The Institute of Medicine released its updated recommended daily intakes of calcium and vitamin D on November 30th. In summary they INCREASED the required vitamin D intake, DECREASED the required calcium intake, and RAISED the maximum safe intake of vitamin D. There recommendations are complicated because they are different for infants, children, adults, and older adults. And, unfortunately these changes fall short of public need.
The free online version of the IOM report is almost impossible to read using their outdated image technology without printing or purchasing the report. There are many errors and misinterpretations of the data by this committee. The committee was constructed of scientists who have a limited knowledge of vitamin D and certainly have not been the major researchers in the field over the last 40 years. I will lay out the data as I see it and as was detailed in The Vitamin D Cure. This will be organized as errors in the logic of the IOM.
ERROR #1: What is the blood level definition of vitamin D deficiency? This is the primary debate. The IOM has set the lowest normal value and the definition of deficiency at < 20 ng/mL. Their conclusions that North Americans for the most part get enough vitamin D are based on choosing this very low level as normal. The presence of disease and calcium, vitamin D, and bone physiology/anatomy define the lower limit; and it’s not 20 ng/mL. Let’s take a closer look.
The IOM’s primary argument for 20 ng/mL is based on clinical disease measurements (rickets, osteoporosis, bone density). The weakness of using this approach to define the lower limit is the heterogeneous origin of all clinical disease states and the insensitivity of clinical symptoms. All clinical symptoms appear late in the course of disease. The heart attack occurs after 30 years of low grade inflammation and plaque formation from unhealthy living. Even the diagnostic tests we use to identify ‘early’ disease represent late findings. The low bone mass on bone density and the osteoporotic fracture that results occurs after decade(s) of abnormal bone metabolism. This is true of lab tests as well.
Let’s look at rickets. Nutritional rickets is defined as a disease of abnormal bone formation that results from vitamin D deficiency and some element of inadequate protein or calcium intake. Similarly, osteomalacia is abnormal bone formation and structural failure related to these same conditions in adults. The symptoms of these diseases result from months to years in children and years to decades in adults of nutritional deficiency and abnormal bone biology.
What is the level of vitamin D that defines patients with these diagnoses? As it turns out there is no agreed upon threshold of vitamin D deficiency associated with nutritional rickets or osteomalacia. Some studies document vitamin D levels just shy of 35 ng/mL in children WITH clinical rickets; just as you can see children with vitamin D levels less than 10 ng/mL without clinically evident rickets. This is true of all the data for osteomalacia as well. Dietary calcium and protein intakes alter the vitamin D threshold for clinical bone disease. Low dietary calcium and low dietary protein intake make rickets more likely at higher vitamin D levels. However, I do not know of any reports of rickets or osteomalacia at vitamin D levels at or above 35 ng/mL. I wonder why?
A recent breakthrough study looking for changes of osteomalacia in bone biopsies helps us understand the disease beyond these late clinical findings. This study was published in the Journal of Bone and Mineral Research in February 2010 and was misinterpreted when reviewed by the IOM. In this study, 675 iliac crest bone biopsies from autopsies of adult men and women from Northern Europe were studied and correlated with vitamin D levels from the biopsy subjects. In a biopsy the scientists can measure the ratio of non-mineralized bone volume to total bone volume. This ratio is increased above 1.2-2% when there is a mineralization defect, such as from vitamin D deficiency or osteomalacia. They did not find any increase in this ratio in subjects with vitamin D levels above 75 nmol/L or 30 ng/mL whether they chose 1.2% or a more conservative 2% cut off. This study avoids the delayed and subjective nature of disease symptoms and the late findings of x-ray studies and simply correlates bone pathology at the microscopic level with vitamin D levels. This study indisputably argues for an optimal vitamin D level of equal to or more than 30 ng/mL. This study ENDS the debate on defining vitamin D deficiency. The pathologic definition of vitamin D deficiency is a blood level
ERROR #2: The IOM reviewed data on a host of diseases. The bulk of epidemiological data was for bone disease (osteoporosis, rickets). The poor sensitivity and late findings of bone densitometry and fractures artificially lower the vitamin D level at which you see clinical disease. The 30 ng/mL cut off for normal is consistent with several lines of physiological evidence. Vitamin D levels much above 30 ng/mL do not lead to further decline in parathyroid hormone levels.
Vitamin D levels below 30 ng/mL are associated with a fall in the absorption of calcium from the intestine. Maximum fractional absorption of calcium from the diet is about 35% at a vitamin D level at or above 35 ng/mL when all other conditions are normal. Calcium absorption from the gut remains stable up to and beyond vitamin D levels of 100 ng/mL. This fractional absorption drops by half at a vitamin D level of 20 ng/mL. Severe calcium deficiency may increase absorption fraction but only if vitamin D levels are above 30 ng/mL. In other words calcium balance is optimized at vitamin D levels above 30 ng/mL.
ERROR #3: The IOM focuses on clinical diseases for which there is controversial data to argue for a lower cut off. The 30 ng/mL or greater level for optimal health is consistent with all the large epidemiological databases. The incidence of type II diabetes, colon cancer, and all-cause mortality all correlate with this same 30 ng/mL threshold for optimal vitamin D function. Click on the highlighted diseases to see the research studies.
Type II Diabetes
Cardiovascular and All-Cause Mortality
ERROR #4: Exercising caution with the supplementation of vitamin D is often justified by comparing it to the failure of studies supplementing vitamin A for cancer prevention and the historic use of estrogens to reduce all-cause mortality in post menopausal women. Let’s look at these two examples.
All the studies looking at vitamin A show that adult Americans not only get adequate vitamin A in their diet but they have normal vitamin A levels in their blood with room to spare. It makes no sense to do a study of supplementation of a nutrient in a population of patients with levels above the lower threshold of normal. You will not see any favorable results. Moreover, Hector DeLuca has shown that vitamin A antagonizes vitamin D function. Vitamin A supplements will further suppress vitamin D metabolism in an already deficient population increasing the risk of malignancy. This is the likely mechanism of increased lung cancer in smokers taking beta-carotene supplements without normalizing vitamin D first.
The second example is estrogen replacement. Estrogen replacement was never a good idea. Think about it. Nature evolves to produce the senescence of ovarian function to protect the woman from the risks of a pregnancy in late adult life and reduce the risk of cancer. Then modern medicine replaces estrogen in post menopausal women thinking it’s the fountain of youth, only to find an increased risk of breast cancer and cardiovascular complications.
Vitamin D replacement is suggested in patients with levels less than 30 ng/mL with a target of 40-65 ng/mL as would be found in wild primates and in life guards and non-mechanized farmers who work in the sun. Nobody is suggesting replacing vitamin D in people with normal levels. Based on data complied by Dr. Reinhold Vieth, there are no credible reports of toxicity in adults with levels under 200 ng/mL. The safety window for vitamin D is seven times greater than the threshold of normal. We are vitamin D deficient because we spend no time outside in the sun unprotected by clothing or sun screen, like our Paleolithic ancestors. Moreover, we do not eat the wild animal protein, wild seafood, and particularly organ meat that we evolved on, which was high in vitamin D.
Vitamin D supplementation is required by most Americans because we are rarely exposed to sun and our diets are filled with grain-based carbohydrates that are devoid of nutrition. Moreover, vitamin D is stored in fat and only liberated with moderate or intense exercise, something that most Americans do not do. Our lifestyle is a perfect storm for vitamin D deficiency.
ERROR #5: The IOM is focusing on deficiency when it should be focusing on optimal health values for vitamin D. The scientific community continues to argue about the lower limit of normal when we now have definitive pathologic data showing that an optimal vitamin D level is at or above 30 ng/mL. Moreover, if no credible toxicity has been reported for vitamin D levels below 200 ng/mL, why are we obsessing over whether our vitamin D level should be 20 ng/mL or 30 ng/mL? This is like arguing over whether your cholesterol should be 220 mg/dL or 200 mg/dL. I personally would like to have a cholesterol of 160 rather than either 220 or 200. Likewise I would rather have a blood pressure in the middle of the normal range not on the cusp of abnormal. Why can’t we focus on what is relevant and design public health recommendations with common sense? I guess common sense rarely comes out of government sponsored committees. Moreover, why wouldn’t you select committee members from the scientists who have been doing the research on vitamin D for the last 50 years.
You decide. I have made up my mind and outlined the logic behind my decision and recommendations; you can read more details in The Vitamin D Cure. Don’t let the government that gave us the food pyramid with three servings of dairy a day and a 55% carbohydrate diet decide your health future. Bureaucrats have a lousy track record at producing good health.
Recipe of the Month
The winter solstice is a celebration of the year’s bounty. I asked Kelly to give us a recipe for something sweet to celebrate. The pork tenderloin provides a contrast to the traditional poultry, ham, and beef roast of the season. The sweet plums, nectarines, and honey are a bright contrast to the herbs of the tenderloin. Buy your ingredients locally and enjoy!
Remember our recipes are courtesy of Chef Kelly (firstname.lastname@example.org). If you have recipes you would like to share or convert to follow the rules of The Vitamin D Cure send them to email@example.com .
Roasted Pork Loin with Orange-Herb Sauce & Roasted Baby Carrots
3 Tbsp. Oil
2 garlic cloves, minced
1 ½ lb. boneless pork loin
1 cup orange juice, a local fruit juice can be substituted (preferably fresh)
½ cup chicken stock or broth
½ cup white wine (of your choice)
4 black peppercorns
1 rosemary sprig
1 oregano sprig
1 parsley sprig
2 Tbsp. chopped parsley
1 ½ lbs. (5-inch) long baby carrots, washed & greens cut
1 red onion, peeled, cut into 8 wedges
2 Tbsp. oil
1 Tbsp. fresh rosemary, chopped
Salt and Pepper
In a large bowl combine 2 Tbsp. oil with the garlic and coat pork; let stand for 1 hour.
Preheat oven to 400 degrees F and in a medium skillet (ovenproof) heat the remaining oil.
Season the pork with S & P and add to the skillet, fat side down. Cook over medium high heat until golden brown (approx. 4 minutes.)
Brown all sides and then turn it fat side up.
Add the OJ, stock or broth, wine, peppercorns and herb sprigs; bring to a boil.
Transfer to the top shelf of the oven and roast for about 35 minutes or until the internal temperature is 145 degrees.
Remove from oven and let rest for at least 10 minutes.
Strain the cooking liquid from the pork into a saucepan and boil until reduced to ½ cup, about 15 minutes.
Season and stir in chopped parsley.
Carve the pork and serve with orange sauce and roasted carrots.
Gently toss together the carrots, red onion, rosemary to coat with the olive oil.
Lay out on a rimmed baking pan. Sprinkle with garlic powder, salt, and pepper.
Roast for 30 to 40 minutes on middle rack or bottom rack (with pork in the oven too), until well browned.
Honey Roasted Fruit with Streusel Topping
• 4 whole Ripe Nectarines
• 4 whole Ripe Red or Purple Plums
• 2 tsp. Honey
• ¼ cup Old Fashioned Oats
• 2 Tbsp. Brown Sugar or Honey
• ¼ cup chopped nuts (Pecans, Walnuts, anything you like)
• ¼ cup Oat Bran
• 2 Tbsp. Canola Oil
• 2 Tbsp. dried fruit (cranberries, raisins, cherries, chopped dates, etc.)
Lightly grease a 9 x 13-inch pan.
Cut each piece of fruit in half and remove the seed or pit.
In the greased baking dish place the fruit flesh-side up, nestling all the fruit together tightly to fit in the pan.
Drizzle the fruit with about 1-2 teaspoons honey.
Roast fruit for 15 minutes.
Meanwhile make the streusel by combining the oats, honey, chopped nuts, oat bran, dried fruit and canola oil; mix well.
Remove fruit from oven and sprinkle fruit with streusel topping; roast for another 15 minutes until the fruit is hot and tender.
Test the fruit by poking it with a fork to see if it comes out easily.
Vitamin D in the News
This international summary of the public health issue of vitamin D deficiency was put together by scientists and clinicians who have spent the better part of the last forty years researching vitamin D. This differs from the IOM committee which was composed of scientist and clinicians with little or no research exposure to vitamin D. This paper should serve as your guide rather than the IOM report. Enjoy!
Vitamin D Cure Success Story
Please share your successes at firstname.lastname@example.org or online at Amazon. Your success story has a powerful impact on motivating others to change their lifestyle.
In October I spent a day at Dole Foods headquarters in the Los Angeles area to film an interview promoting the consumption of fruits and vegetables. This video will soon be available on their web site.
In November I was in San Diego for the 11th Annual Science and Clinical Application of Integrative Holistic Medicine sponsored by the American Board of Integrative Holistic Medicine and Scripps Center for Integrative Medicine . It was a terrific opportunity to interact with many like minds at the leading edge of change in the promotion of optimal health rather than the symptom management of disease.
Happy Holidays! And Happy New Year!