http://secondopinion-tv.org/transcript/vitamin-d-transcript
Panel discussion was May 2010 – may have video at PBS after Sept 2010
Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association, an association of independent, locally operated and community-based Blue Cross and Blue Shield plans, supporting solutions that make quality, affordable health care available to all Americans.
Peter Welcome to Second Opinion, where each week you get to see first hand how some of the country’s leading health care professionals tackle health issues that are important to you. Each week our studio guests are put on the spot with medical cases based on real live experiences. By the end of this program, you’re going to learn the outcome of this week’s case, and we hope you’ll be better able to take charge of your own health care.
I’m your host, Dr. Peter Salgo and today, our panel includes Second Opinion
primary care physician, Dr. Lisa Harris from the University of Rochester Medical Center,
our special guests,
Jackie Dipzinski,
Dr. Reinhold Vieth from the University of Toronto,
author Dr. Eric Madrid, and
Dr. David Bushinsky from the University of Rochester Medical Center.
Welcome to you all. Right now, it’s time to get to work.
Here’s our case. We’re going to be talking about Gretchen. Gretchen is 64 years young; she and her husband live in Seattle. We meet Gretchen in the hospital. She’s just had surgery to repair a hip fracture. She tripped over a throw rug in her home. How common is Gretchen’s problem?
Dr. Harris Certainly for people over age 50 we’re seeing many more hip fractures and femur fractures and things like that, that require surgical repair and hospitalization. It’s becoming much more common.
Peter Well, she had it repaired. This was a good hospital and they did a bunch of lab work, took a good history on her and did some blood counts, lab tests including a full physical, and a bone density test. Who wants to know some of these results? Anything you’d like to know?
Dr. Bushinsky The bone density.
Peter Ah, well the bone density was low, I can tell you that.
Dr. Madrid
What was her vitamin D level?
Peter Her vitamin D level, funny you should ask, was 13. Is that high or low?
Dr. Madrid That’s very low.
Peter What should it be?
Dr. Madrid 32 or more.
Dr. Harris What was her calcium?
Peter It was 9.0. I’m assuming that’s not the ionized calcium, it’s the total.
Dr. Bushinsky And the last thing is her parathyroid hormone level.
Peter Her parathyroid hormone level – you keep asking for the good stuff – 310.
Dr. Bushinsky So that’s high.
Peter I’ve got some other numbers for you, so let me fill you in on some of these things; her BUN was 25, creatinine 1.1 – that’s her kidney functions. Her thyroid stimulating hormone was 0.09, her phosphorus was high at 8, her albumen was low, her CRP, c-reactive protein – measure of inflammation – that was high. Her BMI was 28 and we already know that her vitamin D level was very low.
All right, Lisa, everybody else here, chime in; what’s going on?
Dr. Harris Well, this is a lady who has tripped and fallen and has a broken bone and we’re looking at underlying causes for why a 64-year old who otherwise seems to be healthy would have a break in a major bone. So we look at what other parts of her body that have to do with bone metabolism, and we’ve already talked about vitamin D and calcium, and the PTH – those things have to do with our bone health.
Peter Let me stop you; the PTH is parathyroid hormone. What does that have to do with bones?
Dr. Bushinsky This all fits together with a woman whose vitamin D depleted and to keep her serum calcium up her body is secreting parathyroid hormone which tries to raise her vitamin D level and get calcium out of bone – perhaps accounting for why her bones are so thin.
Peter Let me see if I can put the dominoes together. The vitamin D is too low.
Dr. Bushinsky It’s much too low.
Peter It’s one of those vitamins that helps with calcium and metabolism and you need vitamin D for normal calcium levels. Failing that, the parathyroids go to work and they try to find calcium where they can, and that’s your bones. You’ve been sitting here, Jackie, like the voice of our conscious-
Jackie Yes.
Peter You’ve got some personal experience here. Tell me your story a little bit.
Jackie Well, I’ll take you back quite a ways because in 1998 I was diagnosed with fibromyalgia, yet didn’t have classical symptoms of fibromyalgia. Really through some prodding from myself, we said ‘No, it’s not fibromyalgia.’
Peter What was bothering you? Okay, so somebody must’ve said you have fibromyalgia because you complained of something. What was that?
Jackie Correct. I was having a lot of muscle and bone pain and fatigue, and it was just – the fatigue was probably the biggest piece; I was even having some sleep issues. Then in 2003, I had a very large kidney stone at that point. We really didn’t even look at all of the lab levels at that point, but still was having the same symptoms. I was very fortunate to have my physician who was working with me with my kidney stones to start to look at other avenues as to what was causing some of these other issues. She and I just kept looking at what is the big picture.
We finally did in 2007, we just kept noticing the calcium levels kept rising, my parathyroid levels were rising along with the calcium levels and we did a vitamin D level at that point, which was 13. It took about 6 months of me being on vitamin D to bring my levels back.
Peter I want to get to that in a minute. I just want to editorialize for a moment; you carried the diagnosis of fibromyalgia but that’s not what you had.
Jackie No I did not. It was very frustrating for me as a patient because the whole process was give her this medication to take care of the fibromyalgia, which wasn’t working, so I felt like we were going around in circles around something that was underlying.
Peter They were treating something you didn’t have; no wonder it didn’t work.
Dr. Bushinsky You are such a classic case of someone with osteomylasia and you said the key words: muscle pain and weakness, bone pain. I suspect there are a lot of other people out there, sitting there with diagnoses of things like muscle weakness, fibromyalgia, chronic fatigue syndrome, who are simply vitamin D deficient.
Peter How common is vitamin D deficiency? Is she that abnormal?
Dr. Madrid No, actually that’s quite common. In my practice down in southern California, about 80 percent of our patients are vitamin D deficient.
Peter Now, vitamin D is often called the ‘sunshine vitamin’. He’s from southern California, right? 80 percent of his patients are low; what’s going on?
Dr. Vieth I tend to tend to disagree with your number, actually, for the 25-hydroxy D if 30 is a magic normal number; it’s a very gray area. It’s as if you’re turning a dimmer switch on the light – when is it dark in the room? Nobody knows exactly. It’s a complicated issue; it’s not straight forward. It does indicate the person should be taking a vitamin D supplement.
Peter Is sun the only source for vitamin D that we can point to?
Dr. Vieth It’s 80 percent of the source; the other 20 percent is what you eat. But normally through your food you’re not going to get more than a few hundred units of vitamin D.
Peter It’s not enough.
Dr. Vieth The average American probably consumes about 200 to 400 units per day. 100 units will raise your 25-hydroxy D by about one nanogram per milliliter. You were talking 30 was deficient.
Peter Well, here’s another phrase we haven’t heard; the 25-hydroxy D. What the heck is that?
Dr. Vieth If you get sunshine or take a vitamin D pill, what your liver automatically does within a day or two, it turns that vitamin D into 25-hydroxy D, which is the blood test.
Peter And people put vitamin D – the government actually allowed them to put vitamin D into orange juice, milk, right?
Dr. Bushinsky Yes, but that’s a small amount of vitamin D. You have to drink a quart of milk to get 400 international units of vitamin D and that’s certainly not enough.
Dr. Madrid Also, going back to the orange juice, they’re primarily fortified to prevent rickets.
Peter And that’s not the same, really, as what’s happening with Gretchen?
Dr. Madrid No.
Peter But that’s something you want to prevent and you can do that by supplementing it with vitamin D.
Dr. Madrid Right.
Dr. Vieth They’re part of the same spectrum – osteoporosis, rickets, eventually you don’t have enough calcium in your bones.
Dr. Bushinsky Right. So it’s rickets in children and osteomylasia in adults and it’s a spectrum of the disease, but the whole problem is there is inadequate vitamin D. The reason we ask about the parathyroid hormone, if that’s really elevated that’s biologically telling you the body isn’t seeing enough vitamin D.
Peter So it’s a marker?
Dr. Bushinsky It’s a marker for vitamin D deficiency. So we can argue about what the proper level is, but if the parathyroid hormone level is elevated, it clearly tells us there’s inadequate vitamin D, unless the patient has a primary abnormality.
Dr. Madrid Traditionally, vitamin D deficiency was associated with rickets; since we do not see rickets anymore, most clinicians assume that vitamin D deficiency has been absent. In the last few years, doctors have been ordering more vitamin D tests; we now realize that more people are vitamin D deficient than we realized. There’s been association – people with low levels of vitamin D have higher risk for breast cancer, colon cancer, prostate cancer, heart attacks, strokes…
Peter Is this well established or is this the kind of stuff we hear for all the health food out there? ‘Oh I’ve got a couple of patients and they didn’t have enough vitamin D’.
Dr. Madrid No, there are research studies done by UC-San Diego, Boston University, a lot of leading institutions are putting out articles on this information.
Peter So he’s telling me that vitamin –
Dr. Vieth Well, what I don’t like about the media is ‘Studies say’ – and everything basically with respect to what we’re mentioning beyond bone disease is associational; it’s like doing a survey. People who have lower vitamin D levels may in some cases have disease. It does not mean by taking vitamin D or anything of that nature, you’re going to truly make a difference.
Peter We’re talking about epidemiology, which is studying populations and associating with the lack of or presence of some factor. There’s a very strong history in medicine of the relevance of that kind of study. The Framingham study looked at cholesterol and heart disease; nobody’s really disputing that. What bothers you about what he said?
Dr. Vieth I think it creates false hope associations. The first thing nowadays - Is people go to lot of vitamin D meetings – prostate cancer, why is it higher in people who have higher vitamin D blood levels? Pancreatic cancer, why is it higher in people who have higher vitamin D blood levels? It is not a simple issue.
Peter Do you need to know why to know that it does?
Dr. Bushinsky So an association causes you to generate a hypothesis, which then you can test with a real study – double blind, placebo controlled study – and so the first step is in association. That tells you this is an interesting relationship; maybe it’s true, maybe it’s not. So you have to do a study, give one group a lot of vitamin D, give another group no vitamin D and see what happens.
Peter I want to move on, but I really want to nail this just briefly. It’s one thing to do bench research, clinical research and set it all up and wait 20 years and get results. There’s nothing wrong with what he’s saying; we’ve seen this association, this is really interesting. I’m assuming that’s what you’re saying.
Dr. Madrid Can I give another example? There’s no double-blind, placebo controlled study that shows that cigarettes cause lung cancer; however, there’s not a doctor out there that would tell a patient to continue to smoke because of (LACK OF) epidemiological datA. Again, to purposely not treat somebody who is vitamin D deficient – we know they’re at risk for osteoporosis – to see whether or not they’re going to have a heart attack or a stroke if we withhold medicine, perhaps is unethical to do double-blind placebo studies on vitamin D deficiency.
Peter Let me get back to Gretchen. Gretchen had a bone issue and that – you don’t want me to go there.
Dr. Vieth No, the first thing that she’s got if your vitamin D blood level is going down, what’s the first thing you’re going to see? A myopathy – like the classic thing, like she fell down. If she didn’t fall down, she wouldn’t have been in the hospital. As the vitamin D goes down, your muscle function deteriorates.
Dr. Harris That’s where I think your range of vitamin D comes into play. I don’t think you can say, because her level is 30, she’s necessarily going to have myopathy. She tripped – we’re not sure if she has –
Dr. Vieth That’s just above the cut-off.
Dr. Harris Right, but we’re talking about a range. We don’t have the data yet to say we’re talking about a hard and fast bench research to say that ‘Because your level is 12, you’re going to have myopathy and because you don’t have myopathy, that you don’t have a clinical disease that needs to be treated.’
Peter Okay, let me put a button on this. We can implicate the vitamin D deficiency, which she has by laboratory, on bone disease which might have caused an otherwise trivial fall to lead to a fracture. We may be able to implicate vitamin D deficiency with her fall and myopathy – what about other neurological issues? Isn’t vitamin D and calcium involved with your mental status and your ability to maintain your balance?
Dr. Bushinsky Sure. People who are vitamin D deficient do have muscle weakness, are much more prone to fall, and in this case, repleting vitamin D has been shown to agree to people who are a little more stable, who don’t fall as frequently and might not have tripped on the rug. And certainly if they tripped on the rug, if their bones were a little stronger, might not have broken a bone.
Peter Kind of a lose-lose.
Dr. Bushinsky Right.
Peter I’m looking at your skin. Your fair skinned –
Jackie I’m very fair skinned.
Peter Do you stay out of the sun? Do you burn?
Jackie I do. As a matter of fact, I had a small mole removed off my back that was changing and they basically told me ‘You’re not going to go out in the sun without sunscreen from this point forward because you’ve already had one potential pre-cancerous lesion removed.’ So I was the type of person who did not go outside without sunscreen on – and we’re talking a 50 or higher.
Peter How much sunlight do you need to make enough vitamin D so you don’t wind up with thinning bones and osteoporosis, osteomylasia?
Dr. Madrid About 15 to 20 minutes of your face, arms, and legs exposed between 10 am and 2 pm when the sun is highest in the horizon.
Peter In a latitude where it’s going to work at all.
Dr. Vieth There’s an easy rule of thumb – your shadow has to be shorter than you are tall. The UV index has to be higher than three, so for half the year in much of the continent we cannot do it.
Dr. Bushinsky I would also argue that we probably shouldn’t do it because there’s 1.5 million cases of skin cancer, probably induced by sun every year, and 8,000 people die of metastatic melanoma
Dr. Harris Versus how many people have hip fractures with hospitalization?
Peter And potential lethal consequences.
Dr. Bushinsky So what I’m saying is I would like people to replete their vitamin D with tablets.
Dr. Harris I’d like people to stop the madness and do everything in balance; that means eat healthy, have exercise, and moderate sun exposure.
Dr. Madrid There are a lot of other health benefits to being in the sun, including mental health wellness and depression, the ability of the sunlight to help people with seasonal affective disorder, so I think that definitely moderation what Lisa said, but we don’t want people to go out and sunbathe for two hours a day.
Peter Do you think that we – and this excludes the doctors in ‘we’ – have we been pushing our own agendas too hard? Don’t eat cholesterol, don’t eat eggs, that milk which has vitamin D, stay away from that; it’s bad for your heart. Slather on the sun block, stay out of the sun, that’s bad – and we’ve inadvertently induced something else.
Dr. Bushinsky Everything in medicine has some risk and a benefit. And it’s absolutely important to have good levels of vitamin D, and we have two ways to do it. One is to go out in the sun and our dermatology colleagues will say there is no safe exposure to the sun; if you’re going to go out, use sun block. Or you can take it for pennies a day in tablet form.
Dr. Harris I just want to throw out a caveat in there; we know the risk for vitamin D deficiency is highest for dark-skinned individuals who are not developing skin cancer and melanoma. We have to throw some balance in here. I think if you go outside and put your sun block on when you go outside, you’re still getting enough exposure but you’re not risking melanoma.
Peter You know, my mother used to tell me nothing is 100 percent safe. She would agree with you, Lisa, things in balance at all times. Okay, we’re going to stop for a moment and summarize some of the things we’ve been discussing so far.
Vitamin D regulates cells, systems, and organs in your body. Your body makes vitamin D when exposed to the sun. You can also get it from foods, and you can also get it from supplements. Changes in our lifestyle and our behaviors have caused many people to become vitamin D deficient and this is a problem for some people.
Let me get back to work over here, because we’re talking about Gretchen. She had a hip fracture, as you recall, after a fall. We’ve established that she is vitamin D deficient, and Jackie is joining us over here – thank you again – sharing her story about being vitamin D deficient as well.
Now, Gretchen went to a rehab center afterwards to gain some strength and learn how to walk with her new hip and she’s ready to go home. She’s going to have in-home care for several months. What are you going to do now to prevent her from getting another fracture?
Dr. Vieth Just to understand what’s going on, can you give me a number for her bone density?
Peter Yeah, I actually have that because before sending her out, they put it in the chart. Her Z (?) score is -2.5. What the heck does that mean?
Dr. Vieth That is the decision point from which you say ‘Yes, we have a clinical diagnosis of osteoporosis.’ And at that point, you’re compelled to do a treatment with a drug.
Peter So she has osteoporosis based on that score?
Dr. Vieth Yes, the decision level is 2.5; a score of -2.5 is low bone density to the point where you really have to do something.
Peter What do you want to do?
Dr. Vieth Well, the primary thing is to give a medication; typically it would be a bisphosphonate type of medication, but the thing that – and patients often forget it. The underlying thing for every osteoporosis treatment is to make sure you’ve got enough calcium and enough vitamin D because none of the clinical trials that show these drugs work works without either of them.
Peter So the calcium and vitamin D are clearly, regardless of what her D (?) score was, a woman like this with a low vitamin D level and probably if she’s a typical American, probably an inadequate calcium intake, probably needs to specifically be told vitamin D and calcium.
Dr. Madrid And weight-bearing exercise too. We seem to always forget about that. The more sedentary we are, the less we use our muscles and bones and the weaker our bones become.
Dr. Harris That’s right.
Peter What did your doctor do? What did she tell you when she told you the vitamin D level was low?
Jackie We began the vitamin D but we also did a bone density test as well. I did have thinning in the bones of both hips at 42 years old, so we began the vitamin D and calcium and we’re in a wait-and-see to redo the bone density and see where I’m at in a few more years.
Dr. Madrid This is a great example; now is the time to start acting so she does not become Gretchen with a broken hip 25 years from now.
Dr. Vieth Absolutely.
Dr. Madrid This is when we need to start treating the patients – in their 20s, 30s and 40s – so that her bone density will be increased. We would encourage you to do more weight-bearing exercise and everything in between.
Peter I want to focus on something you mentioned early on that we have to get back to. You were symptomatic and it wasn’t just that your bone fractured as with Gretchen; you were losing sleep, you had muscle pain and joint pain if I remember correctly –
Jackie Yes.
Peter And you started taking calcium and vitamin D, correct?
Jackie Yes.
Peter How did that make you feel?
Jackie Initially it made me feel really awful. I had a lot of bone pain starting in the long bones of my body, going to the smaller bones as it came to the end. What happened was about three or four weeks into taking the medication – I shouldn’t say ‘medication’, the vitamin D – I had just a huge surge, up curve on my fatigue. I seemed to have this energy level that I hadn’t had in a very long time and the muscle and bone pain was gone.
Peter Do you guys describe her initial, terrible symptoms followed by this wonderful, almost magical relief of symptoms, all of that to vitamin D and calcium? Does that make sense to you?
Dr. Madrid I’ve seen this plenty of times where people are diagnosed with fibromyalgia – again, this is a diagnosis of exclusion; we have to rule out osteomylasia as being the cause of her pain – she’s a great example of how, by supplementing with adequate vitamin D, she was able to start strengthening her bones.
Dr. Bushinsky
This is not that unusual. Often people come in with some muscle pain and some bone pain and it gets better with vitamin D.
Dr. Harris Unfortunately, we don’t have the evidence-based medicine that we’d like to have to say that this is true, but there is certainly the anecdotal evidence. We see it all the time, that patients have a little bit of muscle pain, fatigue, decreased exercise tolerance, things like that. you check the vitamin D level, it’s low, you get them a supplement and they do have that surge of energy. I liken this it to when we were looking at diabetes. People were coming in with fatigue and didn’t know what it was, and they had impaired glucose tolerance. When you got them on the proper diet that went away.
Peter But you know where we’re going with this, right? If a little vitamin D and calcium is good, then the next thing we’re going to hear is a lot is even better. How much is too much? Can you overdose on vitamin D?
Dr. Madrid Absolutely you can. That’s why it’s important to check blood levels and make sure you don’t go into a toxic range.
Peter What happens if you get toxic?
Dr. Vieth In the worst case, it’s not different than if you get gastroenteritis. You’ll be dehydrated, you’ll have polyuria, you’ll just –
Peter Frankly, it’s too much urination.
Dr. Vieth Yes, you’ll dry up.
Dr. Bushinsky Yes, you’ve absorbed too much calcium and have a calcium overload.
Dr. Vieth You don’t have to do that if you hit the dose right. A biologically normal dose is around 4,000 units per day, and then when you start talking tens of thousands it’s foolish; there’s no evidence for that.’
Dr. Bushinsky But there’s no evidence that 4,000 is the magic number.
Dr. Vieth It’s biologically normal.
Dr. Bushinsky Not for everybody. That certainly, if we supplement people with 1,000 or 1,500 units, we often get their vitamin D levels into the high 30’s or low 40’s, which I think all of us are reasonably comfortable with.
Peter Let’s pause for a minute and see where we are so far. We are continuing to learn more about the impact of vitamin D in health and disease prevention. Working with your doctor abased on your individual health concerns related to vitamin D levels is the key. Gretchen, I can tell you, was put on about 50,000 units once a week. Her levels of calcium are increasing and vitamin D is increasing.
At this point, Jackie, you’ve been on treatment for a while; how are you feeling right now, today?
Jackie I feel really good. I just maintain the vitamin D every day.
Peter Compared to where you started to where you are right now, how much better do you feel?
Jackie At least 80 percent better.
Peter So you have a way to go but you’re getting there.
Dr. Bushinsky There’s no question with that low level of vitamin D that you were vitamin D deficient.
Peter You know, it’s interesting that this case is not clean; there’s calcium involved, vitamin D involved, parathyroid –
Dr. Harris That’s primary care; that’s what we do every day. We balance the heart, the lungs, the kidneys, everything. That’s why we keep talking about how balance is so important.
Peter And at the end of the day, the real question is, are you feeling better?
Jackie Yes.
Peter That’s great. Thank you so much for being here. Thank all of you for being here as well. We are, unfortunately, out of time but you can continue this conversation on our Web site – www.secondopinion-tv.org, where you’ll find transcripts, videos and more about health care topics. I want to thank you for watching, and again, thank all of you for being here as well. I’m Dr. Peter Salgo and I’ll see you next time, for another ‘Second Opinion’.