, but a dog’s body does make Vitamin C. So, for our four legged friends, vitamin C is not really a vitamin. But for humans it is. I digress, but are you with me?
As you well know, vitamin D is a steroid (not the anabolic type) hormone. Vitamin D receptors (VDR) are in virtually every cell in the human body with calcemic effect and non-calcemic effect. What the NYT article failed to distinguish is that vitamin D has two jobs: 1. It increases absorption of calcium in the body primarily to maintain bone health and; 2. It’s action on the body, independent of calcium metabolism, is to boost immunity, act as anti-inflammatory agent and even reduce risk of cancer.
Another fault of the article is that the writer failed to notice that participants in cancer/vitamin D paper started at a baseline of 33ng/ml suggesting supplementation might not have been necessary. I find it hard to believe that those with normal vitamin D levels in the study were not taking supplements. I almost never see a patient with normal ranges of vitamin D without consuming dietary supplements.
Also, in the CVD / vitamin D study, 50% of participants were current or past smokers. There is not enough vitamin D in the world that can offset the bad effects smoking has on the heart.
What We Know About Vitamin D
The association of vitamin D with the prevention of heart disease, cancer and a multitude of other diseases began about 40 years ago when researchers observed people who live in sunnier areas succumb less to cancer and other diseases. The health benefits were linked to vitamin D since one of the best methods to get vitamin D in the body is through sun exposure.
Interest in vitamin D grew exponentially since then.
A search on PubMed, the primary scientific database in the world, reveals there are 7,000 plus papers written on vitamin D. When searching for “vitamin D and cancer,” there are more than 9,000 studies; and for “vitamin D and cardiovascular disease,” you will find 5,000 studies,“ and for vitamin D and prostate cancer (my field of medicine) there are more than 12,000 published studies. You get it.
After reviewing just the most recent scientific papers on vitamin D, here are two that in my opinion are the most significant:
- In a 9-year follow-up study looking at over 13,000 adults 20 years or older from the Third National Health and Nutrition Examination Survey (NHANES III), there was an increased rate of death in those with low Vitamin D levels (25[OH]D levels <17.8 ng/mL).
- After about 35ng/ml of serum D, mortality slightly climbed again. Women, overall, fared worse with death and blood Vitamin D levels with higher levels than 50 associated with worse mortality. Men do die more with D levels greater than 50 but not as much as women. The sweet spot, that is, where most participants died the least, was around 40 to 45ng/ml. (Melamed et al. 2008).
- The same group was studied for 15-years, and an increased mortality became apparent in those with D levels a step below 40 nmol/L (16ng/ml) and higher than >120 nmol/L (48 ng/ml). Decrease death rates were noticed in those with D levels between 32 and 40ng/ml.
- Another extensive 54-month study, observed over 400,000 and tested for blood vitamin D and noticed that levels between 20-36 ng/mL range were associated with the lowest risk for mortality and morbidity. Levels between 20 ng/ml and higher than 36ng/ml were associated with an increase in all-cause mortality. (Dror et al., 2013).
How This Applies to a Medical Practice
Up until two years ago, I worked to maintain my patient’s vitamin D blood levels at about 80 ng/ml. This is what my colleagues were doing and it’s what I had learned at medical conferences. Since then, took a deep dive into the research literature and I changed my tune.
In my practice, I try to keep patient’s blood levels of vitamin D taken between 35ng/ to 40 ng/ml/ (nmol / l), not much higher. This requires regular testing. There is disagreement I know, but I am basing my opinion on the best science I have come across. Leave a comment if you disagree and tell me why – it’s the only way we will all learn from one another.
Staying within these limits may mean making adjustments based on the season, as well as patient height and weight, skin color and complexion. The best method of obtaining adequate amounts of vitamin D in the body is through sun exposure. Second best method is through supplementation. But this can vary so here are a few considerations:
- Staying between 35 to 40 ng/ml may mean backing off vitamin D during the summer, especially if the patient is frequently outdoors.
- Naturopathic medicine was founded on the use of sunbathing (and fasting, and hydrotherapy) as a cornerstone therapeutic. But vitamin D production may not be the only benefit of sun exposure. There are many health benefits from sun exposure way beyond a nice tan. Ultra Violet Rays (UVA) from the sun also increases Nitric Oxide (NO) production on the skin. This result is strongly associated with widening of the arteries, lower blood pressure, and better sugar metabolism.
- Or it may mean supplementation of 5000 to 10,000 IU a day depending on the patient’s size and complexion. Bigger people need more vitamin D – as this hormone is lipid-soluble (dissolve in fat) – and so do people with darker skin complexions. Dark skinned people tend to have extremely low vitamin D levels which may indicate why this population is more prone to many life-threatening diseases.
- Diet is not enough. Milk (after fortification) and fish contain some vitamin D but not enough to reach good blood levels when eating normal amounts of these foods. Besides, milk consumption is not recommended as many people have milk allergies and dairy intolerances.
Vitamin D is Not a Panacea
It is utterly ridiculous to think that one vitamin, one drug or one surgery is the cure for all maladies. Diseases, especially cancer are complex and have many causes. Finding the one thing to cure the one disease is a reductionist approach in medicine that has failed us time and time again.
Should we tell our patients to take vitamin D but eat high refined carbs and not exercise to cure cancer? Ridiculous I tell you.
Above all, both patients and practitioners should exercise caution taking health advice from the media. Their primary goal of the media to get more people to read their stuff, not provide the best health advice to the public. It is our job to evaluate clinical studies and apply the best knowledge to individual patients.
Geo Espinosa, N.D., L.Ac, C.N.S., RH (AHG) is a renowned naturopathic doctor recognized as an authority in integrative and functional urology. He is the founder and director of the Integrative and Functional Urology Center at New York University Langone Medical Center (NYULMC) and lectures internationally on the application of integrative medicine in clinical settings. He is the author of Thrive – Don’t Survive: Dr. Geo’s guide to living your best life Before & After Prostate Cancer. He has published in numerous peer-reviewed scientific journals related to integrative management of prostate conditions and urological disorders. Dr. Geo has been a medical contributor to Men’s Journal magazine, WebMD and in medical textbooks. Dr. Geo has been acknowledged as one of the top 10 Health Makers for Men’s Health by sharecare.com created by Dr. Mehmet Oz and WebMD. He is a formulator of dietary supplements for prostate, bladder and sexual health and co-founder of XY Wellness, LLC. On his time off from work, Dr. Geo enjoys writing on his popular blog, DrGeo.com and having fun in outdoor activities with his wife and 3 kids.
Scragg R, Stewart AW, et al. Effect of Monthly High-Dose Vitamin D Supplementation on Cardiovascular Disease in the Vitamin D Assessment Study : A Randomized Clinical Trial. JAMA Cardiol. 2017 Apr 5. doi: 10.1001/jamacardio.2017.0175. [Epub ahead of print] PubMed PMID: 28384800.
Lappe J, Watson P, Travers-Gustafson D, Recker R, Garland C, Gorham E, Baggerly K, McDonnell SL. Effect of Vitamin D and Calcium Supplementation on Cancer Incidence in Older Women: A Randomized Clinical Trial. JAMA. 2017 Mar 28;317(12):1234-1243. doi: 10.1001/jama.2017.2115. PubMed PMID: 28350929.
Melamed ML1, Michos ED, Post W, Astor B. 25-hydroxyvitamin D levels and the risk of mortality in the general population. Arch Intern Med. 2008 Aug 11;168(15):1629-37.
Dror Y1, Giveon SM, Hoshen M, Feldhamer I, Balicer RD, Feldman BS. Vitamin D levels for preventing acute coronary syndrome and mortality: evidence of a nonlinear association. J Clin Endocrinol Metab. 2013 May;98(5):2160-7.