Interview with Professor Benjamin Glaser Shaah Tovah 2010

Vitamin D

An interview with Professor Benjamin Glaser M. D. Director of the Endocrinology and Metabolism Service at Hadassah University Hospital

By Debbie Shapiro

[different font] At fifty, Shira felt like a decrepit old lady. "My whole body ached; my muscles, my bones, everything. Just walking or getting out of a chair was difficult." But when Shira discovered that she was too weak to pick up a bottle of soda, she realized that something serious was going on. "I went to dozens of doctors, who sent me to dozens of tests, but they couldn't find anything the matter with me. I was told that my symptoms were psychosomatic and prescribed antidepressants. But I continued digging deeper."

One doctor diagnosed fibromyalgia – and recommended antidepressants. Another thought it was polymyositis, an inflammatory muscle disease, and suggested a series of invasive tests. Finally, one doctor – "a gutte shaliach" – told Shira to test her vitamin D level. Anything under twenty is considered a severe deficiency. Shira had five. "When the doctor saw the result and said, 'You must be in agony,' I started crying. Finally someone believed me!"

Until recently, vitamin D deficiency was almost unheard of; today, it's so widespread that the Israeli Ministry of Health has considered recommending that everyone – across the board – take supplements. Professor Benjamin Glaser, M.D., Director of Endocrinology and Metabolism Service at Hadassah University Hospital, was kind enough to speak with B'shaah Tova about the problem.

First of all, what is vitamin D?

Basically, it's a hormone that we get primarily from the sun. Vitamin D enhances the absorption of calcium and phosphorus from the intestine and promotes their deposition onto the bone, which is why it's so important for bone health, and, as we are discovering more and more, for health in general.

Is vitamin D deficiency a new problem?

The problem itself is not new. We just didn't know about it. In the past, the blood test to check vitamin D levels in the blood was very expensive and most laboratories didn't have right equipment. Today, however, the test is automated and easily available.

For years we knew that those populations not exposed to the sun, such as the elderly or the housebound, do not receive sufficient vitamin D. But it wasn't until we started measuring the general population, the people who live normal lives and do go outside, that we discover the extent of the problem.

To some extent the problem is getting worse. The dermatologists are constantly warning us against excessive sun exposure – and rightly so – and more people are following their recommendations. But as with anything, it doesn't pay to go to extremes.

So how much exposure to the sun does a person need?

Abut five to thirty minutes of exposure to the skin on your face, arms, back or legs (without sunscreen) twice a week. But since that's not always possible, I recommend taking vitamin D supplements. Vitamin D supplements are inexpensive, readily available, and can be purchased without a prescription. Vitamin D deficiency is so widespread that everyone across the board should probably take the supplements, unless there is a medical contraindication.

Your specialty is endocrinology. Why does an endocrinologist deal with vitamin D deficiency?

As an endocrinologist, I treat, among other things, metabolism problems and problems of the parathyroid gland. We discovered that a lot of these problems are related to vitamin D deficiency.  So I started looking into it more deeply. 

Why is vitamin D deficiency problematic?

Severe vitamin D deficiency in small children causes rickets. The bones become soft and bend easily. Although today such a severe form of vitamin D deficiency is rare, I did see one case when I was a medical student on rotation in Beer Sheva. It was a Jewish child of Indian origin. Although the family lived in the desert, both the mother and the child stayed completely covered at all times. The baby wasn't getting any vitamin D from his mother's milk, nor was he getting it from the sun, and his mother did not give him the prescribed vitamin D supplements. A classical textbook case of rickets in the middle of one of the sunniest places on earth!

We need vitamin D to absorb calcium and calcium is necessary for many different mechanisms in the body. The most obvious is for healthy bone. If we are unable to absorb calcium due to insufficient vitamin D, the body breaks down the bones to get the calcium it needs which leads to osteoporosis, fragile, porous bones. Poorly mineralized bone can cause bone pain, which disappears once the vitamin D levels return to normal.

We need calcium for muscle function, so a vitamin D deficiency often results in decreased muscle strength and muscle pain. One of my patients had such a severe vitamin D deficiency that she was incapable of sitting up in bed without assistance. After massive doses of vitamin D she eventually returned to normal.

For reasons that are not entirely clear, vitamin D is necessary for balance, so replacing vitamin D decreases the probability of falling. That, in turn, decreases the likelihood of fractures. As with the bones and muscles, the damage is reversible and once the vitamin D is restored to normal, balance is restored.

There have been a lot of professional articles showing how adequate vitamin D levels decrease the risk of both cancer and autoimmune diseases.

Why?

I don't think that anyone knows the exact mechanism, but we do know that our cells, our muscles and our hormones all need calcium to function properly, and as we explained earlier, vitamin D has a direct impact on calcium absorption. We always knew that there were vitamin D receptors in the gastrointestinal tract, but we're now discovering that they also exist elsewhere. So it's very possible that the decreased cancer risk associated with proper vitamin D levels is immunological. We just don't know for sure.

But what we do know, at least partially, is the vitamin's impact on us. Adequate vitamin D levels in the blood decrease the risk of cancer and autoimmune diseases, such as multiple sclerosis and juvenile diabetes. The benefits are broad spectrum.

I've heard that vitamin D deficiency can cause depression and that correcting the deficiency can cure the depression. Is that true?

Clinically, I've seen a relationship between vitamin D deficiency and depression, but I am not aware of studies that prove that connection. But it makes sense. After all, feeling better and having more energy would have a positive impact on one's mental state.

The symptoms of vitamin D deficiency are vague and cover a broad spectrum. Is it often misdiagnosed?

A lot of people diagnosed with parathyroid problems are actually vitamin D deficit. Some people diagnosed with muscle pain syndromes, fibromyalagia, polymyositis and/or or chronic fatigue syndromes are really lacking sufficient vitamin D, and correcting the vitamin D will improve their condition drastically. Heart palpitations, muscle weakness, bone pain, these are all very non-specific symptoms and are often viewed as psychosomatic, when in fact they can be caused by lack of vitamin D. Of course I'm not claiming that everyone who feels tired or achy will take vitamin D and feel fantastic afterwards. It's not a miracle drug, a quick cure-all, but for some people the change is dramatic.

Vitamin D helps the body absorb calcium, so I assume that if a person is vitamin D deficient, he would also be missing calcium.

I wouldn't put it that strongly, since one can force calcium in if you take enough, but yes this is basically true.  Calcium supplements won’t do anything unless there is vitamin D to help absorption.

Is it recommended to take calcium in addition to the vitamin D?

In general, I recommend that everyone over age fifty take supplementary calcium. We need between one to one and a half grams of calcium per day and older people usually don't get that much from their diet. Therefore, they should take one or two tablets of calcium per day. I know that some people recommend taking calcium with magnesium or claim that one type of calcium is better than another, but I personally have not seen any difference. 

A lot of our readers are mothers of young children. Any recommendations specific for that age group?

Although everyone should get enough vitamin D, babies are especially vulnerable to a vitamin D deficiency. Their bones are developing at a very rapid rate, so they need more calcium than older people, and, as I explained before, vitamin D is necessary to absorb the calcium. For healthy bones in the future, it is imperative that babies get enough vitamin D.

Since most babies do not getting sufficient vitamin D from natural sources, pediatricians and well baby clinics routinely prescribe vitamin D drops. For their children's future health, it's extremely important that mothers remember to give their babies the supplementary vitamin D drops. [export quote]

In America, vitamin D is routinely added to the milk. What about in Israel?

Vitamin D is added to the Israeli skim milk, but it's what I'd call vitamin D corrected, bringing it up to the level of whole milk.

Some people are questioning the normal levels of the vitamin D test, known as the 25-hydroxy vitamin D test. Since almost eighty percent of the people tested are vitamin D deficient or insufficient, they suggest that perhaps the definition of normal is wrong -- after all, we can't all be abnormal! But the suggested normal range is not based on the average person being tested. Studies have shown that to normalize the parathyroid hormone, calcium secretions and other tests, the vitamin D level must be in the range of 30 ng/ml. If the test results are below 20 ng/ml, other blood tests will also be abnormal, and all these abnormal blood tests are signs of abnormal body function.

So maybe everyone should just take the vitamin without bothering taking a blood tests.

Many people agree with you! Since most people need supplementary vitamin D and 2000 units per day will not harm anyone, even if they are not vitamin D deficient, it makes a lot of sense to just tell everyone to take the supplement. It's certainly cost effective. The test costs several hundred shekels, whereas a months worth of vitamin D cost approximately twenty shekels! If I were on Kupat Cholim's board of directors or advising the Ministry of Health, I would recommend giving the vitamin to everyone and saving the test as a diagnostic tool.

Personally, however, I prefer to test my patients. If the results are just a bit below normal, I prescribe between one thousand to one thousand five hundred units per day, whereas if they are extremely low I push it up quickly with a much higher dose than the recommended 2000 units per day. But I really can't give a strong cost-effective argument against treating everyone. What I would be against, however, is not treating anyone.[export quote]

Dr. Tzur, an endocrinologist in Kupat Cholim Meuhedet conducted a study in which she tested the vitamin D level of two different populations: Chareidi yeshiva students and Hesder yeshiva students. One hundred percent of the Chareidi yeshiva students were severely deficient, which is what she expected. Surprisingly enough, however, despite their regularly partaking in outdoor sports, a large percentage of the Hesder yeshiva students were also lacking sufficient vitamin D.

One of the interesting things that we've learned from measuring vitamin D levels is that what was once considered the minimum daily requirement is really much too low. The recommended vitamin D intake was 600 units per day for children, 400 units per day for adults and 800 units per day for people over fifty. But we've learned that those recommendations were wrong and that everyone needs a minimum of 1000 units per day. Multivitamins only provide, perhaps, 200 units, which is far from being sufficient. Bottom line, take supplementary vitamin D!

In Israel, the easiest and cheapest way to get vitamin D is to use the vitamin D drops normally prescribed to infants. One of the pharmaceutical companies recently came out with a product made specifically for adults, but it's really the same baby drops in a different package.

Vitamin D can be taken daily, weekly or even monthly; it makes no difference. In Israel, each drop contains 200 units, so you'll need ten drops to get the recommended 2000 units. It's also possible to take seventy drops per week, or three hundred drops once a month. In the United States tablets containing 50,000 units each are available, so if you take one tablet a month you're getting close to the recommended 2000 units per day of vitamin D.

There are two different types of vitamin D: vitamin D2 and vitamin D3. Although today both are produced synthetically, naturally vitamin D2 is produced from plant material while vitamin D3 is produced from animal material. Vitamin D3 appears to be much more effective and corrects the blood level faster. It's also readily available and most of the supplements contain vitamin D3. If it doesn't, ask for a different supplement!

Is it possible to take too much vitamin D?

It's not impossible, but you'd have to ingest huge amounts, something like 50,000 units a day over a period of time! That's approximately one bottle of vitamin D drops per day! But the recommended amount – 2000 units per day or a bottle of baby drops per month – is harmless.

Should parents first consult with their pediatrician before giving their children supplementary vitamin D?

Although you don't need a prescription for vitamin D supplements, as with any supplement I don't think a parent should give it without first talking it over with the child's pediatrician.

My family doctor told me that vitamin D deficiency is an "epidemic." With the problem so widespread, what's being done to educate the public? 

Not much. Especially among the populations most at risk – such as the Chareidi community – we need to do more to alert both the community leaders and the man on the street. That's why writing articles is so important.

Bottom line: either get sufficient exposure to the sun or take vitamin D supplements!

[different font] Shira was prescribed mega-dosages of vitamin D. "Shortly after I was diagnosed with the deficiency, my orthopedist sent me for a bone scan. It showed dozens of 'hot spots,' which the endocrinologist later explained were hairline fractures caused by the lack of vitamin D. No wonder I was in such pain!

"It took me about six months until I felt better. For years, my bloods tests had been abnormal –-  there were enzymes showing muscle and bone destruction --  but no one understood why. Once my vitamin D levels were normal, these blood tests also became normal.

Today, Shira is healthier than ever. "I have a new lease on life and am able to do things that I never dreamed possible."