The Vitamin D Newsletter - February 19, 2005

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" Vitamin D Newsletter " <jcannell

Professor Barbara Gilchrest

Sat, 18 Feb 2006 17:53:43 -0800

 

 

 

 

The Vitamin D Newsletter

 

February 19, 2005

 

This is a periodic newsletter from the Vitamin D Council, a non-profit

trying to end the epidemic of vitamin D deficiency. If you don't want

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Professor Gilchrest

 

I'm a lot calmer these days. A few years ago, I was angry about the

epidemic of vitamin D deficiency and the millions of needless deaths,

somehow thinking I had to be more vociferous in getting the word out.

Now I just plug along, knowing the truth will prevail, regardless of

what I do, knowing we are speaking of decades, not months, for the

work ahead. As the poet, Patmore, said:

 

 

" For want of me the world's course will not fail:

When all its work is done, the lie shall rot;

The truth is great, and shall prevail,

 

 

When none cares whether it prevail or not. "

 

I also knew it was only a matter of time before the backlash against

vitamin D began. This month, Professor Barbara Gilchrest of Boston

University fired the first broadside.

 

I'm happy to say Professor Gilchrest's paper didn't upset me all that

much, although, like anything that you don't agree with, it was

difficult to read carefully. Scientists, experts, physicians, and

advocates should always read opposing views carefully, less they get

drunk on their own whiskey.

 

Professor Barbara Gilchrest is the same academic who turned me livid

eighteen months ago when she fired Professor Michael Holick for

writing a book. Holick's book simply questioned current dermatology

dogma that sunlight is evil and she fired him: Boston University's

version of academic freedom.

 

This time, Dr. Gilchrest teamed up with Dr. Deon Wolpowitz to write a

broadside against vitamin D and sunlight. The two authors have

something in common: neither had ever published a peer-reviewed paper

about vitamin D before (just search PubMed):

 

J Am Acad Dermatol. 2006 Feb;54(2):301-17. Epub 2006 Jan 4.

 

Nor did the article get much press. Reuters picked it up, but few

other news outlets.

 

Supplements not sun best for boosting vitamin D

 

As an aside, Dr. Gilchrest is one of the invited speakers at the

upcoming 13th Annual Workshop on Vitamin D in Victoria, British

Columbia, from April 8-12, 2006. Professor Tony Norman and Professor

Roger Bouillon, both giants in the vitamin D field, organized this

meeting. Tickets are going fast. The conference is at the gorgeous

Fairmont Empress, a historic hotel one should experience at least once

in your life. Be warned, this is a conference for scientists. Most

of the presentations are technical, just the sort of work that needs

to be done to better understand vitamin D.

 

However, mixed in with the highly technical papers are some very

useful clinical papers. Heike Bischoff-Ferrari, Hector F. Deluca,

Edward Giovannucci, Robert Heaney, Bruce Hollis, Jo Ellen Welsh, Susan

Whiting, and others usually present their data in ways educated lay

people can understand. I was sorry to see that Michael Holick, Cedric

Garland, and Reinhold Vieth were not invited to speak – sorry because

Holick is the giant of the field, Garland because of his recent

incredible paper on vitamin D and cancer, and Vieth because he started

the current vitamin D revolution.

 

At first, I was upset (not livid) to see Dr. Gilchrest invited to

speak at a vitamin D conference. However, the more I thought about

it, the more I realized this is academic freedom at its best. One of

the harshest critics of sun exposure, Dr. Gilchrest, invited to a

conference where many of the attendees are staunch advocates of

sensible sun exposure. I respect her for coming. I only hope that

Professor Norman will invite Professor Michael Holick to debate her.

Now that would be a free exchange of ideas!

 

Getting back to her paper, the most depressing thing about it was the

emails from vitamin D experts around the country, bemoaning the fact

that it is useless to write a rebuttal to the Journal of the American

Academy of Dermatology, useless to try to correct Professor

Gilchrest's mistakes. They have tried in the past - the Journal of

the American Academy of Dermatology will not print any view that

opposes their dogma that God was confused when she created sunlight.

Another blow for free academic discussion of ideas.

 

After carefully reading Gilchrest's paper twice, I'm sorry to say the

paper contains so many inaccuracies that I can't list them all. Some

of the errors are basic. Professor Gilchrest, cholecalciferol is not

previtamin D; it is vitamin D. Professor Gilchrest, vitamin D is not

in the " superfamily of steroid hormones that includes vitamin A and

thyroid hormone, " its receptor is. Professor Gilchrest, vitamin D is

not a steroid hormone; it is a prehormone. Professor Gilchrest,

vitamin A is not a steroid hormone; it has a retinol base, not a

sterol one. Professor Gilchrest, thyroid hormone is not a steroid

hormone; it has a tyrosine base, not a sterol one. When she makes

basic mistakes on freshman biochemistry, how can any reader trust her

interpretation of scientific studies with immense medical and social

consequence?

 

Her first argument is that sunlight and sunbeds kill many people,

mainly due to malignant melanoma. However, she failed to cite the two

biggest and best studies! A large, multi-center European study,

perhaps the best study ever done on the subject, " found no association

between melanoma and risk factors related to UV exposure such as

sunbed use, sunbathing, or number of weeks of holidays in sunny

areas. " In fact, the authors found sunbed use was associated with a

small decreased risk for melanoma! They also found that sun bathing

and sunburns were not associated with melanoma. Fair skin and the

number of moles were the major risk factor for melanoma, not sunbeds,

and sunshine. They even found some evidence of decreasing risk with

increasing sunbed use, concluding " The observed decrease in risk (of

melanoma) with increasing use (of sunbeds) suggest either a protective

effect or could be explained by recall bias with cases under reporting

their true exposure. "

 

Eur J Cancer. 2005 Sep;41(14):2141-9.

 

Actually, recall bias (errors due to what patients tell researchers

they remember), as the authors admit, is likely to skew the results

the other way. Patients with melanoma are more likely to report sun

exposure or sun bed use in an " effort after meaning. " That is, humans

try to find an explanation for their problems and are likely to

falsely remember any factor they think might explain their melanoma.

 

Gilchrest also ignored another recent large European study looking at

melanoma and sun/sunbed exposure. The British authors concluded,

" This case-control study of melanoma did not find that exposure to

natural or artificial radiation was significantly associated with an

increased melanoma risk in the population overall. " Although they

found ten or more sunburns and exposure to sunbeds for individuals

with fair skin yielded significant but small melanoma risks, they

found no overall risks. They concluded, " The fact that no dose

response was found for hours and years of exposure to sunbeds, even in

young subjects, suggests that the use of sunbeds . . . is unlikely to

be a major environmental risk factor for melanoma. "

 

Eur J Cancer. 2004 Feb;40(3):429-35.

 

After she ignores the two best, biggest, and most recent studies of

melanoma and UV light, she goes on argue to sunlight is largely

responsible for the 8,000 melanoma deaths per year. In fact, it is

more likely that the current epidemic of melanoma, like many other

cancers, is partially due to vitamin D deficiency. Vitamin D is such

a stellar anti-carcinogen, doing everything an ideal anti-neoplastic

drug should do, it is easy to see why dermatologists' advice to

melanoma patients – avoid the sun at all costs – is actually killing

patients. A recent large multi-center trial (another one Professor

Gilchrest ignored) looked at evidence of ongoing sun-exposure in

melanoma patients. It concluded, " Sun exposure is associated with

increased survival from melanoma. "

 

J Natl Cancer Inst. 2005 Feb 2;97(3):195-9

 

Professor Gilchrest then argues that the health benefits of vitamin D

beyond bone disease are unproven. She explains that controlled

interventional trials using vitamin D are rare, which is true.

However, it is also true that science never proved that low fat diets

prevent heart disease or stroke with good controlled interventional

trials. The lack of good interventional trials did not prevent modern

medicine from advising low fat diets -- uselessly it seems.

 

JAMA. 2006 Feb 8;295(6):655-66.

 

New York Times, February 8, 2006: Low-Fat Diet Does Not Cut Health

Risks, Study Finds

 

In implying doctors should not act until scientists conclusively prove

a point, Professor Gilchrest misses the point. Sometimes physicians

must act before science conclusively proves a point. We cannot wait.

Scientists can wait. Physicians are obligated to perform a

risk/benefit analysis based on available data and treat their patients

accordingly. If a new therapy is highly risky (like a new cancer

chemotherapy with numerous side effects), then physicians should only

use the drug on patients facing death. If the therapy or advice is

clearly safe (drink eight glasses of water a day) and reasonable, it

can be widely recommended although I dare the reader to find a single

controlled interventional trial showing eight glasses of water a day

does much other than increase bottled water sales.

 

Unlike advising a low fat diet (assuming one also warns against

trans-fats and excess omega 6 consumption), advising people to avoid

the sun is risky advice. Why is it risky? First, it's highly

unnatural advice to give a species that evolved in the sun. Second,

it goes against basic mammalian instincts, as any pet owner will

verify. Third, it goes against basic human instincts - the sun draws

humans to it - and such instincts evolved for a reason. Finally, it

goes against a large body of data that associates both sun exposure

and low latitude with reduced incidence of many diseases. Thus, sun

avoidance is risky advice and physicians should dispense it only after

science has conclusively proven that the benefits of sun-avoidance

outweigh the risks.

 

Consider the advice of the Lancet Editorial Board, commenting on a

petition to set aside public land for nude sunbathing! " On first

consideration, the idea of a community of people deliberately

practicing nudity, especially with public encouragement, strikes the

average person as ridiculous. . . But the discovery that the rays of

the sun on the skin exert a beneficent effect on health has done

something to undermine these prejudices. "

 

Naked and unashamed [editorial]. Lancet 1932;1:688

 

Granted, the Lancet proffered this advice in the 30's, when organized

medicine knew the extraordinary health benefits of sun exposure and

before the dermatologists scared us out of the sun. Whatever you

think of the government sponsoring nudist colonies, you should know

that the best physicians in the 20's and 30's routinely recommended

sun exposure for a breathtakingly wide variety of diseases; many of

the same diseases that are now being associated with vitamin D deficiency.

 

J Am Acad Dermatol. 2003 Jun;48(6):909-18.

 

Professor Gilchrest goes on to say, " " No trail data support the

conclusion that vitamin D supplementation in the absence of

concomitant calcium supplementation is effective in preventing falls. "

I guess she didn't have time to read Sato's recent study that showed

a 59% reduction in falls with ergocalciferol supplementation alone.

 

Cerebrovasc Dis. 2005;20(3):187-92. Epub 2005 Jul 27.

 

She then cites five " high-quality epidemiological and observational

studies, " which " do not support a role for vitamin D in preventing

cancers. " The problem is that two of her studies are reviews, both of

which call for better studies. Two others found the opposite of what

she claimed. For example, the first study she cited concluded,

" Calcium supplementation and vitamin D status appear to act largely

together, not separately, to reduce risk of colorectal adenoma

recurrence. "

 

J Natl Cancer Inst. 2003 Dec 3;95(23):1765-71.

 

The other study she cited as showing no effect of vitamin D on colon

cancer actually concluded, " This trial cohort provides some evidence

that calcium and vitamin D may be inversely associated with adenoma

recurrence. "

 

J Nutr. 2005 Feb;135(2):252-9.

 

If one wants to review the recent evidence that vitamin D prevents

colon cancer, read Professor Giovannucci's latest paper. He

concluded, " Recent studies add more support to a potential role of

vitamin D on risk of colorectal cancer, but suggest that intakes

higher than customary are required if solar ultraviolet-B exposure is

low. "

 

Curr Opin Gastroenterol. 2006 Jan;22(1):24-9.

 

Professor Gilchrest also cited a prostate cancer study as negative,

which actually showed protective effects for those with mid range

vitamin D blood levels, while showing increased risk for those with

high and low levels. She failed to point out the author of this study

accepted Vieth's explanation that high levels put one at risk because

such patients do not maintain them throughout the year. Vitamin D

levels fall precipitously in the autumn and winter. It appears likely

that falling vitamin D levels may be as dangerous as low levels.

 

Int J Cancer. 2004 Jan 1;108(1):104-8.

 

Int J Cancer. 2004 Sep 1;111(3):468; author reply 469.

 

Then she makes another mistake, one I cannot blame her for because I

have made it myself. She says that we make all the vitamin D we can

make in just the first few minutes of sun exposure then we cannot make

anymore. Although we make a lot of vitamin D very quickly in the sun,

vitamin D production continues to rise with sun exposure - up to about

50,000 units after four minimal erythemal doses (if you stay in the

sun four times longer than it takes your skin to begin to turn pink).

In 1982, Adams proved that by simply measuring cholecalciferol levels

in the winter after steadily increasing UVB exposure into the sunburn

range. Increased melanin in the skin (suntan) and other factors will

eventually block such robust production.

 

N Engl J Med. 1982 Mar 25;306(12):722-5.

 

She also fails to mention the role vitamin D may play in preventing

cardiovascular disease (potentially a greater lifesaver than

preventing cancer), a topic recently reviewed by Zittermann.

 

Br J Nutr. 2005 Oct;94(4):483-92.

 

She goes on to say that if science eventually proves that vitamin D is

important, then supplementation, not sunshine, is the answer. That's

risky advice. How does she know all the sun does? She does know that

sun exposure increases the risk of non-melanoma skin cancers and ages

the skin. She incorrectly thinks sun exposure is the major risk

factor for melanoma.

 

She overlooks the benefit side of the safe sun exposure equation. We

know the sun provides vitamin D, which looks as if it may help protect

humans from most of the diseases of civilization. What else does the

sun do? What does the sun do that we don't know it does? Before I

told someone to avoid the sun, I would wait until science completely

understand the relationship between sun and humans. Until then,

supplemetation in the colder months and moderate safe sun exposure in

the warmer ones, with visits to the dermatologists should you develop

signs of skin cancer, is the safest advice.

 

Remember, non-melanoma skin cancers are mostly a nuisance, unless you

ignore them. I have a few frozen every year, thank my dermatologist,

and them go out to celebrate, knowing that long ago, science

associated non-melanoma skin cancers, a marker for sun exposure, with

a reduced risk of dying from internal cancers.

 

Apperly FL. The relation of solar radiation to cancer mortality in

North America. Cancer Res 1941; 1:191-5

 

The Vitamin D Newsletter, January 18, 2003

 

She also argues that if you don't put sunscreen on correctly, and most

people don't, it won't block vitamin D production in the skin. Thank

God! However, she misinterprets Matsuoka's classic paper which not

only showed properly applied sunblock prevents vitamin D production in

the skin, but showed casual exposure of the arms and face will only

produce minimal amounts of vitamin D. That's an important point,

because some are saying the casual exposure of the arms and face is

sufficient. It's not for many people. Furthermore, does it make

sense to expose those parts of your body with the highest cumulative

lifetime radiation burden to additional radiation? When I go in the

sun, I cover my face and hands but expose as much of the rest of my

body as prudence dictates.

 

J Am Acad Dermatol. 1990 May;22(5 Pt 1):772-5.

 

Towards the end of the paper, she makes some good points. " Recent

reviews have summarized an impressive amount of data showing that

hypervitaminosis D from diet (and I infer supplements from her

context) is more a theoretic concern than a reality. " Good for her!

I guess she read your paper Reinhold? As Reinhold Vieth once said,

" Worrying about vitamin D toxicity is like worrying about drowning

when you are dying of thirst. " Everyone should read the paper that

started the vitamin D revolution. (By the way, Reinhold Vieth's

seminal paper is now free to download thanks to the American Journal

of Clinical Nutrition)

 

Am J Clin Nutr. 1999 May;69(5):842-56.

 

She also competently discusses that pet peeve of mine. Casual sun

exposure won't work in the winter at many latitudes; it won't work for

African Americans, the aged, and certain cultural groups who veil

their skin. Supplementation is critical. Although she sees no reason

to strive for natural blood levels (around 50 ng/ml, year around), she

does, correctly point out that casual sun exposure will not protect

our most vulnerable populations from vitamin D deficiency. Professor

Heaney and Professor Hollis have both recently pointed out that many

vulnerable patients have to take more than 2,000 units a day,

especially in the winter, to prevent deficiency.

 

J Steroid Biochem Mol Biol. 2005 Oct;97(1-2):13-9.

 

J Nutr. 2005 Feb;135(2):317-22.

 

At the end of her paper, a paper filled with inaccuracies, selective

references, and apparent ignorance of melanoma literature, she

surrenders. She grudgingly admits vitamin D is probably important and

the issue needs more attention, even obliquely taking the Food and

Nutrition Board to task for not raising guidelines.

 

However, she doesn't discuss potential liability for dermatologists –

an important omission for her dermatology readers. What will happen

to dermatologists who promulgate sunphobia without taking steps to

ensure that advice does not induce vitamin D deficiency in their

patients? Dermatologists in England have already provided the expert

opinion needed in a court of law. After reviewing the role vitamin D

plays in cancer prevention, including prevention of malignant

melanoma, they concluded: " It would seem mandatory to ensure an

adequate vitamin D3 status if sun exposure were seriously curtailed,

certainly in relation to carcinoma of breast, prostate and colon and

probably also malignant melanoma. "

 

Br J Dermatol. 2002 Aug;147(2):197-213.

 

Eighteen months ago, after she fired Professor Michael Holick from her

dermatology department, I was livid. I sent Professor Gilchrest a

registered letter , threatening to file complaints with the AMA's

Council on Ethical and Judicial Affairs for violating the Principles

of Medical Ethics, and with Board of Registration in Medicine of the

Commonwealth of Massachusetts for dispensing harmful medical advice.

I also threatened to run ads in Boston newspapers to find patients who

had developed life-threatening cancers due to her sunphobe advice,

patients who could sue her should she not educate herself about

vitamin D. After I calmed down, and after Michael Holick calmed me

down, I didn't do any of these things.

 

Now I'm looking forward to hearing her speak in Victoria at the 13th

Annual Workshop on Vitamin D . Even with all the mistakes in her

paper, I think Professor Gilchrest has come a long way in the last

eighteen months.

 

Then again, so have I.

 

 

John Cannell, MD

The Vitamin D Council

9100 San Gregorio Road

Atascadero, CA 93422

 

 

This is a periodic newsletter from the Vitamin D Council, a non-profit

trying to end the epidemic of vitamin D deficiency. If you don't want

to get the newsletter, please hit reply and let us know.

 

This newsletter is not copyrighted. Please reproduce it and post it

on Internet sites.

 

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Remember, we are a non-profit and rely on donations to publish our

newsletter and maintain our website. Send your tax-deductible

contributions to:

 

 

 

The Vitamin D Council

 

9100 San Gregorio Road

 

Atascadero, CA 93422