A couple letters about vitamin D.

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A couple letters about vitamin D.

Sunday, September 5th, 2010 | health blog

Two alert readers have sent me some thoughts on vitamin D that I thought might be worth sharing.  The first is from someone who is pointing out that perhaps there is a downside to vitamin D supplementation and the second from someone who has benefited from the vitamin.  One reader writes,

G’Day Doc.

Hope you don’t mind me writing to you with a query?

I suspect you would be well aware of the push to test patients Vitamin D levels…. as there is some concern that in the majority of people, especially in winter months, levels are fairly low.

Are you also aware that there is an underlying controversy brewing… that dosing with Vitamin D could be seriously detrimental?
For the purpose of this email I want to give you a couple of links to follow, and ask if you will give some thought to the argument anti Vitamin D (synthetic) supplementation…. and the thought about the (secosteroid) steroid argument. …

When you have the opportunity to look at the links, I truly would appreciate you thoughts on this matter.

Sincerely, and with blessings,

…

http://www.newswithviews.com/Ellison/shan𘬦.htm

http://bacteriality.com/2009/08/10/iom/

http://autoimmunityresearch.org/transcripts/AR-Albert-VitD.pdf 

In the response I am looking at the third link.&nbsp Here′s my response,

Concerning the appended references, Two of them are from the same people and the third is from the chemist Shane Ellison.  I’ll address the paper in pre-publication first.  I find this paper to be rambling and at times incoherent.  It summarizes part of what is known about vitamin D metabolism and biochemistry and from here spins rather convoluted ideas to oppose a great deal of medical literature indicating the benefits of normalizing vitamin D levels. 

I’ll just give a couple examples, the second of which led me to lose all respect for this submission.  The first then is, the convoluted hypothesis relating to vitamin D and auto-immune disease. The authors concede, “subjects given vitamin D, even in controlled studies, often seem to have lower rates of autoimmune disease and fewer markers of inflammation.” Well they don’t “seem to″ this is what has been seen. From here they note that some physicians have then concluded that vitamin D may be of help in auto-immune diseases, yes that makes sense. They next say that they have an “alternative hypothesis” that vitamin D exerts its effects through its “ability to slow the immune system” whatever the heck “slow the immune system” is supposed to mean. It has been demonstrated as they just conceded that vitamin D lowers markers of inflammation, I suppose this could be called a “slowing” of the immune system though more conventionally it is spoken of as being immunomodulatory. So I don’t see anything too alternative in the alternative. They also state that lowered vitamin D is a disease consequence, which again would seem to support the position of correcting the deficiency, what is so alternative? They seem to be wanting to imply, without stating it that there is a cart before the horse type fallacy in that lowered vitamin D is a protective effect against auto immune diseases, however, it can’t be explicitly stated if one has also previously acknowledged that prospective controlled studies (which by delineating the time course of events resolve cart-before-the horse type fallacies) found vitamin D to be useful.

I could go on, but the premise from here seems to be that slowed immunity is bad and while you may feel better now you’ll be even sicker later. And this brings me to where I lost all respect for this article, look at Figure 2. http://autoimmunityresearch.org/transcripts/AR-Albert-VitD.pdf,

There is one sentence describing/explaining this figure, “At a certain point, depending on the clinical symptom or physiological markers of disease, patients supplementing with vitamin D would be expected to approach a “crossover point” when additional reduction of the immune response is eclipsed by the advancing disease (Figure 2).”

This seems to be the primary premise of the article, so perhaps some seer can answer a few questions for me about this “figure.”

what is the supplement used vit ʪ or ʫ?
what is the dosage and route of administration?
what is the “Actual Disease State” ???
what are the symptoms and markers of the undefined mystery disease?? i.e what is the y-axis, why is it unlabeled?
the number of hashmarks for elapsed time in the two graphs are different, why?
And for the million dollar bonus question, is the study over years or decades?? It can’t be both, gee I didn’t know there was a 60 (or is that 100) year longitudinal study of some amount of some type of vitamin D in an undefined disease with unexplained symptoms and markers of said disease, strange.

I could go on, perhaps discussing that chronic infection is anything but a proven causation for auto-immune diseases, or, for that matter, vitamin D’s well documented anti-infective effects, I think I said enough though in discussing their figure.  Perhaps, this is a pre-pre publication edition, but as I said, I find this article to be in its current incarnation, so much pseudo-scientific gibberish, won’t be surprised if it gets published.  As for Mr. Ellison’s contentions, while there isn’t time to go into it at the moment, I’ll just say I believe he is significantly off base on this one.

A second reader writes,

I stumbled onto your blog today whilst researching Vitamin D and its effects on Rheumatoid Arthritis. … I am 23 years old. … . I was diagnosed with Rheumatoid Arthritis at 12 years of age, so am entering my 11th year with the condition this year. I am currently on Methotrexate (20mg weekly, tablet form) and Enbrel injections, (50mg(?) a week, self injected). I have been on Methotrexate for a long time and am fairly responsive to it, but it just wasn’t enough to stabilise me.

Last year, from Jan-July I went off all my medication to try and follow the alternative″ route, … I was barely able to move, let alone walk, yet I struggled through every day tasks, even trying to exercise, … The severity of my RA was never going to benefit from this sort of treatment, … Anyway, I received Government funding for Enbrel, in Dec of 2009 and began treatment then. Since my very first injection I have benefited greatly and am actually astounded at the change I have made in less than 12 months. … for me it has been a lifesaver, but I am still looking for as many options to remain healthy and help my body heal itself and protect my joints as much as I can from inflammation. …

I have been taking Vitamin D, but fairly inconsistently, due to terrible memory (from the Methotrexate) but recently began to take it much more regularly. I have noticed my energy levels are so much better than previously. I was often absolutely exhausted, after barely physically exerting myself. Fatigue is one of the hardest symptoms of RA to manage or combat.

Then I saw somewhere a post on Vitamin D and RA and started researching it. I was so astounded by the results that have been shown in studies to do with Chronic Pain, back pain etc. When I read this, I also looked back and thought how well my “flares” had been of late, and how that I was actually getting a bit worried as I hadn’t had one in a while so I thought that a large one was on its way.
Reading about this has made me think twice and actually sit up and take notice. … Since taking the Vitamin D, I have noticed less of an impact of the side effects of the Methotrexate. They are still there, but to a lesser degree.

I haven’t been taking the Vitamin D consistently for long enough yet to have any proper results, only a few weeks, but I am very positive and very excited for this recent discovery on my part and I am really glad it has been documented and studied.

And to my reply,

&nbsp… …

I am delighted to hear that you may be getting benefit from vitamin D in your RA.&nbsp The toxicity (and cost) of vitamin D is so negligible, especially as compared to your other RA medicines that I can′t imagine any physician not enthusiastically recommending your continuing to pursue this avenue of treatment.&nbsp I haven′t discussed vitamin D specifically in relation to auto-immune diseases on this site much, but perhaps I can do a post on it in future.&nbsp As you noted there is significant and accumulating evidence that vitamin D has a role to play in the treatment of auto-immune diseases.&nbsp Here’s hoping and praying that your RA stays in check and with vitamin D perhaps you can, in consultation with your physician, decrease or even eliminate some or all of your more side effect riddled meds.

This has been a long post … but I’m not finished yet) Bear with me I just want to say a few more quick words about vitamin D in general.

Yes it is, in my opinion, best to get your vitamin D from moderate sunshine if possible. I do not believe and my understanding is the authoritative Dr. Hollick would agree that there is not any documented molecular difference (also the question of tissue distribution though) between vitamin D3 produced in the skin or consumed in the diet. For a more complete discussion of the biochemistry of vitamin D please see the second half of Vitamin D and Muscloskeletal Pain: Part I.&nbsp There are also other documented benefits from sunlight, including things such as effects on depression, regulation of the sleep/wake cycle in part through effects on melatonin and likely other myriad undocumented effects.&nbsp It is quite commonsensical that sunlight (and fresh air) are healthy, though as Aristotle said, “everything in moderation.”&nbsp Still, it is worth noting that up to the present the American Academy of Dermatology recommends against any direct, unprotected exposure to sunlight.&nbsp They officially recommend that, rain or shine, winter or summer, indoors or out, 2 ounces of ill-defined sunscreen be applied every two hours.&nbsp That is the official position, see, Here Comes the Sun.&nbsp It is not surprising that there might be some rather vocal protests to changing such an extreme and entrenched position.&nbsp&nbsp
In higher latitudes, vitamin D levels vary seasonally decreasing in winter and increasing in summer as was discussed in An Intriguing Epidemiology Article: Part II.  The levels in wintertime are quite often in the “deficient” range and so it makes sense to increase one′s intake of vitamin D in winter.  This might be done through eating more fish for instance, (though in the US, now with the Gulf oil spill … what a world, what a world).  However, I see no problems with using a dietary vitamin D3 supplement in winter, assuming you trust the supplier.  As I said in winter or summer when it rains or I am out of the sun a few days, I take 2,000 IU/day.  It’s not scientific, but I haven’t had a single cold since doing so.  
Now for some I am not going nearly far enough and here I share some of the caution of those questioning all of the vitamin D enthusiasm.&nbsp Some are saying well, 2,000 is old hat you need 5,000 or 10,000 IU/day.&nbsp Whoa tiger.&nbsp This is all very new and medicine and people in general have a habit of really running with the latest and greatest thing only learning later that there may also be possible drawbacks.&nbsp Perhaps 5-10k/day will prove to be a reasonable dose, while dosages used in disease treatment might also be very reasonably expected to be larger than when used as a preventive medicine, but I am still more cautious.&nbsp While vitamin D is extremely non-toxic, it is a fat soluble vitamin with powerful physiologic actions.&nbsp Also, in general many vitamins have a threshold effect at a deficiency level with less clearly documented benefits above the deficiency level.&nbsp In many respects, not worth going into now, vitamin D is in a class by itself.&nbsp In part because of its myriad effects it likely has multiple thresholds for optimal functioning, from calcium metabolism to regulation of antimicrobial peptides to immune system regulation to who knows what else.&nbsp And again, vitamin D is being found to have so many varied and apparently unrelated benefits not because it is unmitigated good, but because in our work-a-day lives so many of us become to some degree or another deficient.
And another thing, what’s with all these new taxes … just kidding. I’ll shut up now and thanks to those who made it this far.
Paul