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Vitamin D Help Us Fight Infections - interview of Dr. Thakkar (transcript) Jan 20, 2021

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Dr Vatsal Thakkar
He is one of the 200+ signers of the open letter: Vitamin D combats COVID-19
Dr. Thakkar takes 10,000 IU daily website www.vatsalthakkar.com
A fraction of the signers take >4,000 IU daily
  24 slides - which nicely support this podcast

Paradocs podcast note for this episode


In VitaminDWiki
COVID-19 treated by Vitamin D - studies, reports, videos
As of Dec 2, 2021, the VitaminDWiki page had:  34 trials 6 trial results,   28 meta-analyses and reviews,   64 observations,   36 recommendations,   55 associations,  89 speculations,  52 videos   see related:   Governments,   HealthProblems,   Hospitals,  Dark Skins,   26 risk factors are ALL associated with low Vit D,   Recent Virus pages   Fight COVID-19 with 50K Vit D weekly   Vaccines
MORTALITY AND Virus (automatically updated)


Transcript

[music]

Introduction

0:00:08.6 Welcome to The Paradocs with your attending, Doctor Eric Larson. He is a practicing anesthesiologist and clinical assistant professor at Michigan State University College of Human Medicine. Listen in as he takes you behind the scenes of what practicing medicine in today's ever-changing world is like with another doctor. The Paradocs is a fun and accidentally informative show for physicians, patients, or anyone who has ever found themselves in a waiting room.

[music]

0:00:47.8 Larsen: Welcome to The Paradocs. I'm your host, Dr. Eric Larson. Thank you for joining me as we explore the US medical system in a fun and informative format through expert analysis. Today's expert is Dr. Vatsal Thakkar. Dr. Thakkar is the founder and CMO of Reimbursify. But more importantly, he is one of the founding members of the Vitamin D for All group, which is a collection of scientists, researchers, and public health advocates who recommend widespread Vitamin D supplementation to treat the very common disorder of Vitamin D deficiency.

0:01:16.1 Larsen: There aren't a whole lot of people out advocating for vitamins and nutrients, frankly, because there's just not a lot of money in it, certainly not what like there is for prescription drugs. We've all heard of big pharma and big tobacco. I don't really think there's a big vitamin. Anyway, we're gonna be talking about Vitamin D and the fairly strong evidence that it has helpful effects and benefits for immunological function, which is especially important at this time of the COVID pandemic. This is in addition to the fairly widespread notion that Vitamin D helps in bone growth and prevents osteoporosis, in addition with calcium.

0:01:50.6 Larsen: But before we get into the show, here's a quick message from Resolve, a physician contract review company. At Resolve, they believe that knowledge is power for physicians and that power gives you control over your financial future. Resolve believes that by mining, analyzing, and synthesizing data, they can provide you with the information insight that empowers you to diagnose the health of your career, fully understand your worth, and maximize your full potential. As a company founded by a doctor for doctors, Resolve's focus is on the well-being of those whose purpose in life is to care for the well-being of others. To have this incredible company review your employment contract, find them at doctorpodcastnetwork.com/resolve. The link is also in the description of this show.

0:02:32.6 Larsen: I'd like to remind you to visit the Show Notes page at theparadocs.com/112, where you can find the links to the letters we discuss here. I especially wanna point out that letter at VitaminDforAll.org, where all the signers of the letter basically advocating for the supplementation of Vitamin D, but they actually state, not only the recommendation, but also what they do themselves personally. So, I think that's very powerful. You'll see, oftentimes, you will say, "You should take between 2000-4000 units," and then they're almost all taking four, sometimes upward to 10,000 units per day. And so, it's just kind of interesting to see that people basically put their money where their mouth is, not that they need to make any money with vitamin D. Outside of, I suppose, some of them do some research.

0:03:09.4 Larsen: On a personal note, I'd like to also add that, after reading some of the research, seeing a couple of talks by these researchers, reading the paper that was written by Dr. Thakkar and a former surgeon general, I began supplementing with vitamin D. And then, after a discussion with this, after this interview, I changed my supplementation, and I actually take more than I was before. And instead of taking it once a week, I take it daily. Anyway, I just wanna kind of add that. So, I've been convinced. Certainly, you can do what you want. Again, as you find in the discussion, Vitamin D supplementation is relatively inexpensive. You have very little to lose, and so it seemed like a no-brainer for me to do.

0:03:43.8 Larsen: I also have been supplementing now for a few months. I do live in Michigan, where we have one sunny day every three weeks maybe in the winter. And then when it is sunny, it's 35 degrees, and you basically just have your face exposed, so the amount of Vitamin D you get is pretty paltry. Anyway, I had it tested and my levels were 52, so I was very happy with that. And actually that's even before I'd done more than a week or two, the increased supplementation. So I suspect that my levels will be between 50 and 70 pretty soon. And it was not that hard to do, but I thought it's important to give you that information for full disclosure before this episode.

0:04:16.3 Larsen: Now, finally, I wanna continue to encourage you to share this show with your friends, family, and colleagues. I think this is an especially important one. We're all worried about infections. And even when this COVID pandemic goes away, which it will at some point, we're still going to be facing constant threats to our immune system. And so this discussion will be pertinent even after this pandemic has passed. But without further ado, Dr. Vatsal Thakkar on Vitamin D for the win. Enjoy.

0:04:43.7 Larsen: Well, hey, I'm here with my new friend Vatsal Thakkar. Dr. Thakkar is the founder, president, Chief Medical Officer of Reimbursify. He's also a former clinical assistant professor at NYU Langone Health System, and all sorts of different positions. He's a psychiatrist by training. And today we're gonna talk about, well, not psychiatry. We're gonna talk about Vitamin D. So, first, thanks for being on the show.

0:05:05.4 Vatsal Thakkar: Yeah, thank you. It's great to be here.

0:05:07.2 Larsen: With COVID, obviously, this is a big, huge topic. We're gonna talk about Vitamin D because I think it's something that I think is some people are discovering both inside and outside of health care. Why don't you talk about how you sort of got into learning more about Vitamin D and its effects within the body?

Thakkar background

0:05:25.7 Thakkar: Sure, Doc. Thanks a lot. So, as you said, I'm a psychiatrist. I've been practicing for more than 15 years, and I opened up my first practice in New York City. It was coming up on 14 years ago now. And that was right around that time that vitamin D was starting to be in the news, and there was an easy blood test available, and there was a lot of correlation with various psychiatric diagnoses. And so, I started just ordering tests on patients to see what their levels were. And lo and behold, most of them were low, and some of them were mind-bogglingly low.

0:06:07.2 Thakkar: It became part of my practice to order a level on every new patient, unless they had recently had one from a physical, and correct it. So, that was the second piece of it. If I found a level that was... I typically wanted their level above 40 ng/mL, deficient is... Well, the normal lab value is 30-100 usually, deficient is usually below 20, and severely deficient, below 12. So, I would typically order the test and if they needed supplementation, I would order that too, just in terms of an over-the-counter dosage.

0:06:39.6 Larsen: I guess that the next question is, what role does Vitamin D have in psychiatry, with mental illness?

0:06:47.0 Thakkar: There's a lot of correlation with various mental illness, depression, psychosis, bipolar disorders, schizophrenia. What we haven't yet seen is that correcting vitamin D deficiency brings robust clinical improvement. The only place I've seen that in my practice would be in fatigue, I would say. Fatigue and low energy, which can obviously be a part of almost any psychiatric condition, but I found that people whose D-levels were really low would notice a benefit when those levels were corrected. That doesn't mean that they were cured of what they came in to see me for.

0:07:25.9 Larsen: Sure, yeah.

0:07:26.4 Thakkar: But they did feel better, and just knowing that it's... Because there was so much correlation data, it seemed to smack at being a risk factor for various things, not just psychiatric, but immunological and medical as well. And so it just felt right, if I'm treating these people I should make sure they have a normal level of vitamin D if they didn't, to begin with. So it made sense to me.

Not much about Vitamin D in med school other than relationship to Calcium

0:07:50.3 Larsen: Yeah, and I think I feel like with medical school, for me, vitamin D was intimately related to calcium and your calcium regulation, your body, and that was sort of it. We really didn't have... There weren't any other associations with Vitamin D and anything else, at least that I recall learning now. Maybe I just skipped that part of physiology, I don't remember.

0:08:10.2 Thakkar: No, you're absolutely right. That's what I remember and I think I went to med school before you, so I probably didn't even learn that much. So right around the time that I started this practice, and I'm ordering all these tests, I thought, I wanna know what my level is. And so I asked my primary care doctor, and he talked me out of it.

[laughter]

Ordered his own Vitamin D Test: 11 ng after a vacation on the beach

0:08:33.3 Thakkar: He said one study says, you should raise it. One study says it doesn't matter, so if it ain't broke, why look for a problem? So about a year later, I was still curious. I decided to order my own level and it was in August of 2012, I had just came back from a beach vacation on Cape Cod with my family, my wife and kids. I thought it was just sort of perfunctory, I just wanted to know what it was, my level. So I ordered it, and it was 11, and I just was shocked at that, and I think that's one of the hidden facts about vitamin D is that there are so many people walking around with a deficiency, sometimes a severe deficiency, and they don't even know it. And here I was, I have brown skin. I'm a I guess a Fitzpatrick type IV. I looked at the scale.

0:09:32.5 Thakkar: And so I need more time in the sun than you do for making the same amount of vitamin D and plus I'm probably heavier than you are, and so that fat cells will suck up vitamin D, so that further drives my level lower, and it was just stunning to know that I was walking around with a severe deficiency. And in the course of testing hundreds of patients, I found another MD I was seeing once who had a single-digit level, and also unbeknownst to him that it was so low.

0:10:01.3 Larsen: I tend to have darker skin though it tends to be more in the summer, but I've got some Mexican in me, although you would know it from my name

[0:10:06.1] ?? Marson. But I've also thought the same thing. We actually have a foster son who's Guatemalan, who lives in our house and Michigan is not exactly known for their sunlight, especially... Well, about six months of the year, we really have almost none much worse than New York. Although you could argue, even if we had some light it wouldn't matter 'cause you're totally covered up and bundled anyway, because just your face is exposed. And his levels were exceptionally low too right, and so he had to start a lot of... I don't remember what the term is, but he had to get mega doses for a couple of weeks to try and drive his levels up.

0:10:43.3 Larsen: Aside from I guess the obvious thing is we know vitamin D is related to calcium, and so if you have low vitamin D-levels, you're gonna have problems with Osteoporosis and bone disorders, but I think what has become more, at least more well known now, or at least is talked about now is, are the other roles that vitamin D have. Why don't you talk about what that has besides general fatigue, you might say, where have you noticed that vitamin D is now important as more than just a vitamin base? Because I think when we look at vitamins, we think of them, I guess physiologically, they're sort of the things that help other enzymes work, and so if you don't have... If you're deficient in the vitamin, you have a problem, but it seems like vitamin D is even more than a vitamin, that it's more like... Almost like a hormonal aspect to it too.

0:11:30.1 Thakkar: Right, absolutely. And I always like to look at current trends in medicine through the lens of history and through evolution, so we're a species that evolved to be outdoors a lot. We have to hunt for food, we might not have had shelter until very recently in our species existence, and so one could argue pretty confidently that 1000 years ago, certainly 10,000 years ago, our vitamin D levels would have been radically higher than they are now. And that's true if you look at populations, for example, African tribesmen who are out wearing little clothes and out in the sun a lot, they have levels that are in the 70s or 80s, which I don't think I ever saw a random level in the 70s or 80s here, when I was testing people in New York City. That's one element that I like to keep in mind.

Last 20 years: Vitamin D in immune system

0:12:28.5 Thakkar: And so what does it do for you? If we've decided that for bone health, we need a level... Some people say 15 or above 20, I think most people would say, you prevent rickets above a level of 20 ng/ml. Then why did we ever have levels higher and could there be another purpose for that? And over the last 20 years, most of the research on vitamin D has been on the immune system, and some of this has come out of correlational studies that showed a whole myriad of autoimmune conditions that correlate with a low vitamin D level, that science has progressed to the point where a low vitamin D level is now considered a modifiable risk factor for developing multiple sclerosis.

0:13:19.0 Thakkar: I don't know when you were in school, what you were told, but what I learned about multiple sclerosis, they said, Well, we know it happens. There's a higher incidents at northern latitudes, and at the time, they explained it as, We think it's because of greater viral infections. There was no vitamin D mentioned, and this was... That lecture I'm referring to it was probably in '95, 1995. So I just thought it was interesting. Here we are, 20 years later, that... I always like to think about... I love what I learned in med school, but I really love what I learned wrong in med school because...

[chuckle]

0:14:00.1 Larsen: Yes, totally.

Half of what is taught in med school will be proven to be wrong

0:14:01.0 Thakkar: Because up to a half of it is gonna be proven wrong, and what's that gonna be? I wanna be on top of that knowledge as it's shifting. A lot of correlational data started coming out around autoimmune conditions, and when you look at the basic science of it, vitamin D gets converted into 25-hydroxyvitamin D, which then gets converted into 1,25-Dihydroxyvitamin D, which is the active form. And it has a whole slew of actions in virtually every organ system in the body. It activates something like a third to a fourth of the human genome, of the human genes.

0:14:43.9 Thakkar: Every cell in our body has a vitamin D receptor, and so you have to ask yourself, "Well, what's it doing besides bone health?" And if you'd really drill down into it, vitamin D specific actions on the immune system include inhibiting pro-inflammatory cytokines, which lead to cytokine storm. It can actually release anti-inflammatory cytokines. It can inhibit T cell over-proliferation, it can enhance the production of cathelicidins and defensins, which are natural anti-viral and anti-microbial peptides, and it enhances things like interleukin 4, 5 and 10, which can fine-tune the immune response.

Low D seems to make the immune system blind

0:15:23.9 Thakkar: So what first occurred to me was, it seems like low vitamin D state makes your immune system a little bit blind, and that's what I wrote about in The Wall Street Journal earlier in the year... Last year as it relates to COVID. And the kernel for that op-ed came from the fact that it was late March, early April, and the data started surfacing. The clinical course of patients was different based on skin tone. And I immediately... Just the radar went off in my head because here I was, I was... My own vitamin D level was probably 10 points lower than my peers, at least. In the people I'd tested, I had intuited that skin tone correlation to their vitamin D level, and I just thought, "Oh, here's a new viral illness. Could there be some vitamin D connection to it?" Started doing research. One of the first pre-prints came out on the topic, and I first made that preliminary connection last April in The Wall Street Journal.

0:16:19.3 Larsen: Yeah, that's so interesting. And I do remember... I do recall that now with multiple sclerosis, for instance, where it was always at the... I think you even said the 45th parallel or something like that.

0:16:28.8 Thakkar: Right.

Above 35th UVB is blocked by going through so much atmosphere from Oct-March

0:16:28.8 Larsen: Or maybe it's the 35th, that if you're above the 35th, it significantly change. And it would be plausible that vitamin D would have some sort of role in that because your exposure to sunlight's a lot less, and it's certainly... Most of the year you're not getting the right angle. Right, it has to be the right angle to actually... For the UV to penetrate.

0:16:44.0 Thakkar: Right, so above... I believe it's above 35th, it's that exact same parallel, that you cannot make vitamin D from sunlight naturally between October and late March.

0:16:57.8 Larsen: Right, 'cause the angle is wrong from the sun.

0:17:00.3 Thakkar: Exactly, yeah, exactly. Yeah, too much of the UV is filtered out.

0:17:04.5 Larsen: Yeah, and I remember thinking the same thing initially, because when you look at the populations who are affected by COVID, the Hispanics and black populations are really hit hard, and part of it, you could say, "Well, it's socio-economic, it's exposure levels," which I think is probably definitely one of the parts here. Maybe more crowded living conditions, things like that. But it was above and beyond what you'd expect just from that. And I think my experience with the healthcare system in general is that, especially when it's something like this, there's probably not a massive disparity in who you treat or how you treat. Pretty much everybody is treated, so I wouldn't expect that that would have such a profound effect on mortality rates.

0:17:46.1 Thakkar: Right, we were talking almost double in some studies. Triple, right? So that's hard to pin on bias or access or... So I agree with you. I was also keen on seeing if there could be some environmental or biological reasons.

Supplementing with Vitamin D appears to be effective

0:18:01.4 Larsen: So we get vitamin D from sunlight. Obviously, we can take vitamin D supplements. And my impression is that that is as effective. It's also incredibly inexpensive. Vitamin D costs pennies to take. I guess if we look at the paper that you wrote, or that you signed on with, that... Was it vitamin D health for all dot com or something?

Vitamindforall org and open letter

0:18:23.2 Thakkar: It's vitamindforall.org. So let me explain a little bit about the evolution of that. So I had written... There have been a few people who were early thinkers and writers on this topic and humbled to potentially be included in that group. There was a researcher in England, Gruff Davies, there was John Umhau, who's a former US Public Health Service scientist and physician who wrote an opinion piece about it. Even Tom Frieden had come out and talked about potentially vitamin D affecting clinical course in COVID back in March of 2020. So we all started connecting with each other in around June, July last summer. I think we all thought that, "Oh, we're bringing this knowledge to the forefront, and so people in higher positions with more resources who are better thinkers [chuckle] will take it and run with it and do what needs to be done to get the solution and the knowledge out there. We didn't see that happen.

0:19:24.0 Larsen: Definitely, yeah.

0:19:25.2 Thakkar: And so that's where... Around summer we decided, okay, well, what more can we all do? And then as we started talking, then the group started to grow. So then it was first four people and then six people, and eight people, and now what we decided to do with, under the... Basically, the initiative of Karl Pfleger, who's a former Google data scientist, who came out of this just from a scientific and statistical perspective, saying it's so plain to see that this is relevant, and why is it not being really advocated for, regarding some form of vitamin D knowledge into the conversation about COVID risk and infection and clinical course?

0:20:13.0 Larsen: And I don't know why it happened this way, but I feel like a lot of it is, people have the impression that this would be over soon or it'd be a couple of months and then this would kind of wash away, I guess, or the vaccine comes out, or we find treatments that are effective. And in many things, it takes a while before people go back to the beginning and say, "Well, what can we do to help optimize people, so when they get exposed to whatever it is, that they're not gonna get as sick?" It's like people getting lung cancer, and so you focus all your attention on chemotherapy and surgery and everything without saying, "You know what, maybe you should stop smoking," right?

0:20:45.7 Thakkar: Right.

0:20:46.8 Larsen: And I think the things... Certainly, it's hard to ask people to lose weight. We're number one eaters here in the United States, and so we like to eat. And so that's probably not something that you think. Also, if you think some thing's gonna be around for just a little while, there's no point trying to lose 10 pounds because it's not really gonna affect things a lot over this... If something is a short-run, right?

0:21:08.7 Thakkar: Right. And...

0:21:09.7 Larsen: But if this is now with us... If it's gonna be with us for years, then absolutely, losing weight and having a healthier lifestyle is gonna make a difference. And so then you can look at preventative measures that seem like a long-term solution.

0:21:20.6 Thakkar: Absolutely. And so that's where it started. And so we decided to come up with an open letter advocating for our leaders and health officials to take this seriously. And we solicited the guidance and endorsement of... It currently stands at around 200 world experts, researchers, clinicians, there are some public health officials who signed on to this letter that basically outlines... It's only two pages, you could see it at vitamindforall.org. It basically outlines all the high-level data that's come out overwhelmingly positive in terms of its potential influence over COVID-19 and just simple strategies. So we advocate that everyone should take a supplement. Most of us recommend that everyone can safely take 4,000 units per day.

0:22:11.9 Thakkar: But basically 2000-4,000 is the recommendation, and that would get the majority of the population to have sufficient levels of Vitamin D. The other aspect to the letter is there are some tips on how to load the dose. So it's safe to take 10,000 units a day for a couple of weeks to get your level up quickly. In fact, I've had friends who've tested positive for COVID, and that's usually my advice to them, if they've not been on a supplement. And here we are in winter, that let's get your level up quickly and then you can drop down to 4,000 a day. We just wanna get this information out there and potentially in the hands of people who have more influence than we do, who are outsiders coming to the Vitamin D table.

0:22:55.4 Larsen: The criticism of Vitamin D is always... It seems to be universally the same in that, okay, so you're saying Vitamin D levels... You kinda make this argument that Vitamin D is involved in all sorts of things: Immunology, hematology, psychiatry, all sorts of aspects of disease, function; Vitamin D is everywhere. So it's ubiquitous. So you're making argument that Vitamin D is this super vitamin, it controls all sorts of things, and if it's low, then you're gonna have all these problems. But we tend to find that people who are most susceptible to COVID or whatever it might be, let's say the flu, right? Yes, they have that low Vitamin D levels. However, there are also people who are metabolically inactive or they're feeble, they're frail, they're unable to get Vitamin D normally in the environment.

0:23:40.2 Larsen: So you're actually finding... You're not finding people who are sick because of Vitamin D, but they are sick and they also have no Vitamin D because they tend to be frail and elderly, right? So it's the classic, correlation is not necessarily causation. So what sort of evidence... 'cause I know people have been really testing that because that is always the argument against hitting people with a lot of supplements of vitamin D, well, expensive pee. You're just make getting expensive pee and stuff. What sort of evidence suggests that it's more than just a correlation, that actually there's some causative meat behind it?

0:24:15.3 Thakkar: Yeah, no, great question. And actually, I didn't start the pandemic thinking, I'm gonna advocate for Vitamin D because I didn't know. [laughter] The data wasn't out yet, even though I was a fan of testing and treating low levels. Before I dive into that, I'd like to also say we could also be biased to think that old age and being overweight are the risk factors. But it could also be that those characteristics drive the Vitamin D level lower, which is the real risk factor for certain things, certainly not for everything. It's theoretically possible.

Study in Spain used Calcifediol

0:24:52.1 Thakkar: So why is it not just correlation? What implies that it's causation? The biggest data that came out, the strongest data that came out pointing in that direction was a study. It was just a small pilot study done in Spain, and it was done back in March. I think the publication came out in September or October, where patients admitted with COVID to the hospital, were given either Calcifediol, which is a very potent Vitamin D analog, or not. So it was open label. There was no placebo. Of the people who got the Calcifediol... Now, keep in mind, Calcifediol can raise your vitamin D, can normalize your Vitamin D level within hours.

0:25:40.4 Larsen: And this is an IV formulation, correct?

0:25:43.8 Thakkar: This was an oral formulation.

0:25:45.5 Larsen: Okay.

0:25:46.2 Thakkar: And it basically... The blood tests that we order for circulating levels of is 25 OHD, and Calcifediol is basically 25 OHD. Whereas if you take Vitamin D from the drug store, you're taking D3, usually, that gets absorbed through the gut, then it has to get converted in the liver over a week or two to 25 OHD. So Calcifediol basically raises and normalizes levels immediately. And there was a stunning 90 plus percent drop in ICU admission for these COVID patients. It went from only 2% of the Calcifediol group needed the ICU versus 50% of the non-Calcifediol group needed the ICU. So it's a very interesting study, right? There was only 76 people, we realize that it's a small study, but a very strong signal. The other ones that came out after that, so there was another study that came out from India where they gave... And this was specifically for mild cases of COVID-19, PCR-positive mild cases. Everyone got... Oh, let me just add about that Spanish study. The authors noted that the population in that part of Spain has an average serum level of 16 ng/mL so it's likely that the majority of that study population was deficient.

0:27:17.9 Larsen: Sure.

Study from India used 420,000 IU in first week

0:27:18.2 Thakkar: Putting that out there. Another study that came out from India was giving high dose Vitamin D replenishment to people who were deficient, and had tested positive for COVID, and had mild cases. And they gave them 60,000 units daily for 7 days for a total of 420,000 units to replenish and pretty quickly. And what they found was that it tripled the rate of the number of people who were clear of the virus by 14 days. So it was about 20% clearance in the placebo group. This study did have a placebo group, and 63% were negative at 14 days of the Vitamin D treated group. In addition, there was a statistically significant reduction in fibrinogen levels in the treated group. So again, there are so many Venn diagrams that seem to coalesce [chuckle] around Vitamin D's effects and COVID-19's effects and how proper levels of vitamin D can actually protect against some of those ill effects of the virus.

0:28:29.8 Larsen: Sure, and I guess just to summarize for those who aren't maybe following that line of reasoning, one of the two major problems, I guess you'd say, with COVID-19 people who have... SARS-CoV-2 is, as I've talked in this show, is actually the name of the virus. COVID-19 is the disease you get if you express symptoms of infection with SARS-CoV-2. So COVID-19, there are two things. One is you get this hyper-inflammatory state of cytokine storm, and so one of the things you mentioned earlier is Vitamin D tends to stabilize and prevent that from getting a crazy response.

0:29:08.0 Larsen: And also, the other thing later on, is that you have a hypercoagulable state where you start clotting a lot. And so you tend to throw clots to your lungs and other organs, and it can cause all sorts of other problems. And that's what happens maybe later. And I've seen people who've gotten strokes, who are otherwise you'd consider healthy people, and they're young people in their 40s. And so the thought then I guess then too is Vitamin D has ability to stabilize and prevent as much of that sort of problems. And if you prevent the overreaction, I guess, from your body to an infection, that's what the Vitamin D does is, I guess... That would be the speculation, I suppose, of its usefulness in this infection.

Half a dozen things that Vitamin D does to help

0:29:53.7 Thakkar: Yeah, absolutely. It seems like there's half a dozen things that Vitamin D can correct that COVID-19... Forgive me, SARS-CoV-2 actually takes advantage of to cause sickness, illness and potentially death.

0:30:11.9 Larsen: Right, yeah, and I think... When you look at it from an evolutionary standpoint or the way the body is designed, it makes sense that your body would be... That a lot of mechanisms for homeostasis and maintaining your normal function would be dependent on something that would be very common, that you'd have a lot of. And so if you were always had a lot of sunlight and always had a good exposure, it would not be surprising that it would be... That you'd find that it would have functions throughout the body in many different places. It's like all the body tissues use oxygen because we have lots of oxygen. There are certain things you could imagine that would be specific to that your body would not be totally dependent on. But you could see why vitamin D would be something essential because it is... The sun is... That's about it. If you don't have the sunlight, you're gonna die for other reasons, too. So it makes sense that we've evolved with using sunlight and oxygen as the main things in our environment.

Mortality rates worse further from equator

0:31:06.8 Thakkar: Yeah, absolutely. And that actually reminds me of another layer of studies that have shown the mortality rate from COVID-19 rises with latitude, sorry.

0:31:20.3 Larsen: Sure, so like worse in Sweden than in Tunisia.

0:31:24.2 Thakkar: Exactly. And so New York and Chicago were hit really hard. And though it seems like our southern states are catching up, but it was never that critical intense onslaught of ICU admissions and mortality rates. And another interesting find was that researchers, and this was 10 years ago, more than 10 years ago, looked at the Spanish Flu Pandemic from 1918. And they found that the mortality rates then as well were three to four times higher in Connecticut than they were in Texas. And there was a gradual linear increase in mortality rates the higher North you went.

0:32:03.4 Larsen: Well, maybe just people were much healthier in the south back then, right? [chuckle]

Perhaps the ICU was invented for the 1918 flu

0:32:07.4 Thakkar: Well, yeah, it's interesting. I don't know. There could be other explanations, although you would argue that people were more active then. And there could not have been a disparity in healthcare resources because there was really no healthcare resources. I think the ICU was invented because of that pandemic.

0:32:27.3 Larsen: Right. Well, and the only difference I suppose would be the lack of air conditioning in the South at the time. But yeah, it's very interesting, and it makes you wonder about, well, other respiratory disease. We're talking about COVID-19 because that's at the front of everyone's mind right now but we have a seasonal flu epidemic that comes by... Well, it's seasonal, it comes by every year in the winter. And it doesn't hit just the United States, it hits the southern hemisphere during our summers. And you wonder how much of that is due to people just being indoors more because it's cold, or if there is some other effect, like the fact that people are indoors and so they get less sun exposure. Their Vitamin D levels tend to be a little bit lower. You wonder if you were able to supplement everyone and get their normal levels, what flu season would look like or other respiratory problems that people have.

0:33:16.5 Thakkar: It's an interesting question. I think some of that variance is due to vitamin D, and there have been researchers who've stated so. One of my co-authors with Surgeon General Carmona was John Umhau, who I mentioned earlier, who in 2006 published a paper on basically exactly that question: Is sunlight the stimulus that causes that geographical and temporal variation that you're describing? There are other elements of physiological response to sunlight that could explain some of it too, that we can't really easily replace in a pill form.

0:33:57.9 Larsen: Sure.

0:33:58.2 Thakkar: For example, nitric oxide released from the skin can have some anti-microbial properties, and has interestingly hypotensive properties, which could be correlated to the fact that... There's been studies that people with my skin tone or darker, when they move to United States, end up having high blood pressure much more often than our relatives or ancestors did. And so could there be a sunlight connection there as well?

0:34:27.9 Larsen: Right, it's also very easy to fall down the rabbit hole and start thinking that vitamin D, or something else, is the one... The cause of everything, right? And so you can end up forgetting the fact that, well, the flu does happen, and they get it in San Diego. I think the angle of the sun's different in the winter, and things like that. But ultimately, there are obviously lots of things that affect it. One is, of course, the fact that you're infected with a virus, and that can cause problems to your body, and whether you have the right vitamin D levels or not doesn't matter. You may just get sick, whether whatever.

Medpage: Don’t Let COVID-19 Patients Die With Vitamin D Deficiency

0:35:02.0 Thakkar: Right, and we... None of us are saying that... In this information campaign, saying that vitamin D is the be-all, end-all, but we want it to be recognized as a factor, and we need all the protective factors we can get. And that's basically how we approached this latest article in MedPage Today last week, where Dr. Carmona, former Surgeon General, and John Umhau and myself wanted to get the information out there, that was trying to make it not controversial. So if people with a vitamin D deficiency do poorly when they have contract COVID-19, develop COVID-19, and if some early intervention studies are showing that replacing that and doing it aggressively decreases that risk, then until we have more data, there's no reason not to pursue that. Because we have thousands of people dying every day, and there has not been shown any harm in even these aggressive dosing regimens of 400,000, 500,000 units over a week in replenishment.


0:36:13.9 Larsen: Sure. Obviously, this is not medical advice. Talk to your physician. You do what you want, do what you want. But I think the things are pretty clear that it's really hard to overdose in vitamin D. I think it's not impossible, but there's certainly stories of people getting... Just accidentally getting mega doses and they're still usually okay.

0:36:33.4 Thakkar: Yeah, I think for the fat-soluble vitamins, I think we've over-emphasized the toxicity, especially for vitamin D. The other fat-soluble vitamins probably are worse for toxicity than vitamin D. So that's something we have to unlearn, I guess.

    • There are genes in th body which naturally deactivate Vitamin D


0:36:50.1 Larsen: Yeah, and so I guess the things are... Right now, we're recording this end of... Well, mid-January, I guess, and the vaccines are rolling out. I've had my first dose. I don't know if you've had one, but I'll be getting another one at some point. But for the rest of the country, it's gonna be months before they're vaccinated. And so if you're waiting three, four months for this vaccine, the virus is still around, there is still a possibility you're getting infected. You'll probably be okay, but you know, you might not, just never know. That's the hard thing about this. This is a pretty inexpensive simple intervention that you can take for yourself.

Vitamin D is super cheap, low risk, and will probably provide protection before vaccination

0:37:24.9 Larsen: Again, it's super cheap. Vitamin D, it's surprising how cheap... It's cheaper than lots of multi-vitamins you can buy. And so it just makes sense to me; why would you not do it? I've started taking it probably a month and a half... About six... A month and half ago or two months ago, because it just seemed to me almost no risk. You've got only upside. I'm not gonna go broke taking it, so why not do it? And I feel like that'd be a useful thing... Message to get out to people to just start... Just do it, because you've got really nothing to lose. It's like drinking more water or something.

[chuckle]

0:38:03.1 Thakkar: Exactly. Yeah, I couldn't have said it better myself. I think some of the pushback we get is that, "Oh well, you're gonna give people false sense of security if it doesn't really do anything... Does it... " There's intervention fatigue, right? So if someone does vitamin D, are they gonna not take the vaccine, or... None of it really made sense to me because it's just one other thing. I try to limit my... Not just limit, I've avoided pretty much all indoor gathering with anyone. I'm wearing a mask anytime I'm out. You can walk and chew gum, so I also take vitamin D, and I increased my dose in the spring last year.

Fear that some taking Vitamin D might assume that they can wear masks less

0:38:44.3 Larsen: Yeah, the fatigue thing is interesting question... Not the physical fatigue, but the intervention fatigue, where people are, "Well, if I do this, I'm not gonna do that." So it's not like people just do three things, and, "Well, if I add this, I gotta take something else off my routine." But it's also like, again, why would you not do it? Potentially, people were maybe not doing anything, and like, "Oh well, I could do that." Or, "I hate this mask. I kinda wear my mask, sort of. But now at least I'm taking vitamin D. I'll still do that, and I'll still wear my mask off and on, like I'm doing anyways." I don't think it probably... I don't think people probably have a list of things that, like, the maximum things they'll do, and they'll just stop doing another just because... Just 'cause you start running, it doesn't mean, well, I'm not gonna walk anymore. Or, it's...

[chuckle]

0:39:25.3 Thakkar: Right, or, I can eat whatever I want 'cause I'm exercising.

0:39:29.2 Larsen: Right, I guess you can argue people get gastric bypasses and think, "Oh, now I can eat M&Ms all day long." But I think you probably... In this case, if people are concerned enough to take Vitamin D, they're probably the type of person who're gonna continue all the other interventions that they're doing as well.

0:39:43.4 Thakkar: Yeah, and what's unique about it is, 40% of the country in winter is deficient. So it's a huge percentage of the population. It's the only vitamin we cannot get enough of from our diet, so we basically need sunlight or a supplement for most people, especially if you have darker skin. And like I said earlier, there seems to be this Venn diagram that overlaps exquisitely with the damage from COVID-19 and so with those three things, it just seems like it should be a no-brainer.

0:40:18.0 Larsen: And if the worst case scenario is it doesn't help you with COVID-19, but you're less likely to break your hip, I think that's a win. I'm more than happy to never do another hip fracture in the OR.

0:40:29.5 Thakkar: Yeah, exactly. Yeah, that's the other thing. Maybe we'll have the Vitamin D levels of our ancestors, that's the worst thing that will happen.

[chuckle]

0:40:38.0 Larsen: So as far as the vitamin D things go, what are you guys doing? I know you've written extensively, Wall Street Journal, like you mentioned, with the former surgeon general and others and you've got your website. Are you finding traction? Were you finding that it's picking up? I feel like for a while, the strange thing about COVID is that there'd be an intervention, people would say... Would almost immediately... Almost be opposed to it. There'd be... People would fall into camps like they're totally against it or they're totally for it. It was very strange. I don't feel like I usually see that in medicine. So how do you feel the adoption has been within, say, hospitals? Are lots of hospitals starting to say... When you come in with COVID-19, they check your vitamin D level, they give the vitamin D. What's your impression for clinicians?

Hospitals not including Vitamin D in protocol (yet)

0:41:23.0 Thakkar: So in the informal survey that I've done around people I know, there really is no... As of a month ago, was no protocol. So people were not routinely checked for vitamin D levels. They were not routinely given vitamin D. When they were given vitamin D, they were given normal doses instead of what should be more aggressive doses if they're in the hospital. And so part of our rationale in last week's article in MedPage Today was that's the group we wanna target as our audience. So we titled it, Don't Let COVID-19 Patients Die With Vitamin D Deficiency, because if all these papers that are coming out are right, the majority of your admissions are deficient.

0:42:16.4 Larsen: Right.

0:42:17.6 Thakkar: And if they're deficient, there's early evidence that shows if you aggressively correct that right when you admit them, they'll have a much better chance of making it, surviving this infection.

0:42:31.0 Larsen: Sure.

0:42:31.5 Thakkar: And so that's what we wanted to get out there and it's just frustrating. Dr. Fauci, a few months ago, said he takes vitamin D. There's unconfirmed reports he takes 6000 units a day, but it's not part of any official recommendation to... Other than he said if you're deficient, you should supplement.

0:42:52.0 Larsen: I found the whole intervention with it comes to COVID, is very strange and that we're not really talking about preventative things at all. Outside of avoiding getting infected, then it's like, "Well, oh, well. [chuckle] We'll have a vaccine at some point." But it doesn't seem to look at risk factors and try to find ways to try and help make yourself healthier. I guess you could argue that's the US medical system in general. We treat things as they become problems. We don't oftentimes attack things before they become problems when it comes to weight or much, I guess maybe cholesterol, but a lot of things we just treat as you... When you come in sick.

0:43:29.5 Thakkar: Right. And the difference here is that there's a death toll every hour...

0:43:32.5 Larsen: Well, yeah.

0:43:33.0 Thakkar: Every day. It's just like... That's what got me staying up 'til one researching this stuff and writing about it and connecting with people, much to the chagrin of my wife and kids.

[chuckle]

0:43:45.4 Larsen: I know. I had to convince my dad to start taking in stuff too, but when it comes to... If someone wanted to just start treating themselves with the assumption that you're probably deficient... If you're in the United States listening to this podcast, you're probably deficient. The recommendation is 4000 a day, 2000-4000 a day, which is what? 14,000-28,000 units a week. Now, you could take with vitamin D, because it's just stored in your fat, you could just take all of it one day a week if you wanted. You could take 20,000 a week or something 'cause I'll just be... I'll admit first right now that I am not someone who remembers to take medicine 'cause I don't take anything. So I figure I'm good enough to remember to take it once a week [chuckle] and so I take a handful once a week and that's my therapy.

0:44:35.2 Thakkar: A year ago, I would have said, "Yeah, absolutely." And in fact, if you wanna take it once every two weeks or once every four weeks, a big mega dose, you could probably do that. But having done the research over the last few months, the immune system effects of vitamin D might actually be autocrine and paracrine and not endocrine, which is the circulating in your bloodstream. So it might be more connected to the actual dose you take every day or every other day. So I've come around to, for this crisis, basically saying try to take it every day or two rather than weekly. And there's now some evidence that some of the studies that failed in the past for vitamin D, seeing vitamin D's effects on various things, if they were given weekly or monthly doses, they were more likely to fail. It might be connected to this issue which is that vitamin D supplementation can act as an autocrine and paracrine function for cells and not just endocrine.

    • Note: 70% of the RCTs use at least 100,000 IU in the first week

0:45:45.9 Larsen: Well, that's disappointing. So now I gotta change my routine.

0:45:50.4 Thakkar: You're probably fine weekly. I wouldn't go less frequently than weekly.

0:45:55.5 Larsen: No, that's okay. Again, I'm not worried about overdosing, so I can take bunch. I can skip a day and then remember the next day and just double it or something like that, it's not that hard.

0:46:05.5 Thakkar: There was a researcher, I forget from which country, who basically wrote an opinion paper, who said at the start of winter, we should just give everyone a 300,000-unit dose.

[chuckle]

0:46:17.2 Thakkar: One dose and carries you through the whole winter, but I don't think it would work. I don't think that would work as easily as he spoke about.

0:46:24.7 Larsen: Well, Dr. Thakkar, I'm gonna have to have you on later to talk about your company which is super interesting, Reimbursify. But if people wanna find your writings, I'm gonna make sure that they're linked to the show notes page at theparadocs.com/112. Where should they find you? It sounds like you're on Twitter, is that the best place to find out what you're up to?

0:46:42.6 Thakkar: Yeah, Twitter is good. My website is vatsalthakkar.com and then the open letter written and signed by 200 experts is at vitamindforall.org.

0:46:56.4 Larsen: And that's the spelled out for, F-O-R?

0:47:00.5 Thakkar: F-O-R. I think both of them work actually, but... F-O-R.

0:47:03.6 Larsen: By both websites. And your Twitter handle, what's that?

0:47:06.5 Thakkar: It's VatsalThakkarMD.

0:47:08.6 Larsen: Well, thanks so much for being on the show. I really appreciate it and hopefully, everyone's got a little bit different idea of what vitamin D is and will have a little curiosity and maybe decide to take a few pills.

0:47:19.8 Thakkar: Thank you so much.

0:47:20.9 Larsen: Thanks. Well, thanks again to Dr. Vatsal Thakkar and our discussion of vitamin D. But before we end, I wanna give you the link to the sponsor once again. If you need help reviewing your employment contract before you sign, reach out to a company with great online reviews and reputation for doing that and more. Find Resolve at www.doctorpodcastnetwork.com/resolve to get the renewal process started today. Thanks again and we'll talk next week.

[music]

0:47:49.5 Announcer: Thanks for listening to The Paradocs. If you like what the doc is doing, please subscribe and leave a review on iTunes or Stitcher and share the show with your friends. Become a supporting listener to get access to special bonuses at patreon.com/theparadocs. Show notes can be found at theparadocs.com.
[music]


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