Dr Wimalawansa and Dr Mobeen Syed Interview
Transcript
Mubin
So the discussion today, we took a detour from the inflammatory pathways and the discussion is going to be about vitamin D. We have Doctor Sunil Wimalawansa with us. Let me just quickly show you some of his work. So this is his research gate. 373 publications 212,559 reads 12,232 citations this is some of his papers that are lined up here on scholar dot google.com dot. You can look for him. Professor Sunil J. Wimalawansa and these are some of the vitamin D discussions. We are actually going to create a series of vitamin D discussions as well.
All this is Doctor Mubin Syed from drbeen.com. welcome to one more show.
So the discussion today we took a detour from the inflammatory pathways and the discussion is going to be about vitamin D. Doctor Professor Sunil J. Wimalawansa is with us. He is. His whole career has been working on vitamin D and its related topics. So let me just give you a quick note about his biography and then we would start having the discussion again. This would be a mini series about vitamin D. Today will be the first lecture. So Doctor Wimalawansa, he's an MD, PhD, MBA, DSc, he's a physician, scientist, researcher, educator, author, innovator, philanthropist, board member, leader and process consultant. His clinical expertise include endocrinology, human nutrition, vitamin D, disease prevention, metabolic diseases, osteoporosis, CKD, health policies and social sciences. Hes a former university professor, professor of medicine, chief of endocrinology, metabolism and nutrition and physiology pharmacology at the Graduate School of Biomedical Sciences bio actually continues. I'm going to, you know, invite doctor Wimalawansa and then hear the rest from him. So Sunil, welcome.
Sunil
Thank you Mubin for especially inviting me to have a discussion on a very important topic on this right time with a lot of assets on vitamin D from big pharma and other organizations for whatever the reasons.
Mubin
Absolutely. So a couple of things for the, for the audience. Number one, this will be a CME lecture. So I have no conflict of interest. I'm sure that doctor Sunil Vimila Wansa also do not have any conflict of interest. And doctor, you can vouch for that, correct?
Sunil
Yes, absolutely. No conflict of.
Mubin
And the second thing is you may hear doctor Sunil would need occasional breaks while he's speaking and the reason for that is that he had a throat reconstruction surgery. This is after many months of voice rests. This is the very first time he is going to speak with us and having him to speak for more than two, three minutes is going to cause stress on his throat and vocal cords. So I'm going to interject every so often to give him voice rest. So don't, don't think that I am rude, but he has already asked me to give him these opportunities. So with this, Sunil, welcome. Tell us a little bit more about your career and your work.
Sunil
Yeah, I've been in throughout my life I've been in academia and never done classical private practice in that sense. But in parallel, I have been doing research almost 45 years. And interestingly, I started some work in vitamin D going back to 1980 82 actually, and in the Royal College of the post Royal Postgraduate Medical School in London under Professor McIntyre, we were doing some studies on the effect of calcitriol 125 antivitamin D on various cancer cell, cancer cell lines. And this is back in 1983, 1984. We clearly showed that adding the certain amount of vitamin D will prevent the cancer cell growth and actually revert back to somewhat stable cells. But again, we didn't know the mechanisms or nothing like that back in how many almost 40 years ago. But now with especially past couple of decades, there have been a fantastic research work published related to mechanism and we can discuss sometime later on how vitamin D affecting neutral cancer cells. And one of my main interest is the immune cell, how the immune system is getting controlled by vitamin D adequacy.
Mubin
That is such an important area. So during the COVID time, as we all started becoming more and more sensitive towards the vitamin D levels, I'm so excited to hear that we can do those kind of well. So let me start with this for our audience's benefit and for this, the listeners afterwards, what is vitamin D? I hear a lot from my audience sometimes in comments that vitamin D is the right vitamin D if you have the sun shining on your skin versus the supplement. And there are some who say you must have supplements. So what is vitamin D and what is the vitamin D from sun versus supplement? Can you please help us?
Sunil
Yeah, happy to, Moby. Now, before I really address that one, I need to say something, another very confusing area. Vitamin D is not a hormone. That's, let's get it very clear, because people keep publishing things like the vitamin D hormone, this and that hormone. Part of the vitamin D is one aspect, which is the 25 hydrox vitamin D converted to catheter from the renal tubular cells and liberate into the circulation. That is by definition vitamin D. That's about one third of the story of the vitamin D. Now, coming back to the question, naturally, vitamin D can be and should be obtained from the sunlight through the uvb ultraviolet B rest. And here's another confusion and people have seen publishing any time of the day, if you go in the sunshine, you get the vitamin D. This is not the case.
Mubin
Interesting. I could actually go anytime. And once again for my audience, my interjections are only to give Sunil some voice rest. So these may be misplaced interjections. I would correct them as I work more with Sunil. But I thought sunil anytime, morning, evening, middle of the day could help us.
Sunil
It's interesting, when I was seeing when I was in high school, the biology teachers, I used to say that oh, the morning sunshine is the best and all these things which we believe. But here's the land, the vitamin D, the ultraviolet risk coming from the sun cannot penetrate in the early morning or afternoon. That angle, it just reflects from the skin. It doesn't get in. So it has to be the angle, what you call a zenith angle from the sun and the 90 degree, that angle is very important. Narrower the angle, higher the amount of uv rays going inside the skin or dermis. So this happens. Ideal time is at 10:30 a.m. till 01:30 p.m. so beyond the outside that the amount of vitamin D generation by exposing the same amount of sunshine is gradually losing by the early morning and evening production of vitamin D is near zero.
Mubin
I did not know this so I'm not making this up to give you the voice rest. I did not know that this time window and this angle was important. So thank you very much for this. So the vitamin D is now how is it manufactured in our skin? And I still am very curious what is the difference from the vitamin D that we take from supplements?
Sunil
Until about two decades ago, the most, almost 90% of the supplemented vitamin D was vitaminD2 coming from the yeast fermentation and then irradiated to generateD2. But there are significant difference between the D2 which is plant based andD3 is animal based. Vitamin D, like salmon or humans all generate in the D3. There's no mechanism D3. The two key differences are the half life for vitaminD2 is shorter. Therefore then it will not retain in the blood for longer period which is very important for biological and physiological activity. Secondly, the competition between theD3 andD2 for receptors. Most people believe that they suggest that they are kind of equal. But the consumption of vitamin D is more rapid. Therefore the levels will not retain.
Mubin
So from the sunlight, do we get vitamin D2 or D3
Sunil
Absolutely.D3. Human cannot produceD3. Only the only plant cells can doD2.
Mubin
Understood. So does that mean that sun going out in sun is an essential part of our daily life?
Sunil
Well we as human beings were evolved over the millions of years to get that, be in the sunshine during the midday time and run around and make our food available and generate enough vitamin D for the entire day. So daily exposure towards the midday sunshine wasn't normal as happening now. Even in some part of Africa they get plenty of sunshine. Their levels, average levels are about 50 nanograms a mil. That's about 125 nanomoles per liter. So that's supposed to be the physiological or healthy level of vitamin D. But understood. Thing is with time over the past few decades we have become more and more indo air conditioned environment and we are exposing to sunlight. This between less and less. Even if you go out we use sunscreen ladies wearing umbrellas. And the amount of vitamin D getting has become significantly lower over the past decades.
Mubin
So two questions here and I think these are very important questions for general public all of us. Number one, so between let's say this, 1011 to 130 how much time should we be out there to get the sufficient amount of vitamin D generated for our daily that day? And secondly, I have heard from some of my audience that they say hey your skin is brown, you can tolerate this skin and maybe youll make less vitamin D than compared to me. But when I go out ill get skin burn more easily as well. Does the color of the skin matter? Number one? And number two, how long should a person be in the sunlight and how much of the body area exposed?
Sunil
Fantastic questions mobin. It's essential to know the answers to both now timing wise. Well let's take a step back. The skin darkness due to melanin pigmentation. I mean there had been a lot of studies on the characterized from level one to level six and they give funny names for those colors. Higher the number is the darker the skin. So like yours probably somewhere between two, two and three. Mine with a brown skin probably close to four. So somebody with darker skin will stay in the sunshine. They need a longer time to generate the same amount of vitamin D compared to somebody with white skin stay in the same sunlight. In other words if we feel somebody with a white skin and dark skin say sometimes for 20 minutes the person with the white skin probably generate three times more vitamin D through their skin which is natural because more UVB will be entering their skin and the darker skin it will be reflected.
Mubin
Understood? Understood. Thank you very much for this. I have a couple of questions before we continue from the audience members. And this is one of our patron that our audience, the cool beans, I call them. We all are a community and we ask questions and we discuss. So here is a question. Renat says, does it mean in winter time here in middle central Europe, where I'm living, I have no vitamin D building by being outdoors. I think that is correct.
Sunil
Wintertime, no matter where you are in the. In the cold climate, or what you call the temperate climate, your generation of vitamin D could be zero, despite plenty of sunshine. Again, the same principle. The angle of the rays coming from the uvb rays coming from the sun is coming such a broad angle, it cannot enter into your skin. Simple as that. We can change that nature.
Mubin
Understood. Thank you very much for this. There is one more comment. Jen says it is important to consider latitude. The further away from the equator you live, the less uvb is available, even midday, especially during the winter.
Sunil
Absolutely correct. Again, away from the equator, the sun rays, the quantity of uvb reaching skin or the earth is become less and less less. Same with the pollution of the air. Will filter, can filter 100% of the vitamin D some area the polluted cities, you can go and check their vitamin D is three, four and five, despite their work outside. Because although uvb rays are filtered off by clouds as well as dust or the contaminated air.
Mubin
Makes sense. Makes sense. So this is a very important question. So I am so glad that you are here. Thank you very much. And someone with this 40 plus years of experience in the vitamin D area and speaking with us, it's like our treatise, Paul Bork says, how should we balance risk of skin cancer with vitamin D formation?
Myth - Melanoma from the sun
Sunil
That's another excellent question. The clearly, the overexposure to the sun, in other words, with the skin burns or blisters, should be avoided at any, any cost. Because continuous damage like that, or even intermittent damage like that can lead to squamous carcinoma and other type of cancer. So it clearly is no point having the blisters and the sun burns. That's too much exposure to sunshine. So ideal thing is to, even for children, is to expose the sun, say 20 30 or 40 minutes, depending on your skin color. And the dark person can stay little longer and then apply enough uvb protection cream and rest of the time you can run around, but you may not developing vitamin D, but you're protected from skin damage. The third thing is important, actually. There's a huge myth by the dermatological societies. It happened about 34 years ago. Skin exposure is the number one cause of melanoma is absolutely incorrect. In fact, the commonest area affected in human from melanoma is the solar the foot. So how many of your solar the foot are actually exposed to the sunshine? None. Zero. So I mean, this is a simple example, but there are a lot of publication, hundreds of publications showing that exported sunlight actually reduced not only the risk at risk of death from melanoma, there's a protective effect of sun and the vitamin D on melanoma, but not the other cancers.
Mubin
Very interesting. So this is so great to hear this. I would wish that you're just sitting here and we continue to ask you these questions. One question that I have. So let me first go here for us is thanks Professor Wimalawansa for overcoming your operation. Please comment on why vitamin D3 is not immediately converted to calciteriol. Therefore, if you have an acute viral infection, should you dose up with calcifediol? Immediate action as well as. Sorry, they just scrolled up 1 second immediate action as well as vitamin C and zinc and quercetin. So I'm going to talk about the accompanying things in a second, but let's take up the vitaminD3 and the dosage. If in an acute situation, what should we do?
Sunil
Again, a fantastic question. Thank you for asking that. It has a deep, deep. So can I show a couple of slides?
Mubin Absolutely. Please.
Sunil
Now this is. I put that to 2 hours ago as you created these slides too. I thought that to be going to be useful. This may be jump in the gun, but at the same time it's actually important. One key aesthetic that you need to have about 40 nanograms per milliliter in the blood as a minimum vitamin D level for most of the diseases. But as you if anybody had read the Institute of Medicine report or in society, their recommending is 2020 nanograms. Meal washing arrived only for skeletal health prevention of recurs in children and osteomalacia in adults. Nothing else. 20 nanograms a milliliter doesn't touch any other diseases or any other body system. So that's why the problem problematic to rely on that. Now on the other hand, historically, I mean this is nothing new, but 30, 40, 50 years ago people have used a uv radiation by sunlight and also artificial uv radiation to treat tb, psoriasis and number of other diseases. Interestingly, when I was a medical student 50 something years ago, I worked for a rotation with the number one tb expert in the world that time, Professor Vairanathan. So I used to ask him why we are taking all the patient to sunshine during the 10:00 in the morning. Don't ask me a question, he says, because we didn't know the reasons behind it, why we are doing that. But the importance that vitamin D generated through the sun exposure and uv exposure has a tremendous amount of beneficial effects on the immune system, including the generation of antimicrobial peptides, a whole bunch of them. So those can actually kill the bacteria, intracellular bacteria like tuberculosis, sarco, and then also to improve the immune system function, to maintain a robust immune system. So this is a slide we publish in the nutrient to summarizing the effects of vitamin D deficiency. I mean, you can also convert this to what happened with vitamin D sufficiency or lack of disorders including cancer and autoimmunity, increasing the metabolic disorders like obesity, diabetes, type two diabetes, or type one diabetes. And then the non traumatic acute illnesses, many of them like pneumonia, to infection, to gastroenteritis, and a whole bunch of chronic diseases like osteoporosis, eye issues and, and then the musculoskeletal disorder is the one had been studies most over the past 80, 90 years. And indeed the pregnancy and the infant has a tremendous effect if we don't have the right level during the pregnancy and during lactation.
Mubin
So just to give you a quick rest, the question that I have is when this research was going on for decades and when researchers like you are aware of these things, why are we? And you don't have to answer this, it may be rhetorical, why isn't this a more public awareness? Why aren't we more publicly discussing these things? Why are we just sticking to 29 milligrams nanogram per milliliter type messaging? Is there a problem with messaging or it's just, this is how medicine is?
Sunil
Well, both. Unfortunately, the messaging has been always been negative for generic medications, including, including for the nutrient, because there's no economic value for entities like a farmer, for example, or the, or even the medical societies, it's no difference. So these are not patented drugs and nobody can make money out of that cost. Treating vitamin with vitamin D for any of these illnesses costs about $5 per person, or even less. This is contrast to about $2,000 using the patented medication. So there are many reasons why this message on public health importance has not been delivered or disseminated and sometimes actually obviously prevented.
Mubin
Understood. Just to give you an example, during this Covid time, someone, I have many medical students or doctors who were my students, someone reached out and he said, we have a hospital, which has developed a habit of bringing people out in the open under the sunlight who have Covid. And that is helping. And of course this is modern time. So other hospitals and doctors protested and said, what are you doing that you're bringing people out? And they said when we bring them out in sunlight, they actually recover faster. So I'm sure that vitamin D is one aspect of it.
Sunil
Yes, because we know through the research by professional like Mike Hollick and exposure to proper exposure to sunlight can generate anything from 8000 to about 15,000 international units per day. So there are plenty of vitamin D can be generated with a proper exposure. When I say proper exposure, at least one third of the skin surface area is exposed to the direct sunlight can generate that amount. It's also important note when I emphasize the direct sunlight, because some people I know have come across many actually having sunbathing inside the, inside the houses or through the window protected. They don't realize that wind, depending the material of the window, it can screen the uv rays up to 100%. So you may not getting vitamin D, but you can still get sunburned because through the other rays like infrared and the UVA rays. So there are a lot of other minor things important to know.
Mubin
Understood? Understood. So I have a question that I'm going to ask you about sufficiency. However, I'm seeing there are tons of questions from the audience as well. So if you don't mind, can I ask you a few questions or should we talk about what does sufficiency mean first?
Sunil
Yes, of course. And I like to ask it by slight society difference, because different agencies and the governments across the world, actually not only us, UK, Germany, France, all of them had been stuck with the Institute of Medicine kind of guidelines with the 20 nanograms as gospel, saying that, okay, that's if you have 20 nanograms, you're good, you don't need to. So to achieve that, they have come up with this with a formula that 600 international unit is sufficient to generate that amount and you don't need anything more, even in the vulnerable people. So, which is not only silly, it's actually dangerous. And somebody has estimated that because of that kind of recommendation, there have been excess over 200,000 deaths across the world, simply because people are adhering to that wrong information coming from the government. This includes the Institute of National Interest of Health, CDC, FDA, all of them, they're stuck in the 40th behind science. So what we need is to move that needle towards the 40 and 50 minimum level, which we know that it covers about 80% of the disorders with 40 nanograms per milliliter and with 50 nanograms per meter and milliliter above. About 97 98% of the various diseases, not the population variation disorders, can be overcome using that one.
Mubin Very interesting.
Sunil
There is a remainder for one person or one and a half percent of the people with rare disorders or common disorders, but they have a abnormal metabolism or something to prevent the conversions. They are the only people who are going to need much higher doses, like 15,000 a day or more, as some people have been treating. And they might need the blood level of serum 25 hydroxy above 8100 or even higher level, but it's a very small percentage of people.
Mubin
Understood? Understood. Thank you very much. So I'm going to quickly scan through some of the questions here and bring you some questions. Just give me one quick second. In the meantime, I see that there is a hand raised by. By Caroline Nylandz. So, Caroline, did you have a question? Let me see if I can find. I have a hard time keeping my vitamin D levels up. Is there a role with low vitamin D and obesity, Lyme disease or mold toxicity?
Sunil
Absolutely, yes. The higher the obesity, when I say higher, means above the. Whatever the BMI level you are supposed to be with high ten weight and your level of vitamin D in the circulation going to reduce. Two reasons. Firstly, the fat cells absorbed vitamin D from the circulation and 24 hydroxy D also. SoD3 and 25 hydroxy D both getting adsorbed into fat cells and they get degraded. They actually doesn't even store them. They degraded part of that. Secondly, there's a liver and other enzymes in the people with obesity and overweight increase the catabolism of vitamin D 325 and 25 hydroxy D. So they will be converted to inactive form of 24 hydroxy vitamin D components. It's happened through the zip enzyme from the liver called 25 hydroxylase. So that enzyme get activated in people with obesity. And there are other disorders also. It can happen. But obesity is classical one because of that, the amount, the turnover of vitamin D is faster, therefore difficult to maintain the 25 hydroxy level. Consequently, they are going to need to increase the intake by three, four or even five fold compared to non obese person.
Mubin
Very interesting. I never actually thought about it this way. I always thought that the fats would store vitamin D and release them when you need it. I did not know that the fat actually the cells would start destroying the vitamin D and kind of depleted. So thank you for this. There is a question here from renette how long does the body store up vitamin D? Can I build up during summer a storage of vitamin D for darker winters?
Sunil
Unfortunately, not the. This toast, we don't know exactly, but this toast will last only for few weeks. So if you don't get exposure or get a vitamin D supplement till from November onwards, by January, your level will be less than half of what you used to be. So that's why the supplementation going to be important for people in the temperate climate, climatic countries. Even if you, as Jen said, even if you go to the sunlight, you will not generate any vitamin D. Understood.
Mubin
So I have a question by Faraz, and there are so many questions. Thank you. There's a question for us is please confirm. It makes no sense to take vitaminD3. When you get the beginnings or prodrome of a viral or bacterial infection, does it make sense to take calcifediol? Is calcifediol antiviral, antibacterial? Immediately.
Sunil
Thank you for the question. Actually, somebody else also asked a similar question. We couldn't answer that one, but ten minutes ago. So you're absolutely right. And vitamin D, when you take orally, it has to get absorbed through the intestine, but it cannot get into the bloodstream directly because they are fat soluble. So vitamin D, they get into the lymphatic system of the gut and very slowly, slowly moving like a. And then finally through the thoracic duct on the neck, get into the circulation. And moreover, that when they get into the liver, it need to get converted or 25, 25 hydroxylated into form. 25 hydroxy vitamin D. So this process usually take about three days in normal human being, but in obese and other people, it might take even a week, somebody's sick. And in the ICU, it might take ten days to get delayed. So absolutely correct that somebody acutely ill, giving vitamin D alone have very little beneficial effects because you need to stimulate the immune system or this body system now, not in three days time, way too late. Patient will be dead by then. So this is the area the calcific diol become life saving. I have published in my last few papers on the importance of this one. So for the audience benefit of calcifediol is basically theD3 orD2. Once they converted to 25 hydroxy, vitamin D is called calcifediol. There are one calcifer dio. So the advantage of casper diol, actually, once you get orally, it get immediately into the bloodstream. It's a water soluble because of the extra hydroxy group. So you get into the, through the intestine, through the hepatic vein, go directly to the liver within about hour or two and the liver will convert it that to 24 hydrox vitamin D and circulatory 25 hydroxy D level increases. Bye. 4 hours. It's pretty fast and that will allow the immune system, for example, to get stimulated and you can see the robust immune activity within one day. So that exactly what we need in somebody with acute diseases.
Mubin
Very interesting. Thank you so much for this one. These are great topics and I see so much misinformation. Not, I'm sure it is not intentional, but just so much confusing information out there. So thank you for this. A few more questions. So apologies, we are more on the questions today than a lecture. So Duane says, do vitamin D lamps provide adequate levels?
Sunil
Yes, but the problem is actually the control and the dose response from the UVB labs and I calibrations are, I don't know, I have not actually studied myself. But people who studied have shown that it's unreliable. But on the other hand, during the winter, for example, somebody's getting sick. It's one of the ways to increase the vitamin D level on a routinely basis, but not somebody's acutely ill, again, because it's generatingD3 that take three, four days to convert it into the real stuff. So generally, generally, most physician, including me, don't recommend to use in the uv labs, but that doesn't mean you cannot use it. You can use it, but you have to, you need to know what exactly you're doing with those. We don't want to have overexposure and get sunburns or overexposed and generate more vitamin D, which is not going to be any additional benefit because skin will destroy those excess generated vitamin D. Understood.
Mubin
Thank you so much. And I want to very quickly remind the audience once more, we have doctor Sunil Wimalawansa with us. Let me just quickly show you some of his work. So this is his research gate. 373 publications, 212,559 reads 12,232 citations. This is some of his papers that are lined up here on scholar dot, google.com dot. You can look for him. Professor Sunil J. Vimala Wansa. And these are some of the vitamin D discussions. We are actually going to create a series of vitamin D discussions as well. So just a quick once again introduction in the middle of the whole discussion now, I have the age old question for you, Sunil. The question is, what is the role of magnesium? Should that be taken with vitamin D separate from vitamin D? How do we take calcium? Is it necessary to take with vitamin D? Does vitamin D cause calcium metabolism issues? And should we take K2 with it or not K2 with it? What happens to the blood thinning and all that? And any comment there?
Sunil
Yeah, it's a complex question with the built in, many questions within that. So let me scale share the screen. I hope you can see that.
Mubin Yes, we can.
Co-factors – Magnesium, Omega-3, Resveratrol, etc.
Sunil
Okay, so here's a slide again, I prepared but 3 hours ago now. So anticipating these kind of questions. So there are several cofactors necessary for either vitamin D or vitamin D receptors or actually the combination of them for them to get together to go to the nucleus to do the genomic actions. So magnesium is one of the key players essential to have the for this particular role of vitamin D receptor activity. Magnesium also necessary for sip enzyme to activate vitaminD3 to 25 hydroxy D as well as Cassidy travolator. So it plays a role in every aspect. And this can be easily avoided by taking a full large size banana every day, which produces about 200 milligrams of magnesium, or take magnesium supplements every other day or something like that. And there's absolutely no harm by doing that kind of thing. But I don't want to see people taking two or three types a day and end up with diarrhea and all the other problems. Anything excess of good thing can be harmful. Now on top of that, there are a lot of other cofactors like resveratrol. And if you look at any of these recent publication, you can see that even omega three fatty acid is a cofactor for vitamin D receptor activity. So increasing magnesium itself, as I said here, is helpful to overcome this disorder. The problem is if you are magnesium deficient, you can give any amount of vitamin D. It may not be active.
Mubin
Understood, thank you very much. I have one more. Faraz is asking for a comment from you that calcifediol is not easily available. It is soluble and is converted to triol in the kidneys, not in the liver. Please. Can professor confirm that Diol is in phosphor triol active via kidney, not liver?
Sunil
Oh, absolutely. Kidney has no capacity to generate Calcitriol because it doesn't have the one alpha hydroxylase enzyme. However, one x ray hydroxylase is enzymes available everywhere, every other cells in the body. Kidney is. Of course we knew that for how many, 80, 90 years now which produced the hormonal form of cassidriol. So 125 dihydrox vitamin D, which is the acting on the musculoskeletal system, prevention of stimulation recurs and other muscular disorders. More importantly, that 24 hydroxy vitamin D is taken up by. Let's take that. BothD3 and 25 hydroxy vitamin D are taken up by peripheral target cells, vascular system and brain, and notably immune cell, all immune cell. So within the immune cells or within these cells, these two are converted to calcitriol. Most important thing, actually, it's the circulatory Calcitriol is about 900 times less thanD3 and 25 hydroxy vitamin D. So it doesn't have a capacity to enter into any other cell other than kidney, muscle and parathyroid gland because those cells have an active mechanism of extracting vitamin D caul into these cells. So immune cell doesn't have that. It had to, depending on the diffusion against a gradient. So level is so low, none of them actually getting into the cells. So these cells. Calcitriol is an essential component for immune cell activity, but they're depending on the circulatoryD3 and 25 hydroxy D. Hence the importance of the daily intake of vitamin D to maintain that higher level. 40 nanograms meal or 50 nanograms, a meal that produce a continuous supply of these precursors for immune cells and other cell, cardiac cells, for example, to generate intracellular calcio, which does all the magic inside the cell.
Mubin
Understood. Thank you so much. So the. Before I go to more questions, I want to ask you something. We were, you and I were discussing about the levels and my curiosity was how many of us actually do not have the correct levels? Meaning how many of us are at risk of diseases that can be easily prevented, hopefully easily prevented, by correcting our vitamin D levels? So what are the stats there? Are we majority in a sufficiency level or adequacy level or not at all? What is your knowledge?
Sunil
So the globally as well as in us data shows that at any given time, 50% of the population are vitamin D deficient. This is considered in the 30 nanograms of meal as a cut open, which is not so any given time, 50% of the world's population. So we're talking about four and half billion people in vitamin D deficiency. So if you take the 40 nanograms as a cutoff point, that increases by another by 20%. And what is necessary for overcoming infection is 50. Only about 15% to 20% of the world's population is having sufficient vitamin D. So you can imagine the negative effect of not having sufficiency causing diseases, infection, complication and dying from infection like Covid.
Mubin
Understood so there is a comment from Jen Aliano. I believe she is Jen, who we both know. So she wrote, immune cells can take diol. Oh, sorry, it's scrolled. Immune cell take Diol directly into the cell for conversion to triolite. So not necessary for the kidneys to convert. It might be helpful to show our diagram, doctor W. So this may be a comment to you.
Sunil
Okay, I can do that. Now that this particular slide is on, that shows that your second part of the question you asked about K2. And let me answer that K2 controversy of the vitamin D. So I'm not going to read any of these slides. These are self explanatory and very simple language. I put that. So theory is that K2 direct the excess calcium, most important, ionized calcium from the blood into bones, away from the soft tissues, particularly the vascular system. That's the whole premise of getting K2 with vitamin D. So here's amount of K2 you might need. Again, this is an area controversial and we do not have specific data to show categorically say that, okay, 50,000 vitamin D need this amount of K2. We don't know that, we don't have that data. But this is, if you read this text says you get an idea of how many micrograms of K2 you're going to need with the different doses of vitamin D. Particularly this one I created a little while ago, shows that every 250 micrograms or 10,000 units of vitamin D going to need 100 micrograms of K2. So that's the K2 comes on the two doses in us and most countries, which is 100 micrograms or 800 micrograms. So very easy, 100 micrograms, you can take daily 800 micrograms. Like myself, we are taking once a week. So it's convenient if you're taking the higher dose, like 50,000, actually, 10 is missing, then you take 800 micrograms. So let me show.
Mubin By the way, thank you very much for clarifying these magnesium and K2 topics.
Sunil
Let me see. Yeah, this is the slide from grassroots health Jen was referring to. So give a good idea of how the vitamin D generation generates. AndD3. And then theD3 is getting converted to 24 hydroxy d at the liver to 24 hydroxylase at the same time. As I said before, that part of that, perhaps a majority of that it absorb into the peripheral target cell. There are millions of them. And converted theD3 and 25 hydroxy D both not only 25 hydroxyl, butD3 and 25 hydroxy D into calcitriol. So bothD3 and 25 hydroxy D are the precursors for which partly generated from the kidney and the other part is generated for the peripheral cells for their own metabolism and activity. Importantly so that calcitriol is one bind to the VDR, what I call actually CTR calcitonin receptor. Together that complex going and bind to the DNA promoter regions and either increase or suppress the gene expression. So that's a genomic part of the action of vitaminD3. However, the vitaminD3, sorry caccitriolose have a non genomic part of vitamin D. It has effects on the membrane, membrane stabilization like in the muscles as well as the vascular endothelial cell, the stabilization depending on this one membrane effects and even more importantly the immune cells. This calcitriol acts as autocrine, also called intracrine and the paracrine effects. Let me explain the two important things. So this enough calcitriol within the immune cells can activate within the cells other area without going into the nucleus. So that's called the intracrine or para autocrine effects of vitamin D. Tremendous activity including the generation of antimicrobial peptides. The paracrine effects is less. Paracrine means actually that catheter will come out of the cells and act on the nearby immune cells. That defects. We don't know that much but it has been demonstrated in in vitro cell culture cells and it has a direct effect on adjacent cells. So all these things are important. But people are only concentrating on the catheter coming out of the kidney which is important but it's not the whole story.
Mubin
Understood. Thank you so much for this one. And we are coming about to an hour as well. So I would like to quickly see if there are some more questions and remind the audience that we will do a series of talks. And I am very much interested in understanding the vitamin D and immune systems role or their effect. Vitamin Ds effect on immune system, on pregnancy, on preventable diseases, infections, Covid like situations and just in general what should be the best levels that we can stay as healthy as possible with this simple trick. So let me just quickly look at some more comments or questions here. So just 1 second. So we talked about vitamin K. So this is an interesting one. Martha says how important is exposure of the eyes to sunlight especially for those who have lens implants or wear prescription glasses with uv filters. Thank you doctor Abhimala once sir.
Sunil
Simple answer is we really don't know details but there are a lot of studies going on right now. And absolutely no direct looking into the sunshine to get the sun rays, it will destroy your retina. So should not never do that. Looking at the sun directly to get the sun level, it's really harmful. So indirect light is what you're referring to, not necessarily the uvs or other areas, because the lighting, sunlight itself has got a therapeutic effects as reported by many other people. Again, it's not. This is not my area of specialty, so I don't know too much details, but it has been reported specifically in psychiatric disorders to alleviation or depression, for example. And people had tied that to increased depression, suicide and death rate in the wintertime to lack of exposure to sunshine. Just one example. So similarly, people who work on the night shift has a higher morbidities and suicidal risks. So all this could be tied to. Again, there's no proof, but the lack of sunshine exposure into the ice and what is going on behind the ice, we don't know, except that it is also directly connected. The melatonin secretion and dinos cycle and many other physiological functions.
Mubin
Understood. Thank you so much for this. There is a Caroline says, number one, she says, you're a wonderful doctor. And then she says, for those of us that live in cloudy climates all year round, do you still recommend that we go outside between eleven to 01:30 p.m. and also supplement with vitamin D and K2 to keep our levels optimized?
Sunil
It's a good question and it's a choice of the people. And not many people have a luxury to go out during between 1030 and 130 to the sunshine. Even if you go there, there's a cloudy. And the atmospheric pollution, you mean you get only very little vitamin D formation. So. And the main barrier is, of course, the work pattern. And you're not. You cannot just walk out of the office and go to sunshine and have a two hour lunch break. So it's not going to happen. So in these circumstances, it's a best option, probably is to get a good quality vitamin D supplementation. Whatever the dose, you can discuss with your own doctor and figure it out to elevate serum level at least to 40 nanograms a meal to keep you healthy.
Mubin
Understood. Thank you very much. So these are my questions. If there is any topic that you want to touch on, I am happy to discuss it. I would request you if we can do a series where we can talk about preventable diseases, pregnancy and other aspects. You or the other part of the team? Other members of the team. I have one last question that I want to put to you. And this might actually be a longer answer so you can totally defer that. And that is how do immune cells become better functional or they work better with vitamin D? What happens?
Sunil
Oh, that takes whole 1 hour to explain. There are multiple mechanisms occurring with either occurring or not occurring with or without vitamin D in the cell. Virtually every immune cells what we calculate as 75% of their function depending on the sufficient availability of cassetriol within their cells. So lesser amount of the vitamin D within those cells, that means a lesser amount in the blood because they had to diffuse your immune function, become less and less so. Beyond 50 nanograms of male immune cells have become robust. They have the functional, proper functional capacity to generate and protect infection, prevent autoimmune disease and whatever else they like to do. But the key driven driving factor of this immune cell activity is vitamin D. For example, vitamin D convert th one cells to th two cells. Th one is inflammatory, th two is non inflammatory and facilitating. That will not happen in the absence of cassetriol. So what we need deficiency like somebody with vitamin D ten for example, their whole system is on inflammatory condition and no wonder these people are having are sick. Similarly, the th 17 cell for example converted to regulated cells which is the beneficial cell only in the presence of sufficient cassette within cell. This is one example. There are many example how immune cell modulated in the presence of sufficient cassette raw intracellularly, not in the blood.
Mubin
That is excellent. Thank you very much. And for the audience, I know that some of you are going to say that the helper one cell towards this hydrotoxic and t helper two towards the B cells and B cells are also going to take part in inflammation. However, when you look at doctor Wimalawansa's comment, t helper two cells release interleukin ten. Interleukin ten in turn dampens or reduces the activity of the innate arm which de amplifies the whole immune system because innate arm then activates the adaptive arm. This is yt helper two by releasing interleukin tendin act sort of a regulators and suppressors, I shouldn't say suppressors but they calm down the information. So this is a very, very interesting mechanism. Sunil, thank you very much. So with this, thank you so much for your presence today you increase the ambience of our neighborhood. And there is Jen's message about some fantastic written interviews as well at the grassroot health. Once again, because it is a CME lecture, I have no conflict of interest. There are no strings attached. I think this is a great area, vitamin D that we all should know and physicians should practice this with their patients. Patients should be aware of this to have a better health. Sunil, last comments for you, please, anything before we break.
Sunil
Your suggestion of discussing different key aspects of vitamin D related disorders. And the system is a great one because that way whoever the person you are interviewing can go into more details and the mechanism for people who like mechanisms and showing some slide also to corroborate what, how these cells interact and helping the body system to prevent disorders. So taking the system or the disorders as a group and discuss, I think it's a great idea, although we should not compartmentalize generally.
Mubin
Absolutely. So thank you so much. Actually, before you go, I see Janta Kumari's hand up. So Janta, if you have already written a question, can you please rewrite it? I would keep an eye on the comments to see your question. In the meantime, Margaret says, thank you very much, Doctor Mubin and Doctor Wimalawansa. Looking forward to future talks on this topic. Nick says, thank you, doctors. Very interesting and useful information. Martha says, super presentation of critical information from brilliant scientists. Many thanks and blessings, Doctor Wimalawansa and Doctor Mubin. Nicole says, thank you so much for your valuable time. Wonderfully informative. Caroline says, wow, such a great lecture. You're both wonderful. So thank you so much. Once again, an audience. Kurveen, thank you very much for your presence as well. We would continue with the series, and I know that this series was for the inflammatory pathways. We'll switch back to that as well. Maybe we'll find another day over these weekdays to continue with the vitamin D series because I think that is as important as understanding the inflammatory pathways and how to keep ourselves healthy. So Doctor Rimula Vansa, thank you so much for your time and the insights.
Sunil It's a pleasure. Thank you.
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VitaminDWiki - FLCCC COVID guidelines now include vitamin D loading doses - Jan 2022 suggested by Sunil
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