Vitamin D update - A Physician Nutrition Specialist's Take

All right, this is Dr. Tom Refai here, a vitamin D update. I'm a past president of the National Board of Physician Nutrition Specialists. I'm a diplomate of the American Board of Lifestyle Medicine Specialists and I'm board certified by the American Board of Internal Medicine. I have run multidisciplinary, intensive lifestyle and nutrition intervention programs for years. I have prescribed tons of vitamin D, measured thousands of vitamin D levels, including both bariatric, non bariatric patients. And I think I'm qualified to give a vitamin D update here. That's going to be maybe a little bit disappointing, but it is what it is because it's been a popular question now, what about vitamin D? Especially with everything that's happening with COVID And I'm not going to discount vitamin D completely. In fact, I'm going to clarify, I think, some really important issues, including the fact that it's not really a vitamin, it's a hormone. So let's get started. Vitamin D is not a vitamin. A vitamin is a micronutrient required for life that must be obtained from diet. That is clearly not the issue with vitamin D, because we all know there's this little sunny thing out there called the sun, right? And then we can have ultraviolet radiation strike the skin and make vitamin D. So that is pretty 101. It's technically not a vitamin. You can get it from food, obviously, but you can also get it from sun. In fact, you potentially can make a lot more from sun or supplements, but in this case, sun. And it's also structurally far more like a steroid hormone. In fact, it's way more. In fact, it is a steroid hormone, much more related to testosterone or estrogen or progesterone or even cortisol than any vitamin or mineral. So there you go, it's a hormone. Now, there are a lot of, to summarize, studies in many years past prior to randomized control trials that I'm going to discuss one that's pretty sobering called vital. And it's a NIH 20,000 person randomized controlled placebo controlled trial. But prior to that, there were a lot of observational studies associating higher D with lower, you name it, lower cardiovascular risk, lower cancer, et cetera, et cetera. And of course, those are the two biggest killers, right? Cardiovascular disease and cancer. So, you know, going to gain a lot of attention if, you know, just pop some vitamin D and you know you're going to do a lot better. You know, I feel better because there's some, there is some vitamin D Association between low vitamin D and depression, et cetera. That being said, those observational studies, I was as a recovering vitamin D evangelist, under the belief that they're not going to be like vitamin E, which observationally looked great but then failed, or like beta carotene, which looked great observationally but then in randomized controlled trials totally failed. In fact, if anything associated with higher cancer risk in former smokers, this was going to be different because it's not a vitamin, it's a hormone. And therefore all the things that everyone who are the naysayers, you were kind of right. I'm humbled. Is not going to be the same because this is different. It's not a vitamin, it's a hormone. And if you have a hormone deficiency, well, the question is, do we. What are the levels that we used to consider ideal, or many even thought that deficiency started at a level of less than 30 in the blood or at least insufficiency. Now we think this might be actually closer to the ideal and you'll see in a minute here, but a blood level of vitamin D, technically called 25 hydroxy vitamin D. Right. 25 hydroxy vitamin D, that's a blood test that you would do, which I don't recommend, is done in the general public only for people at risk. Now that we know what we're talking about more. But a blood test level of 25 hydroxy vitamin D of less than 30 was considered insufficient in need for supplementation. That would leave a massive amount of Americans at level of insufficiency or deficiency. And what we're actually seeing is, and I'll get to the vital trial in a minute here, but it's really probably blood levels of 12 or higher, and probably definitely 30 would be at the upper end, maybe, maybe 35 and maybe safe up to the upper 30s. But you start to get levels of 50 or higher and you start to potentially increase small, but, you know, increase the risk for imbalance and falls, especially given in these massive doses. Right. Vitamin given in massive doses versus what I think is more physiologically parallel small regular doses, because that's what you would make on a daily basis. I mean, if you, your skin could make thousands of units of vitamin D per day, probably put it at more risk of skin cancer, though that's not the biggest killer cancer, but still more risk of skin cancer than you might want. But the skin can make thousands of units of vitamin D a day, maybe 10,000 if you're, maybe even more if you're a lifeguard in Hawaii and you've got nothing but sun exposure all day long. Then you have the skin aging and everything else. So that being said, how much do we really need to get to this blood level? We'll talk about and what are the quality sources? We'll talk about that as well. But let's first share screen here and look at the results of the VITAL trial. Okay again VITAL V I T A L E was a 20,000 subject. 20,000 subjects NIH, no corporate funding at all. Randomized control trial of D3 and Omega 3. This is like a gold standard, really hard to refute study. So if you know you got some better evidence than opposing, go ahead. Good luck. Let's see what we've got here. So vitamin D omega 3 trial and we're going to go to the summary here of the vitamin D omega 3 vital trial. We see here the presenting author here, lead researcher Joanne Manson. This is National Institutes of Health. As we see this is a very very high quality trial. Now let's go ahead and take a look at the study. Average follow up five and a half years average age 6.7. So you'd think with a massive study like that and mean patient age, excuse me at 67, half and half men, women and we had good representation of minorities and so forth, you're going to should be able to find something here. 20% African American diabetes mass index is overweight average. It's America diabetes around 14%. Now primary outcome cardiovascular death, non fatal heart attack or myocardial infarction or stroke for vitamin D3 versus placebo I mean 3.1 versus 3.2. This is an insignificant difference. We have a confidence interval that not only crosses one, doesn't even. I mean you've got a p value of 0.69. I mean this is just, there's nothing here. It's a nothing burger. When you look down here at let's see or what's next here. So this is all cause mortality. Again no difference here. No difference. If you look at a nested within the VITAL trial CKD which is chronic kidney disease in patients with type 2 diabetes. Again, no significant interaction between the two interventions. Now when you look at atrial fibrillation this was I think more along the lines of the omega 3 concern and that's a different topic. But high amounts of omega 3 can increase the risk of heart arrhythmia is another one of those kind of disappointing for supplements when it comes to this trial. Both vitamin D and omega 3. Now that being said, there were some I think positives in terms of Omega 3 and African Americans, for instance. But again, I don't want to deviate from the topic here, which is vitamin D, what amount you take to raise your blood level, about how much? Well, I don't even know. You need to check a blood level. I think most people and you got to ask your doctor. Remember, I'm just a doctor. I'm a board certified doctor on an Internet platform. So you need to talk to your licensed healthcare provider. Disclaimer. But 800 to 1000 international units of vitamin D3 per day of a quality source. I'll talk about USP verification in a second. United States pharmacopia should be enough to get just about anyone, almost not everybody. Not everybody. Okay. There's going to be some people that will need higher dosing to get to a level of above 12. Right. Try to get to that level probably, I would say somewhere, definitely if you're less than 12, you're in the single digits. There's an issue that's going to be where vitamin D in terms of increased cancer risk, increased infection risk, increased cardiovascular risk, increased depression risk, that's there, but that's about 6% of the population. Nevertheless, if you're going to take vitamin D, probably want to get it around the 25, let's say 35 zone. That I think is a sweet spot. And most people will be there at 800 to 1,000 units a day. Obviously talk to your doctor because getting blood tests is expensive. It's not always easy to be asking doctors to be checking your 25 hydroxy vitamin D level regularly. But if you're going to take a source, make sure that it's a quality source and it's probably worth after you've been on a supplement, maybe if you can ask your doc to take a vitamin D level once. But insurance companies are getting wise to this, like, okay, what's the reason? Do they have myalgia? That's muscle pain, which could be caused by severe low vitamin D with a condition called osteomalacia that's associated with bone loss. A cousin of osteoporosis that is also associated with the myalgias as it's hypothyroidism and statin drugs and so forth. Okay, is there osteoporosis? Right. Of course that would be the case, vitamin D. But of course that case you'd be thinking kidney stone. I mean kidney stones. In that case you'd be thinking high vitamin D. But that would be an indication to test. We'd be surprised to see A low level. And then there's also people, by the way, with sarcoidosis that have a disorder that is activates vitamin D significantly. So you have to be careful about supplementing with vitamin D in people with sarcoid, which isn't that uncommon because it can increase the risk for kidney stones and untoward effects of too high a vitamin D level or hormone D level. 1000 units will tend to get your blood level up by about 5 to 10 points, depending on genetics and body fatness, because as body fatness goes up, the blood levels of vitamin D tend to go down and you tend to need more. But at only 6% of the population that's below 12, most people with 5 to 10 and maybe somewhere around 7 to 8 should pop a lot of people up around this zone, maybe even more than necessary. So if you're regularly eating salmon and mushrooms and getting sun and you're living and you're hopefully blocking enough sun so you're not getting burned and fried all the time because we don't want to increase the risk of skin aging and skin cancer, you're probably even fine without a supplement. I take 1000 units most days per week. Now. I used to take 5,000 units. I'm pretty darn sure that didn't help me in any way that I could perceive and hopefully didn't harm me. I don't think that it did. So I'm not saying you're going to die if you take more than 2,000 units a day, which is what the vital trial did. 2000 international units of USP verified D3 per day, which is probably safe. I mean, they didn't really find damage here. So you could say 800 to 2000 guess just because, you know, we've got a randomized control trial for safety as far as benefit, you know, not. Not so sure there. And then there's going to be some rare exceptions. Someone's going to make a comment about how low their blood level was despite taking 4,000 units of vitamin D per day. I don't discount that there are going to be some small percentage of people that. That's why you need to see your licensed healthcare provider and get that question answered. So last but not least, you're going to take. You want to take a quality source that's USP verified. What does it even mean? Generally? USP verified means. I guess I could stop sharing here so you can see the screen better. Usp. And that's backwards. I'm sorry, usp, they should do this like Facebook where you can turn the screen around. Maybe there's a way to do that. You can tell me in the comments how to do it on Zoom. But USP United States Pharmacopoeia is a program that supplements can submit. Well, they have to submit whenever the USP asks randomly for purity testing at the USP labs. And then if it's within a reasonable range, I can't remember, it's got to be I think at least 90% and certainly not more either than the label says. You don't want to overdose or underdose. 90% to 110% of what's claimed on the label is in the actual supplements. Then you're good to go. You can get a USP verification. There's a couple of vitamin D supplements I know of that have it and that's Nature Made and Kirkland Brand and I have nothing to do with them. They don't pay me squat to tell you that, although I wish that they would, frankly. But they're not. So whatever the bottom line is, that is the bottom line on vitamin D and I hope you found that helpful. And if you like this channel, I'm going to be discussing things related to metabolic health and obviously lifestyle as medicine is the primary tool and goal. 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