Can you tell me what could be causing my low vitamin D level? Do you believe that this is the issue, or are the low levels caused by something else?

DEAR READER: Vitamin D is a fat-soluble vitamin that is essential for promoting calcium absorption, maintaining adequate serum calcium and phosphate levels, bone growth and remodeling, reduction of inflammation, and neuromuscular and immune function.

If your levels are low, you are at risk of developing weak, brittle and/or deformed bones. This could also affect your immune system, making you more susceptible to infection, allergens and more. Your low vitamin D level may indeed be the cause of your allergies, which are causing your cold and flu-like symptoms; however, this does not explain why you have a low D level to begin with.

In healthy people, vitamin D deficiency can typically be avoided by adequate sun exposure and a well-balanced diet. Because there are very few foods that naturally contain D, fortified cereals and dairy products are the best way to achieve sufficient dietary amounts.

Older adults, breastfed infants and those with limited sun exposure, dark skin or fat malabsorption are at increased risk of developing deficiency. Obese individuals may have difficulty absorbing vitamin D from sun exposure because the subcutaneous fat essentially blocks part of the D from entering the bloodstream. Those who have undergone gastric bypass may also have difficulty because most forms of this surgery bypass the upper small intestine where D is absorbed.

Symptoms of vitamin D deficiency typically go unnoticed. The most common consequence is weakened bones, also known as rickets in children, osteomalacia in pre-menopausal women and men, and osteoporosis is post-menopausal women. There may be an increased risk of developing cancer, especially that of the digestive tract. There is also research suggesting deficiency may play a role in the prevention and treatment of diabetes types 1 and 2, hypertension, glucose intolerance, multiple sclerosis and more. However, because these studies have not been randomized clinical trials, the implications will continue to be debated until definitive proof is found.

According to the Food and Nutrition Board (FNB) at the Institute of Medicine of the National Academies, adequate intakes (AIs) for healthy people between birth and age 50 should be 200 IU of vitamin D daily. Those aged 51 and over should double that. Recently, the American Academy of Pediatrics issued its own recommended intakes that exceed those of the FNB. This led to an expert committee formation by the FNB, which decided that recommended intakes be re-evaluated. To the best of my knowledge, the decision of this committee should be made public later in 2010. Tolerable upper-intake levels (ULs) for those between birth and 12 months is 1,000 IUs; age 1 and older is 2,000 IUs daily. This, too, was challenged and is currently under review.

I suggest that you speak to your physician to request that the underlying cause be found. It may be as simple as not getting enough sun exposure and may be helped by exposure without sunblock for 15 or 20 minutes each day. Longer unprotected exposure is not recommended because of the increased risk of developing skin cancer.

If the cause cannot be found, follow your physician’s advice regarding supplementation and including more vitamin D-enriched foods into your diet.

You should also be watchful for signs of excess intake. Most commonly, these symptoms are nonspecific and include nausea, weakness, constipation, weight loss, vomiting and poor appetite. If healthy people continually take levels above the UL, it may result in elevated blood levels of calcium, which may cause confusion and other mental-status changes, as well as heart-rhythm abnormalities. There is also an increased risk of developing kidney stones, especially when used in conjunction with calcium; however, because you are deficient and under the care of a physician, these are not likely to result.

To provide related information, I am sending you a copy of my Health Report “Vitamins and Minerals.” Other readers who would like a copy should send a self-addressed stamped No. 10 envelope and a $2 check or money order to Newsletter, P.O. Box 167, Wickliffe, OH 44092. Be sure to mention the title. Order forms are also available for printing on my Web site at www.AskDrGottMD.com.

My question however, doesn’t have to do with the medication. Just before having the DEXA scan, I noticed several enlarged bones in my right foot and ankle. I was tested for Paget’s disease but the results were negative. At my last physical exam, my doctor noticed that my left shoulder blade had enlarged. I have seen several doctors and none can tell me what is causing my bones to enlarge. Do you have any ideas?

DEAR READER:
Because you do not say what type of testing you have had and what types of doctors you have seen I can only give you general suggestions. If these are repeats of what has been done or said, I apologize.

First, I would like to say that I hope along with your Boniva you were told to increase your calcium and vitamin D intake. Boniva and other osteoporosis medications were not designed to treat osteopenia but have been increasingly given to individuals with this pre-osteoporotic condition. If you are not already, I urge you to take 1000-1500 mg of calcium and 600-800 mg of vitamin D daily. This can be achieved through supplements or by increasing your fortified milk, cheese, and yogurt and dark leafy greens intake. Tofu is also often fortified with calcium and vitamin D to round out vegan (no animal products) diets.

Second, I suggest your seek another opinion from an orthopedic specialist who can order testing to determine if you do indeed have Paget’s disease. This condition is defined by abnormal bone break-down and re-growth. The process is sped up in sufferers and often causes bone enlargement. Despite the enlarged bones, they often are weak and brittle which is why Paget’s is often known as “soft bone disease”.

Testing can include X-rays to pinpoint bone enlargement, show re-absorption and other abnormalities. Another valuable test is a bone scan in which a material is injected to show bone better. In Paget’s disease, the affected areas show up darker than healthy, normal bone. A final step is a blood test done to determine the level of alkaline phosphatase. In most individuals with this condition, the levels are elevated. Because I don’t know what testing you have had, I cannot determine if you have had all or some of these.

Treatment for Paget’s disease is similar to that of osteoporosis. It includes biphosphonates such as Fosamax, Boniva and others, and calcitonin. Therapy is aimed at improving bone strength and mineral content.

Therefore, even if you have Paget’s disease, you are already receiving proper care; however, you need to have a diagnosis. If you don’t have Paget’s disease after having thorough testing, you need to know why you are having spontaneous bone enlargement. Ask your primary care physician for a referral to an orthopedic specialist and go from there.

To give you related information, I am sending you a copy of my Health Report “Osteoporosis”. Other readers who would like a copy should send a self-addressed, stamped number 10 envelope and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.

DEAR READER:
As I am sure your doctor mentioned, osteoporosis means “porous bones” and refers to the loss of bone density and bone mass that commonly appears as we age. Mild bone loss is known as osteopenia. Osteoporosis occurs when the loss is so extreme that the bones cannot perform their supportive function. As a result, they can easily break.

The condition is commonly found in postmenopausal women, but can affect men as well. Hunched shoulders and a stooped posture are often attributed to the aging process, but may actually be the result of osteoporosis. Other signs are kidney stone formation, gum recession, tooth plaque, joint pain, thyroid disorders, and lower back pain.

Hormone therapy for women using patches, creams or vaginal rings, was once the gold standard for treatment. Unfortunately, because of safety concerns, this is no longer the case.

Biphosphonates may preserve bone mass and increase bone density in the spine and hips. This treatment can be beneficial for men, younger adults, and those individuals with osteoporosis induced by therapeutic steroid use. Biphosphonates can be taken orally or intravenous infusion. Side effects can include bone, joint and muscle pain (mild to debilitating), severe abdominal pain, nausea and osteonecrosis of the jaw (destruction of the jaw). Those with a history of ulcers or acid reflux should avoid this class of drugs because of the possibility of esophageal inflammation and esophageal ulcers. Common biphosphonates include Fosamax, Actonel and Boniva.

Zoledronic acid (Reclast) is in the bisphonate class and was approved by the FDA in 2007 as the first once-a-year drug for osteoporosis. It is also indicated for the treatment of Paget’s disease (“soft” bone disease) in both men and women. It should be avoided by those with kidney disease. Adverse reactions include bone, joint and muscle pain and osteonecrosis of the jaw. Reclast is given intravenously in a physician’s office.

Raloxifene (Evista) mimics the beneficial effects of estrogen for post-menopausal women only. It is not approved for men or pre-menopausal women. Those with a history of blood clots should not take this drug as there is an increased risk of deep vein and retinal vein thrombosis and pulmonary embolism. Adverse reactions include hot flashes, leg cramps, flu-like symptoms, peripheral edema (leg swelling), and joint pain.

Teriparatide (Forteo) works by stimulating new bone growth. It is an injection given once daily under the skin in the thigh or abdomen. The medication has been found to cause an increased risk of a certain malignant bone cancers in rats and it is not known at this time if it affects humans in the same way. There is a black box warning on this product’s packaging and, in my opinion, the product should be avoided.

There is no practical way to restore bone mass. However numerous treatments to slow the process of deterioration are available. For example, a new emerging therapy without prescription medication shown to significantly reduce back pain and improve posture is known as weighted kypho-orthosis (WKO). It is a harness with attached weights that is worn twice daily for 30 minutes at a time. It is combined with back extension exercises.

Given the drugs now available, it is rather difficult to determine which therapy might be appropriate for every person. Because I am not your personal physician and we have never met, it makes that job even harder. I don’t know your age, current medications, exercise habits, weight, family history, and more. Therefore, I cannot determine the best choice.

I strongly urge you to speak with your physician who knows you and your medical history and can make an appropriate choice. I know this sounds as if I am taking the easy way out, but osteoporosis is an extremely important and complex issue. Were I put on the spot and forced to make a decision, I would probably recommend you take 1200-1500 mg calcium combined with 400 international units (IU) of vitamin D daily. When combined with regular exercise and a nutritious diet high in calcium containing foods, such as yogurt, fat free milk and dark leafy greens, this can be an excellent preventive step and may stop further bone loss if started early in the disease. To determine if it is working, be sure to have a bone density study one year after starting therapy. Bypass all oral and injectable prescription drugs as long as possible or until more time has passed and additional research can be done.
To give you related information, I am sending you copies of my Health Reports “Osteoporosis” and “Consumer Tips on Medicine”. Other readers who would like copies should send a self-addressed, stamped number 10 envelope and $2 per report to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.

I currently take Evista with 1200 mg of calcium. I am a healthy 53-year-old menopausal woman. Is there another drug that I should be taking in lieu of Evista? My doctor has recommended the drug (Boniva, I think), after which you have to be able to stand longer than one to two hours. I’m not thrilled with the idea of that drug either.

DEAR READER:
Every drug has side effects — even non-prescription ones. As I have mentioned before, whether a patient takes a medication or chooses not to do so, the person needs to know about the risk/benefit factors.

Biphosphonates, such as Fosamax and Boniva, do carry the rare risk of osteonecrosis of the jaw. This is increased in individuals with cancer, poor dental hygiene, and more. Evista’s possible risk of premature heart disease is some women is a far more concerning side effect.

If you have moderate to severe osteopenia (bone weakness) or any stage osteoporosis, the choice of medication is up to you and your physician. There will still be a possibility of side effects regardless of the treatment you choose. If you have mild osteopenia, you may be able to prevent worsening by increasing your daily intake of calcium and vitamin D. Speak to your gynecologist or primary care physician about possible options.

Is it possible for me to get enough calcium from my diet without taking the over-the-counter kind? I enjoy all kinds of vegetables and dairy products. I run and take aerobics classes (which includes weights) about three times per week.

DEAR READER: I recommend that you have a bone density exam. This test will let your doctor know how well your bones are absorbing calcium. If you have minor deficiencies (osteopenia) but not osteoporosis, increasing your calcium intake with calcium and vitamin D supplements may stop or slow bone loss. If you have osteoporosis, you should start one of the medications available on the market as well as including extra dietary calcium and vitamin D.

Whether or not you need calcium/vitamin D supplements, they are relatively inexpensive and won’t hurt you. (Incidentally, just because you are slim is not reason enough to assume that you are a candidate for osteoporosis.) As a preventive you may wish to start taking supplements even if you have no problem.

If you decide to take calcium supplements, be sure that you take one that includes vitamin D. The vitamin D works with the calcium in your body and aids absorption. Without it the amount of calcium used by the body is minimal.

To give you related information, I am sending you a copy of my Health Report “Osteoporosis”. Other readers who would like a copy should send a self-addressed, stamped number 10 envelope and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.