Sunday, January 20, 2008

A new epidemic

Vitamin D is the new darling of the news. Over the last 12-18 months there's been a lot of medical and lay press about vitamin D deficiency, especially in older people who don't get out much. Deficiency has been associated with falls (and therefore fractures), muscle weakness and pain, and maybe even poorer cancer outcomes.

Something motivated me to check a level on a patient several months ago. It was extremely low, and I've put on her replacement doses. She's not convinced she feels any differently, but we haven't rechecked her level yet.

So the next time I saw an elderly patient who looked like she didn't get much sun, I checked it again. Bingo! Deficient again.

Check level. Bingo!

Check level. Bingo!

I have to admit, it's been a bit fun. I'm so used to seeing patients for complaints, where either I or the patient is convinced he has insert-your-favorite-easy-to-test-for-condition, only to get a normal lab back. Catching all this deficiency makes me feel like a clever clinician.

I'm now checking on virtually every elder I encounter, and some not-so-elder shut-ins. I've not yet had a normal level.

The real question is whether all of my super-refined-disease-finding accumen will make a difference to anyone. Time will tell. They're all on very large doses of vitamin D, and will need a repeat level in three months.

So to all you bored clinicians, start checking levels. Ch-ching! And if you're an elder who gets little sun, ask your doctor for a level.


Eric, AKA The Pragmatic Caregiver said...

I totally agree; it is an epidemic. The only problem with screening for it is the cost of the assay here is *insane*. . . I think I paid $180.

My level was a whopping 7 ng/mL. Oops. In my defense, I'm the color of Xerox paper, I work indoors, I live in the Pacific Northwest, and I wear sunscreen on the face/neck/ears between the spring and fall equinoxen. What's weird is, I eat crazy quantities of fatty fish and I take fish oil.

Anyway, when you say high-dose supplements, how high are you talking? And how often are you rechecking levels? I'm not finding good management guidelines on this at all.


Dr. Smak said...

Great questions, Eric. My info is from uptodate (my favorite medical resource and well worth the exhorbitant sum they charge for annual subscription), which recommends 50,000 units of vitamin D3 once per week for 8 weeks, followed by 1000 units daily, and a recheck in 3 months. That's for levels under 20. Levels between 20 and 30 can get by with daily 1,000 unit replacement.

Most of my patients have needed a prescription for the 50,000 unit pills - I don't think they're available OTC.

Anonymous said...

I'm 27 and had low levels when my doctor checked for me recently ... so it's not only elderly people that you can have fun looking for low Vitamin D in!

Shelly said...

Just found your blog today and have read every post! I"m an RN turned author, work very part-time with my private duty patient and love reading doctor and nurse blogs.

This post about Vit. D was very interesting; it's fascinating to me how relatively minor things can have such a bit effect on our bodies . . . well, maybe those things aren't so minor!

Anyway, you're on my "favorites" list.

rlbates said...

And do you recommend 15 minutes of sunlight daily (isn't exposure of arms suppose to be enough) for those who can get it? Like a 15 minute walk or sitting in the sunlight?

Dr. Smak said...

Anon - thanks for the tip. I'll have to start casting a wider net.

Shelley - thanks for reading!

Ramona - ideally, if one can find the balance between vitamin D and melanoma endogenous vitamin D has got to be better than taking yet another pill. However, if you live too far from the equator, during winter months you really can't get enough sunshine to get enough D. People that live in very cloudy climates have trouble all year long.

And an update - in the news today, vitamin D deficiency is related to heart disease. Remember, causation doesn't equal correlation. But maybe a little sun ain't so bad?

Femail doc said...

I've also jumped on D band wagon. Crazy low levels in all the pasty white ladies I check, even here in Denver where the sun USUALLY shines most days of the year except for hardly at all in the last month. Uptodate? Sounds useful, how pricey is exorbitant?

Eric, AKA The Pragmatic Caregiver said...

Wow, on looking again at my labs, it was reported as <7. *shiver* I'm pasty, but I'm also closer to the age of Clearasil than Viagra, thanks.

50000 IU is available OTC, FWIW. Just not the Roche preparations.

My understanding, when we were dealing with this in my father-in-law, is that any day the UV Index as reported by is under 3, no amount of sun exposure will trigger the conversion. Another equation I saw was to draw a line between LA and Atlanta, and anyone over that line can't make any between the fall and spring equinoxen.

I'm less worried about melanoma, btw, than by actinic keratoses, AKA the curse of having Nordic Good Looks (tm) and being seen in daylight. Most people with my heritage that had much sun exposure in their adulthood have a standing appointment with a bottle of liquid N2 every few months. Owwie.

laystranger said...

I’ve had fibromyalgia-type symptoms for years and had more or less resigned myself to living with it. However, I recently heard that vit D deficiency can be linked to these sort of symptoms. I figured that I could indeed by deficient given my avoidance of sun over the years so I tried taking a D3 supplement.

Bingo! Symptoms much improved and I don’t think it’s placebo either – I lost faith in the placebo effect, at least in regard to my own health, years ago!

Now I’ve just got to get fit again.