HERB DENENBERG COLUMN FOR NOVEMBER 15, 2009. A(51) VITAMIN D

According to a recent study, as many as 77 percent of all Americans may be deficient in the vitamin essential for bone health, that may prevent H1N1(Swine Flu) and seasonal flu, wheezing, winter-related eczema, upper respiratory infections, and may help prevent cancer, autoimmune diseases such as multiple sclerosis, type 1 diabetes, certain infectious diseases, myocardial infarctions (heart attacks) and many other serious diseases. When subgroups of the population are considered, depending on which of the many reasonable

definitions of deficiency are accepted, the picture is even more ominous. For

example, an important new study from Children's Hospital in Boston found that

as many as 80 percent of Hispanic children and 92 percent of black children

(what the study calls non-Hispanic black children) may also be deficient in

this vitamin.

We're talking about vitamin D, also called the sunshine vitamin, often called

the nutrient of the year if not the decade. It's power as a determinant of

human health can be captured by what happens when someone is D deficient. They

are at risk for what is called rickets in children and osteomalacia in adults.

In its most extreme form, the bones soften and almost melt, making them so

fragile that the simple act of walking up steps may cause bones to fracture

and slight movement may cause excruciating pain. In its most severe form, a

blood test for vitamin D may show zero. Dr. Fred Kaplan, an eminent orthopedic

surgeon at the Hospital of the University of Pennsylvania, whose patient had

zero D, said that is rare even in Third World countries.

Why in the land of plenty and now also the land of over-consumption,

overweight and obesity, can there be an epidemic of a vitamin D deficiency or

any other nutrient? The reasons may not be fully understood, but the picture

is still clear: Over time, we have obtained most of our vitamin D from the

sun. When ultra violet B rays hit the skin they cause the formation of vitamin

D. But in an age of sunscreens and well-placed fear of skin cancer, we tend to

either stay out of the sun or use a sunscreen to shield us from its rays

(including ultraviolet B).

Even if you stayed in the sun all day in some locations you would not get

enough vitamin D. For example, north of Philadelphia between November and

March the suns rays are not strong enough to precipitate the formation of

vitamin D. And during early morning and late afternoon, the sun's rays are not

strong enough to generate vitamin D.

That's a big part of the picture, as authorities find that exposure to the sun

is the main determinant of vitamin D in humans. This leads us to the next

source of vitamin D - our food. Some dairy products, such as milk, are

fortified with vitamin D, but we tend to avoid dairy products due to their

cholesterol and saturated fat content. Other sources are fatty fish such as

salmon, tuna, mackerel, and herring, fortified cereal, and some other foods

such as orange juice (now often fortified both with vitamin D and calcium).

But most people don't eat enough of these foods to get enough vitamin D. So

that leaves supplementation with multi-vitamins that include D, combination

calcium/vitamin D pills, or vitamin D stand-alones.

There may be another reason for the epidemic - the epidemic of the overweight

and obese, who cannot process vitamin D efficiently and are consequently more

likely to be vitamin D deficient. One final reason for identifying the

epidemic is better testing methods for vitamin D. There is a simple blood test

now used to determine vitamin D status.

Still another reason for the D epidemic is the aging of the population, as

older people - even the middle-aged - are more likely to have D deficiency.

There are other risk factors for a D deficiency, but they probably don't play

a big role in the growing number of people with that deficiency. Consumer

Reports catalogued the following risk factors: "Being dark-skinned,

middle-aged, or overweight. Having a history of gastric-bypass surgery or a

condition that interferes with the ability to absorb nutrients from food, such

as celiac disease. Having a history of kidney or liver disease, multiple

sclerosis, osteoporosis, or thyroid problems. Taking medications that reduce

blood levels of vitamin D, such as cholestyralmine (Questran and generic),

colestripel (Colestid and generic), certain anticonvulsants; or orlistat

(Alli, Xenical)" (Consumer Reports on Health, November 2009).

This epidemic of vitamin D deficiency recently came into focus with the

publication of an important study led by Dr. Jonathan Mansback at Children's

Hospital In Boston. The study appears in the November 2009 issue of the

journal Pediatrics. The study looked at vitamin D levels of 5,000 children

and, extrapolating to the entire U.S. population of children, found that

millions were receiving what the study called suboptimal levels of D. As noted

above, depending on the definition of deficiency or suboptimal levels, the

study found 80 percent of Hispanics and 92 percent of black children were at

the suboptimal levels. Others have previously documented widespread vitamin D

deficiency in children. For example, Dr. Babette Zemel (Ph.D.), a vitamin D

expert at Children's Hospital of Philadelphia, who is Director of the

Nutrition and Growth Laboratory of that hospital and

Associate Professor of Pediatrics at Penn's medical school, found that 55

percent of children she studied were vitamin D deficient, in a study published

in 2007.

The Mansback study notes that we're far from knowing everything we should

about how to bring children and adults up to optimal levels, how to avoid any

long-run adverse consequences, and exactly what level of vitamin D is optimal.

It does recommend, in view of its findings, that children take vitamin D

supplements because of the clear health benefits from doing so. The study

doesn't make specific recommendations but the American Academy of Pediatrics

recommends that children with inadequate sun exposure get daily intake of at

least 400 International Units of vitamin D (vitamin D3 is now recommended as

it is better absorbed than D2). The adult recommendations, according to a

report in The American Family Physician (October 2009), as cataloged by

www.medscape.com, are as follows:

"In older adults, vitamin D supplementation of 700 to 800 IU per day is

associated with a lower risk for falls...and fractures.

To prevent vitamin D deficiency, adults with inadequate sun exposure

should have vitamin D intake of 400 to 600 IU per day.

Adults with vitamin D deficiency, except for those with malabsorption

syndromes, should receive maintenance dosages of 800 to 1,000 IU of vitamin D

per day."

Dr. Zemel recommends that most adults take vitamin D supplementation of

between 1,000 and 2,000 IU of vitamin D, which seems to make the most sense in

view of the evidence that I've reviewed. Of course, you may want to run this

issue past your doctor at your next visit. She said there is some variability

in the response to vitamin D, so some may reach optimal levels with 1,000 IU

while others may require more. In severe deficiency cases, more aggressive

supplementation may be called for, such as 500,000 IU by injection.

The Medscape report also notes that excessive amounts of vitamin D can be

toxic. It states, "Because vitamin D is fat soluble and can be stored in fat,

there are concerns regarding toxicity from excessive supplementation. Signs

and symptoms of vitamin D toxicity may include headache, metallic taste,

nephrocalcinosis or vascular calcinosis, pancreatitis, nausea, and vomiting."

There is a study indicating toxicity is reached at 10,000 I.U. daily. Dr.

Zemel told me vitamin D toxicity is extraordinarily rare.

You can be sure there will be continuing and extensive studies of vitamin D to

answer many questions now only incompletely answered. Dr. Mansbach says, "We

need to perform randomized controlled trials to understand if vitamin D

actually improves these wide-ranging health outcomes. At present, however,

there are a lot of studies demonstrating associations between low levels of

vitamin D and poor health. Therefore, we believe many U.S. children would

likely benefit from more vitamin D."

Although evidence is not clear on how to prevent H1N1 flu, the suggestions for

prevention include taking vitamin D supplements, especially in the winter. In

a report in the examiner.com, five simple steps are recommended to prevent

H1N1:

Get enough vitamin D.

Use proper hygiene (for example, frequent hand washing, cough into your

elbow instead of your hands, and avoid contact with public surfaces with your

hands whenever possible).

Adequately rinse the nose and throat.

Get enough sleep.

Consume plenty of garlic and other antiviral herbs.

Dr. Zemel believes it is too early to make hard and fast conclusions on the

vitamin D/H1N1 connection. Dr. Charlene Compher, an expert on diet and health

at Penn agrees it is too early to draw conclusions on H1N1. But Dr. Zemel and

others note that vitamin D does strengthen the immune response, and therefore

may be useful in preventing H1N1.

Dr. James E. Dowd, a professor of medicine at Michigan State University and

Diane Stafford in their book The Vitamin D Cure have this to say about the

flu/vitamin D connection: "More respiratory infections during the winter are

probably directly related to lower vitamin D production." They note several

factors contribute to the winter infection scenario. In the winter, there

aren't as much ultraviolet B rays, which inactivate many viruses. With less

ultraviolet B getting through, humans produce less vitamin D of their own.

Finally, vitamin D is important to mobilize the immune system response to

infections. As a result of all this, respiratory infections start to rise in

late September and peak in February. So Dr. Dowd's final advice is to forget

the chicken soup with too many noodles, too much salt, and too little chicken

and take vitamin D instead. My final advice is to get chicken soup that

doesn't have too much salt, too many noodles, and too little chicken and get

someone who can make unsalted chicken soup, with the noodles and chicken you

want, and then take your vitamin D.

Dr. Bruce Kinosian, a geriatrician at Penn and an expert on diet and health,

did sound a cautionary note, that vitamins thought to be magical cure all

often turn out to have quite the opposite effect. He cites a long list of such

vitamins of the year, which later fizzled. The most prominent case involved

vitamin E, which in excessive doses, was found to cause lung cancer in a

segment of the population.

Perhaps the most fundamental preventive approach was recently recommended by

Dr. Sidney Wolfe of the Health Research Group. He said take the most powerful

and effective drug, which is a healthy lifestyle. This is the same

prescription written over 800 years ago by the eminent Jewish physician and

philosopher Maimonides, who said most of us die as a result of our life style.

Sometimes ancient wisdom is more powerful than modern technology.

And I can’t reisist one more observation on Maimonides. He was born In Cordoba, Spain in 1135. But Cordoba was soon taken over by a Muslim sect that demanded all Infidels convert to Islam. So the family had to emigrate. He ended up in Cairo, where he practiced medicine. Of course, I doubt if he were alive today, even the greatest physician of his time would not be allowed to practice medicine there. Does this piece of history suggest, the more things change, the more they stay the same; and does it also ofter a sad commentary on the state of human progress?

(Herb Denenberg is a former Pennsylvania Insurance Commissioner, Pennsylvania

PUC Commissioner, and Loman Professor at the Wharton School. He has been an

elected member of the Institute of Medicine of the National Academy of the

Sciences since 1973, and has testified many times before Congress on insurance

and health care issues. You can reach Herb at advocate@thebulletin.us.)

Herb Denenberg is a former Pennsylvania Insurance Commissioner, professor at the Wharton School, and Pennsylvania Public Utility Commissioner. He is a member of the Institute of Medicine of the National Academy of Sciences and is a board member of the Center for Safe Medication Use. He is an adjunct professor of insurance and information science and technology at Cabrini College. You can write Herb at POB 7301,St. Davids, PA e-mail him at hdenenberg@aol.com or reach him at his two Web sites: thedenrep_archive.org or denenbergsdump.org