I believe that medicine’s potential is much more than the version we see in the world today. A doctor should be an educator with the goal of bringing patients to a place of deeper understanding of who they are in the world. To me, medicine is ultimately about self-empowerment through self-knowledge and growth.
As the warmer weather again graces our days, I have some important updates and reminders about vitamin D, the sunshine vitamin. We are so fortunate to have ready access to the green pastures and forests here in the Berkshires…and the Sun. As we seek to mitigate the risks of our time, experts are arguing that it’s time to think about how to move more activities outdoors — including socializing, eating, shopping, attending school and holding work meetings. Today we will check in on the Sun’s role in all this.
But first an announcement from Fairview Hospital and BMC. Any elective procedure done at either of the Berkshire Health System hospitals will require a COVID nasal swab done several days prior. To that end Fairview Hospital has set up a testing tent at the old Condor Chevrolet, next to Agway at the junction of Rte 7 and 23. It houses Fairview Physical Therapy now. A doctor’s order is needed. Anyone having a procedure at Fairview Hospital will need be tested first, and I assume testing will be available there for other indications as well.
Disproportionate Burden of Illness
We have all heard that Black/AfricanAmerican persons are overrepresented among COVID-19 hospitalizations and deaths. In NYC death rates among Black/African American persons (92.3 deaths per 100,000 population) and Hispanic/Latino persons (74.3) were substantially higher than that of white (45.2) or Asian (34.5) persons. The CDC’s website lists several factors as being major contributors to the high death rate amongst minority populations. Living conditions, work circumstances, and access to care are high on the list. Other people are talking about taking vitamin D insufficiency into consideration.
The body makes D when it is exposed to Ultraviolet-B rays from the sun. Fair-skinned individuals and those who are younger convert sunshine into vitamin D far better than those who are darker-skinned and over age 50. Older people and people with darker skin need more sun to build up levels. Older people and people with darker skin? Sound familiar? These are the high risk groups with COVID.
Dark skin and low D
Why the association of dark skin and low D? It has to do with the melanin content of the skin. Melanin is a brown-black pigment in the eyes, hair and skin. Melanin causes skin to tan. The darker your skin, the more sun exposure is needed in order to get sufficient vitamin D from the sun. Studies are in!
At the start of the Pandemic many people speculated D was helpful because it has known beneficial effects on the immune system. It has long been recognized as a protection against many conditions and a possible help in treating them. These conditions can include:
Heart disease and high blood pressure
Infections and immune system disorders.
Falls in older people.
Some types of cancer, such as colon, prostate and breast cancers
The enthusiasm for it’s role in the pandemic was a little muted because we just didn’t know. Well, now the data is coming in and there is a strong association with low D levels and worse outcomes. The data is striking.
In a study from the Philippines of over 200 people 85.5% of patients with sufficient (>30ng/ml) Vitamin D had mild cases while 72.8% of patients who were deficient in Vitamin D (<20ng/ml) had severe or critical cases.
In a second study from Indonesia of almost 800 people, patients with Vitamin D insufficiency (between 20 and 30 ng/ml) were 12.55 times more likely to die and patients with Vitamin D deficiency (<20ng/ml) were 19.12 times more likely to die from the disease than patients with sufficient Vitamin D.
In a third small study 100% of ICU patients less than age 75 were found to have low vitamin D. We need more good studies, but in many people’s minds it’s a good idea to understand how to get your D levels up.
Natural vitamin D
As always natural ways to build your body’s forces are best. There are some foods that have a little bit of D in it. Fish is really the main food source and is the reason why cod liver oil is a staple in the healthiest households. The gut can be an important secondary way of getting adequate D, as can supplementing. A word on this later. However, getting outdoors and getting some sun is the primary way we get vitamin D. Exposing at least 30% of the skin to sunlight for 15-20 minutes daily is the way you do it (longer time is needed with darker pigmented skin). I recommend as much skin exposure as you can get away with, just don’t mention my name to the police if they question you.
Like building any skill, the key is consistency. A little bit of sun every day builds your levels safely. 10am to 1pm is the time frame when the sunlight is strong enough to effectively convert steroids in the skin to vitamin D. After you get your 20 minutes of exposure it’s best to cover up to avoid skin damage. You can’t make up for lost time by spending several hours out there. It doesn’t work that way. Slow and steady wins this race too. The Yogis recognized that receiving the Sun with intention intensified the reception of its helpful benefits. Soak it up with gratitude and awareness. Make it a 20 minute meditation.
Melanoma is on the rise, right? Right, but only in indoor workers. Indoor workers receive 3-9 times less UV exposure than outdoor workers and trade in natural light for narrow-spectrum, electric light. I’m not sure which is worse, not seeing the sun or bathing in fluorescents or LEDs all day. Our senses and our skin are quite sensitive to the quality of light in the environment. What a shock to the system electricity has been and continues to be. Patients in hospital rooms with natural light do better. Interesting, right? When we have to be exposed to artificial lighting, it’s OK. We are up for the challenge. Overcoming challenges define us.So I’m not suggesting we try to go back in time, but you must know that getting outside everyday is a great balancer.
Meanwhile, fear of skin cancer probably drives the epidemic of vitamin D deficiency and even melanoma incidence. Melanoma occurrence has been found to decrease with greater sun exposure, and conversely can be increased by sunscreens. The skin is a barrier but also a sensitive point of entry. We need to be mindful of anything we put on our skin. Sunscreen is full of chemicals and can have its own toxicity apart from blocking the helpful effects of the Sun. Sunscreen contributes to D deficiency, and is not proven to help prevent skin cancer. The smartest beach-goer doesn’t use sunscreen. She naps or covers up during the peak hours and drinks up UVB rays in the off peak hours careful not to burn. To be sure, sunscreen has its place just not all day every day. Clean products are preferred as are sunscreens that block UVB and UVA. Sunscreen is a tool to protect from skin damage from the sun. Its the UVA rays that sets a person up for photoaging, wrinkles and certain non-melanoma skin cancers. Skin damage comes from prolonged exposures. The solution is smart daily exposure in the time of the year when the sun is strong enough for us to increase our D levels, and smart supplementing during the winter (and pandemics).
What about windows
Most windows block out UVB rays, but allow UVA rays to penetrate through which is not beneficial as far as vitamin D is concerned because it’s the UVB that helps your D levels. You have to go outside!
(As a review, UVB rays cause burning and some skin cancers and convert steroids in the skin to vitamin D. They are blocked to a large extent by sunscreens. UVA can cause cancer and also skin damage but not burning because they penetrate deeper in the skin. UVA rays are not filtered by ozone and can go through windows. Not all sunscreens block UVA.)
Always second best but sometimes worth the risk. Risk? Yes, taking a supplement that contains too much vitamin D can be toxic in rarecases. It can lead to hypercalcemia, a condition in which too much calcium builds up in the blood, potentially forming deposits. It may also predispose you to kidney stones. Supplementing is helpful when sun exposure is not possible or there is a resistance to its effects, like in the higher risk categories we discussed above. For the prison populations, elderly (over 50?), nursing homes residents its a no-brainer. 4000 international units is considered to be the upper limit of safe supplementation by conservative groups. That’s a pretty decent range to consider right now. We can also check levels to make sure you are minimally above 30, and better yet above 50. Sun bathing
When you use consistent careful Sun exposure to drive your D levels you get the balance that comes with nature. There is no risk of kidney stones or hypercalcemia. Humans have a long history with the Sun. In fact, in our bodies lies a reflection of the whole solar system. The sun has a mystical connection to the heart, which rays forth its warmth to every cell in the body. There are many mysterious qualities to the natural light from the sun. I’ve long recognized that vitamin D levels are a good marker for other immeasurable beneficial effects of being outside. Those are not realized when we supplement and stay indoors. The Sun is the original source. Put on some shorts and a tank top today and sit on your porch. It will keep you healthy and resilient!