Tired of the battle of the experts? Imagine how the experts feel! In this article, I describe my own struggle to decide what to recommend to my readers, before and after the impact of some new official vitamin D recommendations from the Institute of Medicine in late 2010. Readers genuinely concerned about the safety and accuracy of Vitamin D supplementation, as I am, will find the candid tour of the ideas to be quite helpful…
It’s early Saturday morning, and I am getting ready to dive into a pile of Vitamin D science.
I can’t begin to master that science myself, and so I will also have to rely heavily on the opinions of two mentors — opinions that will almost certainly conflict. One is Dr. Tim Taylor, who authored a critical chapter of my own muscle pain book. The other is Dr. Harriet Hall, retired Air Force surgeon and weekly Science-Based Medicine contributor — contributions that I have edited almost every week for the last year. Dr. Hall’s article on Vitamin D is sitting in my inbox right now. So are a stack of citations from Dr. Taylor.
What am I going to think about Vitamin D at this time on Monday?
Let’s do a little before-after experiment, and reveal a little bit about how things work here at the Salamander’s world headquarters. Keeping up with pain science is quite literally a full-time job — a dozen of them, actually — and this situation is a perfect example of the care and exertion that goes into creating this website and keeping it current.
My position until now has been that D deficiency is:
I haven’t held this position with any passion, and if challenged on the science I would admit I have been on scientific terra not-so-firma. It was a curiosity to me, adopted from Dr. Taylor. In the chapter he contributed to my book this summer, Dr. Taylor recommended high doses of Vitamin D for deficient patients, and also set the threshold for deficiency lower than most official sources. Dr. Taylor defended those recommendations with some citations that seemed good enough to me at the time — good enough to publish, anyway — and I cautiously took a pro-D position myself.
That position then seemed to be supported by the science news over the last few months. But this may have been a case of selective hearing (confirmation bias), like when you buy a new car and suddenly you see your model everywhere.
And then on November 30 the Institute of Medicine published a report basically slamming over-prescription of Vitamin D and generally sneering at the idea that deficiency is common.
“Uh oh,” I thought, when these headlines arrived in my inbox.
A flurry of emails with Dr. Taylor resulted in some immediate corrections to the book: it turns out that Dr. Taylor had already revised his own recommendations for Vitamin D — still high, but a lot less high. We then continued the discussion, agreeing that we needed more substantiating evidence to support even the reduced recommendations in the book.
Meanwhile, Harriet Hall agreed to take on the topic for her Tuesday, Dec 7 post at ScienceBasedMedicine.org — which is waiting for my attention as I write this.
So here I am. It’s 7:45am on Saturday.
The cat wants me to stop typing so she can sit on my lap — she’s sitting beside my desk chair purring madly, impatiently — and I’d be only too happy to oblige: I have a new Kindle I want to try out, and three good books on the go. My wife will be awake soon, and we’ll probably go out for our favourite eggs benedict at Mary’s Diner. I have chores, errands, and social events throughout the weekend.
But, somehow, I’m going to try to figure out what to say about Vitamin D by Monday!
I enjoy confessions and corrections of wrongness (they are cleansing for the soul). Alas, I just don’t seem to have any wrongness about vitamin D to confess or correct today.
On a personal level, I was particularly concerned about what Dr. Harriet Hall would have to say about all this in her Dec 7 post at ScienceBasedMedicine.org, summarizing and commenting on the new guidelines.
I didn’t need to worry. Examining the evidence this weekend caused no earthquakes. But it did give me an opportunity to really firm up my opinion.
The recommendations on this website, and the new guidelines, simply have almost nothing to do with each other. This was a false intellectual alarm for me. The Walmart shopper looking at a sale on 5000IU vitamin D capsules is a completely different critter than the chronic pain patient wondering if, perhaps, their vitamin D deficiency could be a factor in their horrible problem. Is the average person deficient? Do they need 5000 IU per day? Probably not. That is what the IoM guidelines are concerned with.
But the pain patient might. The geometry of risk and benefit is completely different for pain patients. If you are a “hurtin’ unit” — as a colleague of mine puts it — vitamin D is worth thinking about.
I know some readers are reading this my perspective on the value of vitamin D in general, but I’m not going there. Read Dr. Hall’s post for that. My job here is much simpler and more focussed on the D-for-pain question.
Answer: probably, yes. There is a fair bit of evidence showing a correlation between low D and musculoskeletal pain. The correlation might not mean anything — but there’s a good chance that it does. And while there is absolutely no evidence that supplementing with D will help pain, it is plausible. And the new IoM guidelines basically had absolutely nothing to at all to say about the pain connection. Ships passing in the night.
What if you are deficient, or borderline? Is it safe and sensible to take higher dosages of vitamin D temporarily to correct to the deficiency? Answer: yes, it’s definitely safe, and probably worthwhile.
The only thing I really scrambled to check carefully this weekend was the safety of higher dosages. Ethically, the idea of erroneously recommending a useless treatment just makes my head explode. If I found that my name is on an unsafe recommendation … well, it doesn’t bear thinking about it …
Again: probably, yes.
The IoM set an upper limit of 4000 IU as a safe average maximum that anyone should be taking — a little less than the popular 5000 IU pills now available.
However, there is a wide margin of error here. There is no question that excessive vitamin D can be dangerous, but it takes a lot. Indeed, megadoses of 50,000 IU/day have failed to produce any sign of toxicity, and when supplement baron Gary Null overdosed on vitamin D in his own contaminated product — talk about poetic justice — he was taking upwards of two million IU per day. That nearly killed him, but it didn’t, and we’re talking about a dose five hundred times larger than the IoM’s upper limit — such a ridiculous number that I’m really only bringing it up as a fun example. Here’s a summary of the recent evidence from Heaney:
Both the intoxication literature and the recent controlled dosing studies have been reanalyzed by Hathcock et al. These authors show that essentially no cases of confirmed intoxication have been reported at serum 25(OH)D levels below 500 nmol/L. Correspondingly, the oral intakes needed to produce such levels are in excess of 20,000 IU/day in otherwise healthy adults and, more usually, above 50,000 IU/day. These findings led Hathcock et al to select 10,000 IU/day as the tolerable upper intake level (TUIL, or UL), with considerable confidence.
I also discussed the toxicity issue briefly with Dr. Hall. She agreed that anything under 50,000 IU is unlikely to be toxic (and again that would be especially true for temporary supplementation for deficient patients).
Mission accomplished: my job was to make sure that it still makes some sense for pain patients to consider D deficiency and that it’s safe to supplement fairly generously, and it does.
Dr. Stewart Leavitt of pain-topics.org has watched the topic of vitamin D for pain closely, and written about it extensively, and he responded to the new IoM guidelines just as I did: by re-examining his position in this clear, readable article, New IOM Report Snubs Vitamin D Research. His report is much more authoritative than mine, and comes to similar conclusions. The IoM report actually “neither confirms nor refutes our prior research and advocacy for vitamin D supplementation as benefitting pain relief, particularly relating to musculoskeletal disorders” and “we do not believe it is necessary or appropriate at this time to recant our prior positions regarding vitamin D for pain.”