I’ve been reading a lot about vitamin D. I know that the new Food and Nutrition Board recommendations are going to come out in May, but a lot of people have been recommending increased amounts of vitamin D already. What are you all doing? Are you recommending vitamin D supplements to your patients with type 2 diabetes in light of the research suggesting that vitamin D has roles in insulin action and insulin secretion? Are you recommending vitamin D to the family members of your patients with type 1 diabetes because of the research linking vitamin D to autoimmune disease?

I find the whole vitamin D story (well what we know of it) very interesting. Virtually every cell in the body has vitamin D receptors suggesting that vitamin D has actions in every cell. Overweight people are likely to have low blood levels of vitamin D because the vitamin is sequestered in fat tissue. People with low blood levels of vitamin D are more likely to have autoimmune diseases. People who live in northern latitudes, where skin synthesis of vitamin D is expected to be less, are more likely to have autoimmune diseases. People with Crohn’s disease are more likely to have low vitamin D levels even between flares. This last part is of great interest to me because I have Crohn’s. A vitamin D researcher suggested to me that supplementing with vitamin D might help prevent a second autoimmune disease or it might help my children prevent an autoimmune disease since they are at higher than average risk. If type 1 diabetes ran in my family, I would wonder if everyone in my family should supplement with vitamin D. It got me thinking, so I wonder what others are doing.

I am not currently recommending Vit. D but have read a lot and two of the RDs are strong proponents of vit. d3, calcium, and magnesium supplements. Some of the research for this is pretty compelling. I, too, am interested in knowing what others are recommending. Roxy

I myself was taking vitamin d and calcium together. I started having pvc's. While at a seminar I talked with an endocrinologist about it. He said not to take both together or at the same time and to take D3
I have done that and have had no more pvc's.

I take vitamin D as it has been promoted as being very beneficial for insulin sensitivity as well as bone density.
Don't know if it actually will work but I figure it might. I also made sure it was ok with my MD and cardiologist.

I recommend that my clients look for a multivitamin that contains vitamin D, and that they ask their doctor to include testing for vitamin D levels in their next set of blood work. It's not uncommon for someone to have very low levels of vitamin D, and need large doses of supplements to bring their levels up to normal. I'm not prepared to recommend more than 400IU of D per day until the recommendations change, unless we have a blood test to go on.

A lot of people are recommending 1000 IUs vitamin D pretty regularly for the average person. Right now, the Tolerable Upper Limit (UL) is set at 2000 IUs. I’m guessing that both the Adequate Intake and the UL will increase in May with the new recommendations, but I’ve been wrong before. I’m hoping to see some new guidelines regarding appropriate screening. I think anyone with diabetes, obesity, autoimmune disease or at risk for autoimmune disease would be appropriate to screen. I find it very curious that obese people tend to have low blood levels of vitamin D because the vitamin is trapped in fat tissue. I’ve not heard that this happens with other fat soluble vitamins though. Like you Lynn, I’m not comfortable telling people to supplement without blood tests to back it up, but when people ask me about it, I look at their total diet and supplement intake and merely ask them to stay below 2000 IUs rather than the 400. I’m hoping more people with chime in on this topic.

At the endo's office I work at we screen too. If low, we recommend 1,000 IU for some, and for some we start at 2,000 IU for a month, then go to the 1,000 IU/day. Or we test again and see where to go.

I hope this helps.

EnJOY!

Joy

I have been reading about vitamin D off and on for over five years now and am aware of its increasing popularity among health professionals due to it's apparent role in a wide spectrum of diseases--both in their prevention and management. 
The endocrinologists whom I work with have also been testing vitamin D levels in their high-risk populations, especially the elderly, obese, and in patients with darker skin color. In most, if not all, cases, the patients levels are low. I understand that the optimal range is also likely to increase to 40-60ng/ml, in conjunction with the forthcoming increase in the RDI by the National Academy of Scientists. My standard recommendation for vitamin D is based on the standard recommendations of various researchers, especially those actively involved in vitamin D research. This would be 1000-2000 IU's/day with a much larger dose prescribed for those with a deficiency-i.e. 50,000IU/week over 2-4 weeks. My family and I take 2000IU's and I will boost my intake to 5000 IU's/day  if I am directly exposed to a respiratory virus/infection. My son, who is up in Michigan, is also on 5000 iU's/day during the winter months. I swear by this vitamin. My family has rarely  been sick for over 5 years now. When we were exposed to people with the swine flu this past October, we got only very minor symptoms and recovered within 48hrs. This might be a complete coincidence, but I am a strong proponent of this vitamin/hormone!

This is why I love this forum! I went back to do some research, and found this info sheet from the NIH:  http://dietary-supplements.info.nih.gov/factsheets/vitamind.asp

Granted, it's based on 1997 recommendations, but this is where I get the information to base my recommendation on 400IU per day. The expert committee expects to have new recommendations released in May 2010, and I'm sure we'll all be eager to hear what they have to say.

The biggest reason I'm leery about recommending larger amounts of supplementation without a blood test is that I've found many of my clients get supplemental D in several forms:  added to their calcium supplement, in their daily multi, as a separate supplement, added to foods. I believe, along with it seems like everyone else participating in this discussion, that the recommendation will be increased soon. Until that happens, I'm going to err on the side of caution - and continue to recommend a blood test as the best way to identify the amount of supplemental D needed.

Can you talk more about the coorelation of PVC's and vit D...this is the first that I've heard of this...

I am not sure if the fact that I had recently had stent placement had any bearing on the pvc's occurring when taking calcium and vit d together but I know after I started taking d3 separately my pvc's stopped immediately.
I am sorry I do not remember the name of the endocrinologist  that I talked with but he is from college station tx and he has many published research papers. He was speaking on Victoza at a dinner conference when we happened to discuss my situation with pvc's.
Turns out it was good advise. Separate the calcium and vitamin d and be sure to take d3.

The 400 IU/d is pretty outdated. I take 1,000 units /d, and I recommend to my female patients at least 800 IU/d. I am not aware of any literature correlating Vit D supplementation with PVCs. However, there is a lot of lit connecting low Vit D with T2DM, T1DM, auto-immune dz and certain types of cancer. Whether or not the lower limit of nl is 30 or 32 or 40, it is likely that a substantial portion of your patients are Vit D insufficient or even Vit D deficient (<15). If D level is indeed <15, you will not get a lot of effect from prescribing 1,000 units daily. Go with 50k weekly x8-12 weeks to refill the depot.

Note that, although vit D is fat-soluble and is stored in adipose tissue, it's sucked out of the bloodstream and stored in fat in obese patients, who are at particularly high risk of D deficiency  - as are institutionalized pts and Alaskans and Boston med students ;-)

I have a talk "The ABC of Vit D" that was recorded for audio-digest. I do not get paid by them, but if you want to get an overview, it's a pretty good start.

Thanks for this information Dr. Thambler. This is the same information that I have read. I also was told that when you are in the full summer sun with exposed skin, your body will absorb 30,000-50,000 units in 20-30 min. time. So a little sun exposure might actually be good for us. Do you think the widespread use of sunscreens may be a contributor to the vit. d deficiency? Royx

It really only takes a few mins to get the sun exposure you need in the summer. I'd rather err on the side of caution and use sunscreen, even though low SPFs drastically diminish UV absorption and thus Vit D production. There's really interesting data investigating Vit D deficiency in countries where women cover themselves fully whenever they go outside (e.g. Burkas).

I've been doing a fair bit of literature review on vitamin D because it's so fascinating and has receptors in just about every cell in the body. An SPF of just 15 blocks 99% of vitamin D synthesis. I agree, I'd rather use sunscreen to protect myself from skin cancer. But I do push my sleeves up for 20 or so minutes most days when I jog in the winter. Twenty minutes is all I can stand!

All -

Another great conversation and an important one in the area of diabetes. I point you to an NutriZine I wrote on this topic a ways back, but it's still pretty current (http://www.presentdiabetes.com/ezines/index.php?pub_year=2008&section_id=13#ezine216).

There's interest in Vitamin D for general health as well as in both types of diabetes - type 2 related to insulin resistance; type 1 related to cause of onset.

Yes current the Institute of Medicine (Food and Nutrition Board)'s is conducting an ongoing review of Vitamin D and calcium. Learn more about this, read transcripts of meetings and learn about the timetable for completion at http://www.iom.edu/Activities/Nutrition/DRIVitDCalcium.aspx.

The report from this consensus group should be out summer 2010. Keep in mind that the Vitamin D and Calcium DRIs haven't been updated since 1997. I know from listening to some of the Dietary Guidelines Advisory Committee (DGAC) meetings (http://www.cnpp.usda.gov/DietaryGuidelines.htm) that the DGAC group will be looking to the IOM panel for their recommendations on Vitamin D and Calcium.

Among the charges for the IOM committee from http://www.iom.edu/Activities/Nutrition/DRIVitDCalcium.aspx:

- assess current relevant data and update as appropriate the DRIs for vitamin D and calcium. The review will include consideration of chronic and non-chronic disease indicators. The study will also incorporate, as appropriate, systematic evidence-based reviews of the literature and an assessment of potential indicators of adequacy and of excess intake. Indicators for adequacy and excess will be selected based on the strength and quality of the evidence and the demonstrated public health significance, taking into consideration sources of uncertainty in the evidence.

- Update Dietary Reference Intakes, as appropriate, using a risk assessment approach that includes (i) identification of indicators of adequacy and hazard, (ii) selection of the indicators of adequacy and the critical adverse effect, (iii) intake-response assessment, (iv) dietary intake assessment, and (v) risk characterization.

Thanks,

Hope Warshaw, MMSc, RD, CDE

Nutrition Section Editor, www.PRESENTdiabetes.com

I went to a conference yesterday and participated in a session on Vitamin D. The speaker reinforced everything we've talked about here:  the inability for people in most parts of the US to utilize UV sunlight to manufacture Vitamin D; the need for women after menopause to increase vitamin D intake; the widespread protective role of Vittamin D in many of the body processes. The speaker recommends 1000-2000IU as a standard for everyone and then relies on blood tests if she suspects lower blood levels of vitamin D or for certain diseases, including diabetes. According to her research, 40-65 ng/dL is the optimum range for blood levels of vitamin D.

I was glad we had this discussion before I went to the meeting! In fact, yesterday I talked about vitamin D supplements with three of my clients!