Vitamin D: Supplements 101

Tina 0:00

Hello and welcome to episode 29 of the cancer pod. Today, we're talking about vitamin D. We're going to cover a lot of what you may already know, and a few things that may surprise you about this essential nutrient. I'm Dr Tina Kaczor and as Leah likes to say I'm the science-y one

Leah 0:15

and I'm Dr Leah Sherman and on the cancer inside

Tina 0:19

And we're two naturopathic doctors who practice integrative cancer care

Leah 0:23

But we're not your doctors

Tina 0:25

This is for education entertainment and informational purposes only

Leah 0:29

do not apply any of this information without first speaking to your doctor

Tina 0:34

The views and opinions expressed on this podcast by the hosts and their guests are solely their own

Leah 0:40

Welcome to the cancer pod

Tina 0:58

Hey, Tina. Hey Leah, how's the weather. That's a little

Leah 1:01

overcast here.

Tina 1:02

Ooh, that's too bad.

Leah 1:05

You have sun

Tina 1:06

you're in the land of sun. I am in central Oregon where the sun shines, I don't know, 330 days a year.

Leah 1:13

Yeah. I'm not jealous at all.

Tina 1:16

Well, I will add it is cold though. It is only probably 30 degrees out there, so it's sunny and cold,

Leah 1:22

but I'm good with that. As long as there's sun,

Tina 1:23

I'm happy. I have to say it is kind of

Leah 1:26

nice. Yeah. When I lived in New Mexico, we had sunny snowy days and it was just so nice. So

Introduction

Leah 1:33

we're talking about the sunshine vitamin today. Aren't we. I didn't know if we should call this supplement two oh one or just stick with 1 0 1, but we're back on our series of talking about supplements, this pod and yeah. Today we're talking about vitamin.

Tina 1:50

I think we should keep it to 1 0 1, cause we're going to keep it basic. And if we do offer more in-depth lessons, then we can call them higher. Now one, four oh one masters class,

Leah 2:02

pick the masterclass in supplements. Okay. So vitamin D what the heck is it? how do we get it? What to do for us and then what to do for us, for us cancer.

Tina 2:18

yeah. And why, what makes it a vitamin? Why is it so vital to our health?

Leah 2:22

Okay, so let's take a quick break and we'll come back. Sounds good. So

Is vitamin D a hormone or a vitamin?

Leah 2:30

Tina vitamin D hormone vitamin. Yes. To both.

Tina 2:36

Yes. I say to both because, vitamin D is a fat soluble vitamin. So we do get it in foods. And we'll talk about that a little bit, but most vitamins, when we talk about a vitamin must be gotten from food, vitamin D can be made by the body. and is actually a hormone substance rather than a vitamin So right there, the word vitamin is a little suspect. That's. We call it a hormone and it really is a hormone because in the larger sense of what a hormone is, it has hormonal actions in the body on cells. So it its structure and its action within cells is actually that of a hormone.

Leah 3:20

Cause it's vitamin Nish, vitamin ESC,

Tina 3:23

vitamin ask. We definitely need it. You know, when we talk about a lot of vitamins, it's synonymous with cofaq. So all the B vitamins for example, are co-factors and that means that they must be present for a reaction to happen for an enzyme to function properly, but they don't have independent actions on cells. They don't go into the nucleus and bind something. The vitamin D, which is a hormone, has a direct action in cells all by itself. It is actually not a cofactor per se. Well, that's why

Leah 3:58

you hear about vitamin D receptors on

Tina 4:01

cells, right? Exactly. Yes. And that gets complicated quickly because there's vitamin D receptors. There's just different types of receptors. Generally, we're talking about a vitamin D receptor that finds another vitamin D receptor and they bind together and form these combinations called dimers. And that goes into the nucleus of a cell, binds the DNA, and that what's called a steroidal element region. And that is very powerful because you're binding the DNA and you're causing the expression of various genes. And those genes go on to create the proteins that have a specific action. So

Leah 4:38

you just delved into 2 0 1 level. That's okay.

Tina 4:42

We'll leave it in. All right. Well, there's a little taster of our 2 0 1. Wait till you get to the master's level.

Leah 4:51

Um, okay. So

How do we get vitamin D?

Leah 4:54

how do we get it? You mentioned that there foods, um, what's cool about it is that our body does make it, as you mentioned and. That it's made like all of these different organs play a part in

Tina 5:06

making it. Yeah. Yeah. So first is son. I think many people know vitamin D as the sunshine vitamin. And that is because it starts with sunshine on your skin. So the UV, the ultraviolet radiation from the sun activates an enzyme. In the skin and that creates what we call pre vitamin D and then that pre vitamin D goes through some changes and becomes vitamin D as we know it, which is the substance that we have circulating in our, in our bodies.

Leah 5:37

Yeah. Cause the liver, the kidneys and the gut are all involved in, in vitamin D. So once again, that's a pretty cool thing.

What the heck is a Vitamer?

Tina 5:47

Yeah. And vitamin D like, Vitamins. It's not one thing there's variations on it. So there's different under the heading of vitamin D there's various steps along that pathway, we're going to call it vitamin D for every one of those steps, whether it's going through the kidney, the liver it's being slightly altered, molecularly each place and vitamin D encompasses all of those compounds. So there's, there's variations. Subtypes of vitamin D we could call them the technical term is vitamins. Oh, you've used that term before. I like it. Cause it's, it's it, we oversimplify the biochemistry a lot just to make it palatable, but it's good to know the complexity. It's kinda like when I look up at the stars, I know the big dipper and it helps me understand, you know, I know the north star, I know a few constellations here and there, but I do understand that the complexity of what I'm looking at is. Bigger than what I know, but I do like to have a few way points.

Leah 6:43

You're not naming every star that makes up the big dipper. You just know as a whole, it's the big difference.

Tina 6:48

That's all I need to know.

Leah 6:49

That's a good analogy.

Sun exposure- avoid or indulge?

Leah 6:51

Okay. So, um, vitamin D it's made starts in our skin. a lot of people, especially. Cancer patients, cancer survivors are told to use sunblock, um, whether it's because they have a history of skin cancer or because the treatments that they're getting, cause them to be really sensitive to the sun. And so sunblock actually blocks the rays that make vitamin D. Which can prevent people from getting it that way. Other things that can keep us our skin from making vitamin D would be depends on where you live. So up in Oregon, it's a higher latitude. And, um, you, you would need to be in the sun a lot longer, or like in the winter, on a sunny day, you're probably not getting as much vitamin D than if you were down in Arizona or New Mexico or Mexico. You know, if you're the closer you are to the equator. The better your skin will be at making

Tina 7:49

vitamin D. Yeah. Yeah. And you just have to picture the angle that the sun is hitting you at. So up here, you know, so let's just say a latitude of 45 degrees is a lot different than. Down in San Diego where I, I think it's more like, you know, you're at a latitude of 35 down there, or something like that. The rays are hitting you more directly hitting your skin more directly and having a bigger effect rather than glancing off of you. I remember finding a

Leah 8:15

website at one point that you could enter in where you were located and it would talk about. A comparison of how, you know, like how long you would need to be in the sun to get the equivalent. And we're not advocating for people to go out and sunbathe and to, you know, just be, be reckless in the sun. But just knowing that, you know, where you're located does determine how much vitamin D you're getting from the sun. I think is

Tina 8:39

important. Yeah. And you know, that whole, the idea of UV exposure being linked to melanomas. Is interesting, right? Because we also know vitamin D deficiency is not good. And so it sounds like a catch 22, but I think rather than sun exposure, you have to think in terms of sun damage. Inflammation in the skin from too much sunshine means that the ultraviolet radiation is causing your skin to be damaged and inflamed. That's a bad

Tanning beds: no? or go?

Tina 9:14

thing.

Leah 9:15

Oh, and can I add a note about, um, full disclosure? I went to tanning beds when I was in my teens. And then also when I moved to Portland, because it was so gray and. Gloomy. And so I started going to tanning beds until I learned about the difference of all the UVA and UVB rays, and one of the things. Tanning salons talk about is, oh, we're providing, you know, you get vitamin D from our beds and you don't because they kind of tone down the UVB rays. Oh. Because those are the burning rains and they talk about, these are the UVA. These are the tanning rays, which are the ones that are the skin cancer rays. So it's, I don't know. I'll go to a tanning salon if you think that that's why, you know, you're doing it for vitamins. Not recommended because it's not the same as the sun. Right. Right. So that was just an aside, but, um, oh, okay. So other ways of getting

Food sources of vitamin D.

Leah 10:13

it through food and most of the food sources, if it's not fortified food, you know, fortified foods would be dairy products, mostly, um, orange juice is a big one.

Tina 10:28

Then they're fortified with ergo. Calciferol right. They're not fortified with anything that's bio-identical, which is vitamin

Leah 10:34

D too. Right. Cause they're different forms as you mentioned. And so the ones that we hear about are vitamin D two and vitamin D three. And so, yeah, so there are, I think almost all dairy products are, are fortified. Um, there might be eggs that are four to five, and then what they're doing is they're feeding it to the animals typically. Oh, If the animals aren't exposed to the sun, because that's how you're going to get vitamin D is because the cow is out in the sun. But I think they supplement it too. I don't know anything about dairy cows, but I do believe I glanced at something that suggested that they needed. I think because they're just producing so much milk all the time. Oh yeah. But they need it for themselves. I think. I don't know. I'm just going to go with that because it's helping out the cows. Seafood. So fresh water, rainbow trout has a fair amount salmon, herring, and you know, there's various other, other seafood as well. So that's the other source. And then for all of you vegans out there, mushrooms really are the only, natural source that's non fortified.

Tina 11:44

Right, right. Yeah. And the fishes, I know have vitamin D. So they're closer to what we would be making ourselves, then what comes in the milk. And

Leah 11:56

they would

Tina 11:56

also have fair that bone is vitamin D and some omega three fatty acids.

Leah 12:01

Yeah. So we've mentioned kind of, you know, what it is. We talked about how we

Who is likely to be deficient?

Leah 12:08

get it. Um, who's at risk for

Tina 12:10

deficiency. Yeah. I mean, as soon as you say sunshine, anyone who's not getting sunshine is, is more likely to be deficient. Right. So anyone who's. Either covering up or avoiding or at such a high latitude, they just don't get much. Right. So there's parts of the world where they have no sunshine for seasons or very little, I should say.

Leah 12:31

Interestingly, there were a lot of people when I lived in Arizona, a lot of patients who are vitamin D deficient because it's so hard. And the sun is so intense people weren't going in the sun or they would just slather on the sunblock. And so, um, they would be deficient cause we would test most of patients if not all,

Tina 12:51

most of them. Yeah. Yeah. So we should say that we routinely test and we'll get to the lab testing too, but you and I routinely test our patients for this.

Leah 13:00

So, um, who's at risk for deficiency, the darker, your complexion, the greater risk you are for having. vitamin D deficiency. So that's, that is a risk factor as we age, malabsorption

Tina 13:16

is at least for the vitamin D that comes in the diet. Right. You're not going to break as well, right? Yeah.

Leah 13:20

So for anything that you take in a, you know, as a supplement or through food malabsorption, um, bariatric surgery or any sort of condition or surgery that might impair those organs that we mentioned. The liver, the small intestine, the, um, kidneys, anything that impairs the pathway to make vitamin D and I'll

Tina 13:44

find a picture. If you include all the organs that either make or process vitamin D into an active form. I mean, that's a lot of Oregon.

Leah 13:52

Yeah. So if you've got any, anything going on with any of those, it may possibly impair, and then obesity is the other is the other potential

BMI and circulating vitamin D.

Leah 14:00

risk factor.

Tina 14:01

Yeah. So in all of those scenarios, when they look at populations, you can see that population wide as the BMI goes up and the obesity is set at 30 kilograms per meter squared, fair BMI, and BMI is simply an equation that uses your weight and your height and comes out with.

Leah 14:21

And that's, it's pretty controversial. It's

Tina 14:23

very controversial because it doesn't talk about composition. So it doesn't matter if you're, as far as the BMI is concerned, it will look the same, whether you are made of fat or muscle. Right. So that is very controversial, but that is where the cutoff is. And it does look like when people are obese. And certainly when they're morbidly obese, you know, when the BMI is up over 35, over 40. There are much lower levels of vitamin D circulating. So generally speaking in population studies, when they look across the BMI's people who are obese are much more likely to need to take vitamin D in a supplemental form to have normal levels.

Leah 14:57

Okay. So we're going to take a break and then we're going to talk about what does a normal level. And

Tina 15:02

more, all right. See you on the other side.

15:05

Vitamin D is a fat-soluble vitamin and it's better absorbed when taken with fat, but how much exactly one study found a moderate amount of fat about 11 grams helped with absorption. That's less than a tablespoon of butter or olive oil and less than an ounce of almonds. So next time you take your D take it with a snack.

Acute, chronic, pharmacologic use of supplemental D.

Leah 15:24

Okay. Before we keep going, I want to kind of review what was covered in our previous episode of supplements. 1 0 1, which was the basics episode. And what we talked about then was, you know, like the use of a vitamin, like what is the appropriate use of a vitamin? And the first one was to prevent or treat an acute nutrient deficiency. The second reason was to prevent delay or. Uh, chronic nutrient deficiency and then the third use of a vitamin is for green pharmacy. And so I'll kind of cover some of that or we'll cover this, for vitamin D. Yes.

Tina 15:58

So as a

Leah 15:58

supplement, as a supplement. Yes. So the acute nutrient deficiency associated with vitamin D is Ricketts. Right. And interestingly, how they. Kind of discovered that vitamin D could help with rickets, which is like the malformation of bones and teeth, um, was that children in more temperate, sunny climates didn't have this condition as much as kids and more industrialized countries, you know, in more Northern climates and the children were being treated with Cod liver oil and sunshine. That was the therapy, but they didn't know that called liver oil had this substance in it, which was vitamin D like no one had discovered the vitamin yet. So that's the, that's the treatment for records.

Tina 16:49

It's always fascinating to me cause there's a lot of traditional remedies that predate the chemistry. So that's another one. Cause we talked about vitamin B12 before you and I, and it being used for anemia of pregnant. Without knowing that they were, you know, using B12. So it's, it's another story where the use of the Cod liver oil as a medicine predates our knowledge of

Leah 17:11

why it was working, why it was working. Yeah. No, it's. And in terms of the chronic nutrient deficiencies, preventing, delaying, or treating using vitamin D, it would be like osteoporosis fractures. There is association with the level of vitamin D and type one diabetes there's information about multiple sclerosis. I think cardiovascular disease might be another one. So th that would be, you know, another reason why someone would take vitamin. And I couldn't really think of anything that was green pharmacy. Oh,

Tina 17:48

ultra high doses of it as a therapeutic, you mean?

Leah 17:51

Or you're just targeting something specifically. Yeah. Um, Kelsa trial, I think is what we had talked about, where there are some studies that use calcitriol. It's the active form of vitamin D and that's been used in clinical trials. Along with chemotherapies. the one that I've heard the most about is with patients with pancreatic cancer. Kelsa trial was used along with gemcitabine, which is a chemotherapy. Is like a first-line treatment. Right. And, um, it was supposed to help with, I think the

Tina 18:28

efficacy. Did we get results from that one?

Leah 18:31

I think there were good results and that's, I had a medical oncologist that I worked with and that's what he would prescribe for his patients. So that's how I learned of it. And then I found the study and there were positive results girls, the med-onc

Tina 18:43

wouldn't have done it. Yeah.

Leah 18:44

I think they've also are looking or have looked at breast cancer and prostate cancer as well. Which prostate cancers?

Tina 18:50

Interesting. Yes. There was a study for patients with prostate cancer up at OSU, which is Oregon health sciences university. I want to say the lead, the PI, and that was Dr. Beer. I believe they found that the calcitriol, the 1 25. Dihydroxy is that how you say

Leah 19:09

calcitriol counsel trial? I don't know.

Tina 19:11

I don't know. It could be tomato. Tomato.

Leah 19:13

Okay. Well, we'll go with tomato,

Tina 19:18

but what they use calcitriol is, um, 1 25 dihydroxy coli calciferol. So that is. The one that targets the tissue and actually has the action within cells. That's also the drug and it's given in what looks like very small doses, but potent doses. But nonetheless, it has been. Pharmacological doses. So beyond what our physiology would ever make in some studies. And I know prostate cancer was one of those, but they found out it didn't do anything either way. It didn't help didn't hurt. So not worth the risk and that scenario,

Leah 19:50

but that, yeah, that was the only thing where I could find, you know, it being used kind of in place of her, along with medications.

Tina 19:56

Um, Can I interject? Yes, they are. There is a lot of research in trying to discover analogs of vitamin D that have. The benefits of vitamin D without some of the risks of taking a vitamin D supplement. So we haven't really talked about the risk, but of course, vitamin D has a lot to do with calcium homeostasis in the body. And

Leah 20:20

it's like, that's balancing homeostasis is 2 0 1 word. So we're going to go

Tina 20:25

with the balance. Yes. Making sure your calcium levels are not too high or too low in vitamin D is. Intimately linked to that, which is why all the bone issues and teeth issues that said a high dose of vitamin D generally isn't used because high calcium can result. And so to avoid that drug companies are trying to find all the good with no risk and creating these vitamin D compounds, which we call analogs.

Leah 20:51

And we're going to get into safety and interactions in a sec. But what I said before the break was, we're going to talk about ideal levels. Um, I guess we should start with, what's considered deficient

Vit D deficiency defined.

Leah 21:04

before we talk about an ideal level. Yeah, cause there's so much controversy. I mean, I I've talked to patients and they're like, I was told my level should be at least a hundred, you know? And then someone else will be like, well, I was told it was in normal range. And then when I look at it and I'm like, well, that's still pretty low. So let's talk about, what's considered a deficiency. And from my understanding deficiency is 20 nanograms per milliliter and less.

Tina 21:31

I think that that is, nobody will argue that if we want to say there's one spot on the scale where nobody will argue that it is deficiency is less than 20.

Leah 21:42

True. Um, then there's the, the wiggle room between 20 and 30. In my mind, if somebody has less than 30 they're deficient. So if someone came in with a level of 28 and they're like, oh, my doctor told me I was not, I was in a normal range. I'd be like, let's, let's kick it up a

Tina 22:02

notch. Yeah. I'm with you on that. And it's interesting. Cause I was just pulling up the NIH levels in front of me and that 20 cutoff is where they put it. Right. So then I'm saying that no matter who you are or how conservative 20. Everybody agrees on. Most labs will tell you normal starts at 30 or 32. And when we use these numbers, we're talking about nanograms per milliliter, because I should point that out because in the United States, we use nanograms per milliliter. Most countries in the world use nanomoles per liter, but because you and I are familiar with nanograms per milliliter, let's just stick to one set of numbers. but I'm with you. I think that anything under 30 certainly is. Insufficient.

Leah 22:47

But what I was working in Oregon 20 was the cutoff. And then when I moved to Arizona, 30 was, and so from my understanding lab values are based on the healthy population that goes to the lab. So if you're in a sunny climate, your low levels are going to be higher than if you're in a cloudy area.

Tina 23:09

Yeah. So, yeah, you're right. And so what does ideals, I personally think the sweet spot is somewhere

What level of 25(OH)D is ideal?

Tina 23:17

around 50. Give or take, so let's just say 40 to 60, so right. Kind of in the middle there. Yeah. I

Leah 23:23

kind of go with 40 to 62, um, except in the case of, people who are taking. Aromatase inhibitors and have that joint pain. There was a study that, showed, they looked at women who were having pains from. Which is an aromatase inhibitor. And if they had levels greater than 66 nanograms per milliliter, they reported less joint pain associated with their, their medication. Yeah.

Tina 23:54

And it's, it is one of the things we haven't mentioned when that is vitamin D appears to be anti-inflammatory. So that study was done for joint pain in women taking an aromatase inhibitor. But I would say, you know, in general, that's you want it to be on. Upper end of normal, which is 60 give or take 60 something. Um, if you have kind of a systemic inflammatory condition, so even osteoarthritis or eczema or whatever your manifestation of a systemic inflammatory condition is, you definitely want to make sure your vitamin D levels are adequate at the very least, and maybe even highlight. We're still within the normal range though. There is no there's no condition or no scenario where I think it should be outside the normal range of the lab. So my labs nearby here go up to 80 as the maximum on there. 80 nanograms per milliliter. Certainly above that, I say, lay off it don't take it. Let's get you back in the normal range because there are true risks of going

Leah 24:56

to high. And especially as we'll discuss, you know, especially with, um, patients who are going through cancer treatment. Okay. So again, let's just, let's just kind of take a quick break and we'll be back talking about what to look for in a lab and all kinds of stuff. Vitamin D and cancer. Ooh. Okay.

Which blood test is ordered?

Leah 25:32

Okay. So we talked about what the deficiency kind of cutoff is, and, you know, the kind of the, the safe range that your lab should be, but what, what are the labs that are ordered?

Tina 25:44

Oh yeah. So we have to be specific about this because you can order a few different ways. So the levels we're talking about when we were talking about these numbers is the serum 25 hydroxy vitamin. So, this is kind of the circulating amount. This is before it goes to the kidneys and gets truly activated. And this is the way it mostly is circulating in the blood.

Leah 26:08

There are times when a Dr. May order the other labs as well, looking at your other types of vitamin D. Yeah.

Tina 26:16

They can order the active form, which. 1 25 dihydroxy vitamin D. And if you're taking calcitriol, if you're taking the active 1 25, dihydroxy vitamin D, then the labs will be ordered to make sure that you're not being overdosed. Sometimes

Leah 26:30

I think when people have like kidney issues, they order that would make sense to

26:35

make

Tina 26:35

sure it's actively. Yeah. I

26:38

mean,

Leah 26:38

I've seen, I've seen, I've seen it ordered. I ordered it once myself, but I think it's because I clicked it wrong, um, in when ordering the lab, I miss clicked it, but,

D & cancers.

Leah 26:50

um, moving on vitamin D and cancer, so that's kind of the, hot topic, you know, Study comes out and talks about the benefit of taking vitamin D. And then another study says there's absolutely no benefit in patients taking vitamin D. So Tina, which isn't,

Tina 27:13

well, one of the first things you have to think about when you're looking at studies for any vitamin or nutrient for that matter is what does the study population they're looking at? If vitamin D is given to a population. Across the board without knowing whether they're deficient. That's one type of study and that is done. It's kind of not a great use of a study design because giving vitamin D across the board, if there's no deficiency, it's likely not to have an effect because people already have plenty of it. When vitamin D is given to people who are deficient, you're more likely to see effects of the vitamin D. So sometimes when you're only reading the headline, you're getting a little blurb in your social media feed or your email. Sometimes those are not well-designed studies and they're giving a new. Vitamin D or some other nutrient to a population that is not proven to be deficient one. Wouldn't expect that to have any effect, unless you're using it in a pharmacological dose and trying to do that drug effect with it. But other than that, um, most of the studies are confusing because the study. Are either in the deficient people or they're both deficient and some of the population is replete, so yeah, we're going to get different results.

Leah 28:24

And

How much D3 to take?

Leah 28:25

so how much vitamin D needs to be taken to bring someone's level up? I know that the, um, Institute for medicine and, you know, NIH and, you know, certain places. Recommend a lot lower levels than what you and I would probably recommend.

Tina 28:44

Yeah. Yeah. So the dietary allowances from the NIH has perspective is somewhere between 400 and 800 IQ. And we were getting away from that ICU. I use stands for international units. They're moving more towards micrograms, both on the labels of supplements and in the recommendations. So 400 IQ is 10 micrograms. 800 IQ is 20 micrograms. And this depends on age. So that's from birth to over 70 years old. It's going to be in that range though 400 to 800 that said, you know, when you put vitamin D in your mouth as a supplement, for example, and you're not getting it from sunshine and you want to supplement it, some of what you need depends on how quickly you're using it and how well you absorb what you just put in your mouth. So ultimately the only. Really know how much to take is to do a lab value. Take more or less accordingly. That's really ultimately what I do with everybody is I don't, if I had to say across the board a safe dose for absolutely everyone who has normal calcium on their labs, I would say a thousand to 2000 IUs per day.

Leah 29:53

Yeah. And I think, I think the Linus Pauling Institute recommends for, um, reducing fracture rate. 800 to a thousand. I use a day reducing falls and fractures in older adults. Um, I think that's the recommendation. I know that, you know, sometimes you have a patient coming to you. I know I have who comes in taking 50,000 international units once a week and that's prescribed by a doctor typically when someone is found to be deficient. And so that. You know, what, what does that come down to? That's like a little over 7,000 a day.

Tina 30:34

Yeah. I've never been a huge fan of that. There have been studies showing that giving large doses infrequently actually led to more fractures when they, when they gave it. And when it was vitamin D three, specifically, what you're talking about, the prescription is vitamin D two, right. Or go calciferol. I, don't always a fan of getting a little closer to how it occurs in the body or a nature when you're eating it from. So vitamin D three and a small amount, I'll tell you, I rarely give the capsules unless people really need that convenience because in my population, I, again, after giving it, I tested on labs, I would say over half of my patients were still deficient. So I would say. Almost always. I recommend it as something that can be absorbed in the mouth. I don't care if it's a sublingual drop, if it's a spray, um, however they want to take it. But going in the mouth that can go across the mucosal barrier of the, of the cheek and gums, and you can absorb it right into the bloodstream. And that way you don't have to worry about malabsorption and that. And generally you take a little bit lesser dose. Like if I'm doing that, I would think 800 to a thousand and then still retest. And if they need more, I can give more. Yeah. My

Leah 31:45

concern with the drops is to make sure that it is. The drop is the dose and not the dropper because I have had patients mix that up and I think that does happen. And so, um, you know, you want to make sure someone's not taking one dropper full when it's supposed to be one to two drops, you know? Yeah.

Tina 32:03

Um, Yeah, I, I would say some of the sprays are actually better because a pump is a pump. I mean, there's no, you can see it. You can feel it. A pump is actually probably easier to titrate the dose more precisely than drops. Cause the other thing is when you have a dropper and you have it up there, you can't tell if you just put one drop in or two, it's not like it's a right.

Leah 32:22

It's not like you can really always feel the drop going in.

Tina 32:26

And there was one study that pulled a bunch of these off the shelf and found that the variability. Pretty large. So you have to go with a good reputable company. Don't just buy, you know, vitamin D drops from some company you don't know the quality of it's really important to make sure it's a good high quality company that you know is not going to overdose you unwittingly. That was an actual study. It was published. We can link to it.

Leah 32:49

Oh, yeah, you have to send me those links so I can put them in the show notes. So, yeah, I think I typically, depending on the season and, you know, where, where you live that kind of like, and the patient's level. I like, I look at all of those before determining how much that they can take. Um, I do like a daily dose, so I, I remember one patient who. It was taking the 50,000 I IU of vitamin D too. And they told me that when they took it, they felt really good. And then by the end of the week, before they took their next dose, they kind of started feeling down again. Their level was super, super low. It was well below 20. And so I recommended that they take. I think, I, I don't remember what it was, but, you know, to take a higher dose every day and to take it around noon to kind of mimic that high sun exposure time. but I thought it was fascinating how they actually felt better after taking a high dose. And then that effect kind of w you know, waned as they, as they got further away from the dose. And as we mentioned before, vitamin D is fat-soluble. So it isn't something that. Vitamin C, which you just kind of pee out. It does hanging out in your body a little bit longer. So there is an increased risk for toxicity because of

Tina 34:12

that. Yeah. And it's toxicity at least acutely, because it has so much to do with calcium balance. That's truly the danger. If calcium goes too high or too high in the bloodstream, it can throw off the heartbeat and a arrhythmias can result. And so this is a very serious. And even fatal side effect. If someone took a hyper toxic dose of it,

Leah 34:34

and there are some medications that it can interact with and. I think it's more, those that also affect calcium. it's probably also anything that affects absorption.

Tina 34:48

you know, I do believe that when people are on steroids, long-term when they're on an oral steroid long-term that can interfere with absorption of vitamin D in the. So if someone's taking, I'm thinking of like my multiple myeloma patients, they're, you know, taking steroids long-term months, years at a time that certainly can add up and you have to make sure that if you're taking a steroid intermittently or chronically taking a steroid, have, you run a D levels checked. And again, it might be another reason I go straight to the mouth. Absorption is there's so many scenarios I can think of that could interfere with the absorption of vitamin D and. Early on. Notice that giving it orally often didn't bump the labs up. And so when I went to the mouth absorbed types, no matter what form was mud.

Leah 35:39

Yeah. And w you know, when there are certain conditions like multiple myeloma where calcium levels are,

Tina 35:47

they're already

Leah 35:48

at risk, they're at risk. That's exactly what I was thinking. And I thought that sounds weird. Yes. So when calcium levels are already at risk, it's really important to make sure you know, your vitamin D level and not to take too much. Right. Many patients come to us and they're taking 10,000 IU a day because someone told them to. And I admit in my past, I may have done that before I worked in oncology. And so, you know, if somebody has. cancer where your calcium levels can kind of go haywire at any moment. just be really careful about how much vitamin D you're

Tina 36:22

taking. Yeah. Yeah. And there's, yeah, there's the, there's a lot of cancers where that can happen. Multi myeloma comes to mind. There are some lung cancers that can develop what's called a paraneoplastic syndrome, which can cause this and that paraneoplastic syndrome reminds me that parathyroid hormone. As intimately linked with this entire story of calcium and vitamin D. So parathyroid whether someone's had one removed, whether someone has a hyperactive one, like there's so much going on with vitamin D that's complicated quickly that the only way to really take it and take it safely is to look at your own lab values. To have peace of mind that you're not doing any harm.

VitD and colorectal cancer.

Leah 37:03

So offline, you had mentioned about a, I believe it was an epidemiologic study looking at vitamin D and colorectal cancer.

Tina 37:13

Yeah. Yeah, it was, um, it was the brothers Garland and. Um, Cedric Garland was one of them. Yeah. Cedric Garland who's down in San Diego himself. Now his entire career has been around vitamin D, but it's kind of a big paper that came out in 1980 and he and his brother epidemiologists looked at colorectal cancer, mortality and sun exposure. And they found across the United States. When you looked at that, that you could see that there was at least some kind of trend where in sunnier climates, there was less. Colorectal cancer mortality than there were in Northern climates. And that was kind of the first tip off his entire career. Again, has been dedicated to vitamin D. So I love that he lives nearby in sunny San Diego. Um, but In a paper that he sent, send it actually to Congress and made recommendations about vitamin D repletion across the nation and how many breast cancers and colorectal cancers in particular that would prevent. So if we could just keep everybody from being deficient, we could probably prevent a lot of various cancers. He had this huge paper came out. Oh gosh, I want to say 2009, that could be. But we'll link to that paper too, but it was basically a plea to Congress and in there, he said, how many hundreds of thousands of people over time could be spared a cancer diagnosis if we could just keep their range up. And he's recommending somewhere in the range of what I was mentioning, which is, you know, 50, 60 nanograms per month. That's his recommendation.

Leah 38:47

And I do remember, um, another one of the medical oncologists I worked with made sure that his patients with colorectal cancer were taking at least 4,000 units a day. So I'm sure that's based on some study. I should look for, again, we're not recommending that this is what people should take. We're just talking about what has been looked

VitD and breast cancer.

Leah 39:08

at.

Tina 39:09

There was one study that came out a couple of years ago, and it was interesting in that they looked at women with stage three breast cancer, and they looked at them over time and they watched so people who started out vitamin D deficient, some of them were given vitamin D as a. The people who got their vitamin D into the normal range for that study had better outcomes than those who remained deficient throughout the study period. So when they were washed over time, basically the women whose vitamin D was corrected from deficient to normal had better outcomes. And what I mean by that is the women with stage three, who went from deficient to replete and vitamin D had less recurrence than those who remained deficient. That's one of the best studies to show. Vitamin D repletion is worth your time.

Leah 39:56

But for those women who were already in the normal range, there was no difference, right? Yeah, no difference. And I think that's the thing that we need to, you know, kind of keep saying is that if somebody is already in the normal range, there isn't really no need

Tina 40:10

to go higher. Right. This is one of those classic scenarios where. More is not always better. And certainly, like I said, I'm going to reiterate that if it's outside the normal range, you need to bring it back down into it because you're, you're definitely pushing your risk benefit beyond limits. You know, you're, you're definitely taking more risks than you are deriving benefit over the 80 nanograms per milliliter, mark.

VitD and prostate cancer.

Leah 40:31

And then there was something that saw, an inverse correlation between vitamin D and prostate cancer

Tina 40:39

that outlier yes. Prostate cancer. Um, so prostate cancer, breast cancer, colorectal cancer, and even some lung cancers are all adenocarcinomas. So this type of glandular tissue adenocarcinomas. So you'd think they'd all behave similarly. They don't. So proscenium here. I know just when you think you can make some generalizations based on a tissue type or something. No prostate cancer, I have always said is its own kind of. Set. You have to look at prostate cancer completely separately than you do breast and colorectal cancer have a lot more in common than prostate with either one of them. It may have to do with the specialized cells of the prostate and how. The whole metabolism of energy is different than the prostate cells. In any case, all bets are off with prostate cancer. It, there does seem to be some inverse correlation where lower vitamin D levels were associated with better outcomes. Um, and they didn't, they were giving it as a supplement. There was nothing like that. It was just looking at populations and looking at men with prostate cancer, how they fared over time. And. The men with the lower levels fared better. The analysis of that information by the way, has a lot to do with testosterone levels as well. And so it gets complicated again very quickly because we're talking about two hormones now. Um, whether testosterone was normal or low may have had some effect on those results, but regardless, we're just looking across the board, it did look like taking a lot of vitamin D was not beneficial for men with prostate cancer. It's so complicated. Yeah. You know, it's because cancer is not a monolithic thing, right? Cancer is, is every Oregon. And even within that Oregon there's subtypes of cancer. So it's not one thing when we say cancer, it's almost just describing how the tissue behaves rather than what the tissue is. Great. So yes, it is complicated. That's why entire careers are dedicated to just one.

The unofficial theme song

Leah 42:40

All right. Tina, anything else that we want to add? I don't think so. Besides

Tina 42:45

the song. Well, the song's kind of a given when we're talking about sunshine.

Leah 42:50

I know. And you actually came up with this song, which, you know, our unofficial theme song for the episode. We can thank

Tina 42:57

John Denver. You're going to sing. Oh God. I can go through that. That's not, it's just not nice.

Leah 43:05

Well, it's a song from my childhood. Um, sunshine on my shoulder. That's what it's called. Right. I don't know. That's how I know it. Sure.

Tina 43:14

That's how I know it. We'll call it that. I think everyone knows that. Well, everyone have a certain, uh, age of a certain

Leah 43:21

age, sunshine on my shoulders. I just did the Google by John Denver. That is our song. I didn't do previous research. So, um, oh, apparently

Tina 43:31

it was the B side. See, you learned something new. Wow.

Leah 43:36

And that's the song that I know, not the other one, but anyways, that came out in 1971. It's a folk song. If you don't know it, you can find the link in our show notes and on our website, I'll post a link to the video. Oh, which on YouTube has received over 11 million

Tina 43:53

views. No wonder. That's how you know it.

Leah 43:59

so I think

Support the show!

Leah 44:00

we kind of covered a lot. Um, I know we covered a lot and if you aren't already remember to subscribe, rate and review, tell us what you think of us and

Tina 44:11

check out our web. The cancer pod.com because we have a few more blog pieces on there. Some information, some recipes that you might like,

Leah 44:19

and you can always buy us a coffee. You know, we do this ourselves. Uh, we do have help with some of our episodes. And so every coffee that is bought for us helps us to focus more on. And less on all this production stuff.

Tina 44:39

Yeah. And we want to do more in-depth lessons because I want to go off on all the biochemistry and, you know, make this into a massive lesson, but I am holding back the 2 0 1 is the 4 0 1 ones in the master's class. And I need to do that. We need to get out there. Yeah, I know. I know. We've

Leah 44:56

got it. We've got ideas. We just need to, we just need to. Get our act together. Yeah. Check out our website, the cancer pod.com. we're on Instagram, Facebook, all kinds of places. We're always the cancer pod. Um,

Tina 45:13

yeah. And send it to a friend.

Leah 45:15

Send us. Yes. If you like what you hear, pass it on. Share with someone you love. And on that note, I'm Dr. Lee.

Tina 45:25

And I'm Dr. Tina Kaeser, and this is the cancer pod until next time.

Leah 46:23

talk about bones?