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Institute of Medicine’s recommendations about vitamin D intake alarmist and unhelpful

Hathcock Paper

A report published in the Times on November 29, 2010 (http://www.nytimes.com/2010/11/30/health/30vitamin.html?_r=2&hp) has created some alarm amongst people taking vitamin D supplements. The NY Times report alluded to the deliberations of a 14 person expert committed assembled by the Institute of Medicine in the US. This group has been meeting regularly since March 2009, attempting to frame Dietary Reference Intakes (DRIs) for vitamin D and calcium, that is they were looking at coming up with the Estimated Average Requirement, which is the amount estimated to satisfy the needs of 50% of people in the American population. The report was released on November 30, 2010. A press release from the IOM states that “Most Americans and Canadians up to age 70 need no more than 600 international units (IUs) of vitamin D per day to maintain health…”. They suggested an upper safe limit of supplementation as 4,000IU per day. The report also noted that all North Americans are receiving enough calcium and vitamin D.

Most people reading this report would be very surprised about these findings. Haven’t we been reading paper after paper about the worldwide epidemic of vitamin D deficiency due to sun avoidance? But the findings can be explained partly by the purpose of the committee, which was to update longstanding and out of date dietary reference values for vitamin D and calcium. DRIs were introduced in 1997 to broaden existing guidelines known as Recommended Dietary Allowances (RDAs) that were used in the US, Canada and Australia to provide nutrition advice with a substantial margin of safety. The RDA was essentially the minimum intake required to meet the requirements of 97-98% of healthy individuals. Additionally, the findings can be partly explained by such committees’ requirements for absolutely proven evidence, much like the Cochrane Collaboration. Most people reading the reviews in the Cochrane Database are struck by the fact that it is almost impossible to prove anything in medicine, and that most of their reviews come out with the conclusion that there is not enough evidence on a particular topic to make definite recommendations, and that more research is needed. The IOM committee for example, made the recommendation that there is evidence that vitamin D was helpful in bone health, but had not been proven to be helpful in any other condition. If we had taken the same approach when Doll and Hill’s groundbreaking epidemiological study came out in 1950 about cigarette smoking causing lung cancer, we would have lost thousands more lives to lung cancer while we waited for definitive proof.

The truth is, as we have long said on this website and in the books ‘Taking Control  of Multiple Sclerosis’ and ‘Overcoming Multiple Sclerosis’, there is compelling evidence that vitamin D deficiency increases the risk of developing MS, and that vitamin D supplementation reduces that risk and very likely reduces the risk of progression of the disease. Most of the evidence supporting these contentions is outlined on this site and in the books; a lot of it appears in the What’s New section, and is very recent, certainly appearing after this committee began preparing its report. For instance, the Southern Tasmanian Longitudinal Cohort Study showed that for every 10nmol/L increase in blood vitamin D level, there was a 12% decrease in the risk of relapse. Further, this was a clear dose-response curve, and extrapolating their data to a zero risk suggested that a level of around 150nmol/L was the minimum protective level. There is much supporting data around this issue on this site and in the books that readers can look into for themselves.

The problems with the IOM report are that this was not their brief, to examine what supplement amount would be best for people with serious illness, just to look at an average requirement for healthy people. And this was just an average amount needed for maintenance, not even for the prevention of serious illness, let alone its treatment. New data are appearing all the time on the potential of vitamin D to prevent a variety of cancers in addition to heart disease, depression, hypertension, diabetes, and so on, as well as osteoporosis. The IOM focused completely on bone health. But as we have long said here, higher doses and higher blood levels of vitamin D are required for management of autoimmune illness than for maintenance of bone health.

To look a little more closely at what the IOM said, their recommendations about not taking large doses of calcium were actually sensible, and we have been arguing this for some time, based on good evidence. Enough said. But with vitamin D, firstly they demanded too high a standard of proof that vitamin D is helpful in conditions other than bone disease, like MS, and secondly they raised the old spectre of toxicity, saying “The onus is on the people who propose extra calcium and vitamin D to show it is safe..” Well, we have very responsibly advised people not to take calcium supplements, as they suggest, because the evidence shows that calcium supplementation is not safe.

But as far as vitamin D goes, the IOM report did not show supplementation is dangerous, they just demanded proof that higher doses are safe. Of course, proving something is safe is much harder than proving something is dangerous. Just one case report of someone coming to harm from taking 10,000IU a day of vitamin D a day would be considered proof that it is dangerous. But, clearly, they were unable to provide that proof, as that hasn’t been reported. Indeed, Hatchcock et al’s 2007 review paper noted that the estimated blood level associated with hypercalcemia, the major toxic side effect was 600nmol/L, and that the safe Tolerable Upper Intake Level of vitamin D was 10,000IU per day. That paper is downloadable above right for those wanting to see the evidence first hand. The IOM’s report conveniently ignores the fact that people in sunny countries often have levels around 200nmol/L without taking supplements, a level that would require at least 10,000IU of vitamin D a day if one was achieving this with supplements. It also ignores the reality that just by standing out in the sun with bathers on in Melbourne at midday today for 10 minutes, you would make 15,000IU of vitamin D. Why would the upper limit of safe intake be 4,000IU, as suggested by the IOM?

It is important for people with MS trying to do the best for their health not to be deterred by such reports. The approach at OMS is to make recommendations based on a distillation of the best and most recently available evidence that will allow people with MS to immediately and safely apply new research to their condition, without having to wait for years for scientists and expert groups to catch up. In this case, it is about balancing risks: the risk of what will happen to people with a serious progressive neurological disorder like MS waiting until such groups decide that vitamin D supplementation is proven beyond doubt to prevent and improve the outcome from MS far outweighs the remote potential risk of toxicity from supplementation at the doses we recommend. To date, such side effects have been reported only in people taking 40,000IU a day or more. We reiterate, people with MS should check their vitamin D levels annually aiming for a blood level of vitamin D that is high-normal, around 150nmol/L or more, but not above the top of the normal range which is about 225nmol/L depending on the laboratory (even though this allows for a margin of safety probably up to about 500nmol/L). This can be achieved with regular low dose sun exposure plus vitamin D supplements; if sun exposure is low or not possible, this may require supplementation with doses up to 10,000IU a day.

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    13 Responses to “Institute of Medicine’s recommendations about vitamin D intake alarmist and unhelpful”

  1. Bea says:

    Hi All,

    I don’t have MS but have suffered most of my life from a kind of arthritis which MD’s find impossiple to classify. For years it frustrated me that I was never prescribed any medicine to prevent but readily given steroids when my condition was really bad and I had difficulty to walk, work or think straight due to pain and swelling.

    About a year ago I started taking Omega 3 (2000 a day) and added to it Vit D3 some 4 months ago. I Have had no pain (apart from stiffness that seems to be permanent), no serious swelling or inflammation since then. Since I live in UK and the sunshine is a luxury I decided to have 7-8 minutes in a tanning shop weekly or every other week. I know tanning shops have bad reputation due to skin cancer but this is the only available substitute for sun I can get here. I would welcome your advice if what I’m doing is right.

    By the way I recommended this site to my friend who has MS and suffers from many symptoms. Needless to say, she lives in Scotland, which is even worse for sunshine than England where I live. I hope she will follow your advice.

    Many thanks and stay well,


  2. Mike Turk says:

    Dr. Jellinek

    I have followed your prescription for living well with MS for 5 over years. Have had no relapes in the past 3 years.

    Live in US in northern Ohio. We believe we hold the dubious distinction of having the highest incidence of MS on the planet. and of course I have the disease. I hold dual masters in social work and computer science. For several year have attempted to get MS tx centers here to sponsor the following on their web sites. Their interest is only in effectiveness of current medictions. Suspect they recieve heavy sponsorhip from various drug companies.

    Perhaps your good country could help with this.

    Would be easy to do and cost next to nothing. Contact google and have them start and possibly create a web page with google maps where people can click on and list the exact locations of where they lived at various times in their lives. Then try and have everyone sign up and fill out the questionairre.Then list all the diseases with which they suffer. It is easy to compare the weather hx., ie sunlight, pollution air and water with incidence, severity and progression of this illness. I am certain that geography has impact not only in developing but also the rate of progression of the disease. I have made a point of meeting hundreds of fellow patients and there are certain small towns near us that have very high incidences and in addition there are particular neighborhoods of large cities.

    Later on additional questions could be added, ie was there anyone that smoked in your house when you while you lived at a particular place. What were the diseases which your ancestors reportedly suffer?

    please email me with your interest in proceeding further.

    Thanks for your good work. We all benefit from it.

    Mike Turk

  3. Mess Positive says:

    Sorry all, I included a couple of URLs in my post here, but they didn’t appear. I’ll try again:
    If these don’t get through, I’ll post in the forum.

  4. Mess Positive says:

    Much the same mythology echoing around on and , although a useful collection of material, it does seem to highlight just how much muddling there is on D.
    I find it a tad unhelpful when pundits firmly recommend a sun dosage without regard to the area of skin exposed, the latitude, atmospheric obscuration of UVB, etc.
    My GP was explicit in saying that 10 minutes on the back of a hand was enough … then i can get my
    D whilst shoveling the snow! Here in England we are the latitude of Hudson Bay.
    The $1/2billion D trade jumps out at me … we know so well that where there’s brass (money) there are forces (though in this case one’d think they’d be for D).
    Many thanks for the heads-up and explanations George.

  5. George says:

    Hi David

    This is, I hope, a very useful site, in that it has all this information. You will find links to 5,000IU, 10,000IU and 50,000IU at http://www.overcomingmultiplesclerosis.org/Recovery-Program/Sunlight-and-Vitamin-D/, and much more besides.

    Be well


  6. David Slawson says:

    Hi George
    thanks for your reply-just read “The Vitamin D Solution ” by Micheal Holick . Very good.
    You mention a source of 5000 iu Vit D could you please post a link?

    Thanks once again.

  7. George says:

    Hi David

    Have a look at the Forum at http://www.overcomingmultiplesclerosis.org/Community/Forum/viewtopic.php?f=7&t=24&p=287&hilit=trevor#p287 for a view on this.

    Be well


  8. David Slawson says:

    I’m new to this site so the question may be redundant but here goes-how does the book’s recommendations regarding vitamin D intake square with Trevor Marshall’s conclusion that vitamin D is a culprit in the progress of autoimmune disease ?

  9. George says:

    Thanks Rebecca

    Yes, those recommendations are not really for people like us who take a very active role in our own health. Sadly, there aren’t too many people so pro-actively looking after their own health. Most of us know very well the doses of vitamin D we need to maintain our health, because we monitor the level carefully, and generally the doses are rather higher than the IOM’s suggested limit.

    Of course, sunshine is even better if you can get it!

    Be well


  10. Rebecca Hoover says:

    Thanks for addressing this issue! I just want to add that I have been closely monitoring my vitamin D level for a long time and have had regular blood tests, and the new recommended doses of vitamin D are simply too low for me and for most I know. I do live in Minnesota where we get little sun about seven months out of the year.

    I have found that even though I am only 5’1″, I need 4,000-5,000 I.U. of vitamin D3 daily to keep my level at the high end of the normal range. For quite a few months I took 10,000 I.U. of D3 and suffered no ill effects. Indeed, I felt better than ever.

    The IOM is already taking considerable criticism for its report on vitamin D and calcium.

  11. George says:

    Hi Gail

    Yes, that highlights the fact that the IOM’s paper was not about people who have an illness using vitamin D as treatment, but rather broad generic guidelines for well people. It is very important for those of us with MS to regularly check our blood level of vitamin D and adjust doses accordingly.

    Thanks for your comment

    Be well


  12. Gail T McLure, PhD says:

    I appreciate this article. I heard the NPR interview and heard no reference to any recommendations based on an individual’s own tested Vitamin D in the system. Wouldn’t you expect a person’s status would be essential to any sort of recommendation?

  13. Amanda says:

    Thank you for clarifying this research George, I think it is important that those of us with MS understand that we don’t always ‘fit’ in with these studies, and that our health needs are very different to the general population, Amanda.

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