If asked, Who is the world’s foremost medical expert on calcium and vitamin D, most scientists would reply, Heaney. Robert P. Heaney, M.D., F.A.C.P., F.A.C.N., John A. Creighton University Professor of Medicine, Department of Medicine of Creighton University has published more than 300 original papers, chapters, monographs, and reviews in scientific journals. He is a frequently invited editorial writer for the major medical journals, including JAMA, Annals of Internal Medicine, American Journal of Clinical Nutrition and the Journal of Clinical Endocrinology and Metabolism. He serves on numerous nutrition and scientific advisory panels. Dr. Heaney was a member of the 1997 Institute of Medicine’s Food and Nutrition Board involved in the development of recommendations for both calcium and vitamin D nutrition1.
In his latest publication, and one that should not be missed, Dr. Heaney calls for a new understanding of long-latency deficiency diseases, one of which is cancer caused from chronic vitamin D deficiency.
He specifically calls for an end to the confusing array of terms that surround vitamin D deficiency, such as insufficiency or hypovitaminosis D. Either you are deficient or you are not. Most importantly, from the standpoint of the calcium economy, Dr. Heaney says that 25-hydroxyvitamin D (calcidiol) levels below 32 ng/ml constitute vitamin D deficiency; ideal levels are unknown but may be slightly higher. According to Professor Heaney, of all the nutrients associated with chronic disease, none have the potential payoff of vitamin D. Remember, vitamin D deficiency is widespread and the diseases associated with that deficiency are legion.
A testimony to Dr. Heaney’s character is his willingness to criticize his own work. Remember, he was on the 1997 expert panel that set the current government vitamin D recommendations, recommendation that are so deficient they assure deficiency for anyone who strictly adheres to them while totally avoiding the sun. In 2003, while announcing his discovery that normal humans utilize about 4,000 IU (not 400) of vitamin D a day, Heaney stated that enough new science now exists to say that his own 1997 recommendations now “fall into a curious zone between irrelevance and inadequacy.”3 Always a gentleman, he goes on to say that his use of terms such as irrelevant and inadequate are not meant as criticism of the 1997 IOM Board. If terms like “irrelevance and inadequacy” aren’t criticism, I’d sure hate to have him upset with me.
However, evidence exists that Professor Heaney’s patience is wearing thin. Last month, the latest in a seemingly endless stream of articles about widespread vitamin D deficiency painted a particularly brutal picture of life in homes for the very old. Osteoporosis is severe, fragility fractures are the rule, and vitamin D deficiency (along with calcium deficiency) is profound enough to cause the unremitting deep pain of osteomalacia.
It seems our grandparents are painfully melting away in nursing homes as they slowly cannibalize their skeleton to maintain their calcium metabolism.
No doubt order sheets in the same nursing homes are replete with the latest and most expensive medications to treat hypertension, osteoporosis, cancer, diabetes, autoimmune illness, osteoarthritis and chronic pain. There is some evidence (not conclusive) that vitamin D may help all of these diseases.
However the evidence is irrefutable, certain, beyond a reasonable doubt, 100%, etc, that adequate vitamin D treatment cures routine vitamin D deficiency. The evidence is also irrefutable that cholecalciferol (the preferred form of vitamin D) costs just pennies a day. However, only one of the 104 patients in the home was receiving supplemental vitamin D. Ninety-nine of the 104 patients had undetectably low 25-hydroxyvitamin D levels. That’s right; virtually all of our grandparents’ levels were too low to measure! In an invited editorial, Professor Heaney expressed his frustration at the suffering caused from such an easily treated entity. In an ominous warning, he noted that “the cost of vitamin D deficiency, while yet to be fully reckoned, may well be massive.” We fear that massive cost will translate not only into needless suffering and death for our patients, but into ethical, political and financial liability for physicians.
Professor Heaney goes on to point out that vitamin D deficiency in the USA (and much of the world) is common, not the exception. Heaney points out that even the nation’s premier hospital, Massachusetts General, is seriously afflicted. In 1988, Thomas, et al, using permissive 25(OH)D standards, found 57% of Mass Generals’ patients were vitamin D deficient (and either not treated or inadequately treated).
In fact, using more healthful 25(OH)D standards, Dr. Heaney points out that 85% of Mass General’s patients were vitamin D deficient. Surprisingly (except to readers of this Newsletter) was the fact that 43% of the patients consuming the Adequate Intake of vitamin D (as defined by the 1997 Institute of Medicine’s Food and Nutrition Board) were still deficient in vitamin D. However, you can bet your retirement savings that those same untreated vitamin D deficient patients hospitalized in Mass General are on the latest, most expensive drugs for osteoporosis, chronic pain, hypertension, heart disease, cancer, diabetes, and autoimmune illness.
We are not saying vitamin D cures or prevents all these conditions; it should be obvious to all that these disease are multifactorial and much more research is needed for scientists to know exactly what role vitamin D plays in each disease. One thing that is known with absolute scientific certainty: inadequate vitamin D intake causes routine vitamin D deficiency; in fact, it explains 100% of the variance.
But arguing the level of scientific proof needed misses the important point. Remember, practicing medicine is not the same as practicing science and it never has been. Physicians are the practitioners of an ancient, respected and well-paid art. Scientists conduct controlled experiments. The practice of medicine is more similar to the practice of farming than it is to the practice of science. Physicians try to humanely do whatever we can do to get sick patients better and to not make well patients sick. If we are good physicians (or farmers), we base what we do on common sense and current literature, and not just on what we learned in school, what the detail men tell us to do, or what our colleagues are doing. All physicians should do (and what the law requires us to do by the way), is what is best for our patients based on what is known in the medical literature, carefully weighing risks versus benefits to arrive at a reasonable plan of action. Physicians do it hundreds of times a day; scientists have never done it, unless, like Professor Heaney, they are both a scientist and a physician.
Professor Heaney clearly believes that vitamin D plays a substantial role in numerous illnesses of modern society and says the cost of such deficiency may be massive. Plaintiff attorneys really love terms like massive. If the costs of the current vitamin D deficiency pandemic are as massive as Professor Heaney fears, then we had better hope for tort reform legislation. Without it, members of the American Medical Association may soon be paying massive settlements to members of the American Trial Lawyers Association.