Vitamin D and The New England Journal of Medicine

An article in today’s New England Journal of Medicine is bound to get a lot of attention, but not for all the right reasons.


The article is a review of vitamin D deficiency and the implications for health and disease.


It is written by a researcher who is well known in vitamin D circles, Dr. Michael Holick from the Boston University School of Medicine where he is a member of their Vitamin D, Skin and Bone Research Laboratory.


What is perhaps less well-known is Dr. Holick’s close relationship with the tanning industry.


Many might end up asking why the Journal would choose someone widely viewed as having a pro-sun exposure and tanning bias to author an authoritative review on the subject, and why they would allow funding from the indoor tanning industry to play a role in the work.  You would have difficulty finding this information unless you knew what to look for and where to look.


Vitamin D issues are no stranger to this blog.  I have written several postings reflecting a changing personal viewpoint on the impact of vitamin D on health, particularly with respect to cancer.


My position has been that the evidence has increasingly suggested that there is a role between vitamin D and cancer incidence, and that further research needs to be done to confirm the apparent positive effect of vitamin D supplementation on reducing the risks of developing various cancers.


Essentially, given the research on vitamin D, we do feel that the question of adequate vitamin D intake needs to be addressed on a national basis by the appropriate scientific advisory bodies to determine whether the current recommendations for daily intake need to be increased.


Also, recognizing that there are three primary means of increasing vitamin D intake—through vitamin D rich foods, sun exposure and supplements—we continue to advocate sun-safe behaviors.  We do not advocate seeking the sun to increase vitamin D, which leaves us with the safe and effective alternative of recommending vitamin D supplements (in the form of vitamin D3) to ensure adequate levels of vitamin D in our bodies.


As to the “correct” level of supplements, some organizations have recommended increasing vitamin D3 daily supplement intake to 800-1000 IU daily.  However, it is our opinion that we need the national standard setting bodies to take a close look at the evidence and make a recommendation, before we can formalize a recommendation that will apply to over 300,000,000 people in the United States and elsewhere.


Now, back to the article.


This is actually a very detailed, in depth scientific review of a very complex subject. 


If you are interested in the topic of vitamin D, how it is made, how it works in the body, and other similar issues, and you are willing to wade through the medical and scientific language, you will likely find this article very interesting and informative. 


The critical role of vitamin D in preventing osteoporosis and fracture as well as its positive impact on muscle strength and reducing falls in the elderly is discussed in this report, which is probably the one reason all experts agree we need to increase vitamin D intake and blood levels.


The report goes on to discuss the role of vitamin D in a number of disease states, including cancer, autoimmune diseases, osteoarthritis, and diabetes among others. 


The causes of vitamin D deficiency are highlighted in one of the tables in the article. 


The most pertinent causes of vitamin D deficiency for most people, according to the author, include sunscreen use, skin pigment (the darker your skin, the less vitamin D you make from sun exposure), aging, seasonal/location/time of day factors, and obesity (fat holds on to vitamin D).


So what are the author’s recommendations to increase vitamin D in the body?


The first recommendation is to increase supplements to 800-1000 IU vitamin D3 daily in those children and adults who are “without adequate sun exposure.”


The author also provides a detailed text and tabular series of recommendations on how to prevent and treat vitamin D deficiency.


High on the list of recommendations for various states of deficiency are the phrases “sensible sun exposure,” “use of tanning bed or other UVB radiation device (e.g., portable Sperti lamp),” and “adequate exposure to sun or ultraviolet radiation.”


The author specifically says that for patients with mild or moderate hepatic failure or intestinal fat malabsorption syndromes and other medical conditions, “exposure to sunlight or ultraviolet B radiation from a tanning bed or other ultraviolet B-emitting device is also effective.  Sensible sun exposure can provide an adequate amount of D3, which is stored in body fat and released during the winter, when vitamin D3 cannot be produced.”


To achieve this, the author recommends “exposure of arms and legs for 5 to 30 minutes (depending on time of day, season, latitude, and skin pigmentation) between the hours of 10am and 3pm twice a week is often adequate.”


He goes on to say, “Most tanning beds emit 2-6% ultraviolet B radiation and are a recommended source of vitamin D3, when used in moderation.   Tanners had robust levels of 25-hydroxyvitamin D…at the end of the winter and higher bone density as compared with nontanners…  For patients with fat malabsorption, exposure to a tanning bed for 30-50% of the time recommended for tanning (with sunscreen on the face) is an excellent means of treating and preventing vitamin D deficiency.”


The article concludes, “Excessive exposure to sunlight, especially sunlight that causes sunburn, will increase the risk of skin cancer.  Thus, sensible sun exposure (or ultraviolet B irradiation) and the use of supplements are needed to fulfill the body’s vitamin D requirement.”


The problem I have with this recommendation is that I don’t know many experts who agree with the sun exposure or tanning-bed part of it. 


The experts are concerned about a number of factors, including the cumulative risks of unprotected sun exposure, the risks to individuals based on their skin pigmentation, the impact of geographic location and time of day when or where exposure occurs, and the fact that is difficult to impossible to make such a one-size fits all recommendation of this type when considering all of the individual variables.


But there is no question that the average person reading this article will come away with the impression that sun exposure and using tanning beds is “ok” as reported in the prestigious New England Journal of Medicine.


But in what may turn out to be the most interesting part of this story, the author acknowledges the support of the National Institutes of Health and the UV Foundation for his research. And while he reports receiving honoraria from several pharmaceutical companies, he did not indicate any similar payment  from the other sources, such as the tanning industry.


A quick check of the Web finds Holick makes no effort to hide his associations with the UV Foundation and another group called the Indoor Tanning Association (ITA). The UV Foundation lists the Indoor Tanning Association, the Osram Company and Future Industries as its major supporters. The purpose of the Indoor Tanning Association is obvious.  The Osram Company makes light bulbs.  Future Industries makes tanning beds, light bulbs and associated tanning paraphernalia.


Coincident to the publication of this article, many states, including California, are now considering new legislation or strengthening existing legislation restricting the use of tanning beds by young people (in fact, I find the timing of this article in the New England Journal as particularly interesting given the fact that California right now is considering a bill to strengthen the control of tanning bed use by young people).


My expert colleagues are not alone in their concerns about tanning beds.  The World Health Organization has issued a report on the cancer causing effects of tanning beds and recommended that people under the age of 18 should not use them.


On both the UV Foundation and ITA Web sites, Dr. Holick is prominently displayed, promoting his recent book touting UV exposure. There is even a link to his pod cast—right next to the ITA’s plea to help defeat the California “under 18 ban.”


So here we are:  a research report in the New England Journal of Medicine that contains a lot of excellent information, and is well written, well organized and very informative.


That said, there is clearly a substantial amount of discussion about vitamin D supplementation, but there is also a strong emphasis on “sensible sun exposure” through a variety of means, including direct exposure and tanning beds. 


On the other side of the recommendation a cadre of well-qualified experts who feel that this is a very dangerous and inappropriate recommendation.  But their views are not represented in the article.


Go figure.



Filed Under: Diet | Prevention | Vitamins


J. Leonard Lichtenfeld's Biography

Dr. Len

J. Leonard Lichtenfeld, MD, MACP: Dr. Lichtenfeld currently serves as Deputy Chief Medical Officer for the American Cancer Society in the Society's Office of the Chief Medical Officer located at the Society's Corporate Center in Atlanta. Dr. Lichtenfeld joined the Society in 2001 as a medical editor, and in 2002 assumed responsibility for managing the Society's then newly created Cancer Control Science Department which included the prevention and early detection of cancer, emerging cancer science and trends, health equity, quality of life for cancer patients, the science of cancer communications and the role of nutrition and physical activity in cancer prevention and cancer care.  In 2014, Dr. Lichtenfeld assumed his current role in the Office of the Chief Medical Officer where he provides extensive support to a number of Society colleagues and activities. As a result of his over four decades of experience in cancer care, Dr. Lichtenfeld is frequently quoted in the print and electronic media regarding the Society's positions on a number of important issues related to cancer. He has testified regularly in legislative and regulatory hearings, and participated on numerous panels regarding cancer care, research, advocacy and related topics. He has served on a number of advisory committees and boards for organizations that collaborate with the Society to reduce the burden of cancer nationally and worldwide. He is well known for his blog ( which first appeared in 2005 and which continues to address many topics related to cancer research and treatment. A board certified medical oncologist and internist who was a practicing physician for over 19 years, Dr. Lichtenfeld has long been engaged in health care policy on a local, state, and national level.  He is active in several state and national medical organizations and has a long-standing interest in professional legislative and regulatory issues related to health care including physician payment, medical care delivery systems, and health information technology. Dr. Lichtenfeld is a graduate of the University of Pennsylvania and Hahnemann Medical College (now Drexel University College of Medicine) in Philadelphia.  His postgraduate training was at Temple University Hospital in Philadelphia, Johns Hopkins University School of Medicine and the National Cancer Institute in Baltimore. He is a member of Alpha Omega Alpha, the national honor medical society.  Dr. Lichtenfeld has received several awards in recognition of his efforts on behalf of his colleagues and his professional activities.  He has been designated a Master of the American College of Physicians in acknowledgement of his contributions to internal medicine.  Dr. Lichtenfeld is married, and resides in Atlanta and Thomasville, Georgia.

Leave a Reply

Your email address will not be published. Required fields are marked *