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Is 5,000 IU/Day of Vitamin D Enough for Pain?

In a recent article, John Cannell, MD Executive Director of the nonprof it Vitamin D Council explains how the organization arrived at its recommendation that all adults should take at least 5,000 IU/day of vitamin D f or the rest of their lives [see blogpost here]. Previously, we had described research surrounding the potential benef its of oral vitamin D3 supplementation f or various pain conditions; however, some may believe that 5,000 IU/day is too much, while it could actually be inadequate f or many patients with chronic pain. As Cannell acknowledges, the U.S. Institute of Medicines Food and Nutrition Board claims that merely 600 IU/day of vitamin D is enough f or most adults, while the Endocrine Society says 2,000 IU/day is suf f icient. However, he notes, We think the saf est thing to do while all the research is going on is to maintain natural vitamin D levels. By natural, Cannell is recommending vitamin D levels obtained by persons with daily sun exposure, such as lif eguards, some construction workers and gardeners, and others who regularly work outside, exposing signif icant areas of their skin to sunshine. T his is how our ancestors behaved throughout our evolutionary history, Cannell observes. Cannell ref erences a relatively good study examining the vitamin D levels of people who get plenty of sun exposure, which was published by Luxwolda et al. [2012] in the British Journal of Nutrition. T he researchers discovered that healthy persons with traditional outdoor lif estyles, living around the Af rican equator (the cradle of mankind), have average circulating vitamin D levels ie, 25(OH)D of 46 ng/mL (115 nmol/L). Cannell remarks that most people do not have their blood tested regularly f or vitamin D, so a recommended daily dose of supplemental vitamin D is needed that (a) is easy to obtain at pharmacies, (b) will get at least 97% of people above 30 ng/mL of 25(OH)D and most persons at 40-to-50 ng/mL, and (d) will not cause anyone to reach toxic levels. Besides those 4 goals, Cannell also takes into account body weight; since, apart f rom genetics, body weight is a signif icant determinant of vitamin D levels. T he more a person weighs, the more vitamin D they need to take. In support of this, Cannell describes a large study by Robert Heaney and colleagues that examined the relationship of body size and vitamin D status [see, Drincic et al. 2012]. T hese investigators f ound that, f or a normal weight adult, 5,000 IU/day of total vitamin D input was needed to obtain a 25(OH)D level of 40 ng/mL. Cannell emphasizes that this pertains to an average adult and the f inal vitamin D level obtained by any dose also depends on baseline level, sun exposure, diet, and genetics. More specif ically, the researchers calculated f rom their data that a total input of 70-80 IU/day/kg-of -bodyweight is needed to achieve 25(OH)D of 40 ng/mL. T hat works out to be about 35 IU/day/pound; so, a 100 pound woman would need 3,500 IU/day of total input, whereas a 300 pound man would need 10,500 IU/day. Note: this is total input f rom all sources, including sunlight, diet, and supplements. Taking all of the above f actors into account and considering that most persons in modern society do not acquire much vitamin D f rom sunlight or diet Cannell concludes that 5,000 IU/day of vitamin D supplementation is about right f or the average adult. CLINICAL COMMENT S:

In his brief article, Cannell does not address specif ic health or medical benef its to be gained by more optimal 25(OH)D levels; although, f rom an evidence-based perspective, his organization has explored the potential of vitamin D in a variety of preventative and therapeutic roles. Additionally, he does not state whether vitamin D3 or D2 is pref erred, but in prior writings oral vitamin D3 supplements, taken daily, have been emphasized by Cannell (as well as by our own research on the subject). In 2008, we published ground-breaking research review papers f ocusing extensively on the potential benef its of vitamin D supplementation in patients with various chronic pain conditions, particularly those musculoskeletal in nature. T hese papers have now been archived and are still accessible as f ollows:

Vitamin D A Neglected 'Analgesic' for Chronic Musculoskeletal Pain: An Evidence-Based Review & Clinical Practice Guidance > Full Report [50-pages; PDF Here] > Practitioner Briefing [7-pages; PDF Here] PPM Journal Article: Vitamin D for Chronic Pain [13-pages; PDF Here] Vitamin D: A Champion of Pain Relief Patient Brochure [6-pages; PDF Here]

Since publication of those papers, a number of f ollowup Pain-Topics UPDATES articles have examined and summarized the latest relevant research f indings and commentary on the subject [click here f or a listing of those articles]. Several points are worth repeating.. Vitamin D def iciencies have been associated with a variety of chronic pain conditions, such as back pain, osteoarthritis, f ibromyalgia, inf lammatory bowel disease, and others. In many cases, research has demonstrated the ef f icacy and saf ety of vitamin D3 supplementation in helping to alleviate pain and to improve f unctionality and quality of lif e. At the same time, much of the research has been of relatively poor quality and biased in one way or another. Larger-scale, randomized, controlled trials with higher vitamin D dosing and adequate f ollowup times are still needed. Unf ortunately, there are inconsistencies in the quality and quantity of vitamin D content in over-thecounter supplements, and higher oral dosages (eg, 1,000 IU D3 tablets) are not available in some countries. Daily oral dosing of vitamin D is more consistent with natural intake than once-weekly or less f requent megadoses administered orally or via injection. T he optimal dose of vitamin D3 supplementation and subsequent 25(OH)D levels in persons with pain have not been determined. While the 5,000 IU/day and 40 ng/mL 25(OH)D recommended above by Cannell may be adequate f or healthy persons, this could be suboptimal in most cases f or helping to ameliorate painf ul conditions. Research to date has not f ully explored ef f ects of more adequate dosing, long-term in pain management. Blood tests f or vitamin D ie, 25(OH)D serum-level assay can be costly and inconsistent f rom one laboratory to another, but this test is the only way to know if supplementation f requency and amount are adequate f or individual patients. Aside f rom the other f actors that may ultimately inf luence 25(OH)D levels, possible interactions with medications eg, antacids, anticonvulsants, corticosteroids, and others may reduce the potency of vitamin D. Malabsorption syndromes and bariatric procedures have been associated with vitamin D insuf f iciency, as have alcohol consumption and tobacco smoking.

Most persons get adequate calcium f rom their diet and do not need extra calcium in conjunction with vitamin D supplementation, unless specif ically indicated. Clearly, there is still much to learn about the role of vitamin D supplementation as an adjunct in the management of chronic pain conditions, which can only be answered by high-quality research trials. Meanwhile, there is ample credible evidence f or practitioners and patients to learn more and consider this relatively saf e and inexpensive therapy. REFERENCES: > Drincic AT, Armas LA, Van Diest EE, Heaney RP. Volumetric dilution, rather than sequestration best explains the low vitamin D status of obesity. Obesity. 2012;20(7):1444-1448 [abstract here]. > Luxwolda MF, Kuipers RS, Kema IP, et al. Traditionally living populations in East Af rica have a mean serum 25hydroxyvitamin D concentration of 115 nmol/L. Br J Nutr. 2012;108(9):1557-1561 [abstract]. Dont Miss Out Stay Up-to-Date on Pain-Topics UPDATES Register [here] to receive e-mailed notif ications of new postings. Or, f ollow us on Twitter [here] or on Facebook [here].