The recent Medscape Medical News The Endocrine Society’s report on a clinical practice guideline on vitamin D released in June sparked a wave of objections in the comments section from doctors and other readers.
A company press release lists key new recommendations on the use of vitamin D supplementation and screening to reduce disease risk in people without established indications for such treatment or testing:
- For healthy adults under 75 years of age, no supplementation at doses higher than the recommended dietary intake;
- Populations that may benefit from higher doses include: children and adolescents 18 years of age and younger to prevent rickets and reduce the risk of respiratory infection; people 75 years of age and older to potentially reduce the risk of mortality; “pregnant people” to potentially reduce various risks; people with prediabetes to potentially reduce the risk of progression;
- No routine testing for 25-hydroxyvitamin D levels, as specific benefits based on these levels have not been identified (including screening in people with dark skin or obesity); and
- Due to insufficient evidence, the expert panel was unable to determine specific thresholds for 25-hydroxyvitamin D blood levels for adequacy or for target levels for disease prevention.
Medscape Medical News covered the release of the guidelines and their simultaneous presentation at the Endocrine Society’s annual meeting. In response to the media coverage, more than 200 physicians and other readers expressed concerns about the guideline, and some stated outright that they would not follow it (readers listed below are identified by the usernames with which they registered on the site) Medscape Medical News website).
One reader who posted under the name Dr. Joseph Destefano went so far as to call the directive “dangerous” and “almost… evil.” Ironically, some readers attacked Medscape Medical Newsbelieving the coverage implied endorsement rather than news reporting.
Ignores potential benefits
Although the guideline is intended to address “otherwise healthy” individuals (with the exceptions noted above), many readers are concerned that the recommendations ignore the potential benefits of supplementation for other health conditions affecting patients and other populations.
“They mainly address issues related to endocrinology and bone health,” wrote Dr. Emilio Gonzalez. “However, vitamin D insufficiency and deficiency are not uncommon and impact the treatment of autoimmune diseases, chronic pain management, immunosuppression, cancer prevention, cardiovascular health, etc. There is a large literature on this topic.”
“They make these statements as if quality studies that contradict their recommendations haven’t been done for years,” said Dr. Brian Batcheldor. “What about the huge population with diseases that impact intestinal absorption, such as Crohn’s disease and celiac disease, cystic fibrosis and ulcerative colitis? What about the one in nine people who have autoimmune diseases today and still haven’t been diagnosed? What about night shift workers or anyone with more restricted access to sun exposure? What about those whose cultural or religious dress codes limit skin exposure?”
This latter group was also mentioned in an article by Dr. Eve Finkelstein who stated, “They don’t take into account women who are totally covered for religious reasons. They have no skin other than part of their face exposed. It makes no sense to not complement them. Ignoring women’s health needs seems to be the norm.”
“I don’t think they considered the effects of vitamin D deficiency on oral health,” commenter Corie Lewis pointed out. “Excess dental calculus due to excess calcium/phosphate in saliva significantly increases an individual’s risk of periodontal disease (gum disease), and low calcium/phosphate in saliva increases the risk of dental caries (cavities), which is usually indicative of an imbalance in the oral microbiome. Vitamin D can help create balance and reduce these oral health risks.”
Kimberley Morris-Windisch said: “Having worked in rheumatology and pain for most of my career, I have seen too many people benefit from correcting vitamin D deficiency. To ignore this is to miss opportunities to improve patients’ health.” Furthermore, “I find it unlikely that this will only improve mortality after age 75. It makes no sense.”
“Also,” she added, “how many do you need to do harm? In 25 years, I’ve seen vitamin D toxicity once and an excessively high level with no symptoms once.”
“WHY? WHY?” Kinchen lamented. “Low levels in pregnant women have long-term effects on fetal development: higher and earlier rates of osteopenia in girls, weaker immune systems overall. There are so many reasons to test. These guidelines not to test are absurd!”
No selection, no need for decision-making?
Several readers questioned the company’s rationale for not screening, as expressed by session moderator Clifford J. Rosen, MD, director of Clinical and translational research and senior scientist at the Maine Medical Center Research Institute, Scarborough, Maine, in a Medscape Medical News report.
“When doctors measure vitamin D levels, they’re forced to make a decision about that,” Rosen said. “That’s where the questions about levels come in. And that’s a big problem. What the panel is saying is don’t screen… That really gets to the heart of the problem, because we don’t have any data that shows that screening improves quality of life… Screening probably doesn’t help in any age group.”
Among the readers’ comments on this subject:
“This is a mistake. Don’t look, because we don’t know what to do with the data. That’s the message this article is giving us. The recommendation is to do nothing. But doing nothing IS an action, not a default.” (Lisa Tracy)
“So you’re not getting tested for vitamin D because you don’t know what to do? See a naturopath, we know what to do!” (Dr. Joyce Roberson)
“Well, how do you treat it… What do you do? 🤔 This seems incompetent at the very least. I suspect it’s vital, easy, and inexpensive… so hide it.” (Holly Kohley)
“Just because we don’t know doesn’t mean we shouldn’t test. The opposite should be done.” (Dr. JJ Gold)
Is it aimed at the industry?
Many commenters suggested that pharmaceutical and/or insurance company considerations played a role in the recommendations. Their comments included the following:
“I feel like people do routine checkups to make sure there are no hidden problems. If you do just a few tests, the chances of not finding a problem are huge… Preventive health care should be about preventing something instead of waiting until you can cure it. Of course, you may end up ‘following the money.’ It’s much more cost-effective to diagnose and treat than to prevent.” (Grace Kyser)
“The current irrational recommendation gives insurance companies an excuse to deny ALL vitamin D testing, even if the proper code is provided. The result is that people suffer. This recommendation is harmful!” (Dr. JJ Gold)
“They’re basically saying don’t look at ‘healthy’ people and ignore them completely. It’s better to wait until they’re old, pregnant, or already sick and diagnosed with a disease. That’s the problem with health care in this country.” (Brittney Lesher)
“Until allopathic medicine waits for serious symptoms to appear before even looking for potential health problems, the most expensive health care system in the world (i.e., sick care) will continue to focus on medical emergencies and ignore prevention…” (Dean Raffelock)
“Not testing? Are you kidding me? Especially when people take dietary supplements? It’s like taking blood pressure medication without measuring blood pressure!… Not testing? Not taking dietary supplements?… I have only one explanation for this nonsense: the pharmaceutical industry lives off the sick, not the healthy.” (Georg Schlomka)
On a somewhat conciliatory and pointed note, Dr. Francesca Luna-Rudin commented, “I would like to remind all my physician colleagues that recommendations should be considered simply “recommendations.” As physicians, we can use guidelines and recommendations in our practice, but if a new recommendation is presented that does not make sense or could cause harm based on our education and training, we are not required to follow it!”
Marilynn Larkin, MA, is an award-winning medical writer and editor whose work has appeared in numerous publications, including Medscape Medical News and its sister publication MDedge, The Lancet (where she was a contributing editor) and Reuters Health.