How do I know the kids are vitamin D deficient?

Vitamin D Council

March 16th, 2012

 

This newsletter is in part made possible by the support of our sponsors

 

The difference between two "normals"
March 16, 2012 -- John Cannell, MD

In a paper the press ignored, well-respected researchers from three different hospitals on the east coast recently reported on high blood calcium levels in three infants and toddlers with rickets who were given vitamin D. The reasons for the high blood calcium, all of which were trivial, were not clear from the paper at first, at least to me.

Vanstone MB, Oberfield SE, Shader L, Ardeshirpour L, Carpenter TO. Hypercalcemia in Children Receiving Pharmacologic Doses of Vitamin D. Pediatrics. 2012 Mar 12.

Before we talk about this recent paper, it is important to remember that (in a paper you are free to download and read in its entirety) the entire country of East Germany had a lot of experience with “pharmacological” (very high) doses of vitamin D in children. Unbelievably, for several decades, every child in East Germany went to the doctor every 3 months where the child received 600,000 IU of vitamin D. All the kids in the entire country got it every three months until the child was 18 months old. That means in the first year and a half of life, every child in the German Democratic Republic (East Germany) had a total dose of 3.6 million units of vitamin D.

Markestad T, Hesse V, Siebenhuner M, Jahreis G, Aksnes L, Plenert W, Aarskog D. Intermittent high-dose vitamin D prophylaxis during infancy: effect on vitamin D metabolites, calcium, and phosphorus. Am J Clin Nutr. 1987 Oct;46(4):652-8

That is way too much as the paper above documents but the amazing thing is that only about 1/3 of the children got high blood calcium and none got clinically toxic. In fact, the authors reported, “All the infants appeared healthy . . .” However, they were not all healthy; some had calcium levels as high as 13 mg/dl, too high but far from fatal. The key, and this is critical, is that the range of calcium considered normal in East Germany was 9.4 to 11.2 mg/dl and these were ranges borrowed from Norway. In the USA, “normal” ranges are 9 to 10.5 mg/dl.

How do we get these calcium ranges? We take several thousand vitamin D deficient children, measure their calcium and use a Gaussian distribution to calculate “normal.” How do I know the kids are vitamin D deficient? Because virtually all the kids in the USA are vitamin D deficient, thanks to video games, the sunscare, and sunblock. For the first time in human history, we are raising a generation of indoor children. Because calcium and vitamin D are connected, such children will have slightly lower calcium levels than would several thousand truly “normal” kids. Therefore, we use the abnormal to calculate the normal.

Next comes my second reading of the recent “toxicity” paper. All three children had rickets but their “hypercalcemia” was all below 11.2 mg/dl. That’s right, none of the children had high blood calcium. They had a calcium level that reflected the fact that someone detected their rickets (rather rare) and gave them the correct amount of vitamin D (total doses of around 150,000 IU), hardly the “pharmacological” doses the authors reported. If they want pharmacological doses, they should take a time train back to East Germany. Pity our children, now, because of these three case reports, children desperately in need of vitamin D will not get it, not because of a conspiracy, but due to the failure to know the difference between normal and normal.

Copyright © 2012 The Vitamin D Council, All rights reserved.

The Vitamin D Council
1241 Johnson Ave. #134
San Luis Obispo, CA 93401

More on Vitamin D

Vitamin D Council

March 13th, 2012

This newsletter is in part made possible by the support of our sponsors

Vitamin D may ease menstrual cramps
March 7, 2012 -- John Cannell, MD

Painful periods or dysmenorrhea are a common problem today. Millions of women suffer 4-7 days of severe abdominal cramps together with irritability, insomnia, depression, and generalized pain requiring medications like ibuprofen and antidepressants. Dr. Antonio Lasco and colleagues at the University of Messina in Italy took the first step in what I predict will be a major trip forward in relieving the suffering of these women by publishing their results from yet another randomized controlled trial.

US News & World Report 2/29/2012 Vitamin D3 Might Ease Menstrual Cramps

Antonino Lasco, MD; Antonino Catalano, MD; Salvatore Benvenga, MD Improvement of Primary Dysmenorrhea Caused by a Single Oral Dose of Vitamin D: Results of a Randomized, Double-blind, Placebo-Controlled Study Arch Intern Med. 2012;172(4):366-367. doi:10.1001/archinternmed.2011.715

First, the authors found that the lower the vitamin D level, the worse the periods. Second, the authors found that a single dose of 300,000 IU of vitamin D (equivalent to 5,000 IU/day) had dramatic results in relieving dysmenorrhea over the next two months. These results came despite the average baseline levels being around 30 ng/ml, a relatively high vitamin D level for a group or population. However, the paper came with a sensible warning in the form of an editorial, saying that no one should take 300,000 IU in an effort to stop painful periods based on one trial.

Elizabeth R. Bertone-Johnson and JoAnn E. Manson Vitamin D for Menstrual and Pain-Related Disorders in Women: Comment on “Improvement of Primary Dysmenorrhea Caused by a Single Oral Dose of Vitamin D” Arch Intern Med. 2012;172(4):367-369

I do not recommend taking a 300,000 IU mega dose. I understand the usefulness of a single high dose in a clinical study (you make sure everyone takes the medications), but I believe vitamin D should be taken daily, not every two months. The Vitamin D Council recommends 5,000 IU/day, which should raise blood levels to the 40-60 ng/ml range (a loading dose of 10,000 IU/day for ten days is also reasonable if your periods are really bad).

This is, in essence, the same dose they used in the study, spread out over two months. Although it is purely speculative, there may be a different optimal range for improving dysmenorrhea but that awaits further study. The good news is that approximately 5,000 IU/day had dramatic effects on of the most disabling conditions suffered monthly by otherwise healthy woman. Way to go Italy with yet another randomized controlled trial, which are now numbering over one hundred or so.

 ~~~

The cost of vitamin D blood tests

Posted on March 10, 2012 by John Cannell, MD

How much more does it cost the medical system to have doctors order vitamin D blood tests? Already, both Canada and Medicare have limited doctor’s ability to test for vitamin D deficiency because the tests cost too much. How much do they cost in the picture of total health care costs?
The stunning answer from Dr. Beth Baily and colleagues at East Tennessee State University is that frequent vitamin D blood tests mean lower, not higher, total medical care costs. That’s right, ordering more vitamin D tests means lower total health care costs.

The researchers looked at the medical records of about 400,000 veterans from six VA medical centers in the Southeastern United States to find about 15,000 veterans who had a vitamin D level checked. Then they added up the total number of subsequent visits (inpatient and outpatient) and the total subsequent health care cost for each veteran, vitamin D tested or not.
As expected, outpatient costs were a little higher for veterans who had vitamin D testing. Then came the real shocker: inpatient costs were from 70% to 300% lower for veterans who’d had the vitamin D tests. The study also showed that the veterans who have been tested and effectively treated for their vitamin D deficiency have the lowest yearly inpatient costs, while the sites that have done the least testing had inpatient costs nearly triple that. While the authors were quick to point out vitamin D did not explain all of this huge difference, it clearly seemed to explain at least some of it and leaves one with the tragic reality that some of our veterans are dying needlessly.
I was so glad to see that the authors write, “The (local) VAMC has made a concerted effort to educate local health care providers regarding vitamin D deficiency over the past few years.” They went on the say, “Immediate implementation of this recommendation is highly desirable.” I agree. This is a public health problem that needs to be immediately treated with public health measures, including better sun exposure guidelines, supplementation guidelines, and food fortification.
Hats off to Drs. Beth Bailey, Todd Manning, and Alan Peiris, and my apologies to the others in the Tennessee VA system that I missed. They have discovered reduced total health care costs in veterans are associated with more vitamin D testing and less expensive subsequent hospital stays. They are government servants of the highest order. Therefore, it appears that Medicare has cut off its nose to spite its face, limiting vitamin D blood tests to save a little money, thus assuring that total costs of treating the elderly will be substantially higher. Now, how can we get this information to President Obama?

About John Cannell, MD

Dr. John Cannell is founder of the Vitamin D Council. He has written many peer-reviewed papers on vitamin D and speaks frequently across the United States on the subject. Dr. Cannell holds an M.D. and has served the medical field as a general practitioner, itinerant emergency physician, and psychiatrist.