Vitamin D: Thoughts on the New DRIs

We know many of you have been reading about the new Dietary Reference Intakes (DRI’s) for Calcium and Vitamin D recently released from the Institute of Medicine. The Clinical Team at The UltraWellness Center (UWC) would like to share our thoughts on this report to help minimize any confusion. Our opinions are based on the conclusions from our clinical team, which includes 4 master’s degrees in nutrition, authors of textbooks on nutrition and international leaders in nutrition education for physicians and dietitians. We have collectively have 100 years of reviewing nutrition research and applying it with thousands of patients. Each week our clinical team meets to discuss health and nutrition topics, review research data and patient outcomes, as well as consult with experts in the field, including Michael F. Holick, PhD, MD, who is the leader in the field of Vitamin D research. Although we agree with an increase in the DRI’s for vitamin D, we feel it is overly cautious and are disappointed that the panel failed to address a large volume of compelling research showing the benefits of OPTIMAL vitamin D intake in many conditions beyond bone health, including cancer, depression, imbalances in the immune system, heart disease, and many others. Vitamin D is a very complex and fascinating nutrient that has multiple roles and effects in the body beyond bone health.
Vitamin D regulates over 150 genes. Facts like this have not been considered in the report.
An important distinction to keep in mind is that the DRI’s are intended as general population-based guidelines. They do not differentiate or take into account a person's unique medical history, genetics, dietary intake, clinical symptomatology, environmental conditions including sunlight exposure or biochemical and nutritional assessment. Our clinical staff at The UltraWellness Center, as well as many of our colleagues practicing functional medicine, have significant "practice-based clinical evidence” from testing thousands of individuals with the goal of optimizing vitamin D status correlated with other biomarkers showing very positive effects on both skeletal and extraskeletal conditions. We routinely check vitamin D levels, monitor clinical symptoms, evaluate our patients’ health status, and tailor medical nutritional therapy accordingly. Based on this wealth of knowledge, here are some of the highlights and our conclusions about the report recently released by the Institute of Medicine:
  1. The report recommended a 300 percent increase in vitamin D for most Americans and doubled the acceptable upper safe limit to 4000 IU a day which means they consider it completely safe to take 4000 IU a day.
  2. They appropriately conclude that most Americans are overdosing on calcium, which has been added to many foods. Countries with low calcium intake, with a plant-based, low-acid diet and plenty of sun exposure have very low rates of osteoporosis. We support the intake of adequate calcium from food, especially dark green leafy vegetables, tahini, and nuts.
  3. The Institute of Medicine’s conclusions and dietary reference intakes (DRI’s) focus on the minimum amounts of nutrients needed to prevent deficiency diseases, not the amount needed create optimal health.
  4. Their conclusions are based on proving the absence of something (like heart disease or cancer over decades), which is harder to prove than the presence of something. Spending decades of research looking for something not to happen is a tough game. Pharmaceutical agents are meant to alter pathology. Nutrients restore normal function, and they do so by optimizing normal biological functions, mostly by their action as coenzymes in thousands of biochemical reactions.
  5. The conclusions are deliberately very conservative based on requirements for absolute proof, not implications from all the collective research. The Institute of Medicine places the burden of proof on those who would suggest that higher levels are effective or safe. However, given the evolutionary human experience of sun exposure and high doses of vitamin D from fatty fish—equivalent to up to 10,000 U a day—perhaps the burden of proof should be on scientists to prove that lower levels of intake are, in fact, safe over long term. Nutrients are not drugs and cannot be studied or evaluated as drugs. They are multifunctional substances each responsible for hundreds of chemical reactions in the body necessary for life.
  6. The conclusions are based on meeting the gold standard of research for evidence-based medicine—namely the randomized controlled trial. While useful for evaluating drug therapy, it is extraordinarily expensive and difficult to perform for compounds such as nutrients that have their benefits over decades, not weeks.
  7. Conclusions should be based on the collective knowledge from paleobiology, basic science, gene expression data, and large population studies—in other words, synthesizing all the data, not simply judging the evidence based on a gold standard that is not the appropriate lens for assessing complex nutritional data. Vitamin D, for example, regulates over 150 genes. Facts like this have not been considered in the report.
  8. The conclusion that the normal ranges for vitamin D blood levels have been inappropriately increased from 20 to 30 ng/dl is based on flawed reasoning. If everyone has low levels, that doesn’t make it normal much less optimal. Since 80 percent of Americans are considered deficient in vitamin D, in their thinking, we should adjust the normal range down so that all those people walking around who seem normal won’t be considered deficient. Should we adjust the “normal weight” of Americans to include a BMI of over 25, because nearly ¾ of our population is in that range? Or should we ask: What are the evolutionary or ideal conditions for health?
  9. Why are the 14 expert opinions of scientists who reviewed the report including Dr. Robert Heaney(i) (one of the world experts on vitamin D who showed that 20 weeks of 10,000 IU a day of vitamin D3 had no adverse effects on healthy young men with normal vitamin D levels) and Dr. Walter Willett of Harvard the most respected nutritionist in the world, (who recommends 2,000 IU of vitamin D3 a day), kept secret? When is open scientific discourse a national security issue? Or does the Institute of Medicine think we will be confused?
  10. Why have they left out of the panel, or the reviewers, Dr. Michael Holick, the discoverer of vitamin D3 (the active thyroid hormone) whose data shows that blood levels up to 100 ng/dl are perfectly safe and has published reviews in every major medical journal(ii)?
  11. For patients with autoimmune and inflammatory diseases, vitamin D status must be measured carefully.
  12. Here is some other compelling data:(iii)
  • 70-80 percent of Americans are vitamin D deficient (25 ng/dl for Caucasians and 16 ng/dl for African Americans).
  • Attaining optimal blood levels of 45 ng/dl requires about 3000-4000 IU a day of vitamin D3 (6 times current recommendations).
  • Achieving blood levels of 45 ng/dl (toxic is considered 250 ng/dl) would results in 400,000 fewer premature deaths per year including reduction of cancer by 35 percent, type 2 diabetes by 33 percent, all cause mortality by 7 percent.(iv)
  • Studies show that vitamin D deficiency increases the risk of influenza 11-fold (1100 percent)(v) and taking vitamin D reduces the risk by 42 percent.(vi)
  • The economic burden due to vitamin D insufficiency in the United States is $40-$53 billion per year from cancer, heart disease, diabetes, influenza, autoimmune disease, depression, fibromyalgia, etc.
Bottom line, here is what we recommend in the face of the absence of evidence of harm and the plethora of evidence for potential benefits:
  1. The average child can conservatively and safely take 1000 IU of vitamin D3 a day, and the average adults should take 2000 IU a day. Some may need significantly more to raise and maintain vitamin D at adequate levels.
  2. For all our adult patients, who are taking > 4,000IU per day we monitor blood levels carefully over the long term.
  3. Blood levels should be at least 30 ng/dl and, for most, optimal levels are between 45 ng/dl to 60 ng/dl
  4. Get most of your calcium from your diet, and don’t take more than 800mg of calcium from supplements per of day.
Be well, Mark Hyman, MD Elizabeth Boham, MS, RD, MD Todd Lepine, MD Pier Boutin, MD Maggie Ward, MS, RD Kathie Swift MS, RD Deb Phillips, MS, LDN, CHES Kelly Forfa, RN Kelly Phair, RN References (i) Heaney, R. 2003. Long-latency deficiency disease: insights from calcium and vitamin D. Am J Clin Nutr. 78:912–9 (ii) Holick, M.F. 2007 Vitamin D deficiency. N Engl J Med. 357(3): 266–81. Review. (iii) Grant, W. 2009. In defense of the sun. Dermato-endocrinology. 1(4): 207–214. (iv) Grant, W.B., Holick, M.F. 2005.Benefits and requirements of vitamin D for optimal health: A review. Altern Med Rev. 10(2): 94–111. Review. (v) Wayse, V., Yousafzai, A., Mogale, K., Filteau, S. 2004. Association of subclinical vitamin D deficiency with severe acute lower respiratory infection in Indian children under 5 y. Eur J Clin Nutr. 58(4): 563–7. (vi) Cannell, J.J., Zasloff, M., Garland, C.F. et al. 2008. On the epidemiology of influenza. Virol J. 5: 29.
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