[devaboone]

I'm the physician who wrote the article. And I agree with you. Vitamin D deficiency is a problem because it leads to bone loss (see part 1: https://www.devaboone.com/post/vitamin-d-part-1-back-to-basi...). And Vitamin D supplements can be very helpful for those with a deficiency. The point that I am trying to make is that Vitamin D should not be thought of as a dietary supplement. I am seeing more and more people with high calcium levels from being on high-dose Vitamin D. If you treat Vitamin D like the steroid hormone that it is, you will treat it like a medicine, and not take outrageous doses because someone online suggested it. At least, that's what I'm trying to get across.

[dm319]

Thanks for your article. As another physician (hey - three in a row on hackernews, clearly this is the new place to hang out), it's been interesting following the Vitamin D story, and I enjoyed reading your article. I was always a bit skeptical of the data, but then came across the first cochrane review for it, and was surprised to see a general reduction in all-cause mortality in a general population. But looking it up again [1], the conclusion seems far more couched. Do you have any comments on the Cochrane reviews?

[1] https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD...

[devaboone]

I really like the Cochrane reviews, and love that they periodically update areas when there is more recent research. And you are correct, their articles on Vitamin D have become less enthusiastic with time. This makes sense I think, since the initial publications on a topic will all be "positive" - they have to find something new to get published (creating a publication bias). And they do try to account for publication bias, but really the best way to fix it is to have more studies. With Vitamin D getting so much attention, you can get published whether you find a correlation or not, so you have a wider range of studies to look at. I wanted to give a summary of the Cochrane reviews and the largest human trials of Vitamin D in the next blog post.

[lisper]

Not a physician, but still following this story closely. Can I ask you docs to weigh in on the recent results regarding the role of vitamin D in covid-19 outcomes?

[devaboone]

This is a correlation. There are lots of conditions that are associated with low Vitamin D. Mortality overall is associated with low Vitamin D. But it doesn't mean that the low Vitamin D caused any of these problems. Having overall poor health leads to Vitamin D deficiency. The increase in mortality is more likely related to your overall health status, not your Vit D status.

[Dahoon]

Do you know anything about the link between schizophrenia and Vit. d?

[tsoukase]

Don't expect to find anything beyond a correlation between VitD levels and any serious disease. In any study that such is found, the substitution had no effect.

[framecowbird]

> I will not give any recommendation without first knowing Vitamin D and calcium levels.

This sounds too risk-averse, and I worry that it scares people off taking Vitamin D at all; yet a low level would be good for most people.

I live in a northern latitude, and Vitamin D deficiency is widespread. What should the public health system recommend? It seems there are two choices:

(a) Regularly test the Vitamin D levels of the entire population, and recommend zero Vitamin D supplements for any individual who has not been tested recently.

(b) Find an average "safe" level that will help most and cause damage in very few.

From a perspective of an individual physician I would see how you might want to cover your risk and go for (a), but thinking about it as a whole population, I would think (b) is the best.

[microcolonel]

Yeah I think it may be a bit overzealous to say that even people who are not supplementing at all, and even in a population where low Vitamin D is common, should wait until they measure k and Vitamin D (which could be not for a long time).

“first, do no harm” seems to be the thread of this caution though, so not exactly unexpected from a doctor.

[zenexer]

My PCP tests my Vitamin D levels annually, and it doesn’t cost me anything; it’s just part of the standard bloodwork. It’s always been fine in the past, but the most recent time I was told it was low and was prescribed Vitamin D.

I’m not a health nut, just someone who has annual physicals. Doesn’t it make more sense to encourage people to spend their time and money on annual checkups and tests, rather than encouraging them to buy supplements they might not need—or, worse, that might harm them? Supplements seem cheap at first, but the costs add up over time.

We should be encouraging people to see doctors, not to make uninformed health decisions that might not be right for them.

[taylodl]

Here in the United States there are millions without insurance and they're unlikely to be able to afford a doctor's visit - as those without insurance also tend to be the poorest. To be honest, many probably can't afford dietary supplements either but for those who can then a blanket recommendation would be good for them. Either that or we should push for a public health measure ensuring everyone gets a physical, including bloodwork, every 5 years whether you have insurance or not. We need to start thinking through workable solutions for the bottom 20%.

[framecowbird]

Yeah, I just don’t see this happening across the whole population. Maybe with an expensive campaign to encourage yearly physicals you will get a certain sector of society; but there are going to be millions who haven’t got insurance, worry they would be wasting a doctor’s time, are scared of the authorities, can’t afford the travel time, and so on.

I believe there is a safe level. In Sweden the government recommends everybody to take 10 micrograms daily, with some groups at 20 micrograms, and this advice is very commonly followed. As far as I understand it that advice does an awful lot more good than it does harm.

[taylodl]

You're probably right. Public health is a difficult issue.

[t0mbstone]

Thank you for writing and sharing this story!

My mother has been plagued many of the same symptoms that your patient had, and she has been searching for a cure for years. All of her blood levels are "within normal ranges", and doctors always dismiss her as being crazy, so she ends up seeking treatment from various "quack" doctors.

It sounds like you are the kind of doctor that is able to analyze the human body holistically and solve underlying problems that other doctors would miss.

How can I find a doctor like you that I can convince my mom to go to?

[chadash]

I don't think it's necessarily a holistic thing... i think it's more that the doctor specializes in this area and most doctors aren't familiar with it.

[devaboone]

This is exactly it. I was able to see it because I deal with this every day. I am not more holistic than other doctors; I just know how to look at calcium and Vitamin D levels.

[mrfusion]

For folks on supplements should you skip a dose when getting a lot of sunlight or does your body know to produce less when not needed?

[Alex3917]

Even if you're taking vitamin D supplements, you probably won't get the full anti-covid benefits unless you also get at least 15 (and preferably 30) minutes of direct sunlight exposure each day. My understanding is that vitamin D causes your skin to produce nitric oxide, but this nitric oxide doesn't actually get released into the rest of your body unless you get actual sun exposure.

[BurningFrog]

> get at least 15 (and preferably 30) minutes of direct sunlight exposure each day

This time is directly proportional to how much skin you expose to the sun. If it's only face & hands you need a lot more than if you're in the swimsuit.

It would be interesting to know what clothing the 15-30 min tip assumes.

Also, sunlight through a window does nothing. You need the UV light.

[jimmaswell]

I wonder if incandescent bulbs were better for us in this one area.

[0134340]

Not a doctor or any profession of relevance but I do use tanning lights. Incandescents produce mostly visible light and very little UVA or UVB for those health concerns. Fluorescents tend to produce more UVB in comparison but still very negligible. Tanning lights generally produce the amount of UVA and UVB needed for vitamin D synthesis although you have to use with caution.

[BurningFrog]

No, they don't produce any UV light.

Even if the filament somehow does (I doubt it), it won't make it through the glass of the bulb.

[hoseja]

I don't think incandescent bulbs produce any significant UV. The temperature is too low.

[SamBam]

Any sources? I've seen much discussion of vitamin D and COVID, and they all appear to imply that supplements would help.

[Alex3917]

https://pubmed.ncbi.nlm.nih.gov/24445737/

[SamBam]

That isn't a source for vitamin D supplements not having an effect on COVID, that's a source saying that sunlight is needed to produce nitric oxide.

Looking online, I see that there is a hypothesis that nitric oxide has a protective effect against COVID, but I don't see that this hypothesis is any better tested than the hypothesis that vitamin D itself has a protective effect against COVID.

So, sunlight will probably get you the best of both worlds, as it would help either way, but there doesn't seem to be real evidence for nitric oxide vs vitamin D.

[Alex3917]

Yeah I would describe the evidence for both as circumstantial but fairly compelling, and very low risk. Even given the unknowns and potential risks, getting enough sun exposure is probably the best anti-Covid intervention from a cost-benefit perspective.

[Florin_Andrei]

> the full anti-covid benefits

The alleged anti-covid benefits.

There's been no causal relation established so far.

[drran]

What about vitamin K2? Will it help to reduce calcium levels back to normal when taken in parallel with D3?

[teilo]

Only if you take K2-MK7. The regular form of K2 will not help much. And you need to take 100mcg of MK7 per 10,000 IU of D. It also helps to build up your potassium levels using potassium citrate or bicarbonate (NEVER potassium chloride) over time. Potassium is critical for cellular mineral transport, and low potassium levels will have an impact on blood calcium.

I know many people on this protocol who have had their blood tested and verified that they have no detectable calcium levels in the blood. And blood testing is key. Anyone on this protocol should be checking their calcium, D, and potassium levels. They should also monitor their blood pressure.

[NickM]

What's wrong with potassium chloride? I've been using lite salt (50/50 sodium chloride and potassium chloride) in my diet to help make sure I get enough potassium, and your comment has me a little concerned.

[teilo]

Potassium chloride is toxic in higher doses, and not tolerated well by the body. If you are using Lite Salt as salt, you probably aren't taking enough to matter. The various studies for potassium toxicity are done using potassium chloride.

The citrate and bicarbonate forms are much better tolerated, and at much higher doses. I take 3 teaspoons a day of potassium citrate, in water, spread throughout the day (I built up to this over time) because I have a mostly meat and dairy diet. This yields approximately 6 grams of potassium a day. For most people building up to 2 teaspoons a day is sufficient. This much potassium chloride would be dangerous.

The primary symptom of too much of the citrate or bicarbonate forms is diarrhea. Also, the metabolic byproduct of citrate is bicarbonate, which has a far greater effect on body pH than taking bicarbonate itself, as the process increases blood pH rather than that of the intestinal tract.

[getpost]

> Only if you take K2-MK7.

Citation? Do you mean MK4?

[joecool1029]

I believe both forms have similar effects but MK7 stays active in the body much longer.

MK4 is the common one in lots of things. MK7 is the form found in quantity in nattō which is not commonly consumed outside Japan. It can be supplemented.

[mlcrypto]

Is it high or low blood pressure they should be looking out for?

[teilo]

Low. But that usually means that you are not properly balancing your potassium and sodium intake.

[mlcrypto]

That's interesting. I've been taking 5000 IU of D daily since COVID. I get barely any sun though. And I noticed noticed my blood pressure went down by 10/10. 110/70 though so I'm happy lol

[e40]

I'd like to know that, too. I've been taking one of these a day:

https://smile.amazon.com/gp/product/B0716RWHX4/ref=ppx_yo_dt...

So, 1000 IU.

[paulirwin]

Thank you for your article. I also had alarming palpitations while on Vitamin D 5000IU, and did not make the connection until months later when I slacked off with taking it and they went away. Started taking them again and the palpitations came back. Went through the full battery of heart tests and everything said I was fine. I posted on here a few months back on another post about Vitamin D, explaining my (admittedly anecdotal) situation, and some commenters seemed not to believe me. Happy to hear that I'm not alone.

[Guest19023892]

Come to think of it, I've had some weird palpitations the last couple of years that have given me a bit of a scare too. I think I started taking Vitamin D supplements around that time (after I had my levels checked). The palpitations seem to happen on and off, and I've also been on the supplements on and off, but I haven't paid attention to if the times match up. I do know I haven't taken the supplements the past few months and it seems the palpitations haven't occurred in that time. I'll probably take the supplements again in the winter, so I'll need to see if the issue returns, and if so, whether not taking them makes it stop again.

[blaser-waffle]

Huh. I'll add some more anec-data to this thread: both my mom and myself have had similar issues.

My folks live in WA near Seattle and, while summers are pretty nice, most of the year is crazy dark and gray, necessitating some Vit D supplementation. My mom was pretty diligent about that and noticed heart palpitation on a few occasions, but no actual heart issues.

I live further north and supplement for the same reasons, and have even gone to the hospital thinking I was having a heart attack -- but all the tests came back fine. Those heart issues were after a long period of supplementation + aggressive workouts. If anything, my heart health was probably better then than most times; doctors attributed the issues to stress.

[paulirwin]

Sorry to hear that. I hope this helps you, as I know how scary and frustrating that is. How many IUs were you taking? I seem to be fine on <= 1000IU taken periodically, but 5000IU daily was too much for me.

[Guest19023892]

I was taking 2000IU daily.

For more details, I'd usually take it late morning with breakfast. I'm a normal weight (155lbs), exercise, eat healthy, low stress, in my 30s, good blood pressure, don't drink coffee. I'd notice the heart issues usually in the evening. Sometimes they would occur almost daily for a week, and then they'd go away for a couple of weeks. Then I'd experience them again one day, and not for another few days. They would occur for about a few seconds or a minute when I was at rest and not doing anything active. It's hard to describe the feeling but it was kind of like a muscle spasm occurring in what I thought my was heart. Or, like some strange beating/squeezing sensation that would occur once, then again 5 seconds later, then a couple of seconds after, then that was it. Or it might return after a few minutes and happen again.

It was an intense and serious enough feeling that it would make me pause whatever I was doing. It would make me think that one of these times it would be a bit worse, I'd end up collapsing, and that would be the end. I'd usually do a bit of cardio for a few minutes because like I said it only seemed to happen when I was at a resting heart rate.

I should probably get my heart checked because there's a good chance the connection with the vitamin D supplements is just a coincidence. Nonetheless, I'll pay attention to see if there seems to be a relation between the two, because although it's unlikely, stranger things have happened.

[BenjiWiebe]

Interesting. I had the reverse problem. I had lots of random muscle twitches and fatigue. Got my vitamin d levels tested, and they were extremely low (don't remember the exact number). I'm now on vitamin D and the symptoms went away.

[oxymoran]

Have you come across people that take high levels of vitamin d as well as get plenty of sun, but whose levels are still less than 30? And further, this is happening to both a father and a son?

[BenjiWiebe]

My doctor told me that abnormally low vitamin D levels can be genetic. Haven't done much research, but looking at my family would agree.

[mrfusion]

How do you feel about vitamin k2 (and magnesium) for lowering the risk of high calcium?

[velox_io]

As far as I'm aware it's only B vitamins that aren't toxic in high volumes. I take 1,500ug of B12 (60,000% nrv - B12 has fairly poor adoption) for a nervous system disorder, seems to stops my toes going purple...

[nowandlater]

I dose a similar amount of B12 as you and likewise see real benefits, but I recently stumbled across some research that claims vitamin B6 and B12 supplemenation show increased incidence of lung cancer in men [1]. I'm wondering if any of the above physicians can comment on this research.

1. https://examine.com/nutrition/vitamin-b-cancer/

[velox_io]

">55 mcg/day [B12] was associated with a 98% greater risk" Wow, that is quite a staggering increase! Luckily it was men who smoke; "As for never-smokers, the paper states they “were excluded from the smoking-stratified analysis because of the low number of participants with incident lung cancer in that group.”

It's interesting how woman weren't affected, but I am all too aware of the link between smoking and lung cancer as the two go hand in hand. My father died of lung cancer and we didn't part on the best of terms as he had a bad cough for a over a decade before being diagnosed, I lacked sympathy as it was virtually a given. Seeing patients needing to go outside to smoke (often with an IV attached) as they are dying is something I'll never get my head. I would name it the Darwin ward, but that is probably insensitive... (ASD)

It makes me angry that medics won't even condon, let along recommend smokers switch to vaping due to politics. They could save 100,000's of lives per year in the US alone (480k smokers die per year).

[baccheion]

Works well. I've been taking at least 50,000 IU/day for over 2 years and serum calcium is always in range. I add milligrams of K2 MK-4, micrograms MK-7, and 100s of mg of magnesium (now over 1g).

[mrfusion]

Wow! Why so much, my dude?

[baccheion]

Because...

[bobobob420]

I walk for 30 minutes a day in direct sunlight. If I do this for a year (been 5 months so far) do I not need to worry about vitamin d intake? I am also a healthy young male in my 20’s

[rnd33]

As others have pointed out, it depends on time of year and where you live. Far north, e.g. Canada, the U.K, Scandinavia the sun won't give you any Vitamin D at all for roughly six months of the year.

[elliekelly]

I’ve been using the DMinder app (not affiliated in any way and it’s totally free) to estimate how much vitamin D I’ve been getting. You input how overcast it is and what percent of your skin is exposed and then it uses your skin tone (input at setup), latitude, altitude, and time of day and it’ll track a rough estimate of how much vitamin D you’ve produced while you’re outside.

There’s also “Quick and Easy Screening for Vitamin D Deficiency in Adults”[1] which has a quick and dirty formula in Table 2 to help assess your risk of deficiency without a blood test.

[1]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4998626/pdf/med...

[nytgop77]

is exposed amount of skin an input?

[SamBam]

It depends on your latitude and skin color, mostly, and other factors like how much clothing you wear.

[getpost]

Can’t find a citation at the moment, but it also depends on what part of your body is exposed. Just resting your forearm on an open car window won’t do it. You have to expose your torso mid-day IIRC.

https://www.healthline.com/nutrition/vitamin-d-from-sun#time...

[gls2ro]

Just as a pure speculation (I am not specialized in this area) I find it a little bit odd that forearm is not enough as I find it is the most common area exposed to sun by people at least in the last 100.000 years.

So I am wondering how come in this case selection did not chose those whose forearms can produce a lot of Vitamin D as it was probably the most exposed part to the sun.

[0134340]

Don't forget that many people used to bathe outside for many millenia. But I too would be interested in how clothing through generations have put selective pressures on humans, if any.

[rrrrrrrrrrrryan]

It probably depends on how much skin is exposed as well as your genetics.

Getting your vitamin D levels tested is a super simple blood test - you can just ask your doctor and they'll prescribe it.

[nradov]

What latitude?

[neop1x]

I have read that vitamin D deficiency can play a role in starting multiple sclerosis. I was years working mostly indoors, not seeing sun much and then one day my eyeballs started flickering and I was diagnosed with multiple sclerosis. Maybe if I monitored vit. D levels and have taken supplements, I could have prevent multiple sclerosis but maybe not. It is not that easy and clear, it seems.

[neuronic]

At least 10.000 IU/day are seemingly not a problem [1]. Old recommendations of only 1.000 IU/day are likely way too low as well [2].

[1] https://www.sciencedirect.com/science/article/abs/pii/S09600...

[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5541280/

[GolDDranks]

The case mentioned in the article was taking 5000 IU/day, and that proved to be too much. I'm not an expert, but 10000 sounds a WHOLE lot.

I started taking 2000 IU/day because I wasn't seeing much of daylight because of the pandemic. I hope that's a safe amount, but it would be nice to get my blood levels checked.

[jdeibele]

There are a fair number of clinics that will do blood tests for you. This is the first one that came up on DDG: https://www.everlywell.com/products/vitamin-d-test/ $49 but you have to prick your finger for the blood they need.

[erosenbe0]

It most certainly should continue to be thought of as a dietary supplement by current definitions, or you are on an errand to redefine that term (in the USA, at least).

It is the responsibility of physicians to discuss diet and supplementation with patients, and know that food and supplements have potent acute and chronic effects, and these effects may be on par with prescription medications.

[WA]

Physicians might know. Quacks don’t. If you simply google for vitamin D, you find so many quack websites as the top result. So your idea of keeping it a supplement is a bit questionable, if it is actually medication and is easily dismissed as harmless by quacks.

[mehmeta]

Can harmful levels of calcium be present even if Vitamin D levels are measured as within the reference range of 30.0 - 100.0 ng/mL?

[computerphage]

This is what happened to Shannon in the story. Her level was 79 ng/ml, but she still had high calcium.

[baccheion]

Unlikely with enough vitamin K2 and magnesium, assuming calcium is below the TUL.

[sizzle]

Is taking 100mg of chelated magnesium 3-5x a day harmful to by health? I've been taking this for a while now and just found out it can increase calcium to dangerous levels (citation needed). Please advise.

[petilon]

I got this from the doctor:

Magnesium is interesting. A lot of these vitamins and minerals interact, in ways many doctors have forgotten. Magnesium is essential for calcium metabolism, so I often recommend it for anyone who takes calcium. It does help with muscle cramps and many take it for insomnia. Magnesium isn't a miracle drug, any more than Vitamin D, but it is a necessary mineral, and people do really notice improvements with muscle soreness. If cramps are the main issue you have, some people swear by magnesium malate - the malic acid in it may also help with sore muscles.

[WaltPurvis]

Could taking calcitriol also lead to overly high calcium levels?

[fizzled]

I'm a ~50somethingish white male experiencing bone loss (via DEXA scan). My two doctors (general and specialist) both said: let's try OTC vitamin D, even though it probably won't do anything because you aren't deficient; if that doesn't do anything we'll provide a prescription for actual vitamin D.

We experimented over two years and OTC VitD didn't help, but my point is, I was confused by two types of Vitamin D: the stuff you can by OTC, and the "real" stuff. How does this compare to the VitD you are referring to?

(I cannot take calcium because I have another disease, and "calcium bolus" is a very real concern for me do to another medication i am on.)

[baccheion]

Someone tried 300 IU/kg vitamin D3 and 45 mg vitamin K2 MK-4 (15 mg 3x/day) for bone health. 100 mcg MK-7. Magnesium was increased to 1,200 mg.

Use a tool like CRON-o-meter to check diet. PRAL score. ZMA.

[rusabd]

try weightlifting - this is the fastest way to increase bone density

[cullinap]

just prescribe sunlight

[rebuilder]

Difficult in places where there is insufficient sunlight for much of the year!

[blaser-waffle]

Basic sunlamps aren't expensive. I grow plants in-doors and suppliment w/ them, the bulbs are ~10-15 bucks and fit in any desk or ceiling lamp.

I have a "happy lamp" by a reading chair in my living room, and sit under it in the mornings while drinking coffee and watching the news. Coffee+Sun perks me up in the morning right quick.

I'm in Edmonton, Canada -- look it up on a map, we're far up there -- and it's basically how I make it through the winters here.

[rebuilder]

So these are UV bulbs? I know bright light is used to combat SAD, but AFAIK that's not about vitamin D, just the light itself having an effect on mood.

[cullinap]

i was mainly joking because I think that most of the times when we peal back the layers of research we see that natural systems have adapted over time for certain reasons. Also there should be further research into how native people in northern climates adapt to low sunlight conditions given their location. Perhaps there are areas of the diet we are overlooking instead of just prescribing vit D as the only fix

[LoSboccacc]

I've had a deficiency diagnosed, I'm worried about the prescribed integrators, since everyone is suggesting daily doses and I'm taking 15000ui/month in a single dose. what's better?

[Markoff]

dunno about difference between effect of daily vs monthly dosage, but 15000IU per month is newborn dosage here in Europe for first year, 1 drop per day = 500IU, so I would not worry too much about such low dosage which is insufficient for adult anyway unless you spend lot of time outside exposed to sun

I'm taking 2500IU daily