A recent editorial about the U.S. Preventive Services Task Force statement

Posted on: January 23, 2015   by  John Cannell, MD

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I love to read what Robert Heaney writes. Professor Heaney recently applied his insightful clinical experience and extensive knowledge of vitamin D to respond to the U.S. Preventive Services Task Force’s (USPSTF) statement that there is not enough information – one way or the other – to issue a recommendation about testing for vitamin D deficiency.

Heaney RP, Armas LA. Screening for Vitamin D Deficiency: Is the Goal Disease Prevention or Full Nutrient Repletion? Ann Intern Med. 2015 Jan 20;162(2):144-145.

First, Heaney takes the task force to task for relying on studies that are simply meaningless, at least as far as vitamin D is concerned. An example of such a study is the very large Women’s Health Initiative (designed 20 years ago, when knowledge of vitamin D was scarce), which used a dose of vitamin D that did not significantly change vitamin D levels. Why would they include a study that did not change vitamin D levels (especially such a large one) in a review or meta-analysis?

Next, he talks about biomarkers. Biomarkers are a measurable condition in an organism that provides insight into the health of that organism. Certain biomarkers change in relationship to vitamin D levels such that one can see what vitamin D level is needed to obtain maximum benefit in relation to any of these biomarkers.

The usual biomarker measured in relation to vitamin D levels is parathyroid hormone (PTH). For example, PTH is increased in vitamin D deficient individuals and generally does not fully decrease in concentration until vitamin D levels reach about 30 ng/ml.  So PTH is a biomarker that says 30 ng/ml is an adequate level. However, Professor Heaney talks about another biomarker, the vitamin D content of human breast milk.

A crucial question is what circulating vitamin D blood levels does a lactating woman have to achieve so that her breast milk has adequate amounts of vitamin D? Heaney points out that research shows that 6,000 IU/day are needed to obtain adequate amounts of vitamin D in a mother’s breast milk so the suckling infant gets enough vitamin D.

Finally, Heaney draws on his clinical experience to point out logic that only a practicing physician would know. When patients know their vitamin D levels, they become very interested in obtaining “healthy levels,” whatever level the treating physician decides is healthy. Patients who do not know their 25(OH)D levels are often not interested in them, thinking that if such levels were important, their doctor would have measured them.

As Dr. Heaney concludes,

“Usually, testing improves patient adherence because it provides patient-specific, personally applicable information. General assurances that one probably needs extra vitamin D are not as compelling a motivator as knowing one’s number. Thus, whether the practitioner adheres to the widely divergent guidelines of the IOM, the Endocrine Society, or the American Geriatrics Society, measuring vitamin D status seems to be warranted, not so much to diagnose deficiency but to determine patient status relative to the selected guideline.”

 

16 Responses to A recent editorial about the U.S. Preventive Services Task Force statement

  1. Rita Celone Umile

    I feel I must always preface my comments here with the statement that I am not a physician nor am I a scientist. I am just someone interested in all things pertaining to good health and nutrition.

    John, you write above that “the usual biomarker measured in relation to vitamin D levels is parathyroid hormone (PTH). For example, PTH is increased in vitamin D deficient individuals and generally does not fully decrease in concentration until vitamin D levels reach about 30 ng/ml. So PTH is a biomarker that says 30 ng/ml is an adequate level.”

    May I ask how the medical community has determined “adequate” to be synonymous with “optimal” with respect to the 25(OH)D level?

    It certainly seems plausible to me that 30 ng/ml might indeed be the minimum threshold when speaking of the 25(OH)D level. And 30 ng/ml might indeed be sufficient for bone health, but that doesn’t mean it is sufficient for the prevention of cancer and autoimmune diseases.

    I wonder what it will take for mainstream medicine to determine an optimal 25(OH)D level for the prevention of cancer and autoimmune diseases, especially when so many studies use very low doses of D?

    I always try to illustrate my point with this example (one given to me by a truly dedicated vitamin D advocate 😉 ):

    What would we think of penicillin if physicians prescribed 5 mg for 10 days in the presence of strep? Isn’t it a 10 day course of 500 mg that’s needed here.

    Why do we think it would be any different with D?

    Clearly, dose matters; and studies that use low doses of D are doomed for failure. Often times to me it seems that these studies actually set us back rather than move us forward.

    It’s difficult to choose to “doctor yourself.” Sometimes this is even foolish. But the number of mainstream physicians open to D and other essential nutrients is paltry.

    I’ve already been way too wordy here. I think I’ve made my point. Thanks for your recent blogs. They’ve been very good. And as always, I’m grateful for the forum we have here.

    Be well,
    Rita

  2. Ron Carmichael

    A striking problem I have learned to anticipate and neutralize is that of the poorly-informed physician. Even when a person gets the 25(OH)D test performed, it is normal practice for the physician to tell the patient, “your levels are fine”. Never revealing the actual numerical value is extremely common.
    The problem is that many physicians still believe that 10 ng/ml is OK, since that level has been shown to prevent rickets, and that is the extent of their functional knowledge about what “vitamin d” is only for.
    I encourage every patient in my pharmacy with whom I counsel, to insist on a number from their doctor. And that the number be close to 50 ng/ml if they want to be healthy. And to let me know what they find out about their number. When a doctor insists on prescribing 50k iu per WEEK, I explain to them the evolutionary aspects of getting D every day, and often they decide that taking 5 to 10k per DAY in addition to the 50K per week is a good idea. I have NO good science that shows this is a bad thing to do.
    And, time and again, it turns out the doctor thought 15 or 20 was “fine”.
    When your primary care giver is CLUELESS about relevant levels of vitamin D, these other aspects are relegated to an inferior position of concern.

  3. Ian

    Actually I find that many Physicians are not so much clueless but conflicted and fearful. This dissonance is the result of considerable conflict in the messages given by health authorities. It is good to see the NICE in the UK are recommending sun exposure between the hours of 11am-3pm in summer. It would be “nicer” if they gave more information on time required to avoid sunburn, time required to achieve adequate and optimal levels and advice to supplement in addition to the sun exposure because the Cancer Society will not do this. The main message people are getting about the sun is to AVOID exposure.

    In addition to this your average physician is very opposed to prophylactic dietary supplementation, here cognitive dissonance results in wanton disregard of research and a strong bias to state dangers of supplementation.

    If you are a medical practitioner, who do you believe? This sounds trite (believe?) because most doctors try to practice evidence based medicine. However, I find that when knowledge is lacking many doctors do one of two things:

    1. don’t treat the patient as a partner in health and fail to advise on or support the patient’s decisions. (A symptom of this is not supplying test data to the patient). A major role of the doctor is to help their patient gain health knowledge, so often badly done. I once heard an orthopaedic surgeon say to a patient: “don’t read stuff on the internet . . .” in a frustrated tone.

    2. psychologise, this is very big problem and is a habitual tool for diminishing the patient’s contribution in exploring healthy/safe options.

    The more our “health authorities” fail to elucidate research and lead in this regard the more our physicians will suffer from cognitive dissonance about vitamin D.

  4. Rita Celone Umile

    Ian you write: “In addition to this your average physician is very opposed to prophylactic dietary supplementation, here cognitive dissonance results in wanton disregard of research and a strong bias to state dangers of supplementation.”

    And I must ask (tongue in cheek): Are there no side effects from chemotherapy? Is there a benefit to halting the progression of cancer while also so debilitating the patient’s quality of life?

    What is the purpose of medicine?

    Is it to extend life by any means, even to the point that life itself is no longer recognizable? Or it is to provide the gentlest, safest treatment that will allow a person to live with dignity for as longer as feasible.

    After all, we cannot cure death.

    We can only hope to live healthy, productive lives.

  5. mbuck

    @Rita,

    Actually, a common dose of penicillin, say for a tooth infection or abscess, is 500mg 3 to 4 times a day, til the the bottle is empty. Been through it a couple times.

    We as patients must really become informed partners with our physicians, even if they remain ignorant or fearful. As such, it behooves us to test our levels as often as necessary and even pass the numbers on to the docs.

    If your doc is conscientious about monitoring your health, your improved health may come to his attention and set him/her to thinking.

    Or not.

    In either case, we will still be the beneficiaries of better health.

    When the preponderance of evidence becomes great and the old guard dies off, then we may begin to see significant change. It took half a century for plate tectonic theory (formerly continental drift) to be accepted. Controversy raged. Careers were ruined.

    Unfortunately, unlike a geologic theory, when it comes to D3 levels, real people will continue to suffer needlessly.

    I continue to enjoy relatively good health. And when everyone around me, even in my own household catch colds in the winter, and they ask me why I don’t get sick, why, I tell them.

    Some listen; some don’t.

    Become the change one desires to see.

    mbuck

  6. Rita Celone Umile

    @Buck,

    Thank you for your response. 😉

    I’m sorry to report that my experiences with physicians have generally been negative. This is an understatement actually.

    To illustrate my point:

    I am responsible for the overall care of my elderly mom and uncle. My mom recently battled daily while in rehab for the right to take her Life Extension vitamins. She lost the battle every single day. And, I was repeatedly called by staff at the rehab center for being an accomplice to her disregard of the policies and protocols. They questioned both our “sanity” for taking vitamins and supplements, including vitamin D. Many staff there insinuated that we were buying pipe dreams.

    Here’s another illustration:

    My uncle’s physician demanded that my uncle bring all his vitamins and supplements for him to review. When my uncle complied the physician told my uncle that if he continued to take these supplements, he would not agree to be his doctor. This physician routinely checks my uncle’s 25(OH)D level to ensure it is 30 ng/ml and not higher. Of course, my uncle could choose a different physician; however, my uncle has “faith” in this man–a mere mortal, and an ignorant one at that.

    For myself, I have stopped visiting my university’s HMO. Hell no, I won’t go is my mantra. And it’s been 3.5 years since my last health examine.

  7. Mark Richards

    @Rita

    Regarding your being harassed by rehab staff, the following excerpt from a Medscape article by Gary J. Stadtmauer, MD might ram home the point that one should press hard against know-it-alls:

    “My partner in practice once had a patient in the emergency department for hours getting fluids for hypotension (blood pressure, 80/50 mm Hg), along with antihistamines and corticosteroids as anaphylaxis management. The patient was concerned and called my partner in the middle of the night. The treating emergency physician refused to give epinephrine and challenged my partner to come in if he wanted to manage the case—which he in fact did, and the patient promptly responded to a single intramuscular dose of 0.3 mg (1:1000) epinephrine.”

    I am very much an advocate for patients educating themselves and making informed decisions, using medical care givers as a trusted partner. I see the job of physicians to educate patients and to advocate for their best interests.

    Your rehab folks need rehab, as does the IOM.

  8. Rita Celone Umile

    The missing piece of the puzzle for my mom (and by default, me, as her general care giver) is that she is not hooked up with a nutritionally-savvy MD.

    Let me share with you medical cowardice:

    Yesterday, we tried to make an appointment for her with her primary physician. His nurse informed us that he no longer wishes to see her as his patient as he doesn’t want to deal with her ideas regarding vitamins and minerals.

  9. Rita Celone Umile

    Now, my mom is not an easy patient for any physician. She’s a difficult person. She wants to maintain optimal blood pressure, glucose levels, and mood only via natural means.

    But, when you have patient that comes to you as says “what can I do in terms of food and exercise to maintain my health?” And, she has nearly 87 years of living to prove she’s serious about maintaining optimal weight, etc. via holistic means, shouldn’t a physician try to work with her–rather than against her?

  10. IAW

    Dear Rita,
    You said above “She wants to maintain optimal blood pressure, glucose levels, and mood only via natural means.” Call me crazy are you are saying these are “present symptoms” she may have? If so it could be low thyroid. If so there really are not any vitamins or minerals that would help except for “D” and she already takes that. If she was diagnosed with low thyroid would she take medicine?
    Ivy

  11. Rita Celone Umile

    She’ll be 87 in April. To this point in time she was taking NO prescription meds. She had NO problems that were not 100% controlled with food and exercise and supplementation of D and its cofactors.

    I repeat: she was had no high blood pressure, and she controlled insulin issues thru food and exercise.

    After a week in the hospital and 10 days in rehab, physicians noted that she had blood pressure problems.

    No one looked to the fact that they were constantly arguing with her about her desire to eat healthy food and to take her supplements.

    Instead, they said her high blood pressure was due to lack of medication.

    If I didn’t trudge food to her, or have others bring it to her, on a daily basis, she also would have insulin issues.

    My point here is that she was controlling all these modern-day chronic illnesses quite nicely without the “help” of ignorant medical doctors.

    My mom got stuck in the mainstream medicine vacuum of intelligence, and in its vat of ignorance, and her health had deteriorated ever since.

    No wonder she is sad.

    In 15 days she went from riding bikes and hiking, to being housebound and declared decrepit.

    She needs a real doctor, not a a mainstream incompetent.

  12. Rita Celone Umile

    <3 I am a bit harsh. I apologize to all the medical doctors reading these comments I've posted. It's been a highly stressful time for my mom and for me. Unfortunately, I envision only stressful times ahead for us. She made it to almost 87 living life her way, only to fall so short in the end. It's a dang shame.

  13. IAW

    Sorry Rita! I did not understand that she did not have the problems until she went in rehab. If I can ask, what happened to her to land her in rehab? You do not have to apologize for anything! Life can be very frustrating.
    I have met many “know-it-all” doctors and absolutely understand your frustration! Hope things get better! My email is still the same should you need to “vent” some more!

  14. Rita Celone Umile

    <3 Thanks IAW. To close my comments here just in case folks are interested in what happened to my mom: she was riding her exercise bike one evening right after Christmas, and when she got off the bike she stepped onto a cluttered floor (we aren't known for our housekeeping skills 😉 But we have other good traits 🙂 ). She slipped on the clutter and pulled the bike down on top of her, cracking 6 ribs. After resting a moment, she got up, showered, and then prepared a set of vitamins to take with her to the hospital. Then she went to bed, setting her alarm for 5:30 AM. In the morning, she called me and asked that I take her to the ER. The rest has been a hellish nightmare. And, there apparently is no end in sight.

  15. David Schneider

     I am a family physician with interest in geriatrics. (not practicing now). The bits of info on Rita’s mom are very interesting, and frustrating. Was her mental status normal after admitted to hospital? (I hope she was admitted.) Did she have a CT or MRI of the head– a hard fall can often cause bleeding around the brain which can be subtle and cause mental decline. (subdural hematoma) Insist on getting a scan if one was not done. Is she on prescription meds- almost any of them can cause severe side effects in an 87 yr old. Mild diabetes in the elderly does not need drugs. Over treating hypertension in the very elderly can cause poor blood flow through narrowed brain arteries, hurting her. The goals and means for treating or knowing not to treat an 87 yr old are completely different than for a 50 yr old, but many MDs are smart but without common sense. For instance starting an 87 year old with no vascular disease, on a statin drug for “high cholesterol”. Duh- their cholesterol was just fine for them. Is she on any OTC meds- such as “sleep aids” or others. Sometimes a fall is the result of a disease or side=effect, and only the results (rib fractures) are treated. A sudden change in mental/ functional status is not “just getting old or demented” It needs a careful evaluation. Try to find a family physician or internist who will do at least a 40 minute initial visit.
    Tell the receptionist it is for “recent decline in mental status after a fall”, and that it is very complicated, and could you have a long first visit. If not, try somewhere else. Good Luck,
    if you find an answer, please post it on this blog.

  16. Rita Celone Umile

    Dear David,

    Please let me clarify:

    1. My mom has NO mental decline. My mom’s personality hasn’t changed in the 50 years that I have personally known her. Two psychiatrists examined her while she was in the hospital. They find her competent but difficult. She strives to be obnoxious, and she always has! But, she currently (as of this afternoon) can add columns of numbers in her head that most mathematicians would need to use a calculator, and she always gets it right.

    2. My mom was admitted to a large teaching hospital. Every part of her body was scanned and examined. No problems other than 6 cracked ribs. The trauma team was amazed at the strength of her bones. She attributes this to D3, its cofactors, lots of exercise, and organic food.

    3. She has always had “white coat” hypertension. She hates doctors (sorry if I’ve offended many of you). If she sees a physician her blood pressure goes sky high.

    4. Mom takes no prescription drugs and no OTC drugs. She was routinely refusing the Percocet the hospital was trying to get her to take to alleviate the pain from her cracked ribs. Mom is a vitamin and mineral and herb type of gal. She does not want any Big Pharma crap.

    5. Mom wants her cholesterol high. She is of the school that states eat that egg yolk, and drink up that olive oil.

    6. The rehab staff said she was fine to go home as along as she stayed on one floor and did not go up and down any stairs. Her home has 3 flights of stairs, and I cannot watch her 24/7, and she wouldn’t stay off those stairs unless someone watched her 24/7. So off I dragged her to her brother’s house, where there is 24/7 caretaker. Well, I hope the caretaker is still there. As of this morning he was begging to quit. The caretaker says mom is obnoxious. See my #1 comment.

    I think I have detoured off the vitamin D path, and for this I apologize.

    Best,
    Rita

    Thanks so much for your response. Yes, mom was admitted to hospital and had scans of head, back, , etc.

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