Host:

Welcome to the Michigan Medicine News Break, your destination for news and stories about the future of healthcare.

I'm here with Dr. Mark Moyad, the Jenkins/Pokempner Director of Preventive and Alternative Medicine for the Department of Urology at University of Michigan Health. He happens to be one of the foremost experts on supplements in the country. He has spent his career educating a wide variety of consumers, professionals, different kinds of folks, about an area that doesn't get a lot of objectivity. As he says, "Bringing objectivity to an area that doesn't get a lot of that."

So, welcome, Dr. Moyad.

Dr. Mark Moyad:

Thank you, Marie Claire. I am so excited to be here. I can't tell you.

Host:

Wonderful. Well, we are chatting today because you have an editorial coming out in the Journal of Urology that talks about a pretty prominent trial about Vitamin D and its impact, one of the many, many research endeavors that you've been involved in.

And I was wondering if we could talk a little bit about different elements of Vitamin D and try to illuminate some of this for consumers a little bit?

So, I thought we'd start with what does Vitamin D naturally do in the body?

Dr. Mark Moyad:

So, Vitamin D always comes back to bone health, and part of that reason makes sense because it helps with the absorption of calcium. As I became older and through my career, we realized that there were Vitamin D receptors from head to toe in the body. Virtually every cell in the human body, doesn't matter where it is, in the brain, in the feet, cardiac, carries Vitamin D receptors.

So, what we've learned over the past several decades is its diverse effects, and we need to figure out what those are beyond bone health. As we'll talk about today, it seems to be involved in all sorts of other pathways.

Host:

What does it not do?

Dr. Mark Moyad:

That's the billion-dollar question. And the answer is, what you notice is, there's always a du jour. There's always something that we want to believe does it all. Right? Takes care of everything for you. Fixes that, fixes this, makes breakfast for you in the morning. You name it, it does it.

So, that's the story. People started seeing that Vitamin D was involved in all these pathways, as an anti-inflammatory, very much involved in immune health, not just bone health, could be involved in cardiovascular health.

So, there was this idea, as I was getting older and we were doing papers, that it does everything. And that's immediately when I went, "That's not possible."

In my career, any time someone's promised to do everything, when you do more studies, you realize it does some things well, other things not so well. We know that getting excessive amounts of it, like anything, that more is not better. And isn't that true of most things in life? Right?

So, the problem with the idea where people are selling it to do everything, which is still going on today, is the idea that if you take mega quantities, you can't run into a problem. And we know now that is absolutely false, and we're also learning that it doesn't do a lot of things that we thought it used to do.

Host:

And the trial that you wrote an editorial about, actually gets into some of that, right? I think it was looking at incontinence and Vitamin D's ability to potentially prevent or treat that. Is that correct?

Dr. Mark Moyad:

So, I was with some faculty members last night. They said, "We liked the editorial." I said, "Great." They said, "That was on incontinence." And I said, "Yeah.' And they said, "Incontinence and Vitamin D. Where did that come from?"

And I said, "That's the point, that, if you name a medical condition over the past 10 years, it was associated with the idea that you weren't getting enough Vitamin D."

So, the VITAL study is over 25,000 healthy people over the age of 50, if you're a man, 55 if you're female, and you're taking otherwise healthy people and exposing them to a placebo, versus 2000 IU of Vitamin D."

And I do also want to say as a side note, that the other reason these Harvard researchers deserve so much credit, is that many of these clinical trials in the past have not had good minority group representation. They did. And they made sure they would. It was brilliant.

Because I had been working so long in this category, the Journal of Urology said, "We feel you should not only write an editorial on the fact that it didn't appear to work for an incontinence, but also, that people are confused as a whole as where does Vitamin D sit right now in clinical medicine? And can you write that?"

So, it wasn't just writing about the fact that the VITAL study has not been effective in a variety of areas, except one, which we can talk about, but how do you even look at or approach Vitamin D right now, knowing what we know about this and other studies?

So, when they gave me the opportunity to write this editorial, I had written similar editorials 10 and 20 years ago, I just jumped at the chance.

Host:

Very cool. And before we get into what Vitamin D actually did help in the-

Dr. Mark Moyad:

Yes.

Host:

... trial, why do you think that Vitamin D has become the supplement that has been recommended to fix seemingly everything? Why has that become the one that gets a gold star, out of all the supplements out there?

Dr. Mark Moyad:

If I go back 10, 20 years ago in urology, in other places, Vitamin E was du jour. I mean, Vitamin E was proposed to do everything. And thanks to a massive phase three trial, we realized that it does a few things, but it didn't do everything we thought it would.

So, part of it is just the evolution of time. Everyone's looking for the next panacea, the next quick fix. I understand that. I really do.

What was different about this supplement story is that low levels of Vitamin D in the blood were tied to higher risks of all sorts of medical conditions. So, what made this very interesting and different was there were so many medical conditions tied to Vitamin D. At the same time, we're learning about Vitamin D. Head to toe, we have receptors for it. And then, third, and probably the most important piece that I bring out in the editorial is, you have a blood test that clinicians and patients are clamoring for, on a large scale. So, you have a test that tells you whether or not you're deficient.

Many of our nutritional blood tests have not reached that point. We're just sort of guessing what's deficiency and what's not. We're figuring it out.

So, you have an embedded test. You have a huge amount of awareness going on. You have all these studies showing it could be a benefit. Plus Vitamin D is, what I love to ... and I love this part, is dirt cheap. If you just follow that momentum wave, it just reaches a crescendo.

Host:

So, now, you said that there was one area that Vitamin D did seem like it could be helpful for. What was that?

Dr. Mark Moyad:

The majority of things they looked at, cardiovascular disease, cancer, muscle health, just to reduce the risk of fractures, and people were already doing fine. If you look at other trials around the same time, depression, prevent Type 2 diabetes, most of them have shown no benefit. Right now, the signal is, it's not exciting. So, this leads to the, "What are we excited about?"

VITAL showed something incredible. It showed the idea that taking 2000 IU of vitamin D3 a day, in this trial, versus placebo, could significantly reduce the risk of being diagnosed with autoimmune disease.

Now, I get so excited, I almost say let's stop the interview because it's that exciting if it really pans out. There are a lot of people high risk for autoimmune disease. There are a lot of families that have a history of autoimmune disease. This would change the narrative in these clinics.

And, so, to me, the VITAL story is one, where a lot of people writing editorials saying, "It's been a failure. It's not working for anything." I don't take that approach. I take the trial was brilliant. We're trying to figure out where its home is. What should we invite it to? As I always say, the dinner table. "The dinner table's small. Who gets invited and for what?"

If this really turns out to be true, if you're talking about psoriatic arthritis, psoriasis, if you're talking about lupus, if you're talking about rheumatoid, I mean, this is an incredibly impactful category of medicine, and it really does so much harm to so many people.

Host:

You mentioned that Vitamin D is really cheap.

Dr. Mark Moyad:

Yes.

Host:

There are some Vitamin D supplements, though, that are more expensive than others. I mean, there's-

Dr. Mark Moyad:

That's right.

Host:

... all different kinds of companies out there, who are hawking Vitamin D at this point, so-

Dr. Mark Moyad:

Oh yeah.

Host:

... do you have any recommendations for consumers for how to decide which supplement to buy if they do need to take it?

Dr. Mark Moyad:

So, I do mention that it's absolutely cheap. I do mention that it was on this roll, and everybody wants a part of the Vitamin D. They want to say they make a better vitamin D, but I have found something interesting in the supplement world. There's a big business out there, but it's a generic business. Meaning, if I go to Walgreens, or I go to CVS, or I go to Costco, or any of these stores, and they're selling me something generic versus the trade product, we know that it's the same ingredient, generally, and, hey, I want to pay less. I want to pay less.

So, many of your low-cost Vitamin D's from reputable companies, in my opinion, are as good as the more expensive ones. What it comes down to, not only in price, it comes down to guaranteeing that what you're reading in the label is actually accurate. And that's where it's a little bit of an Achilles' heel.

So, the old saying in supplements was, "It's the Wild, Wild West." If you buy Vitamin D or anything, you don't know that, because it says 800 IU, you're getting that." But that's not necessarily true anymore today. We have what's called third party control, quality control groups, third party QC groups. And there's a bunch of them out there, and they're really good.

And if a company signs up to work with them, and they get their stamp, one of the ... You don't need more than one stamp. It basically says that what you're selling is what you're selling. Right?

So, one of the most popular you see on TV is USP. If you see a USP label, great. You should feel confident that that's what you're getting. Another one's called NSF. A newer one of the game that people don't realize is UL, Underwriters Laboratories. If you don't know what UL is, I guarantee you've seen it on the back of your refrigerator. You've seen it on your toaster. You've probably seen it in a restroom of somewhere in the airport.

So, look for those quality control seals. Look for a lower price. Look for a reputable company. But again, I hate to sound so conservative here, I don't like when people get excited about taking Vitamin D until they first know, "How much am I getting now from food?" Because that can change overnight.

Host:

Yeah, sure. What foods can we get it from?

Dr. Mark Moyad:

One of the most consistent is oily fish, a fish high in Omega-3. So, salmon, for example, is actually high in Vitamin D. Some of the shellfish are an interesting source. Apart from that, egg yolks, very small sources, here and there. Mushrooms are actually an interesting source if they're irradiated. So, if you actually give it ultraviolet light, you can ... When you go shopping, you'll see that some of the mushrooms have a decent amount of Vitamin D, and others have little to none. It depends on how they were handled, overall.

But the primary source of Vitamin D is not from natural foods, it's from fortification. What makes supplements different than medications is the fortification effect. And what that means is, once a supplement or a nutrient becomes hot, guess what? Everybody wants to add it back into everything, all sorts of foods. They want to add it to their supplement. I can tell you that, as we sit right now, most multivitamins in the past 10 years have doubled, I would say, or tripled their amount. So, everybody wants in on the Vitamin D craze.

The reason it's important to mention that, is because our first inclination is to take it when, in reality, they should be told the story of when there's excitement, there's more fortification, there's more adding it to the food supply. So, what could have been a deficiency, now could quickly turn into an excess before you even take a pill.

I can tell you a lot of people don't realize that they woke up one day in their Vitamin D amount, just in their multi, doubled or tripled. I mean, that could make the difference right there. Right?

Which now brings up the other area, where people were so excited about Vitamin D my whole life, and that is getting more sun. What makes Vitamin D a fascinating story and probably adds to the hype is, it is true that when you're exposed to ultraviolet B light, you do make your own Vitamin D. See, I like to pound my hands when I say that. I get so excited about it. I won't do that on the table anymore.

So, people say, "Well, why don't I just go get more sun?" And I don't like the idea of you trade one condition for another. Skin cancer is a massive problem. Melanoma is a massive problem. We know that. The idea that you have to expose yourself to ultraviolet light to make your own Vitamin D might sound good, but it's not necessary, first of all. And it comes with an added risk overall. Right?

So, you can make it by sunlight. The primary way is through fortified foods, and there's some natural food sources out there that I mentioned. Milk carries a small amount. A lot of your plant-based milks carry a small amount. Orange juice now has added Vitamin D. Some margarine's do. Most multivitamins carry your recommended daily allowance. So, if someone just takes a multivitamin, that might be good enough.

Host:

Which of your healthcare providers should you be talking to, to figure out whether you need to take more Vitamin D or not?

Dr. Mark Moyad:

There are lots of players in this game. Your medical team includes, not only your primary care doctor that you see, not only a specialist you see that should have commentary, working with a dietician or a nutritionist and doing a Vitamin D diary and seeing how much you get over several days is important.

I did this example of my wife and myself. I thought, you know, "How much Vitamin D am I really getting in a week?" So, I did a diary with my friends and a dietician, and I was getting plenty from the fortified sources and the multivitamin I was taking. In fact, I was getting more than enough. I was getting several thousand IU.

One of the players that doesn't get enough attention, besides a dietician, is the pharmacist. Pharmacists have to keep up with drug supplement interactions. And I remember in medical school that my course on nutrition, my course on drug supplement interactions, lasted about as long as this interview, maybe one question in this interview. That's just the reality.

Pharmacists are made keenly aware quickly of any new major drug interaction. For example, there are a lot of patients who are on steroids, like prednisone. We know that can impact calcium, may possibly impact Vitamin D metabolism. There's a question of now how statins might affect Vitamin D for the good or bad and vice versa. Right?

And do we know, for example, people on diuretics, a certain type of diuretics, called thiazide diuretics, they can absorb more calcium than usual, so, those people, you have to be careful about getting more vitamin. There's all these interactions going on, that we're just learning about in real time.

Pharmacists spend a lot of their time learning these things. So, to lean on a pharmacist at some point, before you even get the green light on Vitamin D, and say, "Hey, any new drug interactions or indications you know about?" is really brilliant, because this is what they do, and they do it well. Thank you.

Host:

We love our pharmacists.

Dr. Mark Moyad:

We do love our pharmacists-

Host:

Go pharmacists.

Dr. Mark Moyad:

We do love our pharmacists. Right? We do. It's really smart today to lean on the different members of your team and to look for a consensus.

Host:

You mentioned earlier that there's a blood test that can tell you when you're deficient for Vitamin D. When is that less accurate? Are there any instances where that can be a problem?

Dr. Mark Moyad:

Well, part of the problem with Vitamin D testing is that there are a lot of blood tests, including nutritional tests, that, when there's more inflammation in the body, it can drive that number down.

So, there are a lot of things out there, that with inflammation, the number goes higher. But what people don't realize is, there's certain tests out there that go lower with more inflammation.

It turns out that the Vitamin D blood tests for many chronic inflammatory, and also non-inflammatory conditions, can be driven down by a process, whether it's lung disease, maybe an advanced cancer.

And, so, the thinking was, cause or consequence? Is it the low level of Vitamin D that is causing the increased risk in the problem? Or is the low Vitamin D a consequence of the disease that I was diagnosed with?

And, so, what we've learned a lot about this test is, it's also a consequence. In other words, just because you have a really low level, and you're dealing with some disease, doesn't mean that taking more is going to get rid of the disease. Part of the disease process, as it progresses and advances, is that it's driving this number down.

Host:

Hmm.

Dr. Mark Moyad:

And, so, it's giving people the false sense that, if you fix that number, then you fix the disease. And these are the intricacies of testing that people need to be educated on.

The other reason I'm such a huge fan of VITAL and writing about it, is that it's going to give us a better idea who the test is for, and where it's accurate and where it's not accurate.

So, we talked about the benefits in autoimmune disease, and what number would you need there to achieve that benefit? So, it's important for the audience to realize, I understand the excitement of getting a Vitamin D blood test, but you also have to know that, to generally screen the population is not endorsed, and it's not endorsed for a reason. Because we haven't ... There's not proof enough that just screening every single person who's an adult is cost-effective and provides a benefit. It's only a select number of people.

The other thing that impacts the Vitamin D blood test, interestingly enough, is weight gain. We think that adipose tissue, because Vitamin D is fat-soluble, adipose-soluble, fat-soluble, it goes into adipose tissue and stays out of the bloodstream.

So, one thing that happens is, and this is a really important point as we finish up here, is I always like to think, "How can I naturally raise my Vitamin D level without taking a pill? Can I do that?"

And the answer is, you can. Quitting smoking, becoming of a healthier weight, exercising. When you exercise, you get out a little bit more, for example. Everything that you've been taught, in terms of lifestyle, to become healthier and heart healthier, many studies have shown can actually increase your Vitamin D level, without taking a pill.

I think any clinician out there would tell you that, if someone's cholesterol became better, if their blood sugar became better, if they were able to become a healthier weight overall, if their blood pressure got better, if their mental health maybe even improved, a number of people will see their number go up, be it small or be it large. That has happened in clinical trials, without taking a pill.

Now, if you do all that, and things don't get better, that's different. Vitamin D, I don't think, is any different than a lot of preventive medicine, which is, ideally, if through your diet and becoming healthier, you can raise that number and not lean on high doses of pills, that can increase the risk of problems, especially with D, isn't that a beautiful thing?

It's learning that Vitamin D, it may be just prognostic. It may just be that it's a reflection of how you're doing.

Host:

Yeah. Yeah. Your Vitamin D level is just information. Right?

Dr. Mark Moyad:

It's information. Right. So, this also leads to something I wrote about in Consumer Reports and other places. There's a lot of talk about, in minority groups and ethnicities and African Americans, how they generally carry lower levels of Vitamin D. And a lot of editorials and people will comment as, "Well, they need to supplement more."

And my argument about that is that it might just be identifying a health disparity because access to healthcare in the number of these groups is inadequate. So, why are we looking at the low levels of the blood tests as specifically just an issue with melanin content, even though that's part of the explanation? Part of it is also access, because when people have greater access to becoming healthier, you see Vitamin D levels go up.

So, I thought that D also stood for disparity. It wasn't just the fact that it was about melanin content. It's the fact that, when you look around the United States and other places, the access to healthcare and resources is inadequate. And, so, the Vitamin D blood test might be saying, "Hey, it's not just saying the individual needs more Vitamin D. The individual needs more access to healthcare."

I think what the Vitamin D story screams at us is, it ain't just about Vitamin D. It's about getting our population healthier and getting access to these options.

Host:

The more organic options, often.

Dr. Mark Moyad:

Exactly.

Host:

Yeah.

Dr. Mark Moyad:

Even just primary care. Every year, I work at a thing at the Detroit Lions Stadium, where thousands of individuals come in to get screenings and do different things, and we give a lecture there. And there's clearly still such a great problem, and we saw this during COVID, with access to healthcare.

And I hope one of the stories of today's message on Vitamin D is, yeah, Vitamin D does not cure all, but it also exposes and reflects something going on greater in society.

Host:

Yeah. I think that's a great place to end. So, thank you so much for your time, Dr. Moyad.

Dr. Mark Moyad:

Marie Claire, thank you so much. It was a pleasure and an honor to be here. I'm so excited. I look forward to doing this again.

Host:

Wonderful. Thank you.

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