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From the Townsend Letter
December 2007


The Vitamin D Quiz
by John Cannell, MD

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Time for some continuing education and another quiz!

1) Most of the infants born in the northern half of the US are at risk for rickets, especially if they are breast-fed.
A) True
B) False

True. Dr. Joyce Lee, at the University of Michigan, has recently confirmed that both newborn infants and their mothers in Boston are severely vitamin D deficient. Fifty percent of the mothers and 65% of the infants had vitamin D blood levels below 12 ng/ml (30 nmol/L), which is low enough to cause rickets in the infants and osteomalacia (adult rickets) in the mothers. Healthy levels are at least 40 ng/ml.
Lee JM, et al. Vitamin D deficiency in a healthy group of mothers and newborn infants. Clin Pediatr. (Phila). 2007 Jan;46(1):42-4.

Make no mistake, rickets is a serious problem in the US, even in the summer. This disease of the industrial revolution is getting to be a common problem in African-American infants. Ironically, the incidence is higher in infants who consume the Zion of nature's perfect food, breast milk.
Weisberg P, Scanlon KS, Li R, Cogswell ME. Nutritional rickets among children in the United States: review of cases reported between 1986 and 2003. Am J Clin Nutr. 2004 Dec;80(6 Suppl):1697S-705S.
Ziegler EE, et al. Vitamin D deficiency in breastfed infants in Iowa.
Pediatrics. 2006 Aug;118(2):603-10.

It's not just rickets these breast-fed infants must contend with, but seizures and heart failure as well, both of which can be fatal.
Alouf B, Grigalonis M. Incidental finding of vitamin-D deficient rickets in an otherwise healthy infant – a reappraisal of current vitamin-D supplementation guidelines. J Natl Med Assoc. 2005 Aug;97(8):1170-3.
Ashraf A, et al. Prevalence of hypovitaminosis D in early infantile hypocalcemia.
J Pediatr Endocrinol Metab. 2006 Aug;19(8):1025-31.
Balasubramanian S, Shivbalan S, Kumar PS. Hypocalcemia due to vitamin D deficiency in exclusively breastfed infants. Indian
Pediatr. 2006 Mar;43(3):247-51.
Bloom E, et al. Variable presentations of rickets in children in the emergency department.
Pediatr Emerg Care. 2004 Feb;20(2):126-30.
Cramm KJ, Cattaneo RA, Schremmer RD. An infant with tachypnea.
Pediatr Emerg Care. 2006 Nov;22(11):728-31.

It's not just infants who are having seizures and breaking their bones. A 17-year-old New Yorker had a seizure from low blood calcium caused by vitamin D deficiency; the seizures broke the necks of both of his femurs, usually the strongest bones in the body.
Schnadower D, et al. Hypocalcemic seizures and secondary bilateral femoral fractures in an adolescent with primary vitamin D deficiency. Pediatrics. 2006 Nov;118(5):2226-30.

The reason breast-feeding (still the best way to feed an infant) is a risk factor for infantile rickets, seizures, and heart failure is that breast milk, like any milk, is only as nutritious as the mother who produces it. As most mothers are vitamin D deficient – in spite of their consumption of multivitamins and vitamin D fortified cow's milk – breast milk is a poor source of vitamin D. Even mothers who go into the sun will have deficient breast milk in the winter in northern latitudes. However, as Bruce Hollis and Carol Wagner showed several years ago, mothers who take 4,000 IU of vitamin D daily can safely breast-feed their infant without concern their baby will develop any of these medieval diseases.
Hollis BW, Wagner CL. Vitamin D requirements during lactation: high-dose maternal supplementation as therapy to prevent hypovitaminosis D for both the mother and the nursing infant. Am J Clin Nutr. 2004 Dec;80(6 Suppl):1752S-8S.

Furthermore, it is time to shed a tear for mothers, especially African-American mothers, who followed La Leche League's advice to breast-feed their infants without taking vitamin D supplements. These mothers were dedicated enough to breast-feed and concerned enough to bring their child to an emergency room when their child's bone's started to break – only to be unjustly accused of child abuse. "By the rivers of Babylon, there we sat down, yea, we wept, when we remembered Zion."
Bloom E, et al. Variable presentations of rickets in children in the emergency department. Pediatr Emerg Care. 2004 Feb;20(2):126-30.
Paterson CR. Vitamin D deficiency rickets simulating child abuse.
J Pediatr Orthop. 1981;1(4):423-5.

2) If you take a multivitamin and drink three glasses of milk a day, but totally avoid direct sunlight, you will become vitamin D deficient.
A) True
B) False

The answer is false. I know several years ago I said "true," but research steadily goes on. Dr. Turnbull, working with Dr. Kimlin in Australia, showed that UVB light in the shade is strong enough to activate vitamin D production in the skin. Think of UVB as a ping-pong ball. It bounces off lots of things. When you go into the sun – if the sun is high enough in the sky – UVB light comes through the atmosphere and then starts bouncing around. It bounces at you from the ground, buildings, cars, and even the bottom of clouds. Sitting under a shade tree delivered about half as much UVB as sitting in the direct sun. Furthermore, the damaging UVA radiation under direct sun was three times more than under the shade tree. Sitting in the shade in the summer (and the winter in subtropical and tropical latitudes) is a good way to get vitamin D. You even get some in the car, as long as the windows are down.
Turnbull DJ, Parisi AV, Kimlin MG. Vitamin D effective ultraviolet wavelengths due to scattering in shade. J Steroid Biochem Mol Biol. 2005 Sep;96(5):431-6.

3) The US Federal Government recommends you take a rat poison every day.
A) True
B) False

True, but they don't recommend enough. Vitamin D has been used as a rat poison (rodenticide) for years. (

However, as I said three years ago, it's the dose, the dose, the dose. Humans would have to take tens of thousands of standard 1,000 IU vitamin D capsules to risk chance of death from overdosage. With the 50,000 IU capsule, this margin of safety is 50 times lower. Not one person has ever been reported to have died from taking vitamin D supplements, unless they purchased low-quality supplements that had hundreds of thousands times more vitamin D in them than reported on the label. Not one person has ever been reported to have successfully committed suicide with vitamin D. In fact, water is more toxic than vitamin D. Not only are there more deaths – a lot more – from water intoxication than from vitamin D intoxication, water has a lower therapeutic index (the ratio of toxic to therapeutic doses). The words of the father of toxicology, Paracelsus, ring true over the ages, "All things are poison and nothing is without poison, only the dose permits something not to be poisonous."

4) In a recent study, HDL cholesterol (the good cholesterol) was strongly associated with vitamin D blood levels.
A) True
B) False

True. The association was strong (P<.005) among 120 women with polycystic ovarian disease. However, like dozens of other studies, the authors also found a strong inverse correlation between obesity and vitamin D levels – the higher the vitamin D levels, the thinner the patients – and this may explain the association with HDL cholesterol. Unfortunately, the authors did not look further at their data to see if the association with HDL held after correction for body weight.
Hahn S, et al. Low serum 25-hydroxyvitamin D concentrations are associated with insulin resistance and obesity in women with polycystic ovary syndrome. Exp Clin Endocrinol Diabetes. 2006 Nov;114(10):577-83.

5) People can reach 100 years of age without any vitamin D in their blood.
A) True
B) False

True. When researchers went to an Italian nursing home, they found that 99 of 104 residents had no detectable vitamin D in their blood. All the 104 residents were over 98 years old! But the key word is "can." Before you stop your vitamin D so you can live to 98, know that the study said nothing about what the residents' levels were before they came to the nursing home. A recent large study showed good evidence that low levels are not only associated with going into nursing homes, but with dying as well.
Passeri G, et al. Low vitamin D status, high bone turnover, and bone fractures in centenarians. J Clin Endocrinol Metab. 2003 Nov;88(11):5109-15.
Visser M, et al. Low serum concentrations of 25-hydroxyvitamin D in older persons and the risk of nursing home admission.
Am J Clin Nutr. 2006 Sep;84(3):616-22; quiz 671-2.

6) Being in the sun helps protect you from being in the sun.
A) True
B) False

True. Dr. Dixon, at the University of Sydney, working with Professor Rebecca Mason's group, has presented additional evidence that vitamin D metabolites protect the skin from sun damage and do so via rapid acting pathways that do not involve genetic transcription. As anyone who has ever taken 5,000 IU a day for several months can tell you, your skin is much less likely to burn when you are no longer vitamin D-deficient.
Dixon KM, et al. In vivo relevance for photoprotection by the vitamin D rapid response pathway. J Steroid Biochem Mol Biol. 2007 Jan 11; [Epub ahead of print]

7) It looks like vitamin D deficiency is a major cause of Parkinson's disease.
A) True
B) False

True. In an excellent paper, Drs. Harold and Jonathan Newmark (father and son), present the considerable evidence that vitamin D deficiency is one cause, perhaps the major cause, of Parkinson's disease. (Muhammad Ali has this disease, and, in his case, it may have been caused by boxing. However, a lot of boxers never get Parkinson's disease, and most people who have Parkinson's disease never boxed.) Drs. Newmark remark on a 1997 case report in which a patient with Parkinson's disease steadily improved when treated with 4,000 IU daily. However, their recommendation for an interventional study using only 2,000 IU daily in Parkinsonian patients is regrettable. Such a low dose in such a severe disease may tragically miss a treatment effect and would only have to be repeated in the future with physiological amounts of vitamin D. All clinical interventional studies – in any disease – should use enough vitamin D to obtain and then maintain blood levels at levels obtained from natural summertime sun exposure (at least 50 ng/ml). For many people – the aged, African-Americans, and the obese – this requires 5,000 IU daily. If you know Muhammad Ali, or anyone with Parkinson's disease, suggest they start taking 5,000 IU a day. If they or their doctor are concerned about toxicity, have them read the literature. If they can't do that, have the doctor measure their 25(OH)D and calcium levels every four months. Both patient and doctor will soon realize that 5,000 IU is a physiological dose.
Newmark HL, Newmark J. Vitamin D and Parkinson's disease-A hypothesis. Mov Disord. 2007 Jan 17; [Epub ahead of print].

8) There were at least 100 courageous people in Boston in 1919.
A) True
B) False

True. Five controlled human studies were conducted on volunteers in the desperate days of 1919 when 50,000,000 people in the world had just died from influenza. All five attempted to show influenza is transmitted like the common cold, from the sick to the well. It gave me chills to read what the 100 Boston volunteers were willing to risk in the largest study, one published in the Journal of the American Medical Association.
Rosenau, MJ. Experiments to determine mode of spread of influenza. JAMA. 1919;73:311-313.

In the above study, Rosenau and his six colleagues took 100 volunteers, "all of the most susceptible age," none of whom had ever had influenza. That is, "from the most careful histories that we could elicit, they gave no account of a febrile attack of any kind," during the previous year and thus no evidence they would have had immunity to the 1918 virus. The authors took great care to select their influenza donors from patients in a "distinct focus or outbreak of influenza, sometimes an epidemic in a school with 100 cases, from which we would select typical cases, in order to prevent mistakes in diagnosis of influenza." Rosenau went on to say, "A few of the donors were in the first day of the disease. Others were in the second or third day of the disease."

Now, read this to see if you would volunteer for the experiments, knowing the lethality of the 1918 virus.

Then we proceeded to transfer the virus obtained from cases of the disease; that is, we collected the material and mucous secretions of the mouth and nose and bronchi from cases of the disease and transferred this to our volunteers. We always obtained the material in the following way: The patients with fever, in bed, have a large, shallow, tray-like arrangement before him or her, and we washed out one nostril with some sterile salt solution, using perhaps 5 c.c., which is allowed to run into this tray; and that nostril is blown vigorously into the tray. That is repeated with the other nostril. The patient then gargles the solution. Next, we obtain some bronchial mucous through coughing, and then we swab the mucous surface of each nares and also the mucous membranes of the throat.

Then they mixed all this "stuff" together and squirted it into the noses of the volunteers! "None of them took sick in any way." Undaunted, Rosenau reported they conducted another experiment on ten of these brave souls:

The volunteer was led up to the bedside of the patient; he was introduced. He sat down alongside the bed of the patients. They shook hands, and by instructions, he got as close as he conveniently could, and they talked for several minutes. At the end of five minutes, the patient breathed out as hard as he could, while the volunteer, muzzle to muzzle, received this expired breath, and at the same time was breathing in as the patient breathed out. This they repeated five times, and they did it fairly faithfully in almost all instances. After they had done this five times, the patient coughed directly into the face of the volunteer, face to face, five different times. I may say that the volunteers were perfectly splendid about carrying out the technic [sic] of these experiments. They did it with a high idealism. They were inspired with the thought that they might help others. They went through the program in a splendid spirit. After our volunteer had had this sort of contact with the patients, talking and chatting and shaking hands with him for five minutes, and receiving his breath five times, and then his cough directly in his face, he moved to the next patient whom we had selected, and repeated this, and so on, until this volunteer had had that sort of contact with ten different cases of influenza, in different stages of the disease, mostly fresh cases, none of them more than three days old. We will remember that each one of the ten volunteers had that sort of intimate contact with each one of the ten different influenza patients. They were watched carefully for seven days – and none of them took sick in any way.

Rosenau concluded, "We entered the outbreak with a notion that we knew the cause of the disease, and were quite sure we knew how it was transmitted from person-to-person. Perhaps, if we have learned anything, it is that we are not quite sure what we know about the disease."

Can you imagine volunteering for this study, the year after 50,000,000 people died in the world from influenza? Courageous volunteers who knew nothing about the evidence vitamin D protects one from influenza. I wish modern virologists would read these 1919 studies, which are the only ones that ever attempted to show human influenza is transmitted from the sick to the well. If any reader knows of any controlled human study, in any language, of any date, that proves influenza is propagated by an endless series of transmissions from the sick to the well, I invite its citation for my continuing education.

One last note: Marc Sorenson has written a fine book about vitamin D for the general public: Solar Power for Optimal Health. Marc's book is available through

Reprinted with permission from The Vitamin D Newsletter, February 2006.
The Vitamin D Newsletter is a periodic newsletter from the Vitamin D Council, a non-profit trying to end the epidemic of vitamin D deficiency. The Council is a non-profit and relies on donations to publish the newsletter and maintain the website. Please send your tax-deductible contributions to the following address: The Vitamin D Council, 9100 San Gregorio Road, Atascadero, California 93422.


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