#127 The Right Way to Get Vitamin D

October 19th, 2015 by

The Right Way to Get Vitamin D

“Did your labs come back OK?” my wife Jane asked.

“Yeah,” I replied.  “Everything was what I expected except for my low vitamin D level.”

“What do you do when your vitamin D levels are low?”  Jane asked.

In this article I am going to share with you the latest research on vitamin D, the right and wrong ways to get vitamin D, and the ways in which I am working to get my vitamin D levels up.

Why Does Vitamin D Matter?

Since the childhood bone disease, rickets, was first described in 1650, researchers have long known about a crucial element that was needed for healthy bones. However, it would not be until 1918 that vitamin D was finally discovered.

The fascinating thing is that over the last decade or two we have discovered that not only are low levels of vitamin D associated with bone disease but that it is also linked to a myriad of other problems.  For example, low vitamin D levels are also commonly seen in people who are obese, have high blood pressure, are struggling with diabetes, or have high cholesterol.

Vitamin D and Heart Disease

In addition to the role of vitamin D for healthy bones, vitamin D may prevent cardiovascular disease.  This is especially important given that 74% of Americans are deficient in vitamin D.

For decades now, we have known that heart attacks tend to occur more often in people who don’t get much access to the sun like during the winter months and in geographic areas closer to either the North or South Pole.  In addition, countless studies have shown that heart disease is much more likely to occur in people with low vitamin D levels.

The Chicken or the Egg Conundrum

What we don’t know is whether low vitamin D caused the weight gain, diabetes, high blood pressure, high cholesterol, and heart attacks or whether these medical conditions caused vitamin D levels to drop.  In other words, did vitamin D cause all of these bad things to happen or are low vitamin D levels just a marker of someone with a lot of medical problems?

What is the Ideal Vitamin D Level?

At my hospital, the “normal” range for 25-hydroxyvitamin D levels is 30-80 ng/mL.  As my vitamin D level came back at 25 ng/mL, I was clearly deficient according to these levels.  Is this something that I need to worry about?

As a cardiologist, I am naturally interested in what are the optimal vitamin D levels for health and cardiac function.  As I have reviewed the scientific literature, the best study looking at vitamin D levels, in relationship to heart disease and longevity, is the NHANES III Study.

In the Third National Health and Nutritional Examination Survey (NHANES III Study), which involved 13,331 people, researchers found that a 25-hydroxyvitamin D level below 18 ng/mL or above 50 ng/mL was associated with cardiovascular disease and premature death.  Other studies have shown a similar vitamin D “sweet spot” usually somewhere between 30 and 50 ng/mL which is slightly lower the normal range of my hospital and what has been traditionally recommended.

Atrial Fibrillation and Vitamin D

As atrial fibrillation is the most common heart rhythm abnormality, and it is one of the leading causes of stroke, our team was very interested in looking at whether vitamin D played any role in atrial fibrillation.  In our study of 132,000 patients at Intermountain Healthcare, we found that even low levels of vitamin D (less than 20 ng/mL) had no increased risk of atrial fibrillation.  In contrast, people who took supplements to get their vitamin D levels above 100 ng/mL were 2.5 times more likely to develop atrial fibrillation.  Thus, our study showed that unless you took too much vitamin D, in the form of supplements, there was little link between vitamin D and atrial fibrillation.

What is the Right Way to Get Vitamin D?

The very best way to get the right amount of this critical vitamin is the way nature intended, namely through food and time spent outside.  In fact, nature even created a way whereby we can get enough vitamin D during the warmer months to get us safely through the winter.

For example, one study showed that it takes two months for vitamin D levels to drop after you have been outside in the sun.  This is because vitamin D is a fat soluble vitamin that is stored in fat.  This is nature’s way of protecting our vitamin D levels during the winter.

Studies suggest that our vitamin D levels are, for the most part, determined by how much time we spend outdoors.  As most people rarely get outside, perhaps this could explain why 74% of Americans are vitamin D deficient.

At the time my vitamin D level was checked, like most physicians, I spent most of my time inside of hospitals treating patients.  While I am still busy in my cardiology practice, I now make it a priority to get outside whenever possible.

Do Vitamin D Supplements Prevent Osteoporosis?

Many older women take calcium and vitamin D supplements to prevent osteoporosis.  Unfortunately, two recent large studies, both published in the prestigious British Medical Journal, challenge this long-held recommendation.  Unfortunately, both studies failed to show any benefit in improving bone mineral density or preventing fractures.

Do Vitamin D Supplements Prevent Heart Disease?

As with osteoporosis, vitamin D supplements have proven disappointing when it comes to preventing heart disease.  Paradoxically, people with the lowest levels of vitamin D are at the highest risk of heart disease but yet raising vitamin D levels with supplements have not been shown to help.

Do Vitamin D Supplements Prevent Cancer?

As with bone and cardiovascular disease, the same is true with cancer.  For example, people with low levels of vitamin D are much more likely to suffer from cancer.  However, giving vitamin D supplements have not decreased their cancer risk.

What Should You Do if Your Doctor has Prescribed Vitamin D?

Even though studies have not shown any clear benefit from vitamin D supplementation, if your vitamin D levels are low there may still be a role for supplementation.  As with any doctor prescribed medication or supplement, never stop something that has been prescribed without speaking with your doctor first.

What is the Right Way to Get Vitamin D?

As you can probably tell from this article, the right way to get vitamin D is to spend more time outside.  Of course, you have to be sun smart to minimize your risk of skin cancer.

For example, just 15 minutes of summer sun at mid day can provide you with a dose of vitamin D ranging from 10,000 to 25,000 IU depending on skin color (the vitamin D dose is lower from the sun in people with darker skin), cloud cover, elevation, and whether there is a reflective surface like water.

I should point out that clothing and sunscreen will block vitamin D absorption.  Also, the more skin that is exposed the higher the dose of vitamin D you will get from the sun.

The best time for the ultraviolet B rays and vitamin D production is somewhere between 10 am and 4 pm from April to October.  In contrast, ultraviolet A rays tend to dominate earlier or later in the day.

While too much ultraviolet B rays can cause sunburns, too much ultraviolet A rays can cause skin aging and wrinkling.  Both forms of ultraviolet light can cause skin cancer.

If you live closer to the Earth’s poles, like anything north of Los Angeles in the Northern Hemisphere, you probably will not get much vitamin D from the sun during the winter months unless you do the vitamin D sun “hack” that I describe below.  For people living far from the equator, you will need more vitamin D containing foods when the weather turns cold.

The Best Food Sources of Vitamin D

The very best food source of vitamin D is salmon.  Just a 4-ounce serving of salmon (158 calories) will provide you with 128% of the vitamin D you need for the day.  Other good food sources of vitamin D include sardines, tuna, milk, eggs, and mushrooms.

Vitamin K2: The Missing Link

We can’t just focus on vitamin D.  It is important to realize that vitamin D works in concert with calcium, vitamin K2, and vitamin A to make sure everything in the body is working correctly.

Of these, perhaps the most important may be vitamin K2.  The role of vitamin K2 is to keep calcium out of your arteries, where it can cause heart disease, and instead put it back in your bones.

Natto, Japan, Osteoporosis, and Heart Disease

A diet high in vitamin K2 may explain why the Japanese have extremely low rates of bone fractures despite eating minimal dairy and calcium.  For example, natto, or fermented soy beans, is a delicacy in Japan.  No other food comes anywhere close to comparing to natto when it comes to vitamin K2 content.

While natto tastes disgusting to most Westerners, I have actually learned to tolerate natto and have a tablespoon every morning.  Natto is something you can buy at most Asian grocery stores or you can even buy it online where they ship it to you in refrigerated boxes.

The Calcium Paradox

In addition to strong bones, studies suggest that vitamin K2 may also prevent heart attacks.  Vitamin K2 may be the answer to the “Calcium Paradox” wherein many older people suffer from lack of calcium in their bones (osteoporosis) but yet have too much calcium in the arteries of their heart (coronary artery disease).

How Do You Get More Vitamin K2?

If you cannot stand the taste of natto, how else can you get vitamin K2?  First of all, eat your greens.  Green leafy vegetables are very high in vitamin K1 which can be converted to vitamin K2 by your body.  To learn more about which foods contain vitamin K2, please read my article “9 Signs You May Have Vitamin K2 Deficiency.”

Warfarin, Osteoporosis, and Coronary Artery Calcification

I should point out that the people most at risk for vitamin K2 deficiency are those people taking the blood thinner warfarin (also known as Coumadin).  Warfarin blocks vitamin K and any attempts by you to eat more vitamin K1 or vitamin K2 foods will block this blood thinner.

Studies have shown that people taking warfarin are at higher risk for low bone mineral density and vitamin D as well as at increased risk for coronary artery calcification.  Fortunately, for most people, there are now new blood thinners that are much safer than warfarin.  If you or a loved one are still taking warfarin, speak with your doctor about switching to one of the safer new blood thinners that don’t block vitamin K.

The Wrong Way to Get Vitamin D

As you have probably guessed, the wrong way to get vitamin D is to just blindly take supplements without even first knowing your vitamin D levels.  The problem with supplements is that your body cannot control for toxicity.

In other words, if you take too much vitamin D the excess is just stored in your fat cells and toxicity can occur.  From our research, vitamin D toxicity can cause a dangerous heart condition called atrial fibrillation which can lead to strokes.  Vitamin D toxicity can also lead to dangerous levels of calcium in your blood or kidney stones.

When vitamin D is taken naturally, like through the sun, the body can control levels so that toxicity does not develop.  Given that 74% of Americans are deficient in vitamin D, many people may require supplements at least during the winter months.  However, vitamin D supplements should only be taken under the direction of a physician, who can monitor vitamin D levels, and only after you have first tried natural ways to correct your vitamin D deficiency.

The 5 Right Ways to Get Vitamin D

1. Get Tested

Get tested now to see if you are one of the 74% of Americans who have low levels of vitamin D.  Surprisingly, many insurance companies will not cover this simple and cheap test unless you have osteoporosis.  If your insurance company will not cover a vitamin D test, you can either pay for one out of pocket or purchase a much cheaper home test kit on Amazon or through the Vitamin D Council for as little as $50.

2. Start Winter with Your Vitamin D Tank on Full

Fortunately, studies show that vitamin D levels don’t start to drop until about 2 months after you have spent some time outside in the sun.  Thus, if your vitamin D tank is “full” on November 1, then you can at least get through the end of the year without any deficiencies.

However, in order to keep the tank full until spring, you will need that January vacation to a sunny beach, eat a lot of vitamin D containing foods, or supplement.  Please remember to always be sun smart so that you don’t trade vitamin D deficiency for skin cancer.

3. Eat Foods High in Vitamin D in the Winter

Knowing that vitamin D levels will drop through the winter, focus on the foods which are naturally high in vitamin D like salmon, sardines, tuna, cow milk, eggs, or mushrooms.  Also, many alternative milks, and other foods, are fortified with vitamin D.

4. The Winter Vitamin D “Hack”

Contrary to conventional wisdom, it is still possible to extract some vitamin D from the sun during the winter even if you live north of Los Angeles in the Northern Hemisphere.  However, this may require you to be on the top of a mountain with your skin uncovered and snow on the ground to amplify the sunlight dose.

There are some apps that can help you calculate your vitamin D dose.  By simply entering your latitude, longitude, skin type, how much skin is exposed (not covered by clothing or sunscreen), time of the day, sky cover, altitude, and what kind of surface is below you, you can calculate how much sun you need for your daily vitamin D needs.

5. Supplement When All Else Fails

Supplements should only be “supplements” for what is needed when natural approaches fail. I like USP or GMP certified supplements to minimize your risk of contaminants.

A Contrarian View to Vitamin D

Perhaps the real problem to vitamin D deficiency and the increased risk of osteoporosis, heart disease, and cancer is that most people don’t spend enough time outside.  It could be that low vitamin D levels are really just a marker of someone that rarely gets out.  Given the myriad of health benefits that happen when people are outside, like more physical activity, less stress, and less depression, it could be that the missing link is more time in nature rather than another supplement.

What did I Do for My Low Vitamin D Level?

This is something I struggle with as I hate to put any drugs or supplements into my body unless it is absolutely critical.  My “compromise” for a documented vitamin D deficiency is to eat more wild salmon in the winter, cross country ski at high altitude in just shorts on sunny winter days, and take a low dose of a vitamin D supplement.  Hopefully this approach will help to keep my bones and heart strong.

What do you do to ensure you have enough vitamin D to get you through the winter months?  Please share your comments below for our community to read.

#085 How Much Calcium Do You Really Need? You May Be Surprised…

March 21st, 2015 by

How Much Calcium Do You Really Need?

No one wants brittle bones or to be hunched over.  While the American Dairy Association would have us believe that the answer is to drink more milk, some studies suggest that more milk might actually make things worse.  Popping calcium supplements instead may just increase your risk of a heart attack.  In this article, I’m going to share six things you need to do for strong bones and attempt to answer the question, how much calcium do you really need?

My Calcium Story

The milk industry had convinced me that “got milk” meant “got healthy bones.”  My favorite was this commercial where Mr. Miller’s arms fall off because he did not drink his milk.

For years I tried to follow our government’s advice and get my 3 servings of dairy each day for calcium.  Also, for the first 40+ years of my life I suffered from acid reflux.

When I was young I thought heartburn was “normal” so I never mentioned it to my parents.  As an adult I would buy the “Costco packs” of omeprazole (Prilosec) to make sure I always had enough on hand for my heartburn symptoms.

I also frequently got food stuck in my esophagus.  I thought this was something I had to live with as it was present from my earliest childhood memories.

In my early 40s, while racing to finish lunch prior to a surgery, I got a small bean stuck in my esophagus.  I could not dislodge the bean.  I was panicked because my nurse was paging me to start a surgery.

Fortunately, my partner was able to help me with the surgery as I needed an urgent endoscopy to remove the bean.  I had the endoscopy done without any sedation so that I could get back to my patients.  With the endoscope, my gastroenterologist could clearly see that my esophagus was severely inflamed, narrowed, and scarred from years of untreated eosinophilic esophagitis (EE).

I was put on a steroid and a high dose of Nexium.  I was also told that eosinophilic esophagitis is often due to food allergies and that it was usually a waste of time to try and find the specific food allergen.

Shortly after this time I hit my health crisis.  As part of my turn around, I cut out sugar, processed carbs, dairy, and animal meat except for an occasional wild fish.

I’m really not sure what “cured” me of acid reflux and eosinophilic esophagitis.  Perhaps it was the diet or the nearly 40 pound weight loss that came from eating this way.

Regardless, it is interesting to note that both lifelong conditions did go away when I changed my diet.  If I occasionally have dairy, the heartburn symptoms may come back.  While I have never been tested for food allergies, I suspect that I may have a food allergy to dairy.

When I discovered this possible food allergy to dairy, I started taking calcium supplements to ensure I was getting my recommended 1,000 mg of calcium each day.  However, after seeing the studies linking calcium supplements to heart attacks, I stopped these supplements.  Am I putting myself at risk of developing osteoporosis?

How Much Calcium Do You Really Need?cow and milk

Our government recommends 1,000 mg of calcium each day for adults.  Older Americans need to target 1,200 mg.

Having enough calcium is critical for our bones and teeth.  If there is not enough calcium, the body may pull it from our bones. Osteoporosis occurs when our bone mineral density is low.

Interestingly, the U.S. and Northern Europe have the highest dairy intake in the world. Despite this high dairy consumption, the U.S. and Northern Europe also have the highest rates of osteoporosis and hip fractures.  If dairy is the only answer, how do you explain these findings?

Do We Really Need 1,000 mg of Calcium Daily?

Is 1,000 mg of calcium really our daily target?  What will happen if we don’t reach this number?

Of course, there is a certain amount of calcium that we need each day in our diet.  Studies of animals who are deprived of calcium consistently show that they develop osteoporosis.

When researchers have looked at this question, they have been very surprised.  Getting the targeted amount of calcium, either through dairy or calcium supplementation, does not decrease the risk of bone fractures.  Surprisingly, some studies have even shown that getting more calcium may actually increase your risk of fractures.

Non-dairy eating cultures, like Asia, typically get very low amounts of calcium in their diets.  Indeed, in countries like China where 92% of people are lactose intolerant, their risk of fractures may be six times lower than the U.S.!  Of course, these are studies of Chinese eating their ancestral diet, which was real food, rather than a “modern” diet.

The bottom line is that we really don’t what the right amount of calcium is.  For example, some studies suggest that 300 mg may be okay for physically active Asians eating an ancestral diet.  For those of us living in the “modern world,” the number is probably much higher.  As everyone has different calcium needs, please speak with your healthcare provider to determine what the right number is for you.

What Are the Best Non-Dairy Sources of Calcium?stamp printed in Republic of Guinea commemorates the birth of Po

Contrary to what the milk industry would have us believe, there are also natural non-dairy sources of calcium.  For example, the following things are all very high in calcium:

1. Mineral water

2. “Greens” (spinach, broccoli, kale, etc.)

3. Sardines and canned salmon

4. Sesame seeds

5. Almonds

6. Legumes

7. Oranges

To put the recommended 1,000 mg of daily calcium into perspective, you could get 100% of your daily needs from 143 almonds.  Likewise, you could hit the same 1,000 number with either 6 oz of tofu or four cups of cooked spinach.  As you can see, by combining your daily greens with almonds, legumes, and fruit you can easily hit the daily calcium goal.

Since I have been tracking my daily calcium intake with the free Cronometer app on my smartphone, I consistently crush the 1,000 mg goal without the need for dairy.  For example, I hit 165% of my calcium target yesterday (1,675 mg) mainly from lots of greens and natural mineral water with some legumes, almonds, and fruit.

6 Ways to Prevent Osteoporosisbigstock-Fracture-Distal-Radius-forear-78727889

If dairy and calcium supplements are not the only answer to preventing osteoporosis, how can we prevent this debilitating condition?  As no one wants to walk around hunched over, let me suggest six strategies to prevent osteoporosis.

1. Stay Physically Active

Physical activity is the best way to keep your bones strong.  Weight bearing activities like walking, hiking, running, dancing, skiing, weight lifting, etc. are particularly important.

You would think that Tour de France cyclists would have exceptionally strong bones from all of their grueling training.  Interestingly, world class athletes performing non-weight bearing sports, such as swimming or cycling, often have much weaker bones.

The same is true for astronauts.  Within just a few days in space astronauts will lose 20% of their bone mass.

Gravity really is our friend.  Weight bearing exercises are critical for bone health.

2. Get Enough Vitamin D

Vitamin D is critical for healthy bones.  Studies show that your risk of osteoporosis is also determined by your latitude.  For example, the farther you live from the equator the higher your risk of osteoporosis.  Sadly, the strong media messages warning us of the dangers of sun exposure and skin cancer may actually be increasing our risk of osteoporosis.

Unfortunately, if you live in a higher latitude city, like our family in Park City, it is simply impossible to get all of your vitamin D needs from the sun alone.  There are some foods, like salmon, which are very high in vitamin D.  Besides fish, other natural sources of vitamin D include milk, eggs, and mushrooms.

For most people living in higher latitude cities, vitamin D supplements are often required to maintain normal vitamin D levels during portions of the year.  To find out if you are vitamin D deficient, please speak with your physician about getting tested.

3. Get Enough Vitamin K2

An often overlooked aspect of good bone health is vitamin K2.  Most people have simply never even heard of vitamin K2.

The role of vitamin K2 is to put calcium in your bones and keep it out of your arteries where it can cause heart disease.  Indeed, studies have shown that getting enough vitamin K2 in your diet not only strengthens your bones and teeth but also prevents heart disease.

The very best food source of vitamin K2 is natto or fermented soy beans.  Natto is considered a delicacy in Japan. Perhaps this helps to explain why osteoporosis and heart disease are so much lower in Japan than the rest of the world.

We can also get some vitamin K2 from the conversion of vitamin K1 to K2 by our bodies.  Foods high in vitamin K1 are greens like spinach, broccoli, and kale.  Other foods high in vitamin K2 include liver, eggs from grass fed chickens, and some cheeses like gouda and brie.

To read more about vitamin K2 and see if you have these 9 signs of vitamin K2 deficiency, please read the article I wrote on this subject.

4. Get Enough Calcium

While our government recommends at least 1,000 mg of calcium daily for most adults, we really don’t know exactly how much calcium we need each day.  If you do take calcium supplements, some studies suggest that supplementing calcium alone may increase the risk of osteoporosis.  Calcium may be most beneficial when it is consumed with the right amount of vitamins D, K2, A.

When tracking your calcium intake from food, don’t forget about the contribution from water.  Indeed, the “harder” your water, the higher your daily dose is of calcium and magnesium.

5. Avoid Very High Protein Diets

Although the science has not fully been worked out, some studies suggest that diets off the chart in protein may weaken bones.  Indeed, studies show that the excessive amounts of protein that some people eat puts them at higher risk of hip fractures.

6. Avoid Soda Pop

Did your Mom tell you that soda pop was bad for your bones?  It turns out that this advice may be true.

Many researchers feel that the phosphoric acid in soda pop alters the phosphorous/calcium balance in the body.  Perhaps this is why many studies have shown that soda drinkers are more likely to have osteoporosis and fractures.

Instead of soda pop, choose water instead.  Mineral or “hard water” is very high in natural calcium.  As long as you are not drinking reverse osmosis water, you are getting some calcium in every glass you drink.


Please discuss how much calcium, vitamin D, vitamin K2, and vitamin A you need with your physician.  Also, please work with your physician to minimize your risk of osteoporosis.  Do not self diagnose or treat based on anything that you read in this article.