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Better Bones Blog
Dr. Susan E. Brown

Nutrition for bone health — how to gain weight if you’re too thin

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In a couple of my blog posts, I’ve talked about how inadequate or imbalanced nutrition affects bone health, putting thin persons — particularly thin women — at greater risk for bone fractures. The most recent post, Beauty is Bone Deep, focused on women who try to force a thin physique on their (usually unwilling) bodies for the sake of an unrealistic beauty ideal. But there are those women, and men too, who try and try togain weight rather than lose it, often to no avail. These aren’t people who have an eating disorder or anorexia — they’re otherwise healthy-seeming people who simply can’t gain a single pound.

The problem everyone wants — unless they have it

Now, many folks out there will read this and think, “Gee, that’s a problem I wish I had.” But as people who do have this problem will tell them, the struggle to gain weight is actually harder than the struggle to lose it.

Think about it: there are dozens, if not hundreds, of weight loss solutions out there (some better than others), but there aren’t many workable solutions to gain weight in a healthy manner. If you search the internet, you’ll find most information on weight gain is for bodybuilders and focuses on building bulky muscle, but that’s not something most women (and many men, too) really want. And contrary to the suggestions some of my underweight clients hear, eating cheeseburgers, ice cream and cookies 24/7 does not help, and it’s a highly acidifying, bone-damaging way of life as well.

So what should an underweight woman or man do to gain weight in a healthy manner?

Root causes of being unable to gain weight

Just as with any health issue, solving underweight requires examining root causes. I’ve noticed that people who are underweight fall into several camps:

  • There are those who tell me, “I eat just fine, but I just never seem to put on any weight.”
  • Others say they simply don’t get hungry or don’t feel like eating, so they skip meals. Sometimes, these people say that eating makes them feel sick, so they eat less (or less often) as a result.
  • Some say they eat well some of the time, but that they eat less when they’re under stress — and they’re under stress often.

For people who stay thin despite eating well, I look at three factors. First, are theyreally eating enough food on a regular basis, or is that simply their perception? Is a meal something they sit down to at a table, with 2 or 3 different dishes, and spend time enjoying — or do they consider an apple and a small tub of yogurt consumed between meetings at work to be “lunch”? While the average adult needs 2000-2500 calories, that’s an average; some people require more, but may not realize it — and gaining weight might simply be a matter of eating more nutrient-dense foods. Moreover, if you’re underweight because of a nutritional deficit, you may need to supplement with the 20 key nutrients required for bone health because if your muscles, skin, organs and tissues aren’t getting what they need, they’ll take it from your bones!

Second, I consider whether a metabolic or endocrine issue could be at work. Hyperthyroidism, latent autoimmune diabetes in adults, and various other chronic disorders can prevent people from gaining weight, even when they eat well — and sometimes, these disorders are “silent,” meaning they have no clear-cut symptoms. I often recommend a medical workup for osteoporosis for this very reason. Simple blood tests can generally uncover the presence of autoantibodies or hormone imbalances, however. Such disorders represent significant health issues that need to be addressed by a specialist.

Finally, I’d look at the possibility that they might not be absorbing the food they eat. A great many malabsorption syndromes and digestive issues can prevent a person who eats reasonably well from reaping the benefits of the food they take in. Some of these, like IBS or Crohn’s disease, have obvious symptoms attached — diarrhea, gas, bloating, pain — but others, such as celiac disease, can damage the GI tract and impair nutrient absorption capabilities, sometimes without causing any distinct symptoms related to the digestion. Poor nutrient absorption frequently occurs in older people simply as a byproduct of aging. So if I saw indications of poor nutrient absorption (dry, brittle hair and nails, for instance), I might suggest that a client ask her physician for testing for celiac or other GI issues, and we’d look very closely at how to boost the nutritional and caloric content of her food so she gets more of what she needs. And I’d offer them suggestions for how to strengthen their digestion.

Suggestions for those who aren’t hungry

Those who don’t feel hungry or who don’t feel like eating usually have one of two problems. Either they have an imbalance in the “hunger hormones” that stimulate appetite (often associated with zinc inadequacy), or they simply don’t prioritize meals sufficiently. The second problem is likely more common than the first — many folks are so rushed or busy that they habitually ignore their body’s signals that it needs food, to the point that they genuinely believe they’re not hungry even when they are! These folks benefit by taking time to acknowledge and understand their physiologic needs. I would do the following:

  1. Review their diets to make sure they are getting a full balance of fats, carbohydrates, and proteins
  2. Help them schedule their mealtimes, including time for pre-meal “appetizer” foods such as broth (warm liquids stimulate the appetite).
  3. Suggest an elimination diet or allergy testing for those who say they feel ill or uncomfortable after eating.

If anxiety or worry is prohibiting weight gain

For those who stop eating or eat less due to anxiety or stress, part of the problem is their response to anxiety and worry. For clients whose thinness is related to an anxious mind, I’d help them to learn stress-reduction techniques, and also have them focus on their intentions around eating — that is, to find ways to celebrate their meals as an affirmation of their worth. It doesn’t need to be complicated — simply saying grace before each meal, for example, can send a strong signal from the mind and spirit to the body that the food in front of you is a blessing meant to nourish you. The power of the mind should not be underestimated, and focusing it on nourishment (instead of on anxieties and worries) may be an important component of promoting healthy weight gain.

If you’re underweight, taking steps to build strong muscles, eat a nutritious diet, and reduce stress and anxiety can help you gain weight, meanwhile reducing your fracture risk. Even if the tips outlined above don’t help you to add a single pound of weight, the bone-strengthening benefits of my Better Bones approach may make the difference in staying healthy and avoiding fractures — and isn’t that what matters in the long run?

Better Bones Blog
Dr. Susan E. Brown

Benefits for the immune system

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Research over the last decade clearly documents that vitamin D is a premier modulator of immune function, helping to protect us from infection and at least 16 types of cancer. For example, recent research documents that white blood cells can convert ordinary vitamin D into an active form that is used to make a protein that kills tuberculosis bacteria. Perhaps more striking, however, is the role vitamin D plays in cancer prevention. As it happens, vitamin D is one of the most potent regulators of cell growth, working to prevent initiation and growth of cancerous cells and tumors. Vitamin D activates the “turn off” switch for many types of cancer cells, preventing uncontrolled growth. In fact, at a recent meeting of the American Association for Cancer Research, Dr. Edward Giovannucci of Harvard University challenged “…any of his colleagues to find an area or nutrient or any factor that has such consistent anti-cancer benefits as Vitamin D.” The data, as he notes, are really quite remarkable.

And just what are these data on vitamin D and cancer? For starters, as early as 1941 it was noted that people living in southern states with more sunshine had half the risk of dying from cancer as those living in northern, less sunny states. In 2002, this observation was further quantified in an article by William Grant published in the prestigious journal, Cancer. Using current data from the Atlas of Cancer Mortality, he again documented that residents of sunny southern areas, like the southwest, have half the risk of dying from 13 types of cancer as did residents of areas receiving less direct sun exposure, such as New England. And the concern with skin cancer from sunlight exposure? First of all, the sun exposure needed to improve vitamin D status is minimal. Vitamin D expert Dr. Michael Holick suggests 15 minutes of mid-day sun two or three times a week for light-skinned people, with more for those with dark skin. As for the risk-benefit ratio, it is now estimated that 30 times more cancer deaths are caused from a lack of sunshine exposure than from sun exposure. As Dr. Holick reports, 500 women die a year from non-melanoma skin cancer (likely related to sun exposure) while 27,500 die prematurely due to illnesses related to low vitamin D, often because of lack of sunlight. In other words, roughly 55 women die prematurely due to underexposure for every one death related to overexposure.

Even more convincing than the correlations between sunlight exposure and cancer is the direct association of higher vitamin D blood levels with less cancer incidence. For example, the large US Nurses’ Health Study found that women with the highest blood levels of vitamin D had half the risk of two of the three major types of colon cancer. And this cancer reduction benefit is not just for women. Garland and colleagues at the University of California, San Diego, reported a similar finding for men.

Breast cancer follows a similar pattern. In 2005, it was reported in the European Journal of Cancer that women with low levels of vitamin D were more than five times more likely to be diagnosed with breast cancer than were women with adequate levels. A similar five-fold increased risk for breast cancer in Caucasian women with low activated vitamin D was reported in 1999 by University of North Carolina researchers. Most recently, intervention studies supplementing with vitamin D have produced dramatic results. For example, in 2007 researchers at Creighton University reported the findings of the first intervention trial examining vitamin D and cancer. In this four-year, population-based, double-blind, randomized, placebo-controlled trial, postmenopausal women given 1,100 IU experienced a 60 to 77% reduction in the risk of developing any type of cancer.

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Better Bones Blog
Dr. Susan E. Brown

Key vitamins for bone health — vitamin K1 and K2

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While vitamin K is best known for its role in blood clotting, this nutrient also plays an important part in the maintenance of healthy bones. Noted nutrition authority Dr. Alan Gaby has suggested that vitamin K is as important to bone as calcium. So let’s follow Dr. Gaby’s lead and delve a little deeper into its role in bone health.

Vitamin K is required for the synthesis of osteocalcin, the bone protein matrix upon which calcium crystallizes. Osteocalcin provides the structure and order to bone tissue; without it bone would be fragile and easily broken. Vitamin K also aids in the binding of calcium to the bone matrix — in essence, it serves as the “glue” that binds calcium onto the skeleton.

Just as vitamin K is central to bone formation, so it appears to play an important role in fracture healing. Vitamin K levels fall during recovery from fracture, and it appears that this nutrient is actually drawn from the rest of the body to the site of fracture to speed fracture healing.

Vitamin K is not a single nutrient, but the name given to a group of vitamins of similar composition. The two main groups that occur naturally are phylloquinone, or K1, which is found in plant-based foods, particularly green leafy vegetables; and themenaquinones, or K2, which are produced by bacteria in fermented foods and to some minor extent in our intestinal tracts. In combination with vitamin D and calcium, both vitamins K1 and K2 increase bone quality. But vitamin K2 is more bioavailable, longer lasting, and provides for greater increase in bone strength.

The more we learn about K, the more we see how it takes on various forms and roles in the body. To date most of the research has been done on K1. But a new wave of research is now focusing on K2 — in particular the subset of K2 known asmenaquinone–7, or MK–7. This research documents the superior ability of MK-7 over K1 to enhance both bone and heart health. Getting enough of the K2 forms of this vitamin has been found to be especially important for healthy bones in patients being treated with oral anticoagulants, such as warfarin (Coumadin). (Read more about vitamin K research at the Better Bones Foundation.)

Aside from getting K through dietary sources, vitamin K can also be produced in the body by certain beneficial intestinal bacteria. Long-term use of antibiotics compromise this process and can lead to vitamin K deficiency. Aside from oral antibiotic and anticoagulant use, culprits in vitamin K inadequacy include the freezing of foods, mineral oil laxatives, rancid and hydrogenated fats, radiation, impaired fat absorption, sulfa drugs, and certain liver diseases.

To learn more, read my article on vitamin K — the overlooked bone builder and heart protector.

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Better Bones Blog
Dr. Susan E. Brown

Benefits for heart health and circulation

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Heart disease, our #1 cause of death, is also strongly influenced by vitamin D. The heart, as other muscles, is weakened by lack of this muscle-builder. Further, activated vitamin D works to maintain blood pressure, suppress artery-damaging inflammation, and protect the vessels from calcification in a dose-dependent manner. As a result, vitamin D is inversely associated with heart attacks, strokes, high blood pressure, decreased artery protective apolipoprotein A-1, and heart disease deaths.

Sunlight and its biochemical end-product, vitamin D, enhance heart health in many ways. Even exposure to tanning beds transmitting vitamin D-producing UVB radiation has been found to reduce blood pressure by researchers in both the US and the Netherlands. In addition, while working with heart disease patients, Dr. Michael Holick of Boston University was able to improve heart strength with a program of three weekly exposures to UVB from tanning beds.

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blood sugar control
Dr. Susan E. Brown

Benefits for diabetes and blood sugar control

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In this country, diabetes afflicts more than 20 million Americans and is the sixth leading cause of death; there is an immense need for blood sugar control . As with heart disease and cancer, there is a striking latitudinal association: people who live in sunny climates tend to have lower risk of diabetes. Northern Finns, for example, who experience only two hours of sunlight in December, have the world’s highest reported incidence of type 1 diabetes, and vitamin D supplementation is shown to reduce their risk of this disease. In 1966, 12000 Finnish babies were given 2000 IU vitamin D a day from one year of age and watched over the next thirty years. Those taking the vitamin D decreased their risk of developing type 1 diabetes by 80%. This same study showed that those children low in vitamin D at one year of age had a four-fold increased risk of developing type 1 diabetes.

In the US, the Third National Health and Nutrition Examination Survey (NHANES III) found that as blood levels of vitamin D rose, the risk for diabetes decreased, and those with the highest vitamin D levels had one-quarter the diabetes risks of those with the lowest vitamin D blood levels. In another light, a study by Borissova and colleagues in Bulgaria found that giving vitamin D supplements in the winter to adults with type 2 diabetes improved blood sugar control. Even in sunny Italy, vitamin D blood levels were significantly lower in patients with diabetes.

And what are the mechanisms by which vitamin D helps to prevent diabetes? We now know this nutrient enhances insulin output and insulin sensitivity, and people with a low level of vitamin D have poorly functioning insulin-producing cells and a poor response to insulin, even when their blood sugar levels are normal.

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Better Bones Blog
Dr. Susan E. Brown

Vitamin D: An old bone builder takes on new importance

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Topics covered in this article:

At the height of the Industrial Revolution, there arose a mysterious disease that plagued children in both Northern European and U.S. cities. This disease left children with weak bones, bowed legs, and growth retardation, and in adults it caused pelvic bone deformity so severe that giving birth vaginally was impossible. Birth by Caesarian section became widespread in Britain as a consequence of this bone-deforming disorder, which became known as “rickets” in children and “osteomalacia” in adults. After a 270-year search, in the first quarter of the 1800’s, the cure was found in two seemingly different substances: sunlight exposure and small amounts of cod liver oil.

The “first wave” of vitamin D awareness (early 1900’s to mid-1990’s)

Vitamins are essential biological compounds that cannot be synthesized in the body and must be consumed in the diet. Identification of the substance in cod liver oil that cured bone-deforming rickets led to the classification of this compound as a vitamin — vitamin D. We now know, however, that vitamin D is not so much a “vitamin” as it is a “pre-hormone” produced in skin that is exposed to sunlight. Exposure to a specific spectrum of solar ultraviolet radiation causes a pre-vitamin D compound to be synthesized, which is converted into vitamin D within 1 to 2 days, and later transformed by the liver and kidneys into the active vitamin D hormone.

Throughout our evolution, we humans have obtained the vast majority of our vitamin D from exposure to sunlight. With abundant sunlight exposure, we do not need to consume food sources of vitamin D. In fact, few human foods, aside from fish oils, contain significant amounts of vitamin D (see our vitamin D food chart). Even today with our vitamin D fortified foods, 80% or more of our vitamin D is produced from sunlight exposure.

In the early 1900’s, the discovery of the vitamin D factor in cod liver oil that cured rickets and osteomalacia was a triumph of early nutrition science. Stemming from this success, the “first phase” of vitamin D awareness established the need for vitamin D at the minimal amount that could prevent bone-weakening rickets. The tiny amount of 100 International Units (IU) per day was enough to prevent rickets and for decades was held to be an appropriate and adequate vitamin D intake.

This “first wave” of vitamin D awareness also brought the realization that vitamin D was fat soluble and stored in the body, and thus had a potential for toxic accumulation. For various reasons, vitamin D toxicity became an issue of exaggerated concern, the extent of which is only now becoming evident. Looking back, scientists now realize that vitamin D toxicity is rare and generally occurs from extremely high oral intake, never from sunlight exposure. The early cases of vitamin D toxicity that formed the basis for safety concerns generally involved impurities in vitamin D production, the use of synthetic vitamin D analogues, accidental use of extremely high doses, or individuals with vitamin D hypersensitivity.

Better Bones guidelines for sunlight exposure

  • Short periods, 15-20 minutes daily, of near full-body exposure are best for light-skinned people (without sunscreen).
  • Use sunscreen after this initial period if necessary to avoid a sunburn.
  • The useful ultraviolet rays are strongest between 10 am and 2 pm.
  • Very dark-skinned people require 4-6 times more sunlight exposure than light-skinned people.
  • In northern or southern latitudes distant from the Equator, longer exposure is needed, especially during the spring and fall.
  • In climates of the northern or southern latitudes distant from the Equator, very little or no vitamin D is produced in the skin during the winter months.

The “second wave” of vitamin D awareness (mid-1990’s to 2008)

By the mid-1990’s, a silent revolution had begun. A handful of insightful scientists began challenging our most basic assumptions about vitamin D and began to explore the full importance of this substance for human health. Most importantly, they began to question what might be the optimal level of vitamin D for human health, as opposed to the minimal level used to prevent rickets and osteomalacia. This in turn led to a long overdue critical analysis of both the potential benefit and potential toxicity of vitamin D. Well-respected researchers, including Dr. Reinhold Vieth of the Mt. Sinai Hospital, University of Toronto and the American “calcium guru”, Dr. Robert Heaney of Creighton University in Omaha, Nebraska, blazed this exciting new scientific trail. Today, hundreds of scientific papers are published each month, and we are learning more about the power of vitamin D than anyone could have imagined even twenty years ago. An updated discussion of the wide-ranging health benefits of vitamin D can be found in my article, “Vitamin D: Its benefits are more than ever imagined,” and on many websites, including www.grassrootshealth.org, www.sunarc.org,www.vitamindcouncil.org, and www.vitamin-d.com.

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Vitamin K content in common foods
Dr. Susan E. Brown

A sample of Vitamin-K content in some common foods

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This list was prepared for a 2000 Dutch study on vitamin K. The foods listed were purchased in the Netherlands, where the amounts of vitamin K1/K2 in foods are different and perhaps higher than those from food in US shops. Amounts are shown in mcg/100 g or 100 ml.

Type of food

K1

MK-4

MK-5

MK-6

MK-7

MK-8

MK-9

Meat
Beef0.61.1
Chicken breast8.9
Chicken leg8.5
Pork steak0.32.10.51.1
Salami2.39.0
Luncheon meat3.97.7
Fish
Shrimp0.1
Mackerel2.20.4
Herring0.1
Plaice (flat fish)0.20.30.11.6
Eel0.31.70.10.4
Salmon0.10.5
Fruits and vegetables
Kale817
Spinach387
Broccoli156
Green peas36.0
Sauerkraut25.10.40.81.50.20.81.1
Natto34.77.513.899884.1
Banana0.3
Apple3.0
Orange0.1
Dairy products
Whole milk0.50.80.1
Skimmed milk
Buttermilk0.20.10.10.10.61.4
Whole yoghurt0.40.60.10.2
Skimmed yoghurt0.1
Whipping cream5.15.4
Chocolate6.61.5
Hard cheeses10.44.71.50.81.316.951.1
Soft cheeses2.63.70.30.51.011.439.6
Curd cheese0.30.40.10.20.35.118.7
Egg yolk2.131.40.7
Egg white0.9
Oils and margarines
Margarine93.2
Butter14.915.0
Corn oil2.9
Sunflower oil5.7
Olive oil53.7
Bread
Rye bread0.7
Wheaten bread1.1
Sourdough bread1.0
Buckwheat bread3.01.1
Beverages
Tea0.3
Coffee
Orange juice

Table from Schurges, LJ and C. Vermeer, C.2000. Determination of phylloquinone and menaquinones in food. Haemostasis, 30, 298-307. All samples were assessed in duplicate. Values are mean values. Foods were bought from shops in and around Maastricht, The Netherlands. MK-10 was not detectable in any of the foods.

Food for Vitamin D
Dr. Susan E. Brown

Food Sources of Vitamin D

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Most of the vitamin D our bodies need is made by the exposure of our skin to sunlight. However, people in northern climates do not get sufficient sunlight exposure during late autumn and winter to trigger vitamin D synthesis in the skin. Although few foods contain the amount of vitamin D that most people need on a daily basis, below are foods that can help boost your vitamin D intake.

Food

International Units

Dairy
Milk, nonfat, reduced fat, and whole, vitamin D fortified, 1 cup98 IU
Margarine, fortified, 1 Tbsp (not a wholesome food)60 IU
Butter, 1 Tbsp10 IU
Fish and seafood
Cod liver oil, 1 Tbsp1,360 IU
Salmon, cooked 3½ oz.360 IU
Mackerel, cooked 3½ oz.345 IU
Sardines, canned in oil, drained, 3½ oz.270 IU
Eel, cooked 3½ oz.200 IU
Atlantic Herring (pickled), 3½ oz.680 IU
Eastern Oysters (steamed), 3½ oz.642 IU
Catfish (steamed/poached), 3½ oz.500 IU
Skinless Sardines (water packed), 3½ oz.480 IU
Mackerel (canned/drained), 3½ oz.450 IU
Smoked Chinook Salmon, 3½ oz.320 IU
Small Clams (steamed/cooked moist), 3½ oz.8 IU
Blue Crab (steamed), 3½ oz.4 IU
Fortified Cold Cereals
Dry Cereal, fortified w/40 IU of vitamin D, ¾ cup40-50 IU
Organ meats
Beef Liver (braised), 3½ oz.12-30 IU
Beef Liver (fried), 3½ oz.12 IU
Pork Liver (braised), 3½ oz.12 IU
Chicken Liver (simmered), 3½ oz.12 IU
Lamb Liver (braised), 3½ oz.20 IU
Beef Tripe (raw), 3½ oz.12 IU
Beef Kidney (simmered), 3½ oz.12 IU
Eggs
Egg, 1 whole (vitamin D is present in yolk)25 IU
Benefits of Vitamin D
Dr. Susan E. Brown

Vitamin D: its benefits are more than ever imagined

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Known for almost a century as the “sunshine vitamin” for bone health, new research reveals that vitamin D is good for more than bone… much, much more. In fact, current research from around the world documents that not just osteoporosis, but an astonishing number of diseases, are caused or worsened by insufficient vitamin D. Further, studies show that attaining optimum vitamin D blood levels provides protection from these disorders and aids in their healing.

Benefits for bone health

Vitamin D, and specifically the hormone our body produces from vitamin D, is the body’s most important regulator of calcium absorption. Indeed, scientists now know that people low in vitamin D absorb 65% less calcium than those with adequate levels of this vitamin. Subsequently, needless osteoporotic fractures are much more common in folks with low levels of vitamin D, and the incidence of fractures can be dramatically reduced with vitamin D supplementation.

For example, a recent study in the United Kingdom found that 95% of those suffering a hip fracture were deficient in vitamin D, while other research in the UK and the US documents that simple daily supplementation with 800 IU vitamin D3 with some calcium can often reduce hip fracture incidence by 33 to 50%. (For a review of the literature on vitamin D and fracture reduction, see my article in the March 2008 Alternative Medicine Review.)

Even more, three major vitamin D researchers now suggest that with adequate vitamin D supplementation, we could prevent 50-60% of all osteoporotic fractures.

Benefits for muscles helping to protect bone

Recently it has been discovered that muscle cells, as well as bone and many other cells, have receptors for the active form of vitamin D. It is now clear that vitamin D maintains the function of muscle fibers, thus preserving muscle strength and neuromuscular coordination. This results in stronger muscles, improved muscle function, better balance, and fewer falls among those with an adequate vitamin D level as compared to those who are deficient in this nutrient.

Several large studies now show a 20 to 50% reduction in falls with the daily use of 800 IU vitamin D. Preventing falls among the elderly prevents fracture and other injuries. Also, if you have weak muscles and experience bone pain, consider vitamin D. Bone pain and muscle weakness are typical symptoms of vitamin D deficiency.

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Better Bones Blog
Dr. Susan E. Brown

Vitamin D and swine flu prevention — shining a light on seasonal flu bugs

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Did you ever stop to wonder why we have a “cold and flu season” — that is, why do we tend to get these illnesses in the cold, dark winter? And surely you have noticed that some people are resistant to colds and flu even while others around them are coughing, hacking, and spreading the virus like mad. As science now tells us, the answer, or at least part of it, lies in the sunshine vitamin known as vitamin D.

For years we thought of vitamin D as just another vitamin, but now we know that vitamin D is much, much more. This “vitamin” is really a hormone precursor — it is the stuff the body uses to make a potent hormone known as calcitriol, a hormone capable of signaling over 1000 genes to express or suppress themselves. Our bodies turn the vitamin D we produce — from sunlight exposure or in our diet — into this potent hormone that not only keeps us alive by regulating blood calcium, but also directly influences the functioning of every organ system. The heart, kidneys, gut, lungs, and yes, the immune system, are all influenced by the vitamin D hormone. Your risks of fracture, heart attack, TB, depression, periodontal disease, multiple sclerosis and many other auto-immune diseases, and, as it now appears, even the flu are dramatically lowered if you have optimal vitamin D blood levels. Overall mortality, in fact, is significantly reduced — by 8% — with even modest vitamin D supplementation. Activated vitamin D (calcitriol) is a complex hormone with as many mechanisms of action as the 1000 human genes it regulates.

How “the antibiotic vitamin” improves immunity to the flu

Reams of data have been published in the past decade, documenting the role vitamin D plays in nearly all bodily systems, and the immune system is no exception. As researchers report, the evidence that vitamin D has profound effects on the part of the immune system known as innate immunity is growing fast — a recent article in Science News even tagged vitamin D as the “antibiotic vitamin.”

Innate immunity is the heart of our defense system that is “hard wired” to respond rapidly to microorganisms using genetically encoded response mechanisms. These innate immune system responses include the production of broad-spectrum antimicrobial agents known as antimicrobial peptides (AMP’s). Epithelial cells (skin cells and cells that line our internal passageways) and a wide range of immune cells (such as macrophages) create these natural antibiotic AMP’s upon exposure to microbes. This action, however, is dependent on the presence of vitamin D! This means that our bodies produce their own “homemade” antibiotics — some 200 different types — all of which are up-regulated and stimulated by the active vitamin D hormone. These homemade antibiotics attack and irreversibly damage a wide range of fungi, bacteria, and viruses.

Vitamin D and influenza: the data

Seasonal variation in flu and vitamin D

It’s commonly held that influenza is a highly infectious virus spread by the sick to those who are well. Many people also assume that the virus is spread more easily in the winter because that’s when everyone is “huddled together” indoors.

Decades ago, however, a noted scientist questioned these assumptions and went on to propose that there is an unidentified “seasonal stimulus” associated with flu outbreaks.

As this physician, Dr. Hope–Simpson, documented over and over again, flu incidence was tightly correlated with the winter season, and it was not consistently spread from ill to well after all.

Indeed, we all recognize that there is a flu season — the dark wintertime — but we have also witnessed that not everyone who is exposed to the virus gets sick.

It is now becoming clearer that low wintertime levels of vitamin D — the sunshine vitamin — may indeed be the “seasonal stimulus” that triggers flu outbreaks and influences individual susceptibility to influenza infection.

Reference

The story of the vitamin D–influenza link is actually telling the tale of the work done by Dr. John Cannell. I have been in personal communication with Dr. Cannell over a number of years and have carefully followed his work and that of his non-profit Vitamin D Council.

When I first spoke with Dr. Cannell several years ago, he told me about his work as a psychiatrist at the Atascadero State Hospital in California. Interested in vitamin D, and suspecting common vitamin D deficiency among his inmates, Dr. Cannell regularly tested inmates for vitamin D adequacy. As he expected, he found they had abnormally low levels of vitamin D and, after explaining the benefits of this vitamin, he prescribed for the inmates 2000 IU vitamin D3 (cholecalciferol) a day.

In the late winter of 2005, a virulent strain of influenza hit the maximum-security psychiatric hospital, and although 10% of the 1200 patients ultimately developed the flu’s fever and debilitating muscle aches, there were, no cases of flu among Dr. Cannell’s inmates Dr. Cannell’s, who had been given daily vitamin D supplements. In a 2006 interview, Dr. Cannell said, “First, the ward below mine was quarantined, then the wards on my right, left, and across the hall.” And even though Cannell’s inmates had mingled with the others prior to quarantine, they still managed to avoid the flu.

How was it that his inmates were able to dodge the flu? A few months later, he came across a scientific report stating that vitamin D was found to increase the production of natural antimicrobial compounds in white blood cells. It was then that Dr. Cannell’s “Aha!” moment occurred. Could it have been the vitamin D he routinely gave his inmates that protected them from the flu? Encouraged by his colleagues, Dr. Cannell and seven other noted vitamin D scholars reviewed more than 100 articles that — in one way or another — linked vitamin D with enhanced immunity and fewer respiratory infections.

The research reports that pointed to a D–influenza link included findings like these:

  • Many studies noted an association between rickets, the classic childhood disease of vitamin D deficiency, and increased respiratory infections.
  • A research comparison of 80 rickets-free children found that children with very low 25(OH)D levels (less than 10 ng/mL) were 11 times more likely to be infected with respiratory infections than children with higher vitamin D levels.
  • A 1994 study showed that intervention with vitamin D (60,000 IU a week) and calcium (650 mg/day) produced a significant reduction in the incidence of infections in children with subclinical rickets.

These early research findings, along with his own experience with his inmates, led Dr. Cannell to boldly suggest that vitamin D deficiency could underlie a vulnerability to influenza infection. Since the first article on influenza and vitamin D was published in 2006, a new body of research has developed that strongly supports the hypothesis that low vitamin D levels increase vulnerability to flu and that high vitamin D levels offer a protective effect.

In 2007, Dr. Cannell and colleagues published a second paper on the vitamin D–influenza connection in the Virology Journal. Here they explored 9 key questions including, “Why is influenza both seasonal and ubiquitous, and what happens to the virus between epidemics?” “Why are influenza epidemics so explosive?” “Why do they end so abruptly?” and so forth. An important part of the answers to each of these questions pertains to the fascinating role vitamin D plays in the enhancement of innate immunity.

A series of new studies lends growing support to the theory that low vitamin D levels increase vulnerability to influenza.

  • A study of young Finnish men in military service reported that those with a vitamin D deficiency had significantly more days when they were absent from duty due to respiratory infection than the servicemen who were not vitamin D deficient.
  • A Turkish study of newborn infants found that those with acute lower respiratory infection had lower levels of vitamin D (along with their mothers) than other newborns who were free of respiratory infection.
  • In a study of African-American women, self-reported symptoms of colds and influenza were more than three times lower in the women given 800 IU daily of supplemental vitamin D3 over two years than those in the placebo group. And this relatively low dose effectively abolished the seasonality of colds and flu. A higher dose of 2000 IU given during the last year of this three-year trial virtually eradicated all reports of colds and flu.
  • A very recent report in the Journal of Pediatric Research summarizes the scientific consensus that, in the face of vitamin D deficiency, infants and children appear more susceptible to viral infections than bacterial ones. They concluded that the now recognized connections between vitamin D, infections, and immune function suggest a role for vitamin D supplementation in the pediatric population.

Even more interesting than scientific study — real-life swine flu prevention with vitamin D

While the scientific studies connecting low vitamin D and influenza are interesting, what I find even more valuable and intriguing are the informal reports from clinical settings, where the use of vitamin D amongst patients was tightly linked to a reduction in their vulnerability to the most recent swine flu variant (H1N1). Two very interesting reports from clinical settings were submitted to Dr. Cannell and published in his Vitamin D Council Newsletter in September 2009. These reports help me see the real day-to-day value of vitamin D supplementation even more clearly than the scientific studies do.

The first report is from a doctor in Wisconsin, Dr. Norris Glick, who wrote to Dr. Cannell:

Your recent newsletters and video about Swine flu (H1N1) prompted me to convey our recent experience with an H1N1 outbreak at Central Wisconsin Center (CWC). Unfortunately, the state epidemiologist was not interested in studying it further, so I pass it on to you since I think it is noteworthy.

CWC is a long-term care facility for people with developmental disabilities, home for approx. 275 people with approx. 800 staff. Serum 25-OHD has been monitored in virtually all residents for several years and patients supplemented with vitamin D.

In June 2009, at the time of the well-publicized Wisconsin spike in H1N1 cases, two residents developed influenza-like illness (ILI) and had positive tests for H1N1: one was a long-term resident; the other, a child, was transferred to us with what was later proven to be H1N1.

On the other hand, 60 staff members developed ILI or were documented to have H1N1: of 17 tested for ILI, eight were positive. An additional 43 staff members called in sick with ILI. (Approx. 11–12 staff developed ILI after working on the unit where the child was given care, several of whom had positive H1N1 tests.)

So, it is rather remarkable that only two residents of 275 developed ILI, one of which did not develop it here, while 103 of 800 staff members had ILI. It appears that the spread of H1N1 was not from staff-to-resident but from resident-to-staff (most obvious in the imported case) and between staff, implying that staff were susceptible and our residents protected.

Sincerely,
Norris Glick, MD
Central Wisconsin Center
Madison, WI

Dr.Cannell’s Comment:

This is the first hard data that I am aware of concerning H1N1 and vitamin D. It appears vitamin D is incredibly protective against H1N1. Dr. Carlos Carmago at Mass General ran the numbers in an email to me. Even if one excludes 43 staff members who called in sick with influenza, 0.73% of residents were affected, as compared to 7.5% of staff. This 10-fold difference was statistically significant (P<0.001). That is, the chance that this was a chance occurrence is one less than one in a thousand.

Second, if you read my last newsletter, you will see that children with neurological impairments, like the patients at your hospital, have accounted for 2/3 of the childhood deaths for H1N1 so far in the USA. That is, the CDC knows, because they reported it, that patients with neurological impairments are more likely to die from H1N1.

The second report is from a doctor in Georgia, Dr. Ellie Campbell, who wrote to Dr. Cannell:

Thanks for your update about the hospital in Wisconsin. I have had similar anecdotal evidence from my medical practice here in Georgia. We are one of the 5 states with widespread H1N1 outbreaks.

I share an office with another family physician. I aggressively measure and replete vitamin D. He does not. He is seeing one to 10 cases per week of influenza-like illness.

In my practice — I have had zero cases. My patients are universally on 2000–5000 IU to maintain serum levels 50–80 ng/mL.

Ellie Campbell, DO
Campbell Family Medicine
3925 Johns Creek Court
Ste A Suwannee GA 30024

I’m sure that as time goes by, you will find more healthcare providers reporting their experiences with vitamin D supplementation and flu. You can follow the compelling work of John Cannell by subscribing to the Vitamin D Council newsletter and you can also listen to Dr. Cannell discuss vitamin D and the flu on YouTube.

So what’s a person to do?

So far the US Centers for Disease Control (CDC) has not responded to requests from Dr. Cannell and colleagues that the US take a serious look at the link between low vitamin D and flu susceptibility. The Public Health Agency of Canada, on the other hand, is investigating the role vitamin D might play in protection against swine flu. But this research by the Canadian government, while moving in the right direction, will likely take years.

The flu season, on the other hand, is upon us and, given the safety of vitamin D and its likely benefits, it seems reasonable to hedge your bets and take in sufficient vitamin D to reach the suggested protective vitamin D blood level of 50 to 80 ng/mL 25(OH)D. This represents a vitamin D blood concentration consistent with that obtained from abundant natural summertime sunlight exposure. The amount of vitamin D needed to reach this ideal blood level varies from individual to individual, depending on sunlight exposure, vitamin D reserves, skin color, body fat, age, and the like.

As Dr. Cannell reports, most individuals will probably require somewhere between 2000 IU and 5000 IU vitamin D a day to reach the 50-80 ng/mL level. Luckily, with vitamin D we know the blood level we are striving for (50-80 ng/mL), so you can take 2000 units a day for eight weeks and then ask your physician to test your 25(OH)D blood level. Generally, every additional 1000 IU of vitamin D will raise your level about 10 points of ng/mL.

Wave goodbye to seasonal colds and flu

You don’t have to wait until you feel the symptoms of a cold or the flu coming on — you can begin today and build better immunity against colds and flu infections by supplementing with vitamin D. You may well find that seasonal colds and flu become distant memories.