The Vitamin D Newsletter April 2008

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Vitamin D Question and Answer

Professor Marshall's recent "discovery"

I have been inundated with letters asking about Professor Marshall's recent "discovery." Some have written that to say they have stopped their vitamin D and are going to avoid the sun in order to begin the "Marshall protocol." The immediate cause of this angst is two publications, a press article in Science Daily about Professor Marshall's "study" (which is no study but simply an opinion) in BioEssays. Dr. Trevor Marshall has two degrees, both in electrical engineering. Before I begin, I want to again remind you that I am a psychiatrist who works at a state mental hospital. In my duty to full disclosure, I must say that I have known a lot of psychiatrists in my life and a few electrical engineers. If I knew nothing else of a disagreement between two people but their professions, I would believe the electrical engineer, not the psychiatrist.

In reading his two articles, Dr. Marshall's main hypotheses are simple:

• Vitamin D from sunlight is different than vitamin D from supplements.
• Vitamin D is immunosuppressive and the low blood levels of vitamin D found in many chronic diseases are the result of the disease and not the cause.
• Taking vitamin D will harm you, that is, vitamin D will make many diseases worse, not better.

If you read his blog, you discover that the essence of the Marshall protocol is: "An angiotensin II receptor blocker medication, Benicar, is taken, and sunlight, bright lights and foods and supplements with vitamin D are diligently avoided. This enables the body's immune system, with the help of small doses of antibiotics, to destroy the intracellular bacteria. It can take approximately one to three years to destroy all the bacteria." That is, Dr. Marshall has his "patients" become very vitamin D deficient.

Again, Dr. Marshall conducted no experiment and published no study. He wrote an essay. He presented no evidence for his first hypothesis (sunlight's vitamin D is different than supplements). From all that we know, cholecalciferol is cholecalciferol, regardless if it is made in the skin or put in the mouth. His second hypothesis is certainly possible and that is why all scientists who do association studies warn readers that they don't know what is causing what. Certainly, when low levels of vitamin D are found in certain disease states, it is possible that the low levels are the result, and not the cause, of the disease. Take patients with severe dementia bedridden in a nursing home. At least some of their low 25(OH)D levels are likely the result of confinement and lack of outdoor activity. However, did dementia cause the low vitamin D levels or did low 25 (OH)D contribute to the dementia? One way to look at that question is to look at early dementia, before the patient is placed in a nursing home. On the first day an older patient walks into a neurology clinic, before being confined to a nursing home, what is the relationship between vitamin D levels and dementia? The answer is clear, the lower your 25(OH)D levels the worse your cognition. Wilkins CH, Sheline YI, Roe CM, Birge SJ, Morris JC. Vitamin D deficiency is associated with low mood and worse cognitive performance in older adults. Am J Geriatr Psychiatry. 2006 Dec;14(12):1032–40. Przybelski RJ, Binkley NC. Is vitamin D important for preserving cognition? A positive correlation of serum 25-hydroxyvitamin D concentration with cognitive function. Arch Biochem Biophys. 2007 Apr 15;460(2):202–5.

These studies suggest that the low 25(OH)D levels are contributing to the dementia but do not prove it. Only a randomized controlled trial will definitively answer the question, a trial that has not been done. So you will have to decide if vitamin D is good for your brain or not. Dr. Marshall seems to be saying demented patients should lower their 25(OH)D levels. Keep in mind, an entire chapter in Feldman's textbook is devoted to the ill effects low vitamin D levels have on brain function. Brachet P, et al. Vitamin D, a neuroactive hormone: from brain development to pathological disorders. In Feldman D., Pike JW, Glorieux FH, eds. Vitamin D. San Diego: Elsevier, 2005.

It is true that in some diseases, high doses of vitamin D may be harmful. For example, in the early part of last century, the AMA specifically excluded pulmonary TB from the list of TB infections that ultraviolet light helps. They did so because many of the early pioneers of solariums reported that acutely high doses of sunlight caused some patients with severe pulmonary TB to bleed to death. Thus, these pioneers developed very conservative sun exposure regimes for pulmonary TB patients in which small areas of the skin were progressively exposed to longer and longer periods of sunlight. Using this method, sunlight helped pulmonary TB, often to the point of a cure. Furthermore, it is well known that sunlight can cause high blood calcium in patients with sarcoidosis. In fact, sarcoidosis is one of several granulomatous diseases with vitamin D hypersensitivity where the body loses its ability to regulate activated vitamin D production, causing hypercalcemia. Cronin CC, et al. Precipitation of hypercalcaemia in sarcoidosis by foreign sun holidays: report of four cases. Postgrad Med J. 1990 Apr;66(774):307–9.

Furthermore, although medical science is not yet convinced, some common autoimmune diseases may have an infectious etiology. I recently spoke at length with a rheumatologist who suffers from swollen and painful joints whenever he sunbathes or takes high doses of vitamin D. As long as he limits his vitamin D input his joints are better. To the extent vitamin D upregulates naturally occurring antibiotics of innate immunity, sunlight or vitamin D supplements may cause the battlefield (the joints) to become hot spots. I know of no evidence this is the case but it is certainly possible.

However, if Dr. Marshall's principal hypothesis is correct, that low vitamin D levels are the result of disease, then he is saying that cancer causes low vitamin D levels, not the other way around. The problem is that Professor Joanne Lappe directly disproved that theory in a randomized controlled trial when she found that baseline vitamin D levels were strong and independent predictors of who would get cancer in the future. The lower your levels, the higher the risk. Furthermore, increasing baseline levels from 31 to 38 ng/ml (77.5 to 95 nmol/L) reduced incident cancers by more than 60% over a four year period. Therefore, advising patients to become vitamin D deficient, as the Marshall protocol clearly does, will cause some patients to die from cancer. Lappe JM, Travers-Gustafson D, Davies KM, Recker RR, Heaney RP. Vitamin D and calcium supplementation reduces cancer risk: results of a randomized trial. Am J Clin Nutr. 2007 Jun;85(6):1586–91.

I will not write again about Dr. Marshall's theories. No one in the vitamin D field takes him seriously. Personally, I admire anyone willing to swim against the tide and raise alternative theories. I have done the same with influenza and autism. However, I agree with the New York Times and Jane Brody's conclusion: "In the end, you will have to decide for yourself how much of this vital nutrient to consume each and every day and how to obtain it." Jane Brody. An Oldie Vies for Nutrient of the Decade. New York Times. 2008 Feb 19. I agree. You will have to decide for yourself.

Degenerative Arthritis

No, it is not ok to take that amount of vitamin D—and injecting it into your knees is a first for me! The first sign of vitamin D toxicity is hypercalcuria (excess calcium in the urine), not hypercalcemia (excess calcium in the blood). As vitamin D must be transported in the blood to be hydroxylated by the liver, you should get the same effect for your knees by injecting it in your elbows and I don't recommend either. The amount of vitamin D you are taking and your 25(OH)D levels indicate you will calcify your internal organs, starting with your kidneys.

I advise to lower your 25(OH)D down to less than 100 ng/ml by immediately stopping all vitamin D and staying out of the sun. I'm glad you have lost so much weight and there is reason to think vitamin D will induce weight loss. However, one does not need the doses you are using to induce weight loss. Fay, what you are doing is experimenting with vitamin D as a pharmaceutical agent, not a supplement. It may be that future studies will show pharmaceutical doses of vitamin D (50,000 IU per day) do have a treatment effect on certain diseases. To date, no studies support what you are doing and other studies indicate you are taking toxic doses of vitamin D. Again, stop your vitamin D and stay out of the sun.

Sunshine and Pericarditis

No, like your doctor I have never heard of it either, but unlike your doctor I believe it is possible the sunlight cured your pericarditis. The majority of cases of pericarditis are infectious with viruses the most common agent. Sunlight will trigger formation of antimicrobial peptides, which are potent and broad spectrum antibiotics. Anyone who takes more than 2,000 IU per day knows that lower respiratory infections are less common and by sunbathing in your bathing suit your were getting about 10,000 IU per day.

Vitamin D - Helpful for Heartbeat?

I don't know. If your vitamin D level was low enough to affect you blood calcium the vitamin D would help that. Without 25(OH)D levels, there is no way of knowing what your level was or if your level is in the ideal range now. I personally know of a patient with severe heart disease who refused to go to the hospital. He was on standard medical therapy plus 5,000 IU per day. However, both his severe congestive heart failure and his arrhythmia improved after he started taking 10,000 IU per day.

A case report found sick sinus syndrome disappeared after vitamin D. Other than the case report, I'm not aware of any literature on the subject, one way or the other. Kessel L. Sick sinus syndrome cured by ... vitamin D? Geriatrics. 1990 Aug;45(8):83–5.

Blood Test Only Way To Know

Your case highlights the need to get repeat blood tests. I've been surprised at just how ineffective supplementation can be, especially in obese patients. One has to supplement, get 25(OH)D blood test, adjust supplementation, get another level, etc. Many obese people will need 10,000 IU per day to obtain a level of 50 ng/ml (125 nmol/L), but getting a 25(OH)D is the only way to know how much you need to take. And, levels will go higher in the summer due to incidental sun exposure.

It is becoming widely known that adequate doses of vitamin D helps prevent colds and flu. I'm proud of the fact that the first time such a finding was ever published in the world's literature, it was published by the Vitamin D Council in our November 2005 newsletter.

As far a helping is concerned, the Vitamin D Council would like to run a national advertising campaign. We did run three ads in parts of California to the tune of $4,800. You can see the three ads on our Vitamin D Council YouTube Channel. We would like to run them all around the country but that would cost more than $200,000.00. We need contributions before we can run anymore.

Vitamin D Overdose

The symptoms of vitamin D toxicity are weakness, nausea, vomiting, pain in the joints, loss of appetite, and weight loss. The patient may experience constipation alternating with diarrhea, or have tingling sensations in the mouth.

The toxic dose of vitamin D depends on its frequency. In infants, a single dose of 15 mg (600,000 IU) or greater may be toxic, and has to exceed 0.5 mg (20,000 IU) per day over a prolonged period to be toxic in infants. In adults, a daily dose of 1.0–2.0 mg (40,000–80,000) of vitamin D may be toxic when consumed for a prolonged period. A single dose of about 50mg (2,000,000 IU) or greater is probably toxic for adults. The immediate effect of an overdose of vitamin D is abdominal cramps, nausea, and vomiting, not dry mouth and eyes. Toxic doses of vitamin D taken over a prolonged period of time result in deposits of calcium crystals in the soft tissues of the body that may damage the heart, lungs, and kidneys.

For people who have trouble with supplements, I recommend sunbathing during the warmer months and sun tanning parlors in the colder months. Yes, sun tanning parlors make vitamin D, the most is made by the older type beds. Another possibility is a Sperti vitamin D lamp.

I don't know but this is another example of the use of pharmaceutical doses of vitamin D (this one by mistake). Vitamin D upregulates antimicrobial peptides in the skin, which promote healing. After World War One, solariums were common treatment for non-healing war wounds. I think you should measure 25(OH)D levels on all your patients. If you do, I think you'll find that 50,000 IU per week is giving your patients levels between 50–80 ng/ml (125–200 nmol/L), which is fine.

Professional Athletes Need Vitamin D Too!

Good work. And once again, the first reference in the world's literature that vitamin D will help athletes was published by the Vitamin D Council in our March 2007 newsletter. Can you imagine what will happen in professional sports when athletes realize that vitamin D improves their speed, strength, timing, and quickness?

Sunlight Needed For Malabsorption

You didn't give your weight so I don't know if you're not absorbing it or it is depositing itself in fat tissues. I suspect you are not absorbing it. The two prescription items you mentioned, Calderol and Dedrogyl, are both 25(OH)D. Although they are effective, there is no reason to use them unless your liver is not hydroxylating vitamin D. I suspect that your level would be fine if you started using a sun tan parlor twice a week. Or, you could go to 10,000–15,000 IU per day. However, at that dose, you should get your 25(OH)D level checked every four months. For malabsorption syndromes, a sun tanning parlor once or twice a week is ideal or a home vitamin D lamp.

Vitamin D and COPD

COPD appears to respond to vitamin D in two ways. It improves pulmonary function through an unknown mechanism and it prevents lower respiratory infections that usually exacerbate underlying lung disease. As far as helping, we need donations in order to run a national TV advertising campaign.

Arthritis and Prostate Cancer

You're welcome. While there are no interventional trials using vitamin D in arthritis, cross sectional and longitudinal epidemiological studies suggest it would have a treatment effect. Professor Reinhold Vieth, in an open trial, discovered that 2,000 IU of vitamin D per day slowed the rate of growth of PSA. Other men with prostate cancer have written to me that their PSA returned to normal with higher doses of vitamin D although it takes up to a year.

Increased Body Fat? More 'D' Needed

The resistance is probably due to the relatively low dose and patient's body fat. Many larger adults need 5,000–10,000 IU per day to get adequate levels. I'm glad they have increased the lower limit in France. However, it should be 40 and not 30. Remember Bruce Hollis, in a crucial paper, showed that the kinetics of vitamin D's metabolism is not normalized until levels are above 40 and often 50. His discovery is compelling evidence that levels of 40–50 represent the lower limit of the ideal human range. Hollis BW, Wagner CL, Drezner MK, Binkley NC. Circulating vitamin D3 and 25-hydroxyvitamin D in humans: An important tool to define adequate nutritional vitamin D status. J Steroid Biochem Mol Biol. 2007 Mar;103(3–5):631–4.

Autism

You are not alone. One of the Kaiser hospitals in California is now drawing 25(OH)D levels on all of their subscribers. I know of at least 10 clinics doing the same and treating with adequate doses of vitamin D. They all report that a wide variety of diseases respond. The one exception is advanced cancers and that is to be expected as poorly differentiated cancers lose the ability to activate vitamin D and lose the vitamin D receptor. However, if I had an advanced cancer, I'd still take 20,000 IU per day.

As far as autism goes, I have been unable to interest any autism researchers, even those drawing routine blood of the children, and even at my alma mater, UNC School of Medicine. I continue to believe that gestational and/or early childhood vitamin D deficiency is a major cause of autism. My paper is being distributed this month although I doubt any researchers will act on it. Cannell JJ. Autism and vitamin D. Med Hypotheses. 2008;70(4):750–9.

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