December 31, 2008
Vitamin D and Cesarean Sections:
It has been know for decades that vitamin D deficiency has a negative effect on muscle strength. A study in the December issue of Journal of Clinical Endocrinology & Metabolism reports it’s association with Cesarean Delivery.
25-hydroxyvitamin D levels were measured in 253 mothers at a Boston hospital. The rate of cesarean delivery was 14% in women with levels over 15 nanograms, and 28% in women with levels less than 15 nanograms (a very low level).
The normal 25-hydroxyvitamin D level is 32 to 100 ng. Fulltime male lifeguards have been shown to have levels of 150 ng. at the end of the summer. Out of 1300 untreated patients, I have seen one level at 105 ng. in a 45 year old woman who walked 6 miles a day all year round, and one level of 92 ng. obtained in August from a 60 year old man who fished every weekend in the summer and spent much time gardening. The next highest levels have been in the 50’s. The much talked about toxicity that is mentioned in practically every newspaper article about vitamin D only occurs at levels over 200 ng., which can only be reached by taking 75,000 units or more for an extended length of time.
The ideal level for maximum bone strength is 40 ng. Studies have shown that there is a maximal anti-breast cancer effect at 52 ng. Some vitamin D experts recommend an ideal level of 50 to 70 ng. Studies are needed in people with cancer, but some experts are recommending levels of 70 to 100 ng. in someone with cancer.
In regard to Cesarean sections, the economic cost and suffering of pregnant women could be greatly reduced if gynecologists ordered 25-hydroxyvitamin D levels for all their pregnant patients and treated any insufficiency to at least a level of 32 nanograms. (The ideal level of vitamin D is at least 50 to 70 ng.)



If you read nothing else about vitamin D just read this:

1. Vitamin D increases calcium absorption from the GI tract and puts it in the bones to prevent osteoporosis. Bone has been found to be denser on DEXA scans at levels of at least 40 nanograms.
2. A simple blood test can determine your level. It is covered by insurance just like any other blood test.
3. Vitamin D is produced from the action of sunlight in the skin. Lifeguards at the end of the summer have levels of 150 ng.
4. Although the normal level is 32 to 100 nanograms. there is substantial evidence that the ideal level is at least 50 to 70 ng. It may turn out with further research that the ideal level is even higher.
5. Because of the distance from the equator, the use of sun screen to protect our skins against damage, and clothes! 2/3rds of Americans (and therefore 2/3rds of people that you know) have Vitamin D Insufficiency or Deficiency (levels less than 32 ng.) The 2/3rds figure also applies to children. The 25-hydroxy vitamin D level goes up often from 5 to 10 ng. into the summer and for awhile in autumn.
6. Most of the “normals” are still in the 30’s, below the ideal range. In my 1200 tests, 2/3rds had levels of less than 32 ng.,and only 1% have had ideal levels over 50 ng. without treatment. 99% of 600 people I tested with osteopenia or osteoporosis have levels less than 32 ng.; I have heard from several rheumatologists in South Jersey who have found the same, and large studies have confirmed these results.
7. The treatment is very easy and inexpensive. (less than $1.50 per capsule). Prescription strength vitamin D 50,000 uni\ts is prescribed once a week for 12 weeks; then the dose is adjusted based on follow-up blood levels. Unless there is a major change in a person’s sun exposure, they will need to continue taking the Vitamin D for their lifetime, and yearly blood levels are a good idea. The 50,000 units are by prescription only because there would be some people who would take it every day by mistake.
8. To demonstrate how the knowledge of vitamin D is still evolving, The American Academy of Pediatrics just recommended this month that newborns take in at least 400 units of vitamin D a day. This dose of 40 units per pound per day is equivalent to 42,000 units a week for a 150 pound adult, or 56,000 units a week for a 200 pound adult. In comparison, most adults with a deficiency need from 50,000 units a month to 50,000 units a year to reach and maintain the ideal level.
9. Taking over the counter 400 unit vitamin D is worthless for an adult in treating a deficiency or preventing fractures. Studies have shown it doesn’t work and doesn’t result in normal levels above 32 ng.. It raises the vitamin D level about 5 nanograms. It has been shown repeatedly in long term studies that it doesn’t prevent fractures or illnesses. 800 units a day has been shown to raise the level about 10 nanograms.
10. Vitamin D also prevents hyperproliferation of cells in the body. There is a massive amount of research over 2 decades that deficiency is a substantial risk factor in colon, breast, prostate, and many other cancers. In November, 2008, a study was published that confirmed previous studies that showed that 400 units of vitamin D over 7 years in women didn’t prevent fractures or cancer because it is far too little. Much higher doses are needed to increase levels and prevent breast and other cancers.
11. Vitamin D is a powerful factor in preventing many autoimmune diseases. There are studies that show it stops or slows the progression of multiple sclerosis.
12. There are many other diseases that haven’t been well studied that appear to be associated with vitamin D deficiency.
13. No side effects occur with vitamin D unless the blood level reaches 200 ng. This level is impossible to reach unless an adult takes at least 75,000 units of vitamin D a week for an extended length of time – about 8 months. In spite of this, there is vitamin D hysteria about vitamin D toxicity.
14. Because Vitamin D is so inexpensive, spreading the word about vitamin D deficiency among both doctors and non-doctors has been limited.
15. Osteoporosis fractures cost this country a few billion dollars a year. Fractures are reduced by treating a deficiency at any age. Studies have even shown that treating deficiency in people over 80 years of age reduced the incidence of fractures within 6 months. It is never too late or too early to treat deficiency.
16. Because of the illnesses that can be prevented be correcting vitamin D deficiency, Vitamin D represents it’s own health care plan. Billions of dollars in health care costs could be saved if the Surgeon General of the United States launches a public health education program.
17. The evidence of the benefit with vitamin D is substantial, and more studies will take place in the next decade quantifying the specific risk with cancer and autoimmune diseases, and measuring the effectiveness in treating these conditions. .



If you want to learn more about Vitamin D and confirm much of the information contained in this Handout, a review article was
published in the New England Journal of Medicine July 19. 2007, titled “Vitamin D Deficiency,” and written by Michael Hollick,
MD, PhD. one of the most knowledgeable vitamin D experts in the world.

2/3 of Americans have a low vitamin D level. Because of this, vitamin D experts recommend EVERYONE get tested for 25-hydroxy
vitamin D. Normal level is 32 to 100 ng. Ideal level is at least 50 to 70 ng. Don’t be confused about the normal level.
Labcorp lists 32 to 100 as normal. Quest still lists normal starting at 20 ng, but then explains that 20 to 30 is “insufficiency.”.
Vitamin D is not meant to come from food, but from sun exposure. However we live far from the equator and much of
the year our skin doesn’t make vitamin D. We also use sunscreens. Increase in sun exposure has it’s own
controversies and problems.

Vitamin D increases calcium absorption from our diet (Calcium absorption increases 55% by increasing 25-hyroxyvitamin D levels from
20 ng. to 32 ng. Without vitamin D, only 10% of calcium is absorbed. With not enough calcium being absorbed, the parathyroid glands
make extra hormone to dissolve microscopic areas of the bone and release calcium into the blood to maintain a normal level. Vitamin
D deficiency has been proven to be the most important factor in osteoporosis. Correction of a deficiency cannot only prevent
osteoporosis, but can treat and improve preexisting osteoporosis. It’s never too late, 80 year olds will get less fractures by correcting
vitamin D deficiency within 6 months compared to placebo. Bone has been shown to be the densest at levels up to 40 ng.

It is now known that vitamin D reduces cellular proliferation and Vitamin D deficiency is a powerful risk factor in a variety of cancers,
especially colon, breast, and prostate.Experts in Vitamin D (backed by many studies in the last few decades) have stated that the evidence suggests that if every American had a level of at least 32 ng., the incidence of these cancers would be reduced by 50%.)

There is a powerful connection that’s been known for decades with latitude, vitamin D deficiency, many cancers, and autoimmune diseases:
Multiple sclerosis (substantial evidence), type I diabetes (substantial evidence), and other diseases. Pregnant rats made very deficiency in vitamin D give birth to offspring with brain damage in the same area of the brain involved with schizophrenia in humans, I was skeptical, but I have tested 25 schizophrenics from a boarding home and have been impressed that all 25 had extremely low single
digit levels found only in 5% of the general population. Prenatal vitamin D deficiency in combination with genetics and other factors may be important factors in developing schizophrenia.
Vitamin D deficiency can cause muscle weakness and bone pain. There is one very prominent physician/vitamin D researcher who claims 2 cases of autism have improved with treatment of vitamin D deficiency. There are no significant published studies and I have no experience with autism. Autistic children have been noted to be very allergic in some studies, so a theoretical basis of improvement would be that vitamin D modulates the allergies some of which may attack the nervous system. My advice would be test and correct any deficiency in autistic children and if there is an improvement, that’s a bonus. LATE BREAKING NEWS – A study published in
November, 2008, showed that counties with higher amounts of rain in several states have higher rates of autism, and one theory to explain this is that more rain means less sunshine and lower vitamin D levels.
Atherosclerosis: higher vitamin D are associated with longevity after bypass surgery.

Many of you are probably taking 400 or 600 units of vitamin D a day. 400 units of vitamin D is available in OTC vitamin tablets, /and in 4 glasses of milk. It is a small amount that usually prevents rickets but nothing else, and won’t result in normal levels in most people. It raises the vitamin D level only about 5 ngs. 800 units a day raises the vitamin D level about 10 ng. 1000 unit vitamin D capsules
are somewhat better but still insufficient in many people.(out of the 800 people I have seen with low vitamin D levels in the past 3 years, many have taken 400 units a day for years and it hasn’t worked. Extensive medical studies have shown that 400 units a day doesn’t prevent fractures and doesn’t lower the incidence of cancer.)
In November, 2008, another study showed that 400 units of vitamin D given women over 7 years didn’t reduce fractures or the incidence of breast cancer. The headline reported with this study was extremely misleading since a much higher does of vitamin D is required to raise the level significantly and lower the incidence of fractures and cancer. Don’t be fooled by misleading headlines.

The treatment of vitamin D insufficiency is a prescription of 50,000 unit capsules. The dose is frequently 1 capsules weekly for 3 or more months, then eventually the dose can be reduced based on blood levels. Some people require 50,000 uinits a month to maintain an ideal level, most of my 800 cases have required more, up to one capsule a week.


20 vitamin D 50,000 unit capsules =about $30, or $1.33 a capsule (which means the cost is $5.66 a month at a dose of one a week).
Some people are being charged their co-pay for just a few capsules, and one of my patients paid $20 a capsule. You should not pay more than about $1.50 a capsule. It may be cheaper to not use your insurance.

Vitamin D toxicity can only occur by inadvertent or intention ingestion of excessively high doses, over 75,000 units a week for at least 8 months. The pharmacists always give us a list of side effects.. People taking vitamin D should know that side effects only occur if the blood level reaches over 200 ng. Some people require 50,000 units a week long-term, and there has never been toxicity or side effects with this amount.

The blood test is called 25-hydroxyvitamin D. It is covered by insurance just like any other medically indicated blood test. In the 1200 patients I have obtained a test from, none has been denied for payment from their insurance. Some insurances require diagnosis codes. The following codes legitimately justify the test.

268.9 – vitamin D deficiency (used when a diagnosis is already established).
733.00 – osteoporosis
733.90 - osteopenia
729.1 - myositis - muscle pain is a common symptom of vitamin D deficiency.

I have seen 4 cases since 2005 in which the 1-25-dihydroxy vitamin D level is done by mistake. This test is worthless in determining vitamin D deficiency. Make sure you get the right test.


The goal is a level of at least 50 to 70 ng. within 6 months. With further studies, it may turn out that the level of 100 ng or more that lifeguards have is even more ideal. The blood test should be repeated within 3 to 6 months to make sure it’s high enough; sometimes a higher dose has to be prescribed temporarily.

DO YOU NEED OTHER TESTS?: (I mention this so you won’t be confused if your doctor suggests other tests.)
Some people with low vitamin D levels for years have elevated parathyroid hormones in the blood as a result. A few doctors are getting levels of this hormone in every patient with a low vitamin D. However, the treatment is the same; treat the vitamin D deficiency. I have spoken with an Internist who has been doing this for several years. He told me that the parathyroid hormone level always goes back to
normal within 6 months, so his treatment is never changed. I don’t order this expensive test, but I am mentioning it if your doctor does it for completeness .
On the other hand, if your serum calcium is high or serum phosphorous is low (these tests are done on a comprehensive metabolic profile), then more aggressive workups are necessary. Depending on your age, a DEXA scan may be indicated if your vitamin D level is low. A metabolic profile is routine blood work and includes the serum calcium. If the serum calcium is high, the cause needs to be determined and treated before treating with vitamin D.

1. Will 20 minutes of sun a day be all you need to produce enough vitamin D?
Latitude issue – in South Jersey we make practically no vitamin D in the winter. We use sun screen and wear clothes, this cuts down vitamin D production drastically. Controversy on proper sun exposure exists.
2. Is correction of Vitamin D levels for everybody?
The answer is, ALMOST everybody.
Sarcoidosis is a rare disease of unknown etiology in which the conversion of vitamin D to activated vitamin D occurs at an excess level, so more vitamin D can raise the serum calcium. Sarcoidosis patients should not routinely be given oral vitamin D.
Benign tumors of the parathyroid gland is also very rare. It frequently causes an elevated calcium and decreased production of 25-hydroxyvitamin D. The tumor should be treated and the vitamin D level can be repeated later.
A metabolic profile is done routinely as part of blood work. In the very rare case in which the calcium is elevated, this needs to be addressed prior to any treatment with vitamin D.
3. What are results of 1200 patients?
I’ve seen only 3 people with osteoporosis or osteopenia out of many hundreds who didn’t have low levels.
Breast, prostate, and colon cancer: over 80%.less than 32 ng. Levels often are very low, many in the teens.
Autoimmune diseases: over 80%. Strong studies have been done with multiple sclerosis (treatment) and type
I diabetes (juvenile diabetes) (prevention).
Kidney impairment: (Serum creatinine over 1.5 mg.) 100%. Very critical to correct level. In this case, the vitamin D deficiency occurs AFTER the kidney impairment, it doesn’t cause it. But it can lead to more rapid deterioration of health.

MY RESULTS FROM 2005-PRESENT, 1700 values
67% - less than 32 ng. (1132 cases)
33% - over 32 ng. (568 cases)
1 - 105 ng. 45 year old woman who walked 6 miles a day year round.
1- 105 ng. 70 year old woman who walked 2 miles a day year round.
1- 90 ng. Man who fished a lot and spent a lot of time working on his garden.
10 - in the 50’s – all were people who worked outside
1/3 of values over 32 ng. were in the 40’s.
2/3 of values over 32 ng. were in the 30’s.
I don’t see many teenagers, but 80% of the 24 teenagers I tested were low in vitamin D (<32ng.). Studies have confirmed these figures. 2 mailmen, a jogger, and many others who felt they get “a lot of sun” had low levels.
In addition, studies show cystic fibrosis and impaired kidney function (creatinine 1.5 mg. or higher)resultsl in 100% vitamin D deficiency.

CONCLUSION – 99% of people tested were below the ideal level of 50 to 80 ng.

Robert Baker M.D.
Internal Medicine