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00:03 Dr. Renu Mahtani: Hello, I am Dr. Renu Mahtani, and today I'm going to talk to you about vitamin D toxicity. Is it really something to be so scared of? Especially at this time where vitamin D deficiency is a global pandemic, and we all know there are so many reports, so many studies that vitamin D is a necessity, especially for our immunity, for our immune health. So many viral infections are around and our immune system is weak. So can we enhance the immunity through vitamin D? A strong physiological barrier? Yes, the answer is yes. But at the same time, how about this fear of vitamin D toxicity? So that's what I'm going to be sharing with you today. Whether it's a real fear, a merited one, or a unmerited fear.
The dilemma remains.
- Am I getting enough vitamin D?
- Or, is it too much?
Well, vitamin D safety concerns we have to understand, because vitamin D is not just a supplement, or used as a replacement to correct deficiency, but it does have therapeutic potentials especially as an immune modulator for the host of autoimmune diseases. Of course, under proper medical supervision.
01:40 DM: This is a wonderful write-up by the Mayo Clinic, by none other than Dr. Michael Holick, where he says that, "Vitamin D is not really as toxic as was once thought." He gives a wonderful historical and up-to-date perspective. And I'm going to share it with you in a very simple way. Well, this will also let us know how the word toxicity came in. Early 20th century, when rickets was there, there was a policy of fortifying milk with vitamin D to meet up this deficiency. Same time in the '30s and '40s, massive doses of vitamin D were being given, real high doses. 60,000 to three lakh (100,000) international units daily, to treat conditions like rheumatoid arthritis, psoriasis, asthma, and tuberculosis. Well, in 1950s, a few cases of toxicity were reported basically because of hypercalcemia due to vitamin D, and they found that the reason was unregulated milk fortification. Therefore, fortification was stopped, vitamin D was labeled as toxic, that's how the word came, and obviously, it's use in treating diseases also stopped.
03:00 DM: And then a very low limit for vitamin D was set to see that things remain safe. So the blood level of vitamin D, 20 nanogram per ml was recommended as the desired blood level. But yes, the aim was to prevent rickets. And the recommended daily allowance of vitamin D that was proposed was 600-800 international units daily. So let's have this background in mind, and then let's see what happened eventually. This chart shows vitamin D levels in nanogram per ml, which used to be above 50s, 50 nanogram, and how the levels started to drop, drop, drop, drop 2010, and today, 2020 see what levels we see. Less than three nanogram per ml. Eight, five, four, it's sad. At the same time, we see reports where they are reporting that, "Oh, toxicity is possible above 80." Some labs say above 100. Some labs say above 100 is excess, it is not toxicity. So it is very confusing for a consumer who has gone for his or her blood test report.
04:15 DM: Then there was a realization coming up that the levels recommended of 20 and the dose of 600-800 IU is not adequate, and they've done a big vitamin D mistake. And they found that minimal dose required even for bone health is 40 nanogram per ml. And this can never be achieved by the dose that was recommended. And they found that one needs to take around 9000, 10 times what was recommended. 9000 international units daily to reach the level of 40 nanogram per ml. So the minimal required is 40 nanogram per ml. We simplify it with this chart because then came the recommendations by the reputed Endocrine Society which said that, "Well, sufficient levels in the blood, the range is from 30-100 nanogram per ml." Sufficient, it's good to have these levels. And similar recommendations were given by the Vitamin D Council. And the toxicity levels they mentioned would be above how much? 150 nanogram per ml.
05:23 DM: These were the recommendations given. Well, still labs continue using the old norms in their reports as the standards. And I would like to definitely highlight what the Endocrine Society recommended. Vitamin D state that, "Vitamin D intoxication is usually not observed until the serum levels are more than 150 nanogram per ml." You can see it in the paper. So why are you scared of 80 and 100? A 21st century evaluation of safety of vitamin D. Now that this comes to, "Okay, what could be the dose to get good levels?" They found that as outdoor personalities, our ancestors, used to make 10,000-25,000 international units of vitamin D daily. Yeah? And they found that if somebody is supplementing, long-term intake of up to 10,000 international units per day is safe and gives good physiological benefits.
06:27 DM: And there is no fear of toxicity when vitamin D is being supplemented at the rate of 10,000 international units per day. The target level in the blood is above 40, let us say, 40-60 nanogram per ml, which is way, way far away from the toxic levels. And this can be achieved by either taking 10,000 international units daily, or if that preparation is not available, like in our country in India, we get 60,000 international units in one pill, tablet preparation. It can be taken once a week for three months. And this has to be followed by a maintenance dose. Otherwise whatever has been achieved is going to come down back to zero. So maintenance, half the dose. So one can take 60,000 international units once in 15 days as a maintenance dose, always. Why always? Because food, vegetarian food has no vitamin D. And even otherwise, the other sources are not adequate to meet the complete requirement of vitamin D. And in today's time where our blood levels, you know, the blood levels of vitamin D are so low. See, 10, 15, 20, 30. And if we take even 10,000 IU, we cannot go beyond 60 nanogram per ml. And if somebody has levels above 40, even then 60, 150, very far away from each other. So in these replacement doses, we are absolutely safe.
08:01 DM: So what is this vitamin D toxicity and the fear? Well, friends, let's make it clear into our understanding that vitamin D per se is not toxic, but because it leads to absorption of calcium from the gut. And if the calcium is in excess in the body, that high calcium can give to the manifestations of the so-called vitamin D toxicity. And the calcium we get from diet, usually does not lead to hypercalcemia. It is the supplemental calcium if in excess, that can create a problem. But once again, in the supplemental doses that we have discussed, one can take calcium supplements without the fear of toxicity. But if somebody is landing up into high calcium, well, again, that is the only criteria to say that vitamin D is toxic. So hypercalcemia is the hazard criteria for vitamin D. Well, the fears, the phobias remain. People are still scared of taking vitamin D, but they say, "Oh, that gives kidney stones, kidney disease, heart calcifications." Is it really true? A very latest one, 2020 paper about vitamin D and kidney stones says that, "Therapeutic doses, even therapeutic doses of vitamin D do not really increase lithogenic or kidney stone forming capacity risk." It's not there. In fact, a low level of vitamin D, there's a positive association of vitamin D deficiency with coronary artery or the blood vessels of the heart getting calcified.
09:49 DM: See, the mechanisms are known. Vitamin D deficiency increases chronic kidney disease. All mechanisms are there, and leads to progression of not only kidney, but even cardiovascular disease. So there's no real fear of vitamin D per se leading to problems. In fact, nephrologists give vitamin D to people with kidney diseases. Alright now, coming to the most highest level of vitamin D, which one can go, there are so many papers. This is just for academic interest. We never go to these levels with the doses we are talking of as replacement therapy. Well, in this paper, they found that vitamin D levels above 240 nanogram per ml were required to result in clinically significant hypercalcemia. Another one, pharmacokinetics of vitamin D toxicity, it says that, although current data supports the view that the biomarker, blood concentration of vitamin D must rise above how much? 300 nanogram per ml to produce the so-called vitamin D toxicity, but the more prudent upper limit of 100 has been set, 150 has been set, may be retained to ensure a wide safety margin.
11:13 DM: Those interested must read this paper. This is a study on 4,700 patients, followed-up over a period of seven years who were given vitamin D in three different dose possibilities, either
- 5,000 international units, or
- 10,000 international units daily, or higher doses, like between
- 20,000-50,000 international units daily, the pharmacological doses to treat some conditions.
Well, they found that the vitamin D levels went up ranging from 74 to how much? 384 nanogram per ml and they did not find hypercalcemia, kidney stones, or any other adverse effect. Rather, they found that those who were taking high doses for a therapy, got good results on their medical conditions like asthma, and psoriasis. So there are so many studies. Let's see it concise and find definitely the safety ranges. Although doses higher than 30 have been given, but definitely there is no toxicity below taking 30,000 international units of vitamin D daily. There is no toxicity with that. And when it comes to blood levels, 200 nanogram per ml, below that, there is no fear of vitamin D toxicity, 200 nanogram. Well, you may be wondering, what is this 500? Well, there are some labs which check in nanomoles, a different unit, and there's a difference of 2.5 between the two. So 200 nanogram, below that, rare to see toxicity.
12:51 DM: And that same paper by Mayo Clinic that vitamin D is not as toxic as was once thought. There is enough evidence that vitamin D toxicity is one of the rarest medical conditions, and is typically due to intentional or inadvertent intake of extremely high doses of vitamin D, usually in the range of 50,000 to one lakh (100.000) IUs daily, and that too for months to year, and that too, without monitoring for hypercalcemia. So, fear of vitamin D toxicity is actually unmerited, because their benefits are too many, and we are missing out on that. The fear is actually of high calcium. Elevated levels of only vitamin D, do not correlate with clinical vitamin D toxicity. So if blood levels are, let us say, above 80, 100, or even 150 alone, it does not mean that there is vitamin D toxicity. And a clinical, or a symptomatic vitamin D toxicity will happen only when the blood levels are more than 200 nanogram per ml, and that too, accompanied by high calcium in the blood and high calcium in the urine, hypercalcemia, hypercalciuria, and below normal PTH or parathyroid hormone level. So if somebody has high vitamin D levels, but the calcium levels are low or within the normal range, PTH is within the range, there is nothing like a symptomatic or clinical vitamin D toxicity.
14:31 DM: So friends, to quote Dr. John Cannell, who so beautifully says, "Worrying about vitamin D toxicity is like worrying about drowning when you are dying of thirst." We are so low in vitamin D, we are thirsty for vitamin D, and we are still not taking it because we are fearing that we may get drowned. So, vitamin D toxicity is not really something to be worried about. We need vitamin D for good health. Dr. Coimbra, the famous neurologist from Brazil, who is treating autoimmune conditions with vitamin D, he is my teacher, and he so beautifully says, "Vitamin D is not just a pill or it's just any other conventional medicine, it's actually a gift of sun to us without which no life, no health is possible." Vitamin D according to him is a mechanism that nature took millions of years to develop, and even if the pharmaceutical industry spends 400 years working on this issue, they would not get close to the benefits by making anything else, because it cannot provide what vitamin D can provide to the people. So with this friends, thank you very much, and I wish you all best of health, especially when we are going through this crisis of infections and a weak immune system.
Please don't be scared of vitamin D.
Do supplement it properly and stay healthy.
Thank you so very much.
Overview Toxicity of vitamin D in VitaminDWiki
- Examples of safe without adjusting cofactors:
- 2 million IU daily for 1 week,
- 200,000 IU daily for 1.5 weeks,
- 150,000 IU daily for 2 weeks,
- 50,000 IU daily for 5 weeks
- 14,000 IU daily for 1 year
- All items in category Toxicity and Vitamin D
Items in both categories Toxicity and Loading Dose are listed here:
- Vitamin D Replentishment (Loading doses are not toxic)– Feb 2012
- Can You Overdose on Vitamin D - It's Harder Than You Think
- Vitamin D and UV safe and toxic doses - Vieth 1999
- Barefoot on mega doses of vitamin D and his book on Cancer
- Megadose injection of up to 600,000 IU vitamin D3 every three months for adolescents - April 2010
The TOP articles in Toxicity of Vitamin D are listed here:
- Vitamin D toxicity is extremely rare, accidental, and very mild in Iranian children – July 2020
- Large dose Vitamin D taken in 32 long trials –adverse events were rare - Dec 2018
- Guide for patients on high doses of Vitamin D – Coimbra 2017
- 2000 IU of vitamin D- doctors trained that it was too much, but it is often too little
- Many more people now have vitamin D levels above 50 ng, especially seniors – May 2015
- A vitamin D level of 746 ng due to medication error was not toxic – April 2015
- 1000 IU of vitamin D (per kg) can indeed be toxic – 1947
Vitamin D Toxicity - an unmerited fear - Renu Mahtani video and transcription - Oct 2020
- Some drugs change potency when Vitamin D is increased (increase in a hormone)
- Some chemotherapy can be deadly if the dose size is not reduced while taking high Vitamin D doses
- Vitamin D accumulation in 1 in 300 people due to gene (CYP24A1) can cause Calcium problems – June 2018
- 2 solutions: Reduce Calcium, Increase Water (Coimbra protocol does both)
- Comparing High-dose vitamin D therapies Coimbra and 3 others
- Is too much vitamin D bad – possible causes and cures
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