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How should we educate on vitamin D?

Posted on: September 12, 2013   by  Brant Cebulla

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Lost in the effort to improve global vitamin D awareness is that to date, we actually don’t have very good data on best methods to educate on vitamin D. We know what we want in spreading awareness. We want to educate people to make sure they’re getting enough vitamin D, to make sure they’re not deficient in vitamin D. At minimum, we reduce the incidence of falls and fractures. Some might say we even know what the optimal vitamin D level is, and after we educate, we want people to raise their levels into that range. At maximum, if research pans out, we reduce the incidence of cancer, cardiovascular disease and more.

What’s missing is research that shows how to best educate to meet these goals. You’ll see some individuals and organizations recommend easy things, like “take a supplement,” “get more sun exposure,” or “increase fish consumption.” And you’ll see some individuals and organizations recommend entire protocols, like “Test your vitamin D level, figure out the dose you need, test again, adjust your regimen, repeat.”

Unfortunately, we don’t really have the data to know which works best on a population scale. For example, there is no data on whether recommending a supplement, recommending sun exposure or recommending both – on a population scale – is best to try and raise vitamin D levels. We don’t know if a one-size fits all recommendation, like “Take 5,000 IU/day,” is better than a formulaic recommendation tailored to the individual, i.e. “Take 1,000 IU per 25lbs of body weight,” in efforts to raise an entire population’s vitamin D levels.

And again, we really don’t know if we should be giving people simple directions to get more vitamin D, like “Take a supplement,” or if we should be teaching the end-goal, like “Aim for a level 50 ng/ml, learn how to get there and then off you go.”

At the Vitamin D Council, since there is a lack of data on best education methods for vitamin D, we do our best to educate using all of these angles. We try to layer the presentation of our information, making simple steps accessible first, then if the individual wants to learn more, provide more in depth recommendations and regimens to go by.

We know our methodology works okay by a combination of in-person usability testing and web analytics tracking, the latter which tells us whether people are reading the pages or if they’re deciding to go elsewhere, how long they’re staying on the page, etc. That being said, we don’t have the budget to more rigorously put our information to the test, and we’re still not sure how well we’re meeting our end-goal question: Are we maximally decreasing the percentage of people deficient in vitamin D?

We receive many emails from people saying we should change content, or we should educate in XYZ manner. While we take feedback very seriously and always add it to our list of things to consider, you can’t justify putting education methods into practice unless they are backed by research or they pass through usability testing or something similar. As much as you might be tempted to put common sense into practice, common sense doesn’t always pan out into best-evidence or best-methods.

At this point, you’ve probably taken a gander at what I’m getting at: We really need academia to step up and start looking into best methods to educate on vitamin D.

There have been a few trials that show that traditional counseling from a dietician doesn’t work for vitamin D, where a nutritionist sits down with a client/patient and discusses how to incorporate more vitamin D into the diet. This doesn’t decrease prevalence of vitamin D deficiency for obvious reasons, in that we can’t get much vitamin D from our diet.

How about sun exposure? If we recommend sun exposure, will people actually go get sun exposure? And will they get enough so that they actually raise their vitamin D levels?

In the most recent journal Molecules, researchers out of Saudi Arabia finally looked at this question.

Doctors had 95 patients enroll into their study, of which only 47 completed. The participants were overweight Saudis.

The doctors told the patients that their vitamin D levels were low, and to improve them, they needed to get 5 to 30 minutes of sun exposure twice per week.

And it worked, to a certain extent. After one year, vitamin D levels rose from 30 nmol/l to 37 nmol/l, and the percentage of people with a severely deficient level of less than 25 nmol/l decreased from 44% to 27%.

Unfortunately, the doctors made a huge error in recommending sun exposure only before 10am or after 3pm, well before and past times of peak UVB.

The limitation in the study is the 50% dropout. While the authors didn’t mention why this was, the other half that didn’t complete the study could have easily not gotten much sun exposure at all, as they demonstrated a general lack of compliance, which could well represent the general public. This shortfall in the study is a big enough limitation, where, in my opinion, there is still quite a bit of doubt whether a doctor simply telling his patient to get more sun exposure actually works.

In conclusion, I think it’s important to recognize that we don’t know best-methods to educate on vitamin D. We do take our best guess and try to make up for the lack of research in the area through usability testing, analytics and general principles in providing patient friendly information. This is an area where we need more research, and we hope to see more in the next few years.

Until then, it’s probably best to simply recommend sun exposure and supplements, and if people want to know more, then you can really delve into vitamin D levels and tailoring recommendations.

Source

Al-Daghri NM et al. Effect of Non-Pharmacologic Vitamin D Status Correction on Circulating Bone Markers in Healthy Overweight and Obese Saudis. Molecules, 2013

13 Responses to How should we educate on vitamin D?

  1. Rita and Misty

    Brant!!! What an excellent article…it is just like we are of “one mind.” 🙂

    Thank you, always, for your hard work and effort.

    Brant, you are definitely part of the equation–making the VDC the BEST nutritional website in cyberspace… 🙂

    Be well,
    Rita

  2. Rita and Misty

    I wonder if it would be worthwhile to run a test and comparison of the 25(OH)D level all Vitamin D Council members (willing to participate)….tracking daily dosage, sun exposure, etc.

  3. D-fiant

    When it comes to teaching or education of people, there is a need to have something to teach.
    Is it going to be theory, faith or facts?
    The vitamin D followers are linked in all of these, but the vast majority of people and especially the medical fraternity are skeptical of anything other than the facts! (As they see them)

    Thus the ambassadors of Vitamin D are locked in a struggle with the Vitamin D skeptics.
    The Vit D ambassadors think the world will be a better place if everyone had the correct Vit D level in their blood.
    On the other hand, it seems the majority of the doctors either think Vit D is irrelevant above rickets level or downright dangerous!

    So our focus is not to convince ourselves, as we are already believers, but the path forward to reach our goal is via the shirt tails of the doctors and most of them are unimpressed!

    At all times we must stay grounded in our appreciation of Vit D, and sometimes we have to be prepared to say that Vit D will not achieve many things and we have to be as critical as the doctors, where the tests do not back up the claims / expectations. (Provided the test is carried out correctly)

    Some of the cases of incorrect tests were covered by the council recently, where Vit D benefits were represented by the “U and J” curves. From the doctor’s point of view, they give such reports about 5 seconds and log in their brains…….”High Vit D = bad.” They are not going to analyze the results to query if the test was affected by Vit A, if higher doses would actual improve things and were the people taking Vit D very sick and going to die prematurely anyway? Their clinic opens in 15 minutes and as they scan their computer, the waiting room is already half full.

    Some of the Vit D expectations are showing real promise and the road ahead is almost there, but every long stretch of clear evidence ends for naught if a major bridge is missing to link expectation with conclusive undeniable factual conclusion.

    With pieces of many puzzles missing and filling in the gaps can take time and money, sometimes lots of each! What do we do?

    As I see it there are only two ways to “sell” Vit D……. Emotional and financial.

    From the emotional point of view, Vit D should be seen as “the right thing to do.” Why? …..because it makes people’s lives better- healthier and happier. This is the ambassador point of view. However this is not to say that the government would not take up this call. The care of a nation’s people is a high priority and governments already pour out masses amounts of money to achieve this. What if they could be convinced that there might be a better way, if only some extra funds could be released to finish off some of the tests that are ‘slam dunk’ for success, if only more test money could be found?

    Can we linkup with a wealthy benefactor? Bill Gates and Warren Buffet, and others like them, how could we attract their interest? Do we know what Vit D issue is the most important and the most achievable for the smallest investment? ……. “The biggest bang for our buck?”

    From the financial point of view it is all about return on cost. There is not much to be
    made in selling Vit D, ‘the pill.’ But there could be a lot to be ‘saved’ by selling the ‘benefits’ of Vit D. There was that recent article where a considerable sum was saved in an old people’s home in New Zealand due to a decrease in falls etc.

    So who makes money when people are well? (The presumption being, can they be convinced to part with some of their ‘pre-savings’ for research?)

    Insurance companies – less payouts.
    Government and business – reliable workforce.
    Government – less requirement to subsidize medications.
    Government – less requirement to build hospitals.
    Do we know any big business’s with a conscience and governments who can see beyond the next election?

    Dare I ask? Who loses money when people are well?
    Some doctors – less patients
    Some drug companies – less sick people to sell products to.
    Government (maybe) – more people living to old age require longer pensions, where these apply. But this has to be offset against a longer productive working life and more people may have saved for their own retirement.

    I sense that the Vit D council has changed its focus. I read the section on the “What we do” and it seems a very passive role. You seem to be saying that you are a very lay back bunch of people who help other people figure out the data on Vit D tests and other confusing stuff. So people can look at the website and oh yeah, we are on twitter and facebook. So bye for now…. And get some sun now, you hear?

    So what is happening now? The Vit D council is too restless to sit and wait for the data to arrive. Now you appear to want to get involved with data creation and research initiation.

    So if this is the new Vit D council direction, what would be the first issue you would tackle, how much would is cost, and how long will it take for the results to arrive.

    Recently you asked for support to run the council, and I believe that you went short of the target. How would you raise the money for your first research project? Would the first assignment have “price” as the main deciding factor? One thing is for sure, the old Vit D council will have to make some changes.

    Bye for now….and get some sun!

  4. Rita and Misty

    D-fiant,

    What a great post…thank you…I can already feel my brain start to pick up speed. I’ll certainly be mulling over your comments…and, perhaps I need to apologize (in advance) to Brant for the multitude of emails he’ll be receiving from me… 😉

    Be well,
    Rita

  5. Rita and Misty

    Perhaps a good place to start would be to utilize the below mission statement;

    “an organization with a mission to end the worldwide vitamin D deficiency epidemic by means of outreach, awareness, treatment, research and activism.”

  6. GHamilton

    How to best educate is indeed a difficult question. Even as a physician, with all my tools at hand including blood levels, many patients still look at me very funny when I tell them exactly how much they need (most often I am recommending 10,000 IU/day here is sunny Wisconsin!). However, one by one, when someone got through the winter without getting sick, or a child stopped getting those pesky ear infections, my message is being heard. Of course, I am the only doc in my neck of the woods recommending 10,000 IU daily, testing levels, or realizing the optimal level is >50.
    How does big pharma do it? Fancy commercials and labels. How does the CDC do it? Fear.
    Very effective methods of mass brainwashing without any science involved.
    I guess I still prefer the method we find here…real science, intelligent discussion, passing the message on one by one.
    But, I seriously think we need to focus on the medical community as it seems my peers are the most obstinate when it comes to change.
    Thanks for all you do here!

  7. Rita and Misty

    IMO (here in the USA)–

    1. Physicians educating physicians: talk to your colleagues not only at conferences and seminars, but at lunches, dinner parties, and on the golf course and other social events.

    …and

    2. National policy change(s)…including (but not limited to) food fortification.

    Those who know better are called to do more.

    The medical community is a closed sphere. It will take an intractable physician to penetrate and change this community.

  8. PeterVermont

    With so many hyped up health fads it is important to show that vitamin D is different.

    The most compelling argument, in my view, is that vitamin D is necessary for proper human functioning and that we evolved to have higher levels than most people have now. People are easily convinced that our sun exposure is less than our ancestors — just mention clothing and the amount of time we spend indoors and it is obviously true to most.

    Getting people to think of correcting a deficiency of modern living rather than just another faddish supplement is key.

    A general appeal to evolutionary arguments is powerful. ‘Humans evolved in a specific context and operate best in that. This is why plenty of sunshine and real food are essential to good health.’

  9. Rita and Misty

    Peter…I would prefer to receive my vitamin D via sunshine. In my youth, when a job didn’t demand it, I was beach obsessed. I love to do the iguana pose. Basking in sunshine just makes me feel better.

    However, now (sigh) I am chained to a desk during the week, certainly between the hours of 9 a.m. — 5 p.m. Although I know better, I cannot receive my vitamin D via sunshine at this point in my life. (and I am lax in purchasing a sunlamp, so shame on me).

    Also, I live in Connecticut…above latitude 35 degrees north…in winter the sun’s rays just aren’t strong enough to generate any vitamin D where I live….

    I find much fault with our modern lifestyles. But, I do have to live in this concrete jungle for now.

    So, I take my vitamin D3 supplement…daily…and in sufficient amounts to maintain my 25(OH)D level at the higher end of optimal.

  10. Michael

    As a school teacher you can get fired for talking about Vitamin D either in class or with an individual student. Mentioning in passing that people need more sunshine, or should be in the sun more, or that “Vitamin D is not harmful as you might have heard”, or just about anything that goes contrary to the 400 UI or 800 UI or whatever small dose is officially recommended can get you fired. One parent or one student mentioning it to an administrator or a school nurse or a colleague, any of whom is Vitamin D ignorant, can get you fired.

    A 4th grade African-American girl just back to school with her broken foot in a cast was not allowed outside in the sun because “she should stay inside at recess to rest her foot.” (By the way, she always stays in to help the teacher.) To have suggested that she needed sunshine and vitamin D so that the foot bones could heal better would be tantamount to saying “I’m impersonating a doctor — call the cops, fire me.” You folks reading this don’t understand, I am pretty sure, just how rigidly school personnel are in their set beliefs given to them by commercial television (and the pharmaceutical industry).

    A school custodian fell and broke his forearm (He admitted he had not been outdoors for years.) It was not healing and they re-cast it with a poor prognosis. I pulled him aside and convinced him to take the 5,000 strength Vitamin D pills daily and gave him a whole bottle. Because we were buddies he did it and made a full quick recovery.

    Dark-skinned boys and girls stand in the shade at recess and no teacher sends them out into the sun. Most of these pasty-faced teachers also are hiding in the shade proclaiming they don’t want to get skin cancer. “Come over here children or you will get skin cancer.” It makes the head spin !

    Michael

  11. Rita and Misty

    I hear you Michael. I know what you are going thru. It must be very frustrating for you. I know it is for me!

    I chat up vitamin D all the time–I am a traveling vitamin D road show.

    But, I always rely on information from the Vitamin D Council at the health fairs I attend. I get my legitimacy from Dr. Cannell and Dr. Grant. And, I am always asked by folks at these fairs: “Which doctor(s) are you associated with?”

    I am very grateful for the Vitamin D Council; otherwise, I really would not be able to do the SUCCESSFUL outreach that I do DO!!! 🙂

    Michael, I ask you to be BRAVE and to continue to speak up and out about vitamin D. And, if people question your legitimacy, direct them to the Vitamin D Council…to this extraordinary organization…and refer them to the excellent work of Dr. Cannell and Dr. Grant.

    Be well,
    🙂

  12. jack

    This thought is not original with me, but it makes sense to me that everyone be tested for a 25 (OH) D baseline; then go from there. If I’m not mistaken it was commentary by a major cancer hospital that contained the suggestion.
    Of course that approach would bring about another debate; but everyone needs to know their blood D-level.
    JM

  13. MURPHY

    I think one of the best ways to educate the public re D3 is to tell all the jocks that if they ingest enough D3, they’ll get faster and stronger and will be able to last longer.

    The next best way might be to tell everyone how and why it will make their between-the-sheets activities a lot more enjoyable.

    Actually, the “next best” way might be The Best.

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