VITAMIN D & YOUR HEALTH

Choosing YOUR Right Dose

John Lynch founded Medical Diagnostics, Inc, a public company twice ranked among Business Week's "Best Small Companies" in America. Since then he's authored Our Healthcare Sucks, Obamacare - The Good, the Bad and the Missing, and Cell Phones: Can You Fear Me Now? He also blogs regularly at OurHealthcareSucks.com/ medsmarts/ and tweets as @OurH_careSucks.

GET YOUR VITAMIN D FROM SUN, DIET AND SUPPLEMENTS

How Much Is Too Much?
Vitamin D is almost as hot today as the sun's UVB rays that produce it naturally in our skin. But the optimal amount varies for each of us based on how much noontime sun we get, the amount of melanin in our skin (fair or dark-skinned), and our diet. Although many gurus advise there's zero risk with vitamin D and no need to worry about taking too much, that broad reassurance may be ill-advised for many consumers. Their premise is we have an epidemic of vitamin D deficiency that excuses the hype. But up to a third of those supplementing are at risk for kidney stones and osteoporosis. Other risks, including certain cancers, are discussed in this report. While governmentrecommended doses are too conservative for most consumers, the 5,000 IUs/day widely promoted by vitamin D advocates is too high for many people. As with most things, a happy medium makes sense for most people - although darkskinned people may need more. This report will help you find that happy medium.

John Lynch

President MedSmart Members LLC

P. O. Box 2102 Framingham, Massachusetts 01703 United States

Phone: 1-800-277-6514

john@medsmartmembers.com http://ourhealthcaresucks.com @OurH_careSucks

Vitamin D & Your Health

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Choosing the Right Dose of Vitamin D

Vitamin D may now be the most hyped vitamin supplement on the internet, which means we should assess it very carefully before jumping on the vitamin D bandwagon. That may sound like a pretty safe statement to you, but some of the vitamin's most ardent supporters - and they're not hard to find with a simple online search - would find it quite controversial. You know something's askew when prudent moderation is considered controversial. This post intends to dissect the current state of the evidence about vitamin D - most of it still from weak studies showing associations between low levels of vitamin D and many diseases, but few associations that show these conditions are actually caused by low vitamin D levels. That will change as the results of a large randomly-controlled clinical trial are revealed. Unfortunately, that won't be for several years. Until then, the debate will be plagued by poorlydesigned and under-powered studies producing conflicting results. The recommendations from alternative health gurus tend to be aggressive - suggesting doses of 5,000 IU (international units) a day and more - while conventional medicine takes a more cautious approach. Few in either camp would argue that low vitamin D isn't a problem - both traditional vitamin D deficiency most notably associated with the bone condition of rickets and higher levels that still represent a vitamin D deficit if not an outright deficiency.

Deficiency or Deficit?
These are measured by blood tests and can generally be described as follows: Vitamin D deficiency = under 10 ng/mL (nanograms per militer of blood volume); and Vitamin D deficit = 10-20 ng/mL (this is also called an insufficiency). Before delving deeper into the nuances of whether to supplement with vitamin D and, if so, how much to take, let's step back briefly for a bigger picture perspective.

The Sunshine Vitamin

Vitamin D is best produced with prudent exposure to the suns UVB rays. Light-skinned people generally get sufficient vitamin D from 10-15 minutes exposure to arms and legs 2-3 days a week during summer months and daily in spring and fall, but sunscreen can block out UVB rays and decrease vitamin D production.
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There are two main factors for vitamin D production: 1. Your sun exposure The angle of the suns rays in northern climes, including most of the exposure U.S., is less conducive to vitamin D production than southern climes. Its also different at different times of the day. The 10-15 minutes cited above assumes exposure between roughly 10 AM and 3 in the afternoon or, ideally, between 11 AM and 1 PM; and 2. Your skins abilit y to conver t UVB rays Skin pigmentation is the main factor, although older skin ability to convert rays adults are also less able to produce vitamin D with limited sun exposure. Its no accident of history that dark-skinned people populate southern climes their skin can better resist the harmful effects of excessive sun exposure, while lighter-skinned people populate more northern climes with lesser exposure to the suns damaging effects. What does this mean in practical terms? Most people, especially dark-skinned people, in northern climes like most of the U.S. are unlikely to produce sufficient vitamin D from the sun - its best and most natural source. Many believe that higher rates of chronic diseases among African-Americans are related to vitamin D deficiency from diabetes, high blood pressure, and stroke to more aggressive breast cancers in black women. One of the leading vitamin D researchers, Dr. Michael Holick of the Boston University School of Medicine, states: Vitamin D deficiency is recognized as an epidemic in the U.S.. It's likely that half or more of adults in America are vitamin D deficient in the broader sense of having blood levels below 20 ng/mL. Although the Institute of Medicine has taken a very conservative position on vitamin D (and calcium) supplementation (see below) and would likely find this to be overstated, leading vitamin D experts like Dr. Holick are more likely to find it understated. Our goal here is to reconcile these differences as best we can given the limits of currently available, high-quality evidence. The odds are pretty good that most adults in America can benefit with vitamin D supplementation and your need to supplement increases with age. Even the government's recommended daily allowance, or RDA, for vitamin D increases from 600 IU to 800 IU a day for those over 70. As you'll see, these numbers - while higher than previous RDAs - are still grossly understated for most adults.

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Who's At-Risk?
The following populations are at greater than average risk of vitamin D deficiency: 1. Senior citizens According to Dr. Holicks report (The Vitamin D Epidemic and Its Health citizens Consequences. J. Nutr. 135:2739S-2748S; 2005): A 70-year old person has about 25% of the capacity to produce cholecaciferol (vitamin D3) compared with a healthy young adult; 2. African-Americans & other dark-skinned people - Again, according to Dr. Holick: frican-Americans dark-skinned people Melanin (responsible for dark skin pigmentation) is an extremely effective UVB sunscreenAfrican Americans who are heavily pigmented require at least five to ten times longer exposure than whites to produce adequate (vitamin D) in their skin; 3. Obese people Vitamin D is partially stored in body fat for use during winter months when people sunlight is insufficient for vitamin D production. In heavily overweight children and adults, however, its stored so deeply in body fat as to be unavailable (less bioavailable). Dr. Holicks summary tells us that: Obese individuals are only able to increase their blood levels of vitamin D about 50% compared with normal weight individuals. Such people will likely need vitamin D supplementation at higher doses than those with lesser fat reserves. Dr. Holick recommends they consume 2-3 times the vitamin D as non-obese individuals to achieve the 30 ng/mL or higher that he recommends; and 4. Those who use excess sunscreen Weve been conditioned to slather on sunscreen to prevent exc sunscreen sunburns that may lead to skin cancer. This remains sound advice with an important qualification: some sun exposure without sunscreen is essential for vitamin D production and should be encouraged, not discouraged. Its important, however, not to overdo it. As noted, light skinned people only need about 10-15 minutes a few times a week, while darker-skinned people need more. Its also important what kind of sunscreen is used, as the chemical content of some sunscreens may do more harm than the excess sun exposure theyre designed to prevent.

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Should YOU Supplement?

While infants and children are most at risk for vitamin D deficiency and rickets, those at risk for vitamin D deficits associated with a broad range of diseases - including heart disease, many cancers, diabetes and many more - span a much broader demographic. Older adults, obese, and dark-skinned populations are especially at risk, as discussed above. Whether or not you need to supplement - and most Americans do - depends on the amount of high-UVB sunlight (straddling noontime by an hour or so, or roughly between 11 AM and 1 PM) and how much vitamin D you get from the foods you eat. While there aren't an abundance of vitamin D-rich foods, some are fortified with vitamin D - and diet is always superior to supplements for your nutritional needs. The following table reflects the governments summation of dietary sources of vitamin D:

Dietary Sources of Vitamin D

Food Cod Liver Oil* Swordfish** Salmon (sockeye) Tuna Fish (canned)** Orange Juice Serving 1 tablespoon IUs/Serving 1,360

3 ounces (enriched) 566 3 ounces 3 ounces 1 cup (fortified) 447 154 137 115-124 80

Milk (non/lowfat/whole) 1 cup (fortified) Yogurt (fortified) 6 ounces

Source: Dietary Supplement Fact Sheet: Vitamin D. Office of Dietary Supplements, National Institutes of Health See USDA National Nutrient Database for more complete listing. *Cod Liver Oil is also high in vitamin A that competes for absorption with vitamin D and may be harmful at high levels. **Swordfish is higher in harmful mercury than smaller fish; Light tuna is lower in mercury than white tuna.

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Note that fatty fish are high in both vitamin D and healthful omega 3 oils, the combination currently being researched in supplement form for its possibly synergistic health benefits. Unfortunately, farmed fish - which is most of our commercial fish supply - has virtually no vitamin D. So finding the ideal supply of small (low in mercury) wild (not farmed) fatty fish will be quite the challenge - and an unlikely routine source of vitamin D. If you don't consume these foods routinely in your diet and/or get 10-15 minutes of noontime sun every day (more for darker-skinned people), you very likely should be supplementing with vitamin D - and vitamin D3 has been found to be better absorbed than the D2 form - though both are effective. But before you run off to buy a bottle of 5,000 IU of vitamin D3, there are other factors to consider. The fact that vitamin D is so inexpensive is a mixed blessing, as it may induce consumers to jump too aggressively for a supplement that is not risk-free, no matter what you read on the internet. This shouldn't be surprising, as there's very little in life that's risk-free - and vitamin D is no exception.

How Much Is Too Much

The objective of this report isn't to discourage you from taking vitamin D - most of us can and should do so (as I do). Rather, the intent is to help you determine how much is too much for your particular needs. Many physicians have used 30 ng/mL as the blood level threshold for overall health benefit. Recent evidence and rethinking, however, has caused this threshold to be re-evaluated. And contrary to the message you'll get from many alternative health gurus to target higher blood levels of vitamin D, the best advice now seems to be heading in the opposite direction. According to many clinical researchers, optimal benefit with vitamin D is found at around 25 ng/mL - much lower than the level recommended by most vitamin D advocates. Little gain in benefit above that has been demonstrated for most conditions - and there's increased risk for certain conditions with the much higher levels still being recommended. One such study found a 113% increased rate of mortality in those with vitamin D levels at the clearly deficient level of only 4 ng/mL. But it also found increased mortality rates of 42% in those with blood levels of 56 ng/mL (Journal of Clinical Endocrinology & Metabolism, May, 2012). The latter is within the range many vitamin D advocates heartily recommend, which include 40-60 and 50-80 ng/mL. And while advocates proclaim there's no evidence of toxicity with vitamin D

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until blood levels reach 150-200 ng/mL, you're about to see that there are legitimate concerns about possible harm at blood levels that are a minor fraction of this level of technical toxicity. If the favorable associations vitamin D advocates largely rely upon are worth considering even though they lack the scientific rigor of randomly controlled clinical trials, then so too must the negative associations be considered despite this same failing. Clearly, the evidence for vitamin Ds healthful effects isn't yet as compelling as it is for fish oil. However, the sheer magnitude of studies showing an association between low levels of vitamin D and a broad range of disease is nearly overwhelming. This has prompted even leading medical centers to recommend an increase in the Daily Minimum Requirement for vitamin D intake - although generally not to levels that could pose risk of harm.

Supplements Can't Off-Set Unhealthful Behaviors

The latest data on America's healthiest and least healthy states reveals that our healthiest states are mostly northern states with minimal sun exposure (exception: Hawaii), while southern states with the most sun exposure and naturally-produced form of vitamin D dominate our least healthy states. While higher poverty and less education account for much of this disparity, higher obesity and more sedentary lifestyles also contribute to their higher rates of cancer, stroke, diabetes, and cardiovascular diseases. So don't expect vitamin D - or any other supplement or medication - to compensate for unhealthful lifestyle behaviors. Easy doesn't work - you'll need to make the effort to adopt a healthful diet and embrace physical activity and other lifestyle behaviors proven to reduce your risk for disease. And like all nutrients, vitamin D doesn't function in a vacuum. It interacts with other nutrients in synergistic ways that enhance its healthful benefits. Vitamin D is especially interactive with calcium and vitamin K, so the optimal intake of vitamin D from all sources - sun, diet and supplements may depend on your intake of these related nutrients. Yes, it's complicated and this report is already long enough without trying to tackle this broader subject. Here's a link to a video interview about "What You Need to Know About Vitamin K2, D and Calcium" for those who'd like to learn more about their interactions and interdependency.

Vitamin or Hormone?
Vitamin D was reclassified from a vitamin to a prohormone (or conditional vitamin) decades ago, but is still referred to as a vitamin. Understanding it as a hormone helps explain its broad systemic effects throughout the body, much like other hormones (insulin, estrogen, testosterone).

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But is it a magic bullet? Vitamin D supplementation at adequate doses may be the closest thing we have to a whole-body protectant thats relatively safe at recommended doses, highly effective, and very low cost (would you believe as little as a dollar a month?). While physicians joke about adding cholesterol-lowering statin drugs to our water supply, the evidence suggests that adding vitamin D to the water supply (its currently added to dairy, cereal, and orange juice products) might actually be a sounder - and more affordable - public health measure. There's a lot more to consider than its low cost, however.

Evidence is Mixed
Despite broad enthusiasm for increasing vitamin D consumption to protect against a range of diseases, the evidence can best be described as still evolving. You can find an isolated study or two - of differing quality - to support almost any position on vitamin D. The better approach is to view the totality of the evidence, which suggests more caution than the most ardent of vitamin D advocates would like. But just as it's prudent to avoid overmedication, so too is it prudent to avoid mega-doses of nutritional supplements of all stripes. Remember, no matter what you hear or who you hear it from, there are no magic pills. While many studies have found associations between low levels of vitamin D and higher rates of cancer, heart disease, and a long list of other diseases, few have found major benefit from supplementing with vitamin D. This underscore the huge difference between association and causation. In short, just because people with low levels of vitamin D also have certain medical conditions doesn't mean those conditions are caused by the low levels of vitamin D. In fact, a comprehensive review of the evidence for the federal Agency for Healthcare Research and Quality by Tufts Medical Centers Evidence-Based Practice Center in mid-2009 can only be described as disappointing for vitamin D advocates (Vitamin D and Calcium: A Systematic Review of Health Outcomes. Evidence Report/Technology Assessment Number 183, AHRQ Publication No. 09-E015. August 2009). Despite several studies finding mortality benefit, the entirety of studies failed, on average, to show a mortality benefit.

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This contrasts sharply with fish oil studies that collectively have shown a 23% mortality reduction better than even over-hyped statin drugs. This could be due to several factors, including inadequate dosages in studies to date. Recently revised Recommended Daily Allowances (RDAs) of 600 IU (International Units) for children and adults 70 and under, and 800 IU for adults over age 70, remain rooted in historical need for vitamin D to eliminate the bone development disease of rickets in children. Bone growth and strength remains the best documented benefits of vitamin D although the Institute of Medicine found even this benefit isn't supported by the evidence. Nevertheless, most doctors would agree that vitamin D, which facilitates the absorption of calcium, is essential for bone health. This also makes it vital for anyone trying to lose weight that can sap bone strength. But some research has found much broader adverse effects of vitamin D deficiency - and deficit that has prompted experts to recommend the RDA be further increased.

Vitamin D & Cancer

While the IOM concluded that bone health is the only undisputed benefit of vitamin D blood levels over 20 ng/mL, it did leave the door open to the possibility that vitamin D may help prevent cancer. As noted on a blog post by Dr. J.Leonard Lichtenfeld at the American Cancer Society, the IOM found that... "'The theory that vitamin D can help prevent cancer is biologically plausible. The vitamin D receptor is expressed in most tissues. Studies in cell culture and experimental models suggest that calcitrol promiots cell differentiation, inhibits cancer-cell proliferation, and exhibits antiinflammatory, proapopotic (cancer cell death mechanisms) antiangiogenic (slows growth of tumor-related blood vessels) properties... "Such findings suggest, but don't prove, that vitamin D has a role in preventing the development of cancer or slowing its porgression... "(Regarding claims of vitamin D's cancer-preventing benefits) The (IOM) authors...point out the conflicting and/or inconclusive evidence regarding the possible association...Of interets was their observation that in one study of pancreatic cancer, higher levels of vitamin D were actually associated a significantly increased risk of getting that usually fatal illness. Similar increased risk has also been reported for esophageal cancers... "Their final statement was pretty blunt: 'Despite biologic plausibility and widespread enthusiasm, the IOM Committee found that the evidence that vitamin D reduces cancer incidence and related mortality was inconsistent and inconclusive as to causality. Although future research may demonstrate clear benefits of vitamin D related to cancer...and possibly support higher intake requirements, the existing evidence falls short' (emphases added)."

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So while the broad and often fervid enthusiasm for higher vitamin D intake is understandable given its biological plasibility, the jury's still out on whether there's truly a cause-and-effect relationship or whether other factors are responsible for the apparent association between higher vitamin D blood levels and lower rates of some, but not all, cancers. And the associations found by the IOM investigators - and the Institute of Medicine is a highly regarded source - of higher rates of pancreatic and esophageal cancers are a warning sign that greater caution is required than the public is being led to believe by the most ardent of vitamin D advocates. They undoubtedly mean well - vitamin D supplements are very inexpensive, so there's not a lot of commercial advantage involved - but so did supporters of beta carotene, vitamin E and other supplements that have since fallen into disfavor for most consumers. If you get most of your vitamin D from the sun, then your risk of harm is likely minimized (unless you overdo it and get sunburned or otherwise risk skin cancer). But the actual nutritional benefit from manmade supplements is always less than from natural sources, which suggests that relying solely on high-dose supplements is assuming more risk than is prudent given the current state of the evidence. It's also not prudent to take excess comfort from online comments from folks taking 8,-000 or 10,000 IU/day of vitamin D "for years" with no negative effects. Pancreatic cancer is the most deadly of cancers precisely because it shows no early symptoms and is therefore detected at late stages when treatment options are largely ineffective. Do you really want to take that kind of risk based on some anonymous online source?

Blood Level
The Institute of Medicines vitamin D blood level target is 20 ng/mL, while the Endocrine Society Guidelines target 30 ng/mL. Other experts target much higher levels, as discussed below. Vitamin D is measured in the bloodstream and the objective is to raise your level to that found to be associated with reduced rates of disease in multiple studies. The dosage required to do that is very much different for different people depending on their age, skin pigmentation, sun exposure, body fat composition, and other factors. This, of course, is true for all supplements and medications as well. But it may help explain the apparent disconnect between the population-based (cohort and epidemiological) studies suggesting great disease effects with vitamin D deficiency and the

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randomly controlled trials that have thus far failed to show a cause and effect relationship in which vitamin D supplementation corrects for these deficiencies by reducing disease. Despite these shortcomings, medical experts remain convinced of vitamin Ds utility for disease prevention and possibly even as a therapeutic tool. There are ongoing clinical trials, including one at Boston's prestigious Brigham and Women's Hospital to assess the effects of combined vitamin D and fish oil supplementation. The best way to determine whether youre deficient is to have a blood test done (it can be taken with other blood tests for cholesterol, blood sugar, etc.) to confirm your current level of vitamin D. The optimal test for this is called a serum 25(OH)D test and the optimal level differs for men and women. The general rule of thumb is a level over 30 ng/mL(75 nmol/L) is desirable, but some suggest higher levels in the 50-75 ng/mL range. One of the studies in the Tufts report supports a lower range of 50 -75 nmol/L (19-29 ng/mL) as most beneficial for all cause mortality, while another supported a range of 24 - 32 and a third a range of 30 - 39 for women and 37 - 47 for men. The use of different measures for vitamin D adds to this confusion. The data in the Tufts report is expressed as nmol/L - with >75 nmol/L, or >30 ng/mL, being generally recommended in medical practice. For breast cancer, however, a level over 63 nmol/L (24 ng/mL) was associated with a 72% risk reduction compared to women below this level, which was confirmed in a second study of women over 60. The data for other cancers was inconclusive except for colon and colorectal cancers, with reduced risk at blood levels over 43 nmol/L (16.5 ng/mL). A recent Danish study[1] found a lower threshold for optimal longevity in the 20-24 ng/mL (50-60 nmol/L) range and increased mortality at both very low and very high levels of vitamin D. It also found almost ten times as many people studied had too low vitamin D as too high, so the need for more vitamin D for most people still applies. But maybe not too much. Another recent study published in the January 15, 2013 issue of the American Journal of Cardiology reports on research conducted at Johns Hopkins University School of Medicine. Researchers there examined the records of over 15,000 adults participating in the National Health and Nutrition Examination Survey and found that although vitamin D levels up to 21 ng/mL were associated with reduced inflammation that can lead to cardiovascular disease, that anti-inflammatory benefit was reversed as individuals' blood levels exceeded 21 ng/mL.

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This suggests that a blood level of vitamin D that many vitamin D experts consider deficient, or at least insufficient, may actually be optimal in the 20-25 ng/mL range and that levels above that could be pro-inflammatory. Again, this also isn't the most rigorous of study methodologies, but it's enough to inject a note of caution before jumping on the vitamin D bandwagon. Since its so hard to objectively define an optimal blood level of vitamin D, the best place to start is to make sure yours is at least over 20 ng/mL and possibly over 30 ng/dL the healthful target recommended by the Endocrine Society and many physicians, although those recommendations may be revised downward in light of these latest suggestions of declining benefit and even potential harm over blood levels in the low 20 ng/mL area.

[1] A Reverse J-Shaped Association of All-Cause Mortality with Serum 25-Hydroxyvitamin D in General Practice, the CopD Study, The Journal of Clinical Endocrinology & Metabolism May 9, 2012 jc.2012-1176

DOSAGE
If your blood level isn't at these healthful levels, the issue will be what dosage combined with other measures like more fish in your diet and more sunlight - is necessary to get you to that level and perhaps higher. Although both vitamins D2 and D3 have been shown in clinical studies to produce benefit - and the Institute of Medicine has found reduced risk of toxicity with the D2 form of the vitamin - most agree that vitamin D3 is the better choice due to its increased absorption and utility in the body (D2 requires another conversion process that dilutes its effects). The rest of this discussion assumes vitamin D3 supplementation. The limiting factor is potential toxicity. Although theres considerable testimony that vitamin D3 is safe at levels up to 10,000 IU/day, the Institute of Medicine has set a more conservative upper limit of 4,000 IU/day. Nevertheless, there are many vitamin D products being sold at 5,000 IU that are widely recommended by vitamin D advocates. Many experts recommend from 1,000 3,000 IU/day, with the higher amount reserved for winter months when sun exposure is reduced. Physicians are generally more aware of the potential downsides of exess vitamin D - at extreme levels called "vitamin D intoxication". These include kidney stones and osteoporosis. While vitamin D can help prevent osteoporosis - too little vitamin D results in less calcium absorption that can lead to osteoporosis - too much can actually cause osteoporosis. One recent study found that vitamin D supplementation caused excess excretion of urinary calcium, called hypercalciuria, in up to 33% of the postmenopausal women in the study. According to MedScape, this can cause calcium kidney stones and/or osteoporosis.

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3-9% of women in this study experienced excess blood calcium, called hypercalcemia. MayoClinic.com says this can also lead to kidney stones and osteoporosis and even worse medical conditions like kidney failure, heart arrhythmias (irregular heart beats), and nervous system disorders including dementia and even sometimes fatal comas. A 3-33% risk of harm is nothing to sneeze at despite the cavalier dismissal of such risks by vitamin D devotees. Avoiding these risks will require learning your current 25(OH)D concentration level with a blood test, supplementing with 1,000 IUs/day or more if you are below the 20-40 range, and retesting periodically (every 6 months to a year) to maintain your levels in this range. A more cautious approach would be to target a blood level of 24-30 ng/dL and try to maintain it at that level. Discuss with your physician what the optimal range may be for you given your medical condition and disease risk factors. CAUTION: Men shouldnt be too aggressive with vitamin D. A Finnish study of male smokers found those with the highest blood levels of vitamin D had a three-fold increased rate of pancreatic cancer.[1] This could reflect the effects of smoking on vitamin D utilization in the body, as similar findings occurred for smokers taking beta-carotene supplements some years back. The Institute of Medicine, however, found increased rates of pancreatic cancer at blood levels over 40 ng/mL, which is lower than many vitamin D advocates recommend. Male smokers and those with a family history of pancreatic cancer may want to limit their vitamin D supplementation. Men in general may wish to be cautious in supplementing with vitamin D, as theres some evidence of an association between higher levels of vitamin D in the bloodstream and aggressive forms of prostate cancer.[2] Studies indicate, however, that only 10% of men in America achieve a 30 ng/mL healthful blood level of vitamin D - unlike many post-menopausal women who supplement with vitamin D and calcium to combat osteoporosis - meaning the vast majority of men in America would benefit from vitamin D supplementation. The question is how much vitamin D should they supplement with, as there are risks with overdoing it despite protestations to the contrary by the most zealous of vitamin D advocates. These risks are seldom reported in the mass media another reason to be skeptical of what you hear or see reported in the press - but they should be discussed with your physician if you fall into one of the risk categories described above.

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Your need to monitor your blood level of vitamin D is critical, however. Here's a summary of authoritative recommendations for the blood level of vitamin D you should target: Institute of Medicine - 20 ng/mL (found increased risk for pancreatic cancer at blood levels over 40 ng/mL) Endocrinology Society - 30 ng/mL Dr. Michael Holick - 30-60 ng/mL Grassroots Health expert panel - 40-60 ng/mL ConsumerLab.com - 20-39 ng/mL These average out to a range of 28-41.8 and suggest you may want to target a slightly broader range range of 25 -40 ng/mL as the safety zone for vitamin D blood levels, with higher levels for high-risk people at increased risk for breast, colon and other cancers, for example.

[1] Serum Vitamin D and Risk of Pancreatic Cancer in the Prostate, Lung, Colorectal, and Ovarian Screening Trial. Cancer Res. 69; 1439; 2009. [2] Serum vitamin D concentration and prostate cancer risk: a nested case-control study. J Natl Cancer Inst. 2008 Jun 4;100(11):759-61.

Consistency Counts
Obviously, there's no one-size-fits-all answer for the correct vitamin D dose, but there's little doubt that most people in northern climes - like most of the United States - would benefit from some level of supplementation unless they're able to consistently get 10-15 minutes of daily sun exposure from 11 AM to 1 PM - and even more for darker-skinned people. Since weather changes alone make this unlikely, it's best to figure out - using the guidance and cautions provided above - what your optimal dose is and adjust it for a higher dose during winter months. Since vitamin D shares the same cell receptors with vitamin A, this means they compete for absorption. It's important, therefore, to not overdo your vitamin A intake as that could make it more difficult for you to realize the benefits of the vitamin D dose you think you're getting. Many multivitamins have higher vitamin A levels than necessary, so check your multivitamin to keep your vitamin A (as retinol) consumption below the 3,500 IU a day recommended by

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Dr. Holick (see above link). As he notes, however, there's no concern with vitamin A as beta carotene. This means a multivitamin listing 10,000 IU of vitamin A with 95% as beta carotene would not be a problem, as only 5% - or 500 IU - would be in the form of retinol.

Bottom Line on Dosage

Dr. Holick's a well-recognized expert on vitamin D and his approach is more conservative than the most aggressive of vitamin D advocates. According to his comments on his website, he treats patients with insufficient levels of vitamin D which he considers as being under the widely-accepted level of 30 ng/mL - he puts them on a short-term regimen that equates to roughly 6,000 IU/day for two months and then cuts that in half to about 3000 IU/day as a long-term maintenance dose. If your blood level is already over 30 ng/mL, 1,000-2,000 IU/day would likely be enough to raise it to optimal levels (assuming it's not already at your personal optimal level). Note that this is consitent with the 1,500-2,000 IU/day recommended for adults over age 18 without a vitamin D deficiency by Dr. Holick on his website. Because of their generally larger bodies, men will usually need more than women and obese men and women will need much more. As noted above, Dr. Holick recommends his obese patients take 2-5 times the dose they would otherwise need to attain their optimal blood levels of vitamin D. Dark-skinned people who produce less vitamin D from sun exposure may also need more supplementation than average, as do those with celiac disease or irritable bowel syndrome. Certain medications may also lower your vitamin D levels. According to Consumer Reports, these include the following: corticosteroids like prednisone (Sterapred DS and generic); weight-loss Rx orlistat (Alli and Xenical); cholesterol-lowering Rx cholestyramine (Questar and generic); antiseizure Rx phenytoin (Dilantin and generic); and mineral oil (often used as a laxative).

If taking any of these medications, try to time them so you take them several hours before or after you take vitamin D and ask your doctor if you should be taking a higher dose of vitamin D to compensate.

JOHN LYNCH, MEDSMART MEMBERS LLC 1-800-277-6514 - john@medsmartmembers.com - http://ourhealthcaresucks.com

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Get Regular Blood Tests

The best way to determine whether your dose is appropriate for you is with a lab test in February or March when your blood levels are likely to be at their lowest and use that as your baseline for determining your optimal safe dose. Just don't fall for the hype promoting mega doses of vitamin D3 - or anything else, for that matter. Mega doses are a prescription for harm, no matter how often you hear there's absolutely no toxicity with vitamin D. Keep it calibrated to a achieving a blood level of 25 - 40 ng/mL and try to keep it constant. Some studies have suggested that a consistent level of vitamin D in your bloodstream may be as or more important than the absolute level itself. You'll need regular blood tests to assure that, of course, and they'll cost around $50 a test and more. If you shop around, you can do better than that, though you want a large volume reference lab for better likelihood of accuracy. lef.org has aligned with a national lab service to offer discounted lab testing. If you wait for their spring special pricing, the cost drops to under $40 for members and slightly more for non-members. Unfortunately, most insurers don't yet pay for this lab test (though some do and others may if your doctor orders it). Despite the inconclusive nature of the evidence at present, it's likely that supplementing with vitamin D3 - at a safe and effective dose for your personal profile and kept reasonably constant throughout the year - will be well worth the extra cost and effort this will require.

And Only QUALITY Supplements

A problem with nutritional supplements is they're not subjected to regulatory scrutiny to assure quality - meaning that they're free of contaminants and contain what they claim they contain. This makes it imperative that you use only supplements approved by third-party reference labs. These include ConsumerLab.com (subscription required), which doesn't test every product on the market but tests enough to give consumers solid guidance and assurance they're buying quality products free of contaminants. They also include pricing information to enable you to get the best value - even for low-cost supplements like vitamin D. In the case of vitamin D, there are many ConsumerLab-approved supplements. Make sure you're using one of these and not risking more than is described in this report.

JOHN LYNCH, MEDSMART MEMBERS LLC 1-800-277-6514 - john@medsmartmembers.com - http://ourhealthcaresucks.com

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Additional references and resources: The vitamin D dilemma. How much is too much? What you should know about getting tested. Consumer Reports http://www.consumerreports.org/cro/2012/04/the-vitamin-ddilemma/index.htm Last updated: May 2011 Dietary Reference Intakes for Calcium and Vitamin D. Institute of Medicine, NOVEMBER 2010. http://books.nap.edu/openbook.php?record_id=13050&page=75 A Reverse J-Shaped Association of All-Cause Mortality with Serum 25-Hydroxyvitamin D in General Practice, the CopD Study, The Journal of Clinical Endocrinology & Metabolism May 9, Journal Clinical Endocrinology Metabolism 2012 jc.2012-1176 http://jcem.endojournals.org/content/early/2012/05/09/jc.2012-1176.abstract Vitamin D and calcium supplementation reduces cancer risk: results of a randomized trial. Am J Clin Nutr. 2007 Jun;85(6):1586-91. This RCT study found vitamin D DID reduce cancer incidence. Vitamin D supplementation for prevention of mortality in adults. Cochrane Summaries, August 10, 2011. http://summaries.cochrane.org/CD007470/vitamin-d-supplementation-for-preventionof-mortality-in-adults.[hr] How Much Vitamin D Should You Take Daily? chuck-bluestein.hubpages.com

JOHN LYNCH, MEDSMART MEMBERS LLC 1-800-277-6514 - john@medsmartmembers.com - http://ourhealthcaresucks.com

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To learn more, visit OurHealthcareSucks.com

JOHN LYNCH, MEDSMART MEMBERS LLC 1-800-277-6514 - john@medsmartmembers.com - http://ourhealthcaresucks.com

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JOHN LYNCH, MEDSMART MEMBERS LLC 1-800-277-6514 - john@medsmartmembers.com - http://ourhealthcaresucks.com

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