Vitamin D, part 2: Shannon's story | Hacker News Reader

Vitamin D, part 2: Shannon's story

devaboone.com

420 pointsusefulcat303 comments

While hypervitaminosis D is a real syndrome, as evidenced by this story, low Vitamin D levels are endemic in temperate and northern latitudes. We did a study several years ago ( Vitamin D Status in an Elective Orthopedic Surgical Population. Foot Ankle Int. 2016 Feb;37(2):186-91. doi: 10.1177/1071100715609054) in Vermont among healthy folks who were going to get surgery and roughly 2/3 had low vitamin D levels (<30ng). Low vitamin D is a significant risk factor for fractures, such as hip fractures in the elderly which is a major cause of mortality. So please don't interpret this story as a reason to avoid any vitamin D supplementation. 1-2000 IU/day has been shown to be safe with long term use, but if you have any questions, you should absolutely talk with your primary care provider. PS - Yes, I am a practicing physician.

It's harder to be too high than too low, especially with enough magnesium and vitamin K2. When high, just lower calcium to the 500-600 mg range and use magnesium to eclipse phosphorus.

The sentiment of nutrition hacking with supplements expressed in the parent comment just seems wrong. Not factually wrong, I'm not able to judge, though it could be--one expert says one thing and the other the opposite. It just seems like a dangerous attitude of over-confidence to think you can mix and match supplements based on numbers from blood results. And who has their blood tested so often they can adjust their supplements weekly or monthly--because you wouldn't want to go too long at the wrong level.

There are so many complex systems in the body, and so many interactions such as vitamin D and calcium, that it just seems risky. Some people are knowledgeable about supplements and interactions, others sound knowledgeable but are just selling the next fad. Not to mention that it all depends on the person's specific metabolism and any conditions they might have (such as the patient in the article).

Or do we even need supplements at all if we just ate well and had an active lifestyle? Speaking as someone who just had yogurt and a banana: "Let thy food be thy medicine and thy medicine be thy food."

>It just seems like a dangerous attitude of over-confidence to think you can mix and match supplements based on numbers from blood results.

unfortunately that seems to be the the only option we have - "Let thy be thy doctor" :) From personal experience - thanks to Epic software i was given the total printout of my visit to a doctor few months back - the doctor somehow completely skipped low RBC and other related counts in my blood results which were clearly showing anemia and actually did match my feelings of overall fatigue, especially setting up quickly upon trying to exercise, restless leg syndrome, etc. After looking at those blood numbers myself, i started B12 (B12 deficiency is one of the reasons for iron deficiency, and i have an underlying condition known to cause B12 deficiency which the doctor was actually aware too - though, nevermind, the doctors could do nothing with that condition too) and iron, and the things improved remarkably, in particular RLS is gone and i can exercise without hitting almost immediately that fatigue ceiling.

>Or do we even need supplements at all if we just ate well and had an active lifestyle? Speaking as someone who just had yogurt and a banana: "Let thy food be thy medicine and thy medicine be thy food."

you're enjoying condition which can be summed up as confirmation bias of a healthy person. It is a really great condition - i've enjoyed it myself for about the first 40 years of my life.

There are 2 tests (a few months apart) needed to calibrate vitamin D dose. One could even go through the Coimbra protocol induction (though they don't have MS) to find the optimal amount for them.

As a Vermonter, I have to ask - does the locale have anything to do with the low Vitamin D levels, any more than most of the rest of the northern United States?

Would 5000 - 10000 IU/day be toxic?

Your body makes its own vitamin D in response to sunlight exposure.

Well, yes. But does the region have significantly less sunlight than others? Or is it just the people in question didn't get nearly as much exposure?

Latitude, local geography and weather will all play a role in how much sunlight you get. If you're living in a valley you can have much shorter days than your latitude would suggest. And if the weather is shitty enough to keep you inside much of the year that will obviously have an impact.

Yes, age and skin color also have a large influence on whether your body can utilize the sunlight you receive.

Yep, there were studies that Somali refugee populations in MN and Sweden have very low vitamin D levels (and associated high rate of children autism)

How does the autism follow?

while we don't know "how", there is growing body of work showing a correlation between low level vitamin D - in particular winter pregnancies in Northern Europe countries correlate with higher rate of autism as well as the mentioned studies of the 2 clusters of Somali refugees.

Not all sunlight exposure works though. It needs to have enough UV-B in it. And that’s dictated by the time of year, the location, and the time of day. In some places, you may only get an hour or so of the right kind of rays.

devboone has previously said that less than 3000 IU per day should be safe, but again this should be determined with the help of a physician, not self-selected. She said she has definitely seen toxicity in some of her patients with doses of over 5000 IU per day.

Thank you very much for the straight answer. I'd prefer not to poison myself via Vitamin D! I worry with COVID-19 other people are going to be overcompensating as well.

The easiest solution is just to be stable at a level of supplementation for a few weeks (even zero), then get a test. They're like $40 for the blood test, and then you can tell if you're in the normal range, high or low.

> seen toxicity in some of her patients with doses of over 5000 IU per day.

I believe she said "per day for years".

Yes, the assumption was that this is a daily supplement, meaning an indefinite period of time.

I'm the physician who wrote the article. And I agree with you. Vitamin D deficiency is a problem because it leads to bone loss (see part 1: https://www.devaboone.com/post/vitamin-d-part-1-back-to-basi...). And Vitamin D supplements can be very helpful for those with a deficiency. The point that I am trying to make is that Vitamin D should not be thought of as a dietary supplement. I am seeing more and more people with high calcium levels from being on high-dose Vitamin D. If you treat Vitamin D like the steroid hormone that it is, you will treat it like a medicine, and not take outrageous doses because someone online suggested it. At least, that's what I'm trying to get across.

How do you feel about vitamin k2 (and magnesium) for lowering the risk of high calcium?

As far as I'm aware it's only B vitamins that aren't toxic in high volumes. I take 1,500ug of B12 (60,000% nrv - B12 has fairly poor adoption) for a nervous system disorder, seems to stops my toes going purple...

I dose a similar amount of B12 as you and likewise see real benefits, but I recently stumbled across some research that claims vitamin B6 and B12 supplemenation show increased incidence of lung cancer in men [1]. I'm wondering if any of the above physicians can comment on this research.

1. https://examine.com/nutrition/vitamin-b-cancer/

">55 mcg/day [B12] was associated with a 98% greater risk" Wow, that is quite a staggering increase! Luckily it was men who smoke; "As for never-smokers, the paper states they “were excluded from the smoking-stratified analysis because of the low number of participants with incident lung cancer in that group.”

It's interesting how woman weren't affected, but I am all too aware of the link between smoking and lung cancer as the two go hand in hand. My father died of lung cancer and we didn't part on the best of terms as he had a bad cough for a over a decade before being diagnosed, I lacked sympathy as it was virtually a given. Seeing patients needing to go outside to smoke (often with an IV attached) as they are dying is something I'll never get my head. I would name it the Darwin ward, but that is probably insensitive... (ASD)

It makes me angry that medics won't even condon, let along recommend smokers switch to vaping due to politics. They could save 100,000's of lives per year in the US alone (480k smokers die per year).

Works well. I've been taking at least 50,000 IU/day for over 2 years and serum calcium is always in range. I add milligrams of K2 MK-4, micrograms MK-7, and 100s of mg of magnesium (now over 1g).

Wow! Why so much, my dude?

Because...

For folks on supplements should you skip a dose when getting a lot of sunlight or does your body know to produce less when not needed?

Even if you're taking vitamin D supplements, you probably won't get the full anti-covid benefits unless you also get at least 15 (and preferably 30) minutes of direct sunlight exposure each day. My understanding is that vitamin D causes your skin to produce nitric oxide, but this nitric oxide doesn't actually get released into the rest of your body unless you get actual sun exposure.

Any sources? I've seen much discussion of vitamin D and COVID, and they all appear to imply that supplements would help.

https://pubmed.ncbi.nlm.nih.gov/24445737/

That isn't a source for vitamin D supplements not having an effect on COVID, that's a source saying that sunlight is needed to produce nitric oxide.

Looking online, I see that there is a hypothesis that nitric oxide has a protective effect against COVID, but I don't see that this hypothesis is any better tested than the hypothesis that vitamin D itself has a protective effect against COVID.

So, sunlight will probably get you the best of both worlds, as it would help either way, but there doesn't seem to be real evidence for nitric oxide vs vitamin D.

Yeah I would describe the evidence for both as circumstantial but fairly compelling, and very low risk. Even given the unknowns and potential risks, getting enough sun exposure is probably the best anti-Covid intervention from a cost-benefit perspective.

> the full anti-covid benefits

The alleged anti-covid benefits.

There's been no causal relation established so far.

> get at least 15 (and preferably 30) minutes of direct sunlight exposure each day

This time is directly proportional to how much skin you expose to the sun. If it's only face & hands you need a lot more than if you're in the swimsuit.

It would be interesting to know what clothing the 15-30 min tip assumes.

Also, sunlight through a window does nothing. You need the UV light.

I wonder if incandescent bulbs were better for us in this one area.

Not a doctor or any profession of relevance but I do use tanning lights. Incandescents produce mostly visible light and very little UVA or UVB for those health concerns. Fluorescents tend to produce more UVB in comparison but still very negligible. Tanning lights generally produce the amount of UVA and UVB needed for vitamin D synthesis although you have to use with caution.

I don't think incandescent bulbs produce any significant UV. The temperature is too low.

No, they don't produce any UV light.

Even if the filament somehow does (I doubt it), it won't make it through the glass of the bulb.

I've had a deficiency diagnosed, I'm worried about the prescribed integrators, since everyone is suggesting daily doses and I'm taking 15000ui/month in a single dose. what's better?

dunno about difference between effect of daily vs monthly dosage, but 15000IU per month is newborn dosage here in Europe for first year, 1 drop per day = 500IU, so I would not worry too much about such low dosage which is insufficient for adult anyway unless you spend lot of time outside exposed to sun

I'm taking 2500IU daily

I'm a ~50somethingish white male experiencing bone loss (via DEXA scan). My two doctors (general and specialist) both said: let's try OTC vitamin D, even though it probably won't do anything because you aren't deficient; if that doesn't do anything we'll provide a prescription for actual vitamin D.

We experimented over two years and OTC VitD didn't help, but my point is, I was confused by two types of Vitamin D: the stuff you can by OTC, and the "real" stuff. How does this compare to the VitD you are referring to?

(I cannot take calcium because I have another disease, and "calcium bolus" is a very real concern for me do to another medication i am on.)

try weightlifting - this is the fastest way to increase bone density

Someone tried 300 IU/kg vitamin D3 and 45 mg vitamin K2 MK-4 (15 mg 3x/day) for bone health. 100 mcg MK-7. Magnesium was increased to 1,200 mg.

Use a tool like CRON-o-meter to check diet. PRAL score. ZMA.

Thank you for writing and sharing this story!

My mother has been plagued many of the same symptoms that your patient had, and she has been searching for a cure for years. All of her blood levels are "within normal ranges", and doctors always dismiss her as being crazy, so she ends up seeking treatment from various "quack" doctors.

It sounds like you are the kind of doctor that is able to analyze the human body holistically and solve underlying problems that other doctors would miss.

How can I find a doctor like you that I can convince my mom to go to?

I don't think it's necessarily a holistic thing... i think it's more that the doctor specializes in this area and most doctors aren't familiar with it.

This is exactly it. I was able to see it because I deal with this every day. I am not more holistic than other doctors; I just know how to look at calcium and Vitamin D levels.

just prescribe sunlight

Difficult in places where there is insufficient sunlight for much of the year!

Basic sunlamps aren't expensive. I grow plants in-doors and suppliment w/ them, the bulbs are ~10-15 bucks and fit in any desk or ceiling lamp.

I have a "happy lamp" by a reading chair in my living room, and sit under it in the mornings while drinking coffee and watching the news. Coffee+Sun perks me up in the morning right quick.

I'm in Edmonton, Canada -- look it up on a map, we're far up there -- and it's basically how I make it through the winters here.

So these are UV bulbs? I know bright light is used to combat SAD, but AFAIK that's not about vitamin D, just the light itself having an effect on mood.

i was mainly joking because I think that most of the times when we peal back the layers of research we see that natural systems have adapted over time for certain reasons. Also there should be further research into how native people in northern climates adapt to low sunlight conditions given their location. Perhaps there are areas of the diet we are overlooking instead of just prescribing vit D as the only fix

Can harmful levels of calcium be present even if Vitamin D levels are measured as within the reference range of 30.0 - 100.0 ng/mL?

This is what happened to Shannon in the story. Her level was 79 ng/ml, but she still had high calcium.

Unlikely with enough vitamin K2 and magnesium, assuming calcium is below the TUL.

Have you come across people that take high levels of vitamin d as well as get plenty of sun, but whose levels are still less than 30? And further, this is happening to both a father and a son?

My doctor told me that abnormally low vitamin D levels can be genetic. Haven't done much research, but looking at my family would agree.

I walk for 30 minutes a day in direct sunlight. If I do this for a year (been 5 months so far) do I not need to worry about vitamin d intake? I am also a healthy young male in my 20’s

It probably depends on how much skin is exposed as well as your genetics.

Getting your vitamin D levels tested is a super simple blood test - you can just ask your doctor and they'll prescribe it.

What latitude?

It depends on your latitude and skin color, mostly, and other factors like how much clothing you wear.

As others have pointed out, it depends on time of year and where you live. Far north, e.g. Canada, the U.K, Scandinavia the sun won't give you any Vitamin D at all for roughly six months of the year.

I’ve been using the DMinder app (not affiliated in any way and it’s totally free) to estimate how much vitamin D I’ve been getting. You input how overcast it is and what percent of your skin is exposed and then it uses your skin tone (input at setup), latitude, altitude, and time of day and it’ll track a rough estimate of how much vitamin D you’ve produced while you’re outside.

There’s also “Quick and Easy Screening for Vitamin D Deficiency in Adults”[1] which has a quick and dirty formula in Table 2 to help assess your risk of deficiency without a blood test.

[1]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4998626/pdf/med...

is exposed amount of skin an input?

Can’t find a citation at the moment, but it also depends on what part of your body is exposed. Just resting your forearm on an open car window won’t do it. You have to expose your torso mid-day IIRC.

https://www.healthline.com/nutrition/vitamin-d-from-sun#time...

Just as a pure speculation (I am not specialized in this area) I find it a little bit odd that forearm is not enough as I find it is the most common area exposed to sun by people at least in the last 100.000 years.

So I am wondering how come in this case selection did not chose those whose forearms can produce a lot of Vitamin D as it was probably the most exposed part to the sun.

Don't forget that many people used to bathe outside for many millenia. But I too would be interested in how clothing through generations have put selective pressures on humans, if any.

What about vitamin K2? Will it help to reduce calcium levels back to normal when taken in parallel with D3?

I'd like to know that, too. I've been taking one of these a day:

https://smile.amazon.com/gp/product/B0716RWHX4/ref=ppx_yo_dt...

So, 1000 IU.

Only if you take K2-MK7. The regular form of K2 will not help much. And you need to take 100mcg of MK7 per 10,000 IU of D. It also helps to build up your potassium levels using potassium citrate or bicarbonate (NEVER potassium chloride) over time. Potassium is critical for cellular mineral transport, and low potassium levels will have an impact on blood calcium.

I know many people on this protocol who have had their blood tested and verified that they have no detectable calcium levels in the blood. And blood testing is key. Anyone on this protocol should be checking their calcium, D, and potassium levels. They should also monitor their blood pressure.

Is it high or low blood pressure they should be looking out for?

Low. But that usually means that you are not properly balancing your potassium and sodium intake.

That's interesting. I've been taking 5000 IU of D daily since COVID. I get barely any sun though. And I noticed noticed my blood pressure went down by 10/10. 110/70 though so I'm happy lol

What's wrong with potassium chloride? I've been using lite salt (50/50 sodium chloride and potassium chloride) in my diet to help make sure I get enough potassium, and your comment has me a little concerned.

Potassium chloride is toxic in higher doses, and not tolerated well by the body. If you are using Lite Salt as salt, you probably aren't taking enough to matter. The various studies for potassium toxicity are done using potassium chloride.

The citrate and bicarbonate forms are much better tolerated, and at much higher doses. I take 3 teaspoons a day of potassium citrate, in water, spread throughout the day (I built up to this over time) because I have a mostly meat and dairy diet. This yields approximately 6 grams of potassium a day. For most people building up to 2 teaspoons a day is sufficient. This much potassium chloride would be dangerous.

The primary symptom of too much of the citrate or bicarbonate forms is diarrhea. Also, the metabolic byproduct of citrate is bicarbonate, which has a far greater effect on body pH than taking bicarbonate itself, as the process increases blood pH rather than that of the intestinal tract.

> Only if you take K2-MK7.

Citation? Do you mean MK4?

I believe both forms have similar effects but MK7 stays active in the body much longer.

MK4 is the common one in lots of things. MK7 is the form found in quantity in nattō which is not commonly consumed outside Japan. It can be supplemented.

Thanks for your article. As another physician (hey - three in a row on hackernews, clearly this is the new place to hang out), it's been interesting following the Vitamin D story, and I enjoyed reading your article. I was always a bit skeptical of the data, but then came across the first cochrane review for it, and was surprised to see a general reduction in all-cause mortality in a general population. But looking it up again [1], the conclusion seems far more couched. Do you have any comments on the Cochrane reviews?

[1] https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD...

I really like the Cochrane reviews, and love that they periodically update areas when there is more recent research. And you are correct, their articles on Vitamin D have become less enthusiastic with time. This makes sense I think, since the initial publications on a topic will all be "positive" - they have to find something new to get published (creating a publication bias). And they do try to account for publication bias, but really the best way to fix it is to have more studies. With Vitamin D getting so much attention, you can get published whether you find a correlation or not, so you have a wider range of studies to look at. I wanted to give a summary of the Cochrane reviews and the largest human trials of Vitamin D in the next blog post.

Not a physician, but still following this story closely. Can I ask you docs to weigh in on the recent results regarding the role of vitamin D in covid-19 outcomes?

This is a correlation. There are lots of conditions that are associated with low Vitamin D. Mortality overall is associated with low Vitamin D. But it doesn't mean that the low Vitamin D caused any of these problems. Having overall poor health leads to Vitamin D deficiency. The increase in mortality is more likely related to your overall health status, not your Vit D status.

Do you know anything about the link between schizophrenia and Vit. d?

Don't expect to find anything beyond a correlation between VitD levels and any serious disease. In any study that such is found, the substitution had no effect.

It most certainly should continue to be thought of as a dietary supplement by current definitions, or you are on an errand to redefine that term (in the USA, at least).

It is the responsibility of physicians to discuss diet and supplementation with patients, and know that food and supplements have potent acute and chronic effects, and these effects may be on par with prescription medications.

Physicians might know. Quacks don’t. If you simply google for vitamin D, you find so many quack websites as the top result. So your idea of keeping it a supplement is a bit questionable, if it is actually medication and is easily dismissed as harmless by quacks.

Thank you for your article. I also had alarming palpitations while on Vitamin D 5000IU, and did not make the connection until months later when I slacked off with taking it and they went away. Started taking them again and the palpitations came back. Went through the full battery of heart tests and everything said I was fine. I posted on here a few months back on another post about Vitamin D, explaining my (admittedly anecdotal) situation, and some commenters seemed not to believe me. Happy to hear that I'm not alone.

Interesting. I had the reverse problem. I had lots of random muscle twitches and fatigue. Got my vitamin d levels tested, and they were extremely low (don't remember the exact number). I'm now on vitamin D and the symptoms went away.

Come to think of it, I've had some weird palpitations the last couple of years that have given me a bit of a scare too. I think I started taking Vitamin D supplements around that time (after I had my levels checked). The palpitations seem to happen on and off, and I've also been on the supplements on and off, but I haven't paid attention to if the times match up. I do know I haven't taken the supplements the past few months and it seems the palpitations haven't occurred in that time. I'll probably take the supplements again in the winter, so I'll need to see if the issue returns, and if so, whether not taking them makes it stop again.

Huh. I'll add some more anec-data to this thread: both my mom and myself have had similar issues.

My folks live in WA near Seattle and, while summers are pretty nice, most of the year is crazy dark and gray, necessitating some Vit D supplementation. My mom was pretty diligent about that and noticed heart palpitation on a few occasions, but no actual heart issues.

I live further north and supplement for the same reasons, and have even gone to the hospital thinking I was having a heart attack -- but all the tests came back fine. Those heart issues were after a long period of supplementation + aggressive workouts. If anything, my heart health was probably better then than most times; doctors attributed the issues to stress.

Sorry to hear that. I hope this helps you, as I know how scary and frustrating that is. How many IUs were you taking? I seem to be fine on <= 1000IU taken periodically, but 5000IU daily was too much for me.

I was taking 2000IU daily.

For more details, I'd usually take it late morning with breakfast. I'm a normal weight (155lbs), exercise, eat healthy, low stress, in my 30s, good blood pressure, don't drink coffee. I'd notice the heart issues usually in the evening. Sometimes they would occur almost daily for a week, and then they'd go away for a couple of weeks. Then I'd experience them again one day, and not for another few days. They would occur for about a few seconds or a minute when I was at rest and not doing anything active. It's hard to describe the feeling but it was kind of like a muscle spasm occurring in what I thought my was heart. Or, like some strange beating/squeezing sensation that would occur once, then again 5 seconds later, then a couple of seconds after, then that was it. Or it might return after a few minutes and happen again.

It was an intense and serious enough feeling that it would make me pause whatever I was doing. It would make me think that one of these times it would be a bit worse, I'd end up collapsing, and that would be the end. I'd usually do a bit of cardio for a few minutes because like I said it only seemed to happen when I was at a resting heart rate.

I should probably get my heart checked because there's a good chance the connection with the vitamin D supplements is just a coincidence. Nonetheless, I'll pay attention to see if there seems to be a relation between the two, because although it's unlikely, stranger things have happened.

Is taking 100mg of chelated magnesium 3-5x a day harmful to by health? I've been taking this for a while now and just found out it can increase calcium to dangerous levels (citation needed). Please advise.

I got this from the doctor:

Magnesium is interesting. A lot of these vitamins and minerals interact, in ways many doctors have forgotten. Magnesium is essential for calcium metabolism, so I often recommend it for anyone who takes calcium. It does help with muscle cramps and many take it for insomnia. Magnesium isn't a miracle drug, any more than Vitamin D, but it is a necessary mineral, and people do really notice improvements with muscle soreness. If cramps are the main issue you have, some people swear by magnesium malate - the malic acid in it may also help with sore muscles.

> I will not give any recommendation without first knowing Vitamin D and calcium levels.

This sounds too risk-averse, and I worry that it scares people off taking Vitamin D at all; yet a low level would be good for most people.

I live in a northern latitude, and Vitamin D deficiency is widespread. What should the public health system recommend? It seems there are two choices:

(a) Regularly test the Vitamin D levels of the entire population, and recommend zero Vitamin D supplements for any individual who has not been tested recently.

(b) Find an average "safe" level that will help most and cause damage in very few.

From a perspective of an individual physician I would see how you might want to cover your risk and go for (a), but thinking about it as a whole population, I would think (b) is the best.

Yeah I think it may be a bit overzealous to say that even people who are not supplementing at all, and even in a population where low Vitamin D is common, should wait until they measure k and Vitamin D (which could be not for a long time).

“first, do no harm” seems to be the thread of this caution though, so not exactly unexpected from a doctor.

My PCP tests my Vitamin D levels annually, and it doesn’t cost me anything; it’s just part of the standard bloodwork. It’s always been fine in the past, but the most recent time I was told it was low and was prescribed Vitamin D.

I’m not a health nut, just someone who has annual physicals. Doesn’t it make more sense to encourage people to spend their time and money on annual checkups and tests, rather than encouraging them to buy supplements they might not need—or, worse, that might harm them? Supplements seem cheap at first, but the costs add up over time.

We should be encouraging people to see doctors, not to make uninformed health decisions that might not be right for them.

Here in the United States there are millions without insurance and they're unlikely to be able to afford a doctor's visit - as those without insurance also tend to be the poorest. To be honest, many probably can't afford dietary supplements either but for those who can then a blanket recommendation would be good for them. Either that or we should push for a public health measure ensuring everyone gets a physical, including bloodwork, every 5 years whether you have insurance or not. We need to start thinking through workable solutions for the bottom 20%.

Yeah, I just don’t see this happening across the whole population. Maybe with an expensive campaign to encourage yearly physicals you will get a certain sector of society; but there are going to be millions who haven’t got insurance, worry they would be wasting a doctor’s time, are scared of the authorities, can’t afford the travel time, and so on.

I believe there is a safe level. In Sweden the government recommends everybody to take 10 micrograms daily, with some groups at 20 micrograms, and this advice is very commonly followed. As far as I understand it that advice does an awful lot more good than it does harm.

You're probably right. Public health is a difficult issue.

Could taking calcitriol also lead to overly high calcium levels?

At least 10.000 IU/day are seemingly not a problem [1]. Old recommendations of only 1.000 IU/day are likely way too low as well [2].

[1] https://www.sciencedirect.com/science/article/abs/pii/S09600...

[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5541280/

The case mentioned in the article was taking 5000 IU/day, and that proved to be too much. I'm not an expert, but 10000 sounds a WHOLE lot.

I started taking 2000 IU/day because I wasn't seeing much of daylight because of the pandemic. I hope that's a safe amount, but it would be nice to get my blood levels checked.

There are a fair number of clinics that will do blood tests for you. This is the first one that came up on DDG: https://www.everlywell.com/products/vitamin-d-test/ $49 but you have to prick your finger for the blood they need.

I have read that vitamin D deficiency can play a role in starting multiple sclerosis. I was years working mostly indoors, not seeing sun much and then one day my eyeballs started flickering and I was diagnosed with multiple sclerosis. Maybe if I monitored vit. D levels and have taken supplements, I could have prevent multiple sclerosis but maybe not. It is not that easy and clear, it seems.

This actually reinforces for me the idea that people need individualized expert advice on this. I know that lay people (and I include myself here) tend to think if x is good for you then more x is even better. So you see vitamins marketed with extreme %s over daily recommended levels. Supplementation really seems it should be last resort.

This reminds me somewhat of how people are so concerned about the health effects of too much salt that they end up getting too little, which is also detrimental.

If you are a lay person, as I am, you can still make judgements symptomatically. If you have good reason to believe you are probably deficient, you can conservatively experiment with taking supplements and see if it helps. If your status improves, adjust doses downward as needed.

Keep a journal. Keep a journal. Keep a journal.

If you can't manage it yourself in that manner, yes, seek testing and so forth.

Don't ever take supplements of any kind for any reason if you don't have reason to believe you in particular actually need the supplement. Period.

Journal is huge.

I also keep a log of every medication and supplement and notes on how it affects me. Doctors like being handed a 2 Page document with everything listed and the results.

I also got diagnosed with a rare condition from this. Doctor saw more to the reactions then I had.

People don't realize it, but journaling doesn't have to be hard. If you are talking to yourself, really brief notes can help jog your memory about "That was the day I had two eggs instead of one and otherwise did everything the same" and you don't necessary need to write down every single morsel of food to let yourself know next week "That was the day I had an extra egg with that meal." You know what your "usual" is. "My usual, but with an extra egg" is something that will mean something to future you next week, even if it means nothing ten years from now.

Journaling as a health management tool doesn't have to be complicated and burdensome. Write down what you feel you will need help remembering in a few days when you are wondering "What truck ran me over this time???" and as you get value out of it, you may feel like writing more because you can see it isn't a waste of time.

Just start, no matter how pathetically.

From the article: "It often takes many months for high Vitamin D levels to drop, and it took six months for Shannon’s level to fall into the 50s."

I don't think a journal will help in these circumstances, the time lapse between cause and effect is just too long. Getting tested is cheap and easy (and here I'm thinking of people who are deficient in vitamin D, if the results are too low then it seems that taking a supplement would be a good idea).

This story in specific is being told by the medical specialist who resolved the issue and I was not really trying to give advice for extreme cases where you should pretty obviously be speaking to a medical specialist.

But I've journaled for years and my experience suggests that if you do it regularly, you do get better at noticing things over longer time frames. So, no, it's not useless to journal in such cases.

As with anything, more education and experience with it will get you better at it and how useful it is to you will depend on a lot of factors.

I asked my doctor about getting my levels checked in regards to vitamins, testosterone, etc. She somewhat rudely brushed it off. Is there a good way to ask about this or should I seek out a specialist on my own?

For the basics like this, you can just buy the test online from any of the test vendors like Ulta, LTAPI, etc.

You might want to find a new doctor. The primary care doctors I've had in my life run blood tests for things like vitamin levels (especially B12 and D) annually.

You can just order bloodwork online with no interaction from a doctor and go to a local lab testing corp to get the blood drawn. This is assuming you're in America.

e.g. privatemdlabs.com (I'm not recommending that site, just giving it as an example, though I have used them in the past and everything worked as expected).

I’m thinking of flagging this since it seems to overweight the risk of high vitamin d vs the more common risk of low vitamin d?

Please don't, unless your expertise is comparable to that of the physician who wrote the article.

It came across to me as a warning that we wouldn’t be so cavalier about any other hormone, so we shouldn’t be with Vitamin D either. In that context it’s fine.

I'm the one who wrote the article. I would actually argue that the risk of low Vitamin D has been overplayed. There are very alarmist articles out there about this epidemic of Vitamin D deficiency - which causes people to go out and buy supplements. But there is very little actual data showing that healthy people should take Vitamin D. This is where you get into the large human trials of Vitamin D supplementation, which I want to get into for part 3.

Thank you for writing these articles. Even more thanks for coming here and participating in the discussion.

Your average HN reader has probably seen enough articles posted here about vitamin D deficiency that we are in fact the perfect audience to read about the dangers of taking too much of it.

Funny question I know but how effective are D supplements at improving low D levels?

As I understand it, very effective. But most of the research that correlates low vitamin D levels with various diseases is from observational studies, so there's always a question of whether a low vitamin D level is the causal problem or if it's more complicated, for example maybe lack of sunlight causes other effects in addition to low vitamin D levels and those other effects are the real problem rather than the low vitamin D levels.

IFAICT, most doctors will still prescribe supplements for low vitamin D though. It certainly doesn't seem to hurt, as long as the levels don't get too high as discussed in this article.

There is a site with some data on supplementation's effect on serum D3 levels. Short version, they are effective. https://www.grassrootshealth.net

I totally agree. Right now I'm actually very vitamin D deficient (10 ng/ml) and on 50,000 IU Rx dosage weekly, and I'm in Arizona! I just don't get enough sunlight and wear sunblock all the time due to being extremely fair and feeling like meat in a frying pan when the sun is on me. Also staying indoors due to Corona! But I wouldn't have guessed Vitamin D deficiency.

I haven't had any bone fracture issues (thankfully) since I'm still young, but low vitamin D levels can also apparently give you brain fogginess and depression, which I'm suffering from.

But it does seem like Vitamin D testing isn't on most normal testing regimes, it was only when I presented with depression that I got tested.

Important news from the future: use shade not sunscreen whenever possible. And, as long as you're not often getting peeling-levels of sunburn, don't fear the sun, or the feeling of the hot sun, so much.

Sun exposure is sufficiently correlated with so many health benefits that it is almost certainly causative for those benefits – especially lower rates of heart disease. Endogenous Vitamin-D production is just one mechanism/signal of the sun's influence, not the full story, so supplementation of Vitamin-D can't reproduce all the sun's benefits.

And, other than preventing sunburns, the health benefits of sunscreen are suspiciously under-proven, and the potential effects of long-term exposure-to/blood-absorption-of their ingredients under-studied. In another decade or two, the current levels of sunscreen use, and recommendation by expert bodies that should know better, will likely be considered a public health failure up there with "use margarine not butter" or "replace fats with sugars" or "masks don't help against respiratory epidemics".

Use shade not sunscreen whenever possible.

I would normally be with you but I burn in just a couple of minutes, and I've unfortunately had some really bad burns in the past (where my skin is still very freckled).

I'm totally with you on shade over sunscreen though, I only put sunscreen on my face, and just try to shade everything else. Sadly my skin hates sunscreen too!

Have you looked into or tried any of the mineral-based sunscreens with zinc oxide or titanium dioxide?

While I agree with many things you said: Unfortunately, any UV light exposure is causing harm not just the exposure leading to sunburn. There is no safe level of tanning. Use the same mental model as with X-Ray exposure.

It's very likely the UV is an essential trigger of the benefits of sun exposure – either through supporting chemical processes like internal Vitamin-D synthesis, or simply providing the right amount of chaotic 'eustress' that exercises, without overwhelming, essential self-repair mechanisms. So, I'd strongly disagree that "any UV light exposure is causing harm".

Instead, there's a dose-response curve, as with almost everything else, and some moderate level of UV exposure is almost certainly net-beneficial.

Further, getting a light natural tan from the sun itself, without ever becoming uncomfortably burned, is probably more indicative of that optimal level of UV exposure than remaining ultra-pale from absolute avoidance of all sun-UV.

This isn't a fair analogy since sunlight has many well documented positive effects. Vitamin D production being obvious, but also many understudied effects like nitric oxide release. It's difficult to fully root out confounding effects, but typically people with more sun exposure live for longer, despite having higher rates of skin cancer.

"There is no safe level of tanning" is misinformation and such confident-but-wrong statements should never be used. It's completely false to state that people shouldn't expose themselves to the sun when it's part of our biology. Overexposure and getting frequent sunburns will add up and increase chances of skin cancer, but to say that no level of sun exposure is safe is wrong.

I wouldn't be surprised if sunscreen is the next BPA: https://www.cnn.com/2019/05/06/health/sunscreen-bloodstream-...

To help support this, keep an eye on a UV tracker. I used to be terrified of the Australian sun, but with a UV tracker I know when it's safe to be outside for hours with no sunscreen, and when the danger levels are extreme.

https://www.arpansa.gov.au/our-services/monitoring/ultraviol...

My understanding is that direct sunlight over a major portion of the body for a full 5-8 minutes around noon can be enough to elevate levels sufficiently. In spreading the exposure in this manner one can avoid burns.

What’s your opinion on K2? K2/D3 ratio and how would age affect the ratio?

> low Vitamin D levels are endemic in temperate and northern latitudes

When this last came up, jusssi commented about the actual counter-intuitive distribution of D deficiency:

> under 20% in Northern Europe, 30-60% in rest of Europe, up to 80% in Middle East.

https://eje.bioscientifica.com/view/journals/eje/180/4/EJE-1...

https://news.ycombinator.com/item?id=23255533

We probably wouldn't even expect it to be a straight correlation with "the higher your latitude, the lower your vitamin D."

Skin color is very tightly coupled with latitude, with melanin concentrations evolved to let in a small window of sunlight that (1) allows enough production of vitamin D and (2) prevents destruction of folic acid.

(A few exceptions can be found in communities that have historically eaten large amounts of fish, such as Inuits, who tend to have skin color slightly darker than "expected" because they are getting more vitamin D from diet, and so the the folic acid side of the fitness function "wins.")

Given that, we shouldn't necessarily expect populations whose ancestors have been at one latitude for hundreds/thousands of years, and who get plenty of out-door time, to necessarily be vitamin D deficient.

What is more likely to contribute to higher vitamin D deficiencies in a population would be (1) immigration/expatriation of people to higher latitudes (even over the course of hundreds or thousands of years) and (2) living indoors more.

Naturally, this may result in a hodge-podge of communities with vitamin D deficiencies, which may not be clearly correlated with latitude (although may still show correlation).

> So please don't interpret this story as a reason to avoid any vitamin D supplementation. 1-2000 IU/day has been shown to be safe with long term use

I'll give you a more regular story. Some time ago I thought I needed to take D3 supplements after being exposed to all this PR pushing it and given that I don't eat food rich in it, rarely get sunlight, don't go outside in daylight (densely populated area, supermarkets work 24/7, etc.). So I bought some and took 2000 IU/day for a few days. Suddenly I started feeling numbness on the tip of my toes. After a bit of research I attributed it to D3, immediately stopped taking it, but numbness went away only after a few weeks. It's hard to see how taking it longer could have been safe.

So please don't generalize that 2000 IU is safe just because something showed that it was for some people in certain circumstances given certain country-specific lifestyle, foods, etc. I don't think a decent study on D3 safety even exists.

No offense, but this sounds like a bad diagnosis on your part. It takes more than a few days for Vitamin D problems to arise. The fact that the numbness took a few weeks to go away after taking Vitamin D for only a couple of days means it was most probably some other thing causing the problem.

It took a few weeks to go away completely, but got noticeably better just after a couple of days. I'm pretty confident in that diagnosis, as nothing else have changed.

Do you recommend vitamin D3 or D2 and why? Please advise.

Explain that: Low vitamin D is also common in Africa!

https://theconversation.com/think-vitamin-d-deficiency-is-no...

Because too much clothes maybe? Western clothing style was introduced by colonization

Thanks for your input. I think a valuable thing that can be added to the conversation is a rough evaluation of how long vitamin D takes to leave the body.

It's easy for us to look at a bottle and control how much we're putting in, the tricky part is managing that we're only putting in enough to compensate for what has been used or lost since the last dosage. If people were given a vague idea of the Vitamin D "burn rate", and what factors might increase or decrease that number, I believe your and Dr. Boone's points may be significantly better received by others.

Before adding supplemental vitamin D, first ensure nutrient sufficiency and that all RDAs are being met (with just food). For example, low magnesium impairs vitamin D conversion and is a more common problem. Further, hGH/IGF-1 also pushes for conversion of vitamin D. Insufficient potassium, insulin resistance, and some other things clip hGH/IGF-1.

In some cases, fixing diet and sleep (ZMA for males) normalizes vitamin D. After other steps are taken, then add some amount of D3 if necessary. It's been said it's better gotten from red light (one of those special lamps/light) on the skin, as the body is able to regulate/limit absorption.

Either way, some supplementation is likely to be needed with age. Response of the skin to sunlight declines over time, especially due to rising cortisol.

After a full workup, the doctors had no explanation, so they resorted to what doctors often reach for when confronted with mystery ailments: psychiatric illness.

Yeah. This is a big problem for people with serious and complicated health issues. They are all too often told "It must be in your head" the subtext being "If it were real, I, a super smart doctor type, would be able to figure it out already." It's ugly stuff and it ruins lives.

Also, the lady was prescribed vitamin D and then took it without adjusting the dosage or having a follow-up about it for 5 years. This is a big problem as well. Doctors all too often don't follow up with patients and this is probably in part because of our issues in the US with how we pay for stuff and so on. But it was also a problem for some things when I was a military wife and could see a doctor for free.

I am a writer by trade and I have a serious medical condition. I'm glad to see this piece and I'm glad to see Deva Boone posting on HN, but I will suggest that statements like "Vitamin D is a medication" don't constitute good communication.

The latter part of the piece makes it clear what is intended by that, but it's not currently classified as a medication and I think it is generally more helpful to try to educate people that "life is chemistry" and there is no clear cut demarcation between "drugs" and "not drugs." Sometimes the difference boils down to dosage.

There are lots of things available in small quantities in food items that are "drugs" if you take a large enough amount in one shot and are "drugs" if prescribed in pill form that are "food" when part of your diet. And we need to get a lot savvier about things like that.

Hopefully, this is taken as helpful feedback and not an ugly attack. It is intended as the former and not the latter.

Thanks! It is very helpful. These are great points. I actually tell my patients that every supplement or vitamin should be thought of as a medication. I had written "should be thought of" in the article and then just switched to "is a medication" to make the sentence simpler. It probably changed the meaning too much. It's been very interesting to read the responses on here, and I appreciate the feedback.

What do you think of the idea that doctors don't follow up on their patients? I have a friend who is a physician that can not practice because of medical reasons, he is now experimenting with a business where he reviews peoples medical dossiers to check whether their doctors have missed anything that could be important.

He's got crazy stories of doctors skimming dossiers because of time constraints. A poignant case he described was where a doctor did not notice his patient was 100kg lighter than the last time she visited. How do you miss you've got only a third of the patient you had before he exclaimed when he told me this story.

When I worked at Aflac, there was a quadruplegic former surgeon who came in like once a week and reviewed records for the really hard things that we, in claims, were having trouble figuring out. Because he was quadruplegic, someone brought him upstairs on the elevator and you had to print your entire claim out and someone turned pages for him. He only read it and made a determination. I got to see it firsthand once when one of my claims went to him.

I run a google group called Health Techies and your physician friend is welcome to join, if he is interested. It doesn't see much activity, but, you know, sometimes you get enough people and conversation breaks out, at long last. Or new people show up, have questions, and then conversation happens. Voila!

Huh. So, it sounds like your friend is essentially trying to be House, MD, but, hopefully without the surly attitude, the Vicodin addiction, and a tendency to nearly kill patients at least 3 times an hour.

I had this until I was treated for an autoimmune condition. I was literally on crutches because my knees hurt so badly, it was excruciating. GP was like "we see your autoimmune markers are up a bit, but we don't see anything else, probably in your mind" . I had never had any issue before and I was an avid hiker. The condition would come and go and last a month or so. I ditched him and went to an autoimmune specialist. Along with a couple of other symptoms he diagnosed me and within two weeks it was all gone and never came back. I was on the medication he gave me hydroxychloriquine for about 3 years and he after weaned me off of it and I haven't had any remissions, and I just eat a restrictive diet and avoid wheat and dairy products and I'm perfectly healthy. It's not "in your head" if you have pain and no extreme external stressors that might be affecting your mind/body connection, seek out someone who knows what they're talking about, GPs are good for diagnosing things that show up easily in standard tests otherwise they might just tell you that you're a hypochondriac.

Hi Deva, what do you think about the Vitamin D Hammer?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4463890/

> A colleague of mine and I have introduced vitamin D at doses that have achieved greater than 100 nmol/L in most of our patients for the past number of years, and we now see very few patients in our clinics with the flu or influenzalike illness. In those patients who do have influenza, we have treated them with the vitamin D hammer, as coined by my colleague. This is a 1-time 50 000 IU dose of vitamin D3 or 10 000 IU 3 times daily for 2 to 3 days. The results are dramatic, with complete resolution of symptoms in 48 to 72 hours. One-time doses of vitamin D at this level have been used safely and have never been shown to be toxic.8 We urgently need a study of this intervention.

I'm not Deva, however this is basically an anecdotal case from one clinic. To garner further scientific consideration, they'd need to expand their idea into an RCT, otherwise there are too many confounding factors and lack of control to say that the hammer is actually effective and that we aren't seeing placebo effects, biases introduced, etc.

Agree. It's nice to say that I did something and the patient had amazing results, but it doesn't mean that my action had anything to do with how they felt. Many people will recover from the flu without any treatment. It might not matter whether you give a vitamin.

One pilot study found that a big Vitamin D dose would cut the hospital length in half for people on ventilators.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4939707/

The control group spent on average 36 days in the hospital, the group getting a single 500,000 IU dose of vitamin D3 spent an average of 18 days in the hospital.

It's interesting data but we need to keep in mind that the demonstrated correlation is between "Vit D deficiency" and "worse COVID ICU outcomes". We don't have much yet (that I'm aware of) on D3 mega-supplementation specifically on those who were not D3 deficient to start with.

The linked study was published in 2016, and has nothing to do with covid-19.

And it also flies in the face of the physician comments at the head of this discussion, where a few doses of 5000-10000iu see harmful effects, this study was of a half million iu over 5 days!

Different people handle different amounts... differently. There are some folks with really low levels. Often they can not absorb the vitamin efficiently, for whatever reason. I suspect that most of that high dose is passed in these folks, so a beneficial amount manages to make it through.

Unless you are very low and facing a serious illness these mega-doses are not needed. Supervision by a physician of these doses makes sense.

Doesn’t the flu usually resolve within a few days without a vitamin D hammer? Did they do a controlled blinded study to determine whether it made a difference?

It sounds like Tamiflu, where you're still sick but for a day or two less than without it.

It depends. It can take from few days to few weeks. Also, there can be serious side effects for life.

I agree, there’s a diversity of possible outcomes. I think case reports of flu recovery after a treatment are of limited value absent a quantitative analysis showing the treatment had some effect.

We really need to change the whole medicine paradigm from checking when something is wrong and trying to fix that to doing comprehensive checks regularly and adjusting the necessary supplementation and preventive treatments upfront. I think more and more people are doing this on their own, but in my experience it's still a small minority and far from being seen as essential.

You can, of course, go to far with this and end up with The Island.

Ultimately the crisis in the movie was triggered by denying someone bacon, which honestly is not that implausible.

I think we need to enable technology so people can do these checks themselves/at home. It seems we are holding back the tech because we are afraid of what people will do with the information.

Some companies are doing this, like Everywell.

Testing is still a pain in the butt and gets pricey the more things you’re measuring.

Tech is cool and all, but this can be done much more simply with just reading a lot and keeping a journal and that sort of the thing.

The real sticking point is the minute you know "too much" about the impact things have on the body and try to engage in discussion, someone will have a cow about how you are "practicing medicine without a license" or something.

The problem is that any exercise of real power will get someone's hackles up, even if that power is just a case of "knowledge is power" and medical/health stuff is a super touchy topic for a long list of reasons.

To be fair, A) medicine is complicated, B) lots of people like to talk out of their asses about stuff they don't really know too much about.

I'm very leery of medical advice coming from a non-medical professional. Heck, I even double check medical advice coming from doctors since I've gotten conflicting diagnoses and been prescribed drugs to take for months only to find out from the manufacture website (not the doctor of pharmacists) that a follow up exam is required after five consecutive days of medication to prevent a potentially disabling side-effect.

This is why I enjoy articles such as this one. It's the closest thing to peer-reviewed advice I'm likely to get. Getting to read multiple physicians discuss this topic in detail provides me with a more complete understanding of the topic at hand.

The reason why it happens is somewhat irrelevant to my point. You feeling the need to justify why people do this actually just reinforces my point.

Tech is a means to an end, but whatever means you use, this issue right here is your single largest speed bump for this end goal and wrapping your goal up in shiny tech will not move that needle one tiny iota. That's just not how this works.

Respectfully, there is a reason why one must have a license to practice medicine. It's simply too easy to kill people inadvertently. I guess that's fine if the unlicensed doctor is the only patient.

But then, I do agree that a license doesn't necessarily guarantee competence. A GP being interested in and keeping track of the latest research on nutrition, longevity, etc, would be worth their weight in platinum.

You have completely and totally missed my point while simultaneously sort of making it for me, which I imagine you will fail to see.

Yes, how do we get beyond that sticking point? There are so many things that need to be loosened up IMO:

- Be able to buy contact lenses without a prescription

- Be able to buy CPAPs without a prescription

- Be able to buy portable ultrasound without a prescription (https://www.butterflynetwork.com/)

- Be able to buy an EKG (yay, this is available: https://store.alivecor.com/)

- Be able to buy a Continuous Glucose Monitor

We need some Best Practices.

When I was homeless and on Metafilter, there was a doctor running around cramming her opinions down everyone's throats and everyone let her get away with it because of the way Metafilter works and one of her hobbies was harassing me, a homeless woman, cuz Reasons. (Edit: I was homeless at the time. I'm not anymore, though I'm still dirt poor and yadda.)

And when I posted the best answer one day using internet best practices of backing it up with citations, this did absolutely nothing to get my reputation out of the toilet, even though it probably saved some guy's life. But I remained chopped liver and I was eventually banned from Metafilter for reasons I think are really not how you run a healthy forum.

Metafilter does not have the man power to vet who there is a doctor or not and if they start vetting people, then you start getting into this weird territory of more or less pseudo practicing medicine on the internet. She was posting under an anonymous handle but also wanting to lean on "I need to win every medical question because I am a doctor with a huge ego and personal issues." It was just all kinds of messed up and the mods were not policing it.

If you want to discuss medical stuff on the internet, you can't lean on "I'm a doctor" and also be anonymous. Anyone who is anonymous can claim to be a doctor and we can't verify that.

So if you are a doctor, you should have no problem backing up your claims with citations. And if you aren't a doctor, but can back up your statements with citations, then no one should be harassing you and claiming you are "practicing medicine without a license" for leaving comments in a discussion on the internet.

It's different if the doctor is putting their name and face to it and staking their professional reputation on it, so this is absolutely not some kind of attack of this blog posts. But the internet does a lot of weird social stuff where we haven't yet figured out that the internet works different from meat space and it doesn't work to borrow rubrics from meat space and so forth. It needs its own rubrics.

Another thing I would like to see is that we should be allowed to err on the side of self determination for purposes of doing things to our own bodies without having to justify it. A lot of people with serious conditions are dying, doctors cannot fix them and then the medical system gatekeeps them away from trying experimental stuff and if you are part of such a community and you have such a condition and you are late stage, it's incredibly horrifying and makes zero logical sense.

So those are two things I have thought a lot about. I don't know what else to suggest. I'm too busy just trying to muddle through my pathetic life in the face of my condition and the poverty it helps foster and yadda.

Wasn't that the promise of Theanos? I am interested in diet and nutrition and what is healthy in general, but there are few things you can measure easily by yourself, blood pressure and heart rate being the ones that I can check myself.

Better tech would be nice to have, but the most important part in my opinion is the paradigm shift itself. Medical institutions do offer comprehensive check-ups for healthy individuals already. It's just that not many healthy individuals actually bother to do this. Better tech would just make it easier to increase the data resolution. Which is important, especially as one ages, but not absolutely necessary for enacting the principle itself.

Currently it seems that preventive care is widely accepted and practiced only in a handful of medicine subfields. Gynecology and dentistry come to mind. But this should apply to health care in general.

People can do vitamin D monitoring at home. See above link to www.grassrootshealth.net. They will sell you 2 test kits for serum D3 for $50 (I think). You take the tests 6 months apart, and they send you the results each time, so you can test the efficacy of whatever you are changing (i.e. sun exposure). I was 39ng at my first test, near mid-range and not deficient, and decided to bump up my sun exposure a bit just in case, and never bothered with the second test. I live in a sunny area, fortunately.

This is great, thank you for sharing!

Part 1: https://www.devaboone.com/post/vitamin-d-part-1-back-to-basi...

HN: https://news.ycombinator.com/item?id=24138590

It's nice to see a real blog post about this from a real doctor. There's so much misinformation and terrible writing about supplements online, thanks for writing this.

I agree about posts from a real doctor, but this is using an anecdotal case as a basis to shift a definition of a vitamin? That seems pretty poor form for someone in the scientific community. We should be shown stats of of likelihood of this happening compared with the opposite, studies, ways it can be safe and not safe (such as with K2, with calcium supplements, etc.)

This was not a refreshing read from my standpoint, just feeding the internet echo-chamber.

This is really interesting. I usually do not use anecdotes, but chose this to make one simple point. The point was not what you got from it, though, which means I failed in my messaging. The point was not to shift a definition (Vitamin D is a steroid hormone, and by definition Vitamin D is NOT in fact a vitamin). The point was that I would like people to think of Vitamin D as a medication, not a dietary supplement. I think when you frame it as a medication, people treat it differently. That was the whole point of the post. In the next post, I will go back to being completely scientific, which is my normal state.

I appreciate the response but I completely disagree (I wrote a larger post elsewhere). The amount of people who OD on medication and die or otherwise is significantly higher than any of those on Vitamins, let alone Vitamin D3. When an average of 50% of the population (study linked in other post), and a very small fraction of a % of those will every run into problems (which they can address through going to a physician if they have problems), I _do_ consider it a "very little downside".

I'm happy to look at data that says otherwise, but from my research I haven't found any.

The problem is that a lot of people taking Vitamin D may not need it. The percentage of the population with vitamin D deficiency depends on your definition of deficiency - and that changes. From large trials in humans, there is very little benefit to most adults in taking Vitamin D. If you are deficient and you are an elderly woman in a nursing home, then yes, we have good evidence that vit D supplementation will help you. If you are a younger healthy male, probably not.

Yeah, definitely. And over 99% of them won't have any problem in doing it. A significant problem is that people don't know that they have conditions or problems in the first place -- and when there is very, very little downside, it would be defined as "optionality" in the terms of Nicholas Taleb, and provides something we can do that will help in most cases, or at least, not harm.

Are you saying that you wouldn't suggest supplementing in young deficient males, who are otherwise healthy, or just that the evidence is unclear on the benefits but it's still probably worth supplementing in that case, under medical supervision?

I wouldn't over index on that comment, I thought your blog post was effective.

Strictly scientific is appreciated, but I don't think it'll land as effectively with the audience that most needs to read this kind of thing in the first place.

Thanks. It's hard to balance the strictly scientific with enough of the "softer" stuff to make it interesting for a wide audience.

I didn't say anything about strictly scientific. I think statistical/study-based + anecdotal is great.

Vitamin D is not actually a vitamin and that is easily googled. You don't have to be a physician to know that.

She is absolutely correct that it is a steroid, not a vitamin. Vitamins are things your body cannot manufacture. Vitamin D is something we can manufacture.

She's apparently new to blogging and medical blogging is hard and I'm sure she will get better at effectively communicating what she wants to say with a little practice.

I agree with you that she shouldn't have stated "It is a medication" and I have stated that elsewhere and she clarified why she chose such phrasing and it's a somewhat minor nitpick because the latter part of the article does make it clear what she is trying to get at.

Thanks! Yes, I am very new to this. Hoping that by continuing to write, I'll get better. The comments on here are great for helping me understand how things are interpreted.

You will and you've actually been really well received. I wouldn't worry about the occasional negative remark. Those are going to happen and other people can often figure out that it's someone being weirdly pendantic or whatever.

Bill Gates has said something about "your unhappiest customers are your best source of learning." I like to view big negative reactions to my writing in that light and help me up my game for future pieces.

There are no soft launches and this is all grist for the mill.

I hadn't actually seen that about Vitamin D, I appreciate you pointing it out.

I wasn't arguing anything about it being a steroid -- but the overall intention of the article is to "be careful", is it not? If you "treat it as medication" (even if you're not saying it is), what's the intention of that communication?

I think the underlying message is that people do not respect the power of supplements -- or even food, really -- because we think of them as fundamentally different from "medication." I think the intent is "These things are, in fact, powerful and need to be taken seriously."

My personal framing is "life is chemistry" and every single thing you put into your mouth impacts your chemistry. Over time, it all makes a difference.

But I'm just a stranger on the internet with a medical condition and, like Rodney Dangerfield, I don't get no respect. (shrug)

It is significantly different than medication -- in death rate, OD rate, way that we modify the body, etc. I agree they have similarities but to treat them with the same level of caution (which feels like the emphasis here) would imply a similar level of risk, and I've seen no data that supports that. If you (or the author) has any, I would love to see it.

I'm not really interested in having some big argument with a stranger on the internet over this. I have already told you that I think you are being overly pedantic and her writing will likely improve and get clearer with practice.

I don't agree with you about food and supplements being less powerful than medication. But it's always a can of worms for me to try to present my point of view on that, in part because my so-called qualifications are "I'm a former homemaker who failed to die after doctors wrote me off for dead" and I have had people who think of themselves as very scientific tell me straight up that "Thirteen years of steady forward progress on your incurable condition is not proof you know anything. Wild coincidence. Stranger things have happened." (And now it's been like nineteen and a half years of "wild coincidence" and my patience for being dismissed over that is at an all time low.)

So while I have no objection whatsoever to talking at length with someone genuinely curious to understand why I think food and supplements are at least as powerful if not more powerful than medication, I have zero reason to believe that's what's going on here and I have zero interest in having some pointless internet fight where you dig your heels and decide I'm stupid and I dig my heels and decide you're a jerk.

I suggest you just set aside your judginess of the defects of this early blog post of hers and give her a little growing room and see where she goes with this and see if future posts by her make more sense to you. There's a pandemic on and we are all cranky and short tempered and so forth and doubling down on a minor point like this isn't going to go anywhere good.

> I'm not really interested in having some big argument with a stranger on the internet over this I'm not either -- but you've questioned something that I care about and have dug into quite a bit. And yes, you don't know me, but I consistently adjust my opinion with more data and engage happily with new information all the time and adjust my viewpoints consistently.

You've used quite a bit of attacking words and presumed I'm some internet troll (again without knowing who I am), by calling me pedantic, assuming I'm going to "dig my heels in", patronizingly telling me to "set aside my judginess" to "give her some growing room". I am excited to see evidence-based research by her as that's what she's talking about.

> So while I have no objection whatsoever to talking at length with someone genuinely curious to understand why I think food and supplements are at least as powerful

I beg to differ, as that's me, and yet you're still showing behavior despite me specifically asking for references to show you otherwise. I linked elsewhere (and can link again) my own.

I don't consider the main point of her article a minor point as you are describing, which is clearly something we disagree on, and yes, we're on short tempers (I'm no exception) but your post feels pretty hypocritical to me.

It's not intended to attack you. I am trying to tell you I know from long experience that someone arguing the way you are arguing is someone who isn't really interested in my point of view. You want studies and even if I come up with studies, it will somehow never be enough because of who I am and why I hold the opinions I hold.

I came back to say "I don't see this discussion going good places." That was intended to be a courtesy to let you know I'm sure your interest is sincere but I'm not someone in a position to "convince" you.

You and I see it differently. I'm not going to pretend that I think you are right. But I'm not someone with any credibility.

I didn't want to just give you the silent treatment. That seemed rude to me, but perhaps would have been wiser.

For reasons unrelated to you and this discussion, I am wishing I had never heard of Hacker News and that fact is probably making it difficult for me to not sound screechy no matter how hard I try today. You will need to excuse me, but I just cannot continue this discussion.

I wish that public health was more highly valued, at least in the US. This is such a great opportunity for research and public education efforts by the government

> "...from a real doctor."

you're arguing from authority. it may make sense to trust the expertise of this doctor in this instance, because of her demonstrated reasonableness and the relevant information she brings to bear, but her status as an authority has little bearing on whether you should believe her or not. her expertise and specialization confer additional, unique data in making her reasoning, but by themselves are no shield from error, bias, fallacy, and just plain lack of perspective.

for the record, i do find her reasoning compelling, but not because she's a real doctor. but as with any single data point, it's premature to go all-in on belief (or denial) and behavior change.

I agree more than disagree.

It's the reasonableness and information in an area filled with tons of pseudo-scientific nonsense that's refreshing, 'real doctor' was a colloquialism, but it's not the authority itself that I find important (though it is a point in favor of the information being likely more accurate).

Having an MD doesn't make you instantly right, but it does mean you have some background/training that a lay person doesn't. It has some bearing on likeliness of claims being true.

Few months ago I head how vitamin D is associated with COVID-19 outcomes and went into a rabbit hole to find more information about wtf is Vitamin D, and how our bodies use it/need it.

There are two videos I found particularly informative.

1. https://www.youtube.com/watch?v=91eDzM0qiJM

Cost/Benefit of Optimal Health with Sunshine Vitamin D

William B. Grant, PhD

2015

2. https://www.youtube.com/watch?v=v3pK0dccQ38

D is for Debacle - The Crucial Story of Vitamin D and Human Health

Ivor Cummins BE(Chem), CEng MIEI

2014

The basic rule of thumb I will now use for vitamin D, as a result of this article, will be the same as any other hormone: to commit to having blood hormone levels tested at least twice, once prior to medication (to confirm necessity and safety) and once after every 6-12 weeks of medication (ramping up through annually, once the dose is calibrated, until treatment ends).

If you don’t test it before, you have no idea whether you’re treating anything or not. If you don’t test it after, you have no idea whether you’re taking too little or too much. If you don’t test it every couple months at first, you won’t be able to calibrate your dosage levels properly.

That’s a lot of blood tests, but the alternative is risking wasting your time and money, or wasting your health, time, and money, on potentially useless or harmful dosages. And if you don’t think it’s worth a blood test, you probably ought not take it.

(I do not currently need to take vitamin D, thanks blood tests!)

It is my understanding that vitamin K2 should be taken with vitamin D in order to mitigate calcium overload. I do not know what the appropriate dosages between the two are, however, and I just pop one with the other every other day.

The consensus seems to be around 20mcg K2 Mk.7 all-trans per 1000 IU of D3.

> The consensus seems to be around 20mcg K2 Mk.7 all-trans per 1000 IU of D3.

Source? My doctor prescribed 45mcg K2 per 1000 IU of D3.

My approach is similar - I take 2-3 1000 IU Vitamin D pills every couple of days, sometimes just one, and a K2 a few times a week. My hope is that staggering it out will help me to have more D than the deficient level without overwhelming my system. Now, at least I know what to worry about...

Vitamin K2 is definitely an essential vitamin for bone health and calcium regulation, but it won't counteract high dose Vitamin D. If you are on so much Vitamin D that your calcium is elevated (meaning, you are at a toxic dose of Vitamin D), Vitamin K2 is not going to help. The best thing to do is actually check your Vitamin D levels if you are planning on staying on high dose Vitamin D.

Any ballmark suggested amount of K2 per 1000 IU of D? The supplement I'm currently taking is 100mcg of D3 with 75mcg of MK7 K2.

1-2 mg MK-4 and 100-200 mcg MK-7 per 10,000 IU..

Just do this under the care and monitoring of a physician. That's really the whole point of the linked article, that Vitamin D has achievable toxicity levels and is fat soluble. Don't mess around and self-medicate. That's true for almost anyone.

It's interesting to note that Vitamin D is in the center of attention due its link with COVID-19:

https://www.researchsquare.com/article/rs-21211/v1

I think the jury's still out on whether the link is causal or correlated, and that study in particular is under controversy.

Personally, I think its just because higher Vitamin D levels mean you generally go out more, which is associated with general fitness levels.

I am leaning towards the opposite conclusion based on three things I have heard.

I have heard vitamin D described as a "modulator for the immune system" (isn't the problem with Covid that your immune system is overreacting?). Also I know that its a factor in Multiple Sclerosis, which is an autoimmune disease. Also things like flu infect / kill more people in winter- when people will be getting less sun, and so have less vitamin D.

Terrible piece. First off, the majority of people with D levels of ~80ng/ml are fine, even quite healthy. Her problem was too much calcium, which is related but they (at least not in the article) don't address what her calcium intake was. Probably she was supplementing that too if the original reason for her supplementation was osteopenia. It's not clear if she would have had any problems if she had just dropped her calcium to low-normal intake. Quite a large fraction of Americans consume too much dairy.

Article that cherry pick a single example are terrible when they pick the example that is 100x less common than the other side of the story. 35-40% of the US has D < 20ng/ml. That's probably 100x greater than the number that have D >= this woman's levels (~80) and probably only 1% of folks who have that level have any kind of medical issue with it the way she did.

I completely disagree with the idea that D should be thought of as a medication in the sense of being careful with it. The problem currently is not enough care to make sure to get enough. 19 organizations (all the big important ones) consider 4000 IU/day of vitamin D to be a safe intake without the need to consult a doctor. The Endocrine Society and a few other orgs consider 10,000 IU/day safe. At the level of 5000 IU/day that she was taking, a very large % of people will remain clinically deficient. Many, many more than will have any kind of adverse issues.

The right dose for society to advocate as a default is not the dose that causes huge amount of harm on the low end only to avoid any kind of harm on the high end at all. That kind of asymmetric health optimization is poor public policy. But it's the way doctors think. Cover my ass and make sure to do no harm. The Hippocratic oath is a terrible way to optimize net health of society and it's unfortunate it has become entrenched in public health, not just the actions of individual doctors.

I thought it was a very helpful article — and it made clear that what happened to this patient will not necessarily happen to everyone. It informed me that vitamin D is a hormone (I did not know that!), and that there are things to monitor if you are taking a bunch of it. I have family members who take calcium and vitamin D, and I will ask them if they monitor these things.

It would be bad if this article pretended this patient's experience was the norm, but it didn't. It provided information about what can happen and advocated for people being more circumspect about a particular vitamin/hormone.

Thanks for the feedback. I will edit the article to specify that she was NOT taking any calcium throughout all of this. This is not uncommon - Vitamin D seems to be more effective at raising calcium levels than calcium itself. I do take issue with your claim that the majority of people with Vitamin D levels of 80 are fine. We actually do not know this. I can't say whether they are fine or not. But I can say that I see enough of them with high calcium levels, who are clearly not fine. They may be in the minority. Still, we do need to treat Vitamin D like a medication. Like any medication, some people will do just fine on high doses. Others will not. That's ok; we just need to be aware of that and watch out for harmful effects.

OK so the thesis of this piece is that you shouldn't give blanket advice about what dosage of vitamins to take. But if you Google it, you would immediately see that taking over 4,000 IU of vitamin D per day for extended periods can be toxic. So in this case the woman would have actually benefited from taking the blanket advice rather than taking the 'personalized' advice from her doctor; had she been taking only 1,000 IU per day, I doubt she would have had this issue.

Unfortunately there are a lot of places online that will recommend 5000 units a day or more. And at the store, one of the standard doses for Vit D is 5000 units. I have this dose in my medicine cabinet. And it's not a completely unreasonable dose. Shannon actually did need 5000 units daily - just not for five years. The problem is that no one knew to reconsider it, or look for elevated calcium.

Yeah and one of those places is definitely HN - I've seen crazy recommendations here when it comes to supplements/nutrition.

I'd guess there will even be some in this thread.

Many countries have higher safe dosage limits for vit D than the US.

Toxicity traces back to hypercalcemia. If serum calcium labs are still normal (helped along with added magnesium and vitamin K2), then there aren't any issues.

Its my understanding that any vitamin that is "Fat Soluble" as Vitamin D is, will have a toxicity level. If you're ever looking up Vitamins, figuring you should supplement or not, look at whether its Fat Soluble, then start looking at what the safe dose is.

Zinc is a very common one for people to overdose on because its super common in Cold Lozenges. For an Adult male, one resource I just googled says daily recommended dose is 15mg, or a safe upper dose of 25mg, but some lozenges will have 15mg in a single lozenge!

I believe zinc overdose (possibly via copper deficiency) happened to me and caused my fatigue problem -- suddenly, about 5 hours after waking up, I would go from awake to overwhelmingly tired in about 10 or 15 minutes, and physically not be able to keep my eyes open. After an hour in bed I would drag myself back out but feel sluggish and useless the rest of the day.

I stopped taking zinc and it got better pretty quickly. I can't prove it but I believe that's what it was.

A bit over decade ago when I started running (& cycling) hardcore I had some knee pain and started taking Glucosamine & Chondroitin supplements for it. It seemed to work, maybe it was placebo effect, but regardless I was "sold" on it. A year or so later I started getting hives all over my body. I was (and am) quite healthy, and coupled with the fact that I'm not really allergic to anything this took me by surprise. It got bad enough that I had allergy panels done, which unfortunately came back with allergies to all sorts of things and the docs put me on anti-allergy medication (Zyrtec, along with stronger Rx only stuff). I was quite discouraged, esp when the docs told me that one can become allergic to anything at any point in one's life, and I was slowly starting to accept it. The Zyrtec seemed to help, not 100%, and I didn't seem to have to take it regularly, so it wasn't the end of the world. Then, at one point I took a 10 day trip and didn't take my supplements with me. The hives went away. Thru the process of elimination I traced it down to the Glucosamine & Chondroitin supplement. It's probably been a decade since I've been back to my normal, non-allergic self. I still take Glucosamine & Chondroitin supplements for a period of time at a time, but am keenly aware of not letting things build up to toxic levels after this lesson learned.

> Glucosamine & Chondroitin supplement

Is it the supplement or one of the fillers? I've seen supplements with ridiculous things like carrageenan (an allergen that causes anaphylaxis in some people).

Def the supplement, it was the Glucosamine.

https://www.mayoclinic.org/drugs-supplements-glucosamine/art...

> In supplement form, glucosamine is harvested from shells of shellfish or made in a lab.

The hives might be a shellfish allergy.

> The hives might be a shellfish allergy.

I considered this too, but never had problems eating shellfish. Tho it's possible that in higher quantities the allergens from shellfish were indeed the cause.

Is there a relatively easy way to check vitamin d levels, or does it require a lab test and doctor's visit?

I live in a cloudy northern climate and tend to assume I have low vitamin d in the winter (and a supplement has a noticeable improvement on my mood), but I would love to actually track my levels and understand how much supplementation I need to say in "normal" levels at different times of year.

Recently there are a lot of "request lab test online" websites; ex. https://www.ultalabtests.com/Shop/Items/Item/Vitamin-D-25-Hy...

Simple blood tests. Low Vit D is associated with migraines, so it’s an easy thing to check for.

Source: me. at one point had horrific daily migraines. Now I don’t.

You can buy tests from various labs in the us and mail them back. They have pinprick needles.

Never checked accuracy but never heard anything to suggest they’re inaccurate, and they’re widely used.

At first my reaction was this must have been a one-off case, usually I see D3 in bottles with 500IU, who is taking 10 vitamins thinking this is right?

But I looked it up and there are 5,000IU capsules being marketed now. That seems like a problem. People are going to naturally expect 1-3 pills of anything are safe. Dangerous design.

FDA does take complaints/reports, I wonder if enough people complained they would pull the high dose pills.

I've talked to multiple nutritionists and they often recommend 5,000IU a day -- we shouldn't be going off gut reaction. There are widespread surveys that show high vitamin D3 deficiency and there are many more stories of people who have taken this vitamin at that dose for years without problems.

The point is, we need more than stories. We need study and analysis, not a random call to change the definition because of a story.

FWIW I take one of those 5000 IU capsules - but I take it every Monday.

Better just to get some sun. Your body will self regulate how much is produced in your skin from the ultraviolet that reaches it. Just don’t stay out so long you get burnt.

Unless you live in a northern hemisphere and have darker skin.

Probably best to ask PCP after getting some blood work.

> Unless you live in a northern hemisphere and have darker skin.

Why is this a problem for darker skinned people living in northern hemisphere? Their bodies dont make enough vitamin D even after exposure to the sun?

Darker complexion mean you need to stay out much longer to get the vitamin D you need. This is why humans lost their natural pigmentation when they migrated to Europe and Asia.

Yes, people with darker skin is at higher risk of vitamin D deficiency in northern territories.

"Vitamin D synthesis is highly dependent on the concentration of melanin in the skin as melanin absorbs and scatters UVR-B, resulting in a less efficient conversion of 7-dehydrocholesterol to previtamin D3[3]. Therefore, dark-skinned individuals will experience slower vitamin D synthesis than light-skinned ones. "

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4067096/

Not really "northern hemisphere", but rather northern (and, at least in theory, southern) enough latitudes. The amount UV-B exposure needed for vitamin D synthesis depends on the season and the latitude, as well as probably cloud cover etc.

Anecdotal article I found about latitude vs. UV-B exposure: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5037520/

I live at ~60° of northern latitude, and AFAIK people around here commonly don't get enough UV-B exposure for sufficient vitamin D synthesis for half of the year or so, so you need to get it either from nutrition or supplements.

Not an option for everyone. Some people ate sensitive to the sun due to medical conditions and/ or medications. Some people work night shift.

Often I pack a sandwich for lunch and bring it with me on a walk in the park; it's an easy way to get some sunlight without having to carve time out of your schedule (presuming most of your lunches aren't scheduled as work meetings...)

If you have darker skin or you’re in a high latitude (or winter) things get trickier.

I went on vacation in Costa Rica, leaving my Vitamin D pills at home, thinking the same thing.

Not true! I had to shell out like $30 to buy imported Vitamin D tablets because I could feel the positive effects of my Vitamin D supplementation wearing off within 4 days.

And I had gotten enough sun to get a serious tan already.

People process sunlight and synthesize Vitamin D at different levels.

Sunlight generation declines with age and skin color.

Could that be in your head? Vitamin D lasts a long time in the body, seems unlikely you'd be able to notice any difference after four days.

Does it have such a short run effect? My impression is sun/supplementation build up circulating blood levels, and then what’s in the blood is converted to an active substance the body can actually use.

For a week long vacation your body would just draw down those stores.

Sorry but there's no way your Vitamin D levels would wear off in 4 days.

Even outside of the fact that this isn't an option for a huge portion of the population, for those that it is possible for, is it better? Aren't there all sorts of harmful associations with sunlight exposure?

I can't find it, but I remember reading a study posted here that said the downsides from sun exposure are outweighed by the upsides of getting enough vitamin D. The reasoning was that the issues caused by vitamin D deficiency aren't visible, while skin cancer from too much sunlight is easy to detect at home, and is rarely fatal if you catch it early.

In the US the five year survival rate of melanoma, the most dangerous sort of skin cancer, is something like 99%. In 2015 only 60k people died from it globally; compare that to the billions of people who got more sunlight than the average software engineer practicing sunlight avoidance and I think it's clear there are better things to worry about (for instance, the misery of spending your life in the dark popping pills instead of getting some fresh air for an hour or so a day.)

First, this is not an argument against posting this post...

This is an excellent post (I've shared it on). It'd be a great service to the HN community to do these as an AMA-type-thing. Deva is on here and is very generous with her time but it'd certainly embiggen the impactyness to have a "Deva will be on from 10AM-12PM PT on 2020-08-24 to answer questions. Not medical advice, etc." and "Deva's out." sticky notes at the top.

[In which I suggest someone else undertake an obligation for the community... Aware of that. It's just lovely to have such a person/resource in the community and it'd be good to set expectations (none/some) around her involvement since people are dropping in questions and (I assume) hoping for (free) advice/counsel.]

I'm sure Deva would be up for it, she does it for some patient groups she works with on Facebook, but I'm not sure if Hacker News is a good place for it? Also speaking as Deva's husband I think the kids and I would like to see her at dinner more, joking (she is a regular attendee at dinner), but you would not believe how much effort and time she puts into researching, thinking about and working on these things (along with everything else she is doing).

I feel like I can't win either way. I had a vitamin D deficiency a few years ago and it led to neurological problems and I thought (based on internet advice, especially HN posts) that I should be taking 5000~ IU a day. I still feel no closer to an answer as to the appropriate amount.

Enough in the AM to get serum 25(OH)D in the 40-60 ng/mL range and to push PTH to the bottom of the range, whichever is greater. Assumes more calcium (or magnesium) than phosphorus and all RDAs being met with food.

Some have varying absorption of and resistance to vitamin D based on genetics. Labs provide a much more usable picture.

Bump to 300-500 IU/kg if you want to try something therapeutic. Cut calcium to 500-600 mg (getting more magnesium than phosphorus; at least 2x as much compared to calcium) if doing so.

Add melatonin and/or ZMA if sleep not as good.

I am not a doctor nor any sort of specialist, but consider that you might not need a daily intake for extended periods of time.

Ask a doctor and do research about taking high dosage on the winter months (when you have less exposition to the sun) and no dosage at all the rest of the year.

This is a great point. Vitamin D deficiency causes problems, and should be treated. 5000 units a day can be great for treating a deficiency - until you are no longer deficient. The answer for you is checking your Vitamin D 25-OH level. If it is still low (under around 30), then you may need the high dose. If it is getting too high (above 60) then you need to back off. There isn't a one-size-fits-all dose for everyone.

Is there a better/quicker way of checking these levels rather than going in for a bloodwork panel? I feel like my natural Vitamin D intake can change really dramatically based on the season. I worry that maybe I'm overdoing it in the warmer months. I typically go in once a year for a physical and that's the only time I ever see these levels.

This is an anecdotal case where it was problematic. You should definitely talk with a nutrionist/doctor to get your levels checked, but please don't assume that just because this story called out a problem (anything in too much can be a problem) that it's the normal story. I can name several more anecdotal cases of people taking 5,000IU a day for many more years than described here with no harmful effects (and much healthier than similar people).

Anecdotal stories shouldn't be counted either way, but I've seen far more studies that show the deficiency of Vitamin D3 than overdose.

Here's some data: https://www.medscape.com/answers/819426-102375/what-is-the-p...

It's very, very rare. It can happen, but this is a gross misrepresentation of data.

One issue I found 3-4 years ago was that some common tests undercount D2 by quite a bit (I forget if it was 20% just for D2 or I think it might have been 20% overall D2+D3 in some test samples). I found this because the test my doctor ordered had a statement about using a different test if supplementing with D2. A number of products (like soy milk) contain some amount of D2 so in some cases low vitamin D might be due to inaccurate testing. I haven't checked if the tests have improved in the last few years.

D2 is the active form in plants. In humans it must be converted to D3.

https://www.healthline.com/nutrition/vitamin-d2-vs-d3#sectio...

Seems factual, but raised my eyebrows a couple times. Comparing Vitamin D to steroids is completely gratuitous. Sure, they're structurally similar, but so are oxygen (O2) and Ozone (O3). Have you ever tried to breathe Ozone instead of Oxygen?

From the previous article:

> Unfortunately, we do not have a full unified explanation for how Vitamin D deficiency could lead to the list of diseases that are associated with it. We know the correlations are there, and we can show that the Vitamin D molecule has an effect on multiple cells and organs.

So if you are deficient (as most adults are), you should take Vitamin D to avoid those. It's irrelevant that we do not know pathways. This probably suffers less confounders than other health issues, because Vitamin D comes from the sun.

But in this article:

> A few readers have made comments like this: “I understand that the evidence for Vitamin D in healthy adults doesn’t really show a benefit, but I take Vitamin D because it probably won’t hurt me, and it might help.” This is a common sentiment regarding supplements, but not a statement that most people would make about metoprolol, or any prescribed medication.

It's hard to see how this sentiment isn't exactly correct, at least if you're deficient. Remember, most people are, so if you don't go outdoors a whole lot, you probably are.

I'm also surprised Vitamin K isn't mentioned. I take Vitamin D, but I've heard the standard advice is to always take Vitamin K in addition, which helps to regulate Calcium and avoid the issues described in this article.

A bit disappointed. Anything has a one in a million chance of killing us. What we know is that vitamin D yes, has a chance of hurting, and also has an orders of magnitude higher chance of helping. I was hoping for more information about how to make the risk trade-off, and what we got is an anecdote.

The general rule is to also take into consideration both magnitude of the potential harm and its probability, in order to avoid a wipe-out (you can't recover your losses if you're broke or dead). But even if we take this into consideration, and take the anecdote in the article as a reference point for a "bad case", it's still in the "no lasting harm" category. And very obviously an outlier, since she showed symptoms while test results were in the green.

If anything, this confirms that as a population we should supplement more on Vit D, and when unable to test Vit D levels, we should still chose in favor of supplementation. If it were otherwise I'd have expected better arguments against it.

I didn't update much after reading this. The upper limit is still pretty common sense: don't use high dose supplementation daily for years without testing. Very likely ok to use in any other scenarios: high doses like 50.000 per flu episode, or 1000 or so daily. Never mix sun and supplementation.

How do vitamin D levels decrease over time if you stop supplementing or stop going outside?

For example, say I'm super active and outdoors every day, my D levels are great. Then I get, say, Covid-19, and I stay inside for a week feeling icky. If I'm not recovered yet, are my D levels still good? Or am I now at higher risk for Covid complications because my D has decreased?

There are all sorts of questions that could be answered by understanding this better. If I am outdoorsy and take a day to work inside on a project, should I supplement that day? What if I am a tech worker who is inside most days but I do 2-3 outdoor activities per week? Am I good? Or should I be supplementing?

If I take a D supplement and 2 hours later take a D test, does it matter? What about when I first wake up and haven't been in the sun for 10 hours?

I have no idea the answer to any of these questions (as a tech worker who supplements, goes outside for hikes/rides 2-3/week, and has a Vitamin D test sitting on my self, wondering when I should take it...)

According to my former GP, vitamin D can fall below recommended levels over the winter months if you haven't stored up enough of it during the summer. So it's a matter of months not days.

As I understand it, vitamin D first goes into the blood. Any excess is then stored in your body fat and in your liver where it can last for months.

So I'm thinking that taking supplements right before a blood test could be a bad idea. But that doesn't mean depletion of stored up vitamin D happens within hours. It definitely does not.

Vitamin D has a half life of about a month. However, your actual ability to maintain vitamin D levels is probably proportional to how fair your skin is, much like absorption.

Chris Masterjohn has an interesting talk called "Resolving the Vitamin D Paradox" where his hypothesis is that vitamin D, A, and K all need to be balanced for proper regulation of vitamin K dependent proteins.

https://www.youtube.com/watch?v=9H7tbWVNrXQ

I've seen comments to the effect of "standing outside on a sunny day in a bathing suit for five minutes is the equivalent of 10,000 IU vitamin D." No idea if that's true, and obviously UV exposure has other risks, but strictly speaking, could vitamin D ever be boosted to harmful levels by UV alone?

I've never heard of such a thing. Surely the UV would burn you first.

Here is the study:

https://pubmed.ncbi.nlm.nih.gov/20363523/

It would take roughly an hour per day of exposure to 25% of the skin in summer midday sun to get 5000IU (depending on skin type and UV index).

The article seems to be conflating correlation with causation.

For reference, 5000 IU is 625% USDA DV. (Curiously, 5000 / 600 = 8.33, but 5000 IU bottles are labeled 625%.)

Of course

5000 IU -> 125mcg.

Usual doses sold on pharmacies: 5mcg to 25mcg. I believe the formulation as 625% makes sense as a weekly dosage or as a short term boost to raise levels.

But no, please, let's create panic because people can't read labels.

https://www.sciencedaily.com/releases/2015/03/150317122458.h....

I use an app called D-Minder to check / control my sun exposure. In the summer months I easily get 5000 IU after a 30 min session in the noon sun, approx 12pm. Anecdotally vitamin-D does help with my auto-immune, because I need to take much less thyroid dosage (25mcg as opposed to 75mcg) to arrive at the same TSH levels.

Higher D levels did make my teeth sensitive so I upped my Calcium and Magnesium levels. I take CCM, calcium citrate malate which is absorbed more easily than calcium carbonate. I also take Vitamin K2 as MK7 and drink Kefir regularly.

I've been taking 5000IU per day for YEARS. I just recently started taking K2 100mcg every other day. I've seen countless family doctors and neurologists over the years with this information, and none of them ever said it was high. I live near Portland, OR where you don't see blue skies from November - March. However I get abundant amounts of sun each day when the sun is out during spring/summer/autumn. Getting tested is not an option right now (covid mitigation), so should I taper back to maybe 5000IU every 3 days?

I think it’s a crazy story. Which doctor on earth would prescribe a 5000 IU vitamin D dosage daily without a specific treatment length? Because the recommended dosage is just 400 IU daily and almost all medical sites warn about high dosage above 4000 IU Vitamin D daily, I think the doctor who prescribed a 5000 IU daily dosage without a specific treatment length was plainly irresponsible or the patient was not followed the doctor's instruction correctly, which is equally bad and irresponsible for one’s health.

Anecdotal datapoint: vitamin D provokes depression for me. Take 5000IU in the morning and an episode is guaranteed in the next evening. Episode consists of pretty bad mood and "inability to think" for the lack of better words. And it builds up of course. After about a month of 10000IU daily I was on a brink of suicide. Unfortunately I did no tests whatsoever. I've had zero psychiatric issues before but I do have a fistful of medical conditions.

Vitamin D has less to do with sun than you think. Low Vitamin D levels are also common in Africa. So don't take Vitamin D just because you think you're not outside long enough:

https://theconversation.com/think-vitamin-d-deficiency-is-no...

The "What’s behind the deficiency" section seems to point to sunlight exposure as a very important part of the equation. In particular: > As we found in the study, urbanisation seems to be a major cause. People are spending more time indoors. In contrast, Africans in rural settings have been reported to have one of the highest levels of vitamin D in the world.

That would be in contrast to the common knowledge that 15 min in the sun are enough for a good Vitamin D level, especially 15 min in the African sun. I simply can't imagine that you can live in Africa without getting enough sun. That would mean that you basically have to stay underground all the time. I believe there is a second factor (often overlooked) that causes low Vitamin D level in the blood: Magnesium deficiency: https://pubmed.ncbi.nlm.nih.gov/30541089/

As your previous link mentioned, not all of Africa is equally sunny. But really the difference is that people with darker skin need to spend more time in the sun to get enough Vitamin D. At least one source says folks with very dark skin need six times as much sunlight as those with very light skin. I've seen 3 hours daily recommended before as well. It's going to be challenging for an urban person at any latitude to get that much sunlight in a typical day.

https://health.usnews.com/wellness/articles/2018-07-18/how-m...

Dai (2018): Magnesium status and supplementation influence vitamin D status and metabolism: results from a randomized trial

https://pubmed.ncbi.nlm.nih.gov/30541089/

"Our findings suggest that optimal magnesium status may be important for optimizing 25(OH)D status. "

Keeping your Vitamin D levels in check becomes even more of a challenge if you're not normocalcemic. In my case, Vitamin D levels always turn out to be almost unmeasurably low when I get bloodwork done. If I then supplement high doses of Vitamin D in response to that, the level rises only slightly, and my Calcium level goes up even more than it already is.

Five years taking 5000 UI daily. This goes on to show that short-term usage is likely a benefit.

For people living in the southern hemisphere, don't feel too smug about all the comments that this only affects people 'in northern latitudes'.

What they mean is 'the northern parts of North America'.

If you're south of the equator by, say, 35-40 degrees or more - similar risks & problems apply.

What’s your opinion on K2 + D3? Bone density against osteoporosis, particularly on the elderly?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5471136/

Yeah I noticed you can buy large doses of vitamin D in the USA. It is quite cost-effective to get the 5000 or 10000 IU capsules and take one a week. In Australia you can't usually get more than 1000 IU in a capsule at the normal pharmacy.

Seems to me that 5000 is just too much, and 400 daily recommended might be low. Seems like between 1000-2000 is a sweat spot.

These articles are fantastic. Thank you for taking the time to educate us with your knowledge and experience!

Raise your hand if you thought this was another one of Claude Shannon's many tangents.

I'd suggest you first test vitamin levels and then take appropriate supplements;

Hopped on the last thread a little late and couldn't get a meaningful discussion about this (Perhaps i'm just completely on the wrong foot):

Are these studies just showing that vitamin D is a good predictor of income (because race is a good predictor of income)? Now that the US is starting to have conversations about racial inequality, every time I see a hackernews or reddit post on vitamin D I am asking myself that question. I have read several studies that link low income to higher mortality rates across several different diseases. [0]

And several other studies that link education levels (which are inherently linked to childhood wealth levels) to worse mortality rates as well.[1]

There is a link between lower vitamin d levels and skin color, with an obvious plausible explanation ( Melanin lowers skins ability to produce vitamin D).[2]

In the U.S. at least there is a strong link between income, education levels, and skin color. [3]

While I am hopeful that ongoing research will help us understand the mechanisms by which vitamin-D operates, I really worry that it is somehow a very well dressed red-herring. One one hand a promised panacea: vitamin d supplements, the other a complex economic and political problem that barely anyone can comprehend or are even willing to engage with.

One of the more damning studies shows that vitamin d supplementation is good enough to remove your deficiency, it has reproduced really poorly on any of the other correlated health effects.[4]

Are there any studies that someone can link that would alleviate my concerns? When these kind of population health studies are conducted (I am in no way familiar with how they are actually done), how are factors like income inequality and education level generally controlled for?

And an interesting article related to Vitamin-D health benefits that had a slightly different take on causes for supposed benefits: https://www.outsideonline.com/2380751/sunscreen-sun-exposure...

[0] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4866586/

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4435622/

[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5946242/

[3] https://journals.plos.org/plosone/article?id=10.1371/journal...

[4] https://www.nejm.org/doi/full/10.1056/NEJMoa1809944

Thanks for commenting. These are all great points. For a while I have thought that Vitamin D just became the latest Vitamin C - are people on here old enough to remember when Vitamin C was a miracle drug that treated and prevented cancer? Fortunately you can expel excess Vitamin C much easier than Vitamin D. In my next post on this I really want to go into the human trials. The evidence for Vitamin D supplementation in the general population is just not there. And yes, darker skin color is a risk for Vitamin D deficiency. And the correlations that you mention are all real, which can partly explain the correlations between low Vitamin D and health problems - and then explain why supplementing doesn't seem to help. It's not the Vitamin D causing an increased mortality - it's everything else that might be associated with low Vitamin D and at the same time associated with mortality.

Deva,

Thanks for your articles (P1 and P2) as well as your posts on HN. I'm happy to hear there will be a Part 3. The topics you describe above will be of interest. I'm a layperson who has read many of the recent papers on D3 and have been supplementing 6k IU D3 with 100mg K2-mk7 (recently increased to 10k D3). My 25-H is 71 ng/mL as of last week (lab 'normal' = 20 - 79 ng/mL). Here are some questions I'd appreciate you considering addressing in Part 3.

* Do you think that some patients (like Shannon) have adverse reactions (and others don't) mostly due to random individual sensitivity or does it seem like there are may be some factors that could serve as indicators? For example, I don't even know if a person's size (kg) 'matters' either in the test result or in absorption.

* I've seen claims that some reasonable UV exposure can A) increase uptake of supplemented D3, or B) Is recommended (if possible) because 'UV-sourced D3' is somehow 'different/better'. Yet I haven't found any published discussion of A or B. I realize the answer is likely both complicated and uncertain, but would love to know if either A or B has been evidenced, is unevidenced but 'seems plausible' or unevidenced and doesn't seem plausible.

To be clear, I'm not asking for personalized advice. Just giving you N=1 context on one reader's questions: I currently have no apparent ill-effects from supplementation. Based in part on your post, I'm now considering dropping back to 5k IU D3 as my goal is really to ensure I'm not D3 deficient (not mega-dose). I started supplementing initially due to diagnosed SAD and more recently went up from 6k to 10k in light of possible CV19 bonus benefit (I'm not at elevated CV risk anyway).

Isn't medical error the number 3 cause of death in the US?

No.

I liked the comment on the page - I will never give up my D

I take 10000 IU but not daily. More like once every other day or basically when I remember (more like the latter, 3 times a week). I don't like being religious about it, so it makes sense to me to get a high dosis when I remember.

Of course I don't recommend doing this way to anyone. Do a serum level test and work from there.

From the other comments here it sounds like that's pretty high. If you're worried enough about it to take that much, maybe you should get yourself a blood test done to find out what your levels are like?

I already took a test and my levels were very low. That's when I started supplementing. Taking another test soon to check levels again.

Sounds like you have a good sane approach. Hope you do well.

Get a blood test for serum levels every once in a while, I take 5k in a similar way and found my levels to be at the top of the normal range which led to me being more conscious about doing it less often.

Thanks. That's a good call. I did a test and they were pretty low. That's when I started taking it.

My doctor said that it was fine to take it that way as long as I keep it on a non-daily basis.

I'm taking another serum test soon to see what are the levels and re-adjust as needed.

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