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Vitamin D and Osteoporosis Prevention

Vitamin D and Osteoporosis Prevention

Vitamin D is back in the news again.

You may have seen recent news claiming vitamin D supplementation fails to prevent osteoporosis, fractures or falls.  Published in the Lancet — a Systematic Review and Meta Analysis paper dated October 04, 2018 from the Department of Medicine, University of Auckland, New Zealand and the Health Services Research Unit, University of Aberdeen, Scotland, UK.  They conclude and state at the end of a complex meta-analysis

“we believe there is no justification for more trials of vitamin D supplements with musculoskeletal outcomes because there is no longer equipoise about the effects of vitamin D on these outcomes.”

Rather strong conclusion designed to forestall any further investigation or discussion.  Really?

Now personally, I owe my interest in vitamin D supplementation to my good friend Dr. William Grant of SunArc.  And work that has been done by Dr. John Cannell, who founded the Vitamin D Council headquartered in Marina del Rey, California.  Both are superb sources of ongoing vitamin D research.

A meta-analysis is a literature review of all relevant resource papers.  It suffers from specificity and accuracy of database key words, capture and design.  It is limited by various assumptions, and highly intricate statistical conventions.  Studies are excluded or included based on assumptions of the authors.

One of my current criticisms of all these citations is failure of a popular news article to actually cite the source.  So we cite here.  Effects of Vitamin D supplementation on musculoskeletal health: a systematic review, meta-analysis and trial sequential analysis.  You will have to pay to actually read this paper.  So, I will summarize for you.

The paper is exhaustively written and detailed.  But suffers from a number of limitations and dubious pharmacologic assumptions.

First, it is stated that there was no difference between high-dose vitamin D and low dose vitamin D.  What defines high-dose and low dose?  Low dose was <800 units per day.  High-dose was >800 units per day.  I always have issue with “greater than” or “less than” because of a lack of specificity.   >800 could be 801, 1000, 5000 or 50,000.  You don’t know.  <800 could be 799, 700 or 100.  To be somewhat facetious.  But it is highly important because we don’t know from their study.  What would be the ideal dose of vitamin D?   Who decided on this magical 800 units number?

In fact, that is where 80% of all medical and scientific studies fail.  Who chooses the ideal dose?  On what basis is an ideal dose determined?

I often use a facetious example of Lipitor.  Lipitor will lower your cholesterol.  More specifically, your LDL values.  I could design an experiment using 1 mg of Lipitor for one year.  You will see no benefit.  It is too low.  A study using 1 mg would conclude Lipitor is a worthless drug.  In the other hand, let’s use an arbitrary dose of 100 mg of Lipitor for a study.  After one year I would conclude this is a highly toxic drug causing muscle pains, memory losses and liver abnormalities.  A drug that is too dangerous.  So at some point, scientists determined that the ideal dose of Lipitor is 10 to 40 mg.  With a certain segment of the cardiology community is using extremely high doses of 80 mg.

Dose-response.    A fundamental tenant of good pharmacologic design and use.

Now back to vitamin D.  We are told that the levels achieved were were either >50 nmol/l or >75 nmol/l.  Again we have the problem with the specificity of “greater than.”

Furthermore, most commercial clinical labs report in ng/ml not nanomoles/l.  So  >50 nmol/l  =  >20 ng/mL and >75 nmol/l = >30 ng/mL.  What does this mean?

Vitamin D testing (using GC/MS/MS) is one of the lab tests that that is rationally graded on a continuum. Not simply high or low cutoffs. <15 ng/ml is (severely) deficient.  15 to 30 ng/ml is insufficient.  30 ng/ml to 100 ng/ml is sufficient.  > 100 ng/ml is excess.  And >150 is considered toxic.  Never mind, that it is not toxic.

So that this meta-analysis using a “high value” of >75 nmol/ml  ( >30 ng/mL ) is not high.  It is barely therapeutic.  Just barely at the very lower limits of therapeutic.  Like driving a car with a 1/4 tank of gas.

Personally, and in the Anti-aging / Nutritional Medicine community a consensus seems to be a daily dose of 5000 units is the average starting dose for the overwhelming majority of our patients.  Aiming for 60-80 ng/ml blood values.  That seems to be the ideal dose and value.  There are individual variations so that some of our patients will require 10,000 and 15,000 or as high as 20,000 units daily to achieve good therapeutic levels.  In rare cases patients only need 3000 units.   But clearly 800 units is nearly useless.

So this meta-analysis suffers from so many shortcomings.  A meta-analysis is a poorly controlled study because it is a retrospective look at a host of studies all probably suffering from experimental design weakness.  Then there is the highly intricate retrospective statistical conventions excluding and including various studies for capricious reasons.  Starting with a completely capricious and arbitrary dose and level.  And finally, we have no idea whether blood levels were drawn at one time during a study or weekly or monthly or the beginning or the end.  Most likely levels were drawn very infrequently and then assumed to be constant through the study.   Probably None of these studies were carried longer than one year.

Finally, Vitamin D alone is probably insufficient to enhance bone integrity and prevent osteoporosis.  Empirically, I have observed osteoporosis is prevented by a combination of estrogen or testosterone vigor, vitamin D3, vitamin K2, the right balance of calcium and magnesium, and light weight bearing exercises.  A study simply looking at the efficacy and levels in potency vitamin D will never prove the assertion that osteoporosis cannot be prevented by vitamin D.

There are some political considerations.  The US Preventive Services Taskforce specifically recommended against Vitamin D supplementation to prevent fractures or falls.  They intentionally excluded all of the known experts in vitamin D.  Of which there are only 4 or 5 notable vitamin D researchers in the world.

So beware.  This meta-analysis or study does not prove that vitamin D is either inadequate or useless.  I personally  recommend vitamin D at least 5000 units daily,  Vitamin K2 15 mg,  800-1000 mg calcium 200-600 magnesium, weight-bearing exercises and evaluation of your hormonal status.  This is simply a starting point.  There is considerable variation from patient to patient.  That is why you need expert advice and counsel.   Reference my earlier blogs on Osteoporosis Prevention.   And the importance of Vitamin K2.

Reader beware.

Philip Lee Miller, MD

Carmel CA

My Daily Personal Nutrition Routine

My Daily Personal Nutrition Routine

People ask me what is your personal nutrition routine?  What do you take on a daily basis? What supplements and micronutrient do you take yourself for optimal nutrition? To achieve optimal health and well being in a high stress world today.

Personal Goal

A personal goal and my mission for all of you is health and well-being. Longevity with vigor. Protection from cognitive decline. Prevention of diabetes, arthritis and cardiovascular disease.  Growing older without aging.

It was the famous British physician Sir Thomas Sydenham who said.

” you are as old as your arteries.”

Arterial health is a major goal. This is why we strongly advocate CIMT imaging of your carotid arteries here in our office.

My daily routine starts upon arising (on an empty stomach) with fat soluble nutrients.  This includes:

  • 1 tbl of fish oil
  • Vitamin E 1200 units
  • Vitamin K2 15,000 mcg
  • Vitamin D3 10,000 units
  • Thyroid
  • Phosphatidylserine 300 mg and
  • Nattokinase 100 mg to prevent heart attacks and strokes.

These fat soluble nutrients are more efficiently absorbed with fish oil.  They are taken on an empty stomach so they do not interfere with oatmeal for breakfast.

There is a 45 to 50 minute hiatus.  Read my morning emails.  A morning shower after which I apply my first dose of testosterone cream.


Breakfast starts with Bob’s Red Mill gluten-free oatmeal. Cooked to a creamy consistency over a gas stove. Now my first highly fortified protein shake of the day.

  • 2 scoops of whey-based protein
  • 1 tsp (3 grams) of carnitine tartrate
  • 1 tbl phosphatidylcholine
  • 1 scoop of d-ribose
  • l-deprenyl for cognitive enhancement

This is the most efficient and richest source of high quality protein. The protein shake can be mixed with Odwalla orange juice or your favorite base.

Breakfast is fortified with an array of vitamins and micronutrients.

  • Selenomax 200 mcg
  • OptiZinc 30 mg
  • Nutrient 950 multivitamin
  • DHEA 50 mg
  • Diaxinol
  • 4Sight
  • Vitamin B2
  • Methyl folate 1600 mcg
  • B12 10,000 mcg
  • Alpha lipoic acid 300 mg
  • Ginkgo Biloba 60 mg
  • ProBiotic 100
  • Vitamin C as ascorbyl palmitate
  • “Reacted” chelated Iron 58 mg (read my previous series on iron)

It’s quite a handful, but each of these is designed to improve immune function, cardiovascular function, energy and cognitive vigor.


Lunch is a very sparse affair with my second protein shake of the day.

  • 2 scoops of whey-based protein
  • 1 tsp ( 3 grams) carnitine tartrate
  • Gluco-shield.

It is a quick and efficient source of energy.  This carries me through the day until 5:00 or 6:00 pm.


Dinner is a rich source of protein including fish, chicken or organic beef with some vegetables, most especially broccoli and carrots. My preference at night is a combination of chocolate Rice Dream and chocolate Hemp Milk.

At night I might cheat with a tiny source of extra carbohydrate. The goal is always low carbohydrate, high-protein. This is not a ketogenic diet.  It is a modified Paleo diet.

Ketogenic diets do promote weight loss. I am still concerned about the quality of fats being advocated in ketogenic diets.  Usually including large amounts of butter, cheese, bacon, sausage and other sources of potentially inflammatory Omega-6 oils.  Omega-6 fats potentially increase arachidonic acid which promotes a cascade of inflammatory metabolites.

This is the source of another blog soon.

Dinner is also supplemented with:

  • Nutrient 950 multivitamin 3 caps
  • Diaxinol 1 cap
  • 4Sight 1 cap
  • Ginkgo biloba 60 mg
  • Magnesium 400 mg
  • Alpha lipoic acid (a stellar antioxidant) 300 mg


Just before retiring at night I take

  • Magnesium 200 mg
  • Nattokinase 100 mg

Coda – Ask Jack

Jack LaLanne at age 60. Original fitness guru
Jack age 60

Does that sound like too much? We could have asked Jack LaLanne. Our supreme nutrition and exercise experiment. He took all known supplements and micronutrients for well over 70 years.

Jack once said, “I can’t die, [he most famously liked to say]. It would ruin my image.”

I can remember Coach Dees in high school. He was our cross country coach.  On the first day he said, “Now I want all of you to go out and start drinking wheat germ oil.”   This was 1960 when you went into a tiny proto health-food store with an old guy sitting at the bar drinking carrot juice.  Wheat germ oil was supplied in plain unattractive brown bottles.   It was my first source of concentrated Vitamin E.

In Medical School at UCSD a group of us would read Adele Davis.  Then Linus Pauling started writing about OrthoMolecular Medicine.  He was advocating therapeutic, supra-physiologic doses of vitamins, minerals and selected micronutrients.

It’s been a life-long quest.

We all want healthy and robust longevity in a chaotic world. The ultimate goal of the preventive medicine physician is to set an example and show the way.

Thank you for reading. Now what are you taking? Drop me a line. Don’t forget your Fullscript source of all supplements and micro-nutrients.  Then read (or re-read) my bestselling book.  The Life Extension Revolution.

Philip Lee Miller, M.D.

Carmel California


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