by wayne Persky |
And why those recommendations may be wrong for most people
The Endocrine Society recently revised their vitamin D guidelines for supplementation and screening, and the revisions sparked an uproar among clinicians (Endocrine Society, 2024, June 03).1
The new guidelines make a number of recommendations:
- For Healthy Adults Under 75 — The guidelines recommend no vitamin D supplementation above the recommended dietary intakes unless there are specific health conditions that justify it.
- Populations That May Benefit from Higher Doses — These include children and adolescents to prevent rickets and respiratory infections, individuals over 75 to potentially lower mortality risk, pregnant individuals to reduce various risks, and people with prediabetes to potentially slow disease progression.
- No Routine Vitamin D Testing — The guideline advises against routine testing for 25-hydroxyvitamin D levels, citing insufficient evidence to link these levels with specific health outcomes, even in populations with darker skin or obesity.
- No Specific Blood-Level Thresholds — The panel could not determine specific thresholds for 25-hydroxyvitamin D levels for disease prevention due to insufficient evidence.
These guidelines appear to leave a lot to be desired.
Except for people over 75, pregnancy, and prediabetes (which is not a disease), the endocrine society's guidelines are claimed to be sufficient to prevent rickets, but they have no recommendations to try to prevent or treat any of the other diseases associated with vitamin D deficiency. And the reason for this dilemma is the fact that they continues to be flummoxed by conflicting data regarding vitamin D and disease. In other words, since they don't know what to recommend for various test result levels, they simply recommend against testing.
Let's consider their recommendation for people over 75.
The Endocrine Society recommends that individuals over 75 years old should take 800 IU (20 MCG) of vitamin D daily through food or supplements to maintain adequate levels. This is claimed to be adequate for maintaining a blood level equal to or greater than 20 ng/mL, and this is said to be "Generally considered adequate for bone and overall health in healthy individuals". Is it? Probably, for a few individuals. But probably not for most people.
How many people are truly healthy these days?
Looking at research statistics, few people (less than 3% in the U.S., for example), can actually be considered to be "healthy individuals" these days. A comprehensive study from York University, published in PLOS One, reveals that nearly everyone has some health risk factors, and the relationship between these risk factors and mortality changes over time (York University, 2023, July 8; Yu, Pooni, Ardern, and Kuk, 2023).2,3
Patients suffer, and researchers fiddle, while this paradox goes on and on.
While it may be an oversimplification to say that "virtually every known disease" is associated with vitamin D deficiency, there is a substantial body of research indicating that low levels of vitamin D are linked to a variety of health issues, including bone disorders, autoimmune diseases, cardiovascular diseases, diabetes, infections, mental health conditions, and many others. Medical authorities are quick to point out that it's important to note that correlation (association) does not imply causation.
But here's why that argument is irrelevant:
Even if a disease causes vitamin D deficiency, rather than being caused by vitamin D deficiency, the resulting vitamin D deficiency prevents proper healing, and as a consequence, perpetuates the inflammation, thereby perpetuating the disease. Therefore, their argument is irrelevant as far as long-term health of the general public is concerned, and a huge segment of the population (possibly as many as 97%) might benefit from taking (additional) vitamin D supplements in order to either prevent the development of disease, or enhance healing in cases where disease is already present.
To support this point, criticism and concerns regarding the guidelines are widespread among clinicians.
- Perceived Neglect of Broader Health Implications — Many commenters argued that the guidelines focus too narrowly on endocrinology and bone health, ignoring the broader implications of vitamin D deficiency on autoimmune disorders, chronic pain, immunosuppression, cancer prevention, and cardiovascular health.
- Impact on Special Populations — Concerns were raised about the guidelines’ lack of consideration for populations with limited sun exposure (e.g., those with certain religious dress codes, night workers) and individuals with conditions affecting intestinal absorption, like Crohn's disease, celiac disease, and cystic fibrosis.
- Oral Health Considerations — One commenter pointed out the potential role of vitamin D in maintaining oral health, particularly in balancing calcium and phosphate levels in saliva, which affect periodontal disease and dental caries.
Many healthcare professionals object to the No Screening recommendation.
- Lack of Guidance Post-Screening — The guideline's recommendation against screening due to the uncertainty of how to proceed with treatment after detecting low vitamin D levels was met with strong opposition. Commenters argued that avoiding screening because of uncertainty is misguided and could lead to missed opportunities for preventive care.
- Perceived Incompetence and Neglect — Several healthcare professionals criticized the recommendation as a failure to address patient needs and expressed skepticism about the motives behind it, implying that financial considerations from the pharmaceutical industry or insurance companies might have influenced the guidelines.
Many clinicians raised concerns about ignoring preventive care.
- Impact on Preventive Health — Some commenters felt that the guideline could undermine preventive healthcare by discouraging testing and supplementation, leading to a reactive rather than proactive approach to managing health risks.
- Long-Term Implications for Vulnerable Populations — There were specific concerns about the effects of vitamin D deficiency in pregnant women and the potential long-term health consequences for their offspring.
These guidelines discourage professional discretion.
While the new guidelines don't disallow professional discretion, they certainly appear to discourage discretion. If clinicians order a vitamin D test outside of the allowed selections, then insurance is not likely to cover the cost of the test, nor is Medicare. Making a test more expensive for patients is definitely a disincentive for testing.
The bottom line appears to be:
Vitamin D testing (and vitamin D supplementation) in the future will be discouraged except for certain specific groups. And most importantly, these new guidelines have now been incorporated into the electronic health records (EHR) system. And this likely infuriates many clinicians because it means that in order to get reimbursement from Medicare or insurance for a vitamin D test for any patient, a specific listed reason for ordering the test must be selected, and the listings are limited to the new guidelines. In other words, disease prevention will be discouraged, because patients must have certain symptoms before the electronic health record system will allow reimbursement for a test. The net result will be a combination of declining health due to fewer vitamin D tests, and an increase in the cost of healthcare for many patients.
Vitamin D is especially important for those over 75.
Not only is vitamin D important for calcium absorption, and bone health, but along with magnesium, it's critical for proper immune system function. As we get older, the importance of bone health and immune system function increase dramatically. Bones tend to become fragile with age, and hip fractures often lead to complications that are difficult to overcome, especially with poor healing because of compromised immune system functioning.
We no longer produce enough vitamin D.
Older adults are less able to produce sufficient vitamin D due to decreased skin efficiency in synthesizing the vitamin from sunlight. This, combined with a tendency to spend more time indoors and wear more clothing, significantly reduces natural vitamin D production. Additionally, aging affects the liver and kidneys, organs that are essential for converting vitamin D into its active form, and that tends to increase the likelihood of a more severe deficiency. Consequently, vitamin D deficiency is common in older adults, and in high-latitude countries like the UK, almost half of the population over 75 does not reach sufficient vitamin D levels. Anyone over 75, who has a vitamin D deficiency, almost surely needs more supplemental vitamin D than 800 IU per day.
And what about MC patients?
The 800 IU daily dose of supplemental vitamin D that the endocrine society recommends for people over 75 is a rather unrealistic amount for IBD patients, including microscopic colitis (MC) patients. MC patients (and other IBD patients), typically have unique vitamin D needs due to factors such as impaired absorption and increased inflammation. And that statement is probably true for anyone who has any type of autoimmune disease. While IBD patients who have their symptoms well under control might be able to get by with 1000 to 2000 IU of supplemental vitamin D per day, those who are living with active disease probably need higher doses, such as 4000 or 5000 IU (or more) per day, especially if they are having serious malabsorption problems
And MC (and other IBD) patients, should monitor their blood levels of 25-hydroxyvitamin D to make sure they are absorbing and maintaining adequate levels. Blood tests can help determine if higher doses are needed, especially in patients with persistent deficiency despite supplementation. Optimal blood levels of vitamin D for IBD patients are generally considered to be at least 30–50 ng/mL (75-125 nmol/L). Adequate vitamin D levels helps reduce disease activity and improves overall outcomes. Research suggests that vitamin D has anti-inflammatory effects, which can be particularly beneficial for managing flare-ups and maintaining remission in IBD patients, and that finding almost surely applies to MC patients, as well as most other autoimmune diseases, also.
And MC (and other IBD) patients, should monitor their blood levels of 25-hydroxyvitamin D to make sure they are absorbing and maintaining adequate levels. Blood tests can help determine if higher doses are needed, especially in patients with persistent deficiency despite supplementation. Optimal blood levels of vitamin D for IBD patients are generally considered to be at least 30–50 ng/mL (75-125 nmol/L). Adequate vitamin D levels helps reduce disease activity and improves overall outcomes. Research suggests that vitamin D has anti-inflammatory effects, which can be particularly beneficial for managing flare-ups and maintaining remission in IBD patients, and that finding almost surely applies to MC patients, as well as most other autoimmune diseases, also.
What are the Microscopic Colitis Foundation's vitamin D recommendations?
Because some MC patients are vitamin D deficient when they initially develop the disease, and because MC depletes vitamin D, the Foundation has always recommended that MC patients should take a vitamin D supplement, especially when they are trying to initially put the disease into remission.
Although it's theoretically possible that a newly diagnosed MC patient might have a high vitamin D level, in practice, that possibility appears to be very unlikely. But because vitamin D supplementation is a multifaceted issue, and vitamin D regulates calcium absorption, we recommend reviewing the information in the newsletter at the following link before choosing to begin taking a vitamin D supplement.
https://www.microscopiccolitisfoundation.org/uploads/5/8/3/2/58327395/2956298.pdf
Although it's theoretically possible that a newly diagnosed MC patient might have a high vitamin D level, in practice, that possibility appears to be very unlikely. But because vitamin D supplementation is a multifaceted issue, and vitamin D regulates calcium absorption, we recommend reviewing the information in the newsletter at the following link before choosing to begin taking a vitamin D supplement.
https://www.microscopiccolitisfoundation.org/uploads/5/8/3/2/58327395/2956298.pdf
References
1. Endocrine Society. (2024, June 03). Vitamin D for the Prevention of Disease Guideline Resources. The Endocrine Society, Retrieved from, Retrieved from https://www.endocrine.org/clinical-practice-guidelines/vitamin-d-for-prevention-of-disease
2. York University. (2923, July 8). Surprising Health and Mortality Study: Is Anyone Truly Healthy? SciTechDaily, Retrieved from https://scitechdaily.com/surprising-health-and-mortality-study-is-anyone-truly-healthy/
3. Yu, W. W., Pooni, R., Ardern, C. I., and Kuk, J. (2023). Is anyone truly healthy? Trends in health risk factors prevalence and changes in their associations with all-cause mortality. PLOS ONE, Retrieved from https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0286691