The truth about vitamin D supplements

Vitamin D is the world’s favorite supplement. Governments around the world recommend people take the supplement for at least six months out of the year. But do we really need these pills? Do they even work? And could they actually be harming us? 

In this episode, two of ZOE’s best scientists - Professor Tim Spector and Dr Federica Amati reveal the truth about vitamin D. Tim is scientific co-founder of ZOE and professor of genetic epidemiology at King’s College London. Federica is head nutritionist at ZOE and author of the Sunday Times bestseller ‘Every Body Should Know This’.

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Transcript

[00:00:00] Jonathan Wolf: Welcome to ZOE Science and Nutrition, where world-leading scientists explain how their research can improve your health.

Vitamin D, is also known as the sunshine vitamin. It plays a crucial role in the health of our entire body, from bone fractures to cancer. But there's a dark cloud looming over the sunshine vitamin. Some are calling it an ignored epidemic. A reported one billion people have low vitamin D levels, with almost half of us now classed as dangerously deficient.

It's no wonder that so many people are reaching for the supplements. But are we swinging towards too much vitamin D? Recent years have also seen an increase in people hospitalized with dangerously high levels. Our vitamin D intake is a tightrope walk. On one side deficiency, and on the other side intoxication.

Today, we're joined by two of ZOE's best scientists to steady us during this balancing act. Tim Spector is one of the world's top 100 most cited scientists, a professor of epidemiology, and my scientific co-founder at ZOE. 

I'm also joined by Dr Federica Amati. Federica is the head nutritionist here at ZOE, a scientist at Imperial College London, And the author of the best-selling book, Everybody Should Know This.

You'll finish today's episode knowing exactly how much vitamin D you need and where you can get it. Tim and Federica, thank you for joining me today. 

[00:01:45] Dr Federica Amati: Thanks for having us. 

[00:01:45] Jonathan Wolf: So you know the drill. I don't need to tell you the rules. We're going to jump straight into the quick-fire questions. Are we ready to go for it? 

[00:01:54] Prof. Tim Spector: Ready. 

[00:01:55] Jonathan Wolf: Tim, is vitamin D a vitamin? 

[00:01:59] Prof. Tim Spector: No. 

[00:02:00] Jonathan Wolf: That's going to be a big surprise for many people. It's a good start. Federica. Can vitamin D deficiency increase your risk of developing cancer? 

[00:02:08] Dr Federica Amati: Possibly. 

[00:02:10] Jonathan Wolf: Can you be vitamin D deficient without experiencing any symptoms? 

[00:02:16] Dr Federica Amati: Unlikely. 

[00:02:18] Jonathan Wolf: Tim, can vitamin D supplements be bad for your health? 

[00:02:23] Prof. Tim Spector: Sadly, yes. 

[00:02:26] Jonathan Wolf: And then finally, maybe for both of you, what's the biggest misconception about vitamin D in your opinion?

[00:02:32] Dr Federica Amati: In my opinion, the biggest misconception is that it's a panacea for all ills. It's not. 

[00:02:37] Prof. Tim Spector: I would say that taking more of it is going to give you great benefits and there's no evidence for that. 

[00:02:45] Jonathan Wolf: I think that's going to already shock a lot of people, all this feedback. I mean, I'm already still reeling from vitamin D is not a vitamin, so that's already quite confusing.

I know there is a lot of buzz about vitamin D in the media, and I've noticed more and more vitamin D supplements and fortified foods in the grocery aisles. But I've never really understood what it was and I thought I at least understood it was a vitamin and apparently it's not even that.

So I definitely want to start at the beginning. But before I do that, I just want to tell our listeners, that I think they're in for a bit of a treat because Federica and Tim have slightly different views about what the scientific evidence tells you about vitamin D. 

And this is sort of, I think, a window for a lot of our listeners into what it's like to be at ZOE and try and take the latest cutting-edge science and turn it into real advice. Because one of the things I've learned is if you ever meet someone who is absolutely categorically convinced about what the science says about something, they're not probably a leading researcher because they're always telling me, well, it's a bit nuanced and there's this other study.

And so I think today will be quite fun to understand what does the science really tell us and understand how world-leading scientists like Tim try and pass the latest evidence to understand what might that mean for regular people like me trying to figure out what to do. 

So if vitamin D is not a vitamin, what is it?

[00:04:07] Prof. Tim Spector: It was misnamed a long time ago and the definition of a vitamin is something that the body cannot produce itself and you only need minute quantities in order for it to be effective and keep your body going. 

And so real vitamins are things like the B vitamins. that are key for chemical reactions in the body and our cells that basically keep us alive, and that we can't generate them themselves, so we have to get them from our food.

And that's why vitamin D, as we call it, doesn't meet those criteria, because it's actually in huge amounts compared to the small amounts you need for vitamins already in its natural form, and the body synthesizes itself via sunlight.

So under the skin, you can convert sunlight mixed with various lipids and fats into this compound, which we call a vitamin, but is actually more like a pro-hormone or a form of a steroid. So it's closer to a steroid than it is to a vitamin. 

And I think our reactions to it if we're calling it a steroid, would be very different. It's had fantastic PR for the last hundred years just because it's called a vitamin, wrongly.

[00:05:24] Jonathan Wolf: And so, I understand now it's not a vitamin, I have no idea what a steroid is, so could you help me to understand what it does do? 

[00:05:33] Prof. Tim Spector: Well, we've got to call it vitamin D, I'm not going to rename it now, just, just…

[00:05:38] Dr Federica Amati: Parahormone D. 

[00:05:39] Prof. Tim Spector: There you go, parahormone D is key to many, many functions in the body. That's why we evolved to be able to synthesize it. 

As we moved out of Africa, our skin got lighter so that we could get more sunlight in and convert it into vitamin D. So we know it's very important for our bodily function and it's crucial for our immune health, primarily. That seems to be the main driver of it, but it's involved in all kinds of reactions.

Just like, in a way, the other vitamins are, it's not different in that. It's just, it's coming at it from a different angle. So we know that it's involved in many immune reactions and our response to the environment is fairly crucial. 

And when we talk about immune reactions, we're talking about inflammation. We're talking about the response to allergies, response to aging, and cancers, and it has a very general plan of action.

As well as specific effects on things like bone health and growth. So that's where it sort of comes into its more specific roles, in that you can't create bone properly if you don't have some vitamin D on board.

[00:06:50] Jonathan Wolf: You absolutely need it. I feel like quite a lot of things we end up talking about on the show it’s involved in lots of different things. 

[00:06:57] Prof. Tim Spector: You can't live without it. Absolutely. 

[00:06:59] Jonathan Wolf: But you're saying the key difference between this and generally the vitamins that we talk about is that generally, those are vitamins that the body can't create at all. So you've got to ingest them in like very low levels, but you've got to have it.

Whereas here we can actually make it ourselves. So Federica, is sunlight the only way we can get vitamin D? 

[00:07:17] Dr Federica Amati: So, no, it's not. We can get it in food. I think what's important as well to note is that actually now we've discovered that, for example, vitamin K is made by gut microbes. So it's not the only vitamin that isn't made by some part of our body.

But Tim's right in that it's the vitamin that our body is very well adapted to make plenty of for us if we just get enough sunlight exposure. 

We can also get it in food, but generally speaking, we can't get enough of it in food compared to what we need for our health. So we do need to get some sunlight exposure onto our skin to create vitamin D.

[00:07:50] Jonathan Wolf: What's the recommended daily intake of vitamin D? And I'm sitting here feeling that I know I haven't got enough of it, that no one I know has got enough of it, because I'm surrounded by all this advertising telling me that I need to take more. 

[00:08:02] Dr Federica Amati: So Jonathan, this is really complicated actually, because we have receptors for vitamin D all over our body. Every single tissue, right? And that causes a cascade of reactions, including different gene expressions. 

It's hard to even measure how much vitamin D we have in our bodies, let alone how much of it we're actually converting to other things because that depends on how many receptors you are. So, it's not a simple answer, and it goes back to what Tim was saying, this is a parahormone.

It's a bit like if I said, what's the recommended amount of estrogen that every woman should have? There isn't a recommended amount. But the U.K. and the U.S. differ quite a lot in what they consider to be healthy amounts in the blood and what people should supplement through, not food, but supplementation.

And it's really interesting because when you look at the recommendations, they clearly state that these recommended amounts to take as supplements exclude any exposure to sunlight and any food intake. So, already, these recommendations are aiming at helping people who have very little sunlight exposure and maybe don't have the right foods in their diet to include vitamin D.

These numbers are 28 nanograms in the U.S. as the recommended blood level, whereas in the U.K. we recommend 12 nanograms. And in the U.K. we recommend 400 international units per day for adults. And for the U.S. we recommend 800 international units per day. So very different numbers which we'll get to why that is or why we think that is because it's a very interesting story.

[00:09:35] Prof. Tim Spector: As a supplement, just to make clear that you're talking about that. 

[00:09:37] Dr Federica Amati: Yes, that's exactly, excluding sunlight exposure and food. 

[00:09:40] Prof. Tim Spector: So, it's interesting, because in my career, I obviously started studying vitamin D as a rheumatologist in the late 1980s, and when I started, there weren't many labs measuring vitamin D, and the only cases you saw were these rickets and osteomalacia. 

These are when the bones go all bendy and soft and you might remember those pictures from the 50s and 60s where many poor children had bow legs and stunted growth and there's an adult form of this called osteomalacia. These were serious diseases and people had no vitamin D to grow their bones at all.

And slowly the level of what was seen as the normal level of vitamin D in the blood rose from actually having quite minimal levels where you saw these diseases to every 10 years like doubling up to the point where many organizations around the world or in the U.S. are, you need very high blood levels to be seen as having sufficient vitamin D.

Now, as Federica explains, it's very difficult to know what that level is because you're actually trying to measure things in the cell, not actually directly from the blood. And I think that's been directed more by the vitamin D companies and the commercial pressures than from science. 

Many people, who are experts in vitamin D agree with me that it's just been pushed up and up and up without really any scientific evidence to say that 28 nanograms is better than 14 nanograms and that there isn't a universal amount.

And it's confused by the fact that we did a very large twin study to show that the blood levels you have is not so much dictated by how much you eat or how much you go in the sunshine, but it has a genetic basis. 

So about half of that difference between people is actually genetic. So everyone has their own personal vitamin D blood level that suits them, which makes it even less likely that you can give everyone the same level across the world and say that's what they need.

So, it's extremely problematic, and I think it's been driven more by commercial concerns than by real clinical evidence. 

[00:11:58] Jonathan Wolf: And can I ask a bit more about the consequences of deficiencies? I think you were painting this picture of what happened with children with absolutely no Vitamin D, which sounds pretty terrible.

Are there levels of deficiency still below that? And what percentage of people classify as that? And what happens to you if you're in this low level of vitamin D, but not the complete absence that you were sort of describing? 

[00:12:22] Dr Federica Amati: So that's the difference between deficiency and insufficiency. 

And that's where the lines get a bit blurred, because with deficiency, as Tim described, you see a real change in bone structure in children and in the quality of bone even in adults. So it's quite easy to see and measure.  

[00:12:36] Prof. Tim Spector: What you mean is they can fracture with very painful fractures that look really obvious on the x-ray and they don't heal up well.

[00:12:43] Jonathan Wolf: And so if you're in the U.S. or in Western Europe, what fraction of people have that level of vitamin D deficiency? 

[00:12:49] Dr Federica Amati: It's a tiny, tiny amount that have deficiency. Luckily, rickets is really rare. There is a strange increase in numbers in the U.K. and the U.S., but we think that's mostly related to lifestyle and diet, actually.

But really vanishingly rare to see somebody with rickets or osteomalacia. However, when you look at the reports, countries will report that there's between a 10 to 14% in the U.K. deficiency, and in the U.S. it's up to 30%. Some other papers have suggested that deficiency and insufficiency might be as much as half of the population.

But these are based on numbers from surveys and they are with these inflated numbers that we're expected to reach and you see this across the randomized control trials as well, where some participants in the randomized control trials will go into vitamin D trials with very high blood levels already, and then they're given extra to reach even higher levels.

So I think when you look at clinical reports of osteomalacia or rickets, they're still incredibly low, very rare. But sometimes the reporting of how many adults are missing vitamin D or lacking vitamin D in the U.S. and U.K. can seem alarmingly high. 

[00:13:54] Prof. Tim Spector: But just to clarify, because I used to treat people with osteomalacia, which is the adult form of rickets, and you'd often see this in immigrant populations who are changing their diet, had come from a place where there's a lot of sunshine to no sunshine and their diet wasn't adequate and they may have been lacking it as children anyway. 

So they would come with very painful muscles aching in their body, very tired and they'd have these rather weird fractures for little reason at all. So that's the classical picture of the adult form of rickets which we call osteomalacia and it tells you that's what the symptoms of real vitamin D deficiency are. 

They're painful joints, painful muscles and the consequences with these fractures. Everything else we're talking about is theoretical risks or theoretical problems. This is where we get into this difficult territory.

[00:14:50] Jonathan Wolf: And Tim, can I ask you about the health consequences of what you're talking about, the theoretical deficiency? So you're saying there's these people, it's really clear they're getting these awful fractures, but that's with the extreme deficiency. 

And then we're hearing there's maybe 30% of the population that's deficient. What are the symptoms? 

[00:15:06] Prof. Tim Spector: Depression, tiredness, all kinds of mental illness. There were these conditions like fibromyalgia which were supposed to be associated with it. Everything that couldn't be explained by medical science was in the last several decades, been linked to vitamin D deficiency. 

In general, if you take super healthy people, and you compare them with generally unhealthy people, there will be a difference in their blood vitamin D levels. 

[00:15:34] Jonathan Wolf: And the healthier people will have higher vitamin D on average. 

[00:15:36] Prof. Tim Spector: It's a sort of marker of health. And I think this is why the whole literature is rather confused. But if you think about it, someone on a healthy diet who's going outdoors and doing sports and things is going to have a higher vitamin D level than someone who is unwell and sitting inside and on a poor diet.

So this is where the whole literature has got very confused and people have associated the fact that it's a health marker with the fact that we just have to give you more of that health marker and you can be even better and healthy. 

[00:16:08] Jonathan Wolf: That's really interesting. So, it sounds like everyone agrees you need some vitamin D, or that's a huge problem.

There's quite a lot of controversy about whether a large fraction of the population is really deficient and this is really causing them symptoms, or whether actually it's a much smaller fraction who are truly having symptoms from lack of vitamin D. 

[00:16:32] Prof. Tim Spector: Yeah, well, it's not a controversy in my eyes, but yeah, that's… 

[00:16:34] Jonathan Wolf: And it's not a controversy in your eyes because?

[00:16:36] Prof. Tim Spector: Because I believe that you don't need that much vitamin D and everything above that, you're fine. I've seen so many patients, for example, with extremely low levels, sort of nearly off the charts, including one who was a colleague of mine who was an expert in vitamin D and calcium. He came from Sri Lanka, and he'd been walking around for years with virtually no levels and felt completely fine.

So, I think the idea that it's this amazing thing that is like a thermostat of our health and we just have to top it up every now and again, is very misleading. 

But at the same time, I've seen vitamin D cure some of my patients, and if you give vitamin D to someone with these painful fractures, their pain goes away nearly immediately. 

It's this ground where I think the industry has made a disease where none really existed. 

[00:17:27] Jonathan Wolf: And Federica, I'd love to get your perspective. 

[00:17:29] Dr Federica Amati: I think because it's such a marker of health, I can see how there's lots of studies that show how individuals who suffer with certain conditions, including depression, multiple sclerosis, Crohn's disease, cancer, they tend to have low vitamin D levels.

So, I understand how, when you have these patients, giving them vitamin D could be one of the tools that you use to help improve what's known to be a marker of health. 

And so I know what Tim is saying in terms of the deficiencies are pretty hardcore and easy to spot clinically, but there's this insufficiency range that lends itself to giving your patient or your client an intervention that might be helpful.

And Jonathan, we've just spoken about the fact that vitamin D receptors are all over the body and they impact all tissues. And there's a lot we still don't understand about vitamin D. 

So from a public health perspective, there is little harm in recommending that certain patient groups take vitamin D to help them reach that healthy marker level that we feel would be good for them, basically. 

Now, it's true that the markers are so different between the U.K. and the U.S. I feel that the U.S. has been conflated and inflated because of industry intervention, and there's been lots written about this. 

But if we take the medical cut-offs, I think it can be very helpful to give people vitamin D to get them above that critical deficiency line, and it could be something that helps them without harming them, and that's really important.

[00:19:01] Jonathan Wolf: How would someone know if they're low in vitamin D? 

[00:19:06] Dr Federica Amati: There's a blood test you can have 25-hydroxy D, which is one of the metabolites of vitamin D. So as we said earlier, it's really hard to actually measure vitamin D status, and this is the best proxy measure. 

And so a proxy measure means that it gives us an idea of how your body is breaking this down, but it doesn't necessarily tell us how it's being used or what effects it's having. So again, very hard to know how useful. 

[00:19:27] Prof. Tim Spector: And some countries and other places have an alternative test called the parathyroid hormone, which goes up if you're deficient. And that might be a better way of seeing that. So they go in opposite directions. So if your body needs vitamin D, in a way your parathyroid hormone goes up and therefore it starts to get nutrients from the bone.

[00:19:50] Jonathan Wolf: And I feel this is something that I have been told about by doctors in both the U.S. and the U.K. So is this quite a typical sort of clinician's test?

[00:20:00] Prof. Tim Spector: Absolutely yes, but it's been a problem because we don't know what the normal levels are. And that also goes for parathyroid hormone. It goes for these vitamin D levels.

And so I think, medicine likes to play safe. So what we've done every 10 years, is just keep raising this level, the bar, so that half the population are now seen to be deficient. Whereas it perhaps should be, you know, 1% of the population. You've now got 50% nervous and worried that they've got some deficiency or problem.

So this is the risk of taking this route and treating it like, okay, let's give everyone this. It's all harmless, that'll be fine. And it's absolutely not the case. And I think by focusing on these things, you're then neglecting many other things you could be doing for their health care.

You could be looking much more at their diet, you could be looking at their lifestyle, their exercise levels, or some other disease that they've got. So at the moment, we're very focused on this as the cure-all, and the evidence simply doesn't back it up. 

[00:21:00] Jonathan Wolf: So can we talk a bit about supplementation and the experience, I guess, that people are having and then, I think we're already exposing definitely a spread of view about what to do.

And we said there's quite a big difference between the U.S. and the U.K., which is actually very surprising because it's been very unusual across these podcasts that we ever have that. And I think that itself is interesting. 

It sounds like you're saying 30 to 50% of people might be low on this number. What happens when that's the case? 

[00:21:23] Prof. Tim Spector: Well, if you see your family doctor and they do a blood screen for you and show you're below that level, they would probably prescribe a vitamin D supplement with or without calcium. 

And that, I think, is fairly common around the world, depending on each country's cut-off levels and what their lab is telling them. All of which are very different. And even in the U.S., depending on whether you take, the bone health colleges, the gynecologists, the cardiologists, they've all got slightly different levels, interestingly. 

So there's no real consensus about where that level is. But once you've made that stand and you've taken it, then generally you'll be prescribed a supplement. And be told, oh, this should help X, Y, or Z, whether it's your tiredness, whether it's your depression, whether it's your muscle aches, or it's going to be a general preventive for fractures. 

And that's still commonly practiced, although we now have scores of trials showing that it doesn't work. 

[00:22:27] Jonathan Wolf: I would love to discuss, what does the science say? So, presumably, there have been real clinical trials to try and answer this. 

[00:22:35] Prof. Tim Spector: So there’s two types of study. There were the ones that led to this, which were the epidemiology studies, which compared a hundred different diseases to controls. 

And as we discussed, they found vitamin D levels were generally lower in the disease group than compared to the control group for the reasons we've discussed, virtually all likely be lifestyle and self-selection of people because of their disease. It's not before, it’s after they have the disease. 

These are called observational studies. They're a useful starting point in epidemiology, and that's how, you know, lung cancer and smoking came about. That's the starting point, but it doesn't absolutely prove anything, because there are all these other factors, particularly with something that's involved in lifestyle, diet, and general health.

A disease could lower it. The fact that you're sick, you stay indoors, the fact that you're sick, you're not eating well, all those three things can lower your vitamin D. So that's probably the explanation for why it was associated with a hundred different diseases all erroneously. 

Then you've got the clinical trials, and they're seen as the gold standard of this, and I actually did one about 20 years ago in twins. We gave calcium and vitamin D to one twin and we gave a dummy to the other one and measured their bone densities, et cetera, and found no differences. And we thought this is strange because everyone was saying this should be a miracle cure. 

And at the time there were a few studies dating back to, I think, the late 80s when they did some big studies in France in nursing homes. And they basically randomized nursing homes to be given vitamin D supplements or not and found a difference in fracture within two years of doing this. 

And people said, Oh, wow. And from that point, really, everyone was told vitamin D can prevent fractures and is really important in old age. But bit by bit, there've been another 20 studies or so, including a massive U.S. study called the VITAL trial. that have shown no difference at all in fracture rates. 

[00:24:42] Dr Federica Amati: I will come in on that though and say that the study that was done in the old people's home was looking at people over the age of 65. The VITAL trial, the average age was about 50. So actually when we look at the evidence, there is some suggestion that older people, especially women, who are in a care home setting, may benefit from vitamin D supplementation.

So I think within these trials, there's subgroups of people who do seem to benefit, but they are the minority. And so, Tim was talking about family physicians and prescribing but actually, the public health recommendation in the U.K. is that everyone supplements with vitamin D from October through March.

That's 400 international units of 10 micrograms. So the question becomes whether everyone supplementing is helpful or whether we should really be focusing on the groups in the randomized control trials that did show an improvement in their outcomes. 

[00:25:35] Prof. Tim Spector: Yes, but a lot of people have discredited that very early French study. The guys who were running the study ended up having their own companies selling vitamin D. And it was never been replicated. 

So there's been other subsequent studies in old people's homes that haven't found the same effect. So I'm not saying we can prove definitely, and yes, these are very high-risk individuals and very high risk of hip fractures in old age homes. They don't go out much, the diet not good. 

I think it's still reasonable to do that, but I think we have to be a bit cautious about how great the evidence is. 

[00:26:12] Jonathan Wolf: Did you say there was a third type of study that you were going to talk about as well? 

[00:26:17] Prof. Tim Spector: Yes, there's another study based on genetics, which is called, very complicated Jonathan, I'm sorry about this, it's called Mendelian randomization.

[00:26:27] Jonathan Wolf: Well it's got a fantastic name, I've heard the name before and I don't have any idea what it means, what is Mendelian randomization? 

[00:26:34] Prof. Tim Spector: Well you might remember this monk, Gregor Mendel, who did this pea experiment, and he probably faked a bit of the results, he basically sorted out the idea that you inherit these genes from your parents and they get passed down and the sort of they're mixed up and then that they get separated.

So the idea is that once you've discovered the genes for something for say vitamin D and I actually led a study of this about 10 years ago showing that not only was vitamin D genetic but that you could determine what genes controlled it. So 10 gene variants that we've all got that can make your vitamin D level higher or lower 

[00:27:15] Jonathan Wolf: This is the thing you were saying before that actually amongst different people, like my wife and I might be making very different levels of vitamin D even though we're eating the same food and we're having the same amount of sunlight, right?

[00:27:25] Prof. Tim Spector: Exactly, and it might be perfectly healthy for you to have lower levels than your wife because your genes have decided that's what they want to do. We don't know which way around it works. 

But you would expect that if you've got the genes for low vitamin D, then it doesn't matter what stage you are at in life, you're gonna have had lower vitamin D levels than your wife.

So it's like doing a randomized trial lifelong because you can't change your genes. They can't be influenced by your disease, they can't be influenced by whether you live in Spain or Iceland, it's the same. 

So this was supposed to show that people with these low vitamin D traits, these low vitamin D genes should have higher fracture levels. And they've done this in over a million people now, and there's absolutely no difference. 

[00:28:13] Jonathan Wolf: There's no difference whatsoever if your genes are making more vitamin D than someone else. 

[00:28:18] Prof. Tim Spector: Absolutely none. So if you combine that with the meta-analyses of all these randomized trials, really the evidence that vitamin D supplementation has any role in bone health once you're out of that rare deficiency range, it doesn't exist.

And there's some evidence from about three trials where they gave quite high levels of vitamin D, that you make it worse. 

[00:28:48] Dr Federica Amati: And actually there is more than one trial that showed that if you have the vitamin D plus calcium in some populations, older people can increase risk of cardiovascular disease.

So that's where the vitamin D calcium supplementation issue comes up and I'm always quite wary if people are taking large amounts of calcium supplements. Because, again, the thinking there is that it could help with your bone health. 

[00:29:10] Prof. Tim Spector: Well, there's even less evidence that calcium supplements work compared to vitamin D, and there's even better evidence that it's really harmful for you.

So I don't think anyone listening, unless they've been given specific advice by their doctor should be taking calcium in supplementation. Because there's quite a lot of evidence, both in animals and in humans, that it can lead to atherosclerosis, a sort of clogging up of the arteries. 

Because you think about getting calcium naturally from plants or dairy or whatever form it is, you're getting small, tiny amounts all the time, regularly, which your body's used to. To take a big, one-gram tablet of this once a day that your body's got to deal with, we're not meant to do it, and it's not surprising that it ends up in the wrong place. 

[00:29:57] Jonathan Wolf: You are saying that unless a doctor has specifically prescribed calcium supplementation, Tim, you think people should not be taking it because you think it's not just that it's neutral, it's positively harmful and can hurt your health.

[00:30:11] Prof. Tim Spector: Absolutely, and particularly your heart. 

[00:30:12] Jonathan Wolf: And particularly heart, because I think it's rather terrifying, right? Because you can't buy it at the store or anywhere. It doesn't have great big labels on it saying warning. 

Have we known this forever, or is this different from what we understood 20 or 30 years ago?

[00:30:26] Prof. Tim Spector: We've known it for the last 10 years, but such is the difficulty of changing medical mindsets and the power of the supplement industry that really hasn't still got mainstream. And so most family doctors are still prescribing it, although many of the specialists now are not. 

[00:30:46] Dr Federica Amati: People who suffer with osteoporosis or bone disease sometimes are prescribed both.

The randomized control trials, even in the groups who have a higher chance of problems like osteoporosis, the trials clearly show that the vitamin D plus calcium combination is not helpful. And it's not helpful for the bones, and actually could be dangerous for your heart. 

So it's interesting that it's very clear in the research, but as Tim said, people still take it, and I've seen it as well, where people come to me and they say this is what I'm taking. I'm like, let's not take the calcium. 

[00:31:15] Jonathan Wolf: And what about the vitamin D alone? So I think you're saying very clearly, like if a combination with calcium is like definitely out, is there any downside of taking these vitamin D supplements? 

Is there any risk? Can I take too much? 

[00:31:29] Prof. Tim Spector: Absolutely. We didn't think there was, but in the last 10 years, there have been several trials where they've given people larger than 400 units up to 5,000 units a day, and many people are self-medicating, and in these trials, they've shown that the group that were having, say, vitamin D by injections or large amounts by mouth had increased fractures and increased falls.

So, the researchers in those trials have really changed their minds about it. So, you can overdose on these and increasingly in clinics, we're seeing people who are self-medicating from the internet, you can get very high dose tablets from the internet, which seems very strange. And these are very, very dangerous because you do accumulate the vitamin D in your body.

It doesn't just get peed out like some other B vitamins. So, you will get more and more levels and that can cause real problems. Nerve problems, muscle problems, and because it's called a vitamin, people think it's harmless. 

[00:32:31] Jonathan Wolf: It's not just getting passed straight out if I don't need it? 

[00:32:34] Prof. Tim Spector: Correct, that's right. It does depend on the form you're taking it, but in general, that's correct because it does build up and it is dangerous. 

So, again, it comes back to this idea that taking a supplement in a chemical form is often different to, you know, you can't get too much from sunlight or from food. 

[00:32:55] Jonathan Wolf: So it's more like a drug, right? I could take paracetamol, that's great, it helps with my headache, but I know that if I have loads of that, it could really hurt me or kill me. 

And so you're saying that I should think about vitamin D a bit more like that. 

[00:33:05] Prof. Tim Spector: Yeah, so when you go buy Tylenol, you're not allowed to buy 500 of those tablets.

You can buy unlimited amounts of vitamin D and self-medicate. And I think it's just wrong. And if it was called a steroid, you wouldn't have this, it would be more controlled. And that's why our body is well set. I can go in the sun as much as I like, and as you may have noticed, I've been in the sun.

But my vitamin D isn't going to keep going up. My body knows when I've got enough. We have a system for controlling it when it comes from food or sun. We don't have any system to control it when we're having it as a pharmaceutical. 

[00:33:42] Jonathan Wolf: Everything we've talked about has really been around bone health and the impact on fractures. Is that the whole role of vitamin D? 

Because I feel like lots of people are taking it because they think it's going to help with their general health. And does that also mean that if I'm not worried about fractures, then I can keep taking lots of it because I don't think that's a very big risk for me?

[00:34:00] Dr Federica Amati: No, there's so much more to the research and there's so much more to how we think vitamin D works. 

So we spoke at the beginning, Jonathan, about its role in immune system function, and I think that's where research has been more promising for the use of vitamin D even as supplements. 

Because, for example, with groups of patients who have, for example, Crohn's disease, which is an inflammatory disease, we see that those individuals benefit from vitamin D supplementation in randomized controlled trials. They have a reduced risk of hospitalization and complications. 

Now, if we think about this as a steroid that helps immune system function in individuals who have complicated inflammatory diseases, it makes sense that supplementing with vitamin D could help to mitigate some of these problems. 

Another group that has seen some good outcomes in the VITAL trial is patients who have cancer. Now, not to prevent cancer, but if you already have cancer, taking vitamin D could actually help to reduce mortality risk. 

Now again, this is in a subset of patients, so patients who don't have obesity, whereas patients who do, don't seem to benefit. And that probably comes back to how the vitamin D is stored in tissues.

So again, try to understand how this works in our bodies is really important. And so where I stand is that there is exciting evidence that this could be helpful in certain groups of people and really make a difference on the outcomes for those people. 

[00:35:23] Jonathan Wolf: And so where does this leave the two of you on supplementation?

I'm living in a northerly clime which is dark all winter, and that is going to be true for quite a few of our listeners. And I think they're getting this message that you're just not going to get enough from the sunshine during the winter so you should supplement, that is the outside. 

Should they be supplementing? And if so, how much? 

[00:35:46] Dr Federica Amati: There is reams of evidence that getting outside all year round is helpful for our health for lots of reasons, not just vitamin D. 

Now if you get outside all year round, including in the summer months, being mindful of your skin tone, so some people listening to this, like myself and definitely like Tim can get outside and not wear strong sunscreen and not get sunburned, right?

Other listeners listening know that if they go outside for more than five minutes, they will get sunburned. Sunburn is always a risk factor. But if you can go in the sun and enjoy the 15 to 20 minutes outside, without sunscreen, without getting burnt, so with no redness, then doing that every day is recommended.

Remembering that we accumulate vitamin D means that if we get enough sunlight exposure in the months when there is sunlight, right, then we'll probably have enough to carry us through the winter months. 

But if you're somebody who can't get outside, if you're somebody who has perhaps a really sensitive skin tone and finds it difficult to go outside, or if you're somebody who already has compromised health, so maybe you're an older person living in a care home, maybe you have Crohn's disease, or maybe you've just been diagnosed with cancer, then it may be worth speaking to your healthcare professional and getting some vitamin D supplementation because it could be helpful.

But, I will really, again, come back to this vitamin D toxicity. I've seen vitamin D toxicity, it's really not fun. There is a lot of influencers online that are promoting very high levels of vitamin D. 

So the takeaway for me with vitamin D is if you're one of these groups who could benefit, make sure you're getting the 400 international units in the U.K., that's 10 micrograms. In the U.S., they recommend up to 800 international units, which is 20 micrograms. But really if you're taking 400 international units a day in one of these groups, you could see a benefit. 

[00:37:34] Prof. Tim Spector: So, I don't completely disagree with that. But I don't want to give the impression that everyone living in northern Europe or parts of northern America and Canada, you know, should be so dependent on vitamin D.

I think we've evolved for tens of thousands of years to have the right conditions for our body. So we mustn't forget that. And if we have a diverse diet, then that's also going to help us. 

There are some conditions that, interestingly, I'm fairly convinced vitamin D can prevent, and one of those is something called multiple sclerosis, which many listeners may know about, and my mom actually suffered from.

And there's a link between people getting multiple sclerosis who live actually in the northern hemisphere, and in cold climates, and it gets less as you go towards the equator. This is one where Mendelian randomization studies actually showed a difference in the likelihood of of getting multiple sclerosis.

So there are some rarer diseases where this can be useful and I think it it makes sense. So if you've got any family history or risk then making sure your vitamin D level is adequate can be fine. 

Now, my mother's got it so I've got high risk but I know my vitamin D level is high, because I go in the sun, I have a good diet. So I'm not going to take supplements. 

But someone else might, if they're living in Alaska or living in Scotland, then it'd be quite reasonable in the winter months to take those supplements. But I think we've got to realize that, I would say sunlight and food are a much better option for the vast majority of people.

[00:39:16] Jonathan Wolf: That's really clear. And we've gone on a little bit, but I do want to make sure I touch a bit these alternate ways of getting vitamin D. And so, what are some of the foods that contain vitamin D? 

[00:39:27] Prof. Tim Spector: Well, most people know that it's contained in dairy products, which a lot of people are already eating. So, milk, cheese, keffirs, yogurts, etc.

Then it's in oily fish and it's in mushrooms. And they're the key ones. And many people are not incorporating those in their diets, and that's why I think it's been quite interesting this journey with ZOE and the nutrition program that we're seeing. 

We're getting people to eat these kinds of foods, incorporate them more regularly into their diets, and that's just one example of how we can shift people's attitudes to foods so that they don't need supplements just by thinking intelligently about what they're eating.

[00:40:09] Dr Federica Amati: If we think about it in proportions, I think up to about 30% of our requirements can come from the food we eat. 

[00:40:15] Jonathan Wolf: It could really make a difference to that absolute minimum level of vitamin D you're getting compared to the people living in these terrible conditions a hundred years ago you're talking about.

But compared to the sort of numbers that the government is talking about. This now pushes you over to sunlight, is that right? As the much bigger thing that would drive your vitamin D levels. 

[00:40:34] Dr Federica Amati: Being outside, yeah. 

[00:40:35] Prof. Tim Spector: That's interesting because a lot of places, countries suffering from the most vitamin D deficiency are places like Australia, where they're now avoiding the sun and living in air-conditioned, the inside for six months or more of the year.

So as we're changing our environment away from nature, we are developing some of these new problems. It's about how we live with our evolution and our nature and everyone has to decide, you know, what those special examples are. 

[00:41:07] Dr Federica Amati: That brings up a good point though, Jonathan, as well. If you're a person of color and you have darker skin and you live in cold climates, then you are at higher risk because that sunlight that will actually penetrate your skin and create the vitamin D.

You won't get that in London, right? Very rare, or maybe a couple of weeks a year. So to Tim's point, we've evolved to adapt to our environment, but now we're such an international community all over the world, we have to be aware of what we need for ourselves and our backgrounds to make sure we don't lack. 

But also another important point, we talk about sunlight, I want to be super clear here that there's no hack for sunlight, so having a sunbed so that you create vitamin D is not the way to do it, right? There's this fine line between getting enough sunlight exposure, but not increasing your risk of cancer. 

[00:41:56] Jonathan Wolf: Well, I was going to say, Federica, so both Tim and I are married to dermatologists. So I happen to know that Tim created a storm in dermatology circles earlier this year because the idea of going out in the sun without factor 50 sunscreen is very controversial because quite reasonably, dermatologists spend a lot of time dealing with people with skin cancer and people who end up dying from skin cancer, right? 

So they see that and therefore there's been these very big campaigns right across the states and Europe, Australia, about the extent to which whenever you go outside, you should make sure that you have a really high sunscreen. And I have to say that since I met Justine, I've wear way more sunscreen than I had done before. 

[00:42:42] Dr Federica Amati: And you look so young, Jonathan. 

[00:42:44] Jonathan Wolf: Well, well, thank you. And I am totally convinced that this is great for anti-aging. So I'm sold on that. But I think, Tim, this conversation brings around this question about what the impact might be on vitamin D and health. 

And I think you had what I thought was a fairly nuanced position, but was interestingly very controversial. So will you tell us how you think about sun exposure and sunscreen, given this conversation of vitamin D? 

[00:43:10] Prof. Tim Spector: It was triggered both by a research article I read, which was actually on mice, which normally I don't pay much attention to. But it was showing how vitamin D was really important in helping the immune system deal with cancers.

And the other thing was going in the tube and seeing posters by a U.K. skin charity, but basically sponsored by a sunscreen manufacturer, to say that we need sunscreen all year round in order to stay young and beautiful and to protect us from the harmful rays of the sun. 

The idea has permeated that we need 365 days of protection with a chemical, a pharmaceutical, on our skin, has permeated everywhere. So there are some schools in the U.S. and the U.K. that won't let their children go unless they've got sunscreen every day. 

And this is quite ridiculous in northern climes, where you need every little bit of sunshine just to get enough vitamin D. You're not going to get any harmful radiation in that time it's not going to make a significant difference to your aging. 

Dermatologists are seeing more and more problems of particularly young girls with major skin problems because they're applying so many chemicals to their face. This just seemed to be totally driven by the sunscreen industry, who are going through charities and making it sound like it's all scientific.

When I looked into it, and when I asked melanoma experts like my wife, there was absolutely no evidence. After about two million people had seen this tweet, and I got lots of nearly death threats for insinuating that sunshine might be good, including from doctors and celebrities and various other people.

It turns out the British Dermatological Association came out and said, actually, you know, he's right, there's no rationale for year-round, use of this, and you need every bit of sunshine you can get in winter. 

[00:45:09] Jonathan Wolf: So you're basically suggesting sunscreen in the summer when the sunshine is high and you got this risk of burning all the rest of it. But actually, if you're not lucky enough to be in Florida in the winter or whatever it is, actually, your view is you're better off not having the sunscreen because you're going to increase the vitamin D and that is much better than what you're saying, not really real risks that they're worrying about to do with the skin cancer.

[00:45:34] Prof. Tim Spector:  Correct. It's more likely to do harm than good. And definitely. Your skin health will probably be better if you don't have all these layers on every single day of your life. 

[00:45:43] Jonathan Wolf: Federica, too radical in your opinion? 

[00:45:45] Dr Federica Amati: Well, tell that to women who wear lots of layers, but anyway. 

I think the main thing there though is we have to be mindful of sunburn again, so I, with children especially, we know it's, the evidence is really clear, sunburn in childhood increases your risk of melanoma later in life, and so when it comes to protecting children's skin, or again if you're somebody who's got extremely fair skin, I think we know that you only need about 10 to 20 minutes of sunlight exposure between 10 am and 2 pm, to produce enough vitamin D.

So, you don't necessarily have to have prolonged exposure with no sunscreen. It's just about getting enough in every day. And I do agree with Tim 100% though, that we don't need to be wearing SPF 50 throughout the winter months. It does just seem like a complete waste of money and a waste of a layer on our skin.

[00:46:33] Prof. Tim Spector: But try buying a foundation cream for women that doesn't have SPF, you know, 30 or 50 in it, it's pretty hard. So, women are not given the choice, really, actually, that's the other thing, it's quite interesting. I'd like to talk about COVID-19 briefly, and the immune system. Because I think that was another big area that when I was talking about vitamin D and preventing COVID, you might remember that there was a huge thing about taking it. And this was absolutely crucial to… 

[00:47:00] Dr Federica Amati: It was like 5,000 international units a day to prevent, I remember. 

[00:47:02] Prof. Tim Spector: Everything sold out as usual in this area in a bid to prevent it. We did our own study with ZOE looking at supplements and people, what they were taking. Interestingly, we looked at about a million people and the severity of COVID. We saw a slight effect of vitamin D, but only in women. 

This was a self-report observational study of the fact that it wasn't consistent in men, we said it was probably just selection bias and that women were buying it. And they believed in it for the family, and the men were just being given it. And therefore it didn't help them. 

So it was a placebo effect. But other studies have shown no benefit in COVID for vitamin D. There were some big studies about injecting it for people with the disease that didn't show it unless they were very deficient. So people again in this sort of really deficient category will benefit from vitamin D.

And it's again this nuanced argument that it's really hard to convey to the public that if you're severely deficient in vitamin D, giving it can be life-saving. But if you've already got reasonable levels, having anything extra is really unlikely to help you at all. 

I think the same goes, you know, these studies of cancer and all the things related to the immune system, autoimmune diseases, et cetera.

So I think that's where we just need to think, are you really deficient or not? And only if you're really deficient should you be really worried about this. Otherwise, I think sunshine and a diverse diet is going to be all you really need and we should be worrying about other things and spending our money on other things.

And that's why I think ZOE members who are getting all this education are in a much better position to think about the things that are really important in their health that they can make changes to. Rather than just spending huge amounts of money on supplements that are proven not to work. 

[00:48:56] Jonathan Wolf: Do you know someone who worries about their vitamin D levels? Or maybe worries about their bones? Maybe they're unsure what a healthy vitamin intake really means. 

Why not share this episode with them right now and empower them to make better decisions based on the latest scientific advice? I'm sure they'll thank you. 

So it feels like you're basically saying for most people, they could save all the money they're spending on this vitamin D supplementation and spend it on something else that they're going to eat that is going to have a much bigger impact on their health.

[00:49:28] Prof. Tim Spector: Spending more on real food, getting mushrooms for example that have been sun tanning, the oily fish occasionally, just a more diverse diet and realizing that, yeah, just putting their arms in the sun. in the sunshine and walking in the woods and the garden regularly is good for you.

I think moving away from this miracle fix of the vitamin is really important for these other aspects, this more holistic view of life. 

[00:49:55] Jonathan Wolf: I’ve been umming and ahhing personally about this, about the vitamin D supplementation for the last three years, as Tim knows, but I'm coming away from this podcast pretty clear that as long as I'm able to get some sunshine, it's out the window and I should be thinking about, what am I doing really to feed the good bugs?

[00:50:10] Prof. Tim Spector: Good man, you got it, finally. 

[00:50:12] Dr Federica Amati: And I think for those people who have caring responsibilities, maybe you have children, maybe you're helping with an elderly parent, having it in the home and maybe occasionally giving your child some, or giving your elderly mother some, isn't going to do them harm. 

But there are other things that we can do for our health which are going to have a much bigger impact and actually measurable improvements, to our health. So if you've got some in your cupboard, you don't have to throw it in the bin. 

But definitely don't worry if you skip a few days, unless, as we said, you're in one of these minority groups of people who do have a specific condition that could benefit.

[00:50:47] Jonathan Wolf: Brilliant. Well look, Federica and Tim, thank you very much, and I think for the listener, I hope that was fun, because you can definitely see that there's agreement on what the studies are and what they say, that you can have two scientists looking at this and still have some spread of opinion. 

And we've had a lot of conversations like this over the last seven years, and I imagine we will have many more. 

I'm gonna try and do a quick summary if that's all right. So, my biggest takeaway from all of this is do not take calcium supplements. I think anyone listening, if there's one thing to take away is don't take calcium supplements unless they've been prescribed, and if you have friends or family who are taking calcium supplements, again, ask them has the doctor actually told you to take this, and if not, you should stop. So I think that's actually probably the most valuable thing I've taken away. 

Secondly, vitamin D is not even a vitamin. That does matter a bit, because it means that, for example, you really can overdose on vitamin D and end up with something that's toxic. Because you're saying if it was really a vitamin, you'd just sort of pee it out, but actually it sort of builds up and so that really should shift the way that I think about it and everyone else would think about it.

And then the other bit is there's this huge gap between what the government is saying in terms of saying maybe 30% or more of the population is deficient in vitamin D and what you can really tell from people getting rickets or some of these other diseases, which is a tiny, tiny fraction.

So there is a big debate about really, are so many people deficient or is it actually just a product of the fact that we're all different and our genes are different? 

That the evidence on this has really shifted over the last 20 years where previously, Tim was saying he also thought vitamin D was really good and would prescribe it because it was going to reduce fractures. And basically the data, the studies, one after another have been drip feeding and saying, actually, there is no evidence that if you take this vitamin D, it's going to reduce your risk of fractures, which was the original idea for taking it, and there is real evidence that you can overdose on it.

So if you are taking really high levels of vitamin D, unless your doctor has told you to do it, stop again. 

And then I think critically, while there may be some groups, and Federica's pointing out some groups where supplementation could work, and interestingly, you're tending to talk about groups that might actually be living with some sort of disease. 

Maybe there's a role for people who are very old and in care homes, I think Tim you said that's also possible, but you know, it's, these are relatively small groups.

What we should all be doing is rethinking our attitude to the sun, particularly in the winter for people who are living in very northerly or southerly climates, or people who are living in a place where it's hot and they're putting on so much sunscreen like Australia, Florida all year round, they're getting none. 

And that actually we need to rethink this balance between, yes, you want to avoid cancer, you don't want to burn. But on the other hand, you do want to get some vitamin D from your skin and that for a lot of people, that means that you could probably go out in the winter months without having to have sunscreen. 

And just to wrap up, I would say I've had a personal dispensation from my wife that in the winter six months, I'm allowed to not wear sunscreen. And I think that her view has changed since I've known her. 

So I think what I see there, Tim, is it's obviously, you know, a shift also, you know, in medical views from dermatologists and others as this evidence is changing, right? That the vitamin D is seen as something that matters if you can get it through something like the sun. Whereas this supplementation has come under much more question. 

[00:54:26] Dr Federica Amati: Yeah, and I think Tim's been saying this for a while, actually. I have to say, Jonathan, he's been very skeptical of vitamin D supplementation for general health and the prevention of all diseases.

And the newer evidence is proving that Tim's approach has been right. And I think, quite satisfying for you, I guess, but it's important to always keep an open mind because the status quo on what recommendations are, doesn't always hold. 

[00:54:48] Jonathan Wolf: I don't want to puff up Tim's head anymore since, you know, that we wouldn't want to recommend that. 

[00:54:53] Prof. Tim Spector: Well, there could be another study next year  that proves me wrong, so, you know.

[00:54:57] Dr Federica Amati: You're open to that. 

[00:54:58] Prof. Tim Spector: But if there's another way of giving vitamin D that actually works, because it's so important in the body. It just so happens that the trials that have all been done so far, apart from, say, multiple sclerosis and a few other rare diseases, have not been effective.

But, I'm open to supplements working, but let's look at the evidence clearly and come into it with our eyes open and not be driven by the industry into spending all our money on things that have proven not to work. 

[00:55:29] Jonathan Wolf: And if I were going to wrap up, I'd just say, I think this reminds me of the conversations we have around food and nutrition all the time. Where the latest science is very often completely different from what I was told 30 years ago is the right answer. That it's complex, you have to work it through. 

And it's part of the reason we spent so much time trying to figure out how we use sort of the membership in the app to guide people to understand what to change because, this is just vitamin D, right? It's just one little part of how you think about improving your health. 

It is complex, and I think what's interesting is just how many areas scientists are now saying, actually, you know what, the view that we had 30 years ago with a lot less data, we've really changed a lot, and that there has been an enormous amount of research that's going on around the world in so many of these areas, I think Tim is generally saying, well, actually, you know what, this has really changed my views and our views about what we should do.

[00:56:22] Dr Federica Amati: But I do think that, though the science is complex, I think the advice remains quite simple. And Jonathan, we obviously know this in the app and in the way we speak to our members, but eating a whole-food-based diet where you have a lot of plants on your plate and being active throughout the day, preferably outside, is quite simple in terms of the messaging.

So I think we mustn't lose sight of the fact that these are all things people can do. And it's quite easy to make that change. Obviously, it's easier when you have the help of someone like ZOE to do it. 

[00:56:54] Prof. Tim Spector: Yeah, so it's a holistic approach. It's not about one little chemical. It's all about the thousands of chemicals, the whole complexity of our body that we need to embrace.

And that's why this whole idea of diversity is absolutely crucial. 

[00:57:08] Jonathan Wolf: Brilliant. Thank you both very much. 

[00:57:10] Dr Federica Amati: Thank you. 

[00:57:11] Prof. Tim Spector: Pleasure. 

[00:57:13] Jonathan Wolf: I loved having Tim and Federica on the podcast today. I hope you learned something new and enjoyed watching them disagree a little bit. My biggest takeaway is that, if possible, we should try to get our vitamin D from natural sources.

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